Differential maternal-fetal response to androgenizing luteoma or hyperreactio luteinalis

Retrospective analysis of 26 cases of pregnancy luteoma

BACKGROUND

Pregnancy luteoma is a rare hormone-dependent ovarian tumor-like lesion caused by increased androgenic activity during pregnancy.

OBJECTIVE

To explore the clinical history, ultrasound manifestations, and differential diagnosis of pregnancy luteoma.

METHOD

A retrospective analysis was conducted on 26 cases of pregnancy luteoma diagnosed by postoperative pathology, from 2009 to 2022. All cases were from two hospitals: Shanghai First Maternity and Infant Hospital and International Peace Maternity and Child Health Hospital. The clinical history data and ultrasound characteristics were analyzed and the relevant literature was reviewed.

RESULTS

Among the 26 cases, five of them had preoperative ultrasound images. Among these five cases, three patients showed hyperechoic masses with less internal uniformity, while two demonstrated loculated anechoic zones, with clear boundary and regular morphology. Color Doppler showed no obvious internal blood flow signals, or that blood flow signals were visible within the cyst wall and hyperechoic mass. Among the cases, 16 had multiple gestations, while two visited the clinic due to sudden abdominal pain and a huge ovarian mass was found by ultrasonography. The ovarian lump was detected during routine obstetric ultrasound in three cases. The remaining were ovarian cysts found incidentally during caesarean section. Four patients presented with hairy manifestations and one patient had a deepened voice.

CONCLUSION

There is no characteristic ultrasound of pregnancy luteoma, and its diagnosis is mainly based on clinical history data and laboratory tests.

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.

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.

46,XX DSD: the masculinised female

The 46,XX disorders of sex development (DSDs) cause virilisation or masculinisation of the female foetus. The final common pathway of all 46,XX DSDs is excess dihydrotestosterone (DHT) or potent foreign androgen in the genital tissue during the critical period of sexual differentiation. Whereas the foetal testis is source of androgen in the male, it is the foetal adrenal that produces the DHT precursors in the female. By understanding the principles of human steroid biosynthesis, the pathogenesis of each disorder may be logically deduced, and treatment strategies are rationally constructed. In practice, however, therapies for many of these diseases are fraught with complications and caveats, and current approaches leave much room for improvement. This review discusses these diseases, their pathogenesis and approaches to therapy. We emphasise areas where improved treatments are sorely needed.

Maternal Luteoma of Pregnancy Presenting With Virilization of the Female Infant

BACKGROUND

Virilization in female newborns typically results from congenital adrenal hyperplasia, requiring immediate diagnosis and treatment. We report a rare cause of virilization, maternal pregnancy luteoma, responsible for virilization of both a newborn and the mother. Luteomas are usually asymptomatic tumour-like ovarian lesions of pregnancy that secrete androgens in only 25% of cases. Many female infants born to masculinized mothers will also be virilized.

CASE

A term infant born with ambiguous genitalia was transferred to a referral centre for investigation, diagnosis, and treatment. Assessment identified Prader II-III genitalia, an elevated serum testosterone level, a normal serum 17-hydroxyprogesterone level, and a normal female karyotype (46,XX). The mother had had virilization from the second trimester and was found to have an elevated serum testosterone level. Pelvic ultrasound assessment in the mother showed a complex right ovarian mass. Laparotomy was performed, and the mass was excised. Histopathology examination confirmed a luteoma.

CONCLUSION

High maternal serum testosterone levels due to a luteoma can result in virilization in the female newborn. This report emphasizes the need to consider possible underlying maternal pathology in evaluating a virilized female infant.

Hirsutism and hyperandrogenism associated with hyperreactio luteinalis in a singleton pregnancy: a case report

The incidence of hyperandrogenism during pregnancy is low, although the incidence of some of the ovarian diseases that can cause it is higher. Hyperreactio luteinalis is a rare benign condition that may mimic ovarian and trophoblastic malignancies. A 23-year-old woman at 20 weeks' gestational age presenting with severe hirsutism and ovarian masses was treated conservatively and subsequently gave birth to a healthy female neonate. Final diagnosis was hyperreactio luteinalis. Conservative management with close monitoring of patients with hyperreactio luteinalis represents the best approach in such rare cases. Counseling should be provided to reassure the patient as to the transient effects of hyperandrogenism on the mother and the fetus.

Recurrent severe hyperandrogenism during pregnancy: a case report

This report describes the case of a 28 year old woman with virilisation occurring in two successive pregnancies. Recurrent maternal virilisation is rare (seven previous reports) and this case is unique in its severity. Differential diagnoses include ovarian disease and fetal aromatase deficiency. New techniques to exclude a fetal cause were used in this case. This patient presented during the third trimester of her first pregnancy with rapid onset of hirsuitism, increased musculature, and deepening voice. A blood hormone profile revealed significant hyperandrogenism (testosterone, 72.4 nmol/litre; normal range, 0.5-3.0). She delivered a normal boy and maternal androgen concentrations returned rapidly to normal (testosterone, 0.8 nmol/litre). She presented two years later, during her second pregnancy, with similar symptoms and biochemistry (testosterone, 47.5 nmol/litre). Again, she delivered a healthy normal boy and androgens returned immediately to normal (serum testosterone, 2.0 nmol/litre). Ultrasonography revealed no evidence of ovarian (or adrenal) masses in either pregnancy. Umbilical cord venous blood sampling and placental assays revealed no evidence of fetal aromatase deficiency. Recurrent hyperandrogenism during pregnancy is rare. Ovarian luteoma rarely recurs and hyperreactio luteinalis does not lead to such pronounced androgen concentrations. Therefore, this patient has a unique ovarian condition that could be harmful to offspring and mother.

Prenatal diagnosis of P450 oxidoreductase deficiency (ORD): A disorder causing low pregnancy estriol, maternal and fetal virilization, and the Antley-Bixler syndrome phenotype

We report studies on the second pregnancy of a woman who had previously given birth to a virilized female infant. The cause of the virilization had not been established, but common forms of congenital adrenal hyperplasia (CAH) were excluded. Longitudinal monitoring of the second pregnancy revealed that estriol excretion failed to increase normally, reaching a maximum 0.7 mg/24 hr at the end of pregnancy (normal mean 30 mg/24 hr). The mother showed signs of virilization by the 23rd week of gestation and aromatase deficiency was suspected. However, predicted urinary metabolites for diagnosis of aromatase deficiency (for example, 16alpha-hydroxyandrosterone) were not increased significantly during the pregnancy. Interestingly, excretion of the androgen metabolite androsterone increased rapidly at the beginning of pregnancy and peaked around the 20th week, suggesting increased production of testosterone and 5alphaDHT, probably the cause of maternal virilization. Urine steroid analysis by GC/MS showed gradually increasing excretion (9 mg/24 hr) of the normally minor metabolite 5alpha-pregnane-3beta,20alpha-diol (epiallopregnanediol), an epimer of the dominant progesterone metabolite pregnanediol (5beta-pregnane-3alpha,20alpha-diol). We believe epiallopregnanediol is largely the maternal urinary excretion product of fetal 5-pregnene-3beta,20alpha-diol, the principal metabolite of pregnenolone, implying a build-up of the latter steroid in the fetal adrenal. These findings suggested that the 'block' in the estriol biosynthetic pathway occurs at an early stage with 17-hydroxylation of pregnenolone being affected. The male baby born of this pregnancy had normal genitalia but showed a urinary steroid profile indicating partial deficiencies of P450c17 and P450c21. However, no mutations in the corresponding CYP17 and CYP21 genes were identified. Urinary steroid analysis carried out on his virilized older sibling showed the same pattern of metabolites. Recently, we determined that this disorder is caused by mutations in P450 oxidoreductase (OR), the essential redox partner for CYP17 and CYP21 hydroxylases. The novel metabolic profile has now been seen in many patients, most diagnosed with the skeletal dysplasia Antley-Bixler syndrome. We propose that excessive excretion of epiallopregnanediol together with low estriol may be prenatally diagnostic for OR deficiency (ORD).

Prenatal diagnosis of female pseudohermaphroditism associated with bilateral luteoma of pregnancy: case report

Female pseudohermaphroditism associated with luteoma of pregnancy (LP) is a rare condition characterized by varying degrees of masculinization of a female fetus. We describe a case, diagnosed at 13 weeks gestation. Transvaginal ultrasound at 5 weeks of gestation revealed a normal intrauterine gestational sac and an enlarged maternal right ovary. Re-examination at 13 weeks showed a fetus with male external genitalia. Cytogenetic investigation on amniotic fluid revealed a normal female karyotype 46,XX. Follow-up sonography confirmed the previous assignment of male external genitalia and a second amniocentesis was negative for the SRY gene. High levels of androgens were found in the maternal blood. A diagnosis of female pseudohermaphroditism associated with bilateral LP was made. A healthy girl was born by Caesarean section with complete masculinization of external genitalia (Prader V). Histology confirmed a bilateral LP. To the best of our knowledge this represents the first case of prenatal diagnosis of female pseudohermaphroditism associated with LP and demonstrates the feasibility of diagnosis by sonography from 13 weeks gestation. This is also the first case described of Prader V masculinization associated with LP.

How sexually dimorphic are we? Review and synthesis

The belief that Homo sapiens is absolutely dimorphic with the respect to sex chromosome composition, gonadal structure, hormone levels, and the structure of the internal genital duct systems and external genitalia, derives from the platonic ideal that for each sex there is a single, universally correct developmental pathway and outcome. We surveyed the medical literature from 1955 to the present for studies of the frequency of deviation from the ideal male or female. We conclude that this frequency may be as high as 2% of live births. The frequency of individuals receiving "corrective" genital surgery, however, probably runs between 1 and 2 per 1,000 live births (0.1-0.2%). Am. J. Hum. Biol. 12:151-166, 2000. Copyright 2000 Wiley-Liss, Inc.

How sexually dimorphic are we? Review and synthesis

The belief that Homo sapiens is absolutely dimorphic with the respect to sex chromosome composition, gonadal structure, hormone levels, and the structure of the internal genital duct systems and external genitalia, derives from the platonic ideal that for each sex there is a single, universally correct developmental pathway and outcome. We surveyed the medical literature from 1955 to the present for studies of the frequency of deviation from the ideal male or female. We conclude that this frequency may be as high as 2% of live births. The frequency of individuals receiving "corrective" genital surgery, however, probably runs between 1 and 2 per 1,000 live births (0.1-0.2%). Am. J. Hum. Biol. 12:151-166, 2000. Copyright 2000 Wiley-Liss, Inc.

Hyperreactio luteinalis masquerading as an ovarian neoplasm in a triplet pregnancy

Hyperreactio luteinalis is a non-neoplastic tumor-like ovarian lesion associated with pregnancy. Most patients are asymptomatic, with the ovarian enlargement being incidentally discovered at the time of cesarean section. It can simulate a neoplasm on clinical, gross and sometimes microscopic examination. We report a case of hyperreactio luteinalis in a patient, who was diagnosed as having polycystic ovary disease before conceiving a triplet pregnancy after three treatment cycles of human menopausal gonadotropin-human chorionic gonadotropin therapy, and discuss its pathogenesis.

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.

Recurrent maternal virilization during pregnancy caused by benign androgen-producing ovarian lesions

Benign causes of maternal virilization in pregnancy, such as luteoma of pregnancy and hyperreactio luteinalis, are generally believed to resolve completely post partum and not to recur. We present the fifth case in the literature of recurrent maternal virilization in pregnancy. These lesions should be viewed as potentially recurrent and cases should be managed accordingly.

Hormone-producing tumors of the ovary

The ovary is an endocrine organ that gives rise to a wide variety of neoplastic and tumorlike nonneoplastic conditions, some of which are associated with endocrine activity. The hormones produced may be steroidal or nonsteroidal. The ovary is unique among endocrine organs in reacting to the presence of nonendocrine tumors within it by abnormal or inappropriate production of sex steroidal hormones. A classification of hormone-producing ovarian lesions is proposed based on the World Health Organization's histologicai typing of ovarian tumors.

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.

Human chorionic gonadotropin, estriol, and testosterone changes in two pregnancies with hyperreactio luteinalis

A case of hyperreactio luteinalis is presented with measurements of human chorionic gonadotropin, total and free testosterone, and estriol throughout two term pregnancies. Ovulation induction with menotropins resulted in one spontaneous first-trimester abortion, one singleton term pregnancy, and 1 triplet pregnancy that converted to a singleton term pregnancy after spontaneous degeneration of two fetuses in the first trimester. During the first term pregnancy, levels of human chorionic gonadotropin peaked at 34 weeks of gestation (169,000 mIU/ml) and levels of total testosterone peaked at the same time (1777 ng/dl). Free testosterone (16.6 ng/dl) and estriol (10.8 ng/ml) reached their peak at 36 weeks of gestation. During the second term pregnancy, peak values of human chorionic gonadotropin (150,900 mIU/ml) and total testosterone (870 ng/dl) occurred at 10 and 5 weeks of gestation, respectively, before two fetuses of a triplet pregnancy degenerated.

Management of endocrine disorders in pregnancy. Part II. Pituitary, ovarian and adrenal disease

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