Farook Al-Azzawi

Mechanism of androgen receptor action

Recent research provides a much more detailed understanding of the role of the androgen receptor in normal human development and physiology, its structure, and its functioning. This review discusses genomic and non-genomic actions of the androgen receptor, as well as their co-regulators. We also explore several clinically relevant aspects of the molecular biology of the androgen receptor and its co-regulators.

Oestrogen receptor beta is the predominant oestrogen receptor in human scalp skin.

Abstract: Oestrogens play a major role in non‐classic target tissues in both sexes, yet there have been few studies on estrogens and skin. Recently a second oestrogen receptor (ERβ) has been discovered. Therefore, we have compared the expression of oestrogen receptor alpha (ERα), beta (ERβ), the androgen receptor (AR) and a cell proliferation marker in male and female non‐balding scalp skin. ERβ was the major steroid receptor expressed in human skin. It was highly expressed in epidermis, blood vessels and dermal fibroblasts, in contrast to ERα and AR. In the hair follicle, ERβ expression was localized to nuclei of outer root sheath, epithelial matrix and dermal papilla cells, in contrast to ERα, and the AR, which was only expressed in dermal papilla cells. Serial sections also showed strong nuclear expression of ERβ in the cells of the bulge, while neither ERα nor AR was expressed. In the sebaceous gland, ERβ was expressed in both basal and partially differentiated sebocytes. ERα exhibited a similar pattern of expression, while the AR was expressed in the basal and very early differentiated sebocytes. There was no obvious difference in the expression of either oestrogen receptor in male or female skin. The wide distribution of ERβ in human skin suggests that oestrogens may play an important role in the maintenance of skin and in the regulation of the pilosebaceous unit, and provides further evidence for oestrogen action in non‐classic target tissues. The differential expression of ERα, ERβ and AR in human skin suggests that the mechanisms by which steroid hormones mediate their effects may be more complex than previously thought.

Hormonal changes during menopause

Ovarian senescence occurs gradually during the fourth and fifth decades of life, leading to menopause at an average age of about 51 years. This senescence results in a changing hormonal milieu, with decreases in the levels of estrogens and androgens. Similar changes may be induced by surgical menopause (bilateral oophorectomy) or ovarian failure resulting from cancer treatment. The declining levels of estrogens and androgens affect many tissues of the body and can produce a variety of signs and symptoms, including vasomotor symptoms, decreased bone density, changes in mood and energy, loss of pubic hair and changes in the genital tissues, and effects on sexual function. Accurate measurement of testosterone levels in postmenopausal women requires methods that are validated in the lower ranges of testosterone level observed in this population.

How well do perimenopausal patients accept outpatient hysteroscopy? Visual analogue scoring of acceptability and pain in 100 women

There is growing interest in performing hysteroscopic examination of the uterine cavity as an outpatient procedure. Its sensitivity and specificity in detecting uterine abnormalities are well recognised. This study assessed how outpatient hysteroscopy was tolerated and accepted by 100 women attending a hospital-based menopause clinic. Patients were asked to complete a questionnaire following an outpatient hysteroscopy. Using visual analogue scoring (0 = no pain/completely acceptable, 10 = worst pain imaginable/completely unacceptable), the mean maximum pain experienced during the procedure was 3.25 (S.D. 2.08) and the degree of acceptability was 3.02 (S.D. 1.96). Three percent (N = 3) of patients stated they would prefer a repeat hysteroscopy to be performed under general anaesthetic and 3% (N = 3) of patients stated they would prefer an inpatient stay following a repeat hysteroscopy. These findings demonstrate that outpatient hysteroscopy is well tolerated by perimenopause patients. The advantages of outpatient hysteroscopy to the perimenopausal woman are discussed.

Regular bleeding on hormone replacement therapy: a myth?

The role of postmenopausal oestrogen replacement therapy for the treatment of climacteric symptoms is well established and can be achieved with relatively short courses of therapy. On the other hand, the effect of hormone replacement therapy (HRT) on prevention of osteoporosis and fracture risk (Lindsay et af. 1976) and for protection against cardiovascular disease (Ross et al. 1989) may materialise only if it is used on a long term basis (Ferguson et al. 1989). Despite all the potential benefits of HRT, compliance remains notoriously low, estimated at approximately 50% during one year in sociological and health provision environments as diverse as the UK and New York State (Coope & Marsh 1992; Ryan et al. 1992). A two to threefold increase in the risk of endometrial hyperplasia and carcinoma is associated with prolonged treatment with unopposed oestrogen (Studd et al. 1980). Histological studies have shown that the development of endometrial hyperplasia can be prevented by prescribing women, who are on oestrogen therapy, a 10 to 14 day course of a progestogen each month (Sturdee et al. 1978; Whitehead et al. 1981), and this was confirmed recently in a large prospective clinical trial (Persson et al. 1989). Most women on HRT regimens involving cyclical progestogen experience withdrawal bleeding. This side effect of therapy, especially when bleeding becomes unpredictable, erratic, heavy or prolonged, is a major factor that discourages women from starting HRT and reduces ongoing compliance (Hahn 1989). The possibility of this type of bleeding contributes to a number of phobias particularly likely to deter women from long term use. It is not easy to determine whether it is the attitude towards the menstrual discharge or the sheer inconvenience of unscheduled bleeding which discourages women from continuing treatment. The predictability of menstrual pattern, both in terms of the day of onset and the duration of bleeding, have received little attention. The main studies have focused on median cycle length, median duration of blood loss, mean menstrual blood loss, and the time of onset of uterine bleeding in relation to the length of the progestogen component of the HRT regimen. Such assessments tend to hide the variations in bleeding patterns of individual patients. Current clinical evaluation includes consideration of factors, such as time elapsed since the menopause, the weight of the patient, and smoking habits, as potential aetiologies for the erratic pattern of menstrual discharge in women treated with exogenous sex steroids, but these factors have not been tested in controlled trials. Analysis of menstrual diaries enables the practitioner to assess cycle variability and helps him/her to make decisions regarding further investigational or therapeutic approaches. Although clinical trials involve self-selected symptomatic patients motivated to start treatment, it was notable in four clinical studies, conducted in our research clinics, that about a quarter (23%) of enrolled women withdrew because of an unacceptable bleeding pattern, despite the availability of counselling and support. Therefore, it is not surprising that compliance, especially in asymptomatic women, in the community at large, is worse (Wren & Brown 1991). We have followed the bleeding pattern by assessing menstrual diaries in a number of clinical studies of different HRT preparations. We considered a variability of two-plus days from the day of onset of bleeding to represent an acceptable prediction window of five days in each cycle. Similarly, that a variability in the duration of bleeding of one-plus day to be acceptable, given that the modal duration of menstrual bleeding was five days. Using these criteria, we were able to predict the bleeding patterns of less than one-third of the patients whilst on the various regimens. Oestrogen replacement, whether administered orally or transdermally, and regardless of the prevailing oestradiol level, did not improve the predictability of the day of onset or the duration of menstrual discharge. The type of progestogen used did not influence the poor predictability. The lack of predictability of bleeding, the recurrent episodes of breakthrough bleeding (7 YO), and the fact that more than half the patients bleed before day 11 of the progestogen phase emphasises the need for further investigations (Whitehead et al. 1983). None of the patients with early onset, progestogen-associated bleeding in these studies had a hyperplastic or neoplastic endometrium. This may be a factor related to the length of follow up which was limited to one year; however, one must question the value of continuing to administer the progestogen to complete the 12 day course in women who bleed prior to day 12. I t appears that the reassuring clinical advice of an acceptable bleeding pattern while on HRT makes patients compare their own experience unfavourably to this model. This may contribute to the low compliance. A more pragmatic approach is to counsel women prior to starting postmenopausal hormone replacement that if uterine bleeding were to become unpredictable, further hysteroscopic and histological investigations of the uterine cavity (Downes & Al-Azzawi 1993) and individualisation of treatment will be needed. This calls for a specialist service capable of dealing with these difficulties, thus reassuring

Specific Inhibition of Estrogen Receptor Alpha Function by Antisense Oligodeoxyribonucleotides

We have tested the effect of a range of antisense oligodeoxyribonucleotides (ODN) directed against the human estrogen receptor alpha (ERalpha) on ERalpha protein expression and function. Antisense ERalpha ODN transfected into the ERalpha-positive human breast carcinoma cell line MCF7-K2 showed variable responses dependent on the oligo used. The most active antisense ODN (oligo 7) decreased the levels of ERa protein by 61% as measured by Western blot analysis. Exogenous 17beta-estradiol (17beta-E2), but not 17alpha-E2, augmented this effect, with a threshold effect at 10(-8) M 17beta-E2. The inhibitory effect of antisense ERa oligo 7 was confirmed by measurement of functional ERalpha protein. 3H-17beta-E2 binding to MCF7 cell extracts was inhibited to approximately 40% of control values in the presence of oligo 7. Antisense-transfected MCF7-K2 cell cultures produced a further 30% binding reduction in the presence of exogenous 17beta-E2. An inhibitory effect on 17beta-E2-dependent cell function was confirmed by the demonstration that ERalpha oligo 7-transfected MCF7-K2 cells failed to exhibit 17beta-E2-stimulated cell proliferation. Exogenous 17beta-E2 enhanced the inhibitory effect of the antisense ODN by increasing ODN transfection efficiency but without ERalpha catabolism via the proteosomal pathway, suggesting an effect of 17beta-E2 on the plasma membrane and the existence of different ERalpha degradation pathways in the MCF7-K2 cell subclone. As 17beta-E2 had no effect on ERalpha protein degradation, we conclude that the observed reduction of ERalpha protein levels is due solely to the presence of the antisense ERalpha ODN. Antisense ERalpha ODN molecules, therefore, may form the basis of effective therapies against ERalpha-dependent malignancies.

Immunohistochemical and hysteroscopic assessment of postmenopausal women with uterine bleeding whilst taking Tibolone.

The gonadomimetic steroid Tibolone, is currently widely used for the treatment of menopausal symptoms. Up to 20% of women have been reported to have episodes of bleeding whilst on therapy. We investigated 37 cases who experienced bleeding episodes whilst on Tibolone and compared these to six cases who experienced no bleeding whilst on therapy and who underwent similar investigations in the course of a clinical study. All women underwent a diagnostic hysteroscopy and an endometrial biopsy, under a local anaesthetic. The endometrium was assessed by histology and with immunohistochemical markers for cellular proliferation (Ki67, PCNA), Heat Shock Protein 27 (HSP27) and bcl-2. There were 17 women with intracavitary lesions on hysteroscopy (including one in the control group), 10 with polyps, five with fibroids, two with congenital uterine anomalies. Histological diagnosis was not obtained in 16 cases. The high incidence of uterine polyps in the group who bled on Tibolone suggests an etiologic relation. The staining pattern with HSP27 demonstrated an oestrogenic effect. There were no differences in the bcl-2 immunoreactivity between those who bled and those who did not bleed on treatment which suggests absence of a link. Similarly, there were no differences in the expression of the proliferation markers. We conclude that episodes of bleeding in patients receiving Tibolone for hormone replacement therapy, whilst warranting investigation, should not cause undue concern.

Randomised placebo controlled trial to assess the role of intracervical lignocaine in outpatient hysteroscopy

Sir, The conclusion by Wiener et al. (1992) that screening for carcinoma of the vagina should be performed on all women who had a hysterectomy for cervical intra-epithelial neoplasia (CIN) is not supported by their data. They report only two cases of carcinoma; in one the lesion was incompletely excised and the other occurred in the lower vagina and not at the vault. No cases of carcinoma were found in women who had CTN completely excised. Gemmel eta]. (1990) found that only one vaginal carcinoma in 60 cases over 15 years was associated with previous CIN and this had been incompletely excised at hysterectomy. Screening for vaginal carcinoma in women who have had CIN completely excised at hysterectomy is not an efficient use of resources. The recommendation from the NHS Cervical Screening Programme (March 1992) is that, for lesions that are completely excised, two follow up smears at 6 and 12 months should be performed. If these are normal, cytological surveillance can stop. Patrick Hogston Consultant Gynaecologist Department of Gynaecology St Mary’s Hospital Milton Road Portsmouth PO3 6AD

Thrombophilia and lipid profile in post-menopausal women using a new transdermal oestradiol patch

OBJECTIVEnTo assess the changes, over a 6-month period, in serum lipoproteins, apoproteins and coagulation factors, induced in post-menopausal women treated by a new transdermal oestradiol patch.nnnMETHODSnFifty-three hysterectomised, healthy, post-menopausal women were treated by a new transdermal patch designed to deliver 50 micrograms of 17 beta oestradiol per day (Gynaderm, Shire Developments). One patch was applied twice weekly.nnnRESULTSnForty-two patients completed the study. There was no significant change in the level of total cholesterol, triglycerides, HDL or LDL. There was a significant rise in the level of ApoAI after 3 months on therapy but this was not sustained after 6 months; there was also a significant drop in the level of ApoAII after 6 months on treatment. The changes in ApoB and Lp(a) were not statistically significant. There was a significant drop in the level of antithrombin III and of protein S, and a significant rise in factor VII. The drop in the level of fibrinogen and of protein C were not statistically significant.nnnCONCLUSIONnThe transdermal route of oestradiol administration causes minimal changes in lipoprotein metabolism. The statistically significant changes in the thrombophilia profile parallel those observed with oral HRT, but, similarly, may not reflect clinical significance. The potential of transdermal oestrogens as cardioprotective agents is yet to be determined.

The effect of submucous fibroids on the dose-dependent modulation of uterine bleeding by trimegestone in postmenopausal women treated with hormone replacement therapy.

Objective To assess the value of identifying endometrial structural abnormalities at baseline hysteroscopy in predicting the pattern of bleeding in postmenopausal women treated with hormone replacement therapy.