Distribution of RU 486 and its demethylated metabolites in humans.

The concentrations of RU 486 and its demethylated metabolites were determined by RIA in samples of myometrium, abdominal adipose tissue, and serum, which were collected at hysterectomies performed 12-15 h after oral administration of 200 mg RU 486. The RU 486 concentrations in myometrium were similar in the five women studied, with a mean of 148 +/- 58 (+/- SD) ng/g (344 +/- 135 pmol/g). The adipose tissue RU 486 levels varied more, the mean concentration being 447 +/- 191 ng/g (1041 +/- 445 pmol/g). The serum RU 486 concentrations ranged from 175-899 ng/ml [mean, 396 +/- 259 ng/mL (922 +/- 603 nmol/L)]. In these women the nonprotein-bound fraction of [6,7-3H]RU 486 varied from 1.4-3.1% (mean, 2.3%). The approximate concentrations of the combined mono- and didemethylated metabolites of RU 486 were 1.4, 3.1, and 5.2 times higher in adipose tissue, myometrial tissue, and serum, respectively, than those of the parent RU 486. In vitro, rapid and nonsaturable accumulation of [6,7-3H]RU 486 from phosphate buffer into adipose tissue was inhibited by the addition of alpha 1-acid glycoprotein, the specific serum transport protein for RU 486, to the buffer medium. Accumulation of [6,7-3H]RU 486 in myometrial specimens was poor. The enterohepatic cycling of RU 486 was assessed in four normal subjects by repetitive intake of charcoal subsequent to ingestion of 200 mg RU 486. Compared to other normal subjects, the serum levels and areas under the concentration curves were lower and t1/2 values shorter in the group given charcoal, suggesting that in vivo RU 486 may be partly pooled in the enterohepatic cycle. Our studies suggest that despite the low volume of distribution and the effective serum binding of RU 486, the myometrial and adipose tissue concentrations of RU 486 and its metabolites were similar (approximately 10(-9)-10(-10) mol/g) after oral intake of RU 486.

Intrauterine progestin induces continuous insulin-like growth factor-binding protein-1 production in the human endometrium.

The effect of local intrauterine progestin on endometrial insulin-like growth factor-binding protein-1 (IGFBP-1) production was studied in 60 women using a levonorgestrel-releasing intrauterine device (IUD). Intrauterine progestin was a potent stimulator of stromal cell IGFBP-1 production, with 97% of endometrial specimens showing positive staining by immunohistological methods. After 5 yr or more of intrauterine progestin exposure, 100% (n = 20) of the tissues remained strongly positive for IGFBP-1. The IGFBP-1 content in endometrial tissue homogenates reached values as high as 10 micrograms/mg protein when measured by immunoradiometric assay. In contrast to the continuous endometrial IGFBP-1 production induced by local progestin, no such effect could be found in endometria from subjects with sc progestin-releasing implants or copper IUDs. Although the levonorgestrel-releasing IUD had a striking effect on local endometrial IGFBP-1 production, it had no effect on serum IGFBP-1 levels. By Western ligand blot analysis, the domainating IGF-binding species in endometria exposed to intrauterine progestin was of 28K mol wt, corresponding to IGFBP-1, whereas no IGFBP species of 31-43K, corresponding to IGFBP-2 or IGFBP-3, were detected.

Progesterone-binding properties of the microsomal fraction from chick oviduct.

Progesterone binds to specific high-affinity and limited-capacity binding sites of chick-oviduct microsomes of estrogen-primed chicks. The dissociation constant is 2 x 10(-9) M (range 1.6--3.0) and the number of binding sites 500 femtomoles/mg microsomal protein (range 464--551). Treatment of the estrogen-primed chicks by progesterone had no apparent effect on the progesterone-binding capacity or affinity. Competition studies showed that testosterone, R-5020, Org-2058, D-norgestrel, 5 alpha-dihydrotestosterone and R-2323 were effective competitors of progesterone, in that order, whereas cortisol, estradiol and estrone exhibited only minimal displacement. No displacement of microsome-bound [3H]progesterone was found with fenoterol or prostaglandin F2 alpha. No high-affinity progesterone-binding sites were found in the microsomal fractions of liver, muscle, intestine or brain. On the basis of steroid-binding affinity and steroid-specificity determinations, the microsomal progesterone-binding components seem to be different from the progesterone receptor previously described in chick oviduct cytosol.

Steroids in human myometrium and maternal and umbilical cord plasma before and during labor.

Concentrations of estrone, estradiol, and progesterone in the myometrium, maternal peripheral vein, and mixed umbilical cord plasma were determined before and during labor by radioimmunoassay. Of the 29 patients studied, 4 underwent elective abortions by hysterotomy in the second trimester of pregnancy, and 25 underwent cesarean section (elective or during labor). The concentration of umbilical cord cortisol in the latter group of patients was also determined. Advanced labor was characterized by a high concentration of estrone in the maternal peripheral vein, the umbilical cord, and the myometrium. Concentrations of estradiol, progesterone, and cortisol in cord plasma also increased during labor. From the second trimester to term pregnancy, increases in the concentrations of estrone and estradiol in the myometrium were proportionately greater than those of progesterone. During labor, there were no significant changes in the myometrial concentrations of estrone, estradiol, or progesterone. During labor in term pregnancies, the myometrial concentration of estrone was higher than that of estradiol.

Screening, management, and outcome of pregnancy in diabetic mothers.

During a 3.5-year period 94 latently and manifestly diabetic patients were treated in the State Maternity Hospital of Helsinki. Management of manifestly diabetic patients included strict control of maternal glucose metabolism based on plasma glucose values after meals and on fasting plasma glucose values, early hospitalization, and delivery near term to avoid infant morbidity due to prematurity. Fetal surveillance was based primarily on daily nonstress fetal heart rate monitoring and frequent urinary estriol determinations. Hypertensive disorders were encountered in 33% of patients in class A and 24% of patients in classes B through F; urinary tract infections were found in 17% and repeated maternal hypoglycemic episodes were found in 20% of manifestly diabetic mothers. Diabetic retinopathy showed variable progression during pregnancy in 50% of cases and unchanged in the remaining 50%; only 16% of patients with hypertensive retinopathy showed progression on reexamination. The perinatal mortality was 1.1%. Delivery by cesarean section was performed in 55.3% of cases. The duration of gestation at the moment of delivery was 38.9 weeks in class A and progressively less in classes B through F according to the severity of the diabetic disorder. The following percentages reflecting infant morbidity were encountered: respiratory distress syndrome 5.3%; neonatal hypoglycemia, 10.6%; hyperbilirubinemia, 8.5%; hypocalcemia, 5.3%; and the aspiration syndrome, 5.3%. Two infants had congenital anomalies: 1 had hypospadias and the other had aortic coarctation.

A contraceptive subdermal implant releasing the progestin ST-1435: ovarian function, bleeding patterns, and side effects.

OBJECTIVE: To study ovarian function, bleeding patterns, and side effects during the 1-year use of a new modified contraceptive subdermal implant releasing the progestin ST-1435 with a lifetime of 2 years. DESIGN, PATIENTS: The effect on ovarian function and bleeding patterns of one contraceptive implant releasing the progestin ST-1435 was studied in 26 healthy women who volunteered. Side effects were recorded. SETTING: The outpatient clinic of the City Maternity Hospital, Helsinki, Finland. INTERVENTION: One ST-1435 contraceptive implant was inserted subcutaneously into the ventral aspect of left upper arm. MAIN OUTCOME MEASURES: The women attended the clinic at half-year intervals. Records of bleeding were kept. Blood samples were collected from 5 women before insertion of an implant, from 12 women during the first 5 to 6 weeks of use, and from 10 women during the 6th and 12th month of use. Serum concentrations of ST-1435, progesterone, and estradiol were determined. Side effects were reported. RESULTS: The study covered 302 woman-months. The implant gave serum concentrations of ST-1435 high enough to inhibit ovulation in all of the 37 analyzed cycles. No pregnancies occurred. Irregular bleeding or spotting was the main event observed, especially during the 1st year of use. One half of the users had irregular cycles. None of the women's implants was removed during 1 year of use because of irregular bleeding. The implant was well accepted and tolerated by the women; no hormonal side effects were reported. CONCLUSIONS: One single 4-cm subdermal ST-1435 implant with a lifetime of 2 years showed good contraceptive efficacy and led to suppression of ovulation. No hormonal side effects were reported. Irregular bleeding patterns were common but well-tolerated, and the implant had a high continuation rate.

PIP: Physicians inserted a new 4-cm subdermal implant releasing the progestin ST-1435 (78 mg) into the ventral area of the left upper arm in 26 healthy 20-36 year old women at the outpatient clinic at the City Maternity Hospital in Helsinki, Finland, and followed them for 12 months (total of 302 woman months) to examine its side effects, ovarian function, and bleeding patterns. (This implant has a lifetime of 2 years.) The implant released ST-1435 at serum levels high enough to suppress ovulation in all 37 analyzed menstrual cycles. None of the women became pregnant. Irregular bleeding occurred in 11 women. Even though a high proportion of women experienced irregular bleeding, it did not lead any women to request removal of the implant. The total spotting days decreased significantly between the first 6 months and the last 6 months (24-16 days; p .05). None of the women experience hormonally induced side effects, other than irregular bleeding. After 1 year of use, the continuation rate stood at 89%. 2 women wanted the implant removed so they could become pregnant. 1 woman wanted it removed for personal reasons. In conclusion, the women tolerated this implant well. Moreover, it was effective in preventing pregnancy.

Inhibition of folliculogenesis and ovulation by the antiprogesterone RU 486.

Healthy, regularly menstruating women were treated with the antiprogesterone RU 486, Mifepristone (Roussel-Uclaf, Romainville, France) during the follicular phase of the cycle. Three women were given 25 mg of RU 486 on days 1 to 14 of the cycle and five received 25 mg on days 1 to 21 of the cycle. Venous blood samples were collected three times per week during a control cycle and during one treatment cycle in each subject. Serum concentrations of estradiol (E2), progesterone (P), and RU 486 were determined by radioimmunoassays. No drug-related side effects and no spotting or bleeding during RU 486 treatment were observed. Menstrual bleeding was delayed by 8.7 +/- 3.8 days (mean +/- SD) after treatment over days 1 to 14 and by 12.6 +/- 3.2 days after treatment over days 1 to 21. During the treatment with RU 486, the serum concentrations of E2 remained low, indicating effective inhibition of folliculogenesis. After cessation of RU 486 treatment, serum E2 levels rose to similar values as in the control cycle, and subsequently serum P concentrations also reached ovulatory levels in six out of the eight volunteers. The results showed that the antiprogesterone RU 486 delayed folliculogenesis and luteinization even at low doses when given during the follicular phase of the menstrual cycle. It is speculated that this property of RU 486 could be utilized in the design of an estrogen-free combined oral contraceptives.

PIP: The antiprogesterone RU 486 (mifepristone, Roussel-Uclaf, Romainville, France) was taken by 3 women for days 1-14 of the menstrual cycle, and by 5 women on days 1-21, at a low dose of 25 mg/day, to see whether it would affect ovulation. There is normally a brief progesterone peak before the LH surge that precedes ovulation. To monitor the cycle, women reported bleeding symptoms, and their serum estradiol, progesterone and RU 486 levels were assayed. There were no side effects or bleeding or spotting reported. Serum estradiol levels remained below those recorded in the control cycle, indicating that development of the follicle was inhibited. Estradiol levels rose to follicular phase levels after discontinuation of the drug. Menstruation was delayed by 6, 6 and 14 (mean 8.7) days in the women who took RU 486 for 14 days, and by 8, 12, 12, 13 and 18 days (mean 12.6) days in those who took it for 21 days. The subsequent luteal phase was of normal duration and progesterone level. Based on progesterone level, 2 treatment cycles were anovulatory. Serum RU 486 concentrations ranged from 200 to 1400 ng/ml. It is conceivable that an estrogen-free combined oral contraceptive could be developed based on this property of RU 486.

Suppression of ovarian function with the transdermally given synthetic progestin ST 1435.

OBJECTIVE: To study transdermal administration of the synthetic progestin ST 1435 and effectiveness of the steroid in suppression of ovarian function. DESIGN, PATIENTS: The effect of transdermal administration of the synthetic progestin ST 1435 in suppression of ovarian function was studied in a short term (17 to 93 days) study in healthy regularly menstruating women. SETTING: The outpatient clinic of the City Maternity Hospital, Helsinki, Finland. INTERVENTION: Nine women used the progestin ST 1435 transdermally during a total of 21 menstrual cycles. Treatment was started on the 5th day of the menstrual cycle and continued for 17 to 93 days. Three different daily doses (0.5, 0.8, and 1.0 mg) were tested. The steroid was applied to the periumbical area once a day in a gel. MAIN OUTCOME MEASURES: Serum concentrations of ST 1435, progesterone, and estradiol (E2) were determined during the luteal phase of control cycles and in a total of 16 treatment cycles. Bleeding records were kept and side effects registered. RESULTS: Transdermal absorption of the progestin ST 1435 resulted in relatively constant serum concentrations in each subject, depending on the dose used. All doses caused changes in ovarian function. With the 0.5-mg/d dose, inhibition of ovulation was observed in three of five treatment periods. The 0.8-mg/d dose was high enough to inhibit ovulation in 7 of 10 cycles analyzed. With the 1.0-mg/d dose, the serum concentrations of the progestin were high, and anovulation was seen. Serum E2 concentrations were variable in all cases; occasional high peak values were seen, typical of progestin treatment. Bleeding control was variable; irregular bleeding was seen, especially in anovulatory cases. CONCLUSIONS: A 0.8-mg dose of the progestin ST 1435 administered transdermally once a day appeared to suppress ovulation, if properly applied, and excessive suppression of ovarian function was not seen. The steroid was well accepted. The synthetic progestin ST 1435 given transdermally represents an effective alternative for inhibition of ovulation and for progestin therapy.

PIP: Physicians monitored serum concentrations of the synthetic progestin ST 1435, progesterone, and ethinyl estradiol in 9 healthy 28-42 year old women attending the outpatient clinic at City Maternity Hospital in Helsinki, Finland who agreed to apply ST 1435 gel to the periumbilical area daily for 21 menstrual cycles. They 1st applied it on day 5 of the menstrual cycle and continued treatment for 17-93 days. The physicians wanted to examine the daily dose of ST 1435 needed to suppress ovarian function and ovulation. A daily dose of 0.8 mg ST 1435 achieved the optimal serum concentration of ST 1435 (112-278 pmol/L) to inhibit ovulation. Each woman tended to have constant serum concentrations and those concentrations depended on the dose. All 3 different doses (0.5, 0.8, and 1 mg) affected ovarian function. The 0.5 mg/day dose prevented ovulation in 3 of 5 treatment periods while the 0.8 mg/day dose did in 7 of 10 cycles. Anovulation occurred in the only women who used the 1 mg/day dose. ST 1435 levels (mean 691 pmol/L) were high at this dose. Serum ethinyl estradiol levels differed among the women in each dose group and between dose groups. A few women even had very high levels which typifies progestin treatment. Irregular bleeding occurred in some women especially during the anovulatory cycles. Bleeding control was the only side effect. 0.8 mg/day of ST 1435 applied transdermally appeared to be an effective and acceptable contraceptive. Researchers should conduct more studies on transdermal ST 1435 to account for the interindividual differences in ST 1435 serum levels and to determine ST 1435's efficacy.

Endometrial effect of transdermal estradiol and progestin ST-1435 in postmenopausal women.

OBJECTIVE: To study the endometrial effect of the transdermal synthetic progestin ST-1435. DESIGN: Prospective. SETTING: City Maternity Hospital, Helsinki, Finland. PATIENTS: Eleven postmenopausal women used transdermal estradiol (E2) patches for 6 weeks immediately before a vaginal operation for prolapse. For the last 10 days, 1 mg of ST-1435 transdermally in a gel was combined to the treatment. MAIN OUTCOME MEASURES: Blood samples were taken to follow serum concentrations of E2, follicle-stimulating hormone, and ST-1435. Endometrial samples for histologic examination were collected during the operation to evaluate the effect of the progestin. RESULTS: Transdermal absorption of ST-1435 resulted in reasonably constant serum concentrations of ST-1435 in each subject. A progestin effect on the endometrium was seen in 9 of 10 samples obtained. One sample did not show any progestin effect in spite of adequate ST-1435 levels, but this patient's E2 concentrations were low. CONCLUSIONS: When the estrogen stimulation was adequate, the transdermal ST-1435 induced a progestin effect on the endometrium, i.e., it had an end-organ effect.

Endometrial response to hormone replacement therapy as assessed by expression of insulin-like growth factor-binding protein-1 in the endometrium.

OBJECTIVE: To assess endometrial response to parenteral levonorgestrel in hormone replacement therapy by means of morphological criteria and immunohistochemical staining of insulin-like growth factor-binding protein-1 (IGFBP-1). DESIGN: Endometrial samples were collected from 35 postmenopausal women after 12 to 22 months of continuous combined estrogen-progestin therapy. All subjects were treated with parenteral progestin. A group of 8 women was treated with a subdermal levonorgestrel-releasing implant, and 27 women had a levonorgestrel-releasing intrauterine device (IUD). Sections of formalin-fixed paraffin-embedded biopsies were used for immunohistochemistry and after hematoxylin-eosin staining for routine histologic examination. RESULTS: Atrophic epithelium with pronounced decidual reaction in the stroma was detected by histologic examination in all endometrial samples obtained from 27 women treated with the levonorgestrel-releasing IUD. In contrast, the endometrium was proliferative in seven of eight (87.5 percent) biopsies obtained from women treated with the levonorgestrel-releasing implant. Immunoreactive IGFBP-1 was detected in decidualized stromal cells in all endometrial samples obtained during intrauterine levonorgestrel therapy, whereas only one of eight samples obtained from women treated with subdermal levonorgestrel exhibited weak staining for IGFBP-1. CONCLUSIONS: Our data show that both the morphological and biochemical response of post- menopausal endometrium to parenteral levonorgestrel was strikingly different, depending on the route of progestin administration, and that the decidual reaction and epithelial atrophy induced by intrauterine levonorgestrel were associated with expression IGFBP-1 in decidualized stromal cells.

Interference with ovulation by sequential treatment with the antiprogesterone RU486 and synthetic progestin.

Seven healthy women were treated with the antiprogesterone RU486, 25 mg/d, on days 1 to 14 of the follicular phase of the menstrual cycle, followed by the synthetic progestin NET in the luteal phase of the cycle. Venous blood samples were collected twice per week. Serum E2, P, and RU486 concentrations were determined by RIAs, and FSH and LH by immunofluorometric assays. Ultrasonography was used to measure the sizes of the follicles. Serum concentrations of FSH and LH were not suppressed during the treatment. Ovulation was apparently suppressed during RU486 treatment according to E2 and P concentrations and ultrasonography findings. During NET treatment, some evidence of ovulation and follicle growth were found during the first treatment periods. During the third treatment cycle, there was no evidence of ovulation (n = 2). Estradiol concentrations were sufficient to stimulate normal proliferative growth of the endometrium during the treatment. Control of bleeding was good. The exact mechanism of action of RU486 on steroid synthesis and ovulation is not clear, but it appears to act at the ovarian level. The evidence indicates that sequential RU486/progestin treatment could be developed to result in suppression of follicular growth and ovulation.

PIP: In Finland, physicians at the outpatient clinic at the Helsinki City Maternity Hospital followed 7 26-38 year old women who took 25 mg RU-486/day during days 1-14 (follicular phase) and 5 mg of norethindrone/day (NET) during days 15-24 (luteal phase) for 1 menstrual cycle or for 3 menstrual cycles to investigate the possibility of sequential use of an antiprogesterone and progestin as an oral contraceptive. They used ultrasonography to monitor follicular growth and obtained blood samples 2 times/week to do radioimmunoassays and immunofluorometric assays to measure estradiol, progesterone, RU-486, luteinizing hormone (LH), and follicle stimulating hormone (FSH) levels. They took endometrial biopsies at the end of RU-486 treatment (days 12- 13) and during NET treatment (days 21-22). Before RU-486/NET treatment the physicians performed various tests during a control cycle. RU-486 treatment did not alter FSH or LH levels. Progesterone and estradiol levels and ultrasonography indicated, however, that RU-486 did suppress ovulation. Ovulation and follicle growth did occur during NET treatment, yet during the third cycle no one ovulated. Bleeding control was adequate. It appeared that the mechanism of action of RU-486 on steroid synthesis and ovulation occurred at the ovarian level. Even though RU-486 at least partially inhibited estradiol synthesis, sufficient estradiol remained to stimulate normal proliferative growth of the endometrium. None of the women experienced steroidal side effects from the treatment. These findings indicated that further development of sequential RU-486/progestin treatment could suppress follicular growth and ovulation.

Contraception by Norplant subdermal capsules is not reliable in epileptic patients on anticonvulsant treatment.

The contraceptive efficacy of progestin-only contraception was studied in epileptic patients using NORPLANT subdermal capsules. The effect of anticonvulsants on levonorgestrel plasma levels was determined. NORPLANT subdermal capsules were inserted into nine epileptic women, and ten control women using no medication. Venous blood samples were taken at 0, 1, 3, 6, 9 and 12 months after insertion and the concentration of levonorgestrel was determined by radioimmunoassay. At 3 to 12 months, the overall mean concentration of plasma levonorgestrel was significantly lower in the six epileptics taking phenytoin alone or in combination with other anticonvulsants (203 +/- 128 pg/ml, mean +/- SD) than in the controls (325 +/- 135 pg/ml, p less than 0.01). After one year, nine of the control patients continued the use of NORPLANT and no pregnancies occurred. Two of the nine epileptics became pregnant during contraception by NORPLANT. They both used phenytoin and their plasma concentrations of levonorgestrel were low near the time of conception. Levonorgestrel released from the capsules had no apparent harmful effects on epilepsy and none of the patients reported an increase in seizure frequency. The results show that contraception by the progestin levonorgestrel is not reliable in epileptic patients using anticonvulsants known to induce metabolizing enzymes of the liver.

Levonorgestrel in milk and plasma of breast-feeding women with a levonorgestrel-releasing IUD.

A levonorgestrel-releasing intrauterine contraceptive device was used by 10 breast-feeding women beginning 6 weeks after delivery. Two models of IUD were used. One released 10 microgram (5 patients), the other 30 microgram (5 patients) of levonorgestrel per day. Plasma and milk samples were collected 8 times over a 3-month period and the concentrations of levonorgestrel determined by radioimmunoassay. An improved and sensitive method for the determination of levonorgestrel in milk was developed. A column chromatographic purification of a milk extract before radioimmunoassay made possible the use of large milk samples in order to improve the sensitivity. The plasma concentrations during the follow-up period were 207 +/- 64 pg/ml (mean + SD) in the 10 microgram and 235 +/- 87 pg/ml in the 30 microgram/day releasing IUD groups. The milk levonorgestrel concentrations were 56 +/- 35 and 57 +/- 34 pg/ml, respectively. The plasma to milk ratio of levonorgestrel was initially 100:15 and at the end of the 3-month follow-up period 100:25. There were no significant differences in the milk and plasma concentrations between the study groups. The total amount of levonorgestrel excreted per day in 600 ml breast milk is approximately 0.1 per cent of a daily dose of 30 microgram.

A contraceptive vaginal ring releasing ethinyl estradiol and the progestin ST-1435: bleeding control, serum steroid concentrations, serum lipids and serum chemistry.

Four women used vaginal rings releasing the synthetic progestin ST-1435 and ethinyl estradiol for at least three 21-day cycles with a 7-day treatment-free period between intervals of use. Patterns of bleeding were evaluated and serum concentrations of ST-1435, estradiol, progesterone and ethinyl estradiol were measured by radioimmunoassay. Total serum cholesterol, HDL-cholesterol, LDL-cholesterol, triglycerides and serum chemistry were determined before ring use and during the first and third treatment cycles. The women experienced no difficulties in using the vaginal ring and all continued to use the ring after the first three cycles. Bleeding control was good and hormonal side effects were minimal. Serum steroid concentrations were: ST-1435, 289 +/- 117 pmol/l (mean +/- SD); ethinyl estradiol, 172 +/- 108 pmol/l; and estradiol, 184 +/- 107 pmol/l. Concentrations of serum progesterone were low, indicating complete suppression of ovulation during treatment. Total serum cholesterol increased slightly during use of ring. However, this increase could be accounted for by an increase in serum HDL-cholesterol. Liver function tests were in the normal range during ring use and values of serum chemistry showed no significant changes. This contraceptive vaginal ring presents a good method of contraception, showing good bleeding control and no harmful metabolic effects.

Transdermal absorption of the progestin ST-1435: therapeutic serum steroid concentrations and high excretion of the steroid in saliva.

The synthetic progestin ST-1435 was administered transdermally to six healthy women during the late luteal phase. The steroid was applied to the periumbilical area in a commercial gel ("Progestogel"), also containing progesterone. Single doses of 2.3, 4.5 and 9.0 mg of ST-1435 were given in three experiments and repeated doses of 2.3 mg of ST-1435 for five days were given in another three experiments. Samples of serum and saliva were collected and the concentrations of ST-1435 and progesterone were determined by radioimmunoassays. Transdermal absorption of the synthetic progestin ST-1435 was shown to result in serum steroid concentrations high enough for therapeutic purposes. The concentration of ST-1435 in serum was still high 24 hours after application, reflecting sustained release of the steroid from the skin. In the five-day experiments, relatively constant serum levels were achieved in different individuals, and a single dose per day seems sufficient. High excretion of ST-1435 in saliva was found two hours after gel application. However, the concentrations of serum and salivary ST-1435 were not directly correlated in different individuals. Transdermal application of ST-1435 might offer a good alternative for systemic progestin treatment.

The progestin ST 1435--rapid metabolism in man.

Parenterally administered ST 1435 (Nestorone) is highly potent for contraception, and ovulation can be inhibited with very low serum levels of ST 1435. Orally administered ST 1435 is ineffective in various laboratory animals, presumably due to extensive first-pass metabolism. Thus, ST 1435 has been proposed for lactational contraception, to be metabolized by the suckling infant. We have studied the metabolism of ST 1435 in female volunteers following oral (10 mg), intravenous (iv) (0.1 mg) and transdermal (4.5-9.0 mg) routes of ST 1435 administration. Preliminary studies using rats were performed to develop the methodology of high performance-liquid chromatography (HPLC) fractionation and ST 1435-RIA detection. Rat portal serum revealed 4 distinct peaks of immunoreactive material with the retention times (Rt's) of 7.5, 10, 14.5 and 17.5 min (ST 1435 = 10 min). In systemic serum, only the peak with the Rt of 7.5 min could be detected. Therefore, orally administered ST 1435 is very effectively metabolized by the rat liver; this also explains the previously observed lack of biological effects of oral ST 1435. Following oral administration of ST 1435 to two women, the Rt of the major peak was 10 min. The magnitude of the ST 1435 peak decreased rapidly, and at 24h following ingestion, no ST 1435 could be detected by this method. The t1/2 of ST 1435 was approximately 1-2h. In addition, two minor peaks with Rt's of 4.5 and 16 min could be detected with the ST 1435 RIA at 1-4h following oral ingestion. Competitive receptor binding assays using the human uterine progesterone receptors (hPR) revealed that the ST 1435 fraction exhibits strong binding affinity towards the hPR; thus, in the human, a small fraction of biologically active ST 1435 seems to escape from the first-pass metabolism following oral intake. Following iv and transdermal administration of ST 1435, the only detectable peak with ST 1435-RIA was that of ST 1435. Similar magnitude of the ST 1435 peaks following oral administration of 10 mg and iv administration of 0.1 mg indicated that the bioavailability of ST 1435 is low. These data seem to confirm the suspicion that orally administered ST 1435 is also rapidly metabolized in the human, therefore encouraging further evaluation of ST 1435 during lactation. However, the rapid metabolism seen after oral intake can be successfully circumvented by sustained parenteral administration of ST 1435.

Vaginal contraception with gossypol: a clinical study.

A clinical study concerning the vaginal contraceptive efficacy of gossypol acetic acid was performed. Fifteen women who had undergone tubal sterilization volunteered for the study. The effect of vaginal gossypol-containing gel on spermatozoa was determined by postcoital tests performed in subjects without and after using gossypol gel. After gossypol application, the number of spermatozoa found in cervical mucus was greatly decreased and, in eleven of the fifteen women, all spermatozoa seen were immobilized. In four cases a few poorly motile spermatozoa were seen but they showed no forward progression. We have previously reported that gossypol has an inhibitory effect on herpes simplex virus type 2 in vitro. This anti-viral property of gossypol makes it particularly attractive as a topical barrier contraceptive. The present study shows that gossypol is also promising as a vaginal contraceptive agent in human in vivo experiments.

PIP: 15 women who had undergone tubal sterilization participated in a study of the vaginal contraceptive efficacy of a gel containing gossypol acetic acid. The women were aged 35 on average and had 2-3 children each. Postcoital tests (PCT) were performed 2 weeks before expected menstruation, 1 test after gossypol application, and another after a control application of the vehicle gel without gossypol in the following cycle. The gel was applied about 1 hour before coitus and the PCT was performed about 8 hours later. Gossypol treatment greatly decreased the number of spermatozoa seen in cervical mucus in 13 of 15 test subjects, and all spermatozoa seen were immobilized in 11 of the 15. Poor motility with no forward progress was seen in the other 4 test cases. In control PCTs, 11 of the 15 showed 20 or more spermatozoa per visual field with motility between 20-70%. In 3 of the control PCTs, only 2-15 spermatozoa were seen but the motility was good. The PCTs performed after application of the vehicle gel alone showed 5-30 spermatozoa per visual field and good motility indicating that gel alone had no spermicidal effect. Gossypol gel was well accepted. An in vitro test of the effect of gossypol gel on spermatozoa in cervical mucus demonstrated gradual immobilization within 3-5 minutes. In addition to its antifertility effect, gossypol has antiviral and antigonococcal properties.

Bacterial flora of the cervix in women using an intrauterine device.

The cervical bacterial flora of 18 healthy, parous, sexually active women was analysed before, and 3-5 months after insertion of a copper-releasing intrauterine device (IUD) and after long-term use of an IUD for 3-5.5 years in another nine women. No significant differences were found in the number of aerobic bacteria isolated before or after IUD insertion or after long-term use of an IUD. In contrast to aerobic bacteria, significantly more anaerobes were isolated in the cervix of women having used an IUD for several years when compared to those using barrier contraception with a condom. None of the women had clinical signs of pelvic infection and a cervical bacterial flora rich in anaerobes can be regarded as a normal finding in healthy sexually active women using an IUD for contraception.

Contraception with subdermal implants releasing the progestin ST-1435: a dose-finding study.

A new modified subdermal implant releasing the potent progestin ST-1435 was studied in eleven fertile-aged women. These implants have been developed for contraception and they have a life-time of two years. Three implant lengths of 4, 6 and 8 cm were tested to find the optimal steroid dose for inhibition of ovulation. Serum samples were collected twice per week during a six-week period every six months. The concentrations of serum ST-1435, estradiol and progesterone were determined by RIA. Ovulation was inhibited by all ST-1435 doses tested. The concentration of serum progesterone was below 6 nmol/l in all samples tested showing the absence of luteinization. The concentration of serum ST-1435 increased with increasing ST-1435 dose. Serum estradiol concentrations were quite variable, showing wide range and occasional high peak values typical of progestin treatment; the mean value of serum estradiol concentrations measured did not differ with different ST-1435 doses. The results of steroid determinations led to the conclusion that a single 4 cm subdermal implant is optimal for contraception. With this dosage level, ovulation is inhibited and side effects are minimized. Bleeding control was variable. No hormonal side effects due to the progestin ST-1435 were reported. This method, using a single 4 cm subcutaneous implant releasing the progestin ST-1435 with a life-time of two years, represents a promising alternative for inhibition of ovulation and contraception.

Five years' experience with levonorgestrel-releasing IUDs.

Two levonorgestrel-releasing IUDs and a copper-releasing IUD of the same shape were studied in a randomized comparative study over five years. The levonorgestrel-releasing IUDs released 20 micrograms or 30 micrograms per day. The Pearl index during the 10,600 woman-months of LNG-IUD use was 0.11. The control device releasing copper had a Pearl index of 1.6. The amount and duration of menstrual bleeding was greatly reduced, leading to a high incidence of oligo- or amenorrhea. The continuation rate in this pioneer trial was 53 per 100 users for the levonorgestrel-releasing IUD (LNG-IUDs) and 50 per 100 users for the copper-releasing IUD (Nova T). The removal rates for reasons other than amenorrhea were not significantly different. Discontinuation because of amenorrhea occurred during the first two years, the cumulative termination rate for this reason was 11.6 per 100 users at five years. The LNG-IUDs removed for investigation after five years of use revealed that the devices contained about 40 percent of the original load. The effective lifespan of the device has been demonstrated by this study to be five years; the residual steroid gives an additional safety period of two more years. The LNG-IUD is a highly effective reversible contraceptive method, which strongly reduced the amount and duration of bleeding. During the first two months there is scanty but frequent spotting which, like the high incidence of oligo- and/or amenorrhea, requires counselling of health personnel and women using LNG-IUDs.