Study of myocardial contractility by pulsed wave Doppler tissue imaging does not reveal an inotropic effect of estrogen at physiologic dose

We studied myocardial contractility by pulsed wave Doppler tissue imaging in 6 postmenopausal healthy women. According to a crossover, double-blind protocol, we randomized patients to treatment with transdermal patches of estradiol-17beta or matched placebo. Estradiol-17beta did not modify local systolic and diastolic functions. Thus, at least when acutely administered, estrogen seems to be unable to determine hemodynamic changes at the myocardial level, in opposition to what occurs in the peripheral vascular system.

Oral contraceptives and vascular reactivity of great vessels in women

Blood pressure and great vessel vascular reactivity, evaluated by color Doppler ultrasound, were investigated in users of third-generation oral contraceptives (n = 18) compared to non-users, who were studied either in the follicular (n = 8) or in the luteal (n = 10) phase of the menstrual cycle. Blood pressure measured at rest in the supine position, evaluated both in the follicular phase and in the luteal phase, was similar between oral contraceptive users and non-users. The pulsatility index (an indirect index of resistance to blood flow) of both the internal carotid artery and the axillary artery was similar in control women studied in the follicular phase and in the luteal phase. By contrast, in users of oral contraceptives, pulsatility index values of the internal carotid artery tended to be higher, whilst those of the axillary artery were significantly higher, than those of women in either the follicular phase (p < 0.01) or the luteal phase (p < 0.025). In conclusion, new third-generation oral contraceptives do not have a significant impact on blood pressure control, but still tend to increase vascular resistance to blood flow, particularly in areas more involved in the regulation of blood pressure, for example the axillary artery.

Effects of melatonin on vascular reactivity, catecholamine levels, and blood pressure in healthy men

In this study it was investigated whether the oral administration of melatonin (1 mg) in comparison to placebo was able to reduce blood pressure, vascular reactivity, and catecholamines in men, as previously reported in young women. The administration of melatonin significantly reduced blood pressure, the pulsatility index in the internal carotid artery, and catecholamines levels within 90 minutes. The effect of melatonin on the artery pulsatility index was related to baseline values, being greater in men with higher baseline values. The present data indicate that melatonin may blunt the activity of the cardiovascular system and may have both physiopathologic and clinical implications.

Effect of ovarian suppression on glucose metabolism of young lean women with and without ovarian hyperandrogenism

Gonadal steroids are believed to influence glucose metabolism, oestrogens inducing an improvement and androgens or progestins a deterioration. At baseline and after 3 months of ovarian suppression with a gonadotrophin-releasing hormone analogue (GnRHa: goserelin depot 3.75 mg/28 days), glucose metabolism was evaluated in eight lean women affected by ovarian hyperandrogenism (PCOS) and six age-weight-matched non-hyperandrogenic women (controls) by using both an oral glucose tolerance test (75 g; OGTT) and the minimal model method. The latter method allows calculation of peripheral insulin sensitivity (Si) and glucose dependent glucose utilization (Sg). In PCOS, higher fasting concentrations (P < 0.05) of insulin and C-peptide, and lower Sg (P < 0.05) and Si (P < 0.01) were found. GnRHa did not significantly modify glucose metabolism of controls, while in women with PCOS it decreased fasting glucose (P < 0.05) and significantly increased Si (P < 0.03) up to control values. The present data indicate that strong suppression of ovarian activity improves Si in lean women with PCOS, while it is without relevant effects on glucose metabolism of non-hyperandrogenic women.

Effect of chronic administration of cabergoline on uterine perfusion in women with polycystic ovary syndrome

OBJECTIVE

To confirm whether patients with polycystic ovary syndrome (PCOS) have a reduction in uterine perfusion and to verify whether chronic administration of cabergoline can decrease this high vascular resistance.

DESIGN

Prospective randomized trial.

SETTING

Endocrinological Centre of the Department of Obstetrics and Gynecology, University of Cagliari, Cagliari, Italy.

PATIENT(S)

Thirty patients were enrolled in the study: 20 affected by PCOS and 10 healthy controls. Patients with PCOS were randomly assigned to one of two treatments for 3 months: oral administration of cabergoline (0.5 mg) every week or oral administration of placebo every week.

INTERVENTION(S)

All patients underwent transvaginal ultrasonography associated with Doppler flow measurement of the uterine artery, and serum hormone concentrations were determined during the early follicular phase. In women with PCOS, Doppler flow measurement and hormonal assessment were repeated in the early follicular phase of the third month of treatment.

MAIN OUTCOME MEASURE(S)

Pulsatility index of the uterine artery before and during treatment.

RESULT(S)

The mean pulsatility index of the uterine artery in patients with PCOS was significantly higher than that of the control group (3.29+/-0.5 and 2.01+/-0.2, respectively). Patients with PCOS treated with cabergoline showed a significant increase in uterine perfusion, with a pulsatility index of 3.14+/-0.6 before and 2.39+/-0.5 during the treatment. No difference was found in patients with PCOS treated with placebo.

CONCLUSION(S)

Patients with PCOS have high resistance in the uterine arteries, but chronic administration of cabergoline can increase uterine perfusion.

Effect of desogestrel-containing oral contraceptives on vascular reactivity and catecholamine levels

The modifications induced by new oral contraceptives (OC) on blood pressure, great vessel vascular reactivity by color Doppler, and catecholamine levels were investigated. Young healthy women not taking OC (n = 22; controls) or receiving, for > or = 6 months, OC containing desogestrel with either 30 micrograms (n = 14) or 20 micrograms of EE (n = 8) were enrolled. Blood pressure measured at rest in supine position was similar between controls and OC users. The pulsatility index (PI), an indirect index of resistance to blood flow, of axillary artery was significantly higher (p < 0.05) in 30 micrograms than in 20 micrograms EE OC users or controls. A similar trend, albeit not significant, was observed for the internal carotid artery PI. Norepinephrine (p < 0.01) and dopamine (p < 0.05) but not epinephrine levels, were lower in 30 micrograms EE OC users than in 20 micrograms EE OC users or controls. Thus, both 20 micrograms and 30 micrograms EE OC had no negative effect on blood pressure, but the 30 micrograms EE OC tended to increase great vessel resistance to blood flow, independently of catecholamine levels.

Estradiol-17beta reduces blood pressure and restores the normal amplitude of the circadian blood pressure rhythm in postmenopausal hypertension

After menopause, both systolic (SBP) and diastolic (DBP) blood pressure (BP) become higher in women than in men of the same age, suggesting that estrogen deficiency may influence the age-related increase in BP. We studied 30 postmenopausal women (mean age, 55 +/- 5.7 years; time from menopause, 2-5 years) affected by mild hypertension with no target-organ complications by means of 24-h BP monitoring. None of the group were undergoing estrogen replacement therapy or taking antihypertensive drugs. According to a randomized, double-blind protocol, subjects received patches of transdermal estradiol-17beta (E2) or a matched placebo, with crossover after a 7-day washout period. In 12 patients the 24-h peak-to-trough variation in SBP and DBP amounted to less than 10% (nondippers). Administration of E2 significantly decreased 24-h SBP and DBP in the whole cohort (P < .05). Furthermore, E2 restored the expected reduction in BP during nighttime in the nondipper subgroup. It is well known that estrogen replacement therapy protects against the development of both cardiovascular diseases and stroke. Our data suggest that this activity could be attributed, at least in part, to the activity of E2 in preserving physiologic circadian fluctuation of BP.

High serum levels of soluble IL-2 receptor, cytokines, and C reactive protein correlate with impairment of T cell response in patients with advanced epithelial ovarian cancer

The serum levels of interleukin-(IL-)1 alpha, IL-1 beta, IL-2, IL-6, TNF alpha, and sIL-2R and the proliferative response of peripheral blood mononuclear cells (PBMC) to phytohemagglutinin (PHA), anti-CD3 monoclonal antibody (mAb), recombinant IL-2 (rIL-2), and the combination of PHA or anti-CD3 mAb with rIL-2 were studied and correlated with serum levels of C-reactive protein (CRP) in women with advanced epithelial ovarian cancer. The expression of CD25 and CD122 subunities of membrane-bound IL-2R on PHA- or anti-CD3 mAb-stimulated PBMC was also studied. In comparisons with the controls, PBMC response to PHA, anti-CD3 mAb, and rIL-2 was significantly lower in the cancer patients. The addition of exogenous rIL-2 to the PBMC cultures increased response in both controls and patients but did not modify the significance of the differences. After stimulation with PHA or anti-CD3 mAb, the percentage of PBMC CD25+ or CD122+ was significantly lower in patients. The serum levels of IL-1 alpha, IL-1 beta, IL-6, TNF alpha, sIL-2R, and CRP were significantly increased in patients compared to the controls. Instead, no differences were observed for serum levels of IL-2. A strong association was found between high serum levels of the above-mentioned cytokines, sIL-2R, and CRP. The results of our study on advanced stage (IIIb-IV) ovarian cancer patients are consistent with the previously reported hypothesis that high IL-6 and/or CRP serum levels may represent an important and independent prognostic factor of the likely outcome in cancer patients.

The diagnosis of endometriomas using colour Doppler energy imaging

We studied the role of colour Doppler energy (CDE) (or power Doppler) imaging in the differentiation between endometriomas and other adnexal masses in premenopausal non-pregnant women. A total of 170 consecutive patients with persistent adnexal masses was submitted to B-mode transvaginal ultrasonography associated with CDE imaging evaluation. Plasma concentrations of CA125 were measured before surgery. Using CDE imaging evaluation of vessel distribution, the occurrence of one of the following findings was considered to indicate the likely presence of endometrioma: (i) a round-shaped homogeneous hypoechoic 'tissue' of low-level echoes without papillary proliferations associated with 'poor' vascularization; (ii) a round-shaped homogeneous hypoechoic 'tissue' of low-level echoes with an echogenic portion in which no flow was detected. The overall agreement between the test result and the actual outcome was calculated using the k index. The CDE imaging evaluation was more accurate in the diagnosis of endometriomas compared with B-mode ultrasonography alone (k = 0.88 and 0.80 respectively). According to the logistic regression equation obtained, the probability of the presence of endometrioma varied between a minimum of 1.4% for patients with no risk factors to a maximum of 95.6% for patients with two risk factors (CDE result and value of CA125 >25 IU/ml).

Treatment of obstetric and gynecologic infections with meropenem: comparison with imipenem/cilastatin

The aim of this study was to compare the clinical and bacteriologic efficacy of meropenem with imipenem/cilastatin in the treatment of obstetric and gynecologic infections. This was a controlled, multicenter, randomized study with two parallel groups and a follow-up period of up to 4 weeks. A total of 105 hospital in-patients requiring antibacterial parenteral therapy were enrolled, 52 in the meropenem group and 53 in the imipenem/cilastatin group. Both drugs were administered at 0.5 g every 8 hours, by slow intravenous infusion over 20-30 minutes; for meropenem the administration by intravenous bolus injection (over approximately 5 minutes) was allowed. The mean duration of therapy was 5 days for both treatments. At the end of treatment, all 46 evaluable patients in the meropenem treatment group had a satisfactory clinical response, while in the imipenem/cilastatin group 5/49 patients were clinical failures. The difference between the treatment groups in clinical response was statistically significant (100% vs 89.8%; p=.026). A similar result was seen in the intention-to-treat analysis (98% vs 84.6%; p=0.017). Both treatments were well tolerated, but fewer meropenem patients experienced treatment-related adverse events in comparison with imipenem/cilastatin (11.5% vs 15.1%).

Diagnosis of adnexal malignancies by using color Doppler energy imaging as a secondary test in persistent masses

The purpose of this prospective study was to compare the accuracy of B-mode transvaginal ultrasonography alone and in combination with color Doppler energy (or power Doppler) imaging in differentiating benign from malignant adnexal masses. A total of 192 consecutive persistent adnexal masses (159 benign, 33 malignant) were studied before surgery by B-mode transvaginal ultrasonography with and without color Doppler energy. In addition, CA-125 plasma levels were determined and spectral Doppler analysis was performed. By color Doppler energy imaging, a mass was considered malignant when arterial flow was visualized in an echogenic portion of a mass defined as malignant by B-mode. Intratumoral arterial blood flow could be readily detected by color Doppler energy imaging in all malignant tumors and in 94% of the benign tumors. The combined use of transvaginal B-mode ultrasonography and color Doppler energy imaging has greater accuracy in the diagnosis of ovarian malignancies than transvaginal ultrasonography alone (value of kappa: 0.81 and 0.63, respectively), reducing the number of false-positive results. The use of spectral Doppler analysis was of limited diagnostic value, with a kappa value of 0.17 for the pulsatility index (< 1) and of 0.41 for the resistance index (< 0.4). Also, the association with CA-125 increased the number of false-negative results. In conclusion, the use of color Doppler energy imaging seems to be a useful secondary test when a mass is suspected to be malignant by B-mode ultrasonography.

Influences of melatonin administration on the circulation of women

The cardiovascular effects induced by the daytime administration of melatonin (1 mg) were compared with those of placebo in 17 young, healthy, early follicular-phase women. Compared with placebo, the administration of melatonin modified, within 90 min, the pulsatility index (PI), evaluated by color Doppler ultrasound, of the internal carotid artery, abdominal aorta, and axillary artery. The effect was linearly related to baseline PI, higher baseline PI being associated with greater PI declines. Melatonin administration significantly decreased mean PI of internal carotid artery (P < 0.02), systolic and diastolic blood pressure (P < 0.01), and norepinephrine levels evaluated after 5 min of standing position (P < 0.02). Heart rate and supine catecholamine levels were not modified. These data indicate that in young, healthy women the administration of 1 mg of melatonin greatly influences artery blood flow, decreases blood pressure, and blunts noradrenergic activation. Clinical implications of present data are worthy to be fully explored.

Diurnal rhythms of labor and delivery in women: modulation by parity and seasons

OBJECTIVES

Our purpose was to evaluate in women the diurnal (24 hour) rhythms of the onset of labor and time of delivery and their modulation by parity and seasons.

STUDY DESIGN

A retrospective analysis was performed on 15,910 at term deliveries of single fetuses with noninduced labor.

RESULTS

A diurnal rhythm of labor onset, with peak frequency at 8 PM and 9 AM was observed in nulliparous women but not in multiparous women. No diurnal rhythm of labor length was detectable. A diurnal rhythm of delivery, with peak values at 2 PM was evident in nulliparous but not in multiparous women. In nulliparous women the two acrophases of the diurnal rhythm of labor onset were closer in summer (10 hours) than in winter (13 hours). The acrophase of the diurnal rhythm of delivery progressively shifted to earlier hours from winter (5 PM) to summer (1 PM).

CONCLUSIONS

These data show the attenuation of the diurnal rhythms of labor and delivery in multiparous women and their modulation by seasons.

The effect of transdermal 17-beta-estradiol on glucose metabolism of postmenopausal women is evident during the oral but not the intravenous glucose administration

OBJECTIVES

To evaluate the effect of transdermal 17-beta-estradiol (50 micrograms/day) on glucose metabolism of postmenopausal women.

STUDY DESIGN

A frequently sampled intravenous glucose tolerance test (FSIGT), to calculate insulin sensitivity (SI) and peripheral glucose utilization independent of insulin (SG), and an oral glucose tolerance test (75 g; OGTT), were performed in nine postmenopausal women prior to, and after 2 months of, treatment.

RESULTS

Estradiol decreased insulin and increased the C-peptide/insulin ratio both during fasting (P < 0.02) and OGTT (insulin levels, P < 0.01; C-peptide/insulin ratio, P < 0.05), but not FSIGT. Glucose levels, C-peptide levels, SI and SG were not affected.

CONCLUSIONS

In spite of unmodified SI, the reduction of insulin levels and the increase of the C-peptide/insulin ratio, observed during fasting and OGTT, support a beneficial effect of estradiol on glucose metabolism. This effect probably requires the interplay of estradiol with gastrointestinal factors.

Transvaginal ultrasonography in the diagnosis of pelvic adhesions

We studied the role of transvaginal ultrasonography and clinical factors in the diagnosis of pelvic adhesions in a population of 139 consecutive pre-menopausal non-pregnant women submitted to diagnostic and/or operative laparoscopy between February 1995 and November 1996. All patients underwent transvaginal ultrasonography and were interviewed within 2 days of their laparoscopy. The ultrasonographic impressions were then compared with the laparoscopic diagnosis. Patients were classified as having tuboperitoneal abnormalities if evidence of fimbrial, peritubal and/or peri-ovarian adhesions was encountered during surgery. The overall agreement between the ultrasound test result and the surgical findings was calculated using the kappa index. The adhesion of the ovary to the uterus, as evaluated by transvaginal ultrasonography, is most accurate in diagnosing pelvic adhesions (kappa = 0.5) in comparison with the other ultrasonographic findings and clinical parameters. According to the logistic regression equation that was obtained, the probability of the presence of pelvic adhesions varied between a minimum of 12% for patients with no risk factors to a maximum of 93% for patients with three risk factors (previous pelvic surgery and transvaginal ultrasound findings of blurring of the margins of the ovary and adhesion of the ovary to the uterus).

Color Doppler energy imaging in the diagnosis of fetal intracranial hemorrhage in the second trimester

Unlike conventional color Doppler imaging; color Doppler energy (or power Doppler) displays the intensity of the returning Doppler signal, is less dependent on the orientation of the blood vessel, and is therefore better able to detect low blood velocities. For these reasons it could be useful in some investigations which are difficult to perform, such as transvaginal evaluation of fetal brain vessels. We report a case of a fetal intracranial hyperechoic lesion detected at 26 weeks by transabdominal sonography in a severely growth-retarded fetus. There was absence of diastolic flow in the umbilical artery and low impedance to diastolic flow in the middle cerebral arteries. The fetus was further investigated by transvaginal sonography for the evaluation of the nature and localization of the lesion and an intraventricular hemorrhage in the right brain parenchyma with disorganized supratentorial brain structure was observed. As color Doppler energy imaging is more sensitive to slow flow, it was more reliable than conventional Doppler imaging in confirming the absence of flow within and around the hyperechoic lesion in contrast to the normal vascularity of the contralateral ventricular system. After informed parental counselling, the mother, for psychological reasons, asked to be delivered by Cesarean section. The fetus died 24 h after birth. The autopsy corroborated the ultrasonographic diagnosis. This case report confirms the accuracy of transvaginal ultrasonography in the diagnosis of intracranial hemorrhage and suggests a specific role for color Doppler energy imaging.

Regulation of the 24-hour rhythm of body temperature in menstrual cycles with spontaneous and gonadotropin-induced ovulation

OBJECTIVE

To investigate the relation between gonadal steroids and the 24-hour body temperature rhythm.

PATIENT(S)

Nineteen normally cycling women.

DESIGN

Controlled clinical study in volunteer women.

SETTING

Clinical hospital.

INTERVENTION(S)

Eleven women were studied in the early follicular and luteal menstrual phases of cycles with spontaneous ovulation, and 8 women were studied in the early follicular, preovulatory, and luteal phases of cycles with multiple follicular development.

MAIN OUTCOME MEASURE(S)

Starting at 5:00 P.M., intravaginal body temperature was monitored continuously for 24 hours and its values were related to E2 and P levels.

RESULT(S)

Twenty-four-hour body temperature rhythm parameters were related to the P:E2 ratio. Very low P:E2 ratios in the preovulatory phase were associated with a reduced 24-hour mean and an elevated body temperature rhythm amplitude. The progressive increase in the P:E2 ratio in the early follicular and luteal phases was associated with an increase in the 24-hour mean body temperature and a decrease in the rhythm amplitude. Body temperature differences between the luteal and early follicular phases were less pronounced in cycles with multiple follicular development.

CONCLUSION(S)

A woman's body temperature is related to her P:E2 ratio. Even in the presence of elevated P values, alterations of this ratio may influence negatively the postovulatory rise in body temperature.

[Controlled clinical study of the efficacy and tolerability of methoxybutropate compared to nimesulide in gynecology]

BACKGROUND

This study was conducted to evaluate the efficacy and tolerability of methoxibutropate, a non-steroidal antiinflammatory drug, in gynecology. Methoxibutropate has now been available for some years and has recently been prepared in a new formulation: oral granules.

MATERIALS AND METHODS

This was a double-blind study and enrolled 60 patients of childbearing potential (age: 19 to 42 years), with acute or sub-acute inflammatory diseases involving the genital system. Thirty women were treated for 20 days with 1200 mg/day of oral methoxibutropate. Thirty more women were treated with nimesulide as a control drug. Oral granules of nimesulide were administered in daily dosage of 200 mg. Efficacy was evaluated by assessing symptoms and signs at day 8, 15, 21 and 30 after the start of treatment. Symptoms assessed were: pelvic pain, bloated abdomen, breast tenderness, dysmenorrhea, etc. Signs assessed were: volume and consistency of uterus and adnexa, type and volume of vaginal discharge, pelvic tenderness, vaginal tenderness, etc.

RESULTS AND CONCLUSIONS

All the sixty patients enrolled completed the study, at the end of which the drugs were shown to be equally effective: between day 21 and day 30 after the beginning of treatment, resolution of the assessed signs and symptoms was almost complete, especially with methoxibutropate. Lastly, tolerability was remarkable: side effects were few and mild; also in this case methoxibutropate was slightly better.

Effects of acute administration of transdermal estrogen on postmenopausal women with systemic hypertension

We studied 16 postmenopausal women with mild to moderate hypertension according to a randomized, double-blind protocol. They received patches of transdermal estradiol-17beta rated to deliver 100 mg/day of substance or matched placebo. A 24-hour ambulatory blood pressure (BP) monitoring was performed at baseline and after drug administrations. Our data show that estradiol-17beta exerts beneficial effects, both in lowering elevated BP levels and in maintaining a uniform BP control over 24 hours. Estrogen replacement therapy could be considered when significant changes in BP occur during the postmenopausal period.

Tumor-associated lympho-monocytes from neoplastic effusions are immunologically defective in comparison with patient autologous PBMCs but are capable of releasing high amounts of various cytokines

We studied several in vitro activities of tumor-associated lympho-monocytes (TALMs) and the concentrations of interleukin (IL)-1alpha, IL-1beta, IL-2, IL-4, IL-6, IL-10, tumor necrosis factor (TNF)alpha, interferon (IFN)gamma and soluble IL-2 receptor (slL-2R) in neoplastic effusions and in the serum of advanced stage cancer patients. Comparisons were made with autologous peripheral blood mononuclear cells (PBMCs). Autologous PBMCs were compared with PBMCs from normal subjects used as controls. TALMs were collected from 13 peritoneal and 18 pleural neoplastic effusions, secondary to primary tumors of different sites. After PHA stimulation, concentrations of IL-1alpha, IL-1beta and TNF alpha in culture media of TALMs both from peritoneal and pleural effusions were lower than those of autologous PBMCs and, similarly, concentrations of IL-4 and IL-10 in culture media of TALMs from peritoneal effusions were lower than those of autologous PBMCs, whereas concentrations of IL-4 and IL-10 in culture media of TALMs from pleural effusions were in the same range as those of autologous PBMCs. On the contrary, IL-2, IL-6 and IFN gamma amounts (only from pleural effusions) were significantly higher. IL-1alpha, IL-1beta, IL-2, IL-6 and TNF alpha production from patient PBMCs was lower than that of control PBMCs, whereas production of IL-4, IL-10 and IFN gamma was higher than that of control PBMCs. Both in peritoneal and in pleural effusions concentrations of IL-1alpha, IL-1beta and IL-4 were not different from those measured in autologous serum, whereas those of IL-6, IL-10, TNF alpha, IFN gamma and sIL-2R were significantly higher. The amounts of IL-2 in pleural effusions were not different from those of autologous serum, but in peritoneal effusions they were higher than those of autologous serum. The amounts of IL-1alpha, IL-1beta, IL-2, IL-6, TNF alpha and sIL-2R were higher in patient than in control sera, whereas those of IL-4, IL-10 and IFN gamma were in the same range in patient and in control sera. Cell cycle analysis of cultured TALMs and PBMCs (from 3 patients) showed a significant accumulation of TALMs in the non-cycling G0/G1 cell population compared with autologous PBMCs.