Virilizing adrenal adenoma and primary amenorrhea in a girl with adrenal hyperplasia.

We report a 14-year-old girl with primary amenorrhea and virilization. The chromosomal analysis showed a normal 46,XX female karyotype and the hormonal assays disclosed high serum levels of testosterone (T): 450 ng/dL (normal 5-90), dehidroepiandrosterone-sulfate (DHEA-S): 690 microg/dL (normal 30-450) and 17-hydroxiprogesterone (17-OHP) >20 ng/mL (normal <2). A pelvic ultrasound disclosed a small uterus and bilateral enlargement of the ovaries, a computed axial tomographic scan of the abdomen identified a large right mass in the adrenal gland and a norcholesterol-I 131 adrenal gammagraphy revealed a functional adrenal tumor. The histological analysis of the surgical removed tumor revealed and adrenal adenoma. After surgery, a steep decline to normal serum levels of T and DHEA-S was observed, remaining an elevated level of 17-OHP: 5.4 ng/mL. During the first three months of follow up, the hirsutism declined sharply and spontaneous mammary development occurred, remaining elevated the 17-OHP serum level: 4.8 ng/mL. Prednisone 5 mg/day, was initiated decreasing the 17-OHP to normal level: 1.4 ng/mL, appearing the menarche followed by cyclical menses. One year after surgery, prednisone was withdrawn during one week, and an ACTH test and HLA typing were done, disclosing a 17-OHP response of an heterozygote for adrenal hyperplasia, and identifying B65 a subtype of B14, and DR1, that are frequently associated to adrenal hyperplasia. Previous reports have informed silent adrenal tumors associated to adrenal hyperplasia, but this is the first report of a functional adrenal tumor associated to adrenal hyperplasia.

[Sublingual thyroid gland associated with polycystic ovaries]. / Glándula tiroides sublingual asociada a ovarios poliquísticos.

OBJECTIVE: To describe a young woman with polycystic ovary syndrome and a lingual thyroid gland. CLINICAL HISTORY: A 19-year old woman with secondary amenorrhea whose previous history had been uneventful. She had a normal spontaneous puberty with menarche at 13 years, followed by cyclical menstruations until six months before, when a period of four months of amenorrhea occurred. Physical exploration disclosed a normal young adult woman, without goiter, galactorrhea, acne, nor hirsutism. A pelvic ultrasound showed bilateral enlargement of the ovaries. Hormonal studies showed FSH 4 mUl/mL (nl = 2-12), LH 6 mUl/mL (nl = 2-14) and PRL 12 ng/mL (nl = < 25); TSH 8 microU/mL (nl < 5) and a free thyroxine level of 8.4 ng/dl (nl = 0.75-1.8). A thyroid gammagram with radioiodine disclosed a 6% caption (nl = 8.15%) and a small nodular gland at the base of the tongue. TREATMENT: Levothyroxine 100 micrograms/day was initiated and a month later the TSH level was normal but cyclical menstruations were not established after six months of follow up. COMMENT: The polycystic ovary syndrome is the main endocrine cause of secondary amenorrhea in young women.

[Maternal and fetal morbidity in a group of women with gestational diabetes]. / Morbilidad materna y fetal en un grupo de mujeres con diabetes gestacional.

Normal pregnant women in the second and third trimester were screened to detect gestational diabetes. Using the protocol proposed by the World Health Organization, we identified 33 women whose two hr glucose levels was > 200 mg/dl. Only sixteen women had less than 34 weeks of pregnancy when were seen for the first time at the diabetes clinic, the other seventeen women had more than 34 weeks when they presented to the diabetes clinic. The first group, was called the treated group and the second group was the non-treated group. The main clinical characteristics of these patients, treated vs non-treated, were (X +/- SD): age (years) 33.2 +/- 5.2 (20-40) vs 30.2 +/- 6.5 (20-39), p < 0.05; weeks of pregnancy at diagnosis: 27.9 +/- 4.1 (19-33) vs 36.1 +/- 2.3 (34-40), p < 0.05; weight (Kg): 79.9 +/- 13.1 (61.8-108) vs 87.4 +/- 16.8 (60.8-118), p = NS; length of pregnancy (weeks) 38 +/- 1.3 (36-40) vs 38.4 +/- 1.4 (35-40), p = NS; newborns weight (g): 3,654 +/- 650 (2,475-5,100) vs 3,221 +/- 529 (2,650-4,650), p = NS. There was an intrauterine death of a macrosomic fetus in the non-treated group. There were three macrosomic newborns in the treated group and one in the non-treated group, p = NS. Also, there was a premature newborn of 1,975 g, whose pregnancy was interrupted for acute fetal distress. Delivery by cesarean section occurred in 29 women (87.8%), and it was mainly related to the diabetes diagnosis. The prevalence of macrosomia in the treated group supports the idea that treatment has to be established at least at 24 weeks of pregnancy, to reduce this rate. It is concluded that gestational diabetes is associated to an increase in maternal and fetal morbidity, requiring strict supervision to detect and treat fetal distress and a tight glucose control to decrease the macrosomia rate.

[Diabetes and pregnancy in Mexico]. / Diabetes y embarazo en México.

OBJECTIVE: To review the Mexican studies published in the last 15 years on diabetes mellitus (DM) and pregnancy. MATERIAL AND METHODS: We found five descriptive studies on DM and pregnancy and six on the detection of gestational diabetes (GDM) in normal pregnant women using the oral glucose tolerance test (OGTT). RESULTS: The first group of studies comprised 689 patients: 331 with pregestational DM type 2 and 32 type 1; the other 326 patients (47%) had GDM established by clinical symptoms and hyperglycemia, or by fasting hyperglycemia (> 140 mg/dL) in at least two ocassions. The distribution of types 1 and 2 was similar in the five studies. Maternal complications were toxemia in 18%, polyhydramnios is 10% and urinary infection in 6%. Perinatal mortality was 7%, congenital malformations in 6%, macrosomia in 25% and prematurity in 8%. In the puerperium 71 women with GDM were reevaluated: 48 (68%) were type 2, one (1%) type 1, three (4%) glucose intolerance (GI) and 19 (27%) were normal to an OGTT test. The six studies on GMD in normal pregnants were done using the OGTT. Three studies were done in the city of Monterrey, state of Nuevo Leon and show a prevalence of 4.3 to 6%, mean 5.3%. The other three studies show a prevalence of 10.5 to 11%. In the puerperium, 26 women were reevaluated: only three were type 2 (12%), five GI (19%) and 18 (69%) had a normal response to the OGTT. CONCLUSIONS: Type 2 DM is the more frequent type of diabetes associated to pregnancy in Mexican groups; the systematic screening for GDM in normal pregnant women yields 4 to 11% of positivity.

[Disappearance of the radiographic image of a macroprolactinoma after treatment with bromocriptine]. / Desaparición de la imagen radiográfica de un macroprolactinoma con bromocriptina.

A young woman with amenorrhea-galactorrhea induced by a prolactin (PRL) secreting pituitary macroadenoma, was treated with bromocriptine 5 mg/day per os. Serum PRL levels were normal at 6 weeks and menstruation appeared at 8 weeks of treatment. When twenty months of treatment were completed, a tomographic study of the pituitary was unable to show any enlargement. Controversies related to macroprolactinomas treatment are discussed and it is suggested that treatment with dopamine agonists must be the elective treatment for patients with macroprolactinoma.

[True hermaphroditism with bilateral ovotestis]. / Hermafroditismo verdadero con ovotestis bilateral.

A nineteen years old woman with ambiguous external genitalia was studied. This condition had been previously identified as a newborn, but her parents refused medical attention and it was reared as a girl. At 12-years, she began spontaneous mammary development, appearing pubic and axillary hair, and clitoral enlargement. The menarche occurred at 15-years and it was followed by irregular periods. Physical examination, showed absence of hirsutism and acne, normal mammary development equivalent to grade V of Tanner. The external genitalia showed fused labio-scrotal folds with an small introitus. The urethral meatus was absent and was later located inside the introitus. There was a big phallus similar to an adult penis with a normal glans, flexed by a chordee. Hormonal determinations discarded congenital adrenal hyperplasia. The karyotype was 46,XX and testosterone levels were in adult male range. Pelvic ultrasonography disclosed a normal uterus and both gonads in confirmed by laparoscopy identifying bilateral ovotestis. Testicular tissue was removed and plastic reconstruction of female genitals was done.

Gestational diabetes mellitus and glucose intolerance in a Mexican population.

OBJECTIVE: To determine the prevalence of gestational diabetes mellitus (GDM), glucose intolerance (GI) and macrosomia in a Latin Mexican population, using the one-step procedure proposed by the World Health Organization. METHOD: Consecutive pregnant women (n = 667) who attended the antenatal clinic and delivered at the hospital were recruited after 24 weeks of gestation, mean 34.2 weeks, range 24-40 weeks. After a minimum of 3 days with a 150-g carbohydrate diet, a glucose load of 75 g was administered and 2 h after, a blood sample for glucose was taken, plasma was separated and immediately processed for glucose, using a glucose-oxidase method. RESULTS: Twenty women were diagnosed with GDM (3%), 87 had GI (13%) and 560 had a normal glucose response (84%). Macrosomia occurred in two (10%) of GDM, in nine (10.3%) of GI, and in 29 (5.4%) gravidas with a normal response, respectively. Only one of the macrosomic infants whose mother had GI, had neonatal hypoglycemia and hyperbilirubinemia. CONCLUSION: The overall prevalence of glucose abnormalities during pregnancy was 16%. GI in this group was associated to macrosomia at the same rate as GDM.

[Magnetic resonance diagnosis of insulinoma]. / Diagnóstico de insulinoma por resonancia magnética.

OBJECTIVE: The purpose of this report is to highlight the use of the magnetic resonance imaging in the detection of very small tumors of the pancreas. BACKGROUND: The computed axial tomography and angiography have been the traditional methods in the detection of neoplasms of the pancreas, mostly vascular lesions, both lacking the tissue characterization and contrast; the magnetic resonance scan was performed to rule out a pancreatic tumor in a 37 year old female patient with hypoglycemia, previously treated for seizures. RESULTS: A 1.0 cm nodular hypointense lesion was seen in the union of the body and the tail of the pancreas, confirmed by surgery and pathology as an insular cell tumor. CONCLUSION: Given its axial and tissue contrast resolution, as demonstrated in our case, the magnetic resonance imaging has became the gold standard in the identification of very small tumors of the pancreas.

[Macrosomia and death. Relationship with maternal diabetes]. / Macrosomía y óbito. Relación con diabetes materna.

The incidence of macrosomic newborns and fetal death and its possible relation to maternal diabetes mellitus (DM) was registered during six months at the Hospital de Ginecoobstetricia "Dr. I. Morones", IMSS. Both criteria for macrosomia 4,000 g and 4,500 g, were taken for data collection. We had a total of 15,217 newborns, of these, 872 (5.73%), weighed > 4,000 g, and there were 42 mothers with DM, 4.2% of the group. Taking 4,500 g as criteria for macrosomia, there were 105 newborns (0.69%) of the total and there were 8 mothers with DM, 7.6%. 501 of the pregnancies finished by cesarean section and 337 by delivery. There were 151 fetal deaths, 9.9 for 1,000 newborns, eight fetuses had a weight over 4,000 g, and two mothers had DM. It is concluded that maternal diabetes mellitus occurred in less than 5% of the mothers with macrosomic newborns (> 4,000 g). The incidence of macrosomia is lower than in European populations. Fetal deaths were higher than expected because this hospital concentrates patients with obstetrical complications.

[Medical evaluation of the climacteric patient]. / Evaluación médica de la paciente climatérica.

A pilot program with primary care physicians was established in Clinica Cuauhtémoc y Famosa, focused to evaluate women older than 35 years with climateric symptoms. This program included a survey, a complete gynecological examination with Pap smears, ultrasound pelvic examination and mamography. Also, blood samples were collected for cholesterol, tryglycerides, calcium, phosphorus and alkaline phosphatase. An ECG, bone densitometry of the radius and X-rays of the vertebral column were obtained. This group was formed by 69 women with an age media of 50 years (SD 7.6 years, median 49 years). The survey disclosed that 34/65 women had been hysterectomized, and only 34/64 had received antitetanic immunization in the last 10 years. A preexistent chronic disease occurred in 36/59 women, these were diabetes mellitus, arterial hypertension or degenerative osteoarthritis. Alcohol consumption was recorded in 5/66 women and tabac consumption in 9/66 women, and 32/68 women accepted to be sedentary. Laboratory examinations disclosed hypercholesterolemia in 19/66 women and hypertryglyceridemia in 8/64 women. Osteopenia was detected in 33/60 women. This findings support a systematic plan to provide medical assistance for women in this age, specially if previous epidemiologycal studies have disclosed that coronary disease is the main cause of death for women older than 50 years in this region, that also belongs to the area of highest incidence of diabetes.

[Factors possibly associated with the age at the onset of menopause. Multicenter study]. / Factores que pueden estar asociados con la edad de presentación de la menopausia. Estudio multicéntrico.

A transversal study was performed in 1987 to examine 9,844 postmenopausal women aging from 39 to 59 years, residents from the cities of Durango, Monterrey, Guadalajara and Leon. They had their last menstruation at least 12 months before the interview and they were not pregnant. The objective was to know if the menarche, number of deliveries, use of contraceptive methods and smoking could affect the age of menopause. A case control analysis was performed. Based on frequency distribution of the age on which the menopause appeared, cases were classified as early and late menopause when a median value minus 2 SD and plus 2 SD were found, respectively. For control subjects a median + 1 SD was selected. Two and three controls were randomly assigned for early and late menopause, respectively. In total 1,610 subjects were studied. As a measure of association it was used the odds ratio with a confidence level of 95%. It was performed an analysis of confusion and interaction of variables in this study. The most relevant results were; a significant association between smoking 15 packages of cigarettes a year with an OR of 2.31 (1.05-5.17), to have more than five pregnancies with an OR of Mantel and Haenzel of 0.51 (0.33-0.76) for the early menopause. No association with late menopause was observed. It was found that the mean age of menopause was 45.5 years + 4.5 SD (n = 9,844).

[Bone density and osteoporosis. An opinion]. / Densidad osea y osteoporosis. Una opinión.

Osteoporosis is a serious health problem for women over 45 years of age. It is divided in type I, affecting mainly cancellous bone and type II, affecting cancellous and cortical bone. Type I osteoporosis is related mainly with menopause, meanwhile, type II osteoporosis is related with ageing in both sexes. Osteoporosis has a major impact in the quality of life and the independence of the individuals, being the best treatment its prevention. All women at the beginning of the menopause should receive hormonal replacement treatment and calcium, in order to avoid type I osteoporosis, since treatment for women with established osteoporosis is aimed to halt the process of bone loss. Bone density may be measured in a reliable way by different techniques, allowing to the practitioner an accurate and reproducible measurement in different segments of the body. The main indications for bone densitometry suggested by the NOF are commented, as well as, the variability that may occur in different populations and the concept of normal values of bone density.

[Detection of non-insulin-dependent diabetes mellitus in asymptomatic adults]. / Detección de diabetes mellitus no insulinodependiente en adultos asintomáticos.

A total of 1,011 clinically asymptomatic adults older than 20 years of age, with a minimal fasting of one hour, were screened for diabetes mellitus. This group was selected from a community medical service. The presence of diabetes in first degree relatives (parents, brothers/sisters and children) was investigated by interrogation of the subjects. Weight, height, and the waist and hip perimeters were measured, and the body mass index and the waist/hip ratio were calculated. Obesity was present in 26% of the population and 35.6% had a relative with diabetes mellitus, but 53.8% were younger than 40 years. A capillary blood sample was taken and glucose was measured by a reflectometer glucometer. Individuals with blood glucose levels of 160 mg/dL or higher were appointed for a fasting venous blood sample and glucose was analyzed using the glucose oxidase method. If the glucose levels were > 140 mg/dL, a second fasting venous blood sample was taken 1-2 weeks later, if both results were > 140 mg/dL a diagnosis of diabetes mellitus was established; otherwise it was considered non diagnostic for diabetes mellitus. A total of 17 were detected with > 160 mg/dL by the glucometer and 12/17 persons were diagnosed with diabetes mellitus (1.2%). No person younger than 30 years was detected (n = 307), but 3/237 were detected in the thirty years group (1.26% for this group) and 9 persons were older than 40 years, 1.2% of the total group. Capillary glucose measurements may be used for screening of populations selecting those who require to be submitted to diagnostic tests.

Reduced dopaminergic inhibition of thyrotropin release in hyperprolactinemic ovulatory women.

It has been suggested that menstrual irregularities in hyperprolactinemia are secondary to an increase in hypothalamic dopaminergic activity via a short loop positive feedback of prolactin (PRL). We have studied this question in a relatively new syndrome characterized by hyperprolactinemia without derangements of the hypothalamic-pituitary-ovarian function due to macroprolactinemia (abnormal high amounts of big-big PRL). Central dopaminergic activity was investigated by the administration of the dopamine antagonist domperidone to normal women (n = 7) and women with anovulatory (n = 6) and ovulatory hyperprolactinemia (n = 2). The effects of domperidone were evaluated in all subjects by the measurements of radioimmunoassayable circulating serum PRL and TSH levels. All subjects had a significant increase in serum PRL levels after 90 min of domperidone administration. Anovulatory hyperprolactinemic subjects showed the highest response to domperidone in terms of TSH, whereas normal women and women with ovulatory hyperprolactinemia had similar increments in TSH serum levels after the administration of the dopamine antagonist. These results support the observation that an increase of hypothalamic dopaminergic activity in hyperprolactinemia may account in part for the presence of menstrual irregularities. The presence of a similar pituitary responsiveness in terms of TSH to domperidone in normal and ovulatory hyperprolactinemic women suggests a similar hypothalamic dopaminergic activity in both group of subjects. These findings might offer an explanation for the coexistence of normal ovulatory cycles in spite of hyperprolactinemia.

Noninsulin dependent diabetes mellitus and pregnancy in Mexico.

We analyzed 215 consecutive patients with diabetes mellitus and pregnancy, 118 (54.83%) with noninsulin dependent diabetes mellitus (NIDDM), 90 (41.86%) with gestational diabetes mellitus (GDM) and 7 (3.26%) with insulin dependent diabetes mellitus (IDDM). NIDDM and GDM patients had no significant difference in age and body mass index. There were no maternal deaths, nor episodes of ketoacidosis. Maternal and neonatal complications occurred with a similar frequency in NIDDM and GDM. We concluded that in our population, diabetes associated with insulin-resistance occurred in over 96% of our pregnant diabetic patients and was associated with an increased prevalence of maternal and neonatal complications. Earlier perinatal care has to be established in NIDDM patients, and obese young women should be screened to detect GDM from early gestation and advised to reduce weight before pregnancy ensues.

The stimulatory effect of estradiol 17-beta on prolactin mRNA is inhibited by anti-calmodulin drugs.

The stimulatory action of estrogens on prolactin (PRL) secretion and synthesis is well known; on the other hand, anti-calmodulin drugs have recently been shown to inhibit prolactin in vitro release induced by estrogens. Based on these data, we decided to evaluate the in vivo effect of anti-calmodulin drugs (trifluoperazine and W7) on basal and estradiol-17 beta stimulated levels of PRL mRNA in anterior pituitary lobes obtained from adult male rats. Total RNA was isolated from pooled pituitaries recovered from animals under the same treatment and, from it, hybridizable PRL mRNA was detected. Estradiol-17 beta consistently stimulated PRL mRNA levels by 3-4 fold. The utilization of either trifluoperazine or W7, invariably inhibited estradiol-17 beta stimulated PRL mRNA. Metoclopramide, a drug with antidopaminergic activity, potentiated the stimulatory effect of estradiol-17 beta on PRL mRNA levels. These results suggest that anti-calmodulin drugs have an in vivo antiestrogenic effect on PRL mRNA levels confirming previous in vitro studies. Although, it is difficult to be conclusive about the mechanism through which these drugs act, one possibility is that the calcium-calmodulin system may be involved.

Radial bone mineral content in healthy Mexican women.

Fifty healthy Mexican women from 21 to 70 years of age volunteered to undergo radial bone densitometry. The bone density in ten women per decade was assessed at two sites in the radius of the nondominant forearm; one site was the distal radius at 5 mm of separation from the ulna and the other at one-third of the distal radius. Calcium, inorganic phosphates and alkaline phosphatase were measured in serum samples and the calcium/creatinine ratio in fasting urine samples. Bone density at the distal radius was 360.6 +/- 36.2 mg/cm2, 369.8 +/- 47.9 mg/cm2 and 364.7 +/- 53.7 mg/cm2 in the 21-50 age group. There was no significant difference between these groups; the pooled value of all these samples was 365 +/- 46 mg/cm2. There was significant difference in the 51-60 age group, 290 +/- 48. mg/cm2 (p less than 0.01) and in the 61-70 age group. 277.9 +/- 49.9 mg/cm2 (p less than 0.01). Bone density at the one-third distal radius in the 21-20 age group was 696.3 +/- 60.9 mg/cm2; 31-40, 683.6 +/- 68.4 mg/cm2 and 41-50, 697.9 +/- 53.9 mg/cm2. There was no significant difference among these group; the pool of all these samples showed 692.6 +/- 59.6 mg/cm2. In the 51-60 age group it was 628.0 +/- 63.3 mg/cm2, a non significant difference. On the other hand, the density in the 61-70 group was 573.7 +/- 83.5 mg/cm2, significant (p less than 0.01) when compared to the 21-50 age group.(ABSTRACT TRUNCATED AT 250 WORDS)