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Fanse S, Bao Q, Zou Y, Wang Y, Burgess DJ. Tailoring drug release from long-acting contraceptive levonorgestrel intrauterine systems. J Control Release 2024; 370:S0168-3659(24)00248-7. [PMID: 38648956 DOI: 10.1016/j.jconrel.2024.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 04/15/2024] [Accepted: 04/16/2024] [Indexed: 04/25/2024]
Abstract
The wide array of polydimethylsiloxane (PDMS) variants available on the market, coupled with the intricate combination of additives in silicone polymers, and the incomplete understanding of drug release behavior make formulation development of levonorgestrel intrauterine systems (LNG-IUSs) formidable. Accordingly, the objectives of this work were to investigate the impact of excipients on formulation attributes and in vitro performance of LNG-IUSs, elucidate drug release mechanisms, and thereby improve product understanding. LNG-IUSs with a wide range of additives and fillers were prepared, and in vitro drug release testing was conducted for up to 12 months. Incorporating various additives and/or fillers (silica, silicone resins, silicone oil, PEG, etc.) altered the crystallization kinetics of the crosslinked polymer, the viscosity, and the microstructure. In addition, drug-excipient interactions can occur. Interestingly, additives which increased matrix hydrophobicity and hindered PDMS crystallization facilitated dissolution and permeation of the lipophilic LNG. The influence of additives and lubricants on the mechanical properties of LNG-IUSs were also evaluated. PDMS chemical substitution and molecular weight were deemed to be most critical polymer attributes to the in vitro performance of LNG-IUSs. Drugs with varying physicochemical characteristics were used to prepare IUSs, modeling of the release kinetics was performed, and correlations between release properties and the various physicochemical attributes of the model drugs were established. Strong correlations between first order release rate constants and both drug solubility and Log P underpin the partition and diffusion-based release mechanisms in LNG-IUSs. This is the first comprehensive report to provide a mechanistic understanding of material-property-performance relationships for IUSs. This work offers an evidence-based approach to rational excipient selection and tailoring of drug release to achieve target daily release rates in vivo. The novel insights gained through this research could be helpful for supporting development of brand and generic IUS products as well as their regulatory assessment.
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Affiliation(s)
- Suraj Fanse
- University of Connecticut, School of Pharmacy, Storrs, CT 06269, USA
| | - Quanying Bao
- University of Connecticut, School of Pharmacy, Storrs, CT 06269, USA
| | - Yuan Zou
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, FDA, Silver Spring, MD 20993, USA
| | - Yan Wang
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, FDA, Silver Spring, MD 20993, USA
| | - Diane J Burgess
- University of Connecticut, School of Pharmacy, Storrs, CT 06269, USA.
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Yi H, Stamm CA, Wright G, Mondie WS, Rupp L, Borgelt L. Emergency contraception in a historic southern city: Mystery caller study in Birmingham, Alabama. Contraception 2024; 132:110361. [PMID: 38160962 DOI: 10.1016/j.contraception.2023.110361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 12/18/2023] [Accepted: 12/22/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Alabama's Human Life Protection Act (the Act) signed in 2019 became law in 2022, making provision of abortion a felony offense. OBJECTIVE In 2020, we assessed the accessibility of emergency contraception (EC) pills in Birmingham, Alabama prior to the Act's enactment given the probable increased need for EC access due to abortion criminalization. STUDY DESIGN Pharmacy staff were asked about availability, price, location, and identification requirements to obtain EC. RESULTS Of 69 pharmacies, 59% had levonorgestrel EC and none had ulipristal acetate EC available. CONCLUSION There are persistent barriers to EC accessibility that should be addressed as abortion is increasingly restricted.
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Affiliation(s)
- Heami Yi
- University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO, USA.
| | - Carol A Stamm
- University of Colorado Anschutz Medical Campus, Department of Medicine, Aurora, CO, USA
| | - Garth Wright
- University of Colorado Anschutz Medical Campus, Departments of Clinical Pharmacy and Family Medicine, Aurora, CO, USA
| | - Wei-San Mondie
- Denver Health Medical Center, Department of Family Medicine, Denver, CO, USA
| | - Leanne Rupp
- National Association of Social Workers, Colorado Chapter, Denver, CO, USA
| | - Laura Borgelt
- University of Colorado Anschutz Medical Campus, Departments of Clinical Pharmacy and Family Medicine, Aurora, CO, USA
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3
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Wagner B, Cleland K. Increases in retail sales of over-the-counter levonorgestrel emergency contraception in the United States, 2016-2022. Contraception 2024:110420. [PMID: 38462205 DOI: 10.1016/j.contraception.2024.110420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 03/04/2024] [Accepted: 03/06/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVES To understand patterns in demand for emergency contraception (EC), we characterize the sales of over-the-counter (OTC) levonorgestrel (LNG) EC in the United States from traditional retail outlets. STUDY DESIGN We describe sales of OTC LNG EC using retail sales data aggregated from traditional retail channels, including grocery stores, drug stores, mass merchandisers, club stores, dollar stores, and military outlets. RESULTS Sales of OTC LNG EC doubled between 2016 and 2022 (approximately 7.2-14.8 million). CONCLUSIONS Increasing sales of EC are consistent with increased use and use frequency of EC by those at risk of pregnancy in the United States. IMPLICATIONS OTC LNG EC sales since 2016 exceed what national survey usage estimates would suggest, indicating that national surveys underreport EC use, those using EC purchase it somewhat frequently, and/or individuals stockpile EC for later use. The role of EC in individual contraceptive strategies, particularly as access to reproductive healthcare is restricted, warrants further study.
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Affiliation(s)
- Brandon Wagner
- Department of Sociology, Anthropology, and Social Work, Texas Tech University, Lubbock, TX, United States.
| | - Kelly Cleland
- American Society for Emergency Contraception, Lawrenceville, NJ, United States
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4
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McNealy KR, Oevermann MW, Knabel ML, Fitzwater A, Gipson CD, Barrett ST, Bevins RA. Repeated exposure to physiologically effective doses of contraceptive hormones ethinyl estradiol or levonorgestrel do not alter the reinforcing effects of a brief visual stimulus in ovary-intact rats. Horm Behav 2024; 161:105506. [PMID: 38387104 DOI: 10.1016/j.yhbeh.2024.105506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 02/09/2024] [Accepted: 02/14/2024] [Indexed: 02/24/2024]
Abstract
Estradiol and progesterone potentiate and attenuate reward processes, respectively. Despite these well-characterized effects, there is minimal research on the effects of synthetic estrogens (e.g., ethinyl estradiol, or EE) and progestins (e.g., levonorgestrel, or LEVO) contained in clinically-utilized hormonal contraceptives. The present study characterized the separate effects of repeated exposure to EE or LEVO on responding maintained by a reinforcing visual stimulus. Forty ovary-intact female Sprague-Dawley rats received either sesame oil vehicle (n = 16), 0.18 μg/day EE (n = 16), or 0.6 μg/day LEVO (n = 8) subcutaneous injections 30-min before daily one-hour sessions. Rats' responding was maintained by a 30-sec visual stimulus on a Variable Ratio-3 schedule of reinforcement. The day after rats' last session, we determined rats estrous cycle phase via vaginal cytology before sacrifice and subsequently weighing each rat's uterus to further verify the contraceptive hormone manipulation. The visual stimulus functioned as a reinforcer, but neither EE nor LEVO enhanced visual stimulus maintained responding. Estrous cytology was consistent with normal cycling in vehicle rats and halting of normal cycling in EE and LEVO rats. EE increased uterine weights consistent with typical uterotrophic effects observed with estrogens, further confirming the physiological impacts of our EE and LEVO doses. In conclusion, a physiologically effective dose of neither EE nor LEVO did not alter the reinforcing efficacy of a visual stimulus reinforcer. Future research should characterize the effects of hormonal contraceptives on responding maintained by other reinforcer types to determine the generality of the present findings.
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Affiliation(s)
- Kathleen R McNealy
- University of Nebraska-Lincoln, Department of Psychology, 238 Burnett Hall, Lincoln, NE 68588, USA.
| | - Matthew W Oevermann
- University of Nebraska-Lincoln, Department of Psychology, 238 Burnett Hall, Lincoln, NE 68588, USA
| | - MacKenzie L Knabel
- University of Nebraska-Lincoln, Department of Psychology, 238 Burnett Hall, Lincoln, NE 68588, USA
| | - Anna Fitzwater
- University of Nebraska-Lincoln, Institutional Animal Care Program, 2200 Vine Street, 278 Prem S. Paul Research Center at Whittier School, Lincoln, NE 68583, USA
| | - Cassandra D Gipson
- University of Kentucky, Department of Pharmacology and Nutrition Sciences, 780 Rose Street, MS305, Lexington, KY 40536, USA
| | - Scott T Barrett
- University of Nebraska-Lincoln, Department of Psychology, 238 Burnett Hall, Lincoln, NE 68588, USA
| | - Rick A Bevins
- University of Nebraska-Lincoln, Department of Psychology, 238 Burnett Hall, Lincoln, NE 68588, USA
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5
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Fattore L, Pisanu A, Concas L, Casula C, Siddi C, Pisu MG, Serra M, Concas A, Porcu P. Behavioral characterization of co-exposure to cannabinoids and hormonal contraceptives in female rats. Prog Neuropsychopharmacol Biol Psychiatry 2024; 129:110890. [PMID: 37926338 DOI: 10.1016/j.pnpbp.2023.110890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 10/11/2023] [Accepted: 10/30/2023] [Indexed: 11/07/2023]
Abstract
Hormonal contraceptives are among the most widely used drugs by young healthy women to block ovulation and avoid pregnancy. They reduce the ovarian secretion of estradiol and progesterone, hormones that also modulate neuronal plasticity, cognitive functions, emotions and mood. Cannabis is the most commonly used illicit drug worldwide and its use is increasing among young women, many of which regularly take the "pill". Despite evidence of a bidirectional interaction between the endocannabinoid system and gonadal hormones, only very few studies have examined the consequences of cannabis consumption in young females under hormonal contraceptives treatment. To fill this gap, this study evaluated the behavioral effects of co-exposure to chronic 1) hormonal contraceptives, i.e., ethinyl estradiol (EE) plus levonorgestrel (LNG), one of the synthetic estrogen-progestin combinations of hormonal contraceptives, and 2) cannabinoid receptor agonist, i.e., WIN 55,212-2 (WIN), on motor activity, emotional state and cognitive functions in young adult female rats (8-11/experimental group). Hormonal and cannabinoid treatment started at post-natal day (PND) 52 and 56, respectively, while behavioral testing occurred between PND 84-95. The results show that chronic EE-LNG treatment, at doses (0.020 and 0.060 mg/rat, respectively) known to drastically reduce plasma progesterone levels, and the contextual exposure to WIN, at a dose (12.5 μg/kg/infusion) known to be rewarding in the rat, alters the hormonal milieu but does not cause further changes in locomotor activity compared to EE-LNG or WIN alone, and does not modify anxiety-like state (as measured by the elevated plus maze and the marble burying tests) and cognitive abilities (as measured by the novel object recognition and the prepulse inhibition tests) in young adult female rats. Although exposure to EE-LNG and WIN tends to increase the duration of immobility and to reduce the time spent swimming in the forced swimming test, there was not a significant additive effect suggestive of a depressive-like state. These findings allow deepening the current knowledge on the interaction between cannabinoid agonists and hormonal contraceptives and suggest that low, rewarding doses of cannabinoids do not significantly alter the motor and cognitive skills and do not induce anxiety or depressive-like states in females that use hormonal contraceptives.
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Affiliation(s)
- Liana Fattore
- Neuroscience Institute, National Research Council of Italy (CNR), Cagliari, Italy
| | - Augusta Pisanu
- Neuroscience Institute, National Research Council of Italy (CNR), Cagliari, Italy
| | - Luca Concas
- Neuroscience Institute, National Research Council of Italy (CNR), Cagliari, Italy
| | - Claudia Casula
- Neuroscience Institute, National Research Council of Italy (CNR), Cagliari, Italy
| | - Carlotta Siddi
- Neuroscience Institute, National Research Council of Italy (CNR), Cagliari, Italy
| | | | - Mariangela Serra
- Department of Life and Environment Sciences, Section of Neuroscience and Anthropology, University of Cagliari, Cagliari, Italy
| | - Alessandra Concas
- Department of Life and Environment Sciences, Section of Neuroscience and Anthropology, University of Cagliari, Cagliari, Italy
| | - Patrizia Porcu
- Neuroscience Institute, National Research Council of Italy (CNR), Cagliari, Italy.
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Schuh KM, Ahmed J, Kwak E, Xu CX, Davis TT, Aronoff CB, Tronson NC. A mouse model of oral contraceptive exposure: Depression, motivation, and the stress response. Horm Behav 2024; 158:105470. [PMID: 38061232 DOI: 10.1016/j.yhbeh.2023.105470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 12/01/2023] [Accepted: 12/04/2023] [Indexed: 02/05/2024]
Abstract
Hormonal contraceptives, including oral contraceptives (OCs), regulate hormonal cycles and broadly affect physiological processes, including stress responsivity. Whereas many users describe overall improved mood, up to 10 % of OC users experience adverse effects, including depression and anxiety. Given the link between regulation of hypothalamic-pituitary-adrenal (HPA) axis, stress exposure, and risk for depression, it is likely that OC-effects on stress mediate increased risk or increased resilience to these disorders. In this study, we developed and characterized a tractable mouse model of OC exposure with which to identify the mechanisms underlying OC modulation of brain, behavior, and mood. Specifically, we aimed to determine whether translationally relevant doses of OC-hormones in mice mimic changes in stress responsivity observed in humans taking OCs and describe behavioral changes during OC exposure. Young adult female C57Bl/6 N mice received daily ethinyl estradiol (EE) and levonorgestrel (LVNG) in 10 % sucrose, EE and drospirenone (DRSP) in 10 % sucrose, or 10 % sucrose alone. Translationally relevant doses of EE + LVNG-exposure, but not EE + DRSP, suppressed the acute stress response, consistent with effects observed in human OC users. EE + LVNG caused a specific anhedonia-like effect, without broad changes in stress-coping behavior, other depression-like behaviors, or anxiety-like behaviors. The suppression of regular estrous cycling, together with the blunting of the corticosterone response to acute stress, demonstrate the utility of this model for future studies to identify the mechanisms underlying OC interactions with stress, motivation, and risk for depression.
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Affiliation(s)
- Kristen M Schuh
- Psychology Department, University of Michigan, Ann Arbor, MI 48109, United States of America
| | - Jabir Ahmed
- Psychology Department, University of Michigan, Ann Arbor, MI 48109, United States of America
| | - Esther Kwak
- Psychology Department, University of Michigan, Ann Arbor, MI 48109, United States of America
| | - Cecilia X Xu
- Psychology Department, University of Michigan, Ann Arbor, MI 48109, United States of America
| | - Tronjay T Davis
- Psychology Department, University of Michigan, Ann Arbor, MI 48109, United States of America
| | - Chloe B Aronoff
- Psychology Department, University of Michigan, Ann Arbor, MI 48109, United States of America
| | - Natalie C Tronson
- Psychology Department, University of Michigan, Ann Arbor, MI 48109, United States of America.
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7
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Lv X, Guo L, Wang C. Efficacy of fertility-sparing treatment with LNG-IUS is associated with different ProMisE subtypes of endometrial carcinoma or atypical endometrial hyperplasia. J Gynecol Oncol 2023; 35:35.e27. [PMID: 38216133 DOI: 10.3802/jgo.2024.35.e27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 10/03/2023] [Accepted: 11/26/2023] [Indexed: 01/14/2024] Open
Abstract
OBJECTIVE To determine whether proactive molecular risk classifier for endometrial cancer (ProMisE) could be used to assess the prognosis of patients with atypical endometrial hyperplasia (AEH) or early-stage endometrial cancer (EC) treated with levonorgestrel-releasing intrauterine system (LNG-IUS). METHODS A retrospective cohort study was conducted among 93 AEH or early-stage EC patients who received LNG-IUS to preserve fertility . By immunohistochemistry and gene sequencing, 4 subtypes of ProMisE were identified (p53 wild type [p53 wt], mismatch repair-deficient [MMRd], p53-abnormal, and POLE-mutated). The primary outcome was the time to complete response (CR) after LNG-IUS therapy. Secondary outcomes included the recurrence rate after CR and success rate of conception. RESULTS Among the 93 patients, 15 (16.1%) were classified as MMRd, 6 (6.5%) as POLE-mutated, 5 (5.4%) as p53-abnormal, and 67 (72.0%) as p53 wt. Comparison of serum cancer antigen 125, family history of tumor, and positive rates of programmed cell death 1 ligand 1 protein and Ki67 protein in 4 groups showed statistically significant differences (p<0.05). Patients with the p53-abnormal subtype had the lowest overall CR rate (40%) and the highest recurrence rate (2/2). Patients with POLE-mutated subtype had the best prognosis, and all 6 patients achieved CR. When patients achieved complete remission, assisted reproductive technology was more likely to help them conceive than natural conception (p<0.05). CONCLUSION Patients with early-stage EC or AEH who are more likely to benefit from fertility-sparing treatment can be identified using ProMisE classifier. Patients with POLE-mutated are suitable for fertility-sparing treatment with LNG-IUS.
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Affiliation(s)
- Xiaofeng Lv
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lili Guo
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Changyu Wang
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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8
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Rudzinski P, Lopuszynska I, Pazik D, Adamowicz D, Jargielo A, Cieslik A, Kosieradzka K, Stanczyk J, Meliksetian A, Wosinska A. Emergency contraception - A review. Eur J Obstet Gynecol Reprod Biol 2023; 291:213-218. [PMID: 37922775 DOI: 10.1016/j.ejogrb.2023.10.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 10/21/2023] [Accepted: 10/30/2023] [Indexed: 11/07/2023]
Abstract
Emergency contraception (EC), or postcoital contraception, is a therapy aimed at preventing unintended pregnancy after an act of unprotected or under-protected sexual intercourse. Options include both emergency contraceptive pills (most commonly containing levonorgestrel or ulipristal acetate) and insertion of an intrauterine device. The aim of this paper is to summarize current evidence surrounding the use of emergency contraceptives and to present an evidence-based approach to EC provision. Emergency contraception is a safe and effective option in preventing unwanted pregnancy, irrespective of age, weight, or breastfeeding status. Efforts should be made to increase their availability, as well as knowledge of these methods, both among patients and healthcare providers.
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Affiliation(s)
- Patryk Rudzinski
- Independent Public Clinical Hospital Named After Prof. W. Orłowski of the Centre for Postgraduate Medical Education, Warsaw, Poland.
| | - Inga Lopuszynska
- The National Institute of Medicine of the Ministry of Interior and Administration, Warsaw, Poland
| | - Dorota Pazik
- Independent Public Clinical Hospital Named After Prof. W. Orłowski of the Centre for Postgraduate Medical Education, Warsaw, Poland
| | - Dominik Adamowicz
- University Clinical Centre of the Medical University of Warsaw, Warsaw, Poland
| | - Anna Jargielo
- Military Institute of Medicine - National Research Institute, Warsaw, Poland
| | | | | | - Justyna Stanczyk
- National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Astrik Meliksetian
- The National Institute of Medicine of the Ministry of Interior and Administration, Warsaw, Poland
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9
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Wei H, Pan N, Wang Y, Ma C. Segmented in vitro fertilization and frozen embryo transfer in levonorgestrel-releasing intrauterine device treated patients with endometrial cancer. Arch Gynecol Obstet 2023; 308:1845-1852. [PMID: 37656272 PMCID: PMC10579151 DOI: 10.1007/s00404-023-07170-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 07/20/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE To evaluate the efficacy of levonorgestrel-releasing intrauterine device (LNG-IUD) during controlled ovarian stimulation (COS) in patients with early-stage endometrioid endometrial cancer (EEC). METHODS A retrospective study was conducted on patients with stage IA1 EEC who achieved complete response after fertility-sparing treatment from December 2018 to December 2021, with all the women who underwent COS having LNG-IUDs inserted in their uterine cavity. RESULTS 16 patients were enrolled who underwent 26 COS cycles and average age was 33.19 ± 4.04 years. 12 patients had 19 subsequent frozen-thawed embryo transfer (FET) cycles. Among the other four patients, no embryos were obtained in 1 patient, 1 patient got pregnancy spontaneously with term delivery after COS, 1 patient relapsed before FET, and 1 patient did not receive embryo transfer for personal reason. Among 19 FET cycles, the clinical pregnancy and live birth rates in each ET cycle were 36.84% (7/19) and 26.32% (5/19), respectively. 7 clinical pregnancies resulted in 2 miscarriages (28.6%), and 5 live births (71.4%). Totally 6 patients achieved 7 live births, and the cumulative live birth rate was 37.5% (6/16). Three (18.75%) out of 16 patients relapsed after COS during the follow-up period (31.31 ± 15.89 months) and two of them were initially diagnosed with moderately differentiated EEC. Time interval from COS to relapse was 6.63,11.67 and 16.23 months, respectively. CONCLUSION The combination of LNG-IUD treatment and segmented IVF may be a viable treatment strategy to improve oncological and reproductive outcomes for patients with early-stage EEC.
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Affiliation(s)
- Hongyi Wei
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Haidian District, No. 49 North Huayuan Road, Beijing, 100191, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing, 100191, China
- Department of Obstetrics and Gynecology, Peking University International Hospital, Beijing, 102206, China
| | - Ningning Pan
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Haidian District, No. 49 North Huayuan Road, Beijing, 100191, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing, 100191, China
| | - Yang Wang
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Haidian District, No. 49 North Huayuan Road, Beijing, 100191, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing, 100191, China
| | - Caihong Ma
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Haidian District, No. 49 North Huayuan Road, Beijing, 100191, China.
- National Clinical Research Center for Obstetrics and Gynecology, Beijing, 100191, China.
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10
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Maher EE, White AM, Craig A, Khatri S, Kendrick PT, Matocha ME, Bondy EO, Pallem N, Breakfield G, Botkins M, Sweatt O, Griffin WC, Kaplan B, Weafer JJ, Beckmann JS, Gipson CD. Synthetic contraceptive hormones occlude the ability of nicotine to reduce ethanol consumption in ovary-intact female rats. Drug Alcohol Depend 2023; 252:110983. [PMID: 37778097 DOI: 10.1016/j.drugalcdep.2023.110983] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 09/21/2023] [Accepted: 09/22/2023] [Indexed: 10/03/2023]
Abstract
Rates of tobacco and alcohol use in women are rising, and women are more vulnerable than men to escalating tobacco and alcohol use. Many women use hormonal birth control, with the oral contraceptive pill being the most prevalent. Oral contraceptives contain both a progestin (synthetic progesterone) and a synthetic estrogen (ethinyl estradiol; EE) and are contraindicated for women over 35 years who smoke. Despite this, no studies have examined how synthetic contraceptive hormones impact this pattern of polysubstance use in females. To address this critical gap in the field, we treated ovary-intact female rats with either sesame oil (vehicle), the progestin levonorgestrel (LEVO; contained in formulations such as Alesse®), or the combination of EE+LEVO in addition to either undergoing single (nicotine or saline) or polydrug (nicotine and ethanol; EtOH) self-administration (SA) in a sequential use model. Rats preferred EtOH over water following extended EtOH drinking experience as well as after nicotine or saline SA experience, and rats undergoing only nicotine SA (water controls) consumed more nicotine as compared to rats co-using EtOH and nicotine. Importantly, this effect was occluded in groups treated with contraceptive hormones. In the sequential use group, both LEVO alone and the EE+LEVO combination occluded the ability of nicotine to decrease EtOH consumption. Interestingly, demand experiments suggest an economic substitute effect between nicotine and EtOH. Together, we show that chronic synthetic hormone exposure impacts nicotine and EtOH sequential use, demonstrating the crucial need to understand how chronic use of different contraceptive formulations alter patterns of polydrug use in women.
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Affiliation(s)
- Erin E Maher
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, KY, USA
| | - Ashley M White
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, KY, USA
| | - Ashley Craig
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, KY, USA
| | - Shailesh Khatri
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, KY, USA
| | - Percell T Kendrick
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, KY, USA
| | - Mary E Matocha
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, KY, USA
| | - Emma O Bondy
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, KY, USA
| | - Nikhil Pallem
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, KY, USA
| | - Grace Breakfield
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, KY, USA
| | - Madison Botkins
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, KY, USA
| | - Olivia Sweatt
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - William C Griffin
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Brent Kaplan
- Department of Family and Community Medicine, University of Kentucky, Lexington, KY, USA
| | - Jessica J Weafer
- Department of Psychiatry and Behavioral Health, The Ohio State University, Columbus, OH, USA
| | - Joshua S Beckmann
- Department of Psychology, University of Kentucky, Lexington, KY, USA.
| | - Cassandra D Gipson
- Department of Pharmacology and Nutritional Sciences, University of Kentucky, Lexington, KY, USA.
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Hernández-Silva G, Vega CC, Barrera D, Hernández-Pando R, García-Uribe PÁ, Chirinos M, Larrea F. Gene Expression Changes in the Ovary Mediate Non-Anovulatory Mechanisms of Contraception with Levonorgestrel. Arch Med Res 2023; 54:102892. [PMID: 37804815 DOI: 10.1016/j.arcmed.2023.102892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/06/2023] [Accepted: 09/20/2023] [Indexed: 10/09/2023]
Abstract
BACKGROUND Emergency contraception with levonorgestrel (LNG) is a viable option to prevent unintended pregnancies. Although the efficacy of LNG as an anovulatory agent decreases as treatment approaches ovulation, it still provides some contraceptive benefits. AIM To better understand the contraceptive mechanisms of LNG in ovulatory subjects. METHODS We conducted a study on Wistar rats that received a single dose of LNG (0.01 or 0.05 mg/kg) on the morning of proestrus before ovulation and evaluated its effects on ovarian gene expression, ovulation, and implantation. RESULTS Our findings showed changes in the expression of genes involved in follicular development and oocyte quality. Pregnancy rates - as an indicator of ovulation - and embryo implantation were significantly lower than those in the control group. CONCLUSIONS This study suggests that LNG alters regulatory factors in the ovary that are essential for the development of competent fertilizable oocytes, highlighting the non-anovulatory mechanisms by which levonorgestrel may regulate fertility and suggesting that it could be a novel observation that contributes to the understanding of emergency contraception in humans.
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Affiliation(s)
- Gabriela Hernández-Silva
- Reproductive Biology Department Dr. Carlos Gual Castro, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Claudia Cecilia Vega
- Reproductive Biology Department Dr. Carlos Gual Castro, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - David Barrera
- Reproductive Biology Department Dr. Carlos Gual Castro, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Rogelio Hernández-Pando
- Experimental Pathology Lab, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Pablo Ángel García-Uribe
- Reproductive Biology Department Dr. Carlos Gual Castro, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Mayel Chirinos
- Reproductive Biology Department Dr. Carlos Gual Castro, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
| | - Fernando Larrea
- Reproductive Biology Department Dr. Carlos Gual Castro, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
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Leelakanok N, Kangwanrattanakul K, Petchsomrit A, Sapapsap B, Siritientong T, Methaneethorn J. After morning, phew! A knowledge, attitudes, and practices survey related to emergency oral contraception in Thai pharmacists. J Pharm Policy Pract 2023; 16:97. [PMID: 37528496 PMCID: PMC10391845 DOI: 10.1186/s40545-023-00601-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 07/17/2023] [Indexed: 08/03/2023] Open
Abstract
INTRODUCTION Pharmacists' knowledge and attitude toward Emergency Oral Contraception (EOC) can affect users' access to EOCs, especially where EOCs are provided by pharmacists without the need for prescriptions. We conducted a Knowledge, Attitudes, and Practice (KAP) survey on Thai pharmacists to better understand KAP related to EOCs and the correlation among KAP components. METHODS An in-depth interview, GoogleTrend search, and Pantip.com search were conducted. The findings, together with data from a previously published systematic review and meta-analysis, were used to develop KAP survey questions which were distributed online. Spearman's rank correlation coefficient and linear mixed model were used to investigate the correlation and association among KAP components. RESULTS The in-depth interview with pharmacists showed that sex and unwanted pregnancy are very sensitive topics in Thailand. Sex and EOC education should be provided by parents and healthcare professionals at a young age. This agreed with opinions from Thai internet users that sex literacy was generally low and sex education was not provided adequately. From the total of 421 survey responses, Thai pharmacists had average knowledge, poor attitude, and average practice related to EOCs (median score = 51.02%, 21.81%, and 60.0%, respectively). The correlations between KAP in pharmacists were weak (ρ = 0.107-0.525, p < 0.02). Pharmacists who rated themselves as having higher scores in knowledge and attitude also rated themselves higher in the practice score. However, the total scores describing the knowledge of or attitude toward EOCs were not associated with EOC practice scores. CONCLUSIONS In Thai pharmacists, self-rating KAP scores overestimated total KAP scores. The correlation among KAP components was weak. EOC knowledge and attitudes should be promoted, although this may not improve EOC practice in Thai pharmacists.
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Affiliation(s)
- Nattawut Leelakanok
- Division of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Burapha University, 169 Long-Hard Bangsaen Rd, Mueang, Chonburi, 20131, Thailand
| | - Krittaphas Kangwanrattanakul
- Division of Social and Administrative Pharmacy, Faculty of Pharmaceutical Sciences, Burapha University, 169 Long-Hard Bangsaen Rd., Mueang, Chonburi, 20131, Thailand.
| | - Arpa Petchsomrit
- Division of Pharmaceutical Technology, Faculty of Pharmaceutical Sciences, Burapha University, 169 Long-Hard Bangsaen Rd, Mueang, Chonburi, 20131, Thailand
| | - Bannawich Sapapsap
- Division of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Burapha University, 169 Long-Hard Bangsaen Rd, Mueang, Chonburi, 20131, Thailand
| | - Tippawan Siritientong
- Department of Food and Pharmaceutical Chemistry, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Burn and Wound Care, Chulalongkorn University, Bangkok, Thailand
| | - Janthima Methaneethorn
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
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Watanabe A, Myosho T, Ishibashi A, Yamamoto J, Toda M, Onishi Y, Kobayashi T. Levonorgestrel causes feminization and dose-dependent masculinization in medaka fish (Oryzias latipes): Endocrine-disruption activity and its correlation with sex reversal. Sci Total Environ 2023; 876:162740. [PMID: 36921849 DOI: 10.1016/j.scitotenv.2023.162740] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/02/2023] [Accepted: 03/05/2023] [Indexed: 06/18/2023]
Abstract
The effect of a synthetic progestin, levonorgestrel (LNG), on the sex of exposed embryos was examined in medaka fish (Oryzias latipes). The aims of this study are to clarify the dual effect of LNG on sex and the correlation with its androgenic/estrogenic potential in medaka. LNG exposure causes significant dose-dependent masculinization (0.1-100 μg/L), whereas a decrease in the masculinization ratio is observed at 100 μg/L. LNG also causes significant feminization at 1-100 μg/L, but not in a dose-dependent manner. Exposure of estrogen-responsive gene (choriogeninH-EGFP) transgenic embryos to 100 μg/L LNG produced significant fluorescent signals in hatched fry. In vitro transcriptional assays indicated that LNG at 10-7-10-5 M induced significant activity for estrogen receptor (ESR)2a and ESR2b, but not for ESR1. In pre-self-feeding fry at 5 days post hatching (dph), 1-100 μg/L LNG caused a significant increase in the mRNA of choriogeninH, irrespective of genetic sex. Moreover, LNG (10-10-10-5 M) also caused a significant increase in the transcriptional activity of androgen receptor (AR) α and ARβ in vitro, and 0.1 μg/L LNG significantly increased the mRNA levels of a testis-differentiation initiation factor, gonadal soma-derived factor (gsdf), as an androgen-upregulated and estrogen-downregulated gene, in 5 dph XX fry to levels similar to those in the control XY fry. However, 100 and 10 μg/L LNG suppressed or did not induce gsdf mRNA expression in XY and XX fry, respectively. Together, these findings show that LNG exerts estrogenic and androgenic activities in different concentration ranges, which correlate with the ratio of LNG-induced sex reversal. These results suggest for the first time, that medaka exposure to LNG can induce masculinization and feminization, based on the balance between androgenic and estrogenic activities, and the protocol applied in this study represents an alternative to the traditional animal model used to screen for endocrine-disrupting potential.
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Affiliation(s)
- Akiho Watanabe
- Graduate School of Integrated Pharmaceutical and Nutrition Sciences, University of Shizuoka, Shizuoka 422-8526, Japan
| | - Taijun Myosho
- Graduate School of Integrated Pharmaceutical and Nutrition Sciences, University of Shizuoka, Shizuoka 422-8526, Japan; Laboratory of Molecular Reproductive Biology, Institute for Environmental Sciences, University of Shizuoka, Shizuoka 422-8526, Japan
| | - Ayaka Ishibashi
- Graduate School of Integrated Pharmaceutical and Nutrition Sciences, University of Shizuoka, Shizuoka 422-8526, Japan
| | - Jun Yamamoto
- Institute of Environmental Ecology, IDEA Consultants Inc., 1334-5, Riemon, Yaizu, Shizuoka 421-0212, Japan
| | - Misa Toda
- Institute of Environmental Ecology, IDEA Consultants Inc., 1334-5, Riemon, Yaizu, Shizuoka 421-0212, Japan
| | - Yuta Onishi
- Institute of Environmental Ecology, IDEA Consultants Inc., 1334-5, Riemon, Yaizu, Shizuoka 421-0212, Japan
| | - Tohru Kobayashi
- Graduate School of Integrated Pharmaceutical and Nutrition Sciences, University of Shizuoka, Shizuoka 422-8526, Japan; Laboratory of Molecular Reproductive Biology, Institute for Environmental Sciences, University of Shizuoka, Shizuoka 422-8526, Japan.
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Zürcher A, Knabben L, Janka H, Stute P. Influence of the levonorgestrel-releasing intrauterine system on the risk of breast cancer: a systematic review. Arch Gynecol Obstet 2023; 307:1747-1761. [PMID: 35716207 PMCID: PMC10147797 DOI: 10.1007/s00404-022-06640-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 05/18/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE The intention of this systematic review was to analyze the literature on breast cancer (BC) and the use of the levonorgestrel-releasing intrauterine system (LNG-IUS). METHODS The literature was searched in Medline, Embase, Cochrane Library, CINAHL, Web of Science and ClinicalTrials.com and included search terms related to breast cancer and LNG-IUS. After elimination of duplicates, 326 studies could be identified and were assessed according to inclusion and exclusion criteria. In the end, 10 studies met the defined criteria and were included in the systematic review. RESULTS 6 out of the 10 selected studies were cohort studies, three were case-control studies and one a systematic review/meta-analysis. 6 found a positive association between BC and the use of LNG-IUS. One study only found an increased risk for invasive BC in the subgroup of women aged 40-45 years. In contrast, three studies showed no indication of a higher BC risk. CONCLUSION The results imply an increased BC risk in LNG-IUS users, especially in postmenopausal women and with longer duration of use. Positive effects of the LNG-IUS such as reduced risks for other hormonal cancers have been observed, were, however, not focus of this systematic review. The heterogeneity of the analyzed studies and vast number of confounding factors call for further investigations in this issue. Patients should be advised according to their individual risk profile and hormone-free alternatives may be considered for women with a history of BC.
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Affiliation(s)
| | - Laura Knabben
- Department of Obstetrics and Gynecology, Inselspital, University Clinic Bern, University of Bern, Friedbühlstrasse 19, 3010, Bern, Switzerland
| | - Heidrun Janka
- Medical Library, University Library Bern, University of Bern, Bern, Switzerland
| | - Petra Stute
- Department of Obstetrics and Gynecology, Inselspital, University Clinic Bern, University of Bern, Friedbühlstrasse 19, 3010, Bern, Switzerland.
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15
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Elsayed M, Dardeer KT, Khehra N, Padda I, Graf H, Soliman A, Makram AM, Zeiss R, Schönfeldt-Lecuona C. The potential association between psychiatric symptoms and the use of levonorgestrel intrauterine devices (LNG-IUDs): A systematic review. World J Biol Psychiatry 2023; 24:457-475. [PMID: 36426589 DOI: 10.1080/15622975.2022.2145354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/21/2022] [Accepted: 11/04/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Levonorgestrel (LNG)-intrauterine devices (IUDs) are an effective method of contraception; however, there is growing evidence regarding potential psychiatric side effects such as depressive symptoms, anxiety, and suicidal thoughts. Therefore, we conducted this systematic review to summarise the psychiatric effects of using LNG-IUDs. METHODS We searched six databases (MEDLINE, Web of Science, Scopus, Science Direct, Cochrane Library, and PsycInfo), and we included all study designs. The included studies were extracted, quality assessed, and qualitatively summarised. RESULTS Out of the screened studies, only 22 were finally included. While ten studies showed increased depressive symptoms, two studies showed reduced symptoms. Moreover, one study showed increased anxiety, another one reported an increased risk of suicide, four studies concluded no association with depressive symptoms, and four other studies showed uncertainty about a potential association but mentioned other psychiatric symptoms. CONCLUSION Despite unreliable data, many studies report psychiatric symptoms associated with LNG-IUDs, predominantly depression. Gynaecologists, general practitioners, and psychiatrists should therefore be aware of these potential risks, especially depressive symptoms and suicidality. Counselling patients about these risks should be mandatory. Further studies should investigate the absolute risk of mental disorders associated with LNG-IUDs and other hormonal contraceptives.KEY MESSAGESMany researchers are reporting adverse psychiatric events associated with levonorgestrel intrauterine devices (LNG-IUDs).Despite their effectiveness, a proper psychiatric assessment should be done before inserting LNG-IUDs.Proper counselling regarding the depressive symptoms and suicidality should be done by the treating obstetrician.Further studies should investigate the absolute risk of mental disorders associated with LNG-IUDs and other hormonal contraceptives.
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Affiliation(s)
- Mohamed Elsayed
- Department of Psychiatry and Psychotherapy III, University of Ulm, Ulm, Germany
- Department of Psychiatry, School of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | | | - Nimrat Khehra
- Saint James School of Medicine, Arnos Vale, St Vincent & Grenadines
| | | | - Heiko Graf
- Department of Psychiatry and Psychotherapy III, University of Ulm, Ulm, Germany
| | - Amr Soliman
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health Sciences, Carl von Ossietzky Universität Oldenburg, Oldenburg, Germany
| | | | - René Zeiss
- Department of Psychiatry and Psychotherapy III, University of Ulm, Ulm, Germany
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16
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Jiménez-Skrzypek G, Hernández-Expósito OM, Hernández-Borges J, González-Sálamo J. Sorption of levonorgestrel on polyethylene, polystyrene and polypropylene microplastics. Chemosphere 2023:139042. [PMID: 37244556 DOI: 10.1016/j.chemosphere.2023.139042] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 04/23/2023] [Accepted: 05/24/2023] [Indexed: 05/29/2023]
Abstract
Sorption studies involving microplastics (MPs) are essential to understand the mechanisms implicated in contaminant retention. In this research, a complete study of the sorption behaviour of a hormonal contraceptive -levonorgestrel- in MPs of different composition in two distinct matrices was performed, using high-performance liquid chromatography coupled to a UV detector for the determination of levonorgestrel. Characterization of the studied MPs was achieved by X-ray diffraction and differential scanning calorimetry, and Fourier-transformed infrared spectroscopy. Kinetic and isotherm studies were performed using a batch design under controlled conditions: 500 mg of MPs pellets of 3-5 mm diameter, agitation at 125 rpm, and 30 °C. The comparison of results in ultrapure water and artificial seawater, revealed changes in sorption capacity, and the predominant sorption mechanisms involved. Overall, all studied MPs showed sorption affinity towards levonorgestrel, being low-density polyethylene the one with the highest sorption capacity in ultrapure water and polystyrene in seawater.
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Affiliation(s)
- Gabriel Jiménez-Skrzypek
- Departamento de Química, Unidad Departamental de Química Analítica, Facultad de Ciencias, Universidad de La Laguna (ULL). Avda. Astrofísico Fco. Sánchez, S/n., 38206, San Cristóbal de La Laguna, Spain; Instituto Universitario de Enfermedades Tropicales y Salud Pública de Canarias, Universidad de La Laguna (ULL). Avda. Astrofísico Fco. Sánchez, S/n., 38206, San Cristóbal de La Laguna, Spain
| | - Orlando Manuel Hernández-Expósito
- Centro Asociado de Tenerife de La Universidad Nacional de Educación a Distancia (UNED). C. San Agustín, 30. 38009, San Cristóbal de La Laguna, Spain
| | - Javier Hernández-Borges
- Departamento de Química, Unidad Departamental de Química Analítica, Facultad de Ciencias, Universidad de La Laguna (ULL). Avda. Astrofísico Fco. Sánchez, S/n., 38206, San Cristóbal de La Laguna, Spain; Instituto Universitario de Enfermedades Tropicales y Salud Pública de Canarias, Universidad de La Laguna (ULL). Avda. Astrofísico Fco. Sánchez, S/n., 38206, San Cristóbal de La Laguna, Spain
| | - Javier González-Sálamo
- Departamento de Química, Unidad Departamental de Química Analítica, Facultad de Ciencias, Universidad de La Laguna (ULL). Avda. Astrofísico Fco. Sánchez, S/n., 38206, San Cristóbal de La Laguna, Spain; Instituto Universitario de Enfermedades Tropicales y Salud Pública de Canarias, Universidad de La Laguna (ULL). Avda. Astrofísico Fco. Sánchez, S/n., 38206, San Cristóbal de La Laguna, Spain; Department of Chemistry, Sapienza University, P.le Aldo Moro, 5. 00185, Rome, Italy.
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17
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Knezevic CE, Parsons TL, Gollings R, Pandey A, Marzinke MA. Development and validation of a multiplexed assay for the measurement of long-acting hormonal contraceptives in plasma via liquid chromatography-tandem mass spectrometry. J Pharm Biomed Anal 2023; 228:115321. [PMID: 36924631 PMCID: PMC10065940 DOI: 10.1016/j.jpba.2023.115321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Exogenous progestins are an effective tool for hormonal contraception and family planning. Progestins may be delivered as oral pills, intramuscular or subcutaneous injections, vaginal rings, or intrauterine devices. Drug concentrations may vary based on the route and duration of delivery. Measurement of synthetic steroids in blood plasma can aid in determination of product adherence, evaluation of drug-drug interactions, and investigation of unintended pregnancies. METHODS Drug-free K2EDTA plasma was spiked with the synthetic steroids etonogestrel (ETO), levonorgestrel (LNG), medroxyprogesterone acetate (MPA), and norethisterone (NET). Plasma was combined with isotopically labeled internal standards, and drugs were extracted via liquid-liquid extraction. Samples were then subjected to liquid chromatographic-tandem mass spectrometric (LC-MS/MS) analysis. The method was validated in accordance with regulatory recommendations. The assay was evaluated in a cohort of remnant plasma samples in individuals using one of the aforementioned progestins. RESULTS The analytical measuring range for ETO, MPA, and NET was 20-10,000 pg/mL; the primary linearity for LNG was 20-20,000 pg/mL. The method showed acceptable precision and accuracy for all progestins. Stability was established for 72 h with room temperature storage and through 3 freeze-thaw cycles. All analytes were stable in whole blood incubated at room temperature for 25 h, and at 40°C and 100% humidity for 2 h. Ion suppression was observed for all analytes spiked in plasma; average ion suppression was 31.6%, 66.6%, 32.1% and 41.2% for ETO, LNG, MPA, and NET, respectively. However, internal standards showed comparable ion suppression, and relative matrix effects were minimal. ETO, LNG, MPA, and NET could also be quantified accurately in K3EDTA plasma and serum. Progestins were successfully measured in remnant samples from individuals using hormonal contraceptives. CONCLUSIONS A multiplexed LC-MS/MS assay for the quantification of ETO, LNG, MPA, and NET has been developed and validated. The assay met acceptable performance characteristics and may be used in downstream studies to evaluate progestin pharmacology.
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Affiliation(s)
- Claire E Knezevic
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Teresa L Parsons
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ryann Gollings
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aashish Pandey
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mark A Marzinke
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Cirrincione LR, Nakalema S, Chappell CA, Byakika-Kibwika P, Kyohairwe I, Winchester L, Mackline H, Pham MM, Cohn SE, Siccardi M, Owen A, Fletcher CV, Lamorde M, Scarsi KK. Effect of double-dose levonorgestrel subdermal implant in women taking efavirenz-based antiretroviral therapy: The DoubLNG pharmacokinetic study. Contraception 2023;:109975. [PMID: 36787829 DOI: 10.1016/j.contraception.2023.109975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 01/22/2023] [Accepted: 01/30/2023] [Indexed: 02/16/2023]
Abstract
OBJECTIVE We evaluated the pharmacokinetics of double-dose levonorgestrel (LNG) implants to overcome the drug-drug interaction with efavirenz-based antiretroviral therapy (ART). STUDY DESIGN We conducted a nonrandomized, open-label, parallel-group, longitudinal pharmacokinetic study among Ugandan women ages 18-45 years. Participants with HIV on ART containing efavirenz 600 mg received 300 mg of LNG implants (Jadelle®, Bayer, New Zealand): 300LNG+ART group. We compared our outcomes with women without HIV using standard dose, 150 mg of LNG implants: 150LNG group. The implant was placed on day zero in both groups, and we quantified plasma LNG concentrations over 48 weeks post implant insertion. LNG pharmacokinetic parameters were estimated using noncompartmental techniques. Our primary outcome was the geometric mean ratio with 90% confidence intervals of LNG area under the concentration-time curve over 24 weeks (AUC0-24w) between groups. Demographic data were described as median (interquartile range). A secondary outcome compared between-group percent of LNG concentrations ≥300 pg/mL, a minimum threshold selected a priori based on observed pregnancies in Ugandan women on standard-dose LNG implants plus efavirenz. RESULTS We enrolled 27 women in the 300LNG+ART group (34 [28.0 to 40.5] years and 61.0 [49.8-66.0] kg) and 19 women in the 150LNG group (33 [30.0 to 34.5] years and 64.9 [59.0 to 74.5] kg). LNG AUC0-24w was 34% lower for 300LNG+ART versus 150LNG (geometric mean 9998 vs. 15,231 pg*week/mL, respectively [geometric mean ratio 0.66 (90% confidence intervals, 0.54 to 0.80)]). The percentage of participants with LNG concentrations ≥300 pg/mL was not statistically different between groups at week 24 (300LNG+ART: 74.1%; 150LNG: 89.5%; p = 0.27). CONCLUSION Double-dose LNG implant did not completely overcome the drug-drug interaction with efavirenz. IMPLICATION In women using ART containing efavirenz, placing two implant systems (300 mg) did not normalize LNG pharmacokinetics compared with the standard-dose implant (150 mg), and some women had evidence of ovulatory activity. Alternative ART without drug-drug interactions, such as dolutegravir, is recommended with contraceptive implants.
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19
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Bao Q, Fanse S, Lu XJ, Burgess DJ. Impact of drug loading on release from levonorgestrel intrauterine systems. Int J Pharm 2023; 631:122532. [PMID: 36565771 PMCID: PMC10324521 DOI: 10.1016/j.ijpharm.2022.122532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/26/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022]
Abstract
Levonorgestrel intrauterine systems (LNG-IUSs) are polydimethylsiloxane (PDMS) based non-biodegradable complex drug-device combination products providing efficacy for up to several years based on the strength. A large amount of LNG (e.g., 52 mg in Mirena and Liletta) must be loaded in the LNG-IUS products to maintain the long-acting effect even though LNG is a potent hormone. However, the high amount of LNG not only poses the potential risk of dose dumping, but also leads to drug waste due to incomplete drug utilization close to the end of usage. It has been unclear whether the duration of usage of these products should be extended for full drug utilization or products with lower drug loading should be developed. Therefore, it is critical to understand the impact of strength (or drug loading) on drug release from LNG-IUSs. In the current study, drug reservoirs with a broad range of drug loading (from 0.5% w/w to 50% w/w) were prepared and assembled into LNG-IUSs. Different accelerated release conditions were used to perform release testing of LNG-IUSs with different drug loading. 5% to 10% variation in excipient of the LNG-IUSs did not significantly alter the drug release profiles of the LNG-IUSs. The release rate of LNG-IUSs is inversely proportional to their drug loading at high drug loading (10% w/w, 25% w/w and 50% w/w). Drug release was incomplete for LNG-IUS with low drug loading (2.5% w/w and 1% w/w) and no drug release could be detected for the LNG-IUS with 0.5% w/w drug loading. In addition, the burst effect of the LNG-IUSs with different drug loading was investigated. This is the first research report covering ultra-long duration (more than four years) of real-time drug release from LNG-IUSs with different drug loading (0.5%-50% w/w). The amount of excipient (PDMS) used in the reservoir of LNG-IUSs was determined to be not a critical quality parameter in the formulation design since LNG-IUSs (50% w/w drug loading) with up to 10% variation in excipient did not show significant differences in their release profiles. The drug release kinetics/mechanism remained the same for LNG-IUSs with drug loading ranging from 1% to 50%. In addition, the accelerated release testing methods were confirmed to be representative of the real-time release profiles and this can give confidence in extending the duration of usage for these products provided that the device remains physically intact (no tearing or damage in the outer membrane) and the release rate is within the therapeutic window. It is recommended to perform both real-time and accelerated release testing simultaneously for LNG-IUSs to understand the burst effect as well as the complete release characteristics. Lastly, drug/polymer interaction may play a role when designing LNG-IUS formulations with low drug loading (<5% w/w) since drug/polymer interaction is significant when only a small amount of drug present.
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Affiliation(s)
- Quanying Bao
- University of Connecticut, School of Pharmacy, Storrs, CT 06269, USA
| | - Suraj Fanse
- University of Connecticut, School of Pharmacy, Storrs, CT 06269, USA
| | - Xiaoyu James Lu
- University of Connecticut, School of Pharmacy, Storrs, CT 06269, USA
| | - Diane J Burgess
- University of Connecticut, School of Pharmacy, Storrs, CT 06269, USA.
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20
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Salcedo J, Cleland K, Bartz D, Thompson I. Society of Family Planning Clinical Recommendation: Emergency contraception. Contraception 2023; 121:109958. [PMID: 36693445 DOI: 10.1016/j.contraception.2023.109958] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/30/2022] [Accepted: 01/10/2023] [Indexed: 01/22/2023]
Abstract
Emergency contraception (EC) refers to several contraceptive options that can be used within a few days after unprotected or under protected intercourse or sexual assault to reduce the risk of pregnancy. Current EC options available in the United States include the copper intrauterine device (IUD), levonorgestrel (LNG) 52 mg IUD, oral LNG (such as Plan B One-Step, My Way, Take Action), and oral ulipristal acetate (UPA) (ella). These clinical recommendations review the indications, effectiveness, safety, and side effects of emergency contraceptive methods; considerations for the use of EC by specific patient populations and in specific clinical circumstances and current barriers to emergency contraceptive access. Further research is needed to evaluate the effectiveness of LNG IUDs for emergency contraceptive use; address the effects of repeated use of UPA at different times in the same menstrual cycle; assess the impact on ovulation of initiating or reinitiating different regimens of regular hormonal contraception following UPA use; and elucidate effective emergency contraceptive pill options by body mass indices or weight.
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Affiliation(s)
- Jennifer Salcedo
- Department of Obstetrics and Gynecology, New York Medical College, Valhalla, NY, United States.
| | - Kelly Cleland
- American Society for Emergency Contraception, Lawrenceville, NJ, United States
| | - Deborah Bartz
- Department of Obstetrics and Gynecology, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States
| | - Ivana Thompson
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, United States
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21
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Kheloui S, Smith A, Ismail N. Combined oral contraceptives and mental health: Are adolescence and the gut-brain axis the missing links? Front Neuroendocrinol 2023; 68:101041. [PMID: 36244525 DOI: 10.1016/j.yfrne.2022.101041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/16/2022] [Accepted: 10/07/2022] [Indexed: 11/05/2022]
Abstract
Combined oral contraceptives (containing synthetic forms of estradiol and progestins) are one of the most commonly used drugs among females. However, their effects on the gut-brain axis have not been investigated to a great extent despite clear evidence that suggest bi-directional interactions between the gut microbiome and endogenous sex hormones. Moreover, oral contraceptives are prescribed during adolescence, a critical period of development during which several brain structures and systems, such as hypothalamic-pituitary-gonadal axis, undergo maturation. Considering that oral contraceptives could impact the developing adolescent brain and that these effects may be mediated by the gut-brain axis, further research investigating the effects of oral contraceptives on the gut-brain axis is imperative. This article briefly reviews evidence from animal and human studies on the effects of combined oral contraceptives on the brain and the gut microbiota particularly during adolescence.
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Affiliation(s)
- Sarah Kheloui
- School of Psychology, Faculty of Social Sciences, University of Ottawa, Ottawa, ON, Canada
| | - Andra Smith
- School of Psychology, Faculty of Social Sciences, University of Ottawa, Ottawa, ON, Canada; uOttawa Brain and Mind Research Institute, Ottawa, ON, Canada
| | - Nafissa Ismail
- School of Psychology, Faculty of Social Sciences, University of Ottawa, Ottawa, ON, Canada; uOttawa Brain and Mind Research Institute, Ottawa, ON, Canada; LIFE Research Institute, Ottawa, ON, Canada.
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22
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Lacasse JM, Boulos V, Fisher C, Hamilton S, Heron M, Mac Cionnaith CE, Peronace V, Tito N, Brake WG. Combined effects of the contraceptive hormones, ethinyl estradiol and levonorgestrel, on the use of place and response memory in gonadally-intact female rats. Psychoneuroendocrinology 2023; 147:105974. [PMID: 36403510 DOI: 10.1016/j.psyneuen.2022.105974] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 11/11/2022] [Accepted: 11/11/2022] [Indexed: 11/16/2022]
Abstract
During maze navigation rats can rely on hippocampus-mediated place memory or striatum-mediated response memory. Ovarian hormones bias whether females use place or response memory to reach a reward. Here, we investigated the impact of the contraceptive hormones, ethinyl estradiol (EE) and levonorgestrel (LNG), on memory bias. A total of 63 gonadally-intact female rats were treated with either 10 μg/kg of EE alone, 20 μg/kg of LNG alone, both 10 μg/kg of EE and 20 μg/kg of LNG together, or a sesame oil injection with 5% ethanol as a vehicle control. Rats in the control condition were tested during the diestrus phase of the estrous cycle in order to control for the low circulating levels of gonadotropin and ovarian hormones that occur with oral contraceptive administration. Rats treated with LNG alone had a bias towards the use of place memory compared to diestrus phase control rats. This bias was not observed if LNG was administered in combination with EE. Rats treated with EE or EE+LNG did not have a statistically significant difference in memory bias compared to rats in the control group. These data show that synthetic hormones contained in oral contraceptives administered to females influence which cognitive strategy is predominantly used during navigation.
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Affiliation(s)
- Jesse M Lacasse
- Centre for Studies in Behavioral Neurobiology, Department of Psychology, Concordia University, Montréal H4B 1R6, Canada.
| | - Vanessa Boulos
- Centre for Studies in Behavioral Neurobiology, Department of Psychology, Concordia University, Montréal H4B 1R6, Canada
| | - Caleigh Fisher
- Centre for Studies in Behavioral Neurobiology, Department of Psychology, Concordia University, Montréal H4B 1R6, Canada
| | - Sarran Hamilton
- Centre for Studies in Behavioral Neurobiology, Department of Psychology, Concordia University, Montréal H4B 1R6, Canada
| | - Megan Heron
- Centre for Studies in Behavioral Neurobiology, Department of Psychology, Concordia University, Montréal H4B 1R6, Canada
| | - Conall E Mac Cionnaith
- Centre for Studies in Behavioral Neurobiology, Department of Psychology, Concordia University, Montréal H4B 1R6, Canada
| | - Vanessa Peronace
- Centre for Studies in Behavioral Neurobiology, Department of Psychology, Concordia University, Montréal H4B 1R6, Canada
| | - Noémie Tito
- Centre for Studies in Behavioral Neurobiology, Department of Psychology, Concordia University, Montréal H4B 1R6, Canada
| | - Wayne G Brake
- Centre for Studies in Behavioral Neurobiology, Department of Psychology, Concordia University, Montréal H4B 1R6, Canada.
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23
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Nemet V. Levonorgestrel as a Potential Trigger of Acute Bilateral Central Serous Chorioretinopathy: Case Report. Case Rep Ophthalmol 2023; 14:223-228. [PMID: 37383171 PMCID: PMC10293936 DOI: 10.1159/000530327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 03/21/2023] [Indexed: 06/30/2023] Open
Abstract
This is a first ever report describing a case of acute bilateral central serous chorioretinopathy which developed shortly after the consumption of levonorgestrel as emergency contraception. A 27-year-old female patient visited the emergency department of the clinic due to diminished visual acuity in both eyes. She had taken a single pill of levonorgestrel (1.5 mg) as emergency contraception 2 days prior. Fundus examination showed macular edema. Optical coherence tomography (OCT) revealed serous bilateral detachment of the macular retina. Fluorescein angiography showed a "smokestack" leakage of contrast in the right eye and focal macular leakage in the left eye. Ten days after oral diuretic and topical nonsteroidal anti-inflammatory drugs were prescribed, follow-up examination revealed improvement of best corrected visual acuity and OCT showed complete regression of subretinal fluid. One month and 3 months after the initial visit, the patient's best corrected visual acuity returned to 20/20 and OCT showed no signs of subretinal fluid. This case highlights levonorgestrel as a potential trigger for this serious chorioretinal condition, thus expanding on the literature on possible risk factors and mechanisms of development for central serous chorioretinopathy.
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Affiliation(s)
- Vedran Nemet
- Department of Ophthalmology, University Hospital Centre Osijek, Osijek, Croatia
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24
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D’Arcy S, Cao C, Ahn S, Allan V, Ahmadvand A. Trends of intrauterine device insertion and 'Googling' about intrauterine devices before and during the COVID-19 pandemic in Australia. Digit Health 2022; 8:20552076221145799. [PMID: 36583085 PMCID: PMC9793017 DOI: 10.1177/20552076221145799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022] Open
Abstract
Objective The COVID-19 pandemic significantly disrupted access to primary care in Australia. This could have negatively impacted reproductive health services rates such as intrauterine device insertion rates, and interest in seeking information about intrauterine devices by searching on Google. We aimed to assess the trends of, and the association between, the actual Medicare service utilization rates for intrauterine device insertion and searching about intrauterine devices on Google, before and during the COVID-19 pandemic. Methods We conducted systematic analyses of secondary data from June 2017 to May 2022, using Medicare and Google Trends data sources. We visualized the rates of intrauterine device insertion, plus Google's search volumes about 'Intrauterine device' and 'Progestin IUDs' as topics. Then, we assessed the correlation between intrauterine device insertion rates and Google search, using Spearman correlation. Results The average yearly rates of intrauterine device insertion increased noticeably from 25.1-26.3 in 2018-2019 to 29.3-31.2 per 100,000 population in 2020-2021 (12-18% increase). The highest monthly intrauterine device insertion rate nationally (37 per 100,000 population) was seen in March 2021. By June 2020, search term use for the two intrauterine device-related topics returned to much higher levels (50% increase for 'Progestin IUDs', and 54% for 'Intrauterine device', respectively). A moderately strong correlation was seen between actual intrauterine device insertion rates and search on Google about intrauterine devices (Spearman rho = 0.61, p < 0.000). Conclusion We demonstrated a moderately strong correlation between trends of intrauterine device insertion rates and search on Google about intrauterine devices, before and during the COVID-19 pandemic in Australia. Googling about intrauterine devices could, therefore, be a useful indicator to gauge future interest in actual intrauterine device insertion for months thereafter.
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Affiliation(s)
| | | | | | | | - Alireza Ahmadvand
- Alireza Ahmadvand, Associate Professor in
Primary Care (Academic Title Holder), School of Medicine and Dentistry, Griffith
University, Gold Coast, Parklands Drive, Southport, QLD 4222, Australia.
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25
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Fanse S, Bao Q, Burgess DJ. Long-acting intrauterine systems: Recent advances, current challenges, and future opportunities. Adv Drug Deliv Rev 2022; 191:114581. [PMID: 36270490 PMCID: PMC10302114 DOI: 10.1016/j.addr.2022.114581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/13/2022] [Accepted: 09/27/2022] [Indexed: 01/24/2023]
Abstract
Levonorgestrel intrauterine systems (LNG-IUSs) are complex drug-device combination products designed to release a hormonal contraceptive drug for up to 7 years. These drug delivery systems offers a great promise as a modern method of long-acting reversible contraceptives (LARCs) to improve women's health. Unfortunately, there are some scientific challenges associated with the development of these products which are among the major reasons contributing to the availability of relatively few IUS products on the market. This review summarizes the formulation considerations (drug and excipient attributes), manufacturing methods, advances in characterization and in vitro drug release testing of IUSs, as well as factors influencing drug release from IUSs. A critical discussion on the major challenges to IUS product development is presented. Specifically, insights on bioequivalence evaluation, in vitro-in vivo correlation (IVIVC) establishment, and regulatory challenges are detailed. Lastly, methodological tools to overcome some of these hurdles to product development are proposed. The knowledge furnished through this review will be helpful towards obtaining better product understanding. Such understanding will facilitate the development of these complex drug products, as well as their regulatory approval process.
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Affiliation(s)
- Suraj Fanse
- University of Connecticut, School of Pharmacy, Storrs, CT 06269, USA
| | - Quanying Bao
- University of Connecticut, School of Pharmacy, Storrs, CT 06269, USA
| | - Diane J Burgess
- University of Connecticut, School of Pharmacy, Storrs, CT 06269, USA.
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Mannai A, Hmida L, Bouraoui Z, Guerbej H, Gharred T, Jebali J. Does thermal stress modulate the biochemical and physiological responses of Ruditapes decussatus exposed to the progestin levonorgestrel? Environ Sci Pollut Res Int 2022; 29:85211-85228. [PMID: 35794321 DOI: 10.1007/s11356-022-21786-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 06/28/2022] [Indexed: 06/15/2023]
Abstract
In this study, we investigated the effects of 1000 ng/l levonorgestrel (LNG) alone or combined with increased temperature of 20, 24, and 28 °C on the biochemical and physiological responses of the clam (Ruditapes decussatus) for 28 days. Our results revealed that female clams treated with levonorgestrel (LNG) alone showed enhancement of the antioxidant defense against oxidative stress related to the inductions of catalase (CAT), gluthatione -S -transferase (GST), and protein sulfhydryl (PSH), while the elevated temperatures of 20, 24, and 28 °C diminished most of the specific responses to LNG and was the main factor in the determining the responses to combine exposures. The responses of lysosomal membrane stability, alkaline phosphatase, and NADP+-dependent isocitrate dehydrogenase detected were the most common signs of an adverse effect in all exposures. Female clams' testosterone and estradiol responses to LNG were the most particular manifestations depending on the exposure. Overall, these findings showed clearly that chronic warming stress caused disruption in physiological, biochemical parameters of the female clam R. decussatus, and this may have implications for the whole organism and populations.
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Affiliation(s)
- Asma Mannai
- Laboratory of Genetics Biodiversity and Valorization of Bio-resources (LR11ES41), Higher Institute of Biotechnology of Monastir, University of Monastir, Monastir, Tunisia.
| | - Leila Hmida
- Research Unit Ecosystems & Aquatic Resources (UR13AGRO1), National Agronomic Institute of Tunisia (INAT), University of Carthage, Charles Nicolle Avenue 43, Mahrajene City, 1082, Tunis, Tunisia
| | - Zied Bouraoui
- National Institute of Marine Sciences and Technology, Laboratory of Blue Biotechnology and Aquatic Bioproducts (LR16INSTM05), Monastir, Tunisia
| | - Hamadi Guerbej
- National Institute of Marine Sciences and Technology, Laboratory of Blue Biotechnology and Aquatic Bioproducts (LR16INSTM05), Monastir, Tunisia
| | - Tahar Gharred
- Laboratory of Bioresources: Integrative Biology & Valorization (LR 14ES06), Higher Institute of Biotechnology of Monastir, Monastir, Tunisia
| | - Jamel Jebali
- Laboratory of Genetics Biodiversity and Valorization of Bio-resources (LR11ES41), Higher Institute of Biotechnology of Monastir, University of Monastir, Monastir, Tunisia
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27
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Nidhi, Kumari A, Tirkey S, Prakash J. Effectiveness of Levonorgestrel Releasing Intrauterine System in Perimenopausal Women with Heavy Menstrual Bleeding: A Prospective Study at a Teaching Hospital in India. J Menopausal Med 2022; 28:128-135. [PMID: 36647276 PMCID: PMC9843034 DOI: 10.6118/jmm.22025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 09/10/2022] [Accepted: 10/11/2022] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVES To evaluate the effect of levonorgestrel-releasing intrauterine system (LNG-IUS) on heavy menstrual bleeding in perimenopausal women. METHODS This was a prospective, observational clinical study conducted on 42 perimenopausal women with heavy menstrual bleeding who met the study eligibility criteria. LNG-IUS was inserted in the postmenstrual phase following baseline evaluation. The patients were followed up at the 4, 12, and 24 weeks. Pictorial blood assessment chart (PBAC) score, hemoglobin and serum ferritin levels, and endometrial thickness were assessed before insertion and during the follow-up visits. RESULTS Two patients (4.8%) were lost to follow-up, three patients (7.1%) opted for hysterectomy, two women (4.8%) experienced spontaneous expulsion and 35 (83.3%) women continued the usage. Menstrual blood loss assessed using the median PBAC score (interquartile range) significantly reduced (P < 0.001) from the pre-insertion level of 280 (246-306) to 124 (60-200) at 4 weeks to 45 (34-76) at 12 weeks and further to 32 (20-50) at the end of 24 weeks. Simultaneously, a significant (P < 0.001) improvement in the mean hemoglobin and serum ferritin levels and a significant (P < 0.001) decrease in endometrial thickness were observed. The most common side effect was spotting (50.0%) and vaginal discharge (38.1%). CONCLUSIONS LNG-IUS causes a remarkable reduction in menstrual blood loss and marked improvement in dysmenorrhea. It also reduces anemia by improving the hemoglobin and ferritin levels. Thus, it can serve as an effective treatment option for heavy menstrual bleeding in perimenopausal women and prevent the need for a hysterectomy.
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Affiliation(s)
- Nidhi
- Department of Obstetrics and Gynecology, Rajendra Institute of Medical Sciences (RIMS), Ranchi, India
| | - Archana Kumari
- Department of Obstetrics and Gynecology, Rajendra Institute of Medical Sciences (RIMS), Ranchi, India
| | - Sarita Tirkey
- Department of Obstetrics and Gynecology, Rajendra Institute of Medical Sciences (RIMS), Ranchi, India
| | - Jay Prakash
- Department of Critical Care Medicine, Rajendra Institute of Medical Sciences, Ranchi, India
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28
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Lacasse JM, Gomez-Perales E, Brake WG. Modeling hormonal contraception in female rats: A framework for studies in behavioral neurobiology. Front Neuroendocrinol 2022; 67:101020. [PMID: 35952797 DOI: 10.1016/j.yfrne.2022.101020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/19/2022] [Accepted: 08/03/2022] [Indexed: 12/12/2022]
Abstract
Research on hormonal contraceptives (HC) in animal models is lacking, and as a result, so is our understanding of the impact of HC on the brain and behavior. Here, we provide a review of the pharmacology of HC, as well as the methodology and best practices for designing a model of HC in female rats. We outline specific methodological considerations regarding dosing, route of administration, exposure time/timing, and selecting a control group. We also provide a framework outlining important levels of analysis for thinking about the impact of HC on behavioral and neurobiological outcomes. The purpose of this review is to equip researchers with foundational knowledge, and some basic elements of experimental design for future studies investigating the impact of HC on the brain and behavior of female rats.
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Affiliation(s)
- Jesse M Lacasse
- Centre for Studies in Behavioral Neurobiology, Department of Psychology, Concordia University, Montréal H4B 1R6, Canada.
| | - Eamonn Gomez-Perales
- Centre for Studies in Behavioral Neurobiology, Department of Psychology, Concordia University, Montréal H4B 1R6, Canada
| | - Wayne G Brake
- Centre for Studies in Behavioral Neurobiology, Department of Psychology, Concordia University, Montréal H4B 1R6, Canada.
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29
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Leelakanok N, Parmontree P, Petchsomrit A, Methaneethorn J. A systematic review and meta-analysis of attitude and knowledge involving emergency oral contraceptive use in patients and healthcare providers. Int J Clin Pharm 2022; 44:873-893. [PMID: 35732860 DOI: 10.1007/s11096-022-01445-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 06/12/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Levonorgestrel and ulipristal acetate are common emergency oral contraceptives (EOCs). Lack of knowledge and negative attitude toward EOCs pose barriers to the EOCs access and utilization. AIM This study aimed to summarize the studies on the knowledge and attitudes of healthcare providers and patients on the use of EOCs. METHOD A systematic search was conducted from conception to April 2022 using the following databases: CINAHL Complete, MEDLINE, ScienceDirect, Scopus, and Thai Journal Online. Data were extracted independently and were meta-analyzed using DerSimonian and Laird method for the binary random-effects model. RESULTS 121 articles with a total number of 92,484 participants were included. The awareness of levonorgestrel as an EOC was 66.7% while the awareness of ulipristal acetate as an EOC was 36.9%. EOCs users received EOC information mainly from the internet, media, and friends. We found that 32.2% of EOCs users and providers agreed that EOCs acted post-fertilization, and 39.8% of the prescribers know the correct time to take the pill postcoital. Negative attitudes toward EOC use were found in 25.4% of the participants. For example, 39.4% of the participants agreed that EOCs users had increased sexual activity. CONCLUSION The awareness of EOCs was low and misunderstandings or negative attitudes towards the use or prescription of EOCs were still prevalent. Educating healthcare providers, using media as educational tools, and improving education and economics can be useful in improving EOC users' awareness, knowledge, and attitude towards EOCs.
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Affiliation(s)
- Nattawut Leelakanok
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Burapha University, Chonburi, 20131, Thailand
| | - Porntip Parmontree
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Burapha University, Chonburi, 20131, Thailand.
| | - Arpa Petchsomrit
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Burapha University, Chonburi, 20131, Thailand.,Pharmaceutical Innovations of Natural Products Unit (PhInNat), Faculty of Pharmaceutical Sciences, Burapha University, Chonburi, Thailand
| | - Janthima Methaneethorn
- Pharmacokinetic Research Unit, Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand.,Center of Excellence for Environmental Health and Toxicology, Naresuan University, Phitsanulok, Thailand
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30
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Hua J, Zhu B, Guo W, Wang X, Guo Y, Yang L, Han J, Zhou B. Endocrine disrupting effects induced by levonorgestrel linked to altered DNA methylation in rare minnow (Gobiocypris rarus). Comp Biochem Physiol C Toxicol Pharmacol 2022; 257:109332. [PMID: 35351618 DOI: 10.1016/j.cbpc.2022.109332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/20/2022] [Accepted: 03/20/2022] [Indexed: 11/19/2022]
Abstract
Progestins are worldwide environmental contaminants, however, their ecotoxicological risks and underlying molecular mechanisms of effects are not fully understood. In this study, newly hatched rare minnow (Gobiocypris rarus) larvae were exposed to environmentally realistic concentrations (1 and 10 ng/L) of levonorgestrel (LNG) for 6 months. The sex ratios were not affected by LNG at both concentrations, but the growth was significantly inhibited at 10 ng/L while promoted at 1 ng/L. Histological analysis revealed impaired gonadal development. Plasma concentrations of estradiol in females and testosterone in both sexes were significantly induced after exposure to 1 ng/L LNG; plasma concentrations of 11-ketotestosterone were markedly increased in females exposed to 10 ng/L LNG and in males exposed to both concentrations of LNG. The transcription of cyp19a1a was significantly up-regulated in ovaries exposed to LNG at both concentrations, while cyp17a1 was down-regulated in testes exposed to 10 ng/L LNG. The global DNA methylation level was significantly decreased in testes exposed to 10 ng/L LNG, which might be associated with inhibited spermatogenesis. Gender-specific changes in CpG methylation patterns were induced by LNG in the 5' flanking region of cyp19a1a, with hypomethylation in ovaries but hypermethylation in testes, which was linked to the regulation of cyp19a1a transcription. The results suggest that LNG could induce endocrine disrupting effects in fish at environmentally realistic concentrations, which may be linked to altered DNA methylation. This study indicates potentially high ecological risk of LNG to fish populations, and warrants researches on regulatory mechanisms of epigenetic modifications in progestin-induced effects.
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Affiliation(s)
- Jianghuan Hua
- College of Basic Medical Sciences, Hubei University of Chinese Medicine, Wuhan 430065, China; State Key Laboratory of Freshwater Ecology and Biotechnology, Institute of Hydrobiology, Chinese Academy of Sciences, Wuhan 430072, China
| | - Biran Zhu
- College of Basic Medical Sciences, Hubei University of Chinese Medicine, Wuhan 430065, China; State Key Laboratory of Freshwater Ecology and Biotechnology, Institute of Hydrobiology, Chinese Academy of Sciences, Wuhan 430072, China
| | - Wei Guo
- State Key Laboratory of Freshwater Ecology and Biotechnology, Institute of Hydrobiology, Chinese Academy of Sciences, Wuhan 430072, China
| | - Xianfeng Wang
- College of Fisheries, Henan Normal University, Xinxiang 453007, China
| | - Yongyong Guo
- State Key Laboratory of Freshwater Ecology and Biotechnology, Institute of Hydrobiology, Chinese Academy of Sciences, Wuhan 430072, China
| | - Lihua Yang
- State Key Laboratory of Freshwater Ecology and Biotechnology, Institute of Hydrobiology, Chinese Academy of Sciences, Wuhan 430072, China
| | - Jian Han
- State Key Laboratory of Freshwater Ecology and Biotechnology, Institute of Hydrobiology, Chinese Academy of Sciences, Wuhan 430072, China.
| | - Bingsheng Zhou
- State Key Laboratory of Freshwater Ecology and Biotechnology, Institute of Hydrobiology, Chinese Academy of Sciences, Wuhan 430072, China
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31
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Zhang D, Zhu Q, Xia W, Zhu C, Zhao X, Zhang Y, He C, Ji S, Li X, Zhang J. The role of SK3 in progesterone-induced inhibition of human fallopian tubal contraction. Reprod Biol Endocrinol 2022; 20:73. [PMID: 35488306 PMCID: PMC9052544 DOI: 10.1186/s12958-022-00932-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 03/22/2022] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Normal motor activity of the fallopian tube is critical for human reproduction, and abnormal tubal activity may lead to ectopic pregnancy (EP) or infertility. Progesterone has an inhibitory effect on tubal contraction; however, the underlying mechanisms remain unclear. Small-conductance calcium-activated K+ channel 3 (SK3) is abundantly expressed in platelet-derived growth factor receptor α positive (PDGFRα+) cells and was reported to be important for the relaxation of smooth muscle. The present study aims to explore the expression of SK3 in the human fallopian tube and its role in progesterone-induced inhibition of tubal contraction. METHODS We collected specimens of fallopian tubes from patients treated by salpingectomy for EP (EP group) and other benign gynecological diseases (Non-EP group). The expression of SK3 was detected by quantitative real-time polymerase chain reaction, western blot, immunocytochemistry, and immunohistochemistry analyses. Isometric tension experiments were performed to investigate the role of SK3 in progesterone-induced inhibition of tubal contraction. RESULTS The baseline amplitude and frequency of human fallopian tube contraction were both statistically lower in the EP group compared with the non-EP group. The expression levels of SK3 in different portions of fallopian tubes from the non-EP group were significantly higher than in those from the EP group. Progesterone had an inhibitory effect on tubal contraction, mainly on the amplitude, in both groups, and SK3 as well as other calcium-activated K+ channels may be involved. SK3-expressing PDGFRα (+) cells were detected in the human fallopian tube. CONCLUSIONS The expression of SK3 is lower in the EP group, and SK3 is involved in the progesterone-induced inhibition of human fallopian tube contraction.
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Affiliation(s)
- Duo Zhang
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200030, China
- Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, 200030, China
| | - Qian Zhu
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200030, China
- Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, 200030, China
| | - Wei Xia
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200030, China
- Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, 200030, China
| | - Chenfeng Zhu
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200030, China
- Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, 200030, China
| | - Xiaoya Zhao
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200030, China
- Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, 200030, China
| | - Yiqin Zhang
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200030, China
- Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, 200030, China
| | - Chuqing He
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200030, China
- Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, 200030, China
| | - Sifan Ji
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200030, China
- Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, 200030, China
| | - Xiaocui Li
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, China.
| | - Jian Zhang
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200030, China.
- Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, 200030, China.
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Teigeler M, Schaudien D, Böhmer W, Länge R, Schäfers C. Effects of the Gestagen Levonorgestrel in a Life Cycle Test with Zebrafish (Danio rerio). Environ Toxicol Chem 2022; 41:580-591. [PMID: 33539028 DOI: 10.1002/etc.5008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/25/2020] [Accepted: 01/31/2021] [Indexed: 06/12/2023]
Abstract
The amount of pharmaceuticals transferred to the aquatic environment via municipal and hospital waste water is steadily increasing. The progress in medical research has resulted in the manufacture of active substances of increased stability, specificity, and potency, which can trigger adverse effects in aquatic organisms. Moreover, advanced analytical methods allow the detection of pharmaceuticals in environmental matrices at very low concentrations, which increases the number of substances to be assessed. Levonorgestrel is a synthetic gestagen commonly used in medicinal products for contraception. Because progestogenic compounds could have an impact on fish maturation processes, a life cycle test was performed to assess the effects of levonorgestrel exposure of the embryonic to the adult stages of zebrafish (Danio rerio) at mean measured concentrations of 0.06, 0.16, 0.47, 1.64, and 5.45 ng/L. Apical endpoints were survival, growth, reproduction, and sex ratio. Determination of endocrine modulation was completed by measurement of vitellogenin and 11-keto testosterone in blood plasma, as well as by histopathological analysis of gonads. For all parameters, control values were within the recommended quality range. The most prominent levonorgestrel effect was a shift toward an increased number of male fish at 1.64 and especially 5.45 ng/L, at which point all fish were histologically determined to be males and no spawning occurred; 11-keto testosterone was significantly decreased. A no-observed-effect concentration (NOEC) of 0.47 ng levonorgestrel/L was confirmed by the fertilization capability of adult fish, the male maturation stages, and female gonad histopathology. Whereas hatch and juvenile growth were not affected, posthatch survival was significantly impeded at ≥0.47 ng levonorgestrel/L, although it was not clearly related to the test concentration. For male length and weight, the same NOEC of 0.16 ng/L was obtained at study termination. Environ Toxicol Chem 2022;41:580-591. © 2021 The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.
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Affiliation(s)
- Matthias Teigeler
- Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Schmallenberg, Germany
| | - Dirk Schaudien
- Fraunhofer Institute for Toxicology and Experimental Medicine ITEM, Hannover, Germany
| | - Walter Böhmer
- Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Schmallenberg, Germany
| | | | - Christoph Schäfers
- Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Schmallenberg, Germany
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Huck LC, Truhn D, Wilpert C, Zanderigo E, Raaff V, Dethlefsen E, Bode M, Kuhl CK. Background parenchymal enhancement in contrast-enhanced MR imaging suggests systemic effects of intrauterine contraceptive devices. Eur Radiol 2022; 32:7430-8. [PMID: 35524784 DOI: 10.1007/s00330-022-08809-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 04/03/2022] [Accepted: 04/13/2022] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Levonorgestrel-releasing intrauterine contraceptive devices (LNG-IUDs) are designed to exhibit only local hormonal effects. There is an ongoing debate on whether LNG-IUDs can have side effects similar to systemic hormonal medication. Benign background parenchymal enhancement (BPE) in dynamic contrast-enhanced (DCE) MRI has been established as a sensitive marker of hormonal stimulation of the breast. We investigated the association between LNG-IUD use and BPE in breast MRI to further explore possible systemic effects of LNG-IUDs. METHODS Our hospital database was searched to identify premenopausal women without personal history of breast cancer, oophorectomy, and hormone replacement or antihormone therapy, who had undergone standardized DCE breast MRI at least twice, once with and without an LNG-IUD in place. To avoid confounding aging-related effects on BPE, half of included women had their first MRI without, the other half with, LNG-IUD in place. Degree of BPE was analyzed according to the ACR categories. Wilcoxon-matched-pairs signed-rank test was used to compare the distribution of ACR categories with vs. without LNG-IUD. RESULTS Forty-eight women (mean age, 46 years) were included. In 24/48 women (50% [95% CI: 35.9-64.1%]), ACR categories did not change with vs. without LNG-IUDs. In 23/48 women (48% [33.9-62.1%]), the ACR category was higher with vs. without LNG-IUDs; in 1/48 (2% [0-6%]), the ACR category was lower with vs. without LNG-IUDs. The change of ACR category depending on the presence or absence of an LNG-IUD proved highly significant (p < 0.001). CONCLUSION The use of an LNG-IUD can be associated with increased BPE in breast MRI, providing further evidence that LNG-IUDs do have systemic effects. KEY POINTS • The use of levonorgestrel-releasing intrauterine contraceptive devices is associated with increased background parenchymal enhancement in breast MRI. • This suggests that hormonal effects of these devices are not only confined to the uterine cavity, but may be systemic. • Potential systemic effects of levonorgestrel-releasing intrauterine contraceptive devices should therefore be considered.
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Khafagy GM, Shalaby HL, Saad NE, Hasan MD. Effect of the Monthly Injectable Combined Contraceptives versus Oral Contraceptive Pills on Mood. Korean J Fam Med 2021; 42:471-476. [PMID: 34871488 PMCID: PMC8648491 DOI: 10.4082/kjfm.20.0106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/18/2020] [Indexed: 11/11/2022] Open
Abstract
Background Contraceptive agents are widely used by women of reproductive age, and resulting depression is the most common side effect of this usage. This study aimed to study the effect of monthly injectable combined contraceptives versus that of combined oral contraceptive pills (COC) on patients’ mood. Methods A prospective cohort study was conducted on 124 females aged 18–45 years attending the Kom-Ashfeen Family Medicine Unit, El-Kalyubia, Egypt. Participants were divided into three groups according to their choice: group A included 44 participants who received monthly combined injectable contraceptives (CIC); group B included 40 participants who took COC; and group C included 40 participants who used the copper intrauterine device (IUD). The Patient Health Questionnaire-9 (PHQ-9) score was assessed at the beginning of the study and after 6 months of follow-up. Results After 6 months of follow-up, there were mild but statistically significant increases in the PHQ-9 score in groups A and B, with group A (CIC users) showing the highest increase. Approximately 34.1%, 27.5%, and 15% of CIC, COC, and IUD users, respectively, moved from the non-depression stage to mild depression after 6 months; this change was statistically significant in groups A and B only. Conclusion Monthly injectable combined contraceptives and oral contraceptive pills were associated with an increased risk of developing mild depression; this risk was higher in users of CICs, although the difference was not statistically significant. Thus, it is crucial to counsel patients about this possible risk and to follow them up. However, further studies are required to confirm our results.
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Affiliation(s)
- Ghada M Khafagy
- Department of Family Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - Nagwa E Saad
- Department of Internal Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Marwa D Hasan
- Department of Family Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
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Al Dalaty A, Gualeni B, Coulman SA, Birchall JC. Models and methods to characterise levonorgestrel release from intradermally administered contraceptives. Drug Deliv Transl Res 2021; 12:335-349. [PMID: 34862590 PMCID: PMC8724103 DOI: 10.1007/s13346-021-01091-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2021] [Indexed: 12/24/2022]
Abstract
Microneedle (MN)-based technologies have been proposed as a means to facilitate minimally invasive sustained delivery of long-acting hormonal contraceptives into the skin. Intradermal administration is a new route of delivery for these contraceptives and therefore no established laboratory methods or experimental models are available to predict dermal drug release and pharmacokinetics from candidate MN formulations. This study evaluates an in vitro release (IVR) medium and a medium supplemented with ex vivo human skin homogenate (SH) as potential laboratory models to investigate the dermal release characteristics of one such hormonal contraceptive that is being tested for MN delivery, levonorgestrel (LNG), and provides details of an accompanying novel two-step liquid–liquid drug extraction procedure and sensitive reversed-phase HPLC–UV assay. The extraction efficiency of LNG was 91.7 ± 3.06% from IVR medium and 84.6 ± 1.6% from the medium supplemented with SH. The HPLC–UV methodology had a limit of quantification of 0.005 µg/mL and linearity between 0.005 and 25 µg/mL. Extraction and detection methods for LNG were exemplified in both models using the well-characterised, commercially available sustained-release implant (Jadelle®). Sustained LNG release from the implant was detected in both media over 28 days. This study reports for the first time the use of biologically relevant release models and a rapid, reliable and sensitive methodology to determine release characteristics of LNG from intradermally administered long-acting drug delivery systems.
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Affiliation(s)
- Adnan Al Dalaty
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, CF10 3NB, UK
| | - Benedetta Gualeni
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, CF10 3NB, UK
| | - Sion A Coulman
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, CF10 3NB, UK
| | - James C Birchall
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, CF10 3NB, UK.
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Fanse S, Bao Q, Zou Y, Wang Y, Burgess DJ. Effect of crosslinking on the physicochemical properties of polydimethylsiloxane-based levonorgestrel intrauterine systems. Int J Pharm 2021; 609:121192. [PMID: 34666142 DOI: 10.1016/j.ijpharm.2021.121192] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/03/2021] [Accepted: 10/10/2021] [Indexed: 11/29/2022]
Abstract
Polydimethylsiloxane (PDMS)-based levonorgestrel intrauterine systems (LNG-IUSs) such as Mirena® are long-acting drug-device combination products designed to release LNG for contraceptive purposes up to 6 years. LNG-IUSs consist of a hollow cylindrical drug-PDMS reservoir mounted with a polyethylene frame and covered by an outer PDMS membrane. PDMS is the release-controlling excipient present in both the matrix and the outer membrane. The degree of PDMS crosslinking is a key parameter in LNG-IUS manufacturing, dictating the elasticity and mechanical strength (which are critical parameters in molding and demolding of the cylindrical reservoirs). In addition, elasticity and mechanical strength are also important to prevent deformation during insertion into the uterine cavity. The objectives of this study were to investigate the impact of PDMS crosslinking on the physicochemical properties of LNG-IUSs and to develop appropriate testing methods for characterization of their mechanical strength. Formulations with different degrees of crosslinking were prepared by varying the ratio of the PDMS elastomer base and the crosslinking agent. A novel solvent swelling and extraction method was developed to determine the degree of PDMS crosslinking. The extent of crosslinking was also characterized via FTIR, Raman, 1H NMR, DSC, TGA and dynamic mechanical analysis. As expected, formulations with higher degrees of crosslinking showed lower crystallinity. Interestingly, the less crystalline formulations showed higher Tg values and storage moduli compared to the high crystalline formulations, implying that crosslinking is the predominant parameter governing the physicochemical and mechanical properties in LNG-IUSs. Correlations were established between PDMS crosslinking and the physicochemical properties of LNG-IUSs which will be useful for quality control purposes during formulation screening and development. A better understanding of the physicochemical characteristics of these complex products will facilitate drug product development.
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Affiliation(s)
- Suraj Fanse
- University of Connecticut, School of Pharmacy, Storrs, CT 06269, USA
| | - Quanying Bao
- University of Connecticut, School of Pharmacy, Storrs, CT 06269, USA
| | - Yuan Zou
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, FDA, Silver Spring, MD 20993, USA
| | - Yan Wang
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, FDA, Silver Spring, MD 20993, USA
| | - Diane J Burgess
- University of Connecticut, School of Pharmacy, Storrs, CT 06269, USA.
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Abstract
Intrauterine devices (IUDs) are safe, highly effective, reversible contraception and come in 2 varieties in the United States: nonhormonal (copper) or levonorgestrel hormonal (LNG) IUDs. There are few absolute contraindications, making them appropriate birth control for most patients. Patients are more likely to select an IUD when counseled about IUD removal and factors that are important to them. IUD insertion and removal are uncomplicated office procedures that can be offered by primary care providers.
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Affiliation(s)
- Stephanie Long
- Family Medicine Residency of Idaho, 777 North Raymond Street, Boise, ID 83704, USA; University of Washington, Department of Family Medicine, Seattle, WA, USA
| | - Loren Colson
- Family Medicine Residency of Idaho, 777 North Raymond Street, Boise, ID 83704, USA; University of Washington, Department of Family Medicine, Seattle, WA, USA.
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ChoGlueck C. The FDA ought to change Plan B's label. Contraception 2021; 106:6-9. [PMID: 34748753 DOI: 10.1016/j.contraception.2021.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 10/18/2021] [Accepted: 10/20/2021] [Indexed: 11/17/2022]
Abstract
This commentary defends 3 arguments for changing the label of levonorgestrel-based emergency contraception (LNG EC) so that it no longer supports the possibility of a mechanism of action after fertilization. First, there is no direct scientific evidence confirming any postfertilization mechanisms. Second, despite the weight of evidence, there is still widespread public misunderstanding over the mechanism of LNG EC. Third, this FDA label is not a value-free claim, but instead it has functioned like a political tool for reducing contraceptive access. The label is laden with antiabortion values (even though EC is contraception, not abortion), and it imposes these values on potential users, resulting in barriers to access such as with Burwell v. Hobby Lobby. These 3 arguments together provide scientific, social, and ethical grounds for the FDA to take the initiate in changing Plan B's drug label.
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Affiliation(s)
- Christopher ChoGlueck
- Department of Communication, Liberal Arts, and Social Sciences, New Mexico Institute of Mining and Technology (New Mexico Tech) , Socorro, New Mexico.
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Kaplan S, Bertoia ML, Wang FT, Zhou L, Lass A, Evans A, Dhanda S, Roy D, Seeger JD. Long-term safety of extended levonorgestrel-containing oral contraceptives in the United States. Contraception 2021; 105:26-32. [PMID: 34599911 DOI: 10.1016/j.contraception.2021.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 09/22/2021] [Accepted: 09/22/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To compare the safety profile of Seasonique, a 91-day levonorgestrel-containing combined oral contraceptive (COCLNG), to 28-day COCLNG regarding the risk of venous thromboembolism (VTE) and arterial thromboembolism (ATE). STUDY DESIGN A new user cohort study was conducted in a US health care database from 2006 to 2017. Each 91-day COCLNG treatment episode in females was matched to up to four 28-day COCLNG treatment episodes by propensity score. We identified VTE cases in either (1) an inpatient setting with ICD-9 and ICD-10 diagnosis codes of PE and/or DVT in the primary position, or (2) an outpatient setting with ICD-9 or ICD-10 diagnosis codes of DVT in conjunction with an anticoagulant medication dispensing or alteplase (thrombolytic) during the 30-day period following the date of DVT diagnosis. VTE was validated using medical records. We assessed the study endpoints in the two cohorts using incidence rates and Cox proportional hazards models adjusted for potential confounders. RESULTS Of the 25,593 treatment episodes in 91-day COCLNG and 76,586 treatment episodes in 28-day COCLNG, 35 and 68 patients had VTEs, respectively, corresponding to a hazard ratio (HR) of 1.40 (95% confidence interval [CI], 0.90-2.19). The VTE algorithm had a positive predictive value of 76.4% (95% CI, 66.2%-84.8%). ATEs were recorded in 13 and 28 episodes, respectively, with a corresponding HR of 1.21 (95% CI, 0.58-2.53). CONCLUSIONS These results do not indicate a significant difference between 91-day COCLNG and 28-day COCLNG in terms of VTE or ATE risk. IMPLICATIONS Compared to use of 28-day COCLNG, use of 91-day extended COCLNG was not associated with a significant difference in risk of venous and arterial thromboembolism.
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Affiliation(s)
- Sigal Kaplan
- Global Pharmacovigilance, Teva Pharmaceutical Industries Ltd, Netanya, Israel.
| | | | | | - Li Zhou
- Epidemiology, Optum, Boston, MA, USA
| | | | - Alison Evans
- Drug Safety Research Unit, Southampton, UK; School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
| | - Sandeep Dhanda
- Drug Safety Research Unit, Southampton, UK; School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
| | - Debabrata Roy
- Drug Safety Research Unit, Southampton, UK; School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
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Orr K, Chin J, Cuddeback M, Zimo J, Judge-Golden C, Jarlenski M, Borrero S. Pharmacy availability of emergency contraception in southwestern Pennsylvania: A simulated patient study. Contracept X 2021; 3:100068. [PMID: 34401743 PMCID: PMC8355831 DOI: 10.1016/j.conx.2021.100068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 07/08/2021] [Accepted: 07/12/2021] [Indexed: 11/19/2022] Open
Abstract
Objective To assess the availability of oral emergency contraception in southwestern Pennsylvania pharmacies. Study design We conducted a simulated patient study to assess on-the-shelf availability of levonorgestrel emergency contraception and immediate availability of ulipristal acetate emergency contraception. Results Only 44% of pharmacies stocked levonorgestrel on-the-shelf and only 5% of pharmacies had ulipristal acetate immediately available. Conclusions We found significant barriers to obtaining timely oral emergency contraception in southwestern Pennsylvania. Implications statement Timely access to emergency contraception is important for people's ability to determine if, when, how, and under what circumstances to have children. Pharmacies in southwestern Pennsylvania need to expand access to oral emergency contraception.
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Affiliation(s)
- Katherine Orr
- University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Jennifer Chin
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, United States
- Corresponding author.
| | - Maris Cuddeback
- University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Jessica Zimo
- University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Colleen Judge-Golden
- University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
- Center for Women's Health Research and Innovation, University of Pittsburgh, Pittsburgh, PA, United States
| | - Marian Jarlenski
- Center for Women's Health Research and Innovation, University of Pittsburgh, Pittsburgh, PA, United States
| | - Sonya Borrero
- Center for Women's Health Research and Innovation, University of Pittsburgh, Pittsburgh, PA, United States
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States
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Veeran MG, C K, B B, Painuly D, Aprem AS. RP-HPLC method validation for fast extraction and quantification of Levonorgestrel drug from silicone based intrauterine device intended for in-process and finished formulation. Daru 2021; 29:185-193. [PMID: 33934266 PMCID: PMC8149566 DOI: 10.1007/s40199-021-00396-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 04/13/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND To develop and validate a simple and consistent reversed phase high performance liquid chromatography (RP-HPLC) method for the estimation of Levonorgestrel (LNG) drug from silicone based intrauterine device. METHODS Sample solution was prepared using tetrahydrofuran (THF) as solvent for the drug extraction, and RP-HPLC analysis was performed using Luna C18 analytical column (150 × 4.6 mm, 5 μm, 100 Å - Phenomenex), with a mobile phase consisting of a mixture of acetonitrile and water (50:50, v/v) at a flow rate of 1.0 ml/min and injection volume of 20 μl. Detection was carried out at 241 nm in PDA detector, with a total run time of 15 min. The method was validated in accordance with ICH guidelines. Method applicability was tested for optimizing formulation using quality-by-design approach, to check the stability and content uniformity of levonorgestrel-silicone mixture (core blend), and quantifying the amount of LNG from commercially available silicone based formulation. RESULTS The retention time for LNG drug was obtained at 8.5 min (± 0.3 min). A linear relationship was observed over the concentration range of 2.6-15.6 μg/ml with the correlation coefficient (r) value 0.9999. The method was found to be precise within the acceptable limit (RSD < 2%) and the drug recovery from the intrauterine device was found in the range 99.78-100.0%. Content uniformity for different prototypes developed was observed in the range of 91.6-101.4%, and assay of optimized core blend was in the range of 97.78-106.79% during the 10 days of retention period for stability studies. CONCLUSION The validated method is found to be a simple, accurate, precise, reproducible, and hence can be used for the routine analysis of LNG such as in-process, quality control and stability assays of silicone based intrauterine devices by RP-HPLC.
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Affiliation(s)
- Midhu George Veeran
- Corporate Research and Development Centre, HLL Lifecare Limited, Akkulam, Sreekariyam, Trivandrum, Kerala, 695017, India
| | - Karthikeyan C
- Corporate Research and Development Centre, HLL Lifecare Limited, Akkulam, Sreekariyam, Trivandrum, Kerala, 695017, India
| | - Bharaniraja B
- Corporate Research and Development Centre, HLL Lifecare Limited, Akkulam, Sreekariyam, Trivandrum, Kerala, 695017, India
| | - Diksha Painuly
- Corporate Research and Development Centre, HLL Lifecare Limited, Akkulam, Sreekariyam, Trivandrum, Kerala, 695017, India.
| | - Abi Santhosh Aprem
- Corporate Research and Development Centre, HLL Lifecare Limited, Akkulam, Sreekariyam, Trivandrum, Kerala, 695017, India
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Simu S, Marcovici I, Dobrescu A, Malita D, Dehelean CA, Coricovac D, Olaru F, Draghici GA, Navolan D. Insights into the Behavior of Triple-Negative MDA-MB-231 Breast Carcinoma Cells Following the Treatment with 17β-Ethinylestradiol and Levonorgestrel. Molecules 2021; 26:2776. [PMID: 34066763 PMCID: PMC8125870 DOI: 10.3390/molecules26092776] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 05/04/2021] [Accepted: 05/05/2021] [Indexed: 12/30/2022] Open
Abstract
Oral contraceptives (OCs) are widely used due to their efficiency in preventing unplanned pregnancies and treating several human illnesses. Despite their medical value, the toxicity of OCs remains a public concern. Previous studies indicate the carcinogenic potential of synthetic sex hormones and their link to the development and progression of hormone-dependent malignancies such as breast cancer. However, little is known about their influence on the evolution of triple-negative breast carcinoma (TNBC), a malignancy defined by the absence of estrogen, progesterone, and HER2 receptors. This study reveals that the active ingredients of modern OCs, 17β-Ethinylestradiol, Levonorgestrel, and their combination induce differential effects in MDA-MB-231 TNBC cells. The most relevant behavioral changes occurred after the 24 h treatment with 17β-Ethinylestradiol, summarized as follows: (i) decreased cell viability (64.32% at 10 µM); (ii) cell roundness and loss of confluence; (iii) apoptotic aspect of cell nuclei (fragmentation, membrane blebbing); and (iv) inhibited cell migration, suggesting a potential anticancer effect. Conversely, Levonorgestrel was generally associated with a proliferative activity. The association of the two OCs exerted similar effects as 17β-Ethinylestradiol but was less effective. Further studies are necessary to elucidate the hormones' cytotoxic mechanism of action on TNBC cells.
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Affiliation(s)
- Sebastian Simu
- Research Center for Pharmaco-Toxicological Evaluations, Faculty of Pharmacy, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square No. 2, RO-300041 Timisoara, Romania; (S.S.); (I.M.); (C.A.D.); (D.C.); (G.A.D.)
- Faculty of Pharmacy, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square No. 2, RO-300041 Timisoara, Romania
| | - Iasmina Marcovici
- Research Center for Pharmaco-Toxicological Evaluations, Faculty of Pharmacy, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square No. 2, RO-300041 Timisoara, Romania; (S.S.); (I.M.); (C.A.D.); (D.C.); (G.A.D.)
- Faculty of Pharmacy, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square No. 2, RO-300041 Timisoara, Romania
| | - Amadeus Dobrescu
- Faculty of Medicine, 2nd Department of Surgery, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square No. 2, RO-300041 Timisoara, Romania
| | - Daniel Malita
- Faculty of Medicine, Department of Radiology, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square No. 2, RO-300041 Timisoara, Romania
| | - Cristina Adriana Dehelean
- Research Center for Pharmaco-Toxicological Evaluations, Faculty of Pharmacy, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square No. 2, RO-300041 Timisoara, Romania; (S.S.); (I.M.); (C.A.D.); (D.C.); (G.A.D.)
- Faculty of Pharmacy, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square No. 2, RO-300041 Timisoara, Romania
| | - Dorina Coricovac
- Research Center for Pharmaco-Toxicological Evaluations, Faculty of Pharmacy, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square No. 2, RO-300041 Timisoara, Romania; (S.S.); (I.M.); (C.A.D.); (D.C.); (G.A.D.)
- Faculty of Pharmacy, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square No. 2, RO-300041 Timisoara, Romania
| | - Flavius Olaru
- Faculty of Medicine, Department of Obstetrics and Gynecology, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square No. 2, RO-300041 Timisoara, Romania; (F.O.); (D.N.)
| | - George Andrei Draghici
- Research Center for Pharmaco-Toxicological Evaluations, Faculty of Pharmacy, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square No. 2, RO-300041 Timisoara, Romania; (S.S.); (I.M.); (C.A.D.); (D.C.); (G.A.D.)
- Faculty of Pharmacy, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square No. 2, RO-300041 Timisoara, Romania
| | - Dan Navolan
- Faculty of Medicine, Department of Obstetrics and Gynecology, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square No. 2, RO-300041 Timisoara, Romania; (F.O.); (D.N.)
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McCoy CF, Spence P, Dallal Bashi YH, Murphy DJ, Boyd P, Dangi B, Derrick T, Devlin B, Kleinbeck K, Malcolm RK. Use of simulated vaginal and menstrual fluids to model in vivo discolouration of silicone elastomer vaginal rings. Int J Pharm X 2021; 3:100081. [PMID: 34027386 DOI: 10.1016/j.ijpx.2021.100081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 04/28/2021] [Indexed: 01/13/2023]
Abstract
Vaginal rings releasing antiretrovirals – either alone or in combination with contraceptive progestins – are being developed for prevention of human immunodeficiency virus (HIV) transmission via vaginal sex. Following Phase I trials, significant discolouration was observed on the surface of investigational silicone elastomer antiretroviral-contraceptive matrix-type vaginal rings containing either 25 mg dapivirine or 200 mg dapivirine plus levonorgestrel. In this study, potential causes of the discolouration have been assessed in vitro using simulated vaginal and menstrual fluids (SVF and SMF, respectively) to model in vivo exposure. The fluid compositions also included hydrogen peroxide (H2O2), hydrogen peroxide plus a copper intrauterine device (IUD), or synthetic dyes (representing personal care and household cleaning products). No discolouration was observed for rings exposed to SVF + hydrogen peroxide (with or without an IUD). However, the SVF + dye compositions showed significant ring discolouration, with staining patterns similar to those observed with rings that had been exposed to highly-coloured personal care and household cleaning products during clinical trial use. Exposure of rings to SMF compositions invariably caused yellow surface discolouration, dark spotting and markings, similar to the staining patterns observed following clinical use. The darker marks on the ring surface were identified as blood debris derived from the SMF. The study indicates that surface discolouration of rings in vivo can be attributed to exposure to menstrual fluid or highly coloured personal care or household cleaning products. Discolouration of the rings was not associated with any specific safety risks for the user, though severe discolouration could potentially impact acceptability and adherence.
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Ginstman C, Kopp Kallner H, Fagerberg-Silwer J, Carlsson B, Ärlemalm A, Böttiger Y, Brynhildsen J. Pharmacokinetics of Oral Levonorgestrel in Women After Roux-en-Y Gastric Bypass Surgery and in BMI-Matched Controls. Obes Surg 2020; 30:2217-24. [PMID: 32030619 DOI: 10.1007/s11695-020-04447-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Women are advised to primarily use non-oral contraceptive alternatives after Roux-en-Y gastric bypass since it is not known if the surgery affects the pharmacokinetics of oral contraceptives. METHODS This is a multi-center, open label, phase 2 pharmacokinetic study performed at the University Hospital of Linköping and the Clinical Trials Center, Department of Obstetrics and Gynecology, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden. Fifteen women aged 18-40 years who had previously undergone Roux-en-Y gastric bypass surgery and reached a BMI < 30 were included. Fifteen BMI-matched women with no previous history of Roux-en-Y gastric bypass surgery served as a control group. After administration of a single dose of a combined oral contraceptive containing 0.03 mg ethinylestradiol/0.15 mg levonorgestrel, serum levonorgestrel concentrations were determined during a 24-h period using ultra performance liquid chromatography/tandem mass spectrometry. The area under the plasma concentration time curve of levonorgestrel (AUC0-24h) was the main outcome measure. RESULTS There were no significant differences in the studied pharmacokinetic parameters, AUC0-24h, total AUC, peak serum concentration (Cmax), time to peak serum concentrations (Tmax), apparent oral clearances of levonorgestrel (CLoral), or terminal half-lives (t½) between the groups. CONCLUSION This is to our knowledge the first study to evaluate the pharmacokinetics of oral levonorgestrel in women with a BMI < 30 at least 1 year after RYGB compared with a BMI-matched group of women. We could not find any significant pharmacokinetic differences between the groups, suggesting that oral levonorgestrel may be used in non-obese women after Roux-en-Y gastric bypass once a stable body weight has been reached. CLINICAL TRIAL NUMBER EudraCT 2014-004677-17.
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Silva FR, Grande AJ, Lacerda Macedo AC, Colonetti T, Rocha MC, Rodrigues Uggioni ML, Silva BR, da Rosa MI. Meta-Analysis of Breast Cancer Risk in Levonorgestrel-Releasing Intrauterine System Users. Clin Breast Cancer 2021; 21:497-508. [PMID: 34045174 DOI: 10.1016/j.clbc.2021.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/18/2021] [Accepted: 03/26/2021] [Indexed: 12/24/2022]
Abstract
To map and assess evidence regarding use of the levonorgestrel-releasing intrauterine system (LNG-IUS) and its association with breast cancer, we conducted a systematic review and meta-analysis. A search strategy was developed using the terms "Levonorgestrel-releasing," "LNG-IUS," "intrauterine system," and "breast cancer. The electronic databases searched were MEDLINE, Embase, Cochrane Library, Latin American & Caribbean Health Sciences Literature, and Google Scholar for studies published until August 2020. We included observational studies: prospective or retrospective cohort, case-control, and cross-sectional. A total of 494 studies were identified, 294 studies were evaluated by title and abstract, and 262 were excluded because they did not meet the inclusion criteria. A total of 32 studies were read in full, and 24 were excluded. Thus, eight studies were included in the systematic review. The meta-analysis included four studies (two cohort and two case-control studies). Two subgroup analyses were performed for different study designs. The estimated relative risk for the two cohort studies (144,996 cases), with moderate-quality evidence, was 0.93 (95% confidence interval [CI], 0.840-1.03). The odds ratio estimated for the two case-control studies (5556 cases and 35987 controls), with moderate-quality evidence, was 1.07 (95% CI, 0.91-1.26). Evidence of an increased risk of breast cancer was not observed in levonorgestrel-releasing intrauterine system users.
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Affiliation(s)
- Fabio R Silva
- Laboratory of Biomedicine Translational, Postgraduate Program in Health Sciences, Universidade do Extremo Sul Catarinense, Criciúma, Santa Catarina, Brazil
| | - Antonio Jose Grande
- Laboratory of Evidence-Based Practice, Universidade Estadual de Mato Grosso do Sul, Campo Grande, Mato Grosso do Sul, Brazil
| | - Ana Cristina Lacerda Macedo
- Laboratory of Biomedicine Translational, Postgraduate Program in Health Sciences, Universidade do Extremo Sul Catarinense, Criciúma, Santa Catarina, Brazil
| | - Tamy Colonetti
- Laboratory of Biomedicine Translational, Postgraduate Program in Health Sciences, Universidade do Extremo Sul Catarinense, Criciúma, Santa Catarina, Brazil
| | - Marina C Rocha
- Laboratory of Biomedicine Translational, Postgraduate Program in Health Sciences, Universidade do Extremo Sul Catarinense, Criciúma, Santa Catarina, Brazil
| | - Maria Laura Rodrigues Uggioni
- Laboratory of Biomedicine Translational, Postgraduate Program in Health Sciences, Universidade do Extremo Sul Catarinense, Criciúma, Santa Catarina, Brazil
| | - Bruno R Silva
- Laboratory of Biomedicine Translational, Postgraduate Program in Health Sciences, Universidade do Extremo Sul Catarinense, Criciúma, Santa Catarina, Brazil
| | - Maria Inês da Rosa
- Laboratory of Biomedicine Translational, Postgraduate Program in Health Sciences, Universidade do Extremo Sul Catarinense, Criciúma, Santa Catarina, Brazil.
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Kaplan S, Toussi M, Evans A, Dhanda S, Roy D, Lass A. Real world utilization of 91 day extended levonorgestrel-containing combined oral contraceptives in Europe: a multinational database study. Curr Med Res Opin 2021; 37:515-522. [PMID: 33459071 DOI: 10.1080/03007995.2021.1876008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
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 (COCLNG). 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 COCLNG during the study period. Prescribing patterns of 91 day COCLNG were examined including: (1) treatment duration; (2) indication; (3) use of combined oral contraceptive (COC) before 91 day COCLNG 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 COCLNG 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 COCLNG 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 COCLNG initiation was 14% across GP databases, but was lower (8%) in the French gynecologist database. The frequency of switching from 91 day COCLNG 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 COCLNG 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 (COCLNG) 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 COCLNG initiation, and switching from 91 day COCLNG to combined hormonal contraceptives or other contraceptives, were generally low (14% or less).These findings were mostly consistent across participating countries.
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Affiliation(s)
- Sigal Kaplan
- Teva Pharmaceutical Industries Ltd., Netanya, Israel
| | | | - Alison Evans
- Drug Safety Research Unit, Southampton, UK
- School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
| | - Sandeep Dhanda
- Drug Safety Research Unit, Southampton, UK
- School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
| | - Debabrata Roy
- Drug Safety Research Unit, Southampton, UK
- School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
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Ravi RD, Kalra J, Srinivasan R, Bagga R, Jain V, Suri V, Sachdeva N. A Randomized Clinical Trial of Levonorgestrel Intrauterine System with or without Metformin for Treatment of Endometrial Hyperplasia without Atypia in Indian Women. Asian Pac J Cancer Prev 2021; 22:983-989. [PMID: 33773565 PMCID: PMC8286694 DOI: 10.31557/apjcp.2021.22.3.983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Indexed: 01/07/2023] Open
Abstract
Background: Endometrial cancer is the second most frequent genital malignancy in women, which is showing a constant rise all over world. Endometrial hyperplasia is the precursor of endometrial cancer. Levonorgestrel intrauterine system is the first line management in patients with endometrial hyperplasia without atypia. Metformin has shown to reverse endometrial hyperplasia, but its effectiveness and safety in endometrial hyperplasia is uncertain. Objective: To compare the efficacy in terms of histopathological response, clinical response and safety at the end of 6 months in patients with endometrial hyperplasia without atypia managed with levonorgestrel intrauterine system alone versus patients managed with levonorgestrel intrauterine system plus metformin. Methods: The randomized control trial was conducted on 51 cases of endometrial hyperplasia without atypia. Twenty-five subjects were prescribed metformin 500mg twice daily with levonorgestrel intrauterine system and 26 subjects, with levonorgestrel intrauterine system only for 6 months. At the end of 6 months, endometrial sampling was performed for histopathological response. Results: Clinical response was observed in 23 of 25 subjects in metformin group and 22 of 24 in levonorgestrel only group. The metformin group responded significantly with amenorrhea (p= 0.0053), while levonorgestrel only group responded with regular cycles (p=0.027). At the end of study, of 46 subjects available for histopathological evaluation, 100% subjects in metformin group and 95.45% in levonorgestrel only group (p=0.47826) showed complete response. The metformin group had a significant reduction in body mass index at end of study [P = 0∙023, 95% confidence interval (-1.7802, -0.1418)]. Conclusion: No significant difference in regression of endometrial hyperplasia was observed on adjunctive use of metformin but a significant reduction in BMI was observed. Use of metformin in obese patients may improve the treatment response.
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Affiliation(s)
- Ramya Dinnekere Ravi
- Department of Obstetrics & Gynaecology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jasvinder Kalra
- Department of Obstetrics & Gynaecology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Radhika Srinivasan
- Department of Cytology & Gynecological Pathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rashmi Bagga
- Department of Obstetrics & Gynaecology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vanita Jain
- Department of Obstetrics & Gynaecology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vanita Suri
- Department of Obstetrics & Gynaecology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Naresh Sachdeva
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Cleland K, Marcantonio TL, Hunt ME, Jozkowski KN. "It prevents a fertilized egg from attaching…and causes a miscarriage of the baby": A qualitative assessment of how people understand the mechanism of action of emergency contraceptive pills. Contraception 2021; 103:408-413. [PMID: 33508253 DOI: 10.1016/j.contraception.2021.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 01/15/2021] [Accepted: 01/20/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The mechanism of action (MOA) of emergency contraceptive pills (ECPs) is frequently mischaracterized. Our objective was to identify how members of the general public understand the mechanisms of ECPs. STUDY DESIGN We recruited a convenience sample from social media for a survey about reproductive health attitudes and analyzed spontaneous descriptions of how ECPs work. We inductively coded responses to create themes and subthemes, and collapsed subthemes into three MOA categories based on previous research. RESULTS Among 1443 respondents, 533 mentioned an MOA in their description of ECPs. While nearly half of these responses (49.5%) stated that ECPs prevent pregnancy before fertilization occurs (in accordance with most biomedical ECP research), over 60% described a mechanism related to preventing implantation of a fertilized egg. Nine percent of responses described a postimplantation mechanism that would be considered abortion by mainstream medical standards. Some respondents conveyed significant confusion about the biological processes involved with pregnancy and pregnancy prevention. CONCLUSION Confusion about how ECPs work was common among our sample. The largest group of responses described a mechanism-preventing implantation of a fertilized egg-listed on the Food and Drug Administration (FDA)-approved ECP labels that does not reflect most relevant biomedical research. Mischaracterizations of ECPs' mechanisms have been used to limit access to EC. These misunderstandings were common in our sample and may reflect poor quality sex education and public information, and confusion introduced by the FDA-approved labels. Additional research should identify whether public perception of ECPs' mechanisms influences policy, health care provision, and use of ECPs.
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Affiliation(s)
- Kelly Cleland
- American Society for Emergency Contraception, Lawrenceville NJ, United States.
| | - Tiffany L Marcantonio
- Department of Health, Human Performance and Recreation, University of Arkansas, Fayetteville AR, United States
| | - Mary E Hunt
- Department of Health and Human Development, Western Washington University, Bellingham WA, United States
| | - Kristen N Jozkowski
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington IN, United States
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Hopelian NG, Simmons RG, Sanders JN, Ward K, Jenkins SM, Espey E, Turok DK. Comparison of levonorgestrel level and creamatocrit in milk following immediate versus delayed postpartum placement of the levonorgestrel IUD. BMC Womens Health 2021; 21:33. [PMID: 33478494 PMCID: PMC7818753 DOI: 10.1186/s12905-021-01179-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 01/13/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Breastfeeding and postpartum contraception critically influence infant and maternal health outcomes. In this pilot study, we explore the effects of timing and duration of postpartum levonorgestrel exposure on milk lipid and levonorgestrel content to establish baseline data for future research. METHODS This sub-study recruited a balanced convenience sample from 259 participants enrolled in a parent randomized controlled trial comparing immediate to delayed (4-8 weeks) postpartum levonorgestrel IUD placement. All planned to breastfeed, self-selected for sub-study participation, and provided the first sample at 4-8 weeks postpartum (before IUD placement for the delayed group) and the second four weeks later. We used the Wilcoxon rank sum (inter-group) and signed rank (intra-group) tests to compare milk lipid content (creamatocrit) and levonorgestrel levels between groups and time points. RESULTS We recruited 15 participants from the immediate group and 17 from the delayed group with 10 and 12, respectively, providing both early and late samples. Initially, median levonorgestrel concentration of the immediate group (n = 10) (32.5 pg/mL, IQR: 24.8, 59.4) exceeded that of the delayed group (n = 12) (17.5 pg/mL, IQR: 0.0, 25.8) (p = 0.01). Four weeks later, the values aligned: 26.2 pg/mL (IQR: 20.3, 37.3) vs. 28.0 pg/mL (IQR: 25.2, 40.8). Creamatocrits were similar between both groups and timepoints. CONCLUSIONS Immediate postpartum levonorgestrel IUD placement results in steady, low levels of levonorgestrel in milk without apparent effects on lipid content. These findings provide initial support for the safety of immediate postpartum levonorgestrel IUD initiation, though the study was not powered to detect noninferiority between groups. TRIAL REGISTRATION This randomized controlled trial was registered with ClinicalTrials.gov (Registry No. NCT01990703) on November 21, 2013.
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Affiliation(s)
- Niaree G. Hopelian
- The University of Utah School of Medicine, 30 N 1900 E, 2B200, Salt Lake City, UT 84132 USA
- Present Address: Department of Psychiatry, Neuropsychiatric Institute, University of Illinois, Chicago, 912 S Wood St, Chicago, IL 60612 USA
| | - Rebecca G. Simmons
- Division of Family Planning, Department of Obstetrics and Gynecology, The University of Utah School of Medicine, 30 N 1900 E, 2B200, Salt Lake City, UT 84132 USA
| | - Jessica N. Sanders
- Division of Family Planning, Department of Obstetrics and Gynecology, The University of Utah School of Medicine, 30 N 1900 E, 2B200, Salt Lake City, UT 84132 USA
| | - Katherine Ward
- The University of Utah College of Nursing, 10 S 2000 E, Salt Lake City, UT 84112 USA
| | - Sabrina Malone Jenkins
- Division of Neonatology, Department of Pediatrics, The University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84108 USA
| | - Eve Espey
- Department of Obstetrics and Gynecology, The University of New Mexico School of Medicine, Albuquerque, NM 87131 USA
| | - David K. Turok
- Division of Family Planning, Department of Obstetrics and Gynecology, The University of Utah School of Medicine, 30 N 1900 E, 2B200, Salt Lake City, UT 84132 USA
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Novikova OV, Nosov VB, Panov VA, Novikova EG, Krasnopolskaya KV, Andreeva YY, Shevchuk AS. Live births and maintenance with levonorgestrel IUD improve disease-free survival after fertility-sparing treatment of atypical hyperplasia and early endometrial cancer. Gynecol Oncol 2021; 161:152-9. [PMID: 33461741 DOI: 10.1016/j.ygyno.2021.01.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 01/01/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Our objectives were to (1) compare different regimens of hormonal therapy (HT) in young women with atypical endometrial hyperplasia (AEH) and early endometrial cancer (EC), (2) assess reproductive and oncologic outcomes and (3) explore possible predictors of complete response (CR) and disease free survival (DFS). METHODS Reproductive age women with AEH and Grade 1-2 endometrioid EC with no or minimal myometrial invasion on MRI treated with different regimens of HT were prospectively analyzed. Treatment protocols included levonorgestrel intrauterine device (LNG IUD), gonadotropin-releasing hormone agonist (aGnRH) or high-dose oral medroxyprogesteron acetate (MPA) separately and in combinations. RESULTS Total of 418 patients with AEH (n = 228) and EC (n = 190) aged 19-46 years received HT. Overall CR rate was 96% in AEH and 88% in EC patients (р < 0.001). None of the regimens used in AEH (LNG IUD + 2 D&C vs. LNG IUD + aGnRH vs. LNG IUD + 3 D&C) was found inferior to the others (CR of 98%, 95%, 100%, respectively, p > 0.05) except for MPA alone (CR 87%, р = 0.009). Out of four HT regimens used in EC LNG IUD + aGnRH+3 D&C was superior to all others (CR 96%, р = 0.026) where 2 D&Cs were performed or oral MPA was prescribed. The median follow-up for 339 patients was 33 months (range: 3-136), 68% of patients (n = 232) attempted conception, 38% (n = 89) of them used ART. The birth rate was 42% (n = 97). The rate of recurrence was 26% (50/196) in AEH group and 36% (51/143) in EC group (p = 0.05). Birth after treatment (HR = 0.24) or LNG IUD maintenance (HR = 0.18) were associated with superior DFS (p < 0.001 for both). ART use did not influence DFS. CONCLUSION Hormonal therapy of AEH and early EC with LNG IUD is superior to MPA-containing regimens, however still carries high risk of recurrence. Post-treatment pregnancy rates are satisfactory and can be further improved by broader ART use which was proven safe. Initial diagnosis of AEH, post-treatment child birth and LNG IUD maintenance were associated with decreased rates of recurrence.
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