Red cell alloimmunisation following intrauterine transfusion and the feasibility of providing extended phenotype-matched red cell units.

OBJECTIVES: To analyse the incidence of additional alloantibody formation following intrauterine red cell transfusion and to evaluate the feasibility of providing extended phenotype-matched red cells in future intrauterine transfusion (IUT). BACKGROUND: IUT is performed in severe, life-threatening fetal anaemia, usually in alloimmunised pregnancies. Its complications include the formation of additional alloantibodies to other red cell antigens. MATERIALS AND METHODS: This was an 11-year retrospective, observational study of additional alloantibody formation in patients receiving IUT in the National Maternity Hospital, Dublin. The study included evaluation of the donor population in the Republic of Ireland (RoI) with regards to the feasibility of providing extended phenotype-matched units in future IUT. RESULTS: Following IUT, 22% of mothers formed additional red cell alloantibodies. In 67% of cases, the transfused donor red cells expressed the cognate antigen. Suitable donors are available for most combinations of Fy, Jk and Ss antigens. CONCLUSIONS: In our population, it is feasible to provide more extensively phenotype-matched red cells for future IUT. These can be supplied from the current donor pool with no significant extra phenotyping required. We consider their provision to be a reasonable proactive step in a known at-risk group.

A correlation between severe haemolytic disease of the fetus and newborn and maternal ABO blood group.

OBJECTIVE: To analyse anti-D quantification levels and frequency of intrauterine transfusion (IUT), per maternal ABO blood group. BACKGROUND: Maternally derived red cell allo-antibodies can target fetal red cell antigens in utero leading to haemolytic disease and fetal anaemia. When a clinically significant allo-antibody is formed the priority is ascertaining the risk to the fetus and maternal ABO blood groups are not considered relevant. MATERIALS AND METHODS: This was a 10-year retrospective, observational study carried out on women referred for anti-D quantification (n = 1106), and women whose fetuses required an IUT to treat fetal anaemia (n = 62) due to anti-D, in the Republic of Ireland. RESULTS: Relative to the overall incidence of RhD allo-immunisation by blood group, women of blood group A were more likely to require IUT compared with those who were blood group O (P = 0.002). CONCLUSION: It is known that ABO feto-maternal compatibility can influence the incidence and level of red cell allo-antibodies in pregnancy; however, it does not account for the significantly high rate of severe haemolytic disease requiring IUT seen in blood group A women.

Effects of menstrual cycle phase on metabolomic profiles in premenopausal women.

BACKGROUND: Characterization of the normal degree of physiological variation in the metabolomic profiles of healthy humans is a necessary step in the development of metabolomics as both a clinical research and diagnostic tool. This study investigated the effects of the menstrual cycle on (1)H nuclear magnetic resonance (NMR) derived metabolomic profiles of urine and plasma from healthy women. METHODS: In this study, 34 healthy women were recruited and a first void urine and fasting blood sample were collected from each woman at four different time points during one menstrual cycle. Serum hormone levels were used in combination with the menstrual calendar to classify the urine and plasma samples into five different phases i.e. menstrual, follicular, periovulatory, luteal and premenstrual. The urine and plasma samples were analysed using (1)H NMR spectroscopy and subsequent data were analysed using principal component analysis (PCA) and partial least squares discriminant analysis. RESULTS: PCA of the urine spectra showed no separation of samples based on the phases of the menstrual cycle. Multivariate analysis of the plasma spectra showed a separation of the menstrual phase and the luteal phase samples (R(2) = 0.61, Q(2) = 0.41). Subsequent analysis revealed a significant decrease in levels of glutamine, glycine, alanine, lysine, serine and creatinine and a significant increase in levels of acetoacetate and very low density lipoprotein (VLDL CH(2)) during the luteal phase. CONCLUSIONS: These results establish a need to control for metabolic changes that occur in plasma due to the menstrual cycle in the design of future metabolomic studies involving premenopausal women.

Hyperprolactinaemia: analysis of presentation, diagnosis and treatment in the endocrine service of a general hospital.

The charts of 184 patients with clinically significant hyperprolactinaemia who presented to a teaching hospital between 1978-1995 were reviewed, 158 (86%) females and 26 (14%) males. Hyperprolactinaemia was due to a microadenoma or was idiopathic in 36.4%, drug induced in 16%, associated with a macroadenoma in 12%, due to epilepsy in 7%, with other causes each contributing 5% or less. The presenting symptoms were amenorrhoea in 64%, galactorrhoea in 40.5%, infertility in 15%, visual field defect in 9%, with impotence in 30% and, gynaecomastia in 8% of men. One hundred and one patients were treated with bromocriptine (80%), surgery (35.4%) and radiotherapy (10.7%). Twenty-five percent of patients developed side-effects of bromocriptine for which cabergoline, a new long-lasting dopaminergic agonist, was successfully substituted. Presenting features responded to drug treatment in 70-80% of patients.

Steroidogenesis in an estrogen-producing adrenal tumor in a young woman: comparison with steroid profiles associated with cortisol- and androgen-producing tumors.

There is only one previous report of an estrogen-secreting adrenal tumor occurring in a woman during reproductive years. Our patient presented with mild hirsutism associated with menstrual bleeding every 3-6 weeks. The occurrence of apparently intermenstrual bleeding prompted an evaluation of estrogen levels. Markedly elevated plasma estrone levels were found (860-2305 pmol/L; normal, 50-340). Lesser relative elevations in 11-deoxycortisol and androstenedione were noted. Computed tomographic scanning of the adrenal glands identified a large tumor, which was subsequently resected. Estrone levels fell to 120 pmol/L, and all other abnormalities were corrected. Eighteen months after adrenalectomy, ovulation occurred regularly, and steroid levels were entirely normal. Steroid production in a cell suspension made from tissue obtained from the 190-g tumor was compared with that occurring in normal human adrenal cells. The production of estrone by the tumor cells was 40-fold greater than that by normal adrenal cells. There was also a mild excess of 11-deoxycortisol produced by tumor cells, but the tumor cells were less than 50% as efficient as normal cells in producing cortisol, dehydroepiandrosterone, androstenedione, testosterone, and dehydroepiandrosterone sulfate. Examination of the steroid profile in plasma occurring in three other patients with adrenal tumors reveals that while elevations in estrone occur frequently, this is usually due to the peripheral conversion of very high levels of androstenedione. Estrone, androstenedione, and 11-deoxycortisol plasma levels were elevated in all four patients; dehydroepiandrosterone sulfate was elevated in only two of four patients. After resection of one of these tumors, all steroid levels remained normal despite the occurrence of extensive metastases. These observations confirm the difficulty of making a diagnosis of estrogen excess in a woman during reproductive years because of the paucity of physical signs. The acquisition of aromatase activity was clearly demonstrated by tumor cells from our patient in vitro. Elevated plasma concentrations of estrone, androstenedione, and 11-deoxycortisol provide useful markers for adrenal tumors, but no one steroid can be relied upon in all tumors, and metastases may lack the steroidogenic capabilities of the primary tumor.

Evaluation of an aldosterone radioimmunoassay: the renin-angiotensin-aldosterone axis as a function of sex and age.

A highly specific radioimmunoassay for aldosterone in plasma has been developed utilising extraction from plasma into dichloromethane, an antiserum raised to aldosterone-3-carboxy-methyloxime-BSA and a radio-iodinated derivative of aldosterone. The plasma values obtained after only extraction correlated very well with the results following chromatography over celite. The within- and between-batch variations for plasma pools ranged between 5 and 15%. The range obtained, 100-1806 pmol/L for 96 random upright subjects, was comparable to others reported. Measurement of plasma aldosterone and plasma renin activity in these subjects showed that both these parameters are higher in subjects under 40 years of age than in those over 40. In addition, plasma aldosterone levels are higher in women than in men even though their plasma renin activity levels are similar. The plasma aldosterone/renin activity ratios which provide an index of adrenal sensitivity to stimulation, are lower in men than in women. The findings in this study suggest that higher aldosterone levels in younger subjects are associated with greater stimulation of the adrenals than in older subjects and that the adrenal is more sensitive in women than in men.

Adrenal abnormalities in polycystic ovary syndrome.

This study was undertaken to examine the role of adrenal androgen excess in the pathogenesis of polycystic ovary syndrome (PCOS) and, if such was present, to assess its reversibility using dexamethasone given in physiological dosage at night. Mean plasma testosterone (T), T/sex-hormone binding globulin (T/SHBG) ratio, androstenedione, and 17-OH-progesterone levels were elevated in the 19 patients studied. Plasma estrone values were elevated, whereas estradiol levels were normal. Plasma FSH was decreased and LH responsiveness to LHRH was exaggerated. Metyrapone, an 11-hydroxylase inhibitor, was administered at 2400 h to induce hypocortisolemia and compensatory ACTH secretion so that adrenal androgen and glucocorticoid responsiveness to endogenous stimulation could be examined. Plasma T, androstenedione, and 11-deoxycortisol responses to metyrapone were excessive in PCOS patients, thus indicating a specific adrenal abnormality. After 3 months treatment with dexamethasone, 0.5 mg at night, mean plasma T/SHBG and androstenedione declined to normal, and mean plasma dehydroepiandrosterone and dehydroepiandrosterone sulfate declined to below normal. The mean estrone value was slightly lower during dexamethasone. Plasma LH responsiveness to LHRH was no longer significantly different from normal, but FSH was suppressed. During treatment androgen responsiveness to metyrapone stimulation was normal, whereas 11-deoxycortisol responsiveness was suppressed. Fifteen patients completed 3 months of treatment with dexamethasone. Of these, 10 resumed regular menstruation. The latter group had suppression of plasma T, T/SHBG, androstenedione, dehydroepiandrosterone, and dehydroepiandrosterone sulfate. Only plasma androstenedione fell significantly in the remainder. These observations support the hypothesis that, in at least some patients, PCOS develops in response to abnormal gonadotropin secretion induced by hyperestronemia occurring as a consequence of excessive adrenal androgen secretion.

The relationship between sex steroids and sex-hormone-binding globulin in plasma in physiological and pathological conditions.

Physiological and many pathological changes in plasma sex-hormone-binding globulin (SHBG) levels have been attributed to the opposing effects of androgens which lower, and oestrogens which elevate, levels. We examined four clinical situations in which changes in SHBG levels may not be explained by sex steroid alterations. (1) Dexamethasone caused an increase in SHBG levels in hyperandrogenaemic hirsute women whether or not androgens were suppressed. (2) In male patients with untreated isolated gonadotrophin deficiency there was a highly significant correlation between SHBG levels and age, but there was no relationship between the levels of SHBG and those of plasma testosterone, androstenedione or DHEAS. (3) Two 46-XY siblings, phenotypic female subjects with complete androgen insensitivity, demonstrated a marked decline in SHBG levels between the ages of 9-13 and 12-16 years. (4) SHBG was suppressed in obese oligomenorrhoeic women while plasma concentrations of testosterone, androstenedione and oestradiol were normal and that of oestrone was elevated; however, the testosterone:SHBG ratio, an index of free testosterone, was elevated. These observations indicate that the decline in SHBG levels which normally occurs in men during the second decade of life is independent of androgen activity and is under the influence of as yet unidentified factors. Glucocorticoids in small doses under the influence of as yet unidentified factors. Glucocorticoids in small doses increase SHBG levels independently of sex steroid alterations while elevated free testosterone concentration may contribute to suppression of SHBG in obesity.

Altered androstenedione and estrone dynamics associated with abnormal hormonal profiles in amenorrheic subjects with weight loss or obesity.

The present study was designed for exploration of hormonal disturbances underlying common forms of amenorrhea. Polycystic ovary syndrome (PCO) patients and obese amenorrheic subjects had significantly elevated estrone (E1) levels, elevated luteinizing hormone/follicle-stimulating hormone ratios, and an exaggerated luteinizing hormone response to luteinizing hormone-releasing hormone. However, androstenedione (delta 4A), the precursor of E1, was elevated only in PCO. Thus, the E1/delta 4A ratio, which provides an indirect index of aromatase activity in extraglandular sites, was raised in obese subjects as a group but not in PCO subjects. These findings suggest that elevated E1 levels, which give rise to abnormal gonadotropin secretion, arise from increased available androgens in PCO but from an increased effect of aromatase (present in adipose tissue) in obese subjects. Measurement of androgens and the E1/delta 4A ratio provides insights into the relative contributions of hyperandrogenemia and enhanced aromatase activity to the genesis of amenorrhea in these groups. In patients with suppressed estradiol levels associated with hyperprolactinemia or weight loss, follicle-stimulating hormone levels were suppressed, while luteinizing hormone was not elevated. Prolactin excess explains these findings in hyperprolactinemia. Plasma E1 levels and the E1/delta 4A ratio were suppressed in patients with weight loss, possibly as a consequence of reduced adiposity. This finding suggests that hypothesis that a minimum level of E1, dependent upon adequate adiposity, is critical for the normal mature function of the hypothalamic-pituitary-ovarian axis. Abnormal E1/delta 4A ratios, high in obesity-associated amenorrhea and suppressed in weight loss-associated amenorrhea, may provide specific markers for these groups of patients.

Variable clinical and hormonal manifestations of hyperandrogenemia.

This study was undertaken to contrast the hormonal profiles in patients with various hyperandrogenemic states in an attempt to correlate clinical manifestations with specific hormonal abnormalities. Patients with idiopathic hirsutism, polycystic ovaries, and a syndrome recently described by us, amenorrhea with cryptic hyperandrogenemia, ie, without hirsutism, participated. Total testosterone, the testosterone: sex-hormone-binding globulin (SHBG) ratio, and androstenedione levels were elevated in each group of patients. SHBG levels were suppressed in patients with idiopathic hirsutism and in patients with polycystic ovaries. In patients with polycystic ovaries or cryptic hyperandrogenemia, plasma estrone levels were elevated and the luteinizing hormone (LH) responses to luteinizing-hormone-releasing hormone (LH-RH) were exaggerated. Estrone is derived from androstenedione under the influence of the enzyme, aromatase. While elevated androstenedione occurred in both patients with polycystic ovaries or idiopathic hirsutism, estrone levels were only elevated in patients with polycystic ovaries. Reduced aromatase activity may have protected patients with idiopathic hirsutism from elevated estrone values and, thereby, from menstrual disturbances. The hormonal profiles in polycystic ovary syndrome and in patients with amenorrhea with cryptic hyperandrogenemia were very similar, with the exception that SHBG levels were high normal in three of five patients with cryptic hyperandrogenemia while estrone values were markedly elevated in these patients. Elevated estrone levels may explain the normal SHBG values, which are usually suppressed in hyperandrogenemic states. While each of the hyperandrogenemic disorders studied has a characteristic hormonal profile, the various clinical manifestations cannot be accounted for solely by abnormalities in circulating hormonal levels.(ABSTRACT TRUNCATED AT 250 WORDS)

Prolactin in hirsute women: possible roles for androgens in suppressing basal levels, and for oestrogens in enhancing TRH-induced responses.

Hyperprolactinaemic patients occasionally demonstrate hirsutism and elevated levels of DHA-S, a weak androgen of adrenal origin. Abnormal adrenal function is frequently observed in hirsute patients. These observations prompted speculation that prolactin may modulate normal adrenal secretion and that derangements of adrenal androgen secretion may be due to abnormalities in prolactin. In this study we examined the possibility that elevated prolactin levels may be involved in the pathogenesis of hyperandrogenaemia in hirsute patients. However, basal prolactin levels in hirsute women, with or without menstrual disturbances, 201 +/- 24.3 mU/l (mean +/- SE) and 192 +/- 24.3 mU/l respectively, were significantly suppressed below levels in normal women, 289 +/- 12.2 mU/l. The prolactin responses to stimulation with TRH and to suppression with L-dopa were also studied in hirsute patients. The prolactin response to TRH (maximum increment or integrated response) was exaggerated significantly in hirsute women with menstrual disturbances when compared to normal women, to hirsute women with normal menses or to normal men. This abnormal response may have been due to elevated oestrone levels present in patients with oligomenorrhoea (318 +/- 49.5 pmol/l compared to 191 +/- 12.1 pmol/l in normal women and 161 +/- 15.5 pmol/l in hirsute women with normal menses, P less than 0.05). There were no abnormalities detected in the suppression of prolactin in response to L-dopa in any of these groups. These findings do not support a role for prolactin in the pathogenesis of hyperandrogenaemia in hirsute patients. However, elevated androgen levels in women may bring about suppression of basal prolactin levels to values seen in normal men. (ABSTRACT TRUNCATED AT 250 WORDS)

Plasma sex hormone-binding globulin levels decrease during the second decade of life irrespective of pubertal status.

The plasma concentrations of sex hormone-binding globulin (SHBG) and sex steroids determine the nonprotein bound or free steroid fraction, which probably exerts the biological activity of sex steroids. Androgens lower and estrogens raise SHBG levels. The established pubertal fall in SHBG levels occurring in men has been attributed to rising androgen levels. In this study we examined the relationship between plasma SHBG and androgens in four men with untreated isolated gonadotropin deficiency and in two siblings with complete androgen insensitivity. In patients with untreated isolated gonadotropin deficiency there was a highly significant inverse correlation between SHBG levels and age (r = -0.9, P less than 0.001), although testosterone levels did not rise and there was no relationship between SHBG levels and testosterone, androstenedione, or dehydroepiandrosterone-sulfate. Two 46 XY siblings, who were phenotypic females, with complete androgen insensitivity had a marked decline in SHBG levels from 28.0 ng/ml at 9 yr to 17.1 ng/ml at 13 yr and from 15.2 ng/ml at 12 yr to 8.1 ng/ml at 16 yr, respectively. These observations indicate that the fall in SHBG levels during the second decade of life occurs irrespective of androgen activity and is under the control of other unidentified influences.

Plasma sex hormone-binding globulin and androgen levels in the management of hirsute patients.

Hirsutism in women is a manifestation of excessive androgen action. This may be due to excessive exposure, or to increased sensitivity, of peripheral tissues to androgens. The present study was undertaken to estimate the percentage of hirsute patients with hyperandrogenaemia and to examine the effect of correction of hyperandrogenaemia on the clinical presentation. Plasma testosterone, dihydrotestosterone, sex hormone-binding globulin (SHBG) and androstenedione were determined in 58 hirsute patients before and following 3 months therapy with dexamethasone, 0.5 mg nocte. Testosterone expressed as a function of SHBG (testosterone/SHBG) provides an index of the non-protein bound testosterone fraction. Plasma levels of androstenedione were significantly elevated in 28% of hirsute patients, testosterone in 31% and testosterone/SHBG was elevated in 52%. Five per cent of patients had an elevated androstenedione value together with a normal testosterone/SHBG value. A subgroup of 13 hirsute patients with oligomenorrhoea had significantly higher values for androstenedione and testosterone/SHBG than eumenorrhoeic hirsute patients, and plasma testosterone, androstenedione and testosterone/SHBG values were more frequently elevated. In hirsute patients dexamethasone therapy resulted in suppression of plasma testosterone and androstenedione values, a significant increase in plasma SHBG and a marked fall in testosterone/SHBG. Following treatment with dexamethasone hyperandrogenaemia was corrected in 64% of hirsute patients, a decrease in the rate of hair growth or a resumption of a normal menstrual pattern occurred in 70% and concordant hormonal and clinical changes occurred in 79% of patients. These observations indicate that the testosterone/SHBG ratio is a sensitive index of hyperandrogenaemia, the correction of which is associated with clinical improvement.

Adrenal abnormalities in idiopathic hirsutism.

The possibility that abnormal adrenal androgen production may be present in patients with idiopathic hirsutism was examined. Plasma testosterone, dihydrotestosterone and androstenedione levels were elevated in hirsute patients. In response to exogenous alpha 1-24 ACTH the increments in plasma androstenedione, dehydroepiandrosterone (DHA) and cortisol were significantly greater in hirsute patients than in normal subjects. The testosterone response was exaggerated following endogenous stimulation induced by metyrapone. Treatment with dexamethasone, 0.5 mg each night for 3 months, corrected both the androgen excess and the exaggerated androgen responses but not the excessive cortisol response to stimulation. These observations indicate adrenal abnormalities in idiopathic hirsutism. The dissociation of cortisol and adrenal androgen responsiveness following dexamethasone suggests that the abnormalities observed may be due to excessive adrenal androgen production stimulated by a dexamethasone-suppressible factor other than ACTH. Excess adrenal androgen production may be the primary disorder leading to the development of idiopathic hirsutism.