Superior cycle control with a contraceptive vaginal ring compared with an oral contraceptive containing 30 microg ethinylestradiol and 150 microg levonorgestrel: a randomized trial.

BACKGROUND: This trial was conducted to compare cycle control with vaginal ring a combined contraceptive vaginal ring, and a combined oral contraceptive (COC) delivering 30 mug ethinylestradiol (EE) and 150 mug levonorgestrel. METHODS: This open-label, randomized, multi-centre, Phase III study involved adult women from 11 countries. Subjects were treated with either vaginal ring or a COC for 13 cycles (12 months). RESULTS: A total of 1030 subjects (vaginal ring, n=512; COC, n=518) comprised the intention-to-treat (ITT) population. The percentage of women in the ITT population who completed the trial was 70.9% for vaginal ring and 71.2% for the COC group. The incidence of breakthrough bleeding and spotting over cycles 2-13, the primary efficacy parameter, was lower with vaginal ring (range 2.0-6.4%) than the COC (range 3.5-12.6%), and for cycles 2 and 9 the lower incidence with vaginal ring was confirmed as statistically significant (P=0.003 and P=0.002 respectively). The incidence of intended bleeding was significantly higher over all cycles with vaginal ring (58.8-72.8%) than with the COC (43.4-57.9%). CONCLUSIONS: Cycle control with vaginal ring was excellent and superior to that of a COC containing 30 mug EE.

The contraceptive vaginal ring, NuvaRing, and antimycotic co-medication.

We investigated the effect of antimycotic co-medication on the systemic exposure to etonogestrel (ENG) and ethinylestradiol (EE) released from the contraceptive vaginal ring, NuvaRing. Different formulations of miconazole nitrate and single as well as multiple dosing were investigated during two separate randomized, open-label, crossover studies. The first study recruited 12 women to compare the effects of co-use of NuvaRing and a single dose of antimycotic to NuvaRing alone. The second study recruited 14 women to compare the effects of multiple doses of an antimycotic vaginal suppository to an antimycotic vaginal cream equivalent. Co-administration of all three antimycotic formulations resulted in a slight increase in systemic exposure to ENG and EE over time, with suppositories having a more pronounced effect than a cream formulation in the multiple-dosing study. The increases in serum levels observed with the different antimycotic formulations are not expected to compromise NuvaRing's contraceptive efficacy or tolerability.

The in vivo metabolism of tibolone in animal species.

The in vivo tissue distribution and metabolism of tibolone was studied in different animals to further investigate the compound's tissue-specificity. Tibolone's metabolism was studied in vivo in rats and rabbits by administration of [16-3H]-tibolone and the metabolic pattern was determined in urine and faeces after oral administration to female rats and dogs. The main excretory pathway was found to be excretion in the faeces. Important phase-I metabolic routes were the reduction of the 3-keto to the 3a- or 3beta-hydroxy functions with a preference for 3alpha-OH in rats and for 3beta-OH in dogs. To a lesser extent, hydroxylation reactions at C2 and C7, and a shift of the delta5(10)-double bond to a delta4(5)-position also occurred. The main phase-II metabolic route was sulphate conjugation of the hydroxyl groups at C3 and C17. Since the oxidation reactions form only a minor part of the metabolism of tibolone, it is concluded that the cytochrome P450 enzymes do not play an important role in tibolone's metabolism. For both phases, quantitative differences were found between the species. In human similar metabolites are found. Profiling of the target organs in female rats and rabbits showed a tissue-specific distribution of metabolites. The majority of the metabolites existed as sulphate conjugates and no glucuronidated conjugates were observed. The same metabolites were found in both the circulation and the tissues. However, different tissues had quantitatively different metabolic profiles.

Identification of the human P450 enzymes involved in the in vitro metabolism of the synthetic steroidal hormones Org 4060 and Org 30659.

1. The type of human P450 enzymes involved in the in vitro metabolism of Org 4060 and Org 30659, two synthetic steroidal hormones currently under clinical development by NV Organon for use in oral contraceptive and hormone replacement therapy, was investigated. 2. Both steroids were mainly hydroxylated at the 6beta-position in incubations with human liver microsomes. 3. The results from experiments with supersomes, correlation studies as well as inhibition studies with ketoconazole, a selective inhibitor of CYP3A, strongly suggest that the CYP3A family plays a significant role in the 6beta-hydroxylation of both steroids. 4. Measurements of kinetic parameters of P450 enzymes that could metabolize both steroids, combined with the fact that CYP3A4 is known to be the most abundant P450 enzyme in the human liver, indicate that CYP3A4 will be of major importance for the in vivo human metabolism of Org 4060 and Org 30659.

The in vivo human metabolism of tibolone.

In vivo metabolism of tibolone was studied in three healthy postmenopausal volunteers after daily oral administration of 2.5 mg of tibolone for 5 days and a single dose of 2.5 mg approximately equal 555 kBq of [(14)C]tibolone on day 6. The 0- to 192-h recovery of radioactivity in urine and feces was 31.2 +/- 10.5 and 53.7 +/- 5.1%, respectively. Total 0- to 192-h recovery ranged from 78.5 to 94.2% of the dose and averaged 84.9%. Metabolites were putatively identified using high-pressure liquid chromatography in plasma, urine, and feces. The most important phase I metabolic reactions were reduction of the 3-keto group to 3alpha- and 3beta-hydroxy metabolites, a shift of the Delta(5(10))-double bond to a Delta(4(5))-double bond, a reduction of the Delta(4(5))-double bond to 5alpha,10-dihydro or 5beta,10-dihydro metabolites, and hydroxylation at C2 and C7. The most important phase II metabolic reaction is sulfation of the C17 hydroxy group of tibolone and sulfation of the C3 hydroxy groups. In the circulation, over 75% of tibolone and its metabolites are present in the sulfated form. Local metabolism and local sulfatases may contribute to the tissue-specific activity. Using human microsomes, tibolone, 3alpha-hydroxy tibolone, 3beta-hydroxy tibolone, and Delta(4)-tibolone appeared to be at least 50-fold less potent inhibitors of CYP1A2, CYP2C9, CYP2E1, and CYP3A4 compared with enzyme-selective inhibitors. Tibolone and its metabolites, therefore, are not likely to play a clinically significant role at the level of these cytochrome P450 enzymes with regard to the metabolism of coadministered drugs.

Excretion and metabolism of desogestrel in healthy postmenopausal women.

The metabolism of desogestrel (13-ethyl-11-methylene-18,19-dinor-17alpha-pregn-4-en-20-yn-17-ol), a progestagen used in oral contraceptives and hormone replacement therapy, was studied in vivo after a single oral administration of 150 microg [14C]-labeled desogestrel and 30 microg ethinylestradiol under steady state conditions to healthy postmenopausal women. After this oral administration, desogestrel was extensively metabolized. The dosed radioactivity was predominantly ( approximately 60%) excreted via urine, while about 35% was excreted via the feces. Desogestrel was metabolized mainly at the C3-, C5-, C6- and C13-CH(2)CH(3) positions. At the C3-position, the 3-keto moiety was found and in addition, 3beta-hydroxy and 3alpha-hydroxy groups were observed in combination with a reduced Delta(4)-double bond (5alpha-H). Hydroxy groups were introduced at the C6- (6beta-OH), the C13-ethyl (C13-CH(2)CH(2)OH) and possibly the C15- (15alpha-OH) position of desogestrel. Conjugation of the 3alpha-hydroxy moiety with sulfonic acid and conjugation with glucuronic acid were also major metabolic routes found for desogestrel in postmenopausal women. The 3-keto metabolite of desogestrel (the biologically active metabolite) was the major compound present in plasma at least up to 24 h after administration of the radioactive dose. Species comparison of the metabolic routes of desogestrel after oral administration indicates that in rats and dogs desogestrel is also mainly metabolized at the C3-position, similar to what is now found for postmenopausal women. Most other metabolic routes of desogestrel were found to differ between species. Finally, major metabolic routes found in the present study in postmenopausal women are in line with outcome of previous in vitro metabolism studies with human liver tissue (microsomes and postmitochondrial liver fractions) and intestinal mucosa.

Metabolism of norethisterone and norethisterone derivatives in rat uterus, vagina, and aorta.

The 19-nor-progestogen norethisterone is used as a progestogen component in contraceptives and in continuous- and sequential combined hormone replacement therapy (HRT) in postmenopausal women. Metabolism of norethisterone in HRT target tissues may play a role in its biological response. The aim of this study was to investigate which steroid-metabolizing enzymes are present in rat uterus, vagina, and aorta, three HRT target tissues. Next, the ability of the tissues to metabolize norethisterone was assessed. Furthermore, to investigate the effect of substituents at the 7- and 11-position, the metabolism of Org OM38 (7alpha-methyl-norethisterone), Org 4060 (11beta-ethyl-norethisterone), and Org 34694 (7alpha-methyl,11-ethylidene-norethisterone) was studied. Using radiolabeled progesterone, the presence of 20alpha-hydroxysteroid dehydrogenase, 5alpha-reductase, and 3alpha-hydroxysteroid dehydrogenase activity could be demonstrated in uterus, vagina, and to a lesser extent in aorta. The combined action of the latter two enzyme activities resulted in 3alpha-OH,5alpha-H-norethisterone as the major metabolite of radiolabeled norethisterone in uterus (26.9%), vagina (37.1%), and aorta (1.4%). The norethisterone derivatives, however, were metabolized to a much lesser extent (1.0-7.6%). No formation of 5alpha-reduced forms of Org 4060, Org OM38, or Org 34694 was found, while formation of minor amounts of 3alpha-OH-Org 4060 and 3alpha-OH-Org OM38 could be demonstrated in both uterus, vagina, and aorta. These findings confirm the role of 5alpha-reductase as a rate-limiting step in the metabolism of norethisterone derivatives and show important inhibitory effects of substituents at the 7alpha- and 11-position of the steroid skeleton on 5alpha-reduction.

Excretion balance and metabolism of the progestagen Org 30659 in healthy postmenopausal women.

Metabolism of Org 30659 ((17alpha)-17-hydroxy-11-methylene-19-norpregna-4, 15-dien-20-yn-3-one), a new potent progestagen currently under clinical development by NV Organon for use in oral contraception and hormone replacement therapy, was studied in vivo after oral administration to healthy postmenopausal women. After oral administration of [14C]-Org 30659 to postmenopausal women, the compound was extensively metabolized. The dosed radioactivity was predominantly excreted via urine. Org 30659 was to a large extent metabolized at the C3- and the C17-positions. Phase II metabolism, and in particular conjugation with glucuronic acid at the 17beta-hydroxy group, is the major metabolic route for Org 30659 in vivo. Not only phase II metabolism was observed for Org 30659 after oral administration to postmenopausal volunteers, but also metabolism in the A-ring occurred, especially reduction of the 3-keto-Delta(4) moiety to give 3alpha-hydroxy, 5alpha(beta)-dihydro and 3beta-hydroxy, 5alpha-dihydro derivatives. Oxidative metabolism (6beta-hydroxylation) observed in human liver preparations in vitro, was not observed to a significant extent in vivo. So, in vitro human metabolism is different from the in vivo metabolism, indicating that the in vitro-in vivo extrapolation is far from straightforward, at least when only liver preparations are used. The proper choice of the in vitro system (e.g., microsomes, hepatocytes, slices or individually expressed enzymes) and the substrate concentration can be very important determinative factors for the predictability of the in vitro system for the in vivo situation. Species comparison of the metabolic routes of Org 30659 after oral administration indicated that the monkey seems to be a better representative species than the rat for the metabolism of Org 30659 in humans.

The role of CYP2C in the in vitro bioactivation of the contraceptive steroid desogestrel.

Desogestrel is a 3-deoxo progestogenic steroid that requires bioactivation to 3-ketodesogestrel. In these studies we have attempted to define the pathway of 3-ketodesogestrel formation and characterise the enzymes responsible for this biotransformation in vitro. Initial studies using deuterated desogestrel confirmed that desogestrel is metabolised by human liver microsomes via 3alpha-hydroxy and 3beta-hydroxydesogestrel to 3-ketodesogestrel. Metabolites were analysed by radiometric high-performance liquid chromatography and were identified by liquid chromatography-mass spectrometry and by cochromatography with authentic standards. Desogestrel was metabolised by microsomes from lymphoblasts containing cDNA-expressed CYP2C9 and CYP2C19 to 3alpha-hydroxydesogestrel with small amounts of 3beta-hydroxydesogestrel also being observed. The Km value for 3alpha-hydroxylation by CYP2C9 cell line microsomes was 6.5 microM and the corresponding Vmax value was 1269 pmole. mg-1. min-1. Sulfaphenazole potently inhibited 3alpha-hydroxydesogestrel formation by CYP2C9 microsomes with a Ki value of 0.91 microM. There was a significant negative correlation between 3-ketodesogestrel and CYP3A4 content/activity in a panel of human livers suggesting that the further metabolism of 3-ketodesogestrel is mediated by CYP3A4. Sulfaphenazole partially inhibited 3alpha-hydroxydesogestrel and 3-ketodesogestrel formation in human liver microsomes indicating a possible in vivo role for CYP2C9. In addition, when sulfaphenazole was combined with S-mephenytoin, further inhibition of 3alpha-hydroxydesogestrel formation was observed suggesting a possible role for CYP2C19. This was confirmed in incubations with inhibitory antibodies. Whereas an anti-CYP2C9/2C19 antibody completely abolished desogestrel metabolism, anti-CYP3A4 and anti-CYP2E1 were not inhibitory. We conclude that CYP2C9 and possibly CYP2C19 and important isoforms catalysing the initial hydroxylation of desogestrel.

PIP: Desogestrel is a 3-deoxy progestogenic oral contraceptive steroid which requires bioactivation to 3-ketodesogestrel. Initial studies using deuterated desogestrel have confirmed that desogestrel is metabolized by human liver microsomes through 3(alpha)-hydroxy and 3(beta)-hydroxydesogestrel to 3-ketodesogestrel. While the enzymes responsible for the bioactivation of desogestrel have never been formally identified, there is some evidence for the involvement of CYP isoforms. The CYP family of enzymes is responsible for the oxidation of structurally diverse lipophilic chemicals and plays an important role in the hydroxylation of endogenous steroids leading to the biosynthesis of all major classes of steroid hormones. The authors investigated the pathway of 3-ketodesogestrel formation and characterize the enzymes responsible for that biotransformation in vitro. Their research materials and methodology is described in detail. They conclude that CYP2C9 and possibly CYP2C19 are important isoforms which catalyze the initial hydroxylation of desogestrel.

In vitro and in vivo metabolism of the progestagen Org 30659 in several species.

The metabolism of Org 30659 [(17alpha)-17-hydroxy-11-methylene-19-norpregna-4, 15-dien-20-yn-3-one], a new potent progestagen currently under clinical development by NV Organon for use in oral contraceptive and hormone replacement therapy, was studied in vivo after oral administration to rats and monkeys and in vitro using rat, rabbit, monkey, and human liver microsomes and rat and human hepatocytes. After oral administration of [7-3H]Org 30659 to rats and monkeys, Org 30659 was extensively metabolized in both species. Fecal excretion appeared to be the main route of elimination. In rats, opening of the A-ring, resulting in a 2-OH,4-carboxylic acid, 5alpha-H metabolite of Org 30659, was the major metabolic route in vivo. Other metabolic routes involved the introduction of an OH group at C15beta, followed by a shift of the Delta15-double bond to a 16/17-double bond with subsequent removal of the OH group at C17 and reduction of the 3-keto,Delta4 moiety followed by sulfate conjugation of the 3-OH substituent. These metabolic routes observed in vivo were also major routes in incubations with rat hepatocytes. In rat liver microsomes, Org 30659 was metabolized by reduction of the 3-keto,Delta4 moiety. Rat hepatocyte incubations with Org 30659 were more representative of the in vivo metabolism of Org 30659, compared with rat microsomal incubations. Both in vitro and in vivo, the majority of the metabolites were 3alpha-OH,4,5alpha-dihydro derivatives. In monkeys, Org 30659 was mainly metabolized at the C3- and C17-positions in vivo. The 3-keto moiety was reduced to both 3beta-OH and 3alpha-OH substituents. In addition to phase I metabolites, glucuronic acid conjugates were observed in vivo. In monkey liver microsomes, the 6beta-OH metabolite of Org 30659 was the major metabolite present. Similar to the monkey liver microsomes, rabbit and human liver microsomes converted Org 30659 to the 6beta-OH metabolite. This metabolite was also the major metabolite in incubations with human hepatocytes.

In vitro and in vivo metabolism of desogestrel in several species.

The metabolism of desogestrel (13-ethyl-11-methylene-18, 19-dinor-17alpha-pregn-4-en-20-yn-17-ol), an orally active progestogen, was studied in vivo after administration of single oral doses to rats and dogs and in vitro using rat, rabbit, dog, and human liver microsomes. Metabolites were isolated and identified by NMR and MS analysis. After oral administration of [3H]desogestrel to rats and dogs, desogestrel was extensively metabolized in both species. Radioactivity was predominantly eliminated in the feces. In rats, desogestrel was metabolized mainly at the C3-, C5-, C11-, and C15-positions. Both in vivo and in vitro, the majority of metabolites were 3alpha-hydroxy,4,5alpha-dihydro derivatives. Other main metabolic routes for desogestrel in rats were 15alpha-hydroxylation and epoxidation of the C11-methylene moiety. In addition to phase I metabolites, glucuronic acid and sulfate conjugates of desogestrel were observed in vivo. In dogs, desogestrel was mainly metabolized at the C3- and C17-positions. In contrast to the rat metabolites, metabolites isolated from dog urine or feces were mainly 3beta-hydroxy,4,5alpha-dihydro derivatives. In most of the metabolites present in dog urine and feces, the five-membered D-ring was expanded to a six-membered D-ring, i.e. D-homoannulation to a 17A-keto-D-homo ring. D-Homo metabolites, which were major metabolites in plasma, urine, and feces of dogs, were not observed in vitro. In dog liver microsomes, the 3-keto metabolite of desogestrel was the major metabolite. Similarly to dog liver microsomes, rabbit and human liver microsomes mainly converted desogestrel to its 3-keto metabolite. Predominant positions for further hydroxylation of the 3-keto metabolite of desogestrel were the C6-position (6beta-hydroxy) and the ethyl substituent at the C13-position, for both species.