Longitudinal change of sonographic ovarian aspects and endocrine parameters in irregular cycles of adolescence

Pituitary-ovarian response to the gonadotrophin-releasing hormone-agonist test in anovulatory patients with polycystic ovary syndrome: predictive role of ovarian stroma

OBJECTIVE

To evaluate the influence of ovarian stroma on basal and poststimulus androgen secretion in patients affected by secondary amenorrhoea and polycystic ovaries (PCO) at ultrasound (US).

DESIGN

Prospective study.

PATIENTS

Fifty-one patients with PCO selected from a group of 72 normal weight women aged 20-25 years affected by secondary amenorrhoea and 10 normal ovulatory controls.

METHODS

All subjects underwent US to evaluate volume, area, stromal area and stromal/total area ratio of both ovaries. Plasma levels of gonadotrophins, oestradiol (E2) and androgens were measured before and 24 h after GnRH-a injection. 60 min after stimulus LH and FSH were also assayed.

RESULTS

Thirty patients had increased ovarian stroma (IS) and 21 patients normal ovarian stroma (NS). Significantly higher LH levels characterized the IS group, both basally and after GnRH-a stimulation compared with NS and controls (P < 0.01). Baseline levels of androstenedione, testosterone and 17-OHprogesterone (17-OHP) were significantly higher in IS group. Moreover, 17-OHP hyper-response to GnRH-a was demonstrated in IS group in comparison to NS and control groups (P < 0.005).

CONCLUSIONS

Stroma evaluation may be of use in discriminating between different pathogenic factors in secondary amenorrhoea. This criterion may be applied to support the correct diagnosis of polycystic ovary syndrome (PCOS). Indeed, in line with the most recently proposed guidelines, patients affected by multifollicular ovaries could be classified as PCOS. The possibility of taking into account more than one US criterion or of carefully reanalysing the significance of increased stroma volume should be considered.

Polycystic ovarian syndrome--prognosis and outcomes

Polycystic ovarian syndrome (PCOS) is a condition that is present in 5-6% of women of reproductive age. It has potentially profound implications for women with regard to anovulatory infertility and symptoms related to elevated androgen levels. In addition, in later life women are prone to significant health problems related to hyperinsulinaemia, with an excess risk for diabetes and cardiovascular risk factors. Evidence suggests that the adverse features of PCOS can be ameliorated with lifestyle intervention, such as diet and exercise, while further short-term benefits related to ovulation and cardiac risk factors may be derived from medication with metformin. Evidence for the long-term use of metformin to protect against adverse cardiovascular outcomes and for the use of metformin throughout pregnancy to reduce the risk of miscarriage, gestational diabetes, pre-eclampsia and fetal macrosomia is still lacking.

Metformin-diet ameliorates coronary heart disease risk factors and facilitates resumption of regular menses in adolescents with polycystic ovary syndrome

BACKGROUND

In 35 adolescent females (17 +/- 2 years) with polycystic ovary syndrome (PCOS), median body mass index (BMI) 30.8 kg/m2, we assessed effeicacy of metformin-diet for 1 year for reduction of weight, insulin, HOMA insulin resistance (IR), cholesterol, triglycerides, and resumption of regular menses.

METHODS

Calories (26% protein, 44% carbohydrate) were targeted to 1,500-1,800/day if BMI was <25 or to 1,200-1,500/day if BMI was > or = 25, along with 2,550 mg metformin.

RESULTS

Median weight fell from 82.7 to 79.1 kg (p = 0.009), insulin 16.7 to 13.3 microU/ml (p <0.0001), HOMA IR 3.41 to 2.74 (p = 0.0004), total cholesterol 164 to 151 mg/dl (p = 0.002), and triglyceride 103 to 85 mg/dl (p = 0.006). The percentage of cycles with normal menses rose from a pre-treatment mean of 22% to 74%, p < 0.0001.

CONCLUSIONS

In adolescents with PCOS, metformin-diet reduces weight, insulin, IR, cholesterol, and triglycerides, and facilitates resumption of regular menses.

Follow-up study of two sisters with type A syndrome of severe insulin resistance gives a new insight into PCOS pathogenesis in relation to puberty and pregnancy outcome: a case report

We report two sisters with profound insulin resistance associated with a novel heterozygous missense mutation in exon 19 (His1130Arg) of the insulin receptor gene. The eldest was seen after puberty at age 15 and she presented a severe form of polycystic ovary syndrome (PCOS) with biological hyperandrogenism (HA) mimicking a virilizing tumour. However, she has been able to ovulate under clomiphene citrate (CC) and to achieve two uneventful pregnancies. The patient had no glucose tolerance abnormality during pregnancies. The outcome of pregnancy was good except for a low birthweight. The youngest sister was seen earlier in life (at age 11) before puberty. First, she developed polycystic ovaries (PCO), seen under ultrasound scan, and later also developed full PCOS. This second finding gave us the opportunity to observe that PCO developed before and at the beginning of puberty despite low LH levels. We postulate that the development of PCO was the consequence of an LH-independent intra-ovarian HA likely induced by the severe hyperinsulinism in the context of genetic abnormalities.

Ovarian imaging by magnetic resonance in obese adolescent girls with polycystic ovary syndrome: a pilot study

OBJECTIVE

To determine whether magnetic resonance (MR) imaging can serve as a useful investigational tool in the assessment of the polycystic ovary as compared with transabdominal ultrasound (US) for obese adolescents with polycystic ovary syndrome (PCOS).

DESIGN

Prospective observational study.

SETTING

Tertiary university hospital.

PATIENT(S)

Eleven obese adolescents with PCOS.

INTERVENTION(S)

Pelvic MR and US imaging and blood sampling.

MAIN OUTCOME MEASURE(S)

Total ovarian volume and follicle count; mean follicle count per longitudinal cross-section; stromal area; biochemical correlations with measured ovarian parameters.

RESULT(S)

With MR, the mean (+/-SE) total follicle count (21.9 +/- 1.3) was significantly greater than that observed with US (5.5 +/- 1.7) and significantly correlated with total ovarian volume. Two-dimensional cross-sectional analysis of the ovary by MR revealed a significantly greater mean follicle count (12.1 +/- 0.8) compared with the results obtained by US (3.0 +/- 0.5). The stromal area (173.3 +/- 25.1 mm2) was approximately 35% of the total ovarian surface area. No correlations were observed between biochemical indices and measured ovarian parameters.

CONCLUSION(S)

In contrast to US, MR provides vastly greater delineation of the structural components of the ovary in obese girls with PCOS and thus can serve as an excellent investigational technique to assess the morphological transformation of the adolescent ovary.

Polycystic ovary syndrome in adolescence

Polycystic ovary syndrome (PCOS) is a syndrome of variable combinations of menstrual irregularity, hirsutism or acne, and obesity. It can be diagnosed in adolescence and has early childhood antecedents. PCOS is the single most common endocrine cause of an ovulatory infertility and a major risk factor for the metabolic syndrome and, in turn, development of type 2 diabetes mellitus in women. Thus, it appears that PCOS increases a woman's risk of developing cardiovascular disease. Therefore, identifying girls at risk for PCOS and implementing treatment early in the development of PCOS may be an effective means of preventing some of the long-term complications associated with this syndrome. This article reviews the definition, clinical features, diagnosis, and treatment of PCOS.

Insulin and GH secretion in adolescent girls with irregular cycles: polycystic vs multifollicular ovaries

In the present study insulin (I) and GH secretion was studied in a group of twenty-five young adolescent girls (mean age: 15 +/- 0.23 yr) with cycle irregularity associated to clinical signs of hyperandrogenism in comparison with that observed in eleven normal matched subjects with regular menses. All patients underwent basal hormone measurements and, on two consecutive days, an oral glucose tolerance test (OGTT) and a GHRH iv test. Therefore, all subjects had a transabdominal US scan for the measurement of ovarian volume and the characterization of ovarian morphology. On the basis of the US examination we found patients with polycystic ovaries (PCO-like group) and subjects with multifollicular ovaries (MFO group). PCO-like group exhibited T (p<0.01) and LH (p<0.05) plasma levels higher than control group and the highest free androgen index (FAI) values (13 +/- 0.87). All patients with irregular menses showed plasma concentrations of AUC for I (AUC-I) significantly higher in respect to control group (7359.4 +/- 709 vs 5447 +/- 431 microIU/ml x 180 min, p<0.01) as well as both PCO-like group and MFO group did (p<0.001 and p<0.01) respectively. MFO group showed higher values of the AUC for GH (AUC-GH) (2809 +/- 432 ng/ml x 120 min) in respect to controls (1708 +/- 208 ng/ml x 120 min, p<0.05) and PCO-like subjects (p<0.001), who on the contrary showed the lowest AUC-GH values (618 +/- 119 ng/ml x 120 min). In conclusion, PCO-like patients associated hyperinsulinemia with a blunted GH secretion while MFO patients had higher GH secretion associated with higher AUC-I values in a way suggesting an immature and still developing reproductive system.

Premature pubarche in girls is associated with functional adrenal but not ovarian hyperandrogenism

OBJECTIVE

We hypothesized that there would be evidence of functional ovarian hyperandrogenism in girls with premature pubarche (PP) at diagnosis.

METHODS

White girls <8 years of age and black girls <6 years with PP (n = 15) were studied. Prepubertal girls (n = 13; 5.3-10.9 years) and early pubertal girls (n = 8) served as control subjects. The biochemical marker for functional ovarian hyperandrogenism was the 17-hydroxyprogesterone (17-OHP), androstenedione (AD), and estradiol (E2) response to subcutaneous leuprolide during adrenal suppression with dexamethasone. This was studied in girls with PP and in control subjects.

RESULTS

ACTH stimulated 17-hydroxypregnenolone (17-OH Preg), dehydroepiandrosterone (DHEA), and AD levels, and 17-OH Preg:17-OHP and DHEA:AD ratios were significantly higher in girls with PP than in prepubertal control subjects (n = 18) (P < or =.003). The ovarian response to leuprolide stimulation was comparable in girls with PP and prepubertal control subjects, but the response in prepubertal study subjects was significantly lower than in pubertal control subjects (P =.016 for Delta17-OHP, P =.001 for DeltaAD, and P =.026 for DeltaE2).

CONCLUSIONS

Contrary to the hypothesis, PP in girls was not associated with prepubertal evidence of ovarian hyperandrogenism but was associated with functional adrenal hyperandrogenism.

Androgen and lipid profiles in adolescents with polycystic ovary syndrome who were treated with two forms of combined oral contraceptives

OBJECTIVE

To compare the effects of cyproterone acetate and desogestrel, as part of combined oral contraceptives, on lipid metabolism and hirsutism of adolescents with polycystic ovary syndrome (PCOS).

DESIGN

Prospective randomized clinical trial.

SETTING

Outpatient gynecology clinic (referral center) of a university.

PATIENT(S)

Twenty-eight adolescent girls with clinical and biological hyperandrogenism and six or less menses during the past 12 months.

INTERVENTION(S)

Group A (n = 14) received 0.15 mg of desogestrel plus 0.030 mg of ethinyl estradiol daily. Group B (n = 14) received 2 mg of cyproterone acetate plus 0.035 mg of ethinyl estradiol daily. Treatment was given for 21 days followed by a 7-day rest for a period of 12 months.

MAIN OUTCOME MEASURE(S)

Hirsutism and lipid profile were evaluated before initiation and at 3, 6, 9, and 12 months of treatment. Androgen profile was evaluated before and at 12 months of treatment.

RESULT(S)

A significant decline of the Ferriman-Gallway hirsutism score was observed from the sixth month of therapy in both groups. During therapy, the levels of testosterone, free testosterone, Delta(4)-androstenedione, and 17OH-progesterone decreased significantly, whereas sex hormone-binding globulin (SHBG) increased significantly in both groups. The level of total cholesterol and low density lipoprotein (LDL) cholesterol increased significantly, whereas high density lipoprotein (HDL) cholesterol and apolipoprotein A-I increased significantly from the third month of therapy in both groups. Total cholesterol/HDL cholesterol and LDL cholesterol/HDL cholesterol ratios remained unchanged. The levels of triglycerides increased significantly in the cyproterone acetate-treated group after the third month.

CONCLUSION(S)

Treatment of adolescent girls with PCOS with the two studied formulations is comparably effective in decreasing hirsutism and androgen levels. Both combined oral contraceptives are associated with an increase of total cholesterol, LDL cholesterol, and HDL cholesterol levels and no change of the total cholesterol/HDL cholesterol and LDL cholesterol/HDL cholesterol ratios. Treatment with the cyproterone acetate combined oral contraceptive is associated with a tendency toward increasing the levels of triglycerides.

Polycystic ovaries in adolescents and the relationship with menstrual cycle patterns, luteinizing hormone, androgens, and insulin

STUDY OBJECTIVE

To evaluate the possible role of inappropriate LH secretion, hyperandrogenism, and hyperinsulinemia in the development of polycystic ovaries (PCO) and the polycystic ovary syndrome.

DESIGN

Observational.

SETTING

General population samples.

PARTICIPANTS

58 adolescents with regular menstrual cycles, 50 with irregular menstrual cycles, and 29 with oligomenorrhea (age 16.7+/-0.9 years).

INTERVENTIONS

Transabdominal pelvic ultrasonography and vena puncture.

MAIN OUTCOME MEASURES

PCO; LH, androstenedione, and testosterone levels; overnight fasting insulin concentrations; and oligomenorrhea.

RESULTS

The prevalence of PCO increased significantly with the irregularity of the menstrual cycle pattern, as illustrated by the study, finding PCO in 9% of the girls with regular menstrual cycles, 28% of those with irregular menstrual cycles, and 45% of oligomenorrheic girls. The LH and androgen concentrations were significantly higher in girls with PCO; the insulin levels and the glucose-insulin ratio did not differ when the girls with PCO were compared with girls with normal ovaries. Oligomenorrheic girls with PCO had the highest androgen and LH concentrations; their insulin concentrations and glucose-insulin ratio were in the same range as girls with regular menstrual cycles and normal ovaries; and both their hip and waist girths were wider, although their waist-hip ratio was normal.

CONCLUSIONS

PCO in adolescents is associated with irregular menstrual cycles, oligomenorrhea, and/or high androgen and LH levels; but no relationship was found with the insulin level or glucose-insulin ratio. Thus, it is doubtful that hyperinsulinemia is an important factor in the development of PCO or polycystic ovary syndrome.

Combined oral contraceptive treatment of adolescent girls with polycystic ovary syndrome. Lipid profile

The clinical signs and neuroendocrine features of adolescents with polycystic ovary syndrome (PCOS) resemble those found in adult women with PCOS. These adolescent patients are candidates for long-term treatment by one of the different therapeutic approaches that have been proposed. It is therefore essential that the treatment does not induce unfavorable metabolic effects. We investigated and compared the effects of cyproterone acetate (CA) and desogestrel (D), as part of combined oral contraceptives (COC), on lipid metabolism and hirsutism in adolescents with PCOS. Twenty-four girls with clinical signs of PCOS were recruited. They were all hyperandrogenic and euthyroid and had normal prolactin plasma levels. Non-classic congenital adrenal hyperplasia was ruled out by the ACTH stimulation test. Blood samples were obtained for sex hormone binding globulin (SHBG), total cholesterol (TC), LDL cholesterol, HDL cholesterol, triglycerides (TGs), apolipoproteins A-I, A-II, B, and lipoprotein (a) (Lp(a)) measurements. After the initial examination, therapy was initiated in a randomly selected order (12 and 12 patients were treated daily by 2 mg CA and 0.150 mg D, respectively, plus 0.035 and 0.030 mg ethinylestradiol, respectively). The degree of hirsutism and the lipid profile were reevaluated every 3 months after initiation of therapy for 1 year. Our data show that after 12 months of treatment with the D or CA COC, the Ferriman-Gallway hirsutism score decreased and TC and LDL-C increased. TGs and HDL-C were raised significantly in the CA COC group, whereas apolipoprotein A1 increased during D COC treatment. The atheromatic indices did not change. These data suggest that treatment of adolescent girls with PCOS is comparably effective with the two contraceptive formulations and that the desogestrel COC could be considered in the treatment of adolescent PCOS patients because it does not have side effects on lipid metabolism.

Chronobiologic evolution of luteinizing hormone secretion in adolescence: developmental patterns and speculations on the onset of the polycystic ovary syndrome

OBJECTIVE

To investigate the long-term evolution of the LH circadian profile in adolescent women with anovulatory cycles and normal or elevated LH levels in the first evaluation.

DESIGN

Prospective controlled clinical study.

SETTING

Reproductive endocrinology unit of an academic medical center.

PATIENT(S)

Twelve healthy anovulatory adolescent girls aged 12 to 17 years (5 subjects with high plasma LH level and 7 subjects with normal LH level) and four ovulatory subjects as controls.

INTERVENTION(S)

Blood samples were drawn every 20 minutes for 24 hours beginning at 10:00 A.M. at early and late gynecologic ages.

MAIN OUTCOME MEASURE(S)

Luteinizing hormone, FSH, E2, T, androstenedione, ovarian volume.

RESULT(S)

In the first evaluation, the highest plasma LH levels and greatest pulse amplitude were found early in the morning in the normal-LH group and late in the afternoon in the high-LH group. Controls did not display any significant circadian variation in LH secretion. The second evaluation revealed ovulatory cycles in six of seven subjects (85.7%) in the normal-LH group with the disappearance of the circadian rhythm. Two of five (40%) patients with high LH in the first evaluation became ovulatory with a significant decrease of mean LH levels and the disappearance of the circadian rhythm. Girls of both groups who remained anovulatory still displayed the accentuated circadian profiles that were seen at the first evaluation.

CONCLUSION(S)

An accentuated 24-hour LH periodicity is typical of puberty but disappears in adulthood. The persistence of these rhythms in persistently anovulatory adolescents may indicate a maturational arrest. In particular, the persistence of the high LH circadian profile with the highest values during the day is very similar to that found in polycystic ovary syndrome.