Contraception and dyslipidemia

Association between Heavy Metal Exposure and Dyslipidemia among Korean Adults: From the Korean National Environmental Health Survey, 2015-2017

Cardiovascular disease (CVD) is a leading cause of death in Korea. Dyslipidemia, characterized by the presence of abnormal lipid levels, has been suggested as an early diagnostic and preventable factor for CVD. Recent studies have shown that exposure to lead (Pb), cadmium (Cd), and mercury (Hg) affects lipid metabolism. This study aimed to verify the association between heavy metal concentrations and serum lipid profiles in the general population. A representative sample of 2591 Korean adults from the Korean National Environmental Health Survey (2015−2017) was analyzed. The associations between heavy metals [Blood Pb (BPb), blood Hg (BHg), urinary Hg (UHg), urinary Cd (UCd)] and serum lipid profiles [total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), non-low level of high-density lipoprotein cholesterol (Non-HDL-C)] were assessed using regression analysis. After adjusting for demographic and socioeconomic factors, the proportional changes in serum lipid levels were significantly associated with increases in BPb, BHg, and UHg levels (p for trend < 0.05). Overall, BPb, BHg, and Uhg levels positively correlated with dyslipidemia, whereas UCd levels did not show a significant association. Our results suggest that heavy metal exposure, at low levels, may contribute to an increased prevalence of dyslipidemia in Korean adults.

Hormonal contraception and metabolic outcomes in women with or at risk for HIV infection

OBJECTIVE

The use of hormonal contraception (HC) is increasing in HIV-infected women. Both HC and HIV infection have been associated with adverse metabolic outcomes. We investigated the association of progestin-only and combined (estrogen/progestin) HC with disorders of glucose and lipid metabolism in HIV-infected and uninfected women.

METHODS

Linear mixed models evaluated the association of HC type with fasting high density lipoprotein, low density lipoprotein, triglycerides, the homeostasis model assessment estimate of insulin resistance (HOMA-IR), and glucose in 885 HIV-infected and 408 HIV-uninfected women from the Women's Interagency HIV Study seen between October 2000 and September 2005.

RESULTS

Compared with non-HC users, progestin-only HC was independently associated with lower HDL [-3 mg/dL; 95% confidence interval (CI) -5, -1 in HIV-infected and -6 mg/dL; 95% CI: -9, -3 in HIV-uninfected women] and greater HOMA-IR (+0.86; 95% CI: 0.51-1.22 and +0.56; 95% CI: 0.12-1.01). Combined HC was associated with higher HDL (+5 mg/dL; 95% CI: 2-7 and +5 mg/dL; 95% CI: 3-7).

CONCLUSIONS

HIV-infected women using progestin-only HC have lower HDL and greater HOMA-IR than HIV-infected non-HC users. Combined HC may be preferred in HIV-infected women of reproductive age at risk for cardiovascular disease, but interactions with antiretroviral therapy that may impair contraceptive efficacy have been reported. Alternative HC methods that minimize adverse outcomes but maintain efficacy require further study.

Hormonal contraception and HIV-positive women: metabolic concerns and management strategies

As HIV-positive women live longer lives, and as testing for HIV becomes more routine, clinicians can expect to see more HIV-positive women in their practices. The need to be aware of management issues particular to this population becomes increasingly important. Metabolic dysregulation is a common, long-term complication associated with HIV and is one of the most difficult to manage. Hormonal contraception also is associated with metabolic dysregulation. As more HIV-positive women choose long-term, reversible contraception, the potential for concomitant and additive side effects, and the need for careful, proactive management strategies to avoid these complications, will become more important. This article reviews research detailing the metabolic dysfunction associated with hormonal contraception and with HIV-seropositivity. It highlights reasons for concern regarding the potential, although as yet theoretical, increased risk for metabolic dysfunction when hormonal contraception is used in the presence of HIV. Suggestions for management strategies for women living with HIV who choose to use hormonal contraception are presented. These strategies should be viewed as suggestions for management until substantitive research becomes available.

Effects of misoprostol on lipoprotein (a) levels of ovariectomized rats

OBJECTIVE

To determine the effects of misoprostol on plasma lipoprotein (a) concentrations of ovariectomized rats.

DESIGN

Controlled prospective study.

SETTING

Animal research laboratory.

ANIMAL(S)

Four-month-old female Sprague-Dawley rats.

INTERVENTION(S)

Blood samples were obtained before and 60 days after ovariectomy, and the rats were divided into three groups. Group I (five rats) was treated with vehicle (water); groups II and III (nine and eight rats, respectively) were treated with oral misoprostol at 100 and 200 microg/kg/d, respectively, for 60 days, after which blood was drawn again.

MAIN OUTCOME MEASURE(S)

Serum lipoprotein (a) levels.

RESULT(S)

The median lipoprotein (a) level before ovariectomy was 10.8 mg/dL (range, 10.6-46.5 mg/dL). Sixty days after ovariectomy, the level increased significantly to 15.9 mg/dL (range, 10.6-36.9 mg/dL). After treatment, there was no change in lipoprotein (a) levels in the vehicle-treated group (range, 16.3-21.1 mg/dL); however, the lipoprotein (a) levels decreased significantly in the group treated with 100 microg/kg/d of misoprostol, from 15.4 mg/dL to 10.8 mg/dL, and in the group treated with 200 microg/kg/d of misoprostol, from 17.1 mg/dL to 10.6 mg/dL.

CONCLUSION(S)

Misoprostol caused a significant decrease in lipoprotein (a) levels.

Comparison of the effects of triphasic oral contraceptives with desogestrel or levonorgestrel on apolipoprotein A-I-containing high-density lipoprotein particles

Recent observations suggest that the risk of coronary artery disease (CAD) is associated with both the level and composition of the two major populations of apolipoprotein (apo)-defined high-density lipoprotein (HDL) particles: those containing both apo A-I and apo A-II [Lp(AI,AII)] and those containing apo A-I without apo A-II [Lp(AI)]. While sex hormones are known to affect HDL, their influence on these apo-defined HDL particles is not known. We have determined the effects of two triphasic oral contraceptive (OC) formulations on these HDL particles in healthy normolipidemic women aged 21 to 35 years. The formulations contain comparable quantities of ethinyl estradiol (EE) and either desogestrel (DG), a minimally androgenic progestin, or levonorgestrel (LN), a more androgenic progestin. Lipid and lipoprotein levels were measured during the third week of the normal menstrual cycle and the sixth month of OC use. The DG/EE formulation significantly increased total cholesterol (C) 15%, triglyceride (TG) 99%, phospholipid (PL) 17%, apo A-I 28%, apo A-II 34%, apo B 21%, very-low-density lipoprotein cholesterol (VLDL-C) 238%, HDL-C 20%, and HDL3-C 28% (P < .02 to .005, n = 11), but not low-density lipoprotein cholesterol (LDL-C). The LN/EE formulation also increased total C 15%, TG 33%, apo A-I 15%, HDL3-C 21% (P < .05, n = 10), apo B 30% (P < .005), and, additionally, LDL-C 19% (P < .05). Both formulations increased Lp(AI,AII) (DG/EE, 34%, P < .005; LN/EE, 24%, P < .01). These changes reflected comparable increases of small (7.0 to 8.2 nm) and medium (8.2 to 9.2 nm) particles in the LN/EE group and a predominant increase of medium-sized particles in the DG/EE group. Also, in the LN/EE group but not the DG/EE group, there were fewer large (9.2 to 11.2 nm) particles. Lp(AI) increased only in the DG/EE group (25%, P = .075) and was due to the presence of more large particles. The level of Lp(AI) did not change in the LN/EE group, but the lipid/A-I ratio of these particles was lower (P = .012) and there were more small particles. Thus, triphasic OC formulations with progestins of different androgenicity had different effects on VLDL, LDL, and the level and composition of HDL particles with and without apo A-II, possibly reflecting estrogen/progestin/androgen balance. Estrogen dominance increases both Lp(AI,AII) and Lp(AI) and favors large Lp(AI) particles, while progestin/androgen dominance increases only Lp(AI,AII) and favors small particles. Because of the importance of HDL in the arterial wall physiology, OC formulations with different estrogen and progestin content may affect arterial wall health to a different extent.

Safety evaluation of modern oral contraceptives. Effects on lipoprotein and carbohydrate metabolism

An ideal oral contraceptive should either be neutral as regards metabolic risk markers for arterial disease or should only change them in directions that would be expected to reduce risk. Depending on their formulation, modern low dose oral contraceptives affect systems such as hemostasis, lipoprotein metabolism, and glucose and insulin metabolism. Some of these actions would be expected to decrease the risk of arterial disease and some might be expected to increase risk. Despite these associations there is at present no justification for widespread metabolic screening as a strategy to further improve oral contraceptive safety. Recent developments in atherosclerosis research support the introduction of progestogens such as desogestrel that allow the estrogenic increase in high density lipoprotein levels to persist and that may cause less of an elevation in plasma insulin responses to glucose. The predicted benefit of these formulations in terms of arterial disease is difficult to demonstrate in an epidemiological setting because of the rarity of the disease in young women.

Contraception. A clinical review for the internist

Effective use of contraception allows couples to control their fertility and, in certain instances, is associated with important noncontraceptive benefits. Surgical sterilization offers safe, effective, and permanent contraception for women and men. Low-dose OCPs offer safe, effective contraception for most women able and willing to take pills consistently. In addition, their use confers a variety of important noncontraceptive benefits. The availability of long-acting progestin injectable and implantable methods has made highly effective and convenient birth control available for women who are not good pill takers as well as for those for whom contraceptive doses of estrogen are contraindicated. Barrier methods are readily available and provide protection against STDs; unfortunately, erratic use is all too often associated with inadequate contraceptive efficacy. IUDs offer convenient, highly effective contraception for appropriate candidates.

Oral contraceptives: an update

Despite continual improvement in oral contraceptive formulations, many women still have unwarranted concerns about their safety and remain ignorant of their nonreproductive health benefits. The need for a reliable method of contraception is the greatest among adolescents and women older than 35 years--the two groups in the United States with the highest abortion rates.

The gynecologist and the prevention of cardiovascular disease

This article reviews current concepts regarding the prevention of cardiovascular disease for women, with particular attention to modifiable risk factors. The background describes the magnitude of the problem, assesses the quality of the data with respect to risk factor reduction, and emphasizes several important concepts. Changes at menopause, states of endocrine aberration, and benefits and risks of hormone substitution need to be understood in conjunction with all other potentially modifiable and nonmodifiable cardiovascular risk factors. Primary care physicians have a window of opportunity to prevent this number one women's health problem. Integrating behavior modification is the key to prevention as part of the regular gynecologic visit.

Contraception for patients with psychiatric or medical disorders

The increased risk that pregnancy carries for women with medical disorders must be weighed against the risks of reversible contraception. In the absence of prospective randomized trials of various contraceptive methods and their effect on a given disease process, the clinician must use information regarding the risk of pregnancy in a woman with medical problems, the well-documented failure rates of various methods, and the probability that the patient will use the method (or any other method) effectively. The possible effects of contraceptive methods on cardiovascular, endocrinologic, neurologic, and other medical disorders are discussed as are appropriate contraceptive options and considerations for these women.

Considerations for contraception in women with cardiovascular disorders

Women with hypertension, angina pectoris, or mitral valve prolapse require special considerations when selecting an appropriate method of contraception. All three effective, reversible options (oral contraceptives, intrauterine devices, or progestin implants) carry some degree of added risk for these patient populations. However, pregnancy itself presents certain risks and, in the event of contraceptive failure, certain women with these disorders are at increased risk of developing serious cardiovascular sequelae that affect both mother and fetus. These negative effects can carry far into the neonatal period. This article describes the risk/benefit profiles of the currently available contraceptive options relative to their potential impact in these compromised women.