Group A Streptococcus causing PID from an initial pharyngeal infection. A case report.

BACKGROUND: Pelvic inflammatory disease (PID) is a difficult diagnosis. Five billion dollars is spent on over 1 million women diagnosed each year. Atypical organisms and prior history of tubal ligation may complicate the diagnosis. CASE: A woman who had undergone tubal ligation and abstained from intercourse for over two years developed group A streptococcal salpingitis. It occurred following an upper respiratory infection with the same organism. CONCLUSION: PID is rare in a woman with prior tubal ligation who is not engaging in intercourse. In this case it followed an upper respiratory infection with group A Streptococcus. Low diagnostic suspicion must be maintained for uncommon pathogens in PID in women with prior tubal ligation who are not engaging in intercourse.

Transdermal progesterone cream for vasomotor symptoms and postmenopausal bone loss.

OBJECTIVE: To determine effectiveness of transdermal progesterone cream for controlling vasomotor symptoms and preventing postmenopausal bone loss. METHODS: We randomly assigned 102 healthy women within 5 years of menopause to transdermal progesterone cream or placebo. Study subjects and investigators were masked until data analysis was completed. An initial evaluation included complete history, physical examination, bone mineral density determination, and serum studies (TSH, FSH, lipid profile, and chemistry profile). Subjects were instructed to apply a quarter teaspoon of cream (containing 20 mg progesterone or placebo) to the skin daily. Each woman received daily multivitamins and 1200 mg of calcium and were seen every 4 months for review of symptoms. Bone scans and serum chemistries were repeated after 1 year. RESULTS: Thirty of the 43 (69%) in the treatment group and 26 of the 47 (55%) in the placebo group complained initially of vasomotor symptoms. Improvement or resolution of vasomotor symptoms, as determined by review of weekly symptom diaries, was noted in 25 of 30 (83%) treatment subjects and five of 26 (19%) placebo subjects (P < .001). However, the number of women who showed gain in bone mineral density exceeding 1.2% did not differ (alpha = .05, power of 80%). CONCLUSION: Although we found no protective effect on bone density after 1 year, we did see a significant improvement in vasomotor symptoms in the treated group.

Human follicle fluid vascular endothelial growth factor concentrations are correlated with luteinization in spontaneously developing follicles.

Vascular endothelial growth factor (VEGF) is a cytokine that induces angiogenesis. Angiogenesis is a prominent histologic component of the luteinization process. Luteinization is also characterized by granulosa cell progesterone secretion in response to the luteinizing hormone (LH) surge. Local VEGF production in human pre-ovulatory follicles, induced by LH, was postulated to be a luteinization mediator in women. To investigate this hypothesis, serum and fluid from the dominant follicle of 31 healthy regularly cycling multiparous women undergoing laparoscopic sterilization were obtained. VEGF was measured by enzyme-linked immunosorbent assay, and LH and progesterone were measured by radioimmunoassay. Follicle aspiration was performed at a median of 13 days from the last menstrual period (range 11-17 days). The median pre-ovulatory follicle diameter was 16 mm (range 11-23 mm). Follicle fluid VEGF concentrations (mean 6900 pg/ml, range 1200-17 100 pg/ml) were correlated positively with follicle fluid progesterone concentrations (mean 10 176 nmol/l, range 636-66780 nmol/l, r=0.62, P=0.002). This correlation was even tighter (r=0.87, P < 0.0001) when only samples from the 22 women in the earliest stages of follicle luteinization were considered. In these women serum LH concentrations were also correlated with follicle fluid VEGF concentrations (r=0.51, P=0.02). Our findings demonstrate the close dynamic relationship between VEGF production and early luteinization in human follicles during normal non-stimulated cycles.

Premature ovarian failure: an update.

OBJECTIVE: To present an overview of potential etiologies, clinical manifestations, and treatment modalities of premature ovarian failure (POF). DESIGN: A search of past and current articles on basic ovarian physiology and POF with use of MEDLINE. Additional information was obtained from an active study section on POF at the National Institutes of Health. Specific sections of this manuscript summarize the strengths and weaknesses of the possible pathophysiologic processes and management options of POF as they appear in the literature. RESULT(S): POF is not an uncommon disorder. Although the etiology remains elusive in most cases, several rare specific causes have been discovered. Although POF was once thought to be permanent, a substantial number of patients experience spontaneous remissions. Because of the association with other autoimmune diseases, close follow-up is recommended in patients with POF. Hormone replacement therapy remains the cornerstone of treatment, and the best chance of achieving a pregnancy is through oocyte donation. CONCLUSION(S): An understanding of basic ovarian embryology and physiology will allow clinicians to apply current treatments and develop new innovative therapies for their patients with POF.

Bone loss in young women with karyotypically normal spontaneous premature ovarian failure.

OBJECTIVE: To evaluate the effects of karotypically normal spontaneous premature ovarian failure on femoral neck bone mineral density. METHODS: Eighty-nine women with karyotypically normal spontaneous premature ovarian failure who desired fertility were evaluated at a tertiary care academic center and underwent hip and spinal bone density measurements by conventional dual-photon absorptiometry. Seventy-seven of the women (87%) had sought medical advice previously and had taken a variety of estrogen and progestin replacement regimens at least intermittently. The median (range) age was 32 (20-39) years, and the median (range) time since diagnosis was 1.5 (0.5-11) years. Findings were compared with a reference group of 218 regularly menstruating women of similar age. RESULTS: Sixty of the 89 women with premature ovarian failure (67%, 95% confidence interval 57, 77) had a femoral neck bone mineral density more than 1 standard deviation (SD) below the mean of the reference group (P < .001, chi2 with Yates correction). Even in women in whom the bone mineral density measurement was made within just 1.5 years of the diagnosis, nearly one-half (47%) had a femoral neck bone mineral density more than 1 SD below the mean of the reference group (P < .01). CONCLUSION: Two-thirds of young women with karyotypically normal spontaneous premature ovarian failure have a femoral neck bone mineral density more than 1 SD below the mean of a reference group. These young women need early education regarding strategies to maintain their bone mass and ongoing medical evaluation to maintain compliance with these strategies.

Routine endocrine screening for patients with karyotypically normal spontaneous premature ovarian failure.

OBJECTIVE: To evaluate the usefulness of routine screening for other associated autoimmune endocrine disorders in patients with karyotypically normal spontaneous premature ovarian failure. METHODS: One hundred nineteen women with karyotypically normal spontaneous premature ovarian failure (FSH exceeding 40 mIU/mL) who desired fertility were evaluated at a tertiary care academic center by physical examination, measurement of serum free thyroxine and TSH, ACTH stimulation test, fasting serum glucose, 3-hour glucose tolerance test, measurement of serum electrolytes including total calcium, and measurement of serum vitamin B12. RESULTS: Twenty-two of 119 patients (18.5%) were known to have hypothyroidism and three were known to have Addison disease. Ten new cases of hypothyroidism and three new cases of diabetes mellitus were discovered. However, no new cases of adrenal insufficiency, hypoparathyroidism, or pernicious anemia were found. CONCLUSION: Screening for hypothyroidism and diabetes appears justified in those patients with karyotypically normal spontaneous premature ovarian failure who desire fertility. However, our findings suggest that in these patients, testing for other associated autoimmune endocrine disorders may be reserved for those with clinical indications.

A novel mutation of the luteinizing hormone receptor gene causing male gonadotropin-independent precocious puberty.

Familial male-limited precocious puberty (FMPP) is an autosomal dominant gonadotropin-independent disorder. Affected males generally develop signs of precocious puberty in early childhood. They typically show Leydig cell hyperplasia and increased testosterone production typical for their age, whereas circulating LH concentrations remain prepubertal. Several dominant point mutations of the LH receptor gene were identified in pedigrees with familial male-limited precocious puberty and were shown to cosegregate with the disease. Here we report a novel heterozygote point mutation in the LH receptor gene of a Brazilian boy with gonadotropin-independent precocious puberty. This mutation substitutes alanine 568 with valine at the carboxyterminus of the third cytosolic loop of the LH receptor. The unoccupied mutant receptors confer constitutive activation of adenyl cyclase activity when expressed in COS-7 cells, resulting in 4-fold higher cAMP concentrations over baseline compared with cells expressing an equivalent number of wild-type receptors. The affinity of the mutant receptors to 125I-labeled human LH was not altered compared with the wild type. Mutations of the homologue alanine residue in the alpha 1-adrenergic (in vitro), FSH (in vitro), and TSH (naturally occurring) receptors also result in constitutive adenyl cyclase activation, suggesting that this alanine residue is crucial for signal transduction and a potential site for upregulatory/oncogenic mutations in G-protein coupled receptors.

The use of human recombinant gonadotropin receptors to search for immunoglobulin G-mediated premature ovarian failure.

Anti-FSH receptor antibodies, detected using animal systems, have been reported in a few patients with premature ovarian failure (POF). However, assays based on animal receptors may be inappropriate for detecting inhibiting antibodies in humans. Accordingly, we tested for interfering antibodies in patients with POF using a recombinant system expressing human (h) FSH and LH receptors. A mouse adrenal cell line transfected with the hFSH receptor (Y1-hFSHR) exhibits a dose-dependent increase in progesterone when exposed to hFSH. An embryonal kidney cell line transfected with the hLH receptor gene (hLHR-293) exhibits a dose-dependent increase in cAMP when exposed to hLH. We isolated immunoglobulins G (IgG) from 38 patients with POF and 14 normal women. We stimulated Y1-hFSHR and hLHR-293 cells with hFSH or hLH in the presence of these IgG and determined the resulting progesterone or cAMP response. The progesterone and cAMP responses obtained in the presence of IgG from patients with POF did not differ significantly from the responses in the presence of IgG from normal women. In contrast, antigonadotropin polyclonal antibodies isolated in the same manner as the above IgGs caused a greater than 90% reduction in the response of the Y1-hFSHR and hLHR-293 cells. We did not detect inhibitory antibodies in any of our 38 patients with POF. Therefore, if blocking antibodies interfering with gonadotropin-receptor interaction are a mechanism for POF, they account for a small minority of cases (< 8%).

A potential novel mechanism for precocious puberty in juvenile hypothyroidism.

Some children with juvenile hypothyroidism exhibit unexplained precocious puberty. Interaction of TSH with the human FSH receptor (hFSH-R) is a possible pathophysiological mechanism for this syndrome that has not been explored due to the lack of hFSH-free TSH preparations and the scarcity of a suitable hFSH-R-based assay system. To devise an in vitro FSH bioassay suitable for exploring this mechanism, we expressed hFSH-R complementary DNA in COS-7 cells and stimulated them with recombinant hTSH (rec-hTSH). Rec-hTSH elicited a dose-dependent cAMP response in the in vitro hFSH-R bioassay; however, the concentration of rec-hTSH required for half-maximal stimulation was several logs greater than that of hFSH. Rec-hTSH acted as a competitive inhibitor of hFSH at the hFSH-R, indicating that hTSH and hFSH are acting through the same receptor, namely the hFSH-R. This provides a potential novel mechanism for the precocious puberty of juvenile hypothyroidism.

Receptor binding and signal transduction are dissociable functions requiring different sites on follicle-stimulating hormone.

Separate sites for glycoprotein hormone receptor binding and signal transduction have yet to be elucidated. In general, certain peptide regions are thought to be critical for receptor binding, whereas the oligosacharides are thought to be important for signal transduction. Using site-directed mutagenesis of FSH, we made selective amino acid substitutions and oligosaccharide alterations to try and identify specific sites mediating receptor binding distinct from signal transduction and vice versa. We substituted Lys or Asp for beta Arg35 in the purported receptor binding loop between cysteine-32 and -51, and we substituted Gln for alpha Asn52, alpha Asn78, beta Asn7, or beta Asn24, the attachment sites for each of the oligosaccharide side-chains. We determined the binding and signal-transducing activity of wild-type and mutant human FSH at the human FSH receptor, as recent data suggest that glycoprotein hormone-receptor interactions are species specific. The binding activities of FSH with Lys or Asp substituted for beta Arg35 were reduced 71% and 98%, respectively, but their signal transduction, at equivalent levels of binding activity, was unaffected. The binding activity of FSH lacking the oligosaccharide at alpha Asn52 was enhanced 2- to 3-fold, but its signal-transducing activity, at equivalent levels of receptor binding, was decreased 72%. In contrast, the binding and signal-transducing activities of FSH lacking the alpha Asn78, or alpha Asn7, or beta Asn24 oligosaccharide were unaffected. Thus, a specific amino acid (beta Arg35) is important for high affinity binding, but is not involved in signal transduction, whereas a specific oligosaccharide (alpha Asn52) is important for signal transduction, but is not required for high affinity binding. Therefore, receptor binding and signal transduction are dissociable functions involving different sites on the FSH glycoprotein.

Development of luteinized graafian follicles in patients with karyotypically normal spontaneous premature ovarian failure.

Despite having amenorrhea and markedly elevated serum gonadotropin levels, some women with karyotypically normal spontaneous premature ovarian failure, nevertheless, have ovarian follicles that function intermittently. Graafian follicles capable of responding to these high FSH levels are faced with high serum LH levels as well, which might induce inappropriate luteinization and prevent normal follicle function. We examined this possibility using weekly blood sampling and sonography in 65 patients. Nearly 50% of our patients demonstrated ovarian follicle function [serum estradiol, > 183 pmol/L (50 pg/mL)] during a median of 4 months of observation (range, 2-6 months). However, during this observation, only 16% achieved an ovulatory serum progesterone level [> 9.5 nmol/L (3.0 ng/mL)]. We imaged an antral follicle by sonography in over 40% of patients (27 of 65), and serum estradiol was significantly greater when an antral follicle was present. The follicles in these patients were not functioning normally, however. In contrast to normal women, patients with ovarian failure had poor correlation between follicle diameter and serum estradiol. We biopsied these antral follicles in 6 patients and found luteinized Graafian follicles in all cases. Therefore, luteinized Graafian follicles account for at least 60% of the antral structures imaged (95% confidence limit). Thus, inappropriate luteinization of Graafian follicles appears to be a major pathophysiological mechanism in patients with karyotypically normal spontaneous premature ovarian failure.

A controlled study of danazol for the treatment of karyotypically normal spontaneous premature ovarian failure.

OBJECTIVE: To determine if the immunomodulatory and gonadotropin-suppressing properties of danazol would improve follicle function or ovulation rates in patients with karyotypically normal spontaneous premature ovarian failure. DESIGN: Prospective, double-blind, crossover trial. SETTING: Tertiary care research institution. INTERVENTIONS: Two intervention phases lasting 4 months each: one phase during which patients received a standardized estrogen and progestin replacement regimen and one phase during which each patient received a twice daily 400 mg oral dose of danazol. PATIENTS: Fifty-two patients with karyotypically normal spontaneous premature ovarian failure ranging in age from 21 to 39 years. MAIN OUTCOME MEASURES: We measured serum E2 and P levels weekly during the 2 months after each intervention. We defined a serum E2 > 50 pg/mL (184 pmol/L) as evidence of ovarian follicle function and a P > 3.0 ng/mL (9.5 nmol/L) as evidence for ovulation. RESULTS: Of the 46 patients who completed the study, danazol did not significantly enhance ovarian follicle function or the chance of ovulation. Eight patients ovulated after danazol and four patients ovulated after estrogen and progestin. The power to detect a 30% and a 5% ovulation success rate with therapy was 0.80 and 0.90, respectively. Overall, 30 of 46 women (65%) demonstrated ovarian follicle function and 10 women (21%) ovulated. CONCLUSION: We were unable to demonstrate a statistically significant benefit from the immunomodulatory and gonadotropin-suppressing effects of danazol in patients with karyotypically normal spontaneous premature ovarian failure. These patients often have spontaneous remission. Thus, controlled studies are required to determine the effectiveness of treatments for this condition.

Increased biological activity due to basic isoforms in recombinant human follicle-stimulating hormone produced in a human cell line.

FSH has four asparagine-linked oligosaccharides with variable sialic acid contents, so that FSH is not a single molecule, but a heterogeneous group of isoforms. These isoforms differ in their biological properties and their distribution changes in various physiological states, allowing the modulation of FSH activity. Recombinant human (h) FSH has been produced in Chinese hamster ovary cells and has an isoform profile similar to those of both pituitary FSH standard and purified urinary FSH. These FSH preparations, however, do not contain the full spectrum of FSH isoforms found in the circulation. Production of recombinant hFSH in a cell line with a different pattern of glycosylation could broaden its isoform profile and potentially alter its biological activity. Thus, we transfected human embryonal kidney cells (293) with the human alpha and FSH beta genes to produce recombinant hFSH (hFSH-293) and determined its biological activity in a rat granulosa cell bioassay. Although hFSH-293 was immunologically indistinguishable from pituitary FSH standard, its biological potency was 3- to 6-fold higher than those of two different pituitary FSH standards. To investigate this increased potency, we separated the isoforms of hFSH-293 by chromatofocusing and determined their biological potencies in the rat granulosa cell bioassay. The isoform profile of hFSH-293 demonstrated a greater number of basic isoforms than that of pituitary FSH standard. Several of these basic isoforms exhibited enhanced in vitro biological potency, accounting for the increased biological potency of hFSH-293. This pattern of high in vitro biological activity and more basic isoforms is analogous to the FSH circulating during GnRH stimulation, pubertal induction, and ovulation.

Site-directed mutagenesis defines the individual roles of the glycosylation sites on follicle-stimulating hormone.

To determine the specific role of each follicle-stimulating hormone (FSH) oligosaccharide, we mutated Asn to Gln at each glycosylation site (alpha Gln52, alpha Gln78, alpha Gln52-78, beta Gln7, beta Gln24, and beta Gln7-24) to selectively inhibit oligosaccharide attachment. For wild-type and mutant FSH, we determined the binding affinity to homogenized rat Sertoli cells and the signal-transducing activity in cultured rat granulosa cells. The binding affinity of FSH lacking any one of the oligosaccharides was increased over wild-type FSH, while the signal-transducing activity of FSH lacking the oligosaccharide at alpha Asn52 (alpha Gln52 FSH) was markedly reduced, and that of FSH lacking either beta oligosaccharide (beta Gln7 and beta Gln24 FSH) was slightly reduced. At each FSH beta glycosylation site, we made a second amino acid substitution to inhibit glycosylation (beta Tyr9 and beta Tyr26) and an amino acid substitution that preserved glycosylation (beta Ser9 and beta Ser26). The amino acid sequence of the second beta subunit glycosylation site was important for signal transduction, regardless of the presence or absence of the oligosaccharide. Thus, while each FSH oligosaccharide has a similar impact on binding affinity, the alpha 52 oligosaccharide has a disproportionate role in signal transduction, and the amino acid sequence at beta Asn24 functions in both binding and signal transduction.

Karyotypically normal spontaneous premature ovarian failure: evaluation of association with the class II major histocompatibility complex.

Patients with premature ovarian failure (POF) have been reported to have an increased frequency of the major histocompatibility class (MHC) class II antigen HLA-DR3. Here we attempt to confirm this association. We performed MHC class II immunophenotyping of HLA-DR antigens 1-10 on 102 North American caucasians with confirmed POF and 102 control caucasian women. All patients had experienced amenorrhea before the age of 40 yr and had elevated serum gonadotropins on repeated study. We found no significant increase in HLA-DR3 frequency in patients with POF when compared to our control group (P = 0.52) or even when compared to a large reference population (n = 1927) that did not differ significantly from our control group (P = 0.47). Our patients did have an increased frequency of HLA DR4 compared to this large reference population (41% vs. 23%; P < 0.001), but we were unable to demonstrate increased HLA DR4 frequency using our control group (31%; P = 0.14). In conclusion, despite a power of 99%, we were unable to confirm a significant increase in MHC class II HLA-DR3 frequency in patients with POF.

Virilizing adrenal cortical neoplasm arising ectopically in the thorax.

We describe a 44-yr-old woman with a 12-yr history of clinical virilization and serum testosterone levels up to 28.1 nmol/L (normal range, 1-3.3 nmol/L) in whom repeated clinical evaluation and surgical procedures failed to reveal the source of androgen production. At the time the patient was referred to the Clinical Center of the NIH, an intrathoracic mass was seen on upper cuts of an abdominal computer-aided tomography scan, confirmed by computer-aided tomography scan and magnetic resonance imaging of the chest. A 6 x 5 x 3.5-cm mass, attached to the posterior pericardium, was removed by thoracotomy. Pathological examination revealed an adrenal cortical neoplasm of uncertain malignant potential that contained testosterone, 11-deoxycortisol, progesterone, and 17-hydroxyprogesterone. After the operation, the patient's serum testosterone levels decreased to the normal range. Ectopic adrenal cortical rests in the thorax and neoplasms arising from these rests are extremely rare, and we are not aware of a similar case previously reported. In women with virilization, radiological studies of the thorax as well as other reported sites of ectopic adrenal cortex should be performed if radiological studies of the abdomen and pelvis fail to locate the source of the neoplasm.

Vaginal evisceration with pneumoperitoneum. A case report.

Vaginal evisceration with pneumoperitoneum occurred in a premenopausal woman.

Rectal serosal hematoma: an unusual complication of culdocentesis.

Culdocentesis is currently a widely used diagnostic technique in gynecology. Although associated with numerous theoretical risks, few complications have been documented in anecdotal reports. Rectal serosal hematoma, an unusual complication of culdocentesis, is described.