Int J Gynaecol Obstet 16: 167-169, 1978
Radiographic Abnormalities in Patients with Stein-Leventhal Syndrome Vassilios Tzingounis 1 , Henry Alperin 1 and Puthugramam Natrajan 2 Department of Endocrinology, Medical College of Georgia, Augusta, Georgia, USA Department of Radiology, Medical College of Georgia, Augusta, Georgia, USA
ABSTRACT Tzingounis V, Alperin H, Natrajan P (Depts of Endocrinology and Radiology, Medical College of Georgia, Augusta, GA, USA). Radiographic abnormalities in patients with Stein-Leventhal syndrome. Int J Gynaecol Obstet 16: 167-169, 1978 Radiographic abnormalities in 254 patients with SteinLeventhal syndrome are presented in a retrospective study of the six-year period from 1972-1977. Twenty-two (8.7%) of the patients were found to have abnormal sella turcica x-rays, eight (3.2%) patients had abnormal hysterosalpingograms andJive (2.0%) patients had abnormal intravenous pyelograms. In addition, three patients with an abnormal sella turcica had serum prolactin levels greater than 45 ng/ml, which should be regarded as evidence of a pituitary adenoma. These findings suggest that serum prolactin assays and skull x-rays with polytomography should be routinely performed on patients with Stein-Leventhal syndrome.
normalities in the Stein-Leventhal syndrome (SLS). This paper presents a six-year (1972-1977) retrospective study of x-ray findings on 254 patients with SLS.
MATERIALS A N D M E T H O D S HSG and skull x-rays with polytomography were performed on all 254 women diagnosed as having SLS during the six-year review period. In addition, intravenous pyelography was done in those patients with a congenital uterine anomaly. T h e diagnosis was established in a patient with a history of oligomenorrhea or amenorrhea by the demonstration of bilateral ovarian enlargement by HSG, laparoscopy or laparotomy. In all patients, serum luteinizing hormone values were elevated while serum folliclestimulating hormone levels were within normal limits (5-20 m I U / m l ) (11, 12). Serum prolactin (PRL) assays became available after 1973 and were performed in the last 146 patients (15).
INTRODUCTION RESULTS In their classic paper, Stein and Leventhal described a group of women with secondary amenorrhea in whom bilaterally enlarged polycystic ovaries were found (16). Since then, a vast number of articles have appeared in the literature dealing with the histopathology and endocrinology of this syndrome (2, 6, 7, 19). Hysterosalpingography (HSG) and sella turcica x-rays are performed to detect the presence of ovarian enlargement and to help evaluate possible causes of infertility (10). Except for a paper read by Dr S. Geller at a meeting in Paris, 1977, we were not able to find any references in the literature regarding the incidence of radiologic abV. Tzingounis is a Research Fellow of Endocrinology, Medical College of Georgia, Augusta, GA, USA.
Abnormal x-ray findings were evident in 35 (14%) of the women with SLS. Twenty-two women had abnormal sella turcica x-ray findings; three of these had an enlarged sella turcica and the sella contained demonstrable calcification in the remaining 19. Results of serum P R L values were available in only nine cases. In three of these, P R L levels were elevated and ranged between 45.4 n g / m l and 65.6 n g / m l (normal P R L = < 3 0 n g / m l ) ; galactorrhea was observed in the patient with the highest P R L (Fig. 1). HSG revealed an arcuate uterus in three women and a bicornuate uterus in five others. O n e patient with an abnormal intravenous pyelography had a horse-shoe kidney; four others had duplication of the collecting system.
Int J Gynaecol Obstet 16
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DISCUSSION In our study, the overall incidence of sella turcica abnormalities was 8.7% and 13.6% of these had enlarged sellae. We are unable to estimate whether this incidence is statistically significant due to the lack of any previous study in the literature regarding the incidence of these abnormalities in women with SLS. It would be desirable to investigate further and establish this point. T h e relationship between pituitary tumors and enlargement of the sella turcica has been well documented (9, 17). Although serum P R L levels are usually elevated in these cases, Geller et al reported three cases of Stein-Leventhal syndrome with pituitary microadenoma and normal P R L levels (5). However, in our study, three of nine patients with an abnormal sella were found to have elevated serum P R L levels. Regardless of the presence or absence of hyperprolactinemia, a pituitary microadenoma should be ruled out in all amenorrheic patients (1, 4). Since these tumors may be missed on routine sella x-rays, both P R L assays and thin section tomography utilizing the hypocycloidal technique are indicated for improved diagnosis (8). In our study, 19 of the 22 abnormal sellas were detected by tomography. These abnormalities would have been missed had we performed only routine skull x-rays (Fig. 2). In these 19 women,
IntJ Gynaecol Obstet 16
Fig. 2. Intrasellar calcification (6.2-cm section) in a patient with Stein-Leventhal syndrome without hyperprolactinemia or galactorrhea.
clomiphene citrate a n d / o r ovarian wedge resection failed to induce ovulation. In such patients, Bromoergocryptine could induce ovulatory menses (3). However, pregnancy is not recommended in women harboring a pituitary adenoma, since such tumors may expand during pregnancy (10). Another interesting finding was the high incidence (3.2%) of bicornuate or arcuate uterus in our patients with SLS. The incidence of these congenital uterine malformations has been estimated to be 0.1% in the entire population (13). T h e differences of these incidences were found to be statistically significant (p
Radiographic Abnormalities in Patients with Stein-Leventhal Syndrome Vassilios Tzingounis 1 , Henry Alperin 1 and Puthugramam Natrajan 2 Department of Endocrinology, Medical College of Georgia, Augusta, Georgia, USA Department of Radiology, Medical College of Georgia, Augusta, Georgia, USA
ABSTRACT Tzingounis V, Alperin H, Natrajan P (Depts of Endocrinology and Radiology, Medical College of Georgia, Augusta, GA, USA). Radiographic abnormalities in patients with Stein-Leventhal syndrome. Int J Gynaecol Obstet 16: 167-169, 1978 Radiographic abnormalities in 254 patients with SteinLeventhal syndrome are presented in a retrospective study of the six-year period from 1972-1977. Twenty-two (8.7%) of the patients were found to have abnormal sella turcica x-rays, eight (3.2%) patients had abnormal hysterosalpingograms andJive (2.0%) patients had abnormal intravenous pyelograms. In addition, three patients with an abnormal sella turcica had serum prolactin levels greater than 45 ng/ml, which should be regarded as evidence of a pituitary adenoma. These findings suggest that serum prolactin assays and skull x-rays with polytomography should be routinely performed on patients with Stein-Leventhal syndrome.
normalities in the Stein-Leventhal syndrome (SLS). This paper presents a six-year (1972-1977) retrospective study of x-ray findings on 254 patients with SLS.
MATERIALS A N D M E T H O D S HSG and skull x-rays with polytomography were performed on all 254 women diagnosed as having SLS during the six-year review period. In addition, intravenous pyelography was done in those patients with a congenital uterine anomaly. T h e diagnosis was established in a patient with a history of oligomenorrhea or amenorrhea by the demonstration of bilateral ovarian enlargement by HSG, laparoscopy or laparotomy. In all patients, serum luteinizing hormone values were elevated while serum folliclestimulating hormone levels were within normal limits (5-20 m I U / m l ) (11, 12). Serum prolactin (PRL) assays became available after 1973 and were performed in the last 146 patients (15).
INTRODUCTION RESULTS In their classic paper, Stein and Leventhal described a group of women with secondary amenorrhea in whom bilaterally enlarged polycystic ovaries were found (16). Since then, a vast number of articles have appeared in the literature dealing with the histopathology and endocrinology of this syndrome (2, 6, 7, 19). Hysterosalpingography (HSG) and sella turcica x-rays are performed to detect the presence of ovarian enlargement and to help evaluate possible causes of infertility (10). Except for a paper read by Dr S. Geller at a meeting in Paris, 1977, we were not able to find any references in the literature regarding the incidence of radiologic abV. Tzingounis is a Research Fellow of Endocrinology, Medical College of Georgia, Augusta, GA, USA.
Abnormal x-ray findings were evident in 35 (14%) of the women with SLS. Twenty-two women had abnormal sella turcica x-ray findings; three of these had an enlarged sella turcica and the sella contained demonstrable calcification in the remaining 19. Results of serum P R L values were available in only nine cases. In three of these, P R L levels were elevated and ranged between 45.4 n g / m l and 65.6 n g / m l (normal P R L = < 3 0 n g / m l ) ; galactorrhea was observed in the patient with the highest P R L (Fig. 1). HSG revealed an arcuate uterus in three women and a bicornuate uterus in five others. O n e patient with an abnormal intravenous pyelography had a horse-shoe kidney; four others had duplication of the collecting system.
Int J Gynaecol Obstet 16
] 68
Tzingounis et al
DISCUSSION In our study, the overall incidence of sella turcica abnormalities was 8.7% and 13.6% of these had enlarged sellae. We are unable to estimate whether this incidence is statistically significant due to the lack of any previous study in the literature regarding the incidence of these abnormalities in women with SLS. It would be desirable to investigate further and establish this point. T h e relationship between pituitary tumors and enlargement of the sella turcica has been well documented (9, 17). Although serum P R L levels are usually elevated in these cases, Geller et al reported three cases of Stein-Leventhal syndrome with pituitary microadenoma and normal P R L levels (5). However, in our study, three of nine patients with an abnormal sella were found to have elevated serum P R L levels. Regardless of the presence or absence of hyperprolactinemia, a pituitary microadenoma should be ruled out in all amenorrheic patients (1, 4). Since these tumors may be missed on routine sella x-rays, both P R L assays and thin section tomography utilizing the hypocycloidal technique are indicated for improved diagnosis (8). In our study, 19 of the 22 abnormal sellas were detected by tomography. These abnormalities would have been missed had we performed only routine skull x-rays (Fig. 2). In these 19 women,
IntJ Gynaecol Obstet 16
Fig. 2. Intrasellar calcification (6.2-cm section) in a patient with Stein-Leventhal syndrome without hyperprolactinemia or galactorrhea.
clomiphene citrate a n d / o r ovarian wedge resection failed to induce ovulation. In such patients, Bromoergocryptine could induce ovulatory menses (3). However, pregnancy is not recommended in women harboring a pituitary adenoma, since such tumors may expand during pregnancy (10). Another interesting finding was the high incidence (3.2%) of bicornuate or arcuate uterus in our patients with SLS. The incidence of these congenital uterine malformations has been estimated to be 0.1% in the entire population (13). T h e differences of these incidences were found to be statistically significant (p
