The polycystic ovary syndrome

The Search for the Causes of Common Hyperandrogenism, 1965 to Circa 2015

From 1965 to 2015, immense strides were made into understanding the mechanisms underlying the common androgen excess disorders, premature adrenarche and polycystic ovary syndrome (PCOS). The author reviews the critical discoveries of this era from his perspective investigating these disorders, commencing with his early discoveries of the unique pattern of plasma androgens in premature adrenarche and the elevation of an index of the plasma free testosterone concentration in most hirsute women. The molecular genetic basis, though not the developmental biologic basis, for adrenarche is now known and 11-oxytestosterones shown to be major bioactive adrenal androgens. The evolution of the lines of research into the pathogenesis of PCOS is historically traced: research milestones are cited in the areas of neuroendocrinology, insulin resistance, hyperinsulinism, type 2 diabetes mellitus, folliculogenesis, androgen secretion, obesity, phenotyping, prenatal androgenization, epigenetics, and complex genetics. Large-scale genome-wide association studies led to the 2014 discovery of an unsuspected steroidogenic regulator DENND1A (differentially expressed in normal and neoplastic development). The splice variant DENND1A.V2 is constitutively overexpressed in PCOS theca cells in long-term culture and accounts for their PCOS-like phenotype. The genetics are complex, however: DENND1A intronic variant copy number is related to phenotype severity, and recent data indicate that rare variants in a DENND1A regulatory network and other genes are related to PCOS. Obesity exacerbates PCOS manifestations via insulin resistance and proinflammatory cytokine excess; excess adipose tissue also forms testosterone. Polycystic ovaries in 40 percent of apparently normal women lie on the PCOS functional spectrum. Much remains to be learned.

Establishment and validation of a nomogram model for predicting ovulation in the PCOS women

BACKGROUND

The mechanisms underlying ovulatory dysfunction in PCOS remain debatable. This study aimed to identify the factors affecting ovulation among PCOS patients based on a large sample-sized randomized control trial.

METHODS

Data were obtained from a multi-centered randomized clinical trial, the PCOSAct, which was conducted between 2011 and 2015. Univariate and multivariate analysis using binary logistic regression were used to construct a prediction model and nomogram. The accuracy of the model was assessed using receiver operating characteristic (ROC) curves and calibration curves.

RESULTS

The predictive variables included in the training dataset model were luteinizing hormone (LH), free testosterone, body mass index (BMI), period times per year, and clomiphene treatment. The ROC curve for the model in the training dataset was 0.81 (95% CI [0.77, 0.85]), while in the validation dataset, it was 0.7801 (95% CI [0.72, 0.84]). The model showed good discrimination in both the training and validation datasets. Decision curve analysis demonstrated that the nomogram designed for ovulation had clinical utility and superior discriminative ability for predicting ovulation.

CONCLUSIONS

The nomogram composed of LH, free testosterone, BMI, period times per year and the application of clomiphene may predict the ovulation among PCOS patients.

Dysfunction of Human Estrogen Signaling as a Novel Molecular Signature of Polycystic Ovary Syndrome

Estradiol (E2) is a major hormone-controlling folliculogenesis whose dysfunction may participate in polycystic ovary syndrome (PCOS) infertility. To determine whether both the concentration and action of E2 could be impaired in non-hyperandrogenic overweight PCOS women, we isolated granulosa cells (GCs) and follicular fluid (FF) from follicles of women undergoing ovarian stimulation (27 with PCOS, and 54 without PCOS). An analysis of the transcript abundance of 16 genes in GCs showed that androgen and progesterone receptor expressions were significantly increased in GCs of PCOS (by 2.7-fold and 1.5-fold, respectively), while those of the steroidogenic enzymes CYP11A1 and HSD3B2 were down-regulated (by 56% and 38%, respectively). Remarkably, treatment of GC cultures with E2 revealed its ineffectiveness in regulating the expression of several key endocrine genes (e.g., GREB1 or BCL2) in PCOS. Additionally, a comparison of the steroid concentrations (measured by GC/MS) in GCs with those in FF of matched follicles demonstrated that the significant decline in the E2 concentration (by 23%) in PCOS FF was not the result of the E2 biosynthesis reduction. Overall, our study provides novel hallmarks of PCOS by highlighting the ineffective E2 signaling in GCs as well as the dysregulation in the expression of genes involved in follicular growth, which may contribute to aberrant folliculogenesis in non-hyperandrogenic women with PCOS.

Effect of Prebiotic Dietary Supplement Acacia senegal on Hormonal and Metabolic Markers in Polycystic Ovary Syndrome Patients: A Pilot Study

Background The most prevalent endocrine condition affecting women of reproductive age is polycystic ovarian syndrome (PCOS), which is linked to a variety of metabolic abnormalities. Although the pathogenesis of PCOS is not fully understood, it is known that oxidative stress, altered gut microbiome, and increased gonadotrophin-releasing hormone play a significant role. Gum arabic (GA) is an edible, dried, gummy exudate from the Acacia senegal tree, well-known for its prebiotic and antioxidant effects. The main objective of the study was to assess the changes in hormonal and metabolic profiles in PCOS patients after the ingestion of gum arabic. Method This was a clinical trial conducted on fifteen patients suffering from PCOS, with a mean age of 27.8 years (20-39 years). All patients experienced irregular cycles. Hormonal and metabolic markers (follicular stimulating hormone (FSH), luteinizing hormone (LH), total testosterone (TT), fasting insulin, total cholesterol (TC), and glycosylated hemoglobin (HBA1c) were measured before and after the ingestion of gum arabic (30 g/day of GA dissolved in 250 ml water for eight weeks) on the second day of the menstrual cycle after granting ethical approval from the National Medicine and Poisons Board and from the participants of the study. Results The study demonstrated a significant decrease in the luteinizing hormone level, FSH/LH ratio, and cholesterol pre- and post-gum arabic ingestion (p-values 0.001, 0.013, and 0.007, respectively). Follicular stimulating hormone slightly reduced post-ingestion with no significant difference (p-value 0.414). No significant changes were seen in the testosterone, insulin, or HBA1c levels. Conclusion The study concluded that gum arabic ingestion for eight weeks decreases the luteinizing hormone and LH/FSH ratio and improves the metabolic profile by reducing the cholesterol level in PCOS patients.

Effects of KISS1 structural polymorphism on the risk of polycystic ovary syndrome and reproductive hormones in Iraqi women who take metformin

OBJECTIVE

To identify the effects of metformin and kisspeptin structural polymorphism on the risk of polycystic ovary syndrome (PCOS) in Iraqi women.

METHODS

Samples were collected at the family planning center of Al-Hassan Teaching Hospital (infertility clinic), Iraq. Hormonal and hematological parameters were measured. Kisspeptin structural polymorphisms were analyzed by polymerase chain reaction using a conventional thermal cycler and Phyre2 predictions. Kisspeptin concentrations were assessed by an enzyme-linked immunosorbent assay.

RESULTS

Follicle-stimulating hormone (FSH) was the only sex hormone that changed in women with PCOS after metformin treatment. FSH concentrations were significantly increased after therapy compared with before therapy (9.39 ± 2.1 vs 5.13 ± 1.53 IU/L). We found that a single nucleotide polymorphism substituting G to C was related to PCOS. The kisspeptin structural polymorphism showed that the C allele was related to low FSH concentrations after treatment (6.92 ± 2.2 IU/L to 5.34 ± 1.58 IU/L). Kisspeptin concentrations were significantly lower after metformin treatment than before metformin treatment (395.44 ± 67.83 vs 273.18 ± 42.98 ng/mL).

CONCLUSION

A variation in the KISS1 gene or its protein structure may be involved in the development of PCOS. The response to metformin may be used as an indicator and could contribute to the early diagnosis and medical therapy of PCOS.

Potentials of curcumin against polycystic ovary syndrome: Pharmacological insights and therapeutic promises

Polycystic ovary syndrome (PCOS) is a common hormonal disorder among women (4%-20%) when the ovaries create abnormally high levels of androgens, the male sex hormones that are typically present in women in trace amounts. The primary characteristics of PCOS include oxidative stress, inflammation, hyperglycemia, hyperlipidemia, hyperandrogenism, and insulin resistance. Generally, metformin, spironolactone, eflornithine and oral contraceptives are used to treat PCOS, despite their several side effects. Therefore, finding a potential candidate for treating PCOS is necessary. Curcumin is a major active natural polyphenolic compound derived from turmeric (Curcuma longa). A substantial number of studies have shown that curcumin has anti-inflammatory, anti-oxidative stress, antibacterial, and anti-apoptotic activities. In addition, curcumin reduces hyperglycemia, hyperlipidemia, hyperandrogenism, and insulin resistance in various conditions, including PCOS. The review highlighted the therapeutic aspects of curcumin against the pathophysiology of PCOS. We also offer a hypothesis to improve the development of medicines based on curcumin against PCOS.

Assessment of the effect of endocrine abnormalities on biomacromolecules and lipids by FT-IR and biochemical assays as biomarker of metabolites in early Polycystic ovary syndrome women

Polycystic ovary syndrome (PCOS) is a common endocrinopathy associated with metabolic disturbances. Both in the development and improvement of the disease, the structure of phospholipids and proteins in the blood serum plays important role in the treatment of these disease. Herein, to investigate the metabolic process and the variations of biomacromolecules and lipids between young PCOS women and healthy subjects, biochemistry and Fourier Transform InfraRed spectroscopy (FTIR) methods, were used. Moreover, partial least squares regression (PLS) and Principal component analysis (PCA) to research differentiation of biomacromolecules, were performed. We obtained blood serum of of 100 individuals including 57 with PCOS and 43 healthy controls. The biochemical blood profile of PCOS women was presented by spectroscopic measurements, which is an analytical technique, as well as by laboratory indexes and oxidative stress status measurements. There was a significant structural differentiation between studied groups in the number of functional groups and biomolecules differentiation depending on the protein expression and oxidative stress status. Hence, FTIR spectroscopy and oxidative load can be effectively utilized as tools for classifying quantitative and qualitative changes of biomolecules in PCOS samples. PCOS samples did not correlate with luteinizing hormone (LH) level and proteins but had a negative correlation between carbohydrates and fatty acids, compared with control group.

Effects of Vitamin D Supplementation on Surrogate Markers of Fertility in PCOS Women: A Randomized Controlled Trial

Vitamin D (VD) might play an important role in polycystic ovary syndrome (PCOS) and female fertility. However, evidence from randomized controlled trials (RCT) is sparse. We examined VD effects on anti-Müllerian hormone (AMH) and other endocrine markers in PCOS and non-PCOS women. This is a post hoc analysis of a single-center, double-blind RCT conducted between December 2011 and October 2017 at the endocrine outpatient clinic at the Medical University of Graz, Austria. We included 180 PCOS women and 150 non-PCOS women with serum 25-hydroxyvitamin D (25(OH)D) concentrations <75 nmol/L in the trial. We randomized subjects to receive 20,000 IU of VD3/week (119 PCOS, 99 non-PCOS women) or placebo (61 PCOS, 51 non-PCOS women) for 24 weeks. Outcome measures were AMH, follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, dehydroepiandrosterone sulfate, and androstenedione. In PCOS women, we observed a significant treatment effect on FSH (mean treatment effect 0.94, 95% confidence interval [CI] 0.087 to 1.799, p = 0.031) and LH/FSH ratio (mean treatment effect −0.335, 95% CI −0.621 to 0.050, p = 0.022), whereas no significant effect was observed in non-PCOS women. In PCOS women, VD treatment for 24 weeks had a significant effect on FSH and LH/FSH ratio but no effect on AMH levels.

Indicator of early kidney injury in adolescents with polycystic ovary syndrome: Can urine NGAL level be?

INTRODUCTION AND PURPOSE

The Urinary Neutrophil-gelatinase associated lipocalin (NGAL) levels which are a biomarker for early diagnosis of kidney damage that may develop in patients with Polycystic Ovary Syndrome (PCOS) were investigated in the study.

MATERIAL AND METHODS

The 30 patients diagnosed with Polycystic Ovarian Syndrome between the ages of 13 and 18 who applied to the Yuzuncu Yil University General Children's Outpatient Clinic were included in the PCOS group and 30 healthy adolescents without any known acute or chronic illness and drug use were included in the control group.

FINDINGS

Urine NGAL value was 842.204 ± 21.561 in PCOS group and 775.379 ± 23.98 in control group. NGAL level in PCOS group was statistically significantly higher than control group (p: .045). When we examine the relationship between dyslipidemia and PCOS; While dyslipidemia was positive in 10 (33.7%) patients in the PCOS group, it was negative in 20 (66.7%) patients. While 1 patient had dyslipidemia, 29 patients did not have dyslipidemia in the control group. A significant relationship was found between dyslipidemia and PCOS (p: .005).

CONCLUSION

We found that subclinical kidney dysfunction started in early stage patients in PCOS in our study. The urine NGAL level was thought to increase in response to increased oxidative stress in PCOS. We found no relationship between, insulin resistance and urea, BUN, creatinine and NGAL levels. However, we found a negative correlation between NGAL level and LDL. In addition, dyslipidemia, insulin resistance and ALT elevation were detected in the PCOS group.

A Study on the Clinical and Hormonal Profile of Polycystic Ovarian Syndrome Patients Attending a Tertiary Care Hospital: A Descriptive Cross-sectional Study

INTRODUCTION

Polycystic ovarian syndrome is the most common endocrinological disorder in women of reproductive age and has a considerable metabolic, reproductive, and cardiovascular consequences. This study was designed to provide an overview of the presentation of he clinical profile and hormonal presentation of the patients with polycystic ovarian syndrome attending a tertiary care hospital.

METHODS

A descriptive cross-sectional study was conducted between September 14, 2019 to October 16, 2019 on patients presenting to a tertiary care hospital, after obtaining ethical clearance from Institutional Review Committee (Dated 03/09/2019) and informed consent from the patient or patient relatives. Data entry and analysis were done in Microsoft Excel 10. The data was statistically analysed using Statistical Package for the Social Sciences (SPSS) version 20.0.

RESULTS

The study included 100 PCOS patients. The mean age of the patients was 24.9±4.52 years and the most common group was 26-34 years. The most common presenting symptom was menstrual irregularity which was seen in 86 (86%) of the patients, followed by weight gain in 55 (55%) of the patients. Thirty percent (30 in number) of the patients were overweight, while eleven (11%) of the patients had grade I obesity. LH/FSH ratio was more than or equal to 2 in eighty-three percent 83 (83%) of the patients.

CONCLUSIONS

Polycystic ovarian syndrome has varying clinical manifestations, most commonly affecting the young women of reproductive age group. The commonest presenting complaint in the current study was menstrual abnormality. Majority of the patients had deranged hormonal profile which can lead to an increased risk of cardiovascular disease and type 2 DM. Thus, awareness regarding PCOS is important for early diagnosis and to prevent its sequalae to various complications.

Is there any association between age at menarche and anthropometric indices? A 15-year follow-up population-based cohort study

Anthropometric indices (AI) have been known to be associated with age at menarche (AAM). The aim of this longitudinal study was to evaluate the changes in AI and its association with AAM in a community-based population in Iran. From among 10,192 women, we included 6818, aged ≥ 10 years, who were post-menarche at the time of entering the study and their AAM ranged between 8 and 18 years. Study subjects were divided into groups by tertiles birth cohort (BC) (born ≤ 1939, 1940-1969, and ≥ 1970) and AAM (≤ 11, 12-15, and ≥ 16 years). Generalized estimating equation analysis was performed to evaluate the association between changes of AI in different BCs with AAM groups. Overall mean of AAM was 13.5 ± 1.4 years. Mean body mass index (BMI) was significantly increased over time more in those with early AAM (≤ 11 years) compared to those with AAM ≥ 16 years; changes in mean BMI of 1.24 kg/m² (95% CI 0.32, 2.15), 2.61 kg/m² (95% CI 1.90, 3.33), and 3.99 kg/m² (95% CI 2.46, 5.51) in BC ≥ 1970, BC (1940-1969), and, BC ≤ 1939, respectively.Conclusion: Our findings showed an inverse association of AAM with mean BMI, waist to height ratio, and waist circumference, an association weaker in younger women compared to other age groups. What is Known: • Limited data are available on the association of menarcheal age with anthropometric indices. • Previous studies reported conflicting and inclusive results of this association. What is New: • Our results can provide beneficial information on the association of menarcheal age with anthropometric indices based on different age groups. • This long follow-up study shows an association of menarcheal age with anthropometric indices which are stronger in older women except for height.

PCOS and Hyperprolactinemia: what do we know in 2019?

Polycystic ovary syndrome (PCOS) and hyperprolactinemia (HPRL) are the two most common etiologies of anovulation in women. Since the 1950s, some authors think that there is a pathophysiological link between PCOS and HPRL. Since then, many authors have speculated about the link between these two endocrine entities, but no hypothesis proposed so far could ever be confirmed. Furthermore, PCOS and HPRL are frequent endocrine diseases and a fortuitous association cannot be excluded. The evolution of knowledge about PCOS and HPRL shows that studies conducted before the 2000s are obsolete given current knowledge. Indeed, most of the studies were conducted before consensual diagnosis criteria of PCOS and included small numbers of patients. In addition, the investigation of HPRL in these studies relied on obsolete methods and did not look for the presence of macroprolactinemia. It is therefore possible that HPRL that has been attributed to PCOS corresponded in fact to macroprolactinemia or to pituitary microadenomas of small sizes that could not be detected with the imaging methods of the time. Recent studies that have conducted a rigorous etiological investigation show that HPRL found in PCOS correspond either to non-permanent increase of prolactin levels, to macroprolactinemia or to other etiologies. None of this recent study found HPRL related to PCOS in these patients. Thus, the link between PCOS and HPRL seems to be more of a myth than a well-established medical reality and we believe that the discovery of an HPRL in a PCOS patient needs a standard etiological investigation of HPRL.

Development of Ovulatory Menstrual Cycles in Adolescent Girls

Irregular menstrual cycles due to anovulation are well described in the first few years after menarche, but the normal developmental trajectory from anovulatory to mature ovulatory cycles during adolescence remains undefined. In this article we review the very limited understanding of this final stage of female reproductive axis development and discuss why additional research in this area is critical to the health of women.

Evolutionary origins of polycystic ovary syndrome: An environmental mismatch disorder

Polycystic ovary syndrome (PCOS) is the most common female endocrine disorder and has important evolutionary implications for female reproduction and health. PCOS presents an interesting paradox, as it results in significant anovulation and potential sub-fecundity in industrialized populations, yet it has a surprisingly high prevalence and has a high heritability. In this review, we discuss an overview of PCOS, current diagnostic criteria, associated hormonal pathways and a review of proposed evolutionary hypotheses for the disorder. With a multifactorial etiology that includes ovarian function, metabolism, insulin signaling and multiple genetic risk alleles, PCOS is a complex disorder. We propose that PCOS is a mismatch between previously neutral genetic variants that evolved in physically active subsistence settings that have the potential to become harmful in sedentary industrialized environments. Sedentary obesogenic environments did not exist in ancestral times and exacerbate many of these pathways, resulting in the high prevalence and severity of PCOS today. Overall, the negative impacts of PCOS on reproductive success would likely have been minimal during most of human evolution and unlikely to generate strong selection. Future research and preventative measures should focus on these gene-environment interactions as a form of evolutionary mismatch, particularly in populations that are disproportionately affected by obesity and metabolic disorders.

LAY SUMMARY

The most severe form of polycystic ovary syndrome (PCOS) is likely a result of interactions between genetic predispositions for PCOS and modern obesogenic environments. PCOS would likely have been less severe ancestrally and the fitness reducing effects of PCOS seen today are likely a novel product of sedentary, urban environments.

Gonadotrophins for ovulation induction in women with polycystic ovary syndrome

BACKGROUND

Ovulation induction with follicle stimulating hormone (FSH) is a second-line treatment in women with polycystic ovary syndrome (PCOS) who do not ovulate or conceive on clomiphene citrate.

OBJECTIVES

To compare the effectiveness and safety of gonadotrophins as a second-line treatment for ovulation induction in women with clomiphene citrate-resistant polycystic ovary syndrome (PCOS), and women who do not ovulate or conceive after clomiphene citrate.

SEARCH METHODS

In January 2018, we searched the Cochrane Gynaecology and Fertility Group Specialised Register of Controlled Trials, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, the World Health Organisation clinical trials register, Clinicaltrials.gov, LILACs, and PubMed databases, and Google Scholar. We checked references of in all obtained studies. We had no language restrictions.

SELECTION CRITERIA

All randomised controlled trials reporting data on clinical outcomes in women with PCOS who did not ovulate or conceive on clomiphene citrate, and undergoing ovulation induction with urinary-derived gonadotrophins, including urofollitropin (uFSH) in purified FSH (FSH-P) or highly purified FSH (FSH-HP) form, human menopausal gonadotropin (HMG) and highly purified human menopausal gonadotrophin (HP-HMG), or recombinant FSH (rFSH), or continuing clomiphene citrate. We included trials reporting on ovulation induction followed by intercourse or intrauterine insemination. We excluded studies that described co-treatment with clomiphene citrate, metformin, luteinizing hormone, or letrozole.

DATA COLLECTION AND ANALYSIS

Three review authors (NW, EK, and MvW) independently selected studies for inclusion, assessed risk of bias, and extracted study data. Primary outcomes were live birth rate per woman and multiple pregnancy per woman. Secondary outcomes were clinical pregnancy, miscarriage, incidence of ovarian hyperstimulation syndrome (OHSS) per woman, total gonadotrophin dose, and total duration of stimulation per woman. We combined data using a fixed-effect model to calculate the risk ratio (RR). We summarised the overall quality of evidence for the main outcomes using GRADE criteria.

MAIN RESULTS

The review included 15 trials with 2387 women. Ten trials compared rFSH with urinary-derived gonadotrophins (three compared rFSH with human menopausal gonadotrophin, and seven compared rFSH with FSH-HP), four trials compared FSH-P with HMG. We found no trials that compared FSH-HP with FSH-P. One trial compared FSH with continued clomiphene citrate.Recombinant FSH (rFSH) versus urinary-derived gonadotrophinsThere may be little or no difference in the birth rate between rFSH and urinary-derived gonadotrophins (RR 1.21, 95% confidence interval (CI) 0.83 to 1.78; five trials, N = 505; I² = 9%; low-quality evidence). This suggests that for the observed average live birth per woman who used urinary-derived FSH of 16%, the chance of live birth with rFSH is between 13% and 28%. There may also be little or no difference between groups in incidence of multiple pregnancy (RR 0.86, 95% CI 0.46 to 1.61; eight trials, N = 1368; I² = 0%; low-quality evidence), clinical pregnancy rate (RR 1.05, 95% CI 0.88 to 1.27; eight trials, N = 1330; I² = 0; low-quality evidence), or miscarriage rate (RR 1.20, 95% CI 0.71 to 2.04; seven trials, N = 970; I² = 0; low-quality evidence). We are uncertain whether rFSH reduces the incidence of OHSS (RR 1.48, 95% CI 0.82 to 2.65, ten trials, n=1565, I² = 0%, very low-quality evidence).Human menopausal gonadotrophin (HMG) or HP-HMG versus uFSHWhen compared to uFSH, we are uncertain whether HMG or HP-HMG improves live birth rate (RR 1.28, 95% CI 0.65 to 2.52; three trials, N = 138; I² = 0%; very low quality evidence), or reduces multiple pregnancy rate (RR 2.13, 95% CI 0.51 to 8.91; four trials, N = 161; I² = 0%; very low quality evidence). We are also uncertain whether HMG or HP-HMG improves clinical pregnancy rate (RR 1.31, 95% CI 0.66 to 2.59; three trials, N = 102; I² = 0; very low quality evidence), reduces miscarriage rate (RR 0.33, 95% CI 0.06 to 1.97; two trials, N = 98; I² = 0%; very low quality evidence), or reduces the incidence of OHSS (RR 7.07, 95% CI 0.42 to 117.81; two trials, N = 53; very low quality evidence) when compared to uFSH.Gonadotrophins versus continued clomiphene citrateGonadotrophins resulted in more live births than continued clomiphene citrate (RR 1.24, 95% CI 1.05 to 1.46; one trial, N = 661; I² = 0%; moderate-quality evidence). This suggests that for a woman with a live birth rate of 41% with continued clomiphene citrate, the live birth rate with FSH was between 43% and 60%. There is probably little or no difference in the incidence of multiple pregnancy between treatments (RR 0.89, 95% CI 0.33 to 2.44; one trial, N = 661; I² = 0%; moderate-quality evidence). Gonadotrophins resulted in more clinical pregnancies than continued clomiphene citrate (RR 1.31, 95% CI 1.13 to 1.52; one trial, N = 661; I² = 0%; moderate-quality evidence), and more miscarriages (RR 2.23, 95% CI 1.11 to 4.47; one trial, N = 661; I² = 0%; moderate-quality evidence). None of the women developed OHSS.

AUTHORS' CONCLUSIONS

There may be little or no difference in live birth, incidence of multiple pregnancy, clinical pregnancy rate, or miscarriage rate between urinary-derived gonadotrophins and recombinant follicle stimulating hormone in women with polycystic ovary syndrome. For human menopausal gonadotropin or highly purified human menopausal gonadotrophin versus urinary follicle stimulating hormone we are uncertain whether one or the other improves or lowers live birth, incidence of multiple pregnancy, clinical pregnancy rate, or miscarriage rate. We are uncertain whether any of the interventions reduce the incidence of ovarian hyperstimulation syndrome. We suggest weighing costs and convenience in the decision to use one or the other gonadotrophin. In women with clomiphene citrate failure, gonadotrophins resulted in more live births than continued clomiphene citrate without increasing multiple pregnancies.

MANAGEMENT OF ENDOCRINE DISEASE Hyperandrogenic states in women: pitfalls in laboratory diagnosis

Measuring total testosterone level is the first-line approach in assessing androgen excess in women. The main pitfalls in measuring testosterone relate to its low concentration and to the structural similarity between circulating androgens and testosterone, requiring accurate techniques with high specificity and sensitivity. These goals can be achieved by immunoassay using a specific anti-testosterone monoclonal antibody, ideally after an extraction step. Liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS) will be commonly used for measuring testosterone, providing optimal accuracy with a low limit of detection. Yet, the pitfalls of these two techniques are well identified and must be recognized and systematically addressed. In general, laboratories using direct testosterone immunoassay and mass spectrometry need to operate within a quality framework and be actively engaged in external quality control processes and standardization, so as to ensure appropriate interpretation irrespective of the particular laboratory. Circulating testosterone is strongly bound to sex-hormone-binding globulin (SHBG), and SHBG levels are typically low in overweight hyperandrogenic patients. Thus, low SHBG may decrease circulating testosterone to normal values, which will mask androgen excess status. One way to avoid this pitfall, awaiting direct free testosterone assays that are yet to be developed, is to measure SHBG and calculate free testosterone. A few other pitfalls will be discussed in this review, including those of adrenal androgen exploration, with the aim of helping clinicians to better handle laboratory investigation of androgen excess disorders in women.

Age at menarche and adult body mass index: a Mendelian randomization study

BACKGROUND

Pubertal timing has psychological and physical sequelae. While observational studies have demonstrated an association between age at menarche and adult body mass index (BMI), confounding makes it difficult to infer causality.

METHODS

The Mendelian randomization (MR) technique is not limited by traditional confounding and was used to investigate the presence of a causal effect of age at menarche on adult BMI. MR uses genetic variants as instruments under the assumption that they act on BMI only through age at menarche (no pleiotropy). Using a two-sample MR approach, heterogeneity between the MR estimates from individual instruments was used as a proxy for pleiotropy, with sensitivity analyses performed if detected. Genetic instruments and estimates of their association with age at menarche were obtained from a genome-wide association meta-analysis on 182,416 women. The genetic effects on adult BMI were estimated using data on 80,465 women from the UK Biobank. The presence of a causal effect of age at menarche on adult BMI was further investigated using data on 70,692 women from the GIANT Consortium.

RESULTS

There was evidence of pleiotropy among instruments. Using the UK Biobank data, after removing instruments associated with childhood BMI that were likely exerting pleiotropy, fixed-effect meta-analysis across instruments demonstrated that a 1 year increase in age at menarche reduces adult BMI by 0.38 kg/m² (95% CI 0.25-0.51 kg/m²). However, evidence of pleiotropy remained. MR-Egger regression did not suggest directional bias, and similar estimates to the fixed-effect meta-analysis were obtained in sensitivity analyses when using a random-effect model, multivariable MR, MR-Egger regression, a weighted median estimator and a weighted mode-based estimator. The direction and significance of the causal effect were replicated using GIANT Consortium data.

CONCLUSION

MR provides evidence to support the hypothesis that earlier age at menarche causes higher adult BMI. Complex hormonal and psychological factors may be responsible.

High-fat diet exposure from pre-pubertal age induces polycystic ovary syndrome (PCOS) in rats

Polycystic ovary syndrome (PCOS) is associated with hyperandrogenism, oligo-anovulation, polycystic ovaries and metabolic syndrome. Many researchers reported that PCOS often starts with menarche in adolescents. Presently available animal model focuses on ovarian but not metabolic features of PCOS. Therefore, we hypothesized that high-fat diet feeding to pre-pubertal female rats results in both reproductive and metabolic features of PCOS. Pre-pubertal female rats were divided into two groups: group I received normal pellet diet and group II received high-fat diet (HFD). In the letrozole study, adult female rats were divided into two groups: group I received 1% carboxy methyl cellulose and group II received 1 mg/kg letrozole orally. Oral glucose tolerance test, lipid profile, fasting glucose, insulin, estrus cycle, hormonal profile, ovary weight, luteinizing hormone (LH) receptor and follicle-stimulating hormone receptor expression were measured. Polycystic ovarian morphology was assessed through histopathological changes of ovary. Feeding of HFD gradually increase glucose intolerance and fasting insulin levels. Triglyceride level was higher in HFD study while total cholesterol level was higher in the letrozole study. Alteration in testosterone and estrogen levels was observed in both studies. LH receptor expression was upregulated only in HFD study. Histopathological changes like increase cystic follicle, diminished granulosa cell layer and thickened theca cell layer were observed in letrozole as well as HFD study. High-fat diet initiated at pre-puberty age in rats produces both metabolic disturbances and ovarian changes similar to that observed clinically in PCOS patients. Letrozole on the other hand induces change in ovarian structure and function.

Extraovarian gonadotropin negative feedback revealed by aromatase inhibition in female marmoset monkeys

Whereas the ovary produces the majority of estradiol (E2) in mature female primates, extraovarian sources contribute to E2 synthesis and action, including the brain E2-regulating hypothalamic gonadotropin-releasing hormone. In ovary-intact female rodent models, aromatase inhibition (AI) induces a polycystic ovary syndrome-like hypergonadotropic hyperandrogenism due to absent E2-mediated negative feedback. To examine the role of extraovarian E2 on nonhuman primate gonadotropin regulation, the present study uses letrozole to elicit AI in adult female marmoset monkeys. Sixteen female marmosets (Callithrix jacchus; >2 yr) were randomly assigned to ovary-intact or ovariectomy (OVX) conditions and subsequently placed on a daily oral regimen of either ~200 µl vehicle alone (ovary-intact Control, n = 3; OVX, n = 3) or 1 mg ⋅ kg-1 ⋅ day-1 letrozole in vehicle (ovary-intact AI, n = 4; OVX + AI, n = 6). Blood samples were collected every 10 days, and plasma chorionic gonadotropin (CG) and steroid hormone levels were determined by validated radioimmunoassay and liquid chromatography/tandem mass spectrometry, respectively. Ovary-intact, AI-treated and OVX females exhibited elevated CG (P < 0.01, P = 0.004, respectively) compared with controls, and after 30 days, OVX + AI females exhibited a suprahypergonadotropic phenotype (P = 0.004) compared with ovary-intact + AI and OVX females. Androstenedione (P = 0.03) and testosterone (P = 0.05) were also elevated in ovary-intact, AI-treated females above all other groups. The current study thus confirms in a nonhuman primate that E2 depletion and diminished negative feedback in ovary-intact females engage hypergonadotropic hyperandrogenism. Additionally, we demonstrate that extraovarian estrogens, possibly neuroestrogens, contribute to female negative feedback regulation of gonadotropin release.

The Rotterdam criteria for polycystic ovary syndrome: evidence-based criteria?

The Rotterdam criteria for polycystic ovary syndrome (PCOS) are used by a wide range of medical professionals and researchers. However, the development of these criteria was based on expert meetings and not on evidence-based treatment guidance. Over the last decade, the Rotterdam criteria have been useful in guiding research, and a number of clinical studies on PCOS have been published consequently. We plead to revisit the Rotterdam criteria based on the available evidence in prognostic studies and randomized controlled trials. In this opinion paper, we provide arguments of the strengths and limitations of the Rotterdam criteria in guiding treatment selections and predicting prognoses in women with infertility. While the Rotterdam criteria have shown their advantages in predicting reproductive prognosis, the next step is to evaluate whether they can guide treatment choices in infertility as well as other health aspects of the syndrome. Based on available data in clinical studies, we should be able to determine whether the Rotterdam criteria are evidence-based criteria.

Effects of gonadotropin-releasing hormone agonist and antagonist on ovarian activity in a mouse model for polycystic ovary

PCOS is a major cause of anovulatory infertility in women in their reproductive age. However, its etiology and pathophysiology remain uncertain. The immature mice chronically injected with DHEA, termed as PCO-mice, develop numerous large cystic follicles, high circulating androgen and anovulation similar to PCOS in women. Although PCO-mice show decreased ovarian GnRH I-receptor in immunoblot but show increased immunostaining for GnRH I-receptor in oocytes of cystic follicles. PCO-mice show reduced ovarian LH receptor expression, circulating estradiol and progesterone level compared to normal mice injected with vehicle only. The treatment with low dose of GnRH-Agonist in PCO-mice restores ovarian LH receptor expression to the level of normal mice and promote ovulation and formation of functional corpus luteum. GnRH-Antagonist although cause ovulation in PCO-mice but does not restore LH receptor expression to the level of normal mice, and they show low circulating progesterone and hypertrophied vacuolated corpus luteum. Our study suggests that GnRH-agonist restores ovulation in PCO-mice and produces biphasic and beneficial effect over the use of GnRH-Antagonist.

Gonadotrophins for ovulation induction in women with polycystic ovarian syndrome

BACKGROUND

Ovulation induction with follicle stimulating hormone (FSH) is the second-line treatment in women with polycystic ovary syndrome (PCOS) who do not ovulate or conceive on clomiphene citrate (CC).

OBJECTIVES

To compare the effectiveness and safety of gonadotrophins as a second-line treatment for ovulation induction in women with CC-resistant PCOS.

SEARCH METHODS

We searched the Menstrual Disorders & Subfertility Group's Specialist Register of controlled trials, the Cochrane Central Register of Controlled Trials, MEDLINE (1966 to October 2014), EMBASE (1980 to October 2014), CINAHL (1982 to October 2014), National Research Register and web-based trials databases such as Current Controlled Trials. There was no language restriction.

SELECTION CRITERIA

All randomised controlled trials reporting data on comparing clinical outcomes in women with PCOS who did not ovulate or conceive on CC, and undergoing ovulation induction with urinary FSH (uFSH: FSH-P or FSH-HP), HMG/HP-HMG or recombinant FSH. We included trials reporting on ovulation induction followed by intercourse or intrauterine insemination. We excluded studies that used co-treatment with CC, metformin, LH or letrozole.

DATA COLLECTION AND ANALYSIS

Three review authors (NW, MN and MvW) independently selected studies for inclusion, assessed study quality and extracted study data. Primary outcomes were live birth rate per woman (effectiveness outcome) and incidence of ovarian hyperstimulation syndrome (OHSS) per woman (safety outcome). Secondary outcomes were clinical pregnancy, miscarriage, multiple pregnancy, total gonadotrophin dose and total duration of stimulation per woman. We combined data using a fixed-effect model to calculate the odds ratio (OR). We summarised the overall quality of evidence for the main outcomes using GRADE criteria.

MAIN RESULTS

The review includes 14 trials with 1726 women. Ten trials compared rFSH versus urinary-derived gonadotrophins (three rFSH versus HMG and seven rFSH versus FSH-HP), four trials compared FSH-P with HMG. We found no trials that compared FSH-HP with FSH-P.We found no evidence of a difference in live birth for rFSH versus urinary-derived gonadotrophins (OR 1.26, 95% CI 0.80 to 1.99, 5 trials, 505 women, I² = 0%, low-quality evidence) or clinical pregnancy rate (OR 1.08, 95% CI 0.83 to 1.39, 8 trials, 1330 women, I² = 0, low-quality evidence). This suggests that for the observed average live birth per woman with urinary-derived FSH of 16%, the chance of live birth following rFSH is between 13% and 26%.For the comparison HMG or HP-HMG versus FSH-P there was also no difference in the evidence on live birth rate (OR 1.36, 95% CI 0.58 to 3.18, 3 trials, 138 women, I² = 0%, low-quality evidence). This suggests that for a woman with a live birth rate of 18% with HMG or HP-HMG, the chance of live birth following uFSH is between 9% and 37%.Trial authors used various definitions for OHSS. Pooling the data, we found no evidence of a difference for rFSH versus urinary-derived gonadotrophins (OR 1.52, 95% CI 0.81 to 2.84, 10 trials, 1565 women, I(2) = 0%, very low-quality evidence) and for HMG or HP-HMG versus FSH-P (OR 9.95, 95% CI 0.47 to 210.19, 2 trials, 53 women, I² = 0%, very low-quality evidence).

AUTHORS' CONCLUSIONS

In women with PCOS and CC resistance or CC failure, we found no evidence of a difference in live birth and OHSS rates between urinary-derived gonadotrophins and rFSH or HMG/HP-HMG. Evidence for all outcomes was of low or very low quality. We suggest weighing costs and convenience in the decision to use one or the other.

Effects of resistin on ovarian folliculogenesis and steroidogenesis in the vespertilionid bat, Scotophilus heathi

The bat Scotophilus heathi exhibit prolonged anovulatory condition known as delayed ovulation coinciding with the period of extensive fat accumulation. The present study was undertaken to find out whether extensive accumulation of fat in S. heathi is responsible for suppression of ovarian activity by increasing production of adipokine resistin in the bat. This was achieved by (a) investigating variation in serum resistin level in relation to the changes in the body fat mass and (b) evaluating the effect of resistin treatment on ovarian activity with reference to steroid synthesis. An attempt was also made to determine whether resistin mediate its effects on ovary through signal transducer and activator of transcription 3 (STAT3) signaling mechanism. The results showed significant seasonal variation in serum resistin level with the peak level coinciding with the period of maximum fat accumulation, high circulating androgen level and period of anovulation. The treatment with resistin to the bat caused increase in androstenedione due to stimulatory effects on 3β-hydroxysteroid dehydrogenase, but decrease in estradiol level due to inhibitory effect on aromatase. Resistin treatment increased androgen receptor protein together with increased insulin receptor but not through conventional luteinizing hormone receptor and steroidogenic acute regulatory protein mediated pathways. This study further showed that resistin treatment increases androstenedione synthesis and up-regulates insulin receptor in the ovary through STAT3 mediated pathways. These findings suggest that obese women through increased resistin synthesis may causes development of non-ovulatory antral follicles through insulin receptor signaling cascade.

Decreased inhibin B responses following recombinant human chorionic gonadotropin administration in normal women and women with polycystic ovary syndrome

OBJECTIVE

To determine whether granulosa cells contribute to excess androgen production, by assessing inhibin B (Inh B) responses to hCG in women with polycystic ovary syndrome (PCOS) and in normal women.

DESIGN

Prospective study.

SETTING

Academic medical center.

PATIENT(S)

Twenty women with PCOS and 16 normal women.

INTERVENTION(S)

Blood samples obtained before and 24 hours after injection of 25 μg recombinant hCG (r-hCG).

MAIN OUTCOME MEASURE(S)

Basal and stimulated Inh B, E2, androstenedione (A), and T responses after r-hCG administration.

RESULT(S)

In normal and PCOS women, r-hCG induced a significant reduction of Inh B levels. Lowered Inh B responses were not related to body mass index, PCOS status, or age by multivariate regression. Recombinant hCG significantly increased serum A and E2 in both normal and PCOS women.

CONCLUSION(S)

In normal and PCOS women, Inh B production was decreased following r-hCG administration. These findings strongly suggest that in PCOS women androgen excess is not enhanced by LH-stimulated Inh B production.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00747617.

Dysregulation of ovarian follicular development in female rat: LH decreases FSH sensitivity during preantral-early antral transition

Several clinical studies have shown a correlation of hypersecretion of LH and polycystic ovary syndrome (PCOS), infertility, and miscarriage in women, suggesting that chronically elevated LH impairs fertility. Growth arrest of small antral follicles in PCOS is also assumed to be associated with an abnormal endocrine environment involving increased LH stimulation, a hyperandrogenic milieu, and subsequent dysregulated FSH action in the ovarian follicles. In this study, we examined whether and how LH modulates follicular development and steroid production during preantral-early antral follicle transition by using a rat preantral follicle culture system. LH augments testosterone and estradiol production in preantral follicles via up-regulating mRNA abundance of CYP17A1 and CYP19A1. LH promotes rat preantral follicle growth, and the follicular size reaches that of early antral follicles in vitro, a response attenuated by the specific androgen receptor antagonist and a targeted disruption of androgen receptor gene. Sustained follicle stimulation by LH, but not by androgen, decreases FSH receptor mRNA levels and FSH receptor signaling and inhibits FSH-induced follicular growth. The data suggest that LH promotes preantral-early antral transition via the increased synthesis and growth-promoting action of androgen. However, chronic LH stimulation impairs FSH-dependent antral follicle growth by suppressing granulosa cell FSHR expression via the modulation of intraovarian regulators, including LH-induced thecal factors.

Role of female pelvic anatomy in infertility

Infertility is defined as a couple's failure to achieve pregnancy after one year of regular, unprotected intercourse. The etiology of infertility can be due to female factors, male factors, combined male and female factors, or have an unknown etiology. This review focuses on the role of female pelvic anatomy in infertility. Normal anatomy and the physiology of reproduction will be discussed, as well as the anatomic and pathophysiologic processes that cause infertility including ovulatory disorders, endometriosis, pelvic adhesions, tubal blockage, mullerian anomalies, and abnormalities affecting the uterine cavity such as leiomyomata and endometrial polyps.

Aloe barbadensis Mill. formulation restores lipid profile to normal in a letrozole-induced polycystic ovarian syndrome rat model

Background:

Polycystic ovarian syndrome (PCOS), characterized by ovulatory infertility and hyperandrogenism, is associated with metabolic complications such as dyslipidemia, insulin resistance and endothelial dysfunction. Almost 70% PCOS women have abnormal serum lipid levels (dyslipidemia) and 50% of these women are obese. Several classes of pharmacological agents have been used to manage dyslipidemia. However, studies have shown adverse effects associated with these drugs. In the light of alternate therapy, many medicinal herbs have been reported to show hypoglycemic, anti-hyperlipidemic potential. Aloe barbadensis Mill. or Aloe vera is reported as one such herb. This study was to evaluate the lipid correcting effect of Aloe vera gel (AVG) in a PCOS rat model.

Materials and Methods:

PCOS was induced in Charles Foster female rats by oral administration of non-steroidal aromatase inhibitor letrozole (0.5 mg/kg body weight, 21 days). All rats were hyperglycemic and 90% rats also showed elevated plasma triglycerides, elevated LDL cholesterol levels, and lowered plasma HDL cholesterol levels indicative of a dyslipidemic profile. PCOS positive rats with an aberrant lipid profile were selected for treatment. An AVG formulation (1 ml (10 mg)/day, 30 days) was administered orally.

Results and Conclusion:

AVG treated PCOS rats exhibited significant reduction in plasma triglyceride and LDL cholesterol levels, with an increase in HDL cholesterol. The gel treatment also caused reversion of abnormal estrous cyclicity, glucose intolerance, and lipid metabolizing enzyme activities, bringing them to normal. In conclusion, AVG has phyto components with anti-hyperlipidemic effects and it has shown efficacy in management of not only PCOS but also the associated metabolic complication : dyslipidemia.

Effects of adiponectin on ovarian folliculogenesis and steroidogenesis in the vespertilionid bat, Scotophilus heathi

The bat Scotophilus heathi undergo anovulation, known as delayed ovulation, coinciding with the period of seasonal adiposity due to fat accumulation. Because adiponectin is a well known fat cell product, it might be responsible for adiposity related anovulation in S. heathi. The aim of this study was thus to evaluate the effects of adiponectin treatment on ovarian activity in S. heathi. The bat during the period of delayed ovulation was treated with adiponectin (25 μg/day) for 12 days. Changes taken place in the ovarian activity of the treated bat was compared with the control bat and results obtained are presented here. Adiponectin treatment significantly decreased body mass by depleting adipose tissue. It acts directly upon the ovary and promotes antral follicular development by stimulating cell proliferation and modulating ovarian steroidogenesis. The bat treated with adiponectin showed significant decrease in circulating androstenedione (A4) and estradiol (E2) levels, but increase in circulating progesterone (P4) level. The inhibitory effect of adiponectin on androgen synthesis may be due to decreased thecal-interstitial cells differentiation in stroma by suppressing adiponectin receptor type 1 (AdipoR1), luteinizing hormone (LH) and insulin receptors in the ovary of S. heathi. The study provides evidences suggesting that the adiponectin treatment suppresses adiposity and restores normal ovarian activity.

Infertility in WNIN Obese Mutant Rats-Causes?

We are maintaining two obese mutant rat strains (WNIN/Ob and WNIN/GR-Ob) in our animal facility since 1997. These rat colonies are perpetuated by crossing heterozygous littermates, since the obese phenotypes of both genders turned out be infertile. The present study revealed the reasons for this infertility. The male obese rats, though appeared normal in terms of sperm count, sperm motility and testis histology, however found wanting in terms of libido. This appeared to be due to low circulating testosterone levels seen in these animals, which should also account for low testis and accessory gland weights seen in them. The females exhibited delayed puberty, in terms of days taken for opening of vagina, irregular oestrus cycles and had small ovaries and short and stumpy uterine horns. The FSH peak observed in control lean animals during oestrus stage of the sexual cycle and also the E2 peak of normal oestrus cycle was conspicuously absent in these animals. They also showed elevated levels of progesterone throughout the sexual cycle. Thus the infertility seen in these mutants could be attributed to their abnormal gonadosteroid levels and the resulting anatomical and physiological defects.

Evaluation of glycemic and oxidative/antioxidative status in the estradiol valerate-induced PCOS model of rats

OBJECTIVE

The aim of this study was to show glycemic and oxidative/antioxidative status (GOAS) in rats with estradiol valerate (EV)-induced polycystic ovarian syndrome.

STUDY DESIGN

Thirty mature female rats were randomly allocated to EV-induced PCOS, sham and control groups. Malondialdehyde, catalase and fasting blood glucose levels were determined in order to evaluate GOAS.

RESULTS

There was a statistically significant difference between PCOS and control groups (p<0.001) for hemolysate MDA while no difference was determined for either catalase or fasting blood glucose levels. On histopathological examination, the EV-induced PCOS group revealed disease-characteristic ovarian morphology.

CONCLUSION

There was an increased compensation for oxidative stress by antioxidative biologic mechanisms in EV-induced PCOS rats. Interestingly, the sole result derived from this limited study is that the sesame oil+EV combination is not appropriate for the evaluation of oxidant-antioxidant status and also glycemic condition in PCOS. This study demonstrates the need for better designed experimental studies to elucidate the aetiopathogenesis of PCOS via novel techniques.

Colocalization of FM1-43, Bassoon, and GnRH-1: GnRH-1 release from cell bodies and their neuroprocesses

Pulsatile release of GnRH-1 is critical for reproductive function. However, the cellular mechanism of GnRH-1 neurosecretion is still elusive. In this study, we examined the neurosecretory process of GnRH-1 neurons using time-lapse image acquisition followed by immunocytochemistry with confocal microscopy. To monitor exocytotic processes, cultured GnRH-1 neurons derived from monkey embryos were labeled with the lipophilic dye, FM1-43, or its fixable form FM1-43Fx, in the presence or absence of depolarization signals, and changes in vesicles labeled with FM1-43 were analyzed. The results show FM1-43 was taken up into the cell and labeled puncta in the soma and neuroprocesses in the absence of depolarization signals, indicating that GnRH-1 neurons were spontaneously active. Depolarization of GnRH-1 neurons with high K+ or veratridine challenge increased the intensity and size of puncta in both soma and neuroprocesses, and the veratridine-induced changes in puncta were blocked by tetrodotoxin, indicating that changes in the puncta intensity and size reflect neurosecretory activity. Subsequent double immunocytochemistry for GnRH-1 and the synaptic vesicle marker, vesicle-associated membrane protein, demonstrated that the FM1-43Fx-labeled puncta were synaptic vesicles with the GnRH-1 peptide. Additional double immunocytochemistry for GnRH-1 and the marker of the neurosecretory active zone, Bassoon, indicated that the FM1-43Fx-labeled puncta were located at the sites of neurosecretory active zones in GnRH-1 neurons. These results suggest that GnRH-1 neurons have the capacity to release the peptide from the soma and dendrites. Collectively, we hypothesize that soma-dendritic release of the peptide may be a mechanism of synchronized activity among GnRH-1 neurons.

Thiazolidinediones and Fertility in Polycystic Ovary Syndrome (PCOS)

Polycystic ovary syndrome (PCOS) is the most frequent cause of female infertility. The treatment of PCOS patients with insulin sensitizers, such as metformin or thiazolidinediones, increases the ovulation rate and the number of successful pregnancies. The positive action of the insulin-sensitizing treatments could be explained by a decrease in the peripheral insulin resistance but also by a direct action at the ovarian level. We report in this review different hypotheses of thiazolidinediones actions to improve PCOS (steroid secretion by ovarian cells ; insulin sensitivity in muscle and adipocyte and fat redistribution).

Reproductive hormone levels and anthropometry in postmenopausal women with polycystic ovary syndrome (PCOS): a 21-year follow-up study of women diagnosed with PCOS around 50 years ago and their age-matched controls

CONTEXT

The hormonal and anthropometric profile of premenopausal women with polycystic ovary syndrome (PCOS) is well described, but there is a lack of data concerning changes in these variables into the postmenopausal period.

OBJECTIVE

Our objective was to examine whether PCOS women differ from normal women regarding levels of reproductive hormones, anthropometry, and presence of hirsutism/climacteric symptoms also after menopause.

DESIGN AND SETTING

In this prospective study, women with PCOS (61-79 yr) and age-matched controls, examined in 1987, were reinvestigated at a university hospital.

PARTICIPANTS

Twenty-five PCOS patients (Rotterdam criteria) and 68 controls (randomly allocated from the Gothenburg WHO MONICA study) participated.

INTERVENTIONS

Reexamination and hormonal measurements were done 21 yr after previous visit.

MAIN OUTCOME MEASURES

FSH, LH, TSH, thyroid peroxidase antibodies, prolactin, estrone, estradiol, SHBG, androstenedione, total testosterone, dehydroepiandrosterone sulfate, free androgen index, and anthropometry were determined. Presence of climacteric symptoms, hirsutism, and menopausal age were recorded.

RESULTS

PCOS women had higher free androgen index (P = 0.001) but lower FSH (P < 0.001) and SHBG (P < 0.01) than controls. Menopausal age, body weight, body mass index, waist to hip ratio, LH, prolactin, androstenedione, dehydroepiandrosterone sulfate, total testosterone, estradiol, and estrone were similar in PCOS and controls. Women with PCOS reported hirsutism more frequently (P < 0.001) but had fewer climacteric symptoms (P < 0.05) and hypothyroidism than controls (P < 0.05).

CONCLUSIONS

PCOS women differ from controls with regard to levels of certain reproductive hormones also after menopause, but the established premenopausal increase in waist to hip ratio in PCOS patients disappeared after menopause, mainly due to weight gain among controls. A novel finding was the lower prevalence of hypothyroidism in PCOS women.

Effect of thyroid hormone replacement therapy on ovarian volume and androgen hormones in patients with untreated primary hypothyroidism

BACKGROUND AND OBJECTIVES

Primary hypothyroidism may be associated with ovarian enlargement and/ or cyst formation. We evaluated the effect of thyroid hormone replacement therapy on hormonal changes, ovarian volume and sonographic appearance.

DESIGN AND SETTING

Open, prospective study of women admitted to university gynecology clinic.

PATIENTS AND METHODS

The study included 26 patients with untreated hypothyroidism who had polycystic (n=10) or normal-appearing (n=16) ovaries and 20 euthyroidic controls. Basal serum total testosterone, free testosterone, androstenedione, dehydroepiandosterone-sulfate, prolactin, estradiol, luteinizing hormone, follicle-stimulating hormone, free T3, free T4 and thyroid-stimulating horone, together with ovarian volumes, were determined and repeated after euthyroidism was achieved.

RESULTS

Ovarian volumes of patients with hypothyroidism were significantly greater compared with controls, and their magnitudes diminished significantly during thyroid hormone replacement therapy. Hypothyroidic patients with polycystic ovaries had significantly higher serum free testosterone and dehydroepiandosterone-sulfate, but lower androstenodione levels compared with those who had normal-appearing ovaries. Serum total testosterone concentrations were significantly higher in hypothyroidic patients without polycystic ovaries, and thyroid hormone replacement therapy achieved a significant reduction in total as well as free testosterone.

CONCLUSION

Severe longstanding hypothyroidism leads to increased ovarian volume and/or cyst formation. A decrease in ovarian volume, resolution of ovarian cysts and reversal of the polycystic ovary syndrome-like appearance, together with improvement in serum hormone levels, occurred after euthyroidism was achieved.

Evidence that obesity and androgens have independent and opposing effects on gonadotropin production from puberty to maturity

Optimal fat mass is necessary for normal gonadotropin levels in adults, and both undernutrition and overnutrition suppress gonadotropins: thus, the gonadotropin response to relative adipose mass is biphasic. Adult obesity is associated with blunted luteinizing hormone (LH) pulse amplitude that is partially attributable to increased LH clearance rate. Testosterone appears to have a biphasic effect on gonadotropin production in females. Moderate elevations of testosterone appear to stimulate LH production at both the hypothalamic and pituitary level, while very high levels of testosterone suppress LH. Thus, obesity per se appears to suppress gonadotropin production, and moderate hyperandrogenemia in women appears to stimulate LH. The ordinary hypergonadotropic hyperandrogenism of obese women appears to be an exception to this model because it is usually due to polycystic ovary syndrome (PCOS), a condition in which intrinsic functional ovarian hyperandrogenism and excess adiposity share a common origin that involves insulin-resistant hyperinsulinemia. LH elevation seems to be secondary to hyperandrogenemia and is absent in the most obese cases. Overweight early pubertal girls have significant blunting of sleep-related LH production, which is the first hormonal change of puberty. The data are compatible with the possibility that excess adiposity may paradoxically subtly suppress hypothalamic-pituitary-gonadal function in early puberty although it is known to contribute to the early onset of puberty.

Targeting insulin sensitivity in the treatment of polycystic ovary syndrome

Targeting insulin resistance may result in a list of benefits for women with PCOS, including hormonal, metabolic and ovulatory (and fertility) improvements. The therapeutic strategy to treat PCOS should however depend on the clinical situation, the phenotype, the degree of androgen excess, age, the presence of infertility and the woman's desire to conceive, the presence of obesity and, finally, the spectrum of metabolic abnormalities and the need to treat or prevent long-term associated comorbidities. According to the needs, therapeutic options include, alone or in combination, lifestyle management, particularly in the presence of obesity, the use of insulin sensitizers, metformin and thiazolidinediones, antiandrogens or estro-progestins.

Improvement in quality-of-life questionnaire measures in obese adolescent females with polycystic ovary syndrome treated with lifestyle changes and oral contraceptives, with or without metformin

We studied the effect of metformin or placebo in a lifestyle modification program combined with oral contraceptives (OC) on quality-of-life parameters measured by the polycystic ovary syndrome (PCOS) questionnaire in obese adolescent women with validated PCOS. The quality-of-life indicators were measured at baseline and conclusion for five domains on the PCOS questionnaire, with equal improvement in scores in both placebo and metformin groups, suggesting that the addition of metformin does not add improvement to quality-of-life measures above those observed with lifestyle modification and OC treatment.

Acute effects of testosterone infusion on the serum luteinizing hormone profile in eumenorrheic and polycystic ovary syndrome adolescents

CONTEXT

Little is known about the neuroendocrine effects of androgens on the GnRH-LH unit in females.

OBJECTIVE

Our objective was to evaluate androgen negative feedback on the GnRH-LH axis in eumenorrheic and polycystic ovary syndrome (PCOS) adolescents.

DESIGN AND SETTING

We conducted a prospective, longitudinal, randomized, double-blind study at a pediatric endocrinology clinical research center.

PARTICIPANTS

Seven nonobese PCOS adolescents and seven matched controls (C) were studied in the early follicular phase of three consecutive menstrual cycles or in three consecutive months.

INTERVENTION

Pulsatile LH release was determined during saline [baseline (B)] and constant testosterone (T) infusions: low dose (T-LD) 0.75 and high dose (T-HD) 2.5 mg/12 h iv. Blood samples were drawn every 20 min overnight.

MAIN OUTCOME MEASURES

LH (immunofluorometric assay) and T (electrochemiluminescence immunoassay) were determined at B, and during both T-LD and T-HD. LH profiles were analyzed by deconvolution and approximate entropy analyses.

RESULTS

On T-LD, C and PCOS serum T levels increased 2- to 3-fold vs. B. On T-HD, T values doubled in both groups vs. T-LD. Controls on T-LD had greater 12-h pulsatile LH secretion rate (P < 0.05 vs. B) and on T-HD had lower mean, pulsatile, basal LH release and LH approximate entropy (vs. B, P < 0.05). PCOS did not respond to T-LD. High-dose T did not alter mean LH in PCOS but increased pulsatile and reduced basal LH secretion.

CONCLUSIONS

PCOS adolescents have impaired suppression of pulsatile LH secretion rate consistent with reduced androgen negative feedback. Attenuation of T feedback in nonobese adolescents with PCOS extends the pathophysiology of this syndrome.

The role of intraovarian regulators in the aetiology of polycystic ovarian syndrome

The present review demonstrates that the availability of bioactive FSH and LH in PCOS is normal and that granulosa cells of PCO are not apoptotic and instead hyperexpress functional FSH receptors and may possess intact aromatase activity. Consequently, these cells respond excessively to exogenous FSH stimulation and produce high amounts of oestradiol bothin vivoandin vitro. The altered developmental capacity of follicles from PCOin vivois most likely due to the abnormal follicular milieu of PCO and the culminating effects of intrafollicular inhibitors and stimulators. The failure of ovarian oestradiol production and follicular maturation to dominancein vivomay be due to a mechanism that interferes with the function of FSH, such as intraovarian steroids and growth factors. It has previously been shown that EGF and TGFα have inhibitory actions on follicular development, aromatization and LH receptor formation. In contrast, EGF enhances early follicular recruitment and growth. Therefore, it is hypothesized that EGF/TGFα may have a causal relationship in the mechanisms of anovulatory infertility in women with PCOS. Thus, an aberration in the regulation of follicular fluid EGF and/or TGFα may result in reduced numbers of granulosa cells, cessation of follicle selection and ultimately in the creation and maintenance of PCOS. The exact mechanism by which the hyperfunction of EGF/TGFα occurs and the trigger for this hyperactivity in the ovary remain to be determined. An experimental animal model may be required to assist such investigations in the future.

The estrogen-injected female mouse: new insight into the etiology of PCOS

BACKGROUND

Female mice and rats injected with estrogen perinatally become anovulatory and develop follicular cysts. The current consensus is that this adverse response to estrogen involves the hypothalamus and occurs because of an estrogen-induced alteration in the GnRH delivery system. Whether or not this is true has yet to be firmly established. The present study examined an alternate possibility in which anovulation and cyst development occurs through an estrogen-induced disruption in the immune system, achieved through the intermediation of the thymus gland.

METHODS, RESULTS AND CONCLUSION

A putative role for the thymus in estrogen-induced anovulation and follicular cyst formation (a model of PCOS) was examined in female mice by removing the gland prior to estrogen injection. Whereas all intact, female mice injected with 20 microg estrogen at 5-7 days of age had ovaries with follicular cysts, no cysts were observed in animals in which thymectomy at 3 days of age preceded estrogen injection. In fact, after restoring immune function by thymocyte replacement, the majority of thymectomized, estrogen-injected mice had ovaries with corpora lutea. Thus, when estrogen is unable to act on the thymus, ovulation occurs and follicular cysts do not develop. This implicates the thymus in the cysts' genesis and discounts the role of the hypothalamus. Subsequent research established that the disease is transferable by lymphocyte infusion. Transfer took place between 100-day-old estrogen-injected and 15-day-old naïve mice only when recipients were thymectomized at 3 days of age. Thus, a prerequisite for cyst formation is the absence of regulatory T cells. Their absence in donor mice was judged to be the result of an estrogen-induced increase in the thymus' vascular permeability, causing de facto circumvention of the final stages of regulatory T cell development. The human thymus has a similar vulnerability to steroid action during the fetal stage. We propose that in utero exposure to excessive levels of steroids such as estrogen has a long-term effect on the ability of the thymus to produce regulatory T cells. In female offspring this can lead to PCOS.

Evidence for insulin suppression of baseline luteinizing hormone in women with polycystic ovarian syndrome and normal women

CONTEXT

In women with polycystic ovarian syndrome (PCOS), the relationship of insulin to LH secretion and responses to GnRH remains unresolved. A rigorous analytical examination of this relationship has not been performed.

OBJECTIVE

Our objective was to determine the relationship of basal LH secretion and responses to GnRH, insulin, and other endocrine variables in normal and PCOS women.

DESIGN

In PCOS and normal women, mean composite 12-h LH secretion was analyzed for correlating factors. LH responses to varying doses of GnRH during a fixed rate of insulin infusion and LH responses to a fixed dose of GnRH during varying doses of insulin infusion were analyzed for contributing factors.

PATIENTS AND SETTING

Eighteen PCOS and 21 normal women underwent studies of frequent blood sampling and GnRH stimulation before and during insulin infusion at the General Clinical Research Center, University of California, San Diego.

MAIN OUTCOME MEASURES

Group mean composite 12-h LH levels were assessed with respect to other endocrine variables. In addition, LH responses to GnRH with or without insulin infusion were assessed.

RESULTS

In normal women, insulin negatively predicted mean LH. In PCOS, the combined effect of body mass index (negative) and testosterone (positive) predicted LH. The best predictor of LH was body mass index and insulin combined. Basal LH and LH responses to GnRH were unaltered by insulin infusion in normal women. These measures were reduced during insulin infusion in PCOS women.

CONCLUSIONS

In PCOS, insulin infusion suppresses pituitary response to GnRH. In normal women, insulin negatively correlates with mean LH and suppresses GnRH response at a high infusion rate.

Increased androgen response to follicle-stimulating hormone administration in women with polycystic ovary syndrome

CONTEXT

In women with polycystic ovary syndrome (PCOS), excess ovarian androgen production is driven by increased LH secretion. Studies conducted in animals suggest that the granulosa cell may influence LH-stimulated theca cell androgen production.

OBJECTIVE

The objective of this study was to determine whether FSH enhances androgen production in women with PCOS compared with that of normal women.

DESIGN

A prospective study was conducted to compare androgen production in response to FSH in two groups of women.

SETTING

The study was conducted in a General Clinical Research Center in a tertiary academic medical center.

PATIENTS

Women with PCOS, 18-35 yr (n = 20), and normal ovulatory controls, 18-35 yr (n = 10), were recruited for study.

INTERVENTIONS

Serial blood samples were obtained over a 24-h period after an iv injection of recombinant human FSH (150 IU).

MAIN OUTCOME MEASURES

The main outcome measures were serum 17-hydroxyprogesterone (17-OHP), androstenedione (A), dehydroepiandrosterone (DHEA), testosterone (T), and inhibin B (Inh B) responses after FSH administration.

RESULTS

Basal serum 17-OHP, A, and T levels were markedly increased in women with PCOS compared with that observed in normal women. Basal DHEA and Inh B levels were similar to those of normal controls. After FSH injection, PCOS women demonstrated enhanced production of 17-OHP, A, DHEA, and Inh B, whereas in normal women no increases were observed. T levels declined slightly in both groups.

CONCLUSIONS

These findings provide evidence that, in PCOS women, theca cell androgen production is enhanced by FSH administration and suggest a granulosa-theca cell paracrine mechanism.

The impact of unabated stimulation by human chorionic gonadotropin on the steroid hormone environment of pregnant rats and the spontaneous expression of ovarian cysts in female progeny

Unabated stimulation by low doses of human chorionic gonadotropin (hCG) induces ovarian cysts in pregnant rats. In order to determine the impact of these in vivo treatments on the hormonal milieu of pregnancy, and the potential impact of an aberrant cystic-ovary state during pregnancy on the resulting female offspring, pregnant rats were treated with either 0 (control), 1, or 3 IU hCG twice daily for at least 9 days, beginning on day 13 of pregnancy. Serum was harvested from control and hCG treated animals on days 15, 17, 19, and 22 of pregnancy. Control pregnant rats and animals treated with 1 IU hCG shared similar serum profiles for progesterone (P4), androstenedione (A4), 5alpha-androstane-3alpha,17beta-diol (3alpha-diol), androsterone (A5), and estrone (E1) between days 15 and 22 of pregnancy. Testosterone serum concentrations were similar for control and 1 IU hGG-treated pregnant rats between days 15 and 19 of pregnancy; whereas, on day 22, 1 IU hGG-treated pregnant rats displayed lower serum testosterone than control pregnant rats (P < or = 0.05). In contrast, serum estradiol (E2) concentrations for 1 IU hCG- treated pregnant rats were greater than E2 values observed for control rats on days 15-19 of pregnancy (P < or = 0.05). Serum testosterone and 3alpha-diol values for 3 IU hCG-treated pregnant rats differed from those of control pregnant rats only on day 19 when these values were transiently greater for these hCG-treated animals compared with serum values for control pregnant rats (P < or = 0.05). Serum A4 values for 3 IU hCG-treated pregnant rats were elevated compared to values for control pregnant rats only on days 15 and 17 (P < or = 0.05). In contrast, serum E1, A5, and E2 were elevated on days 19-22, 17-22, and 15-22, respectively, in 3 IU hCG-treated pregnant rats compared to control pregnant rats (P < or = 0.05). No pups from control pregnant rats displayed ovarian cysts during the time they were observed postnatally. In contrast, 6 of 25 pups from 3 IU hCG-treated pregnant rats displayed cystic ovaries, without corpora lutea, on day 55 of age. Serum steroid concentrations for these cyst-bearing progeny were similar to those of female progeny from control pregnant rats, whereas female progeny without ovarian cysts from 3 IU hCG-treated pregnant rats displayed differences in serum steroid values from those of progeny from control pregnant rats (P < or = 0.05). The data support the concept that an aberrant, yet physiologic hormonal environment associated with the induction of ovarian cysts during pregnancy in rats, can lead to the spontaneous establishment of an ovarian cystic state in at least a subset of the female progeny. Further, the date suggest that tonically increased ovarian estrogen production during pregnancy, reflected by tonically elevated peripheral serum estrogen concentrations, may play a pivotal role in the etiology of an ovarian cystic state in this subset of daughters from hCG-induced, cyst-bearing pregnant rats.

Polycystic ovarian disease unmasked by pulsatile GnRH therapy in a subgroup of women with hypothalamic amenorrhea

OBJECTIVE

To present the observation in six out of 120 women treated with pulsatile GnRH for ovulation induction, who developed hyperandrogenemia and polycystic ovaries during treatment.

DESIGN

Clinical observation.

SETTING

Department of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Innsbruck, Austria.

PATIENT(S)

A total of 120 women initially diagnosed as suffering from primary or secondary hypothalamic amenorrhea were treated for ovulation induction with pulsatile administration of GnRH for up to 140 days. There was no indication of the presence of polycystic ovaries or hyperandrogenemia before therapy.

INTERVENTION(S)

Pulsatile GnRH therapy using the Zyklomat pump.

MAIN OUTCOME MEASURE(S)

Ovulatory menstrual cycles.

RESULT(S)

Initially, all patients responded to pulsatile GnRH administration with ovulation and corpus luteum formation. During continuation of treatment, 6 patients developed an increase in LH and LH/FSH ratio as well as a progressive rise in serum T levels resulting in hyperandrogenemia. This was accompanied by the development of polycystic ovaries and cessation of follicular maturation.

CONCLUSION(S)

We conclude from these observations that restoration of normal GnRH stimulation of the pituitary gland can result in the development of hyperandrogenemia and polycystic ovaries, suggesting a pituitary or ovarian defect underlying the pathogenesis of this disorder.