Systematic analysis of combined oral contraceptive prescription patterns in psychotropic drug users across twelve European countries

OBJECTIVE

To investigate prescription patterns of combined oral contraceptives (COC) among psychotropic drug users compared to non-psychotropic drug users in routine clinical practice in Europe.

STUDY DESIGN

A pooled analysis of three large, prospective, multinational cohort studies including women with a new prescription of COC from 12 European countries. We calculated standardized mean differences (SMD) to investigate whether the status of psychotropic drug use (use/no use) or the psychotropic drug class (psycholeptics/psychoanaleptics) is associated with the healthcare professional's choice of a specific type of COC progestin.

RESULTS

Our analysis comprised 143,069 non-psychotropic drug users and 2174 psychotropic drug users. Progestins with the highest frequency in the cohorts were levonorgestrel (non-psychotropic drug users: 33.8%; psychotropic drug users: 32.4%), nomegestrol/nomegestrol acetate (non-psychotropic drug users: 19.1%; psychotropic drug users: 26.4%), and drospirenone (non-psychotropic drug users: 15.9%; psychotropic drug users: 14.8%). SMD analysis indicated no substantial differences in COC prescription patterns between the two cohorts. However, we observed association signals for users of the herbal antidepressant St. John's wort in that those individuals more often received a prescription for drospirenone and less frequently for nomegestrol/nomegestrol acetate compared to non-psychotropic drug users.

CONCLUSIONS

Psychotropic drug user status does not seem to affect healthcare professionals' decisions when prescribing COC. However, limited evidence suggests that the risk for drug interactions might differ by progestin type, and some COC might be more suitable for psychotropic drug users than others. Specific guidelines should be conveyed to healthcare professionals to assist them in contraceptive counseling.

IMPLICATIONS

With exception of St. John's wort, our analysis showed no differential prescription behavior of combined oral contraceptives in psychotropic drug users and non-users. However, healthcare professionals should carefully consider psychotropic drug use in contraceptive counseling as it is still unclear whether drug interactions exist when co-administered with certain oral contraceptives.

Progesterone-primed cycles result in slower embryos without compromising implantation potential and with the advantages of oral administration and potential cost reduction

OBJECTIVE

To study the impact of the use of progesterone on embryo morphokinetics and on the outcomes of intracytoplasmic sperm injection cycles.

DESIGN

Cohort study.

SETTING

Private university-affiliated in vitro fertilization center.

PATIENT(S)

This study included 236 freeze-all intracytoplasmic sperm injection cycles and the resultant 2,768 injected oocytes cultured in a time-lapse imaging incubation system. Patients were matched by age and divided into groups depending on the protocol used to prevent the luteinizing hormone surge: progestin-primed (144 cycles and 1,360 embryos) and gonadotropin hormone-releasing hormone (GnRH) antagonist (144 cycles and 1,408 embryos) groups.

INTERVENTION(S)

The kinetic recorded markers were time to pronuclear appearance and fading, time to 2-8 cells, time to morulation, time to start of blastulation, and time to blastulation. The durations of cell cycles and time to complete synchronous divisions were calculated. The Known Implantation Data Score ranking was recorded. Morphokinetics and clinical outcomes were compared between the groups.

MAIN OUTCOME MEASURE(S)

Embryo morphokinetics and clinical outcomes.

RESULTS

Slower time to pronuclear appearance, time to 2 cells, time to 7 cells, time to start of blastulation, and time to blastulation were observed in embryos derived from progestin-primed cycles than in those from the GnRH antagonist group. No significant differences were noted in any other morphokinetic milestone. Significantly higher cancellation and implantation rates were observed in the progestin-primed group. However, no significant differences were noted in the pregnancy and miscarriage rates. The expenses for treatment using premature GnRH antagonist and progestins were US$318.18 and US$11.05, respectively.

CONCLUSIONS

Exogenous progesterone replaces the GnRH antagonist for the prevention of premature luteinizing hormone surge, in freeze-all cycles, with the advantage of oral administration and potential cost reduction.

Morphologic alterations of the fear circuitry: the role of sex hormones and oral contraceptives

Background

Endogenous sex hormones and oral contraceptives (OCs) have been shown to influence key regions implicated in fear processing. While OC use has been found to impact brain morphology, methodological challenges remain to be addressed, such as avoiding selection bias between OC users and non-users, as well as examining potential lasting effects of OC intake.

Objective

We investigated the current and lasting effects of OC use, as well as the interplay between the current hormonal milieu and history of hormonal contraception use on structural correlates of the fear circuitry. We also examined the role of endogenous and exogenous sex hormones within this network.

Methods

We recruited healthy adults aged 23-35 who identified as women currently using (n = 62) or having used (n = 37) solely combined OCs, women who never used any hormonal contraceptives (n = 40), or men (n = 41). Salivary endogenous sex hormones and current users' salivary ethinyl estradiol (EE) were assessed using liquid chromatography - tandem mass spectrometry. Using structural magnetic resonance imaging, we extracted surface-based gray matter volumes (GMVs) and cortical thickness (CT) for regions of interest of the fear circuitry. Exploratory whole-brain analyses were conducted with surface-based and voxel-based morphometry methods.

Results

Compared to men, all three groups of women exhibited a larger GMV of the dorsal anterior cingulate cortex, while only current users showed a thinner ventromedial prefrontal cortex. Irrespective of the menstrual cycle phase, never users exhibited a thicker right anterior insular cortex than past users. While associations with endogenous sex hormones remain unclear, we showed that EE dosage in current users had a greater influence on brain anatomy compared to salivary EE levels and progestin androgenicity, with lower doses being associated with smaller cortical GMVs.

Discussion

Our results highlight a sex difference for the dorsal anterior cingulate cortex GMV (a fear-promoting region), as well as a reduced CT of the ventromedial prefrontal cortex (a fear-inhibiting region) specific to current OC use. Precisely, this finding was driven by lower EE doses. These findings may represent structural vulnerabilities to anxiety and stress-related disorders. We showed little evidence of durable anatomical effects, suggesting that OC intake can (reversibly) affect fear-related brain morphology.

Serum LH level prior to progestin administration is significant on pregnancy and live birth in programmed frozen-thawed embryo transfer cycles

Purpose

To evaluate the impact of serum LH levels prior to progestin administration on the outcomes of programmed frozen-thawed embryo transfer (FET) cycles.

Methods

Retrospective cohort study was conducted to compare the treatment outcomes between four groups based on the 25 percentiles of serum LH levels before progestin administration in 596 cycles of 518 patients undergoing artificial endometrial preparation protocols for FET. Primary outcome measures were ongoing and live birth rates. Secondary outcome measures were the pregnancy rates, clinical pregnancy rates, and pregnancy loss rates.

Results

The trends in clinical pregnancy (CPR) and live birth rates (LBR) increased from the first to the fourth quartile (Q1 to Q4) of serum LH levels prior to progestin administration (37,0% to 48,3%, p = 0.042, and 22.6% to 39.5%, respectively, p = 0.003). Pregnancy loss rates (PLR) were higher in group Q1, although the difference was not statistically significant. Based on a multivariate logistic regression analysis, a low serum LH level before progestin initiation was found to be the most significant predictor associated with a negative effect on live birth (OR: 0,421, 95% CI 0,178 - 0,994, p=0,048). The day of estrogen initiation was significantly correlated with serum LH levels and quartiles of serum LH levels before progestin administration (r=0,200, p=0,015 and r=0,215, p=0,009, respectively).

Conclusion

The serum LH level prior to progestin administration significantly affects pregnancy and live birth rates in patients undergoing an artificial endometrial preparation protocol for FET. LH monitoring should be incorporated into the follow-up, in addition to assessing endometrial thickness and morphology in artificial FET cycles.

The impacts of endogenous progesterone and exogenous progestin on vascular endothelial cell, and smooth muscle cell function: A narrative review

Vascular endothelial and smooth muscle cell dysfunction proceed the development of numerous vascular diseases, such as atherosclerosis. Both estrogen and progesterone receptors are present on vascular endothelial and smooth muscle cells, and therefore it has been postulated that these compounds may affect vascular function. It has been well-established that estrogen is a vasoprotective compound, however, the effects of progesterone on vascular function are not well understood. This narrative review summarizes the current research investigating the impact of both endogenous progesterone, and exogenous synthetic progestin on vascular endothelial and smooth muscle cell function and identifies discrepancies on their effects in vitro and in vivo. We speculate that an inverted-U dose response curve may exist between nitric oxide bioavailability and progesterone concentration, and that the androgenic properties of a progestin may influence vascular function. Future research is needed to discern the effects of both endogenous progesterone and exogenous progestin on vascular endothelial and smooth muscle cell function with consideration for the impacts of progesterone/progestin dose, and progestin type.

Abiotic transformation of synthetic progestins in representative soil mineral suspensions

Altrenogest (ALT), drospirenone (DRO), and melengestrol acetate (MLA) are three highly potent synthetic progestins that can be released into agricultural soils, while their fate in soil minerals remains unclear. This study explored the transformation of these progestins in MnO₂, SiO₂, and ferrihydrite suspensions and identified their transformation products (TPs) via high resolution mass spectrometry and density functional theory calculations. Transformations were only observed for DRO and MLA in SiO₂ suspension and ALT in MnO₂ suspension (half-lives = 0.86 min - 9.90 day). ALT transformation was facilitated at higher MnO₂ loadings, while DRO and MLA transformations were inhibited at higher SiO₂ loadings. These data indicated that hydrophobic partitioning interaction was dominant at higher SiO₂ loadings rather than specific interaction, which limited subsequent surface-catalyzed transformation. ALT transformation rate decreased with increasing pH because MnO₂ reduction requires proton participation. In contrast, relatively high pH facilitated MLA and DRO transformation, indicating that base-catalyzed hydrolysis occurred in SiO₂ suspension. The clustermap demonstrated the formation of abundant TPs. Lactone ring and acetoxy group hydrolysis was the major transformation pathway for DRO and MLA, with estimated yields of 57.7% and 173.2% at 6 day, respectively. ALT experienced C12 hydroxylation and formed the major TP 326g (yield of 15.4% at 8 hr). ALT also experienced allyl group oxidation and subsequent C5 hydroxylation, forming the major TP 344a (yield of 14.1% at 8 hr). This study demonstrates that TPs of metastable progestins are likely the main species in soils and that TP identification is a particular priority for risk assessment.

Biotransformation kinetics and pathways of typical synthetic progestins in soil microcosms

Gestodene (GES), altrenogest (ALT), and medroxyprogesterone acetate (MPA) are three potent synthetic progestins detected in agricultural soils; however, their biotransformation outcomes in soils remain unclear. This study explored the biotransformation of these progestins in five agricultural soils with different physicochemical properties. The biotransformation data were well-described by a first-order decay model (R² = 0.83-0.99), with estimated half-lives ranging between 12.1 and 188 h. Amplicon sequencing indicated that the presence of progestins changed the bacterial richness and community structure in the soils. Linear correlation, canonical correlation, and two-way correlation network analysis revealed that soil properties can affect biotransformation rates by interfering with progestin-soil interactions or with keystone taxa in soils. The clustermap demonstrated the formation of abundant transformation products (TPs). Isomerization and C4(5) hydrogenation were the major transformation pathways for GES (yields of ∼ 13.7 % and ∼ 10.6 %, respectively). Aromatic dehydrogenation was the major transformation pathway for ALT (yield of ∼ 17.4 %). The C17 hydrolysis with subsequent dehydration and hydrogenation was the major transformation pathway for MPA (yield of ∼ 196 %). In particular, some TPs exhibited progestagenic, androgenic, or estrogenic activity. This study highlights the importance of evaluating the ecotoxicity of progestin and TP mixtures for better understanding their risks in the environment.

Influence of progestin-only hormonal use on hepatocellular adenomas: A retrospective cohort study

OBJECTIVES

Exogenous estrogen is associated with growth of hepatocellular adenomas (HCAs), although the influence of progestin-only agents is unknown. We therefore evaluated the association of progestin-only agents on HCA progression compared to no hormone exposure and compared to estrogen exposure in female patients.

STUDY DESIGN

In this single-center, retrospective cohort study of reproductive-aged female patients (ages 16-45) with diagnosed HCAs between 2003 and 2021, we evaluated radiographic HCA growth during discrete periods of well-defined exogenous hormone exposures.

RESULTS

A total of 34 patients were included. Nineteen (55.9%) had follow-up scans during periods without hormone exposure, 7 (20.6%) during estrogen exposure, and 8 (23.5%) during progestin-only exposure. Over a median follow-up of 11 months, percent change in sum of adenoma diameters from baseline to last available scan was -15.0% with progestin-only agents versus 29.4% with estrogen exposure (p = 0.04), and -7.4% with no hormonal exposure (p = 0.52 compared to progestin-only). Greater than 10% growth was observed in two individuals (25.0%) with progestin-only agent use (one patient on high-dose progestin for menorrhagia) versus five individuals (71.4%) with estrogen use (p = 0.13), and 7 (36.8%) with no exogenous hormone use (p = 0.68 vs progestin-only).

CONCLUSIONS

During discrete periods of progestin-only use, HCA growth overall declined, similar to declining growth during periods without exogenous hormonal exposure. This differed from discrete periods of exogenous estrogen exposure, during which time HCAs demonstrated overall increased growth. Though larger studies are needed, these findings support recent guidance supporting progestin-only agents for female patients with HCAs seeking non-estrogen alternatives for contraception.

IMPLICATIONS

In this small retrospective study, we observed overall decrease in HCA size during discrete periods of progestin-only contraception use, similar to that observed during periods without exogenous hormone exposure, supporting their use as a safe alternative to estrogen-containing contraceptives in this patient population.

Serotonin and the ventilatory effects of etonogestrel, a gonane progestin, in a murine model of congenital central hypoventilation syndrome

INTRODUCTION

Congenital Central Hypoventilation Syndrome, a rare disease caused by PHOX2B mutation, is associated with absent or blunted CO₂/H⁺ chemosensitivity due to the dysfunction of PHOX2B neurons of the retrotrapezoid nucleus. No pharmacological treatment is available. Clinical observations have reported non-systematic CO₂/H⁺ chemosensitivity recovery under desogestrel.

METHODS

Here, we used a preclinical model of Congenital Central Hypoventilation Syndrome, the retrotrapezoid nucleus conditional Phox2b mutant mouse, to investigate whether etonogestrel, the active metabolite of desogestrel, led to a restoration of chemosensitivity by acting on serotonin neurons known to be sensitive to etonogestrel, or retrotrapezoid nucleus PHOX2B residual cells that persist despite the mutation. The influence of etonogestrel on respiratory variables under hypercapnia was investigated using whole-body plethysmographic recording. The effect of etonogestrel, alone or combined with serotonin drugs, on the respiratory rhythm of medullary-spinal cord preparations from Phox2b mutants and wildtype mice was analyzed under metabolic acidosis. c-FOS, serotonin and PHOX2B were immunodetected. Serotonin metabolic pathways were characterized in the medulla oblongata by ultra-high-performance liquid chromatography.

RESULTS

We observed etonogestrel restored chemosensitivity in Phox2b mutants in a non-systematic way. Histological differences between Phox2b mutants with restored chemosensitivity and Phox2b mutant without restored chemosensitivity indicated greater activation of serotonin neurons of the raphe obscurus nucleus but no effect on retrotrapezoid nucleus PHOX2B residual cells. Finally, the increase in serotonergic signaling by the fluoxetine application modulated the respiratory effect of etonogestrel differently between Phox2b mutant mice and their WT littermates or WT OF1 mice, a result which parallels with differences in the functional state of serotonergic metabolic pathways between these different mice.

DISCUSSION

Our work thus highlights that serotonin systems were critically important for the occurrence of an etonogestrel-restoration, an element to consider in potential therapeutic intervention in Congenital Central Hypoventilation Syndrome patients.

The progestin-only pills drospirenone 4 mg and desogestrel 0.075 mg as an option for the management of dysmenorrhea and mastodynia

INTRODUCTION

Dysmenorrhea and mastodynia are the most common gynecologic pain causes in women of all ages and races during their reproductive life. The following study aimed to show the influence of two POP´s in the development of dysmenorrhea and mastodynia after nine months of use.

MATERIAL AND METHODS

A total of 858 women with 6691 drospirenone (DRSP) cycles and 332 women with 2487 desogestrel (DSG) cycles were analyzed. Women included in this study were all child-bearing potentials, at risk of pregnancy, agreeing to use only the study medication for contraception for the duration of the study medication treatment, aged 18 to 45.

RESULTS

At screening, 168 (19.6%) of the 858 patients using DRSP and 64 (19,3%) of the DSG patients reported that they had suffered from dysmenorrhea within six cycles prior to the first visit before starting with the medication. 20,2% of the DRSP and 10,9% of the DSG group had a sever dysmenorrhea. After 9 cycles this was reduced to 0,6% and 3,1% respectively. In total, 96 women (11.2%) in the DRSP and 49 (14,8%) experienced mastodynia within six cycles before the screening. Of these 91.6% in the DRSP group and 91,8% in the DSG group had no or mild mastodynoa at follow-up.

DISCUSSION

The progestins 4 mg and desogestrel 0,075 mg showed a marked effect in the non-contraceptive aspects of dysmenorrhea and mastodynia so that new possibilities are opened for these two benign gynecological diseases. Future studies must reaffirm these first data.

Signal pathway of LH-induced expression of nuclear progestin receptor in vertebrate ovulation

Nuclear progestin receptor (PGR), which is induced in the follicles destined to undergo ovulation, is believed to be obligatory for rupture of the follicles during ovulation in vertebrates. Studies in some mammals and teleost medaka have revealed the outline of the central signaling pathway that leads to the PGR expression in the preovulatory follicles at ovulation. In this review, we summarize the current knowledge on what signaling mediators are involved in the LH-induced follicular expression of PGR at ovulation in these animals. LH-inducibility of follicular PGR expression is conserved. In both group of animals, activation of the LH receptor on the granulosa cell surface with LH commonly results in the increase of intracellular cAMP levels, while the downstream signaling cascades activated by high level of cAMP are totally different between mice and medaka. PGR is currently presumed to be induced via PKA/CREB-mediated transactivation and ERK1/2-dependent signaling in mice, but the receptor is induced via EPAC/RAP and AKT/CREB pathways in the teleost medaka. The differences and similarities in the signaling pathways for PGR expression between them is discussed from comparative and evolutionary aspects. We also discussed questions concerning PGR expression and its regulation needed to be investigated in future.

Long-term treatment of endometriosis-related pain among women seeking hormonal contraception

OBJECTIVE

To evaluate the different effects of a progestin-only contraceptive with desogestrel (DSG) vs combined oral contraceptives (COCs) for a first line long-term treatment of endometriosis-related pain among patients seeking hormonal contraception.

METHODS

An observational retrospective cohort study was conducted in collaboration with a local outpatient clinic for endometriosis among a group of nulliparous young women (n = 216) with endometriosis-related pain and seeking contraception. The cohort was subdivided into a group (n = 73) treated as first line by DSG and another group (n = 75) treated by a COC. During the study, clinical symptoms, side effects and possible changes in OC type use were recorded.

RESULTS

No significant difference was found between the two groups in terms of clinical characteristics and pain scores before treatment. After 6 months both treatments were effective in reducing endometriosis-related pain, and those treated with DSG showed lower levels of dysmenorrhea, dyspareunia and nonmenstrual pelvic pain than COCs group (p < .01). After 12 months, in DSG Group some patients (15%) switched from DSG to a COC for breakthrough bleeding, whereas in COC Group 48% of patients switched to another type of COC for reduced efficacy on pain and/or for side effects. After 3 years of OC treatment, in DSG Group 79% of patients maintained the same therapy, whereas in COC Group only 14% continued the same COC type, 37% switched to another COC and 47% to DSG.

CONCLUSIONS

A progestin-only contraceptive with DSG is a valid option for long term management of endometriosis-related pain in patients seeking hormonal contraception.

Effects of oral contraceptives on spatial cognition depend on pharmacological properties and phase of the contraceptive cycle

The central nervous system effects of oral contraceptives (OCs) are not well-documented. In a set of 3 studies, we investigated a specific cognitive function, mental rotation, in healthy women currently using OCs for contraceptive purposes (n = 201) and in medication-free controls not using OCs (n = 44). Mental rotation was measured using a well-standardized and extensively validated psychometric test, the Vandenberg Mental Rotations Test (MRT). In an initial study (Study 1), current OC users (n = 63) were tested during the active or inactive phases of the contraceptive cycle in a parallel-groups design. Studies 2 and 3 were based on an archival dataset (n = 201 current OC users) that consisted of data on the MRT collected in real-time over a 30-year period and compiled for purposes of the present work. The OCs were combined formulations containing ethinyl estradiol (10-35 ug/day) plus a synthetic progestin. All 4 families of synthetic progestins historically used in OCs were represented in the dataset. Cognitive performance was evaluated during either active OC use ('active phase') or during the washout week of the contraceptive cycle ('inactive phase') when OC steroids are not used. The results showed a significant phase-of-cycle (POC) effect. Accuracy on the MRT was mildly diminished during the active phase of OC use, while scores on verbal fluency and speeded motor tasks were modestly improved. The POC effect was most evident in women using OCs that contained first- or second-generation progestins (the estrane family of progestins or OCs containing levonorgestrel), but not in women using OCs containing recently developed progestins and lower doses of ethinyl estradiol. Using independently established ratings of the estrogenic, androgenic, and progestogenic intensities of the different OC formulations, each brand of OC was classified according to its distinct endocrine profile. Multiple regression revealed that the effects of OC use on the MRT could be predicted based on the estrogenic strength of the contraceptives used. Estrogenic potency, not androgenic or anti-androgenic effects of the OC pill, may underlie the effects of OC usage on spatial cognition.

Solving the Puzzle: What Is the Role of Progestogens in Neovascularization?

Ovarian sex steroids can modulate new vessel formation and development, and the clarification of the underlying mechanism will provide insight into neovascularization-related physiological changes and pathological conditions. Unlike estrogen, which mainly promotes neovascularization through activating classic post-receptor signaling pathways, progesterone (P4) regulates a variety of downstream factors with angiogenic or antiangiogenic effects, exerting various influences on neovascularization. Furthermore, diverse progestins, the synthetic progesterone receptor (PR) agonists structurally related to P4, have been used in numerous studies, which could contribute to unequal actions. As a result, there have been many conflicting observations in the past, making it difficult for researchers to define the exact role of progestogens (PR agonists including naturally occurring P4 and synthetic progestins). This review summarizes available evidence for progestogen-mediated neovascularization under physiological and pathological circumstances, and attempts to elaborate their functional characteristics and regulatory patterns from a comprehensive perspective.

Urinary benzophenones and synthetic progestin in Chinese adults and children: concentration, source and exposure

The endocrine-disrupting activities of UV filters and synthetic progestin have raised concerns about their adverse risks. In this study, 208 urine samples were collected from Shanghai residents for the determination of seven benzophenones (BPs) and six synthetic progestins. The highest median concentration (6.21ng g^-1 Cr) was observed in young adults (21-50 years), followed by a concentration of 3.86 ng g^-1 Cr in elderly adults (over 50 years old), and the lowest median concentration (1.32 ng g^-1 Cr) was found in children (8-11 years old). The detection rates of BP-3 and EE2 in adults were 97% and 82%, and in children were 31% and 24%, respectively. Synthetic progestin levels in Shanghai, China, were relatively low compared to other countries. And the urinary BPs level showed an increasing trend in Chinese in the past 5 years. The principal component analysis suggested that adults' exposure to BP-1 and BP-3 was related, which occurs through food or dermal absorption of these chemicals present in cosmetic products and coatings. And diet was an important exposure pathway for children exposed to BPs. Despite relatively high levels of synthetic progestin for female and obese, the total estimated daily intake (EDI) was still lower than acceptable daily intake adopted by America. In the Monte-Carlo analysis, the 95th percentile of hazard quotients (HQs) was 0.83, which indicated that potential health risks were appreciated in the studied population.

Occurrence and distribution of natural and synthetic progestins, androgens, and estrogens in soils from agricultural production areas in China

The occurrence of biologically potent sex hormones in agricultural soils is of growing concern due to their ability to disrupt the endocrine systems of aquatic organisms after being transported to surface waters via runoff. This study, therefore, examined the large-scale occurrence of 34 natural and synthetic sex hormones (13 progestins, 16 androgens, and 5 estrogens) in soils from 7 provinces and 1 municipality in China. The target sex hormones were detected in 99.3% of the soil samples, indicating their widespread occurrence in most agricultural areas. Additionally, seven synthetic progestins were detected in soils for the first time. The total concentration of the 34 sex hormones (Σsex hormones) in the sampled soils ranged from below the method detection limit to 23.7 ng/g (mean of 4.72 ± 4.07 ng/g), with androgens and progestins being the most dominant hormone groups. Significant correlations were observed among the concentrations of Σestrogens, Σandrogens, and Σprogestins (r = 0.117-0.433, p < 0.001), suggesting similar sources of sex hormones. The mean concentration of Σsex hormones varied considerably across the selected provinces/municipality. Notably, the annual slaughter of poultry and swine (R² = 0.75-0.88), female population (R² = 0.57-0.58), and soil organic carbon content (R² = 0.20-0.55) in each province were significantly correlated with the concentrations or mean concentrations of Σsex hormones, Σestrogens, or Σprogestins. This finding implies that these parameters contributed to the occurrence and distribution of sex hormones in the studied soils. Finally, risk quotients for some sex hormones exceeded 0.01, indicating medium or high risks to agroecosystems. This study highlights the importance of designing an optimal manure fertilization strategy in order to mitigate the risks posed by sex hormones in agroecosystems.

Genotoxic effects of combined multiple stressors on Gammarus locusta haemocytes: Interactions between temperature, pCO2 and the synthetic progestin levonorgestrel

Climate change and pharmaceutical contamination are two priority research topics due to their impacts in the aquatic ecosystems and in the food chain structure. In the bottom of many food chains are the invertebrates, like the amphipods, which are important environmental and ecotoxicological models. In this study, we combined the increase of temperature [ambient and warming temperature], pCO₂ [normocapnia and hypercapnia] and the synthetic progestin levonorgestrel (LNG) [environmentally relevant concentration (10 ng L^-1) and 100-fold higher (1000 ng L^-1)] to evaluate the genotoxic effects on the amphipod Gammarus locusta haemocytes, using the comet assay technique. Additionally, the study examined protective/potentiating effects of the three tested factors against hydrogen peroxide (H₂O₂)-induced DNA damage in haemocytes after ex vivo exposure. Our data revealed no significant effects of any of the three stressors on DNA damage of G. locusta haemocytes or protection against H₂O₂-induced DNA damage after twenty-one days exposure. Only a significant effect of the solvent was visible, since it was able to induce higher DNA damage (i.e. strand breaks) on exposed individuals. On the other hand, LNG exposure seemed to induce a slight increase of DNA damage after H₂O₂ exposure. Our findings suggest that more short-term studies to conclude about the genotoxicity and/or protective effects of the stress factors in G. locusta should be made, attending to the fast turnover rate of repairing cells that could have masked impacts seen only after the end of the experiment.

Interactive effects of increased temperature, pCO2 and the synthetic progestin levonorgestrel on the fitness and breeding of the amphipod Gammarus locusta

Given the lack of knowledge regarding climate change-chemical exposure interactions, it is vital to evaluate how these two drivers jointly impact aquatic species. Thus, for the first time, we aimed at investigating the combined effects of increased temperature, pCO₂ and the synthetic progestin levonorgestrel on survival, growth, consumption rate and reproduction of the amphipod Gammarus locusta. For that, a full factorial design manipulating temperature [ambient temperature and warming (+4 °C)], pCO₂ [normocapnia and hypercapnia (Δ pH 0.5 units)] and the progestin levonorgestrel (LNG: L1 - 10 ngLL^-1 and L2 - 1000 ngLL^-1, control - no progestin and solvent control - vehicle ethanol (0.01%)) was implemented for 21 days. G. locusta was strongly negatively affected by warming, experiencing higher mortality rates (50-80%) than in any other treatments. Instead, growth rates were significantly affected by interactions of LNG with temperature and pCO₂. It was observed, in the short-term (7d) that under ambient temperature (18 °C) and hypercapnic conditions (pH 7.6), the LNG presence promoted the amphipod's growth, while in the medium-term (21d) this response was not observed. Relative consumption rates (RCRs), during the first week were higher than in the third week. Furthermore, in the first week, RCRs were negatively affected by higher temperature while in the third week, RCRs were negatively affected by acidification. Furthermore, it was observed a negative effect of higher temperature and acidification on G. locusta fecundity, contrarily to LNG. Concluding, the impact of increased temperature and pCO₂ was clearly more adverse for the species than exposure to the synthetic progestin, however, some interactions between the progestin and the climate factors were observed. Thus, in a future scenario of global change, the presence of LNG (and other progestins alike) may modulate to a certain level the effects of climate drivers (and vice-versa) on the gammarids fitness and reproduction.

Transcriptional and Biochemical Alterations in Zebrafish Eleuthero-Embryos (Danio rerio) After Exposure to Synthetic Progestogen Dydrogesterone

Little information has so far been known on the effects of synthetic progestogen dydrogesterone (DDG) in organisms like fish. This study aimed to investigate the effects of DDG on the transcriptional and biochemical alterations in zebrafish eleuthero-embryos. Zebrafish eleuthero-embryos were analyzed for the transcriptional alterations by real-time quantitative PCR (RT-qPCR) and biochemical changes by attenuated total reflection Fourier-transform infrared spectroscopy (ATR-FITR) after 144 h exposure to DDG. The results of qPCR analysis showed that DDG exposure significantly suppressed the transcriptions of target genes involved in hypothalamic-pituitary-thyroid (HPT) axis, while it induced the expression of target genes mRNA belonging to hypothalamic-pituitary-gonad (HPG) axis. In addition, ATR-FTIR spectroscopy analysis showed that the biochemical alterations of protein, nucleic acid and lipid were observed following DDG treatment. The finding from this study suggests that DDG exposure could have potential multiple effects in fish.

Anti-progestins suppress the growth of established tumors induced by 7,12-dimethylbenz(a)anthracene: comparison between RU486 and a new 21-substituted-19-nor-progestin

In this report, we evaluate the effects of a 21-substituted-19-nor-progestin, CDB-4124, on 7,12,-dimethylbenz(a)anthracene (DMBA)-induced mammary carcinogenesis in rats in comparison with RU486. Sprague-Dawley female rats were treated with DMBA at 50 days of age in order to induce mammary tumors. When the tumors reached the size of 10-12 mm, the animals were treated for 28 days with the vehicle, RU486, progesterone, CDB-4124 at various doses, or CDB-4124 plus progesterone. Anti-progestins resulted in the regression in the size of the existing tumors, and in the suppressed development of new tumors and tumor multiplicity. Progesterone treatment, however, increased the size and multiplicity. Progesterone rendered an increased number of growing tumors as compared to the regression in the anti-progesterone treatment groups. The combination of CDB-4124 and high doses of progesterone opposed the efficacy of CDB-4124. The growth inhibitory effects of the anti-progestins were correlated with increased apoptosis and reduced cell proliferation. These results indicate that anti-progestins should be developed for the chemoprevention and treatment of hormone-responsive breast cancer.

Removal of etonogestrel contraceptive implants in the operating theater: report on 28 cases

OBJECTIVES

We describe removal procedures for etonogestrel contraceptive implants in the operating theater. In addition, we discuss the management of removal of contraceptive implants that are difficult to palpate or are impalpable.

DESIGN

We conducted a retrospective single-center case series analysis of Implanon removals conducted at a university hospital between January 2002 and April 2005.

MATERIALS AND METHODS

We analyzed case notes for 28 patients who had their contraceptive implant removed in the operating theater.

RESULTS

Intermenstrual bleeding was the principal reason for removal (52.4%). Ten patients already had one attempted removal of their implant. Preoperative ultrasound localized the implant in all cases. Half of the removals were done under local anesthetic, with three cases progressing to general anesthesia (11%). Thirty percent of the implants had migrated from their initial implantation, 37% were in intramuscular tissue and 11% were in the humeral neurovascular sheath. The only postoperative complications were one small seroma and transient paresthesia in the territory of the ulnar nerve. The implant was not found in one case.

CONCLUSIONS

The removal of an implant that is not palpable or difficult to palpate should take place in the operating theater following localization by ultrasound. Patients must be fully informed about the procedure, including its complications and the risk for failure.

Ultrasound localisation and removal of non-palpable Implanon implants

BACKGROUND

Implanon is the trade name for a contraceptive implant that releases etonogestrel over a 3-year period. The rod is inserted into the subdermis of the upper arm. The implant should be palpable and easily removed through a small incision.

AIMS

To determine whether ultrasound is an accurate means of localising and guiding removal of non-palpable Implanon implants.

METHODS

All patients referred to The Northern Hospital, between March 2002 and October 2005, for localisation and/or removal of their non-palpable Implanon implants were included in this study. Ultrasound was used to locate the implants, the implant was considered localised when a linear echogenic rod with posterior acoustic shadowing was identified. When removal of the implant was requested and the implant was clear of neurovascular structures, blunt dissection was performed under ultrasound control and the implant was extracted. If the implant was considered too close to major neurovascular structures, the position of the implant was marked and the patient was referred for surgical removal.

RESULTS

Thirty-four women were included in the study. In 33 patients the implant was identified. In one patient no implant was found and its absence was confirmed by serum assay. Twenty-four patients were referred for implant removal. In 20 patients the implant was successfully removed under ultrasound guidance. In the other four patients the implant was close to neurovascular structures. The position of the implants was marked and surgical removal was successfully performed.

CONCLUSION

Ultrasound is highly accurate at localising and guiding removal of non-palpable Implanon implants.

Chronic inhibition of cardiac Kir2.1 and HERG potassium channels by celastrol with dual effects on both ion conductivity and protein trafficking

A high percentage of drugs and drug candidates has been found to cause cardiotoxicity by reducing potassium conductance, more commonly known as QT prolongation. However, some compounds do not show direct block of ionic flow, suggesting that other mechanisms may also lead to reduction of potassium currents. Using the functional recovery after chemobleaching (FRAC) assay, we have examined a collection of drugs and drug-like compounds for potential perturbation of cardiac potassium channel trafficking. Here we report that a significant number of inhibitory compounds displayed effects on channel expression on the cell surface. Further investigation of celastrol (3-hydroxy-24-nor-2-oxo-1 (10),3,5,7-friedelatetraen-29-oic acid), a cell-permeable dienonephenolic triterpene compound, revealed its potent inhibitory activity on both Kir2.1 and hERG potassium channels, causal to QT prolongation. In addition to acute block of ion conduction, celastrol also alters the rate of ion channel transport and causes a reduction of channel density on the cell surface. In contrast, celastrol has no effects on trafficking of either CD4 or CD8 membrane proteins. Furthermore, the potency for reducing surface expression is approximately 5-10-fold more effective than that for either direct acute inhibition or reported cytoprotectivity via activation of the heat shock transcription factor 1. Because the reduction of potassium channel activity is a common form of druginduced cardiotoxicity, the potent inhibition of cell surface expression by celastrol underscores a need to evaluate drug candidates for their chronic effects on biogenesis of potassium channels. Our results suggest that chronic exposure to certain drugs may be an important aspect of acquired QT prolongation.

Unintended pregnancies with the etonogestrel implant (Implanon): a case series from postmarketing experience in Australia

This paper describes a case series of over 200 unintended pregnancies associated with the etonogestrel implant, Implanon. These cases have been reported to the Australian Adverse Drug Reactions Advisory Committee during the first 3 years of marketing in this country. Of 218 cases included, 45 had insufficient data to assess the reason for contraceptive failure and 46 women were determined to have been already pregnant prior to Implanon insertion. Of the remaining 127 cases, the most common reason for unintended pregnancy was failure to insert the implant in 84 women. Other reasons included incorrect timing of insertion (19 cases), expulsion of Implanon (3 cases) and interaction with hepatic enzyme-inducing medicines (8 cases). The remaining 13 cases were classified as product/method failures once other reasons had been excluded. Using the 204,486 Implanon devices subsidized in this period to estimate the population exposed and the 218 pregnancies reported, the approximate failure rate in postmarketing use was 1 in 1000 insertions. These findings (and reports to medical indemnity insurers) have resulted in the development of guidelines and training for doctors inserting Implanon in Australia.

Ethinylestradiol/Drospirenone

Ethinylestradiol 30microg/drospirenone 3mg (Yasmin, petibelle) [EE/DRSP] is a combined contraceptive pill (CC) for the prevention of pregnancy in women of reproductive age. Drospirenone is a novel progestogen with antimineralocorticoid, progestogenic and antiandrogenic activity. The theoretical (0-0.07) and corrected (0.41-0.71) Pearl indices and pregnancy ratios (0.3-0.84) in young, healthy women aged 18-35 years (or 18-30 years if smokers) given 13-26 cycles of EE/DRSP in large multi-center trials indicate that this CC is highly effective in preventing pregnancy. EE/DRSP is equally as effective as ethinylestradiol 30microg/desogestrel 150microg (EE/DSG; corrected Pearl index 0.28-0.41) in preventing pregnancy. EE/DRSP is generally well tolerated. The frequency and type of adverse event reported in clinical trials are typical of those observed with other CCs, and comparable to those in women receiving EE/DSG. The incidence of intermenstrual bleeding (spotting, breakthrough bleeding or both) during treatment with EE/DRSP in young, healthy women decreased rapidly after the first cycle to 9 to 18% in the second cycle and 6% after 26 cycles, indicating good cycle control. The incidence of intermenstrual bleeding was similar in recipients of EE/DSG (9 and 14% in cycle 2 and 10% in cycle 26). Bodyweight was maintained +/- 2kg in most young women who received EE/DRSP for up to 26 cycles. Neither EE/DRSP nor EE/DSG showed clinically significant effects on blood pressure. EE/DRSP improved premenstrual and menstrual symptoms (negative affect, water retention, increased appetite) compared with baseline in a noncomparative trial. A similar improvement in skin condition (acne, seborrhea) was observed in women receiving EE/DRSP or ethinylestradiol 35microg/cyproterone acetate 2mg in a randomized, double-blind trial.

CONCLUSIONS

Data from several 1- to 2-year studies show that EE/DRSP is an effective oral contraceptive, with Pearl index values similar to those of established low-dose CCs. This combination is well tolerated, demonstrating good cycle control and a beneficial effect on skin condition and well-being (including some premenstrual and menstrual symptoms). EE/DRSP has demonstrated similar efficacy and tolerability to EE/DSG, but long-term clinical experience is required to establish the position of EE/DRSP among other available CCs and to clarify any potential tolerability advantages. Nevertheless, because the management of tolerability is complicated by the idiosyncratic nature of the response of women to CCs containing different progestogens, EE/DRSP appears to be a useful treatment option for women desiring oral contraception.

Antimineralocorticoid activity of a novel oral contraceptive containing drospirenone, a unique progestogen resembling natural progesterone

Sex hormones are known to interfere with the renin-angiotensin-aldosterone system (RAAS) in two ways. First, estrogens strongly stimulate the production of renin substrate (angiotensinogen), leading to increased levels of angiotensin and aldosterone, and sodium retention. Second, progesterone is a potent aldosterone antagonist, which acts on the mineralocorticoid receptor to prevent sodium retention. In combined oral contraceptives, progestogens devoid of antimineralocorticoid and antiandrogenic activity are unable to counteract the sodium-retaining effect of the ethinylestradiol component. As a consequence, these preparations may increase fluid retention, and promote related symptoms such as edema and body weight. Drospirenone is a new progestogen with antimineralocorticoid and antiandrogenic activity. The relationship between the progestogenie and antimincralocorticoid potency of drospirenone is similar to that of endogenous progesterone. At a dosage that suppresses ovulation, drospirenone induces mild natriuresis, which is followed by compensatory stimulation of the RAAS (comparable to a low sodium diet). An oral contraceptive containing 3 mg drospirenone and 30 microg ethinylestradiol. (Yasmin, Schering AG, Berlin, Germany) provides reliable contraception and, due to a lack of sodium retention, may counteract cyclical weight gain and other symptoms related to estrogen-induced fluid retention.

Is [symbol: see text] Yasmin a "truly different" pill?

A combined oral contraceptive (COC) containing the progestogen drospirenone (pronounced dro-spi-re-known) plus the oestrogen ethinylestradiol ([symbol: see text] Yasmin--Schering Health Care) is now available in the UK. Company advertising claims that Yasmin is "truly different", as reliable and safe as other COCs and is "the pill for well-being", with "no associated weight gain" and "a demonstrable positive effect" on premenstrual symptoms and skin condition. Such claims have also appeared in the lay media. Are they justified?

Clinical performance of the levonorgestrel intrauterine system in routine use by the UK Family Planning and Reproductive Health Research Network: 5-year report

OBJECTIVES

This study was undertaken to determine the performance of the levonorgestrel intrauterine system (LNG IUS) in British women in routine clinical use.

DESIGN

Doctors working in general practice and at family planning clinics throughout the UK who collaborate in the UK Family Planning and Reproductive Health Research Network were responsible for the fitting of 678 LNG IUSs.

RESULTS

Gross cumulative event rates at 5 years per 100 women were pregnancy 1.0, expulsion 5.9, removal for bleeding problems 16.7, removal for pain 4.3, and removal for pelvic inflammatory disease (PID) 1.2. Removals were also required for side effects that may be due to absorbed levonorgestrel. Positive effects include effective contraception and considerably reduced quantity of bleeding for most participants.

CONCLUSIONS

A need was identified to counsel women about the early bleeding problems including the possibility of oligomenorrhoea or amenorrhoea. This is considered to be very important as it will help women to persevere so that they can enjoy the longer-term benefits.

Efficacy of the levonorgestrel intrauterine system in treating menorrhagia: actualities and ambiguities

OBJECTIVE

To review the literature on usage of the levonorgestrel intrauterine system (LNG IUS) in women with fibroids or adenomyosis in an attempt to develop a pragmatic approach when faced with enlarged uteri.

DATA SOURCES

Computerised searches of MEDLINE and EMBASE up to December 2000. Some of the information was obtained from references listed in the primary sources and references already known to the authors.

STUDY SELECTION

Studies and case reports were excluded if they did not specifically provide information about LNG IUS usage in women with fibroids and adenomyosis.

DATA EXTRACTION AND SYNTHESIS

After perusal, each relevant publication was summarised and appraised in terms of whether it contained information relevant to the stated objective.

DISCUSSION

This area is sparsely researched, as there were no randomised-controlled studies. One large contraceptive study suggests the LNG IUS has a protective effect from the complications of uterine fibroids and smaller case studies suggest it is also useful in women with symptomatic fibroids. However, there is also evidence of an increased risk of expulsion and there may be a place for initial adjunctive medical treatment to minimise this risk. An observational study and isolated reports of women with adenomyosis report significant symptomatic relief in these women.

CONCLUSION

Available data refute the notion that uterine enlargement is a contraindication to insertion of the LNG IUS, but there appear to be reasons for a cautious approach when dealing with pathological uteri.

IL-15 regulation in human endometrial stromal cells

A greater knowledge of IL-5 regulation within human endometrium is important in understanding key reproductive events and uterine Natural Killer cell function. In the present study, expression of IL-15 mRNA was shown to be up-regulated by both PGE(2) and IFN-gamma in cultures of human endometrial stromal cells (ESC). Release of IL-15 protein was also shown to be under the control of PGE(2) and IFN-gamma using an enzyme-linked immunosorbent assay for IL-15. In addition, 8-Bromo cAMP was able to increase IL-15 release from ESCs (P < 0.005) implying the actions of PGE(2) may be via this second messenger. Addition of a progestin appeared to enhance these effects. Real-time quantitative PCR has demonstrated an up-regulation in IL-15 mRNA expression in the late secretory phase of the menstrual cycle (P < 0.005) and a progressive rise in IFN-gamma expression throughout the secretory phase and into first trimester decidua. These results suggest that IL-15 regulation in the human endometrium is complex and that hormonal control may be indirect.

Mammographic density changes during different postmenopausal hormone replacement therapies

OBJECTIVE

To determine the degree of change in mammographic breast densities during different types of postmenopausal hormone replacement therapies.

DESIGN

A retrospective study.

SETTING

Ege University Hospital.

PATIENT(S)

The mammographies of 216 women on various postmenopausal hormone replacement therapies were evaluated.

INTERVENTION(S)

Estrogen alone (n = 76) or estrogen in cyclic (n = 44) or continuous (n = 61) combination with progestin or tibolone-only (n = 35) replacement therapies were used. Mammographic density was quantified according to the Wolfe classification in patients with different hormone replacement regimens.

MAIN OUTCOME MEASURE(S)

Mammographic density changes were interpreted.

RESULT(S)

An increase in mammographic density was much more common among women receiving continuous combination hormone replacement therapy 31.1% (19 of 61) than among those receiving estrogen-only 3.9% (3 of 76) treatment. There were no significant mammographic breast density changes among women receiving cyclic continuous combination hormone replacement therapy or tibolone-only treatment. The increase in density was apparent already at first visit after the start of hormone replacement therapy. In continuous combined postmenopausal hormone replacement therapy with norethisterone acetate, the increase in mammographic density was 34.1% (15 of 44), followed by medroxyprogesterone acetate 23.5% (4 of 17).

CONCLUSION(S)

Our findings show that mammographic breast density changes related to postmenopausal hormone replacement therapy are dependent on the selected hormone regimen. The continuous administration of the progestin component of the combined-hormone replacement therapy seems to effect the breast density most.

Clinical breast and pelvic examination requirements for hormonal contraception: Current practice vs evidence

Clinical breast and pelvic examinations are commonly accepted practices prior to provision of hormonal contraception. Such examinations, however, may reduce access to highly effective contraceptive methods, and may therefore increase women's overall health risks. These unnecessary requirements also involve ethical considerations and unwittingly reinforce the widely held but incorrect perception that hormonal contraceptive methods are dangerous. This article reviews and summarizes the relevant medical literature and policy statements from major organizations active in the field of contraception. Consensus developed during the last decade supports a change in practice: hormonal contraception can safely be provided based on careful review of medical history and blood pressure measurement. For most women, no further evaluation is necessary. Pelvic and breast examinations and screening for cervical neoplasia and sexually transmitted infection, while important in their own right, do not provide information necessary for identifying women who should avoid hormonal contraceptives or who need further evaluation before making a decision about their use.

Human progesterone receptor shows differential sensitivity to carboxyl group modifying agents when bound to agonist and antagonist ligands

BACKGROUND

Modulation of human uterine progesterone receptor (PR) in relation to its binding to synthetic steroids with known agonist (R5020) and antagonist (triamcinolone acetonide, T.A.) properties was studied in the presence of the specific carboxyl group modifiers, N,N'-dicyclohexylcarbodiimide (DCCD) and 1-ethyl-3-carbodiimide hydrochloride (EDC).

METHODS

Uterine cytosol was treated with DCCD or EDC. The amounts of total bound were detected using the steroid binding measurements. The formation and transformation of progesterone-receptor complexes (PRc) were analyzed using sedimentation rate analysis.

RESULTS

Our studies show that the modification of the COOH group differentially influences the properties of mammalian PR binding with either R5020 or T.A. DCCD and EDC affect the steroid binding of PR by decreasing the binding sites, not by the changing the affinity.

CONCLUSION

Our studies indicate the importance of the carboxyl group in steroid binding by PR. This implies that both aspartic acid and glutamic acid residues, which have the carboxyl group, may play an important role when PR binds with steroid ligands.

The acceptability of a novel oral contraceptive containing drospirenone and its effect on well-being

Low-dose combined oral contraceptives are generally well tolerated and represent an excellent reversible form of contraception that is suitable for most women. Certain aspects of the clinical profile of combined oral contraceptives, such as intermenstrual bleeding and a tendency to weight gain, are, however, known to have an adverse effect on compliance, which may in a few women lead to contraceptive failure or pill discontinuation. Conversely, factors that have a positive effect, such as relief from the symptoms of premenstrual syndrome, can enhance compliance. An oral contraceptive that minimizes the adverse and enhances the positive effects would, therefore, be likely to improve compliance. Recently, a new combined oral contraceptive containing 30 microg ethinylestradiol and 3 mg drospirenone (Yasmin, EE/DRSP) has been developed. The pharmacological profile of drospirenone is very similar to that of natural progesterone; in particular, it has antimineralocorticoid activity. This counteracts estrogen-mediated fluid retention, resulting in stable or slightly lowered body weight. In addition, drospirenone has antiandrogenic activity and therefore a positive effect on skin conditions. Present data also indicate that EE/DRSP has a favorable effect on the symptoms of premenstrual syndrome. In order to evaluate whether the positive effects of drospirenone on body weight, skin and the symptoms of premenstrual syndrome are also observed on well-being, a survey was carried out. This asked women who had been involved in two major clinical trials how they felt after these trials had ended, in comparison with the study periods when they were taking EE/DRSP or a combined oral contraceptive containing 30 microg ethinylestradiol/150 microg desogestrel (Marvelon, EE/DSG). The returned questionnaires demonstrated that, with respect to their disposition before and during menses, women who had taken EE/DRSP felt worse after the trial had ended and they had returned to taking a conventional preparation. This was also evident on the basis of their body weights and the condition of their skin and hair. These results from clinical trials with EE/DRSP indicate that it is a well-tolerated combined oral contraceptive that has a positive effect on body weight, skin and the symptoms of premenstrual syndrome. Overall, the combination of 30 microg ethinylestradiol/3 mg drospirenone appears to improve specific aspects associated with feelings of well-being, which may result in better compliance.

The contraceptive profile of a new oral contraceptive with antimineralocorticoid and antiandrogenic effects

Yasmin (Schering AG, Berlin, Germany), a new oral contraceptive containing 30 microg ethinylestradiol combined with 3 mg drospirenone, effectively inhibits ovulation, as demonstrated by measurement of plasma hormone levels (follicle stimulating hormone, luteinizing hormone, estradiol and progesterone), and echographic evaluation of follicular ripening. Like other low-dose oral contraceptives, the combination of ethinylestradiol and drospirenone markedly limits cervical function, spinnbarkeit and degree of crystallization, resulting in a hostile environment for sperm penetration. Two large, randomized, multicenter, open-label clinical studies have compared the contraceptive efficacy of ethinylestradiol/drospirenone with that of Marvelon, a well-established contraceptive containing 30 microg ethinylestradiol plus 150 microg desogestrel. Both preparations provided effective contraception and good cycle control. There were no negative effects on hemostatic parameters, lipids and carbohydrate metabolism. However, in both studies, ethinylestradiol/drospirenone had a more favorable effect on body weight than ethinylestradiol/desogestrel, with mean body weight remaining lower in the ethinylestradiol/ drospirenone group, the difference between the two preparations being statistically significant. Pre-existing acne and seborrhea were improved by ethinylestradiol/ drospirenone and blood pressure was essentially unchanged. These studies show that ethinylestradiol/drospirenone provides effective oral contraception, excellent cycle control and good tolerability, with effects on body weight and skin condition that are likely to confer a significant beneficial effect on compliance, especially in women with a tendency to gain weight under oral contraceptives due to water retention.

Drospirenone--a new progestogen with antimineralocorticoid activity, resembling natural progesterone

In the second half of a normal menstrual cycle, progesterone levels rise. Progesterone binds to its specific receptor, but also to the mineralocorticoid receptor; thus progesterone acts as a mineralocorticoid antagonist. For this reason, natriuresis is slightly enhanced in the luteal phase, and, as a reflection of the negative sodium balance, plasma renin and aldosterone rise by 20-50%. This rise is of a compensatory nature, and prevents further sodium losses. All conventional synthetic progestogens, whether they are derivatives of 17alpha-hydroxyprogesterone or 19-nortestosterone, lack the antimineralocorticoid effect of natural progesterone. Ethinylestradiol, as the estrogenic component of combined oral contraceptives, is a sodium-retaining drug. This effect is mainly due to a significant increase of the hepatic synthesis of renin substrate (angiotensinogen). Even with low-dose oral contraceptives, systolic and diastolic blood pressure may be raised in susceptible individuals. Drospirenone is a new progestogen, derived from 17alpha-spirolactone, and the relationship between its progestogenic and its antimineralocorticoid potency is almost identical to that of natural progesterone. In an early preclinical study in 12 normal young women, it was found that the oral administration of 2 mg drospirenone for 6 days led to a cumulative sodium loss of 84 mmol and a significant rise in plasma renin and aldosterone, compared with placebo. In a second experiment, it was found that 2 mg drospirenone given from cycle days 5 to 25 to six regularly menstruating women suppressed ovulation and led to a slight natriuresis without a change in blood pressure, while renin and aldosterone levels slightly increased. The natriuresis and the increase in renin and aldosterone levels did not occur in six other women who received 1 mg cyproterone acetate (a progestogen with antiandrogenic properties), instead of drospirenone. Consequently, an oral contraceptive was designed containing 30 microg ethinylestradiol and 3 mg drospirenone (Yasmin, Schering AG, Berlin, Germany) in the hope of developing a contraceptive that might prevent the sodium retention brought about by the effect of ethinylestradiol. In a 6-month study involving 20 regularly menstruating women, it was shown that the addition of drospirenone to ethinylestradiol did indeed prevent the small rise in body weight and blood pressure observed in some women taking a conventional oral contraceptive. In all studies conducted so far with Yasmin, cycle control and tolerability have been found to be good. In conclusion, Yasmin may become an especially well-tolerated combined oral contraceptive, due to the striking similarity between its progestogenic component drospirenone and progesterone.

Yasmin--a new oral contraceptive, a new progestogen: the reasons why

There are over 60 million women using oral contraceptives worldwide, yet there are wide differences between different countries in the use of oral contraceptives and, in particular, in discontinuation rates. Large differences in rates of sterilization and of teenage pregnancy also highlight the fact that there are considerable geographical differences in oral contraceptive use. There are probably many reasons for these differences, including lack of information about the non-contraceptive benefits of oral contraceptives, differences in national health-care policies and systems, women's fears about side-effects and possible side-effects, and social, cultural and religious differences. In order to provide better choices of oral contraceptives, there is a need to consider new oral contraceptives, such as Yasmin (Schering AG, Berlin, Germany), which is formulated with ethinylestradiol and drospirenone, a progestogen which is pharmacologically very similar to progesterone. Unlike other progestogens, drospirenone is associated with weight stability or slight weight loss due to less water retention, one of the factors which is known to be of great importance in supporting compliance with oral contraceptives. Drospirenone also shares with some other progestogens the capacity to improve acne and seborrhea in hyperandrogenic women. Taken together, these properties make it likely that the combination of ethinylestradiol with drospirenone will contribute to improving oral contraceptive compliance, thereby maximizing the overall benefits of oral contraception.