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Yokota N, Inoue R, Kawamura K, Egashira K, Kuma H, Kato K. The effects of dienogest and combined oral contraceptives on protein S-specific activity in endometriosis patients. Eur J Obstet Gynecol Reprod Biol 2024; 295:67-74. [PMID: 38340593 DOI: 10.1016/j.ejogrb.2024.01.028] [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: 08/26/2023] [Revised: 01/15/2024] [Accepted: 01/21/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVE One serious side effect of combined oral contraceptives (COCs) is venous thromboembolism. Reduced activity in activated protein C-related coagulation pathways is attributable to low protein S activity in one-third of Japanese patients with deep vein thrombosis. Herer, we quantified the behavior of protein S-specific activity in response to dienogest (DNG) and COCs using the protein S-specific activity assay system to explore its potential utility as a thrombosis marker. STUDY DESIGN This was a prospective cohort study. Female patients aged 20 - 49 years who were starting drug treatment for endometriosis using DNG or COCs were enrolled. Blood samples were taken before treatment and at the first, third, and sixth months of treatment. To analyze the primary endpoints, changes in total protein S antigen levels, total protein S activity, and protein S-specific activity from baseline to each time point were estimated using a linear mixed-effects model. All statistical analyses were performed in the SAS software version 9.4 (SAS Institute, Cary, NC). A two-sided P < 0.05 was considered statistically significant. RESULTS 64 patients took DNG and 34 patients took COCs. Protein S-specific activity did not change significantly from baseline in the six months after treatment started in either group. In the DNG group, total protein S activity and total protein S antigen levels increased slightly from baseline levels after the treatment. The means for total protein S activity and total protein S antigen levels in the COC group remained within reference limits, but they both decreased markedly in the first month and stayed low. Protein S-specific activity in four women remaind below the reference limit throughout the whole study period, suggesting they may have potential protein S deficiencies. CONCLUSION The effects of DNG on protein S were negligible, though both total protein S activity and antigen levels decreased soon after COC treatment began and remained low. As there was no VTE event during the study, further studies with larger numbers of patients will be needed to confirm that protein S-specific activity can be a surrogate maker of VTE risk.
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Affiliation(s)
- Natsuko Yokota
- Department of Obstetrics and Gynecology, School of Medical Sciences, Kyushu University. 3-1-1 Maidashi, Higashi-ku, Fukuoka city, Fukuoka, Japan.
| | - Reiko Inoue
- Department of Obstetrics and Gynecology, School of Medical Sciences, Kyushu University. 3-1-1 Maidashi, Higashi-ku, Fukuoka city, Fukuoka, Japan.
| | - Keiko Kawamura
- Department of Obstetrics and Gynecology, School of Medical Sciences, Kyushu University. 3-1-1 Maidashi, Higashi-ku, Fukuoka city, Fukuoka, Japan.
| | - Katsuko Egashira
- Department of Obstetrics and Gynecology, School of Medical Sciences, Kyushu University. 3-1-1 Maidashi, Higashi-ku, Fukuoka city, Fukuoka, Japan.
| | - Hiroyuki Kuma
- Faculty of Pharmaceutical Sciences, Nagasaki International University. 2825-7 Hausutenbosu-cho, Sasebo-shi, Nagasaki, Japan.
| | - Kiyoko Kato
- Department of Obstetrics and Gynecology, School of Medical Sciences, Kyushu University. 3-1-1 Maidashi, Higashi-ku, Fukuoka city, Fukuoka, Japan.
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Chéa M, Bourguignon C, Bouvier S, Nouvellon E, Laurent J, Perez-Martin A, Mousty E, Ripart S, Nikolaeva MG, Khizroeva J, Bitsadze V, Makatsariya A, Gris JC. Intimate partner violence as a risk factor for venous thromboembolism in women on combined oral contraceptives: An international matched case-control study. Eur J Intern Med 2024; 122:47-53. [PMID: 38135584 DOI: 10.1016/j.ejim.2023.12.016] [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: 10/11/2023] [Revised: 12/05/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Intimate partner violence (IPV) targeting women is probably underestimated during a woman's lifetime. Venous thromboembolism (VTE) is a multifactorial disease associated with haemostasis-activating conditions. Minor injuries can trigger VTE. OBJECTIVES We aimed to look for an association between VTE and IPV in women taking combined oral contraceptives (COCs) METHODS: We performed a multicentric, international, matched case-control study. Patients were women with a first VTE associated with COC intake. Controls were women taking COCs undergoing regular gynaecological check-ups. Patients and Controls were matched for country, age, length of COC intake and type (997 pairs). IPV was evaluated using the WAST self-administrated questionnaire. RESULTS IPV, defined as a WAST score value at least 5, was diagnosed in 33 Controls (3.3 %) and 109 patients (10.9 %), conditional odds ratio (OR): 3.586, 95 % confidence interval (2.404-5.549), p < 0.0001. After multivariate analysis, the adjusted OR was 3.720 (2.438-5.677), p < 0.0001. Sensitivity analysis using increasing WAST score thresholds confirmed the association. CONCLUSIONS A first VTE in women taking COCs is associated with IPV. This association can have strong human consequences but also raises significant medical issues, for instance on the haemorrhagic risk of anticoagulant treatments in abused women. Pathophysiological studies are warranted.
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Affiliation(s)
- Mathias Chéa
- Department of Haematology, CHU Nîmes, Univ Montpellier, Nîmes, France
| | - Chloé Bourguignon
- Department of Haematology, CHU Nîmes, Univ Montpellier, Nîmes, France; UMR UA11 INSERM IDESP - Montpellier University, France
| | - Sylvie Bouvier
- Department of Haematology, CHU Nîmes, Univ Montpellier, Nîmes, France; UMR UA11 INSERM IDESP - Montpellier University, France; Faculty of Pharmaceutical and Biological Sciences, Montpellier University, France
| | - Eva Nouvellon
- Department of Haematology, CHU Nîmes, Univ Montpellier, Nîmes, France; UMR UA11 INSERM IDESP - Montpellier University, France
| | - Jeremy Laurent
- Department of Haematology, CHU Nîmes, Univ Montpellier, Nîmes, France; Department of Vascular Medicine, University Hospital, Nîmes, France
| | - Antonia Perez-Martin
- UMR UA11 INSERM IDESP - Montpellier University, France; Department of Vascular Medicine, University Hospital, Nîmes, France
| | - Eve Mousty
- Department of Gynaecology and Obstetrics, CHU Nîmes, Univ Montpellier, Nîmes, France
| | - Sylvie Ripart
- Department of Gynaecology and Obstetrics, CHU Nîmes, Univ Montpellier, Nîmes, France
| | | | - Jamilya Khizroeva
- Department of Obstetrics, Gynaecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Victoria Bitsadze
- Department of Obstetrics, Gynaecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Alexander Makatsariya
- Department of Obstetrics, Gynaecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Jean-Christophe Gris
- Department of Haematology, CHU Nîmes, Univ Montpellier, Nîmes, France; UMR UA11 INSERM IDESP - Montpellier University, France; Faculty of Pharmaceutical and Biological Sciences, Montpellier University, France; Department of Obstetrics, Gynaecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russia; FCRIN_INNOVTE network, France.
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Coelingh Bennink HJT, van Gennip FAM, Gerrits MGF, Egberts JFM, Gemzell-Danielsson K, Kopp-Kallner H. Health benefits of combined oral contraceptives - a narrative review. EUR J CONTRACEP REPR 2024; 29:40-52. [PMID: 38426312 DOI: 10.1080/13625187.2024.2317295] [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: 08/18/2023] [Accepted: 02/06/2024] [Indexed: 03/02/2024]
Abstract
PURPOSE This review presents an update of the non-contraceptive health benefits of the combined oral contraceptive pill. METHODS We conducted a literature search for (review) articles that discussed the health benefits of combined oral contraceptives (COCs), in the period from 1980 to 2023. RESULTS We identified 21 subjective and/or objective health benefits of COCs related to (i) the reproductive tract, (ii) non-gynaecological benign disorders and (iii) malignancies. Reproductive tract benefits are related to menstrual bleeding(including anaemia and toxic shock syndrome), dysmenorrhoea, migraine, premenstrual syndrome (PMS), ovarian cysts, Polycystic Ovary Syndrome (PCOS), androgen related symptoms, ectopic pregnancy, hypoestrogenism, endometriosis and adenomyosis, uterine fibroids and pelvic inflammatory disease (PID). Non-gynaecological benefits are related to benign breast disease, osteoporosis, rheumatoid arthritis, multiple sclerosis, asthma and porphyria. Health benefits of COCs related to cancer are lower risks of endometrial cancer, ovarian cancer and colorectal cancer. CONCLUSIONS The use of combined oral contraceptives is accompanied with a range of health benefits, to be balanced against its side-effects and risks. Several health benefits of COCs are a reason for non-contraceptive COC prescription.
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Affiliation(s)
| | | | | | | | | | - Helena Kopp-Kallner
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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Bauerfeind A, von Stockum S, Boehnke T, Heinemann K. Venous Thromboembolic Risk of Estradiol Valerate-Dienogest Compared with Ethinyl Estradiol-Levonorgestrel Combined Oral Contraceptives. Obstet Gynecol 2024; 143:431-434. [PMID: 38227942 DOI: 10.1097/aog.0000000000005509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 12/08/2023] [Indexed: 01/18/2024]
Abstract
This pooled analysis compared the risk of venous thromboembolism (VTE) associated with combined oral contraceptives (COCs) containing estradiol (E2) valerate-dienogest with those containing ethinyl E2-levonorgestrel. Data were retrieved from two large, prospective, observational cohort studies. Propensity score subclassification was applied to balance baseline parameters between the COC user cohorts. Crude and adjusted hazard ratios (HRs) were calculated based on the extended Cox model. The pooled data set included 11,616 E2 valerate-dienogest users and 18,681 ethinyl E2-levonorgestrel users, contributing 17,932 and 29,140 women-years of observation, respectively. A significantly decreased VTE risk in E2 valerate-dienogest COCs compared with ethinyl E2-levonorgestrel COCs was observed (propensity score-stratified HR 0.46, 95% CI, 0.22-0.98). This pooled analysis expands data from a previous postauthorization safety study and provides valuable real-world safety information on the relative safety of current COCs.
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Affiliation(s)
- Anja Bauerfeind
- Berlin Center for Epidemiology and Health Research (ZEG), Berlin, Germany
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Fabunmi OA, Dludla PV, Nkambule BB. High-fat diet promotes coagulation and endothelial activation in Sprague Dawley rats: Short-term effects of combined oral contraceptives. Clin Investig Arterioscler 2024; 36:60-70. [PMID: 37949735 DOI: 10.1016/j.arteri.2023.10.001] [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: 08/14/2023] [Revised: 09/21/2023] [Accepted: 10/09/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Combined oral contraceptives (COCs), use in individuals are associated with increased risk of thrombotic events. This highlights the significance of assessing the impact of COC on promoting coagulation and endothelial activation in high-fat diet (HFD)-fed Sprague Dawley rats. METHODS Twenty (20) five-weeks-old female Sprague Dawley rats weighing between 150 and 200g were subjected to both LFD and HFD-feeding for 8-weeks to determine its influence on basic metabolic status, hemostatic profile, hemodynamic parameters (blood pressure and heart rate), as well as selected biomarkers of coagulation (tissue factor and D-dimer) and endothelial activation (Von Willebrand factor and nitric oxide). Thereafter HFD-fed animals were treated with receive high dose combined oral contraceptive (HCOC) and low dose combine oral contraceptive (LCOC) for 6 weeks. RESULTS Our results showed that beyond weight gain, HFD-feeding was associated with hyperglycemia, increased mean arterial pressure, and reduced nitric oxide levels when compared with LFD group (p<0.05). Interestingly, treatment with high dose of COC for 6-weeks did not significantly alter atherothrombotic markers (p>0.05). However, this study is not without limitation as regulation of these markers remains to be confirmed within the cardiac tissues or endothelial cells of these animals. CONCLUSION HFD-feeding orchestrate the concomitant release of pro-coagulants and endothelial activation markers in rats leading to haemostatic imbalance and endothelial dysfunction. Short-term treatment with COC shows no detrimental effects in these HFD-fed rats. Although in terms of clinical relevance, our findings depict the notion that the risk of CVD in association with COC may depend on the dosage and duration of use among other factors especially in certain conditions. However, additional studies are required to confirm these findings, especially long-term effects of this treatment within the cardiac tissues or endothelial cells of these animals in certain conditions relating to postmenopausal state.
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Affiliation(s)
- Oyesanmi A Fabunmi
- School of Laboratory Medicine and Medical Sciences (SLMMS), College of Health Sciences, University of KwaZulu-Natal, Durban 4000, South Africa; Department of Physiology, College of Medicine, Ekiti State University, Ado-Ekiti 5363, Nigeria
| | - Phiwayinkosi V Dludla
- Cochrane South Africa, South African Medical Research Council, Tygerberg 7505, South Africa; Department of Biochemistry and Microbiology, University of Zululand, KwaDlangezwa 3880, South Africa
| | - Bongani B Nkambule
- School of Laboratory Medicine and Medical Sciences (SLMMS), College of Health Sciences, University of KwaZulu-Natal, Durban 4000, South Africa.
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van der Arend BWH, van Casteren DS, Verhagen IE, MaassenVanDenBrink A, Terwindt GM. Continuous combined oral contraceptive use versus vitamin E in the treatment of menstrual migraine: rationale and protocol of a randomized controlled trial (WHAT!). Trials 2024; 25:123. [PMID: 38360739 PMCID: PMC10870678 DOI: 10.1186/s13063-024-07955-8] [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: 10/19/2023] [Accepted: 01/29/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Currently, there is no evidence-based hormonal treatment for migraine in women. Several small studies suggest a beneficial effect of combined oral contraceptives, but no large randomized controlled trial has been performed. As proof of efficacy is lacking and usage may be accompanied by potentially severe side effects, there is a great need for clarity on this topic. METHODS Women with menstrual migraine (n = 180) are randomly assigned (1:1) to ethinylestradiol/levonorgestrel 30/150 μg or vitamin E 400 IU. Participants start with a baseline period of 4 weeks, which is followed by a 12-week treatment period. During the study period, a E-headache diary will be used, which is time-locked and includes an automated algorithm differentiating headache and migraine days. RESULTS The primary outcome will be change in monthly migraine days (MMD) from baseline (weeks - 4 to 0) to the last 4 weeks of treatment (weeks 9 to 12). Secondary outcomes will be change in monthly headache days (MHD) and 50% responder rates of MMD and MHD. CONCLUSIONS The WHAT! trial aims to investigate effectivity and safety of continuous combined oral contraceptive treatment for menstrual migraine. Immediate implementation of results in clinical practice is possible. TRIAL REGISTRATION Clinical trials.gov NCT04007874 . Registered 28 June 2019.
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Affiliation(s)
- Britt W H van der Arend
- Department of Neurology, Leiden University Medical Center, PO Box 9600, Leiden, 2300 RC, The Netherlands
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Daphne S van Casteren
- Department of Neurology, Leiden University Medical Center, PO Box 9600, Leiden, 2300 RC, The Netherlands
| | - Iris E Verhagen
- Department of Neurology, Leiden University Medical Center, PO Box 9600, Leiden, 2300 RC, The Netherlands
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Antoinette MaassenVanDenBrink
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Gisela M Terwindt
- Department of Neurology, Leiden University Medical Center, PO Box 9600, Leiden, 2300 RC, The Netherlands.
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Fruzzetti F, Cagnacci A, Boolell M, Di Carlo C, Bruni V. Is the multinational, surveillance PRO-E2 study informative for all countries? The Italian data on VTE and contraceptive effectiveness. EUR J CONTRACEP REPR 2024; 29:1-7. [PMID: 38085301 DOI: 10.1080/13625187.2023.2284085] [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: 08/01/2023] [Accepted: 11/11/2023] [Indexed: 02/02/2024]
Abstract
PURPOSE To evaluate whether the thromboembolic risk and contraceptive effectiveness of NOMAC-E2 observed in the PRO-E2 study can be extended to each participating country, as lifestyle, cardiovascular risk factors and prescribing habits may differ geographically. This analysis was performed on the PRO-E2 Italian subpopulation, where smoking habit and women over 35 years were more prevalent compared with the overall study population. MATERIALS AND METHODS Data from NOMAC-E2 or levonorgestrel-containing COCs (COCLNG) new users were descriptively analysed. Incidence rates of thrombosis (events/10,000 women-years [WY]) and the Pearl Index (pregnancies/100 WY) were calculated. RESULTS Overall, 11,179 NOMAC-E2 and 8,504 COCLNG users were followed up to 2 years (34,869 WY). The NOMAC-E2 cohort included more women over 35 vs. COCLNG (37.7% vs. 31.8%; p = 0.001). A comparable low risk of combined deep venous thrombosis of lower extremities (DVT) and pulmonary embolism (PE) was observed in NOMAC-E2 (1.7/10,000 WY; 95% CI: 0.21-6.2) and COCLNG users (6.6/10,000 WY; 95% CI: 2.4-14.4). Similar results were obtained by considering all thromboembolic events (VTE). Unintended pregnancies did not differ between NOMAC-E2 (0.12/100 WY; 95% CI: 0.06-0.21) and COCLNG (0.15/100 WY; 95% CI: 0.08-0.26) cohorts. CONCLUSION Despite the higher age and tobacco use, findings from the Italian subpopulation were broadly consistent with overall PRO-E2 results, confirming a similar low thromboembolic risk and high contraceptive effectiveness of NOMAC-E2 and COCLNG. SHORT CONDENSATION This subgroup analysis of the PRO-E2 study provides comprehensive epidemiological data on the use of combined oral contraceptives in a large Italian cohort, with a higher prevalence of women over 35 years and smokers. The study confirms the low thromboembolic risk and high contraceptive effectiveness of NOMAC-E2 pill.
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Affiliation(s)
- Franca Fruzzetti
- Obstetrics and Gynecology, San Rossore Clinical Center, Pisa, Italy
| | - Angelo Cagnacci
- Obstetrics and Gynaecology Clinic, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Paediatric Sciences, IRCCS-Policlinic Hospital San Martino, University of Genoa, Genoa, Italy
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Stanczyk FZ, Winer SA, Foidart JM, Archer DF. Comparison of estrogenic components used for hormonal contraception. Contraception 2024; 130:110310. [PMID: 37863464 DOI: 10.1016/j.contraception.2023.110310] [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: 04/21/2023] [Revised: 10/12/2023] [Accepted: 10/13/2023] [Indexed: 10/22/2023]
Abstract
Attempts have been made over the years to replace ethinyl estradiol (EE) in combined oral contraceptives (COCs) with the less potent natural estrogen estradiol (E2), or its prodrug, E2 valerate (E2V), to improve their safety and tolerability. Recently, a COC incorporating a novel weak natural estrogen, estetrol (E4), combined with drospirenone, has become available. We present a comparative analysis of the three prevailing estrogens used in COCs, focusing on their structure-function relationships, receptor-binding affinity, potency, metabolism, pharmacokinetic parameters, and pharmacodynamics. The binding affinity of EE to estrogen receptor (ER)α is twice that of E2, whereas its affinity for ERβ is about one-half that of E2. E4 has a lower binding affinity for the ERs than E2. The high potency of EE is notable in its dramatic increase in estrogen-sensitive hepatic globulins and coagulation factors. EE and E2 undergo extensive and comparable metabolism, while E4 produces only a very limited number of metabolites. E4 has the highest bioavailability among the three estrogens, with E2 having <5%. Studies demonstrate consistent ovulation inhibition, although a higher dose of E4 (15 mg) in COCs is required to achieve follicular suppression compared to E2 (1-3 mg) and EE (0.01-0.035 mg). E2 and E4 in COCs may be less stimulatory of coagulant proteins than EE. Studies with E2/dienogest suggest a comparable risk of venous thromboembolism to EE/levonorgestrel, while data assessing risk with an E4-based COC are insufficient. Nevertheless, the E4-based formulation shows promise as a potential alternative to EE and E2 due to its lower potency and possibly fewer side effects.
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Affiliation(s)
- Frank Z Stanczyk
- Department of Obstetrics and Gynecology, University of Southern California, Keck School of Medicine, Los Angeles, CA, United States.
| | - Sharon A Winer
- Department of Obstetrics and Gynecology, University of Southern California, Keck School of Medicine, Los Angeles, CA, United States
| | - Jean-Michel Foidart
- Department of Obstetrics and Gynecology, University of Liege, Liege, Belgium
| | - David F Archer
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, United States
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Hugon-Rodin J, Fontana P, Poncet A, Streuli I, Casini A, Blondon M. Longitudinal profile of estrogen-related thrombotic biomarkers after cessation of combined hormonal contraceptives. Blood 2024; 143:70-78. [PMID: 37939264 DOI: 10.1182/blood.2023021717] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/28/2023] [Accepted: 09/13/2023] [Indexed: 11/10/2023] Open
Abstract
ABSTRACT The persistence of risk of venous thromboembolism (VTE) due to combined hormonal contraceptives (CHCs), after their cessation, is unknown but important to guide clinical practice. The objective of this prospective cohort study was to define the time until normalization of estrogen-related thrombotic biomarkers after CHC cessation. We enrolled women aged 18 to 50 years who had decided to stop their CHC, excluding those with a personal history of VTE, anticoagulation, or pregnancy. The study started before cessation of CHC, with 6 visits afterwards (at 1, 2, 4, 6, and 12 weeks after cessation). Primary outcomes were normalized sensitivity ratios to activated protein C (nAPCsr) and to thrombomodulin (nTMsr), with sex hormone-binding globulin (SHBG) as a secondary end point. We also included control women without CHC. Among 66 CHC users, from baseline until 12 weeks, average levels of nAPCsr, nTMsr, and SHBG decreased from 4.11 (standard deviation [SD], 2.06), 2.53 (SD, 1.03), and 167 nmol/L (SD, 103) to 1.27 (SD, 0.82), 1.11 (SD, 0.58), and 55.4 nmol/L (SD, 26.7), respectively. On a relative scale, 85.8%, 81.3%, and 76.2% of the decrease from baseline until 12 weeks was achieved at 2 weeks and 86.7%, 85.5%, and 87.8% at 4 weeks after CHC cessation, respectively. Levels were not meaningfully modified throughout the study period among 28 control women. In conclusion, CHC cessation is followed by a rapid decrease in estrogen-related thrombotic biomarkers. Two to 4 weeks of cessation before planned major surgery or withdrawal of anticoagulants in patients with VTE appears sufficient for the majority of women. The trial is registered at www.clinicaltrials.gov as #NCT03949985.
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Affiliation(s)
- Justine Hugon-Rodin
- Division of Gynecology, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
- Gynecology Department, Gynecological Endocrinology Unit, Hospital Saint Joseph, INSERM Unité Mixte de Recherche 1153, Équipe de Recherche en Épidémiologie Obstétricale Périnatale et Pédiatrique, Paris, France
| | - Pierre Fontana
- Division of Angiology and Hemostasis, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Antoine Poncet
- Center for Clinical Research, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Isabelle Streuli
- Division of Gynecology, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Alessandro Casini
- Division of Angiology and Hemostasis, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Marc Blondon
- Division of Angiology and Hemostasis, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
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Guida M, Quercitelli L, De Franciscis P, Ferrara C, Marietta M, Iaccheri M, Facchinetti F, Capasso F, Grandi G. A new progestin-only pill (POP): the impact of drospirenone-only pill 4 mg 24 + 4 on coagulation markers and bleeding patterns. EUR J CONTRACEP REPR 2023; 28:308-312. [PMID: 37962511 DOI: 10.1080/13625187.2023.2276668] [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: 07/12/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023]
Abstract
PURPOSE Progestin-only pills (POPs), compared to combined, are not associated with an increased risk of venous thromboembolism, but are associated with a poor cycle control. The aim of this study was to evaluate the impact of a new POP [4 mg drospirenone (DRSP) for 24 days with a 4-day hormone-free interval] on some coagulation markers (both procoagulant and fibrinolytic) and to describe its impact on bleeding patterns. MATERIALS AND METHODS This is a prospective trial, based on serum evaluation of following coagulation markers and tests: Factor (F) X, F VIII, F V, INR, aPTT, Protein S and antithrombin III. A 'bleeding diary' was used to categorise women as having (1) unscheduled bleeding, (2) scheduled bleeding and (3) amenorrhoea. Thirty patients were followed for six 28-day intake cycles, with a follow-up at the end of the 3rd and 6th cycles. RESULTS There was a significant decrease of F X (p = 0.03) (-5.7% at cycle 6). No significant changes have been observed for F VII, F V and INR. A significant increase in aPTT (p = 0.01 at 3 cycles), Protein S (p = 0.0006 at 3 cycles) and antithrombin III (p < 0.0001 at 3 cycles) was recorded. This non-deteriorating coagulation impact was associated with a significant and progressive reduction of days of scheduled and unscheduled bleeding in users between cycles 4 and 6 (from 1.3 ± 0.2 days at cycle 4 to 0.8 ± 0.1 days at cycle 6 and from 2.6 ± 0.4 days at cycle 4 to 0.6 ± 0.2 days at cycle 6, respectively, p < 0.0001). CONCLUSIONS DRSP 24 + 4 use was associated with a non-deteriorating effect on coagulation markers and a significant progressive reduction of days of scheduled and unscheduled bleeding.
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Affiliation(s)
- Maurizio Guida
- Obstetrics and Gynecology, University Federico II, Naples, Italy
| | | | - Pasquale De Franciscis
- Department of Obstetrics and Gynecology, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Cinzia Ferrara
- Obstetrics and Gynecology, University Federico II, Naples, Italy
| | - Marco Marietta
- Obstetrics and Gynecology, Obstetrics and Gynecology Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Mattia Iaccheri
- Obstetrics and Gynecology, Obstetrics and Gynecology Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabio Facchinetti
- Obstetrics and Gynecology, Obstetrics and Gynecology Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Filomena Capasso
- Laboratory of Hemostasis and Thrombosis, AOU Federico II, Naples, Italy
| | - Giovanni Grandi
- Obstetrics and Gynecology, Obstetrics and Gynecology Unit, University of Modena and Reggio Emilia, Modena, Italy
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Creinin MD, Angulo A, Colli E, Archer DF. The efficacy, safety, and tolerability of an estrogen-free oral contraceptive drospirenone 4 mg (24/4-day regimen) in obese users. Contraception 2023; 128:110136. [PMID: 37544572 DOI: 10.1016/j.contraception.2023.110136] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/25/2023] [Accepted: 08/02/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVES This study aimed to compare contraceptive efficacy and safety of drospirenone 4 mg in a 24/4-day regimen in nonobese and obese users and describe pharmacokinetics according to bodyweight. STUDY DESIGN We analyzed data from three drospirenone 4 mg trials (2 European and 1 United States) to report outcomes in nonobese (body mass index <30 kg/m2) and obese (body mass index ≥30 kg/m2) users. We used data from the US trial to calculate the Pearl Index (pregnancies per 100 woman-years) in nonbreastfeeding participants aged ≤35 years at enrollment for confirmed pregnancies. We assessed safety outcomes from all trials based on reported treatment-emergent adverse events. We evaluated pharmacokinetics by bodyweight in the US trial. RESULTS The three trials combined comprised 2152 nonobese and 425 obese participants, including 590 nonobese and 325 obese participants in the US trial. Eight nonobese and four obese participants had confirmed pregnancies in the US trial, resulting in Pearl Indices of 3.0 (95% CI: 1.3-5.8) and 2.9 (95% CI: 0.8-7.3), respectively. Two-hundred forty-four (11.3%) nonobese and 39 (9.2%) obese participants discontinued due to a treatment-emergent adverse event. The pharmacokinetic analysis included 814 participants with a median weight of 73 (interquartile range 61-89) kg and median plasma drospirenone exposure (AUC0-24ss) of 661.3 (interquartile range 522-828) ng∙h/mL. Changing bodyweight from the median to the fifth percentile (51 kg) or 95th percentile (118 kg) changed drospirenone exposure (AUC0-24,ss) by 22.2% and -23.6%, respectively. CONCLUSIONS Drospirenone 4 mg demonstrated similar contraceptive efficacy for both nonobese and obese users despite a difference in exposure based on bodyweight. IMPLICATIONS Our limited comparison between obese and nonobese users of drospirenone-only oral contraception demonstrated no evidence that efficacy or discontinuation for adverse events differs between groups. Serum drospirenone levels vary by bodyweight and may correlate with bleeding outcomes.
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Affiliation(s)
- Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, United States
| | | | | | - David F Archer
- Clinical Research Center, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, United States
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Palacios S, Ayala G, González G, Badilla-Apuy CL, Marchena J, Martínez K, Mostajo D, Vernaza MS, Paradas A, Hernández L, Vásquez-Awad D, Celis-González C, de Melo NR. Combined oral contraceptives: update recommendations of the Latin American contraceptive association. Gynecol Endocrinol 2023; 39:2271072. [PMID: 37857350 DOI: 10.1080/09513590.2023.2271072] [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: 07/26/2023] [Accepted: 10/10/2023] [Indexed: 10/21/2023] Open
Abstract
Background: In recent years, new combined oral contraceptives (COCs) have become available, representing an advance in terms of individualization and compliance by users.Objective: To provide recommendations regarding COCs: formulations, use, efficacy, benefits and safety.Method: For these recommendations, we have used the modified Delphi methodology and carried out a systematic review of studies found in the literature and reviews performed in humans, published in English and Spanish in Pubmed, Medline and advanced medicine and computer networks until the year 2021, using the combination of terms: 'oral contraceptives', 'estroprogestins' and 'combined oral contraceptives'.Results: Regarding the estrogen component, initially switching from mestranol (the pro-drug of ethinylestradiol) to ethinylestradiol (EE) and then reducing the EE dose helped reduce side effects and associated adverse events. Natural estradiol and estradiol valerate are already available and represent a valid alternative to EE. The use of more potent 19-nortestosterone-derived progestins, in order to lower the dose and then the appearance of non-androgenic progestins with different endocrine and metabolic characteristics, has made it possible to individualize the prescription of COC according to the profile of each woman.Conclusion: Advances in the provision of new COCs have improved the risk/benefit ratio by increasing benefits and reducing risks. Currently, the challenge is to tailor contraceptives to individual needs in terms of safety, efficacy, and protection of female reproductive health.
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Affiliation(s)
- Santiago Palacios
- Ginecologia y Obstetricia Department, Clínica Palacios de la Salud de la Mujer, Madrid, Spain
| | - Gabriela Ayala
- Ginecologia y Obstetricia Department, Hospital Metropolitano, Quito, Ecuador
| | - Gemarilis González
- Ginecología y Obstetricia Department, Consultorio América, Ciudad de Panamá, Panamá
| | - Can L Badilla-Apuy
- Ginecología y Obstetricia Department, Oncogine Servicios Médicos S.A., San José, Costa Rica
| | - Jeannette Marchena
- Ginecología y Obstetricia Department, Coordinadora de la Unidad de Medicina Reproductiva de las Clínicas AUNA y Clínica Delgado, Lima, Perú
| | - Katia Martínez
- Centro de Obstetricia y Ginecología, Health Service Medical Center, Santo Domingo, República Dominicana
| | - Desireé Mostajo
- Medical Director, Jefe Médico del Centro Médico PERINAT, Santa Cruz de la Sierra, Bolivia
| | - María S Vernaza
- Ginecología y Obstetricia Department, Laparoscopía Ginecológica, Clínica IMBANACO, Cali, Colombia
| | - Alejandro Paradas
- Obstetrics and Gynecology Department, Hospital Universitario, Maternidad La Altagracia, Santo Domingo, República Dominicana
| | - Luis Hernández
- Departamento de Ginecología y Obstetricia, Hospital Herrera Llerandi, Ciudad de Guatemala, Guatemala
| | - David Vásquez-Awad
- Ginecologia y Obstetricia Department, Academia Nacional de Medicina, Bogotá, Colombia
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Flores-Rodriguez A, Diaz Gonzalez-Colmenero F, Garcia-Leal M, Saenz-Flores M, Burciaga-Jimenez E, Zuñiga-Hernandez JA, Alvarez-Villalobos NA, Rodríguez-Guajardo R, Morales-Martinez FA, Sordia-Hernandez LH, Rodriguez-Gutierrez R. Harms of third- and fourth-generation combined oral contraceptives in premenopausal women: A systematic review and meta-analysis. J Investig Med 2023; 71:871-888. [PMID: 37415461 DOI: 10.1177/10815589231184227] [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] [Indexed: 07/08/2023]
Abstract
We assessed the available evidence regarding adverse effects on surrogate and patient-important health outcomes of third- and fourth-generation combined oral contraceptives among premenopausal women. We performed a systematic review and meta-analysis including randomized controlled trials and observational studies comparing third- and fourth-generation combined oral contraceptives with other generation contraceptives or placebo. Studies that enrolled women aged 15 to 50 years, with at least three cycles of intervention and 6 months of follow-up were included. A total of 33 studies comprising 629,783 women were included. Low-density lipoprotein cholesterol levels were significantly lower in fourth-generation oral contraceptives (mean differences (MD): -0.24 mmol/L; [95% CI -0.39 to -0.08]), while total cholesterol was significantly increased in levonorgestrel users when compared to third-generation oral contraceptives (MD: 0.27 mmol/L; [95% CI 0.04 to 0.50]). A decreased arterial thrombosis incidence was shown in fourth-generation oral contraceptive users, as compared to levonorgestrel (incidence rate ratio (IRR): 0.41; [95% CI 0.19 to 0.86]). No difference was found in the occurrence of deep venous thrombosis between fourth-generation oral contraceptives and levonorgestrel users (IRR: 0.91; [95% CI 0.66 to 1.27]; p = 0.60; I2 = 0%). Regarding the remaining outcomes, data were heterogeneous and showed no clear difference. In premenopausal women, the use of third- and fourth-generation oral contraceptives is associated with an improved lipid profile and lower risk of arterial thrombosis. Data were inconclusive regarding the rest of outcomes assessed. This review was registered in PROSPERO with CRD42020211133.
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Affiliation(s)
- Andrea Flores-Rodriguez
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit Mexico), Universidad Autónoma de Nuevo León, Monterrey, México
| | - Fernando Diaz Gonzalez-Colmenero
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit Mexico), Universidad Autónoma de Nuevo León, Monterrey, México
- Research Unit, University Hospital "Dr. José E. González," Universidad Autónoma de Nuevo León, Monterrey, México
| | - Mariana Garcia-Leal
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit Mexico), Universidad Autónoma de Nuevo León, Monterrey, México
| | - Melissa Saenz-Flores
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit Mexico), Universidad Autónoma de Nuevo León, Monterrey, México
| | - Erick Burciaga-Jimenez
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit Mexico), Universidad Autónoma de Nuevo León, Monterrey, México
| | - Jorge A Zuñiga-Hernandez
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit Mexico), Universidad Autónoma de Nuevo León, Monterrey, México
| | - Neri A Alvarez-Villalobos
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit Mexico), Universidad Autónoma de Nuevo León, Monterrey, México
- Research Unit, University Hospital "Dr. José E. González," Universidad Autónoma de Nuevo León, Monterrey, México
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Rene Rodríguez-Guajardo
- Gynecology and Obstetrics Department, University Hospital "Dr. JosJosé E. González," Universidad Autónoma de Nuevo León, Monterrey, México
| | - Felipe A Morales-Martinez
- Gynecology and Obstetrics Department, University Hospital "Dr. JosJosé E. González," Universidad Autónoma de Nuevo León, Monterrey, México
| | - Luis H Sordia-Hernandez
- Gynecology and Obstetrics Department, University Hospital "Dr. JosJosé E. González," Universidad Autónoma de Nuevo León, Monterrey, México
| | - Rene Rodriguez-Gutierrez
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit Mexico), Universidad Autónoma de Nuevo León, Monterrey, México
- Research Unit, University Hospital "Dr. José E. González," Universidad Autónoma de Nuevo León, Monterrey, México
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
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Icoz M, Yuzbasıoglu S. Evaluation of choroidal thickness and choroidal vascular index in patients using combined oral contraceptive pills. Cutan Ocul Toxicol 2023; 42:232-236. [PMID: 37437218 DOI: 10.1080/15569527.2023.2235429] [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: 02/19/2023] [Revised: 07/04/2023] [Accepted: 07/04/2023] [Indexed: 07/14/2023]
Abstract
PURPOSE To evaluate the choroidal thickness and choroidal vascular index (CVI) in healthy women using the combined oral contraceptive pill (COCp). METHODS This prospective study included 30 women using COCp (3 mg drospirenone/0.03 mg ethinylestradiol) for contraception for at least 1 year and 30 healthy women who did not use COCp. Intraocular pressure (IOP), axial length (AL) and body mass index (BMI) values of all participants were recorded. Subfoveal choroidal thickness (SCT) and choroidal thickness at 1500 micron distance in nasal and temporal regions (NCT, TCT) were measured through optical coherence tomography (OCT) images. Luminal, stromal and total choroidal area values were evaluated by binarization method. The ratio of the luminal choroidal area to the total choroidal area was determined as the CVI value. RESULTS There was no statistically significant difference in IOP and AL values between the two groups at no significant difference in age and BMI index (p > 0.05, for all). SCT, NCT and TCT values were no significant difference in the two groups (p > 0.05, for all). Luminal and stromal choroidal area values were found to be lower in the group using COCp (p = 0.01, p = 0.02 respectively). The CVI value was 62.1 ± 3.6% in the COCp group and 65.6 ± 4.3% in the control group. There was a significant difference between the two groups in terms of CVI value (p = 0.002). CONCLUSION To our knowledge, this is the first study to evaluate CVI in women using COCp, and CVI was found to be lower in individuals using COCp. Therefore, CVI can be used in the follow-up of possible ocular pathologies that may develop in individuals using COCp.
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Affiliation(s)
- Mehmet Icoz
- Department of Ophthalmology, Yozgat City Hospital, Yozgat, Turkey
| | - Sema Yuzbasıoglu
- Department of Ophthalmology, Ministry of Health Ankara City Hospital, Ophthalmology Clinic, Yıldırım Beyazıt University, Ankara, Turkey
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von Stockum S, Becker K, Bauerfeind A, Franke C, Fruzzetti F, Calaf J, Keck C, Heinemann K. NOMAC-E2 compares to LNG combined oral contraceptives in women over forty: real-world PRO-E2 study. Gynecol Endocrinol 2023; 39:2166032. [PMID: 36690019 DOI: 10.1080/09513590.2023.2166032] [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] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE To investigate safety and effectiveness of NOMAC-E2 and levonorgestrel-containing COCs (COCLNG) in users over 40. METHODS In this large, observational study, new users1 of NOMAC-E2 and COCLNG were recruited in Europe, Australia, and Latin America and followed-up via questionnaires. Incidence of venous thromboembolism (VTE) was expressed as incidence rate (IR; events/104 women-years [WY]). Unintended pregnancy was expressed by the Pearl Index (PI; contraceptive failures/100 WY). Mood and weight changes were defined as mean changes in mood score and percentage of body weight. RESULTS Overall, 7,762 NOMAC-E2 and 6,059 COCLNG users over 40 were followed-up. NOMAC-E2 showed no increased VTE risk compared to COCLNG; confirmed events: 5 NOMAC-E2 (IR 5.9; 95% CI, 1.9-13.7) vs 4 COCLNG (IR 5.9; 95% CI, 1.6-15.1). Unintended pregnancy did not differ substantially between cohorts; confirmed events: 4 NOMAC-E2 (PI 0.05; 95% CI, 0.01-0.13) vs 5 COCLNG (PI 0.08; 95% CI, 0.03-0.18). No differential effect on mood and weight was observed between cohorts. CONCLUSIONS NOMAC-E2 can be considered a valid alternative to COCLNG in perimenopausal women.
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Affiliation(s)
- Sophia von Stockum
- Berlin Center for Epidemiology and Health Research (ZEG), Berlin, Germany
| | - Kerstin Becker
- Berlin Center for Epidemiology and Health Research (ZEG), Berlin, Germany
| | - Anja Bauerfeind
- Berlin Center for Epidemiology and Health Research (ZEG), Berlin, Germany
| | - Christian Franke
- Berlin Center for Epidemiology and Health Research (ZEG), Berlin, Germany
| | - Franca Fruzzetti
- Department of Obstetrics and Gynecology, Pisa University Hospital, Pisa, Italy
| | - Joaquim Calaf
- Department of Obstetrics and Gynaecology, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | | | - Klaas Heinemann
- Berlin Center for Epidemiology and Health Research (ZEG), Berlin, Germany
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Bovo AC, Pedrão PG, Guimarães YM, Godoy LR, Resende JCP, Longatto-Filho A, Reis RD. Combined Oral Contraceptive Use and the Risk of Cervical Cancer: Literature Review. Rev Bras Ginecol Obstet 2023; 45:e818-e824. [PMID: 38141603 DOI: 10.1055/s-0043-1776403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2023] Open
Abstract
Cervical cancer (CC) is caused by persistent infection of human papillomavirus of high oncogenic risk (hr-HPV); however, several cofactors are important in its carcinogenesis, such as smoking, multiparity, and prolonged use of oral hormonal contraceptives (COCs). Worldwide, 16% of women use COCs, whereas in Brazil this rate is of ∼ 30%. The safety and adverse effects of COCs are widely discussed in the literature, including the increase in carcinogenic risk. Due to the existence of several drugs, combinations, and dosages of COCs, it is hard to have uniform information in epidemiological studies. Our objective was to perform a narrative review on the role of COCs use in the carcinogenesis of cervical cancer. Several populational studies have suggested an increase in the incidence of cervical cancer for those who have used COCs for > 5 years, but other available studies reach controversial and contradictory results regarding the action of COCs in the development of CC.
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Affiliation(s)
| | | | | | | | | | - Adhemar Longatto-Filho
- Hospital do Câncer de Barretos, Barretos, São Paulo, Brazil
- Faculdade de Medicia, Universidade de São Paulo, São Paulo, SP, Brazil
- Life and Health Sciences Research Institute, Faculdade de Medicina, Universidade do Minho, Braga, Portugal
- Government Associate Laboratory, Braga, Portugal
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Mosorin M, Ollila M, Nordström T, Jokelainen J, Piltonen T, Auvinen J, Morin‐Papunen L, Tapanainen J. Former long-term use of combined hormonal contraception and glucose metabolism disorders in perimenopausal women: A prospective, population-based cohort study. Acta Obstet Gynecol Scand 2023; 102:1488-1495. [PMID: 37568273 PMCID: PMC10577621 DOI: 10.1111/aogs.14636] [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: 11/14/2022] [Revised: 06/13/2023] [Accepted: 06/26/2023] [Indexed: 08/13/2023]
Abstract
INTRODUCTION Current use of combined hormonal contraceptives worsens glucose tolerance and increases the risk of type 2 diabetes mellitus at late fertile age, but the impact of their former use on the risk of glucose metabolism disorders is still controversial. MATERIAL AND METHODS This was a prospective, longitudinal birth cohort study with long-term follow-up consisting of 5889 women. The cohort population has been followed at birth, and at ages of 1, 14, 31 and 46. In total, 3280 (55.7%) women were clinically examined and 2780 also underwent a 2-h oral glucose tolerance test at age 46. Glucose metabolism indices were analyzed in former combined hormonal contraceptive users (n = 1371) and former progestin-only contraceptive users (n = 52) and in women with no history of hormonal contraceptive use (n = 253). RESULTS Compared with women with no history of hormonal contraceptive use, those who formerly used combined hormonal contraceptives for over 10 years had an increased risk of prediabetes (odds ratio [OR] 3.9, 95% confidence interval [CI]: 1.6-9.2) but not of type 2 diabetes mellitus. Former progestin-only contraceptive use was not associated with any glucose metabolism disorders. The results persisted after adjusting for socioeconomic status, smoking, alcohol consumption, parity, body mass index and use of cholesterol-lowering medication. CONCLUSIONS Former long-term use of combined hormonal contraceptives was associated with a significantly increased risk of prediabetes in perimenopausal women, which potentially indicates a need of screening for glucose metabolism disorders in these women.
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Affiliation(s)
- Maria‐Elina Mosorin
- Department of Obstetrics and GynecologyOulu University Hospital, Wellbeing Services County of North Ostrobothnia, University of OuluOuluFinland
- Medical Research CenterOulu University Hospital, University of Oulu, Wellbeing Services County of North OstrobothniaOuluFinland
- Research Unit of Clinical Medicine Oulu University Hospital, University of Oulu, Wellbeing Services County of North OstrobothniaOuluFinland
| | - Meri‐Maija Ollila
- Department of Obstetrics and GynecologyOulu University Hospital, Wellbeing Services County of North Ostrobothnia, University of OuluOuluFinland
- Medical Research CenterOulu University Hospital, University of Oulu, Wellbeing Services County of North OstrobothniaOuluFinland
- Research Unit of Clinical Medicine Oulu University Hospital, University of Oulu, Wellbeing Services County of North OstrobothniaOuluFinland
| | - Tanja Nordström
- Medical Research CenterOulu University Hospital, University of Oulu, Wellbeing Services County of North OstrobothniaOuluFinland
- Center for Life Course Health ResearchUniversity of Oulu, Wellbeing Services County of North OstrobothniaOuluFinland
| | - Jari Jokelainen
- Medical Research CenterOulu University Hospital, University of Oulu, Wellbeing Services County of North OstrobothniaOuluFinland
| | - Terhi Piltonen
- Department of Obstetrics and GynecologyOulu University Hospital, Wellbeing Services County of North Ostrobothnia, University of OuluOuluFinland
- Medical Research CenterOulu University Hospital, University of Oulu, Wellbeing Services County of North OstrobothniaOuluFinland
- Research Unit of Clinical Medicine Oulu University Hospital, University of Oulu, Wellbeing Services County of North OstrobothniaOuluFinland
| | - Juha Auvinen
- Center for Life Course Health ResearchUniversity of Oulu, Wellbeing Services County of North OstrobothniaOuluFinland
- Unit of General PracticeOulu University Hospital, Wellbeing Services County of North OstrobothniaOuluFinland
| | - Laure Morin‐Papunen
- Department of Obstetrics and GynecologyOulu University Hospital, Wellbeing Services County of North Ostrobothnia, University of OuluOuluFinland
- Medical Research CenterOulu University Hospital, University of Oulu, Wellbeing Services County of North OstrobothniaOuluFinland
- Research Unit of Clinical Medicine Oulu University Hospital, University of Oulu, Wellbeing Services County of North OstrobothniaOuluFinland
| | - Juha Tapanainen
- Department of Obstetrics and GynecologyOulu University Hospital, Wellbeing Services County of North Ostrobothnia, University of OuluOuluFinland
- Medical Research CenterOulu University Hospital, University of Oulu, Wellbeing Services County of North OstrobothniaOuluFinland
- Research Unit of Clinical Medicine Oulu University Hospital, University of Oulu, Wellbeing Services County of North OstrobothniaOuluFinland
- Department of Obstetrics and GynecologyUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
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Grandone E, Antonucci E, Colaizzo D, De Laurenzo A, Cosmi B, Cini M, Legnani C, Testa S, Margaglione M, Palareti G. Venous Thromboembolism in Women of Childbearing Age: Insights from the START Registry. Thromb Haemost 2023; 123:1060-1068. [PMID: 37263294 DOI: 10.1055/s-0043-1769592] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Women of childbearing age are exposed to venous thromboembolic risk mainly for pregnancy and use of oral contraceptives. The impact of risk factors (RF) on venous thromboembolism (VTE) in these circumstances is still unclear. AIM In the context of START registry, we aimed to investigate the weight of a series of RF on the occurrence of pregnancy- or combined oral contraceptive (COC)-associated VTE. MATERIALS AND METHODS We selected all women included in the START for VTE occurred between 18-42 years and compared those with a first or recurrent pregnancy/postpartum- (group A) or COC-VTE (group B) with those who had VTE outside these circumstances (group C). Final analysis included a cohort of 532 women. Follow-up data showed that there were no significant differences between the groups in terms of thrombotic and haemorrhagic complications. As for pregnancy-associated VTE, the overall outcome was good in terms of both maternal and fetal prognosis. RESULTS In a binary model of logistic regression, correcting for potential confounders, VTE family history conferred a significant and independent higher risk of COC-VTE compared with group C. Similarly, comparison between group A and C documented that family history significantly affected the risk of pregnancy-associated VTE. VTE in the group C was significantly associated with older age. Lastly, smoke was a significant risk factor for pregnancy/postpartum VTE when group A and group B were compared. CONCLUSION Present data suggest that in the setting of fertile women, family history of VTE has a greater role in predicting COC- and pregnancy/postpartum- VTE than outside these circumstances.
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Affiliation(s)
- Elvira Grandone
- Thrombosis and Haemostasis Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza," San Giovanni Rotondo, Italy
- Ob/Gyn Department, University of Foggia, Foggia, Italy
- Ob/Gyn and Perinatal Medicine Department of The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | | | - Donatella Colaizzo
- Thrombosis and Haemostasis Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza," San Giovanni Rotondo, Italy
| | - Antonio De Laurenzo
- Thrombosis and Haemostasis Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza," San Giovanni Rotondo, Italy
| | - Benilde Cosmi
- UO di Angiologia e Malattie della Coagulazione, Dipartimento Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna; Azienda Ospedaliero Universitaria S. Orsola-Malpighi, IRCCS, Bologna, Italy
| | - Michela Cini
- Fondazione Arianna Anticoagulazione, Bologna, Italy
| | | | - Sophie Testa
- Centro Emostasi e Trombosi, UUOO Laboratorio Analisi chimico-cliniche e microbiologiche, ASST Cremona, Cremona, Italy
| | - Maurizio Margaglione
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
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Noachtar IA, Frokjaer VG, Pletzer B. Mental Health Symptoms in Oral Contraceptive Users During Short-Term Hormone Withdrawal. JAMA Netw Open 2023; 6:e2335957. [PMID: 37755829 PMCID: PMC10534273 DOI: 10.1001/jamanetworkopen.2023.35957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 08/22/2023] [Indexed: 09/28/2023] Open
Abstract
Importance Hormonal contraception has been linked to mood symptoms and the ability to recognize emotions after short periods of treatment, whereas the mental health of users of long-term hormonal contraceptives has had limited investigation. Objective To evaluate whether short-term hormonal withdrawal, which users of combined oral contraceptives (COCs) undergo once a month (pill pause), was associated with altered mood and emotional recognition in long-term users of COCs. Design, Setting, and Participants This case-control study included a community sample of individuals assigned female sex at birth who identified as women and used COC for 6 months or longer. The control group included women with natural menstrual cycles who otherwise fulfilled the same inclusion criteria. The study was conducted between April 2021 and June 2022 in Salzburg, Austria. Exposure COC users and women with natural menstrual cycles were tested twice within a month, once during their active pill phase or luteal phase and once during their pill pause or menses. Main Outcomes and Measures Negative affect, anxiety, and mental health problems were assessed during each session. The percentage increase in mental health symptoms was calculated during the pill pause compared with that during the active intake phase in COC users. How this change compared with mood fluctuations along the menstrual cycle in women with natural menstrual cycles was assessed. Results A total of 181 women aged 18 to 35 years (mean [SD] age, 22.7 [3.5] years) were included in the analysis (61 women with androgenic COC use, 59 with antiandrogenic COC use, 60 women with a menstrual cycle not taking COCs). COC users showed a 12.67% increase in negative affect (95% CI, 6.94%-18.39%), 7.42% increase in anxiety (95% CI, 3.43%-11.40%), and 23.61% increase in mental health symptoms (95% CI, 16.49%-30.73%; P < .001) during the pill pause compared with the active intake phase. The effect size of this change did not differ depending on progestin type (negative affect: F1,117 = 0.30, P = .59; state anxiety: F1,117 = 2.15, P = .15; mental health: F1,117 = .16, P = .69) or ethinylestradiol dose (negative affect: F1,57 = .99, P = .32; state anxiety: F1,57 = 2.30, P = .13; mental health: F1,57 = .14, P = .71) was comparable with mood changes along the menstrual cycle in women with natural cycles (negative affect: F2,175 = 0.13, P = .87; state anxiety: F2,175 = 0.14, P = .32; mental health: F2,175 = 0.65, P = .52). Mood worsening during the pill pause was more pronounced in women with higher baseline depression scores (negative affect increase of 17.95% [95% CI, 7.80%-28.10%] in COC users with higher trait depression [BDI >8]). Emotion recognition performance did not differ between active pill phase and pill pause. Conclusions and Relevance In this case-control study of long-term COC users, withdrawal from contraceptive steroids during the pill pause was associated with adverse mental health symptoms similar to those experienced by women during menses with withdrawal from endogenous steroids. These results question the use of the pill pause from a mental health perspective. Long-term COC users may benefit more from the mood-stabilizing effects of COCs in cases of continuous intake.
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Affiliation(s)
- Isabel A. Noachtar
- Department of Psychology and Centre for Cognitive Neuroscience, University of Salzburg, Salzburg, Austria
| | - Vibe G. Frokjaer
- Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Psychiatric Center Copenhagen, Mental Health Services Capital Region of Denmark, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Belinda Pletzer
- Department of Psychology and Centre for Cognitive Neuroscience, University of Salzburg, Salzburg, Austria
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Brown N, Roldan-Reoyo O, Williams GKR, Stodter A, Moore IS, Mackintosh KA, McNarry MA, Williams EMP. Profiling Hormonal Contraceptive Use and Perceived Impact on Training and Performance in a Global Sample of Women Rugby Players. Int J Sports Physiol Perform 2023; 18:937-943. [PMID: 37353219 DOI: 10.1123/ijspp.2023-0137] [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: 04/06/2023] [Revised: 05/22/2023] [Accepted: 05/23/2023] [Indexed: 06/25/2023]
Abstract
PURPOSE The potential impact of hormonal contraceptives (HCs) on player health and performance in women's rugby union (rugby) is not well understood, despite rugby's growing popularity worldwide. This study investigated the prevalence of HC use and reported associations with training and performance in a global sample of women rugby players. METHOD A globally distributed online survey, seeking to explore experiences in women's rugby, was completed by 1596 current or former adult women 7s or 15s rugby players (mean age 27 [6] y; 7 [5] y playing experience) from 62 countries. The survey included a section of questions about reported HC use, including the type, reason for use, symptoms, and experiences relating to rugby training and performance. RESULTS A total of 606 (38%) participants from 33 of the 62 (53%) countries reported using HCs, with the combined oral contraceptive pill reported as the most frequently used (44%). Almost half of participants using HCs (43%) tracked HC-related symptoms. Over 10% reported altered rugby performance due to HC-related symptoms, 22% required medication to manage symptoms, and 11% used HCs to control or stop their menstrual periods for rugby training and performance. CONCLUSIONS The current study highlights the prevalence of HC use in women's rugby, identifying practices that may negatively affect performance, health, and well-being. Thus, there is an urgent need to better understand the motivations for such practices and knowledge of potential side effects among women rugby players across all levels and countries.
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Affiliation(s)
- Natalie Brown
- Applied Sports, Technology, Exercise and Medicine (A-STEM) Research Centre, Swansea University, Swansea,United Kingdom
- Welsh Institute of Performance Science, Swansea,United Kingdom
| | - Olga Roldan-Reoyo
- Applied Sports, Technology, Exercise and Medicine (A-STEM) Research Centre, Swansea University, Swansea,United Kingdom
| | - Genevieve K R Williams
- Department of Public Health & Sport Sciences, Faculty of Health & Life Sciences, University of Exeter, Devon,United Kingdom
| | - Anna Stodter
- Research Centre for Sport Coaching, Carnegie School of Sport, Leeds Beckett University, Leeds,United Kingdom
| | - Izzy S Moore
- Cardiff School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff,United Kingdom
| | - Kelly A Mackintosh
- Applied Sports, Technology, Exercise and Medicine (A-STEM) Research Centre, Swansea University, Swansea,United Kingdom
- Welsh Institute of Performance Science, Swansea,United Kingdom
| | - Melitta A McNarry
- Applied Sports, Technology, Exercise and Medicine (A-STEM) Research Centre, Swansea University, Swansea,United Kingdom
| | - Elisabeth M P Williams
- Applied Sports, Technology, Exercise and Medicine (A-STEM) Research Centre, Swansea University, Swansea,United Kingdom
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21
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Nelson AL. Drospirenone and estetrol: evaluation of a newly approved novel oral contraceptive. Expert Opin Pharmacother 2023; 24:1757-1764. [PMID: 37691580 DOI: 10.1080/14656566.2023.2247979] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/20/2023] [Accepted: 08/11/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION Estetrol (E4) is a native estrogen produced only by the fetal liver during pregnancy. E4 is the first new estrogen to be used in hormonal contraception since the introduction of oral contraceptives in 1960. Ethinyl estradiol, the most commonly used estrogen in oral contraceptives today, increases the risks of thromboembolism and has other significant hepatic impacts, which induce important drug-drug interactions. On the other hand, Phase 2 E4 characterization studies demonstrated that E4 has negligible impacts on liver, breast, and vascular endothelium due to its distinct tissue selectivity. Combined with drospirenone (DRSP), E4 offers an improved safety profile for oral contraception. AREAS COVERED This paper briefly highlights the unique pharmacokinetic and pharmacodynamic features of E4. The efficacy, safety, and tolerability results from the Phase 2 and 3 studies of the E4/DRSP pill are discussed to provide the reader with a thorough understanding of E4 and information to use when counseling potential users. EXPERT OPINION The estetrol/drospirenone oral contraceptive is effective and well tolerated and provides good cycle control. In the future, estetrol may be the estrogen of choice if subsequent evidence verifies that it reduces the risks associated with current estrogens, such as venous thromboembolism and drug-drug interactions.
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Affiliation(s)
- Anita L Nelson
- Obstetrics and Gynecology, College of Osteopathic Medicine, Western University of Health Sciences, Pomona, CA, USA
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22
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Chane E, Wondifraw H, Hadgu R, Fasil A. Assessment of liver function tests of women taking hormonal contraceptives at University of Gondar comprehensive specialized hospital and Family Guidance Association of Gondar (FGAE), 2022; a comparative cross-sectional study. PLoS One 2023; 18:e0289746. [PMID: 37590278 PMCID: PMC10434896 DOI: 10.1371/journal.pone.0289746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 07/25/2023] [Indexed: 08/19/2023] Open
Abstract
INTRODUCTION Hormonal contraceptives are artificial preparations that contain artificial progestins and Ethinylestradiol; these preparations are utilized by women of reproductive age to prevent pregnancy. Roughly a billion women in the world use some form of contraceptive worldwide. Despite the utility of these preparations, they are linked with several adverse effects, including disturbances of liver functionality and integrity. However, previous studies conducted to assess the association between hormonal contraceptive utilization and liver function tests reported conflicting results, and the effects remained a matter of concern. METHODS The study enrolled a total of 264 participants, who were allocated into two groups. One group of hormonal contraceptive users who use the medication for a minimum of six months: Depot medroxyprogesterone acetate (DMPA), combined oral contraceptives (COC), Norplant, and Implant users and another age-matched non-user control group in a ratio of 1:1. A semi-structured questionnaire was used to collect socio-demographic, behavioral, and clinical data. Five ml serum blood sample was collected for liver function test analysis on a Beckman Coulter Clinical Chemistry analyzer (DXC 700 AU). Independent t-test was used to compare liver function tests of hormonal contraceptive users and non-user controls, whereas ANOVA followed by a Bonferroni post hoc test was used for intra- (between classes of contraceptives) and inter-group (between each class of contraceptives and controls) comparisons and to identify factors associated. RESULTS Hormonal contraceptive users were observed to have a statistically significant higher mean value of liver enzymes assessed compared to non-user control groups: aspartate aminotransferase (AST) (47.07±14.79 versus 25.92±7.37; p <0.001), alanine aminotransferase (ALT) (35.83±13.76 versus 16.56 ± 5.03; p <0.001), alkaline phosphatase (ALP) (63.34±14.74 versus 45.41±14.34, p <0.001) and for γ-glutamyl transferase (GGT) (47.37±24.32 versus 19.45 ± 6.86 p <0.001). Similarly, the mean value of total and direct bilirubin (mg/dL) among HC users showed a statistically significant elevation (0.68 ± 0.22 against 0.32 ± 0.13, p <0.001) for total bilirubin and (0.14 ± 0.06 against 0.06 ± 0.03, p <0.001) for direct bilirubin respectively. However, no statistically significant result was observed in the mean values of total protein and albumin. For total protein (6.7 ± 0.89 versus 6.5 ± 1.15, p 0.07) and for albumin (5.4 ± 0.92 versus 5.3 ± 1.08; p 0.30). The current study also indicates the level of hepatic function test alteration is related to the type of hormonal contraceptives, duration of usage, and level of adherence to a specific class of contraceptives. CONCLUSION AND RECOMMENDATION Hormonal contraceptive use was observed to affect hepatic function. Based on this finding, we strongly recommend to closely monitor liver function tests in women using hormonal contraceptives.
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Affiliation(s)
- Elias Chane
- Department of Clinical Chemistry, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Habtamu Wondifraw
- Department of Clinical Chemistry, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Rishan Hadgu
- Department of Medical Laboratory Science, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia
| | - Alebachew Fasil
- Department of Clinical Chemistry, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Schroll JB, Black AY, Farquhar C, Chen I. Combined oral contraceptive pill for primary dysmenorrhoea. Cochrane Database Syst Rev 2023; 7:CD002120. [PMID: 37523477 PMCID: PMC10388393 DOI: 10.1002/14651858.cd002120.pub4] [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] [Indexed: 08/02/2023]
Abstract
BACKGROUND Dysmenorrhoea (painful menstrual cramps) is common and a major cause of pain in women. Combined oral contraceptives (OCPs) are often used in the management of primary dysmenorrhoea, but there is a need for reporting the benefits and harms. Primary dysmenorrhoea is defined as painful menstrual cramps without pelvic pathology. OBJECTIVES To evaluate the benefits and harms of combined oral contraceptive pills for the management of primary dysmenorrhoea. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date 28 March 2023. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing all combined OCPs with other combined OCPs, placebo, or management with non-steroidal anti-inflammatory drugs (NSAIDs). Participants had to have primary dysmenorrhoea, diagnosed by ruling out pelvic pathology through pelvic examination or ultrasound. DATA COLLECTION AND ANALYSIS We used standard methodological procedures recommended by Cochrane. The primary outcomes were pain score after treatment, improvement in pain, and adverse events. MAIN RESULTS We included 21 RCTs (3723 women). Eleven RCTs compared combined OCP with placebo, eight compared different dosages of combined OCP, one compared two OCP regimens with placebo, and one compared OCP with NSAIDs. OCP versus placebo or no treatment OCPs reduce pain in women with dysmenorrhoea more effectively than placebo. Six studies reported treatment effects on different scales; the result can be interpreted as a moderate reduction in pain (standardised mean difference (SMD) -0.58, 95% confidence interval (CI) -0.74 to -0.41; I² = 28%; 6 RCTs, 588 women; high-quality evidence). Six studies also reported pain improvement as a dichotomous outcome (risk ratio (RR) 1.65, 95% CI 1.29 to 2.10; I² = 69%; 6 RCTs, 717 women; low-quality evidence). The data suggest that in women with a 28% chance of improvement in pain with placebo or no treatment, the improvement in women using combined OCP will be between 37% and 60%. Compared to placebo or no treatment, OCPs probably increase the risk of any adverse events (RR 1.31, 95% CI 1.20 to 1.43; I² = 79%; 7 RCTs, 1025 women; moderate-quality evidence), and may also increase the risk of serious adverse events (RR 1.77, 95% CI 0.49 to 6.43; I² = 22%; 4 RCTs, 512 women; low-quality evidence). Women who received OCPs had an increased risk of irregular bleeding compared to women who received placebo or no treatment (RR 2.63, 95% CI 2.11 to 3.28; I² = 29%; 7 RCTs, 1025 women; high-quality evidence). In women with a risk of irregular bleeding of 18% if using placebo or no treatment, the risk would be between 39% and 60% if using combined OCP. OCPs probably increase the risk of headaches (RR 1.51, 95% CI 1.11 to 2.04; I² = 44%; 5 RCTs, 656 women; moderate-quality evidence), and nausea (RR 1.64, 95% CI 1.17 to 2.30; I² = 39%; 8 RCTs, 948 women; moderate-quality evidence). We are uncertain of the effect of OCP on weight gain (RR 1.83, 95% CI 0.75 to 4.45; 1 RCT, 76 women; low-quality evidence). OCPs may slightly reduce requirements for additional medication (RR 0.63, 95% CI 0.40 to 0.98; I² = 0%; 2 RCTs, 163 women; low-quality evidence), and absence from work (RR 0.63, 95% CI 0.41 to 0.97; I² = 0%; 2 RCTs, 148 women; low-quality evidence). One OCP versus another OCP Continuous use of OCPs (no pause or inactive tablets after the usual 21 days of hormone pills) may reduce pain in women with dysmenorrhoea more effectively than the standard regimen (SMD -0.73, 95% CI -1.13 to 0.34; 2 RCTs, 106 women; low-quality evidence). There was insufficient evidence to determine if there was a difference in pain improvement between ethinylestradiol 20 μg and ethinylestradiol 30 μg OCPs (RR 1.06, 95% CI 0.65 to 1.74; 1 RCT, 326 women; moderate-quality evidence). There is probably little or no difference between third- and fourth-generation and first- and second-generation OCPs (RR 0.99, 95% CI 0.93 to 1.05; 1 RCT, 178 women; moderate-quality evidence). The standard regimen of OCPs may slightly increase the risk of any adverse events over the continuous regimen (RR 1.11, 95% CI 1.01 to 1.22; I² = 76%; 3 RCTs, 602 women; low-quality evidence), and probably increases the risk of irregular bleeding (RR 1.38, 95% CI 1.14 to 1.69; 2 RCTs, 379 women; moderate-quality evidence). Due to lack of studies, it is uncertain if there is a difference between continuous and standard regimen OCPs in serious adverse events (RR 0.34, 95% CI 0.01 to 8.24; 1 RCT, 212 women), headaches (RR 0.94, 95% CI 0.50 to 1.76; I² = 0%; 2 RCTs, 435 women), or nausea (RR 1.08, 95% CI 0.51 to 2.30; I² = 23%; 2 RCTs, 435 women) (all very low-quality evidence). We are uncertain if one type of OCP reduces absence from work more than the other (RR 1.12, 95% CI 0.64 to 1.99; 1 RCT, 445 women; very low-quality evidence). OCPs versus NSAIDs There were insufficient data to determine whether OCPs were more effective than NSAIDs for pain (mean difference -0.30, 95% CI -5.43 to 4.83; 1 RCT, 91 women; low-quality evidence). The study did not report on adverse events. AUTHORS' CONCLUSIONS OCPs are effective for treating dysmenorrhoea, but they cause irregular bleeding, and probably headache and nausea. Long-term effects were not covered in this review. Continuous use of OCPs was probably more effective than the standard regimen but safety should be ensured with long-term data. Due to lack of data, we are uncertain whether NSAIDs are better than OCPs for treating dysmenorrhoea.
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Affiliation(s)
- Jeppe B Schroll
- Department of Obstetrics and Gynaecology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Amanda Y Black
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Canada
| | - Cindy Farquhar
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Innie Chen
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Canada
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24
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Canis M, Guo SW. In the thicket of fears, doubts, and murky facts: some reflections on treatment modalities for endometriosis-associated pain. Hum Reprod 2023; 38:1245-1252. [PMID: 37023473 DOI: 10.1093/humrep/dead061] [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: 11/15/2022] [Revised: 03/15/2023] [Indexed: 04/08/2023] Open
Abstract
Endometriosis-associated pain can be managed by either surgery or hormonal therapy. The final decision as to which treatment modality to take is based on efficacy and possible complications of different treatment modalities, risk of recurrence, and the patient's wishes and preferences. But in the thicket of fears, doubts, and murky facts, the choice may ultimately be the trade-off between irrational fears and ignorance versus scientific evidence. We elaborate some pros and cons of the two treatment modalities and highlight some notable downsides of hormonal therapy, in particular the possible yet unquantified risk of long-term hormonal therapy for malignant transformation, perhaps with the only exception of combined oral contraceptives. Thus, when discussing with patients, we advocate the approach of discussing the advantages and disadvantages of all treatment options in detail, accounting for the known pros and cons with a full understanding of the predictive irrationality of human beings. For endometriosis-associated pain, surgery is definitely not a failure of medicine but, rather, a viable option, especially given the recently surfaced undercurrent of wariness and dissatisfaction with the current hormonal drugs among patients with endometriosis. Above all, there is a pressing need to fill the knowledge gap of perioperative interventions intended to reduce the risk of recurrence and to fulfill the demand for the development of safe and efficacious non-hormonal therapeutics.
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Affiliation(s)
- Michel Canis
- Department of Obstetrics Gynecology and Reproductive Medicine, CHU Clermont Ferrand, Clermont Ferrand, France
| | - Sun-Wei Guo
- Research Institute, Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
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25
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Ma S, Song SJ. Oral contraceptives containing drospirenone for premenstrual syndrome. Cochrane Database Syst Rev 2023; 6:CD006586. [PMID: 37365881 PMCID: PMC10289136 DOI: 10.1002/14651858.cd006586.pub5] [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] [Indexed: 06/28/2023]
Abstract
BACKGROUND Premenstrual syndrome (PMS) is a common problem. Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome. Combined oral contraceptives (COC), which provide both progestin and oestrogen, have been examined for their ability to relieve premenstrual symptoms. A combined oral contraceptive containing drospirenone and a low oestrogen dose has been approved for treating PMDD in women who choose combined oral contraceptives for contraception. OBJECTIVES To evaluate the effectiveness and safety of COCs containing drospirenone in women with PMS. SEARCH METHODS We searched the Cochrane Gynaecology and Fertility Group trial register, CENTRAL (now containing output from two trials registers and CINAHL), MEDLINE, Embase, PsycINFO, LILACS, Google Scholar, and Epistemonikos on 29 June 2022. We checked included studies' reference lists and contacted study authors and experts in the field to identify additional studies. SELECTION CRITERIA We included randomised controlled trials (RCT) that compared COCs containing drospirenone with placebo or with another COC for treatment of women with PMS. DATA COLLECTION AND ANALYSIS We used standard methodological procedures recommended by Cochrane. The primary review outcomes were effects on premenstrual symptoms that were prospectively recorded, and withdrawal due to adverse events. Secondary outcomes included effects on mood, adverse events, and response rate to study medications. MAIN RESULTS We included five RCTs (858 women analysed, most diagnosed with PMDD). The evidence was very low to moderate quality; the main limitations were serious risk of bias due to poor reporting of study methods, and serious inconsistency and imprecision. COCs containing drospirenone and ethinylestradiol (EE) versus placebo COCs containing drospirenone and EE may improve overall premenstrual symptoms (standardised mean difference (SMD) -0.41, 95% confidence interval (CI) -0.59 to -0.24; 2 RCTs, N = 514; I2 = 64%; low-quality evidence); and functional impairment due to premenstrual symptoms in terms of productivity (mean difference (MD) -0.31, 95% CI -0.55 to -0.08; 2 RCTs, N = 432; I2 = 47%; low-quality evidence), social activities (MD -0.29, 95% CI -0.54 to -0.04; 2 RCTs, N = 432; I2 = 53%; low-quality evidence), and relationships (MD -0.30, 95% CI -0.54 to -0.06; 2 RCTs, N = 432; I2 = 45%; low-quality evidence). The effects from COCs containing drospirenone may be small to moderate. COCs containing drospirenone and EE may increase withdrawal from trials due to adverse effects (odds ratio (OR) 3.41, 95% CI 2.01 to 5.78; 4 RCT, N = 776; I2 = 0%; low-quality evidence). This suggests that if you assume the risk of withdrawal due to adverse effects from placebo is 3%, the risk from drospirenone plus EE will be between 6% and 16%. We are uncertain of the effect of drospirenone plus EE on premenstrual mood symptoms, when measured by validated tools that were not developed to assess premenstrual symptoms. COCs containing drospirenone may lead to more adverse effects in total (OR 2.31, 95% CI 1.71 to 3.11; 3 RCT, N = 739; I2 = 0%; low-quality evidence). This suggests that if you assume the risk of having adverse effects from placebo is 28%, the risk from drospirenone plus EE will be between 40% and 54%. It probably leads to more breast pain, and may lead to more nausea, intermenstrual bleeding, and menstrual disorder. Its effect on nervousness, headache, asthenia, and pain is uncertain. There was no report of any rare but serious adverse effects, such as venous thromboembolism in any of the included studies. COCs containing drospirenone may improve response rate (OR 1.65, 95% CI 1.13 to 2.40; 1 RCT, N = 449; I2 not applicable; low-quality evidence). This suggests that if you assume the response rate from placebo is 36%, the risk from drospirenone plus EE will be between 39% and 58%. We did not identify any studies that compared COCs containing drospirenone with other COCs. AUTHORS' CONCLUSIONS COCs containing drospirenone and EE may improve premenstrual symptoms that result in functional impairments in women with PMDD. The placebo also had a significant effect. COCs containing drospirenone and EE may lead to more adverse effects compared to placebo. We do not know whether it works after three cycles, helps women with less severe symptoms, or is better than other combined oral contraceptives that contain a different progestogen.
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Affiliation(s)
- Siyan Ma
- Women's Health, Te Whatu Ora Counties Manukau, Auckland, New Zealand
| | - Sae Jin Song
- Women's Health, Te Whatu Ora Counties Manukau, Auckland, New Zealand
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26
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Yedla D, Vijayan S, Babu TA. Carpal tunnel syndrome ascribed to low-dose combined oral contraceptive pills. Indian J Pharmacol 2023; 55:187-189. [PMID: 37555415 PMCID: PMC10501542 DOI: 10.4103/ijp.ijp_594_22] [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: 08/22/2022] [Revised: 06/02/2023] [Accepted: 07/03/2023] [Indexed: 08/10/2023] Open
Abstract
Carpal tunnel syndrome (CTS) is the most prevalent compressive focal mononeuropathy brought on by median nerve compression, and common manifestations include pain in the wrist joint, decreased sensations along the distribution of the median nerve, a reduction in two-point discrimination, nighttime awakening, and, in more advanced stages, thenar muscle wasting and weakening. CTS, although common, yet underreported adverse effects of oral contraceptives. We report a case of 21-year-old female who developed CTS after using low-dose combined oral contraceptive pills for irregular cycles with polycystic ovary disease.
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Affiliation(s)
- Deepthi Yedla
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh, India
| | - Sharmila Vijayan
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh, India
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Quaas P. [Combined Hormonal Contraception - Which Pill for Which Patient?]. Praxis (Bern 1994) 2023; 112:205-210. [PMID: 36919319 DOI: 10.1024/1661-8157/a003993] [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] [Indexed: 06/18/2023]
Abstract
Combined Hormonal Contraception - Which Pill for Which Patient? Abstract. Combined hormonal contraceptives (CHC) are a valuable and highly effective option in contraceptive counseling. Methods and preparations available in Switzerland are combined oral contraceptives (COC), vaginal rings and transdermal patches. All preparations contain an estrogen and a progestin component. The estrogen component mainly consists of the synthetically produced ethinylestradiol (EE), although newer COC may contain natural estrogens such as estradiol (E2) and estetrol (E4). For the progestin component, a variety of luteal body hormones are available, which enable the health care professional to prescribe a "tailored" product for the patient due to their different partial effects. The individual thromboembolism (TE) risk should always be considered and taken into account when prescribing CHC.
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Affiliation(s)
- Philipp Quaas
- Frauenklinik, Universitätsspital Basel, Universität Basel, Basel, Schweiz
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Karp NS. Discussion: The Impact of Combined Oral Contraceptives on Adolescents with Macromastia. Plast Reconstr Surg 2022; 150:739-740. [PMID: 36170439 DOI: 10.1097/prs.0000000000009514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Nolan S Karp
- From the Hansjörg Wyss Department of Plastic Surgery, New York University Grossman School of Medicine
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Klump KL, Di Dio AM. Combined oral contraceptive use and risk for binge eating in women: Potential gene × hormone interactions. Front Neuroendocrinol 2022; 67:101039. [PMID: 36181777 PMCID: PMC9679583 DOI: 10.1016/j.yfrne.2022.101039] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 08/29/2022] [Accepted: 09/22/2022] [Indexed: 11/24/2022]
Abstract
Extant animal and human data suggest endogenous ovarian hormones increase risk for binge eating in females, possibly via gene × hormone interactions and hormonally induced increases in genetic influences. Approximately 85 % of women will take combined oral contraceptives (COCs) that mimic the riskiest hormonal milieu for binge eating (i.e., post-ovulation when both estrogen and progesterone are present). The purpose of this narrative review is to synthesize findings of binge eating risk in COC users. Few studies have been conducted, but results suggest that COCs may increase risk for binge eating and related phenotypes (e.g., craving for sweets), particularly in genetically vulnerable women. Larger, more systematic human and animal studies of COCs and binge eating are needed. The goal of this work should be to advance personalized medicine by identifying the extent of COC risk as well as the role of gene × hormone interactions in susceptibility.
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Affiliation(s)
- Kelly L Klump
- Department of Psychology, Michigan State University, 316 Physics Road - Room 107B, East Lansing, MI 48824-1116, United States.
| | - Alaina M Di Dio
- Department of Psychology, Oberlin College, South Hall, 121 Elm Street, Oberlin, OH 44074, United States
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Gris JC, Bourguignon C, Bouvier S, Nouvellon É, Laurent J, Perez-Martin A, Mousty È, Nikolaeva MG, Khizroeva J, Bitsadze V, Makatsariya A. Combined oral contraceptive-associated venous thromboembolism revealing an antiphospholipid syndrome: International retrospective study of outcomes. Thromb Res 2022; 219:102-108. [PMID: 36152459 DOI: 10.1016/j.thromres.2022.09.013] [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: 06/14/2022] [Revised: 09/13/2022] [Accepted: 09/15/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Limitations in the data used to define thromboprophylaxis for patients with antiphospholipid antibodies (aPLAbs) and thrombosis include uncertainties after an initial provoked venous thromboembolic event (VTE). We aimed to study such cases associated with combined oral contraceptive (COC) intake. METHODS We retrospectively analysed thrombotic outcomes after a first COC-associated VTE and positive aPLAbs, with a low risk HERDOO2 score, on low-dose aspirin (LDA) secondary thromboprophylaxis, seen from 2010 to 2021 in 3 tertiary referral centres, one in France and 2 in Russia. Data from 264 patients (distal deep vein thrombosis DVT: 62.9 %), cumulating in 1327.7 patient-years of observation, were collected. RESULTS There were 22 cases of thrombosis: 16 distal DVTs, 3 proximal, 1 pulmonary embolism (PE) and 2 transient ischemic attacks. Recurrence rate was 1.66 per 100 patient-years (p-y; 95 % CI: 0.96-2.33). No major bleeding occurred. Risk factors affecting recurrence-free survival were the time between first COC intake and VTE (p < 0.0001; the shortest, the lower), proximal DVT (p = 0.021), active smoking (p = 0.039), an associated systemic disease (p = 0.043) and circulating monocyte counts (p = 0.001). CONCLUSIONS We observed a low risk of recurrence which was modulated by classical risk factors for VTE. These observational data may provide clues for future randomized controlled trials.
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Affiliation(s)
- Jean-Christophe Gris
- Department of Haematology, CHU Nîmes, Univ Montpellier, Nîmes, France; Faculty of Pharmaceutical and Biological Sciences, Montpellier University, France; UMR UA11 INSERM IDESP, Montpellier University, France; Department of Obstetrics and Gynaecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation.
| | - Chloé Bourguignon
- Department of Haematology, CHU Nîmes, Univ Montpellier, Nîmes, France; Faculty of Pharmaceutical and Biological Sciences, Montpellier University, France; UMR UA11 INSERM IDESP, Montpellier University, France
| | - Sylvie Bouvier
- Department of Haematology, CHU Nîmes, Univ Montpellier, Nîmes, France; UMR UA11 INSERM IDESP, Montpellier University, France
| | - Éva Nouvellon
- Department of Haematology, CHU Nîmes, Univ Montpellier, Nîmes, France; UMR UA11 INSERM IDESP, Montpellier University, France
| | - Jeremy Laurent
- Department of Haematology, CHU Nîmes, Univ Montpellier, Nîmes, France; Department of Vascular Medicine, University Hospital, Montpellier, France
| | - Antonia Perez-Martin
- UMR UA11 INSERM IDESP, Montpellier University, France; Department of Vascular Medicine, University Hospital, Montpellier, France
| | - Ève Mousty
- Department of Gynaecology and Obstetrics, CHU Nîmes, Univ Montpellier, Nîmes, France
| | | | - Jamilya Khizroeva
- Department of Obstetrics and Gynaecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Victoria Bitsadze
- Department of Obstetrics and Gynaecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Alexander Makatsariya
- Department of Obstetrics and Gynaecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
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Basciani S, Porcaro G. Counteracting side effects of combined oral contraceptives through the administration of specific micronutrients. Eur Rev Med Pharmacol Sci 2022; 26:4846-4862. [PMID: 35856377 DOI: 10.26355/eurrev_202207_29210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE The occurrence of side effects related to the use of combined oral contraceptives (COCs) - or even the fear of them - often affects patients' compliance and their quality of life. Such adverse effects include both physical and psychological alterations. Therapies based on COCs are related to lower levels of vitamins and minerals, including vitamins B, C and E, zinc, magnesium, and selenium. This review gathers scientific evidence about the effectiveness of the administration of specific micronutrients to address nutritional needs and recover adverse conditions. MATERIALS AND METHODS We reviewed literature searching through different databases (MEDLINE, Scopus, Google Scholar). We used different keywords, including micronutrients, COCs, side effects, B vitamins, vitamin C, vitamin E, vitamin D, zinc, magnesium, selenium and Centella Asiatica. We narrowed the search down to English literature, including both preclinical and clinical studies. The outcome of database search was to highlight beneficial effects of specific micronutrients on the evaluated side reactions. RESULTS Based on the collected evidence, dietary supplementations of specific micronutrients, whose depletion occurs during COC treatments, have significant beneficial effects. By acting on different aspects and pathways, such supplementation prevents and counteracts discomforts and side effects related to COC treatments. CONCLUSIONS Considering the wide use of OCs, taking appropriate dietary supplements could be an effective approach in clinical practice, tailoring therapies and improving both safety and tolerability.
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Affiliation(s)
- S Basciani
- Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Sapienza University of Rome, Rome, Italy.
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Nowosielski K. Do oral combined contraceptive pills modify body image and sexual function? Reprod Biol Endocrinol 2022; 20:94. [PMID: 35765001 PMCID: PMC9238118 DOI: 10.1186/s12958-022-00968-5] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 06/05/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The effect of hormonal contraceptives on sexual function and body image is still controversial. Existing studies have not come to definite conclusions on the association between hormonal contraceptive use and sexual function/presence of sexual dysfunction or changes in body image perception. Thus, this study aimed to evaluate the prevalence of sexual problems/dysfunction in Polish women of reproductive age (18-45 years) and to assess to what extent oral combined contraceptive pills (OCCP) impact body image, sexual function and the prevalence of female sexual dysfunction (FSD). METHODS A total of 495 women were included in this cross-sectional questionnaire-based study. Sexual function was assessed by the Changes in Sexual Function Questionnaire (CSFQ), the prevalence of FSD was assessed by DSM-5 criteria, and body image was assessed by the Body Exposure during Sexual Activity Questionnaire (BESAQ). A total of 237 women using OCCP were the study group (HC), and the rest were controls (CG). A regression model was used to evaluate the influence of the selected variables on sexual function and the presence of FSD. RESULTS The prevalence of FSD was 7.5% in HC and 2.6% in CG, and 22% compared to 14% of women in HC and CG, respectively, reported sexual problems (CSFQ). The demographic characteristics of those using other contraception methods or not using any contraception (control group) were similar. The contraceptive group was characterized by significantly higher importance of sex (4.03 vs. 3.79), worse partner's attitude toward sex (4.35 vs. 4.47), worse self-attitude toward sex (4.35 vs. 4.47), and worse body image (BESAQ) compared to controls. Among all of the variables, a lower level of anxiety (t = -1.99), positive attitudes toward sex (t = 2.05), watching erotic videos (t = 5.58) and a higher importance of sex (t = 5.66) were predictive of better sexual function (R2-0.38, F = 28.9, p = 0.0001). CONCLUSION Sexual behaviors and function are different in those using OCCP compared to nonusers. The prevalence of sexual problems and dysfunction was higher in those using this hormonal method of contraception; however, using OCCP was not a risk factor for either worse sexual function or sexual dysfunction. Partners' attitudes toward sex and general anxiety level were factors contributing to sexual function and the risk of sexual dysfunction in the population of women of reproductive age and should be routinely evaluated in clinical practice, especially before prescribing hormonal contraceptives.
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Affiliation(s)
- Krzysztof Nowosielski
- Department of Gynecology, Obstetrics and Gynecological Oncology, University Clinical Hospital, Medical University of Silesia, ul. Medykow 14, 40-752, Katowice, Poland.
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Niemann J, Schenk L, Stadler G, Richter M. What happens when you stop using the combined contraceptive pill? A qualitative study protocol on consequences and supply needs for women who discontinued the combined contraceptive pill in Germany. BMJ Open 2022; 12:e057089. [PMID: 35760546 PMCID: PMC9237896 DOI: 10.1136/bmjopen-2021-057089] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION For more than 60 years, contraceptive pills have been prescribed to mostly healthy biological women. An emerging body of research concerning the possible physiological and psychological side effects of hormonal contraception has been published over the past two decades. Consequently, discontinuing combined oral contraceptives (COCs) as a conscious decision for reasons other than desired pregnancy has become increasingly common for menstruating individuals. The question remains as to what physical and psychological consequences can be observed after discontinuing COCs. In addition, the consequent healthcare needs and situations of affected individuals in Germany have not been explored. This study aims to gain greater insight into the relationship between discontinuation of COCs and (1) possible health consequences, and (2) to explore the supply situation for affected women within the German healthcare system. METHODS AND ANALYSIS Qualitative episodic interviews with women who discontinue COC therapy will explore possible health consequences, and their current healthcare needs and situations in Germany. The interviews will be transcribed verbatim, coded, and in-depth thematic interpretation will be conducted. Subsequently, expert interviews with health professionals who work with women who discontinue COCs will also be conducted. The expert interviews will be analysed according to the documentary method. Overarching themes will represent the perspectives of women and health professionals on the discontinuation of COCs. ETHICS AND DISSEMINATION Ethical approval for this study has been granted by the Ethics Review Committee of Martin Luther University, Halle-Wittenberg (Germany), reference number 2021-34. The findings will be disseminated via peer-reviewed publications, posting via social media and presentations at conferences. This study is registered on the OSF platform under the following number: https://doi.org/10.17605/OSF.IO/JYWXM.
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Affiliation(s)
- Jana Niemann
- Institute of Medical Sociology, Martin Luther University Halle Wittenberg, Halle, Sachsen-Anhalt, Germany
- Institute of Medical Sociology and Rehabilitation Science, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Liane Schenk
- Institute of Medical Sociology and Rehabilitation Science, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Gertraud Stadler
- Institute for Gender Research in Medicine (GiM), Charité Universitätsmedizin Berlin, Berlin, Germany
- University of Aberdeen, Aberdeen, UK
| | - Matthias Richter
- Institute of Medical Sociology, Martin Luther University Halle Wittenberg, Halle, Sachsen-Anhalt, Germany
- Department of Sport and Health Sciences, Technical University of Munich, Munchen, Bayern, Germany
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Smrekar K, Lodise NM. Combined Oral Contraceptive Use and Breast Cancer Risk: Select Considerations for Clinicians. Nurs Womens Health 2022; 26:242-249. [PMID: 35134383 DOI: 10.1016/j.nwh.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 11/24/2021] [Accepted: 01/01/2022] [Indexed: 06/14/2023]
Abstract
Combined oral contraceptives (COCs) are commonly used by individuals for contraceptive and noncontraceptive purposes, such as the management of dysmenorrhea or to reduce risk for ovarian and endometrial cancer. However, a common consideration that continues to arise is whether COC use increases breast cancer risk. Many researchers have investigated this, but study results are varied and may be affected by variables such as hormone type, an individual's age, and the duration of COC use. In this article, we summarize select breast cancer risk considerations regarding COC use to assist clinicians when counseling individuals considering using oral contraceptives.
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Vannuccini S, Biagiotti C, Esposto MC, La Torre F, Clemenza S, Orlandi G, Capezzuoli T, Petraglia F. Long-term treatment of endometriosis-related pain among women seeking hormonal contraception. Gynecol Endocrinol 2022; 38:398-402. [PMID: 35238265 DOI: 10.1080/09513590.2022.2047172] [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] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVE To evaluate the different effects of a progestin-only contraceptive with desogestrel (DSG) vs combined oral contraceptives (COCs) for a first line long-term treatment of endometriosis-related pain among patients seeking hormonal contraception. METHODS An observational retrospective cohort study was conducted in collaboration with a local outpatient clinic for endometriosis among a group of nulliparous young women (n = 216) with endometriosis-related pain and seeking contraception. The cohort was subdivided into a group (n = 73) treated as first line by DSG and another group (n = 75) treated by a COC. During the study, clinical symptoms, side effects and possible changes in OC type use were recorded. RESULTS No significant difference was found between the two groups in terms of clinical characteristics and pain scores before treatment. After 6 months both treatments were effective in reducing endometriosis-related pain, and those treated with DSG showed lower levels of dysmenorrhea, dyspareunia and nonmenstrual pelvic pain than COCs group (p < .01). After 12 months, in DSG Group some patients (15%) switched from DSG to a COC for breakthrough bleeding, whereas in COC Group 48% of patients switched to another type of COC for reduced efficacy on pain and/or for side effects. After 3 years of OC treatment, in DSG Group 79% of patients maintained the same therapy, whereas in COC Group only 14% continued the same COC type, 37% switched to another COC and 47% to DSG. CONCLUSIONS A progestin-only contraceptive with DSG is a valid option for long term management of endometriosis-related pain in patients seeking hormonal contraception.
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Affiliation(s)
- Silvia Vannuccini
- Obstetrics and Gynecology Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Chiara Biagiotti
- Obstetrics and Gynecology Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | | | - Francesco La Torre
- Obstetrics and Gynecology Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Sara Clemenza
- Obstetrics and Gynecology Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Gretha Orlandi
- Obstetrics and Gynecology Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Tommaso Capezzuoli
- Obstetrics and Gynecology Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Felice Petraglia
- Obstetrics and Gynecology Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
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Regidor PA, Palacios S, Colli E. Bleeding profile of women with cardiovascular risk factors using a drospirenone only pill with 4 mg over nine cycles compared to desogestrel 0.075 mg. Gynecol Endocrinol 2022; 38:333-338. [PMID: 35261299 DOI: 10.1080/09513590.2022.2046729] [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] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE Progestin-only pills are associated with irregular bleeding patterns, including amenorrhea. Desogestrel (DSG) 75 mcg, a pill that inhibits ovulation, shows poor cycle control that may harm acceptability and compliance. A Drospirenone (DRSP)-only pill was developed with 24 & 4 days of active & placebo days every 28-day cycle to improve cycle control. STUDY DESIGN A phase III study in healthy women aged 18 to 45 years was performed to compare the bleeding profile of women taking a DRSP versus DSG over nine cycles. 249 women were older > 35 years: 173 using DRSP and 73 DSG. 259 women had a BMI > 25 kg/m2: 189 using DRSP and 70 DSG and 340 women were smokers: 237 using DRSP and 103 DSG. The amount of unscheduled bleeding/spotting days was analyzed in each of these sub-groups and compared statistically. RESULTS Age: During cycles 2-4, the mean number of unscheduled bleeding days and spotting was 8.1 (SD10.53) for DRSP and 20.1 (19.41) for DSG; p = .0089. BMI > 25 kg/m2: During cycles 2-4 the mean number of unscheduled bleeding days and spotting was 7.8 (SD 12.18) for DRSP and 17.7 for DSG (SD 19.39); p = .0001. Smokers: During cycles 2-4, the mean number of unscheduled bleeding days and spotting was 9.6 (SD 11.69) for DRSP and 17.4 for DSG (SD 17.47); p = .0016. CONCLUSIONS These analyses show the improvement in the bleeding profile of women with specific cardiovascular risk factors using the DRSP only oral contraceptive product compared to DSG.ImplicationsAn improvement in the bleeding profile of women with specific cardiovascular risk factors like age > 35 years, BMI > 25kg/m2, and smokers using the DRSP only oral contraceptive product is described.Herby a higher contraceptive efficacy in these patients that additionally benefit from estrogen-free contraceptive methods is expected.
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Assiri GA, Bannan DF, Alshehri GH, Alshyhani M, Almatri W, Mahmoud MA. The Contraindications to Combined Oral Contraceptives among Reproductive-Aged Women in an Obstetrics and Gynaecology Clinic: A Single-Centre Cross-Sectional Study. Int J Environ Res Public Health 2022; 19:ijerph19031567. [PMID: 35162588 PMCID: PMC8835169 DOI: 10.3390/ijerph19031567] [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] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/15/2022] [Accepted: 01/26/2022] [Indexed: 02/06/2023]
Abstract
This study aimed to determine the estimated proportion of contraindications among women taking combined oral contraceptives (COCs) and to assess the risk factors associated with their contraindications. This study was cross-sectional. Reproductive-aged women (18–49 years) on any COCs between 2018 and 2020 were recruited from one obstetrics–gynaecology clinic in a university-affiliated hospital and were included. Contraindications were defined using the World Health Organization (WHO) Medical Eligibility Criteria (MEC) for Contraceptive Use. Data were collected from electronic medical records for all included women, as well as a standardised, pretested, structured survey for one-third of the women. In this cross-sectional study, 380 women using COCs were included. Their mean age was 31.645 ± 7.366 years. Among them, 131 (34.5%) participated via a survey and electronic records, while the other 249 (65.5%) participated via electronic records only. The majority of the participants had a Bachelor’s degree (59.0%) and were married (62.1%). The overall estimated proportion of patients with at least one contraindication to COCs according to category 3 (relative contraindications) or 4 (absolute contraindications) was 31.3% (95% CI 26.63–35.99). The most common contraindications observed were controlled hypertension, category 3 (12.1%); major surgery with prolonged immobilisation, category 4 (4.7%); migraine with aura at any age, category 4 (4.2%); breastfeeding from six weeks to less than six months postpartum, category 3 (4.0%); and diabetes mellitus with complications, category 4 (3.2%). Significant factors associated with contraindications to COCs were married women (OR 2.19, 95% CI 1.38–3.46), those aged 35 years or more (OR 2.33, 95% CI 1.49–3.66), and those with one or more live births (OR 2.19, 95% CI 1.38–3.46). Ensuring proper assessment prior to prescribing and considering alternatives suitable for long-term use among women taking an oral contraceptive regularly is recommended.
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Affiliation(s)
- Ghadah A. Assiri
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, P.O. Box 2454, Riyadh 11451, Saudi Arabia; (M.A.); (W.A.)
- Correspondence:
| | - Douha F. Bannan
- Pharmacy Practice Department, King Abdulaziz University, Jeddah 80260, Saudi Arabia;
| | - Ghadah H. Alshehri
- Pharmacy Practice Department, College of Pharmacy, Princess Nourah Bint Abdulrahman University, Riyadh 84428, Saudi Arabia;
| | - Manal Alshyhani
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, P.O. Box 2454, Riyadh 11451, Saudi Arabia; (M.A.); (W.A.)
| | - Walaa Almatri
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, P.O. Box 2454, Riyadh 11451, Saudi Arabia; (M.A.); (W.A.)
| | - Mansour A. Mahmoud
- Clinical and Hospital Pharmacy Department, College of Pharmacy, Tibah University, Al-Madinah Al-Munawarah 42353, Saudi Arabia;
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Zhu S, Ma X, Ding X, Gan J, Deng Y, Wang Y, Sun A. Comparative evaluation of low-level light therapy and ethinyl estradiol and desogestrel combined oral contraceptive for clinical efficacy and regulation of serum biochemical parameters in primary dysmenorrhoea: a prospective randomised multicentre trial. Lasers Med Sci 2022; 37:2239-2248. [PMID: 35028764 PMCID: PMC8758216 DOI: 10.1007/s10103-021-03490-z] [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: 07/27/2021] [Accepted: 12/03/2021] [Indexed: 11/26/2022]
Abstract
We aimed to compare low-level light therapy with oral contraceptive pills for pain relief and serum levels of nitric oxide and prostaglandin E2 in patients with primary dysmenorrhoea. This was a randomised, active comparator-controlled, multicentre study. In total, 156 patients were randomised to receive either low-level light therapy with light-emitting diodes (LED) applying on two acupoints, namely, conception vessel 4 (CV4) and CV6 or conventional treatment with oral Marvelon, 30 µg of ethinyl estradiol and 150 µg of desogestrel (DSG/EE), for three consecutive menstrual cycles. The main outcome was the proportion of patients who achieved 33% or more decrease in pain scores measured using the visual analogue scale, which was deemed as efficient rate. Absolute changes in visual analogue scale scores, serum levels of nitric oxide (assessed by nitrites and nitrates reflecting nitric oxide metabolism) and prostaglandin E2 (measured by enzyme-linked immunosorbent assay) were the secondary outcomes. A total of 135 patients completed the study (73 in the light therapy group and 62 in the DSG/EE group). The efficient rate at the end of treatment was comparable between the groups (73.6% vs. 85.7%, χ2 = 2.994, p = 0.084). A more significant reduction in pain scores was observed in the DSG/EE group (39.25% vs. 59.52%, p < 0.001). Serum levels of prostaglandin E2 significantly decreased from baseline but did not differ between groups (- 109.57 ± 3.99 pg/mL vs. - 118.11 ± 12.93 pg/mL, p = 0.51). Nitric oxide concentration remained stable in both groups. Low-level light therapy with LED-based device applied on acupuncture points CV4 and CV6 demonstrated a similar level of dysmenorrhoea pain reduction to DSG/EE combined contraceptive. Both treatment modalities achieved clinically meaningful levels of pain reduction. Registration on ClinicalTrials.gov: TRN: NCT03953716, Date: April 04, 2019.
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Affiliation(s)
- Shiyang Zhu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Shuaifuyuan No. 1, Dongcheng District, Beijing, China
| | - Xiao Ma
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Shuaifuyuan No. 1, Dongcheng District, Beijing, China
| | - Xuesong Ding
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Shuaifuyuan No. 1, Dongcheng District, Beijing, China
| | - Jingwen Gan
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Shuaifuyuan No. 1, Dongcheng District, Beijing, China
| | - Yan Deng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Shuaifuyuan No. 1, Dongcheng District, Beijing, China
| | - Yanfang Wang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Shuaifuyuan No. 1, Dongcheng District, Beijing, China
| | - Aijun Sun
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, Shuaifuyuan No. 1, Dongcheng District, Beijing, China.
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Morimont L, Haguet H, Dogné JM, Gaspard U, Douxfils J. Combined Oral Contraceptives and Venous Thromboembolism: Review and Perspective to Mitigate the Risk. Front Endocrinol (Lausanne) 2021; 12:769187. [PMID: 34956081 PMCID: PMC8697849 DOI: 10.3389/fendo.2021.769187] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/08/2021] [Indexed: 12/02/2022] Open
Abstract
Many factors must be considered and discussed with women when initiating a contraceptive method and the risk of venous thromboembolism (VTE) is one of them. In this review, we discuss the numerous strategies that have been implemented to reduce the thrombotic risk associated with combined oral contraceptives (COCs) from their arrival on the market until today. Evidences suggesting that COCs were associated with an increased risk of VTE appeared rapidly after their marketing. Identified as the main contributor of this risk, the dosage of the estrogen, i.e., ethinylestradiol (EE), was significantly reduced. New progestins were also synthetized (e.g., desogestrel or gestodene) but their weak androgenic activity did not permit to counterbalance the effect of EE as did the initial progestins such as levonorgestrel. Numerous studies assessed the impact of estroprogestative combinations on hemostasis and demonstrated that women under COC suffered from resistance towards activated protein C (APC). Subsequently, the European Medicines Agency updated its guidelines on clinical investigation of steroid contraceptives in which they recommended to assess this biological marker. In 2009, estradiol-containing COCs were marketed and the use of this natural form of estrogen was found to exert a weaker effect on the synthesis of hepatic proteins compared to EE. In this year 2021, a novel COC based on a native estrogen, i.e., estetrol, will be introduced on the market. Associated with drospirenone, this preparation demonstrated minor effects on coagulation proteins as compared with other drospirenone-containing COCs. At the present time, the standard of care when starting a contraception, consists of identifying the presence of hereditary thrombophilia solely on the basis of familial history of VTE. This strategy has however been reported as poorly predictive of hereditary thrombophilia. One rationale and affordable perspective which has already been considered in the past could be the implementation of a baseline screening of the prothrombotic state to provide health care professionals with objective data to support the prescription of the more appropriate contraceptive method. While this strategy was judged too expensive due to limited laboratory solutions, the endogenous thrombin potential-based APC resistance assay could now represent an interesting alternative.
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Affiliation(s)
- Laure Morimont
- Research Department, Qualiblood s.a., Namur, Belgium
- Faculty of Medicine, Department of Pharmacy, Namur Research Institute for Life Sciences (NARILIS), Namur Thrombosis and Hemostasis Center (NTHC), University of Namur, Namur, Belgium
| | - Hélène Haguet
- Research Department, Qualiblood s.a., Namur, Belgium
- Faculty of Medicine, Department of Pharmacy, Namur Research Institute for Life Sciences (NARILIS), Namur Thrombosis and Hemostasis Center (NTHC), University of Namur, Namur, Belgium
| | | | - Ulysse Gaspard
- Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium
| | - Jonathan Douxfils
- Research Department, Qualiblood s.a., Namur, Belgium
- Faculty of Medicine, Department of Pharmacy, Namur Research Institute for Life Sciences (NARILIS), Namur Thrombosis and Hemostasis Center (NTHC), University of Namur, Namur, Belgium
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40
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Abstract
Combined hormonal contraception (CHC) are short-acting, reversible methods containing both estrogen and progestin. Available CHC methods include combined oral contraceptives, transdermal patches, and vaginal rings. The combined oral contraceptive remains the most commonly used contraceptive method in the United States. The general principles of CHC will be reviewed, including mechanism of action and effectiveness. Unless otherwise stated, these principles apply to all CHCs. When discussing clinical studies and specific considerations related only to pills, patches, or rings, the method(s) will be specified. Words that specify sex are used when discussing studies in which sex was specified.
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Affiliation(s)
- Nisha Verma
- Department of GYN/OB, Emory University School of Medicine, Atlanta, Georgia
| | - Carrie Cwiak
- Department of GYN/OB, Emory University School of Medicine, Atlanta, Georgia
| | - Andrew M Kaunitz
- Department of Obstetrics & Gynecology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
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Kumarendran B, O'Reilly MW, Subramanian A, Šumilo D, Toulis K, Gokhale KM, Wijeratne CN, Coomarasamy A, Tahrani AA, Azoulay L, Arlt W, Nirantharakumar K. Polycystic Ovary Syndrome, Combined Oral Contraceptives, and the Risk of Dysglycemia: A Population-Based Cohort Study With a Nested Pharmacoepidemiological Case-Control Study. Diabetes Care 2021; 44:2758-2766. [PMID: 34649997 PMCID: PMC8669537 DOI: 10.2337/dc21-0437] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 09/08/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Irregular menstrual cycles are associated with increased cardiovascular mortality. Polycystic ovary syndrome (PCOS) is characterized by androgen excess and irregular menses; androgens are drivers of increased metabolic risk in women with PCOS. Combined oral contraceptive pills (COCPs) are used in PCOS both for cycle regulation and to reduce the biologically active androgen fraction. We examined COCP use and risk of dysglycemia (prediabetes and type 2 diabetes) in women with PCOS. RESEARCH DESIGN AND METHODS Using a large U.K. primary care database (The Health Improvement Network [THIN]; 3.7 million patients from 787 practices), we carried out a retrospective population-based cohort study to determine dysglycemia risk (64,051 women with PCOS and 123,545 matched control subjects), as well as a nested pharmacoepidemiological case-control study to investigate COCP use in relation to dysglycemia risk (2,407 women with PCOS with [case subjects] and without [control subjects] a diagnosis of dysglycemia during follow-up). Cox models were used to estimate the unadjusted and adjusted hazard ratio, and conditional logistic regression was used to obtain adjusted odds ratios (aORs). RESULTS The adjusted hazard ratio for dysglycemia in women with PCOS was 1.87 (95% CI 1.78-1.97, P < 0.001; adjustment for age, social deprivation, BMI, ethnicity, and smoking), with increased rates of dysglycemia in all BMI subgroups. Women with PCOS and COCP use had a reduced dysglycemia risk (aOR 0.72, 95% CI 0.59-0.87). CONCLUSIONS In this study, limited by its retrospective nature and the use of routinely collected electronic general practice record data, which does not allow for exclusion of the impact of prescription-by-indication bias, women with PCOS exposed to COCPs had a reduced risk of dysglycemia across all BMI subgroups. Future prospective studies should be considered for further understanding of these observations and potential causality.
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Affiliation(s)
- Balachandran Kumarendran
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, U.K
- Department of Community and Family Medicine, Faculty of Medicine, University of Jaffna, Kokkuvil, Sri Lanka
| | - Michael W O'Reilly
- Department of Medicine, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Republic of Ireland
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, U.K
| | - Anuradhaa Subramanian
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, U.K
| | - Dana Šumilo
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, U.K
| | - Konstantinos Toulis
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, U.K
| | - Krishna M Gokhale
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, U.K
| | - Chandrika N Wijeratne
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Arri Coomarasamy
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, U.K
| | - Abd A Tahrani
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, U.K
| | - Laurent Azoulay
- Department of Epidemiology, Biostatistics and Occupational Health and Gerald Bronfman Department of Oncology, McGill University, Toronto, Canada
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, U.K.
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, U.K
| | - Krishnarajah Nirantharakumar
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, U.K.
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, U.K
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Abstract
BACKGROUND This case discusses the challenges created by COVID-19 (coronavirus disease 2019) in the area of hormonal contraception, highlighting the contraception knowledge gap for women in their post COVID-19 period, especially if they had high D-dimer levels. CASE PRESENTATION This case involves a thirty-eight-year-old woman taking combined oral contraception (desogestrel/ethinyl oestradiol tablets) with a history of varicose veins. She recovered from a COVID-19 infection in November 2020. She presented to the emergency room with right lower-limb pain below the knee and progressive swelling for five days in February 2021. Physical examination of the lower limb showed mild swelling and tenderness of the right leg compared to the left leg. D-Dimer was elevated (1.06 mcg/mL FEU). COVID-19 screening was negative. A Doppler scan to exclude DVT was performed considering the clinical picture and high D-dimer level. There was no evidence of DVT in the right limb. She was reassured and discharged with instructions on when to visit the emergency room. The D-dimer had decreased to 0.53 mcg/mL FEU in March 2021. She booked an appointment with family medicine clinics because she was concerned about the continuation of combined oral contraception (desogestrel/ethinyl oestradiol tablets) with high D-dimer and risk of thrombosis. The follow-up D-dimer level in May 2021 was normal (0.4 mcg/mL FEU). The patient preferred to continue taking oral contraception. CONCLUSION An evidence-based consensus is needed to guide clinicians in providing contraception counselling for such patients.
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Affiliation(s)
- Nada A Alyousefi
- Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
- King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia.
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Estetrol/drospirenone (Nextstellis) - a new combination oral contraceptive. Med Lett Drugs Ther 2021; 63:101-2. [PMID: 34181632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
MESH Headings
- Administration, Oral
- Androstenes/administration & dosage
- Androstenes/adverse effects
- Contraceptives, Oral/administration & dosage
- Contraceptives, Oral/adverse effects
- Contraceptives, Oral, Combined/administration & dosage
- Contraceptives, Oral, Combined/adverse effects
- Contraceptives, Oral, Hormonal/administration & dosage
- Contraceptives, Oral, Hormonal/adverse effects
- Drug Administration Schedule
- Drug Interactions
- Estetrol/administration & dosage
- Estetrol/adverse effects
- Female
- Humans
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Gunaratne MDSK, Thorsteinsdottir B, Garovic VD. Combined Oral Contraceptive Pill-Induced Hypertension and Hypertensive Disorders of Pregnancy: Shared Mechanisms and Clinical Similarities. Curr Hypertens Rep 2021; 23:29. [PMID: 33982185 DOI: 10.1007/s11906-021-01147-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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] [Accepted: 04/22/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Oral contraceptive pill-induced hypertension (OCPIH) and hypertensive disorders in pregnancy (HDP) share common risk factors and pathophysiological mechanisms, yet the bidirectional relationship between these two conditions is not well-established. We review and describe OCPIH and HDP to better understand how hormonal and metabolic imbalances affect hypertension. RECENT FINDINGS Oral contraceptive pills continue to be a popular method of contraception, with an incidence of OCPIH ranging from 1-8.5% among OCP users. HDP have an incidence of 5-10% of all pregnancies in the USA and have been shown to be a powerful predictor of lifetime adverse cardiovascular outcomes, including future hypertension. OCPIH and HDP share common risk factors such as age, BMI, past personal and family history of hypertension, as well as pathogenic mechanisms, including alterations in hormonal metabolism and the renin angiotensin aldosterone system; imbalance of vasodilator-vasoconstrictor compounds; and changes in the cardiovascular system. Future research should address additional potential mechanisms that underlie hypertension in these two conditions where endocrine changes, either physiological (pregnancy) or iatrogenic (use of OCP), play a role. This may lead to novel, targeted treatment options to improve hypertension management and overall cardiovascular risk profile management in this subset of young female patients.
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Affiliation(s)
- Madugodaralalage D S K Gunaratne
- Division of Nephrology and Hypertension, Department of Internal Medicine, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN, USA
| | - Bjorg Thorsteinsdottir
- Mayo Clinic KERN Center for the Science of Health Care Delivery and the Knowledge Evaluation and Research Unit, Division of Community Internal Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Vesna D Garovic
- Division of Nephrology and Hypertension, Department of Internal Medicine, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN, USA.
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Abstract
Polycystic ovary syndrome (PCOS) is a common endocrine disorder in reproductive-aged women, characterized by hyperandrogenism, oligo/anovulation, and polycystic ovarian morphology. Combined oral contraceptives (COCs), along with lifestyle modifications, represent the first-line medical treatment for the long-term management of PCOS. Containing low doses of estrogen and different types of progestin, COCs restore menstrual cyclicity, improve hyperandrogenism, and provide additional benefits such as reducing the risk of endometrial cancer. However, potential cardiometabolic risk associated with these agents has been a concern. COCs increase the risk of venous thromboembolism (VTE), related both to the dose of estrogen and the type of progestin involved. Arterial thrombotic events related to COC use occur much less frequently, and usually not a concern for young patients. All patients diagnosed with PCOS should be carefully evaluated for cardiometabolic risk factors at baseline, before initiating a COC. Age, smoking, obesity, glucose intolerance or diabetes, hypertension, dyslipidemia, thrombophilia, and family history of VTE should be recorded. Patients should be re-assessed at consecutive visits, more closely if any baseline cardiometabolic risk factor is present. Individual risk assessment is the key in order to avoid unfavorable outcomes related to COC use in women with PCOS.
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Affiliation(s)
- Seda Hanife Oguz
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Bulent Okan Yildiz
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
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46
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Dorgham N, Sharobim A, Haggag H, El-Kalioby M, Dorgham D. Adding Combined Oral Contraceptives or Metformin to Laser Treatment in Polycystic Ovarian Syndrome Hirsute Patients. J Drugs Dermatol 2021; 20:302-306. [PMID: 33683076 DOI: 10.36849/jdd.5652] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Hirsutism is estimated to affect 10% to 20% of females, provoking significant psychological damage and social embarrassment. Polycystic ovary syndrome is a major cause of hirsutism. AIM Assessing the impact of adding combined oral contraceptives (COCs) or metformin to laser hair removal on the quality of life of polycystic ovarian syndrome (PCOS) patients with hirsutism. METHODOLOGY One-hundred-fifty PCO patients diagnosed with hirsutism were included in this study. Patients were randomized into three groups: group 1 received laser hair removal alone, group 2 received metformin and laser hair removal, and group 3 received COCs and laser hair removal. A diode laser with a wavelength of 810 nm was used for hair removal in all patients according to a protocol of 6 monthly sessions followed by another two sessions after three and six months. Patients were assessed using a visual analog scale (VAS) and Dermatology Life Quality Index (DLQI) and a customized questionnaire (Hirsutism Life Quality Index; HLQI). RESULTS All patients showed a significant improvement in both quality indices (DLQI and HLQI) after treatment relative to pretreatment. Group 3 showed significantly better improvements when compared with group 2 and group 1. At three and six months, group 3 showed non-significantly better DLQI and HLQI as compared with at zero months. On the other hand, group 2 patients displayed significant worsening of both DLQI and HLQI scores at three months, with subsequent improvements again at six. Finally, group 1 patients showed nonsignificant worsening at three months, and significant worsening at 6 months. CONCLUSION Combining hormonal treatment with laser hair removal can achieve greater hair reduction, significant improvements in patients' QOL, and better maintenance as compared with when combining metformin with laser hair removal or conducting alone. J Drugs Dermatol. 2021;20(3):302-306. doi:10.36849/JDD.5652.
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Garg V, Choi JK, James WD, Barbieri JS. Long-term use of spironolactone for acne in women: A case series of 403 patients. J Am Acad Dermatol 2021; 84:1348-1355. [PMID: 33434594 DOI: 10.1016/j.jaad.2020.12.071] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [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: 10/03/2020] [Revised: 12/26/2020] [Accepted: 12/28/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND There are limited data regarding the long-term outcomes of spironolactone use for women with acne and its effect on truncal acne. OBJECTIVE To comprehensively describe outcomes of patients treated with spironolactone in routine clinical practice, including long-term outcomes. METHODS We performed a retrospective case series of 403 adult women treated for acne with spironolactone at an academic medical center between 2008 and 2019. Rates of objective, as assessed by Comprehensive Acne Severity Scale scores, and subjective acne clearance were evaluated, as well as rates of treatment discontinuation, dosage changes, and drug survival. Logistic regression was used to assess for association between incidence of menstrual adverse effects and combined oral contraceptive use. RESULTS As evaluated by Comprehensive Acne Severity Scale scores, at the first follow-up, 75.5%, 84.0%, and 80.2% of patients with available data had reduction or complete clearance of acne on the face, chest, and back, respectively. The mean drug survival was 470.7 days. Menstrual adverse effects were less common among those using combined oral contraception (odds ratio, 0.23; 95% confidence interval, 0.11-0.50). LIMITATIONS This study was conducted at a single academic medical center. CONCLUSIONS Spironolactone improves clinical outcomes and is well tolerated for many adult women with acne using it for an extended duration.
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Affiliation(s)
- Vaibhav Garg
- Department of Dermatology and Cutaneous Biology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Juliana K Choi
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - William D James
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - John S Barbieri
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
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48
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Blondon M, Casini A, Fontana P, Hugon-Rodin J. [Contraception and venous thromboembolism]. Rev Med Suisse 2020; 16:2383-2386. [PMID: 33300698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Combined oral contraceptives remain in 2020 the most used contraceptive method in Switzerland and Europe, and are found in about half of venous thromboembolism (VTE) occurring in women aged up to 50 years. In this narrative review, we describe the determinants of the VTE risk, related to the types of oral contraceptives and to genetic or acquired risk factors of users, while summarizing several current recommendations of prescription for contraceptives. The complex management of contraception at the time of VTE should be discussed with patients, in order to minimize the risks of undesired pregnancy, abnormal uterine bleeding and recurrent VTE.
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Affiliation(s)
- Marc Blondon
- Service d'angiologie et d'hémostase, HUG, 1211 Genève 14, et Faculté de médecine, Université de Genève, 1211 Genève 4
| | - Alessandro Casini
- Service d'angiologie et d'hémostase, HUG, 1211 Genève 14, et Faculté de médecine, Université de Genève, 1211 Genève 4
| | - Pierre Fontana
- Service d'angiologie et d'hémostase, HUG, 1211 Genève 14, et Faculté de médecine, Université de Genève, 1211 Genève 4
| | - Justine Hugon-Rodin
- Service de gynécologie, Groupe hospitalier Paris Saint-Joseph, INSERM, Obstetrical, perinatal and pediatric epidemiology research team, Center for epidemiology and statistics, Rue Raymond-Losserand 185, 75014 Paris
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49
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Mosorin ME, Haverinen A, Ollila MM, Nordström T, Jokelainen J, Keinänen-Kiukaanniemi S, Puukka K, Ruokonen A, Auvinen J, Piltonen T, Morin-Papunen L, Tapanainen JS. Current use of combined hormonal contraception is associated with glucose metabolism disorders in perimenopausal women. Eur J Endocrinol 2020; 183:619-626. [PMID: 33105101 DOI: 10.1530/eje-20-0406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 09/28/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The use of combined hormonal contraceptives (CHCs) worsens glucose tolerance, but the risk for glucose metabolism disorders remains controversial. DESIGN The study is a prospective longitudinal population-based cohort study. METHODS The study was based on a cohort population that comprised 1879 women born in 1966. At age 46, the women answered a questionnaire on contraceptive use and underwent an oral glucose tolerance test. Glucose metabolism indices were evaluated in current CHC (n = 153), progestin-only contraceptive (POC, n = 842), and non-hormonal contraceptive users (n = 884). RESULTS In the entire study population, current CHC use was significantly associated with prediabetes (OR: 2.0, 95% CI: 1.3-3.2) and type 2 diabetes (OR: 3.3, 95% CI: 1.1-9.7) compared to non-hormonal contraceptive use. After 5 years of use, the prediabetes risk increased 2.2-fold (95% CI: 1.3-3.7) and type 2 diabetes risk increased 4.5-fold (95% CI: 1.5-13.5). Compared with the current POC use, current CHC use was significantly associated with prediabetes (OR: 1.9, 95% CI: 1.2-3.0). Current POC use was not associated with any glucose metabolism disorders. The results prevailed after adjusting for BMI and socioeconomic status. CONCLUSIONS CHC use in perimenopausal women was associated with a significantly increased risk of glucose metabolism disorders. This association should be considered in women with increased metabolic risk.
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Affiliation(s)
- Maria-Elina Mosorin
- Department of Obstetrics and Gynecology, Oulu University Hospital, University of Oulu and Medical Research Center, and PEDEGO Research Unit (Research Unit for Pediatrics, Dermatology, Clinical Genetics, Obstetrics and Gynecology), Oulu, Finland
| | - Annina Haverinen
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Meri-Maija Ollila
- Department of Obstetrics and Gynecology, Oulu University Hospital, University of Oulu and Medical Research Center, and PEDEGO Research Unit (Research Unit for Pediatrics, Dermatology, Clinical Genetics, Obstetrics and Gynecology), Oulu, Finland
| | - Tanja Nordström
- Center for Life Course Health Research, University of Oulu, Oulu, Finland
- Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Jari Jokelainen
- Center for Life Course Health Research, University of Oulu, Oulu, Finland
- Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Sirkka Keinänen-Kiukaanniemi
- Center for Life Course Health Research, University of Oulu, Oulu, Finland
- Unit of General Practice, Oulu University Hospital, Oulu, Finland
| | - Katri Puukka
- Nordlab Oulu, Medical Research Center Oulu, Oulu University Hospital and Department of Clinical Chemistry, University of Oulu, Oulu, Finland
| | - Aimo Ruokonen
- Nordlab Oulu, Medical Research Center Oulu, Oulu University Hospital and Department of Clinical Chemistry, University of Oulu, Oulu, Finland
| | - Juha Auvinen
- Center for Life Course Health Research, University of Oulu, Oulu, Finland
- Unit of General Practice, Oulu University Hospital, Oulu, Finland
| | - Terhi Piltonen
- Department of Obstetrics and Gynecology, Oulu University Hospital, University of Oulu and Medical Research Center, and PEDEGO Research Unit (Research Unit for Pediatrics, Dermatology, Clinical Genetics, Obstetrics and Gynecology), Oulu, Finland
| | - Laure Morin-Papunen
- Department of Obstetrics and Gynecology, Oulu University Hospital, University of Oulu and Medical Research Center, and PEDEGO Research Unit (Research Unit for Pediatrics, Dermatology, Clinical Genetics, Obstetrics and Gynecology), Oulu, Finland
| | - Juha S Tapanainen
- Department of Obstetrics and Gynecology, Oulu University Hospital, University of Oulu and Medical Research Center, and PEDEGO Research Unit (Research Unit for Pediatrics, Dermatology, Clinical Genetics, Obstetrics and Gynecology), Oulu, Finland
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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50
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Fraison E, Kostova E, Moran LJ, Bilal S, Ee CC, Venetis C, Costello MF. Metformin versus the combined oral contraceptive pill for hirsutism, acne, and menstrual pattern in polycystic ovary syndrome. Cochrane Database Syst Rev 2020; 8:CD005552. [PMID: 32794179 PMCID: PMC7437400 DOI: 10.1002/14651858.cd005552.pub3] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Metformin has been proposed as possibly a safer and more effective long-term treatment than the oral contraceptive pill (OCP) in women with polycystic ovary syndrome (PCOS). It is important to directly compare the efficacy and safety of metformin versus OCP in the long-term treatment of women with PCOS. This is an update of a Cochrane Review comparing insulin sensitising agents with the OCP and only includes studies on metformin. OBJECTIVES To assess the effectiveness and safety of metformin versus the OCP (alone or in combination) in improving clinical, hormonal, and metabolic features of PCOS. SEARCH METHODS In August 2019 we searched the Cochrane Gynaecology and Fertility Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and CINAHL, the trial registers, handsearched references of the identified articles, and contacted experts in the field to identify additional studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) of the use of metformin versus the OCP (alone or in combination) for women with PCOS. DATA COLLECTION AND ANALYSIS We used standard methods recommended by Cochrane. The primary review outcomes were the clinical parameters of hirsutism and adverse events, both severe (requiring stopping of medication), and minor. In the presence of substantial heterogeneity (I2 statistic > 50), which could be explained by pre-specified subgroup analyses on the basis of BMI, we reported the subgroups separately. MAIN RESULTS This is a substantive update. We identified 38 additional studies. We included 44 RCTs (2253 women), which comprised 39 RCTs on adult women (2047 women) and five RCTs on adolescent women (206 women). Evidence quality ranged from very low to low. The main limitations were risk of bias, imprecision and inconsistency. Metformin versus the OCP In adult women, we are uncertain of the effect of metformin compared to the OCP on hirsutism in subgroup body mass index (BMI) < 25 kg/m2 (mean difference (MD) 0.38, 95% confidence interval (CI) -0.44 to 1.19, 3 RCTs, n = 134, I2 = 50%, very low-quality evidence) and subgroup BMI > 30 kg/m2 (MD -0.38, 95% CI -1.93 to 1.17; 2 RCTs, n = 85, I2 = 34%, low-quality evidence). Metformin may be less effective in improving hirsutism compared to the OCP in the subgroup BMI 25 kg/m2 to 30 kg/m2 (MD 1.92, 95% CI 1.21 to 2.64, 5 RCTs, n = 254, I2 = 0%, low-quality evidence). Metformin may increase severe gastro-intestinal adverse events rate compared to the OCP (Peto odds ratio (OR) 6.42, 95% CI 2.98 to 13.84, 11 RCTs, n = 602, I2 = 0%, low-quality evidence). Metformin may decrease the incidence of severe other adverse events compared to the OCP (Peto OR 0.20, 95% CI 0.09 to 0.44, 8 RCTs, n = 363, I2 = 0%, low-quality evidence). There were no trials reporting on minor adverse events. In adolescents, we are uncertain whether there is a difference between Metformin and the OCP, on hirsutism and adverse events. Metformin versus metformin combined with the OCP In adult women, metformin may be less effective in improving hirsutism compared to Metformin combined with the OCP (MD 1.36, 95% CI 0.62 to 2.11, 3 RCTs, n = 135, I2= 9%, low-quality evidence). We are uncertain if there was a difference between metformin and metformin combined with the OCP for severe gastro-intestinal adverse events (OR 0.74, 95% CI 0.21 to 2.53, 3 RCTs, n = 171, I2 = 0%, low-quality evidence), or for severe other adverse events (OR 0.56, 95% CI 0.11 to 2.82, 2 RCTs, n = 109, I2 = 44%, low-quality evidence). There were no trials reporting on minor adverse events. In adolescents, there were no trials for this comparison. The OCP versus metformin combined with the OCP In adult women, the OCP may be less effective in improving hirsutism compared to metformin combined with the OCP (MD 0.54, 95% CI 0.20 to 0.89, 6 RCTs, n = 389, I2= 1%, low-quality evidence). The OCP may decrease the incidence of severe gastro-intestinal adverse events compared to metformin combined with the OCP (OR 0.20, 95% CI 0.06 to 0.72, 5 RCTs, n = 228, I2 = 0%, low-quality evidence). We are uncertain if there is a difference between the OCP and metformin combined with the OCP for severe other adverse events (OR 1.61, 95% CI 0.49 to 5.37, 4 RCTs, n = 159, I2 = 12%, low-quality evidence). The OCP may decrease the incidence of minor (gastro-intestinal) adverse events compared to metformin combined with the OCP (OR 0.06, 95% CI 0.01 to 0.44, 2 RCTs, n = 98, I2 = 0%, low-quality evidence). In adolescents, we are uncertain whether there is a difference between the OCP, compared to metformin combined with the OCP, on hirsutism or adverse events. AUTHORS' CONCLUSIONS In adult women with PCOS, metformin may be less effective in improving hirsutism compared to the OCP in the subgroup BMI 25 kg/m2 to 30 kg/m2 but we are uncertain if there was a difference between metformin and the OCP in subgroups BMI < 25 kg/m2 and BMI > 30kg/m2. Compared to the OCP, metformin may increase the incidence of severe gastro-intestinal adverse events and decrease the incidence of severe other adverse events with no trials reporting on minor adverse events. Either metformin alone or the OCP alone may be less effective in improving hirsutism compared to metformin combined with the OCP. We are uncertain whether there is a difference between the OCP alone and metformin alone compared to metformin combined with the OCP for severe or minor adverse events except for the OCP versus metformin combined with the OCP where the OCP may decrease the incidence of severe and minor gastro-intestinal adverse events. In adolescent women with PCOS, we are uncertain whether there is a difference between any of the comparisons for hirsutism and adverse events due to either no evidence or very low-quality evidence. Further large well-designed RCTs that stratify for BMI are needed to evaluate metformin versus the OCP and combinations in women with PCOS, in particular adolescent women.
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Affiliation(s)
- Eloise Fraison
- Department of Gynecology and Obstetrics, Hôpital Femme Mère Enfant, Bron, France
| | - Elena Kostova
- Center for Reproductive Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Lisa J Moran
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Australia
| | - Sophia Bilal
- Department of Obstetrics and Gynaecology, Westmead Hospital, Westmead, Australia
| | - Carolyn C Ee
- NICM Health Research Institute, Western Sydney University, Penrith, Australia
| | - Christos Venetis
- Centre for Big Data Research in Health & School of Women's & Children's Health, UNSW Medicine, Sydney, Australia
| | - Michael F Costello
- Division of Obstetrics & Gynaecology, School of Women's and Children's Health, UNSW and Royal Hospital for Women and IVF Australia, Sydney, Australia
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