Levonorgestrel

levonorgestrel, synthetic progestogen (any progestational steroid, such as progesterone) that is used as a form of contraception in women. Levonorgestrel is the mirror compound (enantiomer) of norgestrel, which was synthesized in the early 1960s by American scientist Herschel Smith at the U.S.-based company Wyeth Pharmaceuticals.

As a form of progesterone, levonorgestrel exerts its actions on the hypothalamus through a negative feedback mechanism, which causes a decrease in the secretion of luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Both LH and FSH normally stimulate ovulation. Thus, by reducing their secretion, levonorgestrel serves to inhibit ovulation. The drug also inhibits implantation, the point when a fertilized egg embeds in the uterine wall, where it will grow and develop into an embryo. In addition, levonorgestrel causes the mucus in the cervix to thicken, which blocks the ability of sperm to travel through the uterus and into the fallopian tubes, where fertilization of the egg by a sperm normally takes place.

In the early 1980s levonorgestrel became widely used in a form of contraception marketed as Norplant. In this system levonorgestrel was implanted beneath the skin of the upper arm in six Silastic (silicone-plastic) capsules, which provided birth control for five years. However, this system has been replaced by Norplant II (Jadelle), which uses a different synthetic progestogen, called etonogestrel, implanted under the skin in specially designed rods the size of matchsticks.

Today levonorgestrel may be given alone or in a formulation that also contains estradiol. One of the primary uses of levonorgestrel is in intrauterine devices (IUDs), such as Mirena. This particular IUD, once inserted into the uterus, can remain there for up to five years, releasing about 20 micrograms of levonorgestrel daily. Levonorgestrel also is used in various formulations of oral contraceptives, including in combination with estradiol in Seasonale—an extended-cycle oral contraceptive, which enables an 84-day span between menstruations—and in a morning-after pill called Plan B. In 1999 Plan B became available by prescription in the United States. In 2006, after a long politically charged debate, the U.S. Food and Drug Administration approved the sale of Plan B to women (and men) aged 18 and older without a prescription. At least 40 other countries already sold such emergency contraceptives over the counter (Plan B is marketed internationally under a variety of other trade names, including Vikela, Postinor-2, and Imediat N). When a 0.75-mg tablet is taken within 72 hours of unprotected sex, followed by a second 0.75-mg tablet within the next 12 hours, the drug is about 90 percent effective in preventing pregnancy.

The efficacy of levonorgestrel in preventing pregnancy may be altered in the presence of certain substances, including phenytoin (an antiepileptic drug), nafcillin (a penicillin-derived antibiotic), and St.-John’s-wort (an herbal supplement). Similar to other IUDs, levonorgestrel-releasing IUDs do not protect against sexually transmitted diseases, such as HIV/AIDS and herpes simplex. These devices also increase the risk of pelvic inflammatory disease and infection. Levonorgestrel taken orally sometimes causes changes in menstrual bleeding (i.e., heavier or lighter periods). Other common side effects include nausea, headache, fatigue, and abdominal pain.