Efficacy and safety of a low-dose 21-day combined oral contraceptive containing ethinylestradiol 20microg and drospirenone 3mg.

OBJECTIVE: The purpose of this study was to assess the efficacy and safety of a new low-dose oral contraceptive containing ethinylestradiol 20microg and drospirenone 3mg (EE 20microg/drsp 3mg). METHODS: This was an open-label, non-comparative, multicentre study conducted at 33 centres in Germany and Switzerland. The combined contraceptive was administered over 26 cycles of treatment, with each cycle consisting of once-daily treatment for 21 consecutive days followed by a 7-day hormone-free interval. RESULTS: A total of 527 women were randomised, of whom 516 (97.9%) started treatment and had at least one study observation. Two pregnancies occurred during 11 165 cycles of treatment, giving a Pearl Index of 0.23 (upper limit of 97.5% CI 0.84). The corresponding 2-year cumulative pregnancy rate was 0.44% (95% CIs 0, 1.05). One of the two pregnancies was attributed to non-compliance with treatment, giving an adjusted Pearl Index of 0.12 (upper limit of 97.5% CI 0.67) over 10 827 compliant cycles. Only three (0.6%) women discontinued treatment because of bleeding problems in this long-term study, suggesting an acceptable bleeding profile. Overall, the study drug was well tolerated and adverse events experienced were typical of hormonal contraceptive use. The majority of women who responded (435 of 501; 86.8%) were satisfied or very satisfied with the study treatment and most (367 of 501; 73.3%) would continue with it if given the choice. CONCLUSION: The EE 20microg/drsp 3 mg combined oral contraceptive is an effective and well tolerated contraceptive with an acceptable bleeding pattern.

Comparative study of cytotoxicity, tumor necrosis factor, and prostaglandin release after stimulation of rat Kupffer cells, murine Kupffer cells, and murine inflammatory liver macrophages.

Macrophages (Mphi) and Mphi-depleted (nonadherent) nonparenchymal cells (NPC) of the liver were examined for their cytotoxic potential against tumor cells, production of tumor necrosis factor (TNF), and release of prostaglandins (PG) following stimulation by lipopolysaccharide (LPS), interferon-gamma (IFN gamma), and zymosan. Resident murine liver macrophages had no natural cytotoxicity for the TNF-resistant target cell line P815. Activation of these cells was only obtained by a combination of IFN gamma and LPS. Inflammatory murine macrophages were in a primed stage and could be activated by LPS alone in the absence of IFN gamma. Rat resident macrophages resembled functionally the inflammatory macrophages of the mouse liver rather than the resident macrophages. They displayed natural cytotoxicity against all targets tested and were further activated by LPS in the absence of IFN gamma. Similar results were obtained with respect to macrophage-depleted nonadherent NPC: Mouse NPC had a low level of NK activity against Yac-1 cells. Treatment with pyran copolymer resulted in a strong increase of cytotoxicity against Yac-1; furthermore, a TNF-dependent killing of Wehi 164 and TNF-independent cytotoxicity against P815 cells were now acquired. In the rat NPC prepared from unstimulated animals expressed high levels of natural cytotoxicity against all targets. No major differences could be observed between inflammatory Mphi and Kupffer cells of rat and mouse liver with regard to TNF production and TNF-dependent killing of Wehi 164 tumor cells. The same was true for the spectrum of secreted prostanoids. Upon activation of all cell populations a marked shift toward the production of PGE2 occurred. Experiments involving the cyclooxygenase inhibitor indomethacin showed enhanced TNF-dependent tumor cell killing by nonactivated Mphi in the absence of prostanoid production.

Does tamoxifen change oestrogen and progesterone receptor expression in the endometrium and breast?

We studied the expression of oestrogen and progesterone receptors (ER, PR) in postmenopausal women receiving tamoxifen for breast cancer. In addition the literature addressing the question of ER and PR expression in breast tissue during treatment with tamoxifen was reviewed. We demonstrated consistent expression of ER and PR in endometria from patients receiving tamoxifen, with a trend towards a higher proportion of receptor positive specimens during tamoxifen. In breast cancer tissue, the ER content seemed to be reduced following tamoxifen treatment. After short time exposure to tamoxifen, the PR appeared to be increased, longer treatment caused the PR to go down to pretreatment levels or below.

Benefits and risks of hormone replacement therapy (HRT).

In western countries more than 30% of the female population are postmenopausal. Approximately 30% of postmenopausal women suffer from clinical symptoms of the climacteric such as vasomotor symptoms, associated with hot flushes, night sweat, insomnia and depressive mood. Sufficient hormonal replacement therapy (HRT) will abolish specific menopausal symptoms in over 90% of patients, unspecific symptoms such as headache respond to placebo and HRT equally well. The question of cancer risk related to HRT will be addressed in this review. In combination with progestins, estrogens are obviously protective regarding ovarian and endometrial cancer. The association between HRT and breast cancer risk is presently unclear. Epidemiological data available so far do not provide compelling evidence as to a cause and effect relationship between HRT and breast cancer risk. There seems to be an overall trend towards a slightly increased risk with increasing duration of HRT use. Guidelines for HRT use in women with a history of endometrial and breast cancer are provided in this article.

Characterization and identification of cytochrome P450 metabolites of arachidonic acid released by human peritoneal macrophages obtained from the pouch of Douglas.

Cytochrome P450 metabolism of arachidonic acid (AA) was investigated in human peritoneal macrophages which play a central role in chronic pelvic diseases in women (for example in endometriosis). The formation of eicosanoids other than prostaglandins (PGs) by these cells is still unknown. In non-activated macrophages obtained from women in the reproductive age, the main [(3)H]-AA metabolites coeluted with epoxyeicosatrienoic acids, dihydroxyeicosatrienoic acids (DHETs) and hydroxyeicosatetraenoic acids (HETEs) in reverse-phase HPLC. After zymosan activation a shift to PGs pathway was observed. Treatment with low doses of 2,3,7,8-tetrachlorodibenzo- p -dioxin increased the formation of a metabolite coeluting with 5,6-DHET. By gas chromatography/mass spectrometry 5,6-DHET (after beta-naphthoflavone induction), and 14,15-DHET as well as 11,12-DHET (after AA stimulation) were identified as major epoxygenase metabolites, respectively. The enantioselective formation of 12(S)-HETE was demonstrated by chiral-phase HPLC. Our findings demonstrate that non-activated peritoneal macrophages produce substantial amounts of bioactive cytochrome P450 metabolites of AA.

Tamoxifen for breast cancer prevention.

Tamoxifen is of proven efficacy in the treatment of breast cancer. New data indicate that it might be able to reduce the occurrence of receptor positive breast cancer when taken as a preventative. However trade-offs for this reduction are an increased incidence of endometrial carcinomas and thromboembolic events. Therefore the use of tamoxifen as preventative ought to be restricted to clinical studies or a well defined high risk situation. Whether raloxifen is superior to tamoxifen remains to be shown.

[Physiology of ovarian function]. / Physiologie der Ovarialfunktion.

The ovarian function including follicular maturation, ovulation and corpus luteum formation is regulated by a complex control system composed of hypothalamus, pituitary and the ovary itself. These organs communicate via positive and negative feedback loops and can be considered as a functional entity. Special neurons in the hypothalamus produce gonadotropin-releasing hormone (GnRH) being delivered to the anterior pituitary lobe by the pituitary portal vessels. GnRH binds to specific receptors inducing synthesis and release of the gonadotropins FSH and LH into the circulation. After binding to their specific receptors at the ovary FSH and LH induce follicular maturation, ovulation and corpus luteum formation. The ovary responds to gonadotropin stimulation in dual fashion: secretion of sexsteroids and the liberation of a fertilizable oocyte. In addition the ovary is also able to secrete peptide-hormones such as inhibin and activin. Sexsteroids and inhibin modulate the pulsatile secretion of GnRH and gonadotropins. Cooperation of theca- and granulosa cells at the ovarian level and the corpus luteum formation are described and the significance of growth factors and cytocines is emphasized. The effects of estradiol and progesterone are highlighted by the morphological response of the endometrium. The ovary is actively involved in maintaining cyclicity, as reflected by the processes of follicular growth, follicle rupture and formation of the corpus luteum with the dramatic morphological changes involved.

[Low-dose oral contraception and bone density]. / Niedrig dosierte orale Kontrazeptiva und Knochendichte.

Oral contraceptives (OC) with 20 or 30 mcg Ethinyl-Estradiol (EE) inhibit bone remodeling in all age groups investigated until today as far as the biochemical parameters are considered. In perimenopausal women, OC with 20 or 30 mcg EE reduce the decrease in bone density and may, depending on the starting point, induce an increase in bone density. OC with 20 mcg EE might impede the formation of a physiological peak bone mass in very young women (probably women less than 20 years of age) by a reduction of bone metabolism. This possibility provoked a certain insecurity. However, it should not lead to the consequence that a safe contraceptive method is refused to young women. Unfortunately, there is still a lack of reliable studies allowing a final statement on the effect of low-dose OC on bone density in teenagers. Such studies are urgently needed so that we are able to guarantee in very young women that a reasonable contraception has not to be payed by a long-term risk for the skeletal health. The administration of a progestagen-only pill might be an alternative method for contraception in adolescence. A preparation containing 30 mcg of Levonorgestrel, nearly out of use today, could be of particular interest. A British study (20) has shown that during regular peroral administration of 30 mcg Leveonorgestrel per day, mean serum estradiol concentration decreased only slightly, from 653 to 500 pmol/l. This Estradiol concentration should still allow a normal bone metabolism and therefore a normal formation of the peak bone mass. However, the data actually available do not point convincingly to the conclusion that OC with 20 mcg EE or less might result in an insufficient estrogen concentration for normal bone metabolism. To reach peak bone mass, other factors than estrogens only are needed, such as Calcium, Vitamin D and physical activity.

Cycle control, tolerability, efficacy and acceptability of the vaginal contraceptive ring, NuvaRing: results of clinical experience in Germany.

OBJECTIVES: To investigate the real-life clinical experience of NuvaRing users in Germany. METHODS: An open-label, prospective, uncontrolled, non-randomized, multicentre postmarketing surveillance study was conducted by 1204 gynaecologists amongst 5823 women requesting contraception. The women underwent routine examinations and contraceptive counselling, and were assessed after three and six cycles of NuvaRing use. RESULTS: Good cycle control was observed and there was a reduction in cycle irregularity and inter-menstrual bleeding, bleeding duration and intensity, and dysmenorrhoea. NuvaRing was well tolerated, and had no significant effect on body weight or blood pressure. Nine women became pregnant unintentionally (two had conceived before they started to use NuvaRing, three due to non-compliance, one because of repeated ring expulsion/loss and three during treatment in spite of having applied this latter as instructed). Most women expressed their satisfaction with NuvaRing; 82% were 'very satisfied/ satisfied', 72% planned to continue using it and 82% would recommend it to others. More than 90% of women found NuvaRing 'without problems/easy' to insert and to remove, and more than 80% of the women and their partners were not disturbed by its presence during intercourse. CONCLUSION: NuvaRing is a highly effective and acceptable method of once-monthly contraception that is safe and well tolerated.

Interdependence of tumor necrosis factor, prostaglandin E2, and protein synthesis in lipopolysaccharide-exposed rat Kupffer cells.

Kupffer cells are the main producers of tumor necrosis factor-alpha (TNF; cachectin) and eicosanoids in the liver exposed to lipopolysaccharide (endotoxin; LPS). A very rapid but transient release of TNF is followed by a slow, steady synthesis of prostaglandin E2 (PGE2). TNF itself is able to provoke eicosanoid synthesis in Kupffer cells; the rate and pattern of prostaglandin production are similar to those observed after treatment with LPS. Anti-TNF antibodies completely neutralize TNF action on Kupffer cells, thus ruling out any participation of contaminating LPS. LPS stimulation of PGE2 production in Kupffer cells is reduced by the antiserum to 50%, indicating an involvement of TNF in the stimulatory action of LPS. On the other hand, PGE2, a potent inhibitor of LPS-elicited TNF release, is able to suppress LPS- but not TNF-stimulated eicosanoid synthesis in rat Kupffer cells. In addition to this autocrine circuit, extrahepatic factors participate in the regulation of Kupffer cell activation: glucocorticoids not only inhibit TNF or prostaglandin production, they also reverse the LPS-specific changes in the prostaglandin pattern of Kupffer cells. LPS, TNF or cycloheximide when given alone in the concentration range applied in this study do not affect the viability of rat Kupffer cells. However, the combinations of cycloheximide and either LPS or TNF cause rapid death of the cultured cells. The cytolytic potential of either combination cannot be alleviated by treatment with glucocorticoids.

The release of tumor necrosis factor from endotoxin-stimulated rat Kupffer cells is regulated by prostaglandin E2 and dexamethasone.

Evidence is presented that upon stimulation with endotoxin (lipopolysaccharide, LPS), Kupffer cells, the body's largest pool of sessile macrophages, synthesize and liberate a factor whose immunological, cytotoxic and chemical properties are those described for tumor necrosis factor (TNF)-alpha. Hepatocytes and sinusoidal endothelial cells do not produce detectable amounts of this protein. Ten nanograms of LPS per ml medium are sufficient to stimulate a substantial release of this mediator. Recombinant interferon-gamma (rIFN gamma) per se is a poor inducer of TNF release. Costimulation with endotoxin and rIFN gamma shows only a slight increment in the release of this cytotoxic factor, relative to LPS alone. Exposure of Kupffer cells to the Ca2+ ionophore A23187 or to elicitors of the oxidative burst and superoxide production, e.g. zymosan or phorbol 12-myristate 13-acetate, stimulates only a fraction (20%) of the TNF release seen after endotoxin challenge. Prostaglandin E2, the synthesis of which is strongly enhanced after challenge of rat Kupffer cells with LPS, suppresses the release of TNF by these cells. This autoregulatory mechanism may explain the kinetics of TNF production by stimulated Kupffer cells. Dexamethasone is another important mediator capable of reducing the LPS-elicited TNF formation. An effect of the glucocorticoid hormone can still be provoked if it is added simultaneously with or shortly after LPS. This rapid action requires a mechanism that is different from the time-consuming one leading to the inhibition of prostaglandin synthesis in Kupffer cells.

Prostaglandin release but not superoxide production by rat Kupffer cells stimulated in vitro depends on Na+/H+ exchange.

The release of the prostaglandins E2 and D2, induced by zymosan and phorbol ester in cultured rat Kupffer cells, was found to depend on the extracellular concentration of Na+. Eicosanoid formation following the administration of the Ca2+ ionophore A23187 or of arachidonic acid, however, did not require the presence of sodium ions in the medium. A half-maximal rate of prostaglandin release by zymosan-treated Kupffer cells was obtained between 4 mM and 5 mM Na+; and a Na+ concentration of greater than or equal to 30 mM was required to maximally stimulate prostaglandin E2 and D2 formation in the cultured liver macrophages. In contrast, the superoxide production following the administration of zymosan or of phorbol ester was quite independent of extracellular Na+. The zymosan and phorbol-ester-stimulated release of prostaglandins E2 and D2 was inhibited by amiloride. Artificial intracellular alkalization enhanced the prostanoid production of unstimulated and of zymosan-stimulated cells whereas artificial intracellular acidification inhibited the zymosan-elicited prostaglandin synthesis. In contrast, the superoxide formation was independent of the pH changes. The data presented here suggest that the prostaglandin production elicited by zymosan or phorbol ester in cultured rat Kupffer cells requires an activated Na+/H+ exchange.

Parents' needs after ultrasound diagnosis of a fetal malformation: an empirical deficit analysis.

We studied 56 pregnant women and 24 partners after ultrasound examination in the 18-24h gestational week revealed a fetal malformation. The subjects were followed through the process of examination, information sharing and counselling about the option of terminating the pregnancy. Regardless of sociodemographic variables or attitude towards the pregnancy, the diagnosis was always traumatic. A detailed critique of the physician's behavior and function emphasized his important role in the process of coming to terms with the malformation and gave clear indications of the positive expectations parents had. The affected patients expected the role of the professionally competent expert to be combined with that of the empathetic approachable counsellor, whose ste-by-step explanation would allow them to decide for themselves whether to terminate the pregnancy. The partner's participant was an essential aid to adjustment. It remains to be seen to what extent the functions of the doctor are realistic and justified.

[Recurrent theca cell tumor]. / Rezidivierender Thekazell-Tumor.

Thecomas are considered to be benign ovarian tumours. Whether there are malignant thecomas, is a subject of controversy in literature. This contribution describes a case of recurrent thecoma with a clinically malignant course and histological signs of malignant dedifferentiation. The particular diagnostic and therapeutic consequences of this rare disease are discussed with emphasis on the need for radical surgical intervention.

[Hystero-salpingo-contrast-sonography with 3-d-ultrasound -- a pilot study]. / Hystero-Salpingo-Kontrastsonographie mit 3D-Ultraschall: eine Pilotstudie.

UNLABELLED: Hystero-salpingo-contrast sonography (HyCoSy) is a sensitive method of assessing tubal patency but cannot completely substitute diagnostic laparoscopy with blue dye and hysteroscopy. Three-dimensional sonography has new imaging facilities which could lead to a reduction of invasive diagnostic procedures. AIM: The aim of this pilot study was to analyse the feasibility of HyCoSy by 3D- and 3D-Doppler-sonography. METHODS: In a prospective setting conventional (2D) HyCoSy was performed in 21 patients with an ultrasound device designed for 3D-ultrasound. After the completion of the 2D procedure, 3D-ultrasound was carried out. In five patients an additional 3D-Doppler-HyCoSy was performed. The generated 3D-volumina were then examined. Laparoscopy with blue dye was performed immediately after the ultrasound examination. RESULTS: A total of 42 Fallopian tubes was assessed. On 2D-ultrasound, visibility of the tubes was excellent in 28 and limited in seven tubes. Of the seven tubes not visible on 2D-ultrasound, four were not patent on laparoscopy. On 3D-ultrasound, visibility of the tubes was excellent in 15 and limited in twelve tubes. 15 tubes were not visible on 3D-ultrasound. 3D-Doppler-HyCoSy revealed excellent assessment in eight of ten tubes, even in one of those with limited visibility on 2D- and 3D-HyCoSy. In 19 patients the assessment of the uterine cavity was excellent by 2D- and 3D-HyCoSy, whereas it was limited in two patients. CONCLUSION: It is possible to visualise the full length of the tubes in a very detailed way from the uterine cavity to the fimbrial end in some patients, but the diagnostic power of HyCoSy is not improved by adding 3D-imaging. The accuracy of 3D-ultrasound seemed to be improved by 3D-Doppler-ultrasound.

Recurrent cytogenetic aberrations and loss of constitutional heterozygosity in ovarian carcinomas.

Cancer is regarded as the result of the accumulation of multiple genetic changes leading to either the activation of oncogenes and increased expression of mitogenic pathways or the inactivation of tumor suppressor genes. It was our interest to investigate malignant ovarian tumors with cytogenetic and molecular techniques to evaluate their consistent genetic alterations. Cytogenetic analysis was performed on 30 short-term cultured ovarian carcinomas. Fifteen tumors revealed clonal cytogenetic abnormalities, 10 of which had very complex karyotypes. The most consistent finding was a 19p+ marker chromosome which was present in half of the cytogenetically abnormal tumors with complex chromosome aberrations. Four tumors showed structural rearrangements resulting in loss of 11p13-pter material. Parallel DNA extracts from 18 tumor samples and corresponding normal white blood cells were analyzed by Southern blotting using 4 polymorphic probes spanning the region 11p15.1 to 11p15.5 and one polymorphic probe mapped to 19p13. Regarding the 11p probes, reduction to homozygosity in the tumor DNA was found in 9 of 17 informative cases. Loss of 19p alleles was found in 5 of 13 informative tumors. Our findings suggest that tumor suppressor genes located on the short arms of chromosomes 11 and 19 are involved in the development of human ovarian cancer.

Enhancement of neutrophil adherence to isolated rat liver sinusoidal endothelial cells by supernatants of lipopolysaccharide-activated monocytes. Role of tumor necrosis factor.

Supernatants of endotoxin-activated monocytes have been shown to stimulate human neutrophil adherence to rat liver sinusoidal endothelial cells 3-4-fold. Evidence will be presented that tumor necrosis factor (TNF) is responsible for this phenomenon: (a) in high-performance gel filtration of supernatants of lipopolysaccharide-activated monocytes, neutrophil adhesion-inducing activity coeluted with TNF activity measured in the L929 cell-lysing assay at 25-45 kDa; (b) anti-TNF antibody treatment of supernatants of activated macrophages abolished their adhesion-inducing activity; (c) human recombinant TNF alpha stimulated neutrophil adhesion to sinusoidal endothelial cells in a dose-dependent manner. In addition, polymyxine B sulfate, which was capable of neutralizing direct effects of lipopolysaccharide on neutrophil adhesion, could abolish neither the neutrophil-adhesion-inducing activity of the supernatants of endotoxin-activated monocytes nor the effect of human recombinant TNF itself. The neutrophil-adhesion-inducing activity was due both to a direct activation of neutrophils and to an influence of the sinusoidal endothelium itself by TNF: pretreatment of sinusoidal endothelial cells with TNF followed by thorough washing resulted in an increased neutrophil attachment. Protein synthesis by endothelial cells was not required. However, incubation of sinusoidal endothelium with TNF followed by anti-TNF antibody treatment abrogated the increased neutrophil adhesion. This suggests that TNF bound to sinusoidal endothelial cell surfaces was responsible for neutrophil adhesion. It is concluded that TNF by increasing granulocyte sticking to the endothelial lining of the liver sinusoids may play a significant role in endotoxin-induced inflammation of the liver as it is found in the septic state.