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Progestational Steroid Requirements for Inducing and Maintaining Decidua in Women
Progestational Steroid Requirements for Inducing and Maintaining Decidua in Women William C. Durham, M.D.
THE
is a continuation of studies begun with Bradbury et al. and reported to the American Society for the Study of Sterility in 1952 in Chicago. In that study, further observations were made on the daily dosages of the hormones progesterone and estrogen necessary to induce and maintain a decidual endometrium. It was found that larger intramuscular doses of progesterone are required when it is administered in oil solution (3~0 mg. daily) than when it is given as microcrystals (25 mg. daily) suspended in an aqueous medium. For augmenting the action of progesterone, stilbestrol and equilin were found to be about 5 times as potent as the conjugated estrogens and over 10 times as potent as pure sodium estrone sulfate. In this study, observations were made on the dosages of the newer progestational steroids and an estrogen required to induce and maintain a decidual endometrium in the normal menstruating woman. The study was very similar to the original one in that normal menstruating women between 18 and 40 yr. old in an institution were used as subjects; thus, environment was constant. Control endometrial biopsies were done at weekly intervals to establish normal cycles exhibiting secretory-phase endometrium. Therapy was begun between Days 11 and 18 of a normal 28- to 30-day cycle, preferably when the weekly biopsy showed early secretory-phase endometrium. Therapy STUDY REPORTED IN THIS ARTICLE
This study was supported in part by a grant from The Upjohn Company to the author. Presented at the Sixteenth Annual Meeting of the American Society for the Study of Sterility, Cincinnati, Ohio, Apr. 1-3, 1960. We wish to acknowledge our appreciation to Mrs. Elizabeth Jenkins and Mrs. Mary Booker, nurses at Central State Hospital, Lakeland, Ky., who were so conscientious in their special care of these patients.
46
DURHAM
Fertility & Sterility
begun later was ineffectual. Figure 1 illustrates the plan of study of each patient, showing how she acted as her own control.
PLAN OF STUDY The study was divided into two parts. In the first part, the estrogen, mainly diethylstilbestrol, was administered orally, and the progestational compounds were also given orally. Stilbestrol was selected primarily because of its proved potency in our previous studies. This was a constant factor throughout the study. The oral progestational compounds tested included Enovid # and Norlutinf of the 19-nor progestational steroids and Proverai (17-alphahydroxy-6-alpha-methylprogesterone acetate). In the second part of the study the same estrogen was given orally, and the progestational compounds, 6-alpha-methyl-17 -alpha-acetoxyprogesterone (Provera) and 17 -alphahydroxyprogesterone-caproate (Delalutin§) were given intramuscularly. An injectable estrogen, Delestrogen, § was also tested with Delalutin and with Provera in the second part of the study. Because most of the study patients had a normal menstrual rhythm and several had been observed in the previous study, it was possible to compare the response of the same patient to progesterone and the various new progestational compounds. Endometrial biopsies were obtained each week except during menstrual periods, and treatment was usually started after the endometrium revealed proliferative or early secretory changes. This usually corresponded to Days 11-18 of the cycle in the majority of the patients. Bright red bleeding was the only indication for discontinuing therapy. Intermittent brownish staining was not a sufficient indication as long as decidual changes were demonstrated in the biopsy. RESULTS Oral Progestational Compounds
Enovid (norethynodrel and ethynlestradiol3-methyl ether; Fig. 2). Because of its estrogen content, Enovid was tested alone and also supplemented with stilbestrol. Test doses of 10 and 20 mg. alone, and 10 mg. plus 1 mg. of stilbestrol, were given on a daily schedule. Optimal decidual changes were maintained with the 20-mg. dose and the 1O-mg. dose plus 1 mg. of stilbestrol, * G. D. Searle & Co., Chicago.
t Parke, Davis & Co., Detroit. t The Upjohn Co., Kalamazoo, Mich. § E. R. Squibb & Sons, New York.
r
r
Vol. 12. No.1. 1961
PROGESTATIONAL STEROIDS
47
evidently hecause of the increased amounts of estrogen needed to supplement the progestin. At least three to five trials were made at each dosage level. To demonstrate the estrogenic effect of Enovid, 2 postmenopausal subjects, aged 72 and 78, respectively, were given Enovid alone without estrogen priming. A decidual endometrium was obtained in 1 patient after 13 wk. and in the other patient at the end of 11 wk. of therapy. However, the dose for the former patient was increased to 20 mg. daily at the beginning of the eighth week. Apparently satisfactory priming resulted from the estrogen present in Enovid. The 78-yr.-old subject then had a vaginal hysterectomy. The decidual changes were not demonstrable because therapy had been discontinued in error 1 wk. before surgery. However, an apparent reactivation of an old adenomyosis was demonstrated. Mitotic figures were present in the glands. This patient had received 20 mg. of Enovid daily for 5 wk. before surgery and had 10 mg. daily for 7 wk. before the 20 mg. dose was started. Norlutin (norethinidrone; Fig. 3). A decidual endometrium could not be induced with Norlutin alone when given in doses of 5 mg. daily. In fact, the length of the menstrual cycle was not influenced at this dosage level. However, when the dose was supplemented with 1 mg. of stilbestrol daily, decidual changes were induced but could not be maintained longer than 3-4 wk. Larger doses were not tested, due to lack of adequate supplies of Norlutin. Possibly larger amounts would have yielded results similar to those for -_.Enovid plus stilbestrol. Provera (medroxyprogesterone acetate; Fig. 4). Because of its lack of estrogen content, Provera was supplemented with 1 mg. of stilbestrol daily. Test doses of 2.5, 10, 20, 30, and 40 mg. were given. In Patient V. W., 2.5 mg. failed to delay the onset of flow, and when this dosage plus stilbestrol was continued until the onset of the next bleeding episode, estrogen dominance was evident. Consistent induction and maintenance of decidual edometrium was not obtained until 40 mg. daily were given. Injectable Progestational Compounds
Delalutin (17 alpha-hydroxyprogesterone caproate; Fig. 5 and 6). Lacking estrogenic activity, Delalutin was supplemented daily with 1 mg. of stilbestrol orally; in several patients Delestrogen was given intramuscularly once weekly in place of daily stilbestrol. Dosages of 250 mg. (2ml.) and 375 mg. (3 ml.) of Delalutin were given once weekly. Fairly consistent results were obtained in 4 of 7 patients given 375 mg. of Delalutin weekly and 1 mg. of
48
Fertility & Sterility
DURHAM
oral stilbestrol daily. Patient C. C. maintained decidual changes for 11 wk. and remained amenorrheic for 16 wk. Delestrogen in a I-ml. dose did not seem to furnish sufficient estrogen supplement. However, the 2-ml. dose seemed to furnish adequate amounts for induction and maintenance of decidua, as demonstrated in this patient. Further trials are in progress to determine the optimal mixture of these two drugs that produces consistent results for longer intervals. Inpectable Provera (medroxyprogesterone acetate; Figs. 7-9). Because injectable Provera, an aqueous suspension of 17-alpha-hydroxy-6-alpha-methylprogesterone acetate, is devoid of significant estrogenic activity, it was supplemented with oral stilbestrol and Delestrogen intramuscularly. An arbitrary dosage of 25 mg. q.o.d. plus 1 mg. stilbestrol orally was given to a series of patients. A satisfactory decidual endometrium was induced and maintained in each case. Patient N. N. maintained a decidual endometrium for 23 wk. and remained amenorrheic for 26 wk. A dosage of 25 mg. twice weekly with stilbestrol induced decidual changes for 4 wk. before breakthrough bleeding KEY TO FIG. 1-9 • • • Menstrual period or episode of bleeding after treatment. Regularly spaced letters, denoting endometrial biopsies at 7-day intervals, indicate as follows: P Proliferative (estrogenic) endometrium S Secretory (progestational) endometrium D Decidual reaction HD Hemorrhagic decidua of areas of necrosis / No biopsy attempted ~ Early secretory endometrium with subnuclear vacuoles Mx Mixed type I Tissue insufficient for classification H Home on visit A solid vertical line indicates first secretory biopsy of cycle arbitrarily plotted at that point. Two broken vertical lines (10-14 days after solid vertical line) indicate interval of expected normal menses. I I Dosage and duration of treatment
CONTROL CYCLE
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TREATED CYCLE RECOVERY CYCLE
pI
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Fig. 1. Plan of study of each subject in the series, showing how each acts as her own control. Key to interpretation of this and all subsequent figures is given above.
PROGESTATIONAL STEROIDS
Vol. 12, No. 1, 1961
I I I
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Vaginal Hxsterectomx
Fig. 2. Results obtained when Enovid was given alone and supplemented with oral stilbestrol: 20 mg. alone or 10 mg. supplemented with I mg. of stilbestrol were most consistently effective. Two postmenopausal subjects were given Enovid alone to demonstrate the presence of sufficient estrogen for priming an atrophic endometrium and development of decidua.
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Fig. 4. Results obtained when oral Provera was given with stilbestrol. Forty mg. of Provera were required before decidual changes were maintained for short intervals. Further trials are being made.
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Fig. 5. Results obtained with Delalutin intramuscularly, 1 dose weekly, plus stilbestrol daily. For a constant response, 375 mg. were required. Patient C. C. maintained a decidual endometrium for 11 wk. and remained amenorrheic 16 wk.
.
Vol. 12, No. I, 1961
Delolutin
M.G.
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II
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51
SERIES
DELALUTIN
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PROGESTATIONAL STEROIDS
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Fig. 6. Results obtained when Delestrogen was substituted for stilbestrol. Two milliliters once weekly were required for supplementation of 375 mg. of Delalutin.
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Fig. 7. Results obtained with injectable Provera intramuscularly and oral stilbestrol daily, showing that 25 and 50 mg. q.o.d. with 1-2 mg. of stilbestrol were effective. Subjects M. C. and M. N. were amenorrheic approximately 6 mo.
52
DURHAM
Fertility & Sterility
(17 ~- hydroxy - 6 C(- methyl progesterone acetate)
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a
Feb. 10
Fig, 8, Results obtained when Provera was given twice weekly and once weekly. Twenty-five milligrams twice weekly were ineffective. Fifty milligrams twice weekly and 100 mg. once weekly were adequate, indicating repository effect in these doses. Patient E. B. had uneventful surgery during her treatment interval. Patients E. B. and A. L. have been amenorrheic for 7 and 5 mo., respectively.
(17 ex- hydroxy - 6o(.-methyl progesterone acetate)
J.J. /
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Oct. 14
1150 mg. Provero once wkly.
/
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/
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Feb. 16
I ~ discontinued 1/27160 due to illness
I
•
5 •"
•
/:•
o
o
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Fig, 9. Results obtained when 150 mg. of Provera were given once weekly with stilbestrol daily or Delestrogen once weekly. Patient J. J. bled for a normal interval 3 wk. after treatment was discontinued because of an acute illness. Amenorrhea was present 4 mo. during therapy. Patient K. K. is still under treatment with good response.
•
.
.
Vol. 12. No.1. 1961
PROGESTATIONAL STEROIDS
53
occurred. However, when the dosage was increased to 50 mg. twice weekly, a satisfactory decidual endometrium was maintained for 8 wk. in patient E. B. (Fig. 8). At this point, in an effort to demonstrate the repository effect of the compound, the dosage was changed to 100 mg. once weekly plus the usual daily dose of stilbestrol. A decidual endometrium was maintained for 16 wk. at this dosage. The patient underwent a herniorrhaphy at this time, and the dosage was changed to 150 mg. of Provera once weekly plus 2 ml. of Delestrogen once weekly. Delestrogen was substituted to obviate lack of tolerance for oral stilbestrol during the postoperative period. The patient is still under treatment, having been amenorrheic since July 19, 1959, a total of 8 mo. to date. Biweekly biopsies still show a decidual endometrium. Patient A. L. (Fig. 8) has been amenorrheic with a decidual endometrium since Sept. 23, 1959, on dosages of 100 mg. of Provera once weekly plus 1 mg. of oral stilbestrol daily, a total of 6 mo. This patient is still under treatment. Patients J. J. and K. K. (Fig. 9) were given 150 mg. of Provera intramuscularly once weekly plus the usual dosage of stilbestrol. A satisfactory decidual endometrium was induced and maintained for 10 wk. in Patient J. J. until treatment was discontinued because of an incidental episode of acute phlebitis of the lower leg. Withdrawal bleeding of normal duration occurred 3 wk. later. Delestrogen, 1 ml. weekly, was substituted for stilbestrol for 3 wk. prior to discontinuing the therapy. Patient K. K. is still under treatment and has been amenorrheic since Dec. 20, 1959, with a decidual endometrium for approximately 8 wk. to date. These results indicate that 100--150 mg. of progestational steroid in aqueous suspension match the effectiveness of 250-375 mg. of a progestational steroid in oil suspension. This is in keeping with the results of the previous study, in which doses of 35--50 mg. of progesterone in oil were necessary to match the effectiveness of 25 mg. of progesterone as microcrystals in aqueous suspension.
SUMMARY The experimental study was concerned with the determination of the amounts of the various available progestational steroids required to induce and maintain decidua. For the most part, women with normal menstrual records were used as subjects, and hormonal treatment was started between Days 11 and 18 of their cycles and was continued until bright bleeding was observed. Five sets of observations were made. In the first part of the study, the oral progestational steroids were given alone and supplemented with an oral estrogen. Under the conditions of this
54
DURHAM
Fertility & Sterility
study, Enovid in a dose of 20 mg. daily or 10 mg. daily, supplemented with 1 mg. of stilbestrol daily, induced and maintained a decidual endometrium. Norlutin alone was ineffective in 5-mg. doses. However, when it was supplemented with stilbestrol, a decidual endometrium was maintained for 3-4 wk. Larger doses were not given. Likewise, Provera alone was ineffective, but when S0-40 mg. daily were supplemented with the usual dose of stilbestrol, satisfactory induction and maintenance occurred. In the second part of the study, the injectable progestational steroids were given with an oral and an injectable estrogen. A dose of 100-150 mg. once weekly of the aqueous suspension of Prover a was required, whereas 250-S75 mg. once weekly of Delalutin in oil was necessary for satisfactory maintenance. This is in keeping with the results of a previous study in which larger amounts of crystalline progesterone in oil were required than progesterone in aqueous suspension. Further studies should be made to determine the reason for this difference.
CONCLUSIONS 1. Observations have been made on the dosages of the oral and the injectable progestational steroids necessary for the induction and maintenance of a decidual endometrium. 2. Larger intramuscular doses of a progestational steroid are required when it is administered in oil (250-375 mg. once weekly) than when a related preparation is given suspended in an aqueous medium (100-150 mg. once weekly). Both required estrogen supplementation. S. The oral progestational steroids require an estrogen supplement unless estrogenic activity is inherently present and can be obtained with large doses. 4. Further observations are needed to confirm these conclusions. Owens Medical Center 4122 Shelbyville Rd.
REFERENCES R. c., and BRADBURY, J. T. Induction and maintenance of decidual changes with progesterone and estrogen. ]. GUn. Endocrinol. 11: 134, 1951. 2. BRADBURY, J. T., LONG, R. C., and DURHAM, W. C. Progesterone and estrogen requirements to induce and maintain decidua. Fertil. & Steril. 4:63, 1953.
1.
LONG,
•
THE
is a continuation of studies begun with Bradbury et al. and reported to the American Society for the Study of Sterility in 1952 in Chicago. In that study, further observations were made on the daily dosages of the hormones progesterone and estrogen necessary to induce and maintain a decidual endometrium. It was found that larger intramuscular doses of progesterone are required when it is administered in oil solution (3~0 mg. daily) than when it is given as microcrystals (25 mg. daily) suspended in an aqueous medium. For augmenting the action of progesterone, stilbestrol and equilin were found to be about 5 times as potent as the conjugated estrogens and over 10 times as potent as pure sodium estrone sulfate. In this study, observations were made on the dosages of the newer progestational steroids and an estrogen required to induce and maintain a decidual endometrium in the normal menstruating woman. The study was very similar to the original one in that normal menstruating women between 18 and 40 yr. old in an institution were used as subjects; thus, environment was constant. Control endometrial biopsies were done at weekly intervals to establish normal cycles exhibiting secretory-phase endometrium. Therapy was begun between Days 11 and 18 of a normal 28- to 30-day cycle, preferably when the weekly biopsy showed early secretory-phase endometrium. Therapy STUDY REPORTED IN THIS ARTICLE
This study was supported in part by a grant from The Upjohn Company to the author. Presented at the Sixteenth Annual Meeting of the American Society for the Study of Sterility, Cincinnati, Ohio, Apr. 1-3, 1960. We wish to acknowledge our appreciation to Mrs. Elizabeth Jenkins and Mrs. Mary Booker, nurses at Central State Hospital, Lakeland, Ky., who were so conscientious in their special care of these patients.
46
DURHAM
Fertility & Sterility
begun later was ineffectual. Figure 1 illustrates the plan of study of each patient, showing how she acted as her own control.
PLAN OF STUDY The study was divided into two parts. In the first part, the estrogen, mainly diethylstilbestrol, was administered orally, and the progestational compounds were also given orally. Stilbestrol was selected primarily because of its proved potency in our previous studies. This was a constant factor throughout the study. The oral progestational compounds tested included Enovid # and Norlutinf of the 19-nor progestational steroids and Proverai (17-alphahydroxy-6-alpha-methylprogesterone acetate). In the second part of the study the same estrogen was given orally, and the progestational compounds, 6-alpha-methyl-17 -alpha-acetoxyprogesterone (Provera) and 17 -alphahydroxyprogesterone-caproate (Delalutin§) were given intramuscularly. An injectable estrogen, Delestrogen, § was also tested with Delalutin and with Provera in the second part of the study. Because most of the study patients had a normal menstrual rhythm and several had been observed in the previous study, it was possible to compare the response of the same patient to progesterone and the various new progestational compounds. Endometrial biopsies were obtained each week except during menstrual periods, and treatment was usually started after the endometrium revealed proliferative or early secretory changes. This usually corresponded to Days 11-18 of the cycle in the majority of the patients. Bright red bleeding was the only indication for discontinuing therapy. Intermittent brownish staining was not a sufficient indication as long as decidual changes were demonstrated in the biopsy. RESULTS Oral Progestational Compounds
Enovid (norethynodrel and ethynlestradiol3-methyl ether; Fig. 2). Because of its estrogen content, Enovid was tested alone and also supplemented with stilbestrol. Test doses of 10 and 20 mg. alone, and 10 mg. plus 1 mg. of stilbestrol, were given on a daily schedule. Optimal decidual changes were maintained with the 20-mg. dose and the 1O-mg. dose plus 1 mg. of stilbestrol, * G. D. Searle & Co., Chicago.
t Parke, Davis & Co., Detroit. t The Upjohn Co., Kalamazoo, Mich. § E. R. Squibb & Sons, New York.
r
r
Vol. 12. No.1. 1961
PROGESTATIONAL STEROIDS
47
evidently hecause of the increased amounts of estrogen needed to supplement the progestin. At least three to five trials were made at each dosage level. To demonstrate the estrogenic effect of Enovid, 2 postmenopausal subjects, aged 72 and 78, respectively, were given Enovid alone without estrogen priming. A decidual endometrium was obtained in 1 patient after 13 wk. and in the other patient at the end of 11 wk. of therapy. However, the dose for the former patient was increased to 20 mg. daily at the beginning of the eighth week. Apparently satisfactory priming resulted from the estrogen present in Enovid. The 78-yr.-old subject then had a vaginal hysterectomy. The decidual changes were not demonstrable because therapy had been discontinued in error 1 wk. before surgery. However, an apparent reactivation of an old adenomyosis was demonstrated. Mitotic figures were present in the glands. This patient had received 20 mg. of Enovid daily for 5 wk. before surgery and had 10 mg. daily for 7 wk. before the 20 mg. dose was started. Norlutin (norethinidrone; Fig. 3). A decidual endometrium could not be induced with Norlutin alone when given in doses of 5 mg. daily. In fact, the length of the menstrual cycle was not influenced at this dosage level. However, when the dose was supplemented with 1 mg. of stilbestrol daily, decidual changes were induced but could not be maintained longer than 3-4 wk. Larger doses were not tested, due to lack of adequate supplies of Norlutin. Possibly larger amounts would have yielded results similar to those for -_.Enovid plus stilbestrol. Provera (medroxyprogesterone acetate; Fig. 4). Because of its lack of estrogen content, Provera was supplemented with 1 mg. of stilbestrol daily. Test doses of 2.5, 10, 20, 30, and 40 mg. were given. In Patient V. W., 2.5 mg. failed to delay the onset of flow, and when this dosage plus stilbestrol was continued until the onset of the next bleeding episode, estrogen dominance was evident. Consistent induction and maintenance of decidual edometrium was not obtained until 40 mg. daily were given. Injectable Progestational Compounds
Delalutin (17 alpha-hydroxyprogesterone caproate; Fig. 5 and 6). Lacking estrogenic activity, Delalutin was supplemented daily with 1 mg. of stilbestrol orally; in several patients Delestrogen was given intramuscularly once weekly in place of daily stilbestrol. Dosages of 250 mg. (2ml.) and 375 mg. (3 ml.) of Delalutin were given once weekly. Fairly consistent results were obtained in 4 of 7 patients given 375 mg. of Delalutin weekly and 1 mg. of
48
Fertility & Sterility
DURHAM
oral stilbestrol daily. Patient C. C. maintained decidual changes for 11 wk. and remained amenorrheic for 16 wk. Delestrogen in a I-ml. dose did not seem to furnish sufficient estrogen supplement. However, the 2-ml. dose seemed to furnish adequate amounts for induction and maintenance of decidua, as demonstrated in this patient. Further trials are in progress to determine the optimal mixture of these two drugs that produces consistent results for longer intervals. Inpectable Provera (medroxyprogesterone acetate; Figs. 7-9). Because injectable Provera, an aqueous suspension of 17-alpha-hydroxy-6-alpha-methylprogesterone acetate, is devoid of significant estrogenic activity, it was supplemented with oral stilbestrol and Delestrogen intramuscularly. An arbitrary dosage of 25 mg. q.o.d. plus 1 mg. stilbestrol orally was given to a series of patients. A satisfactory decidual endometrium was induced and maintained in each case. Patient N. N. maintained a decidual endometrium for 23 wk. and remained amenorrheic for 26 wk. A dosage of 25 mg. twice weekly with stilbestrol induced decidual changes for 4 wk. before breakthrough bleeding KEY TO FIG. 1-9 • • • Menstrual period or episode of bleeding after treatment. Regularly spaced letters, denoting endometrial biopsies at 7-day intervals, indicate as follows: P Proliferative (estrogenic) endometrium S Secretory (progestational) endometrium D Decidual reaction HD Hemorrhagic decidua of areas of necrosis / No biopsy attempted ~ Early secretory endometrium with subnuclear vacuoles Mx Mixed type I Tissue insufficient for classification H Home on visit A solid vertical line indicates first secretory biopsy of cycle arbitrarily plotted at that point. Two broken vertical lines (10-14 days after solid vertical line) indicate interval of expected normal menses. I I Dosage and duration of treatment
CONTROL CYCLE
p
p
5o
/
p
p
I
5:
TREATED CYCLE RECOVERY CYCLE
pI
p
p
Fig. 1. Plan of study of each subject in the series, showing how each acts as her own control. Key to interpretation of this and all subsequent figures is given above.
PROGESTATIONAL STEROIDS
Vol. 12, No. 1, 1961
I I I
rj
Mxl
/:
0
49
I
0
HO
/
/
I
0
0
N.S. (cont'd)
/
/
0
(cont'd)
Started Nov. 18th - day 5-6 of cycle
/
0
/
NO
discontinued Mar. 5
F.H.
p
/
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Il0mg.daily
B.K AGE 72
0
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10/16
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0
0
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Img.stilbesterol daily-doy II of cycle
/
I
/
/
/
I
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1/8
0
B.K. (cont'd) /
2/12
/
/
/
/
/
10/23
/
AGE 78
I
/
/
/
Prolif. Stromal Hyperplasia - -
I
10 m2. daily
D.A.
/ (cont'd)
10 m2. daily
/
/
/
I
I
10 mg. daily
1/8
0
D.A. (cont'd)
0
/ 20 mg. daily
/
/ (cont'd)
Vaginal Hxsterectomx
Fig. 2. Results obtained when Enovid was given alone and supplemented with oral stilbestrol: 20 mg. alone or 10 mg. supplemented with I mg. of stilbestrol were most consistently effective. Two postmenopausal subjects were given Enovid alone to demonstrate the presence of sufficient estrogen for priming an atrophic endometrium and development of decidua.
M.N. /
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s 5m I I
M.V.
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/
p
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. sti Ibesterol dail
E.B.
I I I I
Dl
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. stilbesterol dail Fig. 3. Results obtained with Norlutin alone and with stilbestrol. Stilbestrol augmentation was necessary to induce and maintain decidua for a short period.
+
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51 30 m9·
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20 mg.
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40 mg.
-
A.L.
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/
35 day cycle
1 .L....
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I mg. sti I besterol daily p p p P P:I
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Fig. 4. Results obtained when oral Provera was given with stilbestrol. Forty mg. of Provera were required before decidual changes were maintained for short intervals. Further trials are being made.
c:::J M.G._
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p
I mg. stilbesterol orally, daily
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51
5
250 mo·
L~I
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I dose I.M. weekly
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2 mg. I stilbesterol
1
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3 mg. 5lrlbesterol 25 mg. De a utln
50
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375 mg.
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M.N.
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G.C. (cont'd) =;;;;0=;;;;;:;;0;;;;:=~0~~ __ 375 mg. I
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375 mlJ·
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Fig. 5. Results obtained with Delalutin intramuscularly, 1 dose weekly, plus stilbestrol daily. For a constant response, 375 mg. were required. Patient C. C. maintained a decidual endometrium for 11 wk. and remained amenorrheic 16 wk.
.
Vol. 12, No. I, 1961
Delolutin
M.G.
.
+ Delestrogen
II
P
/
I
I
+ /
S
/
/
I
MX'I
S
Delalutin 375 mg.
F.L.
pelestrogen I ee. I I
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Delalutin 375 mg. I
G.C.
s
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/
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0
Delalutin 375 mg.
I
51
SERIES
DELALUTIN
•
•
PROGESTATIONAL STEROIDS
+
I
+
Delestrogen Icc. I I
I I
I I
0
Mxl
I
0
0
0:
0
De lestrogen 2 ee. I I
G.C. (eont'd)
I
0
Fig. 6. Results obtained when Delestrogen was substituted for stilbestrol. Two milliliters once weekly were required for supplementation of 375 mg. of Delalutin.
(Aqueous suspension of 17oc-hydroxy-6oc.-methyl progesterone ) acetate
M.G.
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P
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!
D!
D
D
D
D
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/
. stilbesterol doil
D HD
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M.G. cont'd
/
/
HD
/
/
M.G. conrd
D
Sept. 29
D
/
/
/
D
/
HD
/
D
/
/
/
D
/
D
Fi
M.N. cont'd
/ M.N. cont'd
D
/
stopped Oct. 28, 1959
Fig. 7. Results obtained with injectable Provera intramuscularly and oral stilbestrol daily, showing that 25 and 50 mg. q.o.d. with 1-2 mg. of stilbestrol were effective. Subjects M. C. and M. N. were amenorrheic approximately 6 mo.
52
DURHAM
Fertility & Sterility
(17 ~- hydroxy - 6 C(- methyl progesterone acetate)
/
P
§
S!
/!
/
0
/
25 m .Provero twice wkl .+ 1m. stllbesterol dOli
D
/
/
0
D
/
100 mg.
D E.B. Cont'd
/
/
D
D
/
/
100 !!!S. Provero once
weekl~
D
/
/
D
/
/
+ I mg. stilbesterol doil~1 orall~ D
D
/
Feb. 17 ostill on !ic
150 mg.+ 2cC.aelestro~en wk~. LHERNIORRAPHY
E.B. Cont'd
/:
0
/
•
D!
/
D
/
/
D
/
D
0
0
. sti Ibesterol doil
/
/
D
D
D
D
/
A.L. Cont'd
Still on
a
Feb. 10
Fig, 8, Results obtained when Provera was given twice weekly and once weekly. Twenty-five milligrams twice weekly were ineffective. Fifty milligrams twice weekly and 100 mg. once weekly were adequate, indicating repository effect in these doses. Patient E. B. had uneventful surgery during her treatment interval. Patients E. B. and A. L. have been amenorrheic for 7 and 5 mo., respectively.
(17 ex- hydroxy - 6o(.-methyl progesterone acetate)
J.J. /
P
Oct. 14
1150 mg. Provero once wkly.
/
D J.J. cont'd
5
/
o
o
/
o
+
/
/
/
I mg. Stilbesterol doil~. oroll~
/
(HD)
/
1150 mq.P.wkly.+ I cc.Delestrogen
Feb. 16
I ~ discontinued 1/27160 due to illness
I
•
5 •"
•
/:•
o
o
o
o
Fig, 9. Results obtained when 150 mg. of Provera were given once weekly with stilbestrol daily or Delestrogen once weekly. Patient J. J. bled for a normal interval 3 wk. after treatment was discontinued because of an acute illness. Amenorrhea was present 4 mo. during therapy. Patient K. K. is still under treatment with good response.
•
.
.
Vol. 12. No.1. 1961
PROGESTATIONAL STEROIDS
53
occurred. However, when the dosage was increased to 50 mg. twice weekly, a satisfactory decidual endometrium was maintained for 8 wk. in patient E. B. (Fig. 8). At this point, in an effort to demonstrate the repository effect of the compound, the dosage was changed to 100 mg. once weekly plus the usual daily dose of stilbestrol. A decidual endometrium was maintained for 16 wk. at this dosage. The patient underwent a herniorrhaphy at this time, and the dosage was changed to 150 mg. of Provera once weekly plus 2 ml. of Delestrogen once weekly. Delestrogen was substituted to obviate lack of tolerance for oral stilbestrol during the postoperative period. The patient is still under treatment, having been amenorrheic since July 19, 1959, a total of 8 mo. to date. Biweekly biopsies still show a decidual endometrium. Patient A. L. (Fig. 8) has been amenorrheic with a decidual endometrium since Sept. 23, 1959, on dosages of 100 mg. of Provera once weekly plus 1 mg. of oral stilbestrol daily, a total of 6 mo. This patient is still under treatment. Patients J. J. and K. K. (Fig. 9) were given 150 mg. of Provera intramuscularly once weekly plus the usual dosage of stilbestrol. A satisfactory decidual endometrium was induced and maintained for 10 wk. in Patient J. J. until treatment was discontinued because of an incidental episode of acute phlebitis of the lower leg. Withdrawal bleeding of normal duration occurred 3 wk. later. Delestrogen, 1 ml. weekly, was substituted for stilbestrol for 3 wk. prior to discontinuing the therapy. Patient K. K. is still under treatment and has been amenorrheic since Dec. 20, 1959, with a decidual endometrium for approximately 8 wk. to date. These results indicate that 100--150 mg. of progestational steroid in aqueous suspension match the effectiveness of 250-375 mg. of a progestational steroid in oil suspension. This is in keeping with the results of the previous study, in which doses of 35--50 mg. of progesterone in oil were necessary to match the effectiveness of 25 mg. of progesterone as microcrystals in aqueous suspension.
SUMMARY The experimental study was concerned with the determination of the amounts of the various available progestational steroids required to induce and maintain decidua. For the most part, women with normal menstrual records were used as subjects, and hormonal treatment was started between Days 11 and 18 of their cycles and was continued until bright bleeding was observed. Five sets of observations were made. In the first part of the study, the oral progestational steroids were given alone and supplemented with an oral estrogen. Under the conditions of this
54
DURHAM
Fertility & Sterility
study, Enovid in a dose of 20 mg. daily or 10 mg. daily, supplemented with 1 mg. of stilbestrol daily, induced and maintained a decidual endometrium. Norlutin alone was ineffective in 5-mg. doses. However, when it was supplemented with stilbestrol, a decidual endometrium was maintained for 3-4 wk. Larger doses were not given. Likewise, Provera alone was ineffective, but when S0-40 mg. daily were supplemented with the usual dose of stilbestrol, satisfactory induction and maintenance occurred. In the second part of the study, the injectable progestational steroids were given with an oral and an injectable estrogen. A dose of 100-150 mg. once weekly of the aqueous suspension of Prover a was required, whereas 250-S75 mg. once weekly of Delalutin in oil was necessary for satisfactory maintenance. This is in keeping with the results of a previous study in which larger amounts of crystalline progesterone in oil were required than progesterone in aqueous suspension. Further studies should be made to determine the reason for this difference.
CONCLUSIONS 1. Observations have been made on the dosages of the oral and the injectable progestational steroids necessary for the induction and maintenance of a decidual endometrium. 2. Larger intramuscular doses of a progestational steroid are required when it is administered in oil (250-375 mg. once weekly) than when a related preparation is given suspended in an aqueous medium (100-150 mg. once weekly). Both required estrogen supplementation. S. The oral progestational steroids require an estrogen supplement unless estrogenic activity is inherently present and can be obtained with large doses. 4. Further observations are needed to confirm these conclusions. Owens Medical Center 4122 Shelbyville Rd.
REFERENCES R. c., and BRADBURY, J. T. Induction and maintenance of decidual changes with progesterone and estrogen. ]. GUn. Endocrinol. 11: 134, 1951. 2. BRADBURY, J. T., LONG, R. C., and DURHAM, W. C. Progesterone and estrogen requirements to induce and maintain decidua. Fertil. & Steril. 4:63, 1953.
1.
LONG,
•