Treatment with oral piperazine oestrone sulphate for genuine stress incontinence in postmenopausal women

The use of oestrogens in the treatment of genuine stress incontinence was assessed by a double-blind prospective trial in 36 postmenopausal women with genuine stress incontinence who received 3 months of cyclical treatment with either piperazine oestrone sulphate or a matching placebo. Patients were assessed subjectively and objectively before and after treatment by 7-day bladder charts, urethral pressure profiles (UPP), the Urilos nappy test, vaginal cytology and hormone assays (plasma oestrogens and gonadotrophins). There was no statistical difference in the subjective response to treatment between the two groups. After 6 weeks of treatment there was a greater reduction in the number of pad changes/24 h in the oestrogen-treated patients that approached statistical significance but, because of a marked response in the placebo group, this difference was not significant after 3 months of treatment. There were also no significant differences between the two groups with respect to the UPP or Urilos measurements but the vaginal cytology and hormone profiles were significantly affected by oestrogens. In view of the possible risks of oestrogen therapy its use in genuine stress incontinence is limited.

Prediction of cardiovascular complications in patients with prostatic cancer treated with estrogen

The authors made a randomized prospective study of estrogen therapy versus orchidectomy in patients with prostatic cancer (n = 100, Huddinge Hospital, Sweden) to investigate the possibility of predicting cardiovascular events during hormonal treatment. Patients with preexisting cardiovascular morbidity were excluded (16%). Prior to the allocation of therapy, the following were performed: exercise stress test; physiologic evaluation of the peripheral circulation; blood volume estimation; chest x-ray; blood tests, including hormones, lipoproteins, and antithrombin III; and a physical examination and history by a cardiologist. Thirteen (25%) of the patients given estrogen therapy (n = 53) had cardiovascular complications during the first year of treatment compared with none in the orchidectomy group. The authors made a multivariate discriminant analysis of the pretreatment examinations of the estrogen-treated patients; this resulted in a discriminant function including S-T segment depression in lead CH2 during the exercise stress test and blood tests for cholesterol, follicle-stimulating hormone, and luteinizing hormone. This function correctly classified 84% of the estrogen-treated patients as patients with or without risk of a cardiovascular complication. Briefly stated, if patients with prostatic cancer are examined by means of exercise stress tests and blood tests for luteinizing hormone, cholesterol, and follicle-stimulating hormone prior to treatment, the discriminant function enables the authors to identify an extremely high-risk group for cardiovascular complications if estrogen therapy is commenced. The strong association of an increased luteinizing hormone with cardiovascular complications during estrogen treatment makes it mandatory to investigate its role in the pathogenesis of atherosclerosis and cardiovascular events.

Women's and physicians' utilities for health outcomes in estrogen replacement therapy

Estrogen replacement therapy (ERT) prevents fractures and relieves vasomotor symptoms, but it increases the risk of endometrial cancer. Previous studies and national prescribing patterns show that physicians are conservative in their approach to this therapy. The authors interviewed physicians and perimenopausal women to assess their utilities for the various health outcomes of estrogen replacement therapy. On all outcomes, physicians rated illness episodes followed by recovery as being closer to perfect health than did perimenopausal women. Physicians, in judging which outcomes were most important to women, estimated relief of symptoms above fracture prevention, whereas women rated fracture prevention above symptom relief. These results emphasize the need to assess patients' utilities directly, particularly when utilities for the outcome of a particular therapy may influence the choice of a therapeutic regimen.

Proximal femoral fractures

The absolute number of hip fractures is large, increasing, and related to osteoporosis as well as other factors. By 65 years of age, 50% of women will exhibit bone mineral below the fracture threshold; by age 85, 100%. Trabecular bone loss, which occurs before cortical bone loss, is characteristic of postmenopausal osteoporosis, while cortical bone loss, which increases with age (especially after the age of 70), is characteristic of senile osteoporosis. Estrogen treatment is reasonable for early postmenopausal osteoporosis, less so for the senile variety. The elderly often lose the renal ability to 1-alpha hydroxylate 25-OH vitamin D and thus lose the ability to absorb calcium; they are refractory to D3 therapy, and may require more expensive therapy with 1,25-(OH)2-vitamin D. "Trivial" trauma with falls caused by loose rugs, electric cords, and the like may often be the primary cause of proximal femoral fractures. Sedative drugs are also hazardous. The polyfactorial problem of proximal femoral fractures requires treatment by a multidisciplinary medical team.

Effect of oral hormone replacement therapy on liver function tests

Five oral methods of hormone replacement therapy (HRT) were prescribed to groups of healthy post-menopausal women and their effects on a group of liver function tests were examined. No evidence of deterioration in liver function was noted.

[Diagnosis and therapy of gigantism]

Some of the most important types of nonfamilial tall stature are discussed by stressing the clinical features, diagnostic aspects and therapeutic possibilities. The indications of treatment, the diagnostic procedures and steroid therapy of the familial type of tall stature, the predominant variant of tall stature, are presented in detail. The effects, side effects and contraindications of high dose steroid treatment are described. The important prerequisite for the evaluation of psychosomatic problems of tall stature is the understanding of the dynamics and variations of normal growth. This and the knowledge of methods concerning growth analyses continue to be the basis of an accurate diagnosis.

[Is there a correlation between the degree of proliferation of vaginal and urethral epithelium and the incidence of stress incontinence? A contribution to estrogen therapy in stress incontinence]

The extent of proliferation of the vaginal and urethral epithelium, as well as urodynamic parameters, were studied in 232 patients in order to determine whether there is a relation between the development of stress incontinence and hormone-related epithelial proliferation. A higher build-up of vaginal than of urethral epithelium was found in 74% of the patients. Even in post-menopause patients, epithelial atrophy in the vagina was only found in 29.3%, while in the urethra it was found in 61.3%. Therefore, the vaginal epithelium cannot with confidence be taken as a basis for conclusions concerning the condition of the urethral epithelium. In the group of 145 patients with urinary stress incontinence no link could be established between the extent of proliferation of the urethral epithelium, the urethral occlusion pressure and the functional length of the urethra: The occurrence of an age-related excessively low urethral occlusion pressure (hypotonic urethra) is independent of the extent of proliferation of the vaginal or urethral epithelium. Sedimentation phenomena are also seen equally frequently in cases with atrophic and eutrophic epithelium. Owing to the high percentage of overweight women among those with stress incontinence, the extent of proliferation of the vaginal and urethral epithelium often corresponds to premenopausal cell pictures even in perimenopausal and postmenopausal women; this is a consequence of increased estrogen production in the peripheral fatty tissue. Therefore, estrogen therapy is unsuccessful in women with pure urinary stress incontinence. However, the efficacy of an equivalent therapy, e.g., with estriol, has been confirmed in cases of active and combined incontinence.

[Therapy of advanced prostate cancer]

The carcinoma of the prostate gland is a malignant tumour like the other. The locoregional carcinoma of the prostate gland is locally curatively treated with prostatovesiculectomy, percutaneous high-voltage therapy or interstitial radiotherapy. The disseminated diseases of the prostate gland is systemically palliatively treated. A survey is given of the forms of therapy for the advanced carcinoma of the prostate gland. The estrogen therapy has its justification still nowadays. With the preparation Turisteron (ethinylestradiol propansulphonate) of the VEB Jenapharm an oral depot estrogen is at our disposal, which has distinctly smaller side effects than diethylstilbestrol (DES).

Hormonal replacement therapy in patients after cervical cancer treatment

Study was made of 120 patients after surgery and/or radiotherapy for Stage I and II cervical cancer. A group of 80 patients received hormonal replacement treatment: 40 patients were treated with Trisequens (Novo)--(group T), and 40 with sequentially Dienestrol and Chlormadinon (Polfa)--(group D-Ch); the remaining 40 patients received no hormone therapy (control group). For all groups the observation time was at least 5 years. In both hormonally treated groups, evaluation was made of the effect of hormonal treatment on quality of life (intensity of climacteric complaints, postradiological changes, etc.) and on the results on oncological treatment, with special consideration of the incidence of cancer recurrence. The hormonal treatment enabled control of most climacteric symptoms, without any serious side-effects as well relieved rectal, bladder, and vaginal postradiological complications. In the whole material (120 patients) the results of oncological treatment were satisfactory. In the hormonally treated group and in controls, 5-year survival without cancer symptoms was found in 80 and 65% of cases, respectively (insignificant difference). In the hormonally treated group and in the controls, the incidence of cancer recurrences amounted to 20 and 32%, respectively (insignificant difference). The promising results of the present studies suggest the need for their continuation to aim of improving of quality of life the women treated in premenopausal age for cervical cancer.

Hormonal replacement therapy: benefits, risks, doses

This chapter presents information on the indications for the use of post menopausal hormone therapy. Side effects and risks of this form of therapy are also summarized. Recommendations are made concerning the clinical management of patients receiving hormone treatment.

Serum prolactin assays have no prognostic value in treatment of prostatic cancer by orchidectomy or estrogens

Eighty patients (54-75 years) with cytologically and/or histologically confirmed cancer of the prostate (CAP) were randomly allocated to either orchidectomy (ORX, n = 41) or combined intramuscular and oral estrogen treatment (ESTR, n = 39). Serum levels of prolactin (PRL) were determined prior to treatment and 6, 12 and 24 months after initiation of the treatment. In the ORX group, 32 patients responded to the treatment and 9 did not. In the ESTR group, 27 patients responded and 12 did not. Serum PRL levels were significantly increased by ESTR treatment in responders as well as in nonresponders, but were not affected by ORX. There were no differences in PRL values between responders and nonresponders at any time in any of the two treatment groups. It is concluded that serum PRL assays have no prognostic value in the employed endocrine treatment of CAP.

The role of hormones in the etiology and prevention of endometrial cancer

Unopposed estrogens, both exogenous and endogenous, increase the risk of endometrial cancer although the magnitude of the association between estrogen replacement therapy and adenocarcinoma has been exaggerated by the epidemiologic case-control studies. Not all postmenopausal women need estrogen replacement therapy since some produce sufficient endogenous estrogens to remain asymptomatic and prevent atrophic vaginitis, osteoporosis and atherosclerosis. However, within this group may be those at risk for endometrial cancer, so they need to be identified and treated with cyclic progestogens. Sequential oral contraceptives did not protect young women from adenocarcinoma of the endometrium because of too little progestogen for too short a duration in view of the relatively high dosage of estrogen. However, combination birth control pills significantly decrease the risk for endometrial carcinoma. Endometrial hyperplasia is a precancerous lesion in some women and can be effectively reversed with 10-13 days of progestogen monthly in at least 98% of patients. The progestogen challenge test has been devised to identify postmenopausal women at greatest risk for adenocarcinoma. It should be administered to all postmenopausal women with an intact uterus. This includes asymptomatic women, patients receiving estrogen replacement therapy and women being evaluated for hormone therapy. If there is a positive response to the progestogen challenge, as manifested by withdrawal bleeding, then the progestogen should be continued for 13 days each month for as long as withdrawal bleeding results. If there is no response then the progestogen challenge test should be repeated at each annual examination. Universal use of the progestogen challenge test should prevent nearly all endometrial cancers.