Hypergonadotropic amenorrhea and premature ovarian failure: a review

Amenorrhea with hypergonadotropinism consists of several distinct disorders. Affected individuals should be investigated thoroughly and not merely told they have ovarian failure. Accumulating evidence suggests that some women with "premature ovarian failure" do indeed ovulate again and even conceive. Thus, elevated levels of circulating gonadotropins can no longer be regarded as establishing that the ovaries are devoid of all oocytes. Delineation of all of the causes of hypergonadotropic amenorrhea and the establishment of rational means of inducing ovulation in women with follicles remaining are clearly tasks for present and future investigations.

There is no place in gynecological endoscopy for unipolar of bipolar high-frequency current

In 1981 we showed that there is a clear relationship between the extent of destruction of the vascular and nervous systems within the mesosalpinx, and the occurrence of menstrual disorders, and menopausal symptoms. Depending upon the individual sterilization technique, varying portions of the tubes are destroyed and considerable in jury is done to extensive parts of the mesosalpinx. Since two-thirds of the ovarian blood supply passes through the tubal branch of the uterine artery, after destruction of large areas of the mesosalpinx, a marked disturbance of ovarian metabolism must be expected. Using a patient questionnaire, we investigated the effects of the unipolar high frequency current method and the endo-coagulation procedure with respect to late complications. In the years following high-frequency sterilization (in a total of 258 women) 23 women (8.9) were hysterectomized; in the endocoagulation group only 9 patients (2.3%) underwent hysterectomy, primarily for recurrent therapy-resistent menometrorrhagia. Of the women sterilized by the unipolar HF- technique (total number 258) 20 (7.8%) required post-operative curettage 1-3 times while only 8 patients (2.1%) of the endocoagulation group required such a procedure. We found that 79 patients of the HF-group (30.9%) exhibited menstrual disorders compared with only 45 women 11.7% in the endocoagulation group.

Premature hypergonadotropic ovarian failure: clinicopathological study of 19 cases

During the 5-year period 1977-1982, 57 patients below 35 years of age with secondary amenorrhea were assessed for hypergonadotropic (primary) ovarian failure. The histological findings within the ovaries as well as pertinent clinical and laboratory correlates are described. Nineteen had diagnostic ovarian biopsies performed. The importance of this technique is stressed. The ovaries of 14 patients showed absence of primordial follicles (true premature menopause); three others showed "resistant ovary syndrome" characterized by the presence of primordial follicles but little or no follicular development (including a case of galactosemia, in which the associated ovarian failure has been ascribed to follicular atresia). The remaining two revealed florid chronic perifollicular inflammatory reactions in the presence of both primordial and also developing follicles--one lymphoplasmacytic and the other granulomatous. The former has been previously suggested as evidence of an autoimmune process, but the latter has not hitherto been reported.

Hypergonadotrophic amenorrhoea

Hypergonadotrophic amenorrhoea implies permanent gonadal failure, This has intense psychological, sociological and practical implications for the patient, and an accurate diagnosis is therefore important. Moreover, it is a heterogeneous group including on the one hand some treatable entities and on the other some conditions which could be deleterious to the patient's general health. Although in the majority of patients a precise aetiological factor for the premature disappearance of the oöcytes cannot be identified, future research will most probably implicate immunological mechanisms.

Myasthenia gravis, premature menopause, and thyroid autoimmunity

Two case reports of patients with myasthenia gravis, premature menopause at ages 18 and 29 years, and evidence of thyroid and ovarian autoimmunity are presented. Both patients had elevated gonadotropins, sex steroid values in the menopausal range, and ovaries without follicular activity. An autoimmune etiology is suggested because of the high titers of antithyroid and antiovarian antibodies.

Vascular disease risk factors in women with premature menopause

The vascular disease risk factor profile was studied in 21 women who had experienced a premature menopause due to bilateral oophorectomy. Compared with age-matched menstruating control subjects, oophorectomized women did not differ appreciably with respect to the prevalence of major vascular risk factors other than hyperlipidaemia, nor did they exhibit an excessive prevalence of vascular disease. In oophorectomized women not receiving hormone replacement therapy, the total serum cholesterol and low density lipoprotein (LDL) cholesterol levels were increased, while high density lipoprotein (HDL) cholesterol was not significantly altered. In women receiving replacement with ethinyl oestradiol, the total and LDL cholesterol were significantly decreased while HDL cholesterol was significantly increased, relative to oophorectomized women not receiving hormone replacement. The increased proportion of LDL to HDL in those not receiving hormone replacement suggests that they may be exposed to an increased theoretical long-term vascular risk, and this might justify appropriate hormone replacement in all such women, subject to certain safeguards.

Identification of differing etiologies of clinically diagnosed premature menopause

Investigations were performed in eight young women to determine if the findings of secondary amenorrhea and high follicle-stimulating hormone levels were due to primary ovarian follicular atresia or to other causes. Karyotypes were determined from both peripheral leukocytes and ovarian tissue; one woman had XXX/XX/XO mosaicism. Another woman had normal ovarian histology and probably had the "gonadotropin-resistant ovary syndrome." No autoimmune antibodies were detected, but one woman with myasthenia gravis also had ovarian histology that demonstrated primary ova and a developing follicle. Only five of eight women had primary ovarian follicular atresia, and two of the other three women had conditions theoretically compatible with subsequent pregnancy.

[Gonadal dysgenesis in a mother and her daughter (author's transl)]

The authors present two cases of gonadal dysgenesis in a mother and her daughter. Caryotypes were 46, XX/45, X for the mother (RHG-banding) and 46, X, i (Xq)/45, X for the daughter. Some researches in family did not show any abnormalities to explain this very exceptionnel event in a mother and one of her 3 daughters.

A search for antibodies to luteinizing hormone receptors in premature ovarian failure

We recently published evidence of the presence of circulating antibodies in the sera of patients who had the diagnosis of premature menopause syndrome. This led to the question: Is there a circulating antibody in the sera of patients with premature menopause syndrome which interferes with gonadotropin-luteinizing hormone (LH) receptor interaction on the luteal cell surface? Serum samples from 14 women with the diagnosis of Premature menopause syndrome were examined to see whether they would block the binding of 125I-labeled human chorionic gonadotropin (hCG) to human corpora lutea. All patients had spontaneous cessation of menses before the age of 35 years and documentation of increased gonadotropin secretion and failure of estrogen secretion. When the sera of the study group were incubated with 125I-labeled hCG and LH receptor from human corpora lutea, no difference in binding was observed when compared with controls. This suggests that there is no circulating antibody that interferes with hCG-LH receptor interaction and that would thereby lead to loss of ovarian function in premature menopause syndrome.

Premature menopause. I. Etiology

The premature menopause syndrome has been regarded as one of the organ-specific autoimmune disorders because circulating antibodies to ovarian tissue have been demonstrated. Fifteen women with spontaneous cessation of menses after initial menarche before they were 35 years old were seen between 1975 and 1977. Increased serum levels of gonadotropin and failure of estrogen secretion were documented. Serum from each woman was examined for antibodies to normal ovary. Proteins from ovaries of normal premenopausal women were extracted and iodinated with 125I. The labeled proteins were incubated with sera for 48 hours, after which goat antihuman gamma-globulin was added and allowed to incubate for 72 hours. The precipitate was washed and evaluated for radioactive label. The binding of antibodies increased in the sera of patients with the premature menopause syndrome, compared with the control sera. This suggests that the etiology of premature menopause may be mediated by circulating antibodies to ovarian tissue.

Acute menopausal transition associated with clomiphene therapy: Two case reports

Two patients presenting with anovulation and secondary infertility were treated with clomiphene citrate. Intermittent blood samples were obtained for the first three months of therapy in each case. One patient failed either to ovulate or menstruate in response to clomiphene and the other patient had only two episodes of cyclical bleeding before she too became amenorrhoeic. Hormonal analyses revealed that both women had undergone a rapid and precocious menopausal transition which has persisted throughout the subsequent three years.

X/X translocation and Turner's syndrome in a woman with climacterium praecox

A woman with X/X translocation is presented, and the association between the different types of X/X translocation and Turner's syndrome as well as the question of menstruations and fertility in women with Turner's syndrome are discussed. It is concluded that streak gonads should most probably not be included in the definition of Turner's syndrome.

Dynamic hormonal tests in a case of premature ovarian failure

The case of a patient with premature ovarian failure and a history of polycystic ovarian disease was described. Dynamic gonadal and pituitary tests were done. Ovarian, adrenal, and peripheral veins were catheterized to determine the steroid secretion under HCG stimulation. In vitro studies of the capacity of ovarian steroidogenesis confirmed the refractory nature of the gonad. Lack of gonadal response, both in vivo and in vitro, to stimulation suggests a possible alteration in ovarian sensitivity to gonadotropins as a possible cause of premature menopause.

Sex hormone levels and gonadotrophin release in premature ovarian failure

Premature ovarian failure was studied in ten women under the age of 30; eight had an ovarian biopsy and five of these showed primordial follicles. Plasma levels of oestradiol and progesterone were similar to the follicular phase of a normal menstrual cycle, but in eight patients cervical smears showed a cornification index of less than one per cent. Levels of both androgens and of sex hormone binding globulin capacity were generally normal. Administration of LH-RH caused a release of FSH which was similar to post menopausal women and higher than both. Two patients were treated with exogenous gonadotrophins without effect.

Endocrine modifications in women with premature menopause

The Authors have found 9 cases of premature menopause out of a total of 159 observations of gynecological disfunctional disorders for a 3 year period. The functional investigation has been carried out by radioimmunoassay for PRL, FSH, LH, 17beta-estradiol, progesterone and, in those cases in which it was possible, the spontaneous pulsatility of PRL and gonadotropins has also been studied. The basal PRL was found always in normal range and the pulsatility was sufficiently flat. On the other hand a pool of gonadotropins can still be released by 100 microgram of LH-RH i.v. in spite of high basal levels of pituitary gonadotropins. The pulsatility, especially for FSH, appears like to those of postmenopausal women. 17beta-estradiol and progesterone were at low levels and could not be alterated by HMG-HCG tests. As a conclusion the Authors think that the evaluation of the above reported parameters is an unfailing diagnostic precision in many cases of secondary protovarian amenorrhea for a premature menopause syndrome.

[Radiological observations on bone changes in women after bilateral ovariectomy with and without oestrogen prophylaxis (author's transl)]

A retrospective study was carried out on 69 women who had hysterectomies and bilateral ovariectomies carried out during puberty for non-malignant disease. The effect of oestrogen prophylaxis on bones was studied by various radiological methods (1. Miminal combined cortex thickness in the proximal radius according to Meema; 2. Biconcavity index according to Nordin; 3. Osteoporosis stage in the lumbar spine according to Saville; 4. The Singh index in the proximal femur and 5. Absorption coefficient and relative cortical thickness of the phalanges). It was found the the hormone-treated group (33 cases) showed significantly greater bone density than the control group (36 cases). It is therefore suggested that women undergoing ovariectomy before the menopause, or those with low bone density at the natural menopause, should be treated by long-term oestrogen therapy, provided there are no specific contraindications.

Menopause and myocardial infarction

Age and circumstances of menopause (natural or artificial) are detailed in 104 cases of recent myocardial infarction (MI). The results of this study with statistical analysis show no correlation between the age at menopause and the age at onset of MI; so for this study, an early menopause, cannot be considered, whatever circumstances, as a risk factor for coronary heart disease.

Gonadal karyotyping in women with and without ovarian activity

Results of gonadal karyotyping on 26 patients with cyclic or acyclic ovarian activity and hypogonadotropic or hypergonadotropic hypogonadism are presented. Gonadal culture growth, with the exception of tissue from polycystic ovaries, was usually successful. With one exception, leukocytic and gonadal karyotypes were concordant. Normal ovarian function did not appear to be limited to ovaries of the 46,XX karyotype.

Pregnancy associated with hypergonadotropic hypogonadism

A case of a 30-year-old female with secondary amenorrhea and relative hypergonadotropic hypogonadism is presented. The patient demonstrated persistently elevated levels of gonadotropins in spite of clinical and laboratory evidence of estrogen production. Laparoscopic directed biopsy revealed a total absence of ova, but in spite of this finding, conception ensued. Variations in ovarian sensitivity throughout the female reproductive period and in certain pathologic states are discussed, as well as the apparent limitation of single laparoscopic directed biopsies for confirming the diagnosis of premature menopause. Finally, the theoretical use of exogenous estrogen to induce ovulation in patients with the ovarian insensitivity syndrome is discussed.

Use of clomiphene and luteinizing hormone/follicle stimulating hormone-releasing hormone in investigation of ovulatory failure

A luteinizing hormone/follicle-stimulating hormone-releasing hormone (LH/FSH-RH) test was performed in 70 women with amenorrhoea or anovulatory infertility, or both, and a clomiphene stimulation test was also performed in 24 of these patients. Most patients responded to LH/FSH-RH with significant increases in LH and FSH. In women with gonadal dysgenesis or premature ovarian failure exaggerated responses were observed after LH/FSH-RH and there was no change in high basal LH levels after clomiphene. Patients with absent or impaired responses to LH/FSH-RH failed to respond to clomiphene. All patients with anovulatory menstrual cycles responded to both LH/FSH-RH and clomiphene, while seven out of 13 amenorrhoeic patients with a normal LH/FSH-RH response showed an early LH rise during clomiphene treatment and six were unresponsive. These results suggest a difference between the two groups at hypothalamic level with consequent therapeutic implications.

Mumps oophoritis: a cause of premature menopause

One cause of secondary oligomenorrhea is ovarian infection. A rare type of infection related to the disturbance of menstrual function is mumps oophoritis. Three patients with premature menopause presumably caused by this agent were described. In one patient the symptoms coincided with a subclinical infection during the perinatal period, with subsequent infertility. Another patient seemed to have had a clinically mild oophoritis during the pubertal period, and the third patient became symptomatic following parturition. It appears that this aberration in menstrual function and fertility may be related to the time during which the infection occurs as well as to the severity of the infection. In addition, it is apparent that mumps oophoritis may be a more frequent cause of premature menopause than has heen previously suspected.

The measurement of sequential changes in cortical bone geometry

A method is described whereby the sequential changes occurring in the thickness of the cortices of the metacarpal shafts may be observed. The method utilizes pairs of hand radiographs from which the total bone width and medullary width of the 2nd, 3rd and 4th metacarpals are determined in duplicate using needle-tipped Vernier calipers. The errors are discussed and the precision of the method is shown to compare very favourably with the precision of the most recent densitometric techniques. The rate of loss of bone in post-menopausal women is evaluated, and is shown to be dependent upon the number of years elapsed since the menopause.