Normalization of androgen and sex hormone-binding globulin levels after treatment of hyperprolactinemia.

Twenty-eight women with amenorrhea, galactorrhea and hyperprolactinemia without hirsutism were studied before and after bromocriptine therapy for 2 months. Compared to 15 euprolactinemic controls, hyperprolactinemic women had elevated levels of dehydroepiandrosterone sulfate and androstenedione and lower levels of total testosterone (T), and androst-5-ene-3 beta, 17 beta-diol (Adiol), and 17 beta-estradiol (P less than 0.05). Unbound T and unbound Adiol were significantly elevated, while sex hormone-binding globulin binding capacity was decreased (P less than 0.05) and corticosteroid-binding globulin binding capacity was normal. After treatment with bromocriptine, dehydroepiandrosterone sulfate and androstenedione decreased to control levels, as did unbound Adiol, while 17 beta-estradiol and sex hormone-binding globulin binding capacity levels increased significantly (P less than 0.05). Five hyperprolactinemic women underwent ACTH stimulation tests before and after treatment, and the results were compared to those of seven controls. Steroid ratios in response to ACTH suggested normal 3 beta ol-dehydrogenase-isomerase, 17-20-desmolase and 17 beta-hydroxysteroid dehydrogenase enzymatic activities in hyperprolactinemia. Basal steroid ratios of T to 5 alpha-androstane-17 beta-01-3-one) (DHT) and of unbound T to unbound dihydrotestosterone were elevated (P less than 0.05), suggesting reduced 5 alpha-reductase activity in hyperprolactinemia which is normalized after treatment. Hirsutism was not present in these patients with hyperprolactinemia despite elevated levels of unbound T and Adiol, and may be explained by reduced 5 alpha-reductase activity. Our data suggest that the increased levels of androgens in these patients result from the hyperprolactinemia.

Longitudinal evaluation of the luteal phase and its transition into the follicular phase.

The precise patterns of LH, FSH, and PRL secretion and their correlation with estradiol (E2) and progesterone (P) secretion during the entire luteal phase have not been elucidated. To analyze in detail the secretory patterns of these hormones we performed 29 consecutive studies in 5 healthy, regularly menstruating women throughout their luteal phase [days 0 (ovulation), 2, 6, 10, and 14] and subsequent early follicular phase (day 2F). During each study plasma LH, FSH, PRL, E2, and P were measured at 10-min intervals for 6 h. Both plasma LH concentrations and LH pulse frequency declined from days 0 to 10 and increased thereafter, whereas LH pulse amplitude continued to decline throughout the luteal and early follicular phases. Plasma FSH concentrations followed a pattern similar to that of LH; however, there was a larger increase in the FSH level on days 14 and 2F. Plasma PRL levels declined initially on day 2 and again on day 14. Regression analysis indicated a positive correlation between LH concentrations and LH pulse frequency (r = 0.715; P less than 0.001) and between PRL and E2 concentrations (r = 0.528; P less than 0.01). A negative correlation was found between plasma P concentrations and both LH concentrations (r = -0.521; P less than 0.01) and LH pulse frequency (r = -0.633; P less than 0.001) and between plasma E2 and FSH concentrations (r = -0.762; P less than 0.001). Thirty-six (65%) PRL pulses and only 11 (39%) FSH pulses coincided with LH pulses. There was no clear pulsatile pattern of secretion of either E2 or P. We conclude that 1) the plasma LH, FSH, PRL, E2, and P concentrations vary markedly throughout the luteal phase; 2) the plasma LH level is largely dependent on the frequency of LH pulses; 3) plasma P decreases plasma LH by reducing the frequency of LH pulses; 4) the remarkable synchrony between PRL pulses and LH pulses implies that their secretion may be regulated by a common neuroendocrine mechanism; and 5) the preferential increase in FSH during the late luteal phase may play an important role in follicular recruitment for the subsequent cycle.

A separate mechanism of gonadotropin recovery after pregnancy termination.

To further elucidate the mechanism of return of pituitary secretory function after gestation, eight women were studied for up to 55 days after pregnancy termination. As long as serum estradiol (E2) and progesterone (P) levels were elevated, serum FSH remained low. Four to 6 days after abortion, serum E2 and P decreased to levels seen in the early follicular phase, and thereafter the initial increase in FSH occurred while serum beta-LH remained undetectable. After the initiation of FSH secretion, the levels fluctuated within the normal follicular phase range, resulting in a steady increase of E2 to a mean preovulatory peak of 257 +/- 37 pg/ml at a mean time of 21 +/- 1.3 days after pregnancy termination. This E2 peak was followed by FSH and LH peaks and subsequent ovulation. In contrast to FSH, serum beta-LH levels increased only after PRL-concentrations diminished to 30 ng/ml or less. This initiation of beta-LH secretion followed the advent of FSH secretion in six of eight patients. Therefore, a temporally separate mechanism of FSH and LH secretion after pregnancy termination is theorized. The theory of FSH occurs soon after the E2 and P levels decline while PRL levels are still elevated. However, the secretion of beta-LH increases only after levels have risen from the postabortion decline.

Classification of secondary amenorrhea based on distinct hormonal patterns.

Patients with secondary amenorrhea have been classified into 4 clincal groups. In order to further investigate these 4 groups, LH, FSH, and estradiol (E2) were measured at 15 min intervals for 4 h in 21 patients with secondary amenorrhea. Patients within each group had similar hormonal patterns, but there was a distinct variation among the groups. Three patients in group 1 (polycystic ovaries [PCO]) had elevated basal levels of only LH with marked irregular fluctuations. Seven patients in group II (hypothalamic-pituitary dysfunction) had normal basal levels of LH, FSH, and E2. Only LH showed oscillations of varying mahnitude and frequency. Eight patients in group III (hypothalamic-pituitary failure) had low or low-normal levels of LH, FSH, and low E2 with minimal or absent fluctuations. Three patients in group IV (ovarian failure) had high basal levels of FSH and LH and irregular fluctuations. This study confirmed the rationality of separating patients with secondary amenorrhea into 4 different groups. In addition, it was found that in group III patients, the total amount of LH secreted in a 4-hour period of time appears to be insufficient to stimulate E2 production from the ovary even when a single sample was found to be in the normal range.

PIP: Patients with secondary amenorrhea were classified into 4 groups based on clinical evidence. The patients were classified according to the presence of polycystic ovaries (Group 1), hypothalamic-pituitary dysfunction (Group 2), hypothalamic-pituitary failure (Group 3), and ovarian failure (group 4). These groups were further characterized by measurement of luteinizing hormone (LH), follicle stimulating hormone (FSH), and estradiol (E2) every 15 minutes for 4 hours. 3 patients in Group 1 showed elevated basal levels of LH with inconsistent fluctuations. Normal basal levels of LH, FSH, and E2 were observed in 7 patients in Group 2, though there were oscillations in LH levels of varying magnitude and frequency. Low or low-normal levels of LH, FSH and E2, with minimal or no fluctuations, were found in 8 patients in Group 3. In this group, the total amount of LH secreted over the 4-hour period was insufficient to stimulate E2 production from the ovary. 3 patient in Group 4 showed high basal levels of FSH and LH, with irregular fluctuations. The results support the approach of classifying patients with secondary amenorrhea in 4 groups.

Transient effect of L-5-hydroxytryptophan on pituitary function in men and women.

To further elucidate the role of serotonin in the secretion of pituitary hormones, a loading dose of 0.8 mg/kg for 1 h, following by a maintenance dose of 0.1 mg/kg . h of L-5-hydroxytryptophan (5-HTP) for 23 h were administered iv to five normal men and five normal women. Five additional men received repeated loading doses of 5-HTP 4 and 6 h after the initial one, with or without the maintenance dose. The initial studies demonstrated a significant, but transient, increase in plasma PRL, GH, cortisol (P less than 0.01) and TSH (P less than 0.05) in the five man and a consistent and significant transient increase only in PRL and cortisol in the five women. Plasma LH and FSH values were not affected by 5-HTP administration. The constant administration of 5-HTP revealed a blunting effect on the nocturnal rise of TSH in men. The continuous administration of 5 HTP failed to maintain the rise induced by the loading dose. Individuals receiving additional loading doses of 5-HTP demonstrated a subsequent increase in GH and cortisol, but not in serum PRL. This study suggests that endogenous serotonin may exert its stimulatory effect on pituitary hormone secretion primarily by sporadic release, rather than by continuous secretion.

Differences in the ratio of bioactive to immunoreactive serum luteinizing hormone during vasomotor flushes and hormonal therapy in postmenopausal women.

With the recognition of differences between serum bioactive (bio) and immunoreactive (i) LH concentrations in various clinical situations, we measured changes in the bio:i LH ratio in postmenopausal (PM) women in response to iv GnRH, during the vasomotor flush, and in response to both estrogen and progestin treatment. Bio LH was measured using the mouse interstitial cell assay and LER 907 as standard, with conversion to milliinternational units per ml (Second International Reference Preparation of human menopausal gonadotropin). In 22 PM women, aged 42-56 yr, serum bio LH [455 +/- 73 (+/- SE) mIU/ml] and the bio:i LH ratio (8.3 +/- 0.7) were significantly higher than in premenopausal women (25.5 +/- 5 mIU/ml and 1.5 +/- 0.2, respectively; P less than 0.002). In response to 150 micrograms iv GnRH, there was a greater rise in levels of iLH and bioLH in PM women than in premenopausal women, but there were no changes in the bio:i LH ratio after GnRH. During nine flushing episodes in three women, documented by digital temperature and iLH pulses, there was a significant increase in the bio:i LH ratio (P less than 0.001). After treatment of seven PM women for 2 months with 0.625 mg conjugated estrogens and seven other PM women with 150 mg im depomedroxyprogesterone acetate, vasomotor symptoms decreased significantly. Serum iLH did not change after treatment, but bio:i LH ratios decreased significantly, and 7 of 14 women had levels in the premenopausal range. These data suggest that bioLH and the bio:i LH ratio correlate better than iLH with symptomatology in PM women.

The influence of long-term low dose thyrotropin-releasing hormone infusions on serum thyrotropin and prolactin concentrations in man.

The purpose of the present study was to evaluate in man the relative thyrotroph and lactotroph response to a 48-h low dose constant TRH infusion. Before, during, and after the 75 ng/min TRH constant infusion, serum samples were obtained every 4 h in six euthyroid ambulating male subjects for measurements of TSH, PRL, T4, and T3. The TSH response, employing a specific and sensitive human TSH RIA, demonstrated a significant rise from the mean basal pre-TRH value of 2.35 +/- 0.64 microU/ml (+/- SEM) to 3.68 +/- 0.80 (P < 0.005) during the TRH infusion; this value fell below the basal level to 1.79 +/- 0.47 (P < 0.05) post infusion. Serum T4 values were increased above basal both during (P < 0.025) and after (P < 0.025) TRH infusion, whereas serum T3 values were not significantly changed throughout the entire study period. The daily TSH nocturnal surge was augmented in both absolute and relative terms during the first 24 h or the TRH infusion, unchanged during the second 24 h of infusion, and inhibited during the first postinfusion day. Other than a minimal increase in serum PRL during the first few hours of the infusion, no significant alteration in the mean basal concentration or circadian pattern of PRL secretion was evident during or after the low dose TRH infusion. These findings would indicate that 1) near-physiological stimulation of the pituitary with TRH produces a greater stimulation of TSH release than of PRL release and 2) the factor or factors producing the circadian TSH surge may not be mediated through fluctuations in endogenous TRH.

Effects of prolonged dopamine infusion on anterior pituitary function in normal males.

The influence of a 48-h dopamine (DA) infusion (5-7.5 micrograms/kg.min) on serum PRL, TSH, LH, FSH, and GH values was determined in six normal adult males. Sustained suppression of serum PRL to 78% (P less than 0.01) below baseline levels during DA was followed by an acute rebound of 319% (P less than 0.01) 4 h after stopping DA. Similarly, TSH decreased by 44% during DA but had a more gradual and sustained rebound of 41% (P less than 0.01) over a 36-h period. While both serum LH and FSH initially dropped by 25% (P less than 0.001) and 10% (P less than 0.05), a gradual escape occurred during the DA infusion, followed by rebounds of 23% (P less than 0.01), respectively. A brief rise in serum GH levels occurred with DA treatment, followed by a return to baseline. Subsequently, oscillatory spikes continued throughout the DA infusion but were significantly decreased (P less than 0.01) after stopping DA. Thus, DA administration initially produced a reduction in serum PRL, TSH, LH and PSH while stimulating GH release. PRL and TSH showed a sustained inhibition, whereas LH and FSH progressively escaped after a lesser degree of suppression by DA. The rebound after DA withdrawal probably reflected the discharge of hormone synthesized and stored during DA administration. The inverse relationship between the nadir of inhibition and the peak rebound values (r = 0.92) supports this hypothesis. Clearly, the patterns of serum LH, FSH, and GH values differ with acute and chronic DA administration. These differences are of potential importance in interpreting dopaminergic influences on anterior pituitary function.

Gonadotropin insufficiency in patients with thalassemia major.

To elucidate whether the cause of sexual maturational arrest in thalassemia major is of hypothalamic or pituitary etiology, three female and two male patients were extensively studied. After the iv administration of 150 micrograms gonadotropin-releasing hormone (GnRH) and 500 micrograms of TRH, all patients demonstrated a minimal LH and no FSH response, with variable PRL and TSH responses. The test was repeated after the patients received 100 micrograms GnRH im daily for 7 days. The LH, FSH, PRL, and TSH responses were similar to those obtained previously. The female patients were then retested twice, after priming with 17 beta-estradiol (2 mg daily for 7 days) and again after treatment with human menopausal gonadotropins. The male patients were treated with hCG and, after testosterone reached normal adult male values, the GnRH-TRH stimulation test was repeated. In both the female and male patients, the pituitary responses remained unchanged. These results demonstrate the presence of primary gonadotropin insufficiency as well as the lack of positive estrogen feedback mechanism in patients with thalassemia major. The site of this abnormality has been demonstrated to be the pituitary gland, since hemosiderosis of the pituitary without hypothalamic involvement has been found at autopsy in one patient.

Biochemical and biophysical indices of follicular development in spontaneous and stimulated ovulatory cycles.

This study was designed to evaluate the correlation between the follicular biophysical and biochemical indicators in spontaneous (N = 11) and stimulated (N = 110) ovulatory cycles. Ovulation was induced with clomiphene citrate in 14 cycles, gonadotropin-releasing hormone (GnRH) in 12 cycles, and human menopausal gonadotropins in 84 cycles. Patients were studied daily, starting on day 10, until sonographic verification of ovulation. Each woman had serum estradiol (E2) and LH measured daily and progesterone measured only 7 days after ovulation. In addition, the ovaries were imaged transvaginally daily and the two largest follicular diameters, volumes, cross-sectional areas, and circumferences were measured in all follicles 10 mm or larger in diameter. Ultrasonographic measurements of follicles from clomiphene-stimulated cycles were significantly larger than those from spontaneous, GnRH-, and human menopausal gonadotropins-stimulated cycles (P less than .05). Serum E2 and progesterone secretion in human menopausal gonadotropins- and clomiphene-stimulated cycles were significantly higher than in spontaneous and GnRH-stimulated cycles (P less than .01). Women treated with human menopausal gonadotropins developed significantly more follicles than with any other treatment (P less than .05). Correlation analysis indicated that biophysical variables alone (follicular diameter, volume, cross-sectional area, or circumference) were good indicators of normal follicular development and predicted the mid-cycle LH surge in spontaneous (r = 0.81, P less than .001), GnRH- (r = 0.78, P less than .001), and clomiphene citrate-stimulated cycles (r = 0.83, P less than .001). However, in human menopausal gonadotropins-stimulated cycles, both serum E2 levels and ultrasonographic evaluation were necessary to decide the best time for hCG administration (r = 0.55, P less than .001).

Vaginal bromocriptine: pharmacology and effect on serum prolactin in normal women.

Oral bromocriptine treatment of hyperprolactinemia is frequently associated with gastrointestinal side effects. To assess the efficacy and safety of an alternate route of treatment, we randomly administered 2.5, 5.0, and 7.5 mg of bromocriptine vaginally to five normal women at 1-week intervals. Plasma bromocriptine and prolactin (PRL) levels were measured hourly for 12 hours, then every 2 hours for 12 hours after each dose. At the end of each study, the vagina was flushed with saline for measurement of residual drug. For comparison of serum PRL levels, six additional women were given 2.5 mg bromocriptine orally. After administration of 2.5, 5.0, and 7.5 mg vaginally, plasma bromocriptine was initially detectable at 5.4 +/- 0.4, 4.4 +/- 0.7, and 3.5 +/- 0.6 hours, respectively. For the same vaginal doses, the mean (+/- SEM) peak plasma levels were 555 +/- 164 pg/mL at 12 +/- 0.6 hours, 702 +/- 252 pg/mL at 11.2 +/- 0.9 hours, and 1055 +/- 220 pg/mL at 10.7 +/- 1.7 hours, respectively. After each dose, there was a slow decline in plasma bromocriptine levels, remaining above 50% of peak values at 24 hours. Less than 1% of the administered drug was recovered from the vagina at 24 hours. The pattern of PRL inhibition with all three doses was similar. The mean plasma PRL level decreased by 7 hours, the maximum PRL decrease (64 +/- 3, 75 +/- 1, and 66 +/- 4% after 2.5, 5.0, and 7.5 mg, respectively) occurring at 11 hours, and the plasma PRL levels changed little during the remaining 13 hours.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of bromocriptine on sperm function in vitro and in vivo.

Vaginal bromocriptine is an effective method for the treatment of hyperprolactinemia, but it is unknown whether bromocriptine applied vaginally can interfere with sperm function. Thus, we sought to determine the effects in vitro and in vivo on sperm directly exposed to bromocriptine. Ten semen specimens from normal donors were diluted with Ham's F-10 medium and incubated with 0, 0.01, 0.1, and 1.0 mmol/L bromocriptine solution or diluent without bromocriptine. Computerized semen analysis revealed a 31% decrease in sperm motility, a 24% decrease in sperm average path velocity, and a 33% decrease in sperm average straight line velocity only using 1.0 mmol/L of bromocriptine (P less than .05). In addition, eight women with hyperprolactinemia and infertility who were receiving vaginal bromocriptine consented to a postcoital test. Five became pregnant and delivered normal infants. Four of the five women who had a postcoital test had six, eight, ten, and ten motile sperm per high-power field and one had one to two motile sperm per high-power field. Because sperm function was preserved enough to result in fertilization and term pregnancy, the clinical importance of the in vitro findings is probably minimal and it can be concluded that vaginal bromocriptine can be used in women with infertility due to hyperprolactinemia.

Clinical and laboratory evaluation of patients with primary amenorrhea.

Sixty-two patients with primary amenorrhea were retrospectively categorized into 4 groups: 1) breast development absent and uterus present (29 patients), 2) breast development present and uterus absent (9 patients), 3) both breast development and uterus absent (2 patients), and 4) both breast development and uterus present (22 patients). Patients in category 1 were diagnosed as having hypogonadotropic hypogonadism (low or normal follicle-stimulating hormone [FSH]) or gonadal dysgenesis (elevated FSH). Patients in category 2 were diagnosed as having congenital absence of the uterus (female range testosterone [T] or testicular feminization [male range T]). In the 2 patients in category 3, a 46,XY karyotype occurred with an enzyme defect (17,20 desmolase) in 1 and the other had agonadism. In category 4, 5 patients with elevated prolactin and a pituitary adenoma were identified. The remaining 17 patients were divided into 2 groups based on progesterone withdrawal bleeding. Patients who had withdrawal bleeding and had elevated luteinizing hormone level were diagnosed as having polycystic ovaries and patients with normal gonadotropins as having hypothalamic dysfunction. Patients who did not bleed were diagnosed as having hypothalamic failure (normal or low FSH) or primary ovarian failure (elevated FSH). This study demonstrates that it is possible to classify patients with primary amenorrhea into 4 useful diagnostic categories based on physical examination and a minimal laboratory investigation.

Computed tomography versus magnetic resonance imaging for the evaluation of suspected pituitary adenomas.

The purpose of this study was to evaluate and compare thin-section magnetic resonance imaging (MRI) and high-resolution computed tomography (CT) in patients with suspected pituitary adenomas. Twenty-two patients (19 women and three men) with hyperprolactinemia (N = 16), increased growth hormone secretion (N = 2), increased corticotropin secretion (N = 1), and nonsecreting adenomas (N = 3) were studied with both contrast-enhanced, high-resolution CT scanning and thin-section MRI. Contrast-enhanced examinations consisted of contiguous 1.5-mm coronal sections during contrast infusion. The MRI examinations consisted of spin-echo T1- and T2-weighted sequences with a 2.5-3.0-mm slice thickness on the coronal and sagittal planes. Fourteen women had similar findings on CT and MRI (four macroadenomas, six microadenomas, one wide stalk, two empty sellas, and one normal study). The remaining eight subjects had conflicting results: CT findings were compatible with a microadenoma in all eight patients, whereas MRI detected one enlarged pituitary, two empty sellas (one with prolapse of the optic chiasm) without evidence of adenoma, and five normal examinations. Thus, both studies detected macroadenomas accurately, but CT was frequently unable to diagnose correctly an empty sella. Because patients with possible microadenomas were not submitted to surgery, the accuracy of either radiologic method cannot be assessed at this time. However, we suggest that MRI is superior to CT because of its inherently greater soft-tissue contrast, which allows clear visualization of the optic chiasm, optic nerves, cavernous sinuses, and carotid arteries.

A comparative study between radioreceptor assay and radioimmunoassay for hCG in patients with trophoblastic disease.

The results of a urinary quantitative radioreceptor assay (RRA) were compared with those obtained with an established specific radioimmunoassay (RIA) for hCG in a group of patients with trophoblastic disease. A good correlation (r = 0.95) was found between the two methods for values greater than 10 mIU/ml of hCG. A specific RIA for hCG should be used when the hCG levels fall below 10 mIU/ml. With the use of this urinary RRA, the clinician can follow patients with hydatidiform more for up to 10 weeks after evacuation and have the hCG titer available on the same day the specimen is obtained.

Clomiphene and dexamethasone in women unresponsive to clomiphene alone.

Twelve oligomenorrhic women with polycystic ovary syndrome (PCO) in whom clomiphene (250 mg daily for 5 days) and 10,000 IU human chorionic gonadotropin had failed to induce ovulation were treated with clomiphene and dexamethasone. Eight of the 12 women underwent complete hormonal assessment during treatment. Six of the 12 ovulated and 1 conceived. Serum total and unbound estradiol and testosterone (T), serum dehydroepiandrosterone sulfate (DHEA-S), sex hormone binding-globulin binding capacity (SHBG-BC), luteinizing hormone (LH), follicle-stimulating hormone (FSH) and prolactin (PRL) were measured during clomiphene and dexamethasone therapy. SHBG-BC increased in response to clomiphene whether or not ovulation occurred. After treatment with clomiphene and dexamethasone there was a significant decrease in serum T, unbound T, and DHEA-S 2 weeks after dexamethasone administration, but there were no change in LH, FSH, or PRL. In patients who ovulated after clomiphene and dexamethasone, T and unbound T increased again after clomiphene was begun despite the continuation of dexamethasone. The women who ovulated after clomiphene and dexamethasone treatment had significantly higher pretreatment levels of DHEA-S than those who did not ovulate. Clomiphene and dexamethasone treatment may be beneficial to women who have elevated levels of DHEAS and who fail to ovulate with maximum doses of clomiphene.

Diagnosis of pregnancy with a radioreceptor assay for hCG.

A new serum assay for human chorionic gonadotropin, the radioreceptor assay (RRA), was compared with three commercial urinary agglutination inhibition pregnancy tests (AITs) in a group of women with suspected early pregnancies and ectopic gestations. The accepted definitions by which a laboratory test is characterized, including clinical sensitivity and specificity as well as predictive value of positive and negative tests and efficiency, were calculated for each test in three different time periods of gestation: less than 7 days, between 7 and 14 days, or more than 14 days after the expected menses had been missed. The results of the study showed that the RRA had greater clinical sensitivity and efficiency than the AITs in cases of both early gestation and ectopic pregnancy. The RRA has the disadvantages of requiring the capability to handle radioactive materials and gamma counter. This test is chiefly useful for those patients desiring early termination of pregnancy and those infertility patients anxious for early confirmation of pregnancy.

PIP: Diagnosis of pregnancy with a radioreceptor assay (RRA) for human chorionic gonadotropin (HCG) is reported. The RRA was compared with 3 commercial urinary agglutination inhibition pregnancy tests (AITs) in a group of women with suspected early pregnancies and ectopic gestations. The accepted definitions by which a laboratory test is characterized were calculated for each test in 3 different time periods of gestation: less than 7 days, 7-14 days, or more than 14 days after the expected menses had been missed. The results showed that the RRA had greater clinical sensitivity and efficiency than the AITs in cases of both early gestation and ectopic pregnancy. The RRA has the disadvantages of requiring the capability to handle radioactive materials and a gamma counter. It is concluded that this test is chiefly useful for those patients desiring early termination of pregnancy and those infertility patients anxious for early confirmation of pregnancy.

Prognostic characteristics of serum human chorionic gonadotropin titer regression following molar pregnancy.

The postevacuation serum beta human chorionic gonadotropin (hCG) regression curves of 77 women with hydatid moles were analyzed from the perspective of refining the criteria for diagnosis of gestational trophoblastic neoplasia. Forty-nine patients (64%) demonstrated a spontaneous, progressive fall in serum hCG titers to levels nondetectable by radioimmunoassay within 15 weeks. The regression curves of the remaining 28 patients exhibited a plateau or rise in titer, usually during the first 6 weeks after evacuation. Analysis of the 2 groups demonstrates a statistically significant difference in regression curves that permits early identification of the patient with gestational trophoblastic neoplasia. The significance of these curves is discussed.

Hyperprolactinemia: comparison of thyrotropic-releasing hormone and tomography.

A group of 95 women with unexplained hyperprolactinemia (over 20 ng/mL) underwent radiologic examination of the sella turcica with hypocycloidal polytomography (N = 58), computed axial tomography (N = 8), or both (N = 29). All patients also underwent a thyrotropin-releasing hormone (TRH) stimulation test, with serum prolactin (PRL) measurement before and 20 and 30 minutes after a 500-micrograms intravenous bolus of TRH. Their PRL responses were compared with those of two control groups, nine normal women in the follicular phase of the menstrual cycle, and 13 women in the first five months of gestation with pregnancy-related hyperprolactinemia. Both control groups exhibited PRL increases with 95% confidence limits at least 200% above baseline levels. In all, 12 patients from the study group also had a normal PRL response (more than a 200% increase) to TRH, and none of these women had tomographic findings consistent with a pituitary tumor. The remaining 83 women all had diminished or absent PRL increases after TRH administration; 46 (55%) of these patients had radiographic evidence of an adenoma, whereas 37 (45%) had no clear signs of a tumor on either polytomography or computed axial tomography. No patient with a baseline PRL level in excess of 60 ng/mL had a normal PRL response to TRH. The results of the study indicate that 1) in patients with PRL between 20 and 60 ng/mL, a normal TRH test can be relied upon to avoid the expense and radiation of tomography (computed axial tomography or polytomography), 2) there is no benefit to be obtained in performing a TRH test in patients with a baseline PRL level over 60 ng/mL, and 3) about 45% of patients with hyperprolactinemia and an abnormal TRH test have a normal computed tomography or polytomography. These patients may have a small adenoma, and thus warrant closer follow-up than patients with a normal TRH test.

Reliability of transvaginal ultrasound in detecting first trimester pregnancy abnormalities.

OBJECTIVE: To evaluate the reliability of transvaginal ultrasound (US) and human chorionic gonadotropin (hCG) levels in detecting early abnormalities and predicting outcome of pregnancy. PATIENTS: One hundred thirty-two patients were studied, of which 113 had an intrauterine pregnancy and 19 had an ectopic pregnancy (EP). RESULTS: In 78 with singleton normal pregnancies, US revealed a normal crown-rump length, heart motion, and hCG levels between 1,000 to 107,000 mIU/mL. Of 16 patients with small crown-rump length, heart motion present, and normal hCG levels, 6 aborted and 10 reached term. Thus, 6 of 84 (7.14%) singleton with fetal heart motion aborted. Thirteen with small crown-rump and absent heart motion also aborted. All 8 with an empty gestational sac aborted. In 8, transvaginal US detected four twins, two triplets, and two quadruplets, whereas hCG was not discriminative. Transvaginal US revealed an empty uterus in 19 patients with an EP, whereas serum hCG varied between 37 and 10,500 mIU/mL. CONCLUSION: A fetal crown-rump length compatible with gestational age and fetal heart motion seen by transvaginal US can predict a term pregnancy in greater than 90% of patients.