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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.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.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%.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.

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.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.

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.

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.

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.

Objective To determine the relative influences of induction of withdrawal bleeding, 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 Hopital 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 E 2 and P induced more marked secretory changes and more frequent withdrawal bleeding than the lower doses. There was no evidence of endometrial hyperplasia after 5years of E 2 /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.

Our objective was to characterize the endometria of women of various ages placed on similar estrogen/progesterone replacement regimens prior to attempted donor embryo transfer using histologic, ultrasonographic, and steroid receptor markers in order to determine if advancing age has a detrimental effect on uterine responsiveness to pharmacologic sex steroid replacement therapy.This was a prospective open clinical trial. Functionally agonadal women aged 25 to 60 years receiving hormone replacement therapy underwent transvaginal ultrasound examination of the uterus followed by a timed endometrial biopsy on artificial cycle day 21. Endometrial histology and estrogen and progesterone receptors were analyzed from biopsy material. Subjects were assigned to three groups according to age: Group I, aged 25 to 39 years (n = 48); Group II, aged 40 to 49 years (n = 61); and Group III, aged 50 to 60 years (n = 13). Endometrial preparation was accomplished in all patients using the same sequential regimen consisting of oral micronized estradiol and intramuscular progesterone.Similar histologic, ultrasonographic, and steroid receptor characteristics were noted in all groups of patients regardless of age. A normal appearing midluteal secretory endometrium was demonstrated histologically in 85% of biopsies. However, 15% of biopsies exhibited intraluminal papillary excrescences within the glands and/or increase in the normal gland-to-stroma ratio. Three patients, one from each group, did not initially respond to replacement therapy and required further treatment.Functionally agonadal women exhibit normal or near-normal endometrial responses to sex steroid replacement therapy designed to imitate the natural cycle through the sixth decade of life.

Sixty-three healthy post-menopausal women participated in the study aimed at determining the efficiency of percutaneous administration of estradiol (E2) giving physiological plasma levels of the estrogen to provide an efficient relief of climacteric and urogenital symptoms. Among these women, 31 had previous hysterectomy and were randomly allocated to one of the two estrogen replacement therapies while, similarly, the 32 women having an uterus were randomly divided between two groups who received in addition to estrogens, micronized oral progesterone. As estrogen, women received either E2 by percutaneous administration (Oestrogel) or oral conjugated estrogens (Premarin). With Oestrogel, serum E2 and estrone levels were within those seen during premenopause and showed a ratio close to 1.0. Climacteric symptoms were reduced or eliminated similarly in all groups. No changes was noticed on the concentration of serum angiotensinogen with Oestrogel therapy while a 2.5-fold increase was found in women receiving Premarin. As indicated by the 24-week endometrial biopsy, the progestational response induced by oral progesterone at the dose used was sufficient in twenty out of thirty-two women to cause endometrial atrophy, thus suggesting the need for higher amounts of micronized progesterone in a proportion of women. The present data also indicate that Oestrogel provides efficient relief of climacteric and urogenital symptoms without exerting any detectable effect on hepatic function while maintaining the ratio of serum E2/E1 at the physiological value of 1.0.

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 (E 2 ) 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 E 2 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 E 2 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. A combination of oral E 2 and intramuscular progesterone, given according to Regimen 3 design, reliably produces in-phase secretory endometrium morphologically indistinguishable from a natural spontaneous cycle.

A study was undertaken to determine whether solitary progesterone as says performed on serum samples obtained in the midluteal phase would provide the clinician with a convenient indicator that ovulation had occurred in that cycle. After a normal luteal-phase range was establish ed, single luteal-phase serum progesterone sampling was performed in 51 infertile women with regular menses and 35 oligomenorrheic women undergoing clomiphene citrate therapy. In the follicular phase of the cycle, progesterone levels were consistently less than 2 ng/ml. Between 11 and 4 days prior to the onset of menses in presumptively ovulatory cycles, serum progesterone levels were always 3 ng/ml or greater. Progesterone values in this range were always accompanied by a secretory endometrium and can be considered presumptive evidence of ovulation. This rapid, easily performed technique enables 1 technician to assay 30 or more samples for progesterone in a single working day and the results are available within 24 hours. This assay technique is easier to perform and more reproducible than a urinary pregnanediol assay, and it is expected that clinical laboratories will soon perform serum progesterone assays as a routine procedure.

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.

Since emetine hydrochloride is known to interfere with protein synthesis, it was decided to investigate the efficacy of this compound as a contraceptive agent when administered l'ocally as a component of a medicated intrauterine delivery system (MIDS). Six combinations of emetine dose level and device configuration were tested in the rabbit uterus. On the 10th day after mating the number of corpora lutea and implantation sites were recorded and statistically analyzed. Our results indicate that emetine hydrochloride does have a marked antiimplantation effect and this becomes increasingly pronounced with increases in dose level. It is of interest to note that the surface area of the device is of major importance in determining its overall effectiveness with length being the most critical component of this parameter. It was also found, that under our conditions, when emetine was present in the uterine lumen, it had no observable effect on implantation in the contra lateral horn.

Menstrual blood loss was quantitated in a group of rhesus monkeys before and after intrauterine insertions of silicone rubber devices alone, polyethylene devices alone, and polyethylene plus silicone rubber devices. Silicone rubber was used as the carrier of epsilon aminocaproic acid (EACA) in order to provide sustained drug release in utero . Silicone rubber devices without EACA were used as control devices. A beneficial effect of intrauterine medication with EACA on uterine hemorrhage was demonstrated in monkeys wearing intrauterine devices (IUDs). With the nonmedicated silicone rubber devices alone, MBL increased 96% over preinsertion values, whereas the EACA-releasing silicone rubber devices resulted in only a 33% increase, during the first menstrual period after insertion. Mean menstrual blood volume was increased 109% over preinsertion values (baseline) in animals wearing polyethylene IUDs alone and 132% over baseline in those wearing polyethylene plus control silicone rubber devices; whereas, average menstrual blood loss was increased only 44% in monkeys wearing polyethylene plus EACA silicone rubber devices. Neither a localized or disseminated intravascular coagulation resulting from intrauterine EACA medication was detectable by assay of circulating levels of fibrinogen, plasminogen, and fibrin-fibrinogen degradation products.

The effect of macrophages, endometrial and liver cells on the development of pre-implantation mouse embryos cultured from the two-cell stage to blastocysts was investigated and compared to the effect of polymorphonuclear leukocytes (PMNLs). Homogenized macrophages, endometrial as well as liver cells exhibited the same embryotoxic effect as PMNLs. Phagocytosis did not play a role in this in vitro system. The embryotoxic factor(s) is not species specific, is not limited to uterine cells, and is not affected by storage at -20 °C. The present experiment suggests that cellular products released from leukocytes, macrophages and endometrial cells are responsible for the antifertility effect of intrauterine contraceptive devices.

Freezing and storage of human male gametes is associated with a reduction in the overall semen quality and establishment of pregnancy. This study was done to evaluate the integrity of sperm head ultrastructure (SHU) with computerized and vapor freezing. Comparisons were made between the effect of cryopreservatives glycerol (G) and dimethylsulfoxide (DMSO) on SHU. Twelve ejaculates from five proven fertile donors were studied with the use of routine semen analysis, zona-free hamster ova, and SHU. Both cooling processes, regardless of the preservative used, significantly reduced sperm function and the number of SH with intact plasma membranes. The staged cooling technique was substantially superior to vapor freezing in all parameters analyzed (P less than 0.01). G was less detrimental to the postthaw SHU than 1 M DMSO. A significant positive correlation (r = 0.98; P less than 0.01) was noted between the total number of intact SH and motile sperm. Computerized freezing in a G-diluted semen rendered a sperm environment that allowed the highest number of forms with intact SH membranes and with the best chances to penetrate zona-free hamster ova.

The embryotoxic activity of polymorphonuclear leukocytes (PMNLs), macro-phages abd endometrial cells was studied in vivo. Rabbits were mated, both uterine horns were ligated at the cervical end, and different concentrations of intact or homogenized cells were injected in one horn while the other served as control. The fertility rate, size of implantations and number of cells in uterine flushings were assessed 10 days postcoitum. PMNLs, macrophages, and endometrial cells exhibited a potent antifertility effect, retarded post-implantation growth and attracted large numbers of white cells. A definite dose and effect relationship between the concentration of cells and the different parameters was demonstrated. Phagocytosis did not play a role in this system. The embryotoxic effect is not limited to uterine cells since it could also be demonstrated in liver, thyroid and red blood cells.

The dextran-coated charcoal receptor assay for demonstrating functional estrogen and progesterone receptors was used to evaluate the receptor content of gynecological tumors. An immunocytochemical method, the immunoperoxidase antiperoxidase method, that may detect estrogen receptors, was also employed on the same specimens utilizing sections from formalin-fixed paraffin embedded blocks. The results by the two methods were compared and were correlated with the state of differentiation of the tumors. According to the dextran-coated charcoal method, two cases of well differentiated endometrial adenocarcinoma were strongly positive for both estradiol and progesterone receptors, and three moderately differentiated cases contained lesser amounts of both types of receptors. Six cases of undifferentiated adenocarcinoma ranged from no detectable receptors to very high values, while of five cases of squamous cell carcinoma of the cervix, only two were positive for estradiol receptors by the dextran-coated charcoal method. Staining of tissue sections from these same cases using the immunoperoxidase method, demonstrated a positive correlation to the dextran-coated charcoal assay for estrogen receptors. The Dextran-coated charcoal method is presently being used clinically as a screening measure for statistical probability of a patient's response to hormone therapy. The degree of positive correlation shown here suggests that use of the immunoperoxidase method may have further potential for diagnostic and clinical use, and merits further investigation.

Uterine bleeding in 8 rhesus monkeys was compared in response to plain vs. a specially fitted copper-wrapped IUD. All animals had utero-cutaneous surgical fistulas for accurate IUD insertion and removal. Daily observations for uterine bleeding between menstruations and quantitation of menstrual blood loss (MBL) were made. Following control periods of observation, each monkey was inserted with either a plain or a copper-wrapped IUD and then studied for 4 consecutive menstrual periods. Each IUD was especially fashioned to an estimate of individual uterine cavity size. Some were wrapped with pure copper wire of 30 sp mm surface area. In some animals the devices were later removed from the uterus, the copper wire taken off, and the plain polyethylene oval-Ts reinserted. In some animals originally wearing plain polyethylene devices, the IUDs were removed, wrapped with copper wire, and reinserted into the same monkeys. During the observed 4 consecutive preinsertion periods, MBL averaged 1.54 ml and was the same in the 4 cycles in which a plain polyethylene oval-T device was in place. No intermenstrual bleeding was observed, except slight spotting for the first 1 or 2 days. During the 4 cycles, with the copper-wound device present, mean MBL was 1.28 ml. Having individually fitted each uterine cavity with a best-fitting IUD was considered important. The addition of copper had not increased the bleeding. In humans, especially fitted contraceptive devices may minimize complications of bleeding and pain as compared with standard designs. Bleeding and pain have been the most frequent complications leading to removal of IUDs.

Endometrial blood vessels from hysterectomized uteri of women using intrauterine contraceptive devices (IUDs) were, examined in the electron microscope to search for the location and cause of IUD-associated uterine hemorrhage. The findings revealed vascular gaps in a small percentage of superficial vessels and these gaps were formed from degenerated endothelial cells. Mechanical surface erosion of the endometrium was judged not to be the mechanism of bleeding because the surface epithelium usually was found to be intact by gross and microscopic examination in spite of variable degrees of surface degeneration and denudation. Tentatively, biochemical induction of vascular permeability also did not seem likely. An explanation for IUD-induced uterine bleeding based upon pressure generated between the IUD and the contracting uterus is proposed. Observation of erythrocytes within vessel gaps supports the feasibility that these gaps provide a route for the escape of blood from endometrium exposed to IUDs.

The biological effects of the intrauterine foreign body (IUFB) have been studied in a variety of experimental animals as well as in humans. Significant tissue and biochemical changes resulting from the presence of the foreign body are localized primarily in the female reproductive tract although minor systemic effects have been described in a few species. Differences in the qualitative and quantitative reactions in the female genital tract are the result of the size, configuration and chemical composition of the IUFB, the animal species used experimentally, and the variations in the experimental design. A persistent observation noted in all species studied is the presence of inflammatory cells, principally polymorphonuclear leukocytes, in the endometrium and/or the uterine fluid. It is probable that the cells produced by the foreign body and the associated biochemical changes in the uterus are the underlying cause of the antifertility effect. This nonspecific foreign body reaction appears to be the unifying principle in the mechanism of IUFB action. Other biological changes as described in this paper are most likely secondary phenomena resulting from the foreign body reaction.

The responses of the vaginal and uterine mucosa to mestranol (MEE) were defined by establishing the karyopyknotic index (KI) and the degrees of endometrial proliferation in 6 menopausal women. Each woman received 3 dosages of MEE (5, 20, and 80 mcg. daily) during consecutive treatment courses lasting 14 days, with a 6 week rest period between courses. A change in the KI occurred between the 5 and 20 mcg. dosage with a rise from a mean of 6.6 to a mean of 42.2. The daily dosage of 80 mcg. caused a further slight rise of the KI, although the maximum proliferation of the vaginal mucosa was not achieved with a mean KI of only 5.38. The 5 mcg. MEE dosage did not induce endometrial proliferation; moderate proliferation occurred with the 20 mcg. dosage; late proliferation to mild hyperplasia was observed with the 80 mcg. dosage. More advanced degrees of proliferation did not occur with the dosages studied. Withdrawal bleeding occurred after the 80 mcg. dosage; only spotting occurred after 20 mcg., and occasional bleeding after the 5 mcg. dosage was caused by the biopsy. The prompt reaction of the KI to a specific dosage makes vaginal cytology suitable for detecting the “threshold” dosage for estrogens. Endometrial changes can be graded more precisely, thus enabling the establishment of a dose-related response.

The intrauterine device produces a foreign body reaction in an area crucial for the viability and metabolism of the unimplanted blastocyst and the ascending sperm. After intrauterine foreign body (IUFB) insertion, hysterectomy specimens from 167 patients and endometrial biopsies from 202 women were studied histologically. These tissue specimens were obtained at intervals ranging from a few hours until 5 years after IUFB insertion. Minor tissue damage of the endometrium which was usually limited to the superficial epithelium and stroma was noted in a minority of specimens. Neutrophils, mononuclear cells, and plasma cells were greatly increased in the endometrium during the first 6 months after insertion. Thereafter, mononuclear cells were moderately reduced in quantity, but tissue concentrations remained elevated throughout the course of study. Plasma cells were seen as a transient invader of endometrial tissue, disappearing in most patients 5 months after IUFB insertion. Intrauterine flushings contained increased numbers of inflammatory cells as well as a high content of protein. It is postulated that this sterile tissue reaction in the endometrial cavity is the main causative factor for the contraceptive effect of the IUFB in the human female. This study revealed no evidence of a carcinogenic effect on the endometrium in association with the IUFB.

A study was performed on a group of 100 postpartum women who received an injectable progestin, depo-medroxyprogesterone acetate (DMPA) for contraception. The patients received 150 mg. of DMPA in the immediate puerperium and at intervals of 3 months thereafter. Periodic study of the endometrial histology and vaginal cytology was performed in addition to recording alterations in the bleeding pattern and body weight. No pregnancies occurred, confirming the method's effectiveness. The rate of continued use was also good. There was no significant alteration in body weight. Although vaginal bleeding occurred irregularly and more frequently early in the study, its incidence progressively decreased so that the majority of patients were amenorrheic by the sixth month. The incidence of atrophic endometrium also steadily increased, demonstrating a good correlation with the bleeding pattern. The vaginal cytology consistently demonstrated a low estrogen effect, and there was a high percentage of intermediate cells at all times.

Bacteriologic and histologic studies of the endometrium were carried out to examine the association of pelvic inflammatory disease (PID) with the intrauterine device (IUD). In a major study of 22403 individual case records PID was present in 606 cases after insertion of an IUD about 16% of which were classified as severe. In the experiments Lippes loop D devices were inserted in 75 patients about to undergo vaginal hysterectomy. 49 of 61 specimens had positive cervical cultures but negative endometrial cultures. In 6 of 10 positive endometrial cultures the device had been in place for less than 48 hours; the same organism identified also being present in the endocervical mucus. It is concluded that: 1) all transcervical methods of obtaining endometrial tissue result in bacterial contamination of the endometrium and that the insertion of an intrauterine device may cause a clinically significant infection of the upper genital tract 2) in wom en wearing an IUD with a transcervical appendage acute upper genital tract infection is usually the result of an unrelated cause and 3) that an IUD should not be inserted if there is clinical evidence of infection in the upper genital tract. The histologic findings at various intervals following insertion are summarized.

The introduction of an intrauterine device through the endocervical canal produces a transient endometrial infection as the result of contamination with bacteria from the cervical mucus. These bacteria are nearly always of low virulence. The response of endometrial tissue to the bacteria and to the polyethylene device is similar to a foreign body reaction in other tissues of the body. In this study a correlation has been established between the length of time following the insertion of an IUD and the intensity and incidence of cell types (plasma cells, mononuclear cells, and neutrophils) found in the endometrium. During the first 6 days following IUD insertion, only neutrophils and mononuclear cells (lymphocytes and monocytes) were present in the endometrial stroma. The period of 7 through 49 days was characterized by the presence of neutrophils, plasma cells, and increasing numbers of mononuclear cells. Even though the bacteria are killed shortly after IUD insertion by the endometrial fluids and cells, the inflammatory cell infiltrates persist for many months in response to the IUD itself. The presence of plasma cells in the endometrium is not pathognomonic of an active bacterial infection, but more commonly represents the residual of a previous endometritis.

For 3 months mice (757) were fed diets containing uncured bacon, irradiated with 5.58 megarad of gamma rays, or uncured unirradiated bacon. There were no major differences between the control and experimental groups. No gross or histopathological lesions attributable to irradiation of the lipid were observed. The incidence of spontaneous cancers showed no significant differences among the diet groups and indicated that irradiation of the bacon did not produce carcinogens or growth-altering substances demonstrable under the conditions of the experiments. No significant differences between the degree of unsaturation and peroxide numbers of irradiated and unirradiated bacon lipid was found. Storage of the bacon lipid at room temperature for up to 2 months resulted in a higher peroxide number for the irradiated lipid. (H.H.D.)

A correlation was made between uterine cavitary proteolysis of fibrin and endometrial plasminogen activator level in individual rhesus monkeys between menses. A negative correlation was determined for these factors. Although such correlation does not prove a cause-and-effect relationship, it is consistent with the possibility that tissue release of activator can produce fibrinolysis in the intrauterine environment between menses. The possible relationship of proteolytic activity to the excessive uterine bleeding associated with intrauterine contraceptive devices is discussed.

A metabolic parameter, DNA synthesis, was measured in rabbit blastocysts exposed to Silastic intrauterine devices (IUDs) and compared with those without IUD exposure. Autoradiographic detection of 3 H-thymidine uptake showed that the IUD-exposed blastocysts contained fewer labeled cells than their IUD-free equivalents. The depressed DNA synthesis may be caused by either a block in the cell cycle or a block in DNA synthesis itself Either way, the result could be consistent with the observation that embryo deaths occur at all growth stages: preimplantation, during implantation, and postimplantation.

To study quantitative menstrual blood loss (MBL), 10 normally rhesus monkeys and 18 ovariectomized, hormonally supplemented monkeys (estradiol and progesterone) were inserted with IUDs: a silastic cylinder and 3 modifications the polyethylene Tatum T device. A 92% increase (p.01) in MBL was noted in the Y-T device monkeys (n=7) and a 70% increase (p.05) in the large oval T ones (n=5). MBL was unaffected by the small oval T, and by the cylindrical Silastic devices after the second postinsertion period. Intermenstrual bleeding was observed in 4 of 7 Y-T device animals but was uncorrelated with MBL. It was concluded that rhesus monkeys may serve as good research models for designing human IUDs.

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.

The date of the luteinizing hormone (LH) peak was compared with an independent histological examination of the endometrium in 11 21-37 year old women studied for 1 menstrual cycle in order to evaluate the accuracy and validity of histological endometrial dating. There was a significant correlation (p.01) between endometrial dating and the days after LH peak. The use of the relationship between glandular and stomal histology appeared to be a better morphologic indicator of defective corpus luteum function than a lag in endometrial dating.

Defective leukocyte function manifested by impaired migration (1, 2) and reduced phagocytic (3–5) and bactericidal activity (6) has been observed in patients with uraemia. Also, sera from dialysis patients contain a heat stable factor that inhibited granulocyte Chemotaxis (7). The mechanisms and/or the potential uraemic factors underlying these defects in leukocyte functions are not known.

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.

Cylindrical rings, made of silicone rubber impregnated with medroxyprogesterone acetate were placed in the vaginas of 3 regularly menstruating women on the first cycle day. Silastic rings without medication were used in 3 controls. During the 28 days that the rings were in place, there was continuous systemic absorption of the progestogen as evidenced by elevation of the basal body temperature, shift in maturation index, abolition of the midcycle LH peak, and change in the endometrial histology. In the 3 controls, no significant alterations occurred in any of the parameters measured (BBT, vaginal cytology, endometrial biopsies and gonadotrophins) as compared with the cycles before and after insertion of the ring. After removal of the rings in the test group, the advent of withdrawal bleeding and a fall in the basal body temperature indicated a prompt termination of drug activity. Presumptive evidence of ovulation followed shortly thereafter. It is hoped that this method of administering a progestogen may be developed for family planning.

The effect of Depo-Provera (medroxyprogesterone acetate) alone or w ith various estrogens was studied in 14 patients with endometriosis. A ll the paitents except 1 were followed for 13-62 months. Depo-Provera was administered in doses of 100 mg every 2 weeks for a total dosage of 1000-2000 mg. The drug had an effect lasting 4-7 months after the last injection. The effect on endometriotic tissue was striking and was similar in many respects to those conditions occurring during pregnancy. Except for spotting and breakthrough bleeding side effects were less frequent than those reported for oral progestins and estrogen-progestogen combinations. It is concluded that Depo-Provera is a potent long-lasting progestational agent which is highly useful as an adjunct to surgery in cases of advanced endometrial lesions.

An evaluation of the photometric alkaline hematin procedure was carried out to determine its reliability and practicality in measuring menstrual blood loss (MBL). A reliable method for quantitating MBL was necessitated in order to measure the effect of IUD design on uterine bleeding. MBL was measured in 6 women during 2-4 consecutive cycles (total of 15 cycles). Test samples of blood, either as liquid or soaked into sanitary napkins, vaginal tampons, or cotton pads were incubated at room temperature in 5% (w/v) aqueous sodium hydroxide solution. After incubation, absorbance of the brown-colored alkaline hematin was measured at 550 nm in a Perkin-Elmer Model 124 dual beam spectrophotometer against a blank of either 5% sodium hydroxide or distilled water. The quantity of blood in each sample, represented by eluted, hematin-converted hemoglobin, was determined from a standard curve relating various known volumes of incubated blood to absorbance at 550 nm (A550). Standard volumes of blood were always incubated for the same length of time as the samples. When the samples were diluted with more sodium hydroxide solution than the standards, sample absorbances were multiplied by an appropriate dilution factor. The photometric alkaline hematin procedure indicated a sensitivity to less than .1 ml of blood, within-batch precision of 5% or less (2 C.V.), and an accuracy of measuring human menstrual blood from most sanitary devices generally within plus or minus 5%. The method appeared to be specific for menstrual blood and independent of other materials in genital fluids. Menstrual discharge could be stored for at least 1 month prior to determination without alteration of results. The procudre, once optimized for the authors' purposes, was found to be very practical. The results of the study were consistent with the available literature which indicated that maximum normal menstrual blood flow is between 60 and 80 ml, and the mean is near 30 ml. Variation of measured flow between consecutive menstrual cycles in some individuals (both normal and menorrhagic) revealed the necessity for repeated measurements to properly assess average blood flow in certain cases.

Bacterial and histologic studies were performed on endometrium obtained by 2 methods in 2 different groups of patients wearing the IUD. The first group consisted of 75 patients schedules to have elective vaginal hysterectomies in association with culporrhaphy for symptomatic uterine and vaginal relaxation. The second group was made up of 253 patients who elected to use the IUD as a contraceptive. Cultures were obtained transfundally after hysterectomy in the first group and transcervically in the second. The incidence of sterile endometrial cultures was significantly greater when the transfundal method was employed. Using this method of obtaining cultures it was found that positive endometrial cultures were obtained from all uteri in which the IUD had been inserted within the previous 24-hour period. The incidence of positive endometrial cultures rapidly diminished at the time after insertion increased so that after 1 month had elapsed since insertion of the IUD all the endometrial cavities examined were sterile . The results of the study confirm the statements of others that the occurrence of clinical infection of the upper genital tract in patients having the IUD with nylon threads protruding into the vagina is usually due to an unrelated cause such as coital infection. Even when the threads passes through contaminated endocervical mucus sterile cultures were obtained from the portion of the threads within the endometrial cavity as well as from the loop itself. (AUTHORS MODIFIED)

6 normally menstruating and 21 ovariectomized rhesus monkeys were used to measure the menstrual blood loss (MBL) during an estrous cycle. A reliable method of quantitating MBL should provide better evaluation of the bleeding problem associated with IUDs. The technic used in measuring the MBL and the volume of MBL are presented. The ovariectomized animals were given 25-mcg estradiol im daily for 22 consecutive days of each month and 1.5-mg progesterone daily during the second half of the injection schedule. These injections supported normal endometrial histology. Intravaginal pads were used for the collection of the menstrual blood. MBL was calculated by the Hallberg-Nillson method. Average MBL for all menstrual periods was 2.01 ml. This should provide a necessary parameter for evaluation of IUD-associated uterine hemorrhage.

Dating of maturity of the endometrium by histologic examination was correlated with four methods of ovulation detection in 13 cycling parous women. Histologic dating was assessed independently by two pathologists and correlated with the postovulatory duration as determined by daily transvaginal ultrasound scanning, serum LH measurements, basal body temperature (BBT), and subtraction of 14 days from the onset of menses. In addition, progesterone and estradiol (E2) were measured in daily serum samples. Dating of the endometrial biopsy was highly correlated (P less than .002) with the day of ovulation as determined by ultrasound, and was found to be within 2 days of the correct postovulatory day on evaluation of 25 of 26 (96.1%) of the interpretations. The accuracy of dating using the LH surge was 84.6% (22 of 26 interpretations), and with the BBT thermogenic shift was 76.9% (20 of 26 interpretations). However, dating of the endometrium was within 2 days of the correct day in only 17 of the 26 interpretations as determined by subtracting 14 days from the onset of the subsequent menses. The accuracy of dating was significantly better correlated (P less than .025) with days from ovulation as determined by ultrasound than as calculated from the onset of menses. There was a significant correlation between endometrial dating and the amount of progesterone (P less than .01) and E2 (P less than .01) secreted from the day of ovulation, as determined by transvaginal ultrasound, to the day of biopsy. These data confirm a strong correlation between endometrial dating and ovarian hormone secretion during the postovulatory phase.(ABSTRACT TRUNCATED AT 250 WORDS)

39 New Zealand white female rabbits and 15 Sprague-Dawley female rat s were used to determine if a relatively small silicone plastic intrauterine foreign body (IUFB) would produce an incomplete antifertility action and to correlate the number of inflammatory cells in the uterine fluid with the presence or absence of pregnancy in the IUFB uterine horn. Rabbits were bred 5 days after devices were inserted and rats 3 days after. Both species were sacrificed 10 days postcoitus. Corpora lutea were counted uterine horns flushed implantations noted and cells enumerated. Of 39 rabbits 33 had corpora lutea in both ovaries and each had 1 or more implantation sites. 6 were classified was nonpregnant due to mating failure. There was a significant difference in fertility rates between the 33 control horns and the 33 IUFB horns (.86 vs. .5 p less than .001). There was also a significant difference in the mean number of leukocytes in the ut erine flushings of the IUFB side compared to the control side (32.6 vs. 3/cu. mm p less than .001). As the number of leukocytes increased in the IUFB horns the fertility rate diminished. The implantation site size was significantly smaller in the IUFB horn (p less than .001). Those animals with longer uterine horns containing IUFBs also had more implantation sites than those with shorter horns. The maximum infertility effect of the IUFB was exerted in the immediate vicinity of the device. Also sections of endometrium taken at a distance from the IUFB showed fewer polymorephonuclear leukocytes than in areas nearer to the IUFB. No evidence of resorption of embryos or placentas was found in any horns. In rats the IUFBs almost completely prevented pregnancy in those horns where placed; in the control horns pregnancies were of no rmal frequency (p less than .001). There was a significant difference i n the number of leukocytes in uterine flushings in IUFB and control rats (643 vs. 11 leukocytes/cu. mm p less than .001). When pregnancies occurred in the rabbit IUFB uterine horn the number and size of implantations were found to be inversely proportional to the total number of leukocytes present. The distance of implantation sites from the IUFB was directly proportional to the quantity of leukocytes.