Biomedical subjects
Publications and source records attributed to D C Cumming.
The initiation of breast-feeding was accompanied by an increase in skin conductance followed by increased skin temperature. The pattern was similar to that observed during a menopausal hot flush and differed from sympathetic arousal and simple heating.
Postmenopausal hyperandrogenism with overt clinical effects is rare and often related to ovarian stromal disorders. We present a clinicopathologic study of 4 cases. The patients (age range 41-75 years; mean 62 years) had evidence of hirsutism or frank virilization. Their serum testosterone was elevated with or without increases in their serum androstenedione and DHEA levels. There were two right-ovarian hilus cell tumors, one associated with left-ovarian stromal hyperplasia and the other with bilateral hyperthecosis and nodular hilus cell hyperplasia. The other tumor was a small corticomedullary stromal luteoma with bilateral hyperthecosis and nodular hilus cell hyperplasia. The fourth patient had bilateral hilus cell hyperplasia with mild cortical-stromal hyperplasia. All these patients had rapid normalization of androgen levels after surgery without recurrence after a 2- to 10-year follow-up.
We have examined the value of the Premenstrual Assessment Form (PAF) in 109 women with prospectively validated symptomatic premenstrual change. Results were compared with those of non-complaining women previously published (J Psychosom Res 1990; 34: 439-446.), there was considerable overlap in categorical and numerical scales so that selection of homogeneous populations of complainers could not be achieved. However, fewer than 7% of complainers had a total PAF numerical score in the normal range (defined as 2 SD above the mean total score of controls). Factor analysis of numerical scores in women with symptomatic premenstrual change suggested three factors similar to but not identical with those of non-complaining women. These were physiological depression, anxiety-volatility and increased well-being. While the negative syndromes are compatible with clinical experience, prospective investigation will be required to assess their homogeneity.
Surveys suggest that, despite extensive scientific knowledge of the biologic rhythms and physical changes associated with reproduction and despite the availability of excellent educational material about sexuality including menstruation, young peoples' knowledge of reproductive physiology is inadequate. Superstitions, illogical beliefs, and misinterpretations are more common than accurate understanding. The present article reviews menstrual mythology and describes sources of information for young people. Family and specialist physicians as well as educators in school or in the community need to recognize the limitations of the present methods of sexuality education, must realize that understanding of reproductive processes may be very incomplete, and should be prepared to work cooperatively with informal sources of information (peers, parents, and commercial companies). In addition, menstrual education needs to move away from the focus on hygienic management to that of healthy sexuality and acceptance of self.
A retrospective study of a wide range of premenstrual symptomatology using the Premenstrual Assessment Form found little difference between women taking a low-dose birth control pill and non-pill-takers. These data are in keeping with older, but narrower, studies of women taking high-dose pills and raise questions about mechanisms of symptomatic and subclinical premenstrual changes.
The Premenstrual Assessment Form (PAF) provides frequencies of diagnoses for subjects meeting the criteria for typological classifications which are similar in New York and Edmonton, suggesting that the instrument is stable in assessing premenstrual complaint. However, the frequency with which an unselected population meet the criteria suggests that more strict criteria and/or a "severity index" would be appropriate. It seems likely that a modified form of the PAF could fulfil some of the intentions of its originators.
Cross-sectional studies have suggested that total and bioavailable testosterone levels are reduced in some male athletes. Such changes may be related to loss of body weight, increased serum cortisol, and/or alterations in LH pulsatile release. To determine how endurance training may affect androgen levels, we measured serum total testosterone, sex hormone-binding globulin, free androgen index, LH, FSH, PRL, cortisol, and weight in 15 previously sedentary males. We also examined pulsatile LH release in a subset of 5 subjects. Over 6 months of training, the men increased weekly running mileage to an average of 56 km/week. Total testosterone and free androgen index levels decreased significantly. PRL and cortisol also decreased, while single sample LH and FSH remained unchanged. There was a significant reduction in weight, which did not correlate with changes in serum testosterone levels. LH pulsatile release was not altered by training in the subset of 5 runners. These data confirm previous findings of physiological reduction in serum testosterone and PRL levels and suggest that the testosterone decrease is not related to changes in LH pulsatile release, weight, or increased serum cortisol levels.
Symptomatic premenstrual change remains enigmatic and much disputed. To establish baselines in a non-complaining population, we administered the Premenstrual Assessment Form (PAF) to 133 volunteers not seeking or using treatment for premenstrual symptoms. The PAF, a 95-item self report questionnaire, provides categorical, bipolar and quantitative data on a wide range of premenstrual symptoms. Only 27 women (20.3%) failed to meet criteria for at least one of the negative PAF syndromes suggesting that the criteria are lax for clinical investigative purposes. Most common syndromes were minor and major depressive syndromes (87, 65%) with atypical and hostile subtypes most common, general physical discomfort syndrome (82, 61.7%) and fluid retention syndrome (71, 53.4%). Factor analysis was used with the quantitative data to group symptoms. The analysis suggested three factors: a physiological depression (depression with physical change), an anxiety-volatility, and an increased well-being unrelated to other changes. The clearer delineation of premenstrual changes in non-complaining women will define the control group in research with premenstrually symptomatic complainers.
Increased anxiety and depression are among the most frequently reported psychological problems in women seeking help for severe symptomatic premenstrual change, but there has been little objective evaluation of these symptoms. We therefore examined the results of objective psychological testing in 40 women with no apparent psychiatric or psychological disorder who had reported moderate to extreme increased anxiety and depression on a retrospective assessment form. Scores on the State-Trait Anxiety Inventory and Institute of Personality and Ability Testing (IPAT) Depression Scale increased from the low symptom intermenstrual phase of the cycle (days 5-10) to the premenstrual phase (within the last 6 days of the cycle), suggesting that retrospective complaints of increased premenstrual anxiety and depression can be confirmed on objective psychological assessment. However, it was observed that the distribution of intermenstrual IPAT depression scores was bimodal. Cyclic changes varied among the tests depending upon the IPAT depression score. The study suggests that 2 populations may exist in this screened sample; one population appears to have "pure PMS" and the second groups manifests a premenstrual exacerbation of subclinical depression.
Spironolactone (Aldactone), 100 mg to 200 mg daily, has antiandrogenic effects that may enhance treatment of androgen-excess syndromes, particularly severe hirsutism. Combination therapy with an oral contraceptive or with dexamethasone appears to have a beneficial effect. Side effects are transient. The drug should be avoided during pregnancy and in women who have a family history of breast cancer, although there is no proven association between spironolactone and breast malignancy.
Evidence suggests that acute exercise and endurance training has a suppressive effect on the hypothalamic-pituitary-gonadal (HPG) axis in men and women. To determine if training and acute exercise influence the neuroendocrine regulation of the HPG axis in men we examined pulsatile LH release in six male endurance runners with a training volume of at least 80 km per week, and compared this with values in six age-matched sedentary controls. Blood samples were obtained through an indwelling i.v. cannula from the subjects at 15-min intervals for 6 h following 24 h without significant physical activity and again in the runners, following 60 min of running at a speed equivalent to 5% below the anaerobic threshold. Mean LH pulse frequency and amplitude, as well as areas under the LH pulses and total LH curve, were calculated but only the mean post-exercise area under the total LH curve area was significantly lower than basal values (P less than 0.05) following exercise compared with the resting values in runners. Other measures of LH release did not change with acute exercise. Basal and pre-exercise testosterone levels were also measured and found to be at the lower end of normal men. The mean pre-exercise serum testosterone levels were significantly higher than basal levels. Mean testosterone levels, mean pulse amplitude, and mean area under the LH curve were significantly lower in resting runners than in the controls. The data suggest that exercise induces a general lowering of LH levels but does not inhibit LH pulsatile release. An anticipatory increase in serum testosterone occurred before exercise.
Physical activity has a range of effects on male reproductive function depending upon the intensity and duration of the activity and the fitness of the individual. In general, it appears that relatively short, intense exercise increases serum testosterone levels, but there is debate to what degree haemoconcentration, decreased clearance and/or increased synthesis are involved. It is clear from the promptness of the testosterone increment that the mechanism does not involve gonadotrophin stimulation of the testes. There is suppression of serum testosterone levels during and subsequent to more prolonged exercise (and to some extent in the hours following intense short term exercise). Again the mechanisms are not clear: a variety of systems could influence the decrease of testosterone synthesis, including decreased gonadotrophin, increased cortisol, catecholamine or prolactin levels, or perhaps even an accumulation of metabolic waste materials. Endurance training induces changes in the function of the reproductive axis in men in a manner which appears similar to the changes in women. As in women, there is a subclinical inhibition of normal reproductive function but it is unclear whether clinical expression of reproductive suppression is common in men. The long term, physiological suppression of the hypothalamic-pituitary-gonadal axis in men is probably not of major significance but it is clear that further investigation in several areas is essential to provide continuing reassurance that 'exercise is good for you'.
Pituitary testing is reported in an aspermic man with elevated serum FSH levels and hyperprolactinemia. Responses to clomiphene administration were normal. Serum LH responses to a double bolus of GnRH were substantially increased during bromocryptine therapy but FSH responses were similar with and without bromocryptine. These findings suggest that the elevated prolactin levels inhibited the GnRH-LH axis in this patient even in the presence of elevated serum FSH levels.
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A statistically significant difference in the frequency of out-of-phase biopsies was found on comparison of day dating in two sequential series of late luteal endometrial biopsies taken with the standard 4-mm stainless steel Novak curette and a polypropylene cannula ('Pipelle'). Since the only variable in these two series was the type of biopsy instrument used, it is suggested that the diagnosis of inadequate luteal phase can be affected by an extrinsic non-biological factor, i.e., the type of biopsy instrument used. This technical 'artifact' deserves further study.
Adenomyosis and its localized, tumorlike variant, the adenomyoma, usually afflict multiparous, perimenopausal women and are not considered to cause infertility. Three cases of adenomyoma occurred in young, infertile women. The adenomyoma was not deemed solely responsible for the infertility, although in two cases it could have been contributory. The preoperative diagnosis was leiomyoma, and adenomyoma was not even considered; it was recognized during "myomectomy" in one case. Adenomyoma should be included in the differential diagnosis of a localized uterine tumor in an infertile woman. This preoperative recognition allows the gynecologist to discuss the lesion with the patient, pointing out that the operation may be technically difficult and may result in incomplete removal or hysterectomy and that excision of the tumor may not cure her infertility. It also prepares the gynecologist for the technical problems that may arise intraoperatively. Additional cases of adenomyoma in infertile women need to be reported on before light is shed on its causal relationship to infertility as well as on its diagnosis and management.
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Circulating testosterone levels have generally been reported to increase during short term, intense running or bicycle ergometer exercise. Swimming differs from such activity because of the strenuous arm activity and because it is conducted in a liquid medium in the horizontal position with the weight totally supported. To investigate whether such differences modify the serum testosterone response to exercise, we measured serum testosterone levels before and after a maximal intensity swimming test in ten elite male and ten elite female swimmers. Levels of circulating testosterone fell in 19 of 20 swimmers in contrast to previous reports of exercise in the vertical position. In women mean testosterone levels declined by 39.4% from baseline values and in males, mean testosterone levels declined by 19.0%. Since the incremental protocol was similar to in design to maximal intensity tests conducted on a treadmill or bicycle ergometer, these data suggest that the differing physical circumstances of swimming lead to a qualitatively different testosterone response to exercise.