John Studd

Hormonal profiles after the menopause.

The endocrinological changes of the climacteric have been defined by studying the concentrations of follicle-stimulating hormone (FSH), luteinising hormone (LH), androstenedione, testosterone, oestrone, and oestradiol in 60 normal postmenopausal women of different menopausal ages. The women were studied in six groups, according to the number of years since their menopause. One year after the menopause androstenedione, oestrone, and oestradiol concentrations were reduced to about 20% of the values recorded during the early proliferative phase of the menstrual cycle. At the same time the mean concentration of FSH had risen by a factor of 13-4 and that of LH by a factor of 3-0. Concentrations of both gonadotrophins reached a peak of 18-4 and 3-4 times the proliferative phase value respectively after two to three years, and then gradually declined in the next three decades to values that were 40-50% of these maximal levels. Testosterone concentrations remained mostly in the normal range for premenopausal women but were depressed to 60% of these levels two to five years after the menopause, and the mean androstenedione levels showed a significant increase in the same group of women. The concentrations of both oestrone and oestradiol remained consistently low for 10 years after the menopause, but oestradiol concentrations inexplicably increased in the last two decades, with levels at the lower end of normal range for reproductive women in six patients.

ENDOCRINE CHANGES AND SYMPTOMATOLOGY AFTER OOPHORECTOMY IN PREMENOPAUSAL WOMEN

The symptomatic and endocrine changes following hysterectomy and bilateral oophorectomy have been studied in 100 patients, 1 to 31 years after surgery. The most frequent symptoms at the time of interview were depression (62 patients), insomnia (48 patients), loss of libido (46 patients) and dyspareunia (38 patients). Vasomotor symptoms were recorded in 28 patients. Although 94 patients claimed that hot flushes were the first symptomatic changes noticed, 60 had complete relief from these symptoms within 6 months of surgery; 34 patients had no symptoms and only 4 patients were taking oestrogen therapy at the time of interview. Plasma oestradiol and testosterone levels were 78 per cent and 27 per cent respectively below the mean values of day 1 to 10 of the menstrual cycle, similar to those found at comparable years after a normal menopause. The plasma FSH level was about 14 times and the plasma LH level about twice the respective preoperative value. Unlike after the normal menopause, these gonadotrophin levels did not show any decline with increasing age. There was no correlation between plasma hormone levels and the presence of vasomotor symptoms or depression.

Reduced bone mineral density in HIV positive individuals

A total of 105 HIV-positive patients underwent dual-energy X-ray absorbtiometry (DEXA) scan to assess bone mineral density (BMD). The prevalence of reduced BMD was found to be 71% and was higher in patients who had ever been treated with protease inhibitors (PI). Our results suggest a possible association between PI and reduced BMD, and further complicate the debate regarding when to commence treatment of HIV and with what agents to start.

Correlation of urethral physiology and skin collagen in postmenopausal women

Summary. Connective tissue collagen is thought to contribute to the generation of urethral pressure. It has been previously shown that skin collagen and urethral pressure are oestrogen dependent. This study demonstrates a correlation between urethral pressure measurements and skin collagen content. It is suggested that the beneficial effect of oestrogens on urethral function may be mediated by collagen.

Urogenital prolapse and atrophy at menopause: a prevalence study.

Abstract: For 285 subjects referred to a menopause clinic data were prospectively collected on the time elapsed since the onset of menopause (menopausal age), sexual activity, dyspareunia, smoking, chronic cough and constipation. Prolapse and atrophy were sought on examination. FSH assay confirmed menopausal status. We found an anterior wall prolapse in 51% of the subjects, of which 6% were protruding beyond the introitus. Posterior wall prolapse was present in 27% and apical prolapse in 20%; none was protruding beyond the introitus. No trend was noted between prolapse and menopausal age. Atrophy was evident in 34% of the women, and this was related to menopausal age (P<0.001). Forty per cent of the sexually active women admitted to dyspareunia, of which 2/3 were superficial. This correlated with advancing menopausal age (P<0.02). In conclusion, genital prolapse was frequent in the population of postmenopausal women, predominantly cystocele, but the prevalence did not correlate with menopausal age.

CHARACTERISTICS OF NORMAL LABOUR IN DIFFERENT RACIAL GROUPS

The characteristics of normal labour in 1306 white, Asian and black parturients have been established following a prospective study of 3217 consecutive labours. Asian patients were found to be of significantly shorter stature than white or black women (p<0.001) and their infants significantly lighter than those of white (p<0.001) and of black (p<0.05) women, and a low positive correlation was found between maternal height and infant birth weight. The mean duration of the first stage of labour, taken from the time of admission to the labour ward, was 5‐6 hours in primiparae and 3.7 hours in multiparae. The mean durations of the second stage of labour were 41.5 and 17.4 minutes respectively. The correlations between the duration of the first and second stages of labour were too low to be of value in patient management. Similar low correlations were found between the duration of the second stage of labour and both infant birth weight and the Apgar score at one minute. Cervical dilatation‐time curves, constructed with reference to the cervical dilatation found on admission to the labour ward, revealed no significant differences in the progress of normal labour in the different racial groups.

The effects of subcutaneous hormone implants during the climacteric

Climacteric symptoms in 120 women were treated with a total of 469 hormone implants (oestradiol 50 mg and testosterone 100 mg) over a period of four years. All patients with a uterus were given an oral progestogen to prevent endometrial hyperplasia. There was a marked response to treatment, hot flushes being improved in all patients, depression in 99% and loss of libido in 92%. Patient acceptability of this type of treatment was good and there were few side effects or complications. After therapy, the serum oestradiol exceeded the serum oestrone but remained within normal limits. When climacteric symptoms returned and re-implantation occurred the serum levels of oestrone, oestradiol, luteinising hormone (LH), follicle stimulating hormone (FSH) and testosterone were within the normal range for the reproductive age. This indicates that the return of symptoms is due to a change in the hormone levels rather than absolute hypo- oestrogenism .

Prophylactic blood transfusion in maternal sickle cell syndromes.

Summary. An assessment of the benefits of prophylactic blood transfusion during 51 pregnancies in women with haemoglobin SS, haemoglobin SC and haemoglobin S‐β‐thalassaemia in a retrospective study from 1978 to 1984 has failed to demonstrate any clear conclusions as to their efficacy. Of the transfused patients, 22% developed atypical red cell antibodies and 14% had immediate minor transfusion reactions. Our data show no significant difference in fetal or maternal outcome between those patients who were transfused prophylactically and those who were not. A prospective study to clarify the appropriate place of this important aspect of management in women with sickle cell disease in pregnancy is suggested.

Pregnancy in sickle cell disease in the UK

Summary. The complications and outcome of 125 pregnancies in women with sickle cell disease between 1975 and 1981 are reviewed. There were no maternal deaths, but a perinatal mortality rate of 48 per 1000. The main maternal complications were sickling crises (38%), anaemia (65%), infections (61%) and severe pregnancy‐induced hypertensive disease (5%). There were three patients with eclampsia. There was a 13% spontaneous preterm delivery rate, 25% of the babies were‘light‐for‐dates, fetal distress in labour was seen in 24% and 15% were delivered by caesarean section. There was an increased incidence of involuntary infertility and spontaneous abortion. The treatment by prophylactic blood transfusions is discussed.

Role of testosterone in the treatment of hypoactive sexual desire disorder

Hypoactive sexual desire disorder (HSDD) is a common clinical problem that may have a very negative impact on a womans quality of life. Diagnosis and treatment is challenging, as one must keep in mind the complex web of factors influencing sexual functioning alone or in concert. Data suggest that androgens are significant independent factors affecting sexual desire, sexual activity and satisfaction, as well as other components of womens health such as mood and energy. For decades, physicians used various androgen preparations to improve sexual function in women, based on the results of smaller clinical trials and personal clinical observations when taking care of patients. Today, there is substantial body of evidence from randomized placebo-controlled trials that low-dose testosterone treatment is efficacious in women with HSDD who have an established cause of androgen deficiency such as surgical menopause. Recent data support the hypotheses that androgens may also be beneficial in naturally menopausal women or in premenopausal women with low circulating testosterone levels and a decrease in satisfying sexual activity. No single testosterone level has been found to be predictive for low female sexual function, even though women suffering from HSDD commonly have low testosterone levels. The most frequently reported side effects of testosterone treatment are mild hirsutism or acne. Long-term safety is not yet established. Several clinical trials are in progress to further investigate potential benefits and risks of androgen treatment in women with sexual dysfunction.