[Medical treatment of endometriosis]. / Traitements médicaux de l'endométriose.

Medical treatment of endometriosis has been applied since 40 years. Its rational is based upon the hormone-dependency of the endometriotic lesions inducing a resting status. Adhesions, endometriomas or fibrous sequellae do not respond to medical treatment. Its use in case of associated infertility is very limited. Numerous agents are available for clinical use. Progestins are efficient on pelvic pain, contra-indications, clinical and metabolic tolerance are linked to the hormonal activity of the molecules. They have a low cost. Newer pills deserve to be evaluated. Danazol has now few indications in regards to its clinical and metabolic side-effects. Gn-RH analogs bear a potent efficacy and a very low intrinsic toxicity. They are preferentially used in severe cases, in association with surgery and before an IVF. Add back therapy improves the clinical tolerance and reduces bone mass loss. Many parameters should be taken into account when selecting a specific modality.

[Future of intrauterine contraception (IUDS)]. / Avenir de la contraception endo-uterine.

PIP: Performance of IUDs has improved greatly in the past decade. The reasons for improvement include increased copper content and prevention of copper fragmentation, flexible frames that adapt to the endometrial cavity, better evaluation of the endometrial cavity before insertion, simplified insertion, selection of acceptors, and careful follow-up. NO significant modifications in IUD design have occurred since the use of copper was begun in the 1970s except for use of systems-releasing steroids. The use of copper improved efficacy and permitted use of smaller devices, reducing some side effects especially in small uteruses. The duration of use of copper IUDs has increased, and their efficacy has improved at the same time that modifications have permitted greater local tolerance with no increase in expulsion rate. Greater selectivity of IUD users has improved performance, taking into account known risks for major complications such as extrauterine pregnancy and infection. Prior use of IUD and conditions of follow-up should also be considered in candidate selection. The major weaknesses of IUDs at present are related to the introduction of a foreign body into the uterine cavity; IUD insertion entails potential risks of infection and perforation. However, the active substance should not cause damage to the endometrial mucus or induce cycle disturbances or diminished defenses against pain and infection. Research on IUD frames is oriented toward development of a device adaptable to specific conditions such as the postpartum. 1 new device would completely eliminate plastic and the related side effects. A new miniaturized device is under investigation along with a biodegradable device and an intracervical device. New substances under study for a better contraceptive effect include spermicides, immunological substances, and synthetic progestins. An intracervical device emitting a battery-driven weak electric field is intended to immobilize sperm. Most current research has as its goal the reduction of secondary effects of bleeding, pain, or risk of infection. Among the numerous substances utilized have been antifibrinolytics, prostaglandin inhibitors, sexual steroids, and antibiotics. These systems should provide constant release over a prolonged period, a goal not yet attainable for all these substances.^ieng

[Study of endometrial maturation under the influence of an oestrogen-progestin combination containing 30 mcg of EE and 150 mcg of desogestrel: the value of biopsy of the endometrium in assessing the efficacy of an oestrogen-progestin combination]. / Etude de la maturation de l'endometre sous l'influence d'un estro-progestatif contenant 30 mcg d'EE et 150 mcg de desogestrel: interet de la biopsie de l'endometre pour evaluer l'efficacite d'un estro-progestatif.

PIP: Endometrial biopsies were performed on 21 female volunteers aged 18-40 years to evaluate the inhibitory effects of a new contraceptive formulation and the influence of the steroid on 1 of the major target organs. The formulation contained 30 mcg of ethinyl estradiol and 150 mcg of the new progestin desogestrel. The 21 women had taken the OC for at least 3 months. The aspiration biopsies were performed during 3 different cycle phases in 3 different centers in Nice, Bordeaux, and Paris. 5 biopsies done during days 1-9, 5 during days 10-17, and 7 during days 18-23 were retained. Results from the 17 biopsies were remarkably homogeneous for all cycle dates. The endometrium was constantly hypotrophic, the glandular tubes were of small size, and signs of glandular secretion were present in 16 of 17 cases with intracellular vacuoles and a visible secretion. Mitosis was observed in the glandular cellule in only 1 case. The stroma were edematous in 9 of 17 cases. The results demonstrated a low estrogenic stimulation and a dominant progestagenic action due to the strong antigonadotrophic and progestagenic properties of desogestrel. The advantages of the new generation of progestins such as desogestrel are obvious from the study. The study also demonstrates the need for endometrial biopsies to characterize the overall effects and climate of combined OCs, since some of the most common markers can provide misleading results.^ieng

[Ombrelle 250: a new contraceptive intrauterine device]. / L'Ombrelle 250: un nouveau dispositif intra-uterin contraceptif.

PIP: The umbrella 250 is a new IUD developed in France to minimize rigidity and penetration of the uterine wall so as to lessen side effects of local pain and bleeding. The flexible, supple vactor has the characteristics of a spring to ensure that it remains in place in the fundal position required for efficacy. The device is in the shape of a T whose vertical branch is coated with copper threads containing 250 sq mm of copper. The umbrella 250 comes in 1 size, 31.5 mm long, and is adaptable to any uterine cavity. The cumulative rates of events per 100 women after 12, 24, and 36 months respectively were .2, .9, and .9 for pregnancy; .6, .6, and .6 for expulsion; 1.9, 3.7, and 4.0 for removal for pain or bleeding; .8, 1.7, and 2.8 for removal for other medical reason; 1.7, 5.7, and 7.0 for removal to become pregnant; and .2, 1.2, and 1.4 for removal for personal reasons. The continuation rates were 95.1, 87.0, and 83.9 after 12, 24, and 36 months. There were 461, 373, and 149 insertions and 5755, 10,813, and 13,768 women-months of use in each of the 3 years. A multicenter study covering 925 insertions after 12 months showed 2 accidental pregnancies, 4 expulsions, 27 removals for pain and bleeding, 6 removals for infection, 10 removals for other medical reasons, and 16 removals to become pregnant. 89 patients were lost to follow-up. The continuation rate was 92, and the experience covered 9054 women-months of use. The patients were selected according to the usual criteria for IUD use. Most patients had at least 1 child and were at least 30 years old. The rates of expulsion and removal for pain and bleeding appear to be low, but a true comparative study has not been completed.^ieng

[Psychosocial repercussions of the the treatment of Hodgkin's disease. Assessment by questionnaire with 150 patients]. / Retentissement psychosocial du traitement de la maladie de Hodgkin. Appréciation par questionnaire auprès de 150 malades.

One hundred and fifty patients, treated for Hodgkin's disease (stages I-IIIA) in a cooperative trial and remaining in complete remission after 2 to 7 years, answered a questionnaire dealing with psychosocial status and quality of life. Many informations were gathered and studied by multiparametric methods. Quality of life of patients appears determined by three kinds of parameters: patients' characteristics (age, sex, family and work status); stage of the disease determining the intensity and duration of treatment; practical conditions of treatment. These last parameters may be improved by therapeutic team and all care-takers to decrease bad consequences of disease and treatment and also to increase quality of life after cure.

[Current issues in contraception]. / Actualites en contraception.

PIP: Some controversies regarding currently used contraceptive methods are reviewed. There are no newly available estrogens for oral contraceptives (OCs), but 2 progestins are coming into use: cyproterone acetate, which has a potent antiandrogenic action, and desogestrel, which combines a strong inhibitory effect on ovulaion and a marked peripheral progestin activity with very weak androgenic and anabolizing activity. New systems of administration will be used in the future to avoid the serum "peaks" observed in oral administration. The lack of agreement on the effects and secondary effects of various progestins will be a continuing source of discussion. 2 aspects of combined OCS, residual ovarian activity and androgenicity, are attracting increasing attention. Among new preparations, the combination of 2 mg cyproterone acetate and 50 mcg of ethinyl estradiol (EE) has been shown in multicenter European studies to have good effects on acne and satisfactory acceptance despite some hyperestrogenic secondary effects, which may be improved by a new dosage schedule. Triphasic preparations have given good results with significantly reduced steroid doses. There have been few recent findings concerning risks of OCs. The triphasic formulations and those containing desogestrel are too recent to have been subjected to epidemiologic study. The noncontraceptive benefits of OCs are becoming more apparent; they include protection against ovarian and endometrial cancer, functional ovarian cyst, ectopic pregnancy, salpingitis, benign breast disease, dysmenorrhea, rheumatoid arthritis, menorrhagia, and premenstrual syndrome. Improved knowledge of the mechanisms of action and local effects of IUDs permitted improved utilization. Ultastructural studies and endometrial exploration have show that non-fundally located IUDs entail greater risk of failure and complications. The question of early pregnancy with IUD use is still unresolved. Copper IUDs are now the most widely used type, but there are differences of apinion about whether the copper content should be increased or whether silver should be added to the core of the copper thread. IUDs with natural or synthetic progesterone may reduce bleeding and have other beneficial effects. Currently it is impossible to identify 1 particualr IUD as superior. IUD performance is improved by careful patient selection, choice of IUDs, and follow-up to identify and treat problems at an early stage. Improved spermicides such as Benzalkonjum chloride attracted greater attention to vaginal methods. The posibility of increased risk of toxic shock syndrome and teratogenic effects remain to be evaluated. Post-coital contraception continues to be important as yet no satisfactory new male methods have been developed. The US office of Technology Assessment has published a list of contraceptive developments or improvements expected by the year 2000.^ieng

[Assessment of the performance of a copper intrauterine device: MLCu 375]. / Bilan des performances d'un dispositif intra-uterin au cuivre: le MLCu 375.

PIP: Between November 1977 and May 1978, 120 Multiload Cu 375 (ML Cu 375) IUDs were inserted to be used for periods of 24 months in 24 women or 36 months in 96 women. 4 patients were aged 24 years or younger, 38 were 25-29, 40 were 30-34, 21 were 35-39, 13 were 40-44, and 4 were 45 or over. 9 were nulliparous, 30 were primaparous, and 81 were multiparous. 35 women had used another type of IUD and 5 had expelled another model. At 12, 24 and 36 months respectively there were 1, 2, and 0 pregnancies; 3, 4 and 0 expulsions; 5, 3, and 4 removals for pain; 0, 2, and 1 removal for other medical reasons; 0, 1, and 1 removals for personal reasons; and 2, 4, and 3 removals because of desire for pregnancy. The number of cycles included at 12, 24, and 36 months respectively were 1354, 2454, and 3081, and a total of 20 patients were lost to follow-up over 36 months. The small sample size and limited number of cycles of use prohibit a complete evaluation of the ML Cu 375, but the author's experiences confirm the simplicity of insertion, efficacy, good retention and acceptable tolerance of the device. A review of the literature suggests that IUDs with large doses of copper, such as the ML Cu 375, offer contraceptive efficacy that will be difficult to improve, at least with copper devices.^ieng

[Assessment of the treatment of endometriosis by an antigonadotropin].

PIP: Danazol (2-3 isoxazole-17 beta ethinyltestosterone) is an antigonadotropin used to treat endometriosis. It has a half-life of 4.4 hours in humans. It has no known teratogenic or embryotoxic effects. Danazol use causes slight alterations of liver functions and hyperglycemia curves. Danazol dosages of 200 mg induce ovulation. The secretion of luteinizing hormone is normal or elevated among women using Danazol. Atrophy of the endometrium is observed after 5 or 6 weeks of Danazol use. Regeneration begins on about the 10th day after Danazol use is discontinued. 54 women with endometrial lesions were treated with Danazol. 15 women were treated for severe endometrial lesions with 800 mg of Danazol; 5 experienced significant amelioration of the lesions. Of 31 infertile women, treated with 600-800 mg Danazol, 9 pregnancies were observed. Of 8 women with small endometrial lesions who had been sterile for more than 3 years, 4 pregnancies occurred after treatment with 200-600 mg. Danazol. Sudden flushes, decreased breast size, metrorrhagia, acne, weight gain, artralgia, and digestive and emotional disturbances were the most frequent side effects. The continuity rate was about 90%.^ieng