Low thrombin generation in postmenopausal women using estetrol

OBJECTIVE

Estetrol (E4) represents a novel estrogen of interest to relieve vasomotor symptoms. E4 activates the nuclear estrogen receptor α (ERα) but antagonizes the estradiol ERα-dependent membrane-initiated steroid signaling pathway. The distinct pharmacological properties of E4 could explain its low impact on hemostasis. This study aimed to assess the effect of E4 on coagulation in postmenopausal women, using the thrombin generation assay (TGA).

METHODS

Data were collected from a multicenter, randomized, placebo-controlled, dose-finding study in postmenopausal women (NCT02834312). Oral E4 (2.5 mg, n = 42; 5 mg, n = 29; 10 mg, n = 34; or 15 mg, n = 32) or placebo (n = 31) was administered daily for 12 weeks. Thrombograms and TGA parameters were extracted for each subject at baseline and after 12 weeks of treatment.

RESULTS

After 12 weeks of treatment, all treatment groups showed a mean thrombogram (±95% confidence interval [CI] of the mean) within the reference ranges, that is, the 2.5th-97.5th percentile of all baseline thrombograms (n = 168), as well as for TGA parameters.

CONCLUSIONS

The intake of E4 15 mg for 12 weeks led to significant but not clinically relevant changes compared to baseline as the mean values (±95% CI of the mean) remained within reference ranges, demonstrating a neutral profile of this estrogen on hemostasis.

The benefits of estetrol addition to drospirenone for contraception

Ethinylestradiol and drospirenone combined oral contraceptive formulations have been marketed for >20 years. Drospirenone has antimineralocorticoid and anti-androgenic effects that may offer several health benefits. Recently, 2 new drospirenone-containing oral contraceptives entered the market, 1 as a progestin-only pill containing 4 mg drospirenone and the other as a combined oral contraceptive containing 15 mg estetrol and 3 mg drospirenone. Estetrol has a unique differential effect on nuclear and membrane estrogen α-receptors when compared with other estrogens, leading to low impact on the liver, breast, and hemostasis parameters and a beneficial effect on the endometrium, vagina, cardiovascular system, bone, and brain. Phase 3 clinical studies demonstrated that the Pearl Index (pregnancies per 100-woman-years) for drospirenone alone is 4.0 in the United States and 0.93 in the European Union and for the estetrol-drospirenone combination it is 2.65 and 0.44, respectively. Drospirenone alone demonstrates high rates of unscheduled bleeding and low rates of scheduled bleeding, whereas the estetrol-drospirenone combination demonstrates a predictable and regular bleeding profile for most users with a high stable rate of scheduled bleeding and a low rate of unscheduled bleeding, reported primarily as spotting only. The adverse event profiles and discontinuation rates owing to adverse events are comparable, and no clinically significant effects were observed on metabolic parameters with either product. Hemostatic assays for drospirenone do not fully evaluate all parameters although the testing that is available suggests negligible effects, whereas validated hemostatic assays demonstrate that the estetrol-drospirenone combination has limited impact on hemostasis. The introduction of 4 mg drospirenone and 15 mg estetrol with 3 mg drospirenone are valuable additions to the contraceptive market. Adding estetrol to 3 mg drospirenone provides advantages of contraceptive efficacy and a regular, predictable bleeding profile with minimal impact on hemostasis parameters.

A multicenter, randomized, placebo-controlled study to select the minimum effective dose of estetrol in postmenopausal participants (E4Relief): part 2-vaginal cytology, genitourinary syndrome of menopause, and health-related quality of life

OBJECTIVE

A phase 2 study showed that 15 mg estetrol (E4) alleviates vasomotor symptoms (VMS). Here, we present the effects of E4 15 mg on vaginal cytology, genitourinary syndrome of menopause, and health-related quality of life.

METHODS

In a double-blind, placebo-controlled study, postmenopausal participants (n = 257, 40-65 y) were randomized to receive E4 2.5, 5, 10, or 15 mg or placebo once daily for 12 weeks. Outcomes were the vaginal maturation index and maturation value, genitourinary syndrome of menopause score, and the Menopause Rating Scale to assess health-related quality of life. We focused on E4 15 mg, the dose studied in ongoing phase 3 trials, and tested its effect versus placebo at 12 weeks using analysis of covariance.

RESULTS

Least square (LS) mean percentages of parabasal and intermediate cells decreased, whereas superficial cells increased across E4 doses; for E4 15 mg, the respective changes were -10.81% ( P = 0.0017), -20.96% ( P = 0.0037), and +34.17% ( P < 0.0001). E4 15 mg decreased LS mean intensity score for vaginal dryness and dyspareunia (-0.40, P = 0.03, and -0.47, P = 0.0006, respectively); symptom reporting decreased by 41% and 50%, respectively, and shifted to milder intensity categories. The overall Menopause Rating Scale score decreased with E4 15 mg (LS mean, -3.1; P = 0.069) and across doses was associated with a decreasing frequency and severity of VMS ( r = 0.34 and r = 0.31, P < 0.001).

CONCLUSIONS

E4 demonstrated estrogenic effects in the vagina and decreased signs of atrophy. E4 15 mg is a promising treatment option also for important menopausal symptoms other than VMS.

Impact of estetrol (E4) on hemostasis, metabolism and bone turnover in postmenopausal women

OBJECTIVE

This study aimed to determine the effects of estetrol (E4) on hemostasis, lipids, carbohydrate metabolism and bone turnover in postmenopausal women.

METHODS

This study was a multicenter, randomized, double-blind placebo-controlled phase 2 trial. Participants (n = 180, age 43-64 years) received E4 2.5 mg, 5 mg, 10 mg and 15 mg or placebo once daily for 12 weeks. Changes from baseline at week 12 were evaluated versus placebo for hemostasis parameters, sex hormone binding globulin (SHBG), lipids, carbohydrate metabolism and bone markers.

RESULTS

Changes for hemostasis parameters were minimal with a small increase only in the normalized activated protein C sensitivity ratio in the E4 15 mg group versus placebo. SHBG increased in the E4 5 mg, 10 mg and 15 mg groups versus placebo. High-density lipoprotein cholesterol increased in all E4 groups; changes were not consistent for other lipids. Significant decreases versus placebo were seen for insulin resistance (E4 10 mg group), hemoglobin A1c (E4 15 mg group) and type 1 collagen C-terminal telopeptide (E4 10 mg and 15 mg groups). Small decreases in osteocalcin in the E4 5 mg, 10 mg and 15 mg groups were significant versus the increase observed in placebo.

CONCLUSION

E4 had limited impact on hemostasis and potentially beneficial effects on lipids, carbohydrate metabolism and bone turnover.

Low Thrombin Generation in Users of a Contraceptive Containing Estetrol and Drospirenone

OBJECTIVE

To compare the impact on thrombin generation of the new combined oral contraceptive containing 15 mg estetrol and 3 mg drospirenone with ethinylestradiol (30 or 20 mcg) associated either with 150 mcg levonorgestrel or with 3 mg drospirenone.

METHODS

Data were collected from the "E4/DRSP Endocrine Function, Metabolic Control and Hemostasis Study" (NCT02957630). Overall, the per-protocol set population included 24 subjects in the ethinylestradiol/levonorgestrel arm, 28 subjects in the ethinylestradiol/drospirenone arm, and 34 subjects in the estetrol/drospirenone arm. Thrombograms and thrombin generation parameters (lag time, peak, time to peak, endogenous thrombin potential, and mean velocity rate index) were extracted for each subject at baseline and after 6 cycles of treatment.

RESULTS

After 6 cycles of treatment, ethinylestradiol-containing products arms show a mean thrombogram outside the upper limit of the reference range, that is the 97.5th percentile of all baseline thrombograms. On the other hand, the mean thrombogram of estetrol/drospirenone is within this reference interval. After 6 cycles of treatment, all thrombin generation parameters are statistically less affected by estetrol/drospirenone than ethinylestradiol-containing products.

CONCLUSIONS

In conclusion, an association of 15 mg estetrol with 3 mg drospirenone does not have an impact on thrombin generation compared with ethinylestradiol-containing products that, either associated with levonorgestrel or drospirenone, are able to increase the production of procoagulant factors and decrease the production of anticoagulant ones, shifting the patient to a prothrombotic state. Ethinylestradiol-containing products thus generate prothrombotic environments contrary to estetrol which demonstrates a neutral profile on hemostasis.

RF34 | PMON202 The Human Metabolic Profile of Estetrol

Objectives

Estetrol (E4), a native estrogen produced by the fetal human liver, has four hydroxyl-groups, making it structurally distinct from other estrogens. We determined the human metabolic profile of E4, which is recently marketed combined with drospirenone as a novel contraceptive and is currently in development for the relief of menopausal symptoms.

Method: We studied the in vitro metabolism of E4 using human hepatocytes, human liver microsomes and recombinant CYP enzymes in reaction phenotyping studies to evaluate the role of human cytochrome P450 enzymes, UDP-glucuronosyltransferases (UGT) and sulfotransferases (SULT). Furthermore, we evaluated the in vivo metabolism of E4 in an open-label, non-randomised phase 1 human absorption, distribution, metabolism, and excretion study, in which six healthy postmenopausal participants received a single oral solution containing 15 mg [¹⁴C]-E4. We analysed blood (up to 240h), urine and faecal samples (up to 312h). Metabolite profiling and identification was performed using liquid chromatography with tandem mass spectrometry.

Results

The in vitro studies showed that E4 undergoes extensive phase 2 metabolism to form glucuronide and sulphate conjugates. UGT2B7 is the key enzyme catalysing the direct glucuronidation of E4 and SULT1E1 is the dominant sulfotransferase for sulphate conjugation in vitro. Unlike for other estrogens, oxidative phase 1 metabolism by P450 enzymes does not play a major role in the metabolism of E4. Following oral administration of E4 to humans, the major metabolites observed in human plasma were E4-16-glucuronide, E4-3-glucuronide and E4-glucuronide-sulfate (respectively 62%, 17% and 9% of radioactivity at the time of maximum plasma concentration [Tmax]). At Tmax, unchanged E4 accounts for only 7.5% of plasma radioactivity. Main metabolites quantified in urine during the first 6 hours after administration were E4-16-glucuronide and E4-3-glucuronide (respectively 77.4% and 16.5% of urine radioactivity). Approximately 69% of the total administered radioactivity was recovered in urine and 22% in faeces. Mass spectrometry showed that E4 was not present in urine but was detected in faeces and that E4 is not converted back into one of the other natural estrogens (estriol, estradiol, estrone).

Conclusions

Altogether, these data suggest that E4 has a unique metabolic profile. E4 is a terminal end-product of estrogen metabolism, which is not converted back, in vivo, into active metabolites like estriol, estradiol or estrone. Unlike for other estrogens, CYP450 enzymes do not play a major role in the metabolic pathway of E4.

Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m., Monday, June 13, 2022 12:48 p.m. - 12:53 p.m.

Analytical performance of the endogenous thrombin potential–based activated protein C resistance assay on the automated ST Genesia system

Background

Objectives

Method

Results

Conclusion

Profile of estetrol, a promising native estrogen for oral contraception and the relief of climacteric symptoms of menopause

INTRODUCTION

Estrogens used in women's healthcare have been associated with increased risks of venous thromboembolism (VTE) and breast cancer. Estetrol (E4), an estrogen produced by the human fetal liver, has recently been approved for the first time as a new estrogenic component of a novel combined oral contraceptive (E4/drospirenone [DRSP]) for over a decade. In phase 3 studies, E4/DRSP showed good contraceptive efficacy, a predictable bleeding pattern, and a favorable safety and tolerability profile.

AREAS COVERED

This narrative review discusses E4's pharmacological characteristics, mode of action, and the results of preclinical and clinical studies for contraception, as well as for menopause and oncology.

EXPERT OPINION

Extensive studies have elucidated the properties of E4 that underlie its favorable safety profile. While classical estrogens (such as estradiol) exert their actions via both activation of nuclear and membrane estrogen receptor α (ERα), E4 presents a specific profile of ERα activation: E4 binds and activates nuclear ERα but does not induce the activation of membrane ERα signaling pathways in specific tissues. E4 has a small effect on normal breast tissue proliferation and minimally affects hepatic parameters. This distinct profile of ERα activation, uncoupling nuclear and membrane activation, is unique.

Combined Oral Contraceptives and Venous Thromboembolism: Review and Perspective to Mitigate the Risk

Many factors must be considered and discussed with women when initiating a contraceptive method and the risk of venous thromboembolism (VTE) is one of them. In this review, we discuss the numerous strategies that have been implemented to reduce the thrombotic risk associated with combined oral contraceptives (COCs) from their arrival on the market until today. Evidences suggesting that COCs were associated with an increased risk of VTE appeared rapidly after their marketing. Identified as the main contributor of this risk, the dosage of the estrogen, i.e., ethinylestradiol (EE), was significantly reduced. New progestins were also synthetized (e.g., desogestrel or gestodene) but their weak androgenic activity did not permit to counterbalance the effect of EE as did the initial progestins such as levonorgestrel. Numerous studies assessed the impact of estroprogestative combinations on hemostasis and demonstrated that women under COC suffered from resistance towards activated protein C (APC). Subsequently, the European Medicines Agency updated its guidelines on clinical investigation of steroid contraceptives in which they recommended to assess this biological marker. In 2009, estradiol-containing COCs were marketed and the use of this natural form of estrogen was found to exert a weaker effect on the synthesis of hepatic proteins compared to EE. In this year 2021, a novel COC based on a native estrogen, i.e., estetrol, will be introduced on the market. Associated with drospirenone, this preparation demonstrated minor effects on coagulation proteins as compared with other drospirenone-containing COCs. At the present time, the standard of care when starting a contraception, consists of identifying the presence of hereditary thrombophilia solely on the basis of familial history of VTE. This strategy has however been reported as poorly predictive of hereditary thrombophilia. One rationale and affordable perspective which has already been considered in the past could be the implementation of a baseline screening of the prothrombotic state to provide health care professionals with objective data to support the prescription of the more appropriate contraceptive method. While this strategy was judged too expensive due to limited laboratory solutions, the endogenous thrombin potential-based APC resistance assay could now represent an interesting alternative.

[«I am not pregnant !» About denial of pregnancy…]

The term «denial of pregnancy», although used in current medical practice since 1970, does not yet have a universal definition. The literature allows to define it as «the non-recognition of a pregnancy beyond the first trimester, which can last until delivery and cover it». The changes related to pregnancy are biologically reduced or incorrectly perceived or even ignored. Although often wrongly considered as a rare phenomenon, the literature describes it as having a prevalence of 2 to 3 cases per 1.000 viable deliveries. This case report associated with a short review of the literature aims to optimise the clinician awareness, leading to the diagnosis as well as the potential perinatal consequences linked to this phenomenon.

Exploring the interest in and the usage of the internet among patients eligible for osteoporosis screening

The aim of this study was to evaluate the interest in the Internet and its usage for health-related issues among people eligible for osteoporosis screening. Self-administered questionnaires have been distributed to subjects who were screened for osteoporosis and to menopausal women. 177 patients have responded to the survey (64.5 ± 10.1 years, 88.1% of women). There are 78.5% of Internet users. Among them, 67.2% said searching information about their health and 74.5% said using the Internet for this purpose. All respondents attributed an average score, out of 10, of 5.7 ± 2.3 regarding the reliability of information that they could find on the Internet. The use of the Internet differs significantly depending on age: those who use the Internet are younger (62.1 ± 8.91 years) than those who do not use it (73.3 ± 9.42 years). The socioeconomic status also has an impact on the Internet use: Internet users have a higher education, are more professionally active and have a higher net monthly household income compared to the group of non-users. Even if age and socioeconomic status appear to be determining factors in the use of the Internet for the search of health information in patients eligible for osteoporosis screening, almost 75% of the study population use the Internet for this purpose. Action to promote health through an Internet platform must therefore take these parameters into account.

[The use of intrauterine device in nulliparous over 18 years: a Belgian consensus]

Under the presidency of prof. H. Depypere (UZ Ghent) and Prof. P. Simon (ULB Erasme) a Belgian panel of thirteen experts (gynecologists, representatives of universities and scientific associations for gynecology-obstetrics) reached a consensus on the use of intrauterine systems, both copper IUDs as hormone IUDs, in nultiparous women.

Asymmetric facial skin viscoelasticity during climacteric aging

Background

Climacteric skin aging affects certain biophysical characteristics of facial skin. The purpose of the present study was to assess the symmetric involvement of the cheeks in this stage of the aging process.

Methods

Skin viscoelasticity was compared on both cheeks in premenopausal and post-menopausal women with indoor occupational activities somewhat limiting the influence of chronic sun exposure. Eighty-four healthy women comprising 36 premenopausal women and 48 early post-menopausal women off hormone replacement therapy were enrolled in two groups. The tensile characteristics of both cheeks were tested and compared in each group. A computerized suction device equipped with a 2 mm diameter hollow probe was used to derive viscoelasticity parameters during a five-cycle procedure of 2 seconds each. Skin unfolding, intrinsic distensibility, biological elasticity, and creep extension were measured.

Results

Both biological elasticity and creep extension were asymmetric on the cheeks of the post-menopausal women. In contrast, these differences were more discrete in the premenopausal women.

Conclusion

Facial skin viscoelasticity appeared to be asymmetric following menopause. The possibility of asymmetry should be taken into account in future studies of the effects of hormone replacement therapy and any antiaging procedure on the face in menopausal women.

[Zoely, a combined oral contraceptive, monophasic pill containing estradiol and nomegestrol acetate]

A new combined oral contraceptive called Zoely has just been marketed in Belgium. It contains nomegestrol acetate, a progestin known for its high contraceptive reliability based on its antigonadotropic power and long half-life. This progestin is associated with estradiol and Zoely is devoid of ethinyl estradiol, which is the usual component of the majority of combined oral contraceptives and is primarily responsible for thrombotic side effects of the pill. The compositon and type of regimen of this new oral contraceptive contribute to its efficacy and excellent clinical tolerance.

[Breast cancer in Belgium: why are we the first in Europe?]

Breast cancer incidence in Belgium is on the top of European countries, with 9.697 new cases in 2008 and 106/100.000 women/year. The explanation of this high incidence in our country is probably the accumulation of risk factors (many of them are linked to lifestyle), and the impact of screening and registration of cases. The relative impact of each of theses factors is less clear because we don't have powerful statistical studies. Belgium is slightly above the European mean for breast cancer mortality, with 19,4/100.000 women/year and an all stages 15-year survival of 75%. Breast cancers are responsible for around 3% of all-cause mortality in Belgian women. This article discusses the causes of this high Belgian incidence and of current decrease of incidence in western countries, and reviews known and less known risk factors of breast cancers, with a special focus on menopause hormonal treatments.

[Medication of the month. Femoston Low (0.5 mg estradiol plus 2.5 mg dydrogesterone) for menopausal hormonal replacement therapy]

Femoston Low is a hormone replacement therapy that combines low dosages of steroids, i.e. 0.5 mg of estradiol and 2.5 mg of dydrogesterone. This oral preparation should be taken continuously to treat climacteric symptoms in menopausal women. Femoston Low is in agreement with the recent recommendations for menopausal hormone replacement therapy, which give the preference to low dosage therapy whenever possible. The goals are to potentially minimize the risk of breast cancer, the danger of venous or arterial thrombosis and the glucose and lipid metabolic disturbances. Nevertheless, the preparation should efficaciously oppose to endometrial hyperplasia and yield a high degree of amenorrhea.

[Ulipristal acetate: an emergency contraception extended to 5 days using a progesterone receptor modulator (Ellaone)]

Emergency contraception is a second chance for prevention of pregnancy after unprotected intercourse. Hormonal emergency contraception with levonorgestrel 1.5 mg, only provides an effective contraception from 0 to 72 hours after intercourse with decreasing effectiveness as time elapses. It was accordingly mandatory to develop an alternative approach with a stable contraceptive efficacy and good tolerance for 5 days, knowing additionally that the estimated lifespan of sperm in the female genital tract is about 5 days. In comparative studies bearing on more than 3000 young women, the progesterone receptor modulator (PRM) ulipristal acetate, a progesterone antagonist (taken in a single dose of 30 mg), or levonorgestrel (1.5 mg) were administered. Results indicated that the PRM was as effective as levonorgestrel, or even more, kept a stable efficacy for 120 hours after an unprotected intercourse, and was well tolerated. This establishes ulipristal acetate as the new standard for hormonal emergency contraception.

[Medication of the month. A new combined oral contraceptive containing estradiol valerate and dienogest (Qlaira)]

In combined oral contraception (OC), a drastic reduction of both ethinylestradiol and androgenic progestins mostly derived from 19 NOR testosterone, allowed to moderately reduce the adverse impact of classical combined pills on metabolism and circulation (both arterial and venous). However, the marked hepatic action of ethinylestradiol, even in small dosages, lessens the expected risk reduction. For the first time, an OC has been developed, which contains estradiol valerate (with reduced hepatic action because of lack of a 17alpha ethinyl group) with dienogest, a 19 NOR testosterone-derived nonandrogenic progestin, which powerfully inhibits endometrial proliferation. Thanks to a dynamic modulation of estrogen and progestin doses (26 active days + 2 placebo days), an adequate contraceptive effectiveness, a good cycle control and drug tolerance are achieved, similar to those obtained with a classical low-dose OC. Recent data indicate that this new combination reduces the usually observed metabolic impact. An adequate cycle control (with 20% amenorrhea) is achieved for the first time with estradiol valerate + progestin,, in opposition with prior catastrophic results with other formulations containing 17beta-estradiol. A second combination containing estradiol + nomegestrol acetate (monophasic, 24 active days + 4 placebo days) is under study and seems also to yield promising results. Of course, in-depth study of metabolic and vascular effects of these new combinations is mandatory - and ongoing.

[Prevention of coronary heart disease by early postmenopausal hormone therapy: new supporting data]

The important controversy concerning the potential beneficial, neutral or unfavourable effect of estrogens or estrogen plus progestin on the risk of coronary heart disease in postmenopausal women is beginning to settle down. Reanalysis of large observational and randomized trials according to age and years since menopause and recent additional studies allow to positively state that postmenopausal hormone therapy - and particularly estrogens alone - is safe and effective. For instance, in the Women's Health Initiative study, provided hormone therapy is initiated within 10 years since menopause, a reduction of the risk of coronary heart disease by 12 to 52% according to the use of estrogen plus progestin or estrogen alone, respectively, is observed versus placebo use. Global mortality is also reduced by 30% with both hormone therapies. This favourable effect is not observed when treatment is initiated in older postmenopausal women. These important and reassuring data should encourage regulatory authorities to reassess clinical recommendations in that prospect.

[Female sexual dysfunction and postmenopausal androgen therapy]

Female sexual dysfunction is essentially multifactorial and its therapeutic management is accordingly diversified. However, after natural menopause or, even more, surgical menopause, age, climacteric syndrome, progressive loss of endogenous androgens, all facilitate the occurrence of the Hypoactive Sexual Desire Disorder (HSDD), defined by loss of libido and sexual responsiveness leading to sexually related personal distress. In that prospect, administration of varied medications with androgenic properties has been tried in addition to postmenopausal hormone therapy. Type, dosages, routes of administration of androgens are adapted toward minimizing side effects inasmuch as long-term safety of androgens is not yet clearly established. Recent randomized controlled studies appear very promising in terms of efficacy and safety, at least when androgen therapy is limited to 6-12 months in case of HSDD.

Effect of different contraceptive methods on the oxidative stress status in women aged 40 48 years from the ELAN study in the province of Liege, Belgium

BACKGROUND

Oxidative stress is associated with the development of several disorders including cardiovascular disease and cancer. Among conditions known to influence oxidative stress, the use of oral contraception (OC) in women has been a matter of ongoing discussion.

METHODS

A total of 897 eligible and healthy volunteers were recruited from among the patients of 50 general practitioners participating in the ELAN study (Etude Liégeoise sur les ANtioxydants). A subsample consisting of 209 women aged 40-48 years was studied for a comprehensive oxidative stress status (OSS), including the analysis of antioxidants, trace elements and three markers of oxidative damage to lipids. Among 209 subsample, 49 (23%) were OC users (OCU), 119 (57%) non-contraception users (NCU) and 41 (20%) were intrauterine (hormonal and copper) devices users (IUD).

RESULTS

After adjustment for smoking, systolic and diastolic blood pressure and BMI (or waist circumference), a marked and significant increase in lipid peroxides was observed among OCU women when compared with NCU and IUD users. A cut-off value of 660 microM in lipid peroxides allowed the discrimination of OCU from the two other groups. In contrast, no difference was observed in the plasma concentration of both oxidized low-density lipoprotein (LDL) and their related antibodies. The increased level in lipid peroxides was strongly related to higher concentrations of copper (r < 0.84; P < 0.0001, cut-off value 1.2 mg/l). When compared with NCU and IUD users, plasma antioxidant defences were significantly altered in OCU women as shown by lower levels of beta-carotene (decrease of 39%; P < 0.01) and gamma-tocopherol (decrease by 22%; P < 0.01). In contrast, higher concentrations of selenium (increased by 11.8%; P < 0.01) were observed in OCU women. Blood concentrations of vitamin C, alpha-tocopherol and zinc were unaffected by OC use.

CONCLUSIONS

The intake of OC significantly increases the lipid peroxidation in women aged 40-48 years. This may represent a potential cardiovascular risk factor for these women.

[Therapeutic progress in gynecology: functional approaches]

Over the last ten years, progress in evidence-based medicine coupled with technological breakthroughs and introduction of new drugs have deeply changed the management of our patients. In the field of hormone therapy, lower dosages of estrogens and new progestins have increased tolerance and non-contraceptive benefits of oral contraceptives, while lower-doses, new progestins, new routes of administration have optimized the benefit/risk balance for the treatment of menopause. About 500,000 cycles of IVF are performed worldwide each year, optimizing male and female fertility, with less multiple pregnancies, and use of new recombinant gonadotropin, LHRH agonists/antagonists, new ovarian tissue cryopreservation techniques, etc...

[Therapeutic progress in gynecology: organic diseases]

Over the last ten years, progress in evidence-based medicine coupled with technological and surgical breakthroughs have deeply changed the management of our patients. Uterine bleeding is the first cause of gynaecological consultation and the intrauterine progestin delivery system as well as new hysteroscopic procedures have optimized the therapeutic approach to this problem. Introduction of magnetic resonance imaging and interventional procedures have improved breast disease diagnosis and management; likewise sentinel node localization, introduction of aromatase and growth factors inhibitors, new radiotherapy procedures and pharmacogenomics, have helped to ameliorate breast cancer treatment. Pelvic surgery has been switching more and more towards laparoscopic procedures not only in the field of benign lesions (eg endometriosis), of surgery of prolapse and incontinence with new prosthetic materials, but also for an improved management of gynaecological cancers.

[Can we sort out from the jumble about oral contraceptives and skin cancers?]

Skin contains various hormonal receptors, particularly those for estrogens, progesterone and androgens. Steroid hormones of oral contraceptives affect the skin, in particular the control of the cell cycle, DNA replication, apoptosis and other cellular functions. Some estrogen-responsive pathways have the potential to promote tumor development. The question of whether oral contraceptives increase the risk for the development of skin cancer, particularly melanoma, remains an area of concern. There is some evidence that steroid hormones present in oral contraceptives do not significantly increase the risk of developing skin cancer when estrogen exposure is not excessive.

[Management of Chlamydia tracomatis pelvic infection]

The infection by Chlamydia trachomatis is a serious infection that affects the male and female tractus, and that induces complications such as infertility and extrauterine pregnancy. The antibiotic treatment needed must necessarily reach the intracellular milieu to be efficient enough to eradicate the infection.

[Adenomyosis: update on a frequent but difficult diagnosis]

Adenomyosis is a frequent entity, with difficult diagnosis, often obtained by pathological analysis performed after hysterectomy. This condition can cause abnormal uterine bleeding and dysmenorrhea, frequent reasons for consultation and hysterectomy. The development of ultrasonographic and magnetic resonance imaging techniques allow preoperative diagnosis. They also permit the use of hysteroscopic techniques for conservative uterine surgery, and have brought diagnosis and management of this disease to the front of the scene. This article reviews the pathological description of the disease, its epidemiology, clinical presentations, useful and necessary explorations, etiopathogeny and available therapies.

Skin climacteric aging and hormone replacement therapy

A gender perspective is indispensable for a full understanding of aging. Menopause is a turning point in women's lives. In addition to the effects of chronological aging, sunlight exposure, and other environmental and endogenous stimuli, the climacteric appears to exert some dramatic consequences on skin biology and aspect. The epidermis may become xerotic and exhibit altered functions. The dermis thins out and its elasticity decreases in concert with the decline in bone mass. The skin microcirculation is impaired. These aspects are some of the better worked-out changes of the climacteric, which in turn seem to be stabilized or in part reversible with hormone replacement therapy (HRT). The HRT effect on menopause consequences on hair growth and sebum production is less impressive. This review summarizes some important impacts of the climacteric on skin, and highlights the benefits of HRT that may influence cosmetic dermatology.

[The skin and menopause]

The estrogen deficit occurring at menopause manifests itself under various modalities in the diverse organs and their functions. Skin does not escape this global involutive process. In addition to the effects of chronological ageing, sunlight exposure and other environmental and endogenous stimuli, the climacteric appears to exert some dramatic consequences on skin biology and aspect. The epidermis, its adnexae and the dermis are altered by this process. The epidermis may become xerotic and exhibits altered functions. The dermis thins out and its elasticity decreases in concert with the decline in bone mass. The skin microcirculation is impaired. These aspects are some of the better-worked out skin climacteric changes of which in turn seem to be stabilized or in part reversible with hormone replacement therapy (HRT).

[Extended oestrogen-progestin contraceptive regimens: towards a contraception without menses]

Women's attitude concerning menstruations is changing towards achieving extended cycles with few or even suppressed menses, in view of the unpleasant perimenstrual bleeding, pain and discomfort pattern that may accompany menstruation. Use of combined oral estrogen-progestin contraception in extended "cycles" of 3, 6 and 12 or more months is now under active study. Extended cycle contraception is abided by a better compliance than conventional cycle contraception with ensuing optimized contraceptive effectiveness. Hypothetically, transdermal or transvaginal combined contraception could be used in extended cycles. Tolerance is comparable for both methods and unpredicted bleeding, initially more frequent during long cycle treatment tends to become less frequent after about 6 months a compared with conventional cycles. Usual safety parameters appear to be similar under both contraceptive modalities. Comfort and well being brought by extended cycle use (5 to 10 times fewer days of bloating or perimenstrual pain) allow to estimate that, according to acceptability studies, 10 to 40 percent of women of reproductive age would currently choose extended cycle contraception.

[Contraception in young diabetic women]

Contraception of the diabetic patient is an important matter. It allows to plan adequately the pregnancies, should respect carbohydrate metabolism and should consider the risk of diabetic complications. This review article describes the contraceptive techniques for diabetic patients.

[Menopause-related risks and hormone therapy in diabetic women]

Prevalence of diabetes mellitus (types 1 and 2) in postmenopausal women is about 10-20% according to age. It can be associated with a metabolic syndrome in about 60% of cases, thereby severely increasing cardiovascular risk (among others) in these women. Estrogen or estrogen-progestin replacement therapy does not usually impair diabetes control. It will be submitted to the same indications/contraindications, in relation with the risk/benefit balance, as for all other postmenopausal women. However, increased risks inherent to diabetic subjects concerning metabolism, coagulation/hemostasis, and cardiovascular disease, should be considered. Therefore, estrogen in minimal effective dosages, eventually by transdermal route, as well as metabolically neutral progestins near to progesterone should be preferred. In case of pre-existing or occurring vascular problems, a careful approach or even suppression of replacement therapy should prevail.

[Replacement of the descending aorta sparing the aortic valve: the David's operation]

We report the case of an ascending aortic aneurysm involving the aortic root, with a functionally competent bicuspid aortic valve, treated by the David's operation. This operation allows to fix the aortic root pathology, whilst preserving the native aortic valve. The technical aspects, surgical indications, and potential benefits of this operation are reviewed.

A randomized study on the influence of oral contraceptives containing ethinylestradiol combined with drospirenone or desogestrel on lipid and lipoprotein metabolism over a period of 13 cycles

In this open-label, randomized study we compared the influence of a new oral contraceptive containing 30 microg ethinylestradiol and 3 mg drospirenone (EE + DRSP = Yasmin), with a reference preparation containing 30 microg ethinylestradiol and 150 microg desogestrel (EE + DSG = Marvelon) on the lipid profile. The primary target variables were total high-density lipoprotein (HDL) cholesterol, HDL2 cholesterol and low-density lipoprotein (LDL) cholesterol. These and additional lipid and lipoprotein fractions were measured at baseline and in the 3rd, 6th and 13th treatment cycles in a total of 50 volunteers, and also assessed after density gradient ultracentrifugation. A slight increase in mean total HDL cholesterol vs. baseline was found for the DRSP group (+12.8%) and the DSG group (+11.8%) after 13 treatment cycles. HDL2 cholesterol did not change remarkably in both groups. The mean LDL cholesterol values increased by 10.6% vs. baseline in the DSG group and remained nearly stable in the DRSP group (+1.8%). All measured values remained within the reference ranges. No statistically significant differences were found between the two treatment groups for those primary endpoints. A slight rise in mean total cholesterol was found for all cycles after the initiation of treatment. The mean increase after 1 year of treatment was approximately 8% in both treatment groups. Mean triglyceride levels increased for both treatment groups without leaving the reference range. The increase for total triglycerides was +73.6 % in the DRSP group and +61.3% in DSG group. For total phospholipids, an increase of +13.6% (DRSP) and +18.5% (DSG) over 13 cycles was measured. The apolipoproteins Apo A-I, Apo A-II and Apo B increased slightly more during DRSP treatment than during DSG treatment. The reduction of Apo E was similar in both groups. Lipoprotein (a) remained stable in the DRSP group, whereas it increased by +10.8% in the DSG group. In conclusion, the combined low-dose oral contraceptive Yasmin, with 30 microg ethinylestradiol and 3 mg of the novel progestogen drospirenone, as well as the reference preparation, had little impact on the lipid profile. While both preparations displayed a favorable lipid profile with increased total HDL cholesterol, the antiandrogenic or missing androgenic activity of Yasmin may be regarded as responsible for the stable LDL cholesterol levels. As a result, the ratio of total HDL:LDL was increased, a pattern that is usually considered clinically beneficial with respect to cardiovascular disease risk.

[Medication of the month. Angeliq: new hormonal therapy of menopause, with antialdosterone and antiandrogenic properties]

Following American randomised controlled epidemiologic studies (HERS, WHI), regulatory authorities have advised that postmenopausal hormone therapy, using minimal effective dosages, is indicated for the first line treatment of climacteric symptoms during a limited, and problem-related period of time, and for second line prevention of osteoporosis when a non-hormonal treatment cannot be used. Observation of a discrete increase in cardiovascular and breast cancer risk in hormone users currently appears to partly justify this rather strict attitude. We report here results of studies concerning a new continuous combination regimen (Angeliq), associating a "half-dose" estrogen (estradiol 1 mg/d) with potentially less thrombogenic impact than a standard (2 mg) dose, and the new progestin drospirenone (2 mg/d). The latter demonstrates a high level of endometrial safety as well as unique antialdosterone properties (reduction of symptoms related to water retention; potential cardioprotective effects) and consistent antiandrogenic properties, useful for both metabolic and clinical issues. Accordingly, Angeliq constitutes a new therapeutic approach, in good agreement with updated guidelines related to hormone replacement therapy.

Environmental dichlorodiphenyltrichlorethane or hexachlorobenzene exposure and breast cancer: is there a risk?

The carcinogenic potential of environmental xenoestrogens (i.e., organochlorines) is a matter of controversy. Their pathogenic role as promoters in breast cancer has been previously suggested. In Europe, despite their prohibition since the ’70s, residues persist in soil and rivers resulting in a widespread contamination of the general population. In this study, we have compared the serum levels of p,p'-1,1-dichloro-2, 2-bis (4-chlorophenyl) ethylene (DDE) and hexachlorobenzene (HCB) in 231 women at the time of breast cancer discovery and in 290 age-matched healthy controls. p,p'-DDE was found in 76.2% of cases and in 71.1% of controls but HCB was present only in 12.6% of cases (29 from 231) and in 8.9% of controls (26 from 290). Even if taking all undetectable results (recorded as “0”) into consideration, mean values were significantly different in cases when compared to controls. The serum level of p,p'-DDE was 3.46±3.48 ppb (0.58±0.58 μg/g lipid) in patients and 1.85±2.09 ppb (0.31±0.35 μg/g lipid) in controls (p<0.0001). The HCB serum level was 0.66±1.25 ppb (0.11±0.21 μg/g lipid) in patients and 0.20±1.02 ppb (0.03±0.17 μg/g lipid) in controls (p<0.0001). When considering p,p'-DDE and HCB as binary variables (1 if higher than the limit of quantification, 0 if lower), the presence of both residues was significantly associated with an increased risk of breast cancer development (OR 2.21, 95% CI 1.41–3.48 for p,p'-DDE and OR 4.99, 95% CI 2.95–8.43 for HCB). No excess was observed among parous women or when familial history of breast cancer was considered. In the cancer group, no differences in serum levels of p,p'-DDE or HCB were found in relation with estrogen-receptor (ER) status, Bloom stage or lymph node metastasis, but the HCB level was moderately correlated with tumor size (p=0.026).

[Risk of thromboembolism in contraception and hormone substitution: an update and recommendations]

Venous and arterial thromboembolism events are unfrequent but classical complications of sex steroid therapy, in contraception and menopause. The relative risks induced by these treatments have recently highlighted by the general press, in particular for the 2nd and 3rd generation progestins in oral contraception. In this article, we will review the risks of venous and arterial thromboembolism in patients treated with oral contraception or postmenopausal hormone replacement therapy. Practical guidelines will be defined.

[Body mass changes at menopause: impact of therapeutic strategies]

Weight gain constitutes a worry for perimenopausal patients. Current understanding of the problem indicates that age constitutes the most important factor, whereas menopause contributes to the development of android obesity. Hygyenodietetic counseling allows to reduce or even prevent these problems. Finally, hormone replacement therapy does not induce weight gain: it rather contributes to reduce central adipose deposition and improves the risk profile of menopausal patients, in relation to the nature and metabolic profile of the prescribed molecules.

[Medication of the month. Evra: first contraceptive transdermal patch]

Evra is a transdermal patch releasing 20 micrograms of ethinylestradiol and 150 micrograms of norelgestromin/day during one week. The circulating levels of steroids attained are of similar amplitude though steadier than after intake of an oral combined low-dose estrogen-progestin pill. The transdermal method is user-friendly and is abided by a high degree of acceptability, and a low level of skin irritability. Its contraceptive effectiveness is similar to that conferred by oral contraceptives except if the treated woman is over 90 kg, in which case Evra should not be prescribed. Cycle control is excellent and similar to that of triphasic pills. Adverse effects and tolerance are comparable to those described with low-dose oral contraceptives with a slight estrogen dominance. Lipid and glucose metabolism as well as coagulation are influenced in the same way. Gastrointestinal disturbances (nausea, vomiting) do not prevent the efficacy of the transdermal patch. Compliance with Evra is significantly higher than with oral combined contraceptives--a major point for an effective contraception. Accordingly, Evra constitutes an useful addition to the current array of contraceptive methods.