Artificial intelligence-based image analysis in clinical testing: lessons from cervical cancer screening

Novel screening and diagnostic tests based on artificial intelligence (AI) image recognition algorithms are proliferating. Some initial reports claim outstanding accuracy followed by disappointing lack of confirmation, including our own early work on cervical screening. This is a presentation of lessons learned, organized as a conceptual step-by-step approach to bridge the gap between the creation of an AI algorithm and clinical efficacy. The first fundamental principle is specifying rigorously what the algorithm is designed to identify and what the test is intended to measure (eg, screening, diagnostic, or prognostic). Second, designing the AI algorithm to minimize the most clinically important errors. For example, many equivocal cervical images cannot yet be labeled because the borderline between cases and controls is blurred. To avoid a misclassified case-control dichotomy, we have isolated the equivocal cases and formally included an intermediate, indeterminate class (severity order of classes: case>indeterminate>control). The third principle is evaluating AI algorithms like any other test, using clinical epidemiologic criteria. Repeatability of the algorithm at the borderline, for indeterminate images, has proven extremely informative. Distinguishing between internal and external validation is also essential. Linking the AI algorithm results to clinical risk estimation is the fourth principle. Absolute risk (not relative) is the critical metric for translating a test result into clinical use. Finally, generating risk-based guidelines for clinical use that match local resources and priorities is the last principle in our approach. We are particularly interested in applications to lower-resource settings to address health disparities. We note that similar principles apply to other domains of AI-based image analysis for medical diagnostic testing.

Reproducible and clinically translatable deep neural networks for cervical screening

Cervical cancer is a leading cause of cancer mortality, with approximately 90% of the 250,000 deaths per year occurring in low- and middle-income countries (LMIC). Secondary prevention with cervical screening involves detecting and treating precursor lesions; however, scaling screening efforts in LMIC has been hampered by infrastructure and cost constraints. Recent work has supported the development of an artificial intelligence (AI) pipeline on digital images of the cervix to achieve an accurate and reliable diagnosis of treatable precancerous lesions. In particular, WHO guidelines emphasize visual triage of women testing positive for human papillomavirus (HPV) as the primary screen, and AI could assist in this triage task. In this work, we implemented a comprehensive deep-learning model selection and optimization study on a large, collated, multi-geography, multi-institution, and multi-device dataset of 9462 women (17,013 images). We evaluated relative portability, repeatability, and classification performance. The top performing model, when combined with HPV type, achieved an area under the Receiver Operating Characteristics (ROC) curve (AUC) of 0.89 within our study population of interest, and a limited total extreme misclassification rate of 3.4%, on held-aside test sets. Our model also produced reliable and consistent predictions, achieving a strong quadratic weighted kappa (QWK) of 0.86 and a minimal %2-class disagreement (% 2-Cl. D.) of 0.69%, between image pairs across women. Our work is among the first efforts at designing a robust, repeatable, accurate and clinically translatable deep-learning model for cervical screening.

REPRODUCIBLE AND CLINICALLY TRANSLATABLE DEEP NEURAL NETWORKS FOR CANCER SCREENING

Cervical cancer is a leading cause of cancer mortality, with approximately 90% of the 250,000 deaths per year occurring in low- and middle-income countries (LMIC). Secondary prevention with cervical screening involves detecting and treating precursor lesions; however, scaling screening efforts in LMIC has been hampered by infrastructure and cost constraints. Recent work has supported the development of an artificial intelligence (AI) pipeline on digital images of the cervix to achieve an accurate and reliable diagnosis of treatable precancerous lesions. In particular, WHO guidelines emphasize visual triage of women testing positive for human papillomavirus (HPV) as the primary screen, and AI could assist in this triage task. Published AI reports have exhibited overfitting, lack of portability, and unrealistic, near-perfect performance estimates. To surmount recognized issues, we implemented a comprehensive deep-learning model selection and optimization study on a large, collated, multi-institutional dataset of 9,462 women (17,013 images). We evaluated relative portability, repeatability, and classification performance. The top performing model, when combined with HPV type, achieved an area under the Receiver Operating Characteristics (ROC) curve (AUC) of 0.89 within our study population of interest, and a limited total extreme misclassification rate of 3.4%, on held-aside test sets. Our work is among the first efforts at designing a robust, repeatable, accurate and clinically translatable deep-learning model for cervical screening.

Automatic multiclass intramedullary spinal cord tumor segmentation on MRI with deep learning

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Automatic spinal cord tumor segmentation with deep learning.

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Multi-class model for tumor, edema, and cavity.

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Model trained to recognize astrocytoma, ependymoma, and hemangioblastoma.

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Multi-contrast input for more robustness: Gd-T1w and T2w.

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Method and model are available in open-source Spinal Cord Toolbox (SCT).

Spinal cord tumors lead to neurological morbidity and mortality. Being able to obtain morphometric quantification (size, location, growth rate) of the tumor, edema, and cavity can result in improved monitoring and treatment planning. Such quantification requires the segmentation of these structures into three separate classes. However, manual segmentation of three-dimensional structures is time consuming, tedious and prone to intra- and inter-rater variability, motivating the development of automated methods. Here, we tailor a model adapted to the spinal cord tumor segmentation task. Data were obtained from 343 patients using gadolinium-enhanced T1-weighted and T2-weighted MRI scans with cervical, thoracic, and/or lumbar coverage. The dataset includes the three most common intramedullary spinal cord tumor types: astrocytomas, ependymomas, and hemangioblastomas. The proposed approach is a cascaded architecture with U-Net-based models that segments tumors in a two-stage process: locate and label. The model first finds the spinal cord and generates bounding box coordinates. The images are cropped according to this output, leading to a reduced field of view, which mitigates class imbalance. The tumor is then segmented. The segmentation of the tumor, cavity, and edema (as a single class) reached 76.7 ± 1.5% of Dice score and the segmentation of tumors alone reached 61.8 ± 4.0% Dice score. The true positive detection rate was above 87% for tumor, edema, and cavity. To the best of our knowledge, this is the first fully automatic deep learning model for spinal cord tumor segmentation. The multiclass segmentation pipeline is available in the Spinal Cord Toolbox (https://spinalcordtoolbox.com/). It can be run with custom data on a regular computer within seconds.

SoftSeg: Advantages of soft versus binary training for image segmentation

Most image segmentation algorithms are trained on binary masks formulated as a classification task per pixel. However, in applications such as medical imaging, this "black-and-white" approach is too constraining because the contrast between two tissues is often ill-defined, i.e., the voxels located on objects' edges contain a mixture of tissues (a partial volume effect). Consequently, assigning a single "hard" label can result in a detrimental approximation. Instead, a soft prediction containing non-binary values would overcome that limitation. In this study, we introduce SoftSeg, a deep learning training approach that takes advantage of soft ground truth labels, and is not bound to binary predictions. SoftSeg aims at solving a regression instead of a classification problem. This is achieved by using (i) no binarization after preprocessing and data augmentation, (ii) a normalized ReLU final activation layer (instead of sigmoid), and (iii) a regression loss function (instead of the traditional Dice loss). We assess the impact of these three features on three open-source MRI segmentation datasets from the spinal cord gray matter, the multiple sclerosis brain lesion, and the multimodal brain tumor segmentation challenges. Across multiple random dataset splittings, SoftSeg outperformed the conventional approach, leading to an increase in Dice score of 2.0% on the gray matter dataset (p=0.001), 3.3% for the brain lesions, and 6.5% for the brain tumors. SoftSeg produces consistent soft predictions at tissues' interfaces and shows an increased sensitivity for small objects (e.g., multiple sclerosis lesions). The richness of soft labels could represent the inter-expert variability, the partial volume effect, and complement the model uncertainty estimation, which is typically unclear with binary predictions. The developed training pipeline can easily be incorporated into most of the existing deep learning architectures. SoftSeg is implemented in the freely-available deep learning toolbox ivadomed (https://ivadomed.org).

Replacing an Inpatient Electronic Medical Record

Objective: Since it is important to develop strategies for the successful implementation of electronic clinical information systems, the aim of this study is to explore where, and to what extent, users’ attitudes toward the former system that is being replaced may vary.

Methods: A cross-sectional survey of 346 nurses and physicians practicing in two Canadian teaching hospitals resulted in a total response rate of 63%. User attitudes were measured in three dimensions: a) user satisfaction with the system’s quality attributes, b) perceived system usefulness, and c) perceived impact on quality of care and patient safety. The current system (the one being replaced) was analyzed as a dual system composed of both paper-based and electronic records.

Results: The results on user satisfaction demonstrate a wide variation in opinions, with satisfaction ranging from 4.2 to 7.7 on a 10-point disagree-agree, Likert scale. The quality attributes varied by record type, with differences that were systematically in favor of the electronic record component, which received higher scores. The results also highlighted large differences by user group. Physicians and nurses systematically rated the two record formats differently. The nurses were more satisfied with the attributes of the paper-based record. Multivariate regression analyses results also revealed strong interdependencies among the three dimensions of user attitudes, to the extent that perceived system usefulness was strongly correlated with system quality attributes and the system outcomes were also correlated, although less strongly, with the two former system dimensions.

Conclusion: Understanding users’ attitudes toward a clinical information system in use, both in its paper and electronic aspects, is crucial for developing more successful implementation strategies for electronic record systems.

Replacing an inpatient electronic medical record. Lessons learned from user satisfaction with the former system

OBJECTIVE

Since it is important to develop strategies for the successful implementation of electronic clinical information systems, the aim of this study is to explore where, and to what extent, users' attitudes toward the former system that is being replaced may vary.

METHODS

A cross-sectional survey of 346 nurses and physicians practicing in two Canadian teaching hospitals resulted in a total response rate of 63%. User attitudes were measured in three dimensions: a) user satisfaction with the system's quality attributes, b) perceived system usefulness, and c) perceived impact on quality of care and patient safety. The current system (the one being replaced) was analyzed as a dual system composed of both paper-based and electronic records.

RESULTS

The results on user satisfaction demonstrate a wide variation in opinions, with satisfaction ranging from 4.2 to 7.7 on a 10-point disagree-agree, Likert scale. The quality attributes varied by record type, with differences that were systematically in favor of the electronic record component, which received higher scores. The results also highlighted large differences by user group. Physicians and nurses systematically rated the two record formats differently. The nurses were more satisfied with the attributes of the paper-based record. Multivariate regression analyses results also revealed strong interdependencies among the three dimensions of user attitudes, to the extent that perceived system usefulness was strongly correlated with system quality attributes and the system outcomes were also correlated, although less strongly, with the two former system dimensions.

CONCLUSION

Understanding users' attitudes toward a clinical information system in use, both in its paper and electronic aspects, is crucial for developing more successful implementation strategies for electronic record systems.

Rosiglitazone and ethinyl estradiol/cyproterone acetate as single and combined treatment of overweight women with polycystic ovary syndrome and insulin resistance

BACKGROUND

Few studies have evaluated insulin sensitizers in comparison/association with oral contraceptives (OC) in women with polycystic ovary syndrome (PCOS) with insulin resistance (IR). This study assessed the effects of a thiazolidinedione versus an anti-androgenic estrogen-progestin followed by their sequential combinations in overweight PCOS women.

METHODS AND RESULTS

Twenty-eight candidates in whom elevated insulin was not normalized after 4 months of diet were randomly assigned to 6 months of rosiglitazone 4 mg/day or to ethinyl estradiol 35 mg/cyproterone acetate 2 mg (EE/CPA: 21/28 days cycle). Each group then received both medications for another 6 months. Rosiglitazone reduced insulin, IR indices [homeostasis model assessment (HOMA) and quantitative sensitivity check index (QUICKI)] and the insulin area under the curve in response to an oral glucose tolerance test (OGTT), but had limited effect on lipids, androgens and hirsutism. EE/CPA did not modify insulin and OGTT response but increased high-density lipoprotein cholesterol and triglycerides and decreased androgens and hirsutism. Similar changes occurred during combined treatments. End results were highly significant in combined groups without noticeable side-effects or changes in safety parameters.

CONCLUSIONS

In obese PCOS women with high insulin not corrected by diet, the combination of rosiglitazone and EE/CPA may be used to achieve complementary beneficial effects on endocrine-metabolic anomalies and clinical symptoms.

The effects of flaxseed dietary supplement on lipid profile, bone mineral density, and symptoms in menopausal women: a randomized, double-blind, wheat germ placebo-controlled clinical trial

Phytoestrogens are increasingly incorporated into the diet of menopausal women. However, there are limited data on the efficacy of flaxseed on the consequences of estrogen deficiency in menopausal women. The purpose of the study was to assess the effects of flaxseed incorporation into the diet of healthy menopausal women. One hundred and ninety-nine menopausal women were randomly assigned to consume 40 g flaxseed/d (n = 101) or wheat germ placebo (n = 98) for 12 months. At baseline and at month 12, serum levels of lipids, bone mineral density (BMD), and menopausal symptoms were evaluated. Statistical analysis was performed under the intention to treat principle. Flaxseed reduced serum total (-0.20 +/- 0.51 mmol/liter; P = 0.012) and high-density lipoprotein (-0.08 +/- 0.24 mmol/liter; P = 0.031) cholesterol concentrations compared with wheat germ placebo. BMD did not differ significantly between the two arms. Both flaxseed and wheat germ reduced (P < 0.0001) the severity scores of menopausal symptoms, but no statistical difference was found between the two arms. Our findings suggest that 1-yr incorporation of flaxseed into the diet produced a favorable, but not clinically significant, effect on blood cholesterol and caused no significant change in BMD or symptoms in healthy menopausal women.

The use of low dose oral contraceptives for the management of acne

There is compelling evidence that oral contraceptives (OCs) are effective in the management of mild-moderate acne vulgaris, as well as cumulative evidence that elevated levels of androgens in acne patients, relative to appropriate controls, are an underlying pathophysiological factor in acne. All low dose OCs reduce serum free testosterone (T) to a similar extent, which is contrary to the traditional concept that a patient who has acne should not use an OC containing a progestin with androgenic properties. The efficacy of various OCs to improve acne has been reported in transverse, cohort and comparative studies, and more recently in multicenter, randomized, placebo-controlled trials. Recently, an ultra-low dose OC (Alesse, Wyeth) was shown to effectively reduce non-inflammatory and inflammatory lesions in mild-to-moderate acne, while having a profile of side-effects similar to that of a placebo. Besides its contraceptive efficacy, an ultra-low dose OC represents an attractive alternative as a single or associated medication in the management of acne.

Estrogen/progesterone replacement versus pravastatin and their sequential association in hypercholesterolemic postmenopausal women

OBJECTIVES

The objectives of this study were to assess serum lipid changes in response to an oral estrogen combined with progesterone (Group A) as compared with pravastatin (Group B) and to evaluate the additive effects of the sequential addition of statin to hormonal replacement therapy (HRT) and of HRT to statin.

METHODS

Thirty-seven of 63 hypercholesterolemic menopausal women initially submitted to a 4-month diet were randomised to oral conjugated estrogens (0.625 mg)/micronised progesterone (200 mg) or to pravastatin (40 mg). After 6 months, each group received both medications for another 6 months.

RESULTS

Nineteen percent of women corrected their lipids below decision levels with diet alone. Low density lipoprotein-cholesterol (LDL-C) decreased by 8+/-5% with HRT and by 26+/-3% (P<0.001) with the statin. These single medications increased high density lipoprotein-cholesterol (HDL-C) by 13+/-5% (P<0.01) and 11+/-7%, respectively. Combined interventions produced cumulative LDL-C reductions of 40+/-2 and 42+/-3% (P<0.001) and additive HDL-C augmentations of 16+/-4 and 23+/-5% (P<0.01) with proportional changes in apolipoprotein (Apo)B-100 and ApoA-1. These combined effects brought the atherogenic index (C/HDL-C) for Groups A and B, respectively, from a moderate (5.18+/-0.25 and 5.87+/-0.18) to a reduced (3.35+/-0.20 and 3.52+/-0.19) risk category. Triglycerides (TG) which were increased by HRT and decreased by the statin returned to baseline during combined treatments. No changes in diet, physical activity or anthropomorphometric measurements explained the lipid modifications.

CONCLUSIONS

In menopausal patients with elevated C not responding to diet, pravastatin was most effective to decrease LDL-C, and oral estrogen-micronised progesterone most effective to increase HDL-C. Marked reduction of the atherogenic index is achieved by sequential combinations of medications resulting from beneficial cumulative effects on both C-LDL and C-HDL.

A randomized, controlled trial of a low-dose contraceptive containing 20 microg of ethinyl estradiol and 100 microg of levonorgestrel for acne treatment

OBJECTIVE

To evaluate the efficacy of a low-dose oral contraceptive (OC) containing 100 microg of levonorgestrel (LNG) and 20 microg of ethinyl estradiol (EE) compared with placebo for the treatment of moderate acne.

DESIGN

Multicenter, randomized, double-blind, placebo-controlled clinical trial.

SETTING

Outpatient dermatology clinics.

PATIENT(S)

Women (> or =14 years old; n = 350) with normal menstrual cycles and moderate acne were randomized to receive LNG/EE or placebo for six cycles.

INTERVENTION(S)

Twenty microg of EE and 100 microg of LNG.

MAIN OUTCOME MEASURE(S)

Acne lesion counts and clinician global assessment were performed at baseline and at each cycle. Patient self-assessment was carried out at baseline and at cycles 4 and 6; blood pressure and weight were measured at baseline and at cycles 1, 3, and 6.

RESULT(S)

Inflammatory, noninflammatory, and total lesion counts at cycle 6 with LNG/EE were significantly lower compared to placebo. Patients in the LNG/EE group also had significantly better clinician global and patient self-assessment scores than those in the placebo group at cycle. Changes in weight from baseline were similar between patients in the LNG/EE and placebo groups at all measured time points.

CONCLUSION(S)

This double-blind, placebo-controlled study demonstrates that a low-dose OC containing 20 microg of EE and 100 microg of LNG is an effective and safe treatment for moderate acne.

Haptoglobin is present in human endometrium and shows elevated levels in the decidua during pregnancy

Assuming that haptoglobin, by virtue of its immunomodulatory properties, could be a regulatory factor during reproduction, its presence in the human uterus was determined. Protein extracts from endometrial tissue samples of pregnant and non-pregnant women were analysed by the immunoblot technique and the intensities of specific bands were quantified. Bands corresponding to haptoglobin were identified in tissue samples obtained from both sources. Protein, purified by high-performance liquid chromatography and monitored by Western blot analysis for its haptoglobin identity, was used for amino-terminal sequencing. Sequencing of the 42 kDa protein identified it as the beta chain of haptoglobin. Immunohistochemistry was used to corroborate the findings and to visualize the distribution of haptoglobin in the tissue. The intensity of the 42 kDa band derived from decidua graviditatis was significantly higher than the intensity of bands derived from non-pregnant endometrium in the proliferative phase (P < 0.01) and in the secretory phase (P < 0.05). Immunohistochemical staining with anti-human haptoglobin antibody elicited strong signals in the decidua graviditatis and weaker signals in the normal endometrium, with the latter showing menstrual cycle-dependent variation. Moderate staining of stroma and a lack of staining of epithelium in the proliferative phase contrasted with the strong staining of stroma and moderate level of staining of epithelium observed in the secretory phase. Haptoglobin in the uterus may exert several functions such as the known binding of haemoglobin, but could also be involved in the multi-factorial mechanism protecting the fetus from a maternal allograft-like immune response.

Comparative effect of danazol and a GnRH agonist on monocyte chemotactic protein-1 expression by endometriotic cells

PROBLEM

Endometriosis is associated with a chronic inflammatory process, and the increased number of activated peritoneal macrophages is one of the major hallmarks of this process. The medical treatment of the disease, which is based on the creation of an hypoestrogenic milieu unfavorable to the growth of endometriotic lesions, is often associated with a reduced peritoneal inflammation. The aim of this study was to investigate the ability of current therapeutic agents to modulate, through a direct mechanism, the expression by endometriotic cells of monocyte chemotactic protein-1 (MCP-1), a chemokine endowed with the potent faculty of recruiting and activating macrophages.

METHOD OF STUDY

Cells were stimulated with interleukin-1 beta (IL-1beta) to induce MCP-1 expression. MCP-1 protein secretion and mRNA steady-state levels were evaluated by ELISA and northern blot, respectively.

RESULTS

Our results show that danazol concentrations (10(-7) -10(-5) M), taking into account the therapeutic levels found in the plasma of treated patients, inhibited MCP-1 protein and mRNA steady-state levels in endometriotic cells, whereas buserelin acetate (0.1-10 ng/mL), a GnRH agonist, had no significant effect. Dexamethasone, an anti-inflammatory glucocorticoid, used at concentrations varying between 10(-12) and 10(-6) M, also displayed a dose-dependent inhibitory action.

CONCLUSIONS

These results put into prominence the capability of danazol to directly inhibit the expression of a potent monocyte chemotactic and activating factor by ectopic endometrial cells shedding more light on the mechanisms underlying the clinical effects of hormonal therapeutic agents used in the treatment of endometriosis.

Effect of hormonal agents on monocyte chemotactic protein-1 expression by endometrial epithelial cells of women with endometriosis

OBJECTIVE

To assess whether hormonal agents used in the medical treatment of endometriosis, such as danazol and GnRH agonist, exert direct regulatory action on monocyte chemotactic protein-1 (MCP-1) expression by endometrial epithelial cells.

DESIGN

Primary cultures of epithelial cells isolated from human endometrium were exposed to different concentrations of cytokines and steroid hormone analogs. Expression of MCP-1 was analyzed at the levels of protein and messenger RNA.

SETTING

Gynecology clinic and laboratory of endocrinology of reproduction.

PATIENT(S)

Women presenting for infertility or pelvic pain in whom endometriosis was diagnosed by using laparoscopy.

INTERVENTION(S)

Endometrial tissue biopsy performed at laparoscopy.

MAIN OUTCOME MEASURE(S)

Secretion of MCP-1 protein was measured by using enzyme-linked immunosorbent assay, and mRNA steady-state levels were measured by performing Northern blot analysis.

RESULT(S)

Buserelin acetate, a GnRH agonist (0.1-10 ng/mL), had no significant effect on MCP-1 expression, whereas danazol (10(-7)-10(-5) M), a testosterone analog, and dexamethasone, an anti-inflammatory glucocorticoid hormone (10(-12)-10(-6)M), showed a direct and a dose-dependent inhibitory effect on MCP-1 expression. This effect occurred at the level of protein and mRNA.

CONCLUSION(S)

The findings of the study may affect understanding of the mechanisms by which hormonal treatments act on endometriosis and influence its clinical manifestations.

Ovarian hormones modulate monocyte chemotactic protein-1 expression in endometrial cells of women with endometriosis

Endometriosis, a frequent oestrogen-dependent disease believed to result from an aberrant proliferation of endometrial tissue outside the uterine cavity, is associated with an increased expression of monocyte chemotactic protein-1 (MCP-1) in the intrauterine endometrium. This makes it plausible that migrating endometrial cells are intrinsically able to initiate monocyte chemoattraction and activation, a phenomenon which has been consistently observed in the peritoneal cavity of patients and recently in their eutopic endometrium. To elucidate the mechanisms involved in the regulation of MCP-1 expression in eutopic endometrial cells, we studied the effects of ovarian hormones and found that oestradiol (10(-9) and 10(-8) mol/l) markedly increased MCP-1 mRNA steady-state levels and protein secretion by endometrial cells in response to interleukin-1beta (IL-1beta) (0.1 ng/ml). The IL-1beta-induced MCP-1 expression was even higher following pretreatment of cells with both oestradiol (10(-9) mol/l) and progesterone (5x10(-8) mol/l). This did not seem to be due to increased MCP-1 mRNA stability, but rather to a higher level of gene transcription. Our results provide evidence that ovarian steroids regulate, indirectly, the synthesis and the secretion of a potent chemotactic and activating factor for monocytes/macrophages by endometrial cells of women with endometriosis and reveal a new mechanism for oestradiol action.

Immunohistochemical localization of insulin-like growth factor-binding protein-3 in eutopic and ectopic endometrial tissues

OBJECTIVE

To evaluate the expression of insulin-like growth factor-binding protein-3 (IGFBP-3) in the eutopic endometrium and in endometriotic lesions.

DESIGN

Retrospective immunohistochemical study.

PATIENT(S)

Twenty-five normal women and 39 women with endometriosis.

INTERVENTION(S)

Endometrial and endometriotic tissue biopsies obtained at laparoscopy.

MAIN OUTCOME MEASURE(S)

Expression of IGFBP-3 assessed by immunohistochemistry.

RESULT(S)

In the endometrium, positive immunostaining of IGFBP-3 was observed both in the stroma and the epithelial glands. The intensity of staining in the glands during the secretory phase was significantly higher in women with endometriosis compared with controls (P = .018). An increased expression of IGFBP-3 over controls was found in stages I and II of the disease (P = .018), whereas in stages III and IV, the difference between controls and women with endometriosis was not significant (P = .300). In endometriotic tissues, a much-marked immunostaining of IGFBP-3 was noted in 90% of the glands and 67% of the stroma without apparent differences related to cycle phase.

CONCLUSION(S)

These data show intense staining of IGFBP-3 in endometriosis lesions and increased expression of the protein in the endometrium of patients with endometriosis compared to controls. This marked expression of IGFBP-3 could be related to its previous finding in the peritoneal fluid and to its potential involvement in the pathophysiology of endometriosis.

Physiological and cytogenetic characterization of immortalized human endometriotic cells containing episomal simian virus 40 DNA

The study of misplaced endometrial cells, which abnormally implant and grow outside the uterine cavity, is of considerable interest for the understanding of the pathophysiology of endometriosis. However, endometriotic cells, particularly epithelial cells, required for primary cell culture are not easily available. We report here the characterization of an endometriotic cell line immortalized after infection of primary endometriotic cell cultures with simian virus 40. Transformed cells express T-antigen, and blot hybridization analysis showed that the viral genome is present as an episome. Cytogenetic analysis revealed a polyploid karyotype with numerical and structural rearrangements involving mainly the same chromosomes (6, 10, 11, 15, and 17). The cell line has been maintained in culture for over 80 passages and was still proliferating without any noticeable change in the biological properties investigated. Transformed endometriotic cells expressed both progesterone and estradiol receptors and were stimulated by these ovarian hormones to secrete monocyte chemotactic protein-1, a factor that may play an important role in the recruitment and activation of peritoneal macrophages. In addition, this response was enhanced in interleukin-1-treated cells. Taken together, these findings support the view that this cell line may be an interesting tool for the study of the pathophysiology of endometriosis.

Tumor necrosis factor mutants with selective cytotoxic activity

Tumor necrosis factor (TNF-alpha) has a cytotoxic or cytostatic effect when tested with various malignant cell lines. Clinical trials in cancer patients, however, revealed high systemic toxicity of TNF-alpha. The existence of two types of receptor may partially explain the pleiotropic activity of TNF-alpha. The purpose of this study was to characterize the relative cytotoxic activity of TNF-alpha and TNF mutants on the mouse fibrosarcoma L929 cells in a standard cytotoxicity test, on human larynx carcinoma HEp-2 cells, and on human monoblastoid leukemic cells U937. TNF mutants were obtained by site-directed mutagenesis. The purity of TNF-alpha was established by capillary electrophoresis. TNF-alpha and TNF mutants were analysed by Western blot analysis using monoclonal antibodies against TNF-alpha. The results show that TNF mutants can recognize the different TNF-receptors (TNF-R) selectivity. It is generally believed that activation of TNF-R75 is responsible for the systemic toxicity of TNF-alpha. Hence, the development of TNF mutants, binding selectively to TNF-R55, could lead to new option for an anticancer treatment that would be devoid of the deleterious effect of TNF-alpha.

Patterns of visits to hospital-based emergency rooms

What are the functions of hospital emergency care in our society? How are these functions associated with the characteristics of emergency room users, their environment and with other available medical resources? To answer these questions, an ecological conceptual framework has been developed, along with a procedure which clearly distinguishes between the sources of individual variation (user characteristics) and ecological variation (the users' environment and available medical resources). Four different functions have been identified: (1) care of critical or urgent cases requiring treatment only available in a hospital, (2) care of urgent cases requiring treatment also available elsewhere than in a hospital, (3) care of non-urgent cases requiring treatment only available in a hospital and (4) care of non-urgent cases requiring treatment also available elsewhere than in a hospital. The ecological units selected for this study do not differ statistically with regard to the frequency with which emergency rooms are used for these four functions. However, certain individual factors predicting frequency of utilization do differ depending on the unit; for example, patient health status is not uniformly related to the use of emergency rooms for non-urgent reasons in all units. This association is particularly weak in socio-economically deprived units and more significant at higher socio-economic levels.

Increased expression of monocyte chemotactic protein-1 in the endometrium of women with endometriosis

The pathogenesis of endometriosis, a disease widely believed to arise from an aberrant growth of endometrial tissue outside the uterus, is still unclear. We have previously observed that cytokine-stimulated endometrial cells of women with endometriosis secrete in vitro increased amounts of monocyte chemotactic protein-1 (MCP-1). This factor may be important in the recruitment and activation of peritoneal macrophages observed in endometriosis patients. The present study reports that, in the presence of the disease, such an up-regulation of MCP-1 expression arises in vivo and can be encountered in situ in the intrauterine endometrium. In women with endometriosis, MCP-1 expression was elevated in endometrial glands, both at the level of the protein (immunohistochemistry) and the mRNA (in situ hybridization). This was observed throughout the menstrual cycle and varied according to the stage of the disease. These findings strongly argue in favor of the presence of pathophysiological changes in the eutopic endometrium of patients with endometriosis and make plausible MCP-1 as a key effector cell mediator involved in the pathogenesis of the disease.

Immunoblot detection of decreased antibodies to haptoglobin-like protein in the serum of infertile women with or without endometriosis

The purpose of this study was to find out differences in the levels of antibodies to distinct antigens in the serum of fertile versus infertile patients with and without endometriosis and to identify these antigens. Blood was collected from 61 patients undergoing laparoscopy for pelvic pain, infertility, or tubal ligation. Serum antibodies against serum antigens with apparent molecular masses of 22 kDa and 18 kDa were assessed by immunoblot analysis. Gel filtration, HPLC DEAE ion-exchange chromatography, NH2-terminal sequencing, and double immunodiffusion were used to characterize and identify these proteins. The relative amount of antibodies reacting with 22- and 18-kDa proteins detected in a standard preparation of antigens was significantly lower in the serum of infertile patients with endometriosis (0.20 +/- 0.05 and 0.57 +/- 0.10) and without endometriosis (0.21 +/- 0.06 and 0.53 +/- 0.08) compared to that of control fertile women without endometriosis (0.53 +/- 0.08 and 1.09 +/- 0.13). After purification by chromatography, the NH2-terminal amino acid sequence of the proteins in the 22- and 18-kDa range was identical through 20 amino acids with the alpha chain of the human haptoglobin. Double immunodiffusion implied immunochemical identity between commercial human haptoglobin and the purified proteins. We conclude that infertile patients with and without endometriosis show reduced serum levels of antibodies against a haptoglobin-like protein. These results would indicate an alteration of the immune system or changes in the levels of these antigens in infertility and/or endometriosis.

Association of protease activity against IGFBP-3 with peritoneal fluid mitogens: possible implications for the ectopic growth of endometrial cells in women with endometriosis

BACKGROUND

Recent data indicate the implication of an IGF/IGFBP/protease system in the development of ectopic implants of endometrium (endometriosis) in the pelvic cavity.

MATERIAL AND METHODS

We characterized mitogens and protease(s) against IGFBP-3 in the peritoneal fluid of women with or without endometriosis using preparative isoelectric focusing (IEC) Proteineous fractions were tested for a) mitogenic activity on NIH/3T3 cells and KLE endometrial-like cells, b) proteinolytic activity against radiolabeled IGFBP-3, and c) protein analysis using SDS-PAGE.

RESULTS

A significant increase in the DNA content of cultured cell lines was found in PF fractions having slightly acidic or alkaline pH and containing mainly proteins with molecular weights between 50 and 25 kD. These fractions were also found to cleave IGFBP-3 into 25, 18 and 14 kD fragments. Both activities were present in the PF of subjects with or without endometriosis.

CONCLUSION

The preparative isoelectric focusing system would be an advantageous approach to investigate the possible implication of the PF proteases with IGFBP-3 limited proteolysis generating PF mitogen(s) which possibly participate in the pathophysiology of endometriosis.

Increased monocyte chemotactic protein-1 level and activity in the peripheral blood of women with endometriosis. Le Groupe d'Investigation en Gynécologie

OBJECTIVE

Our purpose was to evaluate monocyte chemotactic protein-1 in the peripheral blood of women with and without endometriosis.

STUDY DESIGN

Fifty-seven patients with endometriosis at laparoscopy done for infertility and pelvic pain were compared with 44 fertile women with no evidence of endometriosis at tubal ligation by laparoscopy. Monocyte chemotactic protein-1 concentration in the plasma was determined by enzyme-linked immunosorbent assay and its biologic activity was evaluated by measuring monocyte chemotaxis with use of a human histiocytic cell line (U937).

RESULTS

Monocyte chemotactic protein-1 concentrations (median and range of values) found in the plasma were higher in patients with endometriosis (163, 0 to 788 pg/ml) than in normal controls (0, 0 to 355 pg/ml). This elevation was significant only in the minimal stage of endometriosis (revised American Fertility Society stage I). However, increased chemotactic activity (mean number of migrating cells/mm2 +/- SEM) was found in the stages I (1240 +/- 141), II (519 +/- 30), and III-IV (523 +/- 23) of the disease compared with normal controls (205 +/- 20). A total of 35% to 44% of this activity was inhibited in the presence of an antibody specific to monocyte chemotactic protein-1.

CONCLUSION

Endometriosis is associated with increased level and activity of monocyte chemotactic protein-1 in the peripheral blood. The elevation and activation of this cytokine could play a relevant role in the immunoinflammatory process associated with the disease.

Secretion of interleukin-6 by human endometriotic cells and regulation by proinflammatory cytokines and sex steroids

Endometriosis is generally associated with an immunoinflammatory process that takes place in the peritoneal cavity of patients. Interleukin (IL)-6, a multifunctional cytokine involved in numerous immunological and proliferative processes, has been found at high concentrations in the peritoneal fluid of endometriosis patients. The purpose of this study was to investigate the ability of endometriotic cells to produce IL-y and to assess the regulation of its secretion by proinflammatory cytokines and sex steroids. Cultures of human endometriotic cells were exposed to different concentrations of cytokines and sex steroid hormones for varying periods of time. IL-6 secretion was measured using an enzyme-linked immunosorbent assay. Endometriotic cells spontaneously released IL-6 in culture. IL-1 beta and tumour necrosis factor (TNF)-alpha (0.1-100.0 ng/ ml) potentiated IL-y secretion in a time- and dose-dependent manner. Interferon-gamma (0.4-400 ng/ml) induced a dose-related increase in IL-6 secretion and showed a synergistic effect on that secretion in combination with TNF-alpha (10 ng/ ml). Either spontaneous or cytokine-induced IL-6 secretion was inhibited by progesterone (10(-8)-10(-5) M) and danazol (10(-6) M), whereas oestradiol (10(-8)-10(-5) M) had a limited inhibitory effect. The antiprogestin RU486 (10(-8)-10(-4) M) antagonized the inhibitory effects of progesterone and danazol, but showed agonist action when used alone. These findings indicate that endometriotic tissue may actively contribute to the biological changes observed in the peritoneal fluid of endometriosis patients. They also provide new insights into the mechanisms of action of progesterone and those of danazol and RU486 used in the treatment of endometriosis.

Human endometrial cells cultured in a type I collagen gel

OBJECTIVE

To elaborate in vitro conditions that enable epithelial and stromal cells of human endometrium to grow within a gel of collagen.

STUDY DESIGN

Primary cultures of epithelial cells derived from human endometrial biopsies were dissociated and mixed with a collagen solution, and the gel was allowed to form at physiologic pH. Control cultures were grown in plastic dishes. DNA replication was assessed by 3H-thymidine incorporation, morphology by histology and cell characterization by monoclonal antibodies to cytokeratins.

RESULTS

Cells grown on plastic dishes exhibited a typical monolayer arrangement, and replication was increased 1.6-fold by the addition of stromal cell-conditioned medium (50% vol/vol). After a two- to three-week period of culture within the collagen gel in the presence of either stromal cells or stromal cell-conditioned medium, epithelial cells formed circular arrangements of cuboidal to columnar cells with open lumina resembling glands. These glandlike structures were cytokeratin positive as assessed by immunohistochemistry, thereby confirming their epithelial nature.

CONCLUSION

The development of differentiated epithelial structures in a three-dimensional gel provides a promising method of studying various biochemical and cellular interactions of eutopic and ectopic endometrium.

Elevated concentration and biologic activity of monocyte chemotactic protein-1 in the peritoneal fluid of patients with endometriosis

OBJECTIVE

To estimate the concentration and the biologic activity of monocyte chemotactic protein-1 (MCP-1) in the peritoneal fluid (PF) of women with and without endometriosis.

DESIGN

A case control study was conducted.

SETTING

Gynecology clinic and Laboratories of endocrinology of reproduction and immunology.

PATIENTS

Women presenting for infertility, pelvic pain, or tubal ligation in which endometriosis was diagnosed at laparoscopy (n = 36) and normal fertile controls presenting for tubal ligation (n = 21).

INTERVENTIONS

Collection of PF via laparoscopy.

MAIN OUTCOME MEASURES

Determination of PF concentrations of MCP-1 by an ELISA and evaluation of its monocyte chemotactic activity using a human hystiocytic cell line (U937). RESULTS. The concentration of MCP-1 (median, range of values) was increased in the PF of endometriosis patients (283, 0 to 1,930 pg/mL; conversion factor to SI unit, 0.155) compared with the control group (140, 0 to 435 pg/mL). The most significant elevation of MCP-1 levels was found in the stage II of the disease (371, 200 to 1,930 pg/mL). An increased chemotactic activity for monocytes (mean number of migrating cells/mm2 +/- SD) also was found in stages I (1,460 +/- 312) and II (1,541 +/- 336) of the disease when compared with fertile controls (393 +/- 56). Forty percent to 53% of this activity was inhibited in the presence of an antibody specific to MCP-1.

CONCLUSIONS

These observations are consistent with previous data indicating increased leukocyte chemotaxis in the PF of patients with endometriosis and suggest that MCP-1 may play a relevant role in the peritoneal inflammatory reaction associated with the disease.

Decreased amounts of antibodies to 22 and 18 kDa antigens in the peritoneal fluid of patients with endometriosis. LE Group d'Investigation en Gynecologie

Accumulated evidence implicates immunological alterations in endometriosis. The purpose of this study was to look for variations in antibodies to distinct antigens in peritoneal fluid of women with and without endometriosis. Peritoneal fluid was aspirated from 17 women undergoing laparoscopy for tubal ligation and 37 patients complaining of symptoms of pain and /or infertility. Peritoneal fluid antibodies to a standard preparation of peritoneal fluid antigens were detected by Western blot analysis using peroxidase-labelled anti-human immunoglobulin G antibodies specific to the Fc region. Antibodies to distinct antigens were quantified by estimating the ratio of the relative optical density between samples and a standard amount of antibodies. Marked changes were found in the antibody detection to two antigens having apparent molecular weights of 22 and 18 kDa. The intensity of the antibody signal was significantly weaker in the peritoneal fluid from endometriosis patients (0.36 +/- 0.06 and 0.46 +/- 0.06) compared with that in women without endometriosis (0.62 +/- 0.08 and 0.75 +/- 0.06). It was also weaker in patients without endometriosis presenting with infertility (0.36 +/- 0.07 and 0.47 +/- 0.08), but only the 18 kDa antigen result was significant. After adjusting for infertility, the P values for the 18 and 22 kDa bands were 0.03 and 0.28 (not significant) respectively in the group of endometriosis patients. These changes were not related to the phase of the menstrual cycle. These data suggest an alteration in the immune response to two distinct antigens in the peritoneal fluid from women with endometriosis and infertility. Further evaluation of these two antigens and their antibodies would be of interest to help understand endometriosis and its associated infertility.

Clinical efficacy and safety of low-dose flutamide alone and combined with an oral contraceptive for the treatment of idiopathic hirsutism

BACKGROUND AND OBJECTIVE

High doses of flutamide, which is the only antiandrogen that specifically blocks the androgen receptor, have recently been used with good clinical results in women with hirsutism. Since regression of hair growth requires long-term therapy, clinical and economic considerations are important. The use of the lowest efficacious dosage could reduce costs. This study was undertaken to compare safety and efficacy of a low dose of flutamide (125 mg twice daily) alone and in combination with a triphasic oral contraceptive (OC) in women with idiopathic hirsutism.

PATIENTS

Flutamide was administered orally in a low dose of 125 mg twice daily for 12 months alone in women with no risk of pregnancy or during the use of an oral contraceptive.

MEASUREMENTS

Women were seen every 3 months and were evaluated for hirsutism score, hormone and lipid measurements.

DESIGN

The study, which was conducted as a prospective open trial, was proposed to patients with idiopathic hirsutism, that is, with serum androgen levels in normal range and LH/FSH ratio less than 2.

RESULTS

A statistically significant decrease in hirsutism score as compared to baseline was observed after only 3 months with either treatment, flutamide alone (16.9 +/- 1.6 vs 14.2 +/- 1.7, P < 0.0001) or the combination of flutamide with OC (15.6 +/- 0.8 vs 11.9 +/- 0.8, P < 0.001). Three months after cessation of treatment a statistically significant decrease from baseline was observed in the two groups. Nevertheless, at 6 months post-treatment this decrease was still significant only in the group who took flutamide in combination with an oral contraceptive. Flutamide alone does not appear to modify the levels of lipoproteins. The association of flutamide with a triphasic formulation significantly increased the HDL-C levels.

CONCLUSIONS

This study shows beneficial effects of a low dose of flutamide in women with idiopathic hirsutism. The addition of an oral contraceptive is judicious to prevent pregnancy and reduce recurrence of hirsutism after cessation of flutamide. Peripheral androgenic blockage does not modify lipid profiles and it might reduce the negative effect of oral contraceptive on HDL-C levels. The addition of electrolysis delays the recurrence of hirsutism after cessation of flutamide.

Phasic serum lipid excursions occur during cyclical oral conjugated oestrogens but not during transdermal oestradiol sequentially combined with oral medroxyprogesterone acetate

BACKGROUND AND OBJECTIVE

Recent data indicate that oral medroxyprogesterone acetate (MPA) has limited unfavourable, neutral or even favourable effects on serum lipid fractions when added to oestrogen replacement therapy. The purpose of this study was to evaluate the serum lipid fractions at the beginning and at the end of each phase of a sequentially combined replacement cycle comparing the oral and the transdermal routes of oestrogen administration.

DESIGN

Randomized study with a matched control group. Oral conjugated oestrogens (OCE, 0.625 mg) or transdermal oestradiol (TE 50 micrograms) was taken from day 1 to day 25 and MPA (5 mg) added on days 14 to 25. Serum lipids were evaluated on days 1, 14 and 25 of monthly replacement cycles.

PATIENTS

The early post-menopausal women in the control group (n = 11) and in the treatment groups (OCE/MPA, n = 15; TE/MPA, n = 17) were evaluated every 3 months for 12 months and every 6 months for another 12 months.

MEASUREMENTS

Serum levels of triglycerides (TG), cholesterol (C) fractions and apolipoproteins (Apo) and their respective ratios were measured at months 1, 3, 6, 9, 12, 18, 24. Menopausal symptoms and uterine bleedings were evaluated in parallel and an endometrial biopsy was performed at the end of the 12th and 24th months of treatment.

RESULTS

After 14 days of OCE, C, LDL-C, and Apo B were decreased and TG, HDL-C and Apo A1 were increased. The sequential addition of MPA accentuated the reduction of LDL-C and Apo B but attenuated the elevation of TG, HDL-C and Apo A1. These changes tended to revert toward baseline during the period free of medication. By contrast, at the end of 14 days of TE there was a non-significant reduction in TG and LDL components and a limited increase in HDL-C and Apo A1. During the subsequent addition of MPA there was no significant decrease in TG, LDL-C or Apo B but an elimination of the increase in HDL components. These combined changes resulted in a significant reduction in the LDL-C/HDL-C ratio and a significant elevation in the Apo A1/Apo B ratio only in the OCE/MPA group.

CONCLUSION

Overall, oral conjugated oestrogens induced favourable intragroup changes in cholesterol fractions whereas transdermal oestradiol maintained serum lipids at levels not different from baseline. The sequential addition of oral medroxyprogesterone acetate attenuated the beneficial elevation of HDL, did not affect the beneficial effect of oestrogens on ratios of cholesterol fractions and attenuated the unfavourable effect of oral conjugated oestrogens on triglycerides. The partial loss of beneficial effects on lipoproteins during cyclical interruption of hormone therapy would be an argument in favour of the evaluation of continuous regimens of oestrogen/progestagen replacement.

Secretion of monocyte chemotactic protein-1 by cytokine-stimulated endometrial cells of women with endometriosis. Le groupe d'investigation en gynécologie

OBJECTIVE

To evaluate in vitro the production of monocyte chemotactic protein-1 (MCP-1) by endometrial cells of patients with and without endometriosis.

DESIGN

Primary cultures of stromal and epithelial cells isolated from human endometrium were exposed during 24 hours to different cytokines. Monocyte chemotactic protein-1 secretion was analyzed in the culture medium.

SETTING

Gynecology clinic and laboratories of endocrinology of reproduction and immunology.

PATIENTS

Women presenting for infertility or pelvic pain in which endometriosis was diagnosed at laparoscopy (n = 6) and women presenting for tubal ligation without laparoscopic evidence of the disease (n = 6).

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

De novo secretion of MCP-1 in the culture supernatant by immunoprecipitation and sodium dodecyl sulfate-polyacrylamide gel electrophoresis after metabolic labeling with 35S-cysteine.

RESULTS

The incubation of endometrial epithelial cells of endometriosis women with either interleukin-1 beta or tumor necrosis factor-alpha resulted in the appearance of at least two and sometimes three bands having approximately 15, 13, and 9 kd molecular weights. These bands were identified as three distinct species of MCP-1 as their immunoprecipitation was prevented effectively in presence of an excess of cold MCP-1. In contrast, the endometrial epithelial cells of only one of six normal women produce significant levels of MCP-1 under the same stimulation conditions. The stromal cells of both groups of subjects do not secrete appreciable amounts of MCP-1 or only small quantities in two cases of endometriosis.

CONCLUSIONS

Monocyte chemotactic protein-1 secretion is upregulated in cytokine-stimulated endometrial epithelial cells of women having endometriosis as compared with normal women without evidence of the disease. Such a difference at the level of eutopic endometrial cell may have a significance in the physiopathology of endometriosis.

Cytokine-induced secretion of monocyte chemotactic protein-1 by human endometriotic cells in culture. The Groupe d'Investigation en Gynécologie

OBJECTIVE

Local secretion of chemotactic factors could contribute to the attraction of macrophages into the peritoneal cavity of women with endometriosis. The purpose of this study was to investigate the ability of endometriotic cells to produce monocyte chemotactic and activating protein-1 in response to interleukin-1 beta and tumor necrosis factor-alpha, which are found in elevated levels in the peritoneal fluid of patients with endometriosis.

STUDY DESIGN

Cultures of fibroblast-like and epithelial cells isolated from endometriotic tissue were incubated with different concentrations of cytokines for varying periods of time. The de novo secretion of monocyte chemotactic protein-1 in the culture supernatants was analyzed by immunoprecipitation and electrophoresis after metabolic labeling with sulfur 35-labeled cysteine.

RESULTS

The incubation of endometriotic fibroblast-like cells with interleukin-1 beta and tumor necrosis factor-alpha resulted in a time- and dose-dependent release of monocyte chemotactic protein-1 into the culture supernatant. Coincubation of the cells with tumor necrosis factor-alpha and interferon gamma resulted in a synergistic and dose-dependent increase of the monocyte chemotactic protein-1 secretion, whereas interferon gamma alone had no significant effect. Preliminary results indicate that monocyte chemotactic protein-1 is also produced by endometriotic epithelial cells in response to the same cytokines.

CONCLUSIONS

Cytokine-stimulated endometriotic cells synthesize and secrete monocyte chemotactic protein-1 in culture, and they may play a relevant role in the recruitment of macrophages to the peritoneal cavity of patients by the local production of chemotactic factors.

N-terminal truncated forms of insulin-like growth factor binding protein-3 in the peritoneal fluid of women without laparoscopic evidence of endometriosis. Le groupe d'investigation en gynécologie

OBJECTIVE

To characterize and purify peritoneal mitogens able to stimulate the proliferation of human endometrial cells in vitro.

DESIGN

Peritoneal fluids (PFs) from 50 patients were collected at laparoscopy and pooled (270 mL) for purification of mitogenic activity.

SETTING

University infertility clinic and endocrinology of reproduction and molecular endocrinology laboratories.

PATIENTS

Fifty subjects presenting for tubal ligation, pelvic pain, mass, or infertility but otherwise having no evidence of endometriosis inflammation, infection, or tumor.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Assessment of mitogenic activity by 3H-thymidine incorporation into mouse embryo fibroblasts and into primary cultures of isolated epithelial and stromal cells of human endometrium.

RESULTS

The PF mitogens were purified successively on carboxymethyl-sepharose and heparin-sepharose columns followed by fractionation on cartridges of C18 silica and reverse-phase high-performance liquid chromatography (HPLC). Four distinct bands were eluted from Sep-Pak, (Mississauga, Ontario, Canada) with molecular weights of 17 to 18, 20, 25, and 29 to 30 kd. The eluted fractions of Sep-Pak exerted preferential mitogenic activity on epithelial-derived human endometrial cells at an equimolar ratio with epidermal growth factor. Microsequencing of the 17 to 18, 20, 25, and 29 to 30 kd bands showed a homologous sequence with N-terminal amino acid sequences of insulin-like growth factor binding protein-3 (IGFBP-3).

CONCLUSION

These data indicate that the PF of normal women without evidence of endometriosis contains N-terminal truncated forms of IGFBP-3 that mediate an apparent preferential mitogenic action on epithelial-derived endometrial cells. Therefore, they could play a role in the ectopic growth of endometrial cells.

Sequential estrogen-progestin addition to gonadotropin-releasing hormone agonist suppression for the chronic treatment of ovarian hyperandrogenism: a pilot study

The purpose of the study was to evaluate the efficacy and safety of a sequential regimen of estrogen-progestin addition to GnRH agonist suppression in ovarian hyperandrogenism. Eight patients presenting with a polycystic ovary syndrome were treated with an sc implant of GnRH agonist every 4 weeks for 48 weeks. Starting at week 9, patients were replaced with 100 micrograms transdermal estradiol patches continuously and sequentially combined with 10 mg oral medroxyprogesterone acetate the last 2 weeks of each 4-week period. The rapid down-regulation of the pituitary-ovarian axis led to significant reduction of testosterone and androstenedione to 48.9% and 67.4% of baseline, respectively. During steroid replacement, testosterone and androstenedione continued to decrease gradually. The baseline hirsutism score (18.7 +/- 1.3) progressively fell to 9.7 +/- 2.0 at the end of treatment. The mean hair diameter was significantly reduced (0.097 +/- 0.004 vs. 0.081 +/- 0.005 mm). A withdrawal bleeding was obtained in 63.6% of the artificial cycles, but breakthrough bleeding occurred during 48% of the sequential replacements. The incidence of menopausal symptoms was low. There was a nonsignificant decrease in bone mineral content of the lumbar spine and the femoral neck but no trend in Ca2+/creatinine and OH-proline (OH-P)/creatinine ratios or in serum triglycerides and cholesterol fractions. There was a nonsignificant increase in hirsutism score in five patients followed up for 24 weeks after cessation of treatment, although there was a rapid return of hormones toward baseline and recurrence of irregular bleeding. Transdermal estradiol addition periodically combined with medroxyprogesterone acetate is effective in reducing hirsutism and is safe in minimizing side effects and bone loss. A regimen allowing a better bleeding control would make this approach a valuable alternative for prolonged or repeated palliative treatment of excessive hair growth and irregular bleeding in polycystic ovary syndrome.

A randomized, double-blind, placebo-controlled study on the effect of conjugated estrogens on skin thickness

OBJECTIVE

Our purpose was to assess the potential benefit of therapy with conjugated estrogens therapy on skin thickness in postmenopausal women.

STUDY DESIGN

Sixty postmenopausal women were randomly allocated to receive conjugated estrogens or placebo treatment for 12 months. Neither participants nor investigators were aware of the group allocation. Skin thickness was measured by ultrasonography at baseline and after 6 to 12 months of treatment. Histologic changes were evaluated by skin biopsy at baseline and after 12 months' treatment. Quality of life and adverse events were recorded at each visit and at the end of treatment.

RESULTS

Treatment with conjugated estrogens for 12 months significantly increases, at the level of the right great trochanter, the thickness of the skin (p < 0.01), as assessed by ultrasonography, and of the dermis (p < 0.05), as assessed by skin biopsy. No statistically significant difference was observed in the control population. Quality of life was reported to be improved (p < 0.05) in women treated with estrogen compared with those in the placebo group.

CONCLUSION

The results may help postmenopausal women to better appraise the benefits of estrogen replacement therapy, and they provide further evidence of the potential of conjugated estrogens in preventing skin aging.

Extending the use of gonadotropin-releasing hormone agonists: the emerging role of steroidal and nonsteroidal agents

OBJECTIVE

To review and summarize the state of the art as it relates to the long-term application of GnRH agonists (GnRH-a).

DESIGN

A retrospective analysis of the available literature and results and an up-to-date review of a rapidly evolving field.

CONCLUSION

Although the precise use of long-term GnRH-a therapy (in conjunction with sex steroid add-back therapy) remains unknown, the information provided strongly supports additional studies in this area to achieve a body of promising preliminary data.

Serum FSH bioactivity and response to acute gonadotrophin releasing hormone (GnRH) agonist stimulation in patients with polycystic ovary syndrome (PCOS) as compared to control groups

OBJECTIVE

We evaluated the biological activity of FSH in the serum of women with polycystic ovary syndrome before and after acute administration of a GnRH agonist as compared to control groups.

DESIGN

FSH, oestradiol and androstenedione response to buserelin (100 micrograms s.c.) comparing seven polycystic ovary patients, six idiopathic hirsute women, 11 normal women in the follicular phase and nine normal men.

MEASUREMENTS

Rat granulosa cell aromatase bioassay in the presence or absence of polyethyleneglycol (PEG) pretreated 2% serum. Serum biological FSH (B-FSH), immunological FSH (I-FSH) and B/I ratio at times 0, 1, 2, 3, 4, 8, 12 and 24 hours. Serum androstenedione and oestradiol at times 0 and 24 hours.

RESULTS

Human gonadotrophin-free (oral contraceptive user and after FSH immunoabsorption) and PEG-pretreated serum increases the aromatase activity in response to increasing doses of purified FSH. The maximum enzymatic activity is however higher with 2% serum than with 4% serum. The amplitude of the B-FSH response to the GnRH agonist is markedly decreased in the polycystic group as compared to the group of normal women. There is also a small decrease in the I-FSH response in the polycystic women. When compared to that of normal women, the area under the curve in the polycystic ovary patients is reduced by 71% for B-FSH (P < 0.01) and by 23% for I-FSH (P < 0.05). The B-FSH and I-FSH responses in men are very small. After an initial decrease the B/I ratio returns to baseline level in normal women but remains low in the other groups. At time 24 hours, there is no significant change in the serum concentration of androstenedione but serum oestradiol, the baseline of which is significantly higher in the polycystic patients than in normal women, is also significantly higher at 24 hours (P < 0.05) in response to the pharmacological release of FSH.

CONCLUSION

The gonadotrophin-free and PEG-pretreated human serum has an inherent stimulatory effect on the rat granulosa aromatase bioassay with a higher activity at 2% serum. Acute GnRH agonist stimulation reveals a deficiency in the FSH response in polycystic ovary patients. The greater deficit in B-FSH than in I-FSH would indicate a possible modification in the FSH isoforms in this syndrome. The meaning of this observation for the understanding of the physiopathology of the polycystic ovary syndrome remains to be evaluated.

Heparin-sepharose binding growth factors in peritoneal fluid of women with endometriosis

OBJECTIVE

To characterize and to purify the growth substances for mouse embryo fibroblasts (NIH/3T3) and endometrial-like cells of the peritoneal fluid of women with endometriosis.

DESIGN

A pool of 102 mL of peritoneal fluid (PF) collected from 24 women with laparoscopic evidence of endometriosis was dialyzed and thereafter chromatographed onto carboxymethyl (CM)-sepharose, heparin-sepharose, cartridges of C18 silica, and reverse-phase high-performance liquid chromatography (reverse-phase HPLC). Mitogenic activity throughout various steps of chromatography was monitored by the increase of the (3H)-thymidine incorporation into NIH/3T3 fibroblasts and enzymatically isolated epithelial cells of rabbit endometrium.

RESULTS

Peritoneal fluid of women with endometriosis contained mitogen(s) for NIH/3T3 fibroblasts that were retained on and eluted from CM-sepharose, heparin-sepharose, cartridges of C18 silica, and reverse-phase HPLC columns performed sequentially. Mitogenic material purified 2,500-fold exerted bioactivity on NIH/3T3 and the enzymatically isolated epithelial cells from rabbit endometrium.

CONCLUSION

Peritoneal fluid of women with endometriosis contains heparin-binding growth factors that can be purified by sequential chromatography on CM-sepharose, heparin-sepharose, and reverse-phase HPLC columns. The presence in the PF of potent mitogens for fibroblasts and endometrium-derived epithelial cells could play an important role in the pathogenesis of endometriosis.

Correlation between ovarian steroids and lipid fractions in relation to age in premenopausal women

OBJECTIVE

We evaluated the effect of sex steroids on the lipid fractions (cholesterol, triglycerides, LDL-C, HLD-C and subfractions HDL2-C and HDL3-C) and on the apolipoproteins (A-1 and B) in relation to age in women.

DESIGN

Twenty-eight normally cycling women belonging to three age groups (20-29, n = 11; 30-39, n = 10; 40-49, n = 7) had blood samples taken daily during one cycle.

MEASUREMENTS

Serum lipid fractions, apolipoproteins (Apo) and ovarian steroids were measured daily during the menstrual cycle. Diet and exercise were also evaluated.

RESULTS

Each age group had comparable profiles for daily serum concentrations of oestradiol, progesterone and testosterone. There were no significant variations of the lipid fractions or of the ApoA-I and ApoB during the menstrual cycle in each group. Using regression analysis, modifications of cholesterol, triglycerides, LDL-C and ApoB were partially but significantly correlated with age. These changes occurred in spite of similar serum concentrations of oestradiol, progesterone and testosterone in the three groups. Lipid fractions were also affected by the increase of body mass index with age, especially HDL-C and HDL2C. However, there were no differences in lipid and energy intake or in energy expenditure during physical leisure activities.

CONCLUSIONS

These results indicate that physiological fluctuations of ovarian steroids have no effects on lipids and Apo in normally cycling women of increasing age. In this study, the age related changes in the lipid fractions were partially correlated with body mass index but not with energy intake or exercise.

Effect of finasteride, a 5 alpha-reductase inhibitor, on serum gonadotropins in normal men

Testosterone exerts negative feedback control on gonadotropin secretion either directly, after aromatization to estradiol, or after 5 alpha-reduction to dihydrotestosterone (DHT). Conflicting data exist as to the role of DHT in the modulation of this negative feedback. To determine whether suppression of endogenous DHT alters gonadotropin secretion, we gave the selective 5 alpha-reductase inhibitor finasteride (5 mg daily), or placebo, to 20 healthy men for 28 days. Basal and GnRH-stimulated LH, bioactive LH, FSH, testosterone, and DHT levels were measured before and after 14 and 28 days of treatment. Basal DHT fell from 1.1 +/- 0.2 to 0.15 +/- 0.04 nmol/L after 28 days of finasteride treatment. A significant rise in baseline testosterone from 17.6 +/- 2.0 to 18.3 +/- 2.3 nmol/L was seen at 14 days (P = 0.046), but not at 28 days. No significant changes were seen in either basal or GnRH-stimulated gonadotropin levels on any day. We conclude that suppression of serum DHT levels with 5 mg finasteride daily in healthy young men has no discernible effect on serum gonadotropin levels.

Mitogen(s) for endometrial-like cells can be detected in human peritoneal fluid

OBJECTIVE

To characterize the presence of mitogen(s) in the peritoneal fluid (PF).

DESIGN

Aliquots of PF aspirated at laparoscopy were assessed for mitogenic activity by the rate of [3H]-thymidine incorporation into the deoxyribonucleic acid of various cell lines.

SETTING

Peritoneal fluids were obtained from patients having a laparoscopy for the investigation of infertility or pelvic pain or for tubal ligation.

PATIENTS

Seven women with laparoscopic evidence of endometriosis (stage I and II) and six without evidence of endometriosis.

INTERVENTION

None.

MAIN OUTCOME MEASURE

After 24 hours of culture in absence of serum, NIH/3T3 mouse embryo fibroblasts, (KLE) human endometrial adenocarcinoma cells, and primary cultures of rabbit endometrial cells were incubated in the presence of appropriate amounts of PF or bovine serum albumin (control) for 22 hours before adding the [3H]-thymidine for 2 hours.

RESULTS

Aliquots of PF containing greater than 100 micrograms/mL total protein concentration stimulated the proliferation of all cell types. This mitogenic effect was dose-dependent and was greatest on endometrial-like cells. The mitogenic activity was fully recovered after adsorption on dextran-coated charcoal and was sensitive to tryptic digestion and to heat. It could not be retained on cartridge of C18 silica and was calculated to have a molecular weight greater than 30,000 by gel permeation chromatography.

CONCLUSIONS

Peritoneal fluid from women with or without endometriosis contain growth factor(s) that are proteinaceous in nature and capable of stimulating the proliferation of endometrial-like cells and fibroblasts. These mitogens could play a role in the pathogenesis of endometriosis.

Cholesterol fractions and apolipoproteins during endometriosis treatment by a gonadotrophin releasing hormone (GnRH) agonist implant or by danazol

OBJECTIVE

The evaluation of cholesterol fractions and apoproteins during ovarian suppression by a GnRH agonist implant vs danazol in the treatment of endometriosis.

DESIGN

A randomized study in 33 patients comparing goserelin (3.6 mg/4 weeks s.c., n = 20) with danazol (2 x 400 mg/day p.o., n = 13) in patients with a laparoscopic diagnosis of endometriosis and treated for 6 months.

MEASUREMENTS

Triglycerides, cholesterol (C), LDL-C, HDL-C subfractions and apoproteins A-1 and B were measured at admission, at months 2, 4 and 6 of treatment and at month 2 post-treatment.

RESULTS

After 1 month of therapy, serum oestradiol levels were maintained in the menopausal range with goserelin and in the early follicular phase range with danazol. Goserelin induced a significant elevation in HDL-C (by 31.4%), in HDL2-C (24.6%) and in HDL3-C (45.7%) but no significant change in LDL-C or in ApoA-1 and ApoB. By contrast, danazol caused significant diminutions in HDL-C (23.9%), HDL2-C (56.6%) and ApoA-1 (35.6%). Moreover, danazol increased LDL-C (10.5%) and ApoB (29.0%, P less than 0.05). The lipoprotein changes during goserelin had a favourable effect on the atherogenic index (cholesterol/HDL-C) and ApoA-1/ApoB ratio whereas those of danazol had opposite effects. These changes reverted 2 months after danazol while HDL was still elevated after goserelin.

CONCLUSIONS

In relation to cholesterol, goserelin is a safe medication. The significance of temporary adverse changes in cholesterol fractions due to danazol is still unknown.