Action of midcycle contraceptive (R 2323) on the human endometrium

Gestrinone combined with ultrasound-guided aspiration and ethanol injection for treatment of chocolate cyst of ovary

AIM

The aim of this study was to determine clinical performance of gestrinone combined with ultrasound-guided aspiration and ethanol injection in treating chocolate cyst of ovary.

METHODS

Sixty-eight patients enrolled in this study were randomly divided into two groups: control group and combination treatment group. In the control group, 34 patients were treated with ultrasound-guided aspiration and ethanol injection. In the combination treatment group, 34 patients received gestrinone p.o. following ultrasound-guided aspiration and ethanol injection.

RESULTS

The recurrence rate of chocolate cyst was 10-fold lower in the combination treatment group (2.94%, 1/34) than in the control group (29.4%, 10/34) at 12 months. The effective rate for reduction of chocolate cyst was significantly higher in the combination treatment group (94.12%, 32/34) than in the control group (64.71%, 22/34) (P = 0.009).

CONCLUSION

Gestrinone combined with ultrasound-guided aspiration and ethanol injection therapy is an effective treatment for ovarian chocolate cyst with low recurrence rate.

Progesterone Threshold Determines Nucleolar Channel System Formation in Human Endometrium

Nucleolar channel systems (NCSs), micron-sized organelles specific to nuclei of human endometrial epithelial cells (EECs), are robust markers of the midluteal phase under the apparent control of progesterone. To gain further insight into the role of progesterone in NCS formation, we quantitatively assessed their sensitivity to oral contraceptive pills (OCPs) using immunofluorescence-based detection of NCSs. Comparison of endometrial biopsies and serum progesterone levels on cycle day (CD) 10 and 20 (LH +6/7) of 6 naturally cycling women and 6 OCP users demonstrated that OCPs interfered with NCS formation on CD20, their natural peak presence. Although this confirmed prior observation based on electron microscopic sampling, OCPs unexpectedly induced limited but distinct amounts of NCSs already on CD10, when they are never present in natural cycles. Thus, OCPs can cause secretory changes in the endometrium during the proliferative phase. In a novel finding, robust NCS formation on CD20 was dependent on a 4 ng/mL progesterone threshold but did not correlate linearly with serum progesterone levels. Given the threshold being close to that serving as evidence for ovulation, NCSs can serve as ovulation markers.

The nucleolar channel system reliably marks the midluteal endometrium regardless of fertility status: a fresh look at an old organelle

OBJECTIVE

To determine whether nucleolar channel systems (NCSs) in the midluteal endometrium are associated with overall fertility status and/or with unexplained infertility.

DESIGN

Retrospective and prospective clinical studies.

SETTING

Repository of stored specimens from prior multicenter study and private infertility center.

PATIENT(S)

Retrospective study that included 97 women (49 fertile couples, 48 infertile couples) who had been randomized for endometrial biopsy during the midluteal or late luteal phase. The prospective study included 78 women with a variety of infertility diagnoses.

INTERVENTION(S)

Endometrial biopsies were obtained and assessed for the presence of NCSs by indirect immunofluorescence.

MAIN OUTCOME MEASURE(S)

The presence of NCS was graded semiquantitatively and dichotomized as normal versus low or absent.

RESULT(S)

Normal presence of NCS was significantly associated with the midluteal phase compared with the late luteal phase (80% vs. 29%). However, there was no association between presence of NCS and fertility status or between presence of NCS and unexplained infertility.

CONCLUSION(S)

Midluteal phase endometrium consistently forms NCSs regardless of fertility status, including unexplained infertility. This indicates a possible role for the NCS in initiating the window of endometrial receptivity. However, the consistent presence of NCSs across several different types of infertility challenges the likelihood that inadequate secretory transformation is a cause of infertility.

Nuclear pore complex proteins mark the implantation window in human endometrium

Nucleolar channel systems (NCSs) are membranous organelles appearing transiently in the epithelial cell nuclei of postovulatory human endometrium. Their characterization and use as markers for a healthy receptive endometrium have been limited because they are only identifiable by electron microscopy. Here we describe the light microscopic detection of NCSs using immunofluorescence. Specifically, the monoclonal nuclear pore complex antibody 414 shows that NCSs are present in about half of all human endometrial epithelial cells but not in any other cell type, tissue or species. Most nuclei contain only a single NCS of uniform 1 microm diameter indicating a tightly controlled organelle. The composition of NCSs is as unique as their structure; they contain only a subset each of the proteins of nuclear pore complexes, inner nuclear membrane, nuclear lamina and endoplasmic reticulum. Validation of our robust NCS detection method on 95 endometrial biopsies defines a 6-day window, days 19-24 (+/-1) of an idealized 28 day cycle, wherein NCSs occur. Therefore, NCSs precede and overlap with the implantation window and serve as potential markers of uterine receptivity. The immunodetection assay, combined with the hitherto underappreciated prevalence of NCSs, now enables simple screening and further molecular and functional dissection.

The hormonal control of implantation

The hormonal control of implantation in mammalian species with and without embryonic diapause is described. In a majority of species displaying the obligate form of diapause the corpora lutea appear to exhibit a low level of steroidogenic activity throughout diapause, full luteal activity being resumed just before the initiation of implantation. Fluctuations in the plasma levels of oestrogen and progesterone during diapause may serve to prime the uterus for implantation. In species exhibiting the facultative form of diapause, such as the rat and mouse, both progesterone and nidatory oestrogen are required for the induction of implantation. In species not displaying embryonic diapause implantation will take place in the presence of progesterone alone. In the light of these considerations the selection of animal models for drug-screening purposes and possible new approaches to contraception are discussed.

The nucleolar channel system of human endometrium is related to endoplasmic reticulum and R-rings

The nucleolar channel system (NCS) is a well-established ultrastructural hallmark of the postovulation endometrium. Its transient presence has been associated with human fertility. Nevertheless, the biogenesis, composition, and function of these intranuclear membrane cisternae are unknown. Membrane systems with a striking ultrastructural resemblance to the NCS, termed R-rings, are induced in nuclei of tissue culture cells by overexpression of the central repeat domain of the nucleolar protein Nopp140. Here we provide a first molecular characterization of the NCS and compare the biogenesis of these two enigmatic organelles. Like the R-rings, the NCS consists of endoplasmic reticulum harboring the marker glucose-6-phosphatase. R-ring formation initiates at the nuclear envelope, apparently by a calcium-mediated Nopp140-membrane interaction, as supported by the calcium-binding ability of Nopp140, the inhibition of R-ring formation by calcium chelators, and the concentration of Nopp140 and complexed calcium in R-rings. Although biogenesis of the NCS may initiate similarly, the reduced presence of complexed calcium and Nopp140 suggests the involvement of additional factors.

Intranuclear endoplasmic reticulum induced by Nopp140 mimics the nucleolar channel system of human endometrium

Exogenous expression of the characteristic repeat domain of the nucleolar chaperone Nopp140 induces the formation of intranuclear structures, termed R-rings. Here, the R-rings are identified as extensive stacks of membrane cisternae in the otherwise membrane-free nucleus. They consist of bona fide endoplasmic reticulum (ER) containing integral membrane proteins of the smooth and rough ER. Although lacking nuclear pore complexes and lamina, the R-rings derive specifically from the inner nuclear membrane. These findings are consistent with the idea that all transmembrane proteins synthesized in the ER and the outer nuclear membrane can freely diffuse through the pore membrane domain into the inner membrane. Uniquely, the soluble transfected Nopp140 is directly involved in the generation of these membrane stacks as it localizes to the electron dense matrix in which they are embedded. The only well-documented example of intranuclear membrane proliferation is the nucleolar channel system of the postovulation human endometrium. The transient emergence of the nucleolar channel system correlates precisely with the readiness of the endometrium for the implantation of the fertilized egg. The nucleolar channel system exhibits an ultrastructure that is indistinguishable from R-rings, and nuclei of human endometrium harbor Nopp140 and ER marker containing structures. Therefore, the nucleolar channel system appears to be identical to the R-rings, suggesting a role for Nopp140 in human reproduction.

Gestrinone in the treatment of menorrhagia

The role of gestrinone, 2.5 mg twice weekly, in treating proven menorrhagia (greater than 80 ml) was examined in 19 women. They were treated for five cycles (2 placebo, 3 active), taking one capsule twice weekly. Placebo had no effect on menstrual blood loss (MBL). On gestrinone 10 women became amenorrhoeic, in five MBL was markedly reduced (5-74 ml) and four did not respond. In three of the non-responders submucous leiomyomas were found at subsequent hysterectomy. Follow-up periods showed a persistent reduction in MBL for nine women in the first post-treatment menstruation.

The effects of steroids on the fine structure of the endometrium

This brief review illustrates the lack of ultrastructural studies on human endometrium, particularly on well-dated material from normal, fertile women. The glandular epithelium, with its triad of unusual organelles in the early luteal phase, poses fascinating problems in cell biology and, probably for this reason, has attracted the most work. Many problems in reproductive biology, in uterine pathology and in the study of unexplained infertility are crying out for detailed study of the luminal epithelium, the stroma and the blood vessels. If this review, by highlighting the gaps in our knowledge, stimulates research into these areas, it will have been successful.

Impact of gestrinone on the course of asymptomatic endometriosis

A new drug, gestrinone, was subjected to the first double blind, randomised placebo controlled trial of any treatment of endometriosis. The disease deteriorated in eight (47%) of the 17 patients prescribed placebo (95% confidence limits 23% and 71%) compared with none of the 18 patients prescribed gestrinone (p = 0.002). There was a difference in elimination of the endometriosis in the gestrinone group compared with placebo but this was not statistically significant (p = 0.057). There was a significant difference in improvement of the disease in the gestrinone group compared with placebo (p = 0.004), confirming that gestrinone is an effective treatment of endometriosis. Endometriosis deteriorates in at least 23% of patients; as it is impossible to predict in whom this will happen, treatment appears to be warranted in all cases.

The biochemistry of human endometrium after two regimens of postcoital contraception: a dl-norgestrel/ethinylestradiol combination or danazol

A combination of 0.5 mg levonorgestrel (in 1 mg dl-norgestrel) and 0.1 mg ethinylestradiol was administered to eight volunteers 48 hours after the start of the luteinizing hormone surge. A second dose was given 12 hours later. Endometrial samples were obtained 24 hours after the first dose was given. The steroid receptor concentration was compared with ovulatory spontaneous cycles. The dl-norgestrel/ethinylestradiol combination caused a significant reduction in receptor concentration. Isocitrate dehydrogenase (a progestin-sensitive enzyme) was also altered, suggesting an effect on endometrial metabolism. Danazol was used in a similar fashion, with two doses each of 400 mg. Nine volunteers were studied. A similar pattern of alteration of endometrial biochemistry was demonstrated but did not reach statistical significance. The relevance to the postcoital use of hormones is discussed.

The response of human endometriotic implants to the anti-progesterone steroid R 2323: a histologic and ultrastructural study

The histology and ultrastructure of small endometriotic lesions were studied in 19 patients before and after hormonal therapy with the anti-progesterone steroid R 2323 (Gestrinone). Histologic results demonstrate that treatment of endometriosis with this steroid does not result in complete elimination of the endometriotic foci, although glandular proliferation and secretion are arrested in most implants. The ultrastructural results indicate that this inhibition of proliferation and secretion is related to an enhanced activity of the lysosomal system in the epithelial cells of some endometriotic foci. In other implants, or even in other cells of the same foci, epithelial cells with only a small amount of supranuclear cytoplasm but lacking lysosomes may be found. The morphologic data demonstrate that the cellular involutionary response to the antiprogesterone drug Gestrinone involves an activation of the lysosomal system, an abortive apocrine secretion of cell remnants and finally, in some implants, an extrusion of individual epithelial cells. Since this involutionary process of endometriotic cells mimics the pre-menstrual lysosomal degradation in the endometrium, it is suggested that the competitive binding of the antiprogesterone Gestrinone to the progesterone receptors of endometriotic epithelium may cause a cellular progesterone withdrawal effect.

Effect of gestrinone in endometriosis tissue and endometrium

The effects of gestrinone (R 2323) on endometrial and endometriosis tissue concentrations of cytosol estrogen and progestin receptors and the activity of 17 beta-hydroxysteroid dehydrogenase (17 beta-HSD) were investigated in 11 patients operated on because of suspected external endometriosis. Serum concentrations of luteinizing hormone, follicle-stimulating hormone, estradiol (E2), progesterone, testosterone (T), and sex-hormone-binding globulin (SHBG) were also investigated. After one control cycle, the patients received 2.5 mg of oral gestrinone twice weekly from the fifth day of the first treatment cycle until the eighth day of the second treatment cycle, the day of operation being day 10. Treatment with gestrinone decreased serum concentrations of T during the second treatment cycle and effected a major decrease in SHBG during both treatment cycles, resulting in highly increased free T and free E2 indices. The effects of gestrinone on the endometrium, a decrease in estrogen and progestin receptors, and induction of 17 beta-HSD are characteristic progestin actions. These parameters remained unchanged in endometriosis tissue. Our data indicate that gestrinone has effects that are typical of androgens and progestins in patients with endometriosis.

The effect of a synthetic progestogen, ethylnorgestrienone, on hypothalamic-pituitary-ovarian function, cervical mucus, vaginal cytology, and endometrial morphology

The antifertility mechanism of a new progestin preparation, ethylnorgestrienone (13 beta-ethyl-17 alpha-ethynyl-17-hydroxy-gona-4,9,11-triene-3-one) (R2323), was evaluated. The compound was administered orally in doses of 5 mg weekly to seven subjects for a total of nine treatment cycles. Each woman served as her own control and was studied during a normal menstrual cycle followed by a cycle in which she received R2323. Serum concentrations of luteinizing hormone (LH), follicle-stimulating hormone (FSH), estradiol, and progesterone, as well as cervical mucus properties, were studied serially during the control and treatment cycles. Results indicated that all control cycles were ovulatory. Ovulatory gonadotropin patterns were observed in four treated cycles, but preovulatory FSH and LH peaks and progesterone production during the luteal phase were suppressed significantly. Estradiol levels showed an early increase during the follicular phase and a significantly decreased preovulatory peak. Cervical mucus properties were altered and sperm penetration in cervical mucus was inhibited in all treatment cycles. These findings suggest that at least two different factors might be involved in the contraceptive mechanism of R2323: (1) alteration of the ovulatory process and progesterone production, and (2) cervical mucus changes leading to inhibition of sperm migration.

Competitive progesterone antagonists: receptor binding and biologic activity of testosterone and 19-nortestosterone derivatives

Testosterone and 19-nortestosterone derivatives were evaluated in a developmental scheme designed to identify competitive progesterone antagonists having abortifacient activity. Compounds that displayed significant binding to the rabbit uterine progesterone receptor were followed in biologic tests for progestational, antiprogestational, and abortifacient activities. Of the seven compounds tested for both progestational and antiprogestational activity, only one, 5 alpha-dihydronorethindrone, behaved exclusively as an antagonist. Five other 19-nortestosterones (19-nortestosterone, 17 beta-hydroxyestra-4, 9(10)-dien-3-one, norethindrone, norethindrone acetate, and R 2323) proved to be mixed agonists/antagonists. 5 alpha-Dihydronorethindrone, norethindrone, and 19-nortestosterone terminated pregnancy during the postnidatory period in rats; in addition, the latter two compounds inhibited progesterone-supported pregnancy in spayed rats and curtailed pregnancy during the postnidatory period in hamsters. These results demonstrate that several 19-nortestosterone derivatives bind to the uterine progesterone receptor and behave either as antagonists or mixed agonists/antagonists.