Hyperprolactinaemia and impotence

Prolactinoma presenting with intermittent third nerve palsy

A patient presented with a painful third nerve palsy. This resolved spontaneously, but recurred several months later. At his second presentation carotid angiography gave normal results, but a high resolution CT scan showed a tumour in the right parasellar region. The serum prolactin was raised at over 22,000 millimicrons/, showing this to be a prolactinoma.

An approach to the management of sexual dysfunction in the adolescent male

Sexual dysfunction in the adolescent male appears to be increasing. Erectile dysfunction (impotence) and premature ejaculation are the most common. Illustrated by three cases, a review of the prominent causes of sexual dysfunction is provided along with a discussion of an approach to adequate sexual history taking, physical evaluation, and treatment.

Effects on penile reflexes and plasma hormones of hyperprolactinemia induced by MtTW15 tumors

The effects of severe hyperprolactinemia induced by MtTW15 tumors (prolactin- and growth-hormone-secreting pituitary adenoma) on penile reflex activity and blood hormones were examined. There was no significant adverse effect of hyperprolactinemia on penile reflexes at 7, 14, or 21 days after tumor inoculation. However, a virtual elimination of penile reflex activity was observed 34 days after inoculation. Additionally, significant decrements in serum testosterone and dihydrotestosterone and an elevation in progesterone were seen at this time concomittant with greatly increased prolactin levels. The results suggest that erectile dysfunction may contribute to hyperprolactinemia-induced copulatory failure.

Adrenalectomy does not prevent the hyperprolactinemic, induced sexual behavior deficits in CDF male rats

Inbred male CDF rats were bilaterally adrenalectomized and received either two pituitaries under each kidney capsule or were sham operated. They were tested at approximately four, seven and eight weeks after surgery. Between the first and second behavioral test, the animals received corticosterone replacement therapy. In each of the three tests, grafted animals exhibited deficits in male sexual behavior as compared to sham-grafted controls. These results suggest that, at least in CDF inbred rats, the adrenal gland is not necessary for the reduction in male sex behavior resulting from chronic hyperprolactinemia.

Hormone profile in hyperprolactinemic infertile men

Serum levels of FSH, LH, prolactin, testosterone, and estradiol in 46 infertile men with hyperprolactinemia were compared with the same in 50 infertile and 30 fertile men with normal serum prolactin levels. Serum FSH levels in hyperprolactinemic men were significantly higher than in the other groups, indicating disturbance of spermatogenic process among those men. Significantly raised serum LH levels were in infertile men with serum prolactin over 1000 U/liter. All men with hyperprolactinemia had significantly lower serum testosterone levels than other infertile and fertile men. Although serum testosterone was not under the lower limit of normal range and high LH levels demonstrated disturbance of Leydig cell function in hyperprolactinemic infertile men, serum estradiol levels were not different among investigated groups. Azoospermic men with raised serum prolactin had higher serum FSH and LH levels than oligospermic men with hyperprolactinemia. These data demonstrated disturbance in hypothalamopituitary-testicular axis in infertile men with hyperprolactinemia. Further studies of prolactin in males with reproductive failure could probably clear this problem.

Hyperprolactinaemia in male diabetics

We recently investigated two patients with diabetes and elevated serum prolactin levels in whom no cause of hyperprolactinaemia could be found. For this reason we measured fasting serum prolactin levels in 72 diabetic males and compared the results with those of 63 healthy males and 90 nondiabetic males attending an Impotence Clinic. The diabetic group had significantly higher serum prolactin levels (13.1 +/- 0.9 ng/ml) than the two control groups (9.9 +/- 0.6 ng/ml for normal males and 7.7 +/- 0.3 ng/ml for the non-diabetic impotent group). Eighteen percent of the diabetics studied had serum prolactin levels above the normal range for males (greater than 20 ng/ml). There was no correlation between serum prolactin levels and duration of diabetes, glycosylated haemoglobin level or presence of clinically apparent retinopathy. The correlation between serum prolactin level and fasting plasma glucose was weak though statistically significant (r = 0.26, P less than 0.05).

Sulpiride-induced hyperprolactinemia and impotence in male psychiatric outpatients

The relationship between erectile dysfunction and sulpiride stimulatory effect on prolactin secretion was studied in 13 married male psychiatric outpatients. The patients population was comprised of 2 groups: patients with anxiety disorders resistant to minor tranquilizers who were treated with sulpiride up to 200 mg/day, and schizophrenic patients treated with sulpiride 600 mg/day. All the patients were maintained on maximal dose for a period of 3 weeks. Sexual function and blood prolactin levels were monitored once weekly. The patients who developed impotence were maintained on higher doses of sulpiride and exhibited higher prolactin levels in comparison to the potent patients. Restoration of potency was observed after reduction or discontinuation of sulpiride treatment. It is concluded that sulpiride induced impotence is associated with hyperprolactinemia.

Prolactin and sexual behavior: a review

Despite the large body of evidence showing that prolactin (PRL) can suppress sexual behavior in humans and rodents, it is still unclear how this hormone affects sexual capacity of male subjects. Few studies have been performed on the effects of PRL on female sexual behavior. Short-term hyperprolactinaemia seems to facilitate some elements of sexual behavior in male rats. Furthermore, contrasting finding exist on the effects of drug-induced hyperprolactinaemia on sexual capacity of male animals. The possible mechanisms of action (on peripheral organs, endocrine, central) or PRL on male behavior are discussed in details.

Altered pulsatile secretion of luteinizing hormone in hypogonadal men with hyperprolactinaemia

To explore the mechanism for the hypogonadism associated with prolactin hypersecretion in men we examined luteinizing hormone (LH) secretory profiles in four hyperprolactinaemic men before and during treatment with bromocriptine. Pretreatment serum prolactin levels were increased 4-100 fold and serum testosterone levels were low in three men and low-normal in the fourth subject. Mean LH levels were low-normal and the frequency of spontaneous LH secretory episodes was less than normal in three of four men. Bromocriptine reduced serum prolactin levels to normal; subsequently, serum testosterone levels increased and libido and potency improved markedly in each man. The rise in serum testosterone levels was associated with an increase in mean LH concentrations and in LH pulse frequency. Mean follicle-stimulating hormone levels also increased during bromocriptine treatment. Insofar as each LH pulse is believed to reflect a discharge of gonadotrophin releasing hormone from the anterior hypothalamus, our data suggest that a major abnormality in hyperprolactinaemic men with hypogonadism is a disorder of the neuroregulatory mechanism for pulsatile gonadotrophin-releasing hormone secretion.

The effects of bromocriptine on the sexual behaviour of hyperprolactinaemic man: a controlled case study

A 44-year old man presented with loss of sexual interest and erectile failure and together with his wife was treated successfully with sexual counselling. He was subsequently found to have been hyperprolactinaemic before and after sex therapy. Comparison of bromocriptine with placebo in two double blind studies showed a modest increase in sexual interest when his prolactin levels fell to normal. In this case, the principal effect of hyperprolactinaemia was on sexual interest. His main problems, erectile impotence and decline in sexual activity, resulted from his and his wife's psychological reaction to this modest hormonal effect. Hyperprolactinaemia appears to have a similar effect to testosterone deficiency in men.

Bromocriptine in the management of infertile men after surgery of prolactin secreting adenomas

This study evaluated bromocriptine treatment in nine patients with prolactin secreting adenomas who continued to have elevated circulating levels of prolactin after surgery, and who were interested in improving their sperm counts. These patients were brought into the study 3.2 +/- 1.8 years (mean +/- SD) after surgery. All of them presented with high circulating levels of prolactin, and eight of the patients had oligozoospermia (range 0-10 X 10(6) spermatozoa/ml). LH and testosterone levels were low in seven patients, and eight patients had low FSH values. All patients were treated for 90 days with 7.5 mg/day of bromocriptine. After treatment, prolactin levels decreased significantly in all patients, while sperm counts increased significantly in five of them. Testosterone levels increased in four subjects. Bromocriptine therefore seems useful in the management of this type of patient because of the observed decline in prolactin levels and the increase in sperm counts. Possible mechanisms involved in this action are discussed.

Ultrastructural lesions in testes from hyperprolactinemic men

Testicular tissue from eight men with prolactinomas and elevated serum prolactin were evaluated by light (LM) and transmission electron microscopy (TEM). A semiquantitative assessment of testicular morphology was employed to provide a morphology index for each tissue specimen. Although in each biopsy specimen germ cell exfoliation was evident, as was abnormal structural change in the seminiferous epithelium, there was no apparent correlation with the overall degree of tissue pathology (morphology index) and the serum level of prolactin. All of the tissue displayed variably thickened seminiferous tubule walls which, when viewed by TEM, were composed of thickened laminae propriae and redundant and involuted basal laminae. Likewise, all tubules contained Sertoli cells with overt cytoplasmic degeneration, principally in the apical (adluminal) region of the cell. This was visualized, in part, as a retraction of the apical cytoplasm from periluminal spermatids and degeneration or absence of Sertoli-germ cell junctional specializations. Sertoli-Sertoli cell junctional complexes appeared structurally intact. Leydig cell ultrastructure was typical of normal cells and contained a variable amount of lipid and smooth endoplasmic reticulum. This also was without positive correlation with the overall degree of tissue pathology or level of serum prolactin. Our results demonstrate the variable degree of testicular pathology associated with hyperprolactinemia in man, and suggest that abnormal tubule walls and altered Sertoli cell ultrastructure are consistent findings in this abnormal endocrine condition.

Endocrine dysfunction in impotence: incidence, significance and cost-effective screening

A comprehensive evaluation of impotence includes assessment of the functional integrity of the hypothalamic-pituitary-gonadal axis. However, little is known about the incidence or significance of hormonal abnormalities in an unselected group of men with erectile failure. A systematic multidisciplinary, multidimensional assessment of 256 impotent men showed clearly an organic etiology in 35.9 per cent, psychogenic in 38.3 per cent and mixed or uncertain in 25.8 per cent. The incidence of hypothalamic-pituitary-gonadal axis abnormalities in the entire group was 17.5 per cent but in only 12.1 per cent did they contribute clearly to erectile dysfunction. A cost-effective screening of the endocrine system in impotent men includes a thorough history and physical examination, and a serum testosterone determination. More sophisticated and expensive investigations should be reserved for patients with a history of drug use known to induce hormonal abnormalities or with somatic evidence of hypogonadism and a depressed serum testosterone level.

The effect of endogenous and exogenous gonadotrophin-releasing hormone on the prolactin response to TRH

The prolactin response to TRH in a group of patients with Kallmann's syndrome was found to be significantly lower compared to a group of hypergonadotrophic hypogonadal patients. Since levels of testicular products are comparably low in both groups, we hypothesize that high endogenous LHRH production might be associated with an increased prolactin response to TRH. In support of this, we were, indeed, able to establish a positive correlation between the magnitude of the prolactin response to TRH and basal and LHRH-stimulated LH/FSH levels (the latter serving as an index of endogenous LHRH production) in: (1) eugonadal men, (2) men with Kallmann's syndrome, (3) oestrogen-treated agonadal men, (4) men with severely impaired spermatogenesis and, (5) agonadal men. A direct relation between LHRH and the prolactin response to TRH was demonstrated in a group of eugonadal men, the prolactin response to TRH being greater after prolonged LHRH pretreatment. We speculate that an increase of endogenous or exogenous LHRH might be associated with decreased hypothalamic dopamine secretion which could directly increase prolactin synthesis. Indirectly, decreased dopamine secretion could augment the potency of TRH in releasing prolactin.

Do endocrines play an etiological role in diabetic and nondiabetic sexual dysfunctions?

Sexually dysfunctional diabetic and nondiabetic males were compared with a group of normal controls using different endocrinological, psychophysiological, and psychological parameters. One hundred male subjects participated in this study: 47 diabetics with sexual dysfunction (DD), 31 nondiabetics with sexual dysfunction (NDD), and 22 normal controls (C). They were evaluated by an internist (physical examination and medical history), a psychologist (psychological and sexual functioning tests), a psychiatrist (psychiatric history and mental status examination), a urologist (genitourinary physical examination), and an endocrine biochemist (evaluation of endocrine factors). Additionally, subjects were evaluated for nocturnal penile tumescence (NPT) during three nights in the sleep laboratory to obtain a differential diagnosis of impotence, that is, psychogenic vs. organic. Both sexually dysfunctional groups showed significant differences on several measures in the psychological and psychophysiological evaluations. There were also significant differences between these two groups and the control group. Plasma levels of total testosterone and serum levels of prolactin, luteinizing hormone (LH) and follicle-stimulating hormone (FSH) showed no significant differences among the three groups, but there were some significant correlations between the endocrine and psychological measures. No significant correlations were found between the endocrine and psychophysiological measures.

Male gonadal function in coeliac disease: III. Pituitary regulation

Pituitary regulation of gonadal function was investigated in 39 consecutive men with treated and untreated coeliac disease and in an intestinal disease control group of 19 men with Crohn's disease of similar age and general nutritional status. Basal serum FSH concentration was increased in 10 of the coeliacs (26%) compared to only two of 19 men with Crohn's disease (11%). This abnormality was observed with equal frequency in both treated and untreated coeliacs, and was not associated with oligospermia. Serum LH concentration was increased in eight of 15 untreated coeliacs (53%) with sub-total villous atrophy, an abnormality which unlike the elevation of serum FSH, appears to return towards normal after gluten withdrawal. Serum LH was high in coeliacs despite marked elevation of the free testosterone index. Exaggerated responses of FSH and LH to LHRH were found in 89% and 45% respectively, of coeliacs with sub-total villous atrophy. However, exaggerated responses of LH alone were found more frequently in coeliacs than in men with Crohn's disease (P less than 0.02) and unlike the exaggerated FSH responses, LH responses were closely related to jejunal morphology. Exaggerated responses of FSH and LH in coeliacs were commonly found when basal gonadotrophin concentrations were normal. The occurrence of exaggerated gonadotrophin responses could not be related to plasma concentration of testosterone, dihydrotestosterone, oestradiol or the free testosterone index. Serum prolactin was modestly raised in 25% of untreated and partially treated coeliacs and in the same proportion of men with Crohn's disease. Elevated serum prolactin concentrations never exceeded 809 mU/l and were not associated with impotence or infertility. This study provides further evidence that in men with coeliac disease there is a derangement of pituitary regulation of gonadal function. This would seem to be part of a wider disturbance of central regulatory mechanisms of endocrine function in coeliac disease.

Endocrine causes of impotence. Optimistic outlook for restoration of potency

Endocrine disorders are important, potentially reversible causes of impotence. Impotence may be an early manifestation of hypopituitarism, nonfunctioning pituitary tumors, prolactin-secreting pituitary tumors, or hyperthyroidism. Treatment of these disorders, as well as many of the other endocrinopathies with which impotence may be associated, usually leads to restoration of libido and potency. When impotence is caused by the autonomic neuropathy of diabetes, however, treatment of the endocrinopathy rarely restores sexual function. Sex therapy or implantation of a penile prosthesis may be useful in selected patients with this cause of impotence.

The correlation of increased serum prolactin levels with decreased sexual desire and activity in elderly men

Serum prolactin levels and sexual function were evaluated in 28 men from 60 to 64 years of age and in 44 men from 65 to 70 years of age. All subjects were married, physically healthy, and had no psychopathology or marital problem. About a third of the men aged 60 to 70 years suffered from impotence. No obvious correlation between elevated levels of serum prolactin and impotence was obtained. Subjects aged 65 to 70 who had decreased libido exhibited a significant elevation of serum prolactin levels, while subjects of the same age group who had reserved (normal) libido appeared to have low serum prolactin levels. Nine of ten men aged 60 to 70 years with serum prolactin levels above 40 ng/ml reported decreased libido. Potent men of both age groups (60-70 years) with high prolactin levels showed a tendency to have a decrease in frequency of sexual intercourse. Thus, it seems that mild hyperprolactinemia in aging men may be associated with decreased sexual desire and frequency of sexual activity.

Hormone profile in infertile men

Plasma basal levels of FSH, LH, prolactin, and testosterone were evaluated in 263 men with fertility problems. Significant increases in FSH were detected in all groups of infertile men except those with infection, varicocele, infection and varicocele, and obstructive azoospermia. No differences in LH were detected in all groups, except those with chromosomal testicular abnormality and idiopathic seminiferous tubular failure where significant increases were revealed. No differences in prolactin were detected, while a decrease was found in testosterone in the group with chromosomal testicular abnormality. FSH seems to be a most valuable hormone index in the routine workup of male infertility, while prolactin does not offer substantial information. The combined LH and testosterone evaluation might be of diagnostic importance in selected cases.

Effects of sulpiride induced hyperprolactinemia on testosterone secretion and metabolism before and after HCG in normal men

The purpose of the study was to investigate the effects of sulpiride-induced hyperprolactinemia on testicular functions, as assessed by evaluation of plasma testosterone (T), dihydrotestosterone (DHT) and 17 beta-estradiol (E2) levels. An HCG test (5000 IU on three consecutive days) was performed in basal conditions and after 12 and 26 days of sulpiride treatment (150 mg daily) in 7 male volunteers, 19 to 32 years of age, as well as in 6 sulpiride-free controls. The results show that after 12 days of induced hyperprolactinemia (mean increase 400%) the T response to HCG was similar to basal test; after 26 days however, the increase of T mean plasma levels was significantly greater. The increase in E2 significantly correlated to that of T during the first and second HCG tests, but no longer after 26 days of hyperprolactinemia, resulting in an imbalance of the E2/T ratio of plasma increments. The response of DHT to HCG was significant in basal conditions and after 26 days of sulpiride and always correlated with T behavior. Data obtained in our experimental conditions suggest that PRL might enhance T secretion. 5 alpha-reductase activity seemed to be partially affected after 12 days of treatment, while a significant inhibition seemed to be exerted on aromatase activity.

Gynecomastia in epileptics treated with phenobarbital, phenytoin and fluoresone: two case reports

Gynecomastia developed in two epileptic patients some months after the addition of oral fluoresone 750 mg daily to the phenobarbital and phenytoin already being administered. The common systemic diseases that may give rise to gynecomastia were excluded. One of the patients presented hyperprolactinemia and a raised estrogen/androgen ratio but the hormone levels were not raised in the other. The onset of symptoms after fluorescence in both cases is highly suggestive, although the pathogenetic mechanism is not clear.

The effect of enalapril on serum prolactin

Twelve healthy male volunteers received single daily oral doses of enalapril (EN) 10 mg for 8 consecutive days. Serum samples for prolactin (PRL) assay were taken on day 0 (baseline) at 12.00 h and 16.00 h, and on days 1 and 8 at 08.00 h (pre-drug), 12.00 h and 16.00 h. The 08.00 h values on day 1 served as the pre-drug baseline. There were no significant changes from baseline in serum PRL levels on days 1 and 8. All mean serum PRL levels on day 8 were significantly (P less than 0.01) lower than the upper limit of the normal range (2-15 ng/ml) found for healthy males in this laboratory. It is concluded that therapeutic doses of EN (10 mg/day, p.o.) for 8 consecutive days do not raise mean serum PRL levels above the normal range in healthy male volunteers.

Effects of testosterone, estradiol, aromatase inhibitor, gonadotropin and prolactin on the response of mouse testes to acute gonadotropin stimulation

These studies determined the local acute responsiveness of the testis to intratesticular administration of human chorionic gonadotropin (hCG) under basal, stimulated (systemic hCG pre-treated), hypogonadotropic (steroid pre-treatment) and hyperprolactinemic conditions in male mice. In addition, testicular testosterone (T) levels were determined after intratesticular administration of the aromatase inhibitor, 4-hydroxyandrostenedione (4-OHA) or progesterone under basal or hCG-stimulated conditions. Intratesticular administration of 0.025, 0.25, 2.5 or 25 mIU hCG resulted in a dose-dependent (3- to 14-fold) increase in testicular T concentrations in hCG compared to vehicle-injected testes. Systemic (i.p.) pre-treatment with 5 IU hCG 24 h before prevented any further increases in the already elevated (10-fold basal) T levels after direct intratesticular hCG injection. Pretreatment with 250 micrograms testosterone propionate (TP) reduced basal testicular T concentrations, but resulted in increased responsiveness to intratesticular hCG administration. In contrast, estradiol benzoate (EB) pretreatment, which also reduced basal testicular T concentrations, did not affect the testicular responsiveness to hCG. Hyperprolactinemia reduced testicular responsiveness to intratesticular administration of 0.025, 0.25 or 2.5 mIU hCG, but basal levels of testicular T were elevated. One hour after intratesticular injections of an aromatase inhibitor, 4-OHA; (0.25 micrograms) testis, T levels were increased in males pre-treated with 5 IU hCG (i.p.) 24 h earlier. Higher doses of 4-OHA (2.5, 25 or 250 micrograms) resulted in significant, dose-related increases in basal testicular T levels which were attenuated by hCG-pre-treatment. Intratesticular administration of 20 micrograms progesterone increased testicular T concentrations 2.7-fold, but this effect was attenuated (1.5-fold) in hCG-pre-treated mice, suggesting that enzymatic lesions beyond progesterone may be involved in hCG-induced testicular desensitization. These results indicate that testicular responsiveness to hCG depends on the existing levels of gonadotropic stimulation. However, it is evident that estrogens and prolactin also influence the sensitivity of the testis to gonadotropin.

The Japanese plasma cell dyscrasia syndrome: case report and theory of pathogenesis

A 54-year-old man developed pigmentation, clubbing, weight loss, oedema, hepatomegaly, lymphadenopathy, cold intolerance, hypotonia and hyporeflexia. Dominant laboratory findings were increased marrow plasma cells with IgA lambda paraproteinaemia, hypothyroidism, hyperprolactinaemia, hyperoestrogenaemia and biopsy-proven peripheral neuropathy. The clinical features and dramatic response to corticosteroids are consistent with the syndrome of plasma cell dyscrasia, polyneuropathy and endocrinopathy found predominantly in Japan. In our patient, immunofluorescence of neural tissues revealed paraprotein deposition. Although the pathogenesis is unknown, these multisystemic features may result from antibody activity or tissue deposition of paraprotein. Furthermore, the endocrinopathy may be localized at the hypothalamic level.

Effect of metoclopramide and lisuride on hypophyseal and gonadal function in men

The effects of chronic treatment over 7 weeks with metoclopramide and lisuride alone as well as the combination of both drugs were studied on basal and TRH/LHRH stimulated serum PRL, testosterone, LH, FSH, GH, and TSH concentrations. The study was conducted under double-blind placebo-controlled conditions and included twenty-four healthy male volunteers. In addition, repeated seminal fluid analyses were performed before, during and after treatment. While the known PRL-stimulatory effect of metoclopramide and the PRL-lowering effect of lisuride could be confirmed, we were unable to demonstrate any substance-related effects on the other hypophyseal or gonadal hormones. In contrast to previously published data no adverse effects of metoclopramide on sperm analysis could be demonstrated.

Endocrine profile in patients with chronic renal failure under zinc replacement

The plasma levels of androstenedione (A), testosterone (T), dihydrotestosterone (DHT), follicle stimulating hormone (FSH), luteinizing hormone (LH), and prolactin (PRL) were studied in 15 men (aged 24-50 years) with chronic renal failure under periodic peritoneal dialysis, before and after 50 mg of elemental zinc (Zn) orally, twice a day for three weeks. Before treatment, they were divided into three groups: group I, plasma A above normal and PRL less than 100 ng/ml; group II, low or normal A levels with PRL less than 100 ng/ml; and group III, normal or high A levels with PRL greater than 100 ng/ml. After oral Zn, plasma FSH, LH, and PRL were unchanged in all groups; however, in groups I and II plasma A was within normal T and DHT rose significantly, the A/(T+DHT) ratio decreased to normal, and the T/DHT ratio rose above normal. In group III plasma androgens remained low and androgen ratios were unchanged. Oral Zn seems to improve the conversion of A to T and also uncovered the possibility that plasma PRL levels greater than 100 ng/ml might cause a blockade in the 5 alfa-reductase.

Is testicular endocrine function abnormal in young men with spinal cord injuries?

Plasma concentrations of FSH, LH, testosterone and prolactin have been studied in seventeen men, aged 19 to 38 years, with traumatic paraplegia. Plasma testosterone, FSH and LH values were normal in all patients. The median LH concentration in patients was significantly higher (P less than 0.05) than in controls but there was no difference for FSH or testosterone. Plasma prolactin was high in five patients and the median prolactin concentration in patients was significantly greater (P less than 0.001) than in controls. It is concluded that there is no evidence of primary testicular failure in young paraplegics but it is possible that testicular hypofunction in some paraplegics may be related to increased prolactin production.

Male gonadal function in coeliac disease: 1. Sexual dysfunction, infertility, and semen quality

The prevalence of hypogonadism, sexual dysfunction and abnormalities of semen quality was determined in 28 consecutive males with coeliac disease. These observations were related to jejunal morphology and nutritional status, and were compared with findings in 19 men with Crohn's disease of similar age and nutritional status. Two of the 28 coeliacs (7%) had clinical evidence of hypogonadism but impotence and decreased sexual activity occurred more commonly, the latter apparently improving after gluten withdrawal. Of the married coeliacs, 19% had infertile marriages, a value greater than expected in the general population. Hypogonadism and sexual dysfunction were not detected in our patients with Crohn's disease. Seminal analysis in coeliacs revealed marked abnormalities of sperm morphology and motility, but only the former appeared to improve after gluten withdrawal. Similar abnormalities, however, were also detected in patients with Crohn's disease, although, unlike the coeliacs, 46% also had reduced concentrations of spermatozoa. Semen quality in coeliac disease could not be clearly related to general or specific (serum vitamin B(12) and red cell folate) nutritional deficiencies or to fertility, although sperm motility was markedly reduced in two of the three coeliacs with infertile marriages. The presence of antisperm antibodies did not appear to be an important aetiological factor in male infertility in coeliac disease. The pathogenesis of infertility and sexual dysfunction in coeliac disease remains unclear, suggesting that factors such as endocrine dysfunction or other specific nutritional deficiency may be involved.

Sexual dysfunction associated with oral antihypertensive medication: a critical survey of the literature

It is commonly held clinical belief that antihypertensive agents affect sexual performance. The authors survey the English language literature concerning oral antihypertensive agents and critically review studies examining sexual side effects. Surprisingly, few studies support much of the conventional clinical wisdom. Evidence is strong for the pathogenicity of guanethidine upon ejaculatory mechanisms. Contrary to expectation, strong evidence also exists for the ability of propranolol, especially in high doses, to inhibit erectile functioning. Only equivocal support was found for the pathogenicity of methyldopa, reserpine, and clonidine upon sexual functioning. The authors suggest that this may be in part due to underdeveloped methodology for assessing the sexual side effects of hypertensive medications. Suggestions are offered for future studies as well as for the clinical evaluation of sexual dysfunction in the hypertensive patient.

Bromocriptine in management of large pituitary tumours

Bromocriptine has an accepted place in the management of small pituitary tumours that secrete either prolactin or growth hormone. The treatment of large tumours with extrasellar extensions is more difficult, however: though surgery is the standard treatment, it is often unsuccessful in returning excessive hormone secretion to normal and may cause hypopituitarism. A prospective trial was undertaken to assess the frequency with which changes in pituitary function and size of large tumours occurs. Nineteen patients were studied before and during treatment with bromocriptine (7.5 to 60 ml/day) for three to 22 months, using contrast radiology and a detailed assessment of pituitary function. Eighteen patients had hyperprolactinaemia and two of these also had raised concentrations of growth hormones; one patient had an apparently non-functioning tumour. In 12 patients (63%) tumour size decreased with bromocriptine and no tumour enlarged. Nine patients had visual-field defects, which improved in seven, becoming normal in five. Pituitary function improved in nine patients (47%) becoming entirely normal in three. Bromocriptine should be the treatment of choice in patients with large pituitary tumours with extrasellar extensions, provided close supervision is maintained.

Circulating gonadotropin profile in severe cases of protein calorie malnutrition

The circulating levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH), and prolactin (PRL) were studied in children of both sexes between 2 and 14 years of age who were suffering from severe protein calorie malnutrition (PCM), namely, kwashiorkor, marasmic kwashiorkor, and marasmus. LH and FSH levels in all the age groups and in all forms of PCM were found to be significantly lowered, thereby explaining the possible delay in the onset of puberty in these children. Circulating PRL levels, on the other hand, were significantly raised in all patients with PCM studied, with values in children with kwashiorkor and marasmic kwashiorkor higher than in children with marasmus, possibly accounting for the presence of edema in the former cases. The present work, therefore, proposes a possible correlation between gonadotropin levels and PCM in children.

Hyperprolactinemia: histological and meiotic analyses in azoospermic men

High serum prolactin was detected in 15 out of 110 azoospermic men (13%). Patients underwent hormone assays, sellar radiography, and testicular biopsy (histological and meiotic analyses). Three patients, with most elevated serum prolactin level, had spermatogenic arrest. Nine patients showed no spermatogenic activity on histological and meiotic preparations. Three patients had normal and decreased spermatogenesis and normal meiotic divisions. The patients with spermatogenic arrest and with preserved spermatogenic process were treated with bromocriptine. Spermatogram in two patients with preserved spermatogenic process was ascertained to nearly normal range, after the treatment. There was no specific histologic or meiotic lesion in azoospermic men.

Hypothalamic-pituitary dysfunction in respiratory hypoxia

Eight hypoxic male patients with stable chronic obstructive airways disease were submitted for combined anterior pituitary function testing. All subjects showed normal growth hormone and essentially normal cortisol responses to adequate hypoglycaemia, two subjects showed delayed responses of thyroid stimulating hormone to administered thyrotrophin releasing hormone and all had basal prolactin levels within normal limits. Basal levels of luteinising hormone were significantly lower than in the group of age-matched controls (p less than 0.02) but there was a normal increment after the injection of gonadotrophin releasing hormone. Basal levels of follicle stimulating hormone were significantly lower than in the controls (p less than 0.01), and there was also a reduced response from the pituitary after injection of gonadotrophin releasing hormone (p less than 0.01). Resting levels of the thyroid hormones thyroxine and tri-iodothyronine were normal while the expected subnormal testosterone level was observed (p less than 0.05). These results show that hypoxia can produce abnormalities of hypothalamic-pituitary function and that these are primarily located in the hypothalamic-pituitary-testicular axis.

Hypothalamic-pituitary-testicular function in men with PRL-secreting tumors

We studied the hypothalamic-pituitary-gonadal system in 33 men with PRL-secreting tumors to determine at which level(s) high PRL levels interfere with testicular function. In basal conditions serum PRL levels ranged between 24-4500 ng/ml, serum LH and FSH concentrations were lower than normal in 61% and 39% of patients; low testosterone (T) levels and sexual impotence appeared more common (85% and 88%) than that we expected on the basis of gonadotropin deficiency. Mean T increase after hCG in 14 patients with prolactinomas was significantly less than in normals (3.3 +/- 0.7) ng/Ml vs 7.3 +/- 0.5 ng/ml; p less than 0.025); a significantly higher T response to hCG was obtained in 5 cases retested after PRL levels had been reduced by therapy. GnRH test induced a normal LH rise in 45% of patients, Mean serum LH increase after clomiphene administration did not differ from that in normals, though 4 out of 10 patients showed an impared response. Metoclopramide injection did not cause a rise of LH in 11 patients so tested. These data, while not excluding a central influence of PRL on LHRH, suggest that in men the antigonadotropic effects of PRL are mainly exerted at the gonadal levels.

Testicular function after renal transplantation

Gonadal function was assessed in seventeen adult male renal transplant recipients, with well established good homograft function, for a mean of 4.9 years. Patients were assessed clinically and by measurement of basal concentrations of FSH, LH, prolactin, testosterone and oestradiol, FSH and LH responses to bolus injections of LHRH and semen analysis. Retrospectively all had symptoms consistent with marked hypogonadism prior to transplantation but in nine out of sixteen this was reversed with transplantation. Residual hypogonadism was evident in seven of sixteen patients and correlated with duration of haemodialysis longer than 1 year (P less than 0.01). Even among patients with clinically normal gonadal function, defects in the hypothalamic--pituitary--testicular axis remained. Elevated basal serum FSH, excessive FSH responses to LHRH and lowered basal serum testosterone were found. In the group with residual hypogonadism more marked changes, including elevated basal LH and excessive LH responses to LHRH, were also found. Fertility was recorded in two men on three occasions since transplantation. Sperm counts were normal in five and abnormal in four patients. Testicular volume and sperm density were inversely correlated with basal and stimulated FSH and LH levels.