Preservation of fertility in women undergoing chemotherapy: current approach and future prospects

PURPOSE

Anticancer treatment causes ovarian failure.

METHODS

Some hormones may have a protective effect on the ovary. Cryopreservation (freezing) of oocytes has had very limited success, and therefore, currently its use before chemotherapy is not a feasible option. However, cryopreservation of embryos is possible. Another solution is oocyte donation followed by in vitro fertilization (IVF).

RESULTS

Ovarian cortical slices containing primordial follicles have been cryopreserved successfully. To restore fertility, cryopreserved-thawed tissue taken from cancer patients before therapy could be replanted after recovery. The possible risk of malignancy restoration could be eliminated by obtaining unilaminar follicles from cryopreserved-thawed tissue and growing them in vitro, followed by routine IVF.

CONCLUSIONS

Although women who undergo chemotherapy face limited options for fertility preservation, intensive studies in cryopreservation and in vitro maturation of follicles harbor hope for brighter prospects in the future.

Oral contraceptives and the risk of hereditary ovarian cancer. Hereditary Ovarian Cancer Clinical Study Group

BACKGROUND

Women with mutations in either the BRCA1 or the BRCA2 gene have a high lifetime risk of ovarian cancer. Oral contraceptives protect against ovarian cancer in general, but it is not known whether they also protect against hereditary forms of ovarian cancer.

METHODS

We enrolled 207 women with hereditary ovarian cancer and 161 of their sisters as controls in a case-control study. All the patients carried a pathogenic mutation in either BRCA1 (179 women) or BRCA2 (28 women). The control women were enrolled regardless of whether or not they had either mutation. Lifetime histories of oral-contraceptive use were obtained by interview or by written questionnaire and were compared between patients and control women, after adjustment for year of birth and parity.

RESULTS

The adjusted odds ratio for ovarian cancer associated with any past use of oral contraceptives was 0.5 (95 percent confidence interval, 0.3 to 0.8). The risk decreased with increasing duration of use (P for trend, <0.001); use for six or more years was associated with a 60 percent reduction in risk. Oral-contraceptive use protected against ovarian cancer both for carriers of the BRCA1 mutation (odds ratio, 0.5; 95 percent confidence interval, 0.3 to 0.9) and for carriers of the BRCA2 mutation (odds ratio, 0.4; 95 percent confidence interval, 0.2 to 1.1).

CONCLUSIONS

Oral-contraceptive use may reduce the risk of ovarian cancer in women with pathogenic mutations in the BRCA1 or BRCA2 gene.

Two-year treatment with oral contraceptives in hyperprolactinemic patients

The aim of this prospective study was the follow-up for 2 years in symptoms, serum prolactin (PRL) levels, and radiological aspects of a group of young patients using oral contraceptives (OC) with hyperprolactinemia. A total of 16 hyperprolactinemic women (eight with idiopathic hyperprolactinemia and eight with pituitary microadenoma) who started OC use were admitted in the study. After 2 years of OC use, the assessable patients showed a nonsignificant decrease in plasma PRL level (26.8 +/- 29.4 micrograms/mL, range 4.2-97.1 micrograms/mL vs 56.3 +/- 31.5 micrograms/mL, range 23.5-144 micrograms/mL). No patient experienced any radiological changes during OC treatment. In conclusion, although the number of observations is limited, the data suggest that after 2 years of follow-up, no harmful effect of OC use was observed in these patients.

Successful pregnancy in a woman with acute myeloid leukemia treated with high-dose whole-body irradiation

BACKGROUND

Although radiotherapy is an integral part of managing certain types of hematologic malignancies, its effect on the reproductive system are well established. We report a case of successful pregnancy in a patient who received high-dose whole-body irradiation (WBI) (1,575 cGy) as part of her treatment for acute myeloid leukemia (AML).

CASE

A 26-year-old woman received high-dose cyclophosphamide accompanied by high-dose (1,575 cGy) WBI as part of her treatment for AML when she was 23 years of age. The patient received oral contraceptives before, during and after treatment. After WBI, the patient developed ovarian failure and amenorrhea, which was confirmed by hormonal evaluation. The amenorrhea persisted for one year. No recurrence of AML was found. The patient was placed on hormone replacement therapy (HRT) because of vasomotor changes. An unexpected pregnancy occurred 14 months later; HRT was discontinued. The patient delivered a normal female infant at 38 weeks of gestation. The infant was followed for eight months; her development appeared to be normal.

CONCLUSION

In this case report, it is unclear whether pregnancy resulted from active folliculogenesis remote from radiation therapy or from possible ovarian protection rendered by the use of oral contraceptives. The benefit of oral contraceptives in protecting the ovary from radiation injury is unknown and remains an area for future research.

Hirsutes. II: Treatment

The treatment of hirsutes includes cosmetic measures, such as bleaching, plucking, electrical epilation and, more recently, laser epilation. Pharmacological therapy consists of anti-androgens and includes the androgen receptor blockers spironolactone and cyproterone acetate. Other drugs reducing androgen expression include oral contraceptives and corticosteroids. A new follicular 5 alpha reductase inhibitor, finasteride, is currently under evaluation, as is the anti-androgen flutamide. Gonadotrophin-releasing hormone agonists reduce androgen expression and show early promise in the treatment of hirsutes.

Analyzing amenorrhea

When menarche has failed to occur or menstrual cycles have stopped, the problem can be traced back to a functional or structural defect in the hypothalamus, pituitary, ovaries, or uterus. In most cases, the history is the principal source of diagnostic information. Necessary laboratory studies include one for the most common cause of amenorrhea: pregnancy.

Urinary 2/16 alpha-hydroxyestrone ratio: correlation with serum insulin-like growth factor binding protein-3 and a potential biomarker of breast cancer risk

Metabolism of estradiol occurs via two mutually exclusive hydroxylative pathways, yielding metabolites of divergent biological properties. 2-hydroxyestrone (2OHE1) is anti-estrogenic while 16 alpha-hydroxyestrone (16 alpha OHE1) is a potent estrogen. The ratio of 2OHE1 to 16 alpha OHE1 (2/16 alpha-OHE1 ratio) represents the net in vivo estrogenic activity. In this study, we sought to determine if the urinary 2/16 alpha-OHE1 ratio could be a predictor of breast cancer risk and the factors which influence this ratio. Variables analysed included age at diagnosis, menopausal status, parity, use of oral contraceptives, body mass index, serum levels of insulin-like growth factor-I (IGF-I), IGF binding proteins (BPs) and the presence of breast cancer. Serum and urine were collected from 65 breast cancer patients and 36 controls after an overnight fast. Urinary estrogen metabolites were measured by enzyme immunoassays while serum levels of IGF-I, BP-1 and BP-3 were determined by immunoradiometric assays. 2OHE1 levels and 2/16 alpha-OHE1 ratios were significantly lower (P < 0.05) while 16 alpha OHE1 levels were higher (P < 0.01) in cancer patients. Multiple linear regression analysis showed that levels of urinary metabolites were influenced by parity and breast carcinoma. 2/16 alpha-OHE1 ratio correlated positively with serum BP-3 level (P = 0.03). By multiple logistic regression, 2/16 alpha-OHE1 ratio was the most significant factor predictive of breast cancer. The odds ratio for women with higher 2/16 alpha-OHE1 ratios was 0.10 (0.03-0.38, 95% confidence interval). In conclusion, the profile of urinary estradiol metabolites was distinctly altered in breast cancer patients. In addition, BP-3 may be a potential mechanism by which estradiol metabolites influence breast cancer progression. As 16 alpha OHE1 has been shown to initiate neoplastic transformation of mammary epithelial cells, the 2/16 alpha-OHE1 ratio may serve as a biomarker of increased risk of breast cancer.

Altered serum levels of insulin-like growth-factor binding proteins in breast cancer patients

BACKGROUND

Insulin-like growth factor 1 (IGF-1) has mitogenic properties for breast cancer cell lines and has been proposed to be an important factor in breast carcinogenesis. We hypothesized that differences in IGF-1 or its binding proteins might increase susceptibility to breast cancer. This case-control study was designed to investigate whether patients with breast cancer have altered levels of either IGF-1 or its intermediary modulatory proteins, the IGF binding proteins (BP).

METHODS

Serum was collected from 90 patients (63 with breast cancer and 27 with benign breast disease) after an overnight fast and before surgery. IGF-1, BP1, and BP3 levels were determined by immunoradiometric assays. In a subset of 66 patients, Western ligand blots were also performed for a semiquantitative measurement of functioning BP levels. A forward stepwise logistic regression model to adjust for other confounding variables (age, menopausal status, parity, age at menarche, use of oral contraceptives, history of breast biopsy, family history of breast cancer, hormone replacement therapy, and body-mass index) was used in the multivariate analysis.

RESULTS

Serum IGF-1 levels were similar in cases and controls. However, levels of BP3 (p < 0.001), BP4 (p < 0.01), and BP1 (p < 0.05) were significantly associated with risk of breast cancer. The level of BP3 was the most significant factor predictive of breast cancer. The odds ratio for breast cancer in women with BP3 levels >2066 ng/ml was 0.18 (95% CI, 0.05-0.55). Correspondingly, women with BP1 levels higher than 39 ng/ml had an odds ratio of 0.21 (95% CI, 0.07-0.68) for breast cancer. When considering only cancer patients (n = 63), decreasing levels of BP4 (p < 0.01) and increasing levels of BP1 (p < 0.02) were significantly associated with progesterone receptor positivity (PR+) in the tumor. The odds ratio of PR+ in patients with BP1 levels higher than 34 ng/ml was 7.49 (95% CI, 1.5-37.4). Better grade of tumor (well and moderately differentiated) was observed in patients with higher levels of BP3 (p < 0.03).

CONCLUSIONS

Distinct differences in BP profiles exist among patients with breast cancer and also among those with high-grade, hormonal receptor-negative tumors. These findings suggest that the bioavailability of IGF-1 as mediated by its binding proteins may participate in both breast carcinogenesis and selection of more aggressive breast carcinomas.

Endometriosis. The case for early, aggressive treatment

While the debate rages on regarding how metabolic and immunologic changes fit into the pathophysiology of endometriosis, the clinician must nonetheless make decisions regarding treatment. This article examines the relevant literature, with particular emphasis on immunologic aspects, nonclassic, early and deep disease as well as data on progression, recurrence and effects of treatment, to propose innovations in the management of early-stage disease. All symptomatic early-stage disease should be treated aggressively--even after conservative surgical resection of all apparent endometriosis, adjunct medical treatment in the form of a gonadotropin-releasing hormone agonist should be strongly considered.

The incidence of HIV infection among women using family planning methods in Dar es Salaam, Tanzania

OBJECTIVES

To determine the risk factors for HIV seroconversion and assess the association between contraceptive use and HIV infection among women attending three large family planning clinics in Dar es Salaam, Tanzania.

DESIGN

Prospective cohort study.

METHODS

Between 1992 and 1995, 2471 HIV-negative women were followed prospectively. Information about sociodemographic characteristics, sexual behavior, contraceptive use and other risk factors was collected at recruitment and updated at follow-up visits. At the end of the study, specimens were collected for HIV testing and laboratory diagnosis of sexually transmitted diseases.

RESULTS

The overall HIV incidence was 3.4 per 100 person-years [95% confidence interval (Cl), 2.6-4.1]. The risk of HIV seroconversion decreased with increasing age (P=0.04, test for trend). Women reporting three or more sex partners during the follow-up period had the highest risk of HIV [age-adjusted relative risk (RR), 4.89; 95% Cl, 2.61-9.17]. Having an uncircumcised husband was associated with a significantly increased risk of HIV (age-adjusted RR, 3.60; 95% Cl, 1.12-11.59). The risk of HIV was also significantly increased among women with gonorrhoea (age-adjusted RR, 3.51; 95% Cl, 1.60-7.71) and candidiasis at baseline (age-adjusted RR, 1.98; 95% Cl, 1.17-3.33) and among women reporting alcohol consumption during the follow-up period. After controlling for other risk factors, the risk of HIV infection amongst users of oral contraceptive, intrauterine device and injectable contraceptive was not significantly increased. Similarly, there was no significant trend associated with increasing duration of use of any of these contraceptive methods.

CONCLUSION

These findings confirm that a large number of new HIV infections continue to occur in this population. Reassuringly, no significant association was observed between HIV and use of specific contraceptive methods. Interventions to reduce further spread of HIV are still urgently needed.

Haemoperitoneum caused by haemorrhagic corpus luteum in a patient with type 3 von Willebrand's disease

In female patients affected by congenital coagulation disorders haemorrhagic corpus luteum must be considered for the differential diagnosis of acute abdomen. We report the complication in a 22-year-old woman with type 3 von Willebrand's disease who presented with abdominal pain and haemorrhagic shock. Along with adequate factor VIII replacement therapy oral contraceptive treatment is the key for the management of this potentially life-threatening complication and the long-term prevention of future bleeding episodes of this origin.

Treating endometriosis pain: a multidisciplinary approach

Endometriosis is a painful recurring disease for which there are several treatments but little or no clinical guides for optimal application. In order to more appropriately treat these patients, we need to take a more holistic long-term approach to disease management.

Beliefs related to the use of oral contraceptives by African American women, ages 18-35

This study looked at modal, salient beliefs regarding intention to use and use of oral contraceptives (OC) in a group of African American women aged 18-35 in a midwest urban community. Data were collected in face-to-face audio taped interviews using a format devised by Ajzen and Fishbein. Questions related to the identified behavior of deliberate action to avoid unwanted pregnancy by instituting the use of a contraceptive method. Twenty-five women consented to participate. Of these, 20 women (80%) reported using oral contraceptives as their primary birth control method. The study reports on women's perceptions of the advantages and disadvantages of OC acquisition and use and important social referents approving or disapproving of OC acquisition and use. Perceived barriers and facilitators to OC acquisition and use are also reported. Identification of individual and group attitudes regarding contraceptive behavior may be valuable in enhancing the provision of successful family planning services to women wishing to avoid delay of childbearing.

Determinants of squamous intraepithelial lesions (SIL) on Pap smear: the role of HPV infection and of HIV-1-induced immunosuppression. DIANAIDS Collaborative Study Group

This study aimed to identify risk factors for squamous intraepithelial lesions (SIL) in women with known HIV status and to explore the association between SIL, HPV subtype, and HIV-induced immunosuppression. The study population consisted of women with known HIV serological status who were attending a network of 16 clinical centres in Italy. Detailed behavioural data, clinical and laboratory parameters, and samples for diagnosis of SIL by Papanicolau smear and HPV infection using a polymerase chain reaction (PCR) were obtained from each study participant. The strength of the association between SIL and possible risk factors was assessed calculating crude and adjusted odds ratios derived from univariate analysis and multivariate models. We enrolled 236 women, of whom 135 (57.2%) were HIV-infected. SIL was diagnosed in 57 women (24.1%); of these, 48 (35.6%) were HIV-infected and 9 (8.9%) were HIV-negative. HPV-DNA was detected in 41 (72%) women with SIL and in 45 (25%) women without SIL. HPV-DNA was more often detected among HIV-infected women than among HIV-negative women (40% vs. 32%), but the difference was not statistically significant. Women infected with high-risk types or with low-risk-uncharacterised types of HPV both had a higher risk of SIL compared with HPV-negative women (respectively, AOR: 17.53 and AOR: 2.89). HIV-infected women with severe or moderate immunosuppression were more likely to have SIL than HIV-negative women (respectively, AOR: 7.29 and AOR: 3.09) also independently from HPV infection. Women reporting use of a contraceptive pill had a 2.5 times higher risk of SIL compared with those who never used hormonal contraceptives. The results confirm that high-risk HPV types are strongly associated with SIL, and that HIV infection may strengthen the effect of HPV at cervical level. The use of oral contraceptives may slightly increase the risk of SIL in women with at-risk behaviour for HIV infection.

Chronic pelvic pain: oral contraceptives and non-steroidal anti-inflammatory compounds

A correct classification of female pelvic pain originating from gynaecological disorders is essential if the most appropriate therapy is to be chosen. Certain types of non-steroidal anti-inflammatory drugs and oral contraceptives reduce the production of prostaglandins, which are responsible in large part for primary dysmenorrhoea. Oestroprogestin formulations become the drugs of choice if the patient also requests contraception. Secondary dysmenorrhoea and chronic pelvic pain may require combined medical and surgical treatment. Oral contraceptives can also be used as post-treatment agents in endometriosis, one of the most common causes of pelvic pain, whereas more specific compounds (GnRH-analogues and Danazol) are used to produce anatomical regression of endometriosis.

Does the menstrual cycle and use of oral contraceptives influence the risk of low back pain? A prospective study among female soccer players

Female sex hormones have been suggested to affect the risk of low back pain. One reason is the fact that back pain is a very common symptom during pregnancy. It also seems to be a more common problem among female than male athletes, e.g. in soccer. Although there are few scientific data supporting a relationship between female sex hormones, use of oral contraceptives and low back pain, many doctors and physiotherapists advise women with low back pain to avoid oral contraceptives. The aim of this study was to evaluate whether low back pain fluctuated during the menstrual cycle and differed between women using and not using oral contraceptives. A questionnaire was sent to 12 female soccer teams; 261 players answered and 50 players (28 with back pain and 22 controls) fulfilled the prospective study. At baseline the players underwent a thorough clinical examination and then filled in a diary concerning menstrual data, back pain, training and matches during one season. A total of 296 menstrual cycles was analysed. No difference in prevalence or severity of back pain was seen between the different phases of the menstrual cycle or between users and non-users of oral contraceptives. Our data do not support the hypothesis that low back pain is influenced by hormonal fluctuations during the menstrual cycle or by use of oral contraceptives.

Dietary habits, reproductive and menstrual factors and risk of dysmenorrhoea

In order to analyze risk factors for dysmenorrhoea, we conducted a case-control study. Cases were 106 women (median age 27 years) with moderate or severe dysmenorrhoea lasting 12 months or more. Controls were 145 women (median age 26 years) without dysmenorrhoea, admitted for routine gynecological examination at the outpatient gynecological services of the same clinic where cases had been identified. In comparison with women reporting short menstrual cycles (every 25 days or less) the relative risk (RR) of dysmenorrhoea was 2.0 and 2.6, respectively, in those reporting their menstrual cycles of 26-30 days and of 31 days or more, and the RR was 3.6 (95% confidence interval (CI): 1.0-13.4) for women reporting totally irregular menstrual cycles. The estimated RRs were, in comparison with women reporting menstrual flows lasting 4 days or less, respectively 2.2 and 1.9 in those reporting menstrual flows lasting 5 and 6 days or more. Fourty-four (58%) cases but only seven (5%) controls reported heavy menstrual flows (RR in comparison with women reporting slight or normal menstrual flow 12.6, 95% CI: 5.0-32.1). As regards dietary factors, no associations emerged between the various food items, with the exception of cheese and eggs, which tended to be more frequently consumed by cases than controls. The results of this study suggest that the risk of dysmenorrhoea is higher in women with irregular, long and heavy menstrual flows. No association emerged between reproductive history and dysmenorrhoea. Likewise, no clear relationship emerged between intake of several dietary factors and risk dysmenorrhoea.

Dysfunctional uterine bleeding and dysmenorrhea

Normal menstruation involves the breakdown, remodelling and repair of the functional endometrial layers. Endometrial destruction and regeneration are largely controlled local factors, that are dependent on the levels of estradiol and progesterone. Prostaglandins and endothelins appear to be powerful vasoactive substances in the control of menstrual blood loss. The tissue endothelin concentration may interact with relaxing factors, such as nitric oxide, prolonging or increasing menstrual blood loss. Disturbances of menstrual bleeding and dysmenorrhea are a major medical problem not only for women but also for their families and health services. Management of dysfunctional uterine bleeding is determined by the needs of the patient: oral contraceptives are used for women of reproductive age with ovulatory uterine bleeding episodes who also require contraception; they have a strong progestogenic effect that is evident as early as the first week of pill intake. In the perimenopausal patient, dysfunctional uterine bleeding may be treated by cyclic progestins with or without conjugated equine estrogens; oral contraceptives can also be used in non-smokers who have no evidence of vascular disease. Dysmenorrhea is defined as a complaint of pain experienced during or immediately before menstruation. In the pathogenesis of dysmenorrhea, prostaglandins and arachinodonic acid metabolites play an important role, being elevated in women with dysmenorrhea. Oral contraceptives are very effective in the treatment of dysmenorrhea; they act mainly by reducing the levels of the prostaglandins and arachinodonic acid metabolites. For women reluctant to take oral contraceptives, non-steroidal anti-inflammatory drugs may be a better option.

Prevalence of endometriosis in adolescent girls with chronic pelvic pain not responding to conventional therapy

STUDY OBJECTIVE

To evaluate adolescent girls with chronic pelvic pain not responding to conventional medical therapy, using advances in operative laparoscopy to determine endometriosis prevalence, clinical stage, and type of lesion.

DESIGN

A descriptive retrospective study of subjects who (1) were referred for the evaluation of chronic pelvic pain, (2) did not respond to a nonsteroidal anti-inflammatory drug and an oral contraceptive pill, and (3) underwent a laparoscopy to determine the etiology of the pelvic pain.

SETTING

Patients referred to a surgical gynecologist in a pediatric/adolescent gynecology and reproductive endocrine academic practice.

PARTICIPANTS

All patients younger than 22 years of age with chronic pelvic pain.

INTERVENTION

Operative laparoscopy to determine the etiology of the chronic pelvic pain.

MAIN OUTCOME MEASURES

Operative laparoscopy results including stage and description of endometriosis.

RESULTS

More than two thirds of the study population (69.6%) was found to have endometriosis. All subjects had either stage I or II as determined by the American Fertility Society's classification system. The nature of the pain in the 32 subjects with endometriosis was both acyclic and cyclic in 20 (62.5%), acyclic only in 9 (28.1%), and cyclic only in 3 (9.4%). Other presenting symptoms included gastrointestinal in 11 (34.3%), urinary in 4 (12.5%), and irregular menses in 3 (9.4%).

CONCLUSIONS

Adolescents with chronic pelvic pain not responding to medical therapy have a high rate of endometriosis and should be referred to a gynecologist who is experienced with the subtle laparoscopic findings of atypical endometriosis to diagnose the etiology of the pelvic pain and initiate appropriate therapy.