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Objectives A few observational studies have suggested that progesterone and dydrogesterone may have a lower risk of breast cancer than other progestogens. In our earlier xenograft animal experiments, progesterone did not stimulate breast tumors. The aim of this study was to test dydrogesterone for the first time. The study also evaluated the effects of PGRMC1 on proliferation with progestogens. Methods (1) In-vitro study. The proliferative effects of dydrogesterone and of progesterone were assessed in vitro using T47D cells transfected with PGRMC1 or empty vector in the presence or absence of estradiol. Additionally, to find the strongest proliferator for inclusion as a comparator in the xenograft animal study, norethisterone, levonorgestrel, desogestrel, dienogest, drospirenone, nomegestrol, and cyproterone acetate were tested. Methods (2) Xenograft main study. PGRMC1-transfected or empty-vector T47D and MCF7 xenotransplants were each treated with four different hormonal preparations: E2+placebo; E2+dydrogesterone; E2+progesterone; E2+norethisterone. A total of 112 castrated mice were randomly allocated to the 16 groups. This was thus a prospective, randomized, blinded, placebo-controlled four-arm study (45–50 days) with the two T47D and two MCF7 xenografts. Tumor volumes were monitored twice weekly. Results (1) In-vitro study. The strongest proliferation was with norethisterone, but only with PGRMC1-transfected cells. There was significant proliferation with dydrogesterone, but not with progesterone in the absence of estradiol. However, no increase in proliferation was achieved by adding dydrogesterone to estradiol compared with the proliferation induced with estradiol alone, in contrast to norethisterone. Results (2) Xenograft main study. There was significantly faster tumor growth with norethisterone + E2 than with E2+placebo in T47D and MCF7 PGRMC1 xenografts, but not with dydrogesterone + E2 or progesterone + E2. There was less tumor growth in empty-vector xenografts, without between-group differences. Conclusion PGRMC1 increases the breast-cell proliferation effects of certain progestogens, including dydrogesterone, in contrast to progesterone, but not during estradiol-induced proliferation, either in vitro or in a xenograft animal model, in contrast to norethisterone. Thus the proliferative potency of dydrogesterone may be similar to that of progesterone. Clinical studies in women overexpressing PGRMC1 are recommended.

The association between low-dose combined oral contraceptives (COCs) and anticoagulation factors in Japanese women has been rarely studied. A total of 394 Japanese women with a new beginning cycle of COC use were enrolled, of whom 335 women visited the clinic within 4 weeks after starting the first cycle of COC. Visits occurred in the active phase (272 women) and the placebo phase (63 women). Free protein S (PS) antigen and activity levels and antithrombin activity levels decreased significantly in both the active and placebo phase groups. Protein C (PC) activity levels increased significantly in both groups. Larger reductions in free PS antigen and activity levels occurred with COC comprising either 30 µg ethinylestradiol/desogestrel or 20 µg ethinylestradiol/drospirenone than that comprising 35 µg ethinylestradiol/norethisterone. In four women with the Japanese-specific PS K196E mutation, mean PS activity was 65% before COC use and 57% during COC use, indicating further decrease with COC use. In conclusion, decreased antigen and activity levels of PS and antithrombin and increased activity levels of PC were observed even during the first cycle of low-dose COC use. The effects on PS and PC activities were also observed in the hormone-free interval.

Previously, levonorgestrel (LNG) has been shown to be an endocrine disruptor of the amphibian thyroid system. In the present study, we investigated whether anti-thyroidal effects are a common property of progestins other than LNG. Premetamorphic Xenopus laevis tadpoles were exposed to norethisterone (NET) and dienogest DIE (each at 0.1-10nM) and LNG (10nM) until completion of metamorphosis. LNG and NET at all concentrations caused a significant developmental retardation whereas DIE did not impair time to metamorphosis. In LNG and 10nM NET exposed animals, tsh mRNA levels increased considerably later than the developmental delay occurred and thyroid histopathology showed no signs of TSH-hyperstimulation. Instead, thyroid glands from these treatments appeared inactive in producing thyroid hormones. Thyroidal transcript levels of dio2 and dio3 were increased by treatments with LNG and NET at 1nM and 10nM, whereas iyd mRNA was reduced by LNG and 10nM NET. Expression of slc5α5 was not changed by any treatment. Effects of DIE differed from those induced by LNG and NET. No developmental delay was measurable; however, tshβ and dio2 mRNAs were increased in pituitary glands of tadpoles exposed to 1.0nM and 10nM DIE. Thyroid histopathology displayed no abnormalities and thyroidal mRNA expression of the genes analyzed (slc5α5, iyd, dio2, dio3) was not changed by DIE. Overall, our results provide evidence that the anti-thyroidal effects already known from LNG are also present in another progestin, namely NET, even at environmentally relevant concentrations. In conclusion we suggest that progestins do not only pose an environmental risk in terms of their impact on reproductive success of aquatic vertebrates, but also with respect to their anti-thyroidal properties affecting amphibian metamorphosis.

// Marina Willibald 1 , Giuliano Bayer 1 , Vanessa Stahlhut 1 , Gereon Poschmann 2 , Kai Stuhler 2, 3 , Berthold Gierke 4 , Michael Pawlak 4 , Harald Seeger 5 , Alfred O. Mueck 5 , Dieter Niederacher 1 , Tanja Fehm 1 and Hans Neubauer 1 1 Department of Obstetrics and Gynecology, University Hospital and Medical Faculty of the Heinrich-Heine University Duesseldorf, Duesseldorf, Germany 2 Molecular Proteomics Laboratory, BMFZ, Heinrich Heine University Duesseldorf, Duesseldorf, Germany 4 Institute for Molecular Medicine, University Hospital Duesseldorf, Duesseldorf, Germany 3 NMI Natural and Medical Sciences Institute at the University of Tuebingen, Reutlingen, Germany 4 Department of Women’s Health, University Hospital and Faculty of Medicine of the Eberhard Karls University Tuebingen, Tuebingen, Germany Correspondence to: Marina Willibald, email: marina.willibald@med.uni-duesseldorf.de Keywords: breast cancer, PGRMC1, progestins, norethisterone, casein Kinase 2 Received: January 24, 2017 Accepted: June 27, 2017 Published: August 02, 2017 ABSTRACT Menopausal hormone therapy, using estrogen and synthetic progestins, is associated with an increased risk of developing breast cancer. The effect of progestins on breast cells is complex and not yet fully understood. In previous in vitro and in vivo studies, we found different progestins to increase the proliferation of Progesterone Receptor Membrane Component-1 (PGRMC1)-overexpressing MCF7 cells (MCF7/PGRMC1), suggesting a possible role of PGRMC1 in transducing membrane-initiated progestin signals. Understanding the activation mechanism of PGRMC1 by progestins will provide deeper insights into the mode of action of progestins on breast cells and the often-reported phenomenon of elevated breast cancer rates upon progestin-based hormone therapy. In the present study, we aimed to further investigate the effect of progestins on receptor activation in MCF7 and T47D breast cancer cell lines. We report that treatment of both breast cancer cell lines with the progestin norethisterone (NET) induces phosphorylation of PGRMC1 at the Casein Kinase 2 (CK2) phosphorylation site Ser181, which can be decreased by treatment with CK2 inhibitor quinalizarin. Point mutation of the Ser181 phosphorylation site in MCF7/PGRMC1 cells impaired proliferation upon NET treatment. This study gives further insights into the mechanism of differential phosphorylation of the receptor and confirms our earlier hypothesis that phosphorylation of the CK2-binding site is essential for activation of PGRMC1. It further suggests an important role of PGRMC1 in the tumorigenesis and progression of breast cancer in progestin-based hormone replacement therapy.

During menopausal hormone therapy (MHT) a possible increase in breast cancer risk is thought to depend mainly on the progestogen component. In vitro studies have shown that the progesterone receptor membrane component 1 (PGRMC1) is important for tumor proliferation induced by progestogens. The primary aim of this study was to compare for the first time the natural progestogen, progesterone (P), with a synthetic progestogen, norethisterone (NET), using a xenograft model.MCF7 cells, transfected with PGRMC1 plasmid or empty vector, were injected into nude mice and estradiol (E2) pellets were implanted. After 12days, NET or P or placebo pellets were implanted. Tumor volumes in all groups (6 mice/group) were monitored for 6-7 weeks. Immunohistochemical expression of PGRMC1 and KI-67 was assessed. These experiments were repeated using T47D cells.Compared with the control condition, E2 and sequential E2/NET combination increased xenograft tumor growth with MCF7 and T47D cells that transgenically expressed PGRMC1 (p0.01); progesterone did not increase growth. Breast cancer cells transfected with empty vectors did not respond to either progestogen. Comparing KI-67 and PGRMC1 expression, the Pearson correlation was r=0.848, p=0.002.E2 plus NET increases tumor growth in human breast cancer cells overexpressing PGRMC1, but there is no change with progesterone. To our knowledge, this is the first comparison of both progestogens in vivo using nude mice, which are frequently used in xenograft models. Clinical trials are needed to determine whether women with overexpression of PGRMC1 are at increased risk of breast cancer if NET instead of progesterone is used in MHT.

BACKGROUND: Heavy menstrual bleeding (HMB) is a menstrual blood loss perceived by women as excessive that affects the health of women of reproductive age, interfering with their physical, emotional, social and material quality of life. Whilst abnormal menstrual bleeding may be associated with underlying pathology, in the present context, HMB is defined as excessive menstrual bleeding in the absence of other systemic or gynaecological disease. The first‐line therapy is usually medical, avoiding possibly unnecessary surgery. Of the wide variety of medications used to reduce HMB, oral progestogens were originally the most commonly prescribed agents. This review assesses the effectiveness of two different types and regimens of oral progestogens in reducing ovulatory HMB. This is the update of a Cochrane review last updated in 2007, and originally named "Effectiveness of cyclical progestagen therapy in reducing heavy menstrual bleeding" (1998). OBJECTIVES: To determine the effectiveness, safety and tolerability of oral progestogen therapy taken either during the luteal phase (short cycle) or for a longer course of 21 days per cycle (long cycle), in achieving a reduction in menstrual blood loss in women of reproductive age with HMB. SEARCH METHODS: In January 2019 we searched Cochrane Gynaecology and Fertility's specialized register, CENTRAL, MEDLINE, Embase, CINAHL and PsycInfo. We also searched trials registers, other sources of unpublished or grey literature and reference lists of retrieved trials. We also checked citation lists of review articles to identify trials. SELECTION CRITERIA: Randomized controlled trials (RCTs) comparing different treatments for HMB that included cyclical oral progestogens were eligible. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials for inclusion, assessed trials for risk of bias and extracted data. We contacted trial authors for clarification of methods or additional data when necessary. We only assessed adverse events if they were separately measured in the included trials. We compared cyclical oral progestogen in different regimens and placebo or other treatments. Our primary outcomes were menstrual blood loss and satisfaction with treatment; the secondary outcomes were number of days of bleeding, quality of life, compliance and acceptability of treatment, adverse events and costs. MAIN RESULTS: This review identified 15 randomized controlled trials (RCTs) with 1071 women in total. Most of the women knew which treatment they were receiving, which may have influenced their judgements about menstrual blood loss and satisfaction. Other aspects of trial quality varied among trials. We did not identify any RCTs comparing progestogen treatment with placebo. We assessed comparisons between oral progestogens and other medical therapies separately according to different regimens. Short‐cycle progestogen therapy during the luteal phase (medroxyprogesterone acetate or norethisterone for 7 to 10 days, from day 15 to 19) was inferior to other medical therapy, including tranexamic acid, danazol and the progestogen‐releasing intrauterine system (Pg‐IUS (off the market since 2001)), releasing 60 mcg of progesterone daily, with respect to reduction of menstrual blood loss (mean difference (MD) 37.29, 95% confidence interval (CI) 17.67 to 56.91; I(2) = 50%; 6 trials, 145 women, low‐quality evidence). The rate of satisfaction and the quality of life with treatment was similar in both groups. The number of bleeding days was greater on the short cycle progestogen group compared to other medical treatments. Adverse events (such as gastrointestinal symptoms and weight gain) were more likely with danazol when compared with progestogen treatment. We note that danazol is no longer in general use for treating HMB. Long‐cycle progestogen therapy (medroxyprogesterone acetate or norethisterone), from day 5 to day 26 of the menstrual cycle, is also inferior compared to the levonorgestrel‐releasing intrauterine system (LNG‐IUS), tranexamic acid and ormeloxifene, but may be similar to the combined vaginal ring with respect to reduction of menstrual blood loss (MD 16.88, 95% CI 10.93 to 22.84; I(2) = 87%; 4 trials, 355 women, very low‐quality evidence). There was no clear evidence of a difference between progestogen therapy long cycle and other medical therapy in terms of headache (OR 1.45, 95% CI 0.40 to 5.31; I(2) = 0%; 2 trials, 189 women; low‐quality evidence). Breakthrough bleeding or spotting was more likely in women with the LNG‐IUS (OR 0.18, 95% CI 0.06 to 0.55; I(2) = 0%; 3 trials, 220 women; low‐quality evidence). No trials reported on days of bleeding or quality of life for this comparison. The evidence supporting these findings was limited by low or very low gradings of quality; thus, we are uncertain about the findings and there is a potential that they may change if we identify other trials. AUTHORS' CONCLUSIONS: Low‐ or very low‐quality evidence suggests that short‐course progestogen was inferior to other medical therapy, including tranexamic acid, danazol and the Pg‐IUS with respect to reduction of menstrual blood loss. Long cycle progestogen therapy (medroxyprogesterone acetate or norethisterone) was also inferior to the LNG‐IUS, tranexamic acid and ormeloxifene, but may be similar to the combined vaginal ring with respect to reduction of menstrual blood loss.

During menopausal transition, various phenotypical and metabolic changes occur, affecting body weight, adipose tissue distribution and energy expenditure as well as insulin secretion and sensitivity. Taken together, these can predispose women to the development of type 2 diabetes mellitus (T2DM). Many women in midlife experience climacteric symptoms, including hot flashes and night sweats. Menopausal hormone therapy (MHT) is then indicated. MHT has a favourable effect on glucose homeostasis in both women without and with T2DM. T2DM was considered in the past as a cardiovascular disease (CVD) equivalent, which would suggest that women with T2DM should not receive MHT. This notion may still deter many clinicians from prescribing MHT to these patients. However, nowadays there is strong evidence to support an individualised approach after careful evaluation of CVD risk. In older women with T2DM (> 60 years old or > 10 years in menopause), MHT should not be initiated, because it may destabilise mature atherosclerotic plaques, resulting in thrombotic episodes. In obese women with T2DM or in women with moderate CVD risk, transdermal 17β-oestradiol could be used. This route of delivery presents beneficial effects regarding triglyceride concentrations and coagulation factors. In peri- or recently post-menopausal diabetic women with low risk for CVD, oral oestrogens can be used, since they exhibit stronger beneficial effects on glucose and lipid profiles. In any case, a progestogen with neutral effects on glucose metabolism should be used, such as natural progesterone, dydrogesterone or transdermal norethisterone. The goal is to maximise benefits and minimise adverse effects.

Objective To evaluate the efficacy and safety of an ultra-low-dose oral contraceptive (NPC-01; 0.02 mg ethinyl estradiol and 1 mg norethisterone) in subjects with dysmenorrhea. Design Placebo-controlled, double-blind, randomized trial. Setting Clinical trial sites. Patient(s) Two hundred fifteen subjects with dysmenorrhea. Intervention(s) Subjects were randomly assigned to receive NPC-01, placebo, or IKH-01 (0.035 mg ethinyl estradiol and 1 mg norethisterone) for four cycles. Main Outcome Measure(s) Total dysmenorrhea score (verbal rating scale) assessing pain on the basis of limited ability to work and need for analgesics. Result(s) The reductions of total dysmenorrhea score and visual analog scale score after the treatment were significantly higher in the NPC-01 group than in the placebo group. Furthermore, the efficacy of NPC-01 was comparable to that of IKH-01. The overall incidence of side effects was significantly higher in the NPC-01 group than in the placebo group. All side effects that occurred in the NPC-01 group were previously reported in patients receiving IKH-01. No serious side effects occurred. Conclusion(s) The ultra-low-dose contraceptive NPC-01 relieved dysmenorrhea as effectively as IKH-01. Thus, NPC-01 could represent a new option for long-term treatment of dysmenorrhea. Clinical Trial Identification Number NCT01129102.

Drug induced liver injury (DILI) is uncommon and severe forms are associated with significant morbidity and mortality. Female sex hormones (estrogens and progestogens) related DILI generally occur with estrogen component. Progesterone component related DILI are infrequently reported. Norethisterone is commonly used drug in gynecologic practice to prevent excess per vaginal bleeding. We report 3 cases of Norethisterone related DILI manifesting as significant rise of transaminases. All of these patients took Norethisterone for prolonged periods and improved completely after withdrawal of drug.

The intramuscular progestin-only injectable contraceptive, depo-medroxyprogesterone acetate (DMPA-IM), is more widely used in Sub-Saharan Africa than another injectable contraceptive, norethisterone enanthate (NET-EN). Epidemiological data show a significant 1.4-fold increased risk of HIV-1 acquisition for DMPA-IM usage, while no such association is shown from limited data for NET-EN. We show that MPA, unlike NET, significantly increases R5-tropic but not X4-tropic HIV-1 replication ex vivo in human endocervical and ectocervical explant tissue from pre-menopausal donors, at physiologically relevant doses. Results support a mechanism whereby MPA, unlike NET, acts via the glucocorticoid receptor (GR) to increase HIV-1 replication in cervical tissue by increasing the relative frequency of CD4+ T cells and activated monocytes. We show that MPA, unlike NET, increases mRNA expression of the CD4 HIV-1 receptor and CCR5 but not CXCR4 chemokine receptors, via the GR. However, increased density of CD4 on CD3+ cells was not observed with MPA by flow cytometry of digested tissue. Results suggest that DMPA-IM may increase HIV-1 acquisition in vivo at least in part via direct effects on cervical tissue to increase founder R5-tropic HIV-1 replication. Our findings support differential biological mechanisms and disaggregation of DMPA-IM and NET-EN regarding HIV-1 acquisition risk category for use in high risk areas.

OBJECTIVE This study aims to compare the effects of a soy-based dietary supplement, low-dose hormone therapy (HT), and placebo on the urogenital system in postmenopausal women. METHODS In this double-blind, randomized, placebo-controlled trial, 60 healthy postmenopausal women aged 40 to 60 years (mean time since menopause, 4.1 y) were randomized into three groups: a soy dietary supplement group (90 mg of isoflavone), a low-dose HT group (1 mg of estradiol plus 0.5 mg of norethisterone), and a placebo group. Urinary, vaginal, and sexual complaints were evaluated using the urogenital subscale of the Menopause Rating Scale. Vaginal maturation value was calculated. Transvaginal sonography was performed to evaluate endometrial thickness. Genital bleeding pattern was assessed. Statistical analysis was performed using χ(2) test, Fisher's exact test, paired Student's t test, Kruskal-Wallis test, Kruskal-Wallis nonparametric test, and analysis of variance. For intergroup comparisons, Kruskal-Wallis nonparametric test (followed by Mann-Whitney U test) was used. RESULTS Vaginal dryness improved significantly in the soy and HT groups (P = 0.04). Urinary and sexual symptoms did not change with treatment in the three groups. After 16 weeks of treatment, there was a significant increase in maturation value only in the HT group (P < 0.01). Vaginal pH decreased only in this group (P < 0.01). There were no statistically significant differences in endometrial thickness between the three groups, and the adverse effects evaluated were similar. CONCLUSIONS This study shows that a soy-based dietary supplement used for 16 weeks fails to exert estrogenic action on the urogenital tract but improves vaginal dryness.

Around 20 progestins (also called gestagens, progestogens, or progestagens) are used today in assisting a range of medical conditions from endometrial cancer to uterine bleeding and as an important component of oral contraception. These progestins can bind to a wide range of receptors including progestin, estrogen, androgen, glucocorticoid, and mineralocorticoid receptor, as well as sex hormone and corticosteroid binding globulins. It appears that only five of these (four synthetic and one natural) progestins have so far been studied in sewage effluent and surface waters. Analysis has reported values as either nondetects or low nanograms per liter in rivers. Seven of the progestins have been examined for their effects on aquatic vertebrates (fish and frogs). The greatest concern is associated with levonorgestrel, norethisterone, and gestodene and their ability to reduce egg production in fish at levels of 0.8-1.0 ng/L. The lack of environmental measurements, and some of the contradictions in existing values, however, hampers our ability to make a risk assessment. Only a few nanograms per liter of ethynodiol diacetate and desogestrel in water would be needed for fish to receive a human therapeutic dose for these progestins according to modeled bioconcentration factors. But for the other synthetic progestins levels would need to reach tens or hundreds of nanograms per liter to achieve a therapeutic dose. Nevertheless, the wide range of compounds, diverse receptor targets, and the effect on fish reproduction at sub-nanogram-per-liter levels should prompt further research. The ability to impair female reproduction at very low concentrations makes the progestins arguably the most important pharmaceutical group of concern after ethinylestradiol.

Background: The aim of the study was to observe the changes in blood oxidative stress levels by oral contraceptive (OC) and/or dydrogesterone (DG) treatment. Methods: A retrospective cohort of 27 premenopausal women with primary dysmenorrhea consisted of the OC treatment group (N = 17) and the DG treatment group (N = 10) by choice of the initial treatment. The OC group included two subgroups: patients with continuous OC treatment (treated for at least 15 months, N = 10) and patients with discontinuous OC treatment (switched to DG treatment after approximately 6 months of initial OC treatment: N = 7). The DG group had 15 months of continuous DG treatment. Blood parameters, including diacron-reactive oxygen metabolites (d-ROMs: an oxidative stress marker), were measured. Results: The d-ROMs level was elevated in the OC group 3 months after initial treatment (mean: from 321 (at baseline) to 512 Carratelli Units (Carr U); P < 0.01), while such changes were not observed in the DG group. The d-ROMs level was reduced in the discontinuous OC subgroup 15 months after initial treatment (from 508 (3 months after initial treatment) to 372 Carr U; P < 0.01), while such changes were not observed in the continuous OC subgroup. The DG group displayed unchanged the d-ROMs level. Conclusion: Replacing OC with DG can attenuate oxidative stress as elevated by OC, thereby alleviating the possible vascular risks with OC treatment. J Clin Med Res. 2018;10(2):146-153 doi: https://doi.org/10.14740/jocmr3307w

The importance of investigating the molecular mechanism of action of medroxyprogesterone acetate (MPA) and norethisterone acetate (NET-A), two clinically important progestins used in hormone therapy (HT), has been highlighted by clinical evidence showing that MPA and norethisterone (NET) increase the risk of the development of breast cancer in HRT users, and that MPA may increase susceptibility to- and transmission of HIV-1. The aim of this study was to compare the molecular mechanisms of action of MPA, NET-A and progesterone (Prog) via the androgen receptor (AR) in a cell line model that can minimize confounding factors such as the presence of other steroid receptors. This study is the first to determine accurate apparent Ki values for Prog, MPA and NET-A toward the human AR in COS-1 cells. The results reveal that these ligands have a similar binding affinity for the AR to that of the natural androgen 5α-dihydrotestosterone (DHT) (Ki's for DHT, Prog, MPA and NET-A are 29.4, 36.6, 19.4 and 21.9 nM, respectively). Moreover, in both transactivation and transrepression transcriptional assays we demonstrate that, unlike Prog, MPA and NET-A are efficacious AR agonists, with activities comparable to DHT. One of the most novel findings of our study is that NET-A, like DHT, induces the ligand-dependent interaction between the NH2- and COOH-terminal domains (N/C-interaction) of the AR independent of promoter-context, while MPA does not induce the N/C interaction on a classical ARE and does so only weakly on an AR-selective ARE. This suggests that MPA and NET-A may exert differential promoter-specific actions via the AR in vivo. Consistent with this, molecular modeling suggests that MPA and NET-A induce subtle differences in the structure of the AR ligand binding domain. Taken together, the results from this study suggest that unlike Prog, both MPA and NET-A used in hormonal therapy are likely to compete with DHT and exert significant and promoter-specific off-target transcriptional effects via the AR, possibly contributing to some of the observed side-effects with the clinical use of MPA and NET-A.

We present a patient who, over the course of 35 years, presented with repeated episodes of ileus and melena and was misdiagnosed several times, leading to several surgeries. Macroscopic and microscopic features of his resected intestine were compatible with cryptogenic multifocal ulcerous stenosis enteritis (CMUSE), but additional angioectatic lesions were also noted. The patient responded dramatically to hormonal therapy consisting of ethinylestradiol and norethisterone. To our knowledge, this is the first reported case of CMUSE that has shown response to hormonal therapy. We suggest that this is a variant of CMUSE in which vasculopathy plays a role in the pathogenesis.

Synthetic progestins (SPs) are used for regulation of fertility, contraception and hormone replacement therapy. The acetylated medroxyprogesterone (MPA), megestrol (MGA) and chlormadinone (CLA) are related to progesterone (P). Other SPs are 19-nortestosterone derivatives such as: norethisterone (NET), norethynodrel (NED) or the 13-ethyl gonane, levonorgestrel (LNG). We studied MPA, NET, NED and LNG in a dose-response manner to induce sexual receptivity in rats. Results showed that MPA, NET and NED act as partial agonists, with similar or lower potency than P. However, LNG is a full agonist. Additionally, the molecules of MPA, MGA, CLA, NET, NED, LNG, and P, were submitted to computer calculations at ab initio quantum mechanics theory, to obtain their electronic structure and molecular properties. The aim was to correlate their behavioral effect with their physicochemical properties. In addition, the crystals of P, NET and LNG bound to the progesterone receptor (PR) were studied. The PR crystallizes as a dimer forming two monomers (mA and mB), in which Gln725 interacts in either of two possible ways with the C3-carbonyl pharmacophore of progestins. P binds differentially to both PR monomers, while NET binds exclusively as mA and LNG binds only as mB in both monomers with no difference. Energetically, binding of LNG and P to mB, is more favorable than that of NET and P to mA. Consequently, this bimodal mechanism increases the action possibilities of SPs on biological systems. Interestingly, progestin potency depends mostly on local molecular structure and electronic features, prevailing over total molecular properties. © 2012 Elsevier Ltd. All rights reserved.

Objectives Low-dose estrogen–progestin (LEP) agents are often used for relieving endometriosis-associated chronic pelvic pain, but a direct effect of LEP on endometriotic lesions remains to be demonstrated. The objective of this study is to investigate the antiproliferative and apoptotic effects of the synthetic progestin norethisterone (NET) against human endometriotic stromal cells (ESCs). Study design Ovarian endometrioma specimens were obtained at laparoscopy from 19 patients with endometriosis, and ESCs were isolated. The antiproliferative effect of compounds against cultured ESCs was evaluated by measuring the inhibition of [ 3 H]thymidine incorporation. The ability of compounds to induce apoptosis in the cultured cells was evaluated by the measurement of caspase 3/7 activity and by nuclear staining. The cytotoxicity of compounds was evaluated by measuring the leakage of lactate dehydrogenase (LDH) into the supernatant of the cell culture. Results NET and progesterone (P4) at concentrations of greater than 10 nM significantly inhibited [ 3 H]thymidine incorporation in a dose-dependent manner. Co-treatment with 17β-estradiol at 0.1 ng/mL did not affect the inhibition of [ 3 H]thymidine incorporation by NET. At concentrations greater than 100 nM, NET significantly increased caspase 3/7 activity and the numbers of apoptotic cells, whereas P4 did not. Treatment of ESCs for 24 h with NET or P4 at concentrations of up to 1000 nM did not cause LDH leakage. Conclusions NET inhibits the proliferation of ESCs and induces their apoptosis. These results suggest a possible direct effect of NET on endometriotic lesions in patients with endometriosis.

Dienogest (DNG) is a 19-nortestosterone derivative (a C-19 progestogen) with a cyanomethyl instead of an ethinyl group at the C-17 position, which may make the compound elicit fewer hepatic effects than other C-19 nortestosterone derivatives. Its similarity to norethisterone is reflected in its high endometrial efficacy, which could explain the high stability of the menstrual cycle women achieve when they use DNG in combination with ethinyl estradiol (EE) or with estradiol valerate (E2V). Its strong endometrial efficacy underlies the use of DNG (on its own) to treat endometriosis, and gives it antiproliferative and anti-inflammatory effects in the treatment of endometriotic lesions. Properties derived from its C-19 derivative structure include its short plasma half-life, of about 10h (which means the drug is not accumulated), and its high oral bioavailability, of more than 90%. However, DNG also has some of the properties of typical of progesterone derivatives, including a lack of effect on the metabolic and cardiovascular systems, and considerable antiandrogenic activity, the latter increased by its lack of affinity to the sex-hormone binding globulin (SHBG), in contrast to other C-19 progestogens. DNG has no glucocorticoid and no antimineralocorticoid activity. It also has no antiestrogenic activity, which suggests that it should not antagonize estradiol's beneficial effects. This is important for its use in the treatment of endometriosis, because, due to DNG's low gonadotropic activity, E2 levels are not decreased to zero, in contrast to treatments with gonadotropin-releasing hormone (GnRH) analogues. This maintenance beneficial E2 effects is of particular importance for the general tolerability of the first contraceptive pill to use E2V instead of EE, although clinical endpoint studies are still ongoing. These studies are expected, on the basis of its pharmacology, to demonstrate the cardiovascular safety of the new pill.

Objective. To evaluate the efficacy of tranexamic acid in the treatment of idiopathic and non-functional heavy menstrual bleeding. Design. Systematic review. Population. Women with a diagnosis of idiopathic and non-functional heavy menstrual bleeding treated with tranexamic acid. Methods. Electronic searches were conducted in literature databases up to February 2011 by two independent reviewers. We included all trials involving the efficacy of tranexamic acid for the treatment of heavy uterine bleeding. Pregnant, postmenopausal and cancer patients were excluded. Main outcome measures. Effect of tranexamic acid treatment on objective reduction of menstrual bleeding and improvement in patient quality of life. Results. A total of 10 studies met our inclusion criteria. Available evidence indicates that tranexamic acid therapy in women with idiopathic menorrhagia resulted in 34–54% reduction in menstrual blood loss. Following tranexamic acid treatment, patient's quality-of-life parameters improved by 46–83%, compared with 15–45% for norethisterone treatment. When compared with placebo, tranexamic acid use significantly decreased the blood loss by 70% in women with menorrhagia secondary to an intrauterine device (p

Background: Oral contraceptive therapy (OCT) is associated with an increased risk of deep vein thrombosis, venous thromboembolism and stroke. However, the underlying mechanisms have not yet been elucidated. The objective of this study was to investigate the influence of OCT on blood levels of an oxidative stress maker in pre‑menopausal women. Methods: Oxidative stress was determined in 87 pre‑menopausal healthy women (24 with and 63 without OCT) using a blood assay for reactive oxygen metabolites (by the d‑ROMs test). The subjects with OCT received a triphasic preparation consisting of ethinyl estradiol and norethisterone. Results: Subjects with OCT showed significantly higher d‑ROMs levels (median: 380; interquartile range: 328‑502 Carr U) than those without OCT (325 [271‑369]; P < 0.05). The results remained the same after adjusting for potential confounders. Conclusions: The use of OCT may increase oxidative stress levels, independent of traditional cardiovascular risk factors, in pre‑menopausal women, providing new insights to the primary prevention of vascular complications in these subjects. Key words: Contraceptives, d‑ROMs test, ethinyl estradiol, norethisterone, oxidative stress marker

Objective To evaluate the efficacy and safety of low-dose oral contraceptives (IKH-01; 0.035 mg ethinyl estradiol and 1 mg norethisterone) for patients with primary dysmenorrhea. Design Placebo-controlled, double-blind, randomized trial. Setting Clinical trial sites in Japan. Patient(s) One hundred fifteen patients with primary dysmenorrhea. Intervention(s) Patients randomly assigned to receive IKH-01 or placebo for four cycles. Main Outcome Measure(s) Total dysmenorrhea score, verbal rating scale defining pain according to limited ability to work and need for analgesics, and visual analog scale (VAS). Result(s) Reduction in total dysmenorrhea score and VAS before and after treatment was significantly higher in the IKH-01 group than in the placebo group. Total dysmenorrhea score and VAS in the IKH-01 group significantly decreased from cycles 2 to 5. Overall incidence of adverse events was significantly higher in the IKH-01 group. Incidence decreased over time in the IKH-01 group; it was invariable in the placebo group. No serious adverse events occurred. Conclusion(s) IKH-01 could be used as a single agent or in combination with analgesics for treatment of primary dysmenorrhea.

Background The aim of this exploratory study was to establish whether we could improve skeletal health with a physiological regimen of SSR in young women with premature ovarian failure (POF). Patients and Methods In an open-label randomised controlled crossover trial, 34 women with POF were randomised to 4-week cycles of pSSR (transdermal oestradiol, 100µg daily for week 1, 150µg for weeks 2-4; vaginal progesterone, 200mg twice-daily weeks 3-4) or sHRT (oral ethinyloestradiol 30µg and 1.5mg norethisterone daily for weeks 1-3, week 4 "pill-free") for 12 months. Bone mineral density (BMD) was measured by DEXA at study entry and after each 12-month treatment period. Blood samples for hormones and markers of bone formation (bone alkaline phosphatase, BALP, and Type I collagen N-terminal propeptide, PINP) and bone resorption (CrossLaps) were collected pre/post washout and after 3, 6 and 12 months of each treatment. Results 18 women, mean 27 (range 19-39) years, completed the study. Both regimens caused similar suppression of LH and FSH. Mean baseline lumbar spine BMD z-score was -0.89 (95% CI -1.27 to -0.51) and increased by +0.17 (CI +0.07 to +0.27) in response to pSSR (P=0.003) compared with +0.07 (CI -0.03 to +0.18) during standard HRT (P=0.2). During pSSR, the increment in lumbar spine BMD z-score was related positively to oestradiol (r = +0.49, P =0.04) and inversely to FSH (r = -0.65, P =0.004). Bone formation markers, BALP and P1NP, increased in the pSSR arm (ANOVA P

Synthetic progestins, such as Norethindrone (NET), are common ingredients in oral contraceptives and in treatment for post-menopausal problems. Given the widespread use of oral contraceptives and post-menopausal treatments, several reports have targeted and identified progestins in aquatic environments. In fish, progestins play an important role in the stimulation of oocyte final maturation and ovulation in females, stimulation of spermiation and sperm motility in males, and the initiation of meiosis in both sexes. They also have a role as pheromones in some species. Given the pivotal role that progestins play in reproduction, their appreciable daily dose (i.e. microg to mg range in contraceptives and hormone replacement therapies) and continuous use pattern, it is important to understand the potential risk these compounds pose once discharged into the aquatic environment. Since little published data are available on this class of compounds, our research focused on the reproductive effects of NET on the fathead minnow and Japanese medaka. A 28 day static-renewal reproduction study with Japanese medaka indicated that NET produces a significant decrease in fecundity at aqueous concentrations >or=25 ng/L. A 21 day flow-though fathead minnow reproduction study also demonstrated that NET causes a significant decrease in fecundity in the low ng/L range. Fathead minnow morphological changes (i.e. female fin spots) suggest that NET exposure may have a potent androgenic effect on fish; however, plasma 11-Ketotestosterone (11-KT) concentrations were reduced in males at the highest exposure concentration. Collectively, these data indicate that further investigation of reproductive responses associated with synthetic progestins is warranted.

Aims: The use of hormone therapy (HT) is a relevant and topical issue in the treatment of menopausal symptoms in women. Information regarding the effects of combination treatment with estrogen and progesterone as well as treatment timing on cognitive function is lacking and was evaluated in healthy pre- and postmenopausal women. Methods: Sixteen premenopausal (45–51 years) and 16 postmenopausal (58–70 years) women were randomly assigned to receive either estrogen + progestin therapy (HT) or placebo (PL) for six months. The study was double-blind. Cognitive performance was measured at baseline and follow up with tests of verbal and visuomotor functions, verbal and visual memory, and attention. Results: In premenopausal women, cognitive attention, when compared to baseline, improved with HT but declined slightly with PL in the two-choice reaction time task (P = 0.049), while PL was associated with better performance in tests of shared attention (P = 0.024) and auditory attention (P

20 healthy female volunteers were enrolled in this study and were randomly divided into 2 groups. 1 group received a single injection of norethisterone enanthate (NET-EN) via gluteal muscle; the other group received NET-EN via the deltoid muscle. The study had a crossover design and after the 1st injection period of 8 weeks there was a steroid-free period of 8 weeks. Blood samples were collected weekly. The serum concentrations of norethisterone estradiol and progesterone were measured by radioimmunoassay. It was found that the elimination rate constant T1/2 and area under the curve for the gluteal and deltoid groups were not significantly different. The peak levels of NET in the serum was somewhat high in the deltoid injection group. The ovarian suppression with NET-EN in some women may last only 60 days or less. (authors)

This study was performed to evaluate the inhibitory effect of synthetic steroids on the hypothalamo-pituitary axis. Six synthetic steroids, used for contraception or other gynecologic indications, were injected to female rats on diestrus 2 (2 mg/kg, sc), and the animals were sacrificed in the afternoon of proestrus. Serum levels of LH, FSH and progesterone, the pituitary contents of LH and FSH, and LH-RH in the median eminence were measured by radioimmunoassays. Among the synthetic steroids tested in this study, norethisterone, d-norgestrel, 3-keto-desogestrel and gestrinone completely blocked the gonadotropin surge on proestrus, showing stronger antigonado-tropic activity than progesterone. Desogestrel did not affect proestrous gonadotropin release at this dose. The suppressive effect of danazol could be seen only in a larger dose (20 mg/kg). These findings reconfirmed previously reported results, which demonstrated that the hypothalamo-pituitary complex was a major site of action of these steroids.

High usage of progestin-only injectable contraceptives, which include the intramuscular injectables depo-medroxyprogesterone acetate (DMPA-IM, Depo-Provera) and norethisterone (NET) enanthate (NET-EN or Nur-Isterate), correlates worldwide with areas of high HIV-1 prevalence. Epidemiological data show a significant association between usage of DMPA-IM and increased HIV-1 acquisition but no such association from limited data for NET-EN. Whether MPA and NET have similar effects on HIV-1 acquisition and pathogenesis, and the relationship between these effects and the dose of MPA, are critical issues for women’s health and access to suitable and safe contraceptives. We show for the first time that MPA, unlike NET, significantly increases HIV-1 replication in peripheral blood mononuclear cells (PBMCs) and a cervical cell line model. The results provide novel evidence for a biological mechanism whereby MPA, acting via the glucocorticoid receptor (GR), increases HIV-1 replication by at least in part increasing expression of the CCR5 HIV-1 coreceptor on target T-lymphocytes. MPA, unlike NET, also increases activation of T-cells and increases the CD4/CD8 ratio, suggesting that multiple mechanisms are involved in the MPA response. Our data offer strong support for different biological mechanisms for MPA versus NET, due to their differential GR activity. The dose-dependence of the MPA response suggests that significant effects are observed within the range of peak serum levels of progestins in DMPA-IM but not NET-EN users. Dose-response results further suggest that effects of contraceptives containing MPA on HIV-1 acquisition and disease progression may be critically dependent on dose, time after injection and intrinsic factors that affect serum concentrations in women. usc Refereed/Peer-reviewed

To evaluate liver function and hemostatic parameters in postmenopausal women who have chronic infection with the hepatitis C virus and climacteric symptoms and are undergoing hormone therapy (HT) (standard dose of transdermal continuous combined hormone therapy).Fifty out of 336 postmenopausal patients with chronic infection with the hepatitis C virus were selected. The non-inclusion criteria were other chronic or systemic liver diseases, severe vascular diseases, autoimmune diseases or malignant tumors. The patients were randomized into two groups: the HT group with 25 patients to be given transdermal hormone therapy (50 microg estradiol plus 170 microg norethisterone/day) and the control group with the other 25 patients (no medication). Hepatic tests (alanine aminotransferase, aspartate aminotransferase, gamma glutamyltransferase, total alkaline phosphatase, albumin, serum bilirubin) and hemostatic parameters (prothrombin time, factor V, fibrinogen) were evaluated at baseline and at 1, 4, 7 and 9 months of treatment.No significant changes in parameters were found in the comparison between the treated group and the controls, except for a decrease in total alkaline phosphatase (p = 0.002), presumably due to changes in bone remodelling.There were no changes in liver function after a 9-month treatment with transdermal estradiol plus norethisterone in symptomatic postmenopausal patients with hepatitis C.

Dienogest (DNG) has the essential properties of an effective progestogen for use in a new contraceptive pill using estradiol valerate as estrogenic component -- it inhibits ovulation and protects against endometrial proliferation. DNG is a derivative of norethisterone (NET), but has a cyanomethyl- instead of an ethinyl-group in C17 position which may offer a variety of benefits regarding hepatic effects. The similarity to NET is reflected in the high endometriotropy and in similar pharmacokinetics like short plasma half-live and high bioavailability. However, DNG also elicits properties of progesterone derivatives like neutrality in metabolic and cardiovascular system and considerable antiandrogenic activity, the latter increased by lack of binding to SHBG as specific property of DNG. It has no glucocorticoid and antimineralocorticoid activity and has no antiestrogenic activity with the consequence that possible beneficial estradiol effects should not be antagonized. This may be of special importance for the tolerability and safety of the first pill with estradiol valerate instead of ethinylestradiol, although well-designed postmarketing studies are still ongoing to demonstrate what can be expected on the basis of pharmacology.

Background This pilot study evaluates the efficacy of norethisterone acetate in treating pain and gastrointestinal symptoms of women with colorectal endometriosis. Methods This prospective study included 40 women with colorectal endometriosis, who had pain and gastrointestinal symptoms. Patients received norethisterone acetate (2.5 mg/day) for 12 months; in case of breakthrough bleeding, the dose of norethisterone acetate was increased by 2.5 mg/day. The degree of patient satisfaction with treatment (primary end-point) and the changes in symptoms (secondary end-point) were evaluated. Side effects of treatment were recorded. Results Norethisterone acetate determined a significant improvement in the intensity of chronic pelvic pain, deep dyspareunia, dyschezia. Treatment determined the disappearance of symptoms related to the menstrual cycle (dysmenorrhea, constipation during the menstrual cycle, diarrhoea during the menstrual cycle and cyclical rectal bleeding). The severity of diarrhoea, intestinal cramping and passage of mucus significantly improved during treatment. On the contrary, the administration of norethisterone acetate did not determine a significant effect on constipation, abdominal bloating and feeling of incomplete evacuation after bowel movements. At the completion of treatment, 57% of the patients with diarrhoea or diarrhoea during the menstrual cycle continued the treatment with norethisterone acetate compared with 17% of the patients with constipation or constipation during the menstrual cycle. Conclusions In some patients with bowel endometriosis, the administration of norethisterone acetate may determine a relief of pain and gastrointestinal symptoms. This therapy has greater benefits in patients with gastrointestinal symptoms related to the menstrual cycle, diarrhoea and intestinal cramping.

The effects of long-term administration of norethisterone, a progestogen-only contraceptive, at a dose of 0.5 mg/rat daily for 75 days, were evaluated in the ovary of cycling rats using histomorphic and karyokinetic (by colchicine technique) techniques. Norethisterone induced follicular atresia, decreased the number of normal follicular population and altered the appearance of the interstitial gland. Atresia was markedly noticed particularly in the follicles less than 200 micron in diameter. In addition, fresh or old corpora lutea were not found in the ovary. Simultaneously the progestin also stimulated the mitotic activity in the granulosa and theca of the normal follicles, especially of 201-300 micron in diameter. The findings suggest that norethisterone causes antifertility mainly by preventing follicular development and inducing atresia, thereby inhibiting perhaps ovulation.

Background Etravirine, a non-nucleoside reverse transcriptase inhibitor (NNRTI) active against NNRTI-resistant HIV, is an inducer of CYP3A4 and an inhibitor of CYP2C9/19. Study Design The effect of etravirine on the pharmacokinetics and pharmacodynamics of ethinylestradiol and norethindrone was assessed in 30 HIV-negative females. Following a run-in cycle with ethinylestradiol/norethindrone, the pharmacokinetics of ethinylestradiol and norethindrone was assessed on Day 15 of Cycle 2. Etravirine 200 mg bid was coadministered on Day 1 to Day 15 of Cycle 3, with pharmacokinetic assessments of ethinylestradiol, norethindrone and etravirine on Day 15. Results When combined with etravirine, the least-squares means (LSM) ratios (90% confidence interval) for ethinylestradiol AUC 24h , C max and C min were 1.22 (1.13���1.31), 1.33 (1.21���1.46) and 1.09 (1.01���1.18), respectively, compared to administration alone. LSM ratios for norethindrone parameters were 0.95 (0.90���0.99), 1.05 (0.98���1.12) and 0.78 (0.68���0.90), respectively. Conclusion These changes are not considered clinically relevant. No loss in contraceptive efficacy is expected when coadministered with etravirine.

Plasma lipids were analyzed in 24 women taking Anovlar (.05 mg ethinyl estradiol and 4 mg norethisterone acetate combined Ovulen (.1 mg mestranol and 1 mg ethynodiol diacetate combined) and Volidan (.05 mg ethinyl estradiol and 4 mg megestrol acetate combined) and in 3 ovariectomized women given various estrogens and progestins. Blood samples were taken before and after 1 3 6 and 12 months of oral contraception and before and at 1-3 week intervals after hormones. Cholesterol was lowered for 6 months by Anovlar. Triglycerides and total phospholipids were raised by Ovulen and Volidan and total phospholipids were lowered by Anovlar. Lecithin and cephalin were increased by Ovulen and Volidan and lysolecithin and sphingomyelin decreased. Anovlar increased sphingomyelin. In the ovariectomized women .01 mg ethinyl estradiol increased triglycerides total phospholipids and decreased lysolecithin. 5 mg norethisterone and ethinyl estradiol decreased triglycerides and total phospholipids. The lipid pattern with 4 mg megestrol acetate and ethinyl estradiol resembled that with ethinyl estradiol alone. The results show that the steroid combination the estrogenic or progestogenic effect and the use of 19-nortestosterone or 17-alpha-hydroxyprogesterone derivatives all have independent effects on the various plasma lipids.

93 British women using various oral contraceptives daily were compared with 89 normal and pregnant controls to determine the effect of contraceptives on platelet aggregation. The 93 test subjects were subdivided as follows: 1) 14 used conventional high-dose estrogen-progestogen combinations; 2) 14 used the conventional low-dose Norinyl-1 preparation; 3) 18 used Ortho-Novin a preparation containing twice the hormone dose of Norinyl-1 i.e. 2 mg of norethisterone and .1 mg of mestraniol; 4) 32 used .5 mg of chlormadinone acetate (pure progestogen); and 15 changed to pure progestogen from combined conventional preparations. A slightly modified Chandlers tube technique showed platelet aggregation to be significantly more accelerated in the pregnant controls than in normal controls or any test group. Platelet aggregation was significantly accelerated in the high- and low-dose groups although a comparison of the two low-dose groups failed to show a significant dose-dependent difference between them. The progestogen group without prior experience showed no significant change at 6 months; but there was a significant acceleration normalized after 1 month and remaining normal at 6 months in subjects who had previously used conventional preparations. A follow-up study showed that the progestogen-only preparations caused a significantly smaller acceleration than the combined preparations after 2 years of use and therefore may offer a lesser risk of thrombosis.

To determine the optimal daily dose of intranasal hormone therapy (HT) in order to achieve adequate endometrial protection.Multicentre, double-blind/double-dummy randomized controlled trial (Phase III) was conducted in 1741 women to compare a daily intranasal dose of 350 microg 17beta-estradiol (E2) together with 50, 175 or 550 microg norethisterone (NET) with the oral administration of 2 mg E2 and 1 mg NET, over a period of 52 weeks. An endometrial biopsy was performed at the end of HT use.Most women (73-86%) had an 'atrophic and/or inactive' endometrium. Lower doses of NET were associated with a higher incidence of 'proliferative' endometrium. The incidence of vaginal bleeding decreased with time. During the last 4 months of the study, 88.1% of women using the highest dose of NET were in amenorrhoea when compared with 71.7% using the oral comparator (difference 16.5%; 95% confidence interval: 10.9-22.0%) (P0.001). Premature discontinuation rates were in the range of 12-17% for the three nasal regimens and 22% for the oral comparator.HT using a fixed intranasal dose of 350 microg E2 combined with 550 microg NET is a safe regimen, in relation to 1 year endometrial safety. This regimen is associated with less vaginal bleeding when compared with an oral comparator using 2 mg E2 and 1 mg NET.

The detection of 19 norandrosterone (19-NA) in a competitor's urine sample is taken as prima facie evidence of administration of nandrolone or other 19-norsteroid but a potential problem is that administration of norethisterone, a progestogen used for menstrual disorders and for hormonal contraception, also results in the excretion of 19-NA that can exceed the laboratory reporting threshold of 2 ng/mL The contribution of norethisterone to urinary 19-NA with and without 19-norandrostenedione. a known norethisterone tablet impurity, requires evaluation. Preparations containing, either

Background The contraceptive effect of the progestogen norethisterone (NET) and its main metabolites 5α-NET and 3β,5α-NET has been demonstrated in several species, and most studies have focused on the effects of these compounds in the uterus. We previously reported that 5α-NET inhibits the progesterone (P 4 )-induced acrosome reaction in pig and mouse spermatozoa and induces severe morphological damage in two-cell fertilized mouse oocytes. Study Design The main goal of this study was to analyze the possible role of P 4 receptor (PR) in the effects of NET and 5α-NET on the oocyte fertilization process. Different steroid treatments were used with or without cumulus-enclosed oocytes. Results It was demonstrated that NET increases the percentage of fertilized oocytes in the same manner as P 4 does, while 5α-NET reduces the percentage of fertilized oocytes. This effect was not reversed by P 4 in the same concentrations. Conclusion A possible molecular mechanism for the effects of 5α-NET may be through a PR localized in the oocyte plasma membrane.

Objectives To determine the effects of low-dose transdermal hormone therapy (HT) on systolic (SBP) and diastolic (DBP) blood pressure (BP) evaluated by 24-h ambulatory blood pressure monitoring (ABPM) in hypertensive postmenopausal women. Methods The study was conducted on 24 hypertensive postmenopausal women aged, on average, 54 years and under treatment with enalapril maleate (10-20 mg/day) combined or not with hydrochlorothiazide (25 mg/day). Thirteen women used a transdermal adhesive containing estradiol and norethisterone (25 and 125 mug active substance/day, respectively) and 11 did not receive HT. ABPM, lipid profile, and climacteric symptoms were evaluated before and 3 and 6 months after treatment. Results After 3 and 6 months of follow-up, there was a statistically significant reduction of the Blatt-Kupperman menopausal index in the treated group (19.6+/-8.3 vs. 9.6+/-5.9 vs. 9.7+/-7.0; P=0.01). No significant difference in any of the ABPM variables (areas under the systolic and diastolic curves, mean SBP and DBP, SBP and DBP loads and wakefulness-sleep variation) or in the lipid profile was observed between or within groups at the three time points studied. Conclusion Low-dose transdermal HT administered for 6 months was effective in improving climacteric symptoms and did not change BP values or circadian pattern in postmenopausal women with mild-to-moderate arterial hypertension taking antihypertensive medications.

The synthetic progestins used so far for contraception and menopausal hormone therapy are derived either from testosterone (19-nortestosterone derivatives) or from progesterone (17-OH progesterone derivatives and 19-norprogesterone derivatives). Among the 19-nortestosterone derivatives, the estrane group include norethisterone (NET) and its metabolites, and the gonane group include levonorgestrel (LNG) and its derivatives. The later, including desogestrel (DSG) and its derivative etonogestrel, gestodene (GES) and norgestimate (norelgestromin), have been referred to as third-generation progestins. Several newprogestins have been synthesized in the last decade and may be considered as a fourth-generation of progestins. Dienogest is referred to as a hybrid progestin being derived from the estrane group with a 17α-cyanomethyl group, and drospirenone derives from spirolactone. These two progestins have no androgenic effect but a partial antiandrogenic effect. The later exerts anti-mineralocorticoid effects. This property leads to a decreased salt and water retention and a lowering in blood pressure in users of pills containing this progestin. The 19-norprogesterone derivatives appear more specifically progestational and do not possess any androgenic, estrogenic or glucocorticoid activity. They are referred to as “pure” progestational molecules as they bind almost exclusively to the progesterone receptor (PR) and do not interfere with the other steroid receptor. This category includes, trimegestone, nomegestrol acetate and Nestorone® is not active orally but proved to be a potent anti-ovulatory agent when given in implants, vaginal rings or percutaneous gel. Non-androgenic progestins would appear neutral on metabolic factors and on the vessels and would have the advantage of avoiding acnea. Progestins with antiandrogenic properties may also be used for the treatment of women with preexisting androgen related conditions. The progestins available for therapy exhibit profound differences according to their structure or metabolites and it is inappropriate to consider the various effects of the old and new molecules as class-effects.

Background An open-label, randomized, crossover study was performed to investigate the effect of multiple doses of darunavir co-administered with low-dose ritonavir (DRV/r) on the steady-state pharmacokinetics of the oral contraceptives ethinyl estradiol (EE) and norethindrone (NE) (commercial name of the combined drug Ortho-Novum 1/35) in 19 HIV-negative healthy women. Methods In session 1, participants received 35 μg EE and 1.0 mg NE from days 1 to 21. In session 2, participants received the same oral contraceptive treatment as in session 1 on days 1 to 21 plus DRV/r (600 mg/100 mg twice daily) on days 1 to 14. Pharmacokinetic assessments were performed on day 14 for each session. Results Steady-state systemic exposure to EE and NE decreased when DRV/r was co-administered, based on the ratio of least square means of the minimum plasma concentration (Cmin), the maximum plasma concentration (Cmax), and the area under the curve (AUC24h) of EE (which decreased by 62%, 32% and 44%, respectively) and NE (which decreased by 30%, 10% and 14%, respectively) compared with administration of EE and NE alone. Five participants discontinued the study due to grade 2 cutaneous events, as required per protocol, during treatment with EE and NE in combination with DRV/r. There were no clinically relevant findings for laboratory and cardiovascular parameters. Conclusions The pharmacokinetic interaction observed here is considered to be clinically relevant as EE concentrations are considerably reduced when DRV/r is co-administered with EE and NE. Alternative or additional contraceptive measures should be used when oestrogen-based contraceptives are co-administered with DRV/r.

Summary Objective Progestins are commonly prescribed for hormone replacement therapy (HRT) and contraception. However, the effects of progestins on bone metabolism remain unclear and are often controversial. Design and patients This study was conducted to test the hypothesis that progestins with no significant glucocorticoid activity may be a better choice for HRT to achieve increased beneficial effects on bone metabolism than progestins with strong glucocorticoid activity. A total of 104 postmenopausal women aged 50–75 years with osteoporosis were allocated randomly to three groups: (1) conjugated oestrogen plus medroxyprogesterone acetate (HRT-MPA, with significant glucocorticoid activity); (2) conjugated oestrogen plus norethisterone (HRT-NET, with no significant glucocorticoid activity); and (3) control (no treatment). Measurements Vertebral X-rays and bone mineral density (BMD) at distal 1/3 radius were assessed at baseline and every 6 months during the 2-year study period, along with markers of bone turnover. The occurrence of new nonvertebral fractures was identified by X-ray. Results After the 2-year treatment, mean BMD changes relative to baseline in the HRT-MPA, HRT-NET and control groups were 1·6%, 2·3% and –1·9%, respectively. In addition, the rate of increase in HRT-NET was significantly greater than that in HRT-MPA (P = 0·019). The incidence of new fractures during the 2-year treatment in the control group was 26% (9/34). HRT-NET treatment significantly inhibited the occurrence of new fractures (RR 0·14, 95% CI 0·02–0·93, P = 0·04), while HRT-MPA treatment failed to show a statistically significant reduction (RR 0·41, 95% CI 0·14–1·24, P = 0·11). Both HRT-MPA and HRT-NET treatments significantly decreased serum osteocalcin levels by 29·4% and 23·5%, respectively, after 6 months of treatment, with the decrease in HRT-MPA being significantly greater than that in HRT-NET (P = 0·042). Conclusions These findings suggest that progestins with no significant glucocorticoid activity may be a better choice for HRT, resulting in increased beneficial effects on bone metabolism compared with progestins with strong glucocorticoid activity.

Objectives Tibolone is a tissue selective compound with estrogenic, androgenic and progestogenic properties in classical bioassays. It is used for alleviation of menopausal symptoms and for osteoporosis prophylaxis in postmenopausal women. Only few data are available regarding the effects of tibolone on the cardiovascular system. We investigated therefore the in vitro effects of tibolone and its metabolites on the vasculature under special controlled conditions, using human female coronary endothelial and smooth muscle cells. Methods The effect on the production of the following markers in endothelial cells from human female coronary arteries was evaluated: nitric oxide synthase, prostacyclin, endothelin, plasminogen-activator-inhibitor-1 (PAI-1), E-Selectin, Intercellular adhesion molecule (ICAM-1), monocyte attracting protein-1 (MCP-1) and the precursor of matrix metalloproteinase-1 (pro-MMP-1). Tibolone, its metabolites, estradiol (E2), E2/norethisterone (NET) and E2/medroxyprogesterone acetate (MPA) were tested at 0.1 μM and 1 μM. The markers were determined by enzyme immunoassays in the cell supernatant. Cell proliferation of smooth muscle cells from female coronary artery was measured by an adenosine triphosphate-assay. Results Tibolone, its 3-hydroxy metabolites, E2/NET, E2/MPA and estradiol alone had significant effects on the synthesis of all markers tested. The magnitude of the tibolone effects, however, was mostly smaller than that of E2/NET and E2/MPA. Concerning smooth muscle cells tibolone and its 3-hydroxy metabolites also elicited an inhibition of the proliferation compared to control values. The strongest effect here was found for E2/NET and E2 alone, whereas E2/MPA had no effect. Conclusion The results of this in vitro study conducted with cells of the most important vascular bed with respect to the problem of cardiovascular risk suggest that tibolone can positively influence the vasculature. However, these tibolone effects may depend on intact vascular cells and may vary due to the different atherosclerotic stages of the vessels. Thus, experimental studies are useful to explore mechanisms, but clearly cannot replace clinical studies.

Tibolone is used for the treatment of climacteric symptoms and osteoporosis in menopausal women. After ingestion, it is rapidly converted to a number of metabolites including 3alpha- and 3beta-hydroxy derivatives and the delta-4, 7alpha-methylnorethisterone (7alpha-MeNET) metabolite, which is rapidly cleared from circulation. Tibolone and some of its metabolites act in a tissue-selective manner to inhibit steroid sulphatase (STS) and 17beta-hydroxysteroid dehydrogenase Type 1 (17beta-HSD1) activities but also stimulate steroid sulphotransferase and 17beta-HSD2 activities. In the present study we have examined whether the ability of tibolone and its 7alpha-MeNET metabolites to regulate the activities of enzymes involved in oestrogen formation or inactivation extends to another key enzyme involved in oestrogen synthesis, the aromatase, which converts androstenedione to oestrone. Using JEG-3 choriocarcinoma cells, which have a high level of aromatase activity, tibolone and 7alpha-MeNET, but not the 3alpha- or 3beta-hydroxy metabolites, were found to inhibit aromatase activity in intact cells and also lysates prepared from these cells (up to 61% inhibition at 10muM). An investigation into the nature of aromatase inhibition by these compounds revealed that they inhibit aromatase activity by a reversible mechanism. Tibolone and 7alpha-MeNET also inhibited aromatase activity in MCF-7 breast cancer cells, which have a much lower level of aromatase activity than JEG-3 cells. It is concluded that, in addition to inhibiting STS and 17beta-HSD1, tibolone and 7alpha-MeNET may exert some of their tissue-selective effects in regulating oestrogen synthesis by also inhibiting aromatase activity.

Background: Macitentan, a dual endothelin receptor antagonist approved for the treatment of pulmonary arterial hypertension, induces cytochrome P450 (CYP) 3A4 at supra-therapeutic concentrations in vitro. Hormonal contraceptives (HCs) are CYP3A4 substrates and their efficacy can be affected by CYP3A4 inducers. Aim: To evaluate the effect of macitentan on the pharmacokinetics (PK) of a combined HC, ethinyl estradiol 35 μg (EE) and norethisterone 1 mg (NE), and safety and tolerability of concomitant use. Methods: In this randomized, cross-over study, 26 healthy women received a single oral dose of HC alone (reference) and concomitantly with 10 mg macitentan at steady state (test), with a washout of 3 weeks. PK, adverse events (AEs), and safety were monitored. No PK interaction was concluded if the 90% confidence intervals (CIs) of geometric mean ratios (GMRs) (test/reference) of the peak plasma concentration (Cmax) and the area under the plasma concentration-time curve from 0 to infinity (AUC0 –∞ ) of EE and NE were within the bioequivalence limits of 0.8 to 1.25. Results: Cmax and AUC0-∞ of the HC were within the bioequivalence limits. For EE, GMRs (90% CIs) of Cmax and AUC0-∞were 0.92 (0.85, 0.99) and 0.95 (0.90, 0.99). These values for NE were 1.02 (0.95, 1.09) and 1.04 (0.98, 1.09), respectively. Overall, study treatments were well tolerated. The most frequently reported AE was headache (69%). One unrelated serious AE (asthma bronchiale) was reported. All AEs resolved without sequelae. No major changes from baseline in safety parameters were reported. Conclusions: Macitentan does not affect the PK of the combined HC. In line with previous clinical data, the PK of CYP3A4 substrates are not affected by macitentan.

Macitentan, a dual endothelin receptor antagonist used in pulmonary arterial hypertension, induces cytochrome P450 (CYP) 3A at supratherapeutic concentrations in vitro. Most combined oral hormonal contraceptives (OCs) are CYP3A substrates and their efficacy can be affected by CYP3A inducers. This randomized crossover study assessed possible pharmacokinetic (PK) interactions between macitentan and an OC containing ethinyl estradiol and norethindrone (or norethisterone). Twenty-six healthy women received a single oral dose of OC alone (reference) and concomitantly with 10 mg macitentan at steady state (test). No PK interaction was concluded if the 90% confidence intervals (CIs) of geometric mean ratios (GMRs; test/reference) of the peak plasma concentration (Cmax ) and the exposure from 0 to infinity (AUC0 - ∞ ) to the OC components were within the equivalence limits of 0.8 to 1.25. Cmax and AUC0-∞ of the OC were within the equivalence limits. For ethinyl estradiol, GMRs (90%CIs) of Cmax and AUC0-∞ were 0.92 (0.85-0.99) and 0.95 (0.90-0.99). For norethindrone, these values were 1.02 (0.95-1.09) and 1.04 (0.98-1.09), respectively. Overall, study treatments were well tolerated. No major changes from baseline in safety parameters were reported in either treatment. Macitentan does not affect the PK of OCs.

Background Steroid pre-treatments may be useful to program GnRH antagonist IVF/ICSI cycles. This prospective study assessed hormonal and ultrasound data collected during the free period after the discontinuation of three different pre-treatments to provide information on the optimal time interval required before starting stimulation. Methods Women were randomized to receive oral contraceptive pill (OCP) [ethinyl estradiol (E(2)) 30 microg + desogestrel 150 microg] (n = 21) or norethisterone 10 mg/day (n = 23) or 17-betaE(2) 4 mg/day (n = 25) or no pre-treatment (n = 24) for one cycle before IVF. Assessments were performed on post-treatment day (PD) 1, 3 and 5, or on spontaneous cycle day (CD) 1 and 3. Results After OCP and progestogen administration, FSH and LH concentrations shifted from strongly suppressed PD1 levels to PD5 values similar to those observed on CD1. Meanwhile, follicle sizes remained small up to PD5. In contrast, estrogen pre-treatment poorly reduced FSH levels on PD1 compared with OCP or progestogen. Consequently, follicle size was more heterogeneous. FSH rebound was maximal on PD3, whereas LH levels were slightly increased up to PD5. Conclusions A 5-day free interval after OCP or progestogen offers the advantages of gonadotrophin recovery and homogeneous follicular cohort, whereas early FSH rebound occurring after estrogen pre-treatment argues for a short free period.

In healthy postmenopausal women, E(2) plus norethisterone acetate (1 mg + 0.5 mg) or tibolone (2.5 mg) similarly modify flow-mediated endothelium-dependent vasodilatation. The effect is dependent on baseline vasodilator reserve, with low values being augmented by either treatment.