Quantitative levonorgestrel plasma level measurements in patients with regular and prolonged use of the levonorgestrel-releasing intrauterine system.

BACKGROUND: The levonorgestrel-releasing intrauterine system (LNG-IUS) is well accepted as an easy-to-use contraceptive with an excellent side-effect profile. It contains a reservoir of 52 mg of levonorgestrel (LNG) with continuous release of the steroid. Its contraceptive use is approved for 5 years. The aim of this study was to determine the plasma concentration of LNG and its variation with time in patients with in-dwelling LNG-IUS Mirena®. STUDY DESIGN: In this study, we determined LNG plasma concentrations in 110 women with LNG-IUS at different time points of use. Time from insertion of the system in the study population ranged from 20 days to 11.1 years. Quantitative LNG levels were determined using a validated liquid chromatography-tandem mass spectrometry assay. RESULTS: The mean±SD LNG plasma level in all women was 147±59 pg/mL. A highly significant negative correlation between LNG plasma level and LNG-IUS time of use could be demonstrated. In the first year of use, LNG plasma level was as high as 191±71 pg/mL, decreasing to 157±68 pg/mL in the second year and 134±41 pg/mL in the third year. Even after exceeding the recommended period of LNG-IUS use, systemic LNG concentrations were detectable: 133±38 pg/mL in the sixth year, 133±48 pg/mL in the seventh year and 117±45 pg/mL in the eighth year. Furthermore, a significant negative correlation between LNG plasma level and body mass index could be shown. CONCLUSION: Systemic LNG concentrations can be found in all patients with LNG-IUS IUS. However, concentrations are much lower than in other forms of LNG application. Moreover, this study demonstrates that a systemic effect of LNG-IUS can also be found after the recommended contraceptive lifespan of 5 years.

An ultra-sensitive online SPE-LC-MS/MS method for the quantification of levonorgestrel released from intrauterine devices.

A selective and sensitive liquid chromatography-tandem mass spectrometry method for the determination of very low levonorgestrel (D-(-)-norgestrel) serum levels such as those found in patients using levonorgestrel-releasing intrauterine devices (IUDs) was developed. To achieve the sub-nanomolar sensitivity needed to measure such serum levels, a diethyl ether extraction sample preparation protocol was applied prior to the online solid-phase extraction-liquid chromatography-tandem mass spectrometry (SPE-LC-MS/MS) assay. Analyte quantification from the selected reaction monitoring experiments relied on the use of sixfold deuterated norgestrel as internal standard. The final method was linear up to 1.50 ng/ml with a lower limit of quantification (LLOQ) of 0.05 ng/ml. It was found to be precise and accurate with imprecision <8% and bias <6% assessed at three control levels. Total analyte recovery measured in patient pools at three concentration levels was found to exceed 92%. Matrix interferences were excluded by post-column analyte infusion experiments. As a proof of concept, a set of IUD patient serum samples was screened for their levonorgestrel content. A total of 97.5% (n = 94) of the samples did show serum levels exceeding the LLOQ, proving the applicability of the assay in relevant clinical cohorts. This method must not be used for diagnostic or therapeutic purposes, since it did not undergo formal performance evaluation in the sense of the in vitro diagnostic directive (98/79/EG) of the European community.

Metformin, naltrexone, or the combination of prednisolone and antiandrogenic oral contraceptives as first-line therapy in hyperinsulinemic women with polycystic ovary syndrome.

To compare the short-term effects of metformin (M), naltrexone (N), and a combination of OC and prednisolone (OC/Pr) on the metabolic state and the ovarian function of PCOS women, we randomized 29 women to a 3-month course of therapy. We observed significant improvements in hyperandrogenemia and ovulation rates in PCOS women of all three groups, in the absence of changes in the metabolic state, suggesting that insulin resistance in PCOS patients is only one of several factors leading to hyperandrogenemic ovarian failure.

Use of the levonorgestrel-releasing intrauterine system: an Austrian perspective.

Approximately 12 million women worldwide use the levonorgestrel-releasing intrauterine system (IUS), with approximately 180,000 users of this IUS currently reported in Austria. A patient satisfaction study of 591 women in Austria revealed a high number of 'very satisfied' (79%) and 'satisfied' (19%) patients. Reliability, comfort, excellent compatibility and less severe, shorter and less painful monthly periods were the most frequently named advantages of the levonorgestrel-releasing IUS. Medication-induced cervical priming before insertion can be carried out on a routine or selective basis (for example in nullipara, in women who have undergone cervical conisation or in women who have previously experienced painful insertion). There is, at present, no evidence of an increased rate of breast cancer through use of the levonorgestrel-releasing IUS. A directly comparative study with oral contraceptives in young nullipara showed excellent results for the levonorgestrel-releasing IUS, with no perforations, inflammation or pregnancies.

Polycystic ovarian disease unmasked by pulsatile GnRH therapy in a subgroup of women with hypothalamic amenorrhea.

OBJECTIVE: To present the observation in six out of 120 women treated with pulsatile GnRH for ovulation induction, who developed hyperandrogenemia and polycystic ovaries during treatment. DESIGN: Clinical observation. SETTING: Department of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Innsbruck, Austria. PATIENT(S): A total of 120 women initially diagnosed as suffering from primary or secondary hypothalamic amenorrhea were treated for ovulation induction with pulsatile administration of GnRH for up to 140 days. There was no indication of the presence of polycystic ovaries or hyperandrogenemia before therapy. INTERVENTION(S): Pulsatile GnRH therapy using the Zyklomat pump. MAIN OUTCOME MEASURE(S): Ovulatory menstrual cycles. RESULT(S): Initially, all patients responded to pulsatile GnRH administration with ovulation and corpus luteum formation. During continuation of treatment, 6 patients developed an increase in LH and LH/FSH ratio as well as a progressive rise in serum T levels resulting in hyperandrogenemia. This was accompanied by the development of polycystic ovaries and cessation of follicular maturation. CONCLUSION(S): We conclude from these observations that restoration of normal GnRH stimulation of the pituitary gland can result in the development of hyperandrogenemia and polycystic ovaries, suggesting a pituitary or ovarian defect underlying the pathogenesis of this disorder.

Symptoms of premenstrual syndrome may be caused by hyperventilation.

OBJECTIVE: To determine whether women with premenstrual syndrome (PMS) differ from healthy women in the extent of hyperventilation during the luteal phase of the cycle. DESIGN: Case report. SETTING: Medical university. PATIENT(S): Three reproductive-age women with severe symptoms of PMS in whom dramatic decline in end-tidal PCO2 (PETCO2) occurred during the luteal phase of the cycle. INTERVENTION(S): Measurements of PETCO2, administration of GnRH agonist triptorelin. MAIN OUTCOME MEASURE(S): PETCO2 was determined daily by sidestream capnometry. RESULT(S): The decline in PETCO2 in women with PMS was 12-18 mm Hg, on the average. This was significantly more pronounced than the decline of PETCO2 that was observed in healthy women. With the decline of PETCO2 the symptoms of PMS appeared. Symptoms disappeared at the end of the luteal phase when PETCO2 was increasing again. During treatment with the GnRH agonist, PETCO2 did not decline, and all women were free of symptoms. CONCLUSION(S): The symptoms of PMS observed in our patients were associated with a pronounced decline of PETCO2 that occurred during the luteal phase of the cycle. Because the symptoms were similar to symptoms observed in the chronic hyperventilation syndrome it is suggested that some symptoms of PMS may be caused by chronic hyperventilation. It appears that in women with PMS the sensitivity of the respiratory center to CO2 is increased more than normal by P or some other secretory product of the corpus luteum, resulting in pronounced hyperventilation with the associated clinical signs and symptoms of a chronic hyperventilation syndrome.

Dysregulated monocyte iron homeostasis and erythropoietin formation in patients with anemia of chronic disease.

Anemia of chronic disease (ACD) is frequently found in patients with chronic immune activation. Since most studies on ACD pathophysiology were performed with cell culture or animal models but not in humans, we examined 37 ACD patients suffering from autoimmune diseases or infections, 10 subjects with iron-deficiency anemia (IDA), 10 anemic patients with hereditary spherocytosis (HS), and 27 age-matched controls. Although hemoglobin concentrations were comparable between ACD and IDA patients, the latter presented with significantly higher serum erythropoietin concentrations than ACD patients. The significant negative correlation between erythropoietin and hemoglobin levels observed in IDA patients was also found in a group of anemic but not hypoferremic hereditary spherocytosis subjects, but not in ACD patients. Increased serum concentrations of the hepcidin precursor prohepcidin were paralleled by a decreased expression of the iron exporter ferroportin in circulating monocytes of ACD patients. In the latter cells, increased amounts of the iron storage protein ferritin and a reduced activity of iron-regulatory protein indicated monocyte iron accumulation. Our data indicate that hypoferremia in ACD may result from downregulation of ferroportin expression by hepcidin and cytokines with subsequent iron retention in monocytes. Together with a diminished erythropoietin formation, the impaired iron recirculation from monocytes may be central in the pathophysiology of ACD in humans.

Female fertility after cytotoxic therapy--protection of ovarian function during chemotherapy of malignant and non-malignant diseases.

Due to the dramatic improvements in cure and survival of young patients of reproductive age suffering from malignant or systemic disease, the preservation of fertility and ovarian function during cytostatic treatment has become of increased importance during the last decade. Pharmacological therapy with GnRH analogues and the cryopreservation of ovarian tissue are discussed in this context. The value of these treatment procedures and their potential clinical applications are critically reviewed in this article.

Possible role of cytokine-induced tryptophan degradation in anaemia of inflammation.

Anaemia of inflammation (AI) is a frequent complication in patients suffering from chronic inflammatory disorders including infections, autoimmune and malignant disease. Cytokine imbalance with a shift towards T-helper (Th)1-type immune response seems to be important in the pathogenesis of this type of anaemia. Interferon-gamma (IFN-gamma) and tumour necrosis factor-alpha may affect the growth and differentiation of erythroid progenitor cells. In macrophages, IFN-gamma strongly induces indoleamine (2,3)-dioxygenase, an enzyme which degrades tryptophan (trp) to kynurenine (kyn). Trp availability is rate limiting for protein biosynthesis and thus cell growth, including erythropoiesis. In this study, trp and kyn concentrations and their relationship to haemoglobin concentrations and to immune activation was examined in 22 patients with AI. Patients with AI presented with lower trp concentrations than healthy controls of similar age, and a significantly higher kyn to trp ratio, suggesting enhanced trp degradation and, because of a positive correlation with neopterin, immune activation. The kyn to trp ratio was inversely correlated to haemoglobin levels. Thus, the limitation of trp availability to erythroid progenitors may be a key mechanism in cytokine-mediated inhibition of erythropoiesis, and the therapeutic modulation of indoleamine (2,3)-dioxygenase and trp levels may be promising targets for AI therapy.