Luigi F. Orsini

Ultrasonic findings in polycystic ovarian disease

The uterus and ovaries of 50 patients with polycystic ovarian disease (PCOD) and 30 eumenorrheic women were studied with a real-time ultrasound mechanical sector scanner. Uterine and ovarian volumes (UV and OV) and the OV/UV ratio were calculated, and ovarian morphology was classified as prevalently solid and cystic. Both ovaries were displayed in 44 of the PCOD and in 25 of the normal patients and appeared bilaterally solid, cystic, or with different morphology, respectively, in 43.2%, 47.7%, and 9.1% of cases in the former group and in 76%, 20%, and 4% in the latter group. Statistically significant differences between normal and PCOD patients were found in OV, UV, and OV/UV ratio. Bilaterally enlarged ovaries with multiple tiny cysts, the classic ultrasonographic picture of the polycystic ovary, were found in only 16 (36.3%) of the PCOD cases, while 34 (77.3%) had an OV/UV ratio greater than 1 standard deviation above the mean. Four ultrasonographic ovarian patterns were observed in the PCOD patients: enlarged cystic; enlarged solid; normal-sized cystic; and normal-sized solid. These findings emphasize the need for a reconsideration of the ultrasonographic criteria of PCOD.

Pelvic ultrasonography in girls with precocious puberty, congenital adrenal hyperplasia, obsesity, or hirsutism

Real-time ultrasonography of the pelvic organs was performed on 151 girls with various complete and incomplete forms of precocious puberty, 20 girls with congenital adrenal hyperplasia, 20 with hirsutism, 18 with obesity, and 133 age-matched normal girls. Uterine and ovarian volumes were calculated and the ovarian morphologic picture was classified as homogeneous, nonhomogeneous (less than three small cystic areas), microcystic (four or more small cystic areas less than 9 mm in diameter), follicular (at least one cystic area greater than 9 mm), and macrocystic (large cystic area greater than 20 mm). Ultrasound imaging allowed an easy distinction between true precocious puberty and premature thelarche or idiopathic premature adrenarche. It was also helpful in the diagnosis of transient sexual precocity, although in these cases the differential diagnosis of precocious puberty can be difficult. In postmenarcheal patients with congenital adrenal hyperplasia, ultrasound study showed a low uterine volume and, frequently, a macrocyst in the ovary. In hirsute girls and in a few obese patients, ovaries had an increased volume and a microcystic structure, similar to those in polycystic ovary syndrome. Pelvic ultrasonography can be useful not only in diagnosing disorders in sexual development but also for greater understanding of the pathogenesis of these and other disorders.

Menstrual Irregularities in Adolescents: Hormonal Pattern and Ovarian Morphology

The endocrine pattern and ovarian characteristics of 110 healthy adolescents with menstrual irregularities were investigated during the early follicular and premenstrual phases and were compared to those of 14 adolescents with regular menstrual cycles and 20 adults. Over a period of six gynecological years a low ovulation rate (49%) was found in the group of subjects with irregular cycles and regular ovulation was noted in only a few subjects. Slight differences in endocrine pattern and ovarian morphology were observed between the group of adolescents with regular cycles and the group of adults. In contrast, adolescents with irregular menses had higher mean values of luteinizing hormone (LH), testosterone (T), and androstenedione (A) in comparison with the other two groups both in follicular and premenstrual phases. Nearly 35% of the subjects with irregular cycles had levels of T, A and LH which were higher than the upper limit of the adult normal range. Lower progesterone (P), 17P and oestradiol values were observed in the premenstrual phase. Within the group of subjects with irregular menses, LH levels were higher in anovulatory than in ovulatory cycles, in both phases of the cycle, while T and A levels were higher and prolactin levels were lower in the premenstrual phase of anovulatory cycles. Unlike irregular anovulatory cycles, irregular ovulatory cycles showed a hormonal pattern similar to that found in the adult group. By ultrasound evaluation, a high percentage of subjects with irregular menses had multicystic ovaries (57.9%) and the mean (+/- SEM) ovarian volume was higher (10.6 +/- 0.5 cm3) than that found in adolescents with regular menses (6.7 +/- 0.8 cm3) and in the adult group (7.7 +/- 0.3 cm3). With the increase in frequency and continuity of ovulation an improvement in the direction of adult volume and ovarian structure was observed. Besides the endocrine similarity the data emphasize the striking similarity, already documented by histological studies, between pubertal ovaries and those seen in micropolycystic ovary syndrome. These endocrine and ovarian characteristics are typical of a large number of adolescents with irregular menstrual cycles: these features may be representative of a developmental step toward adult normality, although the possibility of a pathological evolution for some subjects cannot be excluded.

ANTENATAL RECOGNITION OF CEREBRAL ANOMALIES

Modern ultrasound equipments allow a detailed investigation of the fetal brain from a very early stage of development. Congenital anomalies arising from or involving the central nervous system can be accurately predicted. On the basis of their personal experience, which includes 48 cases, and of a review of the current literature, the authors discuss criteria for the intrauterine diagnosis and obstetrical management of intracranial anomalies such as hydrocephalus, holoprosencephaly, cephaloceles, porencephaly, hydranencephaly, and microcephaly.

Uterine development and endocrine relationships after menarche

Uterine volume and ovarian/uterine ratio during the first 6 postmenarchal years in 143 women were compared with an adult control group. Plasma gonadotropins and sex steroids were also correlated with uterine volume in adolescents. Uterine volume increased progressively and correlated positively with advancing postmenarchal (r = 0.24; p less than 0.05) and chronologic (r = 0.23; p less than 0.05) age. However, normal adult uterine volume was not yet reached by the highest postmenarchal (6 years) and chronologic (18 years) age. The ovarian/uterine ratio decreased gradually with increasing postmenarchal age but was always higher (0.22) than that of control subjects (0.12). Uterine volume correlated positively with plasma estradiol (r = 0.25; p less than 0.05) and dehydroepiandrosterone (r = 0.22; p less than 0.05) and its sulfate (r = 0.22; p less than 0.05) levels. This study indicates that the uterus continues to grow after menarche in conjunction with increasing hormone levels.

Human urinary follicle-stimulating hormone and human menopausal gonadotropin in induction of multiple follicle growth and ovulation

Five normally menstruating women were treated, in an attempt to induce development of multiple follicles, with pharmacologic doses of purified human urinary follicle-stimulating hormone (hU-FSH) and (in another instance) with human menopausal gonadotropin (hMG) administered on the second and third days after the onset of menses. All of the cycles were ovulatory: the follicular phase was short and the luteal phase length was normal in both hMG and hU-FSH treatment. No substantial differences were seen between the two types of treatment in regard to plasma values of FSH, luteinizing hormone (LH), estradiol (E2), testosterone, and progesterone (P). FSH, E2, and P increased to supraphysiologic levels, and LH fluctuated within the normal range. On ultrasound examination, a large number of growing and matured follicles were visualized during both treatments: at human chorionic gonadotropin administration, multiple preovulatory follicles (greater than or equal to 15 mm) and only a few small follicles (less than 10 mm) were imaged, without any difference between the two types of treatment. Multiple corpora lutea were often obtained. These data underline that pharmacologic doses of FSH alone are able to induce the growth of multiple preovulatory follicles when the initiation of stimulation is timed early. Besides this, exogenous LH does not seem to interfere with follicular recruitment, and it is not required for follicular maturation and ovarian steroidogenesis when endogenous normal LH mean values are present.

Intravascular intrauterine transfusion for severe erythroblastosis fetalis using different techniques

Over a 3-year period, 44 ultrasound-guided intravascular transfusions were performed between 18 and 32 weeks on 15 patients with severe erythroblastosis fetalis due to Rh immunization. In 4 fetuses, the first transfusion was performed before 20 weeks, in 6 between 20 and 25 weeks and in the remaining 5 between 25 and 31 weeks. Eight of the 15 fetuses were hydropic at the time of referral. Five transfusions were done in the intrahepatic umbilical vein, 6 were simple transfusions via percutaneous umbilical cord puncture, and 33 were partial exchange. There were 4 intrauterine deaths before 26 weeks, despite successfully performed transfusions: 3 of these fetuses were severely hydropic, while in the remaining fetus hydrops had been reversed in utero. Following delivery by cesarean section at 32 weeks of gestation, 1 of the neonates developed respiratory distress syndrome and died 17 h after birth. The overall survival rate was 67% (10 of 15 cases): 4 of the 8 hydropic fetuses (50%) and 6 of the 7 nonhydropic fetuses (83%) were alive at birth and survived the perinatal period. Three of the 5 losses occurred among the first 4 cases, while in the last 11 cases the survival rate increased to 82% (9 of 11).

Ultrasound study of ovarian and uterine morphology in women with polycystic ovary syndrome before, during and after treatment with cyproterone acetate and ethinyloestradiol

SummaryWomen with the polycystic ovary syndrome were treated cyclically for two years with an oral oestrogen/progestogen combination of 50 mg of cyproterone acetate and 0.05 mg of ethinyloestradiol. Ovarian volume, ovarian texture and uterine size were monitored by ultrasound before, during and after treatment. Menstrual rhythm, ovulation and the degree of hirsutism were also studied clinically. A significant decrease in the ovarian volume and in the number of cystic areas was observed during treatment. Hirsutism was also markedly improved. Some of these beneficial effects persisted after treatment was stopped. The number of subjects who had regular, ovulatory cycles increased after stopping treatment. Growth of uterine muscle occurred during treatment.

Glycosaminoglycan analysis in amniotic fluid and in cultured fibroblasts from normal and holoprosencephalic human embryonic organs

Glycosaminoglycans are polysaccharides involved in epithelial–mesenchymal interaction and cell differentiation and provide a meshwork which is essential to maintain a proper intercellular milieu. The development of embryonic organs can be accompanied by alterations in the glycosaminoglycan pattern. In pregnancies with malformed fetuses, there are alterations in total glycosaminoglycans and their components (chondroitin 4–6 sulphate, dermatan sulphate, and hyaluronic acid) in amniotic fluid. We examined total glycosaminoglycans and the percentage variations of the single classes in both amniotic fluid and culture medium of fibroblasts from heart, lung, and skin obtained from five normal human fetuses and one with holoprosencephaly. In the amniotic fluid total glycosaminoglycans and their sulphate classes were increased, whereas hyaluronic acid was decreased, compared with controls. The extracellular glycosaminoglycans showed hyaluronic acid reduction in skin, while chondroitin 4–6 sulphate plus dermatan sulphate and heparan sulphate were higher in skin and heart. Our data demonstrate that variations in the glycosaminoglycan pattern are associated with alterations of the cellular environment, which can prevent normal organogenesis.

Endocrine and ovarian parameters at various frequencies of ovulation in adolescents

SummaryWe assessed ovarian and endocrine function in 86 adolescents over a six month, period. Postmenstrual Estrone (E1) and Estradiol-17β (E2) levels, premenstrual FSH levels and pre-and postmenstrual LH, Testosterone (T) and Androstenedione (A) levels decreased as the frequency of ovulation increased, while premenstrual E2, Progesterone (P) and 17α-hydroxyprogesterone levels increased. Both right and left ovarian volume and the per cent of multifollicular ovaries decreased with an increase in the frequency of ovulation. In the premenstrual phase P values correlated significantly with frequency of ovulation for FSH (r=−0.43:P<0.001), LH (r=−0.36:P<0.01), T (r=−0.31:P<0.05) and A (r=−0.26:P<0.05). Our data suggest that in the postmenarcheal period the progressive loss of immature endocrine and ovarian characteristics (high LH, FSH, and androgen levels and enlarged, multifollicular ovaries) is linked to an increasing number of ovulations. Progesterone plays a major role in the development of cyclic function characteristic of adult maturity.