Effects of ospemifene, a novel SERM, on biochemical markers of bone turnover in healthy postmenopausal women

Ospemifene is a novel selective estrogen receptor modulator (SERM). Here we studied the effects of ospemifene on bone turnover in postmenopausal women. This was a randomized, double-blind study in which 159 healthy postmenopausal women received 30 (n = 40), 60 (n = 40) or 90 mg (n = 40) of ospemifene or placebo (n = 39) for 3 months. Bone resorption was assessed by measuring the urinary outputs of N- and C-terminal crosslinking telopeptides of type I collagen (NTX and CTX, respectively). Bone formation was assessed by measuring the levels of procollagen type I N propeptide (PINP), procollagen type I C propeptide (PICP), and bone-specific alkaline phosphatase (bone ALP) in serum. All markers were studied at baseline, 3 months, and 2-4 weeks after cessation of the medication. Ospemifene decreased bone resorption dose-dependently, as seen from falls in NTX by 6.1, 9.4 and 12.9% in the 30, 60 and 90 mg ospemifene groups, respectively (p < 0.05 for all dose levels when compared to placebo). CTX values decreased in the 90 mg ospemifene group by 4.8% (p < 0.05). A dose-dependent decrease was also observed in the bone formation markers: PINP values decreased by 9.8 (p < 0.05) and 15.3% (p < 0.01), and PICP values by 12.0 and 11.9% in the 60 and 90 mg ospemifene groups, respectively. Bone ALP decreased in 60 and 90 mg ospemifene groups by 1.9 and 2.6%, respectively (p < 0.05 for both dose levels when compared to placebo). These results show that ospemifene is effective in reducing bone turnover in postmenopausal women.

Combination of cervical interleukin-6 and -8, phosphorylated insulin-like growth factor-binding protein-1 and transvaginal cervical ultrasonography in assessment of the risk of preterm birth

OBJECTIVE

To determine the value of combinations of cervical interleukin-6 (IL-6), cervical interleukin-8 (IL-8), the phosphorylated isoform of insulin-like growth-factor binding protein-1 (IGFBP-1), and cervical ultrasonography in the prediction of preterm birth.

DESIGN

Prospective follow up.

SETTING

Oulu University Hospital maternity clinic from February 1997 to July 1998.

POPULATION

Women with singleton pregnancies (n = 77), referred from outpatient clinics at 22-32 weeks of gestation with symptoms (uterine contractions) or signs (cervical change) of threatened preterm birth. Symptomless women (n = 78) matched for gestational age, parity and maternal age at recruitment were studied as a reference group.

METHODS

A urine sample for bacterial culture was collected, and cervical swab samples for assays of interleukin-6 and -8 and phoshorylated IGFBP-1 were taken before digital cervical examination. A Pap smear for analysis of bacterial vaginosis and samples for analysis of chlamydia and streptococci were also obtained. Cervical measurements were made by transvaginal ultrasonography. The same sampling and cervical measurement were repeated twice at two-week intervals. The cutoff values of the markers were determined by receiver-operating characteristic curve analysis.

MAIN OUTCOME MEASURE

Preterm birth (<37 weeks).

RESULTS

The preterm birth (<37 weeks) rate for women in the study group was 16% (12/77). The cervical interleukin-6 cutoff value (61 ng/L) at first visit had a sensitivity of 73% and a specificity of 61% in predicting preterm birth, with a positive likelihood ratio (LR+ ) of 1.9 (95% CI 1.2-3.0). An ultrasonographically measured cervical index value of > 0.36 at recruitment predicted preterm birth in 25% (5/20) of the study group compared with 9% (5/54); LR+ 2.2 (95% CI 1.03-4.7). Cervical phosphorylated IGFBP-1 > 6.4 microg/L [LR+ 1.8 (95% CI 0.7-2.9)], interleukin-8 > 3739 ng/L [LR+ 1.4 (95% CI 0.9-2.4)], and ultrasonograpic cervical length < 29.3 mm [LR+ 2.7 (95% CI 0.8-9.7)] increased the risk of preterm birth. According to the logistic regression model, a combination of IL-6, and IL-8 and cervical index increased the specificity to 97%, but the sensitivity fell to 30% in detecting preterm birth. There was a significantly increased incidence of puerperal infections if phosphorylated IGFBP-1 concentrations were elevated (> 21.0 microg/L), 36% (4/11) compared with 4.6% (3/65), LR+ 6.7 (95% CI 2.7-17), the sensitivity being 67% (4/6) and the specificity 90% (63/70). Elevated phosphorylated IGFBP-1 concentrations (> 21.6 microg/L) were also associated with an increased risk of neonatal infections; LR+ 8.0 (95% CI 3.5-18).

CONCLUSIONS

An increase in cervical IL-6 concentration and the ultrasonographically measured cervical index appear to be associated with preterm birth. A combination of these markers with measurement of cervical IL-8 appears to be the best predictor of preterm birth. Neither the sensitivity nor specificity of the tests used in this study are good enough to predict preterm birth for clinical decision making. Cervical phosphorylated IGFBP-1 seems to be a marker of puerperal and neonatal infectious morbidity in cases of threatened preterm delivery, suggesting early tissue degradation at the choriodecidual interface.

Insulin-like growth factor-binding protein-1 in cervical secretion as a predictor of preterm delivery

BACKGROUND

The aim of the study was to evaluate whether the phosphorylated isoforms of insulin-like growth factor-binding protein-1 (IGFBP-1), a protein produced by the decidua, can be detected in cervical secretions of pregnant women with preterm uterine contractions, and whether their presence predicts an increased risk of preterm delivery.

METHODS

A prospective analysis of sixty-three women who presented with preterm labor but intact fetal membranes at weeks 22-36+6 days of gestation at the Antenatal clinic at the Department of Obstetrics and Gynecology, Helsinki University Central Hospital. Phosphorylated IGFBP-1 (phIGFBP-1) was measured in cervical swab samples obtained at presentation, using an immunoenzymometric assay. The values > or =10 microg/L were considered as positive. In addition, 58 asymptomatic women at the same gestational stage were studied as controls. Multiple logistic regression was applied to control for confounding variables and to obtain adjusted odds ratios.

RESULTS

The concentration of phIGFBP-1 in cervical samples ranged from undetectable to 95 microg/L. In 17 of the 63 (27%) women with preterm labor it was > or =10 microg/L. Seven of these 17 (41%) women with a positive phIGFBP-1 result delivered preterm, all before 35 weeks of gestation. Among the women with preterm labor and a negative phIGFBP-1 result, three of the 46 (7%) delivered before 37 weeks of gestation (adjusted OR 24, 95% CI 1.2-487), but all after 35 weeks of gestation. In the asymptomatic control population three out of 58 (5%) women had a positive cervical phIGFBP-1 test result but none delivered preterm. Among the controls with a negative cervical phIGFBP-1 test result (55 of 58, 95%), one woman delivered preterm (1 of 55, 2%).

CONCLUSIONS

Pregnant women who are in preterm labor with intact fetal membranes and who have a positive phIGFBP-1 test result in cervical secretion have an increased risk of preterm delivery.

Markers of type I and type III collagen turnover, insulin-like growth factors, and their binding proteins in cord plasma of small premature infants: relationships with fetal growth, gestational age, preeclampsia, and antenatal glucocorticoid treatment

Disorders affecting fetal growth are commonly associated with premature birth. IGFs and their binding proteins (IGFBPs) are potent regulators of fetal growth. In vitro evidence suggests that they regulate collagen turnover. Collagen turnover can be monitored by serum markers of type I collagen synthesis (PINP) and degradation (ICTP) and a marker of type III collagen synthesis (PIIINP). We examined whether these markers in fetal circulation reflect intrauterine growth and maturity, and whether any interrelationship exists between them and fetal IGFs and IGFBPs in preterm infants before 32 wk of gestation. Cord plasma PINP, ICTP, PIIINP, IGF-I, IGF-II, IGFBP-1, and IGFBP-3 were determined for 98 preterm infants. To express birth weight in units adjusted for gestational age, a birth weight SD score (SDS) was calculated. Negative correlations existed between gestational age and PINP (r = -0.43; p < 0.0001), ICTP (r = -0.34; p = 0.002), and PIIINP (r = -0.34; p = 0.0001). Positive correlations existed between birth weight SDS and PINP (r = 0.40; p = 0.0002) and ICTP (r = 0.48; p < 0.0001) but not PIIINP. Moreover, birth weight SDS was positively correlated with IGF-I (r = 0.58; p < 0.0001) and IGFBP-3 (r = 0.44; p < 0.0001) and negatively correlated with IGF-II (r = -0.36; p = 0.003) and IGFBP-1 (r = -0.50; p < 0.0001). Gestational age correlated with IGFBP-3 (r = 0.25; p = 0.03). In preeclampsia, IGF-I was lower (p = 0.002) and IGFBP-1 higher (p < 0.0001), also after adjustment for fetal size. The number of antenatal glucocorticoid treatments was associated with lower ICTP (p = 0.04), higher IGF-I (p = 0.002), lower IGF-II (p = 0.02), lower IGFBP-1 (p = 0.05), and higher IGFBP-3 (p = 0.004), also after adjustment for potential confounders. In multiple regression analysis, the factors significantly associated with PINP (R:(2) = 0.47) were gestational age and IGF-I, and those associated with ICTP (R:(2) = 0.54) were IGF-I, gestational age, and antenatal glucocorticoid treatment. We conclude that IGF-I may be involved in regulation of type I collagen turnover in the growing fetus. Cord blood PINP and ICTP reflect both fetal growth and maturity and deserve evaluation as potential indicators of postnatal growth velocity in preterm infants, whereas PIIINP reflects fetal maturity.

Fibroids and hypertension. A cross-sectional study of women undergoing hysterectomy

OBJECTIVE

To determine whether uterine fibroids are associated with hypertension.

STUDY DESIGN

A total of 543 consecutive women, 41-89 years of age, who underwent hysterectomy in 1984 and 1994 for benign indications at Helsinki University Central Hospital were included in the study. Preoperative information on indications for the procedure, current use of hormone replacement therapy (HRT) or other medication, parity, body mass index and blood pressure (BP) was obtained from medical records. The presence of fibroids was confirmed from the pathology report. Women were classified as hypertensive if they currently used antihypertensive medication, had a history of hypertension without current medication or had a preoperatively measured BP > 140/90 mm Hg.

RESULTS

Women with fibroids were significantly younger and more likely to use HRT than the other women. Uterine fibroids were more frequent among hypertensive (42%) than normotensive (37%) women. In logistic regression analysis, fibroids were statistically significantly associated with hypertension (OR 1.8, 95% CI 1.2-2.7). The association between myomas and hypertension was strongest (OR 3.6, 95% CI 1.2-10.9) among women with hysterectomies for benign adnexal tumors.

CONCLUSION

Uterine fibroids and/or adnexal tumors may share pathogenic features with the development of hypertension.

Heritability and risk factors of uterine fibroids--the Finnish Twin Cohort study

OBJECTIVES

Our aim was to study heritability, risk factors and hospitalization for uterine fibroids.

METHODS

A random sample of 80 MZ and 80 DZ twins from the Finnish Twin Cohort were invited and 51% of the eligible women (n=82, 17 MZ and 16 DZ pairs, 40-47 years, mean age 43.0), underwent a transvaginal ultrasound. The entire cohort of 13872 women was linked to the national hospital discharge registry 1972-1990.

RESULTS

Prevalence of fibroids was 66% and the average number of fibroids 1.7. The casewise concordance for being hospitalized for uterine fibroids was higher in MZ (0.31, 95% CI 0.24-0.37) than in DZ pairs (0.18, 95% CI 0.14-0.22). The proportion of variance in liability to fibroid hospitalization accounted for by genetic factors was 54.8% (95% CI 46.2-62.7%). Women with fibroids had higher body mass index (23.7 vs 21.7, P=0.0086), lower age at first birth (25.7 vs 29.3, P=0.012) and higher parity (3+ children 48.2 vs 29.6%, P=0.009) than women without fibroids. Risk ratio (RR) for fibroids in a MZ twin whose sister had been diagnosed with fibroids was 1.1 (95% CI 0.08;15), for a DZ twin 1.1 (95% CI 0.16;8.8) and for all twins 1.3 (95% CI 0.3; 6.1). Intraclass correlation for the number of fibroids was 0.24 for MZ and 0.11 for DZ twins, yielding an heritability estimate of 0.26.

CONCLUSION

Reproductive and anthropometric factors may have at least as large role in pathogenesis of fibroids than genetic factors.

Insulin-like growth factors and insulin-like growth factor binding proteins in the endometrium. Effect of intrauterine levonorgestrel delivery

Insulin-like growth factor (IGF) system is one of the growth factor systems that are believed to modulate steroid hormone actions in the endometrium through autocrine/paracrine mechanisms. IGF-I and IGF-II stimulate proliferation and differentiation, and maintain differentiated cell functions in several cell types in vitro. Endometrial stromal cells produce IGF-I and IGF-II as well as the high affinity IGF-binding proteins (IGFBP), whereas epithelial cells and, in a lesser amount, stromal cells contain cell membrane receptors for IGF. Oestrogen stimulates IGF-I gene expression, and IGF-II gene expression is associated with endometrial differentiation. The mRNA of six high affinity IGFBPs, which can modulate IGF actions, are expressed in human endometrium. The most abundant IGFBP in human endometrium is IGFBP-1, which is secreted by predecidualized/decidualized endometrial stromal cells in late secretory phase and during pregnancy. The primary negative regulator of IGFBP-1 production is insulin. IGFBP-1 competes with type I IGF receptor for binding of IGF in the endometrium and in cultured human trophoblastic cells. IGF-I mRNA is suppressed and mRNA encoding IGF-II and IGFBP-1 are consistently up-regulated in decidualized endometrium in women treated with the intrauterine levonorgestrel system (LNG-IUS). Strong cytoplasmic staining for IGFBP-1 was detected in decidualized endometrium in women using LNG-IUS for contraception or for endometrial protection during post-menopausal oestrogen replacement therapy. Simultaneously, oestrogen receptors were present, while progesterone receptors were hardly detectable in the endometrium by immunohistochemistry. The latter findings suggest that suppression of IGF-I action by IGFBP-1 may be one of the molecular mechanisms accounting for progestagenic and anti-oestrogenic effects of LNG-IUS in the endometrium. Consequently, examination of local IGF-I, IGF-II and IGFBP-1 expression might provide additional information when evaluating the effect of different progestins on the endometrium at the molecular level.

Markers of collagen metabolism and insulin-like growth factor binding protein-1 in term infants

AIM

To study the relation between fetal growth and markers of collagen metabolism and insulin-like growth factor binding protein-1 (IGFBP-1) in term infants.

METHODS

Cord vein plasma was obtained from 67 term infants of gestational age 37.1-41.7 weeks (39 appropriate for gestational age (AGA), 11 large for gestational age (LGA; relative birth weight >/= 2.0 SD), and 17 small for gestational age (SGA; relative birth weight </= -2.0 SD)) for analysis of markers of metabolism of collagen type I (PICP and ICTP) and III (PIIINP) and of IGFBP-1.

RESULTS

Negative correlations existed between gestational age and PICP (r = -0.294, p = 0.0158), ICTP (r = -0.338, p = 0.0052), and PIIINP (r = -0.432, p = 0.0003). These correlations were also found in SGA infants (all p < 0.05). IGFBP-1 showed negative correlations with birth weight and relative birth weight (r = -0.644, p = 0.0001, and r = -0.693, p = 0.0001 respectively) but not with gestational age (p>0.05).

CONCLUSIONS

In the term fetus, collagen metabolism is primarily dependent on maturity and not on intrauterine growth status, whereas IGFBP-1 reflects intrauterine growth independently of maturity.

Increased leptin concentration in preterm infants of pre-eclamptic mothers

AIM

To study the effect of maternal pre-eclampsia on cord plasma leptin concentrations in preterm infants.

METHODS

Leptin concentration was analysed in cord plasma of 74 preterm infants, gestational age 24 to 32 weeks. Of these, 14 were born to pre-eclamptic mothers, in 10 intrauterine growth retardation (IUGR) was present, and 59 had been exposed antenatally to corticosteroids.

RESULTS

The mean (SD) concentration of cord plasma leptin was 1.31 (0.88) microg/l. A significant correlation was found between leptin concentration and gestational age (r = 0.336; p = 0.0037). Leptin levels were higher in infants of pre-eclamptic mothers (p = 0.0007), in those with IUGR (p = 0.0005), and in infants exposed antenatally to corticosteroids (p = 0.02). In multiple regression analysis, leptin was associated with gestational age and maternal pre-eclampsia (both p < 0.05), but not with antenatal corticosteroids.

CONCLUSIONS

Increased fetal leptin in maternal pre-eclampsia may reflect a physiological adaptation to fetal stress such as hypoxia.

Insulin-like growth factors in obstetrics

Data from a number of studies reported during the past two decades indicate that the insulin-like growth factor (IGF) system, including IGF-I and IGF-II, their receptors and six high-affinity binding proteins, is involved in the control of foetal and placental growth and development. Recent studies that addressed the role of the IGF system in pregnancy and the clinical usefulness of IGF and IGF-binding protein measurements in obstetrics are reviewed and discussed.

Serum insulin-like growth factor binding protein-1 at 16 weeks and subsequent preeclampsia

OBJECTIVE

To determine whether serum concentrations of insulin-like growth factor-binding protein-1 (IGFBP-1), a major decidual protein, at 16 weeks' gestation differ between women who later develop pregnancy-related hypertension and normotensive women.

METHODS

Concentrations of IGFBP-1 were measured using immunoenzymometric assay in serum samples collected for alpha-fetoprotein (AFP) and free beta subunit of hCG (free beta-hCG) determinations in a Down syndrome screening program at 16 weeks' gestation in a population-based cohort of 1049 nulliparous women. After exclusion of subjects with multiple pregnancies, insulin-dependent diabetes, major fetal malformations, and incomplete data, 917 subjects remained eligible.

RESULTS

The mean levels (+/- standard deviation) of IGFBP-1 were significantly lower in 34 women who later developed preeclampsia (73 +/- 43 microg/L, P < .01) and in 80 women with White A diabetes (84.7 +/- 53 microg/L, P < .01) compared with controls (103 +/- 58 microg/L). In seven women with White A diabetes and subsequent preeclampsia IGFBP-1 levels were especially low (41 +/- 34 microg/L). The concentrations of AFP and free beta-hCG in the subgroups with hypertensive disorders were not significantly different from those of normotensive women.

CONCLUSION

Decreased IGFBP-1 levels at 16 weeks' gestation in women who develop preeclampsia might indicate impaired decidual function. Hyperinsulinemia, a known risk factor for preeclampsia, might contribute to decreased concentrations of serum IGFBP-1. However, due to low sensitivity, assay of serum IGFBP-1 was not clinically valuable for predicting preeclampsia.

Phosphorylated isoforms of insulin-like growth factor binding protein-1 in the cervix as a predictor of cervical ripeness

OBJECTIVE

To study the isoforms of insulin-like growth factor binding protein-1 (IGFBP-1) in cervical secretion and to evaluate whether their assessment could serve in prediction of cervical ripeness at term.

METHODS

We measured the concentrations of IGFBP-1 in cervical swab samples of 64 women scheduled for labor induction by amniotomy or cervical ripening with prostaglandin E2 gel. Two immunoenzymometric assays were used: a previously described assay 1, which detects the nonphosphorylated and lesser phosphorylated isoforms, and a novel assay 2, which detects the lesser and highly phosphorylated isoforms of IGFBP-1. A set of 39 amniotic fluid (AF) samples also was analyzed to compare the phosphorylation status of IGFBP-1 in cervical secretion with that in AF.

RESULTS

In all cervical samples, IGFBP-1 concentration was higher by assay 2 than by assay 1, whereas in all AF samples, the results were the opposite. Initially, the median IGFBP-1 concentration in the ripe cervices (Bishop scores 6 or greater; n = 29) was approximately four times as high as that in the unripe cervices (Bishop scores 5 or less; n = 35). The cervical IGFBP-1 concentrations increased eight-fold in 6 hours after the first application of PGE2.

CONCLUSION

Phosphorylated isoforms of IGFBP-1, different from those in AF, are present in the cervical secretion of women with intact fetal membranes and reflect cervical ripeness. A bedside test for those IGFBP-1 isoforms might help in predicting amenability for labor induction.

The effect of intrauterine and oral levonorgestrel administration on serum concentrations of sex hormone-binding globulin, insulin and insulin-like growth factor binding protein-1

BACKGROUND

The concentrations of sex hormone-binding globulin (SHBG) have been shown to decrease during the use of levonorgestrel (LNG)-containing contraception. This decrease has been thought to be due to the androgenic action of LNG. In endogenously hyperandrogenic women, particularly in those with increased body weight, serum SHBG correlates with circulating insulin-like growth factor binding protein-1 (IGFBP-1) concentration, and both are inversely related to insulin. LNG-containing combined contraceptives have also been reported to increase the pancreatic insulin secretion.

OBJECTIVE

To examine whether serum insulin and IGFBP-1 levels are related to SHBG during the use of intrauterine or oral levonorgestrel contraception.

METHODS

Thirty-one fertile women were divided into three study groups: A copper-releasing intrauterine device (IUD) was inserted in control group (n= 10), and the LNG-releasing intrauterine contraceptive system (LNG-IUS) in group II (n= 10), and 30 mirog LNG-containing contraceptive minipills were given in group III (n=11). Twenty-nine women completed the study and one woman was excluded because of a high body mass index. Fasting concentrations of blood glucose, insulin, SHBG, IGFBP-1, testosterone and LNG before and after three-months-use of contraception were measured.

RESULTS

SHBG concentrations decreased slightly during oral LNG contraception, but not during the use of the LNG-IUS. No change was found in blood glucose, serum insulin, serum IGFBP-1 and serum total testosterone concentrations in either group. In our study group, including women with normal body weight, no correlation was detected between insulin and SHBG concentrations before or after LNG contraception, whereas an inverse correlation was found between insulin and IGFBP-1 levels at the baseline as well as after LNG-IUS use (R2= 0.578; p=0.001). Multiple regression analysis showed no significant association between the levels of SHBG and IGFBP-1 as dependent factors, and glucose, insulin, LNG, age, waist-hip ratio and body mass index as dependent factors.

CONCLUSIONS

Our data imply that the effect of levonorgestrel on variables associated with endogenous hyperandrogenism remains borderline in women with normal body mass index.

Insulin-like growth factors in endometrial function

Growth factors and related peptides are believed to mediate and modulate the actions of hormones at their target tissues through autocrine/paracrine mechanisms. Endometrial stromal cells produce insulin-like growth factors I and II (IGF-I and IGF-II) as well as the high-affinity IGF binding proteins (IGFBPs), whereas epithelial cells and, in a lesser amount, also stromal cells contain cell membrane receptors for IGFs. IGFs have proliferative, differentiative and metabolic effects. Estrogen stimulates IGF-I gene expression in the endometrium, and IGF-I is assumed to mediate estrogen action. IGF-II gene expression is associated with endometrial differentiation. All six high-affinity IGFBPs are expressed in human endometrium, the most abundant being IGFBP-1. This is secreted by predecidualized/decidualized endometrial stromal cells in late secretory phase endometrium and pregnancy decidua, i.e. under the action of progesterone. The primary negative regulator of IGFBP-1 expression is insulin, by inhibiting IGFBP-1 transcription. IGFBP-1 inhibits the receptor binding and biological actions of IGF-I in the endometrium and in cultured human trophoblastic cells. These findings support the view that the IGF system has autocrine and paracrine functions in the regulation of endometrial proliferation and differentiation. After implantation, decidual IGFBP-1 may regulate IGF actions at the embryo-endometrial interface, since trophoblast cells contain IGF receptors and express IGF-II, but do not express IGFBP-1. Clinical conditions that are known to increase the risk of endometrial cancer are all characterized by the absence of IGFBP-1. Thus, like unopposed estrogen, unopposed IGF-I action may also lead to uncontrolled endometrial proliferation and favor the development of endometrial cancer. The measurement of mRNAs encoding the IGF system might provide a novel tool to evaluate the endometrial response to endogenous and exogenous estrogens and progestins at the molecular level.

The effect of intrauterine levonorgestrel use on the expression of c-JUN, oestrogen receptors, progesterone receptors and Ki-67 in human endometrium

The major regulators of endometrial function are oestrogen and progesterone, which act through binding their nuclear receptors and by activating transcription of their target genes. Interactions between steroid receptors and transcription proteins, e.g. c-JUN/AP-1, can modulate steroid action at the transcriptional level. The 19-nortestosterone-derived progestin, levonorgestrel, is used for contraception, treatment of menorrhagia and for endometrial protection during hormone replacement therapy, but the signalling pathways of its action are totally undefined. We examined the effect of an intrauterine system, releasing 20 microg of levonorgestrel per 24 h (LNG-IUS), on immunoreactive oestrogen receptor, progesterone receptor, c-JUN and Ki-67 expression in 29 endometrial specimens, obtained from fertile women using the LNG-IUS for contraception. Moderate to strong immunostaining for oestrogen receptors was observed in the stromal cells in all specimens, in glandular epithelial cells in 26 cases and in flattened luminal epithelial cells in 17 specimens. Decidualized stromal cells showed no progesterone receptor immunoreactivity in 19 of the 29 specimens, and weak to moderate immunostaining in 10 cases. Luminal epithelial cells were negative for progesterone receptor in all samples. Intense nuclear staining for C-JUN was observed in epithelial cells in 26 and in decidualized stromal cells in all 29 of the samples. In 16 samples, Ki-67 immunoreactivity was evaluated as weak to moderate in decidualized stroma, and in 13 samples absent. Our data demonstrate that intrauterine release of LNG maintains constant expression of C-JUN and exerts progestational effects in the endometrium in the absence of progesterone receptors. In contrast, LNG-IUS inhibits several cellular responses to oestrogen despite the presence of endogenous oestrogen and oestrogen receptors. These data suggest that the progestational effects induced by progesterone and levonorgestrel are mediated through different signalling pathways.

Cellular localization of c-jun messenger ribonucleic acid and protein and their relation to the proliferation marker Ki-67 in the human endometrium

We studied cellular c-jun messenger RNA (mRNA) expression in the human endometrium during the menstrual cycle (n = 47) and in human decidua during pregnancy (n = 8), by using digoxigenin-labeled RNA probes in in situ hybridization. The same tissue samples were also analyzed for c-Jun protein and the proliferation marker Ki-67. In the proliferative endometrium, strong expression of c-jun was detected in luminal and glandular epithelium as well as in fibroblast-like stromal cells. During the early luteal phase, strong hybridization signals were identified in both epithelial and stromal compartments, with the strongest hybridization in the stromal cells beneath the epithelium. c-jun mRNA was markedly diminished in luminal and glandular epithelia of mid- and late secretory phase endometria, but it remained unchanged in the stroma. Regardless of the phase of the menstrual cycle, significant hybridization was identified in endothelial cells in the endometrium and myometrium, and a low signal was detected in myometrial muscle cells as well. During early gestation, weak expression of c-jun mRNA was observed in glandular epithelial cells and in decidualized stromal cells. In term pregnancy decidua, only low-level hybridization was detected in a few decidual cells. Nuclear immunostaining of c-Jun was detected in luminal and glandular epithelia and in stroma throughout the menstrual cycle. The location of Ki-67 antigen was temporally related to the c-jun mRNA expression in cycling endometrium and pregnancy decidua. From our data we conclude that 1) c-jun mRNA is differentially expressed in endometrial epithelial and stromal cells; 2) c-jun mRNA is cyclically regulated in the human endometrial epithelium; 3) c-jun mRNA expression is temporally related to epithelial proliferation in the endometrium; and 4) c-Jun protein is present in the human endometrium throughout the menstrual cycle.

Evidence of high circulating testosterone in women with prior preeclampsia

Women with prior preeclampsia are characterized by hyperinsulinemia and a 2- to 3-fold excess risk of hypertension and ischemic heart disease in later life. We therefore studied whether these women present changes in pituitary, ovarian, and endothelial factors that could also affect the risk of vascular disorders. Twenty-two women with prior preeclampsia and 22 control women matched by age and body mass index were studied an average of 17 yr after delivery. Women with prior preeclampsia had elevated serum free testosterone levels (20.6 +/- 2.2 vs. 15.0 +/- 1.3 pmol/L, mean +/- SE, P = 0.03), an elevated free androgen index (3.2 +/- 0.5 vs. 1.9 +/- 0.2, P = 0.04), and an elevated free testosterone estradiol ratio (0.089 +/- 0.017 vs. 0.046 +/- 0.006, P = 0.02). The levels of insulin-like growth factor binding protein-1 decreased as expected during a 3-h oral glucose tolerance test without differences between the groups. Levels of FSH, LH, androstenedione, dehydroepiandrosterone sulfate, and endothelin-1, as well as urinary output of prostacyclin and thromboxane A2 metabolites, showed no difference between study groups. A history of preeclampsia an average of 17 yr earlier thus appears to be associated with elevated levels of testosterone, which may contribute to the increased risk of vascular morbidity in such women.

The interleukin-1 system in gestational tissues at term: effect of labour

Previous studies suggest that the interleukin-1 (IL-1) system is involved in preterm labour, at least in cases associated with intrauterine infection. To investigate the effect of term labour without infection on the IL-1 system, the messenger ribonucleic acid (mRNA) expression of IL-1 beta, IL-1 receptor type I (IL-1R tI), IL-1 receptor antagonist (IL-1ra), and IL-1 beta converting enzyme (ICE) were examined by Northern blot analysis and by reverse transcriptase-polymerase chain reaction (RT-PCR) in paired samples of decidua and placenta obtained from women having spontaneous vaginal delivery (group 1) or elective caesarean section (group 2) at term. In addition, concentrations of IL-1 beta and IL-1ra proteins were measured by ELISA in paired decidual and placental cytosols. In all decidual samples, IL-1 beta mRNA was expressed strongly, and the IL-1 beta concentration was 40- to 50-fold higher than in paired placental samples, in which the signal for IL-1 beta mRNA could be detected by RT-PCR only, and the amount of IL-1 beta protein was undetectable or very low. A comparison between the study groups revealed that the decidual IL-1 beta mRNA level tended to be higher in group 1, and the median IL-1 beta concentration in decidual cytosols was significantly higher in group 1 than in group 2 (P < 0.05). The IL-1R tI mRNA transcript was stronger in decidual than in paired placental samples in both groups. The mRNAs encoding ICE and IL-1ra were detected by RT-PCR in decidual and placental samples from both groups. The IL-1ra concentration tended to be higher in decidual cytosols than in paired placental cytosols, but there was no difference between the study groups. The IL-1ra/IL-1 beta ratio was significantly lower in decidual samples in women with spontaneous labour than in women without labour (P < 0.05). The results of this study confirm that decidua is the major site of IL-1 beta production and action in term gestational tissues. Furthermore, the results show that the major change in decidual/placental IL-1 system during parturition is the increase in decidual IL-1 beta production. Whether the increased IL-1 beta production precedes or is a consequence of labour, remains still unclear.

mRNA expression of insulin-like growth factor-I (IGF-I) is suppressed and those of IGF-II and IGF-binding protein-1 are constantly expressed in the endometrium during use of an intrauterine levonorgestrel system

Insulin-like growth factors (IGF-I and IGF-II) are believed to mediate and modulate steroid hormone actions in the endometrium. In this study we determined the effects of an intrauterine system (IUS), releasing 20 microg levonorgestrel (LNG) daily, on endometrial expression of mRNAs encoding IGFs and insulin-like growth factor binding protein (IGFBP)-1. In Northern blotting, IGF-I mRNA was undetectable in all endometrial specimens from women with an LNG-IUS (n = 11) and in pregnancy decidua, whereas several transcripts of 0.6-7.6 kb were detected in proliferative and secretory phase endometria. In contrast, mRNAs encoding IGF-II and IGFBP-1 were strongly expressed in pregnancy and in all endometrial samples from women with an LNG-IUS, but were undetectable in proliferative or early to mid-secretory phase endometria. Using the more sensitive reverse transcriptase-polymerase chain reaction (RT-PCR) method, IGF-I and IGF-II mRNAs were detectable in all cycling endometria, in early pregnancy decidua and in LNG-exposed endometrium. IGFBP-1 mRNA was constantly expressed in LNG-exposed endometrium, in early pregnancy decidua and in premenstrual endometrium, but was undetectable in all specimens from proliferative or early to mid-secretory endometrium. Our data demonstrate that progestin treatment can affect the gene expression of endometrial growth factors in vivo. The consistent expression of mRNAs encoding IGF-II and IGFBP-1, with suppression of IGF-I mRNA in endometria exposed to LNG, suggests that this mode of hormone treatment can inhibit IGF-I action in the endometrium. If IGF-I mediates and modulates oestrogen action, suppression of IGF-I mRNA may be one of the molecular mechanisms which accounts for the antiproliferative effects of progestogens on oestrogen-primed endometrium and the atrophy of endometrial epithelium resulting from use of an LNG-IUS.

Distinct patterns of expression of keratinocyte growth factor and its receptor in endometrial carcinoma

BACKGROUND

Keratinocyte growth factor (KGF) is a member of the fibroblast growth factor (FGF) family. KGF is a stromally derived, paracrine growth factor specifically mitogenic for a variety of epithelial cells. The KGF receptor (KGFR), which is a splice variant of the FGF receptor-2 (FGFR-2)/bek gene, is expressed only in epithelial cells. In this study, the expression of mRNAs encoding KGF, KGFR, and FGFR-2 in endometrial adenocarcinoma and in carcinosarcoma tissues was examined and the expression of the same mRNAs was compared with cycling endometrium.

METHODS

Specimens of tumor tissue were collected from 14 women with well differentiated endometrial adenocarcinoma and from 4 women with carcinosarcoma. All samples were obtained at the primary surgery before any treatment was initiated. In addition, endometrial tissues from 19 premenopausal women with normal menstrual cycles were examined. The expression of specific mRNAs in the endometrial samples was assessed using quantitative reverse transcriptase polymerase chain reaction. The results were analyzed by the nonparametric Kruskal-Wallis statistic.

RESULTS

The KGF mRNA expression was significantly lower in endometrial adenocarcinoma tissue compared with cycling endometrial tissues, whereas no difference was found between carcinosarcoma tissue and cycling endometrium. The relative level of KGFR mRNA in endometrial adenocarcinoma did not differ from that in cycling endometrium, but was significantly higher compared with carcinosarcomas. No differences were observed in FGFR-2 mRNA expression between cycling endometrium and tumor tissues.

CONCLUSIONS

To the authors' knowledge, this study demonstrates for the first time the expression of KGF, KGFR, and FGFR-2 mRNAs in endometrial adenocarcinoma and in carcinosarcoma tissues. The relative level of KGF mRNA expression in adenocarcinoma tissue is decreased compared with that in cycling endometrium. The change in epithelial/stromal cell prominence between cycling endometrium and adenocarcinoma tissue may account for the difference in KGF expression but does not explain why KGF receptor expression in same tissues remains unchanged. The impact of altered KGF expression for endometrial tumorigenesis is still unknown.

Proto-oncogenes c-jun and c-fos are down-regulated in human endometrium during pregnancy: relationship to oestrogen receptor status

Oestrogen is the major stimulatory factor in endometrial cell proliferation. Animal and in-vitro studies have shown that proto-oncogenes c-fos and c-jun are regulated by oestrogen receptor (ER) complex. We have previously shown by Northern blot analysis that proto-oncogenes c-fos and c-jun are strongly expressed in human proliferative and early to mid-secretory endometrium. In this study, we examined the expression of the messenger RNA (mRNA) of the nuclear proto-oncogenes c-fos and c-jun in 10 early (6-10 weeks) and 20 term (30-40 weeks) pregnancy decidua by Northern blotting. In order to investigate the relationship between ER and these proto-oncogenes, the ER and progesterone receptors (PR) were identified in the same tissue samples by immunohistochemistry. When using 30-mer oligonucleotide probes, hardly any signals for c-fos and c-jun could be identified either in early or in late pregnancy decidua. Nuclear ER staining was intense in the epithelium and stroma of proliferative and early to mid-secretory endometrium but was sparsely scattered in stroma and lacking in epithelium during early pregnancy. In late pregnancy decidua, no positive ER staining was detectable. PR were present in abundance both in endometrial epithelium and stroma in proliferative and early secretory phase, and clear positive staining remained in stromal cells in late secretory phase and throughout pregnancy. The temporal association between immunoreactive ERs and the expression of c-fos and c-jun mRNA suggests that the activation of both proto-oncogenes is ER-mediated in human endometrium. The down-regulation of ER is one possible explanation for the repression of these immediate early genes during pregnancy.

Increased incidence of retching and vomiting during periovulatory phase after middle ear surgery

PURPOSE

To assess the effect of the menstrual cycle on postoperative retching and vomiting (R&V) after middle ear surgery, and the efficacy of prophylaxis against R&V in female patients with transdermal scopolamine during either general or local anaesthesia and with intravenous ondansetron during general anaesthesia.

METHOD

A post hoc analysis of the data on 85 female patients with normal menstrual cycles from three prospective studies on the prophylaxis of postoperative nausea and vomiting after middle ear surgery on 205 patients.

RESULTS

Periovulatory period (menstrual dates 11-24) and history of motion sickness were predictors for R&V. During 2-24hr, both the percentage of patients needing droperidol and the mean number of doses were lower in the perimenstrual group (menstrual dates 25-10) than in the periovulatory group 27 vs 51% (P < 0.05) and 0.2 vs 0.7 (P < 0.01), respectively. Prophylaxis with transdermal scopolamine was a predictor for lowered R&V (P < 0.05) and resulted in fewer doses of droperidol (0.4 +/- 0.7 vs 1.4 +/- 1.5, P < 0.01). This reduction was significant during the periovulatory period (from 1.4 +/- 1.3 to 0.3 +/- 0.5, P < 0.005). Ondansetron reduced the mean need for droperidol from 1.4 +/- 1.5 to 0.6 +/- 0.8, (P < 0.05).

CONCLUSION

The incidence of R&V after middle ear surgery was lower during the perimenstrual phase. In the periovulatory phase, transdermal scopolamine was more efficient as prophylaxis against R&V than ondansetron. All female patients scheduled for middle ear surgery should be considered individually to receive prophylaxis against R&V.

Evaluation of a rapid strip test for insulin-like growth factor binding protein-1 in the diagnosis of ruptured fetal membranes

We evaluated the clinical usefulness of a new bedside test (PROM TEST) for insulin-like growth factor binding protein-1 (IGFBP-1) in the detection of ruptured fetal membranes (ROM). Cervicovaginal secretion was sampled between 15 and 37 weeks of gestation from asymptomatic women with apparently intact membranes and from women with clinically confirmed ROM, as well as from symptomatic women with suspected ROM based on history. IGFBP-1 in samples was detected with a dipstick based on immunochromatography. The test result was positive in 100% of cases with unequivocal ROM and in 5.3% of cases with apparently intact membranes. Furthermore, the PROM TEST was positive in 64 of 181 patients evaluated for suspected ROM based on history, but in whom the diagnosis could not be clinically confirmed at the initial evaluation. Fifty of the 64 women (78.1%) were delivered prematurely (< 37 weeks). Five of the 117 PROM-negative patients had elective cesarean section for reasons unrelated to ROM before 37 weeks and 10 of the remaining 112 patients (8.9%) had preterm delivery. Women with equivocal ROM and a positive test result had a 6.9-fold increased relative risk (95% confidence interval 4.2-11.4) of preterm delivery compared with women who had a negative result at the time of evaluation. Multiple logistic regression including PROM TEST result, contractions, vaginal bleeding and cervical changes indicated that a positive PROM TEST result was an independent predictor of preterm delivery (P = 0.0001). In summary, a positive PROM TEST result identifies ROM with high sensitivity and a negative result effectively excludes those with intact membranes. In patients with suspected but clinically unconfirmed ROM, the positive test result is associated with increased risk of preterm delivery, suggesting that microruptures of fetal membranes can also be detected by the PROM TEST.

Normal human ovary and ovarian tumors express glycodelin, a glycoprotein with immunosuppressive and contraceptive properties

Glycodelin is a glycoprotein with potent immunosuppressive and contraceptive activities. It reacts with antibodies against placental protein 14, or progesterone-associated endometrial protein, and has a unique carbohydrate structure. Previous nomenclature is misleading, because glycodelin is neither synthesized in the placenta nor is it endometrium specific. No ovarian synthesis of glycodelin has been demonstrated. We present evidence for glycodelin synthesis in the human ovary and ovarian tumors. In follicular phase, immunoperoxidase staining of microwave-treated tissue sections employing affinity-purified polyclonal antibodies localized glycodelin to areas of stromal cell condensation in ovarian cortex, theca interna, and the granulosa. In luteal phase, cortical stroma was negative or only weakly positive, whereas glycodelin was present in theca interna of the corpus luteum and luteinized granulosa cells and also in corpus albicans and Leydig cells of the ovarian hilus. In situ hybridization gave negative results for glycodelin mRNA in normal ovary, whereas in ovarian tumors strong expression of both the glycodelin mRNA and the protein were found in benign and malignant serous cystadenomas, mucinous ovarian tumors being negative. We conclude that glycodelin is synthesized in human ovarian tumors, and its occurrence in normal human ovary may represent either synthesis or a site of glycodelin action.

Endometrial response to hormone replacement therapy as assessed by expression of insulin-like growth factor-binding protein-1 in the endometrium

OBJECTIVE

To assess endometrial response to parenteral levonorgestrel in hormone replacement therapy by means of morphological criteria and immunohistochemical staining of insulin-like growth factor-binding protein-1 (IGFBP-1).

DESIGN

Endometrial samples were collected from 35 postmenopausal women after 12 to 22 months of continuous combined estrogen-progestin therapy. All subjects were treated with parenteral progestin. A group of 8 women was treated with a subdermal levonorgestrel-releasing implant, and 27 women had a levonorgestrel-releasing intrauterine device (IUD). Sections of formalin-fixed paraffin-embedded biopsies were used for immunohistochemistry and after hematoxylin-eosin staining for routine histologic examination.

RESULTS

Atrophic epithelium with pronounced decidual reaction in the stroma was detected by histologic examination in all endometrial samples obtained from 27 women treated with the levonorgestrel-releasing IUD. In contrast, the endometrium was proliferative in seven of eight (87.5 percent) biopsies obtained from women treated with the levonorgestrel-releasing implant. Immunoreactive IGFBP-1 was detected in decidualized stromal cells in all endometrial samples obtained during intrauterine levonorgestrel therapy, whereas only one of eight samples obtained from women treated with subdermal levonorgestrel exhibited weak staining for IGFBP-1.

CONCLUSIONS

Our data show that both the morphological and biochemical response of post- menopausal endometrium to parenteral levonorgestrel was strikingly different, depending on the route of progestin administration, and that the decidual reaction and epithelial atrophy induced by intrauterine levonorgestrel were associated with expression IGFBP-1 in decidualized stromal cells.

Insulin-like growth factor-binding protein-1: a biochemical marker of endometrial response to progestin during hormone replacement therapy

OBJECTIVES

To compare immunohistochemical localization of insulin-like growth factor binding protein-1 (IGFBP-1) in endometrial stromal cells with endometrial morphology during three regimens of continuous combined hormone replacement therapy.

METHODS

Endometrial samples for morphological examination and immunohistochemical staining with monoclonal antibody against IGFBP-1 were obtained from 30 menopausal women before treatment and after 12 and 24 months of continuous combined hormone replacement therapy. All women received percutaneous estradiolgel releasing 1.5 mg estradiol daily. Regarding progestins, patients were divided into three groups: one group (n = 15) had a 20 micrograms/24 h levonorgestrel-releasing intrauterine device (LNG-IUD); the women in the other two groups received micronised natural progesterone either 100 mg orally (n = 7) or 100-200 mg vaginally (n = 8) daily, 25 days per calendar month.

RESULTS

Before treatment the endometrium of all women was atrophic or subatrophic and no IGFBP-1 could be detected in any of the samples which contained enough stromal cells for evaluation. After 12 and 24 months of treatment, epithelial atrophy with decidual transformation in stroma was detected in all specimens in the LNG-IUD group, and IGFBP-1 was localized in decidualized stromal cells in all samples. In the other two groups, no signs of progestin effect were detected by microscopic examination in any of the endometrial samples and IGFBP-1 staining was completely negative in all of them.

CONCLUSION

A striking difference occurred in both morphological and biochemical response in the endometrium of women treated with LNG-IUD compared with those receiving oral or vaginal micronised progesterone during continuous combined HRT. Micronised progesterone at doses used in this study turned out to be ineffective to prevent the proliferative effect of estrogen. Immunohistochemical localization of IGFBP-1 in endometrial stromal cells strongly correlated with decidual reaction in all endometrial specimens exposed to LNG-IUD, suggesting that the immunostaining of IGFBP-1 can be used as a means of assessing the strength of progestin effect in the endometrium during HRT.

Portal insulin concentrations rather than insulin sensitivity regulate serum sex hormone-binding globulin and insulin-like growth factor binding protein 1 in vivo

Serum sex hormone-binding globulin (SHBG) and insulin-like growth factor-binding protein 1 (IGFBP-1) concentrations have been suggested to be useful markers of insulin sensitivity. As the production of both proteins is inhibited by insulin in the liver, we postulated that their concentrations reflect whole body insulin sensitivity only when the latter parallels changes in endogenous insulin secretion. To test this hypothesis, we determined SHBG and IGFBP-1 concentrations, whole body insulin sensitivity (euglycemic insulin clamp; serum free insulin, approximately 400 pmol/L), and serum insulin and C peptide concentrations in 13 type 1 diabetic patients lacking endogenous insulin secretion and 34 matched normal subjects. Whole body insulin sensitivity was 50% lower in the type 1 diabetic patients (20 +/- 3 mumol/kg.min) than that in the normal subjects (40 +/- 3 mumol/kg.min; P < 0.001). Despite this, serum SHBG (45 +/- 4 vs. 29 +/- 2nmol/L; P < 0.002) and IGFBP-1 (14 +/- 3 vs. 2 +/- 1 micrograms/L; P < 0.002) concentrations were increased in the type 1 diabetic patients. In the normal subjects, SHBG (r = -0.49; P < 0.01) and IGFBP-1 (r = -0.49; P < 0.01) were inversely correlated with serum C peptide and positively correlated with whole body insulin sensitivity (r = 0.54; P < 0.005 and r = 0.54; P < 0.005, respectively). In the type 1 diabetic patients, SHBG and IGFBP-1 concentrations were disproportionately increased when related to insulin sensitivity, but appropriate when related to estimated portal insulin concentrations. Serum T4, free testosterone, and estradiol concentrations were similar in both groups. We conclude that SHBG and IGFBP-1 reflect hepatic insulinization and can only be used as markers of insulin sensitivity in individuals with intact insulin secretion.

Expression of c-kit ligand messenger ribonucleic acids in human ovaries and regulation of their steady state levels by gonadotropins in cultured granulosa-luteal cells

The c-kit ligand (KL), a ligand for the c-kit protooncogene receptor tyrosine kinase, is an important regulator of germ cell development in rodent gonads. However, no information about the role of KL in the ovaries of women or higher primates has been available. We studied the expression of KL messenger RNA (mRNA) in human ovaries and the effect of purified hCG and recombinant human FSH (rhFSH) on KL mRNA steady state levels in cultures of human granulosa-luteal (GL) cells obtained at oocyte harvest for in vitro fertilization. KL complementary DNA was generated by reverse transcription-polymerase chain reaction from human ovarian tissue RNA. Two alternatively spliced KL transcripts encoding 248-amino acid (aa) and 220-aa membrane-associated KL proteins were observed in GL cells and ovarian tissue. In Northern blot analysis of human ovarian and GL cell RNA, a major transcript of approximately 6.0 kilobases was detected. Specific mRNA transcripts for KL were detected in dot blot filter hybridization analyses, and the steady state levels of these mRNAs were lowered in cultured GL cells by both gonadotropins in a distinct time- and concentration-dependent manner. The KL mRNA levels of untreated and hCG- or rhFSH-stimulated GL cells were determined at 2- to 3-day intervals between days 2-10 of culture. An 8-h treatment with hCG was shown to decrease KL mRNA levels on days 2, 3, 5, and 7 of culture, whereas rhFSH decreased KL mRNA levels on days 5 and 7 of culture. Time-course and concentration-dependence studies were performed on days 2-7 of culture. Both gonadotropins decreased KL mRNA levels as early as 2 h after treatment. The maximal response to hCG and rhFSH treatment was observed at 7-24 h. Concentration-dependence studies performed 8 or 24 h after treatment indicated that the maximal inhibition occurred with 10-100 ng/ml hCG and 100-300 ng/ml rhFSH. We conclude that 1) the KL transcripts encoding 248- and 220-aa transmembrane proteins are expressed in vivo in the human ovary and in cultured human GL cells; and 2) KL transcript levels are rapidly decreased by gonadotropins in a time- and concentration-dependent manner in cultured GL cells. Thus, KL expression is hormonally regulated in human granulosa cells, and this growth factor may control the function of the ovarian follicle during the human menstrual cycle.

Monoallelic expression of IGF2 at the human fetal/maternal boundary

IGF2 is expressed in both placental and decidual tissues, enabling an analysis of the parental imprinting over the fetomaternal boundary. Evidence is provided that IGF2 is monoallelically expressed in both placenta and pregnant, as well as nonpregnant, endometrium. These observations suggest that the maternally derived IGF2 allele is inactivated during germline transmission. Comparison of promoter usage in decidua and placental samples shows that the P3 promoter appears to regulated independently of the others. These observations are discussed with respect to current models of IGF2 imprinting and the hypothesized conflict of parental reproductive interests which bears on the phenomenon of parental imprinting.

Cardiovascular morbidity in relation to ovarian function after hysterectomy

OBJECTIVE

To determine if removal of the uterus with ovarian preservation is associated with cardiovascular morbidity and risk factors.

METHODS

Self-reported histories of gynecologic surgery of 3895 women from 40 regions in Finland, 30-95 years old, were collected in 1977-1980, and 78% of hysterectomies were confirmed from the hospital records. Cardiovascular risk factors (total- and high-density lipoprotein cholesterol, education, body mass index [BMI], blood glucose, and triglycerides), parity, and current use of hormone replacement therapy were used to adjust the risk of hypertension (less than 60 years old and diastolic blood pressure [BP] at least 95 mmHg, or 60 years older and diastolic BP at least 100 mmHg), coronary heart disease, and heart failure. The women with unconfirmed hysterectomies and missing information on cardiovascular risk factors were excluded. Thereafter, the final number of subjects included in the analysis was 3780.

RESULTS

One or no ovary was removed in 163 hysterectomies, and in 55 cases, both ovaries were removed. Women with hysterectomy and preservation of at least one ovary had significantly higher diastolic BP and higher BMI than those who had not undergone hysterectomy. Women with hysterectomy and ovarian preservation also had a significantly increased risk of hypertension (odds ratio 2.2, 95% confidence interval 1.5-3.1). The risks of other heart diseases (angina pectoris, myocardial infarction, and heart failure) were not significantly increased.

CONCLUSION

Hysterectomy with ovarian preservation is associated with increased risk of high diastolic BP, diagnosis of hypertension, and increased BMI, but not with other heart diseases. Either hysterectomy increases the risk of hypertension or the increase of BP and the development of myomas, which often lead to hysterectomy, are explained by a common pathogenetic mechanism.

Effect of intrauterine contraceptive devices on cytokine messenger ribonucleic acid expression in the human endometrium

OBJECTIVE

To compare cytokine messenger RNA (mRNA) expression in the endometrium exposed to an intrauterine contraceptive device (IUD) and in normal cycling endometrium.

DESIGN

Quantitative reverse-transcribed polymerase chain reaction was used to assess interleukin (IL) 1 beta, IL-6, tumor necrosis factor alpha (TNF-alpha), and colony-stimulating factor 1 (CSF-1) mRNA expression in endometrial tissue samples obtained by curettage or at hysterectomy from 11 women using a copper-releasing IUD, 10 women having a levonorgestrel-releasing IUD, and 13 fertile women during different phases of the menstrual cycle.

RESULTS

The mRNAs encoding the studied cytokines were detected in all endometrial samples. The mean IL-1 beta, IL-6, and TNF-alpha mRNA levels were higher in the late secretory menstrual phase compared with the proliferative early secretory phase of the menstrual cycle both in endometria exposed to the copper IUD and in the control samples. The IL-1 beta and TNF-alpha mRNA levels were significantly higher in endometria exposed to the copper IUD compared with the control endometria in the late secretory menstrual phase, whereas no difference was found in the expression of these cytokine mRNAs during the proliferative early secretory phase. In contrast, the mean IL-6 mRNA level was higher in the copper IUD-exposed endometria than in the control endometria in the proliferative early secretory but not in the late secretory menstrual phase. In the levonorgestrel IUD-exposed endometria, the mean levels of IL-1 beta, TNF-alpha, and CSF-1 mRNA were similar to those in normal endometrium in the late secretory menstrual phase. The mean IL-6 mRNA level in levonorgestrel IUD-exposed endometria was lower than that in late secretory menstrual phase of controls but, because of a great individual variation in the control samples, the difference did not reach significance. No significant cyclic change nor any difference in relative CSF-1 mRNA levels between the three study groups was detected.

CONCLUSIONS

These data provide the first evidence that the use of IUDs is associated with alterations in endometrial cytokine expression and that the alterations differ depending on the cytokine and the type of IUD. We speculate that cytokines are involved in intrauterine contraceptive effects of IUDs.

The relationship between circulating androgens, obesity, and hyperinsulinemia on serum insulin-like growth factor binding protein-1 in the polycystic ovarian syndrome

OBJECTIVE

Our purpose was to evaluate the relationship of obesity, hyperinsulinemia, and hyperandrogenemia on serum insulin-like growth factor binding protein-1 levels in women with the polycystic ovarian syndrome.

STUDY DESIGN

Insulin-like growth factor binding protein-1, insulin, and androgen levels were studied during a 3-hour intravenous glucose tolerance test in 16 women with polycystic ovarian syndrome (nine obese and seven nonobese) and 20 healthy control women (10 obese and 10 nonobese).

RESULTS

Positive correlations were observed between basal (r = 0.77, p = 0.04) and area under curve (r = 0.86, p < 0.001) insulin-like growth factor binding protein-1 with basal androstenedione in the nonobese women with polycystic ovarian syndrome but not in other groups of women examined or between other androgens and insulin-like growth factor binding protein-1. An inverse relationship was observed between log area under curve insulin-like growth factor binding protein-1 levels and log body mass index in polycystic ovarian syndrome (r = -0.54, p = 0.03) and in normal women (r = -0.43, p = 0.06). The log area under curve insulin-like growth factor binding protein-1 level was approximately an inverse linear function of log area under curve insulin response for both women with polycystic ovarian syndrome (r = -0.70, p < 0.001) and control women (r = -0.72, p < 0.001). Additionally, after the area under curve insulin response during intravenous glucose tolerance testing was controlled for, the decline in area under curve insulin-like growth factor binding protein-1 responses was on average 66% less in both obese and nonobese women with polycystic ovarian syndrome compared with same-weight controls (95% confidence interval 110% to 270%, p = 0.04).

CONCLUSION

These data indicate that insulin and body mass index are the major determinants of circulating insulin-like growth factor binding protein-1 and that chronic hyperandrogenemia does not appear to further reduce serum insulin-like growth factor binding protein-1 levels in obese or normal-weight women with polycystic ovarian syndrome.

Decreased expression of messenger RNAs encoding endothelin receptors and neutral endopeptidase 24.11 in endometrial cancer

In this study, we used reverse transcriptase-polymerase chain reaction (RT-PCR) to compare the expression of mRNAs encoding endothelin-1 (ET-1), endothelin receptors type A (ETA-R) and type B (ETB-R) and ET-1-degrading enzyme neutral endopeptidase 24.11 (NEP) in 15 endometrial cancer tissues and 13 normal endometrial tissues. The relative levels of ET-1 mRNA in endometrial cancer tissues did not differ from those in normal endometrium. Both ETA-R and ETB-R mRNA levels were significantly lower in endometrial cancer tissue than in normal endometrium (P < 0.001). The complete lack of NEP mRNA in endometrial cancer tissues was in marked contrast to results from normal endometrium (P < 0.001). In conclusion, differential expression of mRNAs encoding ET-R and NEP in normal endometrium and endometrial cancer suggests that ET action is altered in endometrial cancer compared with normal endometrium.

Suppressed expression of insulin-like growth factor binding protein-1 mRNA in the endometrium: a molecular mechanism associating endometrial cancer with its risk factors

The insulin-like growth factor (IGF) system is thought to function as a mediator of steroid hormone actions in the endometrium. IGFs (IGF-I and IGF-II) are also potent mitogens in endometrial cancer. The biological actions of IGFs are modulated by specific binding proteins (IGFBP)--6 cloned and sequenced so far--which may either inhibit or enhance the effects of IGF at the cellular level. In the endometrium, IGFBP-1 gene expression is stimulated by progesterone and inhibited by insulin, while IGFBP-1 inhibits the mitogenic action of IGF-I. In this study, we used a quantitative reverse transcriptase polymerase chain reaction (RT-PCR) to investigate IGFBP-1, IGFBP-2, IGFBP-4, IGFBP-5 and IGFBP-6 gene expression in endometrial cancer tissues. Endometrial cancer tissue samples were collected from 20 women (aged 54-79 yrs) with stage I to II well-differentiated endometrial adenocarcinoma. Samples of normal endometrium (n = 14) obtained from women undergoing tubal ligation in various phases of the menstrual cycle, and normal early-pregnancy endometrium (decidua) were studied for comparison. In endometrial cancer tissues, the IGFBP-1 mRNA was undetectable or minimally expressed when studied by RT-PCR. The mean (+ SD) levels of IGFBP-2 and IGFBP-4 and IGFBP-5 mRNAs in endometrial cancer tissues did not differ from those in normal endometrium, in which no cyclic variation was observed, suggesting that the genes encoding IGFBP-2, IGFBP-4 and IGFBP-5 are not hormonally regulated in the endometrium. The IGFBP-6 mRNA expression showed a significant cyclic variation in normal endometrium, with low levels in late-proliferative and early- to mid-secretory phases and high expression in late-secretory and early-proliferative phases. In endometrial cancer tissues, the mean IGFBP-6 mRNA level was similar to that in cycling endometrium during the peri-ovulatory period. In summary, a continuous stimulation of the endometrial epithelial cells by IGFs with suppressed IGFBP-1 expression may lead to an imbalance in the IGF system of the endometrium and trigger an uncontrolled cell proliferation, ultimately resulting in malignant transformation.

Five gynecologic diagnoses associated with hysterectomy--trends in incidence of hospitalizations in Finland, 1971-1986

Trends in hospitalizations for selected gynecologic diagnoses per 100,000 women/year associated with hysterectomy were analyzed using the Finnish hospital discharge register data, including each inpatient episode in all Finnish hospitals, from 1971 to 1986. The diagnoses selected were uterine leiomyoma, genital prolapse, the group 'other disorders of the uterus' including endometriosis, and bleeding disorders. These were the most common indications for hysterectomy in Finland from 1987 to 1989, when national data on surgical procedures were included in the hospital discharge register. Trends in the incidence of hospitalizations for malignant neoplasms were also analyzed, although < 10% of hysterectomies are due to gynecological malignancies. Hospitalizations for leiomyoma, endometriosis and bleeding disorders have statistically increased, significantly, among women aged 45 years or more between 1971 and 1986, whereas hospitalizations for prolapse and malignant neoplasms did not show a significant change. Probable incidence of hysterectomy before 1986 was estimated on the basis of the annual incidence of hospitalization for leiomyoma, and hysterectomy for leiomyomas was estimated from the hospital discharge register data of 1988. According to hospital discharge data in 1988, 90% of the hospitalized women with leiomyoma underwent hysterectomy and half of the hysterectomies were performed for leiomyoma. The estimated incidence of hysterectomy increased from 311/100,000 women to approximately 400/100,000 from 1971 to 1986 (slope = 6.5 hysterectomies/100,000/year; 95% C.I. for slope (4.8:8.2)). As the epidemiology of most of the underlying disorders for indications leading to hysterectomy is poorly known, epidemiological studies should consider the determinants of the occurrence of indications independently whether hysterectomy has been performed or not.

Differential expression of mRNAs for endothelin-related proteins in human endometrium, myometrium and leiomyoma

The expression of mRNAs encoding endothelin-1 (ET-1) and its receptors (ETA-R and ETB-R) as well as the ET degrading enzyme, neutral endopeptidase 24.11 (NEP), was determined in tissue samples of endometrium, myometrium and leiomyoma by using a reverse transcriptase polymerase chain reaction (RT-PCR) technique. ET-1 mRNA was detected in all samples studied. The level of ET-1 mRNA was higher in endometrium than in myometrium (p < 0.01) and leiomyoma (p < 0.001). The ETA-R mRNA was more abundant in endometrium than in myometrium (p < 0.001). For ETB-R mRNA there was no difference between these tissues. In contrast to ETA-R mRNA, which was more abundant in leiomyoma than in myometrium (p < 0.01), the ETB-R mRNA was less abundant in leiomyoma (p < 0.01). The NEP mRNA was detected in all endometrial samples but not in myometrium and leiomyoma. Our results show that the expression and relative levels of mRNAs encoding ET-1, ETA-R, ETB-R, and NEP vary in different tissue compartments of the human uterus. Since the net biological action of ET-1 in a particular cell type presumably depends on the balance between the peptide itself, its receptors and degrading enzymes, these results suggest different roles for ET-1 action in uterine endometrium, myometrium and leiomyoma. The difference in relative abundance of ETA-R and ETB-R mRNAs between myometrium and leiomyoma suggests that an altered ET-R gene expression may be a contributing factor in myomal growth.

Uterine endocrinology and paracrinology: insulin-like growth factor binding protein-1 and placental protein 14 revisited

A large number of proteins and peptides have been identified in the endometrium where they are likely to exert local biological effects. These substances may be enzymes, their inhibitors, proteinases, proteinase inhibitors, hormones, or bioactive peptides with diverse functions. Endometrial function and embryo-endometrial interactions require synchronized actions between endocrine and local factors. As examples of local factors recent studies on the insulin-like growth factor (IGF) system and placental protein 14 (PP14) are reviewed. IGF binding protein-1 (IGFBP-1) and PP14 are products of the secretory phase endometrium: IGFBP-1 is produced by decidualized stromal cells and PP14 by glandular epithelial cells. IGFBP-1 may inhibit the action of IGFs at the endometrial-trophoblastic interphase, and it may also have a role in stromal-epithelial interaction. PP14 has immunosuppressive properties, and recent findings indicate that it may play a part in the fertilization process by inhibiting binding of spermatozoa to the zona.

Incidence, causes and surgical methods for hysterectomy in Finland, 1987-1989

BACKGROUND

The objective of our study was to investigate the incidence of hysterectomy by age, indication and surgical method employed during 1987-1989 in Finland, corrected by 'uteri or cervix at risk' population.

METHODS

Three years (1987-1989) of patient discharges from the Finnish Hospital Discharge Register, which covers all Finnish hospitals including the few private ones, was used. Patients represented all Finnish adult women (approximately 2,000,000).

RESULTS

Approximately 9000 hysterectomies are performed annually in Finland. The annual incidence of hysterectomy was 348/100,000 women (most among women aged 45-49), and after correction for 'uteri or cervix at risk' this rose by 11% to 390/100,000. The most frequent indications were leiomyoma (50%) and endometriosis (11%). Prolapse, menstrual disorders and cancer each accounted for 7-8% of all hysterectomies. The most common surgical approach was total abdominal hysterectomy (36%), while hysterectomy with bilateral oophorectomy and partial hysterectomy each accounted for 20% of operations. Differences in the rates by indication or surgical approach between 'uteri or cervix at risk' corrected and uncorrected estimates varied between 0% and 22%.

CONCLUSIONS

The incidence of, and indications for hysterectomy in Finland are approximately the same as in other European countries, but partial hysterectomy is more common in Finland. Because the correction for the 'uteri or cervix at risk' population produced changes in the rates of hysterectomy, correction should be considered when calculating hysterectomy rates or incidences of cervical or endometrial cancer.

Aging is associated with decreased suppression of insulin-like growth factor binding protein-1 by insulin

We determined whether aging influences circulating insulin-like growth factor-binding protein-1 (IGFBP-1) concentrations and, if so, whether this effect is explained by altered regulation of IGFBP-1 by insulin. Fasting levels of glucose, insulin, and IGFBP-1 were measured in 94 healthy volunteers, ages 24-93 yr. To determine the effect of aging on insulin-induced suppression of IGFBP-1, an oral glucose tolerance test (OGTT) was performed in 10 older (72-92 yr) and 10 younger (24-58 yr) nonobese subjects, matched for sex and body mass index. For all ages combined, the mean glucose level (+/- SE) averaged 4.9 +/- 0.1 mmol/L, and there was no significant change with aging. Fasting insulin and IGFBP-1 concentrations increased with advancing age (r = 0.37, P < 0.001 for age vs. insulin and r = 0.47, P < 0.001 for age vs. IGFBP-1). However, there was no correlation between insulin and IGFBP-1 concentrations. In multiple linear regression analysis, the age-related increase in IGFBP-1 was independent of body mass index. During the OGTT, the mean insulin concentration was significantly higher in the older group compared with the younger group (P < 0.001). Serum IGFBP-1 concentrations were higher in the fasting state as well as during the OGTT, and the mean percent decrease of IGFBP-1 below baseline was significantly smaller in the older compared to the younger subjects at 3 h (35 +/- 5% vs. 55 +/- 2%, P < 0.01). We conclude that aging is associated with decreased suppression of serum IGFBP-1 by insulin, as demonstrated by 1) lack of the inverse correlation between fasting insulin and IGFBP-1 seen in young adults; 2) concurrent elevation of fasting insulin and IGFBP-1 concentrations; and 3) a blunted decrease in serum IGFBP-1 during an OGTT.

Differential expression of keratinocyte growth factor and its receptor in the human uterus

The expression of mRNAs for keratinocyte growth factor (KGF) (also called FGF-7) and its receptor was evaluated in normal human endometrium and myometrium as well as in myoma and in endometrial adenocarcinoma cell lines using reverse transcriptase polymerase chain reaction. Both KGF and its receptor mRNA are expressed in the human endometrium throughout the menstrual cycle, whereas fibroblast growth factor receptor 2 (FGFR-2) mRNA expression is low in this tissue. In endometrial stromal cell enriched preparations KGF mRNA dominates with little expression of KGF receptor (KGFR) and FGFR-2, whereas in the epithelial cell-enriched fraction the KGFR mRNA dominates. Human myometrium and myoma express mRNA for KGF, but not for KGFR. FGFR-2 is expressed in both myometrial and myoma tissues. None of the five endometrial adenocarcinoma cell lines studied expressed KGF mRNA, whereas all cell lines expressed mRNA for either KGFR or FGFR-2 or for both receptors. The results show a selective expression of KGFR and the closely related FGFR-2 in the human uterus with the former being expressed in the endometrium and the latter predominantly in the adjacent myometrium. In the endometrial tissue, selective expression of KGF in stromal cells and KGFR in epithelial cells supports the paracrine function of KGF in epithelial tissue.

Sequential appearance of relaxin, prolactin and IGFBP-1 during growth and differentiation of the human endometrium

Relaxin (RLX) is a product of the human corpus luteum, pregnancy decidua and placenta, prolactin (PRL) and insulin-like growth factor binding protein-1 (IGFBP-1) are products of the cyclic endometrium and of the pregnancy decidua. All three proteins are thought to function interdependently in endometrium/decidua as local factors within the uterus without reaching the systemic circulation. In this study, the avidin-biotin immunoperoxidase method for immunolocalization with monoclonal or polyclonal antibodies has been applied to serial sections of endometria obtained from patients at different stages of the menstrual cycle and in early and late gestation. This allowed the cellular localization of the three proteins to be followed simultaneously through the reproductive stages from cyclic endometrium to term gestational decidua. The production, as opposed to sequestration of RLX from an ovarian source was demonstrated by the application in parallel of an antibody to the processed hormone and its connecting peptide. RLX was shown localized to the glandular and luminal epithelia in the proliferative and secretory phases. The decidualized stromal cells also immunostained for RLX in the late secretory phase and in early and late pregnancy. PRL was localized first to the glandular epithelium and then stroma, appearing after RLX, IGFBP-1 appeared later in the secretory phase and predominantly in the decidualized stromal cells confirming previous studies. In contrast, all three proteins were immunostained in early pregnancy and increased to term gestation.(ABSTRACT TRUNCATED AT 250 WORDS)

Cytokines in reproduction

A growing body of evidence indicates that, in addition to the hormones of hypothalamic, pituitary and gonadal origin, autocrine/paracrine regulators play important roles in the reproductive functions. Cytokines, originally known as immunoregulatory proteins, may affect the neuroendocrine events of reproduction, ovarian/testis function, endometrium, the developing embryo, placenta and parturition. Cytokines can modulate and mediate the actions of hormones at their target cells and, in the opposite way, hormones may regulate the production and action of cytokines at three different levels: cytokine secretion, cytokine receptor expression and cellular responses. Cytokines may also function in an endocrine manner affecting distant targets. As many of the cyclic changes that occur in the ovary and endometrium during the normal menstrual cycle are similar to those associated with the inflammatory and regenerative processes, it is likely that cytokines are involved in these reactions. Furthermore, cytokines secreted by endometrial white blood cells may influence embryo development and trophoblast growth and may play a fundamental role in the mechanisms of immunological reproductive failure. Cytokines have also been implicated in the mechanisms responsible for the onset of parturition.