Effects of a triphasic combination oral contraceptive containing norgestimate/ethinyl estradiol on biochemical markers of bone metabolism in young women with osteopenia secondary to hypothalamic amenorrhea

Hormonal contraception and medical readiness for female service members

Many female military service members choose to use hormonal contraception to prevent pregnancy and/or to control or suppress menses. Hormonal contraception, which comes in many different forms based on dose, estrogen/progestin type, and route of administration (oral, vaginal, transdermal, implant, intrauterine device, injectable), may cause side effects, some of which can influence military medical readiness, or the health status necessary to perform assigned missions. This expert review summarizes the evidence around common military-relevant side effects of hormonal contraception that could impact readiness, including effects on weight and body composition, bone health, psychological health, and physical performance, and serves as a tool for uniformed and civilian clinicians counseling female service members about hormonal contraception. Current evidence suggests some hormonal contraception can lead to weight and fat gain, may modulate susceptibility to mood or mental health disorders, and could impact bone mineral density and stress fracture risk; more research is needed on physical performance effects. Clinicians must be familiar with readiness considerations of each type of hormonal contraception to provide comprehensive patient education and allow for optimal shared decision-making about hormonal contraception use among female Service members. Considering the relative lack of data on the effects of nonoral hormonal contraception routes on readiness outcomes and the growing interest in long-acting reversible contraceptives among female service members, future research should continue to investigate effects of all hormonal contraception methods available to service members.

Hormonal contraceptive use, bone density and biochemical markers of bone metabolism in British Army recruits

INTRODUCTION

Hormonal contraceptive use might impair bone health and increase the risk of stress fracture by decreasing endogenous oestrogen production, a central regulator of bone metabolism. This cross-sectional study investigated bone density and biochemical markers of bone metabolism in women taking hormonal contraceptives on entry to basic military training.

METHODS

Forty-five female British Army recruits had biochemical markers of bone metabolism, areal bone mineral density (aBMD) and tibial speed of sound (tSOS) measured at the start of basic military training. Participants were compared by their method of hormonal contraception: no hormonal contraception (NONE), combined contraceptive pill (CP) or depot-medroxyprogesterone acetate (DMPA) (20±2.8 years, 1.64±0.63 m, 61.7±6.2 kg).

RESULTS

aBMD was not different between groups (p≥0.204), but tSOS was higher in NONE (3%, p=0.014) when compared with DMPA users. Beta C-terminal telopeptide was higher in NONE (45%, p=0.037) and DMPA users (90%, p=0.003) compared with CP users. Procollagen type 1 N-terminal propeptide was higher in DMPA users compared with NONE (43%, p=0.045) and CP users (127%, p=0.001), and higher in NONE compared with CP users (59%, p=0.014). Bone alkaline phosphatase was higher in DMPA users compared with CP users (56%, p=0.044).

CONCLUSIONS

DMPA use was associated with increased bone turnover and decreased cortical bone integrity of the tibia. Lower cortical bone integrity in DMPA users was possibly mediated by increased intracortical remodelling, but trabecular bone was not affected by contraceptive use.

Bone health in functional hypothalamic amenorrhea: What the endocrinologist needs to know

In the original definition by Klinefelter, Albright and Griswold, the expression "hypothalamic hypoestrogenism" was used to describe functional hypothalamic amenorrhoea (FHA). Given the well-known effects of estrogens on bone, the physiopathology of skeletal fragility in this condition may appear self-explanatory. Actually, a growing body of evidence has clarified that estrogens are only part of the story. FHA occurs in eating disorders, overtraining, and during psychological or physical stress. Despite some specific characteristics which differentiate these conditions, relative energy deficiency is a common trigger that initiates the metabolic and endocrine derangements contributing to bone loss. Conversely, data on the impact of amenorrhoea on bone density or microarchitecture are controversial, and reduced bone mass is observed even in patients with preserved menstrual cycle. Consistently, oral estrogen-progestin combinations have not proven beneficial on bone density of amenorrheic women. Low bone density is a highly prevalent finding in these patients and entails an increased risk of stress or fragility fractures, and failure to achieve peak bone mass and target height in young girls. Pharmacological treatments have been studied, including androgens, insulin-like growth factor-1, bisphosphonates, denosumab, teriparatide, leptin, but none of them is currently approved for use in FHA. A timely screening for bone complications and a multidisciplinary, customized approach aiming to restore energy balance, ensure adequate protein, calcium and vitamin D intake, and reverse the detrimental metabolic-endocrine changes typical of this condition, should be the preferred approach until further studies are available.

Effects of oral contraceptives and natural menstrual cycling on environmental learning

BACKGROUND

Endogenous ovarian hormones as well as exogenous oestradiol and progesterone play an important role in cognitive processing. Specifically, these hormones play a role in different aspects of memory, both in terms of storage capacity and temporal duration of the mnemonic track. These hormones also have various effects on different types of memory (i.e., verbal, visuo-spatial, prospective). This study investigated the effects of hormones on topographic memory, a type of memory specifically needed to recall a pathway and to acquire spatial information about locations, distances, and directions.

METHODS

We compared 25 naturally cycling women (NCW) in two different cycling phases, the early follicular phase (4th - 5th days) and the mid-luteal phase (20th-21st days), with 26 women taking oral contraceptives (OC) tested in the active pill phase (20th to 21st day of OC cycle) and the inactive pill phase (2nd to 4th day of OC cycle). Both groups performed the Walking Corsi Test to assess topographic memory in their respective cycling phases. Women were instructed to learn an eight-step sequence path and recall the path five minutes later.

RESULTS

We found that the two groups differed in terms of learning the 8-step sequence path; OC users were always better (4-5 days vs. 20-21 days) than NCW. No differences emerged in the delayed recall of the same path.

CONCLUSIONS

As already observed in other memory domains (i.e., verbal memory, emotional memory), OC users showed an advantage in terms of topographic learning. Our results might be explained by hormonal mechanisms and may suggest the future application of OC in women with topographic disorders or visuo-spatial difficulties.

Food Versus Pharmacy: Assessment of Nutritional and Pharmacological Strategies to Improve Bone Health in Energy-Deficient Exercising Women

PURPOSE OF REVIEW

The review aims to summarize our current knowledge surrounding treatment strategies aimed at recovery of bone mass in energy-deficient women suffering from the Female Athlete Triad.

RECENT FINDINGS

The independent and interactive contributions of energy status versus estrogen status on bone density, geometry, and strength have recently been reported, highlighting the importance of addressing both energy and estrogen in treatment strategies for bone health. This is supported by reports that have identified energy-related features (low body weight and BMI) and estrogen-related features (late age of menarche, oligo/amenorrhea) to be significant risk factors for low bone mineral density and bone stress injury in female athletes and exercising women. Nutritional therapy is the recommended first line of treatment to recover bone mass in energy-deficient female athletes and exercising women. If nutritional therapy fails after 12 months or if fractures or significant worsening in BMD occurs, pharmacological therapy may be considered in the form of transdermal estradiol with cyclic oral progestin (not COC).

Bone mineral density in young women with primary ovarian insufficiency: results of a three-year randomized controlled trial of physiological transdermal estradiol and testosterone replacement

CONTEXT

Women with primary ovarian insufficiency have significantly lower serum estradiol and T levels compared with regularly menstruating women. They also have significantly reduced bone mineral density (BMD).

OBJECTIVE

The objective of the study was to evaluate the efficacy of hormone replacement in maintaining BMD in these young women.

DESIGN AND SETTING

This was a randomized, double-blind, single-center, placebo-controlled clinical trial at the National Institutes of Health clinical center (Bethesda, Maryland).

PARTICIPANTS

Young women with primary ovarian insufficiency participated in the study.

INTERVENTIONS

We compared the effect of estradiol and progestin replacement (n = 72) vs estradiol, progestin, and T replacement (n = 73) on BMD. We also compared findings with a contemporaneous control group of normal women (n = 70). All patients received transdermal estradiol (100 μg/d) plus oral medroxyprogesterone acetate 10 mg/d (12 d/mo) for a 3-month run-in period before being randomized in a double-blinded fashion to the addition of transdermal T (150 μg/d) or placebo.

MAIN OUTCOME MEASURE

Change in BMD at the femoral neck was measured by dual-energy x-ray absorptiometry.

RESULTS

At screening, patients had significantly lower femoral neck BMD compared with control women (0.77 vs 0.81 g/cm(2), P = .001) and did not differ in body mass index, age at menarche, or education level. Normal control women lost femoral neck BMD over the study period, whereas patients on estradiol and progestin therapy gained BMD; and at the end of the study period, femoral neck BMD of patients on estradiol and progestin therapy did not differ from that of control women (0.80 g/cm(2) in both groups, P = .9). The addition of T showed no further benefit (percentage change in BMD 3.9 vs 2.4, respectively, P = .9). Nonetheless, using a repeated-measures model, the T group achieved a mean BMD in the femoral neck 0.015 g/cm(2) higher than the placebo group at 3 years (95% confidence interval -0.005 to 0.034, P = .13). Similar findings were observed in the lumbar spine BMD as well.

CONCLUSION

Long-term physiological transdermal estradiol replacement in combination with oral medroxyprogesterone acetate restores mean femoral neck BMD to normal in young women with spontaneous 46,XX primary ovarian insufficiency. However, the addition of physiological transdermal T replacement did not provide additional benefit.

Does lifetime exposure to hormones predict pretreatment cognitive function in women before adjuvant therapy for breast cancer?

OBJECTIVE

Women with breast cancer have been found to have poorer cognitive function before the initiation of systemic adjuvant therapy than their age- and education-matched counterparts. The basis for this may partly include hormone exposure during the course of a woman's life.

METHODS

We compared cognitive function between postmenopausal women with breast cancer before the initiation of systemic adjuvant therapy and healthy age- and education-matched postmenopausal women and examined whether factors related to lifetime exposure to hormones predicted cognitive function before therapy.

RESULTS

We found that, compared with healthy women, women with breast cancer had poorer memory (P = 0.05) and attention (P = 0.006). Controlling for the covariates age and estimated verbal intelligence, we found that factors related to greater lifetime hormone exposure (oral contraceptive use, greater years since menopause, and longer duration of hormone therapy) predicted cognitive function (executive function, verbal learning and memory, attention, psychomotor efficiency, and visual sustained attention) in women with and without breast cancer but did not explain the differences in cognitive function observed at pretreatment in women with breast cancer.

CONCLUSIONS

Other factors may explain the poorer pretreatment cognitive function in women with breast cancer, including persistent effects of surgical operation and anesthesia, sleep problems, and tumor-related factors. Additional studies are needed to explicate the basis of poorer pretherapy cognitive function in this population.

Combination contraceptives: effects on weight

BACKGROUND

Weight gain is often considered a side effect of combination hormonal contraceptives, and many women and clinicians believe that an association exists. Concern about weight gain can limit the use of this highly effective method of contraception by deterring the initiation of its use and causing early discontinuation among users. However, a causal relationship between combination contraceptives and weight gain has not been established.

OBJECTIVES

The aim of the review was to evaluate the potential association between combination contraceptive use and changes in weight.

SEARCH METHODS

In November 2013, we searched the computerized databases CENTRAL (The Cochrane Library), MEDLINE, POPLINE, EMBASE, and LILACS for studies of combination contraceptives, as well as ClinicalTrials.gov and International Clinical Trials Registry Platform (ICTRP). For the initial review, we also wrote to known investigators and manufacturers to request information about other published or unpublished trials not discovered in our search.

SELECTION CRITERIA

All English-language, randomized controlled trials were eligible if they had at least three treatment cycles and compared a combination contraceptive to a placebo or to a combination contraceptive that differed in drug, dosage, regimen, or study length.

DATA COLLECTION AND ANALYSIS

All titles and abstracts located in the literature searches were assessed. Data were entered and analyzed with RevMan. A second author verified the data entered. For continuous data, we calculated the mean difference and 95% confidence interval (CI) for the mean change in weight between baseline and post-treatment measurements using a fixed-effect model. For categorical data, such as the proportion of women who gained or lost more than a specified amount of weight, the Peto odds ratio with 95% CI was calculated.

MAIN RESULTS

We found 49 trials that met our inclusion criteria. The trials included 85 weight change comparisons for 52 distinct contraceptive pairs (or placebos). The four trials with a placebo or no intervention group did not find evidence supporting a causal association between combination oral contraceptives or a combination skin patch and weight change. Most comparisons of different combination contraceptives showed no substantial difference in weight. In addition, discontinuation of combination contraceptives because of weight change did not differ between groups where this was studied.

AUTHORS' CONCLUSIONS

Available evidence was insufficient to determine the effect of combination contraceptives on weight, but no large effect was evident. Trials to evaluate the link between combination contraceptives and weight change require a placebo or non-hormonal group to control for other factors, including changes in weight over time.

Combination contraceptives: effects on weight

BACKGROUND

Weight gain is often considered a side effect of combination hormonal contraceptives, and many women and clinicians believe that an association exists. Concern about weight gain can limit the use of this highly effective method of contraception by deterring the initiation of its use and causing early discontinuation among users. However, a causal relationship between combination contraceptives and weight gain has not been established.

OBJECTIVES

The aim of the review was to evaluate the potential association between combination contraceptive use and changes in weight.

SEARCH STRATEGY

We searched the computerized databases CENTRAL (The Cochrane Library), MEDLINE, POPLINE, EMBASE, and LILACS for studies of combination contraceptives, as well as ClinicalTrials.gov and International Clinical Trials Registry Platform (ICTRP). Searches were conducted from January to May 2011. We also wrote to known investigators and manufacturers to request information about other published or unpublished trials not discovered in our search.

SELECTION CRITERIA

All English-language, randomized controlled trials were eligible if they had at least three treatment cycles and compared a combination contraceptive to a placebo or to a combination contraceptive that differed in drug, dosage, regimen, or study length.

DATA COLLECTION AND ANALYSIS

All titles and abstracts located in the literature searches were assessed. Data were entered and analyzed with RevMan. A second author verified the data entered. For continuous data, we calculated the mean difference and 95% confidence interval (CI) for the mean change in weight between baseline and post-treatment measurements using a fixed-effect model. For categorical data, such as the proportion of women who gained or lost more than a specified amount of weight, the Peto odds ratio with 95% CI was calculated.

MAIN RESULTS

We found 49 trials that met our inclusion criteria. The trials included 85 weight change comparisons for 52 distinct contraceptive pairs (or placebos). The four trials with a placebo or no intervention group did not find evidence supporting a causal association between combination oral contraceptives or a combination skin patch and weight change. Most comparisons of different combination contraceptives showed no substantial difference in weight. In addition, discontinuation of combination contraceptives because of weight change did not differ between groups where this was studied.

AUTHORS' CONCLUSIONS

Available evidence was insufficient to determine the effect of combination contraceptives on weight, but no large effect was evident. Trials to evaluate the link between combination contraceptives and weight change require a placebo or non-hormonal group to control for other factors, including changes in weight over time.

The effects of hormonal contraceptives on bone turnover markers and bone health

Sex hormones are important regulators of bone metabolism. As hormonal contraceptives contain either oestrogens or progestins, or a combination thereof, it is conceivable that these widely used agents have an effect on bone metabolism and bone health. The main users of hormonal contraceptives, adolescent girls and young women, are still building bone and accruing bone mass and may therefore be particularly susceptible to the effects of hormonal contraceptives on bone. Despite these concerns, the effects of hormonal contraceptives on bone health are still poorly understood. As biochemical markers of bone turnover have been proven useful tools in the assessment and monitoring of bone metabolism, we reviewed the effects of combined and gestagen-only hormonal contraceptives on bone turnover markers and related effects on bone mineral density and fracture risk in premenopausal women, as documented in the literature until January 2009.

The effect of exercise and estrogen on osteoprotegerin in premenopausal women

BACKGROUND

The benefits of exercise are widely recognized, however physically active women can develop exercise associated menstrual cycle disturbances such as amenorrhea (i.e., estrogen deficiency) secondary to a chronic energy deficiency.

OBJECTIVE

To assess the effects of exercise status and estrogen deficiency on osteoprotegerin (OPG) and its relationship to bone resorption in premenopausal exercising women.

DESIGN

Cross-sectional study of serum OPG, urinary c-telopeptides (uCTX), urinary estrone 3-glucuronide (E1G), urinary pregnanediol 3-glucuronide (PdG) and bone mineral density (BMD) measured on multiple occasions in 67 women. Volunteers were retrospectively grouped: 1) sedentary menstruating group (SedMen n=8), 2) exercising menstruating group (ExMen, n=36), and 3) exercising amenorrheic group (ExAmen, n=23). One-way ANOVAs were performed, and LSD post-hoc tests were performed when differences were detected.

RESULTS

Subjects were similar with respect to age (24.2+/-1.0 years), weight (57.8+/-1.7 kg), and height (164.3+/-1.3 cm) (p>0.05). ExMen and ExAmen groups were more aerobically fit (p=0.003) and had less body fat (p=0.002) than the SedMen group. Resting energy expenditure/fat free mass was lowest (p=0.001) in the ExAmen groups. Mean E1G across the measurement period (p<0.001) and overall E1G exposure as assessed by E1G area under the curve (AUC) (p<0.001) were lower in the ExAmen group vs. the SedMen and ExMen groups. U-CTX-I was elevated (p=0.033) in the ExAmen group (281.8+/-40.3 microg/L/mmCr), compared with the SedMen and ExMen groups (184.5+/-22.4, 197.2+/-14.7 microg/L/mmCr, respectively). OPG was suppressed (p=0.005) in the ExAmen group (4.6+/-0.2 pmol/L) vs. ExMen group (5.2+/-0.2 pmol/L), and OPG was lower in the SedMen group (4.1+/-0.3 pmol/L) compared with the ExMen group. Findings were translated to BMD; the ExAmen group had suppressed total body BMD (p=0.014) and L2-L4 BMD (p=0.015) vs. the ExMen group.

CONCLUSIONS

Our results suggest that OPG responds to the bone loading effect of exercise, and that suppressed OPG may play a role in the etiology of increased bone resorption observed in exercising women with chronic estrogen deficiency secondary to hypothalamic amenorrhea.

Combination contraceptives: effects on weight

BACKGROUND

Weight gain is often considered a side effect of combination hormonal contraceptives, and many women and clinicians believe that an association exists. Concern about weight gain can limit the use of this highly effective method of contraception by deterring the initiation of its use and causing early discontinuation among users. However, a causal relationship between combination contraceptives and weight gain has not been established.

OBJECTIVES

The aim of the review was to evaluate the potential association between combination contraceptive use and changes in weight.

SEARCH STRATEGY

We searched the computerized databases MEDLINE, POPLINE, CENTRAL, EMBASE, and LILACS for studies of combination contraceptives, as well as clinical trials databases. We also wrote to known investigators and manufacturers to request information about other published or unpublished trials not discovered in our search.

SELECTION CRITERIA

All English-language, randomized controlled trials were eligible if they had at least three treatment cycles and compared a combination contraceptive to a placebo or to a combination contraceptive that differed in drug, dosage, regimen, or study length.

DATA COLLECTION AND ANALYSIS

All titles and abstracts located in the literature searches were assessed. Data were entered and analyzed with RevMan, and a second author verified the data entered. Depending on the data available, the mean difference using a fixed effects model with 95% confidence interval (CI) was calculated for the mean change in weight between baseline and post-treatment measurements or the Peto odds ratio with 95% confidence interval was calculated using the proportion of women who gained or lost more than a specified amount of weight.

MAIN RESULTS

The three placebo-controlled, randomized trials did not find evidence supporting a causal association between combination oral contraceptives or a combination skin patch and weight gain. Most comparisons of different combination contraceptives showed no substantial difference in weight. In addition, discontinuation of combination contraceptives because of weight gain did not differ between groups where this was studied.

AUTHORS' CONCLUSIONS

Available evidence was insufficient to determine the effect of combination contraceptives on weight, but no large effect was evident.

Effects of menstrual cycle phase and oral contraceptive use on verbal memory

Surgical or pharmacological suppression of ovarian hormones leads to declines in verbal memory, and estrogen treatment reverses these deficits. In the current study, we investigated the effects of menstrual cycle phase and oral contraceptives on verbal memory, as measured by the California Verbal Learning Test, in two groups of premenopausal women - 16 naturally cycling women and 20 current users of estrogen-based oral contraceptives (OCs). Naturally cycling women were assessed twice - once during the early follicular phase (Days 2-4) and once during the midluteal phase (Days 20-22) of the menstrual cycle. OC users were tested on the same cycle days, corresponding to inactive and active pill phases, respectively. We predicted that naturally cycling women would show improved verbal memory during the midluteal phase, when estradiol levels are high, compared with the follicular phase, when estradiol levels are low. We also predicted that OC users, who show no change in endogenous estradiol across the cycle, would show no change in verbal memory. Contrary to predictions, naturally cycling women showed no changes in verbal memory across the cycle, whereas OC users showed enhanced memory during the active pill phase (p<.05). None of the secondary cognitive outcome measures varied with cycle phase or OC use including measures of visuospatial memory, verbal fluency, visuospatial abilities, and attention. Overall, these results suggest that verbal memory performance in premenopausal women varies across the cycle with OC use, but does not vary systematically with changes in endogenous estradiol.

Strategies to reverse bone loss in women with functional hypothalamic amenorrhea: a systematic review of the literature

Functional hypothalamic amenorrhea (FHA) impairs the attainment of peak bone mass and as such can increase the risk of fractures later in life. To document available treatment strategies, we conducted a systematic review of the literature. We report that hormonal therapies have limited effectiveness in increasing bone mass, whereas increased caloric intake resulting in weight gain and/or resumption of menses is an essential strategy for restoring bone mass in women with FHA.

INTRODUCTION

Women with functional hypothalamic amenorrhea (FHA) may not achieve peak bone mass (PBM), which increases the risk of stress fractures, and may increase the risk of osteoporotic fractures in later life.

METHODS

To identify effective treatment strategies for women with FHA, we conducted a systematic review of the literature. We included randomized controlled trials (RCTs), cross-sectional studies, and case studies that reported on the effects of pharmacological and non-pharmacological interventions on bone mineral density (BMD) or bone turnover in women with FHA.

RESULTS

Most published studies (n=26) were designed to treat the hormonal abnormalities observed in women with FHA (such as low estrogen, leptin, insulin-like growth factor-1, and DHEA); however none of these treatments demonstrated consistent improvements in BMD. Therapies containing an estrogen given for 8-24 months resulted in variable improvements (1.0-19.0%) in BMD, but failed to restore bone mass to that of age-matched controls. Three studies reported on the use of bisphosphonates (3-12 months) in anorexic women, which appear to have limited effectiveness to improve BMD compared to nutritional treatments. Another three investigations showed no improvements in BMD after androgen therapy (DHEA and testosterone) in anorexic women. In contrast, reports (n=9) describing an increase in caloric intake that results in weight gain and/or the resumption of menses reported a 1.1-16.9% increase in BMD concomitant with an improvement in bone formation and reduction in bone resorption markers.

CONCLUSIONS

Our literature review indicates that the most successful, and indeed essential strategy for improving BMD in women with FHA is to increase caloric intake such that body mass is increased and there is a resumption of menses. Further long-term studies to determine the persistence of this effect and to determine the effects of this and other strategies on fracture risk are needed.

Safety, efficacy and patient acceptability of the combined estrogen and progestin transdermal contraceptive patch: a review

The worldwide introduction of the first, unique patch for hormonal contraception (ethinyl estradiol/norelgestromin, EE/NGMN patch) was widely recognized as a significant event in the development of drug delivery systems. This innovation offers a number of advantages over the oral route, and extensive clinical trials have proved its safety, efficacy, effectiveness, and tolerability. The weekly administration and ease of use/simplicity of the EE/NGMN patch contribute to its acceptability, and help to resolve the two main problems of non-adherence, namely early discontinuation and inconsistent use. The patch offers additional benefits to adolescents (improvement of dysmenorrhea and acne), adults (improvement in emotional and physical well-being, premenstrual syndrome, and menstrual irregularities), and perimenopausal women (correction of hormonal imbalance, modulation of premenopausal symptoms), thus providing high satisfaction rates (in nearly 90% of users). Since its introduction, the transdermal contraceptive patch has proved to be a useful choice for women who seek a convenient formulation which is easy to use, with additional, non-contraceptive tailored benefits for all the ages.

Evaluation of bone loss and its mechanisms in anorexia nervosa

The purpose of this cross-sectional study was to assess the extent of and mechanisms involved in bone loss in anorexia nervosa patients. We compared 113 anorexia nervosa patients (mean age 25 +/- 8 years, mean duration of disease 5.7 +/- 6.1 years) with 21 age-matched controls. Mean duration of amenorrhea was 3.2 +/- 4.7 years. We measured serum calcium and phosphate; bone remodeling markers (osteocalcin, bone-specific alkaline phosphatase [BSAP], serum crosslaps [CTX], and carboxyl-terminal telopeptide of type I collagen [ICTP]); follicle-stimulating hormone and luteinizing hormone levels; and estradiol (ultrasensitive assay), cortisol, urinary free cortisol, thyroid function, prolactin, and nutritional factors (insulin-like growth factor I [IGF-I], IGF binding protein 3 [IGFBP3]). In controls, only bone remodeling markers and nutritional factors were measured. Osteodensitometry was also performed on both patients and controls. Weight and body mass index (BMI) were significantly lower in anorexia nervosa patients than in controls (P < 0.0001). No significant differences were observed in biological indicators except for IGF-I, which was lower in anorexia nervosa patients (0.9 +/- 0.4 UI/mL) than in controls (1.5 +/- 0.4 UI/mL) (P < 0.0001). Densitometric measurements at three sites were significantly lower in anorexia nervosa patients and correlated with duration of disease and amenorrhea and with IGF-I at the hip only (P < 0.01). In the study population, osteoporosis was observed in 24 patients (21%) and osteopenia in 54 patients (48%). Patients with osteoporosis were significantly older and had longer disease and amenorrhea durations; lower weight and BMI; higher alkaline phosphatase, BSAP, and osteocalcin; and lower serum ICTP, IGF-I, and IGFBP3. All of these differences were significant and remained so even after multiple adjustments were made, except for IGF-I (P = 0.21). When multivariate analysis was performed, we found that age at onset of amenorrhea, weight, alkaline phosphatase, urinary free cortisol, and serum estradiol concentration accounted for 54% of the variance in spinal bone mineral density (BMD). Duration of amenorrhea, alkaline phosphatase, and weight explained 46.6% of the variance in femoral neck BMD. Duration of amenorrhea, IGF-I, and ICTP levels accounted for 38.6% of the variance observed in total hip BMD. The etiology of bone loss in patients with anorexia nervosa is multifactorial. Hypoestrogenia alone cannot account for this loss, and nutritional factors, IGF-I concentrations in particular, seem to play an important role.

Effect of oral contraceptives and hormone replacement therapy on bone mineral density in premenopausal and perimenopausal women: a systematic review

Seventy five articles on the effect of oral contraceptives and other hormone replacement on bone density in premenopausal and perimenopausal women were reviewed. The evidence was appraised using the Oxford Centre for Evidence-Based Medicine levels of evidence. There is good evidence for a positive effect of oral contraceptives on bone density in perimenopausal women, and fair evidence for a positive effect in "hypothalamic" oligo/amenorrhoeic premenopausal women. There is limited evidence for a positive effect in healthy and anorexic premenopausal women. In hypothalamic oligo/amenorrhoeic women, baseline bone density has been shown to be significantly lower than that in healthy controls, therefore the decision to treat is clinically more important. The ideal formulation(s) and duration of treatment remain to be determined by further longitudinal and prospective randomised controlled trials in larger subject populations.

Combination contraceptives: effects on weight

BACKGROUND

Weight gain is often considered a side effect of combination hormonal contraceptives, and many women and clinicians believe that an association exists. Concern about weight gain can limit the use of this highly effective method of contraception by deterring the initiation of its use and causing early discontinuation among users. However, a causal relationship between combination contraceptives and weight gain has not been established.

OBJECTIVES

The aim of the review was to evaluate the potential association between combination contraceptive use and changes in weight.

SEARCH STRATEGY

We searched the computerized databases MEDLINE, POPLINE, CENTRAL, EMBASE, and LILACS for studies of combination contraceptives. We also wrote to known investigators and manufacturers to request information about other published or unpublished trials not discovered in our search.

SELECTION CRITERIA

All English-language, randomized controlled trials were eligible if they had at least three treatment cycles and compared a combination contraceptive to a placebo or to a combination contraceptive that differed in drug, dosage, regimen, and/or study length.

DATA COLLECTION AND ANALYSIS

All titles and abstracts located in the literature searches were assessed. Data were entered and analyzed with RevMan, and a second author verified the data entered. Depending on the data available, the weighted mean difference using a fixed effects model with 95% confidence intervals (CI) was calculated for the mean change in weight between baseline and post-treatment measurements or the Peto odds ratio with 95% confidence intervals was calculated using the proportion of women who gained or lost more than a specified amount of weight.

MAIN RESULTS

The three placebo-controlled, randomized trials did not find evidence supporting a causal association between combination oral contraceptives or a combination skin patch and weight gain. Most comparisons of different combination contraceptives showed no substantial difference in weight. In addition, discontinuation of combination contraceptives because of weight gain did not differ between groups where this was studied.

AUTHORS' CONCLUSIONS

Available evidence was insufficient to determine the effect of combination contraceptives on weight, but no large effect was evident.

Prior oral contraception and postmenopausal fracture: a Women's Health Initiative observational cohort study

OBJECTIVE

To test for the possible association of past oral contraceptive (OC) use and incident fracture after menopause.

DESIGN

A prospective cohort of 93,725 postmenopausal women.

SETTING

Forty Women's Health Initiative (WHI) clinical centers across the United States.

PATIENT(S)

Ethnically diverse 93,725 volunteer postmenopausal women, 50 to 79 years old.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The main outcome was self-reported incident first fracture assessed prospectively by annual questionnaire.

RESULT(S)

The adjusted relative hazard (HR) for fracture among past OC users was 1.07 (95% CI, 1.01-1.15). Among women without any postmenopausal hormone treatment, past OC use for < or =5 years led to an HR of 1.15 (95% CI, 1.04-1.27) and for past OC use >5 years led to an HR of 1.09 (95% CI, 0.97-1.23) compared with never users.

CONCLUSION(S)

This study does not support the idea that past OC use protects against later fracture.

Effects of an oral contraceptive (norgestimate/ethinyl estradiol) on bone mineral density in women with hypothalamic amenorrhea and osteopenia: an open-label extension of a double-blind, placebo-controlled study

OBJECTIVE

The effects of long-term triphasic oral contraceptive administration on bone mineral density (BMD) were investigated in premenopausal women with hypothalamic amenorrhea (HA) and osteopenia.

METHODS

After completing three 28-day cycles in the double-blind phase of a placebo-controlled trial, women (mean age, 26.7 years) who received norgestimate 180-250 microg/ethinyl estradiol 35 microg (NGM/EE, n = 15) or placebo (n = 12) in the double-blind phase were to receive open-label NGM/EE for 10 additional cycles.

RESULTS

For subjects completing > or =10 NGM/EE treatment cycles, mean posteroanterior total lumbar spine BMD (L1-L4) increased from 0.881+/-0.0624 g/cm2 at baseline (last visit prior to NGM/EE) to 0.894+/-0.0654 g/cm2 at final visit (p = .043); no significant changes in hip BMD occurred. Decreases in N-telopeptide, osteocalcin, procollagen type I propeptide and bone-specific alkaline phosphatase levels indicated effects on bone metabolism.

CONCLUSIONS

Long-term administration of triphasic NGM/EE to osteopenic women with HA may increase total lumbar spine BMD.

High dose estrogen treatment increases bone mineral density in male-to-female transsexuals receiving gonadotropin-releasing hormone agonist in the absence of testosterone

OBJECTIVE

To study the effect of estrogen (E) on the male skeleton in the absence of testosterone (T).

DESIGN

Retrospective analyses of 40 middle-aged transsexuals treated with subcutaneous injections of gonadotropin-releasing hormone agonist every 4 weeks and oral 17-beta-estradiol-valerat 6 mg/day over two years until reassignment surgery.

METHODS

The bone mineral density (BMD) in the femoral neck and lumbar spine (L2-L4) was measured with dual-energy X-ray absorptiometry at the beginning of cross-sex hormone treatment, after 12 and 24 months, and serum T, E, sex hormone-binding globulin (SHBG), calcitonin (CAL), osteocalcin (OSC), and urinary free deoxypyridinoline (DPD) were measured.

RESULTS

After 12 months, a significant increase in BMD in the lumbar spine from 1.2 to 1.234 g/cm2 and after 24 months to 1.274 g/cm2 was observed. There was a significant increase in BMD in the femoral neck area from 1.068 to 1.109 g/cm(2) after 24 months. There was a significant decrease in serum T levels from 18.65 to 0.57 nmol/l after 12 months, and to 0.62 nmol/l after 24 months, a significant increase in SHBG levels from 50.09 to 125 nmol/l after 12 months, and to 130 nmol/l after 24 months, and a significant increase in serum E levels from 73.42 to 881.6 pmol/l after 12 months, and to 923.62 pmol/l after 24 months of cross-sex hormone treatment. Serum levels of CAL, OSC and urinary DPD were unchanged.

CONCLUSION

We conclude that high dose E treatment is able to increase BMD significantly in the femoral neck and lumbar spine independently of serum T levels in middle-aged men. There is no risk of osteoporosis developing in male-to-female transsexuals receiving GnRHa when there is an adequate E substitution.

Effect of oral contraceptive treatment on bone mass acquisition in skeletally immature young female rats

The objective of the present study was to investigate the effect of oral contraceptive (OC) treatment on bone mass accrual in skeletally immature young female rats. Animals in the baseline group were killed at the beginning of the experiment and were subjected to bone density assessment by peripheral quantitative computerized tomography (pQCT). The control group was fed a base diet free of phytoestrogens, while animals in the contraceptive group received the same base diet mixed with 2.67 microg desogestrel/100 g body weight and 0.0533 microg ethinyl estradiol/100 g body weight. The duration of the treatment period was 16 weeks. Densitometric measurements by dual energy x-ray absorptiometry and serum bone markers assessment were carried out at baseline, at 8 weeks and at 16 weeks, while pQCT densitometry took place after sacrifice. All bone mineral density and bone mineral content indices measured by dual energy x-ray absorptiometry increased significantly throughout the study period in both the OC and control group. Concerning pQCT measurements, animals in both the OC and the control group had significantly higher cortical density compared with baseline (midtibia: p=.0003 and .0003, respectively). Total area and periosteal circumference were significantly higher in OC group, both in proximal (p=.003 and .003, respectively) and midtibia (p=.048 and .042, respectively) compared with baseline. Osteoprotegerin serum levels increased in both groups, and at the end of the experiment, circulating osteoprotegerin was significantly higher in the OC group compared with controls (p=.032). At the end of the experiment, carboxyl-terminal telopeptides of collagen type I levels were significantly lower in the OC-treated animals compared with controls (p=.046). Our results suggest that OC administration to skeletally immature female rats allows normal bone accrual and may even improve bone geometry. This effect may be mediated through enhanced inhibition of bone resorption.

Physiological aspects and clinical sequelae of energy deficiency and hypoestrogenism in exercising women

Amenorrhoea associated with reduced caloric intake and strenuous exercise leads to hypoestrogenism and is associated with clinical manifestations that include disordered eating, stress fractures, osteoporosis, and, as recently reported, a potential increase in the risk of premature cardiovascular disease. Disordered eating, menstrual irregularities and bone loss comprise the clinical condition known as the 'female athlete triad'. The aetiology of the triad is linked to a high prevalence of disordered eating and cognitive restraint. This results in inadequate caloric intake for high exercise energy expenditures that leads to energy deficiency. This in turn stimulates compensatory mechanisms, such as weight loss or energy conservation, subsequently causing a central suppression of reproductive function and concomitant hypoestrogenism. Because the aetiology of menstrual disturbances and the female athlete triad is causally linked to energy deficiency, there is no justification for fears that exercise itself is unhealthy for women. However, improved detection, monitoring, and treatment of all components of the triad in exercising women should be emphasized. This paper critically reviews the physiological aspects and clinical sequelae of energy deficiency and hypoestrogenism associated with the female athlete triad in exercising women.

The assessment of bone metabolism in female elite endurance athletes by biochemical bone markers

Purpose: Premature osteoporosis is a frequent problem in female athletes. Current concepts suggest that a disruption of the hypothalamic-pituitary axis leads to hypoestrogenism, which then causes amenorrhea and osteoporosis. However, the underlying mechanisms have been insufficiently investigated. Osteoprotegerin (OPG) and soluble TNF-α receptor antagonist ligand (sRANKL) regulate the balance of osteoblasts and osteoclasts. Their role in the pathogenesis of osteoporosis in female athletes has not been studied yet.

Methods: We measured OPG and sRANKL in relation to biochemical bone markers [osteocalcin (OC), bone alkaline phosphatase (BAP), serum β-crosslaps (CTx)] and female sex hormones [estradiol (E2) and luteinizing hormone (LH)] in fastening blood samples from 25 female elite endurance athletes and 25 matched controls.

Results: Athletes exhibited significantly higher levels of the bone resorption marker CTx than controls (0.61±0.26 vs. 0.44±0.15ng/ml). OPG and sRANKL were not changed. Subgroup analysis revealed that athletes using oral contraceptives [A-OCC(−)] had significantly higher levels of CTx (0.82±0.20 vs. 0.50±0.14ng/ml), BAP [37.3 (23.2–54.4) U/l vs. 25.2 (20.3–35.6) U/l] and OPG (3.4±0.8 vs. 2.7±0.8ng/ml) than controls who did not use oral contraceptives [C-OCC(−)]. While the difference for CTx exceeded the least significant change in this marker by approximately 30%, the differences for the bone formation markers OC and BAP were close to the least significant change. In athletes using oral contraceptives [A-OCC(+)] we found no differences compared to controls.

Conclusions: A-OCC(−) athletes have increased bone turnover with a particular stimulation of bone resorption. The increased bone resorption is not accompanied by a shift of the OPG/sRANKL relationship towards an osteoclastogenic constellation. Since increased bone resorption was not detectable in A-OCC(+) athletes, it can be suggested that OCC use might protect bone health in female athletes.