Induction of ovulation in patients with normoprolactinemic amenorrhea by combined therapy with bromocriptine and clomiphene

Bromocriptine is known to be effective in the treatment of women with hyperprolactinemic anovulation or amenorrhea-galactorrhea. A new schedule of combined treatment with bromocriptine and clomiphene citrate was applied to 23 patients with normoprolactinemic amenorrhea who failed to respond to clomiphene alone. Ovulation was restored by treatment in 14 of these patients (60.9%), resulting in pregnancy in 3 women. Treatment resulted in immediate suppression of serum prolactin levels and a gradual increase in serum luteinizing hormone levels and estradiol levels followed by a luteinizing hormone surge. The present results indicate that bromocriptine/clomiphene combination therapy is effective in the treatment of amenorrheic patients with normoprolactinemia who do not respond to clomiphene alone, and suggest that bromocriptine restores the responsiveness of the hypothalamic-pituitary-ovarian system to clomiphene.

A simple hCG stimulation test for normal and hypogonadal males

A simple human chorionic gonadotropin (hCG) test to measure Leydig cell function is described. Plasma testosterone was measured on two occasions, once before intramuscular injection of 10,000 IU of hCG and again four days later. Preliminary tests in 10 adult males showed a maximal increase in plasma testosterone between the third and fifth day that was confirmed in a further 20 normal subjects when measured once on the fourth day. Except for 2 patients with hypospermatogenesis, 24 showed a good response and the mean increase was comparable with that in normal males. Nineteen patients with Klinefelter's syndrome usually had lower basal levels and showed a poor response, with the exception of six patients in whom there were moderate but definite increases. Twelve patients with hypogonadotropic hypogonadism had basal testosterone concentrations below 1 ng/ml and eight responded poorly to hCG stimulation. However, four patients showed a moderate but definite response.

Gonadal findings in cryptorchid boys with Noonan's phenotype

7 patients with Noonan's syndrome, aged 5-16 years, complicated by bilateral cryptorchidism were examined by LH-RH and HCG stimulation tests, long-term HCG stimulation and testicular biopsy. 2 patients showed a good response and there was no effects in the remainder. Histological examination of the tests confirmed interstitial fibrosis in every case and showed abnormalities of the seminiferous tubules in 4 patients while in 1 patient the seminiferous tubules were composed of spermatocytes and spermatids. These hormonal and histological findings show different patterns of disturbance of the pituitary-gonadal system in male patients with Noonan's syndrome.

Pituitary-gonadal function in schoolboys with varicocele and indications of varicocelectomy

Pituitary-gonadal functions were investigated by LH-RH test, HCG test and bilateral testicular biopsies in 5 boys with unilateral varicocele at various pubertal stages and the results were compared with those in the normal boys at puberty. The ages of the patients ranged from 12 to 18 years. With the progress of pubertal stage, both the basal value and response of serum FSH to LH-RH became higher as compared with normal boys. The basal value and response of serum LH showed no significant difference except for one case where higher values and no significant differences in the basal value and response of plasma testosterone to HCG stimulation were observed. The disturbance of spermatogenesis in the affected testis becomes prominent with the progress of puberty, while changes in the testis of opposite side were mild.

Pituitary and gonadal function in prepubertal and pubertal cryptorchidism

LRH and hCG tests were performed in 35 prepubertal and 35 pubertal boys with unilateral or bilateral cryptorchidism to examine the pituitary and gonadal function. Twenty-one normal boys were also examined as controls. In the prepubertal group, distinct increases in serum LH, FSH and testosterone levels by LRH and hCG tests were found in all of the normal and unilateral cryptorchid boys. However, no or very little response was observed in 4 out of 17 boys with bilateral cryptorchidism. In the pubertal group, serum levels of LH, FSH and testosterone in normal boys, in unilateral and in bilateral cryptorchid boys were evidently higher than those in the prepubertal group, and distinct or moderate responses by the LRH and hCG tests were found in all boys examined. Although serum testosterone levels were similar in all groups, serum basal and peak gonadotrophin levels by the LRH test were significantly higher in bilateral cryptorchid boys than in normal and unilateral cryptorchid boys. The difference was more marked in FSH than in LH level. An elevated level of serum LH is suggestive of the hypofunction of not only the seminiferous tubules but also of the Leydig cells in cryptorchid testes.

Plasma luteinizing hormone-releasing hormone levels in normal women and patients with amenorrhea

Plasma levels of immunoreactive luteinizing hormone-releasing hormone (LH-RH) in 89 women with normal menstrual cycles and 109 patients with amenorrhea of various etiologies were determined by specific radioimmunoassay after methanol extraction. The LH-RH levels in patients with hypergonadotropism and Sheehan's syndrome were more than 10 pg/ml, and were significantly higher than basal levels during normal cycles (4.2 +/- 0.3 pg/ml). The mean levels of LH-RH were low in all hypogonadotropic patients with amenorrhea, with the exception of a few patients who showed high LH-RH levels suggestive of a pituitary lesion. The LH-RH levels in patients with polycystic ovary syndrome were comparable with basal levels during normal cycles. It is concluded that, although there is considerable overlap of the plasma LH-RH levels in each group of amenorrheic patients divided according to gonadotropin level, determination of LH-RH levels may be useful for the differentiation of hypothalamic amenorrhea from pituitary amenorrhea.

Prognosis of sexual maturation in prepubertal boys with micropenis

Long-term observations were made of the prognosis for sexual maturation (onset of puberty) in 15 prepubertal boys with micropenis. Testosterone levels before and after HCG administration and LH and FSH responses to LH-RH were measured at the first visit and a few years later. In the eight boys who showed significant responses to the LH-RH and HCG tests, onset of puberty occurred with the exception of one patient. The remaining seven boys who showed no positive response to either stimulation test were treated with injections of HCG. However, no signs of sexual maturation were observed. These data demonstrate clearly that both the HCG test and the LH-RH test are very useful for prognosis of sexual maturation in patients with micropenis.

Changes in plasma LRH during the normal menstrual cycle in women

The plasma concentration of immunoreactive LRH, LS, FSH, oestradiol and progesterone were measured dialy by a sensitive double antibody radioimmunoassay during 12 cycles of 8 normal cyclic women. The mean (+/- SE) immunoreactive LRH levels in the follicular and luteal phase except the immunoreactive LRH peaks during normal cycles were 4.18 +/- 0.38 pg/ml and 4.50 +/- 0.45 mg/ml, respectively. The immunoreactive LRH peaks were observed in 11 of 12 cycles, appearing on day -4 to -1 from the LH surge in 9 cycles and on day +1 and +2 in 2 cycles. The mean value of immunoreactice LRH peaks was 42.0 +/- 11.4 pg/ml with range of 12 to 154 pg/ml. The immunoreactive LRH peak lasted for one day in 10 cycles and for 4 days in one cycle. The immunoreactive LRH peaks in different cycles of the same women did not occur on the same day relative to the LH peak. The plasma immunoreactive LRH levels measured every 10 min for 40 min periods every day in normal cyclic women during the ovulatory phase showed slight, but not significant fluctuations. Plasma oestradiol levels began to increase on day -6, reaching a peak on day -1, and were followed by peaks of LH and FSH. These data indicate that increase in serum oestradiol was followed by release of LRH from the hypothalamus and pre-ovulatory discharge of gonadotrophins from the pituitary.

Luteinizing hormone-releasing hormone in cerebrospinal fluid of women

The concentration of luteinizing hormone-releasing hormone (LH-RH) in both cerebrospinal fluid (CSF) and plasma in 36 women with various conditions were determined, and the correlation of LH-RH concentrations between plasma and CSF was studied. Paired samples of plasma and CSF were obtained just before operation and were extracted with methanol for LH-RH radioimmunoassay. LH and FSH were also measured by radioimmunoassay. The mean plasma LH-RH levels were 3.79 pg/ml in the follicular phase, 4.15 pg/ml in the luteal phase, 12.73 pg/ml in postmenopausal women and 2.31 pg/ml in pregnant women at term. No immunoreactive LH-RH in the CSF was found in 29 out of 36 subjects, and the remaining 7 subjects showed very low levels (less than 0.95 pg/ml). The LH-RH levels in the CSF of post-menopausal women were not higher their those in the remaining 3 groups, although their plasma levels of LH-RH were significantly (p less than 0.001) elevated. The mean plasma levels of LH and FSH in post-menopausal women were significantly higher than those in normal cyclic women and in pregnant women. The present results suggest that little or no LH-RH is present in the CSF, and it is not clear that there is any correlation between the LH-RH level of plasma and those of CSF.

Endocrine and androgen-receptor studies in a patient with XY gonadal agenesis

A 19-year-old phenotypic female with gonadal agenesis and XY karyotype underwent an endocrinologic study. She lacked secondary sexual characteristics and there was posterior labial fusion, absence of vagina, and no gonadal or gonadal duct tissues present at laparotomy. Elevated levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) responded well to intravenous injection of LH-releasing hormone (LH-RH) but did not respond to clomiphene citrate. Both OH and FSH levels were suppressed by administration of testosterone or estrogen. Low serum concentration of testosterone did not respond to human chorionic gonadotropin (hCG) injection. Dihydrotestosterone binding by cultured skin fibroblast revealed the existence of a binding component with low capacity and high affinity. This is the first report of a patient with XY gonadal agenesis in whom androgen receptors in the target cells are demonstrated.

Restoration of oestrogen positive feedback effect on LH release by bromocriptine in hyperprolactinaemic patients with galactorrhoea-amenorrhoea

Five mg of bromocriptine was administered for 3 weeks to 8 hyperprolactinaemic women with galactorrhoea-amernorrhoea, in whom the response of serum luteinizing hormone (LH) and follicle-stimulating hormone (FSH) to 100 micrograms of iv LH-releasing hormone (LH-RH) had been evaluated. Twenty mg of conjugated oestrogen (Premarin) was injected iv any day between the 10th and 12th day from the initiation of the treatment, and serum LH levels were serially determined for 120 h. Hyperresponse of LH with normal FSH response to LH-RH was observed in most patients. Bromocriptine treatment for 10 to 12 days significantly suppressed mean (+/- SE) serum prolactin (PRL) levels from 65.1 +/- 23.0 to 10.4 +/- 2.0 ng/ml, while LH (12.6 +/- 2.1 to 24.8 +/- 5.9 mIU/ml) and oestradiol (40.1 +/- 7.6 to 111.4 +/- 20.8 pg/ml) levels increased significantly. Patients on bromocriptine treatment showed LH release with a peak at 48 h after injection of Premarin. The mean per cent increases in LH were significantly higher than those in untreated patients with galactorrhoea-amenorrhoea between 32 and 96 h after the injection. The present results seem to suggest that the restoration of LH-releasing response to oestrogen following suppression of PRL by bromocriptine may play an important role in induction of ovulation in hyperprolactinaemic patients with galactorrhoea-amenorrhoea.

Restoration of the gonadotrophin response to LH-RH and oestrogen administration in patients after molar abortion

The relation of the hypothalamic-pituitary effect on gonadotrophin secretion and the concentration of serum hCG after molar abortion was investigated. Gonadotrophin release after a bolus injection of LH-RH or conjugated oestrogens was observed in 17 women until 5 months after molar abortion. Little if any response of gonadotrophin was observed at a hCG level of 100 mIU/ml or more, but the response of LH and FSH to LH-RH were restored to normal when the serum hCG level decreased to below 100 mIU/ml. A normal response of LH to conjugated oestrogens was observed at a serum hCG level of 20 mIU/ml or less. These findings suggest that a high level of hCG interferes with pituitary gonadotrophin secretion, that the threshold hCG levels for normal responses of gonadotrophins to LH-RH and oestrogen are 100 and 20 mIU/ml, respectively, and that secretion of gonadotrophins is restored even in the presence of a low hCG level.