Oral contraception and insulin sensitivity: in vivo assessment in normal women and women with previous gestational diabetes

U.S. Medical Eligibility Criteria for Contraceptive Use, 2024

The 2024 U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) comprises recommendations for the use of specific contraceptive methods by persons who have certain characteristics or medical conditions. These recommendations for health care providers were updated by CDC after review of the scientific evidence and a meeting with national experts in Atlanta, Georgia, during January 25-27, 2023. The information in this report replaces the 2016 U.S. MEC (CDC. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR 2016:65[No. RR-3]:1-103). Notable updates include 1) the addition of recommendations for persons with chronic kidney disease; 2) revisions to the recommendations for persons with certain characteristics or medical conditions (i.e., breastfeeding, postpartum, postabortion, obesity, surgery, deep venous thrombosis or pulmonary embolism with or without anticoagulant therapy, thrombophilia, superficial venous thrombosis, valvular heart disease, peripartum cardiomyopathy, systemic lupus erythematosus, high risk for HIV infection, cirrhosis, liver tumor, sickle cell disease, solid organ transplantation, and drug interactions with antiretrovirals used for prevention or treatment of HIV infection); and 3) inclusion of new contraceptive methods, including new doses or formulations of combined oral contraceptives, contraceptive patches, vaginal rings, progestin-only pills, levonorgestrel intrauterine devices, and vaginal pH modulator. The recommendations in this report are intended to serve as a source of evidence-based clinical practice guidance for health care providers. The goals of these recommendations are to remove unnecessary medical barriers to accessing and using contraception and to support the provision of person-centered contraceptive counseling and services in a noncoercive manner. Health care providers should always consider the individual clinical circumstances of each person seeking contraceptive services. This report is not intended to be a substitute for professional medical advice for individual patients; when needed, patients should seek advice from their health care providers about contraceptive use.

The effects of hormonal contraceptives on glycemic regulation

A number of side effects have been linked to the use of hormonal contraceptives, among others, alterations in glucose levels. Hence, the objective of this mini-review is to show the main effects of hormonal contraceptive intake on glycemic regulation. First, the most relevant studies on this topic are described, then the mechanisms that might be accountable for this glycemic regulation impairment as exerted by hormonal contraceptives are discussed. Finally, we briefly discuss the ethical responsibility of health professionals to inform about the potential risks on glycemic homeostasis regarding hormonal contraceptive intake.

Diabetes and pregnancy: an endocrine society clinical practice guideline

OBJECTIVE

Our objective was to formulate a clinical practice guideline for the management of the pregnant woman with diabetes.

PARTICIPANTS

The Task Force was composed of a chair, selected by the Clinical Guidelines Subcommittee of The Endocrine Society, 5 additional experts, a methodologist, and a medical writer.

EVIDENCE

This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe both the strength of recommendations and the quality of evidence.

CONSENSUS PROCESS

One group meeting, several conference calls, and innumerable e-mail communications enabled consensus for all recommendations save one with a majority decision being employed for this single exception.

CONCLUSIONS

Using an evidence-based approach, this Diabetes and Pregnancy Clinical Practice Guideline addresses important clinical issues in the contemporary management of women with type 1 or type 2 diabetes preconceptionally, during pregnancy, and in the postpartum setting and in the diagnosis and management of women with gestational diabetes during and after pregnancy.

Comparative study of the therapeutic effects of oral contraceptive pills containing desogestrel, cyproterone acetate, and drospirenone in patients with polycystic ovary syndrome

OBJECTIVE

To compare the effects of oral contraceptive pills containing desogestrel, cyproterone acetate, and drospirenone, in polycystic ovary syndrome (PCOS), after 6 and 12 months of therapy.

DESIGN

Double-blind randomized controlled trial.

SETTING

Gynecologic clinic of the first author.

PATIENT(S)

Women (n = 171) with PCOS (Androgen Excess Society criteria, 2006).

INTERVENTION(S)

The three-arm trial involved 58, 56, and 57 cases in desogestrel, cyproterone acetate, and drospirenone groups, respectively. Body mass index, abdominal circumference, hirsutism score (modified Ferriman Galwey), acne and acanthosis nigricans scores, and blood pressure were noted. Blood levels of total T, sex hormone-binding globulin, fasting glucose, and fasting insulin were measured. Free androgen index, glucose-insulin ratio, and homeostasis model assessment-insulin resistance were calculated. Follow-up was after 6 and 12 months of treatment.

MAIN OUTCOME MEASURE(S)

Primarily, absolute change in the Free Androgen Index score between the three groups and, secondarily, changes in the clinical and other hormonal and biochemical parameters were studied.

RESULT(S)

Six months of treatment showed similar effects. After 12 months, cyproterone acetate significantly decreased the modified Ferriman Galwey score (change = -5.29) compared with both desogestrel (change = -1.69) and drospirenone (change = -2.12); cyproterone acetate significantly increased sex hormone-binding globulin (change = 142.91) compared with desogestrel (change = 99.53); drospirenone significantly increased sex hormone-binding globulin (change = 131.52) compared with desogestrel; and cyproterone acetate significantly decreased the Free Androgen Index (change = -10.57) compared with desogestrel (change = -5.58).

CONCLUSION(S)

No difference in effects after 6 months. At 12 months, cyproterone acetate showed the strongest antiandrogen activities. Effects on metabolic parameters were identical.

CLINICAL TRIAL REGISTRATION NUMBER

CTRI/2010/091/000332.

Oral contraceptives modify DNA methylation and monocyte-derived macrophage function

Background

Fertile women may be encouraged to use contraception during clinical trials to avoid potential drug effects on fetuses. However, hormonal contraception interferes with pharmacokinetics and pharmacodynamics and modifies internal milieus. Macrophages depend on the milieu to which they are exposed. Therefore, we assessed whether macrophage function would be affected by the use of combined oral contraceptives (OCs) and if this influence depended on the androgenic or non-androgenic properties of progestin.

Methods

Healthy adult women were enrolled and stratified into two groups: women who did not use OCs (Fs) and women treated with OCs (FOCs). FOCs were further stratified as a function of androgenic (FOCA⁺) and non-androgenic (FOCA^-) properties of progestins. Routine hematological, biochemical, inflammatory and endothelial dysfunction parameters were measured. Monocyte-derived macrophages (MDMs) were evaluated for the expression and activity of estrogen receptors and androgen receptors, and release of tumor necrosis factor α (TNFα) was measured from unstimulated and lipopolysaccharide-stimulated cells.

Results

As is already known, the use of OCs changed numerous parameters: the number of lymphocytes, iron levels, total iron-binding capacity of transferrin, triglycerides, high-density lipoprotein, total cholesterol, and C-reactive protein increased, while prothrombin time and alkaline phosphatase decreased. Hormonal levels also varied: cortisol was higher in FOCs, while luteinizing hormone, follicle-stimulating hormone, and testosterone were lower in FOCs. Asymmetric dimethylarginine, an index of endothelial function, was lower in FOC than in Fs, as were cysteine and bilirubin. The androgenic properties of progestins affected the activity of OCs: in particular, white blood cell count, hemoglobin, high-density lipoprotein and calcium were higher in FOCA^- than in FOCA⁺, whereas percentage oxygen saturation and γ-glutamyl transpeptidase were lower in FOCA^- than in FOCA⁺. Importantly, FOCs had a lower global DNA methylation, indicating that OC may have epigenetic effects on gene expression. OC did not modify the expression of androgen receptor but increased estrogen receptor α expression, more considerably in FOCA⁺, and decreased estrogen receptor β, more considerably in FOCA^-. Importantly, the activation state of estrogen receptor β in FOCs was decreased, while estrogen receptor α was not active in either Fs or FOCs. Unstimulated MDMs obtained from FOCs showed higher release of TNFα in comparison with Fs. After lipopolysaccharide stimulation, the release of TNFα was significantly higher in Fs than in FOCs.

Conclusions

OC use induced many changes in hematological and plasmatic markers, modifying hormonal levels, endothelial function, inflammation index and some redox state parameters, producing a perturbation of the internal milieu that impacted macrophagic function. In fact, different levels of estrogen receptor expression and release of TNFα were observed in macrophages derived from OC users. Some of the above activities were linked to the androgenic properties of progestin. Even though it is not known whether these effects are reversible, the results indicate that to avoid potential skewing of results only a single type of OC should be used during a single clinical trial.

Hormonal Contraception and Diabetes

Women with gestational diabetes mellitus are at increased risk for developing diabetes mellitus (DM), mainly type 2 DM, as well as metabolic syndrome. The presence of subsequent pregnancies increases the risk. In addition, pregnancy in patients with type 1 and type 2 DM also elevates the risk of morbidity and mortality for both mothers and offspring. Thus, all women with pre-existing type 1 or type 2 DM should receive preconception care to optimize glycemic control (HbA1c ≤ 6%). In those cases with macrovascular or microvascular complications, family planning is even more important in order to avoid the risk of aggravation of such complications associated with a new pregnancy. The present review analyzes the metabolic and cardiovascular repercussions of hormone contraception in non-diabetic women as well as in type 1 and type 2 DM patients with and without macrovascular and microvascular complications. Finally, the recommendations pertaining to hormonal contraceptive methods for women with diabetes are summarized.

Effects of drospirenone pill in Indian women with polycystic ovary syndrome

OBJECTIVE

To study the effects of treatment with a drospirenone pill (DRSP) (with ethinyl oestradiol, EE) in Indian women with polycystic ovary syndrome (PCOS).

MATERIAL AND METHODS

Fifty-one women with PCOS (Androgen excess society criteria, 2006), with preset inclusion-exclusion criteria, treated with a combination of EE 30 mcg and DRSP 3 mg cyclically in the traditional (21+7) regimen, were evaluated at baseline and after six and twelve cycles of treatment. Parameters studied were - body mass index (BMI), abdominal circumference (AC), Ferriman Galwey (FG) score, presence of acne and acanthosis nigricans, serum testosterone, sex hormone binding globulin (SHBG), fasting glucose and fasting insulin levels. Free Androgen Index (FAI) and Glucose: Insulin ratio (G: I) were calculated.

RESULTS

Significant improvements in clinical and biochemical hyperandrogenic parameters were found at the two points of study. There were no significant changes in BMI, AC, incidence of acanthosis, or metabolic parameters studied.

CONCLUSION

EE/DRSP improves hyperandrogenic parameters significantly without affecting the insulin resistance adversely in Indian women with PCOS.

Divergent effects of a combined hormonal oral contraceptive on insulin sensitivity in lean versus obese women

OBJECTIVE

To evaluate the effects of a commonly used combined hormonal oral contraceptive (OC) on carbohydrate metabolism in obese as compared with lean women.

DESIGN

6-month prospective study.

SETTING

Clinical research center at an academic medical center.

PATIENT(S)

Premenopausal nondiabetic women with body mass index <25 kg/m(2) (n = 15) or >30 kg/m(2) (n = 14).

INTERVENTION(S)

Ethinyl estradiol (35 μg) and norgestimate (0.18/0.215/0.25 mg) for 6 cycles.

MAIN OUTCOME MEASURE(S)

Insulin sensitivity by frequent sampling intravenous glucose tolerance test; other indices of insulin sensitivity (homeostatic model assessment of insulin sensitivity index [ISI HOMA], the Matsuda index); fasting lipid panel.

RESULT(S)

Insulin sensitivity changed from 6.62 ± 3.69 min(-1)/mIU/L (baseline) to 8.23 ± 3.30 min(-1)/mIU/L (6 months) in lean women, and from 4.36 ± 2.32 to 3.82 ± 2.32 min(-1)/mIU/L in obese women. Divergent effects on insulin sensitivity were also observed with ISI HOMA and the Matsuda index. Low-density lipoprotein increased by approximately 20 mg/dL in both the lean and obese groups.

CONCLUSION(S)

Lean and obese women exhibit differential changes in insulin sensitivity when given 6 months of a commonly used oral contraceptive. The mechanisms of these differences and whether these divergent effects persist in the long term require further investigation.

Comparison of effects of 3 mg drospirenone plus 20 μg ethinyl estradiol alone or combined with metformin or cyproterone acetate on classic metabolic cardiovascular risk factors in nonobese women with polycystic ovary syndrome

OBJECTIVE

To evaluate the effects of a pill with drospirenone (3 mg) plus ethinyl E(2) (20 μg) (DRP/20EE) alone or associated with metformin or cyproterone acetate (CPA) on some metabolic cardiovascular risk factors in women with polycystic ovary syndrome (PCOS).

DESIGN

Randomized, open-label clinical trial.

SETTING

Academic medical clinic.

PATIENT(S)

Forty-eight hirsute women with PCOS.

INTERVENTION(S)

Patients were randomized to treatment with DRP/20EE or with DRP/20EE plus metformin (1,500 mg/d) or with DRP/20EE plus CPA (12.5 mg/d, 10 days per cycle) for 6 months.

MAIN OUTCOME MEASURE(S)

Blood pressure, lipid profile, and indexes of glucose tolerance and insulin sensitivity were assessed before and after 6 months of treatment.

RESULT(S)

Body mass index and blood pressure were not modified by any treatment. Treatment with DRP/EE20 did not change the lipid profile; DRP/EE20 plus metformin significantly increased high-density lipoprotein cholesterol concentrations; DRP/EE20 plus CPA significantly increased triglycerides and total cholesterol. The area under the curve for insulin was significantly decreased by DRP/EE20 and DRP/EE20 plus metformin, but it was significantly increased by DRP/EE20 plus CPA. Treatment with DRP/EE20 plus CPA significantly increased the homeostasis model assessment of insulin resistance index and significantly reduced the glucose to insulin ratio index. Treatment with DRP/EE20 significantly increased the glucose to insulin ratio index.

CONCLUSION(S)

Treatment with DRP/EE20 improved insulin sensitivity in hirsute women with PCOS, with no deterioration of lipid profile. This effect was not ameliorated by the addition of metformin. The positive metabolic effects of DRP are abolished by the concomitant use of CPA.

Insulin sensitivity and lipid metabolism with oral contraceptives containing chlormadinone acetate or desogestrel: a randomized trial

BACKGROUND

Second-generation and third-generation oral contraceptives containing 30 mcg or more of ethinylestradiol (EE) decrease insulin sensitivity (SI). In this study, we investigated whether SI is decreased by contraceptives containing lower doses EE or by progestins with antiandrogenic properties.

STUDY DESIGN

Twenty-eight young healthy women were randomly allocated to receive 20 mcg of EE and 150 mcg of desogestrel (DSG) (n=14) or 30 mcg of EE and 2 mg of chlormadinone acetate (CMA) (n=14) for 6 months. SI and glucose utilization independent of insulin (Sg) were investigated by the minimal model method. Lipid modifications were also analyzed.

RESULTS

SI decreased with EE/DSG (7.09+/-1.4 vs. 4.30+/-0.91; p=.04; n=12), but not with EE/CMA (5.79+/-0.93 vs. 6.79+/-1.1; p=.48; n=12). SI modifications observed in the two groups were significantly different (-2.79+/-1.15 vs. 1.0+/-1.38; p=.05). Sg did not vary with either treatment. The response of C-peptide to glucose increased, but significantly so only with EE/CMA (p=.01). The C-peptide/insulin response increased with both EE/DSG (p=.05) and EE/CMA (p=.04). High-density lipoprotein (HDL) cholesterol (p=.02) and triglycerides (p=.02 and p=.01) increased in both groups, but HDL/low-density lipoprotein cholesterol (p=.02), apoprotein A1 (Apo-A1) (p=.04) and Apo-A1/apoprotein B (p=.048) increased significantly only with EE/CMA.

CONCLUSIONS

The present study confirms that DSG, even when associated with low EE dose, decreases SI. By contrast, EE/CMA does not deteriorate SI and induces a favorable lipid profile.

Intermediate-term glucose tolerance in women with a history of gestational diabetes: natural history and potential associations with breastfeeding and contraception

OBJECTIVE

This study investigated the natural history of glucose tolerance by using modern definitions in women after delivery of a pregnancy complicated by gestational diabetes. The association between deterioration of glucose metabolism and contraceptive methods was also studied.

STUDY DESIGN

Retrospective chart review of 592 indigent, primarily Latina women who had been diagnosed with gestational diabetes, monitored for up to 24 months' postpartum.

RESULTS

At the first postpartum visit, 230 women (40.2%) had prediabetes or diabetes. Within the first 12 months, 26.4% experienced deterioration. Of the 89 women monitored for 12-24 months, another 38.5% had prediabetes (n = 13) or diabetes (n = 11) develop. About 22% of women by using only nonhormonal contraception experienced worsening of their glucose status, whereas 35% of combined hormonal contraceptive users and 34% of progestin-only users worsened.

CONCLUSION

Gestational diabetes is a sentinel event signaling the need for frequent testing postpartum.

A longitudinal study of lipids and blood pressure in relation to method of contraception in Latino women with prior gestational diabetes mellitus

OBJECTIVE

To investigate the effect of nonhormonal contraception (NHC), combination oral contraception (COC), and depo-medroxyprogesterone acetate (DMPA) on lipids and blood pressure in women with recent gestational diabetes mellitus (GDM).

RESEARCH DESIGN AND METHODS

An observational cohort of 972 nondiabetic, normotensive, postpartum Latino women who elected NHC (n = 448), COC (n = 430), or DMPA (n = 94) were followed for at least one subsequent metabolic evaluation on the same contraception. Baseline and follow-up measures included glucose tolerance testing, fasting serum LDL and HDL cholesterol, triglycerides, and systolic (SBP) and diastolic (DBP) blood pressure. Patterns of changes in lipids and blood pressure were evaluated by comparing slopes over follow-up time using random coefficient linear mixed-effects models.

RESULTS

Median follow-up times were 20, 12, and 11 months in the NHC, COC, and DMPA groups. The DMPA users gained significantly more weight (4.3 +/- 6.9 kg/year) compared with NHC and COC users (1.2 +/- 4.7 and 0.7 +/- 6.0 kg/year, respectively; P < 0.0001). Patterns of change in LDL cholesterol, triglycerides, and DBP were not significantly different among groups. HDL cholesterol change differed only between COC and NHC groups (adjusted slopes: 1.0 vs. -1.6 mg x dl(-1) x year(-1), respectively; P < 0.0001). SBP change differed only between COC and DMPA groups (adjusted slopes: 1.3 vs. -1.7 mmHg/year, respectively; P = 0.01).

CONCLUSIONS

These results, derived predominantly from the initial 1-2 years of treatment in Hispanic women, demonstrate that DMPA was associated with greater weight gain than NHCs or COCs. Other differences in blood pressure and lipid effects were very small. These findings should be taken into account when advising women with recent GDM about their contraceptive choices.

After Pregnancy Complicated by Diabetes: Postpartum Care and Education

The postpartum period in women with pregestational or gestational diabetes allows the physician and mother to switch from intensive medical and obstetric management into a proactive and preventive mode, and to jointly develop a reproductive health plan. The woman's individual needs regarding contraception and breastfeeding, an appropriate diet to achieve healthy weight goals, the medical management of diabetes, daily exercise, and future pregnancy planning must be considered. Essential is the active participation of the woman, who, through education, gains an understanding of the far-reaching effects her active participation will have on her subsequent health, her newborn child's health, and possibly that of her future children.

Influence of oral contraceptive pills on phenotype expression in women with polycystic ovary syndrome

Polycystic ovarian syndrome (PCOS) is characterized by a heterogeneous phenotype including chronic anovulation, hyperandrogenism and polycystic ovaries. The use of oral contraceptive pills (OCP) alters features characteristic for the syndrome. In the present study, PCOS features were compared between women using or not using OCP at the time of the study. One hundred and one women diagnosed with normogonadotrophic anovulatory infertility were included. A total of 81 (80%) women were diagnosed with PCOS (revised 2003 criteria). From these women, a total of 54 did not use OCP, whereas 27 women did. Corrected for age, women taking OCP had increased serum concentrations of sex hormone-binding globulin (P < 0.001). Serum concentrations of testosterone (P = 0.04) and androstenedione (P = 0.01) were decreased. These differences resulted in a decreased free androgen index for women currently taking OCP compared with women without (P < 0.001). The mean ovarian volume/ovary and the mean follicle number/ovary were not different. Use of OCP influences phenotype expression (the observable trait) of individual women known to suffer from PCOS by reducing hyperandrogenism. Despite taking OCP, women still fulfilled the revised 2003 criteria for the syndrome, as PCO morphology was still present. Hence, OCP use does not appreciably affect the PCOS phenotype.

The Management of Polycystic Ovary Syndrome

It is well known that subjects with polycystic ovary syndrome (PCOS) show very variable clinical and biochemical aspects. Considering long-term repercussions, two main disturbances, not always strictly related, need to be countered: hyperandrogenism and insulin resistance, with compensatory hyperinsulinemia. The aim of this review is to summarize therapeutic perspectives for PCOS, starting from basic approach, such as weight reduction and changes in lifestyle. The benefits of long-term use of oral contraceptives and the criteria of choice of the estro-progestin combinations are discussed. With severe hyperandrogenism, a pure antiandrogen should be added. The experiences with insulin-sensitizing drugs, especially metformin, are reviewed; while their beneficial role as an adjuvant to treatment of ovulatory infertility has been well established, the effects of a long-term treatment, especially in very young patients, are still under debate. Current studies are testing the results of combinations of different treatments at low dosage; randomized comparative trials on the long-term efficacy of these approaches have yet to be scheduled.

Effects of oral contraceptives on glucose flux and substrate oxidation rates during rest and exercise

We examined the effects of oral contraceptives (OC) on glucose flux and whole body substrate oxidation rates during rest (90 min) and two exercise intensities [60-min leg ergometer cycling at 45 and 65% peak O(2) uptake (Vo(2 peak))]. Eight healthy, eumenorrheic women were studied during the follicular and luteal phases before OC and the inactive and high-dose phases after 4 mo of a low-dose, triphasic OC. Subjects were studied in the morning 3 h after a standardized (308 kcal) breakfast. There were significant reductions in glucose rates of appearance and disappearance during exercise of both intensities with OC but not rest. There were no phase effects on substrate oxidation during rest or exercise. These results are interpreted to mean that, in women fed several hours before study, 1) OC decreases glucose flux, but not overall carbohydrate and lipid oxidation rates during moderate-intensity exercise; and 2) synthetic ovarian hormone analogs in the doses contained in OC have greater metabolic effects on glucose metabolism during exercise than do endogenous ovarian hormones.

Effect of oral contraceptive steroid hormones on metabolic parameters of streptozotocin-induced diabetic rat

This study examined the effect of 0.05 mg norgestrel + 0.01 ethinyl estradiol (NEE) Kg x body wt(-1) on body weight, random blood glucose, glycosylated hemoglobin, and plasma insulin levels in streptozotocin-induced diabetic rats. Weight loss, blood glucose, glycosylated hemoglobin, and plasma insulin values of rats treated with NEE before and after the onset of diabetes were not significantly different from that of untreated diabetic rats. In conclusion, oral administration of these contraceptive steroid hormones does not significantly alter the metabolic parameters of diabetic rats.

Occlusive vascular diseases in oral contraceptive users. Epidemiology, pathology and mechanisms

Despite being an unprecedented departure from normal physiology, the combined oral contraceptive is not only highly effective, but it also has a remarkably good safety record. Concerns over safety persist, though, particularly with regard to venous thromboembolism (VTE), stroke and myocardial infarction (MI). Epidemiological studies consistently show an increase in risk of VTE, but the results are more contentious with regard to arterial diseases. Despite 40 years of research, the mechanisms behind these adverse effects are not understood. In this review, we integrate information from published studies of the epidemiology and pathology of the occlusive vascular diseases and their risk factors to identify likely explanations for pathogenesis in oral contraceptive users. Oral contraceptives induce both prothrombotic and fibrinolytic changes in haemostatic factors and an imbalance in haemostasis is likely to be important in oral contraceptive-induced VTE. The complexity of the changes involved and the difficulty of ascribing clinical significance has meant that uncertainty persists. A seriously under-researched area concerns vascular changes in oral contraceptive users. Histologically, endothelial and intimal proliferation have been identified in women exposed to high plasma estrogen concentrations and these lesions are associated with thrombotic occlusion. Other structural changes may result in increased vascular permeability, loss of vascular tone and venous stasis. With regard to arterial disease risk, epidemiological information relating to dose effects and joint effects with other risk factors, and studies of pathology and changes in risk factors, suggests that oral contraceptive use per se does not cause arterial disease. It can, nevertheless, synergise very powerfully with subclinical endothelial damage to promote arterial occlusion. Accordingly, the prothrombotic effects of the oral contraceptive estrogen intervene in a cycle of endothelial damage and repair which would otherwise remain clinically silent or would ultimately progress - in, for example, the presence of cigarette smoking or hypertension - to atherosclerosis. Future work in this area should focus on modification of the effects of established risk factors by oral contraceptive use rather than modification of the supposed risk of oral contraceptive use by established risk factors. Attempts to understand vascular occlusion in oral contraceptive users in terms of the general features of VTE or with reference to atherosclerosis may be limiting, and future work needs to acknowledge that such occlusions may have unique features. Unequivocal identification of the mechanisms involved would contribute considerably to the alleviation of fears over vascular disease and to the development of even safer formulations.

Postpartum care of the woman with diabetes

The postpartum period in women with diabetes or GDM allows both the physician and mother to relax from the intensive medical and obstetric management that has permitted, in most cases, a successful and joyous outcome. The role of the physician, however, must switch to a proactive and preventive mode to formulate a reproductive health plan for women with diabetes and GDM. The plan should be individualized to address glycemic management and surveillance, nutritional management, contraception prescription, future pregnancy planning, and lifestyle changes. Essential to the development of a reproductive health plan is the active participation of the patient, who through education gains an understanding of the far-reaching effects her active participation will have on her subsequent health and possibly on that of her future children.

History of gestational diabetes, insulin resistance and coronary risk

The purpose of this study was to examine characteristics associated with the insulin metabolic syndrome, including insulin resistance, abnormal glucose tolerance, dyslipidemia, obesity, and elevated blood pressure, among women who have experienced gestational diabetes. 39 nondiabetic, young (20-42 years), postpartum (3-18 months) white women were recruited from obstetrical clinics. Twenty-one women had a history of gestational diabetes; 18 had uncomplicated pregnancies. Multivariate analyses revealed a significant difference between groups in insulin resistance (M, measured by euglycemic clamp) and insulin levels (from an oral glucose tolerance test), with insulin resistance showing a statistically stronger difference than insulin levels. Groups also differed significantly when compared on a set of variables associated with insulin metabolic syndrome: glucose tolerance, triglycerides, blood pressure, and body-mass index. Using insulin resistance as a covariate eliminated these group differences, suggesting that insulin resistance is the key factor underlying insulin metabolic syndrome. The higher risk of later developing type 2 diabetes and hypertension in women who have a history of gestational diabetes is explicable by their poorer profile on variables associated with insulin metabolic syndrome, and appears to be attributable to insulin resistance. Thus, insulin resistance appears to distinguish young women at risk for cardiovascular disease.

Safety evaluation of modern oral contraceptives. Effects on lipoprotein and carbohydrate metabolism

An ideal oral contraceptive should either be neutral as regards metabolic risk markers for arterial disease or should only change them in directions that would be expected to reduce risk. Depending on their formulation, modern low dose oral contraceptives affect systems such as hemostasis, lipoprotein metabolism, and glucose and insulin metabolism. Some of these actions would be expected to decrease the risk of arterial disease and some might be expected to increase risk. Despite these associations there is at present no justification for widespread metabolic screening as a strategy to further improve oral contraceptive safety. Recent developments in atherosclerosis research support the introduction of progestogens such as desogestrel that allow the estrogenic increase in high density lipoprotein levels to persist and that may cause less of an elevation in plasma insulin responses to glucose. The predicted benefit of these formulations in terms of arterial disease is difficult to demonstrate in an epidemiological setting because of the rarity of the disease in young women.

Contraception in diabetic women

Contraceptive prescription in diabetic women with current diabetic mellitus (type I or type II) or in prediabetic women with previous gestational diabetes mellitus must consider the specific metabolic effects and risks in diabetic women. This article addresses these issues, enabling the practitioner to develop individually tailored contraceptive programs to meet the changing needs and demands of the reproductive-aged diabetic woman. If focuses on the most efficacious, reversible option available--hormonal methods and intrauterine devices--both of which have been controversial for diabetic women.

Update on the metabolic effects of steroidal contraceptives and their relationship to cardiovascular disease risk

Evaluation of metabolic disturbances has had an important role in the modification of oral contraceptive formulations toward estrogen-progestin combinations with reduced adverse metabolic impact. An increasing number of interrelationships between metabolic risk factors for cardiovascular disease are being recognized, and a metabolic syndrome of disturbances has been identified with insulin resistance as a potential underlying factor. The insulin resistance syndrome includes hyperinsulinemia and impaired glucose tolerance, hypertriglyceridemia, reduced high-density lipoprotein concentrations, and hypertension. Increased concentration of a small, dense, low-density lipoprotein subtype may also be important. Depending on steroid type and dose, combined oral contraceptives may induce all the features of the insulin resistance syndrome. Reduction in estrogen dose and modification of progestin content have resulted in formulations with no adverse effect on high-density lipoprotein and blood pressure, but insulin resistance and hypertriglyceridemia remain. These are caused primarily by the estrogen component. Therefore modification of the estrogen content of oral contraceptives might result in "metabolically transparent" formulations that could conceivably afford a degree of cardiovascular protection.

Prospective evaluation of insulin resistance and lipid metabolism in women receiving oral contraceptives

OBJECTIVES

It has been suggested that normal women receiving oral contraceptives (OC) may develop a series of metabolic side-effects which relate to the risk of cardiovascular disease. These metabolic disturbances include changes in glucose and insulin metabolism, raised serum lipid and lipoprotein concentrations and elevated blood pressure. All these changes indicate that OC might cause insulin resistance. We have prospectively examined the effect of OC on insulin resistance and lipid metabolism including Lp(a) values.

PATIENTS

The study group comprised 13 normally menstruating Chinese women.

DESIGN

The study subjects were given a combined triphasic oral contraceptive which was administered on a 21-day on, 7-day off medication cyclic regimen, the first pill being administered on day 5 from the beginning of menses. The metabolic investigations were carried out during luteal phase before OC and again the third week of the third month of OC administration.

MEASUREMENTS

Metabolic evaluation including insulin secretion and insulin-mediated glucose uptake were evaluated by oral glucose tolerance test and the modification of insulin suppression test. Fasting triglyceride, cholesterol, HDL-cholesterol and Lp(a) concentrations were also measured.

RESULTS

The plasma glucose and insulin responses during a 75-g oral glucose challenge increased significantly (P < 0.05 and P < 0.03, respectively). The steady-state plasma glucose (SSPG) concentrations achieved during constant infusion of glucose, insulin and somatostatin increased significantly after 3 cycles of OC administration (glucose 7.5 +/- 0.8 vs 12.4 +/- 0.7 mmol/l, P < 0.001) while the steady-state plasma insulin (SSPI) concentrations were relatively similar (410 +/- 14 vs 391 +/- 7 pmol/l, NS). Plasma triglyceride levels increased significantly (0.81 +/- 0.12 vs 1.09 +/- 0.19 mmol/l, P < 0.03) following OC administration. Fasting plasma cholesterol, HDL cholesterol and calculated LDL cholesterol concentrations did not change as compared with baseline values, nor did the ratio of total cholesterol to HDL cholesterol. The Lp(a) concentrations did not change during the administration of OC (81 +/- 25 vs 71 +/- 21 mg/l, NS).

CONCLUSIONS

These data indicated that intake of OC for 3 cycles induced glucose intolerance, hyperinsulinaemia and insulin resistance in normal menstruating Chinese women. These changes occurred in association with elevated plasma triglyceride concentrations and no alteration in Lp(a) or other lipid values.

Insulin sensitivity is decreased in normal women by doses of ethinyl estradiol used in oral contraceptives

OBJECTIVE

We determined the independent effects of various doses of ethinyl estradiol used in oral contraceptives or norethindrone acetate, as well as their combination, on insulin sensitivity in normal women.

STUDY DESIGN

Thirty-three normal ovulatory female volunteers were recruited for this study. Insulin tolerance tests were performed after carbohydrate loading to determine the kinetic disappearance of glucose and insulin. After initial testing the women were randomized into four groups: ethinyl estradiol 20 micrograms, 35 micrograms, and 50 micrograms and norethindrone 1 mg. Insulin tolerance tests were repeated after 1 month of treatment and again after a second month, when all ethinyl estradiol groups received the addition of norethindrone 1 mg to their doses of ethinyl estradiol. Plasma glucose and insulin were measured, and insulin sensitivity (K(itt) glucose) and the disappearance of insulin (K(itt) insulin) were calculated.

RESULTS

All groups were comparable at baseline, and no significant changes in fasting glucose and insulin were evident with treatment. After ingestion of 50 micrograms ethinyl estradiol the K(itt) glucose value decreased significantly (p < 0.03) and ingestion of 20 micrograms and 35 micrograms showed individual changes, but as groups the changes were not statistically significant. All ethinyl estradiol groups combined had a significant decrease in K(itt) glucose (p < 0.01). Norethindrone 1 mg alone did not change K(itt) glucose values, and after the addition of norethindrone to ethinyl estradiol, K(itt) glucose values normalized. K(itt) insulin values were also lower with treatment but were lower with ethinyl estradiol plus norethindrone compared with ethinyl estradiol alone (p < 0.04), suggesting an attenuation of insulin clearance with the progestin.

CONCLUSION

Ethinyl estradiol alone decreases insulin sensitivity, and this may occur at lower doses, but norethindrone 1 mg does not appear to do so. However, progestins may alter insulin clearance.

Diabetes mellitus and fertility control: contraception management issues

The need to prevent complications in the woman and fetus mandates that pregnancies in diabetic women always be planned and that safe and effective contraceptives be used at all times until it is determined that pregnancy is a safe and desired option. Pregnancy may aggravate complications of diabetes such as retinopathy and coronary artery disease. A pregnant diabetic woman is also more likely to experience such complications as hypertension, urinary tract infection, polyhydramnios, and cesarean section. Her fetus is at increased risk for congenital malformations, prematurity, stillbirth, neonatal morbidity, and diabetes later in life. Good diabetic control must be maintained before and throughout the pregnancy to minimize the risk of these and other complications. Until such time as good control is achieved and the woman desires pregnancy, a reliable method of contraception should be used. Most recent research supports the use of barrier methods, low-dose monophasic or triphasic oral contraceptives, or progestin-only methods, at least for the short-term. Under some circumstances the intrauterine device may be an appropriate option. Long-term data regarding the use of these methods is lacking. The decision regarding which method of contraception is used should be made by the woman in consultation with her physician.

Effects of a 1-year treatment with a low-dose combined oral contraceptive containing ethinyl estradiol and cyproterone acetate on glucose and insulin metabolism

OBJECTIVE

To study the effects of the slightly estrogen-dominant monophasic low-dose oral contraceptive (OC) Diane-35 (Schering AG, Berlin, Germany) (35 micrograms ethinyl estradiol [EE2] + 2 mg cyproterone acetate, a 17 alpha-hydroxyprogesterone derivative [17-OHP]) on glucose and insulin metabolism.

DESIGN

Seven healthy young women were investigated by using the euglycemic hyperinsulinemic glucose clamp technique (insulin delivery rate = 100 mU/kg per hour for 120 minutes). This test was performed, after an overnight fast, during the last 7 days of a spontaneous cycle and within the last 5 days of pill intake during the sixth and twelfth cycle of a continuous treatment with Diane-35 in each subject.

RESULTS

The three indexes measuring the insulin-induced glucose disposal during the clamp (glucose infusion rate, glucose metabolic clearance rate, and glucose infusion rate divided by plasma insulin plateau levels) were not significantly affected by Diane-35. In contrast, the metabolic clearance rate of the exogenous insulin infused during the clamp tended to be slightly increased with Diane-35 (significant after 6 but not after 12 cycles).

CONCLUSION

These results suggest that a 1-year treatment with the OC Diane-35, which contains EE2 + a 17-OHP rather than a 19-nortestosterone derivative as the progestogen compound, does not significantly alter peripheral (presumably muscular) insulin sensitivity but slightly increases insulin (presumably hepatic) clearance.

Carbohydrate metabolism before and after Norplant removal

Changes in carbohydrate metabolism, measured by oral glucose tolerance test, were studied in Norplant users before and after removal. The mean area under the glucose curve rose from 24.7 min mmol/L before Norplant insertion to 35.1 min mmol/L before removal and decreased to 26.1 min mmol/L four weeks after Norplant removal. The areas before insertion and after removal were not statistically different (95% confidence interval -3.3 to 0.56, P = 0.16). The mean areas under the insulin curves before insertion (53.14 min uU/L) and after removal (59.46 min uU/L), however, were significantly different (95% confidence interval -7.64 to -5.0, P less than 0.0001). We conclude that changes in carbohydrate metabolism induced by Norplant are reversible once the implants are removed. While the changes in glucose induced by Norplant returned to pre-insertion levels within 4 weeks after removal, insulin changes were slower to return to pre-insertion values.

The effect of continuous subdermal levonorgestrel (Norplant) on carbohydrate metabolism

Blood glucose and plasma insulin levels during an oral glucose tolerance test were measured in 20 women using continuous subdermal levonorgestrel (Norplant) for contraception over a 12-month period. Changes in carbohydrate metabolism occurred as early as 1 month but were most marked after 6 months. After 1 month the area under the glucose and insulin curves increased by 12.3% and 37.7%, respectively. This increase was more marked by 6 months, but by 12 months it was significantly less marked. Although changes in the blood glucose and plasma insulin levels at different times during the oral glucose tolerance test occurred, they were all within normal limits for normal women. The peak blood glucose and insulin levels after insertion of the implant occurred 60 minutes after the glucose load, as opposed to 30 minutes before insertion. Apart from this, there was a significant delay in the return of these levels to fasting values. We conclude that this product, like any other progesterone-containing contraceptive, alters carbohydrate metabolism, but these alterations are not clinically significant in normal women. It is, however, possible that in potential cases of diabetes it may predispose to frank diabetes.

Contraception for women with diabetes: an update

Today several effective contraceptive methods are available for women with IDDM. Contraceptive guidance as part of the pre-pregnancy counselling needs to be more widely implemented by general practitioners and in non-specialized obstetrical and gynaecological departments. Women with diabetes are generally well motivated, and thus the barrier methods may prove both acceptable and reliable contraceptive agents for some of these women. When, however, a high risk of user failure can be predicted, the IUD or hormonal contraception may be the only reversible alternative. According to our findings, IUDs can be recommended without reservation to women with IDDM. In women with previous GDM it seems that low dose oral contraceptive compounds may be administered without running the risk of inducing glucose intolerance, but long-term results are still unavailable. Natural oestrogens may be administered in combination with a progestogen for a limited period as an efficient and acceptable mode of contraception in women with IDDM without any concomitant adverse effects on diabetic control. From our investigations it also appears that short-term administration of combined low dose OCs containing the traditional progestogens (e.g. norethisterone or levonorgestrel) or the new gonane progestogens (e.g. gestodene) does not alter glycaemic control in women with IDDM. Similarly, these compounds do not cause any significant changes in lipid/lipoprotein levels during short-term treatment, although the intake of monophasic ethinyloestradiol/norethisterone preparations may result in higher triglyceride levels and tends to increase lipid levels more than triphasic ethinyloestradiol/levonorgestrel compounds. The results from our clinic have shown that OCs can be safely recommended at pre-conception counselling so that women with diabetes can obtain both optimal glycaemic control and efficient spacing of their pregnancies.

An open prospective study on the effects on carbohydrate metabolism of an oral monophasic contraceptive containing gestodene (WL-70)

The effects of a monophasic oral contraceptive (gestodene 75mcg + ethinylestradiol 30 mcg) on plasma glucose (PG) and insulin (IRI) responses to an oral glucose load (OGTT) and on glycosylated haemoglobin Alc (HbAlc), fructosamine (Fr), total cortisol (FT) and transcortin (CBG) were studied in 30 healthy women. Blood samples were taken before treatment and after 6 and 12 cycles. After 6 and 12 months, OGTT-PG and IRI levels showed substantially unchanged values; for HbAlc and Fr the same behaviour was seen with the exception of the latter between 6 and 12 months; FT and CBG showed significant rises. All recorded values were in the normal range. The basal and dynamic PG and IRI behaviour failed to show any significant variations between pre-treatment values and those after 6 and 12 months of OC administration. Other data showed a substantial neutrality for this oral contraceptive containing gestodene.

Oxidative status and oral contraceptive. Its relevance to platelet abnormalities and cardiovascular risk

Oral contraceptive (OC) use is a risk for thrombogenic events. This paper reviews effects of OC on oxidative status, coagulation, and platelet activity. Complicating effects of cardiovascular risk factors such as smoking, diabetes, hyperpidemia, and hypertension, are discussed. From these data we conclude that: 1. OC use modifies slightly but significantly the oxidative status in women and in animals by decreasing in plasma and blood cells the antioxidant defenses (vitamins and enzymes). 2. The changes in the oxidative status are related to an increase in plasma lipid peroxides apparently responsible for the hyperaggregability and possibly the imbalance in clotting factors associated with the OC-induced prethrombotic state. 3. These effects of OC appear to be increased by a high intake of polyunsaturated fat and counteracted by supplements of vitamin E. 4. The risk factors acting synergistically with OC, have all been shown to increase platelet reactivity. In addition, smoking, diabetes, and, to some extent, dyslipidemia are associated with an increased level of lipid peroxides and concomitant changes in the antioxidant defenses that can be additive to those induced by OC. Thus, free radicals and lipid peroxidation could be the underlying mechanism in the predisposition to thrombosis induced by most risk factors in OC users. 5. Results of epidemiologic and experimental studies in this field will be concordant only when diet and natural antioxidants will be systematically taken into consideration.

Effect of low-dose oral contraceptives on carbohydrate and lipid metabolism in women with recent gestational diabetes: results of a controlled, randomized, prospective study

Women with recent gestational diabetes mellitus were randomly assigned to one of two low-dose oral contraceptives to evaluate the effect of low-dose oral contraceptives on carbohydrate and lipid metabolism. A cohort of similar women requesting a non-oral-contraceptive method served as controls. The two oral contraceptives studied were ethinyl estradiol (0.035 mg)-norethindrone (0.40 mg) and ethinyl estradiol (0.030 to 0.040 mg)-levonorgestrel (0.050 to 0.125 mg). A 75 gm, 2-hour oral glucose tolerance test and a fasting lipid profile (total cholesterol, triglyceride, high- and low-density lipoprotein cholesterols) were performed at entry, after 3 months, and after 6 to 13 months of treatment. The prevalence of diabetes at 6 to 13 months (27/156 patients) was not significantly different between groups (non-oral-contraceptive group, 17%; ethinyl estradiol-norethindrone, 15%; ethinyl estradiol-levonorgestrel, 20%). When examined by prior gestational diabetes mellitus class, diabetes mellitus was present in 7% of prior class A1 and 29% of women with prior class A2 disease (p less than 0.001). Mean cholesterol and low-density lipoprotein cholesterol levels were significantly improved in all three groups at 3 months and at 6 to 13 months, whereas triglycerides remained unchanged. There were no differences in cholesterol, low-density lipoprotein cholesterol, or triglycerides levels between the groups. After 6 to 13 months, there was a significant increase in high-density lipoprotein cholesterol in the ethinyl estradiol-norethindrone group compared with the ethinyl estradiol-levonorgestrel and non-oral-contraceptive groups.

Clinical aspects of the relationship between oral contraceptives, abnormalities in carbohydrate metabolism, and the development of cardiovascular disease

Although large epidemiologic studies indicated no difference in the frequency of diabetes mellitus in nonusers and everusers of high-dose combination oral contraceptives, other studies had shown an increased risk of impaired glucose tolerance in current users, which is estimated to be roughly twice as frequent as that in nonusers. Women at risk of developing impaired glucose tolerance while receiving high-dose oral contraceptives either had previous gestational diabetes mellitus or were older, obese, or had a positive family history of diabetes mellitus. The tendency to decreased glucose tolerance seems essentially related to the dosage and chemical structure of the progestogen used in oral contraceptives, namely, estrane and particularly gonane progestins. However, increased frequency of impaired glucose tolerance and potentially diabetes mellitus are obviously not linked to the use of the more potent gonane progestins. The use of low-dose oral contraceptives, particularly with reduced progestogen content (such as in the triphasic formulations and last-generation monophasic preparations), is accompanied by a low risk of impaired glucose tolerance, even in previous gestational diabetes mellitus. The mechanism of decreased glucose tolerance in oral contraceptive users is unknown but seems related partially to increased peripheral resistance that is potentially caused by a postreceptor defect in insulin action. Changes in insulin production or metabolic clearance rate are not excluded by recent, sophisticated investigations of carbohydrate metabolism in oral contraceptive users. Impaired glucose tolerance and diabetes mellitus, chronic hyperglycemia, and hyperinsulinemia are believed to increase atherogenic risk either by their direct action or their effects on lipid metabolism. Newer epidemiologic studies now indicate that the incidence of cardiovascular disease in low-dose, low-risk, current oral contraceptive users has been substantially decreased. The use of low-dose oral contraceptives with reduced dosages of better adapted progestogens seems effective in decreasing alterations in carbohydrate metabolism and may thereby contribute to decrease further atherogenic risk in oral contraceptive users.

Impairment of glucose tolerance: mechanism of action and impact on the cardiovascular system

Macrovascular disease, especially coronary heart diseases, have been found to be linked to glucose intolerance. Insulin resistance in respect to glucose uptake in peripheral tissues seems to play an important role in the development of glucose intolerance, since subjects with coronary heart disease mainly are hyperinsulinemic. Insulin resistance may induce not only glucose intolerance but also hypertension, obesity, and dyslipoproteinemia (high very low-density lipoprotein and low high-density lipoprotein values), all variables that add to the risk of coronary heart disease. On the basis of these findings, a new syndrome has been postulated-syndrome X. This syndrome may be caused by inherited insulin resistance in skeletal muscles, and secondary to that arterial hypertension, obesity, and dyslipoproteinemia may develop. Insulin resistance in noninsulin-dependent diabetic persons and in hypertensive subjects is located in skeletal muscles, where insulin's ability to promote nonoxidative glucose metabolism is reduced. The key enzyme in this pathway, glycogen synthase, is proposed as the causal defect responsible for the insulin resistance state, at least in noninsulin-dependent diabetic patients. The pill (sex steroids) may induce a clinical situation that is similar to syndrome X. However, it is important to emphasize that many more studies are needed to substantiate these hypothetical mechanisms behind coronary heart disease.

Triphasic Randomized Clinical Trial: Comparison of effects on carbohydrate metabolism

One hundred thirty women were randomly assigned to treatment with one of three triphasic oral contraceptives and 43 women using nonhormonal methods served as controls for a 6-month study of the metabolic effects of these formulations. One of the oral contraceptives contained ethinyl estradiol and levonorgestrel, and the other two contained ethinyl estradiol and norethindrone. Compared with pretreatment assessment, all three triphasic oral contraceptives produced small increases in the mean plasma glucose levels that were statistically significant but clinically unimportant. No subjects had abnormal glucose response curves in glucose tolerance test results. Compared with pretreatment assessment, all of the oral contraceptive preparations produced small increases in the mean insulin levels at 3 months but not at 6 months. Overall there were no statistically significant differences among the three formulations in their effects on carbohydrate metabolism as measured by glucose or insulin levels after 6 months of treatment.

Metabolic effects of three new low-dose pills: a six-month experience

We evaluated the effects on glucose and lipid metabolism in 57 healthy volunteers randomly assigned to one of three low-dose oral contraceptives: two monophasic (desogestrel + ethinylestradiol, EE, and cyproterone acetate + EE) and one triphasic (gestodene + EE) contraceptives. Glucose and insulin responses during OGTT were slightly affected by the cyproterone pill. The insulin area/glucose area ratio and HbA1c level were unchanged in all women. No preparation affected total and LDL-cholesterol levels. Triglycerides rose in all groups, while HDL-CH did only in women taking the two monophasic pills. The three low-dose pills assessed in this study have negligible effects on glucose and lipid metabolism.

Use of combined oral contraceptive preparations alters the insulin sensitivity of fatty acid and ketone metabolism

Eight women taking low-dose-oestrogen combined oral contraceptive preparations were compared to eight women in the luteal phase of the menstrual cycle during hourly incremental insulin infusions of 0 (basal), 0.005, 0.01 and 0.05 U/kg/h short-acting insulin. Dose-response relationships between insulin and intermediary metabolites were sought by analysis of variance applied to regression. For insulin (log) and glucose the slope of the relationship was significantly shallower in the oral contraceptive group. For insulin (log) and non-esterified fatty acids the slopes of the regression lines were not different between groups but lines were significantly displaced. For insulin (log) and total ketone bodies (log) slopes of the regression lines were not different but significant displacement was observed. At identical insulin concentrations women taking an oral contraceptive had higher non-esterified fatty acids (NEFA) (difference between groups +0.15 mmol/l, P less than 0.001) and total ketone bodies (log: -0.26 mmol/l, P less than 0.001). The potency of insulin action in oral contraceptive users versus the luteal group was 0.47 (P less than 0.01) for NEFA and 0.38 (P less than 0.001) for total ketone bodies. The results demonstrate, for the first time, in-vivo insulin resistance of NEFA and ketone bodies' metabolism induced by oral contraceptive use.

Prospective study of carbohydrate metabolism in women using a triphasic oral contraceptive containing norethindrone and ethinyl estradiol for 3 months

Thirty-five women with normal carbohydrate metabolism were administered a 3-hour oral glucose tolerance test before and after 3 months' use of a triphasic oral contraceptive that contained ethinyl estradiol and norethindrone. The results show no significant change in either the plasma glucose or the insulin values. This is the first published study with regard to this type of triphasic oral contraceptive, and the study supports claims of the preparation's improved safety.

Plasma glucose and insulin levels in women using a levonorgestrel-containing triphasic oral contraceptive for three months

Plasma glucose and insulin levels were measured for three hours after an oral glucose challenge in twenty-nine women before and after using a triphasic oral contraceptive containing ethinyl estradiol and levonorgestrel for three months. There were significant elevations in the glucose levels during the three-month tolerance test, while the insulin levels were unchanged. These data suggest that this OC can alter carbohydrate metabolism and that long-term studies are needed to assess the extent of this metabolic change.

Oral contraceptives and coronary heart disease: modulation of glucose tolerance and plasma lipid risk factors by progestins

Widespread use of oral contraceptive formulations by women throughout their reproductive life has given rise to concerns about the effects of oral contraceptives on risk factors for coronary heart disease. Oral contraceptive-induced changes in both carbohydrate and lipoprotein risk factors may contribute to an increased risk of coronary heart disease. Carbohydrate and lipoprotein risk factors for coronary heart disease are reviewed, and oral contraceptive-induced changes in carbohydrate and lipoprotein metabolism, which may lead to altered risk status for coronary heart disease, are discussed. The importance of methodology in evaluating the results of studies assessing such oral contraceptive-induced changes is stressed. The role of progestins in influencing coronary heart disease risk factors is surveyed, and differences among progestins commonly used in oral contraceptive formulations are discussed. In addition, the effect of various combination oral contraceptives on risk factor status is outlined. Finally, the implications of available evidence for the selection of progestins for oral contraceptive formulations of the future are discussed. Current data indicate that medium- and low-fixed-dose oral contraceptive formulations containing estrogen/norethindrone acetate have less metabolic impact than do comparable levonorgestrel-containing formulations, including multiphasic formulations. Triphasic formulations may have less effect on coronary heart disease risk factors, although data are not yet conclusive. Novel progestins such as desogestrel may also have lesser effects on metabolic functions, but the reduced androgenicity of such compounds may expose women to an increased risk of estrogen-induced hypertriglyceridemia.

Lack of metabolic effects of a triphasic formulation containing norethindrone in normal women studied prospectively

The glucose and insulin responses to oral glucose tolerance tests and lipid values in normal women taking a triphasic pill containing norethindrone (Ortho 7/7/7) were performed. After three months, no significant changes in these metabolic indices were found. These results confirm and expand the knowledge regarding the metabolic safety of norethindrone-containing triphasic formulations.

Long-term use of an injectable contraceptive: effect of depot-norethisterone oenanthate on carbohydrate metabolism

In order to determine the metabolic effects of long-term use of the injectable contraceptive norethisterone oenanthate, plasma glucose and serum insulin concentrations were studied in two groups of women who had used the method continuously for at least five years. Group 1 comprised 24 subjects, from whom only fasting blood samples were taken. Despite similar plasma glucose concentrations to those of the controls, the subjects had significantly increased serum insulin concentrations (164.5 (39.9) v 120.3 (34.3) pmol/l, p less than 0.01). In addition the insulin:glucose ratios were also significantly increased (34.3 (8.5) v 24.6 (6.7), p less than 0.01), consistent with decreased insulin sensitivity. Group 2 comprised 13 of the original 24 subjects who also had an oral glucose tolerance test. Basal plasma glucose concentrations were similar in the subjects and their controls, whilst the significantly increased insulin:glucose ratios (35.0 (7.7) v 28.7 (5.6), p less than 0.05) were consistent with the results of the larger group. Following oral glucose challenge, plasma glucose concentrations, serum insulin concentrations and insulin:glucose ratios were similar in the subjects and their controls throughout the test. Thus, long-term use of norethisterone oenanthate injections is associated with a decrease in peripheral insulin sensitivity. However, these changes are not associated with any evidence of oral glucose intolerance.