Restructuring support staff classification levels for academic health sciences library positions

Nonprofessional library support staff traditionally hold what are considered to be low-paying, nonchallenging positions. These negative factors make retaining creative and productive employees difficult. This article outlines the approach taken at the Medical College of Georgia's Robert B. Greenblatt, M.D. Library to devise a structure of library staff positions that becomes progressively more demanding. A new nine-level Library Staff Classification Plan resulted. This plan also enables and encourages employees to acquire more skills and to accept more responsibility in order to qualify for higher-level library positions or to advance their present position to receive comparable rewards. The plan expresses the level of responsibilities expected, the employee qualifications desired, and lists representative duties across the spectrum of typical library tasks.

Fibrocystic breast disease: the significance of beta-human chorionic gonadotropin and other polypeptides in breast cyst fluid

Breast cyst fluids from 118 women, aged 29 to 69 years, were analyzed by radioimmunoassays for beta-human chorionic gonadotropin (beta-hCG), luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin (PRL), and thyroid-stimulating hormone (TSH). Blood was drawn at the same time in many cases to compare hormonal levels in serum with those in the breast cyst fluids (BCF). The levels of beta-hCG in BCF were relatively high, with a mean (+/- standard error of the mean [SEM]) of 58.9 +/- 16.8 mIU/ml; serum levels of beta-hCG were negligible. LH and TSH also were elevated in BCF compared with serum levels, exhibiting mean values (+/- SEM) of 26.7 +/- 4.3 mIU/ml and 6.4 +/- 0.44 muIU/ml, respectively. The levels of FSH and PRL in BCF were equivalent to the levels in the serum. The presence of biologically active hCG was suggested in several BCF samples using the rat ovarian hyperemia test. Samples of BCF were assessed for the capacity to stimulate Leydig cell testosterone production in vitro in the presence or absence of an anti-hLH antiserum. Testosterone production was significantly (P less than 0.05) enhanced, even in the presence of the antiserum. These data suggest that BCF contains biologically active hCG.

Gross cystic disease of the breast

The aetiology of fibrocystic disease of the human breast remains problematical. While oestrogens may cause cystic lesions and epithelial proliferation in the mammary glands of experimental animals and certain progestogens (chlormadinone acetate and medroxyprogesterone acetate) may induce severe myoepithelial hyperplasia in beagles, the classical oral contraceptives (oestrogens and progestogens) reduce the incidence of fibrocystic breast disease in women. The role of prolactin in human breast disease is far from clear despite the fact that in rodents mammary tumors fail to develop following oestrogen administration in the absence of prolactin. Because women with gross cystic disease of the breast are at four times greater risk of developing malignant breast disease, it is felt that the administration of courses of danazol, an impeded androgen derived from the progestin, 17 alpha-ethinyl testosterone, has proved effective in lessening fibrocystic disease of the breast, frequently obviating the need for breast biopsy. The study of the hormonal content of fluid aspirated from gross breast cysts should help elucidate the pathophysiology of breast disease. Breast cyst fluid is rich in androgens, particularly dehydroepiandrosterone sulfate; concentrations of polypeptide hormones like FSH, LH, TSH, PRL, and calcitonin are invariably present sometimes in less and at other times in greater amounts than that found in plasma. Of particular interest is the finding of measurable levels of beta-hCG in cyst fluid but not in the serum. The question arises whether the beta-hCG is biologically active or are the assay values merely the expression of radioimmunoassayable components? Preliminary (as yet unpublished) studies reveal excellent bioactivity as measured by testosterone production in Leydig cell cultures. Time will tell whether elevated levels of bioactive beta-hCG portend neoplastic potential.

The use of androgens in the menopause and other gynecic disorders

The use of androgens in the treatment of gynecic disorders has had few adherents because of the belief generally held that androgen administration to the female patient is antiphysiologic and antipharmacologic. Testosterone in physiologic doses complements estrogens and is synergestic rather than contraphysiologic. Physiologic doses of testosterone may be used to advantage in the management of the menopause, sexual dysfunction, lichen planus vel atrophicus, fibrocystic disease of the breast, and sexual infantilism resulting from hypopituitarism as well as in several other disorders.

Changes in lipoproteins with various sex steroids

Menopausal symptoms are a consequence of the decline in sex hormone production, and hormone replacement therapy aims not only to relieve these symptoms but also to prevent the development of diseases of old age such as osteoporosis. The general opinion taken from a wide variety of publications is that the serum lipid concentrations change during hormone replacement therapy with estrogen, progesterone, and testosterone, or when oral contraceptives are administered. The intolerance of many women to oral contraceptives and the many side effects developed from the birth control pill lead us to suggest that pure crystalline estrogen pellets for subcutaneous implantation are an excellent method of contraception, adding beneficial influence upon lipid metabolism by increasing HDL concentration. The use of progestogens (nortestosterone or hydroxysteroid derivatives) in order to induce withdrawal periods and to avoid endometrial hyperplasia is recommended. But it is important to note that the nortestosterone derivatives (norgestrel and norethindrone acetate) differ markedly from the nonadrogenic 17-alpha hydroxyprogesterone derivative in that the former lowers HDL levels noticeably more than the latter.

Correlation between follicle-stimulating hormone, luteinizing hormone, prolactin, and testosterone with sperm cell concentration and motility

Follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin (PRL), and testosterone were measured by radioimmunoassay in blood and seminal plasma of normo-spermic and oligospermic men. These parameters were correlated with sperm cell concentration as well as sperm motility. Average motility in the oligospermic group was significantly decreased as compared with the normospermic group (P less than .001). A significant reciprocal correlation was demonstrated between blood LH concentrations and sperm cell concentrations (P less than .05) as well as sperm motility (P less than .02). In contrast, a significant positive correlation was demonstrated between seminal LH concentrations and sperm cell count and motility (P less than .001). Seminal FSH and testosterone concentrations were positively correlated with sperm output but not sperm motility (P less than .05). The increased concentrations of LH in circulation accompanying idiopathic oligospermia suggests that LH secretion may be linked to the factors regulating spermatogenesis. The significant correlation between seminal testosterone and sperm concentration demonstrated in this study offers further support to this hypothesis. The significance of the correlation between the levels of LH and FSH in seminal plasma and sperm cell concentration and sperm motility is unknown.

Pituitary responsiveness to luteinizing-hormone-releasing hormone in different reproductive disorders. A review

As a result of the use of synthetic luteinizing-hormone-releasing hormone (LHRH) (and its analogs), significant advances in modern clinical practice are being realized. We studied the use of LHRH as a test for pituitary reserve for gonadotropin secretion in different reproductive disorders. Synthetic LHRH was used as a diagnostic test for discriminating pituitary from hypothalamic disorders. After appropriate LHRH priming of the pituitary, LHRH was used to document hypothalamic dysfunction in patients with Kallmann's syndrome who had normal gonadotropin responsiveness to LHRH. The gonadotropin responsiveness to 100 micrograms of LHRH was impaired or absent in patients with panhypopituitarism, craniopharyngiomas, hemochromatosis and acromegaly accompanied by abnormal lactation. In women with gonadal dysgenesis, the absence of gonadal steroid feedback exacerbated the pituitary responsiveness to LHRH. Women with hyperprolactinemia are also known to have a blunted gonadotropin response to endogenous and exogenous LHRH. An experimental rat model was developed in our laboratory to study the site of prolactin action on gonadotropin secretion. LHRH challenge tests during perphenazine-induced hyperprolactinemia in rats indicated that prolactin may decrease pituitary sensitivity to LHRH. Additional experiments indicated that the increased progesterone produced in these hyperprolactinemic (pseudopregnant) rats was probably responsible for the decreased pituitary responsiveness to LHRH. Further studies will be necessary to determine whether prolactin, which can alter ovarian steroidogenesis in vitro, interferes with ovulation directly in addition to affecting the hypothalamic-pituitary axis.

Hormone therapy for sexual dysfunction. The only "true aphrodisiac"

Human sexual behavior is extremely complex indeed. It has been described as the sum total of an individual's makeup, which includes chromosomal sex, gender identification, gonadal adequacy, rearing, environmental influences, hormonal factors, and possible hypothalamic sensitization. In recent years, much has been written about the importance of the psyche in matters of sex and about the mechanics of coitus, as well as the proper amatory prelude. The authors think the time is ripe for an assessment of how hormones modify sexual responsiveness. In particular, they hope this article will help to dispel the notion current in many circles that hormonal therapy is of little value.

Role of estrogens and progesterone in the etiology and prevention of endometrial cancer: review

Our present knowledge of the role of sex steroids in the development as well as the prevention of endometrial cancer is reviewed. Factors which increase the exposure of the uterus to unopposed estrogens, either exogenous or endogenous, are associated with increased risk of endometrial adenocarcinoma. However, there is increasing evidence that progestogens can reverse endometrial hyperplasia and protect against the development of endometrial cancer. The mechanisms to explain the antiestrogenic effects of progestogens include changes in enzyme activity and steroid receptors in endometrial tissue. Postmenopausal women treated with combined estrogen and progestogen have the lowest incidence of endometrial carcinoma. Oral contraceptives containing both estrogen and progestogen in each tablet are protective against adenocarcinoma of the endometrium, while the sequential oral contraceptive pills afforded less protection. The risks and benefits of these hormone therapies are discussed in relation to the etiology and prevention of endometrial cancer.

The protective role of progesterone in the prevention of endometrial cancer

An association between endometrial hyperplasia and corpus cancer has long been suspected. Genetically predisposed women are at greater risk of developing endometrial cancer if subjected to long uninterrupted period of estrogen stimulation. Endometrial cancer need not be inevitable if 14 day courses of an oral progestogen are continued for as long as is necessary; in some women, however, the lesions will progress and, therefore, should be carefully followed with repeated endometrial biopsies. Epidemiological evidence suggests a true link between unopposed estrogens and early, less invasive endometrial cancer, and progestogens appear capable of protecting against the development of cancer and hyperplasia, although complete protection has not yet been achieved. The protective action of progestogens is supported by the fact the none developed endometrial cancer in a series of 490 women of reproductive age who received continuous estrogens by way of pellet implants of 17 beta estradiol for conception control for 1--10 years. Evidence for the protective action of progestogens in estrogen-treated menopausal women was less solid than in non-menopausal women but was nonetheless considerable. Our study of 1058 women, 45 years of age and older, receiving continuous estrogens by way of 17 beta estradiol pellets over a period varying from 1 to 21 years, revealed that the incidence of cancer was not greater and was possibly less than that expected in an untreated population of menopausal women.

The role of estrogens in mastopathy and mammary cancer in perimenopausal women

Fibrocystic disease of the breast (FCD) is an exaggeration of the normal physiologic response to cyclic estrogen and progesterone stimulation. The disorder can persist, with much less severity, in the menopausal woman. Whether FCD predisposes to mammary cancer remains moot. A new steroidal agent, danazol, can eliminate nodosities in the majority of women with FCD. Thermography may identify women who are at greater risk because of increased heat production. Mammography should be employed in women with persistently abnormal thermograms, even though no suggestive breast masses are palpable. Needle biopsy or surgical biopsy should be undertaken whenever a firm indurated mass is palpated, regardless of negative findings with a thermogram or mammogram. In a series of 1548 women treated for 10,715 women-years, the incidence of breast cancer after prolonged estrogen therapy was not increased. Although estrogens and prolactin have been incriminated in the etiology of mammary cancer, no hard facts exist to confirm such allegations.

Fibrocytic breast disease: current status of diagnosis and treatment

Improved diagnostic procedures and use of a new steroidal agent, danazol (Danocrine), should reduce the need for surgical intervention in fibrocystic breast disease. Thermography, a non-invasive procedure that may be used with impunity, may help identify women at high risk. Mammography, which is useful in revealing malignancy in an early stage, should be done in women with tow consecutive abnormal thermograms. Biopsies should be performed, however, on suspicious, firm, irregular masses, regardless of results on thermography or mammography. Use of danazol may be advantageous not only in ameliorating pain and eliminating nodosities, but also in guiding the surgeon to the nodule that is unresponsive to treatment and therefore should be evaluated by biopsy.

Estradiol and progesterone receptors in estrogen-primed endometrium

Estradiol and progesterone receptor levels were measured in endometrial samples obtained from patients who were on different dosages of estradiol therapy and from women in the late proliferative phase of a normal menstrual cycle. Samples of blood were collected at the time of biopsy, and the levels of estradiol, estrone, progesterone, follicle stimulating hormone, and luteinizing hormone were measured in the serum. The patients were divided into five groups. The first group (controls) consisted of patients in their late proliferative phase. The patients in groups two, three, and five were receiving estradiol in various doses by pellet therapy, along with a cyclic progestogen each month. The women in the fourth group also had implantation of estradiol pellets but failed to take the progestogen as advised. In our series, the levels of cytoplasmic estradiol and progesterone receptors were markedly elevated in the no progestogen group compared to the controls. There was no significant difference in the levels of the receptors in the groups which took the progestogen as advised.

Estradiol implants for conception control

Oral contraceptives are associated with serious untoward effects and have been proscribed for woman over 35 years of age. It was thought that the use of a natural estrogen (pellets of 25 mg of 17 beta-estradiol) implanted in descending doses (four, three, two, one) at 6-month intervals might cause less disturbance in metabolic parameters and side effects. Our experience with this regimen encompasses 18,480 cycles of 1,540 women years. The corrected Pearl index was 0.273, which compares favorably with other modes of conception control. Pellet implants proved to be quite acceptable to those who could not tolerate oral contraceptives.

A clinical and cytogenetic study of fifteen patients with 45,X/46XY gonadal dysgenesis

The cytogenetic and phenotypic findings in 15 patients with 45,X/46,XY mosaicism are described. Six patients presented with delayed sexual development without masculinization. The remaining nine patients had varying degrees of masculinization, ranging from clitoromegaly to hypospadic male phenotypes. Cardiovascular/renal anomalies were detected in 2 of the 15 patients. Gonadoblastomas were present in two patients and did not appear to correlate with the degree of masculinization or percentage of 46,XY cells present. Structural Y chromosome abnormalities were seen in three of the 45,X/46,XY probands. MZ twinning occurred in one of the 45,X/46,XY sibships.

The treatment of benign breast disease with danazol

Benign breast disease, aside from fibroadenomas and intraductal papillomas, frequently responds favorably to hormonal therapy. Although the use of estrogen, androgens, and progestogens often proves useful, danazol, in our hands, was found more consistently effective. Danazol, an impeded androgen derived from a progestogen, 17 alpha-ethinyltestosterone, was employed in doses of 100 to 400 mg/day for 3 to 6 months in the treatment of fibrocystic disease. This agent proved efficacious in eliminating nodularity in the majority of cases, with partial resolution in most of the others. Many women to whom surgery had been previously suggested were spared surgical interference because of a satisfactory response to danazol therapy.

Danazol for benign breast disease

Three groups of women with benign breast disease were treated with danazol for 3 to 6 months. Doses of 100 mg per day were given to 40 patients, 200 mg to 55, and 400 mg to 35. The age range of the patients was 20 to 48 years. The patients were rechecked at 6-month intervals over a period of 48 months. Most of them were seen four or more times after completion of therapy. Elimination of nodularity occurred in about two thirds; three experienced no improvement, and partial resolution was obtained in the remainder. Untoward effects were minimal or trivial. Danazol proved to be an excellent hormonal agent in the management of fibrocystic disease of the breast.

Danazol in the treatment of infertility

Danazol, an interesting pharmacologic steroid 'in search of a disease', was first used by my group in the management of endometriosis because of the marked anti-endometrial effects found during clinical trials. The results in alleviating dysmenorrhoea, dyspareunia, and pelvic discomfort were surprisingly good, but more important was the 40 to 50% pregnancy rate that occurred following discontinuation of its use. In addition, because we suspected that women with unexplained infertility might be harbouring an occult or microendometriosis, a 3 month course of 200mg of danazol was tried in such patients, and proved effective in overcoming infertility in roughtly 40% of patients within 6 months after discontinuation of medication. We serendipitously found that some habitual aborters carried to term after a course of danazol. Accordingly, a trial of 100mg daily for 3 months was undertaken with a satisfactory outcome in more instances than could be attributed to chance alone. To readily appreciate the effectiveness of this agent, one must be aware that conceptions may follow the use of placebos or whatever regimen is employed in about 15 to 20% of infertile women. The unusually good results that we and other investigators in the field obtained with danazol rules out a placebo effect.

The significance of oestriol in the management of the post-menopause

Oestrogen replacement therapy relieves many post-menopausal symptoms and has been successfully employed clinically for this purpose for more than four decades. Recently the alleged relationship between oestrogens and cancer has stimulated a re-evaluation of an old oestrogen preparation, oestriol (E3). The dosages of E3 employed appear to vary considerably, and the need was felt to establish the dosage on a scientific basis. Accordingly in the study reported here E3 was administered in various dosages (2, 4, 6, and 8 mg/d) to 52 symptomatic post-menopausal women as oestrogen replacement therapy for a six-month period. Assays of follicle-stimulating hormone (FSH), luteinizing hormone (LH), oestrone (E1) and oestradiol (E2) were performed before and during therapy and vaginal cytology, cervical mucus and endometrial studies were performed during the period of administration. The clinical effectiveness of E3 was found to be directly related to dosage. E3 did not induce endometrial proliferation and proved a poor suppressor of FSH and LH. The ability of oestriol to relieve vasomotor instability and to improve vaginal maturation without inducing notable side effects is sufficient reason for it to be included in the management of the post-menopausal syndrome.

The fate of a large bolus of exogenous estrogen administered to postmenopausal women

Seventeen postmenopausal women were given a bolus of conjugated estrogens (USP, Premarin), 17 beta-estradiol and estriol orally, intravenously or by pellet implantation, and circulating levels of estrone, estradiol and/or estriol were measured by radioimmunoassay at various intervals during a 48--72-h period. Oral administration resulted in a marked rise in serum estrone; parenteral administration resulted in a marked increased in serum estradiol. There was no significant fall in serum gonadotropins during this period. Following estriol administration orally, there was a decided elevation in estriol levels but minimal change in estrone and estradiol.

Danazol treatment of endometriosis: long-term follow-up

Forty-nine women diagnosed as having pelvic endometriosis were treated with 800 mg of danazol/day for a mean duration of 6 months. The average length of the follow-up period was 78 months. Side effects were minimal, and regular ovulatory menses returned within 25 to 90 days (average 42 days). Forty-two (85.7% of these women had associated infertility. Recurrence of symptoms was reported in 33% but in no patient were the symptoms worse than before entering the study. Of 30 patients desirous of pregnancy, 20 were potentially fertile; of these, 10 conceived within 6 months of discontinuing therapy, for a conception rate of 50%. Nine of the remaining ten patients required additional therapeutic procedures (surgery and/or danazol), and four of these conceived within 12 months. These results compare favorably with those of other investigations, since most of our patients were referred to us after being subjected to a variety of regimens, both hormonal and surgical.

Update on the male and female climateric

The gonadal steroids--estrogens and androgens--appear to have a mood-elevating, psychotonic effect. The improved sense of well-being and increased vigor probably is engendered by restoration of somatic efficiency and psychic equilibrium. 1. The male climacteric, as observed in a limited number of men, is associated with a low level of serum testosterone. The levels of follicle-stimulating hormone and luteinizing hormone are not elevated because estrogen concentration continues unaltered well into old age. Androgen replacement therapy often lessens fatigue, depression and headaches, and headaches, and improves libidinous drives. 2. In the aging female, many climatric symptoms other than those due to vasomotor instability were heretofore considered merely coincidental. Recent studies suggest that the metabolism of cerebral hormones is markedly influenced by endogenous and exogenous gonadal steroids. Thus, postmenopausal depression, headaches, and nervousness may be hormone-dependent symptoms. 3. The incidence of endometrial cancer is no greater and is probably less in estrogen-treated women than in women not treated with estrogen, if regular cyclic courses of an oral progestogen are added to the regimen.

Serum levels of estrone and estradiol after implantation of estradiol pellets

Serum estrone, estradiol, progesterone, FSH, and LH levels were studied after the implantation of estradiol pellets in female volunteers in the reproductive age group. The estradiol pellets were implanted at six-month intervals. The first implant consisted of four pellets (25 mg each). Subsequent implants consisted of a reduction by one pellet as compared to the previous implant. The mean serum estradiol levels during the six-month period of implantation or at the end of six-month intervals were in the premenopausal range and did not differ significantly during the study. The serum estrone levels showed a tendency to increase with time even though the number of pellets implanted was decreasing, apparently a result of incomplete absorption of the implanted estradiol during the six-month period. The results of serum progesterone determinations and basal body temperature records indicate that the suppression of ovulation takes place most consistently during the second and subsequent months after estradiol pellet implantation.

'Not Cushing's syndrome'

Cushing's syndrome is characterized by protein wasting secondary to hypergluconeogenesis, which produces thin skin, poor muscle tone, osteoporosis and capillary fragility. These features distinguish patients with true Cushing's syndrome from those who have some of the clinical findings often associated with the syndrome, such as obesity, hypertension, striae and hirsutism. The dexamethasone suppression test helps identify patients with pseudo-Cushing's syndrome.

Role of the hypothalamus in the aging woman

Relationships between the hypothalamus and the pituitary in the aging woman are discussed under the following subheadings: synthesis and release of follicle-stimulating and luteinizing hormones, estrogen receptors, other releasing factors, neurotransmitters, and the mechanisms of hot flushes and migrainoid headaches. The hypothalamus is the main regulator of pituitary function. In the female the hypothalamic-pituitary axis appears to remain functionally intact well into old age.

Appropriate contraception for middle-aged women

The United States Food and Drug Administration and the International Planned Parenthood Federation recommend that women over the age of 40 should utilize forms of contraception other than the pill. This decision was reached as a result of the 1975 clinical papers by Mann and his associates (Mann et al., 1975; Mann & Inman, 1975) and the epidemiological reports of the Royal College of General Practitioners (1977), Mann, Inman & Thorogood (1976) and Vessey, McPherson & Johnson (1977). Several authoritative bodies believed it prudent to suggest that the age limit for oral contraceptive use be lowered to 35, and even to 30 years (Anon, 1977; Planned Parenthood memorandum, 1977). The investigations of Inman & Vessey (1968) point to a precarious rise in mortality figures for women over age 35 on oral contraceptives.

Dynamic hormonal tests in a case of premature ovarian failure

The case of a patient with premature ovarian failure and a history of polycystic ovarian disease was described. Dynamic gonadal and pituitary tests were done. Ovarian, adrenal, and peripheral veins were catheterized to determine the steroid secretion under HCG stimulation. In vitro studies of the capacity of ovarian steroidogenesis confirmed the refractory nature of the gonad. Lack of gonadal response, both in vivo and in vitro, to stimulation suggests a possible alteration in ovarian sensitivity to gonadotropins as a possible cause of premature menopause.

Primary and membranous dysmenorrhea

Organic, physiologic, and psychologic causes of dysmenorrhea are presented. Signs and symptoms include pelvic fullness, nausea, vomiting, diarrhea, urinary frequency, nervousness, and headaches. Primary dysmenorrhea has been treated with analgesics, diuretics, and antispasmodics. Androgen therapy was also found to be effective, but it cannot be used for women who have acne or hirsutism. Surgery is rarely indicated for primary dysmenorrhea.

Treatment of benign breast disease with danazol: a follow-up report

One hundred thirty-five women with benign breast disease (BBD) were treated with danazol, an impeded androgen. Their ages ranged from 19 to 60 years (mean age, 30). The dose varied from 100 to 800 mg per day for 90 to 180 days, depending upon the severity of the disorder. Overall relief of pain was observed in 97% and of tenderness in 90.5%. There was complete or marked improvement of nodosities in 73%. Seventy-eight patients were followed every six months for two to four years. The recurrent symptoms were pain in 6%, tenderness in 6% and nodosities in 10%. Incidentally, we found that 29.3% of infertile women with BBD conceived within 24 months after cessation of a course of therapy. The side effects, when present, were trivial.

The significance of adrenal and ovarian catheterization in patients with polycystic ovary syndrome

A previously unreported series of 15 anovulatory hirsute women with polycystic ovaries made up this study. Each underwent left adrenal and left ovarian vein catherization. Blood samples were obtained from the ovarian, adrenal and peripheral veins to test the levels of testosterone, delta 4 androstenedione (delta 4A), dehydroepiandrosterone (DHEA), estradiol and/or total estrogens, before and after administration of human chorionic gonadotropin (ten cases) and adrenocorticotropic hormone (ACTH) (five cases). Following intravenous human chorionic gonadotropin administration, the only response seen was a slight rise in ovarian levels of delta 4A and DHEA; after intravenous adrenocorticotropic hormone stimulation, the adrenal levels of delta 4A, testosterone and DHEA rose significantly. Peripheral concentrations of testosterone and delta 4A were in the high normal range and DHEA levels were high normal or slightly above normal range.

Estriol in the management of the menopause

Estriol was administered for a six-month period as estrogen replacement therapy to 52 symptomatic postmenopausal women. Assays of serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), estrone, and estradiol were performed before and during therapy. During this period of administration, vaginal cytology, cervical mucus, and endometrial studies were performed. Clinical effectiveness was directly related to dosage (2 to 8 mg/day). Estriol (8 mg/day) failed to induce endometrial proliferation and proved a poor suppressor of FSH and LH. This agent's capacity to relieve vasomotor instability and improve vaginal maturation without notable side effects is sufficient reason to include this drug in the management of the postmenopausal syndrome.

Intrasellar subarachnoid herniation or empty sella associated with galactorrhea

Eight of 115 patients with empty sella had concurrent galactorrhea. All 8 patients had abnormal sellae, and the diagnosis of empty sella was made by polytome pneumoencephalography. There were no obvious endocrine dysfunctions, but 2 patients had elevated prolactin levels. One mechanism for production of galactorrhea may involve compression of the hypothalamus and/or pituitary stalk; this was suggested by most of our observations. There may be a coincidental association of empty sella with galactorrhea, and this association is probably more common than previously noted. Evaluation of patients with galactorrhea and abnormal sellae by polytome pneumoencephalography is emphasized.

The estrogen--cancer controversy

Postmenopausal women should not be denied estrogen therapy because of the controversy about the alleged causal relationship of estrogens to endometrial cancer. A prestigious team of biostatisticians reviewed three publications that claimed this relationship and concluded that no such association could be confirmed. Although the incidence of endometrial cancer has doubled in the past 25 years, there is no valid basis for the assumption that the widespread use of estrogens is the cause. The incidence also has increased in Norway and Czechoslovakia where estrogens are rarely used. Moreover, the histologic pattern of endometrial dysplasias is such that many pathologists will make a diagnosis of endometrial cancer as a safeguard for the patient. Thus the statistics for the incidence of endometrial cancer may be inflated. As a test, the administration of 200 mg of an oral progestogen over 5-10 days will convert a histologic pattern of pseudomalignancy, but not of adenocarcinoma, into one of secretory endometrium. Unopposed endogenous or exogenous estrogens may induce hyperplasia, atypical adenomatous hyperplasia or adenocarcinoma in women who are genetically predisposed. To minimize such a possibility, it is advisable to give a 5-7 day course of an oral progestogen so that the endometrium will be shed as monthly intevals. The benefits of hormone replacement therapy for the postmenopausal woman far outweigh the putative risk of endometrial cancer.

Primary empty sella syndrome with elevated serum prolactin

A young, adult, white female with long-standing amenorrhea-galactorrhea syndrome and known pituitary enlargement since 1969 is presented. Further evaluation revealed PRL levels elevated in the microadenoma range and an empty sella. The presence of a pituitary adenoma, however, could not be confirmed by our studies. The question now arises--in a young woman desirous of pregnancy, should an induction of ovulation be attempted in view of the elevated serum PRL and an empty sella?

A case of bilateral gonadoblastoma in streak gonads

A report of a patient with bilateral gonadoblastomas who sought consultation for primary amenorrhea and infertility is presented. Thelarche and adrenarche occurred spontaneously at age 13. Clitoromegaly and a hypoplastic uterus were noted on physical examination. Flat plate X-ray of the abdomen demonstrated radiopaque material in both adnexa. Urinary 17-ketosteroid levels were normal, but the serum testosterone concentration was elevated. Serum gonadotropin values were markedly elevated, and total serum estrogens levels were very low. The karyotype was XY. The gonads were extirpated, and typical histology is demonstrated. A postulate was made to explain the clinical findings.