Bleeding problems and progestogen-only contraception

A phase I/II study evaluating the pharmacokinetics, pharmacodynamics, and safety of drospirenone as an oral contraceptive in Japanese women

AIM

Drospirenone (DRSP) is a synthetic progestogen approved as a progestin-only pill for contraception in both the United States and Europe. Herein, we conducted a phase I/II study to evaluate the pharmacokinetics, pharmacodynamics, and safety of DRSP in Japanese women.

METHODS

Single and multiple doses of 4 mg of DRSP were orally administered to healthy premenopausal Japanese women. In the multiple-dose period, 4 mg of DRSP was administered once daily for 24 days. Pharmacokinetics, hormone levels, and adverse events (AEs) were investigated.

RESULTS

Twelve Japanese women participated in this study. The single- and multiple-dose pharmacokinetics of DRSP was similar to that reported in previous studies in Caucasians. In the multiple-dose period, no subject displayed a progesterone level of more than 5.03 ng/mL. AEs were observed in 11 (91.7%) subjects. The most common AE was genital hemorrhage, which was observed in six (50.0%) subjects, followed by diarrhea and acne in four (33.3%) subjects each. All AEs resolved or improved at the end of the study, and complete recovery was confirmed in all subjects at follow-up.

CONCLUSIONS

The pharmacokinetics of DRSP in Japanese women was similar to that of previous studies performed in Caucasian women. Repeated administration of DRSP maintained low plasma progesterone levels indicating effective inhibition of ovulation. No notable safety concerns were observed. In this phase I/II study, DRSP had no obvious pharmacokinetic, pharmacodynamic, or safety issues to consider in Japanese women.

Anticoagulant therapy for women: implications for menstruation, pregnancy, and lactation

Estrogen exposure, in the setting of pregnancy, the postpartum state, combined hormonal contraceptives (CHCs), or hormone therapy use, has been clearly associated with increased rates of venous thromboembolism (VTE). Although recurrence rates are low in these settings, up to 70% of anticoagulated menstruating individuals experience abnormal or heavy menstrual bleeding (HMB), which commonly results in iron deficiency with or without anemia. Patients taking rivaroxaban appear to experience higher rates of HMB compared with those on apixaban, dabigatran, or warfarin. HMB can often be diagnosed in a single visit with a good menstrual history assessing for factors with a known association with increased or heavy bleeding, such as changing pads or tampons more often than every 2 hours, clots larger than a quarter, and iron deficiency (ferritin <50  ng/mL). HMB can be managed with hormonal therapies, including those associated with VTE risk, such as CHCs and depot-medroxyprogesterone acetate (DMPA). In many cases, continuing CHCs or DMPA while a patient is therapeutically anticoagulated is reasonable, so long as the therapy is discontinued before anticoagulation is stopped. Modification of the anticoagulation regimen, such as decreasing to a prophylactic dose in the acute treatment period, is not currently recommended. For patients who are currently pregnant, low-molecular-weight heparin (LMWH) is still standard of care during pregnancy; routine monitoring of anti-factor Xa levels is not currently recommended. Warfarin or LMWH may be considered in the postpartum setting, but direct-acting oral anticoagulants are currently not recommended for lactating patients.

Management of heavy menstrual bleeding on anticoagulation

Heavy menstrual bleeding (HMB) is a common complication of anticoagulation, affecting ∼70% of menstruating women receiving oral anticoagulants. The risk of HMB is lower with apixaban and/or dabigatran than with rivaroxaban. HMB can result in iron deficiency with or without anemia, increased need for medical interventions, decreased quality of life, and missed school/work. Mainstays of treatment include hormone therapies such as the levonorgestrel intrauterine system, subdermal implant, and other progesterone-based therapies, which can result in decreased blood loss and, in some cases, amenorrhea. Combined hormone therapies can be used while patients continue receiving anticoagulation and are also highly effective for decreasing menstrual blood loss. Rarely, procedure-based interventions such as endometrial ablation may be required. Patients should be evaluated for iron deficiency and anemia and offered supportive therapies as needed. Abbreviating the course of anticoagulation or skipping doses can increase the risk of recurrent venous thromboembolism by as much as fivefold, but switching oral anticoagulants may be considered. Awareness of HMB and careful history taking at each visit are crucial to avoid a missed diagnosis.

Factors associated with the contraindicated use of oral contraceptives in Brazil

OBJECTIVE

To estimate the prevalence of the contraindicated use of oral contraceptives and the associated factors in Brazilian women.

METHODS

20,454 women who answered the VIGITEL survey in 2008 also participated in this study, of which 3,985 reported using oral contraceptives. We defined the following conditions for the contraindicated use of contraceptives: hypertension; cardiovascular diseases such as heart attack, stroke/cerebrovascular accident; diabetes mellitus; being smoker and 35 years old or older. We estimated the prevalence and 95% confidence intervals of contraindicated use in users of oral contraceptives and the factors associated with contraindication by prevalence ratio and 95% confidence intervals.

RESULTS

In the total population, 21% (95%CI 19.7-21.9) of women showed some contraindication to the use of oral contraceptives, of which 11.7% (95%CI 10.6-13.7) belonged to the group of users of oral contraceptives. The most frequent contraindication in users of oral contraceptives was hypertension (9.1%). The largest proportion of women with at least one contraindication was aged between 45 and 49 years (45.8%) and with education level between zero and eight years (23.8%). The prevalence of contraindication to oral contraceptives was higher in women less educated (zero to eight years of study) (PR = 2.46; 95%CI 1.57-3.86; p < 0.05) and with age between 35-44 years (PR = 4.00; 95%CI 2.34-6.83) and 45-49 years (PR = 5.59; 95%CI 2.90-10.75).

CONCLUSIONS

Age greater than or equal to 35 and low education level were demographic and iniquity factors, respectively, in the contraindicated use of oral contraceptives.

OBJETIVO

Estimar a prevalência de contraindicação ao uso de anticoncepcionais orais e os fatores associados em mulheres brasileiras.

MÉTODOS

Participaram 20.454 mulheres que responderam ao inquérito Vigitel em 2008, das quais 3.985 reportaram uso de contraceptivos orais. Definiu-se como uso contraindicado de anticoncepcionais quando presente pelo menos uma condição: hipertensão; doenças cardiovasculares como infarto, derrame/acidente vascular encefálico; diabetes mellitus; ser tabagista e ter idade igual ou maior de 35 anos. Foram estimadas as prevalências e intervalos de 95% de confiança de uso contraindicado em usuárias de anticoncepcionais orais e fatores associados à contraindicação por meio de razões de prevalência e intervalos de 95% de confiança.

RESULTADOS

Na população total, 21,0% (IC95% 19,7-21,9) das mulheres apresentaram alguma contraindicação ao uso de anticoncepcionais orais, das quais 11,7% (IC95% 10,6-13,7) pertenciam ao grupo de usuárias de anticoncepcionais orais. A contraindicação mais freqüente entre as usuárias de anticoncepcionais orais foi hipertensão (9,1%). A maior proporção de mulheres com pelo menos uma contraindicação tinha entre 45 a 49 anos (45,8%) e escolaridade entre zero e oito (23,8%). A prevalência de contraindicação de anticoncepcionais orais foi maior nas mulheres menos escolarizadas (zero a oito anos de estudos) (RP = 2,46; IC95% 1,57-3,86; p < 0,05) e idade entre 35-44 anos (RP = 4,00; IC95% 2,34-6,83) e 45-49 anos (RP = 5,59; IC95% 2,90-10,75).

CONCLUSÕES

Idade maior ou igual a 35 e escolaridade baixa foram fatores demográficos e de iniquidade, respectivamente, no uso contraindicado de contraceptivos orais.

Contraindications to progestin-only oral contraceptive pills among reproductive-aged women

BACKGROUND

Progestin-only oral contraceptive pills (POPs) have fewer contraindications to use compared to combined pills. However, the overall prevalence of contraindications to POPs among reproductive-aged women has not been assessed.

STUDY DESIGN

We collected information on contraindications to POPs in two studies: (1) the Self-Screening Study, a sample of 1267 reproductive-aged women in the general population in El Paso, TX, and (2) the Prospective Study of OC Users, a sample of current oral contraceptive (OC) users who obtained their pills in El Paso clinics (n=532) or over the counter (OTC) in Mexican pharmacies (n=514). In the Self-Screening Study, we also compared women's self-assessment of contraindications using a checklist to a clinician's evaluation.

RESULTS

Only 1.6% of women in the Self-Screening Study were identified as having at least one contraindication to POPs. The sensitivity of the checklist for identifying women with at least one contraindication was 75.0% [95% confidence interval (CI): 50.6%-90.4%], and the specificity was 99.4% (95% CI: 98.8%-99.7%). In total, 0.6% of women in the Prospective Study of OC Users reported having any contraindication to POPs. There were no significant differences between clinic and OTC users.

CONCLUSION

The prevalence of contraindications to POPs was very low in these samples. POPs may be the best choice for the first OTC oral contraceptive in the United States.

Estrogen-free oral hormonal contraception: benefits of the progestin-only pill

Although combined oral contraceptives (COCs) are commonly used and highly effective in preventing pregnancy, they may not be suitable for some women. COC use is associated with increased rates of cardiovascular events and is not recommended in nonbreastfeeding women in the immediate postpartum period or in breastfeeding women during the initial 6 months of breastfeeding. Moreover, estrogen-related adverse effects, such as headache, are common. Estrogen-free progestin-only pills (POPs) are a valuable option in women who prefer to take an oral hormonal contraceptive, but are ineligible for, or choose not to use, COCs. Although some POPs have been associated with lower contraceptive effectiveness than COCs, the POP containing desogestrel has shown similar contraceptive effectiveness to COCs. The most commonly reported complaints in women using all POPs are bleeding problems. Counseling women interested in using POPs about the variable bleeding patterns associated with this method may improve compliance and acceptance.

Advantages and challenges of oestrogen-free hormonal contraception

BACKGROUND

Not all women tolerate hormonal contraceptives containing oestrogens.

METHODS

The authors selected and evaluated relevant publications on the advantages and challenges of oestrogen-containing and oestrogen-free oral contraceptives obtained from the MEDLINE and Google databases from January 2000 to January 2010. In addition, the reference lists from the obtained publications as well as the authors' clinical experience served as additional sources of information. Emphasis was placed on the common adverse effects and risks associated with oestrogen replacement as well as on the noncontraceptive benefits of combined oral contraceptive pills and progestogen-only pills in the management of menstrual cycle-dependent problems.

FINDINGS

Progestogen-only pills have the potential to abolish many of the common adverse effects associated with oestrogen plus progestogen oral contraceptives and can be used to treat various menstrual cycle-dependent problems. However, only a limited number of clinical comparative studies are available. Progestogen-only pills are associated with a more irregular bleeding pattern than contraceptive pills containing oestrogens, especially during the first few months of therapy. As this is not permanent, adequate counselling is essential in order to prevent unnecessary discontinuation of treatment.

CONCLUSIONS

Progestogen-only pills offer an effective, convenient, and readily reversible method of contraception that is suitable for women with contraindications for oestrogens.

Contraception for the older woman: an update

Although fertility declines with advancing age as the woman approaches the menopause, some risk of pregnancy persists, and effective contraception needs to be offered to avoid an unintended pregnancy. An older woman may have menstrual dysfunction or climacteric symptoms and these factors would need consideration when making the choice of contraception. Low-estrogen dose combined oral contraceptives may be prescribed to healthy non-smoking women up to about 50 years of age. The progestogen-only pill may be an appropriate option in an older woman with declining fertility. The copper intrauterine device is an optimal method for parous women free of pre-existing menstrual problems. The levonorgestrel-releasing intrauterine system is considered the contraceptive method of choice for perimenopausal women with menstrual dysfunction. The woman should be provided with individualized advice so that she has a choice between the newer, effective, largely safe, reversible methods and sterilization.

The effects of an oestrogen-free, desogestrel-containing oral contraceptive in women with cyclical symptoms: results from two studies on oestrogen-related symptoms and dysmenorrhoea

OBJECTIVES

To evaluate the effects of an oestrogen-free oral contraceptive (Cerazette; 75 mcg/day desogestrel) in women with oestrogen-related symptoms during previous combined oral contraceptive (COC) use (ERS study) and in women with dysmenorrhoea (DYS study).

METHODS

Two similarly designed prospective, non-comparative multicentre observational studies were carried out in Germany. Altogether, 403 women with oestrogen-related symptoms during previous COC use and 406 women with dysmenorrhoea took Cerazette continuously. Symptom-related assessments were made at baseline and after 3-4 months, along with bleeding pattern and treatment satisfaction.

RESULTS

In the ERS study, the four oestrogen-related symptoms studied resolved or improved in over 70% of women. Nausea improved/resolved most (92% of women), followed by breast tenderness (90%), oestrogen-related headache (84%) and oedema (74%). In the DYS study, dysmenorrhoea resolved or considerably improved in 93% of the study population. Correspondingly, use of analgesics dropped from 70% of women at baseline to 8% at study end. Adverse events were reported by 7-8% of both study populations and were mainly bleeding irregularities. Most women in both studies were satisfied with treatment (approximately 90%) and wished to continue treatment after study completion (approximately 85%).

CONCLUSIONS

Cerazette in this study set-up improved oestrogen-related symptoms and dysmenorrhoea in women affected and treatment was well accepted.