Progesterone challenge test and estrogen assays in menopausal women with endometrial adenomatous hyperplasia

Use of the progestin challenge test in nonhuman primates (Macaca fascicularis)

OBJECTIVE

To determine whether the progestin challenge test (PCT) would provide a reliable, noninvasive indicator of endometrial stimulation in nonhuman primates. DESIGN; Randomized, 2x2, crossover study. SETTING; Nonhuman primates (Macaca fascicularis) in an academic research environment.

PATIENT(S)

Adult, surgically postmenopausal, female cynomolgous macaques (n = 27) were studied.

INTERVENTION(S)

Females were randomly assigned to receive estradiol (n = 14; 0.028 mg/kg body weight) or vehicle (n = 13) daily. All animals were administered two PCTs in a crossover study design using two doses (0.28 mg/kg or 0.56 mg/kg body weight) of medroxyprogesterone acetate (MPA).

MAIN OUTCOME MEASURE(S)

Incidence and severity of withdrawal bleeding and serum estradiol (E(2)) and progesterone (P(4)) levels were evaluated.

RESULT(S)

Estradiol treatment resulted in endometrial "withdrawal" bleeding in all but one instance. Females receiving daily doses of E(2) exhibited a significantly greater (P<.01) incidence, severity, and duration of withdrawal bleeding compared to control animals. Of the five positive responses observed in the control females, four occurred when the higher dose of MPA was administered.

CONCLUSION(S)

These results indicate that the PCT is a useful, noninvasive method for determining the presence of endometrial stimulation in nonhuman primates.

Strategies to reduce the incidence of endometrial cancer in postmenopausal women

OBJECTIVE

The purpose of this study was to develop strategies to reduce the incidence of endometrial cancer in postmenopausal women by reviewing methods to diagnose women at risk and providing therapies that are effective.

STUDY DESIGN

A literature search for studies between 1975 and 1995 of the association between hormone therapy and endometrial cancer was performed with MEDLINE. There were nine reports with a total of 66 cases of endometrial cancer developing during use of estrogen-progestogen replacement therapy.

RESULTS

The cases of endometrial cancer diagnosed during use of estrogen-progestogen therapy because of abnormal bleeding occurred when the dosage or duration of the progestogen was less than that considered optimum. The minimum effective dosage of medroxyprogesterone acetate is 10 mg and the minimum effective dosage of norethindrone acetate to 2.5 mg. The minimum effective duration of the progestogen is 12 to 14 days when it is used sequentially. Continuous combined therapy with low dosage estrogen and progestogen may not be fully endometrial protective.

CONCLUSIONS

The progestogen challenge test is an effective test to identify women at increased risk for endometrial cancer. There are no adverse effects on lipids and lipoproteins from added progestogen when adequate dosages of estrogen are given. Side effects of progestogens can be managed with mild diuretics or by changing the type, dosage, or route of administration. Cyclic combined therapy may be more endometrial protective than continuous combined hormone replacement is.

Transvaginal ultrasonography and the progestogen challenge test in postmenopausal endometrial evaluation

OBJECTIVE

To analyze the morphologic and ultrasonographic aspects of the endometrium of postmenopausal women according to the progestogen challenge test.

METHODS

The study was conducted on 150 postmenopausal women. Each patient was submitted to transvaginal ultrasonography for measurement of endometrial echo thickness and to endometrial biopsies, followed by the progestogen challenge test.

RESULTS

Women with a negative test presented atrophic endometrium in 94% of cases. The other 6% have shown active endometrium, but none had hyperplasia. However, 56% of the patients with a positive test had atrophic endometrium. There was a correlation between endometrial thickness less than 5 mm and endometrial atrophy in patients with either positive or negative tests.

CONCLUSION

Because the progestogen challenge test is cheap and easy to deal with, it can be done as a primary screening method in asymptomatic postmenopausal women. If the test is positive, ultrasonography is required in order to determine who needs a more accurate examination of the endometrium. If the test is negative, ultrasonography is not required due to the great number of women who have atrophic endometrium.

The progestogen challenge test in postmenopausal women: clinical and morphologic aspects

The clinical aspects and anatomopathological patterns of 150 postmenopausal women were studied using the progestogen challenge test. An endometrial biopsy was obtained and submitted to the progestogen test. A histopathological analysis of the uterine mucosa from women with a positive progestogen test revealed that the endometrium was active in 44 percent of cases and atrophic or inactive in 56 percent. In contrast, among women with a negative response, the endometrium was atrophic in 94 percent of cases and active in 6 percent. Analysis of clinical aspects did not show significant differences between groups in terms of age; age at menarche and at menopause; fasting blood glucose levels; or body mass. However, postmenopausal time was significantly shorter for women with a positive test, with a correlation between postmenopausal time of one to two years and test positivity. The progestogen challenge test for the detection of atrophic endometrium presented 78.57 percent sensitivity, 77.05 percent specificity, 44 percent positive predictive value, and 94 percent negative predictive value. Thus, when negative, the test is highly valuable, indicating the presence of atrophic endometrium in 94 percent of cases. False-negative results occurred in only 6 percent of the subjects, with no case of hyperplasia detected. However, when the response to the test was positive, the endometrium was atrophic in 56 percent of the cases. We suggest that, in order to avoid invasive procedures, the progestogen challenge test be combined with other methods such as transvaginal ultrasonography.

Progesterone challenge test in postmenopausal women at high risk

Endometrial carcinoma is one of the commonest cancers of the female genital tract. There is an increasing need for a non-invasive screening test that is suitable for widespread use, especially in postmenopausal women at high risk. The aim of this study was to test the validity of the progesterone challenge test (PCT) for this purpose. The test was performed in 100 postmenopausal women at risk, and the results were compared with histopathology findings. Atrophic endometrium was found only in the PCT-negative cases, while all the PCT-positive cases showed different morphological patterns histologically, viz., proliferative endometrium (1 case), cystic glandular hyperplasia (4 cases), adenomatous hyperplasia (5 cases), atypical hyperplasia (1 case) and adenocarcinoma (1 case). Using the McNemar test, we found the sensitivity of the PCT to be 91.2% and the specificity to be 100%. The results of this study suggest that the progesterone challenge test is a reliable, non-invasive, easy-to-use endometrial screening test for all postmenopausal women, and especially the high-risk group.

Progestin challenge test in postmenopausal patients

OBJECTIVES

The purpose of this study is to analyze the characteristics of patients identified with the progestin test.

METHODS

We administered the progestin challenge test to 157 postmenopausal women and compared the characteristics of the patients who bled, with those who did not.

RESULTS

Bleeding occurred in 14.01% of cases and we found that the number of patients who bled were significantly and independently more overweight, had higher levels of plasma estradiol, had a clear presence of superficial cells in the vaginal epithelium and had been menopausal for fewer years than those who did not bleed.

CONCLUSIONS

We concluded that the test identifies women at risk from hormone-related endometrial cancer.

Progesterone challenge test for the assessment of endometrial pathology in asymptomatic menopausal women

The progesterone challenge test was correlated with endometrial pathology in 130 asymptomatic menopausal women without hormonal treatment. The sensitivity of the test for detection of endometrial proliferative activity was 76%, specificity 100%, positive predictive value 100% and negative predictive value 94.1%. A 10-day test provided better results than a 5-day test. The test seems useful for detection of those at high risk for endometrial cancer.

Postmenopausal endometrial patterns and serum estradiol concentrations

Eighty postmenopausal women were subjected to endometrial biopsy. Inadequate biopsy was recorded in 30 cases. In the remaining cases (n = 50) the correlation between endometrial patterns and serum estradiol (E2) was performed. These cases were presenting with uterine bleeding (n = 38) or minor gynecological symptoms (n = 12). Proliferative endometrium was the predominant endometrial pattern whereas endometrial malignancy was only present in 15.8% of the bleeding cases. Serum E2 was significantly elevated in cases having malignant endometrium or adenomatous hyperplasia compared to cases having other endometrial patterns. Serum E2 measurement is recommended as a simple screening test for the detection of postmenopausal endometrial hyperplasia and/or malignancy.