Reproductive history of women exposed to diethylstilbestrol in utero

Utérus DES. Polémiques sur l'hystéroplastie d'agrandissement. Arguments contre

Uterine malformations in DES-exposed women are not the only aetiologies for infertility, miscarriages, and other problems in their reproductive life. A global screening of fertility factors of the couple may, for instance, show in them vascular uterine abnormalities which reduce their reproductive potential. Furthermore, these abnormalities are not always predictive of losses of pregnancy, and many exposed women with patent uterine abnormalities can carry a pregnancy to term. Metroplasty for uterine enlargement is a surgical procedure suggested for restoring the size and shape of the uterine cavity. There are no comparative studies for assessing efficacy and safety of metroplasty. Therefore, metroplasty should not be performed routinely, but should only be considered after the couple has undergone a full fertility workup, and the best possible level of fertility has been achieved.

Résultats obstétricaux de 454 femmes exposées au diéthylstilboestrol pendant leur vie fœtale : analyse cas-témoins

OBJECTIVE

To analyze the predictive effect on obstetrical outcome in women with prenatal exposure to diethylstilbestrol (DES) of previous obstetrical history or the specific risk of DES exposure.

PATIENTS AND METHODS

We included all in utero DES-exposed women (454 women) followed and delivered at one maternity unit in Paris and compared them with two control women matched for age, parity, number of late fetal losses, number of previous preterm births, number of singleton or twin fetuses, and follow-up, who were managed by the same team or referred for pregnancy complication.

RESULTS

DES women had a higher rate of preterm birth (19.2%) than matched controls (10.5%), even when considering women with a previous preterm birth or twin pregnancy. The rate of fetal or neonatal deaths were lower in DES-exposed women than in controls. DES women showed a higher rate of severe post partum bleeding (2.8%) than matched controls (1.5%) or the global population of women delivered in this maternity unit.

CONCLUSION

A history of prenatal exposure to DES is a major predictor of preterm birth for primiparous women and for those with an adverse obstetrical history.

Diethylstilbestrol exposure: it's still an issue

Persons exposed to diethylstilbestrol have higher risks of certain health problems. Nurses have an important role in identifying women who received diethylstilbestrol while pregnant and the children of those pregnancies. Identification of these persons allows for risk analysis and counseling, and assists in appropriate referrals for further evaluation and treatment. The following information will help you facilitate this role.

Effect of diethylstilbestrol on reproductive function

OBJECTIVE

To review the effects of in utero exposure to diethylstilbestrol (DES) on müllerian development and subsequent reproductive function.

DESIGN

The literature on DES and reproductive function was reviewed and summary data are presented. The studies were identified through the computerized MEDLINE database and a manual search of relevant bibliographies.

RESULT(S)

In utero exposure to DES resulted in reduced fertility and increased rates of ectopic pregnancy, spontaneous abortion, and preterm delivery.

CONCLUSION(S)

An understanding of the reproductive performance of women who were exposed to DES in utero is useful for counseling these patients regarding their risks and treatment options.

Environmental endocrine modulators and human health: an assessment of the biological evidence

Recently, a great deal of attention and interest has been directed toward the hypothesis that exposure, particularly in utero exposure, to certain environmental chemicals might be capable of causing a spectrum of adverse effects as a result of endocrine modulation. In particular, the hypothesis has focused on the idea that certain organochlorine and other compounds acting as weak estrogens have the capability, either alone or in combination, to produce a variety of adverse effects, including breast, testicular and prostate cancer, adverse effects on male reproductive tract, endometriosis, fertility problems, alterations of sexual behavior, learning disability or delay, and adverse effects on immune and thyroid function. While hormones are potent modulators of biochemical and physiological function, the implication that exposure to environmental hormones (e.g., xenoestrogens) has this capability is uncertain. While it is reasonable to hypothesize that exposure to estrogen-like compounds, whatever their source, could adversely affect human health, biological plausibility alone is an insufficient basis for concluding that environmental endocrine modulators have adversely affected humans. Diethylstilbestrol (DES) is a potent, synthetic estrogen administered under a variety of dosing protocols to millions of women in the belief (now known to be mistaken) that it would prevent miscarriage. As a result of this use, substantial in utero exposure to large numbers of male and female offspring occurred. Numerous studies have been conducted on the health consequences of in utero DES exposure among the adult offspring of these women. There are also extensive animal data on the effects of DES and there is a high degree of concordance between effects observed in animals and humans. The extensive human data in DES-exposed cohorts provide a useful basis for assessing the biological plausibility that potential adverse effects might occur following in utero exposure to compounds identified as environmental estrogens. The effects observed in both animals and humans following in utero exposure to sufficient doses of DES are consistent with basic principles of dose response as well as the possibility of maternal dose levels below which potential non-cancer effects may not occur. Significant differences in estrogenic potency between DES and chemicals identified to date as environmental estrogens, as well as an even larger number of naturally occurring dietary phytoestrogens, must be taken into account when inferring potential effects from in utero exposure to any of these substances. The antiestrogenic properties of many of these same exogenous compounds might also diminish net estrogenic effects. Based on the extensive data on DES-exposed cohorts, it appears unlikely that in utero exposure to usual levels of environmental estrogenic substances, from whatever source, would be sufficient to produce many of the effects (i.e., endometriosis, adverse effects on the male reproductive tract, male and female fertility problems, alterations of sexual behavior, learning problems, immune system effects or thyroid effects) hypothesized as potentially resulting from exposure to chemicals identified to date as environmental estrogens.

Exposure to a xenoestrogen before birth: the diethylstilbestrol experience

The experiences of diethylstilbestrol (DES), used as a medication for pregnant women, provide a panorama of the effects of an elevated exposure to xenoestrogens during the development of a fetus. DES was common as pregnancy medication in North America, and several European countries from the 1950s into the 1970s. It may still be prescribed as pregnancy medication in Third World countries. DES exposure in utero has been shown to have carcinogenic, teratogenic and reproductive effects. The medical community needs to be alerted to appropriate treatment of patients exposed in utero to elevated levels of estrogens.

Prenatal exposure to diethylstilbestrol and the mother-daughter relationship

The psychological consequences resulting from the exposure to diethylstilbestrol (DES), a non-steroidal oestrogen, on the mother-daughter relationship are studied using semi-directive interviews with 43 daughters and 7 mothers treated with DES during their pregnancies. These women referred to gynaecological consultation for DES-related problems. The daughters, exposed to DES during their foetal life, learned about DES after a pregnancy mishap (35% of the cases), or by accident (65% of the cases). All of them were shocked when the existence of DES and its side effects were revealed to them. Consequences on the mother-daughter relationship were absent in 60% of the cases, favourable in 20%, and negative in 20%. Five percent of the women showed hostility towards the medical practice, but 65% were not suspicious of the drugs administered to them during their pregnancies. For 64% of them, administration of DES to their mother had been kept secret. In 7 out of 50 cases, parents alone came for medical assistance in order to manage the secret. Exposure to DES may reveal pre-existing difficulties not only between the mother and the daughter, but sometimes beyond from generation to generation.

Conservative management and pregnancy outcome in diethylstilbestrol-exposed women with and without gross genital tract abnormalities

OBJECTIVES

Our goal was to determine the effect of conservative management on pregnancy outcome in diethylstilbestrol-exposed women with and without gross structural lesions of the genital tract.

STUDY DESIGN

The study included a case series of women prospectively enrolled over a 10-year period.

RESULTS

Pregnancy outcome and both antepartum and intrapartum events occurring in a case series of 120 conservatively managed pregnancies in 50 diethylstilbestrol-exposed women were reviewed. Group A (n = 34, 89 pregnancies) consisted of women with gross upper or lower genital tract lesions associated with diethylstilbestrol exposure, whereas group B (n = 16, 31 pregnancies) consisted of women whose lesions were limited to colposcopic findings. Cerclage was limited to women with a history of cervical incompetence (n = 1, two pregnancies) or acute cervical change in the second trimester (one pregnancy). Women with cervical change occurring after 25 weeks' gestation were managed with bed rest. Group A experienced more spontaneous first-trimester losses than group B (25.8% vs 12.9%, p < 0.01), whereas group B had a greater gestational age at delivery (39.8 +/- 1.5 vs 37.3 +/- 3.8 weeks, p < 0.01) than group A. Overall, pregnancies surviving the first trimester (n = 94) resulted in delivery of a viable infant discharged home 92.2% of the time; 77.9% of pregnancies reached term. The perinatal loss rate was 1.3%. Preterm labor (6.5%) and preterm rupture of membranes (3.8%) resulted in an overall rate of preterm birth of 9.2%. There were no significant differences in length of any labor stage between groups, nor were there any differences in the use of oxytocin augmentation or cesarean section rates between groups. Postpartum hemorrhage and retained placenta were infrequent complications.

CONCLUSIONS

The majority of pregnancy loss in diethylstilbestrol-exposed patients occurs in the first trimester. Cervical incompetence is an infrequent cause of pregnancy loss even in patients with gross structural abnormalities of the genital tract. Patients who had conservative management had good pregnancy outcomes. Prophylactic cerclage for all diethylstilbestrol-exposed patients should not be recommended.

Hysteroscopic metroplasty in the diethylstilbestrol-exposed uterus and similar nonfusion anomalies: effects on subsequent reproductive performance; a preliminary report

OBJECTIVE

To determine the feasibility of correcting the uterine abnormalities seen in diethylstilbestrol (DES)-exposed women and similar anomalies.

DESIGN

Patients served as their own controls.

SETTING

University based and private practice tertiary referral practice.

PATIENTS

Eight patients referred for infertility, recurrent pregnancy loss, or both with an abnormal uterine contour as seen by hysterosalpingogram.

INTERVENTION

Hysteroscopic metroplasty.

OUTCOME MEASURES

Ability to conceive and carry pregnancy to livebirth.

RESULTS

Three of five patients with secondary infertility and recurrent pregnancy losses had livebirths as did a patient with secondary infertility. Two patients with primary infertility failed to conceive.

CONCLUSION

Metroplasty may decrease pregnancy loss in these patients but may not enhance fertility.

Diethylstilboestrol: I, Pharmacology, Toxicology and carcinogenicity in humans

Diethylstilboestrol is still used as an adjunct palliative treatment in certain patients with breast and prostate cancer. Its pharmacological, toxicological and carcinogenic properties are reviewed. In addition to the usual untoward effects following subacute or chronic administration of oestrogens, treatment with diethylstilboestrol has been associated with serious cardiovascular sequelae. Most characteristic are, however, the carcinogenic properties of this drug. Many epidemiological data provide evidence that prenatal exposure to diethylstilboestrol is causally associated with vaginal and cervical clear-cell adenocarcinomas, a very rare type of cancer in the unexposed female population. The intrauterine exposure of males leads to an increased risk of testicular cancer, although the data are less conclusive in this respect. There is some evidence that administration of diethylstilboestrol in large doses to adult women during pregnancy increases the risk of subsequent breast cancer and it probably increases the incidence of endometrial carcinoma, as has been shown with other similar oestrogens given chronically for menopausal symptoms.

Histologic, morphometric, and immunocytochemical analysis of myometrial development in rats and mice: II. Effects of DES on development

The effects of diethylstilbestrol (DES) treatment on myometrial development from the prenatal to adult period were examined in rats and mice by histologic and immunocytochemical methods using anti-actin, -vimentin, and -laminin to assess cytodifferentiation of smooth muscle and fibroblastic cells, and by morphometric procedures to assess quantitatively the effect of DES on the expression of cellular orientation in the emerging inner circular myometrial layer. Neonatal rats and mice were treated with DES from day 0 (day of birth) to day 2 with dosages known to perturb myometrial development. Neonatal treatment with DES increased the degree of circular orientation within the uterine mesenchyme, an effect detectable following as little as 24 hr of DES treatment. This effect on spatial organization of the mesenchyme was followed by an increase in the thickness of the actin-positive middle layer (prospective circular myometrium) of uterine mesenchyme during days 3-15; from day 15 onward, however, the circular myometrial layer began to fragment into irregular bundles of smooth muscle, and the longitudinal myometrial layer became thinner and more irregularly organized than controls. Vimentin localization in rats treated with DES neonatally was more intense than in controls within the circularly orientated uterine mesenchyme at 5 days. By 60 days the circular and longitudinal myometrial layers of DES-treated animals showed strands and bundles of vimentin-positive cells, which were not present in controls. Both rats and mice show comparable effects of DES treatment.

Cervical incompetence

In the early 1950s, when treatment of cervical incompetence was first described, diagnosis seemed relatively simple and management favorable, but after more than 35 years of trying multiple variations of procedures and treatment regimens, no advances have been made. In 1959, Neser questioned the very existence of cervical incompetence as an entity, and concluded that, in the final analysis, the problem is a diagnostic one. Liberal use of cerclage in situations of moderate risk of preterm delivery or as a prophylactic measure for multiple gestation does not appear to improve outcome, as judged by prematurity or survival. Because of advances in neonatal care in the last decade, fetal survival has improved tremendously. It is hoped that, in the future, more objective and accurate criteria for the diagnosis of cervical incompetence will emerge, and that outcome of treatment will be measured not by fetal survival, but by prolongation of pregnancy and by birth weight. At present, making an unequivocal diagnosis of cervical incompetence remains an elusive, challenging, and unsolved problem.

Infertility among daughters either exposed or not exposed to diethylstilbestrol

Infertility was examined among 343 diethylstilbestrol-exposed and 303 unexposed daughters whose mothers participated in an evaluation of diethylstilbestrol use during pregnancy 35 years ago. Of the married individuals who were not using contraception and who were actively trying to conceive, a greater proportion of diethylstilbestrol-exposed women than unexposed subjects experienced primary infertility (33% versus 14%, p less than 0.001). Among those with primary infertility, abnormal hysterosalpingograms were observed in 46% of the diethylstilbestrol-exposed group and in none of the unexposed group (p less than 0.02), while tubal abnormalities were found in 42% of the exposed and in none of the unexposed (p = 0.02). First pregnancies were achieved by 40 (58%) women exposed to diethylstilbestrol and 18 (64%) unexposed subjects. Twenty-four (60%) of the exposed women and 15 (83%) of the unexposed individuals who conceived had a live-born infant who survived. The estimated cumulative rate of first pregnancy was 16% for the exposed group and 36% for the unexposed group at 12 months after the diagnosis of primary infertility (p less than 0.05).

Incidence and aetiology of hydatidiform mole: an epidemiological review

Epidemiological investigation of the incidence and aetiology of hydatidiform mole (HM) is receiving increasing attention. Recent, population-based studies suggest that earlier reports of a very high incidence of HM in Asia, Africa and South-Central America may have been exaggerated, due primarily to selection bias in patients studied at university hospitals. Japanese population studies indicate a two-fold higher rate of HM compared with Caucasian rates but Chinese rates appear to be similar. Population studies presently available suggest a worldwide range of HM somewhere between 0.5 and 2.5/1000 pregnancies. When deliveries form the rate denominator the rates are somewhat higher, depending primarily on the national rate of induced abortions. The independent effects on incidence of geographic locale, ethnicity and socio-cultural factors have not been adequately disentangled although the genetic studies suggest ethnicity might be the predominant variable. Maternal age is the most consistently demonstrated risk factor; teenagers and, especially, women over age 35 being at increased risk. The independent effects of paternal age and pregnancy history are not established. Women with a history of one HM seem to have a ten-fold risk of repeat HM compared with women who have no history of HM. Aetiological studies have not revealed any environmental risk factor for which there is unequivocal agreement about its influence on HM. New case-control studies of HM aetiology must classify HM according to genetic aetiology. Cohort studies are required to explore more fully the relation of HM to malignant sequelae.

Management of the diethylstilbestrol-exposed pregnant patient: a prospective study

Over a 5-year period we have managed 63 diethylstilbestrol-exposed pregnant patients with a standardized protocol requiring weekly cervical examination and decreased physical activity of the patient. Twenty-six patients (42%) underwent a prophylactic cerclage for a history of second-trimester loss or a hypoplastic cervix on initial clinical examination (group I). Thirty-six patients (58%) were followed expectantly (group II). Sixteen patients (44%) in group II demonstrated cervical change and required an emergency cerclage. Twenty-one patients were managed expectantly with no cerclage. The gestational age at delivery for group I was 37.7 +/- 2.80 versus 34.5 +/- 6.9 weeks for patients without a cerclage (p = 0.04). There were no perinatal deaths if a cerclage was performed, whereas there were five deaths (24%) in the group without cerclage. The five deaths occurred at a mean gestational age of 24.40 +/- 4.0 weeks and a mean birth weight of 614.00 +/- 441.73 gm. Patients with a hypoplastic cervix or prior reproductive loss had a better outcome with early cerclage than patients with a normal cervix followed expectantly. We presently lack a reliable method to detect the diethylstilbestrol-exposed patient at greatest risk for perinatal loss. Based on our experience we believe that placement of a cerclage early in pregnancy should be a strong consideration.

Long-term evaluation of the diethylstilbestrol (DES) syndrome in adult female rhesus monkeys (Macaca mulatta)

This study was designed to examine the transplacental effects of diethylstilbestrol (DES) in rhesus monkeys (Macaca mulatta). Nineteen pregnant females received an approximate human therapeutic dose of 1 mg/day DES beginning on gestational day 21 (Group I), day 100 (Group II), or day 130 (Group III) until term. Colposcopic examination and vaginal biopsies were performed in eight female offspring at 6- and 12-month intervals beginning at 3.5 years of age until death between 5 and 12 years of age. Gross and histological evidence of vaginal adenosis was observed in five of eight (62.5%) females. Adenosis, which occurred in all treatment groups, did not develop into neoplasia; rather, it underwent metaplasia and reversion to squamous epithelium, a frequent observation in human DES cases. The vaginal ridging and/or cervical hooding characteristic of the human syndrome was observed in all exposed females. Although menstrual cyclicity was not impaired, there appeared to be a lower pregnancy rate in treated animals compared to age-matched controls. This long-term evaluation of reproductive morphology and function in the rhesus monkey has provided a useful model for studying the history of benign vaginocervical abnormalities induced by prenatal DES treatment.

The obstetric consequences of uterovaginal anomalies

Congenital uterovaginal anomalies can have adverse effects on pregnancy outcome. Early diagnosis and an aggressive evaluation of any patient presenting with mid-trimester abortion, premature labor, malpresentation, or retained placenta may prevent additional pregnancy wastage and maternal morbidity. With more timely and accurate diagnosis, appropriate management is likely to provide the best possible outcome for all such patients.

The role of the estrogen receptor in diethylstilbestrol toxicity

The site and specificity of the tissue response to a toxicant are of central importance; it is in this area of diethylstilbestrol (DES) toxicity that the estrogen receptor would appear to play its primary role. Compilation of the various sites of DES toxicity in humans and experimental animals indicates that lesions appear predominantly in estrogen responsive target tissues suggesting that the presence of the estrogen receptor in such target tissues may help govern the tissue specificity of the toxic insult. DES and many of its oxidative metabolites interact with high affinity with the estrogen receptor. Such an interaction may be responsible for localizing DES to target tissues. Autoradiographic and biochemical studies have supported the localization of radiolabeled DES in susceptible tissues. The intracellular mechanism of receptor binding of DES and certain metabolites could then result in mobilization of these compounds to the nucleus. Experimental evidence has shown that DES and a number of its metabolites are able to translocate receptor to the nucleus of uterine cells. Such an action by the receptor results in an increased probability of potential chemical interactions with the genome. The actual induction of a chemical lesion in the target cell may, at this point, proceed by non-receptor mediated mechanisms. For example, studies using in vitro cell culture systems which contain no estrogen receptors have shown that DES can induce neoplastic cell transformation, mutagenesis, irreversible binding to DNA and protein and unscheduled DNA synthesis. These results raise the possibility that a part of DES toxicity may follow pharmacologic principles established for chemical carcinogens. Following induction of the molecular lesion, the role of the receptor continues in this process by mediating increased protein synthesis and mitogenesis in responsive target tissues which ultimately permits a more extensive expression of the toxic effects. It has been demonstrated that DES is a potent mitogen in vivo in both uterine and pituitary tissues, subsequently, the lesion will perpetuate itself through this receptor mediated biological response. This is particularly important since a number of DES induced reproductive tract tumors are expressed only after additional estrogen exposure. While other tumors have been shown to be estrogen sensitive and will regress without continued estrogen stimulation. Therefore, it should be considered that the presence of the estrogen receptor and the estrogen receptor mediated biological responsiveness of a particular tissue are most important in explaining the specificity of DES toxicity.

Psychosexual milestones in women prenatally exposed to diethylstilbestrol

Thirty women aged 17 to 30 years with a record-confirmed history of prenatal exposure to diethylstilbestrol (DES) were compared to 30 women of similar age and demographic background with a history of abnormal Pap smear findings. Heterosocial and heterosexual histories were assessed by systematic semistructured interviews. The groups differed neither in the age at menarche nor in the age at attainment of various psychosexual milestones.

Upper genital tract abnormalities and pregnancy outcome in diethylstilbestrol-exposed progeny

Previous studies have suggested that there is an association between genital tract abnormalities and pregnancy outcome in women exposed to diethylstilbestrol (DES) in utero. In a collaborative study, 676 DES-exposed women had hysterosalpingographic examinations, and the findings were related to the outcome of pregnancy in 327 of these women. The findings revealed that (1) there is a considerable variation of frequency of different types of upper genital tract anomalies in women from different sources and with different motivations for enrollment in the study, (2) the presence of structural cervical changes and vaginal epithelial changes are markers for the likelihood of abnormalities in the uterine fundus, (3) women with upper genital tract abnormalities have increased odds for poor pregnancy outcome as compared to women with normal hysterosalpingographic findings, and (4) although some abnormalities were most often or consistently associated with poor pregnancy outcome, no specific changes could be related to specific types of pregnancy outcomes.

Drug-induced infertility

Primary infertility may result from the use of various drugs. This phenomenon may be the result of an effect on the hypothalamic-pituitary-gonadal axis or a direct toxic effect on the gonads. Some of the drugs considered in this article demonstrate sex-related differences in their ability to cause infertility; there also may be age-related differences. The drugs described in this review, in regard to their association with the development of infertility, include various individual antineoplastic agents (cyclophosphamide, chlorambucil, busulphan, and methotrexate) and combinations of these chemotherapeutic drugs, glucocorticosteroids, hormonal steroids (diethylstilbestrol, medroxyprogesterone acetate, estrogen, and the constituents of oral contraceptives), antibiotics (sulfasalazine and co-trimoxazole), thyroid supplements, spironolactone, cimetidine, colchicine, marihuana, opiates, and neuroleptic agents.

Developmentally arrested oviduct: a structural and functional defect in mice following prenatal exposure to diethylstilbestrol

To determine the effects of exposure to diethylstilbestrol (DES) on the developing oviduct, timed pregnant CD-1 mice were treated with DES (10-100 micrograms/kg subcutaneous) on days 9-16 of gestation. Prenatal DES-exposed and age-matched control mice were sacrificed from day 16 of gestation to 15 weeks of age and oviductal development was compared. Following prenatal exposure to DES (100 micrograms/kg), the oviduct at all ages examined was uncoiled and shorter, closely adherent to and wrapped around the ovary in an anatomical configuration similar to the fetal mouse. In addition, the demarcation between the oviduct and uterus was not readily apparent. Histological changes in the DES (100 micrograms/kg) oviduct as compared with control at 10-15 weeks of age included a proliferation of columnar epithelium lining the lumen with gland formation extending into the underlying stroma, absence of or a reduced amount of fimbrial tissue, increased thickness of the muscular wall, and inflammatory cell infiltration. Also, as a functional test of uterotubal junction integrity, Coomassie Blue dye was injected into the uterus. The control uterotubal junction confined the fluid to the uterus. In 80% and 100% of the animals exposed prenatally to DES (10 and 100 micrograms/kg, respectively), independent of the extent of the gross abnormality, the dye readily flowed into the oviduct and filled the ovarian bursa. We conclude that prenatal DES exposure can alter fetal development of the mouse oviduct, resulting in an apparent developmental arrest and functional disruption of the integrity of the uterotubal junction. The fetal like configuration of the ovary, oviduct, and uterus suggests the term developmentally arrested oviduct (DAO).

Complications of pregnancy in mice exposed prenatally to DES

Women exposed prenatally to diethylstilbestrol (DES) develop a variety of reproductive tract anomalies. Most of these anomalies have been replicated in strain CD-1 mice after similar DES exposure. Recently, impaired reproductive performance in DES-exposed women has been reported. To see whether the mouse model also replicates this defect, a study of reproduction was performed. Pregnant CD-1 mice were injected with DES and their female offspring were raised to breeding age. The latter were then exposed continuously to untreated males for a maximum of 4 months. Among 74 mated mice, 34 became pregnant and 11 of these pregnancies ended in abortion or stillbirth. Other anomalies encountered were: two fetuses with compressed heads, one of which seemed blocked from delivery by a vaginal adenocarcinoma; two uterine tumors, one of which was a teratocarcinoma; two teratomas located in uterine lumina; and two uteri containing placentas without embryos. Since the frequency of successful pregnancies in the DES-exposed mice was reduced below control levels to a degree similar to that reported for DES-exposed women, the validity of the mouse model has been confirmed for this characteristic.

Reduced fertility in female mice exposed transplacentally to diethylstilbestrol (DES)

Prenatal exposure to diethylstilbestrol (DES), a synthetic estrogen, has been associated with a low incidence of vaginal adenocarcinoma as well as a variety of more numerous benign abnormalities in the reproductive tract of human beings and experimental animals. For the purpose of assessing the effects of prenatal exposure to DES on postnatal reproduction tract function, timed pregnant CD-1 mice were treated subcutaneously with doses of DES ranging from 0.01 to 100 microgram/kg/day on days 9 through 16 gestation. The fertility of the female offspring was determined postnatally by a repetitive forced breeding technique. The most striking effect observed was a dose-related decrease in reproductive capacity ranging from minimal subfertility at the lower DES doses to a high frequency of total sterility at the highest DES doses. Reduced reproductive capacity appeared to be a reflection of both a decrease in the total number of litters and smaller litter sizes. A major component of the sterility seen in those females given higher doses of DES was oviductal/ovarian, since the number of ova recovered from the oviductal ampullae after induced ovulation was less than 30% that of controls. In addition, structural abnormalities of the oviduct, uterus, cervix, and vagina were observed, and contributed to infertility. These data suggest that in utero exposure to DES results in permanent impairment of female mouse reproductive capacity. Recent reports of altered pregnancy outcomes in young women who were exposed in utero to DES demonstrate the clinical importance of the findings obtained in mice.

Menstruation and its disorders in adolescence

This monograph has presented a review of menstrual disorders in adolescents. It has been emphasized that health care professionals who deal with youths should consider a comprehensive approach that places the youth with a menstrual problem within the framework of her adolescent and pubertal development. Thus, a discussion of psychologic growth as well as important aspects of puberty were presented. A thorough medical history and carefully done pelvic examination remain the basis for any evaluation of these young women even in this age of rapidly-advancing medical technology. Many of the menstrual dysfunction problems are related to the sequential, physiologic events of puberty and can be effectively handled by the well-trained general clinician. Specific, complex situations should be referred to the appropriate specialist, preferably someone with an understanding of adolescence. Three basic types of menstrual disorders have been considered: dysmenorrhea, dysfunctional uterine bleeding and amenorrhea. Our conclusion is that there is much the general clinician can do for the adolescent who presents with menstrual dysfunction.

In utero exposure to diethylstilbestrol: adverse effects on the reproductive tract and reproductive performance and male and female offspring

Exposure to diethylstilbestrol (DES) in utero is associated with adverse effects on the reproductive tract in male and female progeny. These effects include epididymal cysts, microphallus, cryptorchidism, and testicular hypoplasia in male subjects and adenosis, clear cell adenocarcinoma, and structural defects of the cervix, vagina, uterus, and fallopian tubes in female subjects. As these offspring have reached reproductive age, reports of adverse reproductive performance have been published, including still controversial reports of menstrual dysfunction and infertility. More well established are increased rates of spontaneous abortion, ectopic pregnancy, premature deliveries, and perinatal deaths, all contributing to an increase in overall adverse pregnancy outcome. Often there is correlation between the DES-associated anatomic abnormalities in the reproductive tract and the adverse reproductive performance. Altered male reproductive capacity is also suggested by diminished semen analyses and sperm penetration assays. A detailed review of these effects of in utero DES exposure is presented.

Reproductive and gynecologic surgical experience in diethylstilbestrol-exposed daughters

Information on reproductive history, gynecologic operations, and examinations was analyzed for 338 diethylstilbestrol (DES)-exposed and 298 unexposed women whose mothers participated in an evaluation of DES use in pregnancy 28 years ago. A history of infrequent menses (less often than every 36 days) was reported more commonly by the exposed women (32%) than by the unexposed women (15%) and the mean duration of menstrual flow was also less. A greater number of exposed women than unexposed women experienced primary infertility (53 versus 19). The reasons for these differences are not currently known. Comparison of the outcomes of first pregnancies showed a higher proportion of premature births, spontaneous abortions, and ectopic pregnancies in the exposed women (P less than 0.001). The difference in the occurrence of ectopic pregnancies was statistically significant (8 versus 0; P less than 0.005). An adverse pregnancy outcome was more likely in DES-exposed women with cervicovaginal ridges. However, when the outcome of all pregnancies were considered, 81% of the exposed women had at least one living child. More exposed women than unexposed women had gynecologic surgical procedures, which may, in part, be due to the increased medical surveillance of the exposed group. The spectrum of diseases at operation in both groups was similar. Adnexal masses and pelvic inflammatory disease were more commonly reported among the exposed women while the occurrence of endometriosis in both groups was similar. For the exposed women who had been examined at the Chicago Lying-In Hospital over a 4-year period, epithelial changes in the vagina had disappeared in 32% and cervicovaginal ridges had disappeared in 57%.

Structure and function of the fallopian tubes following exposure to diethylstilbestrol (DES) during gestation

The association between the use of diethylstilbestrol (DES) and vaginal and cervical adenocarcinoma and adenosis in the progeny was first reported by Herbst et al. in 1971. This progeny will reach a peak as far as reproduction is concerned in this decade. It is estimated that 2 million women may be involved to varying degrees. Changes in uterine and cervical contour and structure have been detailed. Thus DES exposure and anatomic changes in the Müllerian system have been documented. In this report 16 women in the reproductive age group who were exposed to DES in utero and presented with infertility are discussed. On workup for infertility they were found to have unique tubal morphologic features consisting of a foreshortened, convoluted tube with "withered" fimbria with a pinpoint os at laparoscopy. The diagnosis could not be made at the time of hysterosalpingogram. Three patients had surgery in an attempt to correct this condition; and in all cases the surgery was unsuccessful. No statistical data is offered as to epidemiologic factors or incidence rates, but the suspected increase in infertility and ectopic pregnancy rates in patients with DES exposure may corroborate these findings.

Clear cell adenocarcinoma and the current status of DES-exposed females

Currently, over 400 cases of clear cell adenocarcinoma of the vagina and cervix occurring in females born after 1940 have been accessioned into the Registry for Research on Hormonal Transplacental Carcinogenesis. Cases have been identified throughout the United States as well as Australia, Canada, Mexico, and Europe. Intrauterine exposure to DES and similar nonsteroidal estrogens have been uncovered in about two-thirds of the cases with an available maternal history. A peak in the age incidence curve of the DES-related cases has been observed at about 19 years with the age range being 7-30 years. The five-year survival for 400 patients has been 80%. Numerous nonmalignant epithelial changes have been observed. It appears that there has not been an increase in the occurrence of premalignant or malignant squamous cell lesions among the DES exposed. Premature birth has been more common among DES-exposed women. For those in whom there is evidence of a midpregnancy loss or premature ripening of the cervix during pregnancy, a cerclage procedure has been effective in producing a desirable outcome.

Pregnancy outcome in women exposed to diethylstilbestrol in utero

The presence of anomalies in vagina, cervix, and uterine body of women exposed to diethylstilbestrol in utero has provoked interest and concern regarding the reproductive potential of these women. To expand and to evaluate better better the current knowledge in this matter, the outcomes of the pregnancies of exposed women registered in the Stilbestrol Clinic at the Stanford University Medical Center were examined. The results were combined with the published results of similar examinations of other institutions and a summation of all available data is presented. Although it is evident that the majority (79%) of exposed women who have become pregnant and not regularly sought abortion have obtained at least one living infant, the incidence of spontaneous abortion and preterm delivery has consistently been found to be greater in exposed women than in unexposed control women. One of every 30 pregnancies reported in exposed patients has been ectopically located. Additionally, there is suggestive evidence that exposed women with teratologic changes have a higher incidence of pregnancy loss than those without such changes. However, few of these observations can boast statistical validity and statistical validation of the same observation by separate investigators has not been obtained. Moreover, none of th teratologic changes in exposed patients has been seen to preclude normal pregnancy and term delivery.