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Evaluation of an Estrogen, Androgen, Estrogen-Androgen Combination, and a Placebo in the Treatment of the menopause
Department
of: Reviews and Abstracts Selected Abstracts Cei3mxi.n Section
Harris,
Joseph M., Rosenblum, Gordon, Ginsburg, Bear1 L., Stollman, Bernard I)., and Fenmore, Milton S.: The Case for Reevaluation of Indications for Cesarean Section, West. J. Surg. 59: 337, 1951.
The time has come, say the authors, to re-evaluate the indications for cesarean section. The general attempt of obstetricians to limit the incidence of cesarean section to 6 per cent or less has resulted in a persistent high mortality for the fetus and an avoidable maternal trauma. Midforceps operations, which until recently have been considered standard obstetrical procedures, should be eliminated. The routine management of the primipara with breech presentation by cesarean section is advocated. Indications for cesarean section should be liberalized and extended, the ultimate goal being the elimination of all traumatic vaginal deliveries. The discriminatory regulation which requires consultation prior to performing any cesarean section appears to the authors ill advised and tends toward procrastination and makes eesarean section a unique operation. In a series of 2,070 eesarean sections performed at the Cedars of Lebanon Hospital only one mother died, a maternal mortality of less than 0.05 per cent. One thousand nine hundred twenty-one consecutive cesarean seotioms were performed without a maternal death. Fetal mortality during a 13-year period from 1937 to 1950 was 3.13 per cent for vaginal deliveries as compared to 2.99 per cent for cesarean sections. There was a maternal morbidity of 14.04 per cent in the last series of 2,070 cesarean sections. In this report the most common indication for operation was cephalopelvic disproportion which made Previous cesarean section is up approximately one-half of the indications for operation. always an indication for a repeat operation in subsequent pregnancies. Uterine bleeding of placental origin made up approximately 30 per cent and fetal indications provided It is felt that cerebral trauma to babies about 5 per cent of the indications for operation. producing delayed sequelae such as spaetic paralysis and mentally defective individuals can be in large part avoided by liberalizing the indications for the cesarean operation. This paper created much diseussion at the Pacific Coast Obstetrical and Gynecological Many and varied were the opinions expressed. The dismeeting at which it was read. cussion ranged all the way from serious criticism and conscientious objection to the suggestion that perhaps some day all women might be delivered by eesarean section. However, the discussers seemed to agree that the time has come for the elimination, in so far as it is possible, of the traumatic vaginal delivery. Cesarean section is to be preferred to any operation other than the simplest type of low forceps delivery. WILLIAM
BICKERS
Endocrinology Greenblatt, Robert B., Barfield, W. E., Garner, Calk, of an Estrogen, Androgen, Estrogen-Androgen Treatment of the Menopause, J. Clin. Endocrinol. mg.
Four tablets identical of diethylstilbestrol,
in appearance were prepared, another containing 0.25 mg. 117” i
and Harrod, J. P., Jr.: Evaluation Combination, ad a Placebo in the 10: 1547, 1950. one of
a placebo, diethylstilbestrol
one
containing 0.25 and 5 mg. of
Volume 63 Number 5
. SELECTED
ABSTRACTS
1173
methyltestosterone, and still another containing 5 mg. of testosterone. The tablets were designated as A E-1,2,3, and 4 and the contents were unknown to both the physicians and the patients in order to avoid any influence of pre-existing prejudice in evaluating the results of treatment. A course of therapy consisted of three tablets a day for thirty days after which time the medication was switched to another of the preparations either immediately or after a short wait so that the original symptoms might return. One hundred two patients, both private and clinic, with menopausal symptoms, ranging in age from 23 to 62 years, the average being 44 years, were exposed to 284 courses of therapy. Subjective changes such as “hot flushes,” insomnia, formication, nervousness, and changes in libido; and further objective factor~s revealing vaginal cytologic changes, vaginal bleeding, breast turgidity, pelvic congestion, and acne were the criteria used in evaluating the result of the four different types of therapy. When stilbestrol alone was being taken, 96.9 per cent of the patients were relieved of menopausal symptoms but 30.5 per cent complained of nausea and 34.2 per cent experienced bleeding from an intact uterus. Eighty-nine and six-tenths per cent of the patients receiving stilbestrol and testosterone obtained the same relief from menopausal symptoms but in addition there was a higher incidence of a sense of well-being and increased libido. Also there was a significant decrease in the amount of nausea, breast turgidity, and pelvic congestion. Mild acne, hoarsness, or increase in facial hair growth wae produced by this therapy in 13.2 per cent of the cases, but these masculinizing effects regressed soon after the therapy was discontinued. In both of the preceding courses of therapy the improvement in the hypoestrogenic vaginal smear was a constant finding. The courses of therapy with testosterone alone were interesting, in that no vaginal cytological changes appeared when it was the initial therapy and proportionately few patients experienced relief of symptoms. However, when used subsequently to estrogen or estrogen and testosterone treatment the improvement in symptomatology and vaginal cytology was apparently perpetuated. The response to placebo therapy was, as was to be expected, disappointing. It was concluded .that the combination of estrogen and androgen gave, all factors considered, the best results. C. J. EHRENBEFN Greenblatt, Robert B., and Barfield, William B.: The Effect Uterine Bleeding, J. Clin. Endocrinol. 11: 821, 1951.
of Intravenous
Estrogen
in
One of the authors (Greenblatt) previously has described functional uterine bleeding as bleeding which occurs because of physialogic disturbances and not because of pathologic processes. Consequently, in the present study organic and systemic causes of uterine bleeding were ruled out, such as malignant neoplasm,s, cervical polyps, pregnancy states, Horblood dyscrasias, infection, and metabolic disturbances such as hypothyroidism. monal dysfunction is considered the chief cause of functional uterine bleeding, although nutritional, vitamin, nervous, and psychological factors may be contributory. Pelvic inflammatory dmease, endometriosis, endometrial polyps, and uterine myomas may be included in the category of functional bleeding because the response to therapy is similar to that of excessive uterine bleeding which is purely functional and it is postulated that the mechanism of bleeding may be the same. Menstruation is believed to be the result of hormonal (estrogen and progesterone) withdrawal after the proper sequence conditioning of the endometrium, although ovarian dysfunction, which may be primary or secondary to abnormal pituitary or hypothalamic states resulting in unruptured follicle, may produce endometrial bleeding after withdrawal of prolonged estrogenic stimulation. It is pointed out that abnormal uterine bleeding or amenorrhea may occur in the face of proliferative, hyperplastic, progestational, acyclic, or atrophic endometria. Hemostatic control while satisfactory with estrogen, progesterone, and testosterone, alone or
of: Reviews and Abstracts Selected Abstracts Cei3mxi.n Section
Harris,
Joseph M., Rosenblum, Gordon, Ginsburg, Bear1 L., Stollman, Bernard I)., and Fenmore, Milton S.: The Case for Reevaluation of Indications for Cesarean Section, West. J. Surg. 59: 337, 1951.
The time has come, say the authors, to re-evaluate the indications for cesarean section. The general attempt of obstetricians to limit the incidence of cesarean section to 6 per cent or less has resulted in a persistent high mortality for the fetus and an avoidable maternal trauma. Midforceps operations, which until recently have been considered standard obstetrical procedures, should be eliminated. The routine management of the primipara with breech presentation by cesarean section is advocated. Indications for cesarean section should be liberalized and extended, the ultimate goal being the elimination of all traumatic vaginal deliveries. The discriminatory regulation which requires consultation prior to performing any cesarean section appears to the authors ill advised and tends toward procrastination and makes eesarean section a unique operation. In a series of 2,070 eesarean sections performed at the Cedars of Lebanon Hospital only one mother died, a maternal mortality of less than 0.05 per cent. One thousand nine hundred twenty-one consecutive cesarean seotioms were performed without a maternal death. Fetal mortality during a 13-year period from 1937 to 1950 was 3.13 per cent for vaginal deliveries as compared to 2.99 per cent for cesarean sections. There was a maternal morbidity of 14.04 per cent in the last series of 2,070 cesarean sections. In this report the most common indication for operation was cephalopelvic disproportion which made Previous cesarean section is up approximately one-half of the indications for operation. always an indication for a repeat operation in subsequent pregnancies. Uterine bleeding of placental origin made up approximately 30 per cent and fetal indications provided It is felt that cerebral trauma to babies about 5 per cent of the indications for operation. producing delayed sequelae such as spaetic paralysis and mentally defective individuals can be in large part avoided by liberalizing the indications for the cesarean operation. This paper created much diseussion at the Pacific Coast Obstetrical and Gynecological Many and varied were the opinions expressed. The dismeeting at which it was read. cussion ranged all the way from serious criticism and conscientious objection to the suggestion that perhaps some day all women might be delivered by eesarean section. However, the discussers seemed to agree that the time has come for the elimination, in so far as it is possible, of the traumatic vaginal delivery. Cesarean section is to be preferred to any operation other than the simplest type of low forceps delivery. WILLIAM
BICKERS
Endocrinology Greenblatt, Robert B., Barfield, W. E., Garner, Calk, of an Estrogen, Androgen, Estrogen-Androgen Treatment of the Menopause, J. Clin. Endocrinol. mg.
Four tablets identical of diethylstilbestrol,
in appearance were prepared, another containing 0.25 mg. 117” i
and Harrod, J. P., Jr.: Evaluation Combination, ad a Placebo in the 10: 1547, 1950. one of
a placebo, diethylstilbestrol
one
containing 0.25 and 5 mg. of
Volume 63 Number 5
. SELECTED
ABSTRACTS
1173
methyltestosterone, and still another containing 5 mg. of testosterone. The tablets were designated as A E-1,2,3, and 4 and the contents were unknown to both the physicians and the patients in order to avoid any influence of pre-existing prejudice in evaluating the results of treatment. A course of therapy consisted of three tablets a day for thirty days after which time the medication was switched to another of the preparations either immediately or after a short wait so that the original symptoms might return. One hundred two patients, both private and clinic, with menopausal symptoms, ranging in age from 23 to 62 years, the average being 44 years, were exposed to 284 courses of therapy. Subjective changes such as “hot flushes,” insomnia, formication, nervousness, and changes in libido; and further objective factor~s revealing vaginal cytologic changes, vaginal bleeding, breast turgidity, pelvic congestion, and acne were the criteria used in evaluating the result of the four different types of therapy. When stilbestrol alone was being taken, 96.9 per cent of the patients were relieved of menopausal symptoms but 30.5 per cent complained of nausea and 34.2 per cent experienced bleeding from an intact uterus. Eighty-nine and six-tenths per cent of the patients receiving stilbestrol and testosterone obtained the same relief from menopausal symptoms but in addition there was a higher incidence of a sense of well-being and increased libido. Also there was a significant decrease in the amount of nausea, breast turgidity, and pelvic congestion. Mild acne, hoarsness, or increase in facial hair growth wae produced by this therapy in 13.2 per cent of the cases, but these masculinizing effects regressed soon after the therapy was discontinued. In both of the preceding courses of therapy the improvement in the hypoestrogenic vaginal smear was a constant finding. The courses of therapy with testosterone alone were interesting, in that no vaginal cytological changes appeared when it was the initial therapy and proportionately few patients experienced relief of symptoms. However, when used subsequently to estrogen or estrogen and testosterone treatment the improvement in symptomatology and vaginal cytology was apparently perpetuated. The response to placebo therapy was, as was to be expected, disappointing. It was concluded .that the combination of estrogen and androgen gave, all factors considered, the best results. C. J. EHRENBEFN Greenblatt, Robert B., and Barfield, William B.: The Effect Uterine Bleeding, J. Clin. Endocrinol. 11: 821, 1951.
of Intravenous
Estrogen
in
One of the authors (Greenblatt) previously has described functional uterine bleeding as bleeding which occurs because of physialogic disturbances and not because of pathologic processes. Consequently, in the present study organic and systemic causes of uterine bleeding were ruled out, such as malignant neoplasm,s, cervical polyps, pregnancy states, Horblood dyscrasias, infection, and metabolic disturbances such as hypothyroidism. monal dysfunction is considered the chief cause of functional uterine bleeding, although nutritional, vitamin, nervous, and psychological factors may be contributory. Pelvic inflammatory dmease, endometriosis, endometrial polyps, and uterine myomas may be included in the category of functional bleeding because the response to therapy is similar to that of excessive uterine bleeding which is purely functional and it is postulated that the mechanism of bleeding may be the same. Menstruation is believed to be the result of hormonal (estrogen and progesterone) withdrawal after the proper sequence conditioning of the endometrium, although ovarian dysfunction, which may be primary or secondary to abnormal pituitary or hypothalamic states resulting in unruptured follicle, may produce endometrial bleeding after withdrawal of prolonged estrogenic stimulation. It is pointed out that abnormal uterine bleeding or amenorrhea may occur in the face of proliferative, hyperplastic, progestational, acyclic, or atrophic endometria. Hemostatic control while satisfactory with estrogen, progesterone, and testosterone, alone or