The Pill Project - Oral Contraceptive and Serotonergic Brain Signaling

Hormonal Sensitivity and Brain Function: Do Oral Contraceptives Distort Serotonergic Brain Signaling?

Large register based work has shown that starting on oral contraceptives (OCs) is associated with an increased risk of developing depressive episodes. It is not known why this is, but changes in the serotonergic brain system might play a role. Intriguingly, in cross-sectional work, the investigators have demonstrated a lower level of the serotonin 4 receptor globally in the brain of healthy women using oral contraceptives compared to non-users. The order of magnitude of this difference is comparable to what has been observed in depressed individuals relative to healthy controls. In this study, the investigators will apply a longitudinal design to determine if starting on oral contraceptives induces a reduction in the serotonin 4 receptor in healthy women and whether such changes are related to potential changes in measures of cognition as well as mood/affect and sexual desire.

The study is a single-blind randomized placebo-controlled trial with a 3-month intervention paradigm of either Femicept (2nd generation combined oral contraceptive) or placebo. The investigators will include participants until 20 women have completed the study in each arm. Participants will go through an investigational program, including PET and MR brain scans and neuropsychological testing, before starting on the treatment and again during the third pill cycle. To capture changes in mood/ and sexual desire, the participants will complete daily questionnaires during the baseline menstrual cycle and during third pill cycle.

A linear latent variable model will be used to evaluate if OC use induces changes in the serotonin 4 receptor level and such changes will be correlated to changes in secondary outcomes (i.e., cognitive and psychometric measures).

Study Overview

• Status: Recruiting
• Conditions: Major Depressive Disorder; Sexual Behavior; Mood Change; Mood Disturbance; Affect Altered; Affect Blunted; Drug Mechanism
• Intervention / Treatment: Drug: Placebo; Drug: Femicept

Detailed Description

Background:

More than 100 million women worldwide use combined oral contraceptives (OCs), i.e. the most common types that combine estrogen and gestagen. Register-based epidemiological work has recently shown that starting on hormonal contraceptives is associated with an increased risk of developing a depressive episode, and apparently this includes the most severe cases that involve suicide. In addition, the use of OCs has also been linked to reduced sexual desire and interest, one of the common symptoms in depressive disorder. It is unknown why OCs can trigger a depressive episode, at least in a subgroup of women, or how this subgroup at high-risk may be identified in advance.

OCs act by suppressing the hypothalamic-pituitary-gonadal hormonal axis, which drives the reproductive system, resulting in downregulated sex hormones. Such changes in sex-steroid milieu shape human brain biology and function including serotonergic neurotransmission, which is key in maintaining mental health, including regulation of sexual desire. Preliminary and independent data from the Center for Integrated Molecular Brain Imaging (Cimbi) database, strongly suggest that healthy women who use OCs differ in terms of serotonergic brain architecture. In particular when using a potential marker of brain serotonergic function, the investigators have in a cross-sectional study shown, that OC users display lower serotonin 4 receptor (5-HT4R) brain binding relative to non-users. This difference is remarkably large and comparable to what is seen in depressed individuals compared to in healthy controls and to the effects provoked by pharmacological tools as traditional antidepressant drugs (SSRI). The 5-HT4R is relevant in the context of depression, since rodent work points to a fast-acting antidepressant- and anxiolytic-like effect of 5-HT4R stimulation and also, notably, 5-HT4R activation is implicated in behavioral and neurogenic effects of SSRIs. Therefore, a lowered 5HT4R agonism capacity in OC users would offer a plausible explanation for why OC use may provoke depressive symptoms.

The initial cross-sectional observation of a difference in 5-HT4R binding between OC users and non-users warrants replication and validation in an independent dataset and in a study design where causality can be inferred. With this study, the investigators apply longitudinal study design to determine if OC use versus placebo cause changes in 5-HT4R brain binding and if such changes map onto relevant signatures of brain functions and mental states, including sexual desire. The investigators anticipate that this work will substantially advance the understanding of how changes in sex-hormone milieu increase susceptibility for manifest depressive episodes and ideally provide novel preventive and therapeutic opportunities.

Study design:

The investigators will conduct a single-blind randomized placebo-controlled trial with a 3-month intervention paradigm of either OC or placebo. The investigators will include up to 50 healthy women (until 20 women have completed in each arm) at 18-22 years of age. The participants will be allocated to receive a 2nd generation OC (Femicept) or placebo for three pill cycles of 28 days. The participants will undergo an investigational program at baseline (before treatment allocation) and at follow-up (at a specific time in the third pill cycle dependent on treatment arm). The programs consist of 11C-SB207145 PET and MRI/fMRI scan of the brain, neuropsychological testing, collection of blood and saliva samples, completion of questionnaires regarding various trait- and state-related measures including a month at baseline and follow-up of daily questionnaires measuring psychometrics of mood/affect, sexual desire and sleep quality. The participants will be instructed to contact us by e-mail every time they have their first cycle day, i.e. first day of bleeding, during the study, which will be used to estimate menstrual cycle phases.

Randomization:

Participants will be randomized in random block sizes to either Femicept or placebo. The randomization will be carried out by an administrative staff member at Neurobiology Research Unit (Rigshospitalet, Denmark), who will not otherwise be involved in the study or enrollment. The sequence generation will be created via the online service, Sealed EnvelopeTM (www.sealedenvelope.com). Region Hovedstadens Apotek will carry out allocation concealment by sequentially numbered containers. Enrollment and intervention assignment will be carried out by the clinical investigators. The assignment to active or placebo treatment will happen after the baseline assessment. The investigators will be unblinded after a certain time after allocation so they will be able to plan the follow-up investigational program. To evaluate the efficacy of blinding, participants will be asked which group they believed they belonged to prior to unblinding.

Intervention:

Femicept (CampusPharma) is a monophasic 2nd generation combined OC, the recommended type of combined OC due to the lower thromboembolic risk and it is the most used combined OC in Denmark (www.medstat.dk). One packet consists of 21 active pills, containing 150 micrograms levonorgestrel and 30 microgram ethinylestradiol. One pill is taken every day approximately at the same time of the day (with no more than 12 hours variation) for 21 days. Normally, this will be followed by 7 days off the pill before starting on a new pill cycle, however, to decrease complexity and to increase compliance and the timing of pill cycles, a 7-day regime with placebo pills will be added, during which participants will experience withdrawal bleeding. The placebo pill cycle treatment constitutes 28 days with a daily placebo pill.

Evaluation of compliance:

Pill count will be carried out at every pill cycle and plasma estradiol and progesterone will be measured during pill cycle day 18-28 to capture non-compliance based on non-suppressed endogenous ovarian hormone levels indicating if ovulation had occurred. If the participants have missed more than two pills during a pill cycle or if plasma sex steroid levels indicate non-compliance during a pill cycle, it is allowed to extend the treatment with one or two more pill cycles before follow-up, hence, for some participants the intervention may last 4-5 months.

Statistical analysis plan:

The investigators will use linear latent variable models on log-transformed 5-HT4R binding potentials to estimate the multiplicative group effect of OC use (i.e., the percentage change from baseline in 5-HT4R binding potentials) in the regions of interest (neocortex, neostriatum, and the hippocampus) and compare it between the groups. The log-transformed binding potentials will be adjusted for the injected tracer mass per kg body weight. The investigators will compute model diagnostics by using score tests to detect model misspecifications and add parameters until no misspecification can be detected.

Correlation analyses will be used to investigate the association between changes in 5-HT4R binding potentials and secondary outcome measures; affect and sexual desire scores, reward fMRI BOLD signals and verbal memory performances. Mediation analysis will be conducted to test the relation between OC-induced changes in 5-HT4R binding potential and the cortisol awakening response (CAR).

Further, in an explorative approach, the investigators will conduct pooled analyses of baseline data (both OC and placebo group) and potential coupling between baseline imaging outcomes and behavioral outcomes will be performed. Also, analyses of psychometric variations potentially mapping onto menstrual cycle phases will be performed.

Sample size calculation:

Calculations based on intra-subject variability of the 5-HT4R binding on 16 subjects with scan-rescan show that a group size of 20 is required to detect 8-11% difference in 5-HT4R BPND in the region of interest (neostriatum, neocortex, and hippocampus) between OC- and placebo group from baseline to follow-up with a power of 0.8 and a significance level of 0.05 (two-sided). This is equivalent to the effect size seen in the cross-sectional finding for these regions. For the primary analyses, only participants with 5-HT4R follow-up data will be included. Missing data as well as dropouts will be reported in the relevant publications. Dropouts with baseline data can be included in the explorative pooled analyses of the baseline data.

Hypotheses

Primary hypothesis:

1. OC use reduces neostriatal, neocortical, and hippocampal 5-HT4R brain binding from baseline relative to placebo.

   Secondary hypotheses:

2. OC use induces a reduction in positive affect and day to day positive affect variability possibly in a manner dependent on the magnitude of 5-HT4R binding decrease in OC users.
3. OC use induces mood disturbance and lower day to day mood disturbance variability possibly in a manner dependent on the magnitude of 5-HT4R binding decrease in OC users.
4. OC use induces a reduction in sexual desire and day to day sexual desire variability in a manner dependent on the magnitude of 5-HT4R binding decrease in OC users.
5. OC use reduces brain circuit responses to reward stimuli compared to placebo in ventral striatum in a manner dependent on the magnitude of 5-HT4R binding changes.
6. OC use changes resting state functional connectivity brain networks compared to placebo.
7. OC use results in reduced gray matter volumes of the hippocampus.
8. OC use changes white matter integrity.
9. OC use induces a blunted cortisol awakening response (CAR) possibly in a manner dependent on the magnitude of change in 5-HT4R binding and/or changes in hippocampal volume from baseline.
10. The association between 5-HT4R binding and verbal memory performance is dependent on OC use status, such that lower 5-HT4R binding is associated with worse verbal memory performance in the OC use state in contrast to better performance in non-OC use state.
11. OC use results in a bias in processing of emotional information compared to placebo.
12. OC use reduces sleep quality.
13. Within the OC users, the estradiol and/or allopregnanolone levels are associated with the 5-HT4R level, working memory performance, cortisol dynamics and hippocampal volume.
14. OC use induces changes in gene transcript and/or DNA methylation profiles compared to placebo.
15. OC use increases anxiety in a manner dependent on the magnitude of change in 5-HT4R binding.

Ethical considerations:

• Side effects to the intervention: The side effect of most concern is thromboembolic events. However, this risk is only increased from about 1 to 3 per 10.000 women when using 2nd generation OCs, or even less due to the exclusion of those with thromboembolic risk factors, hence it is considered a relatively small risk and acceptable. Further, the blinding of the treatment also raises an ethical concern regarding the risk of pregnancy; even though participants are unaware if they are on OCs or not, they may behave less carefully in regards to preventing pregnancy. To address this, participants will be thoroughly informed to use protection during intercourse and will be offered condoms for free during the study period.
• Exposure to radioactivity during the PET scans: The total exposure will not exceed 10 mSv equal to 3 years of natural background radiation in Denmark, which should be seen in the light of the new knowledge this study can generate.

The study will be conducted in agreement with the Declaration of Helsinki.

• Study Type: Interventional
• Enrollment (Anticipated): 40
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Vibe Frokjaer, MD, PhD; Phone Number: +453545 6714; Email: vibe@nru.dk
• Study Contact Backup: Name: Søren Larsen, MD; Phone Number: +453545 6708; Email: soren.vinther@nru.dk

Study Locations

• Denmark
  • Copenhagen, Denmark, 2100
    • Recruiting
    • Neurobiology Research Unit
    • Contact: Vibe Frokjaer, MD, PhD; Phone Number: +453545 6714; Email: vibe@nru.dk
    • Contact: Soren Larsen, MD; Phone Number: +453545 6708; Email: soren.vinther@nru.dk

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 16 years to 20 years (Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: Female

Description

Inclusion Criteria:

• Healthy women at 18-22 years of age
• No use of hormonal contraception within the last year
• Having a regular menstrual cycle of approximately 28 days, i.e., approximately 28 days between first day of menstrual bleedings.

Exclusion Criteria:

• Current or previous neurological or psychiatric disease, severe somatic disease, or consumption of medical drugs likely to influence the test results
• Non-fluent in Danish or pronounced visual or auditory impairments
• Current or past learning disability
• Current or previous pregnancy
• A wish to become pregnant within the following 6 months
• Participation in experiments with exposure to radioactivity (> 10 mSv) within the last year or significant occupational exposure to radioactivity
• Contraindications for MRI (pacemaker, metal implants, claustrophobia)
• Allergy to the ingredients in the administered drug
• A diagnosis of hypo- or hypertension
• A history of head injury or concussion resulting in loss of consciousness for more than 2 min
• Alcohol abuse
• Drug use other than tobacco and alcohol within the last 30 days
• Cannabis > 50 x lifetime
• Recreational drugs > 10 x lifetime (for each substance)
• Nicotine addiction
• Current psychoactive medication
• Any risk factors for thromboembolic events
• Other contraindications for use of Femicept

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Basic Science
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Femicept; 3x28 days of treatment with Femicept. Each cycle consists of 21 days of active pill (Femicept) and 7 days of placebo pill.	Drug: Femicept; 150 μg levonorgestrel +30 μg ethinylestradiol; Other Names: Combined oral contraceptive
Placebo Comparator: Placebo; 3x28 days of treatment with placebo	Drug: Placebo; Placebo

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in neostriatal, neocortical, and hippocampal 5-HT4R brain binding from baseline to follow-up measured with Positron Emission Tomography (PET) in active vs. placebo group	Difference in latent variable construct of 5-HT4R level based on a quantification of 5-HT4R binding in primary regions of interest; neocortex, neostriatum, and hippocampus. Change is compared between the OC- and the placebo group.	3 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in serial Positive Affect (PA) score derived from daily ratings of the Positive and Negative Affects Schedule (PANAS) questionnaire.	PA score ranges from 10-50 with higher scores representing higher levels of positive affect.	3 months
Change in serial Total Mood Disturbance (TMD) scores derived from daily ratings of the Profile of Mood States - Short Form (POMS-SF) questionnaire	TMD score ranges from -30 to 155 with higher scores representing higher levels of mood disturbance.	3 months
Change in serial sexual desire scores derived from daily ratings of the Element of Desire Questionnaire (EDQ)	EDQ score ranges from 6-35 with higher scores representing higher sexual desire	3 months
Change in the Female Sexual Function Index (FSFI) score	FSFI score ranges from 2-36 with higher scores representing higher sexual functioning	2 and 3 months
Change in reward stimulated BOLD signal in ventral striatum measured with fMRI	The blood-oxygen-level-dependent (BOLD) reward signal derived from the brain activity during monetary reward fMRI paradigm	3 months
Change in BOLD signal in resting state functional connectivity brain networks measured with fMRI	The blood-oxygen-level-dependent (BOLD) signal derived from the brain activity during resting state.	3 months
Change in hippocampal volume	Derived from structural T1 MPRAGE brain MRI	3 months
Change in white matter microstructure	Derived from neurite orientation dispersion and density imaging (NODDI) and diffusion tensor imaging (DTI).	3 months
Change in CAR	Cortisol Awakening Response (CAR) derived from saliva samples collected during the first hour after awakening	3 months
Change in total Verbal Affective Memory Test-24 (VAMT-24) performance	Derived from immediate, short-term and delayed recall with a score range of 0-24 with higher scores representing better performance.	3 months
Change in affective bias for emotional detection	Affective bias measures is derived from the Intensity Morphing Task as detection time for sad minus detection time for happy averaged across increase and decrease conditions. Range score is -100% (indicating negative bias) to +100% (indicating positive bias).	3 months
Change in affective bias for emotion recognition	Affective bias calculated as hit rate for happy minus hit rate for sad in the Emotion Recognition Task. Range score is -100% (indicating negative bias) to +100% (indicating positive bias).	3 months
Change in Letter-Number Sequencing task score	Score ranges from 0-21 with higher scores representing better performance.	3 months
Change in mean daily sleep quality	Derived from serial daily sleep quality reporting on a scale from 0 (very good) to 3 (very bad) during baseline and follow-up cycles.	3 months
Change in Pittsburgh Sleep Quality Index (PSQI)	PSQI ranges from 0-21 with higher scores representing worse sleep quality.	3 months
Plasma estradiol	Sampled at baseline and follow-up	At baseline and after 3 months
Plasma testosterone	Sampled at baseline and follow-up	At baseline and after 3 months
Plasma progesterone	Sampled at baseline and follow-up	At baseline and after 3 months
Serum allopregnanolone	Sampled at baseline and follow-up	At baseline and after 3 months
Gene transcription and methylation profiles	Derived from mRNA and DNA methylation of genes involved in hormonal signaling pathways	At baseline and after 3 months
Change in General Anxiety Disorder 10 (GAD-10) score	GAD-10 score ranges from 0-50 with higher scores representing higher level anxiety	2 and 3 months

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in serial Negative Affect (NA) score derived from daily ratings of the Positive and Negative Affect Schedule (PANAS) questionnaire	NA score ranges from 10-50 with higher scores representing higher levels of negative affect	3 months
Change in Positive Affect (PA) score derived from the Positive and Negative Affect Schedule (PANAS) questionnaire (regarding "last few weeks")	PA score ranges from 10-50 with higher scores representing higher levels of positive affect	2 and 3 months
Change in Negative Affect (NA) score derived from the Positive and Negative Affect Schedule (PANAS) questionnaire (regarding "last few weeks")	NA score ranges from 10-50 with higher scores representing higher levels of negative affect	2 and 3 months
Change in self-reported mental distress scores	A composite measure derived from Perceived Stress Scale (score range: 0-40, higher score indicating more perceived stress), Snaith-Hamilton Pleasure Scale (score range: 0-14, higher score indicating higher level of anhedonia), Beck Depression Inventory-II (score range: 0-63, higher score indicating more severe depressive symptoms), WHO-5 Well-being index (score range: 0-25, higher score representing higher quality of life), Ruminative Responses Scale (score range: 22-88, higher score indicating higher level of ruminative symptoms), and state-related questionnaires from the State Trait Anxiety Inventory (score range: 20-80, higher score indicating higher level of anxiety) and the State-Trait Anger Expression Inventory 2 (score range: 15-60, higher score indicating higher level of anger)	2 and 3 months
Change in the 17-item Hamilton Depression Rating Scale (HDRS-17) score	HDRS-17 score ranges from 0-54 with higher scores representing higher level of depressive symptoms	3 months
Change in mean hours slept	Derived from serial daily reporting of hours slept during baseline and follow-up cycles	3 months
Change in number of nights with trouble sleeping due to 1) difficulty falling a sleep or 2) wakening in the night or early morning	Derived from serial daily reporting about trouble sleeping during baseline and follow-up cycles	3 months
Change in visuospatial memory test performance	Derived from immediate, short-term and delayed recall in a Complex Figure Test (CFT) (Taylor CTF will be used at baseline and Reys CTF at follow-up to avoid learning effects). Score ranges from 0-36 with higher scores representing better performance.	3 months
Change in Symbol Digit Modalities Test (SDMT) score	Derived from change in number of correct guesses with score ranges from 0-110 with higher scores representing better performance.	3 months
Change in Trail Making Test (TMT) Part A and B performance	Derived from time spent with short time representing better performance.	3 months
Change in Intra-Extra Dimensional (IED) performance	Derived from Extra Dimensional Set Errors and latency in Intra-Extra Dimensional Set Shifting	3 months
Change in Simple Reaction Time (SRT) task	Derived from time spent in trials with shorter time representing better performance.	3 months
Color Word Interference Test (CWIT) performance	Derived from test scores in condition 1-4 in D-KEFS Color Word Interference Test (CWIT). The test scores is calculated based on the time spent + corrected errors and uncorrected errors. Shorter time represents better performance.	3 months
Verbal Fluency (VF) performance	Derived from test scores from subcategories ("f", "a", "s", "animals", "boy names", "fruit/furniture") in the Verbal Fluency Task	3 months
Change in low-grade inflammation	Change in hsCRP from baseline to follow-up	3 months
Change in impulsiveness score derived from Barratt Impulsiveness Scale Version 11	Score ranges from 30-120 with higher score indicating more impulsiveness.	3 months

Collaborators and Investigators

• Sponsor: Rigshospitalet, Denmark
• Investigators: Principal Investigator: Vibe Frokjaer, MD, PhD, Neurobiology Research Unit, copenhagen University hospital, Rigshospitalet, Denmark

Study record dates

Study Major Dates

• Study Start (Actual): December 22, 2021
• Primary Completion (Anticipated): August 31, 2024
• Study Completion (Anticipated): August 31, 2025

Study Registration Dates

• First Submitted: December 20, 2021
• First Submitted That Met QC Criteria: January 14, 2022
• First Posted (Actual): January 28, 2022

Study Record Updates

• Last Update Posted (Actual): February 28, 2022
• Last Update Submitted That Met QC Criteria: February 9, 2022
• Last Verified: February 1, 2022

More Information

Terms related to this study

• Keywords: Positron Emission Tomography; Functional Magnetic Resonance Imaging; Magnetic Resonance Imaging; Oral Contraceptive; Hormone sensitivity; serotonin 4 receptor; 5-HT4 receptor; (11C)SB207145
• Additional Relevant MeSH Terms: Mental Disorders; Mood Disorders; Depressive Disorder; Depressive Disorder, Major; Physiological Effects of Drugs; Reproductive Control Agents; Contraceptive Agents, Female; Contraceptive Agents; Contraceptives, Oral; Contraceptives, Oral, Combined
• Other Study ID Numbers: 2021-003366-13

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: Yes
• IPD Plan Description: When the planned analyses from the trial are published, the data will become publicly available. According to the Danish legislation, data will be available only by approval by the Danish Data Protection Agency and with a signed agreement.
• IPD Sharing Time Frame: Data are expected to become available from December 2026.
• IPD Sharing Access Criteria: Data will be available on reasonable request via an application to the Cimbi database of molecular brain PET in healthy humans. Access can be requested through the procedures outlined here: https://cimbi.dk/index.php/documents/category/3-cimbi-database.
• IPD Sharing Supporting Information Type: Study Protocol

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No