Cortical and trabecular bone mineral content in women with endometriosis: effect of gonadotropin-releasing hormone agonist and danazol

A comparison of foot fractures relative to other fragility fractures: a review and analysis of the American Orthopaedic Association's Own the Bone Database

Evidence regarding the risk factors and characteristics of those with foot fragility fractures compared to non-foot fragility fractures is limited. Foot fragility fracture patients are more likely to be younger female with a higher BMI. A foot fragility fracture is strongly predictive of a subsequent foot fragility fracture.

PURPOSE

Osteoporosis can clinically result in fragility fractures. Evidence regarding the risk factors and characteristics of foot fragility fractures compared to non-foot fragility fractures is limited. The American Orthopaedic Association's Own the Bone (OTB) is a bone health initiative with a substantial dataset. The purpose of this study was to examine and compare characteristics of patients presenting with isolated foot fragility fracture to those with a non-foot fragility fracture.

METHODS

Between January 2009 and March of 2022, 58,001 fragility fractures occurred that were included in this cohort. A total of 750 patients had foot fragility fracture(s) and 57,251 patients had a non-foot fragility fracture that included shoulder, arm, elbow, forearm, wrist, spine, ribs, pelvis, hip, thigh, knee, tibia/fibula, and ankle. Demographics, fracture history, bone health factors, medication history, and medication use for each patient were reported in the OTB database. This data was utilized in our secondary cohort comparative analysis of characteristics and the risk of future fractures between foot fragility fracture and non-foot fragility fracture groups.

RESULTS

Foot fragility fracture patients have a significantly higher probability to be younger (66.9 years old), female (91.5%), and have a higher BMI (28.3 kg/m2) compared to non-foot fragility fracture (p < 0.0001) patients. Patients with a foot fragility fracture are nine times (OR = 9.119, CI = 7.44-11.18, p < 0.001) more likely to have had a prior foot fragility fracture. Young, female patients with a prior foot fragility fracture are at higher risk of a future foot fragility fracture, and this risk increased as BMI increased.

CONCLUSIONS

Foot fragility fracture patients are more likely to be female and younger compared to patients with a non-foot fragility fracture. A foot fragility fracture is a sentinel event considering that a prior foot fragility fracture is strongly predictive of a subsequent foot fragility fracture.

LEVEL OF EVIDENCE

3 (retrospective cohort).

The impact of sex steroids on osteonecrosis of the jaw

Sex steroid hormones play a major role in bone homeostasis. Therefore, the use of sex hormones or drugs may increase the risk of osteonecrosis of the jaw (ONJ), a complication caused by damaged bone homeostasis. However, few are known the impact of medications changing sex hormone levels on ONJ. The pathophysiology of ONJ is not clearly understood and many hypotheses exist: cessation of bone remodeling caused by its anti-resorptive effect on osteoclasts; compromised microcirculation due to medication affecting angiogenesis, including bisphosphonate; and impairment of defense mechanism toward local infection. The use of high-dose intravenous bisphosphonate in cancer patients is associated with a high prevalence of ONJ. Exogenous estrogen or androgen replacement was reported to be associated with ONJ. Polycystic ovarian syndrome (PCOS) patients demonstrate an androgen excess status, and androgen overproduction serves as a protective factor in the bone mineral density of young women. To date, there are no reports of ONJ occurrence due to androgen overproduction. In contrast, few reports on the occurrence of ONJ due to estrogen deficiency induced by drugs, such as selective estrogen receptor modulator (SERM), aromatase inhibitors, and gonadotropin-releasing hormone (GnRH) agonists, are available. Thus, the role of sex steroids in the development of ONJ is not known. Further studies are required to demonstrate the exact role of sex steroids in bone homeostasis and ONJ progression. In this review, we will discuss the relationship between medication associated with sex steroids and ONJ.

Adolescent Endometriosis: An Update

Endometriosis is the leading pathologic cause of dysmenorrhea and chronic pelvic pain among adolescents. The appearance of endometriosis in adolescents may be different from that in female adults, resulting in delayed recognition and intervention. This article addresses the epidemiology, pathophysiology, clinical presentation, diagnosis, and management of endometriosis in the adolescent.

Nonsteroidal antiinflammatory drug resistance in dysmenorrhea: epidemiology, causes, and treatment

Although nonsteroidal antiinflammatory drugs can alleviate menstrual pain, about 18% of women with dysmenorrhea are unresponsive, leaving them and their physicians to pursue less well-studied strategies. The goal of this review is to provide a background for treating menstrual pain when first-line options fail. Research on menstrual pain and failure of similar drugs in the antiplatelet category suggested potential mechanisms underlying nonsteroidal antiinflammatory drug resistance. Based on these mechanisms, alternative options may be helpful for refractory cases. This review also identifies key pathways in need of further study to optimize menstrual pain treatment.

Raloxifene Administration in Women Treated with Long Term Gonadotropin-releasing Hormone Agonist for Severe Endometriosis: Effects on Bone Mineral Density

Objectives

To evaluate the efficacy of raloxifene in preventing bone loss associated with long term gonadotropin-releasing hormone agonist (GnRH-a) administration.

Methods

Twenty-two premenopausal women with severe endometriosis were treated with leuprolide acetate depot at a dosage of 3.75 mg/4 weeks, for 48 weeks. Bone mineral density (BMD) was evaluated at admission, and after 12 treatment cycles.

Results

At cycle 12 of GnRH-a plus raloxifene treatment, lumbar spine, trochanter femoral neck, and Ward's BMD differed from before the treatment. A year after treatment, the lumbar spine and trochanter decreased slightly, but were not significantly different.

Conclusions

Our study shows that the administration of GnRH-a plus raloxifene in pre-menopausal women with severe endometriosis, is an effective long-term treatment to prevent bone loss.

Pharmacological treatment of uterine fibroids

Uterine fibroids (UF) are common, benign gynecologic tumors, affecting one in three to four women, with estimates of up to 80%, depending on the population studied. Their etiology is not well established, but it is under the influence of several risk factors, such as early menarche, nulliparity and family history. More than 50% of affected women are asymptomatic, but the lesions may be related to bothersome symptoms, such as abnormal uterine bleeding, pelvic pain and bloating or urinary symptoms. The treatment of UF is classically surgical; however, various medical options are available, providing symptom control while minimizing risks and complications. A large number of clinical trials have evaluated commonly used medical treatments and potentially effective new ones. Through a comprehensive literature search using PubMed, EMBASE, CENTRAL, Scopus and Google Scholar databases, through which we included 41 studies out of 7658 results, we thoroughly explored the different pharmacological options available for management of UF, their indications, advantages and disadvantages.

GnRH agonists: do they have a place in the modern management of fibroid disease?

In the management of women with fibroid disease, GnRH agonists (GnRHa) are frequently used to reduce volume and vascularity before myomectomy, apparently to render the operation easier and reduce operative blood loss, and to enable a transverse supra-pubic incision instead of a midline vertical one. They induce amenorrhoea and thus aid in the correction of pre-operative anaemia. Other gynaecologists use GnRHa to shrink sub mucous fibroids greater than 5 cm in diameter to facilitate access and reduce blood loss and operating time at transcervical resection. GnRHa are also occasionally used as a temporizing measure in women with symptomatic fibroids within the climacteric. We argue against the use of GnRHa in the management of fibroid disease because they are not cost effective, render myomectomy more difficult to apply because they destroy tissue planes, the more difficult enucleation in fact increasing rather than reducing peri-operative blood loss and operating time. When used before myomectomy, they increase the risk of 'recurrence' because they obscure smaller fibroids that 'recur' when the effects of the GnRHa wear off, and are associated with side effects in situations where they confer no benefits, or where alternative cheaper drugs with fewer side effects are available.

Hormone replacement therapy for osteoporosis: clinical and pathophysiological aspects

The pathogenetic role of oestrogen deficiency in osteoporosis was first postulated by Fuller Albright in 1941 and has subsequently become well established. Hormone replacement therapy prevents menopausal bone loss and is the only treatment which has convincingly been shown to reduce fracture risk at both the spine and hip. The mechanisms by which oestrogens affect bone, however, are poorly understood and many aspects of treatment remain ill-defined, in particular with respect to the duration of therapy and its long-term risks and benefits.

GnRH analogues in the treatment of fibroids

Uterine fibroids are estimated to affect up to 25% of women of reproductive age and are a common cause of morbidity, being associated with menstrual dysfunction, iron deficiency anaemia, pregnancy wastage and subfertility. Their pathogenesis remains unknown but their association with ovarian function and oestrogen production is undisputed and supported by their occurrence only after puberty and the shrinkage observed after the menopause. This oestrogen dependency has recently been exploited therapeutically through investigation of the use of agents that induce a hypo-oestrogenic state, the gonadotrophin-releasing hormone (GnRH) or luteinizing hormone-releasing hormone (LHRH) analogues.

Loss of cyclin g1 expression in human uterine leiomyoma cells induces apoptosis

Observations from the authors' laboratory suggest a physiological role for increased cyclin G1 protein levels in human uterine leiomyoma. The hypothesis of the present study is that the strategic modulation of cyclin G1 by antisense technology will inhibit the survival of in vitro-grown uterine leiomyoma cells. Cultured uterine leiomyoma cells were transfected with cyclin G1 ribbon-type antisense oligonucleotide (cyclin G1 RiAS) to effectively reduce cyclin G1 expression. Cell viability, in situ terminal deoxyuridine nick end-labeling (TUNEL) assay, flow cytometry, DNA fragmentation, and expression of cell cycle regulatory-related proteins were evaluated by Western blot. Antisense oligonucleotides compromised uterine leiomyoma cell viability and inducted apoptosis in a caspase-independent mechanism. In situ TUNEL and DNA fragmentation revealed apoptosis induction, and fluorescent-activated cell sorting analysis showed increased sub-G1-phase cells. Furthermore, abrogation of cyclin G1 enhanced p53 accumulation, phosphorylation of p53 at Ser-15 residue, and increased expression of cyclin-dependent kinase inhibitors p21 and p27. These data imply that cyclin G1 expression is associated with growth promotion and the potential utility and novelty of using ribbon-type antisense oligonucleotides as a gene therapy strategy to treat human uterine leiomyoma.

WITHDRAWN: Gonadotrophin-releasing hormone analogues for pain associated with endometriosis

BACKGROUND

Endometriosis is a common gynaecological condition that frequently presents with the symptom of pain. The precise pathogenesis (mode of development) of endometriosis is unclear but it is evident that endometriosis arises by the dissemination of endometrium to ectopic sites and the subsequent establishment of deposits of ectopic endometrium. The observation that endometriosis is rarely seen in the hypo-oestrogenic (low levels of oestrogen) post-menopausal woman led to the concept of medical treatment by induction of a pseudo-menopause using Gonadotrophin Releasing Hormone Analogues (GnRHas). When administered in a non-pulsatile manner (the pituitary is normally stimulated by pulses of natural GnRH and all analogues act on the pituitary at a constant level) their use results in down regulation (switching off) of the pituitary and a hypogonadotrophic hypogonadal state (low levels of female hormones due to non stimulation of the ovary).

OBJECTIVES

To determine the effectiveness of Gonadotrophin Releasing Hormone analogues (GnRHas) in the treatment of the painful symptoms of endometriosis by comparing them with no treatment, placebo, other recognised medical treatments, and surgical interventions.

SEARCH STRATEGY

The search strategy of the Menstrual Disorders and Subfertility review group (please see Review Group details) was used to identify all randomised trials of the use of GnRHas for the treatment of the painful symptoms of endometriosis.

SELECTION CRITERIA

Trials were included if they were randomised, and considered the effectiveness of GnRHas in the treatment of the painful symptoms of endometriosis.

DATA COLLECTION AND ANALYSIS

Twenty-six studies had data appropriate for inclusion in the review. The largest group (15 studies) compared GnRHas with danazol. There are five studies comparing GnRHas with GnRHas plus add-back therapy, three comparing GnRHa with GnRHa in a different form or dose, one compares them with gestrinone, one with the combined oral contraceptive pill, and one with placebo. Data was extracted independently by two reviewers. The authors of eleven studies have been contacted to clarify missing or unclear data. Only four have replied to date. Data on relief of pain, change in revised American Fertility Society (rAFS) scores, and side effects was collected.

MAIN RESULTS

No difference was found between GnRHas and any of the other active comparators with respect to pain relief or reduction in endometriotic deposits. The side effect profiles of the different treatments were different, with danazol and gestrinone having more androgenic side effects, while GnRHas tend to produce more hypo-oestrogenic symptoms.

AUTHORS' CONCLUSIONS

There is little or no difference in the effectiveness of GnRHas in comparison with other medical treatments for endometriosis. GnRHas do appear to be an effective treatment. Differences that do exist relate to side effect profiles. Side effects of GnRHas can be ameliorated by the addition of addback therapy.

Long-term fracture risk among women with proven endometriosis

OBJECTIVE

To determine whether women with pelvic endometriosis are at increased fracture risk.

DESIGN

Historical cohort study.

SETTING

Population-based investigation using the data resources of the Rochester Epidemiology Project.

PATIENT(S)

From Olmsted County, Minnesota, 987 women with endometriosis that was first surgically visualized or histologically proven in 1970-1989.

INTERVENTION(S)

None, observational study.

MAIN OUTCOME MEASURE(S)

Follow-up for fractures through complete inpatient and outpatient community medical records.

RESULT(S)

In 17,408 person-years of follow-up, 256 women experienced 449 different fractures. The cumulative incidence after 20 years (30.8%) was not elevated relative to that expected (30.6%). The independent predictors of any fracture included age (hazard ratio [HR] per 10 years: 1.61; 95% confidence interval [CI] 1.42-1.84]), corticosteroid use (HR: 2.78; 95% CI 1.48-5.24), prior hip, spine, or forearm fracture (HR: 1.82; 95% CI 1.10-3.02), and use of the selective estrogen receptor modulators, tamoxifen or raloxifene (HR: 4.34; 95% CI 2.14-8.81); physical activity was protective (HR: 0.40; 95% CI 0.18-0.88). There was no significant influence on fracture risk of surgery or other medical treatments for endometriosis.

CONCLUSION(S)

Despite reported adverse effects of treatment on bone density, there was no overall increase in long-term fracture risk in this unselected cohort of women with proven endometriosis.

Ethnic distribution of estrogen receptor-alpha polymorphism is associated with a higher prevalence of uterine leiomyomas in black Americans

OBJECTIVE

To investigate whether polymorphisms in the estrogen receptor alpha (ERalpha) gene are associated with an increased risk of uterine leiomyomas (ULMs).

DESIGN

Genomic DNA was isolated from normal myometrium samples collected at the time of the hysterectomy.

SETTING

Volunteers in an academic research environment.

PATIENT(S)

One hundred ninety-eight women with surgically confirmed ULMs and 229 matched controls with nonfibroid uteri.

INTERVENTION(S)

Hysterectomy samples were collected from volunteers.

MAIN OUTCOME MEASURE(S)

The two PvuII and XbaI intronic polymorphisms in the ERalpha gene using polymerase chain reaction and restriction fragment length polymorphism.

RESULT(S)

The ERalpha PP genotype was associated with a significantly increased risk of ULM in black and white women, but not in Hispanic women. Women with the ERalpha PP genotype were 6.42 times (confidence limits 2.04-20.16) more likely to have ULMs than other genotypes. The ERalpha PP genotype was also significantly associated with larger tumor burden (>400 g). The overall prevalence of the PP genotype was significantly higher in black women (35%) than white (13%) or Hispanic (16%) women. Myometrial cell lines expressing the PP genotype exhibited enhanced proliferative response to estrogen in vitro compared with their pp counterparts.

CONCLUSION(S)

The ERalpha PP genotype is a genetic risk factor for ULM development among surgically treated women. The higher prevalence of this genotype in blacks might explain the increased occurrence of this tumor among black women.

Mastodynia refractory to medical therapy: is there a role for mastectomy and breast reconstruction?

BACKGROUND

Mastodynia is among the most frequently reported symptoms in women with breast complaints; it is usually classified as cyclic, noncyclic, or nonbreast in origin. A useful response with medical or conservative therapy is obtained in the majority of these patients. There is a subset of patients, however, who have exhausted every medical effort and psychiatric counseling and will desire mastectomy with breast reconstruction in the hope of alleviating their chronic pain.

METHODS

Three patients with noncyclical, bilateral mastodynia referred for breast reconstruction options from December of 2000 to March of 2004 are presented in this article. Daily breast pain charts with a visual analogue scale for pain assessment were analyzed and recorded for all patients throughout the study period.

RESULTS

Two patients underwent delayed reconstruction and had complete resolution of pain 6 to 8 weeks after bilateral mastectomy, with no recurrence of mastalgia after reconstruction. One patient underwent bilateral mastectomy with immediate reconstruction and achieved complete resolution of her pain 3 months postoperatively. Histopathologic findings of all breast specimens revealed benign breast tissue with proliferative breast disease consistent with mastodynia.

CONCLUSIONS

This modality, which includes mastectomy with or without reconstruction, is a viable alternative after exhaustion of all other nonsurgical options and when quality of life is significantly affected. Although mastectomy for the treatment of mastodynia refractory to medical therapy does not guarantee alleviation of chronic breast pain, it should be considered in these often desperate patients.

Combined oral contraceptives in the treatment of polycystic ovary syndrome

Combined oral contraceptives (COC) are the most often used treatment modality for polycystic ovary syndrome (PCOS). Undisputedly, COC suppress androgen production, thus ameliorating skin androgenic symptoms and improving menstrual dysfunction. On the other hand, there are still many unresolved issues concerning their metabolic effects. COC could decrease insulin sensitivity and deteriorate glucose tolerance, although the negative influence on insulin sensitivity is dependent on other factors (especially obesity) and this need not be expressed in non-obese patients. It is probable that the impairment of glucose tolerance is reversible, as the incidence of diabetes is not increased in past COC users. The effects of COC on the lipid spectrum are dependent on the type of gestagen, but lipid levels usually remain within the reference limits. Combination therapy of COC with weight reduction or insulin sensitizers could further suppress androgen levels and improve metabolic parameters. The establishment of COC after laparoscopic ovarian drilling may further decrease androgen levels. The combination of COC and GnRH analogues is not superior to COC therapy alone. Prospective data about the influence of COC on the risk of diabetes mellitus, coronary artery disease and endometrial cancer in PCOS women are lacking.

Hereditary and acquired angioedema: problems and progress: proceedings of the third C1 esterase inhibitor deficiency workshop and beyond

Hereditary angioedema (HAE), a rare but life-threatening condition, manifests as acute attacks of facial, laryngeal, genital, or peripheral swelling or abdominal pain secondary to intra-abdominal edema. Resulting from mutations affecting C1 esterase inhibitor (C1-INH), inhibitor of the first complement system component, attacks are not histamine-mediated and do not respond to antihistamines or corticosteroids. Low awareness and resemblance to other disorders often delay diagnosis; despite availability of C1-INH replacement in some countries, no approved, safe acute attack therapy exists in the United States. The biennial C1 Esterase Inhibitor Deficiency Workshops resulted from a European initiative for better knowledge and treatment of HAE and related diseases. This supplement contains work presented at the third workshop and expanded content toward a definitive picture of angioedema in the absence of allergy. Most notably, it includes cumulative genetic investigations; multinational laboratory diagnosis recommendations; current pathogenesis hypotheses; suggested prophylaxis and acute attack treatment, including home treatment; future treatment options; and analysis of patient subpopulations, including pediatric patients and patients whose angioedema worsened during pregnancy or hormone administration. Causes and management of acquired angioedema and a new type of angioedema with normal C1-INH are also discussed. Collaborative patient and physician efforts, crucial in rare diseases, are emphasized. This supplement seeks to raise awareness and aid diagnosis of HAE, optimize treatment for all patients, and provide a platform for further research in this rare, partially understood disorder.

Raloxifene prevents the growth of uterine leiomyomas in premenopausal women

OBJECTIVE

To evaluate the effects of raloxifene administration on uterine leiomyoma size in premenopausal women.

DESIGN

Prospective, randomized, open-label, controlled clinical trial.

SETTING

Tertiary care unit, University of Vienna, Austria.

PATIENT(S)

Twenty-five premenopausal women with uterine leiomyomas.

INTERVENTION(S)

Three months of treatment with raloxifene (180 mg/d) or no treatment.

MAIN OUTCOME MEASURE(S)

Baseline to end point percent change difference in leiomyoma volume between the therapy and control groups.

RESULT(S)

Raloxifene treatment prevented the progression of uterine leiomyomas. Compared with no medical intervention, raloxifene resulted in a decrease of myoma volume. Raloxifene was clinically well tolerated. No significant differences were detected in symptoms related to leiomyomas and hormonal status.

CONCLUSION(S)

In premenopausal women, high-dose raloxifene is well tolerated and inhibits the growth of leiomyomas.

Overview on the effects of progestins on bone

In view of the fact that fractures are the clinically relevant events, risk factors for fractures are discussed first. Bone mineral density (BMD) appears to be a much less important risk factor for the most severe hip fractures than the risk of falling. No results of experimental studies on hormones and fractures at advanced age are available. An overview of the effects of progestins on bone is given. Effects of progestins on bone have been studied by in vitro experiments using cell lines and by more relevant clinical observations. Prospective studies have been conducted following the use of progestins contained in oral contraceptives, alone or in combination with oestrogens; long-term contraception by injection of depot preparations; so-called "add-back" hormonal therapy attempting to reverse the adverse effects of gonadotropin releasing hormone agonists on bone and after different regimens of hormone replacement therapy (HRT) in postmenopausal women. From the data there are no indications that the various progestins, used in clinical practice, have either a bone-protective or an oestrogen antagonistic activity. Progestins do not add or subtract much of the protective action of oestrogens on the bones.

Precedence of bone loss over changes in body composition and body fat distribution within a few years after menopause

OBJECTIVE

The present study investigated the sequence of certain phenomena with a few years after menopause: bone mineral loss, decrease in lean body mass, increase in body fat mass, or the shift toward upper body fat distribution.

METHODS

Subjects were 64 postmenopausal women aged 50-53 years with right side dominance (mean age+/-S.D., 51.4+/-1.1 years), and 59 age-matched regularly menstruating premenopausal women (51.7+/-1.2 years) serving as controls. Height, weight, body mass index (BMI, wt./ht.(2)), age at menopause (in postmenopausal women), and years since menopause (YSM) were recorded. Anthropometries, bone mineral density (BMD), and body fat distribution were assessed by dual-energy X-ray absorptiometry.

RESULTS

Age at menopause and YSM in postmenopausal women were 51.7+/-1.2 and 2.3+/-1.7 years, respectively. Age, height, weight, BMI did not differ between the two groups. BMD of the bilateral arm, lumbar spine (L2-4), pelvis, and total body were significantly lower in postmenopausal women. However, leg BMD, trunk-leg fat ratio, body fat mass, and the lean body mass did not differ between the two groups.

CONCLUSION

Within a few years after menopause, bone mineral loss precedes lean mass loss, increase in body fat mass, and a shift toward upper body fat distribution. We can say that bone tissue is more sensitive to hypogonadism than lean and fat tissues are.

Gonadotrophin-releasing hormone analogues for endometriosis: bone mineral density

BACKGROUND

Gonadotrophin-releasing hormone analogues (GnRHas) are generally well tolerated, and are effective in relieving the symptoms of endometriosis (Prentice 2003). Unfortunately the low oestrogen state that they induce is associated with adverse effects including an acceleration in bone mineral density (BMD) loss.

OBJECTIVES

To determine the effect of treatment with gonadotrophin-releasing hormone analogues (GnRHas) on the bone mineral density of women with endometriosis, compared to placebo, no treatment, or other treatments for endometriosis, including GnRHas with add-back therapy.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group's specialised register of controlled trials (23rd October 2002) and the Cochrane Central Register of Controlled Trials (Cochrane Library, issue 4, 2002). We also carried out electronic searches of MEDLINE (1966 - March Week 2 2003) and EMBASE (1980 - March Week 2 2003). We also searched the reference lists of articles and contacted researchers in the field.

SELECTION CRITERIA

Prospective, randomised controlled studies of the use of GnRHas for the treatment of women with endometriosis were considered, where bone density measurements were an end point. The control arm of the studies was either placebo, no treatment, another medical therapy for endometriosis, or GnRHas with add-back therapy.

DATA COLLECTION AND ANALYSIS

Two reviewers (JF and MS) independently assessed trial quality and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

Thirty studies involving 2,391 women were included, however only 15, involving 910 women, could be included in the meta-analysis. The meta-analysis showed that danazol and progesterone + oestrogen add-back are protective of BMD at the lumbar spine both during treatment and for up to six and twelve months after treatment, respectively. Between the groups receiving GnRHa and the groups receiving danazol/gestrinone, there was a significant difference in percentage change of BMD after six months of treatment, the GnRH analogue producing a reduction in BMD from baseline and danazol producing an increase in BMD (SMD -3.43, 95 % CI -3.91 to -2.95). Progesterone only add-back is not protective; after six months of treatment absolute value BMD measurements of the lumbar spine did not differ significantly from the group receiving GnRH analogues (SMD 0.15, 95 % CI -0.21 to 0.52). In the comparison of GnRHa versus GnRHa + HRT add-back, that is oestrogen + progesterone or oestrogen only, there was a significantly bigger BMD loss in the GnRHa only group (SMD -0.49, 95 % CI -0.77 to -0.21). These numbers reflect the absolute value measurements at the lumbar spine after six months of treatment. Due to the small number of studies in the comparison we are unable to conclude whether calcium-regulating agents are protective. No difference was found between low and high dose add-back regimes but again only one study was identified for this comparison. Only one study comparing GnRH analogues with placebo was identified, but the study gave no data. No studies comparing GnRH with the oral contraceptive pill (OCP) or progestagens were identified.

REVIEWER'S CONCLUSIONS

Both danazol and progesterone + oestrogen add-back have been shown to be protective of BMD, while on treatment and up to six and 12 months later, respectively. However, by 24 months of follow-up there was no difference in BMD in those women who had HRT add-back. Studies of danazol versus GnRHa did not report long-term follow-up. The significant side effects associated with danazol limit its use.

Raloxifene administration in women treated with gonadotropin-releasing hormone agonist for uterine leiomyomas: effects on bone metabolism

This prospective randomized, single-blind, placebo-controlled clinical trial was performed to evaluate the efficacy of raloxifene in preventing the bone loss associated with GnRH agonist (GnRH-a) administration. One hundred premenopausal women with uterine leiomyomas were treated with leuprolide acetate depot at a dosage of 3.75 mg/d for 28 d and then randomized into two groups to receive raloxifene hydrochloride at 60 mg/d (group A) or placebo (1 tablet/d; group B). Bone mineral density (BMD) and serum bone metabolism markers were evaluated at admission and after six treatment cycles. Posttreatment BMD differed significantly from baseline BMD in group B but not in group A. BMD was significantly higher in group A than in group B. In group A, serum osteocalcin and bone alkaline phosphatase levels and urinary deoxypyridinoline and pyrilinks-D excretion were unchanged vs. baseline. Differently, posttreatment concentrations of these bone turnover markers were significantly lower in group B compared with baseline and group A values. In conclusion, raloxifene prevents GnRH-a related bone loss in premenopausal women with uterine leiomyomas.

Bone metabolism in postmenopausal women who were treated with a gonadotropin-releasing hormone agonist and tibolone

OBJECTIVE

To study the bone metabolism in postmenopausal women who have been treated with gonadotropin-releasing hormone agonist (GnRH-a) and tibolone.

DESIGN

Prospective, open, controlled clinical trial.

SETTING

Department of Gynecology and Obstetrics, University of Catanzaro, Catanzaro, Italy.

PATIENT(S)

One hundred twenty perimenopausal women with symptomatic uterine leiomyomas (groups A and B), and 40 healthy control women who underwent a normal spontaneous menopause (group C).

INTERVENTION(S)

Treatment for 12 months with leuprolide acetate plus tibolone (group A) or hysterectomy with bilateral oophorectomy (group B).

MAIN OUTCOME MEASURE(S)

Lumbar spine bone mineral density (BMD) and bone turnover markers at entry into the study, after medical treatment (only group A), and 12 months after discontinuation medical treatment (group A) or after surgery (group B). The same parameters were noted in healthy women before and 12 months after menopause (retrospective control group, group C).

RESULT(S)

At the women's entry into the study, no significant difference in BMD and bone turnover markers was detected between groups A and B. In group A, no significant variation in BMD or bone turnover markers was observed 12 months after medical treatment in comparison with baseline. At 12 months after discontinuation of treatment (in women who had achieved menopause) and after surgery, we observed a statistically significant decrease in BMD and in bone turnover markers in both groups in comparison with baseline. At 12 months after they became menopausal, we also observed a statistically significant reduction in BMD and in bone turnover markers in control group C. At the same 12-month follow-up visit, a statistically significant difference in BMD and in bone turnover markers was detected when comparing groups A and B with group C.

CONCLUSION(S)

Women previously treated with GnRH-a and tibolone similar to women who are menopausal as a result of surgery, have higher bone loss after menopause.

Long-term use of gonadotropin-releasing hormone analogs and hormone replacement therapy in the management of endometriosis: a randomized trial with a 6-year follow-up

OBJECTIVE

To identify the effects of long-term GnRH agonist use (6-24 months), with and without add-back therapy, and spontaneous reversibility of bone mass density (BMD) up to 6 years after treatment.

DESIGN

A prospective, randomized, long-term follow-up study.

SETTING

Obstetrics and gynecology department in a university hospital in the United Kingdom.

PATIENT(S)

Forty-nine symptomatic women with a laparoscopic diagnosis of endometriosis who had been identified for treatment with long-acting GnRH agonist and volunteered to participate in the study.

INTERVENTION(S)

Women were randomly allocated to receive hormone replacement therapy (HRT) as a daily oral dose of estradiol, 2 mg, and norethisterone acetate, 1 mg, or no treatment in addition to monthly subcutaneous implants of goserelin acetate for up to 2 years, until cessation of symptoms. Bone mineral density (BMD) at the lumbar spine (C2-C4) and hip (Ward triangle) was measured every 6 months.

MAIN OUTCOME MEASURE(S)

BMD changes in both groups.

RESULT(S)

45 women were followed up for 6 years, at the end of which the groups did not differ significantly in the reduction in mean BMD at the lumbar spine or hip.

CONCLUSION(S)

BMD reduction occurs during long-term GnRH agonist use and is not fully recovered by up to 6 years after treatment. Use of HRT does not affect this process.

Altered hormonal responsiveness of proliferation and apoptosis during myometrial maturation and the development of uterine leiomyomas in the rat

Uterine leiomyomas are responsive to the ovarian steroids, estrogen and progesterone; however, a mechanistic understanding of the role of these hormones in the development of this common gynecologic lesion remains to be elucidated. We have used the Eker rat uterine leiomyoma model to investigate how ovarian hormones regulate or promote the growth of these tumors. Proliferative and apoptotic rates were quantitated in normal uterine tissues and leiomyomas in response to endogenous ovarian steroids. In 2- to 4-mo-old animals, cell proliferation in the normal uterus corresponded with high serum levels of steroid hormones during the estrous cycle, and apoptosis occurred in the rat uterus in all cell types following sharp, cyclical declines in serum hormone levels. It is interesting that the responsiveness of uterine mesenchymal cells changed between 4 and 6 mo of age, with significant decreases in both proliferative and apoptotic rates observed in myometrial and stromal cells of cycling animals. Leiomyomas displayed much higher levels of proliferation than did age-matched myometrium; however, their apoptotic index was significantly decreased in comparison with normal myometrium. This disregulation between proliferative and apoptotic responses, which were tightly regulated during ovarian cycling in the normal myometrium, may contribute to the disruption of tissue homeostasis and underlie neoplastic growth of these tumors.

Myoma coagulation (myolysis)

Myoma coagulation or myolysis by way of the laparoscope or hysteroscope is a valuable addition to the armamentarium of treatments for a problem that remains pervasive among women: uterine leiomyomata. Likewise, surgical techniques include the use of the Nd:YAG laser as well as the bipolar needle. The addition of myolysis to earlier uterine-sparing endometrial ablation or resection markedly improves the success rate of these minimally invasive alternatives to hysterectomy. Myoma coagulation when combined with endometrial ablation among women with symptomatic fibroids and bleeding also reduces all subsequent surgery rates compared with endometrial ablation alone. The continued goal for therapy of fibroids and debilitating menorrhagia must take into consideration the needs and desires of the patient in terms of her lifestyle (e.g., days lost from work because of symptoms) and childbearing plans. Hysterectomy continues to be costly in billions of dollars spent annually as well as in the more fundamental terms of morbidity and mortality when compared with the less invasive alternatives of myomectomy, ablation, and myolysis.

Long-term administration of tibolone plus gonadotropin-releasing hormone agonist for the treatment of uterine leiomyomas: effectiveness and effects on vasomotor symptoms, bone mass, and lipid profiles

OBJECTIVE

To evaluate the effects of long-term administration of GnRH agonist (GnRH-a) plus tibolone for uterine leiomyomatosis.

DESIGN

Prospective open clinical trial.

SETTING

Department of Gynecology, Obstetrics and Pathophysiology of Human Reproduction, University of Naples "Federico II", Naples, Italy.

PATIENT(S)

Twenty-five subjects with symptomatic uterine leiomyomas.

INTERVENTION(S)

Treatment for 2 years with leuprolide acetate (3.75 mg IM every 28 days) and tibolone (2.5 mg/d per os).

MAIN OUTCOME MEASURE(S)

Uterine and uterine leiomyoma sizes, endometrial thickness, lumbar spine bone mineral density (BMD), bone metabolism, lipid profile, myoma-related symptoms at baseline and every 6 months. Hot flashes and vaginal bleeding episodes recorded in a daily symptom diary.

RESULT(S)

After 6 months of treatment, a significant reduction was observed in uterine and leiomyoma volumes and myoma-related symptoms compared with baseline values. No significant change was observed in bone turnover, lumbar BMD, or serum total cholesterol, low-density lipoprotein cholesterol, or triglyceride levels. High-density lipoprotein cholesterol values were significantly lower than baseline values after 6 months of treatment but not after 18 months of therapy. A low mean number of hot flashes per day was observed.

CONCLUSION(S)

Long-term administration of GnRH-a plus tibolone reduces hot flashes and prevents bone loss without changing the lipid profile.

Low-dose danazol after combined surgical and medical therapy reduces the incidence of pelvic pain in women with moderate and severe endometriosis

The most effective therapy for endometriosis is a matter for debate. The aim of the present randomized study was to evaluate the efficacy of low doses of danazol on recurrence of pelvic pain in patients with moderate or severe endometriosis, who had undergone laparoscopic surgery and 6 months of gonadotrophin-releasing hormone analogue (GnRHa) therapy. After surgery, 28 patients with moderate or severe endometriosis underwent therapy for 6 months with GnRHa i. m. every 4 weeks. They were then randomized into two groups: group A (14 subjects) was treated with 100 mg/day danazol for 6 months; group B (14 subjects, control) did not receive any type of therapy. After 12 months of treatment, group A had a significantly (P < 0.01) lower pain score than group B. There was no significant difference between the groups in oestrogen concentrations, bone mineral density or side-effects. The results suggest that low-dose danazol therapy reduces recurrence of pelvic pain in patients with moderate or severe endometriosis, treated surgically, and has few or no metabolic side-effects.

The treatment of severe premenstrual syndrome with goserelin with and without 'add-back' estrogen therapy: a placebo-controlled study

The study aimed to determine if the addition of daily low-dose oral estrogen with a cyclical progestogen given to young women using a depot gonadotropin-releasing hormone (GnRH) analog implant for the treatment of their premenstrual syndrome (PMS) would affect the clinical outcome. In a double-blind placebo-controlled study in a specialist premenstrual syndrome clinic setting, 60 women aged between 20 and 45 years were randomized to one of three treatment groups: Group A (placebo implant four weekly + placebo tablets daily), Group B (goserelin 3.6 mg implant four weekly + estradiol valerate 2 mg daily with norethisterone 5 mg from days 21-28 of a 28-day cycle) or Group C (goserelin 3.6 mg implant four weekly + placebo tablets daily). Differences between PMS scores at 2, 4 and 6 months were compared with pretreatment values. There was a significant improvement in PMS scores in Group C (Zoladex + placebo) after 2, 4 and 6 months of treatment when compared to pretreatment values and Group A (placebo + placebo). The addition of a low-dose oral estrogen with a cyclical progestogen to GnRH analog treatment (Group B) resulted in a less dramatic response when compared to pretreatment values and no significant improvement when compared to Group A (placebo + placebo) at 2, 4 and 6 months of treatment. The addition of a low-dose oral estrogen with a cyclical progestogen to depot GnRH analog therapy in the treatment of PMS reduces the clinical response.

A clinical trial of the effects of tibolone administered with gonadotropin-releasing hormone analogues for the treatment of uterine leiomyomata

OBJECTIVE

To evaluate the effects of tibolone therapy in association with GnRH-a on uterine leiomyomata, on climacteric-like symptoms, on bone metabolism, and on the lipid profile.

DESIGN

A prospective, randomized, double-blind, placebo-controlled, clinical trial.

SETTING

Department of Gynecology and Obstetrics, University of Naples "Federico II," Naples, Italy.

PATIENT(S)

Fifty women with symptomatic uterine leiomyomata.

INTERVENTION(S)

Six months of treatment with leuprolide acetate (3.75 mg every 28 days IM) combined with daily placebo tablets (group A) or with 2.5-mg of tibolone per os (group B).

MAIN OUTCOME MEASURE(S)

Uterine and uterine leiomyomata sizes, lumbar spine bone mineral density, biochemical markers of bone metabolism, lipid profile, and myoma-related symptoms were measured at baseline and after 6 months of treatment. Daily symptom diary in which hot flushes and vaginal bleeding episodes were recorded.

RESULT(S)

No differences between the 2 groups in uterine and uterine leiomyomata size and myoma-related symptoms were detected. After 6 months of treatment, there were statistically significant changes from baseline in bone mineral density and in biochemical markers of bone metabolism in group A but not in group B. Vasomotor symptoms were significantly lower in group B than in group A. There was a statistically significant increase (P<.01) in serum total cholesterol, high-density lipoprotein cholesterol, and triglycerides in group A after 6 months of treatment in comparison with baseline values. The difference in serum total cholesterol and triglyceride levels after 6 months of treatment in group B was not statistically significant in comparison with baseline values, but was statistically significant in comparison with group A values (P<.01). In group B, levels of high-density lipoprotein cholesterol were significantly lower after 6 months of therapy in comparison with baseline values and in comparison with group A values (P<.01). There were no statistically significant changes at baseline and after 6 months of treatment in the level of low-density lipoprotein cholesterol in either group.

CONCLUSION(S)

Administration of tibolone in association with GnRH-a reduces vasomotor symptoms and prevents bone loss, without compromising the therapeutic efficacy of GnRH-a alone.

The effect of gonadotropin-releasing hormone agonist on type I collagen C-telopeptide and N-telopeptide: the predictive value of biochemical markers of bone turnover

To evaluate the clinical utility of recently developed biochemical markers in the assessment of bone metabolism during GnRH agonist (GnRHa) treatment, we compared five bone resorption markers [C-telopeptide (CTX) and N-telopeptide (NTX) of type I collagen, hydroxyproline (Hpr), pyridinoline (Pyr), and deoxypyridinoline (Dpyr)] and two bone formation markers [total alkaline phosphatase (Alp) and osteocalcin (OC)]. Sixty-eight normally menstruating women were injected with a long-acting GnRHa once a month for 24 weeks for the treatment of endometriosis or leiomyoma. The mean percentage bone loss at the lumbar spine was 3.79% at the end of treatment. Although levels of all markers increased significantly as the treatment progressed, CTX and NTX exhibited the highest correlation coefficients between bone loss at 24 weeks and the seven markers measured at 0, 4, 12, 16, and 24 weeks of treatment. Serum estradiol levels were similarly suppressed during the treatment in both fast losers (whose bone loss was more than the mean) and slow losers (whose bone loss was less than the mean). However, significantly higher z-scores of bone resorption markers, but not of bone formation markers, were observed in the fast losers at 24 weeks of treatment, suggesting a more accelerated bone resorption in this group. Whereas the three highest z-scores at 24 weeks of treatment were CTX, NTX, and Dpyr (in that order), the highest z-score (P < 0.05) was observed for CTX in the fast losers. The subjects in the highest quartile of CTX, the highest, and second highest quartiles of NTX at 24 weeks of treatment experienced 2.1, 2.2, and 1.7 times more bone loss (P < 0.001), respectively, than those in the lowest quartiles. Furthermore, the subjects in the highest quartile of both CTX and NTX experienced 3.6 times more bone loss (P < 0.001) than those in the lowest quartile of both markers. These results indicate that both CTX and NTX are useful and sensitive markers for bone resorption in a hypoestrogenic state induced by GnRHa.

The death of osteocytes via apoptosis accompanies estrogen withdrawal in human bone

Estrogen withdrawal in women leads initially to rapid bone loss caused by increased numbers or activity of osteoclasts. We previously have noted apoptosis of lacunar osteocytes associated with conditions of high bone turnover. Therefore, in this study, we investigated whether the increased bone loss associated with GnRH analogue (GnRH-a)-induced estrogen withdrawal affects osteocyte viability in situ in a way that would be directly contrary to the effect of estrogens on osteoclast viability. Transiliac biopsies were obtained from six premenopausal women, between 30-45 yr old, diagnosed as having endometriosis. Biopsies were taken before and after 24 weeks of GnRH-a therapy. Biopsies were snap-frozen and cryostat sectioned. Osteocyte viability, determined by the presence of lactate dehydrogenase (LDH) activity, was reduced in all but one subject after treatment. Furthermore, in every subject, the proportion of osteocytes showing evidence of DNA fragmentation typical of apoptosis increased, as demonstrated using in situ DNA nick translation (P = 0.008). Gel electrophoresis of extracted DNA and morphological studies of chromatin condensation and nuclear fragmentation confirmed that changes typical of apoptosis were affecting the osteocytes. It was concluded that GnRH-a therapy caused a higher prevalence of dead osteocytes in iliac bone, probably caused by the increase in the observed proportion of osteocytes showing apoptotic changes. The capacity of bone to repair microdamage and to modulate the effects of mechanical strain is currently believed to be dependent on osteocyte viability. Our findings have therefore revealed a possible mechanism whereby estrogen deficiency could lead to increased bone fragility with or without an accompanying net bone loss.

Clinical, endocrine, and metabolic effects of two doses of gestrinone in treatment of pelvic endometriosis

OBJECTIVE

Our purpose was to determine and compare the efficacy and hormonal and metabolic effects of 1.25 mg with 2.5 mg of gestrinone given twice a week in the treatment of mild and moderate pelvic endometriosis.

STUDY DESIGN

A phase II, prospective, randomized, double-blind study involving 11 patients given gestrinone 1.25 mg (five patients) or 2.5 mg (six patients) orally twice a week for 24 weeks was performed. Revised American Fertility Society scores were determined by laparoscopy before and at the end of treatment. Serum hormone (free thyroxine, free testosterone, estradiol, progesterone, follicle-stimulating hormone, luteinizing hormone), sex hormone binding globulin, and lipid concentrations were measured before, throughout, and for 6 months after treatment. Quantitated computerized tomography of thoracic 12 through lumbar 4 vertebral bodies were determined before, at the end of, and 6 months after treatment.

RESULTS

Gestrinone 2.5 mg significantly reduced the endometriosis implant score from 10.3 +/- 2.8 to 3.8 +/- 0.8 (p = 0.05). Both doses significantly reduced serum progesterone and sex hormone binding globulin levels. Estradiol, free testosterone, free thyroxine, follicle-stimulating hormone, and luteinizing hormone levels were not significantly affected. Spinal bone increased significantly by 7.1% with 2.5 mg but lost significantly by 7.1% with 1.25 mg gestrinone; these changes had not reversed completely 6 months after stopping treatment.

CONCLUSIONS

In mild to moderate pelvic endometriosis 2.5 mg of gestrinone twice a week was more effective and had a more positive effect on bone mass than did 1.25 mg of gestrinone.

Ipriflavone prevents the loss of bone mass in pharmacological menopause induced by GnRH-agonists

In a double-blind, placebo controlled study, ipriflavone (600 mg/day, T.D.D.) or identical placebo tablets were given with 500 mg/day of calcium to patients treated with the gonadotropin hormone-releasing hormone agonist (Gn-RH-A) leuproreline acetate, 3.75 mg every 30 days for 6 months. In placebo-treated subjects (n = 39), urinary hydroxyproline excretion and plasma osteocalcin levels showed a significant (P < 0.01 and P < 0.05, respectively) increase, whereas spine bone density and total body bone density significantly (P < 0.001 and P < 0.05, respectively) decreased after 3 and 6 months of GnRH-A administration. Conversely, in the ipriflavone-treated group (n = 39), no significant difference in bone markers and bone density was evidenced. These data indicate that ipriflavone can restrain the bone remodeling processes and prevent the rapid bone loss that follows medically induced hypogonadism.

Steroidal and nonsteroidal "add-back" therapy: extending safety and efficacy of gonadotropin-releasing hormone agonists in the gynecologic patient

OBJECTIVE

To assess the efficacy of various steroidal and nonsteroidal add-back regimes in ameliorating hypoestrogenic side effects of long-term GnRH agonist (GnRH-a) therapy in gynecologic patients.

DESIGN

English language literature review.

PATIENTS

Gynecologic patients administered GnRH-a as therapy for ovarian hyperandrogenism, premenstrual syndrome, dysfunctional uterine bleeding, uterine leiomyomata, and symptomatic endometriosis.

INTERVENTIONS

Steroidal and nonsteroidal add-back regimes including estrogens with progestins, progestins alone, and progestins with organic bisphosphonates in combination with various GnRH-a for > or = 6 months of therapy.

MAIN OUTCOME MEASURES

Vasomotor symptoms, bone density changes, lipid profiles, alterations in presenting symptoms, and disease state.

RESULTS

Estrogens in combination with progestins were efficacious as add-back in the management of ovarian hyperandrogenic states, dysfunctional uterine bleeding, premenstrual syndrome, and leiomyomata. Medroxyprogesterone acetate alone is ineffective as add-back for treatment of endometriosis or leiomyomata. Norethindrone is effective as add-back in the management of endometriosis but not leiomyomata, although high doses alter lipid profiles in an undesirable fashion. Organic bisphosphonates show great promise in preserving bone density without other untoward effects.

CONCLUSIONS

No single add-back regime is appropriate for all gynecologic indications for GnRH-a. Ideal protocols preserve the efficacy of agonists while suppressing associated vasomotor symptoms and bone density loss.

Changes in bone mineral content following hormone treatment for endometriosis

The effects of danazol and buserelin on the bone mineral content (BMC) of 19 Japanese women with endometriosis were studied. Subjects received 24-week courses of oral danazol (400 mg/day) or intranasal buserelin (900 micrograms/day). Trabecular BMC of the 3rd lumbar vertebra (L3) was monitored by computerized tomography scans pretreatment, at the end of treatment and 6 months post-treatment. In the buserelin group there was a significant decrease in BMC (10-25.4%, P < 0.01) which was not fully reversed 6 months after therapy, and increased parameters of bone resorption. In the danazol group, there was a slight gain in BMC despite a decrease in serum estrogen. Danazol and buserelin have similar success in the treatment of endometriosis, but the decrease in BMC at L3 suggests that cumulative bone loss may follow repeated buserelin therapy.

Evidence that the loss of bone mass induced by GnRH agonists is not totally recovered

There is disagreement as to whether the loss of bone mass induced by GnRH agonists is reversible. In part, the differences of opinion might be attributed to the fact that the influence of weight and seasonal changes on bone mass is often overlooked. Taking into consideration weight and seasonal changes in bone mass, total (TBBMC) and regional body bone mineral content were measured in 38 women treated with GnRH agonists for 6 months for endometriosis or leiomyomata. Measurements were made at the onset of treatment, at 6 months of treatment and at 6 months after finishing treatment. TBBMC was corrected for body weight. Body weight had increased significantly at 6 months of treatment (P = 0.0175). Regional bone mineral content showed the following: limbs, no changes; head, significantly lower at 12 months than at baseline (P = 0.0036) and at 6 months (P = 0.0343) of therapy; trunk, significantly lower at 6 months (P = 0.0002) compared to baseline, but the values at 1 year were not significantly different from either the baseline or the 6-month values; pelvis, the same pattern of change as in the trunk (P = 0.0349). TBBMC was significantly lower at 6 months of treatment (P < 0.0001) and at 1 year (P = 0.0162). TBBMC adjusted for weight experienced the same changes as unadjusted bone mineral content (P < 0.0001 and P < 0.0009 at 6 months and 1 year, respectively). Our findings indicate that the bone mass lost with GnRH treatment had not been restored 6 months after discontinuing treatment.

Gonadotropin-releasing hormone analogue (goserelin) plus hormone replacement therapy for the treatment of endometriosis: a randomized controlled trial

OBJECTIVE

To determine whether treatment of endometriosis with a GnRH analogue (GnRH-a; goserelin) combined with continuous estrogen and progestogen hormone replacement therapy (HRT) would prevent the hypoestrogenic effects, including loss of bone density, while maintaining efficacy for treatment of endometriosis.

DESIGN

Randomized controlled trial.

PATIENTS

Fifty premenopausal women with laparoscopically diagnosed endometriosis (revised American Fertility Score for endometriosis implants equal to four or greater) and significant symptoms of dysmenorrhoea, dyspareunia, and other pelvic pain.

INTERVENTION

Patients were randomized to receive either goserelin alone, 3.6 mg SC depot every 4 weeks for 24 weeks, or goserelin, 3.6 mg SC depot every 4 weeks for 24 weeks, plus HRT (25 micrograms transdermal 17 beta E2 daily and 5 mg medroxyprogesterone acetate orally daily) for 20 weeks commencing with the second goserelin injection.

RESULTS

There was a significant reduction in the extent of pelvic endometriosis in both groups, with no difference between the groups. Both groups experienced an improvement in symptoms and signs, again with no difference between groups. Hypoestrogenic side effects of hot flushes and loss of libido were significantly less in the group that received HRT. The amount of bone mineral density loss was significantly less in the HRT group at the lumbar spine, although it was not prevented completely.

CONCLUSION

The addition of HRT to GnRH-a for the treatment of endometriosis did not reduce the efficacy of treatment, and adverse hypoestrogenic effects were decreased, although not abolished.

Depot leuprolide acetate versus danazol for treatment of pelvic endometriosis: changes in vertebral bone mass and serum estradiol and calcitonin

OBJECTIVE

To determine changes in trabecular vertebral bone mass, serum E2, and serum calcitonin during and after therapy of pelvic endometriosis with depot leuprolide acetate (LA) or danazol.

DESIGN

Prospective, randomized, double-blind study.

SETTING

Academic university hospital and department of obstetrics and gynecology.

PATIENTS

Twelve women with symptomatic pelvic endometriosis diagnosed and staged by laparoscopy.

INTERVENTIONS

All patients received blinded treatment with either 3.75 mg JM depot LA given every month and daily placebo tablets (n = 6) or 800 mg oral danazol daily with a monthly placebo injection (n = 6) for 24 weeks.

MAIN OUTCOME MEASURES

Quantitated computerized tomography of bone density of thoracic 12 to lumbar 4 vertebral bodies were determined before, at the end of 24 weeks of treatment, and 6 and 12 months after completing treatment. Gain or loss of bone mass was based against pretreatment levels. Serial serum levels of E2 and calcitonin before, throughout, and after therapy were compared with changes in bone mass.

RESULTS

Bone loss with LA was 14.0% +/- 0.5% (mean +/- SEM), recovering to a deficit of 4.2% +/- 3.8% and 3.3%, 6 and 12 months after stopping therapy. Danazol increased bone by 5.4% +/- 2.2%, with a further gain to 8.2% +/- 3.5% and 7.5%, 6 and 12 months after stopping treatment. Serum E2 levels usually were < 25 pg/mL (conversion factor to SI unit, 3.671) with LA but > 47.3 pg/mL with danazol. Calcitonin levels did not change significantly with either treatment.

CONCLUSION

Depot LA produced marked sustained hypoestrogenemia and significant bone loss with incomplete recovery 1 year after stopping treatment. Danazol maintained normoestrogenemia and increased bone mass with the gain maintained even 1 year after stopping therapy.

Bone loss during gonadotropin releasing hormone agonist treatment and use of nasal calcitonin

Gonadotropin releasing hormone (GnRH) agonists have shown to be effective in the treatment of several sex-hormone-dependent conditions. However, their use could be limited by the bone loss they induce. To evaluate the use of nasal salmon calcitonin (sCT) in preventing this bone loss, 40 patients with endometriosis were treated for 6 months with triptoreline (3.75 mg monthly) and calcium (1 g daily), and randomized in three groups-placebo, sCT 100 IU daily and sCT 200 IU daily-in a prospective double-masked study. Dual-energy X-ray absorptiometry and biochemical parameters were used to evaluate the benefit of the treatment. At baseline, there were no statistically significant differences between the groups. After 6 months, estradiol and biochemical markers of bone metabolism were at postmenopausal levels, with no difference between the groups. There was no difference in bone loss in the three groups, at all sites. Mean lumbar bone loss was 4.01 +/- 2.59% (mean +/- SD) in this population. In this study dosages of 100 IU and 200 IU daily of nasal sCT were insufficient to prevent bone loss during GnRH agonist treatment.