Chronic hyperinsulinemia and the adrenal androgen response to acute corticotropin-(1-24) stimulation in hyperandrogenic women

Association of severity of menstrual dysfunction with hyperinsulinemia and dysglycemia in polycystic ovary syndrome

STUDY QUESTION

Is the severity of menstrual cyclicity related to hyperinsulinemia and dysglycemia in women with hyperandrogenic polycystic ovary syndrome (PCOS)?

SUMMARY ANSWER

Hyperandrogenic PCOS women with amenorrhea, compared to those with oligomenorrhea or eumenorrhea, had a greater risk of post-challenge hyperinsulinemia, which may explain their higher prevalence of dysglycemia.

WHAT IS KNOWN ALREADY

PCOS is associated with metabolic dysregulation including insulin resistance (IR) and hyperinsulinemia, risk factors for type 2 diabetes mellitus (T2DM) and other vascular-metabolic morbidities. Although the severity of menstrual cyclicity is associated with IR in PCOS, it is unclear whether, and to what extent, it is related to hyperinsulinemia and glycemic abnormalities.

STUDY DESIGN, SIZE, DURATION

We prospectively compared the degree of menstrual cyclicity with the presence of dysglycemia (elevated 1-h plasma glucose ≥155 mg/dl; abnormal glucose tolerance [AGT], including prediabetes and T2DM; and AUC for glucose [G-AUC]) or dynamic state hyperinsulinemia (peak insulin levels either at 1 or 2 h of the oral glucose tolerance test (oGTT) and AUC for insulin [I-AUC]) in 333 hyperandrogenic PCOS women.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In a tertiary care setting, hyperandrogenic PCOS participants with ovulatory eumenorrhea (Ov-Eumeno, n = 25), anovulatory eumenorrhea (Anov-Eumeno, n = 33), oligomenorrhea (Oligo, n = 150) and amenorrhea (Ameno, n = 125) underwent comprehensive phenotyping and a 2-h 75 g oGTT.

MAIN RESULTS AND THE ROLE OF CHANCE

Mean BMI was greater among Ameno women than among Oligo, Anov-Eumeno or Ov-Eumeno women. Adjusting for BMI, the Ameno group demonstrated higher mean 1- and 2-h insulin and glucose, peak insulin and I-AUC and G-AUC, and either had a higher, or tended toward having a higher, prevalence of elevated 1-h glucose level and prevalence of AGT than the Oligo, Anov-Eumeno or Ov-Eumeno groups. In logistic regression, adjusting for BMI, Ameno women were more likely to have: AGT than Oligo women (odds ratio [OR]: 2.3; 95% CI: 1.3 to 4.2); elevated 1-h glucose (OR: 10.2; CI: 1.3-79.7) than those with Ov-Eumeno; and both AGT (OR: 1.7; CI: 1.1-2.6) and elevated 1-h glucose (OR: 1.8; CI: 1.1-2.8) than those with Anov-Eumeno or Ov-Eumeno when combined. Race/ethnicity, age, waist-to-hip ratio, fasting insulin and glucose, and biochemical or clinical measures of hyperandrogenism were similar across the four menstrual categories.

LIMITATIONS, REASONS FOR CAUTION

Our study was limited by its cross-sectional nature and by studying women affected by PCOS as defined by the Androgen Excess & PCOS Society criteria (i.e. Rotterdam Phenotypes A, B and C) who were identified in the clinical setting. Consequently, extrapolation of the present data to other PCOS phenotypes (e.g. PCOS Phenotype D) should be made with caution.

WIDER IMPLICATIONS OF THE FINDINGS

In hyperandrogenic PCOS phenotypes, a history of amenorrhea, compared to oligomenorrhea or eumenorrhea, suggests a more severe cardiometabolic risk, including a higher degree of hyperinsulinemia and greater prevalence of glycemic abnormalities. These findings may assist in refining the treatment and screening guidelines for glycemic abnormalities in PCOS.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported in part by grants R01-DK073632 and R01-HD29364 from the NIH and an endowment of the Helping Hand of Los Angeles, Inc. (to R.A.). M.D.P. has no competing interests to declare. U.E. is an investor in Concentric Analgesics, Inc. R.A. serves as a consultant for Spruce Biosciences and Fortress Biotech and an advisor for Aurora Forge.

TRIAL REGISTRATION NUMBER

N/A.

Menstrual dysfunction in polycystic ovary syndrome: association with dynamic state insulin resistance rather than hyperandrogenism

OBJECTIVE

To examine the relation of menstrual cyclicity abnormalities to hyperandrogenism (HA) and dynamic state insulin resistance (IR) in oligo-ovulatory women with polycystic ovary syndrome (PCOS).

DESIGN

Prospective cross-sectional study.

SETTING

Tertiary-care academic center.

PATIENT(S)

Fifty-seven women with PCOS (1990 National Institutes of Health criteria) and 57 healthy control women matched by body mass index (BMI).

INTERVENTION(S)

Short insulin tolerance test (ITT).

MAIN OUTCOME MEASURE(S)

Menstrual cyclicity, sex hormone-binding globulin (SHBG), measures of HA (i.e., modified Ferriman-Gallwey score, total and free testosterone, dehydroepiandrosterone sulfate), and the rate constant for plasma glucose disappearance (kITT) derived from the short ITT.

RESULT(S)

Adjusting for age, BMI, and ethnicity, the mean androgen measures were higher and SHBG trended lower, kITT was lower, and the prevalence of IR was higher in PCOS than in controls, independent of menstrual cyclicity. The optimal cutoff point for IR was set at kITT value of 3.57%/minute or lower. Overall, 79% of the women with PCOS had IR. To control further for the effect of ethnicity, a subgroup of 46 non-Hispanic white PCOS participants were studied; those who exhibited amenorrhea (n = 15) or oligomenorrhea (n = 19) had or tended toward having a lower kITT and a higher prevalence of IR than the women with PCOS and oligo-ovulatory eumenorrhea (n = 12). The kITT trended lower and the prevalence of IR trended higher in women with PCOS and amenorrhea than those with oligomenorrhea. The measures of SHBG and HA were similar across the three menstrual groups.

CONCLUSION(S)

Oligo-ovulatory women with PCOS and overt oligo/amenorrhea have greater degrees of IR but not HA when compared with oligo-ovulatory eumenorrheic women with PCOS, suggesting that IR and hyperinsulinemia but not HA play a role in determining the degree of menstrual dysfunction, which can be used as a clinical marker for the degree of IR in oligo-ovulatory PCOS.

Minimal difference in phenotype between adolescents and young adults with polycystic ovary syndrome

OBJECTIVE

To test the hypothesis that the polycystic ovary syndrome (PCOS) phenotype, or its component features, is less severe in adolescents than in young adult patients, in a referred (clinical) population.

DESIGN

Cross-sectional study.

SETTING

Tertiary-care academic medical center.

PATIENT(S)

Two hundred seventy-four adolescents and young adults aged 13.0-24.9 years with PCOS according to the National Institute of Health 1990 criteria. Patients were categorized as adolescents (AD: 13.0-18.9 years; n = 91) and young adults (YA: 19.0-24.9 years; n = 183). Adolescents were further categorized as early adolescents (Early-AD: 13.0-15.9 years; n = 31) and late adolescents (Late-AD: 16.0-18.9 years; n = 60).

INTERVENTION(S)

History, physical examination, hormonal assays with the use of standardized protocols.

MAIN OUTCOME MEASURE(S)

Unadjusted and adjusted odds ratios (ORs; adjusted for body mass index [BMI] when applicable) were calculated for biochemical hyperandrogenism (HA), hirsutism (HIR), acne, and degree of oligo/amenorrhea (OA). PCOS phenotypes were classified as HIR+HA+OA, HA+OA, and HIR+OA.

RESULT(S)

Our analysis demonstrated minimal significant difference in the prevalence of the three PCOS phenotypes, or component features, between AD and YA patients. The risks for obesity were higher for YA versus AD, and the risk of acne was lower for YA versus AD. There was no significant difference between Early-AD and Late-AD. BMI-adjusted models did not significantly modify the main findings.

CONCLUSION(S)

The present study suggests that the PCOS phenotype is established in early adolescence, remains constant into adulthood, and is not related to BMI.

Long-Term Response of Hirsutism and Other Hyperandrogenic Symptoms to Combination Therapy in Polycystic Ovary Syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) affects 5%-15% of women and is the most common cause of hirsutism. Data on the time-course of improvement to suppressive therapy and predictors of that response in PCOS are lacking. The objectives of our study are to determine the long-term response and identify predictors of response in PCOS women treated with suppressive therapy, including spironolactone (SPL) + oral contraceptives (OCs).

MATERIALS AND METHODS

Retrospective cross-sectional analysis of 200 women with PCOS (1990 NIH criteria) treated with suppressive therapy in general, and a subgroup of 138 subjects treated with OCP+SPL who had been prospectively included in a biorepository. Main outcome measure included improvement rate per 100 person-month of follow-up for hirsutism, menstrual irregularity and acne measured qualitatively as "feeling better", and changes in the severity of hirsutism quantified by modified Ferriman-Gallwey [mF-G] score.

RESULTS

During a mean follow-up of 34.2 months, 85.1%, 82.7%, and 79.3% of patients reported improvement in hirsutism, menstrual dysfunction, and acne, respectively. The modified Ferriman-Gallwey (mF-G) hirsutism score improved by 59.9%. The net reduction in mF-G score and the percent of patients reporting improvement in hirsutism were greater for OC+SPL than for either drug alone, with no difference in the percent of patients free of adverse effects. Among those treated with OC+SPL (n = 138), the initial mF-G and sex hormone-binding globulin (SHBG) independently predicted successful therapy for hirsutism.

CONCLUSION

There is a high rate of patient satisfaction with suppressive therapy in PCOS. The efficacy of suppressive therapy for hirsutism was greater with OC+SPL than with either drug alone. Successful treatment of hirsutism with combination OC+SPL requires at least 6 months of therapy, with the proportion of satisfied patients continuing to increase with treatment duration. The probability of patient satisfaction with OC+SPL treatment for hirsutism can be predicted by her initial mF-G score or SHBG level.

DHEA, DHEAS and PCOS

Approximately 20-30% of PCOS women demonstrate excess adrenal precursor androgen (APA) production, primarily using DHEAS as a marker of APA in general and more specifically DHEA, synthesis. The role of APA excess in determining or causing PCOS is unclear, although observations in patients with inherited APA excess (e.g., patients with 21-hydroxylase deficient congenital classic or non-classic adrenal hyperplasia) demonstrate that APA excess can result in a PCOS-like phenotype. Inherited defects of the enzymes responsible for steroid biosynthesis, or defects in cortisol metabolism, account for only a very small fraction of women suffering from hyperandrogenism or APA excess. Rather, women with PCOS and APA excess appear to have a generalized exaggeration in adrenal steroidogenesis in response to ACTH stimulation, although they do not have an overt hypothalamic-pituitary-adrenal axis dysfunction. In general, extra-adrenal factors, including obesity, insulin and glucose levels, and ovarian secretions, play a limited role in the increased APA production observed in PCOS. Substantial heritabilities of APAs, particularly DHEAS, have been found in the general population and in women with PCOS; however, the handful of SNPs discovered to date account only for a small portion of the inheritance of these traits. Paradoxically, and as in men, elevated levels of DHEAS appear to be protective against cardiovascular risk in women, although the role of DHEAS in modulating this risk in women with PCOS remains unknown. In summary, the exact cause of APA excess in PCOS remains unclear, although it may reflect a generalized and inherited exaggeration in androgen biosynthesis of an inherited nature.

Referral bias in defining the phenotype and prevalence of obesity in polycystic ovary syndrome

BACKGROUND

The described phenotype of the polycystic ovary syndrome (PCOS) has been primarily based on findings in a referred (self or otherwise) population. It is possible that the phenotype of PCOS would be different if the disorder were to be detected and studied in its natural (unbiased) state.

OBJECTIVE

Our objective was to compare the phenotype of PCOS detected in an unselected population with that identified in a referral population.

PARTICIPANTS

Participants included 292 PCOS patients identified at a tertiary care outpatient facility (referral PCOS) and 64 PCOS women (unselected PCOS) identified through the screening of a population of 668 seeking a pre-employment physical. Among the women undergoing a pre-employment physical, 563 did not demonstrate features of the disorder (unselected controls). All PCOS subjects met the National Institutes of Health 1990 criteria for the disorder.

MAIN OUTCOME MEASURES

We estimated prevalence of obesity and severity of disease burden.

RESULTS

Referral PCOS subjects had greater mean body mass index and hirsutism score and higher degrees of hyperandrogenemia, were more likely to be non-Hispanic White (83.90%), and demonstrated a more severe PCOS subphenotype than unselected PCOS or unselected controls. The prevalence of obesity and severe obesity in referral PCOS was 2.3 and 2.5 times greater than estimates of the same in unselected PCOS and 2.2 and 3.8 times greater than estimates in unselected controls, respectively. Alternatively, unselected PCOS subjects had a prevalence of obesity and severe obesity and a mean body mass index similar to those of the general population from which they were derived.

CONCLUSION

The phenotype of PCOS, including the racial/ethnic mix, severity of presentation, and rate of obesity, is affected significantly by whether the PCOS subject arises from a referral population or through unselected screening, likely reflecting the degree of patient concern and awareness and access to healthcare.

Achieving a successful pregnancy in women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a disease of complex and still poorly understood cause and of variable phenotypes. It is characterized by anovulation, hyperandrogenism, and polycystic ovaries. Infertility is commonly present. A variety of methods has been used successfully to achieve pregnancy in women with PCOS. Maintenance of pregnancy is complicated by a higher rate of premature spontaneous abortions and high risk of gestational diabetes, hypertension, and preeclampsia. However, with careful monitoring and treatment, the outcome of pregnancy in most women with PCOS is excellent.

Prevalence of hyperandrogenemia in the polycystic ovary syndrome diagnosed by the National Institutes of Health 1990 criteria

OBJECTIVE

To determine the prevalence of elevated total and free T, and DHEAS, alone and in combination, in patients with polycystic ovary syndrome (PCOS).

DESIGN

Cross-sectional analysis.

SETTING

Tertiary care academic medical center.

PATIENT(S)

Seven hundred twenty patients diagnosed with PCOS according to the National Institutes of Health 1990 criteria.

INTERVENTION(S)

History, physical examination, and blood sampling.

MAIN OUTCOME MEASURE(S)

Hyperandrogenemia, defined as at least one androgen value above the 95th percentile of 98 healthy control women (i.e., total T >88 ng/dL, free T >0.75 ng/dL, and DHEAS >2,750 ng/mL).

RESULT(S)

A total of 716 subjects with PCOS were included. The overall prevalence of hyperandrogenemia in PCOS was 75.3%. Supranormal levels of free T were present in 57.6%, of total T in 33.0%, and of DHEAS in 32.7% of patients with PCOS. When assessing the prevalence of two abnormal values, the prevalence of simultaneously elevated androgens was lowest with total T and DHEAS (1.7%) and highest with total T and free T (20.4%). Altogether, simultaneous elevations in all three markers were found in 8.7% of subjects with PCOS.

CONCLUSION(S)

Approximately three-fourths of patients with PCOS diagnosed by the National Institutes of Health 1990 criteria have evidence of hyperandrogenemia; the single most predictive assay was the measurement of free T with approximately 60% of patients demonstrating supranormal levels.

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.

Impact of obesity on the risk for polycystic ovary syndrome

CONTEXT

Although it is well established that adiposity increases the severity of the clinical features of polycystic ovary syndrome (PCOS), the data regarding the prevalence of PCOS in obese women and the change in body weight women presented with PCOS over time are scarce.

OBJECTIVE

The objective of the study was to determine whether obesity increases the risk of PCOS and whether the degree of obesity of PCOS patients has increased, paralleling the rise in obesity in the population.

DESIGN

We analyzed data from two consecutive populational studies assessing the prevalence of PCOS and a database containing all untreated PCOS patients evaluated at a university clinic between 1987 and 2002.

SETTING

The study was conducted at a tertiary care center.

PATIENTS OR OTHER PARTICIPANTS

Participants included 675 women who participated in prevalence studies and 746 PCOS patients.

MAIN OUTCOME MEASURES

Populational prevalence of PCOS according to body mass index (BMI) and change in BMI of PCOS patients over time were measured.

RESULTS

The prevalence rates of PCOS in underweight, normal-weight, overweight, and obese women were 8.2, 9.8, 9.9, and 9.0%, respectively. Prevalence rates reached 12.4 and 11.5% in women with BMI 35-40 kg/m2 and greater than 40 kg/m2 (P = NS). The mean BMI of PCOS patients diagnosed between 1987 and 2002 rose, beginning in 1997 and reaching 37.3 +/- 9.9 kg/m2 in 2000-2002, paralleling the change in BMI of the surrounding population (10-14% obesity rate in 1987, 15-19% in 1997, and 25% or greater in 2002).

CONCLUSION

Our results suggest that the risk of PCOS is only minimally increased with obesity, although the degree of obesity of PCOS patients has increased, similar to that observed in the general population. These data indicate that obesity in PCOS reflects environmental factors to a great extent.

ACTH stimulation test in lean polycystic ovary syndrome patients with insulin resistance

OBJECTIVE

To determine whether insulin resistance in nonobese polycystic ovarian syndrome (PCOS) patients is associated with a higher response to ACTH stimulation.

DESIGN

Controlled prospective study.

SETTING

University hospital ambulatory care unit.

PATIENT(S)

Twenty nonobese PCOS syndrome patients with insulin resistance and a body mass index-matched control group of 20 nonobese PCOS patients without insulin resistance.

INTERVENTION(S)

A 75-g oral glucose tolerance test and an ACTH stimulation test.

MAIN OUTCOME MEASURE(S)

Blood insulin and glucose levels after ingestion of 75 g oral glucose; blood androstenedione (A), 17(OH)-progesterone [17(OH)-P], free and total T, DHEAS, and progesterone (P) response to ACTH stimulation.

RESULT(S)

The proportional increases in the blood levels of total and free T, DHEAS, A, 17(OH)-P, and P following ACTH stimulation were similar in the two groups. Only the insulin area under the curve (AUC) values were significantly different among the two groups. The insulin AUC values were positively correlated to the free T blood levels and the homeostasis model assessment scores.

CONCLUSION(S)

Within the population of nonobese PCOS patients, insulin resistance is not associated with a more pronounced response to ACTH stimulation. The pathogenesis and management of PCOS in nonobese patients may be different from in obese patients.

Prevalence of insulin resistance in the polycystic ovary syndrome using the homeostasis model assessment

OBJECTIVE

To determine the prevalence of insulin resistance (IR) in a large population of patients with the polycystic ovary syndrome (PCOS).

DESIGN

Prospective, case-control.

SETTING

University medical center.

PATIENT(S)

Two hundred seventy-one PCOS patients and 260 eumenorrheic, non-hirsute, control women.

INTERVENTION(S)

History and physical examination and blood sampling.

MAIN OUTCOME MEASURE(S)

Total T, free T, DHEAS, sex hormone-binding globulin, and fasting glucose and insulin levels; homeostatic model assessment values for IR (HOMA-IR) and percent beta-cell function (HOMA-%beta-cell).

RESULT(S)

Patients with PCOS and controls differed significantly in all parameters studied, except fasting glucose. Because the HOMA-IR and HOMA-%beta-cell values were variably associated with race, age, and body mass index, the HOMA-IR and HOMA-%beta-cell values were then adjusted for these cofounders. After adjustment, 64.4% of PCOS patients were noted to be insulin resistant, and 2.6% had beta-cell dysfunction. Compared with PCOS patients without IR (n = 96), patients with IR (n = 174) were more obese and had higher beta-cell function.

CONCLUSION(S)

In patients with PCOS, the prevalence of IR was 64% according to the HOMA-IR measurement, after adjustment. Patients with IR were more clinically affected. Although IR is a common abnormality in PCOS, it does not seem to be a universal feature.

Prevalence of adrenal androgen excess in patients with the polycystic ovary syndrome (PCOS)

OBJECTIVE

To determine the prevalence of adrenal androgen (AA) excess in the polycystic ovary syndrome (PCOS) using age- and race-specific normative values.

DESIGN

Cross-sectional observational study.

PATIENTS

One hundred and eight-two (88 Black and 94 White) age-matched healthy eumenorrhoeic nonhirsute women (controls) and 213 (27 Black and 186 White) women with PCOS were recruited.

MEASUREMENTS

Total testosterone (T), free T, androstenedione (A4), dehydroepiandrosterone sulfate (DHEAS) and SHBG, as well as fasting insulin and glucose, were measured in plasma.

RESULTS

The mean total T, free T, A4, DHEAS and body mass index (BMI) were higher in women with PCOS than in control women. DHEAS levels were significantly lower in Black controls than White controls, whereas fasting insulin and BMI were higher in Black controls. In control and Black PCOS women, DHEAS levels did not correlate with BMI, waist-to-hip ratio (WHR) or fasting insulin. Among White women with PCOS, DHEAS levels correlated negatively with BMI and fasting insulin. DHEAS levels decreased similarly with age in control and PCOS women of either race. For each race and age group the upper 95% normative values for log DHEAS was calculated, and the number of PCOS subjects with log DHEAS values above this level were assessed. The prevalence of supranormal DHEAS levels was 33.3% and 19.9%, respectively, among Black and White women with PCOS.

CONCLUSIONS

The prevalence of DHEAS excess is approximately 20% among White and 30% among Black PCOS patients, when using age- and race-adjusted normative values. This study also indicates that the age-associated decline in DHEAS levels is observable and similar in both control and PCOS women, regardless of race. While BMI and fasting insulin had little impact on circulating DHEAS levels in healthy women, among White PCOS patients these parameters were negatively associated with circulating DHEAS levels.

Prevalence of CYP21 mutations and IRS1 variant among women with polycystic ovary syndrome and adrenal androgen excess

OBJECTIVE

To determine whether frequencies of the mutations in the 21-hydroxylase (CYP21) gene and the G972R variant of the insulin receptor substrate-1 (IRS1) gene are increased in women with polycystic ovary syndrome (PCOS) and adrenal androgen (AA) excess.

DESIGN

Prospective case-control study.

SETTING

University reproductive endocrinology laboratory and outpatient clinic.

PATIENT(S)

Consecutive patients of non-Hispanic white race diagnosed with PCOS (n = 114) and healthy controls (n = 95).

INTERVENTION(S)

Blood and DNA sampling before hormonal therapy.

MAIN OUTCOME MEASURE(S)

Polycystic ovary syndrome patient and healthy control genotypes, with the CYP21 and IRS1 variants.

RESULT(S)

Fifty-four PCOS patients with (DHEAS >3000 ng/mL) and 55 without (DHEAS <2500 ng/mL) AA excess, respectively, were studied. Of 109 patients studied, 16 (14.7%) were found to be heterozygous carriers of mutations in the CYP21 gene. Of these 16, 10 (62.5%) had excessive AA secretion (i.e., excess DHEAS levels). Fifteen patients (13.8%) were found to be heterozygous carriers of the IRS1 variant; 9 (60.0%) of these 15 had excessive AA secretion. There were no significant differences in the allele frequency of CYP21 mutations or the IRS1 variant between PCOS patients with and without AA excess, and controls. None of the subjects were found to be homozygous carriers of CYP21 mutations or the IRS1 variant. Combined heterozygosity for CYP21 mutations and the IRS1 variant was limited to women with PCOS and excessive AA (n = 3).

CONCLUSION(S)

The G972R variant of the IRS1 gene might represent a modifier locus among women who are heterozygous carriers of CYP21 mutations, potentially increasing their risk of developing AA excess in PCOS. Nonetheless, this IRS1 variant and CYP21 mutations seem to play a limited role in the development of PCOS in the population studied.

Glucose action and adrenocortical biosynthesis in women with polycystic ovary syndrome

OBJECTIVE

To determine if insulin or glucose action plays a role in adrenocortical steroidogenesis in the polycystic ovary syndrome (PCOS).

DESIGN

Prospective cohort study.

SETTING

Academic medical center.

PATIENT(S)

Nine reproductive-aged patients with PCOS and nine age-, race-, and body mass index-matched controls.

MAIN OUTCOME MEASURE(S)

Insulin-modified frequently sampled intravenous glucose tolerance testing and an acute 60-minute ACTH-(1-24) stimulation test. From the glucose tolerance test, glucose and insulin were measured and the insulin sensitivity index, glucose effectiveness, and acute insulin response to glucose were determined. Dehydroepiandrosterone sulfate (DHEAS) basally and 17-hydroxypregnenolone, 17-hydroxyprogesterone, DHEA, androstenedione, and cortisol during ACTH testing at 0 and 60 minute (steroid(0) and steroid(60)) were determined. The net change in steroid during the ACTH test was calculated.

RESULT(S)

The insulin sensitivity index had limited correlation with adrenocortical variables in both groups. In patients with PCOS, glucose effectiveness was positively associated with DHEAS, cortisol(0), cortisol(60), change in cortisol, DHEA(0), DHEA(60), change in DHEA, 17-hydroxyprenenolone(60), change in 17-hydroxypregnenolone, DHEA(0), androstenedione(0), 17-hydroxyprenenolone(0), 17-hydroxyprogesterone(0), 17-hydroxyprenenolone(60), and 17-hydroxyprogesterone(60).

CONCLUSION(S)

Adrenocortical biosynthesis, basally and in response to ACTH, appears to be closely associated with glucose effectiveness in PCOS. A common factor determining both the effectiveness of glucose to control its own production or uptake and adrenocortical biosynthesis may be aberrant in PCOS.

Troglitazone decreases adrenal androgen levels in women with polycystic ovary syndrome

OBJECTIVE

To determine whether amelioration of insulin resistance in polycystic ovary syndrome (PCOS) with the insulin sensitizer troglitazone (TGZ) decreases circulating adrenal androgens (AAs), as reflected by DHEAS levels.

DESIGN

Prospective, randomized, double-blind clinical trial.

SETTING

Multicenter study.

SUBJECT(S)

Three-hundred five women with PCOS.

INTERVENTION(S)

Subjects were randomly assigned to receive either placebo (PBO; n = 73) or TGZ in doses of 150 mg/day (TGZ-150; n = 78), 300 mg/day (TGZ-300; n = 77), or 600 mg/day (TGZ-600; n = 77) for 20 weeks. Blood was sampled before (week 0) and at week 20 of treatment.

MAIN OUTCOME MEASURE(S)

DHEAS, insulin, and glucose levels were determined in the blood samples.

RESULT(S)

There were no differences in age, body mass, or racial composition among the groups. Our results indicate that basal insulin declined in a dose-related fashion. Likewise, TGZ administration caused a dose-related decrease in DHEAS levels. To detect extreme effects, we subsequently subdivided patients receiving PBO or TGZ-600 into tertiles according to initial DHEAS levels. Patients receiving PBO in the lowest (n = 27) and highest (n = 22) DHEAS tertiles experienced a 16.8% +/- 62.0% and a -11.1% +/- 17.4% change in DHEAS levels during the study, respectively. Alternatively, patients with PCOS receiving TGZ-600 in both the lowest (n = 29) and the highest (n = 23) DHEAS tertiles experienced a drop in DHEAS levels (-18.7% +/- 27.2% and -26.4% +/- 17.2%, respectively), a significant difference from PBO.

CONCLUSION(S)

In conclusion, improving the insulin resistance-related hyperinsulinemia of PCOS with TGZ results in a decrease in DHEAS levels, regardless of initial DHEAS level. Whether the observed suppression is the direct result of decreased insulin levels or whether it reflects other direct and indirect effects of TGZ remains to be determined.

Dietary genistein suppresses chemically induced prostate cancer in Lobund-Wistar rats

Epidemiological reports suggest that Asians consuming a diet high in soy have a low incidence of clinically manifested prostate cancer. We have tested the hypothesis that life-time exposure to genistein, the primary isoflavone component of soy, is responsible for this protective effect. Lobund-Wistar rats were exposed to 0, 25 and 250 mg genistein/kg AIN-76A diet, starting at conception and continued until necropsy at 11 months. Male offspring were injected s.c. with Flutamide on days 50-66 and with testosterone on days 67-69, injected with N-methylnitrosourea (NMU) into the dorsal prostate on day 70, and given testosterone implants, starting at day 77. Genistein in the diet inhibited the development of NMU-induced prostate invasive adenocarcinomas, in a dose-dependent manner. Genistein did not alter body, prostate and testes weights. Male rats fed 0, 25 and 250 mg genistein/kg diet had serum genistein concentrations of 9, 60 and 861 pmol/ml, and prostate genistein concentrations of 85, 230 and 775 pmol/g tissue. We conclude that lifetime dietary genistein protected against chemically induced prostate cancer development in rats.

Comment: the methionine 196 arginine polymorphism in exon 6 of the TNF receptor 2 gene (TNFRSF1B) is associated with the polycystic ovary syndrome and hyperandrogenism

Inflammatory cytokines such as TNF alpha may play a role in the pathogenesis of common metabolic disorders, including hyperandrogenism and the polycystic ovary syndrome (PCOS). The TNF receptor 2 mediates most of the metabolic effects of TNF alpha. In the present study, we have evaluated serum soluble TNF receptor 2 levels, and several common polymorphisms in the TNF receptor 2 gene (TNFRSF1B), in women presenting with PCOS or hyperandrogenic disorders. Initial studies included 103 hyperandrogenic patients (42 presenting with PCOS) and 36 controls from Spain. The 196R alleles of the M196R (676 T-->G) variant in exon 6 of TNFRSF1B, which is in linkage disequilibrium with a CA-repeat microsatellite polymorphism in intron 4 of TNFRSF1B, tended to be more frequent in hyperandrogenic patients than in controls (P = 0.056), reaching statistical significance when the analysis was restricted to include only PCOS patients (P < 0.03). Extended analysis including another 11 hyperandrogenic patients from Spain and 64 patients and 29 controls from Italy confirmed the association between 196R alleles of the M196R variant and hyperandrogenic disorders (P < 0.05), which was maintained when restricting the analysis to PCOS patients (P < 0.02). On the contrary, the 3'-untranslated region (exon 10) variants 1663 G-->A, 1668 T-->G, and 1690 T-->C were not associated with hyperandrogenism. The soluble TNF receptor 2 levels were not different between patients and controls but were increased in obese subjects, compared with lean individuals, and were affected by the interaction between the 1663 G-->A and 1668 T-->G variants in the 3'-untranslated region of TNFRSF1B. The TNFRSF1B genotype did not influence any clinical or biochemical variable related to hyperandrogenism or insulin sensitivity and was not associated with obesity, both in hyperandrogenic patients and healthy controls considered separately. In conclusion, the M196R (676 T-->G) variant in exon 6 of TNFRSF1B is associated with hyperandrogenism and PCOS, further suggesting a role for inflammatory cytokines in the pathogenesis of these disorders.

Effect of oral micronized progesterone on androgen levels in women with polycystic ovary syndrome

OBJECTIVE

To determine whether the use of oral micronized progesterone (OMP) to induce withdrawal bleeding in women suspected of having polycystic ovary syndrome (PCOS) alters circulating androgen levels.

DESIGN

Prospective clinical trial.

SETTING

Academic medical center.

PATIENT(S)

Eight reproductive-aged women with PCOS.

INTERVENTION(S)

Blood was sampled before (week 0) and weekly after (weeks 1 to 4) the administration of OMP (Prometrium, Solvay Pharmaceuticals, Marietta, GA), 100 mg in the morning and 200 mg before bedtime for 7 days.

MAIN OUTCOME MEASURE(S)

The levels of total testosterone (TT), free testosterone (FT), sex hormone-binding globulin (SHBG), dehydroepiandrosterone sulfate (DHEAS), and androstenedione (A4) were determined in the blood samples.

RESULT(S)

In seven of the eight women studied, menstrual cycle intervals were >3 months, while one was eumenorrheic; six of the eight women had hirsutism (modified Ferriman-Gallwey score >7). Mean age was 28.9 +/- 10.4 years and mean body mass index was 33.9 +/- 4.7 kg/m2. The mean values of TT, FT, SHBG, DHEAS, A4, and 17-OHP did not change with OMP administration. However, a higher 17-OHP level was observable at the completion of OMP administration (week 2).

CONCLUSION(S)

We conclude that the administration of OMP (100 mg in the morning and 200 mg before bedtime for 7 days) to induce withdrawal bleeding in women with PCOS does not significantly alter circulating androgen or 17-OHP levels, and can be used to time blood sampling in these patients.

Dietary genistein down-regulates androgen and estrogen receptor expression in the rat prostate

The incidence of clinically manifested prostate cancer is higher in the United States and Europe than in Asian countries. One of the major differences in lifestyle between these populations is the diet, with Asians consuming a greater amount of soy. Soy and genistein, the predominant isoflavone found in soy, inhibit prostate tumor development in animal models. The purpose of this study was to investigate the effect of dietary genistein on sex steroid receptor expression in the dorsolateral prostate, on circulating androgens, and the potential for toxicity in the male rat reproductive tract. Male Sprague-Dawley rats were fed 25 and 250 mg genistein/kg diet from conception until day 70 postpartum, or 250 and 1000 mg genistein/kg diet from day 56 to 70 postpartum. Exposure to genistein in the diet, starting at conception, resulted in down-regulated androgen receptor (AR), and estrogen receptors (ER)-alpha and -beta mRNA expression in the dorsolateral prostate in a dose-dependent manner. Also, genistein fed to adult rats for 2 weeks reduced mRNA expression of AR, ER-alpha and ER-beta in the dorsolateral prostate. ER-alpha protein levels were significantly reduced in animals fed 1000 mg genistein/kg diet compared to control animals. There were no significant alterations to male reproductive tract histomorphology or weights. We conclude that dietary genistein down-regulated expression of the AR and ER-alpha and -beta in the rat prostate at concentrations comparable to those found in humans on a soy diet. Down-regulated sex steroid receptor expression may be responsible for the lower incidence of prostate cancer in populations on a diet containing high levels of phytoestrogens.

Influence of insulin and testosterone on adrenocortical steroidogenesis in vitro: preliminary studies

OBJECTIVE

The mechanisms underlying the adrenal androgen (AA) excess of polycystic ovary syndrome (PCOS) remain unclear, although it is possible that the adrenocortical dysfunction may be a response to other, extraadrenal factors. Consistent with the pathophysiology of PCOS and with in vivo data in normal and PCOS women, we have hypothesized that insulin inhibits and that T stimulates AA secretion in vitro.

DESIGN

In vitro experimental study.

SETTING

University medical center.

PATIENT(S)

Normal human adrenals (n = 4 women, ages 25-57 years) were obtained with consent at the time of organ donation.

INTERVENTION(S)

Fresh adrenal tissue minces were incubated in serum-free medium with 10-microM pregnenolone substrate and 1-microM ACTH-(1-24). Challenge doses of 0.2, 1, 5, 20, and 100 nM of insulin and 1, 10, 100, 1,000, and 10,000 nM of T were added, and the media were sampled after 8 hours of incubation at 37 degrees C, 4% CO2. Dehydroepiandrosterone (DHEA), DHEA-sulfate (DHEAS), and cortisol (F) were measured by radioimmunoassay (significant effects compared with the case of zero-dose control).

MAIN OUTCOME MEASURE(S)

The production of DHEA, DHEAS, and F in the media of the adrenal minces was compared between different subjects and at different concentrations of T and insulin.

RESULT(S)

Analysis of the combined data from all donors indicated that insulin stimulated DHEAS and suppressed DHEA production but had no consistent effect on F. Similar analyses of the combined data indicated that T had no significant predictable effect on the production of DHEAS, DHEA, or F. When examining donor data individually, insulin and T did elicit significant increases and/or decreases in steroid production within subjects, although no consistent trends were observed.

CONCLUSION(S)

On the basis of these data, it is clear that extra-adrenal factors such as insulin and T have some adrenal regulatory capacity. In general, insulin stimulated DHEAS and decreased DHEA production, suggesting that it increases adrenocortical sulfotransferase activity. However, although in the individual subjects studied, both insulin and T frequently altered the production of DHEAS, DHEA or F, these effects did not appear to be uniform or consistent from subject to subject. Expanded studies are required to confirm these results.

The role of the adrenal cortex in polycystic ovary syndrome

Adrenal androgen excess affects approximately 25% of PCOS patients. The exact etiology of this excess in PCOS patients is unclear. Some evidence that adrenal androgen excess may be a genetic trait. The adrenal androgen response to ACTH is highly individualized, and the relative response seems to be constant over time. In addition, there is a strong familial component to adrenal androgen levels in normal individuals and PCOS patients. It is possible that the tendency to overproduce adrenal androgens is an inherited risk factor for the development of PCOS. Overall, few hyperandrogenic patients actually have isolated deficiencies of 3 beta-hydroxysteroid dehydrogenase, 21-hydroxylase, and 11-hydroxylase. The ovarian hormonal secretion in PCOS can affect adrenal androgen secretion and metabolism, although this factor accounts for only part of this abnormality. More likely, the adrenal androgen excess results from a generalized hyperresponsiveness of the adrenal cortex to ACTH, but without an increase in CRH or ACTH sensitivity. Although glucocorticoid administration may improve the ovulatory function of these patients, the results are modest and cannot be predicted by the circulating androgen levels.

Prevalence of polycystic ovary syndrome (PCOS) in first-degree relatives of patients with PCOS

OBJECTIVE

To determine the rate of clinically evident polycystic ovary syndrome (PCOS) among first-degree female relatives within families with a proband affected by PCOS.

DESIGN

Clinical and biochemical evaluation of the mothers and sisters of 93 patients with PCOS. The diagnosis of PCOS was established by: [1] a history of oligomenorrhea, [2] clinical evidence (i.e., hirsutism) or biochemical evidence (i.e., elevated total or free T) of hyperandrogenism, and [3] the exclusion of related disorders.

SETTING

Tertiary care university.

PATIENT(S)

Patients with PCOS and their mothers and sisters.

INTERVENTION(S)

Interview, physical examination, and hormonal testing on blood samples were performed for all subjects.

MAIN OUTCOME MEASURE(S)

The presence of hirsutism and hyperandrogenemia was determined in the mothers and sisters of the patients with PCOS.

RESULT(S)

Of the 78 mothers and 50 sisters evaluated clinically, 19 (24%) and 16 (32%) were affected with PCOS, respectively. A higher rate of PCOS was observed when only premenopausal women not taking hormones (i.e., untreated) were considered (i.e., 35% of mothers and 40% of sisters), consistent with amelioration of symptoms with hormonal therapy or aging. These rates of PCOS are significantly higher than that observed in our general population (approximately 4%) and suggest the involvement of a major genetic component in the disorder.

CONCLUSION(S)

The rates of PCOS in mothers and sisters of patients with PCOS were 24% and 32%, respectively, although the risk was higher when considering untreated premenopausal women only.

A variant of the glucocorticoid receptor gene is not associated with adrenal androgen excess in women with polycystic ovary syndrome

OBJECTIVE

To determine whether the frequency of the N363S variant of the glucocorticoid receptor (GRL) was increased in women with PCOS and adrenal androgen (AA) excess.

DESIGN

Prospective case-control study.

SETTING

University reproductive endocrinology laboratory and outpatient clinic.

PATIENT(S)

Consecutive patients of non-Hispanic white race diagnosed with PCOS (n = 114) and healthy controls (n = 92).

INTERVENTION(S)

Blood and DNA sampling before hormonal therapy.

MAIN OUTCOME MEASURE(S)

PCOS patient and healthy control genotypes, with the N363S allele representing a variant of GRL.

RESULT(S)

Fifty-four PCOS patients with (DHEAS > or = 3000 ng/mL) and 55 without (DHEAS < or = 2,500 ng/mL) AA excess, respectively, were studied. Six of 109 (5.5%) patients studied were found to be heterozygous carriers of the A-->G base pair substitution at cDNA position 1220, resulting in the missense mutation N363S. Of these six, four had excessive AA secretion (i.e., excess DHEAS levels). There was no significant difference in the allele frequency of the GRL variant between PCOS patients with and without AA excess and controls (3.7% [95% confidence interval: 1.0%-5.7%], 1.8% [0.2%-6. 0%], and 3.3% [2.3%-6.0%]). None of the subjects were found to be homozygous for the N363S allele.

CONCLUSION(S)

The N363S variant of GRL was an uncommon occurrence in our population of healthy women and PCOS patients and did not appear to play a major role in the genetic predisposition to PCOS or to AA excess in PCOS.

Adrenocortical hyperresponsivity to adrenocorticotropic hormone: a mechanism favoring the normal production of cortisol in 21-hydroxylase-deficient nonclassic adrenal hyperplasia

OBJECTIVE

To test the hypothesis that patients with nonclassic adrenal hyperplasia (NCAH) exhibit a generalized exaggeration in their response to ACTH stimulation that favors the normal production of F. Patients with 21-hydroxylase (21-OH)-deficient NCAH do not demonstrate cortisol (F) deficiency.

DESIGN

Prospective controlled study.

SETTING

Tertiary university clinic.

PATIENT(S)

Twenty-four untreated patients with NCAH diagnosed by a 17 alpha-hydroxyprogesterone (17-HP) level of >30.3 nmol/L (>10 ng/mL), and 37 age- and body mass-matched healthy eumenorrheic nonhirsute controls.

INTERVENTION(S)

All study subjects underwent a 60 minute acute stimulation using 0.25 mg of ACTH-(1-24) i.v.

MAIN OUTCOME MEASURE(S)

Basal and stimulated serum levels of pregnenolone (PREG), 17-hydroxypregnenolone (17-HPREG), dehydroepiandrosterone (DHA), progesterone (P4), 17-HP, androstenedione (A4), 11-deoxycortisol (S), and cortisol (F).

RESULT(S)

The median basal (i.e., Steroid(0)) or ACTH-stimulated (i. e., Steroid(60)) serum levels of PREG, 17-HPREG, DHA, P4, 17-HP, A4 and, most importantly, S were higher in NCAH patients than in controls. In contrast, the levels of F at either 0 minute or 60 minutes of stimulation were similar between NCAH and control women. The proportion of NCAH patients with stimulated steroids levels of >the 95th percentile of controls were as follows: 84.21% for PREG(60), 87.5% for 17-HPREG(60), 95.8% for DHA(60), 89.5% for P4(60), 100% for 17-HP(60), 91.7% for A4(60), 29.2% for S(60), and 4. 1% for F(60).

CONCLUSION(S)

A generalized adrenocortical hyperresponsivity to ACTH stimulation seems to be present in patients with 21-OH-deficient NCAH, with an exaggerated production of S evident in approximately 30%. The excess production of S in these NCAH patients may, in part, account for their normal F production.

Total testosterone and DHEAS levels as predictors of androgen-secreting neoplasms: a populational study

Androgen excess affects between 2% and 10% of women. While the majority of these patients suffer from polycystic ovary syndrome, a few present with an androgen-secreting neoplasm. An elevated circulating total testosterone level and dehydroepiandiosterone sulfate (DHEAS) level have been proposed as screening methods for detecting ovarian and adrenal androgen-secreting neoplasms, respectively. To determine the predictive value of these tests for androgen-secreting tumors in a population of consecutive hyperandrogenic patients, we studied 478 consecutive untreated hyperandrogenic patients presenting over a ten-year period (1987-97). All had at least two of the following features: (1) oligomenorrhea (i.e. cycles > 35 days or < 8 cycles/year), (2) hyperandrogenemia (i.e. a total or free testosterone, or DHEAS > 95th percentile of controls), or (3) hirsutism (i.e. a modified Ferriman-Gallwey score > or = 6). None of these patients had a prior diagnosis of an androgen-secreting neoplasm. Basal levels of testosterone and DHEAS were determined in all patients, with transvaginal sonography and an adrenal computed tomography scan in select individuals. Of the 478 patients included, 65% had hirsutism and oligomenorrhea; 20% had hyperandrogenic oligomenorrhea; and 15% had hirsutism and hyperandrogenemia, without overt oligomenorrhea. Overall, 11 (2.3%) patients had a total testosterone > 8.7 nmol/l (250 ng/dl), of which one actually had an androgen-secreting neoplasm (i.e. true-positive). This postmenopausal patient presented with rapidly progressive virilization, and demonstrated an ovarian hilar cell tumor at surgery. The calculated sensitivity of an elevated testosterone level (> 8.67 nmol/l) for a neoplasm was 100% (1/1), the specificity was 98% (467/477), and the negative predictive value was 100% (467/467), but the positive predictive value was only 9% (1/11). Ten subjects had DHEAS levels > 16.3 mumol/l (6000 ng/ml), and none was diagnosed with an adrenocortical tumor. Although the sensitivity and positive predictive value of a high DHEAS for a neoplasm could not be calculated due to the absence of a test case, the specificity was 98% (468/478) and the negative predictive value was 100% (468/468). These data suggest that the measurement of testosterone and DHEAS is not a cost-effective method of screening for these tumors, due to the low frequency of the disorder and the fact that clinical evaluation alone is often sufficient screening.

11beta-hydroxyandrostenedione and delta5-androstenediol as markers of adrenal androgen production in patients with 21-hydroxylase-deficient nonclassic adrenal hyperplasia

OBJECTIVE

To determine the sensitivity of 11beta-hydroxyandrostenedione (11-OHA4) and delta5-androstenediol (ADIOL) as markers of excessive adrenal androgen production.

DESIGN

Prospective study.

SETTING

Academic medical centers.

PATIENT(S)

Thirteen women with untreated 21-hydroxylase-deficient nonclassic adrenal hyperplasia (NCAH) and 18 healthy, eumenorrheic, nonhirsute controls matched for age and body mass index.

INTERVENTION(S)

All subjects were studied before and after acute adrenal stimulation with 0.25 mg of IV ACTH-(1-24).

MAIN OUTCOME MEASURE(S)

Basal levels of total testosterone, sex hormone-binding globulin, DHEAS, and free testosterone were measured. Levels of androstenedione (A4), DHEA, 11-OHA4, and ADIOL were determined before (Steroid0) and 60 minutes after (Steroid60) acute ACTH-(1-24) stimulation.

RESULT(S)

Patients with NCAH had higher median basal levels of DHEAS and total and free testosterone than controls. Patients with NCAH had higher median A4(0), A460, DHEA(0), DHEA60, 11-OHA4(0), ADIOL0, and ADIOL60 levels but similar 11-OHA4(60) levels compared with controls. Among patients with NCAH, 30%, 54%, 15%, and 85% had 11-OHA4(0), ADIOL0, 11-OHA4(60), and ADIOL(60) levels, respectively, above the 95th percentile of controls.

CONCLUSION(S)

Overall, serum levels of 11-OHA4 did not appear to be a very sensitive marker of excessive adrenal androgen production, at least in patients with NCAH. Although ACTH-stimulated ADIOL levels were elevated in 85% of the patients studied, they did not appear to have any advantage over the measurement of A4 or DHEA levels.

Prevalence of 3beta-hydroxysteroid dehydrogenase-deficient nonclassic adrenal hyperplasia in hyperandrogenic women with adrenal androgen excess

OBJECTIVE

We sought to determine the prevalence of 3beta-hydroxysteroid dehydrogenase-deficient nonclassic adrenal hyperplasia among adult hyperandrogenic women with dehydroepiandrosterone sulfate excess.

STUDY DESIGN

Thirty consecutive hyperandrogenic women with hirsutism, oligomenorrhea, or both and dehydroepiandrosterone sulfate levels of >8.5 micromol/L and 24 control subjects were studied. Basal sex hormone binding globulin, total and free testosterone, dehydroepiandrosterone sulfate, 17-hydroxyprogesterone, and basal and 60-minute corticotropin-stimulated 17-hydroxypregnenolone and dehydroepiandrosterone were measured, and the increment (change from basal to 60-minute value) was calculated.

RESULTS

Twenty-six (87%) and 25 (83%) of the 30 hyperandrogenic patients studied had 60-minute dehydroepiandrosterone and change in 0- to 60-minute dehydroepiandrosterone levels greater than the mean + 2 SD of control subjects, respectively. Six (20%) and 6 (20%) of the 30 hyperandrogenic patients had 60-minute 17-hydroxypregnenolone and 0- to 60-minute change in 17-hydroxypregnenolone levels greater than the mean + 2 SD of control subjects, respectively. However, none of the subjects had either 60-minute 17-hydroxypregnenolone levels or 60-minute dehydroepiandrosterone levels or both associated with the diagnosis of genetically proved 3beta-hydroxysteroid dehydrogenase deficiency (>5-fold of the control mean value).

CONCLUSION

3beta-Hydroxysteroid dehydrogenase-deficient nonclassic adrenal hyperplasia is rare even among adult hyperandrogenic patients with adrenal androgen excess.

Effects of strength training on intra-abdominal adipose tissue in obese prepubertal girls

PURPOSE

The purpose of this study was to determine the effects of strength training on fat distribution and its relationship to glucose tolerance in obese prepubertal girls.

METHODS

A strength training intervention study was designed in which the children exercised three times per week for 5 months. Twelve healthy, obese prepubertal girls (ages 7-10 yr, > 95th percentile weight for height) were enrolled in the study. Body composition was measured by dual-energy x-ray absorptiometry and computed tomography, and glucose tolerance was measured by a 3-h oral glucose tolerance test at baseline and after training.

RESULTS

Significant increases in height, weight, fat-free mass, fat mass, and subcutaneous abdominal adipose tissue occurred after training (P < 0.05), whereas intra-abdominal adipose tissue (IAAT) remained stable (N = 11). Insulin area was highly correlated with IAAT before (r = 0.91) and after (r = 0.90) training (both P < 0.01, N = 9).

CONCLUSION

In growing obese prepubertal girls undergoing a strength training program, IAAT remains unchanged, whereas subcutaneous abdominal fat and total body fat increased; insulin area is related to IAAT in these children.

Genistein, a component of soy, inhibits the expression of the EGF and ErbB2/Neu receptors in the rat dorsolateral prostate

BACKGROUND

Epidemiological reports suggest that Asians consuming a diet high in soy have a low incidence of prostate cancer. In animal models, soy and genistein have been demonstrated to suppress the development of prostate cancer. In this study, we investigate the mechanism of action, bioavailability, and potential for toxicity of dietary genistein in a rodent model.

METHODS

Lobund-Wistar rats were fed a 0.025-1.0-mg genistein/g AIN-76A diet. The dorsolateral prostate was subjected to Western blot analysis for expression of tyrosine-phosphorylated proteins, and of the EGF and ErbB2/Neu receptors. Genistein concentrations were measured from serum and prostate using HPLC-mass spectrometry. Body and prostate weights, and circulating testosterone levels, were measured.

RESULTS

Increasing concentrations of genistein in the diet inhibited tyrosine-phosphorylated proteins with molecular weights of 170,000 and 85,000 in the dorsolateral prostate. Western blot analysis revealed that the 1-mg genistein/g AIN-76A diet inhibited by 50% the expression of the EGF receptor and its phosphorylation. In rats fed this diet, serum-free and total genistein concentrations were 137 and 2,712 pmol/ml, respectively. The free and total genistein IC50 values for the EGF receptor were 150 and 600 pmol/g prostate tissue, respectively. Genistein in the diet also inhibited the ErbB2/Neu receptor. Body and dorsolateral prostate weights, and circulating testosterone concentrations, were not adversely effected from exposure to genistein in the diet for 3 weeks.

CONCLUSIONS

We conclude that genistein in the diet can downregulate the EGF and ErbB2/Neu receptors in the rat prostate with no apparent adverse toxicity to the host. The concentration needed to achieve a 50% reduction in EGF receptor expression can be achieved by eating a diet high in soy products or with genistein supplementation. Genistein inhibition of the EGF signaling pathway suggests that this phytoestrogen may be useful in both protecting against and treating prostate cancer.

Role of the ovary in the adrenal androgen excess of hyperandrogenic women

OBJECTIVE

To test the hypothesis that ovarian hormones in women with hyperandrogenism alter adrenocortical steroidogenesis.

DESIGN

Combination of two prospective studies.

SETTING

Academic medical centers.

PATIENT(S)

Eighteen hyperandrogenic patients demonstrating hirsutism with either hyperandrogenemia, oligomenorrhea, or both. Eighteen healthy nonhirsute eumenorrheic untreated women served as controls.

INTERVENTIONS

Blood sampling basally and after acute adrenal stimulation with ACTH, before and after 20-24 weeks of leuprolide administration. Nine patients also received 0.625 mg/d of oral conjugated esterified estrogens and 10 mg of medroxyprogesterone acetate days 1-12 of the month (i.e., estrogen replacement therapy [ERT]), whereas the remaining nine did not.

MAIN OUTCOME MEASURE(S)

Before and after the administration of the GnRH agonist (GnRH-a), the basal concentrations of DHEAS; and the levels of androstenedione (A4), DHEA, androstenediol, 11 beta-hydroxyandrostenedione (11-OHA4), and cortisol before and 60 minutes after acute adrenal stimulation, were measured.

RESULT(S)

Levels of DHEAS, androstenediol, and 11-OHA4 decreased by 15%-30%, regardless of whether patients initially had or did not have DHEAS excess. However, only hyperandrogenic patients with elevated levels of DHEAS showed a significant decrease in basal DHEA levels. No statistically significant difference in the response of either androgen to ACTH (1-24) stimulation was noted with ovarian suppression, regardless of initial DHEAS level or use of ERT.

CONCLUSION(S)

We found no evidence that ovarian hormone secretion affected adrenal steroidogenesis, and those women with the highest adrenal androgen levels had the least response to GnRH-a suppression. These findings further support the concept of an intrinsic, and possibly primary, abnormality of adrenocortical steroidogenesis in a subset of hyperandrogenic women that is independent of ovarian abnormalities.

Measurement of total serum testosterone levels using commercially available kits: high degree of between-kit variability

OBJECTIVE

The measurement of total serum testosterone has an established clinical role in the management of male hypogonadism and female androgen excess disorders. We studied the between-kit variability and precision of six different commercially available testosterone assays and compared them with an established in-house method.

DESIGN

Laboratory observational prospective study.

SETTING

Tertiary university medical center clinical laboratory.

PATIENT(S)

Three groups of samples each of men (n = 36) and women (n = 15) who had high, normal, or low levels of sex hormone-binding globulin (SHBG), respectively, were studied.

INTERVENTION(S)

Individual and pooled (male and female) serum samples were analyzed for total testosterone concentration using six different commercially available assays and one in-house method.

MAIN OUTCOME MEASURE(S)

The between-kit variability and the effect of the mean (+/- SD) SHBG level were determined, the results obtained with the use of the kits and the in-house method were compared, and the intraassay variability (i.e., precision) was evaluated.

RESULT(S)

Male samples demonstrated a 26.3%-40.8% variance in the results obtained with different kits, which was greatest for samples with the lowest SHBG levels. For female samples, between-kit variability ranged from 57%-115% (average, 77%). The percent deviation of the results obtained with the use of commercial methods from those obtained with the use of our in-house assay was greater for men (mean variance, 194%) than for women (mean variance, 67%). The female pool intraassay coefficient of variation was 3.8% with the use of the in-house method and ranged from 8.9%-21.2% with the use of the commercial kits. The male pool intraassay coefficient of variation was 3.1% with the use of the in-house method and ranged from 3.3%-5.5% with the use of the commercial kits.

CONCLUSION(S)

Most commercially available kits for measuring the total serum testosterone level demonstrated significant between-kit variability, which was greatest for female samples. Further, samples with the lowest SHBG levels had the highest between-kit variances. These data strongly suggest that the measurement of total serum testosterone using commercial kits may have limited utility, particularly for the detection of hyperandrogenemia.