Effects of desogestrel on carbohydrate metabolism

Differential off-target glucocorticoid activity of progestins used in endocrine therapy

The glucocorticoid receptor (GR) regulates transcription of genes involved in multiple processes. Medroxyprogesterone acetate (MPA), widely used in the injectable contraceptive Depo-MPA (DMPA), has off-target effects via the GR, which may result in side-effects in endocrine therapy. However, very little is known about the GR activity of other progestins used in endocrine therapy. This study compared GR activities for several progestins, using whole cell binding, dose-response, and GR phosphorylation assays, in both a cell line model and peripheral blood mononuclear cells (PBMCs). MPA, etonogestrel (ETG) and nestorone (NES) exhibit greater relative binding affinities for the GR than levonorgestrel (LNG) and norethisterone/norethindrone (NET) and are partial GR agonists for transactivation but agonists for transrepression on synthetic promoters in COS-1 cells. MPA is a potent agonist for endogenous GR-regulated GILZ and IL6 genes in PBMCs. While ETG and NES also display agonist activity on IL6, they have little effect on GILZ. In contrast, LNG and NET exhibit little to no activity in transactivation models, while both exhibit some transrepressive activity but are generally less potent and/or efficacious than MPA. Antagonist and phosphorylation assays confirmed that MPA and NES act via the GR on endogenous genes in PBMCs. Our results suggest GR-mediated dose-dependent and gene-specific transcriptional side-effects are likely to occur at physiologically relevant concentrations in vivo for MPA, may possibly occur selectively for ETG and NES, but are unlikely to occur for LNG and NET. This suggests that these progestins will exhibit differential side-effects in endocrine therapy via the GR.

Clinical pharmacology of progestins

INTRODUCTION

In this paper, we report general pharmacological profile and major biological activities of natural progesterone (P) and progestins. The aim of this article consists of synthesizing the principal aspects of pharmacology and metabolism of P and progestins related to the clinical consequences of their use.

METHODS

We review scientific literature on the topic "Progestins", evaluating the most relevant data from original articles, reviews and meta-analyses.

EVIDENCE SYNTHESIS

Progestins represent a specific class of synthetic analogues of P clinically employed (alone or associated with estrogens) to manage several gynaecological conditions, for instance multiple abortions, luteal phase defect, premenstrual syndrome, abnormal uterine bleeding, endometriosis and menopause (for hormone replacement therapy). Besides their use in the field of contraception, many non-contraceptive benefits of estroprogestins are mostly due to the activities of progestins. Pharmacological characteristics, dosage and individual metabolism could be listed among the principal aspects influencing their clinical effects.

CONCLUSIONS

The choice of each progestin according to its pharmacological profile is crucial for the appropriate management of any gynaecological condition. An aware knowledge of these compounds is fundamental to hone medical practice.

Safety and Benefits of Contraceptives Implants: A Systematic Review

Progestin-only contraceptive implants provide long-acting, highly effective reversible contraception. We searched the medical publications in PubMed, CENTRAL, and EMBASE for relevant articles on hormonal implants published in English between 1990 and 2021. Levonorgestrel (LNG) 6-capsule subdermal implants represented the first effective system approved for reversible contraception. The etonogestrel (ENG) single rod dispositive has been widely employed in clinical practice, since it is a highly effective and safe contraceptive method. Abnormal menstrual bleeding is a common ENG side effect, representing the main reason for its premature discontinuation. Emerging evidence demonstrated that it is possible to extend the use of the ENG implant beyond the three-year period for which it is approved. The ENG implant could be an effective and discrete alternative to the IUD in young girls, such as post-partum/post-abortion. Implants should be inserted by trained skilled clinicians who previously provide adequate counselling about their contraceptive effect, benefits, and any possible adverse events. More studies are needed to validate the extended use of the ENG implant for up to 5 years.

Oral contraceptives and cardiovascular risk in women with polycystic ovary syndrome

Because women affected by polycystic ovary syndrome (PCOS) present an increased cardiovascular risk, the safety of estroprogestin treatment is debated and contrasting data have been reported. However, cardiovascular risk is not the same in all PCOS women and individual cardiovascular risk should be assessed before staring any estroprogestin treatment. The available data show that products containing both 2nd-generation and 3rd-generation progestins (including drospirenone and cyproterone acetate) represent a safe treatment in PCOS patients with regular cardiovascular risk. In PCOS patients with increased cardiovascular risk, a careful choice of estroprogestin product is needed and cardiovascular risk should be monitored during treatment. In obese PCOS patients with normal glucose tolerance and lipid profile, products containing 2nd-generation progestins may be preferred because of lower venous thromboembolism risk. In PCOS patients with altered lipid profile or glucose intolerance, 3rd-generation progestins should be used but, during treatment, cardiovascular risk should be periodically re-assessed. In special situations, metformin or statins may be added to estroprogestin treatment.

Hormonal Contraception and Diabetes

Women with gestational diabetes mellitus are at increased risk for developing diabetes mellitus (DM), mainly type 2 DM, as well as metabolic syndrome. The presence of subsequent pregnancies increases the risk. In addition, pregnancy in patients with type 1 and type 2 DM also elevates the risk of morbidity and mortality for both mothers and offspring. Thus, all women with pre-existing type 1 or type 2 DM should receive preconception care to optimize glycemic control (HbA1c ≤ 6%). In those cases with macrovascular or microvascular complications, family planning is even more important in order to avoid the risk of aggravation of such complications associated with a new pregnancy. The present review analyzes the metabolic and cardiovascular repercussions of hormone contraception in non-diabetic women as well as in type 1 and type 2 DM patients with and without macrovascular and microvascular complications. Finally, the recommendations pertaining to hormonal contraceptive methods for women with diabetes are summarized.

Estrogen-free oral hormonal contraception: benefits of the progestin-only pill

Although combined oral contraceptives (COCs) are commonly used and highly effective in preventing pregnancy, they may not be suitable for some women. COC use is associated with increased rates of cardiovascular events and is not recommended in nonbreastfeeding women in the immediate postpartum period or in breastfeeding women during the initial 6 months of breastfeeding. Moreover, estrogen-related adverse effects, such as headache, are common. Estrogen-free progestin-only pills (POPs) are a valuable option in women who prefer to take an oral hormonal contraceptive, but are ineligible for, or choose not to use, COCs. Although some POPs have been associated with lower contraceptive effectiveness than COCs, the POP containing desogestrel has shown similar contraceptive effectiveness to COCs. The most commonly reported complaints in women using all POPs are bleeding problems. Counseling women interested in using POPs about the variable bleeding patterns associated with this method may improve compliance and acceptance.

A comparative study on the effects of a contraceptive vaginal ring NuvaRing®and an oral contraceptive on carbohydrate metabolism and adrenal and thyroid function

OBJECTIVES

To compare carbohydrate metabolism, adrenal and thyroid function during use of a combined contraceptive vaginal ring (NuvaRing, NV Organon, Oss, The Netherlands) with those of a combined oral contraceptive.

METHODS

Healthy women aged 18-40 years used either the vaginal ring, delivering 15 microg ethinylestradiol and 120 microg of etonogestrel per day, or a combined oral contraceptive containing 30 microg ethinylestradiol and 150 microg levonorgestrel, for six cycles. Each cycle comprised 3 weeks of use of the ring or the pill followed by 1 ring- or pill-free week. The following parameters were measured at baseline and at the end of cycles 3 and 6: carbohydrate metabolism (glucose, insulin, glycosylated hemoglobin); adrenal function (total cortisol, cortisol binding globulin, dehydroepiandrosterone sulfate); thyroid function (thyroid stimulating hormone, free thyroxine).

RESULTS

Small and similar increases in insulin were seen in both groups. Concentrations of cortisol binding globulin and total cortisol rose significantly less during ring use than during combined oral contraceptive use (cycle 3, p= 0.0002; cycle 6, p < 0.0001). Levels of dehydroepiandrosterone sulfate did not change in either group. Thyroid stimulating hormone levels increased significantly more in the ring group at cycle 3 (p = 0.0016) but free thyroxine levels were unchanged in both groups.

CONCLUSIONS

Both the vaginal ring and the oral contraceptive have no clinically relevant effects on carbohydrate metabolism, adrenal or thyroid function.

Dienogest is a selective progesterone receptor agonist in transactivation analysis with potent oral endometrial activity due to its efficient pharmacokinetic profile

Dienogest was introduced as an oral progestin. Yet its strong oral potency on endometrial activity is not clearly explained. To circumvent this situation, steroid hormone receptor profiling using transactivation assay and endometrial activity test in rabbits were carried out with determination of plasma drug concentration. Agonistic/antagonistic activity on human progesterone receptor (PR), androgen receptor (AR), glucocorticoid receptor (GR), mineralocorticoid receptor (MR), estrogen receptor alpha (ERalpha), or estrogen receptor beta (ERbeta) were determined. Dienogest activate PR (EC50=3.4 or 10.5 nmol/l) with antagonistic activity on AR (EC50=420.6 or 775.0 nmol/l) but not agonistic nor antagonistic action on GR, MR (3000 nmol/l). Dienogest activate neither ERalpha nor ERbeta (3000 nmol/l). Progesterone activated PR with antagonistic activity on AR and on MR. Dydrogesterone showed a similar profile to progesterone. Norethisterone activated PR, AR, and ERalpha. Medroxyprogesterone acetate activated PR, AR, and GR. Danazol activated PR and AR. Collectively, dienogest has a good specificity to PR compared with the other drugs. By oral treatment, dienogest showed the strongest endometrial activity (ED50=0.0042 mg/kg) in McPhail test among other progestins (ED50 values for MPA, DYG, NES were 0.074, 1.9, >0.05 mg/kg, respectively). Dienogest showed higher plasma concentrations than those of the other progestins with higher doses. The estimated plasma concentration of dienogest at ED50 (3.66 nmol/l) was close to its EC50 value to activate PR. Thus, the stronger oral activity of dienogest could be explained simply by its in vitro potency on PR and its oral pharmacokinetic profile.

Insulin sensitivity in streptozotocin-induced diabetic rats treated with different doses of 17beta-oestradiol or progesterone

It has been reported that in streptozotocin (STZ)-induced diabetes, hyperglycaemia leads to progressive insulin resistance of the peripheral tissues. In this study, we tried to elucidate the effects of hyperglycaemia on insulin sensitivity and insulin signalling in ovariectomized (STZ)-induced diabetic rats. In addition, we attempted to demonstrate the role of 17beta-oestradiol and progesterone on insulin sensitivity, focusing on their effects on key proteins of skeletal muscle, insulin receptor (IR) and glucose transporter-4 (Glut-4). Our results show that hyperglycaemia could modulate insulin signalling, at the IR and Glut-4 level, in different ways depending on exposure time. 17beta-Oestradiol and progesterone have different effects on insulin signalling. 17beta-Oestradiol treatment improves insulin sensitivity, but its action is dependent on the exposure time and its plasma level. During the early period of treatment (days 6-11), this hormone counteracts the effects of hyperglycaemia downstream of the IR, whereas during the later period of treatment (days 11-16), it may counteract the effects of hyperglycaemia by modulating IR relative tyrosine phosphorylation. By contrast, progesterone only improves insulin sensitivity during the early period of treatment (days 6-11), and this effect is not associated with changes in IR and Glut-4 content. Both hormones have a protective role in skeletal muscle against the effects of glucose toxicity, but their effects begin at different stages of treatment. These new findings improve our understanding of insulin resistance in type 1 diabetes mellitus and of the risk/benefit ratio when 17beta-oestradiol and progesterone are used in oral contraceptives or hormone replacement therapy taken by menopausal women with controlled type 1 diabetes mellitus.

Effects of two combined oral contraceptives containing ethinyl estradiol 20 μg combined with either drospirenone or desogestrel on lipids, hemostatic parameters and carbohydrate metabolism

OBJECTIVE

To compare the effect of ethinyl estradiol 20 microg/drospirenone 3 mg (EE 20 microg/DRSP 3 mg) administered according to a 24/4 regimen with ethinyl estradiol 20 microg/desogestrel 150 microg (EE 20 microg/DSG 150 microg) administered according to the conventional 21/7 regimen on lipid, carbohydrate and hemostatic parameters.

STUDY DESIGN

In this open-label study, healthy women were randomized to EE 20 microg/DRSP 3 mg or EE 20 microg/DSG 150 microg for seven cycles. Mean differences in high-density lipoprotein (HDL)- and low-density lipoprotein (LDL)-cholesterol levels at cycle 7 compared to baseline were assessed. Secondary variables included changes in other lipid, hemostatic and carbohydrate parameters.

RESULTS

Both treatments increased HDL-cholesterol, but decreased LDL-cholesterol by a comparable extent. Although slightly elevated in both groups, blood glucose and C-peptide levels measured during oral glucose tolerance tests were within normal reference ranges at cycle 7. Overall, the differences in lipid, hemostatic or carbohydrate parameters were not significant between the two treatments.

CONCLUSION

EE 20 microg/DRSP 3 mg has a good safety profile comparable with EE 20 microg/DSG 150 microg.

Insulin sensitivity and premenstrual syndrome

Maintaining normal blood glucose levels is a constant challenge for women with diabetes. Anecdotal reports reveal that many women question if menstrual cycle phases may affect their blood glucose levels. However, results from studies investigating the effect of the menstrual cycle on insulin sensitivity in diabetic women have been conflicting. One variable that may account for the conflicting results is the presence or absence of premenstrual syndrome (PMS), which may exacerbate menstrual cycle-related effects on insulin sensitivity. Treatment of PMS with serotonin reuptake inhibitors may alleviate the symptoms of PMS, as well as improve insulin sensitivity and help regulate blood glucose levels.

Enhancing oral contraceptive success: the potential of new formulations

Reductions in oral contraceptive (OC) estrogen dose and the development of new progestins have resulted in formulations that maintain acceptable cycle control while improving safety. However, the potential safety benefits of low-estrogen doses may be offset by less acceptable cycle control. These observations have led to the development of 2 triphasic OC formulations containing norgestimate and desogestrel in combination with 25 microg ethinyl estradiol (EE). Both of these 25-microg EE triphasic OCs balance fewer estrogen-related side effects with good cycle control comparable to OCs containing higher estrogen doses. However, questions remain about the risk of venous thromboembolism associated with OCs containing desogestrel. A new monophasic 30-microg EE OC contains drospirenone, a spironolactone analogue with which there is limited experience. Although initial data with this OC are intriguing, product labeling highlights safety issues related to its antimineralocorticoid effects and the potential for hyperkalemia. Further experience with this formulation will determine its role in contraceptive practice.

Migraine and oral contraceptives

Initiation of oral contraceptive (OC) therapy in migraine may worsen pre-existing migraine or change the pattern of the individual migraine attacks. Many women experience no change in their migraine and a few show improvement. Evidence is accumulating that migraine increases ischemic stroke risk and that this risk is higher in migraine with aura than in migraine without aura. OCs also increase stroke risk, and the increased stroke risk attributable to each of migraine and OC therapy may be additive. The risk of ischemic stroke in young women is very low and likely remains acceptably low in young women with migraine without aura and in those with a simple migraine aura when OCs are prescribed. However, the presence of a complex or prolonged migraine aura, or of additional stroke risk factors such as increased age, smoking, and hypertension likely increases the ischemic stroke risk further in patients with migraine when OCs are prescribed. Whether OCs can be prescribed safely for the patient with migraine depends upon many factors including patient age, type of migraine, and the presence or absence of other stroke risk factors.

Desogestrel, norgestimate, and gestodene: the newer progestins

OBJECTIVE

To review and compare the newer progestins desogestrel, norgestimate, and gestodene with regard to chemistry, pharmacokinetics, efficacy, and tolerability.

DATA SOURCES

Primary literature on desogestrel, norgestimate, and gestodene was identified from a comprehensive MEDLINE English-literature search from 1984 through 1994, with additional studies selected by review of the references. Indexing terms included progestins, desogestrel, gestodene, norgestimate, levonorgestrel, and norgestrel.

STUDY SELECTION

Only human clinical and pharmacokinetic trials performed in Europe, Canada, and the US were included.

DATA EXTRACTION

All available data from human studies were reviewed; both comparative and noncomparative studies were included because of the paucity of direct comparative information available.

DATA SYNTHESIS

The newer progestins were designed to minimize the adverse effects (e.g., acne, hirsuitism, nausea, carbohydrate and lipid metabolism changes) observed with older oral contraceptives (OCs) while maintaining efficacy and good menstrual cycle control. Desogestrel, norgestimate, and gestodene have minimal amounts of androgenicity and antiestrogenic potential. All of these agents are pharmacokinetically similar to older agents: they are highly bioavailable when administered orally, hepatically metabolized, and obtain steady-state concentrations after 8-10 days of continuous administration. The newer agents have similar Pearl Indexes and slightly better cycle control. Furthermore, the new progestins appear to cause fewer adverse effects, such as acne and hirsuitism, and similar rates of weight gain, blood pressure changes, and lipid and carbohydrate metabolism changes.

CONCLUSIONS

Desogestrel, norgestimate, and gestodene appear to offer clinical advantages because of their decreased androgenicity. Women whose cycles are currently well controlled with other OCs should not be switched to a newer progestin. However, any of the combination OC products that contain these progestins may be prescribed for women intolerant of older agents or to first-time users of OCs. The newer progestins appear to be efficacious and offer similar cycle control, improved safety and tolerability profiles, and comparable price with the older agents.

Clinical and metabolic features of desogestrel: a new oral contraceptive preparation

Desogestrel is a highly selective gonane progestin. A monophasic formulation containing 150 micrograms of desogestrel and 30 micrograms of ethinyl estradiol has recently been approved as an oral contraceptive (OC) in the United States. Although desogestrel-containing formulations are new to the United States, they have been the most widely prescribed OCs in Europe for almost 10 years. An extensive literature demonstrates that desogestrel-containing preparations are safe, effective, and well tolerated by most women. In light of desogestrel's high selectivity, low affinity for androgen receptors, and lack of interference with the increase in sex hormone-binding globulin, desogestrel-containing OCs may be particularly appropriate for women with androgen-induced skin disorders because of their high selectivity. Several European studies have found significant improvement or almost complete resolution of previously existing acne. Desogestrel provides excellent cycle control, no major impact on weight, minimal or no adverse effects on blood pressure, statistically significant increases in high-density lipoprotein cholesterol with low-density lipoprotein cholesterol usually unchanged or reduced, and little effect on glucose tolerance or insulin resistance.