Uterine histopathologic changes after Cu-Fix intrauterine device insertion.

A study of uterine histopathologic changes after the insertion of the Cu-Fix intrauterine device (IUD) was carried out at the Obstetrics and Gynecology Department, Faculty of Medicine, Chulalongkorn University. Ten patients, who had cold conization for a suspicious Papanicolaou smear, were fitted with the Cu-Fix IUD. All patients were diagnosed as having carcinoma-in-situ of the cervix and were scheduled for hysterectomy at 6 weeks postconization. Preoperative ultrasonography showed the IUD anchoring at the uterine fundus, which corresponded with posthysterectomized findings. At the anchoring site of the nylon knot, which serves as a small retention body in the fundus, slight mononuclear cells infiltration in the myometrium was found in only one patient. However, in the endometrium, there was infiltration of mononuclear cells as well as a few plasma cells during the proliferative phase of the cycle. Evidence of local foreign body reaction was found in all patients. No patient had symptoms or signs of pelvic infection.

PIP: A study conducted at Chulalongkorn University in Bangkok, Thailand, investigated uterine histopathologic changes in 10 women fitted with the Copper (CU)-Fix IUD after cold conization for a suspicious Papanicolaou smear. All 10 women were diagnosed with carcinoma-in-situ of the cervix and underwent hysterectomy 6 weeks after IUD insertion. The findings of preoperative ultrasonography for localization of the IUD were compared with hysterectomized specimens, with emphasis on the anchoring site of the device's nylon knot. Slight mononuclear cell infiltration in the myometrium was observed in only 1 woman; normal findings were seen in the remaining patients. Histopathologic analysis revealed diffuse mononuclear cells as well as plasma cell infiltration during the proliferative phase of the menstrual cycle in all 10 women. This finding showed evidence of foreign body reactions similar to those described after insertion of other types of IUDs. No patient had signs or symptoms of pelvic infection. Overall, these results confirm there is no increased risk of uterine infection when the IUD is fixed in the muscle of the fundus.

Antiphospholipid antibodies inhibit prostaglandin release by decidual cells of early pregnancy: possible involvement of extracellular secretory phospholipase A2.

OBJECTIVE: To investigate the effect of antiphospholipid antibodies on eicosanoid production by human decidual cells and the in vitro interaction between antiphospholipid antibodies and secretory phospholipase A2. DESIGN: Cultures of human decidual cells from early pregnancy. SETTING: All decidual specimens were obtained from the Obstetrics and Gynecology Department of the Catholic University, Rome, Italy. PATIENT(S): Patients were undergoing operative laparoscopy for extrauterine pregnancy, with a period of amenorrhea ranging from 6 to 9 weeks. INTERVENTION(S): Decidual samples were collected at laparoscopy by routine uterine curettage. MAIN OUTCOME MEASURE(S): Decidual cells were incubated with antiphospholipid antibodies, and eicosanoids (prostaglandin [PG] E2, PGF2alpha, and thromboxane B2) were assayed by RIA after 24 hours of culture. In vitro interactions between antiphospholipid antibodies and secretory phospholipase A2 were investigated with use of a modified ELISA for phospholipase A2. RESULT(S): Antiphospholipid antibodies reduced eicosanoid release from decidual cells in a dose-dependent fashion. In vitro assays showed that antiphospholipid antibodies bound secretory phospholipase A2 and that a competition occurred between antiphospholipid antibodies and secretory phospholipase A2 for the common substrate cardiolipin. CONCLUSION(S): In light of the critical role played by eicosanoids in decidual function, we suggest that an interaction between antiphospholipid antibodies and secretory phospholipase A2 occurring in vivo might impair important cellular communications at the decidual level in the antiphospholipid antibody syndrome.

PIP: The presence of antiphospholipid antibodies is often associated with poor obstetric histories, including recurrent abortion, intrauterine growth retardation, and preeclampsia. While it has been suggested that these antibodies can affect the function of vascular endothelial cells at the decidual and placental levels, their cellular target and mode of action remain to be determined. Findings are presented from a study to investigate the effect of antiphospholipid antibodies upon eicosanoid production by human decidual cells and the in vitro interaction between antiphospholipid antibodies and secretory phospholipase A2. Specimens of decidualized endometrium were obtained by routine curettage from patients undergoing operative laparoscopy for extrauterine pregnancy in the Obstetrics and Gynecology Department of the Catholic University in Rome, Italy. Analysis determined that antiphospholipid antibodies reduce eicosanoid release from decidual cells in a dose-dependent manner, while in vitro assays showed that antiphospholipid antibodies bound secretory phospholipase A2 and that competition occurred between antiphospholipid antibodies and secretory phospholipase A2 for the common substrate cardiolipin. An interaction between antiphospholipid antibodies and secretory phospholipase A2 occurring in vivo may impair important cellular communications at the decidual level in the antiphospholipid antibody syndrome.

The expression of integrin Beta 3 and intercellular adhesion molecule (ICAM-1) in decidua and chorionic villi during mifepristone induced abortion.

PIP: The effects of mifepristone with misoprostol on the expression of integrin beta3 and intercellular adhesion molecule-1 (ICAM-1) in decidua and chorionic villi tissues in early pregnancy in 10 cases were investigated by immuno-flow cytometry (experimental group). At the same time, 10 other cases induced by mechanical vacuum aspiration were studied as controls. The results showed that the positive rates of integrin beta3 and ICAM-1 in the decidua of the experimental group were 19.1% +or- 5.01% and 20.61% +or- 6.51%; while those in the chorionic villi were 21.32% +or- 4.38% and 20.29% +or- 6.49%, which was significantly lower than those in the control group. These results suggest that integrin beta3 and ICAM-1 may take part in the maintenance of early pregnancy. The mechanism of mifepristone-induced abortion may be mediated by the down-regulation of integrin beta3 and ICAM-1 expression in the decidua and chorionic villi.^ieng

A 2-year comparative study of endometrial histology and cervical cytology of contraceptive implant users in Birmingham, UK.

The objectives of this study were to evaluate the endometrial histology and cervical cytology of users of two contraceptive implants releasing etonogestrel/3-keto-desogestrel (Implanon) and levonorgestrel (Norplant) in West Midlands (UK) users. A 2-year prospective randomized design was used to study 60 implant users. Endometrial histology and cervical cytology were compared before insertion and after 12 and 24 months. At the end of 12 months, the majority of samples were inactive/weakly proliferative in both groups. At the end of 24 months, this remained unchanged in the Implanon group whereas the pattern was more diverse in the Norplant group. Endometrial thickness was significantly reduced in both groups during treatment. Cervical cytology remained unchanged. It is concluded that, after 2 years, there was no evidence of an increasing risk of endometrial hyperplasia, endometrial carcinoma, cervical intra-epithelial neoplasia or cervical carcinoma in either of the two groups of implant users.

PIP: Changes in endometrial histology and cervical cytology related to use of two contraceptive implants were investigated in a 2-year prospective study conducted at Birmingham (UK) Women's Hospital. 60 women with regular menstrual cycles were randomly assigned to receive either Implanon (etonogestrel/3-keto-desogestrel) or Norplant (levonorgestrel). After 12 months of implant use, most endometrial samples in both groups were inactive or only weakly proliferative. After 24 months, this pattern remained unchanged in the Implanon group. It was more diverse, however, in the Norplant group, where there was evidence of proliferative-phase endometrium. Endometrial thickness, assessed quarterly by transvaginal ultrasound scans, was significantly reduced in users of both implants. Cervical cytology remained unchanged from baseline to 24 months. These findings suggest that users of both implant systems are not at increased risk of endometrial hyperplasia, endometrial carcinoma, cervical intra-epithelial neoplasia, or cervical carcinoma.

Clinical and in situ cellular responses to Haemophilus ducreyi in the presence or absence of HIV infection.

We aimed to determine if the clinical and histological features of chancroid are altered by HIV infection. Male patients presenting to the Nairobi special treatment clinic with a clinical diagnosis of chancroid were eligible for the study. A detailed history, physical examination, swabs for Haemophilus ducreyi culture and blood for HIV serology, syphilis serology and CD4 counts were obtained from all patients. Punch biopsies from an ulcer were obtained from 10 patients and either fixed in 10% formalin or snap frozen in Optimum Cutting Temperature (OCT) medium compound at -70 degrees C. Patients were treated with erythromycin and followed for 3 weeks. Chi-square and Student's t-test were used to determine if the clinical and laboratory features of chancroid differed between HIV-seropositive and seronegative individuals. Cox regression survival analysis was used to determine if HIV infection altered cure rates of chancroid at 21 days. Immunohistochemical staining was performed using lymphocytic and macrophage markers and tissue sections were analysed by 2 pathologists in a blinded manner. Between February and November 1994, 109 HIV-seropositive and 211 HIV-seronegative individuals were enrolled in the study. HIV patients had ulcers of longer duration than HIV-seronegative patients (P=0.03). Although cure rates were similar at 3 weeks, HIV patients had lower cure rates at 1 week (23% v 54%, P=0.002). A dense interstitial and perivascular inflammatory infiltrate extending from the reticular to deep dermis was present in all biopsies. This consisted of equal amounts of CD4 and CD8 T-lymphocytes as well as macrophages. The histological and immunohistochemical picture was identical for HIV-positive and negative patients. HIV infection slows the healing rates of chancroid ulcers despite appropriate antibiotic therapy. This clinical difference cannot be attributed to an altered histopathological response to HIV infection. Additional studies are needed to elucidate the mechanisms responsible for this finding.

PIP: Chancroid is caused by infection with Hemophilus ducreyi, and is associated with an increased risk for the sexual transmission of HIV-1. The authors assessed whether the clinical and histological features of chancroid are changed by HIV infection, using 320 male patients who presented during February-November 1994 to the City of Nairobi Special Treatment Clinic with a clinical diagnosis of chancroid. 109 subjects were HIV seropositive and 211 were HIV seronegative. A detailed history, physical examination, swabs for Hemophilus ducreyi culture and blood for HIV serology, syphilis serology, and CD4 counts were obtained from all patients. Punch biopsies from an ulcer were obtained from 10 patients and either fixed in 10% formalin or snap frozen in Optimum Cutting Temperature (OCT) medium compound at -70 degrees Celsius. Patients were treated with erythromycin and followed for 3 weeks. HIV patients had ulcers of longer duration than did HIV-seronegative patients. Although cure rates were similar at 3 weeks, HIV patients had lower cure rates at 1 week (23% vs. 54%). A dense interstitial and perivascular inflammatory infiltrate extending from the reticular to deep dermis was present in all biopsies. The infiltrate consisted of equal amounts of CD4 and CD8 T-lymphocytes as well as macrophages. The histological and immunohistochemical picture was identical for HIV-positive and HIV-negative patients. Study findings therefore indicate that HIV infection slows the healing rates of chancroid ulcers despite appropriate antibiotic therapy. The clinical difference cannot be attributed to an altered histopathological response to HIV infection.

Morphological and functional features of endometrial decidualization following long-term intrauterine levonorgestrel delivery.

Irregular bleeding remains a common reason for the discontinuation of progestin-only contraception. The levonorgestrel releasing intrauterine system (LNG-IUS) has profound morphological effects upon the endometrium. Specific features are gland atrophy and extensive decidual transformation of the stroma. Morphological changes in the endometrium may be associated with perturbation of mechanisms regulating normal endometrial function. This study describes endometrial stromal and glandular features prior to and up to 12 months following insertion of the LNG-IUS. Comparison is made with first trimester decidua. In order to elucidate further mechanisms governing endometrial function with local intrauterine delivery of LNG, we here report histological features consistent with decidualization; a significant increase in granulocyte-macrophage colony stimulating factor (GM-CSF) immunoreactivity in decidualized stromal cells; glandular and stromal prolactin receptor expression and an infiltrate of CD56 + large granular lymphocytes and CD68 + macrophages. We are unaware of previous reports which have documented longitudinally both morphological and functional observations in endometrium exposed to local intrauterine levonorgestrel delivery. These studies demonstrate that long-term administration of intrauterine levonorgestrel results in features of altered morphology and function. No correlation was apparent between the end points in the study and the bleeding patterns described by the subjects. Further evaluation of these features in the context of menstrual bleeding experience may contribute to a better understanding of this troublesome side-effect which often leads to dissatisfaction and discontinuation of the intrauterine system.

PIP: The levonorgestrel-releasing intrauterine system (LNG-IUS) has profound morphologic effects on the endometrium, including gland atrophy and extensive decidual transformation of the stroma. The present study investigated these morphologic changes in tissue samples collected from 14 UK women up to 12 months after insertion of the LNG-IUS. Observed histologic features consistent with decidualization included a significant increase in granulocyte-macrophage colony stimulating factor immunoreactivity in decidualized stromal cells, glandular and stromal prolactin receptor expression, and an infiltrate of CD56+ large granular lymphocytes and CD68+ macrophages. The features of pseudo-decidualization closely resembled the morphology of early pregnancy decidua. These findings confirm that the stromal compartment of the endometrium undergoes changes consistent with decidualization for at least up to 12 months after insertion of an LNG-IUS. There was no correlation between the study endpoints and the menstrual patterns reported by study subjects. Further study of the decidualized nature of the stromal cells in the LNG-exposed endometrium should enhance understanding of the mechanisms responsible for breakthrough bleeding in users of progestogen-only contraceptives.

Genetic damage in exfoliated cells of the uterine cervix. Association and interaction between cigarette smoking and progression to malignant transformation?

OBJECTIVE: To determine, through the micronucleus (MN) test, the cytogenetic effects of cigarette smoking on exfoliated cells from the uterine cervix in women with normal smears and women with inflammatory atypia, squamous intraepithelial lesion (SIL) (cervical intraepithelial neoplasia [CIN] 1-3) and cervical cancer. STUDY DESIGN: The study group consisted of 200 women divided into three subgroups: group 1 (n = 116), women periodically undergoing cervical cytology and residents of Salvador-Bahia; group II (n = 57), women residing in São Paulo and previously selected because of a possible cytopathologic test positive for such conditions as human papillomavirus infections or malignant or premalignant cervical lesions (CIN 1-3); group III (n = 27), inmates of the Tatuapé Penal Institution, São Paulo. All the women underwent cytologic and colposcopic examination, and biopsies were performed on 68 of them. RESULTS: Considering the samples as a whole and using the chi(2) test for rare events, the number of MNs in smokers was significantly greater than in nonsmokers. It was also greater in women with larger exposure to smoking. The occurrence of MN was significantly lower in women with normal smears (smokers and nonsmokers) than in those showing any kind of pathologic alteration. In nonsmokers the occurrence of MN was similar between those with inflammatory atypia (IA) or low grade (L) SIL (CIN 1) and significantly higher in women with more severe lesions or high grade (H) SIL (CIN 2 and 3). Smokers with LSIL (CIN 1) showed a higher number of MNs than nonsmokers with a comparable diagnosis and smokers with IA. No differences were observed when compared with smokers with HSIL (CIN 2 and 3). MN occurrence was not associated with other risk factors for SIL or cancer development, such as age at first coitus, number of sexual partners, multiparity and use of hormonal contraceptives. CONCLUSION: These results suggest that the mutagenic effect of cigarette smoking occurs in cervical cells and that the progression of SIL is associated with increased frequency of chromosomal damage. Moreover, the data suggest that cigarette smoking introduces an additional risk to the progression of low grade LSIL (CIN 1). MN testing would be helpful in monitoring smokers with this kind of lesion.

PIP: Previous studies have shown that cigarette smoking increases the risk of developing squamous intraepithelial lesion (SIL) and cervical cancer. The present study used the micronucleus test to assess the cytogenic effects of smoking on exfoliated cells from 3 subgroups of Brazilian women: group 1 (n = 116), women periodically undergoing cervical cytology; group 2 (n = 57), women with a possibly positive cytologic test for human papillomavirus or malignant or premalignant cervical intraepithelial neoplasia (CIN 1-3); and group 3 (n = 27), inmates of the Tatuape Penal Institute. Overall, micronucleus frequency was significantly greater in smokers than in nonsmokers. The occurrence of micronuclei was significantly lower in women with normal smears (regardless of smoking status) than in women with any evidence of pathologic alterations. In nonsmokers, micronucleus frequency was similar in women with inflammatory atypia or low-grade CIN and significantly higher in women with more severe lesions and CIN 2-3. Smokers with CIN 1 had more micronuclei than nonsmokers with a comparable diagnosis and smokers with inflammatory atypia. No differences were observed in comparisons with smokers with CIN 2-3. Micronucleus occurrence was not associated with age at first coitus, number of sexual partners, multiparity, or use of hormonal contraception. These findings suggest that the mutagenic effect of smoking occurs in cervical cells and that SIL progression is associated with an increased frequency of chromosomal damage. The data further suggest that smoking adds to the risk of progression of low-grade SIL (CIN 1). Micronucleus testing, along with the cervical cytologic smear, is recommended to monitor smokers with this type of lesion.

Immunohistochemical investigations of genital ulcers caused by Haemophilus ducreyi.

To gain information on the specific composition of the inflammatory infiltrate of genital ulcers caused by Haemophilus ducreyi, biopsies of 6 genital ulcers which were diagnosed as chancroid on clinical and microbiological grounds were subjected to immunohistochemical investigations after conventional haematoxylineosin staining. A variety of antibodies reactive against B- and T-cells, plasma cells and granulocytes were used with each tissue sections. The lymphocytic infiltrate of chancroid ulcers consisted of both B- and T-lymphocytes and showed a cluster-like formation. B-lymphocytes were preferentially localized perivascularly in the middle layer, T-lymphocytes mainly in the deep layer of the inflamed oedematous tissue. Results stress the importance of both B- and T-cell mediated immune responses in Haemophilus ducreyi infection.

PIP: Chancroid, the most prevalent form of genital ulcer disease in developing countries, increases the risk of HIV transmission. Use of monoclonal antibodies against leukocyte differentiation antigens enabled analysis of the composition of the inflammatory infiltrate of genital ulcers. In this study, biopsies of six genital ulcers caused by Haemophilus ducreyi were examined immunohistochemically. In each case, staining revealed a superficial necrotic layer of polymorphonuclear leukocytes with fibrin and erythrocytes at the base of the ulcer, a middle layer of the edematous inflammatory dermis with prominent blood vessels and vascular thrombi, and a deep layer of an inflammatory infiltrate of plasma cells and lymphocytes. The lymphocytic infiltrate of chancroid ulcers consisted of both B- and T-lymphocytes and showed a cluster-like formation. B-lymphocytes were preferentially localized perivascularly in the middle layer, while T-lymphocytes tended to be located in the deep layer of the inflamed edematous tissue. These findings provide further evidence of the importance of the involvement of T-cells in the local immune clearance of H. ducreyi. Future studies should investigate lymphocyte secretions detected in genital ulcers caused by H. ducreyi to gain more information on the role of the cellular immune mechanisms in the disease.

Levonorgestrel-releasing intrauterine device-wearing women express contraceptive glycodelin A in endometrium during midcycle: another contraceptive mechanism?

Intrauterine devices (IUDs) exert contraceptive action by interfering with sperm transport, ovum development, fertilization and implantation. Glycodelin A (GdA) is a uterine glycoprotein that has local contraceptive activity by inhibiting sperm-egg binding. GdA is normally absent from endometrium during the fertile midcycle and it is not expressed until the fifth postovulatory day. The phase of menstrual cycle addressed in this study covers the phase when conception is most likely to follow an unprotected intercourse and when GdA is normally absent. We present here evidence that levonorgestrel-releasing IUD (LNg-IUD) is accompanied by 'inappropriate' expression of GdA in endometrium between days 7 and 16 of the menstrual cycle (six out of six cases). The same was also found in copper-releasing IUD (Cu-IUD)-wearing women, but less frequently (four out of 11 cases, P < 0.0345, Fisher's exact test). In-situ hybridization localized GdA mRNA into endometrial glands in the midcycle endometrium, confirming the cellular site of synthesis. Based on the potent inhibitory activity of GdA on sperm-egg binding, the presence of GdA in uterine glands of IUD wearers may lead to prior exposure of sperm to contraceptive GdA, thus contributing to the contraceptive activity of the IUD.

PIP: Glycodelin A (GdA), a uterine glycoprotein that exerts local contraceptive activity by inhibiting sperm-egg binding, is generally absent from the endometrium during the fertile midcycle and is not expressed until postovulatory day 5. In this study of endometrial specimens collected from 6 Finnish users of the levonorgestrel-releasing IUD, "inappropriate" expression of GdA between days 7 and 16 of the cycle was observed in every case. Endometrium samples showed epithelial atrophy and stromal decidualization regardless of the duration of IUD use. GdA was localized to endometrial glands, with only sporadic faint patches in the stroma. Unexpected expression of GdA was also detected in 4 of 11 endometria from women with copper-releasing IUDs. Based on the potent inhibitory activity of GdA on sperm-egg binding, the presence of GdA in the uterine glands of hormone-releasing IUD users may lead to prior exposure of sperm to contraceptive GdA, thus contributing to the fertility control activity of the device.

Distribution of mast cells in the axillary lymph nodes of breast cancer patients.

Fifty mastectomy specimens of carcinoma breast were studied for pattern of mast cell distribution in their axillary lymph nodes. When all axillary nodes were free of tumour, the mean mast cell count was 35.75/sq mm. In the metastatic node the mast cell count was inversely proportional to the amount of metastatic tumour. The mast cell number decreased (25.64/sq mm) as the metastasis developed in any of the enlarged axillary nodes. Their count diminished further (23.55/sq mm) as the amount of metastatic tumour increased in individual nodes and when tumour involved all enlarged nodes. Mean mast cell count was lowest (10.50/sq mm) in metaplastic carcinoma. The mast cells in metastatic nodes were found mainly at the edges of tumour deposits.

PIP: The mast cell profile in the axillary lymph nodes of 50 consecutive women with breast cancer treated by modified radical mastectomy was investigated in a study conducted at Kasturba Medical College (Mangalore, India) in 1992-94. 33 of these women showed axillary lymph node metastasis while the remaining 17 exhibited nodes with reactive changes. 20 women (60.61%) with metastasis had fewer than five enlarged nodes. Metastasis was detected in all enlarged axillary nodes. In the women with reactive changes, 12 (70.59%) had fewer than five enlarged nodes. Mast cell counts were higher in women with sinus histiocytosis and reactive hyperplasia of the nodes than in women with metastasis. The mean mast cell count was 28.97/sq. mm in nodes with metastasis. In the presence of metastasis to any of the lymph nodes or in all enlarged lymph nodes, the mean mast cell count decreased to 25.64/sq. mm and 23.55/sq. mm, respectively. Mean mast cell count was lowest (10.50/sq. mm) in metaplastic carcinoma. Most mast cells were distributed around the tumor deposits. The role of mast cells in lymph node reactions in breast cancer patients merits further study.

The cervico-vaginal epithelium during 20 cycles' use of a combined contraceptive vaginal ring.

The aim of the study was to evaluate the influence of a combined contraceptive vaginal ring (CCVR) made of Silastic on the cervico-vaginal epithelium during 20 cycles of use. A total of 76 volunteers used the CCVR releasing 0.120 mg etonogestrel and 0.015 mg ethinyloestradiol daily. Cytological samples were taken of the vaginal epithelium, the ectocervix and the endocervix before the start, at 4 and 12 months, and at the end of the study. Cytology, hormonal profiles, human papilloma virus (HPV) status, DNA-flow cytometry, bacterial flora, and morphometry was performed on these samples. Colposcopy and histopathology of biopsy specimens were performed at the end. No cytological changes of the squamous epithelium or the columnar epithelium were found. HPV was detected in three samples of three different women. At least two of them reverted to HPV negative during the rest of the study period. Aneuploidy was diagnosed in 11 women before the study. Seven of them changed to diploid during the study. No changes from diploid to aneuploid were seen. Aneuploidy was not seen in any of the HPV positive samples. Although bacterial flora showed considerable variation during the study, no significant influence of the CCVR could be established. Morphometrical analysis showed an increasing nucleus:cytoplasm ratio of the squamous cells during the study. Mild dysplasia was detected in one woman at the end of the study. It was concluded that no unfavourable cytological or bacteriological changes of the cervico-vaginal epithelium were demonstrated during 20 cycles of CCVR use. The vaginal epithelium became more progestogenic during the study.

PIP: A study of a combined contraceptive vaginal ring showed no unfavorable cytologic or bacteriologic changes of the cervico-vaginal epithelium during 20 cycles of use. A Silastic ring releasing 0.120 mg of etonogestrel and 0.015 mg of ethinyl estradiol daily was inserted in 76 healthy volunteers 18-35 years of age. Participants used the vaginal ring for 21-day periods interrupted by 7-day ring-free intervals. Squamous cells were detectable in 94 (98%) vaginal smears, 95 (99%) ectocervical smears, and 17 (18%) endocervical smears. No cytologic changes of the squamous or the columnar epithelium were noted, and atypical metaplastic cells were not diagnosed. The percentage of smears with a mixed estrogen-progestogenic pattern decreased from 83% at baseline to 63% during cycle 4; 50% of smears showed a progestogenic pattern by the end of the study (cycle 20). Half the women demonstrated aneuploidy at baseline, but two-thirds of these women reverted to diploid status during ring use; no changes from diploid to aneuploid were seen. The ring had no significant influence on the bacterial flora of the vagina or on human papillomavirus status. Further investigations involving larger sample sizes are urged to confirm that the combined contraceptive vaginal ring does not lead to cervical dysplasia or other lesions of the cervico-vaginal epithelium.

Progesterone receptors: expression and regulation in the mammalian ovary.

The authors have briefly discussed the molecular structure, regulation, and function of progesterone receptors in the mammalian ovary. Particularly important is the contrast in the regulatory mechanisms of PR induction in the ovary (gonadotropins/membrane receptor mediated) and other well-known progesterone target tissues, such as the uterus and mammary gland (estrogen/nuclear receptor mediated). Future research will focus on how the PR gene responds to these hormonal regulatory signals in this cell-specific manner. Equally important in this discussion has been the mounting evidence indicating that PRs are an essential component of the ovulatory process. The observation that PR-/- knockout mice are incapable of undergoing ovulation, even in response to gonadotropin challenge, further supports the previous physiological evidence indicating that PRs in preovulatory follicles are induced before, and are necessary for, ovulation. Further studies are required to determine the identity of PR-regulated target genes during the periovulatory period. Although our knowledge of PR structure, regulation, and function has increased dramatically during the past decade, many exciting questions remain related to the regulation and function(s) of PRs in the ovary and other tissues.

PIP: Research into the structure, function, expression, and regulation of progesterone receptors (PRs) in the mammalian ovary has the potential to refine understanding of ovulatory processes. A consistent finding of animal studies is the periovulatory expression of the PR gene in the granulosa cells of preovulatory follicles. The presence of PRs in these follicles in the transition from the preovulatory to periovulatory periods may be crucial to successful ovulation given the finding that the blockage of progesterone action at the level of the ovary substantially decreases ovulation rates in hamsters and rats. Estrogen is the primary regulator of PR gene expression in uterine epithelial cells, but not in the ovary. On the other hand, estrogen action is important for preparing granulosa cells for gonadotropin induction of PR gene expression. This cell-specific pattern of gonadotropins/membrane receptor-mediated PR induction in the ovary and estrogen/nuclear receptor mediation in the uterus and mammary gland requires further study. Also needed are studies to determine the identity of PR-regulated target genes during the periovulatory period. The overall thrust of the existing literature, however, indicates that PRs are an essential component of the ovulatory process.

Detection of southern African human immunodeficiency virus type 1 subtypes by polymerase chain reaction: evaluation of different primer pairs and conditions.

The purpose of the study was to develop a specific and sensitive PCR protocol using env, gag and LTR primer pairs to detect HIV-1 subtypes present in the Western Cape, South Africa. Twenty-two virus strains, belonging to HIV-1 subtypes B, C and D, were randomly selected for PCR evaluation. Cell lysates prepared from these virus-infected cultured cells were tested using 5 different primer pairs: gag SK38/SK39; gag 22/SK39; gag a/b, gag c/d (nested); env SK68/SK69 and LTR SK29/SK30. Eight different PCR profiles were evaluated: one profile each for the 3 gag primer pairs, 3 profiles for the env and 2 profiles for the LTR primer pairs. The number of PCR cycles, time per cycle and/or annealing temperature were changed in each profile. The optimum PCR profile for a specific primer pair was defined as that which detected one copy of proviral plasmid DNA after dot-blot hybridisation. Gag primer pairs detected HIV-1 DNA in all 22 samples. With the env primer pair, suboptimal conditions failed to detect most of the HIV-1 subtype C samples. By increasing the number of cycles and time per cycle, a 100% sensitivity was achieved. With the LTR primer pair all samples were detected by decreasing the annealing temperature and increasing the individual cycle times. This confirms that once PCR conditions are optimised, all HIV-1 subtypes in our study could be detected using different PCR primer pairs.

PIP: During 1984-92, in South Africa, virologists isolated HIV-1 from HIV/AIDS patients at hospitals in the Western Cape. Two virologists from the University of Stellenbosch Hospital in Tygerberg selected 22 virus strains, belonging to HIV-1 subtypes B, C, and D, to study in order to develop a specific and sensitive polymerase chain reaction (PCR) protocol using env, gag, and LTR primers. They used five different primer pairs to prepare cell lysates from the HIV-infected cultured cells: gag SK38/SK39, gag 22/SK39, gag a/b, gag c/d (nested), env SK68/SK69, and LTR SK29/SK30. The virologists evaluated eight different PCR profiles: one profile each for the three gag primer pairs, three profiles for the env, and two profiles for the LTR primer pairs. They changed the number of PCR cycles, time per cycle, and/or annealing temperature in each profile. The PCR profile for a specific primer pair that detected one copy of proviral plasmid DNA after dot-blot hybridization was considered the optimum PCR profile. Gag primer pairs detected HIV-1 DNA in all 22 samples. The env primer pair did not detect most HIV-1 subtype C samples. When the researchers increased the number of cycles and time per cycle, the env primer pair achieved 100% sensitivity. When they decreased the annealing temperature and increased the individual cycle times, the LTR primer pairs detected all samples. These findings support that optimization of a PCR assay is necessary to achieve high assay sensitivity, specificity, and reproducibility and that PCR sensitivity should be considered seriously when interpreting PCR results for HIV diagnosis.

Reduced endothelial cell migratory signal production by endometrial explants from women using Norplant contraception.

Bleeding problems can be one of the major reasons for women to discontinue the use of hormonal contraceptives. Causes of endometrial bleeding can include disturbances in endometrial regeneration and angiogenesis. Endothelial cells migrate and proliferate rapidly as part of the angiogenic process under the influence of appropriate stimuli. The aim of this study is to investigate the production of endothelial cell migratory signals by endometrial explants from women receiving Norplant and to compare it to that of those with a normal menstrual cycle. The subjects were selected from Norplant users with an exposure of 3-9 months. The endothelial cell migratory signal production was assayed using the Folkman method (1989), modified by Rogers (1992). Blood serum concentrations of oestradiol, progesterone and sex hormone binding globulin were monitored for 2 weeks prior to endometrial biopsy. Endothelial cell migration toward endometrial explants of 30 women as control and 46 Norplant acceptors was assayed. The results showed that endothelial cell migratory activity toward endometrial explants from the control group was significantly higher than toward those from Norplant acceptors (z = 3.89, P < 0.001). There were no differences between endometrial endothelial cell migratory activities in Norplant acceptors with bleeding or without bleeding problems.

PIP: Researchers examined the production of endothelial cell migratory signals by endometrial explants from 46 Norplant acceptors aged 18-40 and compared it with endothelial cell migratory signals produced by endometrial explants from women using no hormonal contraception or an IUD and having a normal menstrual cycle. The results will provide insight into the role of endothelial cell migration in endometrial bleeding among Norplant acceptors. Both cases and controls attended the Raden Saleh Clinic in Jakarta, Indonesia. Health providers took peripheral blood samples 6 times at 2-3 day intervals before the endometrial biopsy to monitor serum levels of estradiol, progesterone, and sex hormone-binding globulin (SHBG). Laboratory researchers used a three-dimensional collagen matrix culture medium containing dispersed human umbilical vein endothelial cells as modified by Rogers (1992) to conduct the endothelial cell migration assay. Endothelial cell migration toward endometrial explants of the control group was much higher than toward those of the Norplant group (p 0.001). For example, 30 of 46 of the Norplant endometrial explants had a median endothelial cell migratory score of zero compared to 8 of the 30 control biopsies. In fact, only 1 of the control biopsies of the individual 500-cubic-micrometer explants did not respond, while 19 of the like Norplant explants did. In controls, endothelial cell migration was greater in the proliferative phase than in the secretory phases. Endothelial cell migration toward endometrial biopsies of Norplant acceptors with bleeding problems was the same as that toward Norplant acceptors with no bleeding problems. Serum levels of estradiol, progesterone, and SHBG were not associated with endothelial cell migration. These findings do not support the belief that increased angiogenesis in the endometrium of Norplant acceptors is responsible for endometrial bleeding.

HIV-1 and immunological changes during pregnancy: a comparison between HIV-1-seropositive and HIV-1-seronegative women in Nairobi, Kenya.

OBJECTIVE: To assess changes in the proportion of CD4 and CD8 T-lymphocyte profiles during pregnancy, at delivery and postpartum, and to determine whether HIV-1 infection affects the normal profile. DESIGN AND METHODS: A total of 416 pregnant HIV-1-infected women and an age and parity-matched HIV-seronegative group of 407 pregnant women were enrolled into a prospective study on the impact of HIV-1 infection on pregnancy. Maternal blood was obtained for lymphocyte subset determination at enrollment, delivery and 6 weeks postpartum. Whole blood sample drawn in EDTA-containing tubes were used to determine T-helper/inducer (CD4) and T-suppressor/cytotoxic (CD8) cells by direct immunofluorescence using monoclonal antibodies. RESULTS: No relationship was found between gestational age and any immunological variable. The CD4 percentage was lower postpartum than antenatally, in both HIV-1-seropositive and seronegative women, but this was not true for absolute CD4 counts. CD8 absolute counts and percentages were significantly higher postpartum than antenatally. The differences between HIV-1-seropositive and seronegative women in changes over pregnancy in CD4 and CD8 cells and their ratio, were not statistically significant. CONCLUSION: Our findings do not support a short-term synergistic effect of HIV-1 and pregnancy on the immune function as determined by T-lymphocyte subsets.

PIP: The impact of HIV-1 on pregnancy was investigated in a prospective case-control study of 416 pregnant HIV-infected women and 407 age- and parity-matched pregnant HIV-seronegative women from Nairobi, Kenya. No relationship existed between gestational age (14-30 weeks) and any hematologic or immunologic variable studied. In both cases and controls, the CD4 percentage (but not absolute count) was lower postpartum than during pregnancy, while CD8 absolute counts and percentages were significantly higher in the postpartum period. The differences between HIV-positive and HIV-negative women in changes during pregnancy in CD4 and CD8 cells and their ratio were not statistically significant. These findings fail to provide support for a synergistic effect of HIV-1 and pregnancy on immune function. Further studies are needed, however, to assess the long-term effects of pregnancy in HIV-infected women, to determine the impact of pregnancy at different stages of HIV disease, and to establish normal and HIV-1-related T-lymphocyte subset profiles during the entire course of pregnancy in African women.

Natural killer cell activity is reduced in association with oral contraceptive use.

Oral contraceptive (OC) use has been associated with increased incidence of a number of infections, but the mechanisms behind these changes is unclear. The present study compared OC users and nonusers in natural killer (NK) cell activity, NK phenotype, and illness frequency. Subjects were 55 female medical students (19 OC users, 36 nonusers). Three blood samples were obtained, 1 mo apart. Natural cytotoxicity was tested with a 51Cr assay. Self reports of illness symptoms during the previous week were collected at each blood sampling. NK phenotype number was assessed by flow cytometry. Oral contraceptive users had lower natural cytotoxicity and increased frequency of sneezing, gastrointestinal distress, runny nose, sore throat, coughing, and total illness symptoms, relative to nonusers. No differences were found between OC users and nonusers in NK phenotype number. These findings support the hypothesis that differences between users and nonusers in infection rates might be due to alterations in NK activity.

PIP: Oral contraceptive (OC) use has been associated with increased incidence of a number of infections, but the mechanisms behind such changes are unclear. Comparison of lymphocyte phenotypes between contraceptive users and nonusers found no difference in either the percentage or absolute numbers of any cell types. Other data, however, suggest differences in natural cytotoxic activity in contraceptive users. Natural cytotoxic activity in normal women has been found to vary with menstrual phase and estradiol levels, being lowest mid-cycle, shortly following peak estradiol levels. OC users, however, demonstrate no variation in either natural killer (NK) cell activity or estradiol levels over their cycles. The authors report their findings from a study comparing 19 OC users and 36 nonusers in NK cell activity, NK phenotype, and illness frequency. Three blood samples were obtained one month apart from each of the female medical student participants. Natural cytotoxicity was tested with a Cr assay, while NK phenotype number was assessed by flow cytometry. Relative to nonusers, OC users had lower natural cytotoxicity and increased frequency of sneezing, gastrointestinal distress, runny nose, sore throat, coughing, and total illness symptoms. No differences were found between OC users and nonusers in NK phenotype number. These findings support the hypothesis that differences between users and nonusers in infection rates may be due to alterations in NK activity.

Endometrial endothelial cell proliferation in long-term users of subdermal levonorgestrel.

The aim of the present study was to quantify endothelial cell proliferation (a component of angiogenesis) using immunohistochemistry, in the endometrium of users of subdermal levonorgestrel (Norplant). It was postulated that the increased endometrial microvascular density seen in Norplant users, compared to normally cycling women, was associated with an increased rate of endothelial cell proliferation. The results, however, showed that the endometrial endothelial cell proliferative index of Norplant users (0.39 +/- 0.16%; mean +/- SEM) was significantly reduced compared to that seen in normally cycling women (8.99 +/- 1.64). At the same time, total numbers of endometrial endothelial cells per mm2 in Norplant users (317.40 +/- 13.88) were significantly higher than in normally cycling women (223.35 +/- 10.31). It is possible that in the endometrium with levonorgestrel use, there is either a reduced rate of regression of the blood vessels relative to the rest of the tissue, or there is a reduced rate of endothelial cell death or turnover. Peripheral oestrogen and progesterone concentrations, bleeding pattern over the previous 90 days, and the histological appearance of the endometrium did not appear to be associated with the endothelial cell proliferative index. The results suggest that subdermal levonorgestrel use affects the mechanisms that dictate the normal relationship between endometrial blood vessel growth and regression, and the surrounding non-vascular tissue.

PIP: Quantification of endothelial cell proliferation by use of immunohistochemical staining of routinely processed endometrium revealed minimal angiogenesis in Norplant implant acceptors. It was hypothesized that the increased microvascular density of the endometrium of Norplant users and their bleeding problems reflect a levonorgestrel-induced increase in endothelial cell proliferation. 34 endometrial biopsies from 32 women attending the Raden Saleh Clinic in Jakarta, Indonesia, were collected 3-12 months after Norplant insertion. The mean endothelial cell proliferation index for the 32 Norplant users was 0.39 +or- 0.16%; 24 of the 34 biopsies showed no evidence of cell proliferation. There was no significant variation in this index based on the histologic appearance of the biopsy, bleeding pattern, or peripheral blood estrogen and progesterone concentrations. This index is significantly lower than that recorded in another study (8.99 +or- 1.64) during a normal menstrual cycle. Also observed was a significantly increased number of endothelial cells per sq. mm in Norplant users (317.40 +or- 13.88) compared to normally cycling women (223.25 +or- 10.31). Although the study hypothesis was rejected, the factors behind the increased density of blood vessels and endothelial cells in the endometrium of Norplant users remain unclear. It is possible that levonorgestrel induces a reduced rate of regression of the blood vessels compared to the rest of the tissue, or that there is a reduced rate of endothelial cell death or turnover.

The detection of adducts in human cervix tissue DNA using 32P-postlabelling: a study of the relationship with smoking history and oral contraceptive use.

32P-Postlabelling was used to measure DNA adducts in the human cervix. Adduct levels were compared with patient smoking histories and contraceptive use. DNA adducts were found in 43 out of 58 samples. The number of adducts ranged from 0.2 to 59.5 adducts/10(8) nucleotides, though no significant difference was found to exist between the number of DNA adducts detected and the smoking history of each patient. In contrast, a significant difference at the 1% probability level was found between the adduct levels obtained from the cervical DNA of smokers who had used oral contraceptives and smokers who did not. Autoradiograms revealed a variety of adduct patterns. Some were found to have a diagonal zone of radioactivity which migrated from the origin of the TLC plate. Other autoradiograms revealed the presence of additional adduct spots located in the upper regions of the TLC plate, whereas others revealed the presence of these adduct spots alone. The origin of the adduct spots located in the upper regions of the TLC plate is unknown.

Does abortion increase the risk of breast cancer?

According to this hypothesis, an early FFTP [first full-term pregnancy] would provide the greatest protection against breast cancer by drastically reducing, early on, the presence of undifferentiated and hence vulnerable breast cells, thereby decreasing the risk of subsequent transformation ... Other types of pregnancies, however, might increase the risk of breast cancer. If a woman's first pregnancy resulted in a first trimester abortion, the dramatic rise in undifferentiated cells that takes place during the first trimester would not be followed by the marked differentiation occurring during the second and third trimesters. The consequent sharp increase in the number of vulnerable cells would thus elevate breast cancer risk.

PIP: A theory may explain why breast cancer rates have been increasing over several decades: abortion before the first live birth stops the processes transforming the breast during the first pregnancy, which increases the risk of breast cancer. Progestogens stimulate considerable growth of undifferentiated cells in the breast during the first pregnancy, which, if pregnancy continues, results in the budding and branching of the network of milk ducts. This period of rapid growth during the first trimester is when these breast cells are most vulnerable to carcinogens. Interruption of pregnancy during this period prevents these breast cells from becoming differentiated during the second and third trimesters. No less than 26 published studies indicate that abortions prior to the first live birth raises the risk of breast cancer (1.9-3.9 higher risk). Abortions after a first full-term pregnancy have little effect, since the number of undifferentiated cells is considerably smaller due to the earlier pronounced breast development during each full-term pregnancy. Accurate epidemiologic research is not easy because of confounding factors (e.g., oral contraceptive use) and political pressures. Worldwide, one finds high breast cancer rates correlated with high induced abortion rates. In the past, rich women, who tended to have more access to abortion, had 2 times higher breast cancer rates than poor women, but breast cancer rates have increased 53% among poor women while they fell 1% among rich women with the advent of public funding of abortions. Women of religions that strongly object to abortion have lower breast cancer rates than those whose religion allows abortion. Older black women are at a lower risk of breast cancer than older white women, but younger black women are a significantly higher risk than their white peers.

Synthesis of 11-substituted androstenediones and testosterones as human decidual cell growth inhibitors.

11 alpha-Hydroxytestosterone (1a), 11 beta-hydroxytestosterone (1b), 11 alpha-methoxytestosterone (1c), 11 beta-methoxytestosterone (1d), 11-ketotestosterone (1e), and delta 9(11)-testosterone (1f) were synthesized from hydrocortisone (4b) or 11-epi-hydrocortisone (4a). The six target compounds, together with 11 alpha-methoxyandrostenedione (2c), 11 beta-methoxyandrostenedione, (2d) and their lead compound, testosterone (1), were found to effectively inhibit the growth and differentiation of human decidual cells in culture. There is no observable binding of these compounds to estrogen receptor of rabbit uterus. The introduction of a polar group (e.g., hydroxyl and carbonyl) to C-11 of androstenes decreases both the relative binding affinities to progesterone receptor and the inhibitory effects on human decidual cell growth, while the methylation of 11-hydroxyl group minimizes these effects. The similar effects of a polar group at C-11 of testosterone (1) on the inhibitory effects on human decidual cell growth and the relative binding affinities to progesterone receptor of rabbit uterus may suggest that one of the mechanisms of human decidual cell growth inhibition by these compounds is the anti-progestational activity of these androgens.