Clinical and hormonal studies in hyperthecosis of the ovaries

Incessant ovulation: a review of its importance in predicting cancer risk

Estrous cycles are recurring changes in therian mammals induced by estrogen, progesterone, and other hormones culminating in endometrial proliferation, ovulation, and implantation if fertilization occurred. In women, the estrous cycle is the menstrual cycle; but, unlike most mammals, the end of an infertile cycle is marked by endometrial sloughing and the start of another without an anestrous phase. Women stop cycling at menopause, while in most mammals, cycles continue until death. Epidemiologic studies identified menarche, menopause, births, lactation, and oral contraceptive (OC) use as key risk factors for ovarian, breast, and endometrial cancers. A composite variable was created to estimate the number of cycles not interrupted by events that stop ovulation. Captured by the phrase "incessant ovulation", repetitive cycles were first postulated to affect ovarian cancer risk and later extended to breast and endometrial cancers. These associations could be explained by cumulative effects of repetitive tissue changes within reproductive organs, immune consequences of repetitive ovulation through the glycoprotein mucin 1, and residual effects of past ovulations that enhance ovarian production of testosterone. The latter two pathways could affect the risk for cancers in other organs not considered "reproductive".

Confounder factors masking a Leydig-cell ovarian tumor in a post-menopausal woman treated for androgen-positive receptor breast cancer

Post-menopause hyperandrogenism is a condition that needs careful evaluation. Aromatase inhibitors (AI), which are important in the management of positive estrogen breast cancer, and chronic kidney disease (CKD) can puzzle the evaluation of this condition. A postmenopause female with type-2 diabetes and advanced CKD was attended due to progressive virilization, which has started after the introduction of an AI for breast cancer 5 years earlier. Clinical and radiological investigation has confirmed a pure Leydig cell tumor as source of hyperandrogenism. Re-evaluation of the breast tumor immunohistochemistry has shown positive androgen receptor expression and negative expression for estrogen, progesterone and HER-2 receptors. Even though an ovarian tumor was the source of androgen excess, we discuss that AI could exert a slight contribution to patient's virilization by reducing estradiol counterbalance. Also, although the onset of hyperandrogenic symptoms was unclear, we could not exclude that the ovarian tumor had produced enough androgens to play a role in breast tumor progression. This case report supports the literature regarding the possible association between Leydig cell tumor and androgen-receptor-positive breast cancer development. Finally, progressive hyperandrogenic symptoms in postmenopause, even under AI therapy or the presence of advanced CKD, impose a more detailed investigation.

Hyperandrogenism in a postmenopausal woman

Ovarian androgen hypersecretion is a wellrecognized cause of hirsutism and virilization in postmenopausal women. Postmenopausal ovarian hyperthecosis is a nonneoplastic functional disorder, which results from abnormal regulation of ovarian steroidogenesis. We present a patient with postmenopausal hyperandrogenism due to ovarian hyperthecosis.

Ovarian dysfunction in peripubertal hyperinsulinemia

OBJECTIVE

Increasing evidence suggests that hyperinsulinemia plays an important role in the pathogenesis of polycystic ovary syndrome (PCOS). However, the timing for the onset of hyperinsulinemia is not clear. The objective of this study was to examine the effect of peripubertal hyperinsulinemia on the maturing female reproductive axis.

METHODS

Hyperinsulinemia was induced in 28-day-old peripubertal female rats by infusing insulin (0.04 IU/d) via subcutaneously implanted Alzet minipumps (Model #2004; Durect Corp, Cupertino, CA; constant flow rate 0.25 muL/h) for 4 weeks. Control animals were administered normal saline. Estrus cyclicity was monitored regularly. Upon termination of the experimental period, the animals were killed, trunk blood and pituitaries were collected for hormone assays, and ovaries were collected for histological and immunocytochemical studies.

RESULTS

In contrast to the control animals, hyperinsulinemic animals had (1) erratic estrus cycles, with prolonged (2 to 3 days) metestrus-diestrus or diestrus-proestrus stages; (2) significantly (P <.05) decreased levels of serum progesterone, and significantly (P <.05) increased levels of serum testosterone and dehydroepiandrostene sulfate; (3) prematurely luteinized ovarian follicles with prominent thecal and interfollicular stromal proliferation; and (4) markedly reduced expression of growth differentiation factor-9 (GDF-9) and activin receptors (ActR) I and IB in the ovaries.

CONCLUSION

Peripubertal hyperinsulinemia in rats causes hormonal and ovarian changes similar to those in women with PCOS. Based on these novel findings, we speculate that peripubertal hyperinsulinemia may be a risk factor for the development of PCOS later in life.

Polycystic ovary syndrome. A diagnostic challenge

Polycystic ovary syndrome remains a diagnostic challenge because there is no single defining test. The clinical presentation must dictate the extent of the work-up. The typical PCOS patient has a history of irregular menses and appears hirsute. Demonstration of ovulatory dysfunction and hyperandrogenism can also be made by appropriate hormonal measurements. An ultrasound showing multiple small ovarian follicles can support a diagnosis of PCOS in the patient for whom the clinical diagnosis has been made. Other causes of hyperandrogenism and ovulatory dysfunction should be excluded.

Neuroendocrine aspects of polycystic ovary syndrome

A series of investigations have emphasized the heterogeneous nature of the clinical condition known as PCOS and have delineated several factors that may contribute to the hyperandrogenemia and anovulation in this condition. Currently, it remains unclear whether intrinsic abnormalities of ovarian steroidogenesis, the effects of hyperinsulinemia in augmenting LH stimulation of ovarian androgen production, and the persistent rapid frequency of LH/GnRH secretion are primary factors in all patients. Indeed, these factors may have variable roles in different patients, all of whom present with the clinical syndrome of PCOS. A consensus has emerged that abnormalities in the neuroendocrine control of GnRH secretion exist in a significant subset of patients and lead to persistent hypersecretion of LH, which seems to be an important component of the syndrome, particularly in nonobese patients. The relative frequency of primary abnormalities in the regulation of GnRH secretion versus secondary changes reflecting altered circulating concentrations of ovarian steroid remains uncertain. No clear evidence exists for an underlying neuroendocrine abnormality of GnRH regulation in all patients. The recent data showing insensitivity of the hypothalamic GnRH pulse generator to E2 progesterone feedback have suggested potential mechanisms that may explain the abnormalities of GnRH secretion seen in adolescent girls in whom the clinical syndrome of PCOS is destined to develop. Further studies are required in adolescents to establish whether GnRH regulation is impaired during puberty or whether data in adults simply reflect the long-term effects of elevated androgens, estrogens, or other hormones on the hypothalamus. Studies in carefully delineated subgroups of patients with PCOS are needed to establish these points, with a long-term goal of providing patients with improved methods of inducing ovulation and reducing hyperandrogenemia.

Increased bioactive luteinizing hormone levels and bio/immuno ratio in women with hyperthecosis of the ovaries: possible role of hyperinsulinemia

Unlike women with polycystic ovarian disease, women with hyperthecosis have normal or low immunoactive LH levels. They have severe insulin resistance with marked hyperinsulinemia. Bioactive LH levels have not been studied in these women. The purpose of this study was to investigate 1) whether there is an increase in bioactive LH levels in women with hyperthecosis of the ovaries and 2) whether hyperinsulinemia has an effect on LH secretion. Six women with hyperthecosis of the ovaries confirmed by histological examination were included in the study. Six normal women in the midproliferative phase of the cycle served as controls. All women were admitted to the Clinical Research Center at 0800 h, and blood samples were obtained every 15 min for 6 h. All samples were assayed for LH by RIA and bioassay. The PC Pulsar Program was used for pulse analysis of LH secretion. Patients with hyperthecosis had significantly higher (P < 0.002) bioactive LH levels (66.9 +/- 13 mIU/mL) than controls (29.3 +/- 6 mIU/mL). Immunoactive LH levels in hyperthecosis were not significantly different from those in control women. Significantly higher bio/immuno LH ratios (P < 0.001) were observed in women with hyperthecosis (6.2 +/- 0.9) than in normal control women (2.4 +/- 0.5). There was a significant positive correlation between insulin levels and the bio/immuno ratio of LH. Pulse amplitude and interpulse intervals for immunoactive LH in hyperthecosis patients were similar to those in control women. The pulse amplitude of bioactive LH was significantly higher (P < 0.01) in women with hyperthecosis compared to that in normal controls. Hyperinsulinemia induced during LH sampling resulted in increased bioactive LH levels with no change in immunoactive LH. These results indicate that 1) women with hyperthecosis of the ovaries have increased secretion of biologically active LH, and 2) hyperinsulinemia may enhance the secretion of the biologically active form of LH.

Increased expression of messenger ribonucleic acid encoding cytochrome P450 cholesterol side-chain cleavage and P450 17alpha-hydroxylase enzymes in ovarian hyperthecosis

OBJECTIVE

To investigate whether the increased ovarian androgen synthesis in hyperthecosis is due to increased expression of the steroidogenic enzymes essential for androgen synthesis.

DESIGN

Controlled study to investigate concentration of steroidogenic enzymes in the ovarian stroma of women with hyperthecosis of the ovaries.

SETTING

Academic research environment.

PATIENT(S)

Three women with ovarian hyperthecosis and eight with normal ovulatory cycles.

INTERVENTION(S)

Ovarian stromal tissues were obtained from women with hyperthecosis and women with normal ovaries. Diagnosis of hyperthecosis was confirmed by histologic examination of the ovaries. Steroid levels were measured in the ovarian vein serum of one patient with hyperthecosis.

MAIN OUTCOME MEASURE(S)

Tissues were frozen immediately in liquid nitrogen and kept frozen until RNA was extracted. Total RNA was examined by Northern blot analysis using 32P-labeled complementary DNA (cDNA) probes encoding human P450scc and P450(17alpha) enzymes.

RESULT(S)

P450scc and P450(17alpha) messenger RNAs (mRNAs) were detected in the normal ovarian stroma and stromal hyperthecosis. Compared with normal ovarian stroma, P450scc mRNA was increased twofold and P450(17alpha) mRNA was increased threefold in stromal hyperthecosis.

CONCLUSION(S)

[1] Ovarian stroma is probably the site of androgen production in ovarian hyperthecosis. [2] Increased stromal androgen synthesis in hyperthecosis could be due to increased expression of the enzymes P450scc and P450(17alpha) in the ovarian stroma. [3] Markedly increased concentrations of 17alpha-hydroxyprogesterone in the ovarian vein serum indicate possible dysregulation of P450(17alpha) in ovarian hyperthecosis.

Hyperinsulinemia in hyperthecosis of the ovaries

Fasting insulin concentrations and the insulin response to an oral glucose tolerance test were measured in six virilized women with ovarian hyperthecosis and six weight-matched normal women. For comparison, six women with polycystic ovarian disease were also studied. The diagnosis of hyperthecosis was confirmed in all six virilized women by histologic examination of the ovaries. The fasting insulin concentrations were increased in all of the hyperthecosis patients (84 +/- 32 microU/ml). Insulin response to an oral glucose tolerance test was greatly increased (p less than 0.01) in comparison to normal women and women with polycystic ovarian disease. Significant positive correlations were found between peripheral insulin concentrations and ovarian vein testosterone (r = 0.879, p less than 0.02), dihydrotestosterone (r = 0.866, p less than 0.03), and androstenedione (r = 0.992, p less than 0.01) levels. Insulin resistance persisted after removal of the ovaries even though androgen levels returned to normal. These results suggest that a significant degree of insulin resistance exists in women with hyperthecosis and that insulin stimulates ovarian stromal androgen synthesis and thus may play a role in the pathogenesis of ovarian hyperthecosis.

Androgen levels during cyproterone acetate and ethinyl oestradiol treatment of hirsutism

Androgen levels were measured before and during 12 months of treatment with cyproterone acetate (50 mg 5th to 16th day of cycle) and ethinyl oestradiol (50 micrograms 5th to 26th day of cycle) in 26 patients suffering from dysfunctional hirsutism. Patients were included in whom androgen levels after a dexamethasone suppression test fell above the range found in normal non-hirsute women on dexamethasone. Eighty percent of patients showed a substantial improvement of their Ferriman and Gallwey score after 12 months of treatment. During the treatment the mean level of testosterone was 64%, androstenedione 55%, testosterone oestradiol binding globulin 365%, apparent free testosterone 30%, dihydrotestosterone 74%, 5-androstanediol 43%, dehydroepiandrosterone 44%, 5-androstenediol 67% and dehydroepiandrosterone sulphate 74% of basal levels. From the results it is concluded that this treatment is effective both clinically and biochemically in reducing hyperandrogenism.