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Liimatta J, du Toit T, Voegel CD, Jääskeläinen J, Lakka TA, Flück CE. Multiple androgen pathways contribute to the steroid signature of adrenarche. Mol Cell Endocrinol 2024; 592:112293. [PMID: 38838762 DOI: 10.1016/j.mce.2024.112293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 05/06/2024] [Accepted: 06/01/2024] [Indexed: 06/07/2024]
Abstract
CONTEXT Adrenarche is a normal developmental event in mid-childhood characterized by increasing adrenal androgen secretion. The role of the classic androgen pathway has been well described in adrenarche, but the role of newer active androgens and additional androgen pathways is less clear. OBJECTIVE To study the contribution of novel androgens and related steroid biosynthesis pathways to the development of adrenarche, and to identify additional steroid biomarkers of adrenarche. DESIGN A longitudinal study of children aged 6-8 years at baseline, followed up at ages 8-10 and 14-16 years. A total of 34 children (20 girls) with clinical and/or biochemical signs of adrenarche (cases) and 24 children (11 girls) without these signs (controls) at age 8-10 years were included. Serum steroid profiling was performed by liquid chromatography high-resolution mass spectrometry. MAIN OUTCOME MEASURES Thirty-two steroids compartmentalized in progestagens, gluco- and mineralocorticoid pathways, and four androgen related pathways, including the classic, backdoor, 11-oxy, and 11-oxy backdoor pathways. RESULTS The classic and 11-oxy androgen pathways were more active, and serum concentrations of main androgens in the classic (dehydroepiandrosterone, dehydroepiandrosterone sulfate, androstenedione and androsterone) and 11-oxy (11β-hydroxyandrostenedione, 11β-hydroxytestosterone, 11-ketoandrostenedione, and 11-ketotestosterone) pathways were higher in cases at ages 6-8 and 8-10 years. Pregnenolone concentrations at adrenarchal age (8-10 years) and cortisol concentrations at adolescence (14-16 years) were higher in cases. 11β-hydroxyandrosterone and 11-ketoandrosterone tended to be higher in cases with clinical signs compared to cases who had only biochemical evidence of adrenarche, albeit they were detected at low levels. In biomarker analyses, calculated steroid ratios with cortisol, cortisone, or 11-deoxycortisone as dividers were better classifiers for adrenarche than single steroids. Among these ratios, androstenedione/cortisone was the best. CONCLUSIONS The classic and 11-oxy androgen pathways are active in adrenarche. Children with earlier timing of adrenarche have higher serum cortisol levels at late pubertal age, suggesting that early adrenarche might have long-term effects on adrenal steroidogenesis by increasing the activity of the glucocorticoid pathway. Future studies should employ comprehensive steroid profiling to define novel classifiers and biomarkers for adrenarche and premature adrenarche.
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Affiliation(s)
- Jani Liimatta
- Pediatric Endocrinology, Diabetology, and Metabolism, Inselspital, Bern University Hospital, Bern, Switzerland; Department of BioMedical Research (DBMR), University of Bern, Bern, Switzerland; Kuopio Pediatric Research Unit (KuPRU), University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland.
| | - Therina du Toit
- Pediatric Endocrinology, Diabetology, and Metabolism, Inselspital, Bern University Hospital, Bern, Switzerland; Department of BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Clarissa D Voegel
- Department of BioMedical Research (DBMR), University of Bern, Bern, Switzerland; Department of Nephrology and Hypertension, Bern University Hospital, Bern, Switzerland
| | - Jarmo Jääskeläinen
- Kuopio Pediatric Research Unit (KuPRU), University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
| | - Timo A Lakka
- Institute of Biomedicine, School of Medicine, University of Eastern Finland, Kuopio, Finland; Department of Clinical Physiology and Nuclear Medicine, Kuopio University Hospital, Kuopio, Finland; Foundation for Research in Health Exercise and Nutrition, Kuopio Research Institute of Exercise Medicine, Kuopio, Finland
| | - Christa E Flück
- Pediatric Endocrinology, Diabetology, and Metabolism, Inselspital, Bern University Hospital, Bern, Switzerland; Department of BioMedical Research (DBMR), University of Bern, Bern, Switzerland.
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Amin M, Horst N, Wu R, Gragnoli C. Novel corticotropin-releasing hormone receptor genes (CRHR1 and CRHR2) linkage to and association with polycystic ovary syndrome. J Ovarian Res 2023; 16:155. [PMID: 37543650 PMCID: PMC10403835 DOI: 10.1186/s13048-023-01159-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 04/10/2023] [Indexed: 08/07/2023] Open
Abstract
BACKGROUND Women with polycystic ovarian syndrome (PCOS) have increased hypothalamic-pituitary-adrenal (HPA) axis activation, pro-inflammatory mediators, and psychological distress in response to stressors. In women with PCOS, the corticotropin-releasing hormone (CRH) induces an exaggerated HPA response, possibly mediated by one of the CRH receptors (CRHR1 or CRHR2). Both CRHR1 and CRHR2 are implicated in insulin secretion, and variants in CRHR1 and CRHR2 genes may predispose to the mental-metabolic risk for PCOS. METHODS We phenotyped 212 Italian families with type 2 diabetes (T2D) for PCOS following the Rotterdam diagnostic criteria. We analyzed within CRHR1 and CRHR2 genes, respectively, 36 and 18 microarray-variants for parametric linkage to and/or linkage disequilibrium (LD) with PCOS under the recessive with complete penetrance (R1) and dominant with complete penetrance (D1) models. Subsequentially, we ran a secondary analysis under the models dominant with incomplete penetrance (D2) and recessive with incomplete penetrance (R2). RESULTS We detected 22 variants in CRHR1 and 1 variant in CRHR2 significantly (p < 0.05) linked to or in LD with PCOS across different inheritance models. CONCLUSIONS This is the first study to report CRHR1 and CRHR2 as novel risk genes in PCOS. In silico analysis predicted that the detected CRHR1 and CRHR2 risk variants promote negative chromatin activation of their related genes in the ovaries, potentially affecting the female cycle and ovulation. However, CRHR1- and CRHR2-risk variants might also lead to hypercortisolism and confer mental-metabolic pleiotropic effects. Functional studies are needed to confirm the pathogenicity of genes and related variants.
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Affiliation(s)
- Mutaz Amin
- INSERM, US14-Orphanet, 75014, Paris, France
- Department of Biochemistry and Molecular Biology, Faculty of Medicine, Al-Neelain University, Khartoum, Sudan, 11121
| | - Nicholas Horst
- Division of Endocrinology, Department of Medicine, Creighton University School of Medicine, Omaha, NE, 68124, USA
| | - Rongling Wu
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, 17033, USA
- Department of Statistics, Penn State College of Medicine, Hershey, PA, 17033, USA
| | - Claudia Gragnoli
- Division of Endocrinology, Department of Medicine, Creighton University School of Medicine, Omaha, NE, 68124, USA.
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, 17033, USA.
- Molecular Biology Laboratory, Bios Biotech Multi-Diagnostic Health Center, 00197, Rome, Italy.
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Marschalek ML, Marculescu R, Schneeberger C, Marschalek J, Dewailly D, Ott J. A case-control study about markers of stress in normal-/overweight women with polycystic ovary syndrome and in controls. Front Endocrinol (Lausanne) 2023; 14:1173422. [PMID: 37265693 PMCID: PMC10231031 DOI: 10.3389/fendo.2023.1173422] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/02/2023] [Indexed: 06/03/2023] Open
Abstract
Background Polycystic ovary syndrome (PCOS) is linked to an elevated risk of psychological disorders, decreased quality of life and emotional distress. Serum cortisol as a potential stress marker has been found to be increased in women with PCOS. The aim of this study was to evaluate both saliva stress markers and subjective psychological distress in women with PCOS. Methods In a prospective case-control study, 31 PCOS women and 31 healthy controls were included. Salivary cortisol, and metanephrines were collected in the morning and in the evening. Emotional distress and quality of life were assessed by means of the Perceived Stress Scale (PSS-10) and the Short Form-36 (SF-36). Multivariable generalized linear models were applied to test the influence of various parameters on numerical outcome parameters. Results After correction for age and body mass index (BMI), there were no statistically significant differences of salivary biomarkers between PCOS women and healthy controls (p>0.05). PCOS patients revealed significantly higher increased PSS total scores and lower quality of life in all SF-36 modules apart from pain (p< 0.05). The PSS total score was positively correlated to prolactin in PCOS women (r= 0.450; p= 0.011). In overweight/obese PCOS patients, a higher BMI, a higher Ferriman Gallwey score and higher age significantly predicted the PSS total score (p< 0.05). Conclusion Stress measured by salivary biomarkers did not differ between PCOS women and healthy controls, whereas stress scores evaluated by questionnaires were significantly greater in women with PCOS. A higher BMI, hirsutism and a higher age seem to be the main modulators of subjective stress in PCOS. Prolactin might serve as a biomarker for chronic stress in PCOS women.
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Affiliation(s)
- Marie-Louise Marschalek
- Clinical Division of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Vienna, Vienna, Austria
| | - Rodrig Marculescu
- Department of Laboratory Medicine and Institute of Immunology, Medical University Vienna, Vienna, Austria
| | - Christian Schneeberger
- Clinical Division of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Vienna, Vienna, Austria
| | - Julian Marschalek
- Clinical Division of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Johannes Ott
- Clinical Division of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Vienna, Vienna, Austria
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Phylactou M, Clarke SA, Patel B, Baggaley C, Jayasena CN, Kelsey TW, Comninos AN, Dhillo WS, Abbara A. Clinical and biochemical discriminants between functional hypothalamic amenorrhoea (FHA) and polycystic ovary syndrome (PCOS). Clin Endocrinol (Oxf) 2021; 95:239-252. [PMID: 33354766 DOI: 10.1111/cen.14402] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 12/15/2020] [Accepted: 12/16/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Secondary oligo/amenorrhoea occurs in 3%-5% of women of reproductive age. The two most common causes are polycystic ovary syndrome (PCOS) (2%-13%) and functional hypothalamic amenorrhoea (FHA) (1%-2%). Whilst both conditions have distinct pathophysiology and their diagnosis is supported by guidelines, in practice, differentiating these two common causes of menstrual disturbance is challenging. Moreover, both diagnoses are qualified by the need to first exclude other causes of menstrual disturbance. AIM To review clinical, biochemical and radiological parameters that could aid the clinician in distinguishing PCOS and FHA as a cause of menstrual disturbance. RESULTS FHA is uncommon in women with BMI > 24 kg/m2 , whereas both PCOS and FHA can occur in women with lower BMIs. AMH levels are markedly elevated in PCOS; however, milder increases may also be observed in FHA. Likewise, polycystic ovarian morphology (PCOM) is more frequently observed in FHA than in healthy women. Features that are differentially altered between PCOS and FHA include LH, androgen, insulin, AMH and SHBG levels, endometrial thickness and cortisol response to CRH. Other promising diagnostic tests with the potential to distinguish these two conditions pending further study include assessment of 5-alpha-reductase activity, leptin, INSL3, kisspeptin and inhibin B levels. CONCLUSION Further data directly comparing the discriminatory potential of these markers to differentiate PCOS and FHA in women with secondary amenorrhoea would be of value in defining an objective probability for PCOS or FHA diagnosis.
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Affiliation(s)
- Maria Phylactou
- Section of Endocrinology and Investigative Medicine, Hammersmith Hospital, Imperial College London, London, UK
| | - Sophie A Clarke
- Section of Endocrinology and Investigative Medicine, Hammersmith Hospital, Imperial College London, London, UK
| | - Bijal Patel
- Section of Endocrinology and Investigative Medicine, Hammersmith Hospital, Imperial College London, London, UK
| | - Caitlin Baggaley
- Section of Endocrinology and Investigative Medicine, Hammersmith Hospital, Imperial College London, London, UK
| | - Channa N Jayasena
- Section of Endocrinology and Investigative Medicine, Hammersmith Hospital, Imperial College London, London, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Tom W Kelsey
- School of Computer Science, University of St Andrews, St Andrews, UK
| | - Alexander N Comninos
- Section of Endocrinology and Investigative Medicine, Hammersmith Hospital, Imperial College London, London, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Waljit S Dhillo
- Section of Endocrinology and Investigative Medicine, Hammersmith Hospital, Imperial College London, London, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Ali Abbara
- Section of Endocrinology and Investigative Medicine, Hammersmith Hospital, Imperial College London, London, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
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Evaluation of the relationship between serum ferritin and insulin resistance and visceral adiposity index (VAI) in women with polycystic ovary syndrome. Eat Weight Disord 2021; 26:1581-1593. [PMID: 32772321 DOI: 10.1007/s40519-020-00980-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 07/30/2020] [Indexed: 01/08/2023] Open
Abstract
PURPOSE There is a relationship between polycystic ovary syndrome (PCOS) and adipose tissue dysfunction (ADD), but this relationship is not clear. It has been recently shown that iron accumulation in adipose tissue is among the causes of adipose tissue dysfunction. Data on adipose tissue dysfunction in women with PCOS are insufficient. In this study, we aimed to evaluate the relationship between serum ferritin levels (iron accumulation biomarker) and visceral adiposity index (an indicator of adipose tissue dysfunction). METHODS The study is a case-control study. Women with diagnosed PCOS with 2003 Rotterdam Diagnostic Criteria (n = 40) were compared with non-PCOS group (n = 40). In this study, the cholesterol ratios, the homeostatic model evaluation index for insulin resistance (HOMA-IR) and the quantitative insulin sensitivity control index were calculated using biochemical parameters, and the visceral adiposity index (VAI) and the lipid accumulation product (LAP) were calculated using both anthropometric and biochemical parameters. In this study, insulin resistance was evaluated by HOMA-IR and adipose tissue dysfunction was evaluated by VAI index. RESULTS According to the results of this study, women with PCOS have a worse metabolic status than women without PCOS. However, this has been shown only in overweight and obese women, not in women with normal weight. CONCLUSION As a result, the presence of obesity in women with PCOS exacerbates metabolic status. LEVEL OF EVIDENCE Level V, cross-sectional descriptive study.
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Peecher DL, Binder AK, Gabriel KI. Rodent models of mental illness in polycystic ovary syndrome: the potential role of hypothalamic-pituitary-adrenal dysregulation and lessons for behavioral researchers. Biol Reprod 2019; 100:590-600. [PMID: 30388193 DOI: 10.1093/biolre/ioy233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 10/04/2018] [Accepted: 10/31/2018] [Indexed: 12/20/2022] Open
Abstract
Polycystic ovary syndrome (PCOS) is the most commonly diagnosed endocrine disorder in women of reproductive age, with phenotypes including ovarian and metabolic dysfunctions. Women with PCOS also show increased rates of mental illness, dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, and altered responsiveness to stressors that may contribute to the higher rates of mental illness, specifically depression and anxiety. Animal models of PCOS have provided insight into the ovarian and metabolic mechanisms that underlie the syndrome, and several models have been used to study the behavioral consequences associated with PCOS in the laboratory. Several studies in rodent models of PCOS demonstrate changes in anxiety-like behavior, but researchers often neglect to report procedural details or behavioral data crucial to interpreting the differences observed in those studies. Additionally, the impact of potential HPA dysregulation in animal models of PCOS may influence behavioral findings, although only three studies to date have examined this. As such, researchers should consider and report stress-associated variables (e.g., time of day, light/dark cycle, light intensity, housing, and procedures to control experimenter and litter effects) that may influence depression- and anxiety-like behaviors in rodents. This review will summarize the behavioral and HPA-related studies in women with PCOS and rodent models of the disease, and provide considerations for future studies.
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Affiliation(s)
- Danielle L Peecher
- Department of Psychology, Central Washington University, Ellensburg, Washington, USA.,Center for Reproductive Biology, Washington State University, Pullman, Washington, USA
| | - April K Binder
- Center for Reproductive Biology, Washington State University, Pullman, Washington, USA.,Department of Biological Sciences, Central Washington University, Ellensburg, Washington, USA
| | - Kara I Gabriel
- Department of Psychology, Central Washington University, Ellensburg, Washington, USA
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Zangeneh FZ, Naghizadeh MM, Bagheri M, Jafarabadi M. Are CRH & NGF as psychoneuroimmune regulators in women with polycystic ovary syndrome? Gynecol Endocrinol 2017; 33:227-233. [PMID: 27908212 DOI: 10.1080/09513590.2016.1250152] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
PURPOSE Polycystic ovary syndrome (PCOS) affects quality of life and can worsen anxiety and depression either due to the features of PCOS or due to the diagnosis of a chronic disease. Corticotrophin-releasing hormone (CRH) and nerves growth factor (NGF) are the modulator for the actions of the sympathetic nervous and immune systems. METHODS In total, 171 women divided into two groups: study and control groups. Serum CRH, NGF, and interleukins: IL-1α. IL-1β, 17A, and TNFα were determined by ELISA Kits in both groups. RESULTS The results showed that IL-1α (p < 0.001) and β (p = 0.017) significantly increased in PCO group. CRH, NGF, and IL-17α in serum of patients with PCO significantly lower than the control group (p < 0.001). The results of this study indicate: (1) destruction of three cytokines pattern, (2) Reduction of CRH, NGF, and IL-17α in serum of PCO patients can be under the direct influence of the sympathetic nervous system (SAS), and (3) reduction of CRH and NGFα can be reason of psych/emotional distress in women with PCOS. CONCLUSIONS The results of this study confirm (1) low-grade chronic inflammation in PCOS. This impaired cytokine pattern can play a major role in the immune-pathogenesis of PCOS; (2) hyponeurotrophinemia and reduction of CRH in women with PCOS could reflect deficit of neuronal stress-adaptation in these patients.
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Affiliation(s)
- F Z Zangeneh
- a Reproductive Health Research Center, Tehran University of Medical Sciences , Tehran , Iran and
| | - M M Naghizadeh
- b Department of Community Medicine , Medical Faculty, Fasa University of Medical Sciences , Fasa , Iran
| | - M Bagheri
- a Reproductive Health Research Center, Tehran University of Medical Sciences , Tehran , Iran and
| | - M Jafarabadi
- a Reproductive Health Research Center, Tehran University of Medical Sciences , Tehran , Iran and
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MicroRNAs related to androgen metabolism and polycystic ovary syndrome. Chem Biol Interact 2016; 259:8-16. [PMID: 27270454 DOI: 10.1016/j.cbi.2016.06.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Revised: 05/25/2016] [Accepted: 06/03/2016] [Indexed: 01/14/2023]
Abstract
Polycystic ovary syndrome (PCOS) is a frequent endocrine disorder in women. PCOS is associated with altered features of androgen metabolism, increased insulin resistance and impaired fertility. Furthermore, PCOS, being a syndrome diagnosis, is heterogeneous and characterized by polycystic ovaries, chronic anovulation and evidence of hyperandrogenism, as well as being associated with chronic low-grade inflammation and an increased life time risk of type 2 diabetes. A number of androgen species contribute to the symptoms of increased androgen exposure seen in many, though not all, cases of PCOS: Testosterone, androstenedione, dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulfate (DHEAS), where the quantitatively highest amount of androgen is found as DHEAS. The sulfation of DHEA to DHEAS depends on a number of enzymes, and altered sulfate metabolism may be associated with and contribute to the pathogenesis of PCOS. MicroRNAs (miRNAs) are small, non-coding RNAs that are able to regulate gene expression at the post-transcriptional level. Altered miRNA levels have been associated with diabetes, insulin resistance, inflammation and various cancers. Studies have shown that circulating miRNAs are present in whole blood, serum, plasma and the follicular fluid of PCOS patients and that these might serve as potential biomarkers and a new approach for the diagnosis of PCOS. In this review, recent work on miRNAs with respect to PCOS will be summarized. Our understanding of miRNAs, particularly in relation to PCOS, is currently at a very early stage, and additional studies will yield important insight into the molecular mechanisms behind this complex and heterogenic syndrome.
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Unlu E, Unlu B, Yildiz Y, Beker-Acay M, Kacar E, Turamanlar O, Tulmac O, Seven A, Ozuguz U. Adrenal gland volume assessed by magnetic resonance imaging in women with polycystic ovary syndrome. Diagn Interv Imaging 2016; 97:57-63. [DOI: 10.1016/j.diii.2015.02.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 02/10/2015] [Accepted: 02/11/2015] [Indexed: 11/27/2022]
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Blay SL, Aguiar JVA, Passos IC. Polycystic ovary syndrome and mental disorders: a systematic review and exploratory meta-analysis. Neuropsychiatr Dis Treat 2016; 12:2895-2903. [PMID: 27877043 PMCID: PMC5108561 DOI: 10.2147/ndt.s91700] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND The association between depression, anxiety, and polycystic ovary syndrome (PCOS) is still unclear. Therefore, a systematic review and meta-analysis was conducted to assess the rates of comorbid psychiatric disorders among women with PCOS compared to women without it. METHODS PubMed/MEDLINE, Embase, PsycINFO, and Web of Science databases were searched from inception to November 27, 2015. Studies were eligible for inclusion if they were original reports in which the rates of mood (bipolar disorder, dysthymia, or major depressive disorder), obsessive-compulsive spectrum disorders, trauma- and stressor-related disorders, anxiety disorders or psychotic disorders, somatic symptom and related disorders, or eating disorders had been investigated among women with an established diagnosis of PCOS and compared with women without PCOS. Psychiatric diagnosis should have been established by means of a structured diagnostic interview or through a validated screening tool. Data were extracted and pooled using random effects models. RESULTS Six studies were included in the meta-analysis; of these, five reported the rates of anxiety and six provided data on the rates of depression. The rate of subjects with anxiety symptoms was higher in patients with PCOS compared to women without PCOS (odds ratio (OR) =2.76; 95% confidence interval (CI) 1.26 to 6.02; Log OR =1.013; P=0.011). The rate of subjects with depressive symptoms was higher in patients with PCOS compared to women without PCOS (OR =3.51; 95% CI 1.97 to 6.24; Log OR =1.255; P<0.001). CONCLUSION Anxiety and depression symptoms are more prevalent in patients with PCOS.
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Affiliation(s)
- Sergio Luís Blay
- Department of Psychiatry, Federal University of São Paulo (Escola Paulista de Medicina - UNIFESP), São Paulo, SP, Brazil
| | | | - Ives Cavalcante Passos
- Laboratory of Molecular Psychiatry and Department of Psychiatry, Federal University of Rio Grande do Sul, Rio Grande do Sul, Brazil
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Goodarzi MO, Carmina E, Azziz R. DHEA, DHEAS and PCOS. J Steroid Biochem Mol Biol 2015; 145:213-25. [PMID: 25008465 DOI: 10.1016/j.jsbmb.2014.06.003] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 05/16/2014] [Accepted: 06/05/2014] [Indexed: 11/17/2022]
Abstract
Approximately 20-30% of PCOS women demonstrate excess adrenal precursor androgen (APA) production, primarily using DHEAS as a marker of APA in general and more specifically DHEA, synthesis. The role of APA excess in determining or causing PCOS is unclear, although observations in patients with inherited APA excess (e.g., patients with 21-hydroxylase deficient congenital classic or non-classic adrenal hyperplasia) demonstrate that APA excess can result in a PCOS-like phenotype. Inherited defects of the enzymes responsible for steroid biosynthesis, or defects in cortisol metabolism, account for only a very small fraction of women suffering from hyperandrogenism or APA excess. Rather, women with PCOS and APA excess appear to have a generalized exaggeration in adrenal steroidogenesis in response to ACTH stimulation, although they do not have an overt hypothalamic-pituitary-adrenal axis dysfunction. In general, extra-adrenal factors, including obesity, insulin and glucose levels, and ovarian secretions, play a limited role in the increased APA production observed in PCOS. Substantial heritabilities of APAs, particularly DHEAS, have been found in the general population and in women with PCOS; however, the handful of SNPs discovered to date account only for a small portion of the inheritance of these traits. Paradoxically, and as in men, elevated levels of DHEAS appear to be protective against cardiovascular risk in women, although the role of DHEAS in modulating this risk in women with PCOS remains unknown. In summary, the exact cause of APA excess in PCOS remains unclear, although it may reflect a generalized and inherited exaggeration in androgen biosynthesis of an inherited nature.
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Affiliation(s)
| | | | - Ricardo Azziz
- Georgia Regents University, Office of the President, 120 15th St., AA 311, Augusta, GA 30912, USA.
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Tock L, Carneiro G, Pereira AZ, Tufik S, Zanella MT. Adrenocortical production is associated with higher levels of luteinizing hormone in nonobese women with polycystic ovary syndrome. Int J Endocrinol 2014; 2014:620605. [PMID: 24895496 PMCID: PMC4033536 DOI: 10.1155/2014/620605] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Accepted: 04/16/2014] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Luciana Tock
- Division of Endocrinology, Department of Medicine, Universidade Federal de São Paulo, São Paulo, SP, Brazil
- *Luciana Tock:
| | - Gláucia Carneiro
- Division of Endocrinology, Department of Medicine, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Andrea Z. Pereira
- Division of Endocrinology, Department of Medicine, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Sérgio Tufik
- Department of Psychobiology, Sleep Disorders Center, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Maria Teresa Zanella
- Division of Endocrinology, Department of Medicine, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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Abstract
Adrenal steroidogenesis is under the control of the hypothalamic-pituitary-adrenal (HPA) axis. Furthermore, metabolic factors including insulin and obesity-related signals may play a role in the regulation of both enzymes involved in the steroidogenetic pathways, as well as in the regulation of the HPA axis. In women with the polycystic ovary syndrome (PCOS), cortisol production rate is probably normal, although adrenal androgens can be overproduced in a subset of affected women. Cortisol metabolism and regeneration from inactive glucocorticoids can also be disrupted in PCOS, thereby contributing to determining an adrenal hyperandrogenic state. Finally, overactivity of the HPA axis may be related to the high prevalence of psychopathological and eating disorders in women with PCOS, implying a maladaptive allostatic load in the adaptive mechanisms to chronic stress exposure.
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Affiliation(s)
- Renato Pasquali
- b Division of Endocrinology, Department of Clinical Medicine, University Alma Mater Studiorum, St. Orsola-Malpighi Hospital, Via Massarenti 9, 40138, Bologna, Italy.
| | - Alessandra Gambineri
- a Division of Endocrinology, Department of Clinical Medicine, University Alma Mater Studiorum, St. Orsola-Malpighi Hospital, Via Massarenti 9, 40138, Bologna, Italy
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Katsikis I, Karkanaki A, Misichronis G, Delkos D, Kandaraki EA, Panidis D. Phenotypic expression, body mass index and insulin resistance in relation to LH levels in women with polycystic ovary syndrome. Eur J Obstet Gynecol Reprod Biol 2011; 156:181-5. [DOI: 10.1016/j.ejogrb.2011.01.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2010] [Revised: 01/06/2011] [Accepted: 01/25/2011] [Indexed: 10/18/2022]
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Markopoulos MC, Rizos D, Valsamakis G, Deligeoroglou E, Grigoriou O, Chrousos GP, Creatsas G, Mastorakos G. Hyperandrogenism in women with polycystic ovary syndrome persists after menopause. J Clin Endocrinol Metab 2011; 96:623-31. [PMID: 21177795 DOI: 10.1210/jc.2010-0130] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
CONTEXT Ovarian and adrenal hyperandrogenism characterize premenopausal women with polycystic ovary syndrome (PCOS). Androgens decline with age in healthy and PCOS women. OBJECTIVE The objective of the study was to investigate hyperandrogenism in PCOS after menopause. DESIGN This was a case-control, cross-sectional study. SETTING The study was conducted at a university hospital endocrinology unit. PATIENTS Twenty postmenopausal women with PCOS and 20 age- and body mass index-matched controls participated in the study. INTERVENTIONS Serum cortisol, 17-hydroxyprogesterone (17-OHP), Δ(4)-androstenedione (Δ(4)A), dehydroepiandrosterone sulfate (DHEAS), total testosterone (T), and free androgen index (FAI) levels were measured at baseline, after ACTH stimulation, and after 3-d dexamethasone suppression. The ACTH and cortisol levels were measured during the CRH test. MAIN OUTCOME MEASURES Androgen profile at baseline, after ACTH stimulation, and 3-d dexamethasone suppression tests were the main outcome measures. RESULTS Postmenopausal PCOS women had higher 17-OHP, Δ(4)A, DHEAS, total T, FAI (P < 0.05) and lower SHBG (P < 0.05) baseline levels than control women. ACTH and cortisol responses during the CRH test were similar in the two groups. After ACTH stimulation, Δ(4)A, DHEAS, and total T levels were equally increased in both groups. After dexamethasone suppression, LH levels did not change in either group; 17-OHP-, Δ(4)A-, and FAI-suppressed levels remained higher in PCOS than in control women (P < 0.05), whereas total T and DHEAS levels were suppressed to similar values in both groups. CONCLUSIONS In postmenopausal PCOS women, ACTH and cortisol responses to CRH are normal. Androgen levels at baseline are higher in PCOS than control women and remain increased after ACTH stimulation. The dexamethasone suppression results in postmenopausal PCOS women suggest that DHEAS and total T are partially of adrenal origin. Although the ovarian contribution was not fully assessed, increased Δ(4)A production suggests that the ovary also contributes to hyperandrogenism in postmenopausal PCOS women. In conclusion, postmenopausal PCOS women are exposed to higher adrenal and ovarian androgen levels than non-PCOS women.
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Affiliation(s)
- Marios C Markopoulos
- Second Department of Obstetrics and Gynecology, Athens University Medical School, Aretaieion Hospital, Athens 11528, Greece
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Insulin resistance, obesity, inflammation, and depression in polycystic ovary syndrome: biobehavioral mechanisms and interventions. Fertil Steril 2010; 94:1565-74. [PMID: 20471009 DOI: 10.1016/j.fertnstert.2010.03.081] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2009] [Accepted: 03/30/2010] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To summarize physiological and psychological characteristics that are common among women diagnosed with polycystic ovary syndrome (PCOS) and provide evidence suggesting that addressing psychological disturbances can reduce or alleviate physical symptoms of PCOS through behavioral pathways and physiological pathways. METHOD(S) Empirical studies and expert consensuses pertaining to physiological, psychological, and medical management aspects of PCOS were identified and presented in this review. Articles were identified by searching Pubmed, PsycInfo, Medline ISI, CINAHL, or a Web browser (i.e., Google) using numerous combinations of terms pertaining to physiological, psychological, and medical management aspects of PCOS. An article was chosen to be included in this review if it reported findings and/or provided information that related to and helped support the main purpose(s) of this review article. RESULT(S) Available literature on the physiological (i.e., hyperandrogenism, central obesity, inflammation, insulin resistance) and psychological (i.e., depression, anxiety, eating disorders) factors among women with PCOS provides evidence that these various aspects of PCOS are strongly interrelated. CONCLUSION(S) The existence of these relationships among physiological and psychological factors strongly suggests that medical management of PCOS would greatly benefit from inclusion of psychological and behavioral approaches.
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Feng Y, Johansson J, Shao R, Mannerås L, Fernandez-Rodriguez J, Billig H, Stener-Victorin E. Hypothalamic neuroendocrine functions in rats with dihydrotestosterone-induced polycystic ovary syndrome: effects of low-frequency electro-acupuncture. PLoS One 2009; 4:e6638. [PMID: 19680559 PMCID: PMC2722078 DOI: 10.1371/journal.pone.0006638] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2009] [Accepted: 07/07/2009] [Indexed: 11/27/2022] Open
Abstract
Adult female rats continuously exposed to androgens from prepuberty have reproductive and metabolic features of polycystic ovary syndrome (PCOS). We investigated whether such exposure adversely affects estrous cyclicity and the expression and distribution of gonadotropin-releasing hormone (GnRH), GnRH receptors, and corticotrophin-releasing hormone (CRH) in the hypothalamus and whether the effects are mediated by the androgen receptor (AR). We also assessed the effect of low-frequency electro-acupuncture (EA) on those variables. At 21 days of age, rats were randomly divided into three groups (control, PCOS, and PCOS EA; n = 12/group) and implanted subcutaneously with 90-day continuous-release pellets containing vehicle or 5alpha-dihydrostestosterone (DHT). From age 70 days, PCOS EA rats received 2-Hz EA (evoking muscle twitches) five times/week for 4-5 weeks. Hypothalamic protein expression was measured by immunohistochemistry and western blot. DHT-treated rats were acyclic, but controls had regular estrous cycles. In PCOS rats, hypothalamic medial preoptic AR protein expression and the number of AR- and GnRH-immunoreactive cells were increased, but CRH was not affected; however, GnRH receptor expression was decreased in both the pituitary and hypothalamus. Low-frequency EA restored estrous cyclicity within 1 week and reduced the elevated hypothalamic GnRH and AR expression levels. EA did not affect GnRH receptor or CRH expression. Interestingly, nuclear AR co-localized with GnRH in the hypothalamus. Thus, rats with DHT-induced PCOS have disrupted estrous cyclicity and an increased number of hypothalamic cells expressing GnRH, most likely mediated by AR activation. Repeated low-frequency EA normalized estrous cyclicity and restored GnRH and AR protein expression. These results may help explain the beneficial neuroendocrine effects of low-frequency EA in women with PCOS.
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Affiliation(s)
- Yi Feng
- Institute of Neuroscience and Physiology, Department of Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Neurobiology and Integrative Medicine, Shanghai Medical College of Fudan University, Shanghai, China
| | - Julia Johansson
- Institute of Neuroscience and Physiology, Department of Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ruijin Shao
- Institute of Neuroscience and Physiology, Department of Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Louise Mannerås
- Institute of Neuroscience and Physiology, Department of Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Julia Fernandez-Rodriguez
- Centre for Cellular Imaging, Core Facilities, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Håkan Billig
- Institute of Neuroscience and Physiology, Department of Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Elisabet Stener-Victorin
- Institute of Neuroscience and Physiology, Department of Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Disturbed stress responses in women with polycystic ovary syndrome. Psychoneuroendocrinology 2009; 34:727-35. [PMID: 19150179 DOI: 10.1016/j.psyneuen.2008.12.001] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2008] [Revised: 12/05/2008] [Accepted: 12/05/2008] [Indexed: 11/20/2022]
Abstract
BACKGROUND We analyzed the neuroendocrine and immune cell responses to psychosocial stress in PCOS patients compared to BMI-matched healthy controls. METHODS Responses to public speaking stress were analyzed in 32 PCOS patients and 32 BMI-matched healthy controls. At baseline, during, and 10- and 45-min after stress, state anxiety, cardiovascular responses, cortisol, ACTH, as well as circulating leukocyte subpopulations were analyzed, together with hsCRP and serum IL-6 concentrations. RESULTS In response to public speaking stress, both groups showed significant but comparable increases in state anxiety, and blood pressure (all p<0.001; time effects). The ACTH and cortisol stress responses were significantly enhanced in PCOS (both p<0.05; interaction effect). In addition, heart rate was significantly higher in PCOS (p<0.05; group effect). PCOS patients displayed a reduced upregulation of IL-6 levels in response to stress (p<0.05; interaction effect). Baseline levels of circulating leukocyte subpopulations, IL-6 and hsCRP concentrations did not differ between BMI-matched controls and PCOS patients. PCOS patients were characterized by markedly increased psychological distress. CONCLUSIONS PCOS patients showed enhanced HPA-axis and heart rate reactivity as well as a reduced upregulation of IL-6 in response to stress. The altered stress reactivity in PCOS patients may constitute a link between depression, overweight, and the cardiovascular and diabetes risks associated with the diagnosis.
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Puurunen J, Piltonen T, Jaakkola P, Ruokonen A, Morin-Papunen L, Tapanainen JS. Adrenal androgen production capacity remains high up to menopause in women with polycystic ovary syndrome. J Clin Endocrinol Metab 2009; 94:1973-8. [PMID: 19318449 DOI: 10.1210/jc.2008-2583] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Hyperandrogenism is one of the main features of polycystic ovary syndrome (PCOS). Of circulating androgens, 50% of androstenedione and testosterone are of ovarian and adrenal origin, whereas dehydroepiandrosterone (DHEA) and DHEA sulfate are almost uniquely of adrenal origin. Our previous studies have indicated that ovarian androgen production capacity is enhanced in women with PCOS, and it remains high until late reproductive age. To study whether this also applies to adrenal androgen production, ACTH tests were performed in healthy women and in women with PCOS. MATERIALS Sixty-nine healthy women (aged 19-62 yr; body mass index 19.2-35.0 kg/m2) and 58 women with previously diagnosed PCOS (aged 18-59 yr; body mass index 19.0-42.9 kg/m2) participated in the study. METHODS The subjects underwent ACTH stimulation tests, and serum cortisol, 17-hydroxyprogesterone, androstenedione, testosterone, DHEA, and DHEA sulfate levels were analyzed at 0, 30, and 60 min. RESULTS Basal and ACTH-stimulated levels of most adrenal androgens decreased in healthy women with age, whereas in women with PCOS, only the concentrations of basal serum 17-hydroxyprogesterone decreased, and all areas under the curve (AUCs) remained unchanged and significantly higher (except for DHEA) than those in control women. Likewise, at the menopausal transition, pre- and postmenopausal women with PCOS exhibited mainly unchanged and higher basal androgen and AUC levels. CONCLUSIONS Similarly to ovarian endocrine function, serum adrenal steroid levels and adrenal steroid production capacity remain enhanced at least up to menopause in women with PCOS.
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Affiliation(s)
- Johanna Puurunen
- Department of Obstetrics and Gynecology, Oulu University Hospital, Oulu FIN-90014, Finland
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20
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Abbott DH, Bird IM. Nonhuman primates as models for human adrenal androgen production: function and dysfunction. Rev Endocr Metab Disord 2009; 10:33-42. [PMID: 18683055 PMCID: PMC2653599 DOI: 10.1007/s11154-008-9099-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The origin of circulating DHEA and adrenal-derived androgens in humans and nonhuman primates is largely distinct from other mammalian species. In humans and many Old world primates, the fetal adrenal gland and adult zona reticularis (ZR) are known to be the source for production of DHEA (and DHEAS) in mg quantities. In spite of similarities there are also some differences. Herein, we take a comparative endocrine approach to the diversity of adrenal androgen biosynthesis and its developmental timing in three primate species to illustrate how understanding such differences may provide unique insight into mechanisms underlying adrenal androgen regulation and its pathophysiology in humans. We contrast the conventional developmental onset of adrenal DHEA biosynthesis at adrenarche in humans with (1) an earlier, peri-partutrition onset of adrenal DHEA synthesis in rhesus macaques (Old World primate) and (2) a more dynamic and reversible onset of adrenal DHEA biosynthesis in female marmosets (New World primate), and further consider these events in terms of the corresponding developmental changes in expression of CYP17, HSD3B2 and CYB5 in the ZR. We also integrate these observations with recently described biochemical characterization of CYP17 cDNA cloned from each of these nonhuman primate species and the corresponding effects of phosphorylation versus CYB5 coexpression on 17,20 lyase versus 17-hydroxylase activity in each case. In addition, female rhesus macaques exposed in utero to exogenous androgen excess, exhibit symptoms of adrenal hyperandrogenism in adult females in a manner reminiscent of that seen in the human condition of PCOS. The possible mechanisms underlying such adrenal hyperandrogenism are further considered in terms of the effects of altered relative expression of CYP17, HSD3B2 and CYB5 as well as the altered signaling responses of various kinases including protein kinase A, or the insulin sensitive PI3-kinase/AKT signaling pathway which may impact on 17,20 lyase activity. We conclude that while the triggers for the onset of ZR function in all three species show clear differences (age, stage of development, social status, gender), there are still common mechanisms driving an increase in DHEA biosynthesis in each case. A full understanding of the mechanisms that control 17,20 lyase function and dysfunction in humans may best be achieved by comparative studies of the endocrine mechanisms controlling adrenal ZR function and dysfunction in these nonhuman primate species.
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Affiliation(s)
- D H Abbott
- Wisconsin National Primate Research Center, University of Wisconsin, Madison, WI 53715, USA
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Abbott DH, Zhou R, Bird IM, Dumesic DA, Conley AJ. Fetal programming of adrenal androgen excess: lessons from a nonhuman primate model of polycystic ovary syndrome. ENDOCRINE DEVELOPMENT 2008; 13:145-158. [PMID: 18493139 PMCID: PMC2531212 DOI: 10.1159/000134831] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Adrenal androgen excess is found in adult female rhesus monkeys previously exposed to androgen treatment during early gestation. In adulthood, such prenatally androgenized female monkeys exhibit elevated basal circulating levels of dehydroepiandrosterone sulfate (DHEAS), typical of polycystic ovary syndrome (PCOS) women with adrenal androgen excess. Further androgen and glucocorticoid abnormalities in PA female monkeys are revealed by acute ACTH stimulation: DHEA, androstenedione and corticosterone responses are all elevated compared to responses in controls. Pioglitazone treatment, however, diminishes circulating DHEAS responses to ACTH in both prenatally androgenized and control female monkeys, while increasing the 17-hydroxyprogesterone response and reducing the DHEA to 17-hydroxyprogesterone ratio. Since 60-min post-ACTH serum values for 17-hydroxyprogesterone correlate negatively with basal serum insulin levels (all female monkeys on pioglitazone and placebo treatment combined), while similar DHEAS values correlate positively with basal serum insulin levels, circulating insulin levels may preferentially support adrenal androgen biosynthesis in both prenatally androgenized and control female rhesus monkeys. Overall, our findings suggest that differentiation of the monkey adrenal cortex in a hyperandrogenic fetal environment may permanently upregulate adult adrenal androgen biosynthesis through specific elevation of 17,20-lyase activity in the zona fasciculata-reticularis. As adult prenatally androgenized female rhesus monkeys closely emulate PCOS-like symptoms, excess fetal androgen programming may contribute to adult adrenal androgen excess in women with PCOS.
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Affiliation(s)
- David H Abbott
- Department of Obstetrics and Gynecology, Wisconsin National Primate Research Center and Endocrinology-Reproductive Physiology Training Program, University of Wisconsin, Madison, Wisc., USA
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Abstract
Polycystic ovary syndrome is a heterogeneous endocrine disorder that affects about one in 15 women worldwide. The major endocrine disruption is excessive androgen secretion or activity, and a large proportion of women also have abnormal insulin activity. Many body systems are affected in polycystic ovary syndrome, resulting in several health complications, including menstrual dysfunction, infertility, hirsutism, acne, obesity, and metabolic syndrome. Women with this disorder have an established increased risk of developing type 2 diabetes and a still debated increased risk of cardiovascular disease. The diagnostic traits of polycystic ovary syndrome are hyperandrogenism, chronic anovulation, and polycystic ovaries, after exclusion of other conditions that cause these same features. A conclusive definition of the disorder and the importance of the three diagnostic criteria relative to each other remain controversial. The cause of polycystic ovary syndrome is unknown, but studies suggest a strong genetic component that is affected by gestational environment, lifestyle factors, or both.
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Affiliation(s)
- Robert J Norman
- Research Centre for Reproductive Health, School of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, South Australia, Australia
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23
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Romualdi D, Giuliani M, Draisci G, Costantini B, Cristello F, Lanzone A, Guido M. Pioglitazone reduces the adrenal androgen response to corticotropin-releasing factor without changes in ACTH release in hyperinsulinemic women with polycystic ovary syndrome. Fertil Steril 2007; 88:131-8. [PMID: 17336978 DOI: 10.1016/j.fertnstert.2006.11.076] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2006] [Revised: 11/17/2006] [Accepted: 11/17/2006] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The hypothalamic-pituitary-adrenal (HPA) axis seems to hyperfunction at both central and peripheral levels in polycystic ovary syndrome (PCOS). Hyperinsulinemia is involved in the adrenal hyper-responsiveness to ACTH. The present study was performed to investigate the role of insulin in the derangement of the hypothalamic-pituitary compartment of the HPA axis in PCOS. DESIGN Prospective clinical study. SETTING Academic research center. PATIENT(S) Fifteen hyperinsulinemic PCOS women. INTERVENTION(S) Hormonal and lipid assays, oral glucose tolerance test, and corticotropin-releasing factor (1 microg/kg CRF) test before and after 4 months of treatment with the insulin sensitizer pioglitazone (30 mg/day). MAIN OUTCOME MEASURE(S) Glycemic and insulinemic response to glucose load; pituitary and adrenal response to CRF. RESULT(S) We observed a significant reduction in insulin secretion after therapy. Pioglitazone administration did not modify ACTH and cortisol response to CRF. A significant reduction in the adrenal CRF-induced secretion of androstenedione (A) (area under the curve [AUC] 202.76 +/- 78.68 ng/mL x 90 minutes to 147.05 +/- 52.06 ng/mL x 90 minutes) and 17OH-progesterone (AUC 152.92 +/- 59.56 ng/mL x 90 minutes to 117.10 +/- 63.25 ng/mL x 90 minutes') occurred after treatment. A trace response to CRF was observed for DHEAS and testosterone both before and after pioglitazone. CONCLUSION(S) In PCOS subjects, insulin may enhance adrenal steroidogenesis by acting directly on the peripheral gland, with no significant effects on the pituitary response to CRF stimulation.
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Affiliation(s)
- Daniela Romualdi
- Department of Obstetrics and Gynaecology, Università Cattolica del Sacro Cuore, Rome, Italy
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Glintborg D, Hermann AP, Brusgaard K, Hangaard J, Hagen C, Andersen M. Significantly higher adrenocorticotropin-stimulated cortisol and 17-hydroxyprogesterone levels in 337 consecutive, premenopausal, caucasian, hirsute patients compared with healthy controls. J Clin Endocrinol Metab 2005; 90:1347-53. [PMID: 15598692 DOI: 10.1210/jc.2004-1214] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
OBJECTIVE To investigate whether elevated ACTH-stimulated 17-hydroxyprogesterone (17OHP) levels are caused by CYP21 genetic defects or by a general adrenal hyperresponsiveness in hirsute patients. METHODS A total of 337 hirsute patients were evaluated by Ferriman-Gallwey score, serum testosterone, ACTH-stimulated 17OHP, and cortisol during the follicular phase. A cutoff value of 16 nmol/liter for maximum ACTH-stimulated 17OHP (M17OHP) responses was defined as the upper limit of the 95% confidence interval (CI) for the 97.5 percentile in 42 female controls. All patients were offered total screening of the CYP21 gene, and 252 healthy, premenopausal women with regular menses underwent genetic screening. RESULTS Patients were divided into idiopathic hirsutism (IH) (n = 180) and polycystic ovary syndrome (PCOS) (n = 157) groups. M17OHP levels were significantly higher in IH [geometric mean value (nmol/liter +/- 2 sd) 12.2 (4.6-32.3)] and PCOS [11.9 (5.3-27.2)] compared with controls [8.5 (5.1-14.2)] (P < 0.001). A similar percentage of IH and PCOS patients had elevated M17OHP (20.5 vs. 20.8%, not significant), and these also had significantly higher 30-min cortisol levels compared with controls (P < 0.05). The prevalence of CYP21 mutations in patients was 8.6% compared with 6.3% in controls (P = 0.38). Ten of 19 carriers had M17OHP levels below the cutoff limit. CONCLUSION The significantly higher ACTH-stimulated levels of cortisol and 17OHP in hirsute patients indicated adrenal hyperresponsiveness in IH and PCOS. CYP21-carrier status could not explain the observed high prevalence of abnormal ACTH-stimulated 17OHP levels in the hirsute population.
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Affiliation(s)
- D Glintborg
- Odense University Hospital, Department of Endocrinology, Kløvervaenget 10, 3, 5000 Odense C, Denmark.
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Putignano P, Bertolini M, Losa M, Cavagnini F. Screening for Cushing's syndrome in obese women with and without polycystic ovary syndrome. J Endocrinol Invest 2003; 26:539-44. [PMID: 12952368 DOI: 10.1007/bf03345217] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Obesity and insulin resistance, menstrual abnormalities and clinical and biochemical signs of hyperandrogenism are common features in women with polycystic ovary syndrome (PCOS) and Cushing's syndrome (CS). Further, an overdrive of the pituitary-adrenal axis has been documented in PCOS and this condition is often present in women with CS. For this reason, screening for hypercortisolism is often needed in obese women with polycystic ovaries. The aim of this study was to compare the diagnostic value of different screening tests for CS in a population of obese premenopausal women with PCOS and without PCOS (OB) and in a group of patients with CS. We reviewed retrospectively the case records of 117 obese women of reproductive age (60 PCOS and 57 OB, BMI 25.1-70.1, 13-45 yr) who were screened for CS at our Institution in the years 1995-2001 and turned out to be free of the disease. Data were compared with those of 58 premenopausal obese women with active CS (BMI 25.1-50.2 kg/m2, 18-45 yr). Screening for CS was performed by urinary free cortisol (UFC) (three consecutive 24-h urine collections), cortisol circadian rhythm (blood samples taken at 08:00-17:00-24:00 h), and 1 mg overnight dexamethasone suppression test (DST). A 24:00 h plasma cortisol (MNC) of 207 nmol/l, a UFC of 221 nmol/day and plasma cortisol after DST of 50 nmol/l and 138 nmol/l were taken as cut-off values for the diagnosis of CS. As expected, patients with CS showed elevated basal and post-dexamethasone plasma cortisol and UFC levels (p < 0.001 vs OB and PCOS). PCOS had higher UFC (p < 0.005) but not MNC and post-DST plasma cortisol levels compared to OB. DST showed the greatest specificity and diagnostic accuracy in differentiating CS from PCOS and OB (both p < 0.05 vs MNC and UFC, according to the 138 nmol/l criterion) while MNC and UFC displayed a similar discriminatory value. However, by using a lower threshold (50 nmol/l) as response criterion, there were no diagnostic differences between DST and the other tests. Specificity and diagnostic accuracy of UFC measurement was lower in PCOS than in OB (both p < 0.05) whilst there were no differences between groups for DST and MNC. Similarly, the area under the ROC curve relative to DST, giving an estimate of the inherent diagnostic accuracy of the test, was slightly greater than those of MNC and UFC (z = 0.694 and z = 0.833 for DST vs MNC and UFC, respectively, both p = NS). These results indicate that the 1-mg DST and MNC are unaffected by the presence of PCOS and can be safely used to screen for CS premenopausal obese women with PCOS, while caution should be exercised in interpreting mildly elevated UFC levels in these patients.
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Affiliation(s)
- P Putignano
- University of Milan, Istituto Scientifico Ospedale San Luca, Milan, Italy
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26
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Gambineri A, Pelusi C, Vicennati V, Pagotto U, Pasquali R. Obesity and the polycystic ovary syndrome. Int J Obes (Lond) 2002; 26:883-96. [PMID: 12080440 DOI: 10.1038/sj.ijo.0801994] [Citation(s) in RCA: 456] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2001] [Revised: 12/03/2001] [Accepted: 12/20/2001] [Indexed: 12/12/2022]
Abstract
The polycystic ovary syndrome (PCOS) is a condition characterized by hyperandrogenism and chronic oligo-anovulation. However, many features of the metabolic syndrome are inconsistently present in the majority of women with PCOS. Approximately 50% of PCOS women are overweight or obese and most of them have the abdominal phenotype. Obesity may play a pathogenetic role in the development of the syndrome in susceptible individuals. In fact, insulin possesses true gonadotrophic function and an increased insulin availability at the level of ovarian tissue may favour excess androgen synthesis. Obesity, particularly the abdominal phenotype, may be partly responsible for insulin resistance and associated hyperinsulinemia in women with PCOS. Therefore, obesity-related hyperinsulinemia may play a key role in favouring hyperandrogenism in these women. Other factors such as increased estrogen production rate, increased activity of the opioid system and of the hypothalamic-pituitary-adrenal axis, decreased sex hormone binding globulin synthesis and, possibly, high dietary lipid intake, may be additional mechanisms by which obesity favours the development of hyperandrogenism in PCOS. Irrespective of the pathogenetic mechanism involved, obese PCOS women have more severe hyperandrogenism and related clinical features (such as hirsutism, menstrual abnormalities and anovulation) than normal-weight PCOS women. This picture tends to be more pronounced in obese PCOS women with the abdominal phenotype. Body weight loss is associated with beneficial effects on hormones, metabolism and clinical features. A further clinical and endocrinological improvement can also be achieved by adding insulin-sensitizing agents and/or antiandrogens to weight reduction programmes. These obviously emphasize the role of obesity in the pathophysiology of PCOS.
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Affiliation(s)
- A Gambineri
- Endocrinology Unit, Department of Internal Medicine, S. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Bologna, Italy
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27
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Abstract
Current treatment of polycystic ovary syndrome (PCOS) in women is essentially symptomatic. However, there is growing evidence that this disorder is an evolving condition and that it may be associated with major medical outcomes later in life. As a consequence, effective treatments should be instituted as soon as PCOS is diagnosed. Insulin resistance with associated hyperinsulinaemia and increased luteinising hormone (LH)-dependent androgen secretion from the ovary seem to play a central role in the pathogenesis of PCOS. Accordingly, the effects of attenuation of hyper-insulinaemia, LH excess or hyperandrogenism were recently assessed, with promising results. A consistent finding was that attenuation of insulin resistance and hyperinsulinaemia may correct the entire spectrum of endocrine, metabolic and reproductive abnormalities of PCOS in many subjects.
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Affiliation(s)
- P Moghetti
- Divisione di Endocrinologia e Malattie del Metabolismo, Ospedale Maggiore, University of Verona, I-37126 Verona, Italy.
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Ciampelli M, Guido M, Cucinelli F, Cinque B, Barini A, Lanzone A. Hypothalamic-pituitary-adrenal axis sensitivity to opioids in women with polycystic ovary syndrome. Fertil Steril 2000; 73:712-7. [PMID: 10731530 DOI: 10.1016/s0015-0282(99)00602-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
OBJECTIVE To evaluate the influence of the opioid system on the hypothalamic-pituitary-adrenal axis in women with polycystic ovary syndrome (PCOS). DESIGN Controlled clinical study. SETTING Academic research environment. PATIENT(S) Eight lean and 12 obese women with PCOS, and seven lean and 5 obese control subjects. INTERVENTION(S) Each patient received an i.v. bolus of naloxone at a dose of 125 microgram per kilogram of body weight; 48 hours later, each patient received 16 mg of loperamide p.o. MAIN OUTCOME MEASURE(S) Samples were collected for 2 hours for the naloxone test and for 3 hours for the loperamide test. Levels of adrenocorticotropic hormone (ACTH) and cortisol were measured in all plasma samples. RESULT(S) The obese women with PCOS had a greater ACTH and cortisol response to opiate blockade than either the lean women with PCOS or the control subjects, but there was no difference between the lean or obese control subjects and the lean women with PCOS. There was no difference in the responsiveness of the hypothalamic-pituitary-adrenal axis to loperamide between the PCOS and control groups. CONCLUSION(S) The data indicate that the sensitivity of the hypothalamic-pituitary-adrenal axis to opioids cannot be altered in women with PCOS. However, abnormalities of the hypothalamic-pituitary-adrenal axis in women with PCOS could be central in origin, as suggested by the effects of naloxone administration, and probably are related to the anthropometric characteristics of these hyperandrogenic patients.
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Affiliation(s)
- M Ciampelli
- Ospedale G.B. Grassi, Ostia, Catholic University of the Sacred Heart, Rome, Italy
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29
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Chin D, Shackleton C, Prasad VK, Kohn B, David R, Imperato-McGinley J, Cohen H, McMahon DJ, Oberfield SE. Increased 5alpha-reductase and normal 11beta-hydroxysteroid dehydrogenase metabolism of C19 and C21 steroids in a young population with polycystic ovarian syndrome. J Pediatr Endocrinol Metab 2000; 13:253-9. [PMID: 10714750 DOI: 10.1515/jpem.2000.13.3.253] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To test the hypothesis that 5alpha-reductase (5alphaR) and 11beta-hydroxysteroid dehydrogenase (11beta-HSD) activity are increased in adolescent and young-adult women with PCOS and that an altered regulation of the hypothalamic-pituitary-adrenal (HPA) axis occurred in these subjects. DESIGN Prospective non-randomized study in an academic research environment. PATIENTS Eleven women, aged 14 to 25 years, were studied who were at least one year post-menarche and who had a diagnosis of PCOS based on a history of oligomenorrhea and elevated total and or free serum testosterone. INTERVENTION 24-Hour urinary metabolites were assessed in nine subjects and five underwent stimulation with ovine corticotropin releasing factor (oCRF). OUTCOME MEASURES C19 and C21 steroid urinary metabolite 5-alpha/5-beta pairs, 11-oxo/11-hydroxy products and the ratio of the total 5-alpha/5-beta reduced and 11-oxo/11-hydroxy products were compared to values in control women. Urinary cortisol (F) (sum of conjugated and free, and free F) and total F metabolites (the sum of THE, THF, 5alpha-THF, cortolones, and cortols) were determined. A 1 microg/kg oCRF stimulation test was performed with timed samples determined for plasma ACTH and serum F levels. RESULT The 24-hour total and free urinary F were not different from control. However, the total F metabolites were markedly elevated (7922+/-2666 vs 5418+/-1549 microg/24 h, p<0.01). A marked increase in the total 5-alpha reduced C19 and C21 metabolites was observed in the PCOS population vs control (5084+/-1977 vs 2681+/-1188 microg/24 h, p<0.01). The total urinary 11-oxo/11-hydroxy metabolite ratio was not different, p=0.23. The basal values and response of both ACTH and F to oCRF stimulation were not different from those of controls. CONCLUSION There is a marked increase in 5alphaR metabolism of both C19 and C21 steroids in younger women with PCOS.
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Affiliation(s)
- D Chin
- Department of Pediatrics, New York University Medical Center, New York, USA
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30
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Kondoh Y, Uemura T, Ishikawa M, Yokoi N, Hirahara F. Classification of polycystic ovary syndrome into three types according to response to human corticotropin-releasing hormone. Fertil Steril 1999; 72:15-20. [PMID: 10428142 DOI: 10.1016/s0015-0282(99)00195-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate disturbances of the hypothalamic-pituitary-adrenal axis in women with polycystic ovary syndrome (PCOS). DESIGN Retrospective cohort study. SETTING Yokohama City University, Yokohama, Japan. PATIENT(S) Sixty women with PCOS and 19 women with normal menstruation. INTERVENTION(S) Administration of human corticotropin-releasing hormone (hCRH), dexamethasone suppression testing, and stimulation of ovulation with clomiphene citrate. MAIN OUTCOME MEASURE(S) Plasma cortisol and ACTH levels, plasma androstenedione and DHEAS levels, and ovulation rates. RESULT(S) In women with PCOS, plasma ACTH and cortisol levels were significantly higher and the plasma ACTH level after the administration of hCRH was higher than in controls. Based on the response to hCRH, patients with PCOS could be classified into three categories: those with a normal response to hCRH (group 1), those with an exaggerated response of ACTH to hCRH (group 2), and those with a high basal level of cortisol and a poor response to hCRH (group 3). In groups 2 and 3, DHEAS levels were significantly higher, suppression of androstenedione by dexamethasone was significantly greater, and ovulation rates with clomiphene citrate were significantly lower than in group 1. CONCLUSION(S) This classification provides insight into the underlying cause of PCOS and thus is useful in selecting appropriate treatment.
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Affiliation(s)
- Y Kondoh
- Department of Obstetrics and Gynecology, Yokohama City University School of Medicine, Yokohama, Japan
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31
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Guido M, Ciampelli M, Fulghesu AM, Pavone V, Barini A, de Marinis L, Cento R, Caruso A, Lanzone A. Influence of body mass on the hypothalamic-pituitary-adrenal-axis response to naloxone in patients with polycystic ovary syndrome. Fertil Steril 1999; 71:462-7. [PMID: 10065783 DOI: 10.1016/s0015-0282(98)00470-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To evaluate the influence of body mass on the hypothalamic-pituitary-adrenal (HPA)-axis response to naloxone in polycystic ovary syndrome (PCOS). DESIGN Controlled clinical study. SETTING Academic research environment. PATIENT(S) Ten lean and 10 obese women with PCOS compared with 7 lean and 8 obese control subjects matched for body mass index. INTERVENTION(S) Each patient received an IV bolus of naloxone at a dosage of 125 microg/kg. MAIN OUTCOME MEASURE(S) Samples were collected 30 minutes before and 0, 15, 30, 60, 90, and 120 minutes after injection: ACTH and cortisol levels were measured in all plasma samples. RESULT(S) No significant differences were found in the ACTH and cortisol responses to opioid blockade between lean women with PCOS and lean as well as obese control subjects; conversely, obese patients with PCOS showed a higher ACTH and cortisol responses to naloxone compared with all other groups. CONCLUSION(S) Hypothalamic-pituitary-adrenal-axis abnormalities of PCOS may be central in origin and abdominal obesity seems to play a key role in the HPA-axis hyperactivity of women with PCOS when naloxone is administered.
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Affiliation(s)
- M Guido
- Department of Obstetrics and Gynecology, Catholic University of Sacred Heart, Rome, Italy
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32
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Gennarelli G, Holte J, Stridsberg M, Lundqvist U, Massobrio M, Bäckström T, Berne C. Response of the pituitary-adrenal axis to hypoglycemic stress in women with the polycystic ovary syndrome. J Clin Endocrinol Metab 1999; 84:76-81. [PMID: 9920065 DOI: 10.1210/jcem.84.1.5403] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
The role of the adrenals in the polycystic ovary syndrome (PCOS) is debated. Both single steroid-converting enzyme abnormalities and increased adrenal activity have received support. The conventional Synacthen test using pharmacological doses of ACTH results in unphysiological levels of ACTH. Therefore, we used insulin-induced hypoglycemia (0.15 IU/kg BW) to asses the responses of ACTH, cortisol, pregnenolone, 17-hydroxypregnenolone, dehydroepiandrosterone, progesterone, 17-hydroxyprogesterone, and androstenedione in 18 women with PCOS and in 17 normal women of similar age and body mass index. The blood glucose concentration at 30 min was 2 mmol/L or less in all women, i.e. well below the threshold of the hormonal counterregulatory response. The women with PCOS showed a lower ACTH response, expressed as the maximum increment above basal [mean (95% confidence interval): PCOS, 11.1 (6.9-15.3); controls, 19.9 (13.8-26) pmol/L; P < 0.05], but a quantitatively comparable [PCOS, 207.2 (148.5-266.5); controls, 167.1 (100.6-233.2) nmol/L; P = NS] and more prompt cortisol response than the controls (by chi2 test, P < 0.05), resulting in a higher molar ratio between the maximum increments of cortisol and ACTH [PCOS, 13.9 (8.7-19); controls, 8.8 (5.7-12); P < 0.05]. The women with PCOS did, however, show a more rapid decline in cortisol levels than the controls (P < 0.05 at 120 and 180 min). The responses of the androgens and intermediate adrenal steroids were similar in women with PCOS and controls. The findings suggest an adaptation to increased adrenal reactivity to endogenous ACTH in women with PCOS. Exposure to hypoglycemia as a model of stress was not followed by hypersecretion of adrenal androgens and revealed no signs of steroid enzyme disturbances in women with PCOS.
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Affiliation(s)
- G Gennarelli
- Department of Obstetrics and Gynecology, Akademiska Hospital, Uppsala University, Sweden
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33
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Affiliation(s)
- P Moghetti
- Division of Endocrinology and Metabolic Diseases, University of Verona, Italy
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34
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Holte J. Polycystic ovary syndrome and insulin resistance: thrifty genes struggling with over-feeding and sedentary life style? J Endocrinol Invest 1998; 21:589-601. [PMID: 9856413 DOI: 10.1007/bf03350784] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Almost two decades of research have greatly increased our knowledge in the complex field of metabolic aberrations in polycystic ovary syndrome, but still many problems remain unsolved. The statistical association between insulin levels and androgens originally put the focus on possible direct cause-and-effect relationships between these factors. Indeed there is evidence that insulin may affect ovarian functions in multiple ways, presumably in some cases causing anovulation and hyperandrogenism. Clearly, insulin may increase biologically active testosterone through reducing SHBG levels. Conversely, major increases in androgen levels may induce muscular changes leading to reduced insulin-mediated glucose uptake. There are suggestions of increased steroidogenesis in both ovarian and adrenal pathways, with the net result of increased androgen production. There are also findings supporting increased corticosteroid production, which could contribute to insulin resistance directly or through promoting accumulation of abdominal fat, a typical feature of over-weight women with PCOS. Free fatty acids, released in great amounts from abdominal fat, may induce insulin resistance. Insulin resistance may also be due to a primary aberration in the insulin receptor. Putatively increased serine phosphorylation may cause both impairment of the insulin signal and increased 17,20 lyase activity, thus suggesting a common cause for insulin resistance and increased androgen production. There are also findings supporting a high prevalence of beta-cell dysfunction in PCOS, ranging from increased insulin secretion, not explained by insulin resistance or BMI, to failing beta-cell function, mainly in obese women during progress to glucose intolerance and NIDDM. Recent genetic findings also support a multifactorial genesis to PCOS, notably with positive findings both in genes regulating steroidogenesis and insulin secretion. It is suggested that PCOS is the result of "thrifty" genes, providing advantages in times of shortage of nutrition such as muscular strength, moderate abdominal fatness and decreased insulin sensitivity, i.e. an anabolic, energy saving constitution. However, when this constitution is exposed to unlimited food supplies and modern sedentary life style a full-blown PCOS with insulin resistance and infertility is triggered, presumably via several mechanisms, which follow a logical amplification system between two basic anabolic hormones, insulin and testosterone.
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Affiliation(s)
- J Holte
- Department of Obstetrics and Gynaecology, Uppsala University, Akademiska Hospital, Sweden
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35
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Güven M, Açbay O, Sultuybek G. Glucocorticoid receptors on mononuclear leukocytes in polycystic ovary syndrome. Int J Gynaecol Obstet 1998; 63:33-7. [PMID: 9849709 DOI: 10.1016/s0020-7292(98)00126-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Many studies have suggested that there is a possible hormonal dysregulation of hypothalamic-pituitary-adrenal (HPA) axis and an increased cortisol clearance in patients with polycystic ovary syndrome (PCOS). Therefore in this study, we have examined the role of glucocorticoid receptor/s (GR) characteristics in the developing of these abnormalities in patients with PCOS. METHOD For this purpose, the number and affinity of GR in peripheral mononuclear leukocytes (MNL) of 10 patients with PCOS and 10 healthy women (controls) were determined. RESULTS There were no significant differences in the number (6500+/-1001 sites/cell and 6352+/-1697 sites/cell, respectively; P > 0.05) and affinity (3.93+/-0.89 nM and 4.49+/-0.71 nM, respectively; P > 0.05) of GR between the PCOS patients and the controls. CONCLUSIONS These results suggest that the alterations in the HPA axis and in the cortisol metabolism observed in PCOS are not related to GR deficiency.
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Affiliation(s)
- M Güven
- Department of Medical Biology, Cerrahpaşa Medical Faculty, Istanbul University, Turkey
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36
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Azziz R, Black V, Hines GA, Fox LM, Boots LR. Adrenal androgen excess in the polycystic ovary syndrome: sensitivity and responsivity of the hypothalamic-pituitary-adrenal axis. J Clin Endocrinol Metab 1998; 83:2317-23. [PMID: 9661602 DOI: 10.1210/jcem.83.7.4948] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Over 50% of patients with the polycystic ovary syndrome (PCOS) demonstrate excess levels of adrenal androgens (AAs), particularly dehydroepiandrosterone sulfate (DHS). Nonetheless, the mechanism for the AA excess remains unclear. It has been noted that in PCOS the pituitary and ovarian responses to their respective trophic factors (i.e. GnRH and LH, respectively) are exaggerated. Similarly, we have postulated that excess AAs in PCOS arises from dysfunction of the hypothalamic-pituitary-adrenal axis, due to 1) exaggerated pituitary secretion of ACTH in response to hypothalamic CRH, 2) excess sensitivity/responsivity of AAs to ACTH stimulation, or 3) both. To test this hypothesis we studied 12 PCOS patients with AA excess (HI-DHS; DHS, > 8.1 mumol/L or 3000 ng/mL), 12 PCOS patients without AA excess (LO-DHS; DHS, < 7.5 mumol/L or 2750 ng/mL), and 11 controls (normal subjects). Each subject underwent an acute 90-min ovine CRH stimulation test (1 microgram/kg) and an 8-h incremental i.v. stimulation with ACTH-(1-24) at doses ranging from 20-2880 ng/1.5 m2.h) with a final bolus of 0.25 mg. All patient groups had similar mean body mass indexes and ages, and both tests were performed in the morning during the follicular phase (days 3-10) of the same menstrual cycle, separated by 48-96 h. During the acute ovine CRH stimulation test, no significant differences in the net maximal response (i.e. change from baseline to peak level) for ACTH, dehydroepiandrosterone (DHA), androstenedione (A4), or cortisol (F) or for the DHA/ACTH, A4/ACTH, or F/ACTH ratios was observed. Nonetheless, the net response of DHA/F and the areas under the curve (AUCs) for DHA and DHA/F indicated a greater response for HI-DHS vs. LO-DHS or normal subjects. The AUC for A4 and A4/F and the delta A4/delta F ratio (delta = net maximum change) indicated that HI-DHS and LO-DHS had similar responses, which were greater than that of the normal subjects, although the difference between LO-DHS patients and normal subjects reached significance only for the AUC of the A4 response. No difference in the sensitivity (i.e. threshold or minimal stimulatory dose) to ACTH was noted between the groups for any of the steroids measured. Nonetheless, the average dose of ACTH-(1-24) required for a threshold response was higher for DHA than for F and A4 in all groups. No difference in mean responsivity (slope of response to incremental ACTH stimulation) was observed for DHA and F between study groups, whereas the responsivity of A4 was higher in HI-DHS patients than in normal or LO-DHS women. The net maximal and the overall (i.e. AUC) responses of DHA were greater for HI-DHS than for normal or LO-DHS women. The response of A4 and the delta A4/delta F ratio were greater for HI-DHS patients than for LO-DHS patients or normal subjects. Alternatively, HI-DHS and LO-DHS patients had similar overall responses (i.e. AUC) for A4 or A4/F, although both were greater than those of normal subjects. The relative differences in response to incremental ACTH stimulation between steroids was consistent for all subject groups studied, i.e. A4 > F or DHA. In conclusion, our data suggest that AA excess in PCOS patients is related to an exaggerated secretory response of the adrenal cortex for DHA and A4, but not to an altered pituitary responsivity to CRH or to increased sensitivity of these AAs to ACTH stimulation. Whether the increased responsivity to ACTH for these steroids is secondary to increased zonae reticularis mass or to differences in P450c17 alpha activity, particularly of the delta 4 pathway, remains to be determined.
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Affiliation(s)
- R Azziz
- Department of Obstetrics and Gynecology, University of Alabama, Birmingham 35233, USA
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37
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Abstract
STUDY OBJECTIVE To determine whether human chorionic gonadotropin (hCG) stimulation elicits an exaggerated 17-hydroxyprogesterone (17-OHP) response in patients with functional ovarian hyperandrogenism. METHODS In this clinical study, healthy volunteers and hyperandrogenic patients in an outpatient General Clinical Research Center (GCRC) setting were studied. Five adolescent girls with functional ovarian hyperandrogenism were studied. Six healthy women with regular menstrual cycles volunteered for this study. Steroid hormone responses to hCG stimulation were measured before and 30, 240, and 300 minutes after hCG injection. Congenital adrenal hyperplasia was excluded through ACTH stimulation testing and molecular genetic analysis. MAIN OUTCOME MEASURE 17-OHP responses. RESULTS Mean basal 17-OHP concentrations were greater in the hyperandrogenic patients, 110.4+/-41.2 ng/dL versus 61.8+/-28.6 ng/dL. After hCG stimulation, 17-hydroxyprogesterone concentrations significantly increased in the patients and were unchanged in the healthy controls. CONCLUSION hCG stimulation elicited greater 17-hydroxyprogesterone responses in adolescent girls with functional ovarian hyperandrogenism compared with healthy controls. hCG stimulation may be helpful to confirm ovarian hyperandrogenism.
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Affiliation(s)
- S F Witchel
- Division of Endocrinology, Diabetes, and Metabolism, Children's Hospital of Pittsburgh, University of Pittsburgh, Pennsylvania 15213, USA
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Invitti C, De Martin M, Delitala G, Veldhuis JD, Cavagnini F. Altered morning and nighttime pulsatile corticotropin and cortisol release in polycystic ovary syndrome. Metabolism 1998; 47:143-8. [PMID: 9472960 DOI: 10.1016/s0026-0495(98)90210-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
An overdrive of the hypothalamic-pituitary-adrenal (HPA) axis has been postulated in patients with polycystic ovary syndrome (PCOS). However, little is known concerning the pulsatile modes of corticotropin (ACTH) and cortisol secretion in these patients. To further investigate this issue, spontaneous ACTH and cortisol release were evaluated in 16 normal-weight patients with PCOS and 16 control women. Nine PCOS patients and eight controls were studied between 8 AM and 12 AM (noon), and seven PCOS patients and eight controls between 11 PM and 3 AM. Venous blood samples were taken at 10-minute intervals. Cluster analysis was used to assess ACTH and cortisol pulse frequency and amplitude, deconvolution to calculate mean hormone secretion rates, and approximative entropy (ApEn) to measure the orderliness of ACTH and cortisol time-series data. PCOS patients compared with controls displayed increased ACTH and cortisol release (area under the curve [AUC] and mean plasma concentration) both in the morning and at night. This was not due to increased hormonal secretory burst frequency, but to higher hormonal interpeak valley concentrations and, in the case of ACTH, nighttime pulse amplitudes. Mean ACTH and cortisol secretion rates also were increased in PCOS patients. Further, both controls and PCOS patients exhibited significant (0 to 20 minutes lagged) concordance between individual daytime pulsatile ACTH and cortisol release episodes. As shown by increased ApEn values, PCOS patients had more disorderly daytime cortisol release. In addition, the normal daytime correlation between the amount of pulsatile ACTH and cortisol release as observed in the controls was lost in PCOS patients. Finally, cross-correlation analysis showed a more prominent negative correlation in PCOS patients versus controls between plasma cortisol and 40- to 120-minute delayed ACTH concentrations in the morning, indicating a more sustained negative feedback of cortisol on ACTH release in PCOS at this time. Taken together, these findings demonstrate the existence of multifaceted dysregulation of the HPA axis in PCOS.
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Affiliation(s)
- C Invitti
- Endocrinology, University of Milan, Istituto Scientifico Ospedale San Luca, Italy
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Lanzone A, Fulghesu AM, Guido M, Cucinelli F, Caruso A, Mancuso S. Somatostatin treatment reduces the exaggerated response of adrenocorticotropin hormone and cortisol to corticotropin-releasing hormone in polycystic ovary syndrome. Fertil Steril 1997; 67:34-9. [PMID: 8986680 DOI: 10.1016/s0015-0282(97)81852-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate the influence of somatostatin analogue (octreotide) in the function of hypothalamic-pituitary-adrenal (HPA) axis in women with polycystic ovary syndrome (PCOS). SETTING Women referred to the Department of Obstetrics and Gynecology, Università Cattolica del Sacro Cuore. PATIENT(S) Twelve PCOS women and 12 normo-ovulatory controls. INTERVENTION(S) In early follicular phase, I microgram/kg human corticotrophin-releasing hormone (CRH) was injected at 9:00 A.M. and blood samples were collected for 90 minutes after stimulus; ACTH and cortisol plasma levels were measured. The following day at 8:00 A.M., PCOS patients received an ACTH test (250 micrograms IV) and samples were collected 60 minutes after injection. After 6 weeks of octreotide treatment (100 mg s.c. twice daily), PCOS patients repeated the same study. MAIN OUTCOME MEASURE(S) Plasma cortisol and ACTH concentrations. RESULT(S) The ACTH and cortisol baseline levels were similar in PCOS and control patients. The responses to human CRH of ACTH (incremental area = 437.86 +/- 188.7 versus 175.78 +/- 87.6 pmol/L; mean +/- SD) and cortisol (incremental area = 17,293.6 +/- 4,320.3 versus 5,885 (912.1 nmol/L) were significantly greater in PCOS with respect to control subjects. After octreotide treatment, ACTH response significantly decreased and no difference was observed with respect to controls (incremental area = 176.94 +/- 91.4). Cortisol responses were decreased by treatment. However, they remained significantly higher than in controls. Treatment did not modify adrenal response to IV ACTH. CONCLUSION(S) Data suggest that, in the HPA axis, hyperfunction of PCOS somatostatin could be involved partially.
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Affiliation(s)
- A Lanzone
- Oasi Institute of Research, Troina, Italy
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40
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Holte J. Disturbances in insulin secretion and sensitivity in women with the polycystic ovary syndrome. BAILLIERE'S CLINICAL ENDOCRINOLOGY AND METABOLISM 1996; 10:221-47. [PMID: 8773746 DOI: 10.1016/s0950-351x(96)80085-1] [Citation(s) in RCA: 77] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Insulin resistance, defined as a diminished effect of a given dose of insulin on glucose homeostasis, is a highly prevalent feature of women with PCOS. Insulin resistance in PCOS is closely associated with an increase in truncal-abdominal fat mass, elevated free fatty acid levels, increased androgens, particularly free testosterone through reduced SHBG levels, and anovulation. The causes for insulin resistance in PCOS are still unknown. One line of evidence suggests that an increase in truncal-abdominal fat mass and subsequently increased free fatty acid levels induce insulin resistance in women with PCOS. Increased effects of corticosteroids and a relative reduction in oestrogen and progesterone seem to be involved in the aberrant body fat distribution. Conversely, there are also results supporting primary, genetic target cell defects as a cause of insulin resistance in PCOS. An explanation for these seemingly contradictory results could be that the group of women with PCOS is heterogeneous with respect to the primary event in carbohydrate/insulin disturbances. Also insulin secretion in PCOS is characterized by heterogeneity. At one end of the spectrum is a large subgroup of mainly obese women with reduced insulin secretion, which appears to result from failure of the beta cells to compensate for insulin resistance in susceptible women, resulting in glucose intolerance and NIDDM. In the insulin-resistant patients with normal glucose tolerance, most of the hyperinsulinaemia is probably due to secondarily increased insulin secretion and decreased insulin degradation. However, a component of the increased first-phase insulin release is not due to measurable insulin resistance. Notably, this is also found in lean women with normal insulin sensitivity, and is not reversed after weight reduction, in contrast to the findings for insulin resistance. The implications of this enhanced insulin release are not fully clear, but it may tentatively be associated with carbohydrate craving and subsequently increased risks for development of obesity and insulin resistance. It may represent a primary disturbance of insulin secretion in PCOS or may be associated with the perturbed steroid balance in anovulation. The insulin-androgen connection in PCOS appears to be amplified by several different mechanisms, notably in both directions, the initiating event probably varying between individuals. Thus insulin increases the biological availability of potent steroids, primarily testosterone, through the suppression of SHBG synthesis. Insulin is also involved as a progonadotrophin in ovarian steroidogenesis, with the possible net result of interfering with ovulation and/or increasing ovarian androgen production in states of hyperinsulinaemia. Conversely, testosterone may indirectly contribute to insulin resistance through facilitating free fatty acid release from abdominal fat, but perhaps also through direct muscular effects at higher serum levels. It seems likely that this constitution, presumably genetic, would provide evolutionary advantages in times of limited nutrition, given the energy-saving effects of insulin resistance. Hypothetically, hyperinsulinaemia (primary) could provide a stimulus to ensure intake of nourishment, but unlimited food supplies could in some cases initiate a vicious 'anabolic' circle, in which several of the proposed amplifying mechanisms between insulin and androgens--in both directions--could take part.
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Affiliation(s)
- J Holte
- Department of Obstetrics & Gynaecology, Akademiska Hospital, Uppsala, Sweden
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Abstract
Recent studies have led to significant advances in the understanding of the pathogenesis of polycystic ovary syndrome (PCOS), as well as to improvements in the treatment of the commonly associated symptoms. New data continue to implicate etiologic alterations in the hypothalamic-pituitary axis, beginning in the perimenarcheal period, as well as derangements in insulin and insulin-like growth factor metabolism. Current observations also support a role for an increase in adrenal androgen production and an increase in adrenal sensitivity to trophic hormone stimulation in the development of PCOS. Therapeutic regimens for those patients unsuccessfully treated with traditional approaches have been further validated, including the use of flutamide or gonadotropin-releasing hormone agonist-steroidal "add back" for the treatment of hirsutism. Novel approaches to the treatment of infertility are likewise discussed.
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Affiliation(s)
- L C Udoff
- Department of Obstetrics and Gynecology, University of Maryland School of Medicine, Baltimore, USA
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