Breast cancer among young U.S. women in relation to oral contraceptive use.

BACKGROUND: While most studies have found no association between oral contraceptive use and breast cancer, several studies of younger women have reported an association with long-term oral contraceptive use. PURPOSE. We studied the relationship of patterns of oral contraceptive use to breast cancer risk among younger women. These women have had oral contraceptives available their entire reproductive lives and are now entering the breast cancer-prone years. METHODS: A population-based, case-control study of breast cancer was conducted in three counties in western Washington State among women born in 1945 or later, ages 21-45. Case patients were 747 women with breast cancer diagnosed in 1983-1990 and identified through the Seattle-Puget Sound Surveillance, Epidemiology, and End Results cancer registry. Control subjects were 961 women identified by random-digit telephone dialing. Subjects were interviewed in person, using pictures of brands of oral contraceptives and calendars of life events as recall aids. RESULTS: There was no increased incidence of breast cancer associated with ever having used oral contraceptives. Because only 8% of this cohort had never used oral contraceptives, short-term users (< 1 year) were combined with never users as the reference group for further analyses. A small increased risk of breast cancer was associated with long duration of oral contraceptive use (odds ratio for > or = 10 years = 1.3; 95% confidence interval [CI] = 0.9-1.9; P for trend = .03), particularly among women aged 35 years or younger (odds ratio for > or = 10 years = 1.7; 95% CI = 0.9-3.1). Breast cancer was also modestly related to oral contraceptive use early in reproductive life (odds ratio for use within 5 years of menarche = 1.3; 95% CI = 1.0-1.8; P for trend = .04) and to use of high-progestin-potency oral contraceptives for at least 1 year (odds ratio = 1.5; 95% CI = 1.1-2.1). These associations were adjusted for age, age at menarche, term pregnancy, induced abortion, and family history of breast cancer. The associations were not further confounded by case-control differences in education, religion, breast feeding of offspring, or infertility; in oral contraceptive contraindications, indications, or complications; or in measures of breast cancer detection such as mammography or breast biopsy. CONCLUSIONS: Long-term oral contraceptive use among young women or use beginning near menarche may be associated with a small excess breast cancer risk, possibly due to susceptibility to genetic damage in breast epithelial cells at ages of high breast cell proliferative activity. IMPLICATIONS: Future studies should investigate whether the patterns of risk we reported are present as this cohort ages.

PIP: A case control study was conducted in Washington among 21-45 year old white women from King, Pierce, and Snohomish counties (i.e., Seattle metropolitan area) to examine the relationship between oral contraceptive (OC) use and breast cancer. The 747 cases were diagnosed with invasive breast cancer between January 1983 and April 1990. The researchers combined short term OC users with never users since just 8% of all subjects had never used OCs. They controlled for age, age at menarche, term pregnancy, induced abortion, and family history of breast cancer. Longterm use (i.e., =or 10 years) of OCs was associated with a small increased risk of breast cancer (odds ratio [OR] = 1.3; p for trend = 0.03), especially among women not older than 35 years (OR = 1.7). This finding was consistent with results of other studies. OC use early in reproductive life (i.e., within 5 years of menarche) was also associated with a moderate increase in breast cancer (OR = 1.3; p for trend = 0.04). Breast cancer risk was also elevated among women who used high progestin potency OCs (as defined by the Dickey method for classifying OC potency) for at least 1 year (OR = 1.5). Case control differences in education, religion, breast feeding of children, or infertility; in OC contraindications, indications, complications; or in measures of breast cancer detection (e.g., mammography or breast biopsy) did not confound the associations. An association between breast cancer and long term OC use among young women and OC use beginning close to menarche suggest that puberty, a time when breast epithelial cells are undergoing considerable proliferative activity, are susceptible to genetic damage. Further research is needed to determine whether the aforementioned patterns of breast cancer risk continues as the cohort becomes older.

Effects of the antifertility drug enovid in five strains of mice, with particular regard to carcinogenesis.

PIP: The antifertility drug, Enovid, was tested for possible carcinogenicity in female mice of 5 specially selected strains: BALB/c, C3H, C3HfB, A, and C57BI. Enovid was chosen for testing since it is one of the most widely used oral contraceptives. The 5 strains of mice provided maximum genetic variation in the test animals. The drug was fed at 3 dose levels: 5 mcg/gm, 10 mcg/gm and 20 mcg/gm of food. The lowest dose did not prevent reproduction. The 10 mcg dose prevented some females from reproducing. The 20 mcg dose prevented all females from reproducing. The strains of mice differed in their response to Enovid. Weight gain was reduced in all strains. Effect on life-span varied, partly because of the tumors. Cervical and vaginal lesions showed invasion of the epithelium into the stroma but was limited, with few exceptions to the BALB/c females. In the BALB/c strain these lesions occurred in controls as well, but showed more progression and a higher incidence with the highest dose of Enovid. None of these lesions appeared grossly as tumors and none had extended beyond the vaginal wall or metastasized. They were observed only on histologic sections. Neither ovarian nor mammary gland tumors were increased in any strain. In the C3H strain such tumors seemed to be inhibited. In the C3HfB strain there was some inhibition of hepatomas and in the BALB/c strain some inhibition of adrenocortical adenoma. Chromophobe adenomas of the hypophysis were significantly increased in old C57BI females treated with the highest dose of Enovid. Offspring of Enovid-treated females showed no abnormalities. Enovid increased the occurrence and may have advanced the progression of epithelial lesions of the cervix and vagina of old BALB/c females. A study of the lesions in untreated females of this strain might help the understanding of carcinoma in situ in women and possibly the appearance of adeno-carcinoma of the vagina of young women whose mothers had been treated with stilbestrol during the first trimester to maintain pregnancy. Other neoplasms in this strain were not increased by the Enovid therapy. In the C3H strain mammary tumors were reduced by the Enovid and those that did occur were found later than in controls. Results from experimental animals should be applied to humans with care. Such results are of greatest value in directing attention to certain areas for investigation.^ieng

Estrogens and the hypothalamo-pituitary-adrenal axis in man: evidence for normal feedback regulation by corticosteroids.

Estrogen treatment and pregnancy are associated with higher than normal plasma free (nonprotein-bound) cortisol levels. In spite of this, clinical manifestations of steroid excess are not seen in these conditions. To explain this seeming discrepancy, it has been postulated that estrogens may induce tissue resistance to the actions of cortisol, and that one aspect of this resistance may be a higher set-point for ACTH suppression by corticosteroids. This possibility was studied in seven normal women. Plasma total and free cortisol levels as well as urinary cortisol excretion were measured during a control period and during treatment with ethinyl estradiol (100 micrograms/day). During both periods, graded doses of dexamethasone (0.2-mg increments; 0-1.4 mg/day) were administered. Estrogen treatment resulted in elevated plasma total and free cortisol levels, but urinary cortisol excretion was not affected. Dexamethasone administration resulted in a dose-dependent reduction of plasma total and free cortisol as well as urinary cortisol. The dose-response curve for suppression by dexamethasone of urinary cortisol during estrogen treatment was indistinguishable from that during the control period. The dose-response curve for plasma free cortisol suppression suggested that during estrogen treatment, slightly more dexamethasone was required to suppress free cortisol. However, this effect was small. In view of the overall data, we conclude that 1) estrogen does not increase integrated free cortisol prevailing in vivo; 2) estrogen does not significantly alter the hypothalamic or pituitary set-point for ACTH suppression by corticosteroid; 3) the elevation of plasma free cortisol is relatively minor and possibly an in vitro phenomenon; and 4) the present findings are compatible with the absence of clinical hypercorticism in hyperestrogenized states.

Contraception in hypertensive women using a vaginal ring delivering estradiol and levonorgestrel.

Contraception with a vaginal ring (CVR) that delivers estradiol and levonorgestrel was used during a mean of 15.6 menstrual cycles in 12 hypertensive women. Blood pressure (BP) was measured 5 times on each visit during 2 pretreatment control cycles; during the 1st, 2nd, 4th, 6th, and from the 9th to 12th cycles of CVR use; and again after a 1-month recovery period. No significant change in BP occurred during CVR use in any of the subjects. Plasma renin substrate and antithrombin III activity did not vary significantly, which suggests the utility of administering natural estradiol via the vagina, thus avoiding the first pass effect that occurs with oral contraceptives. Significant decreases in plasma sex hormone-binding globulin, cholesterol, high density lipoprotein cholesterol, phospholipids, and triglycerides occurred, indicating an androgenic effect of levonorgestrel. We conclude that the CVR is a method of contraception that does not elevate BP in hypertensive women.

PIP: Contraception with a vaginal ring (CVR) that delivers estradiol and levonorgestrel was used during a mean of 15.6 menstrual cycles in 12 hypertensive women. Blood pressure (BP) was measured 5 times on each visit during 2 pretreatment control cycles; during the 1st, 2nd, 4th, 6th, and from cycles 9-12 of CVR use; and again after a 1-month recovery period. No significant change in BP occurred during CVR use in any of the subjects. Plasma renin substrate and antithrombin III activity did not vary significantly, which suggests the utility of administering natural estradiol via the vagina, thus avoiding the 1st pass effect that occurs with oral contraceptives. Significant decreases in plasma sex hormone-binding globulin, cholesterol, high density lipoprotein cholesterol, phospholipids, and triglycerides occurred, indicating an androgenic effect of levonorgestrel. The authors conclude that the CVR is a method of contraception which does not elevate BP in hypertensive women.

Establishing the minimum effective dose and additive effects of depot progestin in suppression of human spermatogenesis by a testosterone depot.

Hormonally induced azoospermia induced by weekly im injections of testosterone enanthate provides effective and reversible male contraception, but more practical regimens are needed. Given our previous findings that six 200-mg pellets implanted subdermally produced more stable, physiological T levels and reduced the delivered T dose by more than 50% while maintaining equally effective suppression of sperm output with fewer metabolic side-effects than weekly 200-mg testosterone enanthate injections, we sought in this study to determine 1) whether further dose-sparing could be achieved by lower testosterone doses while maintaining efficacy and 2) the efficacy of adding a depot progestin to a suboptimally suppressive depot testosterone dose as a model depot progestin/androgen combination male contraceptive. Healthy volunteers were randomized into groups (n = 10) who received either of two lower T doses (two or four 200-mg T pellets) or four 200-mg T pellets plus a single im injection of 300 mg depot medroxyprogesterone acetate (DMPA). Two T pellets (400 mg, 3 mg/day) had a negligible effect on sperm output. Four T pellets (800 mg, 6 mg/day) suppressed sperm output between the second to fourth postimplant months; output returned to normal by the seventh postimplant month, although only 4 of 10 men became azoospermic or severely oligozoospermic (< 3 mol/L/mL). The addition of a depot progestin markedly increased the extent, but not the rate, of sperm output suppression, with 9 of 10 becoming azoospermic and 10 of 10 becoming severely oligozoospermic. There were no serious adverse effects during the study. Plasma total and free testosterone levels remained within the eugonadal range at all times with each treatment. Plasma epitestosterone was suppressed by all 3 regimens, consistent with a dose-dependent inhibition of endogenous Leydig cell steroidogenesis. Plasma LH and FSH measured by a two-site immunoassay were suppressed in a dose-dependent fashion by T and further suppressed by the addition of DMPA. Sex hormone-binding globulin levels were decreased by DMPA, but not by either T dose. Prostate-specific antigen and lipids (total, low or high density lipoprotein cholesterol, and triglycerides) were not significantly changed in any group. Thus, a depot testosterone preparation with zero order release must be delivered at between 6-9 mg/day to provide optimal (but not uniform) efficacy at inducing azoospermia. The addition of a single depot dose of a progestin to a suboptimal testosterone dose (6 mg/day) markedly enhances the extent, but not the rate, of spermatogenic suppression, with negligible biochemical androgenic side-effects. These findings provide a basis for the use of a progestin/androgen combination depot for hormonal male contraception.

PIP: Clinical research conducted in Australia suggests that a progestin-androgen combination depot has potential for hormonal male contraception. The authors' previous research had indicated that 6 200-mg testosterone enanthate pellets implanted subdermally produced substantial reductions over injections in the delivered testosterone dose while maintaining equally effective suppression of spermatogenesis with few metabolic side effects. The present study sought to determine whether lower testosterone doses would maintain efficiency and to assess the efficacy of adding a depot progestin to a suboptimally suppressive depot testosterone dose (6 mg/day). 10 volunteers received either 2 or 4 200-mg testosterone pellets or 4 200-mg pellets plus a single intramuscular injection of 300-mg depot medroxyprogesterone acetate (DMPA). The testosterone implants alone achieved inadequate suppression of spermatogenesis for a male contraceptive; 400 mg of testosterone (3 mg/day) had a negligible effect on sperm output, while 800 mg (6 mg/day) produced azoospermia or severe oligozoospermia in only 4 of 10 men. However, the addition of DMPA markedly increased the extent, but not the rate, of sperm output suppression: azoospermia was achieved in 9 men and oligozoospermia in all 10 subjects, and sperm suppression persisted for 3 months. Epitestosterone concentrations, used as a marker of Leydig cell steroidogenesis, were decreased in a time- and dose-dependent manner, reaching castrate levels in the combined group. Plasma luteinizing hormone and follicle-stimulating hormone levels were suppressed in a dose-dependent fashion by testosterone and further suppressed by the addition of DMPA. Sex hormone-binding globulin levels were decreased by DMPA, but not by either testosterone dose. Prostate-specific antigens and lipids were not significantly altered by any regimen. There were no discontinuations or reports of side effects.

Combined administration of levonorgestrel and testosterone induces more rapid and effective suppression of spermatogenesis than testosterone alone: a promising male contraceptive approach.

Studies using high dose testosterone (T) administration in normal men as a male contraceptive have resulted in azoospermia rates of only 50-70%. Previous studies of T and progestogen combinations have shown comparable rates of azoospermia, but have been uncontrolled or used T in doses less than that associated with maximal suppression of sperm production. We conducted a randomized, placebo-controlled, single blind trial comparing 6 months of T enanthate administration (100 mg, im, weekly) with the same dose of T enanthate in conjunction with the progestogen levonorgestrel (LNG; 500 micrograms, orally, daily) in 36 normal men, aged 20-42 yr (n = 18 in each group). The primary end points were induction of azoospermia or severe oligospermia (< 3 million sperm/mL). The combination of T plus LNG was much more effective in suppressing sperm production than T alone. Sixty-seven percent of the T plus LNG group (12 of 18) and 33% of the T alone group (6 of 18) achieved azoospermia by 6 months (P = 0.06). Severe oligospermia or azoospermia developed in 94% of the T plus LNG (17 of 18) group compared to 61% of the T alone group (11 of 18; P < 0.05). T plus LNG also suppressed sperm production more rapidly than T alone. Time to azoospermia was 9.9 +/- 1.0 vs. 15.3 +/- 1.9 weeks in the T plus LNG and T alone groups, respectively (mean +/- SEM; P < 0.05). Serum high density lipoprotein cholesterol decreased 21.7 +/- 3.6% in men given T plus LNG (P < 0.05), compared to only a 1.8 +/- 3.8% decrease in men in the T alone group. Average weight gain was 5.3 +/- 0.8 kg in the T plus LNG group and 2.3 +/- 0.9 kg in the T alone group (P < 0.05). Acne and increase in hemoglobin were similar in the two groups. We conclude that combination hormonal therapy with T plus a progestogen might offer a reversible male contraceptive approach with a more rapid onset of action and more reliable induction of both azoospermia and severe oligospermia than T alone.

PIP: In Washington State, 36 men aged 20-42 years were randomly allocated to either the group receiving intramuscular injection of 100 mg/week testosterone (T) enanthate alone or to the group receiving the same dose T plus oral 500 mcg/day levonorgestrel (LNG). This 6-month, placebo-controlled, single blind trial aimed to compare the effectiveness of both regimes in suppressing sperm production. The combination of T plus LNG was more likely than T alone to achieve severe oligospermia or azoospermia in 6 months (94% vs. 61%; p .05). It also achieved azoospermia more quickly than T alone (9.9 vs. 15.3 weeks; p .05). Men in the T plus LNG group experienced greater reduction in serum high density lipoprotein than those in the T alone group (21.7% vs. 1.8%; p .05). They also gained more weight than those in the T alone group (5.3 vs. 2.3 kg; p .05). The two groups experienced a similar rate for acne and increase in hemoglobin. The increase in hemoglobin was significant for both groups. In conclusion, T plus LNG treatment over a 6-month period is a more effective and quicker acting method than T alone for suppressing sperm production to levels low enough to prevent pregnancy.

Biphasic change in pituitary capacity induced by estrogen in hypogonadal women.

PIP: 5 healthy postmenopausal women aged 52-59 years with elevated gonadotropin levels and low estradiol (E2) (10+ or -1.5 pg/mol) concentrations volunteered for this study which measured changes in responses to pulses of luteinizing hormone-releasing factor (LHF) (10 mcg at 2-hour intervals 3 times) and thyroid-releasing factor (TRF) (200 mcg at 2-hour intervals 3 times) for luteinizing hormone (LH), follicle stimulating hormone (FSH), and prolactin (PL) before and during administration of a large dose of ethinyl estradiol (EE) (400 mcg/day) for 5 days. Responses to LRF and TRF stimulation on the 2nd and 5th days of EE treatment were studied in 2 experimental periods in the same individual at an interval of at least 10 weeks between treatments. During 5 days of EE treatment, LH 1st declined (50%) and then returned to the original level, forming a previously observed U-shaped curve. The initial fall in basal FSH level was not followed by a return to pretreatment level. These changes were accompanied by an exponential increase of more than 3-fold in the PL levels. The bidirectional pattern of LH release was associated with parallel changes in pituitary sensitivity to a 10-mcg pulse of LRF. Pituitary reserve, defined as the response to the 2nd and 3rd pulses of LRF, exhibited unidirectional augmentation. This progression in PL release upwards was unaccompanied by changes in pituitary PL sensitivity and reserve. The contribution of hypothalamic LRF and dopamine in the participation of these functional changes of LH, FSH, and PL are discussed.^ieng

Chorea induced by oral contraceptives.

A rare complication of oral contraceptive therapy is the induction of chorea. We here describe five cases of chorea in patients receiving low- or high-dose estrogen-containing contraceptives. All patients were nulliparous, young (average age 19 years), and became symptomatic shortly (average of 5 weeks) after initiation of contraceptive therapy. Two patients previously suffered an episode of Syndenham chorea; one experienced chorea in the course of Henoch-Schönlein purpura; and two had a history of congenital cyanotic heart disease without chorea. Dyskinesia resolved in all patients upon discontinuing the medication. Patients with preexisting striatal abnormalities appear more susceptible to oral contraceptive-induced chorea which is reversible on drug discontinuation. The mechanism of oral contraceptive-induced chorea is unknown, but clinical and experimental data suggest that it involves altered central dopaminergic activity.

PIP: It is known that chorea is a rarely-occurring complication of oral contrceptive therapy. 5 case histories of chorea in patients receiving either low- or high-dose estrogen-containing contraceptives are reviewed. All the patients were young and nulliparous. They developed the symptoms within an average of 5 weeks after therapy initiation. Dyskinesia ceased upon cessation of the oral contraceptive therapy. A summary of 17 previously-reported cases of oral contraceptive-associated chorea is also presented in tabular form. These cases plus the 5 reviewed in this paper suggest that chorea arises in women with abnormalities of the basal ganglia of various etiologies and will probably not occur in normal individuals. Studies with animals have indicated that female sex hormones may enhance central dopaminergic sensitivity, bringing on chorea in oral contraceptive patients. In the 3 of 5 patients here described who had previously experienced an episode of chorea, the contraceptive-induced disorders, i.e., asymmetries, orofacial involvement, and personality changes, were similar to the original movement disorders. The other 2 cases studied here had not experienced a chorea episode but did have a history of neonatal cyanosis.

Antiepileptic medication and oral contraceptive interactions: a national survey of neurologists and obstetricians.

Hepatic enzyme-inducing antiepileptic drugs (AEDs) lower oral contraceptive (OC) sex hormone levels approximately 40% and increase the risk of unplanned pregnancies in women with epilepsy. AEDs also increase the risk of birth defects in offspring of women with epilepsy. We performed a national survey to determine obstetricians' and neurologists' knowledge of OC and AED interactions and the risk of birth defects for women with epilepsy taking AEDs. We received responses to a mailed questionnaire from 160 of 1,000 neurologists (16%) and 147 of 1,000 obstetricians (15%) from 47 states. Practice demographics and ages of responders were typical for U.S. neurologists and obstetricians. Ninety-one percent of neurologists and 75% of obstetricians said they treat women with epilepsy of child-bearing age. Only 4% of the neurologists and none of the obstetricians, however, knew the effects of the six most common AEDs on OCs, even though 27% of neurologists and 21% of obstetricians reported OC failures in their patients taking AEDs. Although increasing OC doses can compensate for insufficient OC sex hormone levels due to AEDs, most physicians do not increase the doses. Even though the risk of birth defects for the offspring of women with epilepsy is 4 to 6%, up from the background level of 2%, 44% of neurologists thought the risk was lower (0 to 3%), and some of the respondents guessed that it was as high as 50%. Many neurologists and obstetricians do not have accurate information to counsel women with epilepsy properly about their contraceptive and pregnancy choices.

PIP: Responses from 160 of 1000 neurologists (16%) and 147 of 1000 obstetricians (15%), selected from an American Medical Association listing to receive a mailed questionnaire, revealed a disturbing lack of knowledge about the interactions between antiepileptic medications and oral contraceptives (OCs). Hepatic enzyme-inducing antiepileptic drugs lower OC estradiol levels by about 40% and may reduce free progestin levels, thereby increasing the risk of unplanned pregnancy; moreover, antiepileptics increase the risk of birth defects in their epileptic users, who already have a 4-6% increased risk of such defects. Physicians can reduce, but not prevent, the risk of unwanted pregnancy by increasing the OC estradiol dose to at least 50 mcg and prescribing valproic acid and gabapentin (non-enzyme-inducing antiepileptics). 91% of neurologists and 75% of obstetricians reported that they treated epileptic women of childbearing age, and 27% of the former and 21% of the latter physicians acknowledged cases of OC failure in these patients. Only 4% of the neurologists and none of the obstetricians knew the effects of the 6 most common antiepileptic drugs on OCs. Just 41% of neurologists and 43% of obstetricians routinely had patients adjust their OC doses if they were taking antiepileptics. Such adjustment was more likely among physicians who had an epileptic patient with an unintended pregnancy and those who had accurate knowledge of OC-antiepileptic drug interactions. 44% of neurologists and 23% of obstetricians underestimated the birth defects risk as 0-3%. Since the physicians who chose to respond to this survey were presumably more concerned and knowledgeable about the reproductive effects of antiepileptic drugs than those who chose not to respond, continuing education efforts are urged to enable health care providers to counsel epileptic women about contraception.

Treatment of seizures with medroxyprogesterone acetate: preliminary report.

Medroxyprogesterone acetate (MPA), a synthetic progesterone, was added to the antiepileptic drug regimen of 14 women who had uncontrolled seizures. Of the 11 women who developed amenorrhea, 7 reported fewer seizures during MPA therapy. Overall reductions in seizure frequency averaged 30% (n = 11), declining from a baseline 8.3 +/- 5.8 seizures per month to 5.1 +/- 4.1 seizures per month (p = 0.02). No serious side effects were encountered, but spotting was common. These preliminary data suggest further evaluation of MPA for catamenial seizures.

PIP: In Connecticut, physicians followed 19 women with tractable epilepsy for 3-5 months to determine baseline seizure frequency. 14 women agreed to enter a clinical trial evaluating synthetic medroxyprogesterone acetate's (MPA) ability to reduce seizure frequency by adding MPA to the usual antiepileptic drug regimen. They all received 10 mg MPA pills 2-4 times each day. 6 women who did experience amenorrhea later received 120-150 mg intramuscular MPA injections (Depo-Provera) every 6-12 weeks instead of oral MPA. The physicians followed the women for 12 months. 11 women eventually experienced amenorrhea and always had low levels of serum progesterone ( or = ng/ml). Seizure frequency fell significantly from a mean of 8.3 seizures/month before MPA administration to 5.1 seizures/month after MPA administration, equaling 39% fewer seizures (p = .02). 7 women who experienced obvious improvement had 52% fewer seizures on average (25-71%) reduction. All women who had fewer seizures did experience partial seizures, however. MPA did not affect the steady state levels of antiepileptic drugs. MPA levels were higher in women receiving oral MPA than they were in those receiving MPA injections (5.2 ng/ml vs. 2.6 ng/ml). Most women had some spotting, particularly during the first few months of the study. Some of these women discontinued treatment because of this side effect, especially women who did not appear to benefit from the treatment. Menstruation returned in 6-12 months in women receiving MPA injections. Further research on MPA's effect on catamenial seizures is needed.

Different effects of two progestins on plasma high density lipoprotein (HDL2) and postheparin plasma hepatic lipase activity.

Two progestins with different androgenic activity were compared for their effects on plasma high density lipoproteins and postheparin plasma lipase activities in premenopausal women. Levonorgestrel, a nortestosterone-derived steroid with androgenic activity reduced plasma HDL cholesterol by 17% (P less than 0.05) and HDL2 cholesterol by 30% (P less than 0.05), without changing the HDL3 cholesterol concentration. At the same time the postheparin plasma hepatic lipase activity was increased by 56% (P less than 0.01) whereas the lipoprotein lipase was not changed. None of these effects was reproduced during administration of medroxyprogesterone acetate, a progestin with low androgenic activity. The results suggest, first, that the decrease of HDL cholesterol observed during treatment with progestins is related to the androgenic activity of the steroid used, and, second, that the change in HDL (HDL2) is caused by androgen-induced increase of hepatic lipase activity.

Synthesis and antifertility activity of some oximinoandrostenes.

PIP: 3-aza-A-homo steroids have been of interest to these authors in their efforts to develop novel progestational agents. Because it exhibits antifertility activity both in humans and animals, 17alpha-ethynyl-19-nortestosterone (norethindrone) was chosen to undergo molecular modification. The syntheses of a number of oximino and 3-aza-A-homoandrostenes are described in the experimental section of the article. The progestational responses of the compounds were tested through the observation of rabbit uteri. The capacity of a compound to inhibit fertility in rate was noted from the minimum effective dose, i.e., the amount of compound in mg/kg per day which completely suppressed litter production (compound given to both male and female). Because of the suspicion that the oximino steroids were acting postcoitally, 17-beta-acetoxy-19-norandrost-4-en-3-one oxime was studied for its postcoital activity in rats. The postcoital antifertility action of the compound appears to be due to lytic degeneration of zygotes and/or their rapid expulsion from the reproductive tract. Some structure-function observations are made concerning the various compounds.^ieng

Effect of oestrogen dose on whole blood platelet activation in women taking new low dose oral contraceptives.

Oral contraceptive use is known to cause changes in the haemostatic system. These changes are thought to be related to oestrogen dose and to provide a possible link between the increased risk of thromboembolic disease known to occur in women taking oestrogen containing oral contraceptives. This study measured whole blood platelet activation, serially, in women taking oral contraceptives containing 20 micrograms and 30 micrograms ethinyloestradiol combined with desogestrel. Increased levels of ADP and arachidonic acid induced aggregation were observed in women taking the 30 micrograms ethinyloestradiol combination. Platelet release of beta-thromboglobulin (beta TG) was also significantly increased. Increased collagen induced aggregation was observed but this failed to reach statistical significance for the individual treatment groups. In women taking the 20 micrograms ethinyloestradiol combination, a significant increase was only observed when platelets were stimulated with arachidonic acid. Platelet factor 4 (PF4) levels were unchanged in both groups. Significantly higher levels of beta TG were observed in women taking the 30 micrograms ethinyloestradiol combination compared with women taking the 20 micrograms ethinyloestradiol combination. These results show that oral contraceptive use is associated with platelet activation. Women taking the 20 micrograms ethinyloestradiol combination show less changes in platelet activation than women taking the 30 micrograms ethinyloestradiol combination. This lower dose pill may therefore be particularly suitable for high risk women wishing to use oral contraception.

PIP: To evaluate the effects of low-dose oral contraceptives (OCs) on platelet function, hematologic measures were compared in 45 Irish women taking OCs containing 20 or 30 mcg of ethinyl estradiol as well as 150 mcg of desogestrel. Serum samples were collected before treatment and at 6, 14, and 22 weeks after OC use commenced. ADP induced whole blood platelet aggregation was significantly increased in users of OCs containing 30 mcg of ethinyl estradiol, reaching a maximum at 22 weeks, but not in users of the low-dose OC. A significant increase in collagen induced aggregation was observed when both groups of OC users were combined, but not when either was tabulated separately. Both groups showed significant increases in arachidonic acid induced aggregation. Platelet count, hematocrit, and platelet factor 4 levels were unaffected. Increased levels of beta-thromboglobulin were observed at 6, 14, and 22 weeks in the 30 mcg group; there was no significant change in the 20 mcg group. Since the low-dose 20 mcg ethinyl estradiol OC produced fewer changes in platelet activation, its use is recommended for women with risk factors for thromboembolic disease.

Changes in haemostatic variables induced by oral contraceptives containing 50 micrograms or 30 micrograms oestrogen: absence of dose-dependent effect on PAI-1 activity.

Several studies have suggested a dose-response relation between the oestrogen content of oral contraceptive (OC) and the risk of both venous thrombosis and arterial disease, when oestrogen doses were higher than 50 micrograms. However, there is no clear epidemiological evidence for a decrease in thrombotic risk with formulations containing less than 50 micrograms oestrogen. Therefore, we investigated haemostatic variables in users of OC containing either 30 micrograms (35 women) or 50 micrograms (29 women) ethinyl estradiol as compared with non users (64 women) matched for age and smoking status. Mean values of antithrombin activity were significantly lower in 30 micrograms or 50 micrograms oestrogen users than in non users (96% and 98% vs 105%, respectively, p < 0.001), but they were not significantly different between the two groups of OC users. There was a significant increase in mean values of factor VII antigen in women taking either 30 micrograms or 50 micrograms oestrogen as compared with non users (96% and 101% vs 85%, respectively, p < 0.005). Although the difference between both groups of OC users was not significant, a positive linear trend in factor VII levels was observed within the 0-50 micrograms oestrogen range (p < 0.001). Mean levels of fibrinogen were slightly higher in 30 micrograms or 50 micrograms oestrogen users than in non users (2.71, 2.66 g/l vs 2.55 g/l, respectively), but there was no significant difference between the three groups.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: In Paris, France, clinicians compared data on 64 women aged 19-40 who used combined oral contraceptives (OCs) for 6-200 months with data on 64 healthy women who did not use OCs for the last two months and who were matched for age and smoking status to investigate activity of plasminogen activator inhibitor 1 (PAI-1), factor VII antigen, fibrinogen concentration, and antithrombin activity in users of OCs containing either 30 mcg or 50 mcg estrogen and in nonusers. OC users exhibited lower mean values of PAI-1 activity than nonusers (4.63-4.89 vs. 6.47 AU/ml; p 0.02). There was no dose-dependent effect of estrogen on PAI-1 activity, however. Antithrombin activity values were much lower in OC users than nonusers (96-98% vs. 105%; p 0.001). The difference between the two groups of OC users was not significant, however. The mean values of factor VII antigen in women using either 30 mcg or 50 mcg estrogen were higher than those for nonusers (96% and 101% vs. 85%, respectively; p 0.005). The difference in factor VII antigen values between the two OC groups was not significant, yet there was a positive linear trend in factor VII levels within the 0-50 mcg estrogen range (p 0.001). No significant difference in the mean fibrinogen levels between the three groups (30 mcg estrogen OC group, 50 mcg estrogen OC group, and nonusers) was observed. Hemostatic variables were not significantly different between 30 mcg estrogen OCs containing 100 mcg, 150 mcg, or 200 mcg levonorgestrel. The researchers could not conduct a valid assessment of the progestogen effect in 50 mcg estrogen OCs due to the wide range of different types of progestogens. These findings suggest an alteration of blood coagulation and fibrinolysis in OC users within the 30-50 mcg estrogen range. Estrogen appears to have a dose-dependent effect on factor VII but no significant effect on PAI-1 activity and other markers of thrombogenic risk and arterial disease risk.

The actions of ethinyloestradiol on the pituitary-adrenal system of the rat.

PIP: A study assessing the effects of estrogen on the pituitary-adrenal axis in rats is reported. In a series of experiments, rats were subjected to single and multiple doses of ethinyl estradiol (EE) and injections of ACTH. Administration of single doses of EE to quiescent rats brought increased plasma and adrenal gland corticosterone concentrations and in vitro corticosteroid production. In animals stressed by ether vapor, the plasma and in vitro corticosterone values were 40% lower than in controls although adrenal corticosterone levels were higher. Treatment with 500 mcg/kg EE per day for 7 days resulted in loss of body weight and hypertrophied, hyperdemic adrenal and pituitary glands in rats sacrificed 1 day after treatment. Rats studied 9 days after treatment showed normal growth and a regression in adrenal size but not in pituitary size. Plasma corticosterone concentration was unchanged 1 day after the 7-day treatment, adrenal weight increased by 58%, and in vivo steroid production was reduced suggesting a distinct hypersecretion of ACTH. Plasma protein binding capacity for corticosterone was unchanged by the 7-day treatment. After 9 days of rest from the EE regimen, an ACTH injection restored in vitro corticosteroid production to normal levels and raised plasma and adrenal content levels in stressed rats which suggests that the adrenal gland regained its function more quickly than the pituitary. Injection with long-acting ACTH caused a 56% increase in adrenal weight and no change in pituitary weight. Adrenal activity was not changed by ACTH treatment suggesting that the adrenal gland was insensitive to an acute release of endogenous ACTH. Inhibition of the pituitary-adrenal response to stress is most likely caused by inhibition of cholesterol synthesis although lack of precursor corticoid secretion due to exhaustion must be considered as a cause. Inhibition of the stress response after extended ACTH treatment is suggested to be due to a decreased sensitivity of the adrenal cortex although a reduction of circulating cholesterol cannot be excluded as a cause.^ieng

The pharmacokinetics of norethisterone in the rabbit and rat after systemic and oral administration: effect of phenobarbitone [proceedings].

PIP: The pharmacokinetics of norethisterone in the rabbit and the rat after systemic and oral administration and the effect of phenobarbitone on pharmicokinetic parameters is presented. Norethisterone was given by iv and oral routes (85 mcg/kg) in the rabbit and by portal administration in the rat. Blood samples were collected over 24 hours in the rabbit and over 2 hours in the rat. Norethisterone was measured in plasma by radioimmunoassay. The plasma concentration-time curve was resolved into values for "fast disposition" half-life, "slow disposition" half-life, and the area under the curve (AUC). In the rabbit, AUC after oral administration was 53% of iv administration, while in the rat the AUC after portal administration was 32% of that after iv administration. In the rabbit phenobarbitone was without effect on plasma norethisterone concentrations after iv administration but significantly reduced the plasma concentration after oral administration. In the rat phenobarbitone had little effect on plasma norethisterone concentrations despite evidence of enzyme induction.^ieng

Transdermal delivery of contraceptives.

Contraceptive agents are administered to the body through a variety of routes. Research has recently been directed at examining the transdermal route for systemic delivery of contraceptive agents, including estrogens and progestins. The transdermal route has several potential advantages over the other routes of administration: (1) improved compliance, (2) once-weekly administration, (3) delivery is easily terminated, and (4) some side effects can be alleviated based on more constant delivery rates. This article reviews the permeability of skin toward contraceptive steroids and how skin permeability is evaluated. The metabolism of contraceptive steroids is also considered. Transdermal delivery systems used to deliver contraceptives are presented, followed by a detailed discussion of several delivery systems for specific contraceptive agents such as levonorgestrel and estradiol. The potential problem of skin irritation is presented as it relates to transdermal contraceptive delivery systems, all of which will be worn chronically.

PIP: This comprehensive review of transdermal delivery systems for estrogens and progestins covers skin structure and absorption of chemical agents by diffusion and partition, permeability and use of enhancers to speed absorption, choices of drugs for transdermal contraceptives, animal and clinical work with estradiol, ethinyl estradiol and levonorgestrel, use of pro-drugs and derivatives, types of transderm delivery systems, metabolism of these drugs by skin and skin flora, and cutaneous side effects, all illustrated graphically and mathematically. Drug absorption entails diffusion through the primarily and mathematically. Drug absorption entails diffusion through the primarily lipophilic stratum corneum, and the hydrophilic epidermis: transport between these layers is often the rate-limiting step. For many drugs, permeability enhancers such as dimethyl sulfoxide, ethanol and ethyl acetate are needed. Good drug candidates for transdermal application must be potent in low doses, have short half-lives, not elicit an allergic response nor be extensively metabolized in skin. The permeability of levonorgestrel has been increased by using esters, and "pro-drugs" which are compounds that increase polarity, but are degraded to the active drug by skin tissue. The estrogens are subject to a minor degree of oxidation, and no significant degradation by skin microbes. There are 3 types of transdermal systems: the membrane, matrix and drug reservoir types. The Estraderm brand system for estradiol is a membrane-moderated design with ethanol as the chemical enhancer. Skin penetration is the rate-limiting step. Levonorgestrel as been tested with ethyl acetate and ethanol as penetration enhancers in rats, rabbits, and in a Phase I trial. The development of a transderm system for a combination of estrogen and progestin is a complex problem because 2 different enhancers must be used. Most transdermal systems are mild skin irritants, but incidence of contact allergy or urticaria are rare, with no cases yet reported from use of Estraderm. Transdermal application of contraceptive steroids is expected to be available eventually.

Anterior pituitary sensitivity in immature female rats stimulated with gonadotrophin releasing hormone in vivo: effect of priming with oestrogen, pregnant mare serum gonadotrophin or brain lesion.

PIP: Anterior pituitary sensitivity, assessed in terms of increments in plasma luteinizing hormone (LH) and follicle stimulating hormone (FSH) concentrations to stimulation with 1 or 2 injections of gonadotrophin releasing hormone (GnRH) was investigated in 26-day-old immature female rats which had received 1 of the following priming treatments: 1) 10 mcg estradiol benzoate (EB) as a single injection on Day 23 or Day 25 or on both days, 2) 10 IU pregnant mare serum gonadotrophin (PMSG) on Day 24, 3) an electrochemical brain lesion placed in the mediobasal hypothalamus on Day 23, or 4) control animals received either vehicle alone or a sham lesion. Pituitary sensitivity assessed at 1000 hours on Day 26 after 1 or 2 injections of GnRH was enhanced to a similar degree in the 3 groups treated with EB in terms of LH (p .01). FSH increased somewhat after EB treatment. In contrast, 48 hours after the injection of PMSG pituitary sensitivity, in terms of both LH and FSH, dropped sharply (p .001). Sensitivity to 1 injection of GnRH was unchanged in lesioned rats. However, a 2nd GnRH injection administered after an hour interval induced a slightly larger LH response in control animals. In another study, rats treated with EB on Day 23 and with 1 mg progesterone at 1200 hours on Day 26, pituitary sensitivity increased at both 1400 and 1700 hours as compared with that in the Day 23 EB-treated group at 1000 hours. PMSG-treated rats maintained their state of decreased responsiveness at 1400 hours, but exhibited increased sensitivity at the time of the gonadotropin surge (1700 hours).^ieng

Serum follicle-stimulating hormone, luteinizing hormone and progesterone concentrations in pseudopregnant rats treated with medroxyprogesterone acetate.

Pseudopregnant rats were treated early in pseudopregnancy with 1 or 10 mg medroxyprogesterone acetate (MPA). Serum FSH, LH and progesterone concentrations were determined on days 2-20 of pseudopregnancy in treated and control rats. The mean duration of pseudopregnancy was 13-5 days in the control animals, but when animals were treated with 1 mg MPA a dioestrous period of 21-4 days was observed. A period with leucocytic vaginal smears of at least 2 months was observed after treatment with 10 mg MPA. Injection with MPA on day 3 of pseudopregnancy did not affect the serum FSH concentrations during the subsequent days. The progesterone pattern was alike in the three groups of animals, i.e. the duration of the activity of the corpora lutea was similar in all groups. However, 10 mg MPA slightly lowered progesterone concentrations on days 4-8 of pseudopregnancy. In the saline-treated rats, LH concentrations decreased from days 2-5, and remained low until they increased after day 11 of pseudopregnancy. This increase was delayed until day 20 in the animals treated with 1 mg MPA, and was not observed in the animals treated with 10 mg MPA. It is argued that the increase of LH concentration at the end of pseudopregnency is not instrumental in the decrease of peripheral progesterone concentration but rather that the decrease in the progesterone concentration leads to the increase in the LH concentration.

PIP: Concentrations of serum follicle stimulating hormone (FSH), luteinizing hormone (LH), and progesterone (P) in pseudopregnant rats treated with medroxyprogesterone acetate (MPA) were measured to determine whether the increase in LH concentration seen is instrumental in the induction of the decrease in luteal progesterone secretion, which is associated with an increase in luteal 20alpha-hydroxyprogesterone secretion. Rats were treated with 1 or 10 mg MPA on the 3rd day of pseudopregnancy. FSH, LH, and P were determined on Days 2-20. Control animals had a 13.5 day mean for pseudopregnancy. Administration of 1 mg MPA sc resulted in a diestrous period of 21.4 days. Leukocytic vaginal smears were seen for 2 months when 10 mg MPA was given. FSH concentration was unaffected by the injection. P was similar for all 3 groups, with a slight depression seen in the high dose group from Day 4 to 8 of pseudopregnancy. In controls, LH decreased from Days 2 to 5 and then increased after Day 11. In animals treated at the low dose, this increase was delayed to Day 20 and it was absent in animals treated with 10 mg MPA. It is suggested that the increase in LH at the end of pseudopregnancy is initiated by the decrease in progesterone concentration.

Sustained effects on synthetic ovarian steroids of rat myometrial contractility.

Ovariectomized rats were given a single dose of synthetic oestrogen or progestogen, or both combined. On selected days after treatment one rat from each treatment group was killed and myometrical contractility in response to spasmogens was measured isometrically in isolated tissue baths. Contractility persisted at a low level after ovariectomy without steroid replacement (controls) for the 60 days of the experiment. The powerful potentiating action of oestrogen reached a maximum in about 10 days and sustained a high level thereafter. Progestogen treatment did not influence contractility to a significant degree when compared with saline, except that the contractions were sometimes of higher frequency and more irregular in size. There was a less powerful potentiating action on contractility with combined oestrogen and progestogen treatment than with oestrogen alone. It reached a maximum in 4 days and declined more rapidly than with oestrogen-treated preparation but was still vigorous for up to 30 days.

PIP: Virgin female Wistar rats were ovariectomized and 2 days later were given a single .2 ml dose of steroid im. Medroxyprogesterone acetate, 100 mg/kg of body weight or estradiol valerate 100 mcg were used. Group 1 (controls) received only solvents, Group 2 received progestogen in saline, Group 3 received the estrogen in oil, and Group 4 received both steroids. On selected days after treatment a rat from each group was killed, the uterus removed, and 2 myometrial strips were suspended in isolated organ baths on Statha G10B strain gauges for isometric recording. After 30 minutes, a dose of either 10 mcg/ml of acetylcholine or .25 mcg/ml of oxytocin was added to each bath. Tension was recorded for 10 minutes followed by a 15-minute wash. These doses were supramaximal. Responses began with a brief contraction and then became a series of fast powerful contrations which continued for 30-60 minutes. Each strip was later removed, prepared for sectioning, and length and cross-section were measured. Controls responded similarly to saline and to oil injections. There was a significnt initial increase in the response to both acetylcholine (p less than .05) and oxytocin (p less than .01). From Days 6 to 20 the responses did not change significantly. After Day 20 the response to acetylcholine declined significantly (p less than .01) but the response to oxytocin was unchanged for the 60 days of the test. With estrogen treatment, increase in response to both spasmogens was highly significant (p less than .001) in the first 18 days at which time it reached a plateau and remained the same for 60 days. With the progestogen treatment the mean response to acetylcholine increased significantly for the first 2 days (p less than .01) then maintained a plateau for the next 3 days equal to the control group and subsequently declined slowly (p less than .001). The contractile response to oxytocin remained constant for 60 days. With estrogen plus progestogen treatment there was a significant increase in contractility up to Day 5 (p less than .001). From Days 5 to 9 plateau levels were maintained with acetycholine and at a lower level with oxytocin. After Day 9 there was a significant decline in both spasmogens effect (p less than .001). With controls and all steroid treatments there was a highly significant difference in responses to acetylcholine and to oxytocin, with acetylcholine consistently giving stronger responses (p less than .001) than oxytocin. Results indicated that medroxyprogesterone acetate required the presence of estrogen for its myometrial action. There was also evidence that estrogen actions were modified by progestogen. It is concluded that single doses of estrogen and progestogen had depot actions of adequate intensity and duration for prolonged studies in myometrial contractility and that there was significant interaction between them when given together. Rat myometrium retained a significant response to spasmogens for at least 60 days after ovariectomy without steroid replacement, perhaps from adrenocortical steroid secretion.