Estrogen Substitution Therapy Research Articles

HOXA10 Expressing UCMSCs Transplantation Improved Endometrial Receptivity on Endometrial Injury.

Endometrial injury is considered the major cause of female infertility. Traditional therapies such as estrogen substitution therapy are not satisfactory due to individual variation in response to treatment, thereby warranting the use of alternative strategies such as stem cell therapy. Transplantation of stem cells, such as umbilical cord mesenchymal stem cells (UCMSCs), has been shown to improve endometrial healing. However, due to the effect of the intrauterine environment, the therapeutic effect of UCMSCs is limited, and its efficacy is unstable. HOXA10, encoded by the HOXA10 gene, plays an important role in endometrium morphology maintenance, proliferation, differentiation, and embryo implantation. Moreover, UCMSCs do not show HOXA10 expression. Our study aimed to evaluate the therapeutic effects of HOXA10-transfected UCMSCs on endometrial injury repair in vivo. First, we established T10-UCMSCs (UCMSCs transfected with HOXA10) for transplantation. To establish the endometrial injury model, we injected 95% ethanol into the uterine cavity and transplanted T10-UCMSCs into the uterine cavity from the cornua uteri. Fourteen days later, uteri were collected for histological and biochemical analysis of endometrial growth and receptivity. Our results showed the endometrial receptivity was better in T10-UCMSCs group than in UCMSCs group, suggesting that HOXA10 could enhance the repairing ability of UCMSCs in the endometrium injury repair. More importantly, the fertility test showed that more embryos were implanted in the T10- UCMSCs group. Our results suggest that UCMSCs with HOXA10 expression could improve the therapeutic effects on endometrial injury repairing.

Estrogen Can Modulate Menopausal Women’s Heart Rate Variability

The aim of our study was to compare the responses of heart rate variability (HRV) with two different types of hormonal substitution therapy (HT) in post-menopausal women (cross-sectional study) and to reveal an effect of HT shortly after beginning of its administration (follow-up study). To elucidate the influence of menopause and effects of different protocols of a HT on autonomic control of heart rate, we evaluated the heart rate variability (HRV) in 5 groups: premenopausal women (n=140), postmenopausal women without HT (n=360), women on HT with conjugated estrogen only (n=168), women on continuous combined estrogen-progesterone HT (n=117), and men (n=140). Frequency-domain of short-term stationary R-R intervals was performed to evaluate the total variance, low frequency power (LF; 0.04-0.15 Hz), high frequency power (HF; 0.15-0.40 Hz), portion of low frequency power (LF%) and ratio of LF to HF (LF/HF). Significantly lower portion of the LF was found in premenopausal women [46.9 (+/-2.7) nu] when compared to untreated postmenopausal women [54.3 (+/-2.9) nu] and men [55.2 (+/-3.0) nu]. Treatment by estrogen only was proved to decrease the LF% [40.1 (+/-2.1) nu] while no effect on HRV was observed in women treated with combination of estrogen and progesterone [57.2 (+/-3.1) nu]. Also the HF was lower in postmenopausal women [4.16 (+/-0.16) ms(2)] than in premenopausal women [4.79 (+/-0.22) ms(2)] and women treated with estrogen only [4.98 (+/-0.25) ms(2)] while in women treated with combined hormonal therapy the average value [3.99 (+/-0.21) ms(2)] did not significantly differ from that of untreated postmenopausal women. The follow-up study also proved increase of high frequency power already after two months of estrogen substitution therapy [4.86 (+/-0.14) ms(2) vs. 4.19 (+/-0.15) ms(2)]. These results suggest that higher vagal modulation of heart rate that seems typical for younger women becomes after menopause similar to that of men. We also proved a positive shift of HRV parameters toward more beneficial values as for a cardiovascular risk in postmenopausal women treated with estrogens but not in those treated by combined estrogen - progesterone substitution therapy.

Intractable Diffuse Alopecia Caused by Multifactorial Side‐Effects in Treatment of Acute Lymphocytic Leukemia: Connection to Iatrogenic Failure of Estrogen Secretion

Treatment of infantile acute lymphocytic leukemia (ALL) may cause failure to thrive and hypogonadism due to hypopituitarism induced by chemotherapy and whole-brain radiotherapy. We report the case of a 22-year-old girl with a genetic predisposition to pattern hair loss who developed inveterate diffuse alopecia. The patient had onset of ALL at 8 years old and underwent bone marrow transplantation (BMT). Diffuse alopecia gradually advanced over her whole body. Her vellus scalp hair gradually came out, and hair loss progressed again at 8 years, after BMT. She later developed iatrogenic failure of secretion of estrogen and was treated with estrogen substitution therapy for 14 months from the age of 20. There was a small increase in the volume of hair during therapy, but alopecia returned to the former level after the therapy was suspended. Histopathologic examinations of the scalp performed during estrogen substitution therapy and 2 years after suspension of the therapy showed a 60% decrease in the number of hair follicles and prominent development of vellus hair. We conclude that estrogen influenced hair growth in the context of a genetic predisposition for pattern hair loss in this case.

Endometrial safety after 5 years of continuous combined transdermal estrogen and intrauterine levonorgestrel delivery for postmenopausal hormone substitution

Objective To investigate endometrial histology and thickness of the endometrium after long-term use of continuous transdermal estrogen substitution combined with intrauterine release of levonorgestrel (LNG) in postmenopausal women. Design A 5-year non-comparative prospective clinical trial. Subjects Out of 182 symptomatic postmenopausal women using estrogen substitution therapy (EST) combined with a novel T-shaped LNG-releasing intrauterine system (Femilis™ Slim LNG-IUS), to prevent endometrial proliferation and bleeding, only those women ( n = 102) who used two consecutive LNG-IUSs, were isolated with the aim to study the long-term effects on the endometrium. The mean age of the women was 57 years (range 47–71). The majority of women received percutaneous 17β estradiol, 1.5 mg daily, or an equivalent dose by patch or orally, on a continuous basis. Main outcome measures Endometrial histology and ultrasonographic evidence of endometrial suppression, after a period of approximately 5 years of use. The mean duration of use of the regimen was 70 months (range 25–98). Results The dominant endometrial histologic picture was that of inactive endometrium characterized by glandular atrophy and stroma decidualization (Kurman classification 5b). No cases of endometrial hyperplasia were found. On transvaginal ultrasound, this corresponds with a thin endometrium (≤5 mm). Conclusion The results of this 5-year study in 102 postmenopausal women using EST demonstrates that the LNG-IUS effectively opposes the estrogenic effect on the endometrium resulting in strong suppression during the entire period of EST. Due to its high efficacy and absence of systemic effects on organ tissues (e.g., breasts), target delivery in the uterine cavity could be a preferred route to administer a progestagen in women using EST.

A mutation c.C2812T in the androgen receptor gene resulting in Pro817Leu substitution may affect dimerization of the androgen receptor and result in androgen insensitivity syndrome

To conduct clinical, genetic, and molecular diagnostics of two sisters with typical symptoms of complete androgen insensitivity syndrome. Case report. Research laboratory at a university of medical science. Two patients with 46,XY karyotype and a female phenotype were diagnosed because of primary amenorrhea. Their sister with 46,XX karyotype, her daughter, and five other family members including their mother also were examined. Orchiectomy, estrogen substitution therapy. Cancer prophylaxis. Multiple-temperature single-stranded conformation polymorphism and sequence analyses of the androgen receptor gene (AR) revealed a c.C2812T transition in exon 7 in the two sisters. Their mother and the third sister (46,XX) were carriers of the same mutation. This mutation, which previously had never been reported, resulted in Pro817Leu substitution in the ligand-binding domain of the androgen. Computer simulation of structural changes generated by Pro817Leu substitution revealed appreciable conformational changes in the region responsible for dimerization of the receptor. The novel c.C2812T transition that might impair dimerization of the receptor is responsible for the clinical symptoms of complete androgen insensitivity syndrome in the affected individuals. Molecular analysis of AR proved to be very useful for genetic counseling of the unaffected sister, who was a carrier of the same mutation.

Continuous combined parenteral estrogen substitution and intrauterine progestogen delivery: the ideal HST combination?

Objective: To evaluate ease of insertion, acceptability and endometrial safety of a novel, miniature intrauterine, T-shaped, levonorgestrel (LNG)-releasing intrauterine system (IUS), Femilis™ Slim LNG-IUS (Contrel Research, Belgium), combined with parenteral estrogen substitution therapy (EST) in postmenopausal women. Design: A prospective, non-comparative, study in postmenopausal women. A 3.0 cm long and 2.0 mm wide coaxial fibrous delivery system, delivering approximately 20 μg/day of levonorgestrel (LNG) was used. The drug compartment is provided with crossarms fixed to the upper part of the drug delivery rod. The calculated duration of release of the system is at least 5 years. The majority of women received percutaneous 17β estradiol (Oestrogel ®, Besins Int., Belgium), 1.5 mg daily on a continuous basis, which provides sufficient blood levels of estrogen in most women to suppress climacteric symptoms and protection against bone loss. Primary outcome measures: ease of insertion, retention and side effects of the T-LNG Slim IUS. Secondary outcome measures: endometrial safety assessed by transvaginal ultrasound examination and by endometrial biopsy in a subset of women. Results: One hundred and seventy insertions were performed in postmenopausal women with median age of age 56.6 (range 43.5–80.3). Insertion was easy in 161 (94.2%) and difficult in 9 (5.3%) women. Pain at insertion was rated as none in 57 women (33.5%), mild in 105 (61.7%), moderate in 7 (4.1%) and severe in 1 (0.5%) woman. The system was well retained in the uterus as no expulsions occurred. At the time of study analysis, the total number of women-months was 1797.5. Ninety-five women had the T-LNG-IUS in place for periods in excess of 1 year. The study was well followed-up with lost-to-follow-up rate (defined as no follow-up during 12 months) of zero at the time of study analysis. The number of women continuing the method was 160 (94.1%) including four women which were released from follow-up for various non-medical related reasons. The histological examinations conducted in 105 women showed predominantly inactive endometrium characterized by a pseudo-decidual reaction of the endometrial stroma with endometrial atrophy. The mean thickness (double-layer) of the endometrium was 3.3 mm (range 2–5 mm) which correlated well with the histology results. Conclusions: The results suggest that the small T-LNG-IUS is easy to insert in most postmenopausal women without anaesthesia and dilatation of the cervix. It is well tolerated, well accepted and effective in suppressing the endometrium during EST. The lack of expulsions of the device in this study is attributed to the optimal design characteristics of the IUS, the absence of uterine bleeding and absent or reduced contractility of the uterus. The study confirms earlier studies conducted with other LNG-releasing systems used for endometrial suppression during EST. The ease of insertion of the small LNG-IUS could be an important incentive to expand the use of the continuous combined regimen with local delivery of the progestogen. It could be a method of choice for endometrial suppression in women using EST with fundamental advantages to systemically applied progestogens which have been the subject of considerable debate as reported in the recent literature.

Endometrial safety with a low-dose intrauterine levonorgestrel-releasing system after 3 years of estrogen substitution therapy

Objective: To evaluate the pharmacodynamic effects of a novel intrauterine drug delivery system, FibroPlant-levonorgestrel (LNG), on the endometrium in 24 postmenopausal women using estrogen substitution therapy (EST) to suppress climacteric symptoms. Design: A 3-year non-comparative prospective clinical trial. Subjects: The treatment with the FibroPlant-LNG intrauterine system (IUS), releasing 14 μg of LNG per day, was part of a regimen for estrogen substitution therapy in symptomatic postmenopausal women to prevent endometrial proliferation and bleeding. The majority of women received percutaneous 17β estradiol, 1.5 mg daily, or an equivalent dose by patch or orally, on a continuous basis. Outcome measures: Menstrual pattern, endometrial histology and ultrasonographic evidence of endometrial suppression, after 3 years of use. Results: The endometrial histology specimen showed profound endometrial suppression with glandular atrophy and stroma decidualization in all women. On transvaginal ultrasound, this corresponds with a thin endometrium (<5 mm) and clinically with a “bleed-free” menstrual pattern or amenorrhoea. Conclusion: The results of this 3-year study in 24 postmenopausal women using EST suggest that the FibroPlant-LNG IUS is effective in causing strong suppression of the endometrium during the entire period of EST. Target delivery in the uterine cavity could be the preferred route of administering a progestin to oppose estrogen stimulation of the endometrium.

Endometrial suppression with a new ‘frameless’ levonorgestrel releasing intrauterine system in perimenopausal and postmenopausal women: a pilot study

Objective: A novel intrauterine drug delivery system, FibroPlant-levonorgestrel (LNG), derived from the frameless GyneFix intrauterine device (IUD) is described and the preliminary results in 30 symptomatic climacteric and postmenopausal women are discussed. The treatment with the FibroPlant-LNG intrauterine system (IUS) was instituted to suppress the endometrium during estrogen substitution therapy (EST) to prevent endometrial proliferation and bleeding. The purpose of the study was to evaluate the clinical and ultrasonographic effect of this new intrauterine progestin delivery system. Methods: Two dosage forms were tested: the first 11 women received a 3-cm long coaxial fibrous delivery system, delivering approximately 10 μg per day of LNG; the remaining 19 women in the study received a 4-cm long delivery system, delivering approximately 14 μg per day. The calculated duration of release of the two systems is approximately 5 years. Twenty-two women were perimenopausal at the start of the treatment. Women in this study were observed for a duration of at least 1 year. Most postmenopausal women received percutaneous 17β-estradiol (Oestrogel), 1.5 mg daily on a continuous basis. Results: All postmenopausal women in the two groups reported amenorrhea during the entire study period (up to two and a half years follow-up). Endometrial atrophy in these women was confirmed by vaginal ultrasound examination. Seventeen of the 22 perimenopausal women reported amenorrhea at the first or second follow-up visit at 1 and 3 months following insertion of the IUS, respectively. The remaining had infrequent scanty bloody discharge needing a panty liner, at the most, for protection. There were no complications in this study (e.g. infection, expulsion or perforation). The FibroPlant-LNG IUS was very well tolerated by all the women and no systemic hormonal side effects were reported. There were no removals for medical reasons. Conclusion: The results of this pilot study suggest that the frameless FibroPlant-LNG IUS is safe, well tolerated and effective in suppressing the endometrium during EST. No differences could be clinically distinguished between the two dosages. Compliance was optimal. The fact that the IUS also acts as a potent contraceptive is of added importance.

Excretion of catecholestrogens in women receiving estrogen-substitution therapy

We compared excretion of classical estrogens and catecholestrogens in smoker and nonsmoker postmenopausal women receiving estrogen-substitution therapy. Combined effect of substitution therapy and smoking, but not smoking along increased production of catecholestrogens, which could enhance the risk of genotoxic (clinically more severe) variant of hormone-induced carcinogenesis.

Long-term effects of allogeneic bone marrow transplantation (BMT) on pituitary, gonad, thyroid and adrenal function in adults.

To evaluate the late-effects of allogeneic bone marrow transplantation (BMT) on endocrine function 20 adults (10 females, 10 males) with hematological malignancies were studied after a mean of 3.2 years (range 1.0-10.0) following BMT. The mean age of patients at the time of BMT was 39 years. Dynamic tests of the hypothalamic-pituitary axis included growth hormone releasing hormone (GHRH), gonadotropin releasing hormone (GnRH) and thyrotropin releasing hormone (TRH) stimulations with measurements of serum growth hormone (GH), follicle stimulating hormone (FSH), luteinizing hormone (LH), thyrotropin (TSH) and prolactin (PRL) responses. Adrenal function was assessed with the adrenocorticotropin (ACTH) test. Five patients (25%) had a subnormal GH response to GHRH stimulation, but all had a normal serum insulin-like growth factor I (IGF-I) value. There was an inverse nonlinear relationship between the body mass index (BMI; kg/m2) and GH response but no relation between the GH response and total body irradiation (TBI), intrathecal treatment or occurrence of graft-versus-host disease. In females, serum FSH and LH basal levels and responses to GnRH, in spite of oestrogen substitution therapy in 9/10 patients, indicated ovarian failure and early menopause. Most responses to GnRH were delayed. All males had elevated serum basal FSH levels indicating damage in seminiferous tubulus and infertility. Serum basal LH was elevated only in four males but testosterone values were all within normal limits. However, the mean free androgen index (FAI) was in the low normal range, and two subjects had abnormally low FAI. Serum free thyroxine (fT4) levels were normal in all but one, but an exaggerated TSH response to TRH occurred in seven patients (35%). Four of them had received TBI and one total nodal irradiation suggesting radiation-induced damage to the thyroid gland. In 19 of the 20 patients, adrenal function judged with ACTH test was normal. We conclude that functional impairments of the hypothalamus-pituitary-gonad/thyroid axis are common while disturbances in GH, adrenal and prolactin occur less often in patients after intensive treatment and BMT. Typically, the target organ is more commonly affected than the hypothalamus-pituitary axis. In spite of normal serum testosterone and LH values, serum FAI may reveal androgen deficiency.

Estrogen Modulates AT 1 Receptor Gene Expression In Vitro and In Vivo

The AT1 receptor has been implicated in the pathogenesis of hypertension and atherosclerosis. Estrogen deficiency is also associated with cardiovascular diseases. Therefore, we examined the AT1 receptor gene expression in ovariectomized rats with and without estrogen replacement therapy and the influence of estrogen on AT1 receptor expression in cultured vascular smooth muscle cells. Rat aortic tissue was examined 5 weeks after ovariectomy. In one group, estrogen (1.7 mg estradiol) was administered during the 5-week period. Functional experiments assessed angiotensin II-induced contraction of aortic rings. AT1 receptor mRNA levels were measured by quantitative polymerase chain reaction and Northern blotting. AT1 receptor density was assessed by radioligand binding assays. These techniques were also applied in cultured vascular smooth muscle cells. The efficacy of angiotensin II on vasoconstriction was significantly increased in aortas from ovariectomized rats. As assessed by radioligand binding assays, AT1 receptor density was increased to 160% without changes in receptor affinity during estrogen deficiency. AT1 receptor mRNA levels were consistently increased to 187% in ovariectomized rats compared with sham-operated animals. Estrogen substitution therapy in ovariectomized rats reversed this AT1 receptor overexpression. To explore the underlying mechanisms, the direct influence of estradiol on AT1 receptor expression was investigated in VSMCs. Estradiol (1 micromol/L) led to a time-dependent downregulation of AT1 receptor mRNA, with a maximum of 33.3% at 12 hours. There was a correlative decrease in AT1 receptor density. This novel observation of estrogen-induced downregulation of AT1 receptor expression could explain the association of estrogen deficiency with hypertension and atherosclerosis, because activation of the AT1 receptor plays a key role in the regulation of blood pressure, fluid homeostasis, and vascular cell growth.

17Beta-estradiol, its metabolites, and progesterone inhibit cardiac fibroblast growth.

Postmenopausal women (PMW) have increased incidence of cardiovascular disease, and estrogen substitution therapy has been shown to have cardioprotective effects. Since abnormal growth of cardiac fibroblasts (CFs) is associated with hypertension and myocardial infarction and estrogen inhibits vascular smooth muscle cell (SMC) growth, it is feasible that estrogen may attenuate cardiac remodeling by inhibiting CF growth, and this possibility was investigated by using cultured CFs. 17Beta-estradiol and progesterone, but not 17alpha-estradiol, estrone, or estriol, inhibited 2.5% FCS-induced proliferation (DNA synthesis and cell number) and collagen synthesis (3H-proline incorporation) in a concentration-dependent manner and to a similar extent in male and female CFs. Compared to 17beta-estradiol, its metabolites 2-hydroxyestradiol and 2-methoxyestradiol were more potent in inhibiting FCS-induced DNA synthesis, collagen synthesis, and cell proliferation. The inhibitory effects of 17beta-estradiol and its metabolites were enhanced in presence of progesterone and 4-hydroxytamoxifen (high-affinity estrogen receptor ligand). Moreover, like estrogens, the dietary phytoestrogens biochanin A and daidzein inhibited FCS-induced growth of CFs. In conclusion, 17beta-estradiol, its metabolites, and progesterone inhibit CF growth in a gender-independent fashion. Moreover, hormone replacement therapy using 17beta-estradiol and progesterone may protect PMW against cardiovascular disease by inhibiting CF growth and cardiac remodeling; whereas estrogens that do not inhibit CF growth may be less effective in protecting PMW against cardiovascular disease. Finally, our studies provide evidence that phytoestrogens inhibit CF growth and may be clinically useful as a substitute for feminizing estrogens in preventing cardiovascular disease in both women and men.

Senile (type II) osteoporosis: pathogenesis and prevention of estrogen deficiency-related bone loss at the proximal femur.

Fractures of the proximal femur are associated with considerable morbidity and mortality. The residual effects of estrogen deficiency-related bone loss (partially) account for the higher incidence of hip fracture in elderly women compared to elderly men. This accelerated phase of postmenopausal bone loss can be prevented by estrogen substitution therapy. However, when estrogen substitution is discontinued, bone density declines at a rate similar to the perimenopausal one. In line with these densitometric data, several studies have provided evidence that the protective effect of estrogen therapy on hip fracture incidence does not persist after discontinuation of substitution. To prevent hip fractures in old age, estrogen treatment may have to be initiated perimenopausally and never discontinued. At present, however, such a strategy cannot be recommended as it has not been settled yet whether the benefits of estrogen substitution outweigh the risks.

Dysfunction of Monocytes and Dendritic Cells in Patients With Premature Ovarian Failure

Due to the presence of ovarian antibodies it has been suggested that premature ovarian failure (POF) belongs to the autoimmune endocrinopathies. Monocytes and the monocyte-derived dendritic cells play a prominent role in the initial stages of endocrine autoimmune reactions: the accumulation of monocytes/dendritic cells and the clustering of dendritic cells in endocrine organs is one of the first phenomena of an autoimmune endocrinopathy. This report describes a study on (1) the chemotactic responsiveness of blood monocytes, and (2) the cluster capability of blood dendritic cells in POF patients. The monocyte chemotaxis was determined using the cell's capability to polarize (changes in shape determined by light microscopy) under the influence of the chemoattractant, N-formyl-methionyl-leucyl-phenylalanine (fMLP). The cluster capability of dendritic cells was tested by allowing the dendritic cells to form aggregates with allogenic lymphocytes in vitro. The blood monocytes of 46% of a total of 28 POF patients showed a decreased fMLP induced monocyte polarization in comparison to healthy control values. None of the young female controls (N = 28) and postmenopausal women (N = 17), showed such a defective monocyte polarization. The blood dendritic cells of 36% of the POF patients showed a decreased cluster capability. Defects in monocyte polarization and dendritic cell clustering were not affected by therapies aimed at changes in the estrogen levels or gonadotropin levels of the patients [using estrogen substitution therapy, gonadotropin-releasing hormone (GnRH) analog, follicle-stimulating hormone (FSH)]. A redistribution of active monocytes and of active dendritic cells from the peripheral blood to the ovaries may be the cause of the described abnormalities. Since similar abnormalities in monocyte function and dendritic cell function have been described in Graves' disease and type I diabetes, the data strengthen the view that POF is one of the endocrine autoimmune diseases.

Decrease of bone mineral density during estrogen substitution therapy

A decrease in bone mineral density (BMD) in patients treated with hormone replacement therapy (HRT) is sometimes observed in clinical practice. In order to assess the frequency and the characteristics of these cases, we reviewed the data of 102 women treated with HRT for more than 2 years, and who had undergone at least 3 lumbar BMD measurements during that period. For each patient, a linear function was fitted to the BMD data in relation to time. The slope was calculated. There was an overall gain in BMD during treatment, mean (± S.E.M.) values of slope 0.007 g/cm 2/year (± 0.002). Fifty-three patients had a slope higher than 0.005, 28 a slope close to 0 (between 0.005 and −0.005) and 21 a slope lower than −0.005. By dividing the patients in tertiles of slopes (tertile l: slope < 0; tertile II: 0 < slope < 0.011; tertile III: slope > 0.011), significant differences were observed between the three groups of slope for the initial BMD ( P < 0.001), hydroxyproline/creatinine ratio ( P < 0.01), weight, DHEAS and alkaline phosphatase ( P < 0.05). Only 1 of the 15 patients with a low bone mass (lower than mean ± I S.D.) had a negative slope, while 9 of the 16 with a high-bone mass (higher than mean ± I S.D.), had a negative slope. Under HRT, about 21% of postmenopausal women have a slight decrease in BMD as assessed by DPA. Because of the DPA coefficient of variation, however, the exact number of bone losers cannot be determined. Nevertheless, the present study suggests that patients with low bone mass are likely to respond better than patients with high bone mass.

Decrease of bone mineral density during estrogen substitution therapy

A decrease in bone mineral density (BMD) in patients treated with hormone replacement therapy (HRT) is sometimes observed in clinical practice. In order to assess the frequency and the characteristics of these cases, we reviewed the data of 102 women treated with HRT for more than 2 years, and who had undergone at least 3 lumbar BMD measurements during that period. For each patient, a linear function was fitted to the BMD data in relation to time. The slope was calculated. There was an overall gain in BMD during treatment, mean (± S.E.M.) values of slope 0.007 g/cm2/year (± 0.002). Fifty-three patients had a slope higher than 0.005, 28 a slope close to 0 (between 0.005 and −0.005) and 21 a slope lower than −0.005. By dividing the patients in tertiles of slopes (tertile l: slope 0.011), significant differences were observed between the three groups of slope for the initial BMD (P < 0.001), hydroxyproline/creatinine ratio (P < 0.01), weight, DHEAS and alkaline phosphatase (P < 0.05). Only 1 of the 15 patients with a low bone mass (lower than mean ± I S.D.) had a negative slope, while 9 of the 16 with a high-bone mass (higher than mean ± I S.D.), had a negative slope. Under HRT, about 21% of postmenopausal women have a slight decrease in BMD as assessed by DPA. Because of the DPA coefficient of variation, however, the exact number of bone losers cannot be determined. Nevertheless, the present study suggests that patients with low bone mass are likely to respond better than patients with high bone mass.

Carbohydrate metabolism during hormonal substitution therapy

Oestrogens and progestogens are known to influence glucose tolerance. Impairment of glucose tolerance is seen in particular among users of progestogens with androgenic properties. Dydrogesterone is frequently used as the progestogen adjunct during oestrogen substitution therapy for the management of climacteric complaints in post-menopausal women. However, no detailed data have been published concerning its effects on carbohydrate metabolism. In this study, 20 healthy post-menopausal women received equine oestrogens at a dose of 0.625 mg/day for 2 mth, following which dydrogesterone was added cyclically (20 mg/day for 12 days/mth) over a period of 6 mth. Oral glucose tolerance tests were performed before and after each treatment regimen. In relation to the concentrations observed after oestrogen was given alone, dydrogesterone induced only a small increase in blood insulin values which was not statistically significant. The effect was similar to that produced by endogenous progesterone, which is known to be of no clinical significance.

Pseudovaginal Perineoscrotal Hypospadias

A 16-year-old adolescent with perineal hypospadias, a microphallus, a bifid, labia-like scrotum, a blind-ending vagina and bilaterally undescended testicles is presented. Despite normal development of the Wolffian duct derivatives--deferentography showed that both ejaculatory ducts opened into the urethra--the patient showed severe developmental abnormality of the external genitalia. On endocrinologic investigation, gonadotropin, testosterone and 17 beta-estradiol levels were within normal limits; in a genital skin fibroblast culture testosterone was not reduced into 5 alpha-dihydrotestosterone, however, androgen receptors could be identified. Since this patient was raised as a girl up to the age of 16 and had developed female identity, the patient was further raised as a female. Bilateral orchiectomy was performed and estrogen substitution therapy was started. Clitoroplasty as well as ileal vaginoplasty were performed.

A comparative study of the effect of oestrogen substitution therapy on breast development in girls with hypo- and hypergonadotrophic hypogonadism.

During treatment of girls with oestrogen deficiency we observed different patterns of breast development in response to therapy. The forty-five girls studied fell into four groups: Group A, gonadal dysgenesis; Group B, isolated gonadotrophin deficiency; Group C, multiple pituitary hormone deficiencies; Group D, congenital adrenal hyperplasia (17-alpha-hydroxylase deficiency). Treatment with oestrogen was given in an identical manner to all. In the patients with gonadal dysgenesis, in whom the hypothalamic-pituitary function was normal, treatment led to full breast development. In isolated gonadotrophin deficiency and multiple pituitary hormone deficiency breast development was incomplete even after 3 years or more of oestrogen treatment. The conspicuous difference in the hormonal status is that the latter two groups lack gonadotrophins, while in gonadal dysgenesis these hormones are grossly elevated. Our conclusion is that gonadotrophins play an important role in mammary gland development, a finding not previously described. In the girl with 17-alpha-hydroxylase deficiency we observed that cortisol was necessary, in addition to sex hormones, for normal breast development.

The Isaacs cell sampler: an alternative to curettage.

The Isaacs cell sampler was tested in 150 women (102 of them postmenopausal) referred for curettage. The results of cytological testing of material obtained with the sampler were compared with histological findings from curettage performed immediately afterwards. Satisfactory aspirates for cytological diagnoses were obtained in 141 patients and satisfactory material for histological diagnosis in 124. In the 102 postmenopausal patients the cytological method yielded 94 satisfactory specimens, while curettage yielded only 76. All the 17 carcinomas were diagnosed cytologically. Of the 12 cases of premalignant change, nine were diagnosed cytologically; two cytologically diagnosed premalignant cases did not, however, yield satisfactory material by curettage. The Isaacs cell sampler is a simple and reliable way of diagnosing malignancies. Further investigation is needed to define the cytological criteria for diagnosing premalignant cases, but as the material is well preserved accuracy should improve with increasing experience. The method should be valuable in screening women having oestrogen substitution therapy.