Low LH Research Articles

MON-474 Coexistence of Thyroid Dysgenesis and Premature Ovarian Failure: A Case Report

Background. Congenital hypothyroidism (CH) secondary to thyroid dysgenesis is rare. It may present with ascites and short stature. Primary ovarian failure (POF) is most commonly associated with autoimmune thyroid diseases1. However, there is no report of the association of POF with congenital hypothyroidism. Clinical case. A 30 year old female presented with increasing abdominal girth, short stature and arrest of menstruation at 27 years old. Newborn screening was not done. Developmental milestones were at par. She had a low timber voice and was slow to respond. Her skin was rough and dry. Her hair was sparse, and she had thin eyebrows. Her tongue was not enlarged. Her abdomen was globular with a positive fluid wave test and shifting dullness. Initial tests indicated a hypothyroid state: elevated TSH (50.40 IU/mL, N=0.35-4.94 IU/mL), low FT4 (0 pmol/L, N=12-22 pmol/L). Ultrasound of the thyroid suggests thyroid dysgenesis (small right thyroid gland measuring 1.4 x 0.2 x 0.4 cm and an absent left thyroid gland). Karyotyping was 46, XX and insulin growth factor 1 was normal. Unexpectedly, further tests were consistent with a concomitant primary ovarian failure: low estradiol (5 pg/mL, N=12.4-233 pg/mL), high FSH (112.7 mIU/mL, N=3.5-12.5 mIU/mL) and LH (61.9 mIU/mL, N = 2.4-12.6 mIU/mL). Chest radiography showed left pleural effusion. Abdominal CT scan showed marked ascites with normal reproductive organs. Anti-TPO antibodies were normal (4.87 IU/mL, N=0-25 IU/mL). The patient was treated with Levothyroxine 50 mcg daily then gradually increased to 100 mcg daily. She was given Spironolactone 50 mg daily and paracentesis was also done to address ascites. The patient had improvement of symptoms after a month of treatment. However, the etiology of POF remains to be further elucidated. Conclusion. This case report emphasizes the importance of the early detection of congenital hypothyroidism through newborn screening. Severe hypothyroidism is rarely seen due to the wide availability of the TSH assay and its diagnosis should instigate further work-up for its etiology. Concomitant premature ovarian failure in the absence of an autoimmune thyroid disorder should prompt further investigation for another etiology since premature ovarian failure is not commonly associated with congenital hypothyroidism. Reference: (1) Ayesha, Jha V, Goswami D. Premature Ovarian Failure: An Association with Autoimmune Diseases. J Clin Diagn Res. 2016;10(10):QC10-QC12.

SAT-279 Crooke’s Cell Adenoma- an Aggressive Form of Cushing’s Disease

Introduction: Cushing’s disease is a condition of cortisol overproduction caused by an ACTH-producing tumor. Corticotroph cells surrounding an ACTH-producing tumor usually undergo Crooke’s hyaline change, where cytokeratin filaments accumulate in the cytoplasm in response to glucocorticoid excess. These changes are thought to be a mechanism of feedback inhibition and thus facilitate a suppression of ACTH. However, in a subtype of ACTH-secreting tumors known as Crooke’s cell adenomas (CCA), the ACTH-producing cells also undergo these hyaline changes. This would be expected to suppress hormone secretion but these cells are still able to release significant amounts of ACTH. Case presentation: A 32-year-old woman presented to the hospital after an episode of syncope. On head MRI, she was found to have a 2 cm sellar mass with optic chiasm compression. Labs showed low TSH, free FT4, T3, FSH, and LH. She was also pre-diabetic with an HgbA1c of 6.2%. Her baseline cortisol of 20.6 µg/dL did not suppress after 1 mg of dexamethasone. After receiving 4 mg of dexamethasone, her cortisol suppressed to 5.2 µg/dL. She was diagnosed with hypopituitarism except for cortisol and a likely ACTH-producing pituitary macroadenoma. She completed a transsphenoidal pituitary resection and pathology revealed Crooke’s hyaline changes with immunohistochemical stains positive for ACTH. The immunostain for the proliferation marker Ki67 showed a relatively low proliferation index. Her course was complicated by diabetes insipidus. She was ultimately discharged on 20 mg hydrocortisone each morning, 10 mg hydrocortisone each afternoon, desmopressin 0.05 µg daily, and levothyroxine 125 µg daily. Two weeks later, the patient was sent to the emergency room by her endocrinologist for hyperglycemia up to 288 mg/dL. She was also found to be newly diabetic with an HgbA1c of 6.5%. A fasting morning cortisol was collected during her admission and showed a cortisol level of <1.0 µg/dL, proving she was cured of Cushing’s disease. However, she will need close endocrinology follow up and MRI imaging of her pituitary for this aggressive type of pituitary adenoma. Discussion: We have come across an interesting case of a young woman who presented for syncope and was found to have a pituitary macroadenoma with pathology consistent with CCA. This type of ACTH-producing tumor is known for aggressive patterns including high rates of recurrence with rates of up to 60% reported in literature, persistent disease after surgery, malignant transformation, and metastases. Despite presentation and symptoms similar to those of other ACTH-producing adenomas, the dangerous pattern of Crooke’s cell adenomas necessitate long-term follow-up in affected patients.

SAT-LB54 Acute Sterile Meningitis as a Primary Manifestation of Pituitary Apoplexy

Background: Pituitary apoplexy (PA) is a rare endocrinopathy that requires prompt diagnosis and treatment. Presentation with acute neutrophilic meningitis is uncommon.Clinical Case: A 67-year-old man presented to our hospital with a 2-week history of worsening bilateral frontal headache, nausea, and dry heaving. On admission, the patient was somnolent with a score of 13 on the GCS assessment (E2, V5, M6). The neurological exam was overall normal with normal ocular motion and intact cranial nerves, except for a left eye peripheral vision defect. Plain head CT revealed a well-circumscribed ovoid pituitary mass with suprasellar enlargement, consistent with a pituitary macroadenoma. Sellar MRI showed a pituitary mass, roughly 20 x 19 x 24 mm, bulging into the suprasellar cistern with optic chiasm elevation. Analysis of pituitary function revealed low ACTH concentration of 2.8 pg/mL (n = 7.2 - 63.3 pg/mL), a low random cortisol level of 1.7 ug/dL (n = 2.9 - 19.4 ug/dL), a low TSH of < 0.1 uIU/mL (n = 0.35 - 4.9 uIU/mL), a low free T4 level of 0.72 ng/dL (n = 0.77 - 1.48 ng/dL), a low LH of 0.8 IU/L (n = 1.7 - 8.6 IU/L) with a very low total testosterone level of < 3 ng/dL (n = 300 - 720 ng/dL) and normal prolactin, IGF-1 and GH levels. On hospital day 2, the patient had worsening encephalopathy with left eye ptosis and decreased vision. Repeat CT and MRI showed no interval change in the pituitary adenoma or evidence of bleeding. An immediate lumbar puncture was performed and CSF analysis revealed an increased leukocyte count of (1106/mm3) with 89% neutrophilic granulocytes, and increased total protein level of 138 mg/dL (n = 15 - 40 mg/dL), red blood cell count of 2040 without xanthochromia and glucose of 130 mg/dL (n = 40 - 70 mg/dL). Based on the laboratory results and new symptoms, empirical antibiotic (vancomycin, ceftriaxone, and ampicillin) therapy was started for suspected bacterial meningitis before the confirmation of the CSF culture study. CSF culture did not grow any organisms. Given the sudden visual impairment and neurological deterioration, the patient underwent transsphenoidal resection of the tumor with free nasal mucosal graft reconstruction. Histological examination revealed a necrotic pituitary adenoma with apoplexy and no evidence of hemorrhage. Postoperatively, his neurological exam greatly improved. His left pupil was reactive to light and the third palsy was improving.Conclusion: This case reinforces the importance of including PA in the differential diagnosis of acute headache, particularly in patients presenting with visual disturbances. Patients with PA often present with sterile meningitis due to increased debris and blood in the subarachnoid space which closely mimics acute bacterial meningitis. While MRI remains a sensitive imaging modality for the detection of PA, the latter remains a clinical diagnosis. Timely diagnosis with high clinical suspicion and treatment is essential.

Central obestatin administration affect the LH and FSH secretory activity in peripubertal sheep

Obestatin – a 23 amino acid peptide is synthesized as another product of the ghrl gene and its synthesis occurs mainly in gastric mucosa cells. This hormone is involved in complex gut-brain neurohormonal networks, thereby can participates in the modulation of gonadotrophic axis activity.The aim of this study was to investigate the consequence of intracerebroventricular infusions of obestatin on LH and FSH pituitary cells secretory activity in peripubertal female sheep. Animals were randomly divided into two groups: the control group (n = 14) received intracerebroventricular infusions of Ringer-Lock solution (120 μL h−1), and the obestatin group (n = 14) was infused with obestatin (25 μg/120 μL h−1) diluted in Ringer-Lock solution. A series of four infusions was performed on three consecutive days. Blood samples were collected on day 0 and day 3. The sheep were slaughtered immediately after the end of the experiment. For molecular biological analysis, pituitaries from 7 sheep from each group (n = 7 + 7) were prepared and frozen in liquid nitrogen immediately after collection and then stored at −80 °C until Real Time RT-qPCR and RIA analyzes. For immunohistochemical analysis, pituitary tissues from the remaining animals (n = 7 + 7) was fixed in situ for further examination.Real-Time qPCR and immunohistochemistry analyses revealed substantial changes in the LH and FSH pituitary cells secretory activity in obestatin-infused sheep. Exogenous obestatin administration reduced LHβ mRNA expression and increased the accumulation of immunoreactive LH in gonadotrophic cells of the adenohypophysis. These changes were accompanied by a decrease in the mean LH concentration in the peripheral blood resulting from the lower LH pulse amplitude. Moreover, an increase in both FSHβ mRNA expression and FSH immunoreactivity and amount in pituitary cells were noted, while mean blood FSH concentration remained unchanged after obestatin treatment.The obtained results showed that exogenous obestatin affected LH secretory activity at the level of protein synthesis, accumulation and release as well as obestatin increase FSHβ mRNA expression and accumulation of this hormone but at the same time have no effect on FSH release to blood. Thus, obestatin can participate in the neuroendocrine network, which modulates gonadotrophic axis activity in sheep.

The Effect of Recombinant LH Addition to Recombinant FSH on Assisted Reproductive Technologies Outcomes in Overweight and Obese Patients without Polycystic Ovary Syndrome

Background: Obesity and overweight negatively affect fertility. Protocols need to be developed in ART treatments for obese and overweight women. Objectives: To investigate the effect of recombinant luteinizing hormone (rLH) addition to recombinant follicle stimulating hormone (rFSH) on treatment outcomes in assisted reproductive technologies (ART) cycles in obese and overweight women without polycystic ovary syndrome. Methods: This retrospective cohort study was carried out in Kocaeli University Faculty of Medicine, Assisted Reproductive Techniques Clinic between January 2016 and March 2019. To analyze the impact of rLH addition to rFSH in GnRH antagonist cycles in overweight and obese, the patients were divided into four groups according to body mass index (BMI) and gonadotropin type; Group 1: patients with BMI ≥ 25 stimulated with rFSH alone (n: 37), Group 2: patients with BMI ≥ 25 stimulated with rFSH + rLH (n: 37), Group 3: patients with BMI between 18.5 - 24.99 stimulated with rFSH alone (n: 33), Group 4: patients with BMI between 18.5 and 24.99 stimulated with rFSH + rLH (n: 30). Patients with polycystic ovary syndrome were excluded. Results: Basal LH levels were found to be significantly lower in obese and overweight patients compared to normoweight patients (p = 0.01). Grade 1 embryo ratio in obese and overweight patients was higher in rLH added obese group than in group LH not included (64.9%, p = 0.005). Ongoing pregnancy rates (OPR) in obese and overweight patients were significantly higher in rLH added group compared to rFSH only group (43.2% vs 18.9% respectively, p = 0.044). However, OPR did not differ significantly in rLH added and rFSH only groups in normoweight patients (p = 0.588). Conclusion: This study has shown that obese and overweight non-PCOS patients have lower endogenous LH levels. It has also shown that rLH supplementation in GnRH antagonist cycles in obese and overweight women improves embryo quality and ongoing pregnancy rates. However rLH addition to rFSH doesn’t seem to have a value in normoweight patients.

280 Quality grading using color and electrical conductivity of beef

Abstract Four sources of beef were used to determine if the degree of variance in color (Hunter LH) and electrical conductivity (EC) measures correlate to quality grade. It also tested the reliability of the Varian spectrophotometer machine for color scores on beef. Source 1 (S1) samples varied in cuts that were frozen then thawed. S2 – S4 were delivered whole and cut into 16 individual, 1-inch thick samples. Source 2 (S2) was a whole boneless ribeye and choice grade; Source 3 (S3) was a whole strip loin, Wagyu breed and prime grade; Source 4 (S4) was a whole strip loin, Akaushi breed and prime grade. All color measurements (n = 48) were taken on raw samples. EC (n = 48) was measured in microsiemens (μS) for 120s with sampling rate of two measures per s. An emulsified meat slurry solution was placed into a 3in wide silicon vessel with copper electrodes attached to both sides, and placed into plastic container connected to a digital multimeter. Analysis of variance (ANOVA) was used for data analysis on color &amp; EC replications and total color &amp; EC means and performed across S1 then S2 – S4. Color results across color mean replications for individual samples were non-significant (P &amp;gt; 0.05, 95% confidence level). Source color means for S1=33.6873, S2=55.4319, S3=47.8122 &amp; S4=53.5633. S1 had the lowest LH mean compared to S2-S4 and presumed to be a result of myoglobin state. These data indicate reliability of the Varian color machine as method for scoring steaks. EC results showed prime grades S3 and S4 had lower scores compared to S1 and S2 with EC means of S1=24.8043, S2=63.5294, S3=17.0451 &amp; S4=18.9656. S3 &amp; S4 both had significant correlations (P &amp;lt; 0.05) between EC and color scores indicating EC and color correlations can be useful in quality grading of beef.

Basal Anti Mullerian hormone levels and endometrial thickness at midcycle can predict the outcome after clomiphene citrate stimulation in anovulatory women with PCOS, a retrospective study

PurposeRecent studies reported that in polycystic ovary syndrome (PCOS) patients, other stimulation agents are superior to the popular first-line regimen, clomiphene citrate (CC) for ovarian stimulation. Nonetheless, CC is still widely used since it is not clear which patients will not respond to it. Furthermore, the prognostic value of endometrium thickness at midcycle is controversial. We aimed to find factors predicting the response to CC and the prognostic value of endometrial thickness at midcycle.MethodsWe collected data retrospectively from 89 anovulatory PCOS patients who had the first stimulation with 50 mg CC. We analyzed the basal levels of AMH, testosterone, LH, LH:FSH ratio and the endometrial thickness at midcycle by univariate, followed by multivariate regression. The outcome measures were pregnancy, follicle maturation and endometrial thickness at midcycle.ResultsStimulation with 50 mg CC resulted in follicle maturation in 50.6% of the women and in 27.0% pregnancies. In the univariate analysis, greater endometrial thickness, lower LH and AMH levels and a lower LH:FSH ratio were associated with pregnancy (p < 0.05). In the multivariate analysis, only endometrial thickness remained predictive (p = 0.045). The endometrial thickness cutoff level of ≥ 8 mm showed a sensitivity of 87.5% (96% CI 67.6–97.3) and a specificity of 66.7% (95% CI 43.0–85.4) for prediction of pregnancy. In the multivariate analysis AMH levels 5.4 (3.4; 7.0) (ng/mL) predicted pregnancy (β = − 0.194 ± 0.092; p = 0.034)ConclusionWe suggest to refrain from CC as first-line regimen in patients with AMH > 7 ng/ml. Under CC treatment, the cutoff value of ≥ 8 mm endometrium thickness at midcycle is associated with a better outcome.

Impact of hypogonadotropic hypogonadism on ovarian reserve and response.

To evaluate the hormonal profile, antral follicle count (AFC) and ovarian response of patients with hypogonadotropic hypogonadism (HH). Observational retrospective cohort including infertile women with HH undergoing assisted reproductive treatment (ART). University-affiliated infertility center. Thirty-three women with HH who underwent ART between January 2007 and September 2018. The control group comprised 66 age-matched counterparts with tubal or male factor infertility. The patients with an abnormal karyotype, and those presenting primary or secondary amenorrhea due to other causes, were cautiously excluded. None. The primary outcome was serum levels of anti-Müllerian hormone (AMH) and AFC. We also investigated whether HH impacts ovarian response and reproductive outcomes. Although AFC was similar between groups, HH patients showed significantly higher AMH levels (4.6 ± 2.7ng/mL vs. 3.0 ± 1.9, p = 0.010) and lower basal FSH and LH. While the HH group needed longer stimulation [13days (11-26) vs. 10 (7-14), p < 0.001] and higher gonadotropin doses [2700IU (825-6300) vs. 2100 (425-5000), p =0.038 ], no significant differences were detected in either the number or maturity of retrieved oocytes, or in the fertilization rate, number of embryos transferred, implantation rate, clinical pregnancy rate and live birth rate per cycle. HH patients present higher AMH levels, but similar AFC. Despite requiring longer stimulation and higher gonadotropin doses, ovarian response and reproductive outcomes seem unaffected.

Androgen production in response to LH is impaired in theca cells from nonovulatory dominant follicles in early-postpartum dairy cows

Most dairy cows develop a dominant follicle within two weeks postpartum, but 60% of these follicles fail to ovulate. In a previous study, we determined that cows destined to ovulate have higher LH pulse frequency and circulating estradiol. The latter characteristic provided a method for distinguishing ovulatory from nonovulatory follicles during development and we found that nonovulatory follicles have lower estradiol and androstenedione in their follicular fluid. We hypothesized that lower LH pulse frequency impairs androgen production by theca cells of nonovulatory cows, reducing their ability to make estradiol. In the present study, we applied our method for predicting follicle fate to collect dominant follicles from predicted ovulatory (n = 7) and nonovulatory (n = 3) follicles. Theca and granulosa cells were separated and cultured in the absence or presence of LH, FSH, and/or testosterone for three days, with daily collection of culture medium for steroid RIAs. Estradiol and progesterone production by granulosa cells were not different between ovulatory and nonovulatory follicles. By contrast, overall androstenedione production by theca cells from ovulatory follicles was significantly higher compared with nonovulatory follicles on all three days of culture and, as culture progressed, theca from nonovulatory follicles had increasingly poorer responses to LH. In the same cultures, the progesterone production by theca cells was similar in ovulatory and nonovulatory groups. In support of our hypothesis, the results show that estradiol production by granulosa cells from nonovulatory follicles is robust when androgen substrate is present, but that thecal androgen production in response to LH is impaired. This suggests that the initial defect in steroidogenesis in dominant follicles that fail to ovulate postpartum is lower production of androgen by theca cells.

Expression of Kisspeptin and its receptor in the hypothalamus of cyclic and acyclic buffalo (Bubalus bubalis)

Kisspeptin (Kiss1), neurokinin-B (NKB) and dynorphin (Dyn) neurons regulate the surge and pulsatile centres of gonadotropin releasing hormone (GnRH) in the hypothalamus and are modulated by the ovarian steroids. Accordingly, we studied the temporospatial expression of Kiss1, its receptor and other genes that regulate GnRH in the preoptic area (POA) and arcuate (ARC) regions of hypothalamus at different phases of bubaline estrous cycle. Brain of buffalo (n = 32) was collected immediately after exsanguination and categorized into early luteal (EL), mid luteal (ML), follicular (FL) stages and acyclic (n = 8/group). Total RNA was extracted from the POA and ARC of each stage and real time PCR amplification of Kiss1, Kiss1r, NKB, NKB receptor (NKBR), Dyn, Dyn receptor (OPRK1), GnRH1, ERα, PR, LEPR and GHSR was done using GAPDH as endogenous control and acyclic stage as calibrator group. Further, immunolocalization of Kiss1 and Kiss1r was done on the hypothalamus. In the POA, significant up-regulation of Kiss1 and NKB with a concomitant down-regulation of Dyn transcripts was recorded at FL stage. There was, however, down-regulation of Kiss1 and Kiss1r during the EL perhaps due to the loss of estradiol as a consequence of ovulation. On the other hand, in the ARC, there was a significant up-regulation of Kiss1 and Dyn at FL and ML, while NKB transcript was consistently down-regulated at any stage of estrous cycle. In the POA, expression of ERα was not modulated; however, PR was down-regulated in the EL. In the ARC, the ERα expression was significantly up-regulated in the EL, whereas, PR was moderately expressed irrespective of the stage of estrous cycle. The immunolocalization study revealed the presence of Kiss1 and Kiss1r in the POA and ARC in the cyclic buffalo with relative abundance at FL. The transcriptional profile of the genes suggests that there is estrous cycle stage specific expression of Kiss1, Kiss1r and other GnRH regulating genes in the POA and ARC regions of hypothalamus in the buffalo. Up-regulation of Kiss1r in the POA during ML and ARC during EL indicates the involvement of kisspeptinergic system in the regulation of low LH pulse frequencies during the early and mid luteal phases in the cyclic buffalo.

Energy Availability is Predictive of LH Pulse Frequency Across a 3-month Diet and Exercise Trial

Exercising women are at risk for low energy availability (EA). Restricting EA to 20 kcal/kgLBM/d for 5 days reduces LH pulse frequency, but it’s unclear how low EA over a longer duration affects LH. Slowed LH pulse frequency reflects reproductive axis suppression and is linked to menstrual disturbances. We showed that daily EA over a 3 month diet and exercise intervention predicted the frequency of menstrual disturbances, but the relation between low EA and upstream LH pulse dynamics is unclear. PURPOSE: To determine if reductions in EA due to diet and exercise over a prolonged period are related to LH pulse frequency in premenopausal, previously sedentary women. METHODS: This was a randomized controlled trial consisting of a 3 month controlled diet and supervised exercise program (5d/wk) leading to moderate weight loss. EA was calculated by measured energy intake (kcal) and recorded exercise energy expenditure (kcal) normalized to fat free mass (kgFFM). EA was measured daily and averaged during baseline and each of 3 intervention menstrual cycles. Blood samples were obtained via intravenous catheter every 10 min for 24hr in the early follicular phase prior to the intervention (n=16) and after 3 months of diet and exercise (n=14). Samples were assayed for LH via Immulite. LH pulse dynamics were assessed by Cluster. Paired t-tests compared Pre-Post differences. A linear mixed model was used to determine if EA predicts LH pulse frequency in the same or subsequent menstrual cycle. RESULTS: Subjects were 20±1 yrs old, 165±1 cm tall, and weighed 58.4±1.1 kg. Average weight loss was 3.1±0.6 kg (p<0.001). LH pulse frequency was 0.81±0.06 pulses/hr prior to the intervention and 0.63±0.08 pulses/hr after (p=0.047). Average EA in the Pre cycle was 38.6±1.8 kcal/kgFFM/d and 27.9±2.1 kcal/kgFFM/d during Post (p<0.001). EA measured within a menstrual cycle was a significant positive predictor (p=0.011) of LH pulse frequency in the same or subsequent cycle. Specifically, for every 1 kcal/kgFFM/d increase in EA, LH pulse frequency increases by 0.014 pulses/hr. CONCLUSIONS: EA is a positive predictor of LH pulse frequency within the same or subsequent menstrual cycle. To prevent suppression of the reproductive axis, EA should be maintained at optimal levels, as a reduction in EA from 38 to 28 kcal/kgFFM/d suppresses LH pulse frequency by 19%.

MON-LB072 Primary Partial Empty Sella Presenting with Prepubertal Hypogonadotropic Hypogonadism: A Case Report

Objective: This is case report which discusses the approach to diagnosis of a 20 year old male presenting with micropenis and absent secondary sex characteristics. Methods: On physical examination, the patient he has eunuchoid habitus, gynecomastia, and a genital and pubic hair development of Tanner Stage 1. He has a flaccid and stretched penile lengths of 2.5 and 3 centimeters respectively, palpable small, firm left testis and undescended right testis. Neurologic examination was unremarkable except for anosmia. Cranial MRI with contrast are suggestive of partially empty sella. Chromosome analysis was done revealing a karyotype with no numerical and structural aberrations and an XY sex chromosome. He has delayed bone age using Greulich-Pyle method and hormonal tests showed low testosterone, LH, FSH, Estradiol and Beta HCG. Results: The patient has no history of pituitary mass, surgery or radiation. However, his mother used an abortifacient on 5th week of pregnancy. With this history, together with the physical examination and diagnostic results of 46XY chromosome, cranial MRI finding of partial empty sella, delayed bone age, and hormonal tests showing low testosterone, LH, FSH, Estradiol and Beta HCG, the patient was diagnosed with Primary Partial Empty Sella Syndrome (Prepubertal Hypogonadotropic Hypogonadism). Conclusion: The incidence of PES varies depending on means of diagnosis ranging from 5.5-35% in general population. It may display with various endocrine problems. However, prepubertal hypogonadotropic hypogonadism as its main manifestation, presenting as micropenis and lack of secondary sex characteristics is rare since its peak incidence commonly occurs late at 30 to 40 years of age and has a sexual predilection for female with female to male ratio of approximately 5:1. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. s presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

SUN-207 Hot Flashes, Flushing, and Sweating in a Middle-Aged Man with Pituitary Macroadenoma

Background: Vasomotor symptoms such as hot flashes and sweating, typical of the menopausal syndrome in women, are less commonly seen in males after loss of testicular function. We present an interesting case of a middle-aged man who was evaluated for progressive episodes of hot flashes, sweating and flushing and was eventually diagnosed with pituitary macroadenoma causing secondary hypogonadism. Clinical Case: A 59 y.o. male was referred endocrinology clinic with intermittent episodes of hot flashes and sweating over the last 2 years. He has had progressive episodes of feeling warm, associated with some flushing, and then transient profuse sweating, usually lasting no more than several minutes. His only other medical problem has been chronic recurrent gout requiring Allopurinol 300 mg daily, Probenecid 500mg twice daily and Colchicine 0.6mg twice daily to prevent gout attacks. He denied any headaches, palpitations, feeling tremulous, no vision symptoms, no breast enlargement or loss of body hair, no constipation or diarrhea. Physical exam was significant for paucity of facial and body hair, and no evidence of gynecomastia. He had an episode in the office visit where he became flushed, diaphoretic, his blood pressure was 120/80 and he did not have tachycardia. Lab studies revealed Prolactin= 19 (n= 2-18 pg/dL), Cortisol 8.6 (6-27 ug/dl), Total Testosterone = 22 (n=250-1100 ng/dL), LH = <1 (n=1.5-9.3 mlU/ml), free T4 0.6 (ref 0.6-1.6 ng/dl) with TSH 1.51 (ref: 0.34 -3.00 uIU/ml), IGF-1 = 49 (34-232 ng/dl), Total metanephrines urine 654 ( 233-716 (Normotensive)), VMA = 3.6 (<8.0 mg/24 h) suggestive of secondary hypogonadism with elevated prolactin and low LH. MRI of the brain revealed mass of the sella extending into the suprasellar region measuring up to 2.0 x 2.3 x 1.8 cm. He then underwent endoscopic transsphenoidal resection of pituitary tumor and histopathology revealed null cell adenoma with widespread oncocytic changes consistent with an oncocytoma. On follow up visit in 1 month, his debilitating sweats have diminished significantly but not disappeared. Conclusion: Hot flushes are common in men who are acutely hypogonadal after orchiectomy or testicular injury, but it is an unusual symptom in patients with hypogonadism secondary to pituitary tumors. There are case reports of pituitary adenoma diagnosed through evaluation of sexual dysfunction and frequent hot flashes. This case illustrates the importance of considering broad etiologies when evaluating new onset hot flashes in middle-aged men, especially in the absence of other presenting features of pituitary macroadenoma and when symptoms of hypogonadism (like erectile dysfunction, low libido, impaired concentration and fatigue) go unreported to physicians.

SAT-LB040 Measuring LH Pulsatility in Patients with Reproductive Disorders Using a Novel Robotic Aptamer-Enabled Electrochemical Reader (RAPTER)

Normal reproductive functioning is critically dependent on pulsatile secretion of LH. Assessment of LH pulsatility is important for the clinical diagnosis of patients with reproductive disorders, but this is not routinely available in the clinic because of the need for frequent blood sampling coupled with expensive serial immunochemical analysis. The emerging technology of electrochemical aptamer-based (E-AB) sensing could potentially offer a generalizable approach for LH pulsatility measurement in humans. E-AB sensors take advantage of the intrinsic properties of nucleic acid aptamers to specifically bind to a molecular target and undergo a reversible conformational change. The conformational change can be measured through the electrochemical signal response. Aptamers, unlike antibodies, can facilitate low-cost repeat analytical measurements. However, there is currently no aptamer-based LH sensing technology. Here, we report the development and application of a novel antibody-free DNA aptamer-mediated electrochemical analysis to accurately assess LH pulsatility in patients with reproductive disorders. Through selective evolution of ligands by exponential enrichment (SELEX), single-stranded DNA oligonucleotides (aptamers) were identified that bind specifically to LH (and that do not bind to the closely related FSH). The aptamers were integrated into E-AB sensors on a robotic platform (which we term RAPTER) to enable sensitive, rapid and repeatable detection of LH. We next determined if the RAPTER system could measure LH pulsatility in clinical samples from patients with reproductive disorders. We obtained 441 serum samples from 3 patient cohorts - young females with regular menstrual cycles (normal LH pulsatility), menopausal women (disordered LH pulsatility, high LH), and women with hypothalamic amenorrhoea (suppressed/ absent LH pulsatility, low LH). Blood sampling was performed every 10 minutes for 8 hours in these patients and samples were analysed using both the current gold standard LH immunochemical assay and RAPTER. We performed a Bland-Altman analysis and plotted the linear regression to compare the results obtained. The RAPTER assay showed an almost perfect correlation with the clinical immunochemical assay (R2= 0.94). Bayesian Spectrum Analysis was used to determine the effective LH pulse interval from both datasets (clinical assay and RAPTER assay). We are able to distinguish 3 patient cohorts based on the time interval ranges. Taken together, the RAPTER system provides a new approach for LH pulsatility determination by reliably and immediately calculating varying LH concentrations within distinct patient cohorts. This has the potential to transform the clinical care of patients with reproductive disorders as LH pulsatility could be measured easily in clinical practice to aid correct diagnosis. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. s presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

MON-418 Symptomatic Pituitary Metastasis: Two Case Reports with Contrasting Clinical Presentations

Introduction: Pituitary metastases (PM) are a rare occurrence with a poor prognosis. The most common cancers to metastasize to the pituitary are breast and lung. Most PMs are asymptomatic, but when symptoms occur the most commonly reported presentation is central DI. Clinical Cases: Case 1. An 86 year old male presented to the hospital with progressive weakness, fatigue and low appetite. He had a history of widely metastatic papillary thyroid cancer treated with thyroidectomy, repeated doses of RAI and repeated neck dissections. Most recent TG was 27,405 ng/mL (nl 2.8-40.9). An 8AM cortisol was checked and found to be low at 0.8 mcg/dL (nl 10-20). Further hormonal workup showed low ACTH, TSH <0.01uIU/mL (nl 0.3-5), FT4 1.43 ng/dL (nl 0.76-1.46) while on LT4, prolactin 38.94ng/mL (nl 2.1-17.7), low LH and FSH consistent with panhypopituitarism. Pituitary MRI showed an infiltrative process enlarging the pituitary gland, with extension into the stalk and hypothalamus concerning for metastatic disease. He was started on steroid replacement. He underwent systemic tyrosine kinase inhibitor therapy as well as pituitary radiation, but unfortunately, he died 7 months after presenting with central AI. Case 2. A 56 year old male was referred to endocrine clinic for polydipsia, polyuria and nocturia. Initial labs showed normal glucose, Na 145 mmol/L (nl 136-145), serum Osm 299mOsm/kg (nl 276-305), and urine Osm 92mOsm/kg (nl 500-800). Water deprivation test confirmed central DI. Further labs showed intact anterior pituitary function. Pituitary MRI showed an infiltrative process in the pituitary gland, affecting stalk and hypothalamus concerning for metastatic disease. Imaging was obtained and showed masses in the lung, kidney, spine, and mediastinal lymph nodes. The patient had a remote history of colon cancer and underwent biopsy of the lymph and renal masses, both showing metastatic colorectal cancer. He was started on DDAVP and symptoms improved. Three weeks later he presented with severe fatigue, dizziness, and hot flashes. Workup showed panhypopituitarism. Repeat MRI showed interval growth of the pituitary lesion. He underwent pituitary radiation and chemotherapy. He did not tolerate the side effects of systemic therapy and enrolled in hospice care. Conclusions: The most commonly reported symptomatic presentation of PM is central DI, however the reported incidence of anterior pituitary dysfunction is rising and clinicians should be aware. Pituitary metastases should remain on the differential in any case of anterior or posterior pituitary dysfunction, particularly in patients with any history of malignancy.

OR15-4 Long-Term Follow-Up of a Female with a Mutation in the Estrogen Receptor Alpha (ESR1) Gene

We previously reported the first female with a mutation in the ESR1 gene encoding estrogen receptor-α (ER-α), which dramatically reduced estrogen signaling in vitro. She presented at 179/12 years with absent breast development, markedly elevated serum estradiol and estrone levels, modestly high gonadotropins, and multicystic ovaries by ultrasound. The natural history of estrogen insensitivity in women is unknown. The purpose of this report is to present: 1) the neuroendocrine phenotype; 2) studies to identify a ligand to stimulate the mutant receptor; and 3) the effect of targeted treatment. We now provide long-term clinical follow up and a detailed hormonal analysis of the patient at age 234/12 years. On no treatment, serum FSH and LH were drawn every 10 minutes for 8 hours, and estradiol and estrone levels were measured every hour during the study. Various compounds that are potential for treatment were used in transient transfection assays to determine if estrogen signaling could be induced. A personalized medicine approach was tailored to our patient, in which she received increasing doses of diethylstilbestrol (DES) with the primary endpoints being increased vaginal discharge and breast development. Follow up exams, labs, pelvic ultrasounds, DXA, and bone age X-rays were completed at various intervals up to age 234/12 years. The Bioethics Board approved this treatment. During the frequent sampling study, E2 was 604 pg/mL, E1 was 596 pg/mL, FSH was 10.0+/-0.1 IU/L (mean+/-SE), and LH was 6.7+/-0.2 IU/L. There were 3 pulses in 8 hr with an LH pulse amplitude of 2.3+/-0.5 IU/L. Although DES was shown to successfully transactivate the mutant ESR1in vitro, both in HEK293 cells and in her lymphoblastoid cells, the patient had no clinical response. After 2.5 years of treatment with increasing doses of DES, there was no vaginal discharge and breasts remained at Tanner 1. At 234/12 years, LH, FSH and E2 were unchanged. A vaginal maturation index showed a predominance of parabasal cells consistent with a lack of estrogen effect. Ultrasound showed bilateral ovarian cysts. At chronologic age 234/12 years, her bone age was 17 years and the epiphysis remained open in the ulnar bone. DXA revealed a Z-score of -2.9 at the femoral neck and -4.5 at the lumbar spine. Our findings in this severely estrogen insensitive female indicate elevated gonadotropins with normal amplitude and low frequency LH pulse dynamics in the presence of markedly increased estrogens. Treatment with DES, which stimulated estrogen signaling in vitro, did not induce secondary sexual characteristics in our patient. She remains hypoestrogenic despite the presence of ovarian cysts with a hypoestrogenic vaginal smear, absent breast development, and low bone mineral mass. Future studies will be directed towards further identification of other potential signaling mechanisms and activators of this mutant receptor.

SUN-229 The Role of Testosterone in Spermatogenesis: Lessons from Proteome Profiling of Human Spermatozoa in Testosterone Deficiency

Testosterone is required during spermatogenesis to mantain the blood-testis barrier and for meiosis, Sertoli-spermatid adhesion and sperm release. Aim of the study was to better understand the effect of hypothalamic-pituitary-testicular axis on sperm protein composition and function.12 male patients with low testosterone and LH levels were consecutively enrolled for this study. Five normogonadic men were enrolled as control group in the protocol. If spermatozoa were detectable in seminal samples, the the ejaculates were washed and the sperm cells were selected using 50% PercollTM. The recovered sperm cells were then suspended in PBS and subjected to a residual leukocyte depletion using CD45 Dynabeads® magnetic cell sorting. The absence of leukocytes was further confirmed both by microscopic observation after staining and by performing a RT-PCR for CD45. Protein solubilization was independently performed on each sperm sample. A comparative proteomic analysis was performed comparing two pools: controls vs hypogonadic patients. The TMTduplexTM Isobaric Mass Tagging Kit was used for the peptide labeling. MS/MS analysis was performed using a LTQ Orbitrap Velos. Data were processed using Proteome Discoverer 1.4.1.14 software, using very stringent filtering criteria. Proteins identified by SEQUEST were analyzed using the PANTHER classification system. Proteomic results have been confirmed by Western Blot. The following primary antibody were used: anti-Lactoferrin polyclonal antibody and anti-PIP polyclonal antibodyWe included in our study 5 oligozoospermic hypogonadic patients with a sperm count >10 x 106/ml and without leukocyte contamination. 42 proteins were under-expressed in the pool of hypogonadic patients; 12 of these 42 increased proteins have been previously reported to be related with spermatogenesis, sperm motility, sperm-oocyte interaction and acrosomal reaction. The distribution of proteins for molecular function revealed that the protein pattern impaired by low blood testosterone is involved in protein binding and hydrolase. Twelve proteins have been over-expressed in the pool of hypogonadic patients, including markers of defective spermatogenesis. Western-blot analysis confirmed proteomic data. This is the first application of high resolution mass spectrometry -based proteomics aimed to reveal an array of proteins in spermatozoa reflecting an impairment of spermatogenesis and sperm function in male secundary hypogonadism.

SUN-432 A Case of Sellar Plasmacytoma Masquerading as Pituitary Carcinoma with Hypopituitarism

Background: Sellar plasmacytomas are rare tumors arising from clonal plasma cells localized to the sellar/parasellar region. They may mimic other pituitary pathology such as pituitary adenomas, chordomas, meningiomas or metastatic carcinomas in both clinical manifestations and radiographic evidence. Certain features such as predominance of cranial nerve palsies and absence of hypopituitarism appear to be more common with sellar plasmacytomas. We present an interesting case of a sellar plasmacytoma, initially mistaken for pituitary carcinoma, with rapid development of hypopituitarism and systemic multiple myeloma. Case: A 75 year old healthy male presented with sudden onset left eye diplopia and retro-orbital pain. Left eye ptosis and diplopia with left lateral and upward gaze were noted on exam. Initial MRI brain revealed a 17mm soft tissue mass involving pituitary and clivus, extending into the left superior orbital fissure, concerning for pituitary carcinoma. With the exception of low LH (1.2) and testosterone (25), baseline pituitary hormone labs, complete blood count and metabolic panel were within normal limits. Within 1 month, he acutely presented with fever, confusion, weakness, and bony pains. Repeat pituitary labs showed low ACTH < 5, AM cortisol 4.3, TSH 0.07, FT4 0.5. New findings of acute renal injury, hypercalcemia, anemia with elevated Mspike, Kappa light chain 39.7 (0.3-2.0mg/dl), kappa/lamda ratio 66.2 (0.3-1.6) and beta2microglobulin 4484 were found. Repeat MRI brain noted multifocal osseous metastatic disease with left sellar and cavernous sinus lesion contiguous with clival osseous lesion displacing pituitary gland, concerning for plasmacytoma. PET/CT showed focal lytic lesions in clivus and posterior left iliac bone. Bone marrow biopsy confirmed 70% myeloma involvement with kappa monotypic plasma cell population. He was started on hydrocortisone, levothyroxine, chemotherapy and XRT. Conclusion: The rarity of plasmacytomas, combined with their clinical presentation and imaging characteristics similar to other sellar tumors, can often result in misdiagnosis. Accuracy of diagnosis is critical, as sellar plasmacytomas and underlying multiple myeloma (present in 50% of cases) require XRT and systemic chemotherapy respectively rather than surgery. Although pituitary function is usually preserved in plasmacytomas, our case shows that acute anterior pituitary dysfunction can be an early presenting sign.

SUN-420 Pituitary Apoplexy Associated With Apixaban

Background: Pituitary apoplexy (PA) is a relatively rare condition associated with sudden hemorrhagic pituitary infarction, and usually occurs in the setting of a pituitary adenoma. Patients typically present with the acute onset of headache, visual changes and pituitary hormonal deficiencies. Oral anticoagulation therapy is a known risk factor for PA and has recently been described in association with the newer anticoagulants, including both thrombin and Factor Xa inhibitors. Clinical Case: An 82 year-old woman with a history of renal cell carcinoma and recent post-operative pulmonary embolism treated with apixiban, presented with acute-onset headache, diplopia, and vomiting. Mental status remained intact. Vital signs were normal. Her physical exam was significant for a left superior temporal quandrantanopsia and was otherwise normal. Brain imaging revealed an 8 x 11 x 12 mm hyperdense mass within the sella representing hemorrhage. She had no known history of pituitary disease. The patient was admitted to the neurosurgical service for close monitoring of her neurologic and hemodynamic status. She was treated with conservative management and empiric glucocorticoids. Pituitary hormone assessment on admission was significant for inappropriately low LH of 0.5 mIU/mL (reference range 10-60) and FSH of 8.6 mIU/mL (reference range 17-114) in a postmenopausal woman. TSH was <0.03 mIU/L (reference range 0.4-5), and free T4 was elevated at 3.31 ng/dL (reference range 0.6-1.2). IGF-1 was within normal limits at 85ng/mL (reference range 31-208). Serum prolactin level was 13.7 ng/mL (normal <20). Cortisol and ACTH were measured after the patient had received empiric stress dose steroids and were thus unreliable. Of note, the patient did not exhibit signs or symptoms of adrenal insufficiency, such as hypotension or electrolyte derangements. Her headache and visual field deficit resolved with conservative treatment and she was discharged on physiologic glucocorticoid replacement therapy. Approximately two months after her initial presentation, the patient generally felt well except mild tremor and insomnia. Repeat endocrine evaluation confirmed central hypogonadism and primary hyperthyroidism. She was diagnosed with Graves’ disease and treated with methimazole. An ACTH stimulation test was normal and hydrocortisone replacement was discontinued. A repeat pituitary MRI demonstrated resolution of the hemorrhage and no evidence of a pituitary adenoma. Conclusion: Anticoagulation therapy, including the newer anticoagulants, is a risk factor for PA and is typically associated with an underlying pituitary tumor. To our knowledge, this is the first case of pituitary hemorrhage in a patient treated with apixaban without evidence of a pituitary tumor.

Stress and reproduction in farm animals

Transport of post-partum cows or sheep before an oestradiol-induced LH surge delayed gonadotrophin secretion possibly by affecting hypothalamic activity but not via an opioid mediated mechanism as the effect could not be reversed by naloxone. In addition, reduced LH responses to GnRH were observed in cattle during transport. In sheep, adrenocorticotrophic hormone (ACTH) also diminished the LH response to GnRH, but only when GnRH was administered 3 h after ACTH, not after 0.5 h. This finding suggests that very early suppression of LH secretion by stressors is not mediated by ACTH action at the pituitary but that immediate activation of the sympathetic nervous system may be involved. In ewes during the breeding season, repeated exposure to GnRH at intervals of 2 h during transport resulted in lower LH responses to the second and third injections. When anoestrous ewes were treated with oestradiol and GnRH while being restrained and isolated, the onset of the LH surge was delayed. The effects of hypothalamus-pituitary-adrenal hyperactivity on LH release may involve suppression of GnRH receptor activity, a reduction in releasable LH, or both factors. Studies in vitro with perifused ovine pituitaries showed that ACTH or corticotrophin releasing hormone markedly suppressed LH secretion in response to the second of two exposures to GnRH. This occurred with pituitaries obtained from anoestrous ewes irrespective of prior treatment with oestradiol, suggesting that compounds from the hypothalamus-pituitary-adrenal do not exert effects on the oestradiol-sensitizing mechanisms on the pituitary. In conclusion, stressors affect reproductive function via actions at the hypothalamus as well as impairing pituitary LH release induced by GnRH.