Studies in sow reproduction: 5. The effect of lactation length of the so w on the subsequent embryonic development

Forty-five female pigs (sows) were allocated at random to one of three lactation lengths: 7 days, 21 days, 42 days. All sows were remated at the first post-weaning oestrus and were slaughtered at 20 days post coitum. The reproductive tracts were removed, dissected and examined. Ovulation rates as determined by luteal count were similar for all three groups, but the number of viable embryos decreased significantly (P < 0·05) from 13·0 for the 42-day lactation group to 9·2 for the 7-day lactation group. This difference was reflected in a significant (P < 0·01) reduction in the percentage embryo survival rate as lactation length was reduced. Uterine lengths for the 7-day lactation group were significantly (P < 0·05) shorter than the other two groups. Six sows in each treatment group were blood sampled: at weaning, at remating, at 2 days post-mating, at 10 days post-mating and at 20 days post-mating. The plasma samples obtained were assayed for progesterone. No differences were observed between treatment groups for plasma progesterone concentration at any of the sampling times. It is concluded that the reduction of the litter size at the next farrowing following a short lactation length is largely a result of increased embryo death in the first 20 days of gestation.

The effect of pregnant mare serum gonadotrophin and human chorionic gonadotrophin on ovulation and on fertility in the ewe

An experiment involving 300 cyclic Merino ewes and designed to study the effects of pregnant mare serum gonadotrophin (PMSG) and human chorionic gonadotrophin (HCG) on ovulation and subsequent fertility is described. PMSG (750 i.u.) was given on the 12th day of the oestrous cycle and HCG (400 and 800 i.u.) was injected intravenously within 3 hr of the onset of oestrus. PMSG induced multiple ovulation and hastened the time of ovulation in relation to the onset of oestrus by 2-3 hr, but did not enhance the precision of the time of ovulation. HCG had no effect upon the time of ovulation but did increase the proportion of follicles which ruptured. Neither PMSG nor HCG, alone or in combination, adversely affected fertility. In fact, HCG increased the proportion of ewes which lambed. Both PMSG and HCG increased the incidence of multiple births. The effect of PMSG on the incidence of multiple births was a direct reflection of its ability to induce multiple ovulation. HCG given alone, or after PMSG increased the incidence of multiple births but its effect was less marked than that of PMSG, and unlike that of PMSG the effect of HCG did not appear to be solely due to an increase in the number of ovulations.

Does anovulation induced by oral contraceptives favor pregnancy during the following two menstrual cycles?

OBJECTIVE

To compare IVF and pregnancy outcomes before and after anovulation induced by oral contraceptives.

DESIGN

Observational clinical study.

SETTING

Infertility clinic.

PATIENT(S)

Forty women with two intact ovaries (32 of 40 couples with male factor infertility and 8 with unknown causes of infertility) underwent 190 IVF treatment cycles (55 natural cycles and 135 clomiphene citrate-stimulated cycles).

INTERVENTION(S)

If the women failed to conceive after 2-4 IVF treatment cycles, oral contraceptives were used to induce anovulation for 1 month before IVF was performed in two consecutive cycles.

MAIN OUTCOME MEASURE(S)

Rates of oocyte retrieval, fertilization, cleavage, preembryo formation, pregnancy, and implantation were compared before and after a period of anovulation.

RESULT(S)

The pregnancy rate per cycle of the first and second cycle combined (23%) and that of the second cycle alone (30%) after a period of anovulation were significantly higher than that observed before a period of anovulation (9%).

CONCLUSION(S)

Anovulation induced by oral contraceptives, showing bilateral ovarian quiescence, enhances pregnancy rates in the following two menstrual cycles of IVF treatment.

Comparison of ovarian follicular activity during treatment with a monthly injectable contraceptive and a low-dose oral contraceptive

Ovarian follicular development occurs during treatment with combined and progestin-only oral contraceptive (OC) pills and progestin-containing subdermal implants, and can be associated with the development of persistent functional cysts that may require surgical removal. Lunelle is a once-a-month injectable contraceptive containing estradiol cypionate 5 mg and medroxyprogesterone acetate 25 mg. A randomized, comparative study was undertaken to compare the effect on ovarian follicular activity associated with use of Lunelle and a low-dose OC. A total of 30 ovulatory subjects were randomly assigned to receive two cycles of treatment with either an OC containing ethinyl estradiol 20 microg and 0.1 mg levonorgestrel or Lunelle. During the second cycle of treatment, pelvic sonography was performed every 4 days, at which time the maximum follicle diameter was measured. Study end points were the presence of follicles >/=10, 20, and 30 mm. In all, 13 of 15 subjects in the OC group and 14 of 15 in the Lunelle group completed the study. Follicles measuring >/=10 mm were present in 11 of 13 (84.6%) in the OC users and in four of 14 (28.6%) in the Lunelle users (p <0.05). In the OC group, six of 13 subjects (46.1%) developed follicles >/=20 mm, and one of 13 (7.7%) developed follicles >/=30 mm. No subjects in the Lunelle group developed a follicle >/=20 mm in diameter. This study indicates that Lunelle is associated with a significantly lower incidence of ovarian follicular development compared to that of an OC containing 20 microg ethinyl estradiol and 0.1 mg levonorgestrel.

Efficacy, bleeding patterns, and side effects of a 1-year contraceptive vaginal ring

A combined contraceptive vaginal ring designed to last 12 months was tested at three clinic sites. This ring released approximately 1 mg of norethindrone acetate (NET-Ac) and 20 micrograms of ethinyl estradiol (EE) daily. A total of 60 women were enrolled to use the ring in a schedule of 3 weeks in/1 week out. Serum norethindrone (NET) and ethinyl estradiol (EE) levels were assayed twice weekly in cycles 6, 9, and 13. Mean NET concentrations between cycles 6 and 9 were relatively stable between 13 and 19 nmol/L but showed a 10%-21% decrease in all centers between cycles 9 and 13. Mean EE concentrations ranged from 75 to 103 pmol/L, but did not have the same decrease as NET between cycles 9 and 13. Cycles with progesterone peaks (> 9.6 nmol/L) compatible with some luteal activity occurred in 4% of cycles sampled in Sydney, 3% in Santo Domingo, and 26% in Los Angeles. Half of these cycles exhibited at least one progesterone value > 32 nmol/L with three of 18 occurring in noncompliant cycles. Heavier body weight was associated with increased probability of luteal activity. Based on serum estradiol peaks > 400 pmol/L, eight of 81 cycles appeared to have marked follicular activity with no luteal activity. No pregnancies occurred. Nausea was reported by about half the subjects in approximately 10% of the visits (mainly in the first 1-2 days in the first cycle immediately after ring insertion). Vomiting was reported by 20% of subjects early in the first cycle only. Headache was reported on occasion by nearly 50% of the women, but the relationship to ring use was uncertain. Vaginal discharge was reported by 17 women (82% of these were from one clinic). Of 60 women, 14 discontinued before completing the study, but only two discontinuations were for medical reasons. Small but statistically significant changes occurred in lipid levels in two of the three centers. All changes remained within normal limits and were similar to those seen with many oral contraceptives. It appears that this ring may perform slightly differently in different populations, but is a highly satisfactory method of contraception for many women. Minor modifications in design could provide higher levels of steroid release and in the later months of the ring life span would assure continuing high levels of contraceptive protection for heavier women.

Pregnancies in women with Turner's syndrome

Ovarian failure is a typical feature in Turner's syndrome. Therefore, hormone replacement therapy (HRT) is necessary to achieve the development of normal female sexual characteristics and to prevent cardiovascular complications and osteoporosis. Spontaneous puberty occurs in 5-10% of women with Turner's syndrome, and 2-5% of them become pregnant spontaneously. Sexually active young women with Turner's syndrome need contraception. It can be administered as contraceptive pills, which also serve as HRT. Oocyte donation is now a treatment option for infertility of these women. Excellent results have been obtained with 46% of embryo transfers resulting in pregnancy. The pregnancies carry high risks and have to be followed up carefully. The children born following oocyte donation have no additional risks. Risks can be reduced by transferring only one embryo at a time to the uterus, thus avoiding twin pregnancies. Ovarian tissue from young girls with Turner's syndrome could be cryopreserved for infertility treatment in the future, but the optimal age of ovarian biopsy has to be studied, and methods of replantation and maturation of oocytes in vitro have still to be developed. Fertility counselling has become important in the treatment of girls with Turner's syndrome.

Activity of the pituitary-ovarian axis in the pill-free interval during use of low-dose combined oral contraceptives

This study was performed to evaluate pituitary-ovarian recovery in the pill-free interval during use of three low-dose combined oral contraceptives (COC). Either the estrogen component or the progestin component was comparable in the study groups, to evaluate their relative influence. Serum luteinizing hormone (LH), follicle-stimulating hormone (FSH), and estradiol (E2) levels were measured and follicle number and size estimated by transvaginal sonography daily during the 7-day pill-free interval in 44 healthy volunteers using three different low-dose oral contraceptives. Healthy volunteers were enrolled using 20 micrograms ethinyl estradiol (EE) + 75 micrograms gestodene (GSD) (Harmonet, Wyeth-Lederle; n = 15), 20 micrograms EE + 150 micrograms desogestrel (DSG) (Mercilon, Organon n = 17), or 30 micrograms EE + 150 micrograms DSG (Marvelon, Organon, n = 12) given according to the usual regimen of one tablet daily during 3 weeks and 1 week pill-free interval. No ovulations were observed. Pituitary hormones were not statistically significantly different at the beginning of the pill-free interval between the study groups. FSH concentrations were significantly higher at the end of the pill-free interval in the 30 micrograms EE group compared with both 20 micrograms EE groups (7.0 [0.6-12.4] IU/L vs 4.9 [1.4-6.1] IU/L and 4.5 [2.4-7.4] IU/L; p = 0.001). In both 20 micrograms EE groups, a single persistent follicle (24 and 28 mm) was present in one subject. Follicle diameters were statistically significantly smaller at the beginning and at the end of the pill-free period in the 30 micrograms EE group compared with both 20 micrograms EE study groups. Dominant follicles (defined as follicle diameter > or = 10 mm) were observed at the end of the pill-free interval in both 20 micrograms EE groups (in 27% and 18% of women, respectively) but not in the 30 micrograms EE group. Finally, the area-under-the-curve for E2 was statistically significantly lower in the 30 micrograms EE group compared with both 20 micrograms EE groups. In conclusion, the EE content rather than the progestin component in the studied COC determined the extent of residual ovarian activity at the beginning of the pill-free interval. Dominant follicles were encountered only in the 20 micrograms EE study groups.

Effects of pretreatment with an oral contraceptive on the time required to achieve pituitary suppression with gonadotropin-releasing hormone analogues and on subsequent implantation and pregnancy rates

OBJECTIVE

To assess the effect of pretreatment with an oral contraceptive (OC) on ovarian cyst formation during pituitary suppression with buserelin acetate.

DESIGN

Prospective randomized trial.

SETTING

Academic medical center.

PATIENT(S)

Eighty-three patients who were undergoing IVF-ET treatment.

INTERVENTION(S)

Patients in the study group were pretreated with an OC for 14 days starting on the first day of menstruation. The administration of SC buserelin acetate was initiated on the last day of OC administration. Patients in the control group began to receive buserelin acetate on day 2 of menstruation. Hormonal assays and ultrasound scans were performed on the first day of menstruation, and 7, 11, and 14 days after the commencement of buserelin acetate administration. Thereafter, these tests were performed weekly until pituitary suppression was achieved.

MAIN OUTCOME MEASURE(S)

Incidence of cyst formation.

RESULT(S)

A cyst developed in 27 patients in the control group (52.9%) and no patients in the study group (odds ratio [OR]=115; 95% confidence interval [CI]=10-617). Patients in the study group achieved pituitary suppression faster (median difference [MD]=7 days; 95% CI=4-14) and required fewer ampules of gonadotropin (MD=10; 95% CI=6-14). They recruited more follicles (MD=3; 95% CI=0-5) and had higher pregnancy rates (37.2% versus 33.3%).

CONCLUSION(S)

Pretreatment with an OC abolishes ovarian cyst formation, shortens the time required to achieve pituitary suppression, and decreases gonadotropin requirements without having a negative effect on pregnancy rates.

Timing of onset of contraceptive effectiveness in Depo-Provera users. II. Effects on ovarian function

OBJECTIVE

To determine the timing of onset of contraceptive effectiveness after the first injection of 150 mg of depot medroxyprogesterone acetate (DMPA) administered between days 8 and 13 of the menstrual cycle.

DESIGN

Descriptive, prospective study.

SETTING

A tertiary university referral center.

PATIENT(S)

Thirty healthy women between 18 and 40 years of age.

INTERVENTION

Volunteers were injected with DMPA between days 8 and 13 (5 women on each day) of the menstrual cycle.

MAIN OUTCOME MEASURE(S)

Ovarian function determined by serum levels of E2 and progesterone and follicular development evaluated by vaginal ultrasound.

RESULT(S)

In nine (30%) of 30 women studied, DMPA did not prevent ovulation. All ovulations occurred in women receiving DMPA between days 10 and 13 of the cycle. No woman who received injections on day 8 or 9 ovulated. Ovulation suppression was more effective in women with low ovarian activity. All ovulation occurred within 3 days after the injection.

CONCLUSION

A back-up contraceptive method, used after the 7th day of the menstrual cycle, is recommended for up to 7 days after the first injection of DMPA.

Tubo-ovarian abscess after tubal ligation

Tubo-ovarian abscess usually results from ascending infection of the lower genital tract. In a few cases it can occur as a result of direct contamination at the time of tubal sterilization. We describe a case that presented seven years after post partum tubal sterilization, showing both acute and chronic components.

A randomized cross-over study on various hormonal parameters of two triphasic oral contraceptives

The effect of two triphasic oral contraceptives (Triquilar [TRQ] and Trisiston [TRS]) containing ethinyl estradiol (EE) and levonorgestrel (LNG) on various hormonal parameters was investigated in 26 women during a cross-over study. TRS consisted of 0.03 mg EE + 0.05 mg LNG (six tablets), 0.04 mg EE + 0.075 mg LNG (six tablets), and 0.03 mg EE + 0.15 mg LNG (nine tablets), whereas TRQ was different in the second phase (five tablets) and third phase (10 tablets). Blood samples were taken on days 6, 11, 21, and 28 of the control and washout cycles and the third treatment cycle. Both formulations inhibited ovulation reliably and decreased the serum levels of gonadotropins, free testosterone, and dehydroepiandosterone sulfate in a time-dependent manner, whereas estradiol and testosterone were already suppressed on day 6, indicating a direct suppressive effect on ovarian steroid synthesis. Prolactin, which rose sporadically in some women, was not significantly changed. In contrast, the levels of sex hormone binding globulin, corticosteroid binding globulin, and cortisol were significantly elevated by 100%. During the hormone-free interval of 7 days, all parameters returned at least partly to baseline. There was no significant difference between the effects of both formulations. The results suggest the possibility of a direct inhibitory effect of contraceptive steroids on ovarian steroid synthesis.

Borderline ovarian tumours: retrospective analysis of twenty-one cases

Twenty-one borderline ovarian tumour cases, diagnosed and treated in our oncology section between 1986 and 1996, were retrospectively analysed. Thirty-three percent of the cases had serous tumours and the rest (66.6%) were mucinous, 57.1% of the mucinous tumours were the intestinal type and the remaining 42.9% were the endocervical type. When all the cases were analysed, the average age was 45.4+/-18.6 years, the average follow-up period was 5.5+/-2.6 years. The preoperative average CA125 level was 55.1+/-51.9 U/mL, and for CA19.9 it was 48.2+/-47.8 U/mL. Of the patients 85.7% were stage I and 14.3% state III. There were not any significant differences between the serous, intestinal-type mucinous and endometroid-type mucinous tumours regarding tumour volumes (p>0.05). When serous and mucinous tumours were compared according to the tumour markers, CA125 levels were significantly higher in the serous tumours (p=0.04) and CA19.9 levels were significantly higher in the mucinous tumours (p=0.02). All of the patients are under our follow-up and are in remission, except one, who died in the third year of the treatment because of chronic renal failure unrelated to the ovarian pathology.

Low-malignant potential epithelial tumors of the ovary: a clinicopathological study

Low-malignant potential (LMP) epithelial tumors of the ovary are a group which occupy an intermediate position between the benign and those of the frankly malignant ovarian neoplasms. The actual incidence, present age and treatment are still being discussed. During the period 1991-1996, from the 650 ovarian tumors which were diagnosed and treated in our institution, 401 were epithelial tumors. The LMP serous epithelial tumors consisted of 4.36% of all serous tumors while LMP mucinous tumors were 9.70% of all mucinous tumors. The LMP serous tumors had an 8 cm diameter on average, 83% were unilocular and 76.5% unilateral. The LMP mucinous tumors had a 17 cm diameter on average, 95% were multilocular and 95% unilateral. The mean age at diagnosis was 39 years for LMP serous tumors and 48 years for LMP mucinous tumors.

Effects of long-term low-dose mifepristone on reproductive function in women

Low-dose antiprogestin administration has been proposed as a new contraceptive modality to interference with endometrial receptivity without disturbing ovarian function. The effects of 1 mg/day mifepristone for 150 days on the menstrual cycle were assessed in 21 surgically sterilized women. The aim was to study each woman for one control cycle and during months 1, 3 and 5 of treatment. Ovulation, endometrial thickness, serum oestradiol and progesterone, urinary luteinizing hormone, endometrial morphology and cervical mucus were assessed. Luteal phase progesterone concentrations were observed in 36 of the 60 treated months assessed and less frequently as treatment progressed. The bleeding pattern was regular in most biphasic cycles, while prolonged interbleeding intervals or no bleeding were associated with monophasic cycles. Altered endometrial morphology was found in all cases irrespective of the occurrence of luteal activity. Increased endometrial thickness and dilated glands were observed in 25 and 34% respectively of the monophasic cycles. Mifepristone, 1 mg/day, interferes with endometrial development while allowing the occurrence of biphasic ovarian cycles and regular bleeding. However, it also prevents ovarian cyclicity in a high proportion of treated months, and this is associated with increased endometrial growth in some women, which may be of concern.

[Late effects of sterilization in women]

Sterilization affects measurably the circulation and the functioning of the ovaries, but further studies are required to estimate the clinical meaning of the change.

Dimeric inhibin serum values as markers of ovarian activity in pill-free intervals

Levels of inhibin A and B as well as other hormones in serum samples obtained during the pill-free interval in women taking combined oral contraceptives (OC) were measured to asses the extent of ovarian activity during that period. Type of pill and day of pill-free interval were recorded during routine gynecologic check-ups, if patients were in the pill-free period and had taken their pills regularly in the previous cycle. In addition to inhibin A and B, serum levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), and progesterone were also quantified. Inhibin B levels rise significantly in parallel with rising levels of FSH, LH, and E2. Progesterone levels were completely suppressed and inhibin A levels rose slightly but insignificantly. Inhibins are sensitive biochemical markers of ovarian activity in pill-free intervals.

Case studies in contraception

Choosing the appropriate type of contraception should be decided by the healthcare professional and the patient. The author presents three unique and different cases, including insightful discussions, that should provide insight and possibly some creative solutions to some of today's contraceptive questions.

The effect of a desogestrel-containing oral contraceptive on glucose tolerance and leptin concentrations in hyperandrogenic women

Ovarian hyperandrogenism can be associated with insulin resistance, hyperinsulinemia, glucose intolerance, and obesity. High levels of the lipostatic hormone, leptin, have also been reported in this condition. The purpose of the present study was to examine the effect of an oral contraceptive (OC) of low androgenicity containing desogestrel on glucose tolerance in hyperandrogenic women and the impact of changes in androgenic/estrogenic status on leptin concentrations. Sixteen nondiabetic hyperandrogenic women, aged 29 +/- 1 yr with a body mass index (BMI) of 36.8 +/- 1.8 kg/m2, underwent an oral glucose tolerance test before and after 6 months of therapy with the OC. Free testosterone decreased and sex hormone-binding globulin increased after therapy (P < 0.001). Glucose tolerance deteriorated significantly, and two women developed diabetes. Body weight, BMI, and leptin did not change significantly. Leptin correlated with BMI before (r = 0.56; P = 0.02) and after (r = 0.51; P = 0.04) treatment, but not with glucose, insulin, total and free testosterone, or sex hormone-binding globulin before or after treatment. In conclusion, 1) glucose tolerance should be monitored in hyperandrogenic women using OC, even those of low androgenicity; and 2) changes in androgenic/estrogenic status had no effect on the leptin concentration, suggesting that its sexual dimorphism is not related to sex steroids.

Effect of once weekly administration of mifepristone on ovarian function in normal women

The effects of mifepristone on ovarian function during a once weekly oral administration regimen were studied in nine healthy women. Each received 25 mg mifepristone on cycle days 3, 10, 17, and 24. Ovulation, as documented by hormonal measurements and ultrasonography, was inhibited during treatment in five subjects, with a midcycle surge of luteinizing hormone and ovulation occurring 6-18 days after the last pill was administered in four of the five subjects. These five treatment cycles were prolonged 9-26 days. The other four subjects had normal cycles as judged by serum hormone levels, ultrasonography, and cycle length. All nine subjects had delayed endometrial growth as indicated by ultrasonography. There was a significant correlation between concentrations of serum mifepristone (10 h and 58 h) and alpha 1-acid glycoprotein, the protein to which mifepristone binds in circulation. Response to mifepristone did not depend on its circulating levels. We conclude that once weekly administration of 25 mg mifepristone can interfere with normal follicular development and function, but the inhibition of ovulation was inconsistent.

Ovarian volume in gynecologically healthy women using no contraception, or using IUD or oral contraception

OBJECTIVE

The aim of this study was to determine the ovarian volume by transvaginal ultrasonography in a gynecologically healthy population of women using no contraception, using intrauterine contraceptive device, or using oral contraceptive.

MATERIALS AND METHOD

The study had a cross-sectional design. The ovaries of 428 women aged 1445 who contacted the family planning clinic in the county of Funen were examined. Most of the statistical analyses were carried out using standard techniques. However polynominal regression analysis was used to model ovarian volumes as a function of the day of cycle.

RESULTS

No differences between the volumes of the right and the left ovary were found in any of the groups. Significant differences were found between the ovarian volumes of the three groups. The ovarian volumes were found to be largest in women using intrauterine contraceptive device, lesser in women using no contraception and smallest in women using oral contraception. A significant difference was found of the ovarian volumes throughout the menstrual cycle in women who were not using oral contraception. The ovarian volumes did not change throughout the menstrual cycle in women using oral contraception. In women not using oral contraception the largest ovary increased in volume from the start of the cycle to day 19, thereafter the volume declined. No evidence of any change of volume over the menstrual cycle was found in the smallest ovary and, for women using oral contraception, both ovaries. There was no correlation between age, height, weight, parity, and ovarian volume in any of the groups.

CONCLUSION

The ovarian volumes, in gynecologically healthy women using intrauterine contraceptive device, are larger than in women using no contraception. It appears that oral contraception reduces the volumes of both ovaries in all phases of the menstrual cycle to equal levels.

Modulation of ovarian function by an oral contraceptive containing 30 micrograms ethinyl estradiol in combination with 2.00 mg dienogest

Twenty-two healthy female volunteers with normal ovulatory cycles, aged between 20 and 34 years (27.3 +/- 4.1), were included in a single-center, noncomparative study to investigate the modulation of ovarian function by an oral contraceptive containing 30 micrograms ethinyl estradiol in combination with 2.00 mg dienogest. At baseline, during three treatment cycles and post-treatment, serum levels of luteinizing hormone, follicle-stimulating hormone, 17 beta-estradiol, and progesterone were assayed and ultrasonography was used to measure follicular size and the thickness of the endometrium. The primary efficacy variable was inhibition of ovulation as measured by ovarian activity grading. All volunteers ovulated during the pretreatment cycle. During treatment, none of the subjects had ovulatory cycles, although there was still some ovarian activity in several subjects. During the first treatment cycle, only 4% (1 subject) of cycles showed active follicle-like structures. The frequency of follicle-like structures increased to 33% and 35% during treatment cycles 2 and 3. The frequency of presumptive luteinized unruptured follicle-like structures was 5% (1 subject) and 15% (3 subjects) in treatment cycles 2 and 3. The serum hormone concentrations were effectively suppressed in comparison to baseline. The ovarian activity returned to baseline during the post-treatment period. One subject was excluded from further study because of a medical problem believed unrelated to use of the oral contraceptive. No serious adverse events were recorded during the course of the study. The results of the present investigation indicate that the modulatory effects on ovarian function of the monophasic oral-contraceptive containing 30 micrograms ethinyl estradiol combined with 2.00 mg dienogest lead to adequate suppression of ovarian activity and effective inhibition of ovulation.

A comparative randomized trial on the impact of two low-dose oral contraceptives on ovarian activity, cervical permeability, and endometrial receptivity

In a double-blind randomized study, the suppression of ovarian activity and anti-conceptive effects on the cervix and endometrium were assessed during administration of two low-dose monophasic oral contraceptives (20 micrograms ethinyl estradiol [EE], 500 micrograms norethisterone--Eve 20 [Grünenthal, Aachen, Germany]; 20 micrograms EE, 150 micrograms desogestrel --Lovelle [Organon, Munich, Germany]). One hundred eighteen healthy women (ages: 18-35 years) were studied in 10 investigation centers during medication with either Eve 20 (n = 59) or Lovelle (n = 59). During three treatment cycles, ovarian activity was evaluated by sonographic determination of follicle-like structures (FLS) and by simultaneous assessment of serum endocrine profiles (gonadotropins LH and FSH, ovarian steroids estradiol [E2] and progesterone [P]). While on either treatment, no ovarian activity (as judged by no FLS and/or reduced sex steroid levels) was found in 90.8% (Eve 20) and 97.2% (Lovelle) of all investigated cycles. Follicular activity or cyst formation were detected in 18 of 173 cycles (Eve 20) and in 5 of 175 cycles (Lovelle), respectively. Gonadotropin levels were suppressed (LH < 6 IU/L, FSH < 8 IU/L) in most treatment cycles (Eve 20 76.6% vs. Lovelle: 84.8%). Serum E2 concentrations exceeding 0.1 nmol/L indicated residual follicular activity in 19.3% (Eve 20) versus 12.2% (Lovelle) of all cycles. An estimated by serum P levels over 5 nmol/L, ovulation had presumably occurred in 4.1% (Eve 20) versus 2.9% (Lovelle) of treatment cycles. However, when the sonographical and endocrinological data were combined, no ovulation was documented in any pill cycle. The quality and quantity of the cervical mucus was found to be minimal in the majority of women. Moreover, the endometrial layer was determined to be low by ultrasound during most pill cycles, indicating equally strong suppressive effects on endometrial receptivity by the two contraceptives. These observations suggest that ovarian activity is suppressed in the majority of cycles during use of low-dose contraceptives. This effect may mainly be medicated by pronounced suppression of serum gonadotropin levels. Strong anti-conceptive effects of these formulations on both cervical permeability and endometrial receptivity are additional factors ensuring the contraceptive efficacy of these formulations.

Intracervical and fundal administration of levonorgestrel for contraception: endometrial thickness, patterns of bleeding, and persisting ovarian follicles

OBJECTIVE(S)

To study the prevalence of persisting ovarian follicles and to assess the endometrial changes and patterns of vaginal bleeding over 1 year of use of a 20 micrograms/24 h levonorgestrel-releasing intracervical contraceptive device.

DESIGN

Prospective, randomized study.

SETTING

Two family planning clinics in Helsinki, Finland.

PATIENT(S)

Women requesting intrauterine hormonal contraception.

INTERVENTION(S)

Insertion of a levonorgestrel-releasing intracervical contraceptive device into the cervical canal (group 1, n = 151) or fundally into the uterine cavity (group 2, n = 147) for contraception.

MAIN OUTCOME MEASURE(S)

Transvaginal ultrasonography of the ovaries and endometrium at insertion and 3, 6, and 12 months after insertion. Data on bleeding were collected using menstrual diary cards.

RESULTS

Persisting ovarian follicles were found in < 8% of women. In both groups, the amount of endometrial tissue decreased significantly in 3 months. The incidence of amenorrhea during the 1st year was higher in the fundal insertion group.

CONCLUSION(S)

The number of persisting follicles was low. Follicles resolved within 6 to 8 weeks. No association was found between persisting follicles and problems of bleeding. Compared with intracervical insertion, fundal insertion resulted in more uniform endometrial suppression and fewer days of bleeding and spotting.

Neuroendocrine mechanism of anovulation in users of contraceptive subdermal implant of nomegestrol acetate (Uniplant)

OBJECTIVE

To evaluate a nomegestrol acetate subdermal contraceptive implant's (Uniplant; Thermex, Monaco) effect on the hypothalamus-pituitary-ovarian axis.

DESIGN

A prospective clinical trial.

SETTING

San Borja-Arriarán Clinical Hospital, University of Chile, School of Medicine.

PATIENT(S)

Normally cycling healthy women.

INTERVENTION(S)

Insertion of Uniplant.

MAIN OUTCOME MEASURE(S)

Luteinizing hormone pulse and endocrine profiles were assessed before, 48 hours after insertion, and after prolonged use of the implant.

RESULT(S)

Anovulation was noted in 100% of users in the first month. Seventy percent of subjects demonstrated follicular development with the absence of ovulation and an endocrine profile similar to the follicular phase: (LH pulse/8 hours 6.85 +/- 0.67, LH amplitude 3.54 +/- 0.65 mIU/mL (conversion factor to SI unit, 1.00), and E2 193 +/- 29.4 pg/mL (conversion factor to SI unit, 3.67), whereas 30% demonstrated no follicular activity with an endocrine profile similar to the luteal phase: (LH pulse/8 hours; 3.66 +/- 0.66, LH amplitude 5.76 +/- 1.73 mIU/mL, and E2 67.5 +/- 4 pg/mL. Clinical characteristics, serum gonadotropin concentration, and LH pulse characteristics failed to predict which subjects would initiate or remain devoid of follicular activity.

CONCLUSION(S)

Uniplant results in anovulation via two mechanisms: hypothalamic suppression in subjects who lack follicular development, and likely suppression of the pituitary LH surge in subjects who initiate follicular activity.

Effect of low daily doses of mifepristone on ovarian function and endometrial development

The effects of low daily doses of the antiprogestin mifepristone (RU 486) on ovarian and endometrial function were studied. The study included one control cycle, three treatment cycles and one follow-up cycle. During the treatment cycles, either 0.1 (n = 5) or 0.5 (n = 5) mg of mifepristone was administered once daily. Urine samples were collected three times weekly during the control and treatment cycles and pregnanediol glucuronide and oestrone glucuronide and luteinizing hormone (LH) were quantified by radioimmunoassay. Blood samples for cortisol measurement were collected once weekly and for serum glycodelin at the onset of menstruation. An endometrial biopsy was obtained in the mid-luteal phase in the control cycle and in the first and third treatment cycles and analysed by morphometric and histochemical methods. Binding of Dolichus biflorus agglutinin (DBA) lectin was measured and expression of progesterone and oestrogen receptors and glycodelin were analysed immunohistochemically. All cycles studied were ovulatory with an LH peak and elevated pregnanediol glucuronide concentrations. Follicular development seemed normal as judged by ultrasound examination. The length of the menstrual cycle and the menstrual bleeding were not significantly altered. Following administration of 0.5 mg mifepristone/day, endometrial development appeared to be slightly retarded and glandular diameter was significantly reduced. Furthermore, significant decreases in DBA lectin binding and endometrial expression of glycodelin were observed. Daily doses of 0.1 mg did not have any significant effect on the endometrium. No differences in oestrogen or progesterone receptor immunoactivity between control and treatment cycles were seen. This study provides further evidence that endometrial function is sensitive even to doses of antiprogestin that are low enough not to disturb ovulation. It remains to be established whether these effects are sufficient to prevent implantation.

Tubal ligation and the risk of ovarian carcinoma

To assess the relationship of tubal ligation and risk of ovarian carcinoma, we conducted a case-control, retrospective analysis of 300 ovarian carcinoma cases and 606 nonmalignant disease controls, seen between 1982 and 1988 at Roswell Park Cancer Institute, Buffalo, New York. Women who had a tubal ligation had reduced risk for the development of ovarian cancer. This relative risk was 0.52, with a 95% confidence interval 0.31 to 0.85 (p = 0.0076). Controls were matched by age. Multivariate analysis adjusted for socioeconomic level, marital status, parity, age at first pregnancy, menarche age, menopause age, irregular menses, breast-feeding duration, body habitus, and oral contraceptive use. Suggested explanations for this observation are offered.

The pharmacodynamic effects of an oral contraceptive containing 3 mg micronized 17 beta-estradiol and 0.150 mg desogestrel for 21 days, followed by 0.030 mg desogestrel only for 7 days

During oral treatment with 3 mg micronized 17 beta-estradiol and 0.150 mg desogestrel for 21 days followed by 0.030 mg (A) desogestrel (15 women) or placebo (B) (14 women) for 7 days, ovarian function, bleeding pattern and estradiol levels were evaluated. The study was performed in a group-comparative, double-blind fashion. During a pre-treatment control cycle, using ultrasound scan, follicular diameter was measured on cycle days 10-16 and endometrial thickness on one of cycle days 22-26. Estradiol was measured at the time of ultrasound scan and progesterone three times in the luteal phase. During three treatment cycles, follicular diameter and endometrial thickness were monitored three times weekly and at the same time, estradiol and progesterone were measured. Treatment resulted in anovulation in all women. Maximum and mean estradiol levels were approximately 900 pmol/l and 550 pmol/l during treatment, respectively, and approximately 200 pmol/l during the estradiol-free weeks in both groups. Ten women showed ovarian activity (follicle size > or = 15 mm) during treatment, seven in group A and three in group B. Endometrial thickness decreased approximately 3 mm during treatment in both groups. The incidence of breakthrough bleeding and spotting was higher in group A when compared to group B. The study indicates that the combination of 3.0 mg micronized estradiol and 0.150 mg desogestrel is an effective and safe contraceptive, offering an acceptable cycle control. The addition of a low dose of desogestrel during the pill-free period did not further suppress ovarian activity nor improve the bleeding pattern. The results of this study should be interpreted with great care, since the number of women studied is relatively small.

Ultrasonographic and endocrine evaluation of ovarian function among Norplant implants users with regular menses

With the objective of evaluating the ovulatory function among long-term Norplant implants users with regular menstrual cycles, we undertook this prospective study including 11 Norplant implants users and 11 control women who were not using hormonal methods of fertility control. Exposed and unexposed women had had at least three regular menstrual cycles preceding enrollment. All women were followed during one menstrual cycle by serial vaginal ultrasound and estradiol (E2), progesterone (P), LH, and FSH measurements. Three Norplant implants users ovulated, three had luteinization of an unruptured follicle (LUF), three had persistent follicle growth up to a mean of 33 mm without rupture, and two had no follicular development beyond 16 mm. Ten of the controls had normal ovulation and one had LUF. Mean peak LH and FSH among Norplant implants users who ovulated were three- to four-fold lower than among controls. Although users of Norplant implants with regular cycles frequently have luteal activity, the results of this study suggest that elevation of P during the second half of the cycle does not necessarily indicate ovulation has occurred and may frequently be associated with the presence of luteinized unruptured follicle. When ovulation occurs, there are usually abnormal hormone levels (low LH/FSH peak, low progesterone) which may also contribute to the contraceptive effect of Norplant implants.

Ovarian activity during regular oral contraceptive use

The aim of this study was to assess whether during regular OC use ovarian activity might lead to ovulation, as assessed by ultrasound (US) evaluation of follicular growth and blood levels of 17-beta-estradiol and progesterone. A total of 51 healthy women with normal menstrual cycles (28 +/- 3 days) and no gynecological symptoms were recruited. A total of 22 patients were given a triphasic OC pill containing 35 mg ethinyl estradiol (EE) and 50 mg desogestrel (DSG) in the first seven tablets; 30 mg EE and 100 mg DSG in tablets 8 to 14, and 30 mg EE and 150 mg DSG in tablets 15 to 21; 29 patients received one of two OC pills, both containing 20 mg EE plus 150 mg DSG (15 patients) or 75 mg of gestodene (14 patients). A total of 86 cycles were monitored: 51 during the 3rd-4th cycle and 35 during the 6th-8th cycle of OC treatment. Follicular-like structures were observed in nine patients. The frequency of follicular-like structures was similar during the 3rd-4th cycle (9%) and during the 6th-8th cycle (11%). There was no relationship between follicular growth and blood levels of E2 and progesterone, which always appeared suppressed. In conclusion, the results of this study suggest that during OC use (even with low dose of ethinyl estradiol), a little ovarian activity may be present without ovulation.

Shorter pill-free interval in combined oral contraceptives decreases follicular development

The objective of the study was to determine the suppressive effect on ovarian activity of 20 micrograms ethinylestradiol plus 75 micrograms gestodene administered for 21 or 23 days. The study was designed as a double-blind, randomized, multicenter trial in 60 women. A pre-treatment cycle, three treatment cycles and a post-treatment period were monitored by ovarian ultrasound and by LH, FSH, 17 beta-estradiol and progesterone measurements every other day. No ovulation and no luteinized, unruptured follicle were observed. Suppression of ovarian activity was more pronounced by the 23-day regimen. 17 beta-Estradiol serum levels during the last six days of a cycle and during the first six days of the next cycle were significantly less (p < 0.05) in the 23-day regimen. The superiority of the 23-day regimen in comparison to the 21-day regimen with regard to the suppression of ovarian activity was shown in this study. The observed differences in the 17 beta-estradiol levels and follicular development between a 21-day and 23-day preparation combine to suggest that shortening the pill-free interval in combined oral contraceptives may increase the contraceptive safety margin in women on low-dose formulations.

Progesterone receptors: expression and regulation in the mammalian ovary

The authors have briefly discussed the molecular structure, regulation, and function of progesterone receptors in the mammalian ovary. Particularly important is the contrast in the regulatory mechanisms of PR induction in the ovary (gonadotropins/membrane receptor mediated) and other well-known progesterone target tissues, such as the uterus and mammary gland (estrogen/nuclear receptor mediated). Future research will focus on how the PR gene responds to these hormonal regulatory signals in this cell-specific manner. Equally important in this discussion has been the mounting evidence indicating that PRs are an essential component of the ovulatory process. The observation that PR-/- knockout mice are incapable of undergoing ovulation, even in response to gonadotropin challenge, further supports the previous physiological evidence indicating that PRs in preovulatory follicles are induced before, and are necessary for, ovulation. Further studies are required to determine the identity of PR-regulated target genes during the periovulatory period. Although our knowledge of PR structure, regulation, and function has increased dramatically during the past decade, many exciting questions remain related to the regulation and function(s) of PRs in the ovary and other tissues.

Comparison of the effects of ovarian cauterization and gonadotropin-releasing hormone agonist and oral contraceptive therapy combination on endocrine changes in women with polycystic ovary disease

OBJECTIVE

To study the effects of laparoscopic ovarian cauterization and combination of long-acting GnRH agonist (GnRH-a) and oral contraceptive (OC) therapy on endocrine changes in women with clomiphene citrate (CC)- resistant polycystic ovary disease (PCOD).

DESIGN

Prospective, randomized.

SETTING

University-based infertility clinic.

PATIENTS

Seventeen women with CC-resistant PCOD were included randomly in the study to either laparoscopic ovarian cautery or GnRH-a and OC therapy for 3 months.

MAIN OUTCOME MEASURES

Serum concentrations of LH, FSH, androstenedione (A), T, and sex hormone-binding globulin (SHBG) were determined before each therapeutic approach and during the follicular phase of first menstrual cycle after the cessation of each treatment.

RESULTS

The mean serum concentrations and the clinical profiles were similar in both groups. Both groups showed significant changes in LH, FSH, A, T, and SHBG compared with pretreatment levels. There were no significant differences in the final concentrations of LH, FSH, and A between the two study groups after each treatment, whereas T and SHBG levels were significantly different in the goserelin and OC group. The decrease in LH and increase in SHBG serum concentrations were greater in the goserelin and OC-treated women [-59% and + 5.9% versus - 70% and + 13.5%, respectively]. Although the SHBG concentration increased in both groups, the serum SHBG concentration of the goserelin and OC group was significantly higher than the other group.

CONCLUSION

Both therapeutic modalities revealed similar effects on the endocrine profiles in women with CC-resistant PCOD. Considering the invasiveness, cost, and potential complications of laparoscopic ovarian cauterization, noninvasive medical treatment with GnRH-a and OC combination may be more effective in restoring the optimal follicular environment in women with PCOD.

Effects of a single contraceptive Silastic implant containing nomegestrol acetate on ovarian function and cervical mucus production during 2 years

OBJECTIVE

To study the mechanism of action of Uniplant (South to South Corporation in Reproductive Health, Salvador, Brazil), a single Silastic capsule containing nomegestrol acetate (Lutenyl, Theramex, France) in women during 2 years.

DESIGN

Comparison between the hormonal levels, follicular development, cervical mucus (CM) production, and endometrial thickness in the menstrual cycle before implant insertion and at 1, 6, 12, 18, and 24 months after implant insertion.

PARTICIPANTS

A total of 15 women of reproductive age were enrolled for the 1st year of use. Twelve of these women continued for a 2nd year of Uniplant use.

MAIN OUTCOME MEASURES

Hormonal plasma levels were measured in control cycles and at 1, 6, 12, 18, and 24 months of Uniplant use. Cervical mucus, follicular development, and endometrial thickness also were evaluated.

RESULTS

In this study, Uniplant blocks ovulation in 86 percent of cycles studied. Disturbances in follicular growth were observed also. Cervical mucus was scanty and viscous in all women during this study. Endometrial thickness was <8 mm in all cycles studied.

CONCLUSION

This study shows that Uniplant is a long-acting contraceptive that probably acts at the hypothalamic-pituitary levels, on the ovary, on CM production, and on the endometrium. These properties suggest the use of Uniplant as a contraceptive agent, especially if one considers the lack of androgenic and metabolic effects and the maintenance of periodic bleeding similar to menstruation.

Contraception with anti-progesterone

Anti-progesterones have potential as contraceptives, acting either by the inhibition of ovulation or the inhibition of endometrial development. Clinical studies have shown that once-a-month treatment with Mifepristone in the early luteal phase is an effective contraceptive method, and that emergency post-coital contraception with Mifepristone is at least as effective as other methods currently used. Recent studies indicate that the endometrium is more susceptible to Mifepristone than are the hypothalamic and pituitary regions, and it may therefore be possible to develop a new contraceptive method based on low daily or once-weekly doses of Mifepristone that does not influence ovarian function.

Tubal sterilization and the risk of endometrial cancer

Several animal and human studies suggest that tubal occlusion may curtail ovarian function, altering the production and balance of endogenous estrogens and progesterone, 2 hormones closely related to endometrial carcinogenesis. Despite this, and the increasing world-wide popularity of this method of contraception, little is known about its relationship with the risk of developing endometrial cancer. To assess whether tubal sterilization influences a woman's risk of developing epithelial endometrial carcinoma, data from a large multicenter population-based case-control study of endometrial cancer were analyzed. Cases were 437 women aged 20 to 54 years with histologically confirmed epithelial endometrial cancer ascertained through 6 population-based cancer registries in the United States. Controls were 3200 women selected at random from the populations of the areas from which the cases were detected. As compared with women who had never had tubal sterilization, women who had had this surgery had a crude odds ratio of 0.58 [95% confidence interval (CI), 0.43-0.78]. However, after adjusting for the combined confounding effects of age and parity, the magnitude of the protective association decreased to 0.87 (95% CI, 0.63-1.20). The magnitude of the protective effect did not significantly change with years since surgery or age at surgery. Although a modest, non-significant protective effect is suggested, these findings indicate that tubal sterilization does not substantially alter the risk of developing epithelial endometrial cancer in women 20 to 54 years of age. If there is an increase in risk, these data indicate that it is unlikely to be any greater than 20%.

Ovarian activity suppression by two different low-dose triphasic oral contraceptives

In an open, randomized study in an outpatient clinic of a large teaching hospital, thirty-one female volunteers with regular cycles and established ovulation by ultrasonography were given one of two triphasic oral contraceptives containing ethinylestradiol combined with levonorgestrel or desogestrel during six cycles of treatment. The main outcome measures were transvaginal ultrasonography and serum E2 and P measurements in pill cycles 1, 3 and 6. No ovarian activity was found in 10 subjects. Among the remaining 21 women who showed ovarian activity, most follicle-like structures developed in the pill-free week and decreased in size or disappeared in the first pill week. One women taking triphasic desogestrel had evidence of a luteinized unruptured follicle and one women taking triphasic levonorgestrel had a possible ovulation. The latter women also showed symptoms of lower abdominal pain. A statistically significant difference in ovarian activity between the two oral contraceptives could not be established. The two triphasic oral contraceptives suppressed ovarian activity to the same degree. A trend was seen towards increasing ovarian activity with duration of use in both treatment groups.

Increased uterine and ovarian vascular resistance following Filshie clip sterilization: preliminary findings obtained with color Doppler ultrasonography

The effect of Filshie clip sterilization on uterine and ovarian circulation was studied with color Doppler ultrasonography in 16 women before and twice after the operation. As a whole, the vascular resistance was slightly raised in the largest uterine artery and in the fundal parts of the uterine arteries; likewise in the ovarian arteries 2 days after sterilization. The resistance in the uterine arteries approached the presterilization level at 3 months after the operation, although these changes were not statistically significant. Two women had pelvic pain in the first days after the procedure, and they were compared with the symptom-free patients. Two days after sterilization, the patients with pain had significantly higher vascular resistance in all parts of the uterine arteries as compared to the symptom-free patients. After 3 months the difference had decreased in the largest uterine arteries and in the middle parts of the uterine arteries, but in the fundal parts the resistance was still higher than before sterilization. Vascular resistance in the ovarian arteries was increased in both groups, although the elevation was more pronounced in patients with pain. These preliminary findings imply that sterilization may cause an increase in the local vascular resistance, which is measurable by color Doppler sonography.

Follicle stimulating hormone-granulosa cell axis involvement in the antifolliculotrophic effect of low dose mifepristone (RU486)

This study was designed to assess the involvement of follicle stimulating hormone (FSH)-granulosa and luteinizing hormone (LH)-theca axes in the antifolliculotrophic effect of mifepristone. Plasma gonadotrophins, including plasma LH bioactivity and pulsatility, oestradiol, testosterone and inhibin concentrations, and follicular growth were monitored in volunteer women treated with placebo or mifepristone in two consecutive cycles. Mifepristone was given either as a single dose of 5 mg (n = 7) when the leading follicle had reached a diameter between 12 and 14 mm, or as a multiple dose of 5 mg/day for 3 days, beginning when the leading follicle had reached a diameter between 14 and 16 mm (n = 5) or between 6 and 11 mm (n = 5). Following the single dose of mifepristone, follicular growth and the accompanying increase in plasma oestradiol were arrested at 12 and 36 h respectively without changes in gonadotrophin or testosterone serum concentrations. The 3 day regimen arrested follicular growth and oestradiol rise and decreased plasma inhibin concentrations when follicles were larger than 12 mm at the onset of treatment. These results indicate that the antifolliculotrophic action of mifepristone is associated with a selective compromise of the FSH-granulosa axis of dominant follicles that have passed a critical stage of growth.

Enlarged follicles in women using oral contraceptives

Ultrasound examination of the ovaries was performed in the first and/or second half of three consecutive cycles in 3 groups of women; Group T who had been using a levonorgestrel triphasic oral contraceptive for at least 6 months, Group P who had been using a progestogen-only pill for at least 6 months, and Group C, a control group. Any follicles greater than 10 mm in diameter and any cysts were measured. Fifty-three scans were performed in Group T, 45 in Group P and 31 in Group C. Only 4 follicles were detected in 17 women in Group T compared to 10 follicles in 15 women in Group P and 7 follicles in the women in Group C; all follicles were 25 mm or less in diameter except for 3 follicles in 2 women. The differences between the groups were not statistically significant. Four enlarged follicles were detected in 3 women during 53 scans in Group T, 15 in 8 women (45 scans) in Group P, and only 1 in 31 scans in Group C. Based upon the proportions of scans with enlarged follicles, the difference between Groups T and P was statistically significant, indicating that the incidence of enlarged follicles was lower in women using a combined oral contraceptive than in those using a progestogen-only pill. Furthermore, the study shows that any enlarged follicles which occurred were transient.

Ovarian function during low-dose oral contraceptive use

Lowering the total steroid dose in modern oral contraceptives (OCs) has been connected with a higher incidence of ovarian follicle and cyst formation. To investigate the presence of ovarian follicles and cysts by means of vaginal ultrasonography and serum hormone determinations during use of two low-dose OCs, 65 volunteers were randomized to receive either 20 micrograms ethinylestradiol (EE) + 150 micrograms desogestrel (group A) or 35 micrograms EE + 250 micrograms norgestimate (group B) for a 2-month study period. At baseline, 39% of women in group A and 31% in group B exhibited at least one follicle < 35 mm in diameter. By the end of the second treatment cycle, the frequency of these follicles had decreased to 14% in each group. Only one subject in the higher estrogen group developed an ovarian cyst > 35 mm. One subject in each group demonstrated hormone levels characteristic of ovulation; no pregnancy occurred in either group. The 20 micrograms EE preparation was not found to lead more often to ovarian follicles or cysts when compared with a 35 micrograms EE preparation, possibly because of the type and dose of the progestogen used.

Effect of levonorgestrel-releasing intrauterine device on hormonal profile and menstrual pattern after long-term use

In the present study 14 women after 6 years' use of levonorgestrel-releasing IUD were investigated for the changes of LH, progesterone (P), estradiol (E2), prolactin (PRL) and serum binding globulin (SHBG) in relation to the levonorgestrel levels throughout a segment of 26-40 days with the aim of comparing the hormonal profiles with those during the first year of use of Lng-IUD. Ultrasound scanning was used to follow the development of follicles along with the RIA measurement of hormones. The results of serum LH, P and E2 showed ovulation in 11 cases with either normal menstrual cycles (5 cases), prolonged or irregular cycles (4 cases) or with amenorrhea for 2-3 years (2 cases). One case showed insufficiency of luteal function and 2 cases showed anovulation but with follicular hyperactivity. Higher percentages of ovulatory cycles (78.5%) were found after 6 years of use. No case of complete suppression of ovulation was found. Anovulatory cycles only constituted 14.3%. Clinically, the development of follicles followed by ultrasound scanning further confirmed the hormonal findings. The persistent enlargement of follicles coincided with high levels of E2. After 6 years of use, the serum levels of levonorgestrel were still maintained at mean levels of 314.26 pmol/L and 470.63 pmol/L in the ovulatory and anovulatory groups, respectively. It is concluded that over two-thirds of the cases have ovulatory cycles after long-term use of Lng-IUD; the contraceptive effect is mainly due to its local action on the endometrium, with much less effect on the ovarian function.

Ethinylestradiol from contraceptive formulations and the ovarian response: an estrogen dose-dependency on natural estradiol concentrations

To evaluate the competitive molecular phenomenon of ethinylestradiol from contraceptive formulations vs. endogenous 17 beta-estradiol in the intra- and extracellular compartments, a descriptive analysis was performed. Plasma and endometrial samples were simultaneously obtained on different days of the pseudomenstrual cycle from oral contraceptive users taking ethinylestradiol/norgestrel (30 micrograms/500 micrograms; n = 13) and ethinylestradiol/norethindrone (50 micrograms/1.0 mg; n = 14) in order to quantify the 17 beta-estradiol concentrations. From our results the chronic administration of these combined oral contraceptives demonstrated that the lower component ethinyl-estradiol (30 micrograms) does not compete substantially at the circulating level, permitting concentrations of natural estradiol such as those seen during follicular maturation in the ovulatory cycle. However, in the endometrium such a cyclicity is not seen, thus the possibility of a local infertility effect should be reconsidered to enable the investigation of a different approach in future methods of contraception.