FERTILITY AND STERILITY
Copyright 2001 American Society for Reproductive Medicine
Printed on acid-free paper in U.S.A.
Vaginal versus oral E administration: effects
on endometrial thickness, uterine perfusion,
Renato Fanchin, M.D., Claudia Righini, M.D., Luca Maria Scho¨nauer, M.D.,Franc¸ois Olivennes, M.D., Joa˜o Sabino Cunha Filho, M.D., and Rene´ Frydman, M.D.
Department of Obstetrics and Gynecology and Reproductive Endocrinology, Hoˆpital Antoine Be´cle`re,Clamart, France
To compare the effects of vaginal or oral E administration on endometrial thickness, uterine
Prospective, randomized, crossover study.
Assisted Reproduction Unit, Clamart, France.
Thirty-nine infertile women undergoing 78 E /P cycles.
Women received micronized 17␤-E , 2 mg/day orally (cycle days 1 to 28) and P, 300
mg/day vaginally (cycle days 15 to 28). After a menstrual cycle washout interval, women received a similartreatment except that 17␤-E was administered vaginally.
Main Outcome Measure(s):
Endometrial thickness, mean uterine artery pulsatility index, endometrial blood
flow, and uterine contraction frequency assessed in ultrasound scans on cycle days 14 and 18.
On day 14, the endometrium was thicker (8.7 Ϯ 0.6 vs. 7.1 Ϯ 0.3 mm, P
Ͻ.0001), pulsatility index
values were lower (2.4 Ϯ 0.1 vs. 3.0 Ϯ 0.2, P
Ͻ.0002), and endometrial blood flow tended to be increased in
the vaginal E cycles as compared to the oral E cycles. On day 18, similar differences remained. However,
P-induced decrease in contraction frequency was slighter in vaginal E cycles (33% vs. 18%, P
Vaginal E administration improves endometrial proliferation and uterine perfusion, presum-
ably because of combined local and systemic effects, but may interfere with P-induced uterine relaxation.
(Fertil Steril 2001;76:994 – 8. 2001 by American Society for Reproductive Medicine.)Key Words:
Hormonal replacement cycle, E , P, ultrasound, endometrial receptivity, embryo implantation
Received February 21,2001; revised andaccepted May 24, 2001.
Adequate uterine estrogenization is a neces-
either the oral (1–3, 16) or transdermal (15)
sary condition for uterine receptivity (1–3).
routes have been used, with comparable effi-
Estrogens partake in key mechanisms that reg-
cacy (17). However, in a fraction of cases, both
ulate uterine preparation to embryo implanta-
approaches fail to achieve proper uterine estro-
tion, such as stimulation of endometrial prolif-
genization and lead to defective endometrial
Annual Meeting of theAmerican Society for
eration (4, 5) and improvement of uterine (6, 7)
thickness (4, 5, 18), uterine perfusion (7–9),
and endometrial (8, 9) perfusion. In addition,
and pregnancy rates (4, 5, 7–9, 18).
estrogens are likely to stimulate myometrial
contractile activity during the follicular phase
may be an interesting alternative. A recent
of the menstrual cycle (12, 14). Subsequently,
study by Tourgeman et al. (19) showed that
uterine contractility undergoes a significant de-
vaginal E administration induces serum and
crease during the luteal phase as a result of P
endometrial tissue E concentrations, respec-
(12–14), presumably to assist in embryo im-
tively, 10-fold and 70-fold higher than the oral
route at similar doses (19). These data provide
further support to the hypothesis of a preferen-
modalities of frozen-thawed ET cycles (15,
tial uterine absorption of vaginally adminis-
16), satisfactory priming of the uterus with
tered drugs (20, 21). However, clinical docu-
exogenous E before ET is required. For this,
mentation on possible beneficial effects of
vaginal E administration on endometrial proliferation and
To prevent the possibility that the effect of one cycle
carried over to the other cycle, women were randomly allo-cated to start the protocol by cycle I or cycle II (19 women
In addition, possible overstimulation of uterine contrac-
followed the cycle I– cycle II sequence, and 20 women
tility by the high peripheral and local E levels (12, 14)
followed the cycle II– cycle I sequence). In addition, be-
induced by vaginal E administration, as well as the effec-
tween the two subsequent cycles, all women respected a
tiveness of subsequent uterine relaxation mediated by P,
washout interval of one menstrual cycle without hormonal
remain to be investigated. This issue is of particular impor-
tance because high-frequency contractions at the time of ETare associated with poor implantation rates (11). The hyper-
contractility at the time of ET may be attributable to an
On days 14 and 18 of cycles I and II, ultrasound scans of
incomplete uterine quiescent action of P in the presence of
a sagittal plane of the uterus were performed using a 4.5- to
the supraphysiologic E levels triggered by controlled ovar-
Elegra, Siemens S.A.S., Saint-Denis, France) by one single
Therefore, we elected to investigate the possible uterine
operator (L.M.S.) at approximately 9:00 AM. The operator
impact of E administered vaginally on endometrial thick-
was not aware of the treatment schedule or the clinical
ness, uterine perfusion, and uterine contractions before and
outcome. Environmental conditions were standardized
throughout the ultrasound examination.
To assess the endometrial thickness, endometrial borders
MATERIALS AND METHODS
were set arbitrarily as the outer limits of the hyperechogenicmyometrium– endometrium interfaces. Endometrial thick-
ness (truly double endometrial thickness) was calculated as
We prospectively studied 39 infertile candidates under-
the greatest distance between the outer limits of the proximal
going 78 E /P replacement cycles with frozen-thawed ETs.
and distal endometrial–myometrial interfaces. Sensitivity of
To limit the possibility of confounding factors in the analysis
endometrial thickness calculation was 0.1 mm. Intra-analysis
of our results, we included only young (Ͻ38 years of age),
coefficient of variation of our measurements were Ͻ5%.
nonsmoking, regularly ovulating, lean (body mass indexes
Uterine perfusion was assessed by uterine artery imped-
ranging between 18 and 25) women, whose uteri were mor-
ance (6, 7) and endometrial blood flow (8, 9) measurements.
phologically normal as confirmed by hysteroscopy and ul-
To evaluate uterine artery impedance, blood flow of the
trasound (absence of fibroids, adenomyosis, or polyps).
ascending branches of the right and left uterine arteries was
Women whose uterine position did not allow adequate visu-
detected by color Doppler and assessed with the mean pul-
alization of the uterus by transvaginal ultrasonography were
satility index calculation. Furthermore, the presence or ab-
not included. In addition, women with a history of dilation
sence of endometrial blood flow was evaluated by power
and curettage or uterine surgery were also excluded, because
Doppler. Power Doppler settings were standardized for ad-
of possible confounding effects of these conditions on uter-
equate sensitivity using a high pass filter at 60 Hz, pulsed
ine perfusion and endometrial morphology. Informed con-
repetition frequency at 400 Hz, and moderate long persis-
sent was obtained from all patients, and this investigation
was approved by our Institutional Review Board.
To assess uterine contraction frequency, 2-minute ultra-
sound scans of a sagittal plane of the uterus were digitized
Each subject underwent two hormone replacement cycles.
on-line using a two image/second rate with a computer-
In cycle I, all 39 women received micronized 17␤-E tablets
assisted image analysis system (IoˆTEC 3.1.2, IoˆDP, Paris,
by the oral route (2 mg/day; Provame`s, Cassenne Laborato-
France), which assists in the quantification of frequency of
ries, Puteaux, France), in the evening, from cycle day 1 to
myometrial contractile activity. The present study respected
28. From day 15 to 28, vaginal micronized P was adminis-
similar methodologic characteristics as previously described
tered at doses of 100 mg in the morning and 200 mg in the
(11, 22). Briefly, uterine contraction frequency assessment
evening (Utrogestan; Besins-Iscovesco Pharmaceuticals,
was based on the analysis of time-dependent variation in the
Paris, France). Two or 3 days after P discontinuation, with-
myometrial– endometrium interfaces and uterine cavity by
using a three-dimension-derived methodology (11, 22).
In cycle II, the same women received the same dose of
micronized 17␤-E (2 mg/day) from cycle day 1 to 28, but E
On days 14 and 18, women underwent blood samplings
tablets were placed in the vaginal fornix. Tablets of E used
for serum E and P measurements. Serum E was determined
in both the oral and the vaginal cycles were similar. From
by an immunometric technique using an Estradiol-60 Amer-
days 15 to 28, women received vaginal micronized P treat-
lite kit (Ortho Clinical Diagnostics, Strasbourg, France). The
lower limit of detection was 14 pg/mL, and intra-assay and
FERTILITY & STERILITY
Serum E and progesterone levels in oral and vaginal E cycles.
: Hormonal levels are expressed as means Ϯ SE.
b Not significant.
Fanchin. Uterine effects of vaginal E . Fertil Steril 2001.
interassay coefficients of variation were 8% and 9% for E ,
E administration induced a remarkable increase in endome-
respectively. Serum P was measured by RIA using an I125
trial thickness as compared to oral E administration on days
Progesterone Coatria kit (Bio-Me´rieux, Paris, France). The
14 and 18 (P
Ͻ.0001). After endometrial exposure to P, an
lower limit of detection was 0.05 ng/mL and intra-assay and
additional increase in endometrial thickness occurred in both
interassay coefficients of variation were, respectively, 8%
Vaginal E administration improved uterine perfusion as
compared to oral E administration, with significantly lower
Measures of central tendency used were means and mea-
mean uterine artery pulsatility index values on days 14 and
sures of variability were standard errors. With the inclusion
18. Consistently, the presence of endometrial blood vessels
of 39 patients into this two-treatment, crossover study the
in the endometrium detected by power Doppler tended to be
probability is Ն90% that the study will detect a treatment
more often observed in the vaginal E cycles than in the oral
difference at a two-sided .05 significance level, if the antic-
E cycles on days 14 and 18. However, these differences did
ipated true difference between the treatments is 1 mm for
endometrial thickness, 1 unit of pulsatility index, and 0.5
The consequences of vaginal or oral E on uterine con-
uterine contraction/minute. Because data distribution was
traction frequency are shown in Table 1. In contrast with the
parametric, statistical assessment of pairwise differences be-
markedly different circulating E levels, uterine contraction
tween cycles I and II was performed by using the paired
frequency remained similar in both cycles on day 14. As
-test. A P
value of Ͻ.05 was considered statisti-
expected, after P administration, a significant reduction in
the contraction frequency occurred from days 14 to 18 inboth the vaginal and oral E cycles (P
Yet, the pace of decrease in uterine contraction frequency
as a result of P administration differed in both cycles. Inter-
Consequences of oral or vaginal E administration on
estingly, when women received vaginal E , the decrease in
serum E and P levels are summarized in Table 1. On day 14,
uterine contraction frequency from days 14 to 18 was less
circulating E levels in the vaginal E cycles were approxi-
than when they received E orally (18% vs. 33%, P
mately 10-fold as high as in the oral E cycles, whereas
thereby leading to higher contraction frequency levels in the
serum P remained at very low levels in all women in both
vaginal E cycles on day 18 (P
slightly yet significantly in the vaginal E cycles. As ex-
The present study compared the relative uterine effects of
pected, vaginal P administration increased serum P to levels
vaginal and oral routes for E administration. To address this
commonly observed in the midluteal phase of the menstrual
issue our investigation set stringent methodologic parame-
cycle in both cycles. Furthermore, both modalities for E2
ters. It selected only young, regularly ovulating, lean, non-
administration were observed to be well tolerated by patients
smoking women. Cases of morphologic uterine abnormali-
with no concurrent bleeding and no detectable side effects.
ties or inadequate uterine visualization at ultrasound scans
were excluded. In addition, the crossover design used for E2
Uterine effects of oral or vaginal E administration ob-
administration reduced confounding effects of individual
served in ultrasound scans are detailed in Table 2. Vaginal
attributes in the interpretation of results. Finally, ultrasound
Fanchin et al.
Uterine effects of oral and vaginal E administration.
: Continuous variables are expressed as means Ϯ SE.
a Pulsatility index.
b Expressed as % of cases in which presence of blood flow in the endometrium was detected by power Doppler.
c Not significant.
Fanchin. Uterine effects of vaginal E . Fertil Steril 2001.
scans were analyzed by an independent operator who was
The slight but significant decrease in serum E levels
not aware of treatment modalities, and the assessment of
observed from days 14 to 18 in the vaginal E cycles may
uterine contraction frequency was assisted by a computer-
result from an interference of P administration in the absorp-
tion of vaginal E tablets. Yet, it is noteworthy that this
Our results showed improved endometrial proliferation,
phenomenon did not exert measurable consequences on en-
as reflected by thicker endometria, and increased uterine
dometrial thickness or induced uterine bleeding. This issue
perfusion, as reflected by lower uterine artery pulsatility
needs, however, to be further clarified in women receiving
index values and enhanced endometrial vascularization, in
oral P rather than vaginally. Incidentally, the uniformly low
the vaginal E as compared to the oral E cycles, at the same
P levels observed on day 14 in all 78 cycles studied confirm
doses (2 mg/day). Moreover, uterine contraction fre-
that either oral and vaginal administration of micronized
17␤-E starting in the early follicular phase of the menstrual
cycles, underwent a less notable reduction after P adminis-
cycle (cycle day 1) are effective to prevent ovulation in
tration in the vaginal E than in the oral E cycles.
patients with functioning ovaries (15, 16), even at doses as
The increased endometrial thickness and improved uter-
ine vascularization observed after vaginal E administration
Yet, in contrast with the differences observed in serum E
may be explained by at least two mechanisms. First, as
levels as well as in endometrial proliferation and perfusion,
supported by our own previous data (20) and those of other
uterine contraction frequency remained similar in both
investigators (19, 21), it is possible that the vaginal route
groups on day 14. This observation agrees with our previous
allows a direct, preferential transport of hormones to the
data that indicated that circulating E levels and uterine
uterus. The privileged uterine effects of drugs administered
contraction frequency in COH cycles are not correlated (11,
vaginally presumably are due to a direct in-between or
22). Furthermore, despite the supraphysiologic E
through cell vagina-to-uterus diffusion or a more elaborate
observed in vaginal E cycles, uterine contraction frequency
local transport mechanism involving either a countercurrent
did not increase beyond the values commonly observed at
circulation system with venous to artery diffusion (20, 21).
the late follicular phase of the menstrual cycle (3– 4 contrac-tions/minute) (10, 14). Taken together, these results lead us
Second, it is conceivable that the markedly high periph-
to hypothesize that maximum uterine contractile activity is
eral E levels achieved with the vaginal route concurred with
reached at physiologic E levels and additional increases in
the direct uterine effects to foster endometrial proliferation
circulating E levels are ineffective to further stimulate uter-
and perfusion. Indeed, the 10-fold gradient between serum
E levels achieved by the vaginal as compared to the oral
route observed in the present study is remarkably similar to
Furthermore, the expected decrease in uterine contraction
that reported by Tourgeman et al. (19) and consistent with
frequency as a result of P administration was milder in the
earlier observations (23–25). These discrepancies in serum
vaginal E cycles as compared to the oral E cycles. This
E levels probably are a consequence of the hepatic inacti-
observation is in keeping with the fact that uterine contrac-
vation of orally administered E (26).
tion frequency remains high during the early luteal phase of
FERTILITY & STERILITY
COH cycles, at the time of ET (11, 22), a phenomenon
The value of ultrasonographic endometrial measurement in the predic-tion of pregnancy following in vitro fertilization. Fertil Steril 1986;45:
associated with poor pregnancy rates (11). The observed
“uterine resistance” to P may result from persistent uterine
5. Gonen Y, Casper RF, Jacobson W, Blankier J. Endometrial thickness
and growth during ovarian stimulation: a possible predictor of implan-
stimulating effects of supraphysiologic E levels that thwart
tation in in vitro fertilization. Fertil Steril 1989;52:446 –50.
the uterine quiescent action of P. Contrasting with the lack of
6. Sterzik K, Grab D, Sasse V, Hutter W, Rosenbusch B, Terinde R.
Doppler sonographic findings and their correlation with implantation in
measurable effects on uterine contraction frequency, it is
an in vitro fertilization program. Fertil Steril 1989;52:825– 8.
possible that chronic uterine exposure to supraphysiologic E
7. de Ziegler D, Bessis R, Frydman R. Vascular resistance of uterine
arteries: physiological effects of estradiol and progesterone. Fertil Steril
levels in the vaginal E cycles increases uterine excitability
to levels that are scarcely counterbalanced by P. Our obser-
8. Steer CV, Campbell S, Tan SL, Crayford T, Mills C, Mason BA, et al.
vation of a more profound uterine relaxation mediated by P
The use of transvaginal color flow imaging after in vitro fertilization toidentify optimum uterine conditions before embryo transfer. Fertil
in the presence of lower circulating E levels (oral E cycle)
supports this hypothesis. Hence, increasing the exposure of
9. Yang JH, Wu MY, Chen CD, Jiang MC, Ho HN, Yang YS. Association
of endometrial blood flow as determined by a modified colour Doppler
the uterus to P to restore satisfactory uterine relaxation at the
technique with subsequent outcome of in-vitro fertilization. Hum Re-
time of transfer of frozen/thawed or egg donation embryos
10. IJland MM, Evers JL, Dunselman GA, Volovics L, Hoogland HJ.
should be considered. Yet, it is noteworthy that mean uterine
Relation between endometrial wavelike activity and fecundability in
contraction frequency after P administration remained below
spontaneous cycles. Fertil Steril 1997;67:492– 6.
11. Fanchin R, Righini C, Olivennes F, Taylor S, de Ziegler D, Frydman R.
potentially harmful levels (Ն5 contractions/minute) (11) in
Uterine contractions at the time of embryo transfer alter pregnancy rates
both treatment cycles, which is reassuring with regard to ET
after in-vitro fertilization. Hum Reprod 1998;13:1968 –74.
12. Csapo AI, Pinto-Dantas CR. The cyclic activity of the nonpregnant
human uterus. A new method for recording intrauterine pressure. FertilSteril 1966;17:34 – 8.
In conclusion, the favorable proliferative and vascular
13. Martinez-Gaudio M, Yoshida T, Bengtsson LP. Propagated and non-
propagated myometrial contractions in normal menstrual cycles. Am J
with the adequate tolerance by patients observed by the
14. Lyons EA, Taylor PJ, Zheng XH, Ballard G, Levi CS, Kredentser JV.
present investigation, encourage us to consider the use of the
Characterization of subendometrial myometrial contractions throughoutthe menstrual cycle in normal fertile women. Fertil Steril 1991;55:
vaginal route for E priming of the uterine receptivity in
frozen-thawed ETs and in egg donation cycles. The observed
15. Schmidt CL, de Ziegler D, Gagliardi CL, Mellon RW, Taney FH,
Kuhar MJ, et al. Transfer of cryopreserved-thawed embryos: the natural
improvement of endometrial thickness and uterine vascular-
cycle versus controlled preparation of the endometrium with gonado-
ization may be attributed to both the putative direct uterine
tropin-releasing hormone agonist and exogenous estradiol and proges-terone (GEEP). Fertil Steril 1989;52:609 –16.
effects of vaginally administered hormones (20, 21) or the
16. Lelaidier C, de Ziegler D, Gaetano J, Hazout A, Fernandez H, Frydman
high circulating E levels achieved by vaginal E adminis-
R. Controlled preparation of the endometrium with exogenous oestra-
diol and progesterone: a novel regimen not using a gonadotrophin-
releasing hormone agonist. Hum Reprod 1992;7:1353– 6.
17. Steingold KA, Matt DW, de Ziegler D, Sealey JE, Fratkin M, Reznikov
Hence, this novel approach may be particularly useful in
S. Comparison of transdermal to oral estradiol administration on hor-
the cases of suboptimal endometrial thickness or unsatisfac-
monal and hepatic parameters in women with premature ovarian failure.
J Clin Endocrinol Metab 1991;73:275– 80.
tory uterine perfusion not only in hormone replacement
18. Hassan HA, Saleh HA. Endometrial unresponsiveness: a novel ap-
cycles, but potentially also in COH cycles. Possible benefi-
proach to assessment and prognosis in in vitro fertilization cycles. FertilSteril 1996;66:604 –7.
cial effects of increasing uterine exposure to P to counter-
19. Tourgeman DE, Gentzchein E, Stanczyk FZ, Paulson RJ. Serum and
balance the uterine exciting effects of supraphysiologic E
tissue hormone levels of vaginally and orally administered estradiol.
Am J Obstet Gynecol 1999;180:1480 –3.
levels and further improve uterine quiescence at the time of
20. Fanchin R, De Ziegler D, Bergeron C, Righini C, Torrisi C, Frydman
ET deserve further investigation (27). Finally, prospective
R. Transvaginal administration of progesterone. Obstet Gynecol 1997;90:396 – 401.
randomized studies are needed to ascertain that the beneficial
21. Cicinelli E, de Ziegler D, Bulletti C, Matteo MG, Schonauer LM,
proliferative and vascular uterine effects of vaginal E ad-
Galantino P. Direct transport of progesterone from vagina to uterus.
ministration will lead to a significant improvement of em-
22. Fanchin R, Ayoubi JM, Olivennes F, Righini C, de Ziegler D, Frydman
bryo implantation outcome in hormone replacement or COH
R. Hormonal influence on the uterine contractility during controlledovarian hyperstimulation. Hum Reprod 2000;15:90 –100.
23. Schiff I, Tulchinsky D, Ryan KJ. Vaginal absorption of estrone and
17beta-estradiol. Fertil Steril 1977;28:1063– 6.
24. Rigg LA, Milanes B, Villanueva B, Yen SS. Efficacy of intravaginal
1. Lutjen P, Trounson A, Leeton J, Findlay J, Wood C, Renou P. The
and intranasal administration of micronized estradiol-17beta. J Clin
establishment and maintenance of pregnancy using in vitro fertilization
and embryo donation in a patient with primary ovarian failure. Nature
25. Shushan A, Simon A, Reubinoff BE, Lewin A, Schenker JG, Laufer N.
The use of vaginal tablets as a vehicle for steroid replacement in a donor
2. Navot D, Laufer N, Kopolovic J, Rabinowitz R, Birkenfeld A, Lewin
oocyte program. Fertil Steril 1994;62:412– 4.
A, et al. Artificially induced endometrial cycles and establishment of
26. Yen SS, Martin PL, Burnier AM, Czekala NM, Greaney MO Jr,
pregnancies in the absence of ovaries. N Engl J Med 1986;314:806 –11.
Callantine MR. Circulating estradiol, estrone and gonadotropin levels
3. Li TC, Cooke ID, Warren MA, Goolamallee M, Graham RA, Aplin JD.
following the administration of orally active 17beta-estradiol in post-
Endometrial responses in artificial cycles: a prospective study compar-
menopausal women. J Clin Endocrinol Metab 1975;40:518 –21.
ing four different oestrogen dosages. Br J Obstet Gynaecol 1992;99:
27. Fanchin R, Righini C, de Ziegler D, Olivennes F, Le´de´e N, Frydman R.
Effects of vaginal progesterone administration on uterine contractility
4. Rabinowitz R, Laufer N, Lewin A, Navot D, Bar I, Margalioth EJ, et al.
at the time of embryo transfer. Fertil Steril 2001;75:1136 – 40.
Fanchin et al.
DATE ISSUED: 22 July 2005 PREPARED BY: SM Peters UPDATED BY: Ursula Potgieter UPDATED : 25 March 2013 MATERIAL SAFETY DATA SHEET NUVAN PROFI 1. COMPANY DETAILS: Address: Tel. Nr.: Emergency Tel Nr.: 083 326 3581 / 082 823 4473 2. PRODUCT IDENTIFICATION: Trade Name: Common Name (ISO): Chemical Name: Simplified formula : Molecular weight:
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