The impact of sex and contraceptive therapy on the plasma and intracellular pharmacokinetics of zidovudine

OBJECTIVES

Zidovudine remains part of combination antiretroviral therapy. Pharmacological studies rely on quantitation of active triphosphates in peripheral blood mononuclear cells. This study evaluated the impact of female sex and contraceptive therapy on zidovudine plasma and intracellular pharmacokinetics and the impact of contraceptive therapy on HIV viral load.

METHODS

Serial plasma and intracellular zidovudine pharmacokinetics following oral and intravenous dosing were determined in 18 men and 20 women treated with zidovudine. Women could repeat pharmacokinetics assessment following 2 months oral or injectable contraceptive therapy. Zidovudine plasma and intracellular mono-, di- and triphosphate concentrations were determined by liquid chromatography tandem mass spectrometry. Plasma and cervical viral loads were determined preceding and following 2 months of contraceptive therapy in women.

RESULTS

Men exhibited higher area under the concentration versus time curve for intracellular zidovudine and zidovudine-monophosphate following oral and intravenous dosing and higher zidovudine triphosphate following oral dosing. There was no difference between men and women in plasma zidovudine parameters. Furthermore, contraceptive therapy had no effect on zidovudine plasma or intracellular pharmacokinetics or on plasma or cervical HIV-1 RNA levels.

CONCLUSIONS

Using an optimized pharmacokinetic design, this study indicated men exhibit significantly higher zidovudine-monophosphate and zidovudine-triphosphate exposure following zidovudine oral administration, having implications for drug toxicity and overall tolerance of zidovudine therapy. The lack of an effect of contraceptive therapy on zidovudine pharmacokinetics is surprising in light of previous pharmacokinetic studies for drugs eliminated primarily through glucuronidation. Contraceptive therapy had no effect on plasma or cervical viral load, results consistent with previous findings.

Comparative study of the effects of two once-a-month injectable contraceptives (Cyclofem® and Mesigyna®) and one oral contraceptive (Ortho-Novum 1/35®) on coagulation and fibrinolysis

A randomized controlled multicenter study was undertaken to monitor the effects on hemostasis of two once-a-month injectable contraceptive preparations, Mesigyna (50 mg norethisterone enanthate and 5 mg estradiol valerate) and Cyclofem (25 mg medroxyprogesterone acetate and 5 mg estradiol cypionate) in comparison with a well-known oral contraceptive (OC) Ortho-Novum 1/35 (norethisterone 1 mg and ethinyl estradiol 35 microg). A total of 378 volunteers from four centers (Bangkok, Hangzhou, Santiago and Singapore) were monitored. Blood sampling took place in one pretreatment cycle, the third and ninth injection intervals and one posttreatment cycle. In each of the three treatment groups, a rise in hemoglobin, and increases in platelet count and in prothrombin time were observed. With treatment there was a significant increase in activated partial thromboplastin time among Mesigyna users, no change among Cyclofem users and a significant decrease among OC users. OC use led to increases in plasma levels of fibrinogen, factor VII, factor X, plasminogen, protein C and decreases in plasma levels of t-PAI and antithrombin. Use of combined injectables induced no change (Cyclofem) or decreases (Mesigyna) in plasma levels of fibrinogen, factor VII, factor X and antithrombin. Use of both combined injectables led to decreases in protein C, slight decreases in plasminogen and increases in plasminogen and fibrinogen. Overall, the injectable preparations may be more beneficial than the oral preparation in not enhancing a hypercoagulable state because of the reduced synthesis of fibrinogen, factors VII and X; however, decreases in antithrombin and protein C, which are potent coagulation inhibitors, may raise some concern. Whether these changes can lead to modifications in the risk of arterial or venous disease can only be ascertained by conducting epidemiological studies.

A rare case of lumbosacral meningioma: nondural attachment and possible enlargement by orally administered sex steroid

STUDY DESIGN

A case report is presented.

OBJECTIVES

To present a very rare case of orally ingested sex hormone pills inducing nondurally attached meningioma in the lumbosacral region.

SUMMARY OF BACKGROUND DATA

Meningiomas are known to enlarge in response to female sex hormones. At this writing, few cases of nondurally based intradural meningioma have been reported. Moreover, meningiomas in the lumbosacral region are very rare. Spinal meningiomas predominantly arise in the fourth to sixth decades of life and are more common in women.

METHODS

The patient was a 20-year-old woman. She had undergone oral sex steroid therapy for long-term oligomenorrhea. The patient complained of intolerable lumbago and numbness in her buttocks. Nonopioid analgesics did not relieve her pain, and she was unable to walk without the aid of a walker. Radiography disclosed a lumbosacral intradural tumor.

RESULTS

Complete removal of the tumor was performed. The tumor was not adherent to the dura, and its appearance was that of a typical neurilemmoma. However, the pathologic diagnosis was meningioma.

CONCLUSIONS

The tumor in the reported case may have enlarged in response to orally ingested sex steroid pills. Nondural attachment intradural meningiomas are quite uncommon. The gross appearance of the tumor during surgery was typical of neurilemmoma. All the cases reported so far, including the current case, have involved tumor located in the lumbosacral region. Care must be taken in the management of lumbosacral intradural tumors because tumors resembling neurilemmoma may in fact represent meningioma, some subtypes of which possess a high rate of recurrence.

Bleeding patterns of women using Lunelle monthly contraceptive injections (medroxyprogesterone acetate and estradiol cypionate injectable suspension) compared with those of women using Ortho-Novum 7/7/7 (norethindrone/ethinyl estradiol triphasic) or other oral contraceptives

Persistent and/or unpredictable bleeding is a common reason for discontinuation of hormonal contraceptive methods. An open-label, nonrandomized, parallel, controlled study compared the efficacy, safety, and cycle control of the new, highly efficacious monthly injectable contraceptive containing 25 mg medroxyprogesterone acetate (MPA) and 5 mg estradiol cypionate (E(2)C) (MPA/E(2)C) (Lunelle Monthly Contraceptive Injection) with that of the frequently used norethindrone 0.5, 0.75, 1.0 mg/0.035 mg ethinyl estradiol (NET/EE) triphasic oral contraceptive (Ortho-Novum 7/7/7). This report directly compares the bleeding patterns of women on MPA/E(2)C to those of women on NET/EE and untreated women. Overall, breakthrough bleeding occurred less frequently in women using MPA/E(2)C than in women using NET/EE (p < or =0.01). However, more women using MPA/E(2)C experienced amenorrhea/missed periods than those on NET/EE (p < or =0.01). In addition, the percentage of women experiencing breakthrough bleeding or amenorrhea while using other oral contraceptives is compared to that of women using MPA/E(2)C. A rapidly reversible method, MPA/E(2)C, combines the high contraceptive efficacy of surgical sterilization with the convenience of monthly administration. These data suggest that, for a large proportion of women, MPA/E(2)C offers predictability in bleeding patterns comparable to or greater than that experienced by ovulatory untreated women or those using combination oral contraceptives.

Histological changes induced by tibolone and estrogen/glucocorticoid on aging skin

OBJECTIVE

The aim of this study was to investigate the oral effects of tibolone and mestranol plus paramethasone on the skin of postmenopausal women. A second purpose was to determine endometrial thickness with transvaginal ultrasound.

MATERIALS AND METHODS

This randomized study was carried out in 39 healthy postmenopausal women. Skin biopsies were obtained from the thigh area by a single punch, before and after treatment, and the sections were evaluated. Current characteristics of both groups were measured at follow-up.

RESULTS

No gross differences were observed in size, distribution or imaging of collagen, elastic or reticular fibers. Statistically significant changes were found in the papillar dermis thickness. There were no statistically significant differences in the sonographic measurements.

CONCLUSION

The estrogen/glucocorticoid combination provides a way to evaluate in parallel the cellular metabolism effects on the irreversible aging process. The current results encourage widening these observations of the possible advantage of this combination, in order to alleviate the cellular degenerative process.

Comparative effects of Lunelle monthly contraceptive injection (medroxyprogesterone acetate and estradiol cypionate injectable suspension) and ortho-Novum 7/7/7 oral contraceptive (norethindrone/ethinyl estradiol triphasic) on lipid profiles. Investigators from the Lunelle Study Group

As part of a 60-week, open-label, nonrandomized, parallel, controlled study comparing a monthly contraceptive injection containing medroxyprogesterone acetate (MPA) 25 mg and estradiol cypionate (E(2)C) 5 mg (Lunelle Monthly Contraceptive Injection) and a norethindrone 0.5, 0.75, 1.0 mg/0.035 mg ethinyl estradiol (NET/EE) triphasic oral contraceptive (Ortho-Novum(R) 7/7/7), a longitudinal examination of lipid profiles was conducted. Lipid parameters were assessed at screening and at weeks 20, 40, and 60 (or the final visit) in 114 women using MPA/E(2)C and 93 using NET/EE (lipid analysis population). Extra blood samples were obtained at weeks 21, 22, and 23 in 61 MPA/E(2)C users and 51 NET/EE users (index-cycle analysis population) to investigate lipid changes during one cycle of use. In the index-cycle population, median changes from screening to week 60 showed a decrease in apolipoprotein (apo) A-I and apo A-II in both groups. MPA/E(2)C users had a decrease in total cholesterol (C), total triglycerides, low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C), with maintenance of the total C/HDL-C ratio. NET/EE users showed an increase in total C and LDL-C, with no change in HDL-C or the total C/HDL-C ratio. Within the index cycle (weeks 20 to 23), median changes in lipid values in both MPA/E(2)C and NET/EE users were generally greatest during the first week after the injection or the start of the pill pack. The results of this first longitudinal examination of serum lipids in US women using MPA/E(2)C confirm earlier findings in women in other countries. However, a direct comparison of the effects of MPA/E(2)C and NET/EE on lipid profiles was not possible in this study because of its design and because of the baseline and pharmacokinetic/pharmacodynamic differences between the two contraceptive groups. The results of this analysis showed that, although overall lipid values decreased, including a significant decrease in HDL cholesterol, the maintenance of the total-C/HDL-C ratio suggests that the effect of MPA/E(2)C on lipid parameters may not negatively affect CVD risk over 1 year of use. However, these results warrant further investigation, given the nature of this trial.

Altered reflex control of cutaneous circulation by female sex steroids is independent of prostaglandins

We tested the hypothesis that the shift in the cutaneous vasodilator response to hyperthermia seen with elevated female reproductive hormones is a prostaglandin-dependent resetting of thermoregulation to higher internal temperatures, similar to that seen in the febrile response to bacterial infection. Using water-perfused suits to control body temperature, we conducted heat stress experiments in resting women under conditions of low and high progesterone and estrogen and repeated these experiments after an acute dose of ibuprofen (800 mg). In six women the hormones were exogenous (oral contraceptives); three women had regular menstrual cycles and were tested in the early follicular and midluteal phases. Resting oral temperature (Tor) was significantly elevated with high hormone status (P < 0.05); this was not affected by ibuprofen treatment (P > 0.2). The Tor threshold for cutaneous vasodilation was significantly increased by high hormone status (+0.27 +/- 0.07 degrees C, P < 0. 02); the shift was not affected by ibuprofen treatment (with ibuprofen: +0.29 +/- 0.08 degrees C, P > 0.2 vs. control experiments). The Tor threshold for sweating was similarly increased by high hormone status (+0.22 +/- 0.05 degrees C, P < 0.05); this shift was not influenced by ibuprofen (with ibuprofen: +0.35 +/- 0. 05, P > 0.1 vs. control experiments). Thus the shift in thermoregulatory control of skin blood flow and sweating mediated by female reproductive steroids is not sensitive to ibuprofen; it therefore appears that this shift is independent of prostaglandins.

Medical therapy for chronic gastrointestinal bleeding of obscure origin

OBJECTIVE

The aim of this study was to evaluate the effectiveness and safety of combined hormonal therapy in patients with recurring occult gastrointestinal bleeding of obscure origin.

METHODS

This was a prospective longitudinal observational study. The setting was an outpatient private practice affiliated with a large university-based hospital. A total of 43 patients, comprising 14 men and 29 women with a mean age of 74 yr (range 48-86 yr), were included. They had a history of recurrent gastrointestinal bleeding of unknown origin for a period of > 1 yr and had required multiple hospitalizations and transfusions. Patients were initially treated with one Enovid 5-mg tablet containing 5 mg norethynodrel and 75 microg of mestranol. Enovid became commercially unavailable and treatment was changed to Ortho-Novum 1/50, containing 1 mg norethindrone and 0.05 milligrams of mestranol, given one tablet b.i.d. Patients were treated and followed for a mean time of 535 days (range 25-1551 days). All patients acted as their own controls and were followed for compliant behavior with periodic hematocrit, serial stool hemoccults, medication counts, and clinical histories regarding transfusion requirements or hospitalization for bleeding or anemia.

RESULTS

Of 43 patients who initially entered the study, 38 were treated with combination hormonal therapy. The remaining five patients were treated with estrogen alone. In 25 patients, initial enteroscopy revealed AVMs in the stomach or proximal small bowel and these were cauterized. In the remaining 18 patients no source of bleeding was found. None of the 38 patients who were treated with combination hormonal therapy rebled as long as they continued their prescribed dosage. All five of the patients treated with estrogen alone had rebleeding episodes. There was no statistical difference with respect to AVM cauterization in the rebleeding rate between those patients who underwent cauterization of their AVMs and those who did not. Side effects of combination hormonal therapy occurred in 11 patients and all were considered to be mild. Seven of these 11 patients (64%) elected to continue treatment.

CONCLUSION

In this long-term observational study, combination hormonal therapy was shown to stop rebleeding in patients with occult gastrointestinal bleeding of obscure origin.

Effect of chronic administration of mestranol, tamoxifen, and toremifene on hepatic ploidy in rats

The nonsteroidal antiestrogen tamoxifen increases the incidence of rat liver cancer through a variety of mechanisms. To compare the effects of tamoxifen (TAM) and a structurally similar analog toremifene (TOR) on rat liver, we determined the ploidy distribution for hepatocytes isolated from rats treated for 18 months with these antiestrogens or the estrogenic compound mestranol (MS). Female Sprague-Dawley rats were subjected to a 70% partial hepatectomy and administered the solvent, trioctanoin, or diethylnitrosamine (10 mg DEN/kg). After a 2-week recovery from the surgery, the rats were administered a basal diet or one containing TAM (250 or 500 ppm), TOR (250, 500, or 750 ppm), or MS (0.2 ppm) for 18 months. Pathologic changes in the liver were examined in the 15-22 rats per treatment group at the 18-month time point. An increased incidence of hepatocellular carcinomas (HCC) was detected in the 500 ppm TAM group, but not with the other treatments that did not include DEN. Both TOR and TAM promoted formation of DEN-initiated HCCs. At sacrifice, four to five rats per group were perfused and the hepatocytes isolated and cultured. Karyotypic analysis was performed on colcemid-blocked cells after 2 days in culture. The hepatic ploidy distribution was characterized in Giemsa-stained metaphase spreads. These studies indicated that chronic treatment with TAM alone resulted in a shift from tetraploid to diploid, as was also observed for rats treated once with DEN. TOR and MS alone did not cause this change in hepatic ploidy at the doses examined. A shift toward an increased content of diploid hepatocytes occurred in all rats treated once with DEN followed by TAM, TOR, or MS. These results indicate that tamoxifen administration results in a shift toward growth of diploid hepatocytes, thus contributing to its carcinogenic action in the rat liver.

The effects of progesterone and progestins on endometrial proliferation

A total of 99 premenopausal and 27 postmenopausal women were evaluated to determine the quantity of glandular proliferation resulting from progestin inhibition of estrogen-primed subjects and of subjects without hormonal stimulation. Endometrial glandular proliferation rates were determined by using mitosis counts, proliferating-cell nuclear antigen (PCNA), and nuclear cyclin (MIB1) immunocytological staining. The endometria of normally cycling premenopausal women, of women who received a synthetic progestin, and of untreated postmenopausal women were studied. In untreated normally cycling premenopausal women, the proliferation of the glandular epithelium was increased during the follicular phase and decreased during the luteal phase. Premenopausal women receiving a synthetic progestin and untreated postmenopausal women who were not estrogen-primed showed minimal epithelial proliferation. Endometrial glandular proliferation is inhibited by endogenous progesterone in premenopausal women. Endometrial proliferation is markedly reduced in premenopausal women receiving a synthetic progestin and in untreated postmenopausal women.

Clinical profiling of recombinant follicle stimulating hormone (rFSH; Puregon): relationship between serum FSH and efficacy

Single-dose and multiple-rising dose studies of recombinant follicle stimulating hormone (rFSH) in hypogonadotrophic male and female volunteers demonstrated that the rate of FSH absorption after i.m. injection is higher in men than in women. In the absence of endogenous FSH, a correlation between serum FSH and body weight became apparent. The elimination half-life of rFSH was not different between the sexes and was comparable with urinary FSH. However, the in-vitro bio:immuno ratio of serum FSH was significantly higher after the administration of rFSH than after urinary FSH. When rFSH was administered daily with a fixed dose, steady state levels were reached within 3-5 days. Serum FSH concentrations increased in a dose-dependent manner when the daily dose was increased weekly over 3 weeks from 75 to 225 IU. In hypogonadotrophic women, rFSH induced normal follicular growth whereas oestrogen synthesis was impaired. In women pituitary suppressed by a high-dose oral contraceptive, the daily administration of 150 IU rFSH for 1 week induced more and larger antral follicles than the same regimen with urinary FSH, whereas the serum immunoactive FSH concentrations measured 24 h after each dosing were similar. It is concluded that even though equal or lower serum immunoactive FSH concentrations were obtained following the administration of rFSH compared with urinary FSH, circulating bioactive FSH concentrations were higher. Therefore, the conventional idea that serum immunoreactive FSH correlates positively with the magnitude of the ovarian response should be reconsidered.

A bioequivalence study of two urinary follicle stimulating hormone preparations: Follegon and Metrodin

The purpose of this study was to demonstrate bioequivalence between two follicle stimulating hormone (FSH)-only gonadotrophin preparations (Follegon(R) and Metrodin(R)) after a single i.m. injection of IU FSH in-vivo bioactivity. A total of 16 healthy normally cycling females were treated for 7 weeks with a high-dose oral contraceptive containing 50 microg ethinyl oestradiol plus 2.5 mg lynestrenol (Lyndiol(R)) to suppress endogenous gonadotrophin production. After 3 and 5 weeks or oral contraceptive treatment, each subject received 300 IU Follegon or Metrodin in a random order. Frequent blood sampling was performed to measure immunoreactive FSH for pharmacokinetic analysis. After normalization for the immunodose administered, Follegon and Metrodin were bioequivalent with respect to the extent and the rate of absorption, the elimination half-life and plasma clearance per kg. The time taken to reach peak plasma FSH concentrations was shorter with Follegon than with Metrodin. Because bioequivalence was proved for the major pharmacokinetic variables, it can be assumed that Follegon and Metrodin are also equally effective inovulation induction, in-vitro fertilization and embryo transfer programmes and the treatment of male infertility.

[Estrogen and progestagen treatment in digestive hemorrhage caused by vascular malformations]

The efficacy of an association of estrogens and progestagens in the treatment of gastrointestinal bleeding by angiodysplasia was analyzed. Thirty-three patients with gastrointestinal bleeding due to vascular malformations were admitted from January 1986 to December 1993. Fifteen of the 33 patients were submitted to surgical or endoscopic treatment. The remaining 18 patients underwent daily oral treatment with a combination of estrogens-progestagens containing 2.5 mg of lynestrenol and 0.075 mg of mestranol. One patient presented a venous thrombosis leading to suppression of treatment at one month of initiation. The 17 remaining patients were treated for a mean of 22 +/- 4 months (range: 3-60). During treatment 13 of the 17 patients (76%) did not present evidence of hemorrhage. Likewise, the number of hemorrhagic episodes per year decreased from 4.4 +/- 1.2 prior to treatment to 0.7 +/- 0.5 during treatment (p < 0.05) with transfusional requirements decreasing from 7.9 +/- 2.8 erythrocyte concentrates per year prior to treatment to 1.2 +/- 1.0 during treatment (p < 0.05). In conclusion, the combined treatment with estrogens and progestagens prevents recurrence of gastrointestinal bleeding by angiodysplasia.

[Estrogens. Replacement therapy. Mestranol 80 ug (1962) versus mestranol 20 ug (1994) in postmenopausal women. Clinical, local, and metabolic effects]

A group of 37 postmenopausal women ingested mestranol (MEE) 20 ug daily per 90 days. Cervical mucus, vaginal citology, endometrial biopsy, 17 beta estradiol (E-2) low density lipoprotein-cholesterol (LDL-C) and high density lipoprotein-cholesterol (HDL-C), were determined in all of them before (phase I) and after such treatment (phase II). Besides, the relieve of vasomotor symptoms, fernlike cristallization and pyknotic nuclei cells, increase and 3/4 of the endometrial samples showed proliferation, in phase II. Endogenous circulating E-2 was not disturbed regardless MEE treatment and inverse relationship was attained on circulating lipoproteins, while LDL-C decrease (p = 0.01), HDL-C increase (p = 0.001), after comparing phase I vs. phase II. Chlormadinone acetate (2 mg/day/3 days) was administered at the end of the MEE treatment to avoid endometrial estrogenic persistence. Current studies should be enlarged to support the usage of new dose and regimen of mestranol replacement therapy.

Are low-dose oral contraceptives safer and better?

It is widely believed that the use of low-dose oral contraceptives decreases thrombotic risks, compared with higher-dose oral contraceptives. Two recent epidemiologic studies infer a lower risk with 30 to 35 mcg than with 50 mcg estrogen oral contraceptives. However, as with prior studies from which similar conclusions were drawn, these studies have major flaws, the worst being that all 50 mcg oral contraceptives are lumped together, whereas 50 mcg mestranol oral contraceptives are actually bioequivalent to 35 mcg ethinyl estradiol oral contraceptives, thus confounding all such studies. Moreover, while rare thrombotic events have received inordinate attention, the major protective effect against endometrial and ovarian cancer that has been shown in older studies among users of oral contraceptives containing > or = 50 mcg ethinyl estradiol or > or = 80 mcg mestranol are almost totally ignored. The theoretical benefits of using lower-dose oral contraceptives have not been demonstrated, whereas the protection against these types of reproductive cancer have been shown repeatedly with high-dose oral contraceptives but not, to date, with lower-dose oral contraceptives. Such protection may be diminished by lowering the oral contraceptive dosage. Should every woman of reproductive age use high-dose oral contraceptives for 2 years? Are we throwing out the baby with the bath water?

Modulatory influence of oral contraceptive pills Ovral and Noracycline on 3-methylcholanthrene-induced carcinogenesis in the uterine cervix of mouse

The present study reports the modulatory influences of combined oral contraceptive formulations, Ovral (0.05 mg ethinylestradiol plus 0.5 mg norgestrel per pill) and Noracycline (0.05 mg ethinylestradiol plus 0.1 mg lynestrenol per pill), on methylcholanthrene (MCA)-induced carcinogenesis in the uterine cervix of Swiss albino mouse. Placement of cotton thread impregnated with beeswax containing approximately 300 micrograms of MCA yielded cervical tumors in 0.0%, 8.6% and 26% animals, respectively, in 30, 60 and 90 days. Concomitant treatments with doses D1 (1/2000th of a pill), D2 (1/200th of a pill) and D3 (1/20th of a pill) of Ovral yielded cervical tumors in 0.0%, 0.0% and 4.5% mice at 30 days, 0.0%, 6.2% and 10% mice at 60 days and in 3.3% (P less than 0.05), 3.4% (P less than 0.05) and 47% mice at 90 days, respectively. Likewise, concomitant treatments with doses D1 (1/2000th of a pill), D2 (1/200th of a pill) and D3 (1/20th of a pill) of Noracycline yielded cervical tumors in 0.0%, 0.0%, 16.6% mice at 30 days, 4%, 3.7% and 54% (P less than 0.05) mice at 60 days and 3.2% (P less than 0.05), 20% and 63% (P less than 0.05) of mice at 90 days, respectively. Both Ovral and Noracycline displayed biphasic action on MCA-induced cervical carcinogenesis in mice. At lower dose levels (D1 and D2), they were inhibitory while at the higher dose level (D3) they were augmentatory in their actions. Both pills also significantly enhanced the incidence of cervical hyperplasia.

Estrogen protection against atherosclerosis and synthetic estrogen production of cirrhosis in the rabbit

Two artificial estrogens, ethinyl estradiol and mestranol, were found to cause cirrhosis in the rabbit liver during a study of atherosclerosis. These drugs showed protective effects against atherosclerosis in cholesterol-fed rabbits when administered orally (1 ppm in diet). These drugs and two naturally occurring estrogens, estrone and estradiol, were similarly effective when administered intramuscularly (1.5 mg per rabbit per week) to rabbits fed a diet lower in cholesterol. Reduction by estrogens of plasma cholesterol did not fully account for the reduction of extent of aortic atherosclerosis. Also, no differences in aortic or platelet eicosanoid production from exogenous arachidonic acid were found to explain the effect on atherogenesis. The 2 artificially modified estrogens, ethinyl estradiol and mestranol, caused portal fibrosis with biliary proliferation (even in rabbits not fed cholesterol). Estrone, estradiol, and testosterone were not injurious in this regard at the dosages used. Only the unmodified estrogens reduced atherosclerosis without damaging the rabbit liver.

A comparative clinical trial of Norinyl 1 + 35 versus Norinyl 1 + 50 in Merida, Yucatan, Mexico

A comparative clinical trial of two combined oral contraceptives differing only in estrogen type and dosage was conducted at the Centro de Investigaciones Hideyo Noguchi in Merida, Yucatan, Mexico. The trial was designed to determine the differences between Norinyl 1 + 50 (Syntex) and Norinyl 1 + 35 (Syntex) in rates of discontinuation and frequency of selected side-effects which might contribute to method discontinuation. Three hundred women were randomly assigned to either the Norinyl 1 + 35 group or to the Norinyl 1 + 50 group and follow-up visits were scheduled at 1, 4, 8 and 12 months after admission. In the Norinyl 1 + 35 group, more women experienced an increase in intermenstrual bleeding (primarily staining and spotting) (p less than 0.05), breast discomfort (p less than 0.05) and nausea than in the Norinyl 1 + 50 group. There was a significantly higher discontinuation rate for personal reasons, such as desired change of method and method not needed, among the women taking Norinyl 1 + 35 (p less than 0.05). The largest number of discontinuations comprised women discontinuing for menstrual problems in both groups. The life-table total discontinuation rate at 12 months was 52.0 for the Norinyl 1 + 35 group and 50.7 for the Norinyl 1 + 50 group. The lost-to-follow-up rates at 12 months were 17.8 for the Norinyl 1 + 35 group and 22.8 for the Norinyl 1 + 50 group.

A comparative study of three oral contraceptives in Ibadan: Norinyl 1/35, Lo-Ovral and Noriday 1/50

A study of three combined oral contraceptives, Norinyl 1/35, Lo-Ovral and Noriday 1/50, was conducted at the University of Ibadan Teaching Hospital, Ibadan, Nigeria, to determine if there were differences in continuation rates and reasons for discontinuation. This report includes analysis of 150 women, all of whom were interval patients, randomly allocated to one of the above oral contraceptives between May 1984 and February 1985. Follow-up visits were scheduled at 1, 4 and 8 months after admission. Significantly more women in the Norinyl 1/35 group (P less than 0.05) reported intermenstrual bleeding, as well as an increase in the occurrence of intermenstrual bleeding compared to women in the Lo-Ovral group. There were no other differences between the groups for side-effects. The continuation rates at 8 months were 90.8% for the Norinyl 1/35 group, 94.4% for the Lo-Ovral group and 87.1% for the Noriday 1/50 group. The corresponding rates for those lost to follow-up were 26.0, 40.8 and 17.7. The rate for total discontinuations (all discontinuations including women lost to follow-up) was 34.0% for the Norinyl 1/35 group, 44.9% for the Lo-Ovral group and 29.4% for the Noriday 1/50 group. There was a significant difference in lost to follow-up rates between the Lo-Ovral group and the Noriday 1/50 group (P less than 0.05). There were no other significant differences between the groups for life table rates (P greater than 0.05). There were no pregnancies reported during the study period.

Hormone prevention of mammary carcinogenesis by norethynodrel-mestranol

The observation that the susceptibility of the mammary gland to chemical carcinogenesis is inversely related to its level of hormonally induced differentiation led us to test whether treatment of virgin rats with an estrogenic-progestagenic hormone combination protected the gland against this carcinogenesis. Virgin Sprague-Dawley rats aged 45, 55, 65, or 75 days had implanted subcutaneously for 21 days a pellet containing norethynodrel-mestranol (NM) (98.5%-1.5%) at two doses, a physiological or low dose (LD) of 0.5 mg, equivalent to the dose used in Enovid for contraception in humans, and a pharmacological or high dose (HD) of 5.0 mg. Twenty-one days after NM pellet removal, the mammary glands of 5 animals per group were examined for the number of terminal end buds (TEBs), terminal ducts (TDs), alveolar buds (ABs) and lobules, and the DNA labeling index (DNA-LI). The remaining animals received 8 mg 7,12-dimethylbenz(a) anthracene (DMBA)/100 g body weight, and tumorigenesis was evaluated at 24 weeks. The percentage of TEBs decreased with age, and further with NM treatment at both doses. Treatment did not significantly modify the percentage of TDs, but increased that of ABs in most groups. The DNA-LI of TEBs remained constant, even during aging and after treatment, whereas both aging and treatment reduced DNA-LI in TDs and ABs. Tumor incidence declined with increasing age from 75% to 44% in the 45 and 75 day-old control groups respectively. Adenocarcinoma incidence followed the same trend. NM treatment had a dose-related protective effect against development of tumors in general and of adenocarcinomas in particular. LD treatment resulted in a marginally significant reduction in adenocarcinoma incidence, whereas HD-treated animals were 0.24 times as likely as controls to develop carcinomas. There was a statistically significant correlation between the percentage of TEBs present in the gland at the time of carcinogen administration and the incidence of adenocarcinomas. It was concluded that treatment of virgin rats with the hormone combination norethynodrel-mestranol resulted in long lasting structural changes in the mammary gland which protected this organ from a subsequent carcinogenic insult.

Pharmacokinetics of three bioequivalent norethindrone/mestranol-50 micrograms and three norethindrone/ethinyl estradiol-35 micrograms OC formulations: are "low-dose" pills really lower?

We have examined the pharmacokinetic parameters derived from the analysis of plasma ethinyl estradiol (EE) and norethindrone levels after administration of a single dose of three bioequivalent norethindrone-1mg/mestranol (ME)-50 micrograms formulations (Ortho-NovumR 1/50, NorinylR 1/50 and Norcept-MR 1/50) and three norethindrone-1mg/ethinyl estradiol-35 micrograms formulations (Ortho-Novum 1/35R, NorinylR 1/35, Norcept-ER 1/35) in a randomized crossover design involving 24 women for the 35 micrograms and 27 women for the 50 micrograms agents. Differences between the AUC-EE of pairs from the same manufacturer (1 + 35 and 1 + 50) were not significantly different, indicating that 50 micrograms of mestranol was equivalent to 35 micrograms ethinyl estradiol with respect to this pharmacokinetic parameter. The Cmax values were also similar. Inter-individual coefficients of variation (C.V.) for the AUC-EE were 47% and 57% for the 1 + 35 and 1 + 50 agents, respectively. Intra-individual C.V.s were 41% and 42%, respectively. For norethindrone, the AUC was larger with the 1 + 50 formulations than with the 1 + 35 group (87.9 vs. 72.8 pg hr/ml). Additionally, the Cmax values were larger for the 1/50 group (17.7 vs. 14.0). Since the amount of norethindrone in the two dosage groups was the same, this difference in the pharmacokinetics between the 35 micrograms EE and the 50 micrograms ME formulations remains unexplained. The inter-individual C.V. averaged 56% for both dosage groups. The intra-individual C.V.s were 17% and 46% for the 1 + 35 and 1 + 50 groups, respectively. The large variation in blood levels of ethinyl estradiol and norethindrone between and within individuals may overshadow clinical differences attributable to differences in dosage.

[Our method of treating Asherman's syndrome]

The paper discusses the problem of treating Asherman's syndrome, which due to common procedures in gynaecology and obstetrics becomes more and more frequent occurrence in gynaecological practice. The genesis of this syndrome is often a result of a too intensive excochleation of the uterus, accompanying infection and lack of endometrial reaction to oestrogens. The authors discussed 14 cases of patients in whom, after excochleation of the uterus, there appeared intrauterine adhesions followed by amenorrhoea. The therapy consisted in removing the adhesions by means of a hysteroscope and inserting an intrauterine device the shape of which was selected depending on the character and localization of adhesions and applying oestrogens locally into the uterus cavity. In order to have the menstrual cycle reconstructed, the patients were administered orally hormones during 4 successive artificially reconstructed cycles. Among the patients undergoing therapy, 86% of them began to menstruate again and 57% of them got pregnant. The use of hysteroscopy reduced maximally the risk of breaking the continuity of the uterus during the resection of large adhesions. Inserting a proper device prevented the recurrence of adhesions and local administering oestrogens into the uterine cavity provided good conditions for the reconstruction of the endometrium.

Assessment of a new low-dose once-a-month injectable contraceptive

Norethisterone (NET) in combination with mestranol (ME), in a macrocrystalline aqueous suspension that provides sustained release of steroids, was assessed as a once-a-month injectable contraceptive in ten healthy women of reproductive age. The ovarian function was studied before and after the intramuscular administration of 12mg NET plus 1.2mg ME, delivered as crystals of 150 micron average size. Serial blood samples were taken throughout the injection intervals in all women to measure serum progesterone (P), estradiol (E2), and NET. The NET/ME preparation effectively inhibited ovulation in 23 out of the 25 injection intervals studied. The administration of this formulation induced in some women a small degree of follicular maturation not followed by luteal activity. The endometrial bleeding patterns after each injection showed a bleeding-free period of two to three weeks. The overall data demonstrate that the parenteral administration of a macrocrystalline steroid preparation of NET/ME can bring about a sustained release contraceptive system at a substantially lower dose than those currently employed in once-a-month injectable contraception.

[Fulminant liver failure in tuberculostatic therapy. A contribution to clinical aspects and pharmacokinetics]

A 23-year old female patient on a prolonged regimen of tuberculostatic chemotherapy finally developed fulminant hepatic failure shortly after addition of hormonal contraception. The pathophysiology of this almost fatal drug reaction is described as a pharmacokinetic interaction: the inherent hepatotoxicity of prothionamide-the drug finally prescribed during convalescence-was significantly potentiated by the Cyt-P-450-inducing effect of the progestagen component of the hormonal contraceptive. Potentiation of hepatotoxicity in connection with tuberculostatic regimes containing rifampicin is well known and this pharmacokinetic phenomenon also pertains to the combination with other Cyt-P-450-inducing drugs such as, for instance, anticonvulsants. However, since the maximum of rifampicin-related Cyt-P-450-inducing effect is limited to the initial 2-3 weeks of therapy, the hepatotoxic risk triggered by this rifampicin-related induction may decline during continuation of therapy. This, unfortunately, does not pertain to the other Cyt-P-450-inducers, whose inductive effect is not time-limited. Progressive severe hepatic damage may follow from such interaction as demonstrated in this case report.

Effects of prenatal administration of mestranol and two progestins on testosterone synthesis and reproductive tract development in male rats

The oestrogen mestranol (0, 0.01, 0.1 mg/kg body weight per day) and the progestins medroxyprogesterone-acetate and norethisterone (0, 2, 20 mg/kg body weight per day each) in sesame oil were intubated intragastrically daily during gestational days 14.5 through 19.5 to pregnant rats. Males were studied as 20.5-day-old foetuses and 4-month-old adults for serum testosterone and LH concentrations, in vitro testosterone synthesis, anogenital distance (foetuses only) and testes, seminal vesicle and ventral prostate weights. Administration of 0.1 mg mestranol decreased by 35 to 70% basal and LH-stimulated testosterone synthesis by both foetal and adult testes in vitro (P less than 0.01). Foetal body weights (P less than 0.05), but not anogenital distances, were significantly decreased. Testosterone content in adult sera was reduced significantly (P less than 0.05) to less than 50% of control. Testes, ventral prostate, seminal vesicle and epididymal weights were unaffected by treatment. Medroxyprogesterone acetate or norethisterone administration did not alter testes endocrine function in foetal or adult offspring. In a small number of rats, pregnant for 10.5, 14.5 or 18.5 days, [3H]ethinyloestradiol was intubated and foetal and placental tissue examined for appearance and content of radioactivity. Radioactivity was detected in 10.5, 14.5 and 18.5 days old placentas, and 14.5 and 18.5 days old foetal liver, gonads and external genitalia. With [3H]medroxyprogesterone acetate, radioactivity was localized in 14.5 day placenta and foetal tissues. Thin-layer chromatographic analysis showed most of the activity to migrate as authentic ethinyloestradiol or medroxyprogesterone acetate. These results demonstrate inhibition of testicular testosterone synthesis by mestranol, presumably by being transferred across the placenta and acting in the foetus.(ABSTRACT TRUNCATED AT 250 WORDS)

Side effects and compliance with low- and conventional-dose oral contraceptives among adolescents

Oral contraceptives are the most popular birth control method for teenagers, yet many teens discontinue use of these contraceptives prematurely. The need to minimize any potential long-term medical complications from the use of contraceptive hormones must be balanced with the desirability of increasing acceptance of contraceptives by adolescents. There has been concern that the use of so-called "low-dose" estrogen preparations, although decreasing the likelihood of complications, may lead to side effects that make compliance less certain. The present study comparing two commonly used oral contraceptive preparations, one low dose, one conventional dose, tests the hypothesis that among adolescents an association exists between oral contraceptive side effects and compliance. Using a double-blind crossover method, 55 sexually active adolescent females received two months each of a preparation containing 35 micrograms ethinyl estradiol and 0.5 mg norethindrone and another containing 50 micrograms mestranol and 1.0 mg norethindrone. The 50-microgram preparation was associated with fewer side effects when administered during the first two months. No differences in side effects were noted in the latter two months, but there was a slight increase in weight gain when compared with the 35-microgram preparation. The most common side effect was inter-menstrual bleeding with the 35-microgram pill. There was no documented relationship between the occurrence of side effects and compliance.

Oral contraceptives in the United States: trends in content and potency

Data from the National Prescription Audit, a nationwide pharmaceutical marketing research data base, were reviewed to study changes in the type of oral contraceptives marketed in the US, their content and their relative oestrogen and progestin potency over the 21-year time period of 1964-84. Three major types and 42 brands of oral contraceptives were marketed in the US during this time period. All oral contraceptives dispensed in the US have contained one of nine different progestins and one of two oestrogens or, in the case of the progestin-only pills, no oestrogen at all. A comprehensive classification listing all 42 brands of oral contraceptives by content and strength is presented. Secular changes in oral contraceptive potency are described in terms of a categorization scheme which simultaneously ranks both the oestrogen and progestin potencies of each oral contraceptive. Over the time period studied, oral contraceptives have evolved from high strength, high potency drugs to much lower strength, lower potency drugs. The epidemiological implications of these shifts in oral contraceptive content and potency are discussed.

Development of a low-dose monthly injectable contraceptive system: II. Pharmacokinetic and pharmacodynamic studies

A drug delivery system which provides a sustained release of norethindrone (NET) and mestranol (ME) for one month after a single intramuscular injection was assessed as a long-acting injectable contraceptive. The system is based upon well defined particle size crystals of the synthetic steroids maintained in suspension with saline solution. Eight healthy ovulating women volunteered for the study; they received a combination of 10 mg of NET plus 1 mg of ME in 1 ml of vehicle by intramuscular injection on day five of their menstrual cycle. Blood samples were drawn at 0, 1, 5, 10, 13, 17 and 21 days after drug administration. The immunoreactive serum levels of estradiol, progesterone, NET and ethinylestradiol were measured by specific radioimmunoassay procedures to assess ovarian function and the kinetic parameters of the synthetic steroids. This newly developed contraceptive system proved to be both effective, and long-lasting as well as devoid of side effects.

Effect of oral contraceptive on liver function tests of women with schistosomiasis in the Philippines

A prospective study was undertaken to determine the effect on liver function tests of a combined oral contraceptive containing norethisterone 1 mg and mestranol 0.05 mg, in women with schistosomiasis japonica in Leyte, Philippines. Women who volunteered and met the standard criteria for oral contraception, with and without infection, were followed for six months of pill intake. Concurrently, non-pill users, both infected and uninfected, were similarly followed. Baseline and six-month liver function tests were compared. Of the 466 subjects admitted in the study, 383 completed six months, and 83 discontinued. At the start of the study, there were no significant differences among the four groups in liver function tests except that the infected women had a higher total protein and alkaline phosphatase, and lower alanine aminotransferase levels. After six months, the only statistically significant finding was a lesser decrease in total protein among the infected pill users compared to the uninfected pill users. This finding was not clinically significant since there was no associated clinical complications; there were fewer number of subjects with abnormal values at the sixth month; and the mean values of this variable remained within normal limits. Our findings show that the use of low dose progestin and estrogen oral contraceptive in the presence of mild schistosomiasis japonica infection does not appear to have adverse effect on liver function tests of young women after six months of contraceptive use.

Bioequivalence of norethindrone and ethinyl estradiol for two different weight tablets with the same hormonal content

Two tablets of differing weights, 100 mg (A) and 50 mg (B), of an oral contraceptive drug (OC) were compared with each other and to a solution (C) of the same components. The composition of the OC consisted of 1 mg of norethindrone (NET) and 0.035 mg of ethinyl estradiol (EE2). Both tablets were shown to differ from the solution, which was more rapidly absorbed, but were not significantly different from each other. Formulation means for NET and EE2, for each of the two products, were similar. Application of an interval test for the ratio of computed parameters demonstrated equivalence of the two formulations with respect to 0-24 hr area under the curve (AUC24) and total area under the curve (AUC+o+) for both NET and EE2 and with respect to concentration maximum (Cmax) for EE2. The data support the hypothesis for bioequivalence of the two formulations with respect to total absorption.

Effect of estrogens on the dexamethasone suppression test in nondepressed women

It is often suggested that estrogens may cause false-positive dexamethasone suppression test (DST) results. In this study of nine healthy, non-depressed women, DSTs were performed at baseline, immediately following administration of 21 days of oral contraceptives containing either 50 or 80 micrograms of mestranol (a synthetic estrogen) in combination with 1 mg of norethindrone (a synthetic progesterone), and 1 month after discontinuing the oral contraceptives. All subjects had post-dexamethasone cortisol levels less than or equal to 5 micrograms/dl during the study with the exception of two subjects in the mestranol 80 microgram group who had positive DSTs immediately following oral contraceptive administration; one of these subjects continued to have a positive DST 1 month later. DST results should be interpreted with caution if high dose estrogens are taken concurrently or have been recently discontinued.

A crossover pill study among Sudanese women

A crossover study from a standard-dose to a low-dose oral contraceptive was conducted in the Sudan. Reported side effects were very few, with a headache the most frequently reported. Switching to the other pill did not affect the rate of any side effects.

Effect of long term hormone replacement on plasma prolactin concentrations in women after oophorectomy

Plasma prolactin concentrations were studied in 88 oophorectomised women who had been receiving mestranol or placebo for three to 11 years. Thirty one of them were also studied under basal conditions and by tests with thyrotrophin releasing hormone. Under basal conditions the mean prolactin concentration was higher in the oestrogen treated group but under non-rested, clinic conditions the difference was lost because of a rise in prolactin value in the placebo group only. Hence the groups showed a different prolactin response to the mild stress of clinic attendance but the same proportionate responsiveness to thyrotrophin releasing hormone. The data suggest that long term hormone replacement has no significant effect on circulating prolactin concentrations under non-rested, everyday conditions and that the prolactin stimulating effects of minor stress and oestrogen may share a similar mechanism.

[Treatment of constitutionally tall girls with physiological estrogen doses in the prepuberty period. An alternative to high-dose estrogen therapy]

The international literature shows that the constitutional tall stature of girls has so far been treated with high estrogen doses after the onset of puberty. But nowadays it is felt however, that the potential risks of high-dose estrogen therapy are considerable. While the hazards of persisting gonadotropine suppression were found to be less important, thrombo-embolic complications or severe changes in the liver cannot be excluded in young people. Epidemiological findings and animal experiments suggest that these complications are dose-dependent. In search of an alternative to high-dose treatment, we--from 1966-1980 and basing on Whitelaw--administered approximately physiologic estrogen doses (80 micrograms of mestranol per day for 21 days, plus 2 mg of chlormadinonacetate per day for 10 days, cyclically) to a total of 86 tall girls ranging in age from 9 to 13 years. Only the group of the 20 girls with a skeletal age of 9-10 years, who were still prepubertal at the beginning of therapy, revealed a satisfactory mean height reduction of 7.6 cm. Serious side-effects of therapy did not occur. The possible drastic reduction of the estrogen dose to about 1/4 of the daily dose or about 1/3 of the overall dose as compared to the conventional method allows us to conclude that the early start of treatment offers a true alternative to the high-dose estrogen therapy of the female tall stature.

[Use of mestranol as an anabolic substance in fattening bulls]

In 5 experiments 137 fattening bulls received between 0 and 20 mg Mestranol per animal and day. In one experiment a dose of 10 mg/day reduced consumption. The cause of this effect could not be found. In three experiments Mestranol increased weight gain by 4-13%. Feed expenditure was significantly decreased in only one experiment, in which 5-10 mg were given (average of all experiments: 4%). In dependence on the amount of Mestranol the weight of skin, horn and testicles decreased, when only 5-10 mg were given, however, protein retention increased whereas fat retention decreased. When 20 mg Mestranol are given per animal and day, the anabolic effect is missing although the NEFcattle-expenditure per kJ retention including maintenance decreases. This is due to a higher fat retention, which is causally inexplicable. The ergotropic effect of Mestranol depends on its dosage and possibly the nutrients in the ration.

Ovulation inhibition following vaginal administration of pills containing norethindrone and mestranol

Plasma levels of estradiol and progesterone were investigated in women using daily vaginal pills containing 1 mg norethindrone and 50 mcg mestranol. Of 13 treatment cycles in ten women using one vaginal pill daily, six were ovulatory and seven anovulatory. All 12 cycles in ten women using two vaginal pills daily were anovulatory.

Influence of psychosocial factors on adolescent compliance with oral contraceptives

This paper prospectively tests the influence of a variety of sociomedical and psychosocial factors on compliance with oral contraceptives among adolescent females from a population at high risk for pregnancy. Fifty-six females aged 14-19 yr from a lower socioeconomic background received a battery of pretest measurements and were then given Ortho-Novum 1/35 combined with riboflavin during an initial visit and 1-, 2-, and 4-month follow-ups. Compliance was measured at each follow-up using a Guttman scale consisting of: (1) avoidance of pregnancy, (2) appointment adherence, (3) pill count, and (4) urinary fluorescence for riboflavin. Six factors were found to be significantly associated with noncompliance: (1) multiple sexual partners, (2) appointment being made by the adolescent, (3) low evaluation of personal health, (4) feelings of hopelessness, (5) worry about becoming pregnant, and (6) previous abortion. These findings suggest that certain indicators of sexual activity and social psychological status may help predict noncompliance in some adolescent females.

Chromosomally competent ovarian failure at adolescence

Three female adolescents are presented with delayed or incomplete secondary sexual development due to primary ovarian failure. All three patients had normal blood leukocyte and ovarian tissue karyotypes. The importance of performing a diagnostic laparoscopy with ovarian biopsy in the setting of chromosome competent ovarian failure (CCOF) is emphasized.

Effect of estrogen/progestin potency on lipid/lipoprotein cholesterol

We studied 374 women taking oral contraceptives, 284 women taking estrogen preparations after menopause, and 1086 women taking no hormones, to determine the relation of plasma lipids and lipoprotein cholesterol concentrations to various types of estrogen/progestin formulations. Premenopausal women, using oral contraceptives containing a relatively low dose of estrogen combined with a medium or high dose of progestin (Norlestrin, Ovral, or Demulen) had a 24 per cent higher median concentration of low-density-lipoprotein cholesterol than did those not using hormones (P less than 0.05). Women using oral contraceptives that are high in estrogen and low in progestin (Enovid or Oracon) had significantly higher concentrations of high-density-lipoprotein cholesterol than did nonusers; those using Ovral, a low-estrogen and high-progestin formulation, had significantly lower levels of high-density-lipoprotein cholesterol. In postmenopausal women the use of estrogen was associated with concentrations of low-density-lipoprotein cholesterol that were 11 to 19 per cent below the levels in postmenopausal women who did not use hormones. The effects of estrogen-progestin balance on low-density and high-density lipoproteins may underlie the increased incidence of stroke and myocardial infarction in women of childbearing age who take oral contraceptives.