[Pregnancy luteoma, a differential diagnostic problem]

Luteomas in pregnancy are benign ovarian tumours which can occur uni- or bilaterally and are mostly detected during laparotomy or Caesarean section. These tumours and the possible virilisation of mother and child regress spontaneously post partum. The described case shows the differential diagnostic problems involved in this rare type of tumour.

Sexual dimorphism in accessory olfactory bulb mitral cells: a quantitative Golgi study

The purpose of the present study was to identify the existence of sexual dimorphism in the dendritic field of accessory olfactory bulb mitral cells in rats and to investigate the effects of male orchidectomy and female androgenization on the day of birth upon this dendritic field. The rapid Golgi method was used to conduct a quantitative study of various characteristics of the dendritic field of accessory olfactory bulb mitral cells. The results indicated greater values for males than females for the following characteristics: (i) somatic area; (ii) degree of branching in the dendritic field; (iii) total dendritic length; and (iv) dendritic density around the neuronal soma. Orchidectomy of males, as well as androgenization of females, on the day of birth inverted these differences.

[The effect of increased production of androgens on the development of body build morphology. Case report of an androgen-active tumor in a monozygotic twin]

The authors present an account on monozygotic twins where in one girl an androgen-active adenoma of the adrenal cortex during early puberty led to the development of the Morphogram of Body Build (Case-report of throughout the period of investigation intact from the hormonal aspect. Four years after resection of the tumour endocrine and anthropometric characteristics of the two sisters were evaluated: the hormonal status of both is normal, the somatic differences are manifested by a different final height, biacromial width and chest circumference. The results are conceived as a precedent for evaluation of risks associated with administration of anabolic steroids in children.

Virilisation of female preterm infants

Two cases of hypertrophy of the clitoris in premature girls are reported; this was associated with persistently high concentrations of adrenal fetal zone androgens.

Virilizing stromal thecosis of the ovary associated with multiple corpora atretica

Virilism can be associated with a variety of ovarian lesions, including stromal hyperplasia. Focal luteinization, a thickened tunica albuginea, and multiple cystic follicles are histologic features that have been associated with stromal hyperplasia in virilized women. This report describes the case of a 57-year-old woman who presented with a four-year history of virilization. The testosterone level was 13.8 nmol/L (3,980 ng/L). At laparotomy, the ovaries were found to be enlarged, each measuring 4 cm in maximum dimension. Salient histologic findings included diffuse stromal hyperplasia interspersed with a marked increase in the number of corpora atretica. Focal luteinization, including in some corpora atretica, was seen. Electron microscopic study demonstrated cells with increased smooth endoplasmic reticulin and mitochondria with tubular cristae as well as other features consistent with theca cells; Reinke crystals were not seen. The testosterone level normalized after removal of the ovaries, and the signs of virilism gradually abated. These results are compatible with an abnormal stimulation of the ovaries as evidenced by an increased though abortive follicular development, stromal hyperplasia, and focal luteinization.

Hyperreactio luteinalis in normal singleton pregnancy

A case of hyperreactio luteinalis in a patient with normal singleton pregnancy is reported. The course of pregnancy had been normal until the 24th week of gestation, when the mother developed lower abdominal pain and signs of virilization. She delivered of a normal female infant at 39 weeks' gestation. The baby did not show any signs of masculinization. Serum testosterone, delta 4-androstene-dione, and 5 alpha-dihydrotestosterone of the mother were markedly elevated. They remained high after the delivery but returned to the normal ranges soon after the partial resection of the enlarged ovaries. Reported causes of hyperreactio luteinalis are reviewed. Their maternal serum androgen levels were compared with cases of luteoma of pregnancy.

Virilization due to a rare ovarian tumor in a postmenopausal woman

A 60-year-old postmenopausal woman presented with evidence of hirsutism, alopecia and mild virilization. Clinical examination and biochemical abnormalities suggested that the source of androgen excess was ovarian, and an ovarian tumor was confirmed and removed at laparotomy followed by normal endocrine profile in the postoperative period.

[Extra-ovarian site of a virilizing lipid cell tumor]

One of the rare tumors causing virilization are the lipid cell tumors which are mostly located in the ovaries. We report here on a 13 year old girl with virilization due to a lipid cell tumor of the broad ligament. The patient showed increased levels of testosterone, androstenedione and 17 alpha-hydroxyprogesterone while normal values of dehydroepiandrosterone, cortisol, estrogens E1 and E2, and gonadotropins were recorded. The endocrinological and histological pictures, as well as the diagnostic aspects will be discussed.

Bilateral ovarian thecosis and virilization in pregnancy. A case report

Virilization is usually associated with amenorrhea, infertility and ovarian stromal lesions. Paradoxically, however, it may also be seen in pregnancy; this type of virilization is rare and accompanies ovarian thecosis. Thecosis, also known as thecomatosis and stromal thecosis, is a complex assortment of types of ovarian stromal proliferation associated with various types and amounts of hormonal activity. A patient had progressive virilization that began about seven years after menarche. Nonetheless, she had six pregnancies and bore five normal living children. Her last child, a female, was not affected by the high maternal testosterone levels. The patient's virilization was associated with an ovarian stromal hyperplasia classified as combined thecosis. In this case, as in some others, there was reason to suspect a genetic basis for such progressive virilization with retained fertility; an analysis of it provides insight into the complex nature of ovarian stromal hyperplasia and hormonal activity.

Anogenital ratio: measure of fetal virilization in premature and full-term newborn infants

To provide normative data, we measured anogenital distances in 115 infants of 25 to 42 weeks gestational age and 10 pregnant women, including anus to fourchette (AF), anus to base of the clitoris (AC), and fourchette to base of the clitoris (FC). All infant measurements showed positive and significant correlations with body surface area, weight, length, and gestational age (P less than 0.001). However, the anogenital ratio (AF/AC) followed a normal distribution and did not correlate with any of the anthropometric variables or age. Mean (+/- SD) value in infants was 0.37 +/- 0.07, and in adults, 0.36 +/- 0.07. An anogenital ratio greater than 0.50 falls outside the 95% confidence limits, suggests labioscrotal fusion, and indicates a need for further evaluation. Because it is independent of body size and gestational age, the anogenital ratio should be useful in diagnosing androgen-induced labioscrotal fusion in both premature and full-term female infants.

Theca lutein cysts with maternal virilization and elevated serum testosterone in pregnancy

A clinicopathological study was performed on a pregnant patient with bilateral multiple ovarian cysts, who presented with pre-eclampsia, marked virilization and exceedingly high levels of serum testosterone. The female fetus showed no evidence of virilization. Microscopic examination of the ovaries revealed theca lutein cysts with granulosa cells which showed the existence of testosterone by immunoperoxidase staining.

[Hyperthecosis ovarii--a tumor-like change in androgenized females]

Hyperthecosis has been repeatedly described as a disease entity separate from polycystic ovaries (PCO) as characterised by stromal luteinisation, obligatory virilism and purely ovarian androgen hypersecretion. This study compares the findings in patients with hyperthecosis (n = 10), PCO (n = 33) and androgen-secreting ovarian tumours (n = 7). It included selective ovarian-adrenal vein catheterisation with measurement of testosterone (T), dihydro-T, androstenedione, DHEA and its sulfate, 17 alpha-hydroxyprogesterone and cortisol before and after dexamethasone; determination of free T, oestrone, oestradiol and prolactin as well as LH and FSH before and after GnRH. In histologically proven hyperthecosis, signs of virilism were absent in 6 cases. A specific hormone profile could not be identified. Mixed ovarian-adrenal androgen hypersecretion was documented in 4 patients (purely ovarian: n = 6). Ovarian T output frequently fell within the tumour range (n = 4). It is concluded that the minor differences between hyperthecosis and PCO represent only variable manifestations of the same heterogeneous disturbance of androgen metabolism. However, it is of special clinical relevance to rule out a tumour in patients with hyperthecosis.

[Adrenal cortex carcinoma in childhood and adolescence]

The presented paper includes the medical records of two girls with adrenal cortical carcinomas on the one hand and the detailed analysis of a collected series of 150 equal cases in pediatric literature on the other hand. In our patients there were a primarily metastatic, non-functioning tumour and a locally invasive, hormone-secreting neoplasm respectively. The latter one produced a Cushing's syndrome with signs of virilization. In this case surgical removal was followed by postoperative irradiation and adjunctive cytostatic therapy with cyclophosphamide and adriamycin for one year. But tumour recurrence occurred within 6 months. A treatment with the antitumour agents aminogluthetimide and o,p' DDD was transiently effective. However drug-induced side effects necessitated the stop of this regimen after 5 months. The analysis of 150 case reports revealed a peak between 1 and 3 years of age, a striking prevalence of the female sex in all age groups, and a metastasizing rate of about 30% at the time of diagnosis. Regional structures, liver and lung were the main locations of metastatic lesions. The occurrence of second primary neoplasms and the association with a group of other conditions particularly congenital disorders have proved to be a remarkable feature of the disease. In primary adrenal cortical tumours the determination of the neoplasm's biological behaviour by morphologic criteria alone can often be very problematical. This fact is especially stressed.

Hyperinsulinemia in hyperthecosis of the ovaries

Fasting insulin concentrations and the insulin response to an oral glucose tolerance test were measured in six virilized women with ovarian hyperthecosis and six weight-matched normal women. For comparison, six women with polycystic ovarian disease were also studied. The diagnosis of hyperthecosis was confirmed in all six virilized women by histologic examination of the ovaries. The fasting insulin concentrations were increased in all of the hyperthecosis patients (84 +/- 32 microU/ml). Insulin response to an oral glucose tolerance test was greatly increased (p less than 0.01) in comparison to normal women and women with polycystic ovarian disease. Significant positive correlations were found between peripheral insulin concentrations and ovarian vein testosterone (r = 0.879, p less than 0.02), dihydrotestosterone (r = 0.866, p less than 0.03), and androstenedione (r = 0.992, p less than 0.01) levels. Insulin resistance persisted after removal of the ovaries even though androgen levels returned to normal. These results suggest that a significant degree of insulin resistance exists in women with hyperthecosis and that insulin stimulates ovarian stromal androgen synthesis and thus may play a role in the pathogenesis of ovarian hyperthecosis.

Histopathology of the human adrenal cortex

The morphological features of the adult human adrenal cortex are described with particular respect to changes induced by alterations in function of the hypothalamo-pituitary axis. The occurrence of nodules in the normal and hyperplastic cortex (Cushing's and Conn's syndromes) is discussed in relation to the diagnostic problems that they still pose. Explanations based on the normal mechanisms of functional zonation in the cortex are provided for the different cell types which comprise cortical neoplasms associated with various syndromes of hypercorticalism (Cushing's, adrenogenital and Conn's syndromes), together with morphological and functional criteria to distinguish adenomas from carcinomas.

Virilization without adrenal hyperplasia in 21-hydroxylase deficiency during fetal life

The characteristic excess production of androgens in the cortisol 21-hydroxylase defect is generally considered to be secondary to ACTH stimulation of alternate pathways. Whenever a morphological examination of the adrenals has been possible in this disorder, adrenocortical hyperplasia was a constant finding. The availability of methods for the prenatal diagnosis of the 21-hydroxylase defect has made it possible to examine some of the manifestations of this disorder during fetal life. We studied a severely virilized 20-week-old aborted female fetus with the 21-hydroxylase defect whose adrenals were neither grossly enlarged nor microscopically hyperplastic. In a pregnancy at risk for congenital adrenal hyperplasia due to a 21-hydroxylase deficiency, amniocentesis was performed in the 18th week of gestation. The 21-hydroxylase defect was established by HLA typing and highly elevated levels of 17-hydroxyprogesterone, testosterone, and androstendione in amniotic fluid. After counselling, the parents, who already had a girl with the salt-wasting form of 21-hydroxylase deficiency, wished termination of the pregnancy. The aborted 20-week-old fetus was within the normal range for gestational age in weight and height. The external genitalia were ambiguous and extremely virilized, with an enlarged clitoris and fused labioscrotal folds. A urogenital sinus opened at the base of the clitoris. The internal organs were female, with a normal uterus and ovaries. Both adrenals were normal in size and weight for their gestational age. Histological examination of the adrenals revealed no abnormalities, and no hyperplasia was detectable. Thus, the adrenals in the 21-hydroxylase defect during fetal life secrete excessive amounts of androgens and cause virilization in the absence of adrenocortical hyperplasia.

[Virilization caused by methandrostenolone-containing cream in 2 prepubertal girls]

Two prepubertal girls were treated with Dianabol cream by their family physicians during 6 and 8 months because of an anal exzema. In both of them, growth velocity and bone maturation were accelerated, and there was hypertrophy of the clitoris and deepening of the voice. In one girl, all symptoms with the exception of the deep voice had disappeared six years after the discontinuation of treatment. In the other girl, final evaluation is not yet possible. The two observations show that androgens and anabolic steroids may have a marked systemic action if applied percutaneously. Treatment with these compounds is indicated very rarely in children and should be restricted to pediatric endocrinologists.

Ovarian and adrenal steroidogenesis in a virilized patient with gonadotropin-resistant ovaries and hilus cell hyperplasia

A 26-year-old woman with secondary amenorrhea, temporal balding, and clitoromegaly was found to have both the gonadotropin-resistant ovary syndrome and hilus cell hyperplasia. Simultaneous sampling of peripheral and ovarian venous blood revealed excess ovarian testosterone secretion to be the probable cause of the patient's virilism. The marked response of the ovary to stimulation by luteinizing hormone (LH) coupled with the lack of ovarian follicular development suggested that an isolated resistance of the ovarian follicle to follicle-stimulating hormone (FSH) was present in this patient. The administration of a daily pharmacologic dose of dexamethasone for 14 days was followed by the patient's first menstrual period in 13 years, raising the possibility that autoimmunity may have been involved in this patient's ovarian resistance to FSH stimulation.

Virilization with diffuse involvement of ovarian androgen secreting cells

A case is reported in which virilization of long duration and gradual progression was found in association with ovarian hyperthecosis and bilateral hilar cell lesions. The frequency occurrence of both masculinizing and nonmasculinizing ovarian tumors in association with ovarian hyperthecosis and polycystic ovaries is discussed.

Enzyme histochemistry of ovarina lipoid cell hyperplasia in a masculinized patient

In an effort to better identify the specific steroids produced by histologically similar cells of certain ovarian tumors, a battery of histochemical assays was performed on a masculinizing tumor removed from a 21-year-old patient. Certain reactions were distinguished that seemed to be specific for the histologically classic luteinized stromal cell, and these reactions can be correlated with those obtained with Leydig and hilar cells. The apparent precursors of the interstitial cells (ISC) of this tumor, and to a lesser extent the immature ISC, possess unusually high cholinesterase activity, especially with the butyryl ester. The importance of the perivascular and neural elements in the process of steroidogenesis is suggested by the findings in this case.

[Morphology of the ovaries in congenital virilization of the external genitalia in persons with genetic and gonadal female sex]

A study was made of the resected ovarian tissue in 7 patients with congenital virilization of the external genitalia (CVEG). In patients with CVEG there occurred not very pronounced changes in the ovaries seen in diencephalic syndromes with the involvement of the ovaries into the pathological process (hypertrophy of the theca interna cells of the cystically changed follicles, hyperplasia of the intestinal tissue of the cortical layer with the transformation of individual cells into epithelioid, etc.). There were clinical signs indicating an acceleration of maturation of the diencephalic structures (some tendency to the acceleration of sexual development, and distinct signs of diencephalic pathology on the EEG). A conclusion was drawn that in the patients with CVEG the ovaries do not serve as the source of andronization of the organism. It is supposed that in these patients the source of hyperandronization existed at the period of formation of the external genitalia of the fetus and that the adrenal cortex of the fetus could serve as this source.

Virilization associated with bilateral luteomas of pregnancy

A case of maternal virilization associated with bilateral luteomas of pregnancy is described. Urinary 17-ketosteroids and plasma testosterone fell from markedly abnormal values to normal limits within 2 weeks of delivery. However, symptoms of virilization persisted in the postpartum state. A possible relation between polycystic ovarian syndrome in the nonpregnant state and luteoma of pregnancy is proposed.

[A clinical, histological, and biochemical study of ovarian arrhenoblastomas: with reference to one case]

The authors review the literature in relation to a detailed study of an ovarian arrhenoblastoma operated on in a young patient who subsequently became pregnant twice, one of these pregnancies developing to full term. This review makes it possible to formulate certain anatomopathological ideas, and above all makes it clear that complete endocrine studies are infrequently carried out. It has been shown in cases of arrhenoblastoma that some of the anomalies of steroidogenesis are secondary to the enzyme disorders, the impression being that, with this kind of tumour, the tumour parenchyma begins to secrete like a normal testicle.