1
|
Sitruk-Ware R, Sussman H, Brinton R, Schumacher M, Singer P, Kumar N, De Nicola AF, El-Etr M, Guennoun R, V Borlongan C. Nestorone (segesterone acetate) effects on neuroregeneration. Front Neuroendocrinol 2024; 73:101136. [PMID: 38670433 DOI: 10.1016/j.yfrne.2024.101136] [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: 02/23/2024] [Revised: 04/08/2024] [Accepted: 04/22/2024] [Indexed: 04/28/2024]
Abstract
Nestorone® (segesterone acetate) is a progestin with a chemical structure closely related to progesterone with high affinity and selectivity for the progesterone receptor without significant interaction with other steroid receptors. It has been developed for female and male contraception and is FDA-approved in a first long-acting contraceptive vaginal system for female contraception. Its safety has been extensively demonstrated in both preclinical and clinical studies for contraceptive indications. Nestorone was found to display neuroprotective and neuroregenerative activity in animal models of various central nervous system diseases, including multiple sclerosis, stroke, and amyotrophic lateral sclerosis. Reviewed herein are neuroprotective and myelin- regenerating properties of Nestorone in various animal models and its translational potential as a therapeutic agent for debilitating neurological diseases for which limited therapeutic options are available (Table 1).
Collapse
Affiliation(s)
| | | | - Roberta Brinton
- Center for Innovation in Brain Science, Tucson, AZ, United States
| | | | | | | | | | - Martine El-Etr
- U1195 Inserm and University Paris-Saclay Le Kremlin Bicêtre, France
| | - Rachida Guennoun
- U1195 Inserm and University Paris-Saclay Le Kremlin Bicêtre, France
| | - Cesar V Borlongan
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| |
Collapse
|
2
|
Özcan Ö, den Elzen WPJ, Hillebrand JJ, den Heijer M, van Loendersloot LL, Fischer J, Hamer H, de Jonge R, Heijboer AC. The effect of hormonal contraceptive therapy on clinical laboratory parameters: a literature review. Clin Chem Lab Med 2024; 62:18-40. [PMID: 37419659 DOI: 10.1515/cclm-2023-0384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 06/14/2023] [Indexed: 07/09/2023]
Abstract
Hormonal contraceptives (HC) are widely used among women in reproductive ages. In this review, the effects of HCs on 91 routine chemistry tests, metabolic tests, and tests for liver function, hemostatic system, renal function, hormones, vitamins and minerals were evaluated. Test parameters were differently affected by the dosage, duration, composition of HCs and route of administration. Most studies concerned the effects of combined oral contraceptives (COC) on the metabolic, hemostatic and (sex) steroids test results. Although the majority of the effects were minor, a major increase was seen in angiotensinogen levels (90-375 %) and the concentrations of the binding proteins (SHBG [∼200 %], CBG [∼100 %], TBG [∼90 %], VDBP [∼30 %], and IGFBPs [∼40 %]). Also, there were significant changes in levels of their bound molecules (testosterone, T3, T4, cortisol, vitamin D, IGF1 and GH). Data about the effects of all kinds of HCs on all test results are limited and sometimes inconclusive due to the large variety in HC, administration routes and dosages. Still, it can be concluded that HC use in women mainly stimulates the liver production of binding proteins. All biochemical test results of women using HC should be assessed carefully and unexpected test results should be further evaluated for both methodological and pre-analytical reasons. As HCs change over time, future studies are needed to learn more about the effects of other types, routes and combinations of HCs on clinical chemistry tests.
Collapse
Affiliation(s)
- Ömer Özcan
- Department of Laboratory Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, The Netherlands
| | - Wendy P J den Elzen
- Department of Laboratory Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Jacquelien J Hillebrand
- Department of Laboratory Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, The Netherlands
| | - Martin den Heijer
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, The Netherlands
- Department of Endocrinology and Metabolism, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Laura L van Loendersloot
- Department of Reproductive Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Johan Fischer
- Department of Laboratory Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Henrike Hamer
- Department of Laboratory Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Robert de Jonge
- Department of Laboratory Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Department of Laboratory Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Annemieke C Heijboer
- Department of Laboratory Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, The Netherlands
- Department of Laboratory Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
| |
Collapse
|
3
|
Gonzalez Deniselle MC, Bettini M, Garrido RM, Meyer M, Lara A, Garay LI, Casas S, Fulgenzi E, Nuñez M, Rugiero MF, De Nicola AF, Gargiulo-Monachelli G. Exposure to endogenous and exogenous sex hormones and reproductive history influence prognosis in women with ALS. Muscle Nerve 2023; 68:414-421. [PMID: 37493444 DOI: 10.1002/mus.27942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 07/03/2023] [Accepted: 07/08/2023] [Indexed: 07/27/2023]
Abstract
INTRODUCTION/AIMS Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease with a higher incidence in men suggesting an influence of sex steroids. Our objective was to investigate past exposure to endogenous and synthetic steroids in female ALS patients and controls. METHODS We administered a questionnaire to 158 postmenopausal women (75 ALS patients and 83 controls). We calculated reproductive time span (RTS), lifetime endogenous estrogen (LEE) and progesterone exposures (LPE), oral contraceptive pill (OCP) use, and reproductive history. RESULTS ALS patients showed shorter LEE and LPE, a lower proportion of breast cancer, and 11% showed no history of pregnancies vs. 4% of controls. Odds ratios (ORs) showed that <17 y of LEE and a delayed menarche (>13 y) constitute risk factors for ALS [OR = 2.1 (95% confidence interval {CI}, 1.08-4.2); and OR = 2.4 (95% CI, 1.1-5.1) respectively]. According to Cox survival analysis, for each year the LEE increased over 17 y, it was independently associated with longer survival [hazard ratio (HR) = 0.37 (95% CI, 0.16-0.85)] after adjusting for smoking, age and site of onset. Multivariate regression analysis demonstrated that for each month using OCP for longer than 40 mo increased the risk of ALS [adjusted OR = 4.1 (95% CI, 1.2-13.8)]. DISCUSSION Thus, longer exposure to endogenous female sex steroids increased survival and reduced ALS susceptibility. In contrast, longer exposure to synthetic sex steroids showed a negative impact by reducing the production of endogenous female sex steroids or due to crossover with other steroid receptors. Given the neuroprotective effects of sex steroids, we suggest that abnormalities of neuroendocrine components may alter motor function in women with ALS.
Collapse
Affiliation(s)
- M Claudia Gonzalez Deniselle
- Laboratory of Neuroendocrine Biochemistry, Instituto de Biología y Medicina Experimental-CONICET, Buenos Aires, Buenos Aires, Argentina
- Department of Physiological Sciences, Faculty of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Mariela Bettini
- Department of Neurology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Rosa M Garrido
- Department of Gynecology, Hospital Marie Curie, Buenos Aires, Argentina
| | - Maria Meyer
- Laboratory of Neuroendocrine Biochemistry, Instituto de Biología y Medicina Experimental-CONICET, Buenos Aires, Buenos Aires, Argentina
| | - Agustina Lara
- Laboratory of Neuroendocrine Biochemistry, Instituto de Biología y Medicina Experimental-CONICET, Buenos Aires, Buenos Aires, Argentina
| | - Laura I Garay
- Laboratory of Neuroendocrine Biochemistry, Instituto de Biología y Medicina Experimental-CONICET, Buenos Aires, Buenos Aires, Argentina
- Department of Human Biochemistry, Faculty of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Sebastian Casas
- Laboratory of Neuroendocrine Biochemistry, Instituto de Biología y Medicina Experimental-CONICET, Buenos Aires, Buenos Aires, Argentina
- Department of Neurology, Hospital Militar Central Cirujano Mayor Dr. Cosme Argerich, Buenos Aires, Argentina
| | - Ernesto Fulgenzi
- Hospital General de Agudos Dr. Ignacio Pirovano, Buenos Aires, Argentina
| | - Myriam Nuñez
- Department of Physics Mathematics, Faculty of Pharmacy and Biochemistry, University of Buenos Aires, Buenos Aires, Argentina
| | - Marcelo F Rugiero
- Department of Gynecology, Hospital Marie Curie, Buenos Aires, Argentina
| | - Alejandro F De Nicola
- Laboratory of Neuroendocrine Biochemistry, Instituto de Biología y Medicina Experimental-CONICET, Buenos Aires, Buenos Aires, Argentina
- Department of Neurology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Gisella Gargiulo-Monachelli
- Laboratory of Neuroendocrine Biochemistry, Instituto de Biología y Medicina Experimental-CONICET, Buenos Aires, Buenos Aires, Argentina
- Department of Neurology, Hospital General de Agudos Juan A. Fernández, Buenos Aires, Argentina
- Department of Neurology, Centro de Educación Médica e Investigaciones Clínicas "Norberto Quirno", CEMIC, Buenos Aires, Argentina
| |
Collapse
|
4
|
Renke G, Callizo C, Paes R, Antunes M, Michels G, Concha L, Almeida O, Valente C, Baesso T, Giovannoni B. Clinical Approaches to Nestorone Subdermal Implant Therapy in Women's Health. Biomedicines 2023; 11:2586. [PMID: 37761027 PMCID: PMC10526950 DOI: 10.3390/biomedicines11092586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 09/11/2023] [Accepted: 09/19/2023] [Indexed: 09/29/2023] Open
Abstract
Segesterone acetate (SA) or Nestorone, a fourth-generation progestogen, is a synthetic compound with high progestational activity and no androgenic, glucocorticoid, or anabolic effects. However, due to its oral inactivity, SA must be used by other routes, such as subcutaneous. Thus, considering its peculiar properties, the SA subdermal implant is successfully used in female contraception and postmenopausal hormone replacement therapy (HRT). In recent years, its potential uses in endometriosis, polycystic ovaries syndrome (PCOS), and a new therapeutic possibility for neuroprotection have made this treatment extremely interesting. However, the absence of a standardized dose and the long-term safety of SA implant therapy in women is still controversial. Here, we present the possible indications, doses, limitations, and side effects of SA implant therapy.
Collapse
Affiliation(s)
- Guilherme Renke
- Nutrindo Ideais Performance and Nutrition Research Center, Rio de Janeiro 22411-040, Brazil (G.M.)
- Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro 21941-913, Brazil
| | - Consuelo Callizo
- Centro de Pesquisa e Assistência em Reprodução Humana, Salvador 40210-341, Brazil
| | - Raphaela Paes
- Nutrindo Ideais Performance and Nutrition Research Center, Rio de Janeiro 22411-040, Brazil (G.M.)
| | - Mariana Antunes
- Nutrindo Ideais Performance and Nutrition Research Center, Rio de Janeiro 22411-040, Brazil (G.M.)
| | - Glaycon Michels
- Nutrindo Ideais Performance and Nutrition Research Center, Rio de Janeiro 22411-040, Brazil (G.M.)
| | - Luana Concha
- Nutrindo Ideais Performance and Nutrition Research Center, Rio de Janeiro 22411-040, Brazil (G.M.)
| | - Ordânio Almeida
- Nutrindo Ideais Performance and Nutrition Research Center, Rio de Janeiro 22411-040, Brazil (G.M.)
| | - Christiane Valente
- Nutrindo Ideais Performance and Nutrition Research Center, Rio de Janeiro 22411-040, Brazil (G.M.)
| | - Thomaz Baesso
- Nutrindo Ideais Performance and Nutrition Research Center, Rio de Janeiro 22411-040, Brazil (G.M.)
| | - Bruna Giovannoni
- Nutrindo Ideais Performance and Nutrition Research Center, Rio de Janeiro 22411-040, Brazil (G.M.)
| |
Collapse
|
5
|
Bernaud VE, Koebele SV, Northup-Smith SN, Willeman MN, Barker C, Schatzki-Lumpkin A, Sanchez MV, Bimonte-Nelson HA. Evaluations of memory, anxiety, and the growth factor IGF-1R after post-surgical menopause treatment with a highly selective progestin. Behav Brain Res 2023; 448:114442. [PMID: 37085118 PMCID: PMC11105077 DOI: 10.1016/j.bbr.2023.114442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 04/16/2023] [Accepted: 04/18/2023] [Indexed: 04/23/2023]
Abstract
Progestogens are a key component of menopausal hormone therapies. While some progestogens can be detrimental to cognition, there is preclinical evidence that progestogens with a strong progesterone-receptor affinity benefit some molecular mechanisms believed to underlie cognitive function. Thus, a progestin that maximizes progesterone-receptor affinity and minimizes affinities to other receptors may be cognitively beneficial. We evaluated segesterone-acetate (SGA), a 19-norprogesterone derivative with a strong progesterone-receptor affinity and no androgenic or estrogenic-receptor activity, hypothesizing that it would enhance cognition. Middle-aged rats underwent Sham or Ovariectomy (Ovx) surgery followed by administration of medroxyprogesterone-acetate (MPA; used as a positive control as we have previously shown MPA-induced cognitive deficits), SGA (low or high dose), or vehicle (one Sham and one Ovx group). Spatial working and reference memory, delayed retention, and anxiety-like behavior were assessed, as were memory- and hormone- related protein assays within the frontal cortex, dorsal hippocampus, and entorhinal cortex. Low-dose SGA impaired spatial working memory, while high-dose SGA had a more extensive detrimental impact, negatively affecting spatial reference memory and delayed retention. Replicating previous findings, MPA impaired spatial reference memory and delayed retention. SGA, but not MPA, alleviated Ovx-induced anxiety-like behaviors. On two working memory measures, IGF-1R expression correlated with better working memory only in rats without hormone manipulation; any hormone manipulation or combination of hormone manipulations used herein altered this relationship. These findings suggest that SGA impairs spatial cognition after surgical menopause, and that surgical menopause with or without progestin administration disrupts relationships between a growth factor critical to neuroplasticity.
Collapse
Affiliation(s)
- Victoria E Bernaud
- Department of Psychology, Arizona State University, 950 S. McAllister Ave., Tempe, AZ 85287, USA; Arizona Alzheimer's Consortium, 4745 N 7th St, Phoenix, AZ 85014, USA
| | - Stephanie V Koebele
- Department of Psychology, Arizona State University, 950 S. McAllister Ave., Tempe, AZ 85287, USA; Arizona Alzheimer's Consortium, 4745 N 7th St, Phoenix, AZ 85014, USA
| | - Steven N Northup-Smith
- Department of Psychology, Arizona State University, 950 S. McAllister Ave., Tempe, AZ 85287, USA; Arizona Alzheimer's Consortium, 4745 N 7th St, Phoenix, AZ 85014, USA
| | - Mari N Willeman
- Department of Psychology, Arizona State University, 950 S. McAllister Ave., Tempe, AZ 85287, USA; Arizona Alzheimer's Consortium, 4745 N 7th St, Phoenix, AZ 85014, USA; TGen Institute, 445 N 5th St, Phoenix, AZ 85004, USA
| | - Charlotte Barker
- Department of Psychology, Arizona State University, 950 S. McAllister Ave., Tempe, AZ 85287, USA; Arizona Alzheimer's Consortium, 4745 N 7th St, Phoenix, AZ 85014, USA
| | - Alex Schatzki-Lumpkin
- Department of Psychology, Arizona State University, 950 S. McAllister Ave., Tempe, AZ 85287, USA; Arizona Alzheimer's Consortium, 4745 N 7th St, Phoenix, AZ 85014, USA
| | - Maria Valenzuela Sanchez
- Department of Psychology, Arizona State University, 950 S. McAllister Ave., Tempe, AZ 85287, USA; Arizona Alzheimer's Consortium, 4745 N 7th St, Phoenix, AZ 85014, USA
| | - Heather A Bimonte-Nelson
- Department of Psychology, Arizona State University, 950 S. McAllister Ave., Tempe, AZ 85287, USA; Arizona Alzheimer's Consortium, 4745 N 7th St, Phoenix, AZ 85014, USA.
| |
Collapse
|
6
|
Lee JY, Castelli V, Kumar N, Sitruk-Ware R, Borlongan CV. Contraceptive drug, Nestorone, enhances stem cell-mediated remodeling of the stroke brain by dampening inflammation and rescuing mitochondria. Free Radic Biol Med 2022; 183:138-145. [PMID: 35341914 DOI: 10.1016/j.freeradbiomed.2022.03.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 03/22/2022] [Indexed: 11/22/2022]
Abstract
Ischemic stroke remains a significant unmet need causing massive mortality and morbidity due to few treatment options with limited therapeutic window. The progestin Nestorone® (segesterone acetate) displays high affinity for the progesterone receptor in exerting its potent birth control and hormone replacement therapy. Accumulating evidence implicates a new utility of Nestorone in affording neuroprotection in a variety of central nervous system diseases, including stroke. However, the mechanism of action mediating Nestorone's neuroprotection in stroke remains unknown. Here, we showed that stand-alone treatments of Nestorone or human amniotic fluid-derived stem cells (hAFSc), but more pronounced with their combined treatment, led to significant improvements in behavioral function and reductions in infarction and peri-infarct cell loss in adult rats with ischemic stroke. We detected significantly lower levels of pro-inflammatory signals (OX6 and IBA1) coupled with enhanced levels of stem cell proliferation (Ki67) and differentiation (DCX and MAP2) in both brain and spleen of stroke rats that received stand-alone or combined treatments of Nestorone and hAFSc. In concert, the in vitro oxygen-glucose deprivation stroke model revealed that neural stem cells treated with Nestorone exhibited increased stem cell proliferation and differentiation that was accompanied by rescue of the mitochondrial respiratory activity characterized by reduced mitochondrial reactive oxygen species, increased ATP, elevated mitochondrial deacetylase Sirtuin 3 (SIRT3), and a normalized ratio of acetyl-superoxide dismutase 2 (Ac-SOD2)/SOD2, suggesting the key role of mitochondrial metabolism and oxidative protection in Nestorone's therapeutic effects in stroke.
Collapse
Affiliation(s)
- Jea-Young Lee
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, 12901 Bruce B. Downs Blvd, Tampa, FL, 33612, USA
| | - Vanessa Castelli
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, 12901 Bruce B. Downs Blvd, Tampa, FL, 33612, USA
| | - Narender Kumar
- Population Council, Center for Biomedical Research, 1230 York Avenue, New York, NY, 10065, USA
| | - Regine Sitruk-Ware
- Population Council, Center for Biomedical Research, 1230 York Avenue, New York, NY, 10065, USA
| | - Cesario V Borlongan
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, 12901 Bruce B. Downs Blvd, Tampa, FL, 33612, USA.
| |
Collapse
|
7
|
Baker CC, Chen MJ. New Contraception Update — Annovera, Phexxi, Slynd, and Twirla. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2022; 11:21-27. [PMID: 35795653 PMCID: PMC9255890 DOI: 10.1007/s13669-021-00321-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Abstract
Purpose of Review
In this review, we discuss the efficacy, safety, and benefits of four new contraceptive products available in the USA, specifically Annovera, Phexxi, Slynd, and Twirla.
Recent Findings
Annovera is a vaginal ring releasing ethinyl estradiol and segesterone acetate that can be used for up to one year (13 cycles), offering patients an effective, user-controlled option that may improve contraceptive access for those in low-resource settings or those with barriers to retrieving monthly prescriptions; however, given limited efficacy and safety data in people with body mass index (BMI) > 29 kg/m2, clinicians may consider whether Annovera is an appropriate contraceptive method for obese patients if there are other acceptable alternatives. Phexxi prescription-only vaginal gel is a user-controlled, non-hormonal, on-demand contraceptive method that represents a novel addition to the market with its additional uses as a personal lubricant and as a potential microbicide for urogenital infection prevention. Slynd, a drospirenone-only pill, provides more flexibility for delayed or missed pills while maintaining efficacy and a more favorable bleeding profile compared with previously available progestin-only pills. Lastly, Twirla is a transdermal patch releasing ethinyl estradiol and levonorgestrel that offers users an additional option for a user-controlled, combined hormonal contraceptive method without daily dosing; however, prescription is limited to patients with BMI < 30 kg/m2 due to decreased efficacy and VTE events in people with obesity.
Summary
The addition of these products expands the available options for pregnancy prevention to address unmet contraceptive needs.
Collapse
Affiliation(s)
- Courtney C. Baker
- Department of Obstetrics and Gynecology, University of California, Davis, 4860 Y Street, Suite 2500, Sacramento, CA 95817, USA
| | - Melissa J. Chen
- Department of Obstetrics and Gynecology, University of California, Davis, 4860 Y Street, Suite 2500, Sacramento, CA 95817, USA
| |
Collapse
|
8
|
Altuntaş E, Tekko IA, Vora LK, Kumar N, Brodsky R, Chevallier O, McAlister E, Kurnia Anjani Q, McCarthy HO, Donnelly RF. Nestorone nanosuspension-loaded dissolving microneedles array patch: A promising novel approach for "on-demand" hormonal female-controlled peritcoital contraception. Int J Pharm 2021; 614:121422. [PMID: 34958899 DOI: 10.1016/j.ijpharm.2021.121422] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 12/17/2022]
Abstract
"On demand" hormonal female-controlled pericoital contraception is one strategy which could be used to minimize the impact of unintended pregnancy. Nestorone (NES) is a potent contraceptive, with relatively few side effects in comparison with other contraceptives. NES presents an attractive option for "on demand" pericoital contraceptive. Unfortunately, the drug is inactive if taken orally, but it has high progestational activity and antiovulatory potency if administered parenterally. Current drug delivery systems, such as a transdermal hydrogel are not so satisfactory. Dissolving microneedles array (DMNs) are an attractive alternative, minimally-invasive, delivery system. In this study, we report, for the first time, development of tip-loaded NES-nanosuspension (NES-NS)-loaded bilayer DMNs to deliver NES intradermally for subsequent release. NES-NS was prepared and optimised, freeze-dried and then used to fabricate DMNs using a blend of two biocompatible polymers, namely poly(vinyl alcohol) and poly(vinyl pyrrolidone). Both NES-NS and the NES-NS-loaded DMNs were fully characterised and the performance of the DMNs was evaluated in vivo using Sprague Dawley rats. Results showed that the finalised NES-NS had particle size and PDI values of 666.06 ± 1.86 nm and 0.183 ± 0.01, respectively. The NES-NS-DMNs had relatively high tips-localised drug loading (approximately 2.26 ± 1.98 mg/array) and exhibited satisfactory mechanical and insertion properties. In Sprague Dawley rats, DMNs delivered NES into the skin, with the drug then appearing in blood and rapidly reaching its maximum concentration (Cmax of 32.68 ± 14.06 ng/mL) within 1h post-DMNs application. Plasma levels above 3.4 ng/mL were maintained for 2 days. This suggests that DMNs are a promising drug delivery system that could be used to deliver NES as an "On demand" hormonal female-controlled pericoital contraceptive.
Collapse
Affiliation(s)
- Ebru Altuntaş
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK; Department of Pharmaceutical Technology, Faculty of Pharmacy, Istanbul University, 34416, Fatih, Istanbul, Turkey
| | - Ismaiel A Tekko
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK; Department of Pharmaceutics and Pharmaceutical Technology, Faculty of Pharmacy, Aleppo University, Aleppo, Syria
| | - Lalitkumar K Vora
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK
| | - Narender Kumar
- Center for Biomedical Research, The Population Council, New York, NY, USA
| | - Rebecca Brodsky
- Center for Biomedical Research, The Population Council, New York, NY, USA
| | - Olivier Chevallier
- Avignon Université, Campus Jean-Henri Fabre, 301 rue Baruch de Spinoza BP 21239, 84911 Avignon cedex 9, France; Institute for Global Food Security, School of Biological Science, Queen's University Belfast, 19 Chlorine Gardens, Belfast BT9 5DL, Northern Ireland, UK
| | - Emma McAlister
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK
| | - Qonita Kurnia Anjani
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK
| | - Helen O McCarthy
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK
| | - Ryan F Donnelly
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK.
| |
Collapse
|
9
|
Fréchou M, Zhu X, Kumar N, Sitruk-Ware R, Schumacher M, Mattern C, Guennoun R. Sex differences in the cerebroprotection by Nestorone intranasal delivery following stroke in mice. Neuropharmacology 2021; 198:108760. [PMID: 34437904 DOI: 10.1016/j.neuropharm.2021.108760] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 08/02/2021] [Accepted: 08/17/2021] [Indexed: 02/08/2023]
Abstract
Our previous studies showed that intranasal delivery of progesterone offers a good bioavailability and neuroprotective efficacy after experimental stroke. We have also demonstrated that progesterone receptors (PR) are essential for cerebroprotection by endogenous progesterone and by progesterone treatment. The identification of PR as a potential drug target for stroke therapy opens new therapeutic indications for selective synthetic progestins. Nestorone® (16-methylene-17α-acetoxy-19-nor-pregn-4-ene-3, 20-dione, also known as segesterone acetate) is a 19-norprogesterone derivative that more potently targets PR than progesterone. The objective of this study was to evaluate the cerebroprotective efficiency of intranasal administration of Nestorone after middle cerebral occlusion (MCAO) in mice. We show here that intranasal administration is a very efficient route to achieve a preferential delivery of Nestorone to the brain and confers a slow elimination and a sustained bioavailability. Furthermore, intranasal administration of Nestorone (at 0.08 mg/kg) improved the functional outcomes and decreased the ischemic lesion in male but not in female mice at 48 h post MCAO. Use of PRNesCre mice, selectively lacking expression of PR in neural cells, and their control PRloxP/loxP littermates showed that the cerebroprotective effects of Nestorone in male mice depended on neural PR as they were not observed in PRNesCre mice. Our findings show that intranasal delivery of Nestorone may be an efficient strategy to promote recovery after stroke in males and confirm the key role of PR in cerebroprotection. Furthermore, they point to sex differences in the response to Nestorone treatment and emphasize the necessity to include males and females in experimental studies.
Collapse
Affiliation(s)
- Magalie Fréchou
- U1195 Inserm and University Paris-Saclay, 80 Rue Du Général Leclerc, 94276, Kremlin-Bicêtre, France.
| | - Xiaoyan Zhu
- U1195 Inserm and University Paris-Saclay, 80 Rue Du Général Leclerc, 94276, Kremlin-Bicêtre, France.
| | - Narender Kumar
- Population Council, Rockefeller University, New York, USA.
| | | | - Michael Schumacher
- U1195 Inserm and University Paris-Saclay, 80 Rue Du Général Leclerc, 94276, Kremlin-Bicêtre, France.
| | - Claudia Mattern
- M et P Pharma AG, Schynweg 7, P.O.Box 11, 6376, Emmetten, Switzerland.
| | - Rachida Guennoun
- U1195 Inserm and University Paris-Saclay, 80 Rue Du Général Leclerc, 94276, Kremlin-Bicêtre, France.
| |
Collapse
|
10
|
Bick AJ, Louw-du Toit R, Skosana SB, Africander D, Hapgood JP. Pharmacokinetics, metabolism and serum concentrations of progestins used in contraception. Pharmacol Ther 2021; 222:107789. [PMID: 33316287 PMCID: PMC8122039 DOI: 10.1016/j.pharmthera.2020.107789] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 11/24/2020] [Indexed: 02/07/2023]
Abstract
Many different forms of hormonal contraception are used by millions of women worldwide. These contraceptives differ in the dose and type of synthetic progestogenic compound (progestin) used, as well as the route of administration and whether or not they contain estrogenic compounds. There is an increasing awareness that different forms of contraception and different progestins have different side-effect profiles, in particular their cardiovascular effects, effects on reproductive cancers and susceptibility to infectious diseases. There is a need to develop new methods to suit different needs and with minimal risks, especially in under-resourced areas. This requires a better understanding of the pharmacokinetics, metabolism, serum and tissue concentrations of progestins used in contraception as well as the biological activities of progestins and their metabolites via steroid receptors. Here we review the current knowledge on these topics and identify the research gaps. We show that there is a paucity of research on most of these topics for most progestins. We find that major impediments to clear conclusions on these topics include a lack of standardized methodologies, comparisons between non-parallel clinical studies and variability of data on serum concentrations between and within studies. The latter is most likely due, at least in part, to differences in intrinsic characteristics of participants. The review highlights the importance of insight on these topics in order to provide the best contraceptive options to women with minimal risks.
Collapse
Affiliation(s)
- Alexis J Bick
- Department of Molecular and Cell Biology, University of Cape Town, Private Bag X3, Rondebosch 7700, South Africa
| | - Renate Louw-du Toit
- Department of Biochemistry, Stellenbosch University, Stellenbosch 7602, South Africa
| | - Salndave B Skosana
- Department of Molecular and Cell Biology, University of Cape Town, Private Bag X3, Rondebosch 7700, South Africa
| | - Donita Africander
- Department of Biochemistry, Stellenbosch University, Stellenbosch 7602, South Africa
| | - Janet P Hapgood
- Department of Molecular and Cell Biology, University of Cape Town, Private Bag X3, Rondebosch 7700, South Africa; Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
| |
Collapse
|
11
|
Sitruk-Ware R, Bonsack B, Brinton R, Schumacher M, Kumar N, Lee JY, Castelli V, Corey S, Coats A, Sadanandan N, Gonzales-Portillo B, Heyck M, Shear A, Blaise C, Zhang H, Sheyner M, García-Sánchez J, Navarro L, El-Etr M, De Nicola AF, Borlongan CV. Progress in progestin-based therapies for neurological disorders. Neurosci Biobehav Rev 2020; 122:38-65. [PMID: 33359391 DOI: 10.1016/j.neubiorev.2020.12.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 11/26/2020] [Accepted: 12/12/2020] [Indexed: 12/16/2022]
Abstract
Hormone therapy, primarily progesterone and progestins, for central nervous system (CNS) disorders represents an emerging field of regenerative medicine. Following a failed clinical trial of progesterone for traumatic brain injury treatment, attention has shifted to the progestin Nestorone for its ability to potently and selectively transactivate progesterone receptors at relatively low doses, resulting in robust neurogenetic, remyelinating, and anti-inflammatory effects. That CNS disorders, including multiple sclerosis (MS), amyotrophic lateral sclerosis (ALS), spinal cord injury (SCI), and stroke, develop via demyelinating, cell death, and/or inflammatory pathological pathways advances Nestorone as an auspicious candidate for these disorders. Here, we assess the scientific and clinical progress over decades of research into progesterone, progestins, and Nestorone as neuroprotective agents in MS, ALS, SCI, and stroke. We also offer recommendations for optimizing timing, dosage, and route of the drug regimen, and identifying candidate patient populations, in advancing Nestorone to the clinic.
Collapse
Affiliation(s)
| | - Brooke Bonsack
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | | | | | | | - Jea-Young Lee
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Vanessa Castelli
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Sydney Corey
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Alexandreya Coats
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Nadia Sadanandan
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Bella Gonzales-Portillo
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Matt Heyck
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Alex Shear
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Cozene Blaise
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Henry Zhang
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Michael Sheyner
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Julián García-Sánchez
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Lisset Navarro
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | | | | | - Cesar V Borlongan
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
| |
Collapse
|
12
|
Chen MJ, Creinin MD, Turok DK, Archer DF, Barnhart KT, Westhoff CL, Thomas MA, Jensen JT, Variano B, Sitruk-Ware R, Shanker A, Long J, Blithe DL. Dose-finding study of a 90-day contraceptive vaginal ring releasing estradiol and segesterone acetate. Contraception 2020; 102:168-173. [PMID: 32416145 DOI: 10.1016/j.contraception.2020.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 04/22/2020] [Accepted: 05/06/2020] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To evaluate serum estradiol (E2) concentrations during use of 90-day contraceptive vaginal rings releasing E2 75, 100, or 200 mcg/day and segesterone acetate (SA) 200 mcg/day to identify a dose that avoids hypoestrogenism. STUDY DESIGN We conducted a multicenter dose-finding study in healthy, reproductive-aged women with regular cycles with sequential enrollment to increasing E2 dose groups. We evaluated serum E2 concentrations twice weekly for the primary outcome of median E2 concentrations throughout initial 30-day use (target ≥40 pg/mL). In an optional 2-cycle extension substudy, we randomized participants to 2- or 4-day ring-free intervals per 30-day cycle to evaluate bleeding and spotting based on daily diary information. RESULTS Sixty-five participants enrolled in E2 75 (n = 22), 100 (n = 21), and 200 (n = 22) mcg/day groups; 35 participated in the substudy. Median serum E2 concentrations in 75 and 100 mcg/day groups were <40 pg/mL. In the 200 mcg/day group, median E2 concentrations peaked on days 4-5 of CVR use at 194 pg/mL (range 114-312 pg/mL) and remained >40 pg/mL throughout 30 days; E2 concentrations were 37 pg/mL (range 28-62 pg/mL) on days 88-90 (n = 11). Among the E2 200 mcg/day substudy participants, all had withdrawal bleeding following ring removal. The 2-day ring-free interval group reported zero median unscheduled bleeding and two (range 0-16) and three (range 0-19) unscheduled spotting days in extension cycles 1 and 2, respectively. The 4-day ring-free interval group reported zero median unscheduled bleeding or spotting days. CONCLUSIONS Estradiol concentrations with rings releasing E2 200 mcg/day and SA 200 mcg/day avoid hypoestrogenism over 30-day use. IMPLICATIONS A 90-day contraceptive vaginal ring releasing estradiol 200 mcg/day and segesterone acetate 200 mcg/day achieves estradiol concentrations that should avoid hypoestrogenism and effectively suppresses ovulation.
Collapse
Affiliation(s)
- Melissa J Chen
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, United States.
| | - Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, United States
| | - David K Turok
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, United States
| | - David F Archer
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, United States
| | - Kurt T Barnhart
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Carolyn L Westhoff
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, United States
| | - Michael A Thomas
- Reproductive Medicine Research, Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Jeffrey T Jensen
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR, United States
| | - Bruce Variano
- Center for Biomedical Research, Population Council, New York, NY, United States
| | - Regine Sitruk-Ware
- Center for Biomedical Research, Population Council, New York, NY, United States
| | | | - Jill Long
- Contraceptive Development Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
| | - Diana L Blithe
- Contraceptive Development Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
| |
Collapse
|
13
|
Micks EA, Jensen JT. A technology evaluation of Annovera: a segesterone acetate and ethinyl estradiol vaginal ring used to prevent pregnancy for up to one year. Expert Opin Drug Deliv 2020; 17:743-752. [PMID: 32410464 DOI: 10.1080/17425247.2020.1764529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The segesterone acetate and ethinyl estradiol contraceptive vaginal ring (SA/EE CVR) was FDA-approved in August 2018 and is now available in the U.S. The CVR is placed vaginally for 21 days followed by a 7-day ring-free interval, when withdrawal bleeding typically occurs. One ring can be used for up to a year (13 cycles). AREAS COVERED This review summarizes this novel method of contraception, including the delivery system and the hormonal components. We describe the potential market, how it is used, the pharmacokinetic properties of the device, and results of clinical trials including efficacy, bleeding profile, acceptability, and safety. EXPERT OPINION The SA/EE CVR represents the first long-lasting user-controlled hormonal contraceptive device. The bleeding pattern is highly favorable and consistent over the entire year and is associated with very low discontinuation. Efficacy and safety are similar to other methods of combined hormonal contraceptives. Unscheduled ring removals increase the risk of failure. Further studies are needed to evaluate continuous use of the ring for greater than 21 days, and potential non-contraceptive benefits of the ring such as reduced menstrual bleeding.
Collapse
Affiliation(s)
- Elizabeth A Micks
- Department of Obstetrics and Gynecology, University of Washington , Seattle, WA, USA
| | - Jeffrey T Jensen
- Department of Obstetrics and Gynecology, Oregon Health & Science University , Portland, OR, USA
| |
Collapse
|
14
|
Nelson AL. Comprehensive overview of the recently FDA-approved contraceptive vaginal ring releasing segesterone acetate and ethinylestradiol: A new year-long, patient controlled, reversible birth control method. Expert Rev Clin Pharmacol 2019; 12:953-963. [DOI: 10.1080/17512433.2019.1669448] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Anita L. Nelson
- Obstetrics & Gynecology, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA, USA
- Obstetrics & Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Obstetrics & Gynecology, University Southern California, Los Angeles, CA, USA
- Research Division, Essential Access Health, Los Angeles, CA, USA
| |
Collapse
|
15
|
Tuazon JP, Sitruk-Ware R, Borlongan CV. Reprint of: Beyond contraception and hormone replacement therapy: Advancing Nestorone to a neuroprotective drug in the clinic. Brain Res 2019; 1719:285-287. [PMID: 31213288 DOI: 10.1016/j.brainres.2019.05.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Neurological diseases such as ischemic stroke can be debilitating and have limited treatments available. The progestin Nestorone® (segesterone acetate) has been evaluated for use in birth control and hormone replacement therapy due to its potency and high affinity for the progesterone receptor. Interestingly, Nestorone also exerts neuroprotection in animals afflicted with various central nervous system diseases, including stroke, which implicates its potential for treating these maladies in clinical settings. In fact, a recent Brain Research paper by Tanaka and colleagues demonstrates Nestorone's ability to reduce infarct sizes and preclude functional impairments in rats subjected to ischemic stroke. This commentary highlights Nestorone's properties as a progestin, its neuroprotective capabilities in animal studies, and how the Tanaka team's findings and previous clinical trials contribute to Nestorone's translation into a therapeutic agent for stroke and other neurological diseases.
Collapse
Affiliation(s)
- Julian P Tuazon
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, 12901 Bruce B. Downs Blvd, Tampa, FL 33612, USA
| | - Regine Sitruk-Ware
- Population Council, Center for Biomedical Research, 1230 York Avenue, New York, NY 10065, USA
| | - Cesario V Borlongan
- Center of Excellence for Aging and Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida College of Medicine, 12901 Bruce B. Downs Blvd, Tampa, FL 33612, USA.
| |
Collapse
|
16
|
Gemzell-Danielsson K, Sitruk-Ware R, Creinin MD, Thomas M, Barnhart KT, Creasy G, Sussman H, Alami M, Burke AE, Weisberg E, Fraser I, Miranda MJ, Gilliam M, Liu J, Carr BR, Plagianos M, Roberts K, Blithe D. Segesterone acetate/ethinyl estradiol 12-month contraceptive vaginal system safety evaluation. Contraception 2019; 99:323-328. [PMID: 30831102 DOI: 10.1016/j.contraception.2019.02.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 02/20/2019] [Accepted: 02/20/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To evaluate safety outcomes from clinical studies of a 12-month contraceptive vaginal system (CVS) releasing an average of segesterone acetate (SA) 150 mcg and ethinyl estradiol (EE) 13 mcg daily. STUDY DESIGN We integrated clinical safety data from nine studies in which women used the CVS for 21 consecutive days and removed it for 7 days of each 28-day cycle. Four studies used the final manufactured CVS, including a 1-year pharmacokinetic study, two 1-year phase 3 trials and a second-year treatment extension study. We assessed safety by evaluating adverse events women reported in a daily diary. We also included data from focused safety studies evaluating endometrial biopsies, vaginal microbiology and liver proteins from one of the phase 3 studies. RESULTS The combined studies included 3052 women; 2308 women [mean age 26.7±5.1 years; mean body mass index (BMI) 24.1±3.7 kg/m2] received the final manufactured CVS, of whom 999 (43.3%) completed 13 cycles of use. Women using the final CVS most commonly reported adverse events of headache (n=601, 26%), nausea (n=420, 18%), vaginal discharge/vulvovaginal mycotic infection (n=242, 10%) and abdominal pain (n=225, 10%). Few (<1.5%) women discontinued for these complaints. Four (0.2%) women experienced venous thromboembolism (VTE), three of whom had risk factors for thrombosis [Factor V Leiden mutation (n=1); BMI>29 kg/m2 (n=2)]. During 21,482 treatment cycles in the phase 3 studies evaluable for expulsion, women reported partial expulsions in 4259 (19.5%) cycles and complete expulsions in 1509 (7%) cycles, most frequently in the initial cycle [499/2050 (24.3%) and 190/2050 (9.3%), respectively]. Safety-focused studies revealed no safety concerns. CONCLUSION The 1-year SA/EE CVS has an acceptable safety profile. Additional studies are warranted in obese women at higher risk of VTE. IMPLICATIONS This 1-year contraceptive vaginal system represents a new long-term, user-controlled and procedure-free option with a safety profile similar to other combination hormonal contraceptives. The same precautions currently used for combination hormonal contraceptive prescriptions apply to this new contraceptive vaginal system.
Collapse
Affiliation(s)
| | | | - Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, USA
| | - Michael Thomas
- Department of Obstetrics and Gynecology, University of Cincinnati, Cincinnati, OH, USA
| | - Kurt T Barnhart
- Department of Obstetrics and Gynecology, Perelman School of medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - George Creasy
- Center for Biomedical Research, Population Council, New York, NY, USA
| | - Heather Sussman
- Center for Biomedical Research, Population Council, New York, NY, USA
| | - Mohcine Alami
- Center for Biomedical Research, Population Council, New York, NY, USA
| | - Anne E Burke
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Bayview Medical Center, Baltimore, MD, USA
| | - Edith Weisberg
- Family Planning NSW, and University of Sydney, Sydney, Australia
| | - Ian Fraser
- University of New South Wales; Family Planning NSW, and University of Sydney, Sydney, Australia
| | | | - Melissa Gilliam
- Department of Obstetrics, Gynecology and Pediatrics, University of Chicago, Chicago, IL, USA
| | - James Liu
- Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, OH, USA
| | | | - Marlena Plagianos
- Center for Biomedical Research, Population Council, New York, NY, USA
| | - Kevin Roberts
- Center for Biomedical Research, Population Council, New York, NY, USA
| | - Diana Blithe
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| |
Collapse
|
17
|
Tuazon JP, Sitruk-Ware R, Borlongan CV. Beyond contraception and hormone replacement therapy: Advancing Nestorone to a neuroprotective drug in the clinic. Brain Res 2019; 1704:161-163. [DOI: 10.1016/j.brainres.2018.10.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 10/11/2018] [Indexed: 01/17/2023]
|
18
|
Yuen F, Wu S, Thirumalai A, Swerdloff RS, Page ST, Liu PY, Dart C, Wu H, Blithe DL, Sitruk-Ware R, Long J, Bai F, Hull L, Bremner WJ, Anawalt BD, Wang C. Preventing secondary exposure to women from men applying a novel nestorone/testosterone contraceptive gel. Andrology 2018; 7:235-243. [PMID: 30556332 DOI: 10.1111/andr.12577] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 11/07/2018] [Accepted: 11/27/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Testosterone (T)/Nestorone (NES) combination gel is a potential transdermal male contraceptive that suppresses gonadotropins and spermatogenesis. Transfer of transdermal T from men to women can be prevented by washing or covering application sites with clothing. OBJECTIVES We hypothesized that showering or wearing a shirt over gel application sites would prevent secondary exposure of T and NES to a woman after close skin contact. MATERIALS AND METHODS Twelve healthy male and 12 healthy female participants were recruited. Men applied T/NES 62 mg/8 mg gel to their shoulders and upper arms. Two hours after application, female partners rubbed the application site for 15 min. Exposure in the female partner was assessed under three conditions: a shirt covered the application site; the man showered prior to skin contact; or without intervention to reduce transfer. Serum T and NES concentrations were measured by LC-MS/MS in serial blood samples for 24 h after gel exposure. MAIN OUTCOMES Change in female serum T and NES levels as measured by average concentration over 24 h (Cavg ). RESULTS Median female serum T Cavg was 23.9 ng/dL (interquartile range, 19.3, 33.9) with the shirt barrier and 26.7 ng/dL (20.7, 33.9) after showering, which was higher than baseline 20.9 ng/dL (16.7, 25.0), both p < 0.03) but lower than without intervention (58.2 ng/dL [30.9, 89.1], both p < 0.01). Female serum NES Cavg and maximum concentration were below the lower limit of quantification with the shirt barrier and after showering, but increased without intervention in six of 12 women (maximum concentration <60 pg/mL). Men had lower average serum NES levels after showering (47 pg/ml [20, 94] compared to no intervention (153.3 pg/mL [51, 241], p < 0.02). CONCLUSION Secondary transfer of T and NES occurs after intensive skin contact with the gel application site. Secondary transfer is decreased by a shirt barrier or showering before contact.
Collapse
Affiliation(s)
- F Yuen
- Department of Medicine, Division of Endocrinology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - S Wu
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - A Thirumalai
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - R S Swerdloff
- Department of Medicine, Division of Endocrinology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - S T Page
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - P Y Liu
- Department of Medicine, Division of Endocrinology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - C Dart
- Health Decisions, Durham, NC, USA
| | - H Wu
- Health Decisions, Durham, NC, USA
| | - D L Blithe
- Contraceptive Development Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - R Sitruk-Ware
- Center for Biomedical Research, Population Council, New York, NY, USA
| | - J Long
- Contraceptive Development Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - F Bai
- Department of Medicine, Division of Endocrinology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - L Hull
- Department of Medicine, Division of Endocrinology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - W J Bremner
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - B D Anawalt
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - C Wang
- Department of Medicine, Division of Endocrinology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| |
Collapse
|
19
|
Parhi R, Swain S. Transdermal Evaporation Drug Delivery System: Concept to Commercial Products. Adv Pharm Bull 2018; 8:535-550. [PMID: 30607327 PMCID: PMC6311647 DOI: 10.15171/apb.2018.063] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 08/27/2018] [Accepted: 10/14/2018] [Indexed: 02/02/2023] Open
Abstract
Since two decades or so transdermal route established itself as better alternative to traditional oral route. This is possible due to continuous innovations in transdermal drug delivery (TDD), which not only enables researchers from academia and industry to successfully develop and launch many new pharmaceuticals but also allow to include new classes of drugs that can be developed into transdermal formulations. These successes are achieved due to the use of novel techniques based on either physical or chemical approaches. However, both of these techniques suffer due to their own disadvantages. Comparatively, a simple method of supersaturation to enhance drug permeation across skin has created a new wave of interest. Even though the application supersaturated principle in topical and TDD has been used from 1960s, but proper control of drug release and formation of stable supersaturated states has been the core of intense research in the last decade. Out of various methods used to get supersaturated system, evaporation method is considered as most efficient and practically feasible for TDD. Therefore, in this review concept of supersaturation, selection of solvent system and the mechanism of inhibition of crystallization are discussed. Application of evaporation systems in the development of transdermal formulations such as solutions, semisolids and metered dose therapeutic systems (MDTS) and the commercial evaporative systems are also discussed in this review.
Collapse
Affiliation(s)
- Rabinarayan Parhi
- GITAM Institute of Pharmacy, GITAM (Deemed to be University), Gandhi Nagar Campus, Rushikonda, Visakhapatnam-530045, Andhra Pradesh, India
| | - Suryakanta Swain
- Southern Institute of Medical Sciences, College of Pharmacy, Department of Pharmaceutics, SIMS Group of Institutions, Mangaldas Nagar, Vijyawada Road, Guntur-522 001, Andhra Pradesh, India
| |
Collapse
|
20
|
Yao G, Quan G, Lin S, Peng T, Wang Q, Ran H, Chen H, Zhang Q, Wang L, Pan X, Wu C. Novel dissolving microneedles for enhanced transdermal delivery of levonorgestrel: In vitro and in vivo characterization. Int J Pharm 2017; 534:378-386. [DOI: 10.1016/j.ijpharm.2017.10.035] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 10/11/2017] [Accepted: 10/15/2017] [Indexed: 11/26/2022]
|
21
|
Zitzmann M, Rohayem J, Raidt J, Kliesch S, Kumar N, Sitruk-Ware R, Nieschlag E. Impact of various progestins with or without transdermal testosterone on gonadotropin levels for non-invasive hormonal male contraception: a randomized clinical trial. Andrology 2017; 5:516-526. [DOI: 10.1111/andr.12328] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 12/05/2016] [Accepted: 12/17/2016] [Indexed: 11/28/2022]
Affiliation(s)
- M. Zitzmann
- Institute of Reproductive Medicine; University Clinics; Muenster Germany
| | - J. Rohayem
- Institute of Reproductive Medicine; University Clinics; Muenster Germany
| | - J. Raidt
- Institute of Reproductive Medicine; University Clinics; Muenster Germany
| | - S. Kliesch
- Institute of Reproductive Medicine; University Clinics; Muenster Germany
| | - N. Kumar
- Population Council; Rockefeller University; New York NY USA
| | - R. Sitruk-Ware
- Population Council; Rockefeller University; New York NY USA
| | - E. Nieschlag
- Institute of Reproductive Medicine; University Clinics; Muenster Germany
- Center of Excellence in Genomic Medicine Research; King Abdulaziz University; Jeddah Saudi Arabia
| |
Collapse
|
22
|
Kumar N, Fagart J, Liere P, Mitchell SJ, Knibb AR, Petit-Topin I, Rame M, El-Etr M, Schumacher M, Lambert JJ, Rafestin-Oblin ME, Sitruk-Ware R. Nestorone® as a Novel Progestin for Nonoral Contraception: Structure-Activity Relationships and Brain Metabolism Studies. Endocrinology 2017; 158:170-182. [PMID: 27824503 PMCID: PMC5412978 DOI: 10.1210/en.2016-1426] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 11/01/2016] [Indexed: 11/19/2022]
Abstract
Nestorone® (NES) is a potent nonandrogenic progestin being developed for contraception. NES is a synthetic progestin that may possess neuroprotective and myelin regenerative potential as added health benefits. In receptor transactivation experiments, NES displayed greater potency than progesterone to transactivate the human progesterone receptor (PR). This was confirmed by docking experiments where NES adopts the same docking position within the PR ligand-binding domain (LBD) as progesterone and forms additional stabilizing contacts between 17α-acetoxy and 16-methylene groups and PR LBD, supporting its higher potency than progesterone. The analog 13-ethyl NES also establishes similar contacts as NES with Met909, leading to comparable potency as NES. In contrast, NES is not stabilized within the human androgen receptor LBD, leading to negligible androgen receptor transactivation. Because progesterone acts in the brain by both PR binding and indirectly via binding of the metabolite allopregnanolone to γ-aminobutyric acid type A receptor (GABAAR), we investigated if NES is metabolized to 3α, 5α-tetrahydronestorone (3α, 5α-THNES) in the brain and if this metabolite could interact with GABAAR. In female mice, low concentrations of reduced NES metabolites were identified by gas chromatography/mass spectrometry in both plasma and brain. Electrophysiological studies showed that 3α, 5α-THNES exhibited only limited activity to enhance GABAAR-evoked responses with WSS-1 cells and did not modulate synaptic GABAARs of mouse cortical neurons. Thus, the inability of reduced metabolite of NES (3α, 5α-THNES) to activate GABAAR suggests that the neuroprotective and myelin regenerative effects of NES are mediated via PR binding and not via its interaction with the GABAAR.
Collapse
Affiliation(s)
- Narender Kumar
- Population Council, Center for Biomedical Research, New York, New York 10065
| | | | - Philippe Liere
- U1195 INSERM, University Paris Sud, Le Kremlin Bicêtre 94276, France; and
| | - Scott J. Mitchell
- Division of Neuroscience, Ninewells Hospital & Medical School, Dundee University, Dundee DD1 9SY, Scotland, United Kingdom
| | - Alanah R. Knibb
- Division of Neuroscience, Ninewells Hospital & Medical School, Dundee University, Dundee DD1 9SY, Scotland, United Kingdom
| | | | - Marion Rame
- U1195 INSERM, University Paris Sud, Le Kremlin Bicêtre 94276, France; and
| | - Martine El-Etr
- U1195 INSERM, University Paris Sud, Le Kremlin Bicêtre 94276, France; and
| | - Michael Schumacher
- U1195 INSERM, University Paris Sud, Le Kremlin Bicêtre 94276, France; and
| | - Jeremy J. Lambert
- Division of Neuroscience, Ninewells Hospital & Medical School, Dundee University, Dundee DD1 9SY, Scotland, United Kingdom
| | | | - Regine Sitruk-Ware
- Population Council, Center for Biomedical Research, New York, New York 10065
| |
Collapse
|
23
|
Abstract
Hormonal male contraception clinical trials began in the 1970s. The method is based on the use of exogenous testosterone alone or in combination with a progestin to suppress the endogenous production of testosterone and spermatogenesis. Studies using testosterone alone showed that the method was very effective with few adverse effects. Addition of a progestin increases the rate and extent of suppression of spermatogenesis. Common adverse effects include acne, injection site pain, mood change including depression, and changes in libido that are usually mild and rarely lead to discontinuation. Current development includes long-acting injectables and transdermal gels and novel androgens that may have both androgenic and progestational activities. Surveys showed that over 50 % of men will accept a new male method and female partners will trust their partner to take oral “male pills.” Partnership between government, nongovernment agencies, academia, and industry may generate adequate interest and collaboration to develop and market the first male hormonal contraception.
Collapse
|
24
|
The progesterone receptor agonist Nestorone holds back proinflammatory mediators and neuropathology in the wobbler mouse model of motoneuron degeneration. Neuroscience 2015; 308:51-63. [DOI: 10.1016/j.neuroscience.2015.09.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 08/20/2015] [Accepted: 09/02/2015] [Indexed: 12/13/2022]
|
25
|
Brache V, Merkatz R, Kumar N, Jesam C, Sussman H, Hoskin E, Roberts K, Alami M, Taylor D, Jorge A, Croxatto H, Lorange E, Mishell DR, Sitruk-Ware R. A dose-finding, cross-over study to evaluate the effect of a Nestorone®/Estradiol transdermal gel delivery on ovulation suppression in normal ovulating women. Contraception 2015; 92:289-97. [DOI: 10.1016/j.contraception.2015.05.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 04/24/2015] [Accepted: 05/13/2015] [Indexed: 11/29/2022]
|
26
|
Jensen JT. Present and future contraception: does discovery of targets lead to new contraceptives? Expert Opin Ther Targets 2015; 19:1429-32. [DOI: 10.1517/14728222.2015.1039939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
|
27
|
Nelson AL. Transdermal contraception methods: today’s patches and new options on the horizon. Expert Opin Pharmacother 2015; 16:863-73. [DOI: 10.1517/14656566.2015.1022531] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
28
|
|
29
|
Efficacy of the selective progesterone receptor agonist Nestorone for chronic experimental autoimmune encephalomyelitis. J Neuroimmunol 2014; 276:89-97. [DOI: 10.1016/j.jneuroim.2014.08.619] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 08/14/2014] [Accepted: 08/19/2014] [Indexed: 11/17/2022]
|
30
|
Roth MY, Shih G, Ilani N, Wang C, Page ST, Bremner WJ, Swerdloff RS, Sitruk-Ware R, Blithe DL, Amory JK. Acceptability of a transdermal gel-based male hormonal contraceptive in a randomized controlled trial. Contraception 2014; 90:407-12. [PMID: 24981149 DOI: 10.1016/j.contraception.2014.05.013] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 05/19/2014] [Accepted: 05/27/2014] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Fifty percent of pregnancies in the United States are unintended despite numerous contraceptive methods available to women. The only male contraceptive methods, vasectomy and condoms, are used by 10% and 16% of couples, respectively. Prior studies have shown efficacy of male hormonal contraceptives in development, but few have evaluated patient acceptability and potential use if commercially available. The objective of this study is to determine if a transdermal gel-based male hormonal contraceptive regimen, containing testosterone and Nestorone® gels, would be acceptable to study participants as a primary contraceptive method. STUDY DESIGN As part of a three-arm, 6-month, double-blind, randomized controlled trial of testosterone and nestorone gels at two academic medical centers, subjects completed a questionnaire to assess the acceptability of the regimen. Of the 99 men randomized, 79 provided data for analysis. RESULTS Overall, 56% (44/79) of men were satisfied or extremely satisfied with this gel-based method of contraception, and 51% (40/79) reported that they would recommend this method to others. One third of subjects (26/79) reported that they would use this as their primary method of contraception if it were commercially available today. However, men with concerns about sexually transmitted disease were significantly less satisfied than men without such concerns (p=0.03). CONCLUSIONS A majority of the men who volunteered to participate in this trial of an experimental male hormonal contraceptive were satisfied with this transdermal male hormonal contraceptive. If commercially available, a combination of topical nesterone and testosterone gels could provide a reversible, effective method of contraception that is appealing to men. IMPLICATIONS A substantial portion of men report they would use this transdermal male contraceptive regimen if commercially available. This method would provide a novel, reversible method of contraception for men, whose current choices are limited to condoms and vasectomy.
Collapse
Affiliation(s)
- Mara Y Roth
- University of Washington, Department of Medicine and Center for Research in Reproduction and Contraception.
| | - Grace Shih
- University of Washington, Department of Family Medicine
| | - Niloufar Ilani
- Harbor-UCLA Medical Center and Los Angeles Biomedical Research Institute, Department of Medicine, Torrance, CA
| | - Christina Wang
- Harbor-UCLA Medical Center and Los Angeles Biomedical Research Institute, Department of Medicine, Torrance, CA
| | - Stephanie T Page
- University of Washington, Department of Medicine and Center for Research in Reproduction and Contraception
| | - William J Bremner
- University of Washington, Department of Medicine and Center for Research in Reproduction and Contraception
| | - Ronald S Swerdloff
- Harbor-UCLA Medical Center and Los Angeles Biomedical Research Institute, Department of Medicine, Torrance, CA
| | | | - Diana L Blithe
- Contraceptive Discovery and Development Branch, NICHD, Bethesda, MD
| | - John K Amory
- University of Washington, Department of Medicine and Center for Research in Reproduction and Contraception
| |
Collapse
|
31
|
Bahamondes L, Bahamondes MV. New and emerging contraceptives: a state-of-the-art review. Int J Womens Health 2014; 6:221-34. [PMID: 24570597 PMCID: PMC3933723 DOI: 10.2147/ijwh.s46811] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background The first hormonal contraceptive was introduced onto the market in several countries 50 years ago; however, the portfolio of contraceptive methods remains restricted with regards to their steroid composition, their cost, and their ability to satisfy the requirements of millions of women/couples in accordance with their different reproductive intentions, behaviors, cultures, and settings. Methods A literature review was conducted using Medline, Embase, and Current Contents databases, up to September 1, 2013 to identify publications reporting new contraceptives in development using combinations of the search terms: contraception, contraceptives, oral contraceptives, patch, vaginal ring, implants, intrauterine contraceptives, and emergency contraception (EC). Also, several experts in the field were also consulted to document ongoing projects on contraception development. Additionally, the Clinicaltrial.gov website was searched for ongoing studies on existing contraceptive methods and new and emerging female contraceptives developed over the past 5 years. Information was also obtained from the pharmaceutical industry. Results Early sexual debut and late menopause means that women may require contraception for up to 30 years. Although oral, injectable, vaginal, transdermal, subdermal, and intrauterine contraceptives are already available, new contraceptives have been developed in an attempt to reduce side effects and avoid early discontinuation, and to fulfill women’s different requirements. Research efforts are focused on replacing ethinyl-estradiol with natural estradiol to reduce thrombotic events. In addition, new, less androgenic progestins are being introduced and selective progesterone receptor modulators and new delivery systems are being used. In addition, research is being conducted into methods that offer dual protection (contraception and protection against human immunodeficiency virus transmission), and contraceptives for use “on demand.” Studies are also investigating non-hormonal contraceptive methods that have additional, non-contraceptive benefits. Conclusion The most pressing need worldwide is, first, that the highly effective contraceptive methods already available should be affordable to most of the population and also that these methods should fulfill the needs of women of different ages and with different reproductive requirements. The development of new contraceptive methods should also take advantage of the knowledge obtained over the past 30 years on gamete physiology and gamete interaction to avoid the use of steroid compounds.
Collapse
Affiliation(s)
- Luis Bahamondes
- Human Reproduction Unit, Department of Obstetrics and Gynaecology, Faculty of Medical Sciences, University of Campinas and National Institute of Hormones and Women's Health, Campinas, SP, Brazil
| | - M Valeria Bahamondes
- Human Reproduction Unit, Department of Obstetrics and Gynaecology, Faculty of Medical Sciences, University of Campinas and National Institute of Hormones and Women's Health, Campinas, SP, Brazil
| |
Collapse
|
32
|
Benagiano G, Gabelnick H, Farris M. Contraceptive devices: subcutaneous delivery systems. Expert Rev Med Devices 2014; 5:623-37. [DOI: 10.1586/17434440.5.5.623] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
33
|
Benagiano G, Gabelnick H, Farris M. Contraceptive devices: intravaginal and intrauterine delivery systems. Expert Rev Med Devices 2014; 5:639-54. [DOI: 10.1586/17434440.5.5.639] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
34
|
Sitruk-Ware R, Nath A, Mishell DR. Contraception technology: past, present and future. Contraception 2013; 87:319-30. [PMID: 22995540 PMCID: PMC3530627 DOI: 10.1016/j.contraception.2012.08.002] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 08/06/2012] [Indexed: 11/22/2022]
Abstract
Steady progress in contraception research has been achieved over the past 50 years. Hormonal and nonhormonal modern contraceptives have improved women's lives by reducing different health conditions that contributed to considerable morbidity. However, the contraceptives available today are not suitable to all users, and the need to expand contraceptive choices still exists. Novel products such as new implants, contraceptive vaginal rings, transdermal patches and newer combinations of oral contraceptives have recently been introduced in family planning programs, and hormonal contraception is widely used for spacing and limiting births. Concerns over the adverse effects of hormonal contraceptives have led to research and development of new combinations with improved metabolic profile. Recent developments include use of natural compounds such as estradiol and estradiol valerate with the hope to decrease thrombotic risk, in combination with newer progestins derived from the progesterone structure or from spirolactone, in order to avoid the androgenic effects. Progesterone antagonists and progesterone receptor modulators are highly effective in blocking ovulation and preventing follicular rupture and are undergoing investigations in the form of oral pills and in semi-long-acting delivery systems. Future developments also include the combination of a contraceptive with an antiretroviral agent for dual contraception and protection against sexually transmitted diseases, to be used before intercourse or on demand, as well as for continuous use in dual-protection rings. Although clinical trials of male contraception have reflected promising results, limited involvement of industry in that area of research has decreased the likelihood of having a male method available in the current decade. Development of nonhormonal methods is still at an early stage of research, with the identification of specific targets within the reproductive system in ovaries and testes, as well as interactions between spermatozoa and ova. It is hoped that the introduction of new methods with additional health benefits would help women and couples with unmet needs to obtain access to a wider range of contraceptives with improved acceptability.
Collapse
|
35
|
Sitruk-Ware R, Nath A. Characteristics and metabolic effects of estrogen and progestins contained in oral contraceptive pills. Best Pract Res Clin Endocrinol Metab 2013; 27:13-24. [PMID: 23384742 DOI: 10.1016/j.beem.2012.09.004] [Citation(s) in RCA: 106] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Estrogen and progestins have been used by millions of women as effective combined oral contraceptives. Oral contraceptives (OCs) modify surrogate markers such as lipoproteins, insulin response to glucose, and coagulation factors, that have been associated with cardiovascular and venous risk. Ethinyl-Estradiol (EE) exerts a stronger effect that natural estradiol (E2) on hepatic metabolism. New progestins with high specificity have been designed to avoid interaction with other receptors and prevent androgenic, estrogenic or glucocorticoid related side-effects. The risks and benefits of new progestins used in contraception depend upon their molecular structure, the type and dose of associated estrogen, and the delivery route. The lower impact of E2-based combinations on metabolic surrogate markers may result in an improved safety profile, but only clinical outcomes are relevant to assess the risk. Large surveillance studies are warranted to confirm this hypothesis.
Collapse
|
36
|
Schumacher M, Hussain R, Gago N, Oudinet JP, Mattern C, Ghoumari AM. Progesterone synthesis in the nervous system: implications for myelination and myelin repair. Front Neurosci 2012; 6:10. [PMID: 22347156 PMCID: PMC3274763 DOI: 10.3389/fnins.2012.00010] [Citation(s) in RCA: 130] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Accepted: 01/16/2012] [Indexed: 11/15/2022] Open
Abstract
Progesterone is well known as a female reproductive hormone and in particular for its role in uterine receptivity, implantation, and the maintenance of pregnancy. However, neuroendocrine research over the past decades has established that progesterone has multiple functions beyond reproduction. Within the nervous system, its neuromodulatory and neuroprotective effects are much studied. Although progesterone has been shown to also promote myelin repair, its influence and that of other steroids on myelination and remyelination is relatively neglected. Reasons for this are that hormonal influences are still not considered as a central problem by most myelin biologists, and that neuroendocrinologists are not sufficiently concerned with the importance of myelin in neuron functions and viability. The effects of progesterone in the nervous system involve a variety of signaling mechanisms. The identification of the classical intracellular progesterone receptors as therapeutic targets for myelin repair suggests new health benefits for synthetic progestins, specifically designed for contraceptive use and hormone replacement therapies. There are also major advantages to use natural progesterone in neuroprotective and myelin repair strategies, because progesterone is converted to biologically active metabolites in nervous tissues and interacts with multiple target proteins. The delivery of progesterone however represents a challenge because of its first-pass metabolism in digestive tract and liver. Recently, the intranasal route of progesterone administration has received attention for easy and efficient targeting of the brain. Progesterone in the brain is derived from the steroidogenic endocrine glands or from local synthesis by neural cells. Stimulating the formation of endogenous progesterone is currently explored as an alternative strategy for neuroprotection, axonal regeneration, and myelin repair.
Collapse
|
37
|
Abstract
INTRODUCTION Progesterone receptor (PR) agonists (progestins) and antagonists are developed for female contraceptives. However, non-contraceptive applications of newer progestins and PR modulators are being given more attention. AREAS COVERED The newer PR agonists including drospirenone, nomegestrol, trimegestone, dienogest and nestorone are being evaluated as contraceptives with health benefits because of their unique pharmacological properties. The selective PR modulators (SPRM; PR antagonists with PR agonistic properties) are under development not only for emergency contraception but also for other health benefits such as the treatment of endometritis and leiomyoma. After searching the literature from PubMed, clinicaltrials.gov and patent database, this review focuses on the effects and mechanisms of these progestins, and SPRMs as contraceptives with other health benefits. EXPERT OPINION PR agonists and antagonists that have novel properties may generate better contraceptive effects with other health benefits.
Collapse
Affiliation(s)
- Ying Su
- The 2nd Affiliated Hospital, Wenzhou Medical College, 109 Xueyuan Road, Wenzhou, Zhejiang 325000, China
| | | | | |
Collapse
|
38
|
Hussain R, El-Etr M, Gaci O, Rakotomamonjy J, Macklin WB, Kumar N, Sitruk-Ware R, Schumacher M, Ghoumari AM. Progesterone and Nestorone facilitate axon remyelination: a role for progesterone receptors. Endocrinology 2011; 152:3820-31. [PMID: 21828184 PMCID: PMC6285137 DOI: 10.1210/en.2011-1219] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Enhancing the endogenous capacity of myelin repair is a major therapeutic challenge in demyelinating diseases such as multiple sclerosis. We found that progesterone and the synthetic 19-norprogesterone derivative 16-methylene-17α-acetoxy-19-norpregn-4-ene-3,20-dione (Nestorone) promote the remyelination of axons by oligodendrocytes after lysolecithin-induced demyelination in organotypic cultures of cerebellar slices taken from postnatal rats or mice. The intracellular progesterone receptors (PR) mediate the proremyelinating actions of Nestorone, because they are not observed in slices from PR knockout mice. Notably, Nestorone was less efficient in heterozygous mice, expressing reduced levels of PR, suggesting PR haploinsufficiency in myelin repair. Using mice expressing the enhanced green fluorescent protein (EGFP) under the control of the proteolipid gene promoter, we showed that both progesterone and Nestorone strongly increased the reappearance of cells of the oligodendroglial lineage in the demyelinated slices. In contrast to Nestorone, the pregnane derivative medroxyprogesterone acetate had no effect. The increase in oligodendroglial cells by Nestorone resulted from enhanced NG2(+) and Olig2(+) oligodendrocyte progenitor cell (OPC) recruitment. In cocultures of lysolecithin-demyelinated cerebellar slices from wild-type mice apposed to brain stem slices of proteolipid gene promoter-EGFP mice, Nestorone stimulated the migration of OPC towards demyelinated axons. In this coculture paradigm, Nestorone indeed markedly increased the number of EGFP(+) cells migrating into the demyelinated cerebellar slices. Our results show that Nestorone stimulates the recruitment and maturation of OPC, two steps which are limiting for efficient myelin repair. They may thus open new perspectives for the use of progestins, which selectively target PR, to promote the endogenous regeneration of myelin.
Collapse
Affiliation(s)
- Rashad Hussain
- Unité Mixte de Recherche 788 Institut National de la Santé et de la Recherche Médicale and University Paris-Sud 11, 80 Rue du Général Leclerc, 94276 Kremlin-Bicêtre, France
| | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Prasad PV, Pal PC, Rao DN, Shrivastav TG, Ge RS. Bird’s Eye View on the Recent Advances in Drug Delivery Systems. ACTA ACUST UNITED AC 2011. [DOI: 10.4236/jbnb.2011.225065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
40
|
|
41
|
Contraception hormonale. Contraception 2011. [DOI: 10.1016/b978-2-294-70921-0.00006-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
42
|
|
43
|
Lopez LM, Grimes DA, Gallo MF, Schulz KF. Skin patch and vaginal ring versus combined oral contraceptives for contraception. Cochrane Database Syst Rev 2010:CD003552. [PMID: 20238323 DOI: 10.1002/14651858.cd003552.pub3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The delivery of combination contraceptive steroids from a skin patch or vaginal ring offers potential advantages over the traditional oral route. The skin patch and vaginal ring could require a lower dose due to increased bioavailability and improved user compliance. OBJECTIVES To compare the contraceptive effectiveness, cycle control, adherence (compliance), and safety of the skin patch or the vaginal ring versus combination oral contraceptives (COCs). SEARCH STRATEGY For trials of the contraceptive patch or the vaginal ring, we searched MEDLINE, POPLINE, CENTRAL, EMBASE, LILACS, ClinicalTrials.gov, and ICTRP. We contacted manufacturers and researchers to identify other trials. SELECTION CRITERIA All randomized controlled trials comparing the skin patch or vaginal ring with a COC. DATA COLLECTION AND ANALYSIS Data were abstracted by two authors and entered into RevMan. For dichotomous variables, the Peto odds ratio (OR) with 95% confidence intervals (CI) was calculated. For continuous variables, the mean difference was computed. MAIN RESULTS We found 5 trials of the skin patch and 10 of the vaginal ring. Contraceptive effectiveness was similar for the patch or ring versus the comparison COC. More patch users discontinued early than COC users: ORs were 1.59 (95% CI 1.26 to 2.00), 1.56 (95% CI 1.18 to 2.06), and 2.57 (95% CI 0.99 to 6.64). Patch users also had more discontinuation due to adverse events. Compared to COC users, patch users reported more breast discomfort, dysmenorrhea, nausea, and vomiting. Patch users reported more compliant cycles than the COC users in two trials: ORs were 2.05 (95% CI 1.83 to 2.29) and 2.76 (95% CI 2.35 to 3.24). The ring trials generally showed similar discontinuation for ring and COC users. Ring users reported less nausea, acne, irritability, and depression than COC users. Ring users had more vaginitis and leukorrhea but less vaginal dryness. Ring users had similar adherence to COC users in two trials but less adherence in one. Cycle control was generally similar for the patch and COC, and was similar or better for the ring versus COC. AUTHORS' CONCLUSIONS Effectiveness was similar for the methods compared. The patch could lead to more discontinuation while the vaginal ring showed little difference. The patch group had better compliance than the COC group but more side effects. Ring users generally had fewer adverse events than COC users but more vaginal irritation and discharge. High losses to follow up can affect the validity of the results.
Collapse
Affiliation(s)
- Laureen M Lopez
- Behavioral and Biomedical Research, Family Health International, P.O. Box 13950, Research Triangle Park, North Carolina, USA, 27709
| | | | | | | |
Collapse
|
44
|
Prasad PV, Bashir M, Sitruk-Ware R, Kumar N. Single-dose pharmacokinetics of Nestorone, a potential female-contraceptive. Steroids 2010; 75:252-64. [PMID: 20064539 DOI: 10.1016/j.steroids.2009.12.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2009] [Revised: 12/26/2009] [Accepted: 12/29/2009] [Indexed: 11/25/2022]
Abstract
A synthetic progestin Nestorone is being developed for female-contraception. This study was conducted to determine the distribution, metabolism, and excretion of tritium-labeled Nestorone ((3)H Nestorone) in adult female rats. Rats were injected subcutaneously (S.C.) with a single dose of 400 microCi (3)H Nestorone/kg BW. Its distribution and concentrations in blood, plasma and other tissues were determined at defined times. The excreta were examined for elimination of (3)H Nestorone. Radioactivity in all samples was analyzed by liquid scintillation counter. Metabolite profiling was performed by HPLC and LC/MS analysis of the plasma, urine, and feces samples. Following subcutaneous injection of (3)H Nestorone, the mean peak concentrations of radioactivity (C(max)) in the blood and plasma were 58.1 and 95.5 ng equiv. (3)H Nestorone/g, respectively, at 2-h postdose (T(max)). Thereafter, the concentration of drug steadily declined through 96-h postdose with a terminal elimination half-life (t(1/2)) of 15.6 h. (3)H Nestorone-derived radioactivity was widely distributed in most tissues by 0.5 h and attained a mean maximal concentration by 2-h postdose. Approximately, 81.4% and 7.62% of the administered dose was excreted via feces and urine, respectively. In vivo metabolism of (3)H Nestorone resulted into a total of 19 metabolites. Among them, two metabolites viz., 17alpha-deacetyl-Nestorone (M9) and 4,5-dihydro-17alpha-deacetyl-Nestorone (M19) were identified by HPLC and LC/MS analysis. Metabolite profiling of plasma samples showed that most of the circulating radioactivity was associated with unchanged parent drug, and M19. The M19 was a major metabolite in the profiled urine and feces samples. Presence of large proportion of drug/drug-related material in feces suggested that the biliary excretion is a main elimination route of (3)H Nestorone. The distribution, metabolism, and excretion profiles of (3)H Nestorone obtained in this study provide a fairly good insight about its fate in women.
Collapse
Affiliation(s)
- Pramod Vishwanath Prasad
- Center for Biomedical Research, The Population Council, The Rockefeller University, 1230 York Avenue, New York, NY 10065, USA.
| | | | | | | |
Collapse
|
45
|
Lenzi E, Pluchino N, Begliuomini S, Casarosa E, Merlini S, Giannini A, Luisi M, Kumar N, Sitruk-Ware R, Genazzani AR. Central modifications of allopregnanolone and beta-endorphin following subcutaneous administration of Nestorone. J Steroid Biochem Mol Biol 2009; 116:15-20. [PMID: 19383544 DOI: 10.1016/j.jsbmb.2009.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2008] [Revised: 04/02/2009] [Accepted: 04/08/2009] [Indexed: 11/25/2022]
Abstract
The aim of the present study was to evaluate the potential action of Nestorone (alone or in combination with estradiol valerate) on the level of allopregnanolone and of the opioid beta-endorphin in selected brain areas. Wistar ovariectomized rats were given 0.05 mg/(kg day) of estradiol valerate (E2V) or subcutaneous Nestorone at three dose levels: low dose (10 microg/(kg day)), antiovulatory dose (50 micro/(kg day)) and high dose (250 microg/(kg day)) with and without E2V. E2V therapy reversed the reduction of allopregnanolone and beta-endorphin induced by ovariectomy anywhere was analyzed except for the adrenal gland. Nestorone showed no effect on allopregnanolone concentration in serum or any part of the brain tissue when given alone while it had a synergistic increasing effect in allopregnanolone concentration in some parts of the brain (hippocampus, hypothalamus, anterior pituitary and serum) when given at high dose of 250 microg/(kg day) in combination with E2V. At lower doses it possesses a synergistic effect with E2V only in the hippocampus (at 50 microg/(kg day)) and in the anterior pituitary (at 10 and 50 microg/(kg day)). Nestorone administered alone at any dose led to significant increase in beta-endorphin levels in the hippocampus only while, in the high dose group, there was a significant increase in endorphin levels in anterior pituitary and hypothalamus in addition to hippocampus as compared to ovariectomized control rats. In addition, only the highest dose of Nestorone added to estrogen increased beta-endorphin levels of hippocampus and plasma. Thus the lower doses of Nestorone alone or in combination with estrogen do not seem to exert any great effect on both allopregnanolone and beta-endorphin. It is only the highest dose of Nestorone that increases allopregnanolone and beta-endorphin levels in selected brain areas, which are the hippocampus, the hypothalamus, the anterior pituitary and serum/plasma. This suggests that Nestorone at the antiovulatory dose levels may not alter the positive effects of estrogen treatment on mood and behaviour.
Collapse
Affiliation(s)
- E Lenzi
- Department of Reproductive Medicine and Child Development, Division of Gynaecology and Obstetrics, University of Pisa, Via Roma 35, 56100 Pisa, Italy
| | | | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Nath A, Sitruk-Ware R. Parenteral administration of progestins for hormonal replacement therapy. EUR J CONTRACEP REPR 2009; 14:88-96. [DOI: 10.1080/13625180902747425] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
47
|
Abstract
The pharmacological properties of progestins used in contraception and hormone replacement therapy (HRT) vary, depending upon the molecules from which they are derived. Very small structural changes may induce considerable differences in effects. It is unclear if the currently available progestins are able to bind specifically to the progesterone receptors, PR-A or PR-B. The clinical relevance of more specific binding to one or the other isoforms of the progesterone receptor is still unknown. The development of new generations of progestins, with improved receptor-selectivity profiles, has been a great challenge. Steroidal and non-steroidal progesterone agonists have also been synthesized, although these molecules are at a very early stage of development. Several new progestins have been synthesized in the past decade, including dienogest, drospirenone, Nestorone, nomegestrol acetate and trimegestone. Drospirenone differs from the classic progestins in its derivation from spirolactone. The major effect of drospirenone is antimineralocorticoid activity. By that property, drospirenone causes decreased salt and water retention, and thus lowering of blood pressure. The affinity of drospirenone for the mineralocorticoid receptor is about five times that of aldosterone, the naturally occurring mineralocorticoid. In addition, drospirenone has no androgenic effect, but does exhibit partial antiandrogenic activity; its antiandrogenic potency is about 30% of that of cyproterone acetate, the progestin with the most potent antiandrogenic activity. This property, shared by several new progestins, may counteract the negative effect of androgens on hair growth, lipid changes, insulin and, possibly, body composition in postmenopausal women. Drospirenone has a long terminal half-life (about 32 hours), and its bioavailability is about 76%. Drospirenone, which has pharmacodynamic properties very similar to those of progesterone, has been developed as a combined oral contraceptive (30 microg ethinylestradiol/3 mg drospirenone; Yasmin, Schering AG, Berlin, Germany). Drospirenone is also available in combination with estradiol as an HRT preparation (1 mg 17beta-estradiol/2 mg drospirenone; Angeliq, Schering AG).
Collapse
Affiliation(s)
- R Sitruk-Ware
- Rockefeller University and Population Council, New York, NY 10021, USA
| |
Collapse
|
48
|
Sitruk-Ware R. New hormonal therapies and regimens in the postmenopause: routes of administration and timing of initiation. Climacteric 2009; 10:358-70. [PMID: 17852138 DOI: 10.1080/13697130701609121] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Since the publication of the Women's Health Initiative (WHI) study followed by the results of the Million Women Study (MWS), the role of hormonal therapy in postmenopausal women has been further challenged. The risks attributed to hormone therapy have been overestimated and the data has been wrongly extrapolated to the whole class of therapies. The trends in postmenopausal hormonal therapy seem now to favor the non-oral delivery routes for both the estrogen and the progestin for women with an intact uterus, based on the assumption that a lesser stimulation of the liver proteins and a neutral metabolic profile would be more favorable in terms of cardiovascular and venous risk. The combination of non-oral administration of estradiol and local delivery of progesterone or a progestin such as levonorgestrel by means of gels, sprays, vaginal rings or intrauterine systems would represent new methods of replacement therapy for the menopausal woman, improving compliance and minimizing the risks of hormone replacement. Several of these systems are either available or in development. Long-term studies on the risk/benefit of various non-oral formulations are certainly warranted.
Collapse
Affiliation(s)
- R Sitruk-Ware
- Center for Biomedical Research, Population Council and Rockefeller University, New York, NY 10021, USA
| |
Collapse
|
49
|
|
50
|
La contraception du post-partum : état des connaissances. ACTA ACUST UNITED AC 2008; 36:603-15. [DOI: 10.1016/j.gyobfe.2008.02.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2007] [Accepted: 02/14/2008] [Indexed: 11/15/2022]
|