- 86 Downloads
The newer progestogens gestodene, desogestrel and norgestimate were developed in an attempt to produce agents with more selective progestational activity that would improve cycle control and minimise metabolic changes and adverse events while effectively preventing pregnancy. In clinical practice, gestodene is combined with ethinylestradiol in monophasic or triphasic combined oral contraceptive preparations. The drug has pharmacokinetic advantages over the other new progestogens in that it is active per se (the others are prodrugs) and has high bioavailability (approximately 100%). The ability of gestodene-containing oral contraceptives to inhibit ovulation is similar to that of preparations containing other progestogens although the required dosage is lower.
In common with oral contraceptives containing desogestrel or norgestimate, and in contrast with those containing levonorgestrel, gestodene-containing preparations are associated with neutral or positive changes in lipid and carbohydrate metabolism. The effects of gestodene preparations on coagulation parameters, like those of desogestrel and levonorgestrel, are balanced by changes in the fibrinolytic system. Although the impact of these changes on clinical cardiovascular end-points has not been determined, the altered lipid profile is not likely to have significant clinical relevance because of the predominantly thrombogenic nature of cardiovascular disease in oral contraceptive users.
Pregnancy rates and Pearl Indices with gestodene-containing preparations are low and similar to those with preparations containing other progestogens. Most pregnancies are attributable to user failure. Cycle control appears to be better with gestodene preparations than with levonorgestrel preparations, and available data suggest that cycle control may also be better with monophasic gestodene/ethinylestradiol than with monophasic desogestrel- or norgestimate-containing preparations, and better with triphasic gestodene- than with triphasic levonorgestrel- or norgestimate-containing preparations. However, differences between the new progestogen-containing preparations need to be confirmed in further large-scale trials.
The most common adverse events with gestodene/ethinylestradiol are headaches and breast tension; the incidence of short term adverse events, including acne, is similar to that with preparations containing other progestogens. Changes in blood pressure and bodyweight are negligible. There are no comparative data on the incidence of cardiovascular events with gestodene-containing and other combined preparations. While the risk of breast cancer appears to be increased with long term combined oral contraceptive use in certain patient subgroups, this risk needs to be balanced against the noncontraceptive benefits of these preparations.
Thus, there is evidence to suggest that gestodene-containing oral contraceptives may have advantages over those containing desogestrel or norgestimate in terms of cycle control, and also over more established progestogen-containing preparations in terms of cycle control, lipid metabolism and possibly carbohydrate metabolism. However, the impact of the observed metabolic changes on cardiovascular end-points are unknown and further large clinical trials are required to confirm the possible advantages of gestodene in terms of cycle control over the other new progestogens.
The ability of gestodene-containing oral contraceptive preparations to inhibit ovulation is similar to that of preparations containing the other new progestogens desogestrel and norgestimate as well as more established progestogens. The dosage of gestodene required to inhibit ovulation is lower than that for other progestogens, and preparations containing gestodene may have a greater suppressive effect on the hypothalamic-pituitary axis. Furthermore, the dosage of progestogen required to transform the endometrium appears to be lower for gestodene and desogestrel than for norgestimate and levonorgestrel.
Gestodene binds to the human progesterone receptor with a lesser affinity than that of 3-keto desogestrel and levonorgestrel. Gestodene also binds to the rat androgen receptor, with a similar affinity to that of 3-keto desogestrel and levonorgestrel. The antiestrogenic activity of gestodene [in terms of changes in sex hormone-binding globulin (SHBG) levels] is less than that of levonorgestrel and similar to that of desogestrel; the relative binding affinity of gestodene for SHBG is slightly greater than that of levonorgestrel and 3-keto desogestrel. However, no significant differences in effects on testosterone levels have been reported in women receiving contraceptive preparations containing one of these progestogens.
The binding affinity of gestodene for animal mineralocorticoid and, to a lesser extent, glucocorticoid receptors appears to be greater than that of levonorgestrel or desogestrel.
Although several differences between the pharmacodynamic effects of gestodene and norgestimate have been reported, they are likely to be of little clinical relevance because norgestimate is rapidly metabolised in vivo and levonorgestrel accounts for at least part of its activity.
In common with desogestrel- and norgestimate-containing oral contraceptive preparations and in contrast with longer established high-dose combined oral contraceptive preparations, gestodene-containing formulations appear to have a neutral or favourable effect on the lipid profile although increased triglyceride levels have been reported. Oral contraceptives containing desogestrel tend to have a more favourable effect on high density lipoprotein-cholesterol levels than those containing gestodene. Although the effects of these lipid changes in terms of cardiovascular end-points have not been determined, their clinical relevance is likely to be low considering the thrombogenic nature of cardiovascular disease in oral contraceptive users. The overall effects of gestodene-containing preparations on haemostatic parameters appear to be similar to those of both desogestrel-and levonorgestrel-containing preparations, with small increases in some parameters associated with coagulation being balanced by an increase in fibrinolytic activity.
Gestodene-containing combined oral contraceptive preparations administered for up to 1 year appear to have no or minimal effects on carbohydrate metabolism in healthy women and in women with diabetes mellitus. In common with desogestrel- and norgestimate-containing preparations, oral contraceptives containing gestodene appear to have fewer effects on carbohydrate metabolism than those containing longer established agents. Long term studies, especially in women aged >35 years, are needed to confirm the results of these short term studies.
Gestodene is an active progestogen whereas the other 2 new progestogens desogestrel and norgestimate are prodrugs. As with other progestogens, the pharmacokinetics of gestodene show considerable intra- and interindividual variation.
Gestodene has high oral bioavailability (almost 100%) and exhibits dose-linear pharmacokinetics. Maximum serum gestodene concentrations following multiple dose gestodene/ethinylestradiol administration are 4-fold higher than after single doses, and progressively increased during each and subsequent treatment cycles for up to 12 cycles. Area under the concentration-time curve (AUCo-24h) values for gestodene are approximately 5- to 8-fold higher after multiple gestodene/ ethinylestradiol administration than after single doses.
AUC values for ethinylestradiol were greater after multiple monophasic or triphasic gestodene/ethinylestradiol administration than after single dose administration. Although gestodene strongly inactivates the cytochrome P450 CYP3A4, the major enzyme involved in the metabolism of ethinylestradiol, the drug does not appear to inhibit the metabolism of ethinylestradiol in vivo. Most available studies report no significant differences in ethinylestradiol concentrations between gestodene- or desogestrel-containing preparations.
Gestodene is extensively metabolised by the liver; several metabolites have been identified including dihydro-gestodene, 3,5 tetrahydro-gestodene and hydroxy-gestodene. The clearance of gestodene is decreased and the terminal elimination half-life is increased with multiple dose compared with single dose gestodene/ ethinylestradiol administration; clearance is dependent on the free-fraction of drug and is therefore sensitive to changes in SHBG levels.
Contraceptive Efficacy and Cycle Control
In noncomparative trials of monophasic gestodene/ethinylestradiol 75μg/30μg (gestodene 75/30) or triphasic gestodene 50/30, 70/40, 100/30, pregnancy rates and Pearl Indices of 0 to 0.11% and 0 to 0.22, respectively, were reported during 6 to 36 cycles of administration to > 100 000 women, despite up to 14% of women missing at least 1 tablet in total. User failure accounted for most pregnancies.
The efficacy of monophasic or triphasic gestodene-containing oral contraceptive preparations in preventing pregnancy appears to be similar to that of monophasic and triphasic desogestrel- and norgestimate-containing preparations and preparations containing the more established progestogens levonorgestrel or norethisterone. Pregnancy rates of 0 to 0.001% and Pearl Indices of 0 to 1 were reported despite a number of pill-taking errors; most pregnancies were attributable to patient failure.
Evidence suggests that the effects of monophasic gestodene/ethinylestradiol on cycle control may be more favourable than those of monophasic desogestrel-, norgestimate- and levonorgestrel-containing oral contraceptive preparations although further large-scale comparative trials are required to confirm these findings. Cycle control with triphasic gestodene/ethinylestradiol also appears to be at least equal to that with triphasic norethisterone/ethinylestradiol or levonorgestrel/ethinylestradiol. Bleeding irregularities decreased after the first few cycles of use and were more common in women with a history of irregular bleeding and in first-time oral contraceptive users.
The most common adverse events with monophasic and triphasic gestodene/ ethinylestradiol preparations are headache (0.6 to 13.1%) and breast tension (0.5 to 12.4%); less common are nervousness (0 to 8.4%), nausea (0 to 6%), depression (0 to 3.9%) and dizziness (0 to 2.9%). Weight gain and increased blood pressure are generally negligible and acne occurs in 0.3 to 5.8% of women. The incidence of these effects after 3 or 4 cycles was similar to that at baseline.
The overall short term adverse event profile of monophasic gestodene/ ethinylestradiol was similar to that of desogestrel/ethinylestradiol, norgestimate/ ethinylestradiol and levonorgestrel/ethinylestradiol. Of note, the incidence of acne was similar to that with levonorgestrel, and tended to decrease from baseline more with gestodene- than with desogestrel- or norgestimate-containing preparations. Adverse events including headache, breast tension, nausea, depression and breakthrough bleeding led to treatment withdrawal in 2 to 8% of patients. No significant between-preparation differences in effects on blood pressure or body weight have been reported.
Based on the apparently balanced effects of gestodene-containing oral contraceptive preparations on haemostasis, a relatively low risk of thromboembolic events is expected with these preparations. However, in common with other combined oral contraceptive agents, it is recommended that these preparations should be avoided in patients with a history of thromboembolic disease.
There appears to be an increased risk of breast cancer with long term (≥4 years) oral contraceptive use in certain subgroups, especially in women aged <20 years. However, it is important to balance the effects of combined oral contraceptive use on breast cancer risk and other potential risks with the positive noncontraceptive benefits of these preparations, principally a reduced risk of endometrial and epithelial ovarian cancer.
Dosage and Administration
Gestodene 75μg is combined with ethinylestradiol 20 or 30μg in monophasic preparations and gestodene 50, 70 and 100μg is combined with ethinylestradiol 30, 40 and 30μg in triphasic preparations. Worldwide standardised guidelines for the administration of individual combined oral contraceptive preparations are not available; the UK prescribing guidelines for the 21-day pack of monophasic gestodene 75/30 are described.
Active tablets should be started on day 1 of bleeding and continued for 21 consecutive days followed by 7 tablet-free days. Subsequent packs are started on the corresponding day after the tablet-free interval. When changing from another oral combined contraceptive preparation, patients should begin gestodene 75/30 on the first day immediately after the last active pill of the previous contraceptive course. Gestodene 75/30 may be started 21 days after a vaginal delivery if the patient is fully ambulant and there are no puerperal complications, and may be started immediately after a first-trimester abortion.
A missed active tablet should be taken as soon as possible; if >1 tablet has been missed, only the most recently missed tablet should be taken. If >12 hours have elapsed after missing 1 tablet, if >1 tablet has been missed or if vomiting or diarrhoea occurs, additional methods of contraception (i.e. barrier methods and spermicides) must be used for the following 7 days while the next 7 active tablets are taken. Additional contraception is also advised in patients receiving concomitant barbiturate, phenylbutazone, phenytoin, rifampicin (rifampin), griseofulvin, or antibacterial therapy.
As with other combined oral contraceptives, there are a number of contraindications to gestodene 75/30 including pregnancy, thrombotic disorders, sickle cell anaemia, disorders of lipid metabolism, liver disease, breast or endometrial cancer and abnormal vaginal bleeding of unknown cause. Onset of migraine or exacerbation of pre-existing migraine, unusually frequent or severe headaches, acute visual or hearing disturbance, significant increase in blood pressure, jaundice, exacerbation of conditions known to be capable of deteriorating during oral contraceptive use or pregnancy, or suspicion of thrombosis or infarction are grounds for immediate withdrawal.
KeywordsOral Contraceptive Levonorgestrel Combine Oral Contraceptive Oral Contraceptive User Desogestrel
Unable to display preview. Download preview PDF.
- 7.Shenfield GM, Griffin JM. Clinical pharmacokinetics of contraceptive steroids. An update. Clin Pharmacokinet 1991; 20: 15–37Google Scholar
- 10.Fitzgerald C, Feichtinger W, Spona J, et al. A comparison of the effects of two monophasic low dose oral contraceptives on the inhibition of ovulation. Contraception 1994; 10: 5–18Google Scholar
- 15.Elger W, Steinbeck H, Schillinger E, et al. Endocrine-pharmacological profile of gestodene. Adv Contra Delv Syst 1995; II: 182–97Google Scholar
- 20.Humpel M, Tauber U, Kuhnz W, et al. Protein binding of active ingredients and comparison of serum ethinyl estradiol, sex hormone-binding globulin, corticosteroid-binding globulin, and cortisol levels in women using a combination of gestodene/ ethinyl estradiol (Femovan) or a combination of desogestrel/ ethinyl estradiol (Marvelon) and single-dose ethinyl estradiol bioequivalence from both oral contraceptives. Am J Obstet Gynecol 1990; 163 (1 Pt 2): 329–33PubMedGoogle Scholar
- 21.Fotherby K. Desogestrel and gestodene in oral contraception: a review of European experience. J Drug Dev 1991; 4: 101–11Google Scholar
- 24.Fotherby K. The new low dose oral contraceptives. J Obstet Gynaecol 1994; 14: 327–32Google Scholar
- 29.Eyong E, Elstein M. Clinical update on a new progestogen-gestodene. Br J Farn Plann 1989; 15: 18–22Google Scholar
- 30.Kuhnz W, Baumann A, Staks T, et al. Pharmacokinetics of gestodene and ethinylestradiol in 14 women during three months of treatment with a new tri-step combination oral contraceptive: serum protein binding of gestodene and influence of treatment on free and total testosterone levels in the serum. Contraception 1993; 48: 303–22PubMedGoogle Scholar
- 37.Thorogood M. Oral contraceptives and cardiovascular disease: an epidemiologic overview. Pharmacoepidemiol Drug Saf 1993; 2: 3–16Google Scholar
- 38.Kuhn FE, Rackley CE. Coronary artery disease in women. Risk factors, evaluation, treatment, and prevention. Arch Intern Med 1993; 153: 2626–36Google Scholar
- 40.Consensus development meeting: metabolic aspects of oral contraceptives of relevance for cardiovascular diseases. Am J Obstet Gynecol 1990; 162: 1335–7Google Scholar
- 48.Garzaflores J, Debourges VV, Martinez M, et al. Safety and efficacy of a combined oral contraceptive — gestodene 75 μg plus ethinyl estradiol 30 μg in Mexican women. Contraception 1994; 10: 19–26Google Scholar
- 52.Solerte SB, Fioravanti M, Spinillo A, et al. Hemorheological, hemostatic and metabolic long-term (24 months) study of young women taking a monophasic pill containing gestodene and ethinylestradiol. It J Gynaecol Obstet 1993; 3: 85–91Google Scholar
- 55.Skouby SO, Petersen KR, Jespersen J. The influence of new low-dose oral contraceptives on metabolic variables. Advances in Contraception 1991; 7 Suppl 2: 77–88Google Scholar
- 76.Jung-Hoffmann C, Kuhl H. Pharmacokinetics and pharmacodynamics of oral contraceptive steroids: factors influencing steroid metabolism. Am J Obstet Gynecol 1990; 163: 2183–97Google Scholar
- 84.Ward S, Back DJ. Metabolism of gestodene in human liver cytosol and microsomes in vitro. J Steroid Biochem Mol Biol 1994; 46: 235–43Google Scholar
- 85.Düsterberg B, Tack J-W, Krause W. Pharmacokinetics and bio-transformation of gestodene in man. In: Elstein M, editor. Gestodene — development of a new gestodene-containing low-dose oral contraceptive. Carnforth: Parthenon Publishing Group Ltd, 1987: 35–44Google Scholar
- 91.Weber-Diehl F, Unger R, Lachnit U. Triphasic combination of ethinyl estradiol and gestodene. Long term clinical trial. Contraception 1992; 46: 19–27Google Scholar
- 93.Brill K, Müller C, Schnitker J. The influence of different modern low-dose oral contraceptives on intermenstrual blleding. Advances in Contraception 1991; 7 Suppl 2: 51–61Google Scholar
- 95.Latin American Oral Contraceptive Study Group. Clinical comparison of monophasic oral contraceptive preparations of gestodene/ethinyl estradiol and desogestrel/ethinyl estradiol. Contraception 1994; 50: 201–14Google Scholar
- 99.Pratt WF, Bachrach CA. What do women use when they stop using the pill? Family Planning Perspectives 1987; 1: 257–66Google Scholar
- 102.International working Group on Enhancing Patient Compliance and Oral Contraceptive Efficacy. A consensus statement: enhancing patient compliance and oral contraceptive efficacy. Br J Fam Plann 1993; 18: 126–9Google Scholar
- 105.Vessey MP. The Jephcott lecture, 1989, an overview of the benefits and risks of combined oral contraceptives. In: Mann RD, editor. Oral contraceptives and breast cancer. Parthenon Publishing, 1989Google Scholar
- 106.Rosenberg MJ, Meehan T. The effect of desogestrel, gestodene, norgestimate and other factors on cycle control: a meta-analysis. [abstract]. Third Congress of the European Society of Contraception, Dublin, Ireland, June 1994.Google Scholar
- 107.Fuchs N, Düsterberg B, Weber-Diehl F, et al. The effect on blood pressure of a monophasic oral contraceptive containing ethinyestradiol and gestodene. Contraception 1995. In pressGoogle Scholar
- 109.Reubinoff BE, Berry E, Grubstein A. Effects of low-dose estrogen oral contraceptives on weight, body composition, and fat distribution in young women. Fertil Steril 1905; 63: 516–21Google Scholar
- 110.Drife JO. The benefits and risks of oral contraceptives. Parthenon Publishing Group, Carnforth, Lancashire, England 1993.Google Scholar
- 111.Klitsch M. The new pills: awaiting the next generation of oral contraceptives. Farn Plann Perspect 1992; 24: 226–8Google Scholar
- 112.Konig H-J, Anagnostopoulos-Schleep J, Mewe R. Cerebrovascular disorders during intake of gestodene containing oral contraceptives — causality or coincidence? [in German]. Med Klin 1991; 86: 333–7Google Scholar
- 113.Farmer RDT, Preston TD. The risk of venous thromboembolism associated with low oestrogen oral contraceptives. J Obstet Gynaecol 1995; 15: 195–200Google Scholar
- 121.Back DJ, Tjia JF, Houlgrave R, et al. Effect of progestogens on the metabolism of ethinyloestradiol by human liver microsomes in vitro [abstract]. Br J Clin Pharmacol 1990; 30: 321PGoogle Scholar