CONTRACEPTION
CHANGES IN METABOLISM INDUCED BY ORAL CONTRACEPTIVES CONTAINING DESOGESTREL AND GESTODENE IN OLDER WOMEN G E Robinson"
Research Fellow
W Bounds',
Research Co-ordinator
I J Mackie2,
Lecturer
J stocks3,
Lecturer
T Burren2,
Research Fellow
S J Machina,
Reader
J Guillebaud',
Medical Director
'The Margaret Pyke Centre for The Study and Training of Family Planning, London, Wl. 2The Haematology Department, University Colle e and Middlesex Schools of Medicine, London, Wl; and s The Department of Human Genetics and Metabolism, St Bartholomew's Hospital Medical School, London, ECl. ABSTRACT Forty women aged 35-45 years were investigated to determine changes in haemostasis, lipids and lipoproteins whilst taking combined contraceptive pills containing the new third generation progestogens, desogestrel and gestodene. There was no statistically significant difference between the two preparations in any of the parameters studied. Women taking the combined pill showed increases in fibrinogen and factor X and a reduction in antithrombin III when compared with their control values. There were also small but significant increases in triglycerides and triglyceride-rich lipoproteins. Total high density lipoprotein cholesterol (HDL), high density lipoprotein-2 cholesterol (HDLZ), high density lipoprotein-3 cholesterol (HDL3) and apolipoprotein A-l were all increased at some stages of the treatment cycle, whereas low density lipoprotein cholesterol (LDL) showed a reduction in the first cycle of treatment. The changes in lipids and lipoproteins would not appear to increase the risk of cardiovascular disease, however the effects of the increase in the pro-coagulant factors are uncertain. INTRODUCTION The increased risk of cardiovascular disease in combined oral contraceptive (COC) users appears to be largely confined to older women wpo smoke. The Oxford Family Planning Association cohort study , which has followed women for an average of sixteen years, found a relative risk of Submitted for publication September 6, 1989 Accepted for publication June 22, 1990 SEPTEMBER 1990VOL. 42 NO. 3
263
death from circulatory disease of 1.5 (95% confidence intervals 0.7-3.0) in users. This is lower than the relative risk of 4.2 reported by The Royal Colle e of General Practitioner's Oral Contraception Study e in 1981. Whilst the majority of studies show an increase in ischaemic heart disease in current users of the combined pill, this increase is concentrated in, if not exclusive to, sm kers. Indeed the Royal College of General Practioner's study 8 demonstrated an increased risk of myocardial infarction only in current users of the oral contraceptive who were also smokers. Those women who smoked more than fifteen cigarettes a day and also were combined pill users had a relative risk of a myocardial infarction of 20.8 (95% confidence interval 5.2-83.1). The aetiology of cardiovascular disease remains incgmpletely underst od although increased plasma levels of LDL and cholesterol s and refuted plasma concentrations of HDL-2 and apolipoprotein A-l are said to be associated with an 'ncrease in risk. Raised levels of fibrinogen and factor VII 5 are also associated with an increased risk of coronary heart disease7. Previous reports show that women who take the COC have raised plasma levels of LDL, cholesterol, and triglycerides o er levels of HDL than those not taking the combined ;;&&a. Furthermore incry ses in plasma levels of fibrinogen and factor VII have been demonstrated. The significance of these changes is not understood but there is concern that COC-induced changes in haemostatic and lipoprotein risk factors might contribute to an increased risk of cardiovascular disease. Most of the available data relates to higher dose COCs than are in general use today. The reduction in dosage of both the oestrogen and progestogen content of the COC has been asspyiated with a reduction in cardiovascular events in users . Recently, two new progestogens have been introduced, desogestrel and gestodene, which are said to be more selective than the other progestogens used in COCs in that they bind with greater affinity to the progestogen receptor Tgd,rith less affinity to the androgen receptor than others . We report the effects of two COCs containing these new, third generation, progestogens on lipoprotein and coagulant protein levels in forty non-smoking women aged 35-45 years. PATIENTS AND METHODS Forty women participated in the study. All volunteers were aged between-35-45 years; Caucasians; non-smokers; of normal weight (defined as a body mass index between 19-25); non-vegetarian; not on any medication and they had not taken any hormonal preparations for at least three months prior to the start of the study. They were randomly allocated to take Femodene (3Oug ethinyl oestradiol, 75ug gestodene; Schering U.K.) or Marvelon (3Oug ethinyl oestradiol,l50ug desogestrel; Organon Holland) for six months. Study visits were between days 18-28 of the control cycle and in the last seven days of tablet taking in cycles 1, 3 and 6. The
264
SEPTEMBER 1BSOVOL.42 NO. 3
combined pill was started on the first day of menstruation following the control cycle. Study visits occurred in the morning between 8 and loam; the volunteer having fasted overnight. On arrival the volunteer rested for thirty minutes and then blood was taken by venepuncture. For coagulation studies, blood was collected into 0.106M tri-sodium citrate (ratio 9:l) and immediately centrifuged at 2,000g for fifteen minutes. For lipid studies, blood was collected into plain glass tubes and serum separated. The titrated plasma and serum were stored in aliquots at -70C until analysis. Serum cholesterol and triglycerides were measured using fully enzymatic procedures (Boehringer Mannheim GmbH Diagnostica). LDL and very low density lipoprotein triglycerides (VLDL) were measured by ultra-centrifugation using Lipid Research Clinic standard procedures. Total HP14 was measured by heparinjmanganous chloride precipitation and the HDL subfractions, HDL2 and HP$3, by low molecular weight dextran sulphate precipitation . Apolipoprotein A-l and B were measured by immun?kurbidimetry using commercial reagents (Orion Diagnostics) Fibrinogen was measured as clottable proteinl'l factor X and factor VII by one-stage clotting assays4nd . Antithrombin III, protein C, plasminogen and alpha-2in were measured by microtitre amidolytic ;~~~$sa* was analysed by the repeated measures analysis of va%nP. Duncan's multiple range test was applied to control for the overall level of significance testing. The mean absolute change from the control sample was analysed since the main purpose of the investigation was to determine the change produced by these oral contraceptives in the metabolic variables measured. All the data was analysed despite some of the volunteers missing the occasional study visit. The analysis of only those volunteers who attended each visit throughout the study might be subject to bias in that those women who dropped out due to side effects would be excluded. However,the analysis of just those women who did attend the entire study reveals the same results. The study was approved by the Middlesex Hospital Ethics Committee. RESULTS The mean aqe and body mass index was 38 .l and 22.2, respectively, in the Femohene group and 38.2 and 20.9 in those taking Marvelon. 34 women attended for all the study visits of which 18 were in the Femodene group and 16 in the Marvelon group. Four women, two from each group, missed one visit and a further two women, both in the Marvelon group, missed two visits. Tables I and II show the changes in coagulation factors and lipids and lipoproteins during pill taking. These changes are illustrated graphically in Figures 1 and 2. The tables show the number of women attending each study visit, the mean change in the metabolic factor for the women
SEPTEMBER 1990VOL. 42 NO. 3
265
Table I : Coagulatwn Factors Mean control values and mean ctunpe frm! control valuer
Treatment Femodew COntlW1 Fibrinogen (P/l)
Cycle 6
Control
cyz1e1
Cycle 3
Cycle 6
2.21
0.31
0.18
0.19
2.15
0.19
0.54
0.53
STOERR
0.11
0.12
0.14
0.11
0.09
0.10
0.18
0.13
20
20
17
19
20
19
16
17
MEAN
0.92
0.02
-0.02
0.05
0.86
0.05
0.03
0.121
STOERR
0.03
0.03
0.03
0.06
0.04
0.03
0.05
0.11
20
20
17
19
20
19
16
17
MEAN
1.01
0.17
0.16
0.30
1.04
0.20
0.33
0.31
N
0.05 20 I
0.05 M I
0.04 I 17
0.06
0.03
0.05
0.07
N FactarX (W/ml)
f&MlOl?
Cycle 3
HEAN
N Factor VII (IU/ml)
Cycle 1
STDERR I
19
I
20
I
1
0.07 I
19
16
17
Antithrcukdn
Pla~ilqen (IU/ml)
l4uN
0.96
0.18
0.16
0.06
1.m
0.06
-0.01
-0.08
STDERR
0.04
0.04
0.06
0.04
0.04
0.04
0.07
0.06
20
20
17
19
19
16
17
MAN
1.04
0.09
0.10
0.10
1.14
-0.02
0.01
-0.05
STDfRR
0.04
0.04
0.04
0.04
0.03
0.04
0.05
O.C6
20
20
17
19
20
19
16
17
N Alpha-Pantiplasmin (IU/nl)
N
M
STDERR.StandwdErnx N-knbwof-
SEPTEMBER 1990 VOL. 42 NO. 3
CONTRACEPTION
kan
Table II: Lipx ad Lipoprotein Levels contml values and man chan9e fmn ccntml
I
Tmatmant
1 Control 1 Cycle 1 Cholesterol (Ml)
1'.html
1 Cycle
1 Cycle1
1
3 1 Cycle 6
-0.18
0.17
0.28
4.90
-0.17
-0.04
-0.05
STCiRR
0.21
0.16
O.lE
0.19
0.18
0.10
0.15
0.14
20
20
17
20
20
19
17
17
16
18
20
19
17
16
WAN
0.21
0.02
0.11
0.15
0.23
0.04
0.06
0.17
STDERR
0.02
0.02
0.06
0.04
0.03
0.04
0.04
0.04
N
*po1ipwmtain Al (P/l)
Cycle 3 1 Cycle 6
4.68
N
wvl)
)
I
MEAN
N
very Lou cmnr1ty LipOpWtOifl
values
20
M
20
20
17
20
20
19
17
17
cull
1.68
0.16
0.17
0.14
1.74
0.06
0.09
0.05
STDERR
0.09
0.05
0.10
0.10
0.09
0.07
0.10
0.13
N Apollpafxotoin WAN B (P/l) STDfRR N
20
20
17
20
20
19
17
17
0.72
0.03
0.M)
-0.02
0.71
0.01
0.09
0.01
0.05
0.04
0.04
0.04
0.04
0.05
0.06
0.03
20
20
17
20
20
19
17
17
STDERR - Standard Error I-Nuderof-
SEPTEMBER 1990 VOL. 42 NO. 3
267
CONTRACEPTION Factor
Fibrinogen 0.6 g,,_
XJq
”
-0
X
I
-0 -0.6 2
El n
,
3
Factor
Vl
6
1 0 IS
bl lU/ml
0 05 0 -0
.
05
-0 -015
Protein
t m Antithrombin
02
1
11 1
_
t
-.
”
,
3
6
Alpha-Z-Antiplasmin
C
04 02 cl
___&E.*-.----
lU/ml -0.2
Plasminoqen
“‘7
+ -A* x
Femodene Marvel on significantly significantly
Figure
268
1:
different different
Mean
change
from control from control
from
control
(p
CHANGES IN METABOLISM INDUCED BY ORAL CONTRACEPTIVES CONTAINING DESOGESTREL AND GESTODENE IN OLDER WOMEN G E Robinson"
Research Fellow
W Bounds',
Research Co-ordinator
I J Mackie2,
Lecturer
J stocks3,
Lecturer
T Burren2,
Research Fellow
S J Machina,
Reader
J Guillebaud',
Medical Director
'The Margaret Pyke Centre for The Study and Training of Family Planning, London, Wl. 2The Haematology Department, University Colle e and Middlesex Schools of Medicine, London, Wl; and s The Department of Human Genetics and Metabolism, St Bartholomew's Hospital Medical School, London, ECl. ABSTRACT Forty women aged 35-45 years were investigated to determine changes in haemostasis, lipids and lipoproteins whilst taking combined contraceptive pills containing the new third generation progestogens, desogestrel and gestodene. There was no statistically significant difference between the two preparations in any of the parameters studied. Women taking the combined pill showed increases in fibrinogen and factor X and a reduction in antithrombin III when compared with their control values. There were also small but significant increases in triglycerides and triglyceride-rich lipoproteins. Total high density lipoprotein cholesterol (HDL), high density lipoprotein-2 cholesterol (HDLZ), high density lipoprotein-3 cholesterol (HDL3) and apolipoprotein A-l were all increased at some stages of the treatment cycle, whereas low density lipoprotein cholesterol (LDL) showed a reduction in the first cycle of treatment. The changes in lipids and lipoproteins would not appear to increase the risk of cardiovascular disease, however the effects of the increase in the pro-coagulant factors are uncertain. INTRODUCTION The increased risk of cardiovascular disease in combined oral contraceptive (COC) users appears to be largely confined to older women wpo smoke. The Oxford Family Planning Association cohort study , which has followed women for an average of sixteen years, found a relative risk of Submitted for publication September 6, 1989 Accepted for publication June 22, 1990 SEPTEMBER 1990VOL. 42 NO. 3
263
death from circulatory disease of 1.5 (95% confidence intervals 0.7-3.0) in users. This is lower than the relative risk of 4.2 reported by The Royal Colle e of General Practitioner's Oral Contraception Study e in 1981. Whilst the majority of studies show an increase in ischaemic heart disease in current users of the combined pill, this increase is concentrated in, if not exclusive to, sm kers. Indeed the Royal College of General Practioner's study 8 demonstrated an increased risk of myocardial infarction only in current users of the oral contraceptive who were also smokers. Those women who smoked more than fifteen cigarettes a day and also were combined pill users had a relative risk of a myocardial infarction of 20.8 (95% confidence interval 5.2-83.1). The aetiology of cardiovascular disease remains incgmpletely underst od although increased plasma levels of LDL and cholesterol s and refuted plasma concentrations of HDL-2 and apolipoprotein A-l are said to be associated with an 'ncrease in risk. Raised levels of fibrinogen and factor VII 5 are also associated with an increased risk of coronary heart disease7. Previous reports show that women who take the COC have raised plasma levels of LDL, cholesterol, and triglycerides o er levels of HDL than those not taking the combined ;;&&a. Furthermore incry ses in plasma levels of fibrinogen and factor VII have been demonstrated. The significance of these changes is not understood but there is concern that COC-induced changes in haemostatic and lipoprotein risk factors might contribute to an increased risk of cardiovascular disease. Most of the available data relates to higher dose COCs than are in general use today. The reduction in dosage of both the oestrogen and progestogen content of the COC has been asspyiated with a reduction in cardiovascular events in users . Recently, two new progestogens have been introduced, desogestrel and gestodene, which are said to be more selective than the other progestogens used in COCs in that they bind with greater affinity to the progestogen receptor Tgd,rith less affinity to the androgen receptor than others . We report the effects of two COCs containing these new, third generation, progestogens on lipoprotein and coagulant protein levels in forty non-smoking women aged 35-45 years. PATIENTS AND METHODS Forty women participated in the study. All volunteers were aged between-35-45 years; Caucasians; non-smokers; of normal weight (defined as a body mass index between 19-25); non-vegetarian; not on any medication and they had not taken any hormonal preparations for at least three months prior to the start of the study. They were randomly allocated to take Femodene (3Oug ethinyl oestradiol, 75ug gestodene; Schering U.K.) or Marvelon (3Oug ethinyl oestradiol,l50ug desogestrel; Organon Holland) for six months. Study visits were between days 18-28 of the control cycle and in the last seven days of tablet taking in cycles 1, 3 and 6. The
264
SEPTEMBER 1BSOVOL.42 NO. 3
combined pill was started on the first day of menstruation following the control cycle. Study visits occurred in the morning between 8 and loam; the volunteer having fasted overnight. On arrival the volunteer rested for thirty minutes and then blood was taken by venepuncture. For coagulation studies, blood was collected into 0.106M tri-sodium citrate (ratio 9:l) and immediately centrifuged at 2,000g for fifteen minutes. For lipid studies, blood was collected into plain glass tubes and serum separated. The titrated plasma and serum were stored in aliquots at -70C until analysis. Serum cholesterol and triglycerides were measured using fully enzymatic procedures (Boehringer Mannheim GmbH Diagnostica). LDL and very low density lipoprotein triglycerides (VLDL) were measured by ultra-centrifugation using Lipid Research Clinic standard procedures. Total HP14 was measured by heparinjmanganous chloride precipitation and the HDL subfractions, HDL2 and HP$3, by low molecular weight dextran sulphate precipitation . Apolipoprotein A-l and B were measured by immun?kurbidimetry using commercial reagents (Orion Diagnostics) Fibrinogen was measured as clottable proteinl'l factor X and factor VII by one-stage clotting assays4nd . Antithrombin III, protein C, plasminogen and alpha-2in were measured by microtitre amidolytic ;~~~$sa* was analysed by the repeated measures analysis of va%nP. Duncan's multiple range test was applied to control for the overall level of significance testing. The mean absolute change from the control sample was analysed since the main purpose of the investigation was to determine the change produced by these oral contraceptives in the metabolic variables measured. All the data was analysed despite some of the volunteers missing the occasional study visit. The analysis of only those volunteers who attended each visit throughout the study might be subject to bias in that those women who dropped out due to side effects would be excluded. However,the analysis of just those women who did attend the entire study reveals the same results. The study was approved by the Middlesex Hospital Ethics Committee. RESULTS The mean aqe and body mass index was 38 .l and 22.2, respectively, in the Femohene group and 38.2 and 20.9 in those taking Marvelon. 34 women attended for all the study visits of which 18 were in the Femodene group and 16 in the Marvelon group. Four women, two from each group, missed one visit and a further two women, both in the Marvelon group, missed two visits. Tables I and II show the changes in coagulation factors and lipids and lipoproteins during pill taking. These changes are illustrated graphically in Figures 1 and 2. The tables show the number of women attending each study visit, the mean change in the metabolic factor for the women
SEPTEMBER 1990VOL. 42 NO. 3
265
Table I : Coagulatwn Factors Mean control values and mean ctunpe frm! control valuer
Treatment Femodew COntlW1 Fibrinogen (P/l)
Cycle 6
Control
cyz1e1
Cycle 3
Cycle 6
2.21
0.31
0.18
0.19
2.15
0.19
0.54
0.53
STOERR
0.11
0.12
0.14
0.11
0.09
0.10
0.18
0.13
20
20
17
19
20
19
16
17
MEAN
0.92
0.02
-0.02
0.05
0.86
0.05
0.03
0.121
STOERR
0.03
0.03
0.03
0.06
0.04
0.03
0.05
0.11
20
20
17
19
20
19
16
17
MEAN
1.01
0.17
0.16
0.30
1.04
0.20
0.33
0.31
N
0.05 20 I
0.05 M I
0.04 I 17
0.06
0.03
0.05
0.07
N FactarX (W/ml)
f&MlOl?
Cycle 3
HEAN
N Factor VII (IU/ml)
Cycle 1
STDERR I
19
I
20
I
1
0.07 I
19
16
17
Antithrcukdn
Pla~ilqen (IU/ml)
l4uN
0.96
0.18
0.16
0.06
1.m
0.06
-0.01
-0.08
STDERR
0.04
0.04
0.06
0.04
0.04
0.04
0.07
0.06
20
20
17
19
19
16
17
MAN
1.04
0.09
0.10
0.10
1.14
-0.02
0.01
-0.05
STDfRR
0.04
0.04
0.04
0.04
0.03
0.04
0.05
O.C6
20
20
17
19
20
19
16
17
N Alpha-Pantiplasmin (IU/nl)
N
M
STDERR.StandwdErnx N-knbwof-
SEPTEMBER 1990 VOL. 42 NO. 3
CONTRACEPTION
kan
Table II: Lipx ad Lipoprotein Levels contml values and man chan9e fmn ccntml
I
Tmatmant
1 Control 1 Cycle 1 Cholesterol (Ml)
1'.html
1 Cycle
1 Cycle1
1
3 1 Cycle 6
-0.18
0.17
0.28
4.90
-0.17
-0.04
-0.05
STCiRR
0.21
0.16
O.lE
0.19
0.18
0.10
0.15
0.14
20
20
17
20
20
19
17
17
16
18
20
19
17
16
WAN
0.21
0.02
0.11
0.15
0.23
0.04
0.06
0.17
STDERR
0.02
0.02
0.06
0.04
0.03
0.04
0.04
0.04
N
*po1ipwmtain Al (P/l)
Cycle 3 1 Cycle 6
4.68
N
wvl)
)
I
MEAN
N
very Lou cmnr1ty LipOpWtOifl
values
20
M
20
20
17
20
20
19
17
17
cull
1.68
0.16
0.17
0.14
1.74
0.06
0.09
0.05
STDERR
0.09
0.05
0.10
0.10
0.09
0.07
0.10
0.13
N Apollpafxotoin WAN B (P/l) STDfRR N
20
20
17
20
20
19
17
17
0.72
0.03
0.M)
-0.02
0.71
0.01
0.09
0.01
0.05
0.04
0.04
0.04
0.04
0.05
0.06
0.03
20
20
17
20
20
19
17
17
STDERR - Standard Error I-Nuderof-
SEPTEMBER 1990 VOL. 42 NO. 3
267
CONTRACEPTION Factor
Fibrinogen 0.6 g,,_
XJq
”
-0
X
I
-0 -0.6 2
El n
,
3
Factor
Vl
6
1 0 IS
bl lU/ml
0 05 0 -0
.
05
-0 -015
Protein
t m Antithrombin
02
1
11 1
_
t
-.
”
,
3
6
Alpha-Z-Antiplasmin
C
04 02 cl
___&E.*-.----
lU/ml -0.2
Plasminoqen
“‘7
+ -A* x
Femodene Marvel on significantly significantly
Figure
268
1:
different different
Mean
change
from control from control
from
control
(p
