Conditions: Contraception
Keywords: Contraception, oral Ethinyl Estradiol Estradiol Valerate Dienogest Insulin resistance Chronic inflammation Coagulation
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 59
Healthy volunteers: yes

Brief summary:
The main objective of the study is to compare the metabolic effects of natural estradiol and synthetic ethinylestradiol used in combined oral contraception in healthy women. A progestin-only preparation will be used in comparison. The main goal is to study the effects on glucose metabolism, coagulation and a markers of chronic inflammation (such as hs-CRP). Our hypothesis is that the natural estradiol preparation will influence blood glucose levels, markers of coagulation and chronic inflammation less than the ethinylestradiol preparation. The progestin-only preparation will not effect these parameters.

Detailed description:

Arms:
arm 1: Ethinyl estradiol / dienogest arm 2: Estradiol valerate / dienogest arm 3: Dienogest

Interventions: intervention 1: Ethinyl estradiol / dienogest intervention 2: Estradiol valerate / dienogest intervention 3: Dienogest
Intervention descriptions: intervention 1: One tablet orally for 9 weeks, continuous use intervention 2: One tablet orally for 9 weeks, continuous use intervention 3: One tablet orally for 9 weeks, continuous use

Protocol document:
Prot_000.pdf: 
Synthetic vs Natural Estradiol in Combined Oral 
Contraception (SYLVI study) 
 
 
 
Registration: NCT02352090 
 
Last updated: 21.4.2014 
 
Publications: 
 
Haverinen A, Kangasniemi M, Luiro K, Piltonen T, Heikinheimo O, Tapanainen JS. Ethinyl 
estradiol vs estradiol valerate in combined oral contraceptives - Effect on glucose tolerance: 
A randomized, controlled clinical trial. Contraception. 2021 Jan;103(1):53-59. doi: 
10.1016/j.contraception.2020.10.014. Epub 2020 Oct 21. PMID: 33098852. 
 
Found at: https://www.contraceptionjournal.org/article/S0010-7824(20)30384-X/fulltext 
 
Kangasniemi MH, Haverinen A, Luiro K, Hiltunen JK, Komsi EK, Arffman RK, Heikinheimo O, 
Tapanainen JS, Piltonen TT. Estradiol Valerate in COC Has More Favorable Inflammatory 
Profile Than Synthetic Ethinyl Estradiol: A Randomized Trial. J Clin Endocrinol Metab. 2020 
Jul 1;105(7):dgaa186. doi: 10.1210/clinem/dgaa186. PMID: 32303765. 
 
Found at: https://academic.oup.com/jcem/article-
abstract/105/7/e2483/5821528?redirectedFrom=fulltext 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
2 
Study protocol 
Title 
Synthetic vs.Natural Estrogen in Combined Oral Contraceptives – Effects on Insulin Sensitivity, 
Inflammation, Coagulation and Endometrium. A Comparison with a Progestin-only 
Preparation. A Randomized Clinical Trial. 
Abbreviated title 
SYLVI-study 
Research group 
Annina Haverinen M.D., Ph.D. Student, University of Helsinki. OB/GYN resident, The Hospital 
District of Helsinki and Uusimaa 
Marika Kangasniemi B.M, Ph.D. Student, Oulu University Hospital 
Terhi Piltonen M.D., Ph.D., OB/GYN resident. Oulu University Hospital. Department of 
Gynecology and Obstetrics, University of Oulu. Clinical Researcher for Academy of Finland. 
Oskari Heikinheimo M.D., Ph.D., Professor, Specialist in OB/GYN, Head of department. 
Helsinki University Central Hospital, Kätilöopisto Hospital. Department of Gynecology and 
Obstetrics, University of Helsinki. 
Juha Tapanainen M.D., Ph.D., Professor, Specialist in OB/GYN, Chief physician. Helsinki 
University, Helsinki University Central Hospital, Naistenklinikka Hospital. Department of 
Gynecology and Obstetrics, University of Helsinki. 
Research centers 
The trial sites are in Helsinki Kätilöopisto Hospital or Naistenklinikka Hospital and in Oulu, 
Oulu University Hospital. 
Kätilöopisto Hospital: Sofialundinkatu 5 A, 00610 Helsinki, Finland 
Naistenklinikka Hospital; Haartmaninkatu 2, 00290 Helsinki, Finland 
Helsingin kaupungin ehkäisyneuvonta: Toinen linja 4 C, 00530 Helsinki, Finland 
Oulu University Hospital: Kajaanintie 50, 90200 Oulu, Finland 
 
 
 
 
 
 


 
3 
Background 
 
The latest formulations of combined oral contraceptives (COC) are based on natural estradiol 
(E2) or its ester estradiol valerate (EV) and antiandrogenic, “fourth generation” progestins. 
Conventional COCs, consisting of synthetic ethinyl estradiol (EE) and different progestins, are 
known to have a negative effect on insulin sensitivity, lipid profile and markers of chronic 
inflammation. Furthermore, conventional COCs induce a change in hemostasis to a more 
prothrombotic state, contributing to the most feared adverse event of COCs, venous 
thromboembolism. This new estradiol based COCs might have a reduced metabolic impact, 
due to a decreased influence on hepatic metabolism and the pharmacological properties of 
antiandrogenic progestins. Previous comparative trials on the metabolic effects of COCs have 
in general been done with preparations containing different doses of EE and E2 combined 
with different types of progestins which hampers with the interpretation of the estrogen 
components effects.  
Aim 
The aim of the study is to compare the metabolic effects of natural estradiol and synthetic 
ethinyl estradiol used in combined oral contraception in healthy, young women.  
Objectives 
The objective of the study  is to evaluate the effects of estradiol valerate (EV) combined with 
dienogest (EV+DNG) compared with ethinyl estradiol (EE) combined with dienogest (EE+DNG) 
on glucose metabolism, inflammation, coagulation activity and other biomarkers. A 
dienogest-only (DNG) preparation will be included in the study as an active control. 
 
Hypothesis 
We hypothesize that the EV+DNG preparation will influence glucose tolerance, biomarkers of 
chronic inflammation and coagulation activity less than the EE+DNG preparation. The DNG-
only preparation will not affect these variables. 
 
Outcome measures 
 
 
Primary Outcome Measure 
• A change in Matsuda index (whole body sensitivity index) from baseline to nine 
weeks 
 
Secondary Outcome Measures 
• Coagulation biomarkers 
• Lipids and markers of chronic inflammation 
• Possibility to ad hoc studies on other biomarkers 
• Bleeding diary, QAL questionnaires 
• Proliferation markers of the endometrium 
 
 


 
4 
 
 
Study design 
 
This is a nine-week, non-blinded, three parallel-group, active-control  clinical randomized trial. 
Enrollment will begin after between April 2015 in Helsinki University and Oulu University 
hospitals.  
 
Study treatments 
 
We will compare the effects of the following hormonal preparations on metabolical 
biomarkers: 
• Group 1—EV+DNG 1–2 mg/2–3 mg (Qlaira® day 1-5 EV+DNG 2 mg/2 mg, day 6–
21 EV+DNG 2 mg/3 mg)  
• Group 2—EE+DNG 0.03 mg/2 mg (Valette® day 1–21 EE+DNG 0.03 mg/2 mg, day 
22–28 placebo) 
• Group 3—DNG-only 2 mg (Visanne® day 1–28 DNG 2 mg).  
Qlaira® and Visanne® were manufactured by Bayer AG, Germany, and Valette® by Jenapharm, 
Germany (Bayer AG).  
Original preparation packages will  altered to match for hormonal contents. Seven tablets will 
be removed from all packages (all placebo and some active tablets), leaving a total of 21 
tablets in each. Study medications will be used continuously without breaks for 63 (21x3) 
days.  
 
 
Figure 1. Hormonal contents of the study preparations 
 
Study participants  
 
Based on the sample size calculation 48 women are needed to find the anticipated difference 
in Matsuda Index. We aim to enroll 60 women to account for possible discontinuation or 
losses to follow up. Voluntary women will be recruited by advertisements in hospital intranet,  
magazines directed to students, flyers in applied science schools and by direct e-mails to 
student organizations.  
 
 
Inclusion criteria 
• 18-35 years 
• Regular menstrual cycle (28 +/- 7 days) 
• Normal weight (body mass index 19-24.9) 
• No regular medications or chronic disease 
• Non-smoking 
Day 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 11 12 13 14 15 16 17 18 19 20 21 
EV+DNG EV 2 mg + DNG 2 mg 
EV 2 mg + DNG 3 mg 
EE+DNG EE 0.03 mg + DNG 2 mg 
DNG 
DNG 2 mg 


 
5 
• Two-month wash-out from hormonal contraceptive use 
• Polycystic ovary syndrome 
 
Exclusion criteria 
• Contraindications for oral contraceptive use (World Health Organization 
medical eligibility criteria for contraceptive use) 
• Pregnancy 
• Lactation 
• Drug or alcohol abuse 
• Finings in gynecological  
• High blood pressure (>140/90 mmHg) 
• Disturbance in glucose tolerance 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
6 
Protocol 
 
Eligible women will be clinically examined before randomization. Anthropometric 
measurements include; height, weight, hip and waist circumference. Additionally, we 
measured blood pressure and women underwent a gynecological exam including sonography. 
We screened women for polycystic ovary syndrome (clinical diagnosis) according to 
Rotterdam criterion and disturbances in carbohydrate metabolism according to WHO by two-
hour glucose tolerance test and excluded women with signs of either.   
 
Study flow 
 
Figure 2 Study flow 


 
7 
 
Screening visit/Study Visit 1 – Baseline, before treatment 
In early menstrual cycle (cycle day 1-5) study preparations will be commenced on the 
following day (cycle days 2–6).  
• Gynecological exam, including vaginal ultrasound 
• Endometrial sample 
• Anthropometric measures, 2h-oralglucose tolerance test, blood samples for 
biomarkers  
• Blood pressure measurement 
• Filling out questionnaires 
 
Study Visit 2 – 5th week of treatment 
• Anthropometric measures, blood samples for biomarkers  
• Blood pressure measurement 
 
Study Visit 3 – 9th week of treatment 
• Gynecological exam, including vaginal ultrasound 
• Endometrial sample 
• Anthropometric measures, 2h-oralglucose tolerance test, blood samples for 
biomarkers  
• Blood pressure measurement 
• Returning bleeding diary 
• Filling out questionnaires 
 
Financial plan 
 
This study is investigator-initiated and will not receive any financial sponsoring from the 
pharmaceutical industry. The study will be financed by the University of Helsinki and Oulu 
research funds, the Academy of Finland, Svenska Kulturfonden, The Finnish Medical Society, 
Finska Läkaresällskapet and Eemil Aaltonen Foundation.  
 
Ethical Considerations 
 
• All participants are insured by the patient insurance during this study.  
• All adverse events will be reported. Serious adverse events it will be reported to FIMEA 
(the Finnish Medicines Agency) and the participant will discontinue the study 
medication.  
• Participation in this study is based on informed consent.  
• This study will be conducted in accordance with the Declaration of Helsinki.  
• The study protocol is approved by the Independent Ethics Committees of Helsinki and 
Oulu University Hospitals and permission to conduct the study was given by both 
hospitals.  
 
Registration 
The study will be registered in the www.clinicaltrials.org and Eudra-CT databases. 


 
8 
 
Results 
 
The results of this study will be reported according to CONSORT guidelines. 

SAP_001.pdf: 
 
Synthetic vs Natural Estradiol in Combined Oral 
Contraception (SYLVI study) 
Registration: NCT02352090 
Last updated: 21.4.2014 
Publications: 
Haverinen A, Kangasniemi M, Luiro K, Piltonen T, Heikinheimo O, Tapanainen JS. Ethinyl 
estradiol vs estradiol valerate in combined oral contraceptives - Effect on glucose tolerance: 
A randomized, controlled clinical trial. Contraception. 2021 Jan;103(1):53-59. DOI: 
10.1016/j.contraception.2020.10.014. Epub 2020 Oct 21. PMID: 33098852. 
Found at: https://www.contraceptionjournal.org/article/S0010-7824(20)30384-X/fulltext 
 
Kangasniemi MH, Haverinen A, Luiro K, Hiltunen JK, Komsi EK, Arffman RK, Heikinheimo O, 
Tapanainen JS, Piltonen TT. Estradiol Valerate in COC Has More Favorable Inflammatory 
Profile Than Synthetic Ethinyl Estradiol: A Randomized Trial. J Clin Endocrinol Metab. 2020 Jul 
1;105(7):dgaa186. DOI: 10.1210/clinem/dgaa186. PMID: 32303765. 
Found at: https://academic.oup.com/jcem/article-
abstract/105/7/e2483/5821528?redirectedFrom=fulltext 
 
 
 
 


Statistical Analysis Plan 
SYLVI- study 
 
Power Calculation  
The power calculation is based on our previous study showing that the Matsuda index 
decreases 23% (from 7.3 [±2.9] to 5.6 [±2.8]) during the use of COC containing EE for nine 
weeks 1. COCs containing EV have not been shown to affect glucose tolerance 2–4. Therefore 
we hypothesize that the Matsuda index decreases significantly in the EE group but remains 
unaffected in the EV and DNG-only groups 2. Based on this previous data, the effect size was 
estimated to be f = 0.25 (f as defined by Cohen). With the significance level set at <0.05 (the 
risk of a-error) and the desired power at 0.8 (risk of 1-b error), 16 participants were required 
in each of the three groups. We aimed to enroll 60 women to allow for possible 
discontinuation 
or 
loss 
during 
follow-up. 
We 
used 
the 
G*Power 
software 
(www.gpower.hhu.de) for the sample size calculation.  
 
Randomization 
The study subjects will be allocated to three parallel treatment groups by randomization in a 
1:1:1 ratio and blocks of six. A statistician will produce the randomization list using a web-
based randomizer (www.sealedenvelope.com). Two research nurses will allocate the women 
to the treatment groups after established eligibility. 
 


Statistical Analysis 
We will use IBM SPSS version 25 and 27 and Prism 9 (Graphpad) for Mac iOS for all statistical 
calculations. The significance level will be set at <0.05. Summarized data will be expressed as 
mean (±SD or 95%CI) or medians (ranges) as appropriate. The change from baseline will be 
described as mean (95%) or median (range) as applicable. Shapiro-Wilks test will test the 
normality of the data, and skewed variables will be log-transformed if needed. Comparisons 
of baseline demographic characteristics among the three groups will be performed using one-
way analysis of variance (ANOVA). Repeated measures will be analyzed with one-way multiple 
measures ANOVA (analysis within-group) and two-way multiple measures ANOVA (analysis 
between groups) or the hierarchal linear mixed model. Corrections for multiplicity 
(Bonferroni) will be applied. Parametric and nonparametric counterparts will be used to 
compare the within-group changes for secondary outcomes. The between-group changes 
from baseline will be analyzed by ANOVA or Kruskal-Wallis test with post hoc tests.  
 
 
 
 
 
 
 
 
 
 
 


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Piltonen T, Puurunen J, Hedberg P, et al. Oral, transdermal and vaginal combined 
contraceptives induce an increase in markers of chronic inflammation and impair 
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3.  
Junge W, Mellinger U, Parke S, Serrani M. Metabolic and haemostatic effects of 
estradiol valerate/dienogest, a novel oral contraceptive. Clin Drug Investig. 
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4.  
De Leo V, Fruzzetti F, Musacchio MC, Scolaro V, Di Sabatino A, Morgante G. Effect of a 
new oral contraceptive with estradiol valerate/dienogest on carbohydrate 
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doi:10.1016/j.contraception.2012.09.003