Managed health care coverage for infertility services: understanding adverse selection

Insurance is an economic tool that individuals can use to reduce or eliminate financial risk. Health insurance provides risk reduction for economic loss caused by the need to pay for health care services. Insurance for any circumstance makes economic sense provided that administrative expenses to the insurer (insurance company or health plan) are no larger than the risk-premium or the value to the insured of having economic risk reduced or eliminated. Infertility has generally been regarded as a social problem rather than a medical one. Insurance companies and health plans have been reluctant to cover infertility services because of a lack of societal agreement that these services should be included and because accurate information about both the appropriate sequence of care and its cost effectiveness has not been available. Some health plans that have extended coverage for infertility services have experienced poor economic outcomes because of adverse selection. Adverse selection occurs when asymmetrical information exists, i.e. when those insured have privately held information about whether they will need the covered services or not. There are ways that the private sector can reduce or eliminate adverse selection without government mandates. These include limited coverage, experience rating, exclusion for pre-existing conditions, mandatory wait provisions, medical examinations and group coverage. When private sector efforts to control for adverse selection fail, government intervention may make sense. Governmental mandates are favoured by some because they compel wide coverage, which reduces overall economic risk. Even this can fail to eliminate adverse selection if individuals or couples who are higher risk for infertility move to areas where coverage is mandated. Given societal acceptance of the need for universal coverage for infertility services, the private sector should be able to create an economically beneficial insurance market for this coverage provided that they avoid adverse selection.

Hysterectomy: improving the patient's decision-making process

Increasingly, patients are expecting to be more involved than they traditionally have been in medical and surgical decision making. The unilateral process of informed consent is evolving into one of informed collaborative choice. Hysterectomy is a procedure that is frequently performed when reasonable surgical and nonsurgical alternatives remain. When professional consensus as to the clear recommendation for hysterectomy is not present, patient choice is particularly important. Because more than 80% of health-care decisions, including those in which one of the choices is hysterectomy, are elective, gynecologists and other health care providers increasingly will need to develop more efficient and collaborative methods to integrate patient autonomy and choice into the decision-making process. There is mounting evidence that both clinical and nonclinical outcomes (satisfaction and cost) may be improved when properly informed consumers collaborate in making medical and surgical decisions. Legal liability for adverse outcomes may be decreased by increased patient participation in medical and surgical decision making. The era of managed care has created an agency problem stemming from the fact that consumers (patients) are concerned that necessary procedures and other treatments may be withheld because of cost considerations. Health plans and medical groups likely will be required to provide objective information about the options that consumers (patients) have when faced with choices, including decision making and hysterectomy. By incorporating patient expectations and preferences as part of the process of decision making, an ethically acceptable and effective method of "rationing by patient choice" may be feasible. Figure 3 is a graphic depiction of such a process of informed collaborative choice progressing from effective choices through efficient choices and then to the one providing the best value for an individual patient.

Managed care in benign gynecology

Although managed care has been viewed by many as an intrusion into medical practice, the stated goals of its proponents are to improve practice outcomes in a cost-effective manner and change the focus of health care to disease prevention and rational clinical resource utilization. Because health care costs have risen consistently in excess of normal inflation, pressure has mounted to move away from traditional fee-for-service reimbursement and indemnity insurance to capitated payment and 'third party' managed care. Studies have shown that the number of providers of gynecologic care is currently in excess of demand based on a managed-care model. Success in managed care will therefore require an understanding of the new economics of health care and a commitment to the appropriate use of medical and surgical interventions. Research should focus on identifying and reducing the unintended and wasteful variation in practice style that currently exists for benign gynecology and all of health care. Clinical guidelines that are derived from actual measured outcomes and adjusted for severity of illness and co-morbid conditions should replace 'clinical opinion' and allow gynecologists to efficiently manage patients with a minimum of third-party interference.

Effect of epidural analgesia for labor on the cesarean delivery rate

OBJECTIVE

To use meta-analysis to evaluate the effect of epidural analgesia on the cesarean delivery rate.

DATA SOURCES

The MEDLINE data base was searched for articles published in English between January 1981 and April 1992. We also interviewed experts and conducted a bibliographic follow-up and manual review of recent journals published from April to July 1992.

METHODS OF STUDY SELECTION

We excluded articles with irrelevant titles, and those case studies, book chapters, or articles that did not provide primary and relevant data. Two hundred thirty articles were read, including articles that reported on women of standard obstetric risk and on cesarean delivery rates for an epidural group and for a concurrent no-epidural group. These criteria yielded six studies for a primary analysis and two others for a secondary analysis.

DATA EXTRACTION AND SYNTHESIS

The sample size of the epidural and no-epidural groups and the number of cesareans within each group were extracted. Tests of homogeneity were conducted. The pooled cesarean delivery risk difference as a result of epidural analgesia was estimated. The cesarean rate for women undergoing epidural analgesia was ten percentage points greater than for no-epidural women (P < .05). More than a nine percentage point increase was shown for cesarean deliveries for dystocia (P < .05), when pooling either all studies or only randomized studies.

CONCLUSIONS

The results of this meta-analysis strongly support an increase in cesarean delivery associated with epidural analgesia. Further research should evaluate the balance between analgesia associated with the use of epidurals, and postpartum morbidity and costs associated with cesarean deliveries.

Making continual improvements to health care

Health care organizations are looking for new ways to optimize the way that they provide health services. The notion that high quality health care means high costs is no longer accepted without question. Business organizations that found themselves at very high levels of inefficiency, not unlike the levels being seen in hospitals and clinics today, were able to transform their businesses by applying the principles of continual improvement. The components of knowledge for improvement, i.e., knowledge of a system, knowledge of variation, knowledge of psychology, and the theory of knowledge may seem to some too obvious to be recognized and applied on a daily basis in the workplace. Businesses and organizations that are failing, however, often lack this knowledge. We cannot be certain that management by continual improvement can or should be applied or modified to work in all health care organizations. Although the delivery of health care services is a business unlike any other, it has much in common with other service industries. The idea that the quality of patient care can be improved by using the principles of continual improvement currently is being tested.

Office sonography and office hysteroscopy

Researchers involved in assessing technology and healthcare, including gynecologic care, have identified differences among the terms efficacy, effectiveness and efficiency. In order to assess the efficiency of procedures such as office sonography and hysteroscopy, it is first necessary to compare them with the alternatives in terms of patient-focused outcomes. Office sonography has been used to diagnose early pregnancy disorders such as ectopic gestations and evaluate other adnexal pathology, with mixed results. The use of office hysteroscopy to assess abnormal bleeding may replace procedures that are associated with greater risk and expense. More information regarding outcomes is needed for both procedures before they can be recommended as efficient alternatives for the diagnosis or treatment of gynecologic conditions.

Long-term effects of transdermal estradiol with and without medroxyprogesterone acetate

OBJECTIVE

To study the long-term biological and metabolical effects of estradiol (E2) administered by transdermal therapeutic systems with and without the addition of medroxyprogesterone acetate (MPA).

DESIGN

Open, randomized, comparative trial.

SETTING

The reproductive endocrine unit of a tertiary care university-affiliated hospital.

PATIENTS

Fifty-seven postmenopausal women were given E2 transdermally, whereas 28 were randomized to take MPA by mouth. Fifteen premenopausal women were studied for comparison.

INTERVENTIONS

Estradiol, 0.1 mg, was administered by a transdermal therapeutic system for 24.5 of 28 days and was cycled for 96 weeks. Medroxyprogesterone acetate, 10 mg, was given for days 13 to 25 of each 28-day cycle (E+P group), whereas the remainder received E2 only.

MAIN OUTCOME MEASURES

Serum E2, estrone (E1), luteinizing hormone, follicle-stimulating hormone, low-density, high-density, very low-density, and total cholesterol, triglycerides, blood pressure, renin substrate, plasma renin activity, and serum aldosterone levels were measured in all subjects at baseline and in the postmenopausal women every 24 weeks until the end of study.

RESULTS

Mean +/- SE levels of E2 rose significantly from baseline at 24 weeks to 426 and 355 pmol/L for the E only and E+P groups, respectively. Smaller increases of estrone (E1) were observed to 263 and 244 pmol/L for the same respective groups. As expected, baseline levels of both gonadotropins were elevated, fell significantly with E2 administration, but remained increased in comparison with values observed in younger women. Decreases of total and low-density lipoprotein (LDL) cholesterol were observed in both groups that reached statistical significance at 48 weeks or later with the exception of LDL cholesterol in the E only group. No significant change of high-density lipoprotein or very low-density lipoprotein cholesterol or triglycerides was observed. There were reductions of mean systolic and diastolic blood pressures in both groups that reached significance at 72 weeks. Mean baseline plasma renin substrate, plasma renin activity, and serum aldosterone levels were within the ranges observed in younger, healthy women and did not change significantly with E2 administration in either group.

CONCLUSION

These data support the long-term efficacy and safety of this form of replacement therapy, particularly in combination with MPA, in women with a uterus.

Appropriateness of hysterectomies performed for multiple preoperative indications

OBJECTIVE

To correlate the listing of multiple preoperative indications for hysterectomy with the risk of non-confirmation of the preoperative diagnosis.

METHODS

Records of 171 women undergoing consecutive hysterectomies for all indications at a large teaching hospital were reviewed for preoperative indication(s), compliance with published preoperative validation criteria for cases in which tissue pathology was not expected, and histologic verification of the preoperative diagnosis for cases in which tissue pathology was expected. Rates of confirmation (histologic verification plus successful compliance with validation criteria) of the preoperative diagnosis were compared between subgroups of cases in which single indications were listed (N = 124) or multiple indications were listed (N = 47) preoperatively.

RESULTS

The rate of confirmation of single indications (115 of 124 cases, 93%) was significantly higher than the rate of confirmation of even one indication in cases in which multiple indications were listed (28 of 47 cases, 60%, P < .0001; relative risk for non-confirmation of multiple indications = 1.55). Multiple indications were more likely to be listed when tissue pathology was not expected, representing 49% of validatable indications as compared with only 18% of histologically verifiable indications (P < .0001). Overall, the rate of compliance with validation criteria (70%) was significantly lower than the rate of histologic verification (90%) (P < .01).

CONCLUSION

These data suggest that listing of multiple preoperative indications for hysterectomy is associated with both decreased appropriateness, as reflected in decreased compliance with generally accepted preoperative validation criteria, and decreased diagnostic accuracy, as reflected in lower rates of histologic verification.

Ovulation induction in women age 40 and older: the importance of basal follicle-stimulating hormone level and chronological age

OBJECTIVES

To determine pregnancy and livebirth rates for women age 40 and older undergoing ovulation induction and to assess the impact of basal follicle-stimulating hormone (FSH) on outcome in these patients.

DESIGN

Prospective, observational.

SETTING

Fertility service of university medical center.

PATIENTS

Infertile couples in whom the female partner was age 40 or older referred for ovulation induction therapy.

INTERVENTION

Assessment of basal hormonal status; ovulation induction.

MAIN OUTCOME MEASURES

Clinical pregnancy rate (PR), livebirth rate.

RESULTS

Analysis of 402 cycles in 85 women age 40 and older demonstrated a clinical PR of 3.5% per cycle (95% confidence interval [CI] 1.7% to 5.3%). The livebirth rate was 1.2% per cycle (95% CI 0.1% to 2.3%). Women with a basal FSH < 25 IU/L and age < 44 years had a clinical PR of 5.2% per cycle (95% CI 2.5% to 7.9%) compared with 0.0% per cycle (95% CI 0.0% to 2.1%) in cases in which either basal FSH was > or = 25 IU/L or age was > or = 44 (P < 0.005). The prognostic importance of basal FSH and chronological age was confirmed by multivariate logistic regression analysis. The predictive value of the resulting regression equation was high (R2 = 0.94; P < 0.01).

CONCLUSIONS

Pregnancy and livebirth rates are generally low during ovulation induction in women age 40 and older. In combination, basal FSH and chronological age are accurate predictors of PR, in these couples and can define a subset of patients with a more favorable prognosis. The spontaneous abortion rate in women who do conceive is high, substantially lowering the livebirth rate.

Rate-based calculation of failure to progress: a proposed quality improvement method

The rate of "failure to progress" as the indication for primary cesarean delivery used by the Joint Commission on Accreditation of Health Care Organizations is based upon the total number of cesareans performed for this indication divided by the total number of primary cesareans. This denominator includes a large number of patients who are not at risk for the diagnosis of failure to progress, including cases of malpresentation or multiple gestation in which cesarean is performed without trial of labor. Each of these variables may vary dramatically between individual physicians and institutions. Inclusion of patients not at risk for failure to progress results in a misclassification bias, which renders this rate less meaningful for purposes of comparison and trend assessment. We describe a simple method that bases the rate of failure to progress upon the population at risk for this diagnosis; that is, the total number of vaginal deliveries plus primary cesareans for failure to progress minus vaginal births after cesarean. Such a method controls for multiple differences in local practice standards and allows more meaningful assessment of trends and intra-institutional and inter-regional comparisons.

Routine hysterectomy for large asymptomatic uterine leiomyomata: a reappraisal

As part of an ongoing quality improvement process, the records of 104 consecutive patients undergoing hysterectomy for uterine leiomyomata were reviewed. The diagnosis was confirmed histologically in 93 cases (89%) and in eight of the remaining 11, other disease such as adenomyosis or an ovarian neoplasm was discovered. The 93 consecutive patients with a confirmed diagnosis of uterine leiomyomata were then stratified according to preoperative estimate of uterine size and actual uterine weight. The physician's clinical estimate of uterine size correlated well with specimen weight (r = 0.65, P less than .001). Intraoperative estimated blood loss correlated less well with actual change in hematocrit (r = 0.31, P = .03). Women with a uterine size estimate larger than 12 weeks' gestation were no more likely to suffer perioperative complications than were those with smaller uteri. Furthermore, there was no significant increase in mean estimated blood loss or blood transfusion in women with larger uteri compared with those with smaller uteri. We conclude that there is no increase in adverse short-term outcomes associated with hysterectomy for leiomyomata in women with uteri greater than 12 weeks' size. Therefore, hysterectomy need not be routinely recommended to asymptomatic women with larger uteri as prophylaxis against increased operative morbidity associated with future growth.

Correlation between sexual abuse and somatization in women with somatic and nonsomatic chronic pelvic pain

After a comprehensive clinical and psychological evaluation, 99 women with pelvic pain of at least 6 months' duration and normal findings at laparoscopy were divided into two groups, including 47 women with probable somatic causes of pain (group 1) and 52 women without identifiable somatic abnormality (group 2). Women without identifiable somatic abnormality (group 2) were younger, had higher mean somatization scores, and reported an earlier mean age at first intercourse, a higher number of total sexual partners, and a higher prevalence of sexual abuse before the age of 20. Within group 2 (nonsomatic pain) but not within group 1, mean somatization scores were significantly higher among women with a history of sexual abuse than among women with a negative history. When analyzed as risks for nonsomatic pelvic pain, the positive predictive value of both a history of sexual abuse and a high somatization score was 78% (relative risk compared with that of women with zero or one risk factor, 2.1; p less than 0.0001). These data suggest that the psychosocial profile of women with nonsomatic pelvic pain differs from that of women with somatic pelvic pain and that previous sexual abuse is a significant predisposing risk for somatization and non-somatic chronic pelvic pain.

Gonadal protection and fecundity rates in cyclophosphamide-treated rats

Premature ovarian failure and reduced fecundity are well-documented consequences of cytotoxic chemotherapy used to treat patients with malignant diseases. To investigate the ability of different hormonal agents to block the effects of cyclophosphamide (CTX) on reproductive function, sexually mature female Long-Evans rats were studied. Model development demonstrated that CTX, 6 mg/kg/day, 5 days/week for 3 weeks, was successful at inducing acyclicity and significantly reducing fertility and fecundity, with acceptable mortality, when compared to higher/lower dosages. Utilizing this model, animals were treated with CTX in combination with an inert vehicle, Lupron, 80 micrograms/kg every 24 h, Lupron, 40 micrograms/kg every 12 h, or s.c. progesterone capsules obtaining serum progesterone levels of 20-30 ng/ml. We concluded that progesterone was able to protect the gonad from the negative effects of CTX, maintaining fertility and fecundity rates not significantly different from those of untreated control animals. Lupron given every 12 h had a similar effect on fertility, but failed to protect fecundity (P less than 0.001).

Nongynecologic somatic pathology in women with chronic pelvic pain and negative laparoscopy

One hundred eighty-three women with chronic pelvic pain were referred to a multidisciplinary chronic pelvic pain clinic after negative laparoscopy. One hundred twenty-two of them completed a thorough medical and psychologic evaluation and were followed for a minimum of six months after completion of therapy. Occult somatic pathology was diagnosed in 57 women (47%), including 19 in whom coexistent psychopathology was diagnosed. Myofascial pain was the most common somatic diagnosis, followed by atypical cyclic pain (dysmenorrhea or mittelschmerz); gastroenterologic, urologic and infectious diseases; and pelvic vascular congestion. No plausible somatic etiology was apparent in the remaining 65 (53%) of the 122 referrals. Nongynecologic somatic pathology accounted for 34 (29%) and gynecologic pathology for 23 (19%) of the referrals, only 6 (5%) of whom ultimately required hysterectomy. Women with a somatic diagnosis were found to be significantly older than the remainder of the referral population. Long-term symptomatic improvement or resolution of pain was obtained in 43 (75%) of the 57 patients with somatic diagnoses. Coexistent psychopathology was found to correlate with a poorer long-term prognosis. Our findings underscore the importance of a multidisciplinary approach to evaluating and treating chronic pelvic pain in women and confirm that hysterectomy is indicated in this setting only rarely.

Quality assurance indicators and short-term outcome of hysterectomy

Fifteen gynecologic quality assurance indicators recently published by The American College of Obstetricians and Gynecologists were applied to a previously reported hysterectomy data base. Chart reviews were performed for the most recent 257 cases in the data base, representing an 18-month interval. The indicators were divided into two groups: those intended to identify morbidity and mortality and those intended to screen for appropriateness of care. Rates of actual morbidity and cases that failed to meet published criteria sets for hysterectomy were determined by chart review regardless of the presence of a quality assurance indicator. A total of 135 indicators were identified in 114 (44%) of the 257 cases, including 64 patients (25%) with morbidity indicators and 50 (19%) with appropriateness indicators. Actual morbidity was correctly identified in all 64 cases in which morbidity indicators were present. Three cases with significant morbidity were identified by chart review but not identified by the indicators, yielding positive and negative predictive values of 100 and 98%, respectively, and an overall accuracy of 99% for morbidity indicators. By contrast, 14 of the 50 cases in which appropriateness indicators were present actually failed to meet published criteria sets. An additional seven cases failing to meet criteria sets were identified by chart review and not identified by the indicators, yielding a positive predictive value of 28%, a negative predictive value of 97%, and an overall accuracy of 83% for appropriateness indicators.

The impact of a quality assurance process on the frequency and confirmation rate of hysterectomy

A criteria-based quality assurance process for hysterectomy was instituted at a large teaching hospital. After this process was initiated, the overall frequency of hysterectomy decreased by 24%, p less than 0.001. Significant reductions were seen in hysterectomy rates for the following indications: chronic pelvic pain (77%, p less than 0.0001), recurrent uterine bleeding (46%, p less than 0.001), preinvasive disease of the uterus (55%, p less than 0.005), and severe infection (70%, p less than 0.025). Adenomyosis was the single indication for which an increase in hysterectomy rate was observed. This increase, however, was completely reversed during the last 2 years of the study. This quality assurance process also resulted in a significant increase in the histologic verification rate (i.e., 82% vs 93%, p less than 0.001). These observations suggest that using such a criteria-based process can reduce the number of hysterectomies performed and improve the accuracy of the preoperative diagnosis.

Pathophysiology and management of endometrial hyperplasia and carcinoma

Endometrial cancer is currently the commonest pelvic malignancy affecting American women, most of whom share the same pathophysiologic basis, that is, unopposed estrogenic stimulation. The initial result of hyperestrogenism is the development of endometrial hyperplasia, which is reversible in most cases by appropriate hormonal therapy. Persistent stimulation eventually leads to atypical hyperplasia with nuclear atypia and invasive carcinoma. Because there is no cost-effective screening method for the detection of endometrial hyperplasia and carcinoma, it is essential to survey the high-risk population with appropriate diagnostic techniques. After diagnosis, therapy should be individualized based on pathologic findings (cell type and histologic grade) and extent of disease (International Federation of Gynaecologists and Obstetricians stage, depth of myometrial invasion, and pelvic and para-aortic lymph node status). Recent studies suggest that sex hormone receptors and nuclear DNA ploidy patterns provide useful prognostic information independent of histologic grade.

The effects of combining norethindrone with a gonadotropin-releasing hormone agonist in the treatment of symptomatic endometriosis

Treatment of endometriosis with gonadotropin-releasing hormone agonists (GnRH-a) is associated with side effects secondary to the induced hypoestrogenic state. In an effort to ameliorate these symptoms, 10 patients with symptomatic endometriosis self-administered the GnRH-a [D-His6(Imbzl)-Pro9-NET]-GnRH in combination with norethindrone daily for 24 weeks. Painful symptoms were significantly suppressed after therapy (P less than 0.005). Objective review of photographs taken at laparoscopy before and after therapy demonstrated significant reduction of visible implants (P less than 0.005). Vasomotor symptoms were minimized when compared with a group of 16 patients previously treated with GnRH-a alone. Bone mineral density of the distal radius assessed by single photon absorptiometry was not reduced during therapy, although lumbar spine bone density assessed by quantitative computerized tomography was minimally but reversibly reduced. No metabolic derangements were detected. The combination of norethindrone with GnRH-a is a well tolerated and effective means of treating symptomatic endometriosis.

Demographic and historic variables in women with idiopathic chronic pelvic pain

A comprehensive historic, demographic, and medical questionnaire was administered to 106 women referred to a multidisciplinary clinic for evaluation of idiopathic chronic pelvic pain and to 92 age-matched, pain-free control patients presenting for routine annual examination. Although racial distribution, mean gravidity and parity, and rates of elective abortion were similar in both groups of respondents, spontaneous abortion was reported significantly more frequently among women with pelvic pain. Patients in the study group were also more likely to be on active military duty, to have undergone previous nongynecologic surgery, and to have sought treatment for unrelated somatic complaints. Finally, although the mean ages at first intercourse were similar, women with idiopathic pelvic pain reported a higher total number of sexual partners and were significantly more likely to have experienced previous significant psychosexual trauma. These findings confirm that predisposing psychosocial variables are important in the pathogenesis of idiopathic pelvic pain and emphasize the significance of multidisciplinary evaluation and management.

Nonsurgical management of chronic pelvic pain: a multidisciplinary approach

Experience with multidisciplinary management of CPP has demonstrated the importance of ruling out and of treating nongynecologic conditions such as myofascial syndrome, irritable bowel syndrome, urethral syndrome, and psychogenic pain in women with CPP and normal laparoscopies. Moreover, current data suggest that availability of a multidisciplinary pelvic pain clinic can reduce the frequency of hysterectomy for this disorder.

Consumer advocacy, elective surgery, and the "golden era of medicine"

The process of medical quality assurance evolved logically from the consumer advocacy movement of the past decades. This process has fundamentally altered the personal and legal relationship between patients and physicians. The need for development and adoption of a medically, ethically, and fiscally sound standard of elective surgical practice is clear and immediate. A system that may be used to evaluate the appropriateness of elective surgical procedures is proposed.

Validation of hysterectomy indications and the quality assurance process

Hysterectomy is one of the most commonly performed major operations in the United States. Despite efforts to explain its high incidence, the perception remains that a significant number of hysterectomies are unjustified. More indications are listed for hysterectomy than for any other major operation. A quality assurance process is presented that requires the surgeon to select preoperatively one designated indication for each hysterectomy performed. The pathology report is expected to verify the surgical indication in 66% of the cases. The other 34% of hysterectomy specimens are not expected to show tissue pathology based on the listed indication. For these cases, predetermined validation criteria must be satisfied in the surgeon's preoperative note. Applying the process in this series of 584 consecutive hysterectomies, 93% (N = 396) of the "pathology expected" indications were verified by the pathology report and 98% (N = 188) of the "no pathology expected" indications were validated by the surgeon's preoperative note. The process of using a single designated indication and reviewing only two documents (the pathology report and the surgeon's preoperative note) has greatly simplified the quality assurance process. This system enables a quality assurance committee to monitor easily the appropriateness of hysterectomy indications for their institution. Information obtained from this process can influence changes regarding the acceptability of certain indications. As a result of this study, adenomyosis, because of its low (38%) verification rate, is no longer considered a reliable preoperative indication for hysterectomy at San Diego Naval Hospital.

Preoperative localization of androgen-secreting tumors: clinical, endocrinologic, and radiologic evaluation of ten patients

A series of 10 patients with benign androgen-secreting neoplasms is presented. Nine tumors were ovarian, and one adrenal. In an attempt to correctly diagnose the presence of tumor and to accurately localize the lesion to a specific gland, steroid hormones in peripheral, ovarian, and adrenal vein serum were analyzed by radioimmunoassay. Little correlation was made in this series with those levels of testosterone (greater than 2 ng/ml) or dehydroepiandrosterone sulfate (greater than 7000 ng/ml) that have been widely used to predict the presence of such tumors. Peripheral testosterone levels were less than 2 ng/ml in 50% of our patients, and the dehydroepiandrosterone sulfate level was greater than 7000 ng/ml in only a single patient with an ovarian lipoid cell tumor. Pelvic ultrasonography was found to be of limited value in evaluating nonpalpable tumor because of the small size (less than 2 cm3) of the majority of these neoplasms. The use of selective retrograde venous catheterization to demonstrate significant effluent-peripheral vein androgen gradients served to accurately localize androgen-secreting tumors in all six patients in which it was used. Our data emphasize the potential pitfalls that exist in the preoperative evaluation of patients with these fascinating neoplasms and the importance of a high degree of suspicion on the part of the physician caring for these women.

Inhibition by indomethacin of increased estradiol extraction by the IUD-containing rat uterine horn

The role of prostaglandins on the extraction of estradiol (E2) by the rat uterine horn in the presence of the intrauterine device (IUD) was evaluated. Increased extraction of E2 by the IUD horn compared to the contralateral control horn was consistently observed irrespective of the estrogen status of the animals. This increased extraction was abolished by indomethacin, an inhibitor of prostaglandin synthesis, suggesting a role of prostaglandin in this process.

The effect of membrane permeability and binding by human serum proteins on sex steroid influx into the uterus

To determine the effect of such factors as capillary membrane permeability, plasma protein binding, and capillary transit time on the availability of sex steroids to the uterus, the unidirectional influxes of 3H-labeled steroids from the circulation into the uterus were measured in vivo in anesthetized rats using a tissue-sampling, single injection technique. When dihydrotestosterone (DHT), estradiol (E2), and progesterone (P) were injected with Ringer's solution, the tissue extraction was in excess of 80%; hence, membrane permeability did not play a limiting role. With the more polar steroids, corticosterone and cortisol, uterine extraction was less than 40%. Significant inhibition of tissue extraction of DHT and E2, but not P, occurred with the addition of 4% albumin to the injection solution. Human sera containing increasing concentrations of sex hormone-binding globulin demonstrated inhibition of extraction of DHT and E2. Human sera also inhibited P extraction, presumably secondary to the presence of cortisol-binding globulin and orosomucoid. Large concentrations of unlabeled DHT, E2, and P in the injection solutions did not result in competitive inhibition of labeled steroid extraction. Thus, there is no evidence for a carrier mechanism mediating steroid transport into the uterus. When tissue extraction of E2 from Ringer's solution was compared in liver, brain, and uterus, no difference of tissue permeability could be found. Liver consistently had higher tissue E2 extraction than brain or uterus in the presence of human sera. The results are compatible with the influx of albumin-bound E2 into all three tissues and the influx of sex hormone-binding globulin-bound E2 into the liver.

In vivo effects of delta 1-testololactone on peripheral aromatization

To evaluate the in vivo effect of delta 1-testololactone on peripheral aromatization, studies were performed on seven postmenopausal women with metastatic breast cancer. Analysis of variance indicated that there were significant increases of circulating androstenedione (p less than 0.05) and estradiol (p less than 0.001) during administration of different doses of testololactone. Androstenedione levels were increased with all doses of testololactone tested (50, 100, 250, and 500 mg every 6 hr for 14 days each), while estradiol rose with only the 250- and 500-mg dosages. With administration, there was a significant decrease of estrone (p less than 0.001) with the mean level falling from 26 +/- 3 (S.E.) to 11 +/- 2 pg/ml. The addition of adrenal suppression (dexamethasone, 1 mg nightly at 11 p.m.) significantly lowered androstenedione (p less than 0.05) but had no effect on estrone or estradiol levels. Long-term therapy (up to 6 months) with the 250-mg dosage showed continual suppression of estrone with no escape being observed. Studies to determine the reason for the increase of estradiol with testololactone suggested cross-reactivity of the antibody with in vivo metabolites of the drug. However, these possible metabolites did not bind to uterine cytosol estrogen receptors. The decrease in estrone with testololactone administration presumably explains its antitumor properties.

Free estradiol in postmenopausal women with and without endometrial cancer

To assess the role of biologically active estradiol in the development of endometrial cancer, 25 patients with endometrial tumors and a similar number of control subjects matched for age and body size were studied. No differences between the 2 groups were found for levels of total estradiol, sex hormone-binding globulin (SHBG), non-SHBG-bound estradiol, and absolute free estradiol. Body size correlated positively with levels of total, non-SHBG-bound, and absolute estradiol and negatively with SHBG levels. The obese postmenopausal women had higher total circulating levels and proportionally greater concentrations of free estradiol than nonobese subjects, suggesting a dual risk for the cellular action of circulating estradiol. These factors could contribute to the association of obesity and the occurrence of this tumor in susceptible women.