Home pregnancy test compared to standard-of-care ultrasound dating in the assessment of pregnancy duration.

OBJECTIVE: To determine the level of agreement between the Clearblue Digital Pregnancy Test with Conception Indicator home pregnancy test and standard-of-care ultrasound in assessing pregnancy duration in a real-life, observational setting encompassing routine, clinical care. RESEARCH DESIGN AND METHODS: This was a prospective observational study of non-pregnant women seeking conception. Women collected daily urine samples from day 1 of their next menstrual cycle. If any volunteer became pregnant, daily urine samples continued to be collected for 43 days after the LH surge. Samples from day -7 to day +28 relative to the expected period (LH surge + 15 days) were tested using the home pregnancy test. This categorised any resulting pregnancies into one of three groups: 1-2 weeks, 2-3 weeks, and 3+ weeks since conception. Information from the standard UK ultrasound dating scan was also recorded by the midwife, including the expected delivery date according to ultrasound and the expected delivery date according to LMP. MAIN OUTCOME MEASURES: Full data were available from 52 pregnant women who had conceived naturally. During the study analysis, 4786 urine samples were cross-compared with 52 routine 12-week NHS ultrasound assessments and the level of agreement between home pregnancy testing and standard-of-care ultrasound in determining pregnancy duration was calculated. RESULTS: The agreement between the gestational age as calculated by the home pregnancy test result and the exact midwife-recorded gestational age using ultrasound was 82.3%. However, when a ± 5-day range was applied to the ultrasound reading (as per routine UK clinical practice), the level of agreement was 98%. CONCLUSIONS: The home pregnancy test provides a significantly high (98%) level of agreement with standard-of-care ultrasound when assessing pregnancy duration in a real-life, observational setting which closely mirrors daily clinical practice.

The effect of nonsteroidal anti-inflammatory drugs on ovulation: a prospective, randomized clinical trial.

OBJECTIVE: To assess the effect of ibuprofen, a nonspecific inhibitor of prostaglandin synthesis, on ovulation. DESIGN: Prospective, randomized, double-blind, placebo-controlled cross-over study. SETTING: University Medical Center. PATIENT(S): Twelve normally cycling women between ages 20 and 40. INTERVENTION(S): Subjects were randomized to either oral ibuprofen (800 mg) or placebo three times per day, beginning when the maximum diameter of the leading follicle reached 16 mm by ultrasound, and continuing for 10 days total. The second cycle was a washout period, and in the third cycle, the subjects were crossed over to the alternate regimen from the first cycle. The probability of delayed follicular collapse was determined using the binomial distribution, and changes in P levels were compared using the paired t test. MAIN OUTCOME MEASURE(S): Urinary LH surge, follicular collapse by serial transvaginal ultrasonography, and serum midluteal P levels. RESULT(S): Eleven of 12 subjects detected an LH surge with both ibuprofen and placebo. Five of 11 women demonstrated a >or=2-day increase in time interval from detection of the LH surge to follicular collapse, and 3 of those 5 had been randomized to ibuprofen. This represents a 27% (3 of 11; 95% confidence limits: 1%, 53%) rate of delay for follicular collapse for ibuprofen. There was no difference in average midluteal P levels for ibuprofen or placebo. CONCLUSION(S): If ibuprofen inhibits follicular collapse, this effect is seen in a small group of study subjects, and this information should be clinically reassuring to patients who take nonsteroidal anti-inflammatory drugs. Serum midluteal P levels were unaffected by administration of ibuprofen.

Perforated duodenal ulcer associated with ovarian hyperstimulation syndrome: Case Report.

Ovarian hyperstimulation syndrome (OHSS) remains the most serious medical complication of controlled ovarian stimulation. An unusual case of perforated duodenal ulcer following critical OHSS is presented. A 29 year old nulligravid woman with polycystic ovarian syndrome underwent her first attempt at in-vitro fertilization. She was admitted to the hospital with critical OHSS and subsequently found to have a perforated posterior duodenal ulcer. She underwent exploratory laparotomy, antrectomy and gastrojejunostomy. Pathological analysis of her gastric antrum confirmed chronic gastritis and Helicobacter pylori. She required prolonged assisted ventilation, vasopressor support, multiple i.v. antibiotics, blood product replacement and nutritional support. The patient was hospitalized for a total of 47 days and then transferred to a rehabilitation facility for an additional 30 days before being discharged to home. In this critically ill patient with OHSS, severe stress associated with invasive monitoring and multiple medical therapies in the intensive care unit as well as H. pylori infection appear to be the most probable causative factors of her perforated viscus. Prompt recognition of potential complications and proper medical intervention are essential in the management of patients with OHSS. Avoidance strategies are still needed.

Relation of plasma oxytocin and prolactin concentrations to milk production in mothers of preterm infants: influence of stress.

Responses of oxytocin and PRL to mechanical breast pumping and the influence of physiological indicators of stress were measured at 2, 4, and 6 weeks postpartum to determine potential causes of inadequate milk production in 18 women with prematurely delivered, nonnursing (<1500 g) infants. Median milk production was similar to that reported in breastfeeding mothers, but a third of mothers were producing less than half as much by week 6. Plasma oxytocin was similar to that previously reported for breastfeeding mothers. The oxytocin area under the curve (AUC) for breast-pumping sessions (70 min) was correlated at each occasion (r = 0.37, 0.58, and 0.55, respectively) with milk yield. Unlike reports of PRL levels in breast-feeding women, PRL AUC declined between weeks 2 and 6 weeks postpartum (P = 0.03); significant increases in plasma PRL occurred in response to pumping at 2 and 4 weeks, but not at 6 weeks. Salivary amylase, a measure of alpha-adrenergic activity, was highly negatively correlated on each occasion with PRL AUC (r = -0.58, -0.68, and -0.86, respectively), but not with oxytocin. Salivary cortisol was negatively correlated to a lesser degree. We hypothesize that deficiencies in preterm lactation are mediated in part upon stress-induced suppression of PRL secretion through an adrenergic mechanism.

Semen quality and human fertility: a prospective study with healthy couples.

Measures of semen quality are used as surrogate measures of male fertility in clinical andrology, reproductive toxicology, epidemiology, and risk assessment. However, only limited data are available to relate those measures to fertility. This prospective study with 210 reproductive-age couples was conducted to provide information on the value of semen quality measures for predicting human male fertility potential and for development of models to estimate the effects of changes in semen quality on fertility in a given population for risk assessment. Couples without known risk factors for infertility and who had discontinued contraception to have a child were accepted. The study followed each couple for up to 12 menstrual cycles while they attempted to conceive and evaluated semen quality measures from multiple ejaculates per man with known abstinence intervals. For each cycle, the day of ovulation was predicted, and the couple was advised to have intercourse multiple times on that day and on the days around it. Among the demographic variables assessed, parity, contraception status prior to entering the study, male education level, and male smoking were associated significantly with 12-cycle pregnancy rate. Several semen quality measures also were associated significantly with pregnancy rate, with percentage morphologically normal sperm by strict criteria and measures involving total number of sperm showing particularly strong associations. Localized regression-smoothing plots of semen quality data against proportion of couples pregnant suggested levels below which fertility declines for several semen quality measures. These results have applications in both clinical andrology and in assessment of risk to male fecundity from environmental or pharmaceutical exposures. In particular, they contribute information on behavior of fertility with varying semen quality and can allow development of models to predict effects on fertility in populations from decrements in semen quality.

Utility of the sperm chromatin structure assay as a diagnostic and prognostic tool in the human fertility clinic.

The sperm chromatin structure assay (SCSA) was used to measure over 500 human semen samples from two independent studies: Study I, 402 samples from 165 presumably fertile couples wishing to achieve pregnancy over 12 menstrual cycles; Study II, samples from 115 patients seeking fertility counselling. The SCSA measures susceptibility to DNA denaturation in situ in spermatozoa exposed to acid for 30 s, followed by acridine orange staining. SCSA data from the male partners of 73 couples (group 1) achieving pregnancy during months 1-3 of Study I were used as the standard of 'sperm chromatin compatible with high fertility' and were significantly different from those of 40 couples (group 3) achieving pregnancy in months 4-12 (P < 0.01) and those of male partners of 31 couples (group 4) not achieving pregnancy (P < 0.001). Group 2 contained couples who had a miscarriage. SCSA values for Study II were almost twice that of the Study I fertility standards. Within-couple repeatability tended to be less for group 3 than for groups 1, 2 or 4. Based on logistic regression, spermatozoa with denatured DNA (cells outside the main population, COMP alpha t) were the best predictor for whether a couple would not achieve pregnancy. Some 84% of males in group 1 had COMP alpha t < 15%, while no couples achieved pregnancy in group 1 with > or = 30% COMP alpha t, a threshold level considered not compatible with good fertility. Using selected cut-off values for chromatin integrity, the SCSA data predicted seven of 18 miscarriages (39%).

Identification of estrogen receptor protein and messenger ribonucleic acid in human spermatozoa.

OBJECTIVE: The processes leading to fertilization involve a series of sequential events including the deposition and transport of sperm in the female genital tract. It is becoming evident that spermatozoa in which a hyperactive state has been induced are more effective in both reaching and penetrating the oocyte. Many of the changes that spermatozoa undergo are the result of their ability to respond to the milieu of the female genital tract. In the presence of estrogen sperm have been shown to have increased their metabolic activity and flagellar activity and to have an increased ability to penetrate oocytes. Most important, these observed changes in sperm physiology occur quickly, suggesting a novel second-messenger system coupled to the estrogen receptor. Established effects of steroid hormones involve mediation of the signal through genomic expression. However, because it has not been definitively demonstrated whether the human sperm express the estrogen receptor, the mechanism by which estrogen exert its effect remains to be elucidated. STUDY DESIGN: The presence of estrogen receptors on human spermatozoa was investigated. Immunohistochemistry performed on human spermatozoa indicates that the estrogen receptors are located on the tailpiece. In addition, protein from human spermatozoa was isolated and subjected to Western blot analysis. RESULTS: Results indicate a single band of approximately 65 kd, similar to that of the native human estrogen receptor. Ribonucleic acid obtained from the human spermatozoa was reverse transcribed into deoxyribonucleic acid. With use of selected primers, this deoxyribonucleic acid was amplified by polymerase chain reaction. Resolution and examination of the expansion products demonstrated a single band of deoxyribonucleic acid of 450 bp, identical to that expected from the selected primers. The specificity of this reverse transcriptase-polymerase chain reaction amplified deoxyribonucleic acid sequence was verified by Southern blotting. CONCLUSION: For the first time we provide evidence as to the expression of estrogen receptor by human spermatozoa.

Incidence and implications of altered semen quality on family planning.

Alterations in the expression of the human genome, or interference with its products, can be induced in the male reproductive system by chemicals mimicking or antagonizing naturally occurring hormones. Opportunities exist for disruption at the hypothalamus, pituitary and testis levels. Recent concerns generated by the increased incidence of testicular cancer, congenital anomalies of the male genitalia and possible alterations in human semen quality have been linked to the environment. The report by Carlsen in 1992 [1] suggested that semen quality has deteriorated over the past six decades. More recent reports suggest that the decline may be globally non-uniform and regional in nature. The effects of any such declines upon overall pregnancy rates are generally unknown, although some studies have attempted to address them. A preliminary review of the impact of a small decrease in sperm concentrations suggests that a directly measurable reduction in fecundity does not occur, but that future problems could be anticipated. Decrements in semen quality will alter the epidemiological probabilities of pregnancy due to coitus on different cycle days and may thereby change the duration of the fertile time. Current understanding of the implications of altered semen quality on relative fertility is not sufficient to change our current teaching and practice of NFP.

Motility and other characteristics of human sperm can be measured by computer-assisted sperm analysis of samples stained with Hoechst 33342.

OBJECTIVE: To develop methods for using a DNA-specific dye to discriminate between motile and nonmotile sperm and static particulate matter in fresh and diluted semen, using computer-assisted sperm analysis (CASA) with the Hamilton Thorne IVOS, TOX version (Hamilton-Thorne Research, Beverly, MA). DESIGN: Donor semen was divided for treatment as fixed stained sperm (Hoechst 33342 stain; Sigma Chemical Company, St. Louis, MO), fresh motile and nonmotile stained sperm, and unstained control sperm. SETTING: Normal human volunteers in an academic research and medical environment. PATIENTS: Selected healthy student volunteers. INTERVENTIONS: Delivered semen to the laboratory within 1 hour of collection. MAIN OUTCOME MEASURE: Semen quality measured by CASA. RESULTS: Fixed or fresh human sperm stained with Hoechst 33342 dye should be diluted to < or = 50 x 10(6) sperm/mL to count sperm accurately. Motile and nonmotile sperm were stained suitably with 5 to 10 micrograms/mL of dye when diluted with a simple diluent, but the dye concentration should be increased to 40 micrograms/mL when egg yolk is in the diluent. CONCLUSIONS: The DNA-specific dye, Hoechst 33342, can be used to discriminate between motile and nonmotile sperm and other particulate matter when evaluated by CASA with instrumentation equipped with suitable optics.

The relationship of the postcoital test and semen characteristics to pregnancy rates in 200 presumed fertile couples.

OBJECTIVE: To evaluate the postcoital test (PCT) and semen analysis (SA) in the prediction of pregnancy in 200 potentially fertile couples. METHODS: 200 couples without risk for infertility were prospectively followed for 1 year. Couples were attempting pregnancy for 12 menstrual cycles. In the first three cycles, the women underwent monthly PCTs and collected daily urines while the men provided bimonthly semen analyses. For the next nine cycles, the couples were monitored for pregnancy. The PCT included hours post-coitus, amount of mucus, spinnbarkeit, number of motile sperm, and percent of motile sperm. Since multiple PCTs and SAs were available for each couple, values were averaged to provide one mean value per couple. The Wilcoxon ranked sum test was used to detect differences in PCT and SA. RESULTS: Pregnancy occurred in 163/200 couples (82%) in 12 cycles. Mean sperm count per high-power field (p = 0.01) and mean number of highly motile sperm (p = 0.03) were higher among women in whom pregnancy occurred. Amount of mucus and spinnbarkeit were similar between women who became pregnant and those who did not. Semen concentration, motile sperm count, and percent motile sperm were significantly higher among men whose partner conceived (P < .02). Only 93 couples (47%) had PCTs that were correctly timed. CONCLUSIONS: Measures predictive of pregnancy included vigorously moving sperm per high-power field, sperm concentration, motile sperm count, and percent motility. Mucus characteristics were not predictive of pregnancy. Additionally, a high number of sperm seen in the PCT correlated with a high number of motile sperm in the SA. These results support the use of the PCT for initial evaluation of the infertile couple.

Evaluation of computer-assisted semen analysis (CASA) with IDENT stain to determine sperm concentration.

This study was undertaken to compare a new fluorescent stain-based computer-assisted semen analysis (CASA) system (IDENT) for determining human sperm concentration to the manual hemacytometric method and to conventional CASA (CASA-CONV). Normal healthy semen donors as well as patients provided samples that were evaluated for sperm concentration with the CASA-IDENT method, the hemacytometer method, and CASA-CONV. Each field was examined visually to determine the sources of overcounting and undercounting for the two CASA methods. Four ranges of sperm concentration were examined: 0-10, > 10-30, > 30-100, and > 100 x 10(6)/ml. The main outcome measures were sperm concentration, debris counted as sperm, and missed sperm. Our results showed that significantly more debris was counted as sperm and more sperm were missed with CASA-CONV than CASA-IDENT. As the sperm density increased, so did the number of counting errors for the CASA-CONV system. The error rate was much greater using CASA-CONV (12.1 +/- 42.2%) than with CASA-IDENT (0.4 +/- 0.7%) when compared to hemacytometer counts (P = 0.068). We conclude that the CASA-IDENT method of sperm counting is highly accurate and less time-consuming when compared to the hemacytometer method. There are significant differences in the amount of debris counted as sperm and number of missed sperm between CASA-CONV and CASA-IDENT with varying sperm density. With both parameters, the counts are more accurate using the CASA-IDENT method.

Estimates of human fertility and pregnancy loss.

OBJECTIVE: To examine the fertility and pregnancy wastage rates in a group of presumably fertile couples. DESIGN: Prospective observational study of 200 couples desiring to achieve pregnancy over 12 menstrual cycles coupled with pregnancy outcome follow-up. SETTING: A university-based obstetrics and gynecological center. PATIENTS: Personal interviews and questionnaires were used to screen couples for entry into the study. Couples were counseled to have intercourse centered on predicted day of ovulation. Phase 1 included the first three cycles in which women collected daily morning urine samples, underwent midcycle postcoital tests, and, if late for their menses, presented for serum hCG testing. Phase 2 encompassed the next nine cycles in which women were contacted monthly by phone and underwent serum hCG testing if menses was delayed. Urine samples from cycles in which clinical (serum hCG) pregnancy did not occur underwent sensitive hCG testing to detect occult pregnancies. Pregnancies were followed until delivery to ascertain outcome. RESULTS: Eighty-two percent of the 200 couples followed for the entire study period conceived. The maximal fertility rate was approximately 30% per cycle in the first two cycles. This rate quickly tapered over the remainder of the study. Pregnancy wastage during phase 1 accounted for 31% of the pregnancies detected. Forty-one percent (15/36) of these losses were seen only by urine hCG testing and were categorized as occult. Eleven of these same patients later achieved clinically recognized conceptions during the study. CONCLUSIONS: These results support the concept that the efficiency of human reproduction is maximum at approximately 30% per cycle. A very significant number of these pregnancies end in spontaneous abortion. In addition, pregnancy loss before missed menses occurs in a significant proportion of women.

Pulsatile GnRH stimulates normal cyclic ovarian function in amenorrheic lactating postpartum women.

The postpartum period is characterized hormonally by elevated levels of PRL and low levels of gonadotropins and sex steroids. In breast feeding, this state of postpartum amenorrhea can persist for an extended period, even though PRL levels decrease slowly. Although the action of PRL on multiple target sites has frequently been suggested as the cause of this ovarian quiescence, a suckling-induced alteration in hypothalamic gonadotropin-releasing hormone (GnRH) production has also been hypothesized. To test this latter hypothesis, we provided a uniform pulsatile GnRH stimulus to eight exclusively breast-feeding women for an 8-week duration beginning at 4 weeks postpartum. Five women with functional hypothalamic amenorrhea served as a comparison group. All women received GnRH administered at a dose of 200 ng/kg every 90 min sc via a portable infusion pump. Serial blood sampling for LH, FSH, and PRL was performed weekly for 5 h at 10-min intervals beginning immediately before initiation of GnRH, during the period of GnRH, and 1 week after the cessation of GnRH. The women collected daily urine aliquots for estrone-3-glucuronide, pregnanediol-3-glucuronide, and LH determinations. Serial transvaginal sonography was used to monitor follicular development. Before GnRH treatment the urinary steroid and serum gonadotropin levels of the two groups were low and similar. As expected, PRL levels were higher in the postpartum women (87 micrograms/mL vs. 4.25 micrograms/L, P < 0.05). After initiation of pulsatile GnRH, LH values increased and FSH values decreased in both groups. The LH increase with GnRH was significantly greater in the breast-feeding group than in the hypothalamic amenorrhea group (19.75 mIU/mL vs. 12.34 mIU/mL, P < 0.05). Analysis of pulse frequency and amplitude revealed a nearly complete 1:1 induction of LH pulses by the exogenous GnRH in both groups, with the breast-feeding group showing a greater amplitude (12.26 mIU/mL vs. 5.34 mIU/mL, P < 0.05). The cycle lengths, urinary steroids, and vaginal ultrasonography demonstrated a more rapid initial ovarian responsiveness in the breast-feeding group, as determined by the length of the first follicular phase. The breast-feeding group also showed a brisker ovarian response, as evidenced by a greater number of follicles that were 12 mm or greater (2.3 vs. 1.2, P < 0.05), and a greater luteal phase peak and integrated pregnanediol excretion, respectively (3.02 micrograms/L creatinine and 39.87 micrograms/L creatinine/cycle vs. 1.89 micrograms/L creatinine and 7.69 micrograms/L creatinine/cycle, P < 0.05).(ABSTRACT TRUNCATED AT 400 WORDS)

Prediction and detection of the fertile period: the markers.

The occurrence and duration of the fertile period in women are strictly related to the time of ovulation. Since the only positive confirmation of ovulation is the identification of an ovum in the female reproductive tract or the subsequent detection of a pregnancy, the prediction and detection of its occurrence have to be based on markers or indicators that lie at varying physiological distances from ovulation itself. These may be variations in hormones and other substances that can be detected in different body fluids or the evidence of their effects on specific target organs. Recent advances in the knowledge of reproductive physiology have allowed the identification of distinct substances and biological phenomena that accompany the occurrence of the fertile period. This article is intended to update and classify the available fertility markers based on their particular nature and modality of expression and, additionally, consider the temporal relationship between the appearance of their specific signals and the time of ovulation. Consequently, those indicators directly related to changes at the ovarian level were defined as direct markers, including ovarian morphology, the reproductive hormones, and the intraovarian regulatory proteins, whereas those reflecting variations observed in different target organs were considered indirect markers, and were further qualified as biochemical, biophysical, and clinical. Subsequently, fertility markers were classified as prospective, immediate, or retrospective, depending on whether they allow the prediction, detection, or confirmation of the ovulatory event, respectively.

Enhanced follicle regulatory protein levels accompany reinitiation of ovulatory function after parturition.

OBJECTIVES: We examined the changes in follicle regulatory protein, estrone-3-glucuronide, pregnanediol-3-glucuronide, and luteinizing hormone levels in first-morning urine samples from postpartum, fully breast-feeding women to characterize the reemergence of these urinary hormones after pregnancy ovarian quiescence and early postpartum period and to determine whether follicle regulatory protein could be used prospectively to predict the return of fertility. STUDY DESIGN: Twenty-five hundred urine samples collected from six postpartum women were evaluated. Daily urine samples collected from normally cycling women were used to establish normal urinary hormone and hormone metabolite cyclicity. Luteinizing hormone, estrone-3-glucuronide, and pregnanediol-3-glucuronide levels were measured by radioimmunoassay. Follicle regulatory protein level was assayed with a double-antibody enzyme-linked immunosorbent assay. RESULTS: Although follicle regulatory protein levels were found to be very low or undetectable in early postpartum urine, they began to rise with episodes of estrone-3-glucuronide and pregnanediol-3-glucuronide secretion. A chi 2 analysis suggests that increasing urinary follicle regulatory protein levels are most closely associated with the luteal phase of the first menstrual cycles in postpartum women. CONCLUSIONS: These results suggest that follicle regulatory protein is of little value in predicting either the onset of renewed ovarian activity or the fertile period.

Acute prolactin and oxytocin responses and milk yield to infant suckling and artificial methods of expression in lactating women.

Breast-feeding is today the major form of infant nutrition in the immediate postpartum period. Despite this, recent trends in modern life-styles have raised obstacles to successful lactation. These include infant illness and maternal responsibilities outside the home, both requiring separation from the mother. While the hormonal dynamics of infant suckling are understood, little is known about the effects of artificial methods of milk expression. A variety of breast pumps exist in the current US market which vary considerably in price and effectiveness. To understand better the ability of these pumps to assist women in the maintenance of lactation, the current study was undertaken to evaluate their effects on milk yield and prolactin and oxytocin release when compared to natural infant suckling. Twenty-three women who were exclusively breast-feeding their infants were randomly assigned to serially use several pumping methods, as well as infant suckling, with blood being taken at 10-minute intervals to determine the hormonal responses. The results reveal variability in the prolactin responses to the artificial pumping methods, with the greatest responses found with an electric pulsatile pump; these responses compare favorably with those of natural infant suckling. Other methods were less successful in causing prolactin elevations. No differences were seen among the methods in the oxytocin response. The results of this study demonstrate striking differences in the ability of breast-pumping methods to produce an acute and sustained prolactin rise in breast-feeding mothers. The large discrepancies found suggest the need for further studies in to enable women and health care providers to choose the most appropriate method for milk expression.(ABSTRACT TRUNCATED AT 250 WORDS)

Laboratory methods for assessing human semen in epidemiologic studies: a consensus report.

It is clear that additional methodologic work needs to be performed. Some data gaps described above are being actively investigated. Other standards were not addressed at this meeting; statistical handling of the data, differences among CASA machines, and factors to consider as potential confounders in analysis are just a few. These may be the subject of future workshops, which will also review progress made in the existing knowledge base. For now, this effort represents a first attempt to share information and to use it to encourage investigators in different laboratories to employ similar methods. In this way more direct comparisons among studies can be made, and our collective data base can be strengthened.

Effects of vehicle supplementation on total estradiol absorption from a transdermal estradiol delivery system.

OBJECTIVE: To evaluate the effects of vehicle supplementation on serum estradiol (E2) delivery pharmacokinetics from the Ciba-Geigy (Summit, NJ) 0.1-mg Estraderm Patch. DESIGN: Postmenopausal women were randomized to a 28-day crossover treatment protocol separated by a 14-day wash out period. SETTING: Normal human volunteers were studied in an academic research environment. PATIENTS, PARTICIPANTS: The subject pool included eight healthy postmenopausal women between 32 and 60 years of age. INTERVENTIONS: In treatment A, a 0.1-mg Estraderm Patch was worn for 7 days; in treatment B, and identical patch was worn into which 0.6 mL of ethanol was injected on day 3 of use. MAIN OUTCOME MEASURES: Serum E2 levels were measured in both groups. RESULTS: Although E2 absorption showed characteristic interpatient variability, addition of ethanol significantly extended the mean time for serum E2 levels to return to baseline, without increasing peak absorption. The mean extension was 50 hours. CONCLUSION: The addition of ethanol to the Estraderm Patch increased the duration of elevated serum E2 levels measured in menopausal women, thus potentially increasing the effective life span of the transdermal therapeutic system.

Factors associated with withdrawal bleeding after administration of oral micronized progesterone in women with secondary amenorrhea.

OBJECTIVE: To compare two dosages of oral micronized progesterone (P) and placebo for withdrawal bleeding and side effects. DESIGN: Prospective, randomized, double-blind. SETTING: Academic institution. PARTICIPANTS: Out of 190 screened with oligomenorrhea/amenorrhea, 60 who qualified completed the study. INTERVENTIONS: A 10-day course of (1) oral micronized P 300 mg, (2) oral micronized P 200 mg, or (3) placebo. MAIN OUTCOME MEASURES: Withdrawal bleeding, side effects, and changes in lipids. Endogenous estradiol (E2) concentrations at baseline and P concentrations during treatment were correlated with bleeding response. RESULTS: Withdrawal bleeding occurred in 90% of women taking 300 mg, 58% of women taking 200 mg, and 29% of women taking placebo (P less than 0.0002 for 300 mg versus placebo). Side effects occurred similarly among the groups (P = not significant). Lipid concentrations were unchanged. Endogenous E2 and treatment P concentrations were of limited predictive value for withdrawal bleeding. CONCLUSIONS: Progesterone 300 mg induced significantly more withdrawal bleeding than placebo, with similar side effects. Bleeding response cannot be predicted reliably from E2 and P concentrations.