An observational study of pregnancy and post-partum outcomes in women with prolactinoma treated with dopamine agonists

BACKGROUND

In women with prolactinoma medical treatment with dopamine agonists (DA) can restore fertility. A number of studies have established the safety of DA during pregnancy and the impact of pregnancy and lactation on remission of prolactinoma. However, the total number of reported cases remains modest and further evidence is needed.

AIMS

To evaluate the safety of DA during pregnancy and remission of prolactinoma after pregnancy and lactation.

MATERIALS AND METHODS

Retrospective cohort study (2002-2014) of 57 pregnancies in 47 women with prolactinoma who received DA. Neonatal and pregnancy complications were recorded. Prolactin levels and treatment data were collected at the time of diagnosis, pre-conception, during pregnancy and lactation, and post-partum (up to 114 months).

RESULTS

DA treatment was stopped a median of 4.5 weeks after conception in 49 pregnancies (86%). There were 49 live births (86% of pregnancies) and six miscarriages. Six pregnancies had an adverse neonatal outcome including two with congenital malformations. Following 26% of pregnancies women achieved remission after birth or lactation, and 25% of women were in remission at last follow-up. Remission was associated with older maternal age (P = 0.036), a lower prolactin level at diagnosis (P = 0.037), and a smaller adenoma at diagnosis (P = 0.045).

CONCLUSIONS

Successful pregnancy and lactation is common after DA treatment for prolactinoma. Fetal exposure in the first four weeks of pregnancy appears to be generally safe. Encouragingly, post-partum and after lactation a quarter of women had a normal prolactin level without medical treatment.

Temporal changes in insulin-like growth factors I and II and in insulin-like growth factor binding proteins 1, 2, and 3 in human milk

AIM

To evaluate the postpartum time course of changes in insulin-like growth factors (IGFs) and their binding proteins (IGFBPs).

METHODS

Breast milk IGF-I and IGF-II and IGFBP-1, IGFBP-2, and IGFBP-3 levels were determined in 23 women with babies born at term, from day 4 until up to 9 months after birth.

RESULTS

The IGFBP-3 levels were highest from day 4 to day 6 and then decreased by days 10-12. In contrast, IGF-I and IGF-II and IGFBP-1 and IGFBP-2 showed little change over the first 2 weeks after birth. Subsequently, all the IGF components showed a moderate decline over approximately the first 1-3 months and then stable levels up to 9 months after birth.

CONCLUSION

Although the possibility cannot be excluded that these changes in levels of IGFs and their binding proteins in human milk represent passive loss from the mammary gland, we speculate that higher early levels of the human milk IGF system contribute to maturation of the infant gut.

LH levels in women with polycystic ovarian syndrome: have modern assays made them irrelevant?

OBJECTIVE

To determine whether using newer monoclonal rather than polyclonal assays for measuring luteinising hormone (LH) alters the predictive value of LH and LH/follicle-stimulating hormone (FSH) ratios for polycystic ovarian syndrome.

DESIGN

Prospective cohort study.

SETTING

Fertility and Reproductive Endocrinology Clinic within a New Zealand Teaching hospital.

POPULATION

Seventy-eight women presenting with oligomenorrhoea or hirsutism and polycystic ovaries on pelvic ultrasound and 59 volunteer controls with ultrasonically normal ovaries and a regular menstrual cycle.

METHODS

Serum LH concentrations were measured using a polyclonal radio-immunoassay (Amerlex-M, Johnson & Johnson) and two monoclonal immunometric assays (Immulite, DPC; Cobas Core, Hoffman La Roche). The proportion of women with an elevated serum LH concentration in each group was calculated using both current local laboratory reference intervals and a new reference range derived from our control group. The LH/FSH ratios for women in both groups were also calculated using the three different LH assays.

MAIN OUTCOME MEASURES

LH concentrations and LH:FSH ratios measured using polyclonal and monoclonal immunoassays.

RESULTS

Using the local laboratory normal range, a significantly higher proportion of women had an elevated LH when measured with a polyclonal assay (23.1%) than when measured with a monoclonal assay (12.8% Core, 6.4% Immulite) (P < 0.05). LH/FSH ratios were significantly lower when monoclonal assay was used and receiver-operator characteristic curves suggest that LH/FSH ratios of 1 or lower provide the most reliable separation of women with polycystic ovarian syndrome from controls when these assays are used.

CONCLUSIONS

Clinicians should be aware that the use of monoclonal LH assays will result in significantly lower measured LH levels and LH/FSH ratios in women with polycystic ovarian syndrome than previously used polyclonal assays. Account should be taken of the assay type used, when using endocrinological parameters in the diagnosis of polycystic ovarian syndrome, or the identification of women who have LH hypersecretion.

Factors associated with pregnancy or miscarriage after clomiphene therapy in WHO group II anovulatory women

OBJECTIVES

The present study was designed to determine whether clinical and endocrine characteristics assessed on initial screening of normogonadotropic oligo/amenorrhoeic infertile patients could predict ovulation and then conception and successful live birth or miscarriage.

STUDY DESIGN

Retrospective cohort study

SETTING

Outpatient clinic.

POPULATION

Eighty-two consecutive women receiving clomiphene citrate (CC) therapy from 1993 to 1998.

RESULTS

A cumulative conception rate of 67% was reached after six or more CC-induced cycles. Patients with failure of ovulation after a full course of CC had more severe oligomenorrhoea (p < 0.001) and greater BMI (p < 0.05) at initial screening. There was no relationship with levels of LH or androgens. In contrast, among women who ovulated in response to CC, conception was associated with less frequent periods, and higher basal levels of LH, free testosterone and androstenedione. Conceptions with subsequent miscarriage were associated with intermediate levels of LH and numbers of spontaneous periods between non-conception and live births.

CONCLUSIONS

These observations are consistent with the hypothesis that failure of ovulation after CC is related to different factors (overweight and severe oligomenorrhoea) from those that predispose to non-conception (low basal LH and androgen levels and mild oligomenorrhoea).

The impact of ethnicity on the presentation of polycystic ovarian syndrome

The effect of ethnicity on the prevalence and presentation of polycystic ovarian syndrome (PCOS) was examined in a cross-sectional study of women with clinical - and ultrasound - diagnosed PCOS. European, Maori and Pacific Island women were seen in proportion to the general population, whereas Indian women were over-represented and Chinese women under-represented. European and Maori women were more likely to present with hirsutism than other ethnic groups (43% versus 25%, p < 0.05), while European women were less likely to present with infertility (46% versus 68%, p < 0.01). The Pacific Island women had little or no acne but other signs of PCOS were similar among ethnic groups. Although less than 10% of patients were referred with obesity, the majority of PCOS women were overweight on examination. Maori and Pacific Island women were more obese and had the highest rates of insulin resistance and lipid abnormalities. The adverse metabolic profile of many of these women, particularly the Maori and Pacific Islanders, is very likely to predispose them to early cardiovascular disease.

Inhibin: a candidate gene for premature ovarian failure

Premature ovarian failure (POF) occurs in 1% of all women, and in 0.1% of women under the age of 30 years. The mechanisms that give rise to POF are largely unknown. Inhibin has a role in regulating the pituitary secretion of FSH, and is therefore a potential candidate gene for ovarian failure. Using single-stranded conformation polymorphism (SSCP) and DNA sequencing, DNA samples were screened from 43 women with POF for mutations in the three inhibin genes. Two variants were found: a 1032C-->T transition in the INHssA gene in one patient, and a 769G-->A transition in the INHalpha gene in three patients. The INHssA variant appears to be a polymorphism, as there was no change in the amino acid sequence of the gene product. The INHalpha variant resulted in a non-conservative amino acid change, with a substitution from alanine to threonine. This alanine is highly conserved across species, and has the potential to affect receptor binding. The INHalpha variant is significantly associated with POF (3/43 patients; 7%) compared with control samples (1/150 normal controls; 0.7%) (Fisher's exact test, P < 0.035). Further analysis of the inhibin gene in POF patients and matched controls will determine its role in the aetiology of POF.

Potential role for growth hormone in human lactation insufficiency

In order to evaluate the galactopoietic response to rhGH in mothers of normal babies with idiopathic lactation insufficiency arising in the early postpartum period, we performed a preliminary, randomised, single blind trial of 3 different doses of hGH: either 0.05, 0.1, or 0.2 IU/kg/day to a maximum of 16 IU/day, for 7 days. Total 24-hour milk production was determined in each mother 1 day prior to initiating therapy and on the last day of therapy. Milk production rose by 36.0 +/- 12.6% in the group receiving 0.2 IU/kg/day (n = 6) but by only 4.7 +/- 9.7%, (p < 0.04) in the combined lower dose group (n = 10). In conclusion, these data suggest that moderate dose hGH therapy in mothers with lactation insufficiency can improve galactopoiesis.

Insulin-like growth factors and their binding proteins in plasma and milk after growth hormone-stimulated galactopoiesis in normally lactating women

We performed a double-blind randomized placebo-controlled trial of recombinant human growth hormone (hGH) in normally lactating women (N = 8 per group) to investigate the endocrine mode of action of the galactopoietic effect of this hormone. Insulin-like growth factors I (IGF-I) and II (IGF-II) and their binding proteins (IGFBP-1, IGFBP-2 and IGFBP-3) were measured by radioimmunoassay in plasma and milk samples collected throughout the study. All assays were validated for human plasma and milk. Human GH treatment (0.1 IU.kg-1 body wt.day-1 for 7 days) increased plasma concentrations of IGF-I from 22.1 +/- 1.3 nmol/l (mean +/- SEM) to 59.7 +/- 2.5 nmol/l (p < 0.01). At the end of the study the increase in plasma IGF-I correlated significantly with the increase in milk volume (r = 0.67, p < 0.005, N = 16). The IGF-I levels were considerably lower in milk, with 0.14 +/- 0.03 nmol/l before and 0.31 +/- 0.04 nmol/l after hGH treatment. The increase in milk IGF-I levels (134.0 +/- 14.5%) with hGH treatment was significant (p < 0.01) and plasma and milk IGF-I concentrations correlated significantly when considering all samples of the study (r = 0.45, p < 0.001, N = 56). The concentrations of IGF-II were not changed significantly with hGH treatment in plasma (52.5 +/- 2.5 nmol/l before and 42.6 +/- 3.9 nmol/l after treatment) or milk (2.1 +/- 0.29 nmol/l before and 2.3 +/- 0.49 nmol/l after hGH treatment).(ABSTRACT TRUNCATED AT 250 WORDS)

Growth hormone stimulates galactopoiesis in healthy lactating women

Sixteen normally lactating women underwent a double-blind randomized placebo-controlled trial of recombinant human growth hormone (hGH) to assess the effect of hGH on milk production in early lactation. Milk volumes were measured by test weighing procedures of the infants and removal of residual milk on a control day and after 7 days of treatment with recombinant hGH (0.1 IU.kg-1 body weight.d-1) or placebo treatment. Although all women were lactating normally before the study commenced, milk volume in 8 hGH treated mothers was increased (p < 0.02) by 18.5 +/- 1.4% (mean +/- SEM) compared to 11.6 +/- 2.0% in the placebo-treated group (N = 8). No adverse effects were seen with hGH treatment and no major changes noted in milk constituents. The hGH concentrations in milk were low and did not change with therapy. Plasma concentrations of IGF-1 increased significantly within 24 h of hGH treatment and increased further towards the end of the trial to values of 2.6-fold above the pretreatment values. The concentration of IGF-1 in milk was approximately 100-fold lower than those observed in plasma and could only be reliably measured after size exclusion chromatography to remove the interfering influence of IGF binding proteins in the radioimmunoassay. All women treated with hGH showed a small increase in milk IGF-1 concentrations but the values remained within the range of values observed in women receiving the placebo treatment (1.2-4.4 micrograms/l). Growth hormone treatment increased milk volume in normal lactating women during early lactation.(ABSTRACT TRUNCATED AT 250 WORDS)

The blood pressure response to unilateral adrenalectomy in primary aldosteronism

The factors determining the outcome of blood pressure after removal of the aldosterone-secreting adenoma in primary aldosteronism are largely unknown. We have studied the results of surgery in 21 patients with this disorder, all of whom were investigated and treated in a single referral centre, and evaluated the contributions of clinical, biochemical and pathological factors to blood pressure outcome. Blood pressure before surgery was high (mean 210/121 mmHg), but after an average period of 5.4 years 12 patients (60 per cent) were considered by their primary physician not to require antihypertensive medication and a further seven had reduced drug requirements. In only two patients was arterial pressure unimproved by surgery. Blood pressure recordings within six months of surgery were not a good predictor of later levels. Of the clinical, electrolyte, hormone and pathological features assessed, only the systolic pressure before surgery, and abnormalities in the optic fundi, correlated statistically with final blood pressure ranking. There was no relationship between the severity of vascular changes in the adrenal or kidney biopsy tissue and final blood pressure. These results show that while the blood pressure response to the removal of a single adrenal adenoma is usually good, it is not possible to predict accurately the final blood pressure response using these criteria.

Successful treatment of scleroderma renal crisis with enalapril

A patient with scleroderma renal crisis is described. At presentation he had severe hypertension, deteriorating renal function, microangiopathic haemolytic anaemia, and elevated levels of renin, aldosterone and noradrenaline. Enalapril controlled blood pressure, stabilized renal function, lowered aldosterone and noradrenaline levels, and improved peripheral circulation. It appears that converting-enzyme inhibitors can favourably alter the outlook of this otherwise fatal disorder.

The effect of peripheral catecholamine concentrations on the pituitary-adrenal response to corticotrophin releasing factor in man

To evaluate the effect of changes in plasma catecholamines on the pituitary-adrenal response to ovine corticotrophin releasing factor (CRF) in normal man, the response to CRF alone (10 subjects) was compared responses after infusions of adrenaline (6 subjects), noradrenaline (6 subjects) and after oral administration of the alpha 2 agonist clonidine (10 subjects). Compared to control levels, plasma adrenaline and noradrenaline concentrations were increased three- and four-fold respectively by exogenous infusions, whereas plasma noradrenaline was significantly lowered by clonidine. Despite these changes in plasma catecholamine levels, the responses of plasma ACTH, cortisol and aldosterone to CRF did not differ significantly from control (CRF alone) in any of the three studies. Neither clonidine pretreatment nor catecholamine infusions altered basal levels of plasma ACTH, cortisol or aldosterone and no effect of CRF or catecholamine manipulations on plasma arginine vasopressin concentration was observed. These results show that modulation of peripheral plasma catecholamine levels within physiological limits does not affect CRF-stimulated release of ACTH or the adrenal response in normal man.

Augmentation of the response to CRF in man: relative contributions of endogenous angiotensin and vasopressin

The plasma ACTH response to corticotrophin releasing factor (CRF) was studied in seven normal individuals. Five subjects were restudied following 4 d of salt restriction which resulted in raised endogenous plasma angiotensin II secretion. In a third experiment six subjects were given CRF following pre-infusion of hypertonic saline which significantly increased endogenous plasma vasopressin (AVP) levels. We were unable to demonstrate that high endogenous plasma AII levels were associated with a significant change in the plasma ACTH or cortisol responses to CRF. However there was an almost three-fold increase in the ACTH response when endogenous plasma AVP was elevated by hypertonic saline. It is concluded that AVP is likely to be of physiological importance in potentiating the ACTH response to CRF and that AVP and CRF together may provide a better test of pituitary ACTH secretion than either peptide alone.