1
|
Zuniga C, Blanchard K, Harper CC, Wollum A, Key K, Henderson JT. Effectiveness and efficacy rates of progestin-only pills: A comprehensive literature review. Contraception 2023; 119:109925. [PMID: 36535414 DOI: 10.1016/j.contraception.2022.109925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/02/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To synthesize published literature on POP effectiveness and efficacy. STUDY DESIGN We searched PubMed Central, PubMed, and the Cochrane library through March 07, 2022. We included articles written in English reporting a Pearl Index or life table rate for pregnancy. We excluded articles only assessing formulations that: were never marketed globally, are only sold in combination with estrogen, are currently sold only for noncontraceptive purposes, or were not given to participants continuously. Four researchers independently extracted data and two analyzed data using Excel and R. RESULTS We included 54 studies. Among studies at low or moderate risk of bias, the median Pearl Index rate (the failure rate during typical use) was 1.63 (range 0.00-14.20, IQR 4.03) and the median method failure Pearl Index rate (the failure rate during perfect use) was 0.97 (range 0.40-6.50, IQR 0.68). Excluding the newer formulations, Desogestrel and Drospirenone, which are closer to combined oral contraceptives in that they prevent pregnancy by inhibiting ovulation, the median Pearl Index rate is 2.00 (range 0.00-14.12, IQR 2.5) and the median method failure Pearl Index rate is 1.05 (range 0.00-10.90, IQR 1.38). CONCLUSIONS Among studies at low or moderate risk of bias, the median Pearl Index rate during typical POP use was much lower than currently estimated (7.00), while the median perfect use rate was similar to current estimates. IMPLICATIONS Future research should investigate the possibility that POPs may be much more effective during typical use than currently believed.
Collapse
Affiliation(s)
| | | | - Cynthia C Harper
- Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California, San Francisco, CA, United States
| | | | - Katherine Key
- Ibis Reproductive Health, Cambridge, MA, United States
| | - Jillian T Henderson
- Kaiser Permanente, Northwest, Center for Health Research, Portland, OR, United States
| |
Collapse
|
2
|
Hagey JM, Givens M, Bryant AG. Clinical Update on Uses for Mifepristone in Obstetrics and Gynecology. Obstet Gynecol Surv 2022; 77:611-623. [PMID: 36242531 DOI: 10.1097/ogx.0000000000001063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
IMPORTANCE Mifepristone (RU-486) is a selective progesterone receptor modulator that has antagonist properties on the uterus and cervix. Mifepristone is an effective abortifacient, prompting limitations on its use in many countries. Mifepristone has many uses outside of induced abortion, but these are less well known and underutilized by clinicians because of challenges in accessing and prescribing this medication. OBJECTIVES To provide clinicians with a history of the development of mifepristone and mechanism of action and safety profile, as well as detail current research on uses of mifepristone in both obstetrics and gynecology. EVIDENCE ACQUISITION A PubMed search of mifepristone and gynecologic and obstetric conditions was conducted between January 2018 and December 2021. Other resources were also searched, including guidelines from the American College of Obstetricians and Gynecologists and the Society of Family Planning. RESULTS Mifepristone is approved by the Food and Drug Administration for first-trimester medication abortion but has other off-label uses in both obstetrics and gynecology. Obstetric uses that have been investigated include management of early pregnancy loss, intrauterine fetal demise, treatment of ectopic pregnancy, and labor induction. Gynecologic uses that have been investigated include contraception, treatment of abnormal uterine bleeding, and as an adjunct in treatment of gynecologic cancers. CONCLUSIONS AND RELEVANCE Mifepristone is a safe and effective medication both for its approved use in first-trimester medication abortion and other off-label uses. Because of its primary use as an abortifacient, mifepristone is underutilized by clinicians. Providers should consider mifepristone for other indications as clinically appropriate.
Collapse
Affiliation(s)
- Jill M Hagey
- Fellow, Division of Complex Family Planning, Department of Obstetrics and Gynecology, University of North Carolina-Chapel Hill, Chapel Hill, NC
| | - Matthew Givens
- Fellow, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
| | - Amy G Bryant
- Associate Professor, Division of Complex Family Planning, Department of Obstetrics and Gynecology, University of North Carolina-Chapel Hill, Chapel Hill, NC
| |
Collapse
|
3
|
FSRH Guideline (August 2022) Progestogen-only Pills. BMJ SEXUAL & REPRODUCTIVE HEALTH 2022; 48:1-75. [PMID: 36316023 DOI: 10.1136/bmjsrh-2022-pop] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
|
4
|
Westhoff CL, Archer DF, Barnhart K, Darney P, Gilliam M, Jensen J, Nelson A, Teal S, Thomas M, Hu J, Brown J, Blithe DL. Evaluation of ovulation and safety outcomes in a multi-center randomized trial of three 84-day ulipristal acetate regimens. Contraception 2022; 112:54-60. [DOI: 10.1016/j.contraception.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/31/2022] [Accepted: 04/06/2022] [Indexed: 11/03/2022]
|
5
|
Westhoff CL, Guo H, Wang Z, Hibshoosh H, Polaneczky M, Pike MC, Ha R. The progesterone-receptor modulator, ulipristal acetate, drastically lowers breast cell proliferation. Breast Cancer Res Treat 2022; 192:321-329. [PMID: 35015210 PMCID: PMC10088437 DOI: 10.1007/s10549-021-06503-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 12/29/2021] [Indexed: 11/02/2022]
Abstract
PURPOSE The proliferation of breast epithelial cells increases during the luteal phase of the menstrual cycle, when they are exposed to progesterone, suggesting that ulipristal acetate, a selective progestin-receptor modulator (SPRM), may reduce breast cell proliferation with potential use in breast cancer chemoprevention. METHODS Women aged 18-39 were randomized 1:1 to ulipristal 10-mg daily or to a combination oral contraceptive (COC) for 84 days. Participants underwent a breast biopsy and breast MRI at baseline and at end of study treatment. Proliferation of breast TDLU cells was evaluated by Ki67 immunohistochemical stain. We evaluated the breast MRIs for background parenchymal enhancement (BPE). All slides and images were masked for outcome evaluation. RESULTS Twenty-eight treatment-compliant participants completed the study; 25 of whom had evaluable Ki67 results at baseline and on-treatment. From baseline to end of treatment, Ki67 % positivity (Ki67%+) decreased a median of 84% in the ulipristal group (N = 13; 2-sided p (2p) = 0.040) versus a median increase of 8% in the COC group (N = 12; 2p = 0.85). Median BPE scores decreased from 3 to 1 in the ulipristal group (p = 0.008) and did not decrease in the COC group. CONCLUSION Ulipristal was associated with a major decrease in Ki67%+ and BPE. Ulipristal would warrant further investigation for breast cancer chemoprevention were it not for concerns about its liver toxicity. Novel SPRMs without liver toxicity could provide a new approach to breast cancer chemoprevention. TRIAL REGISTRATION NCT02922127, 4 October 2016.
Collapse
Affiliation(s)
- Carolyn L Westhoff
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, PH 16-69, 630 West 168th Street, New York, NY, 10032, USA.
| | - Hua Guo
- Department of Pathology, Columbia University Irving Medical Center, New York, NY, USA
| | - Zhong Wang
- Department of Pathology, Columbia University Irving Medical Center, New York, NY, USA
| | - Hanina Hibshoosh
- Department of Pathology, Columbia University Irving Medical Center, New York, NY, USA
| | - Margaret Polaneczky
- Department of Obstetrics and Gynecology, Weill-Cornell Medical Center, New York, NY, USA
| | - Malcolm C Pike
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Richard Ha
- Department of Radiology, Columbia University Irving Medical Center, New York, NY, USA
| |
Collapse
|
6
|
Critchley HOD, Babayev E, Bulun SE, Clark S, Garcia-Grau I, Gregersen PK, Kilcoyne A, Kim JYJ, Lavender M, Marsh EE, Matteson KA, Maybin JA, Metz CN, Moreno I, Silk K, Sommer M, Simon C, Tariyal R, Taylor HS, Wagner GP, Griffith LG. Menstruation: science and society. Am J Obstet Gynecol 2020; 223:624-664. [PMID: 32707266 PMCID: PMC7661839 DOI: 10.1016/j.ajog.2020.06.004] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 05/13/2020] [Accepted: 06/03/2020] [Indexed: 12/11/2022]
Abstract
Women's health concerns are generally underrepresented in basic and translational research, but reproductive health in particular has been hampered by a lack of understanding of basic uterine and menstrual physiology. Menstrual health is an integral part of overall health because between menarche and menopause, most women menstruate. Yet for tens of millions of women around the world, menstruation regularly and often catastrophically disrupts their physical, mental, and social well-being. Enhancing our understanding of the underlying phenomena involved in menstruation, abnormal uterine bleeding, and other menstruation-related disorders will move us closer to the goal of personalized care. Furthermore, a deeper mechanistic understanding of menstruation-a fast, scarless healing process in healthy individuals-will likely yield insights into a myriad of other diseases involving regulation of vascular function locally and systemically. We also recognize that many women now delay pregnancy and that there is an increasing desire for fertility and uterine preservation. In September 2018, the Gynecologic Health and Disease Branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development convened a 2-day meeting, "Menstruation: Science and Society" with an aim to "identify gaps and opportunities in menstruation science and to raise awareness of the need for more research in this field." Experts in fields ranging from the evolutionary role of menstruation to basic endometrial biology (including omic analysis of the endometrium, stem cells and tissue engineering of the endometrium, endometrial microbiome, and abnormal uterine bleeding and fibroids) and translational medicine (imaging and sampling modalities, patient-focused analysis of menstrual disorders including abnormal uterine bleeding, smart technologies or applications and mobile health platforms) to societal challenges in health literacy and dissemination frameworks across different economic and cultural landscapes shared current state-of-the-art and future vision, incorporating the patient voice at the launch of the meeting. Here, we provide an enhanced meeting report with extensive up-to-date (as of submission) context, capturing the spectrum from how the basic processes of menstruation commence in response to progesterone withdrawal, through the role of tissue-resident and circulating stem and progenitor cells in monthly regeneration-and current gaps in knowledge on how dysregulation leads to abnormal uterine bleeding and other menstruation-related disorders such as adenomyosis, endometriosis, and fibroids-to the clinical challenges in diagnostics, treatment, and patient and societal education. We conclude with an overview of how the global agenda concerning menstruation, and specifically menstrual health and hygiene, are gaining momentum, ranging from increasing investment in addressing menstruation-related barriers facing girls in schools in low- to middle-income countries to the more recent "menstrual equity" and "period poverty" movements spreading across high-income countries.
Collapse
Affiliation(s)
- Hilary O D Critchley
- Medical Research Council Centre for Reproductive Health, The University of Edinburgh, United Kingdom.
| | - Elnur Babayev
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Serdar E Bulun
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | - Iolanda Garcia-Grau
- Igenomix Foundation-Instituto de Investigación Sanitaria Hospital Clínico, INCLIVA, Valencia, Spain; Department of Pediatrics, Obstetrics and Gynecology, School of Medicine, University of Valencia, Valencia, Spain
| | - Peter K Gregersen
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY
| | | | | | | | - Erica E Marsh
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI
| | - Kristen A Matteson
- Division of Research, Department of Obstetrics and Gynecology, Women and Infants Hospital, Warren Alpert Medical School of Brown University, Providence, RI
| | - Jacqueline A Maybin
- Medical Research Council Centre for Reproductive Health, The University of Edinburgh, United Kingdom
| | - Christine N Metz
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY
| | - Inmaculada Moreno
- Igenomix Foundation-Instituto de Investigación Sanitaria Hospital Clínico, INCLIVA, Valencia, Spain
| | - Kami Silk
- Department of Communication, University of Delaware, Newark, DE
| | - Marni Sommer
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, NY
| | - Carlos Simon
- Igenomix Foundation-Instituto de Investigación Sanitaria Hospital Clínico, INCLIVA, Valencia, Spain; Department of Pediatrics, Obstetrics and Gynecology, School of Medicine, University of Valencia, Valencia, Spain; Beth Israel Deaconess Medical Center, Harvard University, Boston, MA; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | | | - Hugh S Taylor
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT
| | - Günter P Wagner
- Department of Ecology and Evolutionary Biology, Department of Obstetrics, Gynecology and Reproductive Sciences, Systems Biology Institute, Yale University, New Haven, CT; Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI
| | - Linda G Griffith
- Center for Gynepathology Research, Massachusetts Institute of Technology, Cambridge, MA
| |
Collapse
|
7
|
Critchley HOD, Chodankar RR. 90 YEARS OF PROGESTERONE: Selective progesterone receptor modulators in gynaecological therapies. J Mol Endocrinol 2020; 65:T15-T33. [PMID: 32599565 PMCID: PMC7354704 DOI: 10.1530/jme-19-0238] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 01/30/2020] [Indexed: 12/19/2022]
Abstract
Abnormal uterine bleeding (AUB) is a chronic, debilitating and common condition affecting one in four women of reproductive age. Current treatments (conservative, medical and surgical) may be unsuitable, poorly tolerated or may result in loss of fertility. Selective progesterone receptor modulators (SPRMs) influence progesterone-regulated pathways, a hormone critical to female reproductive health and disease; therefore, SPRMs hold great potential in fulfilling an unmet need in managing gynaecological disorders. SPRMs in current clinical use include RU486 (mifepristone), which is licensed for pregnancy interruption, and CDB-2914 (ulipristal acetate), licensed for managing AUB in women with leiomyomas and in a higher dose as an emergency contraceptive. In this article, we explore the clinical journey of SPRMs and the need for further interrogation of this class of drugs with the ultimate goal of improving women's quality of life.
Collapse
Affiliation(s)
- H O D Critchley
- MRC Centre for Reproductive Health, The University of Edinburgh, The Queen’s Medical Research Institute, Edinburgh Bioquarter, Edinburgh, UK
| | - R R Chodankar
- MRC Centre for Reproductive Health, The University of Edinburgh, The Queen’s Medical Research Institute, Edinburgh Bioquarter, Edinburgh, UK
| |
Collapse
|
8
|
Critchley HOD, Maybin JA, Armstrong GM, Williams ARW. Physiology of the Endometrium and Regulation of Menstruation. Physiol Rev 2020; 100:1149-1179. [DOI: 10.1152/physrev.00031.2019] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The physiological functions of the uterine endometrium (uterine lining) are preparation for implantation, maintenance of pregnancy if implantation occurs, and menstruation in the absence of pregnancy. The endometrium thus plays a pivotal role in reproduction and continuation of our species. Menstruation is a steroid-regulated event, and there are alternatives for a progesterone-primed endometrium, i.e., pregnancy or menstruation. Progesterone withdrawal is the trigger for menstruation. The menstruating endometrium is a physiological example of an injured or “wounded” surface that is required to rapidly repair each month. The physiological events of menstruation and endometrial repair provide an accessible in vivo human model of inflammation and tissue repair. Progress in our understanding of endometrial pathophysiology has been facilitated by modern cellular and molecular discovery tools, along with animal models of simulated menses. Abnormal uterine bleeding (AUB), including heavy menstrual bleeding (HMB), imposes a massive burden on society, affecting one in four women of reproductive age. Understanding structural and nonstructural causes underpinning AUB is essential to optimize and provide precision in patient management. This is facilitated by careful classification of causes of bleeding. We highlight the crucial need for understanding mechanisms underpinning menstruation and its aberrations. The endometrium is a prime target tissue for selective progesterone receptor modulators (SPRMs). This class of compounds has therapeutic potential for the clinical unmet need of HMB. SPRMs reduce menstrual bleeding by mechanisms still largely unknown. Human menstruation remains a taboo topic, and many questions concerning endometrial physiology that pertain to menstrual bleeding are yet to be answered.
Collapse
Affiliation(s)
- Hilary O. D. Critchley
- MRC Centre for Reproductive Health, The University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Jacqueline A. Maybin
- MRC Centre for Reproductive Health, The University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Gregory M. Armstrong
- MRC Centre for Reproductive Health, The University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Alistair R. W. Williams
- MRC Centre for Reproductive Health, The University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, United Kingdom
| |
Collapse
|
9
|
Di Nisio A, Rocca MS, Sabovic I, De Rocco Ponce M, Corsini C, Guidolin D, Zanon C, Acquasaliente L, Carosso AR, De Toni L, Foresta C. Perfluorooctanoic acid alters progesterone activity in human endometrial cells and induces reproductive alterations in young women. CHEMOSPHERE 2020; 242:125208. [PMID: 31896193 DOI: 10.1016/j.chemosphere.2019.125208] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 10/10/2019] [Accepted: 10/23/2019] [Indexed: 06/10/2023]
Abstract
Female fecundity is finely regulated by hormonal signaling, representing a potential target for endocrine-disrupting chemicals. Among the chemicals of most concern are the perfluoroalkyl substances (PFAS), widely used in consumer goods, that are associated with adverse effects on reproductive health. In this context, the endometrium clearly represents an important fertility determining factor. The aim of this study was to investigate PFAS interference on hormonal endometrial regulation. This study was performed within a screening protocol to evaluate reproductive health in high schools. We studied a cohort of 146 exposed females aged 18-21 from the Veneto region in Italy, one of the four areas worldwide heavily polluted with PFAS, and 1080 non-exposed controls. In experiments on Ishikawa cells included UV-Vis spectroscopy, microarray analysis and qPCR. We report a significant dysregulation of the genetic cascade leading to embryo implantation and endometrial receptivity. The most differentially-expressed genes upon PFOA coincubation were ITGB8, KLF5, WNT11, SULT1E1, ALPPL2 and G0S2 (all p < 0.01). By qPCR, we confirmed an antagonistic effect of PFOA on all these genes, which was reversed at higher progesterone levels. Molecular interference of PFOA on progesterone was confirmed by an increase in the intensity of absorption spectra at 250 nm in a dose-dependent manner, but not in the presence of β-estradiol. Age at menarche (+164 days, p = 0.006) and the frequency of girls with irregular periods (29.5% vs 21.5%, p = 0.022) were significantly higher in the exposed group. Our results are indicative of endocrine-disrupting activity of PFAS on progesterone-mediated endometrial function.
Collapse
Affiliation(s)
- A Di Nisio
- Department of Medicine, Operative Unit of Andrology and Medicine of Human Reproduction, University of Padova, Via Giustiniani, 2, 35128, Padova, Italy
| | - M S Rocca
- Familial Cancer Clinic, Veneto Institute of Oncology (IOV-IRCSS), 35128, Padova, Italy
| | - I Sabovic
- Department of Medicine, Operative Unit of Andrology and Medicine of Human Reproduction, University of Padova, Via Giustiniani, 2, 35128, Padova, Italy
| | - M De Rocco Ponce
- Department of Medicine, Operative Unit of Andrology and Medicine of Human Reproduction, University of Padova, Via Giustiniani, 2, 35128, Padova, Italy
| | - C Corsini
- Department of Medicine, Operative Unit of Andrology and Medicine of Human Reproduction, University of Padova, Via Giustiniani, 2, 35128, Padova, Italy
| | - D Guidolin
- Department of Neurosciences, University of Padova, Via Gabelli 65, 35128, Padova, Italy
| | - C Zanon
- Istituto di Ricerca Pediatrica (IRP) - Fondazione Città della Speranza, Corso Stati Uniti 4, Padova, Italy
| | - L Acquasaliente
- Department of Biochemistry and Molecular Biology, Saint Louis University School of Medicine 1100 South Grand Blvd. St. Louis, MO, 63104, USA
| | - A R Carosso
- Department of Surgical Sciences, Gynecology and Obstetrics 1, Physiopathology of Reproduction and IVF Unit, S. Anna Hospital, University of Torino, 10126, Torino, Italy
| | - L De Toni
- Department of Medicine, Operative Unit of Andrology and Medicine of Human Reproduction, University of Padova, Via Giustiniani, 2, 35128, Padova, Italy
| | - C Foresta
- Department of Medicine, Operative Unit of Andrology and Medicine of Human Reproduction, University of Padova, Via Giustiniani, 2, 35128, Padova, Italy.
| |
Collapse
|
10
|
Berger C, Boggavarapu N, Norlin E, Queckbörner S, Hörnaeus K, Falk A, Engman M, Ramström M, Lalitkumar PGL, Gemzell-Danielsson K. Molecular characterization of PRM-associated endometrial changes, PAEC, following mifepristone treatment. Contraception 2018; 98:317-322. [PMID: 29890128 DOI: 10.1016/j.contraception.2018.05.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 05/11/2018] [Accepted: 05/25/2018] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The progesterone receptor modulator (PRM) mifepristone holds the potential to be developed for regular contraception. However, long-term treatment can cause thickening of the endometrium and PRM-associated endometrial changes (PAEC). The objective of this study was to explore the molecular expression of endometrium displaying PAEC after mifepristone treatment in order to understand the future implications of PAEC and safety of long-term use. STUDY DESIGN Endometrial biopsies were obtained from premenopausal women following 3 months of continuous mifepristone treatment. The biopsies were evaluated regarding occurrence of PAEC and followed up by a comparative analysis of gene expression in PAEC endometrium (n=7) with endometrium not displaying PAEC (n=4). Methods used included microarray analysis, Ingenuity Pathway Analysis (IPA) and real-time polymerase chain reaction. RESULTS Three genes relevant within endometrial function were up-regulated with PAEC: THY1 (p=.02), ADAM12 (p=.04) and TN-C (p=.04). The proliferation marker MKi67 was not altered (p=.31). None of the differentially regulated genes were involved in the endometrial cancer-signaling pathway (based on IPA knowledge database). CONCLUSION The genes altered in endometrium displaying PAEC after 3 months of mifepristone exposure are mainly involved in the structural architecture of tissue. IMPLICATIONS PAEC features may be explained by the altered genes and their networks affecting tissue architecture although not involved in endometrial cancer signaling pathways, and thus, treatment with mifepristone at this dosage does not show any adverse effect at endometrial level.
Collapse
Affiliation(s)
- C Berger
- Department of Women´s and Children´s Health, Division of Obstetrics and Gynecology, Karolinska Institutet/ Karolinska University Hospital, S-171 76, Stockholm, Sweden.
| | - N Boggavarapu
- Department of Women´s and Children´s Health, Division of Obstetrics and Gynecology, Karolinska Institutet/ Karolinska University Hospital, S-171 76, Stockholm, Sweden
| | - E Norlin
- Department of Women´s and Children´s Health, Division of Obstetrics and Gynecology, Karolinska Institutet/ Karolinska University Hospital, S-171 76, Stockholm, Sweden
| | - S Queckbörner
- Department of Women´s and Children´s Health, Division of Obstetrics and Gynecology, Karolinska Institutet/ Karolinska University Hospital, S-171 76, Stockholm, Sweden
| | - K Hörnaeus
- Analytical Chemistry, Department of Chemistry-BMC and Science for Life Laboratory, S-751 24, Uppsala, Sweden
| | - A Falk
- Analytical Chemistry, Department of Chemistry-BMC and Science for Life Laboratory, S-751 24, Uppsala, Sweden
| | - M Engman
- Department of Women´s and Children´s Health, Division of Obstetrics and Gynecology, Karolinska Institutet/ Karolinska University Hospital, S-171 76, Stockholm, Sweden
| | - M Ramström
- Analytical Chemistry, Department of Chemistry-BMC and Science for Life Laboratory, S-751 24, Uppsala, Sweden
| | - P G L Lalitkumar
- Department of Women´s and Children´s Health, Division of Obstetrics and Gynecology, Karolinska Institutet/ Karolinska University Hospital, S-171 76, Stockholm, Sweden
| | - K Gemzell-Danielsson
- Department of Women´s and Children´s Health, Division of Obstetrics and Gynecology, Karolinska Institutet/ Karolinska University Hospital, S-171 76, Stockholm, Sweden
| |
Collapse
|
11
|
Singh SS, Belland L, Leyland N, von Riedemann S, Murji A. The past, present, and future of selective progesterone receptor modulators in the management of uterine fibroids. Am J Obstet Gynecol 2018; 218:563-572.e1. [PMID: 29274830 DOI: 10.1016/j.ajog.2017.12.206] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 12/14/2017] [Accepted: 12/14/2017] [Indexed: 12/12/2022]
Abstract
Uterine fibroids are common in women of reproductive age and can have a significant impact on quality of life and fertility. Although a number of international obstetrics/gynecology societies have issued evidence-based clinical practice guidelines for the management of symptomatic uterine fibroids, many of these guidelines do not yet reflect the most recent clinical evidence and approved indication for one of the key medical management options: the selective progesterone receptor modulator class. This article aims to share the clinical experience gained with selective progesterone receptor modulators in Europe and Canada by reviewing the historical development of selective progesterone receptor modulators, current best practices for selective progesterone receptor modulator use based on available data, and potential future uses for selective progesterone receptor modulators in uterine fibroids and other gynecologic conditions.
Collapse
|
12
|
Nelson AL. Investigational hormone receptor agonists as ongoing female contraception: a focus on selective progesterone receptor modulators in early clinical development. Expert Opin Investig Drugs 2015; 24:1321-30. [PMID: 26289789 DOI: 10.1517/13543784.2015.1076791] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION As efforts are made to continue to increase the safety of contraceptive methods, those without estrogen have attracted new attention. Progestin-only options are available in many delivery systems, but most cause disturbed bleeding patterns. For gynecologic patients, selective progesterone receptor modulators (SPRMs) have been approved for medical abortion, for ovulation suppression in emergency contraception, and for the treatment of heavy menstrual bleeding due to leiomyoma. AREAS COVERED This article discusses the role of SPRMs in controlling fertility on an ongoing basis with particular emphasis on mifepristone and ulipristal acetate (UPA), since none of the other compounds has progressed out of early Phase I - II testing. It also discusses important information about the mechanisms of action and safety of these two SPRMs. EXPERT OPINION Of all the investigational hormone agonist/antagonists, SPRMs have demonstrated the greatest potential as ongoing female contraceptives. They have the ability to suppress ovulation after initiation of the luteinizing hormone (LH) surge without affecting ovarian production of estrogen or inducing any significant metabolic changes. SPRMs may well be able to provide longer term contraception as oral agents, vaginal rings, and perhaps even intrauterine devices. UPA has the greatest promise. Current research needs to be expanded.
Collapse
Affiliation(s)
- Anita L Nelson
- a Los Angeles BioMedical Research Institute, David Geffen School of Medicine at UCLA, Harbor-UCLA Medical Center, Department of Obstetrics and Gynecology , 1457 3rd Street, Manhattan Beach, CA 90266, USA +1 310 937 7226 ; +1 310 937 1416 ;
| |
Collapse
|
13
|
Gupta SK, Malik A, Arukha AP. Ovarian and oocyte targets for development of female contraceptives. Expert Opin Ther Targets 2015; 19:1433-46. [DOI: 10.1517/14728222.2015.1051305] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
14
|
Dinh A, Sriprasert I, Williams AR, Archer DF. A review of the endometrial histologic effects of progestins and progesterone receptor modulators in reproductive age women. Contraception 2015; 91:360-7. [DOI: 10.1016/j.contraception.2015.01.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 01/06/2015] [Accepted: 01/08/2015] [Indexed: 10/24/2022]
|
15
|
|
16
|
Patel B, Elguero S, Thakore S, Dahoud W, Bedaiwy M, Mesiano S. Role of nuclear progesterone receptor isoforms in uterine pathophysiology. Hum Reprod Update 2014; 21:155-73. [PMID: 25406186 DOI: 10.1093/humupd/dmu056] [Citation(s) in RCA: 205] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Progesterone is a key hormonal regulator of the female reproductive system. It plays a major role to prepare the uterus for implantation and in the establishment and maintenance of pregnancy. Actions of progesterone on the uterine tissues (endometrium, myometrium and cervix) are mediated by the combined effects of two progesterone receptor (PR) isoforms, designated PR-A and PR-B. Both receptors function primarily as ligand-activated transcription factors. Progesterone action on the uterine tissues is qualitatively and quantitatively determined by the relative levels and transcriptional activities of PR-A and PR-B. The transcriptional activity of the PR isoforms is affected by specific transcriptional coregulators and by PR post-translational modifications that affect gene promoter targeting. In this context, appropriate temporal and cell-specific expression and function of PR-A and PR-B are critical for normal uterine function. METHODS Relevant studies describing the role of PRs in uterine physiology and pathology (endometriosis, uterine leiomyoma, endometrial cancer, cervical cancer and recurrent pregnancy loss) were comprehensively searched using PubMed, Cochrane Library, Web of Science, and Google Scholar and critically reviewed. RESULTS Progesterone, acting through PR-A and PR-B, regulates the development and function of the endometrium and induces changes in cells essential for implantation and the establishment and maintenance of pregnancy. During pregnancy, progesterone via the PRs promotes myometrial relaxation and cervical closure. Withdrawal of PR-mediated progesterone signaling triggers menstruation and parturition. PR-mediated progesterone signaling is anti-mitogenic in endometrial epithelial cells, and as such, mitigates the tropic effects of estrogen on eutopic normal endometrium, and on ectopic implants in endometriosis. Similarly, ligand-activated PRs function as tumor suppressors in endometrial cancer cells through inhibition of key cellular signaling pathways required for growth. In contrast, progesterone via PR activation appears to increase leiomyoma growth. The exact role of PRs in cervical cancer is unclear. PRs regulate implantation and therefore aberrant PR function may be implicated in recurrent pregnancy loss (RPL). PRs likely regulate key immunogenic factors involved in RPL. However, the exact role of PRs in the pathophysiology of RPL and the use of progesterone for therapeutic benefit remains uncertain. CONCLUSIONS PRs are key mediators of progesterone action in uterine tissues and are essential for normal uterine function. Aberrant PR function (due to abnormal expression and/or function) is a major cause of uterine pathophysiology. Further investigation of the underlying mechanisms of PR isoform action in the uterus is required, as this knowledge will afford the opportunity to create progestin/PR-based therapeutics to treat various uterine pathologies.
Collapse
Affiliation(s)
- Bansari Patel
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Sonia Elguero
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Suruchi Thakore
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Wissam Dahoud
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Mohamed Bedaiwy
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC V6H 3N1, Canada
| | - Sam Mesiano
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, OH 44106, USA
| |
Collapse
|
17
|
|
18
|
Orihuela PA. Ulipristal: a progesterone receptor antagonist as an emergency contraceptive. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/eog.09.63] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
19
|
Ouzounian S, Verstraete L, Chabbert-Buffet N. Third-generation oral contraceptives: future implications of current use. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17474108.3.2.189] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
20
|
Abstract
BACKGROUND The introduction of a new progestin-only oral contraceptive in Europe has renewed interest in this class of oral contraceptives. Unlike the more widely used combined oral contraceptives containing an estrogen plus progestin, these pills contain only a progestin (progestogen) and are taken without interruption. How these pills compare to others in their class or to combined oral contraceptives is not clear. OBJECTIVES This review examined randomized controlled trials of progestin-only pills for differences in efficacy, acceptability, and continuation rates. SEARCH METHODS Through October 2013, we searched the computerized databases MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), POPLINE, and LILACS for studies of progestin-only pills. We also searched for current trials via ClinicalTrials.gov and ICTRP. Previous searches also included EMBASE. SELECTION CRITERIA We included all randomized controlled trials in any language that included progestin-only pills for contraception. We incorporated any comparison with a progestin-only pill; this could include different doses, other progestin-only pills, combined oral contraceptives, or other contraceptives. DATA COLLECTION AND ANALYSIS The first author abstracted the data and entered the information into RevMan 5. Another author performed a second, independent data abstraction to verify the initial data entry.We attempted to extract life-table rates (actuarial or continuous) and used the rate difference as the effect measure. Where life-table rates were not published, we used the incidence rate ratio (ratio of Pearl rates). Where only the crude number of events was published, we calculated the Peto odds ratio with 95% confidence interval (CI) using a fixed-effect model. For continuous variables, the mean difference (MD) was computed with 95% CI. Because of disparate exposures, we were not able to combine studies in meta-analysis. MAIN RESULTS Six trials met the inclusion criteria. We have not found any new studies since the initial review. In the trial comparing the desogestrel versus levonorgestrel progestin-only pill, desogestrel was not associated with a significantly lower risk of accidental pregnancy; the rate ratio was 0.27 (95% CI 0.06 to 1.19). However, the desogestrel progestin-only pill caused more bleeding problems, although this difference was not statistically significant. The trial comparing low-dose mifepristone versus a levonorgestrel progestin-only pill found similar pregnancy rates. In the trial comparing ethynodiol diacetate versus a combined oral contraceptive, irregular cycles occurred in all women assigned to the progestin-only pill (odds ratio 135.96; 95% CI 7.61 to 2421.02). In a trial comparing two progestin-only and two combined oral contraceptives, the progestin-only pill containing levonorgestrel 30 μg had higher efficacy than did the pill containing norethisterone 350 μg. An early trial found megestrol acetate inferior to other progestin-only pills in terms of efficacy. A study of the timing of pill initiation after birth found no important differences, but high losses to follow up undermined the trial. AUTHORS' CONCLUSIONS Evidence is insufficient to compare progestin-only pills to each other or to combined oral contraceptives.
Collapse
Affiliation(s)
- David A Grimes
- Obstetrics and Gynecology, University of North Carolina, School of Medicine, CB#7570, Chapel Hill, North Carolina, USA, 27599-7570
| | | | | | | |
Collapse
|
21
|
Endometrial Morphology After Treatment of Uterine Fibroids With the Selective Progesterone Receptor Modulator, Ulipristal Acetate. Int J Gynecol Pathol 2012; 31:556-69. [DOI: 10.1097/pgp.0b013e318251035b] [Citation(s) in RCA: 121] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
22
|
Vaginal ring delivery of selective progesterone receptor modulators for contraception. Contraception 2012; 87:314-8. [PMID: 23040126 DOI: 10.1016/j.contraception.2012.08.038] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2012] [Accepted: 08/28/2012] [Indexed: 11/24/2022]
Abstract
Vaginal ring delivery of selective progesterone receptor modulators (SPRMs) is under development to address the limitations of current hormonal methods that affect use and effectiveness. This method would be appropriate for use in women with contraindications to, or preferences to avoid, estrogens. A contraceptive vaginal ring (CVR) also eliminates the need for daily dosing and therefore might improve the effectiveness of contraception. The principal contraceptive effect of SPRMs is the suppression of ovulation. One limiting factor of chronic SPRM administration is the development of benign endometrial thickening characterized as PRM-associated endometrial changes. Ulipristal acetate (UPA) is approved for use as an emergency contraceptive pill, but no SPRM is approved for regular contraception. The Population Council is developing an ulipristal acetate CVR for regular contraception. The CVR studied is of a matrix design composed of micronized UPA mixed in a silicone rubber matrix The target product is a ring designed for continuous use over 3 months delivering near steady-state drug levels that will suppress ovulation. Results from Phase 1 and 2 studies demonstrate that suppression of ovulation occurs with UPA levels above 6-7 ng/mL.
Collapse
|
23
|
Talaulikar VS, Manyonda I. Progesterone and progesterone receptor modulators in the management of symptomatic uterine fibroids. Eur J Obstet Gynecol Reprod Biol 2012; 165:135-40. [PMID: 22901974 DOI: 10.1016/j.ejogrb.2012.07.023] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Revised: 06/03/2012] [Accepted: 07/25/2012] [Indexed: 10/28/2022]
Abstract
The majority of symptomatic uterine fibroids are currently treated by surgical interventions (myomectomy or hysterectomy) or radiological treatments (uterine artery embolisation or focussed ultrasound surgery). None of these treatments is a panacea, and what is conspicuous is the lack of an effective long-term medical therapy for a disorder so common among women of reproductive age. It has been known for some time that progesterone and its receptors enhance proliferative activity in fibroids and this has raised the possibility that anti-progestins and (PRMs) could be useful in the medical management of fibroids. Some of the compounds which have produced promising results in recent clinical trials or research studies include mifepristone, CDB-4124 (telapristone), CP-8947, J-867 (asoprisnil) and CDB-2914 (ulipristal acetate or UA). UA has recently completed Phase III clinical trials with very encouraging results, and has now acquired a licence for clinical use in Europe. While considerable research has yet to be done on the long-term safety and efficacy of UA there is nevertheless good reason for optimism on the emergence of effective medical therapy in the form of UA and possibly other PRMs.
Collapse
Affiliation(s)
- Vikram Sinai Talaulikar
- Department of Obstetrics & Gynaecology, St. George's Hospital and University of London, Cranmer Terrace, Tooting, London SW17 0RE, United Kingdom.
| | | |
Collapse
|
24
|
Chabbert-Buffet N, Pintiaux A, Bouchard P. The immninent dawn of SPRMs in obstetrics and gynecology. Mol Cell Endocrinol 2012; 358:232-43. [PMID: 22415029 DOI: 10.1016/j.mce.2012.02.021] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Revised: 02/21/2012] [Accepted: 02/22/2012] [Indexed: 12/30/2022]
Abstract
Selective progesterone receptor modulators (SPRMs) have been developed since the late 70s when mifepristone was first described. They act through nuclear progesterone receptors and can have agonist or mixed agonist antagonist actions depending on the cell and tissue. Mifepristone has unique major antagonist properties allowing its use for pregnancy termination. Ulipristal acetate has been marketed in 2009 for emergency contraception and has been recently approved for preoperative myoma treatment. Further perspectives for SPRMs use include long term estrogen free contraception, endometriosis treatment. However long term applications will be possible only after confirmation of endometrial safety.
Collapse
Affiliation(s)
- Nathalie Chabbert-Buffet
- Obstetrics, Gynecology and Reproductive Medicine Department, AP-HP, Hospital Tenon, UPMC Paris 06, Paris, France.
| | | | | |
Collapse
|
25
|
Fischer L, Deppert W, Pfeifer D, Stanzel S, Weimer M, Hanjalic-Beck A, Stein A, Straßer M, Zahradnik H, Schaefer W. Potential hazards to embryo implantation: A human endometrial in vitro model to identify unwanted antigestagenic actions of chemicals. Toxicol Appl Pharmacol 2012; 260:232-40. [DOI: 10.1016/j.taap.2012.02.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Revised: 02/22/2012] [Accepted: 02/26/2012] [Indexed: 10/28/2022]
|
26
|
Brache V, Sitruk-Ware R, Williams A, Blithe D, Croxatto H, Kumar N, Kumar S, Tsong YY, Sivin I, Nath A, Sussman H, Cochon L, Miranda MJ, Reyes V, Faundes A, Mishell D. Effects of a novel estrogen-free, progesterone receptor modulator contraceptive vaginal ring on inhibition of ovulation, bleeding patterns and endometrium in normal women. Contraception 2011; 85:480-8. [PMID: 22176795 DOI: 10.1016/j.contraception.2011.10.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2011] [Revised: 09/28/2011] [Accepted: 10/05/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND Progesterone receptor modulators (PRMs) delivered by contraceptive vaginal rings provide an opportunity for development of an estrogen-free contraceptive that does not require daily oral intake of steroids. The objective of this proof-of-concept study was to determine whether continuous delivery of 600-800 mcg of ulipristal acetate (UPA) from a contraceptive vaginal ring could achieve 80% to 90% inhibition of ovulation. STUDY DESIGN This was a prospective, controlled, open-labeled, multicenter international trial to examine the effectiveness and safety of this prototype vaginal ring. Thirty-nine healthy women, 21-40 years old and not at risk of pregnancy, were enrolled at three clinic sites. Volunteers participated in a control cycle, a 12-week treatment period and a post-treatment cycle. Pharmacodynamic effects on follicular function and inhibition of ovulation, effects on endometrium, bleeding patterns and serum UPA levels were evaluated. RESULTS Mean UPA levels during treatment were nearly constant, approximately 5.1 ng/mL throughout the study. Ovulation was documented in 32% of 111 "4-week treatment cycles." A correlation was observed between serum UPA and degree of inhibition of ovarian activity. There was no evidence of hyperplasia of endometrium, but PRM-associated endometrial changes were frequently observed (41%). CONCLUSION In this study, the minimum effective contraceptive dose was not established. Further studies are required testing higher doses of UPA to attain ovulation suppression in a higher percentage of subjects.
Collapse
Affiliation(s)
- Vivian Brache
- Biomedical Research Department, Profamilia, Santo Domingo 10401, Dominican Republic.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Abstract
Excessive menstrual bleeding reflects aberrant angiogenesis, generally due to submucosal myomas and endometrial polyps, although it is also frequently observed with long-term progestin-only contraception, impaired haemostasis and hormonal disorders. Surgery (hysterectomy, endometrial ablation) is used too frequently. Uterine artery embolisation is also an option for myomas. Medical treatments include combined oral contraception, progestins and levonorgestrel-releasing Intrauterine System. Gonadotropin-releasing hormone agonists provide significant improvements in bleeding for myomas, but also decrease estrogen secretion (e.g. hot flushes, decreased bone mass). Progestins, although used widely, remain poorly effective as they promote myoma cell growth. Recently, Selective Progesterone Receptor Modulators (SPRMs) have been shown to induce amenorrhea whilst maintaining endogenous estrogen secretion. Phase II studies have also demonstrated decreased fibroid size in SPRM-treated women. Although the mechanism of amenorrhea observed after SPRM treatment is still poorly understood, they may control uterine bleeding via a direct effect on endometrial blood vessels. Suppression of bleeding in women with uterine fibroids receiving SPRMs is associated with moderate reductions in uterine artery blood flow, without major changes in angiogenic factors and extracellular matrix composition; a clear difference to modifications observed with progestins. These data suggest major progress in the treatment of excessive menstrual bleeding.
Collapse
Affiliation(s)
- Philippe Bouchard
- Department of Endocrinology, Obstetrics & Gynecology, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France.
| |
Collapse
|
28
|
Bouchard P, Chabbert-Buffet N, Fauser BCJM. Selective progesterone receptor modulators in reproductive medicine: pharmacology, clinical efficacy and safety. Fertil Steril 2011; 96:1175-89. [PMID: 21944187 DOI: 10.1016/j.fertnstert.2011.08.021] [Citation(s) in RCA: 124] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2011] [Revised: 08/08/2011] [Accepted: 08/12/2011] [Indexed: 11/19/2022]
|
29
|
Distinguishing features of endometrial pathology after exposure to the progesterone receptor modulator mifepristone. Hum Pathol 2011; 42:947-53. [PMID: 21315422 DOI: 10.1016/j.humpath.2010.11.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Revised: 11/02/2010] [Accepted: 11/03/2010] [Indexed: 11/22/2022]
Abstract
There is growing interest in the use of progesterone receptor modulators such as mifepristone for treatment of gynecologic and other conditions, but interest in progesterone receptor modulators is dampened by the effects of the agents on the endometrium. In this study, we examined the endometria of women exposed to mifepristone for treatment of leiomyomas in doses of 2.5 and 5 mg and compared them to unexposed endometria. We assessed the reliability of these features by comparing agreement in ratings between pathologists who were blinded to each other's readings. We assessed distinguishing features between exposed and unexposed groups by comparing frequency of features between groups. We found that key features could be reliably assessed by pathologists experienced in endometrial pathology. We observed several features (nonsynchronous endometrium, large fluid filled glands, and abnormal blood vessels) that distinguished endometrial samples that were and were not exposed to the drug. These findings suggest several features that can be tracked during studies involving mifepristone and, potentially, other progesterone receptor modulators.
Collapse
|
30
|
Spitz IM. Mifepristone: where do we come from and where are we going? Contraception 2010; 82:442-52. [DOI: 10.1016/j.contraception.2009.12.012] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2009] [Accepted: 12/15/2009] [Indexed: 01/08/2023]
|
31
|
Wilkens J, Critchley H. Progesterone receptor modulators in gynaecological practice. JOURNAL OF FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE 2010; 36:87-92. [DOI: 10.1783/147118910791069178] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
32
|
Abstract
BACKGROUND The introduction of a new progestin-only oral contraceptive in Europe has renewed interest in this class of oral contraceptives. Unlike the more widely used combined oral contraceptives containing an estrogen plus progestin, these pills contain only a progestin (progestogen) and are taken without interruption. How these pills compare to others in their class or to combined oral contraceptives is not clear. OBJECTIVES This review examined randomized controlled trials of progestin-only pills for differences in efficacy, acceptability, and continuation rates. SEARCH STRATEGY We searched the computerized databases MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), POPLINE, LILACS, and EMBASE for studies of progestin-only pills. We also searched for current trials via ClinicalTrials.gov and ICTRP. SELECTION CRITERIA We included all randomized controlled trials in any language that included progestin-only pills for contraception. We incorporated any comparison with a progestin-only pill; this could include different doses, other progestin-only pills, combined oral contraceptives, or other contraceptives. DATA COLLECTION AND ANALYSIS The first author abstracted the data and entered the information into RevMan 5. Another author performed a second, independent data abstraction to verify the initial data entry. Because of disparate exposures, we were not able to combine studies in meta-analysis. MAIN RESULTS Six trials met the inclusion criteria. In the trial comparing the desogestrel versus levonorgestrel progestin-only pill, desogestrel was not associated with a significantly lower risk of accidental pregnancy; the rate ratio was 0.27 (95% CI 0.06 to 1.19). However, the desogestrel progestin-only pill caused more bleeding problems, although this difference was not statistically significant. The trial comparing low-dose mifepristone versus a levonorgestrel progestin-only pill found similar pregnancy rates. In the trial comparing ethynodiol diacetate versus a combined oral contraceptive, irregular cycles occurred in all women assigned to the progestin-only pill (odds ratio 135.96; 95% CI 7.61 to 2421.02). In a trial comparing two progestin-only and two combined oral contraceptives, the progestin-only pill containing levonorgestrel 30 mug had higher efficacy than did the pill containing norethisterone 350 mug. An early trial found megestrol acetate inferior to other progestin-only pills in terms of efficacy. A study of the timing of pill initiation after birth found no important differences, but high losses to follow up undermined the trial. AUTHORS' CONCLUSIONS Evidence is insufficient to compare progestin-only pills to each other or to combined oral contraceptives.
Collapse
Affiliation(s)
- David A Grimes
- Behavioral and Biomedical Research, Family Health International, PO Box 13950, Research Triangle Park, North Carolina, USA, NC 27709
| | | | | | | |
Collapse
|
33
|
Martin OV, Voulvoulis N. Sustainable risk management of emerging contaminants in municipal wastewaters. PHILOSOPHICAL TRANSACTIONS. SERIES A, MATHEMATICAL, PHYSICAL, AND ENGINEERING SCIENCES 2009; 367:3895-3922. [PMID: 19736227 DOI: 10.1098/rsta.2009.0115] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The presence of emerging contaminants in municipal wastewaters, particularly endocrine-disrupting compounds such as oestrogenic substances, has been the focus of much public concern and scientific attention in recent years. Due to the scientific uncertainty still surrounding their effects, the Precautionary Principle could be invoked for the interim management of potential risks. Therefore, precautionary prevention risk-management measures could be employed to reduce human exposure to the compounds of concern. Steroid oestrogens are generally recognized as the most significant oestrogenically active substances in domestic sewage effluent. As a result, the UK Environment Agency has championed a 'Demonstration Programme' to investigate the potential for removal of steroid oestrogens and alkylphenol ethoxylates during sewage treatment. Ecological and human health risks are interdependent, and ecological injuries may result in increased human exposures to contaminants or other stressors. In this context of limiting exposure to potential contaminants, examining the relative contribution of various compounds and pathways should be taken into account when identifying effective risk-management measures. In addition, the explicit use of ecological objectives within the scope of the implementation of the EU Water Framework Directive poses new challenges and necessitates the development of ecosystem-based decision tools. This paper addresses some of these issues and proposes a species sensitivity distribution approach to support the decision-making process related to the need and implications of sewage treatment work upgrade as risk-management measures to the presence of oestrogenic compounds in sewage effluent.
Collapse
Affiliation(s)
- O V Martin
- Centre for Environmental Policy, , Imperial College London, London SW7 2AZ, UK
| | | |
Collapse
|
34
|
Clinical utility of progesterone receptor modulators and their effect on the endometrium. Curr Opin Obstet Gynecol 2009; 21:318-24. [DOI: 10.1097/gco.0b013e32832e07e8] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
35
|
Chabbert-Buffet N, Ouzounian S, Kairis AP, Bouchard P. Contraceptive applications of progesterone receptor modulators. EUR J CONTRACEP REPR 2009; 13:222-30. [PMID: 18821461 DOI: 10.1080/13625180802267060] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
|
36
|
Engman M, Granberg S, Williams ARW, Meng CX, Lalitkumar PGL, Gemzell-Danielsson K. Mifepristone for treatment of uterine leiomyoma. A prospective randomized placebo controlled trial. Hum Reprod 2009; 24:1870-9. [PMID: 19389793 DOI: 10.1093/humrep/dep100] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Uterine leiomyomas are widely prevalent and frequently cause menorrhagia. The major therapeutic option today is hysterectomy. Medical options are of highest interest. METHODS A total of 30 women with uterine leiomyomas scheduled for surgical intervention were randomized to receive either 50 mg mifepristone or placebo every other day during 3 months prior to surgery. Uterine blood flow and leiomyoma volume were evaluated once a month until surgery. Endometrial biopsies were obtained prior to and at end of treatment. Relevant biochemistry, symptoms and bleeding were recorded. Primary outcome was reduction in uterine leiomyoma size. RESULTS There was a significant percentual decrease (P = 0.021) in the total leiomyoma volume in the mifepristone-treated group, -28 (-48, -8) % (mean +/- 0, 95 confidence interval), compared with the control group values 6 (-13, 25) %. Mifepristone treatment significantly reduced the bleeding days (P = 0.001) and increased serum haemoglobin values (P = 0.046). Serum cortisol levels remained unchanged, while a mild increase in serum androgens was noted. Endometrial biopsies showed no premalignant changes or changes in mitotic indices. CONCLUSION Mifepristone may offer an effective treatment option for women with uterine leiomyoma and the associated pronounced uterovaginal bleeding. Clinical Trials identifier: www.clinicaltrials.gov: NCT00579475.
Collapse
Affiliation(s)
- M Engman
- Department of Woman and Child Health, Division of Obstetrics and Gynaecology, Karolinska Institutet, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | | | | | | | | | | |
Collapse
|
37
|
Ouzounian S, Bouchard P, Chabbert-Buffet N. Effects of antiprogestins on the uterus. ACTA ACUST UNITED AC 2009; 4:269-80. [PMID: 19072476 DOI: 10.2217/17455057.4.3.269] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Progesterone-receptor modulators (PRMs) are progesterone-receptor ligands that can exert agonistic, antagonistic or mixed agonist-antagonist effects depending on the cellular context. The mechanisms of action of these compounds are still incompletely understood. PRMs already have several applications in women's health such as emergency contraception, pregnancy termination, management of early fetal demise and cervical maturation. The main indications that will be developed in the future include dysfunctional bleeding and preoperative treatment of uterine myomas. Other future indications may include estrogen-free contraception, treatment of endometriosis and prevention and treatment of breast cancer. However, the available data from mid- to long-term continuous administration studies has raised the issue of endometrial safety. For this reason, long-term applications of PRMs are currently postponed, although windows of treatment with a short course of progestin therapy, or even by a short interruption of treatment, could improve endometrial aspects if needed.
Collapse
|
38
|
Critchley HOD, Saunders PTK. Hormone Receptor Dynamics in a Receptive Human Endometrium. Reprod Sci 2009; 16:191-9. [DOI: 10.1177/1933719108331121] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Hilary O. D. Critchley
- Division of Reproductive and Developmental Sciences, University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, Scotland,
| | - Philippa T. K. Saunders
- MRC Human Reproductive Sciences Unit, The Queen's Medical Research Institute, Edinburgh, Scotland
| |
Collapse
|
39
|
|
40
|
Schwenkhagen A, Schaudig K. Antigestagene. GYNAKOLOGISCHE ENDOKRINOLOGIE 2008. [DOI: 10.1007/s10304-008-0268-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
41
|
Benagiano G, Bastianelli C, Farris M. Selective progesterone receptor modulators 2: use in reproductive medicine. Expert Opin Pharmacother 2008; 9:2473-85. [PMID: 18778185 DOI: 10.1517/14656566.9.14.2473] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
42
|
Engman M, Skoog L, Soderqvist G, Gemzell-Danielsson K. The effect of mifepristone on breast cell proliferation in premenopausal women evaluated through fine needle aspiration cytology. Hum Reprod 2008; 23:2072-9. [DOI: 10.1093/humrep/den228] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
43
|
Möller C, Hoffmann J, Kirkland TA, Schwede W. Investigational developments for the treatment of progesterone-dependent diseases. Expert Opin Investig Drugs 2008; 17:469-79. [PMID: 18363513 DOI: 10.1517/13543784.17.4.469] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Clinical evidence has shown that conditions such as uterine fibroids, endometriosis and breast cancer are progesterone-dependent diseases. Therefore, progesterone receptor (PR) antagonists and selective PR modulators (SPRMs) are under development for the treatment of these conditions. However, the first PR antagonists that became available exhibit insufficient selectivity or tolerability for the chronic administration required to treat these conditions. Despite initial setbacks, development of second-generation PR antagonists with better selectivity continues forward. OBJECTIVE In this review we would like to summarise prospects for using PR antagonists for the treatment of uterine fibroids, endometriosis and breast cancer, and to give an overview of the development of new steroidal and non-steroidal PR antagonists. METHOD Available preclinical and clinical data and publications have been reviewed with the focus on scientific background and use in the three mentioned indications. RESULTS/CONCLUSION Preclinical and clinical evidence demonstrated that PR antagonists and SPRMs are effective for the treatment of progesterone-dependent diseases. Future development will demonstrate if they can become important drugs.
Collapse
Affiliation(s)
- Carsten Möller
- Bayer Schering Pharma, Global Drug Discovery, Women's Healthcare, Müllerstrasse 178, 13353 Berlin, Germany
| | | | | | | |
Collapse
|
44
|
Critchley HOD, Baird DT. Endometrial effects of hormonal contraception. REPRODUCTIVE MEDICINE AND ASSISTED REPRODUCTIVE TECHNIQUES 2008. [DOI: 10.3109/9780203091500.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
|