Chlormadinone acetate (CMA) in oral contraception--a new opportunity

Comparison of the cytokine responses to acute strength exercise between oral contraceptive users and naturally cycling women

PURPOSE

Cytokines are released as part of an inflammatory reaction in response to strength exercise to initiate muscle repair and morphological adaptations. Whether hormonal fluctuations induced by the menstrual cycle or oral contraceptives affect inflammatory responses to strength exercise remains unknown. Therefore, we aimed to compare the response of cytokines after acute strength exercise in naturally menstruating women and oral contraceptive users.

METHODS

Naturally menstruating women (MC, n = 13, 24 ± 4 years, weekly strength training: 4.3 ± 1.7 h) and women using a monophasic combined pill (> 9 months) (OC, n = 8, 22 ± 3 years, weekly strength training: 4.5 ± 1.9 h) were recruited. A one-repetition-maximum (1RM) test and strength exercise in the squat (4 × 10 repetitions, 70%1RM) was performed in the early follicular phase or pill free interval. Concentrations of oestradiol, IL-1β, IL-1ra, IL-6, IL-8, and IL-10 were assessed before (pre), directly after (post) and 24 h after (post24) strength exercise.

RESULTS

IL-1ra increased from pre to post (+ 51.1 ± 59.4%, p = 0.189) and statistically decreased from post to post24 (- 20.5 ± 13.5%, p = 0.011) only in OC. Additionally, IL-1β statistically decreased from post to post24 (- 39.6 ± 23.0%, p = 0.044) only in OC. There was an interaction effect for IL-1β (p = 0.038) and concentrations were statistically decreased at post24 in OC compared to MC (p = 0.05). IL-8 increased across both groups from post to post24 (+ 66.6 ± 96.3%, p = 0.004).

CONCLUSION

We showed a differential regulation of IL-1β and IL-1ra between OC users in the pill-free interval and naturally cycling women 24 h after strength exercise, while there was no effect on other cytokines. Whether this is associated with previously shown compromised morphological adaptations remains to be investigated.

Progesterone and contraceptive progestin actions on the brain: A systematic review of animal studies and comparison to human neuroimaging studies

In this review we systematically summarize the effects of progesterone and synthetic progestins on neurogenesis, synaptogenesis, myelination and six neurotransmitter systems. Several parallels between progesterone and older generation progestin actions emerged, suggesting actions via progesterone receptors. However, existing results suggest a general lack of knowledge regarding the effects of currently used progestins in hormonal contraception regarding these cellular and molecular brain parameters. Human neuroimaging studies were reviewed with a focus on randomized placebo-controlled trials and cross-sectional studies controlling for progestin type. The prefrontal cortex, amygdala, salience network and hippocampus were identified as regions of interest for future preclinical studies. This review proposes a series of experiments to elucidate the cellular and molecular actions of contraceptive progestins in these areas and link these actions to behavioral markers of emotional and cognitive functioning. Emotional effects of contraceptive progestins appear to be related to 1) alterations in the serotonergic system, 2) direct/indirect modulations of inhibitory GABA-ergic signalling via effects on the allopregnanolone content of the brain, which differ between androgenic and anti-androgenic progestins. Cognitive effects of combined oral contraceptives appear to depend on the ethinylestradiol dose.

Chlormadinone acetate in progestin-primed ovarian stimulation does not negatively affect clinical results

Purpose

To investigate whether progestin-primed ovarian stimulation (PPOS) with chlormadinone acetate (CMA) adversely affects clinical results and neonatal outcomes, or causes congenital deformities.

Methods

This retrospective study was conducted at private IVF clinic from November 2018 to November 2021. Women underwent oocyte retrieval using gonadotropin-releasing hormone (GnRH) antagonist protocol (n = 835) or PPOS protocol (n = 57) were included. Eligible patients were normal ovarian responders (aged <40, AMH ≧1.0 ng/mL) with freeze-all cycle. Embryo developments, clinical results, or neonatal outcomes of singletons derived from transfer of frozen single blastocysts were compared within each group.

Results

Patient characteristics were similar in both groups. The median LH level (mIU/mL) at trigger in the GnRH antagonist group [2.0 (1.2-3.7)] was significantly higher than in the PPOS group [0.9 (0.3-1.7)]. There was no cycle with premature LH surge in the PPOS group. Fertilization and blastocyst formation rates did not differ significantly between groups. Furthermore, clinical outcomes were also similar in the two groups. Congenital abnormality rates did not differ significantly [0.9% (3/329), 0.0% (0/17)].

Conclusions

CMA using ovarian stimulation did not negatively affect clinical results. Our data suggest that PPOS with CMA is an appropriate ovarian stimulation method for normal ovarian responders.

Prospective study of fertility-sparing treatment with chlormadinone acetate for endometrial carcinoma and atypical hyperplasia in young women

OBJECTIVE

To confirm that the efficiency of the use of chlormadinone acetate for 6 months to obtain remission of atypical hyperplasia or endometrial carcinoma is comparable to that of the use of other fertility-sparing treatments.

METHOD

The present study is based on the PREFERE prospective registry. All the patients received 3 or 6 months of chlormadinone acetate and were evaluated by hysteroscopic resection and pipelle sampling every 3 months.

RESULTS

Ninety-four patients were included. Seventy-nine patients achieved complete remission at 6 months (84%). No patients stopped treatment because of a lack of tolerance. Twenty-four per cent of the patients achieved a live birth.

CONCLUSION

Chlormadinone acetate is an effective and well-tolerated fertility-sparing treatment. Its benefits over other progestins are its tolerability, and its absence of contraindications, which make it a good choice for patients with thromboembolism and high vascular risk.

Contraceptive progestins with androgenic properties stimulate breast epithelial cell proliferation

Hormonal contraception exposes women to synthetic progesterone receptor (PR) agonists, progestins, and transiently increases breast cancer risk. How progesterone and progestins affect the breast epithelium is poorly understood because we lack adequate models to study this. We hypothesized that individual progestins differentially affect breast epithelial cell proliferation and hence breast cancer risk. Using mouse mammary tissue ex vivo, we show that testosterone-related progestins induce the PR target and mediator of PR signaling-induced cell proliferation receptor activator of NF-κB ligand (Rankl), whereas progestins with anti-androgenic properties in reporter assays do not. We develop intraductal xenografts of human breast epithelial cells from 36 women, show they remain hormone-responsive and that progesterone and the androgenic progestins, desogestrel, gestodene, and levonorgestrel, promote proliferation but the anti-androgenic, chlormadinone, and cyproterone acetate, do not. Prolonged exposure to androgenic progestins elicits hyperproliferation with cytologic changes. Androgen receptor inhibition interferes with PR agonist- and levonorgestrel-induced RANKL expression and reduces levonorgestrel-driven cell proliferation. Thus, different progestins have distinct biological activities in the breast epithelium to be considered for more informed choices in hormonal contraception.

Dose-Dependent Chlormadinone Acetate Can Suppress Premature LH Surge in Parallel with LH Value Reduction

Background: Progestin-primed ovarian stimulation (PPOS) protocol is reported as an alternative method of premature luteinizing hormone (LH) surge suppression. How much dosage of chlormadinone acetate (CMA), a synthetic progestin, is appropriate treatment for this phenomenon?

Methods: Retrospective case control study was performed at private assisted reproductive technology (ART) clinic in Japan. Collected data was 231 cycles in patients who underwent either PPOS protocol using 12, 6, 4, or 2 mg of CMA, groups 6C, 3C, 2C, and 1C, respectively (total, 113 cycles), or gonadotropin-releasing hormone (GnRH) antagonist protocol, groups 6A, 3A, 2A, and 1A, respectively (total, 118 cycles). In the CMA group, CMA and human menopausal gonadotropin (hMG) or follicle-stimulating hormone (FSH) were administered simultaneously beginning on menstrual cycle day 3. Serum P, E2, and LH were determined on the day of human chorionic gonadotropin (hCG) administration. Occurrence of premature LH surge was compared between two groups. Pregnancy outcomes were also calculated.

Results: Premature LH surge was completely suppressed in CMA groups 6C, 3C, and 2C. On the other hand, this phenomenon was detected in antagonist method groups (5.9%, 7/118). But spontaneous ovulation was not observed in any group, and clinical outcomes are equal to those of GnRH antagonist treatment.

Conclusions: Controlled ovarian stimulation (COS) using CMA can be an appropriate alternative progestin for PPOS protocol. Since CMA is an oral medication, this method can be easy to conduct and cost-effective compared with the antagonist method. From our observation, we suggest 4 mg/day of CMA can control the egg retrieval cycle without LH surge occurrence as in other PPOS methods.

Hormonal contraceptive affects heterosexual but not homosexual behavior in free-ranging female Japanese macaques over 17 mating seasons

We assessed the effect of a progestin-based contraceptive treatment (chlormadinone acetate) on female heterosexual and homosexual behaviors in a free-ranging group of Japanese macaques (Macaca fuscata) living at Arashiyama-Kyoto, Central Japan. The data included estimated intensity of fertility cues, sexual solicitations and mounting behaviors collected daily during 17 consecutive mating seasons (1995-2012) from 159 females. Females that were on contraception: (1) exhibited less intense cues of putative fertility and for shorter periods; (2) were solicited by fewer males, and those males that did solicit them did so less often (i.e., lower heterosexual attractivity); (3) solicited fewer males and when they did perform sexual solicitations they did so less often (i.e., lower heterosexual proceptivity); (4) engaged in shorter heterosexual consortships with fewer male partners (i.e., lower heterosexual receptivity), compared with females that were not on contraception. In contrast, contraceptive treatment had no significant effect on the prevalence, occurrence, frequency, or duration of female homosexual behaviors. Even though heterosexual and homosexual behaviors can both be considered sexual in character and under hormonal control, our results suggested they are, to some extent, dissociable. Because females engaging in homosexual interactions showed less intense cues of putative fertility than those engaging in heterosexual interactions, regardless of contraceptive treatment, we argued that the hormonal threshold required for the expression of heterosexual behavior by females was associated with elevated sex hormones levels compared to homosexual behavior. We discussed the hormonal correlates of sexual behavior and partner preferences in Japanese macaques.

Effects of different progestins on prostaglandin biosynthesis in human endometrial explants

OBJECTIVE

To compare the effects of chlormadinone acetate (CMA), dienogest (DNG) and drospirenone (DRSP) on prostaglandin biosynthesis in a human endometrial explants model.

STUDY DESIGN

Human endometrial explants obtained by aspiration curettage and human endometrial YHES cells were stimulated with interleukin-1β (IL-1β) and exposed to CMA, DNG, DRSP or dexamethasone (DEX; YHES cells). Cellular messenger RNA (mRNA) levels of cyclooxygenase-2 (COX-2) were analyzed by reverse-transcription quantitative real-time polymerase chain reaction. Concentrations of prostaglandin F_2α (PGF_2α) in culture supernatants were measured by enzyme-linked immunosorbent assay.

RESULTS

CMA exerted after IL-1β stimulation a stronger down-regulation of COX-2 mRNA compared to DNG and DRSP in human explants (-55% vs. -40% and 46%, respectively). The effect of CMA on COX-2 mRNA was significantly stronger (p=.025) than that of DNG. Moreover, the effect of CMA was independent from cycle phase or presence of endometriosis. In order to evaluate the impact of the investigated progestins on effector molecules, PGF_2α release was determined in supernatants. Again, CMA reduced the PGF_2α release significantly by an average of -60% (p<.01). In contrast, no significant reduction was found for DNG and DRSP. In YHES cells, only DEX but not the progestins under study exerted a significant down-regulating effect (-79%, p<.01) on COX-2 mRNA after IL-1β stimulation.

CONCLUSION

Among the tested progestins, CMA displayed the most consistent suppression of prostaglandin biosynthesis in human endometrial explants.

IMPLICATION

Among three tested progestins, chlormadinone acetate had the most consistent suppressive effect on prostaglandins in endometrial explants. These findings support clinical observations about the efficacy of chlormadinone acetate in dysmenorrhea treatment.

Risks, benefits size and clinical implications of combined oral contraceptive use in women with polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is a complex condition with high risk for dyslipidemia, dysglycemia, venous thromboembolism, cardiovascular disease and metabolic syndrome. Because the combined oral contraceptive (COC) use has also been associated with impaired fasting glucose, insulin resistance and increased risk of thromboembolism disease, it is rationale to think that the combination of oral contraceptive and PCOS could make it worse or increase the risks.

OBJECTIVE

To examine the current data regarding potential additional risks and benefits of contraceptive use, highlights the major gap in knowledge for designing future studies and, when possible, suggests an adequate COC formulation for a determined PCOS phenotype.

METHODS

English-language publications reporting on the influence of COCS in the development of venous thromboembolism in PCOS patients published until 2017 were searched using PubMed, Cochrane database, and hand search of references found in consulted articles. Ranges of collected data are given; the pooled data are presented as median and first and third quartiles. Wilcoxon signed-ranks test for paired samples was used to compare before-after original data. P value was set at 0.05.

RESULTS

Most of COCs preparations significantly decrease androgens, and increase sex-hormone binding globulin. Therefore, the benefits of COCs are clear in patients with proved hyperandrogenemia. Regarding the impact of COCs on carbohydrate metabolism of PCOS subjects, the data were inconsistent but they tended to show no additional risk. Regarding lipids, most COCs consistently increased high-density lipoprotein cholesterol, triglycerides and total cholesterol concentrations but the clinical implications of these changes need additional studies.

CONCLUSION

The review showed consistent beneficial effect of COCs, particularly for hyperandrogenemic PCOS patients. The benefit size of COC's use by normoandrogenemic PCOS patients is uncertain and need more investigation. The effects of COC use on carbohydrate metabolism of women with PCOS are still unresolved since most studies are observational but the current results demonstrated that COCs do not make their levels worse and may improve insulin sensitivity. The impact of COCs on lipids of PCOS patients seems to be clearer and most preparations increase total cholesterol, high-density lipoprotein cholesterol and triglycerides. In summary, it is important to balance the potential benefits and risks of the COCs individually before prescribing them for PCOS women.

The effect of chlormadinone acetate on odontogenic differentiation of human dental pulp cells: in vitro study

Background

Chlormadinone acetate (CMA) is a derivative of progesterone and is used as an oral contraceptive. The aim of this study was to investigate the effects of CMA on odontogenic differentiation and mineralization of human dental pulp cells (hDPCs) and related signaling pathways.

Methods

Cell viability was determined by the water-soluble tetrazolium (WST)-1 assay. Odontogenic differentiation of hDPCs was evaluated by real-time polymerase chain reaction using odontogenic marker genes, such as alkaline phosphatase (ALP), osteocalcin (OCN), dentin sialophosphoprotein (DSPP), and dentin matrix protein-1 (DMP-1). Mineralization of hDPCs was evaluated by ALP staining and alizarin red staining. The extracellular signal-regulated kinase (ERK) pathway was examined by Western blot analysis.

Results

There was no statistically significant difference in cell viability between the control and CMA-treated groups. Our analysis of odontogenic marker genes indicated that CMA enhanced the expression of those genes. CMA-treated hDPCs showed increased ALP activity and formation of mineralized nodules, compared with control-treated cells. In addition, CMA stimulation resulted in phosphorylation of ERK and resulted in inhibition of downstream molecules by the ERK inhibitor U0126.

Conclusions

These findings suggest that CMA improves odontogenic differentiation and mineralization of hDPCs through the ERK signaling pathway.

Comparison of the effects of chlormadinone acetate versus drospirenone containing oral contraceptives on metabolic and hormonal parameters in women with PCOS for a period of two-year follow-up

OBJECTIVE

A randomized trial to compare the effects of two oral contraceptive pills containing either chlormadinone acetate or drospirenone as the progestogen, in women with PCOS for a period of two-year follow-up.

METHODS

Group A received ethinyl-estradiol 0.03 mg + drospirenone 3 mg (EE + DRSP; n = 56) and Group B received ethinyl-estradiol 0.03 mg + chlormadinone acetate 2 mg (EE + CMA; n = 50). Clinical, hormonal and biochemical parameters were compared at baseline, 6 months, 12 months and 24 months.

RESULTS

The increase in total cholesterol and hsCRP levels was statistically significantly higher at 6, 12 and 24 months in Group B when compared with Group A. The change in the high-density lipoprotein cholesterol level at the 24 months of treatment was statistically significantly higher in Group A. Group A has a significantly higher reduction in FAI at 6 and 24 months, in FGS at 6, 12 and 24 months and in HOMA-IR index at 12 and 24 months when compared with Group B.

CONCLUSIONS

Drospirenone containing combined oral contraceptive (COC) is found to have more favorable effects on lipid profiles, hsCRP levels, insulin resistance and hyperandrogenism when compared with the CMA containing COC and appears to be more beneficial for the long-term cardiovascular and metabolic aspects of PCOS.

Tailoring combination oral contraceptives to the individual woman

BACKGROUND

Over the last 50 years, there has been intense interest in the type of progestin used in combined oral contraceptives (COC) in an attempt to exploit novel properties and minimize adverse events. At the same time, the dose of synthetic estrogen, ethinylestradiol, in COC pills has been reduced to minimize risks for ischemic stroke, myocardial infarction, and venous thromboembolism. New formulations, including extended-cycle or continuous-use COCs or those that use a natural estrogen, estradiol, may offer improvements over their predecessors.

METHODS

A Medline search was performed to encompass studies published since 1990 that pertain to the pharmacology of estrogens and progestins used in COCs, risks and adverse events associated with COCs, and extended or continuous-use COCs.

RESULTS

New progestins structurally related to progesterone and spironolactone may exhibit more selective binding to the progesterone receptor and lack androgenic adverse effects associated with progestins structurally related to testosterone. Recently, COCs containing natural (17β-estradiol) or conjugated estrogen (estradiol valerate) rather than ethinylestradiol have been developed in order to move to a more natural estrogen. Although many of the new progestins incorporated into COCs have not demonstrated the negative effects on lipid metabolism and other adverse events associated with the traditional progestins, the goal of attaining good cycle control has yet to be achieved. Extended-cycle and continuous-use regimens are now available that reduce the frequency of menses, but breakthrough bleeding remains a problem.

CONCLUSIONS

Appropriate counseling to raise awareness of the specific characteristics of the different COC options available may optimize adherence and patient acceptability.

Endocrinological, metabolic and clinical features of treatment with oral contraceptive formulation containing ethinylestradiol plus chlormadinone acetate in nonobese women with polycystic ovary syndrome

BACKGROUND

Chlormadinone acetate (CMA) is a progestin compound similar to progesterone, with antiandrogenic properties. In healthy eumenorrheic women, it was demonstrated that the monophasic estroprogestin formulation containing CMA (2 mg) plus ethinyl estradiol (EE) (30 mcg) (EE30+CMA) is efficacious both in reducing hyperandrogenic symptoms, fat mass and in improving lipoprotein panel, without changes in insulin-glucose metabolism. These metabolic properties are important for women affected by polycystic ovary syndrome (PCOS) in whom there is a predisposition to insulin resistance.

STUDY DESIGN

We studied whether in young nonobese women with PCOS (15 subjects, EE30+CMA-PCOS group) a six-cycle treatment with EE30+CMA can reduce androgen levels, androgen bioavailability and the score of hirsutism and acne, and modify glucose-insulin metabolism evaluated by the oral glucose tolerance test and the body composition evaluated by bio-impedenziometry. These parameters were evaluated before (first visit) and during the sixth cycle of EE30+CMA (second visit). All the results were compared with those of a matched-age-group of nonobese PCOS women (15 subjects, no OC-PCOS group) evaluated before (first visit) and after six menstrual cycles in which they did not use any drug or oral contraceptive (second visit).

RESULTS

In the EE30+CMA-PCOS group women, androgen levels and bioavailability, hirsutism and acne score were significantly lower at the second than at the first visit, whereas they did not change in no OC-PCOS group. At the second visit, in both groups, glucose-insulin metabolism and body composition parameters were not affected.

CONCLUSIONS

A six-cycle treatment with EE30+CMA is efficacious in nonobese PCOS women to improve hyperandrogenic symptoms, without negative interferences both on body composition and on insulin-glucose metabolism.

Effects of an oral contraceptive containing chlormadinone and ethinylestradiol on acne-prone skin of women of different age groups: an open-label, single-centre, phase IV study

BACKGROUND AND OBJECTIVE

Acne-prone skin, a common skin condition not only in adolescents but also in adults, can significantly influence the affected individual's quality of life. The aim of this open-label, prospective, single-centre, phase IV study was to investigate the effects of an oral contraceptive containing chlormadinone 2 mg and ethinylestradiol 0.03 mg (Belara) on the physiology of acne-prone facial skin in healthy women aged 18-37 years.

METHODS

Forty-four Caucasian women requesting hormonal contraception divided into two age groups (group A: 18-27 years; group B: 28-37 years) were treated with chlormadinone/ethinylestradiol for six menstrual cycles. During each treatment phase, each subject took one tablet per day for 21 consecutive days, followed by a 7-day pill-free interval. Medication was commenced on the first day of menses. Changes in skin parameters were evaluated in terms of the clinical sum score (the primary outcome variable, calculated from the number of comedones, the number of papules/papulopustules, and the sebum secretion state), the evaluation of the pore size using standardized photography, and a range of biophysical in vivo measurements, assessed at baseline, after 12 weeks and after 24 weeks.

RESULTS

In both age groups, facial skin condition as quantified by the clinical sum score improved significantly after three and six treatment cycles, with reduced numbers of acne lesions (comedones and papules/papulopustules) and a reduction in seborrhoea. Moreover, there was a statistically significant decrease in pore size. Biophysical evaluations confirmed favourable effects of the medication on diverse skin parameters. Skin surface pH remained within the normal physiological range and there was an improvement in epidermal barrier function (as manifested by decreased transepidermal water loss from the skin of the forehead). Stratum corneum hydration increased in both age groups and the lipid content of the skin surface on the forehead decreased significantly after three treatment cycles in subjects aged 28-37 years. Ultrasound measurements verified that there was no retention of water within the dermis. There was no difference between the two age groups.

CONCLUSION

For the first time, improvements in several facial skin parameters during treatment with a combined oral contraceptive (chlormadinone/ethinyl-estradiol) were quantified by biophysical methods and a clinical sum score. The highly statistically significant improvements in clinical findings and various biophysical skin parameters observed in this study suggest that the antiandrogenic oral contraceptive chlormadinone/ethinylestradiol may be a major therapy option in women with acne-prone skin who request hormonal contraception.