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Even though, progesterone is a hormone naturally produced by ovary, but
whether the external progesterone is as beneficial as the natural for female?
What alterations come in which organ of female reproductive tract due to their
use? We aimed to observe the histopathological changes brought by the long term
use of Depot-medroxyprogesterone acetate (DMPA) “sangini sue”, which is the
highly popular and promoted contraceptive in developing countries, in
reproductive tract of female rat particularly in ovary and Uterine tube. There
was significant change in the morphology of ovary and uterine tube of
experimental group rat compared to the control group. Such as, follicular
atresia, medullary hemorrhage and atrophy of uterine epithelium were seen in
experimental group rat only. In conclusion, long- term use of exogenous
progesterone, such as DMPA for contraception has adverse impact in Female which
outweighs the merits. Instead of promoting this hormonal product, which in long
period attenuates the health of female, other non-hormonal methods of
contraception should be publicized along with their efficacy.
Keywords: Follicular atresia,
Atrophy, Deciliation, Medullary hemorrhage
Abbreviations: DMPA: Depot-Medroxyprogesterone
Acetate; HRT: Hormone Replacement Therapy; POP: Progesterone Only Pill
INTRODUCTION
Unintended pregnancies in
low-and middle-income countries remain a serious obstetric problem and
awareness and promotion of all types of family planning methods are inevitable
in those areas [1]. Family planning has been an important subject for
population planners, couples and individuals because it aims for better health
and because of its sociocultural benefits [2]. Depot medroxyprogesterone
acetate (DMPA) is one of the most effective reversible contraceptives yet its
use is not a without side effect which was developed in 1954 as a treatment for
endometriosis and to prevent habitual or threatened abortions [3]. In cases
where women are at an increased risk of estrogen complications progestin-only
hormonal contraception is often prescribed as the method of choice [4]. The
benefit of DMPA relates to the fact that; it is 99% effective at preventing
pregnancy when used properly, requires only one injection every 3 months; and
offers extended protection due to the crystallized progestin that slowly
dissolves into the bloodstream [5].
Due to these merits it has been used as a contraceptive agent by millions of women in more than 90 countries since 1967 and was approved for use in several developing countries in 1992 [6]. Medroxyprogesterone acetate (17-acetoxy-6-methylpregn-4-ene-3,20-dione; MPA), a synthetic progesterone analog, is used in conception and hormone replacement therapy (HRT) by millions of women worldwide which contraception mechanism is the inhibition of ovulation [7].
Compared to other progestin-only contraceptives, DMPA contains
substantially higher levels of progestin [8]. A 90 day dosage of DMPA adds up
to 150 mg, significantly higher than the 90-day dosages of the progestin-only
pill (POP) (31.50 mg), Mirena IUD (1.8 mg) and Implanon/Nexplanon (etonogestrel
implant) (6.3 mg) [9]. Consequently, DMPA is associated with more side effects,
including irregular menstruation, anxiety, headaches, weakness, fatigue,
bloating, abdominal pain and weight gain [10]. Recent data revealed an
increased risk of fracture caused by the DMPA-induced lack of estrogen over
extended periods of time, particularly in women who have not yet attained peak
bone mass [11]. Additionally, many users experience delays in fertility
following discontinuation [12]. DMPA usage is also directly linked to
amenorrhea in 70% of users after 2 years [13]. So this study intend to observe
the structural changes in the ovary and uterine tube to reveal the association
between the long term use of DMPA and pathological changes in the ovary such as
decrease ovarian follicles, follicular atresia as well as epithelial atrophy in
the uterine tube, which may contribute for the delay return of fertility, in
DMPA users.
MATERIALS AND METHODS
60 healthy female Wistar Albino female rats
weighing 150-200 g were obtained from the animal house of BPKIHS, Dharan. They
were given standard pellet diet and drinking water ad libitum. They were
maintained in a well-ventilated room at controlled ambient temperature (25°C)
with a 12 h in alternating light-dark cycle. They were housed in polypropylene
cage (40 cm × 25 cm × 15 cm) with the paddy husk bed, which was changed on
every 4-5 days [13].
Preparation of the depot-medroxyprogesterone
acetate solution
DMPA vials sold as ‘Sangini’ in Nepal are
manufactured by Pfizer pharmaceuticals group. One vial containing 150 mg/ml
suspension was diluted in distilled water to make the required concentration
for experiment. The experimental groups were given DMPA in the doses of 2.4 mg
intramuscularly per week for 8 weeks.
While the control group rats were treated with
0.25 ml of normal saline intramuscularly for 8 weeks. The doses were converted
from human dose to rat dose by using multiplication factors for dose conversion
between different species by Paget and Barnes as follow [14].
Drug to be given for rat = 0.018 × Human dose
Experimental design
and treatment regimen
Animals were divided into 2 groups, with in each group n=15 rats, Total number n=30 (Table 1).
Experimental
group rats were sacrificed one day after the completion of 8 weeks. The rats
were anesthetized with Ether soaked in cotton. Ovaries and uterine tubes were
fixed by in vivo perfusion method.
After completion of perfusion, the organs were isolated from the body with help
of scalpel and forceps and post fixed for 24 h with Bouin’s Fluid. Thus
obtained organs were cut into pieces of 3 mm to fix in neutral buffered
formalin for 7 days and processed for making paraffin blocks. The blocks were
trimmed, sectioned at 4 μm thicknesses and stained by routine H&E
(Hematoxylin and Eosin) staining. All sections were examined under light
microscope.
Ethical clearance was taken as per the
guideline of Institutional Ethical Review Board (IERB no. 143) of BPKIHS,
Dharan, Nepal.
RESULTS
The microscopic observation was done with the
help of light microscope, where all the slides of case and control group rat
was compared, taking the appearance of follicle and the medulla of ovary in
consideration. While the uterine tube observation was mostly focused to observe
the appearance of uterine epithelium.
There were remarkable differences in the follicular and medullary appearance between the normal and the experimental rat. For instance, in the case group rat’s ovarian follicular atresia as well as the medullary hemorrhage was noticeable compared to the placebo which is shown in Figures 1 and 2, respectively. Similarly, the distinguishable distortion of uterine epithelium was seen in case group rats compared to the normal group rats as demonstrated in Figures 3 and 4, respectively.
DISCUSSION
DMPA has been used for many purposes but it is
mostly used for contraception by many females without any specific medical
supervision particularly in developing countries. With increased popularity,
this drug has been also in attention for the peaking osteoporosis, obesity and
delayed fertility return problem in the users. Present study about the effects
of DMPA in ovary and uterine tube of rat found distinguishable distortion in
the respective viscera which might attribute for the delayed fertility return.
The medullary hemorrhage and follicular atresia
was significant in the ovary of the DMPA treated rat compared to the untreated
rat which is shown in photomicrograph 1 and 2 respectively. Similar findings
were reported by a study conducted in rats by Bhowmik and Mukherjea [15] who
found the degeneration of ovarian follicle along with follicular atresia in
DMPA treated rat which can be due to the apoptotic effect of progesterone on
the ovarian follicle. While the hemorrhage can be due to the toxic effect of
DMPA [15].
Another study conducted by Sivakumar and
Kamakshi [16] revealed significant decrease in the number of follicles as well
as increased follicular atresia with massive size corpus luteum in DMPA treated
rat.
In this study, severe atrophy of uterine
epithelium was observed in the experimental group rat compared to the control
group as shown in photomicrograph 3 and 4 respectively which can be due to the
anti-estrogenic effects of progesterone in the oviduct where progesterone
blocks estradiol-inducible secretory proteins and induces deciliation and
cessation of secretory activity of the oviductal epithelium. It can be further
aggravated by the disturbance in the cell growth and differentiation due to the
effect of steroid hormone.
Another study conducted by Gordon et al. [17] observed
the similar findings, where deciliation and cessation of epithelial growth in
the oviduct of progesterone treated Rhesus monkeys was reported.
Many other studies have found the association
of progesterone with the morphological and functional alteration of uterine
tube. For example, a study conducted by Hegazy and Hegazy [18]. WHO also
reported the reduced mucosa and ciliary activity of uterine tube in DMPA
treated rat [18].
CONCLUSION
It is believed that DMPA is the most effective
contraceptive which has been popular around the world. However, many issues are
ensued these days in the health of injectable contraceptive user female, such
as obesity, loss of bone mineral density, etc., which are considered to be due
to the adverse effect of the injectable contraceptive. This study also revealed
some severe alteration in the uterine tube as well as in the ovary of rat which
could pose massive impact on fertility of female. To conclude, there is dire
need of more rigorous study about the impacts of DMPA in the health of the
users as well as promoting the better option for contraception than the
hormonal.
ACKNOWLEDGEMENT
We would like to express grateful thanks to BP
Koirala Institute of Health Sciences, Nepal for providing research facilities
and we are also thankful to all staffs, research laboratory and animal house
staff for their proper supports during study. We are immensely thankful for the
support provided by Patan Hospital Pathology Laboratory Staff.
CONFLICT OF INTEREST
No conflict of interest among the authors.
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