Oral contraceptives and endometrial cancer: do other risk factors modify the association?

The joint effect of use of combination-type oral contraceptives and other exposure factors on risk of endometrial cancer was examined in data from a multicenter case-control study conducted in 5 areas of the United States. Cases were 405 women with histologically confirmed invasive epithelial endometrial cancer first treated at one of 7 participating hospitals. A total of 297 population-based controls of similar age, race, and geographic area were selected as a comparison group. Information on exposure factors was derived from in-person interviews. Combination-type oral contraceptive (COC) use was associated with a significant reduction in risk of endometrial cancer, with an adjusted odds ratio (OR) of 0.4 (95% confidence interval 0.3 to 0.7) for ever compared to never use. Long-term (> or = 10 years) users experienced a markedly lower risk (OR = 0.2). Women who discontinued COC use > or = 20 years earlier remained at reduced risk (OR = 0.7) compared with non-users. The negative association with COC use was apparent regardless of the presence or level of several other risk factors for endometrial cancer, including age, menopausal status, parity, obesity, ever-use of menopausal estrogens, smoking history, or history of infertility. The magnitude of the negative association observed in COC users, however, was considerably diminished in women with no full-term births and in women who subsequently used replacement estrogens for 3 or more years. These results provide new evidence that the protective effect of COC use lasts for 20 or more years after use is discontinued, and highlight several sub-groups of users in whom the level of protection is attenuated by the presence of other risk factors for this disease.

Pilot trial of a gonadotropin hormone agonist with replacement hormones as a prototype contraceptive to prevent breast cancer

Combination oral contraceptive (COC) users have reduced risks of ovarian and endometrial cancer, but COCs have not reduced breast cancer risk. We have previously argued that a hormonal contraceptive with substantially lower doses of sex-steroids should reduce breast cancer risk by decreasing the breast epithelial cell proliferation below usual premenopausal levels. We report here the preliminary results of a pilot trial with such a prototype contraceptive consisting of an agonist of gonadotropin releasing hormone (GnRHA) administered with low doses of an oral estrogen (0.625 mg of conjugated estrogen, CE, for 6 days every week) and intermittent oral progestogen (10 mg of medroxyprogesterone acetate, MPA, for 13 days every 4 months). Eighteen subjects at five-fold or greater increased breast cancer risk were entered and randomized -12 to the contraceptive arm and 6 to a control arm. The principal endpoints included tolerance of the regimen, vaginal bleeding patterns, and the regimen's effect on the endometrium, bone metabolism, and lipids. A symptom questionnaire was used to assess tolerance; the contraceptive subjects had fewer symptoms following initiation of the regimen. This results from the elimination of symptoms associated with the luteal phase of the menstrual cycle, commonly referred to collectively as premenstrual syndrome, PMS. The few occurrences of hot flushes or vaginal dryness that did occur were eliminated by small increases in estrogen dose (0.9 mg CE). Scheduled vaginal bleeding occurred associated with most periods of progestogen administration. Unscheduled bleeding or spotting was infrequent and decreased with time on the regimen. A beneficial rise in high-density lipoprotein cholesterol was evident in the contraceptive subjects. Despite the use of an estrogen dose which is known to prevent loss of bone mineral density in normal postmenopausal women, an annualized loss of 1.9% was seen in contraceptive subjects. It is hypothesized that this is secondary to inhibition of ovarian androgen production by the GnRHA, which may additionally account for changes in libido occasionally reported with GnRHA. The study continues with the addition of a small dose of androgen to replace that lost by the action of the GnRHA.

Platelet adhesion at low shear rate: study of a normal population

The use of oral contraceptives (OCs) has been associated with vascular complications. The mechanism(s) by which OCs predispose to thrombotic events remains unclear. Recent studies have demonstrated that postmenopausal (PM) women who take estrogen replacement therapy (ERT) have a decreased incidence of myocardial infarction compared to those who do not take ERT. This study was undertaken to determine if healthy individuals have differences in platelet adhesion depending on hormonal status. Men, PM women taking ERT, PM women not taking ERT, OC users, and premenopausal women not taking any medications were studied. Platelet studies were performed in a Hele-Shaw flow chamber at a low shear rate using platelet-rich plasma. The platelet adhesion process to subendothelial components: fibronectin, collagen I and collagen III was recorded using a 35 mm camera mounted on an inverted microscope. Photographs were taken at 30 second intervals for a total of 12 minutes and analyzed using a modified computer program which provided a numerical account of platelet adhesion. OC users had significantly higher platelet adherence to fibronectin, collagen I and collagen III compared to all other groups. All other study groups had similar platelet adhesion independent of hormonal status. These findings suggest that OCs cause increased platelet adhesion in some individuals and this may be one of the mechanisms by which OCs contribute to thrombotic events.

Emergency contraception

The term 'emergency contraception', as employed in this paper, refers to methods that are used as emergency procedures to prevent pregnancy following unprotected intercourse. Alternative, less appropriate, terms are postcoital and 'morning-after' contraception. References to postcoital preparations can be found as far back as 1500 BC in Egyptian papyri, but it was not until fairly recently that contraceptive research has been able to at least partially fulfill that need. The development of hormonal methods of emergency contraception goes back to the 1960s when the first human trials of postcoitally administered high-dose oestrogens were undertaken. Combined oestrogen- progestogen combination therapy (the so-called Yuzpe regimen) was introduced in the early 1970s, while the postcoital insertion of an intrauterine contraceptive device (IUD) for emergency contraception was first reported in 1976. Other compounds that have been tested more recently include levonorgestrel, the antiprogestogen mifepristone, and danazol. Although there is some debate about the magnitude of the protective effect, few people question the important role that emergency contraception can play in preventing unwanted pregnancy and hence maternal mortality and morbidity resulting from unsafe abortion. Given that the most often used methods of emergency contraception, namely the Yuzpe regimen and postcoital insertion of an IUD, rely on technology that has been available for some 30 years, family planning programmes that claim to be concerned with improving women's reproductive health, cannot really be excused if they do not provide emergency contraception as part of their routine services.

Sex steroid hormones and breast cancer: is there a link with oral contraceptives and hormone replacement therapy?

OBJECTIVE

To determine whether use of sex steroid hormones for contraception and hormone replacement therapy alters the risk of breast cancer, and whether the risk varies with their composition, duration of use, the period of a woman's life when the hormones are used, and after successful treatment for breast cancer.

DATA SOURCES

The results of important epidemiological reports, readily available from the English literature and published since 1981, were evaluated, using reports of basic scientific work as a background to the problem.

STUDY SELECTION

An attempt was made to obtain most of the relevant reports. Twenty case-control and seven cohort studies were available on the oral contraceptive pill (OCP) and eleven case-control and five cohort studies on hormone replacement therapy (HRT).

DATA EXTRACTION

The relative risk estimates for breast cancer (and their 95% confidence intervals) determined by each report were tabulated according to the specific conditions of analysis, for example users under age 25, duration of use. Results by meta-analysis from previous studies were also used to determine risk. A significant positive association was present when the risk estimate exceeded 1.0 and the 95% confidence interval did not cross 1.0.

DATA SYNTHESIS

Among OCP users, the vast majority of reports showed no significant risk of breast cancer--overall, longest duration of use, and use before first full-term pregnancy. However, a positive association between breast cancer and users under age 25 was found in three of eight reports. Similarly, the majority of reports showed no significant risk of breast cancer among HRT users, overall as well as in relation to duration of use and interval since first use. There was no increased risk with additional progestogen; it may be protective. An improved prognosis was found in users who developed breast cancer. On the limited data, use of hormones for postmenopausal symptoms did not appear to be harmful to women who had been successfully treated for breast cancer.

CONCLUSIONS

The review revealed good evidence that use of sex steroid hormones had no significant effect on the risk of breast cancer, whether given for contraception or hormone replacement. There was some concern about increased risk with prolonged use of the OCP, especially in younger women. At present, use of these hormones is a matter of informed choice, with individual considerations of the risk-benefit ratio.

Estrogen replacement therapy and the risk of breast cancer: results from the case-control surveillance study

To examine the relation of noncontraceptive estrogen use to the risk of breast cancer among postmenopausal women, the authors conducted a case-control study: 1,686 cases were compared with 2,077 hospital control subjects, of whom 1,120 had non-gynecologic cancers and 957 had nonmalignant (also non-gynecologic) conditions. Data were obtained from 1980 to 1986, by interview of subjects in hospitals in the United States and Canada. The relative risk estimate for any use of replacement estrogens unopposed by progestogens was 1.2 (95% confidence interval (Cl) 1.0-1.4), after adjustment for age and type of menopause; when all known risk factors for breast cancer were taken into account in a multivariate analysis, the estimate was similar. For use of at least 15 years duration, the estimate was 0.9 (95% Cl 0.5-1.9). Most of the unopposed use was of conjugated estrogens: overall, the relative risk (95% Cl) was 1.3 (1.0-1.6); for durations of 15 or more years, it was 0.9 (0.4-1.9); for use of 5 years followed by a latent interval of 15 or more years, it was 1.3 (0.7-2.4); and for current use it was 1.1 (0.7-1.6). There was no evidence of increased breast cancer risk when the conjugated estrogen users were divided according to dose. There was little use of estrogens opposed by progestogens; the relative risk estimate was 1.7 (95% Cl 0.9-3.3). The results of this large study provide no evidence that the use of unopposed conjugated estrogens increases the risk of breast cancer, even after long durations of use or long latent intervals, but the possibility of a modest increase (less than a doubling) could not be excluded. There were insufficient data to evaluate the effects of nonconjugated estrogens and of combined estrogen and progestogen therapy.

Oral contraceptives and neoplasia of the uterine corpus

Effects of oral contraception on neoplasia of the uterine corpus are reviewed on the basis of epidemiologic studies reported to date. A duration-related protective effect against endometrial cancer occurs from use of combined oral contraceptives, those in which each active pill contains both estrogen and progestogen. The risk before age 60 years is reduced by about 38% with two years of use; use of combined OCs for 4, 8, and 12 years, respectively, confers an estimated 51%, 64%, and 70% reduction in endometrial cancer risk. The protective effect appears not to be diminished by discontinued use, even 15 or more years after stopping. Whether protection continues throughout the entire postmenopausal period, even in the presence of long-term hormone replacement therapy, remains to be seen. Use of combined OCs may protect against uterine leiomyomas ("fibroids"), but the evidence is not conclusive. The few findings about effects of oral contraception on the risk of adenomatous hyperplasia are of uncertain validity. Only one study, with few patients, has considered oral contraception in relation to uterine sarcomas.

Exogenous sex hormones and the risk of rheumatoid arthritis

The use of exogenous sex hormones in relation to the risk of rheumatoid arthritis (RA) was examined in a cohort of married nurses 30-55 years of age followed since 1976 in the Nurses' Health Study. Baseline information on the use of oral contraceptives, replacement estrogens, and other potential risk factors was obtained in 1976 and updated every 2 years. During 8 years of followup, 217 incident cases of polyarthritis were ascertained (115 RA and 102 undifferentiated polyarthritis). When compared with women who had never used oral contraceptives, the age-adjusted relative risk was 1.0 (95% confidence interval [CI] 0.7-1.3) for past users; however, too few women were currently using oral contraceptives for a reliable estimate of its effect. Among postmenopausal women, 123 cases of RA were reported. Compared with postmenopausal women who never used replacement estrogens, current users had an age-adjusted relative risk of 1.3 (95% CI 0.9-2.0), past users had an age-adjusted relative risk of 0.7 (95% CI 0.5-1.2), and ever users had a relative risk of 1.0 (95% CI 0.7-1.4). These data do not show a protective effect of past use of oral contraceptives or replacement estrogens for RA; however, a modest protective effect of current oral contraceptive use cannot be excluded.

Clinical aspects of the relationship between oral contraceptives and abnormalities of the hemostatic system: relation to the development of cardiovascular disease

Epidemiologic evidence has established that oral contraceptives increase the risk of both arterial and venous thromboembolic disease. This is dose related in the case of the estrogen component for both arterial and venous events and in the case of progestogens for arterial events. It is probable that the increased rate of thromboembolic events caused by estrogen is related to hypercoagulability. Plasma levels of several clotting factors have been shown to be elevated in oral contraceptive users, and this increase is graduated according to the dose of estrogen. In pregnancy, factor VIIc is increased after cold activation of plasma at 4 degrees C overnight. Likewise, in users of oral contraceptives, both factors VIIc and XIIc are increased, which suggests a direct effect of factor XIIc on the extrinsic system. In men, the risk of ischemic heart disease is strongly and independently related to factor VIIc and fibrinogen levels; thus it is possible that in women taking oral contraceptives, the mechanism of risk is similarly mediated. There is a good case for factor VIIc as the index of flux in the coagulation system and hence of a hypercoagulable state, and indeed it may directly contribute to the generation of thrombin. This article examines the available evidence on clotting factor activity in the risk of cardiovascular disease in oral contraceptive users.

Oncogenic transformation by human papillomavirus type 16 deoxyribonucleic acid in the presence of progesterone or progestins from oral contraceptives

Compelling evidence supports a role of certain types of human papillomaviruses as the cause of cervical cancer. In addition to human papillomaviruses, other agents, such as hormones, have been implicated as cofactors in this type of neoplasia. In this study we provide evidence for oncogenic transformation of primary baby rat kidney cells by human papillomavirus type 16 deoxyribonucleic acid plus ras oncogene in the presence of progesterone but not estrogen. Integrated and intact human papillomavirus type 16 deoxyribonucleic acid is present and expressed in all the five progesterone-transformed colonies that we examined. Moreover, all these cell lines are capable of anchorage-independent growth and induce tumors in syngeneic animals. We also observed oncogenic transformation with human papillomavirus type 16 deoxyribonucleic acid plus ras in the presence of ethanol-soluble extracts from two brands of commonly used oral contraceptive tablets. No transformation is achieved in the presence of ethanol-soluble extracts from the inert tablets, provided in packages of each brand of oral contraceptive. These results may have implications for a papillomavirus-hormone link to cervical neoplasia.

Effects of marine fish oil (omega-3 fatty acids) on lipid profiles in women

1. Cycling women both taking or not taking oral contraceptives and menopausal women on replacement estrogen ingested 3 g daily of marine fish oil for 30 days. 2. Triglycerides decreased in the contraceptive users, cholesterol and LDL increased in the non-contraceptive user; while LDL decreased in the menopausal women. 3. After 14 days removal of the fish oil, lipid profiles generally returned to a pattern generally thought to be harmful. 4. Fish oil appears to alter lipids favorably in women receiving exogenous estrogens compared to natural circulating estrogen.

The effects of oestrogen administration on the plasma free protein S and C4b-binding protein

This study was undertaken to evaluate the effects of oestrogen administration (low dose as an oral contraceptive or higher dose as a hormone replacement therapy) on the levels of plasma free protein S and C4b-binding protein. The participants were 59 women aged 18-49 years, divided into 2 groups: A and B. Group A was composed of 22 post-menopausal women on a hormonal replacement therapy programme (HRT) consisting of 2 mgs daily oestradiol valerate for 21 days. Group B was divided into subgroup B1: 18 women who had been on oral contraceptive for at least one year and subgroup B2 (control): 17 women who were not pregnant and not taking any oral contraceptive. In this study were also included two young women who both suffered from severe thromboembolic disease a few months after initiation of oral contraceptive. The first was 25 years old, with congenital moderately decreased prekallikrein (activity and antigen 40% and 45% respectively) and the second was a 21 year-old woman with congenital moderately decreased plasminogen activity and antigen 45%). In both cases, family members with similarly reduced levels of prekallikrein (PK) and plasminogen (PLG) respectively were free from any thromboembolic disease and had normal protein S levels. In Group A, 22 women at the end of the first cycle of treatment, had lower levels of free protein S (p less than 0.001) than before the initiation of HRT. In subgroup B1, the levels of free protein S were found to be significantly lower than in subgroup B2 (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Estrogens and the hypothalamo-pituitary-adrenal axis in man: evidence for normal feedback regulation by corticosteroids

Estrogen treatment and pregnancy are associated with higher than normal plasma free (nonprotein-bound) cortisol levels. In spite of this, clinical manifestations of steroid excess are not seen in these conditions. To explain this seeming discrepancy, it has been postulated that estrogens may induce tissue resistance to the actions of cortisol, and that one aspect of this resistance may be a higher set-point for ACTH suppression by corticosteroids. This possibility was studied in seven normal women. Plasma total and free cortisol levels as well as urinary cortisol excretion were measured during a control period and during treatment with ethinyl estradiol (100 micrograms/day). During both periods, graded doses of dexamethasone (0.2-mg increments; 0-1.4 mg/day) were administered. Estrogen treatment resulted in elevated plasma total and free cortisol levels, but urinary cortisol excretion was not affected. Dexamethasone administration resulted in a dose-dependent reduction of plasma total and free cortisol as well as urinary cortisol. The dose-response curve for suppression by dexamethasone of urinary cortisol during estrogen treatment was indistinguishable from that during the control period. The dose-response curve for plasma free cortisol suppression suggested that during estrogen treatment, slightly more dexamethasone was required to suppress free cortisol. However, this effect was small. In view of the overall data, we conclude that 1) estrogen does not increase integrated free cortisol prevailing in vivo; 2) estrogen does not significantly alter the hypothalamic or pituitary set-point for ACTH suppression by corticosteroid; 3) the elevation of plasma free cortisol is relatively minor and possibly an in vitro phenomenon; and 4) the present findings are compatible with the absence of clinical hypercorticism in hyperestrogenized states.

Effect of estrogen/progestin potency on lipid/lipoprotein cholesterol

We studied 374 women taking oral contraceptives, 284 women taking estrogen preparations after menopause, and 1086 women taking no hormones, to determine the relation of plasma lipids and lipoprotein cholesterol concentrations to various types of estrogen/progestin formulations. Premenopausal women, using oral contraceptives containing a relatively low dose of estrogen combined with a medium or high dose of progestin (Norlestrin, Ovral, or Demulen) had a 24 per cent higher median concentration of low-density-lipoprotein cholesterol than did those not using hormones (P less than 0.05). Women using oral contraceptives that are high in estrogen and low in progestin (Enovid or Oracon) had significantly higher concentrations of high-density-lipoprotein cholesterol than did nonusers; those using Ovral, a low-estrogen and high-progestin formulation, had significantly lower levels of high-density-lipoprotein cholesterol. In postmenopausal women the use of estrogen was associated with concentrations of low-density-lipoprotein cholesterol that were 11 to 19 per cent below the levels in postmenopausal women who did not use hormones. The effects of estrogen-progestin balance on low-density and high-density lipoproteins may underlie the increased incidence of stroke and myocardial infarction in women of childbearing age who take oral contraceptives.

Estrogen replacement therapy: indications and complications

Estrogen replacement therapy is one of the most controversial issues in the field of reproductive medicine. Indications for its use include hot flashes, vaginal atrophy, and risk of osteoporosis. Risk of heart disease may also be an indication but this use has not been firmly established. The role of estrogen replacement therapy in aging changes of skin needs clarification. Complications of therapy include endometrial cancer, breast cancer, hypertension, hyperlipidemia, and gallbladder disease. The last three complications presumably result from hepatic actions of estrogen replacement therapy.

Evaluation of Delestrogen and Parlodel as a luteolytic agent in humans

Ten women ages 22 to 39 years were treated with a single injection of Delestrogen on day 19 of the menstrual cycle and increasing doses of Parlodel on days 19 to 23. This treatment resulted in a shortening of the luteal phase and a decrease in the production of progesterone and had no effect on serum luteinizing hormone (LH), follicle-stimulating hormone (FSH), or prolactin levels. Side effects reported with this therapy included lethargy, dizziness, nausea, vomiting, hot flashes, depression, and nasal congestion. These preliminary clinical data suggest a combination of estrogen and bromocriptine regimen is luteolytic and may be useful as an interceptive abortifacient preparation in the human being.

Effects induced by two different estrogens on serum individual phospholipids and serum lecithin fatty acid composition

Eleven oophorectomized women (mean age 34.5 +/- 5.9) received two treatment cycles, one of the 17-C-alkylated ethinyl estradiol 20 microgram per day, and the second of the non-alkylated estrogen, estradiol valerate 2 mg per day for six weeks in separate periods preceded by six weeks without hormonal replacement therapy. Blood samples were drawn before and after six weeks on each estrogen. The samples were assayed for individual phospholipids i.e. cephalin, lecithin, lysolecithin and sphingomyelin after separation of these lipids by thin layer chromatography. The relative fatty acid composition of serum and high density lipoprotein lecithin and serum cholesterol ester was determined by gas liquid chromatography. Both estrogens reversed the symptoms of estrogen deficiency and had similar effects on serum individual phospholipids i.e. causing an increase in lecithin concomitant with a decrease in lysolecithin. It is suggested that this lecithin-lysolecithin shift could depend on an inhibition of the hepatic lipase and its phospholipase A1-activity. Both estrogens increased serum lecithin arachidonic acid without causing any change in linoleic acid (the major essential fatty acid), which indicates that this increase in arachidonic acid could be an estrogenic effect independent of dietary factors. Ethinyl estradiol caused an increase in palmitic and a decrease in stearic acid in the 1-position of serum lecithin while estradiol valerate did not influence these fatty acids at all. This palmitic-stearic acid shift induced by ethinyl estradiol is interpreted as a non-hormonal "drug-effect" linked to the liver toxicity of 17-C-alkylated steroids in spite of the lack of influence on routine liver function tests.

Effects of long-term estrogen replacement therapy. II. Neoplasia

Two groups of hypoestrogenic women are analyzed by retrospective comparison. Patients were observed by a single group of physicians for at least five years -- 301 patients treated with replacement estrogen and 309 untreated patients. Of each group, 207 women had uteri in situ. Incidence figures for neoplasia (gynecologic, breast, and all sites) were compared between the two groups and with the Third National Cancer Survey, yielding a risk ratio for the development of adenocarcinoma of the endometrium among estrogen-treated women of 3.8 and 9.3, respectively. There was no increase among any other malignancies. The addition of synthetic progestin to estrogen therapy provided significant protection against the likelihood of developing endometrial cancer and did not reduce previously reported metabolic benefits of estrogen treatment. Data pertaining to estrogen use and details of the patients with endometrial carcinoma are presented.

Endometrial cancer and estrogen use. Report of a large case-control study

Our case-control study of the relation between estrogen use and endometrial cancer involved 451 cases and 888 controls. The overall risk of endometrial carcinoma was sixfold for estrogen users as compared with nonusers; long-term users (greater than five years) had a 15-fold risk. Excess risk was present for both diethylstilberstrol and conjugated estrogens. The risk associated with cyclic use was as great as that for continuous use. Increased risk was associated with estrogen use for all histologic grades of the tumor. The risk of advanced-stage carcinoma was fourfold for estrogen users, but rhe confidence interval was wide, and this question requires further study. Finally, this investigation contradicts the speculation that the association between this cancer and estrogen use can be explained by swifter diagnosis for estrogen users, misclassification of estrogen-related hyperplasia or treatment of early symptoms of the tumor with estrogen.

Comparison of serum oestrogen concentrations in post-menopausal women taking oestrone sulphate and oestradiol

Mean serum concentrations of oestradiol-17beta, oestrone, and oestrone sulphate in postmenopausal women were the same when measured up to six hours after treatment with either piperazine oestrone sulphate 1.5 mg or oestradiol valerate 2 mg. Maximum concentrations of oestradiol were less than those of oestrone, but oestrone sulphate reached concentrations about 30 times higher than those of oestrone. The rapid conversion of oestradiol valerate to oestrone and oestrone sulphate does not support the suggestion that in menopausal women oestradiol is less likely to be associated with a risk of endometrial carcinoma than oestrone sulphate, since the two preparations appear to become identical after ingestion.

Pharmacologic modification of the time course of ovum transport in guinea pigs

Various agents were examined for their effects on ovum transport in the guinea pig. Estrogen significantly accelerated ovum transport in this species. The experiments further demonstrated that estrogen did not act by inducing prostaglandin synthesis, nor by altering plasma progesterone levels. The estrogen-induced acceleration was significantly antagonized by tamoxifen, an antiestrogen that acts by interfering with estrogen receptor synthesis. Cycloheximide also antagonized the effects of estrogen on ovum transport. These data suggest that the modification of ovum transport by estrogen is due to the entrance of estrogen into the nuclei of target cells, and subsequent protein synthesis. Although we assume that this action occurs at the level of the oviduct, our experiments do not prove this assumption.

Effect of oestrogen on the sleep, mood, and anxiety of menopausal women

A double-blind controlled study of the effect of piperazine oestrone sulphate on sleep, depression, anxiety, and hot flushes was performed in 34 perimenopausal women. Half of the patients were given six weeks' placebo followed by eight weeks' oestrogen, and half remained on placebo throughout. Sleep was recorded electrophysiologically every week, and mood and anxiety were rated daily by means of visual analogue scales. Hot flushes were counted daily. Observer rating scales of anxiety and depression were complete at intervals. During the first month of active treatment the amount of intervening wakefulness in the first six hours of sleep decreased significantly more in the oestrone group than in those on placebo. Between the baseline period and the second treatment month the oestrone group showed a significantly greater decrease in the total amount of intervening wakefulness and in the frequency of awakenings. Their total amount of rapid eye movement sleep increased. Mood and anxiety improved and the number of hot flushes decreased to a similar degree in both groups. Although oestrogen did reduce the number of episodes of wakefulness in perimenopausal women complaining of insomnia, its effects on their psychological symptoms were little different to those of placebo.

Metabolic and hormonal effects of post-menopausal oestrogen replacement treatment. II. Plasma lipids

The influence of daily oral cyclical oestrogen treatment on the plasma lipid and lipoprotein concentrations was studied in post-menopausal females. Ethinyloestradiol (EOe) 0.05 mg was administered to 20 subjects and oestradiol valerianate (OeV) 2 mg to 19 subjects. The women were investigated twice before medication and 1, 3 and 6 months after the start of treatment.

During EOe therapy the total cholesterol (TC) decreased 10 per cent, high density lipoprotein (HDL)-TC and HDL-phospholipid (PL) increased 30–40 per cent, approximated low density lipoprotein (LDL)-TC decreased 30 per cent and triglyceride (TG) increased 30–40 per cent. In the OeV treated group the HDL-TC and the HDL-PL concentrations showed a mean increase of 10–15 per cent after 6 cycles.

Augmented HDL-TC level and/or decreased LDL-TC level is believed to reduce the risk for the development of atherosclerotic disease. Increased TG concentration probably raises the risk for ischaemic cardiovascular disease. Thus the net effect on the development of ischaemic cardiovascular disease due to the changes of plasma lipids induced by EOe 0.05 mg can at present not be evaluated while the plasma lipid changes observed during OeV 2 mg might hypothetically retard the development of atherosclerosis.

Only 10 per cent of the changes of lipid and lipoprotein concentrations could be explained statistically by their correlations to the simultaneously occurring alterations in the glucose tolerance and the concentrations of insulin and growth hormone. The dissimilar changes in the lipid parameters in the EOe and OeV groups might be explained by the different oestrogenic potency of the drugs and a dose-response relationship of oestrogen treatment on protein and probably lipoprotein synthesis.

Estrogens for the menopause. Maximizing benefits, minimizing risks

There is a definite place for estrogen replacement in symptomatic menopausal women. Requisites of such therapy are a through history to establish a real need, a complete gynecologic examination with a Pap smear before therapy begins and annually afterward, use of the smallest daily dose of estrogen that gives the desired effect, and periodic attempts to reduce the dosage or stop the hormone. Endometrial biopsy should be done regularly if this is feasible, and any uterine bleeding should be investigated. If the suggestions outlined are followed, maximal benefit can be achieved with minimal risk to the patient.

Estrogens and endometrial carcinoma

A group of 205 women with endometrial carcinoma was matched for age, parity, and year of operation with a group of 205 women who had had hysterectomies for benign disease. In the former group, 32 patients had used conjugated estrogens, while in the latter group 12 had used this hormone, yielding a relative risk of 3.1 (P = 0.0008). Users of other forms of systemic estrogens showed similar elevations in relative risk. Relative risk was related to duration of use, progressing from no evidence of risk among those using the hormone for less than 5 years to an 11.5-fold greater risk for those using it for 10 years or more. Risk was also related to the strength of the medication. The relative risk for users of the 1.25-mg tablets was 12.7 as compared to a two- to fourfold greater risk among users of lesser strength tablets.

Disseminated intravascular coagulation induced by progesterone in the pregnant rat. Prevention by estogens

Fatal disseminated intravascular coagulation (DIC) was induced in female rats by administration of progesterone in late pregnacy. This prevented parturition, with intrauterine fetal death 2 to 4 days past term and subsequent retention of dead fetuses. Concomitantly with or closely following the intrauterine death of their litters, a large proportion of pregnant rats died with histologically evident DIC. Administration of cortisone, heparin, or disoumarin did not prevent DIC, and xi-aminocaproic acid, acetylsalicylic acid, or an onion-rich diet tended to increase its incidence. Antibiotic regimens gave variable results, with significant decrease in DIC only with a combination of two wide-spectrum penicillins. Neomycin and polymyxin had little effect on susceptible Sprague-dawley derived rats, but polymxin caused a significant increase in DIC in a resistant strain of hooded rats. Fatal maternal DIC was completely prevented only by use of natural or synthetic estrogens concurrently with progesterone, although this did not alter the sequence of abnormally prolonged pregnacy with intrauterine fetal death and retention of dead fetuses. Potencies of estrogens varied greatly, but all compounds tested prevented DIC at adequate dosage levels. Diethylstilbestrol, the most potent drug tested, was completely protective at 1 mug daily given subcutaneously. beta-Estradiol was the most effective natural estrogen, giving complete protection with a 10-mug daily subcutaneous injection. Estrogens were much more potent by subcutaneous injection than by oral ingestion, and toxic side effects were sometimes noted with higher levels of the latter. For estrogen therapy to be effective, it was necessary to begin its use before the expected onset of DIC, and in no instance was there evidence of reversal of this process after signs of illness were observed.

Coagulative and fibrinolytic studies on postmenopausal women treated with a new non-steroidal oestrogen

Treatment of postmenopausal women with a non-steroid oestrogen (P1496) in a dose of 50 mg a day for 2 ,days before operation for prolapse did not suppress the histochemically determined fibrinolytic activator content of the vessel wall. Neither was any change found in the concentration of P&P-complex (prothrombin, factor VII, factor X), factor VIII, antithrombin III, alpha1-antitrypsin, alpha2-macroglobulin or the inhibitors of urokinase induced plasminogen activation. Nothing suggested a thrombogenic effect of this non-steroidal oestrogenic compound.

Enzymatic responses of transplanted tumour cells towards estrogen, progesterone and testosterone

The influence of estrogen, progesterone and testosterone on the activities of alkaline and acid phosphatases, adenosine triphosphatase and succinate dehydrogenase were determined by cytochemical methods in sarcoma 180 and Ehrlich's carcinoma cells transplanted in male and female Swiss mice. The results revealed differential effects of the sex hormones on different enzymes which seemed to depend on the type of tumour cell studied and the sex of the host mice.