Ospemifene in clinical practice for vulvo-vaginal atrophy: results at 3 months of follow-up of use

OBJECTIVE

To assess the effect of ospemifene 60 mg/day in vulvovaginal atrophy (VVA) in postmenopausal women under conditions of routine clinical practice after 3 months of follow-up.

METHODS

The AYSEX study is a Spanish observational, prospective, and unicentric study in which 5 gynecologists recruited postmenopausal women with VVA in routine clinical practice treated with ospemifene 60 mg/day as an appropriate therapeutic option. Vaginal health, sexual health, dryness, dyspareunia, quality of life, and satisfaction with treatment were assessed at baseline and after three months using validated scales.

RESULTS

A total of 100 postmenopausal women cytologically and clinically diagnosed with VVA were included in the study. After 3 months of treatment with ospemifene, vaginal health index increased and vaginal pH, dryness, and dyspareunia decreased significantly (p < .0001). A significant improvement was observed in sexual function and quality of life.

CONCLUSIONS

This study in routine clinical practice conditions confirms the results previously reported by randomized controlled trials, including a significant improvement in VVA, sexual function, quality of life, and satisfaction with the treatment.

A single-arm clinical trial investigating the effectiveness of a non-hormonal, hyaluronic acid-based vaginal moisturizer in endometrial cancer survivors

OBJECTIVE

To assess the efficacy of non-hormonal, hyaluronic acid (HLA)-based vaginal gel in improving vulvovaginal estrogen-deprivation symptoms in women with a history of endometrial cancer.

METHODS

For this single-arm, prospective, longitudinal trial, we enrolled disease-free women with a history of endometrial cancer who underwent surgery (total hysterectomy) and postoperative radiation. Participants used HLA daily for the first 2 weeks, and then 3×/week until weeks 12-14; dosage was then increased to 5×/week for non-responders. Vulvovaginal symptoms and pH were assessed at 4 time points (baseline [T1]; 4-6 weeks [T2]; 12-14 weeks [T3]; 22-24 weeks [T4]) with clinical evaluation, the Vaginal Assessment Scale (VAS), Vulvar Assessment Scale (VuAS), Female Sexual Function Index (FSFI), and Menopausal Symptom Checklist (MSCL).

RESULTS

Of 43 patients, mean age was 59 years (range, 38-78); 54% (23/43) were partnered; and 49% (21/43) were sexually active. VAS, VuAS, MSCL, and SAQ (Sexual Activity Questionnaire) scores significantly improved from baseline to each assessment point (all p < .002). FSFI total mean scores significantly increased from T1 to T2 (p < .05) and from T1 to T4 (p < .03). At T1, 41% (16/39) felt confident about future sexual activity compared to 68% (17/25) at T4 (p = .096). Severely elevated vaginal pH (>6.5) decreased from 30% (13/43) at T1 to 19% (5/26) at T4 (p = .41).

CONCLUSION

The HLA-based gel improved vulvovaginal health and sexual function of endometrial cancer survivors in perceived symptoms and clinical exam outcomes. HLA administration 1-2×/week is recommended for women in natural menopause; a 3-5×/week schedule appears more effective for symptom relief in cancer survivors.

Ospemifene efficacy and safety data in women with vulvovaginal atrophy

Vulvovaginal atrophy (VVA) is a frequent, underreported and underdiagnosed condition. Ospemifene is a third-generation Selective Estrogen Receptor Modulator (SERM) that has been shown to be effective in women with VVA and dyspareunia, vaginal dryness and vulvar vestibular symptoms. Some of the possible side effects included by FDA and EMA are hot flushes, headache, muscle spasms, vaginal bleeding and vaginal discharge. Ospemifene does not increase the incidence of endometrial cancer or hyperplasia. While the efficacy is comparable with that of estrogenic treatments, ospemifene is not only well tolerated and safe but also reduces bone turnover in postmenopausal women, and available data indicate no safety concerns for breast tissue.

Local ultra-low-dose estriol gel treatment of vulvo-vaginal atrophy: efficacy and safety of long-term treatment

Vulvo-vaginal atrophy (VVA) is a chronic condition affecting many postmenopausal women. Local estrogen treatment is recommended. Evaluating efficacy and safety of long-term VVA treatment with ultra-low-dose estriol gel, 120 postmenopausal VVA women were enrolled in a prospective study. They received the first cycle of 1 g/day vaginal gel containing 50 µg estriol for 3 weeks and then twice a week for 12 weeks. Moderate or severe VVA women received a second treatment cycle reaching treatment of 30 weeks. Vaginal pH measurement, subjective symptoms, and objective signs assessment of VVA, endometrial thickness and adverse events (AE) were recorded. Of the 99 women, completing the first phase, 43% experienced a complete VVA symptom relief, and 65% presented a milder VVA degree. After 30 weeks, VVA signs significantly improved (p<.01) compared with baseline and first phase results; total objective symptom evaluation including Schiller's test, flattening of folds and vaginal pH significantly improved (p<.01). At study endpoint, none of the patients had severe VVA, 93% had a positive response, 75% had a complete symptom, and sign resolution. No treatment-related endometrial AE were observed. Postmenopausal VVA long term-treatment with ultra-low-dose estriol vaginal gel is safe and effective.

Use of Growth Factors for Vulvo/Vaginal Bio-Stimulation

Vulvo-vaginal atrophy as a main symptom of the Genito Urinary Syndrome of Menopause (GSM) is a consequence of aging, particularly after menopause as a result of follicular ovarian follicle depletion and consequently low estrogen levels. Anatomical structures derived from the urogenital sinus, such as the distal urethra trigone and vestibule, are the most affected areas because of the high concentrations of alfa- and beta-estrogen receptors. The most common symptoms associated with vulvo-vaginal atrophy are dyspareunia, vaginal dryness, irritation, recurrent urinary tract infection and urinary incontinence, which negatively affect the patient's quality of life and sexuality. The purpose of this pilot study was to evaluate a protocol with topical growth factors that seeks to activate collagen and elastin at a molecular level, and thus restore all vaginal functions such as secretion, absorption, elasticity, lubrication and vaginal epithelium thickness.

Intravaginal Testosterone Improves Sexual Satisfaction and Vaginal Symptoms Associated With Aromatase Inhibitors

CONTEXT

Intravaginal testosterone (IVT) is a potential treatment of vulvovaginal atrophy (VVA) associated with aromatase inhibitor (AI) use.

OBJECTIVE

To investigate the effects of IVT on sexual satisfaction, vaginal symptoms, and urinary incontinence (UI) associated with AI use.

DESIGN

Double-blind, randomized, placebo-controlled trial.

SETTING

Academic clinical research center.

PARTICIPANTS

Postmenopausal women taking an AI with VVA symptoms.

INTERVENTION

IVT cream (300 μg per dose) or identical placebo, self-administered daily for 2 weeks and then thrice weekly for 24 weeks.

MAIN OUTCOMES AND MEASURES

The primary outcome was the change in the sexual satisfaction score on the Female Sexual Function Index (FSFI). Secondary outcomes included vaginal symptoms and responses to the Profile of Female Sexual Function, the Female Sexual Distress Scale-Revised (FSDS-R), and the Questionnaire for UI Diagnosis. Serum sex steroids were measured.

RESULTS

A total of 44 women were randomly assigned and 37 provided evaluable data, (mean age 56.4 years, SD 8.8 years). At 26 weeks, the mean between-group difference in the baseline-adjusted change in FSFI satisfaction scores was significantly greater for the IVT group than the placebo group (mean difference 0.73 units; 95% CI, 0.02 to 1.43; P = 0.043). IVT cream resulted in significant improvements, compared with placebo, in FSDS-R scores (P = 0.02), sexual concerns (P < 0.001), sexual responsiveness (P < 0.001), vaginal dryness (P = 0.009), and dyspareunia (P = 0.014). Serum sex steroid levels did not change. Few women had UI symptoms, with no treatment effect.

CONCLUSION

IVT significantly improved sexual satisfaction and reduced dyspareunia in postmenopausal women on AI therapy. The low reporting of UI among women on AI therapy merits further investigation.

Vulvar vestibular effects of ospemifene: a pilot study

The study aimed to assess the effects of ospemifene on vulvar vestibule in postmenopausal women with vulvar pain and dyspareunia. Fifty-five postmenopausal women used oral ospemifene 60 mg/d for 60 d. Symptoms of dryness, burning, and dyspareunia were evaluated on a 10 cm visual analog scale. Visual examination of the vulvar vestibule was also conducted. Patients also underwent current perception threshold (CPT) testing obtained from the vulvar vestibule. Fifty-five patients (94.6%) completed the treatment. Hot flashes were the most frequent adverse effects, but this led to a discontinuation of therapy in three patients (5.4%). After therapy, there was a statistically significant decrease from the baseline in the mean scores for dryness, burning, and dyspareunia and reduction of vestibular trophic score (baseline value of 11.2-4.2 after the therapy, p ≤ 002) and cotton swab test scores (2.81 compared with 1.25, p = .001). There was a difference in CPT values for all nerve fibers and more consistent for C fibers (-38% of sensitivity). These results confirm the efficacy of ospemifene on postmenopausal vestibular symptoms and signs; moreover, the drug was effective in normalizing vestibular innervation sensitivity.

Randomized crossover study investigating daily versus on-demand vulvar Visnadine spray in women affected by female sexual arousal disorder

The aim of the study was to verify the efficacy of vulvar Visnadine spray in premenopausal women affected by female sexual arousal disorder (FSAD). Thirty-eight women aged 25-40 years affected by FSAD were enrolled in the randomized crossover study, by two possible sequences: on-demand, washout, daily (A sequence); and daily, washout, on-demand (B sequence). The Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale (FSDS) were used to assess sexual function and sexual distress, respectively. Color Doppler ultrasonography was used to measure clitoral blood flow. The study had two follow-ups at 30 (T1) and 60 days (T2). Thirty-one women completed the study. Mean (SD) sexual activity and vulvar Visnadine spray usage was 1 ± 0.9 weekly during on-demand administration for both the sequences (Vs T0, p = NS). The mean sexual activity during daily usage was 2 ± 0.9 (Vs T0, p < .004) and 2 ± 0.8 (Vs T0, p < .001) for A and B sequences, respectively. FSFI total score, particularly genital arousal, improved more during the daily than during on-demand phases of both sequences (p < .001). Finally, clitoral blood flow improved significantly during daily usage of both the sequences (p < .001). Our study suggests that vulvar Visnadine spray could improve sexual performance of women affected by FSAD, producing changes in subjective and objective sexual aspects.

Ospemifene for the treatment of vulvovaginal atrophy and dyspareunia in postmenopausal women

Vulvovaginal atrophy (VVA) and dyspareunia are common problems experienced by postmenopausal women, although few seek treatment. Symptom-based therapies include nonhormonal vaginal lubricants, vaginal moisturizers, low-dose vaginal estrogen, and systemic estrogen. The 2013 United States Food and Drug Administration approval of ospemifene, an estrogen agonist/antagonist for the treatment of moderate-to-severe dyspareunia associated with VVA, increased options available to women. Several studies have evaluated the effects of ospemifene on VVA and dyspareunia and indicate an improvement in subjective findings. Objective findings such as a decrease in pH and recovery of a premenopausal vaginal maturation index have been reported. Beneficial effects have also been demonstrated in bone. Evaluations of breast health support the safety of ospemifene, although data are limited to 1 year. Short-term risks appear to be limited and include the development of hot flushes. Until additional comparative studies of ospemifene and estrogens have been performed, ospemifene should be recommended for women with symptoms of VVA and dyspareunia who are unable to tolerate or unwilling to take local or systemic estrogens. In this review, current evidence for the safety and efficacy of ospemifene in the treatment of moderate-to-severe VVA and dyspareunia are evaluated.

Vaginal effects of ospemifene in the ovariectomized rat preclinical model of menopause

Ospemifene is a unique tissue-selective estrogen agonist/antagonist (also known as a selective estrogen receptor modulator [SERM]) with demonstrated efficacy in Phase 3 studies of postmenopausal women with vulvar and vaginal atrophy (VVA). This report describes preclinical studies on the effects of ospemifene in the ovariectomized (OVX) rat model of menopause. Ospemifene (10mg/kg/day) and the SERM comparator, raloxifene (10mg/kg/day) were administered for 2 weeks and both increased vaginal weight; ospemifene was more effective than raloxifene. In addition, ospemifene had a greater effect on increasing vaginal epithelial height compared with raloxifene. The effect on uterine weight was less pronounced for both ospemifene and raloxifene. The ED50 of ospemifene on vaginal epithelial height was 0.39mg/kg/day and the magnitude was nearly the same as was seen with the positive control, 17α-ethinyl estradiol (EE2). In a histological analysis of ospemifene-treated rat vaginas, basal cells were overlaid by 2 to 3 cell layers of thickened goblet-like mucified cells apically; however, the cornification observed with EE2 was absent. Estrogenic activity of ospemifene was confirmed by upregulation of progesterone receptors in vaginal epithelium and stroma. Ospemifene showed similar affinity for estrogen receptor (ER)-α and ER-β, but an overall lower affinity than estradiol. Ospemifene antagonized estrogen response element (ERE)-mediated transactivation on MCF-7 cells, confirming its anti-estrogenic activity in breast cancer cells. The dose response for ospemifene in the rat is consistent with that observed in clinical studies of ospemifene 30 and 60mg, showing that the OVX rat is a highly predictive model of SERM activity in postmenopausal VVA.

[Vulval dermatitis: localized condition--serious problem]

An overview of the literature of the dermatitis of the vulva is presented. The etiology, epidemiology, clinical manifestations, diagnosis, pathological diagnosis, treatment, and prevention of contact, allergic-contact, atopic, and seborrheic dermatitis of the vulva are described in details. Lichen simplex chronicus is additionally described as complication of chronic itching dermatitis.

Persistent erythematous lesion of the vulva: a diagnostic and treatment challenge

The painful, erythematous and eroded vulva often proves to be a diagnostic problem both clinically and histologically. Its differential diagnosis includes both non-neoplastic and neoplastic diseases like Bowen's disease and squamous cell carcinoma (SCC). We report the case of a 62-year-old woman diagnosed, after considerable delay, with Bowen's disease of the vulva that eventually progressed to invasive SCC, despite the treatment with imiquimod 5% cream. Our case indicates, on one hand, that dermoscopy could contribute to the accuracy of the pre-operative clinical diagnosis. On the other hand it confirms the fact that treatment of Bowen's disease of the vulva could be rather intriguing. Although imiquimod 5% cream is an effective, non-invasive treatment option for large lesions or poor healing sites, it should be administered with great consideration in carefully selected cases.

[Pregnancy and malignant diseases. Part III--. Vulvar cancer]

Vulvar cancer is among the rarest gynecological tumors. It is extremely rare in pregnant women. In the scientific literature, data has been recorded for no more than 50 cases of vulvar cancer during pregnancy. The etiological and pathogeneteic role of the HPV infection is discussed. The early histological diagnosis and treatment of every vulvar neoplasia during pregnancy are preconditions for a favorable prognosis for the disease and the pregnancy likewise. The management for women with vulvar cancer and pregnancy needs to be determined by a multidisciplinary staff with obstetrician-gynecologists, oncologists and neonatologists, while the point of view of the patient also has to be taken into account.

[Multicenter randomized, double-blind, placebo-controlled trial of prostaglandin E1 cream for female sexual arousal disorder]

OBJECTIVE

To investigate the efficacy and safety of alprostadil cream in management of female sexual arouse disorder (FSAD), and its appropriate dose for clinical prescription.

METHODS

The volunteers were assigned randomly to four groups which received alprostadil cream in different dosage (500 μg, 700 μg and 900 μg) or placebo cream, respectively. The cream was applied to the clitoris and G-spot before coitus. The efficacy was assessed by comparing the satisfactory rate of sexual arousal, the score of female sexual function index (FSFI) and female sex disorder scale (FSDS) and the general appraised question (GAQ) before and after the treatment. The safety was evaluated by the adverse effects that appeared including symptoms, physical and biochemical examination.

RESULTS

Totally, 400 women enrolled in this study with 374 assigned to the group for efficacy evaluation and 387 cases to the group for safety analysis. No significant difference was found among the four groups in the demographic characters and sexual baseline. The increase of satisfactory percentage of sexual arousal in the four groups (placebo, 500 μg, 700 μg and 900 μg) was 22.63%, 36.67%, 34.01%, and 44.29%, respectively (P<0.05), and the increase was statistically higher in the 900 μg group than in the placebo group (P<0.0167). The elevated FSFI score above the baseline in the treatment groups (900 μg 22.89, 700 μg 21.69, and 500 μg 20.71) were higher than that in the placebo group (14.68, P<0.05), while the reduced FSDS score below the baseline (900 μg 25.97, 700 μg 21.98, and 500 μg 20.27) were higher than that of the placebo (17.60, P<0.05). No significant difference was found in the four groups in GAQ (P=0.054). The main common adverse effect was topical stimulation. No adverse effect was reported in physical and biochemical examination, electrocardiogram (ECG) or Thinprep cytologic test (TCT).

CONCLUSION

Alprostadil cream can treat female sexual arousal disorder effectively with the maximum effect at the dose of 900 μg and without significant adverse effect except for mild topical stimulation.

[Evaluation of Cicatridine efficacy in healing and repairing process of uterine cervix, vagina and vulva--open no-randomized clinical study]

PURPOSE

The aim of the study was to evaluate the efficacy of Cicatridine application in healing and repairing process after operative procedures concerning uterine cervix, vagina and vulva and after brachytherapy due to cervical and endometrial cancer. We also analyzed Cicatridine effect on vaginal athrophical signs in post-menopausal women.

PATIENTS AND METHODS

The examined group consist of 319 women. They were divided into 2 arms. The active arm concerns 213 women who used Cicatridine, while controlled one consists of 106 women. The effect of treatment was estimated after 6 weeks and 3 months by the visual inspection of the cervix and vagina. We also analyzed the subjective filling of patients bound to sexual intercourses by using of Visual Analogue Scale (0%--no effect; 100%--disappearance of pathological symptoms).

RESULTS

In active arm according to control one the reparation of cervix was more often: after surgery procedures (respectively after 6 weeks 93% vs 70%; after 3 months 99% vs 89%) and after brachytherapy (respectively after 3 months 86% vs 0%). In brachytherapy group the lack of discomfort during sexual intercourses was also more often in active arm (respectively 55% vs 0%). In postmenopausal women reduction of symptoms associated with atrophic vaginitis was observed only in active group (respectively after 6 weeks 43% vs 0%; after 3 months 57% vs 0%). In the group of patients after ephisiotomy due to delivery the relief of discomfort during sexual intercourses was also more often in active arm respectively 94% vs 25%).

CONCLUSION

Cicatridine causes fast healing of cervix after gynecological procedures. It influences improvement of atrophical, inflammatory and after radiation therapy effects which improve quality of life and comfort of vagina after brachytherapy due to cervical and endometrial cancer. Cicatridine causes similar effect in vagina of post-menopausal women as locally used estrogens. Cicatridine also causes the feeling of relief and comfort in vagina after delivery as well as fast healing after episiotomy.

The vulval vestibular mucosa?morphological effects of oral contraceptives and menstrual cycle

BACKGROUND

An erythematous and hypersensitive vestibular mucosa has been observed during the use of combined oral contraceptives (COC). Hormonal effects on the vestibular morphology have not been studied.

OBJECTIVES

Our aim was to evaluate the morphology of the vulval vestibular mucosa during the influence of COC and during the menstrual cycle.

METHODS

Forty-five healthy women (20 using COC and 25 not using COC) were included. A 6-mm punch biopsy was obtained from the right posterior vestibule on days 7-11 of the menstrual cycle. A corresponding biopsy was taken 2 weeks later in 16 women without COC. The epithelial morphology was estimated by measuring interdermal papilla distance, dermal papilla to surface, from basal layer to surface and width of dermal papillae. A histopathological assessment was made.

RESULTS

The vulval vestibular mucosa of women using COC displayed a larger distance between the dermal papillae (P = 0.04) and a larger space from the dermal papillae to the epithelial surface (P = 0.03) compared with controls in the follicular phase. Women without COC displayed a larger interdermal papilla distance in the luteal phase compared with the follicular phase, P = 0.02. Histopathology showed more superficial blood vessels in the COC users (P < 0.01).

CONCLUSIONS

The vulval vestibular mucosa of women with COC display an altered morphological pattern with shallow and sparse dermal papillae compared with the follicular phase. Similar findings are seen in women without COC during the luteal phase which indicate a gestagenic effect on the mucosa. Associations between the morphological pattern and changes in mucosal mechanical sensitivity require further studies.

Therapeutic value of trichloroacetic acid in the treatment of isolated genital warts on the external female genitalia

OBJECTIVE

To evaluate the value of 85% trichloroacetic acid (TCA) in the treatment of human papillomavirus (HPV)-associated genital warts of the external genitalia and to detect the recurrence rate and side effects of this therapeutic regimen.

STUDY DESIGN

All patients with a suspected HPV-related papillary vulvar lesion after initial examination underwent vulvoscopic evaluation with a magnification of 8-20x using acetic acid and toluidine blue. Under local anesthesia, biopsies were taken from acuminate or papillary warts for histopathologic confirmation and from suspicious areas to exclude preinvasive or invasive diseases. Following histopathologic diagnosis, patients were treated with 85% TCA.

RESULTS

Overall, 51 patients with isolated vulvar and/or perianal genital warts were included. Of those patients, 11 (21.5%) had acuminate and 40 (78.5%) had papular genital warts. All the women had lesions of the labia minora. The other localizations were as follows: labia majora, 18 (35.3%); lateral vulva, 5 (9.8%); clitoris, 9 (17.6%); fourchette, 16 (31.3%); and perianal area, 7 (13.7%). All lesions were successfully treated by the end of the treatment period (median, 4; range 2-5). None of the patients had recurrence or new lesions during the 6-month follow-up period. In the second 6 months, 9 patients (17.6%) were diagnosed with recurrent lesions. Although all the patients experienced transient burning pain during therapy, none of them discontinued the therapy. Ulceration was observed in 8 patients (15.6%). Of those patients only 3 had permanent scarring (5.8%).

CONCLUSION

We recommend the use of TCA in patients with external genital warts, especially for mild to moderate cases. It is associated with a high success rate and low morbidity if sufficient care is taken during application.

Low Dose of Transdermal Estradiol Gel for Treatment of Symptomatic Postmenopausal Women

OBJECTIVE

To investigate safety and efficacy and identify the lowest effective dose of a new transdermal estradiol (E2) gel for relief of menopausal symptoms in a population of postmenopausal women.

METHODS

This study was a randomized, double-blind, placebo-controlled, multicenter, parallel-group study. Postmenopausal women with at least 60 hot flushes per week applied 0.87 g/d (n=136), 1.7 g/d (n=142), or 2.6 g/d (n=69) E2 gel or placebo gel (n=137) topically for 12 weeks. The changes from baseline in hot flush frequency and severity at 4 and 12 weeks and changes from baseline in vaginal atrophy symptoms at 12 weeks were examined.

RESULTS

With increasing E2 doses, mean trough serum E2 increased from 17 to 29 pg/mL. By weeks 3-5, E2 gel reduced moderate-to-severe hot flush rate by at least seven hot flushes per day (P<.001) and reduced the severity score (P<.01). The numbers needed to treat for benefit for an 80% and 100% decrease in hot flush number were 3.2 and 6.3 for the 0.87-g/d group and 1.3 and 2.3 for the 2.6-g/d group. At week 12, vaginal pH was more acidic and vaginal maturation index more mature compared with placebo (P<.001). The lowest dose improved most bothersome vulvovaginal atrophy symptoms (P<.05). Estradiol gel was well tolerated at the site of application and produced no unexpected adverse effects. The 0.87 g/d dose produced fewest adverse events.

CONCLUSION

The 0.87 g/d dose of this new transdermal E2 gel, which delivers an estimated 0.0125 mg E2 daily, delivered the lowest effective dose for treatment of vasomotor symptoms and vulvovaginal atrophy in a population of postmenopausal women.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT00391417.

LEVEL OF EVIDENCE

I.

Significance of topical estrogens to labial fusion and vaginal introital integrity

PURPOSE

One theory for labial fusion is low prepubertal estrogen levels. Topical estrogens remains the mainstay of therapy. Some patients require surgical lysis of the adhesion. Estrogen's action in regard to collagen may influence recurrent adhesions and adhesions that form after manual disruption or surgical separation. This study assesses the efficacy of topical estrogen to separate the labia, recurrence, and estrogen related side effects. Estrogens may have a role in vaginal healing in genital surgery.

MATERIALS AND METHODS

Retrospective chart review of 109 girls from 3 months to 10 years old (mean 44 months) who had labial fusion. Data was collected on the length of topical estrogen treatment, rate of successful separation, rate of recurrence, percentage requiring surgery, and post-operative outcomes.

RESULTS

Mean length of topical estrogen treatment was 3.7 months (range 0 to 36 months), with separation in 79% (85/107) of patients. Forty-one percent (44/107) had recurrence of labial fusion one to five times (range 2 to 72 months). Surgery was required in 21% (22/107). Ten percent of patients (2/21) had recurrence of labial fusion post-operatively (age 6,10 years, at 1, 18 month post-operatively). Neither of these two patients was responsive to topical estrogen cream post-operatively and required a second surgical separation. Side effects of estrogen were minimal breast development in 6 children and vaginal bleeding in one child. Discontinuance resulted in resolution of side effects.

CONCLUSION

Topical estrogens were effective treatment for labial fusion. After surgical separation of adhesions there was a 10% recurrence rate. Estrogen therapy initiated after surgical failure was unsuccessful.

Medical treatment of vulvar squamous cell hyperplasia

OBJECTIVE

To evaluate symptomatic response and recurrence rates of graduated topical fluorinated corticosteroid in patients with vulvar squamous cell hyperplasia.

METHODS

Nine hundred seventy-six patients with biopsy-proven vulvar squamous cell hyperplasia from 1990 to 2003 were reviewed in this retrospective study. All patients were treated with graduated topical fluorinated corticosteroid. Data were obtained from hospital records. Symptomatic remission and recurrence rates were noted following six months local therapy.

RESULTS

The mean age was 42.55+/-10.93 (15-85). The remission rate was 93.8% in six months. The remission rate was non-significantly higher in postmenopausal patients than that in their premenopausal counterpart (94.9% vs 93.0%, p=0.15). The disease recurred in 6.9% of patients. Of the patients that suffered recurrence 47.5% had persistent disease initially. The patients with following factors older ages (>40 years), postmenopausal period had significantly higher recurrence rates. Four patients with recurrent disease and six patients with persistent disease in the form of vulvar intraepithelial neoplasia I-II or atypical squamous hyperplasia, were treated with skinning vulvectomy.

CONCLUSION

Corticosteroid in the treatment of vulvar squamous cell hyperplasia yielded excellent response rates. In the evaluation of patients without symptomatic relief, the first step should be a vulvar biopsy to exclude the presence of atypical components.

Botulinum toxin A for the management of vulvodynia

Clinically, botulinum toxin A blocks the cholinergic innervation of the target tissue. Recently, it has been proved effective not only at a neuromuscular junction but also within parasympathetic or sympathetic neural synapses. Seven women with pain on genitalia that could not be controlled with conventional pain managements were enrolled in this study. Twenty to 40 U of botulinum toxin A were used in each injection. Injection sites were the vestibule, levator ani muscle or the perineal body. Repeat injections were administered every 2 weeks if the patient's symptoms had not fully subsided. In all patients, pain had disappeared with botulinum toxin A injections. Five patients needed to be injected twice; the other two patients needed only one injection. We did not observe complications related to botulinum toxin A injections, such as pain, hemorrhage, infection, muscle paralysis or other complications. The subjective pain score improved from 8.3 to 1.4, and no one has experienced a recurrence (the follow-up period was four to 24 months, with a mean follow-up of 11.6 months). Botulinum toxin A is effective in blocking nociception. Even though further investigation and well-controlled study will be necessary, we suggest that the botulinum toxin therapy would be useful and safe in managing vulvodynia of muscular or neuroinflammatory origins.

Receptor modifications in vulvar dystrophies before and after treatment with topical hormones: comparison between the dextran-charcoal technique and immunohistochemical evaluation

PURPOSE OF INVESTIGATION

The objective of the study was first to quantify estrogen receptors (ERs) and progesterone receptors (PRs) in dystrophic vulvar tissue before and after topical hormone treatment in an attempt to evaluate whether receptor modifications occurred. Second we compared quantitative analysis with immunohistochemical staining of the vulvar specimens.

METHODS

We studied 115 vulvar specimens obtained from 75 consenting women ranging from 21 to 78 years of age. Of the patients, 12 had histologically normal vulvar skin, 45 had vulvar dystrophies that were not treated by topical steroid therapy, 28 patients had vulvar dystrophies that were treated by testosterone propionate (TP) 2%, 12 patients had vulvar dystrophies that were treated by progesterone in hydroalcoholic gel and 18 patients had vulvar malignant tumors. For immunohistochemical analysis we considered 25 cases of vulvar dystrophies: 11 cases of squamous hyperplasia (SH) and 14 cases of lichen sclerosus (LS). Among these 25 cases, 15 (5 SH and 10 LS) were treated with TP 2%.

RESULTS

After treatment of the vulvar dystrophies with progesterone, the positivity of ERs decreased (58.3% vs 77.8%). After treatment of the vulvar dystrophies with TP 2%, the positivity of PRs significantly decreased (14.3% vs 68.9%) whereas after treatment with progesterone the positivity of PRs increased (83.3%). The immunohistochemical study showed some differences in comparison to the quantitative study. In fact we found low basal positivity especially for PRs (16% vs 68.9% of the quantitative study). This finding was due to the use of a cutoff of at least ++ in order to increase the specificity. After treatment with TP 2%, we observed an increase of immunohistochemical positivity for ERs even in cases that were negative before treatment and a lack of PRs even in cases that were positive before treatment.

CONCLUSIONS

These data demonstrate the efficacy of androgen therapy with TP 2% in vulvar dystrophies with increased trophism due to the increase of ERs.

The vulvar epithelium differs from the skin: implications for cutaneous testing to address topical vulvar exposures

Vulvar tissue is more permeable than exposed skin due to differences in structure, occlusion, hydration and susceptibility to friction. The safety assessment of products that contact the vulva should account for this potentially heightened permeability. Standard clinical patch tests may not sufficiently mimic vulvar exposures. Because testing on the vulva is not routinely feasible, we are investigating new and modified cutaneous test methods to increase the degree of conservatism of the safety assessment. To this end, we have 1) developed a method to assess chemical and frictional effects by means of repeated application to the popliteal fossa (the behind-the-knee test); 2) modified the quantitative risk assessment for the induction of allergic contact dermatitis; and 3) proposed a modified human repeat insult patch test for assessing materials intended for vulvar contact. Modification of the traditional 4-day, irritation patch test by using wet samples or compromized skin sites failed to enhance test sensitivity. Future studies will evaluate testing in subjects with heightened susceptibility to chemical and sensory irritation, in order to increase test sensitivity to chemical irritants. These approaches can be employed to augment the margin of safety when cutaneous test methods are applied to agents that contact the vulva.

Efficacy and safety of topical alprostadil cream for the treatment of female sexual arousal disorder (FSAD): a double-blind, multicenter, randomized, and placebo-controlled clinical trial

We evaluated the efficacy and safety of three doses of a novel alprostadil cream in a randomized, double-blind, placebo-controlled study in 94 women presenting with female sexual arousal disorder of at least 6 month s duration. We sent the subjects home with 10 premeasured doses of 500 g, 1000 g, or 1500 g alprostadil or a placebo cream to be applied to the vulvar area prior to vaginal intercourse over a period of 6 weeks. The primary efficacy parameter, the arousal success rate (as measured by diary responses to the Female Sexual Encounter Profile [FSEP]), was highest in the alprostadil 1000 g group and lowest in the 500 g group, but the responses were not different from that of the placebo cream, at the p = 0.05 level, for any of the three alprostadil doses. However, the change from baseline for Item 6 of the Female Sexual Function Index (FSFI; Rosen et al., 2000; satisfaction with arousal during sexual activity) suggested an important dose-related trend (p = 0.173; 1500 g versus placebo). The mean percent responder rate (responder = > 50% arousal success rate with > 3 sexual attempts) suggested a dose-response effect (p = 0.157; 1500 g versus placebo). Adverse events were generally mild or moderate in intensity and mainly involved localized reactions in the genital area.

Quantitative risk assessment for the induction of allergic contact dermatitis: uncertainty factors for mucosal exposures

The quantitative risk assessment (QRA) paradigm has been extended to evaluating the risk of induction of allergic contact dermatitis from consumer products. Sensitization QRA compares product-related, topical exposures to a safe benchmark, the sensitization reference dose. The latter is based on an experimentally or clinically determined 'no observable adverse effect level' (NOAEL) and further refined by incorporating 'sensitization uncertainty factors' (SUFs) that address variables not adequately reflected in the data from which the threshold NOAEL was derived. A critical area of uncertainty for the risk assessment of oral care or feminine hygiene products is the extrapolation from skin to mucosal exposures. Most sensitization data are derived from skin contact, but the permeability of vulvovaginal and oral mucosae is greater than that of keratinized skin. Consequently, the QRA for some personal products that are exposed to mucosal tissue may require the use of more conservative SUFs. This article reviews the scientific basis for SUFs applied to topical exposure to vulvovaginal and oral mucosae. We propose a 20-fold range in the default uncertainty factor used in the contact sensitization QRA when extrapolating from data derived from the skin to situations involving exposure to non-keratinized mucosal tissue.

Randomized, placebo-controlled, double blind, crossover design trial of the efficacy and safety of Zestra for Women in women with and without female sexual arousal disorder

Zestra for Women is a botanical feminine massage oil formulated to enhance female sexual pleasure and arousal when applied to the vulva. We conducted this randomized, double-blinded, crossover study to evaluate the efficacy and safety of Zestra for Women compared to placebo oil in 10 women with and 10 women without female sexual arousal disorder (FSAD) in conditions of home use in conjunction with sexual activities. Subjects were screened by physical examination, sex therapist interviews, and questionnaires. We randomized qualified subjects to treatment paths and gave them 5 doses of test article and diaries to use at home. At Visit 2, we assessed them by questionnaires and gave them 5 doses of crossover test article and diaries to use at home. At the final visit, we assessed them with questionnaires. We assessed safety by adverse event reports and primary efficacy by responses to a diary question regarding satisfaction with arousal. Secondary efficacy instruments included remaining diary questions, recall-based questionnaires, global assessment questions, and a consumer-testing questionnaire. All 20 subjects completed the study. Three subjects reported single incidences of mild genital burning sensations lasting 5-30 min after use of Zestra for Women. Both normal and FSAD women showed statistically significant improvements, relative to placebo, in level of arousal, level of desire, satisfaction with arousal, genital sensation, ability to have orgasms, and sexual pleasure. Although FSAD women showed greater magnitude of response, the presence of FSAD had no effect on response rates. Zestra for Women was just as effective in women using selective serotonin reuptake inhibitor antidepressants as in women not using antidepressants. Zestra for Women improved sexual function in normal and FSAD women under conditions of home use.

Application of the E-screen assay to test for oestrogenically active substances in swine feed

A pig breeder in central Hesse (Germany) noticed the occurrence of enlarged vulvae in female piglets. Intoxication with oestrogenically active substances by contamination of two feed mixes ingested by the mother sows appeared to be a possible cause. Using a combined technique of the DFG analytical method S19 and the E-screen assay, two feed samples were found to contain powerful oestrogenically active compounds. By co-incubation with the anti-oestrogen tamoxifen it could be clearly demonstrated that the oestrogenic activity was mediated by the oestrogen receptor. These results demonstrate that use of the E-screen assay in combination with the DFG analytical method S19 provides a simple and readily usable prescreening method for the routine detection of oestrogenically active compounds in animal feed. The results from the E-screen assay show that the sows ingested 10-80 microg oestradiol equivalents per day in their feed. Because of the bioavailability of these substances, the oestrogenic active compounds seem to be transferred into the milk and passed to the piglets via suckling. The milk of the dam appears to contain this substance in biologically active form and at such high concentrations that the female piglets had enlarged vulvae.

Study of the vaginal tolerance to Acidform, an acid-buffering, bioadhesive gel

Vaginal tolerance tests were performed with a new potential microbicidal and spermicidal product, an acid-buffering vaginal gel (Acidform) without or with nonoxynol-9 (N-9). The potential advantages over other vaginal products include keeping a low pH, decrease of the irritating effect of N-9 on the cervix or vaginal mucosa associated with greater retention of the product after application, and decreasing "messiness" as compared to other vaginal products. Three groups of six women were admitted and randomly assigned to use Acidform with 0%, 2.5%, and 5% N-9. Colposcopic evaluation for vulvar, vaginal, and cervical signs of irritation was performed and photographs were taken, following a specific World Health Organization protocol, at time 0, and after 24 h and 6 days of application of the gel. No irritation or symptom was reported by users of Acidform without N-9. A generalized and intense erythema in cervix was observed in 10 of 12 Acidform/N-9 users and abrasion occurred in nine of them. Vulvar irritation was seen in seven of these 10 volunteers. N-9 concentration in the gel (2.5% or 5.0%) was not related to the findings. No ulcer, exulceration, or de-epithelialization was observed. Acidform without N-9 was well tolerated by volunteers, but it was unable to protect the cervix, vagina, and vulva from the N-9 effects.

Prenatal dihydrotestosterone differentially masculinizes tonic and surge modes of luteinizing hormone secretion in sheep

The control of LH secretion in sheep is sexually differentiated. Males begin to reduce their sensitivity to inhibitory steroid feedback, leading to a pubertal increase in tonic LH secretion by 10 weeks of age, but females remain hypersensitive until 30 weeks. Moreover, only females can respond to the positive feedback action of estradiol to produce a preovulatory LH surge. Prenatal exposure of the female lamb to testosterone masculinizes tonic LH and abolishes the LH surge postnatally. However, the type of steroid involved is not known because testosterone can be converted to estradiol or dihydrotestosterone (DHT). This study tested the hypothesis that DHT, which cannot be converted to an estrogen, masculinizes tonic LH without defeminizing the LH surge. Pregnant ewes were treated with DHT (800, 400, or 200 mg/week) during the critical period for sexual differentiation of gonadotropin secretion (days 30-90; 145 days is term). To evaluate the time of the decrease in responsiveness to steroid inhibition, a constant steroid feedback signal was produced. At 4 weeks of age, androgenized females (800 mg, n = 5; 400 mg, n = 4; 200 mg, n = 5) and control males (n = 7) and females (n = 9) were gonadectomized and implanted with a SILASTIC brand estradiol capsule. Tonic LH secretion in males began to increase at 6.7 +/- 0.5 weeks (mean +/- SEM). In DHT-treated females, the LH increase began at the same time (800 mg DHT, 10.7 +/- 3.9 weeks; 400 mg DHT, 9.9 +/- 5.9 weeks; 200 mg DHT, 7.1 +/- 4.9 weeks). This was several months earlier than in control females (29.1 +/- 0.8 weeks; P < 0.05). After puberty, estradiol induced LH surges in 8 of 9 control females and 11 of 12 DHT-treated females, but not in any control males. These results lead to the hypothesis that in the sheep, distinct requirements exist for differentiation of 2 types of reproductive hormone control systems, and that conversion of testosterone to an estrogen is not essential for both. Aromatization is necessary to prevent the surge control of GnRH from operating in the male, but nonaromatizable androgens differentiate the tonic control to permit high GnRH secretion earlier in life.

Effect of vulvovaginal estrogen on sensorimotor response of the lower genital tract: a randomized controlled trial

OBJECTIVE

To assess the effect of vulvovaginal estrogen on mucocutaneous sensory threshold and circumvaginal motor strength.

METHODS

Thirty-nine postmenopausal, hypoestrogenic women with mixed lower-genitourinary-tract complaints were placed in four masked treatment arms by permuted-block randomization for 6 weeks. One group received topical estradiol (E2) cream and pelvic muscle biofeedback training, the second received topical E2 cream and sham biofeedback, the third received placebo cream and pelvic muscle biofeedback training, and the fourth received placebo cream and sham biofeedback. Circumvaginal muscle strength was measured by averaging maximum intravaginal pressure (mmHg) generated over a set of four pelvic muscle contractions. Absolute changes in von Frey threshold (mN) and maximum intravaginal pressure (mmHg) over 4 and 6 weeks were reported as summary measures. Of 39 subjects, 30 completed the study.

RESULTS

Topical estradiol cream significantly improved mechanical sensitivity of the vulvar vestibule to von Frey hairs, a -1.2-mN threshold decrease at 4 weeks (F = 10.29; P = .004), and a -1.6-mN threshold decrease at 6 weeks (F = 8.24; P = .009) compared with placebo cream. Stratification by age showed significantly greater improvement in mechanical sensitivity in the older (70-79 years) age group randomized to estrogen cream and a -5.49-mN threshold reduction (F = 17.65; P = .002). Maximum intravaginal pressures during circumvaginal muscle contraction did not differ between estrogen and placebo cream users (F = 0.00; P = .99).

CONCLUSION

Improved sensation to mechanical stimuli can result from a rapidly acting, direct effect of topical E2 cream on the vulvar vestibule.

Ovarian modulation of the oestradiol-induced LH surge in prepubertal and sexually mature gilts

The role of ovarian secretions in modulating positive oestrogen feedback on LH release in late prepubertal and sexually mature gilts was studied. Gilts were either ovariectomized (OVX) at 230 days of age (sexually mature, OVX 230, control), ovariectomized at 160 days of age (pre-pubertal, OVX 160) or ovariectomized at 160 days of age and given either low, high or very high oestradiol substitution therapy (two or three Silastic implants, 5 or 8 cm in length) from 160 days to 230 days (OVX 160 + 2E5, OVX 160 + 2E8 and OVX 160 + 3E8, respectively). The LH surge responses to three i.m. injections of oestradiol benzoate given at intervals of 12 h (in total 10 micrograms oestradiol benzoate kg-1 bodyweight) were compared at 260 days. An additional group of sexually mature gilts was ovariectomized at 260 days (OVX 260) and challenged with oestradiol benzoate at 360 days. LH surges with peak LH concentrations below pretreatment values (resembling LH responses to oestradiol benzoate in immature gilts) were classified as immature, and those with peak LH concentrations above pretreatment values as mature. LH concentrations before treatment with oestradiol benzoate were reduced (P < 0.05) in OVX 160 + 2E8 and OVX 160 + 3E8 gilts compared with OVX 230 (control). When compared with the control group, the time to LH surge peak was longer in OVX 260 gilts, LH peak amplitude was reduced in the OVX 160 group and the area under the curve of the LH surge (ng LH ml-1 plasma (48 h)-1) was less in all other groups (P < 0.05). Classification of LH surges by mature:immature criteria indicated a high mature:immature ratio in OVX 230 gilts (6/1) and a low ratio in OVX 160 (1/7) and OVX 260 (1/6) gilts. The long-term effect of ovariectomy was partially overcome in the OVX 160 + 2E5 group (mature:immature = 3/3). However, previous exposure to supraphysiological concentrations of oestradiol (as in groups OVX 160 + 2E8 and OVX 160 + 3E8) resulted in a high percentage of animals (66% and 100%, respectively) that did not respond to the oestradiol benzoate challenge with an LH surge. Immediately before oestradiol benzoate administration (30 days after removal of implants) plasma oestradiol concentrations in these two groups were still high (P < 0.05) compared with all other groups. GnRH-induced (0.2 microgram kg-1 bodyweight) LH secretion, evaluated 10 days after treatment with oestradiol benzoate, was depressed (P < 0.05) in OVX 160 + 3E8 gilts, but not affected by age at ovariectomy. We suggest that continuous ovarian secretion is necessary for the final maturation of the LH surge mechanism in late prepubertal gilts and also for maintaining the full functionality of this mechanism in sexually mature gilts. The range over which ovarian oestrogens tune the final maturation of this process appears to be rather narrow; however, other ovarian factors may contribute to the final maturation. Furthermore, continued exposure to supraphysiological concentrations of oestradiol was found to be detrimental to the development of the LH surge mechanism.

Androgens in the topical treatment of lichen sclerosus

BACKGROUND

Testosterone propionate has been shown repeatedly to be effective in the treatment of vulvar lichen sclerosus, yet studies of androgens in serum of women with untreated vulvar lichen sclerosus suggested an abnormal activity of 5-alpha reductase in these patients. If impairment of 5-alpha reductase in women with untreated vulvar lichen sclerosus is a proximate cause of this disease, then dihydrotestosterone should be more effective than testosterone propionate in the treatment of the condition.

METHODS

To test this hypothesis, five women with vulvar lichen sclerosus received topically either dihydrotestosterone or testosterone propionate in a double-blind cross-over study.

RESULTS

These androgens appear to be equally effective in inducing objective improvement of the vulvar lichen sclerosus by both gross and microscopic criteria.

CONCLUSIONS

Impairment of 5-alpha reductase may not be germane to the pathogenesis of vulvar lichen sclerosus.

Zearalenone mycotoxicosis in piglets suckling sows fed contaminated grain

An outbreak of zearalenone mycotoxicosis occurred between early March and mid-April involving 62 suckling piglets of both sexes. The clinical picture was characterized by edematous swelling and reddening of the vulva, sometimes associated with reddening and/or necrosis of the tail. Six female piglets had congenital lesions of the external genitalia while in the remainder clinical signs appeared 2 to 3 d after birth. No sows ingesting the contaminated feed had signs of hyperestrogenism. The distribution of affected litters showed a correlation with poor hygienical conditions. Zearalenone residues were detected only in feed samples from mangers where the hyperestrogenic syndrome occurred.

Ras farnesyltransferase inhibitors suppress the phenotype resulting from an activated ras mutation in Caenorhabditis elegans

Attachment of Ras protein to the membrane, which requires farnesylation at its C terminus, is essential for its biological activity. A promising pharmacological approach of antagonizing oncogenic Ras activity is to develop inhibitors of farnesyltransferase. We use Caenorhabditis elegans vulval differentiation, which is controlled by a Ras-mediated signal transduction pathway, as a model system to test previously identified farnesyltransferase inhibitors. We show here that two farnesyltransferase inhibitors, manumycin and gliotoxin, suppress the Multivulva phenotype resulting from an activated let-60 ras mutation, but not the Multivulva phenotype resulting from mutations in the lin-1 gene or the lin-15 gene, which act downstream and upstream of let-60 ras, respectively, in the signaling pathway. These results are consistent with the idea that the suppression of the Multivulva phenotype of let-60 ras by the two inhibitors is specific for Ras protein and that the mutant Ras protein might be more sensitive than wild-type Ras to the farnesyltransferase inhibitors. This work suggests that C. elegans vulval development could be a simple and effective in vivo system for evaluation of farnesyltransferase inhibitors against Ras-activated tumors.

Late injury of cancer therapy on the female reproductive tract

The purpose of this article is to review the late effects of cancer therapy on the female reproductive tract. The anatomic sites detailed are the vulva, vagina, cervix, uterus, fallopian tubes, and ovaries. The available pathophysiology is discussed. Clinical syndromes are presented. Tolerance doses of irradiation for late effects are rarely presented in the literature and are reviewed where available. Management strategies for surgical, radiotherapeutic, and chemotherapeutic late effects are discussed. Endpoints for evaluation of therapeutic late effects have been formulated utilizing the symptoms, objective, management, and analytic (SOMA) format. Late effects on the female reproductive tract from cancer therapy should be recognized and managed appropriately. A grading system for these effects is presented. Endpoints for late effects and tolls for the evaluation need to be further developed.

Early elemental and ionic changes in cultured cells after stimulation with epidermal growth factor

Stimulation of A431 cells (a human vulval epidermal cell line) with 50 ng/ml of epidermal growth factor (EGF) in the presence of 1.7 mM extracellular calcium produced a sharp and sustained rise in intracellular ionic Ca2+, increased elemental Na, decreased K and a rise in Ca. In the absence of extracellular calcium, the initial Ca2+ rise remained but the sustained elevation of intracellular Ca2+ was abolished, Na and K fluxes were variable and the Ca did not change. Increased Na and decreased K was marked at 2 minutes and returned to the control value after 60 minutes. The increase in Ca was an early event. Cells stimulated with EGF showed a pronounced morphological disruption, especially the mitochondria. The response of NR6/SA3 and NR6/DC7 cells (genetically engineered rodent fibroblast cell lines) to EGF stimulation was higher than that of the A431 cells, as was the resting cytoplasmic Ca2+. Untreated NR6/SA3 and NR6/DC7 cells possessed an increased Na/K ratio when compared with A431 cells.

Delayed effects of prenatal or postnatal exposure to diethylstilbestrol in the adult female guinea pig

Of 25 mature female guinea pigs exposed transplacentally to diethylstilbestrol (DES) for more than 20 days before term, 8 showed abnormal changes in the genital tract (stimulation of the epithelium and stroma, cystic glandular hyperplasia of the endometrial glands near the junction of the upper endocervix and endometrium) and 9 showed severe changes (cystic glandular hyperplasia of the endometrial glands throughout the corpus uteri and cornua, squamous metaplasia). Hyperkeratosis of the vulvar and nipple skin was also observed. No neoplastic changes were observed with one exception at 14 months in one ovary. Prenatal exposure to DES for less than 15 days before term or after birth for 3 days failed to result in abnormal changes in the adults. Prenatal exposure to estradiol for more than 20 days also was without effect in the adult, despite the higher tolerated doses given to the mothers. Cycling activity as judged by vaginal opening was abnormal in all experimental groups, suggesting a derangement of the pituitary-hypothalamic function not specifically related to DES exposure. It was concluded that there is a critical period of exposure of the Müllerian duct- and sinus-derived tissues with respect to the delayed effects of prenatal exposure to DES, which is estimated on the basis of embryological studies to range from the 28th to about the 45th day of gestation.

Cytologic and histologic observations on the sex hormone dependence of the vulva

The usefulness of vaginal cytology in the assessment of hormonal function is well accepted. Our study established that the epithelial horny cells exfoliated from the vulvar skin also exhibit morphologically visible signs of hormonal activity. Cytologic analysis of 429 vulvar smears from 174 women during 88 cycles and postmortem histologic examination of vulvar specimens from an additional 65 women showed parakeratotic keratinization to be significantly more frequent premenopausally than postmenopausally. A vulvar "parakeratotic index" was developed that fluctuates along with the well-known eosinophilic and karyopyknotic indices of the vagina and corresponds to the plasma estradiol concentrations during the cycle. Administration of estrogens in postmenopausal women initiates a striking increase in the index, which is otherwise quite low during that phase of life.

Gynecological follow-up of parkinsonian patients on long-term bromocriptine treatment

Bromocriptine given for prolonged times at high doses has been found to induce tumors in the uterus in aged rats. To elucidate the possible tumorigenic effect of long-term treatment with bromocriptine in humans, 35 women treated with this drug for chronic parkinsonism were studied. For each patient a gynecological anamnesis and examination were performed; one or several cervicovaginal smears and endometrial samples were also taken, by jetwash. No evidence of malignant changes was seen. Thus, in this respect bromocriptine would appear to be a safe drug, even for long-term use.

[Cytologic and histologic studies of hormone dependence of the skin of the external female genitalia]

The value of vaginal cytology for functional hormonal diagnosis is generally recognized. Largely unknown was that the cornified cells obtained from the skin of the vulva likewise show morphologically demonstrable signs of hormonal effects. The cytological analysis of 429 cytological smears of the vulva obtained from 174 women during 88 cycles and the histological analysis of excisions of the vulva obtained at 65 female autopsies showed that the parakeratotic type of cornification is significantly more frequent in the premenopause than in the postmenopause. During the menstrual cycle a parakeratosis index can be identified which is parallel to the well known eosinophilic and karyopyknotic indices of cytological smears from the vagina and corresponds as well to the cyclic levels of estradiol in the serum. Exogenous administration of estrogen during the menopause results in a drastic increase of the parakeratotic index which is normally low following the menopause. These observations show that not only the uncornified squamous epithelium of the vagina but also the cornified squamous epithelium of the vulva reacts to endogenous and exogenous hormonal stimulation although in a different pattern.

Ovarian oestrogen-dependent maturation of the LH/FSH surge mechanism during prepubertal development in the gilt

An involvement of ovarian secretions and in particular oestradiol-17 beta in the maturation of the positive feedback mechanism controlling gonadotrophin surge secretion was studied in prepubertal gilts. The LH/FSH responses to an intramuscular injection of age- and body weight-related doses of oestradiol benzoate (OB) were compared in intact gilts at 60 days of age with or without oestradiol-17 beta pretreatment from 30 to 52 days of age. Four further groups of gilts were challenged with OB at 160 days and were intact, ovariectomized at 60 days, ovariectomized at 60 days and given oestrogen therapy from days 60 to 130 or ovariectomized at 130 days. A significant increase in the magnitude of LH surge responses to OB and a decrease in the time to the first consistent period of surge secretion in intact gilts at 160 compared to 60 days of age confirmed earlier studies and is considered to represent a real maturational change in positive feedback activity. A longer response interval was also present in the majority of ovariectomized gilts. Furthermore a significant reduction in the magnitude of OB-induced LH responses at day 160 occurred in gilts ovariectomized at day 60 compared to those ovariectomized at day 130 and with intact control animals. Oestrogen therapy after ovariectomy at day 60 effectively restored the magnitude of the LH response however. It is concluded that maturation of the positive feedback mechanism is ovarian, and probably oestrogen, dependent.