Depot leuprolide acetate versus danazol for treatment of pelvic endometriosis: changes in vertebral bone mass and serum estradiol and calcitonin

OBJECTIVE

To determine changes in trabecular vertebral bone mass, serum E2, and serum calcitonin during and after therapy of pelvic endometriosis with depot leuprolide acetate (LA) or danazol.

DESIGN

Prospective, randomized, double-blind study.

SETTING

Academic university hospital and department of obstetrics and gynecology.

PATIENTS

Twelve women with symptomatic pelvic endometriosis diagnosed and staged by laparoscopy.

INTERVENTIONS

All patients received blinded treatment with either 3.75 mg JM depot LA given every month and daily placebo tablets (n = 6) or 800 mg oral danazol daily with a monthly placebo injection (n = 6) for 24 weeks.

MAIN OUTCOME MEASURES

Quantitated computerized tomography of bone density of thoracic 12 to lumbar 4 vertebral bodies were determined before, at the end of 24 weeks of treatment, and 6 and 12 months after completing treatment. Gain or loss of bone mass was based against pretreatment levels. Serial serum levels of E2 and calcitonin before, throughout, and after therapy were compared with changes in bone mass.

RESULTS

Bone loss with LA was 14.0% +/- 0.5% (mean +/- SEM), recovering to a deficit of 4.2% +/- 3.8% and 3.3%, 6 and 12 months after stopping therapy. Danazol increased bone by 5.4% +/- 2.2%, with a further gain to 8.2% +/- 3.5% and 7.5%, 6 and 12 months after stopping treatment. Serum E2 levels usually were < 25 pg/mL (conversion factor to SI unit, 3.671) with LA but > 47.3 pg/mL with danazol. Calcitonin levels did not change significantly with either treatment.

CONCLUSION

Depot LA produced marked sustained hypoestrogenemia and significant bone loss with incomplete recovery 1 year after stopping treatment. Danazol maintained normoestrogenemia and increased bone mass with the gain maintained even 1 year after stopping therapy.

Baboon corpus luteum: epidermal growth factor receptor messenger ribonucleic acid expression during early, midluteal, and late luteal phases

OBJECTIVE

To determine the presence and compare the relative abundance of messenger RNA for epidermal growth factor receptor (EGFR) in baboon corpora lutea of different luteal ages.

DESIGN

Prospective controlled nonhuman primate study.

SETTING

Animal facility in an academic research institution.

PARTICIPANTS

Six adult female baboons with well-defined regular menstrual cycles. Stage of the menstrual cycle was determined by observation and scoring of perineal turgescence. The day of maximal turgescence was referred to as the day of LH surge.

INTERVENTION

Ten corpora lutea were obtained by luteectomy during early (LH + 1 to 5 days, n = 3), midluteal (LH + 6 to 10 days, n = 3), and late (LH + 11 to 15 days, n = 4) luteal phases.

MAIN OUTCOME MEASURE

Relative levels of messenger RNA for EGFR as determined by ribonuclease protection assay using RNA probe generated from complementary DNA for human EGFR.

RESULTS

Messenger RNA for EGFR is present in baboon corpora lutea with relative levels of 0.51 +/- 0.18 (mean +/- SEM) in the early, 0.43 +/- 0.17 in the midluteal, and 0.50 +/- 0.17 arbitrary units in the late luteal phase.

CONCLUSION

Baboon corpus luteum is a site of EGFR production; the levels of its messenger RNA did not change appreciably throughout the luteal phase.

Quality of life during sequential hormone replacement therapy -- a placebo-controlled study

OBJECTIVE -- The purpose of the study was to determine the efficacy of sequential 17 beta-estradiol and norethindrone acetate (Trisequens) in the relief of vasomotor symptoms by comparing the quality of life data from questionnaires, number and severity of symptoms, and the dropout rate versus placebo treatment. STUDY DESIGN -- Women 40 to 60 years old, who spontaneously complained of menopausal symptoms, were randomly allocated to four consecutive cycles with Trisequens (n = 40) or placebo (n = 42). Analysis of variance and two-tailed tests (P < .05) for all comparisons were used. RESULTS -- The mean number of pretreatment vasomotor symptoms per day was 7 (1.3 severe) for Trisequens and 6 (1.8 severe) for placebo, whereas posttreatment a reduction to 1.3 (0.1 severe) versus 4.2 (1.8 severe), respectively, was observed. Quality of life scores, utilizing the Kupperman Scale, 3-Factor Green Index, and Beck Depression Inventory all produced statistically significant differences (P = 0.0015, 0.0037, 0.0026, 0.0003, 0.0242, respectively). The dropout rate difference between groups was significant (P = 0.028): 12 from the Trisequens group and 23 from the placebo group. CONCLUSION -- Trisequens significantly improves vasomotor symptoms. Quality of life rating scales provide additional data to support the utility of sequential estrogen/progestin treatment for menopause therapy.

Epidermal growth factor receptors in human corpora lutea during the menstrual cycle and pregnancy

We have demonstrated the presence of epidermal growth factor (EGF) and its receptors in human non-gestational corpora lutea. To determine further the characteristics of EGF receptor binding, we examined 30 human corpora lutea throughout the luteal phase and during pregnancy. Scatchard plots of EGF binding in 29 of the 30 corpora lutea were curvilinear, suggesting negative co-operativity. The mean +/- SE of the association constant Ka was (0.9 +/- 0.2) x 10(9) l/mol, the dissociation constant Kd was (2.2 +/- 0.3) x 10(-9) mol/l and the number of binding sites (Rt) was (15.8 +/- 2.1) x 10(-19) mol/micrograms protein for non-gestational corpora lutea. The Kd increased significantly in late pregnancies compared to early pregnancies (P = < 0.005), while Rt was significantly higher in term pregnancies than in either early pregnancy (P < 0.01) or the menstrual cycle (P < 0.001). Corpora lutea atretica (n = 2) and ovarian stroma (n = 6) did not show any EGF binding activity. Our findings demonstrate the presence of specific EGF receptors in human corpora lutea of both the menstrual cycle and pregnancy. The changes in EGF binding parameters in early pregnancy suggest that there may be a relationship between the role of EGF and ovarian steroidogenesis.

Baboon corpus luteum: autonomous pulsatile progesterone secretion and evidence for an intraluteal oscillator demonstrated by in vitro microretrodialysis

Pulsatility of serum progesterone (P) is usually ascribed to stimulation of the corpus luteum (CL) by pulsatile release of pituitary LH. We investigated P secretion by the primate CL by performing microretrodialysis on 6 fresh CL obtained at laparotomy from baboons (Papio anubis) with well defined menstrual cycles. Individually microdialyzed for 24-26 h with Dulbecco's Modified Eagle's Medium and Ham's F-12 enriched with HEPES buffer in a perifusion chamber, the retrodialyzed fluid was collected every 10 min and measured for P, estradiol, and 17 alpha-hydroxyprogesterone by specific and sensitive RIAs. The chronodynamics of hormone secretion were analyzed for pulse detection by PC-Pulsar 3.0. All 6 CL (2 each from early, LH +1 to +5; mid, LH +6 to +10; and late luteal phases, LH +11 to +15) demonstrated pulsatile secretion of P in vitro, with distinct and detectable peaks over the 24-26 h studied. The CL secreted 23-27 pulses of P in 24 h in early luteal, 8-20 pulses in midluteal, and 6-19 pulses in late luteal phases. Peak lengths were 23.8 +/- 18.5 to 35.7 +/- 17.1 min. Four CL gave interpeak intervals of 46-55 min, whereas two gave intervals of 136-137 min. Analysis of distribution of pulses against different interpulse intervals in individual CL and all CL together revealed a bell-shaped distribution, with the largest number of pulses seen at an interpulse interval of 21-40 min. Because of the low concentrations of estradiol and 17 alpha-hydroxyprogesterone retrodialyzed, a similar analysis of these data was not possible. Histological examination of the tissue at the termination of the experiment using hematoxylin and eosin and localization of 3 beta-hydroxysteroid dehydrogenase activity indicates that the steroidogenic potential of the tissue is minimally affected, although some morphological changes do occur. Our findings suggest autonomous pulsatile P secretion by the primate CL, indicating local control by and the presence of an intraluteal oscillator or pulse generator for P secretion.

In vitro microdialysis of the ovine corpus luteum of pregnancy: effects of insulin-like growth factor on progesterone secretion

The effects of insulin-like growth factor-1 (IGF-1) and cAMP on progesterone (P) secretion by CL of streptozotocin-induced-diabetic pregnant ewes were compared with the effects on normal pregnant animals. Two types of CL were identified in the ovaries removed on Days 126.6 +/- 2 of pregnancy. They were either large, reddish in color, and vascular (type A) or small and pale yellow (type B). Both types were found in diabetic and normal sheep. Each CL was divided in two and perfused in parallel for 14 h in an in vitro microdialysis-perifusion system. One half was used to evaluate basal P secretion and the effect of cAMP. The effect of IGF-1 and cAMP infusion was studied in the other half. During microdialysis, fractions were collected every 15 min, and P was determined by RIA. IGF-1 stimulated secretion of P in the large type A, normal and diabetic sheep CL in discrete pulses. The smaller CL (type B) from normal sheep produced comparatively higher levels of P in discrete pulses in the presence of IGF-1. However, the small CL from diabetic sheep showed no response to IGF-1 or cAMP, and P secretion was lower. Thus, it is probable that the large CL may be the "active" CL producing P and that IGF-1 stimulates pulsatile P secretion in such CL from both normal and diabetic pregnant sheep.

Human corpus luteum: human chorionic gonadotropin receptors during ectopic pregnancy

OBJECTIVE

To examine hCG receptor levels and binding kinetics in corpora lutea (CL) from tubal pregnancies.

DESIGN

Corpus luteum from tubal pregnancies, term normal pregnancies, and midluteal phase were obtained and compared for hCG binding.

SETTING

Department of Obstetrics and Gynecology, University Hospital.

INTERVENTIONS

Corpus luteum were obtained at elective cesarean section at term, tubal ligation, or surgery for ectopic pregnancy (EP).

MAIN OUTCOME MEASURES

Human chorionic gonadotropin receptor levels, dissociation and association constants using saturation binding assay, and Scatchard analysis.

RESULTS

Corpus luteum from late tubal pregnancies (> 7 weeks) and term intrauterine pregnancies had undetectable hCG binding. Corpus luteum from early tubal pregnancies (< 6 weeks) had significantly reduced hCG receptors with higher dissociation constants than from midluteal phase CL.

CONCLUSIONS

Significant reduction of hCG receptors with accelerated binding dissociation may be the basis of CL dysfunction in some EPs.

Corpus luteal insufficiency

The corpus luteum is controlled by luteinizing hormone (LH) and intraovarian morphofunctional specialization and autocrine/paracrine mechanisms. Corpus luteal insufficiency produces luteal phase defects (LPD). The poor precision and validation of endometrial histologic dating and single or random multiple serum progesterone measurements produce widely variable diagnoses. The true prevalence rate of LPD may be only 3-5% similar to that due to chance. The role of LPD in causing infertility can be challenged because the diagnosis is not predictive of recurrence in subsequent cycles, and other causes of infertility are not controlled for. Intraobserver and interobserver variability, uterine site of biopsy, luteal phase length, time of ovulation, and luteal phase timing of biopsy have been examined and have confirmed the imprecision of dating as a sensitive and reliable assessment of luteal insufficiency. There is support for either early or late luteal phase biopsy. Endometrial dating using LH timing as a reference point is relatively more reliable. Integrated luteal progesterone is the only currently accurate assessment of luteal sufficiency. Clomiphene does not increase LPD but increases serum progesterone, integrated progesterone, corpus luteum LH/human chorionic gonadotropin (hCG), and insulin-like growth factor-1 (IGF-1) receptors, all of which promote increased progesterone production and do not affect endometrial estrogen and progesterone receptors. hCG is more likely to stimulate progesterone production if given at the mid rather than early luteal phase corresponding to the phase with highest total and available (unoccupied) corpus luteal LH receptors. Careful analysis of published studies on treatment of LPD revealed only one randomized controlled study, and, statistically, all studies revealed no better outcome with progesterone treatment.

Plasma insulin-like growth factor-I, CA-125, estrogen, and progesterone in women with leiomyomas

OBJECTIVE

To determine plasma levels of insulin-like growth factor-I (IGF-I), CA-125, estrone (E1), E2, and P in women with uterine leiomyomas compared with normal women.

DESIGN

Women with leiomyomas were compared with normal women (control).

SETTING

University Department of Obstetrics and Gynecology.

PATIENTS

Fifty-one premenopausal women with uterine myomas > 14 weeks gestation and 30 normal fertile women (controls) were studied. Peripheral blood samples were obtained before myomectomy or hysterectomy and during the nonmenstruating phase in the controls.

MAIN OUTCOME MEASURES

Plasma levels of E1, E2, P, CA-125, and IGF-I were determined by specific and sensitive RIAs and immunoradiometric assays.

RESULTS

Plasma IGF-I levels were 2,006 +/- 185 mU/mL (mean +/- SEM, n = 35) and 2,335 +/- 287 mU/mL (n = 16) in women with leiomyomas during the follicular and luteal phases, respectively, whereas the corresponding values for normal women were 1,702 +/- 120 (n = 30) and 1,774 +/- 239 mU/mL (n = 30). Similarly, plasma CA-125 levels were unchanged in women with leiomyomas (myomas: 18.8 +/- 2.4, 21.5 +/- 3.7 U/mL; normal: 15.9 +/- 1.5, 15.8 +/- 1.3 U/mL during follicular and luteal phases, respectively). Women with leiomyomas had plasma E1, E2, and P levels during the follicular phase (91.9 +/- 11.5 pg/mL; conversion factor to SI unit, 3.699; 94.6 +/- 19.0 pg/mL; conversion factor to SI unit, 3.671; and 1.5 +/- 0.4 ng/mL; conversion factor to SI unit, 3.180, respectively) and the luteal phase (105.8 +/- 11.2 pg/mL; conversion factor to SI unit, 3.699; 128.7 +/- 24.8 pg/mL; conversion factor to SI unit, 3.671; and 9.6 +/- 1.6 ng/mL; conversion factor to SI unit, 3.180) similar to normal women.

CONCLUSION

Plasma levels of IGF-I, CA-125, E1, E2, and P are normal in women with leiomyomas.

Bioequivalence of a 17 beta-estradiol hydroxypropyl-beta-cyclodextrin complex in postmenopausal women

Five postmenopausal women received single doses of a 0.675 mg estradiol hydroxypropyl-beta-cyclodextrin (estradiol-HP beta CD) sublingual tablet by the sublingual and oral route. A single dose of a 1 mg micronized estradiol tablet was given orally for comparison. Blood samples were obtained over 48 hours for measurement of estradiol, estrone, luteinizing hormone (LH) and follicle-stimulating hormone (FSH) concentrations. Sublingual administration produced faster and significantly higher peak estradiol concentrations than after oral administration of either estradiol-HP beta CD or micronized estradiol. The concentration-time area under the curve of estradiol after sublingual estradiol-HP beta CD was also significantly larger than after oral administration of either estradiol-HP beta CD or micronized estradiol, reflecting a larger estradiol bioavailability. The estradiol/estrone concentration ratio after sublingual estradiol-HP beta CD revealed a predominance of estradiol for the first 2 hours after the dose, followed by an estrone predominance. Both oral doses produced a predominant delivery of estrone to the systemic circulation. There was not difference in time-averaged LH suppression between the three phases. However, estradiol-HP beta CD sublingually produced greater FSH suppression than oral micronized estradiol.

Nonsteroidal antiinflammatory drugs and reproduction

The role of nonsteroidal antiinflammatory drugs in human reproduction and reproductive disorders is reviewed. Nonsteroidal antiinflammatory drugs inhibit the biosynthesis of prostanoids and can cross the placental barrier into the fetal circulation. Nonsteroidal antiinflammatory drugs are the treatment of choice in primary dysmenorrhea and intrauterine contraceptive device-induced dysmenorrhea and menorrhagia. Nonsteroidal antiinflammatory drugs can be used for effective control of menorrhagia, preterm labor, and polyhydramnios and for prevention of preeclampsia, but larger definitive clinical trials are needed. Prostaglandin inhibition with some nonsteroidal antiinflammatory drugs appear promising in the relief of some premenstrual symptoms and in the prevention of postoperative pelvic adhesion formation, but more studies are needed in women. Whereas implantation and tubal mobility are mediated by local prostaglandins, the potential use of nonsteroidal antiinflammatory drugs to suppress prostaglandin in these reproductive processes for enhancing or reducing fertility warrants further studies. In the last 2 decades nonsteroidal antiinflammatory drugs have been used increasingly in the treatment of some reproductive disorders and are promising for many others.

Baboon corpus luteum: presence of oxytocin receptors

To determine whether the effect of oxytocin (OT) on progesterone production in primate luteal tissue may be receptor-mediated, we used biochemical procedures to examine the CL of the baboon (Papio anubis) for the presence of OT receptors (OT-R). CL (n = 5) were obtained by luteectomy from the early (LH + 1-5 days), mid- (LH + 6-10 days), and late (LH + 10-15 days) luteal phases. Biopsies from the uterine fundus were also obtained at the same time. Total receptors were measured by incubating the membrane fractions (120,000 x g fraction) with increasing concentrations of [3H]oxytocin (0.08-1.6 nM) for 30 min at 22 degrees C with a protein concentration of 200 micrograms per tube. Nonspecific binding was evaluated by the addition of excess nonradioactive OT. The receptor-bound tritiated ligand was separated from the nonreceptor-bound ligand through use of polyethylene glycol. For the midluteal phase CL, the affinity Kd was 1.70 +/- 0.03 nmol/L and the mean receptor number (RT) was 122.6 +/- 8.3 fmol/mg protein. In comparison, myometrial tissue examined at the same phase of the cycle had a Kd of 1.3 +/- 0.1 nmol/L and an RT of 205.0 +/- 49.7 fmol/mg protein. Receptors were not detectable in the late luteal phase CL and were significantly lower in the early luteal phase CL (50.7 +/- 6.9 fmol/mg protein), with no difference in the Kd value. Competitive studies with structurally related and nonrelated peptides indicated the presence of specific receptors for OT in baboon CL.(ABSTRACT TRUNCATED AT 250 WORDS)

Baboon corpus luteum: the effect of melatonin on in vitro progesterone production

OBJECTIVE

To determine the effect of melatonin on baboon corpus luteum (CL) cell progesterone (P) production.

DESIGN

Five baboon CL obtained during the midluteal phase by luteectomy were dissociated using collagenase, and incubations were performed (50,000 cells per plate) in quadruplicate for 3 hours at 37 degrees C with melatonin (0.001 to 1.0 ng/mL) (basal) or with melatonin and 10 IU of human chorionic gonadotropin (hCG) (hCG-stimulated). Total P was measured by a specific radioimmunoassay.

MAIN OUTCOME MEASURES

Progesterone concentrations measured in the presence and absence of melatonin and hCG.

RESULTS

Melatonin (0.01 to 1.0 ng/mL) inhibited basal P production in all the CL (41.8 +/- 9.9 ng P without melatonin compared with 32.2 +/- 2.0 ng P, 28.4 +/- 2.1 ng with 0.01 and 1.0 ng/mL melatonin, respectively). Human chorionic gonadotropin-stimulated P production was significantly inhibited with as little as 0.01 ng of melatonin (150.8 +/- 11.4 ng with 10 IU hCG versus 120.3 +/- 6.4 ng with 10 IU hCG and 1.0 ng melatonin). The degree of inhibition in the hCG-stimulated cells was greater than in the nonstimulated cells. Melatonin at a concentration of 0.001 ng/mL did not affect P production in both stimulated and nonstimulated cells. Serotonin in similar concentrations had no effect on luteal cell P production.

CONCLUSION

These findings indicate that melatonin exerts a suppressive effect on baboon dispersed luteal cell P production and thus may play a role in luteal function.

Impact of medical treatment of endometriosis on bone mass

A review of studies examining the effect of medical therapy of endometriosis on bone mass and potential approaches to preventing bone loss was undertaken. Studies specifically examining bone density in women with endometriosis treated medically were used. Reports on effects of oral contraceptives and progestins on bone mass were derived from women using them for contraception. Oral contraceptives and medroxyprogesterone acetate apparently did not adversely affect bone mass. While initial studies with dual-photon absorptiometry were unable to detect appreciable bone loss with gonadotropin-releasing hormone agonist, subsequent studies have invariably found significant bone loss beginning as early as 3 months of treatment. Quantitated computerized tomography always shows significant trabecular bone loss of the vertebrae and hip with gonadotropin-releasing hormone agonist. Depot preparations appear to produce more marked loss than daily injections of intranasal spray. Recent studies indicate recovery of bone loss may take longer than 6 months or even 1 year after discontinuation of therapy with considerable individual variation. Danazol produced bone gain. Bone loss with gonadotropin-releasing hormone agonists could be prevented or attenuated with progestins, and this is worthy of further studies. Impact of medical therapy on bone mass should be a practical consideration in the selection of patients, in repeat medical therapy for recurrence of endometriosis, and in formulation of medical therapy so as to attenuate or overcome such silent adverse effects.

Insulin-like growth factor I receptors in human corpora lutea

OBJECTIVE

To determine the presence and binding characteristics of insulin-like growth factor (IGF) receptors in corpora lutea (CL) of spontaneous and clomiphene citrate (CC)-induced cycles and to identify any relationship between IGF receptors and cytosol progesterone (P) and 17 alpha-hydroxyprogesterone (17 alpha-OHP) levels.

DESIGN

Women undergoing bilateral tubal ligation were divided into two groups. One group received no medication (controls) and the other took 50 mg of CC. Midluteal phase CL were recovered at tubal ligation for hormone and receptor analysis.

SETTING

Patients were recruited from a university hospital setting.

PATIENTS

Eleven fertile women 26 to 37 years of age requesting bilateral tubal ligation were studied.

INTERVENTIONS

Four women were given 50 mg/d of CC from days 5 through 9 of study cycle. Seven women did not take any medication. Minilaparotomy bilateral tubal ligation and luteectomy were performed 7 to 9 days after midcycle urinary (LH) surge.

MAIN OUTCOME MEASURES

Insulin-like growth factor receptor concentrations and binding characteristics and cytosol P and 17 alpha-OHP levels in individual CL.

RESULTS

Optimal binding for 125I-IGF-I with membrane fractions of homogenized CL was obtained with incubation at 4 degrees C for 16 hours. Specific binding (mean +/- SEM) was significantly higher in CC-treated (53.6% +/- 4.8%) than in control cycles (25.9% +/- 5.5%, P less than 0.001). Receptor concentrations were also significantly higher in CL from CC-induced (145.6 +/- 21.8 pmol/mg protein) than from control cycles (74.8 +/- 15.2 pmol/mg protein, P less than 0.02). Insulin-like growth factor receptor levels correlated with neither serum nor cytosol P and 17 alpha-OHP in CL from either cycles.

CONCLUSION

Specific IGF-I receptors are present in human CL of the menstrual cycle with higher concentrations present in CC-induced cycles. Thus IGF may express its action on luteal function through its receptors in CL.

Histology of midluteal corpus luteum and endometrium from clomiphene citrate-induced cycles

OBJECTIVE

To determine the histologic development of midluteal corpus luteum (CL) and endometrium in normal fertile women after induction of ovulation with clomiphene citrate (CC). DESIGN, PATIENTS, INTERVENTIONS: Twelve normally cycling women planning to undergo an elective tubal ligation were treated with 50 to 150 mg of CC daily on days 5 through 9 of the cycle. Luteectomy and endometrial biopsy were performed simultaneously 7 days after the urinary luteinizing hormone surge.

RESULTS

Because polyovulation occurred in 10 of the 12 women, 22 CL and 12 endometrial biopsies were studied. Ten women had luteal and endometrial histology that were within 2 days of the ovulation to biopsy interval. The 2 remaining women had endometrial histology that lagged 3 days behind the chronological postovulatory date. In these women, out-of-phase endometrium occurred despite polyovulatory cycles in which two and three histologically normal CL lutea were present and associated with elevated progesterone concentrations.

CONCLUSIONS

In CC-induced ovulatory cycles: (1) midluteal CL histology is normal and (2) apparently out-of-phase preimplantation endometrium occurs in midluteal phase.

Effect of clomiphene citrate on the synthesis and release of the human beta-lactoglobulin homologue, pregnancy associated endometrial alpha 2-globulin, by the uterine endometrium

As an extension to a previous study to examine the effects of clomiphene citrate (CC) on human chorionic gonadotrophin/luteinizing hormone (LH) receptors in human corpora lutea, we sought to determine the effect of CC on the synthesis of the beta-lactoglobulin homologue, pregnancy associated endometrial alpha 2-globulin (alpha 2-PEG) by the luteal phase human endometrium. Seventeen normally-cycling women aged 25.9 +/- 2.1 years (mean +/- SE), undergoing elective tubal ligation, were divided into four groups consisting of controls (n = 2) and three treatment groups. Each of the treatment groups (n = 5/group) was treated with either 50 mg (group 1), 100 mg (group 2) or 150 mg (group 3) of CC daily on days 5 to 9 of the cycle. Portions of endometrial tissue were obtained by curettage 7 to 9 days following the urinary LH surge and were either fixed for histological analyses or cultured in vitro in the presence of [35S]methionine. Tissue media (TCM) that were analysed by two-dimensional gel electrophoresis followed by fluorography indicated that the synthesis of alpha 2-PEG was most markedly reduced in groups 2 and 3. Densitometric scans of TCM Western blots and radioimmunoassay (RIA) of TCM showed that the overall synthesis of alpha 2-PEG decreased from 5.8 +/- 1.9 arbitrary units (AU) and 371.2 +/- 239.3 ng/ml in group 1 to 3.1 +/- 0.8 AU and 69.4 +/- 24.9 ng/ml, and 2.7 +/- 1.1 AU and 52.4 +/- 19.8 ng/ml in groups 2 and 3 respectively. On cycle days 20-22, control values were 5.8 AU and 498.1 ng/ml respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Luteal insufficiency: correlation between endometrial dating and integrated progesterone output in clomiphene citrate-induced cycles

Midluteal phase endometrium was histologically dated with midcycle luteinizing hormone surge time in 29 cycles from 10 parous women during untreated cycles (control) and treatment with clomiphene citrate 50 mg and 150 mg daily on days 5 through 9. Integrated progesterone output for 7 days after luteinizing hormone surge calculated from the daily plasma progesterone levels was 66.6 +/- 9.8 ng/ml in the control group compared with 117.5 +/- 18.6 ng/ml for clomiphene citrate 50 mg treatment and 152.1 +/- 11 ng/ml for clomiphene citrate 150 mg treatment (p less than or equal to 0.05). Only one cycle (clomiphene citrate 150 mg) had an out-of-phase endometrium and a significantly reduced integrated progesterone output of 28 ng/ml. All other cycles showed synchronous endometrial maturation. We conclude that luteal insufficiency as a result of clomiphene citrate treatment in ovulatory women is infrequent and is more likely to be a result of functional outcome of a relative lack of luteal phase progesterone output.

Induction of labor with pulsatile oxytocin

In a prospective, randomized study, 106 patients underwent induction of labor with either pulsed (every 8 minutes) (n = 50) or continuous (n = 56) intravenous infusion of oxytocin. Maternal characteristics, gestational age at induction, induction-delivery interval, analgesia for labor, cesarean section rates, and newborn characteristics were similar in both groups. The mean +/- SEM total oxytocin administered was significantly less in the pulsed group (3564 +/- 487 mU) than in the continuous group (7684 +/- 844 mU; p less than 0.0001); the average dose of oxytocin administered per minute was significantly lower in the pulsed group (3.9 +/- 0.3 mU/min) than in the continuous group (7.8 +/- 0.4 mU/min; p less than 0.0001); the peak or highest administered dose of oxytocin expressed per minute was also signficantly lower in the pulsed group (9.6 +/- 0.8 mU/min) than in the continuous group (14.1 +/- 0.7 mU/min; p less than 0.0001). These significant differences persisted even when controlled for parity, Bishop's score of the cervix, and number of days induction of labor was carried out. Uterine hyperstimulation occurred infrequently in both groups (3.6% to 4.0%). The pulsed group required a significantly smaller infusion volume (25 +/- 14 ml) than the continuous group (780 +/- 84 ml; p less than 0.0001). Thus pulsatile administration uses significantly less oxytocin and infusion fluid but is as effective and safe as continuous infusion.

Luteinizing hormone and human chorionic gonadotropin receptors in human corpora lutea from clomiphene citrate-induced cycles

Midluteal phase corpora lutea (CL) obtained from women induced with 50 mg (n = 5), 100 mg (n = 5), and 150 mg (n = 5) of clomiphene citrate (CC) were measured for luteinizing hormone/human chorionic gonadotropin (LH/hCG) concentrations and cytosol progesterone (P) and 17 alpha-hydroxyprogesterone (17-OHP) and compared with midluteal phase CL from eight normal women (controls). More CL (26) that were significantly heavier (2.0 +/- 0.3 g, [mean +/- SEM]) were obtained with CC than in controls (10). Clomiphene citrate treatment increased LH/hCG receptor concentrations and the dissociation constant significantly from 69 +/- 12 fmol/mg protein and 1.1 +/- 0.2 x 10(-10) M, respectively, in controls to 112 +/- 6 fmol/mg protein and 2.1 +/- 0.1 X 10(-10) M. Cytosol P and 17-OHP levels were not significantly increased. Cumulatively these cellular effects may be responsible for increasing serum P and responsiveness to hCG and for correcting luteal dysfunction.

Transcutaneous electrical nerve stimulation (TENS) for the treatment of primary dysmenorrhea: a randomized crossover comparison with placebo TENS and ibuprofen

In a randomized four-way crossover study, 32 women with primary dysmenorrhea were treated with transcutaneous electrical nerve stimulation (TENS) for two cycles, placebo (sham) TENS for one cycle, or ibuprofen 400 mg four times a day for one cycle. The TENS setting used was 100 pulses per second with 100-microsecond pulse widths. The subjects were allowed to adjust the amplitude to a comfortable level. The pain rescue medication was ibuprofen 400 mg as needed, up to 1600 mg/day. Significantly more subjects who had TENS treatment did not require rescue medication or required less backup ibuprofen at 0-4, 4-8, and 8-12 hours after the onset of dysmenorrhea and starting treatment, as well as during the first 24 hours and for the duration of the menstrual flow, when compared with placebo TENS or ibuprofen-treated cycles (Tukey multiple comparison, P less than .01). Transcutaneous electrical nerve stimulation significantly delayed the need for ibuprofen by an average of 5.9 hours, compared with 0.7 hours when using ibuprofen alone (P less than .05, paired t test). Transcutaneous electrical nerve stimulation alone provided good to excellent subjective pain relief in 42.4% of subjects, compared with 3.2% with placebo TENS, and significantly reduced diarrhea, menstrual flow, clot formation, and fatigue compared with placebo TENS. Transcutaneous electrical nerve stimulation plus less ibuprofen provided pain relief equivalent to that obtained with ibuprofen alone (71 and 75% of the subjects, respectively). We conclude that TENS is a safe, effective, non-medication method for managing primary dysmenorrhea and that TENS plus ibuprofen was the best overall treatment, as indicated by pain relief.

Cytosol progesterone and 17 alpha-hydroxyprogesterone levels and luteinizing hormone and chorionic gonadotropin receptors in human corpora lutea

Cytosol progesterone (P) and 17 alpha-hydroxyprogesterone (17-OHP) levels and luteinizing hormone/human chorionic gonadotropin (LH/hCG) receptors were measured in 27 corpora lutea and four corpora albicantia. Cytosol P concentrations were highest in corpora lutea (mean +/- SEM, 3.1 +/- 0.8 micrograms/g) during the midluteal phase (days 15 to 19) rather than the early (2.2 +/- 0.8 micrograms/g, days 20 to 25) and late luteal phases (1.8 +/- 0.8 micrograms/g, days 26 to 30). Cytosol 17-OHP concentrations also were 3.3 +/- 0.5, 4.3 +/- 0.6, and 3.3 +/- 1.0 micrograms/g in early, midluteal, and late luteal phases, respectively, and was significantly inversely correlated with occupied LH/hCG receptors in midluteal phase. Corpora albicantia had the lowest P (0.3 +/- 0.05 microgram/g) and 17-OHP (0.9 +/- 0.6 micrograms/g) concentrations. Cytosol P and 17-OHP may therefore reflect the balance between the luteal cell production and secretion, whereas the amount of occupied and unoccupied LH/hCG receptors may partially explain the relationship between LH and P secretion.

Retention of intrauterine fetal bone increases menstrual prostaglandins

Intrauterine retention of fetal bone is a rare complication of abortion that can cause secondary infertility by an unknown mechanism. We report such a case in which menstrual fluid prostanoids were measured to elucidate the possible pathophysiology. The pattern of prostanoid increases was similar to that seen in intrauterine device users.