Clin. exp. Immunol. (1992) 90, 401-404
Cystic ovaries in women affected with hereditary angioedema R. PERRICONE*, N. PASETTOt, C. DE CAROLISt, E. VAQUEROt, G. NOCCIOLIt, A. E. PANERAIt & L. FONTANA* *Cattedra di Immunologia Clinica e Allergologia, tClinica Ostetrica e Ginecologica, Dipartimento di Chirurgia, University of Rome "Tor Vergata", Rome, and +Dipartimento di Farmacologia, University of Milan, Milan, Italy
(Acceptedfor publication 6 August 1992)
SUMMARY Polycystic ovary (PCO) syndrome is biochemically characterized by abnormal gonadotropin secretion and polycystic ovaries associated with increase in size and functional activity of stromal tissue; multifollicular ovaries (MFO) are defined by the presence of multiple cysts with no increase in stromal tissue. A central (hypothalamic-pituitary) abnormality, including high plasma fl-endorphin (BE) concentrations without simultaneous elevation of ACTH, was reported for subjects with PCO syndrome. Since we have found the presence of high plasma BE concentrations in hereditary angioedema (HANE) during attacks as well as during symptom-free periods, we studied, by means of pelvic ultrasound scanning employed to determine the prevalence of PCO and of MFO, 13 women of reproductive age affected with HANE who were not on oral contraceptives. We have found PCO in 5/ 13 (38-4%) and MFO in 7/13 (53 8%) HANE patients. Nine patients had oligomenorrhoea (five with PCO, three with MFO, one with normal ovaries), five (three with PCO, two with MFO) were hirsute and only one (with MFO) had weight loss. No patient was obese. Mean plasma LH, testosterone, prolactin, cortisol and ACTH concentrations were normal, while FSH was significantly reduced and LH/FSH ratio increased. BE concentrations were significantly high in all the patients studied. Our results clearly demonstrate that women with HANE frequently have cystic ovaries (polycystic or multifollicular) in the presence of high BE concentrations. Keywords cystic ovaries polycystic ovaries multifollicular ovaries beta-endorphin hereditary angioedema human ovarian follicular fluid
INTRODUCTION The polycystic ovary (PCO) syndrome is biochemically characterized by abnormal gonadotropin secretion and polycystic ovaries with associated increase in size and functional activity of stromal tissue. Patients with the PCO syndrome have menstrual disturbances and hirsutism, but there is a spectrum of clinical presentation [1]. Since pelvic ultrasound scans are of rising importance in diagnosing ovulatory disorders, including PCO, many authors used this approach to identify patients with PCO through a precise anatomical diagnosis [2,3]. Using this procedure Polson et al. [4] have recently found polycystic ovaries in 23% of normal women who were not taking oral contraceptives; furthermore using ultrasound a second group of women with cystic ovaries who were clearly distinguishable from those with characteristic PCO syndrome was identified: these women had a condition termed multifollicular ovaries (MFO), defined by the
A central (hypothalamic-pituitary) abnormality, including high plasma /3-endorphin (BE) concentrations without simultaneous elevation of ACTH, was reported for subjects with PCO syndrome [6]. Recently we have found the presence of increased plasma BE concentrations in hereditary angioedema (HANE) during attacks as well as during symptom-free periods [7,8]. Furthermore, three women affected with HANE who were under clinical management in our department, were submitted to ultrasound scanning because of recurrent abdominal pain (a frequent feature of HANE attacks) and found to have PCO (two) and MFO (one). For the above mentioned reasons we studied, by pelvic ultrasound scanning, 13 women of reproductive age affected with HANE and determined the prevalence of PCO and of MFO in these patients.
presence of multiple cysts with no increase in stromal tissue [5].MAEIL Correspondence: Dr Roberto Perricone, Cattedra di Immunologia
Clinica, University of Rome "Tor Vergata", P~le Umanesimo 10, I-00l44, Rome, Italy.
AN
MTHD
Patients
d/o Ospedale S.Eugenio,
Thirteen female patients ranging from 16 to 38 years, affected with HANE, off therapy, entered this study in symptom-free
401
R. Perricone et al.
402
periods after the experimental procedures had been fully explained and consent obtained. Diagnosis of HANE was made taking into account the clinical characteristics of the acute episodes, the genealogical studies which showed the typical autosomic dominant pattern of inheritance, and the laboratory findings including low concentrations of Cl inhibitor (ClINH) and of C4, and low C1INH functional activity [9]. Eleven patients had low serum concentrations of C1INH protein (type 1) and two (15%) had elevated serum concentrations of a functionally deficient inhibitor protein (type 2) [10,11]. These women were not selected on the basis of menstrual disturbances, infertility, hirsutism, but only on the basis of inherited Cl INH deficiency. Pelvic ultrasonography Pelvic ultrasound scanning by two observers was used to perform diagnosis of PCO or of MFO. PCO were defined according to already reported criteria, i.e. 10 or more cysts 2-18 mm in diameter associated with increase in ovarian stroma [5,12]. MFO was defined according to Adams et al. [5], i.e. normal in size or slightly enlarged and filled by six or more cysts 4-10 mm in diameter, with no increase in stroma. Hormone measurements Measurements of LH, FSH, testosterone, prolactin and cortisol were performed in the early to mid follicular phase by specific radioimmunoassays (Radim SpA, Pomezia, Italy). The intraand interassay coefficients of variation for LH, FSH, testosterone, prolactin, and cortisol, respectively, were 2-8% and 5%, 2-8% and 5%, 6-5% and 7-2%, 25% and 5 5%, 52% and 8-6%. The assay sensitivities were: LH, 2 mIU/ml; FSH, 2 mIU/ml; testosterone, 0-08 ng/ml; prolactin, 0 4 ng/ml; cortisol, 8 ng/ml. ACTH assay has been reported elsewhere [13]. BE concentrations were measured by radioimmunoassay after the samples had been concentrated on C18 Sep-pak (Waters, Milford, MA) and the peptide separated by high-
pressure liquid chromatography (HPLC) as described elsewhere [7,14]: a radial C18 Bondpak column was used with an acetonitrile:trifluoroacetic acid linear gradient ranging from a ratio of 30:70% to 40:60%. The flow rate was 2 ml/min. The lower and upper levels of detection of the peptides varied: 3-6 and 72-144 pg/ml in different assays. To avoid differences between different assays all results were obtained in one single assay. The computer program as configured in our machine did not extrapolate 'real values' when the counts were below the sensitivity of the assay or higher than the highest point of the standard curve acceptable for the same assay; in these cases the values 0 or 144 appeared.
Statistical analysis Statistical evaluation of the data included paired and unpaired Student's t-tests where appropriate (P < 0 05; NS = not significant). A group of 20 healthy female subjects of reproductive age who were not under contraceptives served as control for the HANE patients. RESULTS We have found polycystic ovaries in 5/13 (38 5%) and MFO in 7/13 (53-8%) women of reproductive age affected with HANE who were not under oral contraceptives (Table 1). In the group of controls PCO were found in 3/20 (15%) and MFO in 2/20 (10%). Nine patients had oligomenorrhoea (five with PCO, three with MFO, one with normal ovaries), five (three with PCO, two with MFO) were hirsute (F.G. index > 12) (Table I) and only one (with MFO) had weight loss. No patient was obese. Eleven patients had normal serum LH concentrations, two had LH more than 2 s.d. above the mean obtained in the group of controls. FSH concentrations were significantly reduced if compared with those obtained in the group of controls. LH/ FSH ratio was > 1 and significantly higher in HANE than in controls (Table 2).
Table 1. Clinical characteristics, ovaries and menstrual pattern in HANE women
Patient
Age
G.C. C.P. C.E.* T.M. B.B. V.M. M.C. C.A. C.A.M. M.D. P.R.* A.L. A.N.
20 24 32 18 38 18 20 30 35 16
Ovaries
Associated pathology Oligomenorrhoea Hirsutism
PCO PCO PCO PCO PCO MFO
MFO MFO
Fibrocystic breast dis.
Yes Yes Yes Yes Yes Yes Yes
Yes
-
Yes
Yes Yes
Yes
Yes Yes -
Fibrocystic breast dis.
MFO MFO
Fibrocystic breast dis. MFO MFO Normal MFO PCO 3/13 7/13 26-6+7-8 5/13 (23%) (16-38) (38-5%) (53 8%) 30 27 38
*Type 2 hereditary angioedema (HANE). PCO, polycystic ovaries. MFO, multifollicular ovaries.
9/13 (69I2t%( )
5/13 (38 5%)
403
Cystic ovaries in HANE Table 2. LH, FSH, testosterone and beta-endorphin (BE) levels in HANE women
Patient
Ovaries
LH (mIU/ml)
FSH (mIU/ml)
LH/FSH ratio
Testosterone (ng/ml)
BE (pg/ml)
G.C. C.P. C.E.* T.M. B.B. V.M. M.C. C.A. C.A.M. M.D. P.R.* A.L. A.N.
PCO PCO PCO PCO PCO MFO MFO MFO MFO MFO MFO MFO Normal
192 8 105 127 13 10-7 122 26-2 11 34 10 152 254
13-4 61 77 10.5 81 10-5 76 52 85 54 7-1 71 15 7
14 13 1-3 12 16 1 16 5 13 06 14 21 16
1-09 094 030 058 058 1-10 055 0 52 058 021 0 35 075 0 50
81 144 52 65 80 87 66 25 28 50 60 20 13
87+3 1
1 6+1 1
0-62+0-28
593+352
258+183
Cystic ovaries in women affected with hereditary angioedema R. PERRICONE*, N. PASETTOt, C. DE CAROLISt, E. VAQUEROt, G. NOCCIOLIt, A. E. PANERAIt & L. FONTANA* *Cattedra di Immunologia Clinica e Allergologia, tClinica Ostetrica e Ginecologica, Dipartimento di Chirurgia, University of Rome "Tor Vergata", Rome, and +Dipartimento di Farmacologia, University of Milan, Milan, Italy
(Acceptedfor publication 6 August 1992)
SUMMARY Polycystic ovary (PCO) syndrome is biochemically characterized by abnormal gonadotropin secretion and polycystic ovaries associated with increase in size and functional activity of stromal tissue; multifollicular ovaries (MFO) are defined by the presence of multiple cysts with no increase in stromal tissue. A central (hypothalamic-pituitary) abnormality, including high plasma fl-endorphin (BE) concentrations without simultaneous elevation of ACTH, was reported for subjects with PCO syndrome. Since we have found the presence of high plasma BE concentrations in hereditary angioedema (HANE) during attacks as well as during symptom-free periods, we studied, by means of pelvic ultrasound scanning employed to determine the prevalence of PCO and of MFO, 13 women of reproductive age affected with HANE who were not on oral contraceptives. We have found PCO in 5/ 13 (38-4%) and MFO in 7/13 (53 8%) HANE patients. Nine patients had oligomenorrhoea (five with PCO, three with MFO, one with normal ovaries), five (three with PCO, two with MFO) were hirsute and only one (with MFO) had weight loss. No patient was obese. Mean plasma LH, testosterone, prolactin, cortisol and ACTH concentrations were normal, while FSH was significantly reduced and LH/FSH ratio increased. BE concentrations were significantly high in all the patients studied. Our results clearly demonstrate that women with HANE frequently have cystic ovaries (polycystic or multifollicular) in the presence of high BE concentrations. Keywords cystic ovaries polycystic ovaries multifollicular ovaries beta-endorphin hereditary angioedema human ovarian follicular fluid
INTRODUCTION The polycystic ovary (PCO) syndrome is biochemically characterized by abnormal gonadotropin secretion and polycystic ovaries with associated increase in size and functional activity of stromal tissue. Patients with the PCO syndrome have menstrual disturbances and hirsutism, but there is a spectrum of clinical presentation [1]. Since pelvic ultrasound scans are of rising importance in diagnosing ovulatory disorders, including PCO, many authors used this approach to identify patients with PCO through a precise anatomical diagnosis [2,3]. Using this procedure Polson et al. [4] have recently found polycystic ovaries in 23% of normal women who were not taking oral contraceptives; furthermore using ultrasound a second group of women with cystic ovaries who were clearly distinguishable from those with characteristic PCO syndrome was identified: these women had a condition termed multifollicular ovaries (MFO), defined by the
A central (hypothalamic-pituitary) abnormality, including high plasma /3-endorphin (BE) concentrations without simultaneous elevation of ACTH, was reported for subjects with PCO syndrome [6]. Recently we have found the presence of increased plasma BE concentrations in hereditary angioedema (HANE) during attacks as well as during symptom-free periods [7,8]. Furthermore, three women affected with HANE who were under clinical management in our department, were submitted to ultrasound scanning because of recurrent abdominal pain (a frequent feature of HANE attacks) and found to have PCO (two) and MFO (one). For the above mentioned reasons we studied, by pelvic ultrasound scanning, 13 women of reproductive age affected with HANE and determined the prevalence of PCO and of MFO in these patients.
presence of multiple cysts with no increase in stromal tissue [5].MAEIL Correspondence: Dr Roberto Perricone, Cattedra di Immunologia
Clinica, University of Rome "Tor Vergata", P~le Umanesimo 10, I-00l44, Rome, Italy.
AN
MTHD
Patients
d/o Ospedale S.Eugenio,
Thirteen female patients ranging from 16 to 38 years, affected with HANE, off therapy, entered this study in symptom-free
401
R. Perricone et al.
402
periods after the experimental procedures had been fully explained and consent obtained. Diagnosis of HANE was made taking into account the clinical characteristics of the acute episodes, the genealogical studies which showed the typical autosomic dominant pattern of inheritance, and the laboratory findings including low concentrations of Cl inhibitor (ClINH) and of C4, and low C1INH functional activity [9]. Eleven patients had low serum concentrations of C1INH protein (type 1) and two (15%) had elevated serum concentrations of a functionally deficient inhibitor protein (type 2) [10,11]. These women were not selected on the basis of menstrual disturbances, infertility, hirsutism, but only on the basis of inherited Cl INH deficiency. Pelvic ultrasonography Pelvic ultrasound scanning by two observers was used to perform diagnosis of PCO or of MFO. PCO were defined according to already reported criteria, i.e. 10 or more cysts 2-18 mm in diameter associated with increase in ovarian stroma [5,12]. MFO was defined according to Adams et al. [5], i.e. normal in size or slightly enlarged and filled by six or more cysts 4-10 mm in diameter, with no increase in stroma. Hormone measurements Measurements of LH, FSH, testosterone, prolactin and cortisol were performed in the early to mid follicular phase by specific radioimmunoassays (Radim SpA, Pomezia, Italy). The intraand interassay coefficients of variation for LH, FSH, testosterone, prolactin, and cortisol, respectively, were 2-8% and 5%, 2-8% and 5%, 6-5% and 7-2%, 25% and 5 5%, 52% and 8-6%. The assay sensitivities were: LH, 2 mIU/ml; FSH, 2 mIU/ml; testosterone, 0-08 ng/ml; prolactin, 0 4 ng/ml; cortisol, 8 ng/ml. ACTH assay has been reported elsewhere [13]. BE concentrations were measured by radioimmunoassay after the samples had been concentrated on C18 Sep-pak (Waters, Milford, MA) and the peptide separated by high-
pressure liquid chromatography (HPLC) as described elsewhere [7,14]: a radial C18 Bondpak column was used with an acetonitrile:trifluoroacetic acid linear gradient ranging from a ratio of 30:70% to 40:60%. The flow rate was 2 ml/min. The lower and upper levels of detection of the peptides varied: 3-6 and 72-144 pg/ml in different assays. To avoid differences between different assays all results were obtained in one single assay. The computer program as configured in our machine did not extrapolate 'real values' when the counts were below the sensitivity of the assay or higher than the highest point of the standard curve acceptable for the same assay; in these cases the values 0 or 144 appeared.
Statistical analysis Statistical evaluation of the data included paired and unpaired Student's t-tests where appropriate (P < 0 05; NS = not significant). A group of 20 healthy female subjects of reproductive age who were not under contraceptives served as control for the HANE patients. RESULTS We have found polycystic ovaries in 5/13 (38 5%) and MFO in 7/13 (53-8%) women of reproductive age affected with HANE who were not under oral contraceptives (Table 1). In the group of controls PCO were found in 3/20 (15%) and MFO in 2/20 (10%). Nine patients had oligomenorrhoea (five with PCO, three with MFO, one with normal ovaries), five (three with PCO, two with MFO) were hirsute (F.G. index > 12) (Table I) and only one (with MFO) had weight loss. No patient was obese. Eleven patients had normal serum LH concentrations, two had LH more than 2 s.d. above the mean obtained in the group of controls. FSH concentrations were significantly reduced if compared with those obtained in the group of controls. LH/ FSH ratio was > 1 and significantly higher in HANE than in controls (Table 2).
Table 1. Clinical characteristics, ovaries and menstrual pattern in HANE women
Patient
Age
G.C. C.P. C.E.* T.M. B.B. V.M. M.C. C.A. C.A.M. M.D. P.R.* A.L. A.N.
20 24 32 18 38 18 20 30 35 16
Ovaries
Associated pathology Oligomenorrhoea Hirsutism
PCO PCO PCO PCO PCO MFO
MFO MFO
Fibrocystic breast dis.
Yes Yes Yes Yes Yes Yes Yes
Yes
-
Yes
Yes Yes
Yes
Yes Yes -
Fibrocystic breast dis.
MFO MFO
Fibrocystic breast dis. MFO MFO Normal MFO PCO 3/13 7/13 26-6+7-8 5/13 (23%) (16-38) (38-5%) (53 8%) 30 27 38
*Type 2 hereditary angioedema (HANE). PCO, polycystic ovaries. MFO, multifollicular ovaries.
9/13 (69I2t%( )
5/13 (38 5%)
403
Cystic ovaries in HANE Table 2. LH, FSH, testosterone and beta-endorphin (BE) levels in HANE women
Patient
Ovaries
LH (mIU/ml)
FSH (mIU/ml)
LH/FSH ratio
Testosterone (ng/ml)
BE (pg/ml)
G.C. C.P. C.E.* T.M. B.B. V.M. M.C. C.A. C.A.M. M.D. P.R.* A.L. A.N.
PCO PCO PCO PCO PCO MFO MFO MFO MFO MFO MFO MFO Normal
192 8 105 127 13 10-7 122 26-2 11 34 10 152 254
13-4 61 77 10.5 81 10-5 76 52 85 54 7-1 71 15 7
14 13 1-3 12 16 1 16 5 13 06 14 21 16
1-09 094 030 058 058 1-10 055 0 52 058 021 0 35 075 0 50
81 144 52 65 80 87 66 25 28 50 60 20 13
87+3 1
1 6+1 1
0-62+0-28
593+352
258+183
