Low androgen signaling rescues genome integrity with innate immune response by reducing fertility in humans

Development of the gonads under complex androgen regulation is critical for germ cells specification. In this work we addressed the relationship between androgens and genomic integrity determining human fertility. We used different study groups: individuals with Differences of Sex Development (DSD), including Complete Androgen Insensitivity Syndrome (CAIS) due to mutated androgen receptor (AR), and men with idiopathic nonobstructive azoospermia. Both showed genome integrity status influenced by androgen signaling via innate immune response activation in blood and gonads. Whole proteome analysis connected low AR to interleukin-specific gene expression, while compromised genome stability and tumorigenesis were also supported by interferons. AR expression was associated with predominant DNA damage phenotype, that eliminated AR-positive Sertoli cells as the degeneration of gonads increased. Low AR contributed to resistance from the inhibition of DNA repair in primary leukocytes. Downregulation of androgen promoted apoptosis and specific innate immune response with higher susceptibility in cells carrying genomic instability.

Robotic-Assisted Laparoscopic Approach to Removal of Müllerian Remnants

BACKGROUND

Robotic-assisted laparoscopy (RAL) is an alternative to traditional laparoscopic surgery that might increase a surgeon's ability to offer minimally invasive removal of Müllerian remnants (MR) to patients with complex anatomy. We report on 2 cases of RAL resection of MR.

CASES

RAL allowed for adequate resection of MR without complications in 2 cases. Case 1 was a 13 year-old female adolescent with VACTERL and uterine remnant close to the ureter of her ipsilateral single kidney. Case 2 was a 16 year-old female adolescent with cloacal exstrophy and omphalocele with remnant hindgut and cervical remnant deep in the pelvis close to the ileal conduit.

SUMMARY AND CONCLUSION

In 2 adolescents with complex anatomy and surgical history, RAL allowed for successful removal of MR.

Implications of Ehlers-Danlos Syndrome in a Patient With Mayer-Rokitansky-Küster-Hauser Syndrome

BACKGROUND

Ehlers-Danlos syndromes (EDS) are a heterogenous group of connective tissue disorders characterized by defective collagen production. Patients with EDS have lax and fragile connective tissue in their joints, skin, blood vessels, and hollow organs. This can lead to, among other complications, joint hypermobility, aneurysms, organ prolapse, and musculoskeletal chronic pain. Given that patients with vaginal agenesis, which occurs with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, often require vaginal dilation as part of their treatment, tissue elasticity and fragility are important considerations. This case report aims to describe the intersection of MRKH and EDS and its impact on vaginal dilation.

CASE

A 16-year-old girl with joint hypermobility and type III EDS presented with primary amenorrhea and a karyotype of 46 XX. Magnetic resonance imaging confirmed an absent uterus, cervix, and upper vagina. Physical examination showed Tanner V breasts and Tanner IV pubic hair, and an external genital examination revealed a blind-ending, 1-cm vaginal dimple. The patient was diagnosed with MRKH. Following her diagnosis, she received vaginal dilation instruction and returned for follow-up 2 months later, having quickly progressed to the largest vaginal dilator without symptoms of bleeding, pain, or dysuria. In that timeframe, her vaginal dimple had increased from 1 cm to 7-8 cm in depth, a rate much faster than is typically seen. Because of this rapid progress, a urogenital examination was performed. There was no evidence of urethral abnormality, perforation, or vaginal prolapse.

SUMMARY AND CONCLUSION

Recognition of EDS in patients with Müllerian anomalies has important implications for safe and effective vaginal dilation. All patients using vaginal dilation to lengthen the vagina require education on the technique. This need is heightened in patients with EDS in order to prevent accidental dilation of the urethra due to their tissue elasticity, to avoid tissue prolapse, and to prevent the theoretical risk of vaginal perforation.

P–514 RAN-Translation in Fragile X associated Premature Ovarian Insufficiency (FXPOI): FMRpolyG as a predictive tool

Study question

Does repeat-associated non-AUG (RAN) translation lead to accumulation of polyglycine- containing protein (FMRpolyG) in human lymphocytes and mural granulosa cells of FMR1 premutation carriers?

Summary answer

Lymphocytes and granulosa cells from FMR1 premutation carriers contain intracellular inclusions that stain positive for both FMRpolyG and ubiquitin. What is known already: Fragile-X-associated-Primary-Ovarian-Insufficiency (FXPOI) is characterized by oligo/amenorrhea and hypergonadotropic hypogonadism associated with the expansion of CGG-repeats in the 5’UTR of FMR1, called premutation (PM) (n: 55–200). Approximately 20% of women carrying a FMR1-premutation (PM) allele develop FXPOI. RAN-translation dependent on variable CGG-repeat length is hypothesized to cause FXPOI due to the production of a polyglycine-containing FMR1-protein, FMRpolyG. Recently, FMRpolyG inclusions were found in neuronal brain cells of FXTAS patients and stromal cells of the ovary of an FXPOI patient. Study design, size, duration: Lymphocytes and granulosa cells (GCs) from women with PM (6) and women without PM (10) (controls) were analyzed by immunofluorescence (IF) staining for the presence of inclusions positive for ubiquitin and FMRpolyG. Cell lysis and protein extraction samples were subjected to Fluorescent Western Blot (WB) analysis to detect FMRP and FMRpolyG

Participants/materials, setting, methods

Human GCs were obtained from follicular fluid after oocyte retrieval and lymphocytes were isolated from peripheral blood using Ficoll-Paque. Cells suspended in PBS were adhered to a glass-coverslip placed at the bottom of the 6-well culture plate, via gravity sedimentation. Adhered cells were fixed, IF staining for FMRpolyG and ubiquitin was performed and analyzed by fluorescence microscopy. Fluorescent WB was used to demonstrate the expression of FMRP, FMRpolyG in extracted protein from lymphocytes and GCs.

Main results and the role of chance

FMRP was successfully detected by fluorescence WB in both lymphocytes and GCs. FMRP is mainly present in cytoplasm and was expressed in greater amount in GCs than in leukocytes. Moreover, FMRP expression was significantly decreased in GCs from FMR1-PM compared with controls. Lymphocytes from PM-carriers and controls were immunostained for FMRpolyG and ubiquitin. In PM-carriers, FMRpolyG was present as aggregates, whereas in controls only a weak signal without inclusions was detectable. The expression pattern of FMRpolyG in GCs was similar to that in lymphocytes with a significant increase in PM-carriers. There, the FMRpolyG-aggregates additionally demonstrated as ubiquitin-positive inclusions. These may resemble the toxic potential of these protein fractions involved the ovarian damage in developing FXPOI.

Limitations, reasons for caution

More patients are needed to support the present findings. Further investigation into the possible consequences of these FMRpolyG-positive inclusions in PM-carriers is also advisable.

Wider implications of the findings: We found for the first time FMRpolyG-accumulation in lymphocytes and GCs from FMR1-PM-carriers in ubiquitin-positive inclusions. Future experiments evaluating consistency in more patients and elucidating the impact on fertility and prospective value for individual ovarian reserve are therefore in preparation.

Trial registration number

Not applicable

FMR1 expression in human granulosa cells and variable ovarian response: control by epigenetic mechanisms

In humans, FMR1 (fragile X mental retardation 1) is strongly expressed in granulosa cells (GCs) of the female germline and apparently controls efficiency of folliculogenesis. Major control mechanism(s) of the gene transcription rate seem to be based on the rate of CpG-methylation along the CpG island promoter. Conducting CpG-methylation-specific bisulfite-treated PCR assays and subsequent sequence analyses of both gene alleles, revealed three variably methylated CpG domains (FMR1-VMR (variably methylated region) 1, -2, -3) and one completely unmethylated CpG-region (FMR1-UMR) in this extended FMR1-promoter-region. FMR1-UMR in the core promoter was exclusively present only in female GCs, suggesting expression from both gene alleles, i.e., escaping the female-specific X-inactivation mechanism for the second gene allele. Screening for putative target sites of transcription factors binding with CpG methylation dependence, we identified a target site for the transcriptional activator E2F1 in FMR1-VMR3. Using specific electrophoretic mobility shift assays, we found E2F1 binding efficiency to be dependent on CpG-site methylation in its target sequence. Comparative analysis of these CpGs revealed that CpG 94-methylation in primary GCs of women with normal and reduced efficiency of folliculogenesis statistically significant differences. We therefore conclude that E2F1 binding to FMR1-VMR3 in human GCs is part of an epigenetic mechanism regulating the efficiency of human folliculogenesis. Our data indicate that epigenetic mechanisms may control GC FMR1-expression rates.

Intraindividual Embryo Morphokinetics Are Not Affected by a Switch of the Ovarian Stimulation Protocol Between GnRH Agonist vs. Antagonist Regimens in Consecutive Cycles

Background: The impact of controlled ovarian stimulation (COS) during medically assisted reproduction (MAR) on human embryogenesis is still unclear. Therefore, we investigated if early embryonic development is affected by the type of gonadotropin-releasing hormone (GnRH) analog used to prevent a premature LH surge. We compared embryo morphology and morphokinetics between GnRH agonist and antagonist cycles, both involving human chorionic gonadotropin (hCG)-trigger. To reduce possible confounding factors, we used intraindividual comparison of embryo morphokinetics in consecutive treatment cycles of the same patients that underwent a switch in the COS protocol. Methods: This retrospective cohort study analyzed morphokinetics of embryos from patients (n = 49) undergoing a switch in COS protocols between GnRH agonists followed by GnRH antagonists, or vice versa, after culture in a time-lapse incubator (EmbryoScope®, Vitrolife) in our clinic between 06/2011 and 11/2016 (n = 49 GnRH agonist cycles with n = 172 embryos; n = 49 GnRH antagonist cycles with n = 163 embryos). Among time-lapse cycles we included all embryos of the two consecutive cycles before and after a switch in the type of COS in the same patient. In-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) was performed and embryos were imaged up to day 5. Data were analyzed using Mann-Whitney U test or Fisher's exact test. The significance level was set to p = 0.05. Patients with preimplantation genetic screening cycles were excluded. Results: The mean age (years ± standard deviation) of patients at the time of treatment was 35.7 ± 4.3 (GnRH agonist) and 35.8 ± 4.0 (GnRH antagonist) (p = 0.94). There was no statistically significant difference in the number of oocytes collected or the fertilization rate. The numbers of top quality embryos (TQE), good-quality embryos (GQE), or poor-quality embryos (PQE) were also not different in GnRH agonist vs. antagonist cycles. We found no statistically significant difference between the analyzed morphokinetic parameters between the study groups. Conclusions: Our finding supports the flexible use of GnRH analogs to optimize patient treatment for COS without affecting embryo morphokinetics.

FMR1 expression in human granulosa cells increases with exon 1 CGG repeat length depending on ovarian reserve

BACKGROUND

Fragile-X-Mental-Retardation-1- (FMR1)-gene is supposed to be a key gene for ovarian reserve and folliculogenesis. It contains in its 5'-UTR a triplet-base-repeat (CGG), that varies between 26 and 34 in general population. CGG-repeat-lengths with 55-200 repeats (pre-mutation = PM) show instable heredity with a tendency to increase and are associated with premature-ovarian-insufficiency or failure (POI/POF) in about 20%. FMR1-mRNA-expression in leucocytes and granulosa cells (GCs) increases with CGG-repeat-length in PM-carriers, but variable FMR1-expression profiles were also described in women with POI without PM-FMR1 repeat-length. Additionally, associations between low numbers of retrieved oocytes and elevated FMR1-expression levels have been shown in GCs of females with mid-range PM-CGG-repeats without POI. Effects of FMR1-repeat-lengths-deviations (n < 26 or n > 34) below the PM range (n < 55) on ovarian reserve and response to ovarian stimulation remain controversial.

METHODS

We enrolled 229 women undergoing controlled ovarian hyperstimulation for IVF/ICSI-treatment and devided them in three ovarian-response-subgroups: Poor responder (POR) after Bologna Criteria, polycystic ovary syndrome (PCO) after Rotterdam Criteria, or normal responder (NOR, control group). Subjects were subdivided into six genotypes according to their be-allelic CGG-repeat length. FMR1-CGG-repeat-length was determined using ALF-express-DNA-sequencer or ABI 3100/3130 × 1-sequencer. mRNA was extracted from GCs after follicular aspiration and quantitative FMR1-expression was determined using specific TaqMan-Assay and applying the ΔΔCT method. Kruskall-Wallis-Test or ANOVA were used for simple comparison between ovarian reserve (NOR, POR or PCO) and CGG-subgroups or cohort demographic data. All statistical analysis were performed with SPSS and statistical significance was set at p ≤ 0.05.

RESULTS

A statistically significant increase in FMR1-mRNA-expression-levels was detected in GCs of PORs with heterozygous normal/low-CGG-repeat-length compared with other genotypes (p = 0.044).

CONCLUSION

Female ovarian response may be negatively affected by low CGG-alleles during stimulation. In addition, due to a low-allele-effect, folliculogenesis may be impaired already prior to stimulation leading to diminished ovarian reserve and poor ovarian response. A better understanding of FMR1 expression-regulation in GCs may help to elucidate pathomechanisms of folliculogenesis disorders and to develop risk-adjusted treatments for IVF/ICSI-therapy. Herewith FMR1-genotyping potentially provides a better estimatation of treatment outcome and allows the optimal adaptation of stimulation protocols in future.

Differences in bleeding phenotype and provider interventions in postmenarchal adolescents when compared to adult women with bleeding disorders and heavy menstrual bleeding

INTRODUCTION

Due to lack of patient/health care provider awareness causing delayed diagnosis, the bleeding phenotype and provider interventions in adolescents with heavy menstrual bleeding (HMB) and bleeding disorders (BD) may be different when compared to adults.

AIM

The aim of this study was to compare/characterize bleeding phenotype and provider interventions in postmenarchal adolescents < 18 years and premenopausal adults ≥ 18 years with HMB and BD.

METHODS

Patient demographics, BD, and provider interventions/therapy details for HMB were compared between both age groups enrolled in the Centers for Disease Control and Prevention (CDC) Female Universal Data Collection (UDC) surveillance project in United States hemophilia treatment centres. Cross-sectional descriptive analyses including frequency distributions, summary statistics, bivariate and logistic regression analyses were performed.

RESULTS

Of 269 females (79 adolescents; median age 16 years, interquartile range (IQR) = 2; 190 adults; median age 27 years, IQR = 13) evaluated, BD distribution was similar in both groups. Compared to adolescents, adults more often had family history of bleeding (Adjusted odds ratios [AOR] = 2.6, 1.3-5.6), delay in diagnosis (AOR = 2.5, 1.2-4.9), bleeding with dental procedures (AOR = 2.0, 1.0-4.0), gastrointestinal bleeding (AOR = 4.6, 1.0-21.9), anaemia (AOR = 2.7, 1.4-5.2), utilized desmopressin less often (AOR = 0.4, 0.2-0.8) and underwent gynaecologic procedure/surgery more frequently (AOR = 5.9, 1.3-27.3).

CONCLUSION

Bleeding phenotypes of adolescents and adults with HMB and BD were different with more frequent bleeding complications, anaemia, gynaecologic procedures/surgeries, less desmopressin use and more delay in diagnosing BD in adults. Longitudinal studies are needed to determine whether improved patient/provider awareness and education will translate to early diagnosis and timely management of BD/HMB in adolescents that may prevent/reduce future haematologic/gynaecologic complications.

Crohn's Disease and Gynecologic Manifestations in Young Women

STUDY OBJECTIVE

The purpose of this study was to describe the reproductive and gynecological concerns of young women with Crohn's disease.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective chart review of young women with Crohn's disease and gynecologic concerns at a large, urban tertiary children's hospital.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Documentation of abnormal bleeding, pelvic pain, genital fistula, ulcer, or abscess.

RESULTS

Most of the patients (85.7%) had menstrual concerns reported as abnormal bleeding patterns or chronic pelvic pain. Genital complaints (fistula, ulcer, or abscess) were present in 75% of patients who ultimately required immune modulators or antibiotics to control their Crohn's disease. Genital complaints were present in only 1 of 3 patients who did not have a history of immune modulator use for Crohn's disease related flare.

CONCLUSION

There is a paucity of information available on gynecological concerns occurring in patients with Crohn's disease. Providers should be aware of gynecological manifestations that might appear concurrently with Crohn's colitis, including vulvovaginal pain, vulvar infections, rectovaginal or rectovestibular fistulas, pelvic pain, and menstrual irregularities.

The female reproductive tract: congenital concerns

The incidence and prevalence of conditions of the reproductive tract varies. This is related to both the complexity and spectrum of underlying and associated conditions. In some cases, only retrospective or case data are available, and likely under-reporting occurs, contributing to a lower than expected prevalence. Given the complex nature in which the reproductive tract develops in the fetus, it is important to understand the embryology, especially in situations of congenital anatomic differences. It is interesting to note not only patterns of conditions, but patterns of concurrent conditions or anomalies such as those occurring with isolated Müllerian anomalies, in conjunction with disorders of sexual differentiation or with cloacal malformations. This review will address typical presentation of these conditions, highlights of management and point to areas of research need, including clinical outcomes and genetic implications.

Use of the Lumitex MD Lightmat® Surgical Illuminator for pediatric genital trauma cases: a retrospective case series

STUDY OBJECTIVES

To review the literature regarding repair of pediatric female genital trauma. To review our experience with the use of a lighted retractor at the time of repair of genital trauma in an operating room setting.

STUDY DESIGN

Retrospective case series.

SETTING

Texas Children's Hospital.

PARTICIPANTS

Patients with genital trauma requiring repair in an operating room setting where the Lumitex MD Lightmat Surgical Illuminator (LM) was utilized.

INTERVENTIONS

Use of the LM in pediatric gynecology patients.

RESULTS

Of the 16 cases where the LM lighted retractor was utilized, 12 were found to be performed secondary to genital trauma, resulting from straddle injury or coital trauma. Four patients were identified as having either congenital reproductive tract anomalies or foreign body. Patients ranged in age from 1-21 years with a mean age of 9 ± 4.91 years at the time of their vaginal repair. The mean operative time was 82 ± 47 minutes, with cases ranging from 37-182 minutes, with a median blood loss of 7 mL and an average hospital stay of 1.2 days. There were no surgical complications.

CONCLUSION

Neurosurgeons and otolaryngologists have been optimizing safe visualization of small areas during surgery for years with the use of the LM. In cases of pediatric deep genital trauma, the LM can be used safely for easy visualization, allowing for direct visualization in cases of deep genital trauma.

Diagnostic challenges in patients with bleeding phenotype and von Willebrand exon 28 polymorphism p.D1472H

Exon 28 polymorphism p.D1472H is associated with significantly lower von Willebrand Ristocetin cofactor activity (VWF:RCoF) to von Willebrand antigen (VWF:Ag) ratio compared to normal, but has been reported as not conferring haemorrhagic risk. The impact of this polymorphism while assessing symptomatic patients for von Willebrand disease (VWD) has not been previously analysed. We retrospectively reviewed charts of children with clinically significant bleeding and abnormal VW panel who underwent VW exon 28 analysis. Twenty-three of 63 patients studied had p.D1472H. Of these 23 patients, 6 with borderline low VWF:RCo were given provisional diagnosis of VWD type 1 by treating physicians, which could be alternatively explained as due to the effect of p.D1472H. None of the patients with low VWF:RCo, decreased VWF:RCo/VWF:Ag ratio and p.D1472H had VWD type 2M mutations identified. This study illustrates the challenge in diagnosing VWD using ristocetin-based VW assay in symptomatic patients with p.D1472H.

The utility of ultrasound and magnetic resonance imaging versus surgery for the characterization of müllerian anomalies in the pediatric and adolescent population

STUDY OBJECTIVE

To evaluate the utility of transabdominal ultrasound and magnetic resonance imaging in the evaluation of American Society for Reproductive Medicine (†)(ASRM)-classified müllerian anomalies compared to surgical findings in the pediatric and adolescent population.

DESIGN

Retrospective chart review.

SETTING

Tertiary academic center.

PARTICIPANTS

Thirty-eight patients with müllerian anomalies seen in our pediatric and adolescent gynecology clinic were identified both on the basis of ICD-9 codes and having magnetic resonance imaging at Texas Children's Hospital between 2004 and 2009.

INTERVENTIONS

None.

MAIN OUTCOMES MEASURE

Correlation among transabdominal ultrasound and magnetic resonance imaging findings with surgical findings.

RESULTS

Mean age was 12.2 (± 4.1) years. Twenty-eight patients underwent magnetic resonance imaging and required surgical intervention, and 88.5% demonstrated correlative consistency with surgical findings. Twenty-two patients underwent ultrasound, magnetic resonance imaging, and surgery, which revealed consistency among ultrasound and surgical findings (59.1%) and consistency among magnetic resonance imaging and surgical findings (90.9%). In ASRM diagnoses evaluated by magnetic resonance imaging, surgical findings correlated in 92% (Pearson 0.89). Overall, 55.2% of patients had a renal malformation.

CONCLUSIONS

Magnetic resonance imaging is the gold standard imaging modality for müllerian anomalies and is an effective technique for noninvasive evaluation and accurate classification of the type of anomaly in the pediatric and adolescent population. Magnetic resonance imaging should be considered as an adjunct to transabdominal ultrasound to evaluate müllerian anomalies.

Use of misoprostol for management of unsatisfactory colposcopy in the adolescent: a case report and review of the literature

STUDY OBJECTIVE

To document the ability to use a prostaglandin analogue to achieve satisfactory colposcopy in a patient with cervical stenosis and unsatisfactory colposcopy.

DESIGN

Case report.

RESULTS

Satisfactory colposcopy was achieved by using 100mg of Misoprostol orally, administered the night before the planned colposcopic evaluation.

CONCLUSION

In the presence of persistent atypia in an adolescent female with an unsatisfactory colposcopy, consider using a prostaglandin analogue for adequate evaluation of the endocervix, prior to proceeding with an ablative or excisional therapy.

Didelphic uterus and obstructed hemivagina with renal agenesis: case report and review of the literature

Congenital disorders of development are more common than previously reported and the correct diagnosis is frequently missed leading to suboptimal treatment. Eight cases of uterus didelphys with obstructed hemivagina referred to the Gynecology service at Baylor College of Medicine over a 2-year period were reviewed. Initial presenting symptoms and signs were followed by an incorrect diagnosis by the referring physician 100% of the time. MRI, the most sensitive imaging modality for congenital anomalies (Kublik, RA: Female pelvis. Eur Radiol 1999; 9:1715), was utilized in only 50% of the cases. In this group of patients, hematocolpos and pyocolpos were discovered in equal numbers upon exploration. Ipsilateral renal anomalies were present 100% of the time, while coexisting contralateral anomalies were present 50% of the time. Resection of the vaginal septum was required for abatement of symptoms in all cases presented here. Laparoscopy provided additional information beyond radiologic tests regarding pelvic and urological anatomy. In two cases, resection of the ipsilateral uterine horn was required. These cases demonstrate the difficulty in diagnosis, heterogeneity in presentation, and need for expertise not only in this rare congenital anomaly but also all the other disorders of development of the female genital tract.

Altered skin elastic fibers in hypothyroid myxedema and pretibial myxedema

Elastic fibers account for 2% of dermal volume and are responsible for normal skin resiliency. We investigated a disorder of the dermal elastic component as the mechanism for the decreased elasticity of skin in myxedema. Skin biopsy specimens were obtained from patients with thyroid diseases and normal subjects matched for age, sex, and biopsy location. Elastic fiber concentration, determined by computerized morphometric analysis of Verhoeff-van Gieson-stained sections, was significantly lower than normal in hypothyroid and pretibial myxedema. The decreased elastin concentration was not a consequence of the glycosaminoglycan infiltration. Ultrastructural studies of myxedematous skin showed wide variability of elastic fiber diameter and decreased microfibrils. Myxedema (hypothyroid and pretibial) is consistently associated with quantitative and qualitative defects of dermal elastic fibers.

Histochemical characterization of the cutaneous involvement of acromegaly

We evaluated the pathogenesis of skin thickening in three patients with acromegaly. Growth hormone levels were normal in one patient and were elevated in two patients. Skin biopsy specimens were obtained from the forearm. Hematoxylineosin staining showed slight epidermal thinning and, in two of the patients, a small increase in the number of fibroblasts. Selective stains for collagen, elastic, and reticular fibers disclosed normal connective tissue. The most striking abnormality was increased glycosaminoglycan deposition on the slides stained with colloidal iron. Glycosaminoglycan infiltration occurred mostly in the papillary and upper reticular dermis and was not directly related to the simultaneous growth hormone levels. Tissue digestion with specific enzymes identified hyaluronic acid, chondroitin-4- and 6-sulfate, and dermatan sulfate as the most prominent glycosaminoglycans in the dermis. The skin ultrastructure appeared to be preserved on electron microscopy. We conclude that cutaneous mucinoses is the main cause for the thickening of the skin in acromegaly.