Multicystic ovaries and pituitary pseudo-adenoma associated with primary hypothyroidism

Abstract

Ovarian hyperstimulation syndrome (OHSS) is a well known but poorly understood iatrogenic complication of superovulation. Spontaneous OHSS has been reported with pregnancy, polycystic ovary syndrome, primary hypothyroidism and pituitary adenoma. Only a few cases of massive ovarian enlargement in non-pregnant women with primary hypothyroidism have been reported in the English literature. A definitive pathophysiology remains uncertain, although several postulations were proposed. A 23-year-old nulliparous woman presented with transient bloating of her abdomen associated with menstruation for the last four cycles. She had nausea, headache, faintness, galactorrhoea and clinical signs and symptoms of hypothyroidism (swelling in the hands and feet, cold intolerance, decreased activity, excessive sleepiness, loss of hair and dry skin) for 6 months. Thyroid stimulating hormone and serum prolactin levels were highly elevated (> 100 μg/l and 4,095 μg/l, respectively) and free thyroxine level was low. Abdominal ultrasound showed bilateral multiple thin-walled ovarian cysts. Contrast enhanced CT of brain showed a pituitary macroadenoma. Treatment with levothyroxine was started and showed marked clinical improvement with return to normal menstruation within 4 months. Serial ultrasound showed gradual regression of the ovarian cysts within 6 months. Serum prolactin level was gradually diminished. Awareness that ovarian and pituitary enlargement may be associated with severe hypothyroidism which can be managed successfully, will spare patients dangerous and unnecessary operative intervention for ovarian cysts or pituitary adenoma.

Primary Hypothyroidism Presenting as Spontaneous Ovarian Hyperstimulation

“…Spontaneous OHSS has been mainly reported in cases with elevated levels of hCG as in pregnancy with or without hydatidiform mole [5][6][7][8] or high levels of TSH as in hypothyroidism. There are very sporadic reports in non-pregnant unmarried ladies [9]. One symptom commonly reported in all such cases was pain abdomen.…”

Endocrinal and autoimmune linkage: Evidences from a controlled study of subjects with polycystic ovarian syndrome

“…[ 25 ] Furthermore, a strong interaction between thyroid and ovary is implied by many in vitro researches, both in humans and animals. As human chorionic gonadotropin has a TSH-like effect,[ 26 ] thyroid activity affects the functionality of the reproductive axis[ 27 ] and TSH has been reported highly elevated in ovarian hyperstimulation syndrome[ 28 ] and PCOS patients.…”

Radiological Illustration of Spontaneous Ovarian Hyperstimulation Syndrome

“…Other mechanisms suggest preferential formation of estriol which results in excessive gonadotropin release (with estriol being a weaker suppressor of gonadotropin release than estradiol) [ 23 ]. Patients generally present with mild to moderate OHSS with a good prognosis on Levothyroxine monotherapy [ 22 , 35 ].…”