Relationship between sonographic endometrial thickness and progestin-induced withdrawal bleeding

Diagnostic and therapeutic use of oral micronized progesterone in endocrinology

Progesterone is a natural steroid hormone, while progestins are synthetic molecules. In the female reproductive system, progesterone contributes to the control of luteinizing hormone and follicle-stimulating hormone secretion and their pulsatility, via its receptors on the kisspeptin, neurokinin B, and dynorphin neurons in the hypothalamus. Progesterone together with estradiol controls the cyclic changes of proliferation and decidualization of the endometrium; exerts anti-mitogenic actions on endometrial epithelial cells; regulates normal menstrual bleeding; contributes to fertilization and pregnancy maintenance; participates in the onset of labor. In addition, it exerts numerous effects on other endocrine systems. Micronized progesterone (MP) is natural progesterone with increased bioavailability, due to its pharmacotechnical micronized structure, which makes it an attractive diagnostic and therapeutic tool. This critical literature review aims to summarize and put forward the potential diagnostic and therapeutic uses of MP in the field of endocrinology. During reproductive life, MP is used for diagnostic purposes in the evaluation of primary or secondary amenorrhea as a challenge test. Moreover, it can be prescribed to women presenting with amenorrhea or oligomenorrhea for induction of withdrawal bleeding, in order to time blood-sampling for diagnostic purposes in early follicular phase. Therapeutically, MP, alone or combined with estrogens, is a useful tool in various endocrine disorders including primary amenorrhea, abnormal uterine bleeding due to disordered ovulation, luteal phase deficiency, premenstrual syndrome, polycystic ovary syndrome, secondary amenorrhea [functional hypothalamic amenorrhea, premature ovarian insufficiency], perimenopause and menopause. When administrated per os, acting as a neurosteroid directly or through its metabolites, it exerts beneficial effects on brain function such as alleviation of symptoms of anxiety and depression, asw well as of sleep problems, while it improves working memory in peri- and menopausal women. Micronized progesterone preserves full potential of progesterone activity, without presenting many of the side-effects of progestins. Although it has been associated with more frequent drowsiness and dizziness, it can be well tolerated with nocturnal administration. Because of its better safety profile, especially with regard to metabolic ailments, breast cancer risk and veno-thromboembolism risk, MP is the preferred option for individuals with an increased risk of cardiovascular and metabolic diseases and of all-cause mortality.

Current evaluation of amenorrhea: a committee opinion

The purpose of this American Society for Reproductive Medicine Practice Committee Opinion is to provide clinicians with principles and strategies for the diagnostic evaluation of patients presenting with primary or secondary amenorrhea. This revised document replaces the Practice Committee Document titled "Current evaluation of amenorrhea," last published in 2008 (Fertil Steril 2008;90:S219-25).

Clinical and biochemical discriminants between functional hypothalamic amenorrhoea (FHA) and polycystic ovary syndrome (PCOS)

BACKGROUND

Secondary oligo/amenorrhoea occurs in 3%-5% of women of reproductive age. The two most common causes are polycystic ovary syndrome (PCOS) (2%-13%) and functional hypothalamic amenorrhoea (FHA) (1%-2%). Whilst both conditions have distinct pathophysiology and their diagnosis is supported by guidelines, in practice, differentiating these two common causes of menstrual disturbance is challenging. Moreover, both diagnoses are qualified by the need to first exclude other causes of menstrual disturbance.

AIM

To review clinical, biochemical and radiological parameters that could aid the clinician in distinguishing PCOS and FHA as a cause of menstrual disturbance.

RESULTS

FHA is uncommon in women with BMI > 24 kg/m² , whereas both PCOS and FHA can occur in women with lower BMIs. AMH levels are markedly elevated in PCOS; however, milder increases may also be observed in FHA. Likewise, polycystic ovarian morphology (PCOM) is more frequently observed in FHA than in healthy women. Features that are differentially altered between PCOS and FHA include LH, androgen, insulin, AMH and SHBG levels, endometrial thickness and cortisol response to CRH. Other promising diagnostic tests with the potential to distinguish these two conditions pending further study include assessment of 5-alpha-reductase activity, leptin, INSL3, kisspeptin and inhibin B levels.

CONCLUSION

Further data directly comparing the discriminatory potential of these markers to differentiate PCOS and FHA in women with secondary amenorrhoea would be of value in defining an objective probability for PCOS or FHA diagnosis.

Where Have the Periods Gone? The Evaluation and Management of Functional Hypothalamic Amenorrhea

Functional hypothalamic amenorrhea (FHA) is a common cause of amenorrhea in adolescent girls. It is often seen in the setting of stress, weight loss, or excessive exercise. FHA is a diagnosis of exclusion. Patients with primary or secondary amenorrhea should be evaluated for other causes of amenorrhea before a diagnosis of FHA can be made. The evaluation typically consists of a thorough history and physical examination as well as endocrinological and radiological investigations. FHA, if prolonged, can have significant impacts on metabolic, bone, cardiovascular, mental, and reproductive health. Management often involves a multidisciplinary approach, with a focus on lifestyle modification. Depending on the severity, pharmacologic therapy may also be considered. The aim of this paper is to present a review on the pathophysiology, clinical findings, diagnosis, and management approaches of FHA in adolescent girls.

Efficacy, safety and recurrence of new progestins and selective progesterone receptor modulator for the treatment of endometriosis: a comparison study in mice

BACKGROUND

Current medical treatments for endometriosis are very limited. Progestin and selective progesterone receptor modulators (SPRM) are developed but their efficacy, safety, mechanism and recurrence in endometriosis are not fully studied.

METHODS

In order to compare therapeutic, side effects and therapeutic actions of Esmya, Duphaston and Dienogest in endometriosis. Experimental endometriosis was induced by either intraperitoneal or subcutaneous mouse endometrium transplantation. Lesion size, weight and histology at the end of intervention were compared. Expression of related markers in the endometriotic lesions were examined. Body, uterus and ovary weights, endometrial glands and thickness (ETI), and follicle count were measured. For recurrent study, lesion growth before and after intervention was monitored.

RESULTS

After Esmya, Duphaston, Dienogest treatment, lesion size and weight were significantly decreased. Proliferation Pcna expression was significantly decreased in all groups, but proliferation cells were significantly decreased only in Duphaston group. Apoptosis Mapk1 expression and TUNEL-positive cells were significantly increased in Duphaston group. Adhesion Mmp2 and Itgavβ3 expression were significantly increased in Esmya group. Plau, Hif1α and Vegfa expression, peritoneal fluid PGE2 levels, and ERα and ERβ expression were not affected; while PR expression was significantly lower in all groups. Endometrial gland count in uterus was significantly increased in Dienogest group, ETI was significantly decreased in Duphaston group, and AFC were significantly increased in Esmya group. Upon treatment cessation, lesion growth rebound quickly in Dienogest and Duphaston groups, but slowly in Esmya group.

CONCLUSION

Esmya, Duphaston and Dienogest are effective anti-endometriosis drugs targeting proliferation, apoptosis and adhesion. Esmya, Duphaston and Dienogest are all well tolerable, although endometrial glandular hyperplasia was found in Dienogest, endometrial atrophy in Duphaston, follicle accumulation in Esmya.

The criteria for optimal down-regulation with gonadotropin-releasing hormone-agonist: a retrospective cohort study

OBJECTIVE

The objective of this study is to investigate whether the degree of down-regulation using GnRH-agonists is associated with pregnancy outcomes.

STUDY DESIGN

This retrospective analysis was performed on 2708 cycles from 2514 patients undergoing down-regulation with the luteal phase long protocol. The serum oestradiol (E2D) and luteinising hormone (LHD) levels, the diameter of the largest follicle (DLFD) and the endometrial-thickness (ENTD) after down-regulation were used to evaluate the degree of down-regulation. One-way analysis of variance with the Bonferroni adjustment, the chi-square test and multivariate logistic regression analyses were used for the statistical analysis.

RESULTS

The cumulative clinical pregnancy rates (CCPR) and the cumulative live birth rates (CLBR) were higher in the cycles with E2D < 30 pg/ml (63.7%, OR = 1.405 (1.055-1.870) and 56.8%, OR = 1.372 (1.039-1.813)) and 30-55pg/ml (66.8%, OR = 1.439 (1.104-1.874) and 59.8%, OR = 1.397 (1.080-1.806)) than in those with E2D > 55 pg/ml (62.8% and 54.7%). There was a trend towards lower CCPRs and CLBRs in the cycles with DLFD > 10 mm or ENTD ≥ 6 mm; however, this difference was not significant.

CONCLUSION

The degree of down-regulation is associated with ovarian response, pregnancy, and live birth. We propose the following criteria for optimal down-regulation: E2D 30-55 pg/ml, ENTD < 6 mm, and no apparent ovarian activity.

Monitoring stimulated cycles during in vitro fertilization treatment with ultrasound only--preliminary results

OBJECTIVE

To evaluate if monitoring patients by ultrasound (US) only during in vitro fertilization (IVF) treatment is safe.

DESIGN

Randomized prospective study.

INTERVENTION

Patients undergoing their first IVF treatment were randomized into two groups. The ultrasound only group (study group) was monitored by US for follicle size and endometrial thickness without blood tests. In this group, only one blood test was taken before human chorionic gonadotropin (hCG) injection, to ensure a safe level of estradiol (E(2)) regarding ovarian hyperstimulation syndrome (OHSS) risk. The control group was monitored by ultrasound plus serum estradiol and progesterone concentration at each visit.

MAIN OUTCOME MEASURE

Clinical pregnancy rate.

RESULTS

No differences were found between the groups in the parameters of IVF treatment, induction days, number of ampoules, E(2) level of hCG, as well as embryo quality. The clinical pregnancy rate was not statistically different between the groups, 57.5% vs. 40.0%, respectively (p = 0.25). No OHSS cases were found among the study or control groups.

CONCLUSION

Ultrasound as a single monitoring tool for IVF cycles is reliable, safe, patient friendly, and reduces treatment expenses. In an era of cost effectiveness awareness, this regimen should be considered for routine management in IVF programs.

Current evaluation of amenorrhea

Amenorrhea is absence or abnormal cessation of the menses. Primary and secondary amenorrhea describe the occurrence of amenorrhea before and after menarche, respectively.

Postpartum suppression of ovarian activity with a Deslorelin implant enhanced uterine involution in lactating dairy cows

Holstein cows received, subcutaneously a non-degradable implant containing 5mg of the GnRH agonist Deslorelin (DESL) or no implant (CON) at 2+/-1 days postpartum (dpp). All cows were injected with PGF(2alpha) at 9 dpp. Previous pregnant (PPH) and non-pregnant uterine horns (PNPH) were determined by palpation per rectum. In Experiment 1, cows [DESL implant (n=10) and CON (n=9)] were examined by ultrasonography to record ovarian structures (23, 30 and 37 dpp) and uterine horn and cervical diameters (16, 23, 30 and 37 dpp). Uterine tone was scored before ultrasonography. Vaginoscopy was conducted just after ultrasonography examination to assess cervical discharge and color of the external cervical os. Blood samples were collected on a weekly basis for hormonal analyses. In Experiment 2, cows [DESL implant (n=77) and CON (n=70)] were palpated per rectum and vaginoscopy at 30 dpp for scoring of uterine tone, uterine horns, cervical diameter, and discharge. Blood samples were collected only at 9 dpp. In Experiment 1, DESL-implant-treated cows had more Class 1 follicles (P<0.01), less Class 2 (P<0.01) and Class 3 follicles (P<0.01) and no corpus luteum (CL) formation (P<0.01). In CON cows, six of nine animals had visible CL at 25+/-7 dpp. At 9 dpp plasma concentration of E(2), P(4) (P<0.01) and PGFM (P<0.05) were less in the DESL-implant treatment group. Diameter of PPH (P<0.01), PNPH (P<0.01) and cervix (P=0.08) were less in the DESL-implant treatment associated with greater uterine tone (P=0.07). The DESL-implant cows had a greater frequency of clear cervical discharge (P=0.09) and pink cervical os (P=0.06). In Experiment 2, plasma concentrations of PGFM were less at 9 dpp in DESL-implant treatment (P<0.01). Diameters of the PPH (P<0.01) and PNPH (P<0.01) were less and more uterine tone (P<0.01) in the DESL-implant treatment. Diameter of cervix and frequency of a cervical discharge score did not differ between treatments. Treatment with non-degradable Deslorelin (5mg) implant during postpartum: (1) suppressed ovarian follicular development, (2) enhanced physical involution of the uterus and cervix, (3) increased tone of the uterine wall, (4) decreased frequency of purulent cervical discharges, and (5) reduced inflammatory processes of the reproductive tract.

Cyclical dydrogesterone in secondary amenorrhea: results of a double-blind, placebo-controlled, randomized study

Secondary amenorrhea in women with normal estrogen levels increases the risk of endometrial carcinoma. Cyclical dydrogesterone induces regular withdrawal bleeding and effectively protects the endometrium of postmenopausal women receiving estrogens. In order to assess the efficacy of dydrogesterone in inducing regular withdrawal bleeds in premenopausal women with secondary amenorrhea or oligomenorrhea and normal estrogen levels, a double-blind, randomized, placebo-controlled, multicenter study was conducted in 104 women using cyclical dydrogesterone as is used for estrogen replacement therapy. Treatment consisted of dydrogesterone (10 mg/day on days 1-14 followed by placebo on days 15-28 of each cycle) given for six cycles of 28 days. The control group received placebo throughout the six cycles. Bleeding was documented by the patient on diary cards. The number of women with withdrawal bleeding during the first cycle was twice as high in the dydrogesterone group as in the placebo group (65.4% vs. 30.8%; p = 0.0004). Superiority of dydrogesterone was also observed for regularity of bleeding over the six cycles (p < 0.0001), although endometrial thickness after six cycles did not differ between the groups. In conclusion, dydrogesterone is significantly superior to placebo in inducing withdrawal bleeding, and maintaining regular bleeding, in women with secondary amenorrhea and normal estrogen levels.

Current evaluation of amenorrhea

Amenorrhea is the absence or abnormal cessation of the menses. Primary and secondary amenorrhea describe the occurrence of amenorrhea before and after menarche, respectively.

Current evaluation of amenorrhea

Amenorrhea is the absence or abnormal cessation of the menses. Primary and secondary amenorrhea describe the occurrence of amenorrhea before and after menarche, respectively.

Relationship of ultrasonographic endometrial thickness and uterine size to bone mineral density in postmenopausal women

OBJECTIVES

The aim of the present study was to investigate the relations of ultrasonographic endometrial thickness and uterine size to bone mineral density (BMD).

METHODS

Subjects were 200 postmenopausal women (mean age +/- S.D., 57.4 +/- 7.7 years; range, 46-75 years). Age, age at menopause, years since menopause (YSM), height, weight, and body mass index (BMI, weight/height2) were recorded. Endometrial thickness and uterine size (i.e. uterine volume and cross-sectional area) were measured by transvaginal ultrasonography. BMD of the nondominant forearm (one-tenth of the distance from the distal end of the radius) was measured by dual-energy X-ray absorptiometry. Relations of these variables to BMD were investigated.

RESULTS

BMD was inversely correlated with age and YSM (r = -0.69, P < 0.0001; r = -0.56, P < 0.001, respectively), while was positively correlated with uterine volume, uterine cross-sectional area, and endometrial thickness (r = 0.52, P < 0.001; r = 0.45, P < 0.01; r = 0.32, P < 0.05, respectively). After adjusting for age, YSM, and BMI, BMD was still correlated with uterine volume and uterine cross-section (P < 0.01 and 0.05, respectively), while correlation of endometrial thickness with BMD disappeared.

CONCLUSION

Ultrasonographic uterine size shows higher correlation with BMD than endometrial thickness in postmenopausal women. This may be attributable to the fact that uterine size rather than endometrial thickness reflects the duration of estrogen deficiency after menopause.

Current evaluation of amenorrhea

Amenorrhea is the absence or abnormal cessation of the menses. Primary and secondary amenorrhea describe the occurrence of amenorrhea before and after menarche, respectively.

Prediction of pituitary down-regulation by evaluation of endometrial thickness in an IVF programme

The aim of this retrospective study was to determine whether pituitary down-regulation after gonadotrophin-releasing hormone analogue (GnRHa) administration can be accurately predicted by transvaginal ultrasonographic measurement of endometrial thickness in the presence of menstruation. All cycles of an IVF/intracytoplasmic sperm injection programme in which a long protocol of GnRHa was used for ovarian stimulation were analysed. Overall, 209 patients underwent 223 treatment cycles. Using a serum oestradiol concentration of 50 pg/ml as a cut-off point, the sensitivity, specificity, predictive value and false positive and false negative values were calculated for prediction of pituitary down-regulation from endometrial thickness measurements. Pituitary down-regulation was achieved in 223 treatment cycles in 180 patients (80%). The best combination of the highest specificity (71.7%) and sensitivity (62.5%) is achieved with a linear appearance of the endometrium. Therefore, ultrasonographic measurement of endometrial thickness should be used in combination with serum oestradiol concentration in estimating pituitary down-regulation after GnRHa. In conclusion, the linear appearance of endometrium can be as reliable as serum oestradiol concentration in prediction of pituitary down-regulation after GnRHa.

Use of dydrogesterone as a progestogen for oral contraception

Dydrogesterone is a potent orally active progestogen that has been used in clinical practice for over 40 years. Chemically, it belongs to the class of retrosteroids. Dydrogesterone is closely related to endogenous progesterone. It differs from most other synthetic progestogens in that it has no estrogenic, androgenic, glucocorticoid, or anabolic effects. The use of progestogens such as dydrogesterone is indicated in all cases of relative or absolute endogenous progesterone deficiency. Nowadays, dydrogesterone is mainly used in hormone replacement therapy (HRT). The present pilot study explored whether dydrogesterone could also be used as a progestogen for oral contraception. Given its highly favorable safety and tolerability profile, it would provide improvement over existing progestogens currently used in oral contraceptives (OCs). The results of this study indicate that dydrogesterone might indeed be a suitable candidate for use in oral contraception. This concept is currently being investigated further in two open-label phase II trials.

Factors associated with endometrial bleeding in continuous hormone replacement therapy

OBJECTIVE

To identify clinical and laboratory parameters associated with the occurrence of endometrial bleeding within the first 6 months of treatment in postmenopausal women taking continuous hormone replacement therapy.

DESIGN

We performed a prospective study of 55 postmenopausal women who had amenorrhea for at least 12 months before baseline screening and were taking 0.625 mg conjugated estrogen and 5 mg medroxyprogesterone acetate daily on a continuous basis. Postmenopausal duration was defined as the interval, in months, between the last menstruation and the commencement of treatment. All subjects were instructed to monitor bleeding episodes in a diary and were followed up monthly for at least 12 months.

RESULTS

Thirty-four women (62%) experienced bleeding within the first 6 months of treatment. Using a multivariate approach, a woman with a postmenopausal duration of 24 months or less had a relative risk of 8.2 (95% confidence limits: 1.3, 53.1) of bleeding, as compared with those with a postmenopausal duration of more than 24 months. Furthermore, pretreatment endometrial thickness greater than 5 mm (p < 0.05) and serum estradiol levels greater than 25 pg/mL (p < 0.01) were noted to be significantly correlated with the occurrence of bleeding in women with a postmenopausal duration of more than 24 months.

CONCLUSIONS

Women with a postmenopausal duration of 24 months or less, a pretreatment endometrial thickness greater than 5 mm, and serum estradiol level greater than 25 pg/mL are at risk to have endometrial bleeding within the first 6 months of continuous hormone replacement therapy.

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.

Role of three-dimensional ultrasonographic measurement of endometrium volume as a predictor of pregnancy outcome in an IVF-ET program: a preliminary study

OBJECTIVE

To evaluate the role of three-dimensional (3D) ultrasonographic measurement of the endometrium in predicting pregnancy in an IVF-ET program.

DESIGN

Prospective study.

SETTING

Center for assisted reproductive techniques.

PATIENT(S)

65 women undergoing controlled ovarian hyperstimulation for IVF.

INTERVENTION(S)

Ultrasonographic examination on the day of hCG administration.

MAIN OUTCOME MEASURE(S)

Endometrial volume, endometrial thickness, and pregnancy rate.

RESULT(S)

The mean (+/-SD) endometrium volume (4.16 +/- 1.97 mL), endometrium thickness (11 +/- 2 mm), and estradiol level (1686.82 +/- 1057.10 pg/mL) in 21 pregnant women on the day of hCG administration did not differ statistically differ from the respective values in 44 nonpregnant women (4.53 +/- 1.79 mL; 11 +/- 2 mm, 1883.56 +/- 1147.21 pg/mL). Receiver-operating characteristic curves showed that the area under curve (AUC) was 0.57 for endometrial volume and 0.48 for endometrial thickness. Using a cut-off value of 2.5 mL for endometrial volume to predict pregnancy, results of the Fisher exact test were statistically significant. No significant cut-off value was found for endometrial thickness.

CONCLUSION(S)

Endometrial volume and thickness on the day of hCG administration did not predict occurrence of pregnancy. A minimum volume of 2.5 mL appeared to favor pregnancy. The predictive value of 3D ultrasonographic measurement of endometrial volume and thickness was better than that of 2D measurement.

Prospective evaluation of endometrial thickness as a predictor of pituitary down-regulation after gonadotropin-releasing hormone analogue administration in an in vitro fertilization program

OBJECTIVE

To determine whether pituitary down-regulation after gonadotropin-releasing hormone analogue (GnRH-a) administration can be accurately predicted by transvaginal ultrasonographic measurement of endometrial thickness.

DESIGN

Prospective study.

SETTING

An IVF unit of an academic medical center.

PATIENT(S)

One hundred eighty-one patients undergoing 265 IVF-ET treatment cycles using GnRH-a in the long protocol.

MAIN OUTCOME MEASURE(S)

Serum concentrations of E2 were determined, and endometrial thickness was measured by transvaginal sonography. The accuracy of endometrial thickness for predicting pituitary down-regulation was calculated.

RESULT(S)

Pituitary down-regulation, defined as a serum E2 concentration of < or = 55 pg/mL, was achieved in 77% (204 of 265) of the cycles. An endometrial thickness of < or = 6 mm was found in 92.2% (188 of 204) of cycles in which down-regulation was achieved. An estradiol level of < or = 55 pg/mL was present in 95.9% (188 of 196) of cycles with endometrial thickness of < or = 6 mm.

CONCLUSION(S)

A state of relative hypoestrogenism after GnRH-a administration, indicative of pituitary down-regulation, can be predicted with a high degree of accuracy by ultrasonographic measurement of endometrial thickness. Thus, routine testing for serum E2 concentration may be safely omitted. This may allow further simplification of IVF protocols and increase both cost-effectiveness and patients' convenience.

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.

Endometrial volume change during spontaneous menstrual cycles: volumetry by transvaginal three-dimensional ultrasound

OBJECTIVE

At present, only limited data are available on endometrial volume during the menstrual cycle. Most of these studies deal with animal models and use magnetic resonance imaging for volume measuring. The application of three-dimensional ultrasound in endometrial volume estimation is the subject of this study.

SETTING

Patients visiting the outpatient unit of the division of endocrinology and reproductive medicine of a university hospital.

PATIENT(S)

Twenty patients with a history of a normal menstrual cycle were selected.

INTERVENTION(S)

Ultrasound examinations were performed during a single menstrual cycle in addition to routine laboratory tests.

MAIN OUTCOME MEASURE(S)

Uterus-endometrial volume ratio.

RESULT(S)

Data from 18 patients could be evaluated. In 81 examinations the endometrium volume could be determined. Mean endometrial volume measured by three-dimensional ultrasound was 1.23 cm3. Mean uterus volume was 48.93 cm3. The change of the uterus-endometrial volume ratio showed a good correlation with the day of menstrual cycle. Quadratic regression analysis of volume and cycle length was R2 = 0.432.

CONCLUSION(S)

Three-dimensional ultrasound allows assessment of volume data of the female internal genitalia. In this study changes of the endometrial volume in menstrual cycles were measured. Additional studies are required to give information on the clinical impact of this new technique of endometrial volume estimation.

Endometrial cancer and hormone replacement therapy. Appropriate use of progestins to oppose endogenous and exogenous estrogen

Most instances of endometrial cancer are potentially preventable. Unopposed endogenous estrogen stimulation of the endometrium has been shown to be the predisposing risk factor in most cases. Risk factors have been well-delineated, and it is important to recognize and treat the progesterone-deficient patient. Low-dose oral contraceptive pills in healthy, nonsmoking, older reproductive-aged women are an underutilized treatment modality. The many noncontraceptive benefits of longterm oral contraceptive use until the menopause should be explained to the patient, including the prevention of ovarian and endometrial cancer, the maintenance of bone density, and a reduction in the many surgical procedures performed for menstrual disorders. Progestin therapy in older reproductive-aged women and postmenopausal women with unopposed estrogen production is mandatory to prevent endometrial cancer. Knowledge and skill in simple endometrial sampling techniques performed in patients with known risk factors for endometrial cancer will often detect premalignant lesions that are treatable with progestin therapy or surgery.