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Ntali G, Capatina C. Updating the Landscape for Functioning Gonadotroph Tumors. Medicina (B Aires) 2022; 58:medicina58081071. [PMID: 36013538 PMCID: PMC9414558 DOI: 10.3390/medicina58081071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 08/03/2022] [Accepted: 08/04/2022] [Indexed: 11/16/2022] Open
Abstract
Functioning gonadotroph adenomas (FGAs) are rare tumors, as the overwhelming majority of gonadotroph tumors are clinically silent. Literature is based on case reports and small case series. Gonadotroph tumors are poorly differentiated and produce and secrete hormones inefficiently, but in exceptional cases, they cause clinical syndromes due to hypersecretion of intact gonadotropins. The clinical spectrum of endocrine dysfunction includes an exaggerated response of ovaries characterized as ovarian hyperstimulation syndrome (OHSS) in premenopausal females and adolescent girls, testicular enlargement in males, and isosexual precocious puberty in children. Transsphenoidal surgery and removal of tumor reduces hormonal hypersecretion, improves endocrine dysfunction, and provides tissue for further analysis. Medical therapies (somatostatin analogues, dopamine agonists, GnRH agonists/antagonists) are partially or totally ineffective in many cases, especially with respect to antitumor effect. This review aims to update recent literature on these rare functioning tumors and highlight their therapeutic management.
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Affiliation(s)
- Georgia Ntali
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, 10676 Athens, Greece
- Correspondence:
| | - Cristina Capatina
- Department of Endocrinology, Carol Davila UMPh, 011863 Bucharest, Romania
- Department of Pituitary and Neuroendocrine diseases, CI Parhon National Institute of Endocrinology, 011863 Bucharest, Romania
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Wang L, Liang H, Deng C, Yu Q, Gong F, Feng F, You H, Liang Z, Chen B, Deng K, Ma J, Wang R, Yao Y, Zhu H. Functioning gonadotroph adenomas in premenopausal women: clinical and molecular characterization and review of the literature. Pituitary 2022; 25:454-467. [PMID: 35138520 DOI: 10.1007/s11102-021-01205-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/27/2021] [Indexed: 12/26/2022]
Abstract
PURPOSE To summary the clinical features of premenopausal women with functioning gonadotroph adenomas (FGAs) and preliminarily explore their molecular characterization. METHODS 12 premenopausal females with FGAs in our center were retrospectively analyzed. Previously reported cases were also summarized. The patients were clinically divided into FSH- or LH-predominant types according to their preoperative serum FSH/LH ratio. The expressions of related genes in the tumor tissues of female FGAs, non-functioning gonadotroph adenomas (NFGAs), and silent corticotropin adenomas were evaluated by RT-qPCR. RESULTS Of all the 12 patients with FGAs from our center, 11 (91.7%) were diagnosed as FSH-predominant type, and they all had menstrual disorders, including 9 with spontaneous ovarian hyperstimulation syndrome (sOHSS). Their hormonal profiles showed non-suppressed FSH (12.45 ± 7.34 IU/L) with hyperestrogenemia [median estradiol level 1353.0 pg/mL (636.0, 3535.0)]. The other patient (8.3%) with LH-predominant type mainly manifested with infertility and sustained elevated serum LH without FSH or estradiol increasing. 65 premenopausal FGAs patients were systematic reviewed. 60 patients (92.3%) were FSH-predominant type, including 86.7% presented with menstrual disorders, 16.7% reported infertility, and 98.2% (55/56) showed sOHSS. No sOHSS or hyperestrogenemia were found in the 5 patients (7.7%) with LH-predominant type. Pituitary imaging data revealed macroadenomas and microadenomas accounted for 89.2% and 10.8%, respectively. Of 63 patients (96.9%) who underwent pituitary adenoma resection, 77.8% had complete tumor resection and no recurrence at the last follow-up. The relative expressions of KISS1 mRNA were significantly higher in FGA group than in NFGA group (p = 0.018), and significantly positively correlated with the preoperative serum estradiol levels (p = 0.004). CONCLUSIONS Different clinical features were observed in premenopausal women with FGAs of FSH- or LH-predominant types. The elevated KISS1 expression in tumor tissues might involve in the secretion function of FGAs.
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Affiliation(s)
- Linjie Wang
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, 1# Shuai Fu Yuan, Dong Dan, Beijing, 100730, China
| | - Hanting Liang
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, 1# Shuai Fu Yuan, Dong Dan, Beijing, 100730, China
| | - Chengyan Deng
- Reproductive Center, Department of Obstetrics and Gynaecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Qi Yu
- Reproductive Center, Department of Obstetrics and Gynaecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Fengying Gong
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, 1# Shuai Fu Yuan, Dong Dan, Beijing, 100730, China
| | - Feng Feng
- Department of Radiology, Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, PekingBeijing, China
| | - Hui You
- Department of Radiology, Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, PekingBeijing, China
| | - Zhiyong Liang
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Bo Chen
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Kan Deng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jin Ma
- Department of Ophthalmology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, 1# Shuai Fu Yuan, Dong Dan, Beijing, 100730, China
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yong Yao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.
| | - Huijuan Zhu
- Department of Endocrinology, Key Laboratory of Endocrinology of National Health Commission, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, 1# Shuai Fu Yuan, Dong Dan, Beijing, 100730, China.
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Gonadotroph Pituitary Adenoma Causing Treatable Infertility and Ovarian Hyperstimulation Syndrome in Female Patients: Neurosurgical, Endocrinologic, Gynecologic, and Reproductive Outcomes. World Neurosurg 2021; 150:e162-e175. [PMID: 33684575 DOI: 10.1016/j.wneu.2021.02.115] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 02/22/2021] [Accepted: 02/26/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Gonadotroph pituitary adenoma (Gn-PA) may rarely cause ovarian hyperstimulation syndrome, leading to infertility in women, although this remains poorly described. METHODS We present a quantitative systematic review including 2 patients from our institutional and 48 from the literature with Gn-PA causing ovarian hyperstimulation syndrome to thoroughly describe the clinical features and therapeutic outcomes from multidisciplinary aspects. RESULTS The patients had a mean age of 31.5 years and a mean follicle-stimulating hormone level of 14.4 IU/L. Estradiol level was high in 82% of patients, at >350 pg/mL. The mean maximal adenoma diameter was 22 mm, with a Knosp grade ≥3 in 10 patients. Abdominal surgery preceded adenoma resection in 24 patients (48%). Among 25 patients for whom extent of resection was recorded, total adenoma resection was achieved in 12. Through a mean follow-up of 25 months, adenoma recurrence was observed in 5 patients, who were treated with re-resection (n = 2), radiation (n = 2), and medical therapy followed by bilateral oophorectomy (n = 1). Medical therapies were partially effective or ineffective, and adenoma shrinkage did not follow; gonadotropin-releasing hormone agonists/antagonists were partially effective in 20% of patients (2/10), dopamine agonists in 44% (8/18), and somatostatin analogues in 50% (1/2). Four experienced swelling of tumor/ovaries after gonadotropin-releasing hormone agonists/antagonists administration. Overall, chemical remission was obtained in 26 of 28 patients, normalization of ovaries in 25 of 27, and successful pregnancy in 12 of 14. CONCLUSIONS Adenoma resection is the main treatment, leading to reduction in ovarian size and biochemical remission, with a high likelihood of subsequent spontaneous pregnancy. Increased awareness of this rare condition may help avoid unnecessary abdominal procedures.
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Du X, Zhang W, Wang X, Yu X, Li Z, Guan Y. Follicle-Stimulating Hormone-Secreting Pituitary Adenoma Inducing Spontaneous Ovarian Hyperstimulation Syndrome, Treatment Using In Vitro Fertilization and Embryo Transfer: A Case Report. Front Endocrinol (Lausanne) 2021; 12:621456. [PMID: 34248835 PMCID: PMC8264655 DOI: 10.3389/fendo.2021.621456] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 05/18/2021] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE To describe the management of a patient with a pituitary adenoma secreting follicle-stimulating hormone (FSH) associated with spontaneous ovarian hyperstimulation syndrome (sOHSS) who was treated with in vitro fertilization and embryo transfer (IVF-ET). METHODS We report a clinical case of a woman of reproductive age with menstrual irregularity, infertility and ovarian hyperstimulation due to recurrent pituitary adenoma secreting FSH, which persisted after transsphenoidal surgery.She underwent the diagnosis by magnetic resonance imaging (MRI) and laboratory tests,and finally she was treated with IVF-ET. RESULTS The patient was plagued by a recurrent pituitary adenoma for many years and tried various treatments. After complete transsphenoidal surgery, sOHSS decreased, as shown by a reduction in oestradiol levels and an improvement in the ultrasonography parameters; however, secondary amenorrhea occurred. Finally, pregnancy was achieved through IVF-ET and the symptoms of ovarian hyperstimulation were relieved. CONCLUSIONS IVF-ET was found to be effective for the treatment of recurrent pituitary adenoma, thus representing a therapeutic option that should be taken into consideration in such cases.
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Follicle Cysts of the Ovary: A Report of 30 Cases of a Common Benign Lesion Emphasizing its Unusual Clinical and Pathologic Aspects. Int J Gynecol Pathol 2020; 40:359-368. [PMID: 33075022 DOI: 10.1097/pgp.0000000000000720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The common ovarian follicle cyst is typically straightforward from both clinical and pathologic perspectives, but may have a variety of unusual features from both aspects at various stages of life. Lack of familiarity with these may lead to diagnostic quandaries, the most common of which is distinguishing between a follicle cyst and cystic granulosa cell tumor of either adult or juvenile type. We reviewed 30 cases of follicle cysts, all sent in consultation, to highlight unusual aspects of a common lesion. Patients ranged from 3 d to 47 yr old. Clinical presentations included precocious puberty, pelvic pain, or an incidentally discovered pelvic mass, including those occurring in neonates and in 2 adults with pituitary adenomas, one of which was diagnosed 3 yr after presentation with the ovarian cyst. Size ranged from 0.5 cm (deflated) to 18.5 cm, with 7 exceeding 8 cm in greatest dimension. Twelve cases demonstrated small satellite cystic follicles in the wall of the dominant cyst. The granulosa cell layer varied in thickness and mitotic activity (which ranged from 1 to 36 per 10 HPF), but uniformly displayed round nuclei that lacked nuclear grooves. Luteinization of the granulosa cell layer, theca layer, or both was seen across all clinical scenarios, with unluteinized cysts being most common in precocious puberty patients. This series documents that although typically smaller, a subset of follicle cysts are the same size as cystic granulosa cell tumors and the 2 entities may be grossly indistinguishable. Helpful clues to the diagnosis of follicle cyst are the lack of nuclear grooves (vs. adult granulosa cell tumor) and lack of invagination of granulosa cells into the cyst wall (vs. both forms of granulosa cell tumor). Mitoses in the granulosa cells are of no aid in the differential with either form of granulosa cell tumor as follicle cysts may exhibit brisk mitotic activity. Our series highlights some of the unusual clinical aspects, one relatively well known-an association with isosexual precocity, but 2 not as widely known, those occurring in neonates and those due to a pituitary adenoma, the latter sometimes not being discovered until a few years after presentation with a follicle cyst.
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Multiple Luteinized Follicle Cysts of the Ovary in a Patient With a Pituitary Adenoma. Int J Gynecol Pathol 2019; 38:562-567. [DOI: 10.1097/pgp.0000000000000555] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hirano M, Wada-Hiraike O, Miyamamoto Y, Yamada S, Fujii T, Osuga Y. A case of functioning gonadotroph adenoma in a reproductive aged woman. Endocr J 2019; 66:653-656. [PMID: 31006723 DOI: 10.1507/endocrj.ej19-0066] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
A 34-year-old woman presented our hospital with complaint of irregular menstruation and abnormal uterine bleeding lasting for a month. After her second parturition at the age of 27, her menstrual cycle had been regular, but it suddenly became irregular at the age of 30. Transvaginal ultrasound revealed the presence of ovarian mass, and the patient underwent diagnostic laparoscopic surgery. Bilateral ovaries temporally shrink after puncture but the size soon resumed. Gonadotropins were almost normal, but estradiol and PRL levels turned out to be elevated, and cabergoline treatment was initiated. After referral to our hospital, we found that the ovaries showed multifollicular appearance. Brain magnetic resonance imaging showed an 18-mm macroadenoma in the suprasellar area. To suppress the secretion of endogenous gonadotropins and estrogen, low-dose estrogen-progestin was prescribed. Surprisingly, the treatment temporarily reduced the size of the ovaries. The patient was referred to a neurosurgeon, and a functioning gonadotroph adenoma was suspected. After the resection of the pituitary tumor, her menstrual cycle became regular, and the size of bilateral ovaries became normal. We also noticed that her ovarian reserve judged by anti-Müllerian hormone had been almost diminished after the surgical treatment, probably reflecting the exhaustion of follicular pool. Women with multifollicular ovaries and elevated estradiol levels may have functioning gonadotroph adenomas, although the level of FSH is relatively normal, and ovarian reserve can be followed by measuring anti-Müllerian hormone.
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Affiliation(s)
- Mana Hirano
- Department of Obstetrics and Gynecology, The University of Tokyo Hospital, Tokyo 1138655, Japan
| | - Osamu Wada-Hiraike
- Department of Obstetrics and Gynecology, The University of Tokyo Hospital, Tokyo 1138655, Japan
| | - Yuichiro Miyamamoto
- Department of Obstetrics and Gynecology, The University of Tokyo Hospital, Tokyo 1138655, Japan
| | - Shozo Yamada
- Department of Pituitary and Hypothalamic Surgery, Toranomon Hospital, Tokyo 1058470, Japan
| | - Tomoyuki Fujii
- Department of Obstetrics and Gynecology, The University of Tokyo Hospital, Tokyo 1138655, Japan
| | - Yutaka Osuga
- Department of Obstetrics and Gynecology, The University of Tokyo Hospital, Tokyo 1138655, Japan
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Graillon T, Castinetti F, Chabert-Orsini V, Morange I, Cuny T, Albarel F, Brue T, Dufour H. Functioning gonadotroph adenoma with severe ovarian hyperstimulation syndrome: A new emergency in pituitary adenoma surgery? Surgical considerations and literature review. ANNALES D'ENDOCRINOLOGIE 2019; 80:122-127. [DOI: 10.1016/j.ando.2018.11.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/27/2018] [Accepted: 11/10/2018] [Indexed: 10/27/2022]
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Caretto A, Lanzi R, Piani C, Molgora M, Mortini P, Losa M. Ovarian hyperstimulation syndrome due to follicle-stimulating hormone-secreting pituitary adenomas. Pituitary 2017; 20:553-560. [PMID: 28676954 DOI: 10.1007/s11102-017-0817-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE Gonadotroph adenomas are pituitary adenomas with inefficient and variable secretory characteristics, that is why they are usually considered as a subgroup of nonfunctioning pituitary adenomas (NFPA) and are recognized only at immunohistochemistry. When gonadotroph adenomas secrete active hormones, they may cause spontaneous ovarian hyperstimulation syndrome (OHSS) in premenopausal women. Aim of our study is to describe three women with OHSS diagnosed before the removal of the adenoma and to calculate the prevalence of OHSS in premenopausal women with a clinical diagnosis of NFPA. METHODS We reviewed clinical records of premenopausal women that underwent neurosurgery for NFPA at our centre between 1993 and 2014. OHSS was diagnosed in patients with high levels of FSH, suppressed LH, hyperestrogenism, abdominal symptoms, polymenorrhea, enlarged ovaries with cysts or previous surgery for ovarian cysts. RESULTS 171 women were included into the study; 62 (36.6%) had a gonadotroph adenoma diagnosed at immunohistochemistry. Two patients were retrospectively diagnosed as having OHSS due to gonadotroph adenoma and three had OHSS diagnosed before neurosurgery. The prevalence of OHSS was 2.9% in the overall group of patients with NFPA and 8.1% among patients with a gonadotroph adenoma detected at immunohistochemistry. CONCLUSIONS Frequency of OHSS due to a gonadotroph adenoma is not negligible. Increased awareness of the characteristic clinical and hormonal picture should permit an early detection of this condition in premenopausal women with a pituitary adenoma.
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Affiliation(s)
- Amelia Caretto
- Department of Endocrinology and Metabolic Disease, Istituto Scientifico San Raffaele, Università Vita-Salute, via Olgettina 60, 20132, Milano, Italy
| | - Roberto Lanzi
- Department of Endocrinology and Metabolic Disease, Istituto Scientifico San Raffaele, Università Vita-Salute, via Olgettina 60, 20132, Milano, Italy
| | - Cecilia Piani
- Department of Endocrinology and Metabolic Disease, Istituto Scientifico San Raffaele, Università Vita-Salute, via Olgettina 60, 20132, Milano, Italy
| | - Michela Molgora
- Department of Obestetrics and Gynecology, Istituto Scientifico San Raffaele, Università Vita-Salute, via Olgettina 60, 20132, Milano, Italy
| | - Pietro Mortini
- Department of Neurosurgery, Istituto Scientifico San Raffaele, Università Vita-Salute, via Olgettina 60, 20132, Milano, Italy
| | - Marco Losa
- Department of Neurosurgery, Istituto Scientifico San Raffaele, Università Vita-Salute, via Olgettina 60, 20132, Milano, Italy.
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Oueslati I, Khiari K, Abdallah NB. Spontaneous ovarian hyperstimulation syndrome revealing a pituitary macroadenoma. Indian J Endocrinol Metab 2016; 20:734-735. [PMID: 27730091 PMCID: PMC5040061 DOI: 10.4103/2230-8210.190566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- Ibtissem Oueslati
- Department of Endocrinology, Faculty of Medicine, University of Tunis El Manar, 1007, Tunis, Tunisia
- Department of Endocrinology, Charles Nicolle Hospital, Tunis, Tunisia
| | - Karima Khiari
- Department of Endocrinology, Faculty of Medicine, University of Tunis El Manar, 1007, Tunis, Tunisia
- Department of Endocrinology, Charles Nicolle Hospital, Tunis, Tunisia
| | - Néjib Ben Abdallah
- Department of Endocrinology, Faculty of Medicine, University of Tunis El Manar, 1007, Tunis, Tunisia
- Department of Endocrinology, Charles Nicolle Hospital, Tunis, Tunisia
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Mana DL, Belingeri MS, Manavela M, Guaita S, Danilowicz K, Bruno OD, Cazado EC. FSH-Producing Pituitary Macroadenoma: Report of 2 Cases with Clinical Manifestations of Hormone Excess. AACE Clin Case Rep 2016. [DOI: 10.4158/ep15615.cr] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Raverot G, Assié G, Cotton F, Cogne M, Boulin A, Dherbomez M, Bonneville JF, Massart C. Biological and radiological exploration and management of non-functioning pituitary adenoma. ANNALES D'ENDOCRINOLOGIE 2015; 76:201-9. [DOI: 10.1016/j.ando.2015.04.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 04/29/2015] [Indexed: 11/29/2022]
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Halupczok J, Bidzińska-Speichert B, Lenarcik-Kabza A, Zieliński G, Filus A, Maksymowicz M. Gonadotroph adenoma causing ovarian hyperstimulation syndrome in a premenopausal woman. Gynecol Endocrinol 2014; 30:774-7. [PMID: 24971660 DOI: 10.3109/09513590.2014.934668] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Gonadotroph adenomas occur commonly in middle-aged adults without any specific endocrinological symptoms. To date, only 30 cases of gonadotropinoma causing ovarian hyperstimulation syndrome in pre-menopausal women have been reported. CASE REPORT A 37-year old woman with pituitary macroadenoma and hyperprolactinaemia was admitted to the Department of Endocrinology, Diabetology and Isotope Therapy. She presented with recurrent ovarian cysts, menstrual disturbances, headaches, visual impairment and galactorrhea. Her endocrine profile showed normal values of FSH, elevated concentrations of estradiol and suppressed LH levels. Transsphenoidal resection of the tumor tissue resulted in normalization of the hormone values and improvement in the clinical picture. CONCLUSIONS Gonadotroph adenomas should be considered in the differential diagnosis in premenopausal women with OHSS.
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Affiliation(s)
- Jowita Halupczok
- Department of Endocrinology, Diabetology and Isotope Therapy, Wroclaw Medical University , Wroclaw , Poland
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Katulande P, Kariyawasam SSM, Senanayake HM, Weerakkodi M. Multicystic ovaries and pituitary pseudo-adenoma associated with primary hypothyroidism. J OBSTET GYNAECOL 2014; 33:17-9. [PMID: 23259871 DOI: 10.3109/01443615.2011.565388] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Ovarian hyperstimulation syndrome (OHSS) is a well known but poorly understood iatrogenic complication of superovulation. Spontaneous OHSS has been reported with pregnancy, polycystic ovary syndrome, primary hypothyroidism and pituitary adenoma. Only a few cases of massive ovarian enlargement in non-pregnant women with primary hypothyroidism have been reported in the English literature. A definitive pathophysiology remains uncertain, although several postulations were proposed. A 23-year-old nulliparous woman presented with transient bloating of her abdomen associated with menstruation for the last four cycles. She had nausea, headache, faintness, galactorrhoea and clinical signs and symptoms of hypothyroidism (swelling in the hands and feet, cold intolerance, decreased activity, excessive sleepiness, loss of hair and dry skin) for 6 months. Thyroid stimulating hormone and serum prolactin levels were highly elevated (> 100 μg/l and 4,095 μg/l, respectively) and free thyroxine level was low. Abdominal ultrasound showed bilateral multiple thin-walled ovarian cysts. Contrast enhanced CT of brain showed a pituitary macroadenoma. Treatment with levothyroxine was started and showed marked clinical improvement with return to normal menstruation within 4 months. Serial ultrasound showed gradual regression of the ovarian cysts within 6 months. Serum prolactin level was gradually diminished. Awareness that ovarian and pituitary enlargement may be associated with severe hypothyroidism which can be managed successfully, will spare patients dangerous and unnecessary operative intervention for ovarian cysts or pituitary adenoma.
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Affiliation(s)
- P Katulande
- Department of General Medicine, National Hospital of Sri Lanka, Colombo, Sri Lanka
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Ceccato F, Occhi G, Regazzo D, Randi ML, Cecchin D, Gardiman MP, Manara R, Lombardi G, Denaro L, Mantero F, Scaroni C. Gonadotropin secreting pituitary adenoma associated with erythrocytosis: case report and literature review. Hormones (Athens) 2014; 13:131-9. [PMID: 24722134 DOI: 10.1007/bf03401328] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Most pituitary adenomas with FSH- or LH-positive immunohistochemistry are endocrinologically silent, and neurological symptoms due to their large volume are the first clinical signs; they are rarely reported to be secreting gonadotropins, this usually occurring in cases with clinical endocrine findings. Gonadotropinomas are often treated surgically because they are unresponsive to conventional medical therapies. Temozolomide was recently recommended for non-responder aggressive pituitary adenoma management. CASE REPORT A 43-year-old male with a history of 5 years of erythrocytosis presented with severe headache, orthostatic dizziness, and difficulty walking. MRI documented a giant pituitary adenoma and high uptake of 111In-pentetreotide indicated somatostatin receptor (SSR) expression. Biochemical tests revealed a secreting gonadotropinoma. Therapy with somatostatin analogs and dopamine agonists improved the patient's headache, achieved partial hormone control, slightly reduced the size of the adenoma, and controlled erythrocytosis. Six months after the diagnosis, hormone escape occurred despite therapy, thus neurosurgery was performed. After the procedure the patient died of untreatable intracranial hypertension. The surgical specimen revealed SSR 2 and 3 expression, and temozolomide did not induce apoptosis in primary cell culture. REVIEW OF LITERATURE Among gonadotropinomas, female gender (77%), macroadenoma (84%), young age at diagnosis (28 ± 12 years), delay from first symptoms to diagnosis (up to 15 years), and ovarian cysts/menstrual disorders in females or macro-orchidism in males were the foremost clinical and neuroimaging features. CONCLUSIONS Male gonadotropin-secreting pituitary adenomas may have a variable clinical expression secondary to testosterone excess. Somatostatin analogs, dopamine agonists or temozolomide may have a role that needs to be assessed case by case.
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Affiliation(s)
- Filippo Ceccato
- Endocrinology Unit, Department of Medicine DIMED; University of Padua Medical School, Padua, Italy
| | - Gianluca Occhi
- Endocrinology Unit, Department of Medicine DIMED; University of Padua Medical School, Padua, Italy
| | - Daniela Regazzo
- Endocrinology Unit, Department of Medicine DIMED; University of Padua Medical School, Padua, Italy
| | - Maria Luigia Randi
- Internal Medicine, Department of Medicine DIMED; University of Padua Medical School, Padua, Italy
| | - Diego Cecchin
- Nuclear Medicine Unit, Department of Medicine DIMED; University of Padua Medical School, Padua, Italy
| | - Marina Paola Gardiman
- Surgical Pathology and Cytopathology Unit, Department of Medicine DIMED; University of Padua Medical School, Padua, Italy
| | - Renzo Manara
- Neuroradiologic Unit, University Hospital of Padua, Padua, Italy
| | - Giuseppe Lombardi
- Medical Oncology 1, Venetian Oncology Institute - IRCCS, Padua, Italy
| | - Luca Denaro
- Neurosurgery Division, University Hospital of Padua; Padua, Italy
| | - Franco Mantero
- Endocrinology Unit, Department of Medicine DIMED; University of Padua Medical School, Padua, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine DIMED; University of Padua Medical School, Padua, Italy
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Dharmshaktu P, Kutiyal A, Dhanwal D. Vanishing large ovarian cyst with thyroxine therapy. Endocrinol Diabetes Metab Case Rep 2013; 2013:130050. [PMID: 24683475 PMCID: PMC3965274 DOI: 10.1530/edm-13-0050] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Accepted: 11/11/2013] [Indexed: 11/20/2022] Open
Abstract
A 21-year-old female patient recently diagnosed with severe hypothyroidism was found to have a large ovarian cyst. In view of the large ovarian cyst, she was advised to undergo elective laparotomy in the gynaecology department. She was further evaluated in our medical out-patient department (OPD), and elective surgery was withheld. She was started on thyroxine replacement therapy, and within a period of 4 months, the size of the cyst regressed significantly, thereby improving the condition of the patient significantly. This case report highlights the rare and often missed association between hypothyroidism and ovarian cysts. Although very rare, profound hypothyroidism that can cause ovarian cysts in an adult should always be kept in the differential diagnosis to avoid unnecessary ovarian surgery.
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Affiliation(s)
| | - Aditya Kutiyal
- Department of Medicine Maulana Azad Medical College New Delhi India
| | - Dinesh Dhanwal
- Department of Medicine Maulana Azad Medical College New Delhi India
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17
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Kawaguchi T, Ogawa Y, Ito K, Watanabe M, Tominaga T. Follicle-stimulating hormone-secreting pituitary adenoma manifesting as recurrent ovarian cysts in a young woman--latent risk of unidentified ovarian hyperstimulation: a case report. BMC Res Notes 2013; 6:408. [PMID: 24119690 PMCID: PMC3852055 DOI: 10.1186/1756-0500-6-408] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2013] [Accepted: 10/07/2013] [Indexed: 12/20/2022] Open
Abstract
Background Ovarian hyperstimulation caused by follicle-stimulating hormone-secreting gonadotroph cell adenoma is a rare, with a few reported cases, but almost certainly unnoticed cases occur because of the absence of detailed examinations. We retrospectively reviewed 200 patients treated for gonadotroph cell adenoma in our institute and identified 26 women of reproductive age. Two of these 26 patients had a history of ovarian cysts. One patient was considered to have had typical ovarian hyperstimulation, successfully treated by transsphenoidal surgery. The other patient initially underwent transsphenoidal surgery because of visual disturbance, but endocrinological examinations suggested possible relationships with previous ovarian hyperstimulation. We present the former case and discuss the latent risk of failure to identify this entity. Case presentation A 36-year-old woman with a sellar tumor was referred to our hospital with suspected ovarian hyperstimulation. She had a history of repeated surgery for ovarian cysts. Serum follicle-stimulating hormone and estradiol levels were within the normal ranges, and only the luteinizing hormone level was suppressed significantly. Transsphenoidal surgery achieved gross total tumor removal, and the histological diagnosis was follicle-stimulating hormone-secreting gonadotroph cell adenoma. The serum follicle-stimulating hormone, luteinizing hormone, and estradiol levels returned to the normal ranges postoperatively, and the ovarian cysts subsequently decreased in size without particular interventions. Conclusion Ovarian hyperstimulation could regress after resolving the causes of high follicle-stimulating hormone level, so avoiding unnecessary ovary surgery. Detailed endocrinological examination including estradiol evaluation with pituitary imaging is quite important in women of reproductive age to establish the correct diagnosis.
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Affiliation(s)
- Tomohiro Kawaguchi
- Department of Neurosurgery, Kohnan Hospital, 4-20-1 Nagamachi Minami, Taihaku-ku, Sendai, Miyagi 982-8523, Japan.
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Uchida S, Uchida H, Maruyama T, Kajitani T, Oda H, Miyazaki K, Kagami M, Yoshimura Y. Molecular analysis of a mutated FSH receptor detected in a patient with spontaneous ovarian hyperstimulation syndrome. PLoS One 2013; 8:e75478. [PMID: 24058690 PMCID: PMC3772932 DOI: 10.1371/journal.pone.0075478] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 08/20/2013] [Indexed: 11/18/2022] Open
Abstract
Spontaneous ovarian hyperstimulation syndrome (sOHSS) is a rare event that may result from a FSH-producing pituitary adenoma (FSHoma), activating mutations of the FSH receptor (FSHR), and cross-reactivity of the FSHR to elevated hCG and TSH in the setting of pregnancy or hypothyroidism. The objective of this study was to investigate whether an aberrant FSHR was present in a woman with sOHSS and a non-surgically diagnosed FSHoma whose serum FSH levels and FSH bioactivity were nearly normal. Sequencing of the patient's FSHR gene revealed a heterozygous novel missense mutation c. 1536G>A resulting in an amino acid substitution M512I. We asked whether this mutant FSHR affected FSHR-mediated signaling pathways involving cAMP/protein kinase A (PKA), phosphatidylinositol-3 kinase (PI3K)/protein kinase B (AKT) and v-src sarcoma (Schmidt-Ruppin A-2) viral oncogene homolog kinase (SRC)/ p42/p44 extracellular signal-regulated protein kinases (ERK1/2). Thus, 293T cells expressing wild-type (FSHRwt), the mutant FSHR (FSHRmt), or both (FSHRwt/mt) were treated with FSH and subjected to measurements of intracellular cAMP, cAMP-induced CRE (cAMP response element)-mediated luciferase assays and immunoblot analyses of phosphorylated PI3K and ERK1/2. There were no differences in luciferase activities or phosphorylation levels of ERK1/2 among FSHRwt, FSHRmt cells and FSHwt/mt cells. However, FSHRmt cells showed a significant reduction in both cAMP production and PI3K phosphorylation levels with unchanged phosphorylation of ERK1/2 upon FSH stimulation in comparison to FSHwt cells. Also, FSH treatment did not provoke PI3K phosphorylation in FSHwt/mt cells. These results indicate that the novel missense M512I FSHR mutation identified herein did not participate in hyperactivation of FSHR-mediated signaling pathways but rather in hypoactivation of the FSH-mediated PI3K/AKT pathway. Thus, this study demonstrates a new functional property of this novel mutatnt FSHR, which, however, might not be involved in the pathogenesis of sOHSS in this FSHoma patient.
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Affiliation(s)
- Sayaka Uchida
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
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19
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A pituitary adenoma secreting follicle-stimulating hormone with ovarian hyperstimulation: treatment using a gonadotropin-releasing hormone antagonist. Fertil Steril 2012; 97:231-4. [DOI: 10.1016/j.fertnstert.2011.10.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Revised: 10/10/2011] [Accepted: 10/12/2011] [Indexed: 11/24/2022]
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Shu J, Xing L, Zhang L, Fang S, Huang H. Ignored adult primary hypothyroidism presenting chiefly with persistent ovarian cysts: a need for increased awareness. Reprod Biol Endocrinol 2011; 9:119. [PMID: 21861901 PMCID: PMC3184057 DOI: 10.1186/1477-7827-9-119] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Accepted: 08/23/2011] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Ovarian cysts are a common cause for gynecological surgery. However, some cysts are a direct result of endocrine disorders and do not require surgery. This report describes an unusual case in which persistent ovarian cysts are associated with primary hypothyroidism in a young woman. The data were collected by history-taking, physical examination, laboratory tests, ultrasound, magnetic resonance imaging and a histo-pathological study. In addition, the exons of the gene encoding the human follicle-stimulating hormone receptor were sequenced. DISCUSSION The patient had markedly elevated levels of thyroid-stimulating hormone and follicle-stimulating hormone and an enlarged pituitary gland. After treatment with thyroid hormone replacement, regression of the enlarged pituitary and the ovarian cysts was observed. The possible mechanisms of the pathophysiology are discussed below. SUMMARY It is necessary to consider hypothyroidism and other endocrine disorders in the differential diagnosis of adult patients with ovarian multiple cyst formation in order to prevent inadvertent ovarian surgery.
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Affiliation(s)
- Jing Shu
- Department of Obstetrics & Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Lili Xing
- Department of Obstetrics & Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Lingyan Zhang
- Department of Obstetrics & Gynecology, Xiasha Hospital, Hangzhou 310001, China
| | - Suhua Fang
- Department of Obstetrics & Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Hefeng Huang
- Department of Reproductive Endocrinology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou 310006, China
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21
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[Ovarian hyperstimulation syndrome: pathophysiology, risk factors, prevention, diagnosis and treatment]. ACTA ACUST UNITED AC 2011; 40:593-611. [PMID: 21835557 DOI: 10.1016/j.jgyn.2011.06.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Revised: 06/07/2011] [Accepted: 06/14/2011] [Indexed: 12/26/2022]
Abstract
The ovarian hyperstimulation syndrome is a major complication of ovulation induction for in vitro fertilization, with severe morbidity and possible mortality. Whereas its pathophysiology remains ill-established, the VEGF may play a key role as well as coagulation disturbances. Risk factors for severe OHSS may be related to patients characteristics or to the management of the ovarian stimulation. Two types of OHSS are usually distinguished: the early OHSS, immediately following the ovulation triggering and a later and more severe one, occurring in case of pregnancy. As no etiologic treatment is available, the therapeutic management of OHSS should focus on its related-complications. Thrombotic complications that can occur in venous or arterial vessels represent the major risk of OHSS, possibly conducting to myocardial infarction and cerebrovascular accidents. Once the OHSS is diagnosed, prevention of thrombotic accidents remains the major issue.
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22
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Burgos J, Cobos P, Vidaurrazaga N, Prieto B, Ocerin I, Matorras R. Ovarian hyperstimulation secondary to ectopic secretion of follicle-stimulating hormone. Literature review prompted by a case. Fertil Steril 2009; 92:1168.e5-1168.e8. [PMID: 19608176 DOI: 10.1016/j.fertnstert.2009.06.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2009] [Revised: 06/07/2009] [Accepted: 06/08/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To present an exceptional clinical case of functional follicle-stimulating gonadotropin secretion by a thorax neuroendocrine carcinoid tumor. DESIGN Case report. SETTING Department of Obstetrics and Gynecology, Cruces University Hospital, Vizcaya, Spain. PATIENT(S) A 26-year-old woman with ovarian hyperstimulation. INTERVENTION(S) Diagnosis algorithm. MAIN OUTCOME MEASURE(S) Successful management of ovarian hyperstimulation. RESULT(S) A 26-year-old woman seen with abdominal pain and swelling had bilateral multicystic ovaries. The diagnosis algorithm revealed the presence of ovarian hyperstimulation but with no due etiology. On the basis of the persistence of high levels of FSH a computed tomographic scan was taken looking for an FSH-producing neuroendocrine tumor. CONCLUSION(S) In idiopathic ovarian hyperstimulation secondary to supraphysiologic secretion of FSH, the presence of an FSH-producing neuroendocrine tumor should be considered. As far as we know, there are no similar cases with a confirmed diagnosis published in the literature.
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Affiliation(s)
- Jorge Burgos
- Human Reproduction Unit, Department of Obstetrics and Gynecology, Hospital de Cruces, Vizcaya, Spain; School of Medicine, Universidad del País Vasco, Vizcaya, Spain.
| | - Patricia Cobos
- Human Reproduction Unit, Department of Obstetrics and Gynecology, Hospital de Cruces, Vizcaya, Spain
| | - Nerea Vidaurrazaga
- School of Medicine, Universidad del País Vasco, Vizcaya, Spain; Department of Anatomopathology, Hospital de Cruces, Vizcaya, Spain
| | - Begoña Prieto
- Human Reproduction Unit, Department of Obstetrics and Gynecology, Hospital de Cruces, Vizcaya, Spain
| | - Iratxe Ocerin
- School of Medicine, Universidad del País Vasco, Vizcaya, Spain; Endoscopy Unit, Department of Obstetrics and Gynecology, Hospital de Cruces, Vizcaya, Spain
| | - Roberto Matorras
- Human Reproduction Unit, Department of Obstetrics and Gynecology, Hospital de Cruces, Vizcaya, Spain; School of Medicine, Universidad del País Vasco, Vizcaya, Spain
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Gera PS, Tatpati LL, Allemand MC, Wentworth MA, Coddington CC. Ovarian hyperstimulation syndrome: steps to maximize success and minimize effect for assisted reproductive outcome. Fertil Steril 2009; 94:173-8. [PMID: 19356753 DOI: 10.1016/j.fertnstert.2009.02.049] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2008] [Revised: 02/11/2009] [Accepted: 02/13/2009] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate the strategies used to decrease the risk of ovarian hyperstimulation syndrome (OHSS) and their impact on pregnancy and live birth rates. DESIGN Retrospective cohort analysis. SETTING University hospital. PATIENT(S) One hundred eighty-eight patients undergoing fresh in vitro fertilization (IVF) cycles between 2000 and 2004, with peak serum estradiol levels >2500 pg/mL and presumed to be at risk for OHSS. INTERVENTION(S) Coasting and elective embryo cryopreservation were evaluated for their effect on OHSS and live birth rates. MAIN OUTCOME MEASURE(S) Pregnancy, live birth rates, and OHSS incidence. RESULT(S) Out of 188 patients at risk for OHSS, 21 patients had their cycles coasted (group 1), and elective embryo cryopreservation was performed in 32 patients (group 2). In 135 patients with no other risk factors, ovulation was triggered with human chorionic gonadotropin and embryo transfer was performed (group 3). The incidence in our IVF population was 38 out of 1002 (3.8%). The overall incidence of OHSS for those who had an estradiol level >2500 pg/mL was 20.2% (38 out of 188), and none of the patients in group 1 developed OHSS; 13 out of 32 patients in group 2 (40.6%) and 25 out of 135 (18.5%) patients in group 3 developed OHSS. The live birth rate was 38%, 40%, and 45% in groups 1, 2, and 3, respectively, and the cumulative live birth rate was 52%, 75%, and 59%, respectively. CONCLUSION(S) Elective cryopreservation of embryos with subsequent frozen embryo transfer and coasting are effective ways of maximizing pregnancy and limiting severe OHSS.
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Affiliation(s)
- Puja S Gera
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA
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24
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Ghayuri M, Liu JH. Ovarian Hyperstimulation Syndrome Caused by Pituitary Gonadotroph Adenoma Secreting Follicle-Stimulating Hormone. Obstet Gynecol 2007; 109:547-9. [PMID: 17267890 DOI: 10.1097/01.aog.0000247316.60573.4a] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We report a highly exceptional case in which a gonadotroph adenoma was diagnosed in a patient with normal follicle-stimulating hormone (FSH) levels. CASE A 30-year-old woman with a gonadotroph adenoma presented with hyperstimulation syndrome and normal FSH levels. After treatment of her adenoma she had regular menstrual cycles and subsequently conceived. CONCLUSION Ovarian hyperstimulation caused by a gonadotroph adenoma in a premenopausal woman with normal FSH levels is extremely rare. However, we propose that gonadotroph adenomas be considered in the differential diagnosis of patients who have this constellation of abnormalities.
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Affiliation(s)
- Mohammadreza Ghayuri
- Department of Obstetrics and Gynecology, MacDonald Women's Hospital, Case Western Reserve University, Cleveland, Ohio, USA.
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25
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Knoepfelmacher M, Danilovic DLS, Rosa Nasser RHR, Mendonça BB. Effectiveness of treating ovarian hyperstimulation syndrome with cabergoline in two patients with gonadotropin-producing pituitary adenomas. Fertil Steril 2006; 86:719.e15-8. [PMID: 16952513 DOI: 10.1016/j.fertnstert.2006.01.055] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2005] [Revised: 01/08/2006] [Accepted: 01/08/2006] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To report the effect of cabergoline on ovarian hyperstimulation syndrome associated with gonadotropin-secreting pituitary adenomas. DESIGN Case report. SETTING Outpatient practice. PATIENT(S) Two women with menstrual irregularity, enlarged ovaries, high E(2), and normal gonadotropin levels. INTERVENTION(S) Cabergoline treatment and transsphenoidal surgery. MAIN OUTCOME MEASURE(S) Estradiol levels, transvaginal ultrasonography, and pituitary magnetic resonance imaging. Transsphenoidal surgery showed pituitary adenoma staining for LH in both patients. RESULT(S) Cabergoline was effective in reducing E(2) levels and decreasing ovarian size but ineffective in shrinking the pituitary adenomas. CONCLUSION(S) This is the first description of the effectiveness of cabergoline as the primary treatment of spontaneous ovarian hyperstimulation syndrome in patients with gonadotropin-producing pituitary adenomas.
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Affiliation(s)
- Mirta Knoepfelmacher
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular LIM/42, Disciplina de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
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Sicilia V, Earle J, Mezitis SGE. Multiple Ovarian Cysts and Oligomenorrhea as The Initial Manifestations of A Gonadotropin-Secreting Pituitary Macroadenoma. Endocr Pract 2006; 12:417-21. [PMID: 16901798 DOI: 10.4158/ep.12.4.417] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To report a case of a follicle-stimulating hormone (FSH)-secreting pituitary adenoma, which manifested with oligomenorrhea, dysmenorrhea, and multiple bilateral ovarian cysts. METHODS We present a case report of a 29-year-old woman, including detailed laboratory, radiologic, and pathologic findings, who was diagnosed as having an FSH-secreting pituitary tumor. The pertinent literature is also reviewed. RESULTS A 29-year-old woman, after experiencing oligomenorrhea and increasing abdominal girth for >1 year, presented with an acute abdomen. Ultrasonography revealed multicystic ovaries >15 cm in maximal diameter, causing bilateral adnexal torsion. After bilateral ovarian cystectomies, ultrasound study showed recurrence of the cysts. Relevant laboratory data were as follows: serum FSH 6.8 mIU/mL, luteinizing hormone 0.1 mIU/mL, prolactin 67 ng/mL, human chorionic gonadotropin <2 mIU/mL, progesterone 3.5 ng/dL, estradiol 237 pg/mL, thyrotropin 1.8 microIU/mL, testosterone <4 ng/dL, insulin 8.0 microIU/mL, and fasting plasma glucose 87 mg/dL. Magnetic resonance imaging (MRI) of the brain revealed a 2.5-cm pituitary mass, although the patient had no symptoms of pituitary dysfunction. Transsphenoidal removal of the mass was performed, and pathology studies were positive for FSH-secreting adenoma. Repeated MRI at 3 months showed an 0.8-cm residual tumor. The patient refused adjuvant radiotherapy. Regular menses resumed within 2 months postoperatively, and she later successfully became pregnant. Almost 3 years after treatment, the patient remained asymptomatic, results of pituitary function tests were normal, and follow-up MRI showed no signs of tumor regrowth. CONCLUSION Although very uncommon, gonadotropin-secreting pituitary adenomas should be considered in the differential diagnosis of new-onset oligomenorrhea and dysmenorrhea, especially if associated with multicystic ovaries on ultrasound study, even in the absence of elevated levels of serum gonadotropins. Furthermore, we propose that it may be acceptable to withhold adjuvant radiotherapy in patients who are asymptomatic after transsphenoidal surgical excision of these tumors.
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Affiliation(s)
- Vitaliano Sicilia
- Department of Internal Medicine, Lenox Hill Hospital, New York, New York, USA
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Kihara M, Sugita T, Nagai Y, Saeki N, Tatsuno I, Seki K. Ovarian hyperstimulation caused by gonadotroph cell adenoma: a case report and review of the literature. Gynecol Endocrinol 2006; 22:110-3. [PMID: 16603438 DOI: 10.1080/09513590600581665] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVE We present a case of spontaneous ovarian hyperstimulation caused by pituitary gonadotroph macroadenoma, and include a review of the literature. CASE REPORT A 27-year-old woman presented with irregular menstruation and bilateral multicystic enlargement of the ovaries. Serum estradiol (E(2)) levels were marginally elevated for the follicular phase but within the physiological range. Serum luteinizing hormone (LH) was extremely low, follicle-stimulating hormone (FSH) was normal, and prolactin (PRL) was high. Magnetic resonance imaging disclosed a pituitary macroadenoma. Immunohistochemical examination of the surgically removed adenoma showed intense reactivity for FSH and LH. After the operation, E(2), LH and PRL levels were normalized, the ovaries returned to a normal morphology, and regular menstrual cycles were resumed. CONCLUSION A review of the literature showed that ovarian hyperstimulation caused by pituitary gonadotroph adenoma is not always accompanied by elevated FSH levels. High PRL and E(2) and low LH were reported in the majority of the cases, but E(2) may stay within the range observed in normal menstrual cycles.
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Affiliation(s)
- Maki Kihara
- Department of Reproductive Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan.
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Mor E, Rodi IA, Bayrak A, Paulson RJ, Sokol RZ. Diagnosis of pituitary gonadotroph adenomas in reproductive-aged women. Fertil Steril 2005; 84:757. [PMID: 16169418 DOI: 10.1016/j.fertnstert.2005.02.050] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2004] [Revised: 02/22/2005] [Accepted: 02/22/2005] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To describe the clinical symptoms associated with the diagnosis of pituitary gonadotroph adenoma in premenopausal women. DESIGN Report of three separate cases. SETTING University medical center. PATIENT(S) Three patients: a 31-year-old woman with primary infertility, recurrent adnexal masses, and highly elevated estradiol level; a 30-year-old woman with recurrent multicystic ovaries following multiple cystectomies and transvaginal cyst aspirations, and elevated estradiol level; a 43-year-old woman with bilateral complex cystic adnexal masses and an elevated estradiol level, who underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy for a suspected granulosa cell tumor. INTERVENTION(S) Transsphenoidal resection of a pituitary mass. MAIN OUTCOME MEASURE(S) Serum estradiol, FSH, and LH levels; transvaginal ultrasonography of the ovaries; histologic examination of pituitary tumors. RESULT(S) Transsphenoidal resection of pituitary adenomas resulted in normalization of serum estradiol and FSH levels and resolution of adnexal masses in two of the women. CONCLUSION(S) Pituitary gonadotroph adenoma must be considered in the differential diagnosis in reproductive-aged women presenting with the clinical symptom triad of new onset oligomenorrhea, bilateral cystic adnexal masses, and elevated estradiol and FSH levels with suppressed levels of LH; timely diagnosis may prevent unnecessary and potentially damaging surgical procedures.
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Affiliation(s)
- Eliran Mor
- University of Southern California Keck School of Medicine, Los Angeles, California, USA.
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30
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Maruyama T, Masuda H, Uchida H, Nagashima T, Yoshimura Y. Follicle stimulating hormone-secreting pituitary microadenoma with fluctuating levels of ovarian hyperstimulation. Obstet Gynecol 2005; 105:1215-8. [PMID: 15863587 DOI: 10.1097/01.aog.0000141554.50747.16] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Enlarged multicystic ovaries and an elevated estradiol (E2) concentration have been reported as characteristics of follicle stimulating hormone (FSH)-secreting adenomas in reproductive-aged women. The natural course of the hormone in relationship to the microadenoma and ovarian findings, however, remains largely unknown. CASE A 40-year-old woman with enlarged multicystic ovaries was nonsurgically diagnosed with an FSH-producing pituitary microadenoma. During her subsequent 12-month follow-up, the serum concentration of E2, but not FSH, and the size of the multicystic ovaries fluctuated dramatically. Both the E2 level and ovarian size were transiently normalized. CONCLUSION Because of disease-related fluctuations, a reproductive-aged woman with an FSH-producing adenoma did not always present with laboratory values characteristic of ovarian hyperstimulation. This finding points out a possible pitfall in diagnosis and clinical management.
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Affiliation(s)
- Tetsuo Maruyama
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan.
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31
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Roberts JE, Spandorfer S, Fasouliotis SJ, Lin K, Rosenwaks Z. Spontaneous ovarian hyperstimulation caused by a follicle-stimulating hormone-secreting pituitary adenoma. Fertil Steril 2005; 83:208-10. [PMID: 15652911 DOI: 10.1016/j.fertnstert.2004.06.061] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2004] [Revised: 06/17/2004] [Accepted: 06/17/2004] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To report a case of spontaneous ovarian hyperstimulation resulting from an FSH-secreting pituitary adenoma. DESIGN Case report. SETTING University hospital. PATIENT(S) A 29-year-old previously healthy, nulligravid woman. INTERVENTION(S) Transphenoidal resection of the adenoma. MAIN OUTCOME MEASURE(S) Clinical remission. RESULT(S) After transphenoidal resection of the adenoma, the patient had an uneventful postoperative recovery with complete resolution of ovarian hyperstimulation and associated symptoms. Postoperative magnetic resonance imaging demonstrated residual tumor within the cavernous sinus. CONCLUSION(S) Follicle-stimulating hormone-secreting pituitary adenoma may present as acute spontaneous ovarian hyperstimulation.
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Affiliation(s)
- Jeffrey E Roberts
- Center for Reproductive Medicine and Infertility, Weill Medical College of Cornell University, New York, New York, USA.
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32
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Murakami T, Higashitsuji H, Yoshinaga K, Terada Y, Ito K, Ikeda H. CASE REPORT: Management of ovarian hyperstimulation due to follicle-stimulating hormone-secreting gonadotroph adenoma. BJOG 2004; 111:1297-300. [PMID: 15521879 DOI: 10.1111/j.1471-0528.2004.00409.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Takashi Murakami
- Department of Obstetrics and Gynaecology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
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Mohammad HP, Abbud RA, Parlow AF, Lewin JS, Nilson JH. Targeted overexpression of luteinizing hormone causes ovary-dependent functional adenomas restricted to cells of the Pit-1 lineage. Endocrinology 2003; 144:4626-36. [PMID: 12960102 DOI: 10.1210/en.2003-0357] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The majority of pituitary adenomas in humans are nonmetastasizing, monoclonal neoplasms that occur in approximately 20% of the general population. Their development has been linked to a combination of extrinsic factors and intrinsic defects. We now demonstrate with transgenic mice that targeted and chronic overexpression of LH causes ovarian hyperstimulation and subsequent hyperproliferation of Pit-1-positive cells that culminates in the appearance of functional pituitary adenomas ranging from focal to multifocal expansion of lactotropes, somatotropes, and thyrotropes. Tumors fail to develop in ovariectomized mice, indicating that contributions from the ovary are necessary for adenoma development. Although the link between chronic ovarian hyperstimulation and PRL-secreting adenomas was expected, the involvement of somatotropes and thyrotropes was surprising and suggests that multiple ovarian hormones may contribute to this unusual pathological consequence. In support of this idea, we have found that ovariectomy followed by estrogen replacement results in the expansion of lactotropes selectively in LH overexpressing mice, but not somatotropes and thyrotropes. Collectively, these data indicate that estrogen is sufficient for the formation of lactotrope adenomas only in animals with a hyperstimulated ovary, whereas the appearance of GH- and TSH-secreting adenomas depends on multiple ovarian hormones. Together, our data expand current models of pituitary tumorigenesis by suggesting that chronic ovarian hyperstimulation may underlie the formation of a subset of pituitary adenomas containing lactotropes, somatotropes, and thyrotropes.
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Affiliation(s)
- Helai P Mohammad
- Department of Pharmacology, Case Western Reserve University, Cleveland, Ohio 44106, USA
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Castelbaum AJ, Bigdeli H, Post KD, Freedman MF, Snyder PJ. Exacerbation of ovarian hyperstimulation by leuprolide reveals a gonadotroph adenoma. Fertil Steril 2002; 78:1311-3. [PMID: 12477530 DOI: 10.1016/s0015-0282(02)04342-x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To report a case of a gonadotroph adenoma diagnosed after a dramatic increase in estradiol level and ovarian hyperstimulation in response to a gonadotropin-releasing hormone agonist. DESIGN Case report. SETTING Outpatient practice and university hospital. PATIENT(S) A 35-year-old woman who presented with infertility, amenorrhea, and an elevated basal estradiol concentration. INTERVENTION(S) Ultrasonography, laparoscopy, endocrinologic assays, magnetic resonance imaging, transsphenoidal surgery, and immunocytochemical staining. MAIN OUTCOME MEASURE(S) Ultrasonography and laparoscopy demonstrated bilaterally enlarged ovaries containing multiple preovulatory follicles, similar in appearance in those women undergoing controlled ovarian hyperstimulation with exogenous FSH. The serum estradiol level was moderately elevated, the FSH level was within the normal range, and LH was suppressed. Administration of leuprolide acetate resulted in very elevated estradiol concentrations and even larger ovarian cysts. Magnetic resonance imaging demonstrated a sellar mass. Examination of the tissue excised by transsphenoidal excision of the mass showed a pituitary adenoma that stained strongly for FSH. RESULT(S) Regular menses resumed soon after excision of the gonadotroph adenoma, followed by a spontaneous pregnancy. CONCLUSIONS Gonadotroph adenoma should be suspected in a reproductive age woman with oligomenorrhea or amenorrhea, infertility, multiple preovulatory follicles, and a persistently elevated serum estradiol concentration. Exacerbation of the ovarian hyperstimulation in response to a gonadotropin-releasing hormone agonist in this setting also strongly suggests a gonadotroph adenoma but can be avoided by recognizing the presenting features of this condition.
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Affiliation(s)
- Arthur J Castelbaum
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104-6149, USA
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Abstract
Clinically nonfunctioning pituitary adenomas are one of the most common types of pituitary tumors. Unless they present with symptoms related to local mass effect, most tumors are detected incidentally when imaging studies are performed for other reasons. Although clinically nonfunctioning, most of these tumors have evidence, in vitro, of gonadotropin hormone or glycoprotein subunit production. The gonadotropins or their monomer submits rarely cause clinically identifiable effects. When these tumors present as macroadenomas, often with associated mass effect and hypopituitarism, primary therapy is neurosurgery. The role for medical therapy will be reviewed here.
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Affiliation(s)
- Mansur E Shomali
- Division of Endocrinology, Union Memorial Hospital, Baltimore, MD, USA
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