Bioidentical menopausal hormone therapy: registered hormones (non-oral estradiol ± progesterone) are optimal

The many advantages of registered bioidentical sex hormones over registered, conventional, non-bioidentical menopausal hormone therapy (MHT) are considered. The transdermal route of estrogen administration avoids excess venous thromboembolic and ischemic stroke events. There is some indication that conjugated equine estrogens are more thrombogenic and most likely induce some hypertensive responses; estradiol might also be superior to conjugated equine estrogens (CEE) in terms of global cardiovascular health. The most valid evidence presently suggests that CEE-only treatment does not increase the risk of breast cancer and even may reduce it. But its combination with a synthetic progestogen (mainly medroxyprogesterone acetate) is a critical issue since it seems to be primarily associated with an increased incidence of breast cancer, however similar to or lower than that associated with some common lifestyle factors. Though not yet proven in a randomized, controlled trial, MHT continuously combining oral micronized progesterone with transdermal estradiol can presently be considered as the optimal MHT. It is not only safer than custom-compounded bioidentical hormones but also than oral conventional MHT and has the best breast profile; registered products for such optimal MHT are available around the world and must be preferred.

[Asphyxiating thoracic dysplasia (Jeune syndrome): about two cases]

Asphyxiating thoracic dysplasia (Jeune syndrome) is an osteochondrodysplasia with autosomal recessive inheritance, characterised by a nanism with rhizomelic predominance, associated with a narrow thorax. It induces an alteration of the respiratory function that conditions the prognosis, which is worsened in case of associated visceral lesions (probably related to mutations of genes implicated in ciliary development, as recently described). We report the observation of two severe cases of Jeune syndrome to emphasize the advancement of imaging, especially echography, and molecular biology in establishing prenatal diagnosis as well as prognosis of this syndrome.

Small cell carcinoma of the ovary successfully treated with radiotherapy only after surgery: case report

Small cell ovarian tumors are rare and highly malignant, occurring mainly in young patients. Early mortality is high due to the lack of an effective treatment. The first adjuvant therapy is usually chemotherapy.

CASE

During laparotomy for renal transplant in a 17-year-old girl, the right ovary exhibited a suspicious mass, whose pathological diagnosis was Stage 1A small cell ovarian tumor. Prognosis was poor (young age, hypercalcemia, tumor >10 cm, and presence of large cells). Since chemotherapy is contraindicated for dialysed patients, only radiotherapy was given. The patient is still alive and disease-free ten years after diagnosis.

CONCLUSION

This is the first case with a poor prognosis reported in the literature that has been successfully cured by surgery plus adjuvant radiotherapy only.

The long-term tolerability and efficacy of OESCLIM: results of a 1-year study

OBJECTIVES

A 1-year, open-label, non-comparative study evaluated the long-term tolerability and acceptability of a new generation matrix patch in post menopausal women with estrogen deficiency.

METHODS

Menopausal women (224) from 37 centres in five European countries received OESCLIM 50 microg/d (17-beta estradiol) for 3 months, titrated if necessary to either 25 or 100 microg/d for a further 9 months. Patients received either a continuous or discontinuous estradiol regimen with concomitant sequential progestogen (except hysterectomised patients). Skin tolerability was assessed by patient diaries and questionnaires. Global tolerability, efficacy, laboratory parameters and global acceptability were also monitored.

RESULTS

Almost two-thirds of women did not experience any kind of skin reaction and only 4.3% of all applications (752/17,702) caused site reactions. Of these, the majority caused only slight or no discomfort (63.2%). Only 0.37% of total applications required patch removal; none required therapy. A low percentage of patients withdrew due to tolerability issues: 2.7% due to skin reactions; 7.5% due to hyperestrogenism. The mean number of hot flushes experienced by symptomatic women reduced by 91% from 4.0 at baseline to 0.4 after 2 months. Total cholesterol reduced by 3.9% and LDL cholesterol by 5.1%, with no increase in triglyceride levels. Investigators assessed treatment as effective in 96.8% of cases; well tolerated locally in 93.1% and well tolerated generally in 89.5%. At the end of this 1 year study, 79% of patients wished to continue therapy.

CONCLUSION

OESCLIM is well tolerated locally and systemically in long-term therapy with a high proportion of patients wishing to continue therapy after 1 year.

The efficacy and tolerability of long-term cabergoline therapy in hyperprolactinaemic disorders: an open, uncontrolled, multicentre study. European Multicentre Cabergoline Study Group

OBJECTIVE

We assessed the efficacy and safety of the new, long-acting dopamine agonist drug cabergoline during long-term therapy of hyperprolactinaemia.

DESIGN

Open, prospective, multicentre study.

PATIENTS

One hundred and sixty-two females with either a microprolactinoma (n = 100), idiopathic hyperprolactinaemia (n = 54), empty sella syndrome (n = 7) or residual hyperprolactinaemia after surgery for a macroprolactinoma (n = 1). All had previously been treated with cabergoline or placebo for 4 weeks as part of a dose-finding study.

MEASUREMENTS

Menstrual pattern, adverse symptoms, blood pressure and pulse, serum PRL, blood count, liver and renal function were assessed after one month and subsequently at two-monthly intervals.

RESULTS

Treatment was started at doses of 0.25 mg (n = 3), 0.5 mg (n = 8), 1 mg (n = 150) or 2 mg (n = 1) per week, given either as a single weekly dose (n = 8) or divided into twice-weekly doses (n = 154), and was continued for at least 49 weeks in 123 patients. Final treatment doses ranged from 0.25 mg fortnightly to 2 mg twice weekly: most patients finished the study taking 0.5 mg once (n = 31) or twice (n = 77) weekly. Stable normalization of PRL levels was achieved in 138 subjects (85%), in 129 of whom the effective dose was < 1 mg per week. In the subset of 114 patients completing 49 weeks of therapy and having dose adjustments according to the protocol, the biochemical success rate was 92%. Fifty-nine of the 65 previously amenorrhoeic women (91%) and 44 of the 49 (90%) who were previously oligomenorrhoeic resumed regular menses and/or became pregnant during the study. Adverse events were reported in 64 patients (39.5%). In 84% of cases with adverse events, the symptoms were of mild or moderate severity and most occurred during the first few weeks of therapy; five patients (3%) discontinued treatment because of poor tolerance. The most frequent symptoms were dizziness (13% of patients), headache (13%), nausea (10%) and weakness and/or fatigue (10%). Of 27 patients who had previously been poorly tolerant of other dopamine agonists, 17 (63%) did not experience any side-effects and only one was intolerant of cabergoline. No adverse haematological or biochemical effects were detected except for a slight downward trend in haemoglobin which may have been related to the resumption of regular menses in previously amenorrhoeic or oligomenorrhoeic women. A mild hypotensive effect was observed, mean systolic and diastolic blood pressures falling by 5 and 4 mmHg respectively during treatment.

CONCLUSIONS

The results provide evidence for the long-term effectiveness and safety of cabergoline in the treatment of hyperprolactinaemia. Its ability to normalize PRL and restore gonadal function compares favourably with reported data on reference compounds while its tolerability profile and simple administration schedule offer potential advantages in terms of patient acceptability.

Dose-dependent suppression of serum prolactin by cabergoline in hyperprolactinaemia: a placebo controlled, double blind, multicentre study. European Multicentre Cabergoline Dose-finding Study Group

OBJECTIVE

Dopamine agonists have a well established place in the treatment of hyperprolactinaemic disorders but their use is associated with a high incidence of adverse effects. We have investigated the biochemical efficacy and side-effect profile of a range of doses of the novel, long-acting dopamine agonist, cabergoline, in suppressing prolactin (PRL) in hyperprolactinaemic women.

DESIGN

Multicentre, prospective, randomized, placebo controlled and double blind.

PATIENTS

One hundred and eighty-eight women with hyperprolactinaemia secondary to microprolactinoma (n = 113), idiopathic disease (n = 67), empty sella syndrome (n = 7) or following failed surgery for a macroprolactinoma (n = 1).

MEASUREMENTS

Weekly assessment of adverse symptoms, blood pressure and pulse, serum PRL, blood count, liver and renal function.

RESULTS

Patients received either placebo (n = 20) or cabergoline 0.125 (n = 43), 0.5 (n = 42), 0.75 (n = 42) or 1.0 mg (n = 41) twice weekly for 4 weeks. The five treatment groups were comparable in age (mean 31.8, range 16-46 years), diagnosis, previous therapy, and pretreatment serum PRL. PRL was suppressed to below half the pretreatment level in 5, 60, 90, 95 and 98% and normalized in 0, 30, 74, 74 and 95% of patients taking placebo or cabergoline 0.125, 0.5, 0.75 or 1.0 mg twice weekly respectively (Armitage's test, chi 2 = 39.3, P < 0.01). Cabergoline therapy (all doses) restored menses in 82% of the amenorrhoeic women not previously treated with dopamine agonists. Adverse events were recorded in 45% of patients in the placebo group and in 44, 50, 50 and 58% of those taking 0.125, 0.5, 0.75 and 1.0 mg cabergoline twice weekly (Armitage's test, P > 0.05). Over 95% of reported symptoms were relatively trivial, most frequently transient nausea, headache, dizziness, fatigue and constipation. More severe adverse events, interfering significantly with the patients' lifestyle, occurred in 13 (7.7%) patients taking cabergoline; treatment withdrawal was necessary in only one case. No adverse effects were detected on blood pressure or haematological or biochemical parameters.

CONCLUSIONS

We have shown a linear dose-response relationship for cabergoline in the treatment of hyperprolactinaemia in the range 0.125-1.0 mg twice weekly, with normalization of PRL in up to 95% of cases and acceptable tolerability throughout the dose range.

Effects of the short-acting benzodiazepine triazolam, taken at bedtime, on circadian and sleep-related hormonal profiles in normal men

Studies in rodents have shown that triazolam, a commonly used hypnotic, may shift circadian rhythms, with the direction and magnitude of the phase-shifts being dependent on the time of drug administration. To determine whether benzodiazepine, taken at standard bedtime, modifies the amount and/or temporal organization of hormonal secretion, six normal men were studied during basal conditions and on the first and third days of treatment with 0.5 mg triazolam. In each study, sleep was polygraphically monitored and plasma cortisol, growth hormone (GH), melatonin, and prolactin (PRL) (i.e., hormones influenced by circadian rhythmicity and/or sleep) were measured at 20-min intervals for 24 h. The sleep latency and the number and duration of awakenings were reduced during triazolam treatment as compared to baseline conditions. The only alteration of sleep architecture was a partial suppression of stages III + IV (SW) in late sleep. Triazolam did not affect the mean cortisol and melatonin levels or the total amount of GH secreted over the 24-h span. The circadian timings of the onsets of cortisol and melatonin secretions were essentially unaltered. The nocturnal rise of melatonin was prolonged by 45 to 60 minutes. Sleep-associated GH release was not modified by triazolam. Sleep-associated PRL secretion persisted, but in half of the nights studied was enhanced almost threefold. This effect of the drug on nocturnal PRL secretion was not specific to either the first or the third night of treatment, nor was it specific to certain subjects. Irrespective of the magnitude of the nocturnal elevation, morning PRL levels were slightly but consistently higher after triazolam treatment than under basal conditions. Normal PRL levels resumed around noon. In conclusion, administration of 0.5 mg triazolam at normal bedtime (2230) for three consecutive days may induce a transient hyperprolactinemia, but does not abolish sleep-related hormone secretion and does not affect the timing of endocrine events controlled by the circadian clock. These findings are consistent with studies in hamsters where treatment with triazolam in the early subjective night was also without effect on the rodent circadian clock.

The 24-hour profile of plasma prolactin in men with major endogenous depressive illness

Plasma prolactin (PRL) levels were measured at 15-minute intervals for 24 hours in 18 men suffering from major endogenous depressive illness and in 7 age-matched healthy men. Eleven of the 18 depressed patients were restudied during clinical remission following either electroconvulsive therapy or treatment with amitriptyline hydrochloride. During the acute phase of the illness, the unipolar depressed patients had fragmented patterns of PRL secretion with an early timing of the nocturnal secretory phase of PRL, which started, on the average, 2 hours earlier than in healthy subjects. Moreover, the amplitude of the circadian variation of PRL was reduced in these patients, with subnormal PRL levels occurring during the midsleep period. This latter abnormality was also observed in bipolar patients, who had otherwise normal PRL profiles. These lower midsleep PRL concentrations were associated with a significant increase in the amount of time spent awake during the same period. Antidepressant treatment did not consistently correct the abnormalities in the patterns of PRL release observed during the acute phase of the illness. These results indicate that early timing of nocturnal PRL secretion and damping of the nighttime PRL elevation may be found in men with endogenous depressive disorders. In contrast to disturbances of the corticotropic and somatotropic axes, these abnormalities of PRL secretion may still be present during clinical remission following antidepressant treatment.

Effect of prolactin and estradiol on cell proliferation in the uterus and the MXT mouse mammary neoplasm

With the use of an in vivo tritiated thymidine [( 3H]dThd) nuclear labeling followed by autoradiography, the effects at different times before sacrifice of prolactin (PRL) and/or 17 beta-estradiol (E2) were studied in C57BL X DBA/2f)F1 mice given transplants of the MXT hormone-sensitive mammary tumor whose growth was previously shown to be influenced by E2 and/or progesterone. Uteri were chosen as controls for the methodology. Experiments were conducted on ovariectomized mice submitted to endocrine manipulation to achieve plasma PRL modifications. In addition to E2, the proliferation of cancer cells, assessed by the measurement of thymidine labeling indices (TLIs), was demonstrated to be enhanced by ovine prolactin (oPRL) and Sulpiride and strongly slowed down by castration and 2-bromo-alpha-ergokryptin treatment, thus emphasizing the great importance of PRL in mammary cancer development. Moreover, a pulse of 1 mg oPRL/animal produced a marked TLI rise in tumors, lasting from the 6th to the 48th hour after its injection and reaching a maximum at 24 hours. PRL had no proliferative effect on the uterine luminal epithelium. When PRL and E2 were injected concomitantly, the profile of stimulation was quite similar to that obtained with E2 alone; i.e., a maximum stimulation was observed at the 24th and 36th hours after hormonal pulse. From these data it is concluded that, in spayed mice, not only E2 but also PRL is of major importance leading to enhanced proliferation of MXT mammary neoplastic cells. Further investigations are needed to throw light on the cellular events presiding over the action of PRL and E2 at the cancer cell level.

Inhibition of puerperal lactation by means of a single injection of bromocriptine retard

The efficacy, tolerance and acceptability of a single i.m. injection of 50 mg bromocriptine retard (in polylactic acid microspheres), given within 12 h after delivery for suppression of lactation, were investigated in 47 mothers not willing to breast-feed. Slight to moderate breast discomfort was noticed during the first postpartum days in 23% of the patients but lactation was indeed prevented in all cases and no rebound lactation occurred in any case. Only six patients exhibited at least two symptoms of mammary engorgement (congestion and pain or milk let-down): in this group, blood mean PRL levels were significantly less suppressed on postpartum days 2, 6, 21 and 28 (p less than 0.05 to p less than 0.001) than in the group of mothers completely free of any mammary symptoms. Slight side-effects (mostly dizziness), as mentioned at systematic request, were recorded in 34% of the patients; only 3 patients required treatment for their side-effects. Recovery of ovarian function was evident quite early (by day 28 in 72% of the patients), thus requiring early onset of contraception.

Exercise-induced prolactin release is related to anaerobiosis

The response of plasma PRL to exercise, as performed on a bicycle ergometer under conditions below and above the anaerobic threshold, was studied in 10 normal young men. One hour of submaximal work against a workload at which blood lactic acid remained below 4 mmol/liter (anaerobic threshold) was accompanied by a slight decrease in plasma PRL levels, similar to the changes occurring under control conditions in the same subjects. However, during graded maximal ergometric exercise until exhaustion, plasma PRL rose promptly and significantly (P less than 0.05) when the anaerobic threshold was reached. These data suggest that PRL levels increase provided that the intensity of exercise is such that the anaerobic threshold is reached.

Pergolide mesylate inhibits exercise-induced prolactin release in man

The effects of Pergolide, a potent dopamine agonist, on exercise-induced plasma prolactin (PRL) changes were studied in normal men. Exercises consisted of a graded bicycle ergometer test and of a 20-km endurance run. In both circumstances, treatment with Pergolide, when compared with placebo or control values, resulted in a significant suppression of basal PRL (P less than 0.001) as well as of exercise-induced PRL increase (P less than 0.01). From these experiments it was concluded that augmented levels of PRL in plasma, as seen during or after muscular exercise, are caused by increased pituitary secretion, rather than decreased elimination.

Growth and bone haemodynamic responses to castration in male rats. Reversibility by testosterone

Orchidectomy in postpubertal 55 day old rats, compared to sham-operated controls, led beyond 2 months to a decrease in body weight (87% of controls by 120 d), tibial length (97% of controls) and in tibial calcium content (85% of controls). Bone plasma flow increased three times to reach a peak at 31 days; it was decreased but no significantly at 86 and 120 days. The number of osteoclasts was maximal at 51 days (X 2.3) and was still elevated at 120 days. The calcium accretion rate increased briefly at 31 days (110% of controls) and was diminished at 86 and 120 days (78% of controls). The initial 'physiological' changes in the tibia occurred before any weight change and might be directly due to the lack of androgens. They can be interpreted as inducing the conditions for enhanced bone resorption. Testosterone replacement therapy, initiated after the initial haemodynamic response, inhibited the negative effect of castration on bone growth.

Treatment of hyperprolactinaemic patients with pergolide

Eighteen hyperprolactinaemic patients were orally treated for up to 16 months with pergolide mesylate, a new potent long-lasting dopaminergic ergot derivative. In all cases, Prl normalization (less than 25 ng/ml) was achieved at a once-a-day dose of 50-300 micrograms. All women recovered and/or exhibited normal menstrual function. Among the 6 women wishing to become pregnant, 4 of them conceived within 4 months; there were other causes for infertility than hyperprolactinaemia in the 2 other couples. A macroprolactinoma man experienced important improvement in well-being as well as objective regression of his visual fields defect. This suggests a shrinkage effect of pergolide on the tumoural process. Another man regained normal potency and normal testosterone within 2 weeks. While 10 patients were completely free of any side effect, 7 experienced transiently mild gastro-intestinal side effects or postural hypotension. Only one patient discontinued her treatment because of dizziness. The present study demonstrates the high potency, the good tolerance and the excellent efficacy of pergolide in the treatment of hyperprolactinaemia.

Dopaminergic regulation of prolactin secretion in the hyperprolactinemic syndrome

The prolactin responses to an oral challenge of L-dopa (0.5 g) and bromocriptine (2.5 mg) were studied in 31 hyperprolactinemic females without radiological abnormalities of pituitary fossa, in 12 hyperprolactinemic patients with minor radiological evidence suggesting the presence of a pituitary adenoma and in 16 normal volunteers in the early puerperium with physiological hyperprolactinemia. Administration of bromocriptine was followed by a similar suppression of prolactin secretion in the functional as well as the adenomatous hyperprolactinemic patients. By contrast, a significantly blunted response to L-dopa was noted in the patients with pathological hyperprolactinemia (with and without radiological abnormalities of the pituitary fossa). These results suggest that the L-dopa suppression test might serve as a reliable indicator to detect prolactin-secreting microadenomas in patients with persistent hyperprolactinemia and radiologically normal pituitary fossae.

Exploration of hirsutism: elements for a strategy

50 women complaining of hirsutism were investigated in order to establish an optimal strategy for hirsutism exploration. Basal hormonal evaluations were of great value, especially serum testosterone and, to a lesser degree, DHA-S and LH. LH response to LHRH stimulation appeared of little diagnostic value. ACTH stimulation tests may be useful in detecting enzyme deficiencies in patients with normal basal values. The origin of hyperandrogenism can hardly be detected by the inhibition tests. However, these tests allow to determine whether the androgen secretion is still under ACTH and/or LH control.

Potent 48 hours inhibition of prolactin secretion by pergolide in hyperprolactinaemic women

The duration of the inhibition of Prl secretion by pergolide, a new dopaminergic ergoline, was investigated in 5 hyperprolactinaemic women after a single oral 50 micrograms dose. In each subject, blood samples were collected every 2 h for 18-24 h to establish baseline Prl level and then every 3 h for 48-51 h after pergolide administration. In each subject, levels were potently suppressed by at least 80% of baseline and brought down to the normal range. Prolactin suppression was quite sustained throughout the study period in 4 patients and to a lesser degree in the remaining subject. This potent long-lasting inhibition of Prl secretion should enhance the efficacy and acceptability of the chronic treatment of hyperprolactinaemia with this new dopamine agonist and, for example, allow drug intake only once every other day.

Bromocriptine compared to long-acting estrogens in lactation prevention: clinical efficacy, prolactin secretion and coagulation parameters

Sixty-eight mothers who did not want to breast-feed their babies were submitted to one of the following regimes: an intramuscular injection of estrogen (25 mg) within 1 h after delivery (n = 24) or the administration of bromocriptine for 15 or 23 days (n = 21 and 23, respectively). A careful clinical evaluation was performed every day by the same examiner during the first 7 days postpartum; blood samples were collected on days 0, 3 and 5 for human prolactin (hPRL) and estradiol, also in some cases on day 17; assays were measured by radioimmunoassay. An evaluation of the coagulation parameters was performed on day 5 in 9 estrogen-treated patients and in 25 bromocriptine-treated patients. Only 5 (11%) out of the 44 patients treated with bromocriptine experienced at least one undesirable effect of breast engorgement, in contrast to 16 (67%) out of the 24 estrogen-treated patients; this difference was statistically highly significant (P less than 0.001). Dizziness was a significant side-effect of bromocriptine treatment, occurring in 20% of the cases. In the patients in whom the administration of bromocriptine was withdrawn after 15 days, a significant mean rebound elevation of hPRL levels above the normal range occurred on the 17th day. The latter observation gives some support to earlier proposals to continue bromocriptine for up to a total 3 wk in order to avoid rebound lactation. There was no significant alteration of fibrinogen, Howell time, activated partial thromblastin time (APTT), prothrombin time (PT), thrombin time and coagulation time; mean plasminogen levels were comparable in both treated groups, while mean antithrombin III levels were increased in the bromocriptine-treated group. The significance of the latter finding requires further evaluation.

[Clinical study of veralipride in menopausal sudden flushes (author's transl)]

A double-blind clinical study was conducted to compare the therapeutic activity of veralipride and placebo in menopausal sudden flushes. Comparison of final numerical rate showed a statistical significant superiority for veralipride. Tolerance was excellent and no significant difference was observed between clinical side effects, or biological parameters studied (blood counts and differential, and blood bilirubin, transaminases, glucose, cholesterol, or creatinine levels) in the two groups.

Prolactin secretion in anorexia nervosa

Twenty-nine anorectic female patients were subdivided in three groups: group I when primary amenorrhoea; group II when secondary amenorrhoea together with a weight (for their height) equal or above the 10th percentile of the ratio of total water over body weight (TW/B Wt); group III when secondary amenorrhoea was associated with a weight below this 10th percentile. Despite very low mean oestradiol levels (respectively 22, 36 and 32 pg/ml), prolactin secretion remained normal both in basal conditions as well as after 200 micrograms TRH iv. For group III patients, a delay in the peak prolactin response to TRH was observed but it was not statistically significant.

[Analysis of mechanisms whereby pharmacologically-induced hyperprolactinemia leads to altered gonadotropin secretion (author's transl)]

Chronic hyperprolactinaemia was induced in 10 women since the onset of a cycle for 2 or 3 consecutive cycles by administration of sulpiride (3 X 50 mg/day) or tiapride (100-200 mg/day). The resulting perturbations of the menstrual cycle included short luteal phase cycles, anovulatory cycles and amenorrhoea. The analysis of the hormonal profiles under treatment, as compared to the control cycles, indicate an impact of hyperprolactinaemia both preferentially at the hypothalamic (alteration of the secretion or endogenous LRH) and accessorily at the ovarian (lack of progesterone secretion by the near mature follicle) levels.

Effect of cyproheptadine on thyrotrophin and prolactin secretion in normal man

In order to investigate the effect of cyproheptadine, a compound with antiserotoninergic activity, on the secretion of thyrotrophin (TSH) and prolactin (PRL), the nocturnal secretory patterns of these hormones have been studied in 4 normal men in the basal state and after an oral treatment with the drug. In addition, the TSH and PRL responses to TRH of 6 women were compared in the basal conditions and after cyproheptadine treatment. The TSH nocturnal secretion was slightly modified by drug treatment. The response to TRH as well as the basal levels were comparable in the treated and non-treated subjects. In contrast, the PRL secretion measured through the nocturnal investigation was significantly inhibited by cyproheptadine administration as were the PRL basal levels in the TRH test. The PRL response to TRH was comparable in both situations.

Tiapride-induced chronic hyperprolactinaemia: interference with the human menstrual cycle

Four regularly menstruating volunteers were submitted to an oral treatment, for 3 consecutive cycles and starting on the first day of a cycle, with tiapride at daily doses ranging from 1 x 100 mg to 2 x 100 mg. The first and the last cycle under treatment, as well as a prior control cycle, were thoroughly studied by means of daily measurements of blood concentrations of LH, FSH, prolactin (PRL), oestradiol and progesterone. Tiapride, a benzamide derivative with dopaminergic blocking activity at the level of the lactotrophes, increased mean PRL secretion in each subject but a permanent hyperprolactinaemia above 700 uU/ml was attained only in one subject. Despite these widely fluctuating PRL levels in most subjects, the resulting overall hyperprolactinaemia induced in all cases a progressive deterioration of the function of the corpus luteum: 5 cycles showed luteal phases reduced by 2--5 days, one cycle was characterized by some slight luteinisation but questionable ovulation and the 2 remaining cycles were anovulatory. The interruption of drug intake one week after the onset of menses led thereafter to a cycle with a likely inadequate luteal phase but of normal length. It is concluded that even a non-permanent hyperprolactinaemia can impair the normal function of the hypothalamo-pituitary-ovarian axis, as well as exhibit some effects in a cycle consecutive to the normalization of PRL. With the exception of the impaired luteal progesterone secretion, the pooled hormonal data from the short luteal phase cycles under tiapride-induced hyperprolactinaemia exhibit very little significant differences, as compared to the corresponding values in the control cycles. Some delay in the onset of follicular maturation, however, should be assumed since the follicular phase had been lengthened by 1 to 31 days in 5 of the 6 cycles with luteinisation during treatment. The present results are compatible with a double impact -- both at the ovarian and the hypothalamo-pituitary levels -- of hyperprolactinaemia in its mechanisms of impaired function of the hypothalamo-pituitary ovarian axis.

Prolactin response to TRH in diabetic ketoacidosis

The prolactin response to 200 microgram thyrotropin-releasing hormone (TRH) IV was studied in seven patients with diabetic ketoacidosis, at the start of the treatment, and again, in the same patients, five days after recovery, when the diabetes was well controlled. Normal basal prolactin concentrations and prolactin responses to TRH were found in both situations. There was no correlation between basal prolactin concentrations, or magnitude of prolactin responses to TRH, and any of the metabolic variables measured. These findings do no suggest a role for prolactin in the development of diabetic ketoacidosis.

Unaltered basal prolactin secretion during short-term oestriol treatment in post-menopausal women

Six post-menopausal women were submitted, at 1 month interval, to oral oestriol treatment for 14-day periods at daily doses of 2 and 6 mg. Blood samples were collected for LH, FSH and PRL measurements (by RIA) every other day during treatments as well as during a 14-day control period. Through the effect on LH levels was questionable, oestriol resulted in a clear and significant, although moderate, gradual decrease of mean FSH levels. At the doses used, which are effective in thetreatment of menopausal symptoms, but are devoid of any proliferative effect upon the endometrium, oestriol failed to induce any stimulatory effect on basal PRL secretion in these post-menopausal women.

Alteration of feedback mechanism of estrogen on gonadotropin by sulpiride-induced hyperprolactinemia

Four normally cycling women received an iv injection of 20 mg Premarin (conjugated estrogens equivalent to 20 mg estrone sulfate) on the seventh day of two consecutive cycles; the second experiment was performed under sulpiride-induced hyperprolactinemia (mean PRL level = 906 microU MRC standard 71/222 per ml; significantly 7.8 times greater than mean control level of 115 microU MRC standard 71/222 per ml, P less than 0.001). In comparison to the control experiment, sulpiride-induced hyperprolactinemia prevented the occurrence of any gonadotropin peak within the 84 h of estrogen administration; the negative feedback effect of estrogen on gonadotropin secretion was maintained and was even potentiated. These alterations of feedback mechanisms of estrogen were considered to be related to hyperprolactinemia itself rather than to sulpiride. Five other normally cycling women received iv injections of 100 microgram LRH on the 22nd day of a cycle under sulpiride-induced hyperprolactinemia since the onset of menstruation. Their mean LH response was somewhat greater (although not statistically significant) and their mean FSH response was considerably greater (P less than 0.001 at all times) than those of a control group of 10 women tested in their luteal phase. The results of these LRH tests under sulpiride-induced hyperprolactinemia give some support to the concept that hyperprolactinemia interferes at the hypothalamic or higher level with cyclic release of indogenous LRH.

Acute endocrine profile of sulpiride in the human

Normal men and normally menstruating women received i.m. injections of 0.1 to 4.0 mg/kg sulpiride. This psychotropic drug induced a very rapid (already significant after 5 minutes) and sustained (still significant after 7 hours) elevation of prolactin (PRL) concentrations in all subjects with no consistent modification of LH and FSH. After injection of 4.0 mg/kg, there was similarly no modification of mean TSH concentrations in the women tested in the luteal phase, as well as of mean GH levels in men. Sulpiride prevented the inhibitory effect on PRL levels of 500 mg levodopa, administered orally simultaneously; levodopa administered 2 hours prior to sulpiride failed to counteract the PRL-stimulatory effect of sulpiride. Under chronic sulpiride-induced hyperprolactinaemia, levodopa exhibited however a very slight inhibitory effect on PRL concentrations. These data are in agreement with the hypothesis that sulpiride acts mainly at the pituitary level by blocking dopamine receptors of the lactotropes and support the concept that the menstrual cycle perturbations observed under chronic sulpiride administration result from hyperprolactinaemia itself or from a mechanism quite similar to that by which sulpiride induces hyperprolactinaemia.

Effects of two substituted benzamides, tiapride and sultopride, on gonadotrophins and prolactin

The acute effects in the human of tiapride and sultopride, two new substituted benzamides related to sulpiride, were studied with respect to gonadotrophins (LH and FSH) and prolactin (PRL) secretion. Two different groups of 3 normal men and 3 normally cycling women received im injections of either 100 mg sultopride or 200 mg tiapride. Five min after the injection of either psychotropic drug, the serum PRL concentration increased significantly (P < 0.001 by variance analysis) and reached maximal values by 30 min and remained elevated for at least 6 h; women tended to release more prolactin than men.

Although tiapride (500 nm) had no direct effect on the in vitro synthesis or secretion of prolactin, the drug blocked the inhibitory action of dopamine (500 nm) on the secretion of prolactin. Rats bearing a transplantable prolactin-secreting pituitary tumour MtTW15 have extremely high serum prolactin and through an autofeed mechanism the host's pituitary gland is suppressed. The in vitro synthesis and secretion of prolactin by these rats' pituitary gland is decreased. The in vivo administration of tiapride to these tumour-bearing rats restored the in vitro secretion of prolactin to control values. The in vitro data support the concept that tiapride increases prolactin secretion directly at the pituitary level by blocking the inhibitory activity of dopamine; an additional effect at a higher level can not, however, be ruled out.

In vivo in the human, no significant modification of LH and FSH occurred after either drug, suggesting that the menstrual cycle disturbances observed during chronic treatment with tiapride might be related to hyperprolactinaemia or be the result of a mechanism similar to that inducing hyperprolactinaemia.

Simultaneous study of cortisol, growth hormone and prolactin nyctohemeral variations in normal and obese subjects. Influence of prolonged fasting in obesity

Hourly integrated concentrations (IC) of growth hormone (GH), prolactin (PRL) and cortisol were determined by a continuous sampling procedure in six obese women, before and at the end of a 12 day fast, and in eight normal controls under basal conditions. Hormonal 24 h IC and nyctohemeral variations were calculated from these data. Nyctohemeral rhythms were investigated by the periodogram method. A significant increase over basal values of 24 h IC of PRL, GH and cortisol was observed at the end of the fasting period. Nyctohemeral variations--but not nyctohemeral rhythm--of IC-GH were found in normal subjects. They were abolished in obese patients under basal conditions but restored during fasting. The circadian rhythm of cortisol was not altered in obesity. A shift of the normal nyctohemeral rhythm of PRL was observed in obese patients, but the normal pattern was restored during fasting.

Thyrotrophin, prolactin and growth hormone responses to TRH in barbiturate coma and in depression

The effects of 200 microgram thyrotrophin-releasing hormone (TRH) i.v. on thyrotrophin (TSH), prolactin (PRL), growth hormone (GH) and triiodothyronine (T3) were studied in eight patients with barbiturate coma due to attempted suicide, in the same patients after recovery, in eight depressive patients and in eight normal controls. The patients with barbiturate coma presented normal basal TSH and PRL, elevated basal GH and normal PRL but blunted TSH responses to TRH; their GH concentrations varied widely without consistent relation to TRH administration. The same patients after recovery from coma presented normal TSH and PRL, slightly elevated basal GH, and normal PRL but blunted TSH responses to TRH; in four of these patients, a clear-cut rise in GH (i.e. more than 10 ng/ml) occurred after TRH administration. The depressive patients presented normal basal TSH and PRL, slightly elevated basal GH, and normal PRL but blunted TSH responses to TRH; in four of these patients, a moderated rise in GH (less than 10 ng/ml) occurred after TRH administration. The increment in T3 concentrations 120 min after TRH was found reduced in the comatose patients only. Basal cortisol was measured in all the subjects and found elevated in the comatose patients only. It is concluded that the abnormal TSH and GH responses to TRH observed in patients with barbiturate coma are more likely related to depressive illness than to an effect of barbiturates at the pituitary level. Barbiturates might affect thyroid secretion.

Prolactin secretion and synthesis in short- and long-term organ culture of pituitary tumours from acromegalic patients

To evaluate the in vitro PRL secretion and synthesis by pituitary tumours from acromegalic patients, six somatotrophic and two somatomammotrophic adenomas were collected after surgery and divided into fragments 1 mm3 in size. Fragments were cultured in short-term (1–2–3–4 h) and in long-term organ culture (7 and 14 days). Media were collected for GH and PRL radioimmunoassay and fragments studied by electron microscopy. In two experiments, fragments from a somatotrophic adenoma and from a somatomammotrophic adenoma were cultured for 1 to 4 h and 9 to 16 days with [3H]leucine. In addition the effect of somatostatin (2.5 nmole/ml) upon PRL secretion was studied in short-term incubation. In long-term organ culture PRL concentrations increased in 8 out of 16 media samples collected from the five tumours and one normal pituitary cultured for 14 days, while GH concentrations decreased during the same time in all the experiments. The [3H]PRL/[3H] proteins ratios were 9.7 % on the 9th day of culture and 20.8 % on the 16th day while for GH, the ratios were respectively 40 and 34.7 %. Ultrastructural studies showed, besides GH cells, the presence of PRL secreting cells in the different tumours, after 7 or 14 days of culture. In short-term incubation, PRL concentrations in media increased in most of the samples collected from the three tumours incubated for 1 to 4 h and the [3H]PRL/[3H]proteins ratio was 10.6 % after 1 h and 21 % after 2 h of incubation. A decrease of PRL content (< 50 %) was observed in two of the three tumours incubated with somatostatin.

These data indicate that 1) somatotrophic adenomas, as well as somatomammotrophic ones, are able to secrete and synthesize PRL in vitro, 2) PRL synthesis from these adenomas increases during culture, as from normal pituitary, presumably because of the release of PRL-secreting cells from the PRL inhibitory hypothalamic control (PIF), 3) somatostatin may reduce PRL release in vitro from somatotrophic adenomas as reported in some cases in vivo.

[The sella turcica and pituitary function in congenital hypothyroidism due to thyroid ectopia or hypogenesis (author's transl)]

Nine patients suffering from hypothyroidism due to thyroid ectopia or hypogenesis, with a large sella turcica, were examined at adolescence or during adult life. TSH, prolactin and growth hormone function were studied. Basal plasma TSH, evaluated in 5 cases, was raised and responded explosively to stimulation with TRH. The administration of L-dopa was not associated with any notable changes in TSH. In one case, the chronic administration of l-T3 resulted in a fall followed by normalisation in plasma TSH levels. Basal plasma prolactin, explored in 6 patients, was high in 4 females and normal in 2 males. TRH stimulation resulted in a marked increased in prolactin in the female cases and a moderate increase in the male cases. L-dopa caused a fall only in high prolactin values. Stimulation of GH by argininehydrochloride, insulin hypoglycaemia and L-dopa gave variable responses. In one case, substitutive thyroid hormone therapy restored the GH response to L-dopa and arginine hydrochloride to normal. Paradoxically, GH increase following stimulation with TRH.