Comparative pharmacokinetics of two new steroidal estrogens and ethinylestradiol in postmenopausal women

Risk-Benefit Assessment of Ethinylestradiol Using a Physiologically Based Pharmacokinetic Modeling Approach

Current formulations of combined oral contraceptives (COC) containing ethinylestradiol (EE) have ≤35 μg due to increased risks of cardiovascular diseases (CVD) with higher doses of EE. Low‐dose formulations however, have resulted in increased incidences of breakthrough bleeding and contraceptive failure, particularly when coadministered with inducers of cytochrome P450 enzymes (CYP). The developed physiologically based pharmacokinetic model quantitatively predicted the effect of CYP3A4 inhibition and induction on the pharmacokinetics of EE. The predicted C_max and AUC ratios when coadministered with voriconazole, fluconazole, rifampicin, and carbamazepine were within 1.25 of the observed data. Based on published clinical data, an AUC_ss value of 1,000 pg/ml.h was selected as the threshold for breakthrough bleeding. Prospective application of the model in simulations of different doses of EE (20 μg, 35 μg, and 50 μg) identified percentages of the population at risk of breakthrough bleeding alone and with varying degrees of CYP modulation.

Ursodeoxycholic acid does not affect ethinylestradiol bioavailability in women taking oral contraceptives

OBJECTIVE

Contraception is recommended for female patients during ursodeoxycholic acid (UDCA) treatment for the potential teratogenic effect of this bile acid, and the aim of our study was to determine whether this treatment affects the bioavailability of ethinylestradiol (EE2).

METHODS

In this double-blind, randomised study, we measured EE2 pharmacokinetics in eight healthy volunteers randomly allocated to receive oral contraceptive (30 microg EE2 and 75 microg gestodene) plus either UDCA (8-10 mg/kg per day) or placebo for 21 days during the first of three consecutive menstrual cycles. After a washout period during the second cycle, the subjects received the alternative treatment during the third menstrual cycle. Serum EE2 and UDCA were measured using radioimmunoassay and gas chromatography-mass spectrometry, respectively.

RESULTS

The profile for serum EE2 concentration was similar during UDCA (mean maximum serum concentration 177 pg/ml, SEM 59) and during placebo treatment (153 pg/ml, SEM 62), and mean area under the curve (AUC) was 1374 pg/h per ml (SEM 580) and 1320 pg/h per ml (SEM 551) during the two regimens, respectively. The point estimates and 90% confidence intervals of UDCA/placebo ratios for EE2 AUC and for maximum serum concentration were 1.1 (0.8-1.5) and 1.2 (1.0-1.4), respectively. Mean serum triglycerides concentration increased from 58.3 mg/dl (SEM 6.8) at enrolment to 91.4 mg/dl (SEM 10.7) during placebo (P < 0.01) and to 88.6 mg/dl (SEM 13.7) during UDCA treatment (P < 0.05). During UDCA treatment, serum enrichment with this bile acid and with the metabolite iso-UDCA was 29% (16%) and 3% (2%), respectively.

CONCLUSION

Co-administration with UDCA does not affect the bioavailability of EE2 in healthy volunteers, indicating that contraceptive efficacy is not affected.

Conception and pharmacodynamic profile of drospirenone

Progesterone is more than a progestin. Beyond functions in cycle and pregnancy, progesterone binds with high affinity to the mineralocorticoid receptor (MR) acting as an antagonist, with obvious significance for electrolyte homeostasis, an array of MR-related functions in the circulation as well as in the CNS. Progesterone induces natriuresis at physiological concentrations. Lack of antimineralocorticoid activity with conventional progestins may account for sodium and water retention, minor elevation of blood pressure and "pill hypertension" in susceptible women on oral contraceptives. Ethinylestradiol (EE) contributes to this problem by distinct activation of the renin-angiotensin-aldosterone (RAAS) system. Drospirenone (DRSP: 6beta,7beta,15beta,16beta-dimethylene-3-oxo 17alpha-pregn-4-ene-21,17 carbolactone) is the first synthetic progestin with antialdosterone activity. DRSP and progesterone bind to PR in uterine (affinity of both is about 30% of R5020) and MR in kidney cytosol (affinity about 230 and 100% of aldosterone, respectively). Intrauterine administration of DRSP in silastic tubes induced maximum local progestational effects in rabbits. At systemic subcutaneous (s.c.) administration (McPhail-assay) full endometrial transformation was obtained at 1mg per animal per day. At 1-3mg DRSP per animal per day subcutaneously, pregnancy maintenance after ovariectomy, antiovulatory activity, and antimineralocorticoid activity were seen in the respective assays in rats. The latter activity indicates about eight-fold higher potency than spironolactone. DRSP decreased blood pressure in male hypertensive rats, whereas an increase was noted under conventional progestins. DRSP also prevented hypertension and fetal growth retardation in pregnant rats after L-NAME, an inhibitor of nitric oxide synthase. DRSP has antiandrogenic activity. Feminizing effects were recorded during sexual differentiation in male fetuses at high doses. Powerful antiandrogenic effects were also seen in gonad intact and testosterone substituted castrated male rats. The antiandrogenic potency of DRSP is superior to that of spironolactone but below that of cyproterone acetate. Endometrial transformation, inhibition of ovulation, and antimineralocorticoid, i.e. natriuretic effects and mild antiandrogenic effects were recorded at the same range of oral doses (0.5-4 mg per day) in humans. Combined with EE (3 mg DRSP+30 microg EE), DRSP provides effective inhibition of ovulation and cycle control. Body weight compared to conventional oral contraceptives was reduced. DRSP (3 mg per day+15, 20, or 30 microg ethinyl estradiol per day) prevented the mild increase of blood pressure seen under a conventional levonorgestrel-containing contraceptive and even tended to reduce pretreatment blood pressure. Studies on modulation (i.e. inhibition) of glucocorticoid effects at the MR in the CNS remain an unexplored and interesting area for research.

Prediction of the bioaccumulation factors and body burden of natural and synthetic estrogens in aquatic organisms in the river systems

This study undertakes an initial prediction of the bioaccumulation factors and body burden of the steroid estrogens, estrone, estradiol, estriol and ethinylestradiol in a range of aquatic organisms (plankton, benthic and free-living invertebrates and fish) in river systems using a food-web model. These data are compared to that derived from less complex predictions based on octanol-water partition coefficient and molecular connectivity index. The model predicted that bioaccumulation of steroid estrogens occurred in all organisms, however, the values were small, and the maximum and minimum bioaccumulation factors in this study were found in the fish at the lowest trophic level with ethinylestradiol (332) and the fish at the highest trophic level with estriol (1.8), respectively. Moreover, the bioaccumulation factors were sensitive to the metabolic rates of the estrogens in the free living organisms, while the concentration of estrogens in sediment was a significant factor in determining these values in benthic invertebrates. Biomagnification contributed little to the overall bioaccumulation, but the importance increased in fish exposed to ethinylestradiol. The predicted bioaccumulation factors from the food web model were generally smaller than the calculated bioconcentration factors from the simpler octanol-water partition coefficient/molecular connectivity index based estimates. Compared to literature measured data, the predicted values for fish were approximately 1000 times less than the values observed in laboratory tests, while for invertebrates, the modeled values were less than two orders of magnitude below laboratory results. However, the model predicted a similar bioconcentration factor for plankton in relation to experimental data for Chlorella vulgaris for estrone and estriol.

The effects of natural and synthetic steroid estrogens in relation to their environmental occurrence

Laboratory-based acute toxicity data and physiological studies relating to natural and synthetic steroid estrogens in a range of animals and plants are reviewed. Steroid estrogens may induce adverse effects in animals that do or do not express the estrogen receptor, and in plants, and they may mimic other hormones or induce nonestrogenic effects. Although the findings of such studies should be treated with caution when extrapolated to possible environmental effects, the available data indicate that a wide range of effects may be manifested in a diversity of species. The environmental occurrence of the compounds and possible environmental exposure routes are also reviewed and discussed in relation to the laboratory-based acute toxicity data. While there are likely to be difficulties in relating some of the observed laboratory data to possible environmental effects, studies undertaken on fish are directly relevant because exposure pathways and concentrations were related to those occurring in the environment. Effects that may occur in the environment are discussed in relation to their significance to the individual and at the species level.