Long-term follow-up of mothers and their offspring, 1983
In the early 1950s, a randomized, double-blind, controlled trial of the value of prophylactic stilboestrol therapy given antenatally to reduce the incidence of late pregnancy toxaemia and to improve perinatal mortality was conducted at University College Hospital, London.
Women expecting their first baby were allocated to one or other of two groups. Those in the stilboestrol group started treatment at the 12th week of pregnancy on average and received a mean dose of about 11.5 g of the drug while those in the control group received placebo tablets.
In spite of the fact that the original trial documentation was lost, it was possible to be fairly certain which was the treated group and follow-up data from 650 mothers and 660 offspring were obtained from death certificates, cancer registrations and questionnaires sent to general practitioners.
We found no indication of any harmful long-term effect of stilboestrol exposure during pregnancy on the mothers–in particular 10 out of 331 women in the untreated group and 9 out of 319 women in the treated group were found to have developed breast cancer.
Amongst the daughters, those in the treated group suffered an excess of minor benign lesions of the cervix uteri and an excess (not statistically significant) of unfavourable pregnancy outcomes. None of the daughters had developed clear cell adenocarcinoma of the vagina or cervix uteri.
Amongst the sons, we discovered no evidence of any significant excess of genital tract disorders or of impaired reproductive performance in the treated group but one son developed a (fatal) teratoma of the testis.
Unexpectedly, psychiatric disease (especially depression and anxiety) was reported by general practitioners about twice as often in the treated group offspring (sons and daughters) as in the untreated group. This result cannot be due to bias, and is unlikely to be due to confounding or chance, and may thus represent an adverse effect of exposure to stilboestrol in utero.
A randomized double-blind controlled trial of the value of stilboestrol therapy in pregnancy: long-term follow-up of mothers and their offspring, British journal of obstetrics and gynaecology, NCBI PubMed, PMID: 6357269, 1983.
(DES Daughters) Intrauterine diethylstilbestrol (DES) exposure is associated with an increased risk for the development of clear cell adenocarcinoma (CCA) of the vagina and cervix. The age of the patients at diagnosis has varied from 7-35 years with the highest frequency from 14-22 years. The risk among the exposed, however, is small and is of the order of 1 per 1,000. Almost all of the cases occur in postmenarchal females. Other factors that may increase the risk are maternal history of prior miscarriage, exposure to DES in early gestation, a fall season of birth and prematurity. The occurrence of CCA has paralleled the sales of DES for pregnancy support in the U.S. Both vaginal adenosis (benign glands in the vagina) and CCA are more frequent among those whose mothers began DES in early pregnancy. An increased risk of squamous cell neoplasia has been hypothesized but not proven. The changes that occur in the female genital tract of the DES exposed appear to result from alterations in the development of the mullerian ducts.
Currently there is not definitive evidence for an elevated risk of cancer among DES mothers or DES sons but studies have suggested a possible increase of breast cancer in the former group and testicular cancer in the latter group; a valid association has not been established in either.
The effects in the human of diethylstilbestrol (DES) use during pregnancy, NCBI PubMed, PMID: 3506546, 1987.
Strong epidemiological evidence has linked clear-cell adenocarcinoma of the vagina in young women to maternal ingestion of DES during the 1st 18 weeks of pregnancy. Benign abnormalities of the genital tract have also occurred in daughters of women exposed during pregnancy.
3 data sources have been particularly important for continued assessment of DES:
the 1951 University of Chicago double-blind study following controls, treated women, and offspring;
the National Cooperative Diethylstilbestrol Adenosis (DESAD) project which collects information on thousands of women exposed in utero,
and the Registry of Clear-Cell Adenocarcinoma (Mesonephroma) of the Genital Tract in Young Females.
The risk of clear-cell adenocarcinoma of the vagina and cervix in this group for ages 14 through 24 is estimated to be .14-1.4/1000 females exposed in utero. The risk is highest when exposure was early in intrauterine life. Peak incidence of tumors is between 17-21 years, rarely appearing before the age of 14. Concern over an increase in squamous cell dysplasia was raised, however a Massachusetts General Hospital study showed the prevalence of dysplasia was 2.1% and the incidence .85/1000 women years of follow-up. Benign abnormalities of the genital tract are common among this group and include: vaginal adenosis and structural abnormalities such as cervical hoods, ridges, and T-shaped uterus. The structural abnormalites may predispose to problems with reproduction; the incidence of complications after the 20th week of pregnancy, premature delivery, and perinatal death were found to be significantly increased. Results are conflicting concerning the impact of DES exposure on fertility.
Males exposed to DES in utero may have an increased frequency of anatomic and functional changes including epididymal cyst, hypoplasia of the testes, induration of the testicular capsule and impairment of spermatogenesis, sperm maturation, and accessory gland secretion.
The data are inconclusive concerning the incidence of breast cancer for women who took DES during pregnancy.
The psychological impact on the mothers who took DES and on the exposed offspring is another important consideration.
Diethylstilbestrol in pregnancy: an update, Canadian Medical Association journal, NCBI PubMed, PMID: 7139494, 1982.
DES Sons : malignant lesions have not been reported.
The Department of National Health and Welfare’s special advisory committee are closely monitoring women, who used DES (diethylstilbestrol) for protection of pregnancy, and their offspring.
DES daughters have an increased risk of benign abnormalities of the genital tract and, infrequently, vaginal or cervical cancer.
Prenatal exposure of males to DES have shown a low frequency of epidiymal cysts, hypoplastic testes, induration of the testicular capsule, and impairment of spermatogenesis, sperm maturation, and accessory gland secretion.
Women who used DES during their pregnancy may possibly have an increased risk of breast cancer although the incidence is not statistically significant.
The advisory committee recommends that DES and other estrogenic drugs not be used during pregnancy for treatment of threatened abortion due to the possible abnormalities of the fetus. Instead the committee suggests that DES be used for patients with estrogen-responsive metastatic breast cancer or advanced prostate cancer.
Diethylstilbestrol: risks of malignant disease and congenital malformations, Canadian Medical Association journal, NCBI PubMed, PMID: 455196, 1979. Full text PDF.
A subsequent reanalysis of [Does the administration of diethylstilbestrol during pregnancy have therapeutic value?] data revealed that DES increased the risk of spontaneous abortion, preterm birth, and neonatal death, 1978
Dieckmann’s report that DES had no effect on pregnancy was, in one sense wrong: the published data clearly show that DES significantly increased abortions, neonatal deaths, and premature births (see table).
Although the exact number of pregnant women treated with DES is unknown, it has been estimated to be as high as 2 million. A sizeable fraction of these exposures occurred between 1953, when the Dieckmann paper was published, and 1971, when Herbst’s article appeared.
This exposure might have been avoided if the Dieckmann data had been interpreted correctly to show that DES was harmful to the fetus and newborn.
Dangers of diethylstilboestrol: Review of a 1953 paper, Lancet, NCBI PubMed, PMID: 79882, 1978.
Randomized trial of diethylstilbestrol vs. tamoxifen in postmenopausal women with metastatic breast cancer. An updated analysis, 1999
One hundred fifty-one postmenopausal women with progressive metastatic breast cancer and no prior hormonal therapy were treated with either diethylstilbestrol (DES) or tamoxifen (TAM).
One hundred forty-three eligible patients were followed until death or for a minimum of 14.1 years on the DES arm or 16.7 years on the TAM arm. The overall objective response was 42% for DES and 33% for TAM (p = 0.31) and the median duration of response was 11.8 months for DES and 9.9 months for TAM (p = 0.38). Duration of response and progression-free survival were not found to be significantly different between DES and TAM (p = 0.32 and 0.65, respectively). The median survival was 3.0 years for DES vs. 2.4 years for TAM. The 5-year survival was 35% for the DES arm and 16% for the TAM arm. Survival was significantly better for women on DES than for women on TAM (adjusted p = 0.039). Review of records did not show any difference in pattern of treatment failure or subsequent treatments in the DES and TAM arms. Treatment with DES was more commonly associated with toxicity such as nausea, edema, vaginal bleeding, and cardiac problems, whereas hot flashes were commonly seen with TAM therapy.
The initial treatment with DES is associated with increased survival. The basis of this survival advantage is not known. TAM still is the preferred agent in the treatment of metastatic breast cancer, but this trial underscores the fact that estrogens have activity and remain in the armamentarium for treatment of selected patients with metastatic breast cancer.
Randomized trial of diethylstilbestrol vs. tamoxifen in postmenopausal women with metastatic breast cancer. An updated analysis, Breast cancer research and treatment, NCBI PubMed PMID: 10424402, 1999 Mar.
Side effects of estrogen administration to prostatic cancer patients: clinical and statistical survey of 109 prostatic cancer cases of Kyoto University Hospital, 1993
Since the introduction of hormonal treatment for prostatic cancer by Huggins and Hodges in 1941, severe side effects of synthetic estrogen, which have overcome its benefit, have been reported in the U.S.A. and in European countries.
However, in Japan the adverse effects of estrogen have been reported to be milder than in western countries, and estrogen still has an important role in the treatment of prostatic cancer in Japan.
In this communication, the side-effects of synthetic estrogen administered to 109 prostatic cancer patients, who were admitted to Kyoto University Hospital between 1980-1990 are reported.
Fifty-three (48.6%) of the 109 patients suffered adverse side effects of the estrogen, specifically cardiac disease (20.2%), fluid retention (14.7%) and hypertension (13.8%). Five of these patients died. Among the risk factors analyzed, daily dose, past history of cardio-vascular disease and ECG abnormalities were significantly correlated with the appearance of adverse effects. The reasons why the frequency of lethal side-effects is lower in our cases compared to findings reported by the Veterans Administration group may be the lower daily dose and cessation of estrogen administration when mild adverse effects appear and some other unknown factors, although the background of the patients and method of analysis are not comparable among them.
The overall frequency of side-effects in prostatic cancer patients administered estrogen in our cases is not necessarily lower than in western countries, but the severity of the side effects was milder in our cases. We must be a ware of the potential adverse effects of estrogen.
Side effects of estrogen administration to prostatic cancer patients: clinical and statistical survey of 109 prostatic cancer cases of Kyoto University Hospital, Hinyokika kiyo. Acta urologica Japonica, NCBI PubMed PMID: 8460581, 1993 Jan.
Diethylstilbestrol revisited in advanced breast cancer management, 1990
Prior to the introduction of tamoxifen, diethylstilbestrol (DES) was widely used as the first-line endocrine therapy in postmenopausal women with advanced breast cancer.
Since randomized trials reported that tamoxifen has a similar response rate but fewer side effects than DES, its use has declined markedly.
We administered DES in a dose of 10-20 mg daily to 11 postmenopausal women with advanced breast cancer, all of whom had received previous endocrine and some cytotoxic therapy also.
Four women showed tumour responses to DES (1 complete and 3 partial), 5 had stable disease, and 2 progressive disease. Amongst the patients who responded, 2 had previously been unresponsive to other endocrine treatments. Of the women with stable disease, 3 had prolonged relief of symptoms. No withdrawal responses were noted. The major side effects were nausea (severe in 2 patients, mild in 1) and cardiac failure (2 patients).
We conclude that DES remains a useful, active agent in the management of advanced breast cancer in postmenopausal women, even in patients with tumours unresponsive to other endocrine therapy.
Diethylstilbestrol revisited in advanced breast cancer management, Medical and pediatric oncology, NCBI PubMed PMID: 2355892, 1990.
IN AGREEMENT WITH ITS extragovernmental physician-advisers, FDA has approved, under restricted conditions, postcoital (contraceptive) use of diethylstilbestrol (DES), a synthetic estrogen.
Adequate evidence to support the use of any other estrogen for this purpose is not presently available.
The Agency considers the use of DES for this purpose to be safe only as an emergency measure (in situations such as rape, incest, or where, in the physician’s judgment, the patient’s physical or mental well-being is in jeopardy) and explicitly warns against its routine or frequent use as a contraceptive.
Physicians are urged, prior to prescribing DES for this purpose, to inform patients (or guardians) fully of the possible side effects of the drug, and of alternative measures available and their hazards, so that the patient may participate in an informed way in the decision to use the drug. Pregnancy should be ruled out by appropriate tests prior to instituting therapy, so that no unnecessary exposure of a fetus to DES occurs.
The efficacy of DES in preventing pregnancy depends upon the time-lapse after coitus and dosage of the drug. The currently recommended dosage is 25 mg twice a day for 5 continuous days beginning, preferably, within 24 hours and not later than 72 hours after exposure. When this dosage is given within the specified time interval after sexual intercourse, DES is highly effective in preventing conception. But the patient must be warned to take the full course of the drug in spite of the nausea which commonly occurs, if it is to be effective.
There is at present no positive evidence that the restricted postcoital use of DES carries a significant carcinogenic risk either to the mother or fetus. However, because existing data support the possibility of delayed appearance of carcinoma in females whose mothers have been given DES later in pregnancy, and because teratogenic and other adverse effects on the fetus with the very early administration recommended are ill understood, failure of postcoital treatment with DES deserves serious consideration of voluntary termination of pregnancy.
Before prescribing, the physician should be familiar with the complete FDA-approved labeling on products intended for this use.
More Information – Abstract from WikiVisually
In May 1973, in an attempt to restrict off-label use of DES as a postcoital contraceptive to emergency situations such as rape, a FDA Drug Bulletin was sent to all U.S. physicians and pharmacists that said the FDA had approved, under restricted conditions, postcoital contraceptive use of DES. (In February 1975, the FDA Commissioner testified that the only error in the May 1973 FDA Drug Bulletin was that the FDA had not approved postcoital contraceptive use of DES.)
In September 1973, the FDA published a proposed rule specifying patient labeling and special packaging requirements for any manufacturer seeking FDA approval to market DES as a postcoital contraceptive, inviting manufacturers to submit abbreviated new drug applications (ANDAs) for that indication, and notifying manufacturers that the FDA intended to order the withdrawal of DES 25 mg tablets (which were being used off-label as postcoital contraceptives).
In February 1975, the FDA said it had not yet approved DES as a postcoital contraceptive, but would after March 8, 1975 permit marketing of DES for that indication in emergency situations such as rape or incest if a manufacturer obtained an approved ANDA that provided patient labeling and special packaging as set out in a FDA final rule published in February 1975. To discourage off-label use of DES as a postcoital contraceptive, in February 1975 the FDA ordered DES 25 mg (and higher) tablets removed from the market and ordered the labeling of lower doses (5 mg and lower) of DES still approved for other indications be changed to state: “THIS DRUG PRODUCT SHOULD NOT BE USED AS A POSTCOITAL CONTRACEPTIVE” in block capital letters on the first line of the physician prescribing information package insert and in a prominent and conspicuous location of the container and carton label.
In March 1978, a FDA Drug Bulletin was sent to all U.S. physicians and pharmacists which said: “FDA has not yet given approval for any manufacturer to market DES as a postcoital contraceptive. The Agency, however, will approve this indication for emergency situations such as rape or incest if a manufacturer provides patient labeling and special packaging. To discourage ‘morning after’ use of DES without patient labeling, FDA has removed from the market the 25 mg tablets of DES, formerly used for this purpose“.
Selected Items, from the FDA Drug Bulletin, California Medicine, NCBI PubMed PMC1455105, May 1973.
…”In spite of evidence that success in the macaque should be paralleled by success in man, initial human experimentation was undertaken with some trepidation.
The first cases were rape cases. All of the subjects received 50 mg. of stilbestrol for 4 to 6 days after exposure. The chance of pregnancy following rape is uncertain for many obvious reasons. Sometimes no sperm could be found in the cervix or vagina. In a few instances, temperature charts were started; if no rise occurred, no drug was given. In most of the cases accepted for treatment, exposure occurred near midcycle and fern crystallization of cervical mucus as well as presence of sperm were demonstrated. In this small series of patients, none has become pregnant so far. The subsequent menstruation was generally unremarkable, although in some instances it was either scantier or more profuse or prolonged than usual. Side effects, when they occurred, were those usually associated with administration of estrogen; they consisted of nausea and breast soreness, which ceased shortly after medication was stopped.
A limited number of courageous volunteers furnished an opportunity for further and more adequate observation. Coitus took place at midcycle near the time of the temperature rise. Fern crystallization and Huhner tests with motile sperm were obtained in most instances.
The apparent effect of 5 to 50 mg. of stilbestrol or 0.5 mg. of ethinyl estradiol on the biphasic temperature curve chart is to counteract the thermogenic effect of progesterone or to shorten the luteal phase.
From these charts it was anticipated that the secretory changes in the endometrium might be altered. However, instead of a proliferative or hyperplastic endometrium, endometrial biopsies taken on postovulation days 5 to 7 and 10 to 12 showed a progestational effect with secretion in some instances on both sides of the nucleus, occasionally almost suggestive of an Arias-Stella reaction. The stroma was dense in some areas, markedly edematous in others. Basal vacuolization often persisted up to menstruation, sometirnes giving an early secretory appearance late in the cycle.
In these preliminary trials there have been no pregnancies. While of interest, these clinical studies are incomplete and have as yet no statistical significance.” …
Compounds interfering with ovum implantation and development. 3. The role of estrogens, American journal of obstetrics and gynecology, NCBI PubMed PMID: 4959099, 1966 Nov.