At the ninth Women’s Health Congress, held in Zurich on January 17, 2013, hormonal contraception was the second main topic in the afternoon. Four speakers provided information on the opportunities and risks of modern “pills”.
Suppressing menstruation by extending the timing of combined contraceptive use is becoming more common, explained Saira-Christine Renteria, MD, CHUV, Lausanne.
Long cycle and shortened hormone-free intervals
The goal is to prolong the amenorrheic phase. At least one in five women is significantly limited in her well-being by menstruation, often already in the premenstrual phase. Therefore, delaying menstruation is desirable for many women.
The effects of long cycles have been investigated in several studies. The effectiveness of contraception is very good at 99%, even in overweight women. Compliance was best with oral contraception, compared with hormonal contraception with patch or vaginal ring. There is no “overload” (accumulation) of hormones due to the long cycles. The endometrium is inactive and atrophic, but recovers very rapidly after a three-month cycle.
Uncertainty remains regarding the risks for thromboembolism, cardiovascular events, and the effects on estrogen-dependent tumors (endometrial cancer, breast cancer); long-term studies are still lacking. However, a 2010 study showed that the rate of side effects was the same for three-month long-term cycles over four years as for long-term cycles over one year. A 2011 study found that after one year of continuous contraception with vaginal rings, triglyceride and cholesterol levels increased.
Indications for long-term cycling include primary dysmenorrhea, hemorrhagic diathesis, endometriosis, polycystic ovary syndrome, or cycle-dependent migraine. Two regimens are distinguished: continuous administration of a combination preparation or, after 24 days, a four-day interval with minimal hormone intake if the woman wants to menstruate. It is very important to inform the patient about reversibility, side effects, and management when a pill is missed. If intermittent bleeding occurs or the cycles are irregular, the cause should be clarified – including a pregnancy test.
Pills with natural estrogens – Risks and benefits
PD Dr. med. Gabriele S. Merki, Clinic for Reproductive Endocrinology, University Hospital Zurich, provided information on two new contraceptives with natural estrogens. The preparations that were previously on the market contained ethinylestradiol (EE); this active ingredient is the main factor in the increased risk of thromboembolism, so the EE dose in the pills has already been greatly reduced. However, irregular bleeding or bleeding in the blood occurs more quickly with smaller doses. an unstable endometrium.
Two preparations containing natural estrogens are new on the market:
- Zoely® with nomegestrol acetate (NOMAC) and estradiol (E2), approved in Switzerland for women over 17 years of age.
- Qlaira® with estradiol valerate (E2V) and dienogest (DNG).
The side effects of Zoely, e.g. weight gain or headaches, are the same as with other contraceptives (comparator product in studies: Yasmin®). Unacceptable bleeding was slightly more frequent, and the effect on acne was worse. Qlaira also showed very good tolerability in studies. With both preparations, the thromboembolic markers (e.g. D-dimers) remain within the normal range while the patient is taking them – this is in contrast to the previous pills. It is therefore hoped that the thromboembolic risk will decrease with the two new pills, but this cannot be assessed today. Currently, when prescribing Zoely or Qlaira, the contraindications must be clarified just as well as with other preparations. Data on cardiovascular risks are also currently lacking, although there is less of an increase in CRP when Qlaira is taken than with usual preparations.
Bleeding intensity and duration are reduced by the new preparations. With Zoely, abortion bleeding is absent after one year in about 30% of women; with Claira, this is the case in 20% of women. As a rule, women fail to have individual bleedings (not all bleedings), and the bleeding pattern is very variable. The average bleeding duration for both preparations is four days (at the beginning rather longer bleedings, then decreasing), one day shorter than with usual estrogens. In addition, up to the sixth cycle, about 20% of women have intermittent bleeding, which is the same as with other pills. Because of the reduction in bleeding intensity and duration, the new preparations are particularly suitable for women with hypermenorrhea.
Patients must be well informed about the possibility of abortion and intermittent bleeding. Further benefits of the new preparations are possible, but have not yet been determined – corresponding studies are underway.
Hormones and adolescence – influence on premenstrual “dysphoric disorder”.
Raphaela Jülke, M.D., Adolescent Psychiatric Therapy Unit Kriens, and Ruth Draths, M.D., Women’s Clinic Lucerne, presented the impressive case of a 14-year-old female patient with severe, cycle-dependent depression and anxiety. About 3-8% of all adolescents suffer from depression, women twice as often as men. The depression affects the physical level (eating disorders, physical complaints), behavior (hyperactivity, motor inhibition), affects (joylessness, hopelessness, suicidality) and cognition (thought disorders, inability to make decisions, concentration disorders). A depressive episode lasts an average of eight weeks.
Premenstrual “dysphoric disorder” affects about 2-8% of all women, and there is a high correlation with other mental illnesses. The symptoms are triggered by the fluctuation of ovarian hormones after ovulation. Administration of estrogens and progesterone may trigger symptoms, and GnRH analogs may suppress symptoms (but no data exist on this in adolescents). In patients, one of the goals of treatment is to suppress hormonal fluctuation, e.g. with oral contraceptives. A 21/7 regime shows an insufficient effect. Continuous administration of contraceptives works better, but the studies are insufficient. The presented patient received specific antidepressant therapy as well as continuous oral anticonception, which she continued even after the depression improved.
Source: 9th Women’s Health Congress, January 16-17, 2013, Zurich.
