Emotional reaction to sterilization.

Ninety-four patients sterilized by tubal occlusion were interviewed at the time of hospitalization for surgery and followed at scheduled intervals for a 2-year period. There were no serious problems, medical or psychologic, and all but 3 patients were pleased and satisfied at the end of 2 years. There were no technical failures. Psychosomatic symptoms do develop. They are more prominent and persist longer in the younger age group. Patients having these symptoms are those who had difficulty with contraceptive technics, have a limited understanding of the sterilization procedure, and continue to question its permanency. The need for preoperative evaluation and counseling is emphasized.

PIP: Psychologic and somatic aftereffects are reported for 94 patients sterilized by tubal occlusion at Rush Presbyterian St. Luke's Medical Center, Chicago, from July 1971 to December 1971. An initial interview was conducted at hospitalization, and follow-up interviews were scheduled for 6 weeks, 3 months, 1 year, and 2 years. 3 patients at 6 months and 7 patients at 1 year had health complaints; at 2 years there were none. 40% of the younger (under 26 years old) women had minor complaints at 1 year, and 18% had sought medical attention. By the second year 30% continued to have complaints, but none sought medical attention. Menorrhagia, memometrorrhagia, and dysmenorrhea were reported by 25% of the older group at some follow-up. Among the younger patients, 40% at 6 months, 60% at 1 year, and 65% at 2 years reported menstrual irregularities. At the 2-year follow-up the responses of 93% of the older patients and 77% of the younger patients indicated normal quality of sexual relations. 95% of the older and 75% of the younger group were completely satisfied with the sterilization. The physician must explain details of the procedure and its consequences.

Gynecologic and obstetric problems of the female dancer.

The effect of athletics and exercise on women is a new area of medicine, and little factual information is currently available. This discussion briefly reviews some of the gynecologic and obstetric information available to give guidelines for the woman involved in strenuous physical activity.

PIP: This paper reviews the gynecologic and obstetric literature on problems encountered by women involved in strenuous physical exercise. Those who begin training prior to puberty tend to have delayed menarche as compared with nonactive controls and to experience significantly more menstrual dysfunction. Attainment of a minimum weight or a certain percentage of body fat appears to be an important factor. Increased androgen levels resulting from stress on the adrenal gland or ovary may affect the female athlete's hypothalamus, and weight loss may cause additional abnormalities of the endocrine system. Physical examination of athletes with menstrual dysfunction should include evaluation of height and weight, general nutrition, the presence or absence of galactorrhea, and the presence of obvious hormonal abnormalities. Management of the pregnant athlete is controversial; however, there is general agreement that a woman can continue athletic activity at medium effort until the 8th month of pregnancy, at which point activity should be reduced until the 4th week postpartum. Barrier contraception is generally recommended for physically active women. Currently, there is little factual information on the effects of athletics and exercise on women. For example, it is not known whether there is a lasting negative effect on the young dancer's menstrual cycles and her reproductive capacity after discontinuation of active training. Until more research evidence is accumulated, careful medical follow-up of female dancers can enable them to safely perform with minimal risk of present or future health problems.

Menstrual disturbances after interruption.

PIP: Of 148 women in Bulgaria who were aborted by curettage, 54% had a delay of the first postoperative menstrual period. In over 30% of the patients, there was menorrhagia. In a large portion of the women, the successive menstruations were changed in duration or in quantity. A statistical comparison with changes in menstruation after vacuum aspiration shows fewer instances of prolongation of menstruation, abundant menstruation, more painful menstruation or changes in the periods. All differences between vacuum and curettage are highly significant.^ieng

[Sequelae of tubal ligation]. / Secuelas de la ligadura tubaria.

PIP: A literature review was undertaken of clinical stuides to determine the frequency of menstrual alterations or various psychosocial effects after surgical tubal sterilization. The most frequently mentioned symptoms following bilateral salpingocalsy or salpingectomy are increased menstrual blood loss, dysmenorrhea, dispareunia, pelvic pain, oligemenorrhea, polymenorrhea, and preclimacteric syndrome in some cases. Uribe and colleagues attributed the high frequency of abdominal pain in tubal occlusions achieved with mechanical devices such as rings to the compression pain produced by uncut nerve edings, which do not occur with electrocoagulation or the Pomeroy technique. Alderman and colleagues found that only 6.5% of their patients experienced increased menstrual flow after sterilization, but Rioux found confirmation of menstrual changes to be difficlut and Chamberlain reported change in 2.6-51% of patients, perhaps related to previous use of contraceptives. Radwanska and colleagues found that patients sterilized by electrocoagulation or tubal ligation had a lower average level of serum progesterone in the midluteal cycle phase, 9.4 +or- 4.7 ng/ml compared to 17.4 +or- 7.1 ng/ml for controls. Donnez found that patients sterilized by electrofulguration had an average of 8.5 +or- 6 ng/ml of progesterone in the midluteal phase compared to 15.4 +or- 6.3 ng/ml for those sterilized using Hulka clips. The largest proportion of women with menstrual alterations or pain were younger, lower parity women who were sterilized for medical reasons. Menstrual changes and pelvic symptoms following sterilization are subjective and difficult to evaluate. Some authors cite the rarity of longterm sequelae of sterilization, but others used radioimmunoassay techniques to demonstrate changes in serum progesterone levels that may be linked to alterations in function of the ovaries or corpus luteum following sterilization. Other authors believe that most negative sequelae could be minimized or eliminated with better patient selection and counseling.^ieng

[Hemorrhages in abnormal production of gonadotropins]. / Blødninger ved unormal produksjon av gonadehormoner

PIP: A review of the organic and hormonal causes of irregular menstrual bleeding is presented. Menstrual bleeding irregularities are the most frequent gynecological ailment. Oligomenorrhea is most often caused by a prolonged proliferation phase in the menstrual cycle. In younger women this may be due to insufficient hormonal secretion of the pituitary gland; in older women it may be due to late follicular development in spite of normal glandular secretion. Polymenorrhea is usually caused in younger women by a shortening of the proliferation phase, usually because the ovaries are hypersensitive to pituitary hormones, which causes an aceleration of follicular development. Polymenorrhea in older women is usually due to a shortened secretory phase caused by early degeneration of the corpus luteum, and later may develop into oligomenorrhea or amenorrhea. Irregular corpus luteum function after ovulation can cause bleeding irregularities. When the corpus luteum fails to produce progesterone, the endometrium develops irregularly, causing premenstural spotting or increased volume of menstrual bleeding. Slow degeneration of the corpus luteum causes increased progesterone production and irregular discharge of the endometrium. Anovulation is the most frequent cause of bleeding irregularities, because there is no progesterone secretion. A quick increase in estrogen production in the proliferation phase in conjunction with anovulation causes an irregular discharging of the endometrium with prolonged or increased bleeding. A slow increase in estrogen production during the proliferation phase in conjunction with anovulation causes hyperplasia. In a few patients, anovulation in conjunction with a secretion of estrogen insufficient to maintain the endometrium can cause endometrial atrophy. Irregular bleeding is usually functional in younger women and organic in older women. To diagnose the cause of irregular menstrual bleeding, organic reasons should be explored 1st. A complete history should be taken, then abrasio, recording the basal temperature, and hematological, and hormonal analysis should be used to pinpoint the causes of irregular bleeding. Abrasio is the most common treatment for bleeding irregularities, and hormone treatment is the 2nd most common. Hysterectomy should be used only in extreme cases for treatment of bleeding irregularities.^ieng

Aftermaths of surgical sterilisation with special reference to menstrual disturbances.

With the increasing use of a variety of surgical methods for sterilisation, certain pitfalls of these surgical decisions are emerging. In the present study 216 cases who underwent sterilisation at least 2 years prior to coming for consultation with various problems have been analysed. Menstrual disturbances like menorrhagia (59.2%), dysmenorrhoea (29.6%) and metrorrhagia (5.56%) are the leading symptoms ascribable to a large extent to the operation if not the fullest extent in some cases. The physical and psychological disturbances that have evolved from sterilisation include pain abdomen (25%), vague abdominal discomfort and backache (14.8%), leucorrhoea (12.03%), obesity (8.34%), insomnia (4.17%), irritability (2.78%), depression (2.78%) and regret (1.39%).

PIP: Physicians examined 216 women who presented at Chittaranjan Seva Sadan College of Obstetrics, Gynaecology, and Child Health in Calcutta, India, and had undergone surgical sterilization at least 2 years earlier. Endometrial biopsies during the late secretory phase in the 32 cases with excessive bleeding during the late menstrual period found proliferative changes: dilated glands in 28 cases and poor secretory phase in 4 cases. The 12 ovarian biopsies revealed cortical stromal hyperplasia in 1 case. None of the control cases (i.e., those with no menorrhagia) had any ovarian changes. Observed pelvic pathologies included in the order of frequency: cystic ovaries, hydrosalpinx, uterine fibroids, pelvic endometriosis, uterine prolapse, chronic cervicitis, and scar endometriosis. Most of the 216 women were 25 to 35 years old and the youngest was 22 years old. Menorrhagia was the most common complaint (59.2%) and 30 to 35 year old women suffered from it the most. Among women who had no pelvic pathology, dysfunctional uterine bleeding was responsible for menorrhagia. Dysmenorrhea was the next most frequent complaint (29.6%). Intermenstrual bleeding, abnormally infrequent menstruation, and secondary amenorrhea were other menstrual disturbances (5.56%, 4.17%, and 1.39%, respectively). Other relatively common symptoms associated with surgical sterilization were abdominal pain (25%), abdominal discomfort and backache (14.8%), and whitish, viscid vaginal or uterine discharge (12.03%). Less frequent symptoms were obesity, painful scar, insomnia, irritability, depression, and regret. Proper preoperative and postoperative counseling would have prevented many of the complications.

[Cycle abnormalities and secondary sterility after estrogen-gestagen treatment]. / Zyklusanomalien und sekundare Sterilitat nach Ostrogen-Gestagen-Gaben.

PIP: Menstrual cycle abnormalities and sterility following treatment with combined oral contraceptives in 12 women (aged 19-31 years) are discussed. Ovulation inhibitors had been prescribed for contraception in 7 cases, for menstrual cycle regulation in 5 cases. Estrogenic activity was normal in all patients. Therapy with epimestrol, retrone, clomiphene, or HCG resulted in resumed ovulation in 7 of 10 patients evaluated. The authors believe that these mild disturbances are due to a depression of the hypothalamic center responsible for cyclic LH secretion, and respond well to treatment with ovulation inducers. In their view, however, ovulation inhibitors should not be used to regulate the menstrual cycle.^ieng

Progestin receptor isoforms and prostaglandin dehydrogenase in the endometrium of women using a levonorgestrel-releasing intrauterine system.

This study has examined endometrial tissue in 14 normal women prior to insertion of a levonorgestrel-releasing intrauterine system (LNG-IUS) and thereafter longitudinally for up to 12 months post-insertion. The specific endpoints examined by immunohistochemistry were progesterone receptor (PR) subtypes A + B, oestrogen receptor (ER) and prostaglandin dehydrogenase (PGDH). Two antiprogesterone receptor antibodies, one specific to PR(B) subtype and the other to PR subtype A + B, were employed to examine the localization of both PR isoforms. The activity of PGDH, a progesterone dependent enzyme, was also measured. ER and PR(A+B) and PR subtype B were significantly down-regulated in glands and stroma in the presence of continuous intrauterine LNG delivery. There was an apparent increase in PR(A) immunoreactivity in endometrial glands between 6 and 12 months post-insertion. Consistent with down-regulation of both isoforms of PR was reduced glandular PGDH immunostaining following LNG-IUS insertion, and PGDH activity (as measured by metabolism of excess substrate in vitro). Furthermore, PGDH activity, known to be localized in the glands, significantly increased (P < 0.05) at 12 months post-insertion, coinciding with the observed increase in glandular PR(A+B) immunoreactivity at this time. Since the LNG-IUS suppresses the PR(B) so strongly, PR(A) is likely to be the subtype that mediates long term LNG action in the endometrium. PR(B) is the more suppressed of the two subtypes, and only PR(A) rises along with PGDH activity. Alterations to normal endometrial morphology and function, e.g. perturbation of normal sex steroid receptor expression, following exposure to high concentrations of local LNG, may play a role in the aetiology of bleeding disorders associated with the LNG-IUS. Further elucidation of local uterine mediators involved in the mechanism of bleeding problems is required.

PIP: The effects of a levonorgestrel-releasing intrauterine system (LNG-IUS) on endometrial tissue were investigated in 14 UK women who were followed for 12 months after its insertion. Of particular interest was the etiology of menstrual aberration associated with progestogen-only contraception. In the presence of continuous intrauterine LNG delivery, estrogen receptor and progesterone receptor (PR) subtype A + B and subtype B were significantly downregulated in the endometrial glands and stroma. There was no apparent increase in PR subtype A immunoreactivity in endometrial glands 6-12 months after LNG-IUS insertion. Also observed was reduced glandular prostaglandin dehydrogenase (PGDH) staining and activity. PGDH activity significantly increased at 12 months post-insertion coinciding with the increase in glandular PR subtype A + B. Since the LNG-IUS suppresses the PR subtype B so strongly and only PR subtype A rises along with PGDH activity, PR A is likely the subtype that mediates long-term LNG action in the endometrium. Perturbation of normal sex steroid receptor expression after exposure to high concentrations of local LNG may play a role in the bleeding disorders associated with use of the LNG-IUS. Examination of more local mechanisms in endometrium exposed to an LNG-IUS should help elucidate some of the potential mechanisms regulating endometrial bleeding.

Morphological and functional features of endometrial decidualization following long-term intrauterine levonorgestrel delivery.

Irregular bleeding remains a common reason for the discontinuation of progestin-only contraception. The levonorgestrel releasing intrauterine system (LNG-IUS) has profound morphological effects upon the endometrium. Specific features are gland atrophy and extensive decidual transformation of the stroma. Morphological changes in the endometrium may be associated with perturbation of mechanisms regulating normal endometrial function. This study describes endometrial stromal and glandular features prior to and up to 12 months following insertion of the LNG-IUS. Comparison is made with first trimester decidua. In order to elucidate further mechanisms governing endometrial function with local intrauterine delivery of LNG, we here report histological features consistent with decidualization; a significant increase in granulocyte-macrophage colony stimulating factor (GM-CSF) immunoreactivity in decidualized stromal cells; glandular and stromal prolactin receptor expression and an infiltrate of CD56 + large granular lymphocytes and CD68 + macrophages. We are unaware of previous reports which have documented longitudinally both morphological and functional observations in endometrium exposed to local intrauterine levonorgestrel delivery. These studies demonstrate that long-term administration of intrauterine levonorgestrel results in features of altered morphology and function. No correlation was apparent between the end points in the study and the bleeding patterns described by the subjects. Further evaluation of these features in the context of menstrual bleeding experience may contribute to a better understanding of this troublesome side-effect which often leads to dissatisfaction and discontinuation of the intrauterine system.

PIP: The levonorgestrel-releasing intrauterine system (LNG-IUS) has profound morphologic effects on the endometrium, including gland atrophy and extensive decidual transformation of the stroma. The present study investigated these morphologic changes in tissue samples collected from 14 UK women up to 12 months after insertion of the LNG-IUS. Observed histologic features consistent with decidualization included a significant increase in granulocyte-macrophage colony stimulating factor immunoreactivity in decidualized stromal cells, glandular and stromal prolactin receptor expression, and an infiltrate of CD56+ large granular lymphocytes and CD68+ macrophages. The features of pseudo-decidualization closely resembled the morphology of early pregnancy decidua. These findings confirm that the stromal compartment of the endometrium undergoes changes consistent with decidualization for at least up to 12 months after insertion of an LNG-IUS. There was no correlation between the study endpoints and the menstrual patterns reported by study subjects. Further study of the decidualized nature of the stromal cells in the LNG-exposed endometrium should enhance understanding of the mechanisms responsible for breakthrough bleeding in users of progestogen-only contraceptives.

Menstrual disorders after sterilization with special reference to ovarian activity.

PIP: This study included 125 women with specific complaints following tubal ligation. In most instances the ligations had been done 7 years previously, mostly for multiparity. 92% had been ligated by the abdominal route 88.8% had symptoms including menstrual irregularities, chronic pain, obesity, psychoses, intermittent acute retention of urine, ventral hernia, and 2 cases of sterilization failure. Average age at time of tubectomy had been 31 years; average parity, 3-4. There was a shift towards right in mean maturation index of cervical cells soon after sterilization. This shift then decreased for a year, then gradually rose, stabilizing at 12 years. Amenorrhea was present in 5 cases with high mean maturation levels. 17 cases of oligomenorrhea all showed ahigh estrogenic activtiy. Of 27 cases of menorrhagia endometrial biopsies were taken in 13. 12 showed the proliferative phase and 1 the secretory phase. These findings correlated with cytological findings, but cervical mucus in 3 cases did not coincide. Of the 27 cases 21 were anovular. In all the karyopyknotic index was high. 2 cases showed clinical evidence of inflammation. Of 10 cases of dysmenorrhea, 3 were ovulatory; inflammation was present in 3. In 12 cases of polymenorrhea 7 showed high estrogenic activities. In 1 a polyp had caused the irregular bleeding. The observed shifts of maturation index of cervical cells toward the right are considered indicative of hyperovarian activity. Results show that ovarian activity after sterilization by tubectomy was normal or increased. The increased activity was considered either psychological,neurovascular, or caused by inflammation. Of the 10 cases with inflammation, 9 were associated with menstrual disorders.^ieng

The effect on hormone excretion patterns of depot medroxyprogesterone acetate used as a contraceptive preparation.

PIP: In an attempt to establish the hormone profile of 16 women on depot medroxyprogesterone acetate (150 mg, im, every 3 months), monthly estimations of urinary LH, total urinary estrogen and estriol excretion were made over a period of 3 months. This preparation does not seem to cause absolute suppression of the hypothalamic pituitary since LH levels are around the lower limits of normal. Ovulation did not occur because of a lack of LH surge. Estrogen levels are not unduly depressed and are comparable to those of normally menstruatin, premenopausal women. Estriol excretion is generally greater than that seen in normal non-pregnant women and may be linked to unknown end-products of depot medroxyprogesterone acetate metabolism. The cornification index of 105 unselected women was measured to extablish vaginal estrogen stimulation patterns. The menstrual problems seen in 20% of the patients may be due to a change in end-organ response, level or type of circulating estrogen.^ieng