236 John Rock 



1. The norma i untreated cycle. In the classical 28-ciay cycle, the pseudo- 

 cuboidal lining of the early proliferative gland (cf. Fig. 2, day 5) gradually 

 changes to pscudostratification as ovulation approaches (Fig. 2, day 12). 

 Next is depicted the 4-day postovulatory gland with mobilization of the 

 nuclei toward the lumen. Then the nuclei promptly recede toward the bases 

 of the cells at about 5 days after ovulation (Fig. 2, day 19). In the 21-day 

 gland, i.e. at about 7 days after ovulation, the secreted material begins to 

 accumulate so that the glands dilate and subsequently become ''saw-toothed" 

 on day 25 of the normal cycle. The succeeding premenstrual secretory 

 exhaustion, characteristic of day 27, is also depicted. 



2. The treated cycle. Now let us consider what occurs during a treated 

 cycle. When medication is started on day 5, the entire process is accelerated. 

 Already on the 9th cycle-day, pills having been taken for 4 days, we find the 

 same sort of active gland that, in the normal, untreated cycle, is observed 

 not until 4 days after ovulation, i.e. on about day 18. 



At this stage in the medicated cycle, the speed of epithelial change decreases. 

 On cycle-day 16, the 11th day of treatment, we get a gland which resembles 

 that typical of only the 5th day after ovulation (day 19). Even so, its secretory 

 progress is more advanced than would be the case with a 2-day-old corpus 

 luteum (day 16 of the normal, untreated cycle). 



From then on, the glands regress faster and also further than they do in 

 the ordinary progestational phase of the normal cycle. Many of them become 

 very small, like the postmenstrual glands. We find numerous simple, hypo- 

 trophic glands in the thinned-out endometrium, accompanied by some glands 

 that are characteristic of secretory exhaustion. The reticular stroma of the 

 proliferative and early postovulatory phases also more rapidly and completely 

 progresses toward a predecidua. 



At about the 21st day of the cycle, when the patient has had 16 days of 

 treatment, the pathologist who does not know this consisted of norethynodrel 

 may render a diagnosis: "consistent with beginning pregnancy". This is 

 excusable, for, commonly, the tissue closely resembles that in which pro- 

 gestational stromal mutation has been prolonged; and easily unnoticed is the 

 fact that some of the glands fail to show the regression which is so character- 

 istic of pregnancy dccidua. 



It is noteworthy that this progestin may extend its influence in 15 days 

 to the stroma of the lower uterine area and even into the upper cervix where, 

 in the normal, untreated cycle, we ordinarily do not find the characteristic 

 signs of autogenous progesterone even just before menstruation (Fig. 3). 



VI. EFFECTS OF LONG-TERM USE OF ENOVID 

 A. Ejfect on Ovulation in Postmedication Cycles 



Since Enovid evokes endometrial changes reminiscent of pregnancy, it 

 seemed as though it might be of value in endometriosis for, during pregnancy. 



