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Shaheen K, Kamel HH, Mostafa Mohammed E, Hashim Mohammed A, Ahmed Sileem S, Fouad M, Shehata Sayd Z, ElHodiby ME. Clomiphene citrate as a new modality in management of vaginal bleeding with depomedroxyprogesterone acetate (DMPA): A randomized controlled trial. Steroids 2024; 206:109425. [PMID: 38636732 DOI: 10.1016/j.steroids.2024.109425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/14/2024] [Accepted: 04/15/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Depo-medroxyprogesterone acetate (DMPA) functions as a contraceptive method by inhibiting the secretion of gonadotropins, which prevents follicular maturation and ovulation, as well as thinning of the endometrium leading to unscheduled vaginal bleeding and subsequent discontinuation of DMPA. Our study aimed to evaluate the efficacy and safety of clomiphene citrate (CC) in stopping bleeding among DMPA users. MATERIALS AND METHODS We randomly assigned 200 DMPA users using a computer-generated random numbers table in a 1:1 ratio to one of two groups; the study group, which received CC at a dose of 50 mg twice daily for five days (n = 100), and the control group, which received a placebo for five days (n = 100). Our primary outcome measure was the onset and duration of bleeding cessation. Secondary outcomes included endometrial thickness, recurrence of vaginal bleeding, and any reported side effects associated with CC use. RESULTS Clomiphene citrate significantly resulted in early cessation of vaginal bleeding in 83 % of the patients, which continued for three months of follow-up. In addition, the recurrence of vaginal bleeding was significantly reduced in the CC group compared to the control group (11 % vs. 67 %; p < 0.001). Endometrial thickness was significantly greater in the CC group than in the control group (p < 0.001). Breast tenderness was more frequently reported in the study group, with no difference in dyspareunia between the two groups. CONCLUSIONS Clomiphene citrate is effective in controlling bleeding among DMPA users. Further studies are encouraged to confirm our findings.
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Affiliation(s)
- Kareem Shaheen
- Department of Obstetrics and Gynecology, Faculty of Medicine, Minia University, Minia, Egypt
| | - Hany H Kamel
- Department of Obstetrics and Gynecology, Faculty of Medicine, Minia University, Minia, Egypt
| | - Enas Mostafa Mohammed
- Department of Obstetrics and Gynecology, Faculty of Medicine, Minia University, Minia, Egypt
| | - Ahmed Hashim Mohammed
- Department of Obstetrics and Gynecology, Faculty of Medicine, Al-Azhar University, Assiut, Egypt.
| | - Sileem Ahmed Sileem
- Department of Obstetrics and Gynecology, Faculty of Medicine, Al-Azhar University, Assiut, Egypt
| | - Mahmoud Fouad
- Department of Obstetrics and Gynecology, Faculty of Medicine, Al-Azhar University, Assiut, Egypt
| | - Zainab Shehata Sayd
- Department of Obstetrics and Gynecology, Faculty of Medicine for Girls, Al-Azhar University, Assiut, Egypt
| | - Mohamed E ElHodiby
- Department of Obstetrics and Gynecology, Faculty of Medicine, Misr University for Science and Technology, Giza, Egypt
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Avenant C, Bick AJ, Skosana SB, Dlamini S, Balakrishna Y, Moliki JM, Singata-Madliki M, Hofmeyr GJ, Smit J, Beksinska M, Beesham I, Seocharan I, Batting J, Chen PL, Storbeck KH, Africander D, Hapgood JP. Misreporting contraceptive use and the association of peak study progestin levels with weight and BMI among women randomized to the progestin-only injectable contraceptives DMPA-IM and NET-EN. PLoS One 2023; 18:e0295959. [PMID: 38134043 PMCID: PMC10745193 DOI: 10.1371/journal.pone.0295959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 12/02/2023] [Indexed: 12/24/2023] Open
Abstract
Progestin-only injectable contraceptives, mainly depo-medroxyprogesterone acetate intramuscular (DMPA-IM), are the most widely used contraceptive methods in sub-Saharan Africa. Insufficient robust data on their relative side-effects and serum concentrations limit understanding of reported outcomes in contraception trials. The WHICH clinical trial randomized HIV-negative women to DMPA-IM (n = 262) or norethisterone enanthate (NET-EN) (n = 259) at two South African sites between 2018-2019. We measured serum concentrations of study and non-study progestins at initiation (D0) and peak serum levels, one week after the 24-week injection [25 weeks (25W)], (n = 435) and investigated associations between study progestin levels, and BMI and weight of participants. Peak median serum concentrations were 6.59 (IQR 4.80; 8.70) nM for medroxyprogesterone (MPA) (n = 161) and 13.6 (IQR 9.01; 19.0) nM for norethisterone (NET) (n = 155). MPA was the most commonly quantifiable non-study progestin at D0 in both arms (54%) and at 25W in the NET-EN arm (27%), followed by NET at D0 in both arms (29%) and at 25W in the DMPA-IM arm (19%). Levonorgestrel was quantifiable in both arms [D0 (6.9%); 25W (3.4%)], while other progestins were quantifiable in ≤ 14 participants. Significant negative time-varying associations were detected between MPA and NET concentrations and weight and BMI in both contraceptive arms and a significant increase was detected for peak serum progestin concentrations for normal weight versus obese women. Contraceptive-related reported outcomes are likely confounded by MPA, more so than NET, with reported DMPA-IM effects likely underestimated, at sites where DMPA-IM is widely used, due to misreporting of contraceptive use before and during trials, and 'tail' effects of DMPA-IM use more than six months before trial enrolment. Peak serum levels of MPA and NET are negatively associated with BMI and weight, suggesting another source of variability between trial outcomes and a potential increase in side-effects for normal weight versus overweight and obese women. Trail registration: The clinical trial was registered with the Pan African Clinical Trials Registry (PACTR 202009758229976).
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Affiliation(s)
- Chanel Avenant
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Alexis J. Bick
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Salndave B. Skosana
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Sigcinile Dlamini
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Yusentha Balakrishna
- Biostatistics Research Unit, South African Medical Research Council, Durban, South Africa
| | - Johnson Mosoko Moliki
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
| | - Mandisa Singata-Madliki
- Effective Care Research Unit, Eastern Cape Department of Health, Universities of the Witwatersrand and Fort Hare, East London, South Africa
| | - G. Justus Hofmeyr
- Effective Care Research Unit, Eastern Cape Department of Health, Universities of the Witwatersrand and Fort Hare, East London, South Africa
- Walter Sisulu University, East London, South Africa
- Department of Obstetrics and Gynecology, University of Botswana, Gabarone, Botswana
| | - Jenni Smit
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Mags Beksinska
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Ivana Beesham
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Ishen Seocharan
- Biostatistics Research Unit, South African Medical Research Council, Durban, South Africa
| | - Joanne Batting
- Effective Care Research Unit, Eastern Cape Department of Health, Universities of the Witwatersrand and Fort Hare, East London, South Africa
| | - Pai-Lien Chen
- Family Health International (FHI) 360, Durham, North Carolina, United States of America
| | - Karl-Heinz Storbeck
- Department of Biochemistry, Stellenbosch University, Stellenbosch, South Africa
| | - Donita Africander
- Department of Biochemistry, Stellenbosch University, Stellenbosch, South Africa
| | - Janet P. Hapgood
- Department of Molecular and Cell Biology, University of Cape Town, Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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