J. F. Mortola

Endocrine responses to long-term administration of the antiprogesterone RU486 in patients with pelvic endometriosis

OBJECTIVE To examine endocrine and clinical responses to long-term administration of RU486 in patients with endometriosis. DESIGN Prospective open trial. SETTING Faculty practice of the authors. PATIENTS, PARTICIPANTS Six normally cycling women with endometriosis were recruited. INTERVENTIONS Subjects received RU486 100 mg/d for 3 months. MAIN OUTCOME MEASURE(S) Hormonal changes during RU486 were compared with control data obtained in the preceding cycle during the early follicular phase. Clinical responses were determined by patient assessment and second-look laparoscopy. RESULTS All women became amenorrheic, and daily urinary levels of ovarian steroid metabolites remained acyclic. Mean luteinizing hormone (LH) (P less than 0.02) and LH pulse amplitude (P less than 0.05) were increased without changes in LH pulse frequency. An antiglucocorticoid effect was demonstrated by an increase in serum cortisol (P less than 0.01) and adrenocorticotropic hormone (P less than 0.05) levels. Treatment resulted in an improvement in pelvic pain in all subjects without significant change in the extent of disease as evaluated by follow-up laparoscopy. CONCLUSIONS Daily administration of RU486 results in acyclic ovarian function and improvement in the subjective painful symptoms of endometriosis.

Relative changes in LH pulsatility during the menstrual cycle: using data from hypogonadal women as a reference point.

The basic premise of this study is that the GnRH‐LH pulsatile activity, particularly its frequency characteristics, constitutes, in the absence of any considerable ovarian feedback, the intrinsic rhythm of the hypothalamic‐pituitary unit at its maximal rate. Thus, LH pulse attributes determined in postpubertal hypogonadal subjects may be used as a reference in assessing the degree of influence exerted by endocrine factors that modulate GnRH‐LH pulses. Accordingly, serum LH levels were determined in samples obtained at 15‐min intervals for 24 h in 20 hypogonadal women: 13 postmenopausal women (PMW) and seven women with premature ovarian failure (POF). Similar measurements were performed in 60 normally cycling women: 25 in the early follicular phase (EFP), 13 in the late follicular phase (LFP), seven at midcycle surge (LH surge) and 15 in the midluteal phase (MLP). Significant pulses were identified by the cluster algorithm utilizing factors appropriate for 24 h data series of a sampling frequency of 15‐min intervals. The results show a 24‐h mean (± SE) LH pulse frequency of 78.2±2.8 and 85.5±2.4 min per pulse for young (POF) and older (PMW) hypogonadal women, respectively. During the follicular phase of the cycle, the LH pulse frequency is not significantly different from that of hypogonadal women, but there is a significant (P < 0.05) increase from early to late follicular phases (95.4±3.3 vs 78.8±2‐2 min per pulse). However, when the sleep periods are excluded from the 24‐h data series because of the associated decrease of LH pulse frequency in EFP women, the resulting pulse frequencies are almost identical for EFP, LFP and PMW. An elevation beyond the basic pulse rhythm determined in PMW or POF is not observed in any phase of the menstrual cycle studied, including the midcycle surge. The decrease in LH pulse frequency during the luteal phase of the cycle (151.8±8.0 min per pulse, P < 0.001 vs hypogonadal women) beyond the reference pulse frequency of hypogonadal women is unequivocal. By contrast, the pulse amplitude varies markedly among the groups with the largest found in POF (36.6±4.5 IU/1). It follows, in descending order, PMW (22.7±3.1 IU/1), midcycle surge (17.3±2.8 IU/1), MLP women (7.0±1.3 IU/1) and the EFP (4.9±0.3 IU/I) and LFP (4.0 ±0.4 IU/I). These data support the concept that the changes in the LH pulse frequency during the menstrual cycle can be reduced, but do not exceed the periodicity of the basic rhythm of the GnRH‐LH pulse generator determined in hypogonadal women. Our observations also demonstrate that the pulse amplitude is subject to profound modulation by ovarian factors. Thus, the basic rhythm of GnRH‐LH pulses may serve as a meaningful reference in assessing influences by endocrine factors on GnRH‐LH pulsatile activity.

Alterations in immune responsiveness in women exposed to diethylstilbestrol in utero

In order to study the effect of in utero diethylstilbestrol (DES) exposure on the immune system of adult women, the blastogenic response of peripheral blood lymphocytes to two mitogens was compared in eight DES-exposed patients and in eight age-matched controls with normal menstrual cycles and proven fertility. As measured by the uptake of 3H-thymidine (mean [+/- standard error]), response to the T-cell mitogen phytohemagglutin (PHA) was significantly higher (P less than 0.002) in cells of DES-exposed women (88.6 +/- 5.7 X 10(3) cpm) than in controls (44.0 +/- 8.9 X 10(3) cpm) at the lowest dose of mitogen tested (0.125 microgram/ml). Moreover, lymphocytes of DES-exposed subjects showed maximal blastogenic response to PHA at a concentration (0.125 microgram/ml) two to four times lower (P less than 0.002) than controls (0.25 microgram/ml to 0.5 microgram/ml). Cells of both DES-exposed subjects and controls were maximally responsive to pokeweed mitogen (PWM) at the lowest dose tested (0.625 microgram/ml). These findings suggest that in utero DES exposure is associated with a hyper-reactive immune response during the reproductive years.

Hypothalamic-pituitary-ovarian response to clomiphene citrate in women with polycystic ovary syndrome * †

OBJECTIVE To examine the hypothalamic-pituitary sites of clomiphene citrate (CC) action in women with polycystic ovarian syndrome (PCOS). DESIGN Prospective controlled trial. PATIENTS, PARTICIPANTS Seventeen women with PCOS and 9 normal-cycling women. INTERVENTIONS Subjects with PCOS received CC, 150 mg/d for 5 days. MAIN OUTCOME MEASURES Follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels and LH pulse characteristics and their response to gonadotropin-releasing hormone (GnRH, 10 micrograms) were examined before and after 3 days of CC in PCOS subjects during a 12-hour frequent sampling study (n = 8). Daily urinary estrone glucuronide and pregnanediol glucuronide levels after CC were compared with concentrations in normal-cycling women through one menstrual cycle. In another nine PCOS subjects, pituitary and ovarian hormonal cyclicity was monitored by daily blood sampling. RESULTS Thirteen of 17 treated cycles were ovulatory with normal luteal phases. In the ovulatory cycles, serum LH, FSH, estradiol (E2), and estrone levels increased after CC. Luteinizing hormone pulse frequency was unchanged, but LH pulse amplitude increased significantly after CC. Both LH and FSH response to exogenous GnRH was significantly attenuated after CC treatment. In anovulatory cycles, serum LH, FSH, and E2 increased initially and then returned to baseline and remained unchanged for the ensuring 40 days. CONCLUSIONS Clomiphene citrate-induced ovulation in women with PCOS is accompanied by increased secretion of LH and FSH with enhanced estrogen secretion. The increased LH pulse amplitude after CC, together with decreased pituitary sensitivity to GnRH, suggests a hypothalamic effect.

Depressive episodes in premenstrual syndrome

Episodic depression, a prominent but poorly defined symptom of premenstrual syndrome, was quantitated in 24-hour cortisol secretory episodes (determined by sampling at 20-minute intervals) as biochemical markers, as well as the Beck Depression Inventory and Profile of Mood States as psychometric measures. Results of 16 patients with premenstrual syndrome were compared with six age-matched women with endogenous depression and 16 control women. On both the Profile of Mood States and Beck Depression Inventory, women with premenstrual syndrome showed a marked worsening of scores (p less than 0.01) during the luteal phase compared with either their own follicular phase scores or the scores of controls in either cycle phase. However, Beck Depression Inventory scores were threefold higher (p less than 0.005) in women with depression than in those with luteal phase premenstrual syndrome (3.37 +/- 3.6 vs. 11.9 +/- 2.5). The Profile of Mood States depression scale was also higher (p less than 0.05) in women with depression than in those with premenstrual syndrome, while scores on other Profile of Mood States scales were similar. The numbers of cortisol secretory pulses identified by the cluster algorithm were similar (5 to 6 per 24 hours) in all groups, and the time of circadian nadirs as determined by cosinor rhythmometry were comparable. While the mean amplitude and duration of the cortisol pulses were also similar in women with premenstrual syndrome and controls, both were significantly higher (p less than 0.05) in women with depression. This resulted in markedly enhanced (p less than 0.005) cortisol secretion during a given secretory episode in women with depression and in higher 24-hour transverse mean cortisol values in women with depression (87.8 +/- 5.8 ng/ml) than in either those with premenstrual syndrome (66.7 +/- 3.3 ng/ml) or controls (58.9 +/- 3.3 ng/ml). These data affirm the clinical impression that depressive episodes occurring selectively in the luteal phase of the cycle in women with premenstrual syndrome are not present in controls and demonstrate, for the first time, that these episodes are distinct from endogenous depression as measured by both cortisol secretory parameters and psychological indices.

Effect of human corticotropin-releasing hormone on gonadotropin secretion in cycling and postmenopausal women

OBJECTIVE To test the hypothesis that corticotropin-releasing hormone (CRH) is linked to stress-associated reproductive dysfunction in the human by determining if the administration of human corticotropin-releasing hormone (hCRH) results in an inhibition of gonadotropin secretion. DESIGN Twenty-four-hour prospective study with frequent (every 10 minutes) blood sampling. SETTING University Clinical Research Center. INTERVENTIONS Sequential 8-hour infusions of normal saline, hCRH (1 to 5 micrograms/kg per hour), and hCRH plus naloxone (2 mg/h). SUBJECTS Four normal cycling women and four postmenopausal women. MAIN OUTCOME MEASURES Plasma luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin (PRL), and adrenal and ovarian steroids. RESULTS In response to hCRH, a prompt and sustained rise in cortisol (F) was noted in both normal cycling women and postmenopausal women. No inhibition of LH or FSH was noted during either the hCRH or hCRH plus naloxone infusion in either group of women. Unexpectedly, elevations in the mean LH peak amplitude and the transverse mean LH concentration were noted in the postmenopausal women during the infusion of hCRH as compared with saline. The infusion of hCRH had no apparent effect on concentrations of PRL, FSH, and gonadal and adrenal steroids (except for F). CONCLUSIONS Under these conditions, intravenously administered hCRH has no inhibitory effect on gonadotropin secretion in either premenopausal or postmenopausal women. The mechanism by which stress exerts its deleterious effect on reproductive function in the human remains unknown.

SECRETORY DYNAMICS OF OESTRADIOL (E2) AND PROGESTERONE (P4) DURING PERIODS OF RELATIVE PITUITARY LH QUIESCENCE IN THE MIDLUTEAL PHASE OF THE MENSTRUAL CYCLE

Although the temporal relationship between pulsatile pituitary luteinizing hormone (LH) secretion and steroid hormone release from the corpus luteum has been investigated, the secretory profiles of oestradiol (E2) and progesterone (P4) during periods without any discernible LH pulsatile activity remain unknown. Consequently, blood was sampled at 15‐min intervals for 24 h from 16 women during the midluteal phases (6–8 days after midcycle LH surge) of their cycles. LH was measured in all samples and analysed for significant pulses by the Cluster pulse algorithm. Nine studies showing the lowest LH pulse frequencies and large LH pulse amplitudes were also assessed for E2 and P4 in all samples. All three hormones were released in pulsatile fashions. Pulses of E2 and P4 were found to be synchronous. While the release frequencies for E2 (mean±SEM: 8.9±0.7 pulses/24 h) and P4 (8.5±0.7 pulses/24 h) were comparable, the LH pulse frequency (4.6 ±0.4 pulses/ 24 h) was found to be significantly (P< 0.001) lower than the ovarian steroid pulse frequencies. Maximum (P<0.01) cross‐correlation coefficients were determined at positive time lags of 28.1 ± 7.7 min for LH/E2 and 31.7 ± 5.8 min for LH/P4, indicating that changes in E2 or P4 levels tended to occur within approximately 30 min following LH concentration changes. Further, the degree of concomitance between a steroid pulse and an LH peak was much higher (P< 0.001) than by chance. Maximum (P<0.01) cross‐correlation coefficients between E2 and P4 hormonal data series were found at zero time lag, suggesting that these sex steroids were secreted simultaneously. The pulse amplitudes, pulse durations and areas under the peaks of those E2 or P4 pulses preceded by large (> 5IU/1) amplitude LH pulse were significantly greater (P<0.05 or less for all comparisons) than for steroid pulses not associated with preceding LH pulses. Thus, two populations of steroid pulses were observed; one associated with preceding LH pulses and having greater magnitude of all pulse attributes (duration, amplitude, area under the peaks), and another, not associated with preceding LH pulses and having pulse characteristics of lower magnitude. This observation suggests that the pulsatile release of ovarian steroids is a result of the episodic modulating influence of LH and that pulsatile steroid hormone secretion pertains with smaller magnitude during periods of relative pituitary quiescence of LH pulsatility.

Effects of Dopaminergic Blockade on the Sleep-Associated Changes of Luteinizing Hormone Pulsatility in Early Follicular Phase Women

To investigate the dopaminergic role in the sleep-associated changes of luteinizing hormone (LH) pulsatile pattern, 11 normal cycling women were studied in the early follicular phase (EF, days 3 and 4) of their cycles before and after the administration of metoclopramide (MCP), a dopamine receptor antagonist. Twenty-four-hour infusions of either saline (NaCl 150 mmol/1-50 ml/h) or metoclopramide (MCP, 30 micrograms/kg/h) were conducted in a random sequence. Pulsatile LH activities were assessed in blood samples obtained at 15-min intervals for 48 h. Sleep was electrophysiologically confirmed by EEG during night hours (23.00-07.00 h). Significant sleep-associated decreases in LH pulse frequency (p less than 0.05) and mean LH serum levels (p less than 0.001) with a concurrent increase in LH pulse amplitude (p less than 0.01) were observed during the saline control studies. MCP infusion failed to significantly modify the LH pulsatile activity during either the wake or sleep periods. In particular, it did not prevent the changes in LH pulsatility during sleep. This observation suggests that a dopaminergic mechanism does not critically contribute to the sleep-related changes in LH pulsatile activity in women during the early follicular phase.

Effects of acute hyperprolactinemia on LH pulsatile secretion in hypogonadal and early follicular phase women

To investigate the effects of acute hyperprolactinemia on the 24 h LH pulsatile pattern, 11 women in the early follicular phase (EF, days 3 and 4) and 8 postmenopausal women (PMW) were studied before and during administration of metoclopramide, a dopamine receptor antagonist. Sequential 24 h infusions of either metoclopramide (MCP, 30 micrograms/kg/h) or normal saline were conducted and pulsatile LH activity assessed for 48 hrs. In both EF women and PMW, a prompt (within 90 min, p less than 0.001) and sustained (greater than 45 micrograms/L, p less than 0.001) release of PRL was induced by MCP infusions. MCP-induced hyperprolactinemia failed to modify the LH pulsatile activity in both EF women and PMW. These observations suggest that acute hyperprolactinemia due to dopaminergic blockade has no discernible effect on LH pulsatility and that the reduced LH pulse frequency observed in association with endogenous hyperprolactinemia may result from different neuroendocrine mechanism(s) and/or is time dependent.