Spontaneous ovarian hyperstimulation and primary hypothyroidism with a naturally conceived pregnancy

Ovarian Hyperstimulation syndrome combined with hypothyroidism: a comprehensive review

Ovarian Hyperstimulation Syndrome (OHSS) is a systemic condition marked by the enlargement of the ovaries and heightened vascular permeability. And hypothyroidism (HT) emerges as a potential risk factor for OHSS occurrence. This review presented a comprehensive summary of pertinent case reports involving patients diagnosed with both HT and OHSS. Detailed exploration was conducted into their clinical presentations, diagnostic methodologies, and treatment modalities. Additionally, the review delved into potential interaction mechanisms between HT and OHSS, encompassing various aspects including hormone levels. Moreover, management strategies for mitigating the risk of OHSS in HT patients were thoroughly reviewed and the importance of monitoring thyroid function in those experiencing OHSS was emphasized. This review indicated that the association between HT and OHSS, underscoring its multifaceted complexity. It could accentuate the ongoing necessity for rigorous research and clinical refinement to deepen our comprehension of this association and to bolster diagnostic and therapeutic methodologies for optimal patient care. In conclusion, this review offered valuable insights for future research directions and clinical practices for patients afflicted with OHSS and HT.

Spontaneous Ovarian Hyperstimulation Syndrome Associated With Primary Hypothyroidism

Ovarian hyperstimulation syndrome is a rare condition in pregnant women. Most cases are associated with the use of ovulation induction and stimulation medications. Some studies have reported cases of this condition in non-pregnant women or women undergoing ovulation therapy. In this case report, we report the case of a 27-year-old pregnant Saudi woman presenting with a picture of severe spontaneous ovarian hyperstimulation syndrome secondary to severe undiagnosed hypothyroidism. Treatment with Eltroxin (thyroxine) led to complete improvement and regression of ovarian enlargement after empirical titrating thyroxin replacement therapy, which proved the presence of this causation. The diagnosis was confirmed by laboratory and imaging findings, which helped prompt management and prevented complications of unneeded surgical intervention.

Spontaneous ovarian hyperstimulation syndrome in a pregnant woman with hypothyroidism: a case report

Objective

To study a rare case of spontaneous ovarian hyperstimulation syndrome in a naturally conceived pregnancy associated with overt hypothyroidism.

Design

Case report.

Setting

Endocrinology private practice.

Patient(s)

A 32-year-old woman who was 13 weeks pregnant with bilaterally enlarged ovaries presumed to be secondary to hypothyroidism.

Intervention(s)

Administration of levothyroxine and titration of the dose.

Main Outcome Measure(s)

Regression of signs and symptoms of spontaneous ovarian hyperstimulation syndrome after 12 weeks of therapy.

Result(s)

The patient was diagnosed with severe hypothyroidism, as confirmed by her elevated thyroid-stimulating hormone level. Ultrasound evaluation revealed ovarian enlargement secondary to multiple contiguous cysts with anechoic content. The patient was administered levothyroxine 175 μg/day. Results of hormonal studies demonstrated thyroid function normality at week 12 after treatment. Incomplete regression of ovarian cysts was also noticed within this period. At week 37, the patient developed preeclampsia, and cesarean delivery was recommended. An 8-month postpartum ultrasound evaluation revealed complete regression of the cysts.

Conclusion(s)

Spontaneous ovarian hyperstimulation syndrome secondary to hypothyroidism may be the cause of ovarian enlargement, and levothyroxine replacement seems an appropriate primary therapeutic option. Proper endocrinological assessment of patients is recommended as it may avoid unfavorable outcomes.

Ovarian hyperstimulation syndrome in a spontaneous pregnancy: A potential for missed-diagnosis

Ovarian hyperstimulation syndrome (OHSS) with the natural ovulatory cycle is extremely rare. We report a case of severe OHSS associated with a spontaneous normal singleton pregnancy in a 23-year-old woman presenting with severe abdominal pain, vomiting, and dyspnea. Ultrasonography revealed 10 weeks viable intra-uterine single fetus with bilateral multilocular cystic ovarian masses and ascites. She had supportive therapy inclusive of oral bromocriptine with complete resolution of OHSS and an eventual uncomplicated normal vaginal delivery at 39 weeks of pregnancy.

Unusual Presentation of Hypothyroidism in a Pregnant Woman, Mimicking Gestational Trophoblastic Neoplasm

Hypothyroidism is a common health issue worldwide with varying clinical manifestations. We report a woman who experienced an incomplete abortion and undiagnosed hypothyroidism who was referred to the oncologist with the suspicion of metastatic gestational trophoblastic neoplasm (GTN). A 29-year-old woman with incomplete abortion was referred to an oncologist for possible GTN due to persistent active vaginal bleeding, an elevated beta human chorionic gonadotropin (hCG), abnormal cervical inspection exam, abnormal liver function tests, ovarian enlargement, ascites, and a pleural effusion. She was found to have hypothyroidism in further work-up. She was managed with thyroid hormone replacement therapy and her condition improved after 6 weeks. Complete resolution of the ovarian mass and pericardial and pleural effusion was achieved. This case describes an important experience; hypothyroidism should be considered in the differential diagnosis of any woman with an incomplete abortion presenting with an ovarian mass. Evaluation and correct diagnosis are important to prevent mismanagement.

Spontaneous ovarian hyperstimulation syndrome with primary hypothyroidism: Imaging a rare entity

Ovarian hyperstimulation syndrome is a disorder associated with ovulation induction and is rarely seen in pregnant women. Very few cases of spontaneous ovarian hyperstimulation syndrome have been reported in a woman who is neither pregnant nor undergoing ovulation therapy. This case report describes how spontaneous ovarian hyperstimulation syndrome is associated with primary hypothyroidism in a 25-year-old, nonpregnant woman who is not on ovulation induction therapy. Imaging and laboratory findings confirmed the diagnosis of this rare entity, which aided the clinicians in providing prompt management and in preventing further complications.

Multicystic ovaries and pituitary pseudo-adenoma associated with primary hypothyroidism

Ovarian hyperstimulation syndrome (OHSS) is a well known but poorly understood iatrogenic complication of superovulation. Spontaneous OHSS has been reported with pregnancy, polycystic ovary syndrome, primary hypothyroidism and pituitary adenoma. Only a few cases of massive ovarian enlargement in non-pregnant women with primary hypothyroidism have been reported in the English literature. A definitive pathophysiology remains uncertain, although several postulations were proposed. A 23-year-old nulliparous woman presented with transient bloating of her abdomen associated with menstruation for the last four cycles. She had nausea, headache, faintness, galactorrhoea and clinical signs and symptoms of hypothyroidism (swelling in the hands and feet, cold intolerance, decreased activity, excessive sleepiness, loss of hair and dry skin) for 6 months. Thyroid stimulating hormone and serum prolactin levels were highly elevated (> 100 μg/l and 4,095 μg/l, respectively) and free thyroxine level was low. Abdominal ultrasound showed bilateral multiple thin-walled ovarian cysts. Contrast enhanced CT of brain showed a pituitary macroadenoma. Treatment with levothyroxine was started and showed marked clinical improvement with return to normal menstruation within 4 months. Serial ultrasound showed gradual regression of the ovarian cysts within 6 months. Serum prolactin level was gradually diminished. Awareness that ovarian and pituitary enlargement may be associated with severe hypothyroidism which can be managed successfully, will spare patients dangerous and unnecessary operative intervention for ovarian cysts or pituitary adenoma.

Vanishing large ovarian cyst with thyroxine therapy

A 21-year-old female patient recently diagnosed with severe hypothyroidism was found to have a large ovarian cyst. In view of the large ovarian cyst, she was advised to undergo elective laparotomy in the gynaecology department. She was further evaluated in our medical out-patient department (OPD), and elective surgery was withheld. She was started on thyroxine replacement therapy, and within a period of 4 months, the size of the cyst regressed significantly, thereby improving the condition of the patient significantly. This case report highlights the rare and often missed association between hypothyroidism and ovarian cysts. Although very rare, profound hypothyroidism that can cause ovarian cysts in an adult should always be kept in the differential diagnosis to avoid unnecessary ovarian surgery.

Case report on spontaneous ovarian hyperstimulation syndrome following natural conception associated with primary hypothyroidism

Spontaneous OHSS is a rare event in pregnancy following natural conception and only a few cases have been reported in the literature so far. This report is a case of spontaneously conceived pregnancy with Spontaneous OHSS and Primary hypothyroidism.

Spontaneous ovarian hyperstimulation syndrome: case report, pathophysiological classification and diagnostic algorithm

Spontaneous ovarian hyperstimulation syndrome is an extremely rare condition that occurs in the absence of ovarian hyperstimulation treatment. It can lead to significant morbidity and mortality, and therefore early diagnosis and supportive treatment are essential. We report an affected mother and her daughter with a previously reported heterozygous activating mutation in the FSHR gene. We performed a literature review with particular regard to pathogenesis, with a view to suggesting a pathophysiological classification system and a diagnostic algorithm to assist in the management of this rare condition.

Ignored adult primary hypothyroidism presenting chiefly with persistent ovarian cysts: a need for increased awareness

BACKGROUND

Ovarian cysts are a common cause for gynecological surgery. However, some cysts are a direct result of endocrine disorders and do not require surgery. This report describes an unusual case in which persistent ovarian cysts are associated with primary hypothyroidism in a young woman. The data were collected by history-taking, physical examination, laboratory tests, ultrasound, magnetic resonance imaging and a histo-pathological study. In addition, the exons of the gene encoding the human follicle-stimulating hormone receptor were sequenced.

DISCUSSION

The patient had markedly elevated levels of thyroid-stimulating hormone and follicle-stimulating hormone and an enlarged pituitary gland. After treatment with thyroid hormone replacement, regression of the enlarged pituitary and the ovarian cysts was observed. The possible mechanisms of the pathophysiology are discussed below.

SUMMARY

It is necessary to consider hypothyroidism and other endocrine disorders in the differential diagnosis of adult patients with ovarian multiple cyst formation in order to prevent inadvertent ovarian surgery.

[Ovarian hyperstimulation syndrome: pathophysiology, risk factors, prevention, diagnosis and treatment]

The ovarian hyperstimulation syndrome is a major complication of ovulation induction for in vitro fertilization, with severe morbidity and possible mortality. Whereas its pathophysiology remains ill-established, the VEGF may play a key role as well as coagulation disturbances. Risk factors for severe OHSS may be related to patients characteristics or to the management of the ovarian stimulation. Two types of OHSS are usually distinguished: the early OHSS, immediately following the ovulation triggering and a later and more severe one, occurring in case of pregnancy. As no etiologic treatment is available, the therapeutic management of OHSS should focus on its related-complications. Thrombotic complications that can occur in venous or arterial vessels represent the major risk of OHSS, possibly conducting to myocardial infarction and cerebrovascular accidents. Once the OHSS is diagnosed, prevention of thrombotic accidents remains the major issue.

Effect of thyroid hormone replacement therapy on ovarian volume and androgen hormones in patients with untreated primary hypothyroidism

BACKGROUND AND OBJECTIVES

Primary hypothyroidism may be associated with ovarian enlargement and/ or cyst formation. We evaluated the effect of thyroid hormone replacement therapy on hormonal changes, ovarian volume and sonographic appearance.

DESIGN AND SETTING

Open, prospective study of women admitted to university gynecology clinic.

PATIENTS AND METHODS

The study included 26 patients with untreated hypothyroidism who had polycystic (n=10) or normal-appearing (n=16) ovaries and 20 euthyroidic controls. Basal serum total testosterone, free testosterone, androstenedione, dehydroepiandosterone-sulfate, prolactin, estradiol, luteinizing hormone, follicle-stimulating hormone, free T3, free T4 and thyroid-stimulating horone, together with ovarian volumes, were determined and repeated after euthyroidism was achieved.

RESULTS

Ovarian volumes of patients with hypothyroidism were significantly greater compared with controls, and their magnitudes diminished significantly during thyroid hormone replacement therapy. Hypothyroidic patients with polycystic ovaries had significantly higher serum free testosterone and dehydroepiandosterone-sulfate, but lower androstenodione levels compared with those who had normal-appearing ovaries. Serum total testosterone concentrations were significantly higher in hypothyroidic patients without polycystic ovaries, and thyroid hormone replacement therapy achieved a significant reduction in total as well as free testosterone.

CONCLUSION

Severe longstanding hypothyroidism leads to increased ovarian volume and/or cyst formation. A decrease in ovarian volume, resolution of ovarian cysts and reversal of the polycystic ovary syndrome-like appearance, together with improvement in serum hormone levels, occurred after euthyroidism was achieved.

Two different entities of spontaneous ovarian hyperstimulation in a woman with FSH receptor mutation

Spontaneous ovarian hyperstimulation syndrome (OHSS) is an extremely rare event. Normally OHSS is seen in the context of IVF. In 2003 a mutation of the FSH receptor (FSHR D567N) was identified for the first time as a cause of spontaneous OHSS. In most FSHR mutations, a hypersensitivity to human chorionic gonadotrophin (HCG) or thyroid-stimulating hormone (TSH) is described. This clinical case presents for the first time two occurrences of spontaneous OHSS in a single woman with a FSHR mutation and two different entities. Pathophysiology of both pregnancies was completely different. During the first pregnancy, elevated HCG and androgen concentrations led to spontaneous OHSS and finally to miscarriage. The second pregnancy with spontaneous OHSS was dominated by a latent hypothyroidism and normal HCG concentrations and ended in a delivery of a healthy female newborn. Due to the unusual courses of the pregnancies, the study looked for a mutation in the FSHR and surprisingly identified the same mutation previously described. This report confirms for the first time the in-vitro findings in a single clinical case that TSH as well as HCG leads to spontaneous OHSS in patients with FSHR D567N mutation. Hypothyroidism has to be treated or ruled out.

Spontaneous ovarian hyperstimulation in a pregnant woman with hypothyroidism

OBJECTIVE

This report describes an unusual case in which a naturally conceived pregnancy is associated with spontaneous ovarian hyperstimulation and hypothyroidism.

DESIGN

Case report.

SETTING

University medical center.

PATIENT(S)

A 30-year-old pregnant woman with abdominal pain and distension caused by ovarian hyperstimulation.

INTERVENTION(S)

Medical management and laparotomy.

MAIN OUTCOME MEASURE(S)

Incomplete regression after 3 months.

RESULT(S)

Thyroid-stimulating hormone level was elevated. Hormonal studies confirmed hypothyroidism with spontaneous ovarian hyperstimulation. She was given levothyroxine 200 mug/d. Results of the hormonal tests for thyroid function were normal 3 months after treatment, but in this case the ovarian cysts did not regress completely until delivery. Laparotomy and cesarean section were done for both diagnosis and treatment. Ten weeks after delivery ovarian cysts regressed completely.

CONCLUSION(S)

Thyroid hormone replacement seems to be the best therapeutic approach in some patients, but, in some, complete resolution of the ovarian cysts does not occur after 3 months.

[Pituitary and ovarian mass syndrome in primary hypothyroidism]

INTRODUCTION

Hyperprolactinemia and a pituitary mass syndrome can occur in patient with primary hypoyhroidism. In young women, hypothyroidism can be associated with ovarian cysts.

EXEGESIS

We report a case of a 30 year-old women who was treated for an anemia. She had clinical and biological signs of primary hypothyroidism with hyperprolactinemia at the biology. Pituitary MRI showed a pituitary mass. The pelvic ultrasound examination and CT scan showed a right ovarian cyst. The subsequent thyroid hormone replacement was associated with a clinical, a biological and radiological resolution. It was a pituitary and ovarian mass syndrome secondary to primary hypothyroidism.

CONCLUSION

The recognition of these associations may eliminate unnecessary surgery and lead to the choice of hormone replacement therapy.

Spontaneous ovarian hyperstimulation syndrome caused by hypothyroidism in an adult

A 22-year-old patient presented with abdominal pain and massive ovarian enlargement secondary to severe long standing hypothyroidism, mimicking an ovarian cancer. Treatment with L-thyroxin caused marked regression of the tumor.