Falência ovariana prematura: aspectos atuais

Autoimmune hypothyroidism and intermittent ovarian failure - Case Report

Case presentation: a 35 year-old physical educator sought gynecological care for secondary amenorrhea and infertility. She denied the occurrence of similar problems in her family and referred to hypothyroidism as her only comorbidity, for which she was on levothyroxine 88µg daily. She was tested for beta-HCG, prolactin and TSH levels. She was negative for beta-HCG, and had prolactin and TSH levels of 19ng/ml and 2.04 mIU/ml, respectively. Her progesterone test was negative. The combined test (estradiol + norethisterone acetate) was positive, excluding the possibility of an anatomical cause. One month later, her blood tests were as follows: FSH 100mIU/ml, TSH 1.54mIU/ml, free T4 1.22ng/dl, and anti-TPO 261U/ml. Her FSH level was above 100 and she was diagnosed with premature ovarian failure. Reproductive treatment with donor eggs was proposed as an option. Karyotyping and a test for fragile X syndrome were ordered. A few months later the patient came to our clinic saying she was having menstrual cycles. Blood tests were as follows: FSH 9.2mIU/ml; TSH 2.21mIU/ml; and anti-TPO 14U/ml. Transvaginal ultrasound showed a normal uterus with a thin endometrium and atrophic ovaries. After two years of irregular menstrual cycles, she became amenorrheic again. She chose not to undergo assisted reproduction. This paper discusses the diagnosis of premature ovarian failure in light of current protocols and the association of this condition with diseases such as Hashimoto's thyroiditis, and looks into the difficulty of performing differential diagnosis against Savage syndrome and of offering reproductive counseling especially in cases where the menstrual cycle returns.

Association of BMP15 and GDF9 variants to premature ovarian insufficiency

PURPOSE

To identify genetic variation associated to premature ovarian insufficiency (POI).

METHODS

A total of 74 women with POI (group POI), 45 women with increased FSH levels (group high FSH), and 88 controls (non-POI) were studied. Genotyping of BMP15:c.-9C>G (rs3810682), BMP15:c.328+905A>G (rs3897937), and BMP15:c.852C>T (rs17003221); and GDF9:c.134-694G>A (rs4705974), GDF9:c.-31-951G>A (rs11748063), GDF9:c.-152G>C (rs30177), and GDF9:g.1073C>T (rs803224) was performed by the TaqMan methodology. Chi-square and Fisher's exact tests were performed to evaluate the distribution of genotypes, alleles, odds ratio, and the Hardy-Weinberg equilibrium of each variation. Haplotype analysis was performed for each gene considering the case and control groups. Bonferroni's correction was applied to chi-square and Fisher's exact test data, and p values < 0.007 for genotypes and alleles and < 0.006 for haplotypes were considered significant.

RESULTS

It was observed a statistically significant difference in genotype distribution of BMP15:c.852C>T between group POI and controls (p < 0.001). TT and TC genotypes were more frequently observed in group POI. Genotype distribution in case group POI, however, was not in the Hardy-Weinberg equilibrium, due to the increased number of heterozygotes in the sample. Concerning GDF9, no association was found among the studied genetic variants and POI or high FSH groups.

CONCLUSION

It is concluded from the present study that the genotypes CT and TT from BMP15:c.852C>T variation may be risk factors for the development of POI.

How polymorphic markers contribute to genetic diseases in different populations? The study of inhibin A for premature ovarian insufficiency

OBJECTIVE

To verify the incidence of the G679A mutation in exon 2 of the gene inhibin alpha (INHA), in women with secondary amenorrhea and diagnosis of premature ovarian insufficiency, and in controls.

METHODS

A 5mL sample of peripheral blood was collected from all study participants in an EDTA tube and was used for DNA extraction. For the patient group, 5mL of blood were also collected in a tube containing heparin for karyotype, and 5mL were collected in a dry tube for follicle stimulant hormone dosage. All patient and control samples were initially submitted to analysis of the G679A variant in exon 2 of the INHA gene by PCR-RFLP technique. Samples from patients with premature ovarian insufficiency after PCR-RFLP were submitted to Sanger sequencing of the encoding exons 2 and 3. Sequencing was performed on ABI 3500 GeneticAnalyzer equipment and the results were evaluated by SeqA and Variant Reporter software.

RESULTS

Samples of 70 women with premature ovarian insufficiency and 97 fertile controls were evaluated. The G769A variant was found in only one patient in the Premature Ovarian Insufficiency Group and in no control, and it appears to be rare in Brazilian patients with premature ovarian insufficiency. This polymorphism was previously associated to premature ovarian insufficiency in several populations worldwide.

CONCLUSION

There is genetic heterogeneity regarding the INHA gene in different populations, and among the causes of premature ovarian insufficiency.

Primary ovarian insufficiency: different approaches in three cases and a review of literature

Primary ovarian insufficiency (POI) is the condition of intermittent or permanent gonadal insufficiency that occurs in women before the age of 40. We describe three cases of POI referred to the outpatient endocrinology clinic of a university hospital. The three patients met diagnostic criteria for POI and were managed by specific approaches tailored to individualized goals. In the first case, the main concern was fertility and the reproductive prognosis. The second patient was a carrier of a common genetic cause of POI: premutation of the FMR1 gene. The third case was a patient diagnosed with a POI and established osteoporosis, a common complication of estrogen deprivation. This study reports the treatment and follow-up of these cases, with an emphasis on relevant aspects of individualized management, alongside a brief literature review.

Mammographic breast density in women with premature ovarian failure: a prospective analysis

OBJECTIVE

This study aims to compare breast density between two mammograms in women with premature ovarian failure (POF).

METHODS

A cohort study evaluated 56 women with POF. Two mammograms performed at least 2 years apart were analyzed. Mammogram films were digitalized, and images were assessed using a computer-assisted method; the percentage of breast image that is radiologically dense is referred to as the percentage of mammographic density (PMD). Age at menarche, age at onset of POF, length of POF, length of estrogen-progestin therapy (EPT), body mass index (BMI), pregnancy, and age at the time of each mammogram were evaluated.

RESULTS

The mean (SD) age at POF diagnosis was 32.35 (5.95) years. In the first mammogram, the mean (SD) age, BMI, and length of POF were 37.58 (3.72) years, 26.79 (4.86) kg/m, and 5.25 (4.61) years, respectively. EPT had been used for a mean (SD) of 2.71 (3.12) years. In the second mammogram, the mean (SD) age, BMI, and length of POF were 43.23 (4.98) years, 27.6 (5.39) kg/m, and 10.5 (5.11) years, respectively. EPT had been used for a mean (SD) of 7.25 (4.6) years. The mean (SD) interval between mammograms was 5.25 (3) years, and the mean (SD) PMD decreased from 27.78% (21.04%) to 17.53% (15.71%) (P = 0.007). Comparing PMD between women taking EPT and those not taking EPT, we observed no significant differences. In both instances, multiparous women had lower PMD than nulliparous women (P < 0.05). BMI, length of POF, and pregnancy were negatively correlated with PMD.

CONCLUSIONS

Breast density in young women with POF decreases across a period of 5 years, regardless of EPT use. Further studies may elucidate how this result will correlate with decision-making in clinical therapeutics and breast cancer risk in POF.

Are FSHR polymorphisms risk factors to premature ovarian insufficiency?

Premature ovarian insufficiency (POI) is an ovarian dysfunction characterized by increased FSH levels and amenorrhea before 40 years old. In recent years, the search for genetic causes of POI intensified and studies have been published relating the presence of mutations and polymorphisms in genes associated with development, recruitment and oocyte atresia. The aim of this study was to evaluate the presence of FSHR polymorphisms in our population and contribute with the elucidation of POI etiology. To achieve it, we have studied 100 patients with POI (G1), 60 patients with border line levels of FSH (G2) and 123 controls with regular menopause onset. Cytogenetic analysis of patients' samples and genotyping of Asn680Ser and Ala307Thr polymorphisms were performed in cases and controls. Cytogenetic analysis showed that 92% of G1 patients had normal karyotype, 4% presented polymorphic variants, 3% presented mosaic karyotype involving X chromosome. In G2, 91.6% had normal karyotype results, 3.2% displayed polymorphic variants, and 3.3% presented a mosaic karyotype involving X chromosome. Statistical comparison showed that the polymorphic allele of Ala307Thr polymorphism is more frequent in patients than in controls (G1: p < 0.001 and G2: p = 0.0259). This association has not been previously reported. We concluded that Ala307Thr polymorphism in FSHR can be potentially associated to POI development and can be considered as a screening marker in patients with ovarian failure signals.

Tumor necrosis factor-alpha promoter polymorphisms are associated with idiopathic primary ovarian insufficiency in Korean women

OBJECTIVE

To investigate the possible association between primary ovarian insufficiency (POI) and TNF-α gene polymorphisms in Korean women.

DESIGN

Case-control study.

SETTING

An urban university-based hospital in South Korea.

PATIENT(S)

A cohort of 135 Korean POI patients and 236 controls.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

We analyzed TNF-α gene variants of all participants using the polymerase chain reaction-restriction fragment length polymorphism assay.

RESULT(S)

The TNF-α -1031TC+CC, -238GA+AA, -1031TC+CC/-308GG, -1031TT/-308GA+AA, -1031TC+CC/-238GA+AA, and -308GG/-238GA+AA genotypes were significantly more frequent in POI patients than in controls. Among the haplotypes for the three TNF-α loci, the -1031C/-308G/-238A haplotype was more frequent in POI patients than in controls and conferred POI susceptibility. In analyses of two loci, the -1031T/-308A, -1031C/-308G, -1031C/-238A, and -308G/-238A haplotypes were more frequent in POI patients.

CONCLUSION(S)

The TNF-α -1031C and -238A alleles had strong association with POI. The TNF-α -308A allele showed limited significance for POI risk with the presence of the -1031T allele. Our data suggest that the minor alleles of TNF-α promoter polymorphisms may increase POI risk in Korean women.

Pregnancy after azathioprine therapy for ulcerative colitis in a woman with autoimmune premature ovarian failure and Addison's disease: HLA haplotype characterization

OBJECTIVE

To present a case of fertility restored by azathioprine treatment in a woman with autoimmune premature ovarian failure, Addison's disease, and ulcerative colitis, and to study the genetic background of the three autoimmune diseases.

DESIGN

Case report.

SETTING

Endocrinology and Immunology Units of an university hospital.

PATIENT(S)

A 30-year-old woman with autoimmune premature ovarian failure, Addison's disease, and ulcerative colitis.

INTERVENTION(S)

Azathioprine has been administered as immunosuppressive treatment.

MAIN OUTCOME MEASURE(S)

We performed analysis of human leukocyte antigens expression on lymphocytes and genomic haplotype of the patient.

RESULT(S)

The human leukocyte antigen haplotype of the patient was consistent with the haplotypes predisposing for the three autoimmune diseases, as reported in the literature. The administration of azathioprine restored regular menses and allowed uneventful pregnancy.

CONCLUSION(S)

This is the first clinical evidence of association of immunosuppressive azathioprine treatment and restored ovarian function and fertility in a woman with autoimmune premature ovarian failure. In this patient, the haplotype was associated with susceptibility to autoimmune premature ovarian failure, Addison's disease, and ulcerative colitis.

Genetic aspects of premature ovarian failure: a literature review

BACKGROUND

The diagnosis of premature ovarian failure (POF) is based on the finding of amenorrhea before the age of 40 years associated with follicle-stimulating hormone levels in the menopausal range. It is a heterogeneous disorder affecting approximately 1% of women <40 years, 1:10,000 women by age 20 years and 1:1,000 women by age 30 years. POF is generally characterized by low levels of gonadal hormones (estrogens and inhibins) and high levels of gonadotropins (LH and FSH) (hypergonadotropic amenorrhea).

METHODS

Review of significant articles regarding genetic causes that are associated with POF.

RESULTS

Heterogeneity of POF is reflected by a variety of possible causes, including autoimmunity, toxics, drugs, as well as genetic defects. Changes at a single autosomal locus and many X-linked loci have been implicated in women with POF. X chromosome abnormalities (e.g., Turner syndrome) represent the major cause of primary amenorrhea associated with ovarian dysgenesis. Many genes have been involved in POF development, among them BMP15, FMR1, FMR2, LHR, FSHR, INHA, FOXL2, FOXO3, ERα, SF1, ERβ and CYP19A1 genes.

CONCLUSION

Despite the description of several candidate genes, the cause of POF remains undetermined in the vast majority of cases.