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Torelli FR, Rodrigues-Peres RM, Monteiro I, Lopes-Cendes I, Bahamondes L, Juliato CRT. Gene expression associated with unfavorable vaginal bleeding in women using the etonogestrel subdermal contraceptive implant: a prospective study. Sci Rep 2024; 14:11062. [PMID: 38745005 PMCID: PMC11093992 DOI: 10.1038/s41598-024-61751-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 05/09/2024] [Indexed: 05/16/2024] Open
Abstract
To evaluate gene expression associated with unfavorable vaginal bleeding in users of the Etonogestrel (ENG) contraceptive implant. Prospective study involving 100 women who intended to use the ENG implant. Exclusion criteria included abnormal uterine bleeding, inability to attend a 1-year follow-up, and implant removal for reasons unrelated to vaginal bleeding or loss of follow-up. We obtained endometrial biopsies before implant placement and assessed the expression of 20 selected genes. Users maintained a uterine bleeding diary for 12 months post-implant placement. For statistical analysis, we categorized women into those with or without favorable vaginal bleeding at 3 and 12 months. Women with lower CXCL1 expression had a 6.8-fold increased risk of unfavorable vaginal bleeding at 3 months (OR 6.8, 95% CI 2.21-20.79, p < 0.001), while those with higher BCL6 and BMP6 expression had 6- and 5.1-fold increased risks, respectively. By the 12-month follow-up, women with lower CXCL1 expression had a 5.37-fold increased risk of unfavorable vaginal bleeding (OR 5.37, 95% CI 1.63-17.73, p = 0.006). Women with CXCL1 expression < 0.0675, BCL6 > 0.65, and BMP6 > 3.4 had a higher likelihood of experiencing unfavorable vaginal bleeding at 3 months, and CXCL1 < 0.158 at 12 months. Users of ENG contraceptive implants with elevated BCL6 and BMP6 expression exhibited a higher risk of breakthrough bleeding at the 3-month follow-up. Conversely, reduced CXCL1 expression was associated with an elevated risk of bleeding at both the 3 and 12-month follow-ups.
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Affiliation(s)
- Flávia R Torelli
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Raquel M Rodrigues-Peres
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Ilza Monteiro
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Iscia Lopes-Cendes
- Department of Translational Medicine, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Luis Bahamondes
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Cássia R T Juliato
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil.
- Departamento de Tocoginecologia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas - UNICAMP, Rua Alexander Fleming 101, Campinas, SP, 13083-881, Brazil.
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Bastianelli C, Farris M, Bruni V, Rosato E, Brosens I, Benagiano G. Effects of progestin-only contraceptives on the endometrium. Expert Rev Clin Pharmacol 2020; 13:1103-1123. [PMID: 32903118 DOI: 10.1080/17512433.2020.1821649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The contraceptive activity of synthetic progestins is mediated through three basic mechanisms: (a) An anti-gonadotrophic action leading to the inhibition of ovulation; (b) Changes in cervical mucus characteristics that inhibit sperm penetration and (c) desynchronization of the endometrial picture necessary for implantation. AREAS COVERED Mechanisms involved in the progestin-induced endometrium desynchronization are individually reviewed for each of the routes of administration and, whenever possible, by individual members of the various families of synthetic progestin derivatives. EXPERT OPINION For contraceptive purposes, progestins are today administered through several routes: orally, as injections, subdermally and via the vagina or the uterine cavity. Given this variety of modalities, their effects may differ, depending on the route of administration, concentration reached at the level of the endometrium and the duration of use. These are characterized by inactivation of the endometrium. Progestin-only contraception provides a safe and effective control of fertility regulation, although, they are associated with the problem of endometrial break through bleeding that may lead to discontinuation. Unfortunately, in spite of a major research effort over two decades, there is not, as yet, an established long-term intervention available to manage bleeding irregularities, making mandatory a deeper understanding of the mechanisms involved is required.
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Affiliation(s)
- Carlo Bastianelli
- Department of Maternal and Child Health, Gynecology and Urology, Sapienza University of Rome , Rome, Italy
| | - Manuela Farris
- Department of Maternal and Child Health, Gynecology and Urology, Sapienza University of Rome , Rome, Italy.,Associazione Italiana Educazione Demografica (AIED) , Rome, Italy
| | | | - Elena Rosato
- Department of Maternal and Child Health, Gynecology and Urology, Sapienza University of Rome , Rome, Italy
| | - Ivo Brosens
- Faculty of Medicine, KU Leuven , Leuven, Belgium
| | - Giuseppe Benagiano
- Department of Maternal and Child Health, Gynecology and Urology, Sapienza University of Rome , Rome, Italy
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Ramdhan RC, Simonds E, Wilson C, Loukas M, Oskouian RJ, Tubbs RS. Complications of Subcutaneous Contraception: A Review. Cureus 2018; 10:e2132. [PMID: 29610715 PMCID: PMC5878093 DOI: 10.7759/cureus.2132] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Over 62 million women in the United States are of childbearing age and 60% of them use contraception. Subcutaneous contraceptives include implantable contraceptives and subcutaneous injections. Implantable contraception involves subdermal time-release of synthetic progestin, which allows for several years of continuous, highly effective contraception. Its main effects are inhibition of ovulation and thickening of the cervical mucus. Many complications have been associated with subcutaneous contraception, including menstrual disturbances, headache, weight gain, acne, dizziness, mood disturbances, nausea, lower abdominal pain, hair loss, loss of libido, pain at the implant site, neuropathy, and follicular cysts. Using standard search engines, the complications of subcutaneous contraception are reviewed. Patients should be adequately counseled on the possible complications and side effects of subcutaneous contraception to help them make an informed decision when choosing the right contraceptive to meet their needs.
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Affiliation(s)
- Rebecca C Ramdhan
- Department of Anatomical Sciences, St. George's University School of Medicine, Grenada, West Indies
| | | | | | - Marios Loukas
- Department of Anatomical Sciences, St. George's University School of Medicine, Grenada, West Indies
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Thurman AR, Soper DE. Endometrial histology of Depomedroxyprogesterone acetate users: a pilot study. Infect Dis Obstet Gynecol 2007; 2006:69402. [PMID: 17093355 PMCID: PMC1581473 DOI: 10.1155/idog/2006/69402] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objective. To obtain pilot data on the endometrial histology of Depomedroxyprogesterone acetate (Depo-Provera, DMPA) users
experiencing breakthrough bleeding (BTB) versus users with amenorrhea. To compare the endometrial histology of patients who
used DMPA continuously for 3–12 months versus those who used it for 13 months or
more. Methods. Cross-sectional study. Endometrial
biopsy was obtained fromall consenting patients who used DMPA for at least 3 months. Patients were divided into those
with BTB in the last 3 months versus those with amenorrhea for at least 3 months. Histology results and duration of therapy were
compared. Results. The proportion of women with chronic endometritis, uterine polyps, atrophic, proliferative, or progesteronedominant
endometrium did not differ between those DMPA users with BTB versus those with amenorrhea. Duration of therapy
did not correlate with symptoms of BTB or endometrial histology. Chronic endometritis was the most common histologic finding
(10/40, 25%) and occurred more often in women experiencing BTB (35% versus 15%) (RR 1.62 CI 0.91–2.87). Moreover, 45% of
women with BTB had received DMPA for more than 12 months. Conclusions. BTB was more common than previously reported in women using DMPA for more than 12 months. Chronic endometritis, which may indicate an underlying infectious or intracavitary anatomic etiology, has not been previously reported as a frequent finding in DMPA users, and may be related to ethnic or other sociodemographic characteristics of our patient population. Further study to elucidate the etiology of chronic endometritis
in these patients is warranted.
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Affiliation(s)
- Andrea Ries Thurman
- Department of Obstetrics and Gynecology, Medical University of
South Carolina, 96 Jonathan Lucas Street, CSB #628B, PO Box 250619,
Charleston, SC 29425, USA
- *Andrea Ries Thurman:
| | - David E. Soper
- Department of Obstetrics and Gynecology, Medical University of
South Carolina, 96 Jonathan Lucas Street, CSB #628B, PO Box 250619,
Charleston, SC 29425, USA
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Hickey M, d'Arcangues C. Mechanisms underlying menstrual bleeding disturbances with progestogens. ERNST SCHERING RESEARCH FOUNDATION WORKSHOP 2005:191-217. [PMID: 15704473 DOI: 10.1007/3-540-27147-3_9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Affiliation(s)
- M Hickey
- School of Women's and Infants' Health, University of Western, Australia, King Edward Memorial Hospital.
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Camejo MI. Relation between immunosuppressive PGE(2) and IL-10 to pro-inflammatory IL-6 in seminal plasma of infertile and fertile men. ARCHIVES OF ANDROLOGY 2003; 49:111-6. [PMID: 12623747 DOI: 10.1080/01485010390129232] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
In vitro studies have reported that seminal plasma of fertile men has more inhibitory mitogenic effect and higher suppressive activity on antibody-dependent cellular cytotoxicity than seminal plasma from infertile males. Is it possible that variations in the seminal plasma composition could explain these results? The present study was conducted to investigate the relation between immunosuppressive PGE(2) and IL-10 to pro-inflammatory IL-6 in seminal plasma of infertile and fertile men. Utilizing specific ELISA commercial kit, semen samples from 45 infertile undiagnosed and 25 fertile men were examined for the presence of PGE(2), IL-10, and IL-6. The IL-6 concentration in seminal plasma of infertile men was significantly higher than that of fertile men (p<.0 4). However, levels of IL-10 were lower for the semen of infertile men than that of fertile men (p<.04). No differences were observed in PGE(2) concentrations between both groups. Increase in pro-inflammatory cytokines, such as IL-6, and decrease in immunosuppressive ones, such as IL-10, could alter the tolerance to sperm cell in male and female tracts and reduce the favorable conditions to reach the fecundation and implantation. It is necessary to conduct further studies that include other pro- and anti-inflammatory substances to evaluate the importance of the immune balance of semen in human fertility.
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Affiliation(s)
- M I Camejo
- Universidad Simón Bolívar, Departamento de Biología de Organismos, Caracas, Venezuela.
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Abstract
Implantable contraceptives allow safe and effective fertility regulation for up to 5 years. Currently available devices release low doses of progestogens. Disruption of vaginal bleeding patterns is almost inevitable, particularly during the initial months of use. Irregular and prolonged bleeding as well as amenorrhea are common. Irregular bleeding is unpopular with most women and unacceptable to some. This review describes the vaginal bleeding disturbances induced by modern implantable contraceptives and discusses the implications of these in terms of method use and discontinuations. The cause of the irregular bleeding is not fully understood, but recent evidence suggests that an increase in endometrial vascular fragility might precipitate vessel breakdown and, hence, breakthrough bleeding. This review discusses this evidence and outline the possible mechanisms underlying breakthrough bleeding associated with implantable contraceptives. In addition, therapies for bleeding disturbances are described and their efficacy reviewed.
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Affiliation(s)
- Martha Hickey
- Department of Reproductive Science and Medicine, Imperial College School of Medicine at St. Mary's, London W2 1PG, UK.
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Vincent AJ, Zhang J, Ostor A, Rogers PA, Affandi B, Kovacs G, Salamonsen LA. Matrix metalloproteinase-1 and -3 and mast cells are present in the endometrium of women using progestin-only contraceptives. Hum Reprod 2000; 15:123-30. [PMID: 10611200 DOI: 10.1093/humrep/15.1.123] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Progestin-only contraceptives are associated with menstrual bleeding disturbances; a major reason why these agents are discontinued. The pathogenesis of such abnormal uterine bleeding associated with progestin-only contraceptives remains ill-defined. Matrix metalloproteinases (MMP)s and mast cells (MC)s are postulated to be involved in endometrial breakdown observed in normal menstruation. In this study comparisons were made of the immunolocalization of MMP-1 and -3 and MC in endometrium from women using Norplant or depot medroxyprogesterone acetate (DMPA) with normal controls. Positive MMP immunostaining was observed focally in stromal cells and adjacent extracellular matrix. Quantitative assessment revealed significantly higher MMP-1 immunostaining associated with the use of Norplant compared with DMPA or menstrual phase controls. Endometrial MMP-1 immunostaining in DMPA users was similar to that in menstrual controls. Positive MMP-3 immunolocalization was observed in a minority of endometrial samples. Activated MC, shown by the presence of extracellular MC tryptase, predominated in the endometrium of Norplant and DMPA users as also observed in menstrual phase controls. There was no correlation between MMP immunostaining, number of MC and number of bleeding days reported. These results indicate that in women using progestin-only contraceptives, endometrial MMP-1, -3 and MC demonstrate similarities to menstrual phase controls but also variation with different progestins.
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Affiliation(s)
- A J Vincent
- Prince Henry's Institute of Medical Research, PO Box 5152, Clayton, Victoria 3168, Australia
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Kaewrudee S, Taneepanichskul S, Jaisamraun U, Reinprayoon D. The effect of mefenamic acid on controlling irregular uterine bleeding secondary to Norplant use. Contraception 1999; 60:25-30. [PMID: 10549449 DOI: 10.1016/s0010-7824(99)00059-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The aim of this double-blind, placebo-controlled study was to evaluate the effect of mefenamic acid and placebo on controlling irregular uterine bleeding secondary to Norplant use. A total of 67 Norplant users attending the Family Planning Clinic of Chulalongkorn Hospital all had irregular bleeding. These women were randomly allocated into two groups. A total 34 users received mefenamic acid, 500 mg twice a day for 5 days, and placebos were given to the other 33 in the same manner. The total days of bleeding and spotting and the percentage of women in whom bleeding was stopped were analyzed in weeks 1 and 4. The percentage of subjects in whom bleeding was stopped during week 1 after initial treatment was significantly higher in the mefenamic acid group than the placebo group (76%, 27%; p < 0.001). In the follow-up period (4 weeks after initial treatment), a bleeding-free interval of > 20 days was found in 68% of the subjects treated with mefenamic acid and 33% treated with the placebo; the mean number of bleeding/spotting days was lower with mefenamic acid treatment (11.6 and 17.2 days; p < 0.05). The difference was statistically significant. It is concluded that mefenamic acid was more effective than placebo in short-term control of irregular bleeding and spotting associated with Norplant use.
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Affiliation(s)
- S Kaewrudee
- Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Thailand
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