A metabolic assessment of different oral contraceptives

Fatal Venous Thromboembolism Associated with Different Combined Oral Contraceptives

BACKGROUND

Fatal venous thromboembolism (VTE) is a rare complication of combined oral contraceptive (COC) treatment. This study aims to determine incidences of fatal VTE in relation to the type of COC and the percentage of cases reported to the Swedish Adverse Drug Reactions Advisory Committee (SADRAC). A further aim is to compare the characteristics of reported and not reported cases.

METHODS

This retrospective study is a separate analysis using data from a larger study that included women aged 15-44 years between 1990 and 1999 with VTE coded as the underlying or contributory cause of death in the Swedish Cause of Death Register. COC use within 2 months of the date of symptom onset or death was identified in 28 cases. Sales data were obtained from the National Corporation of Swedish Pharmacies. Reported cases were identified in the SADRAC database.

RESULTS

After excluding two cases where the type of COC was unknown, the crude incidences of fatal VTE were 5.1 (95% CI 2.3, 9.6), 8.6 (95% CI 4.3, 15.4) and 9.1 (95% CI 3.3, 19.8) cases per million women per year for levonorgestrel-, desogestrel- and norethisterone-containing COCs, respectively. Age-adjusted incidences were approximately twice as high for desogestrel- and norethisterone-containing COCs compared with levonorgestrel-containing COCs, although differences were not statistically significant. Thirty-six percent of cases were reported. Reporting was positively associated with information in medical records relevant to the VTE diagnosis that the patient was a COC user and was significantly higher in northern Sweden.

CONCLUSION

Results from this study support a higher incidence of fatal VTE with desogestrel-containing COCs than with levonorgestrel-containing COCs.

Pulmonary embolism associated with combined oral contraceptives: reporting incidences and potential risk factors for a fatal outcome

BACKGROUND

It is established that combined oral contraceptive (COC) treatment increases the risk of a pulmonary embolism (PE), but specific risk factors for a fatal outcome from a PE remain to be determined. This study aimed to identify such risk factors, and to calculate the reporting rates of fatal and non-fatal PE.

METHODS

Cases of suspected PE during treatment with COCs reported to the Swedish Adverse Drug Reactions Advisory Committee (SADRAC) between 1965 and 2001 were included. Medical records were scrutinized for potential risk factors for a venous thromboembolism (VTE). Annual sales data were obtained from the National Corporation of Pharmacies.

RESULTS

A total of 248 cases of a suspected PE were reported; 207 non-fatal and 41 fatal. A VTE was verified in all fatal, and in 83.5% of non-fatal cases. The presence of nausea or abdominal pain, an age >35 years, concomitant treatment with other drugs which may increase the VTE risk, vein or lymph vessel malformation, and a deep vein thrombosis above the knee level were positively associated with a fatal outcome. Chest pain and previous COC use were negatively associated with a fatal outcome. The reporting rate of a PE with a verified VTE was 1.72 (95% confidence interval 1.47-2.00) cases per 100 000 treatment years, and of a fatal PE 0.25 (95% confidence interval 0.16-0.37) cases per 100 000 treatment years.

CONCLUSION

Several specific potential risk factors for a fatal outcome from a COC-induced PE were identified. Recognition of these in combination with a high suspicion of VTE in COC users may reduce the risk of a fatal outcome.

Effects of oral contraceptive pills on serum lipoproteins and triglycerides

Possible effects of a combined oral contraceptive (femenal) on blood triglycerides and high-density-lipoprotein-cholesterol (HDL-Chol) were studied in 25 women who had opted for hormonal contraception. Total serum triglycerides of 64.60 +/- 12.39 mg/dl (mean +/- SD) obtained prior to the commencement of hormonal contraception, did not reveal any statistical difference from the value of 65.49 +/- 7.96 mg/dl obtained after 9 months contraception. Similarly, precontraception HDL-Chol value of 58.05 +/- 6.58 mg/dl was also not statistically different from the treatment value of 58.82 +/- 5.42 mg/dl. Regression analysis of the values between control (precontraception) and treatment (9 months contraception) showed high correlation coefficients: (1) serum triglycerides, R2 = 0.5201; P less than 0.001; (2) serum HDL-Chol, R2 = 0.6590; P less than 0.001. Both the mean body weight and blood pressure of the study subjects remained unchanged after 9 months continuous use of femenal for contraception.

Pharmacokinetics of gestodene and ethinyl estradiol after oral administration of a monophasic contraceptive

The pharmacokinetic and protein-binding properties of gestodene and ethinyl estradiol have been investigated after single and multiple dosing in several studies in 83 healthy, young women. After oral administration, gestodene is completely absorbed and bioavailable and exhibits dose-linear pharmacokinetics. During long-term pill use, serum levels of gestodene were four to five times higher than after single administration, showing a periodic increase from day 1 to day 10 during each cycle. Ultrafiltration studies revealed that 75.3% of total serum gestodene is bound to sex hormone-binding globulin, 24.1% is bound to albumin, and only 0.6% is not protein bound. Thus gestodene levels during steady state are explained by an increase in sex hormone binding-globulin as a result of concomitant administered ethinyl estradiol and a specific binding of gestodene to this protein. Serum levels of ethinyl estradiol during single and multiple administration were identical and were not different from those observed with another preparation containing 30 micrograms of ethinyl estradiol.

Comparison of two triphasic contraceptives with different progestogens: effects on metabolism and coagulation proteins

This study compared the effects of two triphasic oral contraceptives (OCs) taken for 6 pill cycles. One preparation contained levonorgestrel (EE/LN), the other a new progestagen, gestodene (SHG 415G). There were no effects on body weight, dietary habits, blood pressure, HDL-cholesterol or carbohydrate metabolism. Both OCs caused a small but statistically significant increase in plasma total cholesterol, LDL-cholesterol, LDL/HDL-cholesterol ratio and triglyceride concentration. Sex hormone binding globulin was increased by both preparations. Coagulation factor VII and fibrinogen were increased and antithrombin III levels reduced, indicating that both preparations had pro-coagulant activity. The gestodene triphasic preparation was associated with minor side effects similar to those experienced on EE/LN. The metabolic effects were similar despite the lower total steroid dose of the gestodene preparation.

Effect of Anordrin on serum levels of sex hormone binding globulin, caeruloplasmin and ovarian function

Ten doses of 7.5 mg Anordrin were administered on alternate days from day 5 of the menstrual cycle to 20 women. Serum concentrations of both SHBG and CP were significantly increased after the fourth dose but the increases were minor compared to those produced by ethynyloestradiol. Two weeks after stopping Anordrin, serum concentrations of the proteins were still elevated in most women. Ovarian activity was studied in 8 women; serum oestradiol and progesterone concentrations indicated that ovulation occurred at the normal time in three women but was delayed for two weeks or more in the remaining five. The findings suggest that in humans, Anordrin acts as a weak oestrogen and may also have antioestrogenic activity.

Serum lipid and lipoprotein changes induced by new oral contraceptives containing ethinylestradiol plus levonorgestrel or desogestrel

Changes in serum lipid and lipoprotein levels were evaluated in a randomized prospective study conducted in matched healthy young women before and after 6 months' use of three oral contraceptives (OCs): Trigynon (preparation A, n = 13), a triphasic OC containing low doses of ethinylestradiol (EE) and levonorgestrel (LNG); Marvelon (preparation B, n = 14), a monophasic OC containing low doses of EE + Desogestrel (DOG, a new progestogen derived from LNG); and Ovidol (preparation C, n = 11), a sequential OC containing higher doses (50 micrograms) of EE + DOG. After 6 months of use, total triglyceride levels were non-significantly increased by preparations A (+ 29% from basal values) and B (+21%), and very significantly increased by preparation C (+90%). Total cholesterol and phospholipids were unchanged by preparations A and B, whereas phospholipids were significantly increased by preparation C. However, HDL-cholesterol, LDL-cholesterol and their epidemiologically important ratios (HDL-chol:total-chol; LDL-chol:HDL-chol) were kept unchanged by all preparations tested. Apolipoprotein A-1 (Apo A-1) was slightly but significantly increased by all three preparations whereas apolipoprotein B (Apo B) was significantly decreased by preparation B. All ratios Apo A-1:Apo B were accordingly ("favorably") increased, especially during treatment with preparation B. In conclusion, the triphasic OC containing low doses of LNG does not induce obvious, clinically significant, alterations of lipid metabolism, and it is also the case for the low-dose monophasic combination of EE + DOG. The higher-dose sequential preparation of EE + DOG behaves as a more estrogenic compound, increasing total triglyceride concentrations above the normal range.