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Fruzzetti F, Fidecicchi T, Gambacciani M. Oestrogens in oral contraception: considerations for tailoring prescription to women's needs. EUR J CONTRACEP REPR 2024; 29:93-102. [PMID: 38683756 DOI: 10.1080/13625187.2024.2334350] [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: 01/31/2024] [Accepted: 03/19/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND The oestrogenic component of combined oral contraceptives (COCs) has changed over years with the aim of reducing oestrogen-related side effects and risks, whilst maintaining oestrogen beneficial effects, particularly on cycle control. PURPOSE To describe the pharmacological profiles of different oestrogens commonly used in COCs to provide insights on contraceptive prescription tailored to women's needs. RESULTS All COCs ensure a high contraceptive efficacy. COCs containing the natural oestrogens oestradiol (E2), oestradiol valerate (E2V) and estetrol (E4) have limited impact on liver metabolism, lipid and carbohydrate metabolism, haemostasis and sex hormone binding globulin levels, compared with ethinylestradiol (EE). COCs with E2 and E2V appear also to entail a lower elevation of the risk of venous thromboembolism vs. EE-containing pills. No epidemiological data are available for E4-COC. E2- and E2V-containing COCs seem to exert a less stabilising oestrogenic effect on the endometrium compared with EE-COCs. The E4-COC results in a predictable bleeding pattern with a high rate of scheduled bleeding and minimal unscheduled bleeding per cycle. Based on in vitro and in vivo animal data, E4 seems to be associated with a lower effect on cell breast proliferation. CONCLUSION Today various COCs contain different oestrogens. Prescribers must be familiar with the different properties of each oestrogen for a tailored contraceptive recommendation, considering their safety and contraceptive efficacy, as well as women's needs and preferences.
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Affiliation(s)
- Franca Fruzzetti
- Gynecological Endocrinology Unit, San Rossore Clinical Center, Pisa, Italy
| | - Tiziana Fidecicchi
- Department of Obstetrics and Gynecology, Ospedale Santa Chiara, University of Pisa, Pisa, Italy
| | - Marco Gambacciani
- Gynecological Endocrinology Unit, San Rossore Clinical Center, Pisa, Italy
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2
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Stanczyk FZ, Winer SA, Foidart JM, Archer DF. Comparison of estrogenic components used for hormonal contraception. Contraception 2024; 130:110310. [PMID: 37863464 DOI: 10.1016/j.contraception.2023.110310] [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: 04/21/2023] [Revised: 10/12/2023] [Accepted: 10/13/2023] [Indexed: 10/22/2023]
Abstract
Attempts have been made over the years to replace ethinyl estradiol (EE) in combined oral contraceptives (COCs) with the less potent natural estrogen estradiol (E2), or its prodrug, E2 valerate (E2V), to improve their safety and tolerability. Recently, a COC incorporating a novel weak natural estrogen, estetrol (E4), combined with drospirenone, has become available. We present a comparative analysis of the three prevailing estrogens used in COCs, focusing on their structure-function relationships, receptor-binding affinity, potency, metabolism, pharmacokinetic parameters, and pharmacodynamics. The binding affinity of EE to estrogen receptor (ER)α is twice that of E2, whereas its affinity for ERβ is about one-half that of E2. E4 has a lower binding affinity for the ERs than E2. The high potency of EE is notable in its dramatic increase in estrogen-sensitive hepatic globulins and coagulation factors. EE and E2 undergo extensive and comparable metabolism, while E4 produces only a very limited number of metabolites. E4 has the highest bioavailability among the three estrogens, with E2 having <5%. Studies demonstrate consistent ovulation inhibition, although a higher dose of E4 (15 mg) in COCs is required to achieve follicular suppression compared to E2 (1-3 mg) and EE (0.01-0.035 mg). E2 and E4 in COCs may be less stimulatory of coagulant proteins than EE. Studies with E2/dienogest suggest a comparable risk of venous thromboembolism to EE/levonorgestrel, while data assessing risk with an E4-based COC are insufficient. Nevertheless, the E4-based formulation shows promise as a potential alternative to EE and E2 due to its lower potency and possibly fewer side effects.
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Affiliation(s)
- Frank Z Stanczyk
- Department of Obstetrics and Gynecology, University of Southern California, Keck School of Medicine, Los Angeles, CA, United States.
| | - Sharon A Winer
- Department of Obstetrics and Gynecology, University of Southern California, Keck School of Medicine, Los Angeles, CA, United States
| | - Jean-Michel Foidart
- Department of Obstetrics and Gynecology, University of Liege, Liege, Belgium
| | - David F Archer
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, United States
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Creinin MD, Angulo A, Colli E, Archer DF. The efficacy, safety, and tolerability of an estrogen-free oral contraceptive drospirenone 4 mg (24/4-day regimen) in obese users. Contraception 2023; 128:110136. [PMID: 37544572 DOI: 10.1016/j.contraception.2023.110136] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/25/2023] [Accepted: 08/02/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVES This study aimed to compare contraceptive efficacy and safety of drospirenone 4 mg in a 24/4-day regimen in nonobese and obese users and describe pharmacokinetics according to bodyweight. STUDY DESIGN We analyzed data from three drospirenone 4 mg trials (2 European and 1 United States) to report outcomes in nonobese (body mass index <30 kg/m2) and obese (body mass index ≥30 kg/m2) users. We used data from the US trial to calculate the Pearl Index (pregnancies per 100 woman-years) in nonbreastfeeding participants aged ≤35 years at enrollment for confirmed pregnancies. We assessed safety outcomes from all trials based on reported treatment-emergent adverse events. We evaluated pharmacokinetics by bodyweight in the US trial. RESULTS The three trials combined comprised 2152 nonobese and 425 obese participants, including 590 nonobese and 325 obese participants in the US trial. Eight nonobese and four obese participants had confirmed pregnancies in the US trial, resulting in Pearl Indices of 3.0 (95% CI: 1.3-5.8) and 2.9 (95% CI: 0.8-7.3), respectively. Two-hundred forty-four (11.3%) nonobese and 39 (9.2%) obese participants discontinued due to a treatment-emergent adverse event. The pharmacokinetic analysis included 814 participants with a median weight of 73 (interquartile range 61-89) kg and median plasma drospirenone exposure (AUC0-24ss) of 661.3 (interquartile range 522-828) ng∙h/mL. Changing bodyweight from the median to the fifth percentile (51 kg) or 95th percentile (118 kg) changed drospirenone exposure (AUC0-24,ss) by 22.2% and -23.6%, respectively. CONCLUSIONS Drospirenone 4 mg demonstrated similar contraceptive efficacy for both nonobese and obese users despite a difference in exposure based on bodyweight. IMPLICATIONS Our limited comparison between obese and nonobese users of drospirenone-only oral contraception demonstrated no evidence that efficacy or discontinuation for adverse events differs between groups. Serum drospirenone levels vary by bodyweight and may correlate with bleeding outcomes.
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Affiliation(s)
- Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, United States
| | | | | | - David F Archer
- Clinical Research Center, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, United States
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Foidart JM, Gemzell-Danielsson K, Kubba A, Douxfils J, Creinin MD, Gaspard U. The benefits of estetrol addition to drospirenone for contraception. AJOG GLOBAL REPORTS 2023; 3:100266. [PMID: 37854030 PMCID: PMC10580049 DOI: 10.1016/j.xagr.2023.100266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023] Open
Abstract
Ethinylestradiol and drospirenone combined oral contraceptive formulations have been marketed for >20 years. Drospirenone has antimineralocorticoid and anti-androgenic effects that may offer several health benefits. Recently, 2 new drospirenone-containing oral contraceptives entered the market, 1 as a progestin-only pill containing 4 mg drospirenone and the other as a combined oral contraceptive containing 15 mg estetrol and 3 mg drospirenone. Estetrol has a unique differential effect on nuclear and membrane estrogen α-receptors when compared with other estrogens, leading to low impact on the liver, breast, and hemostasis parameters and a beneficial effect on the endometrium, vagina, cardiovascular system, bone, and brain. Phase 3 clinical studies demonstrated that the Pearl Index (pregnancies per 100-woman-years) for drospirenone alone is 4.0 in the United States and 0.93 in the European Union and for the estetrol-drospirenone combination it is 2.65 and 0.44, respectively. Drospirenone alone demonstrates high rates of unscheduled bleeding and low rates of scheduled bleeding, whereas the estetrol-drospirenone combination demonstrates a predictable and regular bleeding profile for most users with a high stable rate of scheduled bleeding and a low rate of unscheduled bleeding, reported primarily as spotting only. The adverse event profiles and discontinuation rates owing to adverse events are comparable, and no clinically significant effects were observed on metabolic parameters with either product. Hemostatic assays for drospirenone do not fully evaluate all parameters although the testing that is available suggests negligible effects, whereas validated hemostatic assays demonstrate that the estetrol-drospirenone combination has limited impact on hemostasis. The introduction of 4 mg drospirenone and 15 mg estetrol with 3 mg drospirenone are valuable additions to the contraceptive market. Adding estetrol to 3 mg drospirenone provides advantages of contraceptive efficacy and a regular, predictable bleeding profile with minimal impact on hemostasis parameters.
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Affiliation(s)
- Jean Michel Foidart
- Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium (Prof Foidart and Prof Gaspard)
- Estetra SRL, an affiliate company of Mithra Pharmaceuticals, Liège, Belgium (Prof Foidart)
| | - Kristina Gemzell-Danielsson
- Department of Women's and Children's Health, Karolinska Institute, and Karolinska University Hospital, Stockholm, Sweden (Prof Gemzell-Danielsson)
| | - Ali Kubba
- Department of Gynecological Oncology, Guy's Hospital, London, United Kingdom (Prof Kubba)
| | - Jonathan Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, University of Namur, Namur, Belgium (Prof Douxfils)
- Qualiblood s.a, Namur, Belgium (Prof Douxfils)
| | - Mitchell D. Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA (Prof Creinin)
| | - Ulysse Gaspard
- Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium (Prof Foidart and Prof Gaspard)
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Palma F, Costa AR, Neves J, Pacheco A, Almeida MC, Bombas T, Silva DP. Perception of oral contraception – do women think differently from gynaecologists? EUR J CONTRACEP REPR 2023; 28:125-131. [PMID: 36971323 DOI: 10.1080/13625187.2023.2185482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
PURPOSE This study aimed to assess the experience and satisfaction with contraceptives and use of Combined Oral Contraceptives (COC) by women and compare their perceptions with those of gynaecologists. METHODS This was a multicentre survey study conducted in Portugal, during April and May, 2021 with women using contraceptives and gynaecologists. Online quantitative questionnaires were carried out. RESULTS A total of 1508 women and 100 gynaecologists were included. Cycle control was the pill non-contraceptive benefit most valued by gynaecologists and women. For gynaecologists, the main pill concern was the risk of thromboembolic events, but they believed that weight gain was the main concern for their patients. The pill was the most used contraceptive (70%) and women were largely (92%) satisfied. The pill was associated with health risks for 85% of users, mainly thrombosis (83%), weight gain (47%), and cancer (37%). The attributes of the pill most valued by women are contraceptive efficacy (82%), followed by low risk of thromboembolic events (68%), good cycle control (60%), non-interference with libido and mood (59%) and weight (53%). CONCLUSION Most women use contraceptive pills and are generally satisfied with their contraceptive. Cycle control was the most valued non-contraceptive benefit for gynaecologists and women, agreeing with physicians' beliefs about women. On the other hand, contrary to physicians' beliefs, that women's main concern is weight gain, women are mainly concerned with risks associated with contraceptives. Thromboembolic events are women's and gynaecologists most valued risk. Finally, this study indicates the need for physicians to better understand what COC users really fear.
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Morimont L, Jost M, Gaspard U, Foidart JM, Dogné JM, Douxfils J. Low Thrombin Generation in Users of a Contraceptive Containing Estetrol and Drospirenone. J Clin Endocrinol Metab 2022; 108:135-143. [PMID: 36099501 PMCID: PMC9759169 DOI: 10.1210/clinem/dgac511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/11/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To compare the impact on thrombin generation of the new combined oral contraceptive containing 15 mg estetrol and 3 mg drospirenone with ethinylestradiol (30 or 20 mcg) associated either with 150 mcg levonorgestrel or with 3 mg drospirenone. METHODS Data were collected from the "E4/DRSP Endocrine Function, Metabolic Control and Hemostasis Study" (NCT02957630). Overall, the per-protocol set population included 24 subjects in the ethinylestradiol/levonorgestrel arm, 28 subjects in the ethinylestradiol/drospirenone arm, and 34 subjects in the estetrol/drospirenone arm. Thrombograms and thrombin generation parameters (lag time, peak, time to peak, endogenous thrombin potential, and mean velocity rate index) were extracted for each subject at baseline and after 6 cycles of treatment. RESULTS After 6 cycles of treatment, ethinylestradiol-containing products arms show a mean thrombogram outside the upper limit of the reference range, that is the 97.5th percentile of all baseline thrombograms. On the other hand, the mean thrombogram of estetrol/drospirenone is within this reference interval. After 6 cycles of treatment, all thrombin generation parameters are statistically less affected by estetrol/drospirenone than ethinylestradiol-containing products. CONCLUSIONS In conclusion, an association of 15 mg estetrol with 3 mg drospirenone does not have an impact on thrombin generation compared with ethinylestradiol-containing products that, either associated with levonorgestrel or drospirenone, are able to increase the production of procoagulant factors and decrease the production of anticoagulant ones, shifting the patient to a prothrombotic state. Ethinylestradiol-containing products thus generate prothrombotic environments contrary to estetrol which demonstrates a neutral profile on hemostasis.
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Affiliation(s)
- Laure Morimont
- Correspondence: Laure Morimont, PharmD, Research Department, Qualiblood sa, Rue du Séminaire 20a, 5000 Namur, Belgium.
| | - Maud Jost
- Estetra SRL, An Affiliate’s Company of Mithra Pharmaceuticals, Liège, 4020 Liège, Belgium
| | - Ulysse Gaspard
- Department of Obstetrics and Gynecology, University of Liège, 4000 Liège, Belgium
| | - Jean-Michel Foidart
- Estetra SRL, An Affiliate’s Company of Mithra Pharmaceuticals, Liège, 4020 Liège, Belgium
- University of Liège, 4000 Liège, Belgium
| | - Jean-Michel Dogné
- Faculty of Medicine, Department of Pharmacy, Namur Research Institute for Life Sciences (NARILIS), Clinical Pharmacology Research Group, University of Namur, 5000 Namur, Belgium
| | - Jonathan Douxfils
- Research Department, Qualiblood sa, 5000 Namur, Belgium
- Faculty of Medicine, Department of Pharmacy, Namur Research Institute for Life Sciences (NARILIS), Clinical Pharmacology Research Group, University of Namur, 5000 Namur, Belgium
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7
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Pooled analysis of two phase 3 trials evaluating the effects of a novel combined oral contraceptive containing estetrol/drospirenone on bleeding patterns in healthy women. Contraception 2022; 116:29-36. [PMID: 35921872 DOI: 10.1016/j.contraception.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 07/27/2022] [Accepted: 07/27/2022] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To evaluate the bleeding patterns of a new combined oral contraceptive containing estetrol (E4) 15 mg/drospirenone (DRSP) 3 mg in a 24/4-day regimen. STUDY DESIGN We pooled bleeding data from two parallel, open-label, 13-cycle phase 3 trials that enrolled participants 16 to 50 years old with body mass index (BMI) ≤35 kg/m2. Participants reported vaginal bleeding/spotting in daily diaries. For this bleeding analysis, we included participants with at least one evaluable cycle. We calculated mean frequencies of scheduled and unscheduled bleeding/spotting episodes and median duration of bleeding/spotting episodes, and assessed associations between treatment compliance, BMI and recent hormonal contraceptive use on bleeding/spotting outcomes. RESULTS We included 3409 participants with 33,815 cycles. Scheduled bleeding/spotting occurred in 87.2% to 90.4% of participants/cycle, with a median duration of 4 to 5 days. Unscheduled bleeding/spotting decreased from 27.1% in Cycle 1 to 20.6% in Cycle 2 to ≤17.5% from Cycle 5 onwards. Most (66.5%) unscheduled bleeding/spotting episodes were spotting-only. Between 5.8% and 7.8% of users/cycle experienced absence of any scheduled or unscheduled bleeding/spotting. Missing one or more active pills resulted in a higher occurrence of unscheduled bleeding/spotting (adjusted odds ratio [aOR] 2.13 [95% confidence interval 1.68-2.70]) and absence of scheduled bleeding/spotting (aOR 2.36 [1.82-3.07]). Participants with a BMI ≥30 kg/m2 reported more absence of scheduled bleeding/spotting (aOR 1.68 [1.37-2.05]). Switchers and starters reported similar frequencies of unscheduled bleeding/spotting (aOR 0.94 [0.83-1.07]) and absence of scheduled bleeding/spotting (aOR 1.00 [0.85-1.19]). Three percent of participants discontinued for a bleeding-related adverse event. CONCLUSION E4/DRSP use results in a predictable bleeding pattern with limited unscheduled bleeding/spotting. Noncompliance and BMI affect bleeding patterns. IMPLICATIONS STATEMENT Most estetrol/drospirenone users experience a predictable and regular bleeding pattern. Providers can educate patients about the expected bleeding patterns and should advise users that they may infrequently experience no scheduled bleeding/spotting. This information may improve user acceptability and continuation of this new oral contraceptive.
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Al Kindi R, Al Salmani A, Al Hadhrami R, Al Sumri S, Al Sumri H. Perspective Chapter: Modern Birth Control Methods. Stud Fam Plann 2022. [DOI: 10.5772/intechopen.103858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This chapter focuses on various modern birth control methods, including combined oral contraceptives, progestogen-only pills, progestogen-only injectables, progestogen-only implants, intrauterine devices, barrier contraceptives, and emergency contraceptive pills. Each contraceptive method is covered in detail, including mechanism of action, effectiveness, health benefits, advantages, disadvantages, risks, and side-effects.
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9
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Bleeding Patterns of Oral Contraceptives with a Cyclic Dosing Regimen: An Overview. J Clin Med 2022; 11:jcm11154634. [PMID: 35956249 PMCID: PMC9369460 DOI: 10.3390/jcm11154634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/29/2022] [Accepted: 07/30/2022] [Indexed: 11/17/2022] Open
Abstract
Bleeding irregularities are one of the major reasons for discontinuation of oral contraceptives (OCs), and therefore clinicians need to set expectations during consultations. In this review we provide an overview of bleeding data of recently marketed cyclic combined OCs (COCs) and one progestin-only pill (POP). We evaluated data from phase 3 trials (≥12 months) used to gain regulatory approval. Overall, each type of OC has its own specific bleeding pattern. These patterns however were assessed by using different bleeding definitions, which hampers comparisons between products. In COCs, the estrogen balances the effects of the progestin on the endometrium, resulting in a regular bleeding pattern. However, this balance seems lost if a too low dose of ethinylestradiol (EE) (e.g., 10 µg in EE/norethindrone acetate 1 mg) is used in an attempt to lower the risk of venous thromboembolism. Replacement of EE by 17β-estradiol (E2) or E2 valerate could lead to suboptimal bleeding profile due to destabilization of the endometrium. Replacement of EE with estetrol (E4) 15 mg in the combination with drospirenone (DRSP) 3 mg is associated with a predictable and regular scheduled bleeding profile, while the POP containing DRSP 4 mg in a 24/4 regimen is associated with a higher rate of unscheduled and absence of scheduled bleeding than combined products.
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10
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Abstract
Estetrol/drospirenone is a combined oral contraceptive (COC) with a plant-synthesised foetal oestrogen (estetrol) and a well-established progestin (drospirenone). In preclinical models, estetrol has lower binding affinity for the oestrogen receptor-α (ER-α) in contrast to estradiol and has antagonistic properties against membrane ER-α in several tissues, including the breast, while retaining agonistic activity on receptors located in the nucleus. The low oestrogenicity of estetrol may potentially contribute to reduced thrombotic risk. Estetrol/drospirenone was an effective contraceptive in phase II and III clinical trials, with regular and predictable bleeding cycles maintained in the majority of women. Estetrol/drospirenone was generally well-tolerated with metrorrhagia reported as the most common treatment-related adverse event, which is consistent with other COCs. Cases of migraines with aura (or severe migraines), deep vein thrombosis, hyperkalaemia and depression were rarely reported during the phase III trials. Overall, estetrol/drospirenone is an effective and generally well-tolerated COC, with a potentially reduced risk of thrombosis. In 2019, an estimated 44% of women aged 15–49 years worldwide used modern contraception methods, and in these women using modern methods, 18% used an oral contraceptive. Estetrol/drospirenone is a combined oral contraceptive (COC) which uses estetrol, a plant-synthesised oestrogen naturally produced by the human foetal liver during pregnancy, in combination with drospirenone, a well-known progestin. Combined, these hormones suppress ovulation, which constitutes their primary mode of action in preventing pregnancy. As estetrol has weaker oestrogen-related effects, it may potentially reduce the risk for blood clots. Estetrol/drospirenone was an effective contraceptive in clinical trials, and most women had regular and predictable bleeding cycles. Metrorrhagia (i.e. abnormal bleeding) was the most commonly reported treatment-related adverse effect; however, this is a common issue with hormonal contraceptives. Cases of severe migraine headaches, deep vein thrombosis, high potassium levels or depression were rarely reported during clinical trials. Estetrol/drospirenone is an effective oral contraceptive, which may offer a contraceptive option with a lower risk for blood clots. However, further research is required to confirm the reduced risk of clotting.
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Gérard C, Arnal JF, Jost M, Douxfils J, Lenfant F, Fontaine C, Houtman R, Archer DF, Reid RL, Lobo RA, Gaspard U, Coelingh Bennink HJT, Creinin MD, Foidart JM. Profile of estetrol, a promising native estrogen for oral contraception and the relief of climacteric symptoms of menopause. Expert Rev Clin Pharmacol 2022; 15:121-137. [PMID: 35306927 DOI: 10.1080/17512433.2022.2054413] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Estrogens used in women's healthcare have been associated with increased risks of venous thromboembolism (VTE) and breast cancer. Estetrol (E4), an estrogen produced by the human fetal liver, has recently been approved for the first time as a new estrogenic component of a novel combined oral contraceptive (E4/drospirenone [DRSP]) for over a decade. In phase 3 studies, E4/DRSP showed good contraceptive efficacy, a predictable bleeding pattern, and a favorable safety and tolerability profile. AREAS COVERED This narrative review discusses E4's pharmacological characteristics, mode of action, and the results of preclinical and clinical studies for contraception, as well as for menopause and oncology. EXPERT OPINION Extensive studies have elucidated the properties of E4 that underlie its favorable safety profile. While classical estrogens (such as estradiol) exert their actions via both activation of nuclear and membrane estrogen receptor α (ERα), E4 presents a specific profile of ERα activation: E4 binds and activates nuclear ERα but does not induce the activation of membrane ERα signaling pathways in specific tissues. E4 has a small effect on normal breast tissue proliferation and minimally affects hepatic parameters. This distinct profile of ERα activation, uncoupling nuclear and membrane activation, is unique.
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Affiliation(s)
- Céline Gérard
- Department Research and Development, Estetra Srl, an Affiliate Company of Mithra Pharmaceuticals, Liège, Belgium
| | - Jean-François Arnal
- CHU de Toulouse, Université Toulouse III, Toulouse, France.,INSERM-UPS UMR U1297, Institut des Maladies Métaboliques et Cardiovasculaires, Université de Toulouse, Toulouse, France
| | - Maud Jost
- Department Research and Development, Estetra Srl, an Affiliate Company of Mithra Pharmaceuticals, Liège, Belgium
| | - Jonathan Douxfils
- Qualiblood S.a, Namur, Belgium.,Department of Pharmacy, Namur Thrombosis and Hemostasis Center, NAmur Research Institute for Life Sciences, University of Namur, Namur, Belgium
| | - Françoise Lenfant
- CHU de Toulouse, Université Toulouse III, Toulouse, France.,INSERM-UPS UMR U1297, Institut des Maladies Métaboliques et Cardiovasculaires, Université de Toulouse, Toulouse, France
| | - Coralie Fontaine
- CHU de Toulouse, Université Toulouse III, Toulouse, France.,INSERM-UPS UMR U1297, Institut des Maladies Métaboliques et Cardiovasculaires, Université de Toulouse, Toulouse, France
| | | | | | - Robert L Reid
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Queen's University, Kingston, Canada
| | - Rogerio A Lobo
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, USA
| | - Ulysse Gaspard
- Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium
| | | | - Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Sacramento, USA
| | - Jean-Michel Foidart
- Department Research and Development, Estetra Srl, an Affiliate Company of Mithra Pharmaceuticals, Liège, Belgium.,Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium
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12
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Creinin MD, Westhoff CL, Bouchard C, Chen MJ, Jensen JT, Kaunitz AM, Achilles SL, Foidart JM, Archer DF. Estetrol-drospirenone combination oral contraceptive: North American phase 3 efficacy and safety results. Contraception 2021; 104:222-228. [PMID: 34000251 DOI: 10.1016/j.contraception.2021.05.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/19/2021] [Accepted: 05/04/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To assess efficacy, cycle control, and safety of an oral contraceptive containing estetrol (E4) 15 mg and drospirenone (DRSP) 3 mg. STUDY DESIGN Women aged 16 to 50 years with a body mass index ≤35 kg/m2 enrolled in this multicenter, open-label, 13-cycle, phase 3 trial evaluating E4/DRSP in a 24-active/4-placebo regimen. Follow-up was scheduled at Cycles 2, 4, 7, and 10 and within 3 weeks of completing Cycle 13. Participants used daily diaries to record pill use and vaginal bleeding. We evaluated efficacy outcomes in women 16 to 35 years and bleeding patterns and safety (adverse events [AEs]) in all participants. We assessed overall and method-failure pregnancy rates using the Pearl index (PI) and life-table analysis. Scheduled bleeding included spotting or bleeding starting during the 4-day placebo period or first 3 days of the next cycle. RESULTS We enrolled 1864 women of whom 1674 were 16 to 35 years. Women 16 to 35 years had a PI of 2.65 (95% CI 1.73-3.88), method-failure PI of 1.43 (95% CI 0.7-2.39) and 13-cycle life-table pregnancy rate of 2.1%. Scheduled bleeding occurred in 82.9% to 87.0% of women per cycle; median duration was 4.5 days. Unscheduled bleeding decreased from 30.3% in Cycle 1 to 21.3% to 22.1% during Cycles 2 to 4 and remained stable (15.5% to 19.2%) thereafter. The most frequently reported AEs were headache (5.0%) and metrorrhagia (4.6%). One-hundred thirty-two (7.1%) women discontinued the study early for an AE, most commonly for metrorrhagia (0.9%) and menorrhagia (0.8%). No thromboembolic events occurred. CONCLUSION E4/DRSP is an effective oral contraceptive with a predictable bleeding pattern for most women and low AE rates. IMPLICATIONS STATEMENT A new oral contraceptive with a novel estrogen, estetrol, combined with drospirenone has efficacy and safety within the range of other available oral contraceptives. Large phase 4 studies will be needed to confirm if this combination is associated with an improved adverse event profile or lower thrombosis risk.
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Affiliation(s)
- Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, United States.
| | - Carolyn L Westhoff
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY, United States
| | - Céline Bouchard
- Clinique de Recherche en Santé des Femmes, Quebec City, QC, Canada
| | - Melissa J Chen
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, United States
| | - Jeffrey T Jensen
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR, United States
| | - Andrew M Kaunitz
- Department of Obstetrics and Gynecology, University of Florida Jacksonville, Jacksonville, FL, United States
| | - Sharon L Achilles
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh/Magee-Womens Hospital, Pittsburgh, PA, United States
| | - Jean-Michel Foidart
- Mithra Pharmaceuticals, Liège, Belgium; Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium
| | - David F Archer
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, United States
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Feinberg T, Rougerie M, Dahan YS, Dahan MH. A review of the use of hormonal contraception in women with non-cardiovascular coexisting medical conditions. A comprehensive review. ACTA ACUST UNITED AC 2020; 72:82-89. [PMID: 32186166 DOI: 10.23736/s0026-4784.20.04509-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Previously, the American College of Obstetrics and Gynecology (ACOG) had published an excellent practice bulletin addressing the use of hormone contraception in women with pre-existing medical conditions. This practice bulletin became out of date. The Centers for Disease Control and prevention (CDC) of the USA subsequently developed a point form guideline for the use of oral contraceptives in women with coexisting medical conditions. EVIDENCE ACQUISITION Although this acts as a guide, it leaves the clinician without an understanding of why they are doing what they are doing. This article is one of two related to women with coexisting medical conditions. EVIDENCE SYNTHESIS In this article we will provide an update of the scientific knowledge since the publication of the ACOG guideline (2006). It is to be used as a supplement for those who desire more information than that found in the CDC guidelines. CONCLUSIONS Although some recommendations have remained unchanged over the years, the development of lower dose contraceptive pills as well as the increased incidence of comorbid conditions, such as metabolic syndrome, in younger women seeking contraception has brought along new research and new evidence to guide clinicians in the prescription of these medications.
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Affiliation(s)
- Tehila Feinberg
- Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Michelle Rougerie
- Department of Obstetrics and Gynecology, McGill University Health Center, McGill University, Montréal, QC, Canada
| | | | - Michael H Dahan
- Department of Obstetrics and Gynecology, McGill University Health Center, McGill University, Montréal, QC, Canada -
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Pradhan S, Gomez-Lobo V. Hormonal Contraceptives, Intrauterine Devices, Gonadotropin-releasing Hormone Analogues and Testosterone: Menstrual Suppression in Special Adolescent Populations. J Pediatr Adolesc Gynecol 2019; 32:S23-S29. [PMID: 30980941 DOI: 10.1016/j.jpag.2019.04.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 04/03/2019] [Accepted: 04/05/2019] [Indexed: 12/17/2022]
Abstract
Menstrual suppression (the use of hormonal contraceptive methods to eliminate or significantly decrease the frequency of menstrual cycles) is frequently used in the adolescent population for the management of menstrual symptoms such as heavy or painful periods, premenstrual syndrome, menstrual migraines, or even for patient preference. However, in cases of menstrual suppression in special populations additional risks and benefits need to be considered. The purpose of this article is to review the options and medical considerations for menstrual suppression in patients undergoing chemotherapy who might be at risk of abnormal uterine bleeding, those with intellectual or physical disability, and transgender and gender nonbinary individuals.
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Affiliation(s)
- Shashwati Pradhan
- Division of Pediatric and Adolescent Gynecology, Washington Hospital Center, Children's National Medical Center, Georgetown University, Washington, DC
| | - Veronica Gomez-Lobo
- Division of Pediatric and Adolescent Gynecology, Washington Hospital Center, Children's National Medical Center, Georgetown University, Washington, DC.
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Black A, Guilbert E, Costescu D, Dunn S, Fisher W, Kives S, Mirosh M, Norman WV, Pymar H, Reid R, Roy G, Varto H, Waddington A, Wagner MS, Whelan AM. No. 329-Canadian Contraception Consensus Part 4 of 4 Chapter 9: Combined Hormonal Contraception. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 39:229-268.e5. [PMID: 28413042 DOI: 10.1016/j.jogc.2016.10.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality. OUTCOMES Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, safety, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the availability of cited contraceptive methods in Canada. EVIDENCE Medline and the Cochrane Database were searched for articles in English on subjects related to contraception, sexuality, and sexual health from January 1994 to December 2015 in order to update the Canadian Contraception Consensus published February-April 2004. Relevant Canadian government publications and position papers from appropriate health and family planning organizations were also reviewed. VALUES The quality of the evidence is rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice are ranked according to the method described in this report. SUMMARY STATEMENTS RECOMMENDATIONS.
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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.
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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
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Zhang C, Yan G. Synergistic drug combinations prediction by integrating pharmacological data. Synth Syst Biotechnol 2019; 4:67-72. [PMID: 30820478 PMCID: PMC6370570 DOI: 10.1016/j.synbio.2018.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 09/30/2018] [Accepted: 10/04/2018] [Indexed: 12/12/2022] Open
Abstract
There is compelling evidence that synergistic drug combinations have become promising strategies for combating complex diseases, and they have evident predominance comparing to traditional one drug - one disease approaches. In this paper, we develop a computational method, namely SyFFM, that takes pharmacological data into consideration and applies field-aware factorization machines to analyze and predict potential synergistic drug combinations. Firstly, features of drug pairs are constructed based on associations between drugs and target, and enzymes, and indication areas. Then, the synergistic scores of drug combinations are obtained by implementing field-aware factorization machines on latent vector space of these features. Finally, synergistic combinations can be predicted by introducing a threshold. We applied SyFFM to predict pairwise synergistic combinations and three-drug synergistic combinations, and the performance is good in terms of cross-validation. Besides, more than 90% combinations of the top ranked predictions are proved by literature and the analysis of parameters in model shows that our method can help to investigate and explain synergistic mechanisms underlying combinatorial therapy.
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Affiliation(s)
- Chengzhi Zhang
- Academy of Mathematics and Systems Science, Chinese Academy of Sciences, Beijing 100190, PR China.,School of Mathematical Sciences, University of Chinese Academy of Sciences, Beijing, 100049, PR China
| | - Guiying Yan
- Academy of Mathematics and Systems Science, Chinese Academy of Sciences, Beijing 100190, PR China.,School of Mathematical Sciences, University of Chinese Academy of Sciences, Beijing, 100049, PR China
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Kolok AS, Ali JM, Rogan EG, Bartelt-Hunt SL. The Fate of Synthetic and Endogenous Hormones Used in the US Beef and Dairy Industries and the Potential for Human Exposure. Curr Environ Health Rep 2018; 5:225-232. [PMID: 29754262 DOI: 10.1007/s40572-018-0197-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW Growth-enhancing chemicals used by the beef and dairy industries may be bioavailable to humans via milk, meat, and other environmental matrices. This review evaluates the potential for environmental transport and bioavailability of the active chemical to humans. RECENT FINDINGS Bovine somatostatin is detectable in milk; however, there is no evidence that the protein persists in the environment nor that it is active in humans. In contrast, steroids are transported through milk and meat to humans where they may exert biological activity. Furthermore, environmental matrices such as raw water and dust may also allow for the environmental transport and bioavailability of steroids to humans. Endogenous and exogenous steroids can be found in the meat, milk, and waste materials produced by cattle. While the concentrations may be low, exposure to these matrices, most notably dairy products made with whole milk, can be a source of exogenous steroids to humans.
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Affiliation(s)
- Alan S Kolok
- Idaho Water Resources Research Institute, University of Idaho, 875 Perimeter Drive, MS 3002, Moscow, ID, 83843, USA.
| | - Jonathan M Ali
- Department of Civil Engineering, University of Nebraska Lincoln, 1110 S. 67th Street, Omaha, NE, 681822-0178, USA
| | - Eleanor G Rogan
- Department of Environmental, Agricultural and Occupational Health, 984388 Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Shannon L Bartelt-Hunt
- Department of Civil Engineering, University of Nebraska Lincoln, 1110 S. 67th Street, Omaha, NE, 681822-0178, USA
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Black A, Guilbert E, Costescu D, Dunn S, Fisher W, Kives S, Mirosh M, Norman WV, Pymar H, Reid R, Roy G, Varto H, Waddington A, Wagner MS, Whelan AM. No 329-Consensus canadien sur la contraception (4e partie de 4) : chapitre 9 – contraception hormonale combinée. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 39:269-314.e5. [DOI: 10.1016/j.jogc.2017.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Lopez LM, Bernholc A, Chen M, Grey TW, Otterness C, Westhoff C, Edelman A, Helmerhorst FM. Hormonal contraceptives for contraception in overweight or obese women. Cochrane Database Syst Rev 2016; 2016:CD008452. [PMID: 27537097 PMCID: PMC9063995 DOI: 10.1002/14651858.cd008452.pub4] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Obesity has reached epidemic proportions around the world. Effectiveness of hormonal contraceptives may be related to metabolic changes in obesity or to greater body mass or body fat. Hormonal contraceptives include oral contraceptives (OCs), injectables, implants, hormonal intrauterine contraception (IUC), the transdermal patch, and the vaginal ring. Given the prevalence of overweight and obesity, the public health impact of any effect on contraceptive efficacy could be substantial. OBJECTIVES To examine the effectiveness of hormonal contraceptives in preventing pregnancy among women who are overweight or obese versus women with a lower body mass index (BMI) or weight. SEARCH METHODS Until 4 August 2016, we searched for studies in PubMed (MEDLINE), CENTRAL, POPLINE, Web of Science, ClinicalTrials.gov, and ICTRP. We examined reference lists of pertinent articles to identify other studies. For the initial review, we wrote to investigators to find additional published or unpublished studies. SELECTION CRITERIA All study designs were eligible. The study could have examined any type of hormonal contraceptive. Reports had to contain information on the specific contraceptive methods used. The primary outcome was pregnancy. Overweight or obese women must have been identified by an analysis cutoff for weight or BMI (kg/m(2)). DATA COLLECTION AND ANALYSIS Two authors independently extracted the data. One entered the data into RevMan and a second verified accuracy. The main comparisons were between overweight or obese women and women of lower weight or BMI. We examined the quality of evidence using the Newcastle-Ottawa Quality Assessment Scale. Where available, we included life-table rates. We also used unadjusted pregnancy rates, relative risk (RR), or rate ratio when those were the only results provided. For dichotomous variables, we computed an odds ratio with 95% confidence interval (CI). MAIN RESULTS With 8 studies added in this update, 17 met our inclusion criteria and had a total of 63,813 women. We focus here on 12 studies that provided high, moderate, or low quality evidence. Most did not show a higher pregnancy risk among overweight or obese women. Of five COC studies, two found BMI to be associated with pregnancy but in different directions. With an OC containing norethindrone acetate and ethinyl estradiol (EE), pregnancy risk was higher for overweight women, i.e. with BMI ≥ 25 versus those with BMI < 25 (reported relative risk 2.49, 95% CI 1.01 to 6.13). In contrast, a trial using an OC with levonorgestrel and EE reported a Pearl Index of 0 for obese women (BMI ≥ 30) versus 5.59 for nonobese women (BMI < 30). The same trial tested a transdermal patch containing levonorgestrel and EE. Within the patch group, obese women in the "treatment-compliant" subgroup had a higher reported Pearl Index than nonobese women (4.63 versus 2.15). Of five implant studies, two that examined the six-capsule levonorgestrel implant showed differences in pregnancy by weight. One study showed higher weight was associated with higher pregnancy rate in years 6 and 7 combined (reported P < 0.05). In the other, pregnancy rates differed in year 5 among the lower weight groups only (reported P < 0.01) and did not involve women weighing 70 kg or more.Analysis of data from other contraceptive methods indicated no association of pregnancy with overweight or obesity. These included depot medroxyprogesterone acetate (subcutaneous), levonorgestrel IUC, the two-rod levonorgestrel implant, and the etonogestrel implant. AUTHORS' CONCLUSIONS The evidence generally did not indicate an association between higher BMI or weight and effectiveness of hormonal contraceptives. However, we found few studies for most contraceptive methods. Studies using BMI, rather than weight alone, can provide information about whether body composition is related to contraceptive effectiveness. The contraceptive methods examined here are among the most effective when used according to the recommended regimen.We considered the overall quality of evidence to be low for the objectives of this review. More recent reports provided evidence of varying quality, while the quality was generally low for older studies. For many trials the quality would be higher for their original purpose rather than the non-randomized comparisons here. Investigators should consider adjusting for potential confounding related to BMI or contraceptive effectiveness. Newer studies included a greater proportion of overweight or obese women, which helps in examining effectiveness and side effects of hormonal contraceptives within those groups.
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Affiliation(s)
- Laureen M Lopez
- FHI 360Clinical and Epidemiological Sciences359 Blackwell St, Suite 200DurhamNorth CarolinaUSA27701
| | - Alissa Bernholc
- FHI 360Biostatistics359 Blackwell St, Suite 200DurhamNorth CarolinaUSA27701
| | - Mario Chen
- FHI 360Biostatistics359 Blackwell St, Suite 200DurhamNorth CarolinaUSA27701
| | - Thomas W Grey
- FHI 360Social and Behavioral Health Sciences359 Blackwell St, Suite 200DurhamNorth CarolinaUSA27701
| | | | - Carolyn Westhoff
- Columbia UniversityDept of Obstetrics and Gynecology630 West 168 StreetNew YorkNew YorkUSANY 10032
| | - Alison Edelman
- Oregon Health & Science UniversityDept. of Obstetrics and GynecologyPortlandOregonUSA
| | - Frans M Helmerhorst
- Leiden University Medical CenterDept. of Clinical EpidemiologyPO Box 9600Albinusdreef 2LeidenNetherlandsNL 2300 RC
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Côté-Leduc M, Roy G. The Pill at 56 and Counting: Still Contracepting After All These Years. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2016. [DOI: 10.1007/s13669-016-0143-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Nakajima ST, Pappadakis J, Archer DF. Body mass index does not affect the efficacy or bleeding profile during use of an ultra-low-dose combined oral contraceptive. Contraception 2016; 93:52-7. [DOI: 10.1016/j.contraception.2015.09.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 09/08/2015] [Accepted: 09/22/2015] [Indexed: 10/23/2022]
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Seidman L, Kroll R, Howard B, Ricciotti N, Hsieh J, Weiss H. Ovulatory effects of three oral contraceptive regimens: a randomized, open-label, descriptive trial. Contraception 2015; 91:495-502. [DOI: 10.1016/j.contraception.2015.03.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 02/26/2015] [Accepted: 03/01/2015] [Indexed: 10/23/2022]
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Abstract
BACKGROUND The dosing, schedules, and other aspects of combined oral contraceptive (COC) design have evolved in recent years to address a variety of issues including short- and long-term safety, bleeding profiles, and contraceptive efficacy. In particular, several newer formulations have altered the length of the hormone-free interval (HFI), in order to minimize two key undesired effects that occur during this time: hormone-withdrawal-associated symptoms (HWaS) and follicular development. OBJECTIVE This primer reviews our current understanding of the key biological processes that occur during the HFI and how this understanding has led to changes in the dosing and schedule of newer COC formulations. MAIN MESSAGE In brief, HWaS are common, underappreciated, and a likely contributor to COC discontinuation; because of this, shortening the HFI and/or supplementing with estrogen during the progestin-free interval may provide relief from these symptoms and improve adherence. A short HFI (with or without estrogen supplementation) may also help maintain effective follicular suppression and contraceptive efficacy, even when the overall dose of estrogen throughout the cycle is low. CONCLUSIONS Taken together, the available data about HWaS and follicular activity during the HFI support the rationale for recent COC designs that use a low estrogen dose and a short HFI. The availability of a variety of COC regimens gives physicians a range of choices when selecting the most appropriate COC for each woman's particular priorities and needs.
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Affiliation(s)
- Brian A Hauck
- a a Department of Obstetrics and Gynecology , Foothills Hospital, University of Calgary , Calgary , Alberta , Canada
| | - Vivien Brown
- b b Department of Family and Community Medicine , University of Toronto , Toronto , Ontario , Canada
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Stanczyk FZ, Archer DF. Gestodene: a review of its pharmacology, potency and tolerability in combined contraceptive preparations. Contraception 2013; 89:242-52. [PMID: 24485094 DOI: 10.1016/j.contraception.2013.12.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 11/28/2013] [Accepted: 12/05/2013] [Indexed: 11/15/2022]
Abstract
Combined progestin-estrogen pills are an established and reliable contraceptive option used by women worldwide. Combined oral contraceptives (COCs) containing the progestins--gestodene, desogestrel or norgestimate--were developed to minimize androgenic side effects and are considered an effective, well-tolerated contraceptive option. Gestodene achieves contraceptive efficacy with the lowest dose of any progestin in a COC, and has an established and favorable short- and long-term tolerability profile. In this review we present an overview of the pharmacology, potency and tolerability of gestodene.
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Affiliation(s)
- Frank Z Stanczyk
- University of Southern California Keck School of Medicine, Los Angeles, CA, USA.
| | - David F Archer
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
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