The effects of nafarelin and danazol on vertebral trabecular bone mass in patients with endometriosis

Gonadotropin-releasing hormone analogues for endometriosis

BACKGROUND

Endometriosis is a common gynaecological condition affecting 6 to 11% of reproductive-age women and may cause dyspareunia, dysmenorrhoea, and infertility. One treatment strategy is medical therapy with gonadotrophin-releasing hormone analogues (GnRHas) to reduce pain due to endometriosis. One of the adverse effects of GnRHas is a decreased bone mineral density. In addition to assessing the effect on pain, quality of life, most troublesome symptom and patients' satisfaction, the current review also evaluated the effect on bone mineral density and risk of adverse effects in women with endometriosis who use GnRHas versus other treatment options.

OBJECTIVES

To assess the effectiveness and safety of GnRH analogues (GnRHas) in the treatment of painful symptoms associated with endometriosis and to determine the effects of GnRHas on bone mineral density of women with endometriosis.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO and the trial registries in May 2022 together with reference checking and contact with study authors and experts in the field to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) which compared GnRHas with other hormonal treatment options, including analgesics, danazol, intra-uterine progestogens, oral or injectable progestogens, gestrinone and also GnRHas compared with no treatment or placebo. Trials comparing GnRHas versus GnRHas in conjunction with add-back therapy (hormonal or non-hormonal) or calcium-regulation agents were also included in this review.  DATA COLLECTION AND ANALYSIS: We used standard methodology as recommended by Cochrane. Primary outcomes are relief of overall pain and the objective measurement of bone mineral density. Secondary outcomes include adverse effects, quality of life, improvement in the most troublesome symptoms and patient satisfaction.  Due to high risk of bias associated with some of the studies, primary analyses of all review outcomes were restricted to studies at low risk of selection bias. Sensitivity analysis including all studies was then performed.

MAIN RESULTS

Seventy-two studies involving 7355 patients were included. The evidence was very low to low quality: the main limitations of all studies were serious risk of bias due to poor reporting of study methods, and serious imprecision.  Trials comparing GnRHas versus no treatment  We did not identify any studies. Trials comparing GnRHas versus placebo There may be a decrease in overall pain, reported as pelvic pain scores (RR 2.14; 95% CI 1.41 to 3.24, 1 RCT, n = 87, low-certainty evidence), dysmenorrhoea scores (RR 2.25; 95% CI 1.59 to 3.16, 1 RCT, n = 85, low-certainty evidence), dyspareunia scores (RR 2.21; 95% CI 1.39 to 3.54, 1 RCT, n = 59, low-certainty evidence), and pelvic tenderness scores (RR 2.28; 95% CI 1.48 to 3.50, 1 RCT, n = 85, low-certainty evidence) after three months of treatment. We are uncertain of the effect for pelvic induration, based on the results found after three months of treatment (RR 1.07; 95% CI 0.64 to 1.79, 1 RCT, n = 81, low-certainty evidence). Besides, treatment with GnRHas may be associated with a greater incidence of hot flushes at three months of treatment (RR 3.08; 95% CI 1.89 to 5.01, 1 RCT, n = 100, low-certainty evidence). Trials comparing GnRHas versus danazol For overall pain, for women treated with either GnRHas or danazol, a subdivision was made between pelvic tenderness, partly resolved and completely resolved. We are uncertain about the effect on relief of overall pain, when a subdivision was made for overall pain (MD -0.30; 95% CI -1.66 to 1.06, 1 RCT, n = 41, very low-certainty evidence), pelvic pain (MD 0.20; 95% CI -0.26 to 0.66, 1 RCT, n = 41, very low-certainty evidence), dysmenorrhoea (MD 0.10; 95% CI -0.49 to 0.69, 1 RCT, n = 41, very low-certainty evidence), dyspareunia (MD -0.20; 95% CI -0.77 to 0.37, 1 RCT, n = 41, very low-certainty evidence), pelvic induration (MD -0.10; 95% CI -0.59 to 0.39, 1 RCT, n = 41, very low-certainty evidence), and pelvic tenderness (MD -0.20; 95% CI -0.78 to 0.38, 1 RCT, n = 41, very low-certainty evidence) after three months of treatment. For pelvic pain (MD 0.50; 95% CI 0.10 to 0.90, 1 RCT, n = 41, very low-certainty evidence) and pelvic induration (MD 0.70; 95% CI 0.21 to 1.19, 1 RCT, n = 41, very low-certainty evidence), the complaints may decrease slightly after treatment with GnRHas, compared to danazol, for six months of treatment. Trials comparing GnRHas versus analgesics  We did not identify any studies. Trials comparing GnRHas versus intra-uterine progestogens We did not identify any low risk of bias studies. Trials comparing GnRHas versus GnRHas in conjunction with calcium-regulating agents There may be a slight decrease in bone mineral density (BMD) after 12 months treatment with GnRHas, compared to GnRHas in conjunction with calcium-regulating agents for anterior-posterior spine (MD -7.00; 95% CI -7.53 to -6.47, 1 RCT, n = 41, very low-certainty evidence) and lateral spine (MD -12.40; 95% CI -13.31 to -11.49, 1 RCT, n = 41, very low-certainty evidence).  AUTHORS' CONCLUSIONS: For relief of overall pain, there may be a slight decrease in favour of treatment with GnRHas compared to placebo or oral or injectable progestogens. We are uncertain about the effect when comparing GnRHas with danazol, intra-uterine progestogens or gestrinone. For BMD, there may be a slight decrease when women are treated with GnRHas, compared to gestrinone. There was a bigger decrease of BMD in favour of GnRHas, compared to GnRHas in conjunction with calcium-regulating agents. However, there may be a slight increase in adverse effects when women are treated with GnRHas, compared to placebo or gestrinone. Due to a very low to low certainty of the evidence, a wide range of outcome measures and a wide range of outcome measurement instruments, the results should be interpreted with caution.

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.

The effect of pharmacological cessation and restoration of menstrual cycle on bone metabolism in premenopausal women with endometriosis

INTRODUCTION

GnRH-analogs induce bone loss. We aimed to investigate the effects of goserelin-induced menstrual cessation (MC) and subsequent menstrual restoration (MR) on bone metabolism (BM).

METHODS

In this prospective cohort study, premenopausal women (PMW) with histologically verified endometriosis (n = 21) received goserelin monthly for 6 months (6 m) resulting in MC and were followed up for another 6 m after MR (12 m). Age- and BMI-matched healthy PMW (n = 20) served as controls for bone mineral density (BMD) measurements. The primary endpoint was changes in lumbar spine (LS)-BMD at 6 m and 12 m; Secondary endpoints were changes in femoral neck (FN)-BMD, bone turnover markers (P1NP and CΤx), sclerostin, and expression of bone-related circulating microRNAs (miRNAs) at 6 m and 12 m.

RESULTS

Goserelin-induced MC reduced LS- and FN-BMD at 6 m (both p < 0.001). From 6 m to 12 m, LS-BMD increased (p < 0.001) but remained below baseline values (p = 0.012), whereas FN-BMD remained stable (p = 1.000). CTx and P1NP levels increased at 6 m (both p < 0.001) and decreased at 12 m (p < 0.001 and p = 0.013, respectively), while CTx (p = 1.000) alone and not P1NP (p = 0.020) returned to baseline. Sclerostin levels did not change. Relative expression of miRNAs targeting RUNX 2 and beta-catenin was significantly downregulated at 6 m compared to baseline (p < 0.001), while the expression of miRNAs targeting osteoblast and osteoclast function at both directions demonstrated a robust increase (up to 400fold) at 12 m (p < 0.001).

CONCLUSIONS

Six months of goserelin-induced MC lead to significant bone loss associated with increased bone turnover and changes in the expression of bone-related miRNAs, changes that are only partially reversed at 6 m after MR.

Efficacy and safety of ASP1707 for endometriosis-associated pelvic pain: the phase II randomized controlled TERRA study

STUDY QUESTION

Does the GnRH antagonist, ASP1707, reduce endometriosis-associated pelvic pain?

SUMMARY ANSWER

ASP1707 significantly reduced endometriosis-associated pelvic pain in a dose-related manner

WHAT IS KNOWN ALREADY

GnRH agonists are an effective therapeutic option for endometriosis that is refractory to non-steroidal anti-inflammatory drugs, oral contraceptives, and progestins. However, GnRH agonists cause complete suppression of estradiol (E2), resulting in hypoestrogenic side-effects such as bone loss that may increase the future risk of osteoporotic fractures.

STUDY DESIGN, SIZE, DURATION

This was a Phase II, multicenter, double-blind, randomized, parallel-group, placebo-controlled study conducted in 540 women from 04 December 2012 to 30 July 2015 in Europe and Japan. A sample size of 504 (84 subjects per group) was calculated to provide ≥80% power to detect a dose-related treatment effect among placebo and ASP1707 doses in change from baseline in pelvic pain, assuming different dose–response curves after 12 weeks of treatment.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Of 912 women with endometriosis-associated pelvic pain screened, 540 were enrolled, and 532 received ≥1 dose of study drug (placebo, n = 88; ASP1707 3 mg, n = 86; ASP1707 5 mg, n = 91; ASP1707 10 mg, n = 90; ASP1707 15 mg, n = 88; leuprorelin, n = 89) for 24 weeks.

MAIN RESULTS AND THE ROLE OF CHANCE

After 12 weeks of treatment with ASP1707, the mean (95% CI) changes in numeric rating score (NRS) for overall pelvic pain (OPP) were −1.56 (−1.91, −1.21), −1.63 (−1.99, −1.27), −1.93 (−2.27, −1.60), −2.29 (−2.64, −1.94), and −2.13 (−2.47, −1.79) for placebo, ASP1707 3 mg, ASP1707 5 mg, ASP1707 10 mg, and ASP1707 15 mg, respectively. Mean (95% CI) changes in NRS for dysmenorrhea were −1.50 (−2.00, −1.00), −2.72 (−3.22, −2.21), −2.85 (−3.33, −2.38), −3.97 (−4.46, −3.48), and −4.18 (−4.66, −3.70), respectively. Mean (95% CI) changes in NRS for non-menstrual pelvic pain (NMPP) were −1.53 (−1.88, −1.19), −1.51 (−1.87, −1.16), −1.80 (−2.14, −1.47), −2.03 (−2.37, −1.68), and −1.86 (−2.20, −1.52), respectively. Statistically significant dose-related treatment effects in reduction in NRS for OPP (P = 0.001), dysmenorrhea (P < 0.001), and NMPP (P = 0.029) were observed after 12 weeks among ASP1707 doses and were maintained through 24 weeks. Serum estradiol and bone mineral density decreased dose dependently with ASP1707 through 24 weeks, however, to a lesser extent than with leuprorelin.

LIMITATIONS, REASON FOR CAUTION

This study was not powered for pairwise comparison of each ASP1707 group versus placebo.

WIDER IMPLICATIONS OF THE FINDINGS

All doses of ASP1707 reduced serum E2 levels to within the target range and to a lesser extent than leuprorelin. ASP1707 is a potential alternative treatment to leuprorelin for endometriosis-associated pelvic pain with lower impact on bone health.

STUDY FUNDING/COMPETING INTEREST(s)

This study was funded by Astellas Pharma Inc. T.D’.H is Vice President and Head of Global Medical Affairs Fertility at Merck, Darmstadt, Germany since October 1, 2015. At the time that the TERRA study was conducted, he served as Principal Investigator in his role as Coordinator of the Leuven University Fertility Center. Since October 2015, T.D’.H has left Leuven University Hospital Gasthuisberg, but continues to serve as Professor in Reproductive Medicine and Biology at KU Leuven (University of Leuven) Belgium and at the Dept of Obstetrics, Gynecology and Reproduction at Yale University, New Haven, USA. T. Fukaya and Y. Osuga report personal consulting fees from Astellas Pharma Inc. during the conduct of the study and outside the submitted work. G.M. Holtkamp, and L. Skillern are employed by Astellas Pharma Europe B.V.; K. Miyazaki is employed by Astellas Pharma Inc.; B. López, was a biostatistician for Astellas Pharma Europe B.V. during conduct of the study; R. Besuyen was a contract Associate Director of Medical Science for Astellas during conduct of the study.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov, www.clinicaltrials.gov, NCT01767090. EudraCT number 2012-002791-14.

TRIAL REGISTRATION DATE

18 December 2012.

DATE OF FIRST SUBJECT’S ENROLLMENT

One subject signed informed consent on 04 December 2012; the first subject was randomized on 16 April 2013.

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.

Treatment of endometriosis with a VEGF-targeted conditionally replicative adenovirus

OBJECTIVE

To evaluate a vascular endothelial growth factor (VEGF)-targeted gene therapy for the treatment of endometriosis.

DESIGN

Analysis of the VEGF gene expression and promoter activity in ectopic and eutopic endometrium. Evaluation of the specific replication and cell-killing effect of a VEGF-targeted adenovirus (Ad5VEGFE1) in endometriotic cells.

PATIENT(S)

Four patients who underwent hysterectomy for benign disease, 30 women with moderate superficial, and 30 women with deep infiltrating endometriosis.

INTERVENTION(S)

Immunostaining and gene expression of VEGF was examined in eutopic endometrium, endometriotic lesions, and normal peritoneum. The VEGF promoter activity was evaluated in eutopic endometrium and endometriotic lesions. A VEGF-targeted conditionally replicative adenovirus (Ad5VEGFE1) was evaluated regarding specific viral replication in endometriosis cells and induction of apoptosis. The biodistribution of the VEGF-targeted conditionally replicative adenovirus was examined in a mouse model.

RESULT(S)

The VEGF gene was highly expressed in ectopic endometrium compared with eutopic endometrium and normal peritoneum. The VEGF promoter was active in endometriotic cells. Ad5VEGFE1 showed efficient viral replication and induction of apoptosis in purified primary endometriotic cells and demonstrated a similar lower targeting to the liver and the uterus in a mouse model.

CONCLUSION(S)

Ad5VEGFE1 is a promising candidate for treating endometriosis and holds potential for clinical testing.

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.

Toward gene therapy of endometriosis: adenovirus-mediated delivery of dominant negative estrogen receptor genes inhibits cell proliferation, reduces cytokine production, and induces apoptosis of endometriotic cells

OBJECTIVE

To use dominant negative mutants of estrogen receptor genes delivered to endometriosis cells via an adenovirus vector (Ad-DN-ER) to abrogate estrogen action on these cells.

DESIGN

Experimental in vitro study.

SETTING

University research laboratory.

PATIENT(S)

Patients with ovarian endometriomas provided endometriotic cells, and patients with uterine prolapse or subserous leiomyoma provided control endometrial cells.

INTERVENTION(S)

Transfection of endometriotic cells by dominant negative estrogen receptor genes via adenovirus vector (Ad-DN-ER).

MAIN OUTCOME MEASURE(S)

The main outcome measures were cellular proliferation, cytokine production, and induction of apoptosis in endometriotic cells.

RESULT(S)

Coxsackievirus-adenovirus receptor mRNA expression and adenovirus transduction efficiency were significantly higher in endometriotic than normal endometrial cells. Ad-DN-ER-treated endometriotic cells, as compared with control virus-treated cells, showed cell rounding and detachment (cell death), a 72% reduction in the number of viable cells 5 days after transduction, significantly less production of monocyte chemotactic protein-1 (7.8 +/- 0.5 vs. 152.8 +/- 1.9 pg/mL, respectively), vascular endothelial growth factor (356.2 +/- 11.6 vs. 997.3 +/- 16.5 pg/mL, respectively), and interleukin-6 (268.7 +/- 2.6 vs. 414.5 +/- 3.6 pg/mL, respectively), and a significantly higher percentage of apoptotic cells (51.2 +/- 7.8 vs. 23.8 +/- 1.7, respectively).

CONCLUSION(S)

An adenovirus can effectively transfect endometriotic cells in vitro. The DN-ER delivered to endometriotic cells via an adenovirus decreases cell proliferation, induces apoptosis, and decreases cytokine production. Adenovirus-mediated gene therapy may represent a potential therapeutic option for endometriosis in the future.

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 effects on bone mineral density and bone metabolism of 6 months' treatment with gonadotropin-releasing hormone analogues in Japanese women: comparison of buserelin acetate with leuprolide acetate

Our objective was to assess the effects of 6 months' treatment with two types of gonadotropin-releasing hormone (GnRH) analogues on lumbar bone mineral density (BMD) and bone metabolism. We studied 27 women who had been given a diagnosis of endometriosis or uterine myoma. The subjects received drug therapy for 6 months and were subsequently followed up for 1 year. The BMD of the lumbar spine (L2, L3, L4) was measured by dual energy X-ray absorptiometry four times: at baseline, after 6 months, after 12 months, and after 18 months. The serum concentrations of sex steroids and bone metabolic markers were measured at the same times as BMD. Compared with the baseline value, the mean decrease in the buserelin group L2-4 BMD was 3.7% at 6 months, 1.7% at 12 months, and 0.4% at 18 months. In the leuprolide group, L2-4 BMD decreased respectively by 5.1%, 6.2%, and 4.3%. Serum concentrations of calcium increased significantly after 6 months of treatment (P < 0.05) and returned to the baseline level at 12 months in both groups. In the leuprolide group, the intact osteocalcin concentration after 6 months was significantly higher than the baseline value, and after 12 months, it decreased to the baseline level. Our results indicate that the effect on BMD of 6 months' treatment with GnRH analogues virtually resolves by 1 year after treatment, provided that drugs affecting bone metabolism are not given during this period.

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.

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.

Randomized placebo-controlled trial of testosterone replacement in men with mild Leydig cell insufficiency following cytotoxic chemotherapy

OBJECTIVE

Testosterone deficiency is associated with significant morbidity, and androgen replacement in overt hypogonadism is clearly beneficial. However, there are few data concerning the response to therapy in young men with mild testosterone deficiency.

DESIGN AND PATIENTS

We have identified a cohort of 35 men, mean age 40.9 years, with mild Leydig cell dysfunction, defined by a raised LH level (LH >or= 8 IU/l) and a testosterone level in the lower half of the normal range or frankly subnormal (testosterone < 20 nmol/l), following treatment with cytotoxic chemotherapy for malignancy. Patients were assigned randomly to 12 months treatment with transdermal testosterone (n = 16) (Andropatch 2.5 mg patches, 1-2 patches per day) or placebo patches (n = 19) in a single blinded manner.

MEASUREMENTS

Measurements of bone mineral density (BMD) and body composition were performed at baseline, 6 months and 12 months using single and dual energy X-ray absorptiometry (SXA, DXA). In addition, spinal BMD was assessed at baseline and 12 months by quantitative CT (QCT). Subjects were reviewed at 3-monthly intervals; at each visit blood was taken for measurement of testosterone, SHBG, LH, FSH, oestradiol, lipids and IGF-1 and patients completed three questionnaires which assessed energy levels, mood and sexual function.

RESULTS

Total testosterone and calculated free testosterone increased significantly in the testosterone-treated group compared with the placebo-treated group (13.3 nmol/l and 342.9 pmol/l at baseline compared with 17.3 nmol/l and 454.8 pmol/l during the study period in the testosterone-treated group; P = 0.05 and P = 0.02, respectively). LH was suppressed into the normal range in 15 of the 16 testosterone-treated men and mean LH significantly reduced from 11.1 IU/l at baseline to 6.8 IU/l during the study. There was no significant change in BMD at the hip, spine or forearm and no change in fat or lean body mass. There was a significant reduction in physical fatigue in the testosterone-treated group compared with the placebo-treated group (P = 0.008) and a borderline improvement in activity score (P = 0.05). There were no significant effects of treatment on mood or sexual function. Neither oestradiol nor IGF-1 levels differed between the two groups during the study. There was no significant change in mean total cholesterol, HDL cholesterol or triglyceride levels, but there was a small, but significant reduction in LDL cholesterol levels in the testosterone-treated group compared with the placebo group (P = 0.02).

CONCLUSIONS

These results suggest that testosterone therapy in young men with raised LH levels and low/normal testosterone levels does not result in significant changes in BMD, body composition, lipids or quality of life, apart from a reduction in physical fatigue and a small reduction in LDL cholesterol. This implies that mild hypogonadism defined on this basis is not of clinical importance in the majority of men, and that androgen replacement cannot be recommended for routine use in these patients.

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.

The impact of mild Leydig cell dysfunction following cytotoxic chemotherapy on bone mineral density (BMD) and body composition

BACKGROUND

Overt testosterone deficiency is associated with a reduction in BMD and alteration in body composition. However, there are few data concerning the impact of mild hypogonadism on these parameters.

PATIENTS AND METHOD

We have identified a cohort of 36 men aged < 55 years with mild Leydig cell impairment, defined by a raised LH level (LH >/= 8 IU/l) in the presence of a testosterone level in the lower half of the normal range or frankly subnormal (< 20 nmol/l), following treatment with procarbazine-containing chemotherapy regimens or high-dose chemotherapy for haematological malignancy. These men underwent measurements of BMD (measured by dual-energy X-ray absorptiometry (DXA), single energy X-ray absorptiometry (SXA) and quantitative CT (QCT)), body composition (DXA), markers of bone turnover, serum lipids and serum IGF-1. To allow for changes that may be directly attributable to the underlying disease or its treatment, results were compared with those obtained in 14 men who had received the same chemotherapy for the same diseases but had normal LH and testosterone levels (controls).

RESULTS

When data from all 50 men were considered together there were significant reductions in BMD of the lumbar spine both by DXA (Z = - 0.34, P = 0.01) and QCT (Z = - 1.5, P < 0. 0001), at the femoral neck (Z = - 0.52, P < 0.0001) and distal forearm (Z = - 0.21, P = 0.05). Mean femoral neck BMD was significantly lower in patients compared with controls (Z = - 0.68 vs. Z = - 0.11, P = 0.05) and there was a nonsignificant trend towards lower lumbar spine BMD measured by QCT (Z = - 1.64 vs. Z = - 1.10; P = 0.09). In addition, serum testosterone level and testosterone:LH ratio significantly correlated with femoral neck BMD (r = 0.28, P = 0.05 and r = 0.37, P = 0.008, respectively). There were no significant differences in lean body mass, fat mass and percentage fat between the patients and controls. There was, however, a difference in the distribution of body fat with a propensity for the patients to accrue truncal fat, and the serum testosterone level significantly inversely correlated with percentage of truncal fat (r = - 0.29, P = 0.04). There were no significant differences in lipid levels, IGF-1 levels or markers of bone turnover between the patients and controls.

CONCLUSIONS

These data suggest that mild Leydig cell impairment may have significant effects on bone mineral density and may result in subtle body composition changes, although in men who have received cytotoxic chemotherapy, other factors also contribute to the observed osteopenia. Testosterone replacement may be beneficial in some of these men and this requires further evaluation.

Dysmenorrhea and pelvic pain in adolescents

Dysmenorrhea and pelvic pain are common complaints in the adolescent population. Although most cases are primary dysmenorrhea and easily treated with NSAIDs or OCPs, pathologic causes should be considered, especially in cases not responding to standard medical management. Endometriosis is the most common finding in teenagers who do not respond to this regimen, but müllerian anomalies and musculoskeletal causes must also be considered.

Reduced bone mineral density in young adults following cure of acute lymphoblastic leukaemia in childhood

Bone mineral density (BMD), serum osteocalcin and type I collagen C-telopeptide (ICTP) were assessed in a cohort of 31 (16 males) adults who had received cranial irradiation in childhood as part of their treatment for acute lymphoblastic leukaemia (ALL). Markers of bone turnover were compared with those of 35 age and body mass index (BMI) matched young adults (18 male). Growth hormone status had previously been determined using an insulin tolerance test and arginine stimulation test. Eight patients were classified as severe growth hormone deficiency (group 1), 12 patients as growth hormone insufficient (group 2) and 11 patients as normal (group 3). Vertebral trabecular BMD, lumbar spine and femoral neck integral BMD and forearm cortical bone mineral content (BMC) was measured 17.8 (6.8-28.6) years after cranial irradiation and was expressed as Z (standard deviation) scores. There was a significant reduction in vertebral trabecular BMD (median Z score -1.25, P < 0.001), in lumbar spine integral BMD (median Z score -0.74, P = 0.001), in forearm cortical BMC (median Z score -1.35, P < 0.001), and less so in femoral neck integral BMD (median Z score -0.43, P = 0.03). There was no difference among the growth hormone status groups for the following BMD measurements: vertebral trabecular BMD, lumbar spine integral BMD or femoral neck integral BMD (P = 0.8, P = 0.96 and P = 0.4 respectively). There was only a marginal significant difference for BMD at the wrist between growth hormone status groups (P = 0.04). There was no correlation between the BMD measurements with time since or age at diagnosis and no difference in markers of bone turnover between patients and controls; median serum osteocalcin 13.3 and 12.0 ng ml (P = 0.7), respectively, and for ICTP 5.0 and 4.9 microg L (P = 0.67) respectively. In conclusion, there is a highly significant reduction in BMD in young adults following treatment for ALL in childhood. The reduction in BMD affects both trabecular and cortical bone but did not seem to be related to time since diagnosis, age at diagnosis, or current growth hormone status. Possible explanations include a direct effect of chemotherapy, steroids or both on bone during childhood and hence an effect on the accretion of bone mass. In view of the risk of fractures in patients with osteopenia, adults treated for ALL in childhood may be at an increased risk of bone fractures later in life irrespective of the underlying cause of the osteopenia and thus intervention should be considered.

Today's treatments: medical, surgical and in partnership

OBJECTIVE

To provide an overview of the medical, surgical and combined therapy options for endometriosis.

RESULTS

Available medical options include danazol, progestogens, gestrinone, oral contraceptive agents, analgesics and gonadotropin-releasing hormone (GnRH) agonists. Used in the short-term, most of these agents relieve pain in a large proportion of patients and produce disease regression, however, they do not prevent recurrence, and are associated with side-effects. However, few data confirm any benefit of short-term medical therapy on fertility. One of the most promising medical approaches appears to be GnRH agonists with add-back hormone replacement therapy. Surgery may relieve pain, eradicate visible disease and improve fertility. A combined approach may facilitate surgery and relieve pain, although any fertility benefit is as yet unproven.

CONCLUSION

Both short-term medical treatment and surgery relieve endometriosis-associated pain and decrease endometriotic implants. However, all approaches have side effects which must be balanced against the benefits when defining suitable treatment for a particular patient.

The evidence for the management of endometriosis

This review article has focussed on identifying the evidence from randomized controlled trials for the medical and surgical management of endometriosis. A critical summary of the medical management has shown that there is little difference in effectiveness of various medical treatments, but there are differences in the side-effect profiles. Few randomized controlled trials have been undertaken in surgery, but these have shown that surgical management is effective in the management of both painful symptoms and subfertility.

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.

Modern medical management of endometriosis

The modern medical management of endometriosis has changed considerably since the first attempts were made to control this disease hormonally over four decades ago. Currently, there are multiple choices for the clinician and patient, including oral contraceptives, danazol, GnRH agonist analogues, and gestrinone. Several advances have been made in the use of GnRH agonists in preventing some of the untoward effects of prolonged hypoestrogenism. These add-back regimens provide the best therapy available today for prolonged medical control of endometriotic symptoms. The antiprogesterones (RU-486) hold promise for the future, but are still in the investigational stage of development.

Retreatment with nafarelin for recurrent endometriosis symptoms: efficacy, safety, and bone mineral density

OBJECTIVE

To assess the efficacy, safety, and effect on bone mineral density of a 3-month course of retreatment with intranasal nafarelin acetate for recurrent symptoms of endometriosis.

DESIGN

Multicenter, open-label, nonrandomized clinical trial.

SETTING

Eleven hospital-based and private practices.

PATIENT(S)

Thirty-six women with endometriosis symptoms recurring after 3 or 6 months of treatment with nafarelin.

INTERVENTION(S)

Nasal nafarelin 200 micrograms twice daily for 3 months.

MAIN OUTCOME MEASURE(S)

Assessments for dysmenorrhea, dyspareunia, pelvic pain, tenderness, and induration. Measurement of bone mineral density of the lumbar spine.

RESULT(S)

Improvements from admission to the end of retreatment were significant for dysmenorrhea, pelvic pain, tenderness, induration, and dyspareunia. Three months after retreatment ended, mean symptom scores for dysmenorrhea and pelvic tenderness, although worse than at the end of retreatment, were still significantly better than scores at admission. Mean bone mineral density 3 months after retreatment was 0.56% lower than before retreatment and 1.94% lower than before initial treatment.

CONCLUSION(S)

Three-month nafarelin retreatment for recurrent endometriosis symptoms was effective and safe.

Updating the clinical experience in endometriosis--the Brazilian perspective

In an open-label, multicentre, randomized, parallel group study, 164 women with endometriosis were assigned to treatment. Out of these women, 81 received danazol (600 mg daily for 8 weeks, then 400 mg for 16 weeks) and 83 were given gestrinone (2.5 mg twice a week for 24 weeks). Five weeks before the start of treatment clinical evaluation and diagnostic laparoscopy were performed during the screening visit. Drug assignment and laboratory data assessment were carried out within 3 days of the estimated onset of the menstrual cycle at baseline visit. The response to treatment was assessed during visits at weeks 2, 4, 8, 12, 16, 20 and 24; at the last visit a second laparoscopy was performed. Therapeutic efficacy was evaluated by analysis of the laparoscopic scores assessed according to the revised American Fertility Society classification. Symptomatic response was measured by clinical scores and laboratory data. In one centre, bone mineral density was also recorded. One patient in the danazol group discontinued treatment due to a cutaneous rash as a probable adverse reaction at the beginning of the study. The therapeutic efficacy of danazol and gestrinone did not differ significantly when the revised American Fertility Society scores were compared. The symptomatic response also showed no statistical difference when clinical examination scores were analysed. There was no significant difference between the drugs in laboratory data, including bone mineral density, with respect to adverse events. Analysis of clinical scores showed that danazol was superior to gestrinone with respect to acne and irregular bleeding. Based on these data, we conclude that both danazol and gestrinone are reliable in the treatment of endometriosis and offer similar results.

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.

Effects of a gonadotropin-releasing hormone agonist on the calcium-parathyroid axis and bone turnover in women with endometriosis

OBJECTIVE

Our purpose was to investigate the effects of nafarelin on bone turnover and mass (bone mineral density, in grams per square centimeter) in women with endometriosis.

STUDY DESIGN

We monitored 22 young women with endometriosis during and 6 months after 6 months of nafarelin treatment. We compared the bone mineral density status of these women with that of healthy controls undergoing sequential bone mineral density measurement.

RESULTS

Subjects had a 2.2% loss in L2-4 bone mineral density by 6 months, increasing 3 months later to 3% and returning toward baseline by 6 months after treatment. Radius bone mineral density did not change in the treatment group. Bone mineral density did not change in controls. Serum and urinary calcium levels rose during treatment. Hydroxyproline excretion increased and remained elevated 6 months after treatment. A rise in serum osteocalcin persisted 3 months after therapy but normalized by 6 months.

CONCLUSIONS

Bone mineral density deficits with nafarelin are reversible. Increased bone turnover persists 6 months beyond treatment, demonstrating the need for careful monitoring of women receiving prolonged or repeated 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.

Effect of growth hormone replacement on bone mass in adults with adult onset growth hormone deficiency

OBJECTIVE

Previous studies of the effect of GH replacement on bone mass in adults with GH deficiency have produced conflicting results. We have studied the effect of 6 and 12 months of GH replacement on bone mass in adults with adult onset GH deficiency.

DESIGN

Double blind placebo controlled study of GH replacement (0.125 IU/kg/week for the first month and 0.25 IU/kg/week thereafter) for 6 months and an open study for a further 6 or 12 months.

PATIENTS

Twenty-two adults (10 men, 12 women), aged 41.5 +/- 2.1 years (mean +/- SE, range 23.6-59.5), with adult onset GH deficiency.

MEASUREMENTS

Single-energy quantitative computed tomography was used to measure vertebral trabecular bone mineral density (BMD), single-photon absorptiometry (SPA) was used to measure forearm cortical and integral bone mineral content and BMD and dual-energy X-ray absorptiometry (DXA) was used to measure lumbar spine, femoral neck, trochanteric and Ward's triangle integral BMD.

RESULTS

After 6 months of GH replacement (n = 21) there was a significant decrease in forearm cortical BMD (SPA: median change -0.009 g/cm2, P = 0.01), forearm integral BMD (SPA: median change -0.016 g/cm2, P = 0.03), lumbar spine BMD (DXA: median change -0.22 g/cm2; P = 0.003) and femoral neck BMD (DXA: median change -0.029 g/cm2, P = 0.006). After 12 months of GH replacement (n = 13) there was a significant decrease in lumbar spine BMD (DXA: median change -0.035 g/cm2, P = 0.002) from baseline. There was no significant increase in bone mass at any site after 6 or 12 months of GH replacement. Change in bone mass was not influenced by sex of the patient or by presence or absence of additional pituitary hormone deficiencies.

CONCLUSION

The response of bone mass to 6 and 12 months of GH replacement in adults with adult onset GH deficiency is disappointing. Longer-term studies are required to determine whether prolonged GH replacement has a beneficial effect on bone mass.

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.

Endometriosis: current management

OBJECTIVE

To review the clinical features, theories of pathogenesis, and current treatment of endometriosis-associated pain and infertility.

DESIGN

We review the manifestation of endometriosis and the possible mechanisms that lead to its symptoms, examine the efficacy of current therapeutic options for pelvic pain and infertility, and provide specific recommendations for treatment based on the current literature.

MATERIAL AND METHODS

Endometriosis is the presence of hormonally responsive endometrial tissue occurring outside the uterine cavity. This condition may be asymptomatic but is often found in association with pelvic pain or infertility (or both). The precise pathogenesis has not been clearly established but likely involves retrograde menstruation with subsequent seeding of endometrial glands at extrauterine sites. The definitive diagnosis and staging of endometriosis are performed by laparoscopy. Various strategies have been used to treat endometriosis including expectant, medical, surgical, and combination management.

RESULTS

The efficacy of treatment varies for pelvic pain and infertility. Endometriosis-associated pain may respond to both medical and surgical management. The use of medical therapy for endometriosis-associated infertility is not supported by current studies. Surgical management of infertility may be efficacious when pelvic anatomy is distorted because of endometriosis. The use of superovulation strategies and in vitro fertilization has been shown to be effective in overcoming endometriosis-associated infertility.

CONCLUSION

Pelvic pain and infertility in the presence of endometriosis necessitate individualization of therapy to achieve treatment goals. Neither medical nor surgical management is efficacious in all circumstances. As a better understanding of the pathogenesis of endometriosis evolves, treatment of this perplexing condition will probably continue to improve.

The effects of gonadotrophin-releasing hormone agonists on iliac crest cancellous bone structure in women with endometriosis

The administration of gonadotrophin-releasing hormone (GnRH) analogs to premenopausal women causes hypoestrogenism and bone loss, but the effects on cancellous microstructure have not been determined. In this study we have assessed bone structure in transiliac biopsies obtained from women before and after treatment for endometriosis with GnRH analogs. Twenty-one premenopausal women were studied, paired biopsies being obtained in 13; five women received both GnRH analogs and Org OD 14 (Tibolone, Livial). Comparison of pre- and post-treatment biopsies in women treated only with GnRH analogs showed a reduction in indices related to connectivity (node-to-terminus ratio, node-to-loop strut length, p < 0.02) and increase in inversely related indices (terminus-to-terminus and node-to-terminus strut length, p < 0.03). No significant changes were seen in any of the structural indices in women receiving both GnRH and Org OD 14 therapy. Activation frequency and bone formation rate at tissue level increased in women treated with GnRH agonists alone, although this change was not statistically significant. Our results suggest that bone loss induced by GnRH analogs may be associated with adverse effects on cancellous microstructure which are unlikely to be reversed following cessation of therapy. Concurrent treatment with Org OD 14 appears to prevent these changes.

Further increase in forearm cortical bone mineral content after discontinuation of growth hormone replacement

OBJECTIVE

Growth hormone replacement of adults with childhood onset GH deficiency results in an increase in bone mineral density (BMD) after 6-12 months of GH replacement. By measuring BMD 12 months after discontinuation of GH replacement we aimed to investigate whether there is an effect of GH replacement on BMD persisting after GH has been withdrawn.

DESIGN

BMD was measured 13 +/- 1 (mean +/- SE, range 11-16) months after discontinuation of GH replacement.

PATIENTS

Ten adults, age 23.2 +/- 1.4 (range 18.8-32.4) years, with childhood onset isolated GH deficiency (2 idiopathic, 8 irradiation induced) who had previously completed a study of the effect of 12 months of GH replacement on BMD.

MEASUREMENTS

Forearm cortical bone mineral content (BMC) was measured using single-photon absorptiometry at the proximal site of the distal forearm. Forearm integral BMC at the ultradistal site of the forearm and bone width at both proximal and ultradistal sites of the distal forearm were measured by the same technique. Vertebral trabecular BMD was measured using quantitative computed tomography.

RESULTS

Forearm cortical BMC was significantly greater than that measured at the time of discontinuation of GH (1.48 +/- 0.04 vs 1.44 +/- 0.05 g/cm). There was no significant change in forearm integral BMC or in vertebral trabecular BMD after discontinuation of GH. There was no significant change in bone width at proximal and ultradistal sites of the distal forearm after discontinuation of GH.

CONCLUSION

After discontinuation of GH replacement the further increase in forearm cortical bone mineral content without a significant increase in forearm bone width suggests that the increase in cortical bone mineral content is due to a persisting effect of previous GH replacement, and not to further spontaneous attainment of bone mass before peak bone mass is reached. These findings emphasize the importance of continuing to monitor bone mass after the stimulus to increase bone turnover has been withdrawn.

Leuprorelin. A review of its pharmacology and therapeutic use in prostatic cancer, endometriosis and other sex hormone-related disorders

Leuprorelin (leuprolide acetate) is a gonadotrophin-releasing hormone (GnRH) analogue used to treat a wide range of sex hormone-related disorders including advanced prostatic cancer, endometriosis and precocious puberty. It acts primarily on the anterior pituitary, inducing a transient early rise in gonadotrophin release. With continued use, leuprorelin causes pituitary desensitisation and/or down-regulation, leading to suppressed circulating levels of gonadotrophins and sex hormones. Clinical trials in men with advanced prostatic cancer demonstrate that leuprorelin (usually monthly depot injections of 3.75 or 7.5 mg) is less likely to cause serious adverse cardiovascular effects than diethylstilbestrol, and has comparable efficacy to bilateral orchiectomy or other GnRH analogues. Therefore, the choice between leuprorelin and orchiectomy may be made on the basis of the patient's treatment preference, along with specific patient characteristics and cost implications. Monthly intramuscular or subcutaneous administration of depot leuprorelin 3.75 mg was superior to placebo, and comparable to oral danazol 800 mg/day or intranasal buserelin 900 micrograms/day, in achieving objective and subjective responses in women with endometriosis. Thus, leuprorelin is an effective alternative to other treatments for women with endometriosis, but the recommended duration of its use in this clinical setting is limited to 6 months because it reduces bone mineral density. In children with central precocious puberty, leuprorelin (usually monthly intramuscular or subcutaneous injections of depot leuprorelin 3.75 to 15mg) decreases mean growth velocity and signs of sexual maturation and increases predicted adult height compared with baseline measurements. Although effects on final adult height are predicted from available data and require confirmation in long term follow-up studies, the absence of effective alternatives to GnRH analogues makes leuprorelin a first-line therapy for children with this rare disease. In women with uterine leiomyomata, monthly intramuscular administration of depot leuprorelin 3.75 mg for 6 months markedly reduces uterine volume and fibroid-related symptoms, but, as with other GnRH analogues, these effects dissipate following discontinuation of the drug. As adjuvant therapy in women undergoing in vitro fertilisation or gamete intrafallopian transfer, leuprorelin (usually 0.5 to 1 mg/day subcutaneously) reduces the risk of cancelled cycles for oocyte retrieval by preventing premature luteinisation. While some studies demonstrate an improvement in intermediate end-points such as increased number of mature oocytes retrieved and embryos available for transfer, a significant effect has not been demonstrated on the rate of live births per stimulated cycle.(ABSTRACT TRUNCATED AT 400 WORDS)

Effect of gonadotropin-releasing hormone agonist on the bone mineral density of patients with endometriosis

OBJECTIVE

To examine changes in bone mineral density (BMD) of patients treated with GnRH agonist (GnRH-a) by dual-energy X-ray absorptiometry and to understand factors related to bone loss.

DESIGN

Prospective controlled trial examining BMD during and after GnRH-a therapy every 24 weeks for 18 months in patients with endometriosis compared with nontreated controls.

SETTING

Outpatients clinic at a university hospital and its affiliated outpatient clinic.

PATIENTS

Twenty-two patients with endometriosis as GnRH-a-treated group, 12 healthy women with normal menstrual cycle, and 7 patients with mild endometriosis as control group.

INTERVENTIONS

Patients were treated with a GnRH-a (buserelin acetate) at 900 micrograms/d by nasal spray for 24 weeks.

RESULTS

The significance of differences in change-rates at all measured points in both groups was assessed by analysis of variance. The interaction between treatment and period was significant, and only week 24 of the GnRH-a-treated group was significantly lower compared with baseline. The reduction rate of BMD was high in patients 33 years of age or younger compared with those who were 34 years of age or older. According to a multiple-regression model, the most important factor related to bone loss was the post-treatment serum levels of E2.

CONCLUSION

At the end of treatment, BMD was significantly lower than that of the control group, and the reduction rate was 3.4%. A factor related to bone loss was degree of ovarian suppression.

Extending the use of gonadotropin-releasing hormone agonists: the emerging role of steroidal and nonsteroidal agents

OBJECTIVE

To review and summarize the state of the art as it relates to the long-term application of GnRH agonists (GnRH-a).

DESIGN

A retrospective analysis of the available literature and results and an up-to-date review of a rapidly evolving field.

CONCLUSION

Although the precise use of long-term GnRH-a therapy (in conjunction with sex steroid add-back therapy) remains unknown, the information provided strongly supports additional studies in this area to achieve a body of promising preliminary data.

Endometriosis: medical therapy

The management of women with endometriosis is complex and necessitates individualization of patient care. The most commonly used medical therapies are danazol, GnRH agonists, medroxyprogesterone acetate and gestrinone. Studies to date have shown these drugs to have equal efficacy in terms of reduction in laparoscopic score and relief of symptoms. However, their side-effects make them unsuitable for long-term use. The addition of low dose hormone replacement therapy to GnRH agonist regimens may allow prolonged use but the current cost of these agents is high. Low dose oral contraceptive pills deserve further investigation. The role of medical treatment for women with endometriosis and infertility is controversial. There is no place for hormonal therapy in such women with stage I or II disease. When expectant management fails, gamete intrafallopian transfer offers excellent results. For those with stage III or IV disease, surgery is preferable with adjunctive medical therapy in selected cases. If pregnancy does not ensue, in vitro fertilization and embryo transfer are the next line of management, and results are optimized by prior medical therapy and aspiration of endometriomas. Major advances have been made in the medical management of endometriosis. However, current treatment strategies are ineffective in eliminating the disease in most women. New approaches are required in both basic and clinical research in order to finally eradicate this often devastating disease.

Correlation of bone histology with parathyroid hormone, vitamin D3, and radiology in end-stage renal disease

We analyzed transiliac bone biopsy specimens from 30 end-stage renal failure patients, taken at the time of admission for CAPD training. Results were compared with values of iPTH, bone alkaline phosphatase, 1,25-dihydroxyvitamin D3, skeletal survey, quantitative computed tomography (QCT) and single photon absorptiometry (SPA) bone density measurements. Osteitis fibrosa was the most common histological diagnosis, present in 15 of the 30 patients (50%), with eight classified as "severe" and seven as "mild." Eight patients (27%) had adynamic bone lesion, four mixed renal osteodystrophy (13%), and two (7%) osteomalacia. The mean age of the adynamic group was higher than the osteitis fibrosa group (41 +/- 12.1 vs. 56 +/- 10.2 years; P < 0.01), and than the mixed group (39 +/- 7.5 vs. 56 +/- 10.2 years; P < 0.02). Levels of iPTH enabled discrimination between groups, but not between individual patients, and values correlated with bone alkaline phosphatase (r = 0.62; P < 0.001). Erosion of the terminal phalanges was seen on the plain X-rays of 7 of 15 patients with mild or severe OF, and in three patients with another diagnosis. The majority of patients (> 90%) had bone density measurements within the normal range. No significant correlation existed between QCT or SPA scores and any of the histomorphometric parameters, or iPTH. We conclude that iPTH is the most helpful non-invasive investigation in this group of patients. Plain X-ray of the hands is the most useful radiological investigation, but single measurements of bone density are not diagnostic.

Impact of medical treatment of endometriosis on bone mass

A review of studies examining the effect of medical therapy of endometriosis on bone mass and potential approaches to preventing bone loss was undertaken. Studies specifically examining bone density in women with endometriosis treated medically were used. Reports on effects of oral contraceptives and progestins on bone mass were derived from women using them for contraception. Oral contraceptives and medroxyprogesterone acetate apparently did not adversely affect bone mass. While initial studies with dual-photon absorptiometry were unable to detect appreciable bone loss with gonadotropin-releasing hormone agonist, subsequent studies have invariably found significant bone loss beginning as early as 3 months of treatment. Quantitated computerized tomography always shows significant trabecular bone loss of the vertebrae and hip with gonadotropin-releasing hormone agonist. Depot preparations appear to produce more marked loss than daily injections of intranasal spray. Recent studies indicate recovery of bone loss may take longer than 6 months or even 1 year after discontinuation of therapy with considerable individual variation. Danazol produced bone gain. Bone loss with gonadotropin-releasing hormone agonists could be prevented or attenuated with progestins, and this is worthy of further studies. Impact of medical therapy on bone mass should be a practical consideration in the selection of patients, in repeat medical therapy for recurrence of endometriosis, and in formulation of medical therapy so as to attenuate or overcome such silent adverse effects.

A randomized double blind placebo controlled trial of the effects on bone metabolism of the combination of nafarelin acetate and norethisterone

OBJECTIVE

We observed the effects on bone metabolism of the addition of different doses of oral norethisterone during treatment with the GnRH agonist nafarelin (Synarel, Syntex).

PATIENTS

Ninety-four women with a subjective complaint of heavy menstrual blood loss or objective evidence of endometriosis received intra-nasal nafarelin 400 micrograms daily for 6 months and also received, in a randomized, double blind manner, either 0.7 mg (n = 24), 1.4 mg (n = 23) or 2.45 mg (n = 23) of oral norethisterone or placebo (n = 24) daily. Follow-up was continued for a further 6 months after treatment.

RESULTS

Thirty-one patients (33%) left the study prematurely and three patients were non-compliant with the study drug. By 6 months significant increases in urinary calcium/creatinine ratio were seen, compared to baseline, in the nafareline and placebo (P = 0.001, n = 14), 0.7 mg (P = 0.04, n = 13) and 1.4 mg norethisterone groups (P = 0.009, n = 17) but not in the nafarelin or 2.45 mg norethisterone groups (P = 0.72, n = 16). Densitometry of the spine, however, showed decreases at 6 months in all groups: 6.14% (P = 0.0004, n = 11), 5.46% n = 0.0006, n = 13), 3.93% (P = 0.008, n = 14) and 4.04% (P = 0.004, n = 16) for the groups receiving nafarelin and placebo, nafarelin and norethisterone 0.7, 1.4 and 2.45 mg respectively. Six months after stopping nafarelin, with or without norethisterone, bone mass was not different from baseline.

CONCLUSION

The concomitant daily use of up to 2.45 mg of norethisterone does not eliminate the bone demineralization seen during GnRH agonist therapy with nafarelin in premenopausal women.

Gonadotropin-releasing hormone agonists and the skeleton

OBJECTIVE

To review and evaluate published studies that have assessed the effect on the skeleton of treatment with gonadotropin-releasing hormone agonists (GnRH-a). The effects on bone biochemistry and bone density are presented.

DATA IDENTIFICATION

Major studies reporting on bone and GnRH-a use were identified through Excerpta Medica and Medline searches.

STUDY SELECTION

Those that have reported on GnRH-a treatment in patients where data relating to skeletal metabolism or bone density were obtained.

RESULTS

Changes in bone biochemistry during GnRH-a therapy indicate that there is altered skeletal metabolism associated with GnRH-a use. The data on changes in bone density after a 6-month course of GnRH-a therapy generally indicate some bone loss. The magnitude of any detected change in bone density depends on the skeletal site assessed and the method of assessment. No significant bone loss has been documented in cortical bone; any bone loss occurring is usually associated with trabecular bone and is partially or completely reversible on withdrawal of GnRH-a treatment.

CONCLUSIONS

A 6-month course of GnRH-a therapy may result in a small reduction in trabecular bone density that is partially or completely reversible on withdrawal of treatment. The magnitude of any persistent residual bone loss is unlikely to be of clinical relevance and the benefits of a single 6-month course of GnRH-a therapy should not be withheld on the basis of a possible effect on bone.