Body weight loss reverts obesity-associated hypogonadotropic hypogonadism: a systematic review and meta-analysis

OBJECTIVE

Few randomized clinical studies have evaluated the impact of diet and physical activity on testosterone levels in obese men with conflicting results. Conversely, studies on bariatric surgery in men generally have shown an increase in testosterone levels. The aim of this study is to perform a systematic review and meta-analysis of available trials on the effect of body weight loss on sex hormones levels.

DESIGN

Meta-analysis.

METHODS

An extensive Medline search was performed including the following words: 'testosterone', 'diet', 'weight loss', 'bariatric surgery', and 'males'. The search was restricted to data from January 1, 1969 up to August 31, 2012.

RESULTS

Out of 266 retrieved articles, 24 were included in the study. Of the latter, 22 evaluated the effect of diet or bariatric surgery, whereas two compared diet and bariatric surgery. Overall, both a low-calorie diet and bariatric surgery are associated with a significant (P<0.0001) increase in plasma sex hormone-binding globulin-bound and -unbound testosterone levels (total testosterone (TT)), with bariatric surgery being more effective in comparison with the low-calorie diet (TT increase: 8.73 (6.51-10.95) vs 2.87 (1.68-4.07) for bariatric surgery and the low-calorie diet, respectively; both P<0.0001 vs baseline). Androgen rise is greater in those patients who lose more weight as well as in younger, non-diabetic subjects with a greater degree of obesity. Body weight loss is also associated with a decrease in estradiol and an increase in gonadotropins levels. Multiple regression analysis shows that the degree of body weight loss is the best determinant of TT rise (B=2.50±0.98, P=0.029).

CONCLUSIONS

These data show that weight loss is associated with an increase in both bound and unbound testosterone levels. The normalization of sex hormones induced by body weight loss is a possible mechanism contributing to the beneficial effects of surgery in morbid obesity.

Medical treatment of prolactinomas

Prolactinomas, the most prevalent type of neuroendocrine disease, account for approximately 40% of all pituitary adenomas. The most important clinical problems associated with prolactinomas are hypogonadism, infertility and hyposexuality. In patients with macroprolactinomas, mass effects, including visual field defects, headaches and neurological disturbances, can also occur. The objectives of therapy are normalization of prolactin levels, to restore eugonadism, and reduction of tumor mass, both of which can be achieved in the majority of patients by treatment with dopamine agonists. Given their association with minimal morbidity, these drugs currently represent the mainstay of treatment for prolactinomas. Novel data indicate that these agents can be successfully withdrawn in a subset of patients after normalization of prolactin levels and tumor disappearance, which suggests the possibility that medical therapy may not be required throughout life. Nevertheless, multimodal therapy that involves surgery, radiotherapy or both may be necessary in some cases, such as patients who are resistant to the effects of dopamine agonists or for those with atypical prolactinomas. This Review reports on efficacy and safety of pharmacotherapy in patients with prolactinomas.

From mental disorder to iatrogenic hypogonadism: dilemmas in conceptualizing gender identity variants as psychiatric conditions

The categorization of gender identity variants (GIVs) as "mental disorders" in the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association is highly controversial among professionals as well as among persons with GIV. After providing a brief history of GIV categorizations in the DSM, this paper presents some of the major issues of the ongoing debate: GIV as psychopathology versus natural variation; definition of "impairment" and "distress" for GID; associated psychopathology and its relation to stigma; the stigma impact of the mental-disorder label itself; the unusual character of "sex reassignment surgery" as a psychiatric treatment; and the consequences for health and mental-health services if the disorder label is removed. Finally, several categorization options are examined: Retaining the GID category, but possibly modifying its grouping with other syndromes; narrowing the definition to dysphoria and taking "disorder" out of the label; categorizing GID as a neurological or medical rather than a psychiatric disorder; removing GID from both the DSM and the International Classification of Diseases (ICD); and creating a special category for GIV in the DSM. I conclude that-as also evident in other DSM categories-the decision on the categorization of GIVs cannot be achieved on a purely scientific basis, and that a consensus for a pragmatic compromise needs to be arrived at that accommodates both scientific considerations and the service needs of persons with GIVs.

Neural transplantation: a review of recent developments and potential applications to the aged brain

Mammalian neural transplantation has recently been recognized to be a valuable technique for studying normal development and regeneration in the central nervous system. In addition, the ability of grafted neurons to reinnervate damaged regions of the host brain and to ameliorate some neuroendocrine deficits, cognitive disorders and motoric dysfunctions in young adult rodents has suggested that transplantation therapy may be effective in treating human neurodegenerative diseases and neurotransmitter deficiencies related to aging. It is of particular interest that initial studies of neuron transplants in aged rodents indicate that cholinergic, dopaminergic and noradrenergic neurons all integrate to some extent with the aged brain, and that the product of this graft-host interaction is improved behavioral performance of aged subjects. The present paper critically reviews the present domain of neural transplantation, its application to studies on the properties of the aged mammalian brain and discusses the possible therapeutic use of transplants in ameliorating transmitter-specific abnormalities associated with Parkinson's disease and Alzheimer's disease.

ENDOCRINE HISTORY: The history of discovery, synthesis and development of testosterone for clinical use

As the most important male hormone, testosterone has an impact on almost all organs and body functions. The biological effects of testosterone and the testes have been known since antiquity, long before testosterone was identified as the active agent. Practical applications of this knowledge were castration of males to produce obedient servants, for punishment, for preservation of the prepubertal soprano voice and even for treatment of diseases. Testes were used in organotherapy and transplanted as treatment for symptoms of hypogonadism on a large scale, although these practices had only placebo effects. In reaction to such malpractice in the first half of the 20th century science and the young pharmaceutical industry initiated the search for the male hormone. After several detours together with their teams in 1935, Ernst Laqueur (Amsterdam) isolated and Adolf Butenandt (Gdansk) as well as Leopold Ruzicka (Zürich) synthesized testosterone. Since then testosterone has been available for clinical use. However, when given orally, testosterone is inactivated in the liver, so that parenteral forms of administration or modifications of the molecule had to be found. Over 85 years the testosterone preparations have been slowly improved so that now physiological serum levels can be achieved.

Angiogenesis and the blood-brain barrier in solid and dissociated cell grafts within the CNS

Available evidence suggests that blood vessels indigenous to solid CNS and peripheral tissues grafted to the brain are sustained and maintain the morphological and permeability characteristics they manifest in normal life. Furthermore, these vessels of graft origin anastomose (albeit not rapidly) with vessels of the surrounding host tissue predominantly at the host-graft interface and less so, or not at all, within the graft itself. For these reasons, blood-brain and brain-blood barriers, evident in the late fetal and neonatal CNS, can be expected to exist within CNS grafts placed intracerebrally or extracerebrally, providing the graft remains viable. Peripheral neural and non-neural tissues not possessing cellular barriers to circulating macromolecules do not acquire such barriers subsequent to their transplantation within the CNS. The absence of a blood-brain barrier in the adrenal gland grafted intracerebrally may be relevant for the treatment of Parkinson's disease with blood-borne therapeutics. Compared to solid tissue grafts, cell suspension grafts have the potential of becoming vascularized rapidly. That cell suspensions of neurons and of glia are supplied with BBB vessels of host origin and that the permeability characteristics of host BBB vessels are altered by a tumor cell suspension reaffirm the belief that the type of transplanted cell/tissue indeed determines the permeability characteristics of the blood vessels supplying it. The suspected immunologic privilege of the CNS is not absolute. Eventual host rejection of allografts placed within the third ventricle may be a dual consequence of the absence of a BBB at the level of the host median eminence and involvement of the minor histocompatibility complex.

Hypogonadism as an additional indication for bariatric surgery in male morbid obesity?

OBJECTIVE

Male obesity is often associated with reduced levels of circulating total (TT) and calculated free testosterone (cFT), with normal/reduced gonadotropins. Bariatric surgery often improves sex steroid and sex hormone-binding globulin (SHBG) levels. The aim of this study was to assess the effects of bariatric surgery on waist circumference (WC) and BMI, and on TT levels, in morbidly obese men, stratified, according to the gonadal state, in eugonadal and hypogonadal (TT<8 nmol/l) subjects.

DESIGN

A cohort of morbidly obese patients (29 with hypogonadism (HG) and 26 without) undergoing bariatric surgery (37, 10, 6, and 2, with Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, biliopancreatic diversion and gastric sleeve, respectively) was studied at 6 and 12 months from the operation.

METHODS

Anthropometric parameters (weight, BMI, WC) and sex hormones (gonadotropins, TT, cFT, estradiol (E2), SHBG) were assessed.

RESULTS

WC was the only parameter significantly correlated with androgens, but not with E2, SHBG, and gonadotropins, at baseline. After surgery, a significant increase in TT, cFT, and SHBG, accompanied by a decrease in E2, was evident in the two groups. However, both TT and cFT, but not E2, SHBG, and gonadotropin variations, were significantly higher in the hypogonadal group at follow-up, with an overall 93% complete recovery from HG. Reduction in WC, but not BMI, was significantly greater in hypogonadal men (ΔWC=-29.4±21.6 vs -14.4±17.4 at 12 months, P=0.047).

CONCLUSIONS

Recovery from obesity-associated HG is one of the beneficial effects of bariatric surgery in morbidly obese men. The present findings suggest that the gonadal state is a predictor of WC decrease after bariatric surgery.

Prolactinomas in males: any differences?

CONTEXT

Prolactinomas in men are usually large and invasive, presenting with signs and symptoms of hypogonadism and mass effects, including visual damage. Prolactin levels are high, associated with low testosterone, anemia, metabolic syndrome and if long-standing also osteoporosis.

RESULTS

Medical treatment with the dopamine agonist, cabergoline, became the preferred first-line treatment for male prolactinomas as well as for giant tumors, leading to prolactin normalization in ~ 80% of treated men, and tumor shrinkage, improved visual fields and recovery of hypogonadism in most patients. Multi-modal approach including surgery and occasionally radiotherapy together with a high-dose cabergoline is saved for resistant and invasive adenomas. Experimental treatments including temozolomide or pasireotide may improve clinical response in men harboring resistant prolactinomas.

CONCLUSIONS

Compared to other pituitary adenomas, secreting and non-secreting, where pituitary surgery is the recommended first-line treatment, men with prolactinomas will usually respond to medical treatment with no need for any additional treatment.

Intrahypothalamic injection of a cell line secreting gonadotropin-releasing hormone results in cellular differentiation and reversal of hypogonadism in mutant mice

GT1 is an immortalized cell line that synthesizes and secretes the neurohormone gonadotropin-releasing hormone (GnRH). We have placed these cells into the brains of adult mutant hypogonadal (hpg) mice, which lack a functional GnRH gene, to determine whether such cells could differentiate in situ and support gonadal development. Immunocytochemical detection of GnRH revealed that these cells migrated widely in the central nervous system and elaborated axonal processes which on rare occasion projected to the normal target, the median eminence. Using a battery of antibodies, we demonstrated that these cells could cleave the GnRH precursor and that the amidated decapeptide as well as other cleavage products were present. The presence of biologically active material and its appropriate secretion were further documented by gonadal growth in both males and females. The morphological differentiation of the GT1 cells correlated with the density of cells injected. Those remaining within the injection site and/or forming a tumor retained a simple, rounded or fibroblastic appearance. Those cells that migrated into the host away from such tumors assumed the simple fusiform shape of normal GnRH neurons with dendrites extending from one or both poles. When cell density was drastically reduced a much more complex dendritic arbor was elaborated. These data suggest that such cell lines can be useful in reversing genetic defects and in studying such processes as GnRH neuronal migration, axonal targeting, and cytological differentiation.

Circulating free testosterone in obese men after bariatric surgery increases in parallel with insulin sensitivity

BACKGROUND AND AIM

Male hypogonadism has been linked to obesity and diabetes. We aimed to study the association of changes in insulin sensitivity and testosterone levels in severe obese patients submitted to bariatric surgery.

SUBJECTS AND METHODS

Prospective intervention study with twenty consecutive patients who underwent bariatric surgery studied before and after significant weight loss. Serum testosterone, SHBG, fasting glucose, and insulin were measured among others. Free testosterone was calculated with the Vermeulen formula and insulin sensitivity with the homeostatic model assessment (HOMA).

RESULTS

At baseline, thirteen patients had low total testosterone levels, whereas eight of these patients also had free testosterone levels below the reference range obtained from the control group. After bariatric surgery total testosterone, SHBG, and free testosterone significantly increased and achieved normal values in all evaluated patients. Insulin sensitivity improved in all of them. Multivariate linear regression showed that changes in fasting glucose (β=-1.868, p=0.001), insulin (β=-3.782, p=0.001), weight (β=-0.622, p=0.002), and SHBG (β=-0.635, p=0.022) were associated with changes in free testosterone (adjusted R2=0.936, F=26.613, p=0.001). When insulin resistance calculated by HOMA was in the model instead of insulin and glucose, it also was associated (β=-3.488, p=0.008) with free testosterone (adjusted R2=0.821, F=11.111, p=0.005).

CONCLUSIONS

Circulating tes tos terone in obese men increases after bariatric surgery in parallel with an improvement in insulin sensitivity.

Gonadal status and outcome of bariatric surgery in obese men

BACKGROUND

Obesity-related hypogonadotrophic hypogonadism (OrHH) occurs in over 40% of morbidly obese men. Obesity-related hypogonadotrophic hypogonadism may reduce the beneficial effects of bariatric surgery.

OBJECTIVE

To assess the impact of OrHH on the outcome of bariatric surgery in men.

PATIENTS AND METHODS

Observational study with measurement of serum gonadal hormones, and assessment of body composition, glucose, lipid and bone metabolism during the first year after bariatric surgery in 13 men with OrHH (free testosterone (free T) <225 pmol/l) and 11 age-matched eugonadal morbidly obese men (free T > 225 pmol/l).

RESULTS

Serum free T was inversely related to body weight (R = -0·65, P < 0·0001) and rose gradually after bariatric surgery, in eugonadal as well as in OrHH men, by 30 pmol/l for every 10 kg loss of weight. In three patients, serum free T remained within the hypogonadal range despite substantial weight loss. Gonadal hormone status prior to surgery did not affect the 1-year outcome of surgery.

CONCLUSION

Obesity-related hypogonadotrophic hypogonadism is a reversible condition in the majority of obese men. It does not reduce the efficacy of bariatric surgery. Preoperative weight-adjusted normal values are recommended to avoid an incorrect diagnosis of hypogonadism in obese men.

Positive feedback in hypogonadal female mice with preoptic area brain transplants

When fetal preoptic area (POA) brain grafts that contain gonadotropin-releasing hormone cells are transplanted into the third ventricle of adult female hypogonadal mice, the animals respond with sexual maturation, persistent estrus, and the ability to ovulate reflexively after mating. However, the absence of normal spontaneous ovulatory cyclicity suggests an impairment in positive feedback. We, therefore, studied the effect of administration of progesterone alone or of sequential estradiol benzoate and progesterone on plasma levels of luteinizing hormone (LH) in groups of hypogonadal (HPG) mice in persistent estrus after receiving POA grafts (HPG/POA). Individual differences in responsivity to progesterone were related in part to the length of time in persistent estrus. Approximately 30% of HPG/POA grafts tested 2 months after graft showed increased levels of plasma LH. This was reduced to 10% when animals were tested 5 months after graft. Sequential administration of estradiol benzoate plus progesterone to intact HPG/POA mice was ineffective in elevating LH. The presence of corpora lutea in ovaries verified that only animals with a progesterone induced LH surge ovulated. Other HPG/POA mice were mated, and the occurrence of reflex ovulation was determined. Four of these mice delivered pups: 3 were previous responders to progesterone. One female mated again during the immediate postpartum period and delivered a second litter. Following weaning of all offspring, this animal displayed spontaneous ovarian cyclicity, confirmed by ovarian histology. This is the first proven example of spontaneous ovulation in a mutant mouse with a brain graft. The results show that some HPB/POA mice are capable of positive feedback responses, and rarely, of becoming spontaneous ovulators.

Reversal of reproductive deficiency in the hpg male mouse by neonatal androgenization

Some aspects of reproductive function in the GnRH-deficient hypogonadal (hpg) mutant mouse can be restored by transplanting normal fetal brain tissue containing GnRH cells into the central nervous system of adult hpg mice. However, hpg males showing physiological response to the graft fail to display sexual behavior and are infertile. We hypothesized that the reproductive deficit of these males is due to insufficient perinatal exposure to testicular androgens as a consequence of the GnRH deficiency. To test this hypothesis we androgenized hpg males by giving them neonatal injections of testosterone propionate (TP). Controls consisted of hpg males not androgenized neonatally and of normal males. All three groups received a TP implant in adulthood, and their copulatory behavior and reproductive capability were recorded. In addition, other hpg males, not androgenized neonatally, received fetal brain transplants containing GnRH neurons and were also tested for copulatory behavior and reproductive capability before and after receiving a TP implant. Three of 8 neonatally androgenized hpg males expressed the full repertoire of male sexual behavior, including intromission and ejaculation, and sired several litters. Three of 7 control hpg males that were not androgenized neonatally but received TP implants in adulthood also displayed mounting and intromission, but there was no evidence of ejaculation, and these males failed to impregnate normal females. Of the 8 hpg males that responded to a fetal transplant with testicular growth, only 1 displayed mounting behavior. However, when given a TP implant, 4 of 8 hpg males with grafts displayed mounting and intromissions.(ABSTRACT TRUNCATED AT 250 WORDS)

Increased galanin synapses onto activated gonadotropin-releasing hormone neuronal cell bodies in normal female mice and in functional preoptic area grafts in hypogonadal mice

Galanin synaptic input onto gonadotropin-releasing hormone (GnRH) neuronal cell bodies was analysed in female mice using the presynaptic vesicle-specific protein, synaptophysin (Syn) as a marker. In the first experiment, forebrain sections from normal ovariectomized ovarian steroid-primed mice exhibiting a surge of luteinizing hormone were processed for immunohistochemical labelling for GnRH, synaptophysin, galanin and Fos. Two representative sections from each brain, one passing through the anterior septum (anterior section) and the other through the organum vasculosum lamina terminalis-preoptic area (posterior section), were analysed under the confocal microscope. None of the GnRH cells analysed in the anterior sections were Fos immunoreactive (IR) or received input from galanin-IR fibres. In contrast, the majority of GnRH cells in the posterior sections analysed were Fos-positive. The number of galanin synapses onto the Fos-positive GnRH cells was significantly higher than that in the Fos-negative cells in this area of the brain, even though the number of Syn-IR appositions was comparable to each other. Transplantation of preoptic area (POA) into the third cerebral ventricle of hypogonadal (HPG) mice corrects deficits in the reproductive system. In the second experiment, synaptic input to GnRH cells was compared between HPG/POA mice with (functional graft) or without (nonfunctional graft) gonadal development. The mean numbers of Syn-IR appositions and galanin synapses per GnRH cell and the proportion of GnRH cells with galanin input were significantly higher in the functional than in the nonfunctional grafts. The results suggest that galanin can act directly on the GnRH cell bodies and may have an important regulatory role on the GnRH system.

Pulsatile administration of gonadotrophin releasing hormone as a diagnostic tool to distinguish hypothalamic from pituitary hypogonadism following neurosurgery

Nine patients suffering from severe amenorrhoea following neurosurgical or radiotherapy for pituitary tumour or craniopharyngeoma were treated with pulsatile gonadotrophin releasing hormone (GnRH) administration. Seven patients did exhibit ovulatory cycles when GnRH was administered i.v. at a dose of 20 micrograms/pulse, but not at lower doses or when GnRH was administered s.c. Pulsatile GnRH administration may be used to assess the functional integrity of pituitary gonadotrophs and to distinguish pituitary from hypothalamic site of lesion resulting in hypogonadotrophic hypogonadism. It may also be used successfully for treatment of infertility in such patients.

Body image, plastic surgery (prosthetic testes) and Kallmann's syndrome

A patient with Kallmann's syndrome received prosthetic testicular implants. In interviews and letters, he demonstrates that delay in electing surgery, and its eventual success, were both related to incorporation of the foreign bodies into the body image.

Increased Free Testosterone Levels in Men with Uncontrolled Type 2 Diabetes Five Years After Randomization to Bariatric Surgery

Hypogonadism frequently occurs in male patients with type 2 diabetes (T2DM) and is linked to insulin resistance and inflammation. Testosterone levels rise acutely in obese patients following bariatric surgery, though long-term changes have not been investigated in a randomized controlled trial. This study evaluated obese men with T2DM randomized to either bariatric surgery or medical therapy. Testosterone, gonadotropins, body composition, insulin sensitivity, and inflammatory markers were evaluated in 32 patients at baseline and at 5 years. Surgical patients had 47.4% increase in free testosterone compared to medical therapy patients who had 2.2% decrease (P = 0.013). Increase in free testosterone correlated with reduction in body weight, high-sensitivity C-reactive protein (hsCRP), and leptin levels. Prolonged improvements in testosterone levels after bariatric surgery in T2DM are found to be related to reduction in body weight and adipogenic inflammation.

Application of a fluorescent dye to study connectivity between third ventricular preoptic area grafts and host hypothalamus

The mutant hypogonadal (hpg) mouse lacks a functioning gene for the neurohormone gonadotropin releasing hormone (GnRH). Previous studies from our laboratory had indicated that the initiation and maintenance of reproductive function in these mice could be brought about by the implantation of normal fetal grafts into adult hosts. Testicular or ovarian growth and other indicators of normal neurosecretory output were always accompanied by survival of GnRH neurons and growth of GnRH axons into the host median eminence where such axons terminate on the hypophysial portal capillaries. To determine if other connections exist between graft and the host hypothalamus, small crystals of the carbocyanine dye, 1,1'-dioctadecyl-3,3,3',3'-tetramethyl-indocarbocyanine perchlorate (DiI) were applied to either graft or host after fixation of the brain. Tissue sections were analyzed for retrograde and and anterograde movement of the dye. When crystals were placed on the graft, labeled axons were found in the host median eminence or in the host hypothalamus taking an arching trajectory toward the median eminence. Retrogradely labeled neurons in the host were few in number and largely confined to the host arcuate nucleus. With DiI crystals applied to the basal hypothalamus, labeled axons were distributed widely in the host but much sparser in the graft. Axons appeared to enter primarily at sites where the graft and host interface lacked an ependymal lining. Small numbers of retrogradely labeled neurons were also seen in the graft. Most were cells of very simple morphology and were distributed randomly in the graft. When double label experiments were carried out most DiI positive cells in the graft contained GnRH. These results indicate the connectivity between host hypothalamus and the third ventricular preoptic area grafts exists but is limited in nature.

An intracellular study of grafted and in situ preoptic area neurones in brain slices from normal and hypogonadal mice

1. Intracellular recordings have been obtained from forty-one preoptic area (POA) neurones at times up to 14 months after they were grafted into the third ventricle of the mouse. Thirty-one neurones were in grafts from hypogonadal (hpg) mice in which a reversal of the hypogonadism was seen (responders), six were in grafts from hpg mice in which no such reversal occurred (non-responders) and four were in grafts from normal mice. 2. The grafted neurones had a mean resting potential (Em) of -57 mV, a mean apparent input resistance (Rm) of 136 M omega and a mean membrane time constant (tau m) of 7.7 ms. The slopes of the current-voltage (I-V) relations were linear. Approximately a quarter of neurones in responders fired action potentials spontaneously either singly or in bursts. Such activity could underlie the release of gonadotrophin hormone-releasing hormone (GnRH) which is known to occur from such grafts. 3. Two types of response were seen when these neurones were depolarized to firing threshold from Em, in one group a single action potential was discharged; in the other group one or more action potentials arising from a transient, slowly rising and falling depolarization (low-threshold response, LTR) was recorded. Some cells in the former category exhibited a LTR when depolarized from a potential more negative than Em. 4. The commonest response to stimulation of the median eminence in responders was an EPSP either alone or in combination with an IPSP. Antidromic action potentials were seen in four neurones and in two of these cells excitatory synaptic inputs could be demonstrated when the host hypothalamus adjacent to the graft was stimulated. It is suggested that these responses may represent activation of an afferent input from the host to neurones in the graft. 5. The morphology of neurones in POA grafts was determined by intrasomatic injection of horseradish peroxidase (HRP). A variety of profiles were seen and although some neurones extended over distances of up to 635 microns and branched extensively only one appeared to enter the host tissue at the ventrolateral edge of the graft. 6. A comparison was made between grafted POA neurones and cells in the medial preoptic area (MPOA), a region which constituted a significant component of the grafted tissue. No significant difference was noted between neurones in the graft and neurones in the MPOA in terms of their passive membrane properties. With regard to the active properties MPOA neurones could also be classified according to whether or not a LTR was elicited when the neurone was depolarized from Em. The major difference between the grafted neurones and those in the MPOA lay in the proportion of cells which exhibited a LTR under such conditions, being significantly greater in the latter group.

Pituitary function in patients with normal pressure hydrocephalus before and after neurosurgical correction

INTRODUCTION

Little is known about pituitary function in patients with normal pressure hydrocephalus (NPH). This study evaluated pituitary function in a large series of patients awaiting neurosurgical correction for NPH. We also sought to ascertain whether surgical correction of hydrocephalus would result in improvement of any noted pituitary dysfunction.

METHODS

Patients with NPH referred for neurosurgical evaluation between February 2010 and January 2011 were eligible for recruitment. Pituitary endocrine evaluation including serum prolactin, free thyroid hormone, TSH, IGF-I, FSH, LH, estradiol, testosterone, cortisol, and ACTH was preformed at baseline and 1 and 3 months after surgery.

RESULTS

Of the 63 patients referred for possible NPH, 32 met study criteria, 20 could provide informed consent, and laboratory evaluation was obtainable in 16. The mean age of these patients was 62±14 yr, and 75% were men. The overall incidence of NPH-associated pituitary dysfunction was 31% (five of 16 patients) at baseline laboratory assessment. Hypogonadism was the most common type of pituitary dysfunction detected.

CONCLUSION

NPH is associated with pituitary dysfunction, observed in a significant proportion (31%) of patients. As such, we recommend that pituitary screening should be considered in all NPH patients. In two patients with hypogonadism, surgical correction of NPH was associated with improved testosterone levels. Therefore, not all patients with NPH-associated pituitary dysfunction will require hormone replacement therapy because surgical correction may correct pituitary deficiencies in some instances.

Varicocele Repair Versus Testosterone Therapy for Older Hypogonadal Men with Clinical Varicocele and Low Testosterone

As men age, serum testosterone levels decrease. This reduction in testosterone levels may cause symptoms leading to hypogonadism. In addition, the presence of a varicocele can impair Leydig cell function, resulting in decreased testosterone production in men. Varicocelectomy and testosterone replacement therapy are both viable treatment options for hypogonadism in elderly male patients. The correct modality of treatment will vary for each patient, but education is essential in order to help men understand their options. Testosterone therapy (TTh) with laboratory monitoring will likely appeal to many men who want to avoid surgery, but for men with hypogonadism and a varicocele, a one-time low-risk microsurgery with the potential to negate the need for further therapy presents an attractive alternative to lifelong TTh. PATIENT SUMMARY: Varicocelectomy and testosterone therapy (TTh) are viable treatment options for hypogonadism in elderly male patients. Treatment modality will vary for each patient, but education is essential to help them understand their options. Although TTh with laboratory monitoring may appeal to men wanting to avoid surgery, those with hypogonadism and a varicocele would likely prefer a one-time low-risk microsurgery to lifelong TTh.

Preoptic area grafts implanted in mammillary bodies of hypogonadal mice: patterns of GnRH neuronal projections

Gonadotropin-releasing hormone (GnRH) axons project to the median eminence, where the peptide is released to stimulate pituitary gonadotrophs. Hypogonadal mice (hpg) do not synthesize GnRH due to a deletion in the gene. When neonatal preoptic area (POA) tissue from normal mice containing GnRH neurons is transplanted into the third ventricle of hpg mice, GnRH axons exit the graft and specifically project to the median eminence, where the release of GnRH in the portal circulation induces the stimulation of the pituitary-gonadal axis. To test the hypothesis that the median eminence region is critical to targeting, we placed POA grafts in the region of the mammillary bodies, which never contains GnRH cell bodies, but is nevertheless close to the median eminence. Control mice received bilateral grafts into the anterior hypothalamus. GnRH axons innervated the median eminence in animals with grafts in the mammillary bodies and posterior hypothalamus. Mice with such grafts for 4-5 months had gonadal development, while those with grafts for shorter periods did not. Anterior hypothalamic grafts merged into the third ventricle and, consistent with previous studies, this resulted in GnRH innervation of the median eminence and gonadal development. However, when grafts were located within dorsal regions such as the thalamus, no median eminence innervation was seen. In these cases, GnRH axons borrowed other bundles of fibers to travel within the host brain. The pattern of innervation from grafts within ventro-caudal regions of the hypothalamus vs. that from dorsal regions supported the hypothesis that the median eminence releases diffusible substances directing GnRH outgrowth.

Brain tissue grafts in the central nervous system: reversal of hypogonadism

Transplantation of brain tissue from normal donors into the central nervous system of animals with specific central neurochemical deficiencies has been used to remedy such defects. The present studies demonstrate that the hypogonadism present in the adult male hypogonadal (hpg) mouse that is secondary to hypothalamic gonadotropin releasing hormone (GnRH) deficiency can be corrected by grafts into the anterior third ventricle of fetal preoptic area (p.o.a.) tissue. The p.o.a. is a primary site of localization of GnRH neurones in rodents. As compared with untreated hpg males, or with hpg males that had received control cortical tissue implants, the hpg animals with p.o.a. grafts showed measurable levels of GnRH within the hypothalamus. Immunocytochemical studies revealed GnRH within the transplants. Increased pituitary and plasma LH and FSH, and testicular growth with full spermatogenesis, were also evident in the hpg males that had received p.o.a. implants.