PERMANENT LOW NORMAL TESTOSTERONE AND LOWER URINARY TRACT SYMPTOMS IN MEN 35 - 45 YEARS OF AGE

In our outpatient practice, we are increasingly seeing men aged 35 to 45 years who have permanent low normal testosterone levels. Aim We set out to investigate whether there is an association between permanent low normal testosterone levels and lower urinary tract symptoms in young men. Patients and Methods For the period from January 2013 to December 2015 at the Andrology office at Hospital "St. Sofia", we examined 73 men aged 35 to 45 years with normal or elevated body mass index, permanent low normal testosterone level and micturition disorders. In order to compare the results we obtained, at the very beginning of the study, we selected a control group of 20 healthy men of the same age. Results We obtained, although within reference ranges, significantly lower values for total testosterone in the 73 men with micturition disorders we studied, compared with those in the control group without micturition disorders. Conclusions 1. Our study shows that in some men at a young age, some deviation in normal testosteronе secretion occurs, with a concomitant decrease in maximum urine flow, which is remarkably different from the same indicator in their peers with a high normal testosterone level. 2. We identify permanent low normal testosterone, overweight, and obesity as predictors of initial lower urinary tract symptoms in young men. 3. According to our study, the altered E2/T ratio is also relevant to the initial onset of lower urinary tract symptoms in young men.

D-Chiro-Inositol improves testosterone levels in older hypogonadal men with low-normal testosterone: a pilot study

BACKGROUND

Several recent journal articles report that D-chiro-inositol (DCI), primarily known as insulin second messenger, influences steroidogenesis. In particular, new evidence is arising on DCI ability to regulate aromatase expression and testosterone biosynthesis. In this regard, DCI administration could represent a good therapeutic opportunity in case of reduced levels of testosterone. Older men generally have lower testosterone concentrations than younger men, and recent randomized controlled trials have examined whether testosterone treatment might improve health outcomes in this age group. There is limited information about the safety of testosterone replacement therapy in these men, hence DCI could represent an interesting alternative for future trials. Therefore, this study aims to evaluate the effect of DCI treatment on testosterone levels in older male patient.

RESULTS

Ten older men with basal low testosterone levels were enrolled in this study. Patients took 600 mg of DCI, two-times per day, for 30 days. We evaluated hormonal and glycaemic parameters, weight, waist circumference, and Body-Mass Index at baseline (T0) and after 30 days (T1). Finally, all patients also filled in the standardized International Index of Erectile Function questionnaire and performed the Handgrip test at T0 and T1. Men receiving DCI showed increased androgen and reduced oestrogen concentrations, and improved glycaemic profiles. DCI was also associated with reduced weight, Body-Mass Index, waist circumference, and improved grip strength and self-reported sexual function. All these effects led to the improvement of sexual function and physical strength.

CONCLUSIONS

In this pilot study, DCI treatment improved the levels of testosterone and androstenedione at the expense of oestrogens in elder men with low basal levels of these hormones without adverse effects.

TRIAL REGISTRATION

Clinicaltrials.gov: D-chiroinositol Administration in Hypogonadal Males, NCT04708249.

New Territory for an Old Disease: 5-Alpha-Reductase Type 2 Deficiency in Bulgaria

Disorders/differences of sexual development (DSD) are a group of conditions, some of which can be clinically indistinguishable mainly due to their phenotypic variability. Defining the molecular basis of their wide spectrum is still in progress. The diagnosis of 5-alpha-reductase type 2 (5α-reductase-2) deficiency is difficult especially in newborns and pre-pubertal individuals, and as a result its frequency might be underestimated. In the present study, we describe the clinical characteristics and molecular defects in 3 nonrelated 5α-reductase-2 deficiency patients of Bulgarian descent. Sequencing analysis revealed the mutations p.Y188CfsX9 and p.G196S, and MLPA analysis showed a deletion of exon 1 in the SRD5A2 gene. The observed genetic substitutions were not detected in 76 additionally screened unrelated controls, but a heterozygous healthy carrier of the p.R171S mutation was found. This is the first study on the molecular basis of 5α-reductase-2 deficiency in Bulgaria. It suggests that the carrier frequency of mutations in the SRD5A2 gene might be noteworthy worldwide. There is no correlation between cultural aspects, location, and/or population size and the number of different mutations in SRD5A2 detected, and more efforts should be made to determine the prevalence of this condition in different geographic areas. Our study supports the importance of genetic testing in 46,XY DSD patients, especially in countries or regions where 5α-reductase-2 deficiency has not been reported so far.

Phenotypic spectrum of POLR3B mutations: isolated hypogonadotropic hypogonadism without neurological or dental anomalies

BACKGROUND

A constellation of neurodegenerative disorders exists (Gordon Holmes syndrome, 4H leucodystrophy, Boucher-Neuhauser syndrome) in which patients suffer from both neurological disease (typically manifested by ataxia) and reproductive failure (idiopathic hypogonadotropic hypogonadism (IHH)). POLR3B, which encodes the second largest subunit of RNA polymerase III (pol III), and POLR3A, which forms the pol III catalytic centre, are associated with 4H leucodystrophy.

METHODS

Whole exome sequencing was performed on a large cohort of subjects with IHH (n=565). Detailed neuroendocrine studies were performed in some individuals within this cohort.

RESULTS

Four individuals (two of them siblings) were identified with two rare nucleotide variants in POLR3B. On initial evaluation, all subjects were free of neurological disease. One patient underwent treatment with exogenous pulsatile gonadotropin-releasing hormone for 8 weeks which failed to result in normalisation of his sex steroid milieu due to pituitary resistance.

CONCLUSIONS

These findings suggest that the spectrum of phenotypes resulting from POLR3B mutations is wider than previously believed and that POLR3B can be associated exclusively with disorders characterised by abnormal gonadotropin secretion.

A Novel SRY Gene Mutation p.F109L in a 46,XY Female with Complete Gonadal Dysgenesis

46,XY complete gonadal dysgenesis (CGD) is a disorder of sexual development that can result from different mutations in genes associated with sex determination. Patients are phenotypically females, and the disease is often diagnosed in late adolescence because of delayed puberty. Here, we present the clinical and molecular data of a 46,XY female CGD patient with gonadoblastoma with dysgerminoma and incidentally found inherited thrombophilia. The clinical significance of the described de novo SRY gene mutation c.325T>C (p.F109L) is discussed. This case report supports the critical role of the HGM domain in the SRY gene and the need of a multidisciplinary approach for CGD patients.

Melatonin receptor 1b polymorphisms in women with Systemic Lupus Erythematosus

AIM

The pineal hormone melatonin could exert an important influence on the immune system and autoimmunity. Its effect on the immunocompetent cells might be mediated at least partially through specific melatonin receptors. However, the role of melatonin - melatonin receptor 1B (MTNR1B) interrelations in human autoimmune diseases is still unknown. Therefore, the present study aimed to investigate the possible influence of the MTNR1B gene polymorphisms for the development and clinical expression of systemic lupus erythematosus (SLE).

METHODS

109 female SLE patients and 101 healthy women were genotyped for the MTNR1B rs1562444, rs10830962 and rs10830963 polymorphisms.

RESULTS

No genotype distribution differences were found between patients and controls. The presence of MTNR1B rs10830963 C/C genotype was related to increased prevalence of leucopenia compared to genotypes C/G and G/G after Bonferroni correction for multiple comparisons [36.5% vs. 14.5%, p=0.014]. Moreover, the rs10830963 G/G carriers had lower number of lupus criteria in comparison to patients with C/C genotype.

CONCLUSIONS

The present data suggested that MTNR1B polymorphisms could influence the clinical features in lupus patients, and especially the susceptibility to leucopenia.

Influence of the body weight on the onset and progression of puberty in boys

BACKGROUND

Unlike in girls, the data on the relationship between pubertal development and body weight in boys are controversial.

METHODS

We measured the height, body weight, body mass index (BMI), pubic hair stages, testicular volume, penis length and circumference of 4030 boys, aged between 7 and 19 years. According to their body weight, the investigated children and adolescents were divided in four groups at each age: underweight boys (BMI <12th percentile), boys with normal weight (12th-84.99th percentile), overweight boys (85th-94.99th percentile) and boys with obesity (BMI ≥95th percentile), and their data were compared.

RESULTS

The onset of puberty occurred when the boys' weight gained 40.33±9.03 kg (median 39.00) and BMI was 18.62±3.12 kg/m2 (median 17.80), whereas the late stage was reached at weight of 62.44±10.39 kg (median 61.00) and BMI 21.47±2.84 kg/m2 (median 21.20). Earlier maturing boys were heavier than their coevals, whereas underweight boys developed puberty later.

CONCLUSIONS

The onset and progression of puberty in boys are in a significant positive relationship with weight and BMI. Moreover, in the overweight boys pubertal development begins and comes to the late stage earlier in comparison with normal weight children, whereas in those who are underweight a delay at every stage of the development is observed.

Decreased daily melatonin levels in women with systemic lupus erythematosus - a short report

BACKGROUND

The neuroendocrine system is known to influence immunity, but the precise interactions between different hormones and autoimmune disorders remain obscure.

AIMS

The present study aimed to investigate the role of daily serum melatonin concentrations in the development of systemic lupus erythematosus (SLE) in women.

STUDY DESIGN

Case-control study.

METHODS

One-hundred and eleven SLE female patients and 46 healthy women were included in the study. Daily serum melatonin levels were investigated in all participants.

RESULTS

SLE patients showed significantly lower daily melatonin levels in comparison to healthy women during the short photoperiod (17.75±7.13 pg/mL [16.05] vs. 21.63±6.60 pg/mL [20.10], p=0.012). Hormone concentrations were inversely related to the SLE activity index (SLEDAI) (r= -0.268, p=0.004), but they did not correlate to any particular American College Rheumatology (ACR) criterion (p>0.05 for all).

CONCLUSION

Daily melatonin levels were decreased in women with systemic lupus erythematosus and correlated inversely to the activity of the autoimmune disease. Further studies are needed to clarify the importance of the pineal and extrapineal melatonin secretion in patients with systemic lupus erythematosus as well as the interrelations between hormones and autoimmunity.

Sperm disturbances in metabolic syndrome: what we actually know

Evaluation of: Lotti F, Corona G, Degli Innocenti S et al. Seminal, ultrasound and psychobiological parameters correlate with metabolic syndrome in male members of infertile couples. Andrology 1(2), 229-239 (2013). Male hypogonadism is considered a fundamental component of metabolic syndrome (MetS), but the data concerning sperm quality in men with MetS are still scarce. The role of MetS in male fertility is poorly investigated owing to the fact that the prevalence of metabolic syndrome increases with age and peaks at the time when reproductive plans of couples are already accomplished. However, the worldwide trend towards a younger age of MetS development, owing to the increase in obesity, and the tendency for reproduction later in life could aggravate the influence of the metabolic disturbances on male reproduction. The present article is an important step in the study of the interrelations between MetS and subfertility.

Mutations in FGF17, IL17RD, DUSP6, SPRY4, and FLRT3 are identified in individuals with congenital hypogonadotropic hypogonadism

Congenital hypogonadotropic hypogonadism (CHH) and its anosmia-associated form (Kallmann syndrome [KS]) are genetically heterogeneous. Among the >15 genes implicated in these conditions, mutations in FGF8 and FGFR1 account for ~12% of cases; notably, KAL1 and HS6ST1 are also involved in FGFR1 signaling and can be mutated in CHH. We therefore hypothesized that mutations in genes encoding a broader range of modulators of the FGFR1 pathway might contribute to the genetics of CHH as causal or modifier mutations. Thus, we aimed to (1) investigate whether CHH individuals harbor mutations in members of the so-called "FGF8 synexpression" group and (2) validate the ability of a bioinformatics algorithm on the basis of protein-protein interactome data (interactome-based affiliation scoring [IBAS]) to identify high-quality candidate genes. On the basis of sequence homology, expression, and structural and functional data, seven genes were selected and sequenced in 386 unrelated CHH individuals and 155 controls. Except for FGF18 and SPRY2, all other genes were found to be mutated in CHH individuals: FGF17 (n = 3 individuals), IL17RD (n = 8), DUSP6 (n = 5), SPRY4 (n = 14), and FLRT3 (n = 3). Independently, IBAS predicted FGF17 and IL17RD as the two top candidates in the entire proteome on the basis of a statistical test of their protein-protein interaction patterns to proteins known to be altered in CHH. Most of the FGF17 and IL17RD mutations altered protein function in vitro. IL17RD mutations were found only in KS individuals and were strongly linked to hearing loss (6/8 individuals). Mutations in genes encoding components of the FGF pathway are associated with complex modes of CHH inheritance and act primarily as contributors to an oligogenic genetic architecture underlying CHH.

Androgen receptor (CAG)n polymorphism and androgen levels in women with systemic lupus erythematosus and healthy controls

Systemic lupus erythematosus (SLE) is an autoimmune disorder that affects mainly females. Therefore, interrelations between the reproductive and immune system have been assumed. Considering the complex influence of hormones and receptors, we aimed to investigate the influence of androgens and androgen receptor (AR) polymorphism in women with SLE. One hundred and sixteen patients and 44 healthy women were investigated. Testosterone, sex hormone-binding globulin (SHBG), dehydroepiandrosterone-sulphate (DHEAS) concentrations and AR (CAG)n polymorphism were determined. SLE patients had significantly lower levels of total and free testosterone and DHEAS in comparison with the controls. No differences in the CAG repeat length between the groups were established. Women with two alleles carrying more than 22 CAG repeats had significantly higher levels of SHBG (101.51 ± 61.81 vs. 69.22 ± 45.93 nmol/l, p = 0.015) and DHEAS (3.11 ± 2.65 vs. 2.11 ± 3.06 μmol/l, p = 0.007) and a tendency to higher testosterone concentrations (2.35 ± 2.10 vs. 1.71 ± 1.70 nmol/l, p = 0.056) in comparison with other women. The CAG repeat length in the relatively longer (CAG)n allele was inversely related to the Systemic Lupus International Collaborating Clinics/ACR index (r = -0.258, p = 0.009). In conclusion, the androgen receptor (CAG)n polymorphism is not related to the development of SLE, but it could modulate the severity of the lupus chronic damages as well as the androgen levels in women.

Anti-Müllerian hormone in women with polycystic ovary syndrome before and after therapy with metformin

Anti-Müllerian hormone (AMH) is largely expressed throughout folliculogenesis and its levels may represent both the quantity and quality of ovarian follicle pool. We conducted this study to evaluate the levels of AMH in women with polycystic ovarian syndrome (PCOS) before and after metformin therapy. 22 consecutive patients with PCOS and 20 healthy age-matched controls were investigated. The patients received 2 550 mg/day metformin for 6 months. Serum levels of AMH, sex hormones, insulin, blood glucose, and lipids were measured before and after metformin therapy. The basal AMH levels in patients with PCOS (42.34±6.42 pmol/l) were significantly elevated in comparison with the controls (21.58±3.41 pmol/l), p=0.008. 17 patients completed 6 months therapy with metformin. Of them, 13 responded clinically by restoration of regular menstrual cycles. The AMH levels of these 13 women decreased from 45.67±9.30 pmol/l to 38.25±6.89 pmol/l (16.27%). In the other 4 patients who did not show satisfactory clinical response to metformin, AMH levels increased from 31.30±16.52 to 80.77±12.73 (p=0.021). The patients who responded to metformin were significantly overweight, had higher BMI, waist circumference, body fat, and blood pressure as compared to nonresponders. AMH levels are significantly elevated in women with PCOS and they may serve as a marker for evaluation of treatment efficacy with metformin. Furthermore, obese PCOS patients are more likely to respond to metformin therapy with maximal doses as compared to the ones with low body mass index.

Growth and development of male external genitalia: a cross-sectional study of 6200 males aged 0 to 19 years

OBJECTIVE

To provide estimates of normal variations in penile measurements and testicular volumes, and to establish reference ranges for clinical use.

DESIGN

Cross-sectional, population-based study.

SETTING

Schools, kindergartens, and child care centers in different parts of Bulgaria.

PARTICIPANTS

A population of 6200 clinically healthy white males aged 0 to 19 years.

INTERVENTIONS

The study physician chose schools, kindergartens, and child care centers randomly and examined children at random until he reached the required number. Each of the 20 age groups (age range, 0-19 years) had an equal number of males (ie, 310).

MAIN OUTCOME MEASURES

The mean (SD) values and fifth, 50th, and 95th percentiles of height (Siber Hegner anthropometer), weight (beam balance), testicular volume (Prader orchidometer), penile length (rigid tape), and penile circumference (measuring tape) from birth to 19 years of age.

RESULTS

Testes did not show any increase in size until the onset of puberty at age 11 years, whereas penile growth was gradual after birth. However, both penile and testicular development demonstrated peak growth from 12 to 16 years of age, which coincided with the maximal male pubertal growth spurt. Data indicate an earlier pubertal development for this study population than that for a similar population several decades ago. Significant differences between urban and rural populations regarding penile length were also noticed.

CONCLUSIONS

Our study provides the contemporary reference range values for height, weight, testicular volume, and penile length and circumference of males aged 0 to 19 years. Our data show that, even by the end of 20th century, there is still some acceleration of male pubertal development. For the first time are reported somatic differences in genitalia within a population between urban and rural representatives.

Prevalence of cryptorchidism among Bulgarian boys

BACKGROUND

Cryptorchidism is the most common congenital defect of the male urogenital system. It may be an important cause for male infertility. The data about its prevalence in South-eastern European countries and especially for the Balkan region are still incomplete.

OBJECTIVE

The aim of the present study was to establish the prevalence of the abnormality in the Bulgarian population living in the different areas of the country.

METHODS

In a population-based cross-sectional study in Bulgaria 6200 Caucasian boys (aged under 1 year to 19 years) from five regions of the country were included. One physician examined all children in order to reduce the inter-observer error.

RESULTS

The prevalence of cryptorchidism was 1.52% for the total group. It was 3.2% for boys under one year of age, 2.1% for those between one and ten years and dropped significantly in older boys (0.6%). No regional or seasonal trends were established.

CONCLUSIONS

Our study suggests a relatively higher prevalence of cryptorchidism in Bulgaria for children younger than one year of age, while the overall prevalence is comparable to those reported for other countries. The prevalence of cryptorchidism did not differ significantly from the prevalence reported thirty years ago.

Melatonin secretion and non-specific immune responses are differentially expressed in corticotropin-dependent and corticotropin-independent Cushing's syndrome

BACKGROUND

This study was done to clarify the relation between melatonin secretion and the hypothalamic-pituitary-adrenal axis.

MATERIAL/METHODS

In this clinical study using a follow-up approach, we investigated the circadian melatonin secretion and immune parameters of patients with corticotropin-dependent (Cushing's disease) and corticotropin-independent Cushing's syndrome. Plasma hormone concentrations, interleukin 1-beta (IL-1beta) and total immunoglobulin E (IgE) were determined before surgical treatment and during remission of the syndrome 1 year later.

RESULTS

Patients with Cushing's disease showed mean nocturnal and diurnal melatonin plasma values similar to those of healthy controls. Only the midday level of patients (taken at 12:00) was significantly higher in comparison to controls (35.44+/-19.5 pg/mL vs 17.14+/-3.58 pg/mL; P<0.05). In contrast, patients with corticotropin-independent Cushing's syndrome had significantly lower mean nocturnal and significantly higher mean diurnal melatonin levels (52.8+/-17.7 pg/mL and 59.2+/-28.7 pg/mL, respectively; P<0.05 and P<0.05) as compared with corresponding values for controls (101.4+/-43.1 pg/mL and 28.9+/-11.7 pg/mL, respectively). In the last group of patients, significantly higher mean IL1beta and plasma IgE concentrations (3.30+/-1.72 pg/mL and 527.8+/-474.0 IU/mL, respectively) were observed compared with controls (1.43+/-0.95 pg/mL and 35.7+/-32.1 IU/mL, respectively) (P<0.05). Remission of the hypercortisolism in these patients resulted in restoration of circadian melatonin secretion and significant reductions in plasma IL1beta and total IgE levels.

CONCLUSIONS

Our results demonstrate a specific mode of melatonin secretion and different nonspecific immune responses in the 2 investigated forms of hypercortisolism, specifically, corticotropin-dependent and corticotropin-independent Cushing's syndrome.

Adolescent varicocele: who is at risk?

OBJECTIVES

Varicocele results from the abnormal dilation of the veins of the pampiniform plexus and is the most common identifiable cause of male infertility. It can develop during puberty and thus affect the testicular growth and function. The aim of this study was to determine the prevalence and the risk factors for the development of the varicocele among Bulgarian boys.

METHODS

In a prospective study, 6200 boys from 5 regions of the country aged 0 to 19 years were evaluated for varicocele. All were clinically healthy. Height, weight, testicular volumes, penile length, and penile circumference were also examined.

RESULTS

Varicocele was found in 4.1% of all investigated boys, whereas in the age group 10 to 19 years, it was 7.9%. After adjustment for age, the negative factors associated with the development of the disorder were height, penile length, and penile circumference, whereas the weight and BMI had a protective role. The prevalence of varicocele demonstrated clear regional differences, and it was found significantly more often among dark-eyed boys. The incidence of the disease increased rapidly during midpuberty.

CONCLUSIONS

The incidence of varicocele is related to some somatometric parameters and with the accelerated pubertal development. Longitudinal studies are needed to clarify better the relations between the adolescent varicocele and puberty.

Disturbances in gonadal axis in women with anorexia nervosa

Anorexia nervosa negatively affects multiple body systems including the reproductive system.

AIM

To assess the disturbances in the hypothalamic-pituitary-gonadal axis (HPG) and the relationship between the gonadotropins and body weight, duration of the disease and amenorrhea we studied 40 female anorexic patients (aged 14-31 years) with a body mass index (BMI) 15.14+/-1.80 kg/m(2) and a degree of weight loss 28.67+/-8.74%. Fifteen healthy, age-matched women with normal weight served as controls.

METHODS

We investigated the disturbances in the gonadotropin levels before and after stimulation with gonadotropin-releasing hormone (GnRH) 100 microg i.v. One week later 100 mg of clomiphene citrate (CC) was administered orally for 5 days.

RESULTS

Basal levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) were significantly lower in the patients. The responses of LH to GnRH were diminished, but those of FSH were exaggerated. However, after clomiphene citrate administration, LH increased 5.4 times whereas FSH increased 1.7 times. The basal levels of LH were significantly correlated with body weight (r=+0.373, p<0.05), BMI (r=+0.385, p<0.01) and percentage of the weight loss (r=-0.356, p<0.05). FSH levels were positively correlated with the duration of the disease (r=+0.481, p<0.01) and amenorrhea (r=+0.540, p<0.01).

CONCLUSIONS

Our study demonstrates dissociation in the secretion of gonadotropins after hypothalamic stimulation in anorexic patients. It also reveals the relationship between alterations in the hormones of the HPG axis, not only with the changes in body weight, but also with the duration of the disease.

Relationship of adolescent gynecomastia with varicocele and somatometric parameters: a cross-sectional study in 6200 healthy boys

PURPOSE

To evaluate the relationship of gynecomastia with varicocele and somatometric parameters in otherwise clinically healthy boys.

METHODS

The relationship between gynecomastia and somatometric parameters was examined with 6200 clinically healthy boys aged 0-19 years of different socioeconomic backgrounds in various schools, kindergartens, and childcare centers. Multivariable logistic regression analysis was used to model the prevalence of gynecomastia (>or=1cm) in relation to height, weight, testicular volume, penile length and circumference, age, pubic hair Tanner stage, and residential status.

RESULTS

Pubic hair Tanner stages 3 and 4 had the highest incidence of gynecomastia. Gynecomastia was found only in boys more than 10 years old and its prevalence in the age group of 10-19 years (n = 3082) was 3.93 %. In boys 10-13 years old, gynecomastia was positively correlated with varicocele, the adjusted odds ratio (OR) was 2.1 (95% confidence interval [CI] = 1.1-4.1). For the age at which gynecomastia was most prevalent (group aged 12-14 years), the adjusted OR of gynecomastia occurring in boys with varicocele, using the Cochran-Mantel-Hasenzel method of adjusting for age was 1.9 (95% CI = 1.1-3.4). Gynecomastia was negatively correlated with body mass index (BMI). In addition, it was weakly correlated with testicular volume, positively in age group 10-13 years and negatively in those 14-19 years. However no relationship was found between gynecomastia and penis size, urban/rural status, and sea level of residence.

CONCLUSIONS

Adolescent gynecomastia is a mid-puberty event. It is significantly associated with varicocele and somatometric parameters including BMI and testicular volume.

Prevalence of micropenis among boys from different regions of Bulgaria

AIMS

Micropenis is a normally formed penis whose length is more than 2.5 SD below the mean penile length for age. However, the definition of this disorder depends on penile length norms.

METHODS

Penile length, circumference and anthropometric values of 310 boys under one year of age from five regions in Bulgaria were investigated.

RESULTS

The mean penile length for all boys was 3.55 +/- 0.46 cm, thus micropenis could be defined as a penile length below 2.40 cm. However, regional differences were observed in penile length and circumference. According to regional mean values and the appropriate definition of micropenis, only two of the children had micropenis.

CONCLUSIONS

In a prospective study of Bulgarian boys we established wide regional variations of normal penile length. Consequently, the diagnostic and therapeutic approach to micropenis should consider the mono-ethnic inter-regional differences.

Low testosterone levels and unimpaired melatonin secretion in young males with metabolic syndrome

The interrelations between testosterone, insulin and melatonin levels in males with metabolic syndrome (MS) are still not clarified, especially in young age groups. The aim of the present study was to compare the testosterone serum levels in young men with MS to those in healthy controls, and to determine the possible changes in their melatonin rhythm, as well as the relation between melatonin, insulin and lipid profile. Fasting insulin and testosterone concentrations were measured in 10 healthy nonobese and 10 MS patients. Blood samples for melatonin, insulin and luteinizing hormone (LH) were collected at 19.00, 03.00 and 11.00 hours. A significant difference was found between the testosterone levels in controls and patients. Luteinizing hormone levels in both groups were similar, however, higher night LH levels in MS patients were observed. No changes in the melatonin concentrations of the two groups were found. In conclusion, total testosterone levels were significantly lower in young men with MS compared with healthy age-matched controls. Mild hypoandrogenia in hyperinsulinaemic patients was not related with changes in their melatonin levels. No alterations in the endogenous melatonin rhythm of the MS patients were found.

Adolescent varicocele: association with somatometric parameters

INTRODUCTION

The developmental changes that occur as a result of puberty have been hypothesized to be important causes of varicocele. Various somatometric parameters were known to affect the occurrence of varicocele during the growth period. We conducted this study in order to examine these relationships and to determine the incidence of varicocele in adolescent males.

PATIENTS AND METHODS

We evaluated 1,200 healthy males aged 0-19 years for varicocele and correlated it with the following somatometric parameters: age, height, body mass index (BMI), pubic hair distribution, penile length and testicular volume.

RESULTS

Adolescent varicocele was found in 5.6% of the participants. The 13- to 19-year age-group had the highest incidence of varicocele (10.5%). Logistic regression analysis showed that the incidence was positively correlated with age, height and penile length (odds ratio 1.61, 1.04 and 1.37, respectively) and negatively correlated with left testicular volume, BMI and pubic hair distribution (odds ratio 0.87, 0.87 and 0.47, respectively).

CONCLUSION

Varicocele was more prevalent in tall boys with a lower BMI, who had quickly progressed through puberty. Our observations suggest that varicocele is associated with various somatometric parameters.

Inhibin B is a better marker of spermatogenesis than other hormones in the evaluation of male factor infertility

OBJECTIVE

To assess the role of inhibin B in the evaluation of male factor infertility.

DESIGN

Prospective study.

SETTING

Reproductive endocrinology clinic.

PATIENT(S)

Seventy-five patients with infertility problems (mean age 31.2 +/- 7.5 years) and 12 controls (32.1 +/- 8.8 years) with proven fertility.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Semen analysis was performed according to World Health Organization guidelines. Testicular volume was assessed with the Prader's orchidometer. Serum levels of inhibin B (pg/mL), LH (mIU/mL), FSH (mIU/mL), prolactin (micro IU/mL), and testosterone (nmol/L) were assessed.

RESULT(S)

The mean +/- SEM inhibin B and testosterone levels were significantly lower in the patients than in the controls (inhibin B: 116.4 +/- 11.7 vs. 181.2 +/- 20.9, P=.008; testosterone: 13.6 +/- 0.9 vs. 25.1 +/- 2.9, P=.008). In general, sperm count and testicular volume in the patients were significantly and positively correlated with inhibin B (sperm count: r = 0.476, P<.0001; testicular volume, right: r = 0.57, P=.0001; left: r = 0.53, P=.0001); the inhibin B-FSH index was negatively correlated with FSH. Inhibin B was more strongly correlated with testicular volume and semen parameters than FSH. Inhibin B in the patients was negatively correlated with FSH (r = -0.723, P=.0001) and LH (r = -0.52, P=.0001) and was positively correlated with testosterone (r = 0.4, P=.0013).

CONCLUSION(S)

Inhibin B measurement is a better marker of fertility status than FSH and LH. Concentration of inhibin B in patients with infertility may provide useful information on spermatogenesis and possibly serve as a more direct marker of spermatogenesis than FSH.

Testosterone replacement therapy in male hypogonadism is not associated with increase of endothelin-1 levels

Differences in endothelin-1 (ET-1) blood plasma levels were established between healthy men and women. Little is known about vascular effects of testosterone and the interactions between sex hormones and endothelin. In order to study the relationship between ET-1 and testosterone in more detail, we have investigated 33 male patients with various forms of hypogonadism (13 with hypergonadotropic hypogonadism and 20 with hypogonadotropic hypogonadism). Fourteen age-matched healthy males served as controls. The basal ET-1 levels in patients with hypogonadism (0.96 +/- 0.12 fmol/mL) (mean +/- SEM) were significantly higher in comparison with the controls (0.44 +/- 0.04 fmol/mL), p < 0.01. Fifteen individuals of these patients were studied during the therapy with testosterone depot 250 mg i.m. The ET-1 levels decreased in this group from 0.99 +/- 0.22 to 0.78 +/- 0.14 fmol/mL at the third and to 0.76 +/- 0.25 fmol/mL at the sixth month of the medication, respectively. The differences were not significant compared with the initial levels, but the concentrations at the sixth month of the treatment were not statistically different in comparison with the ET-1 levels of the controls. There was no significant difference in lipid data between patients before and during testosterone medication, except for the high-density lipoprotein cholesterol, which decreased at the third month of the treatment. Our results show that plasma ET-1 levels in males with hypogonadism are elevated with a tendency to decrease after testosterone administration. The optimum testosterone is not associated with enhanced cardiovascular risk as far as ET-1 plasma levels and lipids are concerned.

Are dehydroepiandrosterone sulphate and lipids associated with erectile dysfunction?

OBJECTIVE

Considering the results of the Massachusetts Male Aging Study (1994) we undertook the current investigation in an attempt to clarify the role of dehydroepiandrosterone sulphate (DHEAS), testosterone and lipids on age related deterioration of erectile function.

METHODS

Forty males (13 under 40 years of age and 27 over 40) with erectile dysfunction were investigated. Seventeen healthy subjects (8 under 40 and 9 over 40 years) volunteered as controls. Serum levels of DHEAS, testosterone, total cholesterol, high-density lipoprotein cholesterol (HDL-ch), low-density lipoprotein cholesterol (LDL-ch) and triglycerides were assessed in blood samples.

RESULTS

Plasma levels of DHEAS in patients over 40 years of age (4.17 +/- 2.76 micromol/l) were significantly lower in comparison with the younger group of patients (10.49 +/- 3.87 micromol/l), P < 0.001. There was no statistically significant difference in the DHEAS levels between patients and controls in the same age group. DHEAS in the patients showed an inverse correlation with age (r = -0.705, P < 0.001) and a positive correlation with testosterone (r = +0.402, P < 0.01). The same was found in the controls. The HDL-ch results were in the reference range. The total cholesterol levels (5.35 +/- 0.74 mmol/l) and LDL-ch levels (3.58 +/- 0.76 mmol/l) of the patients with erectile dysfunction in the group under 40 years were significantly higher in comparison with the controls (4.21 +/- 0.69 and 2.46 +/- 0.74 mmol/l, respectively, P <0.01).

CONCLUSION

The data indicates that the decline in DHEAS is an age-related process rather than a causative factor of erectile dysfunction; total cholesterol and mainly LDL-ch may contribute to erectile dysfunction, especially in younger men.

Altered melatonin secretion in hypogonadal men: clinical evidence

The pineal gland, through the rhythmic production of melatonin, seems to play an important role in the control of the reproductive function of many vertebrate species. In contrast, the effects of the pineal gland in humans and the relationship between gonadotropins and melatonin secretion are not yet clarified. On the basis of these considerations, the aim of the present study was to clarify whether melatonin serum concentrations were altered in males with different hypothalamo-pituitary-gonadal disturbances, in comparison to normal individuals. We have studied 36 individuals divided into three groups according to their gonadotropin status: normals, hypogonadotropic hypogonadism and hypergonadotropic hypogonadism. They were submitted to blood sample withdrawal at 03.00, 11.00 and 19.00 h for melatonin determination according to a radioimmunological method, without extraction of the sample. The results obtained in the present study suggest the existence of an interaction between the pituitary and the pineal gland. In fact, in the case of hypersecretion of gonadotropins, nocturnal melatonin release is reduced, while night melatonin secretion is increased in the opposite situation (hypogonadotropic hypogonadism). Both these endocrine pathologies are characterized by a reduced sexual steroid secretion; for that reason, this reduction cannot be regarded as responsible for the two opposite dysfunctions of melatonin release. In conclusion, our study shows that darkness-dependent release of melatonin in males with hypogonadotropic hypogonadism is significantly higher in comparison with the healthy men, while it is significantly reduced in patients with hypergonadotropic hypogonadism. A strong significant negative correlation is also found between gonadotropins and melatonin release.

Significance of inhibin in reproductive pathophysiology and current clinical applications

The human reproductive process is regulated by complex mechanisms that involve many organs, including the brain, gonads and endocrine system. It has been more than 70 years since the name 'inhibin' was used to describe a substance produced in the gonads that negatively regulates pituitary secretion. Inhibin B controls FSH secretion via a negative feedback mechanism. It is a glycoprotein hormone secreted by the Sertoli cells of the testis and granulosa and theca cells of the ovary. Serum inhibin B concentrations are positively related to testicular volume and sperm counts. Current understanding of inhibin physiology and pathology in the human suggests that inhibin B may be of importance as a marker of Sertoli cell function in men with infertility and as a prognostic indicator in women undergoing ovulation induction therapy. Inhibin concentrations are elevated in patients with granulosa cell tumours and in post-menopausal women with mucinous ovarian cancers. Immunoreactivity against the inhibin alpha-subunit was identified in all cases of adrenal cortical adenoma and carcinoma, and levels are suppressed in the malignant prostate disease. This article discusses the structure, regulation and clinical use of inhibin and other related substances.

The influence of hyperthyroidism on the hypothalamic-pituitary-gonadal axis

We have investigated the function of the hypothalamic-pituitary-gonadal (H-P-G)-axis in patients with severe, untreated Graves' disease. We studied 7 male and 6 female healthy volunteers, and 7 male and 7 female patients with Graves' disease. Hormone profiles were developed by blood sampling every 10 min for an 8 hour period. In women this was done in the early follicular phase of menstrual cycle. LH-, FSH-, and PRL levels were measured using immunoradiometric assays and testosterone (T), estradiol (E2), sex-hormone binding globulin (SHBG), and progesterone (P) were measured with standard assays. The pulsatility of LH, FSH and PRL was calculated using the programmes Pulsar, Cluster and Desade. The temporal relationship of plasma LH, FSH, and PRL pulses was also investigated using specific concordance analysis. Data were evaluated by means of non-parametric statistics. LH-secretion was increased in all hyperthyroid patients, while FSH-secretion was increased in hyperthyroid men only. Pulsatile characteristics of LH- and FSH-secretion (frequency, peak shape) in patients were not different from controls. No change in PRL-secretion was shown. Significant copulsatility occurred between LH and FSH, and LH and PRL. This was more pronounced in hyperthyroid than in healthy study subjects. Plasma levels of steroid hormones and sex-hormone-binding globulin were significantly (p<0.005) increased in hyperthyroid men. Free Androgen Index was significantly (p<0.005) decreased in hyperthyroid males. No other auto immune diseases were noticed. Our results indicate that the function of the H-P-G axis is not impaired in hyperthyroid patients, but gonadotropin levels are increased. Hyperthyroid men show relative primary gonadal insufficiency that may be due to exaggerated SHBG levels. The copulsatility of LH and FSH, and of LH and PRL was confirmed both in patients and controls.

Two male patients with ring Y: definition of an interval in Yq contributing to Turner syndrome

Turner syndrome is thought to result from the haploinsufficiency of genes on the sex chromosomes, but these genes have not been identified yet. We describe two males with deleted ring Y chromosomes, one (TS) with full Turner syndrome and one (DM) without. TS has short stature, skeletal anomalies, lymphogenic obstruction, cardiovascular abnormalities, and miscellaneous features including pigmented naevi, antimongoloid slanting of the palpebral fissures, and widely spaced nipples. In contrast, DM has short stature but no other specific Turner stigmata except high arched palate and a few pigmented naevi. Since little chromosomal mosaicism was detected, the different segments of the Y chromosome retained by these two males identify the location of one or more "anti-Turner" genes. Most of the Yp pseudoautosomal region and Yq were deleted from both patients during the formation of the ring chromosome, while the Y specific portion of Yp and the centromere were retained. The major difference detected was an interval of proximal Yq present in DM and deleted in TS. None of the previously identified genes, DFFRY, DBY, UTY, or TB4Y, lies entirely within this interval, although DFFRY was truncated by DM's breakpoint. These data suggest that one or more additional "anti-Turner" gene(s) remains to be identified in the region of Yq proximal to DFFRY.

Sex differences and similarities of hormonal alterations in patients with anorexia nervosa

The aim of the present study was to gain better insight into hormonal disturbances in male patients with anorexia nervosa. It included six men with anorexia nervosa aged 13-26 years, with a mean body weight of 42.83 +/- 8.03 kg, a body mass index of 15.08 +/- 1.26 and an average degree of weight loss 29.98 +/- 4.73%. The results were compared with those of 15 healthy age-matched males and 40 women with anorexia nervosa. Prolactin, growth hormone and the gonadal and thyroid axis were studied in detail. The gonadotropin basal levels and their responses to gonadotropin-releasing hormone in male patients were lower, but not significantly, in comparison with healthy men. The basal levels and the responses of luteinizing hormone in anorexic women were significantly lower in comparison with female controls, but the decreased basal level of follicle-stimulating hormone showed an exaggerated response to gonadotropin-releasing hormone. In male anorexics the testosterone levels (7.1 +/- 10.9 nmol l-1) were significantly lower. The changes in the thyroid axis and in prolactin secretion were almost the same in male and female patients. The data of this study suggest that endocrine disturbances in males are similar to those in females with anorexia nervosa, but differences exist mainly in relation to the gonadal axis.

Factors related to sex hormone binding globulin concentrations in women with anorexia nervosa

The published reports concerning serum levels of sex hormone binding globulin (SHBG) in women with anorexia nervosa are few in number and controversial. Indeed, very little is known of the factors influencing SHBG concentrations in these patients. In an attempt to clarify this problem we evaluated serum levels of SHBG, estradiol, testosterone, luteinizing hormone, follicle stimulating hormone, triiodothyronine, thyroxine, their free fractions and insulin in 19 women with anorexia nervosa. Plasma glucose levels, total protein, triglycerides and cholesterol were also studied. Seven healthy women with normal weight and regular menstrual cycles served as controls. The serum concentrations of SHBG in patients with anorexia nervosa (165.27 +/- 63.5 nmol/l) were significantly higher (p < 0.01) than those in the control group (96.21 +/- 38.04 nmol/l), but the levels of estradiol, testosterone, free triiodothyronine and the ratio of testosterone to SHBG were significantly lower. An inverse correlation between SHBG and body weight (r = -0.761) was found in the patients. The alterations in SHBG concentrations were not associated with the changes in testosterone, gonadotropins, thyroid hormones and biochemical parameters. These findings suggest that body weight is one of the more important factors influencing the SHBG concentrations in women with anorexia nervosa.

Increased prolactin secretion and thyrotrophin response to thyrotrophin releasing hormone in Klinefelter's syndrome

The reports published thus far on prolactin and thyrotrophin secretion in patients with Klinefelter's syndrome are controversial. The aim of the present study was to investigate the interrelation between prolactin on one hand, and hormones of the hypothalamic-pituitary-gonadal axis and thyrotrophin, on the other, in males with Klinefelter's syndrome. Fifteen patients with Klinefelter's syndrome, aged between 17 and 43 years, and 15 healthy males, aged 22-35 years, were studied. Mean +/- SD basal serum prolactin levels were 529.6 +/- 174.6 mU l-1 in the patients, and 270.1 +/- 113.0 mU l-1 in the control group (P < 0.001). Following 200 micrograms thyrotrophin releasing hormone, an enhanced prolactin response was seen in the males with Klinefelter's syndrome. There was no evidence of any of the well-known causes of hyperprolactinaemia. The response of thyrotrophin to thyrotrophin releasing hormone was more pronounced in Klinefelter patients in comparison with controls. Presumably, in Klinefelter's syndrome both alterations--of prolactin and thyrotrophin secretion--may be caused by decrease of testosterone levels or they could reflect a disturbance in neuroendocrine regulation with some neurotransmitter imbalance.

Elevated basal levels and exaggerated responses to thyrotrophin-releasing hormone of prolactin and thyrotrophin in Turner-Noonan-Syndrome

Basal levels of prolactin (Prl), FSH, LH, testosterone, estradiol, total thyroxine (T4), total triiodothyronine (T3) and thyrotrophin (TSH) were determined in four males with Turner-Noonan-Syndrome. The responsiveness of gonadotrophins to LH-RH (100 micrograms i.v.) and of Prl and TSH (200 micrograms i.v.) was studied. High basal levels and exaggerated responses to TRH of Prl were found in all patients. However no evidence of any of the well known causes of hyperprolactinaemia could be detected in them. The four men were with normal levels of T4 and T3 and showed exaggerated TSH responses to TRH. It is suggested that the alterations in Prl and TSH release are reflections of a congenital disorder in Turner-Noonan-Syndrome not yet well studied.