Histological characteristics and altered expression of interleukins (IL) IL-13 and IL-15 in endometria of levonorgestrel users with different uterine bleeding patterns

OBJECTIVE

To determine the relationship between uterine bleeding patterns in levonorgestrel users with endometrial histology and expression of interleukins (IL) IL-13 and IL-15.

DESIGN

Prospective observational study.

SETTING

Academic research center.

PATIENT(S)

Questionnaires were sent to patients (n = 578) who had levonorgestrel implants concerning bleeding patterns; 35 of these patients were identified to have regular cycle (n = 13), amenorrhea (n = 8), or metrorrhagia (n = 14).

INTERVENTION(S)

Endometrial biopsies, serum, histology, and immunostaining.

MAIN OUTCOME MEASURE(S)

Endometrial histological assessment and immunostaining for IL-13 and IL-15 and for blood levonorgestrel, E2, and progesterone levels by ELISA or RIA.

RESULT(S)

No correlation was found between circulating levonorgestrel, E2, or progesterone levels with the bleeding patterns, although a trend toward a lower E2 level was observed in patients with amenorrhea who had inactive endometrium. There was a direct correlation between bleeding patterns and endometrial histology, as well as IL-13 and IL-15 expression in patients with regular cycles and metrorrhagia, demonstrating secretory and proliferative endometrium, respectively. Some patients in each group were also identified as demonstrating endometritis.

CONCLUSION(S)

Endometrial histology may assist directing therapy and subsequently increasing compliance in progestin-only contraceptive users with irregular bleeding who fail to respond to standard therapies. Altered endometrial expression of IL-13 and IL-15, key cytokines in inflammatory and immune cell trafficking, may influence events, leading to irregular bleeding.

Levonorgestrel and 17beta-estradiol given transdermally for the prevention of postmenopausal osteoporosis

AIM

To evaluate the efficacy and safety of a new transdermal continuous combined hormone replacement therapy (HRT) for the prevention of postmenopausal osteoporosis.

METHODS

212 osteopenic (lumbar spine and/or hip (femoral neck) bone mineral density (BMD) between -1.0 and -2.5 S.D. of the premenopausal mean value) postmenopausal women aged 45-65 years participated in a 2-year prospective study. Treatments were 45 microg 17beta-estradiol combined with 30 (n = 69) or 40 microg (n = 72) levonorgestrel daily or placebo (n = 71) given as a 7-day patch. All received a daily supplement of 500 mg calcium. BMD at lumbar spine (L2-L4), hip and total body, as well as blood and urinary biochemical markers of bone turnover (serum osteocalcin (sOC), serum bone-specific alkaline phosphatase (sBSAP), urinary calcium (uCa) and urinary CrossLaps (uCTX)) were measured regularly.

RESULTS

BMD at the lumbar spine, hip and total body increased by 8, 6 and 3% (P < 0.001), respectively, in the hormone groups versus placebo. The bone markers all decreased accordingly (sOC: 37%, sBSAP: 34% and uCTX: 65% from baseline (all P < 0.001)), except for uCa that did not change significantly. No significant dose-related effect of levonorgestrel was found. Vaginal bleeding/spotting decreased from 48 to 25% of the HRT-treated women during the study period. Skin tolerance was good in 84% of the women with no difference between the study groups. No incidences of endometrial hyperplasia, uterine or mammary cancer occurred.

CONCLUSION

The transdermal combination of 17beta-estradiol and levonorgestrel has a positive effect on BMD in an osteopenic postmenopausal population. Furthermore, a high safety profile was observed.

The effect of continuous oestradiol with intermittent norgestimate on bone mineral density and bone turnover in post-menopausal women

OBJECTIVE

To assess in post-menopausal women the efficacy and tolerability of a continuous oestradiol/intermittent norgestimate HRT regimen to prevent and to reverse post-menopausal loss of bone mineral density (BMD) and to determine the effects on serum bone turnover markers markers.

METHODS

A 1-year, multicentre, international, placebo-controlled, randomised, double-blind clinical trial was conducted in 146 post-menopausal women with an intact uterus in order to assess the effect on bone loss of continuous oral 17beta-oestradiol (1 mg per day) combined with norgestimate (90 microg per day), for 3 consecutive days out of every 6-day treatment period (E2/iNGM). During a second year extension, all women agreeing to continue were on the E2/iNGM regimen. BMD was assessed prior to treatment and after 1 and 2 years or at the end of treatment in women stopping participation prematurely after at least 6 months of treatment. Serum bone turnover markers were determined prior to and at 1 year of treatment Adverse events were collected at three-monthly intervals during clinic visits over the treatment period.

RESULTS

BMD in the lumbar spine, the primary endpoint, was evaluable in 117 subjects completing >6 months of treatment. BMD increased on average by 2.4% in women on the intermittent progestin regimen. It decreased by 1.4% in placebo treated women. The change from baseline and the difference between active and placebo treatment (Delta placebo) were highly significant (P < 0.0001). On E2/iNGM, also the BMD in the total hip increased (+1.49%, Delta placebo 3.73%, P < 0.0001). The serum markers for bone formation osteocalcin and type I collagen N-propeptide were significantly reduced compared to baseline by 31 and 44%, respectively and the bone resorption marker C-terminal crosslinked telopeptide of type I collagen by 59%. Minor increases (<10%) of markers in the placebo group were not significant. During a second year extension of the trial, all subjects were on active treatment. Subjects on placebo who lost (median+/-CI 95%) 0.66% (-2.3 to +0.5) of spine BMD during the first year now gained 4.41% (2.7-7.6). They also gained 1.6% (0.1-0.3.6) in the total hip. Subjects continuously on oestradiol/intermittent norgestimate (E2/iNGM) gained an additional 5.7% (2.3-13.5) in the lumbar spine and +0.1% (-0.6 to +2.2) at the total hip. Side effects reported by women on the intermittent progestin regimen significantly in excess over reports from the placebo group were uterine bleeding, abdominal and breast pain, but not headache. Back pain and weight gain was reported by significantly fewer women on active treatment compared to placebo.

CONCLUSION

The continuous oestradiol/intermittent norgestimate HRT regimen is well tolerated, reduces bone turnover and prevents post-menopausal bone loss in healthy post-menopausal women.

The impact of a monophasic continuous estro-progestogenic treatment on Latin American menopausal women

OBJECTIVE

The present study was undertaken to assess the impact, effectiveness and safety of a monophasic hormone replacement treatment (HRT) for continuous use with regards to the clinical effects, bleeding patterns and lipid profile of menopausal women in four Latin American countries.

DESIGN

Three hundred and six postmenopausal women with natural menopause and uterus present were recruited. This was a multicentre prospective, clinical trial; the participating countries were Brazil (BR), Colombia (CO), Mexico (MX) and Argentina (AR). The study period was 12 months. The HRT regime was formulated in tablets containing 2 mg estradiol E2 and 1mg norethisterone acetate (NETA); one visit every 3 months was solicited.

METHODS

HRT was given as one tablet every day without interruption for 1 year. Climacteric complaints, side-effects, reason for discontinuation, bleeding patterns, lipid profile at baseline and 12 months of treatment were documented.

RESULTS

There were no significant differences between the four populations on clinical measurements. Thirty-four women discontinued, 13 for bleeding problems. The five most common side-effects were mastalgia, bleeding problems, headache, pelvic pain and nausea. 44.8% of women experienced scanty vaginal bleeding during the first 3 months of therapy. Ninety seven percent of women had amenorrhea at the end of the study in MX, BR and AR, and 100% in CO. Body weight was constant during the study, and no correlation was found between body weight and total days with bleeding. The Kupperman index score was used to evaluate the climacteric complaints, and the score decreased from a mean of 25.4 to 5.1 at 12-months visit. Total cholesterol levels were significantly reduced in BR and CO (P < 0.05) between baseline and the final sample; serum triglycerides remained unchanged, HDL-cholesterol was significantly increased in MX (P < 0.05), and LDL-cholesterol was significantly reduced in CO (P < 0.05). The results of this 1-year study emphasize that a continuous combined HRT regimen with 2 mg E2/1 mg NETA is an attractive alternative for postmenopausal women who are at least 1 year after their menopause and optimally 2 years after their menopause. Although the combination of 2 mg E2 with 1 mg NETA in a continuous combined therapy scheme has been in use in the Nordic countries for over a decade and in Latin America for the last 6 years, there have been no previous published reports on its effectivity in Latin American women. This publication reports the experience in a group of 306 Latin American women, and it is the first Latin American publication with this formulation.

The role of hormone replacement therapy in endometrial polyp formation

OBJECTIVE

To evaluate the iatrogenic effect of different protocols of hormone replacement therapy (HRT) on endometrial polyp formation adjusting for the confounding effects of other factors such as age, parity, weight and menopausal status at menopause.

METHODS

Out of 2685 menopause patients 375 (13.9%) eligible patients were enrolled. Patients were randomized to three HRT types and three equal groups were formed. The first group received Premelle 2.5 mg (Group-I) (0.625 mg conjugated estrogen + 2.5 mg medroxyprogestorone), the second received Kliogest (Group-II) (2 mg estradiol + 1 mg norethisterone) and the last received Livial (Group-III) (2.5 mg tibolone) at least for 36 months without giving a break. After the first 18 months patients had their first office hysteroscopy and it was repeated in every 6 months until the end of third year to find out new and recurrent endometrial polyps.

RESULTS

Multiple regression analysis revealed that the type of HRT, late menopause and obesity increased the occurrence of endometrial polyps. In Group-I five polyps, in Group-II ten polyps and in Group-III two polyps were detected. There were significant differences between G-II and G-I and G-II and G-III (P < 0.05), but there was no significant difference between G-I and G-III (P > 0.05). 82.3% of the polyps were detected in the third and fourth hysteroscopic examinations. Endometrial polyp recurrence was encountered in 4 (23.5%) patients, 1 in G-I and 3 in G-II without a significant difference (P > 0.05). No malignancy was detected in any of the specimen.

CONCLUSION

We observed that endometrial polyp formation may be dependent on the type and dosage of the estrogen and progestogen. Especially a progestogen with high antiestrogenic activity may play an important preventive role in the development of endometrial polyps.

[Present and potential uses of mifepristone in gynecology, obstetrics and other medical specialties]

Mifepristone, a derivative of norethindrone, a first generation synthetic progestative, has a very potent antiprogestative activity and to a lesser degree antiandrogenic and antiglucocorticoid activities. This action makes it potentially useful in the treatment of multiple hormone dependent diseases in obstetrics-gynecology as well as in a variety of medical specialties such as neurology, ophthalmology, and oncology. Nevertheless, the label of abortive pill has incited numerous ethical and political debates concerning the permission to market this drug, and this has contributed to the delay in the assessment of the potential indications of mifepristone. Largely under-utilized in practice despite its increasing theoretical benefit, clinical studies should now de conducted. Thus, based on an international review of literature during the last ten years, we have shed light on the present and potential indications of mifepristone in medical practice.

A comparative study of monophasic oral contraceptives containing either drospirenone 3 mg or levonorgestrel 150 μg on premenstrual symptoms

This open-label randomized study compared the effects of two combined oral contraceptives (OCs) containing 3 mg drospirenone (DRSP)/30 microg ethinyl estradiol (EE) with 150 microg levonorgestrel (LNG)/30 microg EE on the prevalence and changes from baseline of premenstrual symptoms after six cycles. The symptoms were measured using the Women's Health Assessment Questionnaire. Subjects receiving DRSP/EE had fewer prevalence of premenstrual symptoms than those receiving LNG/EE after six cycles. A significantly lower score of negative affect category in the premenstrual phase was demonstrated in those receiving DRSP/EE more than LNG/EE. The DRSP/EE group showed a greater improvement of mean scores from baseline in the premenstrual phase compared with those who received LNG/EE on negative affect as seen in the items on anxiety, irritability, feeling sad or blue and weight gain in the category of water retention. In conclusion, OCs containing DRSP have beneficial effects in reducing the prevalence of premenstrual symptoms especially the symptoms of negative affect and weight gain, particularly when compared to LNG/EE. Hence, it should be recommended for women who are susceptible to these adverse symptoms.

Treatment of pelvic endometriosis with etonogestrel subdermal implant (Implanon®)

BACKGROUND

Endometriosis is one of the commonest benign gynaecological disorders and has a peak incidence between 30 and 45 years of age. Treatment options are medical or surgical, depending on the location and extent of the disease and the woman's childbearing aspirations or need for contraception. Over the past five decades several formulations of progestogen have been used to treat endometriosis.

METHODS

Our study was not planned research but a series of case studies of women with severe symptoms of endometriosis treated in an innovative way with a new long-acting progestogen contraceptive system (etonogestrel subdermal implant) which could reasonably have been expected to have a favourable effect on their disease and its symptoms.

RESULTS

Five women with severe pelvic endometriosis were treated. Two of them were nulliparous and wished to become pregnant in due course; the other three had completed their childbearing and were contemplating hysterectomy. One of the five women had relief of pelvic pain but requested removal of the implant after 3 months because of side effects; the other four remained very satisfied with their treatment for the symptoms of pelvic endometriosis. Two of the four very satisfied women have had their implant replaced and the other two are expected to have their implant replaced when necessary.

CONCLUSION

Etonogestrel subdermal implants are an additional treatment option in women with symptoms related to pelvic endometriosis.

Judicious Usage of Estrogen/Progesterone for Angiodysplasia

We recently experienced a case of a female hemodialysis patient with multiple intestinal angiodysplasias. In 2001, she complained of melena, and angiographic embolization halted bleeding from ileum angiodysplasia. In 2002, she again complained of black stool. Abdominal angiography found jejunum angiodysplasia, and pharmacological therapy with estrogen/progesterone was required to stop the bleeding. Ethical demands to develop new hemodialyzers that do not release estrogen-like substances are discussed.

Management of hot flashes in breast cancer survivors and men with prostate cancer

Hot flashes are a significant complaint among many breast cancer survivors and many men undergoing androgen deprivation therapy for prostate cancer. Several therapeutic approaches are available to the suffering man or woman. Many of these individuals have tried nonpharmacologic and nonconventional approaches. However, most nonpharmacologic treatments have not been compared with placebo or were not more effective than placebo in prospective, randomized clinical trials. The most effective nonhormonal treatments for hot flashes include agents from the selective serotonin or noradrenergic reuptake inhibitor (SSRI/SNRI) family. Paroxetine, 10 mg/d, or venlafaxine, 37.5 mg/d, are reasonable initial dosages, and if symptoms do not improve within a week or two, the dosage can be doubled. Gabapentin appears to provide similar benefits, but direct comparisons have not been reported. Because of the strong association between gonadal hormones and breast and prostate cancer, the use of hormonal agents to treat hot flashes in these patients has been limited. However, such hormonal therapies as depomedroxyprogesterone acetate can be prescribed for an informed individual who experiences bothersome symptoms despite nonhormonal treatments.

Emergency contraception--clinical and ethical aspects

Emergency contraception (EC) consists of either 1.5 mg of levonorgestrel (LNG) in one or two doses, or a combination of LNG with ethinylestradiol, administered for up to 5 days after unprotected intercourse. Clinical studies indicate that LNG alone is more effective and has less side effects. Its effectiveness decreases the longer after coitus it is taken. EC is indicated when there is non-compliance or accidents with the use of regular methods of contraception, or when women have had voluntary or imposed unprotected intercourse. The ethics of providing EC has been questioned by some, arguing that it acts by preventing implantation. Scientific evidence does not support this concept, but shows that EC acts mostly before fertilization. Placing obstacles to the access of EC is unethical as it transgresses the ethical principles of autonomy, non-maleficence beneficence and justice. Far from inducing abortions, EC reduces unwanted pregnancies and prevents abortion.

Lack of efficacy of estradiol for depression in postmenopausal women: a randomized, controlled trial

BACKGROUND

Estrogen has been considered as a potential antidepressant in postmenopausal women. Our goal was to study whether estrogen therapy is effective in treating depressive disorders in older postmenopausal women and to determine whether progestins are associated with a deterioration of mood.

METHODS

After 2 weeks of single-blind placebo treatment in 87 patients, 57 were randomly assigned to receive 8 weeks of treatment with estradiol (.1 mg/day; n = 31) or placebo (n = 26). All patients were then treated with medroxyprogesterone 10 mg/day for 2 weeks combined with the study patch. Depressive symptoms were rated with the 21-item Hamilton Depression and Center for Epidemiologic Studies Depression scales.

RESULTS

A clinically significant antidepressant effect of estradiol was excluded after 8 weeks of estradiol treatment. The estradiol group and placebo group improved in depressive symptoms at a similar rate based on the Hamilton Depression Scale (40% decreases in depression for estradiol vs. 44% for placebo). No significant increase in depressive symptoms was demonstrated with the use of progestins; however, positive affect decreased slightly with the use of combined estradiol-medroxyprogesterone compared with medroxyprogesterone alone (5.8%, p =.027).

CONCLUSIONS

Estradiol cannot be considered as an effective treatment in postmenopausal women with mild to moderate depression.

Treatment of endometriosis and chronic pelvic pain with letrozole and norethindrone acetate: a pilot study

OBJECTIVE

To determine the role of an aromatase inhibitor, letrozole, in the treatment of reproductive-age women with endometriosis and associated chronic pelvic pain.

DESIGN

Phase 2, open-label, nonrandomized proof-of-concept study.

SETTING

Outpatient tertiary-care center.

PATIENT(S)

Ten patients with endometriosis, all previously treated both medically and surgically, with unsatisfactory results.

INTERVENTION(S)

Endometriosis was diagnosed by biopsy and scored from an initial diagnostic laparoscopy performed within 1 month before treatment was begun. Oral administration of letrozole (2.5 mg), the progestin norethindrone acetate (2.5 mg), calcium citrate (1,250 mg), and vitamin D (800 IU) was done daily for 6 months. Within 1-2 months after completion of the treatment, a second-look laparoscopy was performed to score and biopsy endometriosis.

MAIN OUTCOME MEASURE(S)

Changes in American Society for Reproductive Medicine (ASRM) scores for endometriosis, pelvic pain assessed by visual analog scale, serum hormone levels (FSH, LH, E(2), and estrone [E(1)]), and bone density (DEXA scan).

RESULT(S)

No histologically demonstrable endometriosis was present in any patient during the second-look laparoscopy. ASRM and pelvic pain scores decreased significantly in response to treatment. Overall, no significant change in bone density was detected. Gonadotropin levels were not significantly altered by treatment, and although circulating E(2) and E(1) levels were reduced, the decrease was not statistically significant.

CONCLUSION(S)

The combination of letrozole and norethindrone acetate achieved marked reduction of laparoscopically visible and histologically confirmed endometriosis in all 10 patients and significant pain relief in nine out of 10 patients who had not responded previously to currently available treatments. On this basis, letrozole should be a candidate for the medical management of endometriosis.

Measurement of Aortic Blood Flow by Magnetic Resonance Below and Above the Origin of the Coronary Arteries in Postmenopausal Hormone Replacement Therapy

PURPOSE

Principal blood flow measures might be assessable by velocity-encoded cine magnetic resonance (VENC MR) of aortic blood flow. The feasibility of using VENC MR for clinical research was tested in a contemporary and controversial human model: the effects of 17beta-estradiol (E) and cyclic norethisterone acetate (NETA) in postmenopausal women.

METHODS

Sixteen postmenopausal women were included in a crossover study (two 12-week periods, 3-month washout) and randomized to E and NETA or placebo. Aortic blood flow (ABF) was measured eight times by VENC MR below and above the coronary arteries (CA) and was used for estimation of coronary artery blood flow (CABF) and peak flow velocity (Vmax). The calculated value of CABF was negative and was corrected by averaging systolic flow. Data were analyzed in a repeated measurement model including analysis of repeatability (CR) and group variability (CV).

RESULTS

The CR and CV of ABF were low (11% and 7%) and corresponded at the two levels. Vmax showed similar levels of reproducibility at the two levels. The coronary artery blood flow was less reproducible (39% and 31%). During treatment, ABF above CA was reduced after 12 weeks (p=0.03), ABF below CA was unchanged, and CABF was significantly increased without detrimental effects of NETA. Vmax was increased at NETA addition (p<0.01).

CONCLUSIONS

Aortic flow quantification by VENC MR is reproducible and useful for assessment of principal haemodynamic changes in smaller studies. Derived measurement of CABF lacks precision. Differences in change below and above CA indicate that oral high-dose E and NETA may induce coronary artery dilatation.

Minimum effectiveness of the levonorgestrel regimen of emergency contraception

The standard method for estimating the effectiveness of emergency contraceptive pills (ECPs) uses external data to calculate the proportion of expected pregnancies averted by the treatment. Because these data may not be applicable to ECP study populations, this approach could result in substantial overestimation of effectiveness. We used data from two published randomized trials of the levonorgestrel and Yuzpe ECP regimens to calculate the minimum effectiveness of the levonorgestrel regimen. Conservatively assuming that the Yuzpe regimen was entirely ineffective in these trials, we estimate that the levonorgestrel regimen prevented at least 49% of expected pregnancies (95% confidence interval: 17%, 69%). Because physiologic data suggests that the Yuzpe regimen does, in fact, have some efficacy, the effectiveness of the levonorgestrel regimen is likely to be higher than our minimum estimate.

Steroid hormones for contraception in men

BACKGROUND

Male hormonal contraception has been an elusive goal. Administration of sex steroids to men can shut off sperm production through effects on the pituitary and hypothalamus. However, this approach also decreases production of testosterone, so "add-back" therapy is needed.

OBJECTIVES

To summarize all randomized controlled trials of male hormonal contraception.

SEARCH STRATEGY

We searched the computerized databases Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Popline, and LILACS (each from inception to February, 2003) for randomized controlled trials of hormonal contraception in men. We wrote to authors of identified trials to seek unpublished or published trials that we might have missed.

SELECTION CRITERIA

We included all randomized controlled trials in any language that compared a steroid hormone with another contraceptive. We excluded non-steroidal male contraceptives, such as gossypol. We included both placebo and active-regimen control groups. All trials identified included only healthy men with normal semen analyses.

DATA COLLECTION AND ANALYSIS

Azoospermia (absence of spermatozoa on semen examination) was the primary outcome measure. Data were insufficient to examine pregnancy rates and side effects.

MAIN RESULTS

The proportion of men who achieved azoospermia varied widely in reports to date. Few significant differences emerged from these trials. Levonorgestrel implants combined with injectable testosterone enanthate (100 mg IM) was significantly more effective than was levonorgestrel 125 mcg by mouth daily combined with testosterone patches (10 mg/d) (OR for azoospermia with the oral levonorgestrel regimen 0.03; 95%CI 0.00-0.29). The addition of levonorgestrel 500 mcg by mouth daily improved the effectiveness of testosterone enanthate 100 mg IM weekly by itself (OR for azoospermia with the combined regimen 4.0; 95%CI 1.00-15.99). Several regimens, including testosterone alone and GnRH agonists and antagonists, had disappointing results.

REVIEWERS' CONCLUSIONS

No male hormonal contraceptive is ready for clinical use. All trials published to date have been small exploratory studies. As a result, their power to detect important differences has been limited and their results imprecise. In addition, the definition of oligospermia has been imprecise or inconsistent in many reports. To avoid bias, future trials need more attention to the methodological requirements for randomized controlled trials. Trials with adequate power would also be helpful.

[Emergency contraception with levonorgestrel for teenagers--efficacy, tolerability, and level of information awareness]

OBJECTIVE

Assessment of efficacy and side effects of emergency contraception for teenagers with levonorgestrel (LNG) and the level of users' informedness about possibilities and practical application.

METHODS

The subjects are healthy girls (n = 49) with regular menstrual cycles at the age between 15 and 19, having had one unprotected or faultily protected sexual intercourse. All of them have administered 0.75 mg LNG within the 72nd hour, repeated after 12 hours. The data have been processed by variational analysis.

RESULTS

One pregnancy was registered of a girl with firstintake at the 67th hour - pregnancy rate - 2,0%. The most frequent side effect was nausea - 26,5%, folowed by breast tenderness - 22,4% and fatigue - 20,4%. An up to 7th day delay in menstrual cycle is non significantly more frequent - 14,3%, followed by a delay of more than 7 days breakthrough bleeding - 8,2%. No significant changes were established in the lenght of the menstrual cycle. Emergency contraception is sought for after unprotected sexual intercourse in 69,4%, and condom failure problems in 30,6%. Only 18,4% have sufficient information about the possibilities and practical use of emergency contraception.

CONCLUSION

LNG provides effective, highly tolerable contraception with a small number of side effects. Need is felt for serious popularization of the application of emergency contraception with teenagers.

[Effects of the hormone replacement therapy on cardiovascular system, bone mass and memory in climacteric patients]

OBJECTIVE

To evaluate the effect of the hormone replacement therapy type estradiol-medroxyprogesterone and tibolona on cardiovascular system, bone mass and memory in the climacteric patients.

PATIENTS AND METHOD

From January through December 2001 at the Specialties Hospital No. 1, we included 77 consecutive climacteric patients. They were divided in 2 groups: premenopause in treatment with estradiol-medroxyprogesterone and postmenopause with tibolona. We studied cardiovascular system, the bone mass and memory. The statistical analysis was by means of t Student for difference between the groups.

RESULTS

With the estradiol-medroxyprogesterone use, the blood pressure diminished significaticantly just for systolic pressure (-10.22/-6.38 mmHg). Cholesterol and triglyceride, both diminished significantly (-43.92 mg and -58.79 mg). There is not significance for the bone mass of lumbar-spine and femoral neck (+0.68% and +0.69%) as neither in the memory test (20-22). With the tibolona use, the blood pressure was not reduced significantly (-6.93/-1.94 mmHg), with single significant reduction for cholesterol (-25.83 mg and -18.15 mg), presenting bone mass significant improvement just for femoral neck (+0.13% and +0.84%) and without improving in the memory test (17-18).

CONCLUSIONS

A diminution of lipids with the estradiol-medroxyprogesterone use, as well as reduction of the cholesterol and improvement of the bone mass with the tibolona use but without benefits in the memory test with both treatments.

Mifepristone for the prevention of breakthrough bleeding in new starters of depo-medroxyprogesterone acetate

Depo-medroxyprogesterone acetate (DMPA) is an effective injectable contraceptive with worldwide availability. However, it is associated with a high incidence of breakthrough bleeding (BTB) during the first 6 months of use which often leads to discontinuation. Mifepristone is a progesterone receptor antagonist that has been demonstrated to decrease BTB caused by the levonorgestrel subdermal implant (Norplant). The purpose of this study was to determine if mifepristone would decrease BTB in new starters of DMPA. Twenty regularly cycling women who were new starters of DMPA were randomized to receive 50 mg of mifepristone or placebo every 2 weeks for 24 weeks. Percent days of BTB and number of cycles with bleeding intervals > or =8 and > or =14 days were evaluated using daily bleeding diaries. Ovulation was determined by measuring thrice-weekly urinary metabolites of estrogen and progesterone. Endometrial concentrations of ER and PR were determined by immunohistochemistry. Mifepristone significantly decreased the percent days of BTB and the number of cycles with prolonged bleeding intervals when compared to placebo. No subject ovulated in either group. ER immunostaining increased and PR immunostaining decreased after mifepristone treatment. In conclusion, a 50 mg dose of mifepristone taken every 2 weeks decreases the incidence of BTB in new starters of DMPA. This effect may be due to modulation of endometrial estrogen and progesterone receptors.