Anette Tønnes Pedersen

Serum Levels of Anti-Müllerian Hormone as a Marker of Ovarian Function in 926 Healthy Females from Birth to Adulthood and in 172 Turner Syndrome Patients

CONTEXT In adult women, anti-Müllerian hormone (AMH) is related to the ovarian follicle pool. Little is known about AMH in girls. OBJECTIVE The objective of the study was to provide a reference range for AMH in girls and adolescents and to evaluate AMH as a marker of ovarian function. SETTING The study was conducted at a tertiary referral center for pediatric endocrinology. MAIN OUTCOME MEASURES We measured AMH in 926 healthy females (longitudinal values during infancy) as well as in 172 Turner syndrome (TS) patients according to age, karyotype (A: 45,X; B: miscellaneous karyotypes; C: 45,X/46,XX), and ovarian function (1: absent puberty; 2: cessation of ovarian function; 3: ongoing ovarian function). RESULTS AMH was undetectable in 54% (38 of 71) of cord blood samples (<2; <2-15 pmol/liter) (median; 2.5th to 97.5th percentile) and increased in all (37 of 37) infants from birth to 3 months (15; 4.5-29.5 pmol/liter). From 8 to 25 yr, AMH levels were stable (19.9; 4.7-60.1 pmol/liter), with the lower level of the reference range clearly above the detection limit. AMH levels were associated with TS-karyotype groups (median A vs. B: <2 vs. 3 pmol/liter, P = 0.044; B vs. C: 3 vs. 16 pmol/liter, P < 0.001) as well as with ovarian function (absent puberty vs. cessation of ovarian function: <2 vs. 6 pmol/liter, P = 0.004; cessation of ovarian function vs. ongoing ovarian function: 6 vs. 14 pmol/liter, P = 0.001). As a screening test of premature ovarian failure in TS, the sensitivity and specificity of AMH less than 8 pmol/liter was 96 and 86%, respectively. CONCLUSION AMH seems to be a promising marker of ovarian function in healthy girls and TS patients.

Hormone replacement therapy and risk of non-fatal stroke

BACKGROUND The effect of postmenopausal hormone replacement therapy (HRT) on the risk of subtypes of stroke is as yet unclear. To investigate the effect of oestrogen and combined oestrogen-progestagen therapy on the risk of non-fatal haemorrhagic and thromboembolic stroke, we carried out a case-control study. METHODS From the Danish National Patient Register we identified all Danish women aged 45-64 years who had a non-fatal, first-ever cerebrovascular attack during 1990-92. Two age-matched controls were randomly selected for each case from the Danish National Person Register. Important correlates of hormone use and stroke, on which information was obtained from postal questionnaires, were controlled for by multivariate analyses based on log-linear graphical models. The analyses included data on 1422 cases classified in four subtypes of stroke (160 subarachnoid haemorrhage, 95 intracerebral haemorrhage, 846 thromboembolic infarction, 321 transient ischaemic attack) and 3171 controls. FINDINGS After adjustment for confounding variables and correction for the trend in sales of HRT preparations, no significant associations were detected between current use of unopposed oestrogen replacement therapy and non-fatal subarachnoid haemorrhage (odds ratio 0.52 [95% CI 0.23-1.22]), intracerebral haemorrhage (0.15 [0.02-1.09]), or thromboembolic infarction (1.16 [0.86-1.58]), respectively, compared with never use. Current use of combined oestrogen-progestagen replacement therapy had no significant influence on the risk of subarachnoid haemorrhage (1.22 [0.79-1.89]), intracerebral haemorrhage (1.17 [0.64-2.13]), or thromboembolic infarction (1.17 [0.92-1.47]). A significantly increased incidence of transient ischaemic attacks among former users of HRT and among current users of unopposed oestrogen may to some extent be explained by selection--HRT users being more aware of symptoms than non-users. INTERPRETATION Unopposed oestrogen and combined oestrogen-progestagen replacement therapy have no influence on the risk of non-fatal thromboembolic or haemorrhagic stroke in women aged 45-64 years.

Increased risk of breast cancer following different regimens of hormone replacement therapy frequently used in Europe.

Epidemiologic studies have shown an increased risk of breast cancer following hormone replacement therapy (HRT). The aim of this study was to investigate whether different treatment regimens or the androgenecity of progestins influence the risk of breast cancer differently. The Danish Nurse Cohort was established in 1993, where all female nurses aged 45 years and above received a mailed questionnaire (n = 23,178). A total of 19,898 women returned the questionnaire (86%). The questionnaire included information on HRT types and regimens, reproductive history and lifestyle‐related factors. Breast cancer cases were ascertained using nationwide registries. The follow‐up ended on 31 December 1999. Women with former cancer diagnoses, women with missing information on HRT, surgical menopause, premenopausal, as well as hysterectomized women were excluded, leaving 10,874 for analyses. Statistical analyses were performed using Cox proportional hazards model. A total of 244 women developed breast cancer during follow‐up. After adjustment for confounding factors, an increased risk of breast cancer was found for the current use of estrogen only (RR = 1.96; 95% CI = 1.16–3.35), for the combined use of estrogen and progestin (RR = 2.70; 95% CI = 1.96–3.73) and for current users of tibolone (RR = 4.27; 95% CI = 1.74–10.51) compared to the never use of HRT. In current users of combined HRT with testosterone‐like progestins, the continuous combined regimens were associated with a statistically significant higher risk of breast cancer than the cyclical combined regimens (RR = 4.16, 95% CI = 2.56–6.75, and RR = 1.94, 95% CI = 1.26–3.00, respectively). An increased risk of breast cancer was noted with longer durations of use for the continuous combined regimens (p for trend = 0.048). The European traditional HRT regimens were associated with an increased risk of breast cancer. The highest risk was found for the use of continuous combined estrogen and progestin.

Evaluation of HE4, CA125, risk of ovarian malignancy algorithm (ROMA) and risk of malignancy index (RMI) as diagnostic tools of epithelial ovarian cancer in patients with a pelvic mass

OBJECTIVE Diagnostic factors are needed to improve the currently used serum CA125 and risk of malignancy index (RMI) in differentiating ovarian cancer (OC) from other pelvic masses, thereby achieving precise and fast referral to a tertiary center and correct selection for further diagnostics. The aim was to evaluate serum Human Epididymis protein 4 (HE4) and the risk of ovarian malignancy algorithm (ROMA) for these purposes. METHODS Serum from 1218 patients in the prospective ongoing pelvic mass study was collected prior to diagnosis. The HE4 and CA125 data were registered and evaluated separately and combined in ROMA and compared to RMI. RESULTS 809 benign tumors, 79 borderline ovarian tumors, 252 OC (64 early and 188 late stage), 9 non-epithelial ovarian tumors and 69 non-ovarian cancers were evaluated. Differentiating between OC and benign disease the specificity was 62.2 (CA125), 63.2 (HE4), 76.5 (ROMA) and 81.5 (RMI) at a set sensitivity of 94.4 which corresponds to RMI=200. The areas under the curve (AUC) were 0.854 (CA125), 0.864 (HE4), 0,897 (ROMA) and 0.905 (RMI) for benign vs. early stage OC. For premenopausal benign vs. OC AUC were 0.925 (CA125), 0.905 (HE4), 0.909 (ROMA) and 0.945 (RMI). CONCLUSION HE4 and ROMA helps differentiating OC from other pelvic masses, even in early stage OC. ROMA performs equally well as the ultrasound depending RMI and might be valuable as a first line biomarker for selecting high risk patients for referral to a tertiary center and further diagnostics. Further improvements of HE4 and ROMA in differentiating pelvic masses are still needed, especially regarding premenopausal women.

Declining trends in conception rates in recent birth cohorts of native Danish women: a possible role of deteriorating male reproductive health.

Recent findings of poor semen quality among at least 20% of normal young men in Denmark prompted us to use unique Danish registers on births and induced abortions to evaluate a possible effect of the poor male fecundity on pregnancy rates among their presumed partners – the younger cohorts of women. We have analysed data from the Danish birth and abortion registries as well as the Danish registry for assisted reproduction (ART) and defined a total natural conception rate (TNCR), which is equal to fertility rate plus induced abortion rate minus ART conception rate. A unique personal identification number allowed the linkage of these databases. Our database included 706 270 native Danish women born between 1960 and 1980. We used projections to estimate the fertility of the later cohorts of women who had not yet finished their reproduction. We found that younger cohorts had progressively lower TNCR and that in terms of their total fertility rate, the declining TNCR is compensated by an increasing use of ART. Our hypothesis of an ongoing birth cohort-related decline in fecundity was also supported by our finding of increasing and substantial use of ART in the management of infertility of relatively young couples in the later cohorts. Furthermore, the lower rates of induced abortion among the younger birth cohorts, often viewed as a success of health education programs, may not be fully explained by improved use of contraception. It seems more likely that decreased fecundity because of widespread poor semen quality among younger cohorts of otherwise normal men may explain some of the observed decline in conception rates. This may imply increasing reproductive health problems and lower fertility in the future, which is difficult to reverse in the short term. The current and projected widespread use of ART in Denmark may be a sign of such an emerging public health problem.

Relation between hormone replacement therapy and ischaemic heart disease in women: prospective observational study

Abstract Objective: To investigate the risk of ischaemic heart disease and myocardial infarction among women using hormone replacement therapy, especially the potential modifying effect of cardiovascular risk factors. Design: Prospective observational study. Setting: Denmark. Participants: 19 898 nurses aged 45 and over completing a questionnaire on lifestyle and use of hormone replacement therapy in 1993. Main outcome measures: All cases of death and incident cases of ischaemic heart disease and myocardial infarction until the end of 1998. Results: Current users of hormone replacement therapy smoked more, consumed more alcohol, had lower self rated health, but were slimmer and had a lower prevalence of diabetes than never users. In current users compared with never users, hormone replacement therapy had no protective effect on ischaemic heart disease (hazard ratio 1.2, 0.9 to 1.7) or myocardial infarction (1.0, 0.6 to 1.7), whereas current users with diabetes had an increased risk of death (3.2, 1.4 to 7.5), ischaemic heart disease (4.2, 1.4 to 12.5), and myocardial infarction (9.2, 2.0 to 41.4) compared with never users with diabetes. Conclusion: Hormone replacement therapy showed no protective effect on ischaemic heart disease, but there was a significantly increased risk of death from all causes and ischaemic heart disease among women with diabetes. What is already known on this topic Observational studies have shown that hormone replacement therapy protects women against ischaemic heart disease Randomised clinical trials found no such effect Little attention has focused on identifying subgroups of women who would or would not benefit from treatment What this study adds Hormone replacement therapy does not protect against ischaemic heart disease Women with diabetes who use hormone replacement therapy are at an increased risk of death from all causes and ischaemic heart disease

The validity of self-reported use of hormone replacement therapy among Danish nurses

Background.  Recent findings from randomized clinical trials on the effects of hormone replacement therapy (HRT) among postmenopausal women contradict findings from observational studies indicating a protective effect on the development of cardiovascular disease. Most observational studies on HRT are based on self‐reported data, although data on the validity of HRT in postmenopausal women are sparse.

RE: Is There a Correlation Between Androgens and Sexual Desire in Women?

We were very interested to read the results of the study by WåhlinJacobsen et al. [1] titled “Is there a correlation between androgens and sexual desire in women?” The researchers used mass spectrometry methods to investigate age-adjusted serum levels of dehydroepiandrosterone sulfate (DHEA-S), androstenedione, and testosterone, as well as androsterone glucuronide (ADT-G)—a measure of total androgen activity. The results were consistent with our published study of 121 women with and 124 women without a diagnosis of Hypoactive Sexual Desire Disorder (using the definition of the Diagnostic and Statistical Manual, 4th edition, text-revised), where no group differences in androgen metabolites were found [2]. We were somewhat perplexed by the apparent change in Wåhlin-Jacobsen et al.’s [1] objective in their paper from investigating a possible correlation between serum levels of testosterone and/or androgen metabolites and sexual desire, to finding a measure that does indeed correlate with desire and to apparently suggest its use hereon. The conclusion in the abstract that ADT-G did not correlate more strongly than circulating androgens with sexual desire and therefore is not superior to measuring circulating androgens with mass spectrometry presupposes an established correlation between androgens and sexual desire. The authors note that “measuring the degradation product of the intracellular testosterone turnover should therefore yield a better estimate of both the intracellular turnover and the total activity of androgens. In contrast to what we expected, however, no statistically significant correlations were established between ADT-G and sexual desire. Therefore, based on these current and previous results, we cannot conclude that ADT-G is a better biomarker of the link between androgens and women’s sexual desire than measuring the amount of circulating androgens.” (p. 12). An explanation for these findings can, however, be based upon the understanding that the metabolite of androgens chosen as a parameter of total androgenic activity, namely ADT-G, although a logical suggestion, could have to take into account a more complex pattern than originally believed [3]. As mentioned by the authors, it could well be that ADT-G represents only a fraction of all androgen metabolites. In fact, it could be that ADT-sulfate and epi-ADT-G (and likely others) could represent a much larger proportion of androgen metabolites than ADT-G alone. However, since the very low serum levels of testosterone observed in women during their whole life essentially result from some leakage of the intracellular testosterone synthesized locally from DHEA [4], it might be reasonable, at the present time, to measure the precursors of intracellular testosterone, namely serum DHEA, DHEA-S, androstene-3β,17β-diol, and androstenedione. In fact, low serum levels of all these four androgen precursors have been correlated with sexual dysfunction [1,2,5]. The authors did find a correlation between total testosterone, free testosterone, androstenedione, and DHEA-S in the subgroup of women aged 25–44 who were not using any hormonal contraception (n = 168). In our study, 246 women were more stringently recruited to exclude confounds such as any medication potentially altering sexual response and desire, scoring in the clinically significant depressed range on a validated measure of depression, significant relationship conflict, and sexual pain, and this study failed to show a correlation between mass spectrometry-measured serum testosterone and desire but showed a correlation with low serum DHEA-S [2]. We maintain our conclusion [2] that in large samples of women, there is not yet conclusive evidence of a significant correlation between accurately measured total testosterone activity and sexual desire. This is not to say androgen activity may not be important, but at this point, such evidence of a correlation has not been empirically supported. As indicated above, it could well be that serum testosterone is not a reliable marker since it represents only leakage of intracellular testosterone made by the intracellular mechanisms of intracrinology [4]. The conclusion of Wåhlin-Jacobsen et al. [1] that as measurement of ADT-G showed no significant correlation with women’s sexual desire, such measurement “did not seem to be an improvement over measuring circulating androgens with MS” (p. 14) suggests that there was a very different a priori objective to the study than what was published. A recent editorial reminds us of the significant dangers inherent to modification of a priori hypotheses and the threat to statistical analyses as well as interpretation of the findings [6]. That the identification/measurement of the most appropriate metabolites of androgens has not yet been determined in no way negates the importance of intracellular testosterone production. We offer this analogy: the hypothetical investigation of a correlation between intake of vitamin C supplements and susceptibility to influenza. Imagine researchers counting vitamin C supplements taken by patients and finding the numbers to correlate negatively with number of influenza infections. However, when measuring their serum vitamin C levels, no correlation is found between vitamin C levels and cases of influenza. If the researchers then said “from here-on just count vitamin C supplements as this correlates better with influenza susceptibility,” perhaps the lack of a scientific demonstration would be more obvious. In summary, with the strong caveat of relatively lax exclusion criteria, the findings by Wåhlin-Jacobsen et al. have added to the literature on women’s sexual desire and androgens, which are based on the currently available most optimal assays for serum androgens and precursor hormones (liquid chromatography-mass spectrometry), and for total (intracellular plus serum) androgens (ADT-G). As in our study [2], precursors of intracellular testosterone correlated with sexual desire in women aged 25–65 years, none of whom were taking systemic sex hormones. In contrast to our study, in the subgroup of 168 women aged 25–45 years, desire also correlated with measures of serum testosterone. It will be important to repeat these measures on this targeted subgroup, but with stricter exclusion criteria as well as the entry criterion of a diagnosis of sexual interest/arousal disorder assessed by detailed interview as currently available questionnaires do not reflect current conceptualization of women’s sexual response or current 1

Hormone replacement therapy and risk of breast cancer: the role of progestins

Epidemiological studies have shown an increased risk of breast cancer associated with the use of hormone replacement therapy (HRT). This notion is mostly based on studies from the USA. During the last decades unopposed estrogen treatment has been used to a lesser extent, whereas the combined estrogen‐progestin treatment regimen is now prescribed worldwide. In the USA the predominant compounds are conjugated estrogens and medroxyprogesterone‐acetate, whereas oestradiol combined with testosterone‐like progestins is commonly used in Europe. These differences are mainly the result of traditions. Recent studies originating from both the USA and Europe suggest that the combined treatment regimens with estrogen and progestin increase the risk of breast cancer beyond the risk following the use of unopposed estrogen. At present it is not known if progestins with different androgenecity influence the risk of breast cancer to a varying degree.

Effect of doxapram on postoperative pulmonary complications after upper abdominal surgery in high-risk patients

In a double-blind randomised trial an infusion of doxapram, 2 mg per min for 6 h immediately after surgery and repeated on the first postoperative day, or the same volume of saline, was given to 39 patients who underwent upper abdominal surgery and who were at high risk of postoperative day, or the same volume of saline, was given to 39 patients who underwent upper abdominal surgery and who were at high risk of postoperative pulmonary complications. The patients were assessed pre-operatively and during the first 5 postoperative days by physical examination, spirometry, blood-gas analysis, and chest radiography. Postoperative pulmonary complications were defined as temperature over 38 degrees C for 2 days, abnormal auscultation, pathological radiography, and/or productive cough. Data from 16 patients per group were analysed. Significantly more patients in the placebo group had three criteria of postoperative pulmonary complication compared with the doxapram group (63% vs 19%). The doxapram group also had higher PaO2 postoperatively.