SERUM COPPER AND ZINC IN HORMONAL CONTRACEPTIVE USERS

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1 FERTILITY AND STERILITY Cpyright 1980 The American Fertility Sciety Vl. 33, N.3, March 1980 Printed in U.8A. SERUM COPPER AND ZINC IN HORMONAL CONTRACEPTIVE USERS KRISHNAMURTHY PREMA, M.D., M.N.A.M.S.* BARU ANANTHA RAMALAKSHMI, M.B.B.S., D.G.O. SOMA BABU, M.Sc., PH.D. Natinal Institute f Nutritin, Indian Cuncil f Medical Research, Hyderabad , India There has been a grwing awareness f pssible alteratins in the trace element prfiles f hrmnal cntraceptive users and their cnsequences. A study f serum cpper and zinc levels' in users f cmbined estrgen-prgestgen cntraceptives and in users f injectable prgestgen was undertaken. Use f cmbined estrgen-prgestgen cntraceptives resulted in a significant decrease in serum zinc levels within 3 days and an increase in serum cpper levels within 10 days. In users f cmbined estrgen-prgestgen cntraceptives the magnitude and time f ccurrence f the decrease in zinc levels and the increase in cpper levels was unaltered by chemical cmpsitin, dsage, rute f administratin, and duratin f use beynd 3 mnths. With injectable prgestgen (nrethindrne enanthate, 20 mg/mnth), a significant decrease in serum zinc levels ccurred within 24 hurs after injectin. Serum cpper levels were nt altered. With injectable prgestgen, the type f drug, the dsage, and the duratin f use beynd the 1 st mnth had n effect n the magnitude f the decrease in serum zinc levels. Fertil Steril33:267, 1980 There has been grwing interest in recent years abut alteratins in varius metablic prcesses and trace element prfiles assciated with the use f hrmnal cntraceptives. The results f several studies have shwn that in wmen using cntraceptives which cntain bth estrgen and prgestgen, serum cpper levels are high, althugh the magnitude f elevatin varies cnsiderably.l-io In the case f zinc, there is n cnsensus abut either the directin f alteratin r the extent f change in cmbinatin pill users.5, 6, 8-11 Data n serum cpper and zinc levels in wmen using injectable prgestgens are meager and cnflicting Sme f these differences may be due t the small number f wmen studied, variatin in the cmpsitin f the pill, duratin f use f the drug, and differences in the methds emplyed fr determinatin f trace elements. It has als been suggested that sme f the variatn might be due Received September 4, 1979; accepted Octber 24, *Reprint requests: K. Prema, M.D., Natinal Institute f Nutritin, Indian Cuncil f Medical Research, Jamai Osmania P.O., Hyderabad , India. 267 t ethnic and nutritinal differences. 7 A study was therefre undertaken t evaluate changes in serum cpper and zinc levels in undernurished Indian wmen using different hrmnal cntraceptives. MATERIALS AND METHODS The effects f cmbined estrgen-prgestgen cntraceptives and prgestatinal cntraceptives n serum cpper and zinc levels were studied. The different types f estrgen-prgestgen cntraceptives studied included the fllwing: (1) cmbinatin pills cntaining 150 f.lg f d-nrgestrel and 30 r 50 f.lg f ethinylestradil (cmbinatin pill); (2) injectins f dihydrprgesterne acetphenide, 100 mg, and estradil enanthate, 5 mg (injectable DHPA + EE); (3) intravaginal rings cntaining d-nrgestrel, 60 t 78 mg, and estradil 30 t 40 mg (IV ring); (4) tw injectable prgestgenepmedrxyprgesterne acetate, 150 mg/3 mnths (DMPA), and nrethindrne enanthate, 20 mgt mnth (NET). The study cnsisted f a lngitudinal cmpnent

2 268 PREMAETAL. TABLE l. Serum and Levels in Wmen Using Hrmnal Cntraceptives (Crss-Sectinal Study) Grup N. f Serum cpper" Serum zinca wmen WIldl WJldl Cntrl ± ± 18.6 Cmbinatin pill, ± ± m f use Cmbinatin pill, ± ± m f use Injectable DMPA ± ± 16.4 NET ± ± 19.6 avalues are means ± standard deviatin. Statistical analysis (, nt significant): Cmpared Cntrl vs. cmbinatin pill (6 m + 12 ml Cmbinatin pill 6 m vs. ;;;.12 m Cntrl VS. DMPA Cntrl vs. NET NETvs. DMPA P < P < P < P < and a crss-sectinal cmpnent. The crss-sectinal study grup cnsisted f 148 wmen nt using any cntraceptin; 150 wmen using a cmbinatin pill, injectable DHPA + EE, r an IV ring; 17 wmen using DMPA; and 22 wmen using NET. The lngitudinal study cnsisted f tw parts. In the first part, serum cpper and zinc levels were serially estimated twice weekly fr 4 weeks in six wmen nt using any cntraceptin, in fur wmen using a cmbinatin pill, in five wmen using an IV ring, in five wmen using injectable DHPA + EE, and in six wmen using NET. In the secnd part, serial estimatins f cpper and zinc levels were btained at 1, 3, 6, and (when pssible) 12 mnths f use in a grup f 42 wmen using a cmbinatin pill, 5 wmen receiving injectable DHPA + EE, 5 wmen using an IV ring, 12 wmen receiving NET, and 6 wmen nt receiving any frm f cntraceptin wh served as cntrls. All bld samples were btained between 9 and 11 A.M. t minimize pssible diurnal variatins. Separated sera were frzen at - 20 C until analyzed. Sera were diluted in 8% n-butanl. Serum cpper and zinc levels were estimated by using a Varian Techtrn mdel 1000 atmic absrptin spectrphtmeter accrding t the methd described by Henkin.14 RESULTS Nn-Oral Cntraceptive users (Cntrl Grup). The mean serum cpper level in the cntrl grup March 1980 was 111 ± 16.5 IJ-g/dl and the mean serum zinc level was 110 ± 18.6 IJ-g/dl (Table 1). Bth cpper and zinc levels varied cnsiderably between individuals (range fr cpper, 72 t 149 IJ-g/dl; fr zinc, 81 t 141 IJ-g/dl). Paired t-tests f serial serum cpper and zinc values shwed that there were n significant day-t-day r mnth-t-mnth variatins in the same subject (Tables 2 and 3). Cmbined Estrgen-Prgestgen Cntraceptive Users. Irrespective f the drug, dse, and rute f administratin, the use f cmbined estrgenprgestgen cntraceptives resulted in an increase in serum cpper levels and a decrease in serum zinc levels (Table 1). Serial estimatin f serum cpper levels shwed that a significant increase ccurred within 10 days after starting the cntraceptive, and levels cntinued t increase until day 25 (Table 2). The highest cncentratins were btained at the end f 3 mnths (Table 3). Use f these cntraceptives beynd 3 mnths up t a perid f 18 mnths did nt result in any further increase in serum cpper levels (Tables 1 and 3). Serum zinc levels decreased significantly within 3 days after starting the cntraceptive, and cmparatively steady levels were reached within 2 weeks (Table 2). Use f these cntraceptives fr lnger duratins was nt assciated with any further decrease in serum zinc levels (Tables 1 and 3). Despite the marked changes in serum cpper and zinc levels, urinary excretin f cpper and zinc in cmbinatin pill users was similar t that f the cntrl grup (Table 4). Injectable Prgestgen Users. Irrespective f the drug and dsage, the use f injectable prgestgen resulted in a decrease in serum zinc levels, but serum cpper levels remained unaltered (Table 1). Serial estimatin f serum zinc levels in wmen using NET 20 mg/mnth shwed that the decrease in serum zinc ccurred within 24 hurs after the injectin and cntinued until day 15 (Table 2). Further use f NET 20 mg/mnth fr as lng as 1 year did nt result in any further decrease in serum zinc levels (Table 3). DISCUSSION Serum cpper and zinc levels in nrmal wmen and in hrmnal cntraceptive users as reprted here are similar t thse reprted in wmen frm develped cuntries despite bvius differences in ethnic, dietary, and nutritinal status.1-6, 8-10 The serum cpper levels reprted in the present study

3 Days >25 Cntrl (6 wmen) TABLE 2. Serial Estimatin f Serum and Levels in Hrmnal Cntraceptive Usersa 2 :- 117 ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± 17.6 avalues are means ± standard deviatin. bp < cp < dp < Grup Cntrl Estrgen-prgestgen Cmbinatin pill Injectable IV ring NET NET 20 mg/mnth (6 wmen) 125 ± ± ± ± 14.2b 124 ± ± 14.9<" 121 ± ± 14.9<" 127 ± ± 13.8<" 128 ± ± 12.8<" 126 ± ± 12.8<" 120 ± ± 14.2<" 126 ± ± 13.2<" Cmbinatin pill (4 wmen) 112 ± ± ± ± ± 26.2<" 168 ± 29.2c 186 ± 28.6 c 78 ± 16.3 d 74 ± 16.8 d 72 ± 17.8'" 70 ± 16.1<" 71 ± 16.2<" IV ring (5 wmen) 113 ± ± ± ± ± 26.8 c 79 ± 19.9 d 76 ± 18.3 d 72 ± 17.2c 70 ± 17.2c TABLE 3. Serum and Levels in Wmen Using Hrmnal Cntraceptives (Lngitudinal Study)a N. f wmen Serum cpper after duratin f use 1 rn 3rn 6 rn fj.g1dl 120 ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± 19.8 avalues are means ± standard deviatin. Statistical analysis (, nt significant): 12 rn 1 rn 114 ± ± ± ± ± ± ± ± 14.8 Injectable DHPA + EE (5 wmen) 108 ± ± ± ± ± 26.4 c 142 ± 26.6 c Serum zinc after duratin f use 78 ± 18.8 d 72 ± 17.6<" 72 ± 17.0c 74 ± 17.7<" 3rn 6rn 12 rn 106 ± ± ± ± ± ± ± ± ± ± ± ± ± [{9 ::>:l N Z ::t: s:: z <: c:: UJ 5l Cmparisn Cntrl vs. cmbinatin pill (in all perids f duratin) Cntrl vs. injectable Cntrl vs. IV ring Cntrl vs. NET Cmbinatin pill vs. injectable Cmbinatin pill vs. IV ring p < p < I:>:) 0) t

4 270 PREMAETAL. March 1980 TABLE 4. Urinary Excretin f and Nn-users f ral cntraceptives Oral cntraceptive users " 1'/f124 hr 24.8 ± ± (28) (27) 21.9 ± ± (27) (26) ayalues are means ± standard deviatin. Figures in parentheses indicate number f wmen studied. are significantly higher than thse reprted fr Nigerian wmen.7 The reasn fr this difference is nt clear at present. It is significant that there was n difference in either the magnitude f the increase in serum cpper levels r the decrease in serum zinc levels r the time when these changes ccurred in relatin t the intrductin f the cntraceptive in wmen using the cmbined estrgen-prgestgen cntraceptive in the frm f an IV ring, injectable prgestgen, r ral cntraceptives. Amng ral cntraceptive users, there were n differences in serum cpper and zinc levels between thse taking a pill cntaining 30 IJ.g f ethinylestradil and thse taking a pill cntaining 50 IJ.g f ethinylestradii. Similarly, there was n difference in the magnitude f the decrease in serum zinc levels between thse using injectable DMPA and thse using NET, even thugh there was a 7-fld difference in the dse f the drug used. The decrease in serum zinc levels bserved in the present study fllwing the intramuscular injectin f NET is similar t that reprted by Funckes et ai.,12 wh fund a decrease in serum zinc levels as early as 4 hurs after the intravenus administratin f! mg f NET. These data indicate that changes in serum cpper and zinc levels brught abut by exgenus sterids are nt affected by the chemical nature f the sterid, the dse, r rute f administratin. The mechanism by which cntraceptive sterids bring abut changes in serum cpper and zinc levels is nt clearly understd. Increases in serum cpper levels ccur during pregnancy, when there are high circulating levels f endgenus estrgen and prgestgens; after exgenus administratin f cmbined estrgen-prgestgen cntraceptives; and after administratin f estrgen alne. Hwever, prgestgen administratin des nt cause an increase in serum cpper levels. The suggestin by Carruthers et ai. 3 that exgenus r endgenus estrgen-induced synthesis f cerulplasmin in the liver is respnsible fr the increase in serum cpper levels gains supprt frm the data btained in the present study. Decreases in serum zinc levels were fund t ccur very sn after the administratin f cntraceptive sterids. The fact that the magnitude and the time f ccurrence f the fall did nt differ in cmbinatin pill users r injectable prgestgen users suggests that in this respect prgestgens and estrgens have similar effects. It has been suggested that this might be due t sterid-induced alteratins in binding affinities. 11, 14 The mechanism by which the sterids bring abut a reductin in serum zinc levels needs elucidatin. The physilgic implicatins f the alteratins in serum cpper and zinc levels in wmen using hrmnal cntraceptives are nt knwn. Decreases in serum zinc levels are reprted t result nt nly in increased platelet aggregatin and stickiness but als in increased sertnin release.15, 16 Pller et a1. 17, 18 have shwn that increased platelet aggregatin ccurs in bth cmbinatin pill users and prgestgen users. The extent t which the decrease in serum zinc levels cntributes t changes in platelet functin in such wmen is nt knwn. The incidence f venus thrmbsis in cmbinatin pill users is knwn t be 4 t 7 times higher than that in a cntrl ppulatin.19 This has been attributed mainly t alteratins in factrs invlved in the cltting mechanism caused by the estrgenic cmpnent f the pill. It has been assumed that users f prgestgens, which d nt cause alteratins in the factrs invlved in cagulatin, are relatively free f the risk f thrmbemblic cnsequences. Epidemilgic verificatin f this assumptin is difficult because f the relatively small number f prgestgen users. Hwever, if changes in platelet functin play a rle in inducing venus thrmbsis, it wuld appear that the ue f prgestgens may nt be withut sme risk. Acknwledgments. The authrs are grateful t Dr. S. G. Srikantia, Directr, Natinal Institute f Nutritin, f-his help and guidance during the investigatin. Our thanks are als expressed t Mr. Mhamad Minuddin Khan, Mr. L. S. R. Murthy, and Mr. M. Chandrasekhar Ra fr their invaluable technical assistance. REFERENCES 1. Briggs MH, Briggs M: Cntraceptives and serum prteins. Br Med J 3:521, Briggs M, Austin J, Stanifrd M: Oral cntraceptives and cpper metablism. Nature 225:81, Carruthers ME, Hbbs CB, Warren RL: Raised serum cpper and caerulplasmin levels in subjects taking ral cntraceptives. J Clin Pathl 19:498, 1966

5 Vl. 33, N.3 SERUM COPPER AND ZINC IN HORMONAL CONTRACEPI'IVE USERS Daunter B, Elstein M: Serum levels f cpper, caerulplasmin and caerulplasmin xidase activity in wmen using cpper-cntaining intrauterine devices and in wmen taking cmbined ral cntraceptives. J Obstet Gynaecl Br Cmmnw 80:644, Halsted JA, Hackley BM, Smith JC Jr: Plasma zinc and cpper in pregnancy and after ral cntraceptives. Lancet 2:278, Margen S, King JC: Effect f ral cntraceptive agents n metablism f sme trace minerals. Am J Clin Nutr 28:392, Olatunbsum DA, Adeniyi FA, Adadevh BK: The effect f ral cntraceptives n serum cpper levels in Nigerian wmen. J Obstet Gynaecl Br Cmmnw 80:937, O'Leary JA, Spellacy WN: and cpper levels in pregnant wmen and thse taking ral cntraceptives. Am J Obstet Gynecl 103:131, Prasad AS, Oberleas D, Lei KY, Mghissi KS, StrykerJC: Effect f ral cntraceptive agents n nutrients. 1. Minerals. Am J Clin Nutr 28:377, Schenker JG, Plishuk WZ, Jungries E: Serum cpper and zinc levels in patients taking ral cntraceptives. Fertil Steril 22:229, Briggs MH, Briggs M, Austin J: Effect f sterid pharmaceuticals n plasma zinc. Nature 232:480, Funckes CG, Chvapil M, Carrl RW, Bressler R: Effect f a lng acting cntraceptive drug, nrethindrne enanthate, n serum zinc and cpper in human vlunteers. Cntraceptin 14:291, Amatayakul K, Sivasmbn B, Thanangkul 0: Vitamin and trace mineral metablism in medrxyprgesterne acetate users. Cntraceptin 18:253, Henkin RI: Newer Trace Elements in Nutritin, Edited by W Mertz, WE Crnatzer. New Yrk, Marcel Dekker, 1971, p Chvapil M: New aspects in bilgical rle fzinc: a stabilizer f macrmlecule and bilgical membranes. Life Sci 13:1041, Chvapil M, Weldy PL, Stankva L, Clark DS, Zukski CF: Inhibitry effect f zinc ins n platelet aggregatin and sertnin release reactin. Life Sci 16:561, Pller L, Thmsn JM, Thmas W: Oestrgen/prgestgen ral cntraceptin and bld cltting: a lng-term fllwup. Br Med J 4:648, Pller L, Thmsn JM, Thmas W, Wray C: Bld cltting and platelet aggregatin during ral prgestgen cntraceptin: a fllw-up study. Br Med J 1:705, Ppulatin Reprts: Oral cntraceptives-update n usage, safety and side effects. Ppulatin Rep, Ser A, N 5, 1979

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