Oral contraceptives for inducing ovulation delay in orthodox Jewish women: a report of 2 cases

BACKGROUND

Orthodox Jewish women are prohibited from participating in sexual intercourse from the start of menstruation to 7 days after the end of flow, when they participate in a ritual bath.

CASE

Two orthodox Jews with ovulation prior to initiating sexual intercourse were treated with oral contraceptives to delay ovulation.

CONCLUSION

Oral contraceptive treatment strategies are effective at delaying ovulation until after the ritual cleansing for orthodox Jewish women with short follicular phases.

Luteinizing hormone secretion is not influenced by insulin infusion in women with polycystic ovary syndrome despite improved insulin sensitivity during pioglitazone treatment

It has been reported in women with polycystic ovary syndrome (PCOS) that LH secretion is not altered by insulin infusion. To determine whether insulin resistance may have precluded an effect of insulin, pulsatile LH secretion and gonadotropin responses to GnRH were examined in PCOS women (n = 9) before and after pioglitazone treatment (45 mg/d) for 20 wk in the presence and absence of a hyperinsulinemic euglycemic clamp (80 mU/m2.min). Frequent blood samples were obtained for 12 h (every 10 min) as well as during sequential administration of GnRH at doses of 2, 10, and 20 microg over 12 h. A significant (P < 0.05) improvement in insulin sensitivity was seen in the subjects after treatment. Mean LH levels, LH pulse frequency and amplitude, as well as gonadotropin responses to GnRH were not influenced by pioglitazone, either with or without insulin infusion. We conclude that in PCOS women, inappropriate gonadotropin release does not appear to be a consequence of hyperinsulinemia.

Tumor-level serum testosterone associated with human immunodeficiency virus lipodystrophy syndrome

BACKGROUND

Human immunodeficiency virus (HIV) lipodystrophy syndrome consists of insulin resistance, hyperlipidemia, increased waist-to-hip ratios, and relative hyperandrogenemia, which resembles polycystic ovary syndrome.

CASE

A 30-year-old HIV-positive multipara with lipodystrophy syndrome had an elevated level of serum total testosterone (244 ng/dL) in the tumor range.

CONCLUSION

In HIV lipodystrophy syndrome, marked elevations of total serum testosterone in the range reserved for androgen-producing tumors may occur. The elevated testosterone levels are derived from the ovary and are responsive to gonadotropin suppression.

Relationship of GnRH-stimulated LH release to episodic LH secretion and baseline endocrine-metabolic measures in women with polycystic ovary syndrome

BACKGROUND AND OBJECTIVE

In polycystic ovary syndrome (PCOS) inappropriate gonadotrophin secretion is characterized by increased pulse frequency and amplitude, elevated 24-h mean serum concentrations, and greater responses to GnRH. While the mechanism(s) responsible for this increased release of LH are not well understood, enhanced LH secretion has been attributed to increased pituitary sensitivity to GnRH and feedback influences from circulating steroid hormones. To address these considerations, we conducted a study to examine the relationships between GnRH-stimulated LH responses, episodic gonadotrophin secretion, and baseline measurements of endocrine-metabolic function in PCOS.

PATIENTS

Serum LH responses to sequential multidose GnRH administration and pulsatile gonadotrophin secretion were examined in 13 PCOS and 13 normal women.

MEASUREMENTS

Serum LH, steroid hormone, insulin and glucose levels were determined in blood samples obtained during assessment of episodic gonadotrophin secretion and LH responses to GnRH stimulation.

DESIGN

Each subject was studied on two consecutive days. On study day 1 each subject underwent frequent blood sampling every 10 min for 12 h. On study day 2 each received sequential doses of GnRH, 2 microg, 10 microg and 20 microg, administered intravenously at 4-h intervals over a continuous 12-h period.

RESULTS

Serum LH responses following GnRH were markedly greater in PCOS compared to normal women, as expected. In individual PCOS, peak LH responses to GnRH were significantly correlated with corresponding basal LH and LH pulse amplitude, but not LH pulse frequency. In the PCOS group, LH responses were positively correlated with serum oestradiol (E2) and inversely related to body mass index (BMI). Between-group differences in LH responsiveness disappeared when controlling for serum testosterone (T) levels.

CONCLUSIONS

These results indicate that the absolute LH increment following GnRH is largely dependent on baseline LH levels and may account for the well-documented difference in LH responsiveness between PCOS and normal women. That neither LH responses to GnRH nor LH pulse amplitude were correlated to LH pulse frequency suggests involvement of other factors along with GnRH to account for increased LH secretion in PCOS. In addition to E2 and BMI, serum testosterone appears to be, at least in part, responsible for differences in LH secretion and release between PCOS and normal women.

Enhanced granulosa cell responsiveness to follicle-stimulating hormone during insulin infusion in women with polycystic ovary syndrome treated with pioglitazone

Women with polycystic ovary syndrome (PCOS) are known to exhibit insulin resistance with compensatory hyperinsulinemia. To determine the role of hyperinsulinemia on follicle function in PCOS, we examined 24-h estradiol (E(2)) responses to recombinant human FSH (r-hFSH), 75 IU, before and during insulin infusion both before and after administration of pioglitazone (30 mg/d) in seven PCOS women. Each subject underwent two 10-h hyperinsulinemic-euglycemic clamps at rates of 30 (low dose) and 200 (high dose) mU/m(2).min, respectively. During both low- and high-dose insulin infusions, E(2) responses to r-hFSH were unaltered compared with that observed in the absence of insulin. Pioglitazone administration for 5 months improved insulin sensitivity as indicated by significantly (P < 0.05) increased glucose infusion rates during the clamp studies. At 3 months of treatment, r-hFSH-stimulated E(2) responses were not different from those observed before treatment. With pioglitazone treatment, E(2) responses to r-hFSH remained unchanged during low-dose insulin infusion, whereas a highly significant (P < 0.02) increased response was noted with the high-dose hyperinsulinemic-euglycemic clamp. In addition to a greater magnitude of response, peak levels of E(2) were sustained longer compared with that seen before treatment. The data indicate that granulosa cell responsiveness to FSH was enhanced by insulin after improved insulin sensitivity induced by pioglitazone. These findings are consistent with the possibility that PCOS granulosa cells are insulin resistant.

Increased luteinizing hormone secretion in women with polycystic ovary syndrome is unaltered by prolonged insulin infusion

In PCOS women with insulin resistance, hyperinsulinemia may contribute to inappropriate gonadotropin secretion. To determine whether insulin influences gonadotropin release in PCOS, pulsatile LH secretion and gonadotropin responses to GnRH were evaluated before (phase 1) and during (phase 2) insulin infusion. In phase 1, 11 PCOS and 9 normal women on separate days underwent 1) frequent blood sampling (q 10 min) for 12 h and 2) gonadotropin stimulation by successive doses of GnRH, 2 microg, 10 microg, and 20 microg, administered i.v. at 4 h intervals over a continuous 12 h. In phase 2, studies were repeated 2 h after initiation of a 12-h hyperinsulinemic-euglycemic clamp (80 mU/m(2).min). Administration of insulin to both groups failed to alter mean serum gonadotropin concentrations, LH pulse frequency, or LH pulse amplitude. Moreover, gonadotropin responses to GnRH were unchanged by insulin infusion. In PCOS and normal women, a significant reduction of serum androstenedione was associated with insulin administration, whereas no differences were noted for the remaining androgens and estrogens measured. These findings demonstrated that in PCOS women, LH secretion and gonadotropin responses to GnRH were not influenced by insulin administration. Insulin infusion had little effect on steroid hormone production with the possible exception of androstenedione. These results suggest that inappropriate LH secretion in PCOS is not a direct consequence of insulin resistance and compensatory hyperinsulinemia.

Evidence for abnormal granulosa cell responsiveness to follicle-stimulating hormone in women with polycystic ovary syndrome

Women with polycystic ovary syndrome (PCOS) undergoing ovulation induction appear to be extremely sensitive to gonadotropin stimulation and at increased risk for ovarian hyperstimulation syndrome. To determine granulosa cell responsiveness to recombinant human FSH (r-hFSH), dose-response studies were conducted in 16 individual PCOS patients and 7 normal women. Each subject received an iv injection of r-hFSH at doses of 0, 37.5, 75, or 150 IU in a randomized fashion on four separate occasions. Blood samples were obtained at frequent intervals before and for 24 h after r-hFSH administration for measurement of gonadotropins and steroid hormones. Our results showed that administration of r-hFSH produced instantaneous and equivalent dose-related increases in serum FSH in PCOS and normal women, which were followed by similar exponential decreases to baseline levels within 24 h in both groups. In PCOS subjects, the peak mean incremental response of serum estradiol (E(2)) to 150 IU of r-hFSH was 1.8-fold greater (P < 0.0001) and considerably accelerated compared with that found in normal women. In contrast, E(2) responses to 37.5 IU and 75 IU were similar between groups. Regression analysis of maximal E(2) concentrations in response to r-hFSH in each individual subject revealed that the slope of the linear trend line in the group of women with PCOS (r = 0.82) was significantly greater (P < 0.01) than that of normal controls (r = 0.71). The time-course of response revealed that in PCOS women, increases of E(2) were not sustained, compared with those of normal controls, because peak concentrations were followed by an estimated 40% decrement in circulating levels, whereas E(2) levels in normal women persisted for 24 h after reaching maximal values. These findings indicate that women with PCOS exhibit a significantly greater capacity for E(2) production in response to iv r-hFSH, compared with normal women. In PCOS, E(2) production was relatively transient because after peak concentrations a marked decline was detected at each dose, unlike normal women who exhibited persistent elevations of E(2) for up to 24 h. That this distinction was dose-dependent supports the concept of an FSH dose-response threshold, beyond which PCOS but not normal women are susceptible to ovarian hyperresponsiveness.

Spontaneous subserosal venous rupture overlying a uterine leiomyoma. A case report

BACKGROUND

Patient age, parity and leiomyoma size are considered risks for venous rupture overlying a leiomyoma.

CASE

A 28-year-old woman presented with abdominal pain and decreasing hematocrit from spontaneous rupture of a uterine leiomyoma vein.

CONCLUSION

Congestion of a vein overlying a leiomyoma, irrespective of the patient's age or parity or size of the leiomyoma, is a risk factor for rupture.

Fibrolamellar hepatic carcinoma with a presentation similar to that of septic pregnancy. A case report

BACKGROUND

Of hepatocellular carcinomas, produce quantifiable levels of beta-hCG.

CASE

A 44-year-old woman presented with fever, abdominal pain, vaginal bleeding and increased serum levels of beta-hCG.

CONCLUSION

Nongestational elevations of serum beta-hCG warrant consideration of a malignant neoplasm.