Myasthenia gravis, premature menopause, and thyroid autoimmunity

Antiovarian antibodies in primary Sjogren's syndrome

Our study aimed at screening patients with primary Sjogren's syndrome (pSs) for the presence of antiovarian antibodies (AOAs). Detection of AOAs in patients' sera was achieved by ELISA, using bovine ovarian extract for coating. Western blot analysis and immunohistochemistry were used to characterize the antibody targets in the extract and to determine their locus on the bovine ovary, respectively. Specific AOAs were detected in 27% of 37 patients (two with premature menopause) and in none of the controls. Immunoreactivity mainly resided in five proteins of the extract with molecular masses 42, 49, 55, 64 and 72 kDa, and it might be attributed to their carbohydrate components. The antibody targets were mainly located in the granulosa and theca interna cells of the follicle, and in the endothelial cells and fibroblasts of corpus luteum. The detection, for the first time, of AOAs in a significant percentage of patients with pSs may suggest autoimmune oophoritis, clinical or subclinical.

Alpha-enolase: a novel autoantigen in patients with premature ovarian failure

OBJECTIVE

Although controversial, the presence of circulating antiovarian antibodies (AOA) may be considered a marker of autoimmune premature ovarian failure (POF). The purpose of the present work was to evaluate the presence of AOA in POF patients, and to identify a possible autoantigen in order to develop a reliable diagnostic tool that might help to determine the real prevalence of autoimmune POF.

DESIGN

Non-randomised study. Blood sampling for determination of circulating AOA.

PATIENTS

One hundred and ten patients with POF and 60 normally menstruating women with no record of autoimmune diseases (controls).

MEASUREMENTS

Presence of circulating AOA was assessed by Western-blot, using cytosolic fraction from human ovarian homogenate as antigen.

RESULTS

Twenty-one of 110 women with POF presented circulating antibodies directed toward an antigen of approximately 50 kD. Sixty control subjects proved negative. After purification and analysis by mass spectrometry, the antigen was identified as alpha-enolase.

CONCLUSION

Determination of the presence of circulating antialpha-enolase antibodies might be instrumental in identifying those patients who may present a putative defect in immunoregulation and therefore a possible autoimmune aetiolgy for POF.

Myasthenia gravis and premature ovarian failure

We describe a patient who developed seropositive myasthenia gravis 16 years after she was diagnosed with autoimmune premature ovarian failure with antibodies to the receptor for follicle-stimulating hormone (FSH). Although thymectomy led to improvement of her myasthenic symptoms, menses did not resume. Such combined seropositivity for antibodies to acetylcholine and ovarian hormone receptors in a patient with myasthenia gravis and premature ovarian failure may reflect common disease mechanisms, although the precise pathogenesis of these disorders remains ill-defined.

Sisters of women with premature ovarian failure may not be ideal ovum donors

OBJECTIVES

To determine whether the sisters of women with premature ovarian failure (POF) showed a response to gonadotropin stimulation comparable to that of anonymous ovum donors.

DESIGN

Historical cohort study.

SETTING

Records of 228 consecutive ovum recipients in an academic assisted reproductive technology program.

PATIENT(S)

Criteria for inclusion were oocyte recipients age < or = 40 years, FSH > 18 mIU/mL (conversion factor to SI unit, 1.00), and/or failure to respond appropriately to controlled ovarian hyperstimulation (COH). Seventy-nine recipients were classified on the basis of whether they received oocytes from anonymous donors (group I, n = 66) or sister donors (group II, n = 13).

MAIN OUTCOME MEASURE(S)

Controlled ovarian hyperstimulation response, pregnancy rates (PRs), and implantation rates.

RESULT(S)

The ages of the donors to groups I and II were comparable (31.1 +/- 16.7 versus 29.8 +/- 7.2 years), but those in group II exhibited a higher baseline FSH level (12.8 +/- 2.1 versus 8.6 +/- 5.8 mIU/mL). Group II versus I had a relative risk of 5.1 for cancellation (4 of 13 [30.8%] versus 4 of 66 [6.1%], respectively). In completed cycles of groups I and II, respectively, there was no difference in serum E2 on the day of hCG administration (2,356 +/- 826 versus 1,847 +/- 843 pg/mL; conversion factor to SI unit, 3,671), number of oocytes retrieved (25 +/- 14 versus 22 +/- 13), number of embryos transferred (4.4 +/- 2.1 versus 4.0 +/- 1.0), spontaneous abortion rate (22.7% versus 25.0%), PR (35.5% versus 36.4%), and implantation rate (16.2% versus 16.4%).

CONCLUSION(S)

There is an increased cancellation rate and, consequently, an overall trend toward decreased ovarian response to gonadotropin stimulation in the sisters of patients with POF. Despite these factors, the implantation rates and PRs of embryos derived from patients reaching retrieval were similar to those from anonymous donors. We recommend counseling women with POF that their sisters may not be ideal ovum donors.

Premature ovarian failure and ovarian autoimmunity

Premature ovarian failure (POF) is defined as a syndrome characterized by menopause before the age of 40 yr. The patients suffer from anovulation and hypoestrogenism. Approximately 1% of women will experience menopause before the age of 40 yr. POF is a heterogeneous disorder with a multicausal pathogenesis involving chromosomal, genetic, enzymatic, infectious, and iatrogenic causes. There remains, however, a group of POF patients without a known etiology, the so-called "idiopathic" form. An autoimmune etiology is hypothesized for the POF cases with a concomitant Addison's disease and/or oöphoritis. It is concluded in this review that POF in association with adrenal autoimmunity and/or Addison's disease (2-10% of the idiopathic POF patients) is indeed an autoimmune disease. The following evidence warrants this view: 1) The presence of autoantibodies to steroid-producing cells in these patients; 2) The characterization of shared autoantigens between adrenal and ovarian steroid-producing cells; 3) The histological picture of the ovaries of such cases (lymphoplasmacellular infiltrate around steroid-producing cells); 4) The existence of various autoimmune animal models for this syndrome, which underlines the autoimmune nature of the disease. There is some circumstantial evidence for an autoimmune pathogenesis in idiopathic POF patients in the absence of adrenal autoimmunity or Addison's disease. Arguments in support of this are: 1) The presence of cellular immune abnormalities in this POF patient group reminiscent of endocrine autoimmune diseases such as IDDM, Graves' disease, and Addison's disease; 2) The more than normal association with IDDM and myasthenia gravis. Data on the presence of various ovarian autoantibodies and anti-receptor antibodies in these patients are, however, inconclusive and need further evaluation. A strong argument against an autoimmune pathogenesis of POF in these patients is the nearly absent histological confirmation (the presence of an oöphoritis) in these cases (< 3%). However, in animal models using ZP immunization, similar follicular depletion and fibrosis (as in the POF women) can be detected. Accepting the concept that POF is a heterogenous disorder in which some of the idiopathic forms are based on an abnormal self-recognition by the immune system will lead to new approaches in the treatment of infertility of these patients. There are already a few reports on a successful ovulation-inducing treatment of selected POF patients (those with other autoimmune phenomena) with immunomodulating therapies, such as high dosages of corticosteroids (288-292).

Determination of the steroidogenic capacity in premature ovarian failure

OBJECTIVE

To determine the secretion of precursors, intermediate and final products of androgen biosynthesis in women with premature ovarian failure (POF).

PATIENTS

Seven patients 20 to 34 years of age with idiopathic POF and a control group of six women 27 to 29 years of age with normal ovarian function studied during the early follicular phase were included. DESIGN, INTERVENTIONS: In all patients an adrenal stimulation test was performed as follows: a short dexamethasone (DEX) inhibition was carried out the night before the corticotropin (ACTH, 0.25 mg, Cortrosyn; Organon, Orangeburg, NY) stimulation test, obtaining blood samples in basal conditions, post-DEX inhibition as well as at 60, 120, and 180 minutes after the ACTH bolus.

MAIN OUTCOME MEASURES

Using specific RIA serum concentrations of delta 5 precursors (pregnenolone, 17-hydroxypregnenolone, DHEA), delta 4 intermediates (P, 17-hydroxyprogesterone, androstenedione) and the final products T and cortisol (F) were measured.

RESULTS

Adrenal inhibition and stimulation responses in both groups of patients showed no differences for delta 5 precursors and F. On the other hand, delta 4 intermediates and androgens exhibited significant differences at the level of response to ACTH stimulation. Patients with POF had significantly lower values than those of control group.

CONCLUSION

An important decrement in the steroidogenesis was noticed in POF, particularly in androgen synthesis, revealing the selective participation of the adrenal gland in steroid production.

Interspecies-specific ovarian autoantigens involved in neonatal thymectomy-induced murine autoimmune oophoritis

PROBLEM

Thymectomy of mice on day 3 after birth (3d-Tx) gives rise to the appearance of a particular type of ovarian lesion known as experimental autoimmune oophoritis (AIO).

METHOD

In the present study, the spleen cells from BALB/c mice having undergone 3 day-Tx AIO were fused with X63-Ag8-6.5.3 myeloma cells, and a number of hybridoma clones producing autoantibodies against ovarian tissue were established.

RESULTS

On the basis of immunohistochemical and protein-chemical analysis, two independent clones, designated at T2.2 and S1.6, were found to react with interstitial tissues surrounding the follicles. These monoclonal antibodies showed broad cross-species reactivity, in that they recognized similar antigenic macromolecules in the rat, pig, human, and mouse. The antigenic determinants were strongly resistant to heat and acid, especially to the treatment of periodic acid, indicating that the antigenic determinants had no relation with carbohydrate components.

CONCLUSIONS

By antibody affinity chromatography, two kinds of autoantigens were identified. SDS-PAGE, under reduced or nonreduced conditions, revealed an 80/85 kDa protein for T2.2, and an 82 kDa for S1.6, respectively.

Premature ovarian failure. I: The association with autoimmunity

Twenty-four patients were investigated for non-organ-specific and organ-specific autoantibodies (Aab) in order to establish a relationship between premature ovarian failure (POF) and autosensitization. Regarding the non-organ-specific Aab, prevalences of clearly raised ANA (42%), nDNA Ab (25%), rheumatoid factors (41%) and smooth muscle Aab (53%) were found in the POF patients. Less outspoken higher prevalences of organ-specific Aab in these patients were also found: parietal cell Aab (23%), islet of Langerhans Aab (20%). Fifteen percent of the patients showed Aab to the adrenal gland, and a single patient had Aab towards the steroid-producing cells (Stpc) of the ovary. Although no single immune parameter could be clearly identified to correlate with POF, autoimmune (AI) phenomena were detected in the majority of the patients (92%). Since AI disease could be present for a considerable time without any clinical symptoms, a further immunological screening and follow up of POF patients may enable us to better understand and manage these patients.

Implications of circulating autoantibodies and peripheral blood lymphocyte subsets for the genesis of premature ovarian failure

Several kinds of circulating autoantibodies and peripheral blood lymphocyte subsets were studied in 20 patients with secondary amenorrhea manifesting hormonal and clinical features of premature ovarian failure (POF). More than one kind of autoantibody was detected in 14 patients (70%). Seven patients (35%) had anti-thyroglobulin antibody, 6 (30%) had anti-parietal cell antibody, 8 (40%) had anti-nuclear antibody, and one patient with chronic thyroiditis had anti-TSH receptor antibody. Anti-adrenal cortex antibody and RA test were negative in all patients. Two patients had clinically evident autoimmune disease; one had myasthenia gravis and the other had chronic thyroiditis. Examination of peripheral blood lymphocyte subsets of 19 patients by flow cytometry revealed an increase in the percentage of OKT3+ cells and OKT4+ cells and a decrease in OKT8+ cells in POF patients compared with age-matched controls, but these differences were not significant. An increase in the OKT4/OKT8 ratio was, however, significant. It has been suggested that an autoimmune mechanism may participate in the genesis of POF, at least in patients with autoimmune diseases; however, the findings in this study support the hypothesis that some pure POF may also be caused by an autoimmune process resulting from a subclinical imbalance in the immunoregulatory system before manifestation of the autoimmune disease.

Immunological disturbances in patients with premature ovarian failure

Eighteen patients with postmenopausal gonadotrophin levels and secondary amenorrhoea before the age of 35 years (premature ovarian failure, POF) were examined for the presence of cellular and humoral immune defects. Six patients had an abnormally low natural killer (NK) cell activity. The levels of circulating immune complexes were increased in six patients. Tissue antibodies were detected in six patients and two of these possessed ovarian antibodies. Leukocyte migration inhibition in the presence of ovarian antigen was slightly enhanced in three patients. Altogether 12 patients (66%) with POF had some immunological defect or defects suggesting that immune mechanisms are often involved in the aetiology of POF.

Endocrine and immunologic studies in a patient with resistant ovary syndrome

A patient with the resistant ovary syndrome is reported. To evaluate the hypothesis that the hypogonadism might be the result of circulating antibodies to gonadotropin receptors or to an abnormal gonadotropin molecule, a series of clinical and laboratory studies was carried out. Administration of human menopausal gonadotropin had no effect on the serum estradiol level. The patient's serum did not affect follicle-stimulating hormone binding to a membrane preparation of monkey testes, suggesting the absence of antibodies to follicle-stimulating hormone receptors, nor did the patient's serum affect in vitro responsiveness of human granulosa cells to human menopausal gonadotropin. Unresponsiveness to exogenous gonadotropins, combined with anatomically normal follicular apparatus and the absence of serum antibodies to gonadotropin receptors, supports the concept of a gonadotropin receptor or a postreceptor defect.

[Thyroid diseases and myasthenia gravis]

In a group of 304 myasthenic patients 15 cases with thyropathies were reported: nine with hyperthyroidism, one with hypothyroidism and five with nontoxic goiter. Four patients presented diffuse simple goiter and one a multinodular goiter with normal thyroid function. No patient came from an endemic goiter region, not even familial goiter. The prevalence and influence of hyperthyroidism on myasthenic symptomatology were studied. Our findings suggest that there is no clinical correlation between both myasthenia symptomatology and thyroid dysfunction, neither significant influence on myasthenic symptoms when the endocrine disorders improve.

The prevalence of autoimmune disorders among patients with primary ovarian failure

Eighty-one patients who had a diagnosis of primary ovarian failure were studied to determine its possible association with autoimmune disorders. All 81 patients displayed 46,XX chromosome complements. On ovarian biopsy, either few or no follicles were demonstrated in 79 patients, and, in two patients, primordial follicles were more abundant. The two patients with a large number of primordial follicles had normal function of other endocrine organs; however, 15 of the 79 patients demonstrating few or no ovarian follicles had associated failure of other endocrine glands, and one patient had myasthenia gravis. Thirteen of these 15 patients sought treatment because of secondary amenorrhea, the age at onset ranging from 11 to 34 years. Of the 81 patients, 11 had primary amenorrhea and 70 had secondary amenorrhea. Among the 79 patients with few or no ovarian follicles, endocrine glandular failure, in addition to ovarian failure, was found in two patients with primary amenorrhea and in 13 patients with secondary amenorrhea. The association of polyglandular failure syndrome and primary ovarian failure, along with demonstration of a lymphocytic infiltrate in ovaries and circulating antibodies in sera of women with premature ovarian failure, suggests that an autoimmune mechanism may be a cause of primary ovarian failure in some cases.

Anti-ovarian and anti-lymphocyte antibodies in patients with chronic vaginal candidiasis

Seventeen of 30 patients with chronic vaginal candidiasis (CVC) of at least 5 years duration had varying degrees of menstrual problems and defective T lymphocyte function; 8 developed amenorrhea. In a group of 40 CVC patients, titers of autoantibodies to ovary, thymocytes, a T-cell line (CCRF-CEM), and a B-cell line (RN114) were significantly higher than those in 45 normal females (69 +/- 3 vs. 5 +/- 2, 70 +/- 27 vs. 4 +/- 2, l7 +/- 6, vs. 4 +/ 2, and 73 +/- 24 vs. 8 +/- 5, respectively, mean +/- S.E.). Antibody titers to sperm, T-cell line HSB-2, and B-cell lines RAJI and BALL-1 were within the normal range. Significant correlations were found between anti-Candida, anti-ovarian, and anti-thymocyte antibody titers. Similar results were found for 6 patients with chronic mucocutaneous candidiasis (CMCC) and in serial samples obtained over a one-year period from a representative patient with both CVC and CMCC. The anti-T-lymphocyte antibodies in these patients were directed primarily against non-suppressor (predominately helper) T cells. Absorption of the sera with either Candida cells, ovarian follicle cells, or thymocytes reduced all three antibody titers; absorption with sperm or B-cell lines did not alter the titers. These results suggest the presence of one or more cross-reactive antigens on ovarian follicle, T lymphocytes (especially the helper cell subpopulation), and Candida.