The effects of progesterone and progestins on endometrial proliferation

A total of 99 premenopausal and 27 postmenopausal women were evaluated to determine the quantity of glandular proliferation resulting from progestin inhibition of estrogen-primed subjects and of subjects without hormonal stimulation. Endometrial glandular proliferation rates were determined by using mitosis counts, proliferating-cell nuclear antigen (PCNA), and nuclear cyclin (MIB1) immunocytological staining. The endometria of normally cycling premenopausal women, of women who received a synthetic progestin, and of untreated postmenopausal women were studied. In untreated normally cycling premenopausal women, the proliferation of the glandular epithelium was increased during the follicular phase and decreased during the luteal phase. Premenopausal women receiving a synthetic progestin and untreated postmenopausal women who were not estrogen-primed showed minimal epithelial proliferation. Endometrial glandular proliferation is inhibited by endogenous progesterone in premenopausal women. Endometrial proliferation is markedly reduced in premenopausal women receiving a synthetic progestin and in untreated postmenopausal women.

The effect of elevated ovarian hormones on periodontal health: oral contraceptives and pregnancy

The most common oral manifestation of elevated levels of ovarian hormones, as seen in pregnancy or oral contraceptive usage, is an increase in gingival inflammation with an accompanying increase in gingival exudate. This gingivitis can be avoided or at least minimized by establishing low plaque levels at the beginning of pregnancy or the beginning of oral contraceptive therapy. It would appear that bacteria are not solely responsible for the gingivitis seen during these times, nor are the ovarian hormones solely responsible for the condition. Data from numerous studies suggest that the ovarian hormones alter the microenvironment of the oral bacteria so as to promote their growth and shifts in their populations. The present article reviews the current state of knowledge concerning the relationship of gingivitis to elevated levels of ovarian hormones, and describes the role that these hormones may play in the gingivitis associated with pregnancy or oral contraceptive usage.

Benefits and risks of oral contraceptive use

As a general rule, the lowest-dose oral contraceptive should be prescribed that minimizes side effects while maintaining contraceptive protection. A woman who experiences mild side effects should be encouraged to tolerate symptoms for three menstrual cycles before a decision is made to change the prescription. Compliance may also be improved by informing women of the noncontraceptive health benefits of oral contraceptives: less menstrual blood loss and a lower incidence of menorrhagia, irregular bleeding, benign breast disease, endometrial cancer, dysmenorrhea, ovarian cysts or tumors, and salpingitis. Adequate patient education and supportive counseling are key factors in patient satisfaction and hence compliance.

Rhabdomyosarcoma of the liver associated with long-term oral contraceptive use. Possible role of estrogens in the genesis of embryologically distinct liver tumors

We report a case of rhabdomyosarcoma arising in a 34-year-old woman with a 16-year history of oral contraceptive use. This is the first reported case of hepatic rhabdomyosarcoma associated with oral contraception. The tumor did not grossly or microscopically involve biliary structures or gall bladder. It was mostly comprised of undifferentiated spindle cells that were histologically similar to embryonal sarcoma. Foci of cells showing rhabdomyoblastic differentiation blended into poorly formed muscle bundles. No epithelial neoplasm was identified by either morphologic or immunohistochemical analysis. A review of the literature reveals that, although the incidence is low, mesenchymal neoplasms of the liver have been associated with oral contraceptive use. Furthermore, there is now evidence that a multipotential progenitor cell exists that can give rise to both epithelial and mesenchymal neoplasms. Thus, there may be a common precursor cell on which estrogens could act, and which could give rise to epithelial, mesenchymal, or mixed neoplasms. Finally, we suggest that embryonal sarcomas of the liver can undergo further differentiation to more well-defined mesencymal elements.

Estrogenic effect of gestodene- or desogestrel-containing oral contraceptives on lipoprotein metabolism

In a randomized comparative study, changes in lipoprotein metabolism during the use of two low-dose oral contraceptives with similar doses of ethinyl estradiol but with different progestogenically active compounds were evaluated for their effective estrogen/androgen balance. Sixty-eight healthy women who did not take hormonally active drugs or were pregnant the previous 3 months took either 75 micrograms of gestodene + 30 micrograms of ethinyl estradiol or 150 micrograms of desogestrel + 30 micrograms ethinyl estradiol during 12 cycles. During the first three cycles serum levels of the following parameters increased: triglycerides, cholesterol in high-density lipoprotein, and apolipoproteins A1, A2, and B. Additional increase was observed in apolipoprotein B only after three and six cycles. The induced changes were not significantly different in the two groups, and the levels generally remained within normal limits. The changes seen with both pills reflect a mild estrogenic dominance. On the basis of current knowledge, moderately altered lipoprotein metabolism is not expected to impose an extra risk of atherosclerosis.

Endogenous and exogenous endocrine factors

The relationship between breast cancer risk and age at menarche, age at first pregnancy, use of birth control pills, and use of postmenopausal replacement estrogens is reviewed.

Cancer of the breast and reproductive tract in relation to use of oral contraceptives

Effects of oral contraception on cancers of the female breast and reproductive tract are critically reviewed from human studies reported since 1980. The cumulative risk of breast cancer through 59 years of age appears to bear no relationship to oral contraceptive (OC) use whatsoever. Studies restricted to women under age 45, however, raise concern about a possible adverse effect from OC use before a first-term pregnancy. A duration-related protective effect against endometrial cancer occurs from use of combined OCs. The risk is reduced by about 40% with 2 years of use, and by about 60% with 4 or more years of oral contraception. Oral contraception in excess of 3 years protects against ovarian cancer. Four years of use confers a 50% reduction in risk and 7 or more years of use confers a 60%-80% reduction in ovarian cancer risk. Studies of cervical dysplasia and carcinoma in situ suggest elevated risks with 2 or more years of OC use, although results are difficult to interpret in view of numerous factors that might distort the findings. The risk of invasive cervical cancer appear to be unaffected by up to 5 years of oral contraception. Beyond this, there is evidence suggesting an elevated risk which approaches a 2-fold increase at 10 years of use. Cancers of the vagina and fallopian tube are extremely rare. Their risks have yet to be characterized in relation to oral contraception.

Oral contraceptives and intrahepatic biliary cystadenoma having an increased level of estrogen receptor

We report a case of intrahepatic biliary cystadenoma in a young woman who had no prior history of liver disease and who had taken oral contraceptives for one year. A 27-year-old woman was admitted to our hospital with a firm epigastric mass. At laparotomy, a large cystic mass was resected from the left hepatic lobe, and diagnosed as biliary cystadenoma. In the tumor tissue, the estrogen receptor content was 14.0 fmol/mg cytosol protein, which was much higher than the 3.0 fmol/mg cytosol protein in the surrounding liver tissue. This is the first case of biliary cystadenoma in which the estrogen receptor content was increased.

Pharmaceutical effect of contraceptive pills on the skin

Described are the various effects of birth control methods on the skin-mainly those of the contraceptive pill. The equilibrium of healthy skins and mucosa might be affected by these chemicals or pharmaceutical agents, causing different manifestations. The skin and mucosa should be looked upon as integral parts of the human body and its functions even where localized symptoms arise.

Alternate delivery systems for contraceptive progestogens

Research continues toward developing an universally acceptable, safe, and effective contraceptive to inhibit the female reproductive process. Progestational systems, either alone or in combination with small amounts of estrogen, approach such an ideal. The pregnane and 19-nortestosterone progestins were examined in this review with regard to contraceptive mechanisms of action and major side effects, such as menstrual abnormalities, metabolic changes, neoplasia, and teratogenicity. These steroids provide highly effective and long-acting contraception, and bypass the oral route of administration, resulting in fewer gastrointestinal and systemic side effects. Data regarding the lack of a deleterious effect of contraceptive progestogens on fetal malformation or cancer of the breast and genital tract reinforce their safety. Further study and refinement are needed, however, to lower the incidence of menstrual abnormalities, hypertension, and detrimental lipid alterations prior to approval for general use.

Lipid and lipoprotein changes in relation to oral contraception and hormonal replacement therapy

Estrogens and progestins for contraception or hormonal replacement therapy are widely used by practitioners. These steroids have substantial effects on lipids and lipoproteins that appear to be primarily related to chemical structure of the compound, dosage, and a patient's hormonal status. Although the mechanisms by which alterations in lipid and lipoproteins affect atherogenesis are not fully understood, epidemiologic studies clearly associate alterations with risk of coronary heart disease. Attention to these alterations by progestins and estrogens, as well as further research on how these steroids may exert other cardiovascular effects, is important because atherosclerotic heart disease is a major cause of morbidity and mortality for women as they age.

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)

Oral contraceptive steroid induced platelet coagulant hyperactivity: dissociation of in vivo and in vitro effects

The use of oral contraceptives (OC) has been associated with an increased risk of thromboembolic events in a subset of women. Factors predisposing to this problem are still not clearly defined although an increased platelet coagulant activity (CA) has been reported. This study was designed to evaluate the CA of platelets from asymptomatic current OC users compared with control subjects. The asymptomatic OC users were found to have evidence of hypercoagulability in the form of increased availability of platelet CA. These findings were present in both collagen stimulated and unstimulated platelets. In order to understand the mechanism we examined the in vitro effects of estradiol and/or progesterone on platelets. Platelets from normal males were incubated for one hour with estrogen and/or progesterone. There was no significant difference in CA of hormone treated platelets compared with control platelets from the same donor. CA was analyzed in platelets exposed to epinephrine, adenosine diphosphate, and collagen in the platelet aggregometer. Although a dose dependent effect was observed on CA of platelets exposed to the range of aggregating agents, the results show no significant difference between CA of the hormone treated and control platelets (p greater than 0.05). Likewise, platelet aggregation and release of nucleotide were not different between hormone treated and control platelets. Thus a direct effect of the hormones on platelets is an unlikely mechanism causing the increased CA seen in OC users.

Coagulation effects of oral contraception

In Europe and North America, estrogen/progestogen oral contraception has been associated with an increase in venous thromboembolism, myocardial infarction, and stroke. These hazards are found mainly in smokers and in women over the age of 35. Venous thromboembolism appears to correlate with the estrogen dosage, and the arterial complications with both the estrogen and progestogen components. Blood coagulation and vascular thrombosis are intimately related. Estrogen/progestogen oral contraception affects blood clotting by increasing plasma fibrinogen and the activity of coagulation factors, especially factors VII and X; antithrombin III, the inhibitor of coagulation, is usually decreased. Platelet activity is also enhanced with acceleration of aggregation. These changes create a state of hypercoagulability that, to a large extent, appears to be counterbalanced by increased fibrinolytic activity. Studies of the oral contraceptives in current use show that the coagulation effects depend on the dosage of estrogen and the type of progestogen used in combination. Current research is aimed at finding the estrogen/progestogen formulations that induce the least changes in the coagulation system and other physiologic processes. In this respect, the new low-dose formulations are a major step forward and should reduce the risk of vascular thrombotic complications.

Progestogen potency in oral contraceptive pills

The most important target organs for combined oral contraceptive preparations are the anterior pituitary gland and the uterus. The long-term unopposed administration of estrogen produces endometrial hyperplasia and amenorrhea, which are unacceptable to most women and their medical advisors. Cyclic administration of progestogens in combination with the estrogen, however, produces predictable endometrial shedding and achieves a regular and acceptable bleeding pattern in most women. This was the main reason that the "delay of menses" test was adopted as the earliest clinical means of comparing the relative potencies of progestogens that were administered orally. Recently attempts have been made to compare the potency of progestogens on the other organ systems by the extrapolation of data derived from studies on the endometrium. This is inappropriate, inasmuch as the effects of progestogens and estrogens independently and in combination differ greatly depending on the target organ. In this article, the literature on this controversial subject is reviewed.

Contrasting diet and body mass among users and nonusers of oral contraceptives and exogenous estrogens: the Lipid Research Clinics Program Prevalence Study

Mean dietary constituent levels using the 24-hour recall method and body mass measures were examined among oral contraceptive and exogenous estrogen users and nonusers in the Lipid Research Clinics Program Prevalence Study. Among women aged 20-44 years, oral contraceptive users had a significantly lower mean Quetelet index of body mass and triceps skinfold thickness and a significantly higher total caloric intake. Among women aged 45-69 years, those taking exogenous estrogens had a significantly lower mean Quetelet index. No significant differences between hormone users and nonusers were seen for per cent of calories from fat (saturated or unsaturated), protein, carbohydrates, starch, sucrose, or alcohol. The higher total caloric intake in oral contraceptive users in contrast to nonusers and the lower body mass in both groups of gonadal hormone users may in part be indicative of other differences in life-style and behavior between the study groups. Further documentation of specific eating patterns, nutrient intake, and energy metabolism in women consuming gonadal hormones and in suitable control subjects seems to be indicated.

Attributable risk ratio estimation from matched-pairs case-control data

Explicit formulas are provided for estimating the attributable risk ratio among the exposed and the entire target population utilizing matched-pairs data. Large-sample standard errors and corresponding confidence intervals are provided. These estimates can be obtained from the cross-classification frequencies of matched pairs by disease and exposure status in the usual 2 X 2 table. The key to the development of these formulas lies in recognizing that attributable risk among the exposed is a direct function of the odds ratio, and population attributable risk is a direct function of the odds ratio and exposure prevalence among only the cases (assuming a rare disease). The formulas presented in this paper require only a calculator for computation. The methodology is illustrated with data from a matched-pairs case-control study of oral conjugated estrogens and endometrial cancer.

Neurology of sex steroids and oral contraceptives

Under normal circumstances, sex steroids interact with diverse neural substrates to modulate a host of activities essential to the preservation of the individual and the species. In addition, sex hormones play an important role in various human neurologic conditions including strokes, migraine, certain movement disorders and peripheral neuropathies, and possibly even the behavior of CNS neoplasms.

Depo-Provera in the treatment of recurrent vulvovaginal candidiasis

The long-acting injectable progestogen Depo-Provera appears to substantially reduce women's susceptibility to recurrent vulvovaginal candidiasis. Pregnancy and exogenous estrogen appear to counteract this effect of the drug. Evidence was derived from 15 patients studied for up to six years.

Pharmacology of estrogens and estrogen-induced effects on nonreproductive organs and systems

The classification of estrogens based on chemical structure and origin is presented. The metabolism of endogenous estrogens and the postulated mechanism of action of steroid hormones are reviewed. Specific effects of estrogen on bone, kidney and coagulation are also discussed.

Risk factors for adenomatous endometrial hyperplasia: a case-control study

A population-based case-control study of histologically confirmed endometrial neoplasia was conducted in Toronto, Canada, between 1977 and 1978. Pathologic slide review resulted in classification of patients to diagnostic categories of endometrial carcinoma, endometrial carcinoma in situ, and endometrial hyperplasia. This report concerns the subset of patients classified as having adenomatous endometrial hyperplasia. Two age-matched neighborhood controls were selected for each case, and analyses included only those case-control sets in which the case and at least one control were concordant on menopausal status. Among postmenopausal women (87 cases and 151 controls), noncontraceptive estrogen use was a statistically significant risk factor (adjusted odds ratio (OR) = 6.7), as was heavy body weight relative to height (Quetelet index) (adjusted OR = 3.2). Long-term (5+ years) estrogen use conferred an estimated relative risk of more than 20, but use of oral contraceptives did not alter risk significantly. Among premenopausal women (62 cases and 97 controls), a high Quetelet index appeared to be a significant protective factor, even when adjusted for oral contraceptive use (adjusted OR = 0.2). While oral contraceptive use was not associated with a change in risk, long duration of use was highly, but statistically not significantly, protective against hyperplasia. The data for pre- and postmenopausal women indicate that both endogenous and exogenous estrogen exposure are important factors in the etiology of adenomatous endometrial hyperplasia.

Reproductive factors, oral contraceptives and risk of malignant melanoma: Western Canada Melanoma Study

A study of 361 female melanoma patients and age matched controls was conducted in the four western provinces of Canada. Analysis of reproductive factors showed a significant negative association between number of livebirths and risk of melanoma. The relationship persisted for superficial spreading melanomas after adjustment for host pigmentation factors, freckling, and educational status. An inverse association between bilateral oophorectomy and risk of superficial spreading melanoma was also seen. No association was found between risk of melanoma and age at first birth, age at menarche and age at natural menopause. No association was found between risk of superficial spreading or nodular melanoma and use of either oral contraceptives or menopausal oestrogens.

A prospective controlled study of the effect on blood pressure of contraceptive preparations containing different types and dosages of progestogen

A prospective controlled study investigated the effects of oral contraceptives on blood pressure in 485 women who were between 17 and 46 years of age and had blood pressures of less than 140/90 mmHg at entry. The women were divided into seven groups depending on the chosen method of contraception: intrauterine device or barrier method (control group): ethinyl oestradiol 30 micrograms plus levonorgestrel 150 micrograms (Microgynon-30 or Ovranette); norethisterone 350 micrograms (Micronor); norgestrel 75 micrograms (Neogest); norethisterone oenanthate 200 mg intramuscularly every 2 months for the first 6 months, then every 3 months thereafter; ethinyl oestradiol 30 micrograms plus ethynodiol diacetate 2 mg (Conova-30); and ethynodiol diacetate 500 micrograms (Femulen). Blood pressures were measured every 3 months by the family planning clinic nurse under standardized conditions using an Elag-Köln automatic sphygmomanometer. After one year, blood pressure had risen significantly (P less than 0.05) in the 137 women taking ethinyl oestradiol plus levonorgestrel (mean systolic and diastolic rises 6.4 and 2.7 mmHg respectively) and in the 91 women taking ethinyl oestradiol plus ethynodiol diacetate (mean systolic and diastolic rises 6.2 and 3.0 mmHg respectively). The 94 women taking the progestogen-only preparations and the 143 women in the control group showed no increases in blood pressure. These data were confirmed after 2 years of follow-up.

Exogenous hormone use and fibrocystic breast disease by histopathologic component

In a hospital-based case-control study of 590 women with biopsy-proven fibrocystic breast disease and 1,018 control women with other surgical conditions, no linear relationship was evident between the use of oral contraceptives or of estrogen replacement therapy and the degree of epithelial atypia of the fibrocystic lesions. Case-control and intracase comparisons suggested that oral contraceptive use might be associated with an increased occurrence of sclerosing adenosis among the premenopausal women and of gross cysts among the postmenopausal women. Estrogen replacement therapy, which was positively associated with fibrocystic breast disease as a whole among the post-menopausal women, was most frequently used among the cases whose biopsy specimens exhibited gross cysts, papillomatosis or papillary hyperplasia.

Estrogens, breast cancer, and intestinal flora

Epidemiologic evidence has linked diet to breast cancer, with the highest cancer rates observed in women who eat a high fat-low fiber diet. There is also substantial information, both clinical and experimental, that implicates estrogens in the etiology of breast cancer. A recent study from our laboratory has shown that diet influences levels of estrogens, and the main mechanism is metabolism of estrogens in the intestine. The intestinal microflora plays a key role in the enterohepatic circulation of estrogens by deconjugating bound estrogens that appear in the bile, thereby permitting the free hormones to be reabsorbed. By suppressing the microflora with antibiotic therapy, fecal estrogens increase and urinary estrogens decrease, changes indicating diminished intestinal reabsorption. A low fat-high fiber diet is associated with similar findings-high fecal estrogens and low urinary estrogens. It appears that the microflora plays a key role in the metabolism of female sex hormones.

Effect of clinical features on the association of estrogens and breast cancer

In a case-control study using several distinctive control subgroups, no increased risk of breast cancer was found in postmenopausal women who used replacement estrogens. When breast cancer patients and control patients with no breast lesions were assembled from patients who had all received mammography, the overall odds ratio was 0.5, and varied from 0.2 to 1.2 according to the patient's indication for estrogen treatment and the clinical reason for mammography. When a biopsy registry was the source of breast cancer patients and control patients with benign breast disease, the odds ratio was 0.8. In a conventional case-control comparison of breast cancer patients with hospitalized patients having other diagnoses, the odds ratio was 0.9 when specific data about exposure were used to classify patients as estrogen users, but the odds ratio was 3.3 when data about exposure were not recorded equally in the compared groups. These results show that calculations of "risk" depend on important clinical phenomena that have not previously been given suitable attention. The data also provide a possible explanation for the perplexing findings among earlier studies in which the odds ratios varied from "protective" to "causal" values. When the data from the present study are partitioned according to differences in patients' clinical characteristics and reasons for the diagnostic breast procedure, the conflicting results of earlier studies can be reconciled.

Role of estrogens and progesterone in the etiology and prevention of endometrial cancer: review

Our present knowledge of the role of sex steroids in the development as well as the prevention of endometrial cancer is reviewed. Factors which increase the exposure of the uterus to unopposed estrogens, either exogenous or endogenous, are associated with increased risk of endometrial adenocarcinoma. However, there is increasing evidence that progestogens can reverse endometrial hyperplasia and protect against the development of endometrial cancer. The mechanisms to explain the antiestrogenic effects of progestogens include changes in enzyme activity and steroid receptors in endometrial tissue. Postmenopausal women treated with combined estrogen and progestogen have the lowest incidence of endometrial carcinoma. Oral contraceptives containing both estrogen and progestogen in each tablet are protective against adenocarcinoma of the endometrium, while the sequential oral contraceptive pills afforded less protection. The risks and benefits of these hormone therapies are discussed in relation to the etiology and prevention of endometrial cancer.

The epidemiology of endometrial cancer in young women

A case-control study was conducted in Los Angeles County, California, of 127 endometrial cancer cases aged 45 years or less at diagnosis, to investigate the role of fertility, obesity and exogenous oestrogens in the development of the disease in young women. Use of sequential oral contraceptive (SOCs) or oestrogen replacement therapy (ERT) for greater than or equal to 2 years was strongly associated with increased risk of endometrial cancer. After excluding these cases, since the SOC or ERT use was probably the cause of their disease, we were left with 110 case-control pairs for further study. Among these remaining case-control pairs increasing parity was strongly associated with decreased risk (relative risk of 0.12 for women of parity 3 compared to nulliparous women, P less than 0.001). Current weight was associated with increased risk (relative risk of 17.7 for women weighing greater than or equal to 190 lbs compared to women weighing less than 130 lbs, P less than 0.001). Combination oral contraceptive (COC) use was associated with a decreased risk, which decreased with duration of COC use (relative risk of approximately 0.28 at 5 years of use, P less than 0.001), but the estimate of the protective effect was reduced and became statistically non-significant when allowance was made for weight and parity. The protective effect of COC use was only clearly evident in women who had less than 3 live-births and weighed less than 170 lbs. These results provide further support for the "unopposed" oestrogen hypothesis of the aetiology of endometrial cancer.

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-induced pancreatitis

Acute pancreatitis in a patient on oral contraceptive therapy is reported, and the relationship of estrogen administration to hyperlipemia and pancreatitis is discussed. A 23-year-old white woman was admitted to a hospital with epigastric pain, nausea, and vomiting. Three previous episodes of abdominal pain had been diagnosed as acute pancreatitis. On the present and previous admissions, she had just completed a cycle on her combination norethindrone 1 mg, mestranol 8 micrograms contraceptive. Laboratory results showed mild leukocytosis and elevated concentrations of blood glucose, alkaline phosphatase, serum amylase, and urine amylase. Serum cholesterol and triglycerides were elevated, and lipoprotein electrophoresis showed a type IV pattern. Abdominal sonogram revealed a normal pancreas, and all other test results were normal. The patient was treated with i.v. fluid replacement, dimenhydrinate, and meperidine hydrochloride. Within 72 hours she was asymptomatic, and serum amylase, triglyceride, and cholesterol concentrations had decreased. She was discharged with a diagnosis of acute pancreatitis secondary to oral-contraceptive-induced hyperlipidemia. Oral contraceptive therapy was not resumed. Predisposing factors, symptoms, and laboratory findings associated with estrogen-induced acute pancreatitis are presented, and the mechanisms through which serum lipid elevations and subsequent pancreatitis occur are discussed. Monitoring serum lipid concentrations before and during estrogen therapy is recommended. Research suggests that patients who are over 40 years old or have family histories of hyperlipemia are at particular risk, and that estrogen therapy should be discontinued if pancreatitis occurs.

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.

Hepatocellular carcinoma associated with oral contraceptive use and pregnancy

Numerous undesirable side effects have been attributed to oral contraception, from mild breast discomfort to thromboembolism. The authors present a case report of hepatocellular carcinoma associated with oral contraceptive use and pregnancy and discuss the potentially fatal association of malignant liver tumors with usage of oral contraception.

Exogenous estrogens and endometrial cancer: a case-control study and assessment of potential biases

Eighty-eight cases with newly diagnosed carcinoma of the endometrium and 177 age-matched neighborhood controls were interviewed to test the hypothesis that exogenous estrogens lead to an increased risk of endometrial cancer. Forth-five per cent of the cases and 22% of the controls reported a history of estrogen use which yielded an odds ratio of 2.9 (confidence interval (Cl) 1.7-5.1). Women with five or more years of estrogen use had an odds ratio of 8.6 (Cl 3.2-23.0). Approximately 80% of the estrogen users had used conjugated equine estrogens. For these women the odds ratio was 4.0 (Cl 1.9-8.4) for daily dosages of more than 1 mg of estrogen. Several sources of bias which might affect the estrogen association were investigated. These included comparability of cases and controls, selection procedures, difference between estrogen users and nonusers, exclusion of controls who had hysterectomy, source of estrogen information, and differential recall. The concept or medical surveillance was evaluated by access to medical care and prior history of dilatation and curettage. The strong association between exogenous estrogen use and endometrial cancer remained after consideration for the effects of these biases.

[Contraceptives and the liver]

Among the typical complications of oral contraceptive use are intrahepatic cholestasis, occurring in women with a special and probably genetical predisposition only, and a thrombotic diathesis secondary to increased hepatocellular synthesis of coagulation factors, both effects induced by the estrogens. This state of hypercoagulability may lead to thrombosis of the hepatic veins and may thus cause the Budd-Chiari syndrome. A tendency to gallstone formation is explained by a derangement in the synthesis of bile acids and by changes in the permeability of liver cell membranes and of epithelial cells of the gallbladder, an effect again due to the estrogen component of the contraceptives. After long-term use, an increased incidence of benign liver cell adenomas is observed; malignant liver tumors do occur very rarely. A causal relationship with focal nodular hyperplasia, however, is unlikely. Only the typical vascular changes of this entity are probably due to the effects of the contraceptives.