A detailed analysis of menstrual blood loss in women using Norplant and Nestorone progestogen-only contraceptive implants or vaginal rings

A clinical observational study on the efficacy of subcutaneous etonogestrel implants for adenomyosis in 20 patients

Objective: To evaluate the efficacy of subcutaneous etonogestrel implants for adenomyosis.Methods: We conducted a clinical observational study of 20 patients suffering from adenomyosis treated with subcutaneous etonogestrel implants from August 2015 to July 2017 and followed up for 36 months. We evaluated the efficacy of subcutaneous etonogestrel implants primarily based on the following indicators: the pictorial blood loss assessment chart (PBAC) for menstrual blood volume, changes in bleeding patterns, the visual analog scale (VAS) pain score for dysmenorrhea, uterine volume, serum cancer antigen 125 (CA125) levels, hemoglobin levels and side effects.Results: During the 3 years of follow-up, subcutaneous etonogestrel implants were removed from six patients, among whom one was diagnosed with endometrial cancer, four had an increased menstrual blood volume, and one entered menopause. In total, 14 patients were treated with subcutaneous etonogestrel implants for 3 years. Among these patients, the number of patients with heavy menstrual bleeding and high PBAC and VAS scores and serum CA125 levels was significantly decreased after implantation compared with that before implantation. In the eight patients with anemia, hemoglobin levels increased gradually. However, the uterine volumes did not significantly change. Bleeding patterns were changed but were tolerable.Conclusion: Subcutaneous etonogestrel implants represent a new option for the clinical treatment of adenomyosis for patients who refuse surgery.

Potentially effective therapy of heavy menstrual bleeding with an oestradiol-nomegestrol acetate oral contraceptive: a pilot study

BACKGROUND

Heavy menstrual bleeding (HMB) exceeding 80 mL per cycle leads to considerable adverse impact on a woman's iron metabolism, incidence of iron deficiency and anaemia, as well as her functioning in society. The objective of the study is to determine the potential efficacy of a Monophasic oestradiol-17β-nomegestrol acetate (E₂/Nomac) combined oral contraceptive pill on measured menstrual blood loss as a pilot study in 12 women with objectively demonstrated HMB (>80 mL per cycle). The pilot study aimed to recruit 20 women.

METHOD

Consented women completed the HMB questionnaire. The blood was taken for haemoglobin, transferrin, iron saturation, TIBC, serum iron and ferritin. Women were given verbal and written detailed instructions for MBL collection for three control cycles and four treatment cycles.

RESULTS

Forty-three women were enrolled, but 31 were ineligible and withdrawn (mainly for failure to meet eligibility criteria). Twelve women entered the treatment phase and commenced the E₂/nomegestrol acetate (NOMAC) 24/4 combined pill treatment on the first day of their fourth cycle. All women with complete MBL measurements had >50% reduction in MBL on treatment (exact 95% confidence interval for proportion with MBL reduction >50%: 69 to 100%). The mean percent reduction in MBL between pretreatment and during treatment was 76.9%, and the median was 79% with a range of 53.7 to 100%.

CONCLUSIONS

This pilot study indicates that the E₂/NOMAC COC will provide a useful potential option for treating HMB in women with FIGO classification AUB-E (primary endometrial causes) but requires a larger placebo-controlled study for confirmation.

Effective treatment of heavy menstrual bleeding with estradiol valerate and dienogest: a randomized controlled trial

OBJECTIVE

To estimate the efficacy of a fixed estrogen step-down and progestin step-up 28-day estradiol (E2) valerate and dienogest oral contraceptive regimen in women with heavy menstrual bleeding, prolonged menstrual bleeding, or heavy and prolonged menstrual bleeding without organic pathology.

METHODS

This double-blind, placebo-controlled study randomized women aged 18 years or older with prolonged, frequent, or heavy menstrual bleeding, objectively confirmed during a 90-day run-in phase, to treatment with E2 valerate and dienogest or placebo (2:1) for 196 days. Data from the last 90 days of treatment and the run-in phase were compared. The primary variable was the "complete response" rate (complete resolution of qualifying abnormal menstrual symptoms, including a 50% or greater reduction in pretreatment menstrual blood loss volume in women with heavy menstrual bleeding). Secondary variables included objective changes in menstrual blood loss volume (alkaline hematin methodology) and iron metabolism parameters. Overall, 180 women were needed to provide 90% power.

RESULTS

There were no marked differences in the characteristics of E2 valerate and dienogest (n=120) and placebo (n=70) recipients. The proportion of "complete responders" in the evaluable group was significantly higher in E2 valerate and dienogest (35/80; 43.8%) compared with placebo (2/48, 4.2%, P<.001) recipients. The mean [standard deviation] reduction in menstrual blood loss with E2 valerate and dienogest from the run-in phase to the efficacy phase was substantial (-353 mL [309 mL]; mean -64.2%; median -70.6%) and significantly greater than that in placebo recipients (-130 mL [338 mL]; mean -7.8%; median -18.7%; P<.001). Significant improvements in hemoglobin, hematocrit, and ferritin were seen with E2 valerate and dienogest, but not with placebo.

CONCLUSION

Oral E2 valerate and dienogest was highly effective compared with placebo in the treatment of women with heavy menstrual bleeding, prolonged menstrual bleeding, or heavy and prolonged menstrual bleeding without organic pathology.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT00293059.

LEVEL OF EVIDENCE

I.

Hormonal contraceptive practices in young Australian women (≤ 25 years) and their possible impact on menstrual frequency and iron requirements

OBJECTIVES

To investigate the hormonal contraceptive practices of female university students aged ≤ 25 years, their menstrual bleeding frequency, and interest in contraceptive regimens that reduce menstrual frequency or duration.

STUDY DESIGN

A 20-item questionnaire was distributed to female students at Griffith University, Gold Coast campus. This included questions relating to: demographics, menstrual bleeding frequency, current contraceptive practices, and interest in future oral contraceptive regimens that reduce menstrual bleeding frequency and duration.

MAIN OUTCOME MEASURES

Determination of hormonal contraceptive practices and menstrual bleeding frequency undertaken by the sample population.

RESULTS

Eight hundred and fifty one participants completed the questionnaire, ~ 2/3rds of respondents are currently using a hormonal contraceptive (66% of all respondents), with the oral contraceptive pill (OCP) being most common. Most women (73%) reported monthly menstruation, although 16% indicated that they sometimes missed their monthly period, with bleeding every two months. Of all OCP users, approximately 2/3rds have skipped their monthly period at some time, the most common reasons being for convenience (89%). Approximately 70% of respondents were interested in OCP regimens that reduced frequency or duration of menstruation.

CONCLUSION

OCP use is popular amongst Australian university women, with many being interested in the concept of using the OCP to delay menstruation. Given this interest and the availability of hormonal contraceptives that reduce menstrual frequency and duration, assessing the impact of reduced menstrual blood loss on iron stores may be warranted.

Menstrual pattern changes from levonorgestrel subdermal implants and DMPA: systematic review and evidence-based comparisons

BACKGROUND

Many women want a lengthy duration of contraception but are wary of the menstrual changes from depot medroxyprogesterone acetate (DMPA). A subdermal levonorgestrel (LNG) implant may be a reasonable alternative. However, information on menstrual changes from these methods has not been summarized and compared in an easy-to-understand form.

STUDY DESIGN

We systematically reviewed the published literature on these contraceptives to find research that used menstrual diaries and standard World Health Organization definitions. We attempted to find information on amenorrhea, number of bleeding or spotting episodes, number of bleeding or spotting days and normal patterns, as reported in four consecutive 90-day reference periods.

RESULTS

We found 16 published articles meeting our criteria and involving diaries of up to 1600 DMPA users and 2300 LNG implant users. We were able to compare the two methods on only three outcomes. For DMPA use, the weighted prevalence of amenorrhea at successive 90-day periods was 12%, 25%, 37% and 46%. The comparable estimates for the LNG implant were 11%, 13%, 9% and 13%. Levonorgestrel implant users experienced a higher average number of bleeding or spotting days compared to DMPA users, but this average was similar to what is expected naturally. At 12 months, normal menstrual patterns were experienced by 23% of LNG implant users compared to 11% of DMPA users.

CONCLUSIONS

Like most hormonal contraception, LNG implants usually produce menstrual changes; however, the changes do not appear to deviate from normal patterns as much as the changes from DMPA. Understanding these differences and other method attributes might help women make an informed choice about which contraceptive to use.

Effects of a single Silastic® contraceptive implant containing nomegestrol acetate (Uniplant) on endometrial morphology and ovarian function for 1 year

PURPOSE

This study was undertaken to evaluate the effects of a subdermal implant containing nomegestrol acetate (Uniplant) on endometrial histology and ovarian function.

METHODS

Twenty healthy female volunteers of reproductive age were included and completed a menstrual diary throughout the study. Hysteroscopy, transvaginal sonography and blood sampling were performed prior to implant insertion (control cycle) and following 6 and 12 months of Uniplant use. Transvaginal sonography was performed every other day from Day 8 of the cycle up to the obtainment of sonographic evidence of a 12-mm follicle, then every day until the obtainment of sonographic evidence of follicular rupture and thereafter every other day until the next menstrual bleeding. Blood samples were taken for the measurement of estradiol, follicle-stimulating hormone, luteinizing hormone and progesterone on the same days on which transvaginal sonography was performed. The implants were removed after 1 year.

RESULTS

Twenty percent of cycles were ovulatory, and 80% were anovulatory. The development of persistent nonluteinized follicle occurred in 40% of all cycles studied, inadequate luteal phase occurred in 20% of cycles and no follicular development occurred in 40%. Endometrial thickness remained below 8 mm in all cycles studied. Alterations in endometrial vascularization were observed in all treated cycles.

CONCLUSION

Our results suggest that this long-acting contraceptive method affects follicular growth and endometrial vascularization, disrupts endometrial architecture and leads to inadequate luteal phase.

Two-year performance of a Nestorone®-releasing contraceptive implant: a three-center study of 300 women

A 2-year trial of a single Nestorone (NES) rod implant was conducted at three Latin American centers, each enrolling 100 women. We studied the safety, effectiveness and acceptability of this progestin-releasing contraceptive implant. Three pregnancies occurred, the last at 18 months of use. Because no pregnancies were expected in the first 18 months, the trial was halted. At that time, 224 women had completed at least 18 months of use, and 99 women had used the implant for more than 24 months. Few participants used adjunctive contraception between the time the study was halted and the time they had their implant removed. No additional pregnancies occurred before the removal of the last implant. The 2-year cumulative pregnancy rate was 1.7 per 100 with a Pearl index of 0.6 per 100 for the 2-year period. The 1-year and 2-year continuation rates were 80.5 and 66.7 per 100, respectively. Menstrual and medical disturbances were the principal reasons for discontinuation, followed by planned pregnancy. Headache and weight gain frequently led to discontinuation. The NES implant had little important effect on most clinical chemistry and lipid parameters. Over the study course, the mean change in hemoglobin was <1%. Slight modification of the design of this single 2-year implant, restoring features previously examined in clinical trials, is likely to improve its effectiveness. A single NES implant appears to provide acceptable contraception for women.

Risks and benefits, advantages and disadvantages of levonorgestrel-releasing contraceptive implants

Levonorgestrel-releasing implants are long acting contraceptives, approved for 5 years of continuous use. Two marketed systems, the six capsule Norplant use of tradenames is for product identification purposes only and does not imply endorsement. and the two rod Jadelle, have essentially equal rates of drug release, pregnancy and adverse events over 5 years of use. Randomised clinical trials and controlled cohort observations indicate that for the first 3 years, when pregnancy rates are at or almost zero, no other contraceptive system is more effective, although etonogestrel implants provide equal effectiveness. Annual pregnancy rates rise in the fifth year of continuous use but remain below 1 per 100 women. Annual pregnancy rates of Norplant users remain below 1 per 100 throughout 7 years of continuous use. Levonorgestrel implants provide low progestogen doses; 40-50 microg/day at 1 year of use, decreasing to 25-30 microg/day in the fifth year. Serum levels of levonorgestrel at 5 years are 60-65% of those levels measured at 1 month of use. Adverse effects with levonorgestrel implants are similar to those observed with progestogen only and combined oral contraceptives. Risks of ectopic pregnancy, other pregnancy complications and pelvic inflammatory disease are reduced in comparison with those of women using copper or non-medicated intrauterine devices. Risks of developing gallbladder disease and hypertension or borderline hypertension, although small, are about 1.5 and 1.8 times greater, respectively, in women using levonorgestrel implants than in women not using hormonal contraception. Other serious diseases have not been found to occur significantly more frequently in levonorgestrel implant users than in women not using hormonal contraception. The great majority of levonorgestrel implant users experience menstrual problems, but serious bleeding problems are not more frequent than in controls. Other health problems reported more frequently by levonogestrel implant users than by women not using hormonal contraception in a study of 16000 women included skin conditions, headache, upper limb neuropathies, dizziness, nervousness, malaise, minor visual disturbances, respiratory conditions, arthropathies, weight change, anxiety and non-clinical depression. Clinical depression is not more frequent in women using implants compared with those not using hormonal contraception (i.e. using intrauterine devices, sterilisation). Removal problems occur less frequently with Jadelle than with Norplant. The mean removal time for Jadelle is half that of Norplant. Levonorgestrel implants in nationally representative scientific samples, in randomised trials, and in controlled cohort studies have continuation rates as high as or higher than any other reversible contraceptive over a duration of 5 years. This would imply that the satisfaction women derive from the contraceptive effectiveness of levonorgestrel implants greatly outweighs the dissatisfaction that may accompany menstrual disturbances and other adverse effects associated with implants.

Newer progestogens

OBJECTIVE

To review the literature on the most recent progestogens to be developed, to provide clinical comparisons with older progestogens and to look at the potential of products not yet marketed.

DATA SOURCES

Searches of Medline and Popline together with requests for bibliographies from the Population Council, Wyeth-Ayerst Research and Schering Health Care.

STUDY SELECTION

Information from technical papers was used to ascertain the metabolic characteristics and receptor binding affinities of the compounds. Previous reviews were scrutinised in order to make comparisons with older compounds. Any available trials were examined to ascertain efficacy, bleeding patterns and tolerability, more weight being given to comparative trials.

DISCUSSION

Five progestogens have been developed in the last decade. They are all devoid of androgenic activity; some have antiandrogenic activity. Combined oral contraceptive (COC) pills containing dienogest and drospirenone are already marketed. Nomegestrol and nestorone have been extensively studied as subdermal implants.

CONCLUSIONS

Newer progestogens used in combination with oestrogen behave very similarly to existing products. Progestogen-only products using new progestogens have potential for significantly better tolerability due to their lack of androgenic activity.

Future trends in contraceptive prevalence and method mix in the developing world

This study reviews existing methodologies for projecting future trends in contraception, evaluates the validity of the assumptions underlying these projections, proposes methodological improvements, and assesses the prospects for new methods of contraception in the coming decade. Demand for contraception can be expected to continue to rise rapidly for the next few decades as populations continue to grow and fertility declines to approach replacement level. As a result of these trends, the number of contraceptive users in the developing world is expected to rise from 549 to 816 million during the next 25 years, according to the most recent UN projection. An examination of the projection methodology found it to be reasonable. Projecting the future distribution of specific contraceptive methods is more difficult. Method choice is affected by trends in several factors, including access to different methods, user characteristics, and technology. The procedure employed by the Futures Group to project method mix was found to be less than optimally designed, and a new methodology is, therefore, proposed.

Vaginal bleeding disturbances and implantable contraceptives

Implantable contraceptives allow safe and effective fertility regulation for up to 5 years. Currently available devices release low doses of progestogens. Disruption of vaginal bleeding patterns is almost inevitable, particularly during the initial months of use. Irregular and prolonged bleeding as well as amenorrhea are common. Irregular bleeding is unpopular with most women and unacceptable to some. This review describes the vaginal bleeding disturbances induced by modern implantable contraceptives and discusses the implications of these in terms of method use and discontinuations. The cause of the irregular bleeding is not fully understood, but recent evidence suggests that an increase in endometrial vascular fragility might precipitate vessel breakdown and, hence, breakthrough bleeding. This review discusses this evidence and outline the possible mechanisms underlying breakthrough bleeding associated with implantable contraceptives. In addition, therapies for bleeding disturbances are described and their efficacy reviewed.