Positions statement: criteria for defining polycystic ovary syndrome as a predominantly hyperandrogenic syndrome: an Androgen Excess Society guideline

The evaluation of metabolic parameters and insulin sensitivity for a more robust diagnosis of the polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is considered predominantly as a hyperandrogenetic syndrome and the evaluation of metabolic parameters and insulin sensitivity is not mandatory.

CONTEXT

PCOS diagnostic criteria [National Institute of Health (NIH), Rotterdam Consensus (ROT), Androgen Excess Society (AES)] are unanimous recognized. We aimed to assess in women with suspected PCOS whether the application of the three diagnostic criteria differently characterizes the metabolic profile and insulin sensitivity.

DESIGN

Retrospective study in a cohort of women admitted to our Outpatient Clinic for suspected PCOS.

PATIENTS

Two hundred and four women with suspected PCOS in comparison to a group of normal, age-matched Sicilian women (N = 34) without signs of metabolic syndrome.

MEASUREMENTS

We evaluated hyperandrogenaemia and clinical hyperandrogenism, ovarian morphology, hypothalamo-hypophyseal axis and metabolic syndrome parameters. An oral glucose tolerance test (OGTT; 75 g glucose) measured areas under the curve (AUC) for insulin, C peptide and homeostasis model assessment of insulin-resistance (HOMA-IR) were performed.

RESULTS

The prevalence of PCOS was 51% according to NIH, 83% to ROT and 70.6% to AES, and only 100 patients were qualified simultaneously under these three criteria. The prevalence of the metabolic syndrome in PCOS women was 26.92% (NIH), 21.77% (ROT) and 23.61% (AES), respectively. In comparison to healthy women, PCOS women showed increased fasting insulinaemia (PCOS/ROT: P = 0.028; PCOS/NIH: P = 0.007; PCOS/EAS: P = 0.023), 120 min insulin after OGTT insulinaemia (for the three criteria: P < 0.001), AUC(2h) insulin (for the three criteria: P < 0.001) and AUC(2h) C peptide (for the three criteria: P < 0.001).

CONCLUSIONS

Our study highlights the fact that regardless of the diagnostic criteria used, evaluation of the metabolic parameters and insulin sensitivity is important for a correct diagnosis of PCOS and a therapeutic approach.

Idiopathic hirsutism: excessive bodily and facial hair in women

Hirsutism is the excessive and increased bodily and facial hair growth in women in locations where hair is normally minimal or absent. It refers to the growth of hair in a pattern normally occurring only in men, and therefore primarily raises psychological, cosmetic and social concerns. Idiopathic hirsutism (IH), where the cause of excessive hair growth is unknown, is considered to be the most common form of hirsutism. It is suspected that this type of hirsutism may be familial, as there is often a family history of the condition. Women with IH will generally have normal menses and normal levels of testosterone. There are many treatment modalities that fall into two broad groups: medical and mechanical treatment. An example of a medical treatment is when an agent is used, which interferes with the synthesis of androgen at the ovarian or adrenal level, or by inhibiting the effect of androgen at the receptor level. An example of a mechanical treatment is laser hair removal, where the hair follicle is destroyed; however, much depends on the on the skill of the treating practitioner, laser type, laser spot size, skin type, hair colour, and the stage at which the hair follicles were during their hair growth cycle, and the delivered wavelength. Laser offers the fastest method of hair loss. Other mechanical treatments include electrolysis, depilatory creams, plucking and waxing. This article presents a general overview of IH, including a definition, diagnostic measures, clinical manifestations, normal and abnormal physiology, and treatment options.

Treatment for polycystic ovary syndrome: a critical appraisal of treatment options

The management of polycystic ovary syndrome (PCOS) usually spans a woman's reproductive years. While the treatment of symptoms is a primary concern, given its long-term nature, the benefits and potential risks need to be assessed and balanced. The variability of presentation coupled with the phenotypic diversity of this patient population, requires the individualization of treatment to each patient. Periodically, the regimen has to be modified owing to a desire for pregnancy, necessitating ovulation induction in this anovulatory group of women. Finally, for any treatment offered, consideration should be given to potential adverse effects on the fetus should spontaneous ovulation and unplanned pregnancy occur. This review highlights the current issues surrounding PCOS and provides a critical appraisal of treatment options.

Dehydroepiandrosterone sulfate and insulin resistance in patients with polycystic ovary syndrome

OBJECTIVE

To test the hypothesis that increasing DHEAS levels is associated with improved insulin resistance in patients with polycystic ovary syndrome (PCOS).

DESIGN

Cross-sectional cohort analysis.

SETTING

Academic medical center.

PATIENT(S)

Three hundred fifty-two women with PCOS.

INTERVENTION(S)

Patients presenting for evaluation of symptoms related to androgen excess were evaluated physically and biochemically through laboratory analysis.

MAIN OUTCOME MEASURE(S)

Circulating DHEAS, total T, free T, sex hormone-binding globulin (SHBG), and 17-hydroxyprogesterone (17-OHP) levels, and calculated homeostasis model assessment of insulin resistance (HOMA-IR).

RESULT(S)

Bivariate analysis indicated that all parameters were associated with HOMA-IR, except 17-OHP and age, and confirmed a negative correlation between DHEAS and HOMA-IR. Multivariate analysis indicated that increases in DHEAS, SHBG, 17-OHP, and age were associated with decreasing HOMA-IR, whereas increases in free T, body mass index (BMI), and waist-to-hip ratio (WHR) were associated with increasing HOMA-IR. In decreasing order of importance, the following variables predicted insulin resistance: BMI > WHR > age > DHEAS > free T > SHBG > 17-OHP.

CONCLUSION(S)

DHEAS is negatively correlated to insulin resistance in patients with PCOS, and in our model ranked just behind other well-established predictors including BMI, WHR, and age. Whether this is due to a direct beneficial effect on insulin action by adrenal androgens such as DHEA, or whether DHEAS simply reflects the circulating levels of hyperinsulinemia, remains to be determined.

The serine phosphorylation hypothesis of polycystic ovary syndrome: a unifying mechanism for hyperandrogenemia and insulin resistance

Polycystic ovary syndrome (PCOS) is a common endocrinopathy affecting 4%-8% of reproductive-aged women. The syndrome is characterized by hyperandrogenemia and disordered gonadotropin secretion and is often associated with insulin resistance. However, rather than being one disease entity caused by a single molecular defect, PCOS under its current diagnostic criteria most likely includes a number of distinct disease processes with similar clinical phenotypes but different pathophysiologic mechanisms. The serine phosphorylation hypothesis can potentially explain two major features of PCOS--hyperandrogenemia and insulin resistance. Further defining the molecular mechanisms regulating androgen biosynthesis and insulin action in PCOS patients will permit a better understanding of the syndrome and may lead to the generation of novel specific pharmacologic therapies.

Endocrine antecedents of polycystic ovary syndrome in fetal and infant prenatally androgenized female rhesus monkeys

Experimentally induced fetal androgen excess induces polycystic ovary syndrome-like traits in adult female rhesus monkeys (Macaca mulatta). Developmental changes leading to this endocrinopathy are not known. We therefore studied 15 time-mated, gravid female rhesus monkeys with known female fetuses. Nine dams received daily s.c. injections of 15 mg of testosterone propionate (TP), and six received injections of oil vehicle (control) from 40 through 80 days of gestation (term, 165 days; range, +/-10 days). All fetuses were delivered by cesarean section using established methods at term. Ultrasound-guided fetal blood sample collection and peripheral venous sample collection of dams and subsequent infants enabled determination of circulating levels of steroid hormones, LH and FSH. The TP injections elevated serum testosterone and androstenedione levels in the dams and prenatally androgenized (PA) fetuses. After cessation of TP injections, testosterone levels returned to values within the reference range for animals in these age groups, whereas serum androstenedione levels in PA infants were elevated. The TP injections did not increase estrogen levels in the dams or the PA fetuses or infants, yet conjugated estrogen levels were elevated in the TP-injected dams. Serum levels of LH and FSH were elevated in late-gestation PA fetuses, and LH levels were elevated in PA infants. These studies suggest that experimentally induced fetal androgen excess increases gonadotropin secretion in PA female fetuses and infants and elevates endogenous androgen levels in PA infants. Thus, in this nonhuman primate model, differential programming of the fetal hypothalamo-pituitary unit with concomitant hyperandrogenism provides evidence to suggest developmental origins of LH and androgen excess in adulthood.

Statins in the treatment of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy affecting reproductive-aged women. The hyperandrogenemia associated with the syndrome is a result of excessive growth and steroidogenic activity of theca-interstitial tissues in response to various factors, including elevated gonadotropins, hyperinsulinemia, and oxidative stress. PCOS frequently coexists with other cardiovascular risk factors, such as dyslipidemia and systemic inflammation. Statins inhibit the synthesis of mevalonate, the key precursor to cholesterol biosynthesis, and reduce cardiovascular morbidity and mortality. Blockade of mevalonate production may also lead to decreased maturation of insulin receptors, inhibition of steroidogenesis (e.g., via limiting the amount of substrate: cholesterol), and alteration of signal transduction pathways that mediate cellular proliferation. The latter depend upon posttranslational modification of proteins (prenylation), a process mediated by mevalonate derivatives. Statins also have intrinsic antioxidant properties. Given the pleiotropic actions of statins, they are likely not only to improve the dyslipidemia associated with PCOS but may also exert other beneficial metabolic and endocrine effects.

Drug insight: insulin-sensitizing drugs in the treatment of polycystic ovary syndrome--a reappraisal

The recognition that insulin resistance has a pivotal role in the pathogenesis of polycystic ovary syndrome (PCOS) revolutionized our understanding of this complex disorder. PCOS causes major metabolic and reproductive morbidities, including substantially increased risk for type 2 diabetes mellitus and the metabolic syndrome. Insulin-sensitizing drugs (ISDs) ameliorate reproductive abnormalities, restore ovulation and regular menses, increase pregnancy rates and reduce androgenic symptoms in affected women with PCOS. Accordingly, ISDs, specifically metformin, have been widely adopted as therapy for this condition. A recent, large, randomized, multicenter, clinical trial that assessed live-birth rates rather than surrogate end points suggested that metformin alone is inferior to clomiphene citrate in treating infertility associated with PCOS. There is, furthermore, no evidence to support the use of metformin during pregnancy to prevent spontaneous abortions or gestational diabetes mellitus in women with PCOS. Renewed safety concerns about thiazolidinediones followed recent studies that reported increased cardiovascular morbidity with these agents. These concerns might preclude thiazolidinedione use in otherwise healthy women with PCOS. Finally, although ISDs improve insulin action and cardiovascular disease risk, there is no evidence that they provide long-term health benefits in PCOS. This article discusses the role of ISDs in PCOS in light of these new data.

Small glutamine-rich tetratricopeptide repeat-containing protein alpha (SGTA), a candidate gene for polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is a heterogenic, complex common genetic disease. Multiple pathways are involved in its pathogenesis, including the androgen signaling pathway and insulin signaling pathway. Small glutamine-rich tetratricopeptide repeat-containing protein alpha (SGTA) is a putative member of the androgen receptor-chaperone-co-chaperone complex, and may play a role in androgen signaling as a co-chaperone. Polymorphisms in the SGTA gene have not been evaluated for a role in PCOS.

METHODS

Women with and without PCOS (287 cases, 187 controls) were genotyped for three single nucleotide polymorphisms (SNPs) in SGTA. SNPs and haplotypes were determined and tested for association with PCOS and component traits of PCOS.

RESULTS

For SNP rs1640262, homozygotes for the minor allele were protected against PCOS (P = 0.009). Haplotype 1 (G-A-T) was associated with increased risk of PCOS (P = 0.015). In women with PCOS, haplotype 2 (A-G-C) was associated with increased insulin resistance (P = 0.013), consequently resulting in increased insulin secretion (P = 0.014).

CONCLUSIONS

This study presents genetic evidence suggesting a potential role of SGTA in the pathogenesis of PCOS. SGTA may provide a connection between multiple pathways in PCOS.

Comparison of hormonal and metabolic markers after a high-fat, Western meal versus a low-fat, high-fiber meal in women with polycystic ovary syndrome

OBJECTIVE

To determine the effect of meal composition on postprandial T levels in women with polycystic ovary syndrome (PCOS).

DESIGN

Randomized, crossover design.

SETTING

Academic research center.

PATIENT(S)

Fifteen women with PCOS.

INTERVENTION(S)

We evaluated changes in T, sex hormone binding globulin (SHBG), DHEAS, cortisol, glucose, and insulin for 6 hours after a high-fat, Western meal (HIFAT) (62% fat, 24% carbohydrate, 1 g fiber) and an isocaloric low-fat, high-fiber meal (HIFIB) (6% fat, 81% carbohydrate, 27 g fiber).

MAIN OUTCOME MEASURE(S)

Change in T levels.

RESULT(S)

Testosterone decreased 27% within 2 hours after both meals. However, T remained below premeal values for 4 hours after the HIFIB meal and 6 hours after the HIFAT meal. Insulin was twofold higher for 2 hours after the HIFIB meal compared with the HIFAT meal. Glucose was higher for 1 hour after the HIFIB meal compared with the HIFAT meal. DHEAS decreased 8%-10% within 2-3 hours after both meals, then increased during the remainder of the study period. Cortisol decreased during the 6-hour period after both meals.

CONCLUSIONS

Diet plays a role in the regulation of T levels in women with PCOS. Further studies are needed to determine the role of diet composition in the treatment of PCOS.

Prevalence of symptoms associated with polycystic ovary syndrome

OBJECTIVE

To establish the prevalence of symptoms associated with polycystic ovary syndrome (PCOS) in a population-based sample of women from Northern Sweden, and to relate symptoms of PCOS to features of metabolic syndrome.

METHODS

A population-based survey of 147 women under 40 years of age sampled from 267 eligible women from the Northern Sweden component of the World Health Organization's MONICA study. The study involved questionnaires, physical examination, and assays of testosterone and sex hormone-binding globulin.

RESULTS

The estimated prevalence of symptoms associated with PCOS was 4.8% in the study population. Features of metabolic syndrome were more common in women with signs of hyperandrogenism than in healthy controls.

CONCLUSION

The estimated prevalence of PCOS in Northern Sweden corresponds with other prevalence studies. A simple questionnaire and analysis of the free androgen index are sufficient to detect the subgroup with the highest risk for metabolic syndrome.

Polycystic ovary syndrome: clinical and imaging features

Polycystic ovary syndrome is the most common endocrine disorder occurring in reproductive-age women. The syndrome is complex, multifactorial, and not always easily defined. Diagnosis is based upon a combination of clinical and biochemical criteria and ovarian morphology. The following review describes the clinical features, pathophysiology, diagnosis, and the role of imaging. Diagnostic imaging techniques are discussed, with emphasis on ultrasound as the main modality used worldwide. Contributions of 3-dimensional and Doppler ultrasound are addressed in addition to potential indications for magnetic resonance imaging in the evaluation of patients with suspected polycystic ovary syndrome.

Polycystic ovary syndrome and oocyte developmental competence

Folliculogenesis is a complex process, in which multiple endocrine and intraovarian paracrine interactions create a changing intrafollicular microenvironment for appropriate oocyte development. Within this microenvironment, bidirectional cumulus cell-oocyte signaling governs the gradual acquisition of developmental competence by the oocyte, defined as the ability of the oocyte to complete meiosis and undergo fertilization, embryogenesis, and term development. These regulatory mechanisms of follicle growth, controlled in part by the oocyte itself, are susceptible to derangement in polycystic ovary syndrome (PCOS), a heterogeneous syndrome characterized by ovarian hyperandrogenism, insulin resistance, and paracrine dysregulation of follicle development. Consequently, only a subset of PCOS patients experience reduced pregnancy outcome after ovarian stimulation for in vitro fertilization. Recent data implicate functional associations between endocrine/paracrine abnormalities, metabolic dysfunction, and altered oocyte gene expression with impaired oocyte developmental competence in women with PCOS. Therefore, an understanding of how developmentally relevant endocrine/paracrine factors interact to promote optimal oocyte developmental is crucial to identify those PCOS patients who might benefit from long-term correction of follicle growth to improve fertility, optimize follicular responsiveness to gonadotropin therapy, and enhance pregnancy outcome by in vitro fertilization.

Polycystic ovary syndrome in obese adolescents

PURPOSE OF REVIEW

As the prevalence of pediatric obesity escalates, polycystic ovary syndrome is an increasingly common morbidity for adolescent females. This review describes recent insights into the pathophysiology and treatment of polycystic ovary syndrome, with special attention given to the relationship between polycystic ovary syndrome and obesity.

RECENT FINDINGS

Recent research has elucidated three key concepts in our understanding of polycystic ovary syndrome. First, patients may enter the hyperandrogenism-hyperinsulinism cycle of polycystic ovary syndrome via several pathways, including genetic polymorphisms that affect androgen synthesis, fetal programming that alters lipid and glucose metabolism, and obesity accompanied by insulin resistance. Second, obesity plays a significant role in the pathophysiology of polycystic ovary syndrome by increasing free androgen concentrations through multiple mechanisms. Finally, just as the etiology of polycystic ovary syndrome is multifactorial, successful treatment will probably require a combination of lifestyle modification and therapeutic interventions.

SUMMARY

Obesity contributes to the pathophysiology of polycystic ovary syndrome and increases the likelihood of associated metabolic and cardiovascular morbidities.

A prospective study of the prevalence of nonclassical congenital adrenal hyperplasia among women presenting with hyperandrogenic symptoms and signs

CONTEXT

The diagnosis of the polycystic ovary syndrome requires the exclusion of nonclassical congenital adrenal hyperplasia (NCAH).

OBJECTIVE

Our objective was to evaluate the actual prevalences of 21-hydroxylase and 11beta-hydroxylase deficiencies among women presenting with hyperandrogenic complaints.

SETTINGS

This study was performed at an academic hospital.

PATIENTS

A total of 270 consecutive unselected women presenting with hyperandrogenic symptoms were prospectively recruited.

INTERVENTIONS

Basal and ACTH-stimulated 11-deoxycortisol and 17-hydroxyprogesterone concentrations were measured.

MAIN OUTCOME MEASURES

The prevalences of 21-hydroxylase and 11beta-hydroxylase deficiencies were calculated, and the diagnostic performance of basal serum 17-hydroxyprogesterone levels for the screening of NCAH was evaluated by receiver operating characteristic curve analysis.

RESULTS

Six of the 270 patients had 21-hydroxylase-deficient NCAH that was confirmed by CYP21 genotyping, whereas no patient was diagnosed with 11beta-hydroxylase deficiency, for an overall NCAH prevalence of 2.2% (95% confidence limits 0.5-3.9%). According to receiver operating characteristic analysis, a single basal serum 17-hydroxyprogesterone determination has a 0.97 (95% confidence interval: 0.934-1.008) chance of detecting NCAH in hyperandrogenic women. In our experience, the most appropriate cutoff value for the detection of NCAH is a 17-hydroxyprogesterone above 1.7 ng/ml, showing a 100% sensitivity and a 88.6% specificity. Five of the six 21-hydroxylase-deficient NCAH patients carried a severe CYP21 allele requiring genetic counseling and highlighting the importance of excluding this disorder among hyperandrogenic patients.

CONCLUSIONS

The prevalence of NCAH among hyperandrogenic patients from Spain is 2.2%. Basal serum 17-hydroxyprogesterone measurements have an excellent diagnostic performance, yet the cutoff value should be established in each laboratory to avoid false-negative results.

A 31-year-old woman with infertility and polycystic ovaries diagnosed with non-classic congenital adrenal hyperplasia due to a novel CYP21 mutation

A 31-yr-old woman presenting with a history of hirsutism, amenorrhea, and infertility was previously assumed to have polycystic ovary syndrome. A new gynecological-endocrine evaluation demonstrated elevated testosterone/SHBG ratio, serum 17-hydroxyprogesterone (17-OHP), and urinary pregnantriol. She was diagnosed with non-classic congenital adrenal hyperplasia. In spite of treatment with dexamethasone and fludrocortisone in doses that suppressed adrenal androgens and 17-OHP into normal range or below, she did not ovulate. Clomiphene citrate and then FSH/hCG treatment in several cycles gave no consistent ovulation. Progesterone levels remained elevated throughout the cycles indicating a possible contribution from the adrenals. Oral glucose tolerance was normal, but the homeostasis model assessment index indicated insulin resistance. With metformin 1500 mg daily the index decreased remarkably from 2.77 to 0.96 with a few ovulations but no pregnancy occurred. Three cycles of IVF treatment thereafter were unsuccessful. Three months after the last in vitro fertilization (IVF) cycle, still on dexamethasone, fludrocortisone, and metformin, her menstruations became regular and she thereafter became pregnant. During pregnancy metformin was discontinued and dexamethasone replaced with prednisolone. Mild gestational diabetes developed and insulin was given. A healthy boy was born at term by elective Cesarean section. A CYP21- gene analysis had not indicated any of the known mutations but after gene sequencing a novel mutation was found, namely R233G. This case confirms the necessity of adding an analysis of 17-OHP when evaluating women with hirsutism and menstrual disturbances and if an elevated value is found, the advantage of performing a mutation analysis to facilitate counseling and decisions on treatment.

Polycystic ovarian syndrome: pathophysiology, molecular aspects and clinical implications

Polycystic ovarian syndrome (PCOS) is universally recognised as the commonest endocrinopathy of women. The definition and the aetiological hypotheses of PCOS are continuously evolving to accommodate expanding knowledge on the syndrome, which is now known to be more complex than purely a reproductive disorder. Increased androgen synthesis, disrupted folliculogenesis and insulin resistance lie at the pathophysiological core of PCOS. An intriguing concept involves the perpetuation of a vicious circle with endocrine/reproductive and metabolic components. An unfavourable metabolic environment may unmask genetic traits of ovarian dysfunction, and the unfolding endocrine derangement could further aggravate the metabolic disarray. This article reviews the molecular mechanisms known to underlie the ovarian and metabolic abnormalities characterising PCOS. The putative interdependence between reproductive and metabolic aspects of PCOS, and therapeutic implications for the management of PCOS, are also discussed.

Metabolic fuel and clinical implications for female reproduction

Reproduction is a physiologically costly process that consumes significant amounts of energy. The physiological mechanisms controlling energy balance are closely linked to fertility. This close relationship ensures that pregnancy and lactation occur only in favourable conditions with respect to energy. The primary metabolic cue that modulates reproduction is the availability of oxidizable fuel. An organism's metabolic status is transmitted to the brain through metabolic fuel detectors. There are many of these detectors at both the peripheral (e.g., leptin, insulin, ghrelin) and central (e.g., neuropeptide Y, melanocortin, orexins) levels. When oxidizable fuel is scarce, the detectors function to inhibit the release of gonadotropin-releasing hormone and luteinizing hormone, thereby altering steroidogenesis, reproductive cyclicity, and sexual behaviour. Infertility can also result when resources are abundant but food intake fails to compensate for increased energy demands. Examples of these conditions in women include anorexia nervosa and exercise-induced amenorrhea. Infertility associated with obesity appears to be less related to an effect of oxidizable fuel on the hypothalamic-pituitary-ovarian axis. Impaired insulin sensitivity may play a role in the etiology of these conditions, but their specific etiology remains unresolved. Research into the metabolic regulation of reproductive function has implications for elucidating mechanisms of impaired pubertal development, nutritional amenorrhea, and obesity-related infertility. A better understanding of these etiologies has far-reaching implications for the prevention and management of reproductive dysfunction and its associated comorbidities.

Female hypogonadism: evaluation of the hypothalamic-pituitary-ovarian axis

Female hypogonadism refers to deficient or abnormal function of the hypothalamic-pituitary-ovarian axis that clinically presents with menstrual cycle disturbances. Female hypogonadism can be due to a congenital or acquired cause, and the defect can be at the level of the hypothalamus, pituitary or ovary. A careful history, physical exam and selected laboratory testing can often determine the locus of the defect and whether it results from a structural or hormonal problem. Laboratory testing generally relies on basal hormone levels; however, timing of blood sampling in relation to menses is important to interpretation of the data.

Polycystic ovaries in nonobese adolescents and young women with ovarian androgen excess: relation to prenatal growth

OBJECTIVE

Reduced growth before birth is known to associate with a smaller ovarian volume in adolescents and women without androgen excess. We studied whether prenatal growth relates also to ovarian size and polycystic ovary (PCO) morphology in nonobese adolescents and young women with ovarian androgen excess.

DESIGN

A cross-sectional analysis of standardized case notes over a 2-yr period was performed.

PATIENTS

Nonobese adolescents and young women (age approximately 17 yr; n = 86) seen for ovarian androgen excess, as confirmed by 17-hydroxy-progesterone hyperresponse to a GnRH agonist, were included in the study.

MEASUREMENTS

Endocrine-metabolic assessment in fasting state, together with a vaginal ultrasound scan to verify the presence or absence of PCO was performed. Birth weight and gestational age were derived from medical records.

RESULTS

PCO prevalence by ultrasound was 38%. Absence of PCO was associated with a shift (P < 0.0005) of the birth weight distribution toward lower values. Patients with a birth weight less than 3.0 kg were 6-fold more likely to have no PCO than to have PCO. Birth weight was across a wide range (1.5-4.0 kg) associated with ovarian volume in hyperandrogenic patients with noncystic ovaries (r = 0.60; P < 0.00001) and was, in a multiple regression analysis, the prime variable linked to ovarian volume (beta = 0.57; P < 0.00001), explaining 32% of its variance.

CONCLUSIONS

The ovarian size and the development of a PCO morphology in nonobese adolescents and young women with ovarian androgen excess relate to prenatal growth. These findings indicate that there are two subgroups of nonobese patients with ovarian androgen excess: one with a normal birth weight distribution and with PCO, and one with lower birth weights and without PCO.

The diagnosis of polycystic ovary syndrome: the criteria are insufficiently robust for clinical research

Polycystic ovary syndrome (PCOS) is a common disorder but has considerable phenotypic variability and this has led to controversy over its exact definition and diagnosis. The objective of this study was to review the recently proposed diagnostic criteria to determine whether they were sufficiently robust for clinical and research practise. We have reviewed the literature pertaining to clinical measurement and quality of laboratory analysis in relation to clinical and biochemical hyperandrogenism. The recently published statements regarding the diagnosis of PCOS assume that the clinical, laboratory and imaging studies are dichotomous variables, without considering the effect of observer subjectivity or measurement variability on the outcome. The data suggest that there is considerable uncertainty of all measurements and lack of clarity of the definition of the term 'hyperandrogenaemia' which can lead to misdiagnosis. The current diagnostic strategies for PCOS are defined too vaguely to ascertain that individuals fit the definition of the syndrome. A pragmatic approach may be taken in the management of an individual depending upon her particular symptoms and needs. However, research into the epidemiology, pathophysiology and treatment of PCOS will require the production of robust definitions of the diagnostic criteria. We propose specific criteria that would answer the criticisms that we have raised.

Adrenocortical dysregulation as a major player in insulin resistance and onset of obesity

The aim of this review is to explore the dysregulation of adrenocortical secretions as a major contributor in the development of obesity and insulin resistance. Disturbance of adipose tissue physiology is one of the primary events in the development of pathologies associated with the metabolic syndrome, such as obesity and type 2 diabetes. Several studies indicate that alterations in metabolism of glucocorticoids (GC) and androgens, as well as aldosterone in excess, are involved in the emergence of metabolic syndrome. Cross talk among adipose tissue, the hypothalamo-pituitary complex, and adrenal gland activity plays a major role in the control of food intake, glucose metabolism, lipid storage, and energy balance. Perturbation of this cross talk induces alterations in the regulatory mechanisms of adrenocortical steroid synthesis, secretion, degradation, and/or recycling, at the level of the zonae glomerulosa (aldosterone), fasciculata (GC and GC metabolites), and reticularis (androgens and androgen precursors DHEA and DHEAS). As a whole, these adrenocortical perturbations contribute to the development of metabolic syndrome at both the paracrine and systemic level by favoring the physiological dysregulation of organs responsive to aldosterone, GC, and/or androgens, including adipose tissue.

Adrenarche and polycystic ovary syndrome: a tale of two hypotheses

Polycystic ovary syndrome (PCOS) is an extremely common endocrine disorder affecting young women, with the potential for both reproductive and non-reproductive adverse outcomes. While oligomenorrhea, hyperandrogenism, and cystic ovarian morphology are recognized characteristics of this syndrome, the origin of these disturbances is not always apparent. During normal growth and development, adrenarche, the prepubertal onset of adrenal androgen secretion, results phenotypically in pubarche. Gonadarche, which is the ovarian response to gonadotropin releasing hormone-mediated gonadotropin secretion, also occurs, leading to reproductive competence, namely the establishment of ovulatory cycles, repeatedly. In this mini-review, an overview of adrenarche and gonadarche are presented, followed by two hypotheses. The first describes an evolutionary role for adrenarche: an advantage in the attainment of reproductive competence. The second proposes that the path to PCOS be viewed from a developmental perspective, namely, that PCOS is a maladaptation of the processes that lead to reproductive competence in women. Its defining characteristics of oligomenorrhea, hyperandrogenism, and cystic ovarian morphology are the final common pathway of multiple possible derangements. Elucidating and understanding these maladaptive processes will be the key to future endeavors at prevention and treatment of this common reproductive disorder.

The adrenal and polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders characterized by androgen excess, oligo-ovulation and polycystic ovaries. Although ovaries are the main source of increased androgens in the syndrome, between 20 and 30% of patients with PCOS have adrenal androgen (AA) excess, detectable primarily by elevated dehydroepiandrosterone sulfate (DHEAS) levels. Patients with PCOS demonstrate a generalized hypersecretion of adrenocortical products, basally and in response to ACTH stimulation. The mechanisms of these abnormalities are unclear although AA excess in PCOS is likely a complex trait, modulated by both intrinsic and acquired factors. To date, no specific genetic defects have been identified. The production of AAs in response to ACTH appears to be closely related to altered factors regulating glucose-mediated glucose disposal, increased peripheral metabolism of cortisol, and to a less extent to the effects of extra-adrenal androgens, insulin resistance, hyperinsulinemia or obesity. Finally, DHEAS levels and the response of AAs to ACTH are relatively constant over time and are closely correlated between PCOS patients and their siblings suggesting that this abnormality is an inherited trait in PCOS.

Glucose intolerance in polycystic ovary syndrome--a position statement of the Androgen Excess Society

OBJECTIVES

Women with polycystic ovarian syndrome (PCOS) are at increased risk for developing glucose intolerance and type 2 diabetes mellitus (DM). Recommendations for the timing and method of screening have varied. The purpose of this statement is to determine the optimal screening method, timing of screening, and treatment modalities for impaired glucose tolerance (IGT) among women with PCOS.

PARTICIPANTS

The expert panel was appointed by the Androgen Excess Society (AES) to review the literature and make recommendations based on the available evidence. Meetings were open, and there was no funding for the panel.

EVIDENCE

A systematic review was conducted of the published, peer-reviewed medical literature using MEDLINE to identify studies that addressed the prevalence, risk factors, testing, and treatment for IGT in both adults and adolescents with PCOS. Unpublished data were not considered.

CONSENSUS PROCESS

The panel held meetings to review the literature and draft the statement as a committee. The AES board members reviewed and critiqued the manuscript, and changes were made based on their comments.

CONCLUSIONS

The panel recommends that all patients with PCOS be screened for IGT with a 2-h oral glucose tolerance test. A few members of the AES board recommend alternatively screening women with PCOS for IGT and type 2 DM using an oral glucose tolerance test only in patients with a body mass index of 30 kg/m2 or greater or in lean patients with additional risk factors. Patients with normal glucose tolerance should be rescreened at least once every 2 yr, or more frequently if additional risk factors are identified. Those with IGT should be screened annually for development of type 2 DM. PCOS patients with IGT should be treated with intensive lifestyle modification and weight loss and considered for treatment with insulin-sensitizing agents.

The metabolic syndrome in women

The metabolic syndrome is estimated to be present in 47 million US residents with a similar age-adjusted prevalence in men (24%) and women (23%). The consideration of various metabolic risk factors as a single entity in the metabolic syndrome provides clinicians with a tool by which they can identify a population at increased risk for type 2 diabetes mellitus and increased cardiovascular morbidity and mortality. Cardiovascular disease is the leading cause of mortality in women in the US. To reduce the risk of cardiovascular disease, efforts have focused on modifying the metabolic risk factors that constitute the metabolic syndrome: abdominal obesity, dyslipidemia, glucose intolerance, and hypertension. In addition, because of several circumstances specific to women, including pregnancy, polycystic ovary syndrome, oral contraceptive therapy use, and menopause, there are special considerations regarding risk factor identification, modification, and clinical management. This article provides a review of diagnostic and therapeutic issues that clinicians should consider when caring for women at risk for developing or diagnosed with the metabolic syndrome.

Obesity and the polycystic ovary syndrome

Polycystic ovarian syndrome (PCOS) is extremely common among reproductive-aged women, but often goes undiagnosed. PCOS is associated with the metabolic syndrome and carries a greatly increased risk of impaired glucose tolerance and type 2 diabetes mellitus, and cardiovascular risks. Treatment of PCOS may provide relief of cosmetic problems and depression by improving patient self-esteem. In addition, because of its association with the metabolic syndrome, type 2 diabetes mellitus, and cardiovascular disease, its recognition and treatment can potentially be life saving. This article reviews the impact, pathophysiology, and associated risks of obesity and the metabolic syndrome in PCOS.

Abdominal adiposity and the polycystic ovary syndrome

Abdominal adiposity, overweightness and obesity are frequently present in patients with polycystic ovary syndrome (PCOS). A large body of evidence suggests that abdominal adiposity and the resulting insulin resistance contribute to ovarian and, possibly, adrenal hyperandrogenism. However, androgen excess itself might also contribute to abdominal fat deposition in hyperandrogenic women. Recent genomic and proteomic analyses of visceral fat from PCOS patients have detected differences in gene expression and protein content compared with those of non-hyperandrogenic women. Here we review the existing evidence for a vicious circle whereby androgen excess favoring the abdominal deposition of fat further facilitates androgen secretion by the ovaries and adrenals in PCOS patients.

The management of insulin resistance in polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) has reproductive and metabolic implications. Insulin resistance (IR), secondary to genetic and lifestyle factors, is integral in the pathogenesis, metabolic, clinical features and the long-term sequelae in the majority of people with PCOS. Therapeutic strategies targeting IR in PCOS ameliorate clinical features and might reduce long-term sequelae including diabetes. The mainstay for improving IR is lifestyle change; however, feasibility and sustainability remain concerns. In PCOS, metformin reduces IR, improves ovarian function, regulates cycles, lowers androgens, improves clinical hyperandrogenism and potentially improves fertility. Metformin is also likely to delay diabetes onset and has a role in PCOS in those at high risk of diabetes; however, further research is needed to clarify specific target subgroups and clinical indications.

Polycystic ovary syndrome

Polycystic ovary syndrome is a heterogeneous endocrine disorder that affects about one in 15 women worldwide. The major endocrine disruption is excessive androgen secretion or activity, and a large proportion of women also have abnormal insulin activity. Many body systems are affected in polycystic ovary syndrome, resulting in several health complications, including menstrual dysfunction, infertility, hirsutism, acne, obesity, and metabolic syndrome. Women with this disorder have an established increased risk of developing type 2 diabetes and a still debated increased risk of cardiovascular disease. The diagnostic traits of polycystic ovary syndrome are hyperandrogenism, chronic anovulation, and polycystic ovaries, after exclusion of other conditions that cause these same features. A conclusive definition of the disorder and the importance of the three diagnostic criteria relative to each other remain controversial. The cause of polycystic ovary syndrome is unknown, but studies suggest a strong genetic component that is affected by gestational environment, lifestyle factors, or both.

Polycystic ovary syndrome update in adolescence

PURPOSE OF REVIEW

To provide an overview of our current understanding of polycystic ovary syndrome, its epidemiology and natural history, and potential therapeutic options.

RECENT FINDINGS

Polycystic ovary syndrome is estimated to affect 5-10% of premenopausal women. While once thought to affect primarily adult women, polycystic ovary syndrome is frequently diagnosed during adolescence and may be increasing in prevalence secondary to the recent trend of increasing obesity among teenagers. Adolescents and young women often present with hirsutism, irregular menses, and obesity. There is increasing evidence that these women are also at increased risk later in life for cardiovascular and metabolic disease. Early treatment may prevent disease progression. Treatment options have focused on improving clinical symptoms of androgen excess and anovulation. Newer therapies, such as insulin-sensitizing agents, are beneficial in correcting the underlying metabolic disorder and, therefore, theoretically may have a more significant impact on reducing associated long-term morbidity.

SUMMARY

An increasing number of adolescents are presenting with signs of polycystic ovary syndrome. While once thought to primarily affect appearance and fertility, it has become clear that women with this syndrome may also potentially face long-term health sequelae. Efforts should be made to diagnose and treat these women in adolescence to minimize the development of symptoms, and prevent the onset of cardiovascular and metabolic problems.

Follicle-stimulating hormone increases tuberin phosphorylation and mammalian target of rapamycin signaling through an extracellular signal-regulated kinase-dependent pathway in rat granulosa cells

FSH-mediated regulation of mammalian target of rapamycin (mTOR) signaling in proliferating granulosa cells and the effect of dihydrotestosterone (DHT) on this pathway were examined. Inhibiting mTOR activation using rapamycin significantly reduced the FSH-mediated increase in cyclin D2 mRNA expression, suggesting that mTOR plays a role in the FSH-mediated increase in granulosa cell proliferation. FSH treatment of granulosa cells showed a 2-fold increase in phosphorylation of p70S6 kinase (p70S6K), the downstream target of mTOR. The increase in p70S6K phosphorylation by FSH treatment was abolished by prior exposure to DHT, suggesting that DHT inhibits FSH-mediated activation of mTOR signaling in cultured granulosa cells. The effect of FSH and DHT treatment on tuberin (TSC2), the upstream regulator of mTOR, was then examined. FSH treatment increased TSC2 phosphorylation, and pretreatment with DHT for 24 h reduced this stimulation. These results indicate that reduced p70S6K phosphorylation observed in DHT-treated cells might be the result of reduced TSC2 phosphorylation. Because Akt is the upstream activator of TSC2 phosphorylation, the effect of Akt inhibition was examined to test whether FSH-mediated TSC2 phosphorylation proceeds through an Akt-dependent pathway. Our results show that inhibiting Akt phosphorylation did not block FSH-stimulated TSC2 phosphorylation, whereas ERK inhibition reduced FSH-mediated stimulation. These results demonstrate the involvement of ERK rather than Akt in FSH-mediated TSC2 phosphorylation in granulosa cells. Based on these observations, we conclude that in granulosa cells, FSH uses a protein kinase A-/ERK-dependent pathway to stimulate TSC2 phosphorylation and mTOR signaling, and DHT treatment significantly reduces this response.

Comparison of ethinyl-estradiol plus cyproterone acetate versus metformin effects on classic metabolic cardiovascular risk factors in women with the polycystic ovary syndrome

CONTEXT

Oral contraceptives may worsen the metabolic profile of patients with polycystic ovary syndrome (PCOS), favoring the use of insulin sensitizers in these patients.

OBJECTIVE

The aim of the study was to compare the effects of a contraceptive pill on metabolic classic cardiovascular risk factors with those of the insulin sensitizer metformin.

DESIGN

We conducted a randomized, parallel, open-label clinical trial.

SETTING

The study was conducted at an academic hospital.

PATIENTS

Thirty-four consecutive PCOS patients were studied.

INTERVENTIONS

Patients were randomized to oral treatment with metformin (850 mg twice daily) or with the Diane(35) Diario pill (35 microg of ethinyl-estradiol plus 2 mg of cyproterone acetate) for 24 wk.

MAIN OUTCOME MEASURES

Hyperandrogenism, lipid profiles, and indexes of glucose tolerance and insulin sensitivity were measured at baseline and after 12 and 24 wk of treatment.

RESULTS

Diane(35) Diario resulted in higher reductions in hirsutism score and serum androgen levels compared with metformin. Menstrual regularity was restored in all the patients treated with Diane(35) Diario compared with only 50% of those receiving metformin. Plasma apolipoprotein A-I and HDL-phospholipid levels increased with Diane(35) Diario, whereas metformin did not induce any change in the lipid profile. On the contrary, the insulin sensitivity index increased with metformin but did not change with Diane(35) Diario. No differences in the frequencies of abnormalities of glucose tolerance and dyslipidemia were found between both treatments.

CONCLUSIONS

Diane(35) Diario appears to be superior to metformin for the control of hyperandrogenism and for the restoration of menstrual regularity in PCOS patients, and it is not associated with any clinically relevant worsening in the classic metabolic cardiovascular risk profile of these women.

Acceleration of luteinizing hormone pulse frequency in adolescent girls with a history of central precocious puberty with versus without hyperandrogenism

Some adolescents with a history of idiopathic central precocious puberty (ICPP) develop hyperandrogenism.

HYPOTHESIS

Luteinizing hormone (LH) hypersecretion could be a common mechanism underlying ICPP and polycystic ovary syndrome.

AIM

To explore the GnRH-LH axis in those patients.

DESIGN

To compare overnight LH secretion in 7 healthy adolescents (CG) with that in patients with prior ICPP [5 with (CPPA) and 7 without (CPPB) hyperandrogenism]. To analyze daytime LH secretion in those patients.

METHODS

LH secretion was quantified by immunofluorometry and deconvolution analysis.

RESULTS

Nighttime mean LH (international units/liter) was higher in CPPA (6.9 +/- 1.5) than in CPPB (3.2 +/- 0.4, p < 0.05) and CG (2.9 +/- 0.4, p < 0.01). Deconvolution analysis revealed a greater nighttime LH frequency (pulses/hour) both in CPPA (0.91 +/- 0.06, p < 0.01) and CPPB (0.74 +/- 0.02, p < 0.05) than in CG (0.45 +/- 0.07). CPPA patients maintained a higher frequency than CPPB. Pulsatile LH production was greater in CPPA than in CG (50 +/- 12 vs. 18 +/- 3 IU/l/day, p < 0.01). Daytime mass of LH released per burst and pulsatile production rate were significantly greater in CPPA than in CPPB patients.

CONCLUSIONS

Hyperandrogenic adolescents with prior ICPP show increased pulsatile LH secretion. Augmentation of LH pulsatility may predispose to or cause hyperandrogenism in some adolescents with a history of precocious puberty.

Developmental programming of cardiovascular disorders: focus on hypertension

Increasing evidence suggests that adult cardiovascular disorders, e.g. hypertension, can be "programmed" in utero. The mechanisms that affect the developing fetus and lead to future cardiovascular disease are not fully established. This review addresses the possible involvement of maternal nutrition, sex steroids and other endocrine factors in the programming of hypertension in adulthood. Some possible mechanisms of subsequent development of hypertension in adulthood, such as elevated sympathetic and renin-angiotensin system activity, and failure of nephron development, also are discussed. Previous studies suggest that maternal undernutrition could be a major factor in fetal programming, but in light of the increased worldwide prevalence of obesity, maternal overnutrition is now receiving increased attention. Special emphasis is given here to this phenomenon. Obesity is associated with increased serum and tissue levels of proinflammatory cytokines, and loss of sensitivity to the adipokine leptin. It is postulated that this causes dysregulation of the hypothalamo-pituitary-adrenal axis, resulting in increased levels of circulating glucocorticoids. These factors could play a major role in programming, during the in utero period, of future hypertension in the offspring of obese mothers.