Oral contraceptive hazards--1981

The role of opioid system and its interaction with sympathetic nervous system in the processing of polycystic ovary syndrome modeling in rat

BACKGROUND

This study was conducted to evaluate the effect of interaction of sympathetic and opioid systems in the processing of polycystic ovary syndrome modeling in rat.

METHODS

Ninety adult female rats (7-8 weeks of age) were treated with EV for 60 days for induction of follicular cysts (PCO modeling). Clonidine and yohimbine were used for sympathic agonist and antagonist and nalterxone was used for opioid system inhibition. Interactions of two systems were studied.

RESULTS

Our results indicate that both systems and interaction of two systems are effective in processing modeling of PCOS in rat. Interaction of two system drugs decreased estradiol (P < 0.05). Qualitative analysis showed that the bulk of cysts and corpus lutea and dominant follicles were increased in PCO rats in comparison with control group.

CONCLUSION

Therefore there could been an alternative in the treatment of the polycystic ovary syndrome in the rat by using adrenergic agonist and antagonists in combination with naltrexone.

Polycystic ovary syndrome: a follow-up study on diabetes mellitus, cardiovascular disease and malignancy 15-25 years after ovarian wedge resection

The aim of the present study was to examine the occurrence of possibly associated diseases in 149 women with polycystic ovary syndrome (PCOS) 15-25 years after ovarian wedge resection. Diabetes mellitus was the only associated disease which showed a significantly increased occurrence. No significant change in cancers specific for the female gender was seen. Likewise, the relative risk of cardiovascular disease was not affected. However, the power of the statistical test was low. This long-term study indicates increased risk of diabetes mellitus in PCOS patients. The study group is too small to give any conclusions about other possibly associated diseases. Family histories, however, revealed that associated diseases are related to genetic disposition rather than to PCOS per se.

Management of Infertility in Women with Polycystic Ovary Syndrome

The management of infertility in women with polycystic ovary syndrome (PCOS) centers around options for inducing ovulation. This is an evidence-based review of the management of PCOS, which includes a MEDLINE search of publications between 1986 and May 2005 and a search of the Cochrane Database. Weight loss, exercise, and metformin will induce ovulation in many insulin-resistant women and obese women with PCOS, and should always be the first-line treatment. Ovulation induction has been performed with clomiphene citrate (clomifene) as the first-line treatment, but the use of aromatase inhibitors has been shown to be as successful. The strategies for reducing the risks of gonadotropin therapy such as low-dose follicle-stimulating hormone (FSH) stimulation and the addition of metformin are discussed. Both gonadotropin releasing-hormone agonists and antagonists are equally effective in in vitro fertilization stimulation in conjunction with FSH therapy. Metformin may have a benefit in pregnancy in reducing the risks of miscarriage and diabetes mellitus; however, prospective trials are still lacking.

Polycystic ovary syndrome: relationship between insulin sensitivity, sex hormone levels and ovarian stromal blood flow

Polycystic ovary syndrome (PCOS) is the most common cause of menstrual disorders, and is characterized by chronic anovulation, hyperandrogenism and infertility. In recent years, it has become apparent that PCOS is also associated with hyperinsulinemia that is probably central to the pathogenesis of PCOS. As a peculiar vascular pattern has been reported to be present in PCOS, the aim of this study was to investigate intraovarian stromal vascularization in PCOS patients and its possible correlation with sex hormones, gonadotropins and insulin levels. Twenty-eight oligomenorrheic or amenorrheic patients with PCOS and 14 eumenorrheic women with a PCOS-like ovarian pattern undergoing endocrine screening and ultrasound color Doppler intraovarian blood flow were recruited to the study. Ten healthy women with regular menses represented the control group. Hormonal assays (follicle-stimulating hormone (FSH), luteinizing hormone (LH), androstenedione, testosterone, sex hormone-binding globulin (SHBG) and estradiol), oral glucose tolerance test (OGTT), baseline and glucose-induced insulin levels, and transvaginal ultrasonographic and color Doppler analysis (pulsatility index (PI), resistance index (RI) and velocity (Vmax) of ovarian stromal flow) were performed in all participants in the early proliferative phase. Endocrine values showed significant differences in PCOS patients compared with PCOS-like women and controls, while PI and RI indices were significantly higher in controls. PCOS patients were divided into hyperinsulinemic (n = 16) and normoinsulinemic (n = 12). Androstenedione was significantly higher (p < 0.01) in the hyperinsulinemic than in the normoinsulinemic patients and controls, while SHBG was significantly (p < 0.01) lower in the hyperinsulinemic group. Analysis of color Doppler intraovarian vascularization showed a significantly lower RI and a higher Vmax in the hyperinsulinemic subjects than in the normoinsulinemic PCOS patients and controls. An increased stromal blood flow was observed in the PCOS and PCOS-like patients by transvaginal color Doppler evaluation, but this technique is not able to differentiate these two similar ovarian patterns. However, hyperinsulinemic PCOS patients had an increased vascularity of the ovarian stroma. A strong correlation between hyperinsulinemia, hyperandrogenism and low SHBG levels was evidenced, and a hyperinsulinemia-induced mechanism for ovarian stromal angiogenesis is discussed.

The effect of a special herbal tea on obesity and anovulation in androgen-sterilized rats

A special herbal tea has been used to treat clomiphene-resistant anovulatory disease and obesity effectively, especially in polycystic ovary syndrome (PCOS) cases with hyperinsulinemia. The effect of the herbal tea on obesity and anovulation was investigated in androgen-sterilized rats (ASR). The ASR model was established by subcutaneous injection of 1.25 mg testosterone propionate to Sprague-Dawley female rats at the age of 9 days. Rats were sacrificed around 112 days of age. ASR manifested with PCO, anovulation, high food intake, elevated body weight, and obesity. Immunocytochemistry demonstrated that estrogen receptors (ER) were predominantly distributed in the cytoplasm of neuropeptide Y (NPY)-containing neurons in the preoptic area (POA), and the coexpression was also found in the nuclei and fibers of NPY-synthesizing neurons in the arcuate nucleus (ARC). Compared with that in normal control rats, NPY expression was increased, the numbers of ER in hypothalamic ARC-median eminence (ME) decreased, gonadotropin-releasing hormone (GnRH) levels in ME was decreased, serum estrogen (E2) and leptin were elevated, and follicular stimulating hormone (FSH) and luteinizing hormone (LH) levels were reduced significantly in ASR. Significantly negative correlations between NPY and ER or GnRH, and between leptin and FSH or LH were observed. A positive correlation existed between serum leptin and body weight. These metabolic-endocrine changes in ASR were normalized after feeding the herbal tea. Both obesity and hypogonadotropin were expressed in ASR. The abnormal ovarian hormone milieu (elevated E2 levels) may have enhanced NPY expression and resulted in less GnRH and gonadotropin secretion. The herbal tea reduced body weight and induced ovulation in ASR.

Polycystic ovary syndrome: clinical perspectives and management

The polycystic ovary syndrome (PCOS) is a common hyperandrogenic disorder and is characterized by a constellation of signs and symptoms often in association with a family history of hyperandrogenism and/or PCOS. It is often associated with hyperinsulinism and insulin resistance, which puts patients at risk for possible potential complications including type 2 diabetes mellitus and cardiovascular disease. Clinical signs may be subtle, and biochemical markers most often include an elevation of free testosterone (T) and possibly dehydroepiandrosterone sulfate (DHEAS). The diagnosis should be sought in any woman with hyperandrogenic features so that appropriate treatment may be used. There is often a good therapeutic response of the hirsutism, acne, or oligomenorrhea associated with PCOS. The new modalities that increase insulin sensitivity as well as weight reduction in the obese woman with PCOS may potentially be useful in modifying the potential later complications of this common endocrinopathy of young adult women.

Laparoscopic ovarian treatment in infertile patients with polycystic ovarian syndrome (PCOS): endocrine changes and clinical outcome

During the years 1991-1994, 97 anovulatory infertile women with polycystic ovarian syndrome (PCOS) were treated with laparoscopic electrocautery of the ovarian surface after they had failed to ovulate under ovarian stimulation. To assess the endocrinological and clinical outcome and in an attempt to determine the mechanism of action, the serum levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH), androstenedione, testosterone and dehydroepiandrosterone sulfate (DHEAS) were determined before and after laparoscopic ovarian cautery. Fifty regularly cycling women undergoing laparoscopy for investigation of infertility or tubal ligation served as controls. In patients with PCOS but not in controls, the reduction of androgen levels and normalization of cycle length were highly significant. In contrast, LH and FSH levels rose during the first 2 days after the operation. These results resemble those reported after ovarian wedge resection. Ovulation was obtained in 90% (81 of 90) and pregnancy in 81.1% (73 of 90) of the patients; that increased to 84.4%, including the non-responders (nine patients) treated with clomiphene citrate (CC), after electrocautery. The response to ovarian electrocautery was influenced by body weight, with an ovulation rate of 95-96% in the slim and moderately obese women, decreasing to 81-82% in the really obese ones. When ovulation was established, the pregnancy rate was independent of body weight. However, a striking relationship was detected between smoking habits and pregnancy rate subsequent to ovarian electrocautery, ranging from 24% in smokers to 92% in non-smoking couples. In 30 second-look operations, de novo adhesions were found in 23.3% of the patients (7 of 30). Therefore, ovarian electrocautery is an effective procedure to improve the intraovarian mechanism of selecting a dominant follicle for patients with PCOS in whom initial medical management fails, and it appears to be one of the possible treatments for this disease. A possible postoperative complication may be adhesion formation that seem to be lower than after ovarian wedge resection.

Functional, long-term human theca and granulosa cell cultures from polycystic ovaries

Reproducible culture conditions for obtaining large numbers of functional PCOS theca interna and granulosalutein cells will be indispensable in studies focussing on the molecular basis for androgen overproduction by ovarian cells of patients with polycystic ovarian syndrome (PCOS). The objective of the present study was to determine if granuiosa and theca interna cells obtained from ovarian follicles of patients with PCOS could be passaged with maintenance of inducible steroidogenic activity. PCOS theca interna and granuiosa cells were obtained from individual follicles of polycystic ovaries containing multiple cystic follicles with characteristic hypertrophied theca interna. Utilizing conditions for growing normal ovarian cells, both cell types were passaged successively and conditions for cell freezing, storing and thawing were established. In granulosa-lutein cultures grown and passed for successive passages, and transferred into serum-free medium, forskolin stimulated aromatase activity increased 3-10-fold over control non-stimulated values. Concurrent treatment with IGF-I (50 ng/mL) enhanced forskolin-stimulated aromatase activity in PCOS granulosa-lutein cultures. In passaged PCOS theca interna cells, forskolinstimulated 17α-hydroxyprogesterone production was increased 4-25-fold over control values. Treatment of PCOS theca interna cells with insulin (50 ng/mL) enhanced forskolin-stimulated 17α-hydroxyprogesterone biosynthesis. The effects of various growth factors and phorbol esters on 17α-hydroxylase activity in cultured PCOS theca interna cells was also investigated. Treatment of PCOS theca cells with EGF, FGF, TGFβ and TPA resulted in the inhibition of forskolin-stimulated 17α-hydroxyprogesterone production. These data suggest that PCOS theca interna and granuiosa cells respond to insulin and to the growth factors similarly to cells obtained from normal cycling ovaries.

Characterization of 24-h cortisol release in obese and non-obese hyperandrogenic women

Excessive androgen output is a well-recognized feature of adrenocortical oversecretion in women with ovarian hyperandrogenism, or polycystic ovary disease (PCOD). However, evidence of a concomitant alteration of cortisol secretion is lacking even though obesity per se, a common clinical feature of PCOD, has been shown to be associated with cortisol oversecretion. To clarify whether a subtle alteration in cortisol secretion exists, a study of 24-h episodic cortisol release and post-prandial cortisol responses was undertaken in eight women with PCOD and eight normal women comprising equal numbers of obese and non-obese subjects. All four groups showed normal biphasic 24-h cortisol secretion profiles but cortisol pulse frequency was increased in the PCOD groups. Independently, both hyperandrogenism and obesity were associated with an accelerated cortisol clearance rate. These changes, together with normal or only slightly elevated 24-h cortisol integrated area under the curve, suggest an increased compensatory cortisol production in women with PCOD. Furthermore, subjects with PCOD and subjects with obesity showed different post-prandial cortisol responses to normal non-obese women. In conclusion, these subtle cortisol abnormalities may be a manifestation of altered central regulation of the hypothalamic-pituitary-adrenal axis and peripheral metabolic abnormalities, and may be linked to the pathophysiology of PCOD.

Practical problems which women encounter with available contraception in Australia

Australian women face major difficulties with contraception because of the limited range of choices, the need for meticulous attention to compliance with most available methods and because of cost limitations for a significant minority of the population. The most commonly used methods are oral contraceptive pills and barrier methods, and each has substantial compliance problems which can be minimized with care and counselling. There is an urgent need for a wider range of options in Australia and for good information and publicity about them. Present progress in this direction gives some hope for the near future.

Endocrinological, ultrasonographic and clinical findings in adolescent and adult polycystic ovary patients: a comparative study

This study was performed to compare clinical and endocrine features and ultrasonographic data of adolescent (< or = 18 years old) and adult (> or = 19 years old) patients with ultrasound-diagnosed polycystic ovaries (PCOs) in our Reproductive Endocrinology outpatient clinic. The adolescent group included 35 PCO patients while 125 were in the adult group. Hirsutism was present in 64.7% of the adolescent group and in 49.6% of the adult group. Menstrual irregularities were detected as oligomenorrhea (42.8%), amenorrhea (20%) and irregular but normal cycles (17.4%) in the adolescent group; the figures for the adult group were 46.4, 8.8 and 23.2%, respectively. These differences were not statistically significant. The mean body mass index of the adult PCO group was significantly higher than the adolescent PCO group (p < 0.05). The endocrine features (estradiol, follicle stimulating hormone, luteinizing hormone (LH), prolactin, total testosterone, free testosterone, 17-OH progesterone, androstenedione, thyroid stimulating hormone, dehydroepiandrosterone sulfate (DHEAS)) and the ovarian volume of both groups were comparable. There was a significant positive correlation between ovarian volume and serum LH, total testosterone, free testosterone, androstenedione and DHEAS in both groups. We conclude that polycystic ovarian syndrome is a disorder with perimenarchal onset, the clinical, endocrine and ultrasound features of which will not change by age, although patients are prone to gain weight as they get older.

17 beta-Oestradiol, androstenedione and inhibin levels in fluid from individual follicles of normal and polycystic ovaries, and in ovaries from androgen treated female to male transsexuals

OBJECTIVE

The aim was to monitor carefully follicular growth arrest in polycystic ovaries by assay of hormones in individual follicles.

DESIGN AND PATIENTS

Fluid from follicles less than or equal to 10 mm was obtained from ovaries of 16 regularly cycling women between days 1 and 12 of the follicular phase (controls, n = 120 follicles), polycystic ovaries of five women with polycystic ovary syndrome (n = 43), and polycystic ovaries from 14 long-term testosterone treated female to male transsexuals (n = 120).

MEASUREMENTS

Fluid was assayed for oestradiol, androstenedione, and immunoactive inhibin. Luteinizing hormone, follicle-stimulating hormone, and testosterone levels were estimated in serum.

RESULTS

Median serum LH was lower in transsexuals than in controls (P less than 0.05), and in polycystic ovary syndrome (P less than 0.01). Median serum testosterone was not significantly different between polycystic ovary syndrome and transsexuals, and was elevated in both groups as compared to controls (P less than 0.01). Oestradiol was present in all follicles obtained from polycystic ovaries of polycystic and transsexual patients, in which no follicle greater than 10 mm could be detected. In the three groups, between-patient differences in mean oestradiol, androstenedione, inhibin, and androstenedione/oestradiol ratio were significantly larger than expected in view of the variation between follicles within individuals. Taking into account this between-patient difference, no significant differences could be established between the three groups for all endocrine parameters. The percentage of presumed healthy follicles (androstenedione/oestradiol ratio less than or equal to 4) was 12% in controls, 17% in polycystics, and 14% in transsexuals, and was not significantly different between groups.

CONCLUSIONS

The results may indicate that (1) abnormally high circulating androgen concentrations with or without elevated LH levels disturb the process of selection, and could therefore play a role in the pathogenesis of polycystic ovaries; (2) in polycystic ovaries from polycystic ovary syndrome and transsexual patients, aromatase activity is present in vivo in small antral follicles, and the proportion of presumed healthy follicles is not different from that encountered in normal ovaries; (3) oestradiol levels are not different between non-dominant follicles of normal and polycystic ovaries, suggesting that only enhancement of aromatase activity by FSH may be disrupted in polycystic ovaries, (4) because androstenedione levels are not different comparing follicles of normal and polycystic ovaries, hyperandrogenaemia in the syndrome seems to originate from the abnormally high number of cystic atretic follicles generally observed in polycystic ovaries; (5) marked variation in the endocrine follicular microenvironment within and between-women precludes pooling fluid from several follicles.

Investigation of adrenal function in women with oligomenorrhoea and hirsutism (clinical PCOS) from the north-east of England using an adrenal stimulation test

OBJECTIVE

To determine the prevalence of adrenal enzyme dysfunction in women presenting with oligomenorrhoea and hirsutism, two clinical features of polycystic ovary syndrome (PCOS).

DESIGN

A prospective study of women attending outpatient clinics with these complaints. Androstenedione, dehydroepiandrosterone (DHEA), 17-hydroxyprogesterone (17-OHP), 11-deoxycortisol and cortisol were measured before and after overnight dexamethasone suppression and at 60 minutes after adrenal stimulation by ACTH injection.

SUBJECTS

Fifty women with clinical features of PCOS and 37 control women with regular cycles and normal hair distribution from the catchment area of the Royal Victoria Infirmary which includes Newcastle upon Tyne, Co. Durham, Cleveland, Cumbria and Northumberland.

MEASUREMENTS

Number of women with steroid responses to ACTH beyond the normal range, as defined by the responses of the control group and in previous studies.

RESULTS

Nineteen women (38%) were found to have some abnormality. One woman (2%) was identified with 21-hydroxylase (21-OHase) deficiency and a second (2%) had an increase in 17-OHP compatible with the heterozygote state for 21-OHase deficiency. Four women (8%) had isolated elevations in the DHEA response consistent with minimal 3 beta-hydroxysteroid dehydrogenase (3 beta-HSD) deficiency. Thirteen women (26%) showed increases in both androstenedione and DHEA, or androstenedione alone, compatible with enhanced 17-20 lyase activity.

CONCLUSIONS

Twelve per cent of the group showed evidence consistent with an adrenal enzyme deficiency; 26% had results in keeping with increased adrenal androgen production without an enzyme deficiency. These findings may be of relevance both in the pathogenesis of the features of PCOS and in determining appropriate treatment for individual patients.

Ovarian morphology in long-term androgen-treated female to male transsexuals. A human model for the study of polycystic ovarian syndrome?

Descriptions of the effect of androgens on ovarian human tissues are exceptional. This opportunity was provided for us by 17 women with transsexualism--female to male transsexuals (TSX)--who had been given androgens for a mean period of 21 months before hystero-salpingo-oophorectomy took place. Twenty-nine ovaries from TSX and 14 control ovaries from 13 regularly cycling women were examined. As compared with controls, TSX ovaries were enlarged and displayed a two-fold increase in cystic follicles and a 3.5-fold increase in atretic follicles; the ovarian cortex was collagenized and three-times thicker. Theca interna hyperplasia and luteinization were uniformly observed in TSX cystic follicles. Stromal hyperplasia was a constant finding in TSX ovaries, accompanied by clusters of luteinized stromal cells in 12 cases. Eventually, these findings met the histological criteria for the diagnosis of polycystic ovaries. These observations demonstrate that androgens alone may induce polycystic changes. The assumption that the role of androgens is pivotal at the follicular level--inducing follicle growth arrest and accelerating cystic changes--in the genesis of polycystic ovaries is reinforced.

Ovarian enlargement as a possible marker of androgen activity in polycystic ovary syndrome

This study has been carried out in an attempt to analyze clinical, hormonal and ultrasonography data and to evaluate their possible interrelationships in a group of 72 women with polycystic ovary syndrome (PCOS). Seventeen (23.6%) PCO women were found to have ovarian volume within normal range, while 72.2% had enlarged ovaries. Serum testosterone, androstenedione and DHEAS levels were higher in PCO women with enlarged ovaries when compared to patients who had ovarian volume within normal range, although the difference was not significant. However, when PCO patients were divided into subgroups according to the degree of ovarian enlargement, it was found that patients with the most enlarged ovaries had significantly higher serum androstenedione levels than those with normal ovarian volume (p = 0.039). Significant positive correlation was established between serum androstenedione concentration and ovarian volume (r = + 0.23, p less than 0.05). Hirsutism was found to be equally present in patients with normal ovarian volume (70.6%) and in patients with enlarged ovaries (71.2%) while oligomenorrhea was present more frequently among PCO women who had ovarian volume within normal range (64.7% vs. 40.4%). The results of our study allow us to suggest ovarian enlargement as a marker of excessive androgen production and disturbances of menstrual cycle in polycystic ovary syndrome.

Contraceptive choices--turning back the clock

Contraceptive choices are being reduced rather than being expanded in many parts of the world, particularly in Western countries. Although this paper presents an Australian perspective, the concerns are shared by family planners in other countries. The reasons for this are multiple and complex and often interrelated but ultimately depend on commercial considerations. The community expectation is that an ideal contraceptive can and does exist, but the media sensationalization of contraceptive problems has given many contraceptive methods a poor image. Contraceptive availability is also affected by liability issues, which have increased the cost of product liability insurance, and medical liability insurance of health professionals, increasing both the cost of contraceptives to the individual and the availability of services such as IUD insertions and sterilization, as practitioners withdraw their services, due to cost of insurance. The cost of marketing a new contraceptive from the time the idea is first developed until it is approved for marketing also deters manufacturers from developing new contraceptives. Delays in drug evaluation procedures in many countries deters companies with already well established contraceptives from marketing them in such countries. The effect of political stands by radical feminists or consumer groups, also effect both the image and the availability of contraceptives, as can be seen with the saga of Depo-Provera, RU486 and intrauterine devices. Similarly, the moral perceptions of anti-abortion groups and health care providers is also a threat to fertility control services. Possible solutions to some of these problems are offered in the paper.

Interactions between insulin and insulin-like growth factor I in the pathogenesis of polycystic ovarian disease

Concentrations of growth factors were examined in 28 patients with clinical and endocrinologic signs of polycystic ovarian disease (PCOD). Elevated levels of total insulin-like growth factor I (IGF-I) and decreased levels of the human growth hormone (HGH) were found. Studies of carbohydrate metabolism and of insulin receptors on erythrocytes indicated insulin resistance in all PCOD patients. Elevated insulin and IGF-I levels seem to play a pathogenetic role in PCOD by influencing the development and steroid production of ovarian follicles. Interactions between insulin and IGF-I could be shown at different levels. A positive correlation between elevated insulin and IGF-I concentrations was demonstrated in patients with different classes of gestational diabetes. Hyperinsulinemia seems to be the trigger mechanism and therefore the key to the pathogenetic loop of polycystic ovarian disease.

The diagnosis of polycystic ovaries in women with oligo-amenorrhoea: predictive power of endocrine tests

The ability of several endocrine tests to distinguish between women with and without polycystic ovaries (PCO) has been studied prospectively in a series of 65 patients with functional oligo-amenorrhoea using ultrasonography as a reference test. In terms of overall diagnostic accuracy, the free androgen index (FAI) (94%) and the progestogen challenge (89%) gave similar results (Cl = -5 to 15%) but both were significantly better than all the other tests including measurement of serum LH (69%), total testosterone (71%) and androstenedione (74%) (minimum Cl = 6 to 23%). The FAI together with LH measurement was the most accurate of the combinations (97%) but this was not significantly better than the best of the combinations incorporating the progestogen challenge (92%; Cl = -3% to 13%). Given the limited availability of the assay for SHBG, these results show that assessment of oestrogen state is a useful method for categorizing patients with functional oligo-amenorrhoea.

Changes in circulating hormone levels after ovarian wedge resection in patients with polycystic ovary syndrome

Serum gonadotropin, prolactin, estradiol, sex hormone binding globulin (SHBG) and androgen levels were measured before, 5 days and 6 weeks following ovarian wedge resection in 9 patients with polycystic ovary syndrome. Elevated levels of LH, androstenedione, testosterone and dehydroepiandrosterone-sulphate (DHEA-S) were found before surgery. There was a marked decrease in androstenedione and DHEA-S levels 5 days following wedge resection, but a rebound effect could be observed 6 weeks later. Serum gonadotropin, prolactin, testosterone and SHBG concentrations were practically unaffected by surgery. At 6-12 months follow up patients showed regular, mainly ovulatory cycles, but pregnancy occurred only in two cases.

Mortality among oral contraceptive users: 20 year follow up of women in a cohort study

OBJECTIVE

To see whether the use of oral contraceptives influences mortality.

DESIGN

Non-randomised cohort study of 17,032 women followed up on an annual basis for an average of nearly 16 years.

SETTING

17 Family planning clinics in England and Scotland.

SUBJECTS

Women recruited during 1968-74. At the time of recruitment each woman was aged 25-39, married, a white British subject, willing to participate, and either a current user of oral contraceptives or a current user of a diaphragm or intrauterine device (without previous exposure to the pill).

MAIN OUTCOME MEASURES

Overall mortality and cause specific mortality.

RESULTS

238 Deaths occurred during the follow up period. The main analyses concerned women entering the study while using either oral contraceptives or a diaphragm or intrauterine device. The overall relative risk of death in the oral contraceptive users was 0.9 (95% confidence interval 0.7 to 1.2). Though the numbers of deaths were small in most individual disease categories, the trends observed were generally consistent with findings in other reports. Thus the relative risk of death in the oral contraceptive users was 4.9 (95% confidence interval 0.7 to 230) for cancer of the cervix, 3.3 (95% confidence interval 0.9 to 17.9) for ischaemic heart disease, and 0.4 (95% confidence interval 0.1 to 1.2) for ovarian cancer. There was a linear trend in the death rates from cervical cancer and ovarian cancer (in opposite directions) with total duration of oral contraceptive use. Death rates from breast cancer (relative risk 0.9; 95% confidence interval 0.5 to 1.4) and suicide and probable suicide (relative risk 1.1; 95% confidence interval 0.3 to 3.6) were much the same in the two contraceptive groups. In 1981 the relative risk of death in oral contraceptive users from circulatory diseases as a group was reported to be 4.2 (95% confidence interval 2.3 to 7.7) in the Royal College of General Practitioners oral contraception study. The corresponding relative risk in this study was only 1.5 (95% confidence interval 0.7 to 3.0).

CONCLUSIONS

These findings contain no significant evidence of any overall effect of oral contraceptive use on mortality. None the less, only small numbers of deaths occurred during the study period and a significant adverse (or beneficial) overall effect might emerge in the future. Interestingly, the mortality from circulatory disease associated with oral contraceptive use was substantially less than that found in the Royal College of General Practitioners study.

Heterogeneity of the polycystic ovary syndrome: clinical, endocrine and ultrasound features in 556 patients

This paper reports an analysis of the clinical, endocrine and ultrasound data within a population of 556 patients with ultrasound-diagnosed polycystic ovaries. Compared with those not so affected, hirsutism was associated with a higher mean serum testosterone concentration, infertility was associated with higher mean gonadotrophin concentrations, obesity was associated with a higher mean serum testosterone concentration, hyperprolactinaemia was associated with a lower mean serum testosterone concentration and smaller ovaries, alopecia was associated with lower mean serum LH and testosterone concentrations, and acanthosis nigricans was associated with obesity and a raised mean serum testosterone concentration. The heterogeneity illustrates the limitations in the use of specific clinical or endocrine criteria as requirements for the diagnosis of the polycystic ovary syndrome.

Bioactive LH in women with polycystic ovaries and the effect of gonadotrophin suppression

Discrepancies between levels of bioactive LH (B-LH) and immunoreactive LH (I-LH) in polycystic ovarian syndrome (PCO) have been reported previously. Serum levels of I-LH, B-LH (by dispersed Leydig cell assay), FSH, oestradiol (E2) and progesterone (Prog) were measured once to three times weekly over 4 weeks in 13 women with classical clinical, ultrasound and endocrine features of PCO. Eleven women attending for infertility but whose profiles when studied three times weekly by combined endocrine and ultrasound assessment were normal and ovulatory served as controls. Seven of the women with PCO were evaluated during and after 3 weeks suppression with ethinyloestradiol (30 micrograms) plus 150 micrograms either of desogestrel or levonorgestrel; two were given both treatments. Both I-LH and B-LH levels were higher in PCO patients (20 +/- SD 5 U/l and 46 +/- 9 U/l respectively, P less than 0.0001), compared with all phases of the normal cycles except the mid-cycle peak. The B-LH to I-LH (B:I LH) ratio in PCO patients (2.5 +/- 0.7) was higher than in all the control cycle phases (P less than 0.05). I-LH, B-LH, B:I LH ratio, FSH and E2 were all suppressed from the second week of oestrogen-progestogen treatment (P less than 0.01) and returned gradually to pretreatment levels by the third or fourth week after suppression. The LH and FSH levels and B:I LH ratio in PCO patients during suppression were comparable with levels in the early and mid-follicular phases of control cycles but the LH/FSH ratio remained significantly raised (P less than 0.01) at 2.3 +/- 0.7.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of long-term testosterone exposure on ovarian function and morphology in the rhesus monkey

This study was aimed at developing a model in the rhesus monkey for the human gynecologic disorder termed the polycystic ovary syndrome (PCOS). The effects of chronic constant androgen exposure upon quantitative ovarian morphology and ovulatory function were examined. Twenty-five normally cycling females, aged 4-12 yr and weighing 3.3-8.2 kg, were enrolled in the study in random fashion. Seventeen animals were implanted subcutaneously (s.c.) with 10 or 25 mg testosterone-filled silastic tubing so as to maintain steady serum levels of testosterone averaging 80 ng/dl (low-dose group, n = 8) and 115 ng/dl (high-dose group, n = 9) for 13-16 months. Eight animals served as controls (sham implants); in these, mean serum testosterone levels averaged 24 ng/dl. No effect of androgen treatment was observed on ovulatory function as gauged by periodic luteal phase progesterone determinations and the presence of a fresh corpus luteum at laparoscopy. Menstrual cycle frequency (number of cycles over number of months of observation) was, however, slightly but significantly (P less than 0.05) reduced in the high-dose (88.9%) vs. the control (96.7%) and low-dose (95.0%) groups. Quantitative morphology, performed by light microscopy on a single ovary obtained from 16 of the 25 animals and read in a blinded fashion, revealed no differences in ovarian weight, capsular width and numbers, size, or proportion of healthy and atretic follicles among the three groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of polycystic ovarian disease by inducing ovulation with pulsatile subcutaneous administration of human menopausal gonadotrophin associated with luteinizing hormone-releasing hormone analogue

Treatment with a combination of luteinizing hormone-releasing analogue (GnRHa, Buserelin) and pulsatile administration of hMG (Group I) were used to induce ovulation in nine patients with polycystic ovary syndrome (PCO). The same patients were also treated with pulsatile hMG administration alone (Group II). Ovulation was observed in all twelve treatment cycles in Group I, and there were two pregnancies. In Group II, ovulation occurred in 22 of 26 treatment cycles. Ovarian hyperstimulation occurred in one cycle of Group I and in 5 of 26 cycles of Group II. The total dose per cycle of hMG to induce ovulation in Group I was significantly lower than that needed when only pulsatile hMG administration was used. In response to Buserelin administration, the concentrations of serum luteinizing hormone (LH) and follicle stimulating hormone (FSH) increased transiently and then declined to the normal range observed in the early follicular phase. The concentrations of FSH increased in response to hMG administration, resulting in a normal LH/FSH ratio. The present data demonstrated that pulsatile subcutaneous administration of hMG in addition to Buserelin was effective in inducing follicular maturation and ovulation in patients with PCO with a lower incidence of serious side-effects.

Polycystic ovarian disease: endocrinological parameters with specific reference to growth hormone and somatomedin-C

Thirty-three women (22-38 years old) with polycystic ovarian disease (PCOD) were included in this study. The criteria for diagnosis were: an LH/FSH ratio greater than 2.0; polycystic ovaries, diagnosed by means of palpation and ultrasound; androgenism and menstrual cycle abnormalities. Using endocrine parameters, we attempted to define distinct forms of PCOD. The patients were placed in three groups according to serum levels of testosterone (T) and 17 alpha-hydroxyprogesterone (17 alpha OHP) and the estrone/androstendione (E1/delta 4A) ratio. Patients in group I (n = 18) had an elevated T level (greater than 1.0 ng/ml) and a 17 alpha OHP level under 4.0 ng/ml. This type of POCD was called the "androgen" type. Patients in group II (n = 7) had normal T- and 17 alpha OHP levels under 4.0 ng/ml and an elevated (E1/delta 4A) ratio. This type of PCOD was called the "estrogen" type. Group III (n = 8) comprised patients with 17 alpha OHP levels over 4.0 ng/ml. This type of PCOD was called the "adrenocortical" type. In two patients of this group, a modified ACTH test revealed late-onset congenital hyperplasia. The endocrine parameters of the patients with PCOD were compared with those of 17 adult without signs of PCOD. Statistical evaluation was done by variance analysis. Women with acromegaly often show signs of androgenism as well as menstrual cycle abnormalities. This may indicate an association between the growth factors human growth hormone (HGH) and somatomedin-C (Sm-C) and the biosynthese and metabolism of steroid hormone. Recent experiments have demonstrated such associations. Our study showed an association between the HGH and Sm-C levels and abnormal steroid hormone concentrations in women with androgen type PCOD (group I). These patients had a significantly decreased HGH level, a significantly decreased HGH/Sm-C ratio, and an increased average Sm-C level. These data suggest that elevated Sm-C levels can, by a negative-feedback mechanism, inhibit pituitary HGH production. We discuss the possible mechanisms causing elevation of plasma Sm-C, HGH, steroid hormones, excessive food intake, and possibly prolactin seem responsible for the clinical manifestation of increased Sm-C production in adolescence and for its level in the fertile years of patients.

A quantitative cytochemical analysis of large antral follicles in two types of rat polycystic ovaries

Ovaries from normal mature rats, rats injected with testosterone propionate (TP), and from aged rats were removed, and large antral follicles examined by quantitative cytochemical techniques in order to analyze possible enzymatic defects that relate to follicular steroidogenesis. The ovaries from the TP-injected and the aged rats were polycystic. Lipid deposition was analyzed in frozen sections stained with Sudan black. A microdensitometer was used to measure delta 5-3 beta-hydroxysteroid dehydrogenase (3 beta OHD) activity and G-6-PD type IH generation in the theca, and in peripheral region, antral region, and corona radiata of large antral follicles. 3 beta OHD is the enzyme that converts pregnenolone to progesterone. Type IH generation is related to the conversion of androstenedione to estradiol. Lipid droplet deposition was comparable in the three types of follicles. Compared to that in normal preovulatory follicles, 3 beta OHD activity was similar in identical regions of large antral follicles in TP-injected rats, but less in the theca and peripheral region of the membrana granulosa of the aged rat. G-6-PD type IH generation was less in the peripheral region of large antral follicles of both TP-injected and aged rats than in preovulatory follicles. Type IH generation was also less in the theca of TP-injected rats than in the theca of normal rats. This study provides evidence that in spite of their normal appearance, large antral follicles in polycystic ovaries are not physiologically sound. Furthermore, the enzymatic disturbance appears to be different in different types of polycystic ovaries.

Increased DHEAs levels in PCO syndrome: evidence for the existence of two subgroups of patients

In 49 patients affected by PCO syndrome the serum levels of dehydroepiandrosterone-sulphate (DHEAs) were determined and correlated with the clinical presentation and the endocrine pattern. Twenty-three patients (47%) had high DHEAs levels (h-DHEAs patients). They presented a milder clinical presentation (low incidence of amenorrhea) than PCO patients with normal DHEAs levels (n-DHEAs patients). In h-DHEAs patients the finding of a normal DHEAs response to ACTH and of slightly increased 170HP serum levels suggested that the elevation of serum DHEAs was not due to an adrenal enzymatic deficiency but to a tonic hyperstimulation of the adrenals. Two subgroups of h-DHEAs patients were identified: in the first subgroup, PRL and estrone levels were increased and probably explained the DHEAs hypersecretion; in the second subgroup, the endocrine pattern was very similar to that observed in n-DHEAs patients and a clear explanation for DHEAs increase was not found, although the possibility of an exaggerated secretion of some pituitary hormones with adrenal androgen stimulating activity must be considered.

Insulin resistance and secretion in polycystic ovarian disease

In order to verify the relationship between insulin resistance and hyperandrogenism in Polycystic ovary disease (PCOD), circulating levels of insulin in response to oral glucose tolerance test (OGTT) were assessed in 23 PCOD patients and 10 matched control subjects without obesity, acanthosis nigricans and impaired glucose tolerance. In PCOD patients serum total testosterone (T), dehydroepiandrosterone sulfate (DHEA-S), LH and LH/FSH ratio were significantly higher than in control subjects; whereas urinary 17-ketosteroids (17-KS) and glycemic response to OGTT were not different. PCOD patients were clearly hyperinsulinemic before and during OGTT compared to the control group: mean +/- SD basal insulin (Io) (23.4 +/- 10.3 vs 11.3 +/- 4.6 microU/ml, p less than 0.001) and the sums of insulin levels (sigma I) during OGTT (341.4 +/- 148.9 vs 162.2 +/- 56 microU/ml, p less than 0.001). In the two groups serum T, but not DHEA-S, LH, urinary 17-KS and the degree of obesity, was strongly associated with Io (r = 0.458, p less than 0.01) and sigma I (r = 0.419, p less than 0.02), as well as with insulin resistance as assessed by basal (r = 0.425, p less than 0.02) and postglucose challenge (r = 0.384, p less than 0.05) insulin to glucose ratio. These results confirm that the hyperinsulinism and insulin resistance in PCOD is not related to obesity and suggest that the hyperandrogenism may be partially responsible of the observed imbalance in glucose-insulin homeostasis.

Oral contraceptives, lipids and cardiovascular disease

Evidence for the involvement of changes in lipid metabolism and oral contraceptive use in the development of cardiovascular disease is briefly reviewed with particular reference to the main object of the article, to assess the effect of different oral contraceptive formulations on serum lipid levels. The preferred formulations should contain a low dose of ethynyloestradiol and should not increase serum levels of cholesterol and LDL-C or reduce those of HDL-C. Such formulations appear to be the triphasic one containing ethynyloestradiol and levonorgestrel and the ethynyloestradiol-desogestrel combination, which appears to be unique in that it may actually increase HDL-C. However other determinants in addition to effects on lipid metabolism will be important in deciding the choice of an oral contraceptive. Any changes which do occur in serum lipid concentrations with OC use appear within the first three months and do not appear to be progressive with continued use after this time.

The effects of prolactin on rat ovarian function

Hyperprolactinemia has been associated with several reproductive disorders. To investigate whether hyperprolactinemia directly affects rat ovarian function, we examined the ovarian histopathology and the activities of the four ovarian enzymes 3 beta-hydroxysteroid dehydrogenase (3 beta-HSD), 17-hydroxylase (17-OH), 17,20-desmolase (17,20-D) and aromatase in hyperprolactinemic rats and controls. Hypophysectomized, gonadotropin-treated Fisher rats were made hyperprolactinemic by isografting pituitary glands under the kidney capsule. The control animals received skeletal muscle. The ovaries were resected, pooled according to prolactin levels and microsomal enzyme activities were measured from each pool. Prolactin (PRL) levels were 344 +/- 23 ng/ml in the hyperprolactinemic rats and 18 +/- 5 ng/ml in the controls (p less than 0.001). Estradiol concentrations were 609 +/- 47 pg/ml in the hyperprolactinemic animals and 56 +/- 13 pg/ml in the controls (p less than 0.001). Ovarian and uterine weights were significantly higher in the hyperprolactinemic rats (p less than 0.02). Ovarian histopathology demonstrated benign polycystic transformation in the hyperprolactinemic animals. Hyperprolactinemia had no effect on 3 beta-HSD, but was associated with significant decreases in the 17-OH, 17,20-D and aromatase activities when compared to controls (p less than 0.001). We conclude that prolactin has a direct effect on rat ovarian function which appears to be independent of changes in gonadotropin secretion.

Oral contraceptives and mortality from circulatory system diseases: an epidemiologic study in Taiwan

An epidemiological study on the association between oral contraceptive (OC) use and circulatory system disease (CSD) mortality undertaken in Taiwan by proxy interview of closest family members of 306 deceased cases, 305 deceased controls, and 611 healthy neighborhood controls indicated that the relative risk between the cases and health controls was 0.98 (0.62-1.54) and that between cases and health controls was 0.82 (0.56-1.21). Use of OC by Taiwanese women has not produced any overwhelming adverse effects on CSD mortality.