Nuclear morphometric changes and therapy monitoring in patients with endometrial hyperplasia: a study comparing effects of intrauterine levonorgestrel and systemic medroxyprogesterone

OBJECTIVE

To show that local application of the levonorgestrel intrauterine device was a better therapy for endometrial hyperplasia (EH) compared to per-oral gestagen treatment based on subjective (WHO criteria) and objective (prognostic data-based morphometric and stereological method/D score, predicting the risk of cancer development for each single patient) evaluation.

METHODS

Women between 30 and 70 years with EH and D score > 0 were treated with levonorgestrel intrauterine device (n = 26) and the results compared to a historic group of women treated with per-oral gestagen (n = 31). In both treatment groups only patients with low risk (D score > 1) and uncertain risk (D score = 0-1) of cancer development were included. Endometrial specimens were investigated prior to treatment and after 3 months of therapy. The endometrial samples from the two groups were examined by light microscopy and objective data-based morphometry to assess tissue characteristics and to evaluate nuclear size variation.

RESULTS

After 3 months all patients treated with levonorgestrel intrauterine device showed regression of hyperplasia, whereas 14 of 31 patients in the per-oral group still had persisting disease. The objective morphometric analysis showed reduction in nuclear size for both treatment groups, including the D score > 1 as well as the D score 0-1 patients. However, the reduction was most obvious for the levonorgestrel intrauterine device-treated patients with initial D score of 0-1.

CONCLUSION

The present study indicates that levonorgestrel intrauterine device is a superior alternative to per oral treatment of endometrial hyperplasia. By using objective morphometric treatment monitoring we have shown that the hyperplasia patients with the highest malignant potential (D score = 0-1) were those taking most benefit from local high-dose levonorgestrel therapy.

Implementation of assisted reproductive technologies following conservative management of FIGO grade I endometrial adenocarcinoma and/or complex hyperplasia with atypia

OBJECTIVE

The objective was to report a series of infertility therapy outcomes following conservative management of endometrial adenocarcinoma and/or complex hyperplasia with atypia.

METHODS

A retrospective review of the University of Iowa assisted reproductive technology database was performed. All women presenting with International Federation of Obstetrics and Gynecology (FIGO) grade I uterine adenocarcinoma and/or complex hyperplasia with atypia were assessed for type and duration of medical management, initial, interim treatment, and preinfertility treatment endometrial biopsy (BX) findings. Assessment of infertility treatment outcomes and postinfertility endometrial biopsy findings were performed. All of the pathology samples were re-reviewed at the Gynecologic Oncology Tumor Board to confirm the diagnosis by a pathologist with a particular expertise in gynecologic pathology.

RESULTS

Four infertile women, three nulligravid and one primigravid, were evaluated with the diagnosis of FIGO grade 1 endometrial adenocarcinoma and/or complex hyperplasia with atypia desiring to preserve fertility. Two women with FIGO grade 1 endometrial adenocarcinoma were successfully treated with high-dose progestational agents resulting in normal proliferative endometrium. In addition, both women with complex hyperplasia with atypia were successfully treated with progestins and/or ovulation induction. Successful pregnancy outcomes were achieved for three of the four women with assisted reproductive technology. A total of five successful pregnancies and eight healthy live-born infants were achieved among three women. One of the four women was unable to conceive despite three cycles of in vitro fertilization. Hysterectomy was performed for recurrent complex hyperplasia with atypia. In our series, we found it can take 3-10 months (mean, 6.25 months; median, 6 months) to obtain benign endometrium preceding infertility therapy.

CONCLUSION

This report demonstrates that conservative management of well-differentiated endometrial adenocarcinoma and/or complex hyperplasia with atypia followed by aggressive assisted reproduction is an option to highly motivated and carefully selected women.

Treatment of atypical endometrial hyperplasia with an insulin-sensitizing agent

Endometrial cancer and hyperplasia have long been associated with diabetes. Hyperinsulinemia may have a direct mitogenic effect on the endometrium and may inhibit the effect of progestogen therapy. This case report describes the treatment of a patient with atypical endometrial hyperplasia with an insulin-sensitizing agent. A 37-year-old patient presented after failed treatment of endometrial hyperplasia with progestogen therapy. One month after initiating metformin therapy the patient's endometrial biopsy demonstrated proliferative endometrium. This patient's atypical endometrial hyperplasia regressed after the initiation of treatment with an insulin-sensitizing agent. This relatively new class of drugs may provide an adjunct to the therapy of endometrial hyperplasia.

A study of two protocols combining aglepristone and cloprostenol to treat open cervix pyometra in the bitch

To compare the efficacy and safety of two protocols using a combination of aglepristone and cloprostenol for the treatment of open cervix pyometra in the bitch and to describe the progesterone (P4) serum profiles before and during treatments, 15 bitches were randomly allocated into two treatment groups: I (n = 8): aglepristone was administered at 10mg/kg, s.c., on Days 1, 3, 8, and 15 (if not cured), combined with cloprostenol at the dose of 1 microg/kg, s.c., on Days 3 and 8, and II (n = 7): received the same treatment with aglepristone as Treatment I but cloprostenol on Days 3, 5, 8 10, 12, and 15 (if not cured). Before the beginning of the treatments and then on Days 8, 15, and 29 all bitches were evaluated for clinical signs, side effects, hemogram, serum P4 concentrations, and uterus diameters. Bitches in both treatment groups, with (n = 6) or without (n = 9; > or =1.2 ng/ml) initial basal P4 serum concentrations, achieved treatment success without side effects and no significant differences, either on Day 15 (6/8 for Treatment I and 4/7 for Treatment II) or on Day 29 (2/8 for Treatment I and 3/7 for Treatment II). In both treatments groups, clinical signs, blood parameters, and uterine diameters improved to normal values throughout the experiments. A significant interaction between day and treatment was found for percentage change in P4 when all bitches were considered together. Redevelopment of pyometra in the next estrous cycle occurred in 20% of the bitches. One nonrecurrent bitch was mated and whelped a normal litter. It is concluded that these two combined protocols proved to be efficient and safe in reversing clinical signs of open cervix pyometra independently of initial P4 concentrations and that the number of cloprostenol administrations seemed to have an effect on P4 serum changes throughout treatments.

[Treatment of hyperplasia endometrium with GNRH agonists]

OBJECTIVES

Untreated hormonal disturbances connected with unbalanced estrogen serum concentrations can influence on pathological proliferation of endometrium. The aim of the study is to assess the effect of GnRH agonists on endometrium in women consulted due to simple hyperplasia endometrium.

MATERIAL AND METHODS

15 women in the mean age 48.5 +/- 3.5 years with the histopathological diagnosis of simple hyperplasia were treated with trioptorelin during 3 months. After therapy all patients were undergone transvaginal ultrasonography and endometrial biopsy.

RESULTS

Atrophic endometrium were observed in all women after a 3-month therapy. The thickness of endometrium decreased from 10.21 +/- 3.2 mm to 3.94 +/- 1.56 mm.

CONCLUSIONS

The efficacy of the therapy of simple hyperplasia in women with GnRH agonist was 100%.

Treatment of nonatypical and atypical endometrial hyperplasia with a levonorgestrel-releasing intrauterine system

OBJECTIVE

A "frameless" intrauterine drug delivery system that releases 14 microg/d of levonorgestrel was used to treat nonatypical and atypical endometrial hyperplasia in 12 women.

STUDY DESIGN

This noncomparative study had up to 3 to 4 years of follow-up.

RESULTS

The cure rate was 100%, as confirmed by repeat endometrial biopsy.

CONCLUSION

This method could be considered an alternative to hysterectomy.

Endometrial hyperplasia with secretory changes

OBJECTIVE

Secretory changes in endometrial hyperplasia are uncommon. The aim of this study is to review the morphologic and clinical findings of 24 cases of endometrial hyperplasia with secretory changes.

METHODS

In 24 patients diagnosed with endometrial hyperplasia with secretory changes during 6 years, clinical characteristics such as menopausal status and hormone treatment were correlated with morphological features. A matched age control group of 24 women with conventional endometrial hyperplasia was used to compare the hormonal effect.

RESULTS

Nineteen patients were premenopausal. Nine women showed simple hyperplasia without atypia and 15 complex hyperplasia, 7 of them with atypia. Seventeen women were under hormonal treatment at the time of diagnosis, 10 of them with progestins. In 7 patients endometrial adenocarcinoma could be seen, 5 coexisting with endometrial hyperplasia with secretory changes and in 2 appearing after 1 and 4 months. In control group only 2 patients were undergoing progestin hormonal treatment.

CONCLUSIONS

Secretory changes can be found in hyperplastic endometrium, particularly in premenopausal women under hormonal treatment with progestins, with the risk of misdiagnosis.

Mechanisms involved in the evolution of progestin resistance in human endometrial hyperplasia--precursor of endometrial cancer

BACKGROUND

Successful treatment of endometrial hyperplasia with progestins is commonly accompanied by the finding of an inactive or suppressed endometrium after therapy. However, approximately 30% of the endometrial hyperplasia cases do not respond to progestins and hyperplastic glands persist. The Fas/FasL system is known to play a role in tissue remodeling as a result of changes in menstrual hormone levels. The aims of this study are to examine Fas/FasL expression in endometrial hyperplasia of pre- and postprogestin treatment samples and to study the Fas/FasL regulation in vitro with Ishikawa cells after progestin stimulation.

DESIGN

Pre- and posttreatment paraffin-embedded endometrial hyperplasia tissue samples from 26 women were examined by immunohistochemistry for changes in Fas/FasL expression related to the administration of progestins. Among 26 patients, 18 were successfully treated with progestins and 8 failed treatment. Fas/ FasL positivity was defined by the presence of 10% or more immunoreactive epithelial cells in each specimen. In positive cases, a percentage or an immunoscore of immunoreactive cells was given by counting 500 cells. Cell viability was evaluated by the MTT assay. The in vitro effects of progesterone on Fas/FasL expression and apoptosis in Ishikawa cells were examined by using Western blot and TUNEL assays, respectively.

RESULTS

Fas immunoreactivity was present in 4/26 (15%) preprogestin cases with an average of 16% of the epithelial cells expressing Fas. FasL was expressed in 21/26 (80%) pretreatment cases with an average of 42% of the hyperplastic glandular cells being positive. In postprogestin cases, an increase of Fas expression (14/18, 77%) with an average of 47% stained cells was seen in responders (P < 0.001), while FasL was found in 16/18 (89%) responders with an average of 65% of cells positive (P = 0.587). In nonresponders, no significant changes in Fas/FasL expression were detected compared to pretreatment samples. With in vitro Ishikawa cells, a slight increase (10-20%) of Fas and FasL protein expression was detected after 24 h of progesterone treatment, but a more significant increase (220-343%) of both Fas and FasL expression was found after 48 h of withdrawing progesterone, which parallels apoptotic activity.

CONCLUSIONS

The Fas/FasL system may be involved in the development of endometrial hyperplasia. Part of the molecular mechanisms of progestin therapy for endometrial hyperplasia is through upregulation of Fas/FasL expression. Dysregulation of Fas/FasL expression in hyperplastic endometrium may be part of the molecular mechanisms for nonresponders to progestin treatment. Intermittent, rather than continuous, progestin treatment may be more effective clinically for the treatment of endometrial hyperplasia.

Atypical endometrial hyperplasia in an 18-year-old woman

The natural history and the factors that lead to the acquisition of atypia in endometrial hyperplasias in young aged women, especially under the age of 20, have not been fully elucidated. In such cases, although there exists a considerable risk of progression to carcinoma, a conservative antiestrogenic treatment is primarily indicated, in attempt to preserve the reproductive ability of the young woman. We report of a 18-year-old girl with atypical hyperplasia of the endometrium, a diagnosis confirmed by reviewing of the histologic material by specialized gynecopathologists. The patient has been treated with gonadotropin releasing hormone agonist (leuprolide acetate) and tibolone for 1 year, which led to endometrial atrophy and amenorrhea, without hypoestrogenic side effects. Six months after cessation of the therapy the endometrial hyperplasia relapsed (this time without atypia), but in about 2 years of follow-up and after short courses of treatment with clomiphene citrate and progestins the biopsy of the endometrium revealed a functional endometrium and the patient presents with an almost regular menstrual cycle.

Matrix metalloproteinase-26 is expressed in human endometrium but not in endometrial carcinoma

BACKGROUND

The human matrix metalloproteinase (MMP)-26, also called matrilysin-2 or endometase, has been isolated as a matrilysin (MMP-7) homolog. Matrix metalloproteinase-26 was expressed in tissue samples from the placenta and endometrial tumors and its expression may be related to the development of endometrial carcinomas.

METHODS

Total RNAs were isolated from 5 endometrial carcinoma cell lines, 36 normal endometrial tissue samples, 4 hyperplasia tissue samples, and from 24 endometrial carcinoma tissue samples. Reverse transcription-polymerase chain reation (RT-PCR) was performed to detect MMP-26 mRNA expression. To identify MMP-26 mRNA localization and protein expression, we performed in situ RT-PCR and immunohistochemistry, respectively.

RESULTS

Reverse transcription-polymerase chain reaction analysis revealed that MMP-26 mRNA was expressed in 24 of 36 normal human endometrial tissue samples. However, MMP-26 mRNA expression was not detected in endometrial carcinoma cell lines nor in endometrial carcinoma tissue samples except for one case. Western blot analysis showed similar results. In situ RT-PCR analysis revealed that MMP-26 expression was localized in the epithelial glandular cells but faint expression was observed in the stromal cells. Subsequently, we separated endometrial tissues into epithelial glandular and stromal cells. Using RT-PCR, the purified epithelial glandular cells exhibited MMP-26 mRNA expression but the purified stromal cells did not. Immunohistochemical analyses revealed that MMP-26 protein expression is also limited to endometrial epithelial glandular cells but not to cancer cells. Therefore, MMP-26 expression is limited to normal epithelial glandular cells.

CONCLUSIONS

We found a significant difference in MMP-26 expression in normal and malignant endometrial tissue samples, although its function is still unknown. These data suggest that MMP-26 may be a candidate for a new tumor marker for endometrial carcinomas.

Relative binding activity of new antigestagens with progesterone receptors in human hyperplastic endometrium

We determined the content and binding capacity of progesterone receptors in the endometrium of patients with adenomatous and fibroid polyps, adenocystic hyperplasia, and atypical hyperplasia before and after gestagen therapy. Hyperplasia of the endometrium was accompanied by changes in affinity of cytosolic progesterone receptors for antigestagens, which provides the possibility of individual correction of hormone therapy.

Treatment for complex atypical hyperplasia of the endometrium

OBJECTIVE

To clarify the clinical outcome of women with complex atypical hyperplasia of the endometrium who were treated either by hysterectomy or a non-surgical treatment with medroxyprogesterone acetate (MPA).

STUDY DESIGN

Thirty of the 53 patients with complex atypical hyperplasia of the endometrium were treated by undergoing hysterectomy and 20 were treated with MPA alone as the primary therapy. Their clinical features and outcomes were evaluated.

RESULTS

The ages of the 53 patients ranged from 28 to 62 years (mean 46.2). Fifteen (75%) of the 20 patients (8 of 12 with low-dose MPA and 6 of 8 with high-dose MPA) responded initially to MPA therapy. Two of the 12 patients who were treated with low-dose MPA progressed to endometrial adenocarcinoma. Three patients treated with high-dose MPA conceived after treatment having three healthy infants.

CONCLUSION

Primary treatment with high-dose MPA is a safe and effective therapy for women with complex atypical hyperplasia of the endometrium who wish to preserve their fertility.

Ultrasonographic Features following Thermal Balloon Endometrial Ablation Therapy

The aim of this study was to evaluate the ultrasonographic changes taking place in the uterus after thermal balloon endometrial ablation therapy. The ultrasonographic findings in the uterus after thermal balloon endometrial ablation in 13 patients were compared to those found in 13 patients treated with gestagen therapy. Examinations took place before initiation of the treatment, on the 1st postoperative day (thermal balloon ablation group only), and 1 and 6 months later. One month after thermal balloon endometrial ablation therapy, the ultrasonographic examination revealed a clear-limited hyperechogenic zone surrounding the uterine cavity which was filled with fluid in 6 out of 10 patients. The ultrasonographic findings may represent a burn-injury-induced obstruction in the cervical canal with subsequent collection of fluid in the uterine cavity and a zone of coagulation in the submucosal layers. At the final examination in the thermal balloon group, the mean endometrial thickness was lower than the pretreatment level. No changes were observed in the gestagen therapy group.

Organ preserving method in the management of atypical endometrial hyperplasia

The problem of organ preservation in the management of atypical endometrial hyperplasia (AEH) comes about especially in patients of reproductive age. Two hundred and fifty-four women with a diagnosis of AEH were hospitalized in our clinic from the period 1991 to 2000. Of those, atypical endometrial hyperplasia with normal uter and appendages was found in 192 women. The remaining 62 patients had diseases of the cervix, corpus uteri, ovaries and oviducts and were subjected to radical hysterectomy. To define the possible sparing tactics of management, 192 women with AEH were divided into two groups. The patients in Group were administered hormonal therapy during a three month period (17alpha OPC - 12.5 g, Depo-Provera - 6 g). If a clinical effect and histological pathomorphism were achieved the patients were subjected to an additional three months of hormonotherapy. Of a total of 96 patients in the first group, 36 (37.5%) who were prescribed hormonotherapy were found to also have mastopathy and endocrine pathology dysfunction of the thyroid gland, and were additionally administered iodine-containing preparations. After completion of the effective hormonotherapy three patients had a normal pregnancy and delivery. Conservative management proved to be effective in 96.4% and ineffective in seven (3.6%) cases. These seven patients were subjected to surgical treatment. All patients in Group 2 were subjected to radical hysterectomy.

Reversal by medical treatment of endometrial hyperplasia caused by estrogen replacement therapy

OBJECTIVE

Endometrial hyperplasia, an entity considered a precursor to endometrial carcinoma, frequently develops in women receiving unopposed estrogens. Progestins used concomitantly with estrogens can largely prevent endometrial hyperplasia and carcinoma. However, the ability of progestins to reverse endometrial hyperplasia induced by estrogens is less well recognized. The purpose of this study was to assess the medical reversal rate of endometrial hyperplasia that develops in women receiving unopposed estrogen replacement therapy (ERT).

DESIGN

Review of recent literature (1990-2000).

RESULTS

Based on four large series, more than 90% of endometrial hyperplasia caused by ERT can be reversed by medical treatment. Discontinuation of estrogen and oral administration of 10 mg/day of medroxyprogesterone acetate continuously for 6 weeks or cyclically for 3 months (2 weeks of each month) are the two regimens most widely used. Other progestins also have been shown to be effective.

CONCLUSIONS

Progestins are highly successful in reversing endometrial hyperplasia caused by ERT.

Metabolic effects associated with high-dose continuous megestrol acetate administration in the treatment of endometrial pathology

OBJECTIVES

To determine the metabolic effects and efficacy of high-dose continuous megestrol acetate administration in the treatment of endometrial pathology.

MATERIAL AND METHODS

27 women with histologically proven endometrial pathology (endometrial hyperplasia and irregularly proliferative endometrium) were treated with megestrol acetate orally 160 mg/d given once-a-day for 3 months. In 5 of 27 patients the dose of megestrol acetate was increased to 320 mg/d to alleviate irregular uterine bleeding. Serum lipid profiles and fasting and 2-h postprandial serum glucose levels were studied at baseline and one week after the therapy was completed.

RESULTS

HDL-cholesterol level significantly lowered from a mean of 50.4+/-11.1 mg/dL to 44.4+/-8.5 mg/dL after 3 months of megestrol acetate therapy (p<0.05). Serum total cholesterol level significantly lowered from a mean of 222.8+/-50.0 mg/dL to 192.7+/-36.5 mg/dL (p<0.05) and apolipoprotein A-I level from a median of 134 mg/dL to 116 mg/dL (p<0.05) after the therapy. Serum LDL-cholesterol, triglyceride, apolipoprotein B, fasting and 2-h postprandial glucose levels did not significantly change after the therapy (p>0.05). The median weight of patients was found to be 70 (53-110) kg before the therapy and 74 (56-111) kg after the therapy (p=0.001).

CONCLUSIONS

The use of megestrol acetate, 160-320 mg/d, in the treatment of endometrial pathology is an effective method without marked harmful effects on serum lipid profiles or glucose levels but is associated with weight gain.

Successful pregnancy in an infertile woman with endometrial hyperplasia and embryo transfer. A case report

BACKGROUND

Successful pregnancy in a woman with complex endometrial hyperplasia with atypia was treated conservatively with gestagens.

CASE

The patient was initially diagnosed with complex hyperplasia of the endometrium with atypia by endometrial curettage and treated with several cycles of different gestagens. After repeated endometrial curettage, in vitro fertilization and embryo transfer were introduced for immediate treatment of the patient's infertility in order to avoid the risk of recurrent hyperplasia of the endometrium from estrogens. A single pregnancy was achieved after transfer of embryos obtained from intracytoplasmic sperm injection. This was performed due to poor semen characteristics. The patient delivered a normal, healthy male infant at term.

CONCLUSION

Conservative treatment of complex endometrial hyperplasia with atypia in young women wishing to preserve fertility should be considered in carefully selected cases.

Conservative therapy for adenocarcinoma and atypical endometrial hyperplasia of the endometrium in young women: central pathologic review and treatment outcome

Thirty-nine patients with endometrioid adenocarcinoma (EA) and atypical hyperplasia (AH) of the endometrium who received conservative treatment to preserve fertility were collected from member institutions of the Japan Gynecologic Oncology Study Group. Twenty-nine and ten were originally diagnosed with EA without myometrial invasion and AH, respectively. We performed a central pathological review to make definite diagnoses, and the diagnosis of EA in 29 cases was changed to AH in ten, complex hyperplasia in three and atypical polypoid adenomyoma in three, and AH in ten was changed to EA in one and simple hyperplasia in one. Nine of 12 women (75%) with EA and 15 of 18 women (83%) with AH had an initial response to medroxyprogesterone acetate (MPA) treatment. Two of nine responders with EA later developed relapse, and one of them had metastasis to the left obturator lymph node. Two became pregnant, and one delivered one full-term infant. One of the responders with AH had a relapse in the endometrium. Five became pregnant, and four delivered four normal infants. The young women with endometrial carcinoma localized in the endometrium who wish to preserve fertility may be treated as successfully with MPA as those with AH.

[Effect of gestagen therapy on clinical and biochemical parameters in patients with atypical endometrial hyperplasia]

The investigation involved 22 reproductive and menopausal women (aged 30-48) with atypical endometrial hyperplasia. In addition to general clinical examination, all the patients underwent ultrasound scanning of the organs of the small pelvis, hysteroscopy and diagnostic curettage for morphological examination both before and after treatment. All tissue samples taken before and after treatment were assayed for cytoplasmic and plasma-membrane receptor levels and a number of biochemical parameters of plasma membranes. Hormone therapy with prolonged-release gestagen-based drugs pointed to changes which occurred in: (1) sex steroid reception at cytosol and plasma-membrane levels; (2) the lipids profile of plasma membranes, and (3) activity of membrane-related enzymes. Among the beneficial results of gestagen treatment was coming most of lipid profile parameters and plasma-membrane enzymes back to normal. However, a decrease in the progesterone reception level in target tissue after 3-6 month treatment may suggest a likelihood of development of tolerance to gestagen. The data also suggest that further research continue in this area of endometrial precancer.

[Chavanprash in the treatment of hyperplastic processes in the endometrium]

Hyperplastic processes in the endometrium are classified as a common gynecological pathology. The drug chavanprash has been shown to improve general bodily resistance, to enhance vital tone of the body. It is endowed with a manifest hepatotropic and antitoxic activity, which fact permits recommending it for use in the combination therapy of hyperplastic processes in the endometrium as well as during the period of rehabilitation in the wake of the course of hormonotherapy.

Apoptosis may be an early event of progestin therapy for endometrial hyperplasia

OBJECTIVE

The aim of this study was to investigate the role of apoptosis during progestin therapy for the treatment of endometrial hyperplasia.

METHODS

Pre- and posttreatment paraffin-embedded endometrial tissue samples from 19 women with endometrial hyperplasia were examined for changes in glandular cellularity and apoptotic activity related to the administration of progestins. Twelve patients were successfully treated with progestin therapy and 7 patients failed treatment. Glandular cellularity was assessed based on calculating the average number of cells per gland obtained on histologic examination of hematoxylin and eosin stained tissue sections. Apoptotic activity was assessed on the same tissue sections by counting the average number of apoptotic cells per 10 high power fields (hpf) using the terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end labeling (TUNEL) assay. The effects of progesterone on apoptotic activity in a low-grade endometrial adenocarcinoma cell line (Ishikawa cells) was also examined using an ELISA cell death detection kit.

RESULTS

Glandular cellularity significantly decreased with progestin therapy in both treatment outcome groups. The reduction in cells per gland was significantly greater in the group of successfully treated cases compared to the treatment failures (P = 0.005). However, within the successfully treated group, in situ detection of apoptotic cells using the TUNEL assay showed no statistical difference between pre- and posttreatment endometrial samples. Interestingly, a significant decrease in apoptosis was found in posttreatment samples of the group with persistent hyperplasia. The average number of apoptotic cells detected in 10 hpf was reduced from 7.9 prior to treatment to 3.1 after progestin therapy (P = 0.03). In the progesterone-treated Ishikawa cell line, an increase in apoptotic activity started at 24 h, reached a peak at 48 h, and continued up to 72 h of hormone treatment. At 48 h, apoptotic activity was 42.6% greater than in the untreated control (P = 0.04). By 72 h of progesterone treatment, apoptosis was 37.2% greater in the treated cells compared to the noninoculated cells (P = 0.04).

CONCLUSIONS

Progestin-induced apoptosis may occur during the early period of treatment for endometrial hyperplasia. Compared to the fully responsive group, persistent endometrial hyperplasia may have intrinsically different molecular mechanisms in response to progestin therapy.

Direct effect of danazol on endometrial hyperplasia in adenomyotic women: treatment with danazol containing intrauterine device

It is well known that danazol has a direct effect on endometriosis tissue and cell. We have been treating adenomyotic women with danazol containing intrauterine device (D-IUD) from June 1993 to August 2000 and significant decrease of dysmenorrhea and serum CA-125 levels were observed. Of fifty-nine adenomyotic women, eight women were also diagnosed by endometrial biopsy as endometrial hyperplasia and one woman was diagnosed as atypical endometrial hyperplasia. In these endometrial hyperplastic patients, endometrial tissues were obtained before insertion and at the time of removal or exchange of D-IUD and examined pathologically. In all of the 9 women, histopathological findings of endometrial hyperplasia disappeared after D-IUD treatment. In particular, in one patient, findings of atypical endometrial hyperplasia also disappeared after D-IUD treatment. She is now closely observed at our clinic using D-IUD. By these evidences, we postulate that D-IUD is one of the treatment choices of endometrial hyperplasia given exposure of the endometrium to such an extraordinary high concentration of danazol released by D-IUD and avoidance of adverse effects of oral danazol or general administration of GnRH and progesterone. In particular, in atypical endometrial hyperplasia case, its mechanisms might give great benefit to patient. However, mechanisms of direct effect of danazol on endometrial hyperplasia remain to be elucidated in the future study.

[Combined hormone therapy in hyperplasia of the endometrium]

The combined hyperplastical endometrial processes are very common pathology. In spite of noticeable achievements in hormonotherapy to treat the above trouble the recurrence rate comes up to as high as 45%. The recurrent combined hyperplastical endometrial processes prophylaxis with making use of the intrauterine system with levonorgestrel "Mirena" has been shown to be effective, with the above-mentioned system having been inserted on completion of the 6-month course of treatment with orgametryl.

Role of progestins in the premenopausal climacteric

Both the prevention of diseases and therapy of symptoms in premenopausal women is a demanding task for the gynecologist. Present day knowledge allows a differentiated approach for the use of the various progestins in the premenopausal period. A women-specific medicine needs individual selection of the progestins, both for substitution and treatment. The various partial effects of the progestins, such as androgenic, antiandrogenic, estrogenic, antiestrogenic, glucocorticoid etc., have to be taken into account and should be applied according to the individuals' needs. The benefits of progestins can be obtained in various clinical conditions, including bleeding disorders; benign proliferative diseases (such as benign breast disease, endometrial hyperplasia and endometriosis); contraception; androgenization; and gynecological oncology.