Spinal cord surgery and galactorrhea: a case report

We report the case of a 39-year-old nonpregnant woman with amenorrhea and galactorrhea after spinal cord surgery. Activation of the afferent neuroendocrine pathway is postulated to have occurred at surgery.

Euthyroid sick syndrome in psychiatric inpatients

Numerous disorders are associated with euthyroid sick syndrome (ESS). This retrospective study examines the incidence and circumstances of ESS among 3188 psychiatric inpatients. There were 324 patients (10.2%) who met strictly defined criteria for ESS. Of these, 95 were hyperthyroxinemic (HT), 6 were hypothyroxinemic, 179 had mildly elevated thyroid-stimulating hormone (HTSH), and 47 had suppressed TSH. All were classified by DSM-III-R discharge diagnoses, encompassing five categories. chi 2 tests of significance of the 95 HT and 179 HTSH subjects revealed the following: 1) no relationship with age or gender; 2) the frequencies of HT and HTSH differed significantly (p < .05 and p < .01, respectively) across the five psychiatric categories; 3) HT frequency was highest in mood disorders (HT in mood versus others p < .02); and 4) HTSH frequency was highest in substance abuse (HTSH in substance abuse versus others p < .02). In conclusion, ESS is common in psychiatric inpatients, especially HT and HTSH; pathophysiologic mechanisms may vary according to psychiatric diagnosis.

Recurrent hyperthyroidism in consecutive pregnancies characterized by hyperemesis

A 34-year-old Caucasian woman was seen and evaluated for hyperemesis and abnormal thyroid function tests, consistent with hyperthyroidism, during her second pregnancy. Her hyperemesis and hyperthyroidism both resolved during the second trimester of this pregnancy. She recounted very similar symptoms of similar duration in her first pregnancy. She was again monitored in a third pregnancy during which hyperemesis and hyperthyroidism were once more documented, resolving during the second trimester. The recurrence of hyperemesis in three consecutive singleton pregnancies, with documentation of transient hyperthyroidism in two of these pregnancies, is suggestive of human chorionic gonadotropin (hCG)-mediated hyperthyroidism. Either the trophoblasts synthesized hCG of high thyrotropic grade or, alternatively, hCG could be modified in the maternal tissues, resulting in molecules with greater thyrotropic activity. These potential mechanisms are discussed.

Bioassayable and immunoassayable prolactin responses to thyrotropin-releasing hormone: use of the Nb2 lymphoma cell bioassay

The peak prolactin response to thyrotropin-releasing hormone (TRH) varies among patients. "Exaggerated" responses have been described and linked to ovulatory dysfunction. Herein we describe our initial observations on bioassayable prolactin (BA-PRL) versus immunoassayable prolactin (RIA-PRL) in women with normal baseline RIA-PRL concentrations but with varying peak RIA-PRL responses to TRH. Twenty-three women of reproductive age with baseline RIA-PRL of =25 ng/mL were administered 500 microg of TRH, and baseline and peak RIA-PRL concentrations were determined. Aliquots of the baseline sample and the sample representing the peak RIA-PRL were used for measuring BA-PRL by means of the Nb2 lymphoma cell bioassay. For each sample, BA/RIA-PRL ratios were determined. Positive correlations were found between peak RIA-PRL and baseline BA/RIA-PRL ratios (P<0.05) and also between baseline and peak BA/RIA-PRL ratios (P<0.001). Negative correlations were found between baseline RIA-PRL and both baseline and peak BA/RIA-PRL ratios (P<0.001 and P<0.05, respectively). We conclude that (1) the lactotroph response to TRH in women with normal RIA-PRL may, in part, be governed by the amount of biologically active prolactin at baseline and (2) the relative proportion of BA-PRL to RIA-PRL produced at baseline is maintained at peak response. Finally, in light of the greater availability of bioactive prolactin in women with exaggerated TRH responses, our findings support the use of bromocriptine in those patients with such responses and ovulatory dysfunction.

Repetitive responses to clomiphene citrate in normal women of late reproductive age

The hormonal response to clomiphene citrate (CC) has been used to evaluate ovarian reserve. In the current study, we tested the reproducibility of response to 100 mg of CC administered for 5 days in a group of 20 women, 35 to 40 years of age, with regular menstrual cycles who completed 57 cycles during the study. Individual hormonal responses to repeated stimulation were not identical. When ovarian responsiveness to CC was categorized as "low" (E(2) and E(2)/FSH ratios =200 pg/mL and =20, respectively) or "high" (E(2) =400 pg/mL and E(2 /FSH ) =61), however, responses of individual subjects seldom spanned both categories. Specifically, only 3 of 20 subjects had both low and high E(2) and low and high E(2/FSH ) ratios (P<0.001). In addition, seven subjects were identified as FSH hyperresponsive in at least one cycle (post-CC FSH =10 IU/L). Only 2 of 21 cycles in these seven subjects had post-CC E(2)/FSH ratios =61, in comparison with 20 of 36 cycles in the other 13 subjects (P<0.01). Thus, despite the cycle-to-cycle variations, the hormonal response of an individual subject could usually be categorized as occurring at one or the other end of the spectrum of ovarian function, these two extremes probably signifying good and poor ovarian reserve. This prediction is further strengthened by the observation of a significant negative correlation between the FSH and E(2) responses after administration of CC (P=0.05).

Age-related differences in cell-mediated immunity to varicella-zoster virus among children and adults immunized with live attenuated varicella vaccine

Live attenuated varicella vaccine elicits protection against varicella-zoster virus (VZV), but adults require two doses to achieve optimal seroconversion rates. To assess the potential role of cell-mediated immunity (CMI), T cell proliferation to VZV antigen was compared in children and adults. Mean stimulation indices (SI) in two cohorts of 39 children tested 6 weeks after vaccination were 28.6 +/- 6.21 and 22.1 +/- 3.84, whereas 20 adult vaccines had a mean SI of 9.1 +/- 0.99 (P = .04). Vaccinees had significant increases in CMI after a second dose of vaccine. At 1 year, VZV CMI was significantly lower in adults after two doses (10.0 +/- 1.13 vs. 15.6 +/- 1.77; P = .02), even though 82% of children received one dose. Limitations in the adult helper T cell response to VZV antigens may explain the need for booster doses to elicit effective immunity and the more frequent occurrence of varicella when adult vaccines are exposed to wild type virus.

Effects of beta-blockade on neurohumoral responses and neurochemical markers in pacing-induced heart failure

We investigated neurohumoral profiles and transmitter and neuroenzyme markers of cardiac autonomic innervation in control (unpaced) dogs and three groups of dogs with pacing-induced heart failure (paced, paced + beta-adrenergic blockade, and paced + cardiac denervation). Left ventricular ejection fraction decreased significantly and to a comparable extent in all paced groups. Pacing increased plasma norepinephrine (NE); increases in NE were not attenuated but instead tended to be exaggerated by treatment with propranolol or cardiac denervation. Atrial hypertrophy occurred in all paced groups compared with the control group. However, atrial and right ventricular hypertrophy were not as pronounced in the paced plus cardiac denervation group as in the paced and paced plus propranolol groups. Pacing also depleted neuropeptide Y and NE from all heart chambers; propranolol treatment did not modify these local tissue changes. Pacing caused selective depletion of neuroenzymes predominantly in the left ventricle; again, propranolol did little to modify these changes. In this study of paced animals with experimentally maintained cardiac dysfunction, failure to modify noradrenergic responses with intrapericardial cardiac denervation suggests that noncardiac sources contribute predominantly to high plasma NE. Failure to modify neurohumoral, neuropeptide, and neuroenzyme responses with beta-antagonist suggests this treatment has little practical direct influence on sympathetic vasomotor activity or neuronal function in heart failure.

Serum androgens in hyperinsulinemic Pima Indian and obese Caucasian women and their response to short-term insulin infusion

Insulin resistance and its attendant hyperinsulinemia has been linked with hyperandrogenism. Insulin resistance is characteristic of the Pima Indians of the Gila River Indian community in central Arizona. Serum androgens, testosterone and dehydroepiandrosterone sulfate (DHEA-S) were quantitated at baseline and in response to low- and high-dose insulin infusion in 11 obese, hyperinsulinemic Pima Indian and 10 obese, hyperinsulinemic Caucasian women and were compared with baseline androgens in 16 nonobese Caucasian women. While there was no significant testosterone or DHEA-S response to short-term insulin infusion in either Pimas or obese Caucasians, both these groups had higher baseline testosterone concentrations (67 +/- 6.5 ng/dl in the Pimas, 55 +/- 5.9 ng/dl in the obese Caucasians) as compared with the nonobese Caucasians (28 +/- 2 ng/dl; p < 0.001). Baseline DHEA-S concentrations were not significantly different in the three groups. Given the hyperinsulinemic status of both the Pimas and the obese Caucasians, the finding of higher testosterone concentrations in these subjects as compared with nonobese Caucasians supports a role for insulin in ovarian androgen production and demonstrates that hormonal interactions that may be operating in obese hyperinsulinemic Caucasian subjects also operate in obese, hyperinsulinemic Pima Indians.

The effect of haloperidol on aldosterone secretion

Haloperidol (0.02 mg/kg, intravenous) did not stimulate aldosterone secretion in six normal controls or in six schizophrenic subjects. This is contrary to our hypothesis, which was based on the finding that peripheral D2 receptor antagonists stimulate aldosterone secretion, including haloperidol in rats and chlorpromazine in man. We speculated that a different dose of haloperidol would stimulate aldosterone in man. As expected, prolactin release was markedly stimulated in both groups of subjects, but no difference was found between groups.

Kinetics and viral protein specificity of the cytotoxic T lymphocyte response in healthy adults immunized with live attenuated varicella vaccine

The cytotoxic T lymphocyte (CTL) response was evaluated in adults given live attenuated varicella vaccine, using target cells expressing varicella-zoster virus (VZV) immediate-early protein (IE62) or VZV glycoproteins gpI, gpIV, or gpV to determine viral protein specificity. The frequency of CTL that recognized IE62 was 1:171,000 +/- 46,000 SE in subjects tested 10 days to 8 weeks after the initial vaccine dose; the induction of CTL specific for gpI was equivalent. CTL recognition of VZV proteins was mediated by CD4+ or CD8+ cells. CTL recognition of IE62 and gpIV persisted in vaccinees (tested approximately 4 years later) and was comparable to that in the naturally immune. The mean frequency of CTL specific for gpV was lower (but not significantly) in vaccinees than in naturally immune subjects. Assay of responder cell frequencies showed persistence of equivalent numbers of T lymphocytes that recognized IE62 and gpI in vaccinees and naturally immune subjects. Immunization with this vaccine elicited memory T lymphocyte responses to VZV comparable to those induced by natural infection.

Comparison of Nb2 lymphoma cell bioassay with immunoassay for human prolactin: the role of estrogen

The Nb2 lymphoma cell bioassay (BA-PRL) is a sensitive measure of serum prolactin under physiologic conditions. Since estrogens prime the lactotroph, prolactin heterogeneity and hence bioassayable prolactin may be influenced. A study was performed to observe the effect on BA-PRL of changing estradiol (E2) concentrations. In 13 normal subjects clomiphene citrate was administered to stimulate ovarian activity and blood samples were obtained before and after stimulation. Estradiol, BA-PRL and immunoassayable prolactin (RIA-PRL) were measured. While there was a substantial increase in E2 post-stimulation (p less than 0.001), there was no significant change in BA-PRL, RIA-PRL or BA/RIA-PRL ratios. Despite the lack of change in the mean BA/RIA-PRL ratio over a wide range of E2 concentrations that include and exceed those normally seen in spontaneous menstrual cycles, it is difficult to drawn conclusions regarding an association between E2 and BA/RIA-PRL ratios as there was no discernible change in the concentration of prolactin (possibly due to the antiestrogenic effect of clomiphene citrate).

Endogenous luteinizing hormone surges following administration of human chorionic gonadotropin: further evidence for lack of loop feedback in humans

The existence of inhibitory short- and ultrashort-loop feedback mechanisms for luteinizing hormone (LH), while documented in animals, has been questioned in humans. Since human chorionic gonadotropin (hCG) binds to LH receptors but can be distinguished from LH in immunoassays, it is possible to identify LH surges in the face of exogenously administered hCG. The present study demonstrates LH surges at midcycle in normal volunteers and in women undergoing controlled ovarian hyperstimulation, given hCG. This provides further evidence for lack of loop feedback control of LH secretion in humans.

Use of the hormonal response to clomiphene citrate as an endocrinological indicator of ovarian ageing

We compared the gonadotrophin and oestradiol responses to clomiphene citrate (CC) in women aged 18-25 versus 35-40 years. Despite similar baseline hormone concentrations and the attainment of similar concentrations of the E and Z isomers of clomiphene, higher follicle stimulating hormone (FSH) concentrations were observed in the older women, possibly indicative of their ageing ovaries. Furthermore, diminished oestradiol responses occurred in a subgroup of women showing FSH hyper-responsiveness to CC. These preliminary results support the concept that the hormonal response to CC may be an indicator of approaching perimenopause.

Polycystic ovary syndrome and the androgen-insulin connection

The association of hyperandrogenism, insulin resistance, and polycystic ovarian disease is well established. The accompanying hyperinsulinemia results in acanthosis nigricans, an epiphenomenon of this syndrome. The knowledge that states of insulin resistance of diverse causes are associated with ovarian hyperandrogenism makes the argument for insulin-driven ovarian androgen secretion compelling. However, equally compelling evidence suggests that hyperandrogenism may contribute to insulin resistance and hyperinsulinemia. The irreconcilable differences between these two hypotheses have resulted in an array of contradictory studies. In this article a unified concept of polycystic ovary syndrome and its androgen-insulin connection is proposed. The hypothesis incorporates the role of hyperinsulinemia in the androgen excess observed (and vice versa); the key to this connection is the androgen-dependent change in regional body fat distribution and its metabolic consequence. The pathophysiologic features of polycystic ovary syndrome, which has important clinical sequelae, deserve further consideration.

Premenstrual syndrome. Tailoring treatment to symptoms

Despite the interest in premenstrual syndrome (PMS) taken by the media and the public in recent years, some women still do not recognize the cyclic nature of their symptoms. Thus, PMS continues to elude diagnosis. Dr Nader discusses the major categories of symptoms and when they occur, summarizes theories on the cause of PMS, and comments on how well these theories have been substantiated by testing. Choosing agents for treatment on the basis of symptoms to be controlled is also described.

Prolactin response to thyrotropin-releasing hormone in normoprolactinemic patients with ovulatory dysfunction and its use for selection of candidates for bromocriptine therapy

It has been suggested in the past that some normoprolactinemic patients with amenorrhea or infertility respond to treatment with bromocriptine. However, the beneficial effect of this therapy in normoprolactinemic women remains controversial. Some authors have suggested that the responders suffer with "reactive" hyperprolactinemia and that this may be detected with thyrotropin releasing hormone (TRH) stimulation. In this study, we performed TRH stimulation tests in 538 patients with ovulatory dysfunction. Only those patients showing a peak prolactin response after TRH which exceeded 40 ng/ml were treated with bromocriptine. A direct correlation between peak prolactin level after TRH and a favorable response to treatment was observed. Serum testosterone and DHEA-sulfate levels did not correlate with prolactin response to TRH. A majority of patients with prolactin hyperresponse to TRH did not show a hyperresponse of TSH to TRH. This study suggests that incidence of beneficial response to bromocriptine therapy in normoprolactinemic women with ovulatory dysfunction is significantly higher in subjects exhibiting excessive prolactin response to TRH stimulation.

Study of the pharmacokinetics of human chorionic gonadotropin and its relation to ovulation

The pharmacokinetics of human chorionic gonadotropin (hCG) was studied in 15 normal volunteers and 15 patients undergoing in vitro fertilization (IVF). Each subject received 6000 IU hCG, intramuscularly (im), at midcycle, and serum was assayed for hCG frequently for 16 hr. All 30 subjects achieved hCG concentrations greater than or equal to 10 IU/liter within 2 hr and 19 (63%) did so within 1 hr of injection. The time taken to attain concentrations of greater than or equal to 20 and greater than or equal to 40 IU/liter correlated positively with the subjects' weight and/or surface area, but the correlation was not strong. Eleven of the 15 IVF patients had oocytes retrieved 34-35 + hr post hCG. Three of the 11 showed evidence of prior "undetected ovulation" at the time of surgery (definite in one, presumed in two). Taking into consideration the pharmacokinetics of hCG and other factors that could lead to undetected ovulation, the authors conclude that (1) hCG is rapidly absorbed in the majority of subjects following im injection, (2) ovulation may occur earlier than 36 hr following hCG in some individuals, and (3) implementation of a shorter (than 35 hr) hCG-to-oocyte retrieval interval would be advised if undetected ovulation is to be avoided.

Pituitary disorders and pregnancy

In conclusion, the physiologic changes that occur in the pituitary during pregnancy make women harboring pituitary tumors more vulnerable to tumor complications, namely tumor expansion resulting in either visual defects or hormone deficiencies. Fortunately, vast experience with the most common of these tumors (prolactinomas) allows us to make specific recommendations to women with such tumor embarking upon pregnancy. These recommendations have been outlined. In addition to tumors, the anterior lobe of the pituitary may be the seat of two rare conditions (Sheehan's syndrome and lymphocytic hypophysitis) that afflict pregnant women predominantly. Their importance lies in the fact that hypopituitarism, sometimes requiring urgent treatment, may result. Finally, pregnancy may have an unfavorable impact upon women with diabetes insipidus, necessitating careful observation. Given the availability of a specific and highly effective therapeutic agent, desmopressin acetate, the management of these women is rarely problematic.

Luteal-phase support in stimulated cycles in an in vitro fertilization/embryo transfer program: progesterone versus human chorionic gonadotropin

A study was undertaken to compare the hormonal parameters [serum concentrations of estradiol (E2), and progesterone (P) and P/E2 ratios] of patients undergoing in vitro fertilization/embryo transfer to whom either progesterone in oil or human chorionic gonadotropin (hCG) was administered as luteal support. Seventeen patients were studied in 20 cycles. In 10 randomly assigned cycles 25 mg of intramuscular progesterone in oil was administered daily from the day of embryo transfer (day +4) until day +18. In the other 10 cycles, 1500 IU of hCG was given intramuscularly on days +4, +7, +10, and +13. Even when accounting for the differences in recruitment in the two groups, the hCG-treated group had significantly higher concentrations of serum P (P less than 0.01) and E2 (P less than 0.05) during the luteal phase. The luteal P/E2 ratios were higher in the progesterone-treated group because of the lower E2 levels in that group, although the difference was not statistically significant. The ratio of the mean luteal P to the preovulatory serum E2 was significantly higher in the hCG-treated group (P less than 0.01). There were three clinical pregnancies in the hCG-treated group. We conclude that (1) higher P concentrations are achieved with hCG treatment than with progesterone treatment during the luteal phase; (2) high luteal P/E2 ratios per se may not be an important determinant of implantation; (3) progesterone production by the corpus luteum is not maximal in progesterone-treated cycles; and (4) the usefulness of hCG as a luteal support agent should be further evaluated.

Ovarian response to human menopausal gonadotropin after therapy with the gonadotropin-releasing hormone agonist leuprolide

Two of three patients receiving leuprolide, a gonadotropin-releasing hormone agonist, demonstrated a decreased ovarian response to gonadotropin stimulation that was consistent with that of an earlier report involving two cases. It would appear that this agonist has direct antigonadal actions.

Patterns of increase in serum estradiol in response to ovarian stimulation and their relationship to oocyte fertilization and cleavage in vitro

The in vitro fertilization and cleavage rates of oocytes obtained from patients exhibiting two different patterns of increase in serial serum concentrations of estradiol (E2) in response to ovarian stimulation were compared. Forty-two cycles (from 38 stimulated patients) were evaluated because they fulfilled requirements from two pre-defined patterns of E2 response to ovarian stimulation. In 16 cycles, serial serum E2 concentrations followed a "plateau" pattern (group A), viz., the rate of increase in the serum concentration of E2 decreased prior to the administration of human chorionic gonadotropin (hCG). In 26 cycles, serial serum E2 concentrations followed a "leap" pattern (group B), in which the rate of increase in serum concentrations of E2 increased progressively up to and including the day of hCG administration. There was no significant difference in the fertilization rate of oocytes obtained from patients exhibiting either pattern A or pattern B (78 versus 74%) but the cleavage rate was significantly higher in ova obtained from patients who exhibited pattern A rather than pattern B (72 vs 50%; P less than or equal to 0.01). In addition, embryos resulting from fertilized ova obtained from women in group A were of better quality morphologically than those obtained from women in group B (mean embryo grades, 3.9 vs 3.2; P less than or equal to 0.005). We conclude that cycles in which serial serum concentrations of E2 follow pattern A in response to stimulation give rise to oocytes that, when fertilized, yield higher cleavage rates and better-quality embryos than oocytes obtained from women in whom serial serum E2 concentrations follow pattern B.(ABSTRACT TRUNCATED AT 250 WORDS)