Prevalence of Endocrine Abnormalities in Adolescent Girls with Menstrual Disorders in a Tertiary Care Hospital in Chennai

Purpose: To identify endocrine abnormalities such as hyperandrogensim, thyroid disorders, and hyperprolactinemia in adolescents with menstrual disorders. Methods: This was a case–control study carried out in adolescent girls aged 10–19 years in the gynecology outpatient department of a tertiary care hospital. The participants’ demographic details, medical, surgical, family, and personal history was obtained. Data of hormonal evaluation, namely serum T3, T4, TSH, serum prolactin and serum testosterone was also collected. Results: The most common menstrual abnormality was oligomenorrhea at 66% followed by menorrhagia at 10%. Primary amenorrhea was seen in 8% cases, metrorrhagia was seen in 4% and polymenorrhea in 4% of cases. Secondary amenorrhea and hypomenorrhea were both seen in 2% of cases. 10% adolescents with menstrual abnormalities had biochemical hyperandrogenism. Only 2% had hyperandrogenism in the control group. Thyroid dysfunction was more prevalent in the adolescents with menstrual disorders (14%) when compared to controls (4%). Among those with oligomenorrhea, only in one case was serum prolactin raised (3.0%). Conclusion: Immaturity of hypothalamic pituitary ovarian axis is considered to be the most common cause of menstrual irregularities in adolescent girls, but endocrine abnormalities may be responsible in some cases. Therefore it is paramount to examine the prevalence endocrine abnormalities among among adolescents with menstrual problems to promote their quality of life, lower her risks for future disease, and ill health.

A Clinico-etiological Evaluation of Hirsutism Patients: A Case Series

Background: Hirsutism is a condition of excess hair growth in females in male-like distribution. It is seen in almost 5-10% of women. Women having hirsutism have a negative impact on quality of life. Aim: All patients were subjected to ultrasound imaging (Sonography) and hormonal evaluation to establish possible causative factors. Methods: A prospective and retrospective study of hirsutism patients, who were evaluated at Samarpan medical research organization, Modasa, Gujarat from 2016 to 2019. Results: In this case series age and clinical presentation were studied in five female patients diagnosed with hirsutism. The patients age ranged from 16 to 22 years with a mean of 19.60 years. All these patients showed localized hair growth on the upper lip, chin, and cheek on the face. Ultrasound study revealed that one of the five patients had a right bulky ovary and four patients showed both ovaries with multiple follicles. In hormonal evaluation, in one of the three patients the LH: FSH ratio was found to be more than 3. Three out of the five patients showed elevated levels of 17-OHP and serum testosterone. Two out of the three patients showed an elevated level of serum insulin. The level of DHEAS, serum prolactin, serum cortisol, and serum TSH were found to be in a normal range. Conclusion: Ultrasonographic (USG) study revealed a positive correlation between PCOS and Hirsutism patients. Hirsutism patients were found to have higher levels of 17-OHP, serum testosterone, serum insulin, and a higher ratio of LH: FSH, one or more at a time suggesting a strong correlation between elevated levels of these hormones and hirsutism. The present study could not establish any meaningful correlation between the level of DHEAS, serum prolactin, serum cortisol, and serum TSH.

Athletic, muscular and hormonal evaluation in CrossFit® athletes using the “Elevation Training Mask”

Introduction: The possibility of performing intense workouts without falling into states of chronic fatigue stimulates the use of devices that improve muscular and hormonal functionality in athletes. The Elevation Training Mask (Training Mask LLC) (ETM) allows the application of hypoxia during exercise. The ETM is integrated into training routines increasing the physical stimulus to improve performance. Objective: We evaluated the impact of ETM on Workouts of the Day (WODs), muscular and hormonal behavior in Crossfit® athletes. Material and method: Prospective cohort study. During 12 weeks 20 Crossfit® athletes trained 60 minutes 3 days a week were randomly divided into 2 groups, control group (CG) (n=10) and ETM group (EG) (n=10) applying an additional progressive simulated altitude between 914 and 2743 meters. WODs (press, squat, deadlift, total CF and grace), macular markers: lactate dehydrogenase (LDH); creatine kinase (CK); myoglobin (Mb) and hormones: testosterone (T); cortisol (C), were evaluated at 2 time points of the study: day 1 (T1) and day 84 (T2). Results: All WODs and parameters LDH, CK, Mb, T and C showed no significant difference (p>0.05) in the time group interaction. In EG, a substantially lower percentage change (Δ) between T1 and T2 was observed in Mb (-16.01±25.82%), CK (6.16±26.05%) and C (-0.18±4.01%) than in CG (Mb: -094±4.39%; CK: 17.98±27.19%; C: 4.56±3.44%). The Δ T1-T2 in the WODs were similar. Conclusion: After 12 weeks of training under simulated hypoxia conditions with ETM there are no improvements in athletic performance assessed by WODs. However, the greater tendency to decrease Mb, CK and C, after using ETM, could stimulate recovery and indicate a lower muscle catabolism of the Crossfit® athlete in the long term.

Adrenal ganglioneuromas : a retrospective multicentric study of 104 cases from the COMETE network.

Objective: Adrenal ganglioneuromas are rare, differentiated, neuroblastic tumors that originate from the peripheral sympathetic nervous system. Because of their rarity, information is limited, derived from small cases series. Our objective was to characterize this tumor and provide help for its management. Methods: A retrospective multicenter analysis of adrenal ganglioneuromas from 20 French centers belonging to the COMETE network and one Belgian center. Results: Among the 104 cases identified, 59.6% were women (N=62/104), median age at diagnosis was 29 years, with 24 pediatric cases. 60.6% (N=63/104) were incidentalomas. Ganglioneuromas were non-secreting tumors in 90.8% of cases (N=89/98), whereas the preoperative hormonal evaluation was indeterminate for 9.2% of patients (N=9/98). Computed tomography imaging, performed on 96 patients, revealed large tumors (median diameter of 50mm) with a non-contrast density >10 Hounsfield Units in 98.1% (N=52/53) and calcifications in 64.6% of cases (N=31/48). Increased uptake on 123I-MIBG scintigraphy and 18F-FDG-PET/CT was observed in 26.7% (N=8/30) and 42.2% (N=19/45) of the tumors, respectively. All 104 patients underwent surgery. No recurrence was observed among the 42 patients who had an imaging follow-up (mean 29.6 months, median 18 months [4-156]). Conclusion: Adrenal ganglioneuromas are large tumors, mostly nonfunctioning, without benign imaging features. Although the duration of follow-up was limited in our series, no recurrence was identified. A review of the literature confirms the absence of post-operative recurrence. Based on all available data, in the absence of special circumstances (genetic form, uncertain histological diagnosis), long-term follow-up is not necessary after complete surgery for patients with an adrenal ganglioneuroma.

Lutetium-177 DOTATATE Therapy Is Associated With Biochemical Endocrine Abnormalities in the Immediate Post-Treatment Period

Introduction: Lutetium-177(177Lu) DOTATATE is a form of peptide receptor radionuclide therapy (PRRT) targeting somatostatin receptor-2 (SSTR2), that is utilized in the treatment of neuroendocrine tumors. As various endocrine glands express SSTR2, 177Lu-DOTATATE can potentially disrupt endocrine function. The immediate post-treatment effects of 177Lu-DOTATATE on endocrine function are not known. Methods: We performed a retrospective analysis of data obtained from patients (≥18 years) enrolled under the 177Lu-DOTATATE trial (NCT03206060) for treatment of SSTR2 positive inoperable/metastatic pheochromocytoma/paraganglioma. 177Lu-DOTATATE (200 mCi) was administered intravenously every 8 weeks, for a total of 4 cycles. Endocrine evaluation was performed on blood samples obtained through an indwelling intravenous catheter during each cycle of PRRT on day 1 (pre-PRRT), day 2 (post-PRRT day 1), day 3 (post-PRRT day 2), day 30 (post-PRRT day 29), and day 60 (day 1 of the next cycle). Hormonal evaluation included ACTH, cortisol, TSH, free T4, GH, FSH, LH, testosterone, estradiol, and prolactin. Baseline abnormal hormonal values, and gonadotrophs in premenopausal women were excluded. Results: Data from 27 subjects (age: 54 ± 12.7 years; 13 female, 14 male) were analyzed. Three out of 27 patients (11.1%) developed clinically significant persistent endocrinopathies - secondary adrenal insufficiency (AI): (n=1 male), primary hypothyroidism: (n=1 male) and hypergonadotropic hypogonadism: (n=1 female). Compared to day 1, there were significant reductions in 1) ACTH (pg/mL) levels on day 2 (36.8 ± 34.1 vs. 23.1 ± 21; p<0.0001), day 3 (36.8 ± 34.1 vs. 24.3 ± 19.4; p<0.0001), and day 30 (36.8 ± 34.1 vs. 27.7 ± 19.1; p=0.01), without significant changes in average cortisol level, apart from 1 patient with undetectable cortisol, who developed secondary AI after 2nd cycle 2) LH (IU/L) levels on day 3 (16.4 ± 13.5 vs. 15.4 ± 13.5; p=0.014), 3) prolactin (ng/mL) on day 2 (9.9 ± 7.0 vs. 7.1 ± 5.7; p<0.0001), day 3 (9.9 ± 7.0 vs. 7.1 ± 5.4; p<0.0001), and day 30 (9.9 ± 7.0 vs. 7.6 ± 5.7; p=0.005), without significant changes in average estrogen and testosterone levels, apart from 1 woman with low estrogens developing hypergonadotropic hypogonadism after 3rd cycle 4) TSH (microIU/L) on day 2 (2.2 ± 1.4 vs. 1.4 ± 0.9; p<0.0001), and day 3 (2.2 ± 1.4 vs. 1.7 ± 1.3; p=0.001), and 5) free T4 (ng/dL) on day 2 (1.1 ± 0.2 vs. 1 ± 0.2; p=0.002). Hormonal values on day 60 were not significantly different from those on day 1, suggesting that majority of these changes were transient. Conclusions:177Lu-DOTATATE can be associated with transient endocrine disruption in the immediate post-treatment period. However, some of these changes may lead to persistent endocrinopathies which are likely associated with radiation exposure to the tissues expressing SSTR2. It is therefore important to periodically assess endocrine function during PRRT.

Recurring Painful Ectopic Gynecomastia in a Young Male - A Case Report

Painful lumps in the axillary area are relatively common and could normally be brought about by several etiologies, more commonly, lipomas, fibroadenoma, hidradenitis suppurativa, lymphoma, or breast cancer. However, recurring painful ectopic gynecomastia in the axillary area of a male patient is of rare occurrence with only few reports in the literature. Here, we report a case of a 25 year old male, who presented to our clinic due to recurring painful right axillary mass. He denied any prior history of trauma, infection, breast mass, or previous lymphadenopathy, decrease in libido nor erectile dysfunction. The mass appeared to be truly subcutaneous at the interface of skin between the superior axilla and the medial arm. Breast exam did not reveal any palpable masses nor abnormalities. Ultrasonography of the right axillary region revealed findings that may represent an accessory axillary breast tissue and histological evaluation revealed an accessory breast tissue with gynecomastia. For such cases, individual treatment requirements can range from simple reassurance to medical treatment or even surgery, all depending on the possible etiology. Due to the diversity of possible etiologies, performing a careful history and physical examination is imperative and the need for hormonal evaluation is warranted to be able to arrive at a certain diagnosis.

Pituitary Macroprolactinoma Apoplexy in a Prepubertal Girl

Background: Prolactinomas are rare in children, with an incidence of 1: 10.000.000 cases, representing less than 2% of all intracranial tumors in this age group (1). Indeed, only a few cases are reported in prepubertal children. Clinical Case: Eight-year old female prepubertal child, previously healthy, presented a progressive loss of the visual acuity in the last 5 months and was admitted to the emergency department with an intensive headache associated with nauseas, started 48 hours before the admission. At the physical examination, the patient was eutrophic, with an infantile genitalia and no breast development or galactorrhea. No focal neurologic deficits were detected and presented normal pupils reflex and preserved extrinsic eye movements. The Campimetry evidenced bitemporal heteronymous hemianopsia and the nuclear magnetic resonance of the central nervous system identified a suprasellar and intrasellar expansive lesion measuring 3.2 x 2.6 x 2.3 cm, with bleeding signs and compression of the optic chiasm. The hormonal evaluation showed: free T4 0.55 ng/dL (normal value: 0.93-1.70ng/dL), total T4 4.8ng/dL (5.1-14.1ng/dL), TSH 4.06µUI/mL (0.6-5.4µUI/mL), morning serum cortisol 1.80mcg/dL (6.2-2mcg/dL), ACTH 7.0pg/mL (<46pg/mL), prolactin 3.376ng/mL (4.8-23.3ng/mL). The patient initially started glucocorticoid replacement, subsequently levothyroxine and cabergoline. A diagnosis of macroprolactinoma with pituitary apoplexy and optic nerve compression was performed and confirmed by the Immunohistochemical after the transsphenoidal resection. No history of any neoplasms were reported by family members and calcium abnormalities were excluded in the child. A significant improvement of the visual field was suddenly observed and the prolactin substantially decreased to 35ng/mL within 30 days after the intervention. CONCLUSION: We report a rare case of macroprolactinoma in a prepubertal girl associated with pituitary apoplexy. Complete assessment and prompt intervention were essential to recover the visual field and to prevent major sequelae. Reference: (1) Yang, A., Cho, S. Y., Park, H., Kim, M. S., Kong, D.S., Shin, H.J., & Jin, D.K. (2020). Clinical, Hormonal, and Neuroradiological Characteristics and Therapeutic Outcomes of Prolactinomas in Children and Adolescents at a Single Center. Frontiers in Endocrinology. 2020; 11:527.

Composite Pheochromocytoma With Ganglioneuroblastoma: A Case Report

Introduction: A composite pheochromocytoma (PC) is an adrenal tumor that is often diagnosed post-operatively on histopathology. PCs are unique in that it is a combination of typicalpheochromocytoma and neural crest derived tumors. The incidence is reported to be less than 3%of adrenal neoplasms. The most common co-existing tumor within a PC is a ganglioneuroma. Wepresent a rare case of PC containing ganglioneuroblastoma (PC-GNBL) in a woman withoutsignificant biochemical manifestation of excess catecholamine production. Case Report: A 63-year-old woman with a prolonged history of uncontrolled hypertension on 4 oral anti-hypertensive medications (Amilodipine 10mg daily, Valsartan/HCTZ 320/25mg daily andClonidine 0.1mg/24h patch) and uncontrolled type 2 diabetes on insulin was diagnosed with a1.5x1.8x1.5cm right adrenal incidentaloma 2 years prior on CT imaging for abdominal pain. Hormonal evaluation was notable for plasma free metanephrine of 66 (<57pg/ml),normetanephrine 229 (<148pg/ml), and total metanephrines of 295 (205 pg/ml). However, 24-hour urine metanephrine evaluation was normal on two occasions: metanephrine 121 and 168mcg/24h (90-315), norepinephrine 237 and 336 mcg/24h (122-676) and total metanephrines 358and 504mcg/24 h (224-832). Hyperaldosteronism and hypercortisolism were ruled out. Follow-up CT scan 14 months later demonstrated growth of the right adrenal nodule to 1.7x2x2cm with49% washout. She underwent laparoscopic right adrenalectomy without perioperativecomplications. Pathology was consistent with a PC-GNBL. The PASS score was 7, consistentwith malignant pheochromocytoma. Within weeks of surgery, she had marked clinicalimprovement. Blood pressure was controlled on one anti-hypertensive and Hgb A1c decreased to7.1% from 11% without requiring insulin. CT abdomen/pelvis 6 months post-operatively did notshow evidence of metastasis. She was referred for genetic testing. Conclusion: This case highlights an unusual presentations of pheochmocytoma. It’s important to recognizethat resistant hypertension can present without episodic headaches, diaphoresis, palpitations, andwithout biochemical evidence of catecholamine excess. Composite PCs are indistinguishableclinically or radiologically from ordinary pheochmocytomas. These exceedingly rare mixedtumors are only diagnosed via surgical pathology. To date, there are only a few cases reported inthe medical literature of co-existing PC-GNBL tumors. Due to the scarcity of composite PCscases, important information regarding its presentation and prognosis are unknown. It remains tobe seen whether the GNBL part of the tumor changes the prognosis of the tumor. However, inour case, the clinical status of our patient improved.

Factors that may interfere in estradiol-progesterone plasmatic concentration in the mid-luteal phase of hyperstimulated cycles for IVF/ICSI

Research question: We have demonstrated that plasmatic estradiol in mid-luteal phasel has prognostic value for clinical and ongoing pregnancy rate. This study investigated the possible factors that could interfere in the value of estradiol-progesterone in the mid luteal phase of cycles of IVF/ICSI Design: Retrospective study, including patients ≤39years old and with dosage of estradiol-progesterone and beta hCG 6-7 days after fresh embryo transfer and the influence of several factors or variables upon these hormones. Results: Of 189 cycles of IVF/ICSI with complete hormonal evaluation in mid-luteal phase, we studied the probably influence of ten factors upon plasmatic concentration of estradiol-progesterone. Only four factors had significant influence. Of them, the most important variable was beta hCG concentration (consequence of trophoblastic mass and number of implanted embryos), followed for number collected oocytes, and of litlle importance, scheme of final maturation with luteal phase correction (did not reach statistical difference), and day of transfer. Conclusion: The estradiol-progesterone in the mid-luteal phase, in this research, were influenced by hCG, number of collected oocytes, scheme for final maturation, but the main influence factor was the beta hCG concentration, although not had been a good correlation coefficient between these hormones, due to a large difference in the their concentrations, as seen in the high values observed on the Standard Deviation. The high percentages of clinical and ongoing pregnancies in the ≥500g/ml group, were the result of higher beta hCG levels, due to the larger number of twin pregnancy in this group.

THE HORMONAL CHANGES AMONG NIGERIAN WOMEN WITH EPILEPSY

This study aims to compare the sex hormones between women with epilepsy (WWE) and their agematched controls. We postulated that a difference in etiology, may be associated with an unexpected hormonal profile. A case control study carried out at the University College Hospital, Ibadan, South western, Nigeria involving seventy-five WWE and age-matched controls. Blood samples for hormonal evaluation follicle stimulating hormone (FSH), luteinizing hormone (LH), estrogen, progesterone and testosterone were taken twice from all the participants during their menstrual cycle. WWE had lower BMI (p: 0.004), cycle length (p: 0.014) and more menstrual pattern irregularities (p< 0.001.) In the pre-ovulatory phase, WWE had lower FSH levels when compared with controls, (p: 0.012). Further stratification shows a higher FSH levels among WWE on medication, (p: 0.003).In the mid-luteal phase, FSH level was lowest in WWE not on medication, WWE on medication had higher levels but lower when compared to the control group, p: 0.002. FWE had lower progesterone levels when compared with the control group, (p: 0.004) with no difference with use of AEDs. Testosterone levels were lower among those with symptomatic epilepsy, (p:0.012)WWE had lower progesterone, lower FSH and more menstrual abnormalities, compare to controls in our population.