Characteristics of the new progestogens in combination oral contraceptives

Dermatologic manifestations of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) affects 5-10% of reproductive-aged women and is one of the most common endocrine disorders in women. The disorder is commonly characterized by elevated levels of androgen and insulin. Women with PCOS may present with a range of signs and symptoms, and face increased risks of reproductive, metabolic, cardiovascular, psychologic, and neoplastic sequelae, particularly if the condition is left unrecognized or untreated. The clinical definition of PCOS has changed in recent years and includes as one of its cardinal criteria the dermatologic manifestations of hyperandrogenism, chiefly hirsutism, acne vulgaris, and androgenetic alopecia. Acanthosis nigricans, a cutaneous sign of hyperinsulinemia, may also be present. These dermatologic features may provide early clinical clues to recognition of PCOS, and treatment of these cutaneous conditions may improve the patient's quality of life and psychologic well-being. The effects of androgen on pilosebaceous units in the skin can vary by anatomic location, producing pathophysiologic effects on hair growth and differentiation, sebaceous gland size and activity, and follicular keratinization. Treatment modalities may include hormonal therapy intended to modulate androgen production and action as well as non-hormonal therapies directed toward specific dermatologic conditions.

Medroxyprogesterone acetate acutely facilitates and sequentially inhibits sexual behavior in female rats

Medroxyprogesterone acetate (MPA), a synthetic progestin commonly used in contraception and hormone replacement therapy, appears to inhibit libido in women, but little is known about the mechanisms through which it may exert this effect. We compared the acute and sequential actions of MPA and natural progesterone (P4) on sexual behavior in female rats to test the hypothesis that MPA inhibits sexual behavior, at least in part, by acting as a potent progesterone receptor (PR) agonist. Ovariectomized females were placed in one of three dose groups (high, mid, or low), and each subject was tested under three different conditions (MPA, P4, and vehicle). The order of progestin treatment was balanced among subjects, and within each dose group equimolar quantities of MPA and P4 were administered. During each trial, females were injected with estradiol benzoate (EB, 4 mug) followed by one of three progestin treatments (MPA, P4, or vehicle) at +44 h, and behavioral testing at +48 h. On the next day, all females were given a standard 500-microg injection of P4 at +68 h and were tested again for sexual behavior at +72 h. On the first day of behavioral testing, both MPA and P4 induced a pronounced rise in receptive and proceptive behavior at the mid and high doses, but at the lowest dose MPA had a much greater effect in comparison to P4. On the second day of behavioral testing, MPA attenuated the expression of proceptive and receptive behavior at both the mid and high doses, whereas P4 only attenuated the expression of lordosis and only did so at the highest dose. These findings illustrate that MPA and P4 have a similar impact on sexual behavior in female rats and suggest that the inhibitory effects of MPA may be attributable, at least in part, to its potent effects at the progesterone receptor.

Medroxyprogesterone acetate antagonizes the effects of estrogen treatment on social and sexual behavior in female macaques

Medroxyprogesterone acetate (MPA) commonly is used in contraception and hormone replacement therapy. However, little is known about its effects within the central nervous system. Using ovariectomized pigtail macaques (Macaca nemestrina), we evaluated the potential for MPA to antagonize estradiol (E2) effects on female sociosexual behavior. Subjects (n = 6) were treated sequentially with placebo, E2 alone, E2 + progesterone (P4), and E2 + MPA. The order of treatments was balanced among subjects, and equimolar quantities of P4 and MPA were administered. During each treatment period, female sexual initiation rates, anxiety-related behavior, and aggression were recorded. Treatment with E2 alone induced a substantial rise in female sexual initiation rates. Although concurrent P4 treatment failed to significantly inhibit sexual behavior, MPA treatment markedly antagonized E2's effects. Neither the E2-only nor the E2 + P4 treatment had an impact on aggression rates, but the E2 + MPA treatment induced a significant rise in this behavior. Both MPA and P4 counteracted the effect of E2 on measures of anxiety. These findings suggest that MPA antagonizes certain behavioral effects of E2 that may be beneficial to women, and that it does so more profoundly or in ways that endogenous P4 does not. The marked increase in aggression seen during MPA treatment suggests that production of negative affect may be a particularly serious side effect of MPA.

A comparative study of the effects of gestodene 60 microg/ethinylestradiol 15 microg and desogestrel 150 microg/ethinylestradiol 20 microg on hemostatic balance, blood lipid levels and carbohydrate metabolism

OBJECTIVES

This multicenter, randomized, parallel-group, open-label study was conducted to compare the effects of gestodene (GTD) 60 microg/ethinylestradiol (EE) 15 microg and desogestrel (DSG) 150 microg/EE 20 microg (Mercilon) on selected metabolic measurements during six cycles in 124 healthy women.

METHODS

GTD/EE subjects received a single pill once daily from days 1 to 24 of a 28-day cycle, followed by placebo pills daily for the last 4 days of the cycle. DSG/EE subjects received a single pill daily from days 1 to 21 of a 28-day cycle, followed by a 7-day pill-free interval. Safety was assessed from changes in hemostatic measurements, lipid profile, glucose tolerance and adverse events.

RESULTS

Both GTD/EE and DSG/EE groups exhibited minimal effects on the lipid profile. An increased glucose response was noted with both treatments and an increased insulin response was noted with GTD/EE. Hemostatic activity was increased in both groups but a counteracting increase in fibrinolytic activity occurred together with an increase in coagulatory activity. The incidence of adverse events was comparable between groups, and no significant differences in cycle control were observed between groups. No pregnancies occurred in either group.

CONCLUSIONS

The 24-day GTD 60 microg/EE 15 microg formulation and DSG/EE produced similar effects on hemostatic balance, lipid metabolism and glucose tolerance, and exhibited comparable efficacy and tolerability.

Hormone-like behavioral effects of levonorgestrel and its metabolites in the male rat

Levonorgestrel (LNG), a contraceptive progestin, exhibits, besides its progestational activity, other hormone-like effects at the peripheral level. To assess whether LNG and its metabolites exert androgenic and/or estrogenic actions at the central nervous system (CNS), their effects on male sexual behavior in castrated rats were examined. LNG, 5alpha-dihydro LNG (5alphaLNG), and the 3alpha,5alpha- and 3beta,5alpha-tetrahydro derivatives of LNG (3alphaLNG and 3betaLNG, respectively) were administered for 3 weeks either alone (1000 microg/day) or in combination (300 microg/day) with 5alpha-dihydrotestosterone (DHT, 300 microg/day) or with estradiol-17beta (E(2), 5 microg/day). Copulatory behavior was assessed twice per week and sex accessory organs weights recorded at the end of treatments. LNG restored full copulatory behavior comparable to that of testosterone treated animals, although with a slight delay, whereas 5alphaLNG induced male sexual behavior in a significantly lower number of subjects. 3betaLNG and 3alphaLNG induced mounting but failed to restore intromission and ejaculation. Combined LNG+E(2) treatment fully activated mounting and intromission, but ejaculation was only partially restored. Combined 5alphaLNG+E(2) treatment and the combinations of 3alphaLNG or 3betaLNG with E(2) were significantly less effective, activating fewer intromissions and ejaculations. 3alphaLNG and 5alphaLNG, in combination with DHT, restored male sexual behavior. LNG, but not its metabolites, induced a significant increase on the weight of sex accessory organs. The overall results demonstrated that high doses of LNG induce a potent androgen agonistic behavioral effect and that its A-ring reduction diminishes this potency and enables a shift towards a weak estrogen-like effect.

Norethisterone is bioconverted to oestrogenic compounds that activate both the oestrogen receptor alpha and oestrogen receptor beta in vitro

In the present study, we used [3H]norethisterone to explore the bioconversion of this compound to A-ring reduced metabolites in African Green Monkey Kidney CV-1 cells and breast cancer T-47D cells. Additionally, we analyzed the capability of each norethisterone tetrahydro-reduced compound to bind the human oestrogen receptors alpha and beta and transactivate an oestrogen-sensitive reporter gene. The results showed that norethisterone is mainly metabolized to 3 alpha,5 alpha-norethisterone (>85% of total [3H]norethisterone added) by CV-1 and T-47D cells, and that both A-ring tetrahydro-reduced metabolites exhibit different capabilities to displace [3H]17beta-oestradiol from the oestrogen receptor alpha and beta, being 3 alpha,5 alpha-norethisterone the weakest competitor. We also found that 3 alpha,5 alpha-norethisterone and 3beta,5 alpha-norethisterone activate both oestrogen receptors at nanomolar concentrations and that the transactivation induced by the oestrogen receptor alpha was generally higher (1.7- to 4.0-fold) than that provoked by the beta receptor isoform. In oestrogen receptor alpha-transfected CV-1 and T-47 D cells, the oestrogenic-like potency of the 3beta,5 alpha-tetrahydro-reduced form was similar to that exhibited by 17beta-oestradiol and 2.5- to 4.0-fold higher than that shown by the 3 alpha,5 alpha-reduced compound; conversely, in the oestrogen receptor beta system the potency of the natural ligand was higher than that presented by the 3beta,5 alpha-tetrahydro-reduced metabolite. In CV-1 cells expressing the oestrogen receptor beta, the transactivation potency of 3beta,5 alpha-norethisterone was approximately 2-fold higher than that exhibited by its 3 alpha,5 alpha-tetrahydro-reduced isomer, whereas in T-47D cells the potency of the 3 alpha,5 alpha-tetrahydro-reduced compound was slightly higher than that shown by the 3beta,5 alpha A-ring reduced norethisterone metabolite. These results demonstrate that CV-1 and T-47D cells possess the enzymatic machinery to bioconvert norethisterone into the 5 alpha-reduced, 3 alpha-hydroxylated form and that neither 3 alpha,5 alpha- or 3beta,5 alpha-norethisterone exhibit preference or selectivity towards a particular oestrogen receptor isoform to induce a particular oestrogenic effect in these cell lines.

Structure-activity relationships (SAR) of contraceptive progestogens studied with four different methods using calculated physicochemical parameters

Structure-activity relationships (SAR) of the contraceptive progestogens for (I) oral contraceptive activity (OCA), (II) androgenic effect, and (III) binding affinity for sex hormone binding globulin (SHBG) were studied using four different methods: principal component analysis (PCA), hierarchical cluster analysis (HCA), neural networks (NN), and electronic indices method (EIM) employing descriptors calculated by the semi-empirical Austin Model I (AM1) method. An additional set of molecules was used to check the reliability of the results obtained for OCA by PCA. Using PCA, three different sets of descriptors were found to correlate with the three different biological activities, I-III, indicating that the interaction between the receptor and the progestogen must depend on the type of biological activity. The descriptors selected by PCA were also employed for SAR analysis of the contraceptive progestogens using two other methods, HCA and NN. Both HCA and NN correctly classified high activity molecules as different from low activity ones. Thus, those descriptors selected by PCA work well in the other two methods of classification. Using the sign of p, a difference of electron densities of selected molecular orbitals in a specified region in a molecule, it was possible to discriminate high activity molecules from low activity molecules in the three different types of activities studied, I-III, with one exception.

Assessment of the oestrogenic activity of the contraceptive progestin levonorgestrel and its non-phenolic metabolites

Levonorgestrel (13beta-ethyl-17alpha-ethynyl-17beta-hydroxy-4-gonen-3-one), a potent contraceptive progestin stimulates growth and proliferation of cultured breast cancer cells through a receptor-mediated mechanism, even though levonorgestrel does not bind to the oestrogen receptor (ER). To assess whether the oestrogen-like effects induced by this synthetic progestin are exerted via its metabolic conversion products, we studied the binding affinity of three A-ring levonorgestrel derivatives to the ER and their capability to transactivate an oestrogen-dependent yeast system co-transfected with the human ER gene and oestrogen responsive elements fused to a beta-galactosidase reporter vector. The results demonstrated that the 3beta,5alpha reduced levonorgestrel derivative and to a lesser extent its 3alpha isomer interact with the oestrogen receptor, with a significantly lower relative binding affinity (2.4% and 0.4%, respectively) than that of oestradiol (100%), while levonorgestrel does not. Both levonorgestrel metabolites were able to activate, in a dose-dependent manner, the beta-galactosidase reporter gene in the yeast expression system, an effect that was precluded by a steroidal antioestrogen. The oestrogenic potency of levonorgestrel metabolites was significantly lower (750-fold) than that of oestradiol. Furthermore, high doses of 3beta,5alpha levonorgestrel (2.5 mg/day/6 days) induced an increase of oestrogen-dependent progestin receptor in the anterior pituitary of castrated rats. The overall data offer a plausible explanation for the weak oestrogenic effects induced by high, non-pharmacological doses of levonorgestrel.

Hormonal properties of norethisterone, 7alpha-methyl-norethisterone and their derivatives

Norethisterone (NET) is a progestagenic compound with very weak androgenicity and estrogenicity. These low androgenic and estrogenic activities may be attributed to NET itself or induced by metabolites of NET. In order to improve the bioactivity of NET, the effects of a 7alpha-methyl substitution were studied. Thus this study has two objectives: first the comparison between biological activities of NET and 7alpha-methyl-NET (MeNET), and second the biological activity of tentative metabolites of NET and those of MeNET. The metabolites consist of a 3-keto-, 3alpha- or 3beta-hydroxy-group located next to a carbon 4 to 5 double bond (Delta(4)) or a 5alpha-hydrogen atom. The 7alpha-methyl substitution was of special interest as it prevents 5alpha-reduction. The biological activities of NET, MeNET and their potential metabolites were assessed by in vitro binding, transactivation and proliferation assays on progesterone (PR), androgen (AR), estrogen (ER) and glucocorticoid (GR) receptors and by in vivo progestagenic McPhail, androgenic Hershberger, estrogenic Allen-Doisy tests and combined estrogenic and progestagenic ovulation inhibition tests. NET is a compound with five- to eight-fold weaker PR binding and transactivation activities than the reference compound Org 2058 (100%) and two-fold stronger than progesterone. Binding and transactivation activities of NET for AR (DHT=100%) are 3.2 and 1.1%, respectively, for ER none (E2=100%) and for GR below 1% (DEX=100%). MeNET is 1.5- to two-fold less progestagenic and ten- to 20-fold more androgenic than NET, while it does not show activity for ER and GR. The relative binding affinity of 5alpha-NET was seven-fold lower for PR and 1.5-fold higher for AR than for NET, while in transactivation assays 5alpha-NET was only active at levels below 1% for all tested receptors. 3beta-Hydroxy-(5alpha-reduced)-metabolites showed clear ER binding and transactivation activities, while 3alpha-hydroxy-(5alpha-reduced)-metabolites did hardly possess these characteristics. These hydroxy metabolites did not bind or activate other receptors. Substitution of 7alpha-methyl to NET metabolites led to similar characteristics, but with higher activities for AR and ER and weaker activity for PR. The outcome of in vivo tests showed a remarkable effect for MeNET. Progestagenic activity in rabbits appeared for NET equipotent to or eight-fold higher than for MeNET, after subcutaneous or oral treatment, respectively. On the other hand, MeNET showed in rats a ten-fold higher androgenicity and eight-fold higher estrogenicity than NET. Ovulation inhibition was induced at very low oral or subcutaneous dose levels, being 120- or ten-fold lower than for NET, respectively. The estrogenicity can also be induced by 3alpha- or 3beta-hydroxy metabolites of MeNET, which are 15 or even more than 40-fold stronger than those of NET, respectively. In conclusion, after the introduction of a 7alpha-methyl substituent to NET an increased estrogenicity and androgenicity and a reduced progestagenic activity was found. The in vivo estrogenicity is mainly due to 3beta-hydroxy-MeNET and to a lesser extent to 3alpha-hydroxy-MeNET, while the androgenicity and progestagenicity are most likely caused by MeNET itself. Since the 7alpha-methyl substituent inhibits 5alpha-reductase, 5alpha-reduced MeNET metabolites can be excluded from biological activities. As MeNET is a very effective ovulation inhibitor, due to its mixed progestagenic and estrogenic profile, a further reduction of androgenicity of MeNET may yield new contraceptives with an attractive profile for contraception.

Contraceptive progestins. Various 11-substituents combined with four 17-substituents: 17alpha-ethynyl, five- and six-membered spiromethylene ethers or six-membered spiromethylene lactones

Norethisterone (NET) is a 19-nortestosterone derivative with progestagenic and some androgenic activity, which was used in the first generation of contraceptives. NET was succeeded by levonorgestrel (LNG) and later on by desogestrel (DSG) and gestodene (GSD). Although these latter two progestins had increased potency, there was still androgenicity with gestodene and to a lesser extent with desogestrel. New progestins were synthesized in order to further enhance progestagenic and to reduce androgenic activity. Four different chemical moieties were introduced in position 17 of 19-nortestosterone, viz. 17alpha-ethynyl, five- and six-membered spiromethylene ethers, and a six-membered-spiromethylene lactone. In combination with these structures seven different substituents were added at position 11, i.e. methylene, methyl, ethyl, ethenyl, ethynyl, 2-propenyl and 1-propynyl. All substituents except for methylene occupied the 11beta-position. All these 32 compounds were synthesized and analysed in vitro and in vivo against etonogestrel (ETG, 3-keto-desogestrel), the biologically active metabolite of desogestrel. Their relative binding potency to progesterone (PR), androgen (AR) and estrogen (ER) receptors were determined in cell lysates of human breast tumor MCF-7 cells and to glucocorticoid (GR) receptors in that of human leukemic IM-9 cells. Moreover, their relative agonistic activities were assessed in Chinese hamster ovary cell-based transactivation assays. All in vivo activities were determined in McPhail (progestagenic), ovulation inhibition (progestagenic and estrogenic), Hershberger (androgenic), hormone screening (glucocorticoid and estrogen) and Allen-Doisy (estrogenic) tests after oral and for the McPhail test also after subcutaneous administration. The progestagenic binding and transactivation potencies of all compounds in the three 17-spiro series were higher than those of the corresponding analogues in the 17alpha-ethynyl series. None of the compounds showed estrogenic or clear androgenic binding and transactivation potential except for a six-membered-spiromethylene lactone with a propynyl group. This compound showed strong androgenic binding. The glucocorticoid binding and transactivation were very low for the compounds with the 17alpha-ethynyl and the five-membered-spiromethylene ether groups, whereas both six-membered-spiro series showed, clearly with methyl and ethynyl substituents, and less pronounced with methylene and ethenyl, higher binding and transactivation values. For the 17alpha-ethynyl series, the McPhail test showed high potencies with methylene, methyl and ethenyl substituents after oral treatment or with propenyl after subcutaneous administration. The introduction of the spiro substituents in position 17 led to high potencies for other 11-substituents as well. Besides methyl, also ethyl, ethynyl and propynyl were potent substituents. With ovulation inhibition tests, the ethyl, ethenyl and ethynyl substituents were the more potent compounds in all four series. However, compounds with methyl or ethynyl additions appeared to be glucocorticoidal in the hormone screening test irrespective of the 17-substituent, while with the three spiro series even methylene and ethenyl groups became active. Androgenicity was only observed at dose levels at or above 5 mg/kg, which is 2.5-fold weaker than ETG. Moreover, estrogenicity appeared negligible with the three spiro series, while with the 17alpha-ethynyl series methyl, ethyl, ethenyl and ethynyl substituents, a very high estrogenic potential was assessed. Based on the high efficacy and low side-effects, the following compounds show a high selectivity: 17alpha-ethynyl with ethyl, ethenyl and 2-propenyl substituents, six-membered spiromethylene ether with ethyl and six-membered-spiromethylene lactone with ethyl, 2-propenyl or 1-propynyl substituents. (ABSTRACT TRUNCATED)

Prescribing and managing oral contraceptive pills and emergency contraception for adolescents

Combination OCPs are safe and effective ways to prevent unintended adolescent pregnancy if they are used properly. Numerous noncontraceptive benefits of OCPs can bolster continued combination OCP use. Progestin-only OCPs are an option, particularly for young women with medical contraindications to taking estrogens; however, because of their lower efficacy, progestin-only pills are not the first choice for oral contraception for adolescents. Health care providers can give young women a second chance to prevent unintended pregnancy by improving their access to emergency contraception through educating and counseling about emergency contraception at all office visits, by prescribing emergency contraceptive pills in advance, or by prescribing emergency contraceptive pills over the telephone.

Contraception for the older woman

Contraception presents particular problems for women over the age of 40. Although fertility is declining and the risk of pregnancy may be small, the consequences of an unplanned pregnancy may be socially devastating and medically ill-advised. Menstrual dysfunction and psychosexual difficulties increase with age and may exacerbate the side-effects of some methods of contraception. The long-term risks of combined hormonal contraception, particularly cardiovascular disease, become more pertinent to women whose natural risk of disease increases with age. Patterns of sexual activity and contraceptive use change with age. The advantages and disadvantages of currently available methods of contraception are difficult to quantify, and the choice of method is very much a matter for individual concern. The increasing prevalence of HRT may complicate matters for some women who are unsure for how long to continue using contraception. Contraceptives of the future may be designed to improve the reproductive health of all women, particularly those approaching the menopause.

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.

Hirsutism and virilization

Preview The appearance of unwanted body hair in a woman is often the result of a benign condition requiring medical and cosmetic therapy only. However, sometimes, especially when accompanied by features of virilization, hirsutism signals an ovarian or adrenal tumor. The authors define the broad categories of causes and review treatment options, from weight loss to surgical intervention.

Contraceptive use and attitudes in reunified Germany

Contraceptive use and attitudes were assessed in a random sample of 1064 German women. The majority (76%) of the sexually active, fertile women who were not pregnant and did not wish to get pregnant at the time of the survey were using very reliable contraceptive methods, namely oral contraceptives (OCs), intrauterine devices (IUDs) or sterilization. Comparison with a previous survey showed that contraceptive practice in West Germany had improved considerably since 1985. Attitudes towards the most reliable methods available (OCs, IUDs and sterilization) were found to be ambivalent. Perceived side effects and health risks were a particular matter of concern to the respondents. Although most respondents (88%) recognized that condoms prevent the transmission of AIDS, 66% of those who had occasional sexual partners did not use barrier methods. It is concluded that German contraceptive practice is reasonably effective and that if attitudes were to become more realistic the level of effectiveness could even be raised.

Plasma concentrations of medroxyprogesterone acetate, estradiol and estrone following oral administration of Klimaxil, Trisequence/Provera and Divina. A randomized, single-blind, triple cross-over bioavailability study in menopausal women

The absorption of estradiol and medroxyprogesterone acetate was investigated in a randomized single-blind, triple cross-over study, in 12 menopausal women, for four different HRT drugs (Klimaxil, a combination tablet containing 17 beta-estradiol 2 mg and medroxy-progesterone acetate 5 mg; Divina, a combination tablet containing 17 beta-estradiol valerate 2 mg and medroxyprogesterone acetate 10 mg; Trisequence, a triphasic preparation containing 17 beta-estradiol 2 mg in the first phase; Provera, a tablet containing medroxyprogesterone acetate 5 mg). Trisequence and Provera were ingested simultaneously. In conclusion, there was no statistically significant difference between the drugs with respect to the estradiol levels. The estrone concentration, however, differed between the different drugs. The serum concentration was higher after intake of tablets containing estradiol than after intake of tablets containing the valerate ester. There was a significant increase in the MPA levels between periods 1 and 3. Finally, Divina produced higher MPA concentrations than Klimaxil and the combination of Trisequence and Provera, although the mean AUC was not twice as high, as might have been expected.

Metabolism of gestodene in human liver cytosol and microsomes in vitro

The metabolism of the progestogen gestodene has been studied in human liver cytosol and microsomal incubations. Extraction with diethyl ether was followed by radiometric HPLC analysis. Metabolites were identified by co-chromatography with authentic standards and mass spectrometry (electron impact and chemical ionization). All the cytosolic incubations (n = 4 livers) produced dihydrogestodene as the major metabolite, with lesser amounts of a tetrahydro derivative. It was not possible to separate the 5 alpha- and 5 beta-isomers of dihydrogestodene on the chromatographic system used. Values of Km and V(max) for the delta 4 reductase were determined. Androstenedione (Ki = 2.85 +/- 1.5 microM; n = 4) and cortisol (ki = 24.1 +/- 8.9 microM; n = 4) both inhibited the delta 4-reductase. In contrast desogestrel showed virtually no inhibition at concentrations up to 200 microM. The major microsomal metabolite of gestodene was a hydroxylated derivative although mass spectral analysis was unable to determine the position of insertion of the hydroxyl moiety. The hydroxylation of gestodene (1 microM) was markedly inhibited by ketoconazole (IC50 < 0.1 microM), and also by cyclosporin. This suggests that the cytochrome P450 isozyme CYP3A4 is important in gestodene metabolism. Theophylline and tolbutamide (substrates of CYPIA and CYP2C, respectively) did not affect gestodene metabolism at concentrations up to 100 microM. In conclusion, the major biotransformation of gestodene (A-ring reduction) occurs in the cytosolic fraction of human liver. Microsomal hydroxylation appears to be catalysed by CYP3A4.

Contraception in Germany: a review

In this paper studies on current contraceptive use and attitudes toward various contraceptive methods in Germany are reviewed. Both the former West and East Germany are considered. On the basis of the existing studies it is difficult to have a clear impression of which methods are currently used in both countries and how contraceptive practice developed over time, due to methodological differences between studies. Nevertheless, it can be concluded that use of reliable contraceptive methods is widespread in both East and West Germany. In this respect East Germany differs considerably from other previously communistic countries. Attitudes were mainly assessed in West Germany, and with respect to oral contraceptives and IUDs great concern appeared to exist regarding the safety of both methods. As far as oral contraceptives are concerned, selective mass media attention toward possible side-effects of oral contraceptives may have contributed to this situation.

Contraceptive choices for women with endocrine complications

Previous confusion regarding the interference by oral contraceptives in measurements of endocrine function have been largely eliminated by the advent of improved, more sensitive assays. There are few if any contraindications to oral contraceptive use in patients with thyroid disease. Patients with prolactinoma can be treated with bromocriptine to restore fertility and prevent mineral loss. However, as a less expensive alternative, oral contraceptives can be prescribed to correct mineral loss, because there is no convincing evidence of an adverse effect on prolactinomas by the steroidal content of the pill. Oral contraceptives comprise a near ideal treatment modality for women with polycystic ovary disease because, among other effects, oral contraceptives reduce synthesis of androgen by inhibiting pituitary gonadotropin secretion.