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The Effect of Oral Administration of Alpha Estradiol and Pregneninolone Upon the Human Castrate Uterus
86
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY SUl\1l\1ARY
Thirteen patients with amenorrhea and oligomenorrhea were treated with pregnant mares' serum. After eight months' observation, regular monthly periods have continued in 3 of the 13, 1 of the 3 having been a case of primary amenorrhea. Four patients with menorrhagia were treated; all 4 of whom showed evidence of immediate improvement. One of the 4 became pregnant after a sterile marriage of five years, and has gone on to full term. Two of the remaining 3 have shown continued benefit after eight months. Endometrial changes in the cases of amenorrhea and oligomenorrhea were inconstant, while in the cases of menorrhagia, the pattern changed from one of hyperplasia to one of proliferation. The authors wish to express their indebtedness to Dr. Wm. H. Yogt, Sr., Director of the Department of Obstetrics and Gynecology, for his suggestions and invaluable ald in carrying out these studies.
REFERENCES
(1) Cole, H. H., and Hart, G. H.: Am. J. Physiol. 93: 57, 1930. (2) EvaM, H. M.: West. J. Surg. 44: 175, 1936. (3) llei
THE EF:r'ECT OF ORAL ADMINISTRATION OF ALPHA BSTRADIOL AND PRBGNBNINOLONE UPON THE HUMAN CASTRATE UTERUS THEODORE
M.D., F.A.C.S., L.M. NEW YORK, N.Y.
lrlEUSTAEDTER,
(DUBLIN),
(From the Departmrnt of Gyneoology, New York Post-Grad'l#(].te Medical School and Hospital, Columbia University)
HE oral effect of estrin, 1 and the combined effect of oral estrin and parenteral progestin2 upon the human castrate endometrium have been previously demonstrated. This presentation eon~erns itself with the application of oral estrin ( dimenformon) • and an oral synthetic progestin derivative (pregneninolone)• upon the endometrium of the human castrate uterus. In addition, an attempt has been made to determine the standard for a human unit of these two ovarian hormones, i.e., the approximate amounts utilized, in milligrams, of crystalline substance during a normal menstrual cycle. •we are indebted to Roche-Organon, Inc. for a supply of dlmentormon and preg-
T
neninolone ( progestoral).
NEUSTAEDTER:
ALPHA ESTRADIOL AND PREGNE:{INOLONE
87
CASE REPORTS AND EXPERIMENTAL PROCEDURES
1.-F. L.* white, female, married, aged Hi years, was subjected to bilateral salpingo·oophorectomy for cystic ovaries. Menstruation began at 14, was irregular with occasional intervals of from three to six months, always painful and profuse, at times lasting thirty days. There had been four full-term pregnancies. The castration s:rndrome developed six months postoperatively. A premedication endometrial biopsy was taken and a scanty amount of tissue obtained; diagnosis of this tissue was atrophic endometrium. Bimlllll!IJ.,tiL Examination: Uterus anterior, freely movable; cervix well epithelized and measured 2% inches from external os to fundus. Adnexa were not palpable. Vaginal mucosa was pale and dry. Sept. 26, 19H9, to Oct. 7, 1939: Dimenformon, 4 mg. daily, for twelve days. October 8 to 19: Dimenformon, 6 mg., plus 75 mg. pregneninolone daily for twelve days. CASE
Fig. 1.-Early to midluteal phase produced with 120 mg. of estradiol and 900 mg. of pregneninolone. X 200.
October 21: Endometrial biopsy was taken and the diagnosis of an early to midluteal phase of endometrium established (:E'ig. 1). October 2H to 26: :Bleeding was reported. The patient noted some increase in libido, flushes disappea1·ed, and the uterine measurement from external os to fundus was 2% inches; vaginal secretion was present and the vaginal mucosa was a normal, pinki~h hue. For a period of three months she was comfortable, when menopausal symptoms reappeared. CASE 2.-J. K.* white, female, married, aged 22 years, was admitted to the Gynecological-Endocrine Clinic, complaining of hot flushes and amenorrhea. :Both ovaries had been removed at two previous operations, but the uterus was left in situ with a Crossen suspension. Menstruation began at 15 years of age, of three days' duration, and occurred every thirty days. For two years prior to operation she menstruated every two weeks for ten to eleven days, with a profuse flow and pain. •These castrates, now receiving oral estrin and oral pregneninolone, were reported upon in a previous communication• after having been given oral estrin and parenteral progestin.
88
AMERICAN;· JOURNAL OF OBSTETRICS ,\ND GYNECOLOGY
Last period four months previously. Flushes, accompanied by headaches, began soon after operation. Bimanual examination revealed a small uterus which was in anterior position, not freely movable. Adnexa were absent. Uterine measurement, from external os to fundus, waR 2¥.! inche~. A premedication biopsy was taken and a meager amount of endometrium obtained; the tissue was diagnosed as atrophic endometrium. Dec. 25, 1939, to Jan. 5, 1940: Dirnenformon 4 mg. daily for twelve days. Jan. !i to 17, 1940: Dimenformon 6 mg. plus 100 mg. pregneninolone daily for twelve days. January 20: Biopsy taken. Diagnosis: mid- to late luteal phase of the endometrium (Fig. 2). January 22 to 26: Bleeding was reported. Uterus measured three inches from external os to fundus. The patient noted. no change in libido but described breast stimulation. Flushes completely disappeared during medication.
Fig. 2.-Late luteal phase produced with 120 mg. of estradiol and 1,200 mg. of pregneninolone. X160.
CASE 3.-P. Z:,* aged 40 years, widow, was admitted to the Gynecological·Endo· crine Clinic complaining of hot :flushes every one-half to two hours, followed by attacks of excessive perspiration, joint pains over entire body, headache, and vertigo. Last menstrual period occurred eight months previously when a bilateral salpingooophorectomy for cystic ovaries was performed. Bimanual examination revealed a ~mall, atrophic, retrodisplaced uterus, measur· ing 21h inches from external os to fundus. The vaginal mucosa was dry and pale. Cervix was atrophic and dilatable with extreme difficulty. Endometrial biopsy revealed atrophic remnants of an early follicular phase. Dec. 24, 1939, to ,Jan. 4, 1940: Dimenforrnon, 4 rng. daily for twelve days. Jan. 4, 1940, to Jan. 15, 1940: Dimenformon, 6 mg. plus 100 mg. pregneninolone daily for twelve days. Jan. 18, 1940: A biopsy was taken and the diagnosis of the endometrial tissue was a late luteal phase (Fig. 3). At this time the uterus measured 2¥.! inches from external os to fundus. January 18: There was spotty bleeding. January 19 and 20: Patient reported bleeding which necessitat
NEUSTAEDTER:
ALPHA ESTRADIOL AND PREGNENINOLONE
89
CASE 4.-C. L.,* white, married, aged 28 years, was admitted to Gynecologieal· Endocrine Clinic complaining of hot :Hushes and nervousness, excessive perspiration, more marked during the night, and frequent frontal headaches. She had had a
Fig. 3.-Mid to late luteal phase produced with 120 mg. of estradiol and 1,200 mg. of pregneninolone. X160.
Fig. 4.-Mid to late lut€fll phase produced with 120 mg. of estradiol and 1,200 mg. of pregneninolone. Xl60.
bilateral salpingo·oophoreetomy four years previously for bilateral dermoid eysts. Menstruation began at 13 years of age and was of four days' duration, with irregu· lar intervals. She had had two normal pregnancies and one spontaneous miscarriage. There had been no menstruation since operation. *See footnote page 87.
90
AMERICAN JOURKAL OF OBSTETRICS AND GYNJl~COLOGY
Bimanual examination revealed the uterus to be slightly smaller than normal, in anterior position, freely movable, cervix small, well epithelizated; uterus measu'red 2 14 inches from external os to fundus. An endometrial biopsy specimen was diagnosed as atrophic endometrium. Feb. 8 to 19, 1940 inclusive: Dimenformon 4 mg. daily for twelve days. February 20 to March 2 inclusive: Dirnenformon 6 mg. daily plus 100 mg. pregneninolone for twelve days. March 5: An endometrial biopsy was taken and a moderate amount of tissue was recovered. Diagnosis was a mid- to late luteal phase of endometrium (Fig. 4). The uterus measured 214 inches from external os to fundus. Patient menstruated March 6 to 9, normal flow. Headaches, backaches and flushes disappeared during medication. .Flushes began to reappear two months later. CASE 5.-M. S., aged 33 years, married, had had no menses for seven years, but had hot flushes one to three times during the day, constant fatigue, headaches, and dizziness; bilateral salpingo-oophorcystectomy, appendectomy 1925, one mlscarriage, one stillbirth; for about four or five years following operation, menses occurred every three to four months for two or three days, moderate flow.
Fig. 5.-Late luteal phase produced with 120 mg. of estradiol and 1,200 mg. of pregneninolone. X160. Bimanual examination showed the external genitals to be atrophic, vaginal orifice small, and barely admltting two :fingers; cervix atrophic, well epithelized; uterus retroflexed and measured 2 inches from external os to fundus, dilatation rather difficult. March 28, 1940: An endometrial biopsy was taken and scant endometrium ob· tained. The diagnosis was atrophic endometrium. March 30 to .Apr. 10, 1940: Dimenformon, 4 mg. daily for twelve days. April 9 to 20: Dhnenformon 6 mg. daily plus pregneninolone 100 mg. daily for twelve days. April 23: Patient reported beginning of staining. An endometrial biopsy was taken and a moderate amount of tissue was obtained which was diagnosed as mid- to late luteal phase (Fig. 5). At this time the uterus measured 21h inches from external os to fundus. There was bleeding from April 23 to 30, necessitating the use of two pads daily. The flushes disappeared during medication and there was no difficulty with cervical dilatation after treatment. The patient was seen Aug. 6, 1940, at which time she had no return of hot flushes.
NEUSTAEDTER:
ALPHA ESTRADIOL AND PREGNENINOLONE
91
COMMENT
The ultimate objective in the field of hormone therapy is replacement of the injectable endocrine products by oral medication. With this purpose in view, an attempt was made to produce, by means of oral medication in the human castrate, the actual changes occurring in the endometrium during a normal menstrual cycle. Many investigations have been made in the past with lower animals and primates, demonstrating the effectiveness of endocrine preparations. Yet it is well known that the differences between human and animal physiology prevent a common application of therapy. It is, therefore, desirable to utilize human physiology so far as possible, in order to ascertain definitely biologic potency. Vp to the present time the literature contains very few reports concerning pregneninolone, a new type of synthetic luteal hormone. Inhoffen and Hohlwega were able to produce a full-blown luteal phase in an in· fantile guinea pig uterus, previously stimulated with ethinyl estradiol, with 4 mg. of pregneninolone. Zondek and Rozin4 report luteal endometrial changes in a prf'· viously estrinized secondary amenorrheic-B. In another instance bleeding similar to menstruation occurred several days after cessation of medication. Clau· berg,s utilizing noncastrated ameiWrrheics, claims luteal changes following administration of 92 mg. of ethinyl estradiol plus 220 mg. of pregneninolone, 100 mg. of progynon C, and 300 mg. of pregneninolone, respectively. He never used more than 400 mg. of pregneninolone, and reports bleeding within six days of cessation of medication, yet none of his microphotographs really shows changes analogous to a normal twenty-two- to twenty-four-day endometrium. Salmon, \Valter and Oeist6 have produced progestational changes in five postmenopausal women with 140, 480, 105, 500, and 540 mg. of pregneninolone, respectively, after intramuscular priming with amounts varying from 120,000 to 655,000 R. lJ. of estradiol benzoate. The second case showed a very good late luteal phase. There was no report of any bleed· ing after medication.
The dosage and timing of this investigation were based upon previously reported oral-parenteral experiments. In that series, 90 mg. of progestin parenterally over a twelve-day period produeed endometrial ehanges comparable to a normal late luteal phase. In the present series, ten tin1es that quantity was given orally to Case 1, 900 mg. in the form of pregneninolone, over a twelve-day period. An early to midluteal phase was produced; since this did not correspond to a late progestational phase, the dose in the other cases was stepped up to 13 times the amount. Cases 2, 3, 4, and 5 received therefore 1,200 mg. of pregneninolone over twelve-day periods and here the endometriums were of the late premenstrual type. Bleeding which was described as menstruation occurred in all patients within forty-eight to seventy-two hours after cessation of medication. In addition, the usual premenstrual molimina were reported. Libido was increased in some and in others there was no ehange. Cases 2 and 5 showed some evidences of uterine growth. All degrees of atrophic changes disappeared with medication. Patients were eompletely free of the menopausal syndrome during medication and for some time afterwards.
92
AMERICAN ,JOURNAL OP OBSTETRICS A:>\D UYNF:COLOUY
As to a possible human unit, or the amounts of both hormones which are actually necessary to produce the desired endometrial changes, assuming that the ratio of effectiveness between oral and parenteral administration is 1 :13; then in actual crystalline substance 9 mg. of estradiol and 90 mg. of progesterone are approximately the amounts utilized in normal menstrual cycles. Some investigators believe that the ratio varies from 1 to 6 :8. This may be true if biologically active extracts were employed; however, the above findings are based entirely upon the use of synthetie preparations. The value of this research problem offers future possibilities in the treatment of certain endocrine disturbances. In instances of atrophic uteri due to intrinsic changes, present-day methods of pituitary and ovarian stimulation, which are very questionable, are insufficient to reestablish normal me.n..
Six female castrates were treated with synthetic oral estradiol and • progestin. The total amount used was 120 mg. of estradiol and 900 to 1,200 mg. of pregneninolone. Progestational changes were produced in all cases. In four instances, the endometrium approximated that of a late luteal phase, whereas one with smaller dosage showed only an early luteal change. The symptoms and atrophic changes characteristic of the menopause completely disappeared during medication and returned months afterward in all patients with one exception. Uterine growth was manifest in two instances. Bleeding occurred in all patients within forty-eight to seventy-two hours after cessation of medication. The ratio of effectiveness between oral and parenteral administration is approximately 1 :13. I wish to express my grateful appreciation to Dr. Walter T. Dannreuther for his kind assistance and constructive criticisms, and to Miss Mary Chin for the preparation of the sections. REFERENCES
(1) Nemtaedter, T.: AM. J. OBST. & GYKEC. 29: 680, 38: 609, 1939. (3) Inhojflm, H. H., and Hohlweg, W.: 96, 1938. (4) Zondek, B., and Rozin, S.: Lancet 1: 504, Zentralbl. f. Gyniik. 62: 1745, 1939. (6) Sal1Mn, U. J., 8. H.: Proc. Soc. Exper. Bioi. & Med. 40: 252, 1939.
1935. (2) Idem: Ibid. Naturwissenschaften 26: 1939. (5) Clav,berg, C.: Walter, R. I., and Geist,
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY SUl\1l\1ARY
Thirteen patients with amenorrhea and oligomenorrhea were treated with pregnant mares' serum. After eight months' observation, regular monthly periods have continued in 3 of the 13, 1 of the 3 having been a case of primary amenorrhea. Four patients with menorrhagia were treated; all 4 of whom showed evidence of immediate improvement. One of the 4 became pregnant after a sterile marriage of five years, and has gone on to full term. Two of the remaining 3 have shown continued benefit after eight months. Endometrial changes in the cases of amenorrhea and oligomenorrhea were inconstant, while in the cases of menorrhagia, the pattern changed from one of hyperplasia to one of proliferation. The authors wish to express their indebtedness to Dr. Wm. H. Yogt, Sr., Director of the Department of Obstetrics and Gynecology, for his suggestions and invaluable ald in carrying out these studies.
REFERENCES
(1) Cole, H. H., and Hart, G. H.: Am. J. Physiol. 93: 57, 1930. (2) EvaM, H. M.: West. J. Surg. 44: 175, 1936. (3) llei
THE EF:r'ECT OF ORAL ADMINISTRATION OF ALPHA BSTRADIOL AND PRBGNBNINOLONE UPON THE HUMAN CASTRATE UTERUS THEODORE
M.D., F.A.C.S., L.M. NEW YORK, N.Y.
lrlEUSTAEDTER,
(DUBLIN),
(From the Departmrnt of Gyneoology, New York Post-Grad'l#(].te Medical School and Hospital, Columbia University)
HE oral effect of estrin, 1 and the combined effect of oral estrin and parenteral progestin2 upon the human castrate endometrium have been previously demonstrated. This presentation eon~erns itself with the application of oral estrin ( dimenformon) • and an oral synthetic progestin derivative (pregneninolone)• upon the endometrium of the human castrate uterus. In addition, an attempt has been made to determine the standard for a human unit of these two ovarian hormones, i.e., the approximate amounts utilized, in milligrams, of crystalline substance during a normal menstrual cycle. •we are indebted to Roche-Organon, Inc. for a supply of dlmentormon and preg-
T
neninolone ( progestoral).
NEUSTAEDTER:
ALPHA ESTRADIOL AND PREGNE:{INOLONE
87
CASE REPORTS AND EXPERIMENTAL PROCEDURES
1.-F. L.* white, female, married, aged Hi years, was subjected to bilateral salpingo·oophorectomy for cystic ovaries. Menstruation began at 14, was irregular with occasional intervals of from three to six months, always painful and profuse, at times lasting thirty days. There had been four full-term pregnancies. The castration s:rndrome developed six months postoperatively. A premedication endometrial biopsy was taken and a scanty amount of tissue obtained; diagnosis of this tissue was atrophic endometrium. Bimlllll!IJ.,tiL Examination: Uterus anterior, freely movable; cervix well epithelized and measured 2% inches from external os to fundus. Adnexa were not palpable. Vaginal mucosa was pale and dry. Sept. 26, 19H9, to Oct. 7, 1939: Dimenformon, 4 mg. daily, for twelve days. October 8 to 19: Dimenformon, 6 mg., plus 75 mg. pregneninolone daily for twelve days. CASE
Fig. 1.-Early to midluteal phase produced with 120 mg. of estradiol and 900 mg. of pregneninolone. X 200.
October 21: Endometrial biopsy was taken and the diagnosis of an early to midluteal phase of endometrium established (:E'ig. 1). October 2H to 26: :Bleeding was reported. The patient noted some increase in libido, flushes disappea1·ed, and the uterine measurement from external os to fundus was 2% inches; vaginal secretion was present and the vaginal mucosa was a normal, pinki~h hue. For a period of three months she was comfortable, when menopausal symptoms reappeared. CASE 2.-J. K.* white, female, married, aged 22 years, was admitted to the Gynecological-Endocrine Clinic, complaining of hot flushes and amenorrhea. :Both ovaries had been removed at two previous operations, but the uterus was left in situ with a Crossen suspension. Menstruation began at 15 years of age, of three days' duration, and occurred every thirty days. For two years prior to operation she menstruated every two weeks for ten to eleven days, with a profuse flow and pain. •These castrates, now receiving oral estrin and oral pregneninolone, were reported upon in a previous communication• after having been given oral estrin and parenteral progestin.
88
AMERICAN;· JOURNAL OF OBSTETRICS ,\ND GYNECOLOGY
Last period four months previously. Flushes, accompanied by headaches, began soon after operation. Bimanual examination revealed a small uterus which was in anterior position, not freely movable. Adnexa were absent. Uterine measurement, from external os to fundus, waR 2¥.! inche~. A premedication biopsy was taken and a meager amount of endometrium obtained; the tissue was diagnosed as atrophic endometrium. Dec. 25, 1939, to Jan. 5, 1940: Dirnenformon 4 mg. daily for twelve days. Jan. !i to 17, 1940: Dimenformon 6 mg. plus 100 mg. pregneninolone daily for twelve days. January 20: Biopsy taken. Diagnosis: mid- to late luteal phase of the endometrium (Fig. 2). January 22 to 26: Bleeding was reported. Uterus measured three inches from external os to fundus. The patient noted. no change in libido but described breast stimulation. Flushes completely disappeared during medication.
Fig. 2.-Late luteal phase produced with 120 mg. of estradiol and 1,200 mg. of pregneninolone. X160.
CASE 3.-P. Z:,* aged 40 years, widow, was admitted to the Gynecological·Endo· crine Clinic complaining of hot :flushes every one-half to two hours, followed by attacks of excessive perspiration, joint pains over entire body, headache, and vertigo. Last menstrual period occurred eight months previously when a bilateral salpingooophorectomy for cystic ovaries was performed. Bimanual examination revealed a ~mall, atrophic, retrodisplaced uterus, measur· ing 21h inches from external os to fundus. The vaginal mucosa was dry and pale. Cervix was atrophic and dilatable with extreme difficulty. Endometrial biopsy revealed atrophic remnants of an early follicular phase. Dec. 24, 1939, to ,Jan. 4, 1940: Dimenforrnon, 4 rng. daily for twelve days. Jan. 4, 1940, to Jan. 15, 1940: Dimenformon, 6 mg. plus 100 mg. pregneninolone daily for twelve days. Jan. 18, 1940: A biopsy was taken and the diagnosis of the endometrial tissue was a late luteal phase (Fig. 3). At this time the uterus measured 2¥.! inches from external os to fundus. January 18: There was spotty bleeding. January 19 and 20: Patient reported bleeding which necessitat
NEUSTAEDTER:
ALPHA ESTRADIOL AND PREGNENINOLONE
89
CASE 4.-C. L.,* white, married, aged 28 years, was admitted to Gynecologieal· Endocrine Clinic complaining of hot :Hushes and nervousness, excessive perspiration, more marked during the night, and frequent frontal headaches. She had had a
Fig. 3.-Mid to late luteal phase produced with 120 mg. of estradiol and 1,200 mg. of pregneninolone. X160.
Fig. 4.-Mid to late lut€fll phase produced with 120 mg. of estradiol and 1,200 mg. of pregneninolone. Xl60.
bilateral salpingo·oophoreetomy four years previously for bilateral dermoid eysts. Menstruation began at 13 years of age and was of four days' duration, with irregu· lar intervals. She had had two normal pregnancies and one spontaneous miscarriage. There had been no menstruation since operation. *See footnote page 87.
90
AMERICAN JOURKAL OF OBSTETRICS AND GYNJl~COLOGY
Bimanual examination revealed the uterus to be slightly smaller than normal, in anterior position, freely movable, cervix small, well epithelizated; uterus measu'red 2 14 inches from external os to fundus. An endometrial biopsy specimen was diagnosed as atrophic endometrium. Feb. 8 to 19, 1940 inclusive: Dimenformon 4 mg. daily for twelve days. February 20 to March 2 inclusive: Dirnenformon 6 mg. daily plus 100 mg. pregneninolone for twelve days. March 5: An endometrial biopsy was taken and a moderate amount of tissue was recovered. Diagnosis was a mid- to late luteal phase of endometrium (Fig. 4). The uterus measured 214 inches from external os to fundus. Patient menstruated March 6 to 9, normal flow. Headaches, backaches and flushes disappeared during medication. .Flushes began to reappear two months later. CASE 5.-M. S., aged 33 years, married, had had no menses for seven years, but had hot flushes one to three times during the day, constant fatigue, headaches, and dizziness; bilateral salpingo-oophorcystectomy, appendectomy 1925, one mlscarriage, one stillbirth; for about four or five years following operation, menses occurred every three to four months for two or three days, moderate flow.
Fig. 5.-Late luteal phase produced with 120 mg. of estradiol and 1,200 mg. of pregneninolone. X160. Bimanual examination showed the external genitals to be atrophic, vaginal orifice small, and barely admltting two :fingers; cervix atrophic, well epithelized; uterus retroflexed and measured 2 inches from external os to fundus, dilatation rather difficult. March 28, 1940: An endometrial biopsy was taken and scant endometrium ob· tained. The diagnosis was atrophic endometrium. March 30 to .Apr. 10, 1940: Dimenformon, 4 mg. daily for twelve days. April 9 to 20: Dhnenformon 6 mg. daily plus pregneninolone 100 mg. daily for twelve days. April 23: Patient reported beginning of staining. An endometrial biopsy was taken and a moderate amount of tissue was obtained which was diagnosed as mid- to late luteal phase (Fig. 5). At this time the uterus measured 21h inches from external os to fundus. There was bleeding from April 23 to 30, necessitating the use of two pads daily. The flushes disappeared during medication and there was no difficulty with cervical dilatation after treatment. The patient was seen Aug. 6, 1940, at which time she had no return of hot flushes.
NEUSTAEDTER:
ALPHA ESTRADIOL AND PREGNENINOLONE
91
COMMENT
The ultimate objective in the field of hormone therapy is replacement of the injectable endocrine products by oral medication. With this purpose in view, an attempt was made to produce, by means of oral medication in the human castrate, the actual changes occurring in the endometrium during a normal menstrual cycle. Many investigations have been made in the past with lower animals and primates, demonstrating the effectiveness of endocrine preparations. Yet it is well known that the differences between human and animal physiology prevent a common application of therapy. It is, therefore, desirable to utilize human physiology so far as possible, in order to ascertain definitely biologic potency. Vp to the present time the literature contains very few reports concerning pregneninolone, a new type of synthetic luteal hormone. Inhoffen and Hohlwega were able to produce a full-blown luteal phase in an in· fantile guinea pig uterus, previously stimulated with ethinyl estradiol, with 4 mg. of pregneninolone. Zondek and Rozin4 report luteal endometrial changes in a prf'· viously estrinized secondary amenorrheic-B. In another instance bleeding similar to menstruation occurred several days after cessation of medication. Clau· berg,s utilizing noncastrated ameiWrrheics, claims luteal changes following administration of 92 mg. of ethinyl estradiol plus 220 mg. of pregneninolone, 100 mg. of progynon C, and 300 mg. of pregneninolone, respectively. He never used more than 400 mg. of pregneninolone, and reports bleeding within six days of cessation of medication, yet none of his microphotographs really shows changes analogous to a normal twenty-two- to twenty-four-day endometrium. Salmon, \Valter and Oeist6 have produced progestational changes in five postmenopausal women with 140, 480, 105, 500, and 540 mg. of pregneninolone, respectively, after intramuscular priming with amounts varying from 120,000 to 655,000 R. lJ. of estradiol benzoate. The second case showed a very good late luteal phase. There was no report of any bleed· ing after medication.
The dosage and timing of this investigation were based upon previously reported oral-parenteral experiments. In that series, 90 mg. of progestin parenterally over a twelve-day period produeed endometrial ehanges comparable to a normal late luteal phase. In the present series, ten tin1es that quantity was given orally to Case 1, 900 mg. in the form of pregneninolone, over a twelve-day period. An early to midluteal phase was produced; since this did not correspond to a late progestational phase, the dose in the other cases was stepped up to 13 times the amount. Cases 2, 3, 4, and 5 received therefore 1,200 mg. of pregneninolone over twelve-day periods and here the endometriums were of the late premenstrual type. Bleeding which was described as menstruation occurred in all patients within forty-eight to seventy-two hours after cessation of medication. In addition, the usual premenstrual molimina were reported. Libido was increased in some and in others there was no ehange. Cases 2 and 5 showed some evidences of uterine growth. All degrees of atrophic changes disappeared with medication. Patients were eompletely free of the menopausal syndrome during medication and for some time afterwards.
92
AMERICAN ,JOURNAL OP OBSTETRICS A:>\D UYNF:COLOUY
As to a possible human unit, or the amounts of both hormones which are actually necessary to produce the desired endometrial changes, assuming that the ratio of effectiveness between oral and parenteral administration is 1 :13; then in actual crystalline substance 9 mg. of estradiol and 90 mg. of progesterone are approximately the amounts utilized in normal menstrual cycles. Some investigators believe that the ratio varies from 1 to 6 :8. This may be true if biologically active extracts were employed; however, the above findings are based entirely upon the use of synthetie preparations. The value of this research problem offers future possibilities in the treatment of certain endocrine disturbances. In instances of atrophic uteri due to intrinsic changes, present-day methods of pituitary and ovarian stimulation, which are very questionable, are insufficient to reestablish normal me.n..
Six female castrates were treated with synthetic oral estradiol and • progestin. The total amount used was 120 mg. of estradiol and 900 to 1,200 mg. of pregneninolone. Progestational changes were produced in all cases. In four instances, the endometrium approximated that of a late luteal phase, whereas one with smaller dosage showed only an early luteal change. The symptoms and atrophic changes characteristic of the menopause completely disappeared during medication and returned months afterward in all patients with one exception. Uterine growth was manifest in two instances. Bleeding occurred in all patients within forty-eight to seventy-two hours after cessation of medication. The ratio of effectiveness between oral and parenteral administration is approximately 1 :13. I wish to express my grateful appreciation to Dr. Walter T. Dannreuther for his kind assistance and constructive criticisms, and to Miss Mary Chin for the preparation of the sections. REFERENCES
(1) Nemtaedter, T.: AM. J. OBST. & GYKEC. 29: 680, 38: 609, 1939. (3) Inhojflm, H. H., and Hohlweg, W.: 96, 1938. (4) Zondek, B., and Rozin, S.: Lancet 1: 504, Zentralbl. f. Gyniik. 62: 1745, 1939. (6) Sal1Mn, U. J., 8. H.: Proc. Soc. Exper. Bioi. & Med. 40: 252, 1939.
1935. (2) Idem: Ibid. Naturwissenschaften 26: 1939. (5) Clav,berg, C.: Walter, R. I., and Geist,