Regression of both pituitary and ovarian cysts after administration of thyroid hormone in a case of primary hypothyroidism

Pituitary Hyperplasia Due to Longstanding Primary Hypothyroidism: A Case Report and Comprehensive Review of the Literature

Hypothyroidism is a frequently diagnosed endocrine disorder. Common signs and symptoms include fatigue, cold intolerance, hoarseness, dry skin, constipation, a slow relaxation phase of deep tendon reflexes, and bradycardia. However, some patients may exhibit atypical signs and symptoms, which can result in diagnostic confusion. Pituitary hyperplasia resulting from longstanding primary hypothyroidism was first described by Niepce in 1851. It is usually asymptomatic, but sometimes, in addition to symptoms of overt hypothyroidism, patients may complain of headaches, hypopituitarism, visual field impairment, and hyperprolactinemia. Furthermore, on imaging, pituitary hyperplasia can be mistaken for a pituitary adenoma. Distinguishing between the two is crucial, as their management differs; the former often responds to thyroid hormone replacement therapy, while the latter might need treatment with surgery and/or radiotherapy. Here we describe a patient who developed pituitary hyperplasia in the setting of longstanding uncompensated primary hypothyroidism due to a lack of compliance with levothyroxine replacement therapy. We also review the clinical, laboratory, and radiologic findings of the case reports available in the literature up to now in order to improve the knowledge and the care of the disease.

Huge Bilateral Ovarian Cysts With Concurrent Hypothyroidism: A Case Report

A 19-year-old girl with a short stature and presenting low intelligence quotient, illegible speech, and a greatly distended abdomen was seen at the gynecological outpatient department. She underwent investigation and was found to have large abdominopelvic multicystic ovaries with no malignant features and CA125 levels within the normal range for premenopausal women. Her thyroid-stimulating hormone (TSH) was markedly elevated. She received a diagnosis of untreated severe hypothyroidism with benign giant ovarian cysts, posing a grave risk of cyst rupture and imminent complications. The parents were counseled, and they accepted the risk, agreeing to conservative therapy. Levothyroxine replacement therapy was initiated, and after one month, her TSH levels normalized. Follow-up ultrasonography after one month of her therapy revealed a marked decrease in ovarian cyst size. Thyroid replacement therapy was continued, and at the end of three months, the cysts disappeared, and the ovaries, much smaller, showed polycystic ovarian morphology. Careful analysis of clinical signs, investigations, and appropriate therapy helped avoid unnecessary surgery.

Spontaneous Ovarian Hyperstimulation Syndrome Associated With Primary Hypothyroidism

Ovarian hyperstimulation syndrome is a rare condition in pregnant women. Most cases are associated with the use of ovulation induction and stimulation medications. Some studies have reported cases of this condition in non-pregnant women or women undergoing ovulation therapy. In this case report, we report the case of a 27-year-old pregnant Saudi woman presenting with a picture of severe spontaneous ovarian hyperstimulation syndrome secondary to severe undiagnosed hypothyroidism. Treatment with Eltroxin (thyroxine) led to complete improvement and regression of ovarian enlargement after empirical titrating thyroxin replacement therapy, which proved the presence of this causation. The diagnosis was confirmed by laboratory and imaging findings, which helped prompt management and prevented complications of unneeded surgical intervention.

Multicystic ovaries and pituitary pseudo-adenoma associated with primary hypothyroidism

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.

Characteristics of girls with pituitary hyperplasia and sexual precocity secondary to primary hypothyroidism

AIM

To investigate the different characteristics of girls with pituitary hyperplasia secondary to primary hypothyroidism (PPH), with and without sexual precocity.

METHODS

Pituitary hyperplasia secondary to primary hypothyroidism girls were divided into two groups: group A, with sexual precocity (n = 8), and group B, without sexual precocity (n = 14). The following values were measured before and after 3 months levothyroxine therapy: free triiodothyronine (FT3 ), free thyroxine (FT4 ), thyrotropin (TSH), follicle-stimulating hormone (FSH), luteinising hormone (LH), prolactin (PRL), estradiol (E2 ), testosterone (T), pituitary height, uterine volume (UV), ovarian volume (OV) and follicular diameter (FD).

RESULTS

Thyrotropin, FSH, PRL, E2 , T, pituitary height, UV, OV and FD were higher in group A than group B (all p < 0.05); FT3 , FT4 and LH levels were not different (all p > 0.05). In all of the PPH girls, pituitary height was correlated with FT3 , FT4 and PRL (r = -0.545, p = 0.009, r = -0.567, p = 0.006 and r = 0.666, p = 0.001, respectively). PRL was positively correlated with UV, FD and FSH (r = 0.581, p = 0.005, r = 0.482, p = 0.031 and r = 0.667, p = 0.001, respectively), and FSH was positively correlated with OV (r = 0.522, p = 0.013). These abnormalities regressed after therapy.

CONCLUSION

Pituitary hyperplasia secondary to primary hypothyroidism girls with sexual precocity have increased plasma TSH, FSH, PRL, E2 and T levels, pituitary height and uterine, ovarian and follicular size.

Vanishing large ovarian cyst with thyroxine therapy

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.

Juvenile hypothyroidism presenting with hypertrichosis, multicystic ovaries, and pituitary adenoma

Primary hypothyroidism may present with atypical features in children. Here we report a 6-year-old female child with primary hypothyroidism presenting with a combination of several atypical features in the form of hypertrichosis, bilateral cystic ovaries, and feedback pituitary adenoma.

Case report on spontaneous ovarian hyperstimulation syndrome following natural conception associated with primary hypothyroidism

Spontaneous OHSS is a rare event in pregnancy following natural conception and only a few cases have been reported in the literature so far. This report is a case of spontaneously conceived pregnancy with Spontaneous OHSS and Primary hypothyroidism.

Acute ovarian torsion and primary hypothyroidism

A 12-year-old girl presented with acute abdominal pain due to an acute ovarian torsion. She required an oophorectomy. Clinical and laboratory assessment confirmed severe primary hypothyroidism. In this report, we review this rare complication of untreated primary hypothyroidism and the physiologic mechanisms proposed to explain this phenomenon.

Spontaneous ovarian hyperstimulation syndrome and pituitary hyperplasia mimicking macroadenoma associated with primary hypothyroidism

We report an unusual case of spontaneous ovarian hyperstimulation syndrome and pituitary hyperplasia mimicking macroadenoma in an adult, non-pregnant woman. Her condition was triggered by unrecognized primary hypothyroidism, which regressed after thyroid hormone replacement therapy. This case highlights the need for clinicians and radiologists to familiarize themselves with the clinical and imaging features detected in case of these complications of primary hypothyroidism, which are not well known in the medical and radiological profession. Such improved knowledge will help avoid delays in diagnosis, progression to life-threatening complications, and unnecessary surgery.

Ignored adult primary hypothyroidism presenting chiefly with persistent ovarian cysts: a need for increased awareness

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.

Effect of thyroid hormone replacement therapy on ovarian volume and androgen hormones in patients with untreated primary hypothyroidism

BACKGROUND AND OBJECTIVES

Primary hypothyroidism may be associated with ovarian enlargement and/ or cyst formation. We evaluated the effect of thyroid hormone replacement therapy on hormonal changes, ovarian volume and sonographic appearance.

DESIGN AND SETTING

Open, prospective study of women admitted to university gynecology clinic.

PATIENTS AND METHODS

The study included 26 patients with untreated hypothyroidism who had polycystic (n=10) or normal-appearing (n=16) ovaries and 20 euthyroidic controls. Basal serum total testosterone, free testosterone, androstenedione, dehydroepiandosterone-sulfate, prolactin, estradiol, luteinizing hormone, follicle-stimulating hormone, free T3, free T4 and thyroid-stimulating horone, together with ovarian volumes, were determined and repeated after euthyroidism was achieved.

RESULTS

Ovarian volumes of patients with hypothyroidism were significantly greater compared with controls, and their magnitudes diminished significantly during thyroid hormone replacement therapy. Hypothyroidic patients with polycystic ovaries had significantly higher serum free testosterone and dehydroepiandosterone-sulfate, but lower androstenodione levels compared with those who had normal-appearing ovaries. Serum total testosterone concentrations were significantly higher in hypothyroidic patients without polycystic ovaries, and thyroid hormone replacement therapy achieved a significant reduction in total as well as free testosterone.

CONCLUSION

Severe longstanding hypothyroidism leads to increased ovarian volume and/or cyst formation. A decrease in ovarian volume, resolution of ovarian cysts and reversal of the polycystic ovary syndrome-like appearance, together with improvement in serum hormone levels, occurred after euthyroidism was achieved.

Acute abdomen and hypothyroidism

Acute abdomen with multicystic ovaries as a presenting manifestation of juvenile primary hypothyroidism is rare. Appropriate diagnosis and levothyroxine treatment is rewarding and avoids inadvertent surgery. We present three such cases.

Primary hypothyroidism in a child simulating a prolactin-secreting adenoma

OBJECTS

To report a case of primary hypothyroidism associated to hyperprolactinemia mimicking a prolactin secreting adenoma.

MATERIALS AND METHODS

A girl (10 years and 10 months old) was evaluated for hyperprolactinemia (prolactin: 317 ng/mL [1.9-25]). Diagnostic evaluation demonstrated free thyroxine (F-T4): 0.22 ng/dL (0.75-1.80) and thyroid-stimulating hormone (TSH): 135 UI/mL (0.3-5.0). Pituitary magnetic resonance imaging (MRI) showed an intrasellar and suprasellar mass measuring 1.9 x 1.7 x 1.7 cm, impinging on the optic chiasm. Due to the possibility of a pseudoprolactinoma caused by hyperplasia of the TSH and prolactin-producing cells, she was treated for the primary hypothyroidism with levothyroxine. After 2 months, F-T4, TSH, and prolactin returned to normal values. A new pituitary MRI, 8 months later, demonstrated a complete resolution of the pituitary mass confirming the initial suspicion of thyrotroph hyperplasia.

CONCLUSION

This paper illustrates the importance of thyroid function investigation in patients with hyperprolactinemia and possible prolactinoma in order to avoid unnecessary surgery.

Evaluating the roles of follicle-stimulating hormone receptor polymorphisms in gonadal hyperstimulation associated with severe juvenile primary hypothyroidism

CONTEXT

Rare activating mutations of the human (h)FSHR have been reported in some women with spontaneous ovarian hyperstimulation in pregnancy, where follicular growth is inappropriately stimulated by elevated concentrations of human chorionic gonadotropin acting through the hFSHR. It is not known whether ovarian hyperstimulation in peripubertal girls with untreated primary hypothyroidism is caused by hFSHR mutations and/or influenced by hFSHR allelic variants, rendering the hFSHR more sensitive to circulating TSH.

OBJECTIVE

The aim of the study was to determine whether mutations of the hFSHR and/or hFSHR allelic variants are associated with greater sensitivity of the hFSHR to TSH.

DESIGN

The hFSHR gene was sequenced from eight pediatric patients displaying gonadal hyperstimulation due to primary hypothyroidism. HEK293 cells expressing different hFSHR allelic combinations were studied for their responsiveness to recombinant (r)hTSH.

SETTING

The study was conducted at university research centers.

PATIENTS

Eight unrelated patients (seven girls and one boy) who exhibited primary hypothyroidism and gonadal hyperstimulation were included in the study.

INTERVENTIONS

There were no interventions.

MAIN OUTCOME MEASURE

DNA sequencing of the hFSHR gene was the main outcome measure. Basal, rhFSHR- and rhTSH receptor-stimulated cAMP levels were assayed in HEK293 cells transfected with the hTSH receptor or different hFSHR allelic combinations. Cell surface receptor numbers were also determined.

RESULTS

No hFSHR mutations were identified in the patient population, but we did identify two known polymorphisms. In vitro experiments demonstrated a dose-dependent and specific rhTSH-dependent increase in cAMP production in HEK293 cells expressing the wild-type hFSHR, regardless of hFSHR isoform.

CONCLUSIONS

Pediatric gonadal hyperstimulation associated with severe primary hypothyroidism is likely due to the actions of the elevated concentrations of TSH on the wild-type hFSHR, and this response is not dependent upon the hFSHR isoform.