1
|
Abstract
Postmenopausal hyperandrogenism is a state of relative or absolute androgen excess originating from the adrenal glands and/or ovaries clinically manifested by the presence of terminal hair in androgen-dependent areas of the body, and other manifestations of hyperandrogenism such as acne and alopecia or the development of virilization. In such circumstances, physicians must exclude the possibility of rare but serious androgen-producing tumors of the adrenal glands or ovaries. Worsening of undiagnosed hyperandrogenic disorders such as polycystic ovary syndrome, congenital adrenal hyperplasia, ovarian hyperthecosis, Cushing syndrome and iatrogenic hyperandrogenism should be considered for differential diagnosis. Elevated serum testosterone not only causes virilizing effects, but also will lead to hypercholesterolemia, insulin resistance, hypertension and cardiac disease. An ovarian androgen-secreting tumor, which is diagnosed in 1-3 of 1000 patients presenting with hirsutism, comprises less than 0.5% of all ovarian tumors. Adrenal tumors, including non-malignant adenomas and malignant carcinomas, are less common than ovarian tumors but cause postmenopausal virilization. Measurement of serum testosterone, sex hormone-binding globulin, dehydroepiandrosterone sulfate, androstenedione and inhibin B is necessary in postmenopausal women with the complaints and signs of hyperandrogenism. Some tests to discard Cushing syndrome should also be done. After an etiological source of androgen hypersecretion has been suspected, we recommend performing magnetic resonance imaging of the adrenal glands or ovaries. Medical management with gonadotropin-releasing hormone agonist/analogues or antagonists has been reported for women who are either unfit for surgery or in whom the source of elevated testosterone is unidentified.
Collapse
Affiliation(s)
- T Yoldemir
- Department of Obstetrics and Gynaecology, Marmara University Hospital, Istanbul, Turkey
| |
Collapse
|
2
|
Kraut E, Lakoff J. Acromegaly Presenting as Severe Hirsutism and Amenorrhea. AACE Clin Case Rep 2018. [DOI: 10.4158/ep171977.cr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
3
|
Kyritsi EM, Dimitriadis GK, Kyrou I, Kaltsas G, Randeva HS. PCOS remains a diagnosis of exclusion: a concise review of key endocrinopathies to exclude. Clin Endocrinol (Oxf) 2017; 86:1-6. [PMID: 27664414 DOI: 10.1111/cen.13245] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 08/13/2016] [Accepted: 09/15/2016] [Indexed: 11/28/2022]
Abstract
Polycystic ovarian syndrome (PCOS) is a heterogenous disorder associated with clinical, endocrine and ultrasonographic features that can also be encountered in a number of other diseases. It has traditionally been suggested that prolactin excess, enzymatic steroidogenic abnormalities and thyroid disorders need to be excluded before a diagnosis of PCOS is made. However, there is paucity of data regarding the prevalence of PCOS phenotype in some of these disorders, whereas other endocrine diseases that exhibit PCOS-like features may elude diagnosis and proper management if not considered. This article reviews the data of currently included entities that exhibit a PCOS phenotype and those that potentially need to be looked for, and attempts to identify specific features that distinguish them from idiopathic PCOS.
Collapse
Affiliation(s)
- Eleni Magdalini Kyritsi
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - George K Dimitriadis
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
- Division of Translational and Experimental Medicine, Warwick Medical School, University of Warwick, Coventry, United Kingdom
- Division of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Campus, London, United Kingdom
| | - Ioannis Kyrou
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
- Division of Translational and Experimental Medicine, Warwick Medical School, University of Warwick, Coventry, United Kingdom
- Aston Medical Research Institute, Aston Medical School, Aston University, Birmingham, United Kingdom
| | - Gregory Kaltsas
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
- Division of Pathophysiology, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Harpal S Randeva
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
- Division of Translational and Experimental Medicine, Warwick Medical School, University of Warwick, Coventry, United Kingdom
- Aston Medical Research Institute, Aston Medical School, Aston University, Birmingham, United Kingdom
| |
Collapse
|
4
|
Pasquali R, Diamanti-Kandarakis E, Gambineri A. MANAGEMENT OF ENDOCRINE DISEASE: Secondary polycystic ovary syndrome: theoretical and practical aspects. Eur J Endocrinol 2016; 175:R157-69. [PMID: 27170519 DOI: 10.1530/eje-16-0374] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 05/11/2016] [Indexed: 12/26/2022]
Abstract
PCOS is a clinical heterogeneous entity of female androgen excess diagnosed by exclusion of other disorders responsible for androgen excess. The concept of secondary PCOS implies that there is a primary well-defined cause leading to the PCOS phenotype with underlying androgen overproduction, regardless of the origin. In these cases, we presume the term of 'secondary PCOS' could be used. In all these conditions, the potential complete recovery of the hyperandrogenemic state as well as the remission of the PCOS phenotype should follow the removal of the cause. If accepted, these concepts could help clinicians to perform in-depth investigations of the potential factors or disorders responsible for the development of these specific forms of secondary PCOS. Additionally, this could contribute to develop further research on factors and mechanisms involved in the development of the classic and the nonclassic PCOS phenotypes.
Collapse
Affiliation(s)
- Renato Pasquali
- Division of EndocrinologyDepartment of Medical & Surgical Sciences, University Alma Mater Studiorum, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Evanthia Diamanti-Kandarakis
- Department of Endocrinology and Diabetes Center of ExcellenceEUROCLINIC, Medical School University of Athens, Athens, Greece
| | - Alessandra Gambineri
- Division of EndocrinologyDepartment of Medical & Surgical Sciences, University Alma Mater Studiorum, S. Orsola-Malpighi Hospital, Bologna, Italy
| |
Collapse
|
5
|
Diamanti-Kandarakis E, Panidis D. Update on Polycystic Ovary Syndrome. WOMENS HEALTH 2016; 2:561-9. [DOI: 10.2217/17455057.2.4.561] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
6
|
Abstract
Postmenopausal hyperandrogenism is a state of relative or absolute androgen excess originating from either the adrenals and/or the ovaries, clinically manifested as the appearance and/or increase in terminal hair growth or the development of symptoms/signs of virilization. In either settings, physicians need to evaluate such patients and exclude the presence of the relatively rare but potentially life-threatening underlying tumorous causes, particularly adrenal androgen-secreting tumors. It has been suggested that the rapidity of onset along with severity of symptom and the degree of androgen excess followed by relevant imaging studies may suffice to identify the source of excessive androgen secretion. However, up to date, there is no consensus regarding specific clinical and hormonal indices and/or imaging modalities required for diagnostic certainty. This is particularly relevant as the aging population is increasing and more cases of postmenopausal women with clinical/biochemical evidence of hyperandrogenism may become apparent. Furthermore, the long-term sequels of nontumorous hyperandrogenism in postmenopausal women in respect to cardiovascular morbidity and mortality still remain unsettled. This review delineates the etiology and pathophysiology of relative and absolute androgen excess in postmenopausal women. Also, it attempts to unravel distinctive clinical features along with specific hormonal cut-off levels and/or appropriate imaging modalities for the facilitation of the differential diagnosis and the identification of potential long-term sequels.
Collapse
Affiliation(s)
- Marios C Markopoulos
- Endocrinology and Metabolism UnitAretaieion University Hospital, Vasilisis Sofias 76, 11528 Athens, GreeceDepartment of BiochemistryDepartment of PathophysiologyLaikon Hospital, National University of Athens, Mikras Asias 75, 11527 Athens, Greece
| | - Evanthia Kassi
- Endocrinology and Metabolism UnitAretaieion University Hospital, Vasilisis Sofias 76, 11528 Athens, GreeceDepartment of BiochemistryDepartment of PathophysiologyLaikon Hospital, National University of Athens, Mikras Asias 75, 11527 Athens, Greece
| | - Krystallenia I Alexandraki
- Endocrinology and Metabolism UnitAretaieion University Hospital, Vasilisis Sofias 76, 11528 Athens, GreeceDepartment of BiochemistryDepartment of PathophysiologyLaikon Hospital, National University of Athens, Mikras Asias 75, 11527 Athens, Greece
| | - George Mastorakos
- Endocrinology and Metabolism UnitAretaieion University Hospital, Vasilisis Sofias 76, 11528 Athens, GreeceDepartment of BiochemistryDepartment of PathophysiologyLaikon Hospital, National University of Athens, Mikras Asias 75, 11527 Athens, Greece
| | - Gregory Kaltsas
- Endocrinology and Metabolism UnitAretaieion University Hospital, Vasilisis Sofias 76, 11528 Athens, GreeceDepartment of BiochemistryDepartment of PathophysiologyLaikon Hospital, National University of Athens, Mikras Asias 75, 11527 Athens, Greece
| |
Collapse
|
7
|
Brzana J, Yedinak CG, Hameed N, Plesiu A, McCartney S, Fleseriu M. Polycystic ovarian syndrome and Cushing's syndrome: a persistent diagnostic quandary. Eur J Obstet Gynecol Reprod Biol 2014; 175:145-8. [DOI: 10.1016/j.ejogrb.2013.12.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 12/02/2013] [Accepted: 12/31/2013] [Indexed: 10/25/2022]
|
8
|
Ikeda K, Baba T, Noguchi H, Nagasawa K, Endo T, Kiya T, Saito T. Excessive androgen exposure in female-to-male transsexual persons of reproductive age induces hyperplasia of the ovarian cortex and stroma but not polycystic ovary morphology. Hum Reprod 2012. [DOI: 10.1093/humrep/des385] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
9
|
Utz AL, Schaefer PW, Snuderl M. Case records of the Massachusetts General Hospital. Case 20-2010. A 32-year-old woman with oligomenorrhea and infertility. N Engl J Med 2010; 363:178-86. [PMID: 20647214 DOI: 10.1056/nejmcpc1004359] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Andrea L Utz
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, USA
| | | | | |
Collapse
|
10
|
Insulin Resistance Directly Contributes to Androgenic Potential Within Ovarian Theca Cells. Fertil Steril 2009; 91:1990-7. [DOI: 10.1016/j.fertnstert.2008.02.167] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2008] [Revised: 02/19/2008] [Accepted: 02/26/2008] [Indexed: 11/20/2022]
|
11
|
Abstract
OBJECTIVE To assess the prevalence of cardiovascular events in an older population of women with polycystic ovary syndrome (PCOS). METHODS We took advantage of the high heritability of PCOS and determined the probable PCOS status of mothers of women with PCOS. The prevalence of cardiovascular events was then determined in these mothers with and without PCOS. In a single endocrine clinic, 308 women with PCOS were interviewed about their mothers' medical history, and the mothers themselves were interviewed if available. The interview addressed menstrual history, fertility, clinical signs of hyperandrogenism, age at incident cardiovascular event, and age at death as reported by daughters. Presence of PCOS in the mothers was defined as a history of infertility, irregular menses, or clinical signs of hyperandrogenism. A cardiovascular event was defined as fatal or nonfatal myocardial infarction, any coronary intervention, angina necessitating emergency department visits, or a cerebrovascular event. RESULTS The mothers were predominantly post-menopausal. Among 182 interviewed (n = 157) or deceased (n = 25) mothers, 59 had probable PCOS. Cardiovascular events were more common (P = .011) among mothers with PCOS (11 of 59 or 18.6%) than among non-PCOS mothers (5 of 123 or 4.1%). After adjustments were made for age and race, probable PCOS was an independent predictor of cardiovascular events (odds ratio, 5.41; 95% confidence interval, 1.78 to 16.40). Cardiovascular events occurred at an early age in mothers of women with PCOS, particularly mothers with probable PCOS themselves. CONCLUSION PCOS-affected mothers of women with PCOS have a higher risk for cardiovascular events in comparison with non-PCOS mothers, and cardiovascular events appear to occur at an earlier than expected age in mothers with PCOS.
Collapse
Affiliation(s)
- Kai I. Cheang
- Department of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
| | - John E. Nestler
- Departments of Medicine and Obstetrics and Gynecology, Virginia Commonwealth University, Richmond, Virginia
| | - Walter Futterweit
- Department of Medicine, Mt. Sinai Medical Center, New York, New York
| |
Collapse
|
12
|
Kaltsas GA, Androulakis II, Tziveriotis K, Papadogias D, Tsikini A, Makras P, Dimitriou K, Stathopoulou A, Piaditis G. Polycystic ovaries and the polycystic ovary syndrome phenotype in women with active acromegaly. Clin Endocrinol (Oxf) 2007; 67:917-22. [PMID: 17651451 DOI: 10.1111/j.1365-2265.2007.02987.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Previous retrospective studies have suggested that women with acromegaly may present with menstrual irregularity and symptoms/signs of hyperandogenism, a phenotype similar to that of the polycystic ovary syndrome (PCOS). OBJECTIVE The aim of this study was to investigate prospectively the presence of the PCOS phenotype (PCOSP) and polycystic ovaries (PCO) on ultrasonography in women with active acromegaly. DESIGN Women within the reproductive age range (21-43 years) with active acromegaly of recent onset and/or previous surgical and/or medical therapy were studied. MAIN OUTCOME MEASURES Subjects underwent a physical examination; fasting bloods for androgens, pituitary hormones and metabolic parameters; an oral glucose tolerance test (OGTT) to estimate disease activity and insulin resistance; and a transvaginal ultrasound. RESULTS Six women had newly diagnosed acromegaly, and eight still had active disease following previous surgical and/or medical treatment. Seven women were found to have PCO and six fulfilled the criteria for PCOSP; six of these women, five with PCOSP, had a pituitary macroadenoma. Women with PCOSP had significantly increased mean ovarian volumes and characteristic ovarian morphology compared to women without PCOSP (P < 0.05), higher levels of IGF-1 and testosterone and lower SHBG levels that did not reach statistical significance. A positive correlation between IGF-1 and mean ovarian volume was identified only in women with PCOSP (r = 0.851, P < 0.05). CONCLUSIONS PCO and PCOSP are relatively common in women with acromegaly and may account for some of the symptoms related to gonadal dysfunction irrespective of the size of the pituitary tumour. It is likely that IGF-1 alone or in combination with GH and/or insulin resistance may be involved.
Collapse
Affiliation(s)
- Gregory A Kaltsas
- Endocrine Unit, Department of Pathophysiology, University of Athens, Athens, Greece.
| | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Fegan PG, Sandeman DD, Krone N, Bosman D, Wood PJ, Stewart PM, Hanley NA. Cushing's syndrome in women with polycystic ovaries and hyperandrogenism. ACTA ACUST UNITED AC 2007; 3:778-83. [DOI: 10.1038/ncpendmet0665] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2007] [Accepted: 09/04/2007] [Indexed: 12/17/2022]
|
14
|
Krentz AJ, von Mühlen D, Barrett-Connor E. Searching for polycystic ovary syndrome in postmenopausal women: evidence of a dose-effect association with prevalent cardiovascular disease. Menopause 2007; 14:284-92. [PMID: 17245231 PMCID: PMC2642654 DOI: 10.1097/gme.0b013e31802cc7ab] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To test the hypothesis that polycystic ovary syndrome (PCOS) is associated with an increased risk of atherosclerotic cardiovascular disease (CVD) in older postmenopausal women. DESIGN Cross-sectional study of community-dwelling non-estrogen-using postmenopausal-white women (N=713; mean+/-SD age, 73.8+/-7.9 years; mean body mass index, 24.0+/-3.5 kg/m) participating in the Rancho Bernardo Study. A putative PCOS phenotype was defined as the presence of three or more of the following features: (1) recalled history of irregular menses, (2) symptomatic premenopausal hyperandrogenism or biochemical evidence of current biochemical hyperandrogenism, (3) history of infertility or miscarriage, (4) central obesity, or (5) insulin resistance. Atherosclerotic CVD was determined from clinical history, electrocardiography, and structured interviews using validated techniques. The analysis was stratified by diabetes status, ascertained from medical history or 75-g oral glucose tolerance tests. RESULTS The PCOS phenotype was present in 9.3% of the entire cohort and 5.8% of nondiabetic women. The prevalence of CVD was similar between women with the phenotype and unaffected women (27.3% vs 24.4%). Among women with intact ovaries and no diabetes, there was a stepwise graded association between an increasing number of features of the PCOS phenotype (ie, none to three or more) and prevalent CVD (P=0.02). A similar association was also observed for coronary heart disease alone (P=0.03). CONCLUSIONS Among nondiabetic postmenopausal women with intact ovaries, prevalent atherosclerotic CVD is associated with features of a putative PCOS phenotype. This finding supports the thesis that PCOS increases the risk of atherosclerotic CVD after menopause.
Collapse
Affiliation(s)
- Andrew J Krentz
- Department of Family and Preventive Medicine, University of California San Diego, La Jolla 92093-0607, USA
| | | | | |
Collapse
|
15
|
Abstract
Complex interactions exist amongst the various components of the neuroendocrine system in order to maintain homeostasis, energy balance and reproductive function. These components include the hypothalamus-pituitary- adrenal and -gonadal axes, the renin-angiotensin-aldosterone system, the sympathetic nervous system and the pancreatic islets. These hormones, peptides and neurotransmitters act in concert to regulate the functions of many organs, notably the liver, muscles, kidneys, thyroid, bone, adrenal glands, adipocytes, vasculature, intestinal tract and gonads, through many intermediary pathways. Endocrine and metabolic disorders can arise from imbalance amongst numerous hormonal factors. These disturbances may be due to endogenous processes, such as increased secretion of hormones from a tumour, as well as exogenous drug administration. Drugs can cause endocrine abnormalities via different mechanisms, including direct alteration of hormone production, changes in the regulation of the hormonal axis, effects on hormonal transport, binding, and signalling, as well as similar changes to counter-regulatory hormone systems. Furthermore, drugs can affect the evaluation of endocrine parameters by causing interference with diagnostic tests. Common drug-induced endocrine and metabolic disorders include disorders of carbohydrate metabolism, electrolyte and calcium abnormalities, as well as drug-induced thyroid and gonadal disorders. An understanding of the proposed mechanisms of these drug effects and their evaluation and differential diagnosis may allow for more critical interpretation of the clinical observations associated with such disorders, better prediction of drug-induced adverse effects and better choices of and rationales for treatment.
Collapse
Affiliation(s)
- Ronald C W Ma
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong, China.
| | | | | | | | | |
Collapse
|
16
|
Nakamura A, Shimizu C, Nagai S, Taniguchi S, Umetsu M, Atsumi T, Wada N, Yoshioka N, Ono Y, Sasano H, Koike T. Unilateral adrenalectomy improves insulin resistance and polycystic ovaries in a middle-aged woman with virilizing adrenocortical adenoma complicated with Cushing's syndrome. J Endocrinol Invest 2007; 30:65-9. [PMID: 17318025 DOI: 10.1007/bf03347398] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
A benign virilizing adrenal adenoma is rare among adrenal neoplasms in middle-aged women. A 39-yr-old Japanese woman who presented with hirsutism, obesity, diabetes mellitus and hypertension was admitted. Plasma concentrations of testosterone and DHEAS were high. While the basal level of plasma ACTH was suppressed, serum cortisol level was high and its circadian rhythm was absent. Serum cortisol level was not suppressed with the low- and high-dose overnight dexamethasone suppression test. Abdominal computed tomography showed a left adrenal tumor, and an adrenocortical scintigraphy revealed uptake of the tracer on the left side. Polycystic ovaries were also found and bone mineral density revealed osteoporosis. Histopathological features of resected adrenal tumor were consistent with those of adrenocortical adenoma. Immunoreactivity of all the steroidogenic enzymes was apparent in the tumor cells and particularly dehydroepiandrosterone sulfotransferase (DHEA-ST) immunoreactivity was markedly expressed. Cortical atrophy and reduced expression of DHEA-ST were detected in the cortex of the adjacent non-neoplastic adrenal gland. Plasma testosterone, DHEAS and cortisol levels returned to normal after surgery, concomitantly with the disappearance of polycystic ovaries. This is a very rare case of virilizing adrenocortical adenoma complicated with Cushing's syndrome (CS).
Collapse
Affiliation(s)
- A Nakamura
- Department of Medicine II, Hokkaido University Graduate School of Medicine, N-15, W-7, Kita-ku, Sapporo 060-8638, Japan
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|