Previous estimates of the rate of progression of the nigral pathology underlying idiopathic parkinsonism (IP) have been derived mainly from pathological studies that have an inherent selection bias. Fluorodopa positron emission tomography (PET) is a reliable tool for assessing nigrostriatal dopaminergic function in vivo. We performed fluorodopa PET on two occasions, 7 years apart, on 16 patients with IP (age at the time of the first scan, 51 +/- 14 yr [mean +/- SD]) and 10 normal controls (age, 54 +/- 16 yr). For the patients with IP, the average duration of symptoms from the time of diagnosis to the first scan was 4.5 years (range, 1-12 yr); their PET index (striatal-occipital)/occipital ratio, dropped by 1.7% per year, from 0.49 +/- 0.08 to 0.43 +/- 0.08 (p < 0.001). The normals' ratio decreased by 0.3% per year from 0.77 +/- 0.05 to 0.75 +/- 0.10 (p = 0.33). The ratios in the IP group progressed significantly faster than the controls (p = 0.036). The rate of decline in IP represents 7.8% per decade, expressed as a fraction of the normals' initial mean value at 54 years of age. These results also permit power analysis for the design of future studies assessing the effect of treatment on the underlying pathology in IP.