Variation of ethinylestradiol blood levels among healthy women using oral contraceptives

Endocrine care of transpeople part II. A review of cross-sex hormonal treatments, outcomes and adverse effects in transwomen

The treatment of transwomen relies on the combined administration of anti-androgens or GnRH analogues to suppress androgen production and thereby reduce male phenotypic characteristics together with oestrogens to develop female characteristics. In transwomen, synthetic oestrogens such as ethinyl oestradiol, as well as conjugated equine oestrogens (CEE), should be avoided to minimize thromboembolic risks especially in older transwomen and in those with risk factors. Currently, available short- and long-term safety studies suggest that cross-sex hormonal therapy (CHT) can be considered safe in transwomen improving the well-being and quality of life of these individuals. Long-term monitoring should aim to decrease cardiovascular risks and should include prostate and breast cancer screenings.

Contraceptive considerations in overweight teens

PURPOSE OF REVIEW

The purpose of this review is to explore the efficacy and safety of contraceptives in overweight adolescents.

RECENT FINDINGS

There are few studies exploring hormonal contraceptive efficacy and safety in overweight and obese adults and almost none addressing these issues in adolescents. Luckily for teens, in terms of safety, many of the comorbidities associated with obesity are yet to transpire and their options for contraception remain relatively unrestricted. Studies of the combined oral contraceptive pill and patch in adults suggest that efficacy may be decreased in overweight adolescents. There is no evidence to suggest that the efficacy of the contraceptive implant or intrauterine device (IUD) is decreased in overweight adolescents. Indeed, these long-acting reversible methods will be the best choice for many adolescents because of their high efficacy. Although the literature is not definitive, there is probably a subset of adolescents who are susceptible to weight gain with use of depot medroxyprogesterone acetate.

SUMMARY

Although there is little research regarding contraceptive efficacy in overweight adolescents, IUDs and implants will be the best methods for many adolescents because of their high efficacy, reversibility, and safety.

Hormonal Contraception and Physiology: A Research-based Theory of Discontinuation Due to Side Effects

Side effects influence the acceptability and continuation of hormonal contraceptives. Counseling the client about the management of side effects is a principal approach advocated for increasing continuation. Evidence of a biological basis for variation in women's tolerance of hormonal contraceptives argues, however, that greater attention should be given to altering the product rather than principally attempting to alter a woman's ability to deal with the product. Discontinuation rates for hormonal contraceptives, largely attributable to side effects and health concerns, are high in nearly all less-developed countries for which Demographic and Health Survey data are available. Oral contraceptives appear to be particularly problematic for Latin American women, most notably in Bolivia. Clinical trials suggest substantial variation in the physiological response to exogenous hormones, and new evidence confirms the hypothesis that the normal hormonal profiles of Bolivian women are significantly lower than those of women in the United States. These findings suggest a need for more population-specific physiological research linked to analyses of the possible association between endogenous hormone differences and contraceptive continuation. Appropriately adjusting the level of the steroid delivered may benefit women's health and improve the acceptability and continuation of hormonal contraceptives.

Body Mass Index, Weight, and Oral Contraceptive Failure Risk

OBJECTIVE

To estimate the effect of body mass index (BMI) and weight on risk of pregnancy while using oral contraceptives (OCs).

METHODS

We conducted a case-control study of 248 health maintenance organization enrollees who became pregnant while using OCs between 1998 and 2001 and 533 age-matched enrollees who were nonpregnant OC users during the same period. Using logistic regression we calculated adjusted odds ratios (ORs) to estimate the risk of pregnancy according to BMI and weight quartile.

RESULTS

Among all OC users, when compared with women having a BMI of 27.3 or less, the risk of pregnancy was nearly 60% higher in women with BMI greater than 27.3 (OR 1.58, 95% confidence interval [CI] 1.11-2.24) and over 70% higher in women with BMI greater than 32.2 (OR 1.72, 95% CI 1.04-2.82). Among consistent users (women who missed no pills in reference month), the risk of pregnancy was more than doubled in women with BMI greater than 27.3 (OR 2.17, 95% CI 1.38-3.41) or BMI greater than 32.2 (OR 2.22, 95% CI 1.18-4.20). When compared with women weighing 74.8 kg or less, among consistent OC users the risk of pregnancy was over 70% higher in women weighing more than 74.8 kg (OR 1.71, 95% CI 1.08-2.71) and nearly doubled in women weighing more than 86.2 kg (OR 1.95, 95% CI 1.06-3.67).

CONCLUSION

Our results suggest that being overweight may increase the risk of becoming pregnant while using OCs. If causal, this association translates to an additional 2-4 pregnancies per 100 woman-years of use among overweight women, for whom consideration of additional or effective alternative contraceptive methods may be warranted.

The effect of desogestrel, gestodene, and other factors on spotting and bleeding

Spotting and bleeding are among the most common side effects associated with oral contraceptive (OC) use and their occurrence is a prime determinant of whether a new user will continue to use OCs. Desogestrel and gestodene are two new progestins that were developed in part to minimize the occurrence of these side effects. Assessing the effect of these progestins is difficult, however, in part because their effects may be subtle, requiring a large sample size and possibly being overshadowed by other factors. To address these issues, we analyzed data from two comparative multicenter clinical trials that included 15,421 cycles among 2767 women. One study compared 75 micrograms gestodene + 30 micrograms ethinyl estradiol (EE) with 150 micrograms desogestrel + 30 micrograms EE, the other compared the same gestodene preparation with 150 micrograms desogestrel + 20 micrograms EE. Both studies found a higher risk of spotting or bleeding in all cycles among users of the desogestrel-containing preparation, with the differences ranging between 20% and 70% higher for the first study and 40% and 140% in the second. These differences were statistically significant in four of six cycles in each study and persisted after controlling for consistency and recency of OC use as well as smoking. After pooling the data and controlling for estrogen dose, the desogestrel-containing preparation was significantly associated with more frequent spotting or bleeding in five of six cycles. Smoking and consistency and recency of OC use were also independent predictors of spotting or bleeding.

Can grapefruit juice influence ethinylestradiol bioavailability?

The effects of grapefruit juice on the bioavailability of 17 alpha-ethinylestradiol (EE2) after a single oral administration of 50 micrograms EE2 have been investigated. The pharmacokinetics of EE2 were studied in an open, randomized, cross-over study in which 13 healthy volunteers were administered the drug with herbal tea or grapefruit juice (naringin, 887 mg/ml). In contrast to herbal tea, grapefruit juice increased the peak plasma concentration (Cmax) significantly to 137% (mean; range 64% to 214%, p = 0.0088) and increased the area under plasma concentration-time curve from 0 to 8 hours (AUC0-8) to 128% (mean; range 81% to 180%, p = 0.0186). This study shows that grapefruit juice increases the bioavailable amount of EE2. A possible explanation may be that grapefruit juice inhibits the metabolic degradation of EE2. Whether the increased bioavailability of EE2 following grapefruit juice administration is of clinical importance should be investigated in long-term studies.

Lansoprazole does not affect the bioavailability of oral contraceptives

The effects of the proton pump inhibitor lansoprazole on the bioavailability of a low-dose oral contraceptive (OC), containing 0.03 mg ethinyloestradiol (EE) and 0.15 mg levonorgestrel (LNG), were investigated. Twenty-four healthy females (aged 19-35 years; weight 60.6 +/- 7.1 kg) participated in a multiple-dose, placebo-controlled, randomized two-way cross-over study. All subjects received the OC over 2 full menstrual cycles from day 1 to day 21 separated by a drug-free interval of 7 days. Lansoprazole (60 mg day-1) or placebo was coadministered for 3 weeks each. Plasma concentrations of EE and LNG were determined by GC-MS. The 90% confidence intervals for ratios of Cmax and AUC after log transformation of both EE and LNG ranged between 91 and 111%, indicating that lansoprazole did not affect the bioavailability of EE and LNG.

Intrasubject variability in the pharmacokinetics of ethynyloestradiol

Intrasubject and intersubject variability in the metabolism of ethynyloestradiol (EE) was assessed in a cross-over randomized study of 6 women who each received 3 months treatment with 50 micrograms EE and 50 micrograms EE with 250 micrograms levonorgestrel (LNG). Blood samples were collected at the end of each treatment month, assayed for EE and the half-life of elimination (Tel) and bioavailability (area under the serum concentration-time curve, AUC) calculated. Intrasubject variability for Tel and AUC varied markedly; the variability was random and not correlated with the formulation administered. The intrasubject variability for Tel and AUC was 31 and 17%, respectively, and intersubject variability 66 and 95%. The intersubject range of values was more than 3-fold for both Tel and AUC and the intrasubject range about 2-fold. The pharmacokinetics of EE were not influenced by LNG; mean values for Tel and AUC were 17.3 +/- 5.5 h and 11.1 +/- 3.8 ng/ml/h, respectively, when EE was administered alone compared with 16.4 +/- 4.8 h and 12.5 +/- 3.9 ng/ml/h when given with LNG. However, EE influenced the metabolism of LNG; Tel for LNG was 19.3 +/- 4.2 h when administered alone and significantly higher (30.0 +/- 11.2 h) when given with EE. There was no correlation between the rate of metabolism of EE and that of LNG. The intrasubject variability shown in this and other studies suggests that genetic factors are less important in intersubject variability than previously thought. Some implications of intrasubject variability are discussed.

Effects of low and high dose oral contraceptives on blood coagulation and thrombogenesis induced by vascular subendothelium exposed to flowing human blood

We investigated the effect of oral contraceptives with low and high estrogen concentration on blood coagulation and thrombogenesis, induced by vascular subendothelium of rabbit aorta exposed to flowing human blood. Twenty healthy women intending to take oral contraceptives were studied [1] before drug ingestion (control), and subsequently during the intake of oral contraceptives with [2] low estrogen content (20 micrograms ethinyl estradiol and 150 micrograms desogestrel per day) and [3] high estrogen content (50 micrograms ethinyl estradiol and 125 micrograms desogestrel per day). All experiments were performed between day 17 and 21 of the menstrual cycle and drug effects were studied during the third tablet cycle. Deposition of fibrin, platelets and platelet thrombi on vascular subendothelium was tested at a defined blood flow and wall shear rate (10 ml/min, 650 s-1) and was quantified by morphometrical techniques. Treatment with the low and high dose contraceptive increased the plasma levels of ethinyl estradiol (728 +/- 139 and 1438 +/- 212 vs. 0 fmol/l [low and high dose vs. control], means +/- SEM, P less than 0.001) and fibrinogen (2.3 +/- 0.1 and 2.6 +/- 0.1 vs. 2.0 +/- 0.1 g/l, P less than 0.05); and decreased antithrombin III activity (95 +/- 3 and 92 +/- 3 vs. 101 +/- 3 %, P less than 0.05). Fibrin deposition on vascular subendothelium was enhanced by the high dose contraceptive only (47 +/- 4 vs. 35 +/- 4 % coverage of the subendothelial surface with fibrin, high dose vs. control, P less than 0.05). The subendothelial deposition of platelets and platelet thrombi was not changed by contraceptive treatment. These results indicate that treatment with high dose contraceptives leads to an increase of fibrin-subendothelial interactions, whereas low dose contraceptives do not significantly alter the blood-subendothelium interactions. observed in this ex vivo model of thrombogenesis.

Effects of 17 alpha-ethinyl oestradiol in vitro on erythrocyte cation transport in men and women

The effects of 17 alpha-ethinyl oestradiol in vitro upon erythrocyte Na(+)-K+ cotransport were investigated in nine normal males and in eight normal females during the mid-follicular phase of the menstrual cycle. At a concentration of 10(-1) mmol/l, Na(+)-K+ cotransport was almost completely inhibited. At concentrations of 10(-12) to 10(-2) mmol/l, a minor concentration-related effect was observed in males but not females. In the same concentration range, there was a significant difference in Na(+)-K+ cotransport between sexes. Thus, erythrocyte Na+K+ cotransport is lower in females than males, probably due to chronic exposure of their erythrocytes to endogenous oestrogen.

Serum pharmacokinetics of orally administered desogestrel and binding of contraceptive progestogens to sex hormone-binding globulin

Serum levels of 3-ketodesogestrel and ethinyl estradiol were analyzed by radioimmunoassay in a balanced crossover study with two tablet formulations containing desogestrel (0.150 mg) and ethinyl estradiol (0.030 mg) in 25 women under steady-state conditions after 21 days of treatment. The pharmacokinetic properties of desogestrel were characterized by the following parameters: (1) maximum serum concentration, (2) time to maximum serum concentration, (3) total area under the serum concentration versus time curve, and (4) serum half-life of elimination. The interindividual variation in these parameters was comparable with that observed with other contraceptive combinations containing ethinyl estradiol and norethisterone, levonorgestrel, or gestodene. The serum distribution of contraceptive progestogens is known to be determined by their affinity to sex hormone-binding globulin and the concentration of sex hormone-binding globulin. We analyzed the structural features that determine binding to sex hormone-binding globulin. The 18-methyl group increased and the 11-methylene group weakened the binding to sex hormone-binding globulin. The double bond at C-15 reinforced the binding only when combined with an 18-methyl group. Therefore, the binding of levonorgestrel (the 18-methyl derivative of norethisterone) and gestodene (the delta-15,18 methyl derivative of norethisterone) to sex hormone-binding globulin was much stronger than that of 3-keto-desogestrel and norethisterone.

Pharmacokinetics and pharmacodynamics of oral contraceptive steroids: factors influencing steroid metabolism

The time-dependent alterations in the serum concentrations of ethinyl estradiol, gestodene, and 3-keto-desogestrel during treatment with 30 micrograms of ethinyl estradiol + 75 micrograms of gestodene or 30 micrograms of ethinyl estradiol + 150 micrograms of desogestrel were investigated during 12 months. The levels of gestodene and 3-keto-desogestrel increased between days 1 and 21 of each cycle, reaching maximal levels during the third and sixth cycles. The serum concentrations of gestodene were fourfold to fivefold higher than those of 3-keto-desogestrel. The ethinyl estradiol levels increased significantly between days 1 and 10 during each cycle and were significantly higher by 70% during intake of ethinyl estradiol/gestodene compared with ethinyl estradiol/desogestrel, although the dose was identical. Intake of gestodene, in addition to 35 micrograms of ethinyl estradiol + 2 mg of cyproterone acetate, caused a rise in ethinyl estradiol levels. During treatment with ethinyl estradiol/gestodene and an additional 150 micrograms of levonorgestrel, there was a continuous increase in gestodene levels, although sex hormone-binding globulin level did not change. During treatment with 30 or 35 micrograms of ethinyl estradiol and 75 micrograms of gestodene, 150 micrograms of desogestrel, or 2 mg of cyproterone acetate, there were large intraindividual and interindividual variations in the steroid levels and ratios of estrogen: progestogen levels. There was no correlation with the occurrence of intermenstrual bleedings. It is concluded that ethinyl estradiol and nortestosterone derivatives may inhibit steroid-metabolizing enzymes in the liver, which results in a rise in the serum levels of contraceptive steroids. The cause of the large intraindividual variations is as yet unknown, but it is probably from changes in steroid metabolism.

Inhibition of oral contraceptive steroid-metabolizing enzymes by steroids and drugs

The major 17 alpha-ethinyl estradiol 2-hydroxylase is humans is the hepatic enzyme cytochrome P-450 IIIA4 (P-450NF), which is known to be inducible by rifampicin or barbiturates. The literature indicates that 17 beta-estradiol, progesterone, and norgestrel are competitive inhibitors and that primaquine and tolbutamide are rather weak noncompetitive inhibitors. Recent experiments in this laboratory indicate that gestodene is a relatively potent mechanism-based inactivator of cytochrome P-450 IIIA4 in vitro. Inhibition requires incubation with the reduced form of nicotinamide adenine dinucleotide phosphate, is time and concentration dependent, and can be partially blocked by the presence of noninhibitory cytochrome P-450 IIIA4 substrates. The in vitro activation by gestodene provides a possible explanation for the increase in plasma estrogen levels reported in women administered gestodene along with 17 alpha-ethinyl estradiol.

Intra- and interindividual variations in contraceptive steroid levels during 12 treatment cycles: no relation to irregular bleedings

During one year of treatment with oral contraceptives containing 30 micrograms ethinylestradiol and 150 micrograms desogestrel (EE/DG) or 30 micrograms EE and 75 micrograms gestodene (EE/GSD), the serum concentrations of EE, 3-keto-desogestrel (KDG) and GSD were determined on day 1, 10 and 21 of the 1st, 3rd, 6th and 12th cycle. The areas under the time-versus-concentration curves were calculated from the levels before and 0.5, 1, 1.5, 2, 3, 4 and 24 hours after intake of a tablet. There were large intra- and interindividual variations both revealing coefficients of variation (C.V.) between 25% and 80% (EE),, 30% and 50% (KDG) and 30% and 65% (GSD). During each cycle, the EE levels increased significantly between day 1 and 10 by 70% on average reaching a steady-state, while the progestogen concentrations rose by 100% (KDG) and 150% (GSD) up to a steady-state between day 10 and 21. After reaching the steady-state, the C.V. were generally lower. The ratios between the levels of EE and the progestogens showed still higher variations indicating different influences on the estrogen and progestogen component. There was no correlation between the steroid levels and weight, height or age. In spite of the large intraindividual variations, most of the women showed a distinct pattern of the levels of EE and the progestogens throughout the year of treatment indicating a genetic or acquired predisposition. The difference in the average AUC of EE, KDG and GSD between the women was 300% at most. During the first cycle of treatment with EE/DG and EE/GSD, about half of the women recorded intermenstrual bleedings which decreased thereafter. There was no relation between the occurrence of irregular bleedings and the average serum levels of EE and the progestogens of the individual women, neither during the first cycle nor during the whole treatment period of 12 cycles. It is concluded that spottings or breakthrough bleedings during treatment with oral contraceptives are not dependent on a distinct pattern of the serum levels of EE and the progestogen.

Metabolism of 17 alpha-ethynylestradiol in humans

17 alpha-Ethynylestradiol is extensively sulfated but the sulfate is thought to primarily be a storage form of this estrogen. 2-Hydroxylation is clearly the major oxidative reaction, and the 2-hydroxy derivative is further transformed by methylation and glucuronidation prior to urinary and fecal excretion. Alterations in the rate of 2-hydroxylation can have major effects on the pharmacokinetics and effectiveness of 17 alpha-ethynylestradiol as a contraceptive. The major human catalyst of the 2-hydroxylation reaction is liver microsomal cytochrome P-450 IIIA4. Lesser amounts of this enzyme are found in other tissues such as the intestine and may contribute to overall clearance of the orally administered contraceptive. In individuals with very low amounts of this enzyme other forms of cytochrome P-450 may make some contribution. Levels of cytochrome P-450 IIIA4 vary widely among individuals and can explain the variation in rates of 17 alpha-ethynylestradiol 2-hydroxylation. The known inducibility of the enzyme by barbiturates and rifampicin explains their effects in enhancing 17 alpha-ethynylestradiol clearance and reducing the effectiveness of the drug. Mechanism-based inactivation of cytochrome P-450 IIIA4 can be seen with 17 alpha-ethynylestradiol and other 17 alpha-acetylenic steroids, and the progestogen gestodene appears to be unusually active in this regard. Other unknown factors may also modulate levels of cytochrome P-450 IIIA4 and its ability to catalyze 17 alpha-ethynylestradiol 2-hydroxylation.

Interaction with the pharmacokinetics of ethinylestradiol and progestogens contained in oral contraceptives

The serum concentrations of ethinylestradiol (EE) during the first 4 h and 24 h after intake of an oral contraceptive containing 30 micrograms EE and 75 micrograms gestodene (EE/GSD) were compared to those after intake of a preparation containing the same EE dose and 150 micrograms desogestrel (EE/DG) in each of 11 women on days 1, 10, and 21 of their 1st, 3rd, 6th, and 12th cycles. There were great interindividual variations, but during treatment with EE/GSD the EE levels were higher and the EE peaks occurred by 30 min later than during treatment with EE/DG. The areas under the EE serum concentration-versus-time curves (AUC) between 0 and 4 h were higher by 37% (p less than 0.03) and between 0 and 24 h higher by 70% (p less than 0.002) during treatment with EE/GSD. During each treatment cycle, the EE levels rose between day 1 and 10. The serum levels of corticosteroid-binding globulin (CBG), which is known to be influenced only by the estrogenic component of the combination pill, increased significantly (p less than 0.01) during each treatment cycle. CBG was elevated on day 21 of the 6th and 12th cycle by 150 to 155% and by 120 to 130% with EE/GSD and EE/DG, respectively. The difference between the two drugs was significant (p less than 0.02). During the pill-free intervals of 7 days between the treatment cycles, the CBG levels decreased but were still elevated by 85% with EE/GSD and 50% with EE/DG at the beginning of the following cycle as compared to the control cycle. The serum levels of cortisol were also significantly more elevated (p less than 0.05) during treatment with EE/GSD as compared to EE/DG. Despite the same EE dose during treatment, the higher EE levels with EE/GSD as compared to EE/DG seem to be due to a retardation of the inactivation and elimination of EE caused by the progestogen component. The rise in the EE levels during each cycle seems to be due to a reduction in the oxidative metabolism by EE itself.

Serum levels of 3-keto-desogestrel and SHBG during 12 cycles of treatment with 30 micrograms ethinylestradiol and 150 micrograms desogestrel

The serum concentrations of 3-keto-desogestrel (KDG) have been determined radioimmunologically in 11 female volunteers on Day 1, 10, and 21 of the 1st, 3rd, 6th, and 12th cycle of treatment with 30 micrograms ethinylestradiol and 150 micrograms desogestrel during the first 4 hours and 24 hours after intake. On the first day of each cycle the KDG levels were low, but increased thereafter until Day 21. Highest serum concentrations were measured on Day 21 of the 3rd and 6th cycle with peak levels between 1.5 and 6.2 ng/ml. Contrary to this, the KDG levels were significantly reduced during the 12th treatment cycle. The serum concentrations of SHBG rose significantly between Day 1 and Day 21 of each cycle reaching values which were 3-fold of those at the beginning of treatment. During the pill-free intervals, SHBG levels decreased but remained elevated as compared to controls. There was a significant correlation between the SHBG levels and the area under the KDG-concentration-versus-time curves (AUC) indicating a pronounced influence of the serum steroid-binding protein upon the pharmacokinetics of KDG. There were great interindividual differences in the KDG levels. The serum levels of the individual woman remain, however, in a relatively constant range throughout the treatment period of 12 months, possibly due to genetic factors.

A randomized cross-over comparison of two low-dose oral contraceptives upon hormonal and metabolic parameters: I. Effects upon sexual hormone levels

The effect of a low-dose triphasic oral contraceptive (OC) containing ethinyl estradiol and levonorgestrel (EE/NG) upon serum levels of endogenous sexual hormones was compared to that of a preparation containing EE and desogestrel (EE/DG). Blood samples were taken on Day 6, 11, 21, and 28 of a control cycle and of the third cycle of treatment with either the EE/NG or EE/DG preparation (11 volunteers each). After a washout period of 3 months, the contraceptives were changed in a cross-over fashion. Blood samples were again taken on Day 6, 11, 21, and 28 of the third washout cycle and the third treatment cycle. There was no significant suppression of serum LH and FSH during treatment with EE/NG and EE/DG except on Day 21, while estradiol levels were significantly lowered. Similar to the gonadotropin concentrations, the estrogen levels showed great individual variations; although they were depressed in the majority of the women, there was a considerable stimulation of follicular activity in 36% of the women under EE/NG and 18% under EE/DG. Both EE/NG and EE/DG suppressed significantly serum progesterone, testosterone, and DHEA-S, while prolactin was unaffected. In three cases an escape ovulation seemed to have occurred, but no pregnancy was observed. The spottings (8/22 women) and breakthrough bleedings (6/22 women) did not correlate with the serum levels of estradiol. The results indicate that the suppression of gonadotropin secretion during treatment with low-dose OC is a time-dependent process which in some women may be at or below the threshold of safe ovulation inhibition.

Reexamining the oral contraceptive issues

Oral contraceptives have been in use since the 1960s. Over the past 20 plus years, the risks and benefits of oral contraceptives have captured the attention of the press and the public. According to current data, oral contraceptives seem to pose the greatest risk for women in their 40s who smoke cigarettes. They have the least risk and greatest benefit for young women, especially nonsmokers. This article focuses on a reexamination of the issues. Are oral contraceptives safe? If so, for whom? How can risk be predicted? What are noncontraceptive benefits? Implications for practice and for the future of oral contraceptives research are presented.

Mode of action of dl-norgestrel and ethinylestradiol combination in postcoital contraception. II. Effect of postovulatory administration on ovarian function and endometrium

A combination of 1.0 mg dl-norgestrel and 0.1 mg ethinylestradiol (EE) was administered orally at 36 hours after the detection of the luteinizing hormone peak and again at 48 hours in 12 healthy volunteers with normal menstrual cycles. The effects on ovarian function were studied by comparing the daily serum levels of progesterone (P), 17 alpha-hydroxyprogesterone, and estradiol (E2) in control (placebo) and treatment cycles. Five subjects showed no significant change in the levels of these steroids but had a shortened luteal phase. The treatment significantly decreased both P and E2 levels in three subjects, while two subjects showed diminished E2 levels only. The remaining two subjects had lower P levels and fluctuating E2 patterns. Endometrial biopsies from both study cycles indicated asynchronous development of the epithelial and stromal components in the treatment cycle. These findings (abnormal luteal phase steroid levels and duration and outphased endometrial development) indicate that corpus luteum function was variously affected by the action of norgestrel-EE treatment.

Differential effects of exogenous oestradiol and progesterone on mood in post-menopausal women: individual dose/effect relationship

This study reports on 56 women who volunteered for consultation at a gynaecological hospital for their climacteric symptoms. The stability of their low oestradiol and high gonadotrophin plasma levels was controlled first. Afterwards they were treated for 3 mth with natural oestradiol (percutaneously). Once the plasma oestradiol levels were proved to be stable during the treatment, natural progesterone was also administered (orally) the last 10 days of treatment. As observed with all steroid administration, the same therapeutic regimen induced different individual plasma levels of the natural steroids. The relationship between mood and plasma levels was as follows. Moderate depressive symptoms were correlated to the lowest plasma oestradiol level, before and after treatment. Only when a moderate increase in oestradiol level was induced did the oestradiol treatment itself lead to a pleasant feeling of well-being. When an excessive increase was induced by the treatment, most of the women complained of unpleasant side effects, mostly irritability and aggressiveness. Progesterone had very few psychological effects if oestradiol levels were low or slightly increased. When plasma oestradiol was high, a moderate elevation of plasma progesterone induced a pleasant tranquillizing effect. A massive elevation of plasma progesterone levels immediately induced an inadequate hypnotic effect, sometimes with dizziness. Therefore, therapeutic administrations of natural steroids appear to strongly influence the mood and behaviour of post-menopausal women. However, the expected pleasant effect could not be successfully achieved without a careful adaptation of the correct dosage to each individual patient.

Plasma levels of ethinylestradiol (EE) during cyclic treatment with combined oral contraceptives

The purpose of the present study was to extend the still limited data concerning ethinylestradiol (EE) plasma levels after repeated daily ingestion of a combination pill during the course of classical cyclic treatment. Plasma EE levels were followed in 13 volunteers throughout, in total, 19 treatment cycles with either a 50 ug EE (+ 125ug d-norgestrel) or a 30 ug (+ 150ug d-norgestrel) containing oral contraceptive. In addition, single plasma EE determinations were performed in 110 chronic oral contraceptive users. Whereas different patterns in plasma EE levels (sampling 24 hours following last pill ingestion) were observed among the different volunteers, the mean levels increased progressively during treatment and reflected closely the differences in dosage. The values obtained in the volunteers at the end of the treatment cycle showed important interindividual variations. The findings during a first treatment cycle or during the following ones were similar and for different treatment cycles in the same patient, the patterns in plasma EE levels were consistent. The results for single plasma determinations in chronic contraceptive users (sampling between 8th and 21st day of treatment cycle, 9 to 24 hours since last pill ingestion) showed more pronounced interindividual variations, the individual EE levels being not correlated to parameters such as body weight, body surface, months of oral contraception prior to the study, sex hormone binding capacity or day of the cycle. However, significant differences in mean plasma EE levels were noticed for patients treated with different commercial preparations with identical EE content, suggesting the existence of differences in bioavailability. The relevancy of plasma EE determinations is discussed and from the results of the present study, it is concluded that a strictly standardized time of sampling is an absolute condition for obtaining interpretable results.

Blood levels of ethynylestradiol, caffeine, aldosterone and desoxycorticosterone in hypertensive oral contraceptive users

Twenty normotensive and ten hypertensive black women taking oral contraceptive (OC) were studied. Age, body weight, family medical history of hypertension, length of OC use, and type of OC were comparable. At midcycle approximately 10-12 hours following OC intake, blood was drawn and the plasma was used to determine ethynylestradiol (EE2), caffeine, aldosterone (Aldo) and desoxycorticosterone (DOC) levels. The results showed that in hypertensive OC users, EE2 and caffeine levels were significantly higher (P less than .01) compared to normotensive OC users. While no significant differences were found in Aldo and DOC levels between hypertensive and normotensive OC users, OC users had higher levels of Aldo (P less than .01) compared to non-OC users.