Posttreatment Strategy Against Hypoxia and Ischemia Based on Selective Targeting of Nonnuclear Estrogen Receptors with PaPE-1

Newly synthesized Pathway Preferential Estrogen-1 (PaPE-1) selectively activates membrane estrogen receptors (mERs), namely, mERα and mERβ, and has been shown to evoke neuroprotection; however, its effectiveness in protecting brain tissue against hypoxia and ischemia has not been verified in a posttreatment paradigm. This is the first study showing that a 6-h delayed posttreatment with PaPE-1 inhibited hypoxia/ischemia-induced neuronal death, as indicated by neutral red uptake in mouse primary cell cultures in vitro. The effect was accompanied by substantial decreases in neurotoxicity and neurodegeneration in terms of LDH release and Fluoro-Jade C staining of damaged cells, respectively. The mechanisms of the neuroprotective action of PaPE-1 also involved apoptosis inhibition demonstrated by normalization of both mitochondrial membrane potential and expression levels of apoptosis-related genes and proteins such as Fas, Fasl, Bcl2, FAS, FASL, BCL2, BAX, and GSK3β. Furthermore, PaPE-1-evoked neuroprotection was mediated through a reduction in ROS formation and restoration of cellular metabolic activity that had become dysregulated due to hypoxia and ischemia. These data provide evidence that targeting membrane non-GPER estrogen receptors with PaPE-1 is an effective therapy that protects brain neurons from hypoxic/ischemic damage, even when applied with a 6-h delay from injury onset.

Exposures to synthetic estrogens at different times during the life, and their effect on breast cancer risk

Women are using estrogens for many purposes, such as to prevent pregnancy or miscarriage, or to treat menopausal symptoms. Estrogens also have been used to treat breast cancer which seems puzzling, since there is convincing evidence to support a link between high lifetime estrogen exposure and increased breast cancer risk. In this review, we discuss the findings that maternal exposure to the synthetic estrogen diethylstilbestrol during pregnancy increases breast cancer risk in both exposed mothers and their daughters. In addition, we review data regarding the use of estrogens in oral contraceptives and as postmenopausal hormone therapy and discuss the opposing effects on breast cancer risk based upon timing of exposure. We place particular emphasis on studies investigating how maternal estrogenic exposures during pregnancy increase breast cancer risk among daughters. New data suggest that these exposures induce epigenetic modifications in the mammary gland and germ cells, thereby causing an inheritable increase in breast cancer risk for multiple generations.

Neuroprotection with non-feminizing estrogen analogues: an overlooked possible therapeutic strategy

Although many of the effects of estrogens on the brain are mediated through estrogen receptors (ERs), there is evidence that neuroprotective activity of estrogens can be mediated by non-ER mechanisms. Herein, we review the substantial evidence that estrogens neuroprotection is in large part non-ER mediated and describe in vitro and in vivo studies that support this conclusion. Also, we described our drug discovery strategy for capitalizing on enhancement in neuroprotection while at the same time, reducing ER binding of a group of synthetic non-feminizing estrogens. Finally, we offer evidence that part of the neuroprotection of these non-feminizing estrogens is due to enhancement in redox potential of the synthesized compounds.

Estrogen analogues: promising target for prevention and treatment of esophageal squamous cell carcinoma in high risk areas

Esophageal cancer (EC) is one of the six most common cancers across the world. The striking 3-4: 1male predominance of esophageal squamous cell carcinoma (ESCC) has not yet been well explained. Our hypothesis is that the changes in level of estrogen and/or subtype of estrogen receptor (ER) may exert a protective factor in esophageal carcinogenesis and thus estrogen analogues may represent a promising target for prevention and treatment of ESCC. Several lines of evidence in a mouse ESCC model have suggested an inhibitory role of estrogen in ESCC growth and development. Consistent with this, our results showed that male and female counterparts from a high incidence area (HIA) for EC had significantly decreased serum estradiol compared to healthy controls from a low incidence area (LIA). Moreover, serum level of estradiol of ESCC patients from the HIA were significantly lower compared to healthy controls from both HIA and LIA. Numerous studies indicate that relatively low androgen level, high estrogen level (environmental and endogenous) and ratio alteration of sex hormones are important factors explaining decreased ESCC incidence. Both ERalpha and ERbeta are ligands to estradiol with different effects on transcription at activator protein-1 sites. Estrogen exerts a suppressive effect, mainly through ERalpha in ESCC, and an accelerative function, mainly through ERbeta. Our hypothesis suggests that administration of novel potent estrogen analogues might be an effective measure for prevention and treatment of ESCC in HIA.

[Effect of estrogens and liposomes on the course of the purulent wounds healing in elderly and senile patients]

The cytological changes dynamics during the process of the purulent wounds healing in elderly and senile patients using estrogens and liposomes in complex of treatment are adduced.

[Synthetic estrogens: some new pharmacological actions and mechanisms]

Many constitutional analogues of estrogen have been reported. In this review, the application, action(s), and mechanism(s) of clinically used synthetic estrogens are described. Estramustine and phosphestrol have been used for many years in the treatment of advanced prostate cancer. Estramustine phosphate is a prodrug that is rapidly on oral administration to the five metabolites, estramustine, estromustine, estradiol, estrone and anticancer drug, nitrogen mustards. Estramustine induces dose- and time-dependent metaphase arrest and breakdown of interphase microtubules. Raloxifene is a selective estrogen receptor modulator from the benzothiophene class that binds to the estrogen receptor and has estrogen-agonist effects on bone. Raloxifene has used in female patients with postmenopausal osteoporosis.

Combination therapy for osteoporosis: considerations and controversy

Combination therapy, the simultaneous use of two pharmaceutical agents with the goal being reduction of fracture risk, is an area of substantial clinical interest. This paper summarizes the rationale, existing clinical trials data, and other considerations relevant to combination therapy for osteoporosis. Combinations of antiresorbers (eg, estrogen plus bisphosphonates) produce greater increases in bone mass than either treatment alone. Conversely, combining anabolic agents (parathyroid hormone) with bisphosphonates does not produce additive effects. None of the existing studies are large enough to determine whether combination treatment reduces fracture risk to a greater extent than use of a single agent. However, it is certain that combination treatment will increase cost and likely that it will increase side effects and reduce therapy adherence. Given the absence of demonstrated fracture reduction benefit, increased cost and likely increase in adverse events, combination therapy is not currently recommended.

Efficacy of tibolone and transdermal estrogen therapy on psychological symptoms in women following surgical menopause

OBJECTIVE

This study investigated the efficacy of tibolone and transdermal estradiol therapy on menopausal and psychological symptoms in women following surgical menopause.

METHOD

Seventy-five women who had undergone surgical menopause were randomized to a 6-month double-blind interventional study treatment with oral 2.5 mg/day tibolone, transdermal 3.9 mg/week estradiol or oral placebo. The patients were assessed using Kupperman's Scale, Hamilton Depression Rating Scale (HDRS) and Hamilton Anxiety Rating Scale (HARS) before and at the end of the 6 months of treatment.

RESULT

Sixty-five subjects completed the study: 23 on tibolone, 21 on transdermal estradiol and 21 on placebo. At the end of the 6 months of therapy, highly significant improvements in menopausal symptoms, depression and anxiety scores were observed in both groups (tibolone and transdermal estradiol groups) as compared with baseline values (p<0.001). However, in the placebo group, there were no significant differences on changes from baseline to the end of treatment (p>0.05).

CONCLUSION

These results suggest that tibolone and transdermal estradiol therapy significantly improve menopausal and psychological symptoms in women following surgical menopause.

Estrogen-like compounds for ischemic neuroprotection

We have synthesized a library of estrogen analogues, including enantiomers of estradiol and A-ring substituted estrogens. These compounds have reduced or no binding to either estrogen receptor-alpha or estrogen receptor-beta, exhibit enhanced neuroprotective activity in in vitro models, and are potent in protecting brain tissue from cerebral ischemia/reperfusion injury. These potent, nonfeminizing estrogen analogues are prime candidates for use in stroke neuroprotection.

Estrogen receptor subtypes alpha and beta contribute to neuroprotection and increased Bcl-2 expression in primary hippocampal neurons

Estrogen receptor (ER) mediated neuroprotection has been demonstrated in both in vitro and in vivo model systems. However, the relative contribution by either ER subtype, ERalpha or ERbeta, to estrogen-induced neuroprotection remains unresolved. To address this question, we investigated the impact of selective ER agonists for either ERalpha, PPT, or ERbeta, DPN, to prevent neurodegeneration in cultured hippocampal neurons exposed to excitotoxic glutamate. Using three indicators of neuronal viability and survival, we demonstrated that both the ERalpha selective agonist PPT and the ERbeta selective agonist DPN protected hippocampal neurons against glutamate-induced cell death in a dose-dependent manner, with the maximal response occurring at 100 pM. Further analyses showed that both PPT and DPN enhanced Bcl-2 expression in hippocampal neurons, with an efficacy comparable to their neuroprotective capacity. Collectively, the present data indicate that activation of either ERalpha or ERbeta can promote neuroprotection in hippocampal neurons, suggesting that both receptor subtypes could be involved in estrogen neuroprotection. As ERbeta is highly expressed in the brain and has little or no expression in the breast or uterus, discovery and design of ERbeta selective molecules could provide a strategy for activating the beneficial effects of estrogen in the brain without activating untoward effects of estrogen in reproductive organs.

[Effect of nylestriol on bone remodeling in ovariectomized rats]

OBJECTIVE

To clarify the effects of nylestriol on microarchitecture and interleukin-6 (IL-6) mRNA expression in tibial bone in ovariectomized rats.

METHODS

30 female rats were randomly allocated into 3 groups: sham, OVX and nylestriol-treated group. Nylestriol-treated group were ovariectomized, then fed with nylestriol for 3 months and the bone mineral density (BMD) was measured in lumbar vertebra by dual energy x-ray absorptiometry. After sacrifice of the animal, bone histomorphometric parameters were measured to study the changes in bone microarchitecture, and RT-PCR was performed to detect the expression of IL-6 mRNA in bone tissue.

RESULTS

BMD was significantly reduced, while IL-6 mRNA level elevated in the OVX group compared with the sham group. Static histomorphometric data showed that the trabecular bone volume, mean trabecular plate thickness and density were reduced while the mean trabecular plate space elevated remarkably in the OVX group in comparison with that in the sham group. As for dynamic parameters, trabecular osteoid surface, tetracyclin labeled surface and bone turnover rate were increased while osteoid maturation rate decreased significantly in the OVX group compared with the sham group. BMD, IL-6 mRNA expression and bone histomorphometric parameters were improved in nylestriol-treated rats.

CONCLUSION

Nylestriol plays an important role in maintaining bone volume and improving bone microarchitecture by markedly inhibiting bone turnover and bone resorption, which might be to some degree attributed to reduced IL-6 expression.

The effect of desogestrel for hormone replacement therapy on the blood lipid profiles of postmenopausal women

OBJECTIVE

To determine the effect of a hormone replacement protocol containing conjugated equine estrogens and desogestrel (which has a highly selective progestogenic and low androgenic effect) as the progestogen, on the plasma lipid profile, as compared with two other hormone replacement treatments (HRT).

METHOD

Eighty-nine healthy postmenopausal women were divided prospectively into four groups. A control group of 24 women did not receive HRT. Twenty-nine women received conjugated equine estrogen and medroxyprogesterone, and 13 women received a protocol containing estradiol, estriol and norethisterone acetate. Fasting blood lipid was taken at the end of each third cycle. The cumulative therapeutic response was calculated in each group as compared with initial values and between groups. Significance was analyzed by t-tests.

RESULTS

A protocol containing desogestrel significantly decreased low-density lipoprotein cholesterol (27%; P < 0.05) and increased high-density lipoprotein cholesterol (HDL-C) by 30% (P < 0.05%) after 9 months. The ratio of total cholesterol to HDL-C also decreased significantly (44%; P < 0.05).

CONCLUSION

The most beneficial effect on plasma lipid profile was obtained with an HRT protocol containing desogestrel as the progesterone.

Relief of Hot Flushes With New Plant-Derived 10-Component Synthetic Conjugated Estrogens

OBJECTIVE

A study was conducted to evaluate the safety and efficacy of 3 different doses of synthetic conjugated estrogens B, a new plant-derived 10-component conjugated estrogens product, for the treatment of menopausal vasomotor symptoms.

METHODS

This was a randomized, double-blind, placebo-controlled trial. Highly symptomatic menopausal women (N = 281) received 12 weeks of a once-daily oral treatment with 0.3 mg, 0.625 mg, or 1.25 mg of 10-component synthetic conjugated estrogen or placebo. Patients recorded the daily frequency and severity of hot flushes. Statistical analyses compared results at weeks 4, 8, and 12 with baseline values.

RESULTS

Statistically significant reductions (P <.05) in the frequency and severity of vasomotor symptoms were observed for all 3 dosage strengths of 10-component synthetic conjugated estrogen compared with placebo. The most commonly reported adverse events in all treatment groups were headaches. No difference in the incidence of treatment-related adverse events was seen between placebo and 10-component synthetic conjugated estrogen groups.

CONCLUSION

The 0.3-mg, 0.625-mg and 1.25-mg dose strengths of 10-component synthetic conjugated estrogen significantly reduced the frequency and severity of vasomotor symptoms compared with placebo, and were well tolerated during this 12-week study.

LEVEL OF EVIDENCE

I

Continuous use of an oral contraceptive for endometriosis-associated recurrent dysmenorrhea that does not respond to a cyclic pill regimen

OBJECTIVE

To ascertain whether long-term reduction of pain is obtained by continuous administration of an oral contraceptive (OC) in women with endometriosis-associated recurrent dysmenorrhea that does not respond to cyclic OC use.

DESIGN

Prospective, therapeutic, self-controlled clinical trial.

SETTING

A tertiary care and referral center for patients with endometriosis.

PATIENT(S)

Fifty women who underwent surgery for endometriosis in the previous year and experienced recurrent dysmenorrhea despite cyclic OC use.

INTERVENTION(S)

Continuous use of an OC containing ethinyl estradiol (0.02 mg) and desogestrel (0.15 mg) for 2 years.

MAIN OUTCOME MEASURE(S)

Dysmenorrhea variation during cyclic and continuous OC use, evaluated with a 100-mm visual analog scale and a 0- to 3-point verbal rating scale, and degree of satisfaction with continuous OC treatment.

RESULT(S)

In the study period, amenorrhea, spotting, and breakthrough bleeding were reported by 19 (38%), 18 (36%), and 13 (26%) women. The mean +/- SD number of >7-day bleeding episodes with consequent 7-day OC suspension was 5.5 +/- 2.1. The mean +/- SD dysmenorrhea visual analog scale and verbal rating scale scores were 75 +/- 13 and 2.4 +/- 0.5 at baseline and 31 +/- 17 and 0.7 +/- 0.6 at 2-year follow-up, respectively. Moderate or severe side effects were reported by 7/50 (14%) women. At final evaluation, 13 (26%) women were very satisfied, 27 (54%) were satisfied, 1 (2%) was uncertain, 8 (16%) were dissatisfied, and 1 (2%) was very dissatisfied.

CONCLUSION(S)

Long-term continuous OC use can be proposed to women with symptomatic endometriosis and menstruation-related pain symptoms.

Metformin or antiandrogen in the treatment of hirsutism in polycystic ovary syndrome

Hirsutism is a common and distressing symptom frequently encountered in women with polycystic ovary syndrome (PCOS), who also show relative insulin resistance. The aim of this trial, in which hirsutism was the primary end point, was to compare the efficacy of the oral antihyperglycemic medication metformin with that of an established treatment, combined ethinyl estradiol and cyproterone acetate. Patients (n = 52) were randomized to receive either metformin (500 mg, three times daily) or Dianette (ethinyl estradiol, 35 micro g; cyproterone acetate, 2 mg) treatment for 12 months, with assessments before treatment, at 6 months, and at 12 months. Both objective and subjective methods of evaluating hirsutism were used, and in addition, patient perceptions were examined. The results show that metformin is potentially an effective treatment for moderate to severe hirsutism in women with PCOS. They also suggest that in some respects (Ferriman-Gallwey score and patient self-assessment), it is more efficacious than the standard treatment (Dianette). The objective evaluation of hair diameter reduction showed that both treatments were moderately effective at multiple anatomical sites. Dianette treatment was responsible for profound suppression of androgen activity, in contrast to metformin, which induced negligible change. However, metformin did reduce markers of insulin resistance. The data suggest that hirsutism may be effectively treated by reducing hyperinsulinemia.

Update and future of hormonal therapy in acne

Hormonal therapy is an important component in the treatment of women with acne who may or may not have elevated serum androgens. The mainstays of hormonal therapy include oral contraceptives and antiandrogens such as cyproterone acetate, flutamide or spironolactone. Recent research over the past several years has unraveled some of the details regarding the way that the skin and sebaceous glands synthesize and metabolize hormones. The knowledge gained from this work may provide an impetus for future drug discovery in the hormonal treatment of acne and lead to improvements in the care of our patients with acne.

Effects of sex steroids on components of the insulin resistance syndrome in transsexual subjects

OBJECTIVE

Sex differences are found in most components of the insulin resistance syndrome and the associated cardiovascular risk profile. These differences are attributed to sex-specific sex steroid profiles, but the effects of sex steroids on the individual components of the insulin resistance syndrome remain incompletely understood.

DESIGN

Prospective, intervention study.

SUBJECTS

In 37 young (age range 16-36 years), nonobese [body mass index (BMI) < 29], transsexual subjects, effects of ethinyl oestradiol (100 micro g/day) + cyproterone acetate (100 mg/day) administration were evaluated in 20 male-to-female transsexuals and of testosterone-ester administration [250 mg intramuscularly (i.m.)/2 weeks] in 17 female-to-male transsexuals.

MEASUREMENTS

We studied lipid spectrum, postheparin hepatic lipase (HL) and lipoprotein lipase (LPL) activity, blood pressure, glucose utilization (by euglycaemic hyperinsulinaemic clamp), and fat areas (by magnetic resonance imaging) at baseline and during 1-year cross-sex hormone administration.

RESULTS

Oestrogens + antiandrogens increased high-density lipoprotein (HDL)-cholesterol and decreased LDL-cholesterol, and HL activity, which are considered beneficial. But this combination also increased triglycerides, blood pressure, subcutaneous fat and visceral fat, and decreased the LDL-particle size, LPL activity and insulin sensitivity, which are all considered detrimental. Testosterone reduced HDL-cholesterol and the LDL-particle size, and increased triglycerides and HL activity. An android fat distribution was induced (i.e. decreased subcutaneous and increased visceral fat). Blood pressure, total and LDL-cholesterol, LPL activity and insulin sensitivity were mainly unaffected.

CONCLUSIONS

The effects of cross-sex hormone treatment - in the dosages used in this study - in healthy, nonobese, young transsexual subjects do not show unequivocally that female sex steroids, given in large amounts to male subjects, have beneficial effects on cardiovascular profile and that high dose testosterone administration to female subjects is detrimental with respect to cardiovascular risk.

A randomized controlled trial of second- versus third-generation oral contraceptives in the treatment of acne vulgaris

OBJECTIVE

This study was undertaken to compare the clinical efficacy of second- versus third-generation oral contraceptives in the treatment of acne.

STUDY DESIGN

Thirty-four women with acne were randomly selected to receive an oral contraceptive containing 0.3 mg of ethinyl estradiol (EE)/0.15 mg of desogestrel or 0.3 mg of EE/0.15 mg of levonorgestrel for 9 months. Acne was scored by lesion counting by a single examiner, and serum was analyzed for sex hormone-binding globulin (SHBG), dehydroepiandrosterone sulfate (DHEAS), and free and total testosterone at baseline and 3-month intervals.

RESULTS

At baseline, the two treatment groups did not differ in the mean age, body mass index, acne lesion counts, SHBG, DHEAS, or free and total testosterone. Mean acne lesion counts decreased significantly in both groups from baseline (P <.02). In subjects completing 9 months of therapy, acne decreased by 52.8% in the EE/levonorgestrel group (n = 9) and by 58.5% in the EE/desogestrel group (n = 7) (between groups: P not significant). Mean SHBG increased by 46.3 nmol/L in the EE/desogestrel group (P not significant), and 20.0 nmol/L in the EE/levonorgestrel group (P <.05). Decreases in free testosterone from baseline occurred in each group, but these differences did not reach statistical significance.

CONCLUSION

Oral contraceptives containing EE/desogestrel and EE/levonorgestrel were both effective in treating acne.

Contrasting effects of two hormone replacement therapies on the cardiovascular and mammary gland outcomes in surgically postmenopausal monkeys

OBJECTIVE

The purpose of this study was to compare the effects of two hormone replacement therapies on the intermediate end points of coronary heart disease and mammary gland hyperplasia in postmenopausal monkeys.

STUDY DESIGN

Surgically postmenopausal cynomolgus monkeys were fed an atherogenic diet for 12 months while receiving no treatment (control, n = 19), conjugated equine estrogens plus continuous medroxyprogesterone acetate (n = 19), or ethinyl estradiol plus norethindrone acetate (n = 21) at doses that were scaled from those doses taken by women.

RESULTS

Quantitative coronary angiography revealed that the arteries of the control group and the conjugated equine estrogens plus continuous medroxyprogesterone acetate-treated animals constricted in response to acetylcholine (-5.4% +/- 1.4% and -6.2% +/- 1.5%, respectively), whereas those arteries in the animals in the ethinyl estradiol plus norethindrone acetate group did not (P =.002). The incidence of dobutamine-induced ST-segment depression in the ethinyl estradiol plus norethindrone acetate group (10.5%) was significantly less than in the control group (68.8%, P =.001) or the conjugated equine estrogens plus continuous medroxyprogesterone acetate group (50%, P =.01). Conjugated equine estrogens plus continuous medroxyprogesterone acetate, but not ethinyl estradiol plus norethindrone acetate, induced diffuse epithelial tissue proliferation in the mammary glands (P =.0006).

CONCLUSION

Ethinyl estradiol plus norethindrone acetate protected against atherosclerosis-induced endothelium-mediated vasoconstriction of coronary arteries and heart rate-induced myocardial ischemia and did not induce epithelial tissue proliferation (tissue density) in the mammary gland.

[Medication of the month. Lowette, a contraceptive for treating acne in young women]

Acne is a multifactorial disorder affecting the vast majority of adolescents and young adults. Among the therapeutic armamentum, estroprogestative contraception can be offered to young women. The choice must, however, be carefully targeted because the estroprogestative associations do not show similar anti-acne efficacy. A new contraceptive associating 20 micrograms of ethinyl estradiol and 100 micrograms of levonorgestrel (Lowette) has proven its clinical efficacy in this indication.

Differences in the use of combined oral contraceptives amongst women with and without acne

BACKGROUND

Cyproterone acetate combined with ethinyl estradiol (CPA/EE) provides a treatment option for women with acne, hirsutism or polycystic ovary syndrome (PCOS). CPA/EE may be prescribed as an oral contraceptive (OC), but is not licensed as such in the UK. The use of CPA/EE steadily increased after its introduction to the UK market in 1987, but there was a marked increase in its share of the OC market after 1995.

METHODS

Using the General Practice Research Database, utilization patterns of CPA/EE and conventional oral contraceptives were compared in women aged 15-39 years, with or without acne or PCOS.

RESULTS

Between 1994 and 1998, CPA/EE accounted for an increasing proportion of all OC use. The proportion of CPA/EE prescribed to women with acne declined between 1994 and 1998, whereas that prescribed to women with PCOS remained constant. The age-specific use of CPA/EE by women with acne or PCOS almost doubled. After 1995, there was a marked increase in the use of products containing levonorgestrel by women with acne or PCOS.

CONCLUSIONS

A large proportion of CPA/EE is prescribed to women with acne and/or PCOS, although this proportion decreased between 1992 and 1998. This has important implications in CPA/EE risk assessment studies.

[Piperazinyl estrone prevents bone loss in ovariectomized rats]

AIM

To determine the effect of piperazinyl estrone, a new estrogen derivative, on bone turnover, bone mass and uteri in ovariectomized rats.

METHODS

Female Sprague-Dawley rats were ovariectomized (OVX) or sham operated (sham) at the age of 3 months and treated with estrone (E) at 0.75 mg.kg-1.d-1, or with piperazinyl estrone (P-E) at 1 or 10 mg.kg-1.d-1, orally, for 3 months. At the time of death, the uterine weight was measured. Bone histomorphometric analysis of proximal tibial metaphyses (PTM) was performed in undecalcified sections.

RESULTS

Bone histomorphometric data showed that the percent trabecular area (% Tb.Ar) of OVX rats with bone high turnover was significantly decreased. The uteri were atrophied. The percent trabecular area (% Tb.Ar) of estrone treated group was increased in decreasing bone turnover manner. But the size and weight of uteri in this group were increased vs OVX group. The bone loss induced by OVX was preserved by P-E treatment, but the mechanism of maintaining bone is different from that of E-treated rats. P-E treatment in low dose did not decrease any bone formation indices, such as percent labeling perimeter, bone formation rate per bone volume (BFR/BV), except bone mineral apposition rate (MAR) compared with E-treated group, and maintained them at OVX level. The uteri were found to be in atrophy compared with the match dose (0.75 mg) of E-treated OVX rats. But rats treated with high dose of P-E showed the same change like E-treated group.

CONCLUSION

The finding of this study shows that lower dosage of piperazinyl estrone has effect on preventing the bone losses in OVX rats, while the bone formation and the uterus are not affected, thus supporting the hypothesis that piperazinyl estrone has the potential to prevent postmenopausal bone loss in women with less side effects.

Economic evaluation of norethisterone acetate/ethinylestradiol (FemHRT) for women with menopausal symptoms

INTRODUCTION

The objective of this study was to assess the cost effectiveness of a continuous combined oral preparation of norethisterone (norethindrone) acetate and ethinylestradiol (NA/EE) [FemHRT] as both a first-line and second-line therapy for menopausal women.

PERSPECTIVE

Third-party payer.

METHODS

The cost effectiveness of NA/EE was assessed as both a first- and second-line therapy in comparison with conjugated equine oestrogen 0.625mg and medroxyprogesterone acetate 2.5mg (CEE/MPA) and no therapy. Analysis was conducted within a Markov model with states relating to the presence and absence of vaginal bleeding, menopausal symptoms and hip fracture. Analysis forecasted life expectancy, QALYs and lifetime costs for a 50-year-old menopausal woman. Compliance was modelled related to menopausal symptoms and vaginal bleeding. For the base-case analysis, it was assumed that compliant women would take therapy for up to 5 years. Sensitivity analysis assumed therapy was taken only for 1 year.

RESULTS

Compared with both CEE/MPA and no therapy, NA/EE led to an increase in both costs and QALYs, both as a first- and second-line therapy. For first-line therapy, the incremental cost per QALY gained for NA/EE was $2200 Canadian dollars ($Can; 1999 values) [compared with no therapy] and was $Can20 300 (compared with CEE/MPA). For second-line therapy, the incremental cost per QALY gained for NA/EE was $Can900 (compared with no therapy) and was $Can16 400 (compared with CEE/MPA). Results were robust to most sensitivity analyses.

CONCLUSIONS

NA/EE is a cost-effective therapy for women with menopausal symptoms both as a first-line and second-line therapy.

Metformin versus ethinyl estradiol-cyproterone acetate in the treatment of nonobese women with polycystic ovary syndrome: a randomized study

Metformin, an insulin-sensitizing drug, has been shown to improve ovarian function and glucose metabolism in obese women with polycystic ovary syndrome (PCOS), but its effects and possible benefits in nonobese PCOS subjects are not well known. Seventeen nonobese (body mass index < 25 kg/m(2)) women with PCOS were randomized to receive either metformin (500 mg twice daily for 3 months, then 1000 mg twice daily for 3 months; n = 8) or ethinyl estradiol (EE, 35 microg)-cyproterone acetate (CA, 2 mg) oral contraceptive pills (EE-CA; n = 9). Waist to hip ratio; serum concentrations of sex steroids, glucose, and insulin during a 75-g oral glucose tolerance test; early phase insulin and C-peptide secretion; and insulin sensitivity using a euglycemic hyperinsulinemic clamp were assessed at baseline and at 3 and 6 months of treatment. Metformin did not have any effect on glucose tolerance or insulin sensitivity, but fasting insulin concentrations decreased from 44.4 +/- 5.1 (SE) to 29.8 +/- 4.3 pmol/liter (P = 0.03), the waist to hip ratio decreased from 0.78 +/- 0.01 to 0.75 +/- 0.01 (P = 0.01), and hepatic insulin clearance increased during the treatment. Furthermore, metformin decreased serum testosterone levels from 2.7 +/- 0.3 to 2.0 +/- 0.2 nmol/liter (P = 0.01) and improved menstrual cyclicity. EE-CA did not have any significant effect on glucose tolerance, serum insulin levels, or insulin sensitivity, but it increased slightly the body mass index (P = 0.09) and significantly serum leptin concentrations (P < 0.001) and decreased serum testosterone levels from 2.1 +/- 0.2 to 1.4 +/- 0.2 nmol/liter (P = 0.03). In conclusion, EE-CA seems to be an efficient mode of therapy for hyperandrogenic symptoms associated with PCOS, but its possible negative effects on insulin and glucose metabolism also have to be taken into consideration in nonobese subjects. Metformin improved hyperandrogenism, hyperinsulinemia, and menstrual cyclicity, most likely through its positive effect on insulin clearance and abdominal adiposity. Thus, similarly to obese PCOS women, nonobese PCOS subjects with anovulation may also benefit from metformin treatment.

The effects of synthetic conjugated estrogens, a (cenestin) on trabecular bone structure and strength in the ovariectomized rat model

This study evaluated the effect of Cenestin, a synthetic conjugated estrogens product, on the maintenance of trabecular bone microarchitecture, bone strength, and of bone turnover in the ovariectomized (ovx) rat model. Two doses of Cenestin were chosen in an attempt to approximate the equivalent human oral doses of 0.3 mg and 0.625 mg. Forty-nine 6-month-old retired female breeder Sprague-Dawley rats were randomly assigned to one of four groups: (1) sham-operated + vehicle; (2) ovx + vehicle; (3) ovx + day 1 post-ovariectomy Cenestin (8.12 mg/kg); (4) ovx + day 1 post-ovariectomy Cenestin (16.24 mg/kg) for 8 weeks. Trabecular structure of the right proximal tibia of each rat was imaged noninvasively by microCT. A compression test to induce a tibial plateau fracture was performed to determine the mechanical properties of the proximal tibia. Urine was collected on days 0, 14, 28, 42 and 56 and serum on days 0, 28 and 56 to assess biochemical markers of bone turnover including deoxypyridinoline crosslinks and osteocalcin. Both biochemical markers of bone turnover were analyzed by ELISA. Trabecular bone mass, structure, and connectivity density in the Cenestin-treated groups did not differ statistically ( p>0.05) from those of the sham-operated + vehicle-treated rats, but all were significantly higher ( p<0.05) than in the ovx + vehicle-treated rats. Structure Model Index, a measure of trabecular plate morphometry, in Cenestin-treated rats maintained a more equal mix of plate- and rod-like structures similar to the sham group, whereas the ovx group had predominantly rod-like trabeculae. Fracture load in the Cenestin (16.24 mg/kg) treated group was 31% ( p<0.01) higher than in the sham + vehicle-treated group and 61% ( p<0.05) higher than in the ovx + vehicle-treated group. Both the sham-operated + vehicle-treated and Cenestin-treated groups showed significantly lower urinary deoxypyridinoline crosslink excretion at all timepoints and serum osteocalcin at day 56 compared with the ovx + vehicle-treated group. In summary, Cenestin maintained trabecular bone microarchitecture and strength in an ovariectomized rat model of estrogen deficiency.

[Roles of sex hormones and oxygen free radical in coronary heart disease]

To examine the roles of sex hormones and oxygen free radical(OFR) in coronary heart disease (CHD), the serum estradiol(E2), testosterone(T), SOD, MDA and lipid levels were measured in 44 postmenopausal women with CHD and 22 health women. Mean levels of T and MDA were significantly higher while mean levels of SOD and E2 were significantly lower in CHD group than those in control group. On relative analysis, there was a positive correlation between E2 and SOD, while a negative correlation was observed between T and MDA in CHD group. Eighteen postmenopausal women with CHD had been receiving nilestriol replacement therapy for 12 weeks. The serum SOD and HDL-C/TC levels increased significantly, but LDL-C and MDA decreased significantly. The overall data suggest that OFR plays an important role in CHD; Low E2 levels is a risk factor of CHD in postmenopausal women; Nilestriol replacement therapy can improve the metabolism of serum lipids and inhibit lipid peroxidation, therefore, it may be of benefit to postmenopausal women with CHD.

Management of the urethral outlet in patients with severe prolapse

PURPOSE OF REVIEW

Numbers of women seeking consultation for pelvic floor disorders, a large portion of which will involve pelvic organ prolapse (POP) and lower urinary tract dysfunction, are expected to reach epidemic proportions within the next decade. A full understanding of the complex impact of pelvic organ prolapse on lower urinary tract function is crucial to successful management.

RECENT FINDINGS

Recent data lend support to the concept that women with POP, but no associated urethral dysfunction, may be best served by a surgical repair that carefully avoids dissection in the periurethral area. Conversely, preoperative evaluation will often reveal bladder outlet obstruction concomitant with 'hidden', 'potential', or 'occult' stress urinary incontinence when the prolapse is reduced. Many of these women will not have incontinence symptoms in daily life. Paradoxically, the mechanical bladder outlet obstruction may induce detrusor instability with subsequent obstructed/overactive bladder symptom complexes not dissimilar to those of men with prostatic bladder outlet obstruction. Anatomic research shows that the vessels and nerves supplying the urethra are particulary vulnerable to surgical techniques used in pelvic organ prolapse repair.

SUMMARY

This mix of obstructed, overactive bladder with hidden stress incontinence increases with degree of POP, and all women with severe prolapse will fair best if evaluated for all three conditions prior to surgical repair.

[Ultrasonographic and lipid changes in polycystic ovary syndrome according to the type of treatment ]

OBJECTIVE

To determine the ultrasonographic and lipid changes in women with polycystic ovary syndrome (PCOS) according to the type of hormonal treatment.

STUDY DESIGN

Thirty-two women with clinical and ultrasonographic diagnosis of PCOS were studied and randomly distributed in one or another treatment group. Group I: chlormadinone (2 mg/day for 5 days every month) (n = 16) and Group II: ethinylestradiol 35 micrograms plus desogestrel 150 mg (21 days every month) (n = 16). At baseline and at third month a pelvic ultrasound was done to assess the number and size of follicles, also total cholesterol and triglycerides were measured.

RESULTS

In both groups a significant decrease was found in the number of follicles in both ovaries, but only in group II there was a significant decrease in follicular size in both ovaries. No differences were found between the groups in the number of follicles or in the final follicular size. In both groups, a significant decrease was found in total cholesterol levels, without changes in triglycerides levels.

CONCLUSION

Only combined therapy decreased follicular size. So the type of treatment should be based on patient expectations such as sexual activity, or for control of androgen excess.

Growth hormone and low dose estrogen in Turner syndrome: results of a United States multi-center trial to near-final height

A cardinal clinical feature of Turner syndrome (TS) is linear growth failure resulting in extreme short stature: the median adult height of untreated women with TS is 143 cm, 20 cm (8 in.) below that of the general female population. In the largest multicenter, randomized, long-term, dose-response study conducted in the United States, 232 subjects with TS received either 0.27 or 0.36 mg/kg.wk of recombinant human GH with either low dose ethinyl E2 or oral placebo. The study was placebo-controlled for both GH and estrogen for the first 18 months and remained placebo-controlled for estrogen for its duration. The near-final height of the 99 subjects whose bone age was at least 14 yr was 148.7 +/- 6.1 cm after 5.5 +/- 1.8 yr of GH started at a mean age of 10.9 +/- 2.3 yr; this represents an average increase of 1.3 +/- 0.6 SD scores from baseline (TS standard). Height was greater than 152.4 cm (60 in.) in 29% of subjects compared with the expected 5% of untreated patients. Mean near-final heights of subjects who received the lower GH dose, with or without estrogen, were 145.1 +/- 5.4 and 149.9 +/- 6.0 cm, respectively; those who received the higher GH dose with or without estrogen achieved mean near-final heights of 149.1 +/- 6.0 and 150.4 +/- 6.0 cm, respectively. Factors that most impacted outcome were younger age, lower bone age/chronological age ratio, lower body weight, and greater height SD score at study entry. This study demonstrates significant GH-induced improvement in height SD score, with correction of height to within the normal channels for a significant number of patients, and provides evidence of a GH dose-response effect. These data also indicate that early administration of estrogen, even at relatively low doses, does not improve gain in near-final height in patients with TS.

[Diffuse hair loss in women]

The complaint "Doctor, I am losing my hair" represents a particular challenge to the physician, and involves making a specific diagnosis, selecting an appropriate therapy, and expressing empathy for the patient's anxiety. Diffuse hair loss in women was formerly classified as an entity of its own. Since the identification of female pattern hair loss, most cases have been recognized to be due to androgenetic alopecia, often during phases of life characterized by fluctuations of sexual hormone levels or in connection with intake or cessation of hormonal therapy. The most difficult differential diagnosis includes androgenetic alopecia, chronic telogen effluvium, and psychogenic pseudo efflvuium. Androgenetic alopecia is due to androgen-induced, non-synchronized, progressive shortening of the hair growth cycle and gradually leads to thinning of the central scalp area. Idiopathic chronic telogen effluvium typically occurs in women, starting abruptly without a recognizable initiating factor, and involves the entire scalp area with increased shedding of telogen hair. It is believed to be due to synchronization phenomena of the cyclic hair growth. Psychogenic pseudo effluvium affects fashion-oriented, self-conscious women suffering of a discrepancy between the actual state of their hair and idealized expectations. Later the problem of age-related hair thinning oft becomes a surrogate for the more generalized problem of senescence. Rational therapy of androgenetic alopecia aims at blocking the androgen effect on hair follicles with estrogens and antiandrogens or at pharmacologically reversing vellus hair transformation with topical minoxidil. In contrast, women with idiopathic chronic telogen effluvium should be reassured that their problem is rather a state of exaggerated "hair shedding" than of actual "hair loss".

Combined treatment with testosterone (T) and ethinylestradiol (EE2) in constitutionally tall boys: is treatment with T plus EE2 more effective in reducing final height in tall boys than T alone?

Estrogens have been shown to rapidly inhibit longitudinal growth in tall boys. To antagonize the initial growth accelerating effect of T, 41 boys with an initial height prediction in excess of 203 cm were treated prospectively with either T enanthate (TE) 250 mg/wk im in combination with ethinylestradiol (EE2) 0.1 mg/d taken orally for the first 5.8 +/- 0.47 wk (mean +/- SE) of treatment (group 1, n = 20) or with TE alone (group 2, n = 21). Patients were randomized to one or the other treatment regimen. Mean (+/-SE) predicted adult height was 206.8 +/- 0.7 cm in group 1 and 206.4 +/- 0.8 cm in group 2. Total duration of treatment was 16.1 +/- 0.8 months and 14.0 +/- 1.2 months in group 1 and 2, respectively (NS). EE2-induced side effects in group 1 (gynecomastia) were limited and fully reversible. No negative long-term sequelae were found at final height with respect to hypothalamic-pituitary-gonadal axis activity and to testis volumes. Although there was a tendency to a lower initial growth velocity measured by knemometry in group 1 (0.30 +/- 0.05 vs. 0.38 +/- 0.05 mm/wk, NS), final height did not differ in both study groups (195.0 +/- 0.8 cm in group 1, 194.6 +/- 0.8 cm in group 2). Similarly, height reduction (initial predicted adult height minus final height) was not significantly different between the two groups (12.0 +/- 0.9 cm in group 1, 11.7 +/- 0.9 cm in group 2). In conclusion, the addition of EE2 during the initial treatment phase to high-dose T in tall boys has no significant effect on height reduction. The results of this clinical trial suggest that the initial growth inhibiting effect of EE2 on the epiphyseal growth plates is overridden by the long-term administration of high dose TE.

Poor uterine development in Turner syndrome with oral oestrogen therapy

OBJECTIVE

To evaluate uterine development in Turner syndrome (TS) patients in relation to treatment with oral ethinyl oestradiol (E2 ) for pubertal induction.

DESIGN AND PATIENTS

Pelvic ultrasound data for 96 TS patients scanned since 1989 were analysed. Patients were classified into three groups: (1) untreated (n = 48); (2) complete spontaneous puberty (n = 10); and (3) treated with ethinyl oestradiol (n = 38). Uterine development was described in the three groups and compared with the normal data.

MEASUREMENTS

Uterine length, fundal-cervical ratio (FCR) and shape were recorded, and presence or absence of ovaries noted. In the treated group, cross-sectional and longitudinal data were combined to compare uterine development with Tanner breast stage.

RESULTS

In untreated girls up to age 10 years there was a variable distribution of uterine length and FCR about the mean. Thereafter, the uterus failed to grow and mature normally. Girls with complete spontaneous puberty had morphologically normal ovaries and uteri, but of 7 girls who attained menarche, 3 subsequently developed secondary oligomenorrhoea or amenorrhoea. In the treated group, in general, breast development and uterine length progressed with increasing E2 dose. However, only 50% of girls with complete secondary sexual development had a mature heart-shaped uterine configuration.

CONCLUSIONS

Our current E2 treatment regimen for TS girls gives rise to satisfactory pubertal induction and maintenance, but failed to induce a fully mature uterus in half the cohort. In view of the high risk of miscarriage in TS in both spontaneous and assisted pregnancies, the effect of more physiological methods of E2 replacement on uterine development should be investigated.

Short-term effects of new synthetic conjugated estrogens on biochemical markers of bone turnover

Fifty early postmenopausal women completed a double-blind, placebo-controlled study evaluating the short-term effect of a new synthetic conjugated estrogens formulation (Cenestin) on bone turnover. Subjects were randomized to either 0.625 mg/day synthetic conjugated estrogens (n = 35) or placebo (n = 15) for 3 months. Biochemical markers were evaluated at baseline (three measurements at Days -2, -1, and 0) and Days 30, 60, and 90. Bone resorption assessed by urinary NTX (-31.4%) and serum CTX (-34.2%) was significantly (p < 0.01) decreased in the estrogen-treated group compared to the placebo group within 1 month of treatment. The mean percent decreases for urinary NTX from baseline during estrogen treatment were -58.0% (p < 0.01 vs. placebo) and -34.1% (ns) after 2 and 3 months, respectively. For serum CTX, the percent changes from baseline were -17.6% (p < 0.01) and -16.9% (p < 0.01) at 2 and 3 months, respectively. As expected, the decrease of both bone formation markers (bone ALP and PINP) was delayed compared to that of bone resorption and significant (p < 0.05-0.01) only after 2 months of treatment in the estrogen-treated group compared to the placebo group. Synthetic conjugated estrogens significantly decreased bone resorption and bone formation comparable to that previously reported for estrogen treatments proven efficacious in preventing postmenopausal bone loss.

The effects of estrogen administration on bone mineral density in adolescents with anorexia nervosa

OBJECTIVE

Profound osteopenia is a serious complication of anorexia nervosa (AN). The aim of this work was to study the effect of prolonged AN on lumbar spine bone mineral density (BMD) and to determine whether oral estrogen administration prevents bone loss in women with this disorder.

SUBJECTS AND METHODS

Thirty-eight amenorrheic women with AN (mean age: 17.3 years) were treated with estrogen (50 microg of ethinyl estradiol) and gestagen (0.5 mg of norgestrel) during 1 year. Clinical variations, biochemical indices and BMD were studied at three different time points, including after a period of amenorrhea of at least 12 months (n=38), after the administration of estrogens for 1 year (n=22), and after a 1-year follow-up period (n=12).

RESULTS

Initial mean BMD was significantly lower than normal (-2.1+/-0.8 s.d.) and less than -2.5 s.d. below normal in 38% of the women with AN. The estrogen-treated group had no significant change in BMD even after the follow-up period and partial recovery of weight. Estradiol and total IGF-I levels were significantly lower throughout the study. All subjects had normal thyroxine (T(4)) and TSH levels and calcium metabolism. However, total tri-iodothyronine (T(3)) was decreased in all anorexic subjects in the first and second study points and were within normal limits after the follow-up period.

CONCLUSIONS

(1) Estrogen replacement alone cannot prevent progressive osteopenia in young women with AN. (2) Other factors, such as the loss of weight, the duration of the amenorrhea and the low levels of total insulin-like growth factor-I (IGF-I) could contribute to the loss of bone mass in women with this disorder.

Low-dose oral contraceptives: protective effect on ovarian cancer risk

Low-dose oral contraceptive (OC) formulations containing 35 microg or less ethinyl estradiol have preferably been prescribed in the last decade, however, few data exist on its relation to ovarian cancer risk. We determined the effects of low-dose OC on the risk of ovarian cancer in a population-based case-control study, including 282 patients ages 20-75 years at diagnosis of incident primary invasive ovarian cancer or borderline tumour between 1993-1996 and 533 control subjects individually matched by age and study area to each case. Analysis excluded women who had undergone a bilateral ovariectomy or had a previous diagnosis of either ovarian cancer or borderline tumour. The association of OC use by ethinyl estradiol dose and ovarian cancer risk was assessed by odds ratios (OR), adjusting simultaneously for the other OC types and determinants of ovarian cancer risk. Ovarian cancer risk was significantly reduced by 52% for ever use of any type of OC. The reduction in risk was 7% per year of use (OR = 0.93, 95% confidence interval [CI] = 0.90-0.96) and was more evident in first-use subjects younger than 25 years. Risk reduction for ovarian cancer was substantial for use of low-dose OC, the odds ratios being 0.86 (95% CI = 0.77-0.94), 0.91 (95% CI = 0.83-1.00), and 0.95 (95% CI = 0.91-0.99) per year of using OC containing <35 microg, 35-<50 microg, and >or=50 microg ethinyl estradiol, respectively. Our study provides evidence that low-dose oral contraceptives confer substantial protection against the development of ovarian cancer.

Phenotype, ovarian function, and growth in patients with 45,X/47,XXX Turner mosaicism: implications for prenatal counseling and estrogen therapy at puberty

OBJECTIVE

Our objective was to determine whether girls with the rare Tur-ner 45,X/47,XXX mosaic karyotype are less severely affected than girls with 2 commoner karyotypes.

STUDY DESIGN

We evaluated growth status, phenotype, and ovarian function in 7 girls with 45,X/47,XXX mosaicism, age-matching each with 2 girls with 45,X and 1 with 45,X/46,Xi(X)(q10) karyotypes.

RESULTS

For the index, 45,X, and 45,X/46,Xi(X)(q10) groups, respectively, the median/mean height SD score at the start of growth hormone therapy/comparable age was -2.0 (-1.2), -2.3 (-2.4), and -2.6 (-2.6), cardiac anomalies were identified in 0 of 7, 4 of 14, and 1 of 7, renal abnormalities in 0 of 7, 4 of 14, and 3 of 7, middle ear problems in 2 of 7, 11 of 14, and 4 of 7, and special educational needs in 0 of 7, 3 of 14, and 1 of 7. Complete spontaneous puberty with menarche was seen in all but 1 girl older than 12 years in the index group compared with only 1 girl in the comparison groups. Ovarian tissue was identified in 6 of 7, 0 of 14, and 1 of 7 girls, and the mean follicle-stimulating hormone was 6, 25, and 21 U/L, respectively.

CONCLUSION

Girls with 45,X/47,XXX karyotype are mildly affected, with good preservation of ovarian function. This result has important implications for prenatal counseling and the need for estrogen therapy at puberty.

A longitudinal study of disturbances of the hypothalamic-pituitary-adrenal axis in women with progestin-negative functional hypothalamic amenorrhea

OBJECTIVE

To longitudinally evaluate disturbances of the hypothalamic-pituitary-adrenal (HPA) axis in women with secondary progestin-negative hypothalamic amenorrhea.

DESIGN

Retrospective cohort study.

SETTING

Yokohama City University, Yokohama, Japan.

PATIENT(S)

Twenty-four women with progestin-negative hypothalamic amenorrhea.

INTERVENTION(S)

Administration of human corticotropin-releasing hormone (hCRH) and treatment with a combination of estrogen and progesterone.

MAIN OUTCOME MEASURE(S)

Plasma cortisol and ACTH concentrations and period required for recovery from amenorrhea.

RESULT(S)

Plasma ACTH concentrations 30 and 60 minutes after injection of hCRH and the percent maximum increment (%Cmax) of ACTH were significantly lower in the amenorrheic patients compared with the control group patients. The basal cortisol was significantly higher, and the %Cmax of cortisol was significantly lower. In the 16 patients who recovered from amenorrhea, there was a significant positive correlation (Y = 1.93X-10.8, r = 0.629) between the basal cortisol concentrations (X) and the period for recovery (Y). The serum E2 gradually increased before recovery, and this E2 increase was preceded by changes in the plasma cortisol concentration and the %Cmax values of cortisol and ACTH.

CONCLUSION(S)

The CRH test might be useful for evaluating the roles of stress and for estimating the period required for recovery in hypothalamic amenorrhea.

A scheme of combined oral contraceptives for women more than 40 years old

OBJECTIVE

To study whether the addition of estrogen to the 7 hormone-free days of a combined oral contraceptive (OC) cycle improves the symptomatology in perimenopausal women with climacteric complaints.

DESIGN

A total of 56 women in their forties presenting with mood disorders and/or hot flashes were included in this randomized double-blind study. Symptoms were evaluated using the Greene test. Subjects were allocated into two groups: 23 women received an OC containing 20 microg of ethinyl-estradiol and 150 mg of desogestrel for 21 days and then 7 placebo tablets (placebo group); the other 33 women received 21 tablets with the same hormone combination, followed by 2 placebo tablets and 5 ethinyl-estradiol tablets of 10 microg each (estrogen group). After three cycles, symptoms were reassessed.

RESULTS

Symptoms were similar in the two groups at the start of the study. Three months later, vasomotor symptoms in the placebo group dropped from 3.3 +/- 1.7 to 1.7 +/- 1.8, and in the estrogen group, from 3.0 +/- 1.7 to 0.7 +/- 0.9 (p < 0.04). Similarly, symptoms of depression fell from 8.8 +/- 4.0 to 6.7 +/- 3.9 in the placebo group and from 10.3 +/- 3.5 to 3.8 +/- 2.9 in the estrogen group (p < 0.002). Somatic symptoms fell with placebo from 10.9 +/- 5.3 to 7.4 +/- 5.4, and with estrogen, from 9.7 +/- 4.9 to 4.0 +/- 2.5 (p < 0.03). Sexual dysfunction as measured by the Greene Scale (loss of sexual interest) also improved more in women who received additional estrogen: 2.0 +/- 0.9 to 0.5 +/- 0.9 vs. 1.8 +/- 1.2 to 1.2 +/- 1.2, p < 0.03. Anxiety symptoms improved in both groups but without any significant difference between them.

CONCLUSIONS

Adding 5 days of estrogen to the classic contraceptive scheme improves the climacteric symptoms of perimenopausal women who use OCs.

[Relationship between sex hormone levels and blood calcitonin gene-related peptide/endothelin-1 in postmenopausal women with coronary heart disease]

OBJECTIVE

To investigate the relationship between sex hormone levels and blood calcitonin gene-related peptide/endothelin-1, and to evaluate the therapeutic effects of nylestriol.

METHODS

Forty perimenopausal women without coronary heart disease (CHD) and 30 postmenopausal women with CHD were studied, and 30 postmenopausal women were divided into two groups and treated randomly with either 2 mg nylestriol or placebo. Serum 17 beta-estradiol (E2), testosterone (T), plasma calcitonin gene-related peptide (CGRP) and endothelin-1 (ET-1) were measured.

RESULTS

In postmenopausal women, serum levels of E2 and plasma concentrations of CGRP decreased, while serum levels of T and plasma concentrations of ET-1 increased; E2 was positively related to CGRP, and negatively related to ET-1; T was negatively related to CGRP or ET-1. In the nylestriol group, compared with the parameters before treatment, plasma CGRP increased and ET-1 decreased after treatment.

CONCLUSION

Estradiol possesses certain effects on endothelial cell, which may be an important aspect of its protective effects.

Gynecologists' patterns of prescribing pessaries

OBJECTIVE

To determine how gynecologists in the United States prescribe pessaries.

STUDY DESIGN

A 34-question (long) survey was sent to 2,000 gynecologists. Those who did not respond were then sent a five-question (short) survey.

RESULTS

Nine hundred forty-seven (47.3%) long and short questionnaires were returned. Eighty-six percent of gynecologists prescribe pessaries. Most received minimal or no training in pessaries in their residencies. The most common pessaries used were the ring and doughnut. Uterine prolapse was treated most often with the Gellhorn and doughnut pessaries. The cube and Gellhorn pessaries were thought to be the most effective for vaginal vault prolapse. The Gehrung and ring pessaries were thought to be most effective for correction of cystocele. However, the ring pessary was considered the easiest to use. Follow-up visits were most often performed at one week, one month and then every three months. Estrogen was used in most cases.

CONCLUSION

Most gynecologists prescribe pessaries. The ring pessary is used most often and is deemed the easiest to use. Pessaries are thought to work for all pelvic organ prolapse defects but are thought to be less effective for posterior defects. Follow-up of patients differs from manufacturers' recommendations.

Insulin action and insulin secretion in polycystic ovary syndrome treated with ethinyl oestradiol/cyproterone acetate

Polycystic ovary syndrome (PCOS) is associated with abnormalities of insulin action and insulin secretion. Ethinyl oestradiol/cyproterone acetate is a common agent used to treat the symptoms of PCOS, but its effects on insulin action and insulin pulsatility have not been examined. We investigated the relationship between insulin action and insulin secretion in 11 patients with PCOS, at diagnosis and after 3 months of treatment with ethinyl oestradiol/cyproterone acetate, and in 13 controls. Insulin action was assessed using the euglycaemic hyperinsulinaemic clamp (2 mU/kg/min for 2 h). Insulin pulsatility was examined over 90 min by 2 min sampling. Short-term insulin pulses were identified using PULSAR. Treatment with ethinyl oestradiol/cyproterone acetate resulted in significant reductions in testosterone (3.3+/-0.7 vs. 1.9+/-0.2 nmol/l, p<0.05), free androgen index (10.2+/-0.7 vs. 1.2+/-0.2, p<0.05) and LH/FSH ratio (2.6+/-0.5 vs. 1.0+/-0.2, p<0.05). During hyperinsulinaemic clamps, the glucose infusion rate (GIR) required to maintain euglycaemia was lower in PCOS compared to controls (33.6+/-2.7 vs. 45.1+/-3.5 micromol/kg/min, p<0.05) but similar in PCOS before and after treatment (33.6+/-2.8 vs. 33.6+/-2.7 micromol/kg/min, p=0.9). Numbers of pulses identified in PCOS and controls were similar and unaltered by ethinyl oestradiol/cyproterone acetate. There was no correlation between GIR and frequency of insulin pulses in PCOS before or after treatment (r=0.2, p=0.6; post r=-0.5, p=0.1) unlike controls (r=-0.6, p=0.04). Despite considerable improvement in androgen profile, treatment with ethinyl oestradiol/cyproterone acetate did not alter insulin action in PCOS, and this insulin resistance does not appear to be determined by insulin pulse frequency.