Hyperandrogenemia in polycystic ovary syndrome: exploration of the role of free testosterone and androstenedione in metabolic phenotype

Objective

To evaluate the association between androstenedione, testosterone, and free testosterone and metabolic disturbances in polycystic ovary syndrome.

Methods

We analyzed the association between androstenedione, testosterone, and free testosterone and metabolic parameters in a cross-sectional study including 706 polycystic ovary syndrome and 140 BMI-matched healthy women. Polycystic ovary syndrome women were categorized into 4 groups: normal androstenedione and normal free testosterone (NA/NFT), elevated androstenedione and normal free testosterone (HA/NFT), normal androstenedione and elevated free testosterone (NA/HFT), elevated androstenedione and free testosterone (HA/HFT).

Results

Polycystic ovary syndrome women with elevated free testosterone levels (HA/HFT and NA/HFT) have an adverse metabolic profile including 2 h glucose, HbA1c, fasting and 2 h insulin, area under the insulin response curve, insulin resistance, insulin sensitivity index (Matsuda), triglycerides, total and high density lipoprotein cholesterol levels compared to NA/NFT (p<0.05 for all age- and BMI-adjusted analyses). In binary logistic regression analysis adjusted for age and BMI, odds ratio for insulin resistance was 2.78 (1.34–5.75, p = 0.006) for polycystic ovary syndrome women with HA/HFT compared to NA/NFT. We found no significantly increased risk of metabolic disorders in polycystic ovary syndrome women with HA/NFT. In multiple linear regression analyses (age- and BMI-adjusted), we found a significant negative association between androstenedione/free testosterone-ratio and area under the insulin response curve, insulin resistance, and total cholesterol/high density lipoprotein cholesterol-ratio and a positive association with Matsuda-index, and high density lipoprotein cholesterol (p<0.05 for all).

Conclusions

Polycystic ovary syndrome women with elevated free testosterone levels but not with isolated androstenedione elevation have an adverse metabolic phenotype. Further, a higher androstenedione/free testosterone-ratio was independently associated with a beneficial metabolic profile.

Serum vitamin D levels and hypogonadism in men

There is inconsistent evidence on a possible association of vitamin D and androgen levels in men. We therefore aim to investigate the association of 25-hydroxyvitamin D (25(OH)D) with androgen levels in a cohort of middle-aged men. This cross-sectional study included 225 men with a median (interquartile range) age of 35 (30-41) years. We measured 25(OH)D, total testosterone (TT) and SHBG concentrations. Hypogonadism was defined as TT <10.4 nmol/L. We found no significant correlation of 25(OH)D and androgen levels. Furthermore, androgen levels were not significantly different across 25(OH)D quintiles. The overall prevalence of hypogonadism was 21.5% and lowest in men within 25(OH)D quintile 4 (82-102 nmol/L). We found a significantly increased risk of hypogonadism in men within the highest 25(OH)D quintile (>102 nmol/L) compared to men in quintile 4 (reference) in crude (OR 5.10, 1.51-17.24, p = 0.009) as well as in multivariate adjusted analysis (OR 9.21, 2.27-37.35, p = 0.002). We found a trend towards increased risk of hypogonadism in men within the lowest 25(OH)D quintile (≤43.9 nmol/L). In conclusion, our data suggest that men with very high 25(OH)D levels (>102 nmol/L) might be at an increased risk of hypogonadism. Furthermore, we observed a trend towards increased risk of hypogonadism in men with very low vitamin D levels indicating a U-shaped association of vitamin D levels and hypogonadism. With respect to risk of male hypogonadism, our results suggest optimal serum 25(OH)D concentrations of 82-102 nmol/L.

Use of and attitudes towards emergency contraception: a survey of women in five European countries

OBJECTIVE

To identify knowledge of and attitudes towards emergency contraception (EC) in women from five European countries.

METHODS

In an internet-based survey, sexually active women aged 16 to 46 years from France, Germany, Italy, Spain, and the UK were asked about their use of and opinions on EC.

RESULTS

Overall, 7170 women completed the survey. Thirty percent reported having had unprotected sexual intercourse during the previous 12 months (population at risk). Twenty-four percent of the population at-risk reported using EC. The most common reasons given for not using EC were: not perceiving themselves to be at risk of pregnancy; and not thinking about EC as an option. A third of respondents indicated they did not know how EC works, with several misconceptions about EC noted e.g., leading to infertility, similar to abortion. Seventy-nine percent of women agreed that EC is a responsible choice to prevent unwanted pregnancy, but nearly a third of women who used EC felt uncomfortable or judged when obtaining it.

CONCLUSIONS

EC is underutilised by three-quarters of the women surveyed. Women do not recognise they may be at risk of pregnancy when contraception fails. There are still several misbeliefs about EC indicating a need for better education of the public.

Emergency contraception

There have been numerous attempts to control fertility after unprotected sexual intercourse (UPSI). From very bizarre methods like the vaginal application of Coca Cola to the more serious attempts using calcium antagonists influencing fertility parameters in sperm to hormonal methods or intrauterine devices. So far, hormonal methods preventing or delaying ovulation have proved to be the most popular starting with the combination of ethinyl estradiol and levonorgestrel (LNG), known as the Yuzpe regimen. The first dose had to be taken within 72 hours of UPSI, a second one 12 hours later. Later on, LNG alone, at first in a regimen similar to the Yuzpe method (2 × 0.75 mg 12 hours apart) showed to be more successful, eventually resulting in the development of a 1.5 mg LNG pill that combined good efficacy with a high ease of use. Several efficacious and easy to use methods for emergency contraception (EC) are available on the market today with the most widely spread being LNG in a single dose of 1.5 mg (given as one tablet of 1.5 mg or 2 tablets of 0.75 mg each) for administration up to 3 days (according to WHO up to 5 days) after UPSI. Its limitations are the non-optimal efficacy which is decreasing the later the drug is taken and the fact that it is only approved for up to 72 hours after UPSI. This regimen has no effect on the endometrium, corpus luteum function and implantation, is not abortive and don't harm the fetus if accidentally taken in early pregnancy. It has no impact on the rate of ectopic pregnancies. It has become the standard method used up to this day in most countries. Since the mid 1970s copper IUDs have been used for EC, which show a high efficacy. Their disadvantages lie in the fact that EC is considered an off label use for most IUDs (not for the GynFix copper IUD in the European Union) and that they might not be acceptable for every patient. Furthermore IUD-insertion is an invasive procedure and it is required trained providers and sterilized facilities. Mifepristone in the dosages of 10 or 25 mg is used with good results as an emergency contraceptive in China for up to 120 hours after UPSI, but has never received any significant consideration in Western countries. While high doses of mifepristone has an effect on endometrial receptivity and will inhibit ovulation if given in the follicular phase and prevent implantation if given in the early luteal phase, low doses such as 10 mg has no impact on the endometrium. Mifepristone does not increase the rate of ectopic pregnancies. The most recent development is the approval of the selective progesterone receptor modulator ulipristal acetate (UPA) in the dosage of 30 mg for EC up to 5 days after UPSI, combining the safe and easy application of the single dose LNG pill with an even higher efficacy. It has shown to be more efficacious than LNG and can be used for up to 120 hours after UPSI; the difference in efficacy is highest for 0-24 hours, followed by 0-72 hours following UPSI. No VTE has been reported following UPA-administration or any progesterone receptor modulator. No effect on endometrium, corpus luteum function and implantation has been observed with doses used for EC. Independent of the substance it should be noted that, if there is a choice, the intake of an oral emergency contraceptive pill should happen as soon as possible after the risk situation. A pre-existing pregnancy must be excluded. Possible contraindications and drug interactions must be considered according to the individual special product informations.

Endometrial safety of a novel monophasic combined oral contraceptive containing 0.02 mg ethinylestradiol and 2 mg chlormadinone acetate administered in a 24/4-day regimen over six cycles

BACKGROUND

This study was conducted to examine whether small doses of ethinylestradiol (EE, 0.02 mg) and chlormadinone acetate (CMA, 2 mg) administered in a novel 24/4-day regimen during six cycles would suffice to suppress proliferation and to cause secretory changes in the endometrium.

STUDY DESIGN

This Phase II, randomized (two assessment groups), single-center, open, uncontrolled, multiple-dosing study treated 59 female subjects. The subjects underwent three endometrial biopsies: one pretreatment, one during medication (either at Cycle 3 or Cycle 6) and one during the first post-treatment cycle.

RESULTS

The study revealed that 0.02 mg EE/2 mg CMA effectively transformed the endometrium from a proliferative state into a secretory or inactive state after three (90% of subjects) and six (76% of subjects) medication cycles. The mean endometrial thickness decreased markedly from 10.2 (SD±3.0) mm (pretreatment) to an unfavorable level for the nidation of a blastocyst [5.3 (SD±2.1) and 4.1 (SD±2.2) mm in Medication Cycles 3 and 6, respectively]. Correspondingly, estradiol and progesterone levels decreased during treatment. In the post-treatment cycle, endometrial biopsy and ultrasound evaluation as well as sex hormone levels suggested a quick return to fertility. There were no signs of hyperplasia, endometrial polyps, neoplasia or other detrimental histopathological changes at any time during the trial. Treatment-related adverse events (AEs) were reported by 22 (37%) of 59 subjects and were reported most commonly in Cycle 1, decreasing continuously thereafter. No AEs led to discontinuation of the trial medication and there were no serious AEs.

CONCLUSIONS

The 24/4-day regimen of 0.02 mg EE/2 mg CMA provided effective and reversible endometrial effects with secretory transformation or suppression without inducing pathological changes.

Hormonal contraception and risk of endometrial cancer: a systematic review

More than 15 case-control studies and at least four large cohort studies demonstrated a decrease in the risk of endometrial cancer of about 50% for ever use of combined oral contraceptives (COCs). In most of these studies, this protective effect persisted for more than 10-15-20 years after cessation of the COC. An increasing protective effect with longer duration of COC use has been found in most studies. The beneficial effect was independent of the composition of COC, i.e. dosage and type of progestogen, combined with ethinyl estradiol 30-50  μg/day. COCs with higher progestogen potency seem to be somewhat more effective. Nonhormonal uterine devices have also been found to be strongly protective; however, data on oral or injectable progestogen-only preparations (POPs) including the levonorgestrel-releasing intrauterine system (LNG-IUS) are still rare, but also suggest similar protective action. COCs, POPs, as well as LNG-IUS can effectively reduce endometrial hyperplasia but should only be used in exceptional cases in patients with or after endometrial cancer. In contrast to nonhormonal IUS, systemic side effects cannot be excluded with LNG-IUS, but they are certainly rare, as the main effect has decreased the endometrial estrogen response because of the high endometrial tissue levels of LNG.

[S2k-guideline for therapy of acne]

To optimize the treatment of acne in Germany, the German Society of Dermatology (DDG) and the Association of German Dermatologists (BVDD) initiated a project to develop consensus-based guidelines for the management of acne. The Acne Guidelines focus on induction therapy, maintenance therapy and treatment of post-acne scarring. They include an evaluation of the most commonly used therapeutic options in Germany. In addition, they offer detailed information on how to administer the various treatments and on contraindications, adverse drug reactions, and drug interactions, taking into account gender and special conditions such as pregnancy and lactation. The Acne Guidelines were developed following the recommendations of the Association of Scientific Medical Societies in Germany (AWMF). The treatment recommendations were developed by an expert group and finalized by an interdisciplinary consensus conference. The first choice treatments for acute acne according to acne type are as follows: 1) comedonal acne: topical retinoids; 2) mild papular/pustular acne: fixed or sequential combinations of BPO and topical retinoids or of BPO and topical antibiotics; 3) moderate papular/pustular acne: oral antibiotic plus BPO or plus topical retinoid, or in a fixed combination 4) acne papulo-pustulosa nodosa and acne conglobata: oral antibiotic plus topical retinoid plus BPO or oral isotretinoin. For maintenance treatment: topical retinoid or its combination with BPO. Particular attention should be paid to compliance and quality of life. Additional treatment options are discussed in the main body of the text.

Highly sensitive determination of the polaron-induced optical absorption of organic charge-transport materials

We examine polaron-induced absorption in organic transport materials using a highly sensitive measurement technique. A hole only device is embedded into a low-loss TE2 waveguide structure, and the current induced change of the waveguide absorption is measured. The exemplary study of 2,2('),7,7(')-tetrakis(N,N-diphenylamine)-9,9(')-spiro-bifluorene (S-TAD) reveals a very low polaron absorption cross section of sigma(p) < or = 2.6 x 10(-18) cm(2) for 560 nm < or = lambda < or = 660 nm. The accuracy of this data is unsurpassed by other techniques used for the unambiguous study of polaronic species in organic thin films.

The use of hormone replacement therapy in patients after breast cancer

Four prospective randomized studies and at least 15 observational studies investigating hormone replacement therapy (HRT) after breast cancer are available. Only the Hormonal replacement therapy After Breast cancer: Is iT Safe (HABITS) study shows an increased risk of relapse. This is probably associated with the relatively high number of patients with HRT treatment after estrogen receptor-positive cancers as well as to the preferred use of estrogen/progestin combined preparations. As is generally known, the progestin component especially seems to be mainly responsible for the probability of increased diagnosis frequency of breast cancer. However, the patient samples in all studies investigating HRT after breast cancer are small. Therefore, HRT should only be used if alternatives, such as specific not contraindicated phyto-preparations or serotonin reuptake inhibitors, are not working. This is primarily due to forensic reasons. According to medical criteria, the data for the alternatives seem to be even more sparse, since many important questions remain unanswered, such as side effects and risks, or also regarding interactions with adjuvant hormone therapy.

The ESHRE/ASRM consensus on polycystic ovary syndrome (PCOS) – an extended critical analysis

The 'ESHRE/ASRM consensus on diagnosis, nomenclature and long-term health risks of polycystic ovarian syndrome (PCOS)' (conference in Rotterdam, Netherlands, March, 2003), which was criticized shortly after its oral presentation in 2003, is still being debated following its publication in 2004. Therefore, an extended, intensive analysis of all parameters and their combinations has been performed, differentiating between inclusion and exclusion criteria. By doing this, the profound significance of the endocrinological part of the syndrome is highlighted. The nomenclature, semantic meaning of terms, definitions, structural balancing, specificity, practicability, flexibility, limitations and reproducibility for both individualization, as well as grouping from the clinical and scientific perspective, have been examined in detail. This analysis supports previous critical comments, and reaches the conclusion that the recommendations of the consensus lack accuracy and specificity, a weakness that results in the risk of overdiagnosis and in a lack of reproducibility. Altogether, they fail to fulfil the criteria of universal guidelines on several levels. Instead, a profound paradigm shift is demanded, from an inconsistent perception to a more systematic, balanced and comprehensive view. A short indication on an alternative sweeping concept of a strictly defined, therapy-targeted classification and diagnostic procedure of female functional androgenization is presented.

[Malaria in the central highlands of Madagascar: control strategies]

The purpose of this article is to present data on malaria in the central highland plateaux of Madagascar and strategies to improve the national malaria control program. Use of rapid diagnosis strips, early home-based fever management with pre-packaged chloroquine treatment kits and proposed new therapeutic combination based on artemisinine are discussed for management of patients with high suspicion of malaria attack. Preventive measures including alternated targeted and full-house indoor spraying for vector control, use of insecticide-impregnated bednets, implementation of intermittent preventive treatment in risk groups, optimization of the epidemic early detection and warning system using the Lot Quality Assurance Sampling method for epidemiological investigation if the alert threshold is exceeded, and provision of rapid diagnosis strips are presented.

Luteal-phase inhibin A and follicular-phase inhibin B levels are not characteristic of patients with an elevated LH-to-FSH ratio

PURPOSE

To test whether serum inhibin levels are related to differences in gonadotropin concentrations between patients with an elevated LH-to-FSH ratio (ELF patients) and controls.

METHODS

32 ELF patients were matched with controls by age, body mass index (BMI), and cycle length.

RESULTS

No statistically significant difference was found in follicular-phase inhibin B levels or midluteal inhibin A levels between cases and controls. Significant negative correlation was observed between follicular-phase inhibin B concentrations and BMI in ELF patients but not among controls. LH and FSH were positively related to inhibin B levels in ELF patients. Midluteal inhibin A correlated with sex hormone-binding globulin in controls but not in ELF patients.

CONCLUSIONS

Neither follicular-phase inhibin B levels nor midluteal inhibin A levels are characteristic of patients with an elevated LH-to-FSH ratio. Opposite correlations with LH and BMI suggest dysregulation of inhibin secretion rather than dimeric inhibins having a central role to the endocrinological imbalance observed in polycystic ovary syndrome.

Intraoperative venous blood sampling to localize a small androgen-producing ovarian tumor

BACKGROUND

Among other causes of virilization, ovarian tumors can be the cause of excessive androgen production. We report the case of a Leydig cell tumor of the ovary where diagnostic attempts to localize the source of hyperandrogenism preoperatively failed owing to relatively small tumor size.

CASE

A 36-year-old woman presented with clinical signs of severe virilization including progressive balding, increased hirsutism, secondary amenorrhea and enlargement of the clitoris. Extensive work-up included endocrinological tests, pelvic ultrasound, magnetic resonance imaging, chromosomal analysis, norcholesterol scintigraphy and selective venous sampling, without direct localization of the source of hyperandrogenism. Persistently high plasma testosterone prompted an explorative laparotomy. Intraoperative selective blood sampling of the ovarian veins and palpation gave evidence of a right ovarian tumor, which was then removed. Histological examination revealed the presence of a pure Leydig cell tumor.

CONCLUSION

Exploratory laparotomy with intraoperative selective blood sampling of the ovarian veins might be a useful approach in patients without accurate preoperative localization of androgen-producing tumors of the ovaries.

Serum CA-125 and inhibin B levels in the prediction of ovarian response to gonadotropin stimulation in in vitro fertilization cycles

There is much controversy about the relationship between serum CA-125 levels during in vitro fertilization (IVF) cycles and ovarian function. To evaluate the prognostic value of serum CA-125 and inhibin B measurements in predicting ovarian response to gonadotropin stimulation, we compared the CA-125 and inhibin B levels of poor and normal responders on the first day of ovarian stimulation, on the day of ovulation induction (OI) and at oocyte pick-up. Sixteen patients with poor ovarian response (3 oocytes, serum estradiol (E2) 900 pg/ml at OI) in IVF/intracytoplasmic sperm injection cycles were matched with normal responders (6 oocytes, E2 1800 pg/ml) by age, spontaneous cycle day-3 follicle-stimulating hormone level and cause of infertility. Inhibin B concentrations were significantly lower at all three time points in poor responders, but CA-125 levels were not. No statistically significant correlation was found between CA-125 levels and any of the clinical or laboratory parameters examined. Thus, CA-125 measurements during stimulation are not useful in predicting or identifying poor ovarian response to gonadotropin stimulation in IVF cycles. The lack of difference in CA-125 concentrations between poor and normal responders and lack of correlation with E2 or inhibin B levels suggest that ovarian steroidogenesis and other granulosa cell functions do not influence the production of CA-125. Inhibin B, however, seems to predict ovarian response as early as at the start of stimulation.

Use of serum inhibin B levels at the start of ovarian stimulation and at oocyte pickup in the prediction of assisted reproduction treatment outcome

OBJECTIVE

To assess whether serum inhibin B levels before gonadotropin administration and at oocyte pickup (OPU) are associated with pregnancy.

DESIGN

Retrospective case-control study.

SETTING

University-based IVF program.

PATIENT(S)

Fifty-five IVF pregnancies and 55 control cycles matched by age, type of infertility, E(2) at ovulation induction, number of oocytes retrieved, and number of embryos replaced.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Association between serum inhibin B at stimulation day 1 (SD1) and OPU and pregnancy; correlation between inhibin B with clinical and endocrine parameters; predictive accuracy of inhibin B measurements at OPU.

RESULT(S)

Inhibin B on SD1 was similar between pregnant and nonpregnant subjects, whereas it was significantly higher at OPU in pregnant cycles, but did not allow differentiation between pregnancy outcomes. Inhibin B on SD1 was positively correlated with same-day E(2) in both groups and inversely with age in pregnant cycles. In both groups, inhibin B at OPU correlated positively with number of oocytes collected and with E(2) at ovulation induction.

CONCLUSION(S)

Higher inhibin B concentrations at OPU are predictive of clinical pregnancy, independently of age, peak E(2), number of oocytes retrieved and number of embryos replaced. Inhibin B on stimulation day 1 did not prove to be a useful predictor.

Skin aging and sex hormones in women - clinical perspectives for intervention by hormone replacement therapy

The skin, the largest organ of the body, is the organ in which changes associated with aging are most visible. The skin is a target organ for various hormones, and sex steroids have a profound influence on the aging process. A decrease in sex steroids thus induces a reduction of those skin functions that are under hormonal control. Keratinocytes, Langerhans' cells, melanocytes, sebaceous glands, collagen content and the synthesis of hyaluronic acid, for example, are under hormonal influence. Topical application of estrogens has a positive effect on skin aging parameters, whilst numerous studies have also shown the positive influence of systemic hormone replacement therapy on skin aging. As an alternative treatment, phytohormones may be administered, with the structural similarity to 17beta-estradiol explaining their estrogen-like effects. However, isoflavonoids exhibit an inferior biological potency to synthetic estrogens. Although a large number of publications have documented the effects of sex hormones on the aging process, it is obvious that hormone replacement should not be administered as an independent treatment for skin aging.

Beneficial Effects of Estrogens on Indices of Renal Damage in Uninephrectomized SHRsp Rats

Renal diseases tend to be less severe among premenopausal female patients, compared with male patients. Experimental data on the effects of estrogens on renal damage are controversial, and potential underlying mechanisms have not been fully clarified. Three-month-old, female, uninephrectomized (UNX), sham-operated or ovariectomized (OVX) SHRsp rats were left untreated or received either 17beta-estradiol 3-benzoate (25 micro g/d) or estriol (0.02 mg/d) daily. After 3 mo, indices of renal damage (glomerulosclerosis index and tubulointerstitial damage index) and glomerular geometric parameters were investigated. The expression of desmin, TGF-beta, endothelin-1, collagen IV, endothelial nitric oxide synthase, and estrogen receptors alpha and beta in the glomeruli and tubulointerstitium was immunohistochemically evaluated. Estradiol and estriol did not significantly affect kidney weights or BP. Estradiol and estriol caused significant reductions in albuminuria (vehicle-treated UNX/OVX animals, 25.4 +/- 8.52 mg/24 h; estradiol-treated UNX/OVX animals, 15.37 +/- 6.12 mg/24 h; estriol-treated UNX/OVX animals, 6.54 +/- 2.24 mg/24 h). The glomerulosclerosis index was significantly lower in estriol- and estradiol-treated animals (estradiol-treated UNX/OVX animals, 0.69 +/- 0.16; estriol-treated UNX/OVX animals, 0.21 +/- 0.12; P < 0.05), compared with vehicle-treated animals (1.46 +/- 0.09); the tubulointerstitial damage index exhibited a similar pattern. The mean glomerular volume was significantly less in estrogen-treated animals. UNX/OVX animals demonstrated significantly greater expression of TGF-beta and endothelin-1 in immunohistochemical, in situ hybridization, and reverse transcription-PCR assays. This increase was abrogated by estriol but not estradiol. Similarly, significantly higher glomerular and tubulointerstitial expression of proliferating cell nuclear antigen and collagen IV was observed in UNX/OVX animals, and expression was decreased by estriol but not estradiol. It was concluded that, in the UNX model of spontaneous renal damage, glomerular lesions and glomerular hypertrophy were reduced by estriol but less consistently by estradiol. In parallel, loss of podocytes, evidence of podocyte injury (i.e., desmin expression), and expression of mediator systems of glomerular damage were decreased, pointing to a major renoprotective action of estriol.

Induction of androgen receptor activity by norgestimate and norelgestromin in MDA-MB 231 breast cancer cells

The function and clinical significance of the androgen receptor (AR) in human breast cancer are still not clear. The synthetic progestins, norgestimate and norelgestromin, were designed to minimize the adverse effects such as acne, hirsuitism and metabolic changes observed with older oral contraceptives while maintaining contraceptive effectiveness and cycle control. AR-mediated effects of these synthetic progestins were studied in an in vitro transactivation assay, employing DNA co-transfection of an AR expression vector and luciferase reporter gene construct in the MDA-MB 231 human breast cancer cell line. Testosterone acetate and 5alpha-dihydrotestosterone induced the reporter gene transcription, whereas incubation of the transfected cells with the natural progestin 17alpha-hydroxyprogesterone did not markedly induce luciferase activity. The progestins norgestimate and norelgestromin exerted a very low androgenic activity. Our data suggest that norgestimate and its metabolite norelgestromin possess weak androgen-like properties. The use of these compounds for clinical application may be of great advantage in the treatment of breast cancer as well as hyperandrogenism in women.

Matrix metalloproteinase 2 and tissue inhibitor of metalloproteinase 2 expression is not regulated by norgestimate or norelgestromin

Steroid hormones regulate endometrial expression of matrix metalloproteinases (MMPs) and their inhibitors. Synthetic progestins are widely used in oral contraceptives and for hormone replacement therapy. To assess whether the synthetic progestins norgestimate and its derivative norelgestromin (17-deacetylnorgestimate) modulate the expression of MMPs, Ishikawa endometrial cancer cells were separately treated with 17 beta-estradiol, 17 alpha-hydroxyprogesterone, norgestimate and norelgestromin. Culture supernatants were assayed for MMPs 2, 3 and 9, and for tissue inhibitors of MMPs (TIMP-1 and TIMP-2) by enzyme-linked immunosorbent assays (ELISAs). No marked modulation of MMP-2 and TIMP-2 expression was observed upon incubation of the cells with the synthetic progestins. By ELISA, neither MMP-3 or MMP-9 nor TIMP-1 immunoreactivity was detected. Interestingly, TIMP-2 expression was down-regulated by 17 beta-estradiol and 17 alpha-hydroxyprogesterone.

Use of serum inhibin A and human chorionic gonadotropin measurements to predict the outcome of in vitro fertilization pregnancies

OBJECTIVE

To assess the clinical value of maternal serum inhibin A measurements in early pregnancy in the prediction of outcome of IVF pregnancies and to compare the predictive accuracy of inhibin A concentrations with serum hCG concentrations.

DESIGN

Retrospective study.University-based IVF program.

PATIENT(S)

One hundred fifty IVF pregnancies of 150 couples were studied during a 4-year period.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The association between pregnancy outcome and age, number of collected oocytes, number of transferred embryos, and serum hCG and inhibin A concentrations in early pregnancy was studied with logistic regression. Predictive accuracy of inhibin A and hCG concentrations was calculated by receiver-operating characteristic (ROC) analysis.

RESULT(S)

Lower serum concentrations of inhibin A and hCG were associated with increased odds for preclinical abortion and early pregnancy loss, whereas higher inhibin A and hCG concentrations were observed in multiple ongoing pregnancies. Inhibin A measurements were superior to hCG in the prediction of preclinical abortions; no significant difference was observed between the predictive value of hCG, inhibin A, or their combination in differentiating between ongoing pregnancies and early pregnancy losses. The discriminative potential of inhibin A for prognosticating multiple ongoing pregnancies was lower than that of hCG.

CONCLUSION(S)

Although serum inhibin A concentrations are more accurate than hCG levels for predicting preclinical abortion after IVF, they had no advantage in forecasting ongoing or multiple ongoing pregnancies, suggesting that routine assessment of serum inhibin A concentrations during follow-up of IVF pregnancies is unjustified.

Synthetic estrogen-mediated activation of ERK 2 intracellular signaling molecule

Ovarian steroids are important modulators of normal cell growth and differentiation as well as of carcinogenesis. External stimuli trigger cell surface receptors, resulting in activation of central signal transduction pathways, that are mediated by members of the mitogen-activated protein kinase (MAPK) family. These in turn, indirectly regulate cellular functions such as cell proliferation, cell cycle, and maintenance of malignant phenotype. In our in vitro study, we have investigated the effects of two synthetic estrogens on ERK 2 activation. Estrogen receptor positive cells were incubated with the synthetic estrogens, ethinylestradiol (10(-9) mol/l) and 17 beta-estradiol valerate (10(-9) mol/l), epidermal growth factor (EGF) (10 ng/ml) and the natural estrogen 17 beta-estradiol (10(-9) mol/l), for 5 min. The same experiments were repeated prior to preincubation with the antiestrogen ICI 182780. ERK 2 or the active form alone were detected by immunoblotting. A cell proliferation assay was used to study the response of cells to various treatments. Time kinetics were performed to study duration of kinase activated state. Cell incubation with EGF as well as with either natural or synthetic estrogen stimulated proliferation. ICI 182780 inhibited this effect, but only in the case of estrogen. Synthetic estrogens activated MAP kinase in a time-dependent fashion, similar to 17 beta-estradiol. The estrogen receptor antagonist ICI 182780 blocked this effect. EGF induced a more pronounced and prolonged activation, even in the presence of the antiestrogen. Ethinylestradiol as used in oral contraceptives, and 17 beta-estradiol and 17 beta-estradiol valerate as used in hormone replacement therapy, are able to activate MAP kinase. This activation was blocked by an antiestrogen.

Cortisol and cortisone in human follicular fluid and serum and the outcome of IVF treatment

BACKGROUND

The glucocorticoid status of ovarian follicular fluid has been linked to oocyte quality. The aim of this study was to examine whether the concentrations of cortisone and cortisol and their calculated ratios in the follicular fluid and serum samples are predictive of IVF outcome.

METHODS

In the prospective study of 387 patients (420 treatment cycles) undergoing IVF treatment the concentrations of cortisone and cortisol were measured with specific assays, and their calculated ratios in the follicular fluid and serum samples obtained after ovarian stimulation and induced ovulation were determined.

RESULTS

In 75 patients, treatment resulted in clinical pregnancy and was associated with significantly lower follicular cortisone (24+/-12 versus 29+/-16 nmol/l, P<0.002) and higher cortisol/cortisone ratio (7.24+/-2.22 versus 6.45+/-2.17 nmol/l, P<0.007). In addition, the ratios of serum cortisone and cortisol to follicular cortisone and cortisol were significantly higher in those women who became pregnant.

CONCLUSIONS

We propose that the follicular fluid glucocorticoid concentration resulting from the conditions in the circulation and the course of the intrafollicular cortisol-cortisone interconversion appear to play a role in the outcome of IVF.

Progestogens with antiandrogenic properties

Chlormadinone acetate, cyproterone acetate and dienogest are potent, orally active progestogens, which have antiandrogenic instead of partial androgenic activity. They act mainly by blocking androgen receptors in target organs, but also reduce the activity of skin 5alpha-reductase, the enzyme responsible for converting testosterone to the more potent androgen, 5alpha-dihydrotestosterone, in sebaceous glands and hair follicles. Chlormadinone acetate and cyproterone acetate also suppress gonadotropin secretion, thereby reducing ovarian and adrenal androgen production. Combined oral contraceptives (COCs) containing antiandrogenic progestogens provide highly effective contraception (gross and adjusted Pearl indices: 0-0.7 and 0-0.3, respectively) with excellent cycle control. Furthermore, COCs containing 2mg of chlormadinone acetate or cyproterone acetate plus 30 or 35 microg of ethinylestradiol produced improvement or resolution of seborrhoea in 80% of users, acne in 59-70%, hirsutism in 36% and androgen-related alopecia in up to 86%. These COCs are generally well tolerated, the main adverse effects being nonspecific or as expected for a COC (headache, breast tenderness and nausea). They have no clinically relevant effects on metabolic or liver functions or on bodyweight. Effects on mood and libido are uncommon (<3.5% and <6% of women, respectively). COCs containing antiandrogenic progestogens are likely to be particularly valuable in women with pre-existing androgen-related disorders who require contraception. They also increase the choice of products available for women with normal skin and hair who are concerned about the possibility of developing seborrhoea or acne with other COCs.

Impact of obesity and leptin levels on the secretion of estradiol, inhibin A and inhibin B during ovarian stimulation with gonadotropins

We examined the impact of high leptin levels on the secretion of estradiol, inhibin A and inhibin B in obese and lean women during ovarian stimulation. Patients undergoing long-term pituitary suppression, ovarian stimulation and in vitro fertilization for non-endocrine reasons were included in this case-control study. Obese women (body mass index (BMI) > 28 kg/m(2); n = 17) were individually matched with lean women (BMI 20-25 kg/m(2); n = 17) for age and baseline follicle stimulating hormone and luteinizing hormone concentrations. Blood samples were collected in a previous menstrual cycle and 1-3 days apart throughout ovarian stimulation. Serum levels of estradiol, leptin, inhibin A and inhibin B were measured. Obese and lean women had similar serum concentrations of estradiol, inhibin A and inhibin B in the follicular and luteal phases of the spontaneous menstrual cycle, and throughout ovarian stimulation. Serum levels of leptin were higher in obese than in lean women, and increased during stimulation in both groups. In the obese group, area-under-the-curve (AUC) leptin levels correlated with AUC inhibin A levels. In the lean group, there was no correlation between AUC leptin levels and AUC levels of ovarian hormones. The results suggest that high leptin concentrations in vivo are not associated with impaired secretion of estradiol and dimeric inhibins during ovarian stimulation.

Isolation and identification of antibacterial compounds from Vernonia colorata leaves

Vernonia colorata (Compositae) is used throughout Africa for a variety of ailments. This prompted the screening of this plant for biological activity. Previous experiments carried out in our laboratory revealed that the leaves possessed high antibacterial activity. Through conventional chromatographic techniques and bioassay-guided fractionation, the following sesquiterpene lactones were isolated and identified by spectroscopic data; vernolide (1), 11beta, 13-dihydrovernolide (2) and vernodalin (3). Only 2 is a novel compound, although its antibacterial activity is low compared to compounds 1 and 3 which had minimum inhibitory concentrations of 0.1-0.5 mg/ml against Gram-positive bacteria.

South-East Asian ovalocytosis among the population of the Highlands of Madagascar: a vestigé of the island's settlement

In the Madagascar Highlands, 0.76% of children from 168 random primary schools, and 19 of 150 families from 3 villages, had oval-shaped erythrocytes. Most harboured the deletion in the band 3 gene characteristic of South-East Asian ovalocytosis. This genetic trait supports the Indonesian origin of the Madagascar settlement.

Role of integrins in invasion of endometrial cancer cell lines

OBJECTIVE

The objective of this study was to determine whether there is a link between integrins and components of the plasminogen system, regarding tumor cell invasion to the artificial extracellular matrix.

METHODS

Immunocytochemistry was performed with antibodies directed against integrins alpha2beta1, alpha4beta1, alpha5beta1, alpha6beta1, and alpha(nu)beta3 Cell adhesion was studied by cell attachment to matrix proteins. Integrin-mediated migration of cells into the artificial matrix was studied in an invasion assay. Last, immunoreactivity of the components of the plasminogen system was estimated by ELISA.

RESULTS

HEC-1A, Ishikawa, and AN3CA cell lines express the alpha 4 beta 1, alpha 5 beta 1, and alpha 6 beta 1 integrins. Adhesion of cells to fibronectin and laminin was inhibited by monoclonal antibodies directed against appropriate integrin subunits. Migration into the matrigel was partially blocked with mAbs to alpha4beta1 as well as alpha5beta1, alpha6beta1 integrins and their combination. No differences in either uPA or PAI-1 immunoreactivity were found after addition of the mAbs.

CONCLUSION

Alpha4beta1, alpha5beta1, and alpha6beta1 heterodimers mediate adhesion as well as migration into the artificial matrix matrigel of endometrial tumor cell lines. A cooperative signaling between these integrins and uPA or its inhibitor in modulation of in vitro cell invasion is rather unprobable.

Preclinical profiles of progestins used in formulations of oral contraceptives and hormone replacement therapy

Progestins used in oral contraceptive formulations available in the United States include norgestimate, desogestrel, norethindrone, norethindrone acetate, and levonorgestrel. Progestins used in the United States in continuous and intermittent formulations of hormone replacement therapy are norgestimate, medroxyprogesterone acetate, and norethindrone acetate. The chemical structure of a progestin determines its relative binding affinity for the progesterone and androgen receptors, as well as the sex hormone binding globulin in human serum, and determines its clinical profile. Overall, the properties of levonorgestrel or norethindrone acetate in this regard differ from norgestimate and are more conducive to androgenic stimulation. Estrogen replacement offers cardioprotective effects in postmenopausal women. Progestins are added to hormone replacement therapy to counteract the well-known increased risk of endometrial hyperplasia associated with the use of unopposed estrogen. Animal models show that for some parameters, including improvement of lipid profiles, progestins can diminish the cardioprotective effect of estrogen. Initial animal studies of norgestimate combined with estrogen do not show an attenuation of estrogenic effects.

Synthetic estrogens-mediated activation of JNK intracellular signaling molecule

Signal transduction pathways regulate the transmission of specific signals to the cells from the surface to the nucleus. Activation of protein kinases such as JNKs (c-jun amino-terminal kinase), a subgroup of the mitogen activated protein kinase (MAPK) family, results in regulation of important cellular functions like cell growth and differentiation. The involvement of estrogens in stimulation of growth of already transformed breast cancer cells in vivo and in vitro accompanied with activation of JNKs prompted us to investigate the role of synthetic estrogens in the regulation of JNK expression. T 47D breast cancer cells were incubated with the synthetic estrogens, ethinylestradiol (10(-9)M) and 17 beta-estradiol valerate (10(-9)M), epidermal growth factor (EGF) (10 ng/ml) and the natural estrogen, 17 beta-estradiol (10(-9)M), for 5 minutes. The same experiments were repeated after pretreatment of the cells with ICI 182780 for 24 hours. EGF as well as natural and synthetic estrogens stimulated proliferation. This effect was reversed by the estrogen receptor blocker ICI 182780, but only in the case of both natural and synthetic estrogen. Like 17 beta-estradiol, synthetic estrogens induced a rapid and transient activation of JNK kinase. ICI 182780 blocked this effect, but not that mediated by EGF. Ethinylestradiol used in oral contraceptives, and 17 beta-estradiol and 17 beta-estradiol valerate for hormone replacement therapy, are able to activate JNK. The estrogen receptor is necessary for JNK activation upon estrogen stimulation.

An investigation on the biological activity of Combretum species

Leaf extracts of 20 Combretum species, many of which are used in southern African traditional medicine, were screened for anti-inflammatory, anthelmintic, anti-bilharzia (antischistosomal) and DNA-damaging activity. Significant activity in more than one bioassay was exhibited by Combretum apiculatum, Combretum hereroense, Combretum molle and Combretum mossambicense. Ethyl acetate extracts were generally most active, followed by acetone and then water extracts.

Malaria in the highlands of Madagascar after five years of indoor house spraying of DDT

The central region of Madagascar is a vast area of highlands (altitude 700-2000 m). Malaria transmission has re-established itself here since the last epidemic of 1985-90 and has caused the deaths of 40,000 persons according to the Minister of Health. To combat the main malaria vector in the region, Anopheles funestus, annual programmes of indoor house spraying of DDT were carried out between December 1993 and January 1998 in most rural areas at altitude 1000-1500 m. A parasitological and serological study was then conducted in the highland schools to evaluate the impact of the programme and set up a database on the region. Using a cluster-sampling method 2 independent selections were conducted (one of 130 sites, the other of 40 sites). During the study, 13,462 schoolchildren were examined, 71% living in sprayed villages. Parasite prevalence among schoolchildren declined as altitude increases, from 11% at 700-900 m to 0.4% at > 1500 m. Below 1500 m, the impact of the spraying on the prevalence of the parasite was very clear (an average decrease of from 20% to 2.7% below 1000 m and of from 4.5% without spraying to 0.8% at 1000-1500 m). Geographical analysis of the data showed that the marginal regions remained the most affected by malaria (especially outside spraying zones), and persistence of 'pockets of transmission' at 1000-1500 m, essentially in areas where spraying has never been used. In 9 schools, anti-Plasmodium antibodies were sought by indirect immunofluorescence on thick smears of parasitized red blood cells. The seroprevalence ranged from 22% to 63%, which suggests that the parasite is still circulating in the region. Even though our data show that vector control continues to be very successful in the Madagascan highlands, rapid reinfection could occur and must be monitored following spraying. To this end, the Minister for Health, with the support of the Italian Co-operation, has placed the region under epidemiological surveillance since 1997. An alert system for the timely detection of the sources of epidemics and the targeting of the antivectoral campaign is also in operation. Our study suggests that this strategy should be reinforced by the spraying of DDT in the marginal zones in order to consolidate the results obtained at higher altitudes.

Isolation of an antibacterial sesquiterpenoid from Warburgia salutaris

The bark of Warburgia salutaris is used in traditional medicine as an expectorant and smoked for coughs and colds, including a topical application for sores and inflammation. A previous screening of South African medicinal plants showed that this plant had promising antibacterial activity. Subsequently, this endangered tree species was selected for bioassay-guided fractionation in order to identify the active principles. Fractionation of the ethyl acetate extract of the stem bark by chromatographic techniques yielded a sesquiterpenoid which exhibited antimicrobial activity against Gram-positive bacteria. The compound, muzigadial, has previously been reported in two other Warburgia species, this being the first time it has been reported from W. salutaris. Muzigadial had minimum inhibitory concentration values ranging from 12.5 to 100 microg ml(-1).