Considerations for hormonal therapy in migraine patients: a critical review of current practice

INTRODUCTION

Migraine, a neurovascular headache disorder, is a leading cause of disability worldwide. Within the multifaceted pathophysiology of migraine, hormonal fluctuations play an evident triggering and exacerbating role, pointing toward the need for identification and proper usage of both existing and new hormonal targets in migraine treatment.

AREAS COVERED

With a threefold higher incidence of migraine in women than in men, the authors delve into sex hormone-related events in migraine patients. A comprehensive overview is given of existing hormonal therapies, including oral contraceptives, intrauterine devices, transdermal and subcutaneous estradiol patches, gnRH-agonists, oral testosterone, and 5α reductase inhibitors. The authors discuss their effectiveness and risks, noting their suitability for different patient profiles. Next, novel evolving hormonal treatments, such as oxytocin and prolactin, are explored. Lastly, the authors cover hormonal conditions associated with migraine, such as polycystic ovary syndrome, endometriosis, and transgender persons receiving gender affirming hormone therapy, aiming to provide more personalized and effective solutions for migraine management.

EXPERT OPINION

Rigorous research into both existing and new hormonal targets, as well as the underlying pathophysiology, is needed to support a tailored approach in migraine treatment, in an ongoing effort to alleviate the impact of migraine on individuals and society.

Role of Estrogens in Menstrual Migraine

Migraine is a major neurological disorder affecting one in nine adults worldwide with a significant impact on health care and socioeconomic systems. Migraine is more prevalent in women than in men, with 17% of all women meeting the diagnostic criteria for migraine. In women, the frequency of migraine attacks shows variations over the menstrual cycle and pregnancy, and the use of combined hormonal contraception (CHC) or hormone replacement therapy (HRT) can unveil or modify migraine disease. In the general population, 18–25% of female migraineurs display a menstrual association of their headache. Here we present an overview on the evidence supporting the role of reproductive hormones, in particular estrogens, in the pathophysiology of migraine. We also analyze the efficacy and safety of prescribing exogenous estrogens as a potential treatment for menstrual-related migraine. Finally, we point to controversial issues and future research areas in the field of reproductive hormones and migraine.

Real world utilization of 91 day extended levonorgestrel-containing combined oral contraceptives in Europe: a multinational database study

OBJECTIVE

As part of the risk management plan in Europe, this study was conducted to characterize drug utilization patterns of Seasonique, a 91 day extended levonorgestrel-containing combined oral contraceptive (COC_LNG).

METHODS

A retrospective observational study was conducted in France, Italy and Belgium using electronic medical record databases obtained from general practitioners (GPs) in all participating countries and gynecologists in France from 2015 to 2018. The study population included women receiving ≥1 prescription of 91 day COC_LNG during the study period. Prescribing patterns of 91 day COC_LNG were examined including: (1) treatment duration; (2) indication; (3) use of combined oral contraceptive (COC) before 91 day COC_LNG initiation; and (4) switch from and to combined hormonal contraceptives (CHCs) or other contraceptives.

RESULTS

Totals of 235, 220, 207 and 659 women using 91 day COC_LNG were identified in French, Italian and Belgian GP, and French gynecologist databases, respectively. Across databases, 46-76% of women were prescribed a single 91 day COC_LNG prescription and median treatment duration ranged from 3 to 6 months. The most common indication was contraception (42-81%), followed by menstrual migraines (2-14%). Use of COC during the 6 months prior to 91 day COC_LNG initiation was 14% across GP databases, but was lower (8%) in the French gynecologist database. The frequency of switching from 91 day COC_LNG to CHCs or other contraceptives was generally low (5-12%), with the highest proportion being among patients of French gynecologists.

CONCLUSIONS

Findings indicate that 91 day COC_LNG was prescribed for relatively short durations and predominantly as indicated for contraception. Most results were comparable across all participating countries. KEY POINTSFindings from this drug utilization study in European databases across general practitioners and French gynecologists confirmed that 91 day extended levonorgestrel-containing combined oral contraceptive (COC_LNG) was prescribed for relatively short durations (median 3-6 months); predominantly for the intended indication of contraception.Combined oral contraceptive use during the 6 months prior to 91 day COC_LNG initiation, and switching from 91 day COC_LNG to combined hormonal contraceptives or other contraceptives, were generally low (14% or less).These findings were mostly consistent across participating countries.

Quality of sexual life of women using the contraceptive vaginal ring in extended cycles: preliminary report

OBJECTIVE

To evaluate the quality of the sexual life of healthy women who are using a contraceptive vaginal ring (CVR) in extended cycles.

METHODS

Fifty-two women (18 to 32 years old) seeking hormonal contraception were enrolled in this prospective study. Women were to use a CVR releasing daily 15 μg of ethinylestradiol (EE) and 120 μg of etonogestrel (ENG) for 63 days, followed by a four-day hormone-free interval, for two such extended cycles. At baseline and at the first (day 63-73) and second (day 126-134) follow-ups the Female Sexual Function Index (FSFI) and the Short Form-36 (SF-36) questionnaires were administered to investigate, respectively, sexual behaviour and the quality of life (QoL). The Female Sexual Distress Scale (FSDS) was used to verify whether sexual dysfunction caused significant personal distress to the woman.

RESULTS

The FSFI and FSDS scores obtained at the first and second follow-up appointments detected an improvement with respect to the baseline score (p < 0.05). QoL measures of body pain, general health and emotional role improved at the first follow-up visit (p < 0.05); at the second one, all variables showed improvement (p < 0.05).

CONCLUSION

According to these preliminary data the CVR in extended cycles could improve the sexual function and the QoL of women.

Extended and continuous combined contraceptive regimens for menstrual suppression

Many women have medical indications for menstrual suppression or a personal preference to reduce or eliminate monthly bleeding, which can be achieved with extended and continuous regimens of combined estrogen and progestin contraceptives. Combined contraceptives are traditionally administered in a 28-day cycle, with 21 days of a contraceptive pill, vaginal ring, or transdermal patch followed by a hormone-free interval that is usually 7 days. During the hormone-free interval, women either take a placebo pill or do not use their combined contraceptive method. Hormone-related symptoms are significantly worse during the hormone-free interval than the days when the contraceptive is used. Alterations of the standard 28-day cyclic regimen for menstrual suppression include decreasing the frequency of the hormone-free interval, thus extending the time between withdrawal bleeding episodes (extended use), and eliminating the hormone-free interval altogether (continuous use). This article reviews menstrual suppression indications and physiology. Research demonstrating that the effectiveness, safety, and side effects of oral, vaginal, and transdermal extended and continuous regimens are comparable to cyclic regimens is summarized. Findings from studies of women's and health care providers' attitudes toward menstrual suppression also are reviewed. Important topics to include in evidence-based counseling for extended and continuous combined contraceptive use are presented.

The new extended-cycle levonorgestrel-ethinyl estradiol oral contraceptives

Effective contraceptive counseling requires an understanding of a woman's preferences and medical history as well as the risks, benefits, side effects, and contraindications of each contraceptive method. Hormonal contraceptives using a variety of delivery methods are highly effective and this review highlights the new extended-cycle levonorgestrel-ethinyl estradiol contraceptives. Extended-cycle OCPs are unique in offering fewer or no withdrawal bleeds over the course of one year but providers need to carefully counsel women regarding the initial increased breakthrough bleeding. Extended-cycle OCPs may be of particular benefit in women with medical comorbidities who would benefit from less withdrawal bleeds, those desiring to avoid monthly menses due to increased hormonal withdrawal symptoms, or simply women who don't desire a monthly period. The risks associated with all extended-cycle OCPs have been found to be similar to those of traditional OCPs therefore counseling on the risks and side effects is comparable to that of any combined hormonal contraceptives. Newer extended-cycle regimens shorten or eliminate the hormone-free interval, decrease frequency of menses to four times per year or eliminate menses altogether. This can reduce the risk of common menstrual symptoms, endometriosis, or severe dysmenorrhea by offering potentially greater ovarian suppression and preventing endogenous estradiol production while still providing highly effective, rapidly reversible, and safe contraception.

Tailoring combination oral contraceptives to the individual woman

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Symptoms of multiple sclerosis in women in relation to cyclical hormone changes

OBJECTIVES

To prospectively investigate if women with multiple sclerosis (MS) experience changes in MS-symptoms in relation to cyclical hormonal changes.

METHODS

Sixty-three women with MS, either with regular, spontaneous menstrual cycles or taking combined oral contraceptives (COCs), were asked to score their MS symptoms every day during three cycles. Symptom scores were analysed in relation to different phases of the spontaneous menstrual- or pill-driven cycle.

RESULTS

Twenty-three women completed the score record. Among the 16 women who were not using a COC there were no significant differences in symptom scores between the phases of the menstrual cycle. The seven women taking a COC reported significantly higher symptom score points for weakness, numbness and tiredness during the pill-free interval compared with the phase during which they took the COC daily.

CONCLUSIONS

This prospective study appears to contradict earlier retrospective studies regarding variations in MS symptoms in relation to the menstrual cycle in women who are not using a COC. The lower symptom scores during the three weeks of pill taking suggest a positive effect of the steroids on the manifestations of MS. Further studies concerning both short- and long-term effects of OC-use on MS symptoms are needed.

Conventional vs. extended-cycle oral contraceptives on the quality of sexual life: comparison between two regimens containing 3 mg drospirenone and 20 µg ethinyl estradiol

INTRODUCTION

Women may use new oral contraceptives (OC) having flexible extended-cycle regimens with a reduced hormone-free interval.

AIM

To study the changes of the quality of sexual life in users of the traditional 21/7 or extended-cycle 24/4 OC regimens both containing 3 mg drospirenone and 20 µg ethinyl estradiol.

METHODS

One hundred fifteen women (age range 18-37 years) were enrolled. Fifty-four women were randomly placed on traditional OC standard regimen, administered for 21 days, followed by a 7-day hormone-free interval (group A); and 61 women were placed on extended-cycle OC regimen covering 24 days of the cycle with a 4-day hormone-free interval (group B). The Short Form-36 (SF-36) validate questionnaire to assess quality of life (QoL) and the Short Personal Experience Questionnaire (SPEQ) to measure the changes of sexual behavior were administered before starting OC intake and at the 3rd and 6th cycle follow-ups.

MAIN OUTCOME MEASURE

The SF-36 and the SPEQ questionnaires.

RESULTS

Group A women reported QoL improvement during the 6th cycle on all the scales (P < 0.05). Group B women reported QoL improvement during the 3rd and 6th cycle (P < 0.05). Satisfaction with sexual activity, arousal, orgasm, and desire increased during the 3rd cycle in women on the group B (P < 0.05). Group A women did not report any change in all SPEQ items. At the 6th cycle, group B women reported better sexual experience than baseline in all SPEQ items (P < 0.05). All subjects who were affected by dyspareunia before OC intake reported decreased genital pain associated with intercourse at the 3rd and 6th cycle of both OC regimens (P < 0.05).

CONCLUSION

Women could use OCs in a subjective flexible modality. The extended-cycle OC might produce positive effects on the quality of sexual life, enforcing the concept of tailoring an OC to a woman.

Computational estimation of rainbow trout estrogen receptor binding affinities for environmental estrogens

Environmental estrogens have been the subject of intense research due to their documented detrimental effects on the health of fish and wildlife and their potential to negatively impact humans. A complete understanding of how these compounds affect health is complicated because environmental estrogens are a structurally heterogeneous group of compounds. In this work, computational molecular dynamics simulations were utilized to predict the binding affinity of different compounds using rainbow trout (Oncorhynchus mykiss) estrogen receptors (ERs) as a model. Specifically, this study presents a comparison of the binding affinity of the natural ligand estradiol-17β to the four rainbow trout ER isoforms with that of three known environmental estrogens 17α-ethinylestradiol, bisphenol A, and raloxifene. Two additional compounds, atrazine and testosterone, that are known to be very weak or non-binders to ERs were tested. The binding affinity of these compounds to the human ERα subtype is also included for comparison. The results of this study suggest that, when compared to estradiol-17β, bisphenol A binds less strongly to all four receptors, 17α-ethinylestradiol binds more strongly, and raloxifene has a high affinity for the α subtype only. The results also show that atrazine and testosterone are weak or non-binders to the ERs. All of the results are in excellent qualitative agreement with the known in vivo estrogenicity of these compounds in the rainbow trout and other fishes. Computational estimation of binding affinities could be a valuable tool for predicting the impact of environmental estrogens in fish and other animals.

Drospirenone/Ethinylestradiol: A Review on Efficacy and Noncontraceptive Benefits

Considerable advances have been made in the field of combined oral contraceptives since their introduction 50 years ago. This ongoing evolution has been focused on reducing the estrogen dose and synthesizing new progestogens. A recently launched combination of ethinylestradiol 20 μg and drospirenone 3 mg demonstrates the advantages of a lower estrogen dose with the antimineralocorticoid activity of drospirenone that is responsible for the drug's significant antiandrogenic and antimineralocorticoid effects, reflected clinically in lower rates of adverse events including less fluid retention. In addition to the drug's contraceptive efficacy, its effects on the skin and other classic noncontraceptive benefits, the ethinylestradiol 20 μg and drospirenone 3 mg combination has demonstrated highly satisfactory results in women with premenstrual dysphoric syndrome.