Urinary Testosterone Response to Human Chorionic Gonadotropin

Urinary Testosterone Response to Human Chorionic Gonadotropin Evaluation of Male Patients with Hypogonadotropic Hypogonadism BRUCE L. FARISS, M.D.,* GERARD M. CERCHIO, M.D.,t and VINCENT C. D1 RAIMONDO, M.D.:t. HuMAN CHORIONIC GONADOTROPIN ( HCG) has been shown to stimulate the testicles to secrete testosterone.1.7 The optimal dose of HCG that will increase testosterone secretion and produce clinical improvement has not been clearly defined. In an attempt to determine this dosage, 3 patients with hypogonadotropic hypogonadism were given increasing doses of HCG intramuscularly and evaluated by their clinical and urinary testosterone responses. METHODS Three male patients with delayed sexual development were selected for this study. Before treatment was started, these young men submitted to thorough clinical examinations, including routine blood tests and roentgenograms of the sella turcica and chest. Urinary testosterone was measured by the method of Wegienka et al., while the urinary 17-ketosteroids were determined by the procedure of Vestergaard (normal adult male, 6-20 mg.j24 hr.). Growth hormone was assayed by a modification of the radioimmunologic technic of Grodsky and Forsham, originally described for insulin, which employs sodium sulfate for preferential separation of bound and From the Metabolic Research Unit and the Department of Medicine, University of California Medical Center, San Francisco, Calif., and the Clinical Investigation Center, U. S. Naval Hospital, Oakland, Calif. We are extremely grateful to Dr. William Odell of the University of California Medical Center at Los Angeles for performing the plasma LH assays in our patients. *Present address: Research and Development, Madigan General Hospital, Tacoma, Wash. tpresent address: Veteran's Administration West Side Hospital, 820 South Damen Ave., Chicago, Ill. :!:Present address: Chief, Department of Medicine, French Hospital, 4131 Geary Blvd., San Francisco, Calif. 632

VoL. 20, No. 4, 1969 HYPOGONADISM AND HCG 633 free hormones. Urinary 17-hydroxycorticosteroids were determined by a modification of the method of Reddy, using the colorimetric method of Silber-Porter (normal male, 6-14 mg.j24 hr.). The initial dose of HCG was 100 I.U. daily for 1 week; the dose was increased to 300, 500, and 1000 I.U. daily at weekly intervals. Then, the patients were changed to a dose of 1000 I.U., three times a week; two patients were studied while receiving 2000 I.U., three times a week. During the treatment, the patients were followed to determine their clinical response and levels of urinary excretion of testosterone and 17 -ketosteroids. CASE HISTORIES Case 1. A 23-year-old college student was evaluated for failure of secondary sexual development. His height was 7H in. He had a high-pitched voice, eunuchoid proportions, sparse body and pubic hair, and prepubertal genitalia. The testicles measured 1 X 1.5 em. and were soft and nontender. No gynecomastia was present. Otherwise, the findings on physical examinatio~ were within normal limits. Case 2. A 22-year-old sailor was evaluated for failure of secondary sexual development. He had a high-pitched voice, prepubertal genitalia with small ( 1 X 2 em.), soft, nontender testicles, no facial hair, and sparse pubic hair. His height was 70 in. His ability to smell was intact. Other physical findings were within normal limits with no gynecomastia. His family history was significant since he had three brothers with similar complaints. Case 3. A 21-year-old college student was seen for failure of secondary sexual development. At the age of 12 years, he was found to have decreased visual acuity of his right eye. He was observed to have a slight impairment of gait. No tremors were noted, and his ability to smell was intact.. These manifestations remain unexplained. A pneumoencephalogram and an examination of his cerebrospinal fluid produced normal findings. An electroencephalogram showed a diffusely abnormal pattern without localization. Physical examination revealed a healthy-appearing male with decreased visual acuity of the right eye. He was alert, cooperative, and oriented. He had difficulty walking on a narrow base and was unsteady during a Romberg test. There was minimal axillary and pubic hair with prepubertal, small ( 1 X 1.5 em.), soft, nontender testicles; no gynecomastia was found. His height was 7ml: in. The findings on roentgenograms of the hips were compatible with a diagnosis of bilateral aseptic necrosis of the femoral heads. All endocrine parameters measured for the 3 patients were normal, with the exception of those for gonadotropins and urinary steroids, including testosterone (Table 1). The normal urinary testosterone values in males are 39-170 mg.j24 hr. Patient 2 had low basal levels of urinary 17-ketosteroids. Buccal smears on

634 FARISS ET AL. FERTILITY & STERILITY TABLE 1. Endocrine Evaluation of Patients 1, 2, and 3 Before Treatment with HCG Patient No. Endocrine laboratory assays 1 2 3 PBI (~g./100 mi.) 5.8 5.7 13 1! (% uptake/24 hr.) 20.0 28.0 Growth hormone (m~g./ml.) Basal 1.1 5.0 5.8 After insulin 14.3 Plasma LH* (mi.u./ml.) 9.0 7.0 10.0 Urinary gonadotropins (M.U.) 5.0 5.0 5.0 Urinary Silber-Porter chromogenst (17-0HCS; mg./24 hr.) Basal 5.9 7.3 5.5 After LV. ACTH 37.9 After oral metyrapone 22.2 16.8 *Normal for males, 6-30 mi.u./ml. t Normal for males, 6-19 17-0HCS; mg./24 hr. all three were chromatin negative. Urinary gonadotropins were less than 5 M.U. in each patient. Levels of plasma luteinizing hormone ( LH) were reported as low normal in all 3 patients, supporting the clinical diagnosis of hypogonadotropic hypogonadism. A normal finding for LH is 6-30 milli-international Units per milliliter ( ml.u.jml.),5 RESULTS Figures 1, 2, and 3 show the response to HCG administration of Patients 1, 2, and 3, respectively. There was no detectable change in urinary testosterone excretion with the administration of 100 and 300 I.U. of HCG daily; however, in Patients 1 and 2, there was a significant increase with the administration of 500 I. U. daily. Patient 3 did not respond to the HCG until the dose was increased to 1000 I.U. daily. All the patients developed bilateral gynecomastia during the third week of treatment with a dose of 500 I.U. of HCG daily. The breasts were tender to palpation for the next month and then gradually resolved in size without tenderness. The patients first noted the onset of hair growth of the face, pubic area, and chest, while receiving 1000 I.U. of HCG daily. At this dose, the patients had an increase in libido, and each patient masturbated. The ejaculate was watery and clear. Patients 1 and 2 have had excellent responses to the HCG, both clinically and as measured by their urinary testosterone levels; Patient 1 had the best response, with his urinary testosterone rising progressively to normal

1---- DAILY --f- ~ ;::::----1 2000 HCG I.U. I.M. 1000 TESTOSTERONE JAg/24hr 12 17-KETOSTEROIDS mg/24 hr 8 HCG I.U. I,M, CREATININE mg I 24 hr 0 :::: fllllllllllll 0 I 2 3 4 I 2 3 4 5 6 7 8 I-WEEKS-+---- MONTHS --j Fig. 1. Response of Patient 1 to HCG administration. f--daily--+-! ;::::---j 2000 1000 HCG I,U, I,M. TESTOSTERONE ~g/24 hr TESTOSTERONE JAg /24hr 17-KETOSTEROIDS mg /24 hr :~ 0 8 17-KETOSTEROIDS mg/24 hr 0 CREATININE mg /24 hr :::: lllllllllll ~~~~Iri~ ~:::~ 1111111111 01234123456 01234123456 I-WEEKS-+- MONTHS --I I-WEEKS--+-- MONTHS--i Fig. 2 (left). Response of Patient 2 to HCG administration. Fig. 3 (right). Response of Patient 3 to HCG administration. Small arrows indicate "less than."

636 FARISS ET AL. FERTILITY & STERILITY male levels, associated with a rise in his urinary 17 -ketosteroids. Patient 2 showed an increase in his urinary testosterone excretion; however, his urinary 17 -ketosteroids were essentially unchanged from his basal levels. It is of interest that Patient 3 had a poor response to HCG, as measured by his level of urinary testosterone excretion, although his urinary 17-ketosteroids were significantly increased, and he showed a good clinical response. During our study the patients have had no side effects or complications related to the continuous administration of HCG, with the exception of the gynecomastia which resolved spontaneously. DISCUSSION Human chorionic gonadotropin has been used as an aid in establishing the diagnosis of hypogonadotropic hypogonadism. 4 Patients with inadequate endogenous gonadotropins who are given a course of HCG treatments have a good response; however, those patients with primary testicular disease do not respond. To treat hypogonadal patients and to accelerate puberty, HCG has also been used, with a recommended dose of 2000-5000 I.U., two or three times a week. If infertility is the primary concern, HCG is not an adequate treatment. 8 The administration of HCG has been reported as increasing the number of Leydig cells in man. However, Pearson and Heller reported an increase in the size of the Leydig cells with no increase in their number. Previous investigators have reported increased levels of urinary testosterone/ plasma testosterone, 6 and urinary 17-ketosteroids 1 after HCG administration. However, change in the level of excretion of the urinary 17- ketosteroids is not consistent as a response to HCG administration. 2 In our study, 3 hypogonadotropic hypogonadal male patients were selected to determine the optimal dosage of HCG necessary to obtain laboratory and clinical improvements. Varying doses were administered, and the patients were evaluated by their clinical response and urinary excretion of testosterone and 17-ketosteroids. These patients have shown an increase in urinary testosterone excretion in response to HCG administration. Kirschner et al. reported that no such increase of plasma testosterone was produced with a dose of 1000 I.U., although acute injections of 2000 I.U. of HCG caused an increase in plasma testosterone secretion. From our data, 1000 I.U. of HCG induces the same response as 2000 I.U., as determined by the clinical and urinary testosterone excretion results. The patients' development of gynecomastia while receiving 500 I.U. of HCG was of interest. The mechanism for this is not known; however, it has been reported that HCG increases the excretion of estrogen in some male

VoL. 20, No.4, 1969 HYPOGONADISM AND HCG 637 patients.u Thus, the gynecomastia may be secondary to an increased production of estrogen. Patients with hypogonadotropic hypogonadism respond to the administration of HCG by an increased production of testosterone and the development of secondary sexual characteristics. In this study, the urinary levels of 17 -ketosteroids and testosterone did not always reflect the clinical course. However, the urinary testosterone response paralleled the clinical changes better than did the 17 -ketosteroid excretion. Therefore, it is important to measure the testosterone level in plasma or urine in attempting to evaluate the effect of HCG administration in men. Furthermore, since the level of urinary testosterone may not always be a true reflection of the amount of plasma testosterone production, patients may have a good clinical response without demonstrating a significant change in the quantity of urinary testosterone excretion. SUMMARY Three male patients with hypogonadotropic hypogonadism were given increasing doses of HCG. While receiving 1000 I.U. of HCG, there were good clinical responses and increased urinary testosterone excretion. Gynecomastia developed during the time the patients were receiving 500 I.U. of HCG daily, but this symptom resolved spontaneously in spite of the continuing therapy with HCG. There was no significant difference in the quantity of testosterone excretion whether the HCG in 1000 I.U. doses was given daily or three times a week, and the level of excretion was essentially the same for HCG doses of 1000 or 2000 I.U. B. L. F. Metabolic Research Unit University of California Medical Center San Francisco, Calif. 94122 REFERENCES 1. CLEVELAND, W. W., AHMAD, N., SANDBERG, D. H., and SAVARD, K. Excretion of testosterone and 17-ketosteroids following administration of HCG and ACTH to normal adult males. Steroids 8:149, 1966. 2. FoLK, R. L., TAYLOR, J. N., SoTOS, J. F., VoRYS, N., and WIELAND, R. G. Effect of chorionic gonadotropin on urinary testosterone and 17 -ketosteroids in prepubertal males and males with spermatic maturation arrest. Amer ] Med Sci 255: 221, 1968. 3. GRODSKY, G. M., and FoRSHAM, P. H. An immunochemical assay of total extractable insulin in man. ] Clin Invest 39:1010, 1960. 4. HELLER, C. G., and NELSON, W. 0. Classification of male hypogonadism and a discussion of the pathologic physiology, diagnosis and treatment. ] Clin Endocr 8:345, 1948. 5. HoRNICHTER, R., HoRTON, R., ODELL, W., and BROWN, J. The syndrome of

638 FARISS ET AL. FERTILITY & STERILITY "isolated" hypogonadotropic hypogonadism in the male. (abst.) Clin Res 16:114, 1968. 6. }EFFCOATE, s. L., BROOKS, R. v., LIM, N. Y., LONDON, D. R., PRUNTY, F. T. G., and SPATHIS, G. S. Androgen production in hypogonadal men. I Endocr 37:401, 1967. 7. KIRSCHNER, M. A., LIPSETT, M. B., and CoLLINS, D. R. Plasma ketosteroids and testosterone in man: A study of the pituitary-testicular axis. I Clin Invest 44:651, 1965. 8. MARTIN, F. I. R. The stimulation and prolonged maintenance of spermatogenesis by human pituitary gonadotrophins in a patient with hypogonadotrophic hypogonadism. I Endocr 38:431, 1967. 9. MROUEH, A., LYTTON, B., and KASE, N. Effects of human chorionic gonadotropin and human menopausal gonadotropin ( Pergonal) in males with oligospermia. I Clin Endocr 27:53, 1967. 10. PEARSON, J. E., and HELLER, C. G. Human chorionic gonadotropin: Effect on Leydig cell number and size in normal man (abst.). Clin Res 16:115, 1968. 11. REDDY, W. J. Modification of the Reddy-Jenkins-Thorn method for the estimation of 17-hydroxycorticoids in urine. Metabolism 3:489, 1954. 12. SILBER, R. H., and PoRTER, C. C. The determination of 17-,21-dihydroxy-20- ketosteroids in urine and plasma. I Biol Chern 210:923, 1954. 13. VESTERGAARD, P. Rapid micro-modification of the Zimmermann/Callow procedure for determination of 17-ketosteroids in urine. Acta Endocr (Kobenhavn) 8: 193, 1951. 14. WEGIENKA, L. C., BowER, B. F., SHINSAKO, J., ELATTAR, T. M., HANE, S., MIMICA, N., DEMERTZE, E., STUTHEIT, J. E., and FoRSHAM, P. H. Gas chromatographic method for the determination of testosterone in urine. Anal Biochem 18: 203, 1967.