Fertility and pregnancy outcome in women with congenital adrenal hyperplasia due to 21-hydroxylase deficiency.

BACKGROUND: Low pregnancy rate has been reported in women with congenital adrenal hyperplasia (CAH) and little information on pregnancy and children is known. METHODS: In a Swedish study, 62 adult women with CAH, aged 18-63 years, and 62 age-matched controls were followed-up. Medical records, including those concerning pregnancies and deliveries, were examined and the 21-hydroxylase genotype of patients was noted. All women answered a questionnaire concerning sexual and reproductive health including health of the children. RESULTS: Pregnancy and delivery rates were significantly lower in women with CAH (P < 0.001, P < 0.0056, respectively), and the severity of the 21-hydroxylase-mutation correlated with the reduced number of children born. More women with salt-wasting CAH were single and had not attempted pregnancy. Pregnancies were normal except for a significantly increased incidence of gestational diabetes in CAH patients (P < 0.0024). The children had normal birthweight and no malformations were observed. A later follow-up of the children showed a normal intellectual and social development. The sex ratio of the offspring differed significantly, with 25% boys in the CAH group compared with 56% among controls (P < 0.016). CAH women had more gynaecological morbidity during menopause. CONCLUSIONS: Pregnancy and delivery rates are reduced in women with CAH mainly due to psychosocial reasons. The outcome of children did not differ from controls. The unexpected sex ratio in children born to mothers with CAH warrants further research.

A 31-year-old woman with infertility and polycystic ovaries diagnosed with non-classic congenital adrenal hyperplasia due to a novel CYP21 mutation.

A 31-yr-old woman presenting with a history of hirsutism, amenorrhea, and infertility was previously assumed to have polycystic ovary syndrome. A new gynecological-endocrine evaluation demonstrated elevated testosterone/SHBG ratio, serum 17-hydroxyprogesterone (17-OHP), and urinary pregnantriol. She was diagnosed with non-classic congenital adrenal hyperplasia. In spite of treatment with dexamethasone and fludrocortisone in doses that suppressed adrenal androgens and 17-OHP into normal range or below, she did not ovulate. Clomiphene citrate and then FSH/hCG treatment in several cycles gave no consistent ovulation. Progesterone levels remained elevated throughout the cycles indicating a possible contribution from the adrenals. Oral glucose tolerance was normal, but the homeostasis model assessment index indicated insulin resistance. With metformin 1500 mg daily the index decreased remarkably from 2.77 to 0.96 with a few ovulations but no pregnancy occurred. Three cycles of IVF treatment thereafter were unsuccessful. Three months after the last in vitro fertilization (IVF) cycle, still on dexamethasone, fludrocortisone, and metformin, her menstruations became regular and she thereafter became pregnant. During pregnancy metformin was discontinued and dexamethasone replaced with prednisolone. Mild gestational diabetes developed and insulin was given. A healthy boy was born at term by elective Cesarean section. A CYP21- gene analysis had not indicated any of the known mutations but after gene sequencing a novel mutation was found, namely R233G. This case confirms the necessity of adding an analysis of 17-OHP when evaluating women with hirsutism and menstrual disturbances and if an elevated value is found, the advantage of performing a mutation analysis to facilitate counseling and decisions on treatment.

Pdx1 level defines pancreatic gene expression pattern and cell lineage differentiation.

The absence of Pdx1 and the expression of brain-4 distinguish alpha-cells from other pancreatic endocrine cell lineages. To define the transcription factor responsible for pancreatic cell differentiation, we employed the reverse tetracycline-dependent transactivator system in INS-I cell-derived subclones INSralphabeta and INSrbeta to achieve tightly controlled and conditional expression of wild type Pdx1 or its dominant-negative mutant, as well as brain-4. INSralphabeta cells express not only insulin but also glucagon and brain-4, while INSrbeta cells express only insulin. Overexpression of Pdx1 eliminated glucagon mRNA and protein in INSralphabeta cells and promoted the expression of beta-cell-specific genes in INSrbeta cells. Induction of dominant-negative Pdx1 in INSralphabeta cells resulted in differentiation of insulin-producing beta-cells into glucagon-containing alpha-cells without altering brain4 expression. Loss of Pdx1 function alone in INSrbeta cells, which do not express endogenous brain-4 and glucagon, was also sufficient to abolish the expression of genes restricted to beta-cells and to cause alpha-cell differentiation. In contrast, induction of brain-4 in INSrbeta cells initiated detectable expression of glucagon but did not affect beta-cell-specific gene expression. In conclusion, Pdx1 confers the expression of pancreatic beta-cell-specific genes, such as genes encoding insulin, islet amyloid polypeptide, Glut2, and Nkx6.1. Pdx1 defines pancreatic cell lineage differentiation. Loss of Pdx1 function rather than expression of brain4 is a prerequisite for alpha-cell differentiation.

Bone mass and body composition of adult women with congenital virilizing 21-hydroxylase deficiency after glucocorticoid treatment since infancy.

AIM: To study bone mass, body composition and androgenic/anabolic activity in adult women with virilizing congenital adrenal hyperplasia (CAH) treated with glucocorticoids since infancy and to relate this to the postmenarcheal glucocorticoid impact. PATIENTS AND METHODS: Thirteen adult women with virilizing CAH treated with gluco- and mineralocorticoids but otherwise medicine-free were investigated with respect to bone mineral content, body composition by dual energy X-ray absorptiometry and endocrine status. In addition an index of accumulated postmenarcheal exogenous glucocorticoid impact was calculated. Seven of the patients had regular menstrual periods, and six were oligomenorrheic but responded with withdrawal bleedings on cyclic progestagens. The data for the patients were compared with those of age-matched healthy reference subjects. RESULTS: In spite of their shorter stature, CAH patients were significantly heavier and had a significantly higher body mass index and fat/lean body mass ratio than the controls. Their bone mineral area density (BMD) was significantly lower than that of the controls. Serum concentrations of androgens were subnormal in all except two of the patients. Strong negative associations were found between BMD and the calculated index of accumulated postmenarcheal glucocorticoid dose but not between BMD and circulating androgen levels. CONCLUSION: The results indicate that glucocorticoids were administered in excess in most of the patients, resulting in subnormal levels of adrenocortical androgens, increased body fat and bone demineralization. Increased catabolic activity due to hypercortisolism rather than decreased androgenic/anabolic steroids is probably the major cause of the subnormal BMD in the treated CAH patients.

Hepatocyte nuclear factor 4alpha regulates the expression of pancreatic beta -cell genes implicated in glucose metabolism and nutrient-induced insulin secretion.

Mutations in the HNF4alpha gene are associated with the subtype 1 of maturity-onset diabetes of the young (MODY1), which is characterized by impaired insulin secretory response to glucose in pancreatic beta-cells. Hepatocyte nuclear factor 4alpha (HNF4alpha) is a transcription factor critical for liver development and hepatocyte-specific gene expression. However, the role of HNF4alpha in the regulation of pancreatic beta-cell gene expression and its correlation with metabolism secretion coupling have not been previously investigated. The tetracycline-inducible system was employed to achieve tightly controlled expression of both wild type (WT) and dominant-negative mutant (DN) of HNF4alpha in INS-1 cells. The induction of WT-HNF4alpha resulted in a left shift in glucose-stimulated insulin secretion, whereas DN-HNF4alpha selectively impaired nutrient-stimulated insulin release. Induction of DN-HNF4alpha also caused defective mitochondrial function substantiated by reduced [(14)C]pyruvate oxidation, attenuated substrate-evoked mitochondrial membrane hyperpolarization, and blunted nutrient-generated cellular ATP production. Quantitative evaluation of HNF4alpha-regulated pancreatic beta-cell gene expression revealed altered mRNA levels of insulin, glucose transporter-2, L-pyruvate kinase, aldolase B, 2-oxoglutarate dehydrogenase E1 subunit, and mitochondrial uncoupling protein-2. The patterns of HNF4alpha-regulated gene expression are strikingly similar to that of its downstream transcription factor HNF1alpha. Indeed, HNF4alpha changed the HNF1alpha mRNA levels and HNF1alpha promoter luciferase activity through altered HNF4alpha binding. These results demonstrate the importance of HNF4alpha in beta-cell metabolism-secretion coupling.

Molecular targets of a human HNF1 alpha mutation responsible for pancreatic beta-cell dysfunction.

The reverse tetracycline-dependent transactivator system was employed in insulinoma INS-1 cells to achieve controlled inducible expression of hepatocyte nuclear factor-1 alpha (HNF1 alpha)-P291fsinsC, the most common mutation associated with subtype 3 of maturity-onset diabetes of the young (MODY3). Nuclear localized HNF1 alpha-P291fsinsC protein exerts its dominant-negative effects by competing with endogenous HNF1 alpha for the cognate DNA-binding site. HNF1 alpha controls multiple genes implicated in pancreatic beta-cell function and notably in metabolism- secretion coupling. In addition to reduced expression of the genes encoding insulin, glucose transporter-2, L-pyruvate kinase, aldolase B and 3-hydroxy-3-methylglutaryl coenzyme A reductase, induction of HNF1 alpha-P291fsinsC also significantly inhibits expression of mitochondrial 2-oxoglutarate dehydrogenase (OGDH) E1 subunit mRNA and protein. OGDH enzyme activity and [(14)C]pyruvate oxidation were also reduced. In contrast, the mRNA and protein levels of mitochondrial uncoupling protein-2 were dramatically increased by HNF1 alpha-P291fsinsC induction. As predicted from this altered gene expression profile, HNF1 alpha-P291fsinsC also inhibits insulin secretory responses to glucose and leucine, correlated with impaired nutrient-evoked mitochondrial ATP production and mitochondrial membrane hyperpolarization. These unprecedented results suggest the molecular mechanism of HNF1 alpha-P291fsinsC causing beta-cell dysfunction.

Functional characterisation of mutations in the ligand-binding domain of the androgen receptor gene in patients with androgen insensitivity syndrome.

Five mutations in the ligand-binding domain of the androgen receptor gene were identified in patients with complete (A765T, C784Y, R831X and M895T) or partial (R840G) androgen insensitivity. A765T and R831X have been reported previously whereas the other three mutations are novel. Receptors carrying these mutations were transiently expressed in COS-1 cells, and androgen binding and capacity to transactivate an androgen-responsive reporter gene were assayed. C784Y led to abolished androgen binding and transactivating capacity, R840G and M895T showed reduced specific binding and partial transactivation. The in vitro functions of the R840G and M895T mutants were improved with supraphysiological concentrations of steroid.

Dominant-negative suppression of HNF-1alpha function results in defective insulin gene transcription and impaired metabolism-secretion coupling in a pancreatic beta-cell line.

Mutations in the hepatocyte nuclear factor-1alpha (HNF-1alpha) have been linked to subtype 3 of maturity-onset diabetes of the young (MODY3), which is characterized by a primary defect in insulin secretion. The role of HNF-1alpha in the regulation of pancreatic beta-cell function was investigated. Gene manipulation allowed graded overexpression of HNF-1alpha and controlled dominant-negative suppression of HNF-1alpha function in insulinoma INS-1 cells. We show that HNF-1alpha is essential for insulin gene transcription, as demonstrated by a pronounced decrease in insulin mRNA expression and in insulin promoter activity under dominant-negative conditions. The expression of genes involved in glucose transport and metabolism including glucose transporter-2 and L-type pyruvate kinase is also regulated by HNF-1alpha. Loss of HNF-1alpha function leads to severe defects in insulin secretory responses to glucose and leucine, resulting from impaired glucose utilization and mitochondrial oxidation. The nutrient-evoked ATP production and subsequent changes in plasma membrane potential and intracellular Ca2+ were diminished by suppression of HNF-1alpha function. These results suggest that HNF-1alpha function is essential for maintaining insulin storage and nutrient-evoked release. The defective mitochondrial oxidation of metabolic substrates causes impaired insulin secretion, indicating a molecular basis for the diabetic phenotype of MODY3 patients.

[Athletic amenorrhea and its consequences. Hard physical training at an early age can cause serious bone damage]. / Idrottsamenorré och dess konsekvenser. Hård fysisk träning i unga år kan ge allvarliga skelettskador.

Strenuous exercise in women is associated with a high incidence of menstrual dysfunction, including amenorrhoea. Athletic amenorrhoea is most common among long-distance runners and ballet dancers, with a prevalence of up to 66 per cent. It is of hypothalamic origin, the pulsatile release of GnRH (gonadotrophin-releasing hormone) being disturbed during exercise, resulting in low gonadotrophin and oestrogen levels. Accumulated evidence suggests athletic amenorrhoea to be related to energy deficiency or to the eating disorders that are prevalent among athletes. The long-term consequences of amenorrhoea are premature osteoporosis and increased risk of musculoskeletal injury. Elite training in young girls tends to delay pubertal development, resulting in decreased bone mass accumulation and reduced growth potential.

Evaluation of undergraduate medical education - why and how?

The education of physicians both at the undergraduate and graduate level is no longer a matter for an individual professor or department in a medical faculty. The curriculum has to be developed and carried out according to the needs of the society in which the physician is going to function. Evaluation of the educational programme by external reviewers should therefore be seen as a normal part of the quality control process of all medical faculties. The most important part of such an evaluation is the self-assessment performed by the faculty and the students; self-assessment, together with advice from the external reviewers, will constitute the basis for necessary curriculum changes.

Bone mineral content of young female former gymnasts.

Intense physical exercise and diet restriction could result in delayed puberty and have a negative influence on the acquisition of peak bone mass during puberty. Nineteen young women who had been in elite gymnastic training during their prepubertal and pubertal years were investigated with regard to their health, menstrual data and bone mineral areal mass (BMA). Twenty-one women of comparable age served as controls. The age of menarche of the "former" gymnasts and the controls was 14.8 +/- 1.8 and 12.1 +/- 1.4 years, respectively. Fourteen of the gymnasts had been or were using oral contraceptives (OCs) and most of the non-users now had regular menstrual periods. During the years preceding the study, physical activity among the "former" gymnasts had gradually declined. Although the gymnasts had had a delayed puberty, no difference was found in total body or spinal BMA compared to the healthy controls. Their normal BMA in early adulthood could reflect a catch-up due to a combination of decreasing athletic activity, normal menstrual cycles and intake of OCs.

A nutrition study in juvenile elite gymnasts.

Twenty-two female teenagers engaged in elite gymnast training and 22 healthy girls of comparable age were studied with regard to nutritional intake. The mean daily intakes of most nutrients in both groups were in accordance with the Swedish Nutritional Recommendations; exceptions were iron and dietary fibre which were too low in both groups. The individual variation was large in both groups and many subjects had an intake below the nutritional recommendations. Both the gymnasts and the reference group had an energy intake significantly below the estimated energy need. The mean daily energy intake was 725 kcal less than the energy need in the gymnast group and 450 kcal less in the reference group. The clinical investigation revealed that several gymnasts had delayed menarche or irregular menstruation as well as less body fat than the reference group. Among the gymnasts, girls with a regular menstrual pattern had more body fat than those who had not started to menstruate. The higher energy expenditure of the gymnasts could partly explain their smaller amounts of body fat, late pubertal development and menstrual patterns.

Bone mineral density in middle-aged women with Turner's syndrome.

Bone mineral density (BMD), bone mineral content and body composition were determined in 47 middle-aged (mean age 47.9 +/- 1.1 years) women with Turner's syndrome. Bone mineral density was measured in the forearm, femoral neck and total body. The women investigated had a BMD lower than the normal mean. When expressed as Z scores (individual values compared to normal reference data matched for age, weight and sex), the median Z score of the total body was -1.23. When comparing women with the karyotype 45,X and mosaic women, the latter showed a higher BMD in all sites of measurement. Duration of hormonal replacement therapy (HRT) differed significantly between the mosaic and the 45,X women, with a longer duration in the mosaic group (20.7 +/- 2 vs 12.1 +/- 2.6 years; p < 0.01). The duration of HRT was found to be the more important factor to maintain bone mass, not the karyotype. Bone mineral density increased with years of HRT but not until after > 20 years of HRT could a significant difference be shown between the women with HRT < or = 20 years and those with HRT > 20 years. No correlation was found between BMD and body weight, body fat or percentage body fat. Whether the osteopenia found in women with Turner's syndrome is similar to that found postmenopausally or is a specific form related to the chromosome aberration remains to be investigated further. The present data support a relation to estrogen deficiency.

Selection of ovarian stimulation protocol is related to IVF treatment outcome in women 35 years of age and older.

PURPOSE: The aim of this study was to assess if the woman's age influenced IVF treatment outcome when a long GnRHa-hMG or a CC-hMG ovarian stimulation protocol was used. Two hundred women were included in the study, 100 women under the age of 35 and 100 women 35 years of age and older (mean 31.8 years and 36.7 years respectively). In the younger group as well as in the older group 50 women were stimulated according to a GnRHa-hMG protocol and 50 women received a CC-hMG regimen. RESULTS: Significant differences between stimulation protocols were found in the older group for the mean numbers of oocytes recovered (4.7 vs 3.0), preembryos obtained (3.2 vs 2.0) and replaced (2.3 vs 1.7), as well as pregnancy (30% vs 10%) and delivery (24% vs 4%) rates per replacement. CONCLUSION: It is concluded that women over 35 years of age seem to have a more favorable outcome of IVF treatment when using a long GnRHa-hMG protocol compared with CC-hMG, while this difference was not as obvious and lacking statistical significance under the age of 35.

Pubertal development in elite juvenile gymnasts. Effects of physical training.

Twenty-two female teenagers engaged in elite gymnast training were prospectively studied during a five-year period and their pubertal development was recorded. Height and weight, as well as stage of development according to Tanner, were registered every six months. FSH, LH, TSH and prolactin were measured in girls who had not yet had their first menstrual period. Twenty-two healthy school girls in the same age group who were not actively engaged in physical exercise served as a control group. Pubertal development was completed during the observation period in all the gymnasts but one, who had primary amenorrhea at the age of eighteen. As a group, the gymnasts had a significantly delayed age of menarche compared to the control group and to normal Swedish girls. They also had significantly less body fat and were shorter and lighter than the control group. They grew much more slowly and did not have the distinct growth spurt seen in the controls. The final height of six of the gymnasts was less than the expected height. The frequency of injuries was high in the gymnasts, which might be a result of hard training combined with late menarche and low body fat.

Life with Turner's syndrome--a psychosocial report from 22 middle-aged women.

Twenty-two middle-aged women (median age 44.5 years) with Turner's syndrome were interviewed about family background, social identity, emotional development, relations, female identity, sexuality and reactions to the diagnosis, to evaluate how the condition has affected their lives and coping style. During the years preceding the diagnosis and hormonal replacement therapy (HRT) they had often isolated themselves as they felt different from their peers. Ovarian failure and infertility, not the body height, were the major problems for most of the women. Infertility had affected the women very deeply and many felt depressed because of this. Adolescent behaviour, a feeling of chronic inferiority or a feeling of grief were different ways of coping with the situation. Median age at sexual debut was 19.5 years. Painful intercourse related to vaginal constriction and sore membranes was commonly reported. Most of the women had stopped HRT because of side-effects. Many of the problems experienced by the women could have been avoided if proper HRT had been administered in due time and on a long-term basis. This emphasizes the importance of regular contact with a gynecologist of special training and interest.

Middle-aged women with Turner's syndrome. Medical status, hormonal treatment and social life.

A study of 49 middle-aged (greater than 35 years old) women with Turner's syndrome was performed to evaluate medical status, hormonal treatment and social life. Most of the women lived a normal social life in stable relationships and all were employed. Some had adopted children and 4 had children of their own. They had all been informed about Turner's syndrome at time of diagnosis, but after the induced puberty they did not know who to turn to with their variety of medical problems. They were healthy except for reduced hearing, which in many cases required hearing aid. Elevated liver enzymes were found in almost all the women. The mechanism behind this finding is unclear, but it does not seem to imply severe liver damage why the indicated estrogen therapy should not be withdrawn from these women. Today amniocentesis and chorionic villus biopsies are commonly used to detect chromosome abnormalities. It is our duty as counsellors to give adequate information on the prognosis of a specific finding in the fetus to help future parents in their decision.