A Review of Integrative Medicine in Gynaecological Oncology.

In recent years complementary and alternative medicine (CAM) has increasingly been the focus of international research. Numerous subsidised trials (7903) and systematic reviews (651) have been published, and the evidence is starting to be integrated into treatment guidelines. However, due to insufficient evidence and/or insufficient good quality evidence, this has mostly not translated to practice recommendations in reviews by the Cochrane collaboration gynaecology group. There is nevertheless a not insignificant number of CAM providers and users. The percentage of oncology patients who use CAM varies between 5 and 90 %. Doctors have been identified as the main providers of CAM. Half of gynaecologists offer CAM because of personal conviction or on suggestion from colleagues. This must be viewed in a critical light, since CAM is mostly practiced without appropriate training, often without sufficient evidence for a given method - and where evidence exists, practice guidelines are lacking - and lack of safety or efficacy testing. The combination of patient demand and lucrativeness for doctors/alternative medicine practitioners, both based on supposed effectiveness CAM, often leads to its indiscriminate use with uncertain outcomes and significant cost for patients. On the other hand there is published, positive level I evidence for a number of CAM treatment forms. The aim of this article is therefore to review the available evidence for CAM in gynaecological oncology practice. The continued need for research is highlighted, as is the need to integrate practices supported by good evidence into conventional gynaecological oncology.

Endometrial cancer.

Radical surgery including complete pelvic and para-arortic lymph node dissection (LND) is both the main therapeutic effort and the decisive staging procedure in patients with invasive endometrial cancer (EC) and should be performed in specialized institutions. Vaginal cuff brachytherapy holds little serious side effects and may be beneficial in preventing vaginal recurrences. External irradiation treatment no longer has a routine indication in primary therapy. The omission of retroperitoneal staging (LND) at primary surgery does not indicate adjuvant radiotherapy but rather second-effort surgery removing pelvic and para-aortic lymph-nodes. External radiotherapy should be reserved for fully staged patients with residual non-resectable tumor manifestation and/or nodal involvement in relation to the extent of tumor involvement and surgical intervention. Hormonal and cytotoxic therapy is experimental in the adjuvant setting. The first step in palliative systemic treatment should be the administration of endocrine therapy when the tumor expresses progesterone receptors and tumor manifestations are not acutely life-threatening. In other cases or when endocrine treatment fails chemotherapy may be considered, which is often limited due to its toxicity. Preferably, palliative hormonal and/or chemotherapy should be administered in controlled clinical trials.

[Are estrogens carcinogens?]. / Sind Estrogene Karzinogene?

It is well accepted that unopposed estrogens increase the risk of developing endometrial cancer. A relationship between estrogen exposure and the risk for breast cancer is very probable. In addition, an association of long-term estrogen substitution and ovarian cancer risk has been postulated recently. Estrogens have been considered as typical tumor promotors. Due to their estrogen-receptor-mediated mitogenic activity, these steroids were supposed to increase the statistical probability of spontaneous mutations. Recent experimental findings, however, suggest that estrogen metabolites, in particular 4-hydroxyestrogens are capable of inducing DNA-damage and transforming mutations. The clinical relevance of these genotoxic properties of estrogens remains to be established, but could obtain great importance. First molecular-epidemiologic studies suggest that due to the specific activity of their estrogen metabolizing enzymes some women might produce relevant amounts of mutagenic estrogen metabolites, increasing their risk for breast-, endometrial- or ovarian cancer respectively. These findings might result in novel preventive strategies. The present data do not justify to abandon the practice of hormone replacement therapy with estrogens or estrogens plus progestins in non hysterectomised women. It seems to be wise, however, to restrict hormone replacement therapy to symptomatic women with a clear indication and, according to the actual trend, limit it temporarily.

Substances with estrogenic activity in effluents of sewage treatment plants in southwestern Germany. 2. Biological analysis.

The proliferation test with human estrogen receptor-positive MCF-7 breast cancer cells (E-Screen assay) was applied for quantitative determination of total estrogenic activity in 24-h composite effluent samples from 16 municipal and two industrial sewage treatment plants (STPs) in the state of Baden-Württemberg, southwestern Germany. The estrogenic efficacy relative to the positive control, 17beta-estradiol, was between 26 and 74% (median, 48%) for the 16 municipal STPs. Estradiol equivalent concentrations (EEQs) were between 0.2 and 7.8 ng/L (median, 1.6 ng/L) and, thereby, were lower than those found in a pilot study, which revealed EEQs of greater than 10 ng/L in the effluents of two other STPs. The EEQs in 14 of the 16 effluent samples were very similar (0.9-3.3 ng/L), indicating a rather constant input of estrogenic substances via STPs into rivers. Additional activated charcoal filtration turned out to be very efficient in further eliminating estrogenic activity from effluents. The EEQs of the E-Screen assay and those calculated from the results of extensive chemical analysis using the estradiol equivalency factors determined for 13 natural and synthetic estrogenic substances were comparable for most of the effluent samples. 17beta-Estradiol, 17alpha-ethinylestradiol, and, to a lesser extent, estrone contributed to 90% or more of the EEQ value.

Input/output balance of estrogenic active compounds in a major municipal sewage plant in Germany.

24 h samples of untreated and treated wastewater were taken in parallel from a modern municipal sewage plant in southern Germany in March and June 1998. After solid phase extraction, total estrogenic activity was quantitatively measured with a miniaturized E-screen assay and the levels of nine estrogenic phenolic chemicals analyzed by HRGC/LRMS. 17Beta-estradiol equivalent concentrations (EEQ) were 58 and 70 ng/l in the influent and 6 ng/l in the effluent, indicating that the load of estrogenic activity of the wastewater was reduced by about 90% in the sewage plant. Less than 3% of the estrogenic activity was found in the sludge. 4-t-octylphenol, 4-nonylphenol, bisphenol A, 2-hydroxybiphenyl, and 4-chloro-3-methylphenol were detected in the untreated wastewater at levels from 0.13 to 3.6 microg/l. 4-t-octylphenol, 4-nonylphenol, and bisphenol A were present in the effluent at concentrations from 0.16 to 0.36 microg/l, 2-hydroxybiphenyl and 4-chloro-3-methylphenol were not detectable. The contribution of the quantified levels of phenolic xenoestrogens to total estrogenic activity in the sewage was 0.7-4.3%.

Effects of single polychlorinated biphenyls on the morphology of cultured rat tubuli seminiferi.

The effects of single polychlorinated biphenyls (PCB) on isolated tubuli seminiferi of the rat were studied. Freshly isolated rat tubuli seminiferi were prepared according to their transillumination pattern, i.e. dark or pale. Tubuli seminiferi with the dark pattern included stages II to VIII and tubuli with the pale pattern represented stages IX to XIV and stage I of the seminiferous cycle. Afterwards, tubuli seminiferi were exposed to single polychlorinated biphenyls for 5 or 24 h in vitro. PCB 126, PCB 77, and PCB 118 were used in final parts per billion (p.p.b.) concentrations as determined by quantitative PCB analysis. Eventually, the specimens were plastic embedded, cut into semithin sections, stained, and morphology was evaluated by light microscopy. Single PCB congeners induced morphological alterations in cultivated rat tubuli seminiferi in a time- and stage-dependent manner. Effects comprised loosened intercellular contacts between germ cells and Sertoli cells as well as cellular fragmentation in the layer of round spermatids. Early spermiogenesis seems particularly susceptible to single PCB congeners in concentration of background magnitude. The target cell has still to be discovered.

Development of a sensitive E-screen assay for quantitative analysis of estrogenic activity in municipal sewage plant effluents.

A simplified proliferation test with human estrogen receptor-positive MCF-7 breast cancer cells (E-screen assay) was optimized and validated for the sensitive quantitative determination of total estrogenic activity in effluent samples from municipal sewage plants. After solid phase extraction of 1 l sewage on either 0.2 g polystyrene copolymer (ENV+) or 1 g RP-C18 material and removal of the solvent, analysis of the extracts in the E-screen assay could be performed without any clean-up step. This was even possible with untreated sewage. Parallel extraction of four sewage samples on both different solid phase materials gave comparable quantitative results in the E-screen. A blank sample did not induce cell proliferation. As additive behaviour of the estrogenic response of single compounds was proven for two different mixtures each containing three xenoestrogens, total estrogenic activity in the sewage samples, expressed as 17 beta-estradiol equivalent concentration (EEQ), could be calculated comparing the EC50 values of the samples with those of the positive control 17 beta-estradiol. The detection limit of the E-screen method was 0.05 pmol EEQ/l (0.014 ng EEQ/l), the limit of quantification 0.25-0.5 pmol EEQ/l (0.07-0.14 ng EEQ/l). In total, extracts of nine effluent and one influent sample from five different municipal sewage plants in South Germany were analyzed in the E-screen. All samples strongly induced cell proliferation in a dose-dependent manner which was completely inhibited by coincubation with 5 nM of the estrogen receptor-antagonist ICI 182,780. The proliferative effect relative to the positive control 17 beta-estradiol (RPE) was between 30 and 101%. 17 beta-Estradiol equivalent concentrations were between 2.5 and 25 ng/l indicating a significant input of estrogenic substances via sewage treatment plants into rivers.

Validation and application of a rapid in vitro assay for assessing the estrogenic potency of halogenated phenolic chemicals.

The E-Screen assay serves as an in vitro tool for the detection of estrogenic activity of chemicals and extracts of environmental samples. Based on the induction of proliferation in human estrogen receptor-positive MCF-7 breast cancer cells we could substantially simplify the assay. As one important step of validation we applied the modified assay for testing nine known xenoestrogens. We could confirm the results of other groups assuring the reproducibility of the E-Screen assay. The results provide evidence that the E-Screen assay is suitable for determination of estradiol equivalency factors (EEFs) for environmental estrogens to rank their estrogenic potency relative to the natural estrogen 17 beta-estradiol. Further, we used the optimized proliferation test to screen nine halogenated phenolic compounds for their possible estrogenic potency. Three widely applied chemicals expressed a weak receptor-mediated estrogenic activity: the flame retardant Tetrabromo-Bisphenol-A, the disinfectant 4-chloro-3-methylphenol, and the herbicide educt 4-chloro-2-methylphenol. Their estrogenic potencies were five to six orders of magnitude lower than that of 17 beta-estradiol.

Tetraploidy and partial endoreduplication in a tripronuclear zygote obtained after intracytoplasmic sperm injection.

OBJECTIVE: To describe a peculiar combination of cytogenetic abnormalities in a tripronuclear zygote obtained after intracytoplasmic sperm injection (ICSI). DESIGN: Case report. SETTING: A university hospital. PATIENT(S): A couple with a 4-year history of primary infertility. Intracytoplasmic sperm injection was performed because of male factor infertility (oligoteratozoospermia). INTERVENTION(S): Ultrasound-guided transvaginal follicular aspiration. MAIN OUTCOME MEASURE(S): Chromosomal karyotype of a tripronuclear one-cell zygote. RESULT(S): Unexpectedly, a tetraploid [92,XXYY, end3, -18, end18] chromosome complement was found, indicating injection of a diploid spermatozoon carrying two Y chromosomes. The parental origin of the other abnormalities could not be determined. The missing chromosomes may be attributed either to a hypodiploid [44,YY,-18,-18] sperm cell or to a hypohaploid [22,X,-18] oocyte. The exact tetraploid count was restored by endoreduplication of two chromosomes. This event could have occurred in one and the same or in two different pronuclei. CONCLUSION(S): Cytogenetic analysis of multipronuclear zygotes appears useful for assessing the incidence of chromosomal abnormalities at the earliest stage of conception. In addition to other methods, it also may contribute to evaluation of the transmission of aberrations by spermatozoa from infertile men.

Influence of nicotine on progesterone and estradiol production of cultured human granulosa cells.

The purpose of this study was to investigate the direct action of one of the main constituents of cigarette smoke on corpus luteum function. Progesterone and estradiol production were measured in the presence and absence of nicotine as free base or bitartrate salt with or without luteinizing hormone (LH) stimulation using radioimmunoassay in an in vitro granulosa cell culture system. Human granulosa cells were obtained from 19 patients undergoing in vitro fertilization embryo transfer treatment for infertility at the University Women's Hospital, Tübinge, Germany. Nicotine free base augmented estradiol secretion and inhibited progesterone secretion by human granulosa cells in a dose-dependent manner. Nicotine bitartrate had little effect on steroid secretion. If granulosa cells were stimulated with LH, both nicotine preparations suppressed estradiol secretion, however, only nicotine bitartrate additionally inhibited progesterone secretion. The results suggest that cigarette smoking specifically affects the control mechanisms of intraovarian processes which are responsible for normal luteal function.

Mercury in urine and ejaculate in husbands of barren couples.

Mercury concentrations in morning urine and ejaculate were detected in 80 husbands of women presenting for infertility treatment. Additionally, the number of their dental amalgam fillings was documented. A routine spermiogram was performed, from which a numerical "fertility index" was calculated. Urinary mercury concentrations were in the range of non-exposed populations, only minute Hg concentrations were determined in ejaculate, 75% of the semen sample concentrations were under the detection limit of 5 micrograms/l. In comparison, 7 proven fertile workers with occupational mercury exposure had elevated levels of mercury in their ejaculates (range 10-65 micrograms/l). No positive correlation could be established between subject mercury concentrations in urine or ejaculate and the quality of their semen, expressed as fertility index. Equally, no such correlation could be established between the fertility index and the number of their dental amalgam fillings. From these preliminary data no evidence can be derived for the alleged relation between the mercury burden from dental amalgam fillings and male fertility disorders.

Concentrations and profiles of PCDDs and PCDFs in human mammary carcinoma tissue.

PCDD/PCDF concentrations in eight mammary carcinoma tissue samples obtained after surgical excision were similar to those found in two healthy breast glandular tissue samples from autopsy material. These levels agree well with mean concentrations in human adipose tissue from German adults. An analogous consistency was found for the congener profiles of the normalized concentrations, also in comparison with mothers' milk from Germany. In spite of similar congener profiles the concentrations in four axillary adipose tissue samples corresponding to the carcinoma samples were about 40% lower. This discrepancy was not found in one tissue pair from a healthy breast.

The effect of histamine on progesterone and estradiol secretion of human granulosa cells in serum-free culture.

The aim of this study was to explore the direct action of histamine on progesterone and estradiol secretion of human granulosa cells cultured in serum-free medium. Human granulosa cells were isolated from preovulatory follicular fluid aspirated from 17 women (32 +/- 3 years old, mean +/- SD) undergoing in vitro fertilization treatment at the University Women's Hospital of Tübingen. Progesterone and estradiol production was measured in the presence and absence of histamine, terfenadine or cimetidine using radioimmunoassays. Statistical analysis of the data was performed by analysis of variance and Newmann-Keul tests. Histamine stimulated a dose-related increase in estradiol secretion with a maximal stimulatory effect at 10(-3) mol/l. This response was blocked specifically by the H1-receptor antagonist terfenadine. Progesterone production in response to histamine stimulation was independent of dose at the limit of significance. The specific H2-receptor antagonist cimetidine did not block the stimulatory effect of histamine. We suggest that histamine has a direct stimulatory effect on steroid production of granulosa cells mediated via the H1-receptor. This effect may have a physiological role in the regulation of granulosa cell function during the menstrual cycle.

Effect of noradrenaline and dopamine on progesterone and estradiol secretion of human granulosa cells.

The aim of this study was to explore the direct action of noradrenaline and dopamine on progesterone and estradiol secretion of human granulosa cells cultured in serum-free medium. Progesterone and estradiol production was measured in the presence and absence of noradrenaline, dopamine or propranolol using radioimmunoassays; statistical analysis was performed by analysis of variance and Newman-Keul's multiple range test. Twenty-six women aged 31 +/- 3 years undergoing in vitro fertilization and embryo transfer for infertility treatment at University Women's Hospital, University of Tübingen, Germany, took part in this study. Noradrenaline significantly inhibited progesterone production by human granulosa cells in a dose-related manner at a concentration of 10(-4)-10(-6) mol/l. Dopamine significantly stimulated estradiol secretion by granulosa cells in an inverse dose-related manner. Both effects were blocked by propranolol. The results suggest that catecholaminergic actions switch over the steroid production of human granulosa cells cultured in serum-free medium from progesterone to estradiol.

Cholinergic stimulation of progesterone and estradiol secretion by human granulosa cells cultured in serum-free medium.

Cholinergic effects on hormone secretion by human granulosa cells (GCs) are not well characterized. The aim of this study was to explore the direct action of acetylcholine and carbachol on progesterone and estradiol secretion of human GCs cultured in serum-free medium. Granulosa cells were obtained from 26 women undergoing in vitro fertilization and embryo transfer. Progesterone and estradiol production was measured in the presence and absence of acetylcholine, carbachol, or atropine using radioimmunoassays; statistical analysis of the data was performed by ANOVA. Acetylcholine significantly stimulated progesterone secretion by GCs in a dose-related manner. Estradiol secretion was also stimulated by acetylcholine, but this effect did not show dose dependency. Carbachol showed a similar stimulatory effect, but to a lower degree; both effects can be blocked by acetylcholine. The results suggest that cholinergic action on steroid production by human GCs is mediated through the muscarinic route, and cholinergic neurotransmission may have a physiological significance in the intra-ovarian regulatory pathways.