Reproductive and Endocrine Outcomes in a Cohort of Danish Women following Auto-Transplantation of Frozen/Thawed Ovarian Tissue from a Single Center

Ovarian tissue cryopreservation (OTC) is a method of fertility preservation in girls and young women prior to gonadotoxic treatment. It is a safe and promising method to restore fertility. The initial recovery of endocrine function is high, but the longevity of the grafted tissue varies. In this single-center, combined retro- and prospective cohort study, we report the reproductive outcome and hormonal recovery following ovarian tissue transplantation (OTT) and evaluate possible predictors of the chance of pregnancy. The study includes 40 women from eastern Denmark undergoing 53 OTTs between 2003 and 2021. Permission to obtain retrospective data was given by the Danish Patient Safety Authorities and prospective data-collection by informed consent. Initial recovery of endocrine function was seen in 18/19 women with POI, and ongoing function of the grafted tissue in 7/14 two years from OTT. Live birth rate (LBR) was 41%, with 20 children to 39 women trying to conceive. Women who conceived had higher AFC at the time of OTC than women who did not (p ± 0.04). Repeated transplantations were not successful in terms of delivery. Half of all pregnancies were achieved by ART, but PRs were lower after ART than by spontaneous conception. LBRs after OTT are encouraging. Chance of pregnancy after OTT is correlated to ovarian reserve at OTC. Repeated transplantations were not successful in terms of unfulfilled pregnancy wish.

DIAGNOSIS OF ENDOCRINE DISEASE: Sex steroid action in adolescence: too much, too little; too early, too late

This review aims to cover the subject of sex steroid action in adolescence. It will include situations with too little sex steroid action, as seen in for example, Turners syndrome and androgen insensitivity issues, too much sex steroid action as seen in adolescent PCOS, CAH and gynecomastia, too late sex steroid action as seen in constitutional delay of growth and puberty and too early sex steroid action as seen in precocious puberty. This review will cover the etiology, the signs and symptoms which the clinician should be attentive to, important differential diagnoses to know and be able to distinguish, long-term health and social consequences of these hormonal disorders and the course of action with regards to medical treatment in the pediatric endocrinological department and for the general practitioner. This review also covers situations with exogenous sex steroid application for therapeutic purposes in the adolescent and young adult. This includes gender-affirming therapy in the transgender child and hormone treatment of tall statured children. It gives some background information of the cause of treatment, the patient's motivation for medicating (or self-medicating), long-term consequences of exogenous sex steroid treatment and clinical outcome of this treatment.

Surgery, gonadotropin-releasing hormone agonist downregulation and in vitro fertilisation in women with infertility and endometriomas

INTRODUCTION

Tonsillectomy is one of the most common procedures in the field of ear, nose and throat procedures. In 2012, the annual incidence in Denmark was 129.4 per 100,000 inhabitants. A common complication is post-tonsillectomy haemorrhaging (PTH). The overall PTH rates vary widely among studies ranging from 0.5% to 33%.

METHODS

This was a nationwide open-population, retrospective and registry-based cohort study in Danes who underwent tonsillectomy complicated by PTH in hospitals and private otorhinolaryngology (ORL) offices in the period from 1991 to 2012.

RESULTS

In the 1991-2012 period, a total of 177,211 tonsillectomies were performed among which 9,221 had a registered PTH (rPTH) (5.2%). The annual incidence rate of rPTH increased from 3% in 1991 to 13% in 2012 (p less-than 0.05). Males aged 20-40 years had a significantly higher risk of rPTH with the highest increase in rPTH incidence rates from 9.0% in 1998 to 16.4% in 2012 (p less-than 0.05). Approx. 12% had a primary rPTH within the first 24 hours; the maximum incidence of rPTH was on day six (14%).

CONCLUSIONS

The rate of rPTH increased from 1991 to 2012 in hospitals and in private ORL office settings alike. There was a significantly higher rate of rPTH in the age group of 20-40 years and a significant geographical difference in rPTH. The highest risk of rPTH was observed on the day of surgery and on day six.

TRIAL REGISTRATION

The Danish Data Protection Agency (record number 2012-41-0158) approved this study.

FUNDING

The Olga Bryde Nielsen Foundation and H. Skouby & E. Skouby's Foundation supported this study financially.

AMH as Predictor of Premature Ovarian Insufficiency: A Longitudinal Study of 120 Turner Syndrome Patients

CONTEXT

The majority of Turner syndrome (TS) patients suffer from accelerated loss of primordial follicles. Low circulating levels of anti-Müllerian hormone (AMH) may predict the lack of spontaneous puberty in prepubertal girls and imminent premature ovarian insufficiency (POI) in TS women with preserved ovarian function.

OBJECTIVES

To evaluate the association between circulating AMH and ovarian status in TS patients.

DESIGN

Longitudinal observational cohort study.

SETTING

Tertiary referral center for pediatric and gynecologic endocrinology.

PARTICIPANTS

A total of 120 TS patients, aged 0 to 48 years.

MAIN OUTCOME MEASURES

Longitudinal measurements of AMH, FSH, LH, estradiol, and inhibin B according to age, karyotype (45,X; 45,X/46,XX mosaicism; miscellaneous karyotypes), and ovarian status (group 0, prepubertal; group 1, never ovarian function; group 2, ongoing ovarian function; and group 3, loss of ovarian function).

RESULTS

Ovarian status was highly associated with the TS karyotype: spontaneous puberty—45,X (three of 44 patients), 45,X/46,XX (15 of 17), miscellaneous (17 of 42); and POI—45,X (three of three), 45,X/46,XX (one of 15), and miscellaneous (eight of 17). AMH was associated with ovarian status (eg, group 1, <2 pmol/L; vs group 2, 19 pmol/L; P < .001). AMH < 4 pmol/L (corresponding to <-2 SD) predicted absent puberty in prepubertal girls and POI in adolescent and adult patients.

CONCLUSION

The majority of women with mosaic karyotype 45,X/46,XX had ongoing ovarian function in early adulthood. AMH < -2 SD predicted failure to enter puberty in young TS girls and imminent POI in adolescent and adult TS patients.

Menopause is associated with decreased whole body fat oxidation during exercise

The purpose of this study was to examine if fat oxidation was affected by menopausal status and to investigate if this could be related to the oxidative capacity of skeletal muscle. Forty-one healthy women were enrolled in this cross-sectional study [premenopausal (n = 19), perimenopausal (n = 8), and postmenopausal (n = 14)]. Estimated insulin sensitivity was obtained from an oral glucose tolerance test. Body composition was measured by dual-energy X-ray absorptiometry and magnetic resonance imaging. Fat oxidation and energy expenditure were measured during an acute exercise bout of 45 min of ergometer biking at 50% of maximal oxygen consumption (Vo2 max). Muscle biopsies from the vastus lateralis of the quadriceps muscle were obtained before and immediately after the exercise bout. Postmenopausal women had 33% [confidence interval (CI) 95%: 12-55] lower whole body fat oxidation (P = 0.005) and 19% (CI 95%: 9-22) lower energy expenditure (P = 0.02) during exercise, as well as 4.28 kg lower lean body mass (LBM) than premenopausal women. Correction for LBM reduced differences in fat oxidation to 23% (P = 0.05), whereas differences in energy expenditure disappeared (P = 0.22). No differences between groups were found in mRNA [carnitine palmitoyltransferase I, β-hydroxyacyl-CoA dehydrogenase (β-HAD), peroxisome proliferator-activated receptor-α, citrate synthase (CS), pyruvate dehydrogenase kinase 4, peroxisome proliferator-activated receptor-γ coactivator-1α (PGC-1α)], protein [phosphorylated AMP-activated protein kinase (AMPK), vascular endothelial growth factor, pyruvate dehydrogenase-1Eα, cytochrome oxidase I], or enzyme activities (β-HAD, CS) in resting skeletal muscle, except for an increased protein level of cytochrome c in the post- and perimenopausal women relative to premenopausal women. Postmenopausal women demonstrated a trend to a blunted exercise-induced increase in phosphorylation of AMPK compared with premenopausal women (P = 0.06). We conclude that reduced whole body fat oxidation after menopause is associated with reduced LBM.

Evaluation of HE4, CA125, risk of ovarian malignancy algorithm (ROMA) and risk of malignancy index (RMI) as diagnostic tools of epithelial ovarian cancer in patients with a pelvic mass

OBJECTIVE

Diagnostic factors are needed to improve the currently used serum CA125 and risk of malignancy index (RMI) in differentiating ovarian cancer (OC) from other pelvic masses, thereby achieving precise and fast referral to a tertiary center and correct selection for further diagnostics. The aim was to evaluate serum Human Epididymis protein 4 (HE4) and the risk of ovarian malignancy algorithm (ROMA) for these purposes.

METHODS

Serum from 1218 patients in the prospective ongoing pelvic mass study was collected prior to diagnosis. The HE4 and CA125 data were registered and evaluated separately and combined in ROMA and compared to RMI.

RESULTS

809 benign tumors, 79 borderline ovarian tumors, 252 OC (64 early and 188 late stage), 9 non-epithelial ovarian tumors and 69 non-ovarian cancers were evaluated. Differentiating between OC and benign disease the specificity was 62.2 (CA125), 63.2 (HE4), 76.5 (ROMA) and 81.5 (RMI) at a set sensitivity of 94.4 which corresponds to RMI=200. The areas under the curve (AUC) were 0.854 (CA125), 0.864 (HE4), 0,897 (ROMA) and 0.905 (RMI) for benign vs. early stage OC. For premenopausal benign vs. OC AUC were 0.925 (CA125), 0.905 (HE4), 0.909 (ROMA) and 0.945 (RMI).

CONCLUSION

HE4 and ROMA helps differentiating OC from other pelvic masses, even in early stage OC. ROMA performs equally well as the ultrasound depending RMI and might be valuable as a first line biomarker for selecting high risk patients for referral to a tertiary center and further diagnostics. Further improvements of HE4 and ROMA in differentiating pelvic masses are still needed, especially regarding premenopausal women.

Risk of malignancy index used as a diagnostic tool in a tertiary centre for patients with a pelvic mass

OBJECTIVE

Risk of malignancy index (RMI), based on a serum cancer antigen 125 level, ultrasound findings and menopausal status, is used to discriminate ovarian cancer from benign pelvic mass. In Denmark, patients with pelvic mass and RMI ≥200 are referred to tertiary gynecologic oncology centers according to the national guidelines for ovarian cancer treatment. The guidelines include recalculation of RMI at the tertiary center and, if indicated, positron emission tomography/computed tomography and fast-track surgery by specialists in cancer surgery. The aim of this study was to validate the use of RMI ≥200 as a tool for preoperative identification of ovarian cancer at a tertiary center.

DESIGN

Prospective observational study.

SETTING

A tertiary center in Copenhagen, Denmark.

POPULATION

One thousand one hundred and fifty-nine women with pelvic mass.

METHODS

The RMI was calculated after ultrasound examination and blood sampling for serum cancer antigen 125 analysis within two weeks before surgery.

MAIN OUTCOME MEASURES

Sensitivity, specificity, positive and negative predictive values were calculated to evaluate the ability of RMI to distinguish between ovarian cancer and benign pelvic mass.

RESULTS

There were 778 women diagnosed with benign pelvic mass, while 251 had ovarian cancer and 74 had borderline ovarian tumor. Fifty-six women were diagnosed with other forms of cancer. Sensitivity and specificity for ovarian cancer vs. benign pelvic mass for RMI ≥200 were 92 and 82%, respectively. Corresponding positive and negative predictive values were 62 and 97%.

CONCLUSIONS

Risk of malignancy index ≥200 is a reliable tool for identifying patients with ovarian cancer pelvic masses at a tertiary centre to select patients for further preoperative examinations.

Endocrine evaluation of reproductive function in girls during infancy, childhood and adolescence

Puberty is characterized by a series a hormonal events leading to the attainment of adult reproductive capacity. Clinical manifestations of the pubertal processes include breast development, pubic hair development, menarche and regular menstrual bleedings. Abnormal pubertal development includes a spectrum of disorders such as premature thelarche, premature adrenarche, central and peripheral precocious puberty, adolescent polycystic ovarian syndrome, functional ovarian hyperandrogenism, late-onset congenital adrenal hyperplasia, primary and secondary amenorrhea, and premature ovarian insufficiency. Diagnosis of these reproductive disorders includes biochemical as well as clinical evaluation. The biochemical evaluation of reproductive function includes measurement of basal reproductive hormone levels and dynamic pituitary or adrenal hormone testing. Correct interpretation of such test results requires detailed knowledge on the normal maturational changes in the hypothalamic-pituitary-ovarian and hypothalamic-pituitary-adrenal axes. Changes in basal reproductive hormone levels in infancy, childhood and adolescence as well as the GnRH and ACTH test procedures in girls and adolescents are described in this chapter.

Serum levels of anti-Müllerian hormone as a marker of ovarian function in 926 healthy females from birth to adulthood and in 172 Turner syndrome patients

CONTEXT

In adult women, anti-Müllerian hormone (AMH) is related to the ovarian follicle pool. Little is known about AMH in girls.

OBJECTIVE

The objective of the study was to provide a reference range for AMH in girls and adolescents and to evaluate AMH as a marker of ovarian function.

SETTING

The study was conducted at a tertiary referral center for pediatric endocrinology.

MAIN OUTCOME MEASURES

We measured AMH in 926 healthy females (longitudinal values during infancy) as well as in 172 Turner syndrome (TS) patients according to age, karyotype (A: 45,X; B: miscellaneous karyotypes; C: 45,X/46,XX), and ovarian function (1: absent puberty; 2: cessation of ovarian function; 3: ongoing ovarian function).

RESULTS

AMH was undetectable in 54% (38 of 71) of cord blood samples (<2; <2-15 pmol/liter) (median; 2.5th to 97.5th percentile) and increased in all (37 of 37) infants from birth to 3 months (15; 4.5-29.5 pmol/liter). From 8 to 25 yr, AMH levels were stable (19.9; 4.7-60.1 pmol/liter), with the lower level of the reference range clearly above the detection limit. AMH levels were associated with TS-karyotype groups (median A vs. B: <2 vs. 3 pmol/liter, P = 0.044; B vs. C: 3 vs. 16 pmol/liter, P < 0.001) as well as with ovarian function (absent puberty vs. cessation of ovarian function: <2 vs. 6 pmol/liter, P = 0.004; cessation of ovarian function vs. ongoing ovarian function: 6 vs. 14 pmol/liter, P = 0.001). As a screening test of premature ovarian failure in TS, the sensitivity and specificity of AMH less than 8 pmol/liter was 96 and 86%, respectively.

CONCLUSION

AMH seems to be a promising marker of ovarian function in healthy girls and TS patients.

Research Methodology and Epidemiology of Relevance in Recurrent Pregnancy Loss

With respect to recurrent pregnancy loss (RPL), unfortunately there is very little consensus about which investigations are useful for identifying causes and evaluating the prognosis, and also about which treatments are effective. In this review, arguments are given for the claim that this lack of consensus may mainly be because studies in the field of RPL have yielded very heterogeneous results. This heterogeneity, in the authors' belief, is caused by the scientists' lack of appreciation, when they do research, of important epidemiological knowledge about RPL (e.g., about the multifactorial background for most of the RPL cases and the importance of matching/adjusting for a series of prognostic variables when groups are mutually compared). Furthermore, many studies in RPL contain methodological flaws that are sometimes severe. A series of important epidemiological features of RPL is highlighted in the review and the most important methodological pitfalls, many of them specific for RPL research, are discussed. Advice is given about to how to avoid the pitfalls in order that the validity of the studies can improve for the benefit of the patients.

The association between early menopause and risk of ischaemic heart disease: Influence of Hormone Therapy

Randomised clinical trials find no protection against development of ischaemic heart disease by use of Hormone Therapy (HT) after the age of 50 years. Observational studies suggest that early menopause is a risk factor for ischaemic heart disease. Yet, a clinical very relevant question is whether HT reduces this risk associated with early menopause.

OBJECTIVE

To analyse whether early menopause based on various causes are independent risk factors for ischaemic heart disease, and to investigate whether the risks are modified by use of HT.

METHODS

In a prospective cohort study questionnaires were mailed to Danish female nurses above 44 years of age in 1993. Information on menopause, use of HT and lifestyle was obtained. In total 19,898 (86%) nurses fulfilled the questionnaire, among them 10.533 were postmenopausal with definable menopausal age, free of previous ischaemic heart disease, stroke or cancer. Through individual linkage to national register incident cases of ischaemic heart disease were identified until end of 1998.

RESULTS

Menopause below both age 40 and 45 was associated with an increased risk of ischaemic heart disease, seeming most pronounced for women who had an early ovariectomy but also among spontaneous menopausal women. Generally HT did not reduce the risk except for the early-ovariectomised women, where no increased risk of ischaemic heart disease for HT users was found.

CONCLUSION

We found an increased risk of ischaemic heart disease associated with early removal of the ovaries that might be reduced with HT. The present study need confirmation from other studies but suggests that early ovariectomised women could benefit from HT.

Breast cancer with different prognostic characteristics developing in Danish women using hormone replacement therapy

The aim of this study is to investigate the risk of developing prognostic different types of breast cancer in women using hormone replacement therapy (HRT). A total of 10 874 postmenopausal Danish Nurses were followed since 1993. Incident breast cancer cases and histopathological information were retrieved through the National Danish registries. The follow-up ended on 31 December 1999. Breast cancer developed in 244 women, of whom 172 were invasive ductal carcinomas. Compared to never users, current users of HRT had an increased risk of a hormone receptor-positive breast cancer, but a neutral risk of receptor-negative breast cancer, relative risk (RR) 3.29 (95% confidence interval (CI): 2.27–4.77) and RR 0.99 (95% CI: 0.42–2.36), respectively (P for difference=0.013). The risk of being diagnosed with low histological malignancy grade was higher than high malignancy grade with RR 4.13 (95% CI: 2.43–7.01) and RR 2.17 (95% CI: 1.42–3.30), respectively (P=0.063). For breast cancers with other prognostic characteristics, the risk was increased equally for the favourable and nonfavourable types. Current users of HRT experience a two- to four-fold increased risk of breast cancer with various prognostic characteristics, both the favourable and nonfavourable types. For receptor status, the risk with HRT was statistically significantly higher for hormone receptor-positive breast cancer compared to receptor-negative breast cancer.

Relation between hormone replacement therapy and ischaemic heart disease in women: prospective observational study

OBJECTIVE

To investigate the risk of ischaemic heart disease and myocardial infarction among women using hormone replacement therapy, especially the potential modifying effect of cardiovascular risk factors.

DESIGN

Prospective observational study.

SETTING

Denmark.

PARTICIPANTS

19 898 nurses aged 45 and over completing a questionnaire on lifestyle and use of hormone replacement therapy in 1993.

MAIN OUTCOME MEASURES

All cases of death and incident cases of ischaemic heart disease and myocardial infarction until the end of 1998.

RESULTS

Current users of hormone replacement therapy smoked more, consumed more alcohol, had lower self rated health, but were slimmer and had a lower prevalence of diabetes than never users. In current users compared with never users, hormone replacement therapy had no protective effect on ischaemic heart disease (hazard ratio 1.2, 0.9 to 1.7) or myocardial infarction (1.0, 0.6 to 1.7), whereas current users with diabetes had an increased risk of death (3.2, 1.4 to 7.5), ischaemic heart disease (4.2, 1.4 to 12.5), and myocardial infarction (9.2, 2.0 to 41.4) compared with never users with diabetes.

CONCLUSION

Hormone replacement therapy showed no protective effect on ischaemic heart disease, but there was a significantly increased risk of death from all causes and ischaemic heart disease among women with diabetes.

The influence of hormone replacement therapy on the aging-related change in cognitive performance. Analysis based on a Danish cohort study

OBJECTIVE

A maintenance and/or improvement of cognitive performance with postmenopausal hormone replacement therapy (HRT) is biological plausible. The objectives of this study were to analyze the impact of HRT on aging-related changes in cognitive performances, and to assess whether women who choose HRT have better cognitive performance prior to HRT.

METHODS

Data derives from a longitudinal sub-cohort of women participating in a large survey of the general adult population-The Danish MONICA (MONItoring CArdiovascular risk factors) Study. Main variables for analyses come from neuropsychological examination consisting of 28 cognitive parameters collected in 1982-1983 and again in 1993-1994, by a computer-aided test technique, the Cognitive Function Scanner((R)). The final analyses comprised 126 'never users', 40 'current users' at follow-up, and 30 'future users' of HRT (women who started HRT during the observation period subsequent to baseline registration).

RESULTS

'Current users' of HRT at follow-up showed a less pronounced decline in cognitive performance compared to 'never users' in one of six parameters for concentration ability and two of eight parameters for visuomotor function. 'Future users' of HRT had better cognitive performance at baseline compared to 'never users' in long-term visual memory, concentration, and reaction time. 'Future users' of HRT were more precise but spent more time in the tests for visuomotor function than 'never users'.

CONCLUSION

HRT-treated women show a postponed aging-related decline in cognitive functioning, partly in concentration and partly in visuomotor function. However, women who choose HRT have better cognitive performance prior to the treatment.

Knowledge, attitudes and management strategies in Scandinavia concerning hormone replacement therapy: a comparison between gynecologists in Denmark, Norway and Sweden

OBJECTIVES

To describe and compare attitudes, knowledge and management strategies concerning the prescription of hormone replacement therapy (HRT) between gynecologists from three Scandinavian countries.

DESIGN AND METHODS

In a cross-sectional study gynecologists in Denmark (n=386), Norway (n=475) and Sweden (n=1323) were invited by letter to complete and return an enclosed questionnaire. Then 1653 of the 2184 (76%) contacted gynecologists completed and returned the questionnaire.

RESULTS

of the 1653 Scandinavian gynecologists, 42% offered HRT to all women provided there was no contraindication, while 58% recommended HRT to selected women after considering the advantages and disadvantages of HRT. In Norway and Sweden, the proportion of gynecologists routinely prescribing HRT for women without contraindications increased with age and in the oldest age group of gynecologists (>55 years) 49 and 56%, respectively, recommended HRT to all women. The gynecologists were unanimous in their choice of the type of HRT for perimenopausal women as 94% preferred cyclical or sequential combined (estrogen/progestogen) treatment or estrogen monotherapy (orally or transdermally) for hysterectomized women (95%). For postmenopausal women, 75% of the gynecologists offered continuous combined HRT while cyclical combined therapy was chosen by 15% of the gynecologists. No significant differences were found between physicians in the three countries regarding indications and contraindications to HRT.

CONCLUSIONS

Scandinavian gynecologists are generally well informed concerning HRT and liberally recommend HRT for women without contraindications.

[Ambulatory mediastinoscopy]

INTRODUCTION

The present study was undertaken to investigate the safety of mediastinoscopy as a routine outpatient procedure.

METHODS

We reviewed the first 108 mediastinoscopies performed at our outpatient surgery centre.

RESULTS

During the period, 1996 to 1999, 108 out of 206 (52%) mediastinoscopy patients were admitted to the outpatient surgery centre, and 86 (80%) of these were discharged the same day. These numbers were 86% and 86% for 1999 alone, which reflects acceptance of outpatient surgery. One patient was admitted because of preoperative mediastinal venous bleeding, which required compression for 24 hours, and 19 more patients were admitted without strict medical indications. Two patients were admitted later the same day after discharge, because of minor wound bleeding, which was stopped by infiltration with adrenalin.

DISCUSSION

Mediastinoscopy can be performed safely as an outpatient procedure on most patients.

Temporal changes in cardiac function and cerebral blood flow during sequential postmenopausal hormone replacement

OBJECTIVE

The purpose was to assess the temporal changes in cardiac function and cerebral blood flow during postmenopausal administration of estrogen with and without progestogen.

STUDY DESIGN

Sixteen postmenopausal volunteers were assessed during estradiol plus sequential norethindrone acetate and placebo in two 12-week periods. Temporal changes were measured by magnetic resonance flow mapping 8 times.

RESULTS

Systemic vascular resistance was reduced during estradiol (-6.9%; P <.05), declined further during the addition of norethindrone acetate, and was accompanied by an increase in stroke volume (maximum increase, 5.2%; P <.05) without fluid retention. Both systolic (-5 mm Hg; P =.03) and diastolic (-3 mm Hg; P =.03) blood pressure were reduced during estradiol. Cerebral blood flow was reduced after 9 weeks of hormone replacement therapy (-37 mL/min; P =.01) but increased to baseline after the addition of norethindrone acetate.

CONCLUSIONS

Sequential hormone replacement therapy is associated with changes in cardiac function, which are of therapeutic potential in cardiovascular disorders. Sequential hormone replacement therapy exhibits an overall neutral effect on cerebral blood flow.

Hormone replacement therapy and hip fracture risk: effect modification by tobacco smoking, alcohol intake, physical activity, and body mass index

The authors prospectively studied the overall effect of hormone replacement therapy (HRT) on hip fracture risk and the effect modification by behavioral habits and body mass index. A total of 6,159 postmenopausal women from the Copenhagen Center for Prospective Population Studies, Copenhagen, Denmark, with initial examination in 1976-1978 were followed until 1993. During follow-up 363 hip fractures were identified. Women who reported current use of HRT had a lower risk of hip fracture as compared with women who were nonusers (relative risk (RR) = 0.71; 95 percent confidence interval (CI): 0.50, 1.01). Use of HRT was associated with a lower risk of hip fracture in former (RR = 0.55; 95 percent CI: 0.22, 1.37) and current (RR = 0.61; 95 percent CI: 0.38, 0.99) smokers but not in never smokers (RR = 1.10; 95 percent CI: 0.60, 2.03). HRT was also associated with lower risk of hip fracture among alcohol drinkers (RR = 0.36; 95 percent CI: 0.14, 0.90) and among sedentary women (RR = 0.42; 95 percent CI: 0.18, 0.98) but not among nondrinkers (RR = 0.99; 95 percent CI: 0.61, 1.61) and physically active women (RR = 0.92; 95 percent CI: 0.42, 2.04). There was no evidence of interaction between use of HRT and body mass index. In conclusion, the protective effect of HRT on hip fracture appears to be strongest in women who ever smoked, in women who drink alcohol, and in women who are sedentary. The results suggest that history of behavioral habits offers important information concerning the probable degree of protection against hip fracture afforded by HRT.

Swedish gynecologists' and general practitioners' views on the climacteric period: knowledge, attitudes and management strategies

AIMS

To investigate attitudes, knowledge and management strategies concerning hormone replacement therapy (HRT) among gynecologists and general practitioners (GPs) in Sweden.

MATERIAL AND METHODS

In 1996 a questionnaire was sent to all Swedish gynecologists (n=1323) and every third general practitioner (GP) (n=1397) regarding indications, contraindications, treatment regimens and their own (or their wives') use of estrogens.

RESULTS

Answers were received from 53% of the GPs and from 80% of the gynecologists. Fifteen per cent of the GPs often considered it difficult to evaluate the advantages and disadvantages of hormone replacement therapy compared to 2% of the gynecologists (p<0.001). Almost 100% of the physicians considered hot flushes, night sweats and osteoporosis to be indications for HRT. Significantly more GPs compared to gynecologists (50% vs 24%) stated that estrogen increased the risk of developing a deep vein thrombosis. Significantly more GPs performed measurements of blood pressure, weight, lipoproteins and palpated the breasts before starting treatment and at the follow-up visits. Significantly more gynecologists performed pelvic examination, vaginal sonography, endometrial biopsy and mammography. Among the female doctors who were either postmenopausal or had climacteric symptoms 72% of the GPs and 88% of the gynecologists were current users of HRT (p<0.01). Corresponding figures for the wives were 68% vs 86% (p<0.001).

CONCLUSION

As earlier contraindications to HRT nowadays have turned into indications it is reasonable that more GPs compared to gynecologists consider it difficult to evaluate advantages and disadvantages of HRT and more gynecologists than GPs took the first initiative to discuss HRT with their patients. The information that far more female doctors and doctors' wives, compared to the Swedish female population, were using HRT is important information when discussing HRT compliance with patients.

Hormone replacement therapy and risk of non-fatal stroke

BACKGROUND

The effect of postmenopausal hormone replacement therapy (HRT) on the risk of subtypes of stroke is as yet unclear. To investigate the effect of oestrogen and combined oestrogen-progestagen therapy on the risk of non-fatal haemorrhagic and thromboembolic stroke, we carried out a case-control study.

METHODS

From the Danish National Patient Register we identified all Danish women aged 45-64 years who had a non-fatal, first-ever cerebrovascular attack during 1990-92. Two age-matched controls were randomly selected for each case from the Danish National Person Register. Important correlates of hormone use and stroke, on which information was obtained from postal questionnaires, were controlled for by multivariate analyses based on log-linear graphical models. The analyses included data on 1422 cases classified in four subtypes of stroke (160 subarachnoid haemorrhage, 95 intracerebral haemorrhage, 846 thromboembolic infarction, 321 transient ischaemic attack) and 3171 controls.

FINDINGS

After adjustment for confounding variables and correction for the trend in sales of HRT preparations, no significant associations were detected between current use of unopposed oestrogen replacement therapy and non-fatal subarachnoid haemorrhage (odds ratio 0.52 [95% CI 0.23-1.22]), intracerebral haemorrhage (0.15 [0.02-1.09]), or thromboembolic infarction (1.16 [0.86-1.58]), respectively, compared with never use. Current use of combined oestrogen-progestagen replacement therapy had no significant influence on the risk of subarachnoid haemorrhage (1.22 [0.79-1.89]), intracerebral haemorrhage (1.17 [0.64-2.13]), or thromboembolic infarction (1.17 [0.92-1.47]). A significantly increased incidence of transient ischaemic attacks among former users of HRT and among current users of unopposed oestrogen may to some extent be explained by selection--HRT users being more aware of symptoms than non-users.

INTERPRETATION

Unopposed oestrogen and combined oestrogen-progestagen replacement therapy have no influence on the risk of non-fatal thromboembolic or haemorrhagic stroke in women aged 45-64 years.

Changes in serum concentrations of growth hormone, insulin, insulin-like growth factor and insulin-like growth factor-binding proteins 1 and 3 and urinary growth hormone excretion during the menstrual cycle

Few studies exist on the physiological changes in the concentrations of growth hormone (GH), insulin-like growth factors (IGF) and IGF-binding proteins (IGFBP) within the menstrual cycle, and some controversy remains. We therefore decided to study the impact of endogenous sex steroids on the GH-IGF-IGFBP axis during the ovulatory menstrual cycle in 10 healthy women (aged 18-40 years). Blood sampling and urinary collection was performed every morning at 0800 h for 32 consecutive days. Every second day the subjects were fasted overnight before blood sampling. Follicle stimulating hormone, luteinizing hormone (LH), oestradiol, progesterone, IGF-I, IGFBP-3, sex hormone-binding globulin, dihydroepiandrosterone sulphate and GH were determined in all samples, whereas insulin and IGFBP-1 were determined in fasted samples only. Serum IGF-I concentrations showed some fluctuation during the menstrual cycle, with significantly higher values in the luteal phase compared to the proliferative phase (P < 0.001). Mean individual variation in IGF-I concentrations throughout the menstrual cycle was 13.2% (SD 4.3; range 0.1-18.3%). There were no cyclic changes in IGFBP-3 serum concentrations and no differences in IGFBP-3 concentrations between the luteal and the proliferative phases. Mean individual variation in IGFBP-3 concentrations throughout the menstrual cycle was 8.8% (SD 2.7; range 3.2-14.1). IGFBP-1 concentrations were inversely associated with insulin concentrations, and showed a significant pre-ovulatory increase that returned to baseline at the day of the LH surge. Fasting insulin concentrations showed large fluctuations throughout the menstrual cycle without any distinct cyclic pattern. No cyclic changes in urinary GH excretion during menstrual cycle were detected. We conclude that, although IGF-I concentrations are dependent on the phase of the menstrual cycle, the variation in IGF-I concentrations throughout the menstrual cycle is relatively small. Therefore, the menstrual cycle does not need to be considered when evaluating IGF-I or IGFBP-3 serum values in women suspected to have GH deficiency.

Physiological effects of ovarian hormones: clinical aspects and compliance

Menopause is marked by the permanent cessation of menstrual bleeding. Deprivation of ovarian hormones due to decreasing ovarian activity causes widespread physiological effects. Disturbances in menstrual pattern and hot flashes are major reasons for hormone replacement therapy (HRT), but prevention of osteoporosis and cardiovascular disease are other considerations. Despite the large number of different hormone treatment regimens available, such problems as continued bleeding and concern about side effects engenders low compliance. To enhance compliance, it is important to ensure that post-menopausal women and their physicians are aware of the probable risks and benefits of hormone therapy before deciding whether or not to use preventive HRT.

[Pain and sensory impairment following parotidectomy. A descriptive study]

From 1985 to 1992 parotidectomy was performed at Vejle Hospital in 114 patients with a parotid tumour. Ninety-five of the patients completed a questionnaire. Twenty-four reported various degrees of pain at the time of the investigation, and 57 reported numbness or uncomfortable sensations of the skin. No association between symptoms and age, gender or follow-up time could be traced. Twenty patients with clinically significant complaints were subsequently interviewed and examined. Five patients had a neuroma in the scar region. Hypoaesthesia was found in 18/20 of the patients. The results emphasize the importance of avoiding unnecessary division of the great auricular nerve in order to reduce the risk of pain and sensory impairment postoperatively. The authors suggest that the posterior branch of the great auricular nerve be spared whenever possible. Patients should be informed about the risk preoperatively.

[Pemphigus vulgaris and benign cicatricial mucous membrane pemphigoid in the upper respiratory tract and esophagus]

Pemphigus vulgaris and benign cicatricial membrane pemphigoid are both autoimmune, blistering, dermatologic diseases characterised clinically by tense bullae on skin or on mucous membranes. Both diseases are rare, but very serious, associated with a high death rate (pemphigus) or high morbidity with cicatricial mucosal lesions (pemphigoid) if untreated. These diseases are discussed and two case stories mentioned where the primary focus was in the upper aerodigestive tract, which is very seldom. The otolaryngologist can make an important contribution to the early recognition, diagnosis, and management of these diseases. The biopsy must undergo immunofluorescence examination.

Two-dimensional nuclear Overhauser enhancement NMR experiments on pelargonidin-3-glucopyranoside, an anthocyanin of low molecular mass

Pelargonidin-3-glucoside has been isolated from the acidified methanolic extract of strawberries (Fragaria anannassa variety Corona) by successive application of an ion-exchange resin, droplet-counter chromatography and gel filtration. The pigment in acidified methanolic solution was studied by means of the two-dimensional nuclear Overhauser enhancement NMR technique, and the sugar unit was found to be attached to the 3-position on the aglycone. At +20 degrees C the pigment was found to be in the extreme narrowing limit where the NOESY cross-peaks are negative. However, at -20 degrees C this low-mass anthocyanin could be studied in the slow motion regime where the NOESY cross-peaks are positive. With a mixing time of 0.3 s, the glucose H1"-H4" proton pair was measured in the initial cross-relaxation rate and their cross-peak volume corresponded to the H1"-H4" distance found in a 4C1 chair conformation.

[Endogenous opioids and their therapeutic use in the treatment of pain]

Cancer patients with chronic pain and obstetric patients have participated in clinical trials of the analgesic effects of endogenous opioids. It is possible to achieve adequate relief of pain in these patients following epidural or intrathecal administration of endogenous opioids. Further investigations are required.

Antibodies against Aspergillus fumigatus in bronchial secretions from patients without aspergillosis

Antibodies to Aspergillus fumigatus were investigated by indirect immunofluorescence (IIF) and enzyme-linked immunosorbent assay (ELISA) in bronchial secretions (BS) and sera from 40 patients with neoplasia, lung infiltrates of non-fungal aetiology or chronic bronchitis. By IIF, IgG aspergillus antibodies were found in 23 samples of BS (58%) (titre range 10-40) and in all 40 sera (titre range 10-1280). IgA aspergillus antibodies were detected in 33 samples of BS (83%) (titre range 10-160) and in 33 sera (83%) (titre range 10-40). IgM aspergillus antibodies occurred in 2 samples of BS (5%) (titre 10 and 40) compared with 35 sera (88%) (titre range 10-40). Antibodies with secretory component (SC) were detected in 20 of 39 BS samples tested (51%) (titre range 10-160). Significantly higher levels of IgA antibodies were detected by ELISA in BS than in serum (2p less than 0.05) and, conversely, significantly higher levels of IgG antibodies were found in serum than in BS (2p less than 0.001). Low levels of antibodies with SC were also detected in BS by ELISA. These results suggest that aspergillus antibodies are produced within the bronchopulmonary system in patients without aspergillosis.

Lingual infarction in giant cell arteritis. A case report

Giant cell arteritis is a disease of the elderly, affecting the temporal or other cranial arteries, often in patients with polymyalgia rheumatica. A case of giant cell arteritis with necrosis of the tongue in a 77-year-old woman is reported. It is important to be aware of this condition because of the serious complications. As the lesion is focally distributed, it is necessary to obtain a large biopsy specimen from the superficial temporal artery in order to make a correct diagnosis. Prompt treatment with corticosteroid in large doses followed by a lower maintenance dose is important to prevent vascular complications.

Epidemic shigellosis on a worktrain in Labrador

An epidemic of shigellosis occurred on a worktrain in western Labrador in October 1974. During the outbreak 62 persons out of a crew of 91 became ill, 11 having recurrent illness; 14 were hospitalized. Epidemiologic analysis with laboratory confirmation implicated unchlorinated and contaminated lake water as the source of the epidemic. Faulty design of water storage tanks perpetuated the use of contaminated water; hence a second wave of illness occurred. The tanks were then thoroughly drained, cleaned and repaired. Many deficiencies in sanitation measures (most of which have since been rectified) were noted at the site of the epidemic as well as at other locations along the railway. Careful sanitation controls are essential in rapidly developing areas of northern Canada.