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Patel AH, Koysombat K, Pierret A, Young M, Comninos AN, Dhillo WS, Abbara A. Kisspeptin in functional hypothalamic amenorrhea: Pathophysiology and therapeutic potential. Ann N Y Acad Sci 2024; 1540:21-46. [PMID: 39287750 DOI: 10.1111/nyas.15220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2024]
Abstract
Functional hypothalamic amenorrhea (FHA) is one of the most common causes of secondary amenorrhea, resulting in anovulation and infertility, and is a low estrogen state that increases the risk of cardiovascular disease and impairs bone health. FHA is characterized by acquired suppression of physiological pulsatile gonadotropin-releasing hormone (GnRH) release by the hypothalamus in the absence of an identifiable structural cause, resulting in a functional hypogonadotropic hypogonadism. FHA results from either decreased energy intake and/or excessive exercise, leading to low energy availability and weight loss-often in combination with psychological stress on top of a background of genetic susceptibility. The hypothalamic neuropeptide kisspeptin is a key component of the GnRH pulse generator, tightly regulating pulsatile GnRH secretion and the downstream reproductive axis. Here, we review the physiological regulation of pulsatile GnRH secretion by hypothalamic kisspeptin neurons and how their activity is modulated by signals of energy status to affect reproductive function. We explore endocrine factors contributing to the suppression of GnRH pulsatility in the pathophysiology of FHA and how hypothalamic kisspeptin neurons likely represent a final common pathway through which these factors affect GnRH pulse generation. Finally, we discuss the therapeutic potential of kisspeptin as a novel treatment for women with FHA.
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Affiliation(s)
- Aaran H Patel
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, UK
- Department of Endocrinology, Chelsea and Westminster Hospital, London, UK
| | - Kanyada Koysombat
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Aureliane Pierret
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, UK
| | - Megan Young
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, UK
| | - Alexander N Comninos
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Waljit S Dhillo
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Ali Abbara
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, UK
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, UK
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Abbara A, Adams S, Phylactou M, Izzi-Engbeaya C, Mills EG, Thurston L, Koysombat K, Hanassab S, Heinis T, Tan TMM, Tsaneva-Atanasova K, Comninos AN, Voliotis M, Dhillo WS. Quantifying the variability in the assessment of reproductive hormone levels. Fertil Steril 2024; 121:334-345. [PMID: 37977226 DOI: 10.1016/j.fertnstert.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 10/24/2023] [Accepted: 11/08/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVE To quantify how representative a single measure of reproductive hormone level is of the daily hormonal profile using data from detailed hormonal sampling in the saline placebo-treated arm conducted over several hours. DESIGN Retrospective analysis of data from previous interventional research studies evaluating reproductive hormones. SETTING Clinical Research Facility at a tertiary reproductive endocrinology centre at Imperial College Hospital NHS Foundation Trust. PATIENTS Overall, 266 individuals, including healthy men and women (n = 142) and those with reproductive disorders and states (n = 124 [11 with functional hypothalamic amenorrhoea, 6 with polycystic ovary syndrome, 62 women and 32 men with hypoactive sexual desire disorder, and 13 postmenopausal women]), were included in the analysis. INTERVENTIONS Data from 266 individuals who had undergone detailed hormonal sampling in the saline placebo-treated arms of previous research studies was used to quantify the variability in reproductive hormones because of pulsatile secretion, diurnal variation, and feeding using coefficient of variation (CV) and entropy. MAIN OUTCOME MEASURES The ability of a single measure of reproductive hormone level to quantify the variability in reproductive hormone levels because of pulsatile secretion, diurnal variation, and nutrient intake. RESULTS The initial morning value of reproductive hormone levels was typically higher than the mean value throughout the day (percentage decrease from initial morning measure to daily mean: luteinizing hormone level 18.4%, follicle-stimulating hormone level 9.7%, testosterone level 9.2%, and estradiol level 2.1%). Luteinizing hormone level was the most variable (CV 28%), followed by sex-steroid hormone levels (testosterone level 12% and estradiol level 13%), whereas follicle-stimulating hormone level was the least variable reproductive hormone (CV 8%). In healthy men, testosterone levels fell between 9:00 am and 5:00 pm by 14.9% (95% confidence interval 4.2, 25.5%), although morning levels correlated with (and could be predicted from) late afternoon levels in the same individual (r2 = 0.53, P<.0001). Testosterone levels were reduced more after a mixed meal (by 34.3%) than during ad libitum feeding (9.5%), after an oral glucose load (6.0%), or an intravenous glucose load (7.4%). CONCLUSION Quantification of the variability of a single measure of reproductive hormone levels informs the reliability of reproductive hormone assessment.
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Affiliation(s)
- Ali Abbara
- Department of Metabolism, Digestion and Reproduction, Imperial College London, Hammersmith Hospital, London, United Kingdom; Department of Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Sophie Adams
- Department of Metabolism, Digestion and Reproduction, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Maria Phylactou
- Department of Metabolism, Digestion and Reproduction, Imperial College London, Hammersmith Hospital, London, United Kingdom; Department of Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Chioma Izzi-Engbeaya
- Department of Metabolism, Digestion and Reproduction, Imperial College London, Hammersmith Hospital, London, United Kingdom; Department of Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Edouard G Mills
- Department of Metabolism, Digestion and Reproduction, Imperial College London, Hammersmith Hospital, London, United Kingdom; Department of Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Layla Thurston
- Department of Metabolism, Digestion and Reproduction, Imperial College London, Hammersmith Hospital, London, United Kingdom; Department of Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Kanyada Koysombat
- Department of Metabolism, Digestion and Reproduction, Imperial College London, Hammersmith Hospital, London, United Kingdom; Department of Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Simon Hanassab
- Department of Metabolism, Digestion and Reproduction, Imperial College London, Hammersmith Hospital, London, United Kingdom; Department of Computing, Imperial College London, London, United Kingdom; UKRI Centre for Doctoral Training in Artificial Intelligence (AI) for Healthcare, Imperial College London, London, United Kingdom
| | - Thomas Heinis
- Department of Computing, Imperial College London, London, United Kingdom
| | - Tricia M-M Tan
- Department of Metabolism, Digestion and Reproduction, Imperial College London, Hammersmith Hospital, London, United Kingdom; Department of Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom; North West London Pathology, London, United Kingdom
| | - Krasimira Tsaneva-Atanasova
- Department of Mathematics and Statistics, and Living Systems Institute, College of Engineering, Mathematics and Physical Sciences, University of Exeter, United Kingdom; EPSRC Hub for Quantitative Modelling in Healthcare, University of Exeter, Exeter, United Kingdom
| | - Alexander N Comninos
- Department of Metabolism, Digestion and Reproduction, Imperial College London, Hammersmith Hospital, London, United Kingdom; Department of Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Margaritis Voliotis
- Department of Mathematics and Statistics, and Living Systems Institute, College of Engineering, Mathematics and Physical Sciences, University of Exeter, United Kingdom; EPSRC Hub for Quantitative Modelling in Healthcare, University of Exeter, Exeter, United Kingdom
| | - Waljit S Dhillo
- Department of Metabolism, Digestion and Reproduction, Imperial College London, Hammersmith Hospital, London, United Kingdom; Department of Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom.
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Simpson EM, Clarke IJ, Scott CJ, Stephen CP, Rao A, Gunn AJ. The GLP-1 agonist, exendin-4, stimulates LH secretion in female sheep. J Endocrinol 2023; 259:e230105. [PMID: 37466202 PMCID: PMC10448581 DOI: 10.1530/joe-23-0105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/18/2023] [Indexed: 07/20/2023]
Abstract
Our previous studies showed that microinjection into the median eminence of the sheep of glucagon-like peptide- 1 (GLP-1) or its receptor agonist exendin-4 stimulates luteinising hormone (LH) secretion, but it is unknown whether the same effect may be obtained by systemic administration of the same. The present study measured the response in terms of plasma LH concentrations to intravenous (iv) infusion of exendin-4. A preliminary study showed that infusion of 2 mg exendin-4 into ewes produced a greater LH response in the follicular phase of the oestrous cycle than the luteal phase. Accordingly, the main study monitored plasma LH levels in response to either 0.5 mg or 2 mg exendin-4 or vehicle (normal saline) delivered by jugular infusion for 1 h in the follicular phase of the oestrous cycle. Blood samples were collected at 10 min intervals before, during and after infusion. Both doses of exendin-4 increased mean plasma LH concentrations and increased LH peripheral pulse amplitude. There was no effect on inter-pulse interval or timing of the preovulatory LH surge. These doses of exendin-4 did not alter plasma insulin or glucose concentrations. Quantitative PCR of the gastrointestinal tract samples from a population of ewes confirmed the expression of the preproglucagon gene (GCG). Expression increased aborally and was greatest in the rectum. It is concluded that endogenous GLP-1, most likely derived from the hindgut, may act systemically to stimulate LH secretion. The present data suggest that this effect may be obtained with levels of agonist that are lower than those functioning as an incretin.
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Affiliation(s)
- Elizabeth M Simpson
- School of Agricultural, Environmental and Veterinary Sciences, Faculty of Science and Health, Charles Sturt University, Wagga Wagga, NSW, Australia
- Gulbali Institute, Charles Sturt University, Wagga Wagga, NSW, Australia
| | - Iain J Clarke
- School of Agriculture Food and Ecosystem Sciences, Faculty of Science, The University of Melbourne, Parkville, VIC, Australia
| | - Christopher J Scott
- School of Dentistry and Medical Science, Faculty of Science and Health, Charles Sturt University, Wagga Wagga, NSW, Australia
| | - Cyril P Stephen
- School of Agricultural, Environmental and Veterinary Sciences, Faculty of Science and Health, Charles Sturt University, Wagga Wagga, NSW, Australia
- Gulbali Institute, Charles Sturt University, Wagga Wagga, NSW, Australia
| | - Alexandra Rao
- School of Agriculture Food and Ecosystem Sciences, Faculty of Science, The University of Melbourne, Parkville, VIC, Australia
| | - Allan J Gunn
- School of Agricultural, Environmental and Veterinary Sciences, Faculty of Science and Health, Charles Sturt University, Wagga Wagga, NSW, Australia
- Gulbali Institute, Charles Sturt University, Wagga Wagga, NSW, Australia
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Morrison AE, Fleming S, Levy MJ. A review of the pathophysiology of functional hypothalamic amenorrhoea in women subject to psychological stress, disordered eating, excessive exercise or a combination of these factors. Clin Endocrinol (Oxf) 2021; 95:229-238. [PMID: 33345352 DOI: 10.1111/cen.14399] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Functional hypothalamic amenorrhoea (FHA) is a common form of secondary amenorrhoea without an identifiable structural cause. Suppression of gonadotrophin-releasing hormone (GnRH) pulsatility results in reduced luteinizing hormone (LH) levels, with subsequent reduction in oestradiol, anovulation and cessation of menstruation. GnRH pulsatility suppression is a recognized complication of psychological stress, disordered eating, low body weight, excessive exercise or a combination of these factors. PATHOPHYSIOLOGY OF FHA Individuals with FHA demonstrate low energy availability (EA), body fat percentage and energy expenditure. Documented adipocytokine changes notably, raised adiponectin, ghrelin, PYY, and decreased leptin, are associated with GnRH suppression. Other endocrine responses seen in this low EA state include low insulin levels, low total T3, increased basal cortisol levels and a reduced response to corticotrophin-releasing hormone (CRH) administration. FHA is associated with raised growth hormone (GH) and low insulin-like growth factor (IGF-1), suggesting relative GH resistance. Kisspeptins are a group of polypeptides, recently discovered to play a major role in the regulation of the reproductive axis through influencing GnRH release. KNDy (kisspeptin/neurokinin B/dynorphin) act on GnRH neurons and a multitude of factors result in their release. IMPLICATIONS FOR FUTURE TREATMENT Management of FHA is imperative to prevent adverse outcomes in bone density, cardiovascular risk profile, psychological well-being and fertility. Outwith modification of nutritional intake and exercise, limited therapeutic strategies are currently available for women with FHA. Advancements in the understanding of the pathophysiological basis of this under-recognized and under-treated clinical entity will aid management and may result in the development of novel therapeutic approaches.
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Affiliation(s)
- Amy E Morrison
- Department of Endocrinology, University Hospitals of Leicester, Leicester, UK
| | - Suzannah Fleming
- Department of Endocrinology, University Hospitals of Leicester, Leicester, UK
| | - Miles J Levy
- Department of Endocrinology, University Hospitals of Leicester, Leicester, UK
- Department of Endocrinology, University of Leicester, Leicester, UK
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Abstract
PURPOSE OF REVIEW Appetite control results from metabolic, behavioral, and environmental factors that influence hunger and the desire to eat. We summarize the latest advances in the hormonal and nutritional strategies to control appetite and reduce hunger. RECENT FINDINGS The fed-hunger-state is regulated by central and peripheric hormones, which modulate energy balance. Leptin, insulin, ghrelin, peptide YY (PYY), and other gut-derived peptides represent the main appetite controllers. The role of orexins, obestatin, and liver-expressed antimicrobial peptide 2 has been uncovered recently. New insights have demonstrated the role of hippocampal activity as a possible mechanism of action. Glucagon-like peptide 1 (GLP1) receptor agonists are well known agents controlling appetite. Association of GLP1 receptor agonist, PYY, or glucose-dependent insulinotropic polypeptide agonists have been tested as new approaches. Appetite-control hormones have also risen as factors involved in the efficacy of bariatric procedures. High-protein, ketogenic diet, and intermittent fasting have been described as nutritional strategies to reduce appetite, although the physiological mechanism and long-term safety remains unclear. SUMMARY Appetite control has been an important target for the treatment of obesity and associated disorders. New studies have demonstrated promising adoption of dietary approaches, hormone-based drugs, and bariatric surgery to control energy intake. Further research will establish a significant association, benefits, and safety of these new therapies.
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Affiliation(s)
- Rachel H Freire
- Departamento de Bioquímica e Imunologia, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
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