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Effect of multiple-dose dexloxiglumide on the pharmacokinetics of oral contraceptives in healthy women.

This study was undertaken to evaluate the effect of dexloxiglumide, a selective cholecystokinin receptor antagonist, on the pharmacokinetics of a combination oral contraceptive (OC). A single-blind, placebo-controlled, 2-period crossover study was conducted in 24 healthy young female subjects who received Ortho Tri-Cyclen containing ethinyl estradiol (EE, 0.035 mg) and norgestimate (NE, 0.180 mg/0.215 mg/0.250 mg per 7-day phase, respectively) for 5 days (days 17-21) concurrently with either 200 mg dexloxiglumide (3 times a day on days 17-20, followed by a single dose on day 21) or matching placebo during 2 consecutive 28-day OC dosing cycles. Plasma was sampled up to 24 hours for the determination of EE, NE, and 17-deactyl norgestimate (17-DNE, a rapidly formed pharmacologically active metabolite of NE). The geometric mean ratios (GMRs, dexloxiglumide/placebo) of the plasma concentration-time curve over 24 hours with corresponding 90% confidence intervals (CIs) for EE and 17-DNE were 1.21 (1.17-1.26) and 0.92 (0.89-0.95), respectively. The GMRs (90% CI) of C(max) for EE and 17-DNE were 1.15 (1.09-1.20) and 0.93 (0.90-0.96), respectively. Coadministration of OC and dexloxiglumide was well tolerated and safe. Comparable systemic exposure of EE and 17-DNE in the presence and absence of dexloxiglumide suggests that dexloxiglumide treatment is unlikely to interfere with the safety and efficacy of oral contraceptives based on the analysis of the resulting pharmacokinetic profile.

Adult↗

A review of transdermal hormonal contraception : focus on the ethinylestradiol/norelgestromin contraceptive patch.

Imperfect use of contraceptive methods notably increases the likelihood of pregnancy. One means of improving user adherence with hormonal contraception is to minimize the dosing schedule. Two forms of hormonal contraceptive have currently achieved this goal: the transdermal patch and the vaginal ring. The first and only transdermal contraceptive patch to receive worldwide regulatory approval (ethinylestradiol/norelgestromin) is a convenient approach to contraception that has a similar efficacy to oral contraceptives (OCs), but with the benefit of once-weekly administration. In addition, transdermal delivery of contraceptive hormones eliminates variability in gastrointestinal absorption, avoids hepatic first-pass metabolism, and prevents the peaks and troughs in serum concentrations that are seen with OCs. Norelgestromin, the progestin contained in the patch, is the active metabolite of norgestimate and is structurally related to 19-nortestosterone. Norgestimate and norelgestromin mimic the physiologic effects of progesterone at the progesterone receptor; however, norelgestromin has negligible direct or indirect androgenic activity, suggesting that it may be suitable for women with disorders related to androgen excess (such as hirsutism, acne, and lipid disorders).Contraceptive effectiveness is usually a function of the efficacy of a contraceptive in combination with compliance with its dosing regimen. The efficacy of the contraceptive patch has been clearly demonstrated in three phase III trials, two of which were randomized comparisons with an OC. The likelihood of pregnancy was similar between these contraceptive methods; however, compliance with the patch was notably better, particularly in younger women. The safety and tolerability profile of the patch was similar to that of the OC. A cost-effectiveness analysis has suggested that the contraceptive patch is more cost effective than the OC, due to decreased costs related to unwanted pregnancy.

Contraception↗

Can changes in sex hormone binding globulin predict the risk of venous thromboembolism with combined oral contraceptive pills?

BACKGROUND: Recent studies have indicated that the risk of thromboembolic disease (VTE) in users of combined oral contraceptive pills (COCs) varies not only with estrogen dose, but also with the progestogen in pills with the same estrogen dose. The aim of this article is to discuss sex hormone binding globulin (SHBG) as a marker of estrogenicity and as a surrogate indicator for the potential risk of VTE in users of COC. MATERIAL AND METHODS: Using data from the literature, we investigated the relationship between the risk of VTE with various COCs and their effects on SHBG. We also collected data on the effects on SHBG by some combined preparations, where there are no VTE data. RESULTS: There appears to be a relationship between the risk of VTE and the effect on SHBG. Monophasic preparations containing levonorgestrel, having the lowest risk of VTE, cause an average SHBG increase of around 50%. COCs containing desogestrel or gestodene cause an average SHBG increase of 200-300%. A preparation with cyproterone acetate, carrying a higher risk of VTE than desogestrel and gestodene, cause a 300-400% SHBG increase. With the recently developed combined preparations, there is a 150% SHBG increase with norgestimate and a 250-300% increase with drosperinone and dienogest. CONCLUSIONS: We propose that the change in SHBG with a COC could be interpreted as a measure of total estrogenicity and used as a predictor of the risk of VTE. Preparations containing drosperinone, dienogest, cyproterone acetate and norgestimate are equally or more estrogenic than the more thoroughly studied COCs, containing desogestrel or gestodene and should not be considered a safer substitute.

Biomarkers↗

Transdermal contraceptive patch delivering norelgestromin and ethinyl estradiol. Effects on the lipid profile.

OBJECTIVE: To evaluate the metabolic impact on lipids of a contraceptive patch that delivers norelgestromin (primary active metabolite of norgestimate) and ethinyl estradiol to the systemic circulation as compared with a placebo patch. STUDY DESIGN: In this randomized, double-blind trial, healthy women received the contraceptive patch (n = 99) or placebo patch (n = 47) for up to 9 cycles. Fasting blood samples were obtained at baseline and cycles 3, 6 and 9 for determining the serum lipid profile. RESULTS: At cycles 3, 6 and 9, mean increases from baseline in high-density lipoprotein (HDL) cholesterol, HDL3 cholesterol, total cholesterol and total triglycerides, and mean decreases in calculated (Friedewald) low-density lipoprotein (LDL)/HDL were observed in the contraceptive patch group (all P < .05 vs. placebo except for total cholesterol at cycle 6). Mean changes in HDL2 and calculated LDL cholesterol were minimal and comparable between treatments. Mean body weight increased from baseline to the end of treatment by 0.8 and 0.6 kg in the 2 groups, respectively; this difference was not significant. CONCLUSION: The lipid changes seen with the contraceptive patch are consistent with those of oral contraceptives containing norgestimate and ethinyl estradiol.

Administration, Cutaneous↗

Effects of E2 and E2/norgestimate hormone therapy on elevated baseline lipids.

OBJECTIVE: To evaluate lipid effects of estradiol/ norgestimate hormone therapy in postmenopausal women with elevated lipid levels. STUDY DESIGN: Postmenopausal women were randomized to E2, 1 mg/intermittent norgestimate (NGM) 90 microg (n = 31), or opposed E2, 1 mg (n = 36), in a 12-month trial. A subset analysis was conducted on participants with unfavorable baseline lipid levels, either total cholesterol (TC) levels > 200 mg/dL, high-density lipoprotein cholesterol (HDL-C) levels < 40 mg/dL, low-density lipoprotein cholesterol (LDL-C) levels > or = 160 mg/dL or triglyceride levels > or = 150 mg/dL. Mean changes and categorical shifts were assessed on fasting blood samples collected at baseline and at 7 and 12 months. RESULTS: Twelve-month mean changes from baseline in women treated with E2/NGM included a 19.8% increase in HDL-C and decreases of 13.4% in LDL-C, 17.5% in triglycerides and 3.3% in TC. Women with poorer lipid profiles at baseline showed the greatest benefit. Results were similar in women randomized to unopposed E2. CONCLUSION: E2/NGM and unopposed E2 were similarly beneficial in modifying lipid fractions in women with unfavorable baseline levels.

Adult↗

Re-evaluation of oral contraceptive classifications.

Classification of combination oral contraceptives (OCs) by "generation"--typically based on the time of introduction of new compounds--is problematic. The estrogen and progestin components may be present in differing doses, and their interaction may therefore vary from one formulation to another. In addition, assigning the progestin component itself to a particular generation does not account for the unique characteristics of individual progestins within that group. These issues can be clarified by understanding the evolution of combination OCs in relation to dosage changes and by differentiating the pharmacologic profiles of individual progestins, particularly norgestimate, desogestrel, and gestodene. Although all sex steroids have the same basic structure, relatively minor structural modifications can cause dramatic alterations in biochemical activity. Progestational activity is the desired pharmacologic effect of progestins used in OCs, whereas androgenic activity, which increases the potential for adverse metabolic and physical side effects, is undesired. In vitro assays of the ability of various OC progestins to bind progestin and androgen receptors suggest that the androgen/progestin (A/P) binding ratio--a measure of progestin selectivity--is more favorable for norgestimate than for levonorgestrel, gestodene, or desogestrel. In vivo measurements of interactions between various progestins and human sex hormone binding globulin (SHBG) support the concept that generational classification of OC progestins is misleading. These compounds also differ clinically, as exemplified by differential effects on lipoprotein metabolism. In summary, progestins exhibit individually unique biochemical and clinical properties.

Animals↗

Characteristics of the new progestogens in combination oral contraceptives.

This review details the characteristic features of three new progestogens which soon will be available in low-dose combination oral contraceptive agents in the United States. Available data suggest that desogestrel, gestodene, and norgestimate are extremely potent progestogens with few androgenic side effects. The smaller changes in lipids induced by these progestogens seem to confer some advantage to the use of preparations containing one of these agents. Whether this advantage is also present clinically remains to be determined.

Blood Coagulation↗

Ovarian function during low-dose oral contraceptive use.

Lowering the total steroid dose in modern oral contraceptives (OCs) has been connected with a higher incidence of ovarian follicle and cyst formation. To investigate the presence of ovarian follicles and cysts by means of vaginal ultrasonography and serum hormone determinations during use of two low-dose OCs, 65 volunteers were randomized to receive either 20 micrograms ethinylestradiol (EE) + 150 micrograms desogestrel (group A) or 35 micrograms EE + 250 micrograms norgestimate (group B) for a 2-month study period. At baseline, 39% of women in group A and 31% in group B exhibited at least one follicle < 35 mm in diameter. By the end of the second treatment cycle, the frequency of these follicles had decreased to 14% in each group. Only one subject in the higher estrogen group developed an ovarian cyst > 35 mm. One subject in each group demonstrated hormone levels characteristic of ovulation; no pregnancy occurred in either group. The 20 micrograms EE preparation was not found to lead more often to ovarian follicles or cysts when compared with a 35 micrograms EE preparation, possibly because of the type and dose of the progestogen used.

Contraceptives, Oral, Combined↗

Sex hormone receptor binding, progestin selectivity, and the new oral contraceptives.

The desired biologic effect of progestins used in OCs is progestational activity. Undesired pharmacologic properties such as androgenic activity are not necessary for contraception and increase the potential for adverse effects. A selective progestin has progestational effects at relatively low concentrations or doses and androgenic effects at only relatively high concentrations or doses. The degree to which progestational activity is maximized and androgenic activity is minimized is a measure of a progestin's selectivity. The ratio of its affinity for progesterone receptors to its affinity for androgen receptors is the selectivity index. To minimize the androgenic side effects associated with the older progestins, the doses used in OCs have been reduced over the years. These dose reductions have decreased the potential for undesired androgenic effects but also have negatively affected cycle control. Three new progestins, norgestimate, desogestrel, and gestodene, have relatively greater affinity for progesterone receptors than for androgen receptors when compared with the older agents, permitting a reduction in androgenic side effects without the need for further dose reduction. Preclinical receptor-binding studies and animal pharmacologic studies have documented the higher selectivity indexes of these new progestins. Their higher ratios of progestational to androgenic activity provide the basis for the reduction in androgenic adverse effects observed with their clinical use.

Animals↗

The androgenicity of oral contraceptives: the young patient's concerns.

Sexual activity is quite common among women aged 14 to 20 in developed countries, averaging perhaps 10% at age 15 to about 70% at 19. Thus, the need for contraception may begin quite early in life and will continue for as long as 30 years. One of the best candidates for long-term contraception for young sexually active females is the oral contraceptive (OC), which provides health benefits besides contraception. Long-term benefits include lowered rates of ovarian and endometrial cancer, as well as of benign breast disease and ovarian cysts. Another benefit is protection against upper-tract sequelae of sexually transmitted diseases. Short-term benefits are correction of menstrual irregularity, reduction in menstrual flow, and diminished premenstrual syndrome and dysmenorrhea. Recent OC formulations contain only one-third the estrogenic potency of older OCs and therefore are associated with dramatic decreases in what were always the major side effects of OCs: heart attack, stroke, and pulmonary embolism. Other side effects of OCs have been most closely associated with the progestogenic component, and are related to the androgenic effects of progestins, particularly some synthetic progestins. However, some new synthetic progestins have been found to have minimal androgen receptor activity in preclinical testing and to cause minimal or no androgen-related side effects in clinical trials. One of these new progestins having a favorable androgenic profile is norgestimate. Its efficacy and safety in combination with low doses of ethinyl estradiol have been documented in the European and the American literature.(ABSTRACT TRUNCATED AT 250 WORDS)

Acne Vulgaris↗

Increased levels of activated factor VII and decreased plasma protein S activity and circulating thrombomodulin during use of oral contraceptives.

In the present study the effect of oral contraceptive (OC) treatment on selected factors involved in the activation, i.e. circulating activated factor VII (cFVIIa), and in the inhibition of blood coagulation, i.e. plasma protein S activity and circulating thrombomodulin (cTM), were for the first time measured in OC users in a prospective study. Beside other coagulation variables, these parameters were measured during treatment with three low estrogen formulations containing different gestagen components (norgestimate, gestodene). During OC treatment increases in the activation markers prothrombin fragment F1 + 2 and D-Dimer were found, suggesting an increased activation of blood coagulation and fibrinolysis. Along with elevated plasma levels of FVII antigen, cFVIIa was also found increased in all three treatment groups, while inhibitory components of blood coagulation, plasma protein S activity and cTM, significantly and similarly decreased during treatment in all three treatment groups. We conclude that low dose estrogen pills induce similar changes in the plasma levels of main regulatory components of blood coagulation, despite differences in their gestagen components. Increased levels of activators and decreased activities of inhibitors may contribute to arterial and venous thrombotic complications seen in predisposed OC users.

Adult↗

Gestoden, an innovative progestogen.

The estrogen component used in virtually all oral contraceptive pills today was synthesized in the laboratories of Schering AG in 1938. The progestogen component varies, but levonorgestrel has become the standard among the lowest-dose pills available. Various attempts to modify the levonorgestrel molecule have resulted in new progestogens like norgestimate and desogestrel without much greater biological activity; therefore, further reduction in dose is unlikely. Gestoden, the newest progestogen from the levonorgestrel class, synthesized in Schering AG's laboratories, is different. Its enhanced biological activity allows for a progestogen content in a fixed combination pill half that in other low-dose pills available today. Furthermore, it has an improved pharmacologic profile with favorable dissociation of the androgenic and progestogenic activities. A unique anti-mineralocorticoid action is seen resembling natural progesterone, a property not presently shared with other synthetic progestogens. Results will be presented from clinical trials with a new monophasic gestoden preparation.

Blood Pressure↗

Investigations on the in vitro metabolism of five synthetic 19-norprogestins using hepatocyte suspensions isolated from five laboratory animal species.

Five synthetic progestins of the 19-nortestosterone type (norethisterone, NET; levonorgestrel, LN; gestodene, GEST; NET-3-oxime, NETO; norgestimate, NGM) were investigated in the in vitro hepatocyte model. Radiolabelled progestins were added to hepatocyte suspensions (3 x 10(6) cells/ml) freshly prepared from female rat, guinea pig, rabbit, dog (beagle) and cynomolgus monkey. Drug level decreases (NET, LN, GEST) and prodrug conversions (NETO, NGM) were followed by radiochromatography (HPLC) for 60 min. In the case of NET and NETO the conversion into ethinyl estradiol (EE2) was quantified by RIA after HPLC separation. Half-lives of drug level decreases (t1/2), areas under the curves (AUC) and metabolic clearance rates (MCR) were estimated for all progestins. For NETO and NGM the percentages of conversion into NET and LN were calculated, respectively, and levels of EE2 determined in the case of NET and NETO. Rat hepatocytes showed an extremely high metabolic activity towards NET, LN and GEST resulting in t1/2 values of below 2 min. Respective values for rabbit hepatocytes ranged from 5-8 min, whereas half-lives calculated for liver cells from guinea pig, dog and monkey were generally above 30 min. A drastic increase in t1/2 was found for NETO (as compared to NET) in hepatocytes from rat, rabbit and monkey but not from guinea pig. Dog hepatocytes degraded NETO about 3 times more rapidly than NET. NGM was degraded much faster than LN in hepatocytes from all species except the rat. Liver cells from guinea pig and dog seem to be able to metabolize the 3-oxime group much more rapidly than hepatocytes from the other animal species. The lowest degree of prodrug conversion of 4% was observed for NGM and dog hepatocytes. Elevated EE2 levels were found in all experiments with NET and NETO. Results of NET, LN and GEST were compared with published in vivo experiments. No correlations were found for t1/2, MCR, and AUC.

Animals↗

The association of serum androsterone glucuronide with inflammatory lesions in women with adult acne.

Serum androsterone glucuronide (AoG) is a metabolite of circulating androgens under the influence of 5alpha-reductase activity and has been shown to be particularly elevated in women with acne. In this study, we wanted to evaluate changes in AoG before and after treatment with an oral contraceptive or placebo, and to assess whether changes correlated with the number and type of acne lesions. In order to accomplish these aims, we obtained sera from a completed prospective randomized trial, which was designed to assess the effectiveness of an oral contraceptive compared to placebo. Assessments were carried out in 56 women with moderate acne who were treated with Ortho Tri-Cyclen (norgestimate and ethinylestradiol) (30 patients) or placebo (26 patients) for 6 months. Before and after treatment, the number and type of skin lesions, serum levels of total T, free-T, DHEAS and AoG were determined. Serum AoG increased significantly in women with moderate acne, although T, free-T and DHEAS were normal. 75% of acne patients had elevated levels of serum AoG. Ratios of serum AoG to androgen precursors were also elevated. Oral contraceptive (OC) treatment significantly reduced levels of free-T and AoG, both of which were unaffected by placebo. While both OC and placebo treatment resulted in improvement of comedones and inflammatory lesions, OC treatment decreased inflammatory lesions to a greater extent (p<0.05). After treatment, serum AoG correlated with the number of inflammatory lesions. Results showed that serum AoG is a sensitive marker of acne in women, even in those with normal circulating precursor androgens; and is lowered by OC treatment, correlating with the reduction of inflammatory lesions. We hypothesize that the increase of serum AoG in normoandrogenic acne may be related to inflammation, and serum AoG may serve as a marker of this process.

Acne Vulgaris↗

Determination of delta4-3-ketosteroids based on oxime formation by difference circular dichroism spectroscopy.

delta4-3-Ketosteroids exhibit an intensive negative Cotton effect on the circular dichroism (CD) spectra in the wavelength range for the n-pi* electronic transition (270-350 nm). With hydroxylamine hydrochloride, delta4-3-ketosteroid compounds can be transformed into oxime derivatives. Following oxime formation, positive ellipticity with low intensity can be registered in this wavelength range. The quantitative determination of delta4-3-ketosteroids is based on the considerable difference between the ellipticities before and after oxime formation. The difference ellipticity for the six ketosteroids examined (norethisterone, levonorgestrel, levonorgestrel acetate, methyltestosterone, testosterone phenylpropionate, nortestosterone phenylpropionate) varies linearly with the concentration in the interval 6 x 10(-6)-3 x 10(-3) mol/L. The method can be well applied to determination of delta4-3-ketosteroid contamination of norgestimate [(+)-13-ethyl-17-hydroxy-18,19-dinor-17alpha-pregn4-en-20-yn-3-one oxime acetate]; 0.02-10% impurity can be measured.

Circular Dichroism↗

Hormonal treatment of acne: review of current best evidence.

BACKGROUND: Recent controlled clinical trials have demonstrated the efficacy of various hormonal preparations, including oral contraceptives, in treatment of acne. OBJECTIVE: The goal of this article is to evaluate the best current evidence on the efficacy of hormonal treatment of acne. METHODS: English-language controlled clinical trials of systemic hormonal treatment of acne were sought by search of references of general dermatology texts, reviews on acne, drug product monographs, and computer-assisted search of MEDLINE, CINAHL, and COCHRANE databases between 1970 and 2003 using the key words hormonal, oral contraceptive, acne, spironolactone, cyproterone, flutamide, and therapy. For each agent, studies fulfilling the highest level of evidence were selected for further evaluation. RESULTS: The literature search recovered two placebo-controlled random controlled trials (RCTs) each of ethinyl estradiol 0.035 mg and norgestimate and ethinyl estradiol 20 microg and leonorgestrel 100 microg, three active-comparator RCTs of ethinyl estradiol 0.035 mg and cyproterone acetate 2 mg, one active comparator RCT of ethinyl estradiol 30 mug and drosperinone 3 mg, three small placebo-controlled RCTs of spironolactone, and one active-comparator RCT of flutamide. CONCLUSIONS: The efficacy of Tri-Cyclen and Alesse in acne is supported by high-quality RCTs (level A evidence). Evidence for the efficacy of Diane-35, spironolactone, and flutamide is derived from lower-quality RCTs (level B evidence). Results from a population-based epidemiological study suggests that Diane-35 is the most effective of these oral contraceptives in the treatment of acne (level B evidence; epidemiological study).

Acne Vulgaris↗

Gastrointestinal metabolism of contraceptive steroids.

A number of oral contraceptive steroids undergo first-pass metabolism in the gastrointestinal mucosa. Ethinyl estradiol (mean systemic bioavailability 40% to 50%) is extensively metabolized, principally to a sulfate conjugate. In vivo studies that use portal vein catheterization and the administration of radiolabeled ethinyl estradiol have shown that the fraction of steroid metabolized in the gut wall is 0.44. In vitro studies with jejunal biopsy samples or larger pieces of jejunum or terminal ileum mounted in Ussing chambers have indicated that more than 30% of added ethinyl estradiol is sulfated. The progestogen desogestrel is a prodrug that is converted to the active metabolite 3-ketodesogestrel. Substantial first-pass metabolism of desogestrel occurs in the gut mucosa, with evidence from Ussing chamber studies for the formation of the active metabolite. Another progestogen, norgestimate, is also metabolized by the gut wall in vitro of which the principal metabolite is the deacetylated product, norgestrel oxime. It seems very likely that this will also occur in vivo. Drug interactions occurring in the gut wall have been reported with ascorbic acid (vitamin C) and paracetamol.

Aged↗

Binding of oral contraceptive progestogens to serum proteins and cytoplasmic receptor.

Some progesterones widely used in oral contraceptives are characterized at the level of high-affinity receptor binding as well as binding to sex hormone-binding globulin and corticosteroid-binding globulin. With regard to binding to sex hormone-binding globulin, gestodene, levonorgestrel, and to a lesser extent 3-ketodesogestrel (which is only formed from the prodrug desogestrel in the body), show a behavior that is manifested in the relatively high affinity to sex hormone-binding globulin, whereas desogestrel and norgestimate do not display any measurable affinity for this specific steroid-binding serum protein. Furthermore, levonorgestrel and gestodene dissociate very much more slowly from the binding sites of sex hormone-binding globulin than 3-ketodesogestrel. A natural affinity of all these synthetic progestogens tested for corticosteroid-binding globulin could not be established. Gestodene, levonorgestrel, and 3-ketodesogestrel bind to the progesterone, glucocorticoid, and androgen receptor with high affinity, apart from slight differences, whereas estrogen receptor affinity could not be demonstrated in any of the progestogens investigated. In relation to aldosterone, the relative binding affinity values of gestodene, levonorgestrel, and the natural progestogen progesterone are relatively high, whereas 3-ketodesogestrel does not display any measurable affinity for this receptor species.

Animals↗