- Email: [email protected]
Effects of estrogenic therapy upon ovarian function
26s
:\MERIC!:\N
.JOl’KS:\J,
OP
ORSTlWRI(‘S
.\SI)
i:YSB:(‘Ol~O(:\
References 1. Evans,
2. Z. 1. 5.
N.:
Hurg., Gym. & Obst. 30: 225, 19911. Kimbrough, R. A., Jr.: ~hf. J. OBST. & Grmc. 28: J.: Am. J. Cancer 25: 530, 1935. McFarland, Jacox, 1%. II-., Major, G., and Baker, M. R.: Radiology Corsczulen, J. A., am1 Stout, A. P.: Ani. J. Rwntgmol.
EFFECTS
OF ESTROGENIC THERAPY FUNCTION
I. When Employed
During
Normal
72,
32: 21:
UPON Menstrual
1!4:34.
51, 1X9. 155,
l!E).
OVARIAN Cycles
(~ENElIALL17 accepted concept of endocrinolog>- is that I he I’UIWtion of a gland is not stimulated but rather is depressed by its owlI intrinsic secretion. This concept has IWW held applicable both IO adcquately and inadequately functioning glands. Two considerations were responkblo 1’or these investigations of t ttca effects of estrogenic therapy upon 111~ func*lional levels of ovaries : (1) The present widesprcxl, contrwph?-siolo~i~~usage of estrogens in women in whom no proved ovarian failures casist, suggested the need for i\ clearer definition of the after effects oi’ this empiricism. (2) The facl that, recovery of frill ovarian j’un&on rcksults in a goodly nuiube~ u I’ women who had had prolonged or csc&vc. cwtrogenic bleeding arlcl who had been treated with a cycalie eslro~t:n-l)l,tJgesterone schedulei raised the question whether or not direct ovarian stimulation had occurred from what appeared t,o 1~ cssentiall~- a ~onplemental or substit.oi ional regime. The present communication is concerned with analyses of t IIt, effects of hormonal and nonhormonal eskogens upon the normal ovarian fun+ t,ion which is characterized by cyclic bleeding from progestational mdometriums. The subsequent and second communication” of this series deals with the effec.ts of estrogenic therapy upon anovulatSory ovarian failure, wherein relatively cyclic cpisodcs of estrogenic bleeding occurred.
A
Methods This investigation concerns 30 healthy women who bled from progestational endometriums. Their ages ranged from 16 1-o35 years, and RWI’aged 24.7 years. Four ecstrogens (3 hormonal and 1 nonhormonal) were employed : estradiol in the forms of its esters, the henzoate,” and the dipropionS.
*EstrmlioI .J.
bemzoate
(~rogynon-B)
supplied
by
Scherina
Corpor’ation,
BloomAeI~l,
HAMBLEN
ET
AL.:
EFFECTS
OF
ESTROGENIC
269
THERAPY
ate;” estrone ;f estriol glucur’onide;$ and diethylstilbestrol.$ Estradiol and estrone were administered intramuscularly in oil. Estriol glucuronide and diethylstilbestrol were given orally. Daily dosages were moderately small: estradiol benzoate 0.33 mg. to 0.67 mg.; estradiol dipropionate 1.5 mg.; estriol glucuronide 450 oral units to 2,400 oral units; and diethylstilbestrol 1 to 6 mg. Sixty-one cycles of therapy were administered during the first half of the ovarian cycle, i.e., from the fifth to the fourteenth day inclusive. Fifteen cycles of treatment extended from the fifth to the twenty-fourth day inclusive. Eight cycles of treatment were given during the last half of the cycle, i.e., from the fifteenth to the twenty-fourth day inclusive. Fifteen patients received therapy during single cycles ; 10 patients during 2 consecutive cycles ; 7 patients during 3 consecutive cycles ; 3 patients during 4 consecutive cycles ; and 1 patient received therapy during 5 consecutive cycles. Endometrial studies were made prior to, during, and after the cessation of treatment. Endometrial samples were taken by biopsy within the first twenty-four hours after t,he onsets of bleeding. Classification of the endometriums was done by one of us (E. C. H.). Data upon the lengths of the cycles, and the durations and amounts of bleeding episodes before, during, and following t,herapy were analyzed. The urinary excretions of sodium pregnanediol glucuronide of 9 patients before and during treatment were investigated by the method of Venning.3 All patients received complete medical, gynecologic, and endocrine surveys which included determinations of basal metabolic rates and roentgenograms of the sella turcica.
Data Therapy was administered during 54 ovarian cycles. Following cessation of therapy clinical data were obtained upon 72 additional cycles. In all a total of 156 cycles was studied. Dosage Schedzcles.-The estrogens employed, their daily doses, the days of treatment in relation to the bleeding cycles, and the endometrial responses resubing are presented in Table I. 1. Efects Upon the Endometrium.---A. Hormonal Estrogens: The endometrial responses were studied during 26 of the 52 cycles of treatment of 16 of 19 patients who received hormonal estrogens. Six of the 26 endometrial responses were estrogenic; all of these were associated with therapy with estradiol. All endometriums studied during cycles treated with estrone and estriol glucnronide were progestational. Estradiol was given during the first half of the cycle (fifth to fourteenth day) in 18 of the 19 cycles of therapy: 11 cycles of treatment employed the dipropionate and 7 the benzoate. Endometrial responses were studied in 11 of t,hese cycles. Use of the benzoate yielded 2 estrogenic and 2 progestational endometriums, and the dipropionate 4 estrogenic and 3 progestational. (One of the progestational responses related to estradiol *E&radio1 dipropionate Summit, N. J. ?Estrone (theelin) tEstrio glucuronide $Diethylstilbestrol Rouses Point. N. Y. Inc.,
(di-ovocylin) supplied by (emmenin) (estrobene)
supplied Parke, and supplied
Davis by
by and -4yerst.
Ciha
Pharmaceutical
Company, McXcnna
Detroit, and
Products, Michigan. Harrison,
Ltd.,
___-
JMrone : 0.3 mg. 0.4
5th 5th 15th 15th
mg.
0.2 mg. ~1.4 mrr.
to to to to
.---_
14th 14th 24th 24th
day day day dav
:
-
---
inclusive inclusive inclusive inclusive/
,
Summary
Estradiol
benzoate
0.33 mg. 0.67 mg. Rstradiol
-
dipropionate
1.5 mg. 1.5 mg.
Estriol 3800 450 900 1800 2400 900 1800
5th to 14th 5th to 14th
glucuronide O.U. 5th O.U. 5th O.U. 5th 0.11. 5th o.u. 5th 0.u. 15th 0.~. 15th
t,o to to to to to
X4 cycles
: 14th 14th 14th 24th 24th 24th
:
~~~
1
Summary ‘-.-.-I-. :
day day
,-I 1 :
: to to to to to to to
inclusive inclusive
-.---
: --_
5th to 14th 15th to 24th
Diethylstilbestrol 1 mg. 5th 3 mg. 5th 6 mg. 5th 1 mg. 5th 2 mg. 5th 3 mg. .?t,h Total:
day day
1 I 1 /
14th 24th 24th 24th 24th 24th 24th
day day day day da,v day
inclusive j inclusive 1 Summarv -__
day day day day day day day
:;
I-
..- 7 -~.
I i 1
inclusive 1 inclusive I inclusive 2 :; inclusive inclusive L! inclwive I incluniw I SumuY~rv .__-./ :
inclwivc inclusive inclusiw inclusive inclusive inclusive
of therzpp:
I
j
/ Summary 41 biopsies
IO, I ’
1
11 1 11’
~.~~._~ I: , j I
:
“I I I
j
1
;
0
7 1 :! -__ “0 : ., --I I studied, 16 estrogenic
I/ I/ 0 II 10 I I_.-2 and 25 progestational. 0
dipropionate theraI)y occurred under circlunstances wherein t,hc cycle length was doubled; accordingly, this response, being only remotely related to therapy, is regarded as having been the result of post-therapy recovery.) The one cycle in which therapy with the dipropionate was given during the latter half (fifteenth to twent,y-fourth day) was characterized by the occurrence of a progestational endometrium. Progestational endometriums were encountered during 12, or 85.7 per cent, of the 14 first treatment cycles in which the endometrium was studied and during 77.7 per cent of the second treatment cycles. Subsequent to the cessation of therapy cndometrial studies were made on 5 patients (4 patients who had had single cycles of therapy and one patient who had had 4 consecutive cycles of therapy) during a total of 8 cycles. Eighty-seven and one-half per cent of these endometriums was progestational. The only estrogenic response occurred in a patirnl whose last therapy (2 cycles prc\-iouslgl had embraced the LISA 01 estradiol dipropionate. B. Nonhomnond Estrogen. (Vieth~~~lst~ilbestrob) : The endometrial rcsponses were studied in 15 of the 32 cycles of treatment with diethylSixty-six and seven-tenths per cent stilbestrol of 9 of the 13 patients.
HAMBLEN
ET
AL.
:
EFFECTS
OF
ESTROGENIC
THERAPY
271
Following cessation of treatment of the endometriums were estrogenic. endometrial studies were made during 11 cycles of 3 patients whose previous therapy had extended over 2 to 4 cycles: 2 endometriums were estrogenic and 9 were progestational, 18.2 per cent and 81.8 per cent, respectively. Table II summarizes the endometrial responses during and after therapy. 2. Effects Upon the Lengths of the [email protected]. Hormonal Estrogens: There were no significant alterations either during or following therapy The cycles during treatment with with estrone or estriol glucuronide. estradiol benzoate and dipropionate were shortened in length with two exceptions ; with estradiol benzoate from 29.5 days to 24.7 days, and estradiol dipropionate from 32.2 days to 26.5 days. The average deviation of the treatment cycle lengths from the pretreatment cycle lengths was, however, -3.1 days for the benzoate and -7.1 days for the dipropionate. Following the cessation of therapy, the cycles were of usual pretreatment lengths. In the cases of the 2 exceptions mentioned, rstradiol therapy was followed by the absence of the expected episodes of bleeding with sequential doubling in the lengths of the cycles. B. NonhormonaJl Estrogen (Dieth~y~stilbestrol): Without relationship to dosage or to the time of the cycle during which diethylstilbestrol was administered, the lengths of treatment cycles were altered in the majority of instances. The cycles of 5 patients were shortened from an average length of 29.6 days to one of 20.3 days. The cycles of 2 patients were lengthened from 25.4 days to 38.2 days. The lengths of the cycles of 5 patients were not altered constantly in any direction. No significant changes occurred in the lengths of the cycles of 1 patient. After cessation of treatment, cycles returned to their usual lengths. Only one episode of uterine bleeding occurred concomitantly with therapy. 3. Effects Upon the Duration and Amount of Bleeding.-A. Hormonal Estrogens: The duration of bleeding was not altered significantly during or after therapy with e&radio1 benzoate or estriol glucuronide. The alterations following employment of the other estrogens were not marked. Following treatment with estrone, the average duration of bleeding was reduced from 6.6 days prior to therapy to 5.0 days during and 4.4 days following cessation of treatment. Following treatment with estradiol dipropionate, the average duration of bleeding was increased from 4.6 days prior to therapy to 5.3 days during treatment, and 3.4 days following cessation of treatment. No marked alterations occurred in the amounts of bleeding during therapy or subsequent to its cessation. B. Nonhormonal Estrogen (Dieth.ylstilbestrol): Following therap;\ with diethylstilbestrol the duration and the amount of bleeding tended to parallel the changes in the lengths of the cycles. 4. Efects Upon Withdrawal Time.-The criterion employed for withdrawal bleeding was the occurrence of episodes of bleeding within a few days after cessations of therapy, and considerably in advance of expected dates of bleeding. A. Hormonal Estrogens: No instance of withdrawal bleeding followed therapy with hormonal estrogens. B. Nonhormonal Estrogen (Diethylstilbestrol): The withdrawal times could be evaluated in 14 cycles of 7 patients. They ranged from two to eight days, the a.verage being six days. The average length of the involved cycles was 19.5 days. 5. Efects Upon the Urinary Excretion of Sodium Pregnanediol Glucuronide.-A. Hormonal Estrogens: The urinary sodium pregnanediol
2 3 1 5 G
1
CASE NO.
-
1
+ l'hel‘ap?,
e-M edd-E e.M e-M e-M cdb-M edd-E e-0 e-0 edd-0 e.M e-M es-0 edd-M CM e-0 PS-0 __~-
- --
--
-
edA, Estradio7 dipropionate edb, Estradiol benzoate e, Estrone es, Estriol glucuronide stb, Djethylstilbestrol OKs. SO therap?., but (l:lt;l
1 2 1 1 1 1 1 2 3 4 1 1 2 1 1 2 ::
SERIES Ok' THER.\FT
on cycle
ORx-0 ORx-MORx-M ORX-0 es-o W-M ORs-0 edb-E R-M ORs-0 ORs-0
2 es-Mt ORs-0 e-M e-M
-
ORs-0 ORx-0 C&l-0 e-0 ORS-Cl
ORx-E
ORx-0
3 edd-E
,,
an<1 blt?c,ling
-
*
/
8,
.“,
OR.x-0
ORx-0
obtained
OKX-M+
-
*,
0,
G
No
t)iol).q
7
Olis-0
--~-
I
I I I
_-
0Xx-O
s
___of E~~~do~~~t?t~inl Res))axacs cstrogenic response or hyperestrogenic response irregular (patchy) progestation irregular (patchy) progestation irregular (patchy) progestation (immature) regular progestation progestation (decidualikr,) progcstatinn
-
STUDIED
ClGSsifiCnt~o~~
ORX-0
()Iis-0
CYC'LES
E, Moderate IS+, Marked M-, Minimal. M, Moderate, M+. Marked. I’-. Minimal I’. Normal I’+. Marked
cc IN! 3ECUTIVE - _. 5 -ORx-P
ORx-0 ORx-P
4 edd-P
9
10
2R 29 30
27
ii 23 24 25 26
20
19
17 18
16
12 13 14 15
11
1 1 1 1 1 2 1 2 1 1 2 1 2 1 1 1 1 1 1 1 2 1 2 1 1 1 2 3
-
1
e-P edd-M e-0 es-0 edd-0 es-0 ed b-0 es-0 es-0 stb-P edb-E stb-0 stb-E stb-M+ stb-0 stb-E stb-E &b-E stb-P stb-E &b-O stb-0 stb-0 stb-0 &b-O stb-0 stb-0
e-M
i
ORx-P stb-0 ORX-0 ORx-0 ORx-E stb-E
ORx-0
stb-0
0Xx-P ORx-0 stb-0 stb-0 ORX-p 0X3x-P &b-P
stb-E stb-E
edb-0
-
stb-P+
ORx-P
stb-0
ORx-M ORx-0
ORx-0
ORx-0 es-0 ORx-0
ORx-0
ORx-0 ORx-0 ORx-P es-0 ORx-0
ORx-0
ORx-0
e-0
e-0
&b-O stb-E stb-E stb-0
edd-RI ORX-P edb-0 .0Xx-O ORx-0 ORx-0 es.0 OBX-0 &b-O edb-P
e-0
-
ORX-M
ORx-0
ORx-Et ORx-0
ORX-0 es-0
ORx-0
ORs-0
I
ORx-0
ORx-0 ORs-0
ORx-0 ORx-0
ORx-0
I
ORx-0
ORx-M ORx-0
ORx-0 ORx-0
ORx-0
ORx-91
ORX-0
-
I
ORx-0
274
AMERICAN
JOURNAL
OF
OBR’I’ETRICS
AND
GYNECOLOGY
glucuronide excretions of 3 patients prior to and during treatment were determined. The amounts excret,ed prior to therapy were 36 nrg., 29 mg., and 0.0 mg., respectively, and during treatment 53 mg., 14 mg., and 17 mg., respectively. The pat,ient who escrel.cd 14 mg. of Ihe pregnanediol complex during therapy bled from an rst,rogenic cndometrium al. the termination of that particular cycle. The number of determinations per patient cycle averaged 18 prior to l.hcrap,v ant1 17 during therapy. B. Nodaormonnl Estrogen (Di~lh~Jlstilbt.si~olj : Levels oi’ sndiunr pregnanediol glucuronide excretion of 6 patients were established prior, t,o and during treatment. Only 2 patients excreted the pregnunediol complex prior to l.herapy and none during therapy. Estrogcnir (bnilometriums terminated three 0P these trcatmcnt, cqles. The number of determinations per paIirnt r~~+lc avcrngsed IS pAor to therapy 311~1151 during treatmenl. Discussion The contraphysiologic employment of moderately small doses oi’ hermonal and nonhormonal estrogens in women with normal ovarian function produced definite effects upon the menstrual cycle. As a group, the hormonal estrogens exerted little depressing effect. upon corpus luteum function. Estradiol dipropionate, however, which was given in the largest amounts, yielded definitely depressing c%ecls. The group percentage of estrogenic endometriums during theral)y ws 16.7 while in the instance of estradiol dipropionate it was grossly 50 1)(‘1’ c~tnt, and on analysis 66.7 per cent. I)iethylstilbestrol, even in the small amounts used, also drprc~cd corpus lnteum function. During therapy with this estrogen 66.7 pe1 cent of all the endometria,l responses studied were estrogenica while 62.5 per cent, of the endometriums at the termination of the first IY&merit cycles were estrogenic. Milligram for milligram dietl~ylst,ilbestrol was given in larger daily doses than the hormonal estrogens. In those cycles, however, in which therapy was given during the first half (fifth to fourteenth day) and from which most of the endometrial data were obtained, diethylstilbestrol was given in amounts of 1 to 2 mg. daily and estradiol in amounts of 1.5 mg. daily. Not only were the doses in milligrams similar hut also the effects on corpus luteum function were similar, 66.7 per caent depression in each instance. The fact that these effects were observed with the two estrogens which were given in largest amounts makes ii probable that use of the other estrogens would have yielded similar results if comparable doseshad been employed. The relative potencies of the various estrogens remain, as yet, COW troversial. From our data it appears that, diethylstilbest,rol in daily dosesof 1.0 mg. during the first half of the cycle is as effective in depressing corpus luteum function as 1.5 mg. of estradiol dipropionatt:. From other work by our group not yet reported and from the literature Table III,4 which summarizes relative potencies, has been compiled.
HAMBLEN TABLE
III.
ET RELATIVE
AL. :
EFFECTS
POTENCIES
RELATIVE
1.0 mg.
estradiol
1.5 mg.
estradiol
2. Vaginal smears’
1.0
estradiol
::. Hemostasis
1.0 mg.
sion of corpus luteum function
1.0
mg.
mg.
ESTROGENIC
OF ESTROGENS
CRITERIA I.. Depres-
4. Manufacturer
OF
IN
THE
HUMAN
3.0 mg. estrone = 0.67 mg. or on the basis of effective dosage = 4.5 mg. estrone = 1.0 mg.
estradiol
2.4
=
estradiol
mg.
3.0 mg. =
5.5
FEWALE
POTENCIES
=
=
275
THERAPY
=
diethylstilbestrol
estrone -= 5 to 6 mg. (daily doses)
diethylstilbestrol
e&one
=
1.2
diethylstilbestrol
mg.
mg.
estrone
diethylstilbestrol
2.3
mg.
diethylstilbestrol
‘s
ClSlittlS*
*Stoddard
and
Metzger:
J.
Clin.
Endocrinology
2:
209,
1942.
Following cessation of therapy with the hormonal estrogens, progestational endometriums were encountered in 87.5 per cent of the cycles. One of the patients who had progestational endometriums following cessation of treatment, had had 4 consecutive cycles of therapy, Following discontinuation of therapy with diethylstilbestrol 80 per cent of the endometriums was progestational. Thus, no permanent depressions of ovarian function followed therapy of the order given by us. Larger dosages of estrogens and more prolonged therapies might alter this finding. The modus operandi of the temporary impairment of ovarian funcCon described is probably one of pituitary depression. Therapy with estradiol benzoate and dipropionate was associated with shortening of the cycle lengths as is shown by the gross averages and the average deviations. H&man5 in a recent article computed the standard deviation of the normal cycle to be k2.2 days. Our average deviations were -7.1 days for estradiol dipropionate and -3.1 days for the benzoate. It is apparent that the effect of the benzoate was hardly significant while that of the dipropionate is quite significant. Here again the difference in effect is in all probability due to the employment of larger doses of the dipropionate. That there were no changes in the cycle lengths during therapy with estrone and estriol glucuronide is probabfy due to the smaller doses used. Since it is the estrogenic phase of the cycle which determines cycle length, the shortening of the cycle lengths during therapy with estradiol dipropionate would presumably be explained on the basis of depression of ovarian function, the occurrence of which has been established by the reversed endometrial responses during therapy. The assumption that shortening of the cycle lengths is due to decreased ovarian function, and thereby a decreased production of estrogens, does not hold true. Such an assumption is similar to sayin, 0 that a short menstrual cycle is indicative of a low level of ovarian function and a long cycle of a high leve1 of function. The additional supply of estrogen given as
276
AMERICAN
JOURSziL
OF
OBSTETRICS
AXD
GYNECOLOGY
therapy most certainly is metabolized and it is impossible to concclive of a. lack in the amount of available estrogen. Ovulation is not a factor in cycle length because the cpcles wer(‘ shortened whether ovulations and progestational responses occurred or not. Ttw q-de lengths were not shortened, as a rule, to the extent that a. withdrawal effect, could be postulated. A possible explanation is Ihal 1he increased supply 0C estrogen causes mme I*apid pPolifet&ion 211~1fliaturittittn of thy t’ti(l~)metrium with a decr~sc in length oi’ the cst,rogenic phase of the cycle. The entire effects of therapy on the c*yclc lengths, therefore, doubtlessly occur at the endometrial level. Diefhyl.stilbestrol ihcrapy ~)roducccl a 11umber of effects on cycle lengths. The cycles ol’ same patients were shortened while others were lcngthenrd. In gs(‘n~ri~I, those patients whoscfi qTle lcng~hs \V1’1!?long before trcntnlent mrt: shrtcned dwing trea lmer11~ and those w-hkh were short before treatment were lengthened during treatment. Of the group of 5 paCents who had changes in both directions, the average cycle length before treatment was 28.0 days and the average deviation of all cycles during treatment was +4.6 days. This sI~ows a significant trend toward lengthening. There is 110 correlation of these l.ariations with dosage, and there is no obvious explanation for t.hcm. It is also intercst,ing but not explained that the duration of bleedin g episode+ should vary with the changes in cycle lengths. Despite the fact that no persistent ill effects of therapy have ijecn encountered, these findings do not, warrant; any conclusions with regard to the ultimate results Ihat, might foliow protracted therapy with ia,rger doses of either hormonal or nonhormonal estrogens.
Summary and Conclusions Moderately small doses of hormonal estrogens (estronca, rastradio1 bcnzoate and dipropionate, and esi.riol glnruronide) and oc a 11011. hormonal estrogen (diethylstilbestrol) were administered contraphysiologically to 30 women who had normal ovarian function. The hormonal estrogens, with the exception of estradiol dipropionate, had no depressing effect upon corpus lul-cum I’nnction, presumii.ijly because of insufficient. dosage. Estradiol dipropionate which was given in larger dosages pi*oduced definite depacssion of ciorpus lnteulll funrt,ion which was equal in degree to the depression produced d[Gn g therapy with diethylst,ilbestrol. Both of these estrogens were given in c;imilnr doses in terms OP milligrams and each produced dcpre&on of corl~us lntsnm function in 66.7 pc~r cclnt, of the t,rea,tment cycles. Definite and qnanlitativc altcr;lt,ic~lls ill the mc~nst~rnal c*y~l~ \verc o/.)served during i,hcrapy with those estrogens which were pivrn in la.rger doses. The changes with dictllylstilhest,rol were marked by their lack of uniformity.
SIEGLER AND BAUER:
EVALUATION
OF PREGNAKEDIOL
COMPLEX
277
The following conclusions seem warranted : 1. Certain hormonal estrogens (estradiol) if given intramuscularly in adequate amounts will depress corpus luteum function. 2. Diethylstilbestrol, even in the moderately small amounts used by mouth, will depress corpus luteum function. 3. This depressing effect is not cumulative and does not persist after therapy. 4. The only direct effect of therapy on the ovarian level of function was the depression of corpus luteum function. 5. The other effects of therapy, i.e., on the cyclicity and duration of bleeding, probably resulted from action directly on the endometrium. We acknowledge the cooperative aid of the group of healthy women studied. Part of the expenses of these studies was defrayed from grants to one of us (E. C. II.) from the Research Council of Duke University, from Ayerst, McKenna and Harrison, Ltd., Montreal, Canada, and from Schering Corporation, Bloomfield, N. J.
References 1. Hamblen, E. C., Cuyler, W. Ii., Pattee, (1. J., and Axelson, G. J.: J. Clin. Endocrin. 1: 211, 1911. 2. Hamblen, E. C., Hirst, D. V., and Cuyler, W. H.: Ani. J. OBST. & GYNEC. In press. 3. Venning, E. H.: J. Biol. Chem. 26: 595, 1938. 4. Cuyler, W. K., Hamblen, E. C., and Davis, C. D.: J. Clin. Endocrin. 2: 453, 1942. 5. Haman, J. 0.: Aat. J. OBST. & GYXEC. 43: 871, 1943. (Section
II
of
this
paper
will
be published
in
the
AN EVALUATION OF THE PREGNANEDIOL INDEX OF OVARIAN AND UTERINE
March
issue.)
COMPLEX AS AN FUNCTION
SAMUEL 1~. SIEGLER, M.D., P.A.C.S., 'AND DAVID BBUER, M.S., M.D. BROOKLTK, N. T. (Prom
T
the Endocrine
and
Sterility
Clinics
of the Unity
Hospital)
HE corpus luteum and its hormones were early. recognized as playing important roles in the complex metabolic and endocrine relationships in the human female. However, it was not until Marrianl isolated pregnanediol from the urine of pregnant women in 1929, that extensive studies were undertaken to elucidate the nature of its significance. Subsequently, Venning and Browne2 contended that pregnanediol was a degradation product of progesterone and devised a Their studies indicated method for its quantitative determination. that pregnanediol was excreted only during the secretory phase of the menstrual cycle. It was suggested therefore that such determinations might afford both a valuable diagnostic index of ovulation and a gauge of the duration and functional activity of the corpus luteum.
:\MERIC!:\N
.JOl’KS:\J,
OP
ORSTlWRI(‘S
.\SI)
i:YSB:(‘Ol~O(:\
References 1. Evans,
2. Z. 1. 5.
N.:
Hurg., Gym. & Obst. 30: 225, 19911. Kimbrough, R. A., Jr.: ~hf. J. OBST. & Grmc. 28: J.: Am. J. Cancer 25: 530, 1935. McFarland, Jacox, 1%. II-., Major, G., and Baker, M. R.: Radiology Corsczulen, J. A., am1 Stout, A. P.: Ani. J. Rwntgmol.
EFFECTS
OF ESTROGENIC THERAPY FUNCTION
I. When Employed
During
Normal
72,
32: 21:
UPON Menstrual
1!4:34.
51, 1X9. 155,
l!E).
OVARIAN Cycles
(~ENElIALL17 accepted concept of endocrinolog>- is that I he I’UIWtion of a gland is not stimulated but rather is depressed by its owlI intrinsic secretion. This concept has IWW held applicable both IO adcquately and inadequately functioning glands. Two considerations were responkblo 1’or these investigations of t ttca effects of estrogenic therapy upon 111~ func*lional levels of ovaries : (1) The present widesprcxl, contrwph?-siolo~i~~usage of estrogens in women in whom no proved ovarian failures casist, suggested the need for i\ clearer definition of the after effects oi’ this empiricism. (2) The facl that, recovery of frill ovarian j’un&on rcksults in a goodly nuiube~ u I’ women who had had prolonged or csc&vc. cwtrogenic bleeding arlcl who had been treated with a cycalie eslro~t:n-l)l,tJgesterone schedulei raised the question whether or not direct ovarian stimulation had occurred from what appeared t,o 1~ cssentiall~- a ~onplemental or substit.oi ional regime. The present communication is concerned with analyses of t IIt, effects of hormonal and nonhormonal eskogens upon the normal ovarian fun+ t,ion which is characterized by cyclic bleeding from progestational mdometriums. The subsequent and second communication” of this series deals with the effec.ts of estrogenic therapy upon anovulatSory ovarian failure, wherein relatively cyclic cpisodcs of estrogenic bleeding occurred.
A
Methods This investigation concerns 30 healthy women who bled from progestational endometriums. Their ages ranged from 16 1-o35 years, and RWI’aged 24.7 years. Four ecstrogens (3 hormonal and 1 nonhormonal) were employed : estradiol in the forms of its esters, the henzoate,” and the dipropionS.
*EstrmlioI .J.
bemzoate
(~rogynon-B)
supplied
by
Scherina
Corpor’ation,
BloomAeI~l,
HAMBLEN
ET
AL.:
EFFECTS
OF
ESTROGENIC
269
THERAPY
ate;” estrone ;f estriol glucur’onide;$ and diethylstilbestrol.$ Estradiol and estrone were administered intramuscularly in oil. Estriol glucuronide and diethylstilbestrol were given orally. Daily dosages were moderately small: estradiol benzoate 0.33 mg. to 0.67 mg.; estradiol dipropionate 1.5 mg.; estriol glucuronide 450 oral units to 2,400 oral units; and diethylstilbestrol 1 to 6 mg. Sixty-one cycles of therapy were administered during the first half of the ovarian cycle, i.e., from the fifth to the fourteenth day inclusive. Fifteen cycles of treatment extended from the fifth to the twenty-fourth day inclusive. Eight cycles of treatment were given during the last half of the cycle, i.e., from the fifteenth to the twenty-fourth day inclusive. Fifteen patients received therapy during single cycles ; 10 patients during 2 consecutive cycles ; 7 patients during 3 consecutive cycles ; 3 patients during 4 consecutive cycles ; and 1 patient received therapy during 5 consecutive cycles. Endometrial studies were made prior to, during, and after the cessation of treatment. Endometrial samples were taken by biopsy within the first twenty-four hours after t,he onsets of bleeding. Classification of the endometriums was done by one of us (E. C. H.). Data upon the lengths of the cycles, and the durations and amounts of bleeding episodes before, during, and following t,herapy were analyzed. The urinary excretions of sodium pregnanediol glucuronide of 9 patients before and during treatment were investigated by the method of Venning.3 All patients received complete medical, gynecologic, and endocrine surveys which included determinations of basal metabolic rates and roentgenograms of the sella turcica.
Data Therapy was administered during 54 ovarian cycles. Following cessation of therapy clinical data were obtained upon 72 additional cycles. In all a total of 156 cycles was studied. Dosage Schedzcles.-The estrogens employed, their daily doses, the days of treatment in relation to the bleeding cycles, and the endometrial responses resubing are presented in Table I. 1. Efects Upon the Endometrium.---A. Hormonal Estrogens: The endometrial responses were studied during 26 of the 52 cycles of treatment of 16 of 19 patients who received hormonal estrogens. Six of the 26 endometrial responses were estrogenic; all of these were associated with therapy with estradiol. All endometriums studied during cycles treated with estrone and estriol glucnronide were progestational. Estradiol was given during the first half of the cycle (fifth to fourteenth day) in 18 of the 19 cycles of therapy: 11 cycles of treatment employed the dipropionate and 7 the benzoate. Endometrial responses were studied in 11 of t,hese cycles. Use of the benzoate yielded 2 estrogenic and 2 progestational endometriums, and the dipropionate 4 estrogenic and 3 progestational. (One of the progestational responses related to estradiol *E&radio1 dipropionate Summit, N. J. ?Estrone (theelin) tEstrio glucuronide $Diethylstilbestrol Rouses Point. N. Y. Inc.,
(di-ovocylin) supplied by (emmenin) (estrobene)
supplied Parke, and supplied
Davis by
by and -4yerst.
Ciha
Pharmaceutical
Company, McXcnna
Detroit, and
Products, Michigan. Harrison,
Ltd.,
___-
JMrone : 0.3 mg. 0.4
5th 5th 15th 15th
mg.
0.2 mg. ~1.4 mrr.
to to to to
.---_
14th 14th 24th 24th
day day day dav
:
-
---
inclusive inclusive inclusive inclusive/
,
Summary
Estradiol
benzoate
0.33 mg. 0.67 mg. Rstradiol
-
dipropionate
1.5 mg. 1.5 mg.
Estriol 3800 450 900 1800 2400 900 1800
5th to 14th 5th to 14th
glucuronide O.U. 5th O.U. 5th O.U. 5th 0.11. 5th o.u. 5th 0.u. 15th 0.~. 15th
t,o to to to to to
X4 cycles
: 14th 14th 14th 24th 24th 24th
:
~~~
1
Summary ‘-.-.-I-. :
day day
,-I 1 :
: to to to to to to to
inclusive inclusive
-.---
: --_
5th to 14th 15th to 24th
Diethylstilbestrol 1 mg. 5th 3 mg. 5th 6 mg. 5th 1 mg. 5th 2 mg. 5th 3 mg. .?t,h Total:
day day
1 I 1 /
14th 24th 24th 24th 24th 24th 24th
day day day day da,v day
inclusive j inclusive 1 Summarv -__
day day day day day day day
:;
I-
..- 7 -~.
I i 1
inclusive 1 inclusive I inclusive 2 :; inclusive inclusive L! inclwive I incluniw I SumuY~rv .__-./ :
inclwivc inclusive inclusiw inclusive inclusive inclusive
of therzpp:
I
j
/ Summary 41 biopsies
IO, I ’
1
11 1 11’
~.~~._~ I: , j I
:
“I I I
j
1
;
0
7 1 :! -__ “0 : ., --I I studied, 16 estrogenic
I/ I/ 0 II 10 I I_.-2 and 25 progestational. 0
dipropionate theraI)y occurred under circlunstances wherein t,hc cycle length was doubled; accordingly, this response, being only remotely related to therapy, is regarded as having been the result of post-therapy recovery.) The one cycle in which therapy with the dipropionate was given during the latter half (fifteenth to twent,y-fourth day) was characterized by the occurrence of a progestational endometrium. Progestational endometriums were encountered during 12, or 85.7 per cent, of the 14 first treatment cycles in which the endometrium was studied and during 77.7 per cent of the second treatment cycles. Subsequent to the cessation of therapy cndometrial studies were made on 5 patients (4 patients who had had single cycles of therapy and one patient who had had 4 consecutive cycles of therapy) during a total of 8 cycles. Eighty-seven and one-half per cent of these endometriums was progestational. The only estrogenic response occurred in a patirnl whose last therapy (2 cycles prc\-iouslgl had embraced the LISA 01 estradiol dipropionate. B. Nonhomnond Estrogen. (Vieth~~~lst~ilbestrob) : The endometrial rcsponses were studied in 15 of the 32 cycles of treatment with diethylSixty-six and seven-tenths per cent stilbestrol of 9 of the 13 patients.
HAMBLEN
ET
AL.
:
EFFECTS
OF
ESTROGENIC
THERAPY
271
Following cessation of treatment of the endometriums were estrogenic. endometrial studies were made during 11 cycles of 3 patients whose previous therapy had extended over 2 to 4 cycles: 2 endometriums were estrogenic and 9 were progestational, 18.2 per cent and 81.8 per cent, respectively. Table II summarizes the endometrial responses during and after therapy. 2. Effects Upon the Lengths of the [email protected]. Hormonal Estrogens: There were no significant alterations either during or following therapy The cycles during treatment with with estrone or estriol glucuronide. estradiol benzoate and dipropionate were shortened in length with two exceptions ; with estradiol benzoate from 29.5 days to 24.7 days, and estradiol dipropionate from 32.2 days to 26.5 days. The average deviation of the treatment cycle lengths from the pretreatment cycle lengths was, however, -3.1 days for the benzoate and -7.1 days for the dipropionate. Following the cessation of therapy, the cycles were of usual pretreatment lengths. In the cases of the 2 exceptions mentioned, rstradiol therapy was followed by the absence of the expected episodes of bleeding with sequential doubling in the lengths of the cycles. B. NonhormonaJl Estrogen (Dieth~y~stilbestrol): Without relationship to dosage or to the time of the cycle during which diethylstilbestrol was administered, the lengths of treatment cycles were altered in the majority of instances. The cycles of 5 patients were shortened from an average length of 29.6 days to one of 20.3 days. The cycles of 2 patients were lengthened from 25.4 days to 38.2 days. The lengths of the cycles of 5 patients were not altered constantly in any direction. No significant changes occurred in the lengths of the cycles of 1 patient. After cessation of treatment, cycles returned to their usual lengths. Only one episode of uterine bleeding occurred concomitantly with therapy. 3. Effects Upon the Duration and Amount of Bleeding.-A. Hormonal Estrogens: The duration of bleeding was not altered significantly during or after therapy with e&radio1 benzoate or estriol glucuronide. The alterations following employment of the other estrogens were not marked. Following treatment with estrone, the average duration of bleeding was reduced from 6.6 days prior to therapy to 5.0 days during and 4.4 days following cessation of treatment. Following treatment with estradiol dipropionate, the average duration of bleeding was increased from 4.6 days prior to therapy to 5.3 days during treatment, and 3.4 days following cessation of treatment. No marked alterations occurred in the amounts of bleeding during therapy or subsequent to its cessation. B. Nonhormonal Estrogen (Dieth.ylstilbestrol): Following therap;\ with diethylstilbestrol the duration and the amount of bleeding tended to parallel the changes in the lengths of the cycles. 4. Efects Upon Withdrawal Time.-The criterion employed for withdrawal bleeding was the occurrence of episodes of bleeding within a few days after cessations of therapy, and considerably in advance of expected dates of bleeding. A. Hormonal Estrogens: No instance of withdrawal bleeding followed therapy with hormonal estrogens. B. Nonhormonal Estrogen (Diethylstilbestrol): The withdrawal times could be evaluated in 14 cycles of 7 patients. They ranged from two to eight days, the a.verage being six days. The average length of the involved cycles was 19.5 days. 5. Efects Upon the Urinary Excretion of Sodium Pregnanediol Glucuronide.-A. Hormonal Estrogens: The urinary sodium pregnanediol
2 3 1 5 G
1
CASE NO.
-
1
+ l'hel‘ap?,
e-M edd-E e.M e-M e-M cdb-M edd-E e-0 e-0 edd-0 e.M e-M es-0 edd-M CM e-0 PS-0 __~-
- --
--
-
edA, Estradio7 dipropionate edb, Estradiol benzoate e, Estrone es, Estriol glucuronide stb, Djethylstilbestrol OKs. SO therap?., but (l:lt;l
1 2 1 1 1 1 1 2 3 4 1 1 2 1 1 2 ::
SERIES Ok' THER.\FT
on cycle
ORx-0 ORx-MORx-M ORX-0 es-o W-M ORs-0 edb-E R-M ORs-0 ORs-0
2 es-Mt ORs-0 e-M e-M
-
ORs-0 ORx-0 C&l-0 e-0 ORS-Cl
ORx-E
ORx-0
3 edd-E
,,
an<1 blt?c,ling
-
*
/
8,
.“,
OR.x-0
ORx-0
obtained
OKX-M+
-
*,
0,
G
No
t)iol).q
7
Olis-0
--~-
I
I I I
_-
0Xx-O
s
___of E~~~do~~~t?t~inl Res))axacs cstrogenic response or hyperestrogenic response irregular (patchy) progestation irregular (patchy) progestation irregular (patchy) progestation (immature) regular progestation progestation (decidualikr,) progcstatinn
-
STUDIED
ClGSsifiCnt~o~~
ORX-0
()Iis-0
CYC'LES
E, Moderate IS+, Marked M-, Minimal. M, Moderate, M+. Marked. I’-. Minimal I’. Normal I’+. Marked
cc IN! 3ECUTIVE - _. 5 -ORx-P
ORx-0 ORx-P
4 edd-P
9
10
2R 29 30
27
ii 23 24 25 26
20
19
17 18
16
12 13 14 15
11
1 1 1 1 1 2 1 2 1 1 2 1 2 1 1 1 1 1 1 1 2 1 2 1 1 1 2 3
-
1
e-P edd-M e-0 es-0 edd-0 es-0 ed b-0 es-0 es-0 stb-P edb-E stb-0 stb-E stb-M+ stb-0 stb-E stb-E &b-E stb-P stb-E &b-O stb-0 stb-0 stb-0 &b-O stb-0 stb-0
e-M
i
ORx-P stb-0 ORX-0 ORx-0 ORx-E stb-E
ORx-0
stb-0
0Xx-P ORx-0 stb-0 stb-0 ORX-p 0X3x-P &b-P
stb-E stb-E
edb-0
-
stb-P+
ORx-P
stb-0
ORx-M ORx-0
ORx-0
ORx-0 es-0 ORx-0
ORx-0
ORx-0 ORx-0 ORx-P es-0 ORx-0
ORx-0
ORx-0
e-0
e-0
&b-O stb-E stb-E stb-0
edd-RI ORX-P edb-0 .0Xx-O ORx-0 ORx-0 es.0 OBX-0 &b-O edb-P
e-0
-
ORX-M
ORx-0
ORx-Et ORx-0
ORX-0 es-0
ORx-0
ORs-0
I
ORx-0
ORx-0 ORs-0
ORx-0 ORx-0
ORx-0
I
ORx-0
ORx-M ORx-0
ORx-0 ORx-0
ORx-0
ORx-91
ORX-0
-
I
ORx-0
274
AMERICAN
JOURNAL
OF
OBR’I’ETRICS
AND
GYNECOLOGY
glucuronide excretions of 3 patients prior to and during treatment were determined. The amounts excret,ed prior to therapy were 36 nrg., 29 mg., and 0.0 mg., respectively, and during treatment 53 mg., 14 mg., and 17 mg., respectively. The pat,ient who escrel.cd 14 mg. of Ihe pregnanediol complex during therapy bled from an rst,rogenic cndometrium al. the termination of that particular cycle. The number of determinations per patient cycle averaged 18 prior to l.hcrap,v ant1 17 during therapy. B. Nodaormonnl Estrogen (Di~lh~Jlstilbt.si~olj : Levels oi’ sndiunr pregnanediol glucuronide excretion of 6 patients were established prior, t,o and during treatment. Only 2 patients excreted the pregnunediol complex prior to l.herapy and none during therapy. Estrogcnir (bnilometriums terminated three 0P these trcatmcnt, cqles. The number of determinations per paIirnt r~~+lc avcrngsed IS pAor to therapy 311~1151 during treatmenl. Discussion The contraphysiologic employment of moderately small doses oi’ hermonal and nonhormonal estrogens in women with normal ovarian function produced definite effects upon the menstrual cycle. As a group, the hormonal estrogens exerted little depressing effect. upon corpus luteum function. Estradiol dipropionate, however, which was given in the largest amounts, yielded definitely depressing c%ecls. The group percentage of estrogenic endometriums during theral)y ws 16.7 while in the instance of estradiol dipropionate it was grossly 50 1)(‘1’ c~tnt, and on analysis 66.7 per cent. I)iethylstilbestrol, even in the small amounts used, also drprc~cd corpus lnteum function. During therapy with this estrogen 66.7 pe1 cent of all the endometria,l responses studied were estrogenica while 62.5 per cent, of the endometriums at the termination of the first IY&merit cycles were estrogenic. Milligram for milligram dietl~ylst,ilbestrol was given in larger daily doses than the hormonal estrogens. In those cycles, however, in which therapy was given during the first half (fifth to fourteenth day) and from which most of the endometrial data were obtained, diethylstilbestrol was given in amounts of 1 to 2 mg. daily and estradiol in amounts of 1.5 mg. daily. Not only were the doses in milligrams similar hut also the effects on corpus luteum function were similar, 66.7 per caent depression in each instance. The fact that these effects were observed with the two estrogens which were given in largest amounts makes ii probable that use of the other estrogens would have yielded similar results if comparable doseshad been employed. The relative potencies of the various estrogens remain, as yet, COW troversial. From our data it appears that, diethylstilbest,rol in daily dosesof 1.0 mg. during the first half of the cycle is as effective in depressing corpus luteum function as 1.5 mg. of estradiol dipropionatt:. From other work by our group not yet reported and from the literature Table III,4 which summarizes relative potencies, has been compiled.
HAMBLEN TABLE
III.
ET RELATIVE
AL. :
EFFECTS
POTENCIES
RELATIVE
1.0 mg.
estradiol
1.5 mg.
estradiol
2. Vaginal smears’
1.0
estradiol
::. Hemostasis
1.0 mg.
sion of corpus luteum function
1.0
mg.
mg.
ESTROGENIC
OF ESTROGENS
CRITERIA I.. Depres-
4. Manufacturer
OF
IN
THE
HUMAN
3.0 mg. estrone = 0.67 mg. or on the basis of effective dosage = 4.5 mg. estrone = 1.0 mg.
estradiol
2.4
=
estradiol
mg.
3.0 mg. =
5.5
FEWALE
POTENCIES
=
=
275
THERAPY
=
diethylstilbestrol
estrone -= 5 to 6 mg. (daily doses)
diethylstilbestrol
e&one
=
1.2
diethylstilbestrol
mg.
mg.
estrone
diethylstilbestrol
2.3
mg.
diethylstilbestrol
‘s
ClSlittlS*
*Stoddard
and
Metzger:
J.
Clin.
Endocrinology
2:
209,
1942.
Following cessation of therapy with the hormonal estrogens, progestational endometriums were encountered in 87.5 per cent of the cycles. One of the patients who had progestational endometriums following cessation of treatment, had had 4 consecutive cycles of therapy, Following discontinuation of therapy with diethylstilbestrol 80 per cent of the endometriums was progestational. Thus, no permanent depressions of ovarian function followed therapy of the order given by us. Larger dosages of estrogens and more prolonged therapies might alter this finding. The modus operandi of the temporary impairment of ovarian funcCon described is probably one of pituitary depression. Therapy with estradiol benzoate and dipropionate was associated with shortening of the cycle lengths as is shown by the gross averages and the average deviations. H&man5 in a recent article computed the standard deviation of the normal cycle to be k2.2 days. Our average deviations were -7.1 days for estradiol dipropionate and -3.1 days for the benzoate. It is apparent that the effect of the benzoate was hardly significant while that of the dipropionate is quite significant. Here again the difference in effect is in all probability due to the employment of larger doses of the dipropionate. That there were no changes in the cycle lengths during therapy with estrone and estriol glucuronide is probabfy due to the smaller doses used. Since it is the estrogenic phase of the cycle which determines cycle length, the shortening of the cycle lengths during therapy with estradiol dipropionate would presumably be explained on the basis of depression of ovarian function, the occurrence of which has been established by the reversed endometrial responses during therapy. The assumption that shortening of the cycle lengths is due to decreased ovarian function, and thereby a decreased production of estrogens, does not hold true. Such an assumption is similar to sayin, 0 that a short menstrual cycle is indicative of a low level of ovarian function and a long cycle of a high leve1 of function. The additional supply of estrogen given as
276
AMERICAN
JOURSziL
OF
OBSTETRICS
AXD
GYNECOLOGY
therapy most certainly is metabolized and it is impossible to concclive of a. lack in the amount of available estrogen. Ovulation is not a factor in cycle length because the cpcles wer(‘ shortened whether ovulations and progestational responses occurred or not. Ttw q-de lengths were not shortened, as a rule, to the extent that a. withdrawal effect, could be postulated. A possible explanation is Ihal 1he increased supply 0C estrogen causes mme I*apid pPolifet&ion 211~1fliaturittittn of thy t’ti(l~)metrium with a decr~sc in length oi’ the cst,rogenic phase of the cycle. The entire effects of therapy on the c*yclc lengths, therefore, doubtlessly occur at the endometrial level. Diefhyl.stilbestrol ihcrapy ~)roducccl a 11umber of effects on cycle lengths. The cycles ol’ same patients were shortened while others were lcngthenrd. In gs(‘n~ri~I, those patients whoscfi qTle lcng~hs \V1’1!?long before trcntnlent mrt: shrtcned dwing trea lmer11~ and those w-hkh were short before treatment were lengthened during treatment. Of the group of 5 paCents who had changes in both directions, the average cycle length before treatment was 28.0 days and the average deviation of all cycles during treatment was +4.6 days. This sI~ows a significant trend toward lengthening. There is 110 correlation of these l.ariations with dosage, and there is no obvious explanation for t.hcm. It is also intercst,ing but not explained that the duration of bleedin g episode+ should vary with the changes in cycle lengths. Despite the fact that no persistent ill effects of therapy have ijecn encountered, these findings do not, warrant; any conclusions with regard to the ultimate results Ihat, might foliow protracted therapy with ia,rger doses of either hormonal or nonhormonal estrogens.
Summary and Conclusions Moderately small doses of hormonal estrogens (estronca, rastradio1 bcnzoate and dipropionate, and esi.riol glnruronide) and oc a 11011. hormonal estrogen (diethylstilbestrol) were administered contraphysiologically to 30 women who had normal ovarian function. The hormonal estrogens, with the exception of estradiol dipropionate, had no depressing effect upon corpus lul-cum I’nnction, presumii.ijly because of insufficient. dosage. Estradiol dipropionate which was given in larger dosages pi*oduced definite depacssion of ciorpus lnteulll funrt,ion which was equal in degree to the depression produced d[Gn g therapy with diethylst,ilbestrol. Both of these estrogens were given in c;imilnr doses in terms OP milligrams and each produced dcpre&on of corl~us lntsnm function in 66.7 pc~r cclnt, of the t,rea,tment cycles. Definite and qnanlitativc altcr;lt,ic~lls ill the mc~nst~rnal c*y~l~ \verc o/.)served during i,hcrapy with those estrogens which were pivrn in la.rger doses. The changes with dictllylstilhest,rol were marked by their lack of uniformity.
SIEGLER AND BAUER:
EVALUATION
OF PREGNAKEDIOL
COMPLEX
277
The following conclusions seem warranted : 1. Certain hormonal estrogens (estradiol) if given intramuscularly in adequate amounts will depress corpus luteum function. 2. Diethylstilbestrol, even in the moderately small amounts used by mouth, will depress corpus luteum function. 3. This depressing effect is not cumulative and does not persist after therapy. 4. The only direct effect of therapy on the ovarian level of function was the depression of corpus luteum function. 5. The other effects of therapy, i.e., on the cyclicity and duration of bleeding, probably resulted from action directly on the endometrium. We acknowledge the cooperative aid of the group of healthy women studied. Part of the expenses of these studies was defrayed from grants to one of us (E. C. II.) from the Research Council of Duke University, from Ayerst, McKenna and Harrison, Ltd., Montreal, Canada, and from Schering Corporation, Bloomfield, N. J.
References 1. Hamblen, E. C., Cuyler, W. Ii., Pattee, (1. J., and Axelson, G. J.: J. Clin. Endocrin. 1: 211, 1911. 2. Hamblen, E. C., Hirst, D. V., and Cuyler, W. H.: Ani. J. OBST. & GYNEC. In press. 3. Venning, E. H.: J. Biol. Chem. 26: 595, 1938. 4. Cuyler, W. K., Hamblen, E. C., and Davis, C. D.: J. Clin. Endocrin. 2: 453, 1942. 5. Haman, J. 0.: Aat. J. OBST. & GYXEC. 43: 871, 1943. (Section
II
of
this
paper
will
be published
in
the
AN EVALUATION OF THE PREGNANEDIOL INDEX OF OVARIAN AND UTERINE
March
issue.)
COMPLEX AS AN FUNCTION
SAMUEL 1~. SIEGLER, M.D., P.A.C.S., 'AND DAVID BBUER, M.S., M.D. BROOKLTK, N. T. (Prom
T
the Endocrine
and
Sterility
Clinics
of the Unity
Hospital)
HE corpus luteum and its hormones were early. recognized as playing important roles in the complex metabolic and endocrine relationships in the human female. However, it was not until Marrianl isolated pregnanediol from the urine of pregnant women in 1929, that extensive studies were undertaken to elucidate the nature of its significance. Subsequently, Venning and Browne2 contended that pregnanediol was a degradation product of progesterone and devised a Their studies indicated method for its quantitative determination. that pregnanediol was excreted only during the secretory phase of the menstrual cycle. It was suggested therefore that such determinations might afford both a valuable diagnostic index of ovulation and a gauge of the duration and functional activity of the corpus luteum.