Estrogen-androgen for hormone replacement. A review

OBJECTIVE

To critically examine the role of androgens as part of postmenopausal hormone replacement therapy.

STUDY DESIGN

Examination of original reports and reviews obtained by electronic database searches and supplemented by manual search of bibliographies.

RESULTS

As compared to estrogens alone, estrogen-androgen therapy may better protect against osteoporosis and increase libido, energy levels and general sense of well-being. However, estrogen-androgen replacement also reduces the beneficial increases in high-density lipoprotein induced by estrogens alone, although this effect may be offset at least partially by decreases in atherogenic triglycerides. The long-term net effect of estrogen-androgen replacement on cardiovascular disease remains unknown.

CONCLUSION

Although the literature includes relatively few clinical trials or well-controlled studies and is further limited by the subjective nature of outcomes, such as sexual and psychological function, the available data suggest that for many postmenopausal women, estrogen-androgen replacement may provide benefits beyond those provided by estrogen-only replacement therapy.

Voiding function following prolapse surgery. Impact of estrogen replacement

OBJECTIVE

To identify factors that would predict postoperative bladder function in postmenopausal women undergoing pelvic reconstructive surgery for pelvic organ prolapse.

STUDY DESIGN

Demographic variables and urodynamic measures were analyzed in respect to the length of postoperative bladder catheterization.

RESULTS

Patient age, the presence of abnormal preoperative voiding patterns or elevated postvoid residuals, the route of surgical approach and the performance of urethropexy did not correlate significantly with the length of postoperative catheterization; only hormonal status did. Postmenopausal women using estrogen replacement therapy required significantly fewer days of catheterization than those who were not receiving estrogen replacement therapy.

CONCLUSION

The use of preoperative estrogen replacement therapy is associated with a reduction in the length of postoperative bladder catheterization in women undergoing pelvic reconstructive surgery for pelvic organ prolapse.

Comparison of oral estrogens and estrogens plus androgen on bone mineral density, menopausal symptoms, and lipid-lipoprotein profiles in surgical menopause

OBJECTIVE

To compare an oral estrogen-androgen combination with estrogens alone on bone, menopausal symptoms, and lipoprotein profiles in postmenopausal women.

METHODS

Surgically menopausal women received oral esterified estrogens (1.25 mg), or esterified estrogens (1.25 mg) and methyltestosterone (2.5 mg) daily, for 2 years. Bone mineral density of the lumbar spine and hip, menopausal symptoms, lipoprotein profiles, and biochemical and hematologic indices were evaluated.

RESULTS

Sixty-six patients were enrolled in the study. Both treatment regimens prevented bone loss at the spine and hip; combined estrogen-androgen therapy was associated with a significant increase in spinal bone mineral density compared with baseline (n = 24; mean score +/- standard error 3.4 +/- 1.2%, P < .01). In the estrogen group, high-density lipoprotein (HDL) cholesterol increased significantly and low-density lipoprotein cholesterol decreased significantly. Cholesterol, HDL cholesterol, and triglycerides decreased significantly in the estrogen-androgen group. Menopausal symptoms of somatic origin (hot flashes, vaginal dryness, and insomnia) were improved significantly by both treatments. Neither adverse hepatic effects nor significant safety or tolerance problems were reported in either group.

CONCLUSION

Oral estrogen-androgen increased vertebral bone mineral density compared with pre-treatment values and relieved somatic symptoms. Safety indices, including lipoprotein levels, indicated that the combination was well tolerated over the 2 years of treatment.

Pelvic relaxation involving the middle compartment

Loss of pelvic support involving the 'middle compartment' is manifested by herniation through the central pelvic floor in proximity to the intersection of an imaginary line from the public symphysis to the coccyx with another from one ischial spine to opposite ischial spine. Loss of middle compartment support may exist in association with 'anterior compartment' defects, 'posterior compartment' defects, or both. The severity of middle compartment relaxation ranges from mild uterine descensus to total uterovaginal prolapse when the uterus is present. When the uterus has been removed, it may range from vaginal vault descent to total vaginal eversion and includes all grades of enterocele. Middle compartment defects are usually not isolated. The recent literature relevant to middle compartment defects consists primarily of additional reports on surgical management, including continued modification and evolution of surgical techniques. Larger surgical series with longer follow-up periods have been reported. Cadaveric and histologic studies have appeared which have added to the understanding of normal anatomy and the disruptions thereof, which can cause middle compartment defects. Sophisticated diagnostic imaging techniques have generated preliminary reports which are of interest.

Abdominal sacral colpopexy in 163 women with posthysterectomy vaginal vault prolapse and enterocele. Evolution of operative techniques

Abdominal sacral colpopexy with retroperitoneal interposition of a suspensory hammock between a prolapsed vaginal vault and the anterior surface of the sacrum was performed on 163 women for correction of vaginal vault prolapse during 18 consecutive years, from 1972 through 1989. Hysterectomy had previously been performed on 160 of the patients, 2 patients had congenital absence of the uterus, and 1 patient underwent vaginal hysterectomy at the time of the sacral colpopexy. The patients had been followed for 9 months to 18 years at this writing, with a median follow-up of 33 months. An additional 25 patients underwent successful sacral colpopexy since the end of the study period, but those data are not included here. Modifications of surgical techniques have evolved from our experience.

Choice of operation for genuine stress incontinence

Surgery, the definitive treatment for most patients with genuine stress urinary incontinence, continues to evolve, as does the rationale for choice and application of given operations. The history of surgical progress to the present is well covered by Kohorn (Obstet Gynecol Clin North Am 1989, 16:841-852) and includes those operations that have progressively supplanted the anterior colporrhaphy on which the gynecologist traditionally depended. Emphasis on the secure retropubic placement of the bladder neck has led to the development of a number of modifications of open retropubic cystourethropexy, minimal incision needle suspension techniques, and various sling operations; recently reported modifications are acknowledged. The rationale of curing incontinence by restoring normal anatomy in the course of identifying and repairing discrete fascial defects has led to increased acceptance and use of the paravaginal or obturator shelf repair.

Thumbtack use for control of presacral bleeding, with description of an instrument for thumbtack application

There is well-known difficulty in controlling hemorrhage from presacral vessels. There are reports on the use of thumbtacks to secure hemostasis in the face of presacral hemorrhage. This communication reports the successful use of thumbtacks to establish presacral hemostasis and describes a simple instrument designed to afford easier and more precise anterior sacral application of thumbtacks. The instrument is easy to make. It was devised because of difficulty encountered with manual placement of hemostatic thumbtacks and the absence of totally satisfactory delivery by any of the standard surgical instruments available.

Suprapubic teloscopy: extraperitoneal intraoperative technique to demonstrate ureteral patency

A simple method for intraoperative visualization of the ureteral orifices to demonstrate ureteral function is described. This method, called suprapubic teloscopy because only the telescope of a cystoscope is used for visualization, allows intraoperative assessment without the need for completely closing the abdomen or repositioning the patient. The use of this equipment, standard in all operating suites, is detailed, and experience with 37 patients is presented.

Failed abdominal sacral colpopexy: observations and recommendations

Abdominal sacral colpopexy provides effective surgical management of the vagina that has prolapsed after hysterectomy. Recurrences of prolapse after this operation are rare. Three patients are presented who did exhibit recurrent prolapse necessitating another operation. In two patients, the synthetic mesh used for colpopexy had separated from the vagina. In the remaining patient, the posterior vaginal wall had ruptured distal to the attachment of mesh to the vagina. In each patient, the mesh had become completely interpenetrated by tissue. We believe that failures can be minimized by suturing the suspensory mesh to the vagina over as extended an area as possible. Reasons for this belief are addressed, and techniques for achieving such an attachment are described. A meticulous culdoplasty beneath the suspensory mesh is also considered important, as is the use of permanent sutures placed through the full thickness of the vagina in attaching the mesh.

Genetic screening of donors for artificial insemination

A routine has been established for genetic screening of donors in an artificial insemination and frozen sperm bank program. This report is a summary and analysis of the information obtained on the first 168 donor applicants and 89 recipients who were genetically screened. The specific forms for screening, family information obtained, characteristics of the donor and recipient groups, and guidelines for acceptance or rejection of donors are discussed. The donor and recipient often failed to perceive that the disorders in the family were genetic. The simple question of whether or not there were genetic or hereditary problems in the family was ineffective, even when the donor or recipient had formal medical training.

Intravenous injection in man of 9 -tetrahydrocannabinol and 11-OH- 9 -tetrahydrocannabinol

A microsuspension of Delta(9)-tetrahydrocannabinol and of its metabolic derivative 11-OH-Delta(9)-tetrahydrocannabinol has been prepared with 25 percent human serum albumin as the vehicle. Intravenous infusion of this preparation to humans indicates that both tetrahydrocannabinols are equally potent in producing the typical marihuana-like pschological and physiological effects.