Altered immune response in adult women exposed to diethylstilbestrol in utero

OBJECTIVE

Between 1940 and 1970, 1.5 million female fetuses were exposed to diethylstilbestrol in utero. Numerous deleterious effects on reproductive anatomic and physiologic characteristics have been documented in these women. However, the effects of this exposure on nonreproductive systems, which may have lifelong consequences as this cohort of women progresses beyond the childbearing years, have received little attention. On the basis of an earlier preliminary observation of altered immune reponse, we hypothesized that diethylstilbestrol-exposed women may show abnormalities in T-cell-mediated immune response.

STUDY DESIGN

Thirteen women exposed to diethylstilbestrol in utero were compared with 13 age- and menstrual cycle phase-matched control subjects with respect to the in vitro T-cell response to the mitogens phytohemagglutinin, concanavalin A, and interleukin 2.

RESULTS

As compared with controls, tritiated thymidine incorporation by T cells harvested from diethylstilbestrol-exposed women was increased 3-fold over a range of concentrations in response to concanavalin A (P <.001), increased by 50% over a range of concentrations in response to phytohemagglutinin (P <.001), and increased 2-fold in response to the endogenous mitogen interleukin 2 (P <.05).

CONCLUSIONS

In vitro evidence suggests that women exposed to diethylstilbestrol have alterations in T-cell-mediated immunity. These changes require further attention with regard to their characterization, their role in the pathogenesis of cancer and autoimmunity, and their presence in normal women exposed to diethylstilbestrol in utero.

Vascular repair after menstruation involves regulation of vascular endothelial growth factor-receptor phosphorylation by sFLT-1

Regeneration of the endometrium after menstruation requires a rapid and highly organized vascular response. Potential regulators of this process include members of the vascular endothelial growth factor (VEGF) family of proteins and their receptors. Although VEGF expression has been detected in the endometrium, the relationship between VEGF production, receptor activation, and endothelial cell proliferation during the endometrial cycle is poorly understood. To better ascertain the relevance of VEGF family members during postmenstrual repair, we have evaluated ligands, receptors, and activity by receptor phosphorylation in human endometrium throughout the menstrual cycle. We found that VEGF is significantly increased at the onset of menstruation, a result of the additive effects of hypoxia, transforming growth factor-alpha, and interleukin-1beta. Both VEGF receptors, FLT-1 and KDR, followed a similar pattern. However, functional activity of KDR, as determined by phosphorylation studies, revealed activation in the late menstrual and early proliferative phases. The degree of KDR phosphorylation was inversely correlated with the presence of sFLT-1. Endothelial cell proliferation analysis in endometrium showed a peak during the late menstrual and early proliferative phases in concert with the presence of VEGF, VEGF receptor phosphorylation, and decrease of sFLT-1. Together, these results suggest that VEGF receptor activation and the subsequent modulation of sFLT-1 in the late menstrual phase likely contributes to the onset of angiogenesis and endothelial repair in the human endometrium.

Multivariate analysis of factors predictive of successful live births in in vitro fertilization (IVF) suggests strategies to improve IVF outcome

PURPOSE

Our purpose was (1) to identify characteristics correlated with pregnancy outcome, (2) to use these characteristics to predict in vitro fertilization (IVF) outcome, and (3) to develop strategies that might improve IVF success.

METHODS

Maternal age, cause for IVF, donor insemination, rank of attempt, serum estradiol and luteinizing hormone levels on the day of human chorionic gonadotropin administration, flexible vs rigid catheter, number of embryos transferred of each morphologic type, and cell number were analyzed by logistic regression.

RESULTS

Variables positively correlated with success are as follows: (1) for pregnancy, endometriosis and 2-, 3-, and 4-cell good and 4-cell excellent embryos; (2) for live births, 2-, 3-, and 4-cell good and 4-cell excellent embryos and donor insemination; and (3) for multiple births, 2- and 4-cell good and 4-cell excellent embryos. Maternal age was negatively correlated with live births.

CONCLUSIONS

Embryos derived from IVF have different potentials for implantation, live births, and multiple births. Transferring one additional good-quality embryo for each 5 years of incremental increase in maternal age is predicated to improve live birth rates without increasing multiple births.

Premenstrual syndrome

Within the past decade, premenstrual syndrome (PMS) has become the subject of rigorous scientific scrutiny. As a result, diagnostic criteria have been developed, and the pathophysiology of the disorder has been partially elucidated. The preponderance of evidence suggests that the disorder is the result of the interaction of cyclic changes in estrogen and progesterone with specific neurotransmitters. Serotonin and gamma-amino butyric acid (GABA) appear to be especially important in this regard. Increased understanding of PMS has enabled the development of specific treatment modalities that, unlike previous prescriptions, have demonstrated efficacy in rigorous and reproducible studies.

The sperm stress test: a novel test that predicts pregnancy in assisted reproductive technologies

OBJECTIVE

To develop a reliable sperm test that would predict pregnancy rate in assisted reproductive technologies.

DESIGN

Blind prospective cohort study.

SETTING

Tertiary-care, university hospital-affiliated IVF program.

PATIENTS

One hundred nineteen sperm samples were obtained from 110 males from couples undergoing IVF or GIFT (ART). Sperm samples were washed by Percoll, incubated at 24 degrees C for 4 hours, and an aliquot of the same sperm suspension was used for ART incubated at 40 degrees C for 4 hours (stress test). Stress test scores are expressed as the ratio of final to initial motility.

RESULTS

Of 119 ART cycles, 24 resulted in pregnancy. Of 24 pregnancies, 23 occurred in cycles that used sperm samples with stress test scores > or = 0.75 and only one with a stress test score < 0.75. The negative predictive value of the test, defined as the absence of pregnancy with scores < 0.75, was 98% and the positive predictive value, defined as the occurrence of pregnancy with scores > or = 0.75, was 36%. Logistic regression analysis indicated that the stress test score alone was correlated significantly with pregnancy after ART.

CONCLUSION

These results indicate that stress test scores < 0.75 are predictive of poor pregnancy outcome in ART.

Gonadotropin-releasing hormone antagonist versus agonist administration in women undergoing controlled ovarian hyperstimulation: cycle performance and in vitro steroidogenesis of granulosa-lutein cells

OBJECTIVES

We sought to determine the effectiveness of a gonadotropin-releasing hormone antagonist compared with an agonist in suppressing a spontaneous luteinizing hormone surge in women undergoing controlled ovarian hyperstimulation for in vitro fertilization and gamete intrafallopian transfer and to examine whether in vivo administration of these analogs effects granulosa-lutein cells steroidogenesis in vitro.

STUDY DESIGN

This prospective case-control study included 30 healthy women undergoing ovarian hyperstimulation with human menopausal gonadotropins. Fifteen women received the Nal-Glu antagonist, 5 mg intramuscularly daily, when the lead follicle was > or = 15 mm or serum estradiol level was > or = 500 pg/ml. The control group included 15 women who underwent oocyte retrieval on the same day as the study subjects and were given the agonist leuprolide acetate, 250 micrograms subcutaneously daily, starting on cycle day 1. Granulosa-lutein cells were purified from follicular aspirates from six subjects and six controls and cultured in parallel, evaluating basal progesterone production, progesterone response to follicle-stimulating hormone or luteinizing hormone and aromatase activity.

RESULTS

No difference was demonstrated in the total amount of gonadotropins received by the two groups. Overall, the gonadotropin-releasing hormone antagonist was given for only 2.5 +/- 0.2 (mean +/- SEM) days before human chorionic gonadotropin administration. The antagonist group showed significantly lower levels of serum luteinizing hormone than did the agonist group, 1.0 +/- 0.2 versus 4.2 +/- 0.5 mIU/ml (p = 0.0001) on the day of human chorionic gonadotropin administration. Serum estradiol levels were significantly lower in the antagonist than the agonist group, 820 +/- 120 versus 1361 +/- 110 pg/ml (p = 0.003) on the day of human chorionic gonadotropin administration. There was no difference in the number of retrieved oocytes, but the antagonist group had a higher proportion of mature oocytes, 82% +/- 4% versus 62.4% (p = 0.02), and a higher proportion of embryos of good quality, 69.8% +/- 9.8% versus 44.3% +/- 7.2% (p = 0.03) in the agonist group. Granulosa-lutein cells from antagonist-treated women showed significantly lower aromatase activity the first 6 hours after retrieval, 17.6 +/- 1.6 versus 31.3 +/- 7.4 ng/ml per 6 hours estradiol (p = 0.03), whereas basal and gonadotropin-stimulated with progesterone responses were similar.

CONCLUSION

Gonadotropin-releasing hormone antagonist administration during the late follicular phase resulted in lower serum luteinizing hormone and estradiol levels and more mature oocytes and embryos of better quality compared with gonadotropin-releasing hormone agonist administration. These results suggest that gonadotropin-releasing hormone antagonist administration in ovarian hyperstimulation has practical advantages over the agonist regimen. Gonadotropin-releasing hormone analogs may have direct action on ovarian function with differential effects on granulosa-lutein cell aromatase activity. This could explain the lower serum estradiol levels routinely observed in women given gonadotropin-releasing hormone antagonist.

Gonadotropin-releasing hormone receptor gene expression in human ovary and granulosa-lutein cells

GnRH regulates gonadotropin biosynthesis and release in the anterior pituitary via specific receptors. Although extrapituitary expression and action of GnRH have been shown in some species, in the human it is not clear whether GnRH has a peripheral action. In this study we sought to determine whether the human ovary expresses GnRH receptor (GnRHR) messenger ribonucleic acid (mRNA). Ovarian tissues from 11 women (32-61 yr old) and granulosa-lutein (GL) cells purified from follicular aspirates of 51 women undergoing oocyte retrieval for in vitro fertilization were analyzed by ribonuclease protection assay and reverse transcriptase-polymerase chain reaction (RT-PCR). Human pituitaries, lymphocytes, and placenta were also studied. Measurable levels of GnRHR mRNA were found by ribonuclease protection assay in 2 of 10 ovaries, in 2 of 4 GL cells preparations from women whose ovarian hyperstimulation involved a GnRH agonist, in GL cells from 3 women whose ovarian hyperstimulation involved a GnRH antagonist, and in human pituitaries. Relative to the total amount of RNA analyzed, the level of GnRHR mRNA was about 200-fold lower in the ovary than in the pituitary. A sequence of 314 basepairs of GnRHR mRNA was amplified by RT-PCR in the pituitary, in 9 of 10 ovaries, and in 4 of 5 GL cell preparations. No message could be amplified in human lymphocytes, and placental specimens showed a weak signal. The relative GnRHR mRNA levels in GL cells from 13 women analyzed by quantitative RT-PCR showed a wide range of individual differences. These results suggest that GnRHR mRNA is expressed in GL cells and the human ovary across different functional stages, implying that multiple ovarian compartments may express GnRH receptors. The administration of GnRH analogs may have a further direct action on the human ovary.

Persistence of premenstrual syndrome during low-dose administration of the progesterone antagonist RU 486

OBJECTIVE

To test whether progesterone or progesterone receptors are important mediators of premenstrual syndrome (PMS) and whether progesterone antagonist RU 486 would alleviate symptoms.

METHODS

Following extensive screening including physical and psychological assessment, seven women with severe PMS participated in a 6-month, randomized, double-blind, placebo-controlled, crossover study. The treatment included 3 months of low-dose RU 486 (5 mg alternate days for four doses, beginning 3 days after the urinary LH surge) or placebo, administered in a similar fashion. Symptoms were evaluated using the Calendar of Premenstrual Experiences, Beck Depression Inventory, State-Trait Anxiety Inventory, and the Profile of Mood States.

RESULTS

Symptoms of PMS were similar during RU 486 and placebo treatments.

CONCLUSION

Luteal-phase administration of low-dose RU 486 does not significantly reduce the physical or behavioral manifestations of PMS.

A risk-benefit appraisal of drugs used in the management of premenstrual syndrome

Recent advances in the understanding of the pathogenesis of premenstrual syndrome (PMS) have allowed the development of appropriate pharmacological interventions. Although at the present time there are no approved medications for this indication in the US, several well-designed studies have been conducted that guide the clinician's treatment of PMS. As a result, less-proven nonpharmacological modalities, such as dietary modification, exercise regimens and psychotherapy, are more quickly supplanted by the use of medication. Three classes of agents have been proven efficacious and are widely used to treat the disorder. These include benzodiazepines (especially alprazolam), selective serotonin reuptake inhibitors (especially fluoxetine), and gonadotropin-releasing hormone (GnRH) [luteinising hormone-releasing hormone (LHRH)] agonists. In addition to these medications which are used to treat the generalised syndrome of PMS, a variety of other drugs are used in the treatment of specific aspects of this disorder. Despite the success of these treatments, each has a substantial adverse effect profile which modulates their use in some patients. Knowledge of these potential adverse effects and their management should help optimise therapy. In addition, a variety of less well-proven pharmacological remedies are commonly in use. The adverse effects of these medications may well outweigh their benefits.

Melatonin rhythms in women with anorexia nervosa and bulimia nervosa

To discern whether the multiple neuroendocrine-metabolic dysfunctions observed in women with anorexia nervosa (AN) and bulimia nervosa (BN) are associated with altered diurnal variations in serum melatonin profiles, we compared cycling and amenorrheic women with normal weight BN (n = 8) and AN (n = 7) to 21 normal cycling controls. Endogenous depression, which has confounded prior studies of melatonin profiles in women with eating disorders, was excluded in all subjects. Serum samples for melatonin measurements were obtained at frequent intervals (every 20 min) in a controlled light-dark environment, and cycling women were studied in the early follicular phase of the menstrual cycle. Mean (+/- SE) peak melatonin levels were similar in AN, BN, and controls (325 +/- 43, 310 +/- 33, and 334 +/- 30 pmol/L, respectively). The time of melatonin peak, the time of onset and offset of the nocturnal serum melatonin excursion, and the duration of the nocturnal elevation were also similar in the three groups. Analysis of covariance revealed no independent effects of age or time of year on the data. Moreover, when subjects were separated into those with and without menstrual cyclicity, no significant differences in any parameter of melatonin diurnal variation were observed. Taken together, these data suggest that pineal melatonin secretion is unaltered in women with eating disorders, in whom depression is excluded, and that the frequent occurrence of amenorrhea in this population is not mediated by melatonin.

Applications of gonadotropin-releasing hormone analogues in the treatment of premenstrual syndrome

A regimen in which a GnRH agonist is used with estrogen-progestin replacement provides a significant potential advance in the treatment of PMS. Substantial evidence indicates that the pathophysiology of PMS is dependent on cyclic progesterone changes which, after a time delay, influence central neurotransmitter systems and peripheral tissues. Because of the myriad neurotransmitter changes induced by progesterone, the most comprehensive treatment of the complex array of symptoms in severe PMS may require pharmacologic agents that reduce circulating progesterone levels. The most effective agent in this regard in a GnRH analogue. Until recently, use of these analogues has been limited to short-term courses as a result of the deleterious effects of hypoestrogenism. Based on newer information, a regimen in which a GnRH agonist is used concomitantly with CEE and MPA replacement appears to ameliorate PMS symptoms substantially while providing a proven estrogen-progestin replacement therapy to protect against the side effects of hypoestrogenism. Before treatment, an accurate diagnosis must be made that rests on exclusion of concomitant psychiatric and/or medical diagnoses and prospective symptom recording. In addition, before use of the GnRH agonist and estrogen-progestin add-back treatment, consideration should be given to agents, such as fluoxetine and alprazolam, which target specific neurotransmitter alterations. Currently, the superiority of one agent over others has not been tested in controlled trials. Nonetheless, in patients who cannot tolerate or do not respond to fluoxetine and alprazolam, a GnRH agonist plus estrogen and progestin appears the indicated treatment of choice.

Hypothalamic-pituitary-ovarian response to clomiphene citrate in women with polycystic ovary syndrome

OBJECTIVE

To examine the hypothalamic-pituitary sites of clomiphene citrate (CC) action in women with polycystic ovarian syndrome (PCOS).

DESIGN

Prospective controlled trial.

PATIENTS, PARTICIPANTS

Seventeen women with PCOS and 9 normal-cycling women.

INTERVENTIONS

Subjects with PCOS received CC, 150 mg/d for 5 days.

MAIN OUTCOME MEASURES

Follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels and LH pulse characteristics and their response to gonadotropin-releasing hormone (GnRH, 10 micrograms) were examined before and after 3 days of CC in PCOS subjects during a 12-hour frequent sampling study (n = 8). Daily urinary estrone glucuronide and pregnanediol glucuronide levels after CC were compared with concentrations in normal-cycling women through one menstrual cycle. In another nine PCOS subjects, pituitary and ovarian hormonal cyclicity was monitored by daily blood sampling.

RESULTS

Thirteen of 17 treated cycles were ovulatory with normal luteal phases. In the ovulatory cycles, serum LH, FSH, estradiol (E2), and estrone levels increased after CC. Luteinizing hormone pulse frequency was unchanged, but LH pulse amplitude increased significantly after CC. Both LH and FSH response to exogenous GnRH was significantly attenuated after CC treatment. In anovulatory cycles, serum LH, FSH, and E2 increased initially and then returned to baseline and remained unchanged for the ensuring 40 days.

CONCLUSIONS

Clomiphene citrate-induced ovulation in women with PCOS is accompanied by increased secretion of LH and FSH with enhanced estrogen secretion. The increased LH pulse amplitude after CC, together with decreased pituitary sensitivity to GnRH, suggests a hypothalamic effect.

Assessment and management of premenstrual syndrome

Premenstrual syndrome has recently become the subject of more rigorous scientific scrutiny. As a result, techniques exist for accurate diagnosis, and the pathophysiology of the disorder is less mysterious. At present, the disorder is thought to be the caused by the interaction of cyclic changes in estrogen and progesterone with a variety of systems, particularly neurotransmitters. Serotonin appears to play an especially important role in this regard. Increased understanding of premenstrual syndrome has enabled the development of specific treatment modalities that, unlike previous prescriptions, have demonstrated efficacy in rigorous and reproducible studies.

Issues in the diagnosis and research of premenstrual syndrome

The diagnosis of PMS depends on the identification of a core symptom complex, including behavioral symptoms of either irritability, accompanied by an internal state of anxiety or depression, and fatigue. (Fatigue is the most common symptom of PMS.) At least one core physical symptoms, bloating of the abdomen or extremities, breast tenderness, and headache also is required to establish the diagnosis. Although these core symptoms are required, none is pathognomonic for the disorder and the timing of the symptoms with respect to the menstrual cycle also must be established. This can only be done accurately using valid and reliable prospective recording instruments, such as COPE. Personality factors, the degree of psychosocial stress faced by the woman, and biochemical markers have little utility in establishing the diagnosis. The literature with respect to the prevalence of PMS in the population, effective treatments for the disorder, and the diagnosis of the disease must be interpreted by recognizing the inclusion in these studies of women with comorbid psychiatric disease, invalid and unreliable symptom inventories, and inadequate characterization of menstrual cycle phases. There are sociologic reasons why the true prevalence and treatment response to interventions may not be seen by the clinician. Nonetheless, the availability of effective treatment for the disorder necessitates accurate diagnosis of the syndrome based on the strict criteria presented. Additional research founded on the development of psychoneuroendocrine models is likely to provide insight into both the pathophysiology and treatment alternatives for PMS.

A circadian rhythm of serum follicle-stimulating hormone in women

While a nocturnal decline in serum LH levels in the early follicular phase of the menstrual cycle has been well established, a diurnal variation in serum FSH levels in women has not been demonstrated. We addressed this issue by determining serum LH and FSH levels at 15-min intervals for 24 h in the early follicular phase (EFP; n = 16) and late follicular phase (LFP; n = 10) of the menstrual cycle and in postmenopausal women (PMW; n = 10). Serum estradiol was simultaneously measured at hourly intervals. As expected, EFP, but not LFP and PMW, women had a 15% nocturnal decline (P less than 0.01) in transverse mean LH levels compared to values in the daytime hours. In contrast, nocturnal FSH transverse mean values were significantly lower than daytime values in all groups studied, demonstrating an 18% decline in EFP (P less than 0.001), a 17% decline in LFP (P less than 0.00001), and a 4.3% decline in PMW (P less than 0.01). Cosinor analysis revealed a circadian rhythm for FSH, with acrophases in the afternoon and nadirs at night in all three groups. The circadian amplitudes were 1.43 +/- 0.22, 1.02 +/- 0.16, and 8.42 +/- 1.31 IU/L for EFP, LFP, and PMW, respectively. The EFP nocturnal decline in LH did not conform to a cosine rhythm. A diurnal variation in estradiol was not present in any of the groups of women. These data constitute the first demonstration of a robust circadian rhythm of serum FSH in women. The comparable timing of the acrophase in all groups of subjects and its presence in the postmenopausal years suggest a central, rather than peripheral, feedback mechanism(s) for the circadian rhythmicity. This observation provides strong evidence for a dissociation in the hypothalamic regulation of pituitary LH and FSH secretion in women. The circadian peak and nadir of circulating FSH may prove to be determining for appropriate follicular development.

Treatment of premenstrual syndrome with fluoxetine: a double-blind, placebo-controlled, crossover study

OBJECTIVE

Although its etiology is unknown, it has been hypothesized that premenstrual syndrome (PMS) is linked to a deficiency of central serotoninergic activity. In the present study, we evaluated the effect of fluoxetine, a specific serotonin uptake inhibitor, on PMS symptoms.

METHODS

Following extensive screening, including several psychological inventories, eight women with severe persistent PMS participated in a 6-month double-blind, placebo-controlled, crossover study which included three months each of daily fluoxetine 20 mg or placebo, administered in a randomized order. Symptoms were evaluated using the Calendar of Premenstrual Experiences and other psychometric measures.

RESULTS

Compared with placebo, treatment with fluoxetine was associated with an improvement in PMS symptoms as judged by highly significant decreases in behavioral (P less than .005), physical (P less than .05), and total (P less than .005) Calendar of Premenstrual Experiences scores; Beck Depression Inventory scores (P less than .005); Profile of Mood States subscales scores including depression (P less than .005), tension (P less than .005), and anger (P less than .01); and State-Trait Anxiety Inventory scores. The use of fluoxetine was associated with a greater mean reduction in behavioral (75%) than in physical scores (40%), with a mean decrease in total Calendar of Premenstrual Experiences scores of 62%, which rendered these scores similar to follicular phase values. Thus, the luteal phase symptomatology of PMS was effectively abolished. At this dose, no significant side effects or complications were noted during treatment.

CONCLUSION

Fluoxetine appears to be a highly effective, well-tolerated treatment for the psychological and physical symptoms accompanying severe PMS.

Hypothalamic-pituitary-thyroidal function in eumenorrheic and amenorrheic athletes

The impact of chronic high volume athletic training on thyroid hormone economy has not been defined. We investigated the status of the hypothalamic-pituitary-thyroid axis (H-P-T) in women athletes with regular menstrual cycles (CA) and with amenorrhea (AA). Their data were compared with each other and with those derived from cyclic sedentary women (CS) matched for a variety of confounding factors including the intensity of exercise, caloric intake, and body weight. Alterations of the H-P-T axis were observed in women athletes compared to CS. While serum levels of T4, T3, free T4, free T3 and rT3 were substantially reduced (P less than 0.01) in AA, only serum T4 levels were significantly decreased in CA. Further, remarkable differences were found between CA and AA in that serum levels of free T4 (P less than 0.01), free T3 (P less than 0.01), and rT3 (P less than 0.05) were significantly lower in AA than in CA. Thyroid binding globulin and sex-hormone binding globulin concentrations were within their normal ranges for all groups of subjects. Both 24-h mean TSH levels and the circadian rhythm of TSH secretion were also comparable. However, the TSH response to TRH stimulation was blunted (P less than 0.01) in AA when compared to CA, but not to CS. Whereas the underlying mechanism(s) to account for the "global" reduction of circulating thyroid hormone in the face of normal TSH levels in AA is presently unknown, these observations provide information of clinical significance: 1) chronic high volume athletic training in women athletes with menstrual cyclicity is accompanied by an isolated T4 reduction; 2) an impaired H-P-T axis occurs selectively in athletic women in whom chronic high volume athletic training is associated with compromised hypothalamic-pituitary-ovarian function and amenorrhea.

Endocrine responses to long-term administration of the antiprogesterone RU486 in patients with pelvic endometriosis

OBJECTIVE

To examine endocrine and clinical responses to long-term administration of RU486 in patients with endometriosis.

DESIGN

Prospective open trial.

SETTING

Faculty practice of the authors.

PATIENTS, PARTICIPANTS

Six normally cycling women with endometriosis were recruited.

INTERVENTIONS

Subjects received RU486 100 mg/d for 3 months.

MAIN OUTCOME MEASURE(S)

Hormonal changes during RU486 were compared with control data obtained in the preceding cycle during the early follicular phase. Clinical responses were determined by patient assessment and second-look laparoscopy.

RESULTS

All women became amenorrheic, and daily urinary levels of ovarian steroid metabolites remained acyclic. Mean luteinizing hormone (LH) (P less than 0.02) and LH pulse amplitude (P less than 0.05) were increased without changes in LH pulse frequency. An antiglucocorticoid effect was demonstrated by an increase in serum cortisol (P less than 0.01) and adrenocorticotropic hormone (P less than 0.05) levels. Treatment resulted in an improvement in pelvic pain in all subjects without significant change in the extent of disease as evaluated by follow-up laparoscopy.

CONCLUSIONS

Daily administration of RU486 results in acyclic ovarian function and improvement in the subjective painful symptoms of endometriosis.

Successful treatment of severe premenstrual syndrome by combined use of gonadotropin-releasing hormone agonist and estrogen/progestin

Although abolishment of ovarian cyclicity by the use of a long-acting GnRH agonist (GnRH-a) provides effective treatment for premenstrual syndrome (PMS), its use is limited by sequellae of the resultant hypoestrogenism. In this study the effects of estrogen/progestin replacement on the symptomatic improvement afforded by GnRH-a were evaluated in eight women with severe PMS. The 8-month study design included 2 months of control, 2 months of GnRH-a alone, and 4 further months in which the exogenous steroids were replaced in randomized, double blind, placebo-controlled cross-over fashion using 1 month each of 1) conjugated equine estrogen (CEE) on days 1-25, 2) 10 mg medroxyprogesterone acetate (MPA) on days 16-25, 3) CEE (days 1-25) plus MPA (days 16-25), and 4) placebo alone. Mood and physical symptoms were measured daily on a valid and reliable instrument, the Calendar of Premenstrual Experiences. As expected, administration of GnRH-a alone resulted in a 75% improvement in luteal phase symptom scores (17.8 +/- 4.8 vs. 4.2 +/- 1.6; P less than 0.01). Combined sequential administration of CEE and MPA in addition to GnRH-a was effective in maintaining the reduced symptom scores seen after GnRH-a alone and was superior to the addition of CEE alone, MPA alone, or placebo. This combination of CEE and MPA resulted in a 60% improvement (P less than 0.05) compared to the luteal phase of control months in both behavioral (14.1 +/- 3.9 vs. 4.2 +/- 0.8) and total (17.8 +/- 4.8 vs. 6.5 +/- 1.8) symptoms. We conclude that the undesirable consequence of ovarian steroid deficiency in the treatment of PMS by GnRH-a can be overcome by the addition of sequential estrogen and progestogen replacements without significantly reducing the effectiveness of GnRH-a in this disorder.

The effects of oral dehydroepiandrosterone on endocrine-metabolic parameters in postmenopausal women

To discern the pharmacological effects of dehydroepiandrosterone (DHEA) in older women with low endogenous DHEA and DHEA sulfate (DS), 1600 mg/day (in four divided doses) were administered orally to six postmenopausal women for 28 days in a double blind placebo-controlled cross-over study. Serum concentrations of androgens after the first 400-mg dose of DHEA increased rapidly and reached a maximum at 180-240 min, resulting in increases over baseline of 6-fold for DHEA (5.8 +/- 2.1 to 28.8 +/- 5.5 nmol/L), 12-fold for DS (3.0 +/- 1.6 to 28.2 +/- 4.6 mumol/L) and androstenedione (1.4 +/- 0.3 to 19.5 +/- 9.8 nmol/L), 2.5-fold for testosterone (0.7 +/- 0.1 to 2.2 +/- 0.6 nmol/L), and 15-fold for dihydrotestosterone (0.2 +/- 0.06 to 2.73 +/- 1.0 nmol/L), but estrone, estradiol, and sex hormone-binding globulin (SHBG) were unchanged. Assessment at weekly intervals revealed a further increase in all androgens which was maximal at 2 weeks and remained markedly elevated, although it declined somewhat by 4 weeks. The increments observed after 2 weeks of DHEA administration reached 15-fold for DHEA (71.9 +/- 14.2 nmol/L), 9-fold for testosterone (6.5 +/- 1.7 nmol/L), and 20-fold for DS (65.1 +/- 14.9 nmol/L), androstenedione (30.5 +/- 11.5 nmol/L), and dihyrotestosterone (3.8 +/- 1.5 nmol/L). Both estrone and estradiol showed a progressive increase to 2-fold the basal value at 4 weeks. Integrated SHBG and thyroid binding globulin levels decreased (P less than 0.05) during DHEA treatment. However, LH, FSH, body weight, and percent body fat, as measured by underwater weighing, were unaltered during the 4-week experiment. A marked decline of 11.3% (P less than 0.05) in serum cholesterol and 20.0% (P less than 0.05) in high density lipoprotein noted within the first week of DHEA administration persisted for the 28-day period and was accompanied by a nonsignificant downward trend in low density lipoprotein, very low density lipoprotein, and triglycerides. Peak insulin levels during the 3-h oral glucose tolerance test were significantly higher (P less than 0.05) after the 28 days of DHEA (1126 +/- 165 vs. 746 +/- 165 pmol/L) and were accompanied by a 50% increase in the integrated insulin response (P less than 0.01) without a significant change in fasting glucose insulin or glucose-6-phosphate dehydrogenase values.(ABSTRACT TRUNCATED AT 400 WORDS)

The predictive role of psychosocial stress on symptom severity in premenstrual syndrome

Twenty-five women with well defined, severe premenstrual syndrome (PMS) were studied prospectively during three consecutive menstrual cycles to examine the association between concurrent psychosocial stress and symptom severity. Stress, mood, physical symptoms, and urinary ovarian steroid metabolites were measured daily. Stress accounted for only 6% and 10% of the unique variance in physical symptom and mood scores, respectively, across the menstrual cycle. In individual woman, there was no association between the severity of symptoms and the cumulative daily stress reported during each cycle. We conclude that in this carefully screened population of women without coexisting psychiatric disorder, PMS symptom severity could not be determined by the amount of psychosocial stress.

Diagnosis of premenstrual syndrome by a simple, prospective, and reliable instrument: the calendar of premenstrual experiences

To establish a quantitative method for the diagnosis of premenstrual syndrome (PMS), a simple prospective inventory, the calendar of premenstrual experiences, was constructed. The validity and reliability of this instrument were assessed by administering it throughout two consecutive ovulatory cycles to 36 rigidly screened women with PMS and to 18 controls. To establish concurrent validity, scores on behavioral items were correlated with simultaneously obtained scores on lengthier, well-validated psychiatric inventories designed to measure depression rather than PMS, the Beck Depression Inventory and the Profile of Mood States. The results showed that the calendar of premenstrual experiences luteal phase score distinguished PMS women from controls correctly in 104 of 108 cycles, with a 2.8% false-negative rate and no false positives when used for two consecutive cycles. An upper limit follicular phase score was observed beneath which all PMS and normal control subjects fell, suggesting that a higher score is not consistent with PMS. Correlation coefficients of calendar item scores with Profile of Mood States scale scores were 0.58 for tension, 0.51 for depression, 0.46 for anger, 0.61 for fatigue, and 0.57 for confusion (P less than .0001 for all correlations). The correlation of the calendar depression item with the Beck Depression Inventory score was 0.56 (P less than .0001). The test-retest reliability of the calendar given in the same phase of two consecutive menstrual cycles was high (r = 0.78, P less than .0001). We conclude that this instrument is a valid, reliable, and practical PMS inventory, applicable to clinical and some research settings.

Relative changes in LH pulsatility during the menstrual cycle: using data from hypogonadal women as a reference point

The basic premise of this study is that the GnRH-LH pulsatile activity, particularly its frequency characteristics, constitutes, in the absence of any considerable ovarian feedback, the intrinsic rhythm of the hypothalamic-pituitary unit at its maximal rate. Thus, LH pulse attributes determined in postpubertal hypogonadal subjects may be used as a reference in assessing the degree of influence exerted by endocrine factors that modulate GnRH-LH pulses. Accordingly, serum LH levels were determined in samples obtained at 15-min intervals for 24 h in 20 hypogonadal women: 13 postmenopausal women (PMW) and seven women with premature ovarian failure (POF). Similar measurements were performed in 60 normally cycling women: 25 in the early follicular phase (EFP), 13 in the late follicular phase (LFP), seven at midcycle surge (LH surge) and 15 in the midluteal phase (MLP). Significant pulses were identified by the cluster algorithm utilizing factors appropriate for 24 h data series of a sampling frequency of 15-min intervals. The results show a 24-h mean (+/- SE) LH pulse frequency of 78.2 +/- 2.8 and 85.5 +/- 2.4 min per pulse for young (POF) and older (PMW) hypogonadal women, respectively. During the follicular phase of the cycle, the LH pulse frequency is not significantly different from that of hypogonadal women, but there is a significant (P less than 0.05) increase from early to late follicular phases (95.4 +/- 3.3 vs 78.8 +/- 2.2 min per pulse). However, when the sleep periods are excluded from the 24-h data series because of the associated decrease of LH pulse frequency in EFP women, the resulting pulse frequencies are almost identical for EFP, LFP and PMW. An elevation beyond the basic pulse rhythm determined in PMW or POF is not observed in any phase of the menstrual cycle studied, including the midcycle surge. The decrease in LH pulse frequency during the luteal phase of the cycle (151.8 +/- 8.0 min per pulse, P less than 0.001 vs hypogonadal women) beyond the reference pulse frequency of hypogonadal women is unequivocal. By contrast, the pulse amplitude varies markedly among the groups with the largest found in POF (36.6 +/- 4.5 IU/l). It follows, in descending order, PMW (22.7 +/- 3.1 IU/l), midcycle surge (17.3 +/- 2.8 IU/l), MLP women (7.0 +/- 1.3 IU/l) and the EFP (4.9 +/- 0.3 IU/l) and LFP (4.0 +/- 0.4 IU/l).(ABSTRACT TRUNCATED AT 250 WORDS)

Pulsatile cosecretion of estradiol and progesterone by the midluteal phase corpus luteum: temporal link to luteinizing hormone pulses

Using recently defined analytical tools that permit quantitative and integrated assessments of pulsatile activities of two or more hormones, we have examined the coincidence of pulses of estradiol (E2), progesterone (P4), and LH determined in blood withdrawn at 15-min sampling intervals for a duration of 24 h in each of 15 women during the midluteal phase of the human menstrual cycle. The occurrence of E2 and P4 pulses is simultaneous, as their peaks were maximally correlated at zero time lag (P less than 10(-4], and there were comparable periodicities for E2 (13.5 +/- 0.7 pulses/24 h) and P4 (11.2 +/- 0.7 pulses/24 h). This coupling of E2 and P4 pulses suggests cosecretion by the mature corpus luteum. These E2 and P4 pulses are significantly coupled with LH pulses, with a lag time of about 30 min and/or 45 min for P4 (P = 0.029) and 0 min and/or 15 min for E2 (P = 0.032). Further, when considered together, LH, E2, and P4 are found to be triply copulsatile (P = 0.0066). However, significant numbers of discrete pulses of P4 and E2 are observed without antecedent LH pulses, suggesting some degree of corpus luteum autonomy. In conclusion, orchestrated synchrony of pulsatile pituitary and ovarian (corpus luteum) signaling can be demonstrated by the coordinated temporal release of LH, E2, and P4 in normal cycling women.

Secretory dynamics of oestradiol (E2) and progesterone (P4) during periods of relative pituitary LH quiescence in the midluteal phase of the menstrual cycle

Although the temporal relationship between pulsatile pituitary luteinizing hormone (LH) secretion and steroid hormone release from the corpus luteum has been investigated, the secretory profiles of oestradiol (E2) and progesterone (P4) during periods without any discernible LH pulsatile activity remain unknown. Consequently, blood was sampled at 15-min intervals for 24 h from 16 women during the midluteal phases (6-8 days after midcycle LH surge) of their cycles. LH was measured in all samples and analysed for significant pulses by the Cluster pulse algorithm. Nine studies showing the lowest LH pulse frequencies and large LH pulse amplitudes were also assessed for E2 and P4 in all samples. All three hormones were released in pulsatile fashions. Pulses of E2 and P4 were found to be synchronous. While the release frequencies for E2 (mean +/- SEM: 8.9 +/- 0.7 pulses/24 h) and P4 (8.5 +/- 0.7 pulses/24 h) were comparable, the LH pulse frequency (4.6 +/- 0.4 pulses/24 h) was found to be significantly (P less than 0.001) lower than the ovarian steroid pulse frequencies. Maximum (P less than 0.01) cross-correlation coefficients were determined at positive time lags of 28.1 +/- 7.7 min for LH/E2 and 31.7 +/- 5.8 min for LH/P4, indicating that changes in E2 or P4 levels tended to occur within approximately 30 min following LH concentration changes. Further, the degree of concomitance between a steroid pulse and an LH peak was much higher (P less than 0.001) than by chance. Maximum (P less than 0.01) cross-correlation coefficients between E2 and P4 hormonal data series were found at zero time lag, suggesting that these sex steroids were secreted simultaneously. The pulse amplitudes, pulse durations and areas under the peaks of those E2 or P4 pulses preceded by large (greater than 5 IU/l) amplitude LH pulse were significantly greater (P less than 0.05 or less for all comparisons) than for steroid pulses not associated with preceding LH pulses. Thus, two populations of steroid pulses were observed; one associated with preceding LH pulses and having greater magnitude of all pulse attributes (duration, amplitude, area under the peaks), and another, not associated with preceding LH pulses and having pulse characteristics of lower magnitude. This observation suggests that the pulsatile release of ovarian steroids is a result of the episodic modulating influence of LH and that pulsatile steroid hormone secretion pertains with smaller magnitude during periods of relative pituitary quiescence of LH pulsatility.

Depressive episodes in premenstrual syndrome

Episodic depression, a prominent but poorly defined symptom of premenstrual syndrome, was quantitated in 24-hour cortisol secretory episodes (determined by sampling at 20-minute intervals) as biochemical markers, as well as the Beck Depression Inventory and Profile of Mood States as psychometric measures. Results of 16 patients with premenstrual syndrome were compared with six age-matched women with endogenous depression and 16 control women. On both the Profile of Mood States and Beck Depression Inventory, women with premenstrual syndrome showed a marked worsening of scores (p less than 0.01) during the luteal phase compared with either their own follicular phase scores or the scores of controls in either cycle phase. However, Beck Depression Inventory scores were threefold higher (p less than 0.005) in women with depression than in those with luteal phase premenstrual syndrome (3.37 +/- 3.6 vs. 11.9 +/- 2.5). The Profile of Mood States depression scale was also higher (p less than 0.05) in women with depression than in those with premenstrual syndrome, while scores on other Profile of Mood States scales were similar. The numbers of cortisol secretory pulses identified by the cluster algorithm were similar (5 to 6 per 24 hours) in all groups, and the time of circadian nadirs as determined by cosinor rhythmometry were comparable. While the mean amplitude and duration of the cortisol pulses were also similar in women with premenstrual syndrome and controls, both were significantly higher (p less than 0.05) in women with depression. This resulted in markedly enhanced (p less than 0.005) cortisol secretion during a given secretory episode in women with depression and in higher 24-hour transverse mean cortisol values in women with depression (87.8 +/- 5.8 ng/ml) than in either those with premenstrual syndrome (66.7 +/- 3.3 ng/ml) or controls (58.9 +/- 3.3 ng/ml). These data affirm the clinical impression that depressive episodes occurring selectively in the luteal phase of the cycle in women with premenstrual syndrome are not present in controls and demonstrate, for the first time, that these episodes are distinct from endogenous depression as measured by both cortisol secretory parameters and psychological indices.

Suppression of bioactive and immunoreactive follicle-stimulating hormone and luteinizing hormone levels by a potent gonadotropin-releasing hormone antagonist: pharmacodynamic studies

Dose-dependent gonadotropin suppression by a potent gonadotropin-releasing hormone (GnRH) antagonist, Nal1 Glu6 [( Ac-D2Nal1,D4ClPhe2,D3Pal3,Arg5,DGlu(AA)6,- DAla10]GnRH), was determined in five postmenopausal women by frequent sampling for immunoreactive luteinizing hormone (I-LH) and immunoreactive follicle stimulating hormone (I-FSH) for 72 hours after single intramuscular (IM) injections of 10, 50, 150, and 300 micrograms/kg. Bioactive (B) LH and B-FSH also were measured after the IM administration of the 50-micrograms/kg dose. Serum levels of Nal1 Glu6 were determined by a radioreceptor assay for the first 24 hours after the 50-micrograms/kg IM dose and in three women after a 10-micrograms/kg intravenous (IV) dose. While the disappearance rate of serum Nal1 Glu6 after a 10-micrograms/kg IV injection was rapid, gonadotropin suppression persisted longer than detectable serum levels. In contrast, after a 50-micrograms/kg IM injection, the decline from peak circulating levels was slower, contributing to its longer duration of action (greater than 24 hours). All IM doses tested resulted in a similar 51% to 63% decrease in I-LH, which was maximal by 8 hours. The duration of action was dose-dependent, with decreased levels lasting up to 72 hours at the 300-micrograms/kg dose. While decline of I-FSH was smaller (14% to 33%), the duration of suppression was also dose-dependent, although the nadir occurs later (8 to 9 hours after administration) and suppression lasted longer (72 hours at the 150-micrograms/kg dose). The reduction of B-LH was greater than that of I-LH and the suppression of B-FSH also was greater than that of I-FSH.(ABSTRACT TRUNCATED AT 250 WORDS)

Alterations of the adrenocorticotropin-cortisol axis in normal weight bulimic women: evidence for a central mechanism

We studied pituitary-adrenal function in eight women with normal weight bulimia and seven normal women by measuring plasma ACTH and serum cortisol levels at 20-min intervals for 24 h and the responses to human CRH (hCRH) and to a noon meal. The bulimic women had increased 24-h transverse mean plasma ACTH [1.09 +/- 0.06 (+/- SE) vs. 0.75 +/- 0.14 pmol/L; P less than 0.05] and serum cortisol (235 +/- 21 vs. 152 +/- 9 nmol/L; P less than 0.005) concentrations. While the 24-h ACTH and cortisol pulse frequencies were unaltered, the bulimic women had higher (P less than 0.05) mean peak ACTH (1.46 +/- 0.09 vs. 1.03 +/- 0.15 pmol/L) and cortisol values (331 +/- 33 vs. 239 +/- 17 nmol/L). Despite having higher mean and peak plasma ACTH and serum cortisol values, the bulimic women had a blunted response of both ACTH (P less than 0.001) and cortisol (P less than 0.005) to hCRH, which included a lower mean maximal plasma ACTH response, decreased (P less than 0.05) integrated area under the ACTH response curve (161 +/- 12 vs. 231 +/- 23 pmol/min.L), a lower (P less than 0.05) maximum cortisol response (284 +/- 35 vs. 413 +/- 19 nmol/L), and decreased (P less than 0.05) area under the cortisol curve (11.1 +/- 1.9 vs. 15.9 +/- 1.3 X 10(3) nmol/min.L). The circadian variations of both ACTH and cortisol were maintained in the bulimic women; the nadir and acrophase times were similar to those of the normal women. However, the rise in serum cortisol that occurred within 1 h after the lunch meal in the normal women (104 +/- 35 nmol) did not occur in the bulimic women (P less than 0.05). These data demonstrate that marked changes in hypothalamic-pituitary-adrenal function occur in bulimia in the absence of weight disturbance and suggest central activation of CRH and/or synergistic factors as well as alterations in signals from gut to brain in this syndrome.

The use of psychotropic agents in pregnancy and lactation

The question of which psychotropic medications are safe during pregnancy is likely to remain unanswered for many years to come. There are ethical limitations to performing the type of prospective controlled studies required to answer a scientific question of this type definitively. At the present time, in all patients with worsening psychiatric illness during pregnancy, be it in the schizophrenic, affective, anxiety disorder, or personality disorder spectrum, outpatient psychotherapy, hospitalization, and milieu therapy should be attempted prior to the routine use of psychotropic medication. Prior to pregnancy, withdrawal of psychotropic medications should be attempted under close supervision. Situations will arise in which hospitalization is not sufficient to avert psychotic decompensation. In both schizophrenic illnesses and acute mania, neuroleptics should be used, especially in the first trimester in preference to lithium. The use of high-potency neuroleptics appears preferable to low-potency agents as the first line of therapy, although subsequent management decisions will depend on ability to control side effects. In depression, TCAs should be used in cases of suicidality or incapacitating vegetative signs after the first trimester if supportive measures fail. There appears to be no rationale for withdrawal of TCAs prior to labor. In the third trimester, use of TCAs, low-potency neuroleptics, or lithium should be accompanied by obstetrical surveillance. In severe anxiety or insomnia following the first trimester, the occasional use of benzodiazepines may be warranted except during labor and the first week postpartum. The chronic use of benzodiazepines during any phase of pregnancy and in breastfeeding women is contraindicated. The importance of close rapport between the treating physician and the pregnant or breastfeeding patient cannot be overstated and will obviate or decrease reliance on psychotropic medication in many cases.

Alterations in the hypothalamic-pituitary-ovarian and the hypothalamic-pituitary-adrenal axes in athletic women

The functional integrity of the hypothalamic-pituitary-ovarian and hypothalamic-pituitary-adrenal axes was assessed by determining pulsatile LH, ACTH, and cortisol secretion during the early follicular phase in athletic women with regular menstrual cycles (CA; n = 9), athletic women with amenorrhea (AA; n = 9), and regularly cyclic sedentary women (CS; n = 8). The CA and AA women were not significantly different in body composition, exercise training, psychometric tests, or dietary consumption. The CA women had shorter luteal phases (P less than 0.05) and lower urinary excretion of pregnanediol glucuronide than the CS women. In the AA women, urinary estrone glucuronide, pregnanediol glucuronide, and LH excretion were low throughout a 30-day period. The CA women had a 24-h pattern of pulsatile LH secretion characterized by reduced frequency (P less than 0.05) and increased amplitude (P less than 0.05), yielding an overall increased 24-h mean level (P less than 0.05), but interpulse intervals similar to those in the CS women. During sleep, LH pulse frequency slowed in the CS and CA women, while pulse amplitude increased and the mean serum LH level decreased in both groups. The AA women had even fewer pulses (P less than 0.05) of normal amplitude occurring at much more variable (P less than 0.01) interpulse intervals. Sleep-associated changes in LH pulsatility were absent. Responses to a 10-microgram bolus GnRH dose revealed blunted (P less than 0.05) FSH release in CA and augmented (P less than 0.05) LH release in AA women. The groups did not differ in any 24-h ACTH pulse pattern parameter or in cortisol pulse frequencies. Yet, early morning (0200-0800 h) serum cortisol levels were higher (P less than 0.05) in both groups of athletes, and this elevation was extended through the day (0800-2000 h; P less than 0.001) and evening (2000-0200 h; P less than 0.05) in the AA women. The plasma ACTH and serum cortisol responses to bolus human CRH administration were blunted in the CA and AA women [change from baseline (delta) in ACTH, P less than 0.05 and P less than 0.01; delta cortisol, P less than 0.01 and P less than 0.01, respectively], but adrenal sensitivity (delta cortisol/delta ACTH ratio) was increased (P less than 0.05). The plasma ACTH and serum cortisol responses to meals also were blunted in the athletic groups (P less than 0.05).(ABSTRACT TRUNCATED AT 400 WORDS)

Neuroendocrine aberrations in women with functional hypothalamic amenorrhea

To further elucidate the neuroendocrine regulation of anterior pituitary function in women with functional hypothalamic amenorrhea (FHA), we measured serum LH, FSH, cortisol, GH, PRL, TSH concentrations simultaneously at frequent intervals for 24 h in 10 women with FHA and in 10 normal women in the early follicular phase (NC). Using the same data, we separately analyzed the cortisol-PRL responses to meals in these women. In addition, the pituitary responses to the simultaneous administration of GnRH, CRH, GHRH, and TRH were assessed in 6 FHA and 6 normal women. The 24-h secretory pattern of each hormone except TSH was altered in the women with FHA. Compared to normal women, the women with FHA had a 53% reduction in LH pulse frequency (P less than 0.0001) and an increase in the mean LH interpulse interval (P less than 0.01); LH pulse amplitude was similar. The 24-h integrated LH and FSH concentrations were reduced 30% (P = 0.01) and 19% (P less than 0.05), respectively. The mean cortisol pulse frequency, amplitude, interpulse interval, and duration were similar in the two groups, but integrated 24-h cortisol secretion was 17% higher in the women with FHA (P less than 0.05). This increase was greatest from 0800-1600 h, but also was present from 2400-0800 h. Cortisol levels were similar in the two groups from 1600-2400 h, resulting in an amplified circadian excursion. In contrast, the 24-h serum PRL levels were markedly lower at all times (P less than 0.0001), the sleep-associated nocturnal elevation of PRL was proportionately greater (P less than 0.05), and serum GH levels were increased at night in the women with FHA (P less than 0.05). Although 24-h serum TSH levels were similar at all times, T3 (P less than 0.05) and T4 (P less than 0.01) levels were lower in the FHA women. The responses of serum cortisol to lunch (P less than 0.01) and dinner (P less than 0.05) and those of serum PRL to lunch (P less than 0.05) and dinner (P = 0.08) were blunted in the women with FHA. Pituitary hormone increments in response to the simultaneous iv administration of GnRH, CRH, GHRH, and TRH were similar in the two groups, except for a blunted PRL response to TRH in the women with FHA (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of dopaminergic blockade on the sleep-associated changes of luteinizing hormone pulsatility in early follicular phase women

To investigate the dopaminergic role in the sleep-associated changes of luteinizing hormone (LH) pulsatile pattern, 11 normal cycling women were studied in the early follicular phase (EF, days 3 and 4) of their cycles before and after the administration of metoclopramide (MCP), a dopamine receptor antagonist. Twenty-four-hour infusions of either saline (NaCl 150 mmol/1-50 ml/h) or metoclopramide (MCP, 30 micrograms/kg/h) were conducted in a random sequence. Pulsatile LH activities were assessed in blood samples obtained at 15-min intervals for 48 h. Sleep was electrophysiologically confirmed by EEG during night hours (23.00-07.00 h). Significant sleep-associated decreases in LH pulse frequency (p less than 0.05) and mean LH serum levels (p less than 0.001) with a concurrent increase in LH pulse amplitude (p less than 0.01) were observed during the saline control studies. MCP infusion failed to significantly modify the LH pulsatile activity during either the wake or sleep periods. In particular, it did not prevent the changes in LH pulsatility during sleep. This observation suggests that a dopaminergic mechanism does not critically contribute to the sleep-related changes in LH pulsatile activity in women during the early follicular phase.

Role of endogenous opioid peptides in the initiation of the midcycle luteinizing hormone surge in normal cycling women

While compelling evidence indicates a pivotal role for endogenous opioids in the regulation of GnRH-LH pulsatile activity during the late follicular and luteal phases of the menstrual cycle, the participation, if any, of the opioidergic mechanism in the initiation of the midcycle surge has not been examined. Accordingly, we measured serum LH, FSH, estradiol (E2) and progesterone (P4) levels daily during 2 consecutive cycles in 12 normal cycling women. After a control cycle, each woman was infused with naloxone (30 micrograms/kg.h) for 24 h starting 3 days before the anticipated spontaneous midcycle surge. Blood samples were obtained at 15-min intervals for 8 h before, during, and 16 h after the naloxone infusion. Serum LH and FSH concentrations were measured in all samples, and serum E2 and P4 concentrations at 2-h intervals. Pulsatile LH secretion was analyzed using the cluster program. The opioidergic blockade elicited a robust increase in LH pulsatile activity and a 3-fold rise in serum FSH levels in 6 of the 12 women. This increased gonadotropin secretion lasted more than 24 h and was characterized by a progressive increase in LH pulse amplitude, which was 9-fold greater during the last 8 h of naloxone infusion [mean LH pulse amplitude, 36.5 +/- 4.5 (+/- SE) vs. 4.1 +/- 0.4 IU/L; P less than 0.001]. This increase was accompanied by a corresponding increase in transverse mean serum LH levels (83.3 +/- 13 vs. 20.7 +/- 3.2 IU/L; P less than 0.001), but no alteration of the interpulse interval (93 +/- 11 vs. 85 +/- 4 min). The peak serum LH concentrations exceeded 100 IU/L in all 6 of these women. This naloxone-advanced gonadotropin surge, resembling closely the spontaneous midcycle surge, resulted in a significantly shortened (P less than 0.001) follicular phase and a more than 2-fold elevation of serum P4, followed by assumed ovulation and normal luteal function. These 6 women had serum E2 levels immediately before naloxone infusion that were comparable to those during the preovulatory peak during the control cycle. In the 6 women who did not have a naloxone-induced increase in gonadotropin secretion the preinfusion serum E2 levels were substantially lower (P less than 0.001) than the values during the control cycle. These findings suggest that a transient decrease in opioidergic activity may contribute to the initiation of the midcycle gonadotropin surge in women.

Dopaminergic control of circadian and pulsatile pituitary thyrotropin release in women

Dopamine (DA) inhibits pituitary TSH release, but its role as a regulator of circadian and pulsatile TSH secretion is not clear. Accordingly, we studied the 24-h TSH secretory patterns in seven normal women in the early follicular phase of their cycles before and during DA receptor blockade by metoclopramide (MCP). Serum TSH was measured by a highly sensitive (0.05 mU/L) RIA at 15-min intervals for 48 h during sequential 24-h saline and 24-h MCP infusions (30 micrograms/kg.h). Sleep was confirmed by electroencephalogram between 2300-0700 h. All women had a nocturnal rise of TSH, independent of sleep, which began in the late afternoon and reached a peak (acrophase) after midnight during the saline infusion. This circadian periodicity was composed of a series of TSH pulses with greater magnitude and frequency during nocturnal hours. Infusion of MCP had no effect on pulse frequency, but the pulse amplitude increased (P less than 0.05), especially at night. As a consequence, the circadian excursion of TSH, as assessed by cosinor function, was exaggerated. The mean acrophase amplitude and mesor levels increased (P less than 0.05), but the nadir and acrophase times did not change. These findings suggest that DA is an inhibitor of TSH pulse amplitude throughout the 24-h biological clock. By inference, the neuroendocrine mechanism(s) that underlies the nocturnal increase in TSH secretion is not due to decreased dopaminergic inhibition.

Effects of acute hyperprolactinemia on LH pulsatile secretion in hypogonadal and early follicular phase women

To investigate the effects of acute hyperprolactinemia on the 24 h LH pulsatile pattern, 11 women in the early follicular phase (EF, days 3 and 4) and 8 postmenopausal women (PMW) were studied before and during administration of metoclopramide, a dopamine receptor antagonist. Sequential 24 h infusions of either metoclopramide (MCP, 30 micrograms/kg/h) or normal saline were conducted and pulsatile LH activity assessed for 48 hrs. In both EF women and PMW, a prompt (within 90 min, p less than 0.001) and sustained (greater than 45 micrograms/L, p less than 0.001) release of PRL was induced by MCP infusions. MCP-induced hyperprolactinemia failed to modify the LH pulsatile activity in both EF women and PMW. These observations suggest that acute hyperprolactinemia due to dopaminergic blockade has no discernible effect on LH pulsatility and that the reduced LH pulse frequency observed in association with endogenous hyperprolactinemia may result from different neuroendocrine mechanism(s) and/or is time dependent.

Amplification of nocturnal melatonin secretion in women with functional hypothalamic amenorrhea

Plasma melatonin levels were determined by a sensitive RIA at 30 min intervals for 24h in 7 women with functional hypothalamic amenorrhea (HA) and in 7 age and season matched normal cycling women in the early follicular phase (NC). While daytime melatonin concentrations were nondetectable in both groups, the integrated nocturnal levels were 3-fold greater in HA (244 +/- 58 (SE) vs 74 +/- 32 pmol-min/Lx10(3), p less than 0.005). This melatonin increase in HA was due to an elevated peak amplitude (p less than 0.01) and extended duration (p less than 0.05). The latter was mostly due to a significant delay in the offset time of the amplified nocturnal melatonin secretion.

Pulsatile rhythms of adrenocorticotropin (ACTH) and cortisol in women with endogenous depression: evidence for increased ACTH pulse frequency

Plasma ACTH and serum cortisol levels were measured at 20-min intervals for 24 h in six young women with unipolar endogenous depression and in eight normal women during the early follicular phase of the menstrual cycle. The women with depression had a marked increase (P less than 0.005) in mean ACTH pulse frequency [14.5 +/- 0.6 (+/-SE) pulses/24 h] compared with normal women (9.9 +/- 0.7 pulses/24 h), while mean ACTH pulse amplitude and 24-h transverse mean ACTH levels were similar in the two groups. In contrast, 24-h transverse mean cortisol levels were higher (P less than 0.02) in the depressed women (242 +/- 28 nmol/L) than in the normal women (163 +/- 10 nmol/L). This hypercortisolemia in the depressed women was accompanied by markedly increased (P less than 0.001) episodic cortisol secretion (286 +/- 24 X 10(2) nmol/L X min) compared with that in normal women (155 +/- 17 X 10(2) nmol/L X min), and the secretory episodes were both longer in duration (P less than 0.05) and of higher amplitude (P less than 0.05) in the depressed women. The circadian variations in ACTH and cortisol were maintained in these depressed women, and the times of the circadian nadir, as determined by cosinor analysis, were similar to those in the normal women. However, the mean length of the evening quiescent period of cortisol secretion was far shorter (P less than 0.005) in the depressed women (27 +/- 8 vs. 202 +/- 40 min). Moreover, the postlunch rise in serum cortisol was significantly higher (P less than 0.02) in the depressed women (204 +/- 29 vs. 111 +/- 15 nmol/L). These results provide evidence that the hypercortisolism in depressed women is associated with an increase in ACTH pulse frequency, expanded cortisol secretory episodes, including a greater postlunch rise in cortisol, and a shortened evening quiescent period of cortisol secretion. Our findings provide evidence for centrally mediated activation of the ACTH-cortisol system in women with depression without a phase shift in circadian rhythm.

Alterations in immune responsiveness in women exposed to diethylstilbestrol in utero

In order to study the effect of in utero diethylstilbestrol (DES) exposure on the immune system of adult women, the blastogenic response of peripheral blood lymphocytes to two mitogens was compared in eight DES-exposed patients and in eight age-matched controls with normal menstrual cycles and proven fertility. As measured by the uptake of 3H-thymidine (mean [+/- standard error]), response to the T-cell mitogen phytohemagglutin (PHA) was significantly higher (P less than 0.002) in cells of DES-exposed women (88.6 +/- 5.7 X 10(3) cpm) than in controls (44.0 +/- 8.9 X 10(3) cpm) at the lowest dose of mitogen tested (0.125 microgram/ml). Moreover, lymphocytes of DES-exposed subjects showed maximal blastogenic response to PHA at a concentration (0.125 microgram/ml) two to four times lower (P less than 0.002) than controls (0.25 microgram/ml to 0.5 microgram/ml). Cells of both DES-exposed subjects and controls were maximally responsive to pokeweed mitogen (PWM) at the lowest dose tested (0.625 microgram/ml). These findings suggest that in utero DES exposure is associated with a hyper-reactive immune response during the reproductive years.