E. Diczfalusy

Endometrial morphology and peripheral hormone levels in women with regular menstrual cycles

Endometrial biopsies from 90 women with regular menstrual cycles and a hormonal profile compatible with normal luteal function were morphometrically assessed using 11 different indices and the results were plotted in 48-hour periods around the day of the luteinizing hormone (LH) surge (LH +/- 0). The endometrial dating reached its highest significance from days LH -3/-2 to days LH +7/+8, when the changes occurred with a high degree of regularity regardless of the length of the preovulatory and postovulatory phases. It is proposed therefore that the dating of the endometrium should be related to the LH surge rather than to the ideal 28-day cycle. The results also seem to suggest the existence of a regulatory mechanism for the synchronization of follicular maturation and midcycle endometrial development. Further study of the factors involved in this mechanism may result in a better understanding of certain forms of unexplained infertility.

Morphometric analysis of the human endometrium in relation to peripheral hormone levels

Twelve indices were quantitated at three sites in 68 endometrial biopsies from 14 women in five cycles each in which daily plasma levels of luteinizing hormone (LH), estradiol (E 2 ), and progesterone (P) were measured. It was found that a single biopsy specimen is representative of the entire endometrium. Using classic dating, 59% of the biopsies were correct. The error rate increased with the distance from the LH surge. The morphometric indices revealed significant differences among all 48-hour secretory phase periods except days LH +7 to LH +10. The glandular diameter was positively correlated with proliferative phase E 2 levels and with secretory phase P levels; the latter were negatively correlated with stromal mitoses. Basal vacuoles were negatively correlated with E 2 and positively with P levels.

Pharmacokinetic and Pharmacodynamic Effects of Small Doses of Norethisterone Released from Vaginal Rings Continuously During 90 Days

The pharmacokinetic and pharmacodynamic effects of norethisterone (17 α-ethinyl-17β-hydroxy-4-estren-3-one; NET) released continuously from vaginal devices at a rate of 50 μg/24 h and 200 μg/24 h, respectively, were investigated during a 90-day period in two groups of seven women each with regular menstrual periods. Blood samples were taken three times weekly (mondays, Wednesdays, and fridays) during a control cycle and during the entire study period for the estimation of estradiol, progesterone, and NET levels, and hourly blood samples were collected throughout a 24-hour period after 6 weeks of exposure to assess the short term variation in NET levels. In addition, an endometrial biopsy was taken on days 21–23 of the control cycle and after 6 and 10 weeks with the device in situ.

THE PREDICTION AND/OR DETECTION OF OVULATION BY MEANS OF URINARY STEROID ASSAYS

Twenty normally menstruating women volunteered for a study in which plasma samples were collected daily during an entire menstrual cycle. On the same days, samples of morning urine were also collected, as well as random samples of urine voided at the visit to the Outpatient Clinic. Progesterone (P), estradiol (E2) and lutropin (LH) were assayed in plasma, and pregnanediol-3-glucuronide (PdG), estrone-glucuronide (E1G), estriol-16-glucuronide (E3G), P, and E2 were measured in urine using radioimmunoassays. Progesterone in urine was assayed both with and without preceding chromatography. All urinary glucuronides and progesterone exhibited cyclic patterns similar to those of E2 or P in plasma. Seven-fold increases from early follicular to luteal phase values (for PdG and urinary P; the latter both with and without chromatography), or to peak levels (for E1G and E3G) were observed. The difference between the baseline and peak levels was less distinct (approximately 5-fold) for E2 in urine. The day-to-day coefficient of variation of early follicular phase values decreased from 40% to 25% by calculating the ratios of the glucuronides or P to creatinine (C). The peaks of estrogen glucuronides were delayed mostly by 1 day in comparison to the peaks of E2 in plasma. The urinary peaks of estrogens were in most cases more closely clustered around the day of the LH-peak when the measurements were corrected for C. For the determination of the first significant rise of steroid levels in a cycle, the calculation of a sustained rise (leading to a significant cumulative sum - CUSUM) was found superior when compared to other recommended indices, such as a 50% increase over the mean of 3 preceding values, or the increase over the baseline level plus 2 standard deviations. Sustained rises were calculated for all indices studied (including the ratio of urinary E1G to PdG). The ratio of E1G to C in morning urine gave consistently the most compact distribution of sustained rises. It is concluded that daily measurements of urinary PdG (or P) and E1G (or, possibly, E2) could substitute the serial assays of P and E2 in peripheral blood in the retrospective assessment of the ovarian functionn. The day-to-day variation can be significantly reduced, if results are expressed per concentration of C. For the prediction of ovulation or fertile period, the best index of urinary steroids appears to be the sustained rise in the ratio of E1G to C. However, this best method is still not good enough in terms of overall reliability and practicability.

Long-acting contraceptive agents: Design of the who chemical synthesis programme

The great demand for improved long-acting injectable steroid contraceptives, particularly in developing countries, and the relative lack of interest from the pharmaceutical industry to develop such products stimulated WHO to launch a synthetic and screening programme to find improved, safe and acceptable injectable preparations. More than 210 esters of norethisterone (17 alpha-ethynyl-17 beta-hydroxyestr-4-en-3-one) and levonorgestrel (D-(-)-13 beta-ethyl-17 alpha-ethynyl-17 beta-hydroxygon-4-en-3-one) have been prepared in university-based research laboratories situated mainly in developing countries, and then screened by NICHHD in animal models. The following three compounds, levonorgestrel butanoate, cyclopropylcarboxylate and cyclobutylcarboxylate, proved to be particularly long-acting when administered as microcrystalline suspensions. The overall strategy of this research and development programme is described.

The interaction between sex hormone binding globulin and levonorgestrel released from vaginal rings in women

The levels of levonorgestrel (L-NOG), progesterone and estradiol were measured in plasma samples of 17 normally menstruating women during a control cycle and during a subsequent period (90 days) with a L-NOG-releasing vaginal ring. During days 38-66 after the insertion of the vaginal ring the concentrations of sex hormone binding globulin binding sites (hereafter: SHBG levels) were also assayed. Significant correlations were found not only between the corresponding levels of SHBG and L-NOG during exposure to the latter compound (r = 0.44; P less than 0.05), but also between the levels of SHBG in the control cycle and the levels of L-NOG measured during exposure (r = 0.60; P less than 0.01). Furthermore, the decrease in SHBG levels during the vaginal administration of L-NOG was directly proportional to the levels of SHBG in the pretreatment cycle (r = 0.64; P less than 0.01). A significant relationship was found between the levels of L-NOG (and, hence - indirectly - the levels of SHBG) and the degree of suppression of ovarian function. Thus the levels of L-NOG were lower (P less than 0.01) in the subjects (n = 8) with an apparently normal or partially suppressed ovulatory-like pattern of progesterone than in those subjects (n = 9) in whom progesterone levels were completely suppressed.

A clinical pharmacological study of a new type of vaginal delivery system for levonorgestrel

The pharmacokinetic and pharmacodynamic effects of a new type of levonorgestrel-releasing vaginal device (with an in vitro release rate of 25 micrograms/24 h) were studied in a group of 18 normally menstruating women during a period of 90 days of continuous use. Peripheral blood samples were drawn three times weekly (Mondays, Wednesdays, Fridays) during a pretreatment (control) cycle and during the 90 days (3 segments) of exposure to levonorgestrel and the levels of levonorgestrel, progesterone and estradiol were analyzed. Blood samples were also drawn at frequent intervals during the first day and daily during the first week with the devices in situ. In addition, endometrial biopsy specimens were obtained during days 20-22 of the control cycle and then 6 and 10 weeks following the insertion of the devices for morphometric analysis and for the assay of progesterone and estradiol levels. Following insertion of the devices, plasma levels rapidly rose to 1 nmol/l in 12 hours; a plateau of approximately 1.6 nmol/l was reached in 3-4 days, after which the plasma levels declined in a linear fashion with a daily average rate of 7.4 pmol/l to 60% of the initial level in 90 days time. Of the 54 treatment segments of 30 days, 68% were anovulatory and 24% showed normal, ovulatory-like estradiol and progesterone levels. A complete set of three biopsies were obtained from 15 of the 18 subjects. Of the biopsies obtained during exposure to levonorgestrel only one exhibited signs of atrophy, 80% showed suppressed or arrested proliferation, and 10% had a normal cyclic appearance.(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacokinetic studies with a vaginal delivery system releasing levonorgestrel at a near zero order rate for one year

Vaginal rings releasing approximately 20 micrograms levonorgestrel per 24 hours were used continuously by ten women for a period of one year. Circulating plasma levels of levonorgestrel (L-NOG) were measured every second week. Steroid hormone binding globulin (SHBG) levels were measured in the first and last four blood samples drawn. A linear relationship between the logarithms of L-NOG concentrations and duration of use was found, indicating an exponential character of decrease in L-NOG levels during the study year. An average of 72% of the mean initial levels of L-NOG was found in the circulation after 6 months and 52% after one years use. The L-NOG levels decreased daily by 1.1 pmol/l (0.13%) on the average. The SHBG levels were not influenced by the long-term exposure to L-NOG. The initial SHBG levels were significantly correlated (r = 0.88; P less than 0.001) to the initial L-NOG levels. The rings were well tolerated. Only in two of the ten subjects did the average number of bleeding days per month increase from a pretreatment value of 4.5 days per month to 8.3 and 9.5 days per month, respectively.

Pharmacodynamic effects of ethinyl estradiol in women using vaginal devices releasing small doses of levonorgestrel at a constant rate

Eight normally menstruating women were provided with vaginal devices releasing levonorgestrel (NOG)4) at a constant rate of 20 micrograms/24 h. On day 71 or 72 following the insertion of the device, oral doses of 50 micrograms of ethinyl estradiol (EE) were administered daily for one week. Peripheral blood samples were drawn three times weekly during a pretreatment (control) cycle and from day 29 of the treatment period. The levels of progesterone (P), estradiol (E2) and NOG were measured by radioimmunoassay, sex hormone binding globulin (SHBG) by a steady state polyacrylamide gel electrophoresis and the percentage of binding of NOG, testosterone (T) and E2 by equilibrium dialysis of diluted plasma. An endometrial smear and a biopsy were taken from each subject on 3 occasions, viz. during the control cycle (cycle day 20-22), during the period with the NOG-releasing device in situ (44-50 days after the insertion of the device), and on the 7th day of concomitant EE administration.

Pituitary, ovarian and endometrial effects of graded doses of medroxyprogesterone acetate administered on cycle days 7 to 10

Eighteen apparently healthy women with normal menstrual cycles were studied during a control cycle and then during a treatment cycle, in which graded doses (2.5, 5.0 and 10 mg/day) of medroxyprogesterone acetate (MPA) were administered orally on cycle days 7 to 10. In both the control and the treatment cycle peripheral blood was drawn daily for the assay of luteinizing hormone (LH), estradiol (E2) and progesterone (PROG) and an endometrial biopsy was taken on cycle day 11. The lowest dose of MPA (2.5 mg X 4) did not influence the various cycle characteristics. Administration of higher doses (5.0 or 10 mg X 4) resulted in a lengthening of the duration of E2-peak (P less than 0.05), an increase in the area under the E2-peak (P less than 0.05), a decrease in the area under the PROG-curve (P less than 0.05) and a reduction in the height of the LH-peak (P less than 0.05). Furthermore, in 5 of these 12 subjects there was no ovulatory-like PROG-pattern during the cycle in which MPA was administered for 4 days. Morphometric analysis of the endometrial biopsy specimens revealed that the administration of MPA increased the diameter of endometrial glands (P less than 0.01) and the number of vacuolated glandular cells (P less than 0.001), decreased the number of glandular (P less than 0.01) and stromal (P less than 0.05) mitoses and reduced pseudostratification (P less than 0.001). There was no change in the number of endometrial glands and in glandular epithelial height. No leukocytic infiltration was observed. Dating of the biopsies indicated that all control biopsies were proliferative and all, but one (a suppressed proliferation including predecidual reaction), biopsies obtained after MPA administration were early secretory. The most conspicuous effect of MPA administration was a marked increase in subnuclear vacuolation, which could be demonstrated even at the lowest dose (P less than 0.01).