Efficacy and tolerability of pulsed estrogen therapy: a 12-week double-blind placebo-controlled study in highly symptomatic postmenopausal women.

OBJECTIVE: To confirm the efficacy and safety of pulsed estrogen therapy, a transient daily hormone exposure, for climacteric symptoms in highly symptomatic postmenopausal women. PATIENTS AND METHODS: In this multicenter, double-blind, parallel-group study, early postmenopausal women with at least seven moderate to severe vasomotor symptoms per day were randomized to receive intranasal estradiol, 150 or 300 microg/day, or placebo, for 12 weeks. The primary outcome measure was the mean daily number of moderate to severe vasomotor symptoms, as recorded in patient diaries. RESULTS: A total of 165 patients were randomized. The mean daily number of moderate to severe vasomotor symptoms decreased significantly more (p < 0.001) in the 150-microg/day (-7.86) and 300-microg/day (-9.39) groups than in the placebo group (-5.22). The decrease reached significance more rapidly with the 300-microg/day dose (from week 2) than with the 150-microg/day dose (from week 8). The rate of emergent adverse events with both doses was similar to that with placebo. CONCLUSIONS: Pulsed estrogen therapy, achieved by intranasal estradiol 150 microg/day and 300 microg/day, significantlyreduced the incidence of moderate to severe vasomotor symptoms, compared with placebo. The 300-microg/day dose demonstrated a greater and more rapid therapeutic effect, with no clinically significant difference in tolerability, compared with the 150-microg/day dose, and therefore offers the best efficacy/safety ratio when initiating treatment with intranasal estradiol.

[Vaginal hysterectomy in fibroma. Apropos of 453 cases. Retrospective comparison with 509 cases of abdominal hysterectomy]. / Hystérectomie vaginale pour fibrome. A propos de 453 cas. Comparaison rétrospective à 509 hystérectomies abdominales.

The authors present a series of 962 hysterectomies for fibroma carried out between January 1981 and December 1995 in the Department of Gynecology and Obstetrics of CHU Toulouse-La Grave. They carried out 453 vaginal hysterectomies and 509 abdominal hysterectomies. They compared the largest series reported in the literature, between vaginal and abdominal technique. The vaginal route has the obvious advantages of speed of operation, less operative trauma, lower risk of thrombo-embolic disease and the hospital stay is shorter. Laparoscopic assistance allows to extend indications of vaginal route.

Influence of ovarian cysts on the results of in vitro fertilization.

OBJECTIVE: To determine if ovarian cysts are associated with a particular basal endocrine profile and impair follicular growth. DESIGN: Retrospective study. SETTING: In Vitro Fertilization (IVF) Center. PATIENTS: Nine hundred fourteen stimulation cycles stimulated with a combination of luteinizing hormone-releasing hormone analogues (LH-RH-a) and human menopausal gonadotropins (hMG) in a long protocol in an IVF program. RESULTS: After 15 days of LH-RH-a therapy, ovarian cysts (> or = 20 mm) were observed in 8% of cases. These cysts were not related to a particular basal endocrine profile and did not impair follicular growth and IVF results. However, puncturing these cysts enhanced the quality of subsequent follicular growth. On the contrary, cysts appearing during hMG treatment (> or = 25 mm) were related with a lower LH:follicle-stimulating hormone ratio (0.79 +/- 0.52 versus 0.92 +/- 0.74 in absence of cyst) and to a lower ovarian response as assessed by the maximal estradiol level to the total number of hMG ampules ratio (51.6 +/- 36.5 versus 65.9 +/- 47.9 in absence of cyst). However, this difference had no influence on the pregnancy per stimulation rate (18% versus 16% in absence of cyst; not significant). CONCLUSIONS: Results show that the pathogens of ovarian cysts appearing during the blockage phase and during the stimulation phase are different. However, they do not impair the results of IVF, and thus it is not necessary to cancel the attempt in case of ovarian cyst.

Paradoxical ovarian stimulations in the use of LHRH analogs.

In the case of in vitro fertilization, LHRH analogs are used to induce an hypophysary blockage, before the phase of stimulation, via administration of exogenous gonadotropin. During in vitro fertilization attempts using LHRH analogs, the blockage is controlled after 14 days of treatment through measurement of the plasmatic estradiol and pelvic ultra-sonography. In this retrospective study, which concerned 1075 in vitro fertilization cycles, a paradoxical ovarian stimulation with LHRH analogs was observed in 93 cases (8.7%), with high estradiol levels and follicular growth (detected by ultra-sonography), in spite of low FSH and LH levels. In 4 cases, a follicular puncture was performed, which allowed to collect oocytes from which embryos were obtained, thus confirming the observed follicular growth and maturation. The most probable hypothesis explaining this phenomenon seems to be a direct ovarian stimulation, effectuated in vivo by LHRH analogs. This stimulation is only observed in certain patients, and apparently more frequently, with certain LHRH analogs, probably through a variation in the expression of ovarian LHRH receptors.

Paradoxical ovarian stimulations in the use of LHRH analogs.

In the case of in vitro fertilization, LHRH analogs are used to induce a hypophysial blockage before the phase of stimulation, via administration of exogenous gonadotropin. During in vitro fertilization attempts using LHRH analogs, the blockage is controlled after 14 days of treatment by measuring plasmatic estradiol and by pelvic ultrasonography. In this retrospective study, which concerned 1075 in vitro fertilization cycles, a paradoxical ovarian stimulation with LHRH analogs was observed in 93 cases (8.7%) with high estradiol levels and follicular growth (detected by ultrasonography), in spite of low FSH and LH levels. In 4 cases, a follicular puncture was performed, which made it possible to collect oocytes from which embryos were obtained, thus confirming the observed follicular growth and maturation. The most probable hypothesis explaining this phenomenon seems to be direct ovarian stimulation effectuated in vivo by LHRH analogs. This stimulation is only observed in certain patients, and, more frequently it seems, with certain LHRH analogs, which is probably due to a variation in the expression of ovarian LHRH receptors.

Randomized trial of three luteinizing hormone-releasing hormone analogues used for ovarian stimulation in an in vitro fertilization program.

OBJECTIVE: To determine if biochemical differences in luteinizing hormone-releasing hormone analogues (LH-RH-a) have a clinical influence, we studied three of these molecules: buserelin acetate (group B), triptorelin (group T), and leuprorelin (group L). DESIGN: Clinical trial. SETTING: In Vitro Fertilization (IVF) Center. PATIENTS: Two hundred forty-six patients, undergoing their first IVF attempt, were randomly allocated to one group. The analogues were used in a long protocol for ovarian stimulation in an IVF program. RESULTS: After 15 days of LH-RH-a therapy, the follicle-stimulating hormone level was lower in group B (2.9 +/- 1, 4.3 +/- 1.7, 4.8 +/- 2.1 UI/L for B, T, and L groups, respectively; P less than 0.001), although no difference was found in LH and estradiol (E2) levels. After follicular growth stimulation by human menopausal gonadotropins (hMG), E2 level was significantly lower in B group (1,799 +/- 1,101, 2,440 +/- 1,298, 2,137 +/- 1,044 pg/mL for B, T, and L groups, respectively; P less than 0.01), as well as the E2 level per hMG ampule (67 +/- 51, 97 +/- 61, 82 +/- 49 for B, T, and L groups respectively; P less than 0.01). The pregnancy per stimulated cycle rate was not significantly different among the groups. CONCLUSIONS: These results suggest that LH-RH-a could act not only on the pituitary but also on the ovaries. Moreover, these data suggest that buserelin acetate could be preferentially used for high responders and triptorelin for poor responders.

[Complications of hysterectomies]. / Complications des hystérectomies.

The authors review results concerning 1,127 hysterectomies performed in the Department of Obstetrics and Gynecology of the La Grave Hospital (Toulouse, France). They compare those of abdominal hysterectomy and those of vaginal hysterectomy (359). With regard to vaginal procedures, they draw a distinction between simple hysterectomies and prolapse repairs. The results of this series are comparable with those in the literature: similar overall morbidity after vaginal (41 per cent) and abdominal (33 per cent) hysterectomy. This morbidity was lower in cases of simple vaginal hysterectomy (26 per cent). The majority of complications were infectious or febrile: 29 per cent of abdominal hysterectomies and 30 per cent of vaginal hysterectomies, including 16.4 per cent of simple vaginal hysterectomies. The authors compared abdominal hysterectomies and simple vaginal hysterectomies. The latter have many advantages: rarer mortality, overall morbidity and thrombo-embolic complications, shorter hospital stay, more comfortable and less costly postoperative course. Thus when the choice is available, gynecologists should opt for vaginal hysterectomy.