Salivary testosterone: relationship to unbound plasma testosterone in normal and hyperandrogenic women

High salivary testosterone-to-androstenedione ratio and adverse metabolic phenotypes in women with polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is characterized by a combination of hormonal and metabolic disturbances, such as insulin resistance, glucose intolerance, anovulation and hyperandrogenism. Clinical phenotypes of PCOS show different patterns of steroid hormones that have been investigated to some extent. This study aimed to establish a liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for the quantification of salivary testosterone and androstenedione and to describe the salivary testosterone-to-androstenedione (T/A4) ratio as a new tool for the assessment of hyperandrogenism and metabolic health.

MATERIAL AND METHODS

Saliva and serum samples of 274 patients with PCOS and 51 healthy women were used for the quantification of steroid hormones. A comprehensive clinical and metabolic assessment was performed. Salivary testosterone and androstenedione were measured via LC-MS/MS. The salivary T/A4 ratio was calculated and correlated with hormones and metabolic parameters.

RESULTS

Salivary testosterone (P < 0·001), androstenedione (P < 0·001) and the salivary T/A4 ratio (P < 0·001) were significantly higher in patients with patients compared to healthy women. In patients with PCOS, a high salivary T/A4 ratio was associated with an adverse metabolic phenotype, that is glucose intolerance (P = 0·019), insulin resistance (P < 0·001), metabolic syndrome (P < 0·001), obesity (P < 0·001) and oligo-/anovulation (P = 0·001). Significant correlations of the salivary T/A4 ratio with adverse metabolic parameters were found.

CONCLUSION

Quantification of salivary androgens provides an attractive alternative to serum analysis and helps in characterizing metabolic health in women with PCOS. Our data show a strong link between a high salivary T/A4 ratio and an adverse metabolic phenotype in patients with PCOS.

Testosterone in human studies: Modest associations between plasma and salivary measurements

Testosterone is involved in many processes like aggression and mood disorders. As it may easily diffuse from blood into saliva, salivary testosterone is thought to reflect plasma free testosterone level. If so, it would provide a welcome noninvasive and less stressful alternative to blood sampling. Past research did not reveal consensus regarding the strength of the association, but sample sizes were small. This study aimed to analyse the association in a large cohort. In total, 2,048 participants (age range 18-65 years; 696 males and 1,352 females) were included and saliva (using cotton Salivettes) and plasma were collected for testosterone measurements. Levels were determined by enzyme-linked immunosorbent assay and radioimmunoassay respectively. Free testosterone was calculated by the Vermeulen algorithm. Associations were determined using linear regression analyses. Plasma total and free testosterone showed a significant association with salivary testosterone in men (adjusted β = .09, p = .01; and β = .15, p < .001, respectively) and in women (adjusted β = .08, p = .004; and crude β = .09, p = .002 respectively). The modest associations indicate that there are many influencing factors of both technical and biological origin.

Salivary flow, testosterone, and femur bone mineral density in menopausal women with oral dryness feeling

OBJECTIVES

We compared salivary flow, serum and saliva testosterone, and femur bone mineral density (BMD) of menopausal women with or without xerostomia.

STUDY DESIGN

A case/control study was performed on 60 selected menopausal women with or without xerostomia. BMD and testosterone concentration were measured by a dual-energy x-ray absorptiometry system and enzyme-linked immunosorbent assay method, respectively.

RESULTS

Multinomial logistic regression demonstrated that low saliva flow rate (odds ratio [OR] = 22.8, 95% confidence interval [CI]: 5.4, 96.8), low femur BMD (OR = 6.0, CI: 1.8, 20.0), high stimulated saliva testosterone (OR = 5.2, CI: 2.0, 18.9), high unstimulated saliva testosterone (OR = 3.8, 95% CI: 1.6, 12.3), and high serum testosterone (OR = 2.7, CI: 1.1, 7.2) were associated with an increased risk of xerostomia in menopausal women.

CONCLUSIONS

High serum and salivary testosterone and low femur BMD and saliva flow were associated with xerostomia. Of these factors, low salivary flow seems to be the most important element in the perception of dry mouth.

16-androstene steroids in the submaxillary salivary gland of the boar in relation to measures of boar taint in carcasses

Fifteen Large White boars were randomly allocated to three groups of five pigs. The boars were slaughtered over a period of time at one of three live weights: group 1 (pork weight), 63 to 68 kg (mean age 141 days), group 2 (bacon weight), 90 to 97 kg (mean age 203 days) and group 3 (heavy weight), 121 to 133 kg (mean age 268 days). Testes, bulbourethral glands, submaxillary salivary glands, blood and thoracic fat were taken from each pig and the glands weighed and steroids determined in extracts of the submaxillary glands, blood plasma and fat. Testosterone and the boar taint steroid, 5a-androstenone (5a-androst-16-en-3-one) were measured in plasma by radioimmunoassay (RIA). 3a-androstenol (5a-androst-16-en-3a-ol) and 5a-androstenone were determined separately in submaxillary glands by gas-liquid chromatography and together semi-quantitatively by a colour reaction. 5a-androstenone was also determined in submaxillary glands by RIA and in fat by enzyme-linked immunosorbent assay. Mean somatic characteristics differed significantly between the groups, but due to the wide variation in steroid concentrations between individual boars, mean differences for steroid concentrations between groups were not significant.

Significant positive correlations were found in boars between bulbourethral gland weight, submaxillary gland weight, concentrations of 3a-androstenol and 5a-androstenone in the submaxillary gland and concentrations of free plasma 5a-androstenone and fat 5a-androstenone (P < 0·05). The application of a simple colour reaction to detect readily extractable 16-androstene steroids (16-androstenes) in submaxillary gland tissue is discussed in relation to other methods for determining boar taint.

Chewing gum has large effects on salivary testosterone, estradiol, and secretory immunoglobulin A assays in women and men

Salivary assays are increasingly prevalent in behavioral research, and chewing gum is a widely used sialogogue. Methodological investigations into sialogogues have provided mixed results, and few of these have incorporated multiple analytes, gums, and genders. To test effects of gum on salivary testosterone (T), estradiol (E), and immunoglobulin A (IgA) assays, participants (86 women; 91 men) provided two saliva samples, the first of which was unstimulated. Participants were randomly assigned to one of the following seven conditions for the second sample, which was provided after the first: No Gum or one of six sugar-free gums with one of two flavors and three brands. This design avoided the confounding of time and condition by comparing endogenously vs. exogenously induced changes in analytes. Chewing gum significantly decreased production time for the second saliva samples by 3-6 min, and had very large effects on assay results, leading to lower IgA and higher T and E in men and women. Variability was large and differed by gender/sex. Implications include strong gum-assay immunoreactivity, the importance of gender/sex in methodological investigations, and that immunoreactivity can differ in degree and direction depending on analytes.

Undetectable salivary testosterone in young women with premature ovarian failure

BACKGROUND

The extent of androgen deficiency in young women with premature ovarian failure (POF) is unclear.

AIM

Cross-sectional study of androgen status in young women with POF.

PATIENTS

Twenty women with POF: six had Turner syndrome (group A); eight had iatrogenic POF either secondary to bilateral oophorectomy or treatment of malignancy (group B); and six had idiopathic POF (group C). The median age was 30.5 years (range 19-39); in groups B and C the median duration of ovarian failure was 10.0 years (range 1-35).

METHODS

After a 2-month wash-out period without sex steroid replacement (SSR), serum testosterone (T), androstenedione (A4), dehydroepiandrosterone (DHEAS), SHBG, salivary testosterone (SalT) and the free androgen index [FAI = (serum T/SHBG) x 100] were measured.

RESULTS

Median serum A4 was 4.6 nmol/l (10th, 90th centiles, 3.6, 5.1) and DHEAS was 3.2 micromol/l (10th, 90th centiles, 2.3, 9.3). Although median serum T was relatively low at 1.4 nmol/l (10th, 90th centiles, 1.1, 1.7), median SHBG was also low at 34 nmol/l (10th, 90th centiles 22.2, 67.5) and the median calculated FAI was within the normal range at 3.7 (10th, 90th centiles, 2.3, 7.0). However, SalT was undetectable in almost all subjects in the three groups of POF.

CONCLUSIONS

Serum T and SHBG are relatively low in young women with POF and their FAI is therefore within the normal range. However, SalT, which measures free testosterone, is consistently low to undetectable in these young women with POF. The reliability of the FAI as a marker of androgen deficiency remains questionable.

Androgen insufficiency in women: diagnostic and therapeutic implications

The proposed key symptoms of the female androgen insufficiency syndrome (FAIS) include reduced libido, diminished well being and lowered mood. The diagnosis of FAIS is made on the basis of these symptoms in the setting of a low serum free testosterone level. However, there is currently no readily available inexpensive assay which reliably measures free testosterone levels in the female range. The diagnosis of FAIS is further complicated by the lack of data demonstrating a minimum serum free testosterone level which, if below this, correlates with the symptoms of FAIS. Despite the complexities involved with defining FAIS, the symptoms have been reported to respond well to testosterone replacement. There is a need for formulations of testosterone therapy specifically designed for use in women, along with clear guidelines regarding optimal therapeutic doses and long-term safety data.

Salivary testosterone and body composition among Ariaal males

To determine if testosterone is negatively related to acute and/or chronic nutritional status among men in a subsistence society, saliva samples and anthropometric measures were compared among nomadic and settled Ariaal pastoralists of northern Kenya. Fifty-six nomadic men and 62 settled men facing drought conditions, estimated ages 22-96 years, were sampled. Measures included height, weight, four skinfolds, and %body fat by bioelectric impedance (BIA). Saliva samples were assayed for testosterone using radioimmunoassay. Overall, both body mass index (BMI) (avg. = 17.8 +/- 6.0 kg/m(2)) and salivary testosterone (T) levels (avg. am value = 176.8 +/- 74.8 pmol/l) were low compared to values from Western populations. Comparison of the two subpopulations revealed no significant difference in height, weight, BMI, or lean body mass. However, nomadic males exhibited significantly smaller skinfolds. Evening, but not morning, salivary T values differed between the subpopulations. Age-related changes in body composition included a significant decline in BMI with age, related to loss of body fat, but with little change in lean body mass. Age-related declines in BMI and %body fat were more pronounced among the nomadic males. am salivary T values declined with age; again, the decline was significantly greater among nomadic males. pm salivary T levels showed no significant decline with age. When controlled for residence and age, salivary T was positively related to %body fat and WHR ratio, but not lean body mass. These results provide evidence that salivary T is related to acute nutritional status among males in an energetically stressed subsistence population, in accordance with life history theories of somatic allocation.

The diagnostic applications of saliva--a review

This review examines the diagnostic application of saliva for systemic diseases. As a diagnostic fluid, saliva offers distinctive advantages over serum because it can be collected non-invasively by individuals with modest training. Furthermore, saliva may provide a cost-effective approach for the screening of large populations. Gland-specific saliva can be used for diagnosis of pathology specific to one of the major salivary glands. Whole saliva, however, is most frequently used for diagnosis of systemic diseases, since it is readily collected and contains serum constituents. These constituents are derived from the local vasculature of the salivary glands and also reach the oral cavity via the flow of gingival fluid. Analysis of saliva may be useful for the diagnosis of hereditary disorders, autoimmune diseases, malignant and infectious diseases, and endocrine disorders, as well as in the assessment of therapeutic levels of drugs and the monitoring of illicit drug use.

Biosocial aspects of domestic violence

Domestic violence, defined as acts of verbal abuse and physical violence performed against women by current intimate main partners, was surveyed by means of the Conflict Tactics Scale. We examined the relationships between a biological variable (testosterone level), social variables (demographics, social integration), and behaviour (substance use) and self-reported domestic violence. Forced-entry OLS regression models allowed us to study how social and behavioural variables modified the effects of testosterone on this specific violent behaviour. The sample consisted of 54 men who had a main sexual partner and who identified themselves as Black, White, or Hispanic. The men were recruited from various social-service-agency sites in the area of Miami, Florida, on the basis of their risk factors for HIV/AIDS. The sample can best be described as culturally diverse men of low socioeconomic status who had a main sexual partner. A high percentage of participants reported some level of both verbal and physical aggression towards their partners. Testosterone levels were significantly associated with levels of both verbal aggression and physical violence self-reported by the men. Testosterone level, demographic characteristics, and alcohol consumption contributed to explaining the variance in self-reported verbal and physical abuse. The high heritability of testosterone level and its association with violent behaviour warrant the inclusion of this variable in studies of antisocial and criminal behaviour including domestic violence.

Salivary testosterone determination in studies of child health and development

Measurement of hormones in children's saliva has excited interest because of numerous potential applications in developmental studies. Although assays of children's saliva for some hormones (e.g., cortisol) are widely available and used, the availability and use of assays of children's saliva testosterone is restricted. By adapting a commercially available serum testosterone kit, our laboratory has developed a reliable, efficient, and highly sensitive procedure for measuring testosterone in children's saliva that does not require separation or extraction. The minimum detection limit was 0.8 pg/mL. Intraassay coefficients of variation (CV) were between 3.66 and 6. 78% at concentrations 9.25 to 86.41 pg/mL, and interassay CVs were between 5.70 and 6.61% at concentrations of 7.3 to 118.51 pg/mL. The standard curve was highly reproducible (M slope = -0.70 and Mr = 0. 99). Method accuracy, determined by spike recovery, and linearity, determined by serial dilution, were 99.20 and 92.80%, respectively. Values from matched serum and saliva samples showed strong linear relationships. The assay captured near 99.09% of the range of individual differences in boys' (N = 90) and girls' (N = 85), ages 8-12, am and pm salivary testosterone levels. This assay can be easily applied to the investigation of testosterone-behavior relations in the context of studies on child health and development. It may help many child development researchers improve or expand their research activities.

A time-resolved fluorescence immunoassay for the measurement of testosterone in saliva: monitoring of testosterone replacement therapy with testosterone buciclate

Monitoring of testosterone replacement therapy requires a reliable method for testosterone measurement. Determination of salivary testosterone, which reflects the hormone's biologically active plasma fraction, is a superior technique for this purpose. The aim of the present study was to establish a new sensitive time-resolved fluorescence immunoassay for the accurate measurement of testosterone levels in saliva and to validate it by monitoring testosterone replacement therapy in eight hypogonadal men. A clinical phase I-study with the new ester testosterone buciclate was performed to search for new testosterone preparations to produce constant serum levels in the therapy of male hypogonadism. After two control examinations eight male patients with primary hypogonadism were randomly assigned to two treatment groups (n = 2 x 4) and given single doses of either 200 mg (group I) or 600 mg (group II) testosterone buciclate intramuscularly. Saliva and blood samples were obtained 1, 2, 3, 5 and 7 days post injection and then weekly for three months. The time-resolved fluorescence immunoassay for salivary testosterone shows a detection limit of 16 pmol/l, an intra-assay CV of 8.9% (at a testosterone concentration of 302 pmol/l), an inter-assay CV of 8.7% (at a testosterone concentration of 305 pmol/l) and a good correlation with an established radioimmunoassay of r = 0.89. The sample volume required by this method is only 180 microliters for extraction and duplicate determination. The assay procedure requires no more than three hours. In group I (200 mg) testosterone did not increase to normal levels either in saliva or in serum. However, in group II, androgen levels increased significantly and were maintained in the normal range for up to 12 weeks with maximal salivary testosterone levels of 303 +/- 18 pmol/l (mean +/- SE) and maximal testosterone levels of 13.1 +/- 0.9 nmol/l (mean +/- SE) in serum in study week 6 and 7. The time-resolved fluorescence immunoassay for salivary testosterone provides a useful tool for monitoring androgen status in men and women and is well suited for the follow-up of testosterone replacement therapy on an outpatient basis. The long-acting ester testosterone buciclate is a promising agent for substitution therapy of male hypogonadism and in combination with testosterone monitoring in saliva offers an interesting new perspective for male contraception.

Overdiagnosis of 21-hydroxylase late onset congenital adrenal hyperplasia: correlation of corticotropin test and human leukocyte antigen typing

OBJECTIVE

To evaluate the reliability of the ACTH test as a means for detection of late onset congenital adrenal hyperplasia (CAH) and discriminating it from polycystic ovary syndrome (PCOS), by repeating the test after 6 months of cyproterone acetate and ethinyl E2 treatment.

DESIGN

Follow-up comparison study.

SETTING

Reproductive Endocrinology in an university tertiary center.

PATIENTS

Thirty-one young women with hirsutism, oligoamenorrhea, and acne, 21 of them detected as late onset CAH, and 10 as non-late onset CAH (PCOS).

INTERVENTION

Cyproterone acetate and ethinyl E2 treatment for > or = 6 months. The ACTH test, before and after 6 months of cyproterone acetate + ethinyl E2 treatment, and human leukocyte antigen (HLA) typing.

MAIN OUTCOME MEASURE

The ACTH test interpretation correlated to HLA typing.

RESULTS

By repeating the ACTH stimulation test in the 31 women (after cyproterone acetate + ethinyl E2 administration), we found a diminution in the rate of accumulation of 17 alpha-hydroxyprogesterone (delta 17-OHP) + P, in all 21-hydroxylase late onset CAH cases. As a result of treatment with cyproterone acetate + ethinyl E2, a decrease in the accumulation rate of 17-OHP + P, below the discriminative value for late onset CAH (6.5 ng/dL per minute), was noted among 12 of 21 women defined primarily as late onset CAH. Among the nine other women, a decrease in the accumulation rate of 17-OHP + P was noted, however not < 6.5 ng/dL per minute.

CONCLUSIONS

The interpretation of delta 17-OHP + P for the diagnosis of late onset CAH may be too sensitive as to the correct clinical diagnosis of late onset CAH. By repeating the ACTH test after 6 months of treatment with cyproterone acetate-ethinyl E2, specificity and accuracy may be improved.

A clinical evaluation of a direct radioimmunoassay of testosterone

We report the evaluation of a commercial coated tube kit (Medgenix) to the measurement of testosterone in plasma/serum samples. The accuracy, precision, specificity and recovery of the assay and the affinity of antibody for ligand were established. The range of concentrations of testosterone providing satisfactory analyses was 0.48-48 nmol/l, which is appropriate for general clinical use. Results of analysis of male and female samples obtained from the routine hospital laboratory in endocrinologically-defined groups were also reviewed. In all groups of male subjects and in normal females, the kit provided results in close agreement to those of an extraction method. With samples from women with various reproductive disorders, as well as with some samples obtained from external quality controls, the kit showed a small but significant negative bias relative to the results of the extraction method. There was, however, no evidence of bias with samples from a separate group of volunteer women with the polycystic ovary syndrome. No interference due to SHBG was detected. Clinical sensitivities using the kit were equivalent to those obtained using the extraction RIA. There was no evidence of spuriously high results in samples from females which has been a common problem with direct radioimmunoassay of testosterone.

Relations between sex hormone level and characters of hair and skin in healthy young men

Total testosterone and dihydrotestosterone in blood serum as well as free testosterone in saliva were determined by radioimmunoassay in 110 healthy young men. The results were compared with the development of terminal hair on the trunk and limbs, with the disposition to balding and with the disposition to acne. No significant correlations were found between terminal hair development and absolute androgen levels; however, some significant values were observed in the case of the metabolic rate of dihydrotestosterone/testosterone and the proportion of free to total testosterone. The disposition to balding also correlates positively with the latter ratio. Yet the absolute serum androgen concentrations in men with a disposition to balding is lower than in men with no reduction of scalp hair. The widespread assumption that androgen levels are in general elevated in bald-trait men must therefore be rejected. In accordance with this finding, men with a disposition to balding are morphologically (with regard to anthropometric measures) no more masculine than those with good scalp hair growth. When body build and age are taken into consideration, the relations between terminal hair and androgen ratio are also problematical. No relationship could be found between acne and androgens.

The effect of pretreatment of saliva on steroid hormone concentrations

We investigated the effect of the pretreatment (sonification or centrifugation) of saliva samples on the concentration of several steroid hormones as measured with highly specific RIA after extraction and chromatography. It appeared that sonification of saliva resulted in significantly higher values for progesterone, cortisone, 17-hydroxyprogesterone, testosterone and oestradiol (10-49% increase), compared with the levels recorded after centrifugation. No differences were demonstrated for the concentrations of cortisol and androstenedione, except that a sex-dependent difference effect was observed in the values for androstenedione: concentrations measured in sonificated male saliva were lower than those measured in supernatant saliva.

Free testosterone levels in plasma and saliva as determined by a direct solid-phase radioimmunoassay: a critical evaluation

We compared unbound (free) testosterone radioimmunoassay concentrations in plasma and saliva from men, using a direct radioimmunoassay kit involving a ligand analog of testosterone as tracer. The assay failed to reveal detectable testosterone concentrations in saliva. In plasma the free testosterone levels were about 4 times lower than those obtained by calculation or ultrafiltration methods. Moreover, unexpected similar free testosterone levels were obtained in samples comparable in their total testosterone content but distinct in their steroid binding protein content (buffered testosterone dilutions). We suspect that free testosterone levels determined with this direct radioimmunoassay probably do not reflect the true free testosterone values and conclude that their significance remains to be established.

Plasma C19 steroid sulphate levels and indices of androgen bioavailability in female pattern androgenic alopecia

Female pattern androgenic alopecia (AA) is a relatively common endocrine abnormality in premenopausal women. However, unlike hirsutism, little is known about the androgen metabolism and plasma C19 steroid sulphate profiles in this disorder. We have therefore measured the plasma levels of dehydroepiandrosterone sulphate (DHEA-S), 5-androstene-3 beta,17 beta-diol sulphate (5-ADIOL-S), 5 alpha-androstane-3 alpha, 17 beta-diol sulphate (3 alpha-DIOL-S), androstenedione (AD), total testosterone (T), free testosterone (FT), sex hormone binding globulin (SHBG), non-SHBG bound T, luteinizing hormone (LH) and follicle stimulating hormone (FSH), and have calculated the free androgen index (FAI): 100 x T (nmol/l) divided by SHBG (nmol/l), in premenopausal women with AA (n = 25-45) and in normal premenopausal women (n = 17-73). While mean plasma concentrations of DHEA-S and T were not significantly different from controls, mean SHBG concentrations were significantly lower (47 +/- 3 vs 64 +/- 3 nmol/l) and the mean free androgen index (4.4 +/- 0.4 vs 2.4 +/- 0.2), and mean concentrations of free testosterone (45 +/- 5 vs 26 +/- 1.4 pmol/l), non-SHBG bound T (0.9 +/- 0.2 vs 0.6 +/- 0.1 nmol/l) and androstenedione (4.3 +/- 0.3 vs 3.4 +/- 0.2 nmol/l) were significantly elevated in women with AA. Furthermore, mean plasma concentrations of 5-ADIOL-S (512 +/- 42 nmol/l) and 3 alpha-DIOL-S (76 +/- 7 nmol/l) were significantly higher than levels found in normal women (272 +/- 12 nmol/l and 52 +/- 2 nmol/l respectively). The nature of the hyperandrogenism associated with AA may thus only be revealed by a comprehensive plasma androgen and androgen sulphate profile, which may explain apparently aberrant data for a given patient. In addition, 5-ADIOL-S and 3 alpha-DIOL-S may serve as excellent plasma markers of both the existence of the disorder and the efficacy of its treatment.

Salivary free testosterone in hirsutism

A sensitive, specific and accurate direct radioimmunoassay of testosterone in human saliva is described. A single salivary testosterone result is shown to be of greater diagnostic use in hirsutism than any of the currently used serum androgen assays. Thus, of 50 hirsute patients, salivary testosterone (Sa-T) was elevated in 34 patients, sex hormone-binding globulin (SHBG) was decreased in 30 women, serum testosterone (S-T) elevated in 13, dehydroepiandrosterone sulphate (DHEA-S) was elevated in 14, and androstenedione in three of the investigated group.

Salivary testosterone levels and the progress of puberty in the normal boy

Salivary testosterone (ST) levels were measured in 84 boys aged 7.3-16.2 from the Edinburgh Growth Study. The correlation coefficient between matched plasma/saliva samples was 0.88. Six samples were collected over the course of one day from 0900 to 2100 h each month in the majority of the children for 4 consecutive months. Mean daily ST levels showed a significant rise between each pubertal stage (genital (G) and pubic hair (PH]. The rise in ST became more rapid once a mean testicular volume (MTV) of 10 ml had been reached. The diurnal rhythm was assessed by individual curve fitting on the log scale and by cosinor analysis. A rhythm was present prepubertally and developed into a pattern similar to that of the adult rhythm by stage G3. The monthly rate of rise of ST was greatest at stage G4. A significant rise in ST levels was detectable immediately prior to an increase in MTV to 3 ml. This allowed earlier recognition of the clinical onset of puberty at testicular volume of 3 ml, which in this group occurred at 10.9 (SD 0.9) years. ST is a non-invasive and sensitive method for the serial monitoring of gonadal function in the prepubertal and adolescent boy.

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

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

Serum androstanediol glucuronide concentrations in normal and hirsute women and patients with thyroid dysfunction

There is currently much interest in measurements of 5 alpha-androstane-3 alpha, 17 beta-diol glucuronide (AdiolG) as a marker of peripheral androgen metabolism. We have therefore developed an assay to measure serum AdiolG levels and report that mean concentrations in hirsute (2.9 +/- 1.9 nmol/l, mean +/- SD, n = 15) and non-hirsute (1.9 +/- 0.6 nmol/l, n = 7) women with polycystic ovaries do not differ significantly from concentrations in normal women (2.2 +/- 0.8 nmol/l, n = 20). However, a correlation was found between serum AdiolG levels and Body Mass Index (r = 0.48, P less than 0.05) for women with polycystic ovaries, suggesting that weight may be an important factor in determining concentrations of this steroid conjugate. Serum AdiolG levels were significantly reduced in hypothyroid women (0.6 +/- 0.4 nmol/l, n = 5) and women receiving oral contraceptive therapy (0.6 +/- 0.4 nmol/l, n = 28) but increased in hyperthyroid women (4.0 +/- 0.6 nmol/l, n = 5). The results from this study do not support the hypothesis that serum AdiolG levels provide a marker of peripheral androgen metabolism in hirsute women and show that it is essential to exclude from such investigations any women with thyroid abnormalities or receiving oral contraceptive therapy.

Anti-androgens in gynaecological practice

Hirsutism and acne in women are common distressing problems. Unwanted hair growth, acne and seborrhoea result from the action of androgens on the skin. Such effects depend not only on increased androgen production by the ovary or adrenal gland but also on the bioavailability of androgen to peripheral tissues. This in turn is related to transport of androgens in plasma by specific binding proteins and to peripheral metabolism of testosterone and androstenedione to their more potent 5 alpha-reduced derivatives. An effective anti-androgen is one which blocks the androgen receptor-mediated actions of testosterone and DHT on skin. CPA, the treatment of choice in the UK, is a potent androgen receptor-blocking steroid which also has progestational properties. When combined with ethinyloestradiol it also suppresses ovarian function, thus reducing androgen production, and provides effective contraception.

Sex hormone binding globulin in saliva

Measurement of salivary steroid hormone concentrations has frequently been advocated as a convenient alternative to plasma measurements. This is partly due to the belief that salivary steroid concentrations are a reliable reflection of the plasma free hormone level, a belief reinforced by earlier inability to demonstrate the presence of significant quantities of steroid binding proteins. Recent reports confirm that such quantities of these proteins are present in saliva and that they retain their steroid binding activity. We have measured sex hormone binding globulin (SHBG) and albumin in saliva from 14 men, 21 non-pregnant women and 36 pregnant women. No differences in the concentration of salivary albumin was evident in any of the groups studied whereas a significant difference in the concentration of SHBG was evident between men and non-pregnant women, and non-pregnant and pregnant individuals. Although much lower, salivary SHBG and albumin concentrations broadly reflect those found in plasma. Furthermore, a highly significant correlation existed between salivary SHBG and albumin concentrations in all groups studied. It now seems generally accepted that the albumin present in saliva arises from contamination by either traces of blood or gingival fluids. The close relationship between the concentrations of albumin and SHBG in saliva suggests that they both gain entry by a similar route. Furthermore, their presence may significantly influence the concentration of certain steroids in saliva, and this may explain the occasional failure of salivary steroid concentrations to accurately reflect the plasma free hormone levels.

The effects of reverse sequential anti-androgen therapy (cyproterone acetate and ethinyl estradiol) on hematological parameters

Hematological parameters were studied in female patients receiving reverse-sequential anti-androgen therapy for hirsutism and acne. A significant fall in hemoglobin, total red cell count and packed cell volume occurred after 3-month treatment in 30 patients during the 10-day cyproterone acetate and ethinyl estradiol phase; this change was sustained in 14 patients studied to 12 months. A fall in hemoglobin and packed cell volume alone occurred after 3 months in 31 patients in the ethinyl estradiol phase. Reverse-sequential therapy may influence hemopoiesis by its anti-androgenic action on erythropoiesis, although we found no relationship between changes in hematological parameters and total testosterone levels.

Direct assay for testosterone in saliva: relationship with a direct serum free testosterone assay

A direct non-extraction radioimmunoassay for salivary testosterone is described using a modified commercial kit procedure that is in use for total serum testosterone (T). Serum free testosterone was also measured by direct radioimmunoassay. A significant correlation (r = 0.83, p less than 0.01, n = 194) was obtained between salivary and serum free testosterone in matched serum and saliva samples over a wide range of concentrations. Within- and between-batch precision for the salivary testosterone method was 11% and 18%, respectively at a concentration of 170 pmol/l. Recovery of added T was 89% +/- 15% (mean +/- 2 SD) dilution of high samples showed parallelism. Salivary testosterone measured by direct radioimmunoassay offers a simple cheaper alternative to serum free testosterone measurement with the additional advantages of a stress-free non-invasive sampling procedure.

Studies on the measurement of 25-hydroxy vitamin D in human saliva

A competitive protein-binding assay for 25-hydroxy vitamin D (25-OHD) in saliva has been established by adaptation of that previously described for 25-OHD in serum (Fairney et al. 1979). Random values of salivary 25-OHD in patients attending hospital for venesection showed a wide range of results (105-1000 pg/ml, n 55). These values corresponded to 1.2% of the total serum values with which they showed a significant relation (r 0.45, P less than 0.001). There was no relation between salivary 25-OHD and measured serum free 25-OHD in eighteen pairs of saliva and serum studied. Studies in two individuals showed that salivary 25-OHD values varied throughout the day and that a vitamin D load (19.5 micrograms), given as pickled herrings at lunch, produced a marked rise in 25-OHD values 5-8 h later. Diurnal profile studies of salivary 25-OHD in Caucasian and Asian 11-year-old male schoolchildren showed lower values in Asian children eating a vegetarian diet, and a significant variation with time and ethnic group (P less than 0.001). It is concluded that 25-OHD is present in saliva and that the values vary throughout the day. The values obtained may relate to dietary intake of vitamin D and the subject's ethnic origin.

Salivary androgens in hirsutism: are they of use in routine evaluation?

In the biochemical evaluation of hirsutism, 50% or less of patients have an elevated total serum testosterone. Recent work has suggested that measuring salivary testosterone or a derived serum 'free testosterone index' may be of use in the evaluation of hyperandrogenism. We have measured serum total, derived serum free indices and salivary concentrations of testosterone and 5 alpha-dihydrotestosterone in an unselected group of hirsute patients in order to assess their value in the routine evaluation of hirsutism. The assays were performed using a novel oxidation procedure to overcome the need for chromatographic separation. The 'free testosterone index' gave the best discrimination. Salivary androgen concentrations were comparatively poor and cannot be recommended for routine use.

Testosterone assays: guidelines for the provision of a clinical biochemistry service

Approximately one year after the devolution of testosterone assays from the SAS, the Analytical Methods Working Party of the Association of Clinical Biochemists set up a working party to investigate the performance of the assays, to survey the available methodology and to give guidance on the factors that influence the assay. This document represents a summary of the deliberations of the group and forms one of a series of similar reports.

Gas chromatography-mass spectrometric analysis of salivary testosterone with reference to diethylstilboestrol-treated prostatic cancer patients

Testosterone has been quantified in saliva by gas chromatography-mass spectrometry with selected ion monitoring of the t-butyldimethylsilyl ether (TBDMS) of the oxime derivative. High specificity of instrumental analysis has been complemented by immunoadsorption for extraction of the analyte. The sensitivity of the detection is approx. 4 pmol/l and the precision of quantification is 3.4% CV for a value of 160 pmol/l and 11% for a value of 25 pmol/l. Female subjects had salivary concentrations of testosterone of 14-52 pmol/l, while testosterone was not detected in the saliva of prostatic cancer patients treated with diethylstilboestrol (DES).

Hormones in saliva

Since the collection of saliva is noninvasive, nonstressful and usually very convenient there have been many recent studies examining the clinical relevance of measuring various hormones in saliva. It now appears that the measurement of most unconjugated steroids in saliva will provide clinically useful data whereas the measurement of conjugated steroids, thyroid hormones, and protein hormones is unlikely to be clinically relevant. The key factors determining whether the salivary concentration of a hormone or drug is likely to be clinically relevant are the mechanisms by which the material enters the saliva; the "free to protein bound" ratio for the material; and the structure of the material, i.e., its molecular weight, polarity and the presence of ionizable groups.

Adrenocorticosteroids: chemistry, synthesis and disturbances in disease

The biosynthesis of adrenocortical steroids is now a reasonably well understood process, which proceeds by discrete, enzyme directed steps from cholesterol to the various hormonal steroids. However, much of our knowledge derives from studies of animal tissues and there is a need for further studies of human glands. In particular, the details of individual enzyme systems, and the extent and significance of compartmentalization of steroid intermediates requires further exploration. The adrenal metabolic errors also merit further study, to clarify some aspects of congenital adrenal hyperplasia and to explain the relationship between biochemical and clinical observations. The advent of immunoassay methods for the measurement of steroid hormone levels in plasma has changed the approach to diagnostic steroid endocrinology, with less emphasis now on the measurement of urinary steroid metabolites, particularly in regard to androgens. The newer and sensitive methods available also allow the assay of steroid hormones in saliva, and the ready availability of this fluid, and the fact that sampling is a non-invasive technique makes salivary steroid assay an attractive alternative to other, traditional methods of investigation requiring blood or urine collection. Inhibitors of steroid biosynthesis and of steroid action have been used with considerable success in diagnostic techniques and to a limited extent in the treatment of steroid disorders. As our understanding of the details of steroid biosynthesis, mechanism of steroid action, and control of steroid secretion improve, further progress in designing clinically useful inhibitors should be possible.

Development and application of a direct radioimmunoassay for aldosterone in saliva

A previously described direct radioimmunoassay for plasma aldosterone has been modified to enable direct measurement of the steroid in saliva. The specificity of the method has been demonstrated by assay after high pressure liquid chromatographic purification of saliva extracts. Assay of matched plasma and saliva samples taken from normal subjects during unrestricted and controlled sodium intakes, either under basal conditions or while undergoing ACTH stimulation or dexamethasone suppression, confirms that salivary aldosterone values provide a good reflection of levels in plasma. Mean salivary aldosterone values are approximately one-third of those in plasma. Sampling immediately upon waking appears to provide reliable values for salivary aldosterone, and the potential application of this technique to the screening of hypertensive patients is discussed.

Direct radioimmunoassay (RIA) of salivary testosterone: correlation with free and total serum testosterone

Simple and sensitive direct RIA for determination of salivary testosterone was developed by using RSL NOSOLVEX TM (125 1) kit produced by Radioassay System Laboratories (Carson, California). In addition, a relationship between salivary and serum free and total testosterone concentrations was studied in randomly selected 45 healthy subjects, 5 females on oral contraceptive pills and 28 hypertensive patients on various treatment regimens. The lowest weight of testosterone detectable by our modified method was equivalent to 1 pg/ml of saliva, taking into account analytical variability. Intra- and interassay coefficients of variation were 5.09 +/- 2.7% and 8.2 +/- 5.9% respectively. Statistically significant correlations were found between salivary and serum free testosterone (r = 0.97) and salivary and serum total testosterone concentrations (r = 0.70-0.87). The exception to this was a group of hypertensive females in which no correlation (r = 0.14) between salivary and total serum testosterone was found. It is also of interest that, while salivary testosterone was significantly increased in subjects taking oral contraceptives and most of the hypertensive patients the total serum testosterone concentration was in normal range. Our findings suggest that determination of salivary testosterone is a reliable method to detect changes in the concentration of available biologically active hormone in the circulation.

Hormonal profile and serum zinc levels in uraemic men with gonadal dysfunction undergoing haemodialysis

Serum gonadal hormones, gonadotrophins and zinc levels were studied in thirteen men aged 29-62 yr with chronic renal failure undergoing haemodialysis. All patients had decreased libido and impotence. Serum testosterone levels in patients (18.5 +/- 1.3 (SEM) nmol/l) were significantly lower (p less than 0.05) than in the control group (24.1 +/- 2.2 (SEM) nmol/l) although salivary testosterone levels were strictly within the normal range. Mean serum 17-beta-oestradiol and luteinizing hormone levels (0.19 +/- 0.03 (SEM) nmol/l, and 57.4 +/- 13.1 (SEM) IU/l, respectively) were significantly higher (p less than 0.05 and p less than 0.005, respectively) than in the control group (0.11 +/- 0.02 (SEM) nmol/l and 14.8 +/- 1.9 (SEM) IU/l, respectively). Mean progesterone and follicle-stimulating hormone levels in patients were not significantly different from those of control subjects. Mean prolactin values in patients (1,019 +/- 285 (SEM) mIU/l) were significantly higher (p less than 0.01) than in the control group (211 +/- 24 (SEM) mIU/l). Serum prolactin levels in five patients were extremely high (above 1,200 mIU/l). There was no statistically significant difference in serum zinc levels between patients and controls. As salivary testosterone is normal, it seems that hyperprolactinaemia and raised serum 17-beta-oestradiol levels may be responsible, at least in part, for sexual dysfunction in male patients with chronic renal failure receiving haemodialysis.

A steady-state gel filtration method on micro-columns for the measurement of percentage free testosterone in serum

A method is described for measuring the percentage of free testosterone in serum using steady-state gel filtration on micro-columns of Sephadex G50 (fine). The method has a coefficient of variation of 4.0% and up to 20 samples can be processed in a day. Reference ranges have been established for normal women at different stages of their menstrual cycles and for normal men; there is good agreement with values published by workers using other methods. This method combined with a specific and precise method for measuring total testosterone opens up the possibility for the routine measurement of free testosterone concentration in serum.

Investigation of hirsutism: testosterone is not enough

In a consecutive series of 41 hirsute women clinically classified as benign androgen excess, only 34% were found to have elevated plasma 'total' testosterone (T), 22% having subnormal sex hormone binding globulin (SHBG). When expressed as the ratio T/SHBG ('free androgen index'), 85% of the patients had values above the normal range. It is concluded that this index is more reliable than total testosterone in assessing androgen status in female patients.

Plasma and salivary androstenedione and dihydrotestosterone in women with hyperandrogenism

Sensitive radioimmunoassays (RIA) have been developed to measure salivary and plasma androstenedione and dihydrotestosterone levels in normal women, women with polycystic ovaries (PCO) and idiopathic hirsutism, and patients on antiandrogen therapy. There was a highly significant correlation (r = 0.92, P less than 0.001) between the concentration of androstenedione in saliva and the unbound concentration in plasma. The unbound plasma androstenedione was measured in the dialysate by RIA and ranged from 6.0-10.4% of the total concentration. Salivary and plasma androstenedione levels in patients with PCO (185 +/- 72 pg/ml (n = 11) and 3262 +/- 814 pg/ml (n = 12) respectively) and in those with hirsutism (151 +/- 110 pg/ml (n = 25) and 2177 +/- 1096 pg/ml (n = 25) were significantly higher than levels in normal women (78 +/- 30 pg/ml (n = 18) and 787 +/- 355 pg/ml (n = 18). A good correlation (r = 0.82, P less than 0.001) was also found between salivary and unbound plasma dihydrotestosterone concentrations. Salivary and plasma dihydrotestosterone levels in patients with PCO (8.2 +/- 3.3 pg/ml (n = 9) and 167 +/- 45 pg/ml (n = 11) respectively and hirsutism (6.0 +/- 2.1 pg/ml (n = 14) and 176 +/- 69 pg/ml (n = 17) were significantly higher than levels in normal women (4.5 +/- 1.3 pg/ml (n = 17) and 90 +/- 44 pg/ml (n = 16), although there was a large overlap between groups. A similar decrease was observed in salivary and plasma androstenedione levels after treatment with cyproterone acetate (CA) and ethinyl oestradiol (EE) for 3 months. Plasma dihydrotestosterone levels remained elevated in 47% of treated women whereas only 21% of cases had raised salivary dihydrotestosterone levels. It is concluded that, as with testosterone salivary androstenedione and dihydrotestosterone measurements give a good reflection of their biologically active levels in normal, hyperandrogenic and CA + EE treated women.