Female troubles: an analysis of menstrual cycle research in the NINR portfolio as a model for science development in women's health.

The National Institute for Nursing Research (NINR) has been active in developing a research portfolio of investigator-initiated studies in addressing the cause and consequences of menstrual cycle and menopause-related health problems. This chapter provides an overview of the nature and level of research activity funded by NINR since its inception in 1986, major findings generated by the most successful award recipients, the impact on the broader field of women's reproductive health and directions for future research. Presented here is an analysis of research designs and methodologies framed within the context of 4 stages of scientific development in the field: exploratory, descriptive studies in well women; illness as a biobehavioral phenomenon; knowledge generation in understudied populations; and the development and testing of clinical therapeutics for symptom management and health promotion strategies. Nursing science contributions to the NINR portfolio of women's health research has been focused primarily on the definition and management of the symptoms of premenstrual syndrome and menopause. The increasing numbers of intervention studies suggests a coming-of-age in nursing science with respect to the development of evidence-based outcome data for the management of menstrual cycle and menopause-related symptoms. Clearly, the range and diversity of NINR grant-funded activity suggest that menstrual cycle research is a strong area of interest in nursing science.

Concentrations of follicle-stimulating hormone correlate with alkaline phosphatase and a marker for vitamin K status in the perimenopause.

Serum alkaline phosphatase (ALP), a gross marker of bone turnover, has been reported to be elevated after menopause, a period characterized by hallmark increases in follicle-stimulating hormone (FSH). Whether the ALP rise coincides with the perimenopausal transition when changes in FSH, estrogen levels, and menstrual cycles are first apparent is not known. The purpose of this cross-sectional study was twofold: (1) to characterize the influence of the perimenopausal transition on ALP activity and (2) to correlate ALP activity with more precise markers for bone, osteocalcin (OC), and vitamin K status assessed with undercarboxylated osteocalcin (ucOC). Thirty-eight studies of hourly FSH were conducted on cycle day 6 of the follicular phase in perimenopausal women volunteers, aged 40-54 years (mean body mass index [BMI] = 24.2 +/- 0.5). Mean FSH was used to define the perimenopausal stage (early perimenopausal, mean FSH 15 IU/L, n = 11). As expected, late perimenopausal women had irregular and longer menstrual cycles, lower estradiol (E(2)) and estrone (E(1)) levels, and a lower frequency of ovulations vs. the early group. ALP was higher (76.5 +/- 8.3 vs. 58.3 +/- 2.7 IU/L, p = 0.045) compared with the early perimenopausal group. In a subsample (n = 10), OC was associated with ALP (r = 0.69, p < 0.03), FSH was positively related to ucOC concentrations (r = 0.7, p < 0.03), and women with E(1) concentrations <40 pg/ml had double the percentage of ucOC compared with those where E(1) was >40 pg/ml (46.3% +/- 6.6% vs. 22.0% +/- 3. 1%, p < 0.006). Clinical markers of the perimenopause are associated with a nonspecific but inexpensive marker of enhanced bone turnover (i.e., higher ALP) and correlate well with more precise markers of bone activity. These findings suggest that health-promotion strategies for preserving bone should be instituted well before the last menstrual period.

Relation of demographic and lifestyle factors to symptoms in a multi-racial/ethnic population of women 40-55 years of age.

A community-based survey was conducted during 1995-1997 of factors related to menopausal and other symptoms in a multi-racial/ethnic sample of 16,065 women aged 40-55 years. Each of seven sites comprising the Study of Women's Health across the Nation (SWAN) surveyed one of four minority populations and a Caucasian population. The largest adjusted prevalence odds ratios for all symptoms, particularly hot flashes or night sweats (odds ratios = 2.06-4.32), were for women who were peri- or postmenopausal. Most symptoms were reported least frequently by Japanese and Chinese (odds ratios = 0.47-0.67 compared with Caucasian) women. African-American women reported vasomotor symptoms and vaginal dryness more (odds ratios = 1.17-1.63) but urine leakage and difficulty sleeping less (odds ratios = 0.64-0.72) than Caucasians. Hispanic women reported urine leakage, vaginal dryness, heart pounding, and forgetfulness more (odds ratios = 1.22-1.85). Hot flashes or night sweats, urine leakage, and stiffness or soreness were associated with a high body mass index (odds ratios = 1.15-2.18 for women with a body mass index > or =27 vs. 19-26.9 kg/m2). Most symptoms were reported most frequently among women who had difficulty paying for basics (odds ratios = 1.15-2.05), who smoked (odds ratios = 1.21-1.78), and who rated themselves less physically active than other women their age (odds ratios = 1.24-2.33). These results suggest that lifestyle, menstrual status, race/ethnicity, and socioeconomic status affect symptoms in this age group.

Making babies in the 21st century: new strategies, old dilemmas.

Self-regulation of assisted reproduction by the medical community is not working. The continuing ban on in vitro fertilization (IVF) embryo research will only further erode the opportunity to develop comprehensive policies to protect the growing numbers of infertile couples, former cancer patients, gamete donors and their offspring produced through assisted reproduction. The President's National Bioethics Advisory Commission (NBAC) with the help of the Institute of Medicine can serve as an effective policy-building body because of its expertise, public forum, and national authority. National guidelines have been developed for gene therapy and xenotransplantation which could serve as models for dealing with the thorny bioethical dilemmas of assisted reproduction. In the interim, research on the social and ethical aspects of assisted reproduction should be a high priority for the NIH.

Informed consent issues in assisted reproduction.

Given the enormous ethicolegal controversies surrounding the use of assisted reproductive technologies (ART) in the United States, the most important role for nurses may be helping couples and third party participants obtain fully informed consent. The high compensation fees for egg donors may place them at special risk of exploitation. New government and professional guidelines, broader representation on ethics committees, and expanded counseling about risks and benefits can help reduce the potential for litigation and enhance patient autonomy.

Net increase in stimulatory input resulting from a decrease in inhibin B and an increase in activin A may contribute in part to the rise in follicular phase follicle-stimulating hormone of aging cycling women.

Recent studies suggest that an age-related decline in ovarian inhibin B may play a role in the increase in follicular phase FSH in menstrual cycles of older women. Considering that the peripheral feedback regulation of FSH is dictated by the overall tone of inhibins, activins, and follistatins as well as estradiol, it is essential to determine the relative inputs of all of these regulators in assessing whether the collective peripheral input to FSH is one of inhibition or stimulation. To test the hypothesis that changes in the overall tone of peripheral feedback may contribute to this hallmark sign of aging, we compared the concentrations of dimeric inhibin A, inhibin B, activin A, and total and free follistatin in 7 young (mean age, 27.9 +/- 2.6 yr) and 10 older (mean age, 43.6 +/- 0.9 yr) cycling women during the follicular (FOLL; cycle day 6) and midluteal (ML; 7 days post-LH surge) phases of the menstrual cycle. Subjects were preselected on the basis of FOLL phase FSH levels (older, > or = 8.0 mIU/mL; younger, < 8 mIU/mL). Circulating FSH regulatory peptide concentrations were determined from samples pooled from blood drawn every 10 min for 8 daytime h using specific 2-site assays. In the older group, cycle length was shorter (29.1 +/- 0.5 vs. 26.1 +/- 0.5, young vs. older; P < 0.001), mean LH levels during the follicular phase were higher (LH, 5.6 +/- 0.8 vs. 8.8 +/- 1.1 mIU/mL, young vs. older; P < 0.001). Mean FSH levels for the older and younger groups averaged 10.8 +/- 0.8 and 6.2 +/- 0.3 mIU/mL, respectively. Estradiol levels were higher, but not statistically different, than those in the younger group (99 +/- 13 vs. 169 +/- 25 pmol/L, young vs. older; P = 0.06). In both age groups, inhibin B levels were higher in the FOLL vs. ML phase, inhibin A levels were higher in the ML vs. FOLL phase, but total activin A and total and free follistatin did not differ across cycle days. FOLL phase inhibin A levels were higher in the older group (16.3 +/- 2.4 vs. 26.4 +/- 3.4 pg/mL, young vs. older; P = 0.024), but levels of inhibin B were lower (323 +/- 80 vs. 163 +/- 24 pg/mL, young vs. older; P = 0.03). Overall, the estimated total inhibin activity (inhibin A plus inhibin B) was lower in older cycling than in younger women (339 +/- 82 and 189 +/- 24 pg/mL, young vs. older). Total and free follistatin levels were not different among the 2 groups of women. In contrast, total activin A levels were higher in the older cycling group (0.51 +/- 0.05 and 0.68 +/- 0.05 ng/mL, young vs. older; P = 0.02). No differences in age groups were observed during the ML phase for any of the variables measured. These data suggest that a net increase in stimulatory input resulting from a decrease in inhibin B and an increase in activin A may contribute in part to the monotropic FSH increase in aging women.

A two-site chemiluminescent assay for activin-free follistatin reveals that most follistatin circulating in men and normal cycling women is in an activin-bound state.

Follistatin (FS) is a monomeric protein that binds and regulates the bioavailability of activin. Previously, we found circulating levels of total FS to be similar in men and cycling women. Because relative amounts of activin-bound and free FS are important considerations in determining activin bioavailability, we asked here whether the relative proportions of these two changed during different physiologic states. For this, we developed a two-site, solid-phase, immunochemiluminescent assay for free FS. The assay recognizes the 288 or 315 amino acid variants of human FS and has a detectable limit of 1 ng/mL. Inhibin, transforming growth factor-beta, or alpha-2-macroglobulin do not cross-react or interfere in this assay. Preincubation of FS with activin results in dose-dependent loss of immunoreactivity, confirming specificity of the assay for free FS. Human follicular fluid, pituitary extract, and serum with added FS dilute parallel with the recombinant human FS-288 standard. Recovery of recombinant human FS-288 from serum is quantitative. Using this assay, we found circulating concentrations of free FS to be at or below the detection limit of the assay throughout the menstrual cycle. Comparison of circulating total and free FS levels in postmenopausal or cycling women and normal men suggested that at least 90% is activin-bound. In contrast, measurable quantities of free FS were found in follicular fluid and pituitary extracts. The results of this study, showing that most circulating FS is normally activin-bound, argue against an endocrine role for FS and suggest that a major role of circulating FS is to bind and neutralize the bioactivity of circulating activin. The roles of FS as a local autocrine or paracrine regulator of activin in target tissues, where FS exists in free form, or as an endocrine regulator in human pathophysiology, warrants further investigation.

Intensive hormone monitoring in women with unexplained infertility: evidence for subtle abnormalities suggestive of diminished ovarian reserve.

OBJECTIVE: To determine hormone levels across the menstrual cycle in women with rigorously defined unexplained infertility. DESIGN: Prospective study. SETTING: National Center for Infertility Research at Michigan. PATIENT(S): Evaluation of 1,885 women with infertility identified 12 women who met the following rigorously defined criteria for unexplained infertility: [1] infertility of > or = 24 months' duration, with no male factor, anatomic or functional disorders of the reproductive tract, or immunologic infertility; [2] normal body mass index (BMI); (3) ovulatory cycles ranging from 26 to 32 days; [4] normal luteal phase determined by endometrial biopsy; and [5] normal baseline hormonal profile. Controls (n = 12) were healthy, parous women with normal ovulatory cycles and normal hormonal screens, and were matched for age and BMI with patients. MAIN OUTCOME MEASURE(S): Daily gonadotropin and steroid hormone levels across the menstrual cycle. RESULT(S): Basal FSH and LH levels in the early, middle and late follicular phases were increased significantly in the group with unexplained fertility compared with the normal controls. The mean (+/-SD) early follicular FSH levels were 7.0 +/- 0.57 mIU/mL in the unexplained-infertility group and 4.7 +/- 0.37 mIU/mL (conversion factor to SI units, 1.00) in the normal controls, respectively. There was no difference between groups over the periovulatory or luteal phase. Midluteal mean (+/-SD) P levels were lower in the unexplained-infertility group than in the normal controls (13.7 +/- 1.6 versus 24.0 +/- 3.2 ng/mL [conversion factor to SI units, 3.180]). Mean E2 concentrations were elevated in the group with unexplained infertility versus normal controls in the early through the late follicular phase but reached significance only in the midfollicular phase. Mean prolactin levels were elevated consistently across the menstrual cycle in the unexplained-infertility group compared with those in normal controls but reached significance only in the early and late follicular and midluteal phases of the cycle. Cortisol concentrations were similar between the two groups. CONCLUSION(S): These data indicate that there are subtle alterations in various hormones measured across the menstrual cycle in women with unexplained infertility compared with those in normal controls, suggesting a diminished ovarian reserve.

Age effects of follicle-stimulating hormone and pulsatile luteinizing hormone secretion across the menstrual cycle of premenopausal women.

To characterize the differential aging response in gonadotropin secretion that occurs before menopause, we assessed pulsatile LH and serial FSH, estradiol (E2), and progesterone (P) concentrations in aging women across the menstrual cycle. We conducted 96 daytime studies during the follicular, midluteal, and late luteal phases of the same menstrual cycle in 32 volunteers, aged 40-50 yr (n = 16) and 19-39 yr (n = 16). Mean cycle length was shorter in the older women (26 +/- 0.4 vs. 27.6 +/- 0.6 days; P = 0.02), but mean plasma E2 and P values were similar in the two age groups. Mean plasma FSH was higher in the older group on all 3 study days. For LH, an age difference was observed during the late luteal phase, when mean plasma LH and pulse amplitude were higher in women over 40 yr of age (mean LH, 6.4 +/- 0.7 vs. 3.0 +/- 0.5 IU/L (P = 0.002); mean amplitude, 4.0 +/- 0.5 vs. 2.8 +/- 0.2 IU/L (P = 0.03)]. Pulse frequency was higher in the older group, but not different from that in younger women on all study days. When the subjects aged 35-39 yr were analyzed as a third age group (n = 8), age effects for mean LH persisted, and pulse frequency was higher in the group over 40 yr of age vs. women under age 35 yr (n = 8) in both the follicular phase (7.1 +/- 0.4 us. 5.6 +/- 0.8; P = 0.03) and late luteal phase (5.8 +/- 0.7 vs. 4.4 +/- 0.3; P = 0.03). Although highly variable, individual patterns of gonadotropin secretion in the women over age 40 yr included a sustained elevation in the FSH/LH ratio as well as a failure to demonstrate slow frequency, high amplitude LH pulses in the midluteal phase. In conclusion, 1) the age-related increase in FSH concentrations in ovulatory women, although more pronounced, is associated with phase-dependent enhancement of pulsatile LH secretion; 2) the higher LH concentrations are brought about by changes in both pulse frequency and amplitude; and 3) these age effects preempt overt reductions in cyclic E2 or P concentrations.

Perimenstrual symptoms among Chinese women in an urban area of China.

We explored perimenstrual symptoms among 16 Chinese women in an urban area of southeastern China using a retrospective questionnaire, the Menstrual Distress Questionnaire (MDQ), and a prospective daily symptom diary, the Daily Health Diary (DHD), modified for cultural relevance. Mean scores on the DHD were significantly (p < .03) higher during the perimenstrual phase for the symptoms fatigue, increased sensitivity to cold, increased sleeping, abdominal pain/discomfort, painful or tender breasts, and decreased sexual desire. The women who reported higher DHD physical symptom scores prospectively were more likely to recall more severe physical symptoms retrospectively on the MDQ. However, there were remarkable discrepancies between the DHD and MDQ regarding psychoemotional symptoms. By retrospective MDQ, the percentages of women who experienced severe mood swings and irritability ranged from 13% to 25% during the premenstrual and menstrual phases; on the DHDs, however, these emotional symptoms were not statistically associated with the menstrual cycle. The failure of prospective charting to confirm the retrospective reports of cyclic psychoemotional symptoms agrees with findings of studies of U.S. samples. We conclude that perimenstrual distress in Chinese women may be affected by the data collection methods.

Pulsatile LH secretion in women with premenstrual syndrome (PMS): evidence for normal neuroregulation of the menstrual cycle.

The premenstrual syndrome (PMS) has been proposed to result from excessive exposure to and/or withdrawal of brain opioid activity during the luteal phase. Because hypothalamic opioids are believed to modulate GnRH secretion, in part under the influence of ovarian steroids, we performed longitudinal studies of gonadotropin and ovarian steroid secretion across ovulatory, symptomatic cycles of 17 PMS patients and 8 normal volunteers. Pulsatile LH secretion was measured every 10 min for 8 hr at times when central opioid activity was expected to be low (early follicular phase), high (mid-luteal phase; ML), and declining (late luteal phase). In both subject groups, a cycle-phase effect was observed for LH pulse frequency (p = < 0.001) and amplitude (p = 0.002), and for the transverse mean concentrations of LH (p = 0.05), FSH (p < = 0.001), estradiol (E2) (p = < 0.001) and progesterone (P) (p = < 0.001). ML P secretion in PMS patients was pulsatile, and mean concentrations (over 30-60 min) were similar to those of normal controls. The changes in pulsatile LH secretion across the cycle were not different in the PMS patients compared to the normal women, though mean FSH in the ML phase was higher in the PMS group (p = < 0.05). The similar changes in luteal LH pulse frequency fail to provide evidence that GnRH secretion is impaired, thus challenging the view that the neuroregulation of the menstrual cycle in women with PMS is markedly altered.

A prospective study of the menstrual cycle and spinal cord injury.

Sixty seven menstrual cycles were studied prospectively in a nonclinical sample of 20 women who had suffered a traumatic spinal cord injury (quadriplegia n = 13; paraplegia n = 7) at least 1 yr before assessment. Level of injury did not influence cycle length (mean +/- SE = 28.7 +/- 3 days), duration of menses (4.6 +/- 1 days) or serum concentrations of gonadotropins and ovarian hormones. Midluteal phase serum progesterone values were consistent with ovulation (progesterone = greater than 5 ng/ml) in 93% of the cycles in which endocrine measures were obtained; but the ability of basal body temperature pattern to predict serum progesterone was low (43%). Cyclic dysmenorrhea was reported by 13 women with injuries ranging from C5 to T12. These findings suggest that ovulatory menstrual cycles are common in women after traumatic spinal cord injury and support the need for contraception by those wishing to avoid pregnancy. Basal body temperature charts revealed potential problems in applying the symptothermal method of natural family planning to a population of women at risk for oral contraceptives.

Symptom patterns in women with premenstrual syndrome complaints: a prospective assessment using a marker for ovulation and screening criteria for adequate ovarian function.

This study examined the symtom patterns of women seeking help for Premenstrual Syndrome (PMS) complaints. Seven women who were less than 35 yrs, within 10% of ideal body weight and who had experienced a full-term pregnancy, completed a daily health diary during an ovulatory menstrual cycle. In the luteal phase, symptom summary scores of the PMS group increased (P less than 0.05) and were markedly higher (P less than 0.5) from baseline acyclic scores of four ovulatory women who denied menstrual-related distress. To examine severity changes in individual symptoms, a total of 399 cases representing 57 symptoms from the seven 45-day diaries were evaluated for menstrual cycle entrainment. Of the 246 symptoms that met the criteria for a cycle phase change (62%), the classic PMS pattern of low/high severity was the most common (40%). Seven different subtypes of the PMS pattern were identified; four of these subtypes demonstrated a severity score elevation at ovulation as well as during the premenstruum. For individual women, the majority of symptoms (65%) displayed only two pattern types, suggesting a common rhythmic entrainment of symptom intensity.

Surrogate pregnancy: clinical features of forty-four cases.

This record analysis describes the obstetric outcomes of a series of 44 pregnancies occurring in 41 women who underwent donor insemination as participants in a private surrogate parenting program between 1981 and 1985. The typical surrogate mother was 25 years old with a high school education and married with one child 2 years old. Twenty-nine percent of the sample reported no source of income other than welfare. Two thirds of the histories included at least one of the following perinatal risk factors: smoking (n = 19), low annual income (n = 15), unmarried status (n = 12), or parity of 0 or greater than 4 (n = 5). Six losses occurred in the first or second trimester. Thirty-nine viable infants were born to 37 women and include one set of fraternal twins. Three of the singleton newborns weighed less than 2500 gm; newborn morbidity after preterm delivery occurred in one case. Women with complications (n = 14) were similar in maternal age, education, parity, annual income, marital status, and smoking history to women without complications (n = 24). A role for psychosocial stress and financial motivation in the etiology of these outcomes is explored.

The roles of estradiol and progesterone in decreasing luteinizing hormone pulse frequency in the luteal phase of the menstrual cycle.

During the luteal phase of the menstrual cycle, plasma progesterone (P) and estradiol (E2) concentrations are elevated, and LH (and by inference GnRH) pulse frequency is slow. In contrast, LH pulse frequency increases during the early follicular phase when plasma E2 and P are lower. To examine the mechanism(s) responsible for the slower GnRH pulse frequency in the luteal phase, we maintained plasma P, E2, or both at midluteal concentrations from the midluteal phase to the time of the next early follicular phase and measured the effects on LH secretion. Thirteen normal women with regular menstrual cycles were studied during two or three cycles. Blood was obtained every 10 min during 10-h studies. Control cycle luteal and early follicular studies were followed by a second control study in the luteal phase of the treatment cycle. P (six women), E2 (seven women), or both (five women) then were given twice daily by im injection for 6-12 days until the day corresponding to the early follicular study of the control cycle (EF + P, EF + E2, or EF + E2 + P). A final study was performed 1 week after the injections were discontinued (F). LH pulse frequency was low in the midluteal phase [3.2 +/- 0.2 (+/- SE) pulses/10 h] and increased by the early follicular phase (8.0 +/- 0.8 pulses/10 h) in the control cycles. The increase in LH pulse frequency was not significantly inhibited by administration of P (6.7 +/- 0.7 pulses/10 h; EF + P). However, during both E2 alone and E2 + P, LH pulse frequency remained low (EF + E2, 3.6 +/- 0.8; EF + E2 + P, 2.0 +/- 0.7 pulses/10 h). The mean plasma FSH concentrations paralleled changes in LH pulse frequency, increasing from the luteal to the early follicular phase in the control cycles and during P injections and remaining low during E2 and E2 + P injections. We conclude that continued exposure to P alone does not maintain GnRH pulse frequency at midluteal phase values and that any effect of P requires the presence of E2. As E2 alone maintained lower LH pulse frequency, E2 may act directly to decrease the pulsatile GnRH secretion or it may potentiate the effects of low (less than 3.2 nmol/L) P concentrations.