The expression and localization of selected matrix metalloproteinases (MMP-2, -7 and -9) and their tissue inhibitors (TIMP-2 and -3) in follicular cysts of sows.

Matrix metalloproteinases (MMPs) are a family of enzymes that degrade extracellular matrix (ECM) molecules, playing a vital role in tissue remodeling under physiological and pathological conditions. Their expression and/or activity are regulated by specific tissue inhibitors of MMPs named TIMPs. Recently, an imbalance in the MMP/TIMP system has been found in human and bovine ovarian cysts, but its role in porcine cyst pathogenesis is unknown. This study examined mRNA expression, protein abundance and localization for selected members of the MMP/TIMP system in follicular cysts of sows. Based on histological analysis, we have assessed follicular (FC) and follicular lutein (FLC) cysts with preovulatory follicles (PF) used as a control. Regarding the pattern of MMP expression, increased MMP2, MMP7 and MMP9 mRNA levels were observed in FLC. Furthermore, both pro- and active forms of MMP-2 and MMP-9 proteins were more abundant in FLC. In FC, the abundance of latent and active forms of MMP-9 and the active form of MMP-2 were greater when compared with PF. In relation to TIMPs, TIMP-2 mRNA and protein expression were increased in FLC, whereas TIMP-3 was up-regulated in both FC and FLC only at the protein level. Using immunofluorescence, MMP-2, MMP-7, TIMP-2 and TIMP-3 were detected in granulosa and theca compartments of FC and within the entire luteinized wall of FLC. Notably, MMP-9 occurred weakly in the granulosa layer of FC, but abundantly in the theca compartment of FC and in the luteinized FLC. Taken together, our findings indicate altered expression of the MMP/TIMP system, suggestive of increased ECM degradation, in sow follicular cysts. These components may be involved in the pathogenesis of porcine ovarian cysts through the ECM remodeling.

Altered vitamin D metabolic system in follicular cysts of sows.

This study aimed to examine 25OHD3 concentration in the fluid of follicular and follicular lutein cysts of sows in comparison with preovulatory follicles as well as immunolocalize vitamin D metabolic enzymes (CYP27B1 and CYP24A1) and determine their protein abundances in the cyst wall. We have shown for the first time that 25OHD3 level in the fluid of both cyst types was significantly lower than in preovulatory follicles. Furthermore, we have demonstrated CYP27B1 and CYP24A1 protein immunolocalization and abundance in follicular and follicular lutein cysts. The abundance of protein for both metabolic enzymes was decreased in ovarian cysts when compared to preovulatory follicles. We propose that altered VD metabolism in ovarian cyst might associate with their formation in sows.

Prevalence and clinical relevance of underlying pathological conditions in painful adolescent idiopathic scoliosis: a MRI-based study.

STUDY DESIGN: Cross-sectional comparative study. OBJECTIVES: Evaluate prevalence and clinical relevance of an underlying pathology in painful adolescent idiopathic scoliosis (AIS) patients after a non-diagnostic history, physical examination and spinal X-ray using Magnetic Resonance Image (MRI) as diagnostic tool. Discrepancies regarding indications of routine MRI screening in painful AIS patients are multifactorial. Few studies have investigated relationship and practical importance of painful AIS with an underlying pathology by MRI. METHOD: A total of 152-consecutive AIS patients complaining of back pain during a 36-month period were enrolled. All patients underwent whole-spine MRI after a non-diagnostic history, physical examination and spinal X-ray. Underlying pathologies were reported as neural and non-neural axis abnormalities based on MRI reports. Variables such as sex, age, constant or intermittent pain, night pain, back pain location (thoracic or lumbar pain), Cobb-angle and follow-up were evaluated as clinical markers to predict presence of underlying MRI pathologies. RESULTS: The presence of an underlying pathology was found by MRI in 54 painful AIS patients (35.5%). Isolated syringomyelia was the only neural axis abnormality found in 6 patients (3.9%). Non-neural axis abnormalities (31.6%) were composed by: 32 herniated nucleus pulposus, 5 vertebral disc desiccation, 4 ovarian cysts, 3 renal cysts, 2 sacral cysts, and 2 vertebral hemangiomas. There was no association with gender, age of presentation, initial coronal Cobb angle and follow up; with presence of an underlying pathology. Lumbar pain location was identified as an adequate clinical marker that correlated with presence of an underlying pathology (p = 0.01). CONCLUSIONS: Prevalence of underlying pathologies diagnosed by MRI in painful AIS was found high (35.5%), but it's clinical relevance and implication are debatable. The use of MRI did not affect orthopedic management of painful AIS patients who showed an underlying pathology. A thorough evaluation must be performed by clinicians; and discussed with patients and family prior to undergo further imaging management. LEVEL OF EVIDENCE: Level III.

Suggestive hypothesis on a case report: Patient presenting with cyclical ovarian cysts coupled to increased cholestatic enzymes.

We describe the case of a childbearing-age woman presenting with spontaneous recurrent functional ovarian cysts and, more interestingly, chronic and asymptomatic elevation of cholestatic parameters. The patient showed no history of chronic viral infections, immunological and metabolic disorders, alcohol abuse and environmental toxins exposition. Hepatic ultrasonography and cholangio-pancreatography-magnetic-resonance excluded any morphological and structural abnormalities, while liver biopsy evidenced only minimal and not specific features of inflammation. Cholestasis indices obtained prompt recovery after each cycle of synthetic hormone therapy, implanted to treat functional ovarian cysts. She has continuously experienced the off-therapy asynchronous recurrence of liver laboratory abnormalities and functional ovarian cysts. The favorable effect of the synthetic hormone therapy to obtaining a stable recovery of this unexplained long-lasting cholestatic syndrome could be likely explained by downregulation of an endogenous ovarian overproduction, although estrogen-regulated local intracellular transduction pathways cannot be excluded.

Dienogest enhances autophagy induction in endometriotic cells by impairing activation of AKT, ERK1/2, and mTOR.

OBJECTIVE: To elucidate the therapeutic mechanisms of progestin and the effects of progesterone and progestin (dienogest) on autophagy induction and regulation in endometriotic cells, specifically the effects of progesterone and dienogest on the phosphoinositide-3/protein kinase B (PI3K-AKT) and mitogen-activated protein kinase kinases 1 and 2 (MEK1/2)/extracellular-signal-regulated kinase 1/2 (ERK1/2) pathways, which activate mammalian target of rapamycin (mTOR), a major negative regulator of autophagy. DESIGN: In vitro study using human endometriotic cyst stromal cells (ECSCs). SETTING: University medical center. PATIENT(S): Fifteen patients with ovarian endometrioma. INTERVENTION(S): ECSCs treated with progesterone or dienogest. MAIN OUTCOME MEASURE(S): Autophagy as measured by the expression of the microtubule-associated protein light chain 3-II (LC3-II) and autophagosome formation, and levels of AKT, ERK1/2, and mTOR activity to quantify the phosphorylation of AKT, ERK1/2, and S6K (the downstream target of mTOR). RESULT(S): Progesterone treatment had not statistically significant effect on LC3-II expression, autophagosome formation, or phosphorylation of AKT, ERK1/2, or S6K in estrogen-treated ECSCs. However, dienogest treatment up-regulated LC3-II expression and stimulated autophagosome formation. These effects were accompanied by decreased activation of AKT, ERK1/2, and S6K. Furthermore, incubation of ECSCs with AKT and ERK1/2 inhibitors, which mimicked dienogest-mediated inhibition of AKT and ERK1/2 activity, suppressed S6K activity, followed by an increase in LC3-II expression. In addition, cotreatment with dienogest and 3-methyladenine (autophagy inhibitor) decreased the levels of apoptosis of ECSCs compared with the single treatment with dienogest. CONCLUSION(S): Our results suggest that dienogest treatment of endometriotic cells suppresses AKT and ERK1/2 activity, thereby in turn inhibiting mTOR, inducing autophagy, and promoting apoptosis.

Wisteria floribunda agglutinin-binding glycan expression is decreased in endometriomata.

BACKGROUND: Glycosylation is one of the most common post-translational modifications of eukaryotic proteins and is known to undergo dynamic changes in a wide range of biological processes. To date, however, the glycan expression profiles in endometriosis are largely unknown. The objective of the study was to identify the panel of glycans that were aberrantly expressed in endometriosis, a hormone-dependent disease. METHODS: The glycan expression profiles in primary cultured human endometriotic cyst stromal cells (ECSCs) and normal endometrial stromal cells (NESCs) were determined by lectin microarray analysis. Distribution of Wisteria floribunda agglutinin (WFA)-binding glycans in ovarian endometriotic cysts and eutopic proliferative phase endometrium were assessed by lectin histochemistry. The expressions of N-acetylgalactosaminyl transferases that synthesize WFA-binding glycans were evaluated in ECSCs and NESCs. RESULTS: We found that the levels of WFA-binding glycans were decreased in ECSCs. Lectin histochemistry revealed that WFA-binding glycans were decreased only in the stromal components of the ovarian endometriotic cysts, but not in the epithelial components, compared to the eutopic proliferative phase endometrium. The expressions of N-acetylgalactosaminyl transferases that synthesize WFA-binding glycans were downregulated in ECSCs. CONCLUSIONS: Utilizing lectin microarray analysis and lectin histochemistry, we found that WFA-binding glycans were decreased in endometriosis. The synthetic enzymes of WFA-binding glycans were significantly downregulated in ECSCs. It is suggested that reduced expression of N-glycans with WFA-binding properties on ECSCs is a novel characteristics of endometriosis.

The activity of class I, II, III and IV alcohol dehydrogenase isoenzymes and aldehyde dehydrogenase in ovarian cancer and ovarian cysts.

PURPOSE: The metabolism of cancerous cells is in many ways different than in healthy cells. In ovarian cancer, cells exhibit activity of alcohol dehydrogenase (ADH) and aldehyde dehydrogenase (ALDH), which participate in metabolism of many biological substances. The aim of this study was to compare the metabolism of ovarian cancer cells, ovarian cysts and normal ovarian cells by measurement of ADH isoenzymes and ALDH activities. MATERIAL AND METHODS: The study material consisted of 36 cancerous ovarian tissues. Class III, IV of ADH and total ADH activity was measured by the photometric method and class I, II ADH and ALDH activity by the fluorometric method with class-specific fluorogenic substrates. RESULTS: The activity of the class I ADH isoenzyme and the total ADH was significantly higher in ovarian cancer as compared to ovarian cysts and healthy tissues but there are no significant differences between ovarian cysts and healthy cells. The other classes of ADH tested, did not show significant differences between activity of cancerous cells and healthy ovary. CONCLUSION: The increased activity of total ADH in ovarian cancer, especially the class I isoenzyme and normal activity of ALDH, may be the factor for the disturbances in important biological substances metabolism and could increase the concentration of highly carcinogenic acetaldehyde.

Ovarian localization of 11ß-hydroxysteroid dehydrogenase (11ßHSD): effects of ACTH stimulation and its relationship with bovine cystic ovarian disease.

Cystic ovarian disease (COD) is an important cause of infertility in cattle, and ACTH has been involved in regulatory mechanisms related to ovarian function associated with ovulation, steroidogenesis, and luteal function. Here, we examined the localization of 11ß-hydroxysteroid dehydrogenase type 1 (11ßHSD1) and 11ßHSD2 proteins in the ovary of healthy cows and animals with spontaneous and ACTH-induced COD and the in vitro response of the follicular wall exposed to ACTH. After stimulation by ACTH, we documented changes in 11ßHSD expression and cortisol secretion by the follicular wall of large antral and follicular cysts. Follicular cysts showed a higher constitutive expression of both enzymes, whereas ACTH induced an increase in 11ßHSD1 in tertiary follicles and follicular cysts and a decrease in 11ßHSD2 in follicular cysts. Moderate expression of 11ßHSD1 was observed by immunohistochemistry in granulosa of control animals, with an increase (P < 0.05) from primary to secondary, tertiary, and atretic follicles. The level of immunostaining in theca interna was lower than that in granulosa. The expression of 11ßHSD2 was lower in the granulosa of primary follicles than in that of secondary, tertiary, and atretic follicles and was lower in the theca interna than in the granulosa. In ACTH-induced and spontaneously occurring follicular cysts, differences from controls were observed only in the expression of 11ßHSD1 in the granulosa, being higher (P < 0.05) than in tertiary follicles. These findings indicate that follicular cysts may be exposed to high local concentrations of active glucocorticoids and indicate a local role for cortisol in COD pathogenesis and in regulatory mechanisms of ovarian function.

Supraphysiological leptin levels shift the profile of steroidogenesis in porcine ovarian follicles toward progesterone and testosterone secretion through increased expressions of CYP11A1 and 17b-HSD: a tissue culture approach.

Evidence from both clinical and animal studies suggests that exposure to excess androgens results in cyst formation. The present in vitro study assessed the effects of supraphysiological concentrations of leptin (20 and 40 ng/ml) on progesterone (P(4)), androstenedione androstendione (A(4)), testosterone and estradiol (E(2)) secretion by ELISA and the expression of CYP11A1, CYP17, 17b-hydroxysteroid dehydrogenase (17b-HSD) and CYP19 by western blot to answer the question of whether leptin could be independent risk factor for cystformation in pigs. Small- and medium-sized ovarian follicles were collected from prepubertal and cycling pigs. Increased P(4) and testosterone secretions were observed in both small- and medium-sized follicles in prepubertal and cycling animals whereas there was no change in E2 secretion. Leptin treatment resulted in an increase in CYP11A1 and 17b-HSD protein expression but had no effect on CYP17 and CYP19 expression in follicles of either size from prepubertal and cycling pigs. Results of presented data suggest that leptin in elevated doses, by stimulatory effect on CYP11A1 and 17b-HSD protein expression resulting in elevated P(4) and testosterone secretions could be an independent risk factor for cyst formation in both prepubertal and cycling pigs.

Up-regulation of p21-activated kinase 1 by in vitro treatment with interleukin 1-beta and its increased expression in ovarian endometriotic cysts.

We evaluated whether the proinflammatory cytokines can regulate p21-activated kinase (Pak1) expression in endometrial cells as well as whether its expression is increased in endometriotic cysts. We found that interleukin-1ß up-regulates Pak1 expression in endometrial stromal cells (ESC) and that the immunoreactivity of Pak1 is increased in the endometriotic cysts.

Activity of telomerase in ovarian cancer cells. Clinical implications.

Estimation of telomerase activity in cell nuclei of ovarian malignant tumours may provide an independent prognostic index. The test for telomerase activity in tumour cell nuclei may be accepted as a useful diagnostic test with application for differential diagnoses of benign ovarian tumours vs tumours of a borderline or malignant character.

GSTP1-1 in ovarian cyst fluid and disease outcome of patients with ovarian cancer.

Detoxification enzymes, especially glutathione S-transferase P1-1 (GSTP1-1), have been implicated in resistance to platinum-based chemotherapy. We studied GSTP1-1 levels in ovarian cyst fluid (oCF), obtained during surgery before chemotherapy, of patients with epithelial ovarian cancer and clinical outcomes were correlated. GSTP1-1 was determined by ELISA in oCF of 56 patients with epithelial ovarian cancer and 109 noncancer controls (21 borderline and 88 benign ovarian tumors). Differences in median GSTP1-1 between clinicopathologic subgroups were studied using Mann-Whitney U and Kruskal Wallis tests. Differences in disease-free (DFS) and overall survival (OS) between groups were analyzed by applying Kaplan-Meyer estimates and log-rank tests. Univariate and multivariate analysis were done using Cox proportional hazard model. Significantly higher levels of GSTP1-1 were found in the oCF of malignant (median, 383; range, 10-32,695 ng/mL) compared with benign (median, 20; range, 0-1,128 ng/mL) ovarian tumors (P < 0.01). Significantly higher GSTP1-1 levels were found in patients with advanced International Federation of Gynaecologists and Obstetricians stage (P = 0.01), high-grade tumors (P = 0.44), and/or high levels of preoperative CA 125 (P = 0.01). Of patients who received chemotherapy (stage, >or=Ic; n = 30), high GSTP1-1 levels were significantly associated with a poor DFS and OS (log-rank P = 0.047 and P = 0.033, respectively). International Federation of Gynaecologists and Obstetricians stage was the only independent predictor for DFS. GSTP1-1 was the only independent predictor for OS.

PTEN promoter methylation and LOH of 10q22-23 locus in PTEN expression of ovarian clear cell adenocarcinomas.

OBJECTIVES: Loss of phosphatase and tensin homolog (PTEN) expression is common in ovarian clear cell adenocarcinomas (OCCA), but PTEN mutations are not frequently observed in OCCA. The mechanism of PTEN gene silencing in OCCA is still not clear. MATERIALS AND METHODS: Immunohistochemical analysis of PTEN expression was performed in 40 OCCA paraffin-embedded tissues. PTEN promoter methylation in 24 OCCA tissues and 5 OCCA cell lines was examined by methylation-specific PCR. Eighteen OCCA patients and 13 serous adenocarcinomas were analyzed for loss of heterozygosity (LOH) at 10q23 with five polymorphic markers. RESULTS: Of the 40 OCCAs, 37.5% (15/40) had reduced PTEN immunoreactivity, LOH was found in 33% (6/18) of OCCAs, and 31% (4/13) of serous adenocarcinomas. In the 33% of OCCAs with LOH, only 33% (2/6) lost PTEN expression. PTEN promoter was unmethylated in 5 OCCA cell lines and 24 OCCA tissues detected by MSP-PCR. No significant correlation between PTEN expression and advanced stage disease or overall survival was found. CONCLUSION: Our results indicate that reduced PTEN expression was detected in more than one third of OCCA cases. Neither PTEN promoter methylation nor LOH at 10q23 locus is significantly related to PTEN inactivation and is not an adverse prognostic factor in OCCA.

[Cytochrome P-450 aromatase expression in the ectopic and eutopic endometrium in endometriosis].

An immunoperoxidase test was used to reveal the expression of cytochrome P-450 aromatase in the eutopic and ectopic endometrium of 14 patients with ovarian endometriosis and 26 with adenomyosis, whose age ranged from 21 to 47 years (38+/-2.0 years). Five endometrial samples taken at autopsy from the women who had died from injuries at ages of 32 to 47 years and who had no uterine or ovarian abnormities served as the control. Control observations revealed no aromatase expression by endometrial epithelial and stromal cells. Aromatase expression in the eutopic endometrium was found in patients with ovarian endometriosis and adenomysis in 80 and 58% of cases, respectively; while that in the ectopic endothelium was in all cases in both groups. In external genital endometriosis, the sensitivity and specificity of the test were 75 and 100%, respectively. In the glandular and stromal epithelium of both the ectopic and eutopic endometrium, aromatase expression increased with the higher extent of endometriosis.

Alteration of focal adhesion kinase expression in eutopic endometrium of women with endometriosis.

OBJECTIVE: To investigate whether focal adhesion kinase (FAK) expression is altered in eutopic endometrium of women with endometriosis. DESIGN: Experimental study using human endometrial tissue. SETTING: Academic research center. PATIENT(S): Women with or without endometriosis who were undergoing surgery for benign indications. INTERVENTION(S): Endometrial biopsy. MAIN OUTCOME MEASURE(S): Expression of FAK was assessed by immunohistochemistry, Western blotting analysis, and reverse-transcription polymerase chain reaction. RESULT(S): At secretory phase, the average level of endometrial FAK expression of women with endometriosis was significantly higher than that of controls, but no significant difference was found between the two groups at proliferative phase. There was a positive correlation between FAK expression in secretory endometrial tissues and disease stage and pelvic pain in women with endometriosis. Furthermore, the endometrial FAK protein expression varied with the serum E(2) at proliferative phase and with the ratio of E(2) to P at secretory phase. CONCLUSION(S): The study showed a significant increase of FAK expression in the secretory endometrial tissues of women with endometriosis, a relationship between FAK expression and disease stage, pelvic pain, and serum steroid hormones. Those results suggest that FAK may play a role in the pathogenesis of endometriosis and be regulated by steroid hormones.

Difference in expression of matrix metalloproteinase-2 and matrix metalloproteinase-9 in patients with persistent ovarian cysts.

Matrix metalloproteinase-1 (MMP-1), MMP-2, and MMP-9 expression with real-time quantitative polymerase chain reaction were analyzed in endometriotic and nonendometriotic ovarian cysts. Although MMP-1 was not detected, MMP-9 and MMP-2 were expressed in all of the cysts. In particular, in five of six nonendometriotic cysts (83.3%) MMP-2 expression was higher than in endometriotic cysts. These data may represent new molecular elements helpful in differential diagnosis of endometriotic lesions.

Increased activity of lysosomal enzymes in the peritoneal fluid of patients with gynecologic cancers and pelvic inflammatory disease.

PURPOSE: To investigate whether the activity of lysosomal enzymes is increased in the peritoneal fluid of patients with gynecologic cancers compared to activity in the peritoneal fluid from normal subjects and those with pelvic inflammatory disease, and fluid from benign ovarian cysts. PATIENTS AND METHODS: beta-glucuronidase, beta-galactosidase, and alpha-mannosidase activity was measured in the peritoneal fluid from patients with gynecologic cancer, pelvic inflammatory disease, and normal subjects, and fluid from benign ovarian cysts. RESULTS: The mean+/-SD of beta-glucuronidase, beta-galactosidase, and alpha-mannosidase activity in the gynecologic cancers was 120+/-50 nmol, 203+/-86 nmol, and 240+/-119 nmol 4-methylumbelliferone/ml/h, respectively; in the normal control subjects it was 22+/-9 nmol, 46+/-10 nmol, and 80+/-23 nmol, respectively (P=0.00003, 0.0001, and 0.0001, respectively). The activity was increased even in cases without malignant cells in the peritoneal fluid. In pelvic inflammatory disease it was 148+/-82 nmol, 278+/-112 nmol, and 291+/-140 nmol, respectively. The activity in the fluid of the ovarian cysts was similar to that of the normal peritoneal fluid. There was a significant positive correlation between enzyme activity and stage of cancer, that was stronger for beta-glucuronidase (r=0.889, P=0.003). CONCLUSION: The increased lysosomal enzyme activity in gynecologic cancers, without overlapping between patients and normal subjects or benign ovarian cyst fluid, indicates that such measurements might be applied for diagnostic purposes.

Gonadotropin-releasing hormone agonist inhibits estrone sulfatase expression of cystic endometriosis in the ovary.

OBJECTIVE: To clarify the inhibitory effect of GnRH agonist on estrone (E(1)) sulfatase expression. DESIGN: Retrospective immunohistochemical study. SETTING: The Jikei University Hospital, Tokyo, Japan. PATIENT(S): Thirty-three women who had undergone cystectomy of the ovary or oophorectomy and were proved histopathologically to have cystic endometriosis in the ovary. INTERVENTION(S): Fifteen of the 33 patients were treated with GnRH agonists monthly for 2-6 months before surgery. The other 18 patients did not receive any hormonal therapy. Tissue sections were immunostained with an anti-E(1) sulfatase monoclonal antibody (KM1049) originating from human placenta. MAIN OUTCOME MEASURE(S): Microscopic evaluation to assess the presence and localization of E(1) sulfatase and to describe any variations in its expression with or without treatment with GnRH agonist. RESULT(S): Immunostaining showed that E(1) sulfatase was localized only on the glandular epithelial cells of cystic endometriosis in the ovary. The immunostaining with anti-E(1) sulfatase proved that GnRH agonist inhibited E(1) sulfatase expression in the cystic endometriosis in the ovary. CONCLUSION(S): Gonadotropin-releasing hormone agonist inhibits E(1) sulfatase expression in cystic endometriosis in the ovary.

Analysis of cyclooxygenase-2 (COX-2) expression in different sites of endometriosis and correlation with clinico-pathological parameters.

BACKGROUND: Recent studies have demonstrated the overexpression of cyclooxygenase-2 (COX-2) in endometriosis. The aim of this study was to investigate the expression of COX-2 in different anatomical sites of endometriosis and its association with clinico-pathological parameters in a single institutional series of patients undergoing operative treatment. METHODS: COX-2 expression was analysed by immunohistochemistry in 136 samples of endometriotic tissue from 103 patients affected by endometriosis. RESULTS: COX-2 immunoreaction was observed in 78.5% of ovarian endometriotic cysts, in 11.1% of peritoneal implants and 13.3% of recto-vaginal nodules. COX-2 positivity was not distributed differently according to age, pre-operative serum levels of CA125 and AFS score. Moreover, COX-2 positivity did not show any significant variation according to the subjective intensity of pain, as dysmenorrhoea, chronic pelvic pain, lower urinary tract or gastrointestinal symptoms, or according to infertility. CONCLUSIONS: Increased COX-2 expression in the endometriotic ovarian cyst wall was observed with respect to other extraovarian localizations. No relevant correlations between COX-2 positivity and clinico-pathological characteristics and symptoms of patients were observed.

Deficiency of 17,20-lyase causing giant ovarian cysts in a girl and a female phenotype in her 46,XY sister: case report.

A 13-year-old girl was referred because of progressive abdominal pain caused by ovarian torsion and giant ovarian cysts. Secondary sexual characteristics were absent. Hormone analysis revealed markedly elevated serum levels of progesterone and 17-hydroxyprogesterone in combination with very low peripheral concentrations of C19 steroids (dehydroepiandrosterone and androstenedione) and estrogens. Serum concentrations of FSH and LH exceeded the upper limit of normal levels in adult women. The patient's 16-year-old 46,XY sibling showed a female phenotype with similar hormonal disturbances. Both siblings were found to be compound heterozygotes for two mutations in the CYP17 gene: an R347C mutation in one allele and a 25-base pair deletion in exon 1 in the other. The resulting block in 17,20-lyase activity caused an inability to synthesize androgens and estrogens, and increased levels of gonadotrophins due to a lack of negative feedback. The increased levels of gonadotrophins most likely stimulated growth of the ovarian cysts. The administration of a GnRH antagonist reduced the size of the cysts within a few weeks. At present, the girl is being treated with a combination of a GnRH agonist and hormone replacement therapy.