Effects of conjugated equine estrogens or raloxifene on lipid profile, coagulation and fibrinolysis factors in postmenopausal women.

OBJECTIVES: To compare the effect of conjugated equine estrogens (CEE) and raloxifene on lipid profile and hemostasis. MATERIALS AND METHODS: A double-blind, randomized and parallel study was performed with 90 healthy postmenopausal women, aged 54 +/- 5 years, divided into three groups and submitted to daily therapy with either CEE 0.625 mg, raloxifene 60 mg or placebo for 4 months. The lipid profile, coagulation and fibrinolytic factors were analyzed. RESULTS: CEE increased the levels of high density lipoprotein cholesterol (HDL-C) from 49.0 to 56.8 mg/dl (p < 0.001), very low density lipoprotein cholesterol (VLDL-C) from 17.2 to 22.3 mg/dl (p < 0.001), and triglycerides from 86.0 to 111.7 mg/dl (p < 0.001), and decreased the levels of low density lipoprotein cholesterol (LDL-C) from 121.0 to 106.5 mg/dl (p < 0.001). The only significant effect of raloxifene was an increase in the levels of HDL-C from 46.0 to 47.8 mg/dl (p = 0.019). There was no significant reduction in LDL-C, from 115.5 to 110.2 mg/dl (p = 0.06), VLDL-C, from 21.7 to 20.0 mg/dl (p = 0.201), and triglycerides, from 108 to 100 mg/dl (p = 0.201). CEE decreased the levels of fibrinogen, from 370.5 to 326.8 g/l (p = 0.039) and the levels of antithrombin III, from 99.5 to 93.2% (p < 0.001). Raloxifene decreased the levels of fibrinogen, from 354.7 to 302.0 g/l (p = 0.009) and the levels of antithrombin III, from 102.4 to 98.5% (p = 0.039). CEE increased levels of protein C from 103.7 to 115.3 mg/l (p < 0.001) and raloxifene did not change the levels of protein C (107.9 to 105.1 mg/l; p = 0.158). CEE decreased the antigen levels of tissue plasminogen activator (t-PA) from 8.8 to 6.8 U/ml (p < 0.001), and of plasminogen activator inhibitor (PAI-1) from 30.8 to 21.6 U/ml (p < 0.010), whereas raloxifene had no significant effect on either t-PA, from 9.6 to 9.2 U/ml (p = 0.235) or PAI-1 antigen levels, from 32.1 to 30.4 U/ml (p = 0.538). CONCLUSION Both CEE and raloxifene exert significant effects on the lipid and coagulation profile. CEE had a more significant effect on fibrinolysis than raloxifene. These effects may have a significant impact on the cardiovascular risk that needs to be confirmed in larger studies.

Uterine artery embolization for the treatment of uterine leiomyomata.

OBJECTIVES: To evaluate the results of the uterine artery embolization (UAE) for the treatment of uterine fibroids. METHODS: Twenty-six patients with ultrasonographic diagnosis of uterine leiomyomata were submitted to UAE with polyvinyl alcohol particles. Imaging and clinical follow-up was performed before the procedure, at 3 months, and 1 year after. RESULTS: All procedures but one were technically successful. Control of menorrhagia and pelvic pain were reported after UAE by 87.5% and 84.2% of patients, respectively. The initial medium uterine volume was 385 cm(3), after 3 months 255 cm(3) and after 1 year 202 cm(3). The mean uterine volume decrease was 29% after 3 months and 41% after 1 year of follow-up (P<0.001). Clinical and biochemical findings consistent with ovarian failure were observed in three patients (12% of the patients). CONCLUSIONS: UAE represents a new therapeutic approach in the treatment of uterine leiomyomata. The procedure appears effective in controlling symptoms and represents an alternative to hysterectomy.

Efficacy and acceptability of two monophasic oral contraceptives containing ethinylestradiol and either desogestrel or gestodene.

OBJECTIVE: To assess the contraceptive efficacy, cycle control and acceptability of two monophasic oral contraceptives containing either 30 micrograms ethinylestradiol plus 150 micrograms desogestrel or 30 micrograms ethinylestradiol plus 75 micrograms gestodene. METHODS: In a randomized, open-label, six-cycle, group-comparative, multicenter study performed in Brazil, pregnancies, cycle-control parameters, incidence of side-effects and the presence and severity of acne vulgaris were assessed, and blood pressure and body weight were measured at pretreatment and after one, three and six cycles of oral contraceptive use. RESULTS: Of the 595 women enrolled, 274 (86.7%) in the desogestrel/ethinylestradiol group and 227 (81.4%) in the gestodene/ethinylestradiol group completed the six cycles, providing data for 1753 and 1487 treatment cycles, respectively. Two pregnancies occurred, one of which (in the desogestrel/ethinylestradiol group) was attributed to user failure, whilst the other (in the gestodene/ethinylestradiol group) was thought to result from method failure. Cycle control was observed to be excellent; the incidences of irregular bleeding and minor side-effects were low in both groups and decreased after an initial increase in the first cycle. Pre-existing acne improved in both groups, whereas blood pressure and body weight remained essentially unchanged. CONCLUSIONS: Both desogestrel/ethinylestradiol and gestodene/ethinylestradiol provide effective oral contraception with comparable cycle control and acceptability.

A virilizing Leydig cell tumor of the ovary associated with stromal hyperplasia under gonadotropin control.

A 34-yr-old nulliparous black woman presented with hair loss, facial hirsutism, irregular menses and infertility associated with greatly increased serum total testosterone levels. The adrenal glands and the ovaries were normal on radiological and ultrasonographic investigation. Catheterization of the veins draining from the adrenal glands and the ovaries yielded testosterone levels of 20.3 nmol/L and 20.0 nmol/L in the right and the left adrenal veins, respectively, and 17.9 nmol/L and 27.4 nmol/L in the right and left ovaries venous plexus, respectively. Sequencial dexamethasone and ethynyl estradiol suppression test showed a decrease in cortisol level with no change in total testosterone level on dexamethasone while an increase in testosterone from 10.5 nmol/L to 20.1 nmol/L was observed ten days after ethynil estradiol had been associated to dexamethasone. When a gonadotropin-releasing hormone agonist (gonadorelin 3.5 mg i.m.) was administered for 2 months, serum gonadotropins levels decreased to less than 2 IU/L, total testosterone to 3.8 nmol/L and estradiol to less than 36 pmol/L. The patient was submitted to a pelvic exploratory laparotomy and a left salpingo-oophorectomy was performed. A solid and circumscribed ovarian tumor of 1.0 cm in diameter was found. The pathological diagnosis was a Leydig cell tumor with surrounding stromal hyperplasia. These findings may suggest that this tumor was gonadotropin-dependent being indirectly stimulated by ethynil estradiol, through a sensitization of the pituitary gonadotropes and increase in gonadotropin levels and suppressed by a gonadotropin-releasing hormone agonist.

Updating the clinical experience in endometriosis--the Brazilian perspective.

In an open-label, multicentre, randomized, parallel group study, 164 women with endometriosis were assigned to treatment. Out of these women, 81 received danazol (600 mg daily for 8 weeks, then 400 mg for 16 weeks) and 83 were given gestrinone (2.5 mg twice a week for 24 weeks). Five weeks before the start of treatment clinical evaluation and diagnostic laparoscopy were performed during the screening visit. Drug assignment and laboratory data assessment were carried out within 3 days of the estimated onset of the menstrual cycle at baseline visit. The response to treatment was assessed during visits at weeks 2, 4, 8, 12, 16, 20 and 24; at the last visit a second laparoscopy was performed. Therapeutic efficacy was evaluated by analysis of the laparoscopic scores assessed according to the revised American Fertility Society classification. Symptomatic response was measured by clinical scores and laboratory data. In one centre, bone mineral density was also recorded. One patient in the danazol group discontinued treatment due to a cutaneous rash as a probable adverse reaction at the beginning of the study. The therapeutic efficacy of danazol and gestrinone did not differ significantly when the revised American Fertility Society scores were compared. The symptomatic response also showed no statistical difference when clinical examination scores were analysed. There was no significant difference between the drugs in laboratory data, including bone mineral density, with respect to adverse events. Analysis of clinical scores showed that danazol was superior to gestrinone with respect to acne and irregular bleeding. Based on these data, we conclude that both danazol and gestrinone are reliable in the treatment of endometriosis and offer similar results.

[Quality of care in family planning clinical services in Latin America]. / Calidad de atencion en los servicios clinicos de planificacion familiar en America Latina.

PIP: Quality of care in family planning is a difficult concept to measure because of the multitude of factors contributing to it and the subjective nature of many of them. Because family planning programs were developed largely in response to rapid demographic growth, their evaluation has concentrated on fulfillment of quantified goals such as numbers of new users, coverage, or prevalence. Such measures give no indication of the relative satisfaction or dissatisfaction of users. Family planning programs seeking high volume tend to have many new acceptors with low continuation rates, and a choice of methods limited to those considered highly effective and easy to distribute. In most Latin American programs, only oral contraceptives and surgical sterilization have high prevalence rates. In recent years, however, community pressure for greater attention to users needs and disappointment with results of programs oriented to obtaining high rates of new users have prompted greater attention top satisfaction of family planning clients and to quality of services. A recent review identified 6 crucial elements in determining the quality of family planning care: 1) free and informed selection of methods 2) information provided to clients 3) technical competence of service providers 4) interpersonal relations between clients and workers 5) mechanisms to promote continuation of use and 6) adequate provision of additional services. This work surveys the quality of family planning services in Latin America, using these 6 factors as a point of departure. The current situation, the ideal and minimal acceptable levels, and the most promising strategies for achieving improvements are assessed for each factor. Free selection of contraceptive method is restricted in most Latin American family planning programs because access is limited to a few methods, because inadequate information is provided to users, because high prices of some methods limit accessibility, or because some methods are considered inappropriate for particular clients or populations. The information provided to clients may be incomplete or biased, the personnel providing it may be inadequately trained, information provided by different types of workers may be incoherent of conflicting, or information provision may be neglected once the method has been chosen. Great regional differences have been found in the technical competence of family planning workers. Physicians working in family planning are usually technically competent for the most common techniques but often lack adequate training in other methods. Interpersonal relations often show a lack of concern for the needs of the client, a lack of warmth, and lack of respect for elementary modesty and privacy. Operational studies can be of great use in comparing results of different strategies to improve the quality of care on contraceptive acceptance and continuation rates.^ieng

The significance of female sex steroids on the vascular permeability of the traumatised uterine serosa of rats.

Using experiments with conjugated hormones, and their influence on vascular permeability assessed by the colloidal carbon technique, we have investigated the effect of female sex steroids on the microcirculation of the uterine horn of virgin rats. We found that oestrogen inhibited vascular permeability in inflammatory conditions. Progesterone increased vascular permeability.

[Menstrual dysfunction]. / Disfuncao menstrual.

PIP: The various types of menstrual dysfunctions are classified, their symptoms are described, and appropriate treatment is suggested. The types considered are: subfollicular, persistent follicular (subdivided into simple, macrofollicular and microfollicular or androgenic), subluteal and persistent luteal. The subfollicular type is characterized by the early onset of menopause (before age 40); the follicular type by amenorrhea and sterility (simple type), alternating amenorrhea and bleeding (macrofollicular), and amenorrhea with occasional bleeding and hirsutism (microfollicular); the subluteal type by sterility; and the luteal type by either amenorrhea or hypermenorrhea. The type of dysfunction can be detected by laboratory tests (such as urinary estrogens, pregnanediol, and gonadotropins, functional cytology, 17-ketosteroids, plasma testosterone, appearance of the endometrium, and basal temperature). The subfollicular type is treated with estrogen, with or without progesterone, the follicular type with cyclical administration of progesterone (clomiphene can also be used), the subluteal type with progesterone, 17alpha-hydroxyprogesterone, and chorionic gonadotropin, and the luteal type with high doses of progesterone.^ieng