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Anderson RA. Kisspeptin and neurokinin B neuroendocrine pathways in the control of human ovulation. J Neuroendocrinol 2024:e13371. [PMID: 38404024 DOI: 10.1111/jne.13371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/09/2024] [Accepted: 01/11/2024] [Indexed: 02/27/2024]
Abstract
The roles of initially kisspeptin and subsequently neurokinin B pathways in the regulation of human reproduction through the control of GnRH secretion were first identified 20 years ago, as essential for the onset of puberty in both boys and girls. Within that short time we already now have the first licence for clinical use for a neurokinin antagonist in a related indication, for menopausal vasomotor symptoms. Between these two markers of the start and end of the reproductive lifespan, it is clear that these pathways underlie many of the aspects of the hypothalamic regulation of reproduction which had hitherto been enigmatic. In this review, we describe the data currently available from studies designed to elucidate the roles of kisspeptin and neurokinin B in human ovarian function, specifically the regulation of follicle development leading up to ovulation, and in the control of the mid-cycle GnRH/LH surge that triggers ovulation. These studies, undertaken with only very limited pharmacological tools, provide evidence that the neurokinin B pathway is important in controlling the hypothalamic contribution to the precise gonadotropic drive to the ovary that is necessary for mono-ovulation, whereas the switch from negative to positive estrogenic feedback results in kisspeptin-mediated increased GnRH secretion. Potential therapeutic opportunities in conditions characterised by disordered hypothalamic/pituitary function, polycystic ovary syndrome, and functional hypothalamic amenorrhoea, and in the induced LH surge that is a necessary part of IVF treatment are discussed.
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Anderson RA, Millar RP. The roles of kisspeptin and neurokinin B in GnRH pulse generation in humans, and their potential clinical application. J Neuroendocrinol 2022; 34:e13081. [PMID: 34962670 DOI: 10.1111/jne.13081] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/22/2021] [Accepted: 12/14/2021] [Indexed: 12/22/2022]
Abstract
The delivery of gonadotropin-releasing hormone (GnRH) in a pulsatile mode to the gonadotropes has long been known to be essential for normal reproductive function. There have been numerous studies aimed at dissecting out the mechanisms underlying GnRH pulse generation. The discovery of kisspeptin as an upstream regulator of GnRH attracted the possibility that pulsatile kisspeptin governed the pulsatile secretion of GnRH. Subsequent studies have shown the importance of the neurokinin B (NKB) system in modulating kisspeptin secretion and this GnRH. A number of studies in laboratory rodents have supported this notion. By contrast, we present data from clinical studies in men and women, in a range of contexts, showing that continuous infusion of kisspeptin 10 at receptor-saturating levels gives rise to an increase in luteinizing hormone (LH) (GnRH) pulse frequency. This has been demonstrated in normal healthy and hypogonadal men, in normal women during the mid-cycle LH surge, in men and women with mutations in the genes encoding NKB or its receptor, neurokinin 3 receptor (NK3R), in women with polycystic ovary syndrome treated with NK3R antagonist, and in women treated with NK3R antagonist during the LH surge. These finds indicate that pulsatile secretion and action of kisspeptin on GnRH neurons is not required for the generation of LH (GnRH) pulses in humans. We also report that there is an absence of desensitization in humans exposed to continuous infusion of kisspeptin-10 at receptor-saturating concentrations over 22 h and briefly review GnRH, kisspeptin and NKB analogs and their clinical application.
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Affiliation(s)
- Richard A Anderson
- MRC Centre for Reproductive Health, Queens Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Robert P Millar
- Department of Immunology, Faculty of Health Sciences, Centre for Neuroendocrinology, University of Pretoria, Pretoria, South Africa
- Department of Integrative Biomedical Sciences, Faculty of Health Sciences, Institute of Infectious Disease and Molecular Medicine, Observatory, South Africa
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Hypothalamic neurokinin signalling and its application in reproductive medicine. Pharmacol Ther 2021; 230:107960. [PMID: 34273412 DOI: 10.1016/j.pharmthera.2021.107960] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/06/2021] [Accepted: 07/08/2021] [Indexed: 12/29/2022]
Abstract
The discovery of the essential requirement for kisspeptin and subsequently neurokinin B signalling for human reproductive function has sparked renewed interest in the neuroendocrinology of reproduction. A key discovery has been a population of cells co-expressing both these neuropeptides and dynorphin in the hypothalamus, directly regulating gonadotropin hormone releasing hormone (GnRH) secretion and thus pituitary secretion of gonadotropins. These neurons also project to the vasomotor centre, and their overactivity in estrogen deficiency results in the common and debilitating hot flushes of the menopause. Several antagonists to the neurokinin 3 receptor, for which neurokinin B is the endogenous ligand, have been developed, and are entering clinical studies in human reproductive function and clinical trials. Even single doses can elicit marked declines in testosterone levels in men, and their use has elicited evidence of the regulation of ovarian follicle growth in women. The most advanced indication is the treatment of menopausal vasomotor symptoms, where these drugs show remarkable results in both the degree and speed of symptom control. A range of other reproductive indications are starting to be explored, notably in polycystic ovary syndrome, the most common endocrinopathy in women.
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Abbara A, Eng PC, Phylactou M, Clarke SA, Richardson R, Sykes CM, Phumsatitpong C, Mills E, Modi M, Izzi-Engbeaya C, Papadopoulou D, Purugganan K, Jayasena CN, Webber L, Salim R, Owen B, Bech P, Comninos AN, McArdle CA, Voliotis M, Tsaneva-Atanasova K, Moenter S, Hanyaloglu A, Dhillo WS. Kisspeptin receptor agonist has therapeutic potential for female reproductive disorders. J Clin Invest 2021; 130:6739-6753. [PMID: 33196464 DOI: 10.1172/jci139681] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 09/03/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUNDKisspeptin is a key regulator of hypothalamic gonadotropin-releasing hormone (GnRH) neurons and is essential for reproductive health. A specific kisspeptin receptor (KISS1R) agonist could significantly expand the potential clinical utility of therapeutics targeting the kisspeptin pathway. Herein, we investigate the effects of a KISS1R agonist, MVT-602, in healthy women and in women with reproductive disorders.METHODSWe conducted in vivo and in vitro studies to characterize the action of MVT-602 in comparison with native kisspeptin-54 (KP54). We determined the pharmacokinetic and pharmacodynamic properties of MVT-602 (doses 0.01 and 0.03 nmol/kg) versus KP54 (9.6 nmol/kg) in the follicular phase of healthy women (n = 9), and in women with polycystic ovary syndrome (PCOS; n = 6) or hypothalamic amenorrhea (HA; n = 6). Further, we investigated their effects on KISS1R-mediated inositol monophosphate (IP1) and Ca2+ signaling in cell lines and on action potential firing of GnRH neurons in brain slices.RESULTSIn healthy women, the amplitude of luteinizing hormone (LH) rise was similar to that after KP54, but peaked later (21.4 vs. 4.7 hours; P = 0.0002), with correspondingly increased AUC of LH exposure (169.0 vs. 38.5 IU∙h/L; P = 0.0058). LH increases following MVT-602 were similar in PCOS and healthy women, but advanced in HA (P = 0.004). In keeping with the clinical data, MVT-602 induced more potent signaling of KISS1R-mediated IP1 accumulation and a longer duration of GnRH neuron firing than KP54 (115 vs. 55 minutes; P = 0.0012).CONCLUSIONTaken together, these clinical and mechanistic data identify MVT-602 as having considerable therapeutic potential for the treatment of female reproductive disorders.TRIAL REGISTRATIONInternational Standard Randomised Controlled Trial Number (ISRCTN) Registry, ISRCTN21681316.FUNDINGNational Institute for Health Research and NIH.
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Affiliation(s)
- Ali Abbara
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Pei Chia Eng
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Maria Phylactou
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Sophie A Clarke
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Rachel Richardson
- Institute of Reproductive and Developmental Biology, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
| | - Charlene M Sykes
- Department of Molecular & Integrative Physiology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Edouard Mills
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Manish Modi
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Chioma Izzi-Engbeaya
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Debbie Papadopoulou
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | | | - Channa N Jayasena
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Lisa Webber
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | | | - Bryn Owen
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Paul Bech
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Alexander N Comninos
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Craig A McArdle
- Department of Translational Medicine, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | | | - Krasimira Tsaneva-Atanasova
- Department of Mathematics and Living Systems Institute, and.,EPSRC Centre for Predictive Modelling in Healthcare, University of Exeter, Exeter, United Kingdom
| | - Suzanne Moenter
- Department of Molecular & Integrative Physiology, University of Michigan, Ann Arbor, Michigan, USA.,Department of Internal Medicine, and.,Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Aylin Hanyaloglu
- Institute of Reproductive and Developmental Biology, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
| | - Waljit S Dhillo
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
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Chabbert-Buffet N, Kolanska K, Daraï E, Bouchard P. Selective progesterone receptor modulators: current applications and perspectives. Climacteric 2018; 21:375-379. [PMID: 29338440 DOI: 10.1080/13697137.2017.1386650] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Selective progesterone receptor modulators (SPRMs) are steroid progesterone receptor ligands able to induce agonistic or antagonistic activities. Mifepristone, the class leader, was primarily used for pregnancy termination from the 1980s. Emergency contraception with extended activity was the second major development 30 years later, with mifepristone in some countries and ulipristal acetate world-wide. More recently, ulipristal acetate was released for the treatment of myoma-related uterine bleeding. In addition to a very rapid cessation of bleeding, SPRMs allow a decrease in myoma volume, as do gonadotropin releasing hormone analogs. However, estradiol secretion is not blunted by SPRMs. This offers new alternatives for myoma treatment, especially in women close to menopause. In conclusion, use of SPRMs has allowed significant progress in emergency contraception and treatment of myoma-related symptoms. Numerous future perspectives in women's health care are currently under evaluation.
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Affiliation(s)
- N Chabbert-Buffet
- a Obstetrics and Gynecology Department , University Hospital Paris Est, Tenon APHP, University Pierre and Marie Curie , Paris , France
| | - K Kolanska
- a Obstetrics and Gynecology Department , University Hospital Paris Est, Tenon APHP, University Pierre and Marie Curie , Paris , France
| | - E Daraï
- a Obstetrics and Gynecology Department , University Hospital Paris Est, Tenon APHP, University Pierre and Marie Curie , Paris , France
| | - P Bouchard
- b Endocrinology Unit , University Hospital Paris Est, Saint Antoine APHP, University Pierre and Marie Curie , Paris , France
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The history and use of the progesterone receptor modulator ulipristal acetate for heavy menstrual bleeding with uterine fibroids. Best Pract Res Clin Obstet Gynaecol 2017; 40:105-110. [DOI: 10.1016/j.bpobgyn.2016.12.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 12/07/2016] [Indexed: 12/21/2022]
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Skorupskaite K, George JT, Veldhuis JD, Millar RP, Anderson RA. Interactions Between Neurokinin B and Kisspeptin in Mediating Estrogen Feedback in Healthy Women. J Clin Endocrinol Metab 2016; 101:4628-4636. [PMID: 27636018 PMCID: PMC5155690 DOI: 10.1210/jc.2016-2132] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Kisspeptin and neurokinin B (NKB) are obligate for normal gonadotropin secretion, but their hierarchy is unexplored in normal women. OBJECTIVE To investigate the interaction between kisspeptin and NKB on estrogen-regulated LH secretion. DESIGN Women were treated with neurokinin-3 receptor (NK3R) antagonist followed by transdermal estradiol to induce LH secretion 48 hours later, with kisspeptin-10 or vehicle infusion during estrogen administration in a 2-way crossover study. SETTING Clinical research facility. PATIENTS OR OTHER PARTICIPANTS Healthy females with regular menses. INTERVENTION(S) NK3R antagonist AZD4901 40 mg twice daily orally was taken from cycle day 4-6 for 6 days (n = 10, with 10 no treatment controls). Transdermal estradiol patches (200 μg/d) were applied after 5 days of NK3R antagonist treatment. At 24-hour estradiol treatment, women were randomized to 7-hour kisspeptin-10 (4 μg/kg/h) or vehicle iv infusion, with the alternate infusion in a subsequent cycle. MAIN OUTCOME MEASURE(S) Plasma gonadotropin and estradiol secretion. RESULTS After an initial suppression, LH secretion was increased 48 hours after estradiol treatment. Kisspeptin-10 increased LH secretion during the inhibitory phase, and LH remained elevated beyond the discontinuation of kisspeptin-10 infusion. NK3R antagonist decreased LH pulse frequency (0.5 ± 0.2 vs 0.7 ± 0.2 pulses/h, P < .05) and stimulated FSH response to kisspeptin-10 infusion (10.7 ± 11.0 vs 5.0 ± 3.6 IU/L, P < .05) with a nonsignificant rise in LH. The duration of LH response was blunted, with LH being lower at 48 hours (7.5 ± 4.8 vs 15.0 ± 11.4 IU/L, P < .05). CONCLUSIONS These data demonstrate that NKB signaling regulates GnRH/LH secretion in normal women, and is predominantly proximal to kisspeptin in mediating estrogenic positive and negative feedback on LH secretion.
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Affiliation(s)
- Karolina Skorupskaite
- MRC Centre for Reproductive Health (K.S., J.T.G., R.A.A.), The Queen's Medical Research Institute, University of Edinburgh, Edinburgh EH16 4TJ, United Kingdom; Endocrine Research Unit (J.D.V.), Center for Translational Science Activities, Mayo Clinic, Rochester, Minnesota 55905; and Mammal Research Unit and Centre for Neuroendocrinology (R.P.M.), University of Pretoria, 0028 Pretoria, South Africa and MRC Receptor Biology Unit, Institute for Infectious Diseases and Molecular Medicine, University of Cape Town, 7925 Observatory, South Africa
| | - Jyothis T George
- MRC Centre for Reproductive Health (K.S., J.T.G., R.A.A.), The Queen's Medical Research Institute, University of Edinburgh, Edinburgh EH16 4TJ, United Kingdom; Endocrine Research Unit (J.D.V.), Center for Translational Science Activities, Mayo Clinic, Rochester, Minnesota 55905; and Mammal Research Unit and Centre for Neuroendocrinology (R.P.M.), University of Pretoria, 0028 Pretoria, South Africa and MRC Receptor Biology Unit, Institute for Infectious Diseases and Molecular Medicine, University of Cape Town, 7925 Observatory, South Africa
| | - Johannes D Veldhuis
- MRC Centre for Reproductive Health (K.S., J.T.G., R.A.A.), The Queen's Medical Research Institute, University of Edinburgh, Edinburgh EH16 4TJ, United Kingdom; Endocrine Research Unit (J.D.V.), Center for Translational Science Activities, Mayo Clinic, Rochester, Minnesota 55905; and Mammal Research Unit and Centre for Neuroendocrinology (R.P.M.), University of Pretoria, 0028 Pretoria, South Africa and MRC Receptor Biology Unit, Institute for Infectious Diseases and Molecular Medicine, University of Cape Town, 7925 Observatory, South Africa
| | - Robert P Millar
- MRC Centre for Reproductive Health (K.S., J.T.G., R.A.A.), The Queen's Medical Research Institute, University of Edinburgh, Edinburgh EH16 4TJ, United Kingdom; Endocrine Research Unit (J.D.V.), Center for Translational Science Activities, Mayo Clinic, Rochester, Minnesota 55905; and Mammal Research Unit and Centre for Neuroendocrinology (R.P.M.), University of Pretoria, 0028 Pretoria, South Africa and MRC Receptor Biology Unit, Institute for Infectious Diseases and Molecular Medicine, University of Cape Town, 7925 Observatory, South Africa
| | - Richard A Anderson
- MRC Centre for Reproductive Health (K.S., J.T.G., R.A.A.), The Queen's Medical Research Institute, University of Edinburgh, Edinburgh EH16 4TJ, United Kingdom; Endocrine Research Unit (J.D.V.), Center for Translational Science Activities, Mayo Clinic, Rochester, Minnesota 55905; and Mammal Research Unit and Centre for Neuroendocrinology (R.P.M.), University of Pretoria, 0028 Pretoria, South Africa and MRC Receptor Biology Unit, Institute for Infectious Diseases and Molecular Medicine, University of Cape Town, 7925 Observatory, South Africa
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Boggavarapu NR, Berger C, von Grothusen C, Menezes J, Gemzell-Danielsson K, Lalitkumar PGL. Effects of low doses of mifepristone on human embryo implantation process in a three-dimensional human endometrial in vitro co-culture system. Contraception 2016; 94:143-51. [PMID: 27001000 DOI: 10.1016/j.contraception.2016.03.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 02/18/2016] [Accepted: 03/14/2016] [Indexed: 12/20/2022]
Abstract
OBJECTIVES We wanted to explore the effects of two different low doses (0.5μM and 0.05μM) of mifepristone, exposed during the receptive period, on the human embryo implantation process, using a well-established three-dimensional in vitro cell culture model, specifically developed to study this process. METHODS An in vitro three-dimensional cell culture model was constructed using human endometrial cells isolated from the endometrium of proven fertile women, collected on cycle day LH+4. After 5 days of culture, supernumerary human embryos were added and cultured for another 5 days with mifepristone 0.5μM (n=8) or 0.05μM (n=10) or vehicle as control (n=10). The cultures were checked for embryo attachment and terminated. We studied the expression of 16 reported endometrial receptivity markers in the endometrial constructs using real-time polymerase chain reaction. RESULTS None of the embryos in 0.5μM of mifepristone attached to the endometrial constructs (p=.004), whereas 4 out of 10 in 0.05μM (p=.3698) and 7 out of 10 embryos in the control group attached to the cultures. We found that most of the studied receptivity markers were significantly altered with mifepristone exposure in a similar direction in both treatment groups. Only IL6 was significantly differentially expressed between the treatment groups (p=.017). CONCLUSION We report for the first time that exposure to a low concentration (0.5μM) of mifepristone during the receptive period successfully inhibits human embryo implantation process in vitro. Further, we observed a dose-dependent effect of mifepristone on endometrial receptivity at the functional level. IMPLICATION This study contributes new knowledge that low dose of mifepristone during the short period of receptive phase can inhibit endometrial receptivity, which further promotes mifepristone as a contraceptive agent. This could give women a treatment choice to avoid unwanted pregnancy with high efficacy and minimal side effects.
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Affiliation(s)
- N R Boggavarapu
- Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet/Karolinska University Hospital, S-171 76, Stockholm, Sweden
| | - C Berger
- Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet/Karolinska University Hospital, S-171 76, Stockholm, Sweden
| | - C von Grothusen
- Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet/Karolinska University Hospital, S-171 76, Stockholm, Sweden
| | - J Menezes
- Fertilitetscentrum, Stockholm, Sweden
| | - K Gemzell-Danielsson
- Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet/Karolinska University Hospital, S-171 76, Stockholm, Sweden.
| | - P G L Lalitkumar
- Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet/Karolinska University Hospital, S-171 76, Stockholm, Sweden.
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Bouchard P. Selective progesterone receptor modulators: a class with multiple actions and applications in reproductive endocrinology, and gynecology. Gynecol Endocrinol 2014; 30:683-4. [PMID: 25242338 DOI: 10.3109/09513590.2014.950647] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Among the remarkable progress made in the treatment of hormone-dependent diseases, recently selective steroid receptor modulators (SPRM) have been remarkable tools to improve the prognosis of multiple hormone-dependent cancers (breast, prostate). Because of their remarkable properties, both agonistic and mainly antagonistic, to modulate progesterone action. They have allowed a better understanding of progesterone action and progress in contraception and treatment of abnormal uterine bleeding as well as in the medical treatment of uterine fibroids.
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Chabbert-Buffet N, Pintiaux A, Bouchard P. The immninent dawn of SPRMs in obstetrics and gynecology. Mol Cell Endocrinol 2012; 358:232-43. [PMID: 22415029 DOI: 10.1016/j.mce.2012.02.021] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Revised: 02/21/2012] [Accepted: 02/22/2012] [Indexed: 12/30/2022]
Abstract
Selective progesterone receptor modulators (SPRMs) have been developed since the late 70s when mifepristone was first described. They act through nuclear progesterone receptors and can have agonist or mixed agonist antagonist actions depending on the cell and tissue. Mifepristone has unique major antagonist properties allowing its use for pregnancy termination. Ulipristal acetate has been marketed in 2009 for emergency contraception and has been recently approved for preoperative myoma treatment. Further perspectives for SPRMs use include long term estrogen free contraception, endometriosis treatment. However long term applications will be possible only after confirmation of endometrial safety.
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Affiliation(s)
- Nathalie Chabbert-Buffet
- Obstetrics, Gynecology and Reproductive Medicine Department, AP-HP, Hospital Tenon, UPMC Paris 06, Paris, France.
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Bouchard P, Chabbert-Buffet N, Fauser BCJM. Selective progesterone receptor modulators in reproductive medicine: pharmacology, clinical efficacy and safety. Fertil Steril 2011; 96:1175-89. [PMID: 21944187 DOI: 10.1016/j.fertnstert.2011.08.021] [Citation(s) in RCA: 124] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2011] [Revised: 08/08/2011] [Accepted: 08/12/2011] [Indexed: 11/19/2022]
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Ouzounian S, Bouchard P, Chabbert-Buffet N. Effects of antiprogestins on the uterus. ACTA ACUST UNITED AC 2009; 4:269-80. [PMID: 19072476 DOI: 10.2217/17455057.4.3.269] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Progesterone-receptor modulators (PRMs) are progesterone-receptor ligands that can exert agonistic, antagonistic or mixed agonist-antagonist effects depending on the cellular context. The mechanisms of action of these compounds are still incompletely understood. PRMs already have several applications in women's health such as emergency contraception, pregnancy termination, management of early fetal demise and cervical maturation. The main indications that will be developed in the future include dysfunctional bleeding and preoperative treatment of uterine myomas. Other future indications may include estrogen-free contraception, treatment of endometriosis and prevention and treatment of breast cancer. However, the available data from mid- to long-term continuous administration studies has raised the issue of endometrial safety. For this reason, long-term applications of PRMs are currently postponed, although windows of treatment with a short course of progestin therapy, or even by a short interruption of treatment, could improve endometrial aspects if needed.
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Horne FM, Blithe DL. Progesterone receptor modulators and the endometrium: changes and consequences. Hum Reprod Update 2007; 13:567-80. [PMID: 17630398 DOI: 10.1093/humupd/dmm023] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Progesterone receptor modulators (PRMs) have been used for contraceptive research, as well as for treatment of fibroids, endometriosis and heavy or irregular menstrual bleeding. Long-term treatment with these compounds results in changes to the endometrium resulting in potential confusion in trying to characterize endometrial biopsies. A meeting was held to discuss the properties of PRMs, the effects of perturbed hormonal control of the endometrium and the need for further understanding of the biology of progesterone receptor action to facilitate the development of new PRMs. A panel of pathologists was convened to evaluate endometrial changes associated with a minimum of three months of chronic treatment with PRMs. Four different agents were used in the treatment regimens but the pathologists were blinded to treatment regimen or agent. The panel agreed that the endometrial biopsies did not fit into a classification of either proliferative or secretory endometrium but exhibited an unusual architecture that could be characterized as glandular dilatation. There was little evidence of mitosis, consistent with a proposed anti-proliferative effect of PRMs. The panel concluded that the biopsies did not reveal evidence of safety concern and that pathologists and investigators familiar with endometrial effects of chronic PRM exposure should consider working with pharmaceutical companies and regulatory agencies to develop standard descriptions of PRM-associated endometrial changes as well as the types of histologic changes that would signal a need for intervention.
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Heikinheimo O, Leminen R, Raivio T. Mifepristone may inhibit the midcycle gonadotropin surge at both ovarian and pituitary sites of action. Fertil Steril 2005; 84:1545-6. [PMID: 16275268 DOI: 10.1016/j.fertnstert.2005.04.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2005] [Revised: 04/28/2005] [Accepted: 04/28/2005] [Indexed: 11/24/2022]
Abstract
The ability of mifepristone to delay ovulation is thought to be based on the antigonadotropic effects of the drug. In the current work, late-follicular phase administration of mifepristone resulted in decrease in both circulating FSH and inhibin B, suggesting both central and ovarian sites of action.
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Affiliation(s)
- Oskari Heikinheimo
- Department of Obstetrics and Gynecology, University of Helsinki, Helsinki, Finland.
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Leminen R, Raivio T, Ranta S, Oehler J, von Hertzen H, Jänne OA, Heikinheimo O. Late follicular phase administration of mifepristone suppresses circulating leptin and FSH - mechanism(s) of action in emergency contraception? Eur J Endocrinol 2005; 152:411-8. [PMID: 15757858 DOI: 10.1530/eje.1.01884] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Low dose mifepristone (RU486) is highly effective in emergency post-coital contraception (EC), although the mechanism(s) of action remains unclear. We studied the endocrine actions of 10 mg mifepristone administered orally as a single dose to eight healthy volunteers (aged 20-45 years) during the late follicular phase. METHODS Serum levels of LH, FSH, oestradiol, progesterone, leptin, mifepristone, cortisol, and gluco-corticoid bioactivity (GBA) were measured before and 1, 2, 4 and 8 h after ingestion of mifepristone on cycle day 10 or 11 (study day 1), and follow-up was continued for 10 days. Ovarian ultrasonography was performed on study days 1 and 7. Similar measurements were carried out during a control cycle. RESULTS Mifepristone postponed ovulation, as evidenced by a 3.4+/-1.1 day (means+/-s.d.) delay (P < 0.005) in the LH surge and 3.6+/-4.0 day prolongation of the treatment cycle (P = 0.08). During the mifepristone cycle, an LH surge was displayed by five subjects when serum mifepristone levels had declined to 9.5+/-7.1 nmol/l. During the day of mifepristone administration, circulating GBA (P < 0.001) and leptin (P < 0.001) levels declined. On the day after mifepristone administration, mean serum FSH and leptin levels were lower than pretreatment values (3.8+/-1.8 IU/l vs 5.2+/-1.1 IU/l, n = 7, P < 0.05; 28.9+/-6.7 microg/l vs 33.2+/-9.0 microg/l, n = 7, P < 0.05 respectively), and the corresponding difference in the mean serum oestradiol concentration was borderline (452+/-252 pmol/l vs 647+/-406 pmol/l, n = 7, P = 0.056). In contrast to the control cycle, individual leptin levels declined during the follow-up after ingestion of mifepristone (n = 8, P < 0.01). CONCLUSIONS These data showed that the commonly employed dose of mifepristone for EC delays ovulation and prolongs the menstrual cycle, when given during the late follicular phase. The mechanism of action of mifepristone may include a reduction of FSH secretion via a decrease in circulating leptin.
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Affiliation(s)
- Riikka Leminen
- Department of Obstetrics and Gynecology, University of Helsinki, Helsinki, Finland
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Crawford JL, McNeilly JR, McNeilly AS. No Evidence for Pituitary Priming to Gonadotropin-Releasing Hormone in Relation to Luteinizing Hormone (LH) Secretion Prior to the Preovulatory LH Surge in Ewes1. Biol Reprod 2004; 71:224-35. [PMID: 15031142 DOI: 10.1095/biolreprod.104.027615] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
The purpose of this study was to determine the occurrence of and the regulatory mechanisms involved in priming of the pituitary to GnRH before the preovulatory LH surge in sheep. Experiment 1: Forty-two ewes had progestagen devices removed after 14 days and were assigned to luteal (Lut) or follicular (Foll) groups. Fifteen days later, blood sampling was initiated either immediately or 36 h after induced luteolysis in groups Lut and Foll, respectively. After 4 h, ewes were administered either saline (n = 5) or 250 ng (n = 8) or 10 microg (n = 8) of GnRH. Five ewes per treatment group were killed 1 h later, while remaining animals were blood sampled for a further 7 h. Experiment 2: Eighteen ewes were allocated to Lut and Foll groups (described above). Blood samples were collected from 2 h before GnRH (10 microg) treatment until 7 h after. Despite up-regulated GnRH-R mRNA levels in Foll ewes, pituitary content and plasma levels of LH and LHbeta mRNA levels were similar between groups. Mean FSHbeta mRNA and plasma FSH levels were elevated in Lut ewes but declined after GnRH treatment. Inversely, plasma estradiol and inhibin-A concentrations were higher in Foll ewes and declined after GnRH treatment. Fewer LH(+ve)/secretogranin II(-ve) (SgII(-ve)) granules were present in gonadotropes of Foll ewes, coincident with increased basal LH levels. Fewer smaller sized granules were present after GnRH treatment. In conclusion, there was no evidence of self-priming before onset of the preovulatory LH surge. Constitutive release of LH(+ve)/SgII(-ve) granules may maintain basal LH levels while smaller sized, presumably mature granules may be preferentially released after GnRH stimulation.
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Affiliation(s)
- J L Crawford
- Human Reproductive Sciences Unit, Medical Research Council, University of Edinburgh Centre for Reproductive Biology, Edinburgh EH16 4SB, United Kingdom.
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Leminen R, Ranta S, von Hertzen H, Oehler J, Heikinheimo O. Pharmacokinetics of 10 mg of mifepristone. Contraception 2003; 68:427-9. [PMID: 14698072 DOI: 10.1016/s0010-7824(03)00181-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The results of several randomized studies have verified the efficacy of 10 mg mifepristone in emergency contraception. In the present study we characterized the pharmacokinetics of 10 mg mifepristone. Eight healthy female volunteers received a single oral dose of mifepristone on the day 10 or 11 of their menstrual cycle. Blood samples were collected at 0, 1, 2, 4 and 8 h, daily for the next 6 days and on day 10 after mifepristone. Mifepristone concentrations were determined by radioimmunoassay preceded by column chromatography. A peak level of 1.41 +/- 0.31 micromol/L (mean +/- SD) was measured at 1 h. Individual elimination phase half-lives varied from 15.3 to 26.8 h, the mean (+/- SD) value being 19.6 +/- 4.50 h. Serum mifepristone concentrations exceeded 10 nmol/L in all volunteers for an average of 4.9 days. The pharmacokinetic data on 10 mg mifepristone are in line with previous pharmacokinetic and clinical data, and encourage further development of the 10-mg dose in emergency contraception.
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Affiliation(s)
- Riikka Leminen
- Department of Obstetrics and Gynecology, University of Helsinki, P.O. Box 140, SF-00029, HUS, Helsinki, Finland
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Glasier AF, Wang H, Davie JE, Kelly RW, Critchley HOD. Administration of an antiprogesterone up-regulates estrogen receptors in the endometrium of women using Norplant: a pilot study. Fertil Steril 2002; 77:366-72. [PMID: 11821099 DOI: 10.1016/s0015-0282(01)02997-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine the effect of a single dose of mifepristone (200 mg) on endometrial estrogen and progesterone receptors in Norplant users. DESIGN A prospective single-blind placebo-controlled pilot study. SETTING; Women were recruited from a large family planning clinic and were studied either at the clinic or in a clinical research unit attached to a teaching hospital gynecology department. PATIENT(S) Eight women using Norplant and experiencing vaginal bleeding more often than once every 24 days. All completed the study. INTERVENTION(S) Endometrial biopsies were taken after treatment with both placebo and 200 mg of mifepristone, both given at the start of a bleeding episode. MAIN OUTCOME MEASURE(S) Expression of endometrial progesterone (PR) and estrogen (ER) receptors, ovulation, and vaginal bleeding. RESULT(S) Mifepristone administration was associated with down-regulation of PR receptor subtype B and up-regulation of ER. Women treated with mifepristone showed a tendency to increased ovulation rates and reduced vaginal bleeding. CONCLUSION(S) The effect of mifepristone on endometrial steroid receptors was consistent with functional inhibition of progesterone. The findings warrant further investigation of this regimen as a strategy to reduce frequent bleeding.
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Affiliation(s)
- Anna F Glasier
- Department of Obstetrics and Gynaecology, Centre for Reproductive Biology, University of Edinburgh, 37 Chalmers Street, Edinburgh, EH9 3ET, Scotland, UK.
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Abstract
Mifepristone is an orally-active progesterone receptor antagonist. When a single dose of mifepristone is given in the mid- or late follicular phase, it may diminish or inhibit the luteinising hormone (LH) surge. In the early luteal phase, a single dose of mifepristone induces significant changes in the endometrium without affecting the hormonal levels or menstruation. When it is given in the mid-luteal phase, there will also be significant changes in the endometrium and some women may have two episodes of vaginal bleeding. A clinical trial suggests that a single dose of mifepristone in the early luteal phase may be an effective contraceptive agent but the lack of a cheap and easy method to identify the LH surge limits its clinical application. The administration of mifepristone alone or in combination with a prostaglandin does not appear to be an effective form of contraception. When used together with a prostaglandin, it may be an effective method for menstrual regulation but the cost and possible side effects of the prostaglandins limit its use. Mifepristone is a very effective method for emergency contraception. The incidence of side effects was also lower than that of the Yuzpe regimen. Lowering the dose of mifepristone from 600 to 10 mg does not decrease its efficacy but the incidence of delay in onset of the subsequent menses is reduced. Despite its efficacy, the reputation of mifepristone as an abortion pill may limit its access in many countries.
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Affiliation(s)
- P C Ho
- Department of Obstetrics and Gynaecology, University of Hong Kong.
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Croxatto HB, Devoto L, Durand M, Ezcurra E, Larrea F, Nagle C, Ortiz ME, Vantman D, Vega M, von Hertzen H. Mechanism of action of hormonal preparations used for emergency contraception: a review of the literature. Contraception 2001; 63:111-21. [PMID: 11368982 DOI: 10.1016/s0010-7824(01)00184-6] [Citation(s) in RCA: 123] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- H B Croxatto
- Instituto Chileno de Medicina Reproductiva, Santiago, Chile.
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van Heusden AM, Killick SR, Coelingh Bennink HJ, Fauser BC. Single monthly administration of the anti-progestagen Org 31710 in users of the 75 microg desogestrel progestagen-only pill: effects on pituitary-ovarian activity. Hum Reprod 2000; 15:629-36. [PMID: 10686210 DOI: 10.1093/humrep/15.3.629] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Endocrine and ultrasound effects were studied of an intermittent (every 28 days) oral administration of 150 mg of the anti-progestagen Org 31710 during the continued daily use of 75 microg desogestrel (DSG) for progestagen-only contraception. A randomized, double-blind, placebo-controlled two-centre study was conducted in 50 healthy volunteers. Serum luteinizing hormone (LH), follicle stimulating hormone (FSH), oestradiol and progesterone concentrations, and follicle number and size were studied, as well as endometrial thickness, which was assessed by transvaginal sonography at least twice weekly during a single medication cycle (cycle 3-5). Forty-eight women were evaluated (Org 31710, n = 25; placebo, n = 23). Seven ovulations were observed in the treated group versus none in the placebo group. LH concentrations were higher on days 9 and 11 and oestradiol concentrations lower on day 3 in the treated group, irrespective of whether ovulation occurred. No parameter could predict ovulation. Endometrial thickness was greater on cycle days 7-13 and 19 in the treated group. However, within the Org 31710 group, no significant differences were found in volunteers who did or did not ovulate. Observed differences may be attributed to a competitive effect of Org 31710 with progestagen-induced suppression of the pituitary-ovarian axis, altered oestradiol feedback mechanisms, and/or altered receptor availability.
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Affiliation(s)
- A M van Heusden
- Division of Reproductive Medicine, Department of Obstetrics and Gynaecology, Erasmus University Medical Centre Rotterdam, 3015 GD Rotterdam, The Netherlands
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Abstract
Estradiol secreted by growing ovarian follicle(s) has been considered classically to be the neural trigger for the preovulatory surge of gonadotropins. The observation that the estradiol-induced gonadotropin surge in ovariectomized rats is of lesser magnitude and duration than that found in the cycling rat at proestrus has resulted in a search for other steroid regulators. Progesterone is a major regulator of the preovulatory gonadotropin surge. It can only act in the presence of an estrogen background, which is necessary for the synthesis of progesterone receptors. In the estrogen-primed ovariectomized rat, progesterone is able to initiate and enhance the gonadotropin surge to the magnitude observed on the day of proestrus and limit it to 1 day. The physiological role of progresterone in the induction of the preovulatory gonadotropin surge has been demonstrated by the attenuation of the progesterone-induced surge and the endogenous proestrus surge by progesterone receptor antagonist RU486 and the progesterone synthesis inhibitor trilostane. The promoter region of the follicle-stimulating hormone (FHS)-beta gene contains multiple progesterone response elements and progesterone brings about FSH release as well. The reduction of progesterone in the 5 alpha-position appears to be important for the regulation of progesterone secretion. Corticosteroids appear to play a significant role in the secondary FSH surge on late proestrus and early estrus.
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Affiliation(s)
- V B Mahesh
- Department of Physiology and Endocrinology, Medical College of Georgia, Augusta 30912-3000, USA.
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Cameron ST, Thong KJ, Baird DT. Effect of daily low dose mifepristone on the ovarian cycle and on dynamics of follicle growth. Clin Endocrinol (Oxf) 1995; 43:407-14. [PMID: 7586613 DOI: 10.1111/j.1365-2265.1995.tb02610.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND OBJECTIVE The antiprogestin mifepristone has been shown to disrupt folliculogenesis and endometrial maturation and, therefore, has the potential to be used as a novel form of contraception. The purpose of this study was to investigate further the effects of daily administration of a low dose of mifepristone (2mg) on the ovarian cycle and on the dynamics of follicle growth. SUBJECTS Six healthy female volunteers were given 2mg mifepristone daily for 30 days following an ovulatory control cycle. MEASUREMENTS Follicle growth was monitored with transvaginal ultrasonography and hormonal measurements in blood and urine were used to monitor effects on the ovarian cycle. In addition, concentrations of cortisol and ACTH in serum were measured to assess the effects of mifepristone on the pituitary-adrenal axis. RESULTS Treatment with mifepristone retarded the follicular growth rate in all women (P = 0.01). Ovulation was inhibited in 4 of 6 subjects and appeared to be mediated through an effect on the hypothalamo-pituitary axis, as no surge of FSH or LH occurred. In these subjects the dominant follicle continued to grow and developed into a persistent follicle. In two cases the persistent follicle remained functional and ovulation occurred soon after stopping treatment. In the remaining two subjects, the dominant follicle developed into a non-functioning cyst ( > 30 mm) which persisted for one month after the end of the post-treatment cycle. In the two subjects who ovulated, the LH surge was delayed by 6 and 7 days but was followed by a luteal phase of normal length. There was no significant change in the concentration of ACTH or cortisol suggesting that treatment with mifepristone in this dose has little if any effect on the pituitary-adrenal axis. CONCLUSION These findings add further evidence to support the contraceptive potential of mifepristone through effects on follicular development and on the menstrual cycle.
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Affiliation(s)
- S T Cameron
- Department of Obstetrics and Gynaecology, University of Edinburgh, UK
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