CONTRACEPTION
IMMUNE REACTIVITY OF WOMEN ON HORMONAL CONTRACEPTIVES Dinitrochlorobenzene sensitization test and skin reactivity to irritants
G. Gerretsen z
J. Kremer ~
J.P
E. Bleumink ~ ,
G.C. de Gast ~ ,
Nater zz,
T.H. The ~
ABSTRACT To evaluate the influence of sex steroids on immunity in 87 women on hormonal contraceptives, sensitization tests were performed with the contact allergen, 2,4-dinitrochlorobenzene (DNCB). Forty--five women were taking oral contraceptives of combined oestrogen/progestogen of the same brand (low oestrogenic and middle range progestogenic activity); 27 had received intramuscular injections of medroxyprogesterone acetate and 15 women were using a sequential pill. The results were compared with those of 44 women not taking contraceptive steroids and matched for age. In women on the combined pill and those who had received intramuscular progesterone, the mean DNCB reactivity was significantly increased (0.02< p< 0.05 and 0.001 < p< 0.Olj respectively), whereas women using a sequential pill proved to show a decreased skin reactivity in the oestrogenic phase of this pill. (p = 0.05). The changes observed proved to be specific, since no statistically significant differences in overall skin reactivity to irritants between the four groups of women could be observed. The clinical implications of these results have been considered.
Department of Obstetrics and Gynaecology •X
Department of Dermatology
XXX
Department of Internal Medicine State University, Groningen, The Netherlands
Accepted
for
publication
JANUARY 1979 VOL. 19 NO. 1
December
28,
1978
83
CONTRACEPTION
INTRODUCTION It is now well documented that both in animals and men, high circulating levels of sex steroids may lead to an altered immunologic reactivity (1). Studies in women receiving hormonal contraceptives with i~ ~f~o and f~ ~ft~o parameters for cell-mediated immune reactivity have led totat first glanc~contradictory results (l, 2, 3). However, when classifying the "pill" for the progestogenic potency by clinical or histological assessment (4, 5, 6), it seems justifiable to assume that contraceptives with high oestrogenic and low progestogenic potency may provoke a suppression of cellmediated immune reactivity and the pill with an opposite hormonal composition, has an averse effect, i.e. activation of cellmediated immune responsiveness. In this report evidence will be presented for this view. The DNCB sensitization test was used as a measure for cellmediated immune reactivity. Three groups of women on hormonal contraceptives were studied; these groups were homogeneous with regard to the type and brand of contraceptives used. To rule out the possibility that the effects noted were due to an altered overall skin susceptibility, the skin reactivity to primary irritants was measured as well. MATERIAL AND METHOD PATIENTS Eigthy-eight women using hormonal contraceptives were studied. All attended the family-planning clinic of the Department of Obstetrics and Gynaecology, University Hospital Groningen, The Netherlands. Their ages varied from 18 to 45 years. There were three sub-groups: ]. Forty-five women were taking combined oral contraceptives of identical composition, Neogynon or Stederil-d (0.25 mg d-norgestrel and 0.05 mg ethinyloestradiol). This pill is considered to have a middle range progestogenic and a low oestrogenic potency (6, 7). 2. Twenty-eight women were receiving intramuscular injections of Depoprovera (150 mg medroxyprogesterone acetate) at threemonth intervals. 3. Fifteen women were using the sequential pill, Serial (16 capsules containing 0.1 mg ethinyloestradiol and 5 capsules containing O.l mg ethinyloestradiol and O.l mg megestrol acetate).
84
JANUARY 1979 VOL. 19 NO. 1
CONTRACEPTION
These women were the female partner of infertile couples. The infertility was probably due to a reduced capability of the spermatozoa to penetrate the cervical mucus. Therefore a sperm cervical mucus contact (SCMC) test (8) was performed. The SCMC test did not reveal the presence of sperm agglutinins in the females. Furthermore a complete fertility investigation of the women did not detect any abnormality. The control group consisted of 44 women attending either the Gynaecological Department or the Fertility Clinic. On gynaecological examination these women were normal. They had normal menstrual cycles and used no medications. Hormonal contracep~on had not been used except in five cases, in which it had been discontinued more than a year ago. To reduce the possible influence of the cycle phase, the control group was examined, regardless of the phase of the menstrual cycle. Since DNCB reactivity declines with age, all groups were matched in this respect. SENSITIZATION PROCEDURE WITH DNCB The sensitization test with the contact allergen DNCB was performed according to methods described by Bleumink et aZ (9). In short, all subjects were sensitized with 2 mg of purified DNCB on the forearm. Two weeks later, challenges were performed by patch testing (silver-patch-testers from van der Bend, Brielle - The Netherlands) on the back with 3, 10and 30 ~g of the allergenic substance in acetone. The reactions were read after 48 hours and scored according to the recommendations of the International Contact Dermatitis Research Group: erythema with infiltration +; erythema plus papules ++; erythema, papules and vesicles +++; confluent vesicles ++++. The sum of the three patch test concentrations was taken as a measure of DNCB reactivity (DNCB score). TEST METHOD FOR SKIN REACTIVITY TO PRIMARY IRRITANTS The procedure for testing skin reactivity to primary irritants has been described in detail elsewhere (I0). The following irritants were tested: - T;: croton oil, 20% in mineral oil - T2: thymoquinon, I% in ethanol 96% T3: crotonaldehyde 7.5% + sodium laurylsulphate 4% in aqua dest. Patch tests were performed on the back of the women in a similar way as described above. The reactions were read 48 hours after applications and scored as positive when at the test site marked erythema was observed. -
JANUARY 1979 VOL. 19 NO. 1
85
CONTRACEPTION
The sum of the reactions on the three test solutions was taken as a measure for skin reactivity to primary irritants (toxic score). The number of patients assayed is recorded in Table II. Statistical analyses were performed with the student-t and chi square tests. RESULTS In Table I the average DNCB scores are recorded of the three groups of women on hormonal contraceptives. Women taking the combination pill of the same middle range progestogenic and low oestrogenic potency (Stederil, Neogynon) and women receiving intramuscular injections of medroxyprogesterone showed an increased DNCB reactivity as compared to controls matched for age. Table I
DNCB reactivity in women on hormonal contraceptives compared with controls
Group
N
DNCB mean score
SD
SEM
p
I. Combination (progestogenic predominance)
45
I0.9
l.l
0.17
0.02
IMMUNE REACTIVITY OF WOMEN ON HORMONAL CONTRACEPTIVES Dinitrochlorobenzene sensitization test and skin reactivity to irritants
G. Gerretsen z
J. Kremer ~
J.P
E. Bleumink ~ ,
G.C. de Gast ~ ,
Nater zz,
T.H. The ~
ABSTRACT To evaluate the influence of sex steroids on immunity in 87 women on hormonal contraceptives, sensitization tests were performed with the contact allergen, 2,4-dinitrochlorobenzene (DNCB). Forty--five women were taking oral contraceptives of combined oestrogen/progestogen of the same brand (low oestrogenic and middle range progestogenic activity); 27 had received intramuscular injections of medroxyprogesterone acetate and 15 women were using a sequential pill. The results were compared with those of 44 women not taking contraceptive steroids and matched for age. In women on the combined pill and those who had received intramuscular progesterone, the mean DNCB reactivity was significantly increased (0.02< p< 0.05 and 0.001 < p< 0.Olj respectively), whereas women using a sequential pill proved to show a decreased skin reactivity in the oestrogenic phase of this pill. (p = 0.05). The changes observed proved to be specific, since no statistically significant differences in overall skin reactivity to irritants between the four groups of women could be observed. The clinical implications of these results have been considered.
Department of Obstetrics and Gynaecology •X
Department of Dermatology
XXX
Department of Internal Medicine State University, Groningen, The Netherlands
Accepted
for
publication
JANUARY 1979 VOL. 19 NO. 1
December
28,
1978
83
CONTRACEPTION
INTRODUCTION It is now well documented that both in animals and men, high circulating levels of sex steroids may lead to an altered immunologic reactivity (1). Studies in women receiving hormonal contraceptives with i~ ~f~o and f~ ~ft~o parameters for cell-mediated immune reactivity have led totat first glanc~contradictory results (l, 2, 3). However, when classifying the "pill" for the progestogenic potency by clinical or histological assessment (4, 5, 6), it seems justifiable to assume that contraceptives with high oestrogenic and low progestogenic potency may provoke a suppression of cellmediated immune reactivity and the pill with an opposite hormonal composition, has an averse effect, i.e. activation of cellmediated immune responsiveness. In this report evidence will be presented for this view. The DNCB sensitization test was used as a measure for cellmediated immune reactivity. Three groups of women on hormonal contraceptives were studied; these groups were homogeneous with regard to the type and brand of contraceptives used. To rule out the possibility that the effects noted were due to an altered overall skin susceptibility, the skin reactivity to primary irritants was measured as well. MATERIAL AND METHOD PATIENTS Eigthy-eight women using hormonal contraceptives were studied. All attended the family-planning clinic of the Department of Obstetrics and Gynaecology, University Hospital Groningen, The Netherlands. Their ages varied from 18 to 45 years. There were three sub-groups: ]. Forty-five women were taking combined oral contraceptives of identical composition, Neogynon or Stederil-d (0.25 mg d-norgestrel and 0.05 mg ethinyloestradiol). This pill is considered to have a middle range progestogenic and a low oestrogenic potency (6, 7). 2. Twenty-eight women were receiving intramuscular injections of Depoprovera (150 mg medroxyprogesterone acetate) at threemonth intervals. 3. Fifteen women were using the sequential pill, Serial (16 capsules containing 0.1 mg ethinyloestradiol and 5 capsules containing O.l mg ethinyloestradiol and O.l mg megestrol acetate).
84
JANUARY 1979 VOL. 19 NO. 1
CONTRACEPTION
These women were the female partner of infertile couples. The infertility was probably due to a reduced capability of the spermatozoa to penetrate the cervical mucus. Therefore a sperm cervical mucus contact (SCMC) test (8) was performed. The SCMC test did not reveal the presence of sperm agglutinins in the females. Furthermore a complete fertility investigation of the women did not detect any abnormality. The control group consisted of 44 women attending either the Gynaecological Department or the Fertility Clinic. On gynaecological examination these women were normal. They had normal menstrual cycles and used no medications. Hormonal contracep~on had not been used except in five cases, in which it had been discontinued more than a year ago. To reduce the possible influence of the cycle phase, the control group was examined, regardless of the phase of the menstrual cycle. Since DNCB reactivity declines with age, all groups were matched in this respect. SENSITIZATION PROCEDURE WITH DNCB The sensitization test with the contact allergen DNCB was performed according to methods described by Bleumink et aZ (9). In short, all subjects were sensitized with 2 mg of purified DNCB on the forearm. Two weeks later, challenges were performed by patch testing (silver-patch-testers from van der Bend, Brielle - The Netherlands) on the back with 3, 10and 30 ~g of the allergenic substance in acetone. The reactions were read after 48 hours and scored according to the recommendations of the International Contact Dermatitis Research Group: erythema with infiltration +; erythema plus papules ++; erythema, papules and vesicles +++; confluent vesicles ++++. The sum of the three patch test concentrations was taken as a measure of DNCB reactivity (DNCB score). TEST METHOD FOR SKIN REACTIVITY TO PRIMARY IRRITANTS The procedure for testing skin reactivity to primary irritants has been described in detail elsewhere (I0). The following irritants were tested: - T;: croton oil, 20% in mineral oil - T2: thymoquinon, I% in ethanol 96% T3: crotonaldehyde 7.5% + sodium laurylsulphate 4% in aqua dest. Patch tests were performed on the back of the women in a similar way as described above. The reactions were read 48 hours after applications and scored as positive when at the test site marked erythema was observed. -
JANUARY 1979 VOL. 19 NO. 1
85
CONTRACEPTION
The sum of the reactions on the three test solutions was taken as a measure for skin reactivity to primary irritants (toxic score). The number of patients assayed is recorded in Table II. Statistical analyses were performed with the student-t and chi square tests. RESULTS In Table I the average DNCB scores are recorded of the three groups of women on hormonal contraceptives. Women taking the combination pill of the same middle range progestogenic and low oestrogenic potency (Stederil, Neogynon) and women receiving intramuscular injections of medroxyprogesterone showed an increased DNCB reactivity as compared to controls matched for age. Table I
DNCB reactivity in women on hormonal contraceptives compared with controls
Group
N
DNCB mean score
SD
SEM
p
I. Combination (progestogenic predominance)
45
I0.9
l.l
0.17
0.02
