bluuebunny/crossref_metadata_2025 huggingface dataset:
Leptin Secreted in the Testicular Microenvironment Promotes the Endogenous Function of Leydig Cells Through Hedgehog Signaling Pathway
Authors: Arora Himanshu , Parmar Madhumita , Khodamoradi Kajal , Qureshi Rehana , Hare Joshua M , Ramasamy Ranjith
Published: May 2021

Objective: Testosterone deficiency (TD) is a common health concern, affecting around 1 in 5 men globally. However, the factors responsible for TD remain largely unknown. Leydig cells produce testosterone in the testes under the pulsatile control of luteinizing hormone (LH) from the pituitary gland. Leydig stem cells (LSC) have the potential to differentiate into adult Leydig cells, which can increase testosterone levels; however, the factors promoting differentiation are unknown. In the present study we evaluated the paracrine factors released from the testicular microenvironment (TME) (comprised of Sertoli and peritubular myoid cells) that modulate the differentiation of Leydig stem cells to adult Leydig cells. Additionally, we explored the underlying mechanism of action of these paracrine factors.

Methods: Tissue samples were obtained from a total of 13 men with testicular failure, who underwent testis biopsies for sperm retrieval. Using an IRB approved protocol, about 10mg of testicular tissue from each sample were processed for LSC isolation, culturing, and characterization. Cytokine antibody array was performed to identify the paracrine factors released by Sertoli and peritubular myoid cells using unsorted and CD146+ve sorted cells. The cells were treated with hedgehog signaling agonist and antagonist to validate the specificity of paracrine factors identified. Immunostaining was performed to evaluate changes at the protein level. Flow cytometry was performed to study the shift in the population of cells post leptin treatment. GraphPad Prism (GraphPad Software) was used for statistical analysis.

Results: This study revealed that the TME plays an instrumental role in Leydig stem cell differentiation and testosterone production through regulation of the desert hedgehog (DHH) signaling pathway. TME-secreted leptin induces LSC differentiation and increases testosterone production. However, these effects are inversely concentration-dependent: positive at low leptin doses and negative at higher leptin doses. Mechanistically, leptin acts on LSCs upstream of DHH in a unidirectional fashion, as DHH gain or loss of function was shown to have no effects on Leptin levels.

Conclusions: These findings identify leptin as a key paracrine factor released by cells within the TME that modulate LSC differentiation and testosterone production from adult Leydig cells, a finding that is key to developing new niche therapies for TD.
P53 Gain-of-Function Mutants and Steroids in Ovarian Cancer Cell Metastasis
Authors: Candelaria Nicholes , Padmanabhan Achuth , Lanz Rainer , Wong Kwong , Richards JoAnne S
Published: May 2021

High-grade serous ovarian cancer (HGSOC) is a heterogeneous disease for which there currentlyis no cure. Because p53 is mutated in >90% of all ovarian cancer, we studied specific gain-of-function (GOF) p53 mutants and steroid hormones for tumor morphology and metastasis in vivo. For this, we analyzed ALST (WT p53), SKOV3 (p53 null), TYK-NU (p53-R175H), OVCAR3 (p53-R248Q) and OVCA420 (p53-R273H) cell line xenografts in Foxn1-/- mice. ALST cells failed tometastasize, likely due to the known apoptotic effects of WT p53. SKOV3 and the p53-GOF celllines metastasized to the omentum and exhibited distinct morphologies: SKOV3, epithelial-like;TYK-Nu, vascular-like; OVCAR3, epithelial/mesenchymal; and OVCA420 epithelial exclusive. Despite different morphologies and p53 status, each tumor type contained large, Polyploid GiantCancer Cells (PGCCs) that are stem-like cells undergoing endoreplication. A specificphosphorylated, active form of β−catenin (pCTNNB1-S31/S37/T41; pCTNNB1) co-localizedselectively with GOF p53 and the mitotic stress regulatory kinase pMSK1-T581 in mitotic cells andPGCCs, indicating that in addition to GOF p53 mutants, pCTNNB1 and pMSK1 play a role intumor progression. To determine if ALST cells could be rendered metastatic, the p53 GOFmutants R175H and R273H were stably expressed in these cells. Remarkably, the ALST(WT/R273H) cells, but not the ALST (WT/R175H) cells, formed solid tumors on the ovary, visceralfat and uterus; but not on the omentum where OVCA420 (p53-R273H) cells formed tumors. TheALST (WT/R273H) tumors harbored discreet populations of pCTNNB1+ mitotic cells and PGCCsand exhibited distinct growth-promoting responses to estradiol while showing growth-inhibitoryeffects of DHT and nuclear AR in the tumor-associated stromal cells. Stably expressing p53-R175H or p53-R273H GOF mutants in SKOV3 (p53 null) cells enhanced tumor progression withthe R273H mutant being most aggressive. The parental SKOV3 tumors also contained pCTNNB1that was associated with mitotic cells and PGCCs. In the SKOV3 p53-R175H cells - and moreimpressively in the p53-R273H cells - pCTNNB1 co-localized with p53 in PGCCs. Whereas ESR1staining was diffuse in the ALST-R273H cells, it was nuclear in the SKOV3 cell lines. However,tumor promotion by estrogen and inhibition by DHT were observed in each SKOV3 cell line,suggesting that stromal cells may also contribute to the steroid dependent effects. Collectively, 1)elevated levels of specific phosphorylated forms of CTNNB1 and MSK1 identify mitotic cells andPGCCs within the tumors and new targets for therapeutic approaches; 2) knowing the status ofp53, and the presence and localization of pCTNNB1 and pMSK1 and steroid hormone receptorsin ovarian tumors suggest combinatorial approaches should be considered to combat the mostlethal gynecological cancer. NIH-CA181808; NIH-HD097321 (JSR).
Upregulation of Aryl Hydrocarbon Receptor in Granulosa Cells by Endoplasmic Reticulum Stress Contributes to the PCOS Pathophysiology
Authors: Kunitomi Chisato , Harada Miyuki , Azhary Jerilee M K , Kusamoto Akari
Published: May 2021

Studies have demonstrated that endocrine disrupting chemicals (EDC) are involved in the pathophysiology of PCOS, and aryl hydrocarbon receptor (AHR) mediates the cellular effect of EDC by inducing xenobiotic metabolizing enzymes including cytochrome P450 1B1 (CYP1B1). However, recent studies suggest the novel role of AHR in various diseases, including obesity and cancer progression, independent from the EDC metabolism. We previously demonstrated that endoplasmic reticulum (ER) stress, a newly recognized local factor, contributes to PCOS pathology by affecting diverse functions of granulosa cells. We hypothesized that ER stress induces the expression of AHR and activates its downstream signaling in granulosa cells, irrespective of the presence of EDCs, thereby promoting PCOS pathogenesis. At first, we determined the upregulation of AHR, AHR nuclear translocator (ARNT), and AHR target gene cytochrome P450 1B1 (CYP1B1) in the granulosa cells of PCOS patients and model mice by immunohistochemical staining and qPCR. We examined CYP1B1 as a representative AHR target gene. Treatment of cultured human granulosa-lutein cells (GLCs) with tunicamycin (ER stress inducer) upregulated the expression of AHR, ARNT and CYP1B1. Knockdown of AHR decreased the tunicamycin-induced expression and activity of CYP1B1, suggesting the intermediary role of AHR in upregulation of AHR activity by ER stress. To confirm the role of AHR in vivo, we administered the AHR antagonist CH223191 to PCOS model mice. The administration of the antagonist restored estrous cycling and decreased the number of atretic antral follicles, concomitant with downregulation of AHR and CYP1B1 in granulosa cells. Taken together, this study indicates that AHR and downstream signaling are activated by ER stress in GLCs of PCOS. Moreover, downregulation of local AHR expression and activation restores a normal reproductive phenotype in a PCOS mouse model. Our findings demonstrate that AHR activated by ER stress in the follicular microenvironment contributes to PCOS pathology, and that AHR represents a novel therapeutic target for PCOS.
Changes in Clinical Presentation and Perioperative Management of Pheochromocytomas and Paragangliomas: A Four-Decade Experience in a Academic Center
Authors: Uslar Thomas , Francisco Ignacio San , Olmos Roberto Ignacio , Macchiavello Stefano Pietro , Zuñiga Alvaro , Rojas Pablo , Garrido Marcelo , Huete Alvaro , Medez Gonzalo , Cifuentes Joaquin , Castro Fernando , Zemelman Jose Tomas , Olivari Daniela , Fardella Carlos E , Arteaga Eugenio , Ruiz-Tagle Jose Miguel Dominguez , Valdes Gloria , Tagle Rodrigo , Baudrand Rene
Published: May 2021

Objective: Latin American reports on pheochromocytomas and paragangliomas (PPGL) are scarce. Recent studies have shown changes in both clinical presentation and management of these patients. We aimed to assess the main characteristics of PPGL patients in a single academic center over the last four decades. Experimental design: Cohort study. Patients and methods: Demographic, clinical, biochemical, genetic and perioperative data from 105 PPGL patients were retrospectively and prospectively collected over the 1980–2019 period. Patients were categorized into four groups (14 patients in the 1st, 25 patients in the 2nd, 27 patients in the 3th and 39 patients in the 4th decade) according to the date of diagnosis. Results: The mean age at diagnosis was 46±19 years, and the tumor size was 5.3±2.2 cm, female gender was 63%, bilateral tumor of 15%, paragangliomas 9% and metastatic disease in 15%. The aforementioned parameters remained stable across the four decades. During the study period we observed significant increases in doxazosin dosing (2.7±2.6 mg vs. 8.0±4.5 p<0.003) and laparoscopic procedures (28% vs. 84% p<0.001) along with a decrease in the length of hospital stay (10.0±8.9 vs. 3.8±1.7 days p=0.007). Among the 24 genetic tests performed, we identified 59% germline mutations. The most frequent mutations were RET (18%) and SDHX (18%), followed by VHL (14%), MAX (5%) and NF1 (4%). Notably, in the last decade we observed a dramatic increase in the proportion of incidental PPGL diagnosis (0% vs. 53% p<0.001) and genetic testing analyses (0 vs. 19 p<0.001). When comparing incidental diagnosis (n=25) versus clinically suspicious cases(n=50), incidentalomas had fewer adrenergic symptoms (38 vs. 62%; p<0.001), and lower rates of hypertension (64 vs. 80%; p=0.01), hypertension crises (28 vs. 44%; p=0.02), functionality (79 vs. 100%; p=0.01) and total catecholamines and/or metanephrine levels (8.4 vs. 12.5 fold above the upper normal limit; p=0.04). Conclusions: The implementation of a multidisciplinary program increased diagnosis and genetic testing and also optimized anesthesia and surgical procedure, translating into a notorious improvement in perioperative outcomes. In addition, we observed a change in the clinical presentation of PPGL in recent decades with a

marked increase in incidental cases, which highlights the importance of early diagnosis and treatment.
A Rare Case of Autoimmune Progesterone Disease
Authors: Padmanaban Preethi
Published: May 2021

Background: Autoimmune progesterone disease is a rare disease, with fewer than 200 reported cases. Unfortunately, there are no published estimates of incidence or prevalence.

Clinical Case: A 24 year-old woman with no significant past medical history presented with sudden and new onset swelling of the lips which was unresponsive to Benadryl and prednisone. Swelling eventually progressed into blistering over the lips, oral, pharyngeal mucosa and tongue. She was admitted to the hospital for suspicion of Steven Johnson syndrome and was discharged after resolution of skin and oral lesions following treatment. She presented again in 3 months with full body rash and blisters now involving oral and vaginal mucosa. She underwent biopsy of these lesions during this admission and findings were suspicious for drug eruption vs erythema multiforme. Unfortunately, inciting drug or event could not be associated even with pathological diagnosis. She continued to have mucocutaneous flare every month for the next 8 months with multiple hospitalizations and was treated with antibiotics during these admissions. Over the course of her evaluation, it was noted that her symptoms seemed to coincide with her menstrual cycles. Her IUD was removed and she was started on OCPs but her symptoms persisted without any improvement. She underwent intradermal progesterone challenge test at tertiary center for ongoing cyclical dermatitis and tested positive for progesterone sensitivity. She was diagnosed with Autoimmune Progesterone dermatitis. She had to ultimately undergo total abdominal hysterectomy and bilateral salphingo-oophorectomy as she failed OCPs and had adverse effects to progesterone desensitization including full body rash and blisters. Post operatively, she has been started on IM depot injections of estrogen and vaginal estrogen cream.

Conclusion: Autoimmune progesterone disease also known as progesterone dermatitis or progesterone hypersensitivity is not associated with other autoimmune diseases and usually affects women of reproductive age. It is a rare disorder with variable presentation and often overlaps with other forms of dermatosis. It is commonly underdiagnosed or misdiagnosed and appropriate treatment is often delayed. High clinical suspicion for symptoms of cyclical nature is necessary for making the diagnosis.
Virilization Secondary to an Ovarian Leydig Cell Tumor
Authors: Symczyk Oksana , Turner Jennifer Sarah , Barghouthi Nadia , Perini Jessica Antoinette
Published: May 2021

A 60-year-old female presented with a three-year history of virilizing symptoms including facial hirsutism and deepening of voice. Her medical history was significant for renal transplantation with immunosuppressive therapy consisting of mycophenolate, cyclosporine, and low-dose prednisone. She was noted to have temporal balding and darkly pigmented terminal hair on the upper lip, cheeks, chin, shoulders, and sternum. Pelvic examination revealed clitoromegaly. Menarche occurred at age 12 with regular menstrual cycles until menopause which occurred at age 50. She had two pregnancies: a miscarriage followed by a successful pregnancy.

Labs revealed an elevated total testosterone of 530 ng/dL (< 60 ng/dL), free testosterone 14.8 ng/dL (<0.87 ng/dL), androstenedione 2140 ng/dL (<200 ng/dL), and 17-hydroxyprogesterone 704 ng/dL (<285 ng/dL). LH, FSH, and estradiol were inappropriately normal in this post-menopausal female. Prolactin, TSH, DHEA-S, IGF-1 were within normal limits. Transvaginal ultrasound found a 2 cm hypoechoic right ovarian mass which was confirmed on MRI. MRI also revealed a 5 mm right adrenal nodule. Tumor markers including CA-125, Inhibin A, Inhibin B, HCG, and AFP were within normal limits. Dexamethasone suppression testing did not lower the testosterone level. 17-hydroxyprogesterone level after cosyntropin stimulation testing was 704 ng/dL (<1000 ng/dL). The patient underwent laparoscopic bilateral oophorectomy and salpingectomy, pelvic washout and omental biopsy. Pathology was consistent with a benign Leydig cell tumor. Following oophorectomy there was complete normalization of the total testosterone level (15 ng/dL, n< 60 ng/dL).

A thorough history and physical exam is vital in determining the cause of hirsutism. Medications, including over-the-counter and herbal formulations should be carefully reviewed. Although cyclosporine has been associated with hirsutism, patients typically present with vellus hair formation in the affected areas rather than darkly pigmented terminal hair. In this case, hirsutism progressively worsened following menopause and physical examination was significant for virilization. Hirsutism in a combination with virilization is typically neoplastic in nature. Endogenous androgen production can originate from either the adrenal glands or ovaries. In our patient, with workup showing both ovarian and adrenal as potential sources of endogenous androgen production, an adrenal cause was excluded due to a normal DHEA-S level at baseline and a lack of suppression of testosterone after dexamethasone suppression testing. As a result, the source was localized to the ovary. While excessive androgen production resulting in virilization is seen with ovarian tumors, Leydig stromal cell tumors are extremely rare and account for less than 0.1% of all ovarian tumors.
Cardiovascular Risk Factors in Transgender Women Undergoing Long-Term Gender-Affirming Hormone Therapy: A Cross-Sectional Study
Authors: Alvares Leonardo A M , Santos Lívia M , Ramos Henrique A , Rodeghel Larissa G , Cavenaghi Nathan B , Araújo Clara M , Santana Thiago R , Mendonca Berenice Bilharinho , Costa Elaine Maria Frade , Domenice Sorahia
Published: May 2021

Introduction: Few data of long-term outcomes of cardiovascular (CVRF) risk factors of transgender women (TW) undergoing gender-affirming hormone therapy (GAHT) are available. Objectives: Evaluate CV risk factors after long-term GAHT in TW. Methods: A cross-sectional study was carried out with 8 TW (average age of 34.0 ±4.8 yo), 8 matched CM and 8 CW on age, body mass index (BMI) and activity level. All TW were non-gonadectomized subjects and were in estrogen [(E); transdermal estradiol (n=2), oral estradiol (n=3) and conjugated estrogen (n=3)] plus cyproterone acetate (CA) (n=8) therapy in an average time of 15.6 ±8.7 years. Results: Total Testosterone (ng/dL) level of TW, CW and CM were 83,5 (range 12,0-637,0), 20,5 (range 12,0-41,0) and 480,5 (range 264,0-843,0), respectively. It was similar between TW and CW (p=0,7284) and different in the comparison TWvsCM (p=0,0325). In TW group, the median of blood glucose was 84 mg / dL, HBA1c 5.1%, total cholesterol 146 mg / dL, HDLc 43 mg / dL, LDLc 89 mg / dL and triglycerides 81.5 mg / dL. In the comparison with other groups, there was no difference from the statistical point of view. It is necessary to emphasize the HDLc of TW (43 mg/dL) which was exactly the same of CM (p>0,999) and lower than CW (60 mg/dL)(p=0,0720). Systolic Blood Pressure (SBP)(mmHg) of TW (126±13) was higher than that of CW (95±11;p<0.001) and equal to that of CM (115±9;p=0.1489). Regards Diastolic Blood Pressure (DBP) (mmHg), the medians of TW, CW and CM were 80, 60 and 80, respectively, and in the comparison TWxCW p = 0.0070 and TWxCM p> 0.9999. Discussion: Youth TW (16.3 ± 1.4 yo) taking an average estradiol dose of 1.5 ± 1.0 mg/day, with an average AGHT duration of 12.3 ± 9.9 months matched to controls on age and BMI did have higher HDL than CW and TW participants were more insulin resistant than CM. About SBP of that youth TW (107 ± 12), it was lower than CW 113 ± 7 (p>0,05) and CM 116 ± 8 (p<0,001). Other previous study showed that after 6 months of estradiol use, in doses ranging from 2 to 8 mg daily glucose enhanced 6 mg/dL (from 86 to 92) as well as TC from 170 to 178 mg/dL, HDLc from 50 to 54 mg/dL, TGL from 102 to 115 mg/dL, and LDL did not change (93), while a systematic review and meta-analysis showed increased only in TG levels. SBP and DBP increased on average of 7,2 mmHg and 5,7 mmHg, respectively. Conclusion: Metabolic findings observed after the first few months of TW GAHT appear to remain at long term, except for HDLc. SBP and DBP appear to increase in the long term, after a drop initially observed.
Case Report: Invasive Endometrial Cancer in a Trans Man and Risk of Testosterone Therapy
Authors: Jeevananthan Athavi , Iyengar Ravi M
Published: May 2021

Background: Only one case of uterine cancer in a trans man on testosterone is noted in literature prior to this case. No clinical evidence nor guidelines exist regarding testosterone therapy for this subset of patients.

Clinical Case: A 41-year-old trans man was seen by Gynecology for vaginal bleeding, with work-up revealing thickened endometrium and biopsy with endometrial adenocarcinoma. Testosterone therapy was held, and patient underwent total hysterectomy with BSO and bilateral pelvic/aortic lymph node dissection. Pathology demonstrated stage IIIA invasive adenocarcinoma, endometrium type with focal squamous differentiation, low grade. The tumor extended into the endocervical stroma with small metastasis to one ovary. He received adjunct pelvic radiation and sandwich chemotherapy with carboplatin and taxol. Concurrently, he was referred to Endocrinology for management of hormone replacement therapy (HRT). He originally started weekly testosterone injections and anastrozole at an outside facility in 2016 and underwent bilateral mastectomy in 2017. Testosterone was held perioperatively and during chemoradiation, for a total duration of 9 months. The patient experienced worsening gender dysphoria during this time. Discussion was held on goal to restart HRT in the setting of a theoretical risk of testosterone conversion to estradiol with increased risk of cancer recurrence; thus, patient initially chose to delay re-initiation of HRT. Following the completion of chemotherapy, he started on low-dose (30mg) weekly IM testosterone with plans for continued monitoring of testosterone and estradiol levels.

Conclusion: Research is needed in monitoring the effects of testosterone therapy on reproductive organs in patients assigned female at birth, and whether anastrozole therapy has protective effects for estrogen-driven cancers. Further, guidance is needed on monitoring of uterine lining in trans men and whether this should be standard of practice.
Partial Gender-Affirming Hormone Treatment in Non-Binary Transgender Individuals in a Referral Center Cohort
Authors: Van Dijken Josianne , Steensma Thomas , Wensing-Kruger Annelijn , Den Heijer Martin , Anton Dreijerink Koen Marie
Published: May 2021

Context: Hormone treatment (HT) is a cornerstone of gender-affirming therapy in transgender and gender non-conforming people. Non-binary and genderqueer (NBGQ) people, individuals identifying in between or outside the male to female binary, are increasingly recognized. Not all trans people and NBGQ binary individuals seek full HT. Current guidelines for HT of transgender and gender non-conforming people do not include specific regimens for people who seek partial treatment. Objective: To compare HT prescribed to NBGQ and binary trans people. Design: Retrospective study. Setting: Referral clinic for gender dysphoria. Participants: 602 applicants for gender care in 2013-2015. Intervention: GenderQueer Identity questionnaires at entry were used to categorize people as NBGQ or binary transgender. Medical records were assessed until the end of 2019. Main Outcome Measures: prescribed HT, serum estradiol and testosterone concentrations. Results: 113 individuals identified as non-binary and 489 as binary transgender. NBGQ persons were more likely to receive partial HT than binary transgender people (11% versus 4.7%, p=0.02). None of the NBGQ individuals who received partial HT had undergone gonadectomy, hypogonadism did not occur. NBGQ individuals assigned male at birth using only estradiol had similar estradiol and higher testosterone serum concentrations compared with individuals using conventional HT. Conclusions: NBGQ individuals are more likely to receive partial HT compared with binary transgender people. In the future, tailored endocrine counseling may further shape partial HT regimens for NBGQ individuals.
Patient Characteristics Associated With the Receipt of Hormone Therapy Among Transgender Patients in the Veterans Health Administration
Authors: Wong Denise H , Vimalananda Varsha G , Reisman Joel I , Rao Sowmya R , Shipherd Jillian C , Wolfe Hill L , Blosnich John R , Livingston Nicholas A , Jasuja Guneet K
Published: May 2021

Background: Many transgender patients experience gender dysphoria as a result of an incongruence between their gender identity and sex assigned at birth. Gender-affirming hormone therapy improves the quality of life for transgender patients seeking to increase alignment of their secondary sex characteristics and gender identity. However, little is known about the patient factors that are associated with receipt of this therapy which is critical to identifying areas for improvement in care for transgender patients. Objective: To evaluate patient characteristics associated with transgender patients’ receipt of hormone therapy from the Veterans Health Administration (VHA). Methods: Inpatient and outpatient data were reviewed for transgender patients, identified through ICD-9/ICD-10 diagnosis codes for gender identity disorder (GID), receiving VHA health care from January 2006 to December 2018. We evaluated receipt of hormone therapy (testosterone or estrogen +/- spironolactone) from the VHA, socio-demographics, comorbidities, social stressors, military sexual trauma, and documented suicide attempts. Adjusted Odds Ratios (aOR) and 95% Confidence Intervals (CI) were obtained from a multivariable logistic regression model used to ascertain the relationship between patient characteristics and hormone therapy. Results: Of 9,406 patients with documented GID, 5,487 (58.3%) received hormone therapy from the VHA. Compared to patients not receiving hormone therapy, a higher proportion of patients receiving hormone therapy were younger (21-29 years: 18.1% vs. 11.6%; 30-39 years: 20.0% vs. 14.6%; 40-49 years: 16.2% vs. 13.6%), had documentation of a positive military sexual trauma screening (22.2% vs. 16.2%; p<0.0001), and a suicide attempt (11.4% vs. 9.9%; p=0.0067). There were significant associations between receipt of hormone therapy and: 1) younger age (aOR: 1.33; 95% CI: 1.29-1.36; p<0.0001); 2) Black non-Hispanic patients (aOR: 0.58; 95% CI: 050-0.68; p<0.0001); 3) increasing number of comorbidities (aOR: 0.86; 95% CI: 0.84-0.88; p<0.0001); and 4) increasing number of social stressors (aOR: 0.86; 95% CI: 0.83-0.90; p<0.0001). Conclusions: Age, race/ethnicity, comorbidities, and social stressors among other factors are associated with receipt of hormone therapy among transgender patients in the VHA. Subsequent efforts should focus on understanding clinician- and site-level determinants to facilitate the design of effective quality improvement measures that optimize gender affirming hormone therapy through VHA for transgender patients.
Prolactinoma in a Male to Female Transgender Woman on Gender Affirming Hormone Therapy
Authors: Harned Leighton K , Harper Rene J
Published: May 2021

Background: Estrogen promotes prolactin secretion and its role in prolactin secreting adenomas is still under investigation. The genesis and resolution of prolactinomas may be affected by gender affirming hormone therapy.

Case Description: A 50 year old transgender female presented with new onset tunnel vision and extremity parathesias for one day. She had been taking oral estrogen for six years. Physical exam showed bilateral gynecomastia as well as galactorrhea. Her visual fields were intact by confrontation.

Her brain MRI revealed a pituitary macroadenoma measuring 1.4cm x 1.3cm x 1.3cm. Laboratory studies showed prolactin 538 ng/mL (<20 ng/mL), IGF-1 89.0 (66-303 ng/ml). TSH 1.7 (0.4-4.7 mcIU/mL), Free T4 0.997 (0.58-1.76 ng/dL) and estradiol 103 pg/ml (N/A).

She was treated with bromocriptine 5mg daily. Three months later galactorrhea had resolved, but gynecomastia was unchanged. The patient had a prolactin level of 3 ng/mL. Follow up brain MRI at one and three years showed no significant decrease in size of macroadenoma. Discussion: Despite this patient’s biochemical and symptomatic response to dopamine agonist therapy, her pituitary adenoma did not decrease in size over 3 years, which is a common occurrence with macroprolactinomas. However, her prolactin levels declined and her galactorrhea resolved with therapy. Research into the long term effects of gender transition therapy remains mainly in the realm of case reports and retrospective studies. Our review of the medical literature suggests that some transgender patients on estrogen therapy may have an increased risk of developing pituitary adenomas. However, guidelines have not yet been published and currently there are no recommendations for routine imaging or biochemical assessment during follow-up of these patients. While there are established reference ranges for prolactin levels for men, non-pregnant and pregnant women, no established reference ranges for prolactin levels are available for transgender women on gender affirming hormone therapy. Studies indicate that 76-86% of patients have a reduction in the size of their prolactinomas after dopamine agonist therapy. However, the same may not be true for transgender women on transfeminine hormone therapy with estrogen.

Conclusion: Prolactinomas may commonly occur and be masked in transgender women on gender affirming hormone therapy due to the expected symptoms of gynecomastia, erectile dysfunction, and diminished libido from reduced testosterone levels. Estrogen promotes prolactin secretion by the pituitary gland and may have a role in development and expansion of prolactinomas. More research is needed in regards to the assessment and monitoring of the pituitary gland in transgender women on gender affirming hormone therapy with estrogen.
Evaluation of Enzymatic Activity of Various HSD17B3 Mutants Using Androgen Receptor-Mediated Transactivation
Authors: Yazawa Takashi , Sato Takahiro , Ida Takanori
Published: May 2021

17β-Hydroxysteroid dehydrogenases (17β-HSDs, HSD17B) catalyze the reduction of 17-ketosteroids and the oxidation of 17β-hydroxysteroids to regulate the production of sex steroids. Among HSD17B family, 17β-HSD type 3 (HSD17B3) is expressed in testicular Leydig cells and contributes to development of male sexual characteristics by converting androstenedione (A4) to testosterone (T). Mutations of HSD17B3 genes cause a 46,XY disorder of sexual development (46,XY DSD) as a result of low T production. Therefore, the evaluation of HSD17B3 enzymatic activity is important for understanding and diagnosing this disorder. Although various amino acid substitutions of HSD17B3 have been reported in previous studies, the enzymatic activities of these proteins were often not defined. This is probably due to the difficulties that such enzymatic activities have been evaluated by quantifying the conversion of A4 into T using radioactive isotopes and liquid chromatography-mass spectrometry-mass spectrometry (LC-MS/MS). We adapted a method that easily evaluates enzymatic activity of HSD17B3 proteins by quantifying the conversion from A4 to T using androgen receptor (AR)-mediated transactivation. HEK293 cells were transfected to express human HSD17B3, and incubated medium containing A4. Depending on the incubation time with HSD17B3-expressing cells, the culture media progressively increased luciferase activities in CV-1 cells, transfected with the AR expression vector and androgen-responsive reporter. These luciferase activities reflected T concentrations in culture media defined by LC-MS/MS. This system is also applicable to detect the conversion of A4 to T by HSD17B1 and HSD17B5. In addition, it can evaluate the conversion of 11-ketoandrostenedione to 11-ketotestosterone by HSD17B family. Establishment of HEK293 cells expressing various missense mutations in the HSD17B3 gene with (N74T, A188V, M197K, A200V,, V225M, H271R) or without (V31I, E67K and G289S) the manifestation of 46,XY DSD revealed that this system is effective to evaluate the enzymatic activities of mutant proteins. A188V, A200V, V225M and H271R mutations completely inactivated the enzymatic function. N74T and M197K mutations showed some residual activities. In contrast, V31I, E67K and G289S substitutions showed similar activities as the wild-type protein.
Multicenter Analysis of Cardiometabolic-Related Diagnosesin Transgender Adolescents
Authors: Valentine Anna , Davis Shanlee Marie , Dempsey Amanda , Furniss Anna , Juarez-Colunga Elizabeth , Pyle Laura , Reirden Daniel , Nokoff Natalie
Published: May 2021

Background: Studies of transgender adults on gender affirming hormone therapy have shown increased rates of cardiovascular events (myocardial infarction and stroke) and features of metabolic syndrome including increased body mass index (BMI, transgender males) and dyslipidemia (transgender males and females). Studies in youth are limited by mostly small, single-center studies. With 1.8% of adolescents identifying as transgender, and increasing referral rates to gender clinics for care, more information is needed to better inform clinicians, patients and families about potential health risks in this cohort. PEDSnet, a pediatric Learning Health System, captures data from some of the largest pediatric care institutions in the U.S. We aimed to evaluate differences in diagnoses related to metabolic syndrome or cardiometabolic risk among youth with a diagnosis of gender dysphoria compared to matched cisgender controls. Methods: All youth with a diagnosis of gender dysphoria (n=4,177) and at least one outpatient encounter were extracted from the PEDSnet database (6 sites, years 2009-2019) and propensity-score matched on 7 variables (year of birth, age at last visit, site, race, ethnicity, insurance status, duration in database) to 4 controls without gender dysphoria (n=16,664). The odds of having a diagnosis of overweight/obesity, hypertension, dyslipidemia, dysglycemia, liver dysfunction, polycystic ovary syndrome (PCOS) or metabolic syndrome, was examined using generalized estimating equations with an interaction term for sex (as listed in the chart). Results: Of the transgender youth, 66% were female sex, 73% were white race, 9% were of Hispanic ethnicity, and 61% had private insurance. The control group was similar: 67% female sex, 72% white, 9% Hispanic, and 61% had private insurance. Transgender youth and controls both had on average 7 years duration in the database and were 16.2 years old at last visit. Transgender youth had higher odds of dyslipidemia (OR: 1.6 [95% CI: 1.3, 1.8], p<0.0001) and metabolic syndrome diagnoses (1.9 [95% CI: 1.2, 3.0], p=0.0086), with no significant difference based on sex, as compared to controls. Transgender youth with a female sex (though not male sex) had higher odds of overweight/obesity (1.7 [95% CI: 1.5, 1.9], p<0.0001) and PCOS diagnoses (1.9 [95% CI: 1.3, 2.8], p=0.0006), as compared to controls. There was no significant difference in the odds of having a diagnosis of hypertension, dysglycemia or liver dysfunction in transgender youth compared to controls. Conclusions: This large, geographically diverse cohort of transgender youth had a higher odds of being diagnosed with dyslipidemia and metabolic syndrome (both sexes), as well as elevated BMI or PCOS among those with a female sex listed. Future investigations will include analyses based on GAHT prescriptions and will further inform risk analysis and monitoring guidelines in this population.
Glucocorticoid Receptor Condensates Link DNA-Dependent Receptor Dimerization and Transcriptional Transactivation
Authors: Frank Filipp , Liu Xu , Ortlund Eric
Published: May 2021

The glucocorticoid receptor (GR) is a ligand-regulated transcription factor (TF) that controls the tissue- and gene-specific transactivation and transrepression of thousands of target genes. Distinct GR DNA binding sequences with activating or repressive activities have been identified, but how they modulate transcription in opposite ways is not known. We show that GR forms phase-separated condensates that specifically concentrate known co-regulators via their intrinsically disordered regions (IDRs) in vitro. A combination of dynamic, multivalent (between IDRs) and specific, stable interactions (between LxxLL motifs and the GR ligand binding domain) control the degree of recruitment. Importantly, GR DNA-binding directs the selective partitioning of co-regulators within GR condensates such that activating DNAs cause enhanced recruitment of co-activators. Our work shows that condensation controls GR function by modulating co-regulator recruitment and provides a mechanism for the up- and down-regulation of GR target genes controlled by distinct DNA recognition elements.
Investigating the Role Intestinal-Specific FXR and SHP in Regulating Lipid Metabolism in Mice
Authors: Nguyen James ThienToan , Anakk Sayeepriyadarshini
Published: May 2021

Dysregulation of lipid metabolism is a causal factor that can lead to a variety of disorders, such as obesity and metabolic syndrome. Dietary fats are digested in the small intestine by the physiological detergents known as bile acids. They emulsify the fats and break them down into smaller molecules in order for the enterocytes to absorb the nutrients through simple diffusion or through the utilization of specific lipid transporters. Interestingly, the nuclear receptors farnesoid X receptor (FXR) and small heterodimer partner (SHP) not only regulates bile acid synthesis and circulation, but also lipid metabolism. Although many studies have examined the role of FXR in hepatic and intestinal lipid metabolism, studies investigating the role of SHP in the intestine are still lacking. Although FXR and SHP cooperate to regulate many metabolic pathways, FXR or SHP knockout models exhibit different lipid phenotypes. These data indicate there are FXR-dependent and -independent pathways of SHP that controls lipid metabolism. To delineate these two interconnecting yet separate pathways, we will utilize intestine-specific Shp knockout (IShpKO) and intestine-specific Fxr knockout (IFxrKO) mice model and place them on high fat diet to investigate their intestinal intestinal absorption and transportation of lipids. We will also monitor the bile acid pool in the intestine, serum, and liver in these knockouts to evaluate the consequence of intestinal deletion of Fxr as well as Shp on bile acid homeostasis and how this may affect lipid absorption. These experiments will identify how FXR and/or SHP regulates intestinal fat digestion and absorption and if this is secondary to the alterations in bile acid concentration and lipid transporters. In addition, we will also investigate the intestinal Fxr-Shp double knockout (IDKO) mice model to determine their combined contribution in intestinal lipid metabolism. Overall, the results obtained from this research will elucidate if intestinal FXR and SHP cooperate or can independently regulate lipid metabolism and homeostasis.
Measurement of Steroid Fatty Acyl Esters in Blood and Brain
Authors: Gray Sofia L , Jalabert Cecilia , Ma Chunqi , Soma Kiran K
Published: May 2021

Steroid fatty acyl esters (FAEs) are a class of steroid conjugates that are abundant in circulation, have long half-lives, and are stored in lipid-rich tissues. Steroid-FAEs are present in many species, but their functions are poorly understood. They can be metabolized to active, unconjugated steroids and therefore may act as a reservoir of steroids. Dehydroepiandrosterone (DHEA) is an androgen precursor that can be conjugated to various fatty acids. DHEA also modulates aggression in several species, including songbirds, rodents and humans. Recent studies suggest that DHEA-FAEs might be present in songbird blood and/or brain, in part, to regulate aggression. Here, we (1) investigated the abundance of multiple fatty acids in songbird blood and (2) developed an indirect method to measure DHEA-FAEs in songbird blood and brain. First, preliminary work demonstrated high circulating levels of total (esterified and non-esterified) fatty acids, especially oleic, linoleic, and palmitic acids. These data, in conjunction with previous research, suggest that these fatty acids might be conjugated to steroids, including DHEA. Second, we successfully developed a saponification technique to indirectly measure DHEA-FAEs. Saponification cleaves the bond between the steroid molecule and the fatty acid, and we then measure the unconjugated steroid. DHEA-FAEs were incubated in 0.5M potassium hydroxide in ethanol for 30 min at room temperature, and steroids were subsequently extracted twice with dichloromethane. Unconjugated DHEA was quantified using liquid chromatography-tandem mass spectrometry (LC-MS/MS), the gold standard in steroid measurement. DHEA recovery was 88% using reference standards in neat solution. We validated this method with song sparrow plasma and chicken serum and obtained recoveries of 94-105% with intra-assay variation of 2.6%. Future research will directly measure specific DHEA-FAEs (e.g. DHEA-oleate) in blood and brain using LC-MS/MS. This research will elucidate the possible roles of steroid-FAEs in brain function and the regulation of steroid-dependent behavior. This work may also clarify the identities, levels and functions of steroid-FAEs in other species, including rodent models and humans. These data have implications for basic and clinical neuroendocrinology, offering insights into a possible storage system for steroids that may influence social behaviour.
Structural Insights of Transcriptionally Active, Full-Length Androgen Receptor Coactivator Complexes
Authors: Yu Xinzhe , Yi Ping
Published: May 2021

Steroid hormone receptors activate gene transcription by binding specific DNA sequences and recruiting coactivators to initiate transcription of their target genes. For most nuclear hormone receptors (NRs), the ligand-dependent activation function domain-2 (AF-2), residing in the C-terminal ligand binding domain (LBD), is a primary contributor to the NR transcriptional activity. In contrast to other steroid receptors such as estrogen receptor-α (ERα), the transcriptional activation function of androgen receptor (AR) is thought to be largely dependent on its ligand-independent activation function domain-1 (AF-1) located in its N-terminal domain (NTD). It remains unclear why AR utilizes a different activation function domain from other steroid receptors despite the fact that NRs share similar domain organizations and have a highly conserved DNA binding domain (DBD) and LBD. Here we present cryo-electron microscopic structures of DNA-bound full-length AR and its functional complex structure with its key coactivators, steroid receptor coactivator-3 (SRC-3) and the histone acetyltransferase p300. The structures reveal that androgen-bound full-length AR dimerization follows a unique head-to-head and tail-to-tail manner with all of the domains involved. The DBD and LBD are located at the center of the dimer interface. The NTDs wrap around the LBDs through their unique intra- and inter-molecular N- and C-terminal interactions and connect to each other. We observe that unlike ERα, AR binds a single SRC-3 molecule along with a single p300 molecule. The AR NTD appears to be the primary site for recruitment of both coactivators. The N-terminal region of SRC-3, rather than its receptor interaction domain, is important for this interaction. The structures presented here highlight the importance of the AR NTD for its transcriptional functions and provide a structural basis for understanding the assembly of the AR:coactivator complex and its domain contributions to transcriptional regulation.
A Randomised, Controlled Trial of Adjunctive Cholestyramine or Prednisolone Compared to Standard Therapy for the Treatment of Uncontrolled Graves’ Disease (the Chops Study)
Authors: Kim Khoo Serena Sert , Hussein Zanariah , Krishnan Gayathri Devi , Tee Hwee Ching , Chan Pei Lin , Alias Siti Aribah , Nor Lisa Mohamed , Badarudin Nurul Zaidah , Valayatham Vijiya Mala , Fung Yin Khet
Published: May 2021

Introduction: Antithyroid drugs (ATDs) are recommended effective treatment for uncontrolled Graves’ disease but achieves maximal antithyroid effects between 6 to 12 weeks. Cholestyramine sequesters thyroid hormones in the intestine and enhances its fecal excretion. Steroids inhibits the conversion of thyroxine to triiodothyronine peripherally and blocks thyroid hormone production. We hypothesize that adjunctive cholestyramine or prednisolone to ATDs may reduce circulating thyroid hormones and improve biochemical control.

Methods: In this multicenter, open labelled, parallel-group trial, we randomly assigned in a 1:1:1 ratio, adult Graves’ disease patients with moderate to severe hyperthyroidism (FT4 levels > 40 pmol/L) to receive either adjunctive cholestyramine 4g twice daily or prednisolone 30 mg daily in tapering down doses in addition to standard treatment or standard treatment alone for 4 weeks. Standard treatment was carbimazole 30mg daily and propanolol 40mg BD for 4 weeks. The primary endpoint was change from baseline for FT4 and FT3 levels at the end of 2 and 4 weeks of intervention. Safety endpoints including gastrointestinal adverse events, hypokalemia, hypothyroid and hyperglycemia were recorded.

Results: A total of 107 patients were screened and 97 patients randomised. Baseline demographics, clinical and biochemical characteristics were similar between the

groups. The baseline median FT4 levels were 51.6 pmol/L (42.2-71.1) and FT3 levels 22.5 pmol/L (5.7-30.8). Both FT4 and FT3 declined at two and four weeks from baseline but were no different between the three groups. At week 2, median FT4 levels declined by 43.3% (25.8-53.3), 39.8% (19.1-55.1) and 33.4% (20.1-62.0) (p=0.988) and at 4 weeks, 50.9% (33.3-63.8), 57.8% (39-70.9), 55.8% (36.2-72.0) (p =0.362) in the cholestyramine, prednisolone and standard treatment group respectively. Median FT3 levels reduced by 51.2% (22.8- 58.9), 59.9% (38.9-69.3) and 50.9% (26.9-63.9) (p=0.084) at week 2 and 60% (39.2-67.9), 67.5% (38.4-78.4), 63.1% (45.7-69.3) (p=0.387) in the corresponding cholestyramine, prednisolone and standard treatment only group. A higher number of gastrointestinal adverse events: constipation, bloating, diarrhea, abdominal pain and vomiting were observed in the cholestyramine group in the first 2 weeks of treatment and no difference in the incidence of hypokalemia between groups.

Conclusion: Adjunctive cholestyramine or prednisolone did not improve the biochemical control of uncontrolled moderate to severe Graves’ disease when added to ATDs. The additional use of cholestyramine resulted in a higher number of gastrointestinal adverse events but were mild and self-limiting.