Hyperprolactinemia in polycystic ovary syndrome**Supported in part by National Institutes of Health grant RR-59 from the General Clinical Research Center Program, National H.D. 13136

The polycystic ovary syndrome: the first 150 years of study

The communities of reproductive medicine and reproductive sciences have been witness to an enormous acceleration of interest in polycystic ovary syndrome (PCO) since the mid-19th century. Although progress has been increasingly palpable, the fundamentals of the etiology and pathophysiology of PCO remain as elusive as ever. Particularly lacking is a requisite understanding of events at the cellular and molecular levels. As we cross the millennial divide, it appears appropriate that an interim progress report be crafted. This treatise is attempting to meet this objective. What follows traces the chronology of the recorded history of PCO in 4 parts.

To what extent does polycystic ovary syndrome influence the cut-off value of prolactin? Findings of a community-based study

PURPOSE

Polycystic ovary syndrome (PCOS) and hyperprolactinemia are the most frequent endocrine disorders in women which share several common features. There are inconsistent results regarding the existence of a possible pathophysiological interplay between these endocrinopathies and the elevation of prolactin (PRL) in PCOS. The purpose of this study was to explore the upper reference limit of PRL in PCOS women.

PATIENTS AND METHODS

This study is a cross-sectional analysis using data collected from two population-based PCOS prevalence studies. After considering the exclusion criteria, 216 women with PCOS diagnosed based on the Rotterdam criteria and 702 eumenorrheic non-hirsute controls, were enrolled. The age distribution of PRL and the effect of PCOS on the percentiles of serum PRL were compared between the PCOS group and controls. The possible contributing factors for the elevation of PRL were evaluated.

RESULTS

In the subgroup of women with PCOS, aged ≤35 years, the age-adjusted model of quantile regression revealed a significant elevation of PRL from the 60th percentile onwards, leading to an increase of nearly 10 ​ng/ml (p ​= ​0.023, 95% CI 1.3-17.62) of the 95th percentile of PRL. Hyperprolactinemic PCOS women had higher levels of luteinizing hormone (LH).

CONCLUSIONS

In PCOS women, aged ≤35 years, the upper reference limit of serum PRL was approximately 1.5-fold higher than in controls. The pathway underlying PRL elevation in PCOS might be attributed to a decline in central dopaminergic tone associated with PCOS which leads to an increase in levels of both - PRL and LH.

The value of prolactin in predicting prolactinοma in hyperprolactinaemic polycystic ovarian syndrome

BACKGROUND

To identify a serum prolactin (PRL) cut-off value indicative of a PRL-producing adenoma in women with polycystic ovarian syndrome (PCOS) and hyperprolactinaemia and characterize such patients.

MATERIALS AND METHODS

In the present retrospective case-control study, the medical records of 528 PCOS women were reviewed. Pituitary magnetic resonance imaging (MRI) was performed in PCOS patients with PRL levels ≥94.0 ng/mL and/or symptoms suspicious of a pituitary adenoma (PA). Prolactinoma diagnosis was made in the presence of an MRI-identifiable PA with biochemical and radiological response to dopamine agonists. Receiver operating characteristic (ROC) curve analysis was performed to determine a serum PRL threshold that could identify hyperprolactinaemic PCOS subjects with prolactinomas. Clinical, metabolic and endocrine parameters were also analysed.

RESULTS

Among 528 patients with PCOS, 60 (11.4%) had elevated PRL levels. Of 44 (73.3%) patients who had pituitary imaging, 19 had PAs, 18 normal MRI and 7 other abnormalities. Patients harbouring prolactinomas had significantly higher PRL levels compared to patients without adenomas (median PRL 95.4 vs 49.2 ng/mL, P < .0001). A PRL threshold of 85.2 ng/mL could distinguish patients with prolactinomas with 77% sensitivity and 100% specificity [Area Under the curve (AUC) (95%) 0.91(0.8-1.018), P = .0001]. PCOS women with prolactinomas were younger and had lower LH levels compared to women without prolactinomas.

CONCLUSIONS

In women with PCOS, PRL levels exceeding 85.2 ng/mL are highly suggestive of a prolactinoma warranting pituitary imaging. Pituitary MRI could also be considered in young PCOS patients with milder PRL elevation and low LH levels.

Herbal medicine for the management of polycystic ovary syndrome (PCOS) and associated oligo/amenorrhoea and hyperandrogenism; a review of the laboratory evidence for effects with corroborative clinical findings

BACKGROUND

Polycystic ovary syndrome (PCOS) is a prevalent, complex endocrine disorder characterised by polycystic ovaries, chronic anovulation and hyperandrogenism leading to symptoms of irregular menstrual cycles, hirsutism, acne and infertility. Evidence based medical management emphasises a multidisciplinary approach for PCOS, as conventional pharmaceutical treatment addresses single symptoms, may be contra-indicated, is often associated with side effects and not effective in some cases. In addition women with PCOS have expressed a strong desire for alternative treatments. This review examines the reproductive endocrine effects in PCOS for an alternative treatment, herbal medicine. The aim of this review was to identify consistent evidence from both pre-clinical and clinical research, to add to the evidence base for herbal medicine in PCOS (and associated oligo/amenorrhoea and hyperandrogenism) and to inform herbal selection in the provision clinical care for these common conditions.

METHODS

We undertook two searches of the scientific literature. The first search sought pre-clinical studies which explained the reproductive endocrine effects of whole herbal extracts in oligo/amenorrhoea, hyperandrogenism and PCOS. Herbal medicines from the first search informed key words for the second search. The second search sought clinical studies, which corroborated laboratory findings. Subjects included women with PCOS, menstrual irregularities and hyperandrogenism.

RESULTS

A total of 33 studies were included in this review. Eighteen pre-clinical studies reported mechanisms of effect and fifteen clinical studies corroborated pre-clinical findings, including eight randomised controlled trials, and 762 women with menstrual irregularities, hyperandrogenism and/or PCOS. Interventions included herbal extracts of Vitex agnus-castus, Cimicifuga racemosa, Tribulus terrestris, Glycyrrhiza spp., Paeonia lactiflora and Cinnamomum cassia. Endocrine outcomes included reduced luteinising hormone (LH), prolactin, fasting insulin and testosterone. There was evidence for the regulation of ovulation, improved metabolic hormone profile and improved fertility outcomes in PCOS. There was evidence for an equivalent effect of two herbal medicines and the pharmaceutical agents bromocriptine (and Vitex agnus-castus) and clomiphene citrate (and Cimicifuga racemosa). There was less robust evidence for the complementary combination of spirinolactone and Glycyrrhiza spp. for hyperandrogenism.

CONCLUSIONS

Preclinical and clinical studies provide evidence that six herbal medicines may have beneficial effects for women with oligo/amenorrhea, hyperandrogenism and PCOS. However the quantity of pre-clinical data was limited, and the quality of clinical evidence was variable. Further pre-clinical studies are needed to explain the effects of herbal medicines not included in this review with current clinical evidence but an absence of pre-clinical data.

Prevalence of hyperprolactinemia in adolescents and young women with menstruation-related problems

OBJECTIVE

The aim of this study was to evaluate the prevalence of hyperprolactinemia in adolescents and young women with menstrual problems.

STUDY DESIGN

This study included 1704 young women with menstruation-related problems. The patients were classified into group I (age, 11-20 years) or group II (age, 21-30 years); the prevalence of hyperprolactinemia was analyzed according to age and categories of menstruation-related problems.

RESULTS

For primary amenorrhea and oligomenorrhea, the prevalence of hyperprolactinemia was low in both groups. However, hyperprolactinemia was a relatively common cause of secondary amenorrhea (5.5% for group I and 13.8% for group II, respectively); it was more frequent in group II (P = .001); the prevalence of prolactinoma was also higher in group II (P = .015). For abnormal uterine bleeding, hyperprolactinemia was more common in group II (2.6% for group I and 9.4% for group II; P < .001), but causes were similar.

CONCLUSION

Hyperprolactinemia is not rare in young women with menstruation-related problems; its prevalence varies according to age and manifestations.

[Physiopathological link between polycystic ovary syndrome and hyperprolactinemia: myth or reality?]

Polycystic ovary syndrome (PCOS) and hyperprolactinemia are the two most common etiologies of disorders of the cycle in women. In clinical practice, it is not unusual to find hyperprolactinemia associated with clinical, hormonal and ultrasound features of PCOS. However, currently, there is no evidence of a pathophysiological link between these two entities. Thus, this association seems to be fortuitous. Therefore, hyperprolactinemia in women with PCOS must lead to etiological investigations, including eliminating macroprolactinemia (excess of "big prolactin" and/or "big-big prolactin"). Finally, symptomatic hyperprolactinemias (excluding macroprolactinemia) can "mask" an underlying PCOS through a gonadotropic inhibition. Moreover, symptomatic hyperprolactinemias can provide clinical and ultrasound features of a "moderate" PCOS. Therefore, in agreement with the consensus of Rotterdam, PCOS must remain a diagnosis of exclusion, after eliminating symptomatic hyperprolactinemias (excluded macroprolactinemia) and all other etiologies of hyperandrogenism.

Polycystic ovary syndrome or hyperprolactinaemia: a study of mild hyperprolactinaemia

Polycystic ovary syndrome (PCOS) and hyperprolactinaemia are both common causes of secondary amenorrhoea in reproductive women. The relationship between PCOS and hyperprolactinaemia has been reported with controversial results. To evaluate the clinical and laboratory features of women with mild hyperprolactinaemia and PCOS, we studied 474 Taiwan Chinese women: 101 had mild hyperprolactinaemia, 266 had PCOS and 107 were the control group. In this study, we found that 64% of the women with mild hyperprolactinaemia fulfilled the PCOS diagnostic criteria, regardless of their prolactin levels. Obese women with PCOS had significantly lower luteinising hormone (LH) and LH-to-FSH ratios than non-obese women with PCOS. Obese hyperprolactinaemic women had significantly lower follicle-stimulating hormone (FSH), but higher LH-to-FSH ratios than the non-obese hyperprolactinaemic women. For women with PCOS, the BMIs were significantly negative with LH (γ = -0.253, p < 0.001), but not with FSH (γ = -0.061, p = 0.319). For the hyperprolactinaemic women, the BMIs were significantly negative with FSH (γ = -0.353, p < 0.001), but not with LH (γ = -0.021, p = 0.837). Although PCOS-related syndrome was very prevalent in women with hyperprolactinaemia, the patterns of disturbance in gonadotropin secretion were different between the PCOS and the hyperprolactinaemia patients.

The Androgen Excess and PCOS Society criteria for the polycystic ovary syndrome: the complete task force report

OBJECTIVE

To review all available data and recommend a definition for polycystic ovary syndrome (PCOS) based on published peer-reviewed data, whether already in use or not, to guide clinical diagnosis and future research.

DESIGN

Literature review and expert consensus.

SETTING

Professional society.

PATIENTS

None.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

A systematic review of the published peer-reviewed medical literature, by querying MEDLINE databases, to identify studies evaluating the epidemiology or phenotypic aspects of PCOS.

RESULT(S)

The Task Force drafted the initial report, following a consensus process via electronic communication, which was then reviewed and critiqued by the Androgen Excess and PCOS (AE-PCOS) Society AE-PCOS Board of Directors. No section was finalized until all members were satisfied with the contents, and minority opinions noted. Statements were not included that were not supported by peer-reviewed evidence.

CONCLUSION(S)

Based on the available data, it is the view of the AE-PCOS Society Task Force that PCOS should be defined by the presence of hyperandrogenism (clinical and/or biochemical), ovarian dysfunction (oligo-anovulation and/or polycystic ovaries), and the exclusion of related disorders. However, a minority considered the possibility that there may be forms of PCOS without overt evidence of hyperandrogenism, but recognized that more data are required before validating this supposition. Finally, the Task Force recognized and fully expects that the definition of this syndrome will evolve over time to incorporate new research findings.

Basic infertility including polycystic ovary syndrome

Infertility in women has many possible causes and must be approached systematically. The most common cause of medically treatable infertility is the polycystic ovary syndrome (PCOS). This syndrome is common in young women and is the cause of anovulatory infertility in 70% of cases. It is therefore an important condition to screen and manage in primary care medical settings. In the past 10 years, insulin sensitization with weight loss or metformin has been shown to be a safe and effective treatment for PCOS infertility that eliminates the risk of multiple pregnancy and may reduce the risk of early pregnancy loss as compared with ovulation-inductor drugs. The authors believe metformin should be considered as first-line therapy because it has the advantage to allow for normal single ovulation, for reduced early pregnancy loss, and, most importantly, lifestyle modifications and weight loss before pregnancy. Losing weight not only improves fertility but also reduces adverse pregnancy outcomes associated with obesity.

Polycystic ovary syndrome and hyperprolactinemia are distinct entities

The aims of the present study were to identify the cause of hyperprolactinemia in polycystic ovary syndrome (PCOS) and to compare prolactin (PRL) levels between PCOS women without hyperprolactinemia and women with insulin resistance and without PCOS. A group of 82 women (age: 27.1 +/- 7.6 years) with PCOS was included in the study. Their PRL levels were measured and compared with those of women with insulin resistance without PCOS (controls; n = 42; age: 29.2 +/- 8.2 years). Among the 82 PCOS women, 13 (16%) presented high PRL levels (103.9 +/- 136.0 microg/l). The causes of hyperprolactinemia were: pituitary tumor (responding to cabergoline) in nine cases (69%; PRL range: 28.6 - 538 microg/l); oral hormonal contraceptive treatment in two cases (15%; PRL: 46 and 55 microg/l, respectively); and use of buspirone and tianeptine in one case (8%; PRL: 37.1 microg/l); one case (8%; PRL: 34.4 microg/l) had macroprolactinemia. In drug-induced hyperprolactinemic patients PRL levels normalized after treatment interruption. The average PRL level in the 69 remaining patients was 12.1 +/- 5.5 microg/l, a value not statistically different from that of the control group (11.8 +/- 4.9 microg/l). This result leads us to conclude that PCOS patients with increased PRL levels must be investigated for other causes of hyperprolactinemia, because hyperprolactinemia is not a clinical manifestation of PCOS.

Technology insight: measuring prolactin in clinical samples

Measurement of prolactin is one of the most commonly undertaken hormonal investigations in evaluating patients with reproductive disorders. Hyperprolactinemia is found in up to 17% of such cases. Diagnostic evaluation of hyperprolactinemia is difficult but is facilitated by a logical approach where a thorough patient history is obtained, secondary causes of hyperprolactinemia are excluded, and the limitations of current prolactin assays are appreciated. Once hyperprolactinemia has been confirmed, attempts to establish the underlying cause can start. Given current workloads, laboratories rely on automated platforms to measure prolactin, most of which employ two-site immunoassay sandwich methods. Although generally robust and reliable, such immunoassays are susceptible to interference, and good collaboration between clinicians and the laboratory helps to minimize problems. A major challenge facing laboratories is correct differentiation of patients with true hyperprolactinemia from those with macroprolactinemia. Macroprolactin is a high-molecular-mass, biologically inactive form of prolactin that is detected to varying degrees by all prolactin immunoassays. Conservative estimates suggest that the presence of macroprolactin leads to misdiagnosis in as many as 10% of all reported instances of biochemical hyperprolactinemia. In the absence of specific testing, macroprolactin represents a diagnostic pitfall that results in the misdiagnosis and mismanagement of large numbers of patients.

Diagnosis and management of the dermatologic manifestations of the polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a complex phenotypic spectrum of primarily hyperandrogenic signs and symptoms. PCOS is the most common endocrine disturbance to affect women of reproductive years. Although patients affected are often very disturbed by the cutaneous manifestations, including acne, hirsutism, alopecia, obesity, and acanthosis nigricans, the clinical manifestations of PCOS ramify far beyond the skin. PCOS frequently causes menstrual abnormalities and infertility. Insulin resistance is both pathogenic and a cause of numerous serious health consequences. The accurate diagnosis and recognition of cutaneous hyperandrogenism in PCOS are discussed. The differential diagnosis is reviewed. The work-up and approach to evaluation of patients with PCOS is presented. Although no uniform treatment approach for the management of the cutaneous manifestations of PCOS has been agreed upon, the data on various treatment options and the author's treatment approach to these patients are presented.

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

OBJECTIVE

The Androgen Excess Society (AES) charged a task force to review all available data and recommend an evidence-based definition for polycystic ovary syndrome (PCOS), whether already in use or not, to guide clinical diagnosis and future research.

PARTICIPANTS

Participants included expert investigators in the field.

EVIDENCE

Based on a systematic review of the published peer-reviewed medical literature, by querying MEDLINE databases, we tried to identify studies evaluating the epidemiology or phenotypic aspects of PCOS.

CONSENSUS PROCESS

The task force drafted the initial report, following a consensus process via electronic communication, which was then reviewed and critiqued by the AES Board of Directors. No section was finalized until all members were satisfied with the contents and minority opinions noted. Statements that were not supported by peer-reviewed evidence were not included.

CONCLUSIONS

Based on the available data, it is the view of the AES Task Force on the Phenotype of PCOS that there should be acceptance of the original 1990 National Institutes of Health criteria with some modifications, taking into consideration the concerns expressed in the proceedings of the 2003 Rotterdam conference. A principal conclusion was that PCOS should be first considered a disorder of androgen excess or hyperandrogenism, although a minority considered the possibility that there may be forms of PCOS without overt evidence of hyperandrogenism but recognized that more data are required before validating this supposition. Finally, the task force recognized, and fully expects, that the definition of this syndrome will evolve over time to incorporate new research findings.

The origins and sequelae of abnormal neuroendocrine function in polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a common clinical disorder characterized by ovulatory dysfunction and hyperandrogenaemia. A neuroendocrine hallmark of PCOS is persistently rapid LH (GnRH) pulsatility, which favours pituitary synthesis of LH over that of FSH and contributes to the increased LH concentrations and LH : FSH ratios typical of PCOS. Inadequate FSH levels contribute to impaired follicular development, whereas elevated LH levels augment ovarian androgen production. Whereas luteal phase elevations in progesterone normally slow GnRH pulse frequency, women with PCOS do not experience normal progesterone-mediated slowing, due in part to impaired hypothalamic progesterone sensitivity. This reduction in hypothalamic progesterone sensitivity appears to be mediated by elevated androgens because sensitivity can be restored with the androgen receptor blocker flutamide. The ovulatory and hormonal abnormalities associated with PCOS generally present during puberty, typically associated with hyperandrogenaemia. Along with elevated LH concentration and pulsatility, some girls with hyperandrogenaemia have impaired hypothalamic progesterone sensitivity similar to that seen in adult women with PCOS. We propose that peripubertal hyperandrogenaemia may lead to persistently rapid GnRH pulse frequency via impaired hypothalamic feedback inhibition. The subsequent abnormalities in gonadotropin secretion, androgen production and ovulatory function may support progression towards the adult PCOS phenotype.

Pituitary imaging is indicated for the evaluation of hyperprolactinemia

OBJECTIVE

To evaluate the signs and symptoms associated with hyperprolactinemia and establish guidelines for a minimal serum PRL level for which pituitary imaging is indicated.

DESIGN

Retrospective study.

SETTING

Reproductive endocrinology clinic in a university hospital.

PATIENT(S)

One hundred four consecutive patients with hyperprolactinemia, mean age 30 +/- 6.5 (range 19-44) years.

INTERVENTION(S)

Classification of clinical symptoms, serum hormone measurements, and pituitary magnetic resonance imaging (MRI).

MAIN OUTCOME MEASURE(S)

Incidence of presenting symptoms, serum PRL levels, and pituitary tumor size.

RESULT(S)

Median (range) PRL value was 82.6 ng/mL (25-1,342). Reported symptoms from most to least common were infertility (48%), headaches (39%), oligoamenorrhea (29%), galactorrhea (24%), and visual changes (13%). Hypothyroidism was diagnosed in 2 of 104 (1.9%) patients. Of 86 patients who had pituitary imaging, 23 (26%) had normal findings and 63 (74%) had pituitary tumor; of these, 47 (55% of total imaged) had microadenomas and 16 (19% of total imaged) had macroadenomas. There was a statistically significant association between the tumor size and the PRL level. However, 11% of the patients with microadenomas had PRL levels >200 ng/mL, and 44% of the patients with macroadenomas had PRL levels between 25 and 200 ng/mL.

CONCLUSION(S)

The most common symptoms in the population studied were infertility and headaches. Coexisting thyroid disease was an uncommon finding. Most patients had a pituitary tumor on MRI. Although tumor size correlated with the serum PRL level, some macroadenomas were detected in women with only moderately elevated PRL values. On the basis of these findings, pituitary imaging should be obtained to identify pituitary tumors in all patients with persistently elevated PRL levels.

Macroprolactinemia in women presenting with hyperandrogenic symptoms: Implications for the management of polycystic ovary syndrome

Eight of 109 consecutive hyperandrogenic patients had increased serum PRL levels; macroprolactinemia was diagnosed in 4 patients by measuring PRL levels after precipitation of serum with polyethylene glycol, and after detecting macroprolactinemia, these 4 patients were diagnosed with polycystic ovary syndrome (PCOS). Therefore, macroprolactinemia must be ruled out in women presenting with hyperandrogenic symptoms and increased serum PRL concentrations to avoid misdiagnosis (hyperprolactinemia is an exclusion criterion for the diagnosis of PCOS), unnecessary diagnostic tests, and inappropriate use of dopaminergic agonists.

Insulin resistance, polycystic ovary syndrome, and type 2 diabetes mellitus

OBJECTIVE

To review the definition and prevalence of two insulin resistance (IR)-associated phenotypes, polycystic ovary syndrome (PCOS) and type 2 diabetes mellitus, as well as the risk and nature of their simultaneous presentation.

DESIGN

Review of published literature.

RESULT(S)

Insulin resistance affects between 10% and 25% of the general population. Two common disorders frequently associated with IR are PCOS, affecting 4% to 6% of reproductive-aged women, and type 2 diabetes mellitus, which is observed in about 2% to 6% of similarly aged women. Overall, about 50% to 70% of women with PCOS and 80% to 100% of patients with type 2 diabetes mellitus have variable degrees of IR. Insulin resistance and its secondary hyperinsulinemia appear to underlie many of the endocrine features of PCOS in a large proportion of such patients. The risk of type 2 diabetes mellitus among PCOS patients is 5- to 10-fold higher than normal. In turn, the risk of PCOS among reproductive-aged type 2 diabetes mellitus patients appears to be similarly increased.

CONCLUSION(S)

It remains to be determined whether PCOS and type 2 diabetes mellitus represent no more than different clinical manifestations of the same IR syndrome, with their phenotypic differences due to the presence or absence of a coincidental genetic defect at the level of the ovary or pancreas, respectively, or representing the result of etiologically different subtypes of IR syndromes.

Polycystic ovary syndrome and ovulation induction

Before initiating treatment to induce ovulation in cases of PCOS, an appropriate evaluation of the patient and her partner, based on individual considerations, is important to optimize outcome. For obese patients with PCOS, weight-loss measures should be pursued before pharmacologic treatment is initiated. For most patients, the pharmacologic agent of choice to induce ovulation is clomiphene citrate, alone or in combination with a glucocorticoid. Treatment with metformin, alone or in combination with clomiphene citrate, may also be beneficial. For patients not responsive to clomiphene citrate, injectable gonadotropin treatment is usually warranted, although, depending on individual circumstances, laparoscopic ovarian drilling may be appropriate.

Hypothalamic dopaminergic tone and prolactin bioactivity in women with polycystic ovary syndrome

BACKGROUND

The present study was carried out to investigate the functional significance of the reduced dopaminergic tone in subjects affected with polycystic ovary syndrome (PCOS).

METHODS

Our group evaluated the response of pituitary PRL, LH, FSH, and TSH to the administration of a single 10-mg oral dose of the dopamine (DA) receptor antagonist metoclopramide in lean (n = 7) and obese (n = 8) PCOS women and in 11 regularly cycling age- and weight-matched controls (six lean and five obese). In addition, circulating PRL bioactivity was evaluated by its mitogenic activity on a lymphoma cell bioassay.

RESULTS

Oral administration of metoclopramide resulted in a significant increase in serum PRL in all subjects; however, the highest increments, regardless of body mass index (BMI), were observed in control women (p <0.005). Measurements of PRL mitogenic activity on the Nb2 lymphoma cell bioassay revealed a significant increase in the bioactive/immunoreactive (B/I) ratio of PRL under basal and stimulated conditions in obese PCOS subjects (p <0.05). Mean fasting glucose/insulin and glucose/insulin-AUC ratios were significantly lower (p <0.001) in obese PCOS when compared with all other groups.

CONCLUSIONS

These data support the existence of low DA hypothalamic tone in PCOS women that is likely involved in the inappropriate LH and PRL secretion frequently seen in this syndrome. In addition, our results suggest changes in PRL bioactivity in obese PCOS that may play a role in the development of hyperinsulinemia; however, whether PRL has a functional significance in the development of the metabolic disturbances frequently seen in PCOS remains to be elucidated.

The prevalence of polycystic ovaries in women with type 2 diabetes mellitus

OBJECTIVE

Polycystic ovary syndrome (PCOS) and type 2 diabetes mellitus are both common conditions associated with insulin resistance and compensatory hyperinsulinaemia. Previous reports have noted that impaired glucose tolerance and diabetes are common in women with PCOS. In this report we present the results of the converse study: the prevalence of polycystic ovaries in premenopausal women presenting with type 2 diabetes mellitus.

SUBJECTS

Subjects were recruited from a hospital Diabetes Clinic. A search of computerized records identified 49 premenopausal women with type 2 diabetes mellitus being treated with diet alone or oral hypoglycaemic agents of whom 38 (76%) patients agreed to be studied.

DESIGN

A cross-sectional study recording clinical, demographic and anthropometric data. Measurements of fasting metabolic parameters, reproductive endocrine profiles and ovarian dimensions were taken.

RESULTS

Eighty-two percent of women with type 2 diabetes mellitus had polycystic ovaries on ultrasound. Of these women, 52% had clinical evidence of cutaneous hyperandrogenism and/or menstrual disturbance. Correlations between metabolic and reproductive parameters were consistent with a stimulatory action of insulin on the ovary. There was no significant difference between the PCO and non-PCO groups with respect to metabolic profiles.

CONCLUSIONS

Women with type 2 diabetes mellitus have a higher prevalence of polycystic ovaries than that reported in the general population. Not all women with hyperinsulinaemia due to type 2 diabetes mellitus, however, develop PCO suggesting that hyperinsulinaemia alone is not sufficient for the expression of this ovarian morphology.

Menstrual disorders in adolescents. Excess androgens and the polycystic ovary syndrome

The fundamental clinical features of PCOS include hirsutism and menstrual irregularities from the time of menarche. Obesity is present in approximately 50% of these patients, some of whom also carry a diagnosis of NIDDM. The biochemical abnormalities associated with the clinical picture include LH hypersecretion, hyperandrogenism, acyclic estrogen production, subnormal SHBG levels, and hyperinsulinemia. Hirsutism usually progresses slowly in patients with PCOS; however, the clinical presentation can resemble virilizing tumors, late-onset CAH, or Cushing syndrome. Virilization or rapidly progressive hirsutism requires immediate investigation to rule out a virilizing tumor. Goals of therapy for teenage patients include decreasing levels of bioavailable androgen, blockade of androgen action at target tissues, stabilization of the endometrium, and reduction of insulin resistance. Although the original description of PCOS by Stein and Leventhal was published in 1935, the cause of PCOS remains unknown. This reason, coupled with the fact that PCOS-related insulin resistance is an important cause of NIDDM in women, has caused this disorder to become one of interest and active investigation. Future research will likely be able to delineate mechanisms behind the defects of carbohydrate metabolism and ascertain large multigeneration kindreds for linkage analyses to identify affected genes. Future studies are also likely to confirm whether young women with PCOS are at increased risk for cardiovascular disease and other long-term health complications. As new pathophysiologic mechanisms are identified, the promise of new therapies arises, including treatments that could potentially reduce the long-term incidence of adverse health consequences.

Effect of chronic administration of cabergoline on uterine perfusion in women with polycystic ovary syndrome

OBJECTIVE

To confirm whether patients with polycystic ovary syndrome (PCOS) have a reduction in uterine perfusion and to verify whether chronic administration of cabergoline can decrease this high vascular resistance.

DESIGN

Prospective randomized trial.

SETTING

Endocrinological Centre of the Department of Obstetrics and Gynecology, University of Cagliari, Cagliari, Italy.

PATIENT(S)

Thirty patients were enrolled in the study: 20 affected by PCOS and 10 healthy controls. Patients with PCOS were randomly assigned to one of two treatments for 3 months: oral administration of cabergoline (0.5 mg) every week or oral administration of placebo every week.

INTERVENTION(S)

All patients underwent transvaginal ultrasonography associated with Doppler flow measurement of the uterine artery, and serum hormone concentrations were determined during the early follicular phase. In women with PCOS, Doppler flow measurement and hormonal assessment were repeated in the early follicular phase of the third month of treatment.

MAIN OUTCOME MEASURE(S)

Pulsatility index of the uterine artery before and during treatment.

RESULT(S)

The mean pulsatility index of the uterine artery in patients with PCOS was significantly higher than that of the control group (3.29+/-0.5 and 2.01+/-0.2, respectively). Patients with PCOS treated with cabergoline showed a significant increase in uterine perfusion, with a pulsatility index of 3.14+/-0.6 before and 2.39+/-0.5 during the treatment. No difference was found in patients with PCOS treated with placebo.

CONCLUSION(S)

Patients with PCOS have high resistance in the uterine arteries, but chronic administration of cabergoline can increase uterine perfusion.

The chronic administration of cabergoline normalizes androgen secretion and improves menstrual cyclicity in women with polycystic ovary syndrome

OBJECTIVE

To investigate whether the administration of the long-lasting dopaminergic drug, cabergoline, improves endocrine and clinical features of women with polycystic ovary syndrome (PCOS).

PATIENTS

Twenty-nine women participated in the study: 14 women with clinical and endocrinologic features of PCOS and 15 age- and weight-matched normal cycling women. Each subject was assigned randomly to receive either a tablet of cabergoline at the dose of 0.5 mg/wk or placebo for 4 months. Sixteen subjects (PCOS: n = 8; controls: n = 8) received cabergoline, whereas 13 (PCOS: n = 6; controls: n = 7) received placebo.

INTERVENTIONS

Both before and during the 4th month of treatment, blood samples were collected every 10 minutes from 9:00 A.M. to 3:00 P.M., 3 to 7 days after spontaneous or medroxy-progesterone acetate (MPA; 5 mg daily for 5 days)-induced menses. Follicle-stimulating hormone and androgen levels were measured in the basal samples, whereas LH levels were measured in all samples.

MAIN OUTCOME MEASURES

Menstrual cyclicity, LH pulsatility, and circulating levels of FSH, PRL, E2, total T, free T, androstenedione, 17 alpha-hydroxyprogesterone, DHEAS, and sex hormone-binding globulin.

RESULTS

Both in controls and in PCOS-affected women, cabergoline administration blunted plasma PRL levels without affecting LH pulsatility. Androgen levels were reduced in controls and normalized in PCOS. Cabergoline, but not placebo, induced menses reappearance in amenorrheic and a normalization of menstrual cyclicity in oligoamenorrheic women with PCOS.

CONCLUSIONS

The administration of cabergoline is capable to normalize androgen levels and to improve menstrual cyclicity in PCOS-affected women. Cabergoline may represent an useful treatment for menstrual irregularities of PCOS patients.

Evidence that an altered prolactin release is consequent to abnormal ovarian activity in polycystic ovary syndrome

OBJECTIVE

To investigate whether endogenous dopaminergic activity is impaired in polycystic ovary syndrome (PCOS)-affected women and is normalized by medical ovariectomy.

PATIENTS

Women with PCOS untreated (n = 23) and treated for 3 months with GnRH analogue (GnRH-a) administration (n = 10) and normal cycling young women (n = 23) as controls.

INTERVENTIONS

Acute blockade of dopaminergic receptors by the IV administration of 5 mg of the dopaminergic receptor blocking agent sulpiride (sulpiride test) was performed 3 to 7 days after the initiation of spontaneous menses in cycling women or medroxyprogesterone acetate-induced menses in PCOS women. In PCOS women treated with GnRH-a administration (goserelin depot, 3.6 mg SC every 28 days), the sulpiride test was repeated 10 to 15 days after the third GnRH-a administration.

MAIN OUTCOME MEASURE

Basal PRL levels and PRL increase induced by sulpiride.

RESULTS

Basal PRL levels and the PRL response to sulpiride were increased in women with PCOS. In women with PCOS medical ovariectomy induced by GnRH-a administration reversed to normal both basal and sulpiride-stimulated PRL levels.

CONCLUSIONS

In women with PCOS the abnormal regulation of PRL and presumably of hypothalamic neurotransmitters controlling PRL secretion is not a primary alteration but it is likely dependent on abnormal ovarian functionality.

Partial uncoupling of luteinizing hormone and prolactin pulse coincidence in hyperandrogenemic women

A partly synchronized pulsatile secretion of luteinizing hormone (LH) and prolactin has previously been suggested as an indication of the coupling of the respective pulse generators under certain conditions. In women with hyperandrogenemic chronic anovulation, episodic LH secretion is disturbed. It was, therefore, the aim of the present study to evaluate possible changes in episodic prolactin secretion pattern and in LH/prolactin co-pulsatility, and to relate the results to the accelerated LH pulse frequencies often seen in patients with hyperandrogenemic chronic anovulation. Blood samples of 32 patients with hyperandrogenemia were taken at 10-min intervals between 10.00 and 20.00. Nine regularly cycling women with normal hormone levels served as controls. In the women with hyperandrogenemia, despite an average 41% rise of LH pulse frequency, prolactin pulse frequency decreased slightly by 14% as compared to controls; no correlation between the two parameters was found (r = 0.162). The number of coincident LH and prolactin pulses increased continuously with accelerating LH frequency. The best fitting function was a hyperbola which was limited by the maximal observed prolactin frequency. As a consequence, the fraction of LH pulses that were co-secreted with prolactin episodes decreased with higher LH pulse frequencies, while the fraction of prolactin pulses concomitant with LH pulses increased. Our data provide evidence that in women with hyperandrogenemic chronic anovulation a pathological LH pulse frequency is no longer coupled with pulsatile prolactin secretion, suggesting an isolated alteration of the central neuronal control mechanism for LH secretion.

Clinical impact of hyperprolactinaemia

Prolactinomas are benign, functioning pituitary tumours that cause reproductive dysfunction in men and women. PRL-secreting microadenomas have a benign clinical course and may even disappear without treatment. Absolute indications for treatment of hyperprolactinaemia include the need to restore fertility and the presence of a macroadenoma. A dopamine agonist is the treatment of choice regardless of tumour size and will normalize PRL and restore menses in the majority of cases. Hypogonadism induced by hyperprolactinaemia is associated with decreased spinal bone mineral content, but it is not clear whether the bone loss is progressive. Bone mass improves after treatment of the hyperprolactinaemia but does not normalize. The safety of chronic oestrogen therapy in women with hyperprolactinaemic amenorrhoea who are not desirous of fertility remains to be elucidated by ongoing clinical trials.

Can women with gonadotropin levels diagnostic of polycystic ovarian syndrome benefit from therapy with dopamine agonists?

On the basis of LH and FSH data the incidence of PCOS in a series of 33 infertile women with hyperprolactinemia due to differing causes was found to be 39%. Where the elevations of prolactin were intermittent (spikers), the incidence was 44%, compared to 33% in a control population and 23% (9% histologically confirmed) in a 1991 Dublin general infertility clinic population. Androgen levels were uninformative, as were TRH stimulation test results. All 33 infertile women were treated with dopamine agonists. Four pregnancies occurred in the PCOS group. Two were hyperprolactinemic spikers on dopamine agonists plus antiestrogens. Four of the 10 pregnancies in the non-PCOS group were also on dopamine agonists plus antiestrogens. Two of these were spikers. The use of dopaminergic drugs to lower circulating prolactin is established. The addition of an antiestrogen in a concomitant PCOS situation is rational. There appears to be little justification, however, to use them in any anovulatory situation, including PCOS in the absence of hyperprolactinemia.

Hirsutism. A practical approach to improving physical and mental well-being

The stigma and embarrassment of hirsutism and the lack of public knowledge regarding effective therapy prevent some women from seeking treatment. Heightened physician awareness and a simple, practical approach to the hirsute patient allow adequate assessment and therapeutic recommendations. Decreased hair growth, a return to normal menstrual cycling, and lowered risk of endometrial cancer can be achieved by pharmacologic therapy with few serious side effects. Treatment has a significant effect on both physical and mental well-being and can produce a remarkable change in a patient who has suffered embarrassment for many years.

Dopamine might not be involved in the pathogenesis of polycystic ovary syndrome

The possible alteration in dopamine (DA) metabolism as an etiological factor was investigated in 31 normoprolactinemic patients with typical polycystic ovary syndrome (PCOS) in comparison with 14 normal women (early follicular phase). Subjects were submitted to intravenous infusion of 4 micrograms/kg DA per minute over a period of 3 hours and blood samples were collected every 30 minutes over a period of 5 hours. Two days later subjects were submitted to intravenous infusion of 10 mg metoclopramide (MCP) as a bolus and blood samples were collected every 15 minutes over a period of 2 hours. Dopamine infusion caused a similar maximum decrease (MD) in LH levels in both the PCOS and control groups (50.9% and 47.5%, respectively). No changes in plasma LH levels were observed in either group after MCP infusion. Dopamine caused a 50.2% and 60.4% MD in prolactin (PRL) in the PCOS and control groups, respectively, the difference being statistically non-significant. Metoclopramide increased PRL levels by 1261.0% and 1832.0% in the PCOS and control groups, respectively (not significant). In a double-blind study, the PCOS patients were treated with 5 mg/day bromocriptine (n = 16) or placebo (n = 15) over a period of 3 months and evaluated in clinical and laboratory terms during and after treatment. Seven patients in each group had monthly menstrual periods, but only 1 in each group had an ovulatory cycle (progesterone greater than 5 ng/ml). During treatment, median plasma PRL levels were significantly decreased only in bromocriptine-treated patients (10.8 vs 7.3 ng/ml). The present results lead us to question whether dopamine is indeed involved in the pathogenesis of normoprolactinemic PCOS and whether bromocriptine treatment is of benefit in this type of patients.

Cervical mucus prolactin levels in normal fertile and infertile women

Cervical mucus and serum samples were obtained from 42 anovular women and 20 normal ovular fertile women (controls) for the determination of prolactin concentration by a solid phase radioimmunoassay. The former group was subgrouped into 14 galactorrhoeic (9 with oligohypomenorrhea and 5 with amenorrhea) and 28 non-galactorrhoeic (19 with oligohypomenorrhea and 9 with amenorrhea). The level of prolactin in cervical mucus of normally menstruating women was significantly higher than that of serum at P less than 0.0125 (11.68 +/- 0.77 ng/ml and 16.09 +/- 1.65 ng/ml, mean +/- SE, respectively). Serum prolactin level in galactorrhoeic amenorrhea cases was 8.2 times that of controls, while cervical mucus prolactin amounted to 32 times its control value. The rise of cervical mucus prolactin in cases of galactorrhea oligohypomenorrhea was 21 times its control value which is markedly higher than that of serum (1.9 times). The average rise of serum prolactin in the whole group of galactorrhea with abnormal menstrual function was about 4 times the control value, while the average rise of cervical mucus prolactin was about 41 times the corresponding control value. In the cases of galactorrhea with menstrual dysfunction, serum prolactin level may be normal in 50% of cases, while cervical mucus prolactin is strikingly elevated in 100% of cases. The possibility of pituitary adenoma should be considered if the level of serum or cervical mucus prolactin exceeds 100 ng/ml and 600 ng/ml respectively. The possible physiological role of cervical mucus prolactin and its source are discussed.

Heterogeneity of the polycystic ovary syndrome: clinical, endocrine and ultrasound features in 556 patients

This paper reports an analysis of the clinical, endocrine and ultrasound data within a population of 556 patients with ultrasound-diagnosed polycystic ovaries. Compared with those not so affected, hirsutism was associated with a higher mean serum testosterone concentration, infertility was associated with higher mean gonadotrophin concentrations, obesity was associated with a higher mean serum testosterone concentration, hyperprolactinaemia was associated with a lower mean serum testosterone concentration and smaller ovaries, alopecia was associated with lower mean serum LH and testosterone concentrations, and acanthosis nigricans was associated with obesity and a raised mean serum testosterone concentration. The heterogeneity illustrates the limitations in the use of specific clinical or endocrine criteria as requirements for the diagnosis of the polycystic ovary syndrome.

The role of hyperinsulinemia in the pathogenesis of ovarian hyperandrogenism

The evidence that supports the hypothesis that insulin and LH both regulate ovarian androgen production was presented. The most dramatic clinical example of the association between hyperinsulinemia and hyperandrogenism is the HAIR-AN syndrome. Our hypothesis is that, in the HAIR-AN syndrome, the severe insulin resistance causes a compensatory hyperinsulinemia, which stimulates ovarian androgen production if adequate LH is present. The acanthosis nigricans is an epiphenomenon of the syndrome. Acanthosis nigricans is a dermatologic manifestation of severe insulin resistance. In vitro evidence suggests that insulin and IGF-I stimulate androgen production in incubations of human stroma and theca. The stromatropic effects of insulin may sensitize the stroma to the stimulatory effects of LH. In some hyperandrogenic-insulin-resistant women, a glucose load appears to produce an acute rise in circulating androgens. The magnitude of the rise in circulating androgens is proportional to the magnitude of the insulin response to the glucose load. These data suggest that hyperinsulinemia may play a central role in the development of ovarian hyperandrogenism.

The effects of corticotropin, opioid peptides and crude pituitary extract on the production of dehydroepiandrosterone and corticosterone by mature rat adrenal cells in tissue culture

In order to study the steroidogenic response to pituitary factors, a technique of monolayer tissue culture of mature female rat adrenal cells was used. During the first 24 h, rat adrenal cells produced dehydroepiandrosterone (DHEA) and small amount of corticosterone but in the absence of corticotropin (ACTH), the release of these two steroids were reduced to very low levels. The addition of synthetic alpha-ACTH-(1-24) [0.01-100 ng/ml] elicited a marked increase in the production of both steroids. This stimulating effect was not observed when synthetic methionine and leucine-enkephalins (1-100 ng/ml), human beta-endorphin (1-100 ng/ml) or human beta-lipotropin (1 ng/ml), were added to the culture medium. When these peptides were added concomitantly with alpha-ACTH (1-24) at half of the maximum response dose (1 ng/ml), no synergistic effect upon DHEA and corticosterone production was shown. The addition of crude extract from rat pituitary gland (1-100 ng/ml) with or without alpha-ACTH-(1-24) definitely showed both a stimulatory and synergistic effect upon the production of these two steroids. Furthermore, the ratio between DHEA production and corticosterone production was significantly higher when crude extract of the pituitary gland was given alone or concomitantly with alpha-ACTH(1-24) than when alpha-ACTH(1-24) was given alone. These data suggest the existence of a still undefined pituitary adrenal androgen stimulating which may preferentially stimulate DHEA production over corticosterone production.

Prolactin secretion in polycystic ovary syndrome: circadian rhythmicity and dynamic aspects

The circadian rhythms of plasma prolactin (PRL) and cortisol and of oral temperature were simultaneously studied in 24 women with polycystic ovary syndrome (PCOS). The PRL response to thyrotropin-releasing hormone (TRH) and domperidone was also evaluated in some of these patients. The physiological circadian chrono-organization of prolactin and cortisol secretion and of oral temperature was maintained in PCOS. The PRL responsiveness to the specific stimulations fell within normal limits. These results do not support the hypothesis of an impaired central dopaminergic regulation of prolactin secretion in PCOS.

Secretory dynamics of bioactive and immunoreactive prolactin in polycystic ovary syndrome

To further investigate prolactin (PRL) secretion in polycystic ovary syndrome (PCO), the authors evaluated immunoreactive (immuno) and bioactive (bio) PRL levels in the basal state and in response to provocative testing with intravenous dopamine (DA), metoclopramide (MCP), and gonadotropin-releasing hormone (GnRH), before and after disulfiram. Basal measurements of immuno-PRL, bio-PRL, and the ratio of bio/immuno-PRL were similar in PCO and controls. The immuno-PRL decrement after DA was greater than that of bio-PRL in both groups (P less than 0.05). After MCP, immuno-PRL increased more than bio-PRL in PCO (P less than 0.01), and this immuno-PRL increment was greater than that of controls (P less than 0.05). Bio-PRL and immuno-PRL increased after GnRH in PCO, but not controls, and these responses were inhibited by disulfiram. These data confirm PRL hypersecretion in some women with PCO, which is better expressed by immunoreactivity than bioactivity. Given the assay systems and patients studied, bioactivity

Prevalence of and markers for the attenuated form of congenital adrenal hyperplasia and hyperprolactinemia masquerading as polycystic ovarian disease

To determine the prevalence of the attenuated form of congenital adrenal hyperplasia (CAH) and hyperprolactinemia (HPPN) relative to polycystic ovarian disease (PCOD), 100 consecutive women presenting with the classic clinical features of PCOD were evaluated by basal hormonal profiles and subsequent adrenocorticotropic hormone (ACTH) stimulation tests. The study also sought biochemical markers for CAH other than ACTH stimulation. The prevalences were found to be as follows: PCOD, 65%; PCOD with HPPN, 9%; HPPN, 3%, end-organ hypersensitivity (EOH), 4%; homozygotic CAH, 4%; and heterozygotic CAH, 15%. Other than the differential response to ACTH, the only other biochemical markers observed for homozygotic CAH were significantly higher basal levels of testosterone (T) and 17 alpha-hydroxyprogesterone (17-OHP). Luteinizing hormone/follicle-stimulating hormone ratio, androstenedione, and dehydroepiandrosterone sulfate all showed no significant differences between homozygotic CAH, heterozygotic CAH, HPPN, PCOD, and EOH. This study establishes the relative prevalences of the syndromes commonly mimicking PCOD. We also conclude that the observed low incidence of CAH does not justify routine ACTH testing on all patients presenting with features of PCOD--however, our data suggest that patients with basal serum levels of T and 17-OHP greater than 50% above the upper limit of normal should undergo this dynamic test, especially if there are also certain clinical features suggestive of CAH.

Does testosterone affect the normal menstrual cycle?

In order to throw further light on the role of androgens in the aetiology of the polycystic ovary syndrome (PCO) we have examined the effect of artificially increasing serum testosterone levels on menstrual function in a group of ovulating women. Six women were studied who had either severe premenstrual syndrome or loss of libido for which they were treated with 100 mg testosterone by s.c. implantation. All had regular menstrual cycles. For 1 month before implantation serum LH, FSH, oestradiol (E2), progesterone and testosterone were measured three times per week. All women showed normal cyclical variation of LH, FSH, E2 and progesterone. Following implantation, three times weekly blood samples were taken during the first and third cycles. No patient had any disturbance of menstrual pattern. All continued to show cyclical changes of LH, FSH, E2 and progesterone. Serum E2 and progesterone were lower but not significantly so in the luteal phase of the treated cycles. This was despite a mean serum testosterone which rose from 1.3 to 7.1 nmol/l at the end of the third week following implantation and to 4.1 nmol/l at the end of the third month. Sex hormone binding globulin levels fell as expected by 18.5% during the first cycle. The lack of significant effect of a markedly elevated serum testosterone level on cyclical hormone changes is indirect evidence that in PCO the primary cause of the menstrual disturbance is not excessive production of ovarian or adrenal testosterone.

Increased DHEAs levels in PCO syndrome: evidence for the existence of two subgroups of patients

In 49 patients affected by PCO syndrome the serum levels of dehydroepiandrosterone-sulphate (DHEAs) were determined and correlated with the clinical presentation and the endocrine pattern. Twenty-three patients (47%) had high DHEAs levels (h-DHEAs patients). They presented a milder clinical presentation (low incidence of amenorrhea) than PCO patients with normal DHEAs levels (n-DHEAs patients). In h-DHEAs patients the finding of a normal DHEAs response to ACTH and of slightly increased 170HP serum levels suggested that the elevation of serum DHEAs was not due to an adrenal enzymatic deficiency but to a tonic hyperstimulation of the adrenals. Two subgroups of h-DHEAs patients were identified: in the first subgroup, PRL and estrone levels were increased and probably explained the DHEAs hypersecretion; in the second subgroup, the endocrine pattern was very similar to that observed in n-DHEAs patients and a clear explanation for DHEAs increase was not found, although the possibility of an exaggerated secretion of some pituitary hormones with adrenal androgen stimulating activity must be considered.

Adrenocorticotropic hormone testing in idiopathic hirsutism and polycystic ovarian disease: a test of limited usefulness

The plasma 17 alpha-hydroxyprogesterone (17-OHP) concentration was determined in the basal state and 60 minutes after cosyntropin, 0.25 mg, in 139 patients with idiopathic hirsutism (IH) and polycystic ovarian disease (PCOD). Although there was an increased response of 17-OHP in subjects with PCOD when compared with IH subjects, in no instance was stimulated 17-OHP abnormal in the presence of normal basal 17-OHP. Two subjects with 21-hydroxylase (21-OH) deficiency were discovered; both demonstrated elevated basal levels of 17-OHP. We therefore conclude that routine adrenocorticotropic hormone testing is not a useful tool in detecting 21-OH deficiency in hyperandrogenic women.

Clinical and biologic antecedents of the amenorrhea/hyperprolactinemia syndrome: a case-control study

Clinical, reproductive, and biologic antecedents of women with the amenorrhea/hyperprolactinemia (A/H) syndrome, most with pituitary prolactinomas, and matched healthy subjects were examined in a case-control study. Women with A/H had more frequent irregularity in early menstrual cycle patterns and excess facial hair, had less frequent catamenial symptoms, and were heavier at the time of study when compared with control subjects. The patients reported a more frequent history of thyroid disease and chest trauma. There were no significant differences between the patients and control subjects with respect to prior use of oral contraceptives, estrogens, psychotropic drugs, alcohol, or other substances known to alter serum prolactin levels, nor were there significant differences in the family history of gynecologic conditions or malignancies or the syndromes of multiple endocrine neoplasia. The implications of these findings are discussed.