Conséquences de la chimiothérapie anticancéreuse sur la fertilité de la femme

Sterility is a potential toxic effect of chemotherapy. This risk is well established for alkylating agents, but is less clearly defined for anthracyclines, methotrexate and fluorouracil and poorly defined for alkaloids, platinum, etoposide and taxanes. The main predictive factors for ovarian toxicity are the additive effect of cytotoxic drugs, the cumulative dose of each drug and the patient’s age. This effect of chemotherapy is evaluated on menstrual cycles, hormonal assays and the number of pregnancies observed in patient cohorts. Chemotherapy induces destruction of oocytes and granulosa cells. In mice, it has been shown that adriamycin may induce oocyte apoptosis, which can be prevented by modulation of cycle cell signalling (dysregulation of Bax gene or, on the contrary, expression of its antagonist gene Bcl-2 or inhibition of apoptosis with sphingosine-1-phosphate or caspase inhibitors). Clinical data in the literature are usually based on retrospective studies and are somewhat confused: global fertility after MOPP chemotherapy for Hodgkin’s disease is about 20%, adjuvant chemotherapy with CMF, F(A)C or TAC for breast cancer induces amenorrhea in 50% to 70% of cases, PVB or BEP chemotherapy for ovarian germ cell tumors has little effect on fertility when the uterus and one ovary can be preserved, and the majority of women treated with methotrexate, actinomycin D or various combinations for persistent trophoblastic disease remain fertile. Preservation of fertility is a major goal for cancer patients receiving chemotherapy: in vitro fertilization could preserve the couple’s fertility, but is usually not feasible as it would delay initiation of chemotherapy until after stimulation of ovulation; oocyte or ovarian tissue cryopreservation is at the stage of research; oral contraceptives have not been demonstrated to be effective to preserve ovarian function; gonadotropin releasing hormone (GnRH) agonists prevent cyclophosphamide toxicity in rat and monkey ovaries, and a few pilot clinical studies suggest that chemotherapy-induced amenorrhea could be prevented by administration of GnRH analogues simultaneously to chemotherapy, but randomised studies are necessary.     

Menstrual disorders in adolescence: pathophysiology and treatment.

Menstrual problems including amenorrhea, oligomenorrhea, irregular cycles, abnormal uterine bleeding or dysmenorrhea represent 50% of adolescents' gynecologic complaints. Irregular and anovulatory cycles are common during the first postmenarcheal years and may reflect a normal transient step of ovarian hyperandrogenism, but they may also result from hormonal abnormalities affecting the adrenals, the ovaries or the pituitary. Amenorrhea may be a sign of late puberty or of a problem affecting the hypothalamus, the pituitary or the ovaries. Evaluation includes a complete physical examination, basal hormonal determinations of the hypothalamic-pituitary-ovarian function, of the thyroid, of the androgens and of the nutritional and growth parameters. This first evaluation must be completed by a karyotype analysis in case of primary amenorrhea or by the measurements of free testosterone, androstanediol glucuronide and testosterone glucuronide in case of hirsutism, and may be followed by X-rays, echography or dynamic tests depending on the first results. Therapy will always be directed towards the etiology of the disease. Abnormal uterine bleeding is generally the result of anovulatory cycles and responds to hormonal therapy, but a systemic illness, a local pathology or a complicated pregnancy must always be excluded. In case of dysmenorrhea, endometriosis must be excluded. Simple dysmenorrhea is generally suppressed by antiprostaglandins.     

Hypertension developing in women using oral contraceptions]

Attention to the problem of hypertension in women using oral contraceptives has been increasing as the use of these preparations has increased. It is estimated that between 1-5% to 15-18% of those women using these preparations suffer from hypertension. Some sources have linked the occurrence of hypertension to a concentration of renin in the blood. It is not clear to this author, though, whether this is the result of some physiological disruption caused by the contraceptive, or caused by some other malfunction of this mechanism. The appearance of hypertension in the course of hormonal contraceptive use is considered to be an indication for the discontinuation of its use.     

Oral contraceptives and trisomy 21. A retrospective study of 730 cases (author's transl)]

A retrospective study of 730 cases of trisomy 21 and of 1 035 cases of abnormal children without a detectable chromosomal aberration, allows the study of the frequency of use of oral contraceptives by their mothers. The statistical analysis shows no notable differences for mothers 30 years old and younger. Among the mothers 30 to 38 years old, these is an excess of pill-taking by mothers of trisomy 21 children. For this second category of mothers (30 to 38 years) this excess is significant (a) when the delay between the cessation of pill-taking and the conception of the child is six months of less; (b) when the duration of pill-taking has been longer than one year; and (c), when those two factors are present simultaneously. Moreover, the frequency of males is significantly reduced in trisomy 21 children when their mothers have taken the pill. As a whole, for the subsample of mothers 30 and older, a correlation is observed between the three factors analysed, pill-taking, sex ratio, and trisomy 21. In view of the fact that decrease of the sex ratio and the increase of the frequency of trisomy 21 both are correlated with maternal aging in the general population, it seems remarkable that a correlation between these two variables and the use of oral contraceptives is observed only when the women had already passed the first of their reproduction period.     

Post-pill amenorrhea and anovulation (author's transl)]

The numerous pregnancies that occur as early as the first cycle after the discontinuation of an oral contraceptive prove that in general ovulation reappears immediately and that after a period of "rest" more or less prolonged the ovaries reasume their normal function very rapidly. However, in less than 1% of the cases the discontinuation of oral contrecption is followed by anovulation or even amenorrhea. The authors try to find an explanation to this over supression syndrome and review the different treatments that have been proposed in the bibliography, but keeping in mind that within a year 14% of the anovulations and 5% of the amenorrbeas will have disappeared spontaneously.     

Hormonal contraceptive use and mate retention behavior in women and their male partners

Female hormonal contraceptive use has been associated with a variety of physical and psychological side effects. Women who use hormonal contraceptives report more intense affective responses to partner infidelity and greater overall sexual jealousy than women not using hormonal contraceptives. Recently, researchers have found that using hormonal contraceptives with higher levels of synthetic estradiol, but not progestin, is associated with significantly higher levels of self-reported jealousy in women. Here, we extend these findings by examining the relationship between mate retention behavior in heterosexual women and their male partners and women's use of hormonal contraceptives. We find that women using hormonal contraceptives report more frequent use of mate retention tactics, specifically behaviors directed toward their partners (i.e., intersexual manipulations). Men partnered with women using hormonal contraceptives also report more frequent mate retention behavior, although this relationship may be confounded by relationship satisfaction. Additionally, among women using hormonal contraceptives, the dose of synthetic estradiol, but not of synthetic progesterone, positively predicts mate retention behavior frequency. These findings demonstrate how hormonal contraceptive use may influence behavior that directly affects the quality of romantic relationships as perceived by both female and male partners.     

Vascular dysfunction as a cause of endometrial bleeding

Introduction.?Heavy menstrual bleeding (HMB) and the spotting and bleeding (S/B) associated with the use of hormonal contraceptives are distinct entities affecting endometrial vasculature and hemostasis. Materials and methods.?An overview of the major etiologies and potential treatments for each condition is provided. Results.?HMB is potentially caused by several different hemostatic dysfunctions. Combination oral contraceptives, levonorgestrel-releasing intrauterine system, non-steroidal anti-inflammatory drugs, and anti-fibrinolytics all have been shown to have some degree of efficacy in treating HMB. The basic cause of HMB is unknown in the majority of cases. Endometrial S/B related to hormonal contraceptives is a common occurrence and may well have a common etiology in altered angiogenesis resulting in abnormal blood vessels with fragile vessel walls. There is no effective treatment for this problem. Conclusions.?Medical therapy for HMB is limited and effective for reducing blood loss during menstruation. There is no effective treatment for the S/B associated with hormonal contraceptives.     

Butterfly phenology in Mediterranean mountains using space‐for‐time substitution

Inferring species' responses to climate change in the absence of long‐term time series data is a challenge, but can be achieved by substituting space for time. For example, thermal elevational gradients represent suitable proxies to study phenological responses to warming. We used butterfly data from two Mediterranean mountain areas to test whether mean dates of appearance of communities and individual species show a delay with increasing altitude, and an accompanying shortening in the duration of flight periods. We found a 14‐day delay in the mean date of appearance per kilometer increase in altitude for butterfly communities overall, and an average 23‐day shift for 26 selected species, alongside average summer temperature lapse rates of 3°C per km. At higher elevations, there was a shortening of the flight period for the community of 3 days/km, with an 8.8‐day average decline per km for individual species. Rates of phenological delay differed significantly between the two mountain ranges, although this did not seem to result from the respective temperature lapse rates. These results suggest that climate warming could lead to advanced and lengthened flight periods for Mediterranean mountain butterfly communities. However, although multivoltine species showed the expected response of delayed and shortened flight periods at higher elevations, univoltine species showed more pronounced delays in terms of species appearance. Hence, while projections of overall community responses to climate change may benefit from space‐for‐time substitutions, understanding species‐specific responses to local features of habitat and climate may be needed to accurately predict the effects of climate change on phenology.     

Vitamin A,Pregnancy, and Oral Contraceptives

It has been shown that women receiving oral contraceptives have increased levels of serum vitamin A. High vitamin A levels may constitute a teratogenic hazard and it has been suggested that women who conceive soon after discontinuing oral contraceptive therapy may be especially at risk to this hazard.We have confirmed a significant increase in vitamin A levels in women taking oral contraceptives. During early pregnancy there is no significant difference in vitamin A levels between women who have recently been taking oral contraceptives and those who have not. We have been unable to show that either taking oral contraceptives shortly before pregnancy or a high vitamin A level during the first trimester of pregnancy, comparable to that of a woman taking oral contraceptives, has any detrimental effect on the outcome of pregnancy. It seems unlikely that women who conceive soon after discontinuing oral contraception run any teratogenic risk from increased vitamin A levels.     

Involuntary movements in patients taking oral contraceptives

Involuntary movements developed in five women taking oral contraceptives. In one, the sudden onset of a unilateral disturbance suggested a cerebral thrombosis; this case is considered to be a further example of the increased risk of cerebrovascular disease associated with oral contraception. The four other patients suffered a relapse of Sydenham''s chorea between one and four months after starting an oral contraceptive regimen. Possibly an underlying vascular mechanism was responsible for these relapses.     

Reproductive and external hormonal factors and the risk of renal cell cancer in the Netherlands Cohort Study

BackgroundSeveral reproductive and hormonal factors, like age at menarche, parity, age at menopause, use of oral contraceptives and postmenopausal treatment, have been associated with the risk of renal cell cancer (RCC) in women, but results have not always been consistent. We therefore investigated the association between these factors and the risk of RCC in postmenopausal women participating in the Netherlands Cohort Study on Diet and Cancer.MethodsInformation on reproductive history, exogenous hormone use and gynecological surgery was obtained through a self-administered questionnaire at baseline in 1986. After 20.3 years of follow-up, 204 cases and 2280 subcohort members were available for case-cohort analysis. Multivariable hazard ratios (HR) were calculated using Cox Proportional Hazard analysis.ResultsWomen who reported a hysterectomy had an increased RCC risk compared to women who did not (HR, 1.42, 95%CI, 1.01–2.00). Women with a natural age at menopause between 45 and 49 years compared to 50–54 years had an increased RCC risk (HR, 1.61; 95%CI, 1.10–2.35). RCC risk was slightly and not statistically significant increased among parous women with three or more children and age at first birth before 25 years compared to nulliparous women (HR, 1.36; 95% confidence interval (CI), 0.84–2.20). No associations were observed with RCC risk for age at menarche, use of oral contraceptives and use of hormonal replacement therapy.ConclusionHysterectomy and age at natural menopause were associated with an increased RCC risk. Other hormonal and reproductive factors and RCC risk were not increased. Further studies are required to establish the mechanism(s) that explain the observed association.     

Cellular composition of cervical smears in relation to the day of the menstrual cycle and the method of contraception

The influence of the day of the menstrual cycle and the method of contraception on the cellular composition of cervical smears was investigated. The percentage of unsatisfactory smears during the first four days of the cycle was understandably very high, leaving only 80% of the smears of sufficient quality for cytologic diagnosis. The percentage of smears of insufficient quality during the remainder of the cycle was significantly higher in women using oral hormonal contraceptives. The percentages of smears containing endocervical columnar cells, a criterion for judging smears to be of high quality, differed significantly among women using different modes of contraception. The highest percentage of smears without endocervical columnar cells was found in women using oral contraceptives; during the first half of the cycle in these women, smears were of higher quality than during the second half of the cycle. In women not practicing contraception or using nonhormonal methods of contraception, the differences in cellular composition during the cycle, though significant, were too small to be of practical importance. Women using oral contraceptives thus have an increased risk for a potential false-negative diagnosis because of the higher percentage of smears of unreliable quality taken in these women. In women using oral hormonal contraceptives, smears should be taken during the first half of the cycle because of the higher percentage of smears of high quality in that period.     

Oral Contraceptives and Female Mortality Trends

Death rates for Ontario females aged 15 to 44 during the years 1959-61 and 1966-68 have been compared to see if there have been any changes in these rates which might be related to the widespread use of oral contraceptives since 1961. Overall mortality (all causes) has declined significantly during this time, as have the rates for deaths due to child-birth and pregnancy, and from cancer of the uterus. Death rates from ischemic heart disease and cancer of the breast have not shown any significant change, but there has been a substantial increase in the rates ascribed to venous thromboembolism and suicide.It must be stressed that a change in the recorded death rate does not necessarily mean that there has been a corresponding change in the incidence of the disease in question, or that such a change is related to the use of oral contraceptives. However, if oral contraceptives do cause an increase in a fatal disease, the effect should show up, sooner or later, in routine mortality statistics, and periodic examination of death rates may therefore provide a useful starting point for more detailed epidemiological investigation.To assist physicians in counselling patients, a diagram has been prepared showing the relative importance of some selected causes of death in females aged 15 to 44, and the extent to which these death rates have changed since the introduction of oral contraceptives.     

Estimate of Venous Thromboembolism and Related-Deaths Attributable to the Use of Combined Oral Contraceptives in France

Purpose

To estimate the number of venous thromboembolic events and related-premature mortality (including immediate in-hospital lethality) attributable to the use of combined oral contraceptives in women aged 15 to 49 years-old between 2000 and 2011 in France.

Methods

French data on sales of combined oral contraceptives and on contraception behaviours from two national surveys conducted in 2000 and 2010 were combined to estimate the number of exposed women according to contraceptives generation and age. Absolute risk of first time venous thromboembolism in non-users of hormonal contraception and increased risk of thromboembolism in users vs. non-users of hormonal contraception were estimated on the basis of literature data. Finally, immediate in-hospital lethality due to pulmonary embolism and premature mortality due to recurrent venous thromboembolism were estimated from the French national database of hospitalisation and literature data.

Results

In France, more than four million women are daily exposed to combined oral contraceptives. The mean annual number of venous thromboembolic events attributable to their use was 2,529 (778 associated to the use of first- and second-generation contraceptives and 1,751 to the use of third- and fourth-generation contraceptives), corresponding to 20 premature deaths (six with first- and second-generation contraceptives and fourteen with third- and fourth-generation contraceptives), of which there were eight to nine immediate in-hospital deaths. As compared to the use of first- and second-generation contraceptives, exposure to third- and fourth-generation contraceptives led to a mean annual excess of 1,167 venous thromboembolic events and nine premature deaths (including three immediate in-hospital deaths).

Conclusions

Corrective actions should be considered to limit exposure to third- and fourth-generation contraceptives, and thus optimise the benefit-risk ratio of combined oral contraception.     

Postoperative Thromboembolism and the Use of Oral Contraceptives

We have previously reported the results of a retrospective study of the relationship between oral contraceptives and deep vein thrombosis and pulmonary embolism occurring in the absence of an evident predisposing cause. The present paper describes a similar investigation of the relationship between oral contraceptives and thromboembolism following certain surgical procedures.Of 30 patients with thromboembolism, 12 (40%) had been using oral contraceptives during the month preceding surgery, while only 9 of 60 matched controls (15%) had been doing so. From these data it is estimated that the risk of postoperative thromboembolism is increased threefold to fourfold by the use of contraceptive steroids.It is recognized that few of the episodes of deep vein thrombosis and pulmonary embolism that occur postoperatively are detectable clinically, and that not all of these are recorded in discharge summaries or diagnostic indexes. Despite these considerations, we have been unable to detect any important bias in the data which could account for the observed association between oral contraceptives and the development of postoperative thromboembolism.     

Ovarian neoplasms,functional ovarian cysts,and oral contraceptives.

The incidence of ovarian neoplasms and functional ovarian cysts diagnosed at laparotomy or laparoscopy among the 17,000 women taking part in the Oxford Family Planning Association contraceptive study was investigated. Epithelial cancer of the ovary was only 25% as common among those who had ever taken oral contraceptives as those who had never done so (95% confidence interval 8% to 67%). There was little evidence of any important association between use of oral contraceptives and benign teratoma or cystadenoma. Functional cysts of the ovary occurred much less commonly in women who had recently (in the six months preceding diagnosis) taken combined oral contraceptives (but not in those who had taken progestogen only oral contraceptives) than in those who had never taken oral contraceptives or had taken them in the past. This protective effect was more pronounced for corpus luteum cysts (78% reduction; 95% confidence interval 47% to 93%) than for follicular cysts (49% reduction; 95% confidence interval 20% to 70%). It is estimated that about 28 (95% confidence interval 16 to 35) operations for functional ovarian cysts are avoided among every 100,000 women who take oral contraceptives each year.     

Shifts in gonadotropin and steroid levels that precede anestrus in female golden hamsters exposed to a short photoperiod

Female golden hamsters exposed to short photoperiods become anestrous and exhibit daily surges of gonadotropins and progesterone. Since little is known about the transition between the cycling and anovulatory states, the following experiments were done to determine whether there are hormonal changes that precede cessation of estrous cyclicity. Females killed on the morning of estrus, up to the tenth estrous cycle in short days, showed no hormonal or ovarian morphologic evidence of changes in reproductive function. When assessed on the afternoon of estrus, however, serum levels of luteinizing hormone and progesterone increased significantly before vaginal and ovarian cyclicity ceased. Females sampled in both the morning and afternoon at increasing durations since their last vaginal estrus revealed that maximal daily surges of both gonadotropins and progesterone were not consistently manifested until the vaginal cycle had been absent for 2 weeks. By then, estrogen levels and uterine weights were low and ovaries showed hypertrophied interstitia and arrested follicular growth. We have demonstrated that there are hormonal changes in females before the loss of the vaginal cycle and onset of major daily hormonal surges. Our results suggest that alterations in feedback relationships between steroid hormones and gonadotropins may precede photoperiod-induced anestrus.     

Pregnancy induced hypertension: evidence for increased cell membrane permeability to sodium.

In a cross sectional study of 137 women of childbearing age (16-40) the effects of normal pregnancy, hypertensive pregnancy, and oral contraceptives on red cell electrolyte content and sodium efflux rates were examined and the results compared with values in a control group of normotensive, non-pregnant women. Efflux rate constants were significantly increased in normotensive pregnancy and in women taking oral contraceptives. This was associated with a significant increase in sodium permeability in the contraceptive group. A much larger increase in sodium permeability and efflux rate constant was seen in the hypertensive group. The results permit a hypothesis that the hormonal changes induced by pregnancy and oral contraceptives increase membrane permeability to sodium and stimulate sodium efflux. The rise in blood pressure associated with use of oral contraceptives may have a similar aetiology to that occurring in pregnancy induced hypertension.     

Epidemiology of endometriosis in women attending family planning clinics.

OBJECTIVE--To describe the epidemiology of endometriosis in women attending family planning clinics with special reference to contraceptive methods. DESIGN--Non-randomised cohort study with follow up of subjects for up to 23 years. Disease was measured by first hospital admission rates since endometriosis can be diagnosed with accuracy only at laparotomy or laparoscopy. SETTING--17 family planning centres in England and Scotland. SUBJECTS--17,032 married white women aged 25-39 years at entry during 1968-74 who were taking oral contraceptives or using an intrauterine device or diaphragm. About 99% of the women approached agreed to participate and annual loss to follow up was about 0.3%. MAIN OUTCOME MEASURES--Diagnosis of endometriosis, age, parity, and history of contraceptive use. RESULTS--Endometriosis was significantly related to age, peaking at ages 40-44 (chi 2 for heterogeneity = 30.9, p < 0.001). Endometriosis was not linked to duration of taking oral contraceptives. Nevertheless, the risk of endometriosis was low in women currently taking oral contraceptives (relative risk 0.4; 95% confidence interval 0.2 to 0.7), but higher in women who had formerly taken them (1.8; 1.0 to 3.1 in women who had stopped 25-48 months previously) compared with women who had never taken the pill. A similar pattern was seen for use of intrauterine devices (relative risk 0.4 (0.2 to 0.7) in current users and 1.4 (0.4 to 3.2) in users 49-72 months previously compared with never users). No association was found between endometriosis and use of the diaphragm. CONCLUSIONS--Oral contraceptives seem to temporarily suppress endometriosis. Endometriosis may be diagnosed late in women using intrauterine devices as pain and bleeding occur with both.     

Hormonal Contraception and the Risk of HIV Acquisition: An Individual Participant Data Meta-analysis

BackgroundObservational studies of a putative association between hormonal contraception (HC) and HIV acquisition have produced conflicting results. We conducted an individual participant data (IPD) meta-analysis of studies from sub-Saharan Africa to compare the incidence of HIV infection in women using combined oral contraceptives (COCs) or the injectable progestins depot-medroxyprogesterone acetate (DMPA) or norethisterone enanthate (NET-EN) with women not using HC.ConclusionsThis IPD meta-analysis found no evidence that COC or NET-EN use increases women’s risk of HIV but adds to the evidence that DMPA may increase HIV risk, underscoring the need for additional safe and effective contraceptive options for women at high HIV risk. A randomized controlled trial would provide more definitive evidence about the effects of hormonal contraception, particularly DMPA, on HIV risk.