Effects of progestin-only contraceptives on the endometrium

Patient satisfaction with two different management modalities for erratic bleeding during continuous hormone therapy for endometriosis-associated symptoms: A before-after study

OBJECTIVE

To evaluate patient satisfaction with the management of erratic bleeding during continuous hormone therapy for endometriosis using two different strategies: an active approach (tailored cycling), which involved discontinuation of the therapy; and a passive approach, which involved waiting for spontaneous resolution of the bleeding.

METHODS

This was an observational before-after study. All patients enrolled within a previously defined time limit were instructed to adopt a passive strategy to manage erratic bleeding, while all patients enrolled after that defined time were instructed to discontinue therapy for 7 days (tailored cycling). Degree of satisfaction, characteristics of bleeding, and level of dysmenorrhoea were compared and analysed at the time of enrolment and after 6 and 12 months.

RESULTS

In total, 201 patients were included in the study. Satisfaction was 29% higher among patients in the passive strategy group compared with those in the tailored cycling group; this difference was significant. No significant differences were identified for the other outcomes.

CONCLUSION

Patients may be more satisfied with the use of a passive approach to manage irregular bleeding during continuous hormone therapy for endometriosis-associated pain. All patients should be provided with comprehensive information regarding all available management strategies for unpredictable irregular bleeding. This will enable patients to make informed decisions based on their personal experience and preferences, without external pressure, thus improving compliance, adherence and, ideally, satisfaction with treatment.

The effect of norethisterone acetate on the uterine telocytes, immune cells and progesterone receptors in albino rats

This study is the first attempt to examine the effects of NETA on immune cells and telocytes. The results of this study form an important knowledge base for the development of new information on the mechanism of contraceptive action of NETA in the uterus. Norethisterone acetate (NETA) is a synthetic progestogen medication commonly utilized in birth control pills, menopausal hormone therapy, and for curing abnormal uterine bleeding and endometriosis. Furthermore NETA has many beneficial uses in veterinary medicine as control and synchronization of estrous cycle. The impact of NETA on the endometrial stromal cells (ESCs), telocytes, and uterine immune cells is not well understood. Therefore, this study focuses on assessing changes in uterine immune cells, ESCs, and telocytes following exposure to NETA in albino rats. To achieve this objective, fourteen adult female albino rats were randomly divided into two groups: a control group and an NETA-treated group. Rats in the control group received daily pelleted food, water, and were oral administered of 2 ml distilled water. In contrast, rats in the NETA-treated group received daily pelleted food, water, and were orally administered 20 µg of NETA dissolved in 2 ml distilled water. The experiment spanned three weeks. The findings of this study revealed that NETA usage increases the infiltration and activity of immune cells (eosinophils, neutrophils, macrophages, lymphocytes, and mast cells). Furthermore, it enhances the vesicular activity of uterine telocytes and their communication with various immune cells. NETA also influences decidualization and the immunoexpression of progesterone receptors in uterine epithelial and immune cells. This study concludes that the primary mechanism by which NETA controls pregnancy is through decidual (pregnancy-like) effects or improper decidualization, which inhibits fertilization and implantation respectively. Our research provides evidence of the contraceptive mechanism of NETA from an immunological perspective in an animal model.

Flexible progestin-primed ovarian stimulation versus a GnRH antagonist protocol in predicted suboptimal responders undergoing freeze-all cycles: a randomized non-inferiority trial

STUDY QUESTION

Are live birth rates (LBRs) per woman following flexible progestin-primed ovarian stimulation (fPPOS) treatment non-inferior to LBRs per woman following the conventional GnRH-antagonist protocol in expected suboptimal responders undergoing freeze-all cycles in assisted reproduction treatment?

SUMMARY ANSWER

In women expected to have a suboptimal response, the 12-month likelihood of live birth with the fPPOS treatment did not achieve the non-inferiority criteria when compared to the standard GnRH antagonist protocol for IVF/ICSI treatment with a freeze-all strategy.

WHAT IS KNOWN ALREADY

The standard PPOS protocol is effective for ovarian stimulation, where medroxyprogesterone acetate (MPA) is conventionally administered in the early follicular phase for ovulatory suppression. Recent retrospective cohort studies on donor cycles have shown the potential to prevent premature ovulation and maintain oocyte yields by delaying the administration of MPA until the midcycle (referred to as fPPOS), similar to GnRH antagonist injections. With milder pituitary suppression, the fPPOS protocol may be a less costly option for women expected to have a low or suboptimal response if a fresh embryo transfer is not intended.

STUDY DESIGN, SIZE, DURATION

This was a non-inferiority, open-label randomized controlled trial conducted at a tertiary assisted reproduction center. A total of 484 participants were randomized in the study between July 2020 and June 2023 with a 1:1 allocation.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Infertile women with a predicted suboptimal ovarian response (<40 years old, antral follicle count <10, and basal serum FSH < 12 mIU/ml) were randomly assigned to receive either fPPOS treatment or GnRH antagonist treatment. MPA (10 mg) or GnRH antagonist (0.25 mg) was administered daily once the leading follicle reached 14 mm and continued until the day of trigger. All viable embryos were cryopreserved for subsequent frozen-thawed embryo transfer in both groups. The primary endpoint was the proportion of live births per woman within 12 months post-randomization (with a non-inferiority margin of -12.5%). The analysis was assessed in the per-protocol population.

MAIN RESULTS AND THE ROLE OF CHANCE

Twenty-two women withdrew at the beginning of the stimulation phase due to COVID-19. Eight women did not proceed with the assigned frozen embryo transfer, and six switched from the fPPOS to the antagonist protocol. Overall, 449 women were included in the per-protocol analysis, with 216 in the fPPOS group and 233 in the GnRH antagonist group. The LBRs per woman were 44.4% (96/216) for participants in the fPPOS group and 48.9% (114/233) for participants in the GnRH antagonist group [risk ratio (RR) 0.91 (95% CI, 0.74, 1.11), risk difference (RD) -4.5% (95% CI, -13.7, 4.7)], which did not meet the non-inferiority criterion (-12.5%). Oocyte and embryonic parameters were not significantly different between the two groups. Nine women (4.17%) in the fPPOS group experienced a premature luteinizing hormone surge, compared to five women (2.15%) in the antagonist group. Only one woman in the fPPOS group ovulated before oocyte retrieval.

LIMITATIONS, REASONS FOR CAUTION

The distinct routes of administration for the medications precluded blinding in this open-label trial, potentially influencing outcome assessments. All participants were recruited in a single center from one country, limiting the generalizability.

WIDER IMPLICATIONS OF THE FINDINGS

While MPA is considered a patient-friendly alternative to antagonists for women undergoing scheduled freeze-all cycles, the GnRH antagonist protocol should still be the preferred treatment for anticipated suboptimal responders in terms of LBR.

STUDY FUNDING/COMPETING INTEREST(S)

This trial was funded by Science and Technology Department of Shaanxi Province, China (2021SF-210). Innovation Team of Shaanxi Provincial Health and Reproductive Medicine Research (2023TD-04); Key Industrial Chain Projects in Shaanxi Province: Research on Assisted Reproductive Technologies and Precision Prevention System for Genetic Diseases Preconception (2023-ZDLSF-48). Science and Technology Department of Shaanxi Province, China (2022SF-564). B.W.M. reports consultancy, travel support and research funding from Merck KGaA and consultancy for Organon and Norgine; owning stock in ObsEva; and holding an NHMRC Investigator Grant (GNT1176437). Other authors declare no conflicts of interest. All other authors have nothing to declare.

TRIAL REGISTRATION NUMBER

Registered at Chinese clinical trial registry (www.chictr.org.cn). Registry Identifier: ChiCTR2000030356.

TRIAL REGISTRATION DATE

29 February 2020.

DATE OF FIRST PATIENT’S ENROLMENT

11 March 2020.

Tips and tricks for the management of contraceptive etonogestrel implant in clinical practice: an Expert Opinion

The use of long-acting reversible contraceptives (LARCs) is increasing globally due to their higher ability to effectively prevent unintended pregnancies in comparison to short-acting reversible contraceptives (SARCs), especially in adolescence. LARCs include intrauterine devices (copper- or levonorgestrel-releasing) and subcutaneous implants. For LARCs application a dedicated training is needed. Particularly, this Expert Opinion is aiming to open to expert debates on the subcutaneous implant, in particular etonogestrel (ENG)-releasing one, as a cutting-edge form of hormonal contraception. It provides up-to-date guidance about practical advice and technical tips for the ENG implant insertion/removal derived from many years of clinical experience, along with recommendations for the management of unscheduled bleeding during contraception with this method.

Management of Endometriosis-Related Pain: Comparing the Effectiveness of Hormonal Therapy, Surgical Interventions, and Complementary Therapies

Endometriosis is a chronic, inflammatory disease characterized by the presence of endometrial-like tissue outside the uterus, affecting women of reproductive age. It is linked with debilitating pain, infertility, and a notable impact on the patient's quality of life. This review aims to highlight the effectiveness of hormonal therapy, surgical procedures, and complementary therapies in managing endometriosis-related pain, providing a comprehensive overview of current treatment options and their implications for clinical practice. The literature reveals that hormonal therapies, including combined oral contraceptives, progestins, and gonadotropin-releasing hormone (GnRH) agonists, are frequently used to manage endometriosis-related pain by suppressing ovarian function and reducing menstrual flow. Surgical interventions, such as laparoscopy and hysterectomy, offer pain relief by removing endometrial lesions but carry risks of recurrence and complications. Complementary therapies, including acupuncture, dietary modifications, and physical therapy, are increasingly recognized for their potential to minimize pain and improve patients' quality of life, though evidence of their effectiveness varies. The review highlights the need for personalized treatment plans that consider patient preferences, symptom severity, and reproductive goals. Future research should concentrate on the long-term outcomes of different therapies, the advancement of non-invasive diagnostic methods, and the identification of biomarkers for tailored treatment approaches. Clinicians are encouraged to adopt an interdisciplinary approach to endometriosis management, integrating medical, surgical, and complementary therapies to optimize patient outcomes.

In vitro evaluation of oral contraceptives on long-tailed macaque (Macaca fascicularis) primary ovarian cells

Hormonal contraception has been advocated as an alternative population control method for the long-tailed macaque population, which has increased exponentially due to anthropogenic changes and incidental food subsidies from human food waste. Risks of increased zoonosis and conflict are imminent if the population growth of long-tailed macaques is unchecked. However, there's a gap in the literature about the effect of hormonal contraceptives on long-tailed macaque reproductive tissues cell line. The present study aims to investigate the effect of oral contraceptives (Nordette, Noriday, and Ella) on long-tailed macaque ovarian cells. We determine the cell viability and cytotoxicity as well as the morphological changes of the drugs on long-tailed macaque ovarian cells using the MTT assay, Acridine orange/propidium iodide double staining method, morphological examination, and the 4, 6-diamidino-2-phenylindole (DAPI) staining method. For the MTT assay, The drugs were dissolved in culture media before use to have a concentration ranging from 0.5 μg/mL, 2.5 μg/mL, 0.125 μg/mL, 0.0625 μg/mL, and 0.0315 μg/mL to have three replicates for each treatment. In contrast, the concentration of 0.0315 μg/mL was used for the morphological and histopathological analysis. The result of the study indicates that human oral contraceptives (Nordette, Noriday, and Ella) inhibit the growth of long-tailed macaque ovarian cells and induce apoptosis in a concentration- and time-dependent manner (at a concentration of 0.0315 μg/mL and an IC50 lower than 10 μg/mL), With a statistically significant value of ****P < 0.001 for each drug compared to the negative control. The result of the present study contributes toward addressing the gap in the literature on the effect of oral contraceptives in long-tailed macaque ovarian cells. Hence, we conclude that human oral contraceptives (Nordette, Noriday, and Ella) are safe and effective in long-tailed macaque ovarian cells as such could be used to develop non-invasive oral contraceptives for controlling the population of long-tailed macaques as an alternative population control method.

The effect of Norethisterone acetate on the uterus of albino rats: histological, histochemical and ultrastructure study

BACKGROUND

Norethisterone acetate (NETA), also known as norethindrone acetate is a progestogens medication that is widely used in birth control pills, menopausal hormone therapy, and for the treatment of gynecological disorders as abnormal uterine bleeding and endometriosis. There is a lack of detailed histological information regarding the effects of NETA on the uterine structure. So, the present study focuses on the uterine histological, histochemical and ultrastructure changes following the exposure to NETA in the albino rats. To do this aim, fourteen adult female albino rats were used. They were randomly divided into two equally groups: Control group and NETA treated group. Albino rats of control group were administered daily food, water and orally distilled water only, while rats of NETA treated group were administered daily orally 20 µg of NETA dissolved in 2 ml distilled water, food, and water. The experiment was continued for three weeks.

RESULTS

The findings of the present work indicated that the use of NETA has negative effects on the endometrial epithelium (proliferation, autophagy and apoptosis), glands (necrotic, apoptotic or pseudosecretory glands) and stromal and myometrial reactions (granulocytes, connective tissue remodeling, apoptosis, myocytes hypertrophy).

CONCLUSION

This work revealed that NETA has desynchronized progestogenic effect on the uterine tissues of the albino rat and thereby prevent implantation and pregnancy.

Deciphering molecular basis of pesticide-induced recurrent pregnancy loss: insights from transcriptomics analysis

Recent studies have revealed a notable connection between pesticide exposure and Recurrent Pregnancy Loss (RPL), yet the precise molecular underpinning of this toxicity remains elusive. Through the alignment of Differentially Expressed Genes (DEGs) of healthy and RPL patients with the target genes of 9 pesticide components, we identified a set of 12 genes responsible for RPL etiology. Interestingly, biological process showed that besides RPL, those 12 genes also associated with preeclampsia and cardiovascular disease. Enrichment analysis showed the engagement of these genes associated with essential roles in the molecular transport of small molecules, as well as the aldosterone-regulated sodium reabsorption, endocrine and other factor-regulated calcium reabsorption, mineral absorption, ion homeostasis, and ion transport by P-type ATPases. Notably, the crosstalk targets between pesticide components played crucial roles in influencing RPL results, suggesting a role in attenuating pesticide agents that contribute to RPL. It is important to note that non-significant concentration of the pesticide components observed in both control and RPL samples should not prematurely undermine the potential for pesticides to induce RPL in humans. This study emphasizes the complexity of pesticide induced RPL and highlights avenues for further research and precautionary measures.

Oestrogens in oral contraception: considerations for tailoring prescription to women's needs

BACKGROUND

The oestrogenic component of combined oral contraceptives (COCs) has changed over years with the aim of reducing oestrogen-related side effects and risks, whilst maintaining oestrogen beneficial effects, particularly on cycle control.

PURPOSE

To describe the pharmacological profiles of different oestrogens commonly used in COCs to provide insights on contraceptive prescription tailored to women's needs.

RESULTS

All COCs ensure a high contraceptive efficacy. COCs containing the natural oestrogens oestradiol (E2), oestradiol valerate (E2V) and estetrol (E4) have limited impact on liver metabolism, lipid and carbohydrate metabolism, haemostasis and sex hormone binding globulin levels, compared with ethinylestradiol (EE). COCs with E2 and E2V appear also to entail a lower elevation of the risk of venous thromboembolism vs. EE-containing pills. No epidemiological data are available for E4-COC. E2- and E2V-containing COCs seem to exert a less stabilising oestrogenic effect on the endometrium compared with EE-COCs. The E4-COC results in a predictable bleeding pattern with a high rate of scheduled bleeding and minimal unscheduled bleeding per cycle. Based on in vitro and in vivo animal data, E4 seems to be associated with a lower effect on cell breast proliferation.

CONCLUSION

Today various COCs contain different oestrogens. Prescribers must be familiar with the different properties of each oestrogen for a tailored contraceptive recommendation, considering their safety and contraceptive efficacy, as well as women's needs and preferences.

Women's health, hormonal balance, and personal autonomy

Hormone-based contraception disrupts hormonal balance, creating artificial states of anovulation and threatening women's health. We reviewed its main adverse effects and mechanisms on accelerated ovarian aging, mental health (emotional disruptions, depression, and suicide), sexuality (reduced libido), cardiovascular (brain stroke, myocardial infarction, hypertension, and thrombosis), and oncological (breast, cervical, and endometrial cancers). Other "collateral damage" includes negative effects on communication, scientific mistrust, poor physician-patient relationships, increased patient burden, economic drain on the healthcare system, and environmental pollution. Hormone-sensitive tumors present a dilemma owing to their potential dual effects: preventing some cancers vs. higher risk for others remains controversial, with denial or dismissal as non-relevant adverse effects, information avoidance, and modification of scientific criteria. This lack of clinical assessment poses challenges to women's health and their right to autonomy. Overcoming these challenges requires an anthropological integration of sexuality, as the focus on genital bodily union alone fails to encompass the intimate relational expression of individuals, complete sexual satisfaction, and the intertwined feelings of trust, safety, tenderness, and endorsement of women's femininity.

Experiences of progestin-only pill users in the United States and attitudes toward over-the-counter access

CONTEXT

Removing the prescription requirement and making oral contraceptive pills available over the counter (OTC) could increase contraceptive access in the United States. Despite current efforts to make a progestin-only pill (POP) available OTC, there are no qualitative data exploring the experiences of POP users and their perspectives on making POPs available OTC.

METHODS

We conducted six online, asynchronous focus group discussions with 36 POP users between July and November 2020. We stratified focus group discussion placement based on three reasons for POP use: breastfeeding, having a contraindication to estrogen (for a reason other than breastfeeding), and for any other reason. We thematically analyzed these data using inductive and deductive coding.

RESULTS

The majority of participants described their overall POP experience as positive, mostly because they experienced minor or no side effects and thought the pill was effective. Participants overwhelmingly supported OTC availability of POPs and expressed interest in purchasing an OTC POP. Over one-third of participants had very limited knowledge or held inaccurate assumptions about POPs before they started using this method and many stressed the need to disseminate accurate information and resources about POPs to the public.

CONCLUSIONS

Most focus group discussion participants were satisfied with POPs and supported OTC access. While misconceptions and concerns about POPs should be addressed, an OTC POP has the potential to be a safe, effective, and convenient contraceptive option in the United States.

A commentary on progestin-only pills and the "three-hour window" guidelines: Timing of ingestion and mechanisms of action

Clinical guidelines for progestin-only pills (POPs) state that each pill should be taken at the same time each day, with only a "three-hour window" of tolerance before back-up contraception should be used. In this commentary, we summarize studies examining the timing of ingestion and mechanisms of action for various POP formulations and dosages. We found that different progestins have different properties that determine the effect of delayed or missed pills on effectiveness at preventing pregnancy. Our findings highlight that there is more margin for error for some POPs than guidelines suggest. The three-hour window recommendation should be re-evaluated in light of these findings. Since clinicians, potential POP users, and regulatory bodies rely on current guidelines to make decisions about POP use, a critical evaluation and update of these guidelines are urgently needed.