The efficacy of non-contraceptive uses for hormonal contraceptives

Reversible female contraceptives: historical, current, and future perspectives†

Contraception is a practice with extensive and complicated social and scientific histories. From cycle tracking, to the very first prescription contraceptive pill, to now having over-the-counter contraceptives on demand, family planning is an aspect of healthcare that has undergone and will continue to undergo several transformations through time. This review provides a comprehensive overview of current reversible hormonal and non-hormonal birth control methods as well as their mechanism of action, safety, and effectiveness specifically for individuals who can become pregnant. Additionally, we discuss the latest Food and Drug Administration (FDA)-approved hormonal method containing estetrol and drospirenone that has not yet been used worldwide as well as the first FDA-approved hormonal over-the-counter progestin-only pills. We also review available data on novel hormonal delivery through microchip, microneedle, and the latest FDA-approved non-hormonal methods such as vaginal pH regulators. Finally, this review will assist in advancing female contraceptive method development by underlining constructive directions for future pursuits. Information was gathered from the NCBI and Google Scholars databases using English and included publications from 1900 to present. Search terms included contraceptive names as well as efficacy, safety, and mechanism of action. In summary, we suggest that investigators consider the side effects and acceptability together with the efficacy of contraceptive candidate towards their development.

Is primary dysmenorrhea a precursor of future endometriosis development?

Primary dysmenorrhea (PD) is the most common gynecologic disorder during adolescence and it is characterized by crampy lower abdominal pain that occurs during menstruation. Secondary dysmenorrhea, in contrast, has the same clinical features but occurs in women with a disease that could account for their symptoms (endometriosis, adenomyosis, uterine fibroids, pelvic inflammatory disease). Endometriosis is the most common cause of secondary dysmenorrhea and it should be considered in patients with persistent and clinically significant dysmenorrhea despite treatment. It is often diagnosed after a long delay, increasing the likelihood of pain chronicity and fertility problems at a later age. Women who suffer from dysmenorrhea in adolescence have higher risk of endometriosis in future. The open question is if endometriosis was already present at the onset of dysmenorrhea but undiagnosed or if PD favors subsequent development of endometriosis-associated pain. Since PD is associated with higher risk for developing chronic pain state and shares some of the same pain pathways of endometriosis (prostaglandins overproduction, inflammation, peripheral sensitization, central sensitization and abnormal stress responses), a correlation between PD and endometriosis is suggested. To know whether it is a risk factor for the development of endometriosis-associated pain may provide an opportunity for early intervention and prevention. The present review aims to investigate the clinical and pathogenetic features of PD and endometriosis in order to identify a possible association between the two conditions.

Effect of administration of monophasic oral contraceptive on the body composition and aerobic and anaerobic capacities of female athletes

AIM

To examine the effects of administration of monophasic oral contraceptive (OC) on the body composition and aerobic and anaerobic capacities of female athletes.

METHODS

Ten female athletes (23.0 ± 4.1 years old) participated in this study. All the subjects were examined during the menstrual cycle (early follicular [EF], middle luteal [ML]) and OC cycle (inactive OC, and active OC phases). After the menstrual cycle measurements, all the subjects began taking OC. The athletes tested using a body composition, circumferences, the lactate curve test, the maximal oxygen consumption test, and the Wingate test during all phases.

RESULTS

Waist circumference was lower during the OC cycle than menstrual cycle (P < 0.05), and the other circumferences of parts were not different during the menstrual or OC cycles. However, there were no differences in body composition before and after taking OC. The phase of the menstrual or OC cycle did not affect maximal oxygen consumption, heart rate max or power output at a blood lactate concentration of 2 and 4 mmol/L between the menstrual and OC cycle phases. Although, the peak blood lactate level after the Wingate test was higher during the OC cycle (inactive OC phase, 13.0 ± 2.4 mmol/L; active OC phase, 12.4 ± 3.0 mmol/L) than during the menstrual cycle (EF phase, 11.9 ± 2.1 mmol/L; ML phase, 11.4 ± 2.1 mmol/L; P < 0.05), the peak and average power in the Wingate test did not change during the menstrual and OC cycle phases.

CONCLUSION

Administration of monophasic OC did not affect the body composition or aerobic and anaerobic capacities of female athletes.

Health-related quality of life in undergraduate women using any contraceptive

Objective

The aim of this research was to assess university students’ health-related quality of life whether they use some contraceptive method or not.

Methods

This research is a cross-sectional study. Female participants who studied a degree in health at the University of Seville (Spain) were recruited. Respondents completed a demographic questionnaire and health-related quality of life was measured with validated instrument SEC-QoL (Sociedad Española de Contracepción- Quality of Life) in Spanish that measured five dimensions: sexual, social, breast, menstrual and psychosocial.

Results

A total of 992 women aged 21.37 (3.6) years old participated in this study. Women who used a contraceptive method reached higher scores at the SEC-QoL questionnaire 47.09 (17.04) and 46.91 (18.73) than those that didn’t. Likewise, women who chose a hormonal method showed a better overall health-related quality of life, compared to those who used a non-hormonal method. Participants who used hormonal contraceptives obtained higher scores in all health-related quality of life domains (social, menstrual, breast and sexual), except psychological domain when compared to those who used a non hormonal method or none. Furthermore, a moderated mediation model showed that the effect of the current contraceptive method on health-related quality of life was partially explained by the moderated mediation of the time using this method, the reason for using it and the existence of a partner.

Conclusion

The usage of hormonal contraceptives increases health-related quality of life in young women. Several variables regarding the experience with contraceptive methods should be considered in order to examine the effect on health-related quality of life in undergraduate women.

Heavy menstrual bleeding diagnosis and medical management

Heavy menstrual bleeding (HMB) is a common gynecological problem that has a significant impact on a woman’s quality of life and the activities of daily living. Due to the difficulty in accurately describing menstrual bleeding abnormalities using older terminology, the PALM-COEIN classification system of the Federation Internationale de Gynecologie et d’Obstetrique was proposed to describe and identify the etiology of abnormal endometrial bleeding. As there is no single pathway that is associated with HMB, there are several therapeutic interventions involving different molecular pathways to reduce HMB. This article will highlight the current evidence as it relates to the etiology of HMB as well as medical modalities of treatment.

Abnormal Uterine Bleeding

Abnormal uterine bleeding is a frequent condition in Gynecology. It may impact physical, emotional sexual and professional aspects of the lives of women, impairing their quality of life. In cases of acute and severe bleeding, women may need urgent treatment with volumetric replacement and prescription of hemostatic substances. In some specific cases with more intense and prolonged bleeding, surgical treatment may be necessary. The objective of this chapter is to describe the main evidence on the treatment of women with abnormal uterine bleeding, both acute and chronic. Didactically, the treatment options were based on the current International Federation of Gynecology and Obstetrics (FIGO) classification system (PALM-COEIN). The etiologies of PALM-COEIN are: uterine Polyp (P), Adenomyosis (A), Leiomyoma (L), precursor and Malignant lesions of the uterine body (M), Coagulopathies (C), Ovulatory dysfunction (O), Endometrial dysfunction (E), Iatrogenic (I), and Not yet classified (N). The articles were selected according to the recommendation grades of the PubMed, Cochrane and Embase databases, and those in which the main objective was the reduction of uterine menstrual bleeding were included. Only studies written in English were included. All editorial or complete papers that were not consistent with abnormal uterine bleeding, or studies in animal models, were excluded. The main objective of the treatment is the reduction of menstrual flow and morbidity and the improvement of quality of life. It is important to emphasize that the treatment in the acute phase aims to hemodynamically stabilize the patient and stop excessive bleeding, while the treatment in the chronic phase is based on correcting menstrual dysfunction according to its etiology and clinical manifestations. The treatment may be surgical or pharmacological, and the latter is based mainly on hormonal therapy, anti-inflammatory drugs and antifibrinolytics.

Medical management of heavy menstrual bleeding

Women with benign heavy menstrual bleeding have the choice of a number of medical treatment options to reduce their blood loss and improve quality of life. The role of the clinician is to provide information to facilitate women in making an appropriate choice. Unfortunately, many options can be associated with hormonal side effects, prevention of fertility and lack of efficacy, leading to discontinuation and progression to surgical interventions. Herein, we discuss the various options currently available to women, including antifibrinolytics, nonsteroidal anti-inflammatory preparations, oral contraceptive pills and oral, injectable and intrauterine progestogens. In addition, we describe the more novel option of selective progesterone receptor modulators and their current benefits and limitations.

The effect of oral contraceptives on aromatase and Cox-2 expression in the endometrium of patients with idiopathic menorrhagia or adenomyosis

Background

The presence of aromatase and cyclooxygenase-2 (Cox-2) expression was investigated in the endometrium of patients with idiopathic menorrhagia or adenomyosis. The effect of oral contraceptives administered in extended regimens on the endometrial expression of these enzymes was also investigated.

Methods and results

Aromatase expression was detected by immunohistochemistry in the endometrial glands and stroma of patients with idiopathic menorrhagia or adenomyosis. There was no difference in the percentage of aromatase expression in the endometria between the two groups. The mean intensity of Cox-2 expression in the glandular epithelium also did not differ significantly between the groups. Among the patients using oral contraceptives in extended regimens, the relative decrease in both aromatase and Cox-2 expression was significantly greater in amenorrheic patients compared with those who were experiencing breakthrough bleeding.

Conclusion

The presence of aromatase expression in the endometrium is associated with the occurrence of menorrhagia, irrespective of the presence of adenomyosis. Continuous expression of these enzymes in the endometrium of users of oral contraceptives in extended regimens is positively associated with the presence of breakthrough bleeding. This suggests a role for both aromatase and Cox-2 in the etiology of abnormal uterine bleeding.

Markers of adult endometriosis detectable in adolescence

Endometriosis, a disease of young females that is possibly a devastating ailment requiring surgery, appears to be associated with certain features encountered in adolescence. First among these symptoms is the history of severe and lasting dysmenorrhea at the time of adolescence and the need to use oral contraceptives (OCs) for alleviating dysmenorrhea that failed to respond to nonsteroidal anti-inflammatory drugs (NSAIDs). Further awareness about existing associations between certain symptoms experienced at adolescence and the later development of endometriosis is important. Indeed, the possibility of diagnosing endometriosis earlier when suggested by clinical history could lead to less extensive surgery and thus, less damage. Experimental verification of this insight, however, is needed before the concept that early diagnosis means lesser destructive surgery can be ascertained.

Deleterious effects of progestagen treatment in VEGF expression in corpora lutea of pregnant ewes

The aim of the current study was to determine the possible effects of progestagen oestrous synchronization on vascular endothelial growth factor (VEGF) expression during sheep luteogenesis and the peri-implantation period and the relationship with luteal function. At days 9, 11, 13, 15, 17 and 21 of pregnancy, the ovaries from 30 progestagen treated and 30 ewes cycling after cloprostenol injection were evaluated by ultrasonography and, thereafter, collected and processed for immunohistochemical evaluation of VEGF; blood samples were drawn for evaluating plasma progesterone. The progestagen-treated group showed smaller corpora lutea than cloprostenol-treated and lower progesterone secretion. The expression of VEGF in the luteal cells increased with time in the cloprostenol group, but not in the progestagen-treated group, which even showed a decrease between days 11 and 13. In progestagen-treated sheep, VEGF expression in granulosa-derived parenchymal lobule capillaries was correlated with the size of the luteal tissue, larger corpora lutea had higher expression, and tended to have a higher progesterone secretion. In conclusion, the current study indicates the existence of deleterious effects from exogenous progestagen treatments on progesterone secretion from induced corpora lutea, which correlate with alterations in the expression of VEGF in the luteal tissue and, this, presumably in the processes of neoangiogenesis and luteogenesis.

Oral contraceptives and risk of endometriosis: a systematic review and meta-analysis

BACKGROUND

Combined oral contraceptives (OCs) inhibit ovulation, substantially reduce the volume of menstrual flow and may hypothetically interfere with implantation of refluxed endometrial cells. The aim of this review is to establish if OC use influences the risk of endometriosis.

METHODS

We performed a MEDLINE search to identify all studies published in the last four decades (January 1970 to January 2010) in the English language on the relationship between OC exposure and risk of endometriosis. Two authors abstracted data on standardized forms.

RESULTS

We identified 608 potentially relevant studies and 18 studies (6 cross-sectional, 7 case-control and 5 cohort) were selected. Pooling of the results derived from all the included reports independently from study design, yielded a common relative risk of 0.63 [95% confidence interval (CI), 0.47-0.85] for current OC users, 1.21 (95% CI, 0.94-1.56) for past users and 1.19 (95% CI, 0.89-1.60) for ever users. Methodological drawbacks, such as uncertain temporal relationship between exposure and outcome in cross-sectional studies and suboptimal selection of controls in case-control studies, limit the quality of the available evidence.

CONCLUSIONS

The risk of endometriosis appears reduced during OC use. However, it is not possible to exclude the possibility that the apparent protective effect of OC against endometriosis is the result of postponement of surgical evaluation due to temporary suppression of pain symptoms. Confounding by selection and indication biases may explain the trend towards an increase in risk of endometriosis observed after discontinuation, but further clarification is needed. To date, the hypothesis of recommending OCs for primary prevention of endometriosis does not seem sufficiently substantiated.

The effect of oral contraceptives on aromatase expression in the eutopic endometrium of patients with endometriosis

OBJECTIVE

To determine the effect of oral contraceptives containing gestodene on aromatase expression in the endometrium of patients diagnosed with endometriosis.

PATIENTS AND METHODS

Endometrial biopsies were taken at the time of laparoscopy in 40 patients with endometriosis, 16 of whom were using an oral contraceptive containing gestodene at the time of laparoscopy. The remaining 24 patients were receiving no form of treatment for endometriosis. Endometrial biopsies taken from 23 patients with normal echographic signs and no symptoms were used as controls. Aromatase expression was evaluated in endometrial samples using immunohistochemistry.

RESULTS

In the untreated, symptomatic endometriosis patients, aromatase expression was detected during the proliferative phase in 92% of cases, while in the symptom-free control patients aromatase was expressed in only 9% of cases. In patients with endometriosis who were using oral contraceptives, there were significantly fewer cases of positive endometria compared with the untreated patients with endometriosis (6%).

CONCLUSION

Oral contraceptives containing gestodene are effective in decreasing aromatase expression in the eutopic endometrium of patients with endometriosis.

Short-term oral contraceptive use and the risk of epithelial ovarian cancer

Oral contraceptive (OC) use has been consistently linked to a reduction in ovarian cancer in a dose-dependent fashion. Whether short-term OC use is protective remains controversial. In 1994-1998 in the Delaware Valley of Pennsylvania, the authors examined the association between short-term OC use and ovarian cancer in a population-based case-control study comparing 608 incident epithelial ovarian cancer cases with 926 community controls. Using unconditional logistic regression and adjusting for known confounders, they found a significant reduction in ovarian cancer risk for women who had used OCs for < or =6 months (odds ratio = 0.73, 95% confidence interval: 0.54, 0.99). This protective effect was observed in only that group who had used OCs for < or =6 months and stopped because of side effects (odds ratio = 0.59, 95% confidence interval: 0.40, 0.87 for side effects and odds ratio = 0.91, 95% confidence interval: 0.60, 1.37 for non-side-effects). Women who used OCs for >6 months were at a reduced risk independent of their reason for stopping. Results were similar when stratifying by parity and hormone therapy use. Thus, OC use for as little as 6 months provides significant protection against ovarian cancer risk, protection that appears limited to those women who stop using OCs because of side effects. Mediating factors may reflect endogenous hormone levels, OC metabolism, or OC bioactivity.