Clinical experience of a combined oral contraceptive with very low dose ethinyl estradiol

BACKGROUND

The risk of thromboembolic events related to the ethinyl estradiol (EE) dose in oral contraceptive (OC) pills has led to a further dose reduction.

METHODS

An OC pill with 150 micrograms desogestrel combined with only 20 micrograms EE was compared with a pill containing the same dose of desogestrel but 30 micrograms of EE in a Scandinavian multicentre study with follow-up visits after 3, 6 and 12 months.

RESULTS

In almost 5,000 cycles with each pill the numbers of pregnancies due to method failure with the lower and higher EE dose pills were 0 and 2, respectively. Irregular bleedings were slightly more common with the lower EE dose, but tended to decrease over the year of study. Other side effects were uncommon. Regarding metabolic effects, both pills tended to raise the plasma HDL level and the lower EE dose pill also reduced LDL. Free testosterone was reduced by two-thirds with both pills, showing beneficial effects on acne.

CONCLUSIONS

It is concluded that both these pills are reliable and safe, but that many women would accept a slightly greater risk of irregular bleeding with the 20 micrograms EE dose pill in exchange for a reduction in potential risk related to the estrogenic component of OC pills.

Multicenter trial of two monophasic oral contraceptives containing 30 mcg ethinylestradiol and either desogestrel or gestodene in Thai women

The efficacy and acceptability of two third generation oral contraceptives in Thai women were evaluated in a prospective, open, group-comparative, randomized, multicenter trial of women asking for contraception. In six Family Planning Centers and Outpatient Gynaecological Clinics in urban areas in Thailand, 783 healthy women who were at risk for pregnancy and did not have contraindications to oral contraceptive use were randomly allocated to one of the two study groups. An oral contraceptive containing 30 mcg ethinylestradiol and 150 mcg desogestrel was given to 394 women and an oral contraceptive with the same amount of ethinylestradiol and 75 mcg gestodene to 389 women during 6 cycles. Criteria of cycle control, side effects and the presence and severity of acne vulgaris were assessed and blood pressure and body weight measured at pretreatment and after cycles 1, 3 and 6. Furthermore, the efficacy was evaluated after the last cycle. No pregnancies occurred with either of the contraceptives. The incidences of irregular bleeding and minor side effects in both groups were very low and decreased after an initial increase in the first cycle. Acne improved in both groups. Blood pressure and body weight remained unchanged. The two oral contraceptives were found to be effective and acceptable in Thai women. Compared to Caucasian women, the incidences of irregular bleeding and side effects were apparently lower in these Asian women. Furthermore, the effects of both oral contraceptives were comparable.

Ultrasound evaluation of ovarian activity under oral contraceptives

The trend towards changing the composition of the contraceptive pill in order to decrease side effects might lead to increased ovarian activity. This may decrease reliability. Therefore, a non-invasive method for monitoring the suppressive effect of the pill on ovarian function is warranted. The aim of the present study was to investigate whether or not diagnostic ultrasound might be the method of choice for studying residual ovarian activity during pill use. In 89 women on a low-dose oral contraceptive (30 mcg ethinyl-estradiol (EE)/75 mcg gestodene), the first two months of pill-intake were monitored extensively with diagnostic ultrasound. The study revealed that only one ultrasound investigation was needed during the first week of pill intake to discover all relevant cases of residual ovarian activity. Follow-up investigations are needed to quantify this activity more specifically.

Comparison of Yuzpe regimen, danazol, and mifepristone (RU486) in oral postcoital contraception

OBJECTIVE

To compare the effectiveness and acceptability of three regimens of postcoital contraception.

DESIGN

Randomised group comparison of ethinyloestradiol 100 micrograms plus levonorgestrel 500 micrograms repeated after 12 hours (Yuzpe method); danazol 600 mg repeated after 12 hours; and mifepristone 600 mg single dose.

SETTING

Community family planning clinic.

SUBJECTS

616 consecutive women with regular cycles aged 16 to 45 years.

MAIN OUTCOME MEASURES

Number of pregnancies, incidence of side effects, and timing of next period.

RESULTS

The raw pregnancy rates (with 95% confidence intervals) for the Yuzpe, danazol, and mifepristone groups were 2.62% (0.86% to 6.00%), 4.66% (2.15% to 8.67%), and 0% (0% to 1.87%) respectively. Overall, these rates differed significantly (chi 2 = 8.988, df = 2; p = 0.011). The differences between the mifepristone and Yuzpe groups and between the mifepristone and danazol groups were also significant. Side effects were more common and more severe in the Yuzpe group (133 women (70%)) than in either the danazol group (58 (30%)) or the mifepristone group (72 (37%)). The Yuzpe regimen tended to induce bleeding early but mifepristone prolonged the cycle. Three women bled more than seven days late in the Yuzpe group compared with 49 in the mifepristone group.

CONCLUSIONS

Mifepristone was effective in reducing expected pregnancy rates and the Yuzpe method also had a clinical effect. Danazol had little or no effect. A further multicentre trial is needed.

Six-month carbohydrate metabolism studies in women using oral contraceptives containing gestodene and ethinyl estradiol

Twenty-five women had their carbohydrate metabolism prospectively evaluated during the six months that they used a gestodene and ethinyl estradiol monophasic oral contraceptive. Serum glucose and insulin levels were measured during a 75-gram three-hour oral glucose tolerance test. At the six-month test, the three-hour glucose and the fasting and three-hour insulin values were significantly elevated. The literature on carbohydrate metabolism during gestodene oral contraceptive use is also reviewed.

[Effect of estrogen on the blast transformation of lymphocytes and interleukin-2 production in lupus erythematosus]

The mitogenic response of peripheral lymphocytes was investigated in 12 patients with systemic lupus erythematosus and in healthy female volunteers who were on 11 and without 9 contraceptive pills. The effect of estrogen (ethinyl-estradiol 10(-5)-10(-6)-10(-7)M) was studied on Phytohaemagglutinin and Pokeweed mitogen induced blastogenic transformation and interleukin-2 production of peripheral lymphocytes in vitro. We observed a significantly depressed Phytohaemagglutinin induced lymphoblastic transformation both in patients and women taking oral contraceptive in presence of 10(-5)M estrogen as compared to normal controls. However there was no significant alteration neither in the response of lymphocyte nor in the production of interleukin-2 using of Pokeweed mitogen. The stimulataneous inhibition of the interleukin-2 production proved to be moderate. Marked significant correlation (r greater than = 0.8) vas detected between lymphoblastic transformation and interleukin-2 production in healthy females. Correlation coefficient measured in females taking oral contraceptive (r less than = 0.64) and patients with systemic lupus erythematosus (r less than = 0.34) suggest that in these groups the inhibition of lymphoblastic transformation is due to the inhibition effect of estrogen on the interleukin-2 production.

Low estrogen oral contraceptives and the hypothalamo-pituitary axis

The hypothalamo-pituitary axis in a group of 10 women (17-25 years of age) taking low-dose-estrogen oral contraceptives (20 micrograms ethinylestradiol (EE) + 150 micrograms desogestrel) for at least 6 months was investigated. The subjects underwent the GnRH (50 micrograms) and TRH (200 micrograms) stimulation tests for the evaluation of LH, FSH, Pr1, TSH and GH secretion. In the basal blood sample, E2, P, free T, A and SHBG levels were also determined. An elevation in LH response to GnRH was found, whereas FSH was inhibited. After TRH administration, the Pr1 response was the same in the oral contraceptive cycle as in the pretreatment cycle. Similar results were observed after TSH. Significantly, GH responded to TRH stimulation in the oral contraceptive cycles, but not in the pretreatment cycles. These results show that the new combination of 20 micrograms EE and desogestrel blocks hypothalamic production of GnRH. The different response to GnRH of LH and FSH reveals a differentiated sensitivity to the oral contraceptive which seems to inhibit the pituitary FSH-secreting gonadotrope cells in particular.

Open prospective multicenter trial with a new monophasic contraceptive combination containing gestodene

In a large and open prospective multicenter trial of 12,250 cycles from 2,378 women, contraceptive efficacy, clinical tolerance and acceptability of a new monophasic contraceptive combination containing 75 mcg gestodene (delta-5-levonorgestrel) and 30 mcg ethinyl oestradiol were studied. The objective was to assess efficacy, safety, side effects and cycle control of this oral contraceptive on healthy women using no other additional birth control methods. Two women became pregnant (0.016%) during the trial; both were patient failures. There was no effect on systolic or diastolic pressures. An average weight increase of 0.3 kg was noted. Cycle control was excellent with 95% of the cycles free of spotting and 98% free of breakthrough bleeding after six cycles. No serious complications occurred. There was an overall incidence of 14% reported side effects (after six cycles), indicating that the hormonal combination is well tolerated. It should be noted that 41.4% of the patients had some complaint before starting the treatment. For all complaints, a highly significant improvement was seen during the treatment.

An open prospective study on the effects on carbohydrate metabolism of an oral monophasic contraceptive containing gestodene (WL-70)

The effects of a monophasic oral contraceptive (gestodene 75mcg + ethinylestradiol 30 mcg) on plasma glucose (PG) and insulin (IRI) responses to an oral glucose load (OGTT) and on glycosylated haemoglobin Alc (HbAlc), fructosamine (Fr), total cortisol (FT) and transcortin (CBG) were studied in 30 healthy women. Blood samples were taken before treatment and after 6 and 12 cycles. After 6 and 12 months, OGTT-PG and IRI levels showed substantially unchanged values; for HbAlc and Fr the same behaviour was seen with the exception of the latter between 6 and 12 months; FT and CBG showed significant rises. All recorded values were in the normal range. The basal and dynamic PG and IRI behaviour failed to show any significant variations between pre-treatment values and those after 6 and 12 months of OC administration. Other data showed a substantial neutrality for this oral contraceptive containing gestodene.

Complexion changes in oral contraceptive users. Results from a phase IV multicenter trial evaluating the safety and efficacy of ethynodiol diacetate, 1 mg, with ethinyl estradiol, 35 micrograms

An open-label, phase IV, multicenter survey of obstetrician-gynecologists was conducted to evaluate the efficacy and safety of a low-dose monophasic oral contraceptive, ethynodiol diacetate, 1 mg, with ethinyl estradiol, 35 micrograms. Surveys from 983 community-based physicians reported on 6,382 women. Most patients did not experience "clinically noticeable complexion changes" (5,695/6,382, or 89.2%). Of the 687 patients with complexion changes, nearly three-fourths reported an improvement (501/687, or 72.9%). A follow-up questionnaire was sent to 127 respondents (18.6%) who reported worsening of the complexion; 70% of the questionnaires were returned. Most complexion worsening was of slight degree (63%), reported by the patient and not the physician (84% vs. 16%), and experienced during the first two to three months (84%). Although the literature includes many references to skin condition "improvement" on oral contraceptives, this report of a descriptive study gives clinicians as estimate of the incidence and severity of complexion changes in actual use.

Efficacy and safety of ethynodiol diacetate, 1 mg, with ethinyl estradiol, 35 micrograms, with an emphasis on contraceptive efficacy. A phase IV trial

A phase IV trial evaluated the efficacy and safety of a monophasic oral contraceptive formulation, ethynodiol diacetate, 1 mg, plus ethinyl estradiol, 35 micrograms (EDA 1 mg with EE 35 micrograms) (Demulen 1/35). Nine hundred eighty-three community-based obstetrician-gynecologists treated a total of 7,759 patients with EDA 1 mg with EE 35 micrograms for one to eight months. Clinical evaluation forms on 6,382 patients were amenable to analysis for safety (including breakthrough bleeding, ovarian cyst formation and complexion changes); 5,412 patients were evaluable for efficacy (prevention of pregnancy), with a total of 21,440 cycles recorded. The study results were interpreted in terms of the impact on clinical management of oral contraceptive users and the methods, strengths and weaknesses of phase IV trials, particularly as they relate to confirmation of the results reported here.

A neutrophilic reaction of Sweet's syndrome type associated with the oral contraceptive

A case is presented of a Sweet's syndrome-like eruption in association with the oral contraceptive. A 46 year old caucasian woman developed recurrent episodes of erythematous tender plaques on her trunk six weeks after commencement of the oral contraceptive (OC). Her condition clinically and histologically resembled Sweet's dermatosis. On cessation of the OC there was complete resolution of her lesions and she remains well 12 months later. This is the first report, to our knowledge, of a neutrophilic reaction to the oral contraceptive, and we believe that drugs may be implicated in the aetiology of atypical neutrophilic reactions simulating Sweet's syndrome in patients who are otherwise well.

Incidence of ovarian cyst formation in women taking ethynodiol diacetate, 1 mg, with ethinyl estradiol, 35 micrograms

A total of 7,759 women were treated with ethynodiol diacetate, 1 mg, with ethinyl estradiol, 35 micrograms (EDA 1 mg with EE 35 micrograms) in a field study involving 983 obstetrician-gynecologists evaluating the incidence of ovarian cyst formation. Six thousand three hundred eighty-two patients were evaluable; 1,377 could not be evaluated because of failure to meet inclusion criteria or inconsistent or incomplete data collection. Cysts were detected in 80 patients at the time of the final visit. Follow-up questionnaires were received on 61% of patients and confirmed the presence of 12 newly formed ovarian cysts in patients taking EDA 1 mg with EE 35 micrograms. Only three women required an operation for ovarian cysts; two women had functional ovarian cysts (one follicular and one luteal), and one had a neoplastic cyst (cystadenoma). Thus, the incidence of ovarian cyst formation requiring surgical intervention was 0.05% in women taking EDA 1 mg with EE 35 micrograms.

A comparative study on the effects of a monophasic pill containing desogestrel plus 20 micrograms ethinylestradiol, a triphasic combination containing levonorgestrel and a monophasic combination containing gestodene on coagulatory factors

The changes in haemostasis during oral contraception are related to the ethinylestradiol dose present in the formulation taken by the patient. An open, randomized longitudinal study was performed to evaluate and compare the effects that low-dose oral contraceptives (OCs) containing different doses of ethinylestradiol exert on the haemostatic system. Eighty-nine healthy women, aged 18-45 years, were randomly assigned to treatment with 3 different OCs: a monophasic pill containing 30 micrograms of ethinylestradiol plus 75 micrograms of gestodene (GSD/30) (30 subjects), a triphasic pill containing levonorgestrel (TRI/LNG) (28 subjects), a monophasic pill containing 20 micrograms ethinylestradiol plus 150 micrograms of desogestrel (DOG/20) (31 subjects). From every woman, blood samples were collected before treatment and at the 3rd and 6th cycle of pill intake. The number of platelets significantly increased (p less than 0.01) during treatment with TRI/LNG. Fibrinogen plasma values were significantly increased (p less than 0.05) only in women treated with the preparation GSD/30. Fibrinopeptide A (FPA) plasma levels significantly increased (p less than 0.01) during treatment with the pills TRI/LNG and GSD/30, but the levels of FPA were unchanged in the group treated with DOG/20. The overall results of this study confirm that the effects of OCs on haemostasis are dependent on the ethinylestradiol dose. Moreover, they suggest that with reduction of the ethinylestradiol component to 20 micrograms, the effects of OCs on haemostasis seem to be virtually eliminated.

Hormonal postcoital contraception with an ethinylestradiol-norgestrel combination and two danazol regimens

The ethinylestradiol-norgestrel combination (EE-NG) for postcoital contraception, as described by Yuzpe, has been shown to be an effective method but with frequent side effects. To overcome the problem of adverse effects a new approach using danazol was proposed, but the efficacy and acceptability of this treatment have not yet been tested in large studies. In a 5-year period at the AIECS Family Planning Centre in Milan we treated 2448 women requesting postcoital contraception using Yuzpe's regimen and two danazol regimens (800 mg/1200 mg). The patients' acceptability for danazol treatment was higher than for Yuzpe's regimen due to fewer, milder and shorter side effects. Nine pregnancies occurred in the EE-NG group (2.21%), 17 in the 800 mg group (1.71%) and 6 in the 1200 mg group (0.82%). Our study shows a statistically significant efficacy against expected pregnancy rates both with Yuzpe's regimen and with danazol. The 1200 mg danazol treatment seems to be more effective and can be considered a valid alternative to the EE-NG combination for hormonal postcoital contraception.

Comparative studies of 30 micrograms ethinyl estradiol combined with gestodene and desogestrel on blood coagulation, fibrinolysis, and platelets

An association between an increase in the incidence of thromboembolic disease and the use of combined oral contraceptives has been shown by several epidemiologic studies. Evidence of the vascular complications of oral contraceptives suggests that venous thromboembolism correlates with estrogen dosage and arterial complications with both estrogen and progestogen components. In 60 healthy, randomly allocated women, the effects of ethinyl estradiol, 30 micrograms, combined with gestodene, 75 micrograms, and desogestrel, 150 micrograms, on blood coagulation, fibrinolysis, and platelet function were compared. Subjects were studied before oral contraceptive use, at 12, 24, 36, and 48 weeks of treatment, and at 6 and 12 weeks after treatment. Both oral contraceptives affected the hemostatic system, but our results indicate that the ethinyl estradiol/gestodene combination causes changes in the hemostatic system similar to those in the ethinyl estradiol/desogestrel combination. Factors VII and X activity were slightly higher with the ethinyl estradiol/desogestrel combination than with the ethinyl estradiol/gestodene combination, possibly reflecting a greater estrogenic effect.

Effects of newer oral contraceptives on the inhibition of coagulation and fibrinolysis in relation to dosage and type of steroid

Oral contraceptives influence plasma proteins, causing changes in plasma procoagulants and fibrinolytic effectors. Estrogen is thought to be responsible for these changes, whereas progestogens, in particular those with an androgenic effect, may influence the magnitude of the changes. This concept is consistent with epidemiologic studies, suggesting a correlation between estrogen dose and cardiovascular episodes in oral contraceptive users. A delayed resolution of fibrin might contribute to an increased risk caused by decreased coagulation inhibition or fibrinolytic efficacy. Estrogen (30 micrograms or more) has a dose-dependent effect on clotting factors, including antithrombin III and proteins C and S. The effect of high- and low-dose oral contraceptives containing various progestogens on the fibrinolytic system is less clear. We have found that low-dose oral contraceptives containing levonorgestrel or lynestrenol enhance fibrinolysis, as revealed by an increase in plasminogen (30% to 40%), a decrease in histidine-rich glycoprotein (15% to 26%), an increase in tissue plasminogen activator activity (greater than 150%), and a decrease in tissue plasminogen activator inhibition (30% to 40%), concomitant with a slight decrease in tissue plasminogen activator antigen level (15% to 20%). New oral contraceptives contain less androgenic progestogens. Preliminary results of an ongoing study of women receiving either 20 micrograms of ethinyl estradiol with 150 micrograms of desogestrel or 30 micrograms of ethinyl estradiol plus 75 micrograms of gestodene revealed no change or changes similar to the older low-dose preparations after 6 months of treatment. Of particular importance was the finding that coagulation activation, expressed by the levels of thrombin-antithrombin III-complexes, fibrin formation, and the efficacy of fibrinolysis, expressed by the levels of fibrin degradation products, was identical in the two groups.

Enhanced generation and resolution of fibrin in women above the age of 30 years using oral contraceptives low in estrogen

Epidemiologic studies have suggested a relationship between the use of oral contraceptives and mortality from cardiovascular diseases in older women. Therefore we studied generation and resolution of fibrin in 28 healthy women above age 30 years, using oral contraceptives containing 30 to 50 micrograms of ethinyl estradiol. Thirty healthy nonusers served as control subjects. The oral contraceptive group had increased plasma concentration of thrombin-antithrombin III complexes (p less than 0.01), which indicated an enhanced generation of thrombin, increased plasma activity of tissue-type plasminogen activator (p less than 0.01), decreased plasma activity of plasminogen activator inhibition (p less than 0.01), and increased plasma concentration of fibrin degradation products (p less than 0.04). Interestingly, the ratio of thrombin-antithrombin III complexes/fibrin degradation products did not deviate significantly between groups. Twelve of the 28 women using oral contraceptives were light smokers, that is, less than 15 cigarettes per day. There were no differences in the determined variables between smokers and nonsmokers. Our study suggests that healthy women older than 30 years who use oral contraceptives containing 30 to 50 micrograms of ethinyl estradiol have an enhanced generation and resolution of fibrin, while the hemostatic balance is unaltered. These findings are unaffected by moderate cigarette smoking.

[Oral contraceptives and blood diseases are the most common causes of Budd-Chiari syndrome]

Two cases of young patients with the chronic form of Budd-Chiari syndrome are reported. The first concerns a 22-year-old woman with a 6-month history of hepatomegaly, who had used oral contraceptives almost continuously during the five years preceding diagnosis. In a thorough diagnostic work-up, thromboses were detected in all but one of the hepatic veins, and a possible non-occluding thrombosis in the retrohepatic portion of the inferior vena cava. In the blood and bone marrow, findings were compatible with polycythaemia rubra vera, and a high anti-cardiolipin antibody titre was found. The second case concerns a 25-year-old male smoker with normal bone marrow, who had thromboses in at least two of the hepatic veins, though the inferior vena cava was not occluded. In both cases a mesocaval shunt was interposed with synthetic grafts, and postoperatively the patients are doing well--at sixteen and five months, respectively. Both are maintained on anticoagulants, and even without diuretics there has been no recurrence of ascites. The woman takes a small dose of hydroxy-urea to control her hypercoagulability. To our knowledge, hers is the first case to be reported of Budd-Chiari syndrome with hypercoagulability due to the concomitant presence of oral contraceptives, polycythaemia rubra vera and anti-phospholipid antibodies.

The effect of triphasic oral contraceptives on plasma lipids and lipoproteins

To determine the effect of triphasic oral contraceptives on plasma lipid transport, 150 nonsmoking women with normolipidemia, ages 18 to 35 years, were randomly assigned to receive one of three contraceptive formulations: (1) ethinyl estradiol, 30, 40, and 30 micrograms/day, each for 6, 5, and 10 days per menstrual cycle, and levonorgestrel, 50, 75, and 125 micrograms/day, each for 6, 5, and 10 days; (2) ethinyl estradiol, 35 micrograms/day for 21 days, and phased norethindrone, 500, 750, and 1000 micrograms/day each for 7 consecutive days; and (3) ethinyl estradiol, 35 micrograms/day for 21 consecutive days, and norethindrone, 500, 1000, and 500 micrograms/day for 7, 9, and 5 days, respectively. A control group consisting of 49 women taking a nonhormonal form of contraception was also included. After 6 months of oral contraceptive treatment, significant increases in plasma triglyceride (28% to 52%) and plasma apolipoprotein B levels (20% to 23%) were observed in each treatment group. The changes in total plasma cholesterol (3% to 10%) and low-density lipoprotein cholesterol values (0% to 11%) were less striking. Changes in total high-density lipoprotein cholesterol levels were statistically insignificant (-2% to -4%); however, high-density lipoprotein2 cholesterol levels decreased by 29% to 33% and high-density lipoprotein3 cholesterol levels increased by 20% to 23%. Concomitantly, plasma apoliporprotein A-1 values increased by 5% to 12%. No consistent significant differences among analyses were observed between and of the groups receiving different oral contraceptives for 6 months.

Haemorheological consequences of oestrogen and progestogen therapy

A clinical investigation was undertaken of the haemorheological effects of short-term administration of synthetic sex hormones. In a randomised controlled investigative trial, groups of 20 women taking ethynyloestradiol, norethisterone, combined norgestrel and ethynyloestradiol or no therapy had their blood viscosity and its major determinants measured before and after 3 months of treatment. Oestrogens and progestogens, singly or in combination, were found to cause a rise in blood viscosity. Oestrogens did so by raising haematocrit and plasma fibrinogen, parameters that are similarly raised in other conditions such as pregnancy and following surgery when venous thromboembolism is common. The synthetic progestogen, on the other hand, raised the blood viscosity by increasing the haematocrit and decreasing erythrocyte deformability, parameters that are similarly altered in occlusive arterial disease. The combined preparation raised blood viscosity by altering all three parameters. These observations indicate the pathways whereby various synthetic oestrogens and progestogens in oral contraceptives or replacement therapy may be associated with different types of cardiovascular pathology.

Evaluation of the clinical performance of three triphasic oral contraceptives: a multicenter, randomized comparative trial

Three hundred thirteen women participated in an open, multicenter comparison of the incidence of intermenstrual bleeding (breakthrough bleeding and or spotting) associated with the use of three triphasic oral contraceptives. Triphasil (n = 107), containing levonorgestrel and ethinyl estradiol, and Ortho-Novum 7/7/7 (n = 97) and Tri-Norinyl (n = 109), both of which contain norethindrone and ethinyl estradiol, were administered over four cycles for a total of 1141 cycles. The total incidence of intermenstrual bleeding was significantly lower with Triphasil (17.2%) than with Ortho-Novum 7/7/7 (39.5%) or Tri-Norinyl (49.0%). The pattern remained the same when findings were analyzed cycle by cycle and for breakthrough bleeding and spotting separately. The incidence of other side effects was comparable for all regimens. Results of this study demonstrate superior cycle control with Triphasil compared with Ortho-Novum 7/7/7 and Tri-Norinyl during the first four cycles of use.

Lipid and lipoprotein changes in women taking low-dose, triphasic oral contraceptives: a controlled, comparative, 12-month clinical trial

Effects on lipid/lipoprotein metabolism of two triphasic oral contraceptives, Triphasil (ethinyl estradiol/levonorgestrel) and Ortho-Novum 7/7/7 (ethinyl estradiol/norethindrone) were compared in a 12-month controlled, prospective clinical trial. The data indicate that use of both estrogen-progestin preparations were accompanied by increases in cholesterol, low-density lipoprotein and high-density lipoprotein3 cholesterol, apolipoproteins A1 and B, and triglycerides. Also observed were a decline in high-density lipoprotein cholesterol and greater decreases in high-density lipoprotein2 cholesterol levels; the latter were below the lower limits of laboratory's reference range. All other changes remained within clinically acceptable limits. There were no statistically significant differences between the test preparations, suggesting that the impact on lipid metabolism of the triphasic preparations Triphasil and Ortho-Novum 7/7/7 are similar and, given the dynamic balance between the various fractions, are unlikely to impart an adverse cardiovascular risk.

Metabolism of the contraceptive steroid desogestrel by the intestinal mucosa

1. The intestinal mucosal metabolism of the progestogen oral contraceptive desogestrel (Dg) has been studied in vitro using the Ussing chamber technique. Histologically normal ileum or colon was obtained from eight patients undergoing various resections. The mucosal sheets were mounted between two perspex chambers. 2. Two hours after addition of [3H]-Dg (0.2 microCi; 100 ng) to the mucosal chamber, more than 90% of the steroid was present in that chamber. In studies with colon, metabolite analysis showed that 55.4 +/- 11.7% (mean +/- s.d.; n = 6) of drug present was Dg, 28.9 +/- 11.4% as unconjugated Phase I metabolites, 13.3 +/- 2.6% as sulphate conjugates and 2.5 +/- 1.5% as glucuronide conjugates. 3. By co-chromatography with authentic metabolites and mass spectrometry, it was shown that 3-keto desogestrel is formed in the mucosa. This is the active metabolite of desogestrel. A large peak of radioactivity did not co-chromatograph with any known metabolites and has been tentatively identified as ring hydroxylated products of 3-keto desogestrel. 4. The effect of the synthetic oestrogen ethinyloestradiol (EE2) on the metabolite profile of Dg was studied. In the presence of increasing concentrations of EE2 (100 ng, 1 and 10 micrograms), there was competition for sulphation such that the sulphate fraction decreased by 32, 49 and 48% respectively. 5. The results of this study indicate substantial first pass metabolism of desogestrel by the gut mucosa with evidence for the formation of the active metabolite. The extent of phase I metabolism is unusual.

Comparative metabolic effects of three types of combined oral contraceptive pills in Chinese women

The results of a prospective longitudinal controlled study comparing some metabolic effects of a low-dose levonorgestrel-ethinyl oestradiol combined oral contraceptive (Microgynon 30), a desogestrel-ethinyl oestradiol-containing pill (Marvelon) and a levonorgestrel-ethinyl oestradiol triphasic preparation (Triquilar) after one year of treatment in ethnic Chinese women are presented. Serum cholesterol levels are similar for the three pills at 6 and 12 months of treatment. Marvelon and Triquilar users showed rises in triglyceride levels while Microgynon 30 users had no change after one year of treatment. Lipoprotein fractions showed favourable changes in Triquilar and Marvelon users with significant rise in HDL fractions at 6 and 12 months; Microgynon 30 users had equivocal changes in HDL fractions. Carbohydrate metabolism as reflected by glucose tolerance showed deterioration with all 3 pills, being least with Microgynon 30 and greatest with Marvelon at 12 months.

Effect of low-dose oral contraceptives on natural killer cell activity

Several reports indicate an association between oral contraceptives and increased infection rates. One mechanism that could explain this increased infection rate is a decrease in immune function. A study comparing T cell subsets showed no differences in numbers between oral contraceptive users and controls. In this study, natural killer cell activity was compared in women before and 3 and 6 months after oral contraceptive use. There was a statistically significant decrease in NK cell activity after three months. There was no further decrease by six months and the differences were no longer significant due to greater variability. No infections were reported during the study period. Thus, the observed reduction in NK activity was either physiologically insignificant or the previously reported increase in infections may be the result of non-immunological factors.

Plasma glucose and insulin levels in women using a levonorgestrel-containing triphasic oral contraceptive for three months

Plasma glucose and insulin levels were measured for three hours after an oral glucose challenge in twenty-nine women before and after using a triphasic oral contraceptive containing ethinyl estradiol and levonorgestrel for three months. There were significant elevations in the glucose levels during the three-month tolerance test, while the insulin levels were unchanged. These data suggest that this OC can alter carbohydrate metabolism and that long-term studies are needed to assess the extent of this metabolic change.

Breast cancer risk in relation to type of estrogen contained in oral contraceptives

We report analyses designed to address the recent hypothesis that women who use combination-type OCs containing ethinylestradiol (EE) are at increased risk of breast cancer before age 45, if use of such OCs occurs prior to first term pregnancy (FTP). Our findings, based on data from 1679 cases and 1689 controls, 20-44 years of age, from the population-based Cancer and Steroid Hormone Study, are against the hypothesis. The relative risk of breast cancer by duration of exclusive use prior to FTP of OCs containing EE is estimated to be 1.0 (1-12 months EE use), 1.2 (13-48 months EE use), and 0.9 (49+ months EE use). There was no evidence of a latent effect. Among parous women with 49+ months exclusive use prior to FTP of EE-containing OCs, the relative risk of breast cancer was estimated as 0.9 (0-4 years after FTP) and 0.6 (5-9 years after FTP). Among nulliparous women with 49+ months exclusive use of EE-containing OCs, the relative risk of breast cancer was estimated as 1.0 (0-4 years since first use), 0.7 (5-9 years since first use), and 1.1 (10-14 years since first use). With regard to exclusive use of OCs containing mestranol, parous women who used such preparations long-term before their FTP showed no alteration of breast cancer risk, even 15 years or more after pregnancy. Nulliparous women with exclusive use of ME-containing OCs did show elevations in breast cancer risk, but the magnitude of risk in relation to duration of use and latent interval shows no pattern that suggests a cause-effect relationship.

Isolated angiitis of the brain in a young female on the contraceptive pill

The case of a 15 year old girl with a rapidly progressing right sided hemiparesis is reported. The history and clinical manifestations were suggestive of either herpes simplex encephalitis or occlusion of the left middle cerebral artery. At necropsy an occlusive thrombosis of the left middle cerebral artery due to a segmental necrotizing granulomatous panarteritis was found. The cause was obscure. A plausible incriminating factor was the contraceptive pill.

Phasic approach to oral contraceptives

Oral contraceptives were initially very high in estrogen and progestogen and had a uniform dosage schedule throughout the entire cycle. These early oral contraceptives were associated with high rates of side effects and complications. As a result, the hormone levels have been gradually reduced to attain the minimal amount necessary for contraception while most of the undesired side effects and complications have been eliminated. Recently, a new approach has been added. This mechanism consists of altering the dose of estrogen or progestogen or both during the month and is referred to as the phasic approach. The newest phasic pills now use a triphasic approach. Three basic formulations of the triphasic pill have been developed. In two of the three formulations, the progestogen level is altered, whereas the estrogen level remains stable; in the third formulation, both estrogen and progestogen are changed. Multiple clinical studies of the triphasics, such as ethinyl estradiol and levonorgestrel, prove that there is a significant reduction in the incidence of side effects and complications related to oral contraception.

New progestogens in oral contraceptives

The aim of using new synthetic progestogens (gestodene and norgestimate) in oral hormonal contraceptives is to find a combination that has a more beneficial effect on metabolism and endometrium than presently available formulations. Our studies with low-dose pills containing 30 micrograms ethinyl estradiol/150 micrograms levonorgestrel or 30 micrograms ethinyl estradiol/150 micrograms desogestrel compared with the new pills with 35 micrograms ethinyl estradiol/250 micrograms norgestimate or 30 micrograms ethinyl estradiol/75 micrograms gestodene revealed no significant alterations of serum glucose after glucose loading. With all four combination pills, insulin levels were slightly elevated when compared with controls. Studies of the lipid metabolism showed that depending on the type and estrogen combination, progestogens have different effects on lipid metabolism. The new progestogens seem to have a more pronounced effect on triglycerides, whereas total cholesterol and high-density lipoprotein cholesterol remain almost unchanged. In general, it could be shown that low-dose oral contraceptives have little impact on lipid metabolism. Studies with low-dose monophasic preparations, including the new formulations, reveal only a low effect on blood coagulation. According to our and other data on the new progestogens in oral contraceptives available so far, it can be expected that such low-dose monophasic and triphasic combination pills will be beneficial during longtime use with respect to side effects on the cardiovascular system and control of the menstrual cycle.

The production of pregnancy associated alpha glycoprotein (PAG) from human peripheral blood mononuclear cells

A sensitive enzyme-linked immuno-assay has been developed which can measure the amounts of pregnancy-associated alpha 2 glycoprotein (PAG) produced by human peripheral blood mononuclear cells (MNC) in culture. Ethinyl oestradiol, indomethacin and pokeweed mitogen (PWM) stimulated PAG production directly while indomethacin produced an additional increase in PAG production by PWM-stimulated MNC probably by inhibiting the production of prostaglandins with down-regulatory effects on the MNC. Oestrogen stimulation of MNC produced significant increases in PAG levels only by the MNC of women on oral contraceptives but not from the cells of males or of females of reproductive age not on oral contraceptives. Since PAG has immunosuppressive properties these observations may be of relevance in understanding the mechanisms involved in the significant decrease in the incidence of rheumatoid arthritis in women taking oral contraceptives.

Clinical and metabolic study of a new pill containing 20 mcg ethinylestradiol plus 0.150 mg desogestrel

The clinical and metabolic effects of a short-term treatment with a combination contraceptive pill containing 0.150 mg desogestrel and 20 mcg ethinylestradiol were evaluated in a group of 17 healthy women. In spite of the low estrogen content, the pill exerted a good cycle control and the incidence of irregular bleedings was low. The minor side effects commonly associated with oral contraceptive (OC) use rarely occurred, and an improvement of premenstrual symptoms was reported during pill intake. As for the different biochemical parameters tested, the formulation induced a significant increase of fibrinopeptide A (FPA) plasma levels. However, the resulting increase of peptide was lower than that induced by pills containing 30 mcg ethinylestradiol. No significant modifications of plasma total cholesterol (T-CH) and low-density lipoprotein cholesterol (LDL-CH) were observed, while triglycerides (TG), high-density lipoprotein cholesterol (HDL-CH) concentrations and the HDL-CH/LDL-CH ratio significantly increased. A significant increase of apolipoproteins AI (Apo AI) and apolipoproteins AII (Apo AII) concentrations was also observed. Moreover, the pill did not alter fasting insulin and glucose levels and their response to an oral glucose tolerance test (OGTT). It may be concluded that this new formulation can be considered acceptable for clinical use, mainly in consideration of the minor or no changes in the biochemical parameters regarded as risk factors for venous and arterial diseases.

The triphasics: insights for effective clinical use

Three triphasic oral contraceptive preparations are currently being widely used in the United States. These are Ortho-Novum 7/7/7 (Ortho Pharmaceutical), Tri-Norinyl (Syntex) and Triphasil (Wyeth). The hormone manipulation in these formulations more closely mimics the normal menstrual cycle and decreases the total amount of hormone delivered. These drugs were formulated to decrease menstrual irregularities and nuisance side effects and increase menstrual control, while maintaining efficacy and safety. This article describes these products, their mechanisms of action, efficacy and selected areas of concern for clinical practice in relation to side effects, safety and menstrual control. Findings and suggestions related to the therapeutic administration, patient use, counseling and management of these newer oral contraceptives will assist the nurse practitioner in providing optimum care to the consumer.

Evaluation of a new triphasic oral contraceptive in private practice

We evaluated the clinical and metabolic effects of a new triphasic regimen developed in the continuing attempt to reduce the dose of estrogen and progestogen in oral contraceptives. A combination of ethinyl estradiol (EE) and levonorgestrel (LNg) was used (six tablets with 30 micrograms EE + 50 micrograms LNg, five tablets with 40 micrograms EE + 75 micrograms LNg, and 10 tablets with 30 micrograms EE + 125 micrograms LNg), also known as Triphasil (Wyeth). In a private practice, 409 subjects participated in 7,286 treatment cycles. Three pregnancies occurred, all due to subject failure. Menstrual regulation was excellent and the incidence of side effects extremely low. Withdrawals from the study for possibly drug-related medical reasons totaled 9.0% through 56 cycles of treatment. Metabolic changes also were evaluated in 14 of these women over a 6-month period. The only statistically significant increase in carbohydrate values occurred at 6 months. The mean glucose level at 30 minutes of the oral glucose tolerance test was above the baseline mean value, but serum insulin levels showed no statistically significant deviation. Lipid values presented are total lipids, total cholesterol, triglycerides, alpha-, beta-, and pre-beta-lipoproteins, and high density and low density lipoprotein cholesterol. There was no statistically significant difference between the mean values at baseline and those during treatment for any lipid variable. These results indicate that this triphasic oral contraceptive has a high degree of efficacy, a low incidence of side effects, excellent cycle control, and high subject compliance, and would seem to indicate a minimal influence on the metabolism of lipids and carbohydrates in the small number of subjects studied.

[Danazol: a new hormonal post-coital contraceptive method]

During a 9-month period, 84 female patients received post-coital contraception consisting either of an association of ethinyl estradiol/norgestrel or of danazol, in order to compare the safety and any adverse reaction of these 2 treatments. Overall, the patients treated with danazol presented 1/3 as many side effects. Nausea was reduced to 1/3 in frequency and vomiting to 1/9 in this group. 5 pregnancies were confirmed in the ethinyl estradiol/norgesterol group and 2 in the danazol group. Although more cases are needed, it would appear that danazol is characterized by greater efficacy and patient acceptability.

A comparison of high-dose estrogens versus low-dose ethinylestradiol and norgestrel combination in postcoital interception: a study in 493 women

Ethinylestradiol (EE), at a dosage of 5 mg/day for 5 consecutive days (5 mg EE), has generally been used for interception. A combination of 200 micrograms EE and 2 mg dl-norgestrel (EE + NG) was proposed as an effective alternative. Efficacy and tolerance of these methods were compared in a randomized, double-blind study. A group of 465 women was studied with a follow-up rate of 94.3%. In the 5 mg EE group a pregnancy rate of 0.9% was observed, and in the EE + NG group a rate of 0.4% was found. These rates differ significantly from the expected rates (P less than 0.0005, in both series). Nausea was noted in 59.1% of the 5 mg EE group and in 54.0% of the EE + NG series. Nausea and vomiting occurred in 20.8% and 15.8%, respectively. The efficacy of both methods as alternative morning-after medication was confirmed. The new method is preferable because treatment is limited to only 1 day.

Pharmacodynamic studies on desogestrel administered alone and in combination with ethinylestradiol

Most progestogens in oral contraceptives are testosterone derivatives and have androgenic side effects such as weight increase, acne and hirsutism. They pose a problem to many women just like the clinical picture of the polycystic ovary syndrome (PCO) with obesity, hirsutism, acne and amenorrhea. The aim of this study was to evaluate androgenicity of the most used progestogens with special reference to desogestrel which is a new progestogen. Radioimmunoassay was used for hormone determination while serum proteins were determined with electroimmunoassay or in some studies for sex hormone binding globulin (SHBG) with capacity assays. Serum lipids and lipoproteins were determined in serum and after ultracentrifugation in HDL, LDL and VLDL fractions. In a comparative study on levonorgestrel/ethinylestradiol (EE) (n = 10) versus desogestrel/ethinylestradiol (n = 10) the latter combination gave increases in SHBG capacity while the former did not. Similar increases in estrogen-sensitive proteins cortisol binding globulin (CBG) and ceruloplasmin indicated that the estrogenicity and "antiestrogenicity" was the same for the two combinations whereas the androgenicity of levonorgestrel was greater giving a reduction in the EE-induced increase in SHBG (SHBG is increased by estrogens and suppressed by androgens). When giving desogestrel 0.125-0.500 mg and lynestrenol 5 mg alone in daily doses to a group of regularly menstruating women (n = 8) strong suppression of SHBG was achieved while ceruloplasmin, CBG and thyroxine binding globulin (TBG) did not change. TBG is decreased and prealbumin increased by androgenic/anabolic activity but only a moderate increase in prealbumin was found during lynestrenol treatment. The changes in SHBG are probably the result of a dose-dependent receptor interaction related to 17 alpha-alkylation in 19-norsteroids. Twenty women with PCO were treated for 8 months with 0.150 mg desogestrel/0.030 mg EE. Evaluation was done before treatment and after 3 and 8 "pill" cycles regarding androgens, estradiol, SHBG, hirsutism and body weight. Spontaneous menstrual cycles were assessed after treatment. Serum lipids and lipoproteins were studied before treatment and at the end of the third "cycle". In PCO the suppression of increased total and free testosterone levels (in comparison to 22 healthy women) was evident during treatment, concordant with increases in SHBG capacity. Hirsutism was suppressed and body weight was reduced in obese women.(ABSTRACT TRUNCATED AT 400 WORDS)

The effects of cyproterone acetate and ethinyl oestradiol on carbohydrate metabolism

Carbohydrate metabolism was studied in a group of 66 women, taking cyproterone acetate (CA) and ethinyloestradiol (EO) as anti-androgen therapy for the treatment of hirsutism and/or acne. A reverse sequential treatment cycle was used and women were studied in two groups: the first when taking the combination of CA and EO during the first 12 days of the treatment cycle, and the second taking EO alone during days 13 to 22. The combination reduced fasting plasma glucose and raised fasting plasma insulin concentrations. There was deterioration of glucose tolerance with increased plasma insulin concentrations and these effects were progressive with time. The plasma insulin response to intravenous tolbutamide was increased by 50% but there was no accompanying change in the glucose nadir as compared with controls. These results show that the combination of CA and EO causes insulin resistance. Plasma C-peptide concentrations following oral glucose were unchanged compared with controls. This shows that the observed hyperinsulinaemia was due to a reduction of hepatic uptake of insulin rather than its increased secretion. We propose that these effects are due to a CA-induced elevation of fasting plasma insulin resulting in downregulation of hepatic insulin receptors with subsequent induction of insulin resistance and impairment of hepatic insulin uptake. C-peptide concentrations following i.v. tolbutamide were significantly higher on treatment with CA and EO than in controls indicating increased pancreatic secretion of insulin. Tests carried out while patients were taking EO alone showed impairment of glucose tolerance only with no change in insulin levels. There was an increase in plasma insulin in response to tolbutamide but this was not significant. We conclude that these results are explained by a reduced but persisting effect of CA.

Further investigations on the cytological effects of some contraceptives

Anovlar induces a mitodepressive effect, producing abnormal prophases and a considerable number of micronuclei, i.e. Anovlar can produce major cytological abnormalities. On the other hand, Lyndiol induces minor abnormalities leaving the process of mitosis to proceed almost normally. Microgynon 30 did not show any effect on any of the mitotic stages. Our conclusion may offer an explanation for the contradictory results found in the literature upon the cytological effect of oral contraceptives, although the major chemical constitution of all contraceptives used is the same, still there are minor differences in their chemical structure. These minor differences in chemical structure may be the deciding cause whether or not a contraceptive is harmful.