[Is there a place for stepped hormone assay in the development of hyperandrogenism?]

Clinical hyperandrogenism is common in women. Nevertheless, it is important to identify the cause. As the hyperandrogenism may be ovarian or adrenal in origin, making the difference requires hormonal testing and ovarian and/or adrenal imaging. We present the case report of a patient explored in our clinic, that illustrates the difficulties to determine the origin of the endocrine disorder. The interest of employing selective ovarian and adrenal venous catheterization to aid in the diagnosis and the localization of the androgen-secreting tumor is discussed.

[An update in intrauterine contraception]

Intrauterine devices (IUD) are the oldest of the modern contraceptives. There are currently two types of IUDs: copper IUD (Cu-IUD) and levonorgestrel IUD (LNG-IUD). Both offer high contraceptive effectiveness. Although they have been used for decades, the literature still brings its share of new information on IUDs: impact on oncological risk, non-contraceptive benefits, rare adverse effects, and impact on women's well-being. In addition, Cu-DIU is recognized as the most effective emergency contraceptive and can be inserted up to 5-7 days after the at-risk sexual intercourse. Research is now looking at the effectiveness of LNG-IUD in emergency contraception. Finally, new IUD concepts are also being evaluated: they should allow a reduction in the rate of expulsion, intermenstrual and heavy menstrual bleeding, an increase in comfort and in IUDs duration of use. This article makes an update on the latest developments in terms of intrauterine contraceptives.

[How to explore... hyperandrogenism associated with insulin resistance ? An example based on the HAIR-AN syndrome.]

HAIR-AN, a syndrome associating hyperandrogenism, insulin resistance and acanthosis nigricans, is currently considered as a severe form of polycystic ovary syndrome. The physiopathology of this syndrome relies on the insulin resistance which is the basis of a vicious circle : the resulting hyperinsulinism leads to an excessive production of androgens. The latter increases abdominal fat deposition which in turn worsens the insulin resistance. Hyperinsulinism is also responsible for the acanthosis nigricans by stimulating the IGF-1 receptors on keratinocytes and fibroblasts. Hyperandrogenism is clinically translated into hirsutism that can be severe. Frequently, menstrual irregularity and obesity are part of the syndrome. HAIR-AN syndrome begins soon after puberty and is currently under-diagnosed. Treatment relies on an improvement in insulin-resistance by a loss of body weight and the use of insulin sensitizers. Moreover, anti-androgenic drugs will help improving hirsutism. Although more invasive, bariatric surgery has shown a great efficacy in this syndrome : by permitting a substantial loss of weight, it often normalizes insulin-sensitivity, allowing for improvements in hyperandrogenism and acanthosis nigricans.

[Emergency contraception : practical guideline]

The goal of emergency contraception (EC) is to avoid unintended pregnancies after unprotected sexual intercourse (UPSI) or incorrect use of regular contraception. EC is intended for occasional use and does not replace effective regular contraception. A thorough understanding of EC is mandatory for optimal use of EC by healthcare professionals. Three EC methods are available in Belgium : oral levonorgestrel (LNG), oral ulipristal acetate (UA) and copper intrauterine device (Cu-IUD). EC should be offered as soon as possible after UPSI. The guidance aims to summarise the available evidence on EC methods, mechanism of action, and advantages/disadvantages of each method.

[Polycystic ovary syndrome : the advantages of multidisciplinary management]

The polycystic ovary syndrome is one of the most frequent endocrine disorders in women of reproductive age. The first signs and symptoms of the disease may be present as early as puberty. Diagnostic criteria include hyperandrogenism (clinical or biological), ovulatory dysfunction and polycystic ovarian morphology on ultrasound. The consequences of the syndrome are multiple. These consist of fertility issues and metabolic anomalies with increased cardiovascular risk, but also sleep disturbances, increased risk of endometrial hyperplasia and endometrial cancer and a potentially important psychological impact with decreased quality of life. The management of polycystic ovary syndrome is multidisciplinary and treatment is variable, depending on symptoms and the patient's desire for fertility. In all cases, measures aiming to improve the metabolic dysfunction are essential, going from adopting a healthy lifestyle to adequate therapy of each metabolic anomaly.

Impact of implementation of a breech clinic in a tertiary hospital

BACKGROUND

The incidence of breech presentation in single pregnancies at term is between three to 5 %. In order to support eligible women in their choice of mode of delivery, a dedicated breech clinic with a care pathway was developed in December 2015 in a tertiary referral centre in Brussels. The primary objective of this study was to evaluate the vaginal birth rate before and after the introduction of a dedicated breech clinic. The secondary objective was to compare the early neonatal outcomes before and after the breech clinic was introduced.

METHODS

This was a single centre retrospective and prospective study. The inclusion criteria were term (from 37 weeks), singleton fetus and breech presentation at delivery. The exclusion criteria were suspected intrauterine growth restriction, severe fetal malformations and intrauterine fetal demise. We used a composite outcome as an indicator of neonatal morbidity and mortality.

RESULTS

After the introduction of the breech clinic, we observed a significant increase in planned vaginal delivery from 7.4% (12/162) to 53.0% (61/115) (OR: 13.5; 95% CI: 6.7-27.0). The effective vaginal breech delivery rate (planned and unexpected) significantly increased from 4.3% (7/162) pre-implementation of breech clinic to 43.5% (50/115) post-implementation (OR: 17.0; 95% CI: 7.3-39.6). Neonatal outcomes were not statistically different between the before and after periods.

CONCLUSION

The introduction of a dedicated breech clinic has led to an increase in vaginal deliveries for breech babies without adversely affecting neonatal outcomes.

[Management of dysmenorrhea]

Dysmenorrhea is one of the most common reasons for consultation in gynecology. The social and economic burdens are important. Dysmenorrhea may therefore be considered as a major public health issue. Its management is not yet optimal as dysmenorrhea still affects the quality of life of many patients. Primary dysmenorrhea, with no underlying organic cause, results from myometrial hyper contractility, arteriolar vasoconstriction, and tissue hypoxia. Secondary dysmenorrhea may involve the pathophysiological mechanisms of primary dysmenorrhea, but is mainly the expression of an underlying gynecological pathology. Although the pathophysiology of primary dysmenorrhea is well established, studies are now focusing on treatments to improve the management of these patients, who are often young. Nonsteroidal anti-inflammatory drugs and oral contraception remain the recommended firstline drugs, but their effectiveness can be enhanced by complementary therapy such as local heat application or regular exercise. Studies on other unconventional complementary therapies, such as ginger consumption, are very encouraging and need to be reinforced to incorporate recommendations for the management of primary dysmenorrhea.

[Retrospective assessment of the influence of gestational age on the first trimester medical abortion efficiency]

There are two methods of abortion : the medical and the surgical methods, each with its own specific benefits. Theoretically, the limit of medical abortion gestational age is 7 weeks of amenorrhea. However, since 2011, our university department provides the opportunity of a drug regimen until 9 weeks of amenorrhea. This paper describes the results of a retrospective study which covers 804 patients who were submitted to a medical abortion with gestational ages of 6 to 9 weeks. The purpose is to investigate the efficiency of the medical approach up to 9 weeks and to assess the drug dose required according to the term of pregnancy. Our work shows an efficiency of 95 % of medical abortion up to 9 weeks gestation, with no significant variation with the gestational age. However, maintaining this level of efficiency during the progress of pregnancy requires an increase of the administered doses of misoprostol. In addition, there is a significant increase in the use of analgesics. The medical abortion procedure remains effective until 9 weeks of gestation. This pharmacological approach reduces the risks induced, in the short and long term by the surgical procedure.

[Ulipristal acetate (Esmya): a selective modulator of progesterone receptors, new treatment of uterine fibromatosis]

Uterine fibromatosis is a frequent benign gynaecological disease causing heavy menstrual bleeding and in some cases anaemia. Until now, medical treatment aimed to obtain amenorrhea by administration of progestins or Gn-RH agonists. By inducing hypo-oestrogenism, a reduction of myoma size is observed with Gn-RH agonists but after cessation of the treatment, initial myoma size is noted. The impact of progesterone in myoma growth is nowadays demonstrated and use of selective modulators of progesterone receptors represents a new medical approach of this disease.

[Management of gestational diabetes]

Pregnancy is associated with relative carbohydrate intolerance and insulin resistance. Gestational diabetes mellitus (GDM) is recognized as a risk factor for a number of adverse outcomes during pregnancy, including excessive fetal growth, increased incidence of birth trauma and neonatal metabolic abnormalities. This recognition has led to recommendations to screen all pregnant women for GDM and to treat those whose glucose tolerance tests exceed threshold criteria. Numerous epidemiological studies show that GDM affects between 1 and 25% of pregnancies, depending on the ethnicity of the population studied and the diagnostic criteria. Intervention to change lifestyle and, if maternal hyperglycemia persists, treatment with additional oral medication or insulin injections have shown to improve perinatal outcomes. Patients with GDM have a high risk of developing type 2 diabetes in the years after delivery and these women are encouraged to practice specific health behaviours (dietary habits, physical activity) during the postpartum period. The present article discusses the management of GDM in the light of data from the latest studies and international recommendations.

[Premature ovarian failure, from genetics to clinical]

Premature Ovarian Failure (POF) is a condition with complicated clinical presentation. An estimated 1% of the population is affected before the age of 40, with 0.1% affected prior to the age of 30. There are many causes of POI: genetic aberrations, auto-immune ovarian damage, iatrogenic factors following surgery, radiotherapy or chemotherapy, environmental factors (viruses, toxins, smoking) and metabolic. The majority of POF cases have idiopathic etiologies.

[Screening strategy and diagnostic criteria for gestational diabetes. Proposals of the GGOLFB]

For nearly 50 years, the strategy of screening and the diagnostic criteria for gestational diabetes have been the subject of endless controversies. They differ between countries and from one center to another, mainly because of the lack of hard data allowing to define glycemic thresholds at which a therapeutic management is needed. Recently, a large observational study has demonstrated the existence of a robust relationship between maternal blood sugar and several fetomaternal perinatal complications. This relationship is linear, with no clear threshold that would define gestational diabetes unambiguously. Meanwhile, two randomized intervention trials have shown that the therapeutic management of mild gestational diabetes was associated with improved perinatal outcomes. Based on these data, the "International Association of Diabetes and Pregnancy Study Group" (IADPSG) released new recommendations on screening methods and diagnostic criteria for gestational diabetes. Although already endorsed by several international associations and implemented in some countries, these recommendations still raise questions and criticisms. This is why the "Groupement des Gynécologues Obstétriciens de Langue Française de Belgique" (GGOLFB) organized a meeting between diabetologists and gynecologists which allowed to reach a consensus on the strategy that we intend to implement in our respective centers. The purpose of this paper is to briefly overview the recent advances in gestational diabetes and more particularly to make our key conclusions known to the medical community. This will enable the standardization of the management of gestational diabetes in the French-speaking part of Belgium.

[Screening strategy and diagnostic criteria for gestational diabetes. Proposals of the GGOLFB]

For nearly 50 years, the strategy of screening and the diagnostic criteria for gestational diabetes have been the subject of endless controversies. They differ between countries and from one center to another, mainly because of the lack of hard data allowing to define glycemic thresholds at which a therapeutic management is needed. Recently, a large observational study has demonstrated the existence of a robust relationship between maternal blood sugar and several fetomaternal perinatal complications. This relationship is linear, with no clear threshold that would define gestational diabetes unambiguously. Meanwhile, two randomized intervention trials have shown that the therapeutic management of mild gestational diabetes was associated with improved perinatal outcomes. Based on these data, the " International Association of Diabetes and Pregnancy Study Group "(IADPSG) released new recommendations on screening methods and diagnostic criteria for gestational diabetes. Although already endorsed by several international associations and implemented in some countries, these recommendations still raise questions and criticisms. This is why the "Groupement des Gynécologues Obstétriciens de Langue Française de Belgique " (GGOLFB) organized a meeting between diabetologists and gynecologists which allowed to reach a consensus on the strategy that we intend to implement in our respective centers. The purpose of this paper is to briefly overview the recent advances in gestational diabetes and more particularly to make our key conclusions known to the medical community. This will enable the standardization of the management of gestational diabetes in the French-speaking part of Belgium.

[Zoely, a combined oral contraceptive, monophasic pill containing estradiol and nomegestrol acetate]

A new combined oral contraceptive called Zoely has just been marketed in Belgium. It contains nomegestrol acetate, a progestin known for its high contraceptive reliability based on its antigonadotropic power and long half-life. This progestin is associated with estradiol and Zoely is devoid of ethinyl estradiol, which is the usual component of the majority of combined oral contraceptives and is primarily responsible for thrombotic side effects of the pill. The compositon and type of regimen of this new oral contraceptive contribute to its efficacy and excellent clinical tolerance.

[Management of estrogen deficiency after breast cancer]

The prevention and the treatment of oestrogen deficiency induced by breast cancer treatments are crucial in the management of patients. The impacts of this deficiency must not be neglected: quality of life impairments inducing eventually premature withdrawal of hormonotherapies, and excess of bone and cardio-vascular morbidities and mortalities, especially in good prognosis young women. Management strategies of short and long term effects of this deficiency are reviewed and discussed here.

[Medication of the month. A new combined oral contraceptive containing estradiol valerate and dienogest (Qlaira)]

In combined oral contraception (OC), a drastic reduction of both ethinylestradiol and androgenic progestins mostly derived from 19 NOR testosterone, allowed to moderately reduce the adverse impact of classical combined pills on metabolism and circulation (both arterial and venous). However, the marked hepatic action of ethinylestradiol, even in small dosages, lessens the expected risk reduction. For the first time, an OC has been developed, which contains estradiol valerate (with reduced hepatic action because of lack of a 17alpha ethinyl group) with dienogest, a 19 NOR testosterone-derived nonandrogenic progestin, which powerfully inhibits endometrial proliferation. Thanks to a dynamic modulation of estrogen and progestin doses (26 active days + 2 placebo days), an adequate contraceptive effectiveness, a good cycle control and drug tolerance are achieved, similar to those obtained with a classical low-dose OC. Recent data indicate that this new combination reduces the usually observed metabolic impact. An adequate cycle control (with 20% amenorrhea) is achieved for the first time with estradiol valerate + progestin,, in opposition with prior catastrophic results with other formulations containing 17beta-estradiol. A second combination containing estradiol + nomegestrol acetate (monophasic, 24 active days + 4 placebo days) is under study and seems also to yield promising results. Of course, in-depth study of metabolic and vascular effects of these new combinations is mandatory - and ongoing.

[Therapeutic inertia in contraception]

The efficiency of contraception is linked to the method and the patient's compliance. The advice given by the physician about contraception use is essential to avoid unintended pregnancy. The accuracy of contraceptive choice and the individualized adaptation over time contribute to safe contraception.

[Diabetes and pregnancy: impact of medical inertia and therapeutic compliance]

Pregnancy and infant outcomes are related to maternal blood glucose profile. Managing preexisting diabetes and achieving euglycaemia before and during the pregnancy reduce the risk for complications. Screening, diagnosis and treatment of gestational diabetes are important issues from a public health point of view, more particularly because of the progression of this disease due to obesity epidemics among young people. Pregnancy in a diabetic woman is a critical situation where neither clinical inertia nor patient's non-compliance could be accepted.

Hormone therapy and breast cancer risk

Hormone therapy (HT) is the most efficacious intervention for the relief of climacteric symptoms. Controversies surrounding HT have left many women puzzled and afraid. Gynecologists are faced with long-standing beneficial assumptions challenged by an abundance of robust detrimental new data, with little guidance on how to interpret these findings. Prescriptions for HT (and incidence of breast cancers in some areas) have fallen over the last 3 years due to anxiety provoked about breast cancer risk and recurrence. The current 'clinical climate' is against HT. Due to a lack of effective alternatives, women suffering from estrogen-deficiency symptoms are still requesting objective information about HT, particularly those at higher risk of breast cancer or those with a past history of breast cancer. In this situation, discussion of the current clinical uncertainty surrounding the use of HT must be undertaken to ensure that women are adequately informed. The objective of this presentation is to provide a framework for understanding breast cancer risk associated with HT. What are the precise molecular mechanisms of estrogen and progestin in the initiation of breast cancer? Does the risk of estrogen-only therapy on breast cancer vary by dose, constituent, route and duration of administration and cessation of use? Does HT, in addition to increasing risk for breast cancer, affect the type of breast cancer (lobular and ductal) diagnosed? Is HT associated with breast cancers that have better prognostic factors? How relevant are the changes in mammographic breast density associated with HT for the evaluation of breast cancer risk? What is the additional global health risk/benefit ratio associated with the selective use of progesterone or progestin that may confer a significant cardiovascular benefit, such as drospirenone? It is currently assumed and tested that new hormones with particular pharmacological profiles may ultimately achieve their therapeutic goal of relieving climacteric symptoms without an associated moderate increased risk of breast cancer.

Persistence of an intact endometrial matrix and vessels structure in women exposed to VA-2914, a selective progesterone receptor modulator

BACKGROUND

VA-2914 is a selective progesterone receptor modulator with potential contraceptive activity that induces amenorrhea, whereas progestins cause endometrial spotting and bleeding. This abnormal bleeding due to progestins is a consequence of focal stromal proteolysis by an increase in naked vessel size and density.

OBJECTIVE

Our objective was to quantify the effects of VA-2914 on endometrial vascularization, fibrillar matrix, and vascular endothelial growth factor (VEGF)-A expression in endometrial biopsies from 41 women before and after 12 wk daily treatment with a placebo, or 2.5, 5, or 10 mg VA-2914.

METHODS

Collagen fibrillar network was stained by silver impregnation. Vessel area, density, and structure were quantified with a computer-assisted image analysis system after double immunostaining using an anti-von Willebrand factor (endothelial cells) and an anti-alpha smooth muscle actin (vascular smooth muscle cells) marker antibody. VEGF-A mRNAs were quantified by RT-PCR and localized by immunohistochemistry.

RESULTS

The endometrial vessels, collagen network, and mRNA levels of VEGF-A were identical during the luteal phase at baseline and in VA-2914 treated women. VEGF-A distribution was unchanged.

CONCLUSIONS

VA-2914 does not alter the endometrial matrix and cells, and does not modify the endometrial vessel morphology as compared with baseline biopsies.

[Secondary amenorrhea and cerebral ventriculomegaly]

Cerebral ventriculomegaly and hydrocephalus are not frequently associated with endocrine disorders of the gonadotropic axis. The mechanism of this association is not clarified. The most probable cause is however a partial hypothalamic dysfunction. The examination of the few reported cases is in favour of this explanation. We present the case of a young woman with a cerebral ventriculomegaly and suffering from secondary amenorrhea. Shunt was not necessary from the neurological point of view, the problem of secondary amenorrhea and anovulatory infertility was solved by clomiphen citrate therapy.

[Four clinical cases of dysgerminoma]

Dysgerminoma is an ovarian germ cell tumor occurring more frequently among young women. The efficacy of chemotherapy allows conservative surgery sparing fertility. A stadification surgery will avoid chemotherapy for patients with stage Ia. The others stages will receive a cisplatine-based regime. A ct-scan is performed twice a year and, in case of recurrence, a first or a second chemotherapy should be prescribed.

[Gestational diabetes: an update]

Gestational diabetes mellitus is one of the major medical complications of pregnancy. This review describes the short and long term consequences of this affection, the screening strategy and the diagnosis approach. The obstetrical management and the diabetes treatment with dietary strategies reducing carbohydrate intake and minimising the postprandial glucose levels are explained. Insulin treatment indication, place of insulin analogues, and use of oral antihyperglycaemic agents are also discussed.

[Hormone replacement therapy one year after the results of the Women's Health Initiative]

The currently reported data concerning the large WHI randomized controlled trial compare the impact of continuous combined conjugated estrogens + medroxyprogesterone acetate vs placebo in postmenopausal women. These results appear largely pessimistic. After 5.2 years of hormone replacement, an excess of coronary heart disease, cerebrovascular disease, venous thromboembolism, breast cancer incidence and extension, mild cognitive impairment and dementia is recorded. By contrast, osteoporotic fracture risk and colorectal cancer are decreased during hormone replacement. Accordingly, this hormonal treatment can no longer be recommended on a long term basis, except after extensive risk-benefit balance evaluation. It should no longer be prescribed for prevention of chronic diseases. It remains indicated during 4-5 years for relief of vasomotor symptoms, genital atrophy and, potentially, for some aspects of quality of life. HRT should probably be prescribed in minimal-effective dosages; new regimens, routes of administration, new compounds and associations should be envisaged in order to avoid cardiovascular or breast problems. However these new approaches ask for thorough validation studies.

[Postmenopausal hormone replacement therapy and breast cancer risk: an update]

Numerous studies have examined the risk of breast cancer in patients with postmenopausal hormone substitution. Most of these studies are retrospective, and a few recent studies are prospective. The observed results present with weak variations from baseline and major heterogeneity. Some studies highlight a slightly increased relative risk of breast cancer. A reanalysis of 51 studies demonstrates a relative risk of 1.35 for developing breast cancer during hormone substitution, with a 2.3% increased risk per year of use. Recently, the results of the WHI study have shown a slight increase of some risks of disease, including breast cancer (relative risk, 1.26). These results have induced the interruption of one of the 3 arms of the study (that of the patients treated with an estrogen-progestin combination), and have provoked a new discussion about the benefits and risks associated with hormone substitution. These facts have been largely related and commented in the general press. In this article, we review the important studies concerning this topic.

[Clinical study of the month. Benefit/risk balance of postmenopausal estrogen-progestin treatment in peril in the Women's Health Initiative study: practical attitude of the clinician]

The Women's Health Initiative (WHI) is sponsored by the NIH. The study focuses on risk and benefits of strategies that could potentially reduce the incidence of heart disease, breast and colon cancer, and fractures in postmenopausal women. One arm of the study, a double-blind, placebo-controlled trial, looking at the effects of continuous combined estrogen-progestin regimen was stopped prematurely based on health risks which exceeded health benefits. The main reason for this decision was the increase in risk of invasive breast cancer, as well as a slight increase in the rate of myocardial infarction and stroke. In this paper, we inform our colleagues of the detailed results of the study. We comment on its limitation and discuss the new original observations. Finally, we integrate the others to previous world literature data that are confirmed by the WHI study. It is important for the individual prescribing practitioner to issue practical conclusions and therapeutic recommendations. The department of Obstetrics and Gynaecologic of the University of Liege, in agreement with the European Menopause Society and the International Menopause Society, is convinced that there is no alternative to the hormone replacement therapy for menopausal symptoms. We should stick to the traditional indications for hormones, namely vasomotor symptoms and osteoporosis. We should continue to recommend hormones for symptomatic women. One should realize that the risk for breast cancer appears only after several years of use, and the risk for cardiovascular events below age 60 is very small (the age of the patients was 63 at inclusion in the WHI study). We should encourage women to take the necessary measures for routine, periodic breast examinations (both manual, echographic and radiographic). Women who use HRT for more than 5 years should discuss the latest data of the WHI study with their physician, in order to consider their individual benefit-risk equation. Those who feel good on hormones and are fully satisfied with this treatment should learn of possible harm after long-term use. It is important to take into account the importance of quality of life. We should leave to the patient the final decision whether or not to continue the treatment. It is presently impossible to decide whether other estroprogestin associations, other administration routes and other molecules such as estradiol, natural progesterone or other progestins, SERMS and Tibolone could have an impact very different from that of the estroprogestin combination used in the WHI study. It is the duty of every physician to decide, from the complex epidemiological data obtained in the aged women (63-68 years) with a high cardiovascular risk in the WHI study, if it is possible or not in each individual case to recommend the initiation or pursue of an hormone replacement therapy.

[Revised postmenopausal treatments? A new polemic!]

The study by Schairer et al. aims to determine whether increases in risk of breast cancer associated with the estrogen-progestin regimen are greater than those associated with estrogen alone. This study is a cohort of follow-up data for 1980-1995 from the Breast Cancer Detection Demonstration Project, a nationwide breast cancer screening program that involved 29 screening centers throughout the United States. A total of 46,355 postmenopausal women were followed. During follow up, 2,082 cases of breast cancer were identified. Increases in risk with estrogen only and estrogen-progestin only were restricted to use within the previous 4 years. The relative risk increased by 0.01 with each year of estrogen-only use and by 0.08 with each year of estrogen-progestin-only use among recent users. Among women with a Body Mass Index of 24.4 kg/m2 or less, increases in relative risk with each year of estrogen-only use and estrogen-progestin-only use among recent users were 0.03 and 0.12, respectively. The authors conclude that the estrogen-progestin regimen increases breast cancer risk beyond that associated with estrogen alone. This study was largely commented in the lay media. Unfortunately the Belgian media introduced the confusion between the relative risk and the risk attributable to estrogen and estrogen-progestin. The aim of this manuscript is to precisely inform our colleagues, to analyze the Schairer study and to present the actual figures of risk associated with the use of estrogen and estrogen-progestin replacement therapy. Finally, we formulate some suggestions for the physician to whom the patient declares: "Did you read the negative effects of hormones?". What should we advice?

[Transdermal replacement hormone therapy: a trend or an advantage?]

This review describes the clinical usefulness of transdermal hormone replacement therapy. This route of administration is particularly important in women with hypertriglyceridemia, in hypertensive postmenopausal women, in women who smoke or have an increased risk of biliary or liver disorder, for those who display a reduced glucose tolerance or in women who are at risk of thrombotic disorders. The avoidance of the "first passage effect" is ensured by the transdermal application of estrogen and probably explains the superiority of this route of steroid administration.

Expression of stromelysin-3 in the human placenta and placental bed

Human placentation is mediated by fetal trophoblastic cells which penetrate into the decidualized uterine endometrium. Trophoblast invasion requires the precisely regulated secretion of specific proteinases able to degrade the endometrial basement membranes and extracellular matrix. To document further the involvement of these proteinases during human placentation, we evaluated in vivo the expression of stromelysin-3, a member of the metalloproteinase family, during the first and third trimesters of pregnancy, by means of immunohistochemistry, in situ hybridization and Northern blot analysis. Human extravillous trophoblasts invading the maternal decidua produced stromelysin-3 during both, the first and third trimesters of pregnancy, but to a lesser extent during the latter. In floating villi, stromelysin-3 expression was restricted to the syncytiotrophoblasts that line intervillous vascular spaces. In conclusion, stromelysin-3 is expressed by differentiated, non-proliferative villous and extravillous trophoblastic cells in early and late placental beds and villi, and its pattern of expression evolves during pregnancy. Our observations suggest that stromelysin-3 could play a role in human placentation.

Expression of gelatinases A and B and their tissue inhibitors by cells of early and term human placenta and gestational endometrium

BACKGROUND

Human placentation is mediated by fetal trophoblastic cells that invade the maternal uterine endometrium. Trophoblast invasion requires a precisely regulated secretion of specific proteolytic enzymes able to degrade the endometrial basement membrane and extracellular matrix.

EXPERIMENTAL DESIGN

Several studies have documented the key roles of matrix metalloproteinases and their tissue inhibitors in the invasion of various matrices by cultured trophoblasts. In vitro studies suggest that placentation could result from a balance between the secretion of these enzymes by trophoblast cells and their inhibition by the natural tissue inhibitors (TIMPs) produced by maternal decidual cells. The precise localization and levels of expression of these proteins that account for and control invasion during human placentation in vivo however, have not been described. We have evaluated, in vivo, by immunohistochemistry, Northern blot analysis and in situ hybridization, the expression of two metalloproteinases (gelatinases A and B) and their two tissue inhibitors (TIMPs 1 and 2) in placental villi and placental beds of first and third trimesters of normal pregnancy.

RESULTS

Human first trimester intermediate trophoblast produced both gelatinases A and B; these two gelatinases were respectively less and no more detected at term in these cells. We found that both TIMP1 and 2 were also expressed in maternal decidual cells with a dramatic increase of TIMP1 at the term of pregnancy. In floating villi, gelatinase A and TIMP1 were localized in the stromal compartment, whereas gelatinase B and TIMP2 were codistributed in trophoblast cells.

CONCLUSIONS

The gelatinases A and B and their tissue inhibitors are thus expressed by specific cells in early and late placental beds and villi. This pattern of expression varies during pregnancy. Therefore, our morphologic study supports biologic findings suggesting that these proteins may participate in placentation.