Adjusting the dose to the individual response of the patient during the induction of ovulation with pulsatile gonadotropin-releasing hormone

To identify the effective dose of intravenous pulsatile gonadotropin-releasing hormone necessary to induce ovulation in patients with chronic anovulation of diverse etiology, 40 women were subdivided into four groups: idiopathic hypogonadotropic hypogonadism (IHH), functional hypothalamic amenorrhea, normoandrogenic oligomenorrhea, and polycystic ovarian syndrome (PCOS). During 90 treatment cycles, the dose was the only parameter that was progressively adjusted. The overall ovulation rate per cycle was 100% in IHH, functional hypothalamic amenorrhea, and normoandrogenic oligomenorrhea, using only 5 micrograms/90 minutes in functional hypothalamic amenorrhea and normoandrogenic oligomenorrhea and up to 7.5 micrograms/90 minutes in IHH. In PCOS, the ovulation rate was 67.6%, using up to 20 micrograms/90 minutes. The lesser degree of effectiveness observed in PCOS can probably be explained by the different basal endocrine profile presented by these subjects.

Domperidone-induced acute dystonia and polycystic ovary syndrome

The occurrence of acute dystonic reactions (ADRs) due to domperidone administration in two young women is reported. In both patients, a typical polycystic ovary (PCO) syndrome was found. The possibility that the relative hyperestrogenism typical of PCO syndrome acted as a facilitating factor for ADR is discussed.

Evolution of antimicrobial prophylaxis in obstetric surgery

Problems concerning antimicrobial prophylaxis in obstetric surgery are reviewed from the first experiences with multiple-dose treatments to the new short-term prophylaxis. With the purpose to evaluate the effectiveness of a short-term scheme, a controlled population of 134 obstetric patients was treated with a double dose of 2 g i.m. of cefotetan. Clinically important infectious complications were not observed.

A comparative study on the effects of a monophasic pill containing desogestrel plus 20 micrograms ethinylestradiol, a triphasic combination containing levonorgestrel and a monophasic combination containing gestodene on coagulatory factors

The changes in haemostasis during oral contraception are related to the ethinylestradiol dose present in the formulation taken by the patient. An open, randomized longitudinal study was performed to evaluate and compare the effects that low-dose oral contraceptives (OCs) containing different doses of ethinylestradiol exert on the haemostatic system. Eighty-nine healthy women, aged 18-45 years, were randomly assigned to treatment with 3 different OCs: a monophasic pill containing 30 micrograms of ethinylestradiol plus 75 micrograms of gestodene (GSD/30) (30 subjects), a triphasic pill containing levonorgestrel (TRI/LNG) (28 subjects), a monophasic pill containing 20 micrograms ethinylestradiol plus 150 micrograms of desogestrel (DOG/20) (31 subjects). From every woman, blood samples were collected before treatment and at the 3rd and 6th cycle of pill intake. The number of platelets significantly increased (p less than 0.01) during treatment with TRI/LNG. Fibrinogen plasma values were significantly increased (p less than 0.05) only in women treated with the preparation GSD/30. Fibrinopeptide A (FPA) plasma levels significantly increased (p less than 0.01) during treatment with the pills TRI/LNG and GSD/30, but the levels of FPA were unchanged in the group treated with DOG/20. The overall results of this study confirm that the effects of OCs on haemostasis are dependent on the ethinylestradiol dose. Moreover, they suggest that with reduction of the ethinylestradiol component to 20 micrograms, the effects of OCs on haemostasis seem to be virtually eliminated.

Repeated transient hypergonadotropic amenorrhea during pharmacologic induction of multiple follicular development with exogenous gonadotropins

Human gonadotropins are widely used for induction of ovulation in the treatment of anovulatory infertility and for induction of multiple follicular development (MFD) in in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), and artificial insemination with husband's semen (AIH) programs. Reported is a patient with normal menstrual cycles, who had two episodes of gonadal unresponsiveness to human gonadotropin therapy, followed by transient hypergonadotropic amenorrhea ("resistant ovary" syndrome), during induction of MFD in conjunction with AIH as treatment for unexplained infertility. The first episode occurred during the sixth cycle of a first series of MFD induction with daily intramuscular injections of exogenous gonadotropins. The second episode occurred during the second cycle of a second series of MFD induction with intravenous pulsatile administration of FSH. On both occasions, normalization of endogenous gonadotropin levels and reappearance of ovulatory cycles occurred spontaneously, after two and three months, respectively. A similar mechanism could occur in the failures of MFD induction observed in IVF programs.

Reduced luteinizing hormone secretion in women with Parkinson's disease

Plasma luteinizing hormone (LH) levels were significantly lower in 10 postmenopausal women with Parkinson's disease (PD) compared to age-matched controls. The remaining hypophyseal hormones and gonadal steroids were similar in PD patients and in controls, suggesting a selective alteration of hypothalamic dopaminergic mechanisms which regulate LH secretion.

[Clinical experience with methoxybutropate vs. bromelin in the treatment of female pelvic inflammation]

This study reports the results of a controlled randomized clinical trial performed on 30 young women with PID (Pelvic Inflammatory Disease), using a new anti- inflammatory-analgesic: methoxybutropate. The quali-quantitative symptomatical assessment showed that the improvement of the pain has been more marked and faster with methoxybutropate than hot observed in control group treated with bromeline.

Ultrasound monitoring of testis and prostate maturation in hypogonadotropic hypogonadic males during gonadotropin-releasing hormone treatment

The effects of the administration of gonadotropin-releasing hormone (GnRH) on the increase of testis and prostate volume was monitored by ultrasound in six patients affected by idiopathic hypogonadotropic hypogonadism. A significant increase of testis volume was observed after 90 and 180 days (6.65 versus 3.32 mL, 99.1% net increase and 8.47 mL, 176.8% increase, respectively) of pulsatile GnRH treatment. A similar increase of prostate volume was observed at day 90 (12.67 versus 7.78 mL, 70.3% net increase) and day 180 (14.70 mL, 97.7% increase). The ultrasound monitoring of the modifications of testis and prostate volume may represent a biological assay of the effects of GnRH treatment and offer additional data on the response of target organs to the hormonal treatment.

Possible involvement of dopaminergic mechanisms in the antimigraine action of flunarizine

Flunarizine, a calcium antagonist widely used in the prophylactic treatment of migraine, may interfere with dopaminergic systems. Flunarizine therapy can in fact induce extrapyramidal side effects and can increase basal as well as stimulated prolactin levels. To better define the mechanism of flunarizine action in migraine, we studied prolactin and growth hormone responses to thyrotropin releasing hormone and sulpiride in 13 female migraineurs before and after 60 days of flunarizine therapy. The treatment did not modify basal prolactin and growth hormone levels, but prolactin response to thyrotropin releasing hormone was enhanced. A paradoxical increase of growth hormone to thyrotropin releasing hormone observed before therapy was blunted after flunarizine treatment. These data indicate a modulatory action of flunarizine on dopaminergic systems which might to some extent explain the antimigraine action of this drug.

Effects of transdermal 17 beta-estradiol treatment and naloxone infusion on gonadotropin response to gonadotropin-releasing hormone in postmenopausal women

Estrogens exert both inhibitory and stimulatory effects on the secretion of GnRH and gonadotropins in women. The endogenous opioid peptides seem to mediate, at least in part, the inhibitory action exerted by estrogens on LH secretion. However, the mechanisms that mediate the stimulatory effect of estrogens on LH secretion are still unclear. The present study was performed to evaluate whether the endogenous opioid peptides could also participate in the stimulatory effect that estrogens exert on the gonadotropin response to GnRH. In postmenopausal women, a GnRH test was performed both under basal conditions and during the second month of treatment with transdermal 17 beta-estradiol (E2). In untreated postmenopausal women, two different doses of naloxone infusion failed to modify the LH and FSH responses to GnRH stimulation. During treatment with transdermal E2, the LH response to GnRH was significantly increased, while the FSH response was similar to that before treatment. Naloxone completely counteracted the enhanced LH response to GnRH observed during E2 treatment. On the other hand, naloxone did not significantly modify the FSH response to GnRH. The present results confirm that E2 exerts a sensitizing effect on the pituitary LH response to GnRH and suggest that the endogenous opioid system could be involved in this effect.

Effect of naloxone on body temperature in postmenopausal women with Parkinson's disease

The role exerted by the endogenous opioid system on thermoregulation has been studied in six postmenopausal women affected by Parkinson's disease and in 6 age-matched, normal postmenopausal women, as controls. The women randomly received an infusion of the opioid antagonist naloxone (1.6 mg/h for 4 h) or of saline on two consecutive days. Body temperature, as evaluated by rectal temperature, was significantly lower (p less than 0.05) in Parkinsonian than in normal women, and it did not vary during saline infusion, in either groups. Naloxone infusion significantly reduced (p less than 0.01) body temperature in normal postmenopausal women, but it was unable to modify body temperature in women affected by Parkinson's disease. The low basal body temperature values and the inability of naloxone to exert a hypothermic effect in women suffering from Parkinson's disease seem to constitute further evidence for an impaired regulation of body temperature and impaired activity of the endogenous opioid system in this pathology.

Clinical and metabolic effects of a pill containing 30 mcg ethinylestradiol plus 75 mcg gestodene

The clinical and metabolic effects of a short-term treatment with a combination contraceptive pill containing 30 mcg ethinylestradiol and 75 mcg gestodene were evaluated in a group of 31 healthy women. The pill exerted good cycle control and the incidence of irregular bleeding was low. Side effects rarely occurred, and an improvement in premenstrual symptoms was reported during pill intake. Among the different biochemical parameters tested to monitor the coagulatory system, the only modification observed was an increase of fibrinopeptide A plasma levels, confirming that low-dose pills have less effects on the haemostatic system than oral contraceptives with a higher estrogen content. No significant modification in plasma total cholesterol, triglycerides, high density lipoprotein-cholesterol (HDL-CH), HDL2-CH, nor low density lipoprotein-cholesterol were observed. HDL3-CH levels were significantly increased. Moreover, the pill did not significantly alter the fasting insulin and glucose levels nor their response to an oral glucose tolerance test. It may be suggested that this new formulation has high efficacy and clinical acceptability, primarily due to the total absence of any adverse metabolic effect.

Influence of oestradiol and progesterone on pulsatile LH secretion in postmenopausal women

Pulsatile LH secretion was studied in six healthy postmenopausal women. Blood samples were obtained every 10 min during an 8-h saline infusion performed before and during the administration of transdermal oestradiol alone (E2; 50 micrograms/day) and in combination with vaginal progesterone (P; 100 mg twice daily). Plasma E2 and P levels reached values similar to those found in the early follicular phase and in the luteal phase of the menstrual cycle, respectively. The mean plasma LH levels significantly decreased (P less than 0.01) during transdermal E2 with and without vaginal P. A significant increase in the frequency (P less than 0.025) and the amplitude (P less than 0.05) of LH pulses was observed during transdermal E2. The administration of vaginal P to oestrongenized women significantly blunted the frequency (P less than 0.05) and enhanced the amplitude (P less than 0.05) of LH pulses. In all experimental conditions, the mean plasma LH levels showed a positive linear correlation with the amplitude of LH pulses. The present results show that peripheral levels of E2, similar to those of the early follicular phase of the menstrual cycle, can influence the pulsatile pattern of LH secretion, enhancing the frequency and the amplitude of LH pulses. In oestrogenized patients, the increase of peripheral P plasma levels to postovulatory values restored a pulsatile pattern of LH secretion similar to that of the early luteal phase of menstrual cycle.

[Effects of low-dose oral contraceptives on sugar metabolism]

The effects on carbohydrate metabolism by four low-dose oral contraceptives were evaluated in four low-dose oral contraceptives were evaluated-66 young women randomly divided in four groups. In the various preparations there were a different dosage of estrogen (ethinylestradiol) together different doses and types of progestogen (desogestrel, gestodene, cyproterone acetate). After six months of treatment, in all groups a slight increase of glycemic and insulinemic responses during OGTT was observed; the significance was achieved with the preparation containing cyproterone acetate alone. Glycated hemoglobin did not change. Our results suggest that these new low-dose oral contraceptives induced negligible metabolic side effects.

Reduction in the size of prolactin-producing pituitary tumor after Cabergoline administration

Different weekly doses (400 to 3,000 micrograms) of the new, long-acting dopamine agonist Cabergoline (Farmitalia Carlo Erba, Milan, Italy) were given to 11 hyperprolactinemic women with pituitary tumor. Pituitary computerized tomography (CT) scans were performed before the start of treatment and after 3 (n = 5), 6 (n = 3), and 9 (n = 3) months of Cabergoline administration. Plasma prolactin (PRL) was determined in blood samples collected before and at weekly intervals during Cabergoline administration. Cabergoline induced marked inhibition of PRL secretion in conjunction with a CT demonstration of reduction in the pituitary tumor size in all patients. The potent, long-lasting PRL inhibitory effect of Cabergoline and the absence of side effects typical of dopaminergic compounds suggest that the use of this drug is advantageous over others in the medical treatment of hyperprolactinemia.

Raised maternal plasma alpha-fetoprotein and pregnancy outcome

With the aim of evaluating the clinical value of raised maternal plasma alpha-fetoprotein (AFP) in women with singleton fetuses without structural abnormalities, the outcome of pregnancy was evaluated in a group of 20 women with these characteristics. Only 6 women (30%) delivered fetuses with appropriate birthweight at term; there were 6 pregnancy losses (30%), and the remaining pregnancies ended in pre-term delivery and/or birth of a small for gestational age fetus. Ultrasound examination supplied additional information in 3 cases only. Amniocentesis did not seem to affect pregnancy outcome in this group of high-risk pregnancies. Serial AFP testing was useless for monitoring these pregnancies. It is concluded that raised maternal plasma AFP must be regarded as a marker of poor pregnancy outcome even after exclusion of neural tube defects.

Cabergoline: long-acting oral treatment of hyperprolactinemic disorders

Cabergoline, a new orally active dopaminergic drug with an extremely long-lasting PRL-lowering effect, was given to 48 hyperprolactinemic women for 3-18 months (median, 8 months) at doses varying between 0.2-3 mg/week administered one to three times weekly. Serum PRL levels declined to normal in 41 women, 30 of whom received 0.2-1 mg cabergoline once weekly, 8 received 0.2-0.5 mg twice weekly, and 3 received 0.4-0.6 mg 3 times weekly. Five women had slightly supranormal serum PRL levels while receiving 0.3-0.6 mg once weekly, but the dose was not increased because the lower dose had produced the desired clinical benefit. Two women had 50% reductions in their serum PRL levels, but remained hyperprolactinemic while receiving 2-3 mg cabergoline weekly. Among 30 amenorrheic women, 28 had resumption of menses, the exceptions being 2 hypopituitary women, presumptive evidence of ovulation was available in 21. Marked tumor shrinkage occurred after 3-month treatment in 5 of the 6 women who had macroprolactinomas. Only 4 women had side-effects during the first weeks of treatment, and these vanished despite continued cabergoline administration at the same or reduced, but still effective, doses. In a short term, double blind study, cabergoline at 3 different schedules (0.4 mg twice weekly, 0.2 mg 4 times weekly, and 0.4 mg 3 times weekly for 3 weeks, followed by 0.4 mg twice weekly) or placebo was given to a total of 24 hyperprolactinemic women (6 in each subgroup) for 8 weeks, with weekly evaluation of serum PRL levels and side-effects. All 3 cabergoline schedules, but not placebo, induced significant reductions in serum PRL concentrations during the 8-week treatment period. Mild transient side-effects occurred in 7 drug-treated patients (nausea in 5; dizziness in 3). We conclude that cabergoline is effective treatment for hyperprolactinemia. Its efficacy, tolerability, and long duration of action may make it the drug of choice for patients with hyperprolactinemia.

Effects of the antidopaminergic drug veralipride on LH and PRL secretion in postmenopausal women

Patterns of LH and PRL secretion have been evaluated in 15 postmenopausal women before and after the chronic blockage of the D2 dopamine receptors with veralipride (100 mg twice daily, for 30 days). In addition, the possible influence of the antidopaminergic drug on the activity of the endogenous opioid system has been evaluated by the infusion of the opioid antagonist naloxone, performed before and during veralipride administration. Mean plasma LH levels were significantly blunted (p less than 0.05) and mean plasma PRL levels were significantly increased (p less than 0.001) by veralipride administration. The frequency of both LH and PRL secretory pulses was not modified, while the mean pulse amplitude of both hormones was significantly increased (p less than 0.05 for LH; p less than 0.001 for PRL) by veralipride administration. In untreated postmenopausal women naloxone infusion did not modify LH secretion. Following veralipride, the infusion of naloxone significantly increased (p less than 0.05) the mean plasma LH levels, had no influence on the frequency and significantly reduced (p less than 0.01) the amplitude of LH pulses, expressed as the percent increase from the nadir to the peak. Both before and after veralipride administration, naloxone failed to modify the pattern of PRL secretion. In untreated postmenopausal women, the percentage of concomitant PRL and LH pulses was significantly higher (p less than 0.001) during naloxone than during saline infusion, and this effect was amplified by veralipride administration (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Unbalanced progesterone and estradiol secretion in catamenial epilepsy

Ten women with a documented history of catamenial epilepsy underwent a hormonal study to evaluate hypophyseal-gonadal function. Baseline values of luteinizing hormone, follicle-stimulating hormone and prolactin were similar in catamenial seizure patients and in control groups throughout a complete menstrual cycle. Stimulated secretions of the same hypophyseal hormones in catamenial seizure patients overlapped those of the controls. The luteal secretion ratio of progesterone to estradiol was significantly reduced in catamenial seizure patients versus normal controls. In a subgroup of catamenial seizure patients on antiepileptic therapy, luteal progesterone levels were remarkably decreased compared to normal and epileptic controls. These results indicate that catamenial epilepsy is characterized by an imbalance in ovarian steroid secretion and emphasize the need for an endocrinological assessment in these patients.

Induction of multiple follicular development as a therapy for unexplained or male-related infertility

Most invasive techniques (i.e., in-vitro fertilization, gamete intrafallopian transfer) used for the therapy of unexplained or male-related infertility involve the induction of multiple follicular development (MFD). The efficacy of MFD in conjunction with a non-invasive technique (artificial insemination with husband's semen) was evaluated in a group of 41 couples with long-lasting infertility. MFD was obtained by means of clomiphene citrate and exogenous gonadotropins. Within 6 months of treatment, pregnancy was achieved by 52.2% of couples with male-related infertility and by 54.5% of couples with unexplained infertility. Sperm parameters, age of the female partner and preovulatory estradiol peak did not show any significant difference between couples who conceived and those who did not. It is concluded that induction of MFD represents an effective therapy and might replace invasive techniques for the treatment of the above conditions.

Urinary excretion of N-acetyl-beta-D-glucosaminidase and alanine aminopeptidase during pregnancy

The assay of enzyme activity in urine seems a reliable and safe method to monitor different kidney diseases. However, its use in pregnant patients might be limited by the modifications of kidney function during pregnancy. The aim of the present study was to evaluate the trend of excretion of the lysosomal enzyme N-acetyl-beta-D-glucosaminidase (NAG) and the brush border enzyme alanine aminopeptidase (AAP) during uncomplicated pregnancies. NAG excretion showed a significant increase (P less than 0.001) throughout pregnancy, while no significant modification of AAP levels was demonstrated. These data support the hypothesis that the two enzymes are excreted into the urine through different mechanisms and might constitute markers for different pathological events. As the increase of NAG excretion may be related to the kidney functional adaptation to pregnancy, different cut-off limits must be established in this period.

Regulation of body temperature in postmenopausal women: interactions between bromocriptine and the endogenous opioid system

The role exerted by the endogenous opioid system on thermoregulation has been studied in nine postmenopausal women before and after the chronic administration of the dopamine agonist bromocriptine (5 mg/day). These women randomly received an infusion of the opioid antagonist naloxone (1.6 mg/h for 4 h) or saline on two consecutive days, before and after 30 days of bromocriptine administration. Body temperature as evaluated by rectal temperature, did not vary during saline infusion performed both before and after 30 days of bromocriptine administration. In untreated women naloxone infusion significantly reduced body core temperature. The hypothermic response to naloxone was significantly greater following chronic bromocriptine administration. These results indicate that bromocriptine seems to increase the activity of the endogenous opioid system on the mechanisms which regulate body temperature in postmenopausal women.

Use of sulprostone for induction of preoperative cervical dilation or uterine evacuation: a comparison among the effects of different treatment schedules

Sulprostone was administered to 144 pregnant women to induce either preoperative cervical dilation or uterine evacuation. A comparison was performed to select the drug treatment schedule showing the greatest effects with the lowest incidence of side effects. As for preoperative cervical dilation, the local (intracervical/intramural) injection of 50 + 50 micrograms and the intramuscular treatment with 500 micrograms of sulprostone showed the most favorable effects on the cervix after 12 and 6 hours, respectively. The cervix dilated 8 mm or more in 82.6% of subjects treated locally and in 85.7% of those treated intramuscularly. No patient experienced a serious side effect, but two displayed vomiting after receiving 500 micrograms of the drug. Uterine evacuation was induced by both repeated intramuscular injections (500 micrograms every 4 hours) and continuous intravenous infusion (2.8 micrograms/minute for 6 hours) of sulprostone in more than 90% of the patients with intact pregnancy, missed abortion, or fetal death. The efficacy of the drug was not influenced by gestational age or parity. Gastrointestinal symptoms were the only recorded side effects, with negligible incidence and intensity for both routes of sulprostone administration.