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de Souza Pinto LP, Ferrari G, Dos Santos IK, de Mello Roesler CR, de Mello Gindri I. Evaluation of safety and effectiveness of gestrinone in the treatment of endometriosis: a systematic review and meta-analysis. Arch Gynecol Obstet 2023; 307:21-37. [PMID: 36434439 DOI: 10.1007/s00404-022-06846-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 10/25/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE Endometriosis is a common chronic gynecological disease defined as the presence of endometrial glands and stroma tissue outside the uterus. Gestrinone is an effective antiestrogen that induces endometrial atrophy and/or amenorrhea. The purpose of this systematic review is to provide an evaluation of safety and effectiveness of gestrinone for the treatment of endometriosis. METHODS We performed a search in six electronic databases: PubMed, MEDLINE (ovid), Embase, Cochrane CENTRAL (clinical trials), Web of Science and Scopus. Our selected primary outcomes were the changes in dysmenorrhea, pain relief including pelvic pain and dyspareunia. The secondary outcomes embrace hormones parameters, pregnancy rate and adverse events. RESULTS Of 3269 references screened, 16 studies were included involving 1286 women. All studies compared gestrinone with other drugs treatments (placebo, Danazol, Mifepristone tablets, Leuprolide acetate, Quyu Jiedu Recipe) during 6 months. When compared with other drugs treatments, gestrinone relieved dysmenorrhea, pelvic pain, and morphologic response in the ovary. There was an increase on the pregnancy rate. Regarding the side effects observed, gestrinone showed the same adverse events and increased the risk of acne and seborrhea when compared to other treatments. Even if there was any difference in efficacy between gestrinone, danazol, leuprolide acetate, or Quyu Jiedu Recipe Chinese Medicine, it remains unclear due to insufficient data. CONCLUSION Based limited evidence available suggests that gestrinone appeared to be safe and may have some efficacy advantages over danazol, as well as other therapeutic interventions for treating endometriosis. However, this conclusion should be interpreted with caution, due the quality of the evidence provided is generally very low or unclear. TRIAL REGISTRATION CRD42021284148.
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Affiliation(s)
| | - Gustavo Ferrari
- Iaso Biodelivery Fabricação de Dispositivos com Liberação de Fármacos LTDA, Florianópolis, SC, Brazil.,Biomechanics Engineering Laboratory, Department of Mechanical Engineering, University Hospital &, Federal University of Santa Catarina (UFSC), Florianópolis, SC, Brazil.,Bio Meds Pharmaceutica LTDA, Florianópolis, SC, 88050-001, Brazil.,NIMMA-Núcleo de Inovação em Moldagem e Manufatura Aditiva, Department of Mechanical Engineering, Federal University of Santa Catarina (UFSC), Florianópolis, SC, Brazil
| | | | - Carlos Rodrigo de Mello Roesler
- Biomechanics Engineering Laboratory, Department of Mechanical Engineering, University Hospital &, Federal University of Santa Catarina (UFSC), Florianópolis, SC, Brazil
| | - Izabelle de Mello Gindri
- Iaso Biodelivery Fabricação de Dispositivos com Liberação de Fármacos LTDA, Florianópolis, SC, Brazil. .,Bio Meds Pharmaceutica LTDA, Florianópolis, SC, 88050-001, Brazil.
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Ciou HH, Lee TH, Wang HC, Ding YR, Tseng CJ, Wang PH, Tsai MH, Tzeng SL. Repurposing gestrinone for tumor suppressor through P21 reduction regulated by JNK in gynecological cancer. Transl Res 2022; 243:21-32. [PMID: 34921996 DOI: 10.1016/j.trsl.2021.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 11/23/2021] [Accepted: 12/06/2021] [Indexed: 11/19/2022]
Abstract
Endometriosis has been shown to increase the risk of gynecological cancers. However, the effect of gestrinone, a clinical endometriosis drug, on gynecological cancers remains unclear. This study aimed to understand the effect of gestrinone on gynecological cancers. A retrospective study was conducted using the Longitudinal Health Insurance Database 2000 of the Taiwan National Health Insurance Research Database (NHIRD) to observe the risk of gynecological cancers. Medication records from the Department of Obstetrics and Gynecology, Chung Shan Medical University Hospital CSMUH and cancer records from the Taiwan Cancer Registry were collected to analyze the correlation between gestrinone use and gynecological cancers. Subsequently, human cell lines were used to investigate the effect of gestrinone on gynecological cancers. A total of 8330 endometriosis patients were enrolled, and analyses revealed that endometriosis patients had a higher risk of developing ovarian and endometrial cancer. However, the rate of cervical cancer was not statistically different (P = 0.249). Analyses of both the NHIRD and CSMUH databases revealed that gestrinone may reduce the risk of gynecological cancer. Cellular experiments verified the anticancer effects of gestrinone, which effectively and specifically inhibited the growth of HeLa cervical cancer cells, decreased P21 expression via JNK phosphorylation, and induced apoptosis. Combining the results of clinical database analysis and cell experiments, our findings prove that gestrinone has the potential to protect against cancer through regulation of the JNK-P21 axis. Repurposing the anticancer efficacy of gestrinone may be a strategy for targeted therapy in the future.
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Affiliation(s)
- Huai-How Ciou
- Institute of Medicine, Chung Shan Medical University, Taichung 40203, Taiwan
| | - Tsung-Hsien Lee
- Institute of Medicine, Chung Shan Medical University, Taichung 40203, Taiwan; Department of Obstetrics and Gynecology, Chung Shan Medical University Hospital, Taichung 40203, Taiwan
| | - Hsin-Chieh Wang
- Institute of Medicine, Chung Shan Medical University, Taichung 40203, Taiwan
| | - You-Ren Ding
- Institute of Medicine, Chung Shan Medical University, Taichung 40203, Taiwan
| | - Chih-Jen Tseng
- Department of Obstetrics and Gynecology, Chung Shan Medical University Hospital, Taichung 40203, Taiwan; Medical Information Department, Chung Shan Medical University Hospital, Taichung 40203, Taiwan; School of Medicine, Chung Shan Medical University, Taichung 40203, Taiwan
| | - Po-Hui Wang
- Institute of Medicine, Chung Shan Medical University, Taichung 40203, Taiwan; Department of Obstetrics and Gynecology, Chung Shan Medical University Hospital, Taichung 40203, Taiwan
| | - Meng-Hsiun Tsai
- Department of Management Information Systems, National Chung Hsing University, Taichung 40227, Taiwan; Institute of Genomics and Bioinformatics, National Chung Hsing University, Taichung 40227, Taiwan
| | - Shu-Ling Tzeng
- Institute of Medicine, Chung Shan Medical University, Taichung 40203, Taiwan; Department of Medical Research, Chung Shan Medical University Hospital, Taichung 40203, Taiwan.
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Abstract
BACKGROUND Endometriosis is defined as the presence of endometrial tissue (glands and stroma) outside the uterine cavity. This condition is oestrogen-dependent and thus is seen primarily during the reproductive years. Owing to their antiproliferative effects in the endometrium, progesterone receptor modulators (PRMs) have been advocated for treatment of endometriosis. OBJECTIVES To assess the effectiveness and safety of PRMs primarily in terms of pain relief as compared with other treatments or placebo or no treatment in women of reproductive age with endometriosis. SEARCH METHODS We searched the following electronic databases, trial registers, and websites: the Cochrane Gynaecology and Fertility Group (CGFG) Specialised Register of Controlled Trials, the Central Register of Studies Online (CRSO), MEDLINE, Embase, PsycINFO, clinicaltrials.gov, and the World Health Organization (WHO) platform, from inception to 28 November 2016. We handsearched reference lists of articles retrieved by the search. SELECTION CRITERIA We included randomised controlled trials (RCTs) published in all languages that examined effects of PRMs for treatment of symptomatic endometriosis. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as expected by the Cochrane Collaboration. Primary outcomes included measures of pain and side effects. MAIN RESULTS We included 10 randomised controlled trials (RCTs) with 960 women. Two RCTs compared mifepristone versus placebo or versus a different dose of mifepristone, one RCT compared asoprisnil versus placebo, one compared ulipristal versus leuprolide acetate, and four compared gestrinone versus danazol, gonadotropin-releasing hormone (GnRH) analogues, or a different dose of gestrinone. The quality of evidence ranged from high to very low. The main limitations were serious risk of bias (associated with poor reporting of methods and high or unclear rates of attrition in most studies), very serious imprecision (associated with low event rates and wide confidence intervals), and indirectness (outcome assessed in a select subgroup of participants). Mifepristone versus placebo One study made this comparison and reported rates of painful symptoms among women who reported symptoms at baseline.At three months, the mifepristone group had lower rates of dysmenorrhoea (odds ratio (OR) 0.08, 95% confidence interval (CI) 0.04 to 0.17; one RCT, n =352; moderate-quality evidence), suggesting that if 40% of women taking placebo experience dysmenorrhoea, then between 3% and 10% of women taking mifepristone will do so. The mifepristone group also had lower rates of dyspareunia (OR 0.23, 95% CI 0.11 to 0.51; one RCT, n = 223; low-quality evidence). However, the mifepristone group had higher rates of side effects: Nearly 90% had amenorrhoea and 24% had hot flushes, although the placebo group reported only one event of each (1%) (high-quality evidence). Evidence was insufficient to show differences in rates of nausea, vomiting, or fatigue, if present. Mifepristone dose comparisons Two studies compared doses of mifepristone and found insufficient evidence to show differences between different doses in terms of effectiveness or safety, if present. However, subgroup analysis of comparisons between mifepristone and placebo suggest that the 2.5 mg dose may be less effective than 5 mg or 10 mg for treating dysmenorrhoea or dyspareunia. Gestrinone comparisons Ons study compared gestrinone with danazol, and another study compared gestrinone with leuprolin.Evidence was insufficient to show differences, if present, between gestrinone and danazol in rate of pain relief (those reporting no or mild pelvic pain) (OR 0.71, 95% CI 0.33 to 1.56; two RCTs, n = 230; very low-quality evidence), dysmenorrhoea (OR 0.72, 95% CI 0.39 to 1.33; two RCTs, n = 214; very low-quality evidence), or dyspareunia (OR 0.83, 95% CI 0.37 to 1.86; two RCTs, n = 222; very low-quality evidence). The gestrinone group had a higher rate of hirsutism (OR 2.63, 95% CI 1.60 to 4.32; two RCTs, n = 302; very low-quality evidence) and a lower rate of decreased breast size (OR 0.62, 95% CI 0.38 to 0.98; two RCTs, n = 302; low-quality evidence). Evidence was insufficient to show differences between groups, if present, in rate of hot flushes (OR 0.79, 95% CI 0.50 to 1.26; two RCTs, n = 302; very low-quality evidence) or acne (OR 1.45, 95% CI 0.90 to 2.33; two RCTs, n = 302; low-quality evidence).When researchers compared gestrinone versus leuprolin through measurements on the 1 to 3 verbal rating scale (lower score denotes benefit), the mean dysmenorrhoea score was higher in the gestrinone group (MD 0.35 points, 95% CI 0.12 to 0.58; one RCT, n = 55; low-quality evidence), but the mean dyspareunia score was lower in this group (MD 0.33 points, 95% CI 0.62 to 0.04; low-quality evidence). The gestrinone group had lower rates of amenorrhoea (OR 0.04, 95% CI 0.01 to 0.38; one RCT, n = 49; low-quality evidence) and hot flushes (OR 0.20, 95% CI 0.06 to 0.63; one study, n = 55; low quality evidence) but higher rates of spotting or bleeding (OR 22.92, 95% CI 2.64 to 198.66; one RCT, n = 49; low-quality evidence).Evidence was insufficient to show differences in effectiveness or safety between different doses of gestrinone, if present. Asoprisnil versus placebo One study (n = 130) made this comparison but did not report data suitable for analysis. Ulipristal versus leuprolide acetate One study (n = 38) made this comparison but did not report data suitable for analysis. AUTHORS' CONCLUSIONS Among women with endometriosis, moderate-quality evidence shows that mifepristone relieves dysmenorrhoea, and low-quality evidence suggests that this agent relieves dyspareunia, although amenorrhoea and hot flushes are common side effects. Data on dosage were inconclusive, although they suggest that the 2.5 mg dose of mifepristone may be less effective than higher doses. We found insufficient evidence to permit firm conclusions about the safety and effectiveness of other progesterone receptor modulators.
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Affiliation(s)
- Jing Fu
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynecologyChengduSichuanChina
| | - Hao Song
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynecologyChengduSichuanChina
- Ministry of EducationKey Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University)ChengduChina
| | - Min Zhou
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynecologyChengduSichuanChina
| | - Huili Zhu
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynecologyChengduSichuanChina
| | - Yuhe Wang
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynecologyChengduSichuanChina
| | - Hengxi Chen
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynecologyChengduSichuanChina
| | - Wei Huang
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynecologyChengduSichuanChina
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Abstract
BACKGROUND Endometriosis is a chronic inflammatory condition defined by the presence of glands and stroma outside the uterine cavity. It occurs in 7% to 10% of all women of reproductive age and may present as pain or infertility. The pelvic pain may be in the form of dysmenorrhoea, dyspareunia or pelvic pain. Initially a combination of estrogens and progestagens was used to create a pseudopregnancy and alleviate the symptoms associated with endometriosis. Progestagens alone or anti-progestagens have been considered as alternatives because they are inexpensive and may have a better side effect profile than other choices. OBJECTIVES To determine the effectiveness of both the progestagens and anti-progestagens in the treatment of painful symptoms ascribed to the diagnosis of endometriosis. SEARCH METHODS We used the search strategy of the Menstrual Disorders and Subfertility Group to identify all publications which described or might have described randomised controlled trials (RCTs) of any progestagen or any anti-progestagen in the treatment of symptomatic endometriosis. We updated the review in 2011. SELECTION CRITERIA We considered only RCTs which compared the use of progestagens and anti-progestagens with other interventions, placebo or no treatment for the alleviation of symptomatic endometriosis. DATA COLLECTION AND ANALYSIS We have added six new studies, bringing the total of included studies to 13 in the update of this review. The six newly included studies evaluated progestagens (comparisons with placebo, danazol, oral or subdermal contraceptive, oral contraceptive pill and danazol, gonadotrophin-releasing hormone (GnRH) analogue and other drugs). The remaining studies compared the anti-progestagen gestrinone with danazol, GnRH analogues or itself. MAIN RESULTS The progestagen medroxyprogesterone acetate (100 mg daily) appeared to be more effective at reducing all symptoms up to 12 months of follow-up (MD -0.70, 95% CI -8.61 to -5.39; P < 0.00001) compared with placebo. There was evidence of significantly more cases of acne (six versus one) and oedema (11 versus one) in the medroxyprogesterone acetate group compared with placebo. There was no evidence of a difference in objective efficacy between dydrogesterone and placebo.There was no evidence of a benefit with depot administration of progestagens versus other treatments (low dose oral contraceptive or leuprolide acetate) for reduced symptoms. The depot progestagen group experienced significantly more adverse effects.There was no overall evidence of a benefit of oral progestagens over other medical treatment at six months of follow-up for self-reported efficacy. Amenorrhoea and bleeding were more frequently reported in the progestagen group compared with other treatment groups.There was no evidence of a benefit of anti-progestagens (gestrinone) compared with danazol. GnRH analogue (leuprorelin) was found to significantly improve dysmenorrhoea compared with gestrinone (MD 0.82, 95% CI 0.15 to 1.49; P = 0.02) although it was also associated with increased hot flushes (OR 0.20, 95% CI 0.06 to -0.63; P = 0.006). AUTHORS' CONCLUSIONS There is only limited evidence to support the use of progestagens and anti-progestagens for pain associated with endometriosis.
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Affiliation(s)
- Julie Brown
- University of AucklandObstetrics and GynaecologyFMHSAucklandNew Zealand
| | - Sari Kives
- St Michaels HospitalObstetrics & GynecologyTorontoCanada
| | - Muhammad Akhtar
- University Hospitals, Coventry & Warwickshire NHS TrustClinical Reproductive Medicine UnitClifford Bridge RoadCoventryUK
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5
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Murshid KR. A Review of Mastalgia in Patients with Fibrocystic Breast Changes and the Non-Surgical Treatment Options. J Taibah Univ Med Sci 2011. [DOI: 10.1016/s1658-3612(11)70151-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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6
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Abstract
Androgens can increase muscular mass and strength and remain the most frequently abused and widely available drugs used in sports doping. Banning the administration of natural or synthetic androgens has led to a variety of strategies to circumvent the ban of the most effective ergogenic agents for power sports. Among these, a variety of indirect androgen doping strategies aiming to produce a sustained rise in endogenous testosterone have been utilized. These include oestrogen blockade by drugs that act as oestrogen receptor antagonists (antioestrogen) or aromatase inhibitors. The physiological and pharmacological basis for the effects of oestrogen blockade in men, but not women, are reviewed.
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7
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Surrey ES. The role of progestins in treating the pain of endometriosis. J Minim Invasive Gynecol 2007; 13:528-34. [PMID: 17097575 DOI: 10.1016/j.jmig.2006.06.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2006] [Accepted: 06/10/2006] [Indexed: 11/20/2022]
Abstract
Progestins, synthetic progestational agents, have been used in the management of symptomatic endometriosis both as primary therapy and as an adjunct to surgical resection. A variety of oral agents have been employed in this regard with investigators demonstrating differing degrees of benefit. Unfortunately, due to the lack of large-scale, appropriately controlled, randomized trials, or dose-ranging studies, no single agent can be demonstrated to be truly efficacious. The lack of a standardized instrument to evaluate painful symptoms makes comparative analysis more difficult. Injectable administration of long-acting depot medroxyprogesterone acetate preparations intramuscularly or subcutaneously has been investigated in three randomized trials. The lower dose subcutaneous injection holds promise with an apparent reduction in side effects. Issues of reversible bone mineral density loss, breakthrough bleeding, and return of menses have not been completely resolved. Selective progesterone receptor modulators represent an intriguing alternative. These orally administered agents have been shown in preliminary investigations to be not only efficacious in reducing symptoms but also associated with minimal side effects. Further investigation of these agents is clearly required.
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Affiliation(s)
- Eric S Surrey
- Colorado Center for Reproductive Medicine, Englewood, Colorado, USA.
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8
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Pereira de Jésus-Tran K, Côté PL, Cantin L, Blanchet J, Labrie F, Breton R. Comparison of crystal structures of human androgen receptor ligand-binding domain complexed with various agonists reveals molecular determinants responsible for binding affinity. Protein Sci 2006; 15:987-99. [PMID: 16641486 PMCID: PMC2242507 DOI: 10.1110/ps.051905906] [Citation(s) in RCA: 178] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Androgens exert their effects by binding to the highly specific androgen receptor (AR). In addition to natural potent androgens, AR binds a variety of synthetic agonist or antagonist molecules with different affinities. To identify molecular determinants responsible for this selectivity, we have determined the crystal structure of the human androgen receptor ligand-binding domain (hARLBD) in complex with two natural androgens, testosterone (Testo) and dihydrotestosterone (DHT), and with an androgenic steroid used in sport doping, tetrahydrogestrinone (THG), at 1.64, 1.90, and 1.75 A resolution, respectively. Comparison of these structures first highlights the flexibility of several residues buried in the ligand-binding pocket that can accommodate a variety of ligand structures. As expected, the ligand structure itself (dimension, presence, and position of unsaturated bonds that influence the geometry of the steroidal nucleus or the electronic properties of the neighboring atoms, etc.) determines the number of interactions it can make with the hARLBD. Indeed, THG--which possesses the highest affinity--establishes more van der Waals contacts with the receptor than the other steroids, whereas the geometry of the atoms forming electrostatic interactions at both extremities of the steroid nucleus seems mainly responsible for the higher affinity measured experimentally for DHT over Testo. Moreover, estimation of the ligand-receptor interaction energy through modeling confirms that even minor modifications in ligand structure have a great impact on the strength of these interactions. Our crystallographic data combined with those obtained by modeling will be helpful in the design of novel molecules with stronger affinity for the AR.
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Affiliation(s)
- Karine Pereira de Jésus-Tran
- Oncology and Molecular Endocrinology Research Center, Laval University Medical Center (CHUL) and Laval University, Québec, QC G1V 4G2, Canada
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Fedele L, Bianchi S, Fontana E, Berlanda N, Frontino G, Bulfoni A. Medical management of endometriosis. WOMEN'S HEALTH (LONDON, ENGLAND) 2006; 2:297-308. [PMID: 19803901 DOI: 10.2217/17455057.2.2.297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Current approved medical therapies for endometriosis rely on drugs that suppress ovarian steroids and induce a hypoestrogenic state, which determines the atrophy of the ectopic endometrium. Gonadotropin-releasing hormone analogs such as danazol, progestogens and estrogen-progestin combinations have all proven effective in relieving pain and reducing the extent of endometriotic implants. However, symptoms often recur after discontinuation of therapy and hypoestrogenism-related side effects limit the long-term use of most medications. Recently, knowledge of the pathogenesis of endometriosis, particularly at the molecular level, has grown substantially, providing a rational basis for the development of new drugs with precise targets that may be safely administered over the long term.
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Affiliation(s)
- Luigi Fedele
- Clinica Ostetrico-Ginecologica "Luigi Mangiagalli", Università di Milano, Via commenda n 1220122 Milano, Italy.
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10
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Abstract
The recent identification of tetrahydrogestrinone (THG), the first true "designer androgen," as a sports doping agent reflects both an alarmingly sophisticated illicit manufacturing facility and an underground network of androgen abusers in elite sports, as well as the still untapped potential for designer androgens in medicine. Never marketed, THG was apparently developed as a potent androgen that was undetectable by conventional International Olympic Committee-mandated urinary sports doping tests. As a potent androgen and progestin with unspecified contaminants, its distribution for use at high doses without any prior biological or toxicological evaluation poses significant health risks. Yet this diversion of science also highlights the prospect of designer androgens for use in human medicine. Designer androgens also offer the possibility of tissue-specific effects enhancing the beneficial effects of androgens while mitigating the undesirable ones. Further developments require better understanding of the postreceptor tissue selectivity of androgens, comparable to the mechanism underlying that of partial estrogen agonists (SERMs). This experience highlights the ongoing need for vigilance to detect novel drug doping strategies in order to maintain fairness and safety in elite sports. This will require the deployment of generic catch-all tests, such as sensitive and specific in vitro androgen bioassays, coupled with the development of mass spectrometry-based tests for specific doping agents.
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11
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Abstract
Pain is one of the most common breast symptoms experienced by women. It can be severe enough to interfere with usual daily activities, but the etiology and optimal treatment remain undefined. Breast pain is typically approached according to its classification as cyclic mastalgia, noncyclic mastalgia, and extramammary (nonbreast) pain. Cyclic mastalgia is breast pain that has a clear relationship to the menstrual cycle. Noncyclic mastalgia may be constant or intermittent but is not associated with the menstrual cycle and often occurs after menopause. Extramammary pain arises from the chest wall or other sources and is interpreted as having a cause within the breast. The risk of cancer in a woman presenting with breast pain as her only symptom is extremely low. After appropriate clinical evaluation, most patients with breast pain respond favorably to a combination of reassurance and nonpharmacological measures. The medications danazol, tamoxifen, and bromocriptine are effective; however, the potentially serious adverse effects of these medications limit their use to selected patients with severe, sustained breast pain. The status of other therapeutic strategies and directions for future research are discussed.
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Affiliation(s)
- Robin L Smith
- Breast Diagnostic Clinic, Division of General Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minn 55905, USA
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12
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Abstract
In view of the fact that fractures are the clinically relevant events, risk factors for fractures are discussed first. Bone mineral density (BMD) appears to be a much less important risk factor for the most severe hip fractures than the risk of falling. No results of experimental studies on hormones and fractures at advanced age are available. An overview of the effects of progestins on bone is given. Effects of progestins on bone have been studied by in vitro experiments using cell lines and by more relevant clinical observations. Prospective studies have been conducted following the use of progestins contained in oral contraceptives, alone or in combination with oestrogens; long-term contraception by injection of depot preparations; so-called "add-back" hormonal therapy attempting to reverse the adverse effects of gonadotropin releasing hormone agonists on bone and after different regimens of hormone replacement therapy (HRT) in postmenopausal women. From the data there are no indications that the various progestins, used in clinical practice, have either a bone-protective or an oestrogen antagonistic activity. Progestins do not add or subtract much of the protective action of oestrogens on the bones.
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Affiliation(s)
- Jos H H Thijssen
- Endocrinological Laboratory, University Medical Center Utrecht KE.03.139.2, P.O. Box 85090, 3508 AB Utrecht, The Netherlands.
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13
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Abstract
In the coming years, basic science research into the mechanisms of endometriosis development and persistence almost certainly will open new avenues for treatment. A wide armamentarium of medical therapies already exists, however. The efficacy of most of these methods in reducing endometriosis-associated pain is well established. The choice of which to use depends largely on patient preference after an appropriate discussion of risks, side effects, and cost. Typically, oral contraceptives and NSAIDs are first-line therapy because of their low cost and mild side effects (Box 6). Because of its greater potential for suppressing endometrial development, consideration should be given to prescribing a low-dose monophasic oral contraceptive continuously. If adequate relief is not obtained or if side effects prove intolerable, consideration should be given to the use of progestins (oral, intramuscular, or IUD) or a GnRH agonist with immediate add-back therapy. Progestins are less expensive, but GnRH agonists with add-back may be better tolerated. If none of these medications proves beneficial or if side effects are too pronounced, then repeat surgery is warranted. The surgery may have analgesic value and serves to reconfirm the diagnosis. Finally, if endometriosis is identified at the time of surgery, then consideration should be given to prescribing medical therapy postoperatively.
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Affiliation(s)
- Neal G Mahutte
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Yale University School of Medicine, New Haven, CT 06520, USA.
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14
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Sagsveen M, Farmer JE, Prentice A, Breeze A. Gonadotrophin-releasing hormone analogues for endometriosis: bone mineral density. Cochrane Database Syst Rev 2003; 2003:CD001297. [PMID: 14583930 PMCID: PMC7027701 DOI: 10.1002/14651858.cd001297] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Gonadotrophin-releasing hormone analogues (GnRHas) are generally well tolerated, and are effective in relieving the symptoms of endometriosis (Prentice 2003). Unfortunately the low oestrogen state that they induce is associated with adverse effects including an acceleration in bone mineral density (BMD) loss. OBJECTIVES To determine the effect of treatment with gonadotrophin-releasing hormone analogues (GnRHas) on the bone mineral density of women with endometriosis, compared to placebo, no treatment, or other treatments for endometriosis, including GnRHas with add-back therapy. SEARCH STRATEGY We searched the Cochrane Menstrual Disorders and Subfertility Group's specialised register of controlled trials (23rd October 2002) and the Cochrane Central Register of Controlled Trials (Cochrane Library, issue 4, 2002). We also carried out electronic searches of MEDLINE (1966 - March Week 2 2003) and EMBASE (1980 - March Week 2 2003). We also searched the reference lists of articles and contacted researchers in the field. SELECTION CRITERIA Prospective, randomised controlled studies of the use of GnRHas for the treatment of women with endometriosis were considered, where bone density measurements were an end point. The control arm of the studies was either placebo, no treatment, another medical therapy for endometriosis, or GnRHas with add-back therapy. DATA COLLECTION AND ANALYSIS Two reviewers (JF and MS) independently assessed trial quality and extracted data. Study authors were contacted for additional information. MAIN RESULTS Thirty studies involving 2,391 women were included, however only 15, involving 910 women, could be included in the meta-analysis. The meta-analysis showed that danazol and progesterone + oestrogen add-back are protective of BMD at the lumbar spine both during treatment and for up to six and twelve months after treatment, respectively. Between the groups receiving GnRHa and the groups receiving danazol/gestrinone, there was a significant difference in percentage change of BMD after six months of treatment, the GnRH analogue producing a reduction in BMD from baseline and danazol producing an increase in BMD (SMD -3.43, 95 % CI -3.91 to -2.95). Progesterone only add-back is not protective; after six months of treatment absolute value BMD measurements of the lumbar spine did not differ significantly from the group receiving GnRH analogues (SMD 0.15, 95 % CI -0.21 to 0.52). In the comparison of GnRHa versus GnRHa + HRT add-back, that is oestrogen + progesterone or oestrogen only, there was a significantly bigger BMD loss in the GnRHa only group (SMD -0.49, 95 % CI -0.77 to -0.21). These numbers reflect the absolute value measurements at the lumbar spine after six months of treatment. Due to the small number of studies in the comparison we are unable to conclude whether calcium-regulating agents are protective. No difference was found between low and high dose add-back regimes but again only one study was identified for this comparison. Only one study comparing GnRH analogues with placebo was identified, but the study gave no data. No studies comparing GnRH with the oral contraceptive pill (OCP) or progestagens were identified. REVIEWER'S CONCLUSIONS Both danazol and progesterone + oestrogen add-back have been shown to be protective of BMD, while on treatment and up to six and 12 months later, respectively. However, by 24 months of follow-up there was no difference in BMD in those women who had HRT add-back. Studies of danazol versus GnRHa did not report long-term follow-up. The significant side effects associated with danazol limit its use.
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Affiliation(s)
- M Sagsveen
- Cochrane Menstrual Disorders and Subfertility Group, University of Auckland, National Women's Hospital, Claude Road, Epsom, Auckland, New Zealand, 1003.
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15
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Prentice A, Deary AJ, Bland E. Progestagens and anti-progestagens for pain associated with endometriosis. Cochrane Database Syst Rev 2000:CD002122. [PMID: 10796864 DOI: 10.1002/14651858.cd002122] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Endometriosis is a gynaecological condition that presents either with the problem of infertility or with painful symptoms. The clinical observation of an apparent resolution of symptoms during pregnancy gave rise to the concept of treating patients with a pseudo-pregnancy regime. Initially combinations of high dose oestrogens and progestagens were used but this was subsequently replaced by progestogens alone. More recently progestogens of both progestagens and anti-progestagens in the treatment of symptomatiprogestogenssis OBJECTIVES To determine the effectiveness of both the progestagens and anti-progestagens in the treatment of painful symptoms ascribed to the diagnosis of endometriosis. SEARCH STRATEGY The search strategy of the Menstrual Disorders and Subfertility Group was utilised to identify all publications which described or might have described randomised trials of any progestagen or any anti-progestagen in the treatment of symptomatic endometriosis. SELECTION CRITERIA Trials were included if they were randomised and considered the effectiveness of either a progestagen or an anti-progestagen in the treatment of painful symptoms associated with endometriosis. DATA COLLECTION AND ANALYSIS Seven studies were considered to be appropriate for inclusion in this review. Only three studies evaluating progestagens were included (comparison with placebo, danazol and oral contraceptive plus danazol). All other studies compared the anti-progestagen, gestrinone, with other medical therapies. MAIN RESULTS Progestagens appear to be an effective therapy for the painful symptoms associated with endometriosis. Gestrinone is as effective as other established medical therapies (danazol and GnRH analogues). REVIEWER'S CONCLUSIONS The limited available data suggests that both continuous progestagens and anti-progestagens are effective therapies in the treatment of painful symptoms associated with endometriosis. Progestagens given in the luteal phase are not effective. These conclusions should be accepted cautiously due to a lack of data.
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Affiliation(s)
- A Prentice
- Department of Obstetrics and Gynaecology, University of Cambridge, The Rosie Hospital, Robinson Way, Cambridge, UK, CB2 2SW.
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16
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Affiliation(s)
- J H Thijssen
- Department of Endocrinology, Academisch Ziekenhuis, Utrecht, The Netherlands
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Abstract
This review article has focussed on identifying the evidence from randomized controlled trials for the medical and surgical management of endometriosis. A critical summary of the medical management has shown that there is little difference in effectiveness of various medical treatments, but there are differences in the side-effect profiles. Few randomized controlled trials have been undertaken in surgery, but these have shown that surgical management is effective in the management of both painful symptoms and subfertility.
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Affiliation(s)
- C Farquhar
- Department of Obstetrics and Gynaecology, University of Auckland School of Medicine, National Women's Hospital, New Zealand.
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