BritishJournal of Obstetrics and Gynaecology January 1979. Vol. 86. pp 64-68
OESTROGEN-GONADOTROPHIN FEEDBACK ABNORMALITIES IN HYPERPROLACTINAEMIC AMENORRHOEA DEMONSTRATED BY THE RESPONSE TO CLOMIPHENE ADMINISTRATION BY
M. R. GLASS,Senior Registrar R. W . SHAW,Lecturer
W . R. BUTT,Professor of Endocrinology
R . LOGANEDWARDS, Consultant Gynaecologist Department of Clinical Endocrinology, Birmingham and Midland Hospital for Women Sparkhill, Birmingham 1 I AND
D . R . LONDON, Consultant Physician The Queen Elizabeth Hospital, Edgbaston, Birmingham 15
Summary Clomiphene was administered to 16 patients with elevated serum prolactin levels in doses of 100, 200 and 300 mg/day for five days in succeeding months and total urinary oestrogens estimated on days 0, 5 , 8 , 12 and 15 following commencement of treatment. The responses were compared with six patients who were amenorrhoeic but had normal serum prolactin levels and absent positive feedback to oestrogen. The increased outputs of oestrogens were similar in the two groups. In the hyperprolactinaemic group 5 out of 16 subjects showed evidence of ovulation whilst the remainder showed a secondary failure of response. Six subjects who failed to ovulate were treated with clomiphene and human chorionic gonadotrophin (HCG) and ovulations were induced in 31 out of 34 treatment cycles but no pregnancies were achieved. The responses to clomiphene therapy in the hyperprolactinaemic subjects were compared to the assessment of positive feedback mechanisms by means of oestrogen provocation and oestrogen amplification tests and good correlation was obtained. Only those with evidence of positive feedback to these tests were likely to ovulate on clomiphene. production from the developing ovarian follicle increases. For ovulation to occur, the patient must be able to respond to this increased oestrogen production with a positive feedback release of gonadotrophins, and a failure to do this has been shown to be a reason for failure to ovulate on clomiphene (Marshall et al, 1973). Failure of positive feedback in most patients with hyperprolactinaemic amenorrhoea (Glass
ANTI-OESTROGENS, such as clomiphene, are widely used for the induction of ovulation. They are thought to act primarily at the hypothalamus by occupying and therefore blocking oestrogen receptor sites. This removes the negative feedback action of oestrogen and allows the release of FSH and LH (Kato el al, 1968; Kahwanago et al, 1970; Vaitukaitis et al, 1971). Under the influence of the gonadotrophins, oestrogen 64
CLOMIPHENERESPONSE IN HYPERPROLACTINAEMIA
el al, 1975 and 1976a; Aono et al, 1976) may account for this poor response to clomiphene therapy and for the need to give clomiphene followed by human chorionic gonadotrophin (HCG) to achieve apparent ovulation (Gambrel1 et al, 1971). The presence of intact negative oestrogen feedback ensures follicular development under the influence of clomiphene (Glass et al, 1976~). The present study is an investigation into clomiphene responsiveness of subjects with hyperprolactinaemic amenorrhoea, and is aimed at further understanding of the gonadotrophin release mechanisms.
METHODS Clomiphene was administered to 16 patients with hyperprolactinaemic amenorrhoea in doses of 100,200 and 300 mg per day for five days in succeeding months. Basal serum prolactin concentrations in these patients ranged from 940 to 7500 mu/l. Twenty-four hour urine collections for the estimation of total urinary oestrogens were made on the day before clomiphene administration and on days 5, 8, 12 and 15 following the commencement of clomiphene. Blood was taken on day 18 for estimation of serum progesterone. Six women with serum prolactin concentrations within the normal range and amenorrhoea associated with either psychological problems or oral contraception, and with absent positive oestrogen feedback, were selected for study for comparison of oestrogen production. They were given 100 mg and 200 mg courses of clomiphene for five days and hormone estimations made as in the hyperprolactinaemic patients. Six hyperprolactinaemic subjects were treated with clomiphene followed by HCG to induce ovulation. A dose of 5000 IU of HCG was administered intramuscularly 13 to 15 days following commencement of clomiphene, the timing was determined by the peak in urinary total oestrogen excretion. Three types of responses following clomiphene were defined : (1) Ovulatory. Elevation of total urinary oestrogens, biphasic temperature chart and elevated serum progesterone (greater than 15 nmol/l) on day 18.
65
( 2 ) Secondary failure. Increase of total urinary oestrogens, but monophasic temperature chart and no increase in serum progesterone (less than 15 nmol/l) on day 18. (3) Primary failure. No increase in total urinary oestrogens, flat monophasic temperature chart and no elevation of serum progesterone on day 18. Responses to clomiphene were correlated with the response in individual subjects to the oestrogen provocation or amplification studies. For the oestrogen provocation test, 1 mg of oestradiol benzoate was administered intramuscularly at zero hour. Blood samples for L H and FSH estimations were obtained at 0, 24, 48, 56, 72 and 96 hours. An increase of at least 8 u/l of LH above baseline indicated the presence of positive oestrogen feedback (Shaw et al, 1975a; Glass et al, 1975). In the oestrogen amplification test a control response to a 100 pg intravenous dose of LHRH was undertaken with collection of blood samples just before and at 20, 30, 60 and 90 minutes after LHRH administration. A 2 . 5 mg dose of oestradiol benzoate was then given by intramuscular injection and a repeat LHRH test performed 44 hours later. The sum of increments of L H and FSH responses were calculated and an increase of at least 10 u/l for LH or 6 u/l for FSH in the second postoestrogen LHRH test indicated a positive amplification response (Glass et al, 1976~). Total urinary oestrogens were measured by the method of Brown et a1 (1968). Radioimmunoassay was used to measure serum prolactin and progesterone concentrations (Glass et al, 19766; Shaw el al, 1974). RESULTS Total urinary oestrogen values in the 6 normoprolactinaemic and the 13 hyperprolactinaemic women who received both 100 and 200 mg courses of clomiphene are shown in Table I. The maximum excretion of oestrogen was generally between days 8 and 12, but in two of the patients with normal prolactin levels and in five of those who were hyperprolactinaemic, the amount excreted continued to rise until day 15. Peak values on days 8 to 12 ranged from 119 to 357 nmo1/24 hours at the 100 mg dose and
66
GLASS, SHAW, BUTT, LOGAN EDWARDS AND LONDON
TABLE I Total urinary oestrogen excretion before treatment and maximum following clomiphene administration at different doses 100 mg cIomiphene/day for five days
200 mg cIomiphene/day for five days
Total urinary oestrogens (nmo1/24 hours)
Total urinary oestrogens (nmo1/24 hours)
Basal
Day
Basal
Maximum
Day
15"
Maximum
Patients with hyperprolactinaemia 1 97 2 54 4 64 6 32 7 61 8 31 9 45 11 40 12 33 29 13 14 18 15 30 16 21
316 133 126 319 163 323 782 119 203 152 61 223 110
61 52 63 48 66 95 34 29 40 32 36 25 28
392 160 308 452 114 1238 315 203 340 260 178 328 158
15*
12 5 8 15* 12 15* 8 15* 8 12 8 12
Patients with normalprolactin levels 17 30 160 18 22 126 19 30 219 20 63 119 21 49 357 22 61 525
8 8 8 8 12 15*
24 37 32 59 36 58
540 401 430 170 208 309
12 8 12 8
12 8 12 12 12 15* 12 8 8 15* 12 8
15*
12
* Maximum excretion of Day 15-concentration may still be rising. from 170 to 540 nmo1/24 hours at the 200 mg dose of clomiphene in patients with normal prolactin values, and from 61 to 323 nmo1/24 hours at 100 mg and 114 to 1238 nmo1/24 hours at the 200 mg dose in those with hyperprolactinaemia.
Assessment of responses and ovulation Sixteen women with hyperprolactinaemia were given a total of 37 months of treatment with clomiphene at doses ranging from 100 to 300 mg per day for five days. There were six ovulatory cycles in five of the patients, while in all the others there was a secondary failure, namely an increase in oestrogen excretion but no ovulation (Table 11). Four of the five patients who ovulated showed a positive feedback in the amplification test but three of these showed only a marginal response in the provocation test. Patient No. 5 who ovulated on both 200 and 300 mg doses of clomiphene showed no positive feedback in either test. The only other anomalous result was
in patient No. 6 who failed to ovulate, although she demonstrated positive feedback in the provocation but not in the amplification test. Six of the hyperprolactinaemic patients who had failed to ovulate on clomiphene alone were subsequently treated with HCG following clomiphene therapy and they each showed ovulatory responses. Three of the subjects were treated for a total of 34 cycles and in 31 of these ovulatory responses were noted but no pregnancies occurred.
DISCUSSION This study has substantiated previous evidence that patients with hyperprolactinaemic amenorrhoea have an abnormality of positive oestrogen feedback so that failure of ovulation occurs following clomiphene therapy, despite adequate follicular development. Only 6 of the 37 treatment cycles with clomiphene alone were associated with ovulatory changes and in these 6 cycles no pregnancies occurred. The study also confirms that negative oestro-
CLOMIPHENE RESPONSE IN HYPERPROLACTINAEMIA
67
TABLE I1 Clomiphene responses in 16 hyperprolactinaemic amenorrhoeic patients and comparison with oestrogen provocation and amplificationtests Clomiphene response 100 mg
Patients showing evidence of ovulation 1. 2" 2. 2" 3. Owl". 4. 2" 5. Patients showing no evidence of ovulation 6. 2" 7. 2" 8. 2" 9. 2" 10. 2" 11. 2" 12. 20 13. 2" 14. 2" 15. 2" 16. 20
Positive feedback response
200 mg
300 mg
Owl". 2"
OVUl".
2" Owl".
2" 2" 20 2" 2" 20 2" 2.3 2"
2"
-
Ovul".
Ovul".
Oestrogen provocation
Oestrogen amplification
Present ?Present ?Present ?Present Absent
Present Present Present Present Absent
Present Absent Absent Absent Absent Absent Absent Absent Absent Absent Absent
Absent Absent Absent Absent -
-
-
Ovul". = Ovulation 2" = Secondaryfailure (see text).
gen feedback mechanisms are intact as shown in our previous oestrogen amplification studies (Glass et a/, 1976a), since the production of oestrogen was similar in response to clomiphene in both the hyperprolactinaemic patients and in those with normal prolactin levels. This is consistent with the more direct observations of Thorner et al (1974) who reported increased gonadotrophin levels during clomiphene treatment in hyperprolactinaemic patients, which again indicates intact negative oestrogen feedback. Addition of HCG to the treatment regimens induced biphasic temperature charts with elevated serum progesterone concentrations and menstruation in all subjects so treated. Thus it would appear that ovulation can be induced in this manner although no pregnancies occurred. One subject had a laparoscopy six days after the injection of HCG when the serum progesterone level was 94 nmol/l and an apparently normal corpus luteum was seen, with some blood in the pouch of Douglas suggesting rupture, and there was a secretory endometrium. This
suggests that ovulation and not merely luteinization, with retention of ovum, had occurred during that course of treatment. However, a possible further deleterious action of elevated prolactin levels on fertilization or implantation may be postulated from the failure to conceive following induced ovulation with clomiphene and HCG in the presence of hyperprolactinaemia. In contrast Gambrel1 et al (1971) recorded ovulation in 7 out of 9 subjects with amenorrhoea-galactorrhoea, three of whom conceived following clomiphene and HCG treatment. An effect of prolactin on ovarian steroidogenesis has now been postulated either in the puerperium (Reyes et al, 1972) or in amenorrhoeagalactorrhoea syndromes (McNeilly, 1974). McNatty et a l (1974) showed that although a low level of prolactin is necessary for the production of progesterone by the human ovary in vitro, high levels inhibit progesterone synthesis even with levels of LH and FSH normally sufficient to induce maximum steroidogenesis. The clomiphene test results, however, indicate that total oestrogen production is adequate in
68
GLASS, SHAW, BUTT, LOGAN EDWARDS AND LONDON
these patients with elevated serum prolactin levels and similar to some other groups of amenorrhoeic women treated with clomiphene. Following HCG injection, progesterone production and the length of the luteal phases (on average 12 days) were also normal. Thus gross estimates of ovarian steroidogenesis with elevated prolactin levels suggest that steroidogenesis is not affected adversely, at least during treatment with clomiphene and HCG. The generally good correlation between the results of the oestrogen provocation test, using a 1 mg dose, the oestrogen amplification tests, using a 2-5 mg oestradiol benzoate dose, and the subsequent clomiphene responses, corroborates the previous published findings of Shaw (1976) and Shaw et a1 (1975a and b) and suggests that these tests are satisfactory assessments of feedback mechanisms in subjects with amenorrhoea.
ACKNOWLEDGEMENTS This work was supported by grants from the Central Birmingham Health District Special Trustees Fund and the Medical Research Council. Our thanks to the Staff of the Department of Clinical Endocrinology who kindly performed the various assays. REFERENCES Aono, T., Miyake, A., Shioji, T., Kinugasa, T., Onishi, T., and Kurachi, K. (1976): Journal of Clinical Endocrinology and Metabolism, 42,696. Brown, J. B., MacLeod, S. C., MacNaughton, C., Smith, M. A., and Smyth, B. (1968): Journal of Endocrinology,42,5.
Gambrell, R. D. Jnr., Greenblatt, R. B., and Mahesh, V. B. (1971): American Journal of Obstetrics and Gynecology, 110,838. Glass, M. R., Shaw, R.W., Butt, W. R., Logan Edwards, R., and London, D. R. (1975): British Medical Journal, 3,274. Glass, M . R.,Shaw, R.W., Williams, J. W., Butt, W. R., Logan Edwards, R., and London, D. R. (1976a): Clinical Endocrinoiogy, 5,52 1 erratum, 740. Glass, M. R., Williams, J. W., Butt, W. R.,Logan Edwards, R., and London, D. R. (19766): British Journal of Obstetrics and Gynaecology, 83,495. Kahwanago, I., Heinrichs, W. L., and Herman, W. L. (1 970) : Endocrinology, 86,13 19. Kato, J., Kobayashi, T., and Villee, C. A. (1968): Endocrinology, 82,1049. Marshall, J . C., Morris, R.,Court, J., and Butt, W. R. (1973):Journalof Endocrinology, 59, xxlv. McNatty, K. P., Sawers, R. S., and McNeilly, A. S. ( 1974): Nature, 250,653. McNeilly, A. S. (1974): British Journal of Hospital Medicine, 12,57. Reyes, F. I., Winter, J. S. D., and Faiman, C. C. (1972): American Journal of Obstetrics and Gynecology, 114, 589. Shaw, R. W. (1976): British Journal of Obstetrics and Gynaecology, 83,412. Shaw, R. W., Butt, W. R., London, D. R., and Marshall, J. C. (1974):Journal of Obstetrics and Gynaecofogy of the British Commonwealth, 81,632. Shaw, R. W., Butt, W. R., London, D. R., and Marshall, J. C. (1975a):Clinical Endocrinology,4,267. Shaw, R. W., Duignan, N. M., Butt, W. R., Logan Edwards, R., and London, D. R. (19756): British Journal of Obstetrics and Gynaecology,82,952. Thorner, M. O., McNeilly, A. S., Hagan, C., and Besser, G. M. (1 974) : British Medical Journal, 2,4 19. Vaitukaitis, J. L., Bermudas, J. A., Cargille, C. M., Lipsett, M. B., and Ross, G. T. (1971):Journal of Clinical Endocrinology and Metabolism, 32,503.
OESTROGEN-GONADOTROPHIN FEEDBACK ABNORMALITIES IN HYPERPROLACTINAEMIC AMENORRHOEA DEMONSTRATED BY THE RESPONSE TO CLOMIPHENE ADMINISTRATION BY
M. R. GLASS,Senior Registrar R. W . SHAW,Lecturer
W . R. BUTT,Professor of Endocrinology
R . LOGANEDWARDS, Consultant Gynaecologist Department of Clinical Endocrinology, Birmingham and Midland Hospital for Women Sparkhill, Birmingham 1 I AND
D . R . LONDON, Consultant Physician The Queen Elizabeth Hospital, Edgbaston, Birmingham 15
Summary Clomiphene was administered to 16 patients with elevated serum prolactin levels in doses of 100, 200 and 300 mg/day for five days in succeeding months and total urinary oestrogens estimated on days 0, 5 , 8 , 12 and 15 following commencement of treatment. The responses were compared with six patients who were amenorrhoeic but had normal serum prolactin levels and absent positive feedback to oestrogen. The increased outputs of oestrogens were similar in the two groups. In the hyperprolactinaemic group 5 out of 16 subjects showed evidence of ovulation whilst the remainder showed a secondary failure of response. Six subjects who failed to ovulate were treated with clomiphene and human chorionic gonadotrophin (HCG) and ovulations were induced in 31 out of 34 treatment cycles but no pregnancies were achieved. The responses to clomiphene therapy in the hyperprolactinaemic subjects were compared to the assessment of positive feedback mechanisms by means of oestrogen provocation and oestrogen amplification tests and good correlation was obtained. Only those with evidence of positive feedback to these tests were likely to ovulate on clomiphene. production from the developing ovarian follicle increases. For ovulation to occur, the patient must be able to respond to this increased oestrogen production with a positive feedback release of gonadotrophins, and a failure to do this has been shown to be a reason for failure to ovulate on clomiphene (Marshall et al, 1973). Failure of positive feedback in most patients with hyperprolactinaemic amenorrhoea (Glass
ANTI-OESTROGENS, such as clomiphene, are widely used for the induction of ovulation. They are thought to act primarily at the hypothalamus by occupying and therefore blocking oestrogen receptor sites. This removes the negative feedback action of oestrogen and allows the release of FSH and LH (Kato el al, 1968; Kahwanago et al, 1970; Vaitukaitis et al, 1971). Under the influence of the gonadotrophins, oestrogen 64
CLOMIPHENERESPONSE IN HYPERPROLACTINAEMIA
el al, 1975 and 1976a; Aono et al, 1976) may account for this poor response to clomiphene therapy and for the need to give clomiphene followed by human chorionic gonadotrophin (HCG) to achieve apparent ovulation (Gambrel1 et al, 1971). The presence of intact negative oestrogen feedback ensures follicular development under the influence of clomiphene (Glass et al, 1976~). The present study is an investigation into clomiphene responsiveness of subjects with hyperprolactinaemic amenorrhoea, and is aimed at further understanding of the gonadotrophin release mechanisms.
METHODS Clomiphene was administered to 16 patients with hyperprolactinaemic amenorrhoea in doses of 100,200 and 300 mg per day for five days in succeeding months. Basal serum prolactin concentrations in these patients ranged from 940 to 7500 mu/l. Twenty-four hour urine collections for the estimation of total urinary oestrogens were made on the day before clomiphene administration and on days 5, 8, 12 and 15 following the commencement of clomiphene. Blood was taken on day 18 for estimation of serum progesterone. Six women with serum prolactin concentrations within the normal range and amenorrhoea associated with either psychological problems or oral contraception, and with absent positive oestrogen feedback, were selected for study for comparison of oestrogen production. They were given 100 mg and 200 mg courses of clomiphene for five days and hormone estimations made as in the hyperprolactinaemic patients. Six hyperprolactinaemic subjects were treated with clomiphene followed by HCG to induce ovulation. A dose of 5000 IU of HCG was administered intramuscularly 13 to 15 days following commencement of clomiphene, the timing was determined by the peak in urinary total oestrogen excretion. Three types of responses following clomiphene were defined : (1) Ovulatory. Elevation of total urinary oestrogens, biphasic temperature chart and elevated serum progesterone (greater than 15 nmol/l) on day 18.
65
( 2 ) Secondary failure. Increase of total urinary oestrogens, but monophasic temperature chart and no increase in serum progesterone (less than 15 nmol/l) on day 18. (3) Primary failure. No increase in total urinary oestrogens, flat monophasic temperature chart and no elevation of serum progesterone on day 18. Responses to clomiphene were correlated with the response in individual subjects to the oestrogen provocation or amplification studies. For the oestrogen provocation test, 1 mg of oestradiol benzoate was administered intramuscularly at zero hour. Blood samples for L H and FSH estimations were obtained at 0, 24, 48, 56, 72 and 96 hours. An increase of at least 8 u/l of LH above baseline indicated the presence of positive oestrogen feedback (Shaw et al, 1975a; Glass et al, 1975). In the oestrogen amplification test a control response to a 100 pg intravenous dose of LHRH was undertaken with collection of blood samples just before and at 20, 30, 60 and 90 minutes after LHRH administration. A 2 . 5 mg dose of oestradiol benzoate was then given by intramuscular injection and a repeat LHRH test performed 44 hours later. The sum of increments of L H and FSH responses were calculated and an increase of at least 10 u/l for LH or 6 u/l for FSH in the second postoestrogen LHRH test indicated a positive amplification response (Glass et al, 1976~). Total urinary oestrogens were measured by the method of Brown et a1 (1968). Radioimmunoassay was used to measure serum prolactin and progesterone concentrations (Glass et al, 19766; Shaw el al, 1974). RESULTS Total urinary oestrogen values in the 6 normoprolactinaemic and the 13 hyperprolactinaemic women who received both 100 and 200 mg courses of clomiphene are shown in Table I. The maximum excretion of oestrogen was generally between days 8 and 12, but in two of the patients with normal prolactin levels and in five of those who were hyperprolactinaemic, the amount excreted continued to rise until day 15. Peak values on days 8 to 12 ranged from 119 to 357 nmo1/24 hours at the 100 mg dose and
66
GLASS, SHAW, BUTT, LOGAN EDWARDS AND LONDON
TABLE I Total urinary oestrogen excretion before treatment and maximum following clomiphene administration at different doses 100 mg cIomiphene/day for five days
200 mg cIomiphene/day for five days
Total urinary oestrogens (nmo1/24 hours)
Total urinary oestrogens (nmo1/24 hours)
Basal
Day
Basal
Maximum
Day
15"
Maximum
Patients with hyperprolactinaemia 1 97 2 54 4 64 6 32 7 61 8 31 9 45 11 40 12 33 29 13 14 18 15 30 16 21
316 133 126 319 163 323 782 119 203 152 61 223 110
61 52 63 48 66 95 34 29 40 32 36 25 28
392 160 308 452 114 1238 315 203 340 260 178 328 158
15*
12 5 8 15* 12 15* 8 15* 8 12 8 12
Patients with normalprolactin levels 17 30 160 18 22 126 19 30 219 20 63 119 21 49 357 22 61 525
8 8 8 8 12 15*
24 37 32 59 36 58
540 401 430 170 208 309
12 8 12 8
12 8 12 12 12 15* 12 8 8 15* 12 8
15*
12
* Maximum excretion of Day 15-concentration may still be rising. from 170 to 540 nmo1/24 hours at the 200 mg dose of clomiphene in patients with normal prolactin values, and from 61 to 323 nmo1/24 hours at 100 mg and 114 to 1238 nmo1/24 hours at the 200 mg dose in those with hyperprolactinaemia.
Assessment of responses and ovulation Sixteen women with hyperprolactinaemia were given a total of 37 months of treatment with clomiphene at doses ranging from 100 to 300 mg per day for five days. There were six ovulatory cycles in five of the patients, while in all the others there was a secondary failure, namely an increase in oestrogen excretion but no ovulation (Table 11). Four of the five patients who ovulated showed a positive feedback in the amplification test but three of these showed only a marginal response in the provocation test. Patient No. 5 who ovulated on both 200 and 300 mg doses of clomiphene showed no positive feedback in either test. The only other anomalous result was
in patient No. 6 who failed to ovulate, although she demonstrated positive feedback in the provocation but not in the amplification test. Six of the hyperprolactinaemic patients who had failed to ovulate on clomiphene alone were subsequently treated with HCG following clomiphene therapy and they each showed ovulatory responses. Three of the subjects were treated for a total of 34 cycles and in 31 of these ovulatory responses were noted but no pregnancies occurred.
DISCUSSION This study has substantiated previous evidence that patients with hyperprolactinaemic amenorrhoea have an abnormality of positive oestrogen feedback so that failure of ovulation occurs following clomiphene therapy, despite adequate follicular development. Only 6 of the 37 treatment cycles with clomiphene alone were associated with ovulatory changes and in these 6 cycles no pregnancies occurred. The study also confirms that negative oestro-
CLOMIPHENE RESPONSE IN HYPERPROLACTINAEMIA
67
TABLE I1 Clomiphene responses in 16 hyperprolactinaemic amenorrhoeic patients and comparison with oestrogen provocation and amplificationtests Clomiphene response 100 mg
Patients showing evidence of ovulation 1. 2" 2. 2" 3. Owl". 4. 2" 5. Patients showing no evidence of ovulation 6. 2" 7. 2" 8. 2" 9. 2" 10. 2" 11. 2" 12. 20 13. 2" 14. 2" 15. 2" 16. 20
Positive feedback response
200 mg
300 mg
Owl". 2"
OVUl".
2" Owl".
2" 2" 20 2" 2" 20 2" 2.3 2"
2"
-
Ovul".
Ovul".
Oestrogen provocation
Oestrogen amplification
Present ?Present ?Present ?Present Absent
Present Present Present Present Absent
Present Absent Absent Absent Absent Absent Absent Absent Absent Absent Absent
Absent Absent Absent Absent -
-
-
Ovul". = Ovulation 2" = Secondaryfailure (see text).
gen feedback mechanisms are intact as shown in our previous oestrogen amplification studies (Glass et a/, 1976a), since the production of oestrogen was similar in response to clomiphene in both the hyperprolactinaemic patients and in those with normal prolactin levels. This is consistent with the more direct observations of Thorner et al (1974) who reported increased gonadotrophin levels during clomiphene treatment in hyperprolactinaemic patients, which again indicates intact negative oestrogen feedback. Addition of HCG to the treatment regimens induced biphasic temperature charts with elevated serum progesterone concentrations and menstruation in all subjects so treated. Thus it would appear that ovulation can be induced in this manner although no pregnancies occurred. One subject had a laparoscopy six days after the injection of HCG when the serum progesterone level was 94 nmol/l and an apparently normal corpus luteum was seen, with some blood in the pouch of Douglas suggesting rupture, and there was a secretory endometrium. This
suggests that ovulation and not merely luteinization, with retention of ovum, had occurred during that course of treatment. However, a possible further deleterious action of elevated prolactin levels on fertilization or implantation may be postulated from the failure to conceive following induced ovulation with clomiphene and HCG in the presence of hyperprolactinaemia. In contrast Gambrel1 et al (1971) recorded ovulation in 7 out of 9 subjects with amenorrhoea-galactorrhoea, three of whom conceived following clomiphene and HCG treatment. An effect of prolactin on ovarian steroidogenesis has now been postulated either in the puerperium (Reyes et al, 1972) or in amenorrhoeagalactorrhoea syndromes (McNeilly, 1974). McNatty et a l (1974) showed that although a low level of prolactin is necessary for the production of progesterone by the human ovary in vitro, high levels inhibit progesterone synthesis even with levels of LH and FSH normally sufficient to induce maximum steroidogenesis. The clomiphene test results, however, indicate that total oestrogen production is adequate in
68
GLASS, SHAW, BUTT, LOGAN EDWARDS AND LONDON
these patients with elevated serum prolactin levels and similar to some other groups of amenorrhoeic women treated with clomiphene. Following HCG injection, progesterone production and the length of the luteal phases (on average 12 days) were also normal. Thus gross estimates of ovarian steroidogenesis with elevated prolactin levels suggest that steroidogenesis is not affected adversely, at least during treatment with clomiphene and HCG. The generally good correlation between the results of the oestrogen provocation test, using a 1 mg dose, the oestrogen amplification tests, using a 2-5 mg oestradiol benzoate dose, and the subsequent clomiphene responses, corroborates the previous published findings of Shaw (1976) and Shaw et a1 (1975a and b) and suggests that these tests are satisfactory assessments of feedback mechanisms in subjects with amenorrhoea.
ACKNOWLEDGEMENTS This work was supported by grants from the Central Birmingham Health District Special Trustees Fund and the Medical Research Council. Our thanks to the Staff of the Department of Clinical Endocrinology who kindly performed the various assays. REFERENCES Aono, T., Miyake, A., Shioji, T., Kinugasa, T., Onishi, T., and Kurachi, K. (1976): Journal of Clinical Endocrinology and Metabolism, 42,696. Brown, J. B., MacLeod, S. C., MacNaughton, C., Smith, M. A., and Smyth, B. (1968): Journal of Endocrinology,42,5.
Gambrell, R. D. Jnr., Greenblatt, R. B., and Mahesh, V. B. (1971): American Journal of Obstetrics and Gynecology, 110,838. Glass, M. R., Shaw, R.W., Butt, W. R., Logan Edwards, R., and London, D. R. (1975): British Medical Journal, 3,274. Glass, M . R.,Shaw, R.W., Williams, J. W., Butt, W. R., Logan Edwards, R., and London, D. R. (1976a): Clinical Endocrinoiogy, 5,52 1 erratum, 740. Glass, M. R., Williams, J. W., Butt, W. R.,Logan Edwards, R., and London, D. R. (19766): British Journal of Obstetrics and Gynaecology, 83,495. Kahwanago, I., Heinrichs, W. L., and Herman, W. L. (1 970) : Endocrinology, 86,13 19. Kato, J., Kobayashi, T., and Villee, C. A. (1968): Endocrinology, 82,1049. Marshall, J . C., Morris, R.,Court, J., and Butt, W. R. (1973):Journalof Endocrinology, 59, xxlv. McNatty, K. P., Sawers, R. S., and McNeilly, A. S. ( 1974): Nature, 250,653. McNeilly, A. S. (1974): British Journal of Hospital Medicine, 12,57. Reyes, F. I., Winter, J. S. D., and Faiman, C. C. (1972): American Journal of Obstetrics and Gynecology, 114, 589. Shaw, R. W. (1976): British Journal of Obstetrics and Gynaecology, 83,412. Shaw, R. W., Butt, W. R., London, D. R., and Marshall, J. C. (1974):Journal of Obstetrics and Gynaecofogy of the British Commonwealth, 81,632. Shaw, R. W., Butt, W. R., London, D. R., and Marshall, J. C. (1975a):Clinical Endocrinology,4,267. Shaw, R. W., Duignan, N. M., Butt, W. R., Logan Edwards, R., and London, D. R. (19756): British Journal of Obstetrics and Gynaecology,82,952. Thorner, M. O., McNeilly, A. S., Hagan, C., and Besser, G. M. (1 974) : British Medical Journal, 2,4 19. Vaitukaitis, J. L., Bermudas, J. A., Cargille, C. M., Lipsett, M. B., and Ross, G. T. (1971):Journal of Clinical Endocrinology and Metabolism, 32,503.
