Endocrine studies in a pregnancy complicated by ovarian theca lutein cysts and hyperreactio luteinalis

Hyperreactio luteinalis and follicle-stimulating hormone receptor gene activation mutations: A case report

INTRODUCTION AND IMPORTANCE

Spontaneous ovarian luteal hyperfunction after pregnancy is associated with activating mutations in the follicle-stimulating hormone receptor gene, and clarification of the etiology can help with subsequent treatment.

PRESENTATION OF CASE

A 32-year-old woman presented with enlarged ovaries and bilateral ovarian polycystic echoes at 12 weeks of both pregnancies. The first pregnancy underwent transabdominal bilateral ovarian aspiration at 17 weeks and was spontaneously aborted 4 days after the procedure. After the discovery of bilateral ovarian polycystic echoes in the second pregnancy, genetic testing suggested the presence of activating mutations in the follicle-stimulating hormone receptor (FSHR) gene, resulting in ovarian luteinization, and the patient's condition was stabilized after conservative treatment.

CLINICAL DISCUSSION

Ovarian luteal hyperfunction may be associated with hyperandrogenemia, thyroid-stimulating hormone abnormalities, abnormal testosterone levels, and genetic mutations. When ovarian luteal hyperfunction occurs, it is recommended to search for the etiology and treat the symptoms.

CONCLUSION

Patients presenting with spontaneous ovarian hyperlutealization should be operated on cautiously, treated conservatively, closely observed, and managed for complications, and genetic testing should be performed to clarify the etiology if necessary.

Molecular pathways in placental-fetal development and disruption

The first trimester of pregnancy ranks high in priority when minimizing harmful exposures, given the wide-ranging types of organogenesis occurring between 4- and 12-weeks' gestation. One way to quantify potential harm to the fetus in the first trimester is to measure a corollary effect on the placenta. Placental biomarkers are widely present in maternal circulation, cord blood, and placental tissue biopsied at birth or at the time of pregnancy termination. Here we evaluate ten diverse pathways involving molecules expressed in the first trimester human placenta based on their relevance to normal fetal development and to the hypothesis of placental-fetal endocrine disruption (perturbation in development that results in abnormal endocrine function in the offspring), namely: human chorionic gonadotropin (hCG), thyroid hormone regulation, peroxisome proliferator activated receptor protein gamma (PPARγ), leptin, transforming growth factor beta, epiregulin, growth differentiation factor 15, small nucleolar RNAs, serotonin, and vitamin D. Some of these are well-established as biomarkers of placental-fetal endocrine disruption, while others are not well studied and were selected based on discovery analyses of the placental transcriptome. A literature search on these biomarkers summarizes evidence of placenta-specific production and regulation of each biomarker, and their role in fetal reproductive tract, brain, and other specific domains of fetal development. In this review, we extend the theory of fetal programming to placental-fetal programming.

Hyperreactio Luteinalis (Multiple Luteinized Follicle Cysts): A Report of 10 Cases

Hyperreactio luteinalis is a rare entity arising in pregnancy and in the setting of gestational trophoblastic diseases (ie choriocarcinoma, molar pregnancy) that presents with, typically, bilateral ovarian enlargement due to numerous follicle cysts. While the phenomenon is benign and spontaneously regresses following delivery or treatment, a specimen may be seen in pathology when oophorectomy or cystectomy is performed to exclude malignancy or to manage acute complications such as torsion. Such resections may exhibit overlapping microscopic features with cystic granulosa cell tumors. We thus reviewed 10 cases of hyperreactio luteinalis in the setting of pregnancy, the largest pathologic cohort to date, to highlight notable features of this disorder. Patients ranged from 22 to 30 yr old. Most patients (n=6) presented at time of cesarean section with incidentally discovered ovarian masses. Three patients presented in the postpartum period, and 1 underwent surgery at 28 wk gestation due to the finding of a unilateral ovarian mass. The ovaries ranged from 8.5 to 29 cm and were multicystic and bilateral in 8 of the cases. Histologic examination demonstrated multiple, variably sized cystic follicles lined by a granulosa cell layer of varying thickness and theca cells with marked eosinophilic cytoplasm. Stromal edema was often prominent, with theca cells occasionally noted in nests, cords, and as single cells in foci of edema. Mitoses were generally seen more often in the granulosa cell layer (mean=2.6 per high power fields) compared with the theca cell layer (mean=1 per 10 high power fields). This series documents the key features of hyperreactio luteinalis that differentiate it from the other benign mass forming lesions encountered in pregnancy, most notably large solitary follicle cyst of pregnancy and puerperium, as well as cystic granulosa cell tumors, especially the juvenile variant, which may also present during pregnancy. Of particular use in differentiating them from juvenile granulosa cell tumor is the absence of pale or vacuolated cytoplasm and solid growth of granulosa cells in cases of hyperreactio luteinalis.

Testosterone serum levels are not predictive of maternal virilization in hyperreactio luteinalis

Background

Elevated concentrations of circulating testosterone are present in hyperreactio luteinalis (HL), a pregnancy-specific, self-limited condition. HL is associated with maternal virilization in about 30% of cases. The correlation between testosterone levels and maternal virilization has not yet been quantified. Our aim was to identify a testosterone cut-off level which may allow to predict maternal virilization.

Methods

A literature research was performed. Publications were chosen if serum testosterone concentrations and presence or absence of maternal virilization was mentioned. Additionally, we report serial levels of steroids analyzed by Liquid chromatography–tandem mass spectrometry (LC–MS/MS) in one case of HL managed at our institution.

Results

In all, 31 cases fulfilled the search criteria. We found significant overlap between testosterone levels in asymptomatic women and women with signs of virilization (range 6.2–37.3 nmol/l and 13.7–197.5 nmol/l, respectively). The method applied for testosterone analysis was mentioned in three reports only. Peak serum testosterone concentration in our case was 120.3 nmol/l.

Conclusion

From the available data, maternal virilization in HL cannot be predicted by the level of circulating testosterone. However, comparability of results is hampered by the analytical methods applied. LC–MS/MS should preferably be used for reporting concentrations of circulating testosterone.

Hyperreactio luteinalis and hypothyroidism: A case report

We report a case of hyperreactio luteinalis (HL) and hypothyroidism diagnosed at 13 weeks of pregnancy. A 29-year-old woman with a spontaneous 13-week singleton pregnancy presented with hirsutism and a pelvic mass. Ultrasound showed a viable pregnancy compatible with the gestational age and multiple cystic lesions on both ovaries. Her TSH levels were markedly elevated and diagnostic of hypothyroidism, for which she was treated. Two days after presentation, she had a spontaneous abortion. The products of conception were histologically normal. Follow-up at 3 months showed resolution of the ovarian cysts, and the previously elevated androgen levels were in the normal range. Hyperreactio luteinalis was diagnosed. Her elevated TSH levels may have contributed to hyperreactio luteinalis through the activation of the hCG receptor.

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Hyperreactio luteinalis is a rare condition, characterized by the enlargement of both ovaries and hyperandrogenism.

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We report a case of hyperreactio luteinalis (HL) and hypothyroidism in a spontaneous 13-week singleton pregnancy.

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Increased levels of thyroid stimulating hormone may have contributed to hyperreactio luteinalis.

Recurrent maternal virilization during pregnancy in patients with PCOS: two clinical cases

BACKGROUND

Maternal virilization during pregnancy is a rare phenomenon. Polycystic ovary syndrome (PCOS), luteoma and luteinic cysts are the most frequent and benign etiologies. This article presents two cases of recurrent maternal virilization during pregnancy.

CLINICAL CASES

Our reported cases were young women with Afro-Caribbean and Nigerian origins. Data were collected by history-taking, clinical examination, laboratory investigations, transabdominal ultrasonographic examination and Magnetic Resonance Imaging. Both patients were diagnosed with PCOS according to the Rotterdam criteria. During each of their pregnancies they both developed an explosive hirsutism, a deepening in the voice, a clitoromegaly. Gestational diabetes occurred during pregnancies. There was no fetal virilization, despite raising androgen levels, more than tenfold to normal. Improvement of hirsutism and normalization of androgens were described in postpartum.

CONCLUSION

Only few cases of maternal virilization during pregnancy were reported in literature and even fewer concern recurrent and bilateral ovarian etiology. Hyperplasia of ovarian theca cells seems to be the most likely explanation, which would suggest that PCOS belongs to a spectrum of abnormal reactivity of the ovary to human Chorionic Gonadotrophin (hCG) stimulation along with luteoma and luteinic cyst of pregnancy.  Insulin resistance could worsen hyperandrogenism but is not enough to explain virilization. Treatment should focus on protecting the fetus of possible virilization as well as its mother, but also on preserving the subsequent fertility in both.

Developmental Programming of Ovarian Functions and Dysfunctions

The pathophysiological mechanisms underlying the origin of several ovarian pathologies remain unclear. In addition to the genetic basis, developmental insults are gaining attention as a basis for the origin of these pathologies. Such early insults include maternal over or under nutrition, stress, and exposure to environmental chemicals. This chapter reviews the development and physiological function of the ovary, the known ovarian pathologies, the developmental check points of ovarian differentiation impacted by developmental insults, the role played by steroidal and metabolic factors as mediaries, the epigenetic mechanisms via which these mediaries induce their effects, and the knowledge gaps for targeting future studies to ultimately aid in the development of improved treatments.

Conservative management of hyperreactio luteinalis: a case report

Hyperreactio luteinalis (HL) is characterized by bilaterally enlarged ovaries containing multiple self-limited theca lutein cysts and is usually associated with increased production of human chorionic gonadotropin in the presence of trophoblastic disease or multiple pregnancies. About 30 cases of HL have been reported in patients with normal singleton pregnancies, and most of these patients required surgical intervention during their first pregnancy because of ovarian torsion or to rule out of ovarian malignancy. However, the accurate diagnosis of HL by means of laboratory tests and magnetic resonance imaging and the exclusion of ovarian malignancy in asymptomatic pregnant woman may avoid unnecessary surgical intervention or termination of pregnancy. The present report describes case of HL in a woman with a normal singleton pregnancy in whom conservative management allowed the preservation of both ovaries.

Management of ovarian disease in pregnancy

The ovary is a complex structure that is responsible for maintaining the endocrine support for a pregnancy during the first trimester until the placenta is sufficiently developed to assume this role. Most ovarian disorders of pregnancy actually relate to pre-existing ovarian conditions such as polycystic ovary syndrome and premature ovarian insufficiency. Both of these are associated with increased complications in pregnancy and require careful monitoring. Ovarian disorders that are a particular consequence of the hormonal milieu of pregnancy such as pregnancy luteoma (PL) and hyperreactio luteinalis (HL) are rare. However, they have important implications for both the mother and the foetus since they can be confused with ovarian malignancy leading to unnecessary surgery. This review focuses on the salient aspects of management of these ovarian conditions during pregnancy.

Delayed Lactogenesis II: A Comparison of Four Cases

Lactogenesis II is the onset of copious milk production (i.e., the milk "coming in"), which usually occurs between 30 to 40 hours postpartum. When lactogenesis II fails to occur or is delayed, it may be due to a number of underlying hormonal or non-hormonal conditions. Of the various hormonal etiologies, many can be identified with the aid of a few standard blood tests. Gestational ovarian theca lutein cysts may cause delayed lactogenesis II and are fairly easily detected by ordering testosterone levels. Although this condition can delay lactogenesis II for as long as 31 days, with proper management women affected by these cysts have established breastfeeding. Three of the four women reviewed in this article were eventually able to produce 100% of their infants' caloric requirements.

Bilateral theca lutein cysts: A rare cause of acute abdomen in pregnancy

Theca lutein cysts (hyperreactio luteinalis) are benign cysts usually associated with molar pregnancy. We report a case of bilateral theca lutein cysts with normal intrauterine singleton pregnancy presenting as an acute abdomen requiring surgical intervention. Laparotomy revealed bilateral theca lutein cysts one of which was torted, necessitating salpingo-ovariotomy.

Colocalization of P450c17 and cytochrome b5 in androgen-synthesizing tissues of the human

Androgens are an integral part of human physiology. The de novo production of androgens is generally limited to the adrenal cortex and the gonads. Androgen synthesis by these steroidogenic tissues requires the bifunctional enzyme cytochrome P450c17, which catalyzes both 17 hydroxylase and 17,20 lyase activities. 17,20-lyase activity is relevant to the regulation of androgen production, and is allosterically modulated through the action of an accessory protein, cytochrome b5 (CytB5). Our objective was to determine the cellular localization of P450c17 and CytB5 in androgen-synthesizing tissues of the human. Immunohistochemical analyses of P450c17 and CytB5 were performed on fetal and adult human adrenals, ovaries, and testes. In the fetal adrenal, CytB5 and P450c17 were both found in the cells of the fetal zone, but not in the neocortex. In the adult adrenal, the zona fasciculata was immunoreactive for P450c17 only, whereas the zona reticularis was immunopositive for both P450c17 and CytB5. In the adult gonads, P450c17 and CytB5 were colocalized in the Leydig cells of the testis, theca interna cells of the follicle, theca lutein cells, and isolated cell clusters in the ovarian stroma. Whereas P450c17 and CytB5 were colocalized in the Leydig cells of the fetal testes, there was no immunostaining for either in the midgestational fetal ovary. Our findings of colocalization of CytB5 and P450c17 are strongly supportive of the view that CytB5 plays an important role in the regulation of the androgen biosynthetic pathway in the fetal and adult human.

Delayed lactogenesis II secondary to gestational ovarian theca lutein cysts in two normal singleton pregnancies

Hyperreactio luteinalis is an unusual condition in which, during pregnancy, both ovaries are enlarged by multiple theca lutein cysts that produce a high level of testosterone. Several weeks postpartum, the cysts resolve and testosterone level returns to normal. Two case studies are presented in which mothers with gestational ovarian theca lutein cysts experienced delayed lactogenesis II. The elevated testosterone at the time of birth suppressed milk production. Once the testosterone level dropped to approximately 300 ng/dL, milk production began. After the initial delay, both mothers breastfed their infants without supplementation.

Hyperreactio luteinalis associated with chronic renal failure

Hyperreactio luteinalis is a rare benign condition characterized by bilateral ovarian enlargement associated with pregnancies where high concentrations of maternal serum human chorionic gonadotrophins are present. This condition may mimic the ovarian hyperstimulation syndrome. We report a case of a 34 year old woman with a history of chronic renal failure on haemodialysis who presented at 10 weeks' gestational age with hyperreactio luteinalis which was treated conservatively. Because of chronic renal failure, the presentation and course of the disease was different from that which has been previously reported.

Hyperreactio luteinalis differentiated from severe ovarian hyperstimulation syndrome in a spontaneously conceived pregnancy

The clinical presentation of hyperreactio luteinalis can mimic ovarian hyperstimulation. Historically, though, the former most often leads to unnecessary surgery whereas the latter is treated supportively. We present a case of a 32-year-old woman who was initially seen with markedly enlarged multicystic ovaries, ascites, and pleural effusions in the tenth week of a spontaneously conceived gestation. Despite a noniatrogenic cause, the patient received supportive management, as would be given with ovarian hyperstimulation syndrome. Making the distinction between hyperreactio luteinalis and ovarian hyperstimulation syndrome has important consequences for diagnosis and management.

Hyperreactio luteinalis: intraoperative finding during a cesarean section in a twin pregnancy

Bilateral ovarian enlargement can be found in the course of a cesarean section. It is necessary to keep in mind that hyperreactio luteinalis is a benign condition, because the appropriate management is conservative. We present an unexpected, intraoperatively diagnosed case of bilateral ovarian cystic-solid tumours (13 cm) in a twin pregnancy.

Virilization during pregnancy with spontaneous resolution postpartum: a case report and review of the English literature

The incidence of gestational hyperandrogenism secondary to ovarian pathology is low. However, when the condition does exist, diagnosis should be made with minimally invasive modalities. It is important to provide appropriate medical/surgical intervention without disturbing the pregnancy iatrogenically or causing unnecessary maternal morbidity. This case report adds to the existing radiographic data concerning this rare obstetrical condition. Presented is a review of the English literature on virilizing ovarian tumors during pregnancy, and a discussion of an approach to managing these tumors when they occur during pregnancy.

Hyperreactio luteinalis in normal singleton pregnancy

A case of hyperreactio luteinalis in a patient with normal singleton pregnancy is reported. The course of pregnancy had been normal until the 24th week of gestation, when the mother developed lower abdominal pain and signs of virilization. She delivered of a normal female infant at 39 weeks' gestation. The baby did not show any signs of masculinization. Serum testosterone, delta 4-androstene-dione, and 5 alpha-dihydrotestosterone of the mother were markedly elevated. They remained high after the delivery but returned to the normal ranges soon after the partial resection of the enlarged ovaries. Reported causes of hyperreactio luteinalis are reviewed. Their maternal serum androgen levels were compared with cases of luteoma of pregnancy.