Clinical features and circulating gonadotropin, insulin, and androgen interactions in women with polycystic ovarian disease

Adrenocortical production is associated with higher levels of luteinizing hormone in nonobese women with polycystic ovary syndrome

Objective. Insulin resistance (IR) and ovarian and adrenal hyperandrogenism are a common finding in women with polycystic ovary syndrome (PCOS). The aim of the present study was to access possible differences in insulin resistance, gonadotropins, and androgens production in obese and nonobese PCOS women. Study Design. We studied 37 PCOS women (16 nonobese and 21 obese) and 18 nonobese controls. Fasting glucose, insulin, androgens, and gonadotropins levels were determined. Salivary cortisol was measured basal and in the morning after dexamethasone (DEX) 0.25 mg. Results. Nonobese PCOS women showed higher basal salivary cortisol and serum dehydroepiandrosterone sulfate and luteinizing hormone (LH) levels than controls and obese PCOS. These hormones levels did not differ between the obese and control groups. After DEX administration no differences were found between the three groups. In PCOS women, salivary cortisol levels showed negative correlation with BMI (r = -0.52; P = 0.001) and insulin (r = -0.47; P = 0.003) and positive correlation with LH (r = 0.40; P = 0.016). Conclusion. Our results show an increased adrenocortical production in nonobese PCOS women, not related to IR and associated with a normal hypothalamic-pituitary-adrenal suppression. Higher LH levels might be involved in this event.

Reproducibility of luteinizing hormone hypersecretion in different phases of the menstrual cycle in polycystic ovary syndrome

AIM

We evaluated the reproducibility of an elevated luteinizing hormone (LH) level or elevated LH/follicle-stimulating hormone (FSH) ratio in different phases of the menstrual cycle in patients with polycystic ovary syndrome (PCOS). Furthermore, we evaluated the influence of cycle days and body mass index on LH levels using different days from menses or withdrawal bleeding.

METHODS

Forty-three patients with PCOS and 37 controls were enrolled. All patients with PCOS had elevated LH levels and LH/FSH ratio, polycystic ovarian morphology and chronic anovulation at diagnosis. After their diagnoses, we measured serum LH and FSH in the early period and/or late period of the follicular phase.

RESULTS

The rate of patients with elevated LH levels and LH/FSH ratio were significantly higher in the late phase than in the early phase in PCOS. In the early phase, only 52% of patients had elevated LH levels and LH/FSH ratio. We failed to demonstrate an inverse relationship between the LH level and BMI.

CONCLUSIONS

LH levels of patients with PCOS were strongly influenced by the days from menses or withdrawal bleeding. In the early period, the reproducibility of elevated LH levels or LH/FSH ratio was poor even in patients previously diagnosed with them.

Luteinizing hormone pulsatility in patients with major ovarian hyperandrogenism

Hyperandrogenism and ovulatory dysfunction are common in women with either polycystic ovary (PCOS) or ovarian virilizing tumor. However, contrasting with the numerous studies that have extensively described gonadotropin secretory abnormalities, principally increased LH pulse amplitude and frequency, few studies have concerned gonadotropin secretion in patients with ovarian virilizing tumors; low gonadotropin levels have occasionally been reported, but never extensively studied. The goal of the present study was to further evaluate the pulsatility of LH secretion in women with ovarian virilizing tumor compared with that of PCOS patients. Eighteen women with major hyperandrogenism (plasma testosterone level >1.2 ng/ml) were studied (5 women with ovarian virilizing tumor, 13 women with PCOS, and 10 control women). Mean plasma LH level, LH pulse number and amplitude were dramatically low in patients with ovarian tumors when compared to both PCOS (p<0.001) and controls (p<0.001). In case of major hyperandrogenism, LH pulse pattern differs markedly between women with ovarian virilizing tumor or PCOS, suggesting different mechanisms of hypothalamic or pituitary feedback.

Diagnostic performance of serum total testosterone for Japanese patients with polycystic ovary syndrome

It is reported that the incidence of clinical and biochemical hyperandrogenism may be lower in Japanese patients with PCOS. Hyperandrogenism is included as a referential but not as an essential factor in the diagnostic criteria of the Japanese Society of Obstetrics and Gynecology (JSOG 1993). However, some patients with the typical clinical features of PCOS are not diagnosed with PCOS using JSOG 1993 criteria because they do not have a high LH level, which is defined as essential for diagnosis. In this study, we compared total testosterone (T) levels between Japanese patients with PCOS diagnosed using the JSOG 1993 criteria and normal menstrual women (controls). Fifty controls and 46 patients with PCOS were enrolled in this study. Furthermore, we evaluated the sensitivity and specificity of each cut-off value of T. The mean T level of patients with PCOS was significantly higher than that of the control (86 +/- 48 vs 68 +/- 46, P<0.01), and the prevalence rates of hyperandrogenism (T >114 ng/dL; defined as the mean +2SD of the control) were 10.2% in patients with PCOS and 4% in controls. The area under the ROC curve of T was 0.72, and there was no decision threshold to diagnose PCOS by T alone with both high sensitivity and high specificity. If the threshold is set as 110 ng/dL in order to gain high specificity, 94% of women whose serum level passed the threshold will be patients with PCOS. Although T should not be used as an independent essential factor of Japanese PCOS, it might be useful as a complementary factor in order to diagnose patients who have typical clinical features of PCOS but does not fulfill the JSOG 1993 criteria for PCOS.

Diagnosis, epidemiology, and genetics of the polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a heterogeneous disorder, and its definition remains fluid and controversial. PCOS is characterized by clinical and/or biochemical hyperandrogenism, and is frequently accompanied by ovulatory dysfunction and polycystic ovaries. PCOS is a diagnosis of exclusion, with other androgen excess and related disorders to be excluded. The prevalence of PCOS is 6.5-8.0% of unselected women of reproductive age, using the NIH 1990 criteria. Genetically, PCOS is a common, complex disorder. Despite repeated attempts to identify the putative gene or genes responsible for this disorder, the PCOS gene(s) remain elusive.

Inverse relationship between luteinizing hormone and body mass index in polycystic ovarian syndrome: investigation of hypothalamic and pituitary contributions

CONTEXT

Patients with polycystic ovarian syndrome (PCOS) have increased LH relative to FSH, but LH is modified by body mass index (BMI).

OBJECTIVE

The objective of the study was to determine whether the impact of BMI on neuroendocrine dysregulation in PCOS is mediated at the hypothalamic or pituitary level. PARTICIPANTS/INTERVENTIONS/SETTING: Twenty-four women with PCOS across a spectrum of BMIs underwent frequent blood sampling, iv administration of GnRH (75 ng/kg), and sc administration of the NAL-GLU GnRH antagonist (5 microg/kg) in the General Clinical Research Center at an academic hospital.

MAIN OUTCOME MEASURES

LH pulse frequency and LH response to submaximal GnRH receptor blockade were used as measures of hypothalamic function; LH response to GnRH was used as a measure of pituitary responsiveness.

RESULTS

BMI was negatively correlated with mean LH, LH/FSH, and LH pulse amplitude. There was no effect of BMI on LH pulse frequency. Percent inhibition of LH was decreased in PCOS, compared with normal women (53.9 +/- 1.5 vs. 63.1 +/- 4.1, respectively; P < 0.01), suggesting an increase in the amount of endogenous GnRH, but was not influenced by BMI. Pituitary responsiveness to GnRH was inversely correlated with BMI (peak LH, R = -0.475, P < 0.02; and LH area under the curve R = -0.412, P < 0.02).

CONCLUSIONS

LH pulse frequency and quantity of GnRH are increased in PCOS, but there is no influence of BMI on either marker of hypothalamic function. The pituitary response to a weight-based dose of GnRH is inversely related to BMI in PCOS. These studies suggest that the effect of BMI on LH is mediated at a pituitary and not a hypothalamic level in PCOS.

The pathophysiology of polycystic ovary syndrome: trying to understand PCOS and its endocrinology

The pathophysiology of the polycystic ovary syndrome (PCOS) encompasses inherent ovarian dysfunction that is strongly influenced by external factors, such as disturbances of the hypothalamic-pituitary-ovarian axis and hyperinsulinaemia. Exaggerated gonadotrophin releasing hormone (GnRH) pulsatility results in hypersecretion of luteinising hormone (LH), which has effects both on ovarian androgen production and oocyte development. Disturbed ovarian-pituitary and hypothalamic feedback accentuates the 0gonadotrophin abnormalities. Hyperinsulinaemia is secondary both to insulin resistance at the periphery and to abnormal pancreatic beta cell function. PCOS runs in families and a number of genetic abnormalities appear to result in features of the syndrome and account for the heterogeneity of the symptoms. Environmental influences, such as nutrition and lifestyle, further influence expression of the syndrome.

Pathogenesis of polycystic ovary syndrome: what is the role of obesity?

Both obesity and the polycystic ovary syndrome (PCOS) are commonly seen in women of reproductive age. Fifty percent of all patients with PCOS are obese, and the presence of obesity affects the clinical manifestations of PCOS. The underlying pathogenetic mechanisms appear to involve insulin resistance and hyperinsulinemia, the magnitude of which is greater in obese than in non-obese women with PCOS. Specific effects of obesity on the manifestations of PCOS, underlying mechanisms of the interactions between obesity and PCOS, and therapeutic implications of these interactions are discussed in this article.

Relationship between insulin resistance and gonadotropin dissociation in obese and nonobese women with polycystic ovary syndrome

OBJECTIVE

To test the interdependence between insulin resistance (IR) and gonadotropin dissociation (GD) in polycystic ovary syndrome (PCOS).

DESIGN

Cross-sectional prospective study.

SETTING

Clinical research center.

PATIENT(S)

Thirty-two PCOS patients aged 19-34 years; 16 obese (BMI > or = 27) and 16 nonobese (BMI < 27).

INTERVENTION(S)

A 75-g oral glucose tolerance test (OGTT) and a 100-microg i.v. GnRH test were performed on different days. Blood was taken at 0, 30, 60, 90, 120, and 180 minutes in each test. Serum glucose, insulin, LH, and FSH were measured.

MAIN OUTCOME MEASURE(S)

Area under the curve was calculated for glucose, insulin, and glucose-to-insulin ratio (GIR), and for LH, FSH, and LH-FSH ratio.

RESULT(S)

Glucose, insulin, and GIR were not modified significantly during the GnRH test, nor LH, FSH and LH-FSH ratio throughout the OGTT. There were no significant differences in GIR response of patients with and without GD, nor in LH-FSH ratio of patients with and without IR, after OGTT and GnRH test. However, obese patients with IR had a significantly larger (P<.04) area under the curve for LH-FSH ratio than those without IR after GnRH test, but not after OGTT test.

CONCLUSION(S)

Insulin resistance and GD do not appear to be related events in PCOS, suggesting that each one might be determined by different genetic disorders. However, IR can affect GD after chronic stimulation in obese patients.

Polycystic ovary syndrome--a systemic disorder?

Polycystic ovary syndrome (PCOS) is the commonest endocrine disturbance affecting women. There is considerable heterogeneity of symptoms and signs amongst women with PCOS and for an individual these may change over time. PCOS is familial and genetics appear to be associated with disturbances of insulin secretion. Polycystic ovaries can exist without clinical signs of the syndrome, which may then become expressed over time. There are a number of interlinking factors that affect expression of PCOS. A gain in weight is associated with a worsening of symptoms whilst weight loss will ameliorate the endocrine and metabolic profile and symptomatology. Women with PCOS are characterized by the presence of insulin resistance, central obesity and dyslipidaemia, which appears to place them at a higher risk of developing diabetes as well as cardiovascular disease. A number of studies have confirmed the higher incidence of diabetes, although they have not shown a higher risk of mortality from ischaemic heart disease (IHD). Cross-sectional studies have demonstrated a significant association between PCOS and IHD. Prospective, long-term longitudinal studies confirming this risk are still awaited. Weight loss remains the most effective first line therapeutic intervention in women with PCOS and recently the use of insulin sensitizing agents has demonstrated benefit.

New approach to polycystic ovary syndrome and other forms of anovulatory infertility

Anovulation can be classified in the clinic on the basis of serum hormone assays. Low gonadotropins along with low estrogen concentrations are suggestive of a central origin of the disease, whereas low estrogen levels along with elevated gonadotropins indicate a primary defect at the ovarian level. Most anovulatory patients (approximately 80%) present with serum FSH and estradiol levels within the normal range (World Health Organization class II). Polycystic ovary syndrome (PCOS) is a common but poorly defined heterogeneous clinical entity. Historically, characteristic ovarian abnormalities represented a hallmark of the syndrome. Because several etiological factors may lead to a similar end point (i.e., polycystic ovaries), the development of a clinically applicable classification of the syndrome has proven difficult. Clinical, morphological, biochemical, endocrine, and, more recently, molecular studies have identified an array of underlying abnormalities and added to the confusion concerning the pathophysiology of the disease. Despite the vast literature regarding the etiology and classification of PCOS, no consensus has been reached regarding the validity of criteria used to diagnose the syndrome. For instance, the significance of elevated serum luteinizing hormone (LH) concentrations, insulin resistance or polycystic-appearing ovaries assessed by ultrasound for PCOS diagnosis remains uncertain. In contrast, hyperandrogenism and chronic anovulation generally are believed to be mandatory diagnostic features. Patients with PCOS might visit a dermatologist for hirsutism, a generalist, or internist for complaints related to obesity or a gynecologist for irregular or absent bleeding. However, most patients seek the care of a gynecologist because of cycle abnormalities (oligomenorrhea) and infertility. In PCOS, serum FSH and estradiol (E2) levels are usually found to be within the (broad) normal ranges, whereas LH may either be normal or elevated. Because PCOS with normal or high LH does not seem to represent different clinical entities, it seems justifiable to consider this syndrome as a subgroup of WHO-II patients, although estrogen levels may be tonically elevated in these patients. This review will focus on characteristics of the heterogeneous group of WHO-II patients in an attempt to identify factors involved in the etiology and possible ovulation induction outcome of PCOS.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader will be able to outline the current classification of anovulatory infertility and to explain the characteristics and features used for classification.

Relationship between serum müllerian-inhibiting substance and other reproductive hormones in untreated women with polycystic ovary syndrome and normal women

OBJECTIVE

To examine the relationship of serum müllerian-inhibiting substance (MIS), E(2), free-T, LH, and FSH in untreated women with polycystic ovary syndrome (PCOS) and in women with normal menstrual cycles.

DESIGN

A prospective study.

SETTING

University Departments of Obstetrics and Gynecology and Surgery.

PATIENT(S)

Twenty-seven women with PCOS and 20 women with normal menstrual cycles.

INTERVENTION(S)

Serum was collected from women with PCOS and from normal women during the early follicular phase of the menstrual cycle, stored frozen until assayed.

MAIN OUTCOME MEASURE(S)

Serum levels of MIS, E(2), free-T, TSH, LH, and FSH were measured.

RESULT(S)

Serum müllerian-inhibiting substance levels in PCOS patients were significantly higher compared with normal women (+/- SE; 5.3 +/- 0.7 and 1.4 +/- 0.2 ng/mL, respectively). An inverse correlation (r = -0.5965) was found between serum levels of MIS and E(2) in PCOS women, but not in normal women. Women with PCOS had higher serum LH levels than those of normal women (15.2 +/- 1.2 and 5.0 +/- 0.7 mIU/mL).

CONCLUSION

In this study, women with PCOS have significantly higher serum MIS levels than normal women. The inverse relationship between müllerian-inhibiting substance and E(2) levels suggests that MIS may modulate ovarian E(2) synthesis and have a role in the disordered folliculogenesis characteristic of PCOS.

Mechanisms of hypothalamic-pituitary-gonadal disruption in polycystic ovarian syndrome

Although the pathogenesis of polycystic ovarian syndrome (PCOS) is still controversial, a series of investigations has demonstrated an array of neuroendocrine abnormalities as a major component of the syndrome. From a neuroendocrine perspective, patients with PCOS exhibit an accelerated frequency and/or higher amplitude of LH pulses, augmentation of LH secretory burst mass, and a more disorderly LH release. Elevated in vitro LH bioactivity and a preponderance of basic LH isoforms, which correlate positively with elevated serum 17-hydroxyprogesterone, androstenedione, and testosterone concentrations, also characterize adolescents with PCOS. Heightened GnRH drive of gonadotropin secretion and a steroid-permissive milieu appear to jointly promote elevated secretion of basic LH isoforms. Positive feedback is implied, because hypersecretion of highly bioactive LH in PCOS probably contributes to inordinate androgen output. However, the precise nature of feedback disruption remains uncertain. Indeed, recent data suggest that PCOS is marked by anomalies of both feedforward and feedback signaling between GnRH/LH and ovarian androgens. From a single hormone perspective, the individual patterns of LH and androstenedione release are consistently more irregular in patients with PCOS. Bihormonal analysis has disclosed concomitant uncoupling of the pairwise synchrony of LH and testosterone, LH and androstenedione, and testosterone and androstenedione secretion. The foregoing ensemble of findings points to deterioration of both orderly uniglandular and coordinate bihormonal output in PCOS. Additional studies are needed to establish the primary pathophysiologic mechanisms underlying this disorder.

Specific factors predict the response to pulsatile gonadotropin-releasing hormone therapy in polycystic ovarian syndrome

Ovulation induction is particularly challenging in patients with polycystic ovarian syndrome (PCOS) and may be complicated by multifollicular development. Pulsatile GnRH stimulates monofollicular development in women with anovulatory infertility; however, ovulation rates are considerably lower in the subgroup of patients with PCOS. The aim of this retrospective study was to determine specific hormonal, metabolic, and ovarian morphological characteristics that predict an ovulatory response to pulsatile GnRH therapy in patients with PCOS. Subjects with PCOS were defined by chronic amenorrhea or oligomenorrhea and clinical and/or biochemical hyperandrogenism in the absence of an adrenal or pituitary disorder. At baseline, gonadotropin dynamics were assessed by 10-min blood sampling, insulin resistance by fasting insulin levels, ovarian morphology by transvaginal ultrasound, and androgen production by total testosterone levels. Intravenous pulsatile GnRH was then administered. During GnRH stimulation, daily blood samples were analyzed for gonadotropins, estradiol (E(2)), progesterone, inhibin B, and androgen levels, and serial ultrasounds were performed. Forty-one women with PCOS underwent a total of 144 ovulation induction cycles with pulsatile GnRH. Fifty-six percent of patients ovulated with 40% of ovulatory patients achieving pregnancy. Among the baseline characteristics, ovulatory cycles were associated with lower body mass index (P < 0.05), lower fasting insulin (P = 0.02), lower 17-hydroxyprogesterone and testosterone responses to hCG (P < 0.03) and higher FSH (P < 0.05). In the first week of pulsatile GnRH treatment, E(2) and the size of the largest follicle were higher (P < 0.03), whereas androstenedione was lower (P < 0.01) in ovulatory compared with anovulatory patients. Estradiol levels of 230 pg/mL (844 pmol/L) or more and androstenedione levels of 2.5 ng/mL (8.7 nmol/L) or less on day 4 and follicle diameter of 11 mm or more by day 7 of pulsatile GnRH treatment had positive predictive values for ovulation of 86.4%, 88.4%, and 99.6%, respectively. Ovulatory patients who conceived had lower free testosterone levels at baseline (P < 0.04). In conclusion, pulsatile GnRH is an effective and safe method of ovulation induction in a subset of patients with PCOS. Patient characteristics associated with successful ovulation in response to pulsatile GnRH include lower body mass index and fasting insulin levels, lower androgen response to hCG, and higher baseline FSH. In ovulatory patients, high free testosterone is negatively associated with pregnancy. A trial of pulsatile GnRH therapy may be useful in all PCOS patients, as E(2) and androstenedione levels on day 4 or follicle diameter on day 7 of therapy are highly predictive of the ovulatory response in this group of patients.

Alterations in cardiac flow parameters in patients with polycystic ovarian syndrome

The aim of this study was to examine the echocardiographic profiles of patients with polycystic ovarian syndrome (PCOS). Serum concentrations of follicle stimulating hormone, luteinizing hormone, androstenedione, free testosterone, prolactin, DHEA-SO(4) and 17-OH-progesterone, lipid profile (high and low density lipoproteins, triglyceride and total cholesterol) and basal and total insulin after a glucose tolerance test were measured in 35 patients with PCOS and 35 healthy controls matched for body mass index. Doppler, two dimensional M mode echocardiography was performed for the following indices: isovolumetric relaxation time (IVRT), E wave duration time (EVT), A wave duration time (AVT), E wave deceleration time (DT), peak early diastolic flow velocity (PEV), peak late diastolic flow velocity (PAV), E wave velocity time integral (FVI-E), A wave velocity time integral (FVI-A), atrial filling fraction (AFF), ejection fraction (EF), pre-ejection time (PEP), ejection time (ET) and aortic flow velocity time integral (FVI). Androstenedione, free testosterone, low density lipoproteins and cholesterol concentrations were significantly higher in patients with PCOS. There was no difference in basal and total insulin concentrations. IVRT, AVT, FVI-A, AFF, and PEP were higher in patients with PCOS, while PEV, FVI-E, EF, ET, EVT and EVT/AVT were higher in the control group. There was a positive correlation between basal insulin values and IVRT, and between total insulin values and EF. These changes are consistent with a non-restrictive type of diastolic dysfunction and left ventricular stiffness. PCOS may lead to diastolic dysfunction via hyperinsulinaemia and male type dyslipidaemia.

Diagnosis of polycystic ovary syndrome

The clinical features of polycystic ovary syndrome (PCOS) include hirsutism and irregular menses, which are the results of ovarian hyperandrogenism and chronic, unopposed estrogen secretion. The discovery that most women with PCOS are insulin-resistant and have compensatory hyperinsulinemia, with increased risk for type 2 diabetes mellitus, designates this condition as a reproductive-metabolic disorder. That the symptoms of PCOS may be mimicked by other endocrine disorders of the ovary and adrenal glands warrants careful evaluation to exclude these associated conditions.

Role of the mutations Trp8 => Arg and Ile15 => Thr of the human luteinizing hormone beta-subunit in women with polycystic ovary syndrome

OBJECTIVE

To evaluate the clinical significance of LH in the form of a mutant beta-subunit in women with polycystic ovary syndrome (PCOS).

DESIGN

Prospective, controlled study.

SETTING

University hospital.

PATIENT(S)

Thirty healthy women and 30 women with PCOS.

INTERVENTION(S)

Clinical, ultrasonographic, and hormonal findings were used to define PCOS. Nucleotide mutations within codons 8 and 15 in the LH beta-subunit gene (Trp8 => Arg and Ile15 => Thr) were analyzed with the use of polymerase chain reaction and subsequent restriction fragment length polymorphism.

MAIN OUTCOME MEASURE(S)

Serum levels of gonadotropins, androgens, E2, and prolactin were determined, and the results of restriction fragment length polymorphism were analyzed.

RESULT(S)

Five women in the control group and one woman in the PCOS group were found to be affected by the LHbeta gene mutations. No difference was observed in serum androgen and E2 levels between the affected women and 25 healthy women who were homozygous for the wild-type LH. However, women whose serum LH levels were < or = 5.1 mIU/mL had a higher risk of having mutant LH.

CONCLUSION(S)

The frequency of LH mutations in women with PCOS is similar to that in healthy women. The presence of the variant does not cause any significant change in serum levels of androgens and E2.

Polycystic ovary syndrome

Polycystic ovary syndrome is a syndrome and not a disease. It reflects multiple potential etiologies and variable clinical presentations that are reviewed in this article. In addition to menstrual dysfunction and hyperandrogenism, women with polycystic ovary syndrome also may have hypothalamic-pituitary abnormalities, polycystic ovaries on pelvic ultrasonography, infertility, obesity, and insulin resistance. A familial pattern occurs in some cases, suggesting a genetic component to the disorder. The three major pathophysiologic hypotheses that have been proposed to explain the clinical findings of the disorder as well as treatment options are reviewed in this article.

Insights into hypothalamic-pituitary dysfunction in polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is characterized by menstrual dysfunction and hyperandrogenism in the absence of other known causes. While the pathogenesis of PCOS remains elusive and is likely to involve abnormalities in several systems, there has long been an association of abnormal gonadotropin secretion with this disorder. In recent studies we have determined that 94% of women meeting the broad criteria for PCOS have an increased LH/FSH ratio. Several lines of evidence suggest that the mechanisms underlying the increased LH/FSH ratio in PCOS include an increased frequency of GnRH secretion. Decreased sensitivity to progesterone negative feedback on the GnRH pulse generator may play a role in this neuroendocrine defect. Additional factors which may contribute to the low to normal FSH levels in the face of increased LH include chronic mild estrogen increases and possibly inhibin. In addition to these effects on the differential control of FSH, there is increased pituitary sensitivity of LH secretion to GnRH. Both estrogen and androgens have been proposed as candidates mediating these effects. Superimposed on these underlying abnormalities in gonadotropin secretion is a marked inhibitory effect of obesity on LH secretion which may be mediated at either a pituitary or hypothalamic level.

Late endocrine effects of ovarian electrocautery in women with polycystic ovary syndrome

OBJECTIVE

To examine the duration of the changes in endocrine indices produced by ovarian electrocautery in women with polycystic ovary syndrome (PCOS).

DESIGN

Long-term observational study.

SETTING

University hospital.

PATIENT(S)

Infertile women with PCOS.

INTERVENTION(S)

Ovarian electrocautery was performed through the laparoscope. Blood was sampled before the operation and at defined intervals thereafter. After the establishment of regular cycles, sampling was performed 1 week before the menstrual period.

MAIN OUTCOME MEASURE(S)

The patients were observed before and at defined intervals for up to 20 years after ovarian electrocautery. Serum concentrations of hypophyseal and ovarian hormones were determined, including sex hormone-binding globulin (SHBG).

RESULT(S)

There was a clear shift from anovulation to ovulatory cycles and a significant decrease in androgens and gonadotropins. The concentration of SHBG increased. These effects lasted for many years; after 18-20 years, two thirds of the women were still ovulating.

CONCLUSION(S)

Ovarian electrocautery for PCOS normalizes ovarian function, including androgen production, and the results seem to be stable for 18-20 years.

Relation of luteinizing hormone levels to body mass index in premenopausal women

OBJECTIVE

To assess the relationship between body mass index (BMI) and basal LH and the LH-FSH ratio in normally menstruating women.

DESIGN

Cross-sectional analysis.

SETTING

A teaching hospital clinic.

PATIENT(S)

Premenopausal women without cancer, not currently using oral contraceptives, selected from a familial ovarian cancer clinic or the general population.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Early follicular phase plasma LH and FSH.

RESULT(S)

Luteinizing hormone increased slightly and nonsignificantly (P = 0.44) from the first to the second quintile of BMI and decreased over all subsequent quintiles. Women in the highest quintile of BMI (> 27.1) had significantly lower LH levels than women in the lowest quintile of BMI (< or = 20.4; P = 0.003). Compared with women in the second quintile of BMI who had the highest LH levels, women in the highest quintile of BMI had LH levels that were 40% lower. The relationship between BMI and the LH-FSH ratio was similar, though not as strong.

CONCLUSION(S)

Over most of the range of BMIs observed in this study, BMI was inversely associated with LH. These results suggest that the upper limits of normal for LH may need to be shifted downward for heavier women.

Determinants of abnormal gonadotropin secretion in clinically defined women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a heterogeneous disorder of reproductive age women characterized in its broadest definition by the presence of oligoamenorrhea and hyperandrogenism and the absence of other disorders. Defects of gonadotropin secretion, including an elevated LH level, elevated LH to FSH ratio, and an increased frequency and amplitude of LH pulsations have been described, but the prevalence of these defects in a large, unbiased population of PCOS patients has not been determined. Sixty-one women with PCOS defined by oligomenorrhea and hyperandrogenism and 24 normal women in the early follicular phase had LH samples obtained every 10 min for 8-12 h. Pool LH levels from the frequent sampling studies were within the normal range in the 9 PCOS patients (14.8%) who were studied within 21 days after a documented spontaneous ovulation. Excluding these post-ovulatory patients, 75.0% of the PCOS patients had an elevated pool LH level (above the 95th percentile of the normal controls), and 94% had an elevated LH to FSH ratio. In the anovulatory PCOS patients, pool LH correlated positively with 17-OH progesterone (R = 0.30, P = 0.03), but not with estradiol, estrone, testosterone, androstenedione, or DHEA-S. Pool LH and LH to FSH ratio correlated positively with LH pulse frequency (R = 0.40, P = 0.004 for pool LH, and R = 0.39; P = 0.005 for LH/FSH). There was also a strong negative correlation between pool LH and body mass index (BMI) (R = -0.59, P < 10(-5)). The relationship between BMI and LH secretion in the PCOS patients appeared to be strongest with body fatness, as pool LH was correlated inversely with percent body fat, whether measured by skinfolds (R = -0.61, P < 10(-5)), bioimpedance (R = -0.55, P < 10(-4)), or dual energy x-ray absorptiometry (DEXA) (R = -0.70, P = 0.001; n = 18 for DEXA only). By DEXA, the only body region that was highly correlated with pool LH was the trunk (R = -0.71, P = 0.001). The relationship between body fatness and LH secretion occurred via a decrease in LH pulse amplitude (R = -0.63, P < 10(-5) for BMI; R = -0.58, P < 10(-4) for bioimpedance; and R = -0.64, P = 0.004 for whole body DEXA), with no significant change in pulse frequency with increasing obesity (R = -0.17, P = 0.23 for BMI).

IN CONCLUSION

1) the prevalence of gonadotropin abnormalities is very high in women with PCOS selected on purely clinical grounds, but is modified by recent spontaneous ovulation; 2) the positive relationship between LH pulse frequency and both pool LH and LH to FSH ratio supports the hypothesis that a rapid frequency of GnRH secretion may play a key etiologic role in the gonadotropin defect in PCOS patients; 3) pool LH and LH pulse amplitude are inversely related to body mass index and percent body fat in a continuous fashion; and 4) the occurrence of a continuous spectrum of gonadotropin abnormalities varying with body fat suggests that nonobese and obese patients with PCOS do not represent distinct pathophysiologic subsets of this disorder.

The relation of the gonadotrophin response to chlormadinone according to body weight in patients with amenorrhea due to polycystic ovarian syndrome

OBJECTIVE

To analyze the influence of weight on gonadotrophin response after chlormadinone (hydroxyprogesterone derivative) induced uterine bleeding in women with amenorrhea due to polycystic ovarian syndrome (PCOS).

DESIGN

A comparative study.

METHODS

Thirty-six patients with PCOS were classified according to body mass index into three weight groups, normal, overweight and obese. Luteinizing hormone (LH) and follicle stimulating hormone (FSH) levels were measured during amenorrhea and between days 3-5 after a chlormadinone (2 mg/day for 5 days) induced uterine bleed. Statistical analysis was performed with Wilcox-on test for paired groups and Mann-Whitney U-test for independent groups.

RESULTS

Overall LH, FSH levels and the LH/FSH ratio fell significantly (P < 0.001, P < 0.01 and P < 0.001, respectively) after chlormadinone administration. The LH levels decreased in all three weight groups, the LH/FSH ratio only fell in those normal and overweight subjects, and FSH did not change in any group. When comparing the group with normal weight and those with overweight and obesity no hormonal differences were found.

CONCLUSION

These results show that chlormadinone has an inhibitory effect predominantly over LH secretion which reduces the LH/FSH ratio, but this is independent of body weight.

Gonadotropin levels in women with polycystic ovary syndrome: their relationship to body weight and insulin levels

The purpose of this work was to investigate the relationship of gonadotropin levels to body weight and insulin levels in woman with polycystic ovary syndrome (PCOS). Specifically, we wished to test the hypothesis that circulating luteinizing hormone (LH) and insulin levels are different in obese and normal weight patients with PCOS. The basal plasma levels of gonadotropins, estrogens, androgens and sex hormone-binding globulin, the gonadotropin responses to gonadotropin releasing hormone (GnRH) and the insulin and C-peptide responses to a 3-hour oral glucose tolerance test (OGTT) were measured in 19 obese and 19 normal weight patients with PCOS and 7 obese and 8 normal weight ovulatory controls. Data of the patients were evaluated according to body weight (obese vs normal weight) and basal LH (high vs normal). There was no significant difference in basal LH and androgen levels and in the insulin response to oral glucose between obese and normal weight patients with PCOS. Compared to the weight matched controls, both obese and non obese patients showed significantly higher LH responses to GnRH and C-peptide responses to OGTT. When the high LH patients (no = 18) were compared those with normal LH (no = 20), the high LH subjects exhibited significantly higher androstenedione levels. Both obese (no = 10) and normal weight (no = 8) patients with high LH showed significantly greater C-peptide responses to OGTT than obese (no = 9) and non obese (no = 11) patients with normal LH. However, as compared with the weight matched controls, both the high LH and normal LH patients had significantly greater C-peptide responses to OGTT. We conclude that obese and non obese patients with PCOS do not seem to differ in the prevalence of elevated LH levels or in the LH secretory pattern. Insulin resistance, expressed by an enhanced pancreatic sensitivity to oral glucose, is present in both the high LH and the normal LH subjects, even though the PCOS patients with elevated LH tend to be more insulin resistant and hyperandrogenic than the normal LH patients.

Superovulation with urinary human follicle-stimulating hormone: correlations with body mass index and body fat distribution

Our objective was to investigate the relationship between body mass index (BMI), waist/hip ratio (WHR), follicle-stimulating hormone (FSH) dose, length of stimulation and clinical outcome in infertile women with and without polycystic ovary syndrome (PCOS) undergoing controlled ovarian hyperstimulation. Controlled ovarian hyperstimulation was induced in 60 women for a total of 111 cycles (48% in PCOS patients) with urinary human FSH (u-hFSH). A significant correlation between BMI, u-hFSH dose and duration of stimulation was found in PCOS and non-PCOS patients with WHR < 0.8. These correlations were not present in PCOS patients with WHR > 0.8. Pregnant patients received significantly less ampules of u-hFSH. From our data we suggest a controlled ovarian hyperstimulation protocol, for obese non-PCOS patients and obese PCOS patients with WHR < 0.8, starting with a double dose of u-FSH.

Serum free testosterone in polycystic ovary syndrome measured with a new reference method

OBJECTIVE

To quantify the actual serum free T with a specific new reference method in women with polycystic ovary syndrome (PCOS) and to analyze the effects of serum free T, total T, and the T:sex hormone-binding globulin (SHBG) ratio on the diagnosis of PCOS.

SETTING

Outpatient clinic of reproductive endocrinology at Turku University Central Hospital, Turku, Finland.

PATIENTS

Forty-four oligomenorrheic women with PCOS and 26 weight-matched control women with regular menstrual cycles.

MAIN OUTCOME MEASURES

The concentrations of free T, total T, androstenedione (A), LH, FSH, SHBG, and insulin in serum.

RESULTS

The mean concentrations of free T, total T, A, and LH as well as the LH:FSH and T:SHBG ratios were higher, whereas the mean concentrations of FSH was lower in the women with PCOS than in healthy women. No differences were found in the free T, total T, or T:SHBG levels or in the body mass indexes (BMIs) between the hirsute (n=26) and nonhirsute (n = 18) women with PCOS. Both elevated free T concentrations and high T:SHBG ratios were associated with obesity, but serum total T was independent of BMI. The serum free T measurement discriminated PCOS women from controls to a similar extent as total T and T:SHBG ratio as judged by a receiver operating characteristics analysis.

CONCLUSIONS

The present data indicate that determination of free T provides little additional information in the diagnosis of hirsutism or PCOS and does not have to be included to the basic evaluation of these patients. Only half of women with PCOS exhibited elevated serum free T concentrations.

Prevalence of an immunological LH beta-subunit variant in a UK population of healthy women and women with polycystic ovary syndrome

OBJECTIVE

An immunological LH beta-subunit variant has been described, which is undetectable using monoclonal antibodies directed to the intact LH molecule alone. Subjects have been found homozygous or heterozygous for nucleotide mutations within codons 8 and 15 in the LH beta-subunit gene. The prevalence of the variant LH beta-subunit has been estimated in a healthy UK population of women of reproductive age and in women with polycystic ovary syndrome (PCOS). The relationship of the variant molecule to the clinical and hormonal parameters of the subjects has been evaluated.

DESIGN

The control and PCOS subjects were screened for the presence of the mutation by using a ratio of two immunofluorometric assays using monoclonal antibodies (Mab). One assay, not detecting the LH variant, uses a Mab directed to the intact LH molecule and a beta-specific Mab. The other assay, detecting both the variant and wild-type LH, uses two beta-subunit specific Mabs. The mutations in the LH beta-subunit gene were confirmed by restriction fragment length polymorphism. The relationship of the presence of the variant to the clinical and hormonal parameters was assessed by ANOVA.

PATIENTS

Two hundred and twelve normal ovulatory women, of whom 66 (31%) were obese (body mass index > 25) and 146 (69%) non-obese, and 153 women with PCOS, 115 (75%) obese and 38 (25%) non-obese participated in the study.

RESULTS

The variant LH was detected in 31 (15%) controls and 32 (21%) PCOS subjects (P = 0.124) using specific Mab. Obese PCOS had a higher incidence of the heterozygous LH variant compared to obese controls (odds ratio 2.5, P = 0.03), and compared to non-obese PCOS (odds ratio 6.3, P = 0.01). The previously described two mutations in codon 8 and codon 15 were present in all subjects detected to be mutant hetero of homo-zygous by RFLP. There was no relationship between the presence of the variant LH and the clinical and hormonal parameter in the PCOS subjects; however, in the controls the presence of the variant LH was associated with a higher serum total testosterone (P = 0.046), oestradiol (P = 0.03) and SHBG (P = 0.002).

CONCLUSIONS

The results of this study show that the variant LH beta-subunit is a common polymorphism occurring in 15% of a healthy UK population of women. The prevalence was not higher in women with PCOS, though it was over represented in obese women with PCOS. The presence of the variant did not alter the clinical or hormonal expression of the disorder in women with PCOS. Its presence in the controls was however associated with higher serum oestradiol and probably secondary elevation of SHBG and testosterone, suggesting that the variant form of LH may be associated with subtle changes in the function of the hypothalamic-pituitary-gonadal axis.

Sensitivity of plasma insulin levels in obese and non-obese women with functional hyperandrogenism

Hyperinsulinemia has been implicated in the etiology of functional hyperandrogenism (FH). In a prospective controlled trial, we determined the sensitivity and diagnostic accuracy of fasting plasma insulin levels in 37 females of reproductive age with FH, who were further subdivided into obese (body mass index (BMI) > 25 kg/m2, n = 22) and non-obese (n = 15) groups, in women with (n = 30) and without (n = 7) polycystic ovaries on vaginal endosonography and in controls of similar age (n = 29) who were body mass-matched to the non-obese FH subgroup. Insulin, testosterone, androstenedione, luteinizing hormone (LH), LH/follicle-stimulating hormone (FSH) ratio and dehydroepiandrosterone sulfate (DHEA-S) levels were measured by conventional radio-immunoassay. All hormonal parameters, including insulin (p , 0.0001), were significantly increased in the FH group vs. controls. Mean BMI and insulin did not differ between the subgroups with and without polycystic ovaries. Only insulin was increased (p = 0.0012) in the obese FH vs. non-obese FH subgroup. In the FH group, insulin showed the highest coefficient of variation (0.76) but also the best sensitivity (0.57) and diagnostic accuracy (0.73), equal that of testosterone (0.54 and 0.73, respectively). Insulin was more sensitive (0.72) than testosterone (0.59) in the obese FH subgroup, but less sensitive (0.27) than testosterone (0.47) in the non-obese FH subgroup. Multiple correlation analysis showed a significant linear relationship (p < 0.0001) between insulin and BMI but no correlation between insulin and the other parameters.(ABSTRACT TRUNCATED AT 250 WORDS)

The independent effects of polycystic ovary syndrome and obesity on serum concentrations of gonadotrophins and sex steroids in premenopausal women

OBJECTIVE

To investigate the basal levels of gonadotrophins and sex steroids, with special reference to the effects of obesity and body fat distribution, in premenopausal women, both those with polycystic ovary syndrome (PCOS) and those with normal ovaries and regular menstrual cycles.

DESIGN

Cross-sectional study. The separate effects of obesity (and body fat distribution and fasting insulin levels) and PCOS on endocrine variables were evaluated by means of analysis of covariance.

PATIENTS

Sixty-seven women with anovulatory menstrual cycles and polycystic ovaries according to ultrasonography and 59 women with normal ovaries and regular cycles, both groups covering a wide range of body mass index (BMI, PCOS, 17.6-37.4, mean 25.7 kg/m2; controls, 18.8-40.9, mean 25.1 kg/m2).

MEASUREMENTS

Serum levels of gonadotrophins, sex steroid hormones, prolactin and GH obtained in the early follicular phase in the controls, fasting insulin levels, anthropometric measures (BMI, skinfolds, waist hip ratio).

RESULTS

Mean serum concentrations of LH, androstenedione, testosterone, the free androgen index (FAI; all P < 0.0001) and DHEAS (P < 0.01) were higher, and serum FSH (P < 0.01) and serum SHBG levels lower (P < 0.0001), in the PCOS group than in the controls. Women with PCOS had a more pronounced upper body fat distribution and higher fasting insulin levels than the controls. Independent of PCOS, BMI was positively associated with serum levels of FSH (P < 0.001) and negatively with levels of LH (P < 0.05), LH/FSH ratio (P < 0.0001), SHBG (P < 0.0001) and androstenedione (P < 0.01), whereas for levels of testosterone, FAI and DHEAS the impact of obesity differed significantly between the groups. Thus, in the PCOS group, testosterone levels (P < 0.05) and the FAI (P < 0.001) were positively associated with BMI, whereas they were constant throughout the entire range of BMI in the controls. DHEAS levels were positively associated with BMI in the PCOS group (P < 0.05) and negatively in the controls (P < 0.01). Measures of upper body fat were related to testosterone and FAI levels, independent of BMI.

CONCLUSIONS

Lower FSH levels were found in women with PCOS than during the early follicular phase of normally ovulating women, suggesting a role in anovulation in PCOS. Obesity itself exerted effects on endocrine variables, with the net result of a reduced LH/FSH ratio and lower serum levels of androstenedione and SHBG in both groups; obesity was associated with increased levels of DHEAS, testosterone and FAI exclusively in the women with PCOS. The results underline the endocrine impact of obesity and body fat distribution and the necessity of applying reference values of BMI matched subjects when establishing the endocrine profile of women with PCOS.

Clinical implications of hyperinsulinaemia in women

In the polycystic ovary syndrome, hyperinsulinaemia is commonly found in women with hirsutism, oligomenorrhoea and acanthosis nigricans and this subset of patients possess adverse risk factors for coronary artery disease, particularly reduced HDL2 concentrations. Conversely, raised serum insulin concentrations are not common in women with PCOS in whom raised serum LH concentrations or regular menstrual cycles are present. We postulate that both direct ovarian and indirect actions of insulin (through changes in IGFI-I, IGFBP-I and SHBG concentrations) play important roles in determining androgen concentrations in women. Many intriguing questions follow from this link between the control of nutrition and reproduction and many old observations required re-examination in this new light. Vital to our understanding in this field will be the cause of moderate hyperinsulinaemia, the action of insulin on the normal ovary, and the importance of adverse surrogate risk factors for heart disease in hyperinsulinaemic women.

Insulin resistance improves in hyperandrogenic women treated with Lupron

OBJECTIVE

To examine if changes in insulin sensitivity and glucose effectiveness in women with polycystic ovarian disease (PCOD) occurred after ovarian androgen suppression with a GnRH agonist, leuprolide acetate (LA, Lupron; TAP Pharmaceuticals, Deerfield, IL) using the minimal model method.

DESIGN

Twelve patients with PCOD were tested in the untreated state (baseline) and after 6 weeks of LA treatment. Subjects were divided into two groups based on the degree of impairment of their baseline insulin sensitivity index (SI; (min-1) (microU/mL-1): mild insulin resistance (SI > 1) or severe insulin resistance (SI < 1).

RESULTS

In all patients, serum T was significantly decreased from elevated baseline levels to normal female concentrations after 6 weeks of LA therapy. Insulin sensitivity in PCOD patients with mild insulin resistance significantly improved from baseline after 6 weeks of LA therapy, whereas no change in SI on LA therapy was seen in PCOD women with severe insulin resistance. Glucose utilization independent of increased insulin secretion did not change as a function of LA treatment in either group.

CONCLUSION

These findings indicate a significant improvement in SI in mildly insulin-resistant women with PCOD after suppression of ovarian function with LA treatment.

Roles of LH and insulin resistance in lean and obese polycystic ovary syndrome

OBJECTIVE

The relationship between insulin resistance and hyperandrogenism led us to study insulin resistance in polycystic ovary syndrome (PCOS) in order to determine its prevalence and pathogenesis.

DESIGN

Blood samples were taken on the 8th day after menses commenced.

PATIENTS

Sixty-one women with PCOS, 30 with normal weight (BMI < 25 kg/m2) (group 1) and 31 with obesity (BMI > 26 kg/m2) (group 2) were studied. They were divided also according to LH level: group A, low or normal LH (n = 23) and group B, high LH (n = 38). Twenty lean control women and 16 obese control women were studied.

MEASUREMENTS

Serum LH, testosterone, free testosterone, dehydroepiandrosterone, sex-hormone binding globulin, androstenedione, and fasting insulin were measured. Insulin sensitivity was explored by the insulin tolerance test (ITT). ITT was performed by bolus i.v. insulin of 0.1 IU/kg. Blood glucose was measured before (-5,0) and after injection (3, 5, 7, 10, 15 minutes). Insulin sensitivity was given by the ratio of glycaemic variation to initial blood glucose (delta G/G index).

RESULTS

delta G/G was correlated with other insulin resistance parameters, particularly fasting insulin r = 0.40, P < 0.01. The PCOS groups had the following insulin resistances (mean +/- SEM) compared to matched groups: delta G/G lean PCOS vs lead controls: 0.45 +/- 0.02 vs 0.61 +/- 0.01, P < 0.001; delta G/G obese PCOS vs obese controls: 0.32 +/- 0.02 vs 0.40 +/- 0.01, P < 0.02. Insulin resistance was higher in group A than in group B: delta G/G 0.29 +/- 0.02 vs 0.45 +/- 0.02, P < 0.001. The prevalence of insulin resistance was 63% in lean PCOS and 51% in obese PCOS. Positive correlations between delta G/G index and LH were found in group 1 and 2, respectively r = 0.45, P < 0.01 and r = 0.55, P < 0.01.

CONCLUSION

PCOS was associated with a significant decrease of insulin sensitivity, independent of obesity. The correlation between LH and insulin sensitivity suggests a complementary action in PCOS.

Serum FSH bioactivity and response to acute gonadotrophin releasing hormone (GnRH) agonist stimulation in patients with polycystic ovary syndrome (PCOS) as compared to control groups

OBJECTIVE

We evaluated the biological activity of FSH in the serum of women with polycystic ovary syndrome before and after acute administration of a GnRH agonist as compared to control groups.

DESIGN

FSH, oestradiol and androstenedione response to buserelin (100 micrograms s.c.) comparing seven polycystic ovary patients, six idiopathic hirsute women, 11 normal women in the follicular phase and nine normal men.

MEASUREMENTS

Rat granulosa cell aromatase bioassay in the presence or absence of polyethyleneglycol (PEG) pretreated 2% serum. Serum biological FSH (B-FSH), immunological FSH (I-FSH) and B/I ratio at times 0, 1, 2, 3, 4, 8, 12 and 24 hours. Serum androstenedione and oestradiol at times 0 and 24 hours.

RESULTS

Human gonadotrophin-free (oral contraceptive user and after FSH immunoabsorption) and PEG-pretreated serum increases the aromatase activity in response to increasing doses of purified FSH. The maximum enzymatic activity is however higher with 2% serum than with 4% serum. The amplitude of the B-FSH response to the GnRH agonist is markedly decreased in the polycystic group as compared to the group of normal women. There is also a small decrease in the I-FSH response in the polycystic women. When compared to that of normal women, the area under the curve in the polycystic ovary patients is reduced by 71% for B-FSH (P < 0.01) and by 23% for I-FSH (P < 0.05). The B-FSH and I-FSH responses in men are very small. After an initial decrease the B/I ratio returns to baseline level in normal women but remains low in the other groups. At time 24 hours, there is no significant change in the serum concentration of androstenedione but serum oestradiol, the baseline of which is significantly higher in the polycystic patients than in normal women, is also significantly higher at 24 hours (P < 0.05) in response to the pharmacological release of FSH.

CONCLUSION

The gonadotrophin-free and PEG-pretreated human serum has an inherent stimulatory effect on the rat granulosa aromatase bioassay with a higher activity at 2% serum. Acute GnRH agonist stimulation reveals a deficiency in the FSH response in polycystic ovary patients. The greater deficit in B-FSH than in I-FSH would indicate a possible modification in the FSH isoforms in this syndrome. The meaning of this observation for the understanding of the physiopathology of the polycystic ovary syndrome remains to be evaluated.

The significance of a single serum LH measurement in women with cycle disturbances: discrepancies between immunoreactive and bioactive hormone estimates

OBJECTIVE

We evaluated the significance of single serum LH estimates (as assessed by radiometric assay (IRMA) and Leydig cell in-vitro bioassay (BIO)) for the diagnosis of polycystic ovary syndrome (PCOS) in women with infertility and cycle abnormalities.

DESIGN

Hormonal and clinical comparisons between subgroups were made based on classification according to (a) rigid clinical and endocrine (excluding LH) characteristics of PCOS, (b) elevated IRMA-LH concentrations, (c) BIO-LH levels. In addition, androgen modulation of LH biopotency was studied in these patients.

PATIENTS

Ninety-nine women presenting at our infertility Unit with oligo/amenorrhoea.

MEASUREMENTS AND RESULTS

Of the total study group, 35 women were diagnosed positive as PCOS and 42 showed elevated IRMA-LH levels. Only 51% (n = 18) of PCOS patients showed elevated IRMA-LH levels, and in PCOS significantly higher levels of BIO-LH, androstenedione, oestrone, and BIO/IRMA-LH ratios were found as compared to non-PCOS patients. In the group with elevated IRMA-LH only 43% (n = 18) of subjects were diagnosed as PCOS, and no difference in BIO/IRMA-LH ratios was found. With increasing BIO-LH levels the probability of PCOS rises sharply (P < 0.001), whereas this probability is of only marginal significance (P < 0.06) for IRMA-LH. In the total study group a correlation is observed between serum testosterone (T) levels and IRMA-LH (r = 0.47), and BIO-LH (r = 0.51) concentrations. This correlation is absent comparing serum T and BIO/IRMA-LH ratios (r = 0.15).

CONCLUSIONS

Results presented in this study indicate that (1) women with infertility and oligo/amenorrhoea classified based on signs of PCOS or IRMA-LH levels, exhibit different clinical and endocrine characteristics, (2) only 51% of PCOS women exhibit elevated IRMA-LH concentrations, and only 43% of women with elevated IRMA-LH were diagnosed as PCOS, (3) IRMA-LH levels are a poor predictor of PCOS, whereas the predictive value of BIO-LH is better, (4) elevated BIO/IRMA-LH ratios in PCOS are dependent on alterations in BIO-LH, rather than IRMA-LH concentrations, and (5) no correlation was observed between serum T levels and BIO/IRMA-LH ratios.

Serum androgen and gonadotropin levels decline after progestogen-induced withdrawal bleeding in oligomenorrheic women with or without polycystic ovaries

OBJECTIVE

To examine the effect of short-term progestogen treatment on androgen, gonadotropin, and sex hormone-binding globulin (SHBG) levels in oligomenorrheic women.

DESIGN

Comparative study of changes in hormonal parameters in patients with or without ultrasonographically diagnosed polycystic ovarian disease (PCOD).

SETTING

Open patient clinic of reproductive endocrinology at University Central Hospital of Turku, Finland.

PATIENTS

Seventy-five oligomenorrheic women with (n = 51) or without (n = 24) PCOD.

MAIN OUTCOME MEASURES

Serum concentrations of testosterone (T), androstenedione (A), dehydroepiandrosterone sulfate, luteinizing hormone (LH), follicle-stimulating hormone (FSH), and SHBG.

RESULTS

The levels of T, A, LH, and the LH:FSH ratios decreased significantly after oral treatment with medroxyprogesterone acetate (10 mg/d for 10 days) in non-PCOD women and in women with PCOD decreasing the frequencies of pathological laboratory findings, in particular elevated levels of LH:FSH ratio and A in PCOD women and of LH:FSH ratio in non-PCOD women. The levels of T, A, and LH as well as the LH:FSH ratio were significantly higher in women with PCOD. Obesity was associated with high free androgen indices, low LH:FSH ratios, and low concentrations of LH, A, and SHBG.

CONCLUSIONS

The serum samples for hormonal analyses used as an aid in diagnosing PCOD should be obtained without pretreatment with progestogen because it masks the biochemical findings of PCOD.

Body weight, hyperinsulinemia, and gonadotropin levels in the polycystic ovarian syndrome: evidence of two distinct populations

OBJECTIVE

To investigate the impact of body weight (BW) and insulin levels on gonadotropin and androgen levels in women with the polycystic ovarian syndrome (PCOS).

DESIGN

Comparative study of endocrinologic parameters in PCOS women.

SETTING

University Hospital Reproductive Endocrinology Unit.

PATIENTS

Thirty obese and 19 nonobese women with PCOS. Seven obese and 7 nonobese normal women.

MAIN OUTCOME MEASURES

Serum concentrations of insulin, testosterone, androstenedione, luteinizing hormone (LH), follicle-stimulating hormone. Serum LH response to gonadotropin-releasing hormone (GnRH) administration and assessment of insulin resistance by the continuous infusion of glucose with model assessment (CIGMA) test.

RESULTS

Fasting insulin levels correlated with body mass index (BMI). Basal LH levels correlated inversely with BMI. Nonobese women with PCOS had a higher LH response to GnRH than obese women with PCOS. Only obese women with PCOS showed insulin resistance and fasting hyperinsulinemia.

CONCLUSIONS

The data suggest that women with PCOS may be divided into two subgroups: those with obesity, insulin resistance, hyperinsulinemia, and normal/minimally elevated LH levels and those with normal BW, elevated LH levels, and normoinsulinemia.