Report of 3 cases. 1969). Isolated deficiency of pituitary gonadotrophin secretion is uncommon,

Transcription

1 The Medical Unit, The Princess Margaret Hospital, Christchurch, New Zealand PITUITARY AND GONADAL FUNCTION IN HYPOGONADOTROPHIC HYPOGONADISM Report of 3 cases By E. A. Espiner and R. A. Donald ABSTRACT Hypothalamic-pituitary function and gonadal histology and responsiveness have been assessed in three patients with isolated deficiency of gonadotrophin secretion. Gonadotrophin secretion was uniformly reduced and sex steroid excretion markedly impaired in all three cases. Biopsy of the gonad showed immature glands and no increment in steroid excretion resulted from stimulation using human chorionic gonadotrophin. No response in gonadotrophins to clomiphene occurred in 2 of the 3 patients tested. Whereas normal ACTH and adrenal response to hypoglycaemic stress and metopirone was shown in 2 of the 3 cases, the increment in growth hormone secretion was reduced. Following sex steroid therapy, the growth hormone response was improved and increased ACTH release during hypoglycaemia was observed in one patient. No change in gonadotrophin secretion occurred during longterm sex steroid therapy. Failure to mature sexually in man may be due to primary disease of the gonad, hypothalamic-pituitary disease or possibly a combination of both (Bardin et al. 1969). Isolated deficiency of pituitary gonadotrophin secretion is uncommon, but better techniques for gonadotrophin assay in blood and urine, together with development of adequate tests of pituitary trophic hormone secretion in general, have facilitated earlier and more definitive detection (Odell 1966). Although studies indicate that gonadotrophin secretion is low in these cases, there have

2 been recent reports that gonadotrophin secretion may increase following the administration of clomiphene [Boyar 1969). Apart from the seven male patients studied by Bardin et al. (1969) there are few detailed reports of pituitary trophic hormone secretion or data concerning gonadal pathology and respon siveness to exogenous stimulation in patients with this disorder. In this paper details of pituitary function before and after sex steroid replacement therapy, together with gonadal histology and responsiveness to human chorionic gonado trophin, are reported in three cases of isolated gonadotrophin deficiency. In two of these three cases the responsiveness to clomiphene was also assessed. MATERIALS AND METHODS Radioimmunoassay techniques were used to measure plasma corticotrophin (ACTH) (Donald 1971), growth hormone (HGH) (Wool & Selenkow 1968) and Iuteinising hor mone (LH) (Donald 1972). Plasma immunoreactive follicle stimulating hormone (FSH) was measured by courtesy of Dr. H. Burger (Melbourne). Urinary gonadotrophins were measured by the mouse uterine assay, urinary ketosteroids by the method of Drekter et al. (1952) and ketogenic steroids by the method of Metcalf (1963). Urinary oestrogens were assayed fluorimetrically by the technique of Brown et al. (1968). Urinary androsterone and aetiocholanolone were assayed by gas chromatography according to the method of Metcalf (1970). Plasma cortisol was measured by the fluorimetrie technique of demoor et al. (1960). Details of the insulin tolerance testing (ITT) procedure (Donald 1971) and metopirone test of ACTH reserve (Donald et al. 1972), have been published previously. As a test of gonadal responsiveness to exogenous stimulation, human chorionic gonado trophin (HCG) 4500 IU was administered daily by intramuscular injection for three successive days. Prior to, and during this test, dexamethasone 2 mg per day was ad ministered to suppress the adrenal contribution to urinary androgen excretion. Case 1 CASE REPORTS A 26 year old male automobile assembler presented for reasons of inadequate sexual development. He first sought medical advice at the age of 12 years for undescended testes. Bilateral orchidopexies were attempted but without success. It was noted at operation that both epididymes were quite separate from the bodies of the testes. At the age of 18, left orchidopexy was repeated, again unsuccessfully. Two years later when investigated for hypogonadism, the patient complained of weakness, lassitude and absence of erections except on rare occasions. Apart from a slight growth of pubic hair, there was no evidence of puberty. At this time it was noted that the bone age was 4 years behind the chronological age. Because of the previous history, a diagnosis of primary hypogonadism was made and the patient received testosterone implants on two

3 occasions. Treatment then lapsed until the age of 25 years when he received a further course of five injections. Following the injection, he noted some deepening of his voice and an increase in penile size. One year later, when referred to this Unit for the first time, it was apparent that his muscle strength was poor, erections were very infrequent with no emissions, he shaved only once a week and he was continuing to grow in height. Direct questioning re vealed that his sense of smell had never been satisfactory. Family history was significant in that two half brothers of the patient (the father had married twice) had required injections for undescended testes and later to hasten the onset of puberty. The patient's mother re-married on two further occasions and four of the ten children resulting from these marriages have matured nor mally. The other six are still pre-pubertal in age. No history of anosmia could be obtained in any relative of the patient. The family pedigree is shown in Fig. 1. Physical examination revealed a youthful looking man with eunuchoid pro portions (Fig. 2). Height was 189 cm, pubes to sole 106 cm, crown to pubes 83 cm, arm span 206 cm, body weight 70.6 kg. Arching of the palate was accentuated, the mandible was increased in size and the supraorbital ridges were prominent. There was no other feature of acromegaly. There was a female distribution of pubic hair and a scanty growth of axillary hair. The scrotum was undeveloped and a small testis was just palpable in the left inguinal canal, the right testis being absent. The penis was 5 cm in stretched length and the prostate was impalpable. The skin was soft and adipose tissue was of normal pre-pubertal distribution. The voice was of normal adult pitch. The optic fundi and visual fields were normal. Sense of smell was tested extensively using acetone, eugenol, isoamyl acetate, n-propanol, formic acid, n-heptaldehyde, methyl salicylate, methyl propionate, benzene, dettol, turpénf o*=ç è" 0 proposito! ^ -o'j^' O.H.0 S^ìr *cr< undescended testes, hypogonadism and anosmia w undescended testes, delayed puberty delayed puberty * * <Wr «, - Pedigree of family of Case 1.

4 Fig. 2. Three cases of hypogonadotrophic hypogonadism, showing eunuchoid habitus. Case 1 had received some previous androgen therapy. Left: Case 1; Centre: Case 2; Right: Case 3. tine, ammonia and oil of eucalyptus. The patient responded only to trigeminal and local irritants, the olfactory loss being marked and general. Routine laboratory tests including blood count, urinalysis, blood sugar, urea and electrolytes were within normal limits. The buccal smear was chromatin negative and the karyotype (cultured blood leucocytes) was normal male (46XY). X-ray of the skull showed a normal pituitary fossa, but there was irregular thickening of the inner table of the skull. The bone age was only 16 years and the bone density was uniformly reduced. Biopsy of the testis taken at the age of 18, is shown in Fig. 3. The appearances unstimulated testis and are consistent with gonadotrophin deficiency. Tests of endocrine function are summarised in Tables 1 and 2 and Fig. 4. The patient responded well to testosterone injections (Sustanon 250 mg) at two weekly intervals. Case 2 are those of an immature A 20 year old storeman presented with failure of pubertal development. Birth history and early infancy were apparently normal, and subsequently scholastic attainments were average. At 13 years of age, the genitalia were noticeably small and the testes were undescended. Orchidopexy was performed

5 Fig. 3. Gonadal biopsy in 3 cases of hypogonadotrophic hypogonadism. Upper left: Case 1: Testicular biopsy showing immature seminiferous tubules and severe interstitial atrophy (H & 530). Upper right: Case 2: Testicular biopsy showing absence of both spermatogenesis and Leydig cells (H & 530). Lower: Case 3: Ovarian biopsy showing scattered ova and one Graafian follicle. A thickened capsule and abundant fibrous stroma is also seen (H & 212).

6 on each testis in turn at 13 and 14 years of age. Despite an increase in his height no pubertal changes occurred and the patient showed no interest in female company. Occasional erections were experienced but no voice change, body or facial hairgrowth or nocturnal emission had occurred. On direct questioning the patient admitted to a poor sense of smell. At the age of 20 he considered he was still increasing in height and his shoe size had increased between 18 and 20 years of age. There was no other significant past medical history. In the family history, there was no known endocrine disease, anosmia or infertility, although the patient's nephew (aged 12 years) had recently under gone orchidopexy for undescended testes. Physical examination (Fig. 2) showed an immature young man with eunuchoid features. Height 161 cm, arm span 167 cm, crown to pubes 70 cm, pubes to sole 91 cm. Body weight was 51.6 kg, fat distribution was normal, though muscle development was reduced. The genitalia were infantile (penis 6 cm in stretched length, testis volume 4 ml and 3 ml right) but otherwise normal. There was no significant pubic hairgrowth and facial and axillary hair were Table 1. Pituitary function tests. Case 1 Case 2 Case 3 Normal range Pituitary-thyroid PBI «g/100 ml 6.0 T3 Resin uptake % 20.2 Total thyroxine /ig/100 ml h 131 neck uptake /o Pitaitary-adrenal 1 Hour cortisol increment after Synacthen (/ig/100 ml) 19 Urine KGS after metopirone (mg/d) 135 Maximum plasma ACTH after metopirone (pg/ml) 415 Pituitary-gonadal Plasma LH mu/ml Plasma FSH mu/ml Urine total gonadotrophins (IU/d) Posterior pituitary Urine osmolality after 12 h fluid restriction m..os/l < < > > 750

7 Table 2. Effect of HCG stimulation on steroid excretion. Steroid Case Control mg/d day 3 Dexa 2 HCG* 4500 IU/d day 3 HCG weekly for 4 weeks Ketosteroids (mg/d) (Normal range) < 10 Ketogenic steroids (mg/d) (Normal range) < Androsterone and aetiocholanolone (mg/d) (Normal male range) 1.4 < <0.5 > Total oestrogens (Mgfd) (Normal range) 2 < < < 1 > 20 (females) > 10 (males) 1-2 * Administered while receiving dexamethasone (2 mg daily) except in Case 2. absent. The prostate was impalpable. Complete anosmia was demonstrated to substances detailed in Case 1, though taste sensitivity was normal. There was no other abnormal clinical finding or evidence of congenital abnormality. Optic fundi and visual fields were normal. Routine laboratory studies including blood count, Wasserman reaction, electrolytes, uric acid, cholesterol, calcium and phosphorus, glucose tolerance and creatinine clearance were within normal limits. Buccal smear was chromatin negative and karyotype (cultured blood leucocytes) was normal (46XY) male. Bone age as taken from an X-ray of the left wrist was 14 years. Apart from generalised retardation of bone development, no abnormality was shown on chest, skull or skeletal radiographs. Biopsy of the left testis showed a prepubertal appearance (Fig. 3). Seminiferous tubules were small and lined en-

8 Table 3. Effect of clomiphene on plasma gonadotrophins. Normal range Control Clomiphene 200 mg/d Day mg/d 1 week 6 weeks Case 2 Plasma LH mu/ml Plasma FSH mu/ml < 0.9 Case 3 Plasma LH mu/ml Plasma FSH mu/ml < < 0.9 Clomiphene 50 mg/d tirely by Sertoli cells. There was no thickening of the tubular lamina propria or interbular fibrosis ind Leydig cells were not seen. Other tests of endocrine function are listed in Tables 1-3 and shown in Fig. 4. The patient is currently being treated with testosterone (Sustanon 250 mg) at two weekly intervals. Case 3 A 19 year old female bank clerk was referred because of primary amenorrhoea and diminished sexual development. Apart from infectious mononucleosis at the age of 13 years there was no significant medical history. A small amount of pubic hair developed at years of age, but menstruation and breast development did not occur. Increase in the size of hands and feet had been noted over the two years prior to her referral. Her sense of smell was normal and no family history of anosmia, infertility or endocrine disease could be elicited. The patient's physical appearance (Fig. 2) was eunuchoidal (height 165 cm, arm span 177 cm). Breast tissue was minimal and pubic and axillary hair sparse or absent. Both phenotype and gender role were entirely feminine, external genitalia were normal female (though infantile), and the uterine cervix just palpable rectally. Optic fundi, visual field and olfaction were normal and examination of other systems gave normal results. There was no evidence of neck webbing, cubitus valgus or other congenital abnormality. Routine laboratory tests, as detailed in Case 2, were within normal limits. Buccal smear was chromatin positive and karyotype (blood leucocyte culture) normal female (46XX). Bone age, taken from an X-ray of the left wrist was

9 13 years. X-rays of skull, spine and skeleton were normal apart from retarded development and moderately reduced bone density. No oestrogen effect was seen in a vaginal smear. Other tests of endocrine function are shown in Tables 1-3 and Fig. 4. To exclude gonadal dysgenesis, laparotomy and ovarian biopsy were under taken. Infantile, but otherwise normal uterus and Fallopian tubes were seen. Both ovaries were small and child-like. A small section was taken from the left ovary for histology (Fig. 3), and culture for karyotype analysis. Normal ovarian stroma with a few primordial follicles, and occasional Graafian fol licles were seen. At least one collapsed follicular cyst was present and smaller scars in the stroma were considered to be remnants of atretic follicles. No was consistent Leydig cells were seen and the overall histological appearance with diminished or absent trophic hormone stimulation. Cultured cells from the gonad were found to be of normal chromosomal constitution (46 XX). The patient was subsequently treated with female sex hormones to develop secondary sex features and adequate bone maturation. Sequential determina tion of plasma LH during this replacement therapy have shown no significant changes, and are all abnormally low. response to HYPOGLYCAEMIC STRESS pg/ml ACTH CORTISOL ng/ml HGH PRE therapy pg/ml >jg/o Fig. 4. Plasma ACTH, HGH, and cortisol response to insulin induced hypoglycaemia in 3 patients before and after sex steroid therapy for hypogonadotrophic hypogonadism. In each case the lines connect control and the peak levels of the response. A-* Case 1 - Case 2 o-o Case 3

10 Pituitary hormone secretion RESULTS Adequacy of thyrotrophin secretion, as shown by standard tests of thyroid function, was proved in all three cases (Table 1). Adrenocortical responsive ness to administered ACTH was also normal as was the pituitary and adrenal response to metopirone in the two patients tested. During insulin induced hypoglycaemia, a normal response in plasma cortisol and plasma ACTH was observed in two cases while the response was less than expected in Case 2, despite adequate hypoglycaemic stress (Fig. 4). The increment in plasma HGH concentration was also subnormal in two patients and in the third patient (Case 1 who had received some prior testosterone replacement), the HGH in crement was at the lower limit of normal (Fig. 4). Antidiuretic hormone secre tion as reflected by urine osmolality following fluid restriction, was normal in the two patients tested. Plasma gonadotrophins drawn under basal conditions were abnormally low in all patients on repeated testing though just detectable in two. Urinary total gonadotrophins were similarly reduced in all cases (Table 1). With clomiphene (Table 3), no response in plasma LH concentration occurred either on short term (Cases 2 and 3) or long term (Case 2) administration. Gonadal steroid secretion Basal excretion of sex steroids was markedly diminished. In the two males, androsterone and aetiocholanolone (A + E) excretion was less than 0.5 mg per 24 h on the third day of dexamethasone treatment. Urinary oestrogens were similarly reduced in the female patient (Case 3). With HCG stimulation for three days, there was no change in sex steroid excretion in any of the three cases. A more prolonged course in one patient (Case 1) showed no increase in androgen excretion at any stage of the four weeks therapy. These results are listed in Table 2. Pituitary function following sex steroid therapy Because HGH response to insulin induced hypoglycaemia was lower than expected in these three patients, repeat testing was carried out following sex steroid replacement therapy. Duration of therapy prior to repeat IT"1 varied from 1-2 years and in all cases had resulted in marked skeletal and sexual maturation. In contrast to the response pre therapy, HGH secretion was within normal limits after sex steroid replacement and the response in ACTH secre tion in one subject (Case 2) was also improved (Fig. 4). Repeated plasma LH determinations during the replacement phase have shown no change in any of the three patients.

11 - despite DISCUSSION These three patients have impaired secretion of both LH and FSH yet rela tively normal secretion of other pituitary trophic hormones. All cases pre sented in late adolescence with features of inadequate sexual maturation, con tinued skeletal growth and with markedly delayed epiphyseal bone union. However, it is interesting to note that with the exception of one case, gonado trophins were detectable in the plasma and in all cases the phenotypic ex pression was consistent with genetic sex. In one patient (Case 1) there were features of anomalous testicular development in that the epididymis was sepa rate from the testis, but even in this case the phenotype was undoubtedly male. Thus sufficient gonadotrophin secretion, with resulting gonadal sex steroid secretion, appears to be present for the normal expression of gender and at least near normal development prior to puberty. However, the expected pubertal increase in gonadotrophin secretion (August et al. 1972) fails to occur, presumably because of abnormalities in hypothalamic function. Further evi dence that the disorder in gonadotrophin secretion is not necessarily complete is given by reports of the stimulatory effects of clomiphene (Boyar 1969). No such response to clomiphene was found in the two patients tested in this report protracted treatment in one instance. Failure to respond to clomi phene may not rule out a hypothalamic defect in these patients since variations in pituitary responsiveness, depending upon the severity of the hypothalamic defect, would be expected. The use of gonadotrophin releasing hormones will be of obvious help in the differentiation of hypothalamic versus pituitary based disorders (Abe et al. 1972). In keeping with the low gonadotrophin secretion, the gonadal histology of these cases showed immature development with greatly reduced germ cell pro duction. In the two male subjects tubules were small and lined by Sertoli cells without spermatogonia and Leydig cells were virtually absent. Similar findings in male subjects have been reported previously (Bardin et al. 1969; Schroffner 8c Furth 1970; Boyar 1969). The separation of the epididymis from the testis as observed in Case 1 of the present report, together with accompanying cryptorchidism may also reflect gonadotrophin deficiency in early develop ment. Alternatively this defect could be regarded as a separate congenital abnormality known to be widespread in patients with Kallmann's syndrome - (Prunty et al. 1969; Kallmann et al. 1944). Previous reports of histology of the gonad in females with hypogonadotrophic hypogonadism are less common (Odell 1966; Sparkes et al. 1968). In Case 3 of the present series, the internal genitalia were normal female but immature while the ovaries appeared at laparotomy as small and discreet organs in contrast to the fibrous bands ob served in gonadal dysgenesis. The histological appearance showed a relatively abundant stroma with Graafian follicles and small cystic areas were also

12 observed, as previously reported in ovaries of normal young girls (Merrill 1963). In view of these histological findings it is not surprising that the patients failed to respond to trophic hormone stimulation, in this case administered as HCG. Similar defective responses were reported in male subjects with Kallmann's syndrome by Bardin et al. (1969) who considered that this failure to respond, despite protracted treatment in some instances, represented an endorgan failure separate from the hypothalamic-pituitary deficiency. This view was reinforced by this group's demonstration of greater responses to HCG in prepubertal normal boys compared to males with Kallmann's syndrome. In Case 1 of the present report HCG therapy was given for four weeks without change in androgen excretion rates yet others have observed satisfactory clinical responses to HCG (Boyar 1969; Anderson 1970). Whether these varia tions in responsiveness reflect the severity of the gonadotrophin deficiency is open to question until such time as gonadotrophin measurements in normal children are closely compared to those observed in patients with deficiency syndromes. The responsiveness of female patients to trophic hormone stimula tion and the possibilities of future conception also remain to be evaluated. A report of pregnancy in 2 of 3 such patients when given appropriate trophic hormone stimulation (Tagatz et al. 1970) suggests that the ovary may be more responsive than the testis in this syndrome. Whereas pituitary gonadotrophin secretion has been well studied, less atten tion has been given to hypothalamic-pituitary regulation of other trophic hor mones in such patients. When these tests have been carried out, the response of the end organ has usually been assessed, rather than direct estimation of the pituitary trophic hormones themselves. In the present three patients both thyroid and adrenal function appeared to be normal and normal increments in ACTH secretion were obtained in 2 of the 3 cases when provocative tests of hypothalamic function were employed. HGH secretion, however, was reduced in comparison to the expected response of normal adults. In Case 1 the HGH response to hypoglycaemia was at the lower limit of normal whereas in the remaining two cases it was clearly subnormal. Repeat testing after sex hormone replacement therapy showed an augmented HGH secretion in these latter two patients, the post treatment responses being within the normal range. Since Case 1 had received androgens prior to the initial insulin tolerance test, it seems likely that the impairment in HGH secretion is related to relative sex hormone deficiency rather than to an intrinsic hypothalamic failure. We have observed (Livesey et al. 1972) along with others (Eastman et al. 1971; Illig 8c Prader 1970) that the HGH response to hypoglycaemia is less marked in prepubertal boys and improves rapidly after androgen replacement therapy. Oestrogens are also facilitatory especially with respect to the growth hormone promoting stimuli such as exercise (Frantz 8c Rabkin 1965) and hypoglycaemia

13 (Lippe et al. 1971). Change in ACTH secretion after sex hormone therapy was less conclusive in these patients and no change in gonadotrophins was observed. The genetic aspects in Kallmann's syndrome have received considerable attention (Sparkes et al. 1968; McKusick 1962), although the mode of in heritance is still controversial. Familial disease is likely in Case 2 of the present report and very strongly suggested by the family history of Case 1. In this instance, transmission of the defect appears to be from father to son, so that an autosomal mode of inheritance rather than an X linked recessive (Kallmann et al. 1944; McKusick 1962) is favoured. Similar observations have been made by others (Schroffner 8c Furth 1970; Hockaday 1966) in patients with Kallmann's syndrome. ACKNOWLEDGMENTS We wish to thank Dr. P. Fitzgerald, Cytogenetics Unit, Christchurch Hospital for undertaking the chromosomal studies; Dr. G. Dunkley, Otago University Medical School for the urine gonadotrophin assays and Medical Unit Staff for supervision of blood and urine collections. We are also indebted to the United States National Pituitary Agency for pro viding purified HGH, ACTH and LH, used in this study. This work was supported in part by the Medical Research Council of New Zealand and the Canterbury Medical Research Foundation. REFERENCES Abe K., Nagata N., Saito S., Tanaka., Kaneko T., Shimizu. 8c Yanaihara.: Endocr. jap. 19 (1972) 77. Anderson D. C: Proc. roy. Soc. Med. 63 (1970) 575. August G. P., Grumbach M. M. 8c Kaplan S. L.: J. clin. Endocr. 34 (1972) 319. Bardin C. W., Ross G. T., Rifkind A. B., Cargille C. M. 8c Lipsett M. B.: J. clin. Invest. 48 (1969) Boyar R. M.: Ann. intern. Med. 71 (1969) Brown J. B., MacNaughton C, Smith M. A. 8c Smyth B.: J. clin. Endocr. 28 (1968) 175. demoor P., Raskin M. 8c Steeno G: Ann. Endocr. (Paris) 21 (1960) 479. Donald R..: J. clin. Endocr. 32 (1971) 225. Donald R..:.. med. J. 75 (1972) 200. Donald R.., Espiner E. A. 8c Beaven D. W.: J. Endocr. 52 (1972) 517. Drekter I. ]., Heisler., Seism R. G., Stern S., Pearson S. 8c Magavack. H.: J. Endocr. 12 (1952) 55. Eastman C. J., Lazarus L.. Stuart M. C. 8c Casey J. H.: Aust. & N. Z. J. Med. 1 No. 2 (1971) 154. Frantz A. G. 8c Rabkin M. T.: J. clin. Endocr. 25 (1965) Hockaday R. D. R.: Postgrad. Med. J. 42 (1966) 572. lllig R. 8c Pruder.: J. clin. Endocr. 30 (1970) 615. Kallmann F. J., Schonfeld W. A. 8c Barrera S. E.: Amer. J. Mental Deficiency 48 (1944) 203.

14 Lippe., Wong S. R. 8c Kaplan S..: J. clin. Endocr. 33 (1971) 949. Livesey ]. H., Donald R.., Espiner E. A. 8c Salamonsen L..: N. Z. Med. J. 76 (1972) 261. McKusick V..: Quart. Rev. Biol. 37 (1962) 69. Merrill J..: South. Med. J. 56 (1963) 225. Metcalf M. G.: J. Endocr. 26 (1963) 415. Metcalf M. G.: Clin. Biochem. 3 (1970) 271. Odell W. D.: J. Amer. med. Ass. 197 (1966) Prunty F. T. G., Davidson N. McD., Hutchinson J. S. M. 8c Reid D. ].: Proc. roi. Soc. Med. 62 (1969) 27. Schroffner W. G. 8c Furth E. D.: J. clin. Endocr. 31 (1970) 267. Sparkes R. D., Simpson R. W. 8c Paidsen C..: Arch, intern. Med. 121 (1968) 534. Tagatz G., Fialkow P. J., Smith D. & Spadoni L.: New Engl. J. Med. 283 (1970) Wool M. S. 8c Selenkow H..: Acta endocr. (Kbh.) 57 (1968) 109. Received on December 22nd, 1972.