A randomized double-blind comparison of two single doses of mifepristone for emergency contraception

BACKGROUND

Previous trials have shown the potential of 10 mg of mifepristone in emergency contraception. The aim of this trial was to investigate whether 10 mg of mifepristone has the same efficacy as 25 mg.

METHODS

This double-blind, randomized trial was carried out in 10 family planning institutes and hospitals in China. Women who met recruitment criteria and requested emergency contraception within 120 h of a single act of unprotected coitus were randomized using a computer-generated list to either 10 or 25 mg of mifepristone within each centre.

RESULTS

Among 3052 women enrolled, the outcome was known for 3030 women, 1516 in the 10 mg group and 1514 in the 25 mg group. Seventeen pregnancies occurred in each group, giving a pregnancy rate of 1.1%. The relative risk of pregnancy for women treated with 10 mg mifepristone compared with those treated with 25 mg was 1.0 (95% CI: 0.51-1.95) and equivalence was demonstrated within a two-fold margin. Both doses prevented 85-86% of pregnancies expected to have occurred if no treatment had been given. The pregnancy rate nearly doubled if women had further acts of intercourse. Efficacy decreased with treatment delay. Side-effects were uncommon and mild.

CONCLUSIONS

A dose of 10 mg of mifepristone is sufficient for emergency contraception. Earlier treatment is preferable, although the method can be used effectively for up to 5 days after intercourse.

Flow cytometry of porcine ovarian cells: antiprogestins play an important role in progesterone receptor upregulation

To investigate the mechanism of antiprogestins in the regulation of ovarian function, a dual-chamber culture system was prepared with the amnion membrane of human placenta. Isolated porcine granulosa and thecal cells were grown on both sides of the amnion and co-cultured with or without RU486 and ZK98, 734. After 48 h incubation, the progesterone receptor (PR) and estrogen receptor (ER) of both cells were detected by flow cytometry. Progesterone and estradiol concentrations in the media were measured by radioimmunoassay. The results showed that antiprogestins increased PR contents in both cells; no significant change was found for ER. At the same time the progesterone and estradiol production by granulosa cells was inhibited; the progesterone production by thecal cells was reduced also. These data suggest that progesterone regulates progesterone synthesis. This autocrine/paracrine action may be the approach through which progesterone controls PR upregulation. It could be one mechanism for the inhibition of follicle development and steroidogenic function by antiprogestins.

The comparative trial of TCu 380A IUD and progesterone-releasing vaginal ring used by lactating women

The objective of this paper was to compare the efficacy, acceptability, safety, and bleeding pattern of TCu 380A intrauterine device (IUD) and progesterone-releasing vaginal ring used by breastfeeding women. The study population included 97 breastfeeding women using IUD and 100 women using vaginal ring. Of the IUD users, no insertion failure, perforation, or accidental pregnancy occurred in 12 months. There was one IUD expulsion. There were no discontinuations of IUD due to medical reasons other than expulsion. The total discontinuation rate was 2.3%. In the ring group, no accidental pregnancy occurred. The major reasons for discontinuation were ring use-related problems and vaginal problems. The total discontinuation rate was 65.4% within 1 year. The frequency of any one complaint among the ring users was higher than that among the IUD users. There were no differences in the proportion of women having no sexual activity and in the weight of their babies between the two groups. Compared with the IUD users, the median number of bleeding/spotting (B/S) episodes and B/S days of the vaginal ring users were fewer; consequently, the mean length of B/S-free interval was longer in all four reference periods; the mean length of B/S episode and segment were the same; the occurrence of amenorrhea was more frequent; in contrast, the proportions of normal bleeding patterns were fewer. The frequencies of prolonged bleeding, frequent bleeding, and infrequent bleeding patterns did not differ between the two groups. The percentage of irregular bleeding was fewer only in the first two reference periods. It is concluded that the TCu 380A IUD and progesterone-releasing vaginal ring used by breastfeeding women are safe and effective. The higher discontinuation rate of the ring users was mainly because of use-related problems. Breastfeeding women with TCu 380A IUD had better tolerance and acceptability. The TCu 380A IUD does not, but the progesterone-releasing vaginal ring does, suppress the recovery of ovarian function. However, once return of menstruation occurred, there were no differences in bleeding patterns between the two contraceptive methods.

Current practice of family planning in China

Current practice of family planning in China is based on the population policy and strategy of the country. Comprehensive contraceptive methods are provided in family planning clinics at all levels. Among the methods used, intrauterine devices and tubal sterilization are most popular. Vasectomy is popular in some provinces. Oral pills, injectables and subdermal implants occupy a small proportion. Incidence of abortion is high due to failure of methods and unprotected intercourse. Attention is paid to the adoption of emergency contraception to prevent unwanted pregnancy. Improvement in quality of care is the key to a successful family planning program. Basic research is essential for development of new contraceptive technology.

NORPLANT and the levonorgestrel IUD in Chinese family planning programmes

NORPLANT was introduced into the Chinese family planning programmes in 1984 by the Population Council. After a pilot study of 1200 cases in four centres in China, the study was expanded to 12 centres with 10,718 cases of NORPLANT and 1208 cases of NORPLANT-2 followed up for more than 6 years. The 5 years net cumulative pregnancy rates were 0.5-1.2 and the net cumulative continuation rates were around 65-72 per 100 users. There were significant differences in pregnancy rates between different groups of body weight and age, i.e. the pregnancy rates were higher in groups with body weight over 70 kg and those aged below 25 years. The age, body weight and dependence on contraceptive effectiveness of NORPLANT should be taken into account in the selection of users. Nationwide large-scale studies in provincial and country rural areas and postmarketing surveillance are being carried out. Changes in ovarian function and endometrium have been studied. Levonorgestrel IUD (LNg-IUD) was introduced into China in 1985. Comparative clinical studies on NORPLANT and LNg-IUD, pharmacokinetic and pharmacodynamic studies and endometrial studies of LNg-IUD were performed. The higher percentage (55.1%) of ovarian suppression in Chinese users of LNg-IUD may be attributed to ethnic differences among Caucasian women in their susceptibility to steroid hormones. Results showed favourable acceptance of both devices among Chinese women. The studies promoted the incorporation of new long-acting contraceptive methods into the Chinese family planning programmes.

A study of the effect of B-EP and naloxone on the function of the hypothalamo-pituitary-testicular axis of the rat

To investigate whether endogenous opioid peptides (EOP) play an important role in intragonadal regulation of testicular function and regulation of the hypothalamic-pituitary-gonadal axis of the male rat, the authors employed two principal methods: culture of testicular Leydig cells and Sertoli cells, and in vitro perifusion of hypothalamo-pituitary Leydig cells of the adult rat. The results demonstrated that incubation of Leydig cells with B-endorphin (B-EP 10(-9) = 10(-6) mol/L) or naloxone (NAL 10(-5) = 10(-8) mol/L) manifested no significant changes of non-stimulated or hCG-stimulated testosterone secretion both in 20 and 60 day-old rats. Similar results were obtained when the cells were treated with B-EP (10(-10) = 10(-7) mol/L) for 48 h during culture. Pretreatment of incubated Leydig cells with B-EP in similar concentrations for 48 h showed no effect on the response to hCG stimulation. In addition, treatment with B-EP in vitro for 24 or 72 h manifested no effects on estradiol production by aromatization of cultured Sertoli cells. Neither NAL 10(-5) given in vitro nor NAL (5 mg/body weight) injected subcutaneously 1 h before decapitation affected LH and testosterone release from the perifused hypothalamo-pituitary Leydig cells system. These results could not support the hypothesis that B-EP is a local regulator of testicular function. The physiological significance of EOP in regulating the function of gonadal axis of adult male rat remains to be investigated further.

Pharmacokinetic and pharmacodynamic studies of levonorgestrel-releasing intrauterine device

Intrauterine devices releasing 20 micrograms/day levonorgestrel were inserted in 10 women (ages 25-34). Bleeding and spotting patterns were recorded on a menstrual card during one year of follow-up. Blood samples were collected for radioimmunoassays of LH, estradiol (E2), progesterone (P) and levonorgestrel (LNG) and for sex hormone binding globulin (SHBG) 3 times a week during the 1st month of use, and twice a week during the 6th and 12th treatment months. Among the 10 women, two experienced irregular cycles with prolonged intermenstrual spotting, four had amenorrhea in the latter part of treatment months, while the other four had regular cycles. According to the serum levels of E2 and P, the hormone profiles were divided into four types of reaction: A) anovulatory, B) anovulatory but with high follicular activity, C) ovulatory but with luteal insufficiency, and D) ovulatory. Among the 29 treatment cycles, there were 10 D-type, 3 C-type, 13 B-type and 3 A-type of ovarian reactions: 44.8% of the cycles were ovulatory (C + D) and 55.2% were anovulatory (A + B). In general, serum levels of levonorgestrel were low in ovulatory cycles and were high in anovulatory cycles. The difference was statistically significant. There were marked individual differences. The decline of serum LNG from the 1st (492 pmol/l) to the 6th (320 pmol/l) treatment months was 34.9% on average. The amenorrheic cycles coincided mostly with the hormonal profile of ovulatory types, which indicated that the cause of amenorrhea is due to the local effect of levonorgestrel on the endometrium. The levonorgestrel levels were significantly correlated with serum SHBG, r = 0.8856, p less than 0.001, and with E2, r = 0.4661, p less than 0.05.

[Changes in histopathology and enzyme histochemistry of thymus in cadmium exposure mice]

The changes in histopathology and enzyme histochemistry of thymus induced by a single intraperitoneal injection of sublethal doses of cadmium chloride into Kunming male mice were examined. The swollen endothelium of capillaries was observed, with an obviously decreased activity of ICDH, LDH and ATPase, which seemed to be due to direct inhibition by cadmium at the 4th hour. The necroses of the cortex thymocytes were found at the 8th hour after injection and reached an extreme at the 16-24th hour, while few necroses of the lymphocytes in the medulla. Beginning 4th to 8th hour after exposure, the activity of enzymes was located in mitochondria of the cortex thymocytes, i.e., SDH, ICDH, CCO and ATPase, was decreased gradually. It suggested that thymic cortex had a marked impairment of blood supply and anoxia. Within 2 days after a single injection the cortex of the gland was mainly populated by epithelial reticular cells except a few lymphocytes. It was noted that there were some bigger cells which were characterized by their large size, basophilic cytoplasma, rough chromatin and high mitotic ability and activity of MDH, LDH, G-6-PD increased in these cells. From above observation the author concluded that the cause of cadmium-induced acute thymic atrophy was lymphocyte necroses within thymic cortex. The mechanism of the cortex thymocytes necrosis was possibly secondary to an anoxia of cortex resulting from capillary damage in the cortex. The ability of thymic regeneration is strong after being damaged. The regenerate cells possessed characteristics of morphology and enzyme histochemistry of immature cells, which probably came from the bone marrow.

[Mucus histochemical study of bilirubin cholangiolithiasis in rabbit model]

Sulfated mucopolysaccharides have an important role in pigment gallstone formation. In this experiment, the animal model of bilirubin cholangiolithiasis was made with Japanese hybrid big-ear white rabbits. The source, nature, quantity and distribution of sulfated mucopolysaccharides in the cause of bilirubin cholangiolithiasis were observed by means of mucous histochemical study. There were three characteristic pathologic changes observed in this experiment: 1. In normal condition, the sulfated mucopolysaccharides were secreted by epithelium of biliary tracts and the quantity was minimum. When bacterial infection was present in the biliary tracts, they were secreted mainly by the proliferative glands in submucosa of the bile duct; 2. In 26 rabbits where the bilirubin cholangiolithiasis developed, there were many proliferative glands in submucosa of the bile duct. Most of the glands produced sulfonated acid mucin. In 5 rabbits where the gallstones did not develop in the stone growing stage, the proliferative glands were not present in the bile duct. It was suggested that there was a close relationship between the proliferative glands and the formation of bilirubin cholangiolithiasis, and 3. The glands in submucosa of the biliary tract provided the refuge where the bacteria could not be cleaned out easily and so it was difficult to control the infection of the biliary tract.

[Lung tumors induction short-term test of chloroprene in mice]

In a previous report by the authors, positive results in both case-control study mouse lung tumor induction short-term test of chloroprene for carcinogenicity was conducted to determine whether chloroprene monomer itself could induce tumor. Kuangming albino mice weaned 2 wk were subjected to inhale 0.0, 2.9 +/- 0.34, 19.18 +/- 1.89, 189.00 +/- 13.26 mg/m3, chloroprene (GC purity 99.69%) 4 h daily (except Sunday) for 7 month. All survivors were killed at the end of the 8th month or when moribund. No lung tumor was found before the 6th month. Thus survivors at the 6th month were counted as effective animals. Most lung tumors observed were papillo-adenoma (50/57), and a few were adenoma (7/57). Tumor incidence of the 2.9 mg/m3 group increased to 8.1% in comparison with that of the control group (1.3%) at a significant level of P less than 0.05; and the higher the concentration the higher the incidence. Examination of the multiplicity of tumors also demonstrated the dose-response relationship, and the number of tumors per mouse in the 189 mg/m3 group was significant at P less than 0.01.

[Changes of hormone levels in follicular fluid in women with normal menstruation]

Levels of estradiol (E2), progesterone (P0), androstenedione (A), testosterone (T), follicle stimulating hormone (FSH), luteinizing hormone (LH) and prolactin (PRL) in ovarian follicles of different sizes and at different phases of normal menstrual cycles were determined and, their relationships with those in peripheral blood were studied. According to the diameters, the follicles were divided into large (greater than 14 mm), median (8-14 mm) and small (less than 8 mm) ones. The results showed that the levels of E2, P0, FSH and LH were lower, whereas those of A and T were higher in small and median follicles, as compared with the large follicles. In the large follicles, particularly at the preovulatory phase, E2, P0, FSH and LH reached maximum levels. The concentration of E2 was 9815 nmol/L, P0, 3316 nmol/L, FSH 1.34 IU/L and LH 3.91 IU/L at the preovulatory phase. The concentrations of A and T were much lower in large follicles, being 280 nmol/L and 137 nmol/L respectively. No significant difference was found in PRL levels in follicles of different sizes. The steroid hormones in the follicular fluid were about 7-20,000 times higher than those in the peripheral blood, while FSH and LH were only about 10-80% and PRL was slightly higher than in peripheral blood.

Pharmacokinetic and pharmacodynamic studies of vaginal rings releasing low-dose levonorgestrel

Pharmacokinetic and pharmacodynamic effects of a vaginal ring releasing 20 micrograms/day levonorgestrel (L-NOG) have been studied in 15 women. Serum levels of L-NOG, estradiol and progesterone were measured three times a week in a control menstrual cycle and a treatment period of 3 months after the insertion of the first vaginal ring. All control cycles were normal ovulatory. Among the 36 treatment cycles 13 were ovulatory (36%), 5 ovulatory with inadequate luteal function (14%), 14 anovulatory but with marked follicle activity (39%) and 4 anovulatory (11%). In the groups with ovulatory reaction the serum levels of L-NOG showed a decline of 54% of the initial level at the end of the treatment period, calculated according to the linear regression equation of Y = 0.903-0.0142X, while in the groups without ovulation the L-NOG levels were higher and the decline was 24% of the initial level (Y = 1.034-0.0086X). There were distinct individual differences in the levels of L-NOG and ovarian reactions. Marked follicle activity with very high estradiol levels were found in correlation with high L-NOG in 7 treatment cycles, particularly in the B type of reaction (B = anovulatory cycle with marked follicle activity). More intermenstrual bleeding and spotting occurred in the second treatment cycles, particularly in those with anovulatory reactions.

The endocrinological profile of normal menstrual cycles in a population of Chinese women

Endocrinological profiles of normal menstrual cycles were studied in 41 Chinese women. Daily serum concentration of luteinizing hormone (LH), follicle stimulating hormone (FSH), prolactin (PRL), estradiol (E2) and progesterone (P) were determined by RIA. Thirty-four cycles were of normal length (26-35 days) and 6 cycles were prolonged up to 40 days with a follicular phase of 22-26 days. One cycle was anovulatory. Cyclical changes of LH, FSH, E2 and P were typical of ovulatory cycles in other populations as reported in the literature. In the normal cycle group the geometric mean of the LH midcycle peak level was 46 IU/1, the FSH peak was 10 IU/1, the preovulatory estradiol peak was 1229 pmol/1 and the progesterone luteal maximum was 50 nmol/1. The pattern of cyclical changes in the prolonged ovulatory cycles was similar to the normal length cycles, except that there were significantly higher levels of LH in both follicular and luteal phases, lower FSH in luteal phase, and lower progesterone in luteal phase. A majority of cycles had a midcycle elevation of prolactin and mean PRL levels in the late luteal phase were higher than those in the follicular phase.