Relative diagnostic value of serum non-SHBG-bound testosterone, free androgen index and free testosterone in the assessment of mild to moderate hirsutism

Inulin-type fructans with different degrees of polymerization improve insulin resistance, metabolic parameters, and hormonal status in overweight and obese women with polycystic ovary syndrome: A randomized double-blind, placebo-controlled clinical trial

Polycystic ovary syndrome (PCOS) is associated with reproductive disorders and adverse cardiometabolic risk factors that can negatively impact the general health of women. Inulin-type fructans (ITFs) are proposed to beneficially affect risk factors associated with metabolic disorders. Whether ITFs can help with the management of PCOS by modifying insulin resistance (IR) and androgen levels has not yet been explored. The aim of this study was to investigate the effects of ITFs with different degrees of polymerization on insulin resistance, blood lipids, anthropometric measures, and hormonal status in overweight and obese women with PCOS. In a randomized double-blind placebo-controlled trial, seventy-five women with PCOS aged 18-40 years old were randomly assigned to receive 10 g/day of high-performance inulin (HPI) or oligofructose-enriched inulin (OEI) or maltodextrin for 12 weeks. Biochemical and clinical outcomes were measured at baseline and after the intervention. Participants in the HPI and OEI groups experienced improvements in waist circumference, total testosterone, free androgen index, sex hormone-binding globulin, and triglycerides compared to the placebo group. Also, the number of women with irregular menses or oligomenorrhoea decreased significantly in both ITF groups. Participants in the HPI group reported lower body mass, fasting insulin, and HOMA-IR, as well as a higher quantitative insulin sensitivity check index. ITF supplementation, especially with long-chain ITFs, when given for 12 weeks may improve metabolic outcomes, androgen status and clinical manifestations in women with PCOS.

An updated clinico-investigative approach to diagnosis of cutaneous hyperandrogenism in relation to adult female acne, female pattern alopecia & hirsutism a primer for dermatologists

INTRODUCTION

Hyperandrogenism is a clinical state consequent to excess androgen production by the ovary, adrenals, or increased peripheral conversion of androgens. The varied manifestations of hyperandrogenism include seborrhea, acne, infertility, hirsutism, or overt virilization of which adult female acne, hirsutism, and female pattern hair loss are of clinical relevance to dermatologists.

AREAS COVERED

We limited our narrative review to literature published during period from 1 January 1985 to Dec 2022 and searched PubMed/MEDLINE, Web of Science (WOS), Scopus, and Embase databases with main search keywords were 'Hyperandrogenism,' 'Female,' 'Biochemical,' 'Dermatological', and 'Dermatology.' We detail the common etiological causes, nuances in interpretation of biochemical tests and imaging tools, followed by an algorithmic approach which can help avoid extensive tests and diagnose the common causes of hyperandrogenism.

EXPERT OPINION

Based on current data, total testosterone, sex hormone binding globulin, DHEAS, prolactin, free androgen index, and peripheral androgenic metabolites like 3-alpha diol and androsterone glucuronide are ideal tests though not all are required in all patients. Abnormalities in these biochemical investigations may require radiological examination for further clarification. Total testosterone levels can help delineate broadly the varied causes of hyperandrogenism. Serum AMH could be used for defining PCOM in adults.

Metformin versus metformin plus pioglitazone on gonadal and metabolic profiles in normal-weight women with polycystic ovary syndrome: a single-center, open-labeled prospective randomized controlled trial

OBJECTIVE

To investigate the effects of metformin (MET) monotherapy and pioglitazone plus MET (PIOMET) therapy on gonadal and metabolic profiles in normal-weight women with polycystic ovary syndrome (PCOS).

METHODS

Sixty normal-weight women with PCOS were recruited between January and September 2022 at the Shengjing Hospital of China Medical University. They were randomly assigned to the MET or PIOMET groups for 12 weeks of MET monotherapy or PIOMET therapy. Anthropometric measurements, menstrual cycle changes, gonadal profiles, and the oral glucose insulin-releasing test (OGIRT) were performed at baseline and after the 12-week treatment.

RESULTS

Thirty-six participants completed the trial. MET and PIOMET therapies improved menstrual cycles after the 4- and 12-week treatments; however, there was no statistical difference between the two groups. PIOMET therapy improved luteinizing hormone (LH), luteinizing hormone/follicle stimulating hormone (LH/FSH) ratio, and free androgen index (FAI) levels after the 4-week treatment, whereas MET monotherapy only improved total testosterone (TT) levels compared to baseline (P < 0.05). Both MET and PIOMET therapies improved TT and anti-Mullerian hormone (AMH) levels after the 12-week treatment (P < 0.05). In addition, only PIOMET therapy significantly improved sex hormone-binding globulin (SHBG), FAI, and androstenedione (AND) levels than the baseline (P < 0.05). PIOMET therapy improved SHBG and AMH levels more effectively than MET monotherapy (P < 0.05). Furthermore, PIOMET treatment was more effective in improving blood glucose levels at 120 and 180 min of OGIRT compared to MET monotherapy (P < 0.05).

CONCLUSIONS

In normal-weight women with PCOS, PIOMET treatment may have more benefits in improving SHBG, AMH, and postprandial glucose levels than MET monotherapy, and did not affect weight. However, the study findings need to be confirmed in PCOS study populations with larger sample sizes.

Quantitative risk-benefit profiles of oral contraceptives, insulin sensitizers and antiandrogens for women with polycystic ovary syndrome: A model-based meta-analysis

Oral contraceptives (OCs), insulin sensitizers, and antiandrogens (AAs), alone or in combination, are commonly used for treating non-fertility indications in polycystic ovary syndrome (PCOS). However, unclear risk-benefit profiles jeopardize their appropriate clinical applications. This study aimed to quantitatively evaluate the effects of the aforementioned medications and to compare their risk-benefit profiles. Randomized controlled trials published until 14th March 2022 were searched in PubMed and Embase. A model-based meta-analysis was developed to examine the time-effect profiles of each medication. The maximal percentage change of the effect (Emax) and time to achieve half of Emax (T50) were estimated. Primary outcomes included menstruation, hirsutism score, free androgen index (FAI), body mass index (BMI), insulin sensitivity, and lipid profiles. Overall, 200 studies (9,685 patients and 385 arms) were identified for modeling. OCs performed exceptionally well in improving menstruation (Emax: 149%; T50: 7.44 weeks), hirsutism score (Emax: 66.2%; T50: 26.2 weeks), and FAI (Emax: 75.7%; T50: 0.51 weeks). However, OCs elevated the triglyceride (TG) level (Emax: 12.6%; T50:1.19 weeks). After 12-week OC treatment, the TG level of approximately 30% of patients, whose baselines were normal, exceeded the reference limit. This suggested that OC-induced dyslipidemia should be routinely monitored. The maximal BMI-lowering effect of metformin was similar to that of placebo (Emax: 3.80%); however, metformin had a shorter T50 (6.67 weeks versus 12.9 weeks). Further, active lifestyle intervention plus placebo significantly decreased BMI (Emax: 8.78%). Adding metformin to active lifestyle intervention accelerated the BMI-lowering effect within 24 weeks, whereas with the extension of this addition beyond 24 weeks, BMI did not reduce further, which indicated that benefits were limited from this prolonged addition. AAs were less potent in reducing hirsutism score (Emax: 40.2% versus 66.2%) and FAI (Emax: 34.5% versus 75.7%) compared to OCs. OC plus metformin combined OC-derived androgen-suppressing effects and metformin-derived insulin-sensitizing effects, and partially relieved the OC-induced TG increase (Emax: 9.76%). Baseline dependency was found in most clinical responses, implying that pharmacotherapies tailored based on baselines achieved more clinical improvements. This study presents new quantitative evidence on pharmacotherapies for PCOS. Currently, long-term risk-benefit profiles and emerging therapies are inadequately reported and require more further research.

Non-alcoholic fatty liver disease is associated with hyperandrogenism in women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a highly complex reproductive metabolic disorder and women with PCOS have high prevalence of non-alcoholic fatty liver disease (NAFLD). Despite both hyperandrogenism and insulin resistance are common pathophysiologies in NAFLD and PCOS, this association is still controversial. Therefore, the aim of this study is to evaluate the relationship between hyperandrogenism and NAFLD in females diagnosed with PCOS. We recruited 667 women diagnosed with PCOS and 289 women with regular menstrual cycles as control. The PCOS diagnosis was made using National Institute of Child Health and Human Disease criteria. Total and free testosterone levels (TT and TF, respectively), and free androgen index (FAI) were used as measures of hyperandrogenism. Fatty liver index and liver fat score (FLI and LFS, respectively), and hepatic steatosis index (HSI) were used to assess NAFLD. The prevalence of NAFLD in PCOS women evaluated by LFS, FLI, and HIS were 19.9, 10.3, and 32.2%, respectively. In the control group, the incidence was 2.1, 0.7, and 4.2%, respectively. Both FT and FAI levels showed significant association with increased NAFLD-related indices, after adjusting for insulin resistance and other factors (LFS (OR 3.18 (95% CI 1.53-6.63) in FT; 1.12 (1.04-1.22) in FAI), FLI (OR 2.68 (95% CI 1.43-5.03) in FT; 1.13 (1.06-1.20) in FAI), and HSI (OR 3.29 (95% CI 2.08-5.21) in FT; 1.5 (1.09-1.21) in FAI). TT did not exhibit association with any NAFLD index. In women with PCOS, significantly higher rate of NAFLD was observed compared to the control women. The FT and FAI were independently associated with NAFLD in women with PCOS. The findings suggest the possibility of hyperandrogenism contributing to the progression and/or development of NAFLD in PCOS.

The free androgen index is inaccurate in women when the SHBG concentration is low

OBJECTIVE/CONTEXT

The free androgen index (FAI) is known to give erroneous results in men, but it is still a commonly used test for the investigation of hyperandrogenism in women. This study aimed to compare the results of the FAI with the gold standard equilibrium dialysis method for free testosterone in women.

DESIGN/PATIENTS

Free serum testosterone T (ED-T) and total serum T (T) were measured by equilibrium dialysis and LC-MS/MS in patients with polycystic ovarian syndrome (n = 130), normal female controls (n = 53) and normal males (n = 120). Calculated free T (cFT) and free androgen index (FAI) were also measured in these patients. In addition, cFT was retrospectively calculated in 4223 female patients with a normal T (<1.6 nmol/L) routinely investigated for hyperandrogenism.

RESULTS

The cFT showed good agreement with measured ED-T, and the ratio cFT/ED-T was stable across all SHBG concentrations. In contrast, the FAI/ED-T ratio and the FAI/cFT ratio increased when the concentration of SHBG fell below 30 nmol/L.

CONCLUSIONS

The FAI is not a reliable indicator of free T when the SHBG concentration is low and would give misleading information in a large number of women being investigated for hyperandrogenism.

Osteocalcin and Sex Hormone Binding Globulin Compete on a Specific Binding Site of GPRC6A

The undercarboxylated form of osteocalcin (ucOC) regulates male fertility and energy metabolism, acting through the G protein-coupled receptor (GPRC)6A, thus forming a new pancreas-bone-testis axis. Recently, GPRC6A has also been suggested to mediate the nongenomic responses of free testosterone (T). However, these data did not consider the physiological scenario, where circulating T is mainly bound to sex hormone-binding globulin (SHBG) and only a small percentage circulates freely in the blood. Here, by the use of computational modelling, we document the existence of similar structural moieties between ucOC and SHBG that are predicted to bind to GPRC6A at docking analysis. This hypothesis of competition was assessed by binding experiments on human embryonic kidney-293 cells transfected with human GPRC6A gene. Unliganded SHBG specifically bound the membrane of human embryonic kidney-293 cells transfected with GPRC6A and was displaced by ucOC when coincubated at 100-fold molar excess. Furthermore, specific downstream Erk1/2 phosphorylation after stimulation of GPRC6A with ucOC was significantly blunted by 100-fold molar excess of unliganded SHBG. Intriguingly previous incubation with unliganded SHBG, followed by incubation with T, induced Erk1/2 phosphorylation in a dose-dependent manner. Neither binding nor stimulating activities were shown for SHBG saturated with T. Experiments on mutation constructs of GPRC6A strengthened the hypothesis of a common binding site of ucOC and SHBG. Given the role of GPRC6A on energy metabolism, these data agree with epidemiological association between SHBG levels and insulin sensitivity, suggest GPRC6A as a likely SHBG receptor, and add bases for the possible regulation of androgen activity in a nonsteroidal manner.

Androgenic sex steroids contribute to metabolic risk beyond intra-abdominal fat in overweight/obese black and white women

OBJECTIVE

To determine the independent contribution of androgenic sex hormones beyond visceral adipose tissue (VAT) on metabolic risk.

DESIGN AND METHODS

A cross-sectional evaluation of 66 (36 white and 30 black) premenopausal overweight/obese women using multiple regression analyses to determine the independent effects of sex hormone-binding globulin (SHBG), total testosterone (TT), and free testosterone using the free androgen index (FAI) on metabolic variables above VAT.

RESULTS

SHBG contributed to the variance in insulin (P = 0.003), insulin resistance using HOMA-IR (P = 0.006), and high-density lipoprotein cholesterol2 (P = 0.029). TT contributed to the variance in systolic and diastolic blood pressure (P < 0.001), total cholesterol (P = 0.003), low-density lipoprotein cholesterol (P = 0.003), and apolipoprotein B (P = 0.004). FAI contributed to the variance in the greatest number of metabolic variables beyond VAT. There was also a significant race-FAI interaction for fasting glucose (P = 0.013). A Pearson's correlation coefficient showed a significant relationship between FAI and glucose in white women (r = 0.48, P = 0.003) while showing no relationship in black women (r = -0.01, P = 0.941).

CONCLUSIONS

Our study showed that androgenic sex steroids contributed significantly to the variance in metabolic variables associated with health risk. However, they do not provide sufficient information relevant to glucose status in black women.

Paraoxonase-1 is not affected in polycystic ovary syndrome without metabolic syndrome and insulin resistance, but oxidative stress is altered

Paraoxonase-1 (PON1) activity is decreased in polycystic ovary syndrome (PCOS) having metabolic syndrome (MetS) or insulin resistance (IR). We aimed to assess PON1 activity and oxidative stress in PCOS without MetS or IR. Metabolic and hormonal parameters, high-sensitive C-reactive protein (hs-CRP), oxidative stress parameters (total antioxidant status (TAS), total oxidative stress (TOS), oxidative stress index (OSI), lipid hydroperoxide (LOOH), total free sulfhydryl (--SH) groups), PON and arylesterase were analyzed in 30 normal weighed patients with PCOS without MetS or IR and 20 normal controls. Hs-CRP, PON, arylesterase, and TAS levels of PCOS and control groups were similar. LOOH, TOS, and OSI of PCOS group were higher than in the controls (p < 0.05; p < 0.001, and p < 0.001, respectively). - SH group levels showed a positive correlation with free testosterone (fT). TOS positively correlated with free androgen index (FAI), body mass index (BMI), waist-to-hip ratio (WHR), LOOH, and OSI. This study showed that oxidative stress is increased in PCOS even in the absence of MetS or IR. PON1 activity appears not to be affected in PCOS without MetS and IR. Several metabolic and antropometric risk factors may aggravate this altered oxidative state in PCOS.

Late-onset male hypogonadism: clinical and laboratory evaluation

Late-onset male hypogonadism (LOH) is a clinical and biochemical syndrome associated with advancing age and characterised by low serum testosterone concentrations. An understanding of the physiology of androgens in the ageing man is essential for the appropriate diagnosis of LOH. Clinical assessment of androgen status relevant to clinical biochemists and chemical pathologists is outlined in this review. Laboratory investigations of androgen status in men are not without pitfalls and the authors highlight problems associated with measuring and calculating serum testosterone and its fractions, the interpretation of which can be problematic. Current clinical guidelines and recommendations regarding the diagnosis and monitoring of LOH are also summarised.

Racial Disparities between the Sex Steroid Milieu and the Metabolic Risk Profile

Aims and Method. The present study examined the relationship between the metabolic risk profile (MRP) and total testosterone (TT) and free testosterone using the free androgen index (FAI) and sex hormone binding globulin (SHBG) in 36 Caucasian American (CA) and 30 African-American (AA) women volunteering for a weight loss study. Results. After controlling for age, significant relationships were found between TT and diastolic blood pressure (P = .004 and P = .015 in CA and AA women, resp.). Additionally, total cholesterol (P = .003), low density lipoprotein cholesterol (P = .004), apolipoprotein B (P = .006), and the total cholesterol/high density lipoprotein cholesterol (P = .027) were significantly related to TT in AA women only. In CA women, similar measures of glucose/insulin status related to FAI, were also related to SHBG. In both CA and AA women, SHBG was related to waist (P = .031 and P = .022 resp.). Conclusion. Our findings showed racial disparities in the relationship between the sex steroid milieu and the MRP in overweight/obese CA and AA women.

Hormonal evaluation of the infertile male: has it evolved?

An endocrinologic evaluation of patients who have male-factor infertility has clearly evolved and leads to specific diagnoses and treatment strategies in a large population of infertile men. A well-considered endocrine evaluation is especially essential with the ever-growing popularity of assisted reproductive techniques and continued refinements with intracytoplasmic sperm injection.

The aphrodisiac herb Tribulus terrestris does not influence the androgen production in young men

OBJECTIVE

The aim of the current study is to investigate the influence of Tribulus terrestris extract on androgen metabolism in young males.

DESIGN AND METHODS

Twenty-one healthy young 20-36 years old men with body weight ranging from 60 to 125 kg were randomly separated into three groups-two experimental (each n=7) and a control (placebo) one (n=7). The experimental groups were named TT1 and TT2 and the subjects were assigned to consume 20 and 10 mg/kg body weight per day of Tribulus terrestris extract, respectively, separated into three daily intakes for 4 weeks. Testosterone, androstenedione and luteinizing hormone levels in the serum were measured 24 h before supplementation (clear probe), and at 24, 72, 240, 408 and 576 h from the beginning of the supplementation.

RESULTS

There was no significant difference between Tribulus terrestris supplemented groups and controls in the serum testosterone (TT1 (mean+/-S.D.: 15.75+/-1.75 nmol/l); TT2 (mean+/-S.D.: 16.32+/-1.57 nmol/l); controls (mean+/-S.D.: 17.74+/-1.09 nmol/l) (p>0.05)), androstenedione (TT1 (mean+/-S.D.: 1.927+/-0.126 ng/ml); TT2 (mean+/-S.D.: 2.026+/-0.256 ng/ml); controls (mean+/-S.D.: 1.952+/-0.236 ng/ml) (p>0.05)) or luteinizing hormone (TT1 (mean+/-S.D.: 4.662+/-0.274U/l); TT2 (mean+/-S.D.: 4.103+/-0.869U/l); controls (mean+/-S.D.: 4.170+/-0.406U/l) (p>0.05)) levels. All results were within the normal range. The findings in the current study anticipate that Tribulus terrestris steroid saponins possess neither direct nor indirect androgen-increasing properties. The study will be extended in the clarifying the probable mode of action of Tribulus terrestris steroid saponins.

Utilization of commercial laboratory results in management of hyperandrogenism in women

OBJECTIVE

To compare results from testosterone radioimmunoassay kits commonly used by commercial laboratories as well as their reference ranges and to analyze the scientific literature for ranges of serum testosterone levels in normal women and those with hyperandrogenism.

METHODS

We reviewed quality assurance reports of various testosterone ligand challenges from four groups of laboratories and summarized testosterone data from 17 published reports about normal women and 14 studies of hyperandrogenic women.

RESULTS

A significant variability was demonstrated between the radioimmunoassay kits at all concentrations (for example, a sample with a mean testosterone level of 96.1 ng/dL was reported by some laboratories as containing 71.8 ng/dL and by others as 123.4 ng/dL). All laboratories provide essentially the same "reference range" (approximately 10 to 90 ng/dL) but do not report how the range was established. The scientific literature clearly shows a significant separation in serum testosterone levels between normal (that is, not hyperandrogenic) and hyperandrogenic women. Most hyperandrogenic women had testosterone levels >50 ng/dL, whereas most normal control subjects had levels <40 ng/dL. Thus, most of these women with hyperandrogenism would have been considered to have normal testosterone levels if the reference ranges of commercial laboratories were used.

CONCLUSION

These data illustrate the difficulty that physicians face when they are required to use different commercial laboratories to measure serum testosterone levels. We propose that (1) reference ranges be established on a clinically defined population for each hormone and method used, (2) laboratory reports include information about method and reference range population, and (3) physicians be allowed to choose which laboratories are used for their patients' hormone determinations, for consistency of results.

Evaluation of an algorithm for calculation of serum “Bioavailable” testosterone (BAT)

OBJECTIVES

To evaluate a recently published algorithm for calculation of serum "Bioavailable" Testosterone (BAT) using serum Total Testosterone (TT), Sex Steroid Binding Globulin (SSBG) [also commonly known as Sex Hormone Binding Globulin (SHBG)] and albumin concentrations as parameters, in comparison with a locally available "salting-out" BAT method. If satisfactory, this calculation could serve as a substitute for the BAT assay, which would amount to a major cost saving and faster turnaround time.

DESIGN AND METHODS

During a 6-month period, 426 serum samples referred for BAT analysis to the Hospitals In-Common Laboratory of Toronto were also analyzed in-house for TT, SSBG and albumin for computation of comparison calculated BAT results.

RESULTS

A good statistical correlation was obtained, but only after unexpectedly drastic empirical modification of the association constant values: r=0.95, Calculated %BAT=0.971 x Measured %BAT + 0.008. The endocrinologist/andrologist of our team (JB), who was the responsible physician for all patients included in this study, reviewed the tabulated and charted calculated BAT results and verified that they were clinically equivalent.

CONCLUSIONS

Although it is feasible to calculate BAT, the algorithm is not directly portable. Before adopting such a calculation each laboratory should compare it with the locally available BAT method and consider adjusting the calculation to optimize the correlation. Future reassessment may be necessary whenever the SSBG, TT or BAT assay is changed.

Neck circumference a good predictor of raised insulin and free androgen index in obese premenopausal women: changes with weight loss

OBJECTIVE

Severe obesity can be associated with evidence of androgen excess and insulin resistance, which are features of the metabolic and polycystic ovary syndromes (PCOS). In this study, we examined the association between clinical and biochemical features of these syndromes and assess changes with weight loss.

DESIGN

A consecutive series of 107 severely obese premenopausal women presenting for obesity surgery.

MEASUREMENTS

Pre-operative assessment included details of clinical comorbidity, anthropometric measures and biochemical measures, including fasting insulin, glucose, lipid profile and sex hormone analysis. Changes in these measures for 42 of 52 (81%) patients at 1 year post surgery are reported.

RESULTS

Neck circumference and younger age were independent predictors of higher free androgen index (FAI) (combined r2 = 0.36). If neck circumference is not included, then younger age, higher body mass index and raised fasting insulin levels were all independent predictors of FAI (r2 = 0.29). Waist to hip ratio showed no predictive value (r = 0.14). Neck circumference was also a good clinical predictor of menstrual irregularity, hirsutism, infertility, insulin resistance and the PCOS. Neck circumference of less than 39, 39-42 and greater than 42 cm reflect a low, intermediate and high risk of the metabolic and PCOS syndromes in obese premenopausal women. For 42 patients who were followed for 1 year after surgery, the weight loss was associated with reduction of FAI, less insulin resistance and improved menstrual regularity and resolution of the PCOS in 11 of 12 cases.

CONCLUSIONS

Neck circumference is a good predictive measure of hyperinsulinaemia and raised androgens in obese premenopausal women. Weight loss following surgery improves ovarian function and vasculopathic risk.

Obesity regulates bioavailable testosterone levels in women with or without polycystic ovary syndrome

OBJECTIVE

To evaluate [1] the effects of levels of sex hormone-binding globulin (SHBG), albumin, and total testosterone on the distribution of testosterone between SHBG-bound and non-SHBG-bound fractions; [2] the independent effects of polycystic ovary syndrome (PCOS) and body mass index on serum levels of total testosterone, non-SHBG-bound testosterone, SHBG, and albumin; and [3] the usefulness of levels of total testosterone and non-SHBG-bound testosterone and of the free androgen index in the diagnosis of PCOS.

DESIGN

Retrospective clinical study.

SETTING

An academic research environment.

PATIENT(S)

Forty-three women with oligomenorrhea and PCOS. Twenty-five women with regular menstrual cycles and without hirsutism served as controls.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Levels of non-SHBG-bound testosterone, total testosterone, SHBG, and albumin in serum.

RESULT(S)

Levels of total testosterone and non-SHBG-bound testosterone, and the free androgen index were higher in patients with PCOS than in healthy controls. PCOS did not have an effect on the levels of SHBG or albumin, or on the percentage of non-SHBG-bound testosterone. Levels of SHBG and albumin were inversely related to body mass index. The percentage and concentration of non-SHBG-bound testosterone and the free androgen index were directly related to body mass index. Hirsutism did not have an effect on any outcome measure.

CONCLUSION(S)

The distribution of total testosterone into SHBG-bound and non-SHBG-bound fractions is associated with body mass index, not with PCOS. The high levels of non-SHBG-bound testosterone and the high free androgen index in patients with PCOS reflect mainly high levels of total testosterone. Thus, the measurement of levels of non-SHBG-bound testosterone and the calculation of the free androgen index provide no further information in the diagnosis of PCOS beyond that provided by the measurement of levels of total testosterone.

Sex-hormone binding globulin as an indicator of the hepatic impacts of continuous combined hormone replacement regimens

OBJECTIVES

Nonoral administration of hormone replacement therapy avoids the first pass metabolism of steroids in the liver. We wanted to determine to what extent it has an effect on the serum concentrations of sex-hormone binding globulin and the free testosterone index.

METHODS

Postmenopausal women received 50 microg per day transdermal estradiol associated with the use of a levonorgestrel-releasing intrauterine device (20 women) or a daily oral dose of 2 mg of estradiol and 1 mg of norethisterone acetate (20 women) for 1 year. Eight women, five in the nonoral and three in the oral therapy group discontinued the study.

RESULTS

Although serum sex-hormone binding globulin concentrations decreased in women receiving transdermal estradiol in combination with a levonorgestrel-releasing intrauterine device, the free testosterone index did not change significantly. In the continuous oral regimen, no significant changes in serum sex-hormone binding globulin or free testosterone index were observed. The free testosterone index, however, was significantly higher in the nonoral therapy group after 6 and 12 months of treatment than in the oral therapy group.

CONCLUSIONS

Continuous progestin combined with continuous estrogen in oral and nonoral replacement therapy does not lead to a substantial androgenic excess in postmenopausal women. The intrauterine administration of levonorgestrel appears to have some hepatic effect.

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.

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

OBJECTIVE

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

SETTING

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

PATIENTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Testosterone levels during systemic and inhaled corticosteroid therapy

Testosterone has importance both as a sex hormone and as an anabolic steroid promoting bone formation. Osteoporosis is associated with both hypogonadism and corticosteroid therapy. Testosterone levels are reduced by long term prednisolone treatment. Although high dose inhaled corticosteroid therapy may cause a variety of systemic effects including adrenal suppression, dermal thinning and a reduction in total bone calcium, its effect on testosterone levels is not known. Testosterone, luteinizing hormone, follicle stimulating hormone and sex hormone binding globulin were therefore measured in 35 male patients with respiratory disease attending an outpatient clinic (median age 58, range 21-75 years). They were grouped according to steroid therapy and compared with 19 age matched controls. Mean (SD) testosterone levels were 33% lower in 12 men on long term oral prednisolone [14.5 (6.0) nmol 1-1] than in controls [21.7 (6.3) nmol 1-1], but were not significantly reduced in 10 patients on low dose inhaled beclomethasone [200-800 micrograms day-1: 19.7 (3.7)] nor in 13 men taking high dose inhaled beclomethasone [1500-2,250 micrograms day-1: 17.9 (5.6)]. Levels of luteinizing hormone, follicle stimulating hormone and sex hormone binding globulin were similar in all four groups. These cross sectional data confirm that long term systemic corticosteroid therapy reduces testosterone levels. However, testosterone was reduced by only 18% (NS) by long term inhaled corticosteroids. Other mechanisms to explain the disordered bone metabolism should now be explored.

Circadian variation in serum free and non-SHBG-bound testosterone in normal men: measurements, and simulation using a mass action model

OBJECTIVE

We measured the changes in testosterone fractions in serum of normal men over a 24-hour period, and determined whether they could be simulated on the basis of current understanding of the interactions between steroids and binding proteins in the blood.

DESIGN

Starting from between 0830 and 0930 h, blood samples were taken every 45 minutes for 25.5 hours.

PATIENTS

Five healthy males aged 26-45 years. All participants worked on a hospital campus and while being sampled carried out their normal activities during waking hours.

MEASUREMENTS

The concentrations of testosterone (RIA) and albumin, and the percentage non-sex hormone binding globulin-bound testosterone (ammonium sulphate precipitation) and percentage free testosterone (rate dialysis), were measured on each sample. Cortisol (RIA) and sex hormone-binding globulin (SHBG) (IRMA) concentrations were measured on every second sample, and that of corticosteroid-binding globulin on two samples from each series.

RESULTS

In all participants the levels of free and non-SHBG-bound testosterone in early morning samples (near 0530 h) were significantly different from those taken before midnight (P < 0.0005). Significant circadian rhythms (P < 0.05) in the concentration of testosterone and in the level of the free fraction were detected in all participants, and in four of the five participants for the non-SHBG-bound fraction. The amplitude of the free testosterone rhythm (34 +/- 2% of basal) was greater than that for testosterone itself (24 +/- 3% of basal). The 24-hour rhythm of the non-SHBG-bound fraction was similar to the total and free fractions except for the period 0330-0900 h when the level of this fraction declined by 15-45% over 1.5-3 hours. This decline was coincident with the initial rise in the concentration of cortisol. A decline of 10.5 +/- SEM 1.0% in the concentration of albumin, and 12.0 +/- 1.1% in that of SHBG occurred when the mean ambulant and supine levels were compared; analysis indicated significant circadian rhythms in the concentrations of these proteins. Simulation was used to investigate possible causes for the circadian rhythms in free and non-SHBG-bound testosterone. Simulation results matched the measured data well in qualitative terms, but quantitatively there were differences.

CONCLUSIONS

Increasing saturation of the binding proteins following rises in testosterone production, and the small but significant changes in protein concentration, probably related to postural changes, were implicated as the major factors in the rhythm amplitude. However, the early morning decline in the non-SHBG-bound fraction was not explained by these factors. The rise in cortisol concentration at this time is a probable cause. Alternatively, simulation suggests that a substance appearing in the early morning and competing with testosterone for albumin binding sites may be responsible.

Androgen biology as a basis for the diagnosis and treatment of androgenic disorders in women. II

In the May 1993 issue of the Journal we reviewed the basic science of androgen biology in women. We now discuss the evaluation of suspected hyperandrogenism and the therapeutic modalities available.

Androgen biology as a basis for the diagnosis and treatment of androgenic disorders in women. I

Disorders of androgen excess in women are common in the practice of dermatology. The literature regarding the evaluation and treatment of women with cutaneous hyperandrogenism (acne, hirsutism, and alopecia) is vast and is contained in numerous subspecialty journals. At first glance, the basic science knowledge required to understand androgen biology appears exceedingly complex. However, an understanding of androgen physiology and a familiarity with the relevant literature are the basis of appropriate evaluations and treatment recommendations. In the first of this two-part series, we review the basic science of androgen biology and pathophysiology in women. The second part of this series will cover the evaluation of suspected hyperandrogenic women and the therapeutic modalities that are available.