CONTRACEPTION CHANGES ORAL
IN LIPID
METABOLISM
CONTRACEPTIVES
OURING
CONTAINING
GESTOOENE
12 MONTHS
OF TREATMENT
30 pg ETHINYLESTRAOIOL
WITH
TWO
AND 75 /Jg
OR 150 /Jg DESOGESTREL
W. Mar-z, C. Jung-Hoffmann,
F. Heidt,
W. Gross
and H. Kuhl
Division of Gynecological Endocrinology, Department of Obstetrics and Gynecology and Department of Biological Chemistry, J. W. Goethe-University, D-6000 Frankfurt, F. R. Germany
ABSTRACT The effect of two oral contraceptives containing 30 pg ethinylestradiol + 75 pg gestodene (EE/GSD) or 30 pg ethinylestradiol + 150 pg desogestrel (EE/DG) upon serum lipids and lipoproteins were measured in 11 women each on days 1, 10, and 21 of the first, third, sixth, and twelfth treatment cycle and compared to the levels on days 1, 10, and 21 of the preceding control cycle. There was no change in total cholesterol (CH) and phospholipids (PL), while total triglycerides (TG) were significantly elevated only during treatment with EE/GSD. After 3 and 6 months of intake of both oral contraceptives, a transitory increase in the TG content of very lowdensity lipoprotein (VLDL) and low-density lipoprotein (LDL), and a decrease in LDL-PL was observed. After 12 months, VLDL-CH, VLDL-PL, and apolipoprotein B were significantly elevated, while VLDL-TG and all components of LDL were unchanged. Most of the components of highdensity lipoprotein (HOL) were increased due to a rise in HDL3 and apolipoprotein A-II, while HDL2 and apolipoprotein A-I were not altered. There was no significant difference between the effects of the two preparations, although those of EE/GSD were mostly more pronounced. The time-dependent change in the effects of the oral contraceptives on various parameters of lipid metabolism demonstrates that the relevance of results of short-time studies may be questionable. There was also a significant alteration in some parameters between day 1 and 10 of the treatment cycles and a tendency to return to the pretreatment levels during the pill-free week, e.g., in total TG and in the PL component of VLDL, LDL and HDL. The increase in HDL, VLDL, and total TG reflects a slight preponderance of the effect of ethinylestradiol on lipid metabolism. The unchanged total CH and LDL-CH and the elevated HDL levels indicate that the risk of the development of atherosclerosis is in all probability not increased during treatment with both preparations. Submitted for publication Accepted for publication
MARCH 1990 VOL. 41 NO. 3
July 14, 1989 November 1, 1989
245
CONTRACEPTION
INTRODUCTION Oral treatment with synthetic sex steroids has been demonstrated to alter the serum concentrations and composition of lipoproteins. These effects are both dependent on the dose and type of the steroids. Most oral contraceptives contain ethinylestradiol (EE) in doses between 30 and 50 pg, while a series of different progestogens are used in various dosages. In general, estrogens increase the serum levels of triglycerides (TG), very low-density lipoproteins (VLDL), high-density lipoproteins (HDL), and apolipoprotein A, and decrease low-density lipoprotein-cholesterol (LDL-CH) (l), while progestogens, particularly those with some androgenic activity, have the opposite effect (2,3). Estrogens inhibit hepatic TG hydrolase, while progestogens derived from nortestosterone stimulate the enzyme (2,4). Moreover, the synthesis of apolipoprotein Eland hepatic LDL receptors is stimulated by EE, but not influenced by progestogens (5,6). Therefore, the resultant effect of an oral contraceptive on lipid metabolism which may influence the risk of atherosclerosis during longterm treatment, depends on the composition of the preparation (7,8). Moreover, it has been observed that the duration of treatment plays a role, too (9,lO). A new oral contraceptive containing 30 pg ethinylestradiol and only 75 pg gestodene (GSD), a highly active progestogen, was claimed by the producer to exert no metabolic effects in women. This has to be called in question in the light of very high serum levels of gestodene after intake of this preparation (11). During 12 months of treatment, we compared the effects of EE/GSD on 19 serum parameters of lipid metabolism with those of a preparation containing 30 pg EE and 150 Pg desogestrel (EE/DG). MATERIALS AND METHODS Volunteers and sample collection: Twenty-two normal healthy volunteers with regular menstrual cycles, ages between 18 and 35 years, participated in the study. Informed consent was obtained. The women had not used hormonal contraceptives for at least 3 months prior to the study and were not under interfering pharmacologic therapy. An internal and gynecological examination, including a Papanicolaou smear, was carried out prior to the selection of the subjects. During a control cycle, ovulation was confirmed to have probably taken place by the determination of serum progesterone (>3 ng/ml). Two groups of 11 women each were randomly assigned to take the preparation EE/GSD (Schering AG, Berlin, Federal Republic of Germany) or EE/DG (Organon GmbH, Oberschleissheim, Federal Republic of Germany) during 12 months. The subjects of both groups were similar in terms of height, weight, body-mass index, smoking, alcohol, exercise, and diet. They were obliged not to change their habits during the study. Blood samples were taken by venipuncture after overnight fasting between 8 and 10 AM on days 1 (i.e. 24 h after first pill intake), 10, and 21 of the first, third, sixth, and twelfth treatment cycle and of the control cycle preceding the first treatment cycle. Each sample was
246
MARCH
1990 VOL. 41 NO. 3
CONTRACEPTION
drawn into tubes containing EDTAm K2 (1.5 to 2 mg/ml). Plasma was prepared by low-speed centrifugation (1500 x g, 30 min) and kept at 4 oC during storage. Determination of lipids and lipoproteins: All determinations were completed within one week after blood collection. Cholesterol (CH) (CHODPAP-Method), triglycerides (TG) (GPO-PAP) and phospholipids (PL) were determined using reagents from Boehringer (Mannheim, Federal Republic of Germany). VLDL were quantified in terms of their lipid constituents after preparative ultracentrifugation at dC1.006 kg/l (12). HDL were determined after phosphotungstatefMgC12precipitation of apolipoprotein B containing lipoproteins, and HDL subfraction HDL2 and HDL3 were resolved by ultracentrifugation in the respective supernatants at d = 1.125 kg/l as described previously (13). LDL were calculated as difference between total lipids and HDL + VLDL. Apolipoproteins A-I and A-II were quantified by zone immunoelectrophoresis (14) and apolipoprotein B was measured by conventional radial immunodiffusion using NOR Partigen plates (Behringwerke AG, Marburg, Federal Republic of Germany). Statistical analysis: Data-were analyzed by multivariate analysis of variance (repeated measurements' design) (comparison of EE/GSD versus EE/DG; time-dependent effects) or by Student's paired t-test (treatment cycles versus control cycle or between treatment cycles). RESULTS Although some of the effects on lipids and lipoproteins were more pronounced with EE/GSD, there was no significant difference between both low-dose oral contraceptives due to the large intra- and interindividual variations. The only exception were the HDL-TG levels which were significantly higher with EE/GSD (~~0.05) (Table IV). The baseline measurements of all lipid and lipoprotein parameters were not different by randomization. There was no significant change in total CH and total PL during treatment with both preparations as compared to controls. The CH and PL levels were, however, significantly higher during the 6th and 12th cycle as compared to the first cycle due to a transitory decrease (not significant) during the first month of treatment (Table I). The high levels on day 1 of the treatment cycles demonstrate that there is no decrease during the pill-free interval of 7 days between the treatment cycles. Total TG increased significantly by 30 to 40% during treatment with EE/GSD, while the rise by 10 to 2D% with EEfDG was not significant (Table I and VII). There was a transitory small decrease in LDL-CH and a decline in LDL-PL by 20 to 3D% in both groups during the first treatment cycle which diminished gradually thereafter, while LDL-TG were elevated during the 3rd and 6th month only in the women taking EE/GSD. During the 12th treatment cycle, the LDL components did not differ from the control values (Table II and VII). There was no change in the composition of VLDL at the beginning of treatment with EE/GSD and EE/DG. During the 6th and 12th cycle, however, VLDL-CH was significantly elevated by 30 to 50% (EE/GSD) and by 15% (EE/DG), and VLDL-PL by 3D% (EE/ GSD and EE/DG) (Table III and VII). The TG content of VLDL was only
MARCH
1990 VOL. 41 NO. 3
247
I
**
p < 0.01
versus
control;
Day 1
Total PL (mg/dU
21.7 21.6 26.6 28.6 28.1
70.2 + 16.3 65.4 + 21.3 93.8 + 23.2 95.3 z 28.4 87.3 + 29.1
+ + + + +
Control Cycle 1 Cycle 3 Cycle 6 Cycle 12
178.6 174.1 192.9 204.0 201.6
Day 1
of total
+ + + t +
19.0 27.2 25.6 20.6 24.3
+ 2 + + +
15.3 23.4 23.3 26.4 41.7
##
p
IN LIPID
METABOLISM
CONTRACEPTIVES
OURING
CONTAINING
GESTOOENE
12 MONTHS
OF TREATMENT
30 pg ETHINYLESTRAOIOL
WITH
TWO
AND 75 /Jg
OR 150 /Jg DESOGESTREL
W. Mar-z, C. Jung-Hoffmann,
F. Heidt,
W. Gross
and H. Kuhl
Division of Gynecological Endocrinology, Department of Obstetrics and Gynecology and Department of Biological Chemistry, J. W. Goethe-University, D-6000 Frankfurt, F. R. Germany
ABSTRACT The effect of two oral contraceptives containing 30 pg ethinylestradiol + 75 pg gestodene (EE/GSD) or 30 pg ethinylestradiol + 150 pg desogestrel (EE/DG) upon serum lipids and lipoproteins were measured in 11 women each on days 1, 10, and 21 of the first, third, sixth, and twelfth treatment cycle and compared to the levels on days 1, 10, and 21 of the preceding control cycle. There was no change in total cholesterol (CH) and phospholipids (PL), while total triglycerides (TG) were significantly elevated only during treatment with EE/GSD. After 3 and 6 months of intake of both oral contraceptives, a transitory increase in the TG content of very lowdensity lipoprotein (VLDL) and low-density lipoprotein (LDL), and a decrease in LDL-PL was observed. After 12 months, VLDL-CH, VLDL-PL, and apolipoprotein B were significantly elevated, while VLDL-TG and all components of LDL were unchanged. Most of the components of highdensity lipoprotein (HOL) were increased due to a rise in HDL3 and apolipoprotein A-II, while HDL2 and apolipoprotein A-I were not altered. There was no significant difference between the effects of the two preparations, although those of EE/GSD were mostly more pronounced. The time-dependent change in the effects of the oral contraceptives on various parameters of lipid metabolism demonstrates that the relevance of results of short-time studies may be questionable. There was also a significant alteration in some parameters between day 1 and 10 of the treatment cycles and a tendency to return to the pretreatment levels during the pill-free week, e.g., in total TG and in the PL component of VLDL, LDL and HDL. The increase in HDL, VLDL, and total TG reflects a slight preponderance of the effect of ethinylestradiol on lipid metabolism. The unchanged total CH and LDL-CH and the elevated HDL levels indicate that the risk of the development of atherosclerosis is in all probability not increased during treatment with both preparations. Submitted for publication Accepted for publication
MARCH 1990 VOL. 41 NO. 3
July 14, 1989 November 1, 1989
245
CONTRACEPTION
INTRODUCTION Oral treatment with synthetic sex steroids has been demonstrated to alter the serum concentrations and composition of lipoproteins. These effects are both dependent on the dose and type of the steroids. Most oral contraceptives contain ethinylestradiol (EE) in doses between 30 and 50 pg, while a series of different progestogens are used in various dosages. In general, estrogens increase the serum levels of triglycerides (TG), very low-density lipoproteins (VLDL), high-density lipoproteins (HDL), and apolipoprotein A, and decrease low-density lipoprotein-cholesterol (LDL-CH) (l), while progestogens, particularly those with some androgenic activity, have the opposite effect (2,3). Estrogens inhibit hepatic TG hydrolase, while progestogens derived from nortestosterone stimulate the enzyme (2,4). Moreover, the synthesis of apolipoprotein Eland hepatic LDL receptors is stimulated by EE, but not influenced by progestogens (5,6). Therefore, the resultant effect of an oral contraceptive on lipid metabolism which may influence the risk of atherosclerosis during longterm treatment, depends on the composition of the preparation (7,8). Moreover, it has been observed that the duration of treatment plays a role, too (9,lO). A new oral contraceptive containing 30 pg ethinylestradiol and only 75 pg gestodene (GSD), a highly active progestogen, was claimed by the producer to exert no metabolic effects in women. This has to be called in question in the light of very high serum levels of gestodene after intake of this preparation (11). During 12 months of treatment, we compared the effects of EE/GSD on 19 serum parameters of lipid metabolism with those of a preparation containing 30 pg EE and 150 Pg desogestrel (EE/DG). MATERIALS AND METHODS Volunteers and sample collection: Twenty-two normal healthy volunteers with regular menstrual cycles, ages between 18 and 35 years, participated in the study. Informed consent was obtained. The women had not used hormonal contraceptives for at least 3 months prior to the study and were not under interfering pharmacologic therapy. An internal and gynecological examination, including a Papanicolaou smear, was carried out prior to the selection of the subjects. During a control cycle, ovulation was confirmed to have probably taken place by the determination of serum progesterone (>3 ng/ml). Two groups of 11 women each were randomly assigned to take the preparation EE/GSD (Schering AG, Berlin, Federal Republic of Germany) or EE/DG (Organon GmbH, Oberschleissheim, Federal Republic of Germany) during 12 months. The subjects of both groups were similar in terms of height, weight, body-mass index, smoking, alcohol, exercise, and diet. They were obliged not to change their habits during the study. Blood samples were taken by venipuncture after overnight fasting between 8 and 10 AM on days 1 (i.e. 24 h after first pill intake), 10, and 21 of the first, third, sixth, and twelfth treatment cycle and of the control cycle preceding the first treatment cycle. Each sample was
246
MARCH
1990 VOL. 41 NO. 3
CONTRACEPTION
drawn into tubes containing EDTAm K2 (1.5 to 2 mg/ml). Plasma was prepared by low-speed centrifugation (1500 x g, 30 min) and kept at 4 oC during storage. Determination of lipids and lipoproteins: All determinations were completed within one week after blood collection. Cholesterol (CH) (CHODPAP-Method), triglycerides (TG) (GPO-PAP) and phospholipids (PL) were determined using reagents from Boehringer (Mannheim, Federal Republic of Germany). VLDL were quantified in terms of their lipid constituents after preparative ultracentrifugation at dC1.006 kg/l (12). HDL were determined after phosphotungstatefMgC12precipitation of apolipoprotein B containing lipoproteins, and HDL subfraction HDL2 and HDL3 were resolved by ultracentrifugation in the respective supernatants at d = 1.125 kg/l as described previously (13). LDL were calculated as difference between total lipids and HDL + VLDL. Apolipoproteins A-I and A-II were quantified by zone immunoelectrophoresis (14) and apolipoprotein B was measured by conventional radial immunodiffusion using NOR Partigen plates (Behringwerke AG, Marburg, Federal Republic of Germany). Statistical analysis: Data-were analyzed by multivariate analysis of variance (repeated measurements' design) (comparison of EE/GSD versus EE/DG; time-dependent effects) or by Student's paired t-test (treatment cycles versus control cycle or between treatment cycles). RESULTS Although some of the effects on lipids and lipoproteins were more pronounced with EE/GSD, there was no significant difference between both low-dose oral contraceptives due to the large intra- and interindividual variations. The only exception were the HDL-TG levels which were significantly higher with EE/GSD (~~0.05) (Table IV). The baseline measurements of all lipid and lipoprotein parameters were not different by randomization. There was no significant change in total CH and total PL during treatment with both preparations as compared to controls. The CH and PL levels were, however, significantly higher during the 6th and 12th cycle as compared to the first cycle due to a transitory decrease (not significant) during the first month of treatment (Table I). The high levels on day 1 of the treatment cycles demonstrate that there is no decrease during the pill-free interval of 7 days between the treatment cycles. Total TG increased significantly by 30 to 40% during treatment with EE/GSD, while the rise by 10 to 2D% with EEfDG was not significant (Table I and VII). There was a transitory small decrease in LDL-CH and a decline in LDL-PL by 20 to 3D% in both groups during the first treatment cycle which diminished gradually thereafter, while LDL-TG were elevated during the 3rd and 6th month only in the women taking EE/GSD. During the 12th treatment cycle, the LDL components did not differ from the control values (Table II and VII). There was no change in the composition of VLDL at the beginning of treatment with EE/GSD and EE/DG. During the 6th and 12th cycle, however, VLDL-CH was significantly elevated by 30 to 50% (EE/GSD) and by 15% (EE/DG), and VLDL-PL by 3D% (EE/ GSD and EE/DG) (Table III and VII). The TG content of VLDL was only
MARCH
1990 VOL. 41 NO. 3
247
I
**
p < 0.01
versus
control;
Day 1
Total PL (mg/dU
21.7 21.6 26.6 28.6 28.1
70.2 + 16.3 65.4 + 21.3 93.8 + 23.2 95.3 z 28.4 87.3 + 29.1
+ + + + +
Control Cycle 1 Cycle 3 Cycle 6 Cycle 12
178.6 174.1 192.9 204.0 201.6
Day 1
of total
+ + + t +
19.0 27.2 25.6 20.6 24.3
+ 2 + + +
15.3 23.4 23.3 26.4 41.7
##
p
