Helpful diagnostic markers of steroidogenesis for defining hyperandrogenemia in hirsute women

Prevalence of polycystic ovary syndrome under NIH criteria among the tenth-grade Chinese schoolgirls in Guangzhou area: a cross-sectional epidemiological survey

BACKGROUND

Polycystic ovary syndrome (PCOS) is currently considered to have a peri-adolescence onset and continuously influence the reproductive and metabolic health of the patients, while the diagnostic criteria among adolescent population haven't been universally unified till now. This survey seeks to preliminarily evaluate the prevalence of PCOS in the tenth grade schoolgirls in Guangzhou area under NIH criteria and analyze the clinical features of adolescents with PCOS.

METHODS

The cross-sectional epidemiological survey was carried out among the tenth grade schoolgirls in Guangzhou area by the method of cluster sampling. The contents of this survey included the questionnaire, physical exams and serum measurements. Until now, totally 1294 girls underwent this survey and 1095 serum samples were restored. 235 non-hirsute (mFG < 6), postmenarcheally 2-year girls were randomly selected as the control group, among which the cut-off value of biochemical hyperandrogenemia was set accordingly. The prevalence of PCOS among this population was preliminarily evaluated according to the NIH criteria.

RESULTS

Along with the increase of gynecological age, the menstruations of girls was becoming more regular and the incidence of oligomenorrhea or amenorrhea was declining. Even among those who were less than 2 years after menarche, those whose menstrual cycle were longer than 90 days accounted for lower than 5%. The 95th percentile of mFG score was 6 among the girls who were < 2 years after menarche, and 5 among the girls who were > 2 years after menarche. Among the 235 healthy girls, the 95th percentile values of Testosterone (T), Free androgen index (FAI) and Androstenedione (A2) were 2.28 nmol/mL, 4.37, and 5.20 nmol/mL respectively. Based on the NIH criteria, the prevalence of PCOS in this survey was 3.86%. The prevalence of adolescent PCOS tend to slightly increase with age and gynecological age, but the difference was not statistically significant. The prevalence of PCOS among obese girls was markedly higher than that in lean girls.

CONCLUSION

Based on the NIH criteria, the prevalence of PCOS among the tenth grade schoolgirls in Guangzhou area was 3.86%. The diagnosis of hyperandrogenism among adolescents should also be based on both clinical and biochemical parameters.

Association between biochemical hyperandrogenism parameters and modified Ferriman-Gallwey score in patients with hirsutism in Basrah (Southern Iraq)

Introduction

Hyperandrogenemia is the most frequent endocrine disorder in women causing a variety of adverse metabolic disturbances. Establishing the diagnosis of androgen overproduction has significant implications for the follow-up and treatment of patients.

Aim

To investigate the severity of hirsutism and its correlation with serum androgen in women with hirsutism from Basrah (Southern Iraq).

Material and methods

This was a cross-sectional study of 300 hirsute women, mean age: 26.6 ±7.1 years with a modified Ferriman and Gallwey (mFG) score of 8 or higher. Assessment of hirsutism severity was performed and hormonal markers including total testosterone (TT), calculated free testosterone (FT) and dehydroepiandrosterone sulfate (DHEA-S), were measured.

Results

There was a significant correlation between the severity of hirsutism using mFG score and FT, TT levels (p < 0.001 and p < 0.047, respectively), while no association was seen between mFG score and DHEA-S.

Conclusions

Our data suggest that FT and, to a less extent, TT were important biochemical hyperandrogenism markers that correlate with severity of hirsutism. DHEA-S was not found to be beneficial.

Exploring the activity of the enzyme 11β-hydroxylase in the polycystic ovary syndrome

Background Hyperandrogenemic polycystic ovary syndrome (PCOS) may have occult corticosteroidogenic enzyme abnormalities. The current study compares the activities of 11β-hydroxylase between normoandrogenemic PCOS (NA-PCOS) and hyperandrogenemic PCOS (HA-PCOS) phenotypes. Materials and methods Anthropometric, and biochemical variables were compared between normal cycling women [n = 272] and those with PCOS [n = 453]; either normoandrogenemic [n = 98] or hyperandrogenemic [n = 355]. Univariate and multivariate logistic regression analyses were performed using 11β-hydroxylase enzyme activity as the criterion variable. Results 11β-Hydroxylase enzyme activity tended to be slightly higher in both PCOS subgroups and did not change with ethnicity. Using univariate logistic regression, 11β-hydroxylase activity in controls was associated with dehydroepiandrosterone, insulin, homeostatic model for insulin resistance (HOMA-IR), and high-density lipoprotein cholesterol (HDL-C). In NA-PCOS women the activity of 11β-hydroxylase was associated with estradiol (E2), androstenedione (A4), and androstenedione/dehydroepiandrosterone ratio; in the hyperandrogenemic (HA-PCOS) group, 11β-hydroxylase activity associated with sex-hormone binding globulin (SHBG), 17-hydroxypregnenolone (17-OHPE), fasting glucose, and β-cell activity. After multivariate logistic regression, androstenedione/dehydroepiandrosterone ratio, and β-cell activity were the best predictors of 11β-hydroxylase activity in controls; in NA-PCOS group only androstenedione/dehydroepiandrosterone ratio was confirmed as a significant predictor of 11β-hydroxylase activity, and in HA-PCOS patients, 17-OHPE and β-cell activity demonstrated to be significant predictors. Conclusions 11β-Hydroxylase activity was equal in different ethnicities. The prevalence of decreased 11β-hydroxylase activity was higher in the HA-PCOS phenotype. 17-OHPE, and β-cell function are significant predictors of 11β-hydroxylase activity in HA-PCOS subjects. These findings may help to identify which PCOS patient would have benefit in measuring 11-deoxycortisol (compound S) and 11β-hydroxylase enzyme activity.

No. 350-Hirsutism: Evaluation and Treatment

OBJECTIVES

To review the etiology, evaluation, and treatment of hirsutism.

EVALUATION

A thorough history and physical examination plus selected laboratory evaluations will confirm the diagnosis and direct treatment.

TREATMENT

Pharmacologic interventions can suppress ovarian or adrenal androgen production and block androgen receptors in the hair follicle. Hair removal methods and lifestyle modifications may improve or hasten the therapeutic response.

OUTCOMES

At least 6 to 9 months of therapy are required to produce improvement in hirsutism.

EVIDENCE

The quality of evidence reported in this guideline has been determined using the criteria described by the Canadian Task Force on the Periodic Health Examination.

RECOMMENDATIONS

Hirsutism can be slowly but dramatically improved with a 3-pronged approach to treatment: mechanical hair removal, suppression of androgen production, and androgen receptor blockade. Lifestyle changes, including weight loss and exercise, will lower serum androgen levels and improve self-esteem in patients with polycystic ovary syndrome. The patient should be educated regarding the associated health problems or long-term medical consequences of hyperandrogenism, particularly in the context of polycystic ovary syndrome, including obesity, irregular menses, anovulation, infertility, pregnancy-induced hypertension, diabetes, hyperlipidemia, hypertension, and heart disease.

SUMMARY STATEMENTS

RECOMMENDATIONS.

New insights into steroidogenesis in normo- and hyperandrogenic polycystic ovary syndrome patients

OBJECTIVE: This study sought to examine corticosteroidogenic enzyme activities in normo- and hyperandrogenic polycystic ovary syndrome (PCOS) patients. SUBJECTS AND METHODS: This cohort study included 81 patients with biochemical hyperandrogenism and 41 patients with normal androgen levels. Enzyme activities were assessed according to the serum steroid product/precursor ratios at baseline and after adrenal stimulation. RESULTS: At baseline, in the delta 4 (Δ4) pathway, hyperandrogenic patients showed greater 17-hydroxylase and 17,20 lyase activities in converting progesterone (P4) into 17-hydroxyprogesterone (17-OHP4) and 17-hydroxypregnenolone (17-OHPE) into androstenedione (A) (p = 0.0005 and p = 0.047, respectively) compared to normoandrogenic patients. In the delta 5 (Δ5) pathway, the 17-hydroxylase and 17,20 lyase enzymes showed similar activities in both groups. Hyperandrogenic patients presented lower 21-hydroxylase, lower 11β-hydroxylase (p = 0.0001), and statistically significant increases in 3β-hydroxysteroid dehydrogenase II (3β-HSDII) activities (p < 0.0001). Following tetracosactrin stimulation, only the 17,20 lyase activity remained up-regulated in the Δ4 pathway (p < 0.0001). CONCLUSION: Hyperandrogenic patients had higher 17,20 lyase activity, both at baseline and after adrenal stimulation. Greater conversion of dehydroepiandrosterone (DHEA) into A with normal conversion of 17-OHPE to 17-OHP4 in hyperandrogenic PCOS patients indicated different levels of 3β-HSDII activity in adrenal cells, and hyperandrogenic patients had lower 11β-hydroxylase and 21-hydroxylase activities.

Ferriman-Gallwey scores, serum androgen and mullerian inhibiting substance levels in hirstute adolescent girls

OBJECTIVE

To study Ferriman-Gallwey (FG) scoring in adolescents with an aim to correlate these scores with serum androgens and mullerian inhibiting substance (MIS).

DESIGN

Cross sectional study.

SETTING

Pediatric and Adolescent Gynecology Clinic of a university hospital.

PATIENTS

Twenty-four hirsute adolescent girls age 12-19 with a FG score of 6 or greater.

INTERVENTIONS

FG examination and collection of serum levels of MIS, total testosterone, free testosterone, follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin, cortisol, and androstenedione.

MAIN OUTCOME MEASURES

Correlation between FG scores in adolescents and serum androgens and MIS.

RESULTS

Weak correlations were seen between FG score and FSH, free-testosterone, total testosterone, and cortisol. Increasing FG scores correlated with an increase in cortisol. As FG score increased, FSH, free-testosterone, and total testosterone decreased. There was no statistical relationship between FG score and LH, androstenedione, prolactin, and MIS. There were weak positive correlations between MIS levels and FSH, total testosterone, and androstenedione. There was no evidence for a linear relationship between MIS levels and LH, free testosterone, cortisol, prolactin, and FG score.

CONCLUSIONS

The utility of FG scoring in adolescents is unknown. There were no direct correlations found with MIS levels and FG score. MIS was not found to be a predictor of hirsutism. A larger study is needed to assess the clinical relevance of FG scoring and presence of underlying causes of hirsutism in adolescents.

The female athlete triad

Context:

The female athlete triad (the triad) is an interrelationship of menstrual dysfunction, low energy availability (with or without an eating disorder), and decreased bone mineral density; it is relatively common among young women participating in sports. Diagnosis and treatment of this potentially serious condition is complicated and often requires an interdisciplinary team.

Evidence Acquisition:

Articles from 1981 to present found on PubMed were selected for review of major components of the female athlete triad as well as strategies for diagnosis and treatment of the conditions.

Results:

The main goal in treatment of young female athletes with the triad is a natural return of menses as well as enhancement of bone mineral density. While no specific drug intervention has been shown to consistently improve bone mineral density in this patient population, maximizing energy availability and optimizing vitamin D and calcium intake are recommended.

Conclusions:

Treatment requires a multidisciplinary approach involving health care professionals as well as coaches and family members. Prevention of this condition is important to minimize complications of the female athlete triad.

A rational approach to the diagnosis of polycystic ovarian syndrome during adolescence

Polycystic ovarian syndrome (PCOS) is a lifelong disorder characterized by hyperandrogenism and ovulatory dysfunction, with a wide spectrum of clinical symptoms and signs. Three different sets of diagnostic criteria have been established in order to define this disease in adult women, but there is controversy regarding the use of these criteria in adolescence. During puberty, the adult criteria for ovulatory dysfunction does not seem applicable, because an irregular menstrual pattern and a decreased ovulatory rate is a physiologic event during this period of life. Also, a higher prevalence of polycystic ovarian morphology (PCOM) may be observed during this period, so PCOM is not a useful criterion to define PCOS in young women. These findings suggest that a key factor to diagnose to PCOS during adolescence is hyperandrogenism. In addition, since PCOM is not clearly associated with hyperandrogenism during this period of life, the term "polycystic ovarian syndrome" during adolescence creates confusion and may be misleading.

Cushing's disease in a patient with steroid 21-hydroxylase deficiency

Cushing's disease rarely appears as a consequence of hereditary disease. However, familial diseases with diminished glucocorticoid feedback are associated with secondary hypercorticotropinism and have been shown to give rise to pituitary adenomas. We here describe the rare case of a 30-year old female patient with congenital adrenal hyperplasia who also showed clinical signs and a typical history of hypercortisolism that was specified as Cushing's disease. After removal of a pituitary microadenoma, serum-cortisol levels fell below normal and the symptoms improved. However, after four years the menstrual cycle was irregular again and ACTH levels were in the upper range of normal. A corticotropin challenge showed a minor cortisol response but a marked increase in 17-hydroxyprogesterone serum concentrations. Genetic analysis revealed a homozygous mutation in exon 7 of the CYP21A2 gene (CTG>TTG, p.V281L). We conclude that a marked ACTH drive was able to override insufficient 21-hydroxylation and even to cause hypercortisolism. Although we describe a rare case, the impairment of the glucocorticoid feedback system in the context of congenital adrenal hyperplasia and other diseases may contribute to the development of secondary hypercorticotropinism as well as corticotropin producing adenomas.

Total testosterone assays in women with polycystic ovary syndrome: precision and correlation with hirsutism

CONTEXT

There is no standardized assay of testosterone in women. Liquid chromatography mass spectrometry (LC/MS) has been proposed as the preferable assay by an Endocrine Society Position Statement.

OBJECTIVE

The aim was to compare assay results from a direct RIA with two LC/MS.

DESIGN AND SETTING

We conducted a blinded laboratory study including masked duplicate samples at three laboratories--two academic (University of Virginia, RIA; and Mayo Clinic, LC/MS) and one commercial (Quest, LC/MS).

PARTICIPANTS AND INTERVENTIONS

Baseline testosterone levels from 596 women with PCOS who participated in a large, multicenter, randomized controlled infertility trial performed at academic health centers in the United States were run by varying assays, and results were compared.

MAIN OUTCOME MEASURE

We measured assay precision and correlation and baseline Ferriman-Gallwey hirsutism scores.

RESULTS

Median testosterone levels were highest with RIA. The correlations between the blinded samples that were run in duplicate were comparable. The correlation coefficient (CC) between LC/MS at Quest and Mayo was 0.83 [95% confidence interval (CI), 0.80-0.85], between RIA and LC/MS at Mayo was 0.79 (95% CI, 0.76-0.82), and between RIA and LC/MS at Quest was 0.67 (95% CI, 0.63-0.72). Interassay variation was highest at the lower levels of total testosterone (≤50 ng/dl). The CC for Quest LC/MS was significantly different from those derived from the other assays. We found similar correlations between total testosterone levels and hirsutism score with the RIA (CC=0.24), LC/MS at Mayo (CC=0.15), or Quest (CC=0.17).

CONCLUSIONS

A testosterone RIA is comparable to LC/MS assays. There is significant variability between LC/MS assays and poor precision with all assays at low testosterone levels.