Micronized progesterone regulation of the endometrial glandular cycling pool.

We sought to determine if micronized progesterone in estrogen-primed women has an effect on the available cycling pool of proliferating glandular cells by studying 107 postmenopausal women who participated in a double-blind cyclical HRT trial. Each received 0.625 mg/day of conjugated equine estrogen (Premarin) orally for 6 weeks (cycle 1), followed by a baseline endometrial biopsy. These women were randomized to one of four doses (100 through 400 mg/day) of progesterone taken the last 10 days of each cycle or to estrogen only. Cyclical HRT (25-day cycles) was continued for three more cycles. Endometrial biopsies were performed at the end of cycle 4 and 64 subjects demonstrated an adequate biopsy for immunohistochemical evaluation. The number of proliferating gland cells was determined by an immunohistochemical stain measuring positive MIB1 staining nuclei per thousand gland cells. The number of proliferating endometrial gland cells in the cycling pool of women receiving 300- and 400-mg daily doses of progesterone was low (mean 4.9 and 1.7, respectively) when compared with women receiving 100 mg progesterone (mean 27.0) or to unopposed estrogen (mean 30.3). Late secretory endometrium from 19 premenopausal women had a mean of 0.6. In the progesterone-treated subjects, biopsies showed that secretory maturation increased as the serum progesterone and doses of progesterone increased. We conclude that micronized progesterone given to estrogen-primed menopausal women results in a dose dependent decrease in endometrial gland proliferation. The use of an immunohistochemical stain and the diagnosis of histologic secretory maturation are complementary techniques in determining the inhibition of glandular proliferation.

Norethindrone acetate and estradiol-induced endometrial hyperplasia.

OBJECTIVE: To identify the lowest effective continuous dose of norethindrone acetate that significantly reduces 12-month incidence of endometrial hyperplasia associated with unopposed 17beta-estradiol (E2), 1 mg. METHODS: In a double-masked, randomized, multicenter study, 1176 healthy postmenopausal women 45 years of age or older without evidence of endometrial abnormalities were given 12 months of treatment with unopposed E2, 1 mg, or continuous-combined regimens of E2, 1 mg, and norethindrone acetate, 0.1 mg, 0.25 mg, or 0.5 mg. Endometrial histology was evaluated at the end of the treatment period. RESULTS: Continuous-combined E2-norethindrone acetate regimens significantly reduced 12-month incidence of endometrial hyperplasia compared with unopposed E2 1 mg (P <.001). Endometrial hyperplasia occurred in 14.6% of women treated with unopposed E2 1 mg, whereas in all continuous-combined groups, the rate decreased to less than 1%. Among patients who received E2-norethindrone acetate 0.1 mg, incidence was 0.8%; among those who received 0.25 mg and 0.5 mg, it was 0.4%. CONCLUSION: Continuous norethindrone acetate at doses as low as 0.1 mg combined with E2 1 mg effectively negated risk for endometrial hyperplasia associated with unopposed E2 1 mg, at least for the first year of therapy.

The effects of progesterone and progestins on endometrial proliferation.

A total of 99 premenopausal and 27 postmenopausal women were evaluated to determine the quantity of glandular proliferation resulting from progestin inhibition of estrogen-primed subjects and of subjects without hormonal stimulation. Endometrial glandular proliferation rates were determined by using mitosis counts, proliferating-cell nuclear antigen (PCNA), and nuclear cyclin (MIB1) immunocytological staining. The endometria of normally cycling premenopausal women, of women who received a synthetic progestin, and of untreated postmenopausal women were studied. In untreated normally cycling premenopausal women, the proliferation of the glandular epithelium was increased during the follicular phase and decreased during the luteal phase. Premenopausal women receiving a synthetic progestin and untreated postmenopausal women who were not estrogen-primed showed minimal epithelial proliferation. Endometrial glandular proliferation is inhibited by endogenous progesterone in premenopausal women. Endometrial proliferation is markedly reduced in premenopausal women receiving a synthetic progestin and in untreated postmenopausal women.

PIP: Use of micronized progesterone or a synthetic progestin has been shown to counter the proliferative effect of estrogen on the endometrium in pre- and postmenopausal women. The present study measured endometrial glandular proliferation rates in 99 pre- and 27 postmenopausal US women. Determinations were based on mitosis counts and both proliferating cell nuclear antigen and nuclear cyclin immunocytologic staining of endometrial tissue. In the untreated, normally cycling premenopausal subjects, glandular epithelial proliferation increased during the follicular phase and decreased during the luteal phase. Premenopausal women who received a synthetic progestin and untreated postmenopausal women who were not estrogen-primed showed minimal epithelial proliferation. The mean mitosis rate of proliferative phase glands was 12.3 compared with 1.6 and 0.01 after administration of the oral contraceptives norethindrone or norethynodrel, respectively. Among premenopausal women, the intensity of the stromal pseudodecidualization and inhibition of glandular development was greatest in those receiving monthly medroxyprogesterone acetate injections. The combination of progestin potency, dosage, and duration determined the mitoses, stroma, and glands that were present in the three groups of subjects. The methods used in this study may be of use in determining optimal dosages of exogenous progestins in women who are receiving hormone replacement therapy and the potential exists for predicting adverse endometrial responses to progestational therapy.

Assessing the importance of endometrial biopsy prior to oocyte donation.

The importance of performing an endometrial biopsy in women preparing for oocyte donation goes beyond confirming the histologic response to hormone replacement therapy. Additional information related to uterine architecture, ease of embryo transfer, status of the ovaries, and patient compliance is also gained. Finally, the return visit provides an opportunity to discuss plans for the upcoming cycle. Whereas this report does not specifically address the question as to how many pregnancies were contingent upon the satisfactory performance of the mock cycle, we estimate that due to a combination of factors (i.e., lack of endometrial response, patient noncompliance, difficult embryo transfer), the likelihood of pregnancy in many cases would have been substantially reduced had the preliminary cycle not been attempted.

Fusarium graminearum A 3/5 as a novel host for heterologous protein production.

We describe a novel fungal expression system which utilizes the Quorn myco-protein fungus Fusarium graminearum A 3/5. A transformation system was developed for F. graminearum and was used to introduce the coding and regulatory regions of a trypsin gene from Fusarium oxysporum. The protein was efficiently expressed, processed and secreted by the recombinant host strain. In addition, the promoter and terminator of the F. oxysporum trypsin gene have been successfully utilized to drive the expression of a cellulase gene from Scytalidium thermophilum and a lipase gene from Thermomyces lanuginosus in F. graminearum.

Prevention of endometrial hyperplasia by progesterone during long-term estradiol replacement: influence of bleeding pattern and secretory changes.

OBJECTIVE: To determine the relative influences of induction of withdrawal bleedings secretory transformation, and reduction of mitosis in glands on prevention of endometrial hyperplasia during long-term hormonal replacement therapy. DESIGN: Observational expanded clinical case report. SETTING: Reproductive Endocrine Department of Hospital Necker, Paris, France, and Pathology Department of Women's Hospital, Los Angeles County and University of Southern California Medical Center, Los Angeles, California. PATIENTS: Postmenopausal women seeking treatment for symptomatic menopause. INTERVENTIONS: Endometrial biopsy and/or ambulatory hysteroscopy. MAIN OUTCOME MEASURE: Endometrial histology including progestational maturation patterns and glandular epithelial mitosis rates. Macroscopic endometrial appearance. RESULTS: The use of larger doses of E2 and P induced more marked secretory changes and more frequent withdrawal bleeding than the lower doses. There was no evidence of endometrial hyperplasia after 5 years of E2/P replacement therapy independently of bleeding pattern or progestational maturation. Consistent reduction of mitosis rates in glandular epithelium was found after 9 or more days of P administration in each cycle. CONCLUSIONS: Control of endometrial growth is mainly related to control of mitosis in glands by a relatively low doses of P. Induction of withdrawal bleeding and endometrial secretory transformation, which require larger doses of Progesterone, do not provide additional benefit for prevention of hyperplasia. Induction of amenorrhea with a relatively low dose of P may be offered to women seeking hormone replacement therapy with similar levels of safety.

Fructose-1,6-bisphosphatase of the yeast Kluyveromyces lactis.

The fructose-1,6-bisphosphatase [Fru(1,6)P2ase] gene of the budding yeast, Kluyveromyces lactis, was cloned and sequenced. The gene encodes one open reading frame predicting a 354-amino-acid polypeptide. The polypeptide is different from other Fru(1,6)P2ases in that it contains a short amino-acid-insert region close to a basic residue located at the binding site for the allosteric inhibitor AMP. Comparison of the biochemical properties of the K. lactis enzyme with its closest homolog, the Saccharomyces cerevisiae Fru(1,6)P2ase (74% amino acid identity), reveals that the K. lactis enzyme is significantly less sensitive to AMP (Ki = 540 microM) than the S. cerevisiae enzyme (Ki = 190 microM). However, studies with a K. lactis Fru(1,6)P2ase mutant, in which the insert region (amino acids 152-160) was deleted by site-directed mutagenesis [(des-152-160)Fru(1,6)P2ase], showed that the mutant enzyme had higher sensitivity to AMP inhibition (Ki = 280 microM) than the control K. lactis enzyme. Thus, the nine-amino-acid insert region appears to be responsible for the decreased AMP inhibition shown by the K. lactis wild-type enzyme. Catabolite-repression and catabolite-inactivation studies show that, unlike the complete repression of FBP1 mRNA and inactivation of enzyme activity by glucose seen in S. cerevisiae, mRNA levels and enzyme activity of K. lactis Fru(1,6)P2ase decreased only about 2-4-fold due to the presence of glucose in the cell-culture medium.

Diagnosis of hepatitis C virus (HCV) infection using an immunodominant chimeric polyprotein to capture circulating antibodies: reevaluation of the role of HCV in liver disease.

Structural and nonstructural regions of the HCV-encoded polyprotein have been expressed in recombinant yeast, bacteria, or insect cells and used to capture and measure reactive antibodies circulating in different individuals. The putative nucleocapsid protein (C) and nonstructural proteins 3-5 (NS3-NS5) were found to contain the most immunodominant epitopes. The NS3, NS4, and C regions were expressed in yeast in the form of a fused, chimeric polyprotein (C25) and a capture assay for reactive antibody was developed. This anti-C25 assay detects all previously identified HCV-seropositive cases and provides a substantially more sensitive diagnostic for both acute and chronic HCV infections than the current anti-C100-3 (NS4) assay. Anti-C25 was detected more frequently than anti-C100-3 in chronic, transfusion-associated non-A, non-B hepatitis patients from the United States (95% vs. 71%) and Japan (98% vs. 82%), in cryptogenic cirrhosis patients from the United States (62% vs. 28%), and in hepatitis B surface antigen-negative cases of hepatocellular carcinoma from Japan (83% vs. 63%). These data indicate that HCV has a greater role in these liver diseases than was previously thought. In volunteer United States blood donors sampled following the introduction of anti-C100-3 screening, the prevalence of anti-C25 and anti-C100-3 was 0.5% and 0.08%, respectively.

Postmenopausal hormone replacement with a combination estrogen-progestin regimen for five days per week.

A group of 15 postmenopausal women who had not recently received estrogen replacement were enrolled in a study during which they received 0.625 mg of conjugated equine estrogen and 2.5 mg of medroxyprogesterone acetate daily from Monday through Friday of each week for six months. No treatment was given on the weekend. Endometrial biopsy specimens at the end of therapy revealed minimal growth of glands and stroma and a low mean mitosis count. Of the 12 women who completed the trial, 5 were completely amenorrheic, and only 4 of the 15 bled beyond the second month of treatment. Of those four, two spotted for only a few days. In the 12 women who completed the trial there was a significant increase in high density lipoprotein cholesterol and a nonsignificant lowering of low density lipoprotein cholesterol. The results of this study indicate that comparative trials between this regimen and one in which the two drugs are given daily for seven days a week are warranted.

Endometrial responses to various hormone replacement regimens in ovarian failure patients preparing for embryo donation.

Various regimens are recommended for replacing sex steroids in ovarian failure patients attempting donor embryo transfer. We histologically assessed endometrial biopsies obtained on simulated cycle day 26 from functionally agonadal patients (n = 19) receiving hormone replacement according to three different regimens: Regimen 1, oral micronized estradiol (E2) 2 mg days 1-5, 4 mg days 6-9, 6 mg days 10-13, 4 mg days 14-28, with progesterone vaginal suppositories, 100 mg day 15 followed by 200 mg days 16-28; Regimen 2, oral micronized E2 1 mg days 1-5, 2 mg days 6-9, 6 mg days 10-13, 2 mg days 14-28, with progesterone vaginal suppositories, 100 mg day 15 followed by 200 mg days 16-28; Regimen 3: oral micronized E2 1 mg days 1-5, 2 mg days 6-9, 6 mg days 10-13, 2 mg days 14-28, progesterone 50 mg intramuscularly delivered day 15 followed by 100 mg intramuscularly days 16-28. Biopsies were interpreted according to Noyes criteria. While all regimens resulted in variable degrees of stromal pseudodecidualization, Regimen 1 biopsies uniformly demonstrated glandular abnormalities consistent with excessive estrogen stimulation. This included aberrant maturation, intraluminal papillary excrescences and variations in epithelium size and stratification. Regimen 2 biopsies were morphologically normal in most patients, yet many manifested minor variations in gland maturity. Only Regimen 3 biopsies were consistently normal on day 26 or slightly advanced in maturation. We conclude that endometrial morphology differs according to the hormone replacement preparation and route of administration.(ABSTRACT TRUNCATED AT 250 WORDS)

Results of tubal embryo transfer in premature ovarian failure.

The transfer of embryos generated in vitro to the fallopian tubes in 11 cases of premature ovarian failure resulted in 9 clinical pregnancies. This approach may have theoretical advantages over GIFT and IVF-ET in agonadal patients.

A randomized clinical trial comparing Pipelle and Tis-u-trap for endometrial biopsy.

Recent publications have suggested that use of the Pipelle endometrial suction curette is a safe and effective method by which to obtain samples of endometrial tissue. To address this issue, we performed a randomized clinical trial comparing the Pipelle to the Tis-u-trap in 156 patients. The Pipelle was as effective as the Tis-u-trap in obtaining endometrial samples in both the adequacy of the specimen (Pipelle 88%, Tis-u-trap 84%) and the quality of the specimen (P = .26). This trial confirms the favorable observational reports on the use of the Pipelle for endometrial biopsy.

Yeast mutants conferring resistance to toxic effects of cloned human insulin-like growth factor I.

The production of extracellular human insulin-like growth factor I (IGF-I) in yeast is deleterious to the growth of the host organism. Mutants resistant to the toxic effects of IGF-I production were isolated. A subset of these mutants produced levels of IGF-I greater than the parent strain and were due to chromosomal recessive mutations at a single locus, hpx1. The overproduction of IGF-I was independent of the original promoter and vector expression system. The mutant strains also displayed enhanced extracellular production of other heterologous proteins.

Clinical and ultrastructural findings of an androgenizing Krukenberg tumor in pregnancy.

A clinical and ultrastructural study of an androgenizing Krukenberg tumor in pregnancy is presented. Ultrastructural observations suggested the abundant, hyperplastic, luteinized ovarian interstitial cells as the probable cause of elevated circulating levels of testosterone (5400 ng/dL). The unusual fine structure of these cells, which included large intramitochondrial lipid droplets and abundant smooth endoplasmic reticulum, was indistinguishable from that reported to occur in Leydig cells stimulated by exogenous gonadotropins.

Cytodiagnosis of Candida organisms in cervical smears.

Cervical smears and cervical scrapings cultured on Sabouraud agar from 31 women suspected of having Candida genital infections were examined in a study of the cytomorphology of this fungal infection in cervical smears. Of the 31 samples, 20 (64.5%) grew C. albicans in culture. One sample (3.2%) grew C. paratropicalis, 2 (6.4%) grew mixed C. albicans and Torulopsis glabrata and 2 (6.4%) grew T. glabrata alone. Of the 25 fungus-positive samples, 20 (80%) had fungus-positive cervical smears and 5 (20%) had fungus-negative smears. There was no instance in which the cervical smear was positive but the culture was negative. Among the cases positive for C. albicans, organisms occurred in two forms: pseudohyphae without blastospores (29.4%) and pseudohyphae with blastospores (70.6%). T. glabrata was present in the smears as budding and nonbudding yeasts. Although the sensitivity of the cervical smear in detecting fungus in culture-positive patients was only 80%, the cervical smear can still be a useful means of rapid identification of C. albicans when blastospores and pseudomycelium are present. The presence of budding or nonbudding yeast without pseudohyphae should strongly suggest a T. glabrata infection.

Biochemical and histologic effects of sequential estrogen/progestin therapy on the endometrium of postmenopausal women.

Medroxyprogesterone acetate in doses of 10, 5, and 2.5 mg was administered sequentially to three groups of postmenopausal women receiving 0.3 mg, 0.625 mg, and 1.25 mg of conjugated equine estrogens, respectively. Serial endometrial biopsies were performed on these women before therapy, during estrogen therapy alone, and during sequential estrogen-progestin therapy. Endometrial histology and estrogen receptor concentrations were assessed. A linear increase of cytosolic estrogen receptor concentration occurred over the dosage range of conjugated equine estrogen. When medroxyprogesterone acetate was added to the estrogen therapy, the concentrations of estrogen receptors fell. Within the groups of women receiving 0.3 mg and 0.625 mg of conjugated equine estrogen, all doses of medroxyprogesterone acetate were equally effective in reducing the levels of cytosolic receptor to pretreatment levels. However, at the conjugated equine estrogen dose of 1.25 mg, only 5 mg and 10 mg doses were effective in reducing the cytosolic receptor concentration to pretreatment levels. Histologically, little effect was observed from the lowest doses of either drug. However, even though 5 and 10 mg of medroxyprogesterone acetate were identical biochemically, the 10 mg dose was the only one producing a homogeneous, secretory pattern within the endometrium.

Comparison of techniques for selection of motile spermatozoa.

Procedures to separate motile sperm with high rates of recovery may have clinical application in in vitro fertilization and intrauterine insemination in increasing the probability of fertilization by a normal sperm and subsequent normal embryonic development. A two-step continuous Percoll gradient was an effective means of separating motile sperm which also had enhanced ability to penetrate zona-free hamster ova. However, the requirement for a high-speed centrifuge and rotor makes the procedure impractical in many cases. A one-step discontinuous Percoll gradient was also effective in separating a population of motile sperm. Comparison of the discontinuous Percoll gradient with other techniques for separation of motile sperm indicated the discontinuous Percoll gradient had advantages in terms of recovery, enhancement of motility, and increased ability to penetrate zona-free hamster ova. The velocity of selected sperm was not significantly different among techniques. The one-step discontinuous Percoll gradient appears to have value both for increasing homogeneity of human sperm populations used for basic research and in clinical practice for male subfertility.

Ultrastructural hemostasis in response to vascular injury induced by intrauterine devices in human endometrium.

PIP: 8 micrographs are presented to help elucidate the mechanism of endometrial bleeding caused by IUDs. A previous study, which reported endometrial vessels with defects or gaps in the superficial portion of IUD-exposed endometrium, is expanded. Since the endothelial cells forming these gaps were in stages of degeneration to complete necrosis, perhaps IUD/endometrial interactions injured some of the superficial vessels which then degenerated, formed gaps, and allowed blood to escape. However, the same endothelial degeneration should initiate platelet adhesion, aggregation, and thrombosis. Yet the micrographs showed degenerated endothelial cells at the vessel gaps, gaps which represent disintegrated endothelial cells, and collagen which appeared to be directly exposed to luminal blood through the gaps. All of these hemostasis-initiating conditions resulted in a surprizing low level of activity. Rarity of platelet and/or fibrin thrombi plugging vessel gaps in IUD-exposed endometrium supported the feasibility of bleeding through small gaps. The interstitial hemorrhage is apparent by electron micrograph. When the concentration of red cells within the superficial endometrium became sufficiently high, apparently the erythrocytes either exuded through the spaces between surface epithelial cells or ruptured into the uterine caivty and resulted in clinical bleeding.^ieng