GnRH Stimulation Research Articles

Estradiol Priming Improves Gonadotrope Sensitivity and Pro-Inflammatory Cytokines in Obese Women.

Obesity is associated with a pro-inflammatory state and relative hypogonadotropic hypogonadism. Estrogen (E2) is a potential link between these phenomena because it exhibits negative feedback on gonadotropin secretion and also inhibits production of pro-inflammatory cytokines. We sought to examine the effect of estrogen priming on the hypothalamic-pituitary-ovarian axis in obesity. This was an interventional study at an academic center of 11 obese and 10 normal-weight (NW) women. A frequent blood-sampling study and one month of daily urinary collection were performed before and after administration of transdermal estradiol 0.1 mg/d for one entire menstrual cycle. Serum LH and FSH before and after GnRH stimulation, and urinary estrogen and progesterone metabolites were measured. E2 increased LH pulse amplitude and FSH response to GnRH (P = .048, and P < .03, respectively) in obese but not NW women. After E2 priming, ovulatory obese but not NW women had a 25% increase in luteal progesterone (P = .01). Obese women had significantly higher baseline IL-6, IL-10, TGF-β, and IL-12 compared with NW (all P < .05); these levels were reduced after E2 (-6% for IL-1β, -21% for IL-8, -5% for TGF-β, -5% for IL-12; all P < .05) in obese but not in NW women. E2 priming seems to improve hypothalamic-pituitary-ovarian axis function and systemic inflammation in ovulatory, obese women. Reducing chronic inflammation at the pituitary level may decrease the burden of obesity on fertility.

The nonsteroidal mycoestrogen zearalenone and its five metabolites suppress LH secretion from the bovine anterior pituitary cells via the estradiol receptor GPR30 in vitro

Picomolar concentrations of estradiol produce nongenomic suppression of GnRH-induced LH secretion from the anterior pituitary (AP) of cattle via G-protein–coupled receptor 30 (GPR30). Zearalenone (ZEN) is the nonsteroidal mycoestrogen produced by Fusarium fungi and has been detected in cereal grains, animal feed, and ruminant urine worldwide. Zearalenone has a prolonged blood half-life that results from enterohepatic cycling. There are five metabolites of ZEN: α-zearalanol (α-ZAL), β-zearalanol (β-ZAL), α-zearalenol (α-ZOL), β-zearalenol (β-ZOL), and zearalanone, which may persist for long periods in animals and humans after consumption of ZEN-contaminated feed. We recently reported that GPR30 bound with α-ZAL decreases cytoplasmic cAMP but not gene expression of LHα and LHβ subunits, and GPR30 bound with α-ZAL suppresses GnRH-induced LH release in bovine AP cells in vitro. We tested the hypothesis that GPR30 bound with ZEN or one of the four previously untested metabolites suppresses GnRH-induced LH release from the bovine AP cells in vitro. Anterior pituitary cells were cultured for 3 days under steroid-free conditions and were then incubated with various concentrations (0.001–10 nM) of estradiol or one of the ZEN analogs for 5 minutes before GnRH stimulation. Gonadotropin-releasing hormone–stimulated LH secretion from AP cells was inhibited by all of the test concentrations of ZEN, 0.001 to 1 nM of α-ZAL, and 0.001 to 0.1 nM of the remaining four analogs. Pretreatment for 5 minutes with a GPR30-specific antagonist, G36, inhibited estradiol- and the ZEN analog–induced suppression of LH secretion from cultured AP cells. G36 alone had no significant effect on LH secretion. The estimated order of the nongenomic inhibiting effect was ZEN, α-ZAL, zearalanone, α-ZOL, β-ZOL, and β-ZAL, which is quite different from the reported order for their genomic effects. Therefore, ZEN and all of its metabolites suppress LH secretion from the bovine AP cells via GPR30 in vitro.

GnRH Regulates Gonadotropin Gene Expression Through NADPH/Dual Oxidase-Derived Reactive Oxygen Species.

The appropriate control of synthesis and secretion of the gonadotropin hormones LH and FSH by pituitary gonadotropes is essential for the regulation of reproduction. The hypothalamic neuropeptide GnRH is the central regulator of both processes, coordinating secretion with transcription and translation of the gonadotropin hormone subunit genes. The MAPK family of second messengers is strongly induced in gonadotropes upon GnRH stimulation, and multiple pathways activate these kinases. Intracellular reactive oxygen species participate in signaling cascades that target MAPKs, but also participate in signaling events indicative of cell stress. The NADPH oxidase (NOX)/dual oxidase (DUOX) family is a major enzymatic source of intracellular reactive oxygen, and we show that GnRH stimulation of mouse primary pituitary cells and the LβT2 gonadotrope cell line elevates intracellular reactive oxygen via NOX/DUOX activity. Mouse pituitary and LβT2 cells abundantly express NOX/DUOX and cofactor mRNAs. Pharmacological inhibition of NOX/DUOX activity diminishes GnRH-stimulated activation of MAPKs, immediate-early gene expression, and gonadotropin subunit gene expression. Inhibitor studies implicate the calcium-activated DUOX family as a major, but not exclusive, participant in GnRH signaling. Knockdown of DUOX2 in LβT2 cells reduces GnRH-induced Fshb, but not Lhb mRNA levels, suggesting differential sensitivity to DUOX activity. Finally, GnRH pulse-stimulated FSH and LH secretion are suppressed by inhibition of NOX/DUOX activity. These results indicate that reactive oxygen is a potent signaling intermediate produced in response to GnRH stimulation and further suggest that reactive oxygen derived from other sources may influence the gonadotrope response to GnRH stimulation.

Leydig cell tumor in a boy with undiagnosed precocious puberty due to congenital adrenal hyperplasia

Results A 5-year-old boy presented with penis and testicular enlargement for 1 year. The past medical history had no severe vomiting or failure to thrive. His height was 120 cm (> 95th percentile). His penis was 7 cm and asymmetric testicles. Scrotal ultrasound detected his left testicle was 1.5×0.9 cm and his right testicle was 3.0 × 2.0 cm with a heterogeneous hypoechoic mass 1.8 × 2.0 cm at inferior pole with sheath thickness, clearly margin. His bone age was 14 years. His serum 17-hydroxypregnenolone and testosterone levels were elevated to 1768 ng/dl and 694.5 ng/dl, respectively. His serum hCG was below 1.2 IU/L and DHEA-S < 0.001 mcg/ml. An absent LH response after GnRH stimulation was recorded. He was diagnosed with CAH and treated with hydrocortisone. After one month of treatment, his serum 17-hydroxypregnenolone and testosterone levels decreased to 11 ng/dl and 20.75 ng/dl, respectively. Then, he underwent an open testis biopsy for further evaluating of the mass of his right testicle. Histological examination of the testicle demonstrated large, polygonal, and eosinophilic cells with round nuclei and prominent nucleoli, which are consistent findings with Leydig cell tumors. Thereafter, the child underwent radical orchiectomy of his right testicle. Conclusion Undiagnosed congenital adrenal hyperplasia can affect normal development. Universal newborn screening is recommended for congenital adrenal hyperplasia. Written informed consent was obtained from the patient for publication of this abstract and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.

The non-steroidal mycoestrogen zeranol suppresses luteinizing hormone secretion from the anterior pituitary of cattle via the estradiol receptor GPR30 in a rapid, non-genomic manner

Picomolar concentrations of estradiol produce rapid suppression of GnRH-induced luteinizing hormone (LH) secretion from the anterior pituitary (AP) of cattle via G-protein-coupled receptor 30 (GPR30). Zeranol is a strong estrogenic metabolite derived from zearalenone, a non-steroidal mycoestrogen produced by Fusarium that induces reproductive disorders in domestic animals. The hypothesis was tested that zeranol suppresses GnRH-induced LH release from the AP of cattle via GPR30 in a rapid, non-genomic manner. The AP cells (n=15) were cultured for 3 days in steroid-free conditions and then treated them with estradiol (0.001–10nM) or zeranol (0.001–100nM) for 5min before GnRH stimulation. Pre-treatment with 0.001–0.1nM estradiol suppressed GnRH-stimulated LH secretion. Pre-treatment with zeranol at concentrations of 0.001nM (P<0.01), 0.01nM (P<0.01), 0.1nM (P<0.05), and 1nM (P<0.05), but not at concentrations of 10 and 100nM, also inhibited GnRH-stimulated LH secretion from AP cells. Pre-treatment for 5min with a GPR30-specific antagonist, G36, inhibited estradiol or zeranol suppression of LH secretion from cultured AP cells. Cyclic AMP measurements and quantitative PCR analyses revealed that pre-treatment with small amounts of estradiol (P<0.05) or zeranol (P<0.01) decreased cAMP, but not gene expressions of the LHα, LHβ, or FSHβ subunits in the AP cells. Hence, zeranol may suppress luteinizing hormone secretion from the AP of cattle via GPR30 in a rapid, non-genomic manner.

Impact of BMI on gonadorelin-stimulated LH peak in premenarcheal girls with idiopathic central precocious puberty.

To clarify the impact of body mass index (BMI) on luteinizing hormone (LH) secretion in response to gonadorelin (GnRH) stimulation testing in girls diagnosed with idiopathic central precocious puberty (ICPP). Retrospective single-center cohort study was carried out in 865 confirmed ICPP girls who underwent GnRH stimulation tests. Pubertal development according to Tanner, sex hormone parameters, and LH secretion in response to GnRH-stimulation was compared. Around 609 girls were of normal weight (70.4%), while 168 children (19.4%) were overweight, and 88 (10.2%) were obese. Peak LH levels after GnRH were much higher in the normal-weight group, with a median of 9.1 mIU ml(-1) (interquartile 5.2-13.1), compared with the median peak LH in the overweight and obese groups (8.5 mIU ml(-1), interquartile 5.3-11.6, and 6.2 mIU ml(-1), interquartile 5.3-11.0, respectively P < 0.001 for all comparisons). Peak LH/FSH ratio was also lower in the obese group (median 0.6, interquartile 0.68-0.90) compared with the normal-weight (median 0.8, interquartile 0.61-1.11) and overweight (median 0.8, interquartile 0.64-0.92) groups. Higher BMI is associated with lower LH response to GnRH-stimulation testing in girls with ICPP. It is recommended that BMI should be considered when interpreting GnRH-stimulation tests.

Rapid communication: A microRNA-132/212 pathway mediates GnRH activation of FSH expression.

GnRH plays a key role in the vertebrate reproductive system by stimulating biosynthesis and secretion of pituitary gonadotropins. However, the potential involvement of microRNAs (miRNAs) on this activation has still to be explored. In this study, we investigated the role of miRNA-132 and miRNA-212, two tandemly expressed miRNAs that target the same transcripts, on GnRH-induced FSH expression. We first showed that the GnRH stimulation of FSH secretion was reduced and Fshb mRNA abolished by blocking miR-132/212 action in rat pituitary cells. In mouse LβT2 gonadotrope cells, the GnRH stimulation of Fshb mRNA was also demonstrated to be dependent on miR-132/212 and reproduced by overexpressing one or both miRNAs. We then showed that the miR-132/212-mediated action of GnRH involved a posttranscriptional decrease of sirtuin 1 (SIRT1) deacetylase. The lower level of SIRT1 deacetylase correlated with an increase in the acetylated form of Forkhead Box O1 (FOXO1), a transcriptional repressor of Fshb. Interestingly, we show that the acetylated mimicking mutant of FOXO1 was localized outside the nucleus, thus alleviating its repressive effect on Fshb transcription. Overall, we demonstrate that the GnRH stimulation of Fshb expression is dependent on miR-132/212 and involves a SIRT1-FOXO1 pathway. This is the first demonstration of an obligatory microRNA pathway in the GnRH-regulated expression of a gonadotropin gene.

A new role for wilms tumor protein 1: differential activities of + KTS and -KTS variants to regulate LHβ transcription.

Luteinizing hormone (LH) is synthesized and secreted throughout the reproductive cycle from gonadotrope cells in the anterior pituitary, and is required for steroidogenesis and ovulation. LH contains an α-subunit common with FSH, and a unique LHβ subunit that defines biological activity. Basal LHβ transcription is low and stimulated by hypothalamic GnRH, which induces synthesis of early growth response protein-1 (Egr1), and stimulates binding of transcription factors Egr1 and steroidogenic factor-1 (SF1) on the promoter. WT1 (Wilms tumor protein1) is a zinc finger transcription factor with an essential role in urogenital system development, and which regulates several reproductive genes via interactions with SF1 or binding to GC-rich elements such as Egr1 binding sites. We investigated a potential role for WT1 in LHβ transcription in clonal mouse gonadotrope LβT2 cells. WT1 was present in LβT2 and mouse pituitary cells, and protein bound to the endogenous LHβ promoter. Interestingly, mRNAs for WT1(+KTS), which contains a three amino-acid insertion between the 3rd and 4th zinc fingers, and the WT1 (-KTS) variant were both expressed at significant levels. WT1 mRNAs and protein were decreased approximately 50% by GnRH treatment, under conditions where Egr1 mRNA and protein, and LHβ transcription, were stimulated. Decreasing expression of mRNA for WT1 (-KTS) decreased stimulation of LHβ and Egr1 by GnRH, whereas decreasing both WT1 (-KTS) and (+KTS) increased endogenous LHβ transcription, and prevented LHβ but not Egr1 stimulation by GnRH, suggesting differing biological activities for the WT1 isoforms. Overexpression of WT1 showed that WT1(-KTS) enhanced LHβ promoter GnRH stimulation 2-to-3-fold and required the 3’Egr1 site, but WT1(+KTS) repressed both basal and GnRH-stimulated LHβ promoter activity by approximately 70%. Our data suggest that WT1 can modulate LHβ transcription, with differential roles for the two WT1 variants; WT1 (-KTS) enhances and WT1 (+KTS) suppresses transcription.

Gonadotropin releasing hormone analog treatment in children with congenital adrenal hyperplasia complicated by central precocious puberty.

Congenital adrenal hyperplasia (CAH) can be complicated by central precocious puberty (CPP) in children, which may compromise final height. We aimed to evaluate the effect of gonadotropin-releasing hormone analog (GnRHa) therapy on growth in children with CAH. Twelve children with CAH were enrolled in a follow-up study. Eight patients underwent the GnRH stimulation test. GnRHa-treatment was administered at 3.75 mg every 4 weeks; the dose had to be increased to 7.5 mg in three patients. Bone age, growth velocities and body mass index of the patients were monitored during treatment. Median chronologic age and bone age at diagnosis were 6.8 (3.5) years and 11 (1.2) years, respectively. Median follow-up was 4.4 (4.9) years. A significant difference was found in the median ratio of bone age to chronological age between diagnosis and last visit (p=0.005) and between the beginning of GnRHa treatment and last visit (p=0.004). Median growth velocity was 4 (2.5) cm, 3.4 (5.2) cm and 5.5 (5.5) cm at the end of the first, second and third years of the therapy, respectively. Second-year growth velocity was inversely correlated with median bone age at diagnosis (rho:-0.758, p=0.004) and at the initiation of therapy (rho:-0.876, p<0.001). GnRHa therapy should be considered for augmentation of linear growth and diminishment of bone age advancement in children with CAH complicated by CPP, particularly in children who do not have extremely advanced bone age for chronological age.

In vivo oestrogenic modulation of Egr1 and Pitx1 gene expression in female rat pituitary gland.

EGR1 and PITX1 are transcription factors required for gonadotroph cell Lhb promoter activation. To determine changes in Egr1 and Pitx1 mRNA levels in central and peripheral pituitary stimulations, an in vivo model based on i.c.v. pulsatile (1 pulse/0.5 h over 2 h) GnRH agonist (1.5 nM buserelin) or antagonist (2 nM antide) microinjections was used. The microinjections were given to ovariectomised and 17β-oestradiol (E2) (3×20 μg), ERA (ESR1) agonist propyl pyrazole triol (PPT) (3×0.5 mg), ERB (ESR2) agonist diarylpropionitrile (DPN) (3×0.5 mg) s.c. pre-treated rats 30 min after last pulse anterior pituitaries were excised. Relative mRNA expression was determined by quantitative RT-PCR (qRT-PCR). Results revealed a gene-specific response for GnRH and/or oestrogenic stimulations in vivo. Buserelin pulses enhanced Egr1 expression by 66% in ovariectomised rats, whereas the oestradiol-supplemented+i.c.v. NaCl-microinjected group showed a 50% increase in Egr1 mRNA expression. The oestrogenic signal was transmitted via ERA (ESR1) and ERB (ESR2) activation as administration of PPT and DPN resulted in 97 and 62%, respectively, elevation in Egr1 mRNA expression. A synergistic action of GnRH agonist and 17β-oestradiol (E2) stimulation of the Egr1 gene transcription in vivo were found. GnRHR activity did not affect Pitx1 mRNA expression; regardless of NaCl, buserelin or antide i.c.v. pulses, s.c. oestrogenic supplementation (with E2, PPT or DPN) consistently decreased (by -46, -48 and -41% respectively) the Pitx1 mRNA in the anterior pituitary gland. Orchestrated Egr1 and Pitx1 activities depending on specific central and peripheral regulatory inputs could be responsible for physiologically variable Lhb gene promoter activation in vivo.

Clinical value of triptorelin stimulation test in differential diagnosis of disorder due to delayed puberty: 128 cases report

Objective To evaluate the diagnostic value of triptorelin stimulation test in disorders due to delayed puberty.Methods Triptorelin stimulation test was carried out in 128 teenagers with delayed puberty,due to idiopathic hypogonadotropic hypogonadism(IHH) in 77 cases and constitutional delayed puberty(CDP) in 51.Blood samples were obtained 15 min before and 0,30,60,and 120 min after tripotorelin administration,and the levels of LH and FSH were determined.An extended GnRH stimulation test was carried out in 3 patients with IHH.Results Peak LH,peak FSH,and LH increment were parameters with high diagnostic value.A cut-off point at 8.2 IU/L of peak LH showed a sensitivity of 87％ and a specificity of 80.4％ in the differential diagnosis of IHH and CDP.Conclusion Peak LH cut-off point at 8.2 IU/L of triptorelin stimulation test seems to be sufficient to confirm diagnosis of IHH and CDP.An extended GnRH stimulation test may distinguish hypothalamic from the pituitary hypogonadotropic hypogonadism. Key words: Idiopathic hypogonadotropic hypogonadism; Constitutional delayed puberty; Triptorelin stimulation test ; LH

The gonadotroph natriuretic peptide system is sensitive to pulsatile GnRH stimulation: insights into CNP/GC-B signalling in gonadotroph function

The gonadotroph natriuretic peptide system is sensitive to pulsatile GnRH stimulation: insights into CNP/GC-B signalling in gonadotroph function

The diagnostic value of first-voided urinary LH compared with GNRH-stimulated gonadotropins in differentiating slowly progressive from rapidly progressive precocious puberty in girls

Characterization of pubertal progression is required to prevent unnecessary intervention in unsustained or slowly progressive (SP) precocious puberty (PP), while delivering hormonal suppression in rapidly progressive (RP) PP. We aimed to assess the diagnostic value of first-voided urinary LH (ULH) compared with GNRH-stimulated gonadotropins in differentiating these forms of PP. A total of 62 girls with PP underwent both GNRH stimulation and ULH assay. Fifteen girls with peak LH ≥ 10 IU/L started treatment immediately, whereas the other 47 girls were evaluated after 6 months for pubertal advancement, height acceleration, and bone-age maturation. Based on these criteria, the participants were assigned to five subgroups: pubertal regression, no progression or progression by one, two or three criteria. The first three subgroups were defined as SP-PP (n=29), while the other two subgroups were defined as RP-PP (n=18). An additional 23 prepubertal girls were evaluated for ULH. ULH but not serum gonadotropins could distinguish girls with two and three criteria from less progressive subgroups. By comparison with SP-PP (i.e. regression group and groups 0 and 1), those with RP-PP (group 2+3) had lower peak FSH (9.28±2.51 vs 12.57±4.30; P=0.007) and higher peak LH:FSH ratio (0.42±0.30 vs 0.22±0.12; P=0.022) and ULH (1.63±0.65 vs 1.05±0.26 IU/l; P<0.001). Based on receiver operating characteristics analysis, a ULH cutoff of 1.16 IU/l had a better sensitivity (83%) and positive and negative predictive values (65 and 88% respectively) than the other two parameters, with a specificity of 72%. ULH assay is a noninvasive, reliable method that can assist in the distinction between SP- and RP-PP.

The correlation between GnRH stimulation testing and obstetric ultrasonographic parameters in precocious puberty.

The aim of this study was to determine reliable cut-off levels of basal gonadotropin and to assess the correlation of obstetric ultrasound parameters with the GnRH stimulation test. The GnRH stimulation test was performed in a cohort of young female patients who presented at our hospital for the evaluation of early signs of puberty. Using receiver operating curves (ROCs), the sensitivity and specificity of basal luteinising hormone (LH), follicle stimulating hormone (FSH), basal and stimulated LH/FSH ratio, oestradiol levels and ultrasonographic parameters were evaluated at each level, and the area under curve (AUC) was measured. One hundred female children were assessed. We found that LH levels, peak LH/FSH ratio, fundal/cervical ratio, uterus length, and ovarian volume were reliable predictors of central precocious puberty (CPP). Cut-off levels of basal LH and the peak LH/FSH ratio had high specificity in our cohort. In addition, obstetric ultrasound parameters represent reliable predictors for the diagnosis of CPP.

Precocious puberty in children.

To determine the etiology of precocious puberty in children and to compare the clinical and laboratory parameters of central and peripheral precocious puberty. Cross-sectional study. Endocrine Clinic at National Institute of Child Health, Karachi, from January 2009 to December 2011. Children presenting with precocious puberty were included. The age of onset of puberty was documented. Clinical evaluation, Tanner staging, height, height SDS, weight, weight SDS, body mass index, bone age, pelvic USG, plasma estradiol level and GnRH stimulation were done. Ultrasound of adrenal glands, serum level of 17 hydroxyprogesterone, ACTH, Renin, aldosterone and testosterone were performed in children with peripheral precocious puberty. MRI of adrenal glands and gonads was done in patients with suspected tumor of that organ and MRI of brain was done in patients with central precocious puberty. Skeletal survey was done in patients with Mc Cune-Albright syndrome. CAH (81.8%) indentified as a main cause in peripheral percocious puberty and idiopathic (67.74%) in central precocious puberty. Eighty five patients were registered during this period. The conditions causing precocious puberty were central precocious puberty (36.47%), peripheral precocious puberty (38.82%), premature pubarche (10.58%) and premature thelarche (14.11%). There was a difference in the age of onset of puberty in case of central precocious puberty (mean=3, 2-6 years) versus peripheral precocious puberty (mean=5.25; 3.62 - 7.0 years). Children with central precocious puberty showed higher height SDS, weight SDS, FSH, LH than those with peripheral precocious puberty. Etiology in majority of cases with peripheral precocious puberty was congenital adrenal hyperplasia and idiopathic in central precocious puberty. Central precocious puberty children showed higher height SDS, weight SDS, FSH, LH than peripheral precocious puberty.

Three cases of pediatric patients with testicular microlithiasis showing gynecomastia and testicular enlargement

Results Case 1) A 9.4-year-old boy presented with bilateral testicular enlargement accompanied by other pubertal signs. His bone age was 11 years and serum levels of LH and FSH after GnRH stimulation were within pubertal limits. Scrotal ultrasonography (US) showed TM in both testes. He revealed early puberty and no malignant evolution. Case 2) A 9.4-year-old boy with Down syndrome presented with bilateral testicular enlargement and accelerated growth velocity. His bone age was 11 years and serum levels of LH and FSH after GnRH stimulation were within pubertal limits. He had TM at US in both testes. He underwent right orchiopexy. He also revealed early puberty and no malignant change. Case 3) A 11year-old boy complained of gynecomastia without other findings of puberty. His bone age was 11 years. He also had TM at US in both testes. No focal testicular lesion or malignancy developed during the review period. Conclusions Our report underline the usefulness of scrotal US for finding an occult TM in a patient with gynecomastia without other findings of puberty. In addition, TM may be predictive factor for early puberty evolution, but a large number of patients with a longer follow-up period may be needed to accurately discern the possible association between TM and precocious puberty.

A pilot study on children with bone-age advancement without early sexual maturation; auxological and laboratory (GNRH stimulation) characteristics

Social concern over precocious puberty (PP) is rising nowadays, and there is actually increased visit to hospital due to PP. Among them children with no pubertal sign showing advanced bone-age (BA) have been found in many cases. This study was done to see clinical and laboratory characteristics in these children with so called 'asymptomatic PP'. Among children whom visited for evaluation of early sexual maturation between July 2007 and June 2009, children with advanced BA more than 1 yr without any pubertal sign were enrolled. Their clinical, laboratory data including GnRH stimulation test and auxological data were analyzed retrospectively. Thirty-eight children with asympomatic PP were enrolled. Male:female ratio was 1:1. Chronological ages (CA) were 9.3±1.1 yrs in boys, 8.1±1.4 yrs, in girls. BA were 11.3±0.9 yrs in boys, 9.8±1.4 yrs in girls. Positive result (peak LH>5 IU/L) of GnRH stimulation test was found in 18 out of 38 children (47.4%) -18 boys (69%) and 8 girls (31%). Patients were divided into 2 groups (positive and negativ e group) based on GnRH stimulation test. Basal LH value of positive group was significantly higher than negative group in boys (0.4±0.5 vs 0.1±0.1 IU/L, respectively, p<0.05) and girls (1.0±1.7 vs 0.1±0.0 IU/L, respectively, p<0.05). However, there were no significant differences between groups in height, chronological age, progression of BA, BMI. Children with BA advancement without secondary sexual characteristics was found. Their clinical course is unknown yet. Further study is necessary to confirm chracteristics of BA advancement without early sexual maturation, so-called 'asymptomatic PP'.

Precocious puberty in children

To determine the etiology of precocious puberty in children and to compare the clinical and laboratory parameters of central and peripheral precocious puberty.Cross-sectional study.Endocrine Clinic at National Institute of Child Health, Karachi, from January 2009 to December 2011.Children presenting with precocious puberty were included. The age of onset of puberty was documented. Clinical evaluation, Tanner staging, height, height SDS, weight, weight SDS, body mass index, bone age, pelvic USG, plasma estradiol level and GnRH stimulation were done. Ultrasound of adrenal glands, serum level of 17 hydroxyprogesterone, ACTH, Renin, aldosterone and testosterone were performed in children with peripheral precocious puberty. MRI of adrenal glands and gonads was done in patients with suspected tumor of that organ and MRI of brain was done in patients with central precocious puberty. Skeletal survey was done in patients with Mc Cune-Albright syndrome.CAH (81.8%) indentified as a main cause in peripheral percocious puberty and idiopathic (67.74%) in central precocious puberty. Eighty five patients were registered during this period. The conditions causing precocious puberty were central precocious puberty (36.47%), peripheral precocious puberty (38.82%), premature pubarche (10.58%) and premature thelarche (14.11%). There was a difference in the age of onset of puberty in case of central precocious puberty (mean=3, 2-6 years) versus peripheral precocious puberty (mean=5.25; 3.62 - 7.0 years). Children with central precocious puberty showed higher height SDS, weight SDS, FSH, LH than those with peripheral precocious puberty.Etiology in majority of cases with peripheral precocious puberty was congenital adrenal hyperplasia and idiopathic in central precocious puberty. Central precocious puberty children showed higher height SDS, weight SDS, FSH, LH than peripheral precocious puberty.

Uterus-like mass of the broad ligament

function and for preserving fertility. Imagingmayhelp to establish timely diagnosis. In most cases of concomitant bilateral adnexal torsion, cystic tumors in adnexa/ovaries were identified preoperatively by ultrasound or computed tomography [1–3]. However, diminished Doppler flows were noted only in 1 case [1]. In the past, removalwithout untwisting of ischemicor gangrenouslooking ovaries to prevent thromboembolism or housing of malignancies was advocated. Because the clinical significance of embolism is questionable and the risk of malignancy is low (b2%), conservation is the accepted management in pediatric ovarian torsion. Two months after detorsion, follicles can been found inmore than 90% of patients, indicating ovarian viability after temporary ischemia [4]. The patient in the reported case presented postoperatively with signs of precocious puberty. Bilaterally enlarged, cystic ovaries combined with premature breast enlargement without hormonal changes are indicative of an autonomous ovarian cyst rather than endocrine ovarian activity as seen in secreting ovarian tumors (typically unilateral) or central precocious puberty (maturation of the entire hypothalamic–pituitary–gonadal axis) with the full spectrum of physical and hormonal changes of puberty. Autonomous ovarian cysts are found in 5% of girls with ovarian cysts, causing isosexual precocious pseudopuberty in some cases. Patients present with signs of estrogenization (bilateral breast development, vaginal discharge/bleeding, swelling of the labia minora), with elevated estrogen levels and suppressed gonadotropin response to GnRH stimulation. Bone age is rarely advanced. As in the present case, these findings depend on the stage of the disease. Autonomous ovarian cysts develop and regress spontaneously after 2–3 months, while clinical signs of precocity may still be present after hormone levels have normalized and the cysts are no longer detectable. The entity is self-limiting and requires mostly no treatment. However, prolonged exposure to estrogen may lead tomaturation of the GnRHpulse generator, resulting in central precocious puberty (so-called combined precocious puberty), and may require GnRH therapy to prevent loss of height potential.

Precocious pseudopuberty due to an autonomous ovarian follicular cyst: case report with a review of literatures

BackgroundSmall follicular cysts are commonly found in the ovaries of prepubertal girls, and in most cases, they are of no clinical importance. These cysts are usually self-limiting and resolve spontaneously. However, occasionally, these cysts may enlarge and continue to produce estrogen, resulting in signs of sexual precocity. Here, we report a case of precocious pseudopuberty associated with an autonomous ovarian follicular cyst.Case presentationA 5.9-year-old girl initially presented to a local clinic with vaginal bleeding and a large unilateral ovarian cyst. At 6 months after the initial acute episode, the patient visited our hospital as the ovarian cyst had persisted and increased in size. Endocrinological examination showed elevated estrogen levels and suppressed gonadotropin levels on GnRH stimulation test. Also, no skin pigmentation or bone anomaly was noted. Based on these observations, laparoscopic cystectomy was performed, and histologic analysis confirmed the diagnosis of a follicular cyst. After the laparoscopic cystectomy, the patient’s hormone levels returned to normal and no ovarian cyst was detected by ultrasound.ConclusionsAs autonomous ovarian cysts are usually self-limiting disorder, no treatment is necessary. Therefore, surgical management should be deferred as long as possible to avoid the risk of repeat surgery, as pseudoprecocious puberty due to autonomous ovarian cysts can resolve spontaneoulsy and frequently recurs. Precocious pseudopuberty with an ovarian cyst may be due to granulosa cell tumor or may be one symptom of the McCune-Albright Syndrome (MAS). A careful longer-term follow up of patients with autonomous ovarian cysts and/or molecular studies may be necessary in such cases.