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Health Effects of Progestins Contained in Cocs, with A A PHACTICAL JOURNAL FOR NUHSE PRACTITIONEn5 I i - 1- November 2007 The Official Journal of NPWHj- A 7 .-. Vol. G, No. 11 A Peer-Reviewed Journal &$ Health Effects of Progestins Contained in t COCs, with a -.'P Focus on Norgestimate- -.-I. 21 ? NPWH 2007 ' Annual Conference Abstracts HEALTH EFFECTS OF PROLESTINS CONTAINED IN COCs, WITH A FOGUS ON NORGESTIMATE by Penelope M. Bosarge, MSN, WHNP ased on interviews with more Nurse practitioners (NPs) and their reproductive-aged than 7600 female adolescents and women aged 15 to 44 patients face numerous challenges, particularly when it years, more than 98% who have comes to choosing a method of birth control. If a combined ever had sexual intercourse have used at least one contraceptive oral contraceptive (COC) is judged to be an appropriate meth~d.~The leading method of contraception in the United choice for a given woman, then her NP will need to select a States in 2002 was the Pill, used particular product from among many that are available. by 11.6 million women, and the second leading method was Among the various COC brands on the market, several female sterilization, used by 10.3 million women.2The condom contain norgestimate (NGM), a progestin introduced in was the third-leading method, 1992. Fvteen years of clinical use of NGM-containing used by about 9 million women and their partners. The condom COCs, as well as continued scientz$c investigations of these is the leading method at first intercourse, but the Pill is the products, support their efficacy, safety, and tolerability leading method among women (ie, these products have minimal androgenic and estrogenic younger than 30 yearse2 effects and provide excellent cycle control). NGM-containing Because COCs are a reversible form of contraception, they are a COCs also ofer a host of noncontraceptive benefits. Of note, good choice for younger women who want to postpone pregnancy NGM is the No. 1 prescribed progestin in COCs when or for women in their 20s or 30s brand-name and generic products are included.' All of these who wish to space their pregnan- cies a few or several years apart. findings provide the rationalefor this review article on the Unlike most prescription medica- progestins contained in COCs, with a focus on NGM. tions, which are intended for acute or short-term use, COCs may be used for many years or November 2007 Vol. 6, No. 11 I I even decades. This length of time luteinizing hormone (LH) from dimethisterone, medroxyproges- translates into potential exposure the anterior pituitary gland." In terone acetate, NET or NET to hormone components of 20 to addition, progestins create a thick acetate (NETA), norethynodrel, 30 years or even longer. So, a cervical mucus that slows sperm or norgestrel. Levonorgestrel COC formulation that has proved transport and inhibits capacita- (LNG) was then developed, and to be effective, safe, and well tol- tion (activation of enzymes per- served as the main progestin erated over the long term is likely mitting sperm to penetrate the ingredient in COCs through to be used successfully. ovum) .I1Progestins also affect 1989." By contrast, women are less likely cilia in the Fallopian tubes, Eight Progestins Used in COCs to continue using a COC that is decreasing the intensity and fre- Today-In 2007, eight progestins associated with unwanted side quency of their action. The result with various structures, biologic effects (eg, estrogenic effects may be a slowing effect on the activities, and clinical effects, are such as breast tenderness, nausea, rate of ovum tran~port.'~Finally, used in COC formulations in this and bloating or androgenic side progestins alter the lining of the country (Figure l).l5.I6Seven of effects such as hirsutism and uterus and make it more difficult the eight progestins are 14 acne):" or with a relatively higher for the fertilized egg to implant.12 nortestosterone derivatives classi- rate of unscheduled bleeding fied as first-generation estranes (now the preferred term for BRIEF HISTORY OF PROGESTINS (NET, NETA, and ethynodiol breakthrough bleeding/spotting diacetate) , second-generation [BTB/BTS] or intermenstrual The first synthetic progestins, gonanes (norgestrel and LNG), bleeding) ." Of note, cycle con- norethindrone (NET) and or third-generation gonanes (des- trol is affected not only by estro- norethynodrel, were introduced ogestrel [DSG] and NGM). An gen dose, but also by patient in the 1950s, fueling the emerg- older progestin, norethynodrel, is characteristics and progestin dose ing contraceptive industry. In not commonly prescribed because and type.g 1960, the first COC on the mar- of its high estrogenic activity and ket contained 9.85 mg of pro- Thus, NPs who will be making is not discussed further in this gestin.'"~ the mid-1970s, COCs prescribing decisions need to article. The eighth progestin avail- understand the differences available in the United States able in the United States is among the progestin components contained one of these pro- drospirenone (DRSP) , an analog of COCs to properly assess the gestins: ethynodiol diacetate, of spironolactone, a potassium- risk/benefit ratio for each woman based on her overall health status and her predisposition for certain health-related conditions. NPs also need to continually assess each woman's health, personal needs, and preferences at each office visit to make sure that her COC regimen continues to be a safe and appropriate choice. PROGESTINS' MECHANISM OF ACTION COCs prevent pregnancy primar- ily by inhibiting ovulation through the combined actions of progestin and estrogen.'"The dominant component is proges- tin, which inhibits ovulation by suppressing the cyclical release of 10 Women's Health Care: A Practical Journal for Nurse Practitioners sparing diuretic. DRSP has a molecular structure and activity TABLE 1. H RELATIVE HORMONAL ACTIVITIES OF SELEC'TEO PROGES'IINS'g~'u profile that differ markedly from those of the other progestins." Progestin Progestational Effects Androgenic Effects Just as an aside, experts in the sci- Estranes entific and healthcare communi- Norethindrone Olt, t, or tt Olt or t ties do not necessarily agree on Norethindrone acetate tt ttt the classification of the different Ethynodiol diacetate tt t progestins by generation (ie, sec- ond or third generation) .".'Most Gonanes (Second-Generation) experts base this classification on Norgestrel t or tt tt or ttt the time of the introduction of a Levonorgestrel t t or tt new parent compound, but some base it on structural and physio- Gonanes (Third-Generation) logic differences or efficacy. Desogestrel ttt 01 t Thus, NGM is sometimes classi- Norgestimate Olt Olt fied as a second-generation pro- gestin because it derives most of Spironolactone Derivative its activity from LNG, but it is also Drospirenone 01 t 0 classified as a third-generation progestin because it is relatively 0 = no activity; Olt = low activity; t = medium activity; tt = high activity; ttt = very high activity. newer than other progestins and because it has minimal andro- genic effects compared with LNG and norgestrel. predisposed to the development sutism. Also, progestins with of certain disorders.'" greater androgenic activity tend Spectrum of Progestins' to have a relatively more deleteri- Hormonal Activities-Synthetic Androgenic properties. Andro- ous effect on lipid and carbohy- progestins used in COCs differ genicity is determined by the abil- drate metabolism. not only in their hormonal ity of a progestin to bind to potency, but also in their spec- androgen receptors-that is, its Progestins with androgenic prop- trum of hormonal activities.'" androgenic relative binding affin- erties may counteract favorable Beside their progestogenic and ity. Sex hormone-binding globu- ethinyl estradiol (EE)-induced anti-estrogenic effects, contra- lin (SHBG), a glycoprotein, binds changes in lipoprotein metabo- ceptive progestins may exert androgens and prevents expres- lism, but they do not cause ather- estrogenic, androgenic, anti- sion of androgenic activity. osclerosis in the presence of EE.'" androgenic, glucocorticoid Estrogen stimulates SHBG On the other hand, COCs con- and/or antimineralocorticoid release. Some progestins bind to taining androgenic progestogens effects (Tables 1 and 2) .'wo As a SHBG--leaving more androgens that attenuate EE-dependent consequence, progestins may "freen-thereby leading to andro- changes in hemostasis may be affect various metabolic parame- genic side effects. Newer proges- associated with a lower risk of ters and modulate estrogen- tins (eg, NGM, DSG, DRSP), as venous thromboembolic disease induced alterations in lipid compared with older progestins, than are COCs whose progestins metabolism, hemostasis, and vari- compete less for SHBG and are have a less androgenic pr~file.'~ ous other factors. For most therefore less androgenic. Pro- Progestins with androgenic activ- women, the differences in the gestins with higher androgenic ity may also antagonize estrogen- hormonal pattern of progestins activity (eg, NETA, norgestrel) induced alterations in various used in COCs are without clinical are more likely than other pro- other hepatic proteins and modu- consequence, but these differ- gestins to have androgen-related late the effect of EE on growth ences may be relevant for wornen side effects such as acne and hir- factors.'%y contrast, progestins November 2007 Vol. 6, No. 11 I Progestin Co~nments Norethindrone NET is a first-generation progestin with low progestational and slight estrogenic activity. NET tends to be
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