CONTRACEPTION

TRANSIENT REDUCTION IN SERUM HDL-CHOLESTEROL FOLLOWING MEDROXY- PROGESTERONE ACETATE AND TESTOSTERONE CYPIONATE ADMINISTRATION TO HEALTHY MEN

Karl E. Friedl, Stephen R. Plymate and C. Alvin Paulsen

Department of Clinical Investigation, Madigan Army Medical Center, Tacoma, WA 98431 and Pacific Medical Center, University of Washington, Seattle, WA 98114, USA

ABSTRACT

Serum lipids were examined in thirty normal male volunteers who had received depo-medroxyprogesterone acetate (DMPA) and testosterone cypionate (TC) in a male contraceptive trial. Progestagens have been implicated in the changes in serum lipids observed in women using oral contraceptives and this has led to concern about cardiovascular health risks associated with the long-term use of some of these preparations. The following study was done to determine if similar effects occur in men. The men in this study were divided into three DMPA dose groups (50, 100, 200 mg/month) and received intramuscular injections for six months; all men received 250 mg/month TC. There was no significant change in serum high density lipoprotein-cholesterol (HDL-C) levels during the six months of drug administration when compared to levels in the control period. However, there was a marked decrease in HDL-C during the first three months after discontinuation of the drugs (p < 0.02). This observed change was consistent in each of the three DMPA dose groups but no dose relationship was observed. There was no statistically significant change in serum concentrations of total cholesterol, low density lipoprotein-cholesteroi, triglycerides insulin in any period of the experiment. Serum testosterone (T;)f estradiol, and sex hormone binding globulin (SHBG). luteinizing hormone (LH), and follicle stimulating hormone (FSH) concentrations were all significantly depressed during the drug administration period. A progestagen dose relationship was observed only for the decrease in serum testosterone and LH concentrations, Serum T and SHBG levels were still significantly reduced at 4-6 months after cessation of the drug administration. These findings demonstrate that DMPA can cause a reduction in serum HDL-C levels. It is suggested that HDL-C concentrations fell only following DMPA withdrawal as a consequence of steroid hormone changes specific to this period.

Submitted for publication November 8, 1884 Accepted for publication April 4, 1985

APRIL 1985 VOL. 31 NO. 4 409

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INTRODUCTION

Androgens, estrogens, and certain progestational agents are known to influence serum HDL-C levels in men and conen (l-9). Other factors which influence HDL-C include body weight, smoking, age, alcohol

consumption, and exercise (10-12). Recent evidence indicates that progestagens used in oral contraceptives reduce HDL-C in women (1). While much attention has been given to the effects of androgens and estrogens, the effects of progestagens in men have generally been overlooked. In view of the relationship between reduced plasma HDL-C levels and cardiovascular disease in men, a reduction in HDL-C similar to that seen in women could have significant health implications for any contraceptive agents that include a progestational compound (13,14).

Most of the evidence for steroid-induced changes in plasma lipids is based on correlation studies which have examined simple relationships between endogenous steroid and plasma lipids (2,3). Few studies have examined the direct effects of steroid administration on serum lipids. Early studies have shown that the higher endogenous androgen levels are associated with higher HDL-C levels (2,3). Paradoxically, exogenous androgen administration decreases HDL-C levels rather dramatically

(495). In terms of F :trogen administration, such steroids are generally reported to increase HDL-C but, again, paradoxically, endogenous estrogens appear to interact with androgens to decrease HDL-C (6). Therefore, the contributions of the individual components in the

steroid-induced HDL-C changes are not clear. In women, progestagen administration by itself decreases HDL-C levels (7). Furthermore, changes in progesterone and HDL-C levels during the menstrual cycle suggest that progesterone may have a suppressive effect on HDL-C (8). There are no published studies describing the effects of progestagens alone or in combination with other steroids on serum lipids in men.

The current interest in male contraceptive research using

progestagen-androgen combinations (15.16) has led to the question of

whether or not any alteration in plasma lipids occurs. The following study of serum lipids in normal men exposed to depo-medroxyprogesterone acetate (DMPA) and testosterone cypionate (TC) was undertaken to examine this question.

METHODS

Data from thirty men who volunteered for a study of DMPA and TC

male contraceptive treatments were originally examined in terms of seminal fluid analysis, serum hormone levels and clinical effects. For details, with respect to the seminal fluid changes and the clinical observations, the reader is referred to previous publications (15,16).

The frozen serum samples were later analyzed for HDL-C and total cholesterol levels. After signing a consent form, each volunteer had undergone a complete physical examination. All were in good health with no history of coronary artery disease, peripheral vascular disease or

hypertension. Blood samples were drawn monthly for three months prior

410 APRIL 1985VOL.31N0.4

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to drug administration. Subjects were then randomized to one of three

drug dose groups and given intramuscular injections of DMPA and TC once

monthly for six months. Group 1 received 50 mg DMPA t 250 mg TC, Group

2 received 100 mg D>lPA t 250 mg TC, and Group 3 received 200 mg DNPA t

250 mg TC. Blood samples were collected monthly during this drug administration period, just prior to the next injection. Following drug administration, blood sampling was continued for six months. Each blood

sample was obtained after a minimum of 12 hours fasting. Samples were stored undisturbed at -20 "C in tightly sealed containers for up to four years before analysis.

Total cholesterol (CHOL) was measured using an enzymatic assay and

IIDL-C was measured by the same method after precipitation of LDL and VLDL with phosphotungstate-Yg2+ (17). The reagents used were obtained

from Sigma Diagnostics (St. Louis, MO). Serum triglycerides were measured using an enyzmatic method with a system manufactured by Smith- Kline Laboratories (Philadelphia, PA). LDL-cholesterol (LDL-C) was calculated using the formula: LDL-C = [CHOL - (HDL-C t TRIG/5)]. This

method of estimation is reported to correlate well with direct LDL-C analyses when serum triglyceride levels do not exceed 400 mg/dl (18).

Serum testosterone (T), estradiol (E2), luteinizing hormone (LH), and follicle stimulating hormone (FSH) were measured as previously

described (19.20). Sex hormone binding globulin (SHBG) was measured by the DHT-dextran-coated charcoal saturation analysis method previously

reported (19). 17a-Hydroxyprogesterone (17aOHP) was measured using a double antibody KIA with reagents from Radioassay Systems Labs, Inc.

(Carson, CA). The intra- and inter-assay coefficients of variation for

the latter assay were 9.2 and 10.6%, respectively. Insulin levels were measured by radioimmunoassay (Cambridge Nuclear Radiopharmaceutical

Corp., Billerica, MA).

The mean age of the subjects was 31.3 ~6.5 (sd) years, with a

range from 22 to 52 years. There were six smokers distributed between

the dose groups with one cigar smoker and the other five consuming l/2 to 1 pack of cigarettes per day. Body weights averaged 79 +lO (sd) kg

at the beginning of the experiment. At the end of the drug administration period, body weights reflected increases of l-3% over the control period weights.

Statistics were performed using the SPSS statistics program (Fort Detrick, MD). Data were analyzed for any differences between treatment

periods and between dose groups in a hierarchical stepdown analysis of variance (ANOVA). controlling for body weight and smoking as covariates. Where significance was detected by ANOVA, the data were further analyzed by Duncan's multiple range test. This was done within individual DFIPA

dose groups only if there were significant differences indicated by group in the ANOVA. Where no significant dose difference was indicated, the test was applied to the groups collectively. Testosterone and HDL-C monthly values were displayed as a smoothed, three-point running mean. This was done by averaging the monthly values with the two neighboring monthly values. The values were then normalized as percentages of the control mean value for each dose group.

APRIL1985 VOL.31 NO.4 411

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RESULTS

Changes in plasma HDL-C concentrations are illustrated for each dose

group in Figure 1. There was no statistically significant difference between HDL-C control values and values during drug administration; however, HDL-C did fall significantly (p < 0.02) during the first three months of the post-drug administration period (Table I). LDL-C, triglycerides, and total cholesterol were not significantly altered during or after drug administration. Serum insulin also did not change during or following DMPA administration, when compared to control ValUE5.

Serum testosterone levels decreased as expected during DMPA administration (Figure 2). These decreases from control levels were dose related: i.e. changes of -47%, -62%, and -70% were observed for Group 1, Group 2, and Group 3, respectively (p < 0.01). Significant decreases in estradiol (-42%) and 17a-hydroxyprogesterone (-60%) levels were also noted but there was no clear dose relationship (Table II).

DRUG ADMINISTRATION

70-1 o- 012345

RECOVERY

- GROUP 1 t--d GROUP 2 .-e...- GROUP 3

I I I I 1 I 123456

Months

Figure 1. Changes in serum HDL-C levels during DWA + 'TC clinical trials.

412 APRIL 1985 VOL. 31 NO. 4

TABLE I. SERUM HDL-C, LDL-C AND TRIGLYCERIDE LEVELS DURING DMPA + TC CLINICAL TRIAL

Group I

Control

Drllg

Post-Drug Administration

Administration

l-3 Months

4-6 Months

HDL-C (mg/dl)

53 k 16

46 + 16

43 * 19

46 + 14

LDL-C (mg/dl)

133 f 50

97 t 52

94 i 108

141 + 53

Triglycerides

(mg/dl)

85 i 54

73 k 39

80 + 86

74 f 49

Group 2

HDL-C (mg/dl)

48 k 16

43 2 19

32 + 10

44 * 19

LDL-C (mg/dl)

120 * 21

135 5 37

139 2 71

150 + 42

Triglycerides

(mg/dl)

70 i- 39

87 t 70

147 5 116

80 2 73

Group 3

HDL-C (mg/dl)

62 * 27

60 * 24

38 +_ 9

61 + 39

LDL-C (mg/dl)

108 T 35

140 i 36

131 + 84

140 + 55

Triglycertdes

(mg/dl)

69 k 47

72 + 32

75 t 48

94 + 51

- _-

All Groups

HDL-C (mg/dl)

55 + 20

48 + 19

* 38 t 15

50 t 27

LDL-C (mg/dl)

120 + 73

121 + 73

116 -' 92

144 t 46

Triglycertdes

(mg/dl)

76 i 47

78 i 50

104 ? 83

83 + 58

Values represent

means + standard deviations.

*

Values are significantly

different

from control values (p <0.05, Duncan's multiple

range test).

Normal

HDL-C

ranges:

(28 - 72 mg/dl);

LDL-C (97 - 160 mg/dl); Triglycerides

(50 - 150 mg/dl).

TABLE II.

SERUM TES'I'OSTERONE, ESTRADIOL

AND SHBG LEVELS DURING DMPA + TC CLINICAL

TRIAL

z U

P

Group 1

Testosterone

(ng/ml)

Estradiol

(pg/ml)

SHBG (ng DHT bound/ml)

Group 2

Testosterone

(ng/ml)

Estradiol

(pg/ml)

SHBG (ng DHT bound/ml)

Group 3

Testosterone

(ng/ml)

Estradiol

(pg/ml)

SHBC (ng DHT bound/ml)

Control

5.5 + 1.7

31 + 17

8.0 f 3.3

7.3 + 1.9

35 t 17

11.5 f 5.6

5.6 i 1.8

37 + 17

7.1 t 4.0

hug

Administration

*2.9 t 1.7

* 21 r 11

6.9 2 3.0

t2.8 + 1.9

* 19 _+ 12

*8.2 + 4.6

*1.7 + 1.8

*18+9

*4.9 i 3.1

Post-Drug

Administration

l-3 Months

4-6 Months

"3.9 + 1.1

5.9 + 2.0

*20?

9

38 + 22

7.3 + 1.8

5.5 * 2.1

*5.0 i 2.2

*4.9 f 1.8

*19i9

28 t 14

10.5 -t 6.5

*6.4 + 2.7

*2.3 + 1.0

*3.9 i 1.4

40 '- 30

31 ? 14

*3.0 -' 1.4

7.3 + 3.1

All Groups

Testosterone

(ng/ml)

6.1 2 2.5

*2.5 + 1.3

*4.0 t 1.7

*4.9 + 1.9

Estradiol

(pg/ml)

35 + 17

* 20 + 11

* 23 -' 16

33 ? 17

SHBG (ng DHT bound/ml)

9.0 + 4.5

*6.7 + 3.8

7.1 k 4.7

*6.4 k 2.7

Values represent means + standard deviations.

*

Values are significantly

different

from control values (p <0.05, Duncan's multiple

range test).

Normal

Testosterone

(2.4 -

ranges:

15.0 ng/ml); Estradiol

(5 - 50 pg/ml);

SHBG (3 - 12 ng/ml).

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DRUG

140 ADMINISTRATION

1

01 01 2345

RECOVERY

*---* GROUP 2 . . . . . . . . . GROUP 3

Months Firlure 2. 7 Changes in serum testosterone levels during DHPA + TC clinical trials.

Serum testosterone. estradiol, and 17a-hydroxyprogesterone were all fOUIld to be significantly lower in the early post-drue exposure period. These changes persisted throughout the first three months of that period. During the second three months post-drug administration, the mean values for testosterone approached but did not reach control levels (Table II). The changes in serum 17a-hydroxyprogesteronc matched the changes seen for testosterone throughout the course of the study.

Finally, serum I,fl, FSH, and SILEG levels also decreased during drug administration (Table II and Table 111). Only LH demonstrated a D!LPA dose relationship (p < 0.01).

This study shows that when D’IPA and TC were administered monthly, ;ii)L,-C levels were not affected during the druo, treatment but, to our surprise, L!DI,-C levels fell by approximately 1% of control values within 60 days after the last combination injection. This drop was transj ent in nature and increased towards control values in all three dose groups within 150 days after final drug administration (Figure 1).

APRIL 1985 VOL. 31 NO. 4 415

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416 APRIL 1985 VOL. 3 1 NO. 4

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On the basis of past studies in women, we had considered that DMPA

administration to men might lead to a decrease in HDL-C but this did not happen during drug administration. The absence of change in HDL-C concentrations during drug administration might be explained in terms of

opposing influences of high levels of progestagen and decreased androgen concentrations. The inverse relationship between androgen and !IDL-C concentration previously observed in men treated with androgen tends to

support this suggestion (4.5). On the other hand, the simple positive association between endogenous androgen and HDL-C levels which has been reported (2,3) is in conflict with these reports and with more recent

studies which employed multivariate analyses (9). While the monthly

administration of 250 mg of TC in our study would be expected to enhance any progestagen-induced decrement in HDL-C, TC at these dose levels has been shown to influence plasma androgen levels for only lo-12 days (21).

During this study, blood was drawn at monthly intervals 30 days after

each TC injection. Thus, it is unlikely that there was any resjdual TC effect on serum HDL-C concentration since the half-life of this lipid is

quite short (22). Therefore, we suggest that the simultaneous

suppression of androgen levels compensated for any direct effect that DMPA night have had on HDL-C levels.

The significant decline in HDL-C seen only after cessation of the D:dPA and TC administration is difficult to explain. Similar regimens of DMPA have resulted in measurably elevated plasma levels of

medroxyprogesterone acetate for up to 4-6 months past injection (23,24). Thus, DMPA exerts its effect for a prolonged period and this is substantiated in our study by the continued suppression of serum FSH, Lfi

and T levels. Thus the prolonged effect of DMPA which is still present

while endogenous testosterone is gradually beginning to rise might be responsible for the transient but significant drop in IIDL-C levels

during the first three months of the post-injection period.

Unfortunately, serum levels of DMPA were not measured in our volunteers.

Furthermore, a group of men receiving DMPA alone should be studied.

Recent studies with 14 days administration of DMPA alone to a group of

normal men showed that during the short period of drug exposure, no decrease in HDL-C occurs (25).

To summarize, the administration of DMPA and TC in this study scheme did not change serum LDL-C or IIDL-C significantly. However, a

significant decrease in HDL-C was seen during the early post-drug administration period. Whether this change in HDL-C was due to prolonged DMPA exposure or is unique to the early withdrawal period, when DMPA is still present but endogenous testosterone is still low but increasing, cannot be determined.

ACKNOWLEDGEMENTS

The authors express their gratitude to Elaine Kost, Kathy Hellum, Troy Patience, and Eugenia Hough for their individual technical assistance in data analysis and in the manuscript preparation.

The original study (15,lh) was performed with the assistance of a Grant-in-Aid from the UpJohn Company, Kalamazoo, Michigan, USA.

APRlL 1985 VOL. 3 1 NO. 4 417

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Financial support provided for the lipid studies by the Task Force on

the Regulation of Male Fertility of the World Health Organization (H9/445/20/AC) and by the National Institute of Child Health and flriman Development (P50 HD12629) is gratefully acknowledged.

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.

1.

2

3.

4.

5.

6.

7.

8.

9.

Wahl.P., Wal potency on 1

(1983).

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