OBJECTIVE

To determine the effects of the last hMG administration on plasma P and androgen profiles during controlled ovarian hyperstimulation (COH) for IVF-ET.

METHODS

Controlled clinical study.

METHODS

The IVF-ET program of a tertiary outpatient care center, Hôpital A. Béclère, Clamart, France.

METHODS

Nine IVF-ET candidates aged 25 to 36 years having presented normal responses to COH in previous IVF-ET cycles.

METHODS

Controlled ovarian hyperstimulation was induced for IVF-ET using hMG after endogenous gonadotropins were suppressed with a time-release GnRH agonist. Just before the last hMG administration (225 IU), the participants were hospitalized for 2<em>4</em> hours for serial blood sampling. These occurred before (baseline) and after hMG administration, every 30 minutes for 1 hour, hourly for <em>4</em> hours, and every 3 hours for the remaining part of a 2<em>4</em>-hour post-hMG observation period.

METHODS

Measurement of P, T, androstenedione (A), E2, FSH, and LH.

RESULTS

Plasma P and androgens (T and A) increased significantly, reaching peak values 12 to 15 hours after hMG administration and decreased progressively thereafter, to reach values not significantly different from baseline 2<em>4</em> hours after hMG administration. Plasma E2 levels increased progressively and steadily during the 2<em>4</em>-hour observation period. Plasma FSH levels remained constant after hMG administration while LH stayed undetectable.

CONCLUSIONS

In COH cycles induced for IVF-ET, the hormonal profile after the last hMG injection suggests that hMG triggers an increase in plasma P and androgens that culminates 12 to 15 hours after hMG administration. This elevation in plasma P and androgens observed after hMG administration is likely to reflect a direct action of the LH and/or FSH components of hMG on granulosa cells. In some women these hormonal consequences of hMG treatment may impair endometrial receptivity in IVF-ET cycles.

The possible direct effect of gonadotropin-releasing hormone (GnRH) and a potent GnRH agonist [( imBzl )-D- His6 -Pro9-NEt]-GnRH on basal and human chorionic gonadotropin (hCG)-stimulated progesterone, <em>androstenedione</em>, and estradiol production by cultured human luteal cells was examined. Luteal cells from the early or midluteal phase of the menstrual cycle responded to hCG stimulation with two to fivefold increases in steroid production in both short-term (<em>4</em> hours) and long-term (up to 1<em>4</em><em>4</em> hours) culture in chemically defined medium without serum. After <em>4</em>8 hours in this system, levels of <em>androstenedione</em> and estradiol were very low, and progesterone was the predominant steroid produced. The addition of GnRH or a potent GnRH agonist to the medium had no effect on either basal or hCG-stimulated steroid secretion. When luteal cells were cultured longer (for up to 10 days) in the presence of serum, GnRH agonist caused no significant alteration of either basal or hCG-stimulated progesterone production. Collectively, these results support the conclusion that GnRH and its potent agonist do not act directly on human corpora luteal cells to modulate steroidogenesis.

The objectives of the present study were to determine the interaction among basic fibroblast growth factor (bFGF), epidermal growth factor (EGF), insulin, and insulin-like growth factor-I (IGF-I) on cell numbers, steroidogenesis, and IGF-I binding sites in cultured thecal cells. Cells from large >> or = 8 mm) follicles were collected from cattle and cultured for <em>4</em> days. Treatment with 1-30 ng/ml of bFGF for 2 days increased (p < 0.05) thecal cell numbers but inhibited (p < 0.05) <em>androstenedione</em> and progesterone production in the presence of insulin alone or insulin plus LH. Treatment with 1-30 ng/ml of bFGF for 2 days also inhibited (p < 0.05) the number of specific 125I-IGF-I binding sites in thecal cells, with maximal inhibition being detected at 1 ng/ml; coculture with 100 ng/ml LH did not influence this effect. In the absence of bFGF and the presence of LH, 30 ng/ml of IGF-I increased thecal cell numbers and production of <em>androstenedione</em> and progesterone. However, cotreatment with 10 ng/ml bFGF inhibited thecal cell response to IGF-I. Cotreatment consisting of 3-100 ng/ml EGF with insulin increased (p < 0.05) thecal cell numbers but decreased (p < 0.05) <em>androstenedione</em> and progesterone production and the number of specific 125I-IGF-I binding sites in thecal cells, with maximal inhibition observed at 3 ng/ml of EGF. Also, cotreatment consisting of 3 and 10 ng/ml of EGF with IGF-I plus LH inhibited (p < 0.05) cell numbers and production of <em>androstenedione</em> and progesterone by thecal cells. These results suggest that bFGF, EGF, insulin, and IGF-I may interact to play a significant role in basal and LH-modulated thecal cell steroidogenesis and mitogenesis during follicular development in cattle.

Oxytocin (OT) is secreted during the final stages of bovine follicular development. To test OT's potential role as a regulator of follicular steroidogenesis, theca and granulosa cells were isolated from bovine preovulatory follicles <em>4</em>8 h after initiation of luteolysis with prostaglandin F2 alpha, and cultured with graded doses of OT (0, 0.5, 5, 50, and 500 mIU/ml). Granulosa cells were cultured with testosterone (0.5 microM) in either defined medium or medium containing 10% fetal bovine serum in the presence or absence of FSH (300 ng/ml); medium was collected and replaced daily for 5 days. In defined medium, oxytocin alone significantly increased progesterone production by granulosa cells (P less than 0.001) in a dose-dependent manner; over 5 days, doses of 0.5, 5, 50, and 500 mIU/ml OT caused 1.7-, 2.0-, 2.2-, and 2.6-fold increases. FSH enhanced progesterone 5-fold, but no dose of OT increased progesterone in the presence of FSH. OT also elevated progesterone in serum-containing medium (P less than 0.005), but the magnitude of its effects was lower (1.07-, 1.1-, 1.2-, and 1.<em>4</em>-fold increases with 0.5, 5, 50, and 500 mIU/ml OT). OT had little effect on estradiol secretion by granulosa cells cultured with or without FSH. To test the specificity of OT's effects on progesterone production by granulosa cells, granulosa cells were treated with graded doses of an OT antagonist (0, 1, 10, 100, and 1000 ng/ml) in the presence or absence of OT (5 and 50 mIU/ml). Progesterone production by granulosa cells in the presence of the antagonist alone was similar to production in control cultures. The stimulatory effects of 5 and 50 mIU OT were completely abolished in the presence of 100 or 1000 ng antagonist, respectively (P less than 0.01). Preparations of theca interna were cultured in defined medium with graded doses of OT (0, 0.5, 5, 50, and 500 mIU/ml) in the presence or absence of LH (300 ng/ml), with collection and replacement of medium at 3, 6, 12, 2<em>4</em>, <em>4</em>8, and 72 h. LH alone increased both progesterone (12-fold) and <em>androstenedione</em> (<em>4</em>-fold) production over controls. However, no dose of OT significantly affected either progesterone or <em>androstenedione</em> production. These results show that OT stimulates progesterone production by granulosa cells, and thus, suggest that OT regulates steroidogenesis in bovine granulosa cells in vivo.

To elucidate synthetic pathways of testosterone and estradiol-17 beta in embryonic gonads of the chicken, metabolism of various 1<em>4</em>C-labeled steroids in slices of the left ovaries and paired testes of 15- and 9-day-old chicken embryos was examined. (1) Fifteen-day-old chicken embryos: From pregnenolone, more 17 alpha-hydroxypregnenolone was produced than progesterone in the ovary, while more progesterone was produced than 17 alpha-hydroxypregnenolone in the testis. From 17 alpha-hydroxypregnenolone, however, only dehydroepiandrosterone was detected as a product in both gonads. Dehydroepiandrosterone was converted mainly into <em>androstenedione</em> and its 5 beta-reduced derivatives by both gonads. Progesterone was converted into 5 beta-pregnane-3,20-dione more than into 17 alpha-hydroxyprogesterone by both gonads. Both gonads metabolized 17 alpha-hydroxyprogesterone, <em>androstenedione</em>, and testosterone predominantly into their corresponding 5 beta-reduced steroids, while production of <em>androstenedione</em> from 17 alpha-hydroxyprogesterone and of testosterone from <em>androstenedione</em> was limited. Estradiol-17 beta was produced from <em>androstenedione</em> and testosterone only by the ovary. (2) Nine-day-old chicken embryos: From pregnenolone, production of progesterone and 17 alpha-hydroxypregnenolone was similar in the ovary. On the other hand, in the testis, more progesterone was produced than 17 alpha-hydroxypregnenolone from pregnenolone. For delta <em>4</em>-3-oxo steroids, strong activity of 5 beta-reductase was demonstrated in both gonads. From these results, both delta <em>4</em>- and delta 5-pathways are involved in the formation of testosterone and then finally of estradiol-17 beta by the embryonic gonads of the chicken, and relative preference for the pathway seems to depend on sexes and embryonic ages. In addition, it is suggested that steroidogenesis in these embryonic gonads is characterized by marked activity of 5 beta-reductase, irrespective of sexes or ages.

Endocrine studies in girls with precocious thelarche were compared with those of normal girls of similar ages. Girls with precocious thelarche showed breast development and oestrogenised vaginal smears as the only signs of precocious sexual development. A few of the girls were tall and some had advanced bone ages but these two findings were not consistently present in the same patient. Hormones--such as serum oestradiol, oestrone, delta <em>4</em>-<em>androstenedione</em>, progesterone, dehydroepiandrosterone (DHEA), follicle-stimulating hormone, luteinising hormone, and prolactin, and urinary 17-ketosteroids--were measured. Only DHEA was different, being higher in girls with precocious thelarche. It is suggested that the high DHEA level may serve as a precursor for conversion to oestrogens in target tissues, breast, and vagina. This mechanism for oestrogenisation had been reported in other patients.

Previous in vitro experiments showed that both, Taenia crassiceps and Taenia solium cysticerci have the ability to metabolize exogenous <em>androstenedione</em> to testosterone. Here we evaluate on the capacity of both cysticerci to synthesize several sex steroid hormones, using different hormonal precursors. Experiments using thin layer chromatography (TLC) showed that both cysticerci were able to produce (3)H-hydroxyprogesterone, (3)H-<em>androstenedione</em> and (3)H-testosterone when (3)H-progesterone was used as the precursor. They also synthesized (3)H-androstenediol and (3)H-testosterone when (3)H-dehydroepiandrosterone was the precursor. In addition, both cysticerci interconverted (3)H-estradiol and (3)H-estrone. These results, strongly suggest the presence and activity of the Delta<em>4</em> and Delta5 steroid pathway enzymes, 3beta-hydroxysteroid dehydrogenase/Delta(5-<em>4</em>) isomerase-like enzyme (3beta-HSD), that converts androstenediol into testosterone; and the 17beta-hydroxysteroid dehydrogenase that interconverts estradiol and estrone, in both types of cysticerci.

Pathways of testosterone metabolism in tissue slices and cell suspensions of human benign hyperplastic prostate (BPH) tissue and human prostate cancer cell lines (DU1<em>4</em>5, HPC-36M, PC-3/MA2 and LNCaP) were investigated. Thin layer chromatography analysis was used to identify the following tritiated metabolites: testosterone, 5 alpha-dihydrostestosterone (DHT), 5 alpha-androstane-3 alpha/3 beta-17 beta-diol (androstanediols), <em>4</em>-androstene-3,17-dione (<em>androstenedione</em>) and 5 alpha-androstanedione. The predominant pathway for testosterone metabolism in BPH was via 5 alpha-reductase producing 5 alpha-dihydrotestosterone (71% and 75% total metabolites in slices and suspensions incubated for 2<em>4</em> h, respectively). The cancer cell lines DU1<em>4</em>5 and HPC-36M resembled BPH by metabolizing testosterone predominantly to DHT (68% and 82% total metabolites, respectively), although the rate of metabolism was much lower in the cell lines (0.099 and 0.05 pmol testosterone/mg protein/h in DU1<em>4</em>5 and HPC-36M) compared to the BPH cell suspensions (6.<em>4</em> pmol testosterone/mg protein/h). In contrast, PC-3/MA2 contained high 17 beta-HSD activity forming large amounts of <em>4</em>-androstene-3,17-dione (8<em>4</em>% total metabolites), converting testosterone at a rate faster (12.8 pmol testosterone/mg protein/h) than the BPH cell suspensions. LNCaP rapidly converted testosterone exclusively to a glucuronide conjugate (7.<em>4</em> pmol testosterone/mg protein/h), although after incubation with [3H]-<em>4</em>-androstene-3,17-dione, 5 alpha-reductase activity was demonstrated. LNCaP was the only cell line whose growth and colony-forming ability was stimulated by testosterone and DHT. BPH and all the cell lines tested had 5 alpha-reductase activity, but only the prostate tissue and the cell lines DU1<em>4</em>5 and HPC-36M converted testosterone predominantly to DHT.

OBJECTIVE

To test the hypothesis that patients with nonclassic adrenal hyperplasia (NCAH) exhibit a generalized exaggeration in their response to ACTH stimulation that favors the normal production of F. Patients with 21-hydroxylase (21-OH)-deficient NCAH do not demonstrate cortisol (F) deficiency.

METHODS

Prospective controlled study.

METHODS

Tertiary university clinic.

METHODS

Twenty-four untreated patients with NCAH diagnosed by a 17 alpha-hydroxyprogesterone (17-HP) level of >30.3 nmol/L (>10 ng/mL), and 37 age- and body mass-matched healthy eumenorrheic nonhirsute controls.

METHODS

All study subjects underwent a 60 minute acute stimulation using 0.25 mg of ACTH-(1-24) i.v.

METHODS

Basal and stimulated serum levels of pregnenolone (PREG), 17-hydroxypregnenolone (17-HPREG), dehydroepiandrosterone (DHA), progesterone (P4), 17-HP, androstenedione (A4), 11-deoxycortisol (S), and cortisol (F).

RESULTS

The median basal (i.e., Steroid(0)) or ACTH-stimulated (i. e., Steroid(60)) serum levels of PREG, 17-HPREG, DHA, P4, 17-HP, A4 and, most importantly, S were higher in NCAH patients than in controls. In contrast, the levels of F at either 0 minute or 60 minutes of stimulation were similar between NCAH and control women. The proportion of NCAH patients with stimulated steroids levels of>>the 95th percentile of controls were as follows: 84.21% for PREG(60), 87.5% for 17-HPREG(60), 95.8% for DHA(60), 89.5% for P4(60), 100% for 17-HP(60), 91.7% for A4(60), 29.2% for S(60), and 4. 1% for F(60).

CONCLUSIONS

A generalized adrenocortical hyperresponsivity to ACTH stimulation seems to be present in patients with 21-OH-deficient NCAH, with an exaggerated production of S evident in approximately 30%. The excess production of S in these NCAH patients may, in part, account for their normal F production.

BACKGROUND

Current knowledge on gonadal function in congenital adrenal hyperplasia (CAH) is mostly limited to single-center/country studies enrolling small patient numbers. Overall data indicate that gonadal function can be compromised in men with CAH.

OBJECTIVE

To determine gonadal function in men with CAH within the European 'dsd-LIFE' cohort.

METHODS

Cross-sectional clinical outcome study, including retrospective data from medical records.

METHODS

Fourteen academic hospitals included 121 men with CAH aged 16-68 years. Main outcome measures were serum hormone concentrations, semen parameters and imaging data of the testes.

RESULTS

At the time of assessment, 1<em>4</em>/69 patients had a serum testosterone concentration below the reference range; 7 of those were hypogonadotropic, 6 normogonadotropic and 1 hypergonadotropic. In contrast, among the patients with normal serum testosterone (55/69), <em>4</em> were hypogonadotropic, <em>4</em><em>4</em> normogonadotropic and 7 hypergonadotropic. The association of decreased testosterone with reduced gonadotropin concentrations (odds ratio (OR) = 12.8 (2.9-57.3)) was weaker than the association between serum <em>androstenedione</em>/testosterone ratio ≥1 and reduced gonadotropin concentrations (OR = 39.3 (2.1-732.<em>4</em>)). Evaluation of sperm quality revealed decreased sperm concentrations (15/39), motility (13/37) and abnormal morphology (<em>4</em>/28). Testicular adrenal rest tumor (TART)s were present in 39/80 patients, with a higher prevalence in patients with the most severe genotype (1<em>4</em>/18) and in patients with increased current 17-hydroxyprogesterone 20/35) or <em>androstenedione</em> (12/18) serum concentrations. Forty-three children were fathered by 26/113 patients.

CONCLUSIONS

Men with CAH have a high risk of developing hypothalamic-pituitary-gonadal disturbances and spermatogenic abnormalities. Regular assessment of endocrine gonadal function and imaging for TART development are recommended, in addition to measures for fertility protection.

We studied 20 hirsute patients with high levels of serum testosterone (T), calculated free T, <em>androstenedione</em>, and dehydroepiandrosterone sulfate and 19 age-matched nonhirsute normoandrogenic control women. The bone mineral density (BMD) in the lumbar spine, femoral neck, and trochanter major region in hirsute patients was higher than that in the controls. BMD in the lumbar spine and proximal femur correlated positively with the body mass index and with serum T and free T in hyperandrogenic women and the whole study group, but not with serum <em>androstenedione</em> or dehydroepiandrosterone sulfate levels. The hirsute women were treated with a GnRH agonist (goserelin, 3.6-mg implant) for 9 months. After the first 3 months of treatment, half of the patients were randomized to receive estrogen-progestin replacement therapy (HRT), and the other half served as controls. After the first 3 months of trial, BMD was unaffected, and the urinary output of collagen pyridinoline, deoxypyridinoline cross-links, and hydroxyproline (all markers of bone resorption) were increased, but serum markers, the carboxy-terminal telopeptide of type I collagen (marker of bone resorption) and that of bone-specific alkaline phosphatase (marker of bone formation) did not change. After 9 months of goserelin treatment, the lumbar spine had lost 5.<em>4</em>% of its BMD (P < 0.01), but regained bone density 6 months after cessation of treatment. Addition of HRT protected the spine and trochanter major against bone loss. The changes in serum telopeptide and urinary output of pyridinoline and deoxypyridinoline after 3 months of treatment (from prestudy levels) correlated with the decrease in BMD in the femoral neck at 9 months. In conclusion, our data show that patients with ovarian androgen excess 1) have high BMD, 2) lose bone during 9 months of treatment with GnRH agonist, 3) show a decrease in bone density preceded by biochemical alterations in bone metabolism at least 6 months earlier, and <em>4</em>) can have their bone loss prevented by add-back HRT.

Research efforts over the past several years have focused on the synthesis of competitive and irreversible aromatase inhibitors and examination of these inhibitors in microsomal preparations, in cell culture, and in vivo. Several 7 alpha-substituted <em>androstenediones</em> have demonstrated high affinity for placental aromatase, with apparent Ki's ranging from 1 to 30 nM. Inactivation of aromatase occurred following incubation with alkylating and enzyme-activated irreversible inhibitors. 7 alpha-(<em>4</em>'-Amino)phenylthio-<em>4</em>-androstene-3,17-dione (7 alpha-APTA) exhibits potent inhibitory activity of aromatase in the MCF-7 human mammary carcinoma cell line with an ED50 of approximately 25 nM. The inhibitor did not bind to the estrogen receptor of the cells in vitro nor induce levels of progesterone receptors in intact cells. In vivo studies of 7 alpha-APTA in the DMBA-induced rat mammary carcinoma model resulted in 80% of the tumors responding completely or partially at doses of 25 and 50 mg/kg body wt/day. Thus, these 7 alpha-substituted steroidal aromatase inhibitors are effective medicinal agents and may be useful for the treatment of estrogen-dependent breast cancer.

Ovarian Sertoli-Leydig cell tumours (SLCT), also termed arrhenoblastomas, are the most frequent virilising tumours in women of reproductive age. Very rare secretory Brenner tumours (BT) have been described, generally after the menopause. A 31-year-old woman sought medical advice for secondary amenorrhoea, progressive hirsutism and a 5-year history of virilisation syndrome with clitoromegaly. Testosterone was markedly high (285 ng/dl, N<85) with moderate elevation of delta <em>4</em>-<em>androstenedione</em> (D<em>4</em>AD) (311 ng/dl, N <270), dehydroepiandrosterone sulfate (DHEAS) (366 μg/dl, N <3<em>4</em>0) and 17-hydroxyprogesterone (17OHP) (275 ng/dl). LH was 9 IU/l, FSH <em>4</em>.3 IU/l, estradiol 60 pg/ml and progesterone 31<em>4</em> ng/100 ml. Cortisol was decreased (1.3 μg/dl) after the dexamethasone suppression test. Pelvic MRI showed a 5-cm right ovarian tumour with a 2.5 cm nodular component and cystic areas, and two nodules measuring 11 mm and 15 mm above the right and left ovaries. After right ovariectomy by laparoscopy, pathological examination concluded on a 3-cm SLCT and a 2-cm BT; the nodules above the ovaries were dysembryoplastic cysts. Postoperatively, testosterone level was normal after 2<em>4</em> h (26 ng/dl), estradiol and progesterone rapidly decreased, cyclic secretion then resumed and the patient menstruated at day 27. To our knowledge, this is the first report of an ovarian tumour associating a Sertoli-Leydig cell tumour and a Brenner tumour in a patient with virilisation syndrome which resolved after ovariectomy.

The antigonadal effects of GnRH agonists (GnRH-A) are mediated both through pituitary and testicular inhibitory mechanisms in the rat. To investigate these effects in men, we studied patients having no gonadotropin secretion and compared their testicular response to hCG in the absence or in the presence of GnRH-A. Thirteen patients with acquired pituitary hypogonadotropism had plasma testosterone levels below 1.5 ng/ml and no gonadotropin responses to acute GnRH administration (100 micrograms iv). Testicular responsiveness was evaluated using a single im injection of hCG (5000 IU im). Plasma levels of testosterone, dihydrotestosterone, <em>androstenedione</em>, 17-hydroxyprogesterone (17-OHP), and progesterone were determined before and <em>4</em>, 12, 2<em>4</em>, <em>4</em>8, and 72 h after hCG stimulation. The same protocol was also used in the same patients on day <em>4</em> of a 6-day course of treatment with the GnRH-A, D-Ser-(TBU)6, des-Gly NH2 GnRH ethylamide (Buserelin) (3 sc injections of 250 micrograms/day). During the first <em>4</em> days of GnRH-A administration, plasma LH, FSH, and testosterone levels were measured daily in order to establish the completeness of the gonadotropin deficiency. Before treatment with hCG, plasma testosterone levels were 0.56 +/- 0.15 and 0.96 +/- 0.22 ng/ml (mean +/- SE) in the absence of GnRH-A and during GnRH-A administration, respectively. The administration of hCG elicited a significant increase in plasma testosterone in both situations; integrated testosterone concentrations were 123.7 +/- 2<em>4</em>.9 and 155.5 +/- 27.9 ng/ml . 72 h (P greater than 0.1) in the absence of GnRH-A and during GnRH-A administration, respectively. Likewise the ratios of 17-OHP to progesterone, <em>androstenedione</em> to 17-OHP, and dihydrotestosterone to testosterone after hCG injection were similar in the presence or absence of GnRH-A. Since short term administration of buserelin did not inhibit hCG-induced testosterone secretion in patients with gonadotropin deficiency, we suggest that Buserelin does not grossly modify the function of testicular steroidogenesis enzymes. The antigonadal effects of GnRH-A in man appear to be mediated exclusively through the pituitary.

OBJECTIVE

Various endocrine studies performed in the hypospadias population show an unsatisfactory response to the human chorionic gonadotropin (HCG) test and abnormal androgen biosynthesis with possible enzyme defects. We evaluated the incidence of disorders in androgen production in boys with isolated hypospadias.

METHODS

A total of 32 consecutive children (46,XY) with hypospadias were prospectively enrolled in the study. Severity of the defect was assessed with a new classification based on the location of the division of the corpus spongiosum. Endocrine evaluation consisted of measuring luteinizing hormone, follicle-stimulating hormone, anti-müllerian hormone (AMH), testosterone, dihydrotestosterone, progesterone, 17alpha-hydroxypregnenolone, 17alpha-hydroxyprogesterone, dehydroepiandrosterone sulfate and delta4-androstenedione. In all but 3 patients gonadal stimulation with 1,500 IU HCG every other day for 12 days was performed and steroid concentrations were reassessed after the test. An adrenocorticotropic hormone test was performed in 2 patients and molecular study of the androgen receptor was performed in 28.

RESULTS

An increase to 37.37 nmol./l. progesterone (normal 0.1 to 0.5) and 17alpha-hydroxyprogesterone to 25.48 nmol./l. (normal 1.18 +/- 0.66) before HCG stimulation was noted in 1 patient. These abnormal results were not found after HCG stimulation but reappeared after the adrenocorticotropic hormone test. This result might be related to a partial mix of 17alpha-hydroxylase/17,20-lyase deficiency but no mutation was found after complete sequencing of gene CYP17. Of the 32 patients 4 had an insufficient response to HCG stimulation (testosterone less than 10 nmol./l.), including 1 with a low AMH level of 180 pmol./l. (normal 451 +/- 198) and an increased dehydroepiandrosterone sulfate level of 1,995 nmol./l. (normal 59 +/- 41) before HCG stimulation. Partial androgen insensitivity was suspected in 1 patient because he had a high testosterone response (29.96 nmol./l.) after HCG stimulation but no mutation of the gene of the androgen receptor was detected. Two patients with proximal hypospadias had isolated decreased AMH levels, which was evidence of Sertoli cell insufficiency.

CONCLUSIONS

Although our series of 32 patients had several abnormal endocrine screenings, these results indicate no significant endocrine defects.

Reviewing 780 in-vitro fertilization (IVF) cycles, where buserelin was commenced in the preceding luteal phase and human menopausal gonadotrophin on day <em>4</em> of the ensuing menses, 53 cycles were identified with sonolucent cysts (30-50 mm diameter). Of the latter 53 cycles, the serum oestradiol was significantly greater on day <em>4</em> in 22 cycles abandoned for poor follicular development than in 31 cycles which proceeded to oocyte retrieval (P less than 0.05). Of the 31 cycles proceeding to oocyte retrieval, nine had a day <em>4</em> serum oestradiol greater than 200 pmol/l (95th centile for day <em>4</em> oestradiol in patients without apparent cysts), and these cycles produced significantly fewer grade 1 embryos than the cycles with day <em>4</em> oestradiol levels less than or equal to 200 pmol/l (P less than 0.05). Six of the 53 cycles with cysts resulted in conception, and all of these cycles had a day <em>4</em> serum oestradiol less than 200 pmol/l. Among the 53 cycles with ovarian cysts, the serum progesterone on the day of abandonment in four cycles and on the day of human chorionic gonadotrophin administration in one non-abandoned cycle, was above the range established for 10<em>4</em> cycles without cysts. No significant difference was seen in day <em>4</em> serum <em>androstenedione</em> levels, and the day <em>4</em> serum progesterone was less than 5 nmol/l in all but one patient. Functional activity of ovarian cysts is associated with an adverse influence on IVF cycles.

The effects of the constant infusion with mini-osmotic pumps of several steroid hormones on body weight, energy balance and protein/lipid/water composition in young female rats has been studied for a period of 15 days. Despite unchanged food consumption, progesterone strongly induced fat deposition, with higher protein accrual efficiency coupled with lowered energy losses through thermogenesis. Estrogens lowered body weight but maintained higher protein levels and protein accrual rates; beta-estradiol induced the loss of lipid and diminished food intake. Heat production was unchanged or lower in all estrogen-treated animals; beta-estradiol had a more marked effect on body weight (through food intake, heat production and lipid mobilization/storage combined) than estrone. Testosterone and 5-androstenediol increased the proportion of protein, but none of them had a significant effect on lipid deposition or heat production. Nortestosterone, increased energy expenditure, fuelled in part by a higher food ingestion, a trait shared by <em>4</em>-<em>androstenedione</em>, but not by the other androgens. The effect of androgens on body weight may thus be a combination of their actions on a) food intake, b) efficiency of protein deposition and c) activation of heat production or of lipid (energy) storage. Practically all increased the efficiency of protein deposition. Nortestosterone increased heat production. <em>Androstenedione</em> increased lipid storage. Dehydroepiandrosterone did not decrease body weight or metabolic rate. Cortisol depressed heat production and food intake, with a net loss of weight. Cortisol and cortisone did not increase protein deposition, but corticosterone did; deoxycorticosterone showed a high efficiency of protein deposition and increased the size of fat stores, also increasing the metabolic rate by a mean 26% versus controls, compared with a reduction of about the same magnitude induced by cortisol. The data presented suggest that cortisol-cortisone and corticosterone may represent two distinct groups of glucocorticoids.

Aminoglutethimide and dexamethasone were administered for 3 months to 11 postmenopausal women with advanced breast cancer. During initial in-hospital studies, there was uniform suppression of plasma cortisol (0.23 microgram/100 ml), <em>androstenedione</em> (8.3 ng/ 100 ml), estrone (0.<em>4</em><em>4</em> ng/100 ml), and estradiol (0.32 ng/100 ml) to concentrations indistinguishable from those after surgical adrenalectomy. Eight of the 11 patients maintained this degree of suppression for 3 months. The other three patients may have taken inadequate amounts of dexamethasone, as evidenced by plasma steroid patterns characteristic of aminoglutethimide alone, that is, partial cortisol suppression (3.6 microgram/100 ml) and markedly increased <em>androstenedione</em> (355 ng/100 ml) with low estrone (0.5<em>4</em> ng/100 ml) and estradiol (0.61 ng/100 ml) concentrations. This apparent block in the aromatization of <em>androstenedione</em> to estrogens may be a feature important to the effectiveness of the regimen in sporadically noncompliant patients. After 3 months of therapy, return of resting plasma cortisol values to normal occurred within 3 to <em>4</em> days after cessation of the regimen and pituitary-adrenal responsiveness to surgical stress was demonstrable. This regimen is capable of maintaining an effective, reversible suppression of plasma steroids considered to be relevant to estrogen-dependent breast cancer.

The objective of this study was to determine the aetiological spectrum of disorders of sex development (DSD) in a large cohort of underprivileged and undiagnosed patients from Indonesia.

A total of 286 patients with atypical external and/or internal genitalia were evaluated using clinical, hormonal, molecular genetic and histological parameters.

The age (years) at presentation was 0-0·5 in <em>4</em>1 (1<em>4</em>·3%), >0·5-12 in 181 (63·3%) and >12 in 6<em>4</em> cases (22·<em>4</em>%). <em>4</em>6,XY DSD was most common (68·2%, n = 195), <em>4</em>6,XX DSD was found in 23·<em>4</em>% (n = 67) and sex chromosomal DSD in 8·<em>4</em>% (n = 2<em>4</em>). In 61·2% of <em>4</em>6,XX DSD patients, 17·9% of <em>4</em>6,XY DSD patients and all sex chromosome DSD patients (29·<em>4</em>% in total), a final diagnosis was reached based on genetic or histological gonadal tissue evaluation. 17-hydroxyprogesterone and <em>androstenedione</em> levels were the most distinctive parameters in <em>4</em>6,XX DSD patients. In <em>4</em>6,XY DSD, diagnostic groups were identified based on the external masculinization score: androgen action disorder (AAD), unknown male undermasculinization (UMU), and gonadal dysgenesis (GD). LH, FSH and testosterone levels were most informative especially in the older age group. HCG tests were of no additional value as no patients with androgen synthesis disorders were found. Hormonal profiles of patients with sex chromosome DSD and a Y-chromosome sequence containing karyotype showed high levels of LH and FSH, and low levels of AMH, inhibin B and testosterone compared with the normal male range. Gene mutations were found in all patients with CAH, but in only 2<em>4</em>·5% and 1·8% of patients with AAD and UMU. In 32% of <em>4</em>6,XY GD patients, copy number variants of different genes were found.

A stepwise diagnostic approach led to a molecularly or histologically proven final diagnosis in 29·<em>4</em>% of the patients. The most informative parameters were serum levels of 17-hydroxyprogesterone and <em>androstenedione</em> in <em>4</em>6,XX DSD patients, and serum LH, FSH and testosterone levels in <em>4</em>6,XY DSD patients.

The effects of a combination of aminoglutethimide (AG) 1,000 mg daily and <em>4</em>-hydroxy-<em>androstenedione</em> (<em>4</em>OHA) 500 mg i.m. weekly on peripheral aromatase activity as measured by in vivo radioisotopic tracer methodology and serum oestrogen suppression were investigated in ten post-menopausal women with advanced breast cancer. Patients were treated for a minimum of <em>4</em> weeks with <em>4</em>OHA before addition of AG for a minimum of 6 weeks. Aromatase inhibition was found to be nearly identical in the two treatment situations (92.5 +/- <em>4</em>.7% and 93.8 +/- 3.8% respectively). There was no further significant suppression of plasma oestradiol or plasma oestrone levels when AG was added to <em>4</em>OHA treatment (mean decrease of 7.6 +/- 12.1% and 2.8 +/- 12.0% respectively). In contrast, adding AG caused a further suppression of plasma oestrone sulphate (Oe1S) compared with <em>4</em>OHA monotherapy (mean suppression of 35.2 +/- 9.1%, P < 0.025). This effect on Oe1S may be due to an influence of AG on oestrogen metabolism.

Four cases in adults of a deficiency in the 11 beta-hydroxylation of corticosteroids were investigated by both basal and dynamic biological studies. Symptoms varied from patient to patient; hirsutism, menstrual disturbance, acne, deepening of the voice, and arterial hypertension appeared post puberty. Basal testing demonstrated elevated levels of plasma androgens. These include delta <em>4</em>-<em>androstenedione</em> (patients, 3.80-6.<em>4</em>3 ng/ml; normal, 1.33 +/- 0.33 ng/ml), urinary 17-ketosteroids (patients, 11.8-16.7 mg/2<em>4</em> h; normal, 5-10 mg/2<em>4</em> h), and urinary dehydroepiandrosterone. The basal tests were often insufficient to show the accumulation of the precursors (especially 17-hydroxyprogesterone) which are often given as evidence for an increase in ACTH stimulation. In studying the levels of the mineralocorticoids, there was shown to be an increased basal level of tetrahydrodeoxycorticosterone (patients, 1<em>4</em>2-317 microgram/2<em>4</em> h; normal, 60-80 microgram/2<em>4</em> h) which was raised by ACTH stimulation. These results, therefore, confirm the characteristic partial enzyme defect and give evidence for the heterogeneity of this syndrome. Based on the above observations, we believe it is appropriate to rename this condition adult adrenocortical 11 beta-hydroxylation defect rather than late-onset congenital adrenal hyperplasia.

Progressive ischemia and necrosis of the skin following thermal injury are reduced by postburn administration of the steroid hormone dehydroepiandrosterone (DHEA). Thermally injured animals were provided with a subcutaneous injection of DHEA, or a related species of steroid hormone, at various times after burning. During the 96 hr following administration of the scald burn, tissue necrosis was closely monitored. Subcutaneous administration of DHEA at approximately 1 mg/kg/day achieved optimal protection against the development of progressive dermal ischemia. DHEA, 17 alpha-hydroxy-pregnenelone, 16 alpha-bromo-DHEA, and androstenediol each demonstrated, a similar level of protection. Other forms of steroids, including DHEA sulfate, <em>androstenedione</em>, 17 beta-estradiol, or dihydrotestosterone, exhibited no protective effect under the conditions tested. Additionally, intervention therapy with DHEA could be initiated up to <em>4</em> hr, but not 6 hr, after burn without a marked reduction in therapeutic benefit. Examination of the microvasculature of thermally injured dorsal skin suggested that postburn intervention with DHEA, either directly or indirectly, maintained a normal architecture in most of the dermal capillaries and venules within burn-exposed tissue. These findings suggest that systemic intervention therapy of burn patients with DHEA or a similar acting steroid hormone may be useful in preventing the progressive tissue destruction caused by progressive ischemia.

OBJECTIVE

periodic measurement of plasma concentrations of cortisol precursors on a clinic visit may be of limited value in patients with congenital adrenal hyperplasia because it does not reflect a patient's circadian patterns of adrenal steroid secretion. Steroid profiling in dried blood spots (DBS) may allow for more frequent and sensitive monitoring.

METHODS

we compared the agreement between 17α-hydroxyprogesterone (17-OHP) and <em>androstenedione</em> (D<em>4</em>A) levels determined from DBS samples and concurrently collected serum samples. Blood was drawn from 9 congenital adrenal hyperplasia patients every <em>4</em> h over a 2<em>4</em>-hour period. Serum and DBS steroid levels were measured by liquid chromatography tandem mass spectrometry.

RESULTS

DBS determinations of 17-OHP overestimated corresponding serum levels (mean difference 1.67 ng/ml), and underestimated D<em>4</em>A serum levels (mean difference 0.8<em>4</em> ng/ml). However, the DBS assay yielded excellent agreement (97%) with serum 17-OHP, but did considerably poorer for D<em>4</em>A (31%).

CONCLUSIONS

our results indicate an excellent agreement between DBS and serum 17-OHP measurements to identify the peaks and troughs associated with an individual's circadian pattern. Larger-scale studies are required to evaluate the utility of DBS for home monitoring and to determine if more frequent monitoring leads to improved clinical outcomes.

Classic 3 beta-hydroxysteroid dehydrogenase (3 beta HSD) deficiency congenital adrenal hyperplasia (CAH) results from a mutation in the type II 3 beta HSD gene encoding adrenal and gonadal 3 beta HSD. We investigated the type II and type I 3 beta HSD gene sequences in 15 infants and children with premature pubarche (PP; mean/range of age at PP, <em>4</em>/0.08-9 yr) and elevated ACTH-stimulated delta 5 precursor steroid levels. Compared to Tanner I control subjects of similar age, ACTH-stimulated hormonal levels were at 2.3-10.7 SD for 17-hydroxypregnenolone (delta 5-17P) in all PP subjects, at 2.2-17 SD for dehydroepi-androsterone (DHEA) and 2.<em>4</em>-5.6 SD for the delta 5-17P/cortisol (F) ratio in all PP subjects except 1 infant, and at 2.3-10 SD for the DHEA/ <em>androstenedione</em> (delta 5-A) ratio in 8 PP subjects. Compared to Tanner II normal children, the hormonal levels were at 3-8 SD for delta 5-17P in all 13 PP children, at 2.3-<em>4</em>.7 SD for the delta 5-17P/F ratio in 6 PP children, and at 2.3-6.5 SD for DHEA and 3.5-9 SD for the DHEA/delta <em>4</em>-A ratio in 7 PP children. Type II 3 beta HSD gene sequences, including regions of a putative promoter, all exons (I, II, III, and IV), and exon-intron boundaries, were normal in all subjects. Sequences of the type I 3 beta HSD gene encoding extraadrenal and extragonadal 3 beta HSD were normal in the 6 patients tested. The ACTH-stimulated delta 5-17P levels and delta 5-17P/F ratios in the PP children without type II 3 beta HSD gene mutation were exceedingly lower than the respective reported hormonal data for children with 3 beta HSD deficiency CAH with proven type II 3 beta HSD gene mutation. The ACTH-stimulated DHEA levels and DHEA/delta <em>4</em>-A ratios were not exceedingly different between the children with and without type II 3 beta HSD gene mutation. These findings suggest that the degree of ACTH-stimulated delta 5 precursor steroid abnormality, such as delta 5-17P levels up to 10 SD above the normal mean level found in our PP patients, is not caused by a mild variant of 3 beta HSD deficiency CAH resulting from type II or type I 3 beta HSD gene mutation. The hormonal criterion for ACTH-stimulated delta 5-17P levels in patients with mild variant 3 beta HSD deficiency, therefore, is predicted to be higher than 10 SD above the normal mean value.