RÉSUMÉ
Menopausal hormone therapy(MHT)is used to treat menopausal complaints including the genitourinary syn-drome of menopause,to prevent osteoporosis,and to treat bleeding problems.Since these can be the indications also in young women,especially with POI(premature ovarian insufficiency)or with surgical menopause(bilateral oophorectomy),also the old term"Hormone Replacement Therapy(HRT)"is still used.The effective component is the estrogen component without relevant difference in the efficacy of the various MHT-preparations.Addi-tional preventive benefits are reduction of cardiovascular disease(including prevention of diabetes mellitus and metabolic syndrome),reduction of colon cancer,and perhaps also Alzheimer's disease,if started within a"win-dow of opportunity",i.e.in perimenopause or within 6-10 years after menopause.Primary indication for progestogen addition is to avoid the development of estrogen-dependent endome-trial cancer,i.e.addition not recommended in hysterectomized women.Two main schedules,sequential-or continuous-combined estrogen/progestogen regimens,are used for treatment of bleeding problems.For this and for optimizing menstrual regulation detailed recommendations are given including proposed dosages for the available different progestogens if added to oral or transdermal estradiol in different estrogen dosages.The WHI-study demonstrated the main risks using MHT within a"worst-case scenario",i.e.start of MHT in old women with high risk for breast cancer and cardiovascular diseases,whereby only"conjugated equine estro-gens"and"medroxprogesterone acetate"have been tested.One main result was that the progestogen component is decisive for the risk of breast cancer,which according to own experimental research and observational studies may be reduced using the physiological progesterone or its isomer dydrogesterone.In addition we propose to push forward research for screening patients with increased breast cancer risk like we have done in the past decade demonstrating that certain membrane-bound receptors in breast cancer tissue or blood can increase this risk.To reduce the risk of venous thromboembolism and stroke,transdermal estradiol(gels,patches,)should be used,in free combination with progesterone or dydrogesterone as"golden standard"in patients with increased risk.To increase the compliance in our patients without special risks we mostly use the available fix-combinations of estradiol/dydrogesterone getting strong efficacy,good menstrual regulation or amenorrhea,respectively,but also other combinations may be indicated to take advantage of for example androgenic or antiandrogenic pro-gestogens.
RÉSUMÉ
Resumo: Este artigo discute os principais aspectos do uso de protocolos hormonais baseados na aplicação de estrógeno seguido de progestágenos em receptoras anovulatórias o acíclicas, seja em anestro ou transição nos protocolos de transferência de embriões. A maioria das éguas apresentam comportamento poliéstrico estacional, com o que manifestam estro e ciclos ovulatórios nos períodos de maior luminosidade diária. O ciclo reprodutivo anual das éguas é caracterizado pela presença de quatro fases definidas pela dinâmica folicular: de anestro, de transição de primavera, ovulatória e de transição de outono. Durante as fases de transição e anestro, a incidência das ovulações diminui ou é nula, ou que dificulta a sincronização das ovulações entre doadoras e receptoras durante a preparação para a transferência de embriões. Alguns estudos mostram que as receptoras anovulatórias/acíclicas mantidas com protocolos com base em esteroides apresentam mudanças uterinas similares às que acontecem nas éguas gestantes. Contudo, não há pesquisas suficientes que permitam esclarecer o melhor protocolo de esteroides, no que se refere à dose, tempos de tratamento e vias de administração.
Abstract: This article discusses the main aspects of using hormonal protocols based on the application of estrogen followed by progestogen in anovulatory or acyclic recipients, either in anestrous or transition in embryo transfer protocols. Most mares demonstrate seasonally polyestrous behavior, by which they manifest estrus and ovulatory cycles during periods of higher daily luminosity. The annual reproductive cycle of mares is characterized by the presence of four phases defined by follicular dynamics: anestrous, spring transition, ovulatory, and autumn transition. During the phases of transition and anestrous, the incidence of ovulations decreases or is zero, making it difficult to synchronize ovulations between donors and recipients in preparation for embryo transfer. Some studies have shown that anovulatory/acyclic recipient mares managed with steroid-based protocols have similar uterine changes to those observed in pregnant mares. However, there is no sufficient research to allow to clarify the best steroid protocol with respect to dose, treatment times, and routes of administration.
Resumen: Este artículo discute los principales aspectos del uso de protocolos hormonales basados en la aplicación de estrógeno seguido de progestágeno en receptoras anovulatorias o acíclicas, sea en anestro o transición en los protocolos de transferencia de embriones. La mayoría de las yeguas presentan comportamiento poliéstrico estacional, con lo que manifiestan estro y ciclos ovulatorios en los periodos de mayor luminosidad diaria. El ciclo reproductivo anual de las yeguas es caracterizado por la presencia de cuatro fases definidas por la dinámica folicular: de anestro, de transición de primavera, ovulatoria y de transición de otoño. Durante las fases de transición y anestro, la incidencia de las ovulaciones disminuye o es nula, lo que dificulta la sincronización de las ovulaciones entre donadoras y receptoras durante la preparación para la transferencia de embriones. Algunos estudios han mostrado que las receptoras anovulatorias/acíclicas mantenidas con protocolos con base en esteroides presentan cambios uterinos similares a los que pasan en las yeguas gestantes. Sin embargo, no hay investigaciones suficientes que permitan aclarar el mejor protocolo de esteroides, con respecto a dosis, tiempos de tratamiento y vías de administración.
RÉSUMÉ
The effect of substitution of equine chorionic gonadotropin (eCG) by follicle stimulating hormone (FSH) in synchronization protocols of ovulation in dairy goats was evaluated. Twelve goats received intravaginal sponges impregnated with 60mg of medroxyprogesterone acetate (MAP) for 10 days. The sponges were removed and the animals were distributed into two groups (G): G1 (n=6) treated with 0.5mL of a synthetic analogue of PGF2 α and 100 IU of eCG for each 10kg weight, intramuscular injection (IM); and G2 (n=6) treated with 0.5mL of a synthetic analogue of PGF2α and 20mg of FSH (IM). All animals were monitored for estrus detection with aid of a ruffian after sponge removal. The ovarian dynamics were analyzed by ultrasound, since six hours after sponge removed. Each animal was analyzed in time elapsed of six hours until 12 hours after ovulation detection. For data analyses, the Wilcoxon test and variance analyses were used. There was not difference between the analyzed parameters (P>0.05). In this way, eCG can be replaced by FSH in synchronization protocols of ovulation in dairy goats.
Sujet(s)
Animaux , Hormone folliculostimulante , Gonadotrophine équine/analyse , Ovulation , Techniques de reproduction/médecine vétérinaireRÉSUMÉ
O tratamento do hipogonadismo hipogonadotrófico na mulher adulta com hipopituitarismo inclui diversas alternativas terapêuticas de estrógenos e progestágenos, sendo a via oral a de menor custo e a de maior comodidade à paciente. A rota estrogênica oral, entretanto, exerce marcada influência sobre o eixo hormônio de crescimento/fator de crescimento insulina-símile número 1 (GH/IGF-1) nessas mulheres. O tratamento com estrógenos orais, concomitante ao uso de GH em pacientes com hipopituitarismo, antagoniza as ações biológicas do GH e agrava as anormalidades de composição corporal e o metabolismo em geral. Presume-se que o estrógeno oral iniba a secreção/produção de IGF-1 por meio de efeito de primeira passagem hepática, causando aumento da secreção de GH por intermédio de inibição do feedback negativo de IGF-1 em mulheres normais. Isso é demonstrado clinicamente por redução da massa magra, aumento da massa gorda, perfil lipídico aterogênico e prejuízo do bem-estar psicológico. Alguns estudos apontam que os progestágenos com ação androgênica revertem o efeito de diminuição dos níveis séricos de IGF-1 induzida pelos estrógenos orais. Os progestágenos neutros não apresentam esse efeito, porém, quanto maior a potência androgênica, maior será a reversão do efeito de diminuição de IGF-1. Na presente revisão da literatura, serão abordados os aspectos clínicos da reposição com estrógenos e progestágenos nas mulheres com hipopituitarismo, suas interações nas outras deficiências hormonais, bem como o impacto do uso de estrógenos sobre as ações metabólicas do GH.
Treatment of hypogonadotropic hypogonadism in adult women with hypopituitarism can include a wide range of estrogen and progestogen treatment alternatives and oral administration is the route of least cost and greatest patient comfort. The oral estrogen route has a major impact on the growth hormone-insulin-like growth factor I (GH/IGF-1) axis. Oral estrogen therapy, when given concurrently with GH to patients with hypopituitarism, antagonizes the biological effects of GH treatment and aggravates the abnormalities of body composition and the metabolism in general. It is presumed that oral estrogen suppresses the secretion/production of IGF-1 by a hepatic first-pass mechanism, resulting in increased GH secretion by means of suppressing the IGF-1 negative feedback that is present in healthy women. This is clinically manifested in reduced lean body mass, increased fat mass, an atherogenic lipid profile and damage to psychological well-being. Some studies have indicated that progestogens with androgenic actions reverse the effect of reduced serum IGF-1 levels that is induced by the oral estrogens. Neutral progestogens do not exert this effect, however the stronger the androgenic potentialis, the more the effect of reduced IGF-1 will be reversed. This bibliographical review will deal with the clinical aspects of estrogen and progestogen replacement in women with hypopituitarism, their interactions with other hormone deficiencies and the impact of estrogen treatment on the metabolic actions of GH.