Pituitary-ovarian function in women with minimal or mild endometriosis and otherwise unexplained infertility

OBJECTIVE

To determine whether abnormalities of pituitary-ovarian function are associated with minor degrees of endometriosis in women with otherwise unexplained infertility.

DESIGN

Comparison of pituitary-ovarian function in a group of 22 patients with that in a control group of 10 healthy fertile women.

PATIENTS

Twenty-two women with minimal or mild endometriosis and otherwise unexplained infertility.

MEASUREMENTS

Ovarian ultrasound and radioimmunoassay of pituitary and ovarian hormones.

RESULTS

Abnormalities, including luteinization of unruptured follicles, broad LH surges and low concentrations of progesterone during the luteal phase, were demonstrated in 82% of study cycles.

CONCLUSION

Pituitary-ovarian dysfunction appears to be associated with minimal or mild endometriosis in women with otherwise unexplained infertility but the diversity of endocrine abnormalities demonstrated suggests that endometriosis is unlikely to be an aetiological factor in their development.

Glucagon in women with polycystic ovary syndrome (PCO): relationship to abnormalities of insulin and androgens

To investigate the glucagon status of women with polycystic ovary syndrome (PCO) and to relate this to serum concentrations of insulin, androgens and SHBG, 44 women with PCO and 23 control subjects underwent a 75-g oral glucose tolerance test. Although obese (body mass index greater than 30 kg/m2) women with PCO had higher concentrations of glucose and insulin than overweight (BMI 25-30 kg/m2) and non-obese (BMI less than 25 kg/m2) women with PCO and control subjects, fasting and summed values of glucagon in response to oral glucose were similar in all groups. The fasting and summed concentrations of glucagon were inversely related to those of testosterone and androstenedione in obese women with PCO, but no other relationships were demonstrated between hormone values and those of glucagon in the other groups. We conclude that glucagon is not implicated in peripheral insulin resistance in women with PCO.

Lack of predictive value of HbA1 for impaired glucose tolerance in polycystic ovary syndrome

Twenty-seven women with polycystic ovary syndrome (PCO) and 17 control women had a 75 g oral glucose tolerance test (oGTT) performed. Although glucose tolerance was impaired in the obese (body mass index greater than 25 kg/m2) women with PCO, glycosylated hemoglobin (HbA1) concentrations did not exceed the normal upper limit (7.2%). In all 44 women, there was no correlation between HbA1 and fasting glucose (r = 0.082, p = 0.63) but there was a significant correlation between HbA1 and summed glucose levels through the oGTT (r = 0.389, p = 0.02). HbA1 measurement does not predict the presence of impaired glucose tolerance in women with PCO.

Gonadotrophin responses to oestrogen provocation in women with minimal endometriosis

The gonadotrophin responses to the negative and positive feedback effects of orally administered ethinyl oestradiol in 12 women with minimal endometriosis were compared with those in six normal women of proven fertility. Basal concentrations of LH, FSH and oestradiol did not differ between the two groups. LH and FSH concentration declined within 12-24 h of starting treatment and there was no difference between minimum values, which occurred in both groups after 12-48 h. In five women with minimal endometriosis, LH concentrations subsequently increased above basal values to maximum values indistinguishable in magnitude and timing from those in the control group. An exaggerated LH response to oestrogen positive feedback occurred in one subject. In the remaining six women LH concentrations increased above levels which could be attributed to episodic variation in basal LH secretion but maximum LH values were below control limits. There was no relationship between previously documented progesterone secretion nor LH concentrations during the early luteal phase of the cycle and the LH response to oestrogen positive feedback. These data suggest that minor abnormalities of hypothalamopituitary function may contribute to infertility associated with minimal endometriosis.

Hypothalamic function in women with secondary hypogonadism and unresponsive to clomiphene therapy

Seven women with secondary hypogonadism who had been previously unresponsive to two 5-d courses of clomiphene citrate, were treated with clomiphene citrate 100 mg daily for 10 d. LH and FSH concentrations were measured in serum collected at 15-min intervals for 5 h before and on the 10th day of treatment and oestradiol was measured in the first two samples on each day. Four women responded with an increase in the amplitude of LH pulses and in mean LH values and in three there was a marked increase in serum oestradiol concentrations. Three women who showed no gonadotrophin response were subsequently unresponsive to pulsatile LHRH therapy. These preliminary data are consistent with the hypothesis that hypothalamic hypogonadotrophism may result from hypersensitivity of the hypothalamus to oestrogen negative feedback and that the hypothalamic potential for secretion of LHRH is unimpaired. Prolonged treatment with clomiphene may provide a simple test of hypothalamic function in women with normal pituitary function.

A comparison of prostaglandin E2 pessaries and laminaria tents for ripening the cervix before termination of pregnancy

Forty primigravid women aged 15-45 years were randomly allocated to receive either an intravaginal pessary of 3 mg prostaglandin E2 (PGE2) or an intracervical 5-mm laminaria tent (LT) 12-16 h before termination of pregnancy at 6-14 weeks gestation. The degree of dilatation of the cervix at operation and its resistance to further dilatation during the procedure were assessed by a 'blind' operator. Laminaria tents were more effective in achieving dilatation and softening of the cervix than were PGE2 pessaries and in 40% of women no further dilatation was necessary. There were no associated side-effects or complications. A cervical tear occurred in two of 20 patients treated with PGE2 pessaries and all 20 required further dilatation of the cervix. Laminaria tents provide a simple, safe, acceptable and effective means of 'ripening' the cervix prior to termination of early pregnancy.

The effects of chronic treatment with LHRH on gonadotrophin secretion and pituitary responsiveness to LHRH in women with secondary hypogonadism

Twenty women with secondary hypogonadism and four normal women in the early follicular phase of the cycle were treated for 7 days with 10, 50 or 100 micrograms synthetic LHRH administered intramuscularly at 4 h intervals. Concentrations of pituitary and ovarian hormones in plasma were measured at intervals during the treatment period. The episodic pattern of LH secretion and the gonadotrophin responses to acute stimulation with LHRH were evaluated before and after treatment. In normal women the concentrations of gonadotrophins and the LH response to LHRH remained unchanged, whilst the FSH response to LHRH was reduced after treatment. Concentrations of oestradiol rose progressively in response to treatment, indicating follicular development. In hypogonadal subjects with unimpaired pituitary function, treatment with LHRH induced a marked but transient increase in the concentrations of LH and FSH in plasma and a progressive rise in that of oestradiol. The concentration of progesterone was increased in four of the 11 subjects. However, the amplitude of LH pulses and the responses of FSH and LH to LHRH after treatment were suppressed below pretreatment values. Women with hypogonadotrophic hypogonadism and diminished pituitary responses to LHRH exhibited a sustained increase in the concentrations of LH, FSH and oestradiol in plasma to normal follicular phase levels. The amplitude of LH pulses and the LH response to LHRH were increased after treatment but did not reach normal values. The FSH response to LHRH was further reduced after treatment. Treatment of similar subjects with 10 micrograms LHRH induced a small increase in the concentration of gonadotrophins but not of ovarian steroids. These data demonstrate that the effect of chronic treatment with LHRH on women with secondary hypogonadism depends on the level of endogenous gonadotrophins. The dose of LHRH used in hypogonadal women receiving treatment by intermittent injection may require adjusting according to the level of gonadotrophin secretion if an optimal response is to be obtained.

Assessment of pituitary secretory capacity in women with hypogonadotrophic hypogonadism by using a long-acting synthetic analogue of luteinizing hormone releasing factor

The gonadotrophin responses to single and repeated injections of a long-acting synthetic analogue of luteinizing hormone releasing factor (LRF), d-Ser(TBU)6EA10LHRH, were investigated in 10 women with normoprolactinaemic hypogonadotrophic hypogonadism. Abnormal luteinizing hormone (LH) responses were observed in two of the five patients treated with 5 micrograms of the analogue and in all five patients treated with three injections of 10, 20 and 10 micrograms administered at intervals of 10-14 h. However, the LH response to repeated injections of the analogue was of similar magnitude and duration to that observed in normal women in response to an oestrogen provocation test in the early-to-mid follicular phase of the cycle. Thus failure of the LH response to oestrogen provocation in women with hypogonadotrophism results from hypothalamic rather than primary pituitary dysfunction. This study confirms the usefulness of this analogue of LRF in the assessment of pituitary secretory function in women with abnormal responses to oestrogen positive feed-back.