Luteoma of Pregnancy Associated with Nearly Complete Virilization of Genetically Female Twins

ObjectiveTo describe a pregnancy that was complicated by the virilization of the mother and two 46XX infants.MethodsWe outline the clinical presentation and diagnosis of the virilization of a mother and her twins, reviewing pertinent literature.ResultsWe report the case of a 40-year-old Caucasian female who conceived a trichorionic triplet pregnancy through in vitro fertilization (IVF) but underwent cytoreduction at 13 weeks of gestation, leaving a diamniotic dichorionic twin pregnancy. At 16 weeks of gestation the mother experienced increasing acne, facial hair, and deepening of her voice. Due to preeclampsia, the twins were delivered via caesarean section at 33 weeks of gestation. The infants had male-appearing external genitalia (Prader score IV-V) but no palpable gonads. Congenital adrenal hyperplasia was ruled out for both twins and they were both found to have a uterus and a 46XX karyotype. Maternal testosterone level was elevated at birth (1,981 ng/dL), but the infants had normal levels. Maternal testosterone levels returned to normal after delivery, consistent with a luteoma of pregnancy, although imaging was negative for a mass.ConclusionThis is the second reported case of complete virilization associated with a luteoma of pregnancy. Whether or not IVF and related procedures increase the risk for a luteoma and whether or not fetal reduction procedures disrupt placental aromatases and increase the risk of virilization in the face of elevated androgen levels are questions that require further research. (Endocr Pract. 2014;20:e18-e23)     

Reproductive endocrine functions in men with primary hypothyroidism: effect of thyroxine replacement

Reproductive endocrine functions were studied in men with primary hypothyroidism during the hypothyroid phase and after achieving euthyroid status with thyroxine substitution therapy. Hypergonadotropism [luteinising hormone (LH), 18.7 +/- 7.3 IU/l; follicle-stimulating hormone (FSH), 6.3 +/- 2.0 IU/l], low serum testosterone (6.1 +/- 2.8 nmol/l), low serum sex-hormone-binding globulin (SHBG; 13.2 +/- 2.0 nmol/l) and subnormal testosterone response to human chorionic gonadotropin hCG; (30% increase in serum testosterone following hCG) observed during the hypothyroid phase were restored to normal (LH, 7.2 +/- 2.0 IU/l; FSH, 2.7 +/- 0.9 IU/l; testosterone, 12.9 +/- 2.7 nmol/l; SHBG, 26.5 +/- 8.4 nmol/l, and 2-fold increase in serum testosterone following hCG) with thyroxine substitution therapy. Some improvement in sperm count and motility was also observed.     

Maternal testosterone and fetal sex

To investigate the influence of fetal sex on maternal testosterone levels throughout pregnancy, blood was sampled from 37 healthy pregnant women from week 14 until term and at 6 weeks postpartum. Testosterone concentrations were measured with a highly specific RIA after chromatographic purification. Mean (+/- SD) testosterone at the end of gestation was significantly higher compared to non-pregnant values (3.10 +/- 2.38 mM/l, n = 32 vs 1.14 +/- 1.06 nM/l, n = 35). It appeared that in women carrying a male fetus testosterone levels gradually increased during pregnancy up to 3.99 +/- 2.72 nM/l. In women carrying a female fetus the levels decreased after the first trimester from 2.44 nM/l to 1.80 nM/l. A statistically significant difference (P less than 0.01) existed in maternal testosterone concentrations between both groups during the second half of pregnancy.     

Acute hormonal response to sublingual androstenediol intake in young men.

The effectiveness of orally ingested androstenediol in raising serum testosterone concentrations may be limited because of hepatic breakdown of the ingested androgens. Because androstenediol administered sublingually with cyclodextrin bypasses first-pass hepatic catabolism, we evaluated the acute hormonal response to sublingual cyclodextrin androstenediol supplement in young men. Eight men (22.9 +/- 1.2 yr) experienced in strength training consumed either 20 mg androstenediol in a sublingual cyclodextrin tablet (Sl Diol) or placebo (Pl) separated by at least 1 wk in a randomized, double-blind, crossover manner. Blood samples were collected before supplementation and at 30-min intervals for 3 h after supplementation. Serum hormone concentrations did not change with Pl. Serum androstenedione concentrations were increased (P < 0.05) above baseline (11.2 +/- 1.1 nmol/l) with Sl Diol from 60 to 180 min after intake and reached a peak concentration of 25.2 +/- 2.9 nmol/l at 120 min. Serum free testosterone concentrations were increased from 86.2 +/- 9.1 pmol/l with Sl Diol from 30 to 180 min and reached a peak concentration of 175.4 +/- 12.2 pmol/l at 60 min. Serum total testosterone concentrations increased above basal (25.6 +/- 2.3 nmol/l) from 30 to 180 min with Sl Diol and reached a peak concentration of 47.9 + 2.9 nmol/l at 60 min. Serum estradiol concentrations were elevated (P < 0.05) above baseline (0.08 +/- 0.01 nmol/l) from 30 to 180 min with Sl Diol and reached 0.14 +/- 0.02 nmol/l at 180 min. These data indicate that sublingual cyclodextrin androstenediol intake increases serum androstenedione, free testosterone, total testosterone, and estradiol concentrations.     

Effects of normalization of plasma testosterone levels in hypogonadal men on plasma levels and urinary excretion of asymmetric dimethylarginine (ADMA).

Elevated plasma levels of asymmetric dimethylarginine (ADMA) inhibit nitric oxide formation and exert a proatherogenic action. Low testosterone (T) levels are associated with increased cardiovascular risks. This study analyzed the effects of normalization of plasma T levels on plasma levels and urinary excretion of ADMA in hypgonadal men (n=10) receiving transdermal T administration. Plasma T levels, starting from clearly hypogonadal T plasma concentrations with a mean level of 4.0+/-2.72 nmol/l at baseline, rose to >10 nmol/l after 2 weeks, with plasma T levels within the normal range of men (mean level of 22.5+/-11.3 nmol/l) over the last 16 weeks of the 24 weeks of T administration. Normalization of plasma T led to a small but significant fall of plasma ADMA (519+/-55 vs. 472+/-59 nmol/l, p=0.031). The outcome of this study may be viewed as a favorable effect of normalization of plasma testosterone on plasma ADMA since even small elevations of plasma ADMA significantly increase cardiovascular risk. While this effect of normalization of plasma T may impress as favorable, most available studies on effects of T administration to hypogonadal men have not shown beneficial effects on functions of the vascular wall.     

Two brothers with non-classical 21-hydroxylase deficiency: to treat or not to treat?

Variations in phenotype in 21-hydroxylase deficiency (21OHD) have cautioned against initiating treatment in the absence of abnormal clinical features. We report 2 Caucasian brothers with compound heterozygous mutations of the CYP21 gene and mild clinical and biochemical features of late-presenting 21OHD. The index case presented aged 8.5 years with mild genital virilization and bone age advanced by 5 years. Elevated basal and synacthen-stimulated 17-hydroxyprogesterone (17OHP; 22.4 and 246 nmol/l) and androstenedione (10.9 and 19.9 nmol/l) levels confirmed 21OHD. His younger brother was investigated at age 7.3 years, and although examination showed normal pre-pubertal genitalia, basal and synacthen-stimulated 17OHP (32.4 and 281 nmol/l) and androstenedione (6.2 and 9.0 nmol/l) were abnormal, and bone age was advanced by 1.5 years. Because of actual or incipient virilization, both patients were treated with glucocorticoid replacement 8-12 mg/m(2)/day. This decision is discussed in the context of published guidelines for the management of 21OHD.     

Free androgen index is superior to total testosterone for short-term assessment of the gonadal axis after renal transplantation

OBJECTIVE: Recent studies have assessed gonadal function in association with different immunosuppressive drugs in transplanted patients mainly relying on the measurement of total testosterone. It is the aim of this study to assess the short-term changes of the hypothalamic-pituitary-gonadal axis following renal transplantation using the free androgen index (FAI). PATIENTS AND METHODS: The sequential changes in total testosterone, sex hormone-binding globulin (SHBG), gonadotropin and prolactin concentrations were measured in 22 male patients before and after 1-3 days, and 1, 2 and 3 weeks following renal transplantation. RESULTS: Total testosterone and SHBG concentrations dropped significantly after transplantation (total testosterone: baseline: 15.2 +/- 1.6 nmol/l vs. 1 week: 7.9 +/- 0.8 nmol/l vs. 2 weeks: 9.8 +/- 0.9 nmol/l, SHBG: baseline: 29.9 +/- 3.2 nmol/l vs. 1 week: 19.9 +/- 2.1 nmol/l, 2 weeks: 18.9 +/- 2.4 nmol/l, p < 0.01). FAI decreased significantly after day 1-3 returning to values near baseline thereafter (baseline: 60 +/- 9% vs. day 1-3: 38 +/- 6%, 2 weeks: 61 +/- 7%; p < 0.01). There was a significant positive correlation between FAI and renal function. CONCLUSION: Measurement of the free androgen index is superior to total testosterone for assessment of the pituitary-gonadal axis in the first weeks after renal transplantation.     

Regulation of plasma corticosteroid-binding globulin in adult cynomolgus monkey (Macaca fascicularis) during different reproductive states

The plasma concentration of the corticosteroid-binding globulin (mCBG) has been measured in Macaca fascicularis, during different stages of reproduction and under hormonal treatments. The mCBG level was determined by a specific electroimmunoassay. There was no difference between females in the follicular phase and intact males; mCBG concentrations were respectively (mean +/- SEM) 469 +/- 53 and 443 +/- 25.6 nmol/l. The mCBG levels levels were similar during both the luteal (469 +/- 33.5 nmol/l) and the follicular phase (469 +/- 53 nmol/l). Compared to intact males, the mCBG levels were higher (P less than 0.05) in castrated males (527 +/- 6.6 nmol/l). During gestation, no systematic variations were found and the mCBG levels were not statistically different from the values found during the follicular phase. When estradiol benzoate was administered to castrated animals, the mCBG concentrations increased rapidly. In contrast, the values were reduced slightly by testosterone treatment. The sex-steroid action on the mCBG levels was discussed and compared with the mSBP levels. We question also, the mechanisms involved in the regulation of the mCBG levels during pregnancy.     

Androgen content of the blood of male hamadryas baboons over the course of a year

Annual blood plasma levels of testosterone, 5 alpha-dehydrotestosterone and dehydroepiandrosterone were measured in hamadryas baboon males using radioimmunoassay. Fluctuations characterized by a decrease in testosterone and 5 alpha-dehydrotestosterone concentrations in spring and an increase in their levels in autumn have been established. Dehydroepiandrosterone level was characterized by two minimal points--at the beginning of the year and in August. The following average annual levels of androgens have been determined: 22.5 nmol/l for testosterone; 4.7 nmol/l for 5 alpha-dehydrotestosterone; 19.0 nmol/l for hydroepiandrosterone.     

Inhibition of human placental aromatase by mefloquine

Aromatase activity of human placental microsomes was inhibited competitively by the antimalarial drug, mefloquine, but not by the related drug, chloroquine. In the absence of any drug, the Km for testosterone was 47.1 +/- 2.3 nmol/l (mean +/- SD, n = 2). In the presence of chloroquine 500 mumol/l, the Km remained unchanged (47.4 +/- 1.8 nmol/l (mean +/- SD, n = 2), whereas mefloquine inhibited competitively with respect to substrate with a Ki value of 72 +/- 4.2 mumol/l (mean +/- SD, n = 2).     

Blood testosterone in rats: correlation with individual anxiety and its derangement after the "death threat"

After preliminary testing on a multiparameter scale, test and experimental groups of Wistar male rats were formed on the principle of identical distribution of individuals with different anxiety levels. A negative Spearman correlation between the testosterone blood concentration and the level of anxiety was observed in intact rats: the minimum hormonal concentrations (lower than 5 nmol/l) were found in rats with high anxiety, whereas the maximum concentrations (up to 16 nmol/l) corresponded to the higher anxiety level (prevalence of passive defense reactions during testing). After a sort-term exposure to life-threatening situation (viewing of a boa's attacking and devouring two victim rats from the test group), the correlation was deranged because of appearance of a scatter in testosterone blood concentration (from 3 to 21 nmol/l) in rats with low anxiety. Neurotization with inescapable pain stimulation also deranged the initial anxiety-testosterone correlation, but, as distinct from the exposure to life-threatening situation, eliminated individual differences in testosterone concentration at its low level. The results suggest the existence of multiple ways of adaptation to life-threatening situations in a rat population.     

Hyperandrogenic states in pregnancy

Hyperandrogenic states in pregnancy are almost always the result of a condition that arises during pregnancy. The onset of virilization symptoms is often very fast. The mother is protected against hyperandrogenism by a high level of SHBG, by placental aromatase and a high level of progesterone. The fetus is protected from the mother's hyperandrogenism partly by the placental aromatase, that transforms the androgens into estrogens, and partly by SHGB. Nevertheless there is a significant risk of virilization of the female fetus if the mother's hyperandrogenic state is serious. The most frequent cause of hyperandrogenic states during pregnancy are pregnancy luteoma and hyperreactio luteinalis. Hormonal production is evident in a third of all luteomas, which corresponds to virilization in 25-35 % of mothers with luteoma. The female fetus is afflicted with virilization with two thirds of virilized mothers. Hyperreactio luteinalis is created in connection with a high level of hCG, e.g. during multi-fetus pregnancies. This condition most frequently arises in the third trimester, virilization of the mother occurs in a third of cases. Virilization of the fetus has not yet been described. The most serious cause of hyperandrogenism is represented by ovarian tumors, which are fortunately rare.     

Dynamics of morphophysiological charateristics in female water voles (Arvicola amphibius L.) during pregnancy

Pregnancy and lactation need increased energy consumption and are accompanied by morphological and physiological changes of various maternal organs and systems. In water voles, connection of female interior characteristics has been poorly studied. Under standard vivarium conditions, we evaluated morphophysiological parameters of non-reproducing females and of females at the early (1–7 days), intermediate (8–14 days), and late (15–21 days) stages of pregnancy. There were established effect of the reproductive state on mass of abdominal and brown adipose tissue, liver, adrenals, spleen and an increment of body mass (without uterus with embryos). In pregnant females, as compared with the non-pregnant ones, the blood thyroxine level was significantly lower (16.2 ± 0.8 and 21.7 ± 1.4 pmol/l) and the blood testosterone level was higher (1.29 ± 0.19 and 0.83 ± 0.09 nmol/l). The blood glucose content fell in the end of pregnancy. Dynamics of morphophysiological parameters at the period of pregnancy reflects the compensatory body reactions providing preservation of embryos and preparation to lactation of offspring.     

Serum 5-androstene-3 beta,17 beta-diol sulphate, sex hormone binding globulin and free androgen index in girls with premature adrenarche

Serum sex hormone binding globulin (SHBG), testosterone (T), DHEA sulphate (DHEA-S), androstenedione (AD) and delta 5-androstene-3 beta,17 beta-diol sulphate (5-ADIOL-S) levels were measured by specific radioimmunoassay in 16 girls presenting with premature adrenarche (PA) and in 14 normal girls. Mean levels of steroids measured were elevated, and SHBG significantly depressed, in the girls with PA, with values (mean +/- SE) for DHEA-S (1.73 +/- 0.17 vs 0.25 +/- 0.06 mumol/l), 5-ADIOL-S (104 +/- 8 vs 31 +/- 4 nmol/l), AD (0.89 +/- 0.06 vs 0.62 +/- 0.04 nmol/l), and T (0.49 +/- 0.03 vs 0.23 +/- 0.06 nmol/l). SHBG levels were 68 +/- 6 vs 108 +/- 5 nmol/l, and the free androgen index [100 x T (nmol/l) divided by SHBG (nmol/l)] was 0.89 +/- 0.17 vs 0.22 +/- 0.01. These studies show that SHBG is depressed in girls with premature adrenarche; with the increased testosterone levels, this results in a markedly elevated free androgen index, a measure of testosterone which is bioavailable to target tissue. This may be compounded by the elevated levels of 5-ADIOL-S in girls with PA since its role may be as a prohormone for more potent androgens (testosterone, 5 alpha-dihydrotestosterone) in target tissues such as pubic skin.     

Changes in serum testosterone and estradiol concentrations following acute androstenedione ingestion in young women.

The effect of androstenedione intake on serum hormone concentrations in women is equivocal. Therefore, we examined the hormonal response to androstenedione intake in healthy young (22.1 +/- 0.4 y) women for 4 hours. On day 3 of the follicular phase, subjects ingested placebo, 100, or 300 mg androstenedione in a random, double-blind, cross-over manner. Blood samples were collected before and every 30 min for 240 min after intake. Serum androstenedione concentrations (means +/- SE) increased above basal (6.2 +/- 0.8 nmol/l) from 60-240 min for both 100 mg (22.6 +/- 1.0 nmol/l at 240 min) and 300 mg (28.1 +/- 1.3 nmol/l at 210 min). Androstenedione intake increased serum total testosterone concentrations above basal (1.2 +/- 0.2 nmol/l) from 120-240 min (5.5 +/- 0.9 nmol/l at 210 min) with 100 mg and from 60-240 with 300 mg (10.2 +/- 1.6 nmol/l at 210 min). Androstenedione intake also increased serum estradiol concentrations (basal 191 +/- 24 pmol/l) at 150 min with 100 mg (237 +/- 35 pmol/l) and from 150-240 min with 300 mg (reaching 260 +/- 32 pmol/l at 240 min). These data indicate that, in contrast to men, androstenedione intake in women increases serum testosterone concentrations.     

Trial of support treatment with human chorionic gonadotrophin in the luteal phase after treatment with buserelin and human menopausal gonadotrophin in women taking part in an in vitro fertilisation programme.

OBJECTIVE--To evaluate the effect of support with human chorionic gonadotrophin in the luteal phase in women taking part in an in vitro fertilisation programme after buserelin and human menopausal gonadotrophin were used to hyperstimulate their ovaries. DESIGN--Controlled group comparison. SETTING--Outpatient department of a private hospital. PATIENTS--115 Women with indications for in vitro fertilisation, all of whom had at least one embryo transferred. INTERVENTIONS--After suppression of the pituitary with buserelin the ovaries of all the women were stimulated with human menopausal gonadotrophin on day 4 of the luteal phase. Human chorionic gonadotrophin (10,000 IU) was given to induce ovulation, and oocytes were recovered 34 hours later. Embryos were transferred 46 to 48 hours after insemination. Women who had received the 10,000 IU of human chorionic gonadotrophin on a date that was an uneven number (n = 61) were allocated to receive support doses of 2500 IU human chorionic gonadotrophin three and six days after that date. The remaining 54 women did not receive hormonal support. END POINT--Determination of the rates of pregnancy. MEASUREMENTS and main results--Support with human chorionic gonadotrophin did not significantly alter the progesterone or oestradiol concentrations in the early or mid-luteal phase. The mean (range) progesterone concentrations in the late luteal phase in women who did not become pregnant were, however, significantly higher in those who received support (16(9-110) nmol/l nu 8(4-46) nmol/l), and the luteal phase was significantly longer in this group (14 days nu 12 days). The rate of pregnancy was significantly higher in the women who received support than in those who did not (25/61 nu 8/54). CONCLUSIONS--When buserelin and human menopausal gonadotrophin are used to hyperstimulate ovaries support with human chorionic gonadotrophin in the luteal phase has a beneficial effect on in vitro fertilisation.     

Paradoxical surge of corticotropin after glucocorticoid replacement in central adrenal insufficiency

A 78-yr-old man was admitted in emergency with fatigue, anorexia, vomiting, hypothermia (35.1 °C on a hot August day), hypotension (89/56 mmHg) and hyponatraemia (126 mEq/l). Plasma corticotropin and cortisol were severely depressed: 0.84 pmol/L and 33.1 nmol/L respectively (reference range, 1.5-13.9 pmol/L and 110-505 nmol/L, respectively). Thyroid stimulating hormone was low-normal and free-triiodothyronine and free-thyroxine were subnormal. Magnetic resonance imaging revealed swelling of the pituitary gland and the stalk. The patient recovered after glucocorticoid replacement (200 mg/day intravenous hydrocortisone on Day 1 followed by tapering). Central diabetes insipidus which had become apparent had been treated with 1-desamino-8-D-arginine vasopressin. A surge of corticotropin and cortisol, 19.4 pmol/L and 712.1 nmol/L respectively, was found on Day 5 when luteinizing hormone, follicle stimulating hormone, and testosterone were subnormal and prolactin was slightly elevated. Subsequently, corticotropin and cortisol levels normalized together with normalization of luteinizing hormone, follicle stimulating hormone, anti-diuretic hormone, thyroid stimulating hormone, prolactin, testosterone and thyroid hormone levels. Shrinkage of the pituitary gland occurred after one month. Serum immunoglobulin G4 was elevated (3.21 and 6.02 g/l at 1- and 3-month follow-ups respectively). In conclusion, a paradoxical surge of corticotropin after glucocorticoid replacement was observed in a patient with central adrenal insufficiency due to immunoglobulin G4-related hypophysitis. Surge of ACTH in central adrenal insufficiency after glucocorticoid replacement has rarely been reported, and this is the second such case report.     

A comparison of serum androgens in pre-eclamptic and normotensive pregnant women during the third trimester of pregnancy

Objective: To compare the serum androgens level during the third trimester of pregnancy between normotensive and pre-eclamptic women. Method: A case-control study was performed on 64 pregnant women with the gestational age of 28-34 weeks. 32 women were pre-eclamptic (case group), and 32 women were normotensive till term gestation (control group). The serum level of androgens including sex hormone binding globulin (SHBG), total and free testosterone, androstenedione (ADD), and dehydroepiandrosterone sulfate (DHEA-S), were compared between the two groups. Results: The women of the two groups had no statistically significant difference according to age, gestational age, BMI (body mass index), parity and fetal sex. Serum level of SHBG (90.86 ± 9.30 vs. 55.86 ± 8.02 nmol/l, p = 0.02), total testosterone (3.70 ± 0.57 vs. 2.06 ± 0.24 ng/ml, p = 0.01), free testosterone (1.28 ± 0. 17 vs. 0. 74 ± 0.07 pg/ml, p = 0.01), and ADD (2.47 ± 0.10 vs. 2.17 ± 0.10 ng/ml, p = 0.04), was higher in the pre-eclamptic women. However, there was no difference between the two groups for DHEA-S (0.75 ± 0.18 vs. 0.51 ± 0.08 μg/ml, p = 0.19). Conclusion: Serum androgen levels during third trimester of pregnancy are higher in pre-eclamptic women and this may propose an effect of androgens in the pathogenesis of pre-eclampsia.     

Effects of low testosterone levels and of adrenal androgens on growth of prostate tumor models in nude mice

Two transplantable, androgen dependent prostate tumor models of human origin, PC-82 and PC-EW, were used to study the effect of low androgen levels and adrenal androgens on prostate tumor cell proliferation. Tumor load of the PC-82 and PC-EW tumors could be maintained constant when plasma testosterone levels were 0.8 and 0.9 nmol/l, respectively, corresponding with an intratissue 5-dihydrotestosterone level of 3–4 pmol/g tissue. This critical androgen level for prostate tumor growth stimulation amounted to 2–3 times the castration level and proved to be similar for both tumor models. Relatively high levels of androstenedione resulted in physiological levels of plasma testosterone causing androgen concentrations in PC-82 tumor tissue exceeding the critical level for tumor growth. These results indicate that submaximal suppression of androgens can stop tumor growth in these prostate tumor models.     

17,20-desmolase deficiency in a female newborn, paradoxically virilized in utero

The patient was born with ambiguous genitalia (stade III of Prader). The karyotype revealed a normal female genotype. A defect in 21-hydroxylase, at first suspected, was denied by the hormonal studies. Indeed, extremely high levels of pregnenolone, pregnenolone sulfate, progesterone were found in association with low plasma levels of delta 4-androstenedione, testosterone, dehydroepiandrosterone and its sulfate, while cortisol 17OH-progesterone and ACTH levels and plasma renin activity were normal. The hormonal pattern was thus consistent with 17,20-desmolase deficiency. The dynamic studies further supported this contention: all the progestagens rose further after ACTH stimulation and were suppressed by dexamethasone. Meanwhile, all androgens failed to rise after ACTH: the responses of cortisol were normal. The in utero virilization of the female fetus was not understood until an history of virilization was allegedly found in the mother (luteoma of pregnancy). This is the first case of 17-20 desmolase defect recognized in a female newborn. This child, born with ambiguous genitalia had presented the concurrence of two very rare conditions. The in utero virilization of maternal origin enabled us to make the diagnosis of the 17-20 desmolase defect, which otherwise would have been ignored in a XX subject in the neonatal period because it would obviously be unsymptomatic at this age.