Hiperprolactinemia funcional idiopática en el varón. Efecto de la hiperprolactinemia en la función sexual a propósito de un caso con 29 años de seguimiento / Functional idiopathic hyperprolactinemia in males. Effect of hyperprolactinemia in sexual functioning: Case report with 29 years of follow-up

La hiperprolactinemia tumoral o no tumoral determina daño gonadal y sexual. Presentamos el caso de un varón con hiperprolactinemia idiopática confirmada por 29 a˜nos de seguimiento con permanente imagen hipofisaria normal, excluyendo otras enfermedades. La disfunción sexual se inició con deseo sexual hipoactivo, posteriormente disfunción eréctil central, manteniéndose la erección reflexogénica, que se perdió después de hiperprolactinemia prolongada. Bromocriptina normalizó la hiperprolactinemia, persistiendo el hipogonadismo; la administración de clomifeno corrigió la hipotestosteronemia y la disfunción sexual, situación mantenida al suspender dicho fármaco. Se recae al suspender bromocriptina por intolerancia. Cabergolina logra la normoprolactinemia, persistiendo la hipotestosteronemia sin respuesta a clomifeno, por lo que se indicó una terapia de reemplazo androgénico. Se suspendió cabergolina, lo que reanudó la hiperprolactinemia y la disfunción sexual, a pesar de la terapia con testosterona. Reinició cabergolina más testosterona, lográndose normoprolactinemia, normotestosteronemia y vida sexual normal. Este prolongado seguimiento de un paciente con hiperprolactinemia idiopática enfatiza el rol inhibitorio de prolactina en el deseo sexual hipoactivo y la disfunción eréctil, y el daño progresivo de la respuesta sexual y del eje hipotálamo-hipófisis testicular (AU)

Tumoral and non-tumoral male hyperprolactinemia cause gonadal and sexual damage. We present a man with idiopathic hyperprolactinemia and hypogonadotropic hypogonadism confirmed throughout the 29 years of follow-up, with permanent normal pituitary image. Other etiologies for hyperprolactinemia were excluded. Sexual dysfunction first began with hypoactive sexual desire and later central erectile dysfunction. Reflexogenic erection was normal, but was lost after chronic hyperprolactinemia. Bromocriptine normalized hyperprolactinemia, but hypogonadotropic hypogonadism persisted. Clomiphene administration improved hypogonadotropic hypogonadism and sexual dysfunction. Bromocriptine and clomiphene were mantained for 2 years. Clomiphene withdrawal did not cause a relapse. After bromocriptine withdrawal due to intolerance, a relapse of hyperprolactinemia and sexual dysfunction occurred. Cabergoline administration normalized hyperprolactinemia, but hypogonadotropic hypogonadism persisted. Testosterone replacement therapy was indicated because of the negative clomiphene response. Cabergoline withdrawal caused hyperprolactinemia and sexual dysfunction despite testosterone therapy. Cabergoline plus testosterone produce normal prolactin, testosterone and sexual function. This case of idiopathic hyperprolactinemia emphasizes the inhibitory role of prolactin in hypoactive sexual desire, erectile dysfunction and gonadal function (AU)

[Etiological study of gynecomastia: results of a prospective study and recommendations]. / Etiología de la ginecomastía: Importancia de no subdiagnosticar una ginecomastia patológica.

BACKGROUND: Gynecomastia can be physiological or pathological. A limited study of gynecomastia is recommended during puberty and in the elderly, ages in which gynecomastia is usually considered physiological. Other authors suggest that this condition should be studied when it is painful, rapidly growing, of recent onset, when its diameter is more than 4 cm and when is associated to testicular masses. AIM: To investigate the causes of gynecomastia and to evaluate the above mentioned criteria to exclude pathological conditions. MATERIAL AND METHODS: Prospective study of 117 patients aged 10 to 83 years, consulting for gynecomastia. All were subjected to a standardized study including a clinical examination and measurement of plasma estradiol and testosterone levels. RESULTS: Forty one percent of gynecomastias were considered pathological and the rest, physiological. Among pathological conditions, 18 patients had an endocrine etiology (hypogonadism in ten patients, estrogen secreting tumors in three, hyperestrogenism of unknown etiology in four and peripheral resistance to androgens in one), in 17 it was secondary to medications and in 13 it was secondary to other causes (idiopathic, pesticide exposure, alcoholism, diabetes or re feeding). In 79% of 86 patients of less than 20 years, the condition was physiological and in four of five elderly subjects, it was pathological. Thirty nine percent of pathological gynecomastias lacked the signs and symptoms that according to authors, should prompt a thorough study. CONCLUSIONS: All patients with gynecomastia should be studied with a complete medical history and the measurement of estradiol and testosterone levels. The criteria proposed to conduct minimal studies in gynecomastia, would miss a large volume of pathological conditions.

Etiología de la ginecomastía: Importancia de no subdiagnosticar una ginecomastia patológica / Etiological study of gynecomastia: Results of a prospective study and recommendations

Background : Gynecomastia can be physiological or pathological. A limited study of gynecomastia is recommended during puberty and in the elderly, ages in which gynecomastia is usually considered physiological. Other authors suggest that this condition should be studied when it is painful, rapidly growing, of recent onset, when its diameter is more than 4 cm and when is associated to testicular masses. Aim: To investigate the causes of gynecomastia and to evaluate the above mentioned criteria to exclude pathological conditions. Material and methods: Prospective study of 117 patients aged 10 to 83 years, consulting for gynecomastia. All were subjected to a standardized study including a clinical examination and measurement of plasma estradiol and testosterone levels. Results: Forty one percent of gynecomastias were considered pathological and the rest, physiological. Among pathological conditions, 18 patients had an endocrine etiology (hypogonadism in ten patients, estrogen secreting tumors in three, hyperestrogenism of unknown etiology in four and peripheral resistance to androgens in one), in 17 it was secondary to medications and in 13 it was secondary to other causes (idiopathic, pesticide exposure, alcoholism, diabetes or re feeding). In 79 percent of 86 patients of less than 20 years, the condition was physiological and in four of five elderly subjects, it was pathological. Thirty nine percent of pathological gynecomastias lacked the signs and symptoms that according to authors, should prompt a thorough study. Conclusions: All patients with gynecomastia should be studied with a complete medical history and the measurement of estradiol and testosterone levels. The criteria proposed to conduct minimal studies in gynecomastia, would miss a large volume of pathological conditions.

[Effectiveness of flutamide alone or combined with oral contraceptives in the treatment of hirsutism in women]. / Eficacia de la flutamida en el tratamiento del hirsutismo. Contribución del uso combinado con anticonceptivos orales en mujeres normoandrogénicas.

BACKGROUND: Flutamide is an antiandrogen devoid of other hormonal effects, except for a decrease in the secretion of adrenal androgens such as dehydroepidandrosterone sulphate (DHEA-s) and androstenedione. AIM: To assess the effectiveness of flutamide in the treatment of hirsutism, used as monotherapy or combined with oral contraceptives (OC). PATIENTS AND METHODS: Women with peripheral hirsutism (defined as the presence of normal serum androgen levels and normal ovulatory menstrual cycles) were assigned to receive flutamide alone (500 mg/day) or flutamide plus an OC (ethynylestradiol 0.03 mg and desogestrel 150 microg). Hirsute with hyperandrogenism (polycystic ovary syndrome) were assigned to receive flutamide plus an OC. The degree of hirsutism was assessed using a clinical score (Moncada) at three, six and twelve months of therapy. RESULTS: Twenty five women with peripheral hirsutism received flutamide alone and 18 receive flutamide plus the contraceptive. Eighteen women with polycystic ovary syndrome were studied. At three months, the reduction in hirsutism was 11.2, 15.9 and 24.7% in women with peripheral hirsutism receiving flutamide alone or flutamide plus OC and in hyperandrogenic women receiving flutamide plus OC, respectively. At twelve months, the figures were 57.2, 57.3 and 52.5% respectively. In hyperandrogenic women, at baseline and three months, serum testosterone levels were 0.96 and 0.42 ng/nl and serum DHEA-s levels were 2,980 and 1,490 ng/ml respectively. No collateral effects of treatment or elevations in serum transaminase levels were observed. CONCLUSIONS: Flutamide is effective in the treatment of hirsutism in women with normal or elevated androgen levels. Adding OC did not improve the efficacy of the drug.

[Favorable reproductive and menstrual evolution in adult women, who presented in the adolescence, menstrual disturbances by hypothalamic dysfunction and lack of response to clomiphene]. / Evolución menstrual y reproductiva favorable en mujeres adultas, que presentaron en la adolescencia trastornos menstruales por disfunción hipotalámica con respuesta alterada al clomifeno.

BACKGROUND: Hypothalamic dysfunction is a cause of menstrual disturbances in women, in whom other diseases have been discarded. This condition is characterized by a failure of the GNRH pulse generation system and is associated to psychological and environmental factors. A lack of ovulatory response to the administration of clomiphene can be a sign of bad prognosis in hypothalamic dysfunction. AIM: To report the natural history of patients with hypothalamic dysfunction and a bad or deficient response to the administration of clomiphene. PATIENTS AND METHODS: Fifty patients with hypothalamic dysfunction, that consulted for menstrual disturbances at the age of 15 to 20 years old, were studied. All received clomiphene and 31 had an ovulatory response, 12 had menses without ovulation and 7 did not menstruate. Of these 19 women eleven were interviewed again about their menstrual and reproductive history, after a lapse of 9 to 17 years of loss from follow up. RESULTS: Eight of the eleven women had stressful events during adolescence (going away from family house in 3, starting university studies in 3, migration out of the natal country in one and non competitive physical activity in one). All restarted their menses and eight with active sexual life had spontaneous pregnancies, giving birth from two to five children. Ovulatory cycles were documented in women without active sexual life. CONCLUSIONS: In teenagers with hypothalamic dysfunction and menstrual disturbances, a deficient or bad response to clomiphene does not necessarily indicate a bad prognosis in terms of menses or fertility.