Noncontraceptive effects of hormonal contraceptives: Bone mass, sexually transmitted disease and pelvic inflammatory disease, cardiovascular disease, menstrual function, and future fertility

Reproductive hormones and cardiovascular disease mechanism of action and clinical implications

The bulk of the experimental data suggest beneficial effects of estrogen (both premenopausal use of OCs and postmenopausal use of ERT-HRT). An intriguing finding from the monkey studies is that social subordination, which induces estrogen deficiency in female monkeys, accelerates atherosclerosis premenopausally and predicts extent of postmenopausal atherosclerosis. This effect can be inhibited by exogenous estrogen, premenopausally. The results suggest that more effort on detecting and regulating premenopausal ovarian dysfunction may be justified. A complication in understanding estrogen action may be the result of varying extents of arterial damage. For example, primary prevention studies in both postmenopausal animals and women have provided strong evidence of atheroprotection with a variety of estrogens. In contrast, the results of secondary prevention studies [10,12] have in general suggested little cardioprotection with either ERT or HRT. Studies in rabbits suggest the antiatherogenic effect of estrogen may not be present when the endothelium is damaged [64]. The state of the endothelium may be critical for some estrogen actions. For those effects of estrogen that require the ER, be it ERalpha or ERbeta, the presence of the receptor may vary with age, disease state, or type of hormone therapy. If continuous combined HRT therapy decreases ER in the artery as it does in the uterus, this may eliminate those estrogen actions requiring the ER, but not others. Older women who have not been exposed to estrogens for many years may be more sensitive to some estrogen effects, and may need lower doses of ERT-HRT. Recent reports suggest that lower doses of estrogens maintain beneficial effects on lipoproteins and coagulation factors [95], while also requiring lower doses of progestogens to protect the uterus [96]. These beneficial findings are very promising in light of the improvements in CHD risk and decreased stroke risk reported with low-dose estrogens [5]. It ill be interesting to see if CRP is increased with lower doses of estrogens and whether these changes are associated with increased early risk of CHD. Perhaps older women with CHD are also more obese, may have diabetes, and may be more susceptible to inflammatory and thrombotic effects of higher doses of estrogens. There are many questions left unanswered. It is hoped that some of the answers may come from the WHI, which is a large prospective trial assessing ERT and HRT. The age range is also relatively large and may be able to determine if older women respond differently than younger women. Some initial data from the WHI have been made available suggesting a small increased risk in the first 2 years and a trend for decreasing risk in the last months of the first 2 years [34]. Just recently, the CEE + MPA arm of the study was stopped early by the data and-safety monitoring board as the overall health risks exceeded benefits with increases in both breast cancer and CVD [97]. The remainder of the study groups including an estrogen-only arm, are expected to continue until 2005.

The female athlete. Before and beyond puberty

As the twentieth century progressed, the female athlete became an accepted participant of sports at all levels. This article reviews various aspects of female sports participation. After an historical perspective, selected comments are provided on psychologic and physiologic aspects. Concepts of adolescent gynecology are reviewed, including breast and menstrual problems and pregnancy. Other areas reviewed include iron deficiency anemia, stress urinary incontinence, and sports injuries in female athletes.

Menstrual cycle, contraception, and performance

Although understanding of the unique physiology of the female athlete has increased, there are still many questions to be answered. Endogenous and exogenous female sex steroids have been shown to influence various cardiovascular, respiratory, and metabolic parameters, but these changes probably have minimal impact on the ability of most recreational athletes to participate in and enjoy their sport. Statistically significant data may or may not have clinical or performance relevance. By the same token, a statistically nonsignificant change may mean the difference between first and second place to an elite athlete. For an athlete concerned about maximizing performance, individual variability in menstrual cycle changes to various performance parameters must be considered. It is difficult to predict how accurately controlled laboratory findings from a study population apply to an individual competitor on the playing field. Athletes taking OCs for contraception or for menstrual cycle control may be able to minimize any potential side effects and performance influences by taking the lower dose triphasic pills and the newer progestins. For women with menstrual dysfunction, OCs may provide a predictable hormonal milieu for training and competition. Further scientific study is needed using large-scale, prospective, randomized clinical trials on trained athletes and accurate hormonal measurements to determine the phase of the menstrual cycle to determine short- and long-term effects of cycle phase and OCs in exercising women. As more questions continue to be answered, physicians and sport scientists will be better able to guide women not only to maximize their performance but to ensure lifelong good health.

Distress and reduced fertility: a follow-up study of first-pregnancy planners

OBJECTIVE

To assess the effect of psychological distress on time to first pregnancy.

DESIGN

A follow-up study of time to pregnancy with prospective data on distress, with controlling for potential confounding variables.

SETTING

Two university hospitals.

PATIENT(S)

Danish couples (n = 430) who were planning their first pregnancy and had no previous reproductive experience were followed for six menstrual cycles. Psychological distress was measured in each menstrual cycle by the General Health Questionnaire.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

A clinically recognized pregnancy or a biochemical pregnancy detected in urine samples from each period of vaginal bleeding.

RESULT(S)

For cycles with the highest distress score (General Health Questionnaire score >80th percentile), the probability of conception per cycle was 12.8%, compared with 16.5% in other cycles (adjusted odds ratio [OR] 0.6; 95% confidence interval [CI] 0.4-1.0). The effect of distress was found almost exclusively among women with long menstrual cycles (OR 0.1; 95% CI 0.01-0.4 and OR 0.9; 95% CI 0.5-1.4 for women with cycles of > or =35 and <35 days, respectively). An increased incidence of early embryonal loss was also found among highly distressed women with long cycles, but was based on a small number of observations.

CONCLUSION(S)

Psychological distress may be a risk factor for reduced fertility in women with long menstrual cycles.

Sexually transmitted diseases and oral contraceptive use during adolescence

Sexually transmitted diseases (STD) cause lower genital tract infections (cervicitis, vaginitis) or ascending infections of the fallopian tubes, and, possibly, pelvic inflammatory disease (PID). The syphilis bacterium, human immunodeficiency virus (HIV), and the hepatitis virus cause systematic disease. Although oral contraceptives (OCs) are the most reliable contraceptive method, they have limited anti-STD properties and their relationship with STDs remain unclear. Various mechanisms explain a protective role of OCs against STDs; however, in no way can OCs be considered a safe anti-STD contraceptive method, when compared to specific barrier methods, which provide both contraception and anti-STD protection. The above has been confirmed by a recent study performed in our institution where 10.3% and 6.9% of OC users presented a prevalence of Chlamydia trachomatis and Mycoplasma, respectively, when compared to 0% and 4.5% infection rates found among condom users. It is concluded that although OCs possess some anti-STD properties, mainly in the prevention of PID, they should be used in combination with a barrier method.

Use of depo-provera in teens

Currently, depot-medroxyprogesterone acetate is the only contraceptive injection available in the United States. Its use was approved by the U.S. Food and Drug Administration in October 1992. This article describes the mechanisms of action, advantages, disadvantages, and contraindications of this very effective contraceptive agent. In addition, the initial workup, the treatment, and the follow-up of the teen receiving depot-medroxyprogesterone acetate are presented.