Types of combined oral contraceptives used by US women

Association between combined oral contraceptive prescription and cervical artery dissection: A retrospective cohort study

BACKGROUND

To date, research has identified positive associations between combined oral contraceptives (COCs) and adverse vascular events, however, evidence regarding the possible association with cervical artery dissection (CeAD) remains limited. We tested the hypothesis of a positive association between COCs and CeAD within one year following COC initiation compared to matched controls initiating intrauterine devices (IUDs), as measured by risk ratio (RR).

METHODS

We queried de-identified United States health records data (TriNetX, Inc.) from 2014 to 2024 for females aged 15-50 years without previous cerebrovascular disease or CeAD, creating mutually exclusive cohorts initiating either COCs or IUDs. We used propensity matching to control for variables associated with CeAD. Our primary outcome included the RR for CeAD within one year follow-up. We secondarily explored cumulative CeAD incidence and RR of stroke, also examining outcomes for females with ≥2 COC prescriptions (COC2).

RESULTS

After matching there were 214,020 patients per cohort (mean age 31 years). The incidence and risk of CeAD was greater among those prescribed COCs compared to matched controls with IUDs [95 % CI] (COCs: 0.016 %, IUDs: 0.008 %; RR 1.94 [1.10,3.43]; P = 0.0195). A similar association was observed for stroke (COCs: 0.106 %, IUDs: 0.057 %; RR = 1.86 [1.49,2.32]; P < 0.0001). The secondary COC2 analysis revealed similar findings.

CONCLUSIONS

The present findings suggest that females prescribed COCs have an increased risk of CeAD and stroke compared to matched controls using IUDs. These observations should be viewed as preliminary, require corroboration by other studies, and in isolation do not replace the broader clinical and shared decision-making regarding contraceptive use.

What intrinsic factors affect the central corneal thickness?

The cornea is one of the tissues responsible for covering and protecting the inner structures of the eye. Central corneal thickness (CCT) is defined as the distance between the anterior epithelial surface and the posterior surface of the endothelial layer. This parameter plays a very important role regarding intraocular pressure (IOP) measurement, evaluation of corneal uniformity, selection of a suitable technique for corneal refractive surgery and the planning of surgical procedures to overcome corneal disease. This comprehensive review elucidates the multifaceted factors influencing the central corneal thickness. Recognising the impact of these factors not only enhances our understanding of corneal dynamics but also contributes significantly to the refinement of diagnostic and therapeutic strategies in ophthalmology.

A Perspective on Hormonal Contraception Usage in Central Nervous System Injury

Naturally occurring life stages in women are associated with changes in the milieu of endogenous ovarian hormones. Women of childbearing age may be exposed to exogenous ovarian hormone(s) because of their use of varying combinations of estrogen and progesterone hormones-containing oral contraceptives (OC; also known as "the pill"). If women have central nervous system (CNS) injury such as spinal cord injury (SCI) and traumatic brain injury (TBI) during their childbearing age, they are likely to retain their reproductive capabilities and may use OC. Many deleterious side effects of long-term OC use have been reported, such as aberrant blood clotting and endothelial dysfunction that consequently increase the risk of myocardial infarction, venous thromboembolism, and ischemic brain injury. Although controversial, studies have suggested that OC use is associated with neuropsychiatric ramifications, including uncontrollable mood swings and poorer cognitive performance. Our understanding about how the combination of endogenous hormones and OC-conferred exogenous hormones affect outcomes after CNS injuries remains limited. Therefore, understanding the impact of OC use on CNS injury outcomes needs further investigation to reveal underlying mechanisms, promote reporting in clinical or epidemiological studies, and raise awareness of possible compounded consequences. The goal of the current review is to discuss the impacts of CNS injury on endogenous ovarian hormones and vice-versa, as well as the putative consequences of exogenous ovarian hormones (OC) on the CNS to identify potential gaps in our knowledge to consider for future laboratory, epidemiological, and clinical studies.

The effect of hormonal contraceptive therapy on clinical laboratory parameters: a literature review

Hormonal contraceptives (HC) are widely used among women in reproductive ages. In this review, the effects of HCs on 91 routine chemistry tests, metabolic tests, and tests for liver function, hemostatic system, renal function, hormones, vitamins and minerals were evaluated. Test parameters were differently affected by the dosage, duration, composition of HCs and route of administration. Most studies concerned the effects of combined oral contraceptives (COC) on the metabolic, hemostatic and (sex) steroids test results. Although the majority of the effects were minor, a major increase was seen in angiotensinogen levels (90-375 %) and the concentrations of the binding proteins (SHBG [∼200 %], CBG [∼100 %], TBG [∼90 %], VDBP [∼30 %], and IGFBPs [∼40 %]). Also, there were significant changes in levels of their bound molecules (testosterone, T3, T4, cortisol, vitamin D, IGF1 and GH). Data about the effects of all kinds of HCs on all test results are limited and sometimes inconclusive due to the large variety in HC, administration routes and dosages. Still, it can be concluded that HC use in women mainly stimulates the liver production of binding proteins. All biochemical test results of women using HC should be assessed carefully and unexpected test results should be further evaluated for both methodological and pre-analytical reasons. As HCs change over time, future studies are needed to learn more about the effects of other types, routes and combinations of HCs on clinical chemistry tests.

The effects of oral contraceptives on resting autonomic function and the autonomic response to physiological stressors: a systematic review

PURPOSE

This systematic review aimed to summarize how oral contraceptives (OC) affect resting autonomic function and the autonomic response to a variety of physiological stressors.

METHODS

A search strategy was created to retrieve citations investigating physiological responses comparing OC users to non-users (NOC) in response to autonomic reflex activation.

RESULTS

A total of 6148 citations were identified across databases from inception to June 2, 2022, and 3870 citations were screened at the abstract level after deduplication. Then, 133 texts were assessed at full-text level, and only 40 studies met eligibility requirements. Included citations were grouped by the aspect of autonomic function assessed, including autonomic reflex (i.e., baroreflex, chemoreflex, mechanoreflex, metaboreflex, and venoarterial reflex), or indicators (i.e., heart rate variability, pulse wave velocity, and sympathetic electrodermal activity), and physiological stressors that may alter autonomic function (i.e., auditory, exercise, mental or orthostatic stress, altitude, cold pressor test, sweat test, and vasodilatory infusions).

CONCLUSION

OC influence the physiological responses to chemoreflex, mechanoreflex, and metaboreflex activation. In terms of autonomic indices and physiological stressors, there are more inconsistencies within the OC literature, which may be due to estrogen dosage within the OC formulation (i.e., heart rate variability) or the intensity of the stressor (exercise intensity/duration or orthostatic stress). Further research is required to elucidate the effects of OC on these aspects of autonomic function because of the relatively small amount of available research. Furthermore, researchers should more clearly define or stratify OC use by duration, dose, and/or hormone cycling to further elucidate the effects of OC.

The importance of translationally evaluating steroid hormone contributions to substance use

Clinically, women appear to be more susceptible to certain aspects of substance use disorders (SUDs). The steroid hormones 17β-estradiol (E2) and progesterone (Pg) have been linked to women-specific drug behaviors. Here, we review clinical and preclinical studies investigating how cycling ovarian hormones affect nicotine-, cocaine-, and opioid-related behaviors. We also highlight gaps in the literature regarding how synthetic steroid hormone use may influence drug-related behaviors. In addition, we explore how E2 and Pg are known to interact in brain reward pathways and provide evidence of how these interactions may influence drug-related behaviors. The synthesis of this review demonstrates the critical need to study women-specific factors that may influence aspects of SUDs, which may play important roles in addiction processes in a sex-specific fashion. It is important to understand factors that impact women's health and may be key to moving the field forward toward more efficacious and individualized treatment strategies.

The Impact of Nicotine along with Oral Contraceptive Exposure on Brain Fatty Acid Metabolism in Female Rats

Smoking-derived nicotine (N) and oral contraceptive (OC) synergistically exacerbate ischemic brain damage in females, and the underlying mechanisms remain elusive. In a previous study, we showed that N + OC exposure altered brain glucose metabolism in females. Since lipid metabolism complements glycolysis, the current study aims to examine the metabolic fingerprint of fatty acids in the brain of female rats exposed to N+/-OC. Adolescent and adult Sprague-Dawley female rats were randomly (n = 8 per group) exposed to either saline or N (4.5 mg/kg) +/-OC (combined OC or placebo delivered via oral gavage) for 16-21 days. Following exposure, brain tissue was harvested for unbiased metabolomic analysis (performed by Metabolon Inc., Morrisville, NC, USA) and the metabolomic profile changes were complemented with Western blot analysis of key enzymes in the lipid pathway. Metabolomic data showed significant accumulation of fatty acids and phosphatidylcholine (PC) metabolites in the brain. Adolescent, more so than adult females, exposed to N + OC showed significant increases in carnitine-conjugated fatty acid metabolites compared to saline control animals. These changes in fatty acyl carnitines were accompanied by an increase in a subset of free fatty acids, suggesting elevated fatty acid β-oxidation in the mitochondria to meet energy demand. In support, β-hydroxybutyrate was significantly lower in N + OC exposure groups in adolescent animals, implying a complete shunting of acetyl CoA for energy production via the TCA cycle. The reported changes in fatty acids and PC metabolism due to N + OC could inhibit post-translational palmitoylation of membrane proteins and synaptic vesicle formation, respectively, thus exacerbating ischemic brain damage in female rats.

Fostemsavir and ethinyl estradiol drug interaction: Clinical recommendations for co‐administration

OBJECTIVES

Fostemsavir, a prodrug of temsavir, is indicated for heavily treatment-experienced adults with multidrug-resistant HIV-1 infection, antiretroviral (ARV) intolerance, or safety considerations. Understanding drug-drug interactions (DDIs) is important in individuals taking fostemsavir with hormonal contraceptives or menopausal or gender-affirming hormonal therapies.

METHODS

Effect of temsavir (active moiety) on the pharmacokinetics of ethinyl estradiol (EE) and norethindrone (NET) was evaluated in an open-label, single-sequence, four-cycle, four-treatment study in 26 healthy female participants (study 206279, NCT02480881). Relevant ARV-contraceptive interaction studies and guideline recommendations were reviewed; that information was then applied to other contraceptive methods and hormone-based therapies to predict the impact of fostemsavir co-administration.

RESULTS

Temsavir increased EE concentrations by 40% and had no effect on NET concentrations. Fostemsavir co-administration with hormone therapy is not expected to impact hormone treatment efficacy. Fostemsavir did not impact progestin; therefore, progestin-only and non-hormonal contraceptives will not be impacted by fostemsavir. Recommendations for co-administration of fostemsavir and hormonal contraceptives or menopausal or gender-affirming hormone therapies are based upon known and predicted DDIs, ensuring adequate hormonal concentrations to maintain the target effect.

CONCLUSIONS

Applying the results of Study 206279 and other relevant ARV-contraceptive studies, we recommend that when co-administering fostemsavir with combined oral contraceptives (COCs) and other oestrogen-based therapies, EE dose should not exceed 30 μg or equivalent, and caution is advised in the case of individuals with risk factors for thromboembolic events. Other oestrogen-based therapies may be co-administered with fostemsavir, with monitoring of oestrogen concentrations and appropriate dose adjustments. No impact of fostemsavir on COC efficacy is expected.

Oral contraceptives and stroke: Foes or friends

Incidents of strokes are increased in young women relative to young men, suggesting that oral contraceptive (OC) use is one of the causes of stroke among young women. Long-term exposures to the varying combinations of estrogen and progestogen found in OCs affect blood clotting, lipid and lipoprotein metabolism, endothelial function, and de novo synthesis of neurosteroids, especially brain-derived 17β-estradiol. The latter is essential for neuroprotection, memory, sexual differentiation, synaptic transmission, and behavior. Deleterious effects of OCs may be exacerbated due to comorbidities like polycystic ovary syndrome, sickle cell anemia, COVID-19, exposures to endocrine disrupting chemicals, and conventional or electronic cigarette smoking. The goal of the current review is to revisit the available literature regarding the impact of OC use on stroke, to explain possible underlying mechanisms, and to identify gaps in our understanding to promote future research to reduce and cure stroke in OC users.

Combined oral contraceptive use and risk for binge eating in women: Potential gene × hormone interactions

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.

The association between hormonal contraceptive use and smoking, negative affect, and cessation attempts in college females

Exogenous and endogenous female hormones influence nicotine use and cessation, potentially through mechanisms such as anxiety and negative affect. In the present study, college females using all types of hormonal contraceptives (HC) were compared to those not using HC to determine the potential influence on current smoking, negative affect, and current and past cessation attempts. Differences between progestin-only and combination HC were also examined. Of the 1,431 participants, 53.2% (n = 761) reported current HC use, and 12.3% (n = 176) of participants endorsed current smoking. Women currently using HC were significantly more likely to smoke (13.5%; n = 103) compared to women not using HC (10.9%; n = 73), p = .04. There was a significant main effect of HC use being associated with lower anxiety levels (p = .005), as well as a significant HC use by smoking status interaction, such that women who smoke using HC reported the lowest levels of anxiety among participants (p = .01). Participants using HC were more likely to be making a current attempt to quit smoking than those not using HC (p = .04) and were more likely to have made past quit attempts (p = .04). No significant differences were observed across women using progestin-only, combined estrogen and progestin, and women not using HC. These findings provide evidence that exogenous hormones may be an advantageous treatment target and that they warrant additional study.

Evaluating the Cognitive Impacts of Drospirenone, a Spironolactone-Derived Progestin, Independently and in Combination With Ethinyl Estradiol in Ovariectomized Adult Rats

Oral contraceptives and hormone therapies require a progestogen component to prevent ovulation, curtail uterine hyperplasia, and reduce gynecological cancer risk. Diverse classes of synthetic progestogens, called progestins, are used as natural progesterone alternatives due to progesterone’s low oral bioavailability. Progesterone and several synthetic analogs can negatively impact cognition and reverse some neuroprotective estrogen effects. Here, we investigate drospirenone, a spironolactone-derived progestin, which has unique pharmacological properties compared to other clinically-available progestins and natural progesterone, for its impact on spatial memory, anxiety-like behavior, and brain regions crucial to these cognitive tasks. Experiment 1 assessed three drospirenone doses in young adult, ovariectomized rats, and found that a moderate drospirenone dose benefited spatial memory. Experiment 2 investigated this moderate drospirenone dose with and without concomitant ethinyl estradiol (EE) treatment, the most common synthetic estrogen in oral contraceptives. Results demonstrate that the addition of EE to drospirenone administration reversed the beneficial working memory effects of drospirenone. The hippocampus, entorhinal cortex, and perirhinal cortex were then probed for proteins known to elicit estrogen- and progestin- mediated effects on learning and memory, including glutamate decarboxylase (GAD)65, GAD67, and insulin-like growth factor receptor protein expression, using western blot. EE increased GAD expression in the perirhinal cortex. Taken together, results underscore the necessity to consider the distinct cognitive and neural impacts of clinically-available synthetic estrogen and progesterone analogs, and why they produce unique cognitive profiles when administered together compared to those observed when each hormone is administered separately.

Reproductive and hormonal risk factors for sarcoidosis: a nested case–control study

Background

Sarcoidosis incidence peaks in females around the fifth decade of life, which coincides with menopause, suggesting hormonal factors play a role in disease development. We investigated whether longer exposure to reproductive and hormonal factors is associated with reduced sarcoidosis risk.

Methods

We conducted a matched case–control study nested within the Mammography Screening Project. Incident sarcoidosis cases were identified via medical records and matched to controls on birth and questionnaire date (1:4). Information on hormonal factors was obtained through questionnaires prior to sarcoidosis diagnosis. Multilevel modelling was used to estimate adjusted odds ratios with 95% credible intervals (OR; 95% CI).

Results

In total, 32 sarcoidosis cases and 124 controls were included. Higher sarcoidosis odds were associated with older age at menarche (OR 1.19: 95% CI 0.92–1.55), natural menopause versus non-natural (OR 1.53: 95% CI 0.80–2.93), later age at first pregnancy (OR 1.11: 95% CI 0.76–1.63) and ever hormone replacement therapy (HRT) use (OR 1.40: 95% CI 0.76–2.59). Lower odds were associated with older age at menopause (OR 0.90: 95% CI 0.52–1.55), longer duration of oral contraceptive use (OR 0.70: 95% CI 0.45–1.07), longer duration of HRT use (OR 0.61: 95% CI 0.22–1.70), ever local estrogen therapy (LET) use (OR 0.83: 95% CI 0.34–2.04) and longer duration of LET use (OR 0.78: 95% CI 0.21–2.81). However, the CIs could not rule out null associations.

Conclusion

Given the inconsistency and modest magnitude in our estimates, and that the 95% credible intervals included one, it still remains unclear whether longer estrogen exposure is associated with reduced sarcoidosis risk.

Effect of oral contraceptives on energy balance in women: A review of current knowledge and potential cellular mechanisms

Body weight management is currently of major concern as the obesity epidemic is still a worldwide challenge. As women face more difficulties to lose weight than men, there is an urgent need to better understand the underlying reasons and mechanisms. Recent data have suggested that the use of oral contraceptive (OC) could be involved. The necessity of utilization and development of contraceptive strategies for birth regulation is undeniable and contraceptive pills appear as a quite easy approach. Moreover, OC also represent a strategy for the management of premenstrual symptoms, acne or bulimia nervosa. The exact impact of OC on body weight remains not clearly established. Thus, after exploring the potential underlying mechanisms by which OC could influence the two side of energy balance, we then provide an overview of the available evidence regarding the effects of OC on energy balance (i.e. energy expenditure and energy intake). Finally, we highlight the necessity for future research to clarify the cellular effects of OC and how the individualization of OC prescriptions can improve long-term weight loss management.

Menstrual Irregularity, Hormonal Contraceptive Use, and Bone Stress Injuries in Collegiate Female Athletes in the United States

BACKGROUND

Menstrual irregularity (MI) is common in female athletes and is a component of the Female Athlete Triad (Triad). Many athletes with the Triad are started on hormonal contraceptives (HC) for MI, but this interferes with the ability to monitor menstrual cycle regularity and can mask other causes of MI. There are limited studies investigating the relationship between MI, HC use, and injury in female collegiate athletes.

OBJECTIVE

To examine the prevalence of and relationship between HC use, MI, and bone stress injuries in female collegiate athletes in the United States.

DESIGN

Cross-sectional study.

SETTING

Online survey.

PARTICIPANTS

1020 U.S. female collegiate athletes (age ≥ 18 years).

METHODS OR INTERVENTIONS

Assessment of risk factors for menstrual irregularity and bone stress injuries was conducted via a one-time survey.

MAIN OUTCOME MEASURES

HC use, MI, history of stress fractures.

RESULTS

Current HC use prevalence was 65% (95% confidence interval [CI], 61.9%, 67.8%). Of all athletes, 47% reported past MI. Of the athletes who were not currently using HCs, 32% had current MI. Compared with athletes without past MI, more athletes with past MI reported current HC use (73% vs. 57%) and indicated menstrual cycle consistency as the primary reason for use (24% vs. 4%) (P < .001). Additionally, 25% of athletes reported a history of stress fractures, which was associated with lean/aesthetic sports participation (odds ratio [95% CI]: 1.9 [1.4, 2.5]; P < .001) and less oral contraceptive pill (OCP) use (0.7 [0.5, 1.0]; P = .043). Compared with OCPs, injectable HCs were associated with greater odds of a history of stress fractures (4.5[1.6, 12.3]; P = .004).

CONCLUSIONS

HC use was prevalent among this cohort of female collegiate athletes, and almost half of the athletes reported past MI. A goal of menstrual cycle regularity was cited by 24% of athletes as a primary reason to use HCs, which shows that more athlete education is needed to avoid masking MI and the Triad with HCs. Further studies elucidating the relationship between HC use, MI, and sports-related injury are warranted.

Real world utilization of 91 day extended levonorgestrel-containing combined oral contraceptives in Europe: a multinational database study

OBJECTIVE

As part of the risk management plan in Europe, this study was conducted to characterize drug utilization patterns of Seasonique, a 91 day extended levonorgestrel-containing combined oral contraceptive (COC_LNG).

METHODS

A retrospective observational study was conducted in France, Italy and Belgium using electronic medical record databases obtained from general practitioners (GPs) in all participating countries and gynecologists in France from 2015 to 2018. The study population included women receiving ≥1 prescription of 91 day COC_LNG during the study period. Prescribing patterns of 91 day COC_LNG were examined including: (1) treatment duration; (2) indication; (3) use of combined oral contraceptive (COC) before 91 day COC_LNG initiation; and (4) switch from and to combined hormonal contraceptives (CHCs) or other contraceptives.

RESULTS

Totals of 235, 220, 207 and 659 women using 91 day COC_LNG were identified in French, Italian and Belgian GP, and French gynecologist databases, respectively. Across databases, 46-76% of women were prescribed a single 91 day COC_LNG prescription and median treatment duration ranged from 3 to 6 months. The most common indication was contraception (42-81%), followed by menstrual migraines (2-14%). Use of COC during the 6 months prior to 91 day COC_LNG initiation was 14% across GP databases, but was lower (8%) in the French gynecologist database. The frequency of switching from 91 day COC_LNG to CHCs or other contraceptives was generally low (5-12%), with the highest proportion being among patients of French gynecologists.

CONCLUSIONS

Findings indicate that 91 day COC_LNG was prescribed for relatively short durations and predominantly as indicated for contraception. Most results were comparable across all participating countries. KEY POINTSFindings from this drug utilization study in European databases across general practitioners and French gynecologists confirmed that 91 day extended levonorgestrel-containing combined oral contraceptive (COC_LNG) was prescribed for relatively short durations (median 3-6 months); predominantly for the intended indication of contraception.Combined oral contraceptive use during the 6 months prior to 91 day COC_LNG initiation, and switching from 91 day COC_LNG to combined hormonal contraceptives or other contraceptives, were generally low (14% or less).These findings were mostly consistent across participating countries.

Administration of Exogenous Hormones and the Implications for Cigarette Smoking-Related Behaviors

PURPOSE OF REVIEW

Preclinical evidence indicates progesterone and estrogen influence drug-taking behaviors, including nicotine/tobacco. However, clinical research on this relationship is less clear. This lack of clarity may be due to measuring naturally occurring endogenous hormones to examine this relationship, which introduces substantial error. Therefore, the goal of this review is to examine the link between the delivery of exogenous hormones and cigarette smoking-related behavior.

RECENT FINDINGS

Exogenous progesterone may have favorable effects on cognition, symptomatology, consumption, and smoking cessation. Hormonal replacement therapy does not have a clear relationship with smoking-related behaviors. Oral contraceptive use may have adverse effects on stress response, nicotine metabolism, and symptomatology. Additional research is needed to explore how the administration of exogenous hormones may (a) strengthen research methodology on this topic, (b) enhance our understanding of the role of progesterone/estrogen on smoking-related behaviors, and (c) improve smoking cessation outcomes.

Development and testing of a module to promote generic oral contraceptive prescribing among nurse practitioners

Although generic oral contraceptives (OCPs) can improve adherence and reduce health care expenditures, use of generic OCPs remains low, and the factors that affect generic prescribing are not well understood. We aimed to understand the barriers and facilitators of generic OCP prescribing and potential solutions to increase generic OCP prescribing, as well as pilot an educational module to address clinician misconceptions about generic OCPs. We developed focus group scripts using the 4D model of appreciative inquiry. A total of four focus groups occurred, two at the American Association of Nurse Practitioners (AANP) national conference and two at the American College of Physicians (ACP) Internal Medicine meeting. Focus group transcripts were analyzed using a constant comparative method with no a priori hypothesis to generate emerging and reoccurring themes. Findings from these focus groups were used to develop an educational module promoting generic OCP prescribing. Participants were recruited from the AANP Network for Research and the ACP Research Panel. This study demonstrates that health system factors, workflow factors, clinician factors, and patient factors were the main barriers to and facilitators of generic OCP prescribing. Nurse practitioners were responsive to an educational module and reported increased willingness to discuss and prescribe generic OCPs after completing the module. Interventions to increase generic OCP prescribing must address clinician and patient factors within the context of workflow and larger health system factors.

Resistance Training and Skeletal Muscle Protein Metabolism in Eumenorrheic Females: Implications for Researchers and Practitioners

Resistance training is essential for health and performance and confers many benefits such as increasing skeletal muscle mass, increasing strength and power output, and improving metabolic health. Resistance training is a major component of the physical activity guidelines, yet research in female populations is limited. Recent increases in the promotion of, and the participation by, females in sport and exercise, highlight the need for an increase in understanding of evidence-based best practice exercise prescription for females. The aim of this review is to provide an overview of the current research regarding resistance training performance and skeletal muscle adaptation in females, with a focus on the hormonal variables that may influence resistance training outcomes. Findings suggest that the menstrual cycle phase may impact strength, but not skeletal muscle protein metabolism. In comparison, oral contraception use in females may reduce skeletal muscle protein synthesis, but not strength outcomes, when compared to non-users. Future research should investigate the role of resistance training in the maintenance of skeletal muscle protein metabolism during pregnancy, menopause and in athletes experiencing relative energy deficiency in sport. The review concludes with recommendations for researchers to assist them in the inclusion of female participants in resistance training research specifically, with commentary on the most appropriate methods of controlling for, or understanding the implications of, hormonal fluctuations. For practitioners, the current evidence suggests possible resistance training practices that could optimise performance outcomes in females, although further research is warranted.

Assessing safety in hormonal male contraception: a critical appraisal of adverse events reported in a male contraceptive trial

INTRODUCTION

There is unmet need for male contraceptive options, but a recent injectable combination male contraceptive trial was terminated early due to adverse events (AEs).

METHODS

We examined the frequency of reported AEs by male research participants compared with AEs reported in prescribing information of approved female hormonal contraceptive methods. Published data from trials of the top five most-used female hormonal contraceptives, supplemented by contemporary contraceptive research, were compared with the frequency of AEs reported in a male injectable hormonal contraceptive trial.

RESULTS

We observed similar frequencies of AEs reported by users of male contraceptives compared with those reported by female users. Among quantitatively comparable AEs, compared with men, women reported experiencing higher frequencies of headaches, pelvic pain, and weight gain and similar frequencies of decreased libido. Compared with women, men reported experiencing higher frequencies of acne and mood changes. Men discontinued participation due to AEs at a lower frequency than women.

CONCLUSIONS

Female hormonal methods generally have similar frequencies of AEs to those reported in a recent male hormonal contraceptive trial, and male users had lower rates of discontinuation due to AEs. There were fewer serious AEs of the male contraceptive than reported in contemporary female trials which resulted in FDA licensure. This suggests there may be implicit bias in the scientific community regarding the level of acceptable risk for users of male contraceptive methods.

The effect of multiple doses of ubrogepant on the pharmacokinetics of an oral contraceptive in healthy women: Results of an open-label, single-center, two-period, fixed-sequence study

Background:

Ubrogepant is a novel, oral calcitonin gene–related peptide receptor antagonist for acute treatment of migraine. This study evaluated potential drug–drug interactions between ubrogepant and an oral contraceptive containing ethinyl estradiol (EE) and norgestimate (NGM).

Methods:

This open-label, single-center, two-period, fixed-sequence study enrolled healthy, postmenopausal or oophorectomized, adult women. In period 1, participants received a single oral dose of EE 0.035 mg/NGM 0.25 mg (EE-NGM) followed by a 7-day washout. In period 2, participants received oral ubrogepant 50 mg daily on days 1–14; single-dose EE-NGM was coadministered with ubrogepant on day 10. Pharmacokinetic parameters for plasma EE and norelgestromin (NGMN) were compared with and without ubrogepant.

Results:

Twenty-two participants aged 46–66 years were enrolled; 21 completed the study. Geometric mean ratios and 90% confidence intervals for the comparison of EE-NGM + ubrogepant to EE-NGM alone were contained within 0.80 and 1.25 for area under the plasma drug concentration–time curve (AUC) from time zero to infinity (AUC0–∞; 0.96 [0.91, 1.01]) and C max (0.91 [0.82, 1.004]) of NGMN and AUC0–∞ (0.97 [0.93, 1.01]) of EE, but not C max of EE (0.74 [0.69, 0.79]). Median t max of EE was delayed following EE-NGM + ubrogepant (3.0 h) versus EE-NGM alone (median of 1.5 h), whereas median t max of NGMN was unchanged (1.5 h). Geometric mean apparent terminal half-life ( t ½) was similar with and without ubrogepant for EE (23 vs. 21 h) and NGMN (36 h both conditions). All ubrogepant-related adverse events were mild or moderate.

Conclusion:

Ubrogepant did not demonstrate potential for clinically meaningful drug–drug interactions with an EE-NGM oral contraceptive.

Trial registration:

Not applicable (phase 1 trial)

Hormonal contraceptive use in Australian women: Who is using what?

BACKGROUND

In Australia many hormonal contraceptives are not Pharmaceutical Benefits Scheme (PBS) supported, hence the use of different formulations have not been quantified.

OBJECTIVES

To document the use of hormonal contraceptives and factors associated with their use.

MATERIALS AND METHODS

Cross-sectional, online questionnaire-based study of 6986 Australian women, aged 18-39 years, recruited by email invitation from two large, representative databases. Main outcome measures were the prevalence of use of hormonal contraceptives and associated socio-demographic characteristics.

RESULTS

Of the 6600 potential hormone contraceptive users, 43.2% were current users. Most (63.6%) reported using a combined oral contraceptive (COC) of which 30.9% were non-PBS-supported anti-androgenic progestin-containing COCs. Use of long-acting reversible contraceptives (LARC) or an injectable contraceptive was reported by 26.8%. Education beyond secondary school, being Australian born, rural residency, normal body mass index, age <25 years and nulliparity were significantly associated with hormonal contraceptive use. Women who reported polycystic ovary syndrome or acne were more likely to be taking a third or fourth generation COC (P < 0.0001) and endometriosis was significantly associated with intrauterine system (IUS) use. Third or fourth generation COC use was reported by 12.1% of obese, current smokers.

CONCLUSION

An estimated one-third of Australian women aged 18-39 are taking a non-PBS-supported anti-androgenic progestin COC, highlighting inequity in access to COC options. That hormonal contraceptive use is higher in rural areas is a novel finding and the proportion of LARC or injectable use suggests that uptake in Australia is higher than previously reported.

Hormonal Contraceptives, Female Sexual Dysfunction, and Managing Strategies: A Review

In recent decades, hormonal contraceptives (HC) has made a difference in the control of female fertility, taking an unequivocal role in improving contraceptive efficacy. Some side effects of hormonal treatments have been carefully studied. However, the influence of these drugs on female sexual functioning is not so clear, although variations in the plasma levels of sexual hormones could be associated with sexual dysfunction. Permanent hormonal modifications, during menopause or caused by some endocrine pathologies, could be directly related to sexual dysfunction in some cases but not in all of them. HC use seems to be responsible for a decrease of circulating androgen, estradiol, and progesterone levels, as well as for the inhibition of oxytocin functioning. Hormonal contraceptive use could alter women's pair-bonding behavior, reduce neural response to the expectation of erotic stimuli, and increase sexual jealousy. There are contradictory results from different studies regarding the association between sexual dysfunction and hormonal contraceptives, so it could be firmly said that additional research is needed. When contraceptive-related female sexual dysfunction is suspected, the recommended therapy is the discontinuation of contraceptives with consideration of an alternative method, such as levonorgestrel-releasing intrauterine systems, copper intrauterine contraceptives, etonogestrel implants, the permanent sterilization of either partner (when future fertility is not desired), or a contraceptive ring.

Hormonal Contraceptives and Mood: Review of the Literature and Implications for Future Research

PURPOSE OF REVIEW

We examine recent studies that investigate the effects of hormonal contraception on mood in different populations of women, including women in the general population and women with diagnosed psychiatric and gynecologic disorders. We address the mechanisms of several types of hormonal contraceptives and assess how these may affect mood and gynecologic disorders.

RECENT FINDINGS

The effects of hormonal contraceptives seem to be most relevant in selected subsets of women, as they may promote improved mental health in particular psychiatric disorders such as PMDD. Currently, there is no consistent evidence for negative effects of most hormonal contraceptives in the general population. Even though some studies reveal that certain individuals appear susceptible to negative mood effects from some forms of hormonal contraceptives, more research is needed to better identify these susceptible individuals.

Oral Contraceptives and Cigarette Smoking: A Review of the Literature and Future Directions

INTRODUCTION

Evidence continues to mount indicating that endogenous sex hormones (eg, progesterone and estradiol) play a significant role in smoking-related outcomes. Although approximately one out of four premenopausal smokers use oral contraceptives (OCs), which significantly alter progesterone and estradiol levels, relatively little is known about how OCs may influence smoking-related outcomes. Thus, the goal of this review article is to describe the state of the literature and offer recommendations for future directions.

METHODS

In March 2017, we searched seven databases, with a restriction to articles written in English, using the following keywords: nicotine, smoker(s), smoking, tobacco, cigarettes, abstinence, withdrawal, and craving(s). We did not restrict on the publication date, type, or study design.

RESULTS

A total of 13 studies were identified. Three studies indicated faster nicotine metabolism in OC users compared to nonusers. Five of six laboratory studies that examined physiological stress response noted heightened response in OC users compared to nonusers. Three studies examined cessation-related symptomatology (eg, craving) with mixed results. One cross-sectional study observed greater odds of current smoking among OC users, and no studies have explored the relationship between OC use and cessation outcomes.

CONCLUSIONS

Relatively few studies were identified on the role of OCs in smoking-related outcomes. Future work could explore the relationship between OC use and mood, stress, weight gain, and brain function/connectivity, as well as cessation outcomes. Understanding the role of OC use in these areas may lead to the development of novel smoking cessation interventions for premenopausal women.

IMPLICATIONS

This is the first review of the relationship between oral contraceptives (OCs) and smoking-related outcomes. The existing literature suggests that the use of OCs is related to increased nicotine metabolism and physiological stress response. However, the relationship between OC use and smoking-related symptoms (eg, craving) is mixed. Further, no published data were available on OC use and smoking cessation outcomes. Therefore, we recommend additional research be conducted to characterize the relationship between OC use and smoking cessation outcomes, perhaps as a function of the effect of OC use on mood, stress, weight gain, and brain function/connectivity.

Gender-specific considerations in physical activity, thermogenesis and fat oxidation: implications for obesity management

With current 'one-size-fits-all' obesity prevention and management strategies proving largely ineffective, the focus has shifted towards a more tailored, individualized approach. However, investigation of the mechanisms underlying inter-individual variability in metabolic profile and response to intervention often yield conflicting results. Indeed, it is perhaps surprising that despite at least a century of recognition that sex hormones influence metabolism, firm conclusions regarding the effects of the menstrual cycle, hormonal contraception and menopause on many aspects of energy expenditure and substrate utilization remain to be drawn. In this review, we examine current evidence relating to gender-specific considerations in the promotion of physical activity, thermogenesis and fat oxidation for body-weight regulation, including the relationship between sex hormone status and non-exercise activity thermogenesis - an energy expenditure compartment that is often overlooked in favour of traditional exercise/sport physical activities yet presents a viable target in the search for effective weight management.

Association of Risk for Venous Thromboembolism With Use of Low-Dose Extended- and Continuous-Cycle Combined Oral Contraceptives: A Safety Study Using the Sentinel Distributed Database

IMPORTANCE

Continuous/extended cyclic estrogen use (84/7 or 365/0 days cycles) in combined oral contraceptives (COCs) could potentially expose women to an increased cumulative dose of estrogen, compared with traditional cyclic regimens (21/7 days cycle), and may increase the risk for venous thromboembolism (VTE).

OBJECTIVE

To determine, while holding the progestogen type constant, whether the risk for VTE is higher with use of continuous/extended COCs than with cyclic COCs among women who initiated a COC containing ethinyl estradiol and levonorgestrel.

DESIGN, SETTING, AND PARTICIPANTS

Incident user retrospective cohort study of primarily commercially insured US population identified from the Sentinel Distributed Database. Participants were women aged 18 to 50 years at the time of initiating a study COC between May 2007 and September 2015. Using a propensity score approach and Cox proportional hazards regression models, we estimated the hazard ratios of VTE overall and separately by ethinyl estradiol dose and age groups.

EXPOSURES

Initiation of continuous/extended or traditional cyclic COCs containing ethinyl estradiol or levonorgestrel of any dose.

MAIN OUTCOMES AND MEASURES

First VTE hospitalization that occurred during the study follow-up, identified by an inpatient International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code of 415.1, 415.1x, 453, 453.x, or 453.xx.

RESULTS

We identified 210 691 initiators of continuous/extended COCs (mean [SD] age, 30.4 [8.6] years) and 522 316 initiators of cyclic COCs (mean [SD] age, 28.8 [8.3] years), with a mean of 0.7 person-years at risk among continuous/extended and cyclic users. Baseline cardiovascular and metabolic conditions (7.2% vs 4.7%), gynecological conditions (39.7% vs 32.3%), and health services utilization were slightly higher among continuous/extended cyclic than cyclic COC users. Propensity score matching decreased the hazard ratio estimates from 1.84 (95% CI, 1.53-2.21) to 1.32 (95% CI, 1.07-1.64) for continuous/extended use compared with cyclic COC use. The absolute risk difference (0.27 per 1000 persons) and the incidence rate difference (0.35 cases per 1000 person-years [1.44 vs 1.09 cases per 1000 person-years]) between the 2 propensity score-matched cohorts remained low, which may not translate into a clinically significant risk differences between cyclic and noncyclic estrogen use.

CONCLUSIONS AND RELEVANCE

Holding the progestogen type constant (levonorgestrel), we observed a slightly elevated VTE risk in association with continuous/extended COC use when compared with cyclic COC use. However, due to the small absolute risk difference and potential residual confounding, our findings did not show strong evidence supporting a VTE risk difference between continuous/extended and cyclic COC use.

Period Prevalence and Perceived Side Effects of Hormonal Contraceptive Use and the Menstrual Cycle in Elite Athletes

PURPOSE

To identify the period prevalence of hormonal contraceptive (HC) use and characterize the perceived side effects associated with the menstrual cycle and HC use.

METHODS

A total of 430 elite female athletes completed a questionnaire to assess the period prevalence of HC use, the reasons for initiation and discontinuation of HCs, and the side effects experienced by HC and non-HC users. Descriptive statistics, between-groups comparisons, and associations between categorical variables were calculated.

RESULTS

Of athletes studied, 49.5% were currently using HCs and 69.8% had used HCs at some point. Combined oral contraceptives were most commonly used (68.1%), with 30.0% using progestin-only contraceptives (implant = 13.1%, injection = 3.7%, and intrauterine system = 2.8%). Perceived negative side effects were more common with progestin-only HC use (39.1%) compared with combined-HC use (17.8%; P = .001) and were most prevalent in implant users (53.6%; P = .004). HC users reported perceived positive side effects relating to their ability to predict and/or manipulate the timing, frequency, and amount of menstrual bleeding. Non-HC users had a menstrual cycle length of 29 (5) d and 77.4% reported negative side effects during their menstrual cycle, primarily during days 1-2 of menstruation (81.6%).

CONCLUSIONS

Approximately half of elite athletes used HCs, and progestin-only contraceptive users reported greater incidences of negative side effects, especially with the implant. Because of the high interindividual variability in reported side effects, athletes and practitioners should maintain an open dialogue to pursue the best interests of the athlete.

Recurrent venous thromboembolism and abnormal uterine bleeding with anticoagulant and hormone therapy use

Women receiving vitamin K antagonists (VKAs) require adequate contraception because of the potential for fetal complications. It is unknown whether the use of hormonal therapy, especially those containing estrogens, is associated with recurrent venous thromboembolism (VTE) during anticoagulation. Despite the absence of data, World Health Organization guidelines state that use of estrogen-containing contraceptives confers an "unacceptable health risk" during established anticoagulation for VTE. We compared the incidences of recurrent VTE and abnormal uterine bleeding with and without concomitant hormonal therapy in women aged <60 years who were receiving anticoagulation with rivaroxaban or enoxaparin/VKA for confirmed VTE. Incidence densities in percentage per year were computed for the on and off estrogen-containing or progestin-only therapy periods. Cox regression models were fitted, with hormonal therapy (on vs off) as a time-dependent variable to derive the hazard ratio (HR) for the effects on recurrent VTE and abnormal uterine bleeding. In total, 1888 women were included. VTE incidence densities on and off hormonal therapy were 3.7%/year and 4.7%/year (adjusted HR, 0.56; 95% confidence interval [CI], 0.23-1.39), respectively, and were 3.7%/year and 3.8%/year, respectively, for estrogen-containing and progestin-only therapy. The adjusted HR for all abnormal uterine bleeding (on vs off hormonal therapy) was 1.02 (95% CI, 0.66-1.57). Abnormal uterine bleeding occurred more frequently with rivaroxaban than with enoxaparin/VKA (HR, 2.13; 95% CI, 1.57-2.89). Hormonal therapy was not associated with an increased risk of recurrent VTE in women receiving therapeutic anticoagulation. The observed increased risk of abnormal uterine bleeding with rivaroxaban needs further exploration.

Extended regimen combined oral contraception: A review of evolving concepts and acceptance by women and clinicians

Objectives: The clinical utility of extended regimen combined oral contraceptives (COCs) is increasingly being recognised. Our objective was to understand the attitudes of women and clinicians about the use of these regimens. We present the rationale for extended regimen COCs from a historical perspective, and trace their evolution and growing popularity in light of their clinical benefits. We conclude by offering potential strategies for counselling women about extended regimen COC options.

Methods: We conducted a MEDLINE search to identify and summarise studies of extended regimen COCs, focusing on attitudes of women and clinicians regarding efficacy, safety/tolerability and fewer scheduled bleeding episodes and other potential benefits.

Results: The body of contemporary literature on extended regimen COCs suggests that their contraceptive efficacy is comparable to that of conventional 28-day (i.e., 21/7) regimens. For women seeking contraception that allows infrequent scheduled bleeding episodes, particularly those who suffer from hormone withdrawal symptoms and cyclical symptoms (e.g., headache, mood changes, dysmenorrhoea, heavy menstrual bleeding), extended regimen COCs are an effective and safe option. Although satisfaction with extended regimen COCs in clinical trials is high, misperceptions about continuous hormone use may still limit the widespread acceptance of this approach.

Conclusions: Despite the widespread acceptance among clinicians of extended regimen COCs as an effective and safe contraceptive option, these regimens are underused, likely due to a lack of awareness about their availability and utility among women. Improved patient education and counselling regarding the safety and benefits of extended regimen COCs may help women make more informed contraceptive choices.

Cost-Effectiveness of Immediate Compared With Delayed Postpartum Etonogestrel Implant Insertion

OBJECTIVE

To evaluate the cost-effectiveness of immediate compared with delayed (6 weeks) postpartum etonogestrel implant insertion in preventing future unintended pregnancy.

METHODS

We constructed a decision-analytic model to examine a hypothetical population of women who request a contraceptive implant after giving birth. The timeframe for analysis was from the time of childbirth to 1 year postpartum. Model inputs were derived from a comprehensive literature review. We compared immediate (before discharge from the childbirth hospital stay) compared with delayed (at first postpartum office visit) postpartum placement of the contraceptive implant from a health care system's perspective. Implant insertion and removal, loss to follow-up at the postpartum visit, use of alternative contraceptive methods, and contraceptive failure were incorporated into the model. We calculated the incremental cost of immediate insertion for each pregnancy prevented during the first postpartum year and cost savings associated with pregnancies prevented. One-way sensitivity analyses were also performed. Cost estimates are reported in 2014 U.S. dollars.

RESULTS

Immediate postpartum implant insertion is associated with higher expected cost than delayed insertion ($1,091/patient compared with $650/patient) but is more effective in preventing pregnancies (expected pregnancy rate: 2.4% and 21.6%, respectively). This results in an incremental cost-effectiveness ratio of $2,304 per pregnancy prevented. When taking into consideration medical costs of the resulting unintended pregnancies that could be avoided, immediate implant insertion is expected to save $1,263 per patient.

CONCLUSION

Immediate postpartum provision of the contraceptive implant is cost-effective in preventing unintended pregnancies and should be provided to women requesting this form of contraception.

Oral contraceptives and cognition: A role for ethinyl estradiol

This article is part of a Special Issue "Estradiol and cognition". Estrogens have been seen to play a role in human cognitive abilities, but questions remain about the cognitive impact of ethinyl estradiol, which is contained in many oral contraceptives (OCs). Inconsistencies in past studies likely reflect small samples and heterogeneous groups of OC users. The aims of the present work were to examine OC effects on sex-typed spatial and verbal abilities by (a) comparing mental rotations and expressional fluency in normally-cycling (NC) women and men to OC users considered as a heterogeneous group and then to homogeneous groups of OC users created by classifying pills according to their active constituents, and (b) determining the relation between synthetic hormone doses in OCs and mental rotations and expressional fluency. Participants were 136 men, 93 NC women, and 148 OC users, including homogeneous monophasic (n = 55) and triphasic (n = 43) OC groups, aged 18 to 30 years. Significant effects of OC use were seen in homogeneous group comparisons but not when OC users were considered as a heterogeneous group. On mental rotations, men outperformed women, and monophasic OC users outperformed NC women. The latter difference may be attributable to estradiol, as ethinyl estradiol was inversely related to spatial ability among OC users and was lower in monophasic than in triphasic users. On expressional fluency, NC women and monophasic OC users outperformed men, and monophasic users outperformed triphasic users. Thus, results show the importance of ethinyl estradiol and of considering pill constituents when studying the cognitive effects of OCs.

Hormonal contraceptive use and risk of glioma among younger women: a nationwide case-control study

AIM

Oral contraceptive use influences the risk for certain cancers. However, few studies have examined any link with risk of central nervous system tumours. We investigated the association between hormonal contraceptive use and glioma risk among premenopausal women in a population-based setting.

METHODS

Using national administrative and health registries in Denmark to conduct a nationwide case-control study, we identified all women ages 15 to 49 years with a first time diagnosis of histologically verified glioma between 2000 and 2009. Each case was age-matched to eight population controls using risk set sampling. Based on prescription data, exposure until 2 years prior to the index date was categorized according to hormonal contraceptive type, i.e. combined oestrogen-progestagen or progestagen only, and duration of use (<1, 1 to <5, ≥5 years). We used conditional logistic regression to compute odds ratios (ORs) with 95% confidence intervals (CIs) for glioma associated with hormonal contraceptive use, adjusting for potential confounders.

RESULTS

We identified 317 cases and 2126 controls. Ever use of hormonal contraceptive was associated with an OR of 1.5 (95% CI 1.2, 2.0) and the OR increased with duration of use (long term, ≥5 years: OR 1.9; 95% CI 1.2, 2.9). The association between long term hormonal contraceptive use and glioma risk was most pronounced for progestagen only therapy (OR 2.4; 95% CI 1.1, 5.1), especially when this regimen constituted the sole hormonal contraceptive therapy (OR 4.1; 95% CI 0.8, 20.8).

CONCLUSION

Long term hormonal contraceptive use may increase the risk of glioma.

Oral contraceptives and menopausal hormone therapy: relative and attributable risks of cardiovascular disease, cancer, and other health outcomes

PURPOSE

To summarize the relative risks (RRs) and attributable risks (ARs) of major health outcomes associated with use of combined oral contraceptives (OCs) and menopausal hormone therapy (HT).

METHODS

For OCs, measures of association are from meta-analyses of observational studies. For HT, these measures are from the Women's Health Initiative, a large randomized trial of HT for chronic disease prevention in postmenopausal women aged 50 to 79 years.

RESULTS

Current OC use increases risks of venous thromboembolism and ischemic stroke. However, women of reproductive age are at low baseline risk, so the ARs are small. OC use also increases risk of breast and liver cancer and reduces risk of ovarian, endometrial, and colorectal cancer; the net effect is a modest reduction in total cancer. The Women's Health Initiative results show that HT does not prevent coronary events or overall chronic disease in postmenopausal women as a whole. Subgroup analyses suggest that timing of HT initiation influences the relation between such therapy and coronary risk, and its overall risk-benefit balance, with more favorable effects (on a relative scale) in younger or recently menopausal women than in older women or those further past the menopausal transition. However, even if the RR do not vary by these characteristics, the low absolute baseline risks of younger or recently menopausal women translate into low ARs in this group.

CONCLUSIONS

OC and HT can safely be used for contraception and treatment of vasomotor symptoms, respectively, by healthy women at low baseline risk for cardiovascular disease and breast cancer.

Oral contraceptives and menopausal hormone therapy: relative and attributable risks of cardiovascular disease, cancer, and other health outcomes

PURPOSE

To summarize the relative risks (RRs) and attributable risks (ARs) of major health outcomes associated with use of combined oral contraceptives (OCs) and menopausal hormone therapy (HT).

METHODS

For OCs, measures of association are from meta-analyses of observational studies. For HT, these measures are from the Women's Health Initiative, a large randomized trial of HT for chronic disease prevention in postmenopausal women aged 50 to 79 years.

RESULTS

Current OC use increases risks of venous thromboembolism and ischemic stroke. However, women of reproductive age are at low baseline risk, so the ARs are small. OC use also increases risk of breast and liver cancer and reduces risk of ovarian, endometrial, and colorectal cancer; the net effect is a modest reduction in total cancer. The Women's Health Initiative results show that HT does not prevent coronary events or overall chronic disease in postmenopausal women as a whole. Subgroup analyses suggest that timing of HT initiation influences the relation between such therapy and coronary risk, and its overall risk-benefit balance, with more favorable effects (on a relative scale) in younger or recently menopausal women than in older women or those further past the menopausal transition. However, even if the RR do not vary by these characteristics, the low absolute baseline risks of younger or recently menopausal women translate into low ARs in this group.

CONCLUSIONS

OC and HT can safely be used for contraception and treatment of vasomotor symptoms, respectively, by healthy women at low baseline risk for cardiovascular disease and breast cancer.

Pharmacologic sex hormones in pregnancy in relation to offspring obesity

OBJECTIVE

To assess the association between in utero exposure to either diethylstilbestrol (DES) or an oral contraceptive in pregnancy and offspring obesity.

METHODS

Using data from the Collaborative Perinatal Project (1959-1974), a multicenter prospective study of pregnant women and their offspring, we examined overweight or obesity among 34,419 children with height and weight data at age 7 years. Generalized linear models to estimate the adjusted odds ratio (aOR) for overweight or obesity (≥85th percentile) or obesity (≥95th percentile) in the offspring according to exposure during different months of pregnancy were used.

RESULTS

Oral contraceptive use during pregnancy was positively associated with offspring overweight or obesity and obesity. The magnitude of association was strongest in the first 2 months of pregnancy for obesity (aOR 2.0, 95% CI: 1.1, 3.7). DES use was also associated with offspring overweight or obesity and obesity, with the association being strongest for exposure beginning between months 3 and 5 (e.g., for exposure beginning in months 3-4, the aOR for obesity was 2.8, 95% CI: 1.3, 6.3).

CONCLUSIONS

Pharmacologic sex hormone use in pregnancy may be associated with childhood obesity. Whether contemporary, lower dose oral contraceptive formulations are similarly associated with increased risk of childhood obesity is unclear.

Combined hormonal contraceptives: prescribing patterns, compliance, and benefits versus risks

Combined hormonal contraceptives [combined oral contraceptives (COCs)] have been available for over 50 years and the impact of this invention may not be overestimated. Today over 100 million women are current users and in Western Europe and the United States approximately 80% of women of fertile ages can be considered as ever-users. Over the years several drawbacks have been identified and media alarms on risks are frequently presented, resulting in suboptimal compliance and low compliance and continuation rates. Poor compliance and discontinuation is a big problem and is not generally identified by prescribers. During ideal use COCs offer very good protection against unwanted pregnancies, however there is a big problem with compliance and continuation and thus the 'real-life' efficacy is much lower. Reasons for poor compliance include side effects and fear of side effects and it is crucial that the prescriber gives the individual woman thorough and balanced information on the benefits and risks. Most well known is the increased risk of venous thromboembolism, but also an elevated risk of arterial thrombosis and several types of cancer has been reported. The risk estimates are low but according to the large number of users a substantial number of extra cases will occur. However, use of COCs also offers several additional health benefits with significant impact on morbidity and quality of life. COC use is associated with a substantial decrease in the risk of ovarian cancer, endometrial cancer and colorectal cancer. Moreover, COCs are a major option of treatment for women suffering from heavy menstrual bleeding and dysmenorrhea as well as hirsutism and acne vulgaris. The net effect of the additional health effects of COC- use may very well be positive, i.e. a slight increase in life expectancy.

A comparison of self-reported oral contraceptive use and automated pharmacy data in perimenopausal and early postmenopausal women

PURPOSE

Oral contraceptive (OC) use can occur throughout a woman's reproductive life span with the potential for long-term impacts on health. To assess potential measurement error in prior OC use, this study compared level of agreement between self-reported prior OC use and pharmacy dispensing data in perimenopausal and/or early postmenopausal women.

METHODS

The study's 1399 women (ages, 45-59 years) were participants in a population-based case-control study of the association between OC use and fracture risk. Episodes of lifetime self-reported OC use (in months) were collected, by telephone interview, for January 1, 2008 through November 25, 2012. Pharmacy fills, back to 1980, were collected from automated data. Agreement was measured using the prevalence-adjusted and bias-adjusted kappa index.

RESULTS

The number of women with OC pharmacy fills was 11% to 45% higher than those who reported OC use during each time period. Between-measures agreement was better for more recent use. Prevalence-adjusted and bias-adjusted kappa index values ranged from 0.88 (95% confidence interval, 0.85-0.90) within 5 years from the reference date to 0.65 (95% confidence interval, 0.59-0.71) within 15 to 20 years.

CONCLUSIONS

For studies designed to assess the long-term effects of OC use, the current results are reassuring in noting moderate agreement between self-reported OC use and pharmacy data for up to 15 to 20 years before the interview.

Evolution of extended use of the combined oral contraceptive pill

BACKGROUND

Extended use of the combined oral contraceptive pill (COC), defined as taking active pills for at least 28&emsp14;days, has been used in order to avoid bleeding at important times and to treat gynaecological conditions such as endometriosis. We examined the main issues involved in extended use of the COC and how it has evolved from being one of medicine's best-kept secrets to becoming more widely accepted by women and the medical community.

STUDY DESIGN

Literature review, using Medline, Embase, Pubmed, CINHAL Plus, the Cochrane Database of Systematic Reviews and the Ovid database for all relevant clinical trials, systematic reviews, meta-analyses, literature reviews, scientific papers and individual opinions between 1950 and October 2013.

RESULTS

Accumulating evidence supports various forms of extended pill use as suitable alternatives to the standard (21/7) regimen. In terms of user preference, much hinges on whether women wish to reduce the frequency or duration of scheduled bleeding on the combined pill. Available data on the safety of extended pill regimens do not give cause for concern, but longer term data should be collected.

CONCLUSIONS

Information for women considering extended COC regimens should keep pace with research findings to ensure that women and clinicians are better informed about the choices available.

History of oral contraceptive drugs and their use worldwide

The first hormonal pill, called Enovid(®), was approved by the Federal Drug Administration (FDA) in May 1960. It contained mestranol and norethisterone. Over the years, oral contraceptives have evolved through gradual lowering of ethinyl estradiol (EE) content, introduction of 17β estradiol, and many different progestins. The standard regimen allows for 21 days of pill containing steroids and a pill-free interval of 7 days. Recently, continuous or extended regimens have been approved. In order to improve compliance, alternative routes of combined oral contraceptive (COC) administration have been developed such as vaginal or transdermal routes. In 2009, according to the United Nations, the mean global percentage using contraception in women who are married or in union was 62.7%. COC represented 8.8% of contraceptive prevalence, reaching 15.4% in more developed countries. More than 100 million women worldwide use COCs. However, each year, many unintended pregnancies occur, indicating that contraception still needs to be promoted.