SUI in postmenopausal women: advantages of an intraurethral + intravaginal Er:YAG laser

OBJECTIVE

This study aimed to compare the efficacy of concomitant application of an intraurethral (IU) + intravaginal (IV) non-ablative Erbium (Er):YAG laser with IV application in improving the symptoms of stress urinary incontinence (SUI) in women.

METHODS

This observational retrospective cohort study included 122 patients with SUI, 60 women in the IU + IV laser arm and 62 in the IV laser arm. The primary outcome was the International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form score at entry and at 3, 6 and 12 months from baseline.

RESULTS

Demographic characteristics were comparable in both arms. Significant improvement in SUI symptoms was seen 3 months after the intervention and was sustained until the end of month 12 in both arms. The women who had severe SUI symptoms initially showed greater improvement. A higher number of women who initially had mild to moderate SUI symptoms were dry after treatment. Patients treated with IU + IV Er:YAG laser showed significant improvement in SUI symptoms compared to IV laser only, especially at postmenopausal state (p = 0.003).

CONCLUSIONS

The Er:YAG laser appears to be an efficient treatment method for SUI. Concomitant application of an IU + IV Er:YAG laser is more effective in relieving SUI symptoms at postmenopausal state.

Can fibromyalgia be considered a characteristic symptom of climacterium?

Fibromyalgia syndrome (FMS) is a chronic pain syndrome, characterised by diffuse pain in musculoskeletal system and accompanied by stiffness, fatigue, tender points, sleep disturbances and cognitive and gastrointestinal symptoms. It affects middle-aged women (between 40 and 65) predominantly. Climacteric syndrome, which is characterised by vasomotor, somatic (headache, sleep disorders, myalgia and arthralgia) and psychical (mood changes) symptoms, results from the change in brain neurotransmitter concentrations due to gradual decline of ovarian hormone levels. Currently, studies focus on the similarities of FMS and climacteric syndrome in terms of age of occurrence, epidemiology, etiopathogenesis, symptomatology and treatment. Hormonal fluctuation during menopausal transition is likely the triggering factor for both syndromes. Therefore, hormone replacement therapy is a favourable approach in the treatment of FMS due to the antiallodynic, anti-inflammatory and neuroprotective effect of oestrogen. In this review, we emphasise the similarity of FMS and climacteric syndrome and suggested that FMS could be considered as a characteristic symptom of climacterium.

Serum kisspeptin levels correlated with anti-mullerian hormone levels in women with and without polycystic ovarian syndrome

MATERIALS AND METHODS

This was a prospective, cross-sectional, comparative study that included 70 women with PCOS and 58 non PCOS controls. PCOS patients were diagnosed according to the Rotterdam criteria. Age, body mass index (BMI), number of menstrual cycles per year, and the Ferriman-Gallwey Score were determined for each woman. Serum levels of kisspeptin, follicle stimulating hormone (FSH), luteinizing hormone (LH), thyroid stimulating hormone (TSH), estradiol, total testosterone, dehydroepiandrosterone sulfate (DHEA-S), AMH, fasting glucose and insulin were determined.

RESULTS

Women with PCOS were younger (p < .001), with higher BMI (p = .027) and glucose values (p < .001); while displaying less number of menstrual cycles per year (p < .001). Although serum kisspeptin levels were similar in both groups, age was negatively (r= -0.33, p = .00018) and serum AMH levels were positively correlated (r = 0.25, p = .0039) with the serum kisspeptin levels in women with the PCOS. After adjusting for age, serum kisspeptin levels were comparable in both groups (p > .05). Serum LH, AMH, DHEA-S and total testosterone glucose, insulin levels and HOMA-IR values were significantly higher in women with PCOS as compared to controls (all p < .05).

CONCLUSIONS

Serum kisspeptin levels were similar in women with and without PCOS but positively correlated with AMH serum levels in PCOS women.

Er:YAG laser in hysterectomized women with stress urinary incontinence: a VELA retrospective cohort, non-inferiority study

Objective: To test whether the erbium-doped yttrium aluminum garnet (Er:YAG) SMOOTH^® laser treatment efficacy on stress urinary incontinence (SUI) in hysterectomized patients is non-inferior to its efficacy in non-hysterectomized patients.Methods: In this real-world, retrospective cohort study performed in Turkey, Croatia and Italy, we enrolled a consecutive sample of 35 hysterectomized and 34 non-hysterectomized patients with SUI. We used the Er:YAG SMOOTH^® laser (Fotona, Slovenia) with a wave length of 2940 nm. The primary outcome was median reduction of SUI symptoms measured by the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short-Form (ICIQ-SF) with the non-inferiority margin defined as the minimum clinically important difference of ICIQ-SF (δ < 2.52 points).Results: In hysterectomized patients, the ICIQ-SF was reduced by 5 points (95% confidence interval 3-8; p < 0.001), a reduction of 45% (95% confidence interval 36-67%). After adjustment for baseline ICIQ-SF and five covariates, the reduction of symptoms in the hysterectomized group was not inferior to the reduction in the non-hysterectomized group.Conclusion: The Er:YAG SMOOTH^® laser treatment seems to improve the symptoms of SUI in hysterectomized women not clinically relevantly less than in non-hysterectomized women. It seems that the beneficial effect of Er:YAG SMOOTH^® laser treatment for SUI in hysterectomized women is time-limited.

Leriche's syndrome and twin pregnancy

Leriche's syndrome is characterized by chronic obstruction of the abdominal aorta and iliac arteries. A patient with Leriche's syndrome presented with twin pregnancy and severe preeclampsia at 32 weeks' gestation. Cesarean delivery was performed and the patient was admitted to the intensive care unit. Magnetic resonance angiography showed total occlusion of the distal abdominal aorta, common, and external iliac arteries. There were extensive collateral vessels between the lumbar arteries and iliolumbar arteries. The patient was discharged in an improved clinical condition. Leriche's syndrome and pregnancy demonstrating complete aortic, common, and external iliac artery occlusion is very rare in the literature. Despite complete occlusion, viability of the fetus can be achieved with collateral vessels.

Effects of vitamin K in postmenopausal women: mini review

Possible benefits of vitamin K on bone health, fracture risk, markers of bone formation and resorption, cardiovascular health, and cancer risk in postmenopausal women have been investigated for over three decades; yet there is no clear evidence-based universal recommendation for its use. Interventional studies showed that vitamin K1 provided significant improvement in undercarboxylated osteocalcin (ucOC) levels in postmenopausal women with normal bone mineral density (BMD); however, there are inconsistent results in women with low BMD. There is no study showing any improvement in bone-alkaline-phosphatase (BAP), n-telopeptide of type-1 collagen (NTX), 25-hydroxy-vitamin D, and urinary markers. Improvement in BMD could not be shown in the majority of the studies; there is no interventional study evaluating the fracture risk. Studies evaluating the isolated effects of menatetrenone (MK-4) showed significant improvement in osteocalcin (OC); however, there are inconsistent results on BAP, NTX, and urinary markers. BMD was found to be significantly increased in the majority of studies. The fracture risk was assessed in three studies, which showed decreased fracture risk to some extent. Although there are proven beneficial effects on some of the bone formation markers, there is not enough evidence-based data to support a role for vitamin K supplementation in osteoporosis prevention among healthy, postmenopausal women receiving vitamin D and calcium supplementation. Interventional studies investigating the isolated role of vitamin K on cardiovascular health are required. Longterm clinical trials are required to evaluate the effect of vitamin K on gynecological cancers. MK-4 seems safe even at doses as high as 45 mg/day.

Transobturator tape (TOT) procedure with fluoroscopic guidance: gaining confidence and valuable experience!

OBJECTIVES

To report a successful transobturator tape (TOT) procedure performed under fluoroscopic guidance without any complications.

METHODS

The diagnosis of stress urinary incontinence (SUI) was confirmed with urodynamic tests in a 54-year-old woman. TOT procedure was performed under the guidance of fluoroscopy.

RESULTS

SUI was treated successfully with TOT procedure. Fluoroscopic guidance not only decreased the length of the procedure but also avoided the possible complications. The operator gained confidence and valuable experience.

CONCLUSIONS

TOT procedure can be successfully performed under fluoroscopic guidance avoiding the possible complications and enhancing the learning curve period. We recommend the usage of fluoroscopy especially for the inexperienced operators. The benefits overweigh the cost of fluoroscopy and the absorbed dose of radiation which is calculated to be lower than accepted limits.

The effect of tibolone versus 17β-estradiol on climacteric symptoms in women with surgical menopause: A randomized, cross-over study

OBJECTIVE

To compare the effectiveness of tibolone and 17beta-estradiol on climacteric symptoms, in a randomized, single-blind, cross-over study in surgically menopausal women.

MATERIAL AND METHODS

Forty surgically menopausal women were divided randomly into two groups. Group A received treatment with tibolone for 6 months, while group B received 17beta-estradiol. After 3 weeks washout period, treatment protocols were exchanged for another 6 months. The climacteric symptoms were assessed with Greene Climacteric Scale at baseline, during washout and after the treatments. Statistical analysis was done with the Wilcoxon's Sign Rank test.

RESULTS

Both treatments significantly improved the scores of all subscales with respect to baseline. However, the improvement in psychological, somatic and sexual subscales were significantly superior in the tibolone group compared with 17beta-estradiol group. Both treatments showed comparable improvements in the relief of vasomotor symptoms.

CONCLUSION

Our findings suggest that tibolone may improve mood, libido and somatic symptoms in surgically menopausal women to a greater extent than estrogen therapy alone.

Successful pregnancy achieved by assisted reproductive techniques in a woman with severe congenital bicuspid aortic valve stenosis

OBJECTIVES

To report a twin pregnancy achieved by assisted reproductive techniques in a woman with severe congenital bicuspid aortic valve stenosis.

METHODS

Intracytoplasmic sperm injection and embryo transfer was performed in a 38-year-old woman with a complaint of infertility for 8 years due to male factor and who previously had the diagnosis of severe congenital bicuspid aortic stenosis. Clinical and echocardiography follow-up during pregnancy was done.

RESULTS

The woman had severe congenital aortic stenosis with a valve area of 0.4 cm(2) and a peak gradient of 57 mmHg. In the first trial, twin pregnancy was achieved. She had an uneventful course of pregnancy in terms of cardiac functions. She underwent caesarean section at 36 weeks of gestation and had a healthy female and a male newborns.

CONCLUSIONS

A woman with a severe congenital bicuspid aortic valve may get pregnant and deliver healthy newborns with intensive prenatal care and follow-up. The severe congenital bicuspid aortic valve stenosis may not be considered an absolute contraindication for assisted reproductive techniques and pregnancy.

Difference in αvβ3 integrin expression in endometrial stromal cell in subgroups of women with unexplained infertility

OBJECTIVE

The aim of the study was to evaluate the endometrial receptivity by using alpha(v)beta3 expression in the midsecretory phase in different endometrial compartments in women with unexplained infertility.

STUDY DESIGN

A prospective controlled clinical trial in a setting of a university teaching hospital was performed. Thirty-three fertile and 33 infertile women were included in the study. Midluteal endometrial biopsies of the endometrium were carried out during the implantation window. Immunohistochemical staining was performed for the expression of alpha(v)beta3 in endometrial samples. Alpha(v)beta3 expression was measured using the HSCORE scoring system in the endometrial glandular and luminal epithelium and in the endometrial stroma. Serum levels of estradiol, progesterone, follicle-stimulating hormone, luteinizing hormone, thyroid-stimulating hormone, prolactin, total testosterone and dehydroepiandrosterone sulphate were measured in the early follicular phase and in the midluteal phase.

RESULTS

The average alpha(v)beta3 integrin expression at different sites of the endometrium was not different in the infertile and fertile controls. However, the stromal alpha(v)beta3 integrin was found to be expressed significantly less in a subgroup of women with lower than average alpha(v)beta3 integrin expression in luminal epithelium than in fertile controls and significantly more in a subgroup of women with higher than average alpha(v)beta3 integrin expression in luminal epithelium. There was no difference in stromal alpha(v)beta3 integrin expression in the lower or higher glandular alpha(v)beta3 integrin expression subgroups.

CONCLUSIONS

Alpha(v)beta3 integrin expression in endometrial stromal cells may be different in subgroups of women with unexplained infertility.

Serum leptin levels in hypertensive disorder of pregnancy

OBJECTIVE

To determine serum leptin levels in hypertensive disorder of pregnancy.

MATERIALS AND METHODS

In this prospective, cross-sectional, case control study, we measured serum leptin levels of 58 hypertensive pregnant women and 54 normal pregnant women. We also did blood and urine analysis for the evaluation of the severity of hypertensive disorder of pregnancy. The patients were followed until after delivery and information about labour was recorded. We analysed the difference and correlation between anthropometric measures, hormonal and biochemical parameters, and serum leptin levels in two groups.

RESULTS

In the study group, serum leptin levels were determined to be higher than the control group. Neonatal birth weight was significantly lower in the hypertensive group. While the serum uric acid, urea, aspartate aminotransferase, fibronectin, and fasting blood glucose levels were found to be higher, serum total protein and albumin levels were significantly lower among the hypertensive pregnant women. Hypertensive pregnant women were more insulin resistant. Serum leptin levels were highly and positively correlated with serum fibronectin, and C peptide levels. A negative significant correlation was observed between maternal serum leptin levels and neonatal birth weight among the pregnant women having the hypertensive disorders.

CONCLUSION

Serum leptin levels in hypertensive pregnant women appear to be higher. The determination of serum leptin levels may be as important as serum fibronectin and C peptide levels in the management of hypertensive disorder of pregnancy. C peptide and insulin may be due to hyperinsulinemia which leads to increased stimulation of leptin production by fatty tissue. Insulin resistance which appears in late pregnancy is more significant especially in pregnancies complicated by preeclampsia.

Is endometrial apoptosis evidence of endometrial aging in unexplained infertility? a preliminary report

OBJECTIVE

To investigate spontaneous endometrial apoptosis in women with unexplained infertility and to find out whether there is a possible relationship between endometrial apoptosis, age, and hormonal parameters.

STUDY DESIGN

This study was designed as a prospective, case-controlled study in a University Hospital setting. A total of 34 endometrial biopsies were performed from 17 women with unexplained infertility and 17 fertile controls, who were admitted for tubal ligation. Endometrium was sampled on the seventh post-ovulatory day. On the same day of endometrial sampling, serum levels of FSH, LH, PRL, TSH, E2, progesterone, 17alpha-hydroxyprogesterone, testosterone and DHEA-S were determined. Endometrial glandular and stromal apoptosis were investigated by DNA nick end labeling (TUNEL) method on each sample. Endometrial apoptotic index was calculated and correlated with age and hormonal parameters.

RESULTS

There was no difference in either endometrial glandular apoptotic index (AI) or stromal AI between the groups. However, the mean glandular AI was significantly higher than the mean stromal AI (p = 0.0001). There was a strong correlation between endometrial AI and age (r = 0.91, p = 0.02). Serum T levels were significantly found to be decreased in the unexplained infertility group (p = 0.0001). In addition, serum TSH levels were positively correlated with AI in the glandular endometrium in women with unexplained infertility (r = 0.611, p = 0.009).

CONCLUSION

Endometrial apoptosis increases with age. Serum levels of testosterone were lower in unexplained infertility. The effect of serum TSH levels on apoptosis in the glandular epithelium of the endometrium needs further studies.

Primary psoas muscle abscess diagnosed and treated during pregnancy: case report and literature review

BACKGROUND: Primary psoas muscle abscess is rare and can be difficult to diagnose, particularly during pregnancy. CASE: To our knowledge, this is the first case of primary psoas muscle abscess diagnosed during pregnancy. Clinical investigation did not reveal any infection spreading from adjacent structures. Surgical drainage and simultaneous Cesarean delivery of the infant, combined with appropriate antibiotics, enabled a cure. CONCLUSION: The possibility of psoas muscle abscess should be taken into account when investigating lower back pain during pregnancy if conventional approaches are unsatisfactory.

Is serum leptin level regulated by thyroid functions, lipid metabolism and insulin resistance in polycystic ovary syndrome?

Our aim was to determine whether serum leptin level is regulated by thyroid hormones, lipid metabolic products and insulin resistance status in women with polycystic ovary syndrome (PCOS). A prospective case-controlled study was carried out in Istanbul University, Cerrahpasa School of Medicine in 25 lean PCOS (L-PCOS) women, 19 obese PCOS (O-PCOS) women and 28 normal women. The diagnosis of PCOS was established according to the clinical, hormonal (elevated luteinizing hormone and serum androgens) and ultrasonographic findings. Fasting serum levels of thyroid stimulating hormone (TSH), free triiodothyronine (FT3), free thyroxine (FT4), fasting glucose, insulin, total cholesterol (TC), triglyceride (TG), high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol (LDL-C), very low-density lipoprotein-cholesterol (VLDL-C) and leptin were measured and compared in the three groups and the correlations between serum levels of leptin and other parameters were evaluated. Serum leptin levels were higher in the O-PCOS group, while its level was comparable between the L-PCOS and control groups. Serum levels of FT4 were significantly lower in both L-PCOS and O-PCOS groups than the control group. Women in both L-PCOS and O-PCOS groups were found to be significantly hyperinsulinemic and insulin resistant. Serum levels of TC, VLDL-C and TG were significantly higher in the O-PCOS group, while serum HDL-C level was lower. There was a poor correlation between serum leptin, and FT4, TC, TG, HDL-C and VLDL-C levels. A significant correlation was observed between serum leptin levels and both BMI and insulin resistance status in PCOS. We believe that, although thyroid hormones and lipid metabolic products do not seem to participate in the regulation of serum leptin levels, BMI and insulin resistance status may have a key role in women with PCOS.

Mammographic density increase in women receiving different hormone replacement regimens

OBJECTIVE

we investigated effects of different regimens of hormone replacement therapy (HRT) on mammographic density.

METHODS

ninety-five postmenopausal women, who were on different HRT regimens and completed their 4-year mammographic follow-up, were included into this retrospective and comparative study. Twenty-three of these women, who had surgical menopause, received conjugated equine estrogens (CEE) (Group I) only, 26 of them received CEE and continuous medroxyprogesterone acetate (MPA) (Group II), 21 women received CEE and cyclic MPA (Group III), and the remaining 25 women received tibolone (Group IV) therapy. Before commencing on HRT, a baseline high-resolution mammography was performed, and repeated at 6-12-month intervals during the period of 4-year follow-up. All mammographies were evaluated according to the Wolfe classification.

RESULTS

a diffuse increase in mammographic density was detected in five women (22%) in group I, nine women (35%) in group II, four women (19%) in group III, and two women (8%) in group IV. The increase in mammographic density was more common among women in group II than those in the other three groups. However, a statistically significant difference was found only between groups II and IV.

CONCLUSIONS

different HRT regimens have different effects on breast parenchymal density on mammography. Continuous combination HRT may be more commonly associated with an increase in breast density than other forms of HRT.

Acute cortical blindness complicating pre-eclampsia

Cortical blindness in pre-eclampsia due petechial hemorrhages, ischemia, focal edema and infarction of the occipital cortex, is mostly reversible.

Apoptosis in the placenta of pregnancies complicated with IUGR

OBJECTIVE

In this study we have investigated the presence of apoptosis in the placental tissue of pregnancies complicated with intra-uterine growth restriction (IUGR).

METHOD

Placental samples were obtained from 22 normal third trimester pregnancies and 20 pregnancies complicated with IUGR. The criteria for fetal growth impairment were clinical evidence of sub-optimal growth, ultrasonographic demonstration of deviation from normal percentiles of growth and birth weight under 10th percentile. Terminal deoxynucleotidyl transferase mediated deoxyuridine triphosphate nick end labelling (TUNEL) staining was used to demonstrate the apoptotic cells in all samples. Student-t, Mann-Withney U-test, Fisher exact test and Spearman correlation were used for statistical analysis.

RESULTS

We detected apoptosis in 10 placentas in the study group vs. none in the control group. Placentas from pregnancies complicated with IUGR demonstrated 0.12% (0.1%-0.4%) apoptotic cells. The rate of apoptotic cells in the placenta was significantly higher in pregnancies complicated with IUGR than normal uncomplicated pregnancy (P=0.0019). Apoptosis were more abundant in the trophoblasts, especially cytotrophoblasts, in the placenta. We could not find a correlation between the apoptosis in the placenta of pregnancies complicated with IUGR and birth weight, multi-parity, gestational age, birth weight percentile and mode of delivery (C/S vs. vaginal delivery).

CONCLUSION

We believe that the increased number of apoptosis in the placenta of pregnancies complicated with IUGR may have an important compensatory role to transmit nutrition and gas exchange easily to the fetus.

Craniopharyngioma and Bardet-Biedl syndrome. A case report

BACKGROUND

Bardet-Biedl syndrome is a rare disorder and associated with a variety of anomalies.

CASE

An 18-year-old woman was referred with primary amenorrhea. Following physical, ophthalmologic, psychiatric, hormonal and radiologic examinations, the diagnosis of both craniopharyngioma and Bardet-Biedl syndrome was established.

CONCLUSION

Although the pathogenesis of hypogonadism in a woman with Bardet-Biedl syndrome remains unclear, cranial structures, especially the hypothalamus and pituitary gland, should be investigated to reveal any possible abnormalities.

Symptomatic treatment of premenstrual mastalgia in premenopausal women with lisuride maleate: a double-blind placebo-controlled randomized study

OBJECTIVE

To determine the therapeutic effect of lisuride maleate on premenstrual mastalgia in premenopausal women.

DESIGN

Double-blind randomized prospective study.

SETTING

Department of obstetrics and gynecology at a university hospital.

PATIENT(S)

Sixty women with premenstrual mastalgia were included in the study. Study and control groups consisted of 30 women each.

INTERVENTION(S)

Women enrolled in the study and control group were given one tablet daily (0.2 mg) of lisuride maleate or placebo orally for 2 months. Severity of mastalgia was evaluated using the visual analog scale.

MAIN OUTCOME MEASURE(S)

Severity of mastalgia and side effects of the drug administered.

RESULT(S)

Mastalgia subsided significantly in women receiving lisuride maleate compared with controls. There were no significant side effects from lisuride maleate. Prolactin levels decreased significantly in the group receiving lisuride, which correlated well with pain resolution.

CONCLUSION(S)

Lisuride maleate may be useful for the symptomatic treatment of premenstrual mastalgia.

Sperm-preparation techniques for men with normal and abnormal semen analysis. A comparison

OBJECTIVE

To compare two commonly used sperm-preparation techniques, density gradient centrifugation and swim-up procedures, with respect to their effects on acrosome reaction (AR), hypoosmotic swelling (HOS) and nuclear maturity in men with abnormal and normal semen analyses.

STUDY DESIGN

In accordance with World Health Organization criteria, 23 men with abnormal (group I) and 20 men with normal (group II) semen analyses were included in a prospective, controlled study. Each semen specimen was divided into aliquots in order to assess AR, HOS and nuclear maturity, determined with acridine orange staining, in both raw and processed semen samples using the density gradient centrifugation and swim-up techniques.

RESULTS

Initial semen samples in group I revealed diminished AR, HOS and nuclear maturity rates in comparison to those in group II. In group I, density gradient centrifugation improved AR, HOS and nuclear maturity rates more than did swim-up. However, in group II it improved only the AR; HOS rates were better than with swim-up. There was a significant positive correlation between sperm concentration and HOS rate in raw semen samples from group I. In the same group, motility and morphology correlated with the nuclear maturity rate but not with AR and HOS rates. Semen samples with better motility (> 20%) or morphology (> 25%) showed better nuclear maturity rates (> 50%) in men with abnormal semen analyses. Motility had a sensitivity of 77% and specificity of 90% in predicting nuclear maturity. Morphology had similar sensitivity but lower specificity (70%).

CONCLUSION

Density gradient centrifugation is superior to the swim-up technique in improving AR, HOS and nuclear maturity rates in men with abnormal semen analyses. However, when only nuclear maturity rate is taken into account, the swim-up technique seems to be sufficient for selecting spermatozoa in men with normal semen analyses. The nuclear maturity rate also correlates with sperm morphology and motility.

Results of the ACTH stimulation test in hirsute women

OBJECTIVE

To determine the incidence of late-onset congenital adrenal hyperplasia (LOCAH) due to 21-hydroxylase deficiency among hirsute women and to evaluate the results of the ACTH stimulation test with the clinical characteristics.

STUDY DESIGN

Prospective, controlled study. One hundred women with hirsutism and 14 normally cycling women without hirsutism were included in this study at the Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Cerrahpasa School of Medicine, Istanbul University. After basal serum progesterone (P) and 17 hydroxyprogesterone (17OHP) levels were determined, an ACTH stimulation test was performed on cycle day 3-5. The same parameters were checked 30 minutes later. We estimated the 21 hydroxylase activity by calculating the change in 17OHP (17OHP 30-0) and the summed rate of the change in P and 17OHP ([P30-0] + [17OHP30-01/30 minutes). The 95th percentile for these estimates in normal women were calculated, and values above three times the 95th percentile were considered to distinguish women with LOCAH due to 21-hydroxylase deficiency.

RESULTS

The 95th percentile for 17OHP 30-0 and (P30-0) + (17OHP30-0)/30 minutes in normal women was 1.6 and 8.9 ng/dL/min, respectively. Regarding 17OHP 30-0 values, three women with hirsutism had levels above three times the 95th percentile of these estimates, and 28 women had estimates of more than the 95th percentile but less than threefold. Seventeen of 28 women had oligomenorrhea, and all had severe hirsutism. The women with severe hirsutism and oligomenorrhea had significantly higher ACTH-stimulated serum 17OHP levels and values for 17OHP 30-0 and (P30-0 + (17OHP30-0)/30 min) than did normally cycling women.

CONCLUSION

The incidence of LOCAH due to 21-hydroxylase deficiency and mild 21-hydroxylase deficiency is 3% and 28%, respectively, in women with hirsutism. Clinical characteristics are not helpful in determining 21-hydroxylase deficiency. However, the incidence of 21-hydroxylase deficiency is more common among women with severe hirsutism and oligomenorrhea. The change in serum 17OHP 30-0 seems to be greater than the summed rate of change in serum 17OHP and P in the detection of 21-hydroxylase enzyme deficiency.

Changes in bone mineral density with age, menopausal status and body mass index in Turkish women

OBJECTIVE

The aim was to evaluate changes in bone mineral density (BMD) with age and body mass index (BMI) in healthy pre- and postmenopausal women living in the urban areas of Turkey.

DESIGN

The study was prospective, carried out from 1993 to 1997.

SETTING

The study carried out at a university hospital, the Istanbul University Cerrahpasa School of Medicine, Turkey.

PATIENTS

The study group consisted of 849 healthy women of ages 20-84 years, admitted to the Istanbul University Cerrahpasa School of Medicine. The cases were divided into age groups, starting with 20-29 years and ending with 70 years and over. For regression analysis, the cases were further regrouped as 20-39, 40-59 and 60 years and over. Dual energy X-ray absorptiometry (DEXA) was used to measure BMD in the lumbar vertebrae (L2-L4) and in the classical locations of the proximal femur such as the femoral neck, the Ward's triangle and the trochanter. Multiple regression analysis was performed for the evaluation of annual changes in BMD with respect to age and/or BMI.

RESULTS

A significant decrease in BMD started especially in the 40-49 age group, matching the average age of menopause in the study population. In contrast to the non-significant changes in the 20-39 age group, a significant decrease in BMD in the 40-59 age group, which included the average age of menopause, was detected in all locations (p < 0.0001). In addition to the significant effect of the menopause on BMD, an association between BMD and BMI was found in every location and age group (p = 0.02 to p < 0.0001). The total bone loss in the 70 and over age group, in comparison with the 30-39 age group, was 18.78% in L2-L4, 21.69% in the femoral neck, 32.68% in the Ward's triangle and 14.11% in the trochanter. Corresponding values between age groups 70 and over and 60-69 were 0.25%, 7.62%, 11.94% and 8.29%, respectively. Women in the older age groups had a slower decline in BMD in the lumbar vertebrae, in comparison with the proximal femur. Moreover, the maximum postmenopausal total bone mineral loss was in the Ward's triangle.

CONCLUSIONS

The present results, confirming the results of other studies, have revealed a significant association between BMD and the menopausal status of women in the Turkish population. Additionally, a significant correlation has been detected between BMI and BMD, regardless of location and age.

Role of the mutations Trp8 => Arg and Ile15 => Thr of the human luteinizing hormone beta-subunit in women with polycystic ovary syndrome

OBJECTIVE

To evaluate the clinical significance of LH in the form of a mutant beta-subunit in women with polycystic ovary syndrome (PCOS).

DESIGN

Prospective, controlled study.

SETTING

University hospital.

PATIENT(S)

Thirty healthy women and 30 women with PCOS.

INTERVENTION(S)

Clinical, ultrasonographic, and hormonal findings were used to define PCOS. Nucleotide mutations within codons 8 and 15 in the LH beta-subunit gene (Trp8 => Arg and Ile15 => Thr) were analyzed with the use of polymerase chain reaction and subsequent restriction fragment length polymorphism.

MAIN OUTCOME MEASURE(S)

Serum levels of gonadotropins, androgens, E2, and prolactin were determined, and the results of restriction fragment length polymorphism were analyzed.

RESULT(S)

Five women in the control group and one woman in the PCOS group were found to be affected by the LHbeta gene mutations. No difference was observed in serum androgen and E2 levels between the affected women and 25 healthy women who were homozygous for the wild-type LH. However, women whose serum LH levels were < or = 5.1 mIU/mL had a higher risk of having mutant LH.

CONCLUSION(S)

The frequency of LH mutations in women with PCOS is similar to that in healthy women. The presence of the variant does not cause any significant change in serum levels of androgens and E2.

Ovarian stromal hypertrophy in polycystic ovary syndrome

OBJECTIVE

To investigate the relationship between the ovarian stromal area and clinical hormonal characteristics in women with polycystic ovary syndrome (PCOS).

STUDY DESIGN

Twenty-eight women with PCOS (group 1) and 26 healthy women (group 2) participated in this study. For measuring the ovarian stromal area, transvaginal ultrasonography was performed on all women during the early follicular phase of the menstrual cycle. Venous blood was sampled from the women to determine serum follicle stimulating hormone, luteinizing hormone (LH), estradiol, androstenedione, free testosterone (FT), total testosterone (TT), 17 alpha-hydroxyprogesterone, dehydroepiandrosterone sulfate, and fasting insulin and glucose levels. Two-tailed t and Pearson correlation tests were used for statistical analysis.

RESULTS

Women with PCOS were heavier, and their serum FT, TT and LH levels were significantly higher than in the normals (P < .001, P < .012 and P < .001, respectively). The ovarian stromal area measured by transvaginal ultrasonography was also significantly larger than in the normals (P < .001). Only basal serum insulin levels seemed to correlate positively with the ovarian stromal area in women with PCOS (r = .43 P = .09).

CONCLUSION

Although transvaginal ultrasonography has played an important role in the evaluation of women with PCOS, we could not demonstrate a relationship between the ovarian stromal area and hormonal characteristics of PCOS. Therefore, transvaginal ultrasonography and hormonal parameters must be used as complementary diagnostic methods in women with PCOS.

Adrenal androgenic response to 2-hour ACTH stimulation test in women with PCOS

Adrenal function may be abnormal in women with polycystic ovary syndrome (PCOS). This study aims to evaluate adrenal steroid response to the adrenocorticotropic hormone (ACTH) stimulation test and to find out the effect of high serum testosterone levels on adrenal response. We have also investigated any subtle enzyme deficiency by extending blood sampling to 2 h with 30 min intervals following ACTH administration. Twenty-eight women with PCOS and 18 healthy controls without hirsutism and oligomenorrhea were included in the study. After determining their serum basal levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH), testosterone, dehydroepiandrosterone sulfate (DHEAS), 17-hydroxyprogesterone (17-OHP), and progesterone, ACTH stimulation test was performed. The change in serum 17-OHP and the summed rate of change in serum 17-OHP and progesterone levels were estimated and 95th percentile for each value was computed. Women with PCOS were heavier and more hirsute than controls (p < 0.01, p < 0.001, respectively). Serum basal LH, LH:FSH ratio, testosterone (p < 0.001, for all), DHEAS (p < 0.01), and 17-OHP (p < 0.05) were higher in women with PCOS. All of the 17-OHP measurements, including basal and each 30 min interval after the administration of ACTH, were higher in women with PCOS than those of healthy controls (p < 0.05, p < 0.002, p < 0.001, p < 0.015, p < 0.018, respectively). However, the incremental changes in serum 17-OHP30-0, 17-OHP60-0, 17-OHP90-0, 17-OHP120-0, and the summed rate of change in serum 17-OHP and progesterone in women with PCOS were not different from those in healthy controls. The incremental response in terms of serum progesterone, DHEAS, and testosterone levels to the ACTH stimulation test for each 30 min interval was not different in women with PCOS than in healthy controls. We were not able to show any critical value for serum basal testosterone and DHEAS levels that would effect response to ACTH stimulation in terms of 17-OHP levels. We have concluded that extending the duration of blood sampling up to 2 h has no advantage in evaluating adrenal steroid response to ACTH stimulation. Since serum 17-OHP levels remain within normal limits in response to ACTH stimulation, the origin of elevated serum basal 17-OHP levels may be polycystic ovaries. Elevated serum testosterone level does not have any adverse effect on adrenal function. Serum progesterone measurement seems to have no place in the diagnosis of 21-hydroxylase deficiency. Adrenal androgenic response to ACTH stimulation is normal in women with PCOS.

Mammographic changes in women receiving tibolone therapy

OBJECTIVE

To investigate the effects of tibolone therapy for menopausal symptoms on mammographic findings and to identify any association between mammographic changes and the demographic and hormonal characteristics of women receiving tibolone.

DESIGN

A prospective study.

SETTING

A university hospital.

PATIENT(S)

Seventy-five women who were in the climacteric or postmenopausal period were recruited, and 25 of them were followed up for 24 months.

INTERVENTION(S)

After high-resolution mammographies were performed and blood samples were collected, tibolone (2.5 mg/d) was administered orally to all patients. At the end of the 24-month follow-up period, blood samples were collected again and mammographies were repeated.

MAIN OUTCOME MEASURE(S)

Serum levels of LH, FSH, prolactin, estradiol, testosterone, and DHEAS were determined from the collected samples, and mammographies were interpreted.

RESULT(S)

At the end of the 24-month follow-up period, mammographic changes were observed in only two women (8%). Women who had no change in mammography constituted group I (n = 23). Women who had a change constituted group II (n = 2). Although the initial hormone levels were not different, the increase in serum DHEAS in group I was significantly higher than in group II (z = 2.30, P = 0.021).

CONCLUSION(S)

The frequency of mammographic changes in women receiving tibolone therapy was found to be 8% at the end of the 24-month follow-up. The serum DHEAS level may be an important hormonal marker complementary to mammographic screening for women receiving tibolone therapy. We strongly believe that tibolone is safe in terms of mammographic changes in postmenopausal women.

Antibiotic therapy in men with leukocytospermia

OBJECTIVE

In this prospective study, we aimed to determine the efficacy of doxycycline and doxycycline plus ceftriaxone for the treatment of asymptomatic men with leukocytospermia.

METHOD

Seventy men were included in this randomized and placebo-controlled study. White blood cell (WBC) concentrations were determined by peroxidase assay during the routine semen analysis. Twenty-four of 70 men with leukocytospermia were randomized as control group and administered placebo (group I), 25 received doxycyline alone (group II), and 21, doxycycline plus ceftriaxone (group III). Doxycycline, 100 mg, was given twice a day for ten days and ceftriaxone, 1 g, in two doses for only one day. After the treatment, semen analyses were repeated.

RESULTS

After the treatment there was a significant decrease in WBC counts in groups II and III when compared with group I (P < .05). Both antibiotic regimens were found to be equally effective. However, the time needed for resolution of leukocytospermia (approximately 4 weeks) was similar between the control and treatment groups.

CONCLUSION

Although both antibiotic regimens significantly, and equally, improved the white blood cell counts in men with leukocytospermia, they failed to treat the leukocytospermia, i.e., to bring the count below the limit of one million WBC/mL. Therefore, it is doubtful that antibiotic therapy should be recommended for asymptomatic men with leukocytospermia.

DNA ploidy of ectopic pregnancy and first trimester spontaneous abortion investigated by flow cytometry

BACKGROUND

To compare the success rate of DNA flow cytometry in determining the DNA ploidy status in ectopic pregnancy and first trimester spontaneous abortion.

METHODS

Thirteen women with ectopic pregnancy (Group I) and 17 women with first trimester spontaneous abortion (Group II) were included into this study. DNA flow cytometric analysis was performed on all specimens. Aneuploidy was classified according to DNA index. The first trimester spontaneous abortions were also karyotyped after long-term culture of chronic villi. Student-t test and Fisher's exact test were used in statistical comparisons.

RESULTS

DNA aneuploidy was found in five women with ectopic pregnancy (38.5%) versus in 12 women with first trimester spontaneous abortion (70.6%), and it was comparable. A triploidy and a tetraploidy were detected in group I. Six tubal ectopic pregnancies were unruptured at laparatomy and four of them had aneuploid DNA content.

CONCLUSIONS

We believed that DNA flow cytometry was successful in determining the ploidy status of ectopic pregnancy and first trimester spontaneous abortion. In addition, it was interesting that ectopic pregnancies with aneuploid DNA content tended to be unruptured. However, this suggestion needs to be confirmed by further studies with larger numbers of cases.

Mammographic changes in women on hormonal replacement therapy

OBJECTIVES

In the present retrospective study, we aimed to determine the frequency and the types of mammographic changes of breast parenchyma in women receiving hormone replacement therapy (HRT). We also investigated whether there was an association between mammographic changes and some clinical and hormonal characteristics of the women on HRT.

METHODS

One-hundred and eight women were included into the study. Of the 108 women, 19 were climacteric, four premature menopause, 50 spontaneous menopause and 35 surgical menopause. Prior to the start of HRT, an initial mammography was performed and it was repeated at 6- to 18-month intervals according to the women's status. Estrogen alone was started for 35 surgical menopause women and a combination of estrogen plus progesterone for the remaining 73 women.

RESULTS

Group I consisted of 96 women with no parenchymal changes or a decrease in parenchymal density on mammography, whereas group II consisted of 12 women with an increase in parenchymal density (11%) during the mean period of 24 months. Endogenous E2 levels were significantly higher in group II than in group I (52.4 +/- 42.3 pg/ml vs. 32.3 +/- 29.3 pg/ml, P < 0.05). Climacterium or types of menopause did not affect the mammographical density changes. Neither the type nor the duration of HRT had an effect on mammographic density increase.

CONCLUSIONS

We concluded that the endogenous E2 level might be an important role in screening the women mammographically. Long-term follow-up studies were concluded to be needed in order to evaluate the effects of HRT on mammographic changes.