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Rosenfield RL. The Search for the Causes of Common Hyperandrogenism, 1965 to Circa 2015. Endocr Rev 2024; 45:553-592. [PMID: 38457123 DOI: 10.1210/endrev/bnae007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 12/23/2023] [Accepted: 03/06/2024] [Indexed: 03/09/2024]
Abstract
From 1965 to 2015, immense strides were made into understanding the mechanisms underlying the common androgen excess disorders, premature adrenarche and polycystic ovary syndrome (PCOS). The author reviews the critical discoveries of this era from his perspective investigating these disorders, commencing with his early discoveries of the unique pattern of plasma androgens in premature adrenarche and the elevation of an index of the plasma free testosterone concentration in most hirsute women. The molecular genetic basis, though not the developmental biologic basis, for adrenarche is now known and 11-oxytestosterones shown to be major bioactive adrenal androgens. The evolution of the lines of research into the pathogenesis of PCOS is historically traced: research milestones are cited in the areas of neuroendocrinology, insulin resistance, hyperinsulinism, type 2 diabetes mellitus, folliculogenesis, androgen secretion, obesity, phenotyping, prenatal androgenization, epigenetics, and complex genetics. Large-scale genome-wide association studies led to the 2014 discovery of an unsuspected steroidogenic regulator DENND1A (differentially expressed in normal and neoplastic development). The splice variant DENND1A.V2 is constitutively overexpressed in PCOS theca cells in long-term culture and accounts for their PCOS-like phenotype. The genetics are complex, however: DENND1A intronic variant copy number is related to phenotype severity, and recent data indicate that rare variants in a DENND1A regulatory network and other genes are related to PCOS. Obesity exacerbates PCOS manifestations via insulin resistance and proinflammatory cytokine excess; excess adipose tissue also forms testosterone. Polycystic ovaries in 40 percent of apparently normal women lie on the PCOS functional spectrum. Much remains to be learned.
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Affiliation(s)
- Robert L Rosenfield
- Department of Pediatrics and Medicine, The University of Chicago, Chicago, IL 94109, USA
- Department of Pediatrics, The University of California, San Francisco, San Francisco, CA 94143, USA
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Das S, Bhattacharya N, Mahata R, Ghosh S, Bhar AS, Srivastava P. Correlation of Follicle-stimulating Hormone, Anti-Mullerian Hormone, and Antral Follicle Count with Age in Ovarian Reserve Testing. Int J Appl Basic Med Res 2024; 14:162-168. [PMID: 39310079 PMCID: PMC11412561 DOI: 10.4103/ijabmr.ijabmr_81_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 07/11/2024] [Accepted: 07/16/2024] [Indexed: 09/25/2024] Open
Abstract
Objective Ovarian reserve and hence ovarian response has a key role in assisted reproductive technology and predicting response to gonadotrophins in controlled ovarian hyperstimulation. Various tools, namely follicle-stimulating hormone (FSH), anti-Mullerian hormone (AMH), antral follicle count (AFC), estradiol, etc., have been studied to discover the best determinant of ovarian reserve. The aim of our study is to correlate different reproductive hormones with age of women to estimate ovarian reserve and to evaluate reliable marker for aiding infertility treatment. Materials and Methods It is an observational study performed for 6 months, with 88 women (aged 21-39 years) having a complaint of infertility, enrolled in the infertility clinic of a tertiary care hospital. Baseline scan for AFC was done for every patient and their blood was sent for serum FSH, AMH analysis. Statistical procedures were employed to determine the association between age and reproductive hormones (i.e. FSH and AMH) as independent variables and AFC as a dependent variable. Results A strong negative correlation was noted between FSH and AMH and between age and AMH (r = -0.492 and r = -0.498, respectively). A weak negative correlation was seen between AMH and total AFC (r = -0.241). A moderate positive correlation was seen on comparing age and FSH (r = 0.331), whereas no correlation was seen on comparing FSH with AFC and AMH with AFC. The presence of ovarian cyst did not affect AMH or AFC but reduced FSH values significantly. Conclusion In the quest to determine a panel test for ovarian reserve testing we conclude, FSH and AFC should perform fairly in poor resource and low socioeconomic setting. The combination of FSH with AMH and AFC might aid in better determination of ovarian reserve in tertiary centers with available resources.
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Affiliation(s)
- Subrata Das
- Department of Obstetrics and Gynaecology, ESI PGI MSR, ESIC Medical College and ESIC Hospital and ODC (EZ), Kolkata, West Bengal, India
| | - Namrata Bhattacharya
- Department of Obstetrics and Gynaecology, ESI PGI MSR, ESIC Medical College and ESIC Hospital and ODC (EZ), Kolkata, West Bengal, India
| | - Ritu Mahata
- Department of Obstetrics and Gynaecology, ESI PGI MSR, ESIC Medical College and ESIC Hospital and ODC (EZ), Kolkata, West Bengal, India
| | - Sudip Ghosh
- Department of Community Medicine, Burdwan Medical College, Burdwan, West Bengal, India
| | - Anindya Sundar Bhar
- Department of Obstetrics and Gynaecology, ESI PGI MSR, ESIC Medical College and ESIC Hospital and ODC (EZ), Kolkata, West Bengal, India
| | - Pragati Srivastava
- Department of Obstetrics and Gynaecology, ESI PGI MSR, ESIC Medical College and ESIC Hospital and ODC (EZ), Kolkata, West Bengal, India
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Polinski KJ, Robinson SL, Putnick DL, Sundaram R, Bell E, Joseph PV, Segars J, Guan W, Silver RM, Schisterman EF, Mumford SL, Yeung EH. Examination of newborn DNA methylation among women with polycystic ovary syndrome/hirsutism. Epigenetics 2023; 18:2282319. [PMID: 37992405 PMCID: PMC10732621 DOI: 10.1080/15592294.2023.2282319] [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: 04/03/2023] [Accepted: 11/06/2023] [Indexed: 11/24/2023] Open
Abstract
Research suggests that polycystic ovary syndrome (PCOS) traits (e.g., hyperandrogenism) may create a suboptimal intrauterine environment and induce epigenetic modifications. Therefore, we assessed the associations of PCOS traits with neonatal DNA methylation (DNAm) using two independent cohorts. DNAm was measured in both cohorts using the Infinium MethylationEPIC array. Multivariable robust linear regression was used to determine associations of maternal PCOS exposure or preconception testosterone with methylation β-values at each CpG probe and corrected for multiple testing by false-discovery rate (FDR). In the birth cohort, 12% (102/849) had a PCOS diagnosis (8.1% PCOS without hirsutism; 3.9% PCOS with hirsutism). Infants exposed to maternal PCOS with hirsutism compared to no PCOS had differential DNAm at cg02372539 [β(SE): -0.080 (0.010); FDR p = 0.009], cg08471713 [β(SE):0.077 (0.014); FDR p = 0.016] and cg17897916 [β(SE):0.050 (0.009); FDR p = 0.009] with adjustment for maternal characteristics including pre-pregnancy BMI. PCOS with hirsutism was also associated with 8 differentially methylated regions (DMRs). PCOS without hirsutism was not associated with individual CpGs. In an independent preconception cohort, total testosterone concentrations were associated with 3 DMRs but not with individual CpGs, though the top quartile of testosterone compared to the lowest was marginally associated with increased DNAm at cg21472377 near an uncharacterized locus (FDR p = 0.09). Examination of these probes and DMRs indicate they may be under foetal genetic control. Overall, we found several associations among newborns exposed to PCOS, specifically when hirsutism was reported, and among newborns of women with relatively higher testosterone around conception.
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Affiliation(s)
- Kristen J. Polinski
- Division of Population Health Research, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
| | - Sonia L. Robinson
- Division of Population Health Research, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
| | - Diane L. Putnick
- Division of Population Health Research, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
| | - Rajeshwari Sundaram
- Division of Population Health Research, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
| | - Erin Bell
- Department of Environmental Health Sciences, Epidemiology and Biostatistics, University at Albany School of Public Health, Albany, NY, United States
| | - Paule V. Joseph
- Section of Sensory Science and Metabolism, Division of Intramural Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD, United States
| | - James Segars
- Division of Reproductive Science and Women’s Health Research, Johns Hopkins Department of Gynecology & Obstetrics, Baltimore, MD, United States
| | - Weihua Guan
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Robert M. Silver
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, United States
| | - Enrique F. Schisterman
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Sunni L. Mumford
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Edwina H. Yeung
- Division of Population Health Research, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
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Myers SH, Russo M, Dinicola S, Forte G, Unfer V. Questioning PCOS phenotypes for reclassification and tailored therapy. Trends Endocrinol Metab 2023; 34:694-703. [PMID: 37661546 DOI: 10.1016/j.tem.2023.08.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/04/2023] [Accepted: 08/07/2023] [Indexed: 09/05/2023]
Abstract
Precise diagnoses are essential for defining appropriate treatments. This is particularly true for polycystic ovary syndrome (PCOS), whose phenotypical manifestations have recently suggested a possible diversity of etiological factors. PCOS is defined on the basis of gynecological and endocrinological alterations, but the patients often display considerable metabolic impairments, such as insulin resistance, that may worsen typical symptoms. The Rotterdam criteria fail to address this aspect, and the medical community has recently started to consider them as misleading diagnostic tools, casting doubts on whether the term PCOS is suited to describe all the clinical manifestations observed. This Opinion collects and critically discusses the scientific reports that question the definition of PCOS, calling for a revision of the current diagnostic criteria.
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Affiliation(s)
| | | | - Simona Dinicola
- R&D Department, Lo.Li Pharma, 00156 Rome, Italy; The Experts Group on Inositol in Basic and Clinical Research, Rome 00161, Italy
| | | | - Vittorio Unfer
- The Experts Group on Inositol in Basic and Clinical Research, Rome 00161, Italy; UniCamillus - Saint Camillus International University of Health Sciences, Rome 00156, Italy.
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Wang DD, Cao JX, Jiang WJ, Hou JW, Yan MH, Sun ZG, Song JY. Comparison of pregnancy outcomes of letrozole-induced frozen-thawed embryo transfer cycles in PCOS women with two different abnormal ovulation patterns: A retrospective cohort study. Medicine (Baltimore) 2023; 102:e33049. [PMID: 36800580 PMCID: PMC9936047 DOI: 10.1097/md.0000000000033049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
No studies have been conducted on the impact of different types of ovulatory dysfunction on the outcomes of frozen-thawed embryo transfers (FETs) in a letrozole-stimulated cycle in women with polycystic ovarian syndrome (PCOS). This study aimed to compare whether pregnancy outcomes of the letrozole-induced protocol in FET cycles differed between oligo-ovulatory and anovulatory women with PCOS. In a retrospective cohort study, women with PCOS who had undergone letrozole-induced FET at a university-affiliated fertility clinic from February 2014 to October 2020 were identified. The primary end point was live birth rate (LBR) per embryo transfer. Propensity score matching and multivariate logistic regression analyses were performed to control for the relevant confounders. A total of 652 women with PCOS undergoing letrozole-induced FET were included in the final analysis. Three hundred sixty-three of these women had oligo-ovulatory periods, while 289 had anovulatory periods. Propensity score matching analysis showed that LBR did not differ between groups (36.8% in oligo-ovulatory group vs 32.8% in anovulatory group, P = .431). Nevertheless, after controlling for potential confounding factors, LBR was significantly lower in anovulatory than oligo-ovulatory women (adjusted odds ratio 1.57, 95% confidence interval 1.08-2.29, P = .018). Furthermore, the pregnancy loss rate among the oligo-ovulatory group remained lower than those among the anovulatory group (adjusted odds ratio 0.23, 95% confidence interval 0.12-0.44, P < .001). Despite adjustment for confounding factors, those with oligo-ovulatory PCOS had a higher LBR and lower pregnancy loss rate compared with those with anovulatory PCOS. This may indicate that when oligo-ovulation is detected, PCOS patients should be intervened in time to conceive as soon as possible. Prospective studies must be conducted in the future to verify our findings.
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Affiliation(s)
- Dan-Dan Wang
- The First Clinical College, Shandong University of Traditional Chinese Medicine, Jinan, People’s Republic of China
| | - Jing-Xian Cao
- The First Clinical College, Shandong University of Traditional Chinese Medicine, Jinan, People’s Republic of China
| | - Wen-Jing Jiang
- The First Clinical College, Shandong University of Traditional Chinese Medicine, Jinan, People’s Republic of China
| | - Jin-Wei Hou
- The First Clinical College, Shandong University of Traditional Chinese Medicine, Jinan, People’s Republic of China
| | - Meng-Han Yan
- School of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, People’s Republic of China
| | - Zhen-Gao Sun
- The First Clinical College, Shandong University of Traditional Chinese Medicine, Jinan, People’s Republic of China
- Reproductive and Genetic Center of Integrated Medicine, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, People’s Republic of China
| | - Jing-Yan Song
- The First Clinical College, Shandong University of Traditional Chinese Medicine, Jinan, People’s Republic of China
- Reproductive and Genetic Center of Integrated Medicine, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, People’s Republic of China
- * Correspondence: Jing-Yan Song, The First Clinical College, Shandong University of Traditional Chinese Medicine, Jinan 250014, People’s Republic of China (e-mail: )
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Parker J, O'Brien C, Gersh FL. Developmental origins and transgenerational inheritance of polycystic ovary syndrome. Aust N Z J Obstet Gynaecol 2021; 61:922-926. [PMID: 34403138 DOI: 10.1111/ajo.13420] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 08/01/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND There has been increasing awareness that polycystic ovary syndrome (PCOS) phenotypes may represent a mismatch between ancient genetically programmed metabolic and reproductive survival mechanisms and modern lifestyle practices. In-utero developmental programming of metabolic and endocrine pathways may play an important role in activating gene variants that predispose the offspring to develop PCOS when exposed to specific postnatal conditions. Postnatal exposure to lifestyle factors such as poor-quality diet and endocrine disrupting chemicals may modulate epigenetically programmed pathways that result in the observed pathophysiological changes and clinical features seen in women with PCOS. AIM To review the developmental origins and transgenerational transmission of PCOS and the impact of lifestyle, androgens and endocrine disrupting chemicals on fetal epigenetic programming. MATERIALS AND METHODS The literature was reviewed using Google, Google Scholar, Medline and PubMed databases. The results are presented as a narrative review. RESULTS Human observational and animal experimental data support the hypothesis that PCOS is an inherited condition that arises as a result of developmental programming of normal gene variants. It is likely that these genes can be amplified by in-utero androgen exposure and activated by a range of postnatal lifestyle and environmental factors. Endocrine disrupting chemicals have the potential to influence developmental programming of PCOS susceptibility genes. CONCLUSIONS The current evidence suggests that developmental epigenetic programming following exposure to an adverse maternal metabolic and endocrine environment contributes to the pathogenesis of PCOS. Lifestyle interventions, as recommended by the International Guidelines, have the potential to reduce both symptoms and transgenerational transmission of PCOS.
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Affiliation(s)
- Jim Parker
- School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
| | - Claire O'Brien
- Faculty of Science and Technology, University of Canberra, Canberra, Australian Capital Territory, Australia
| | - Felice L Gersh
- Internal Medicine, University of Arizona College of Medicine, Irvine, CA, USA
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Bloom MS, Perkins NJ, Sjaarda LA, Mumford SL, Ye A, Kim K, Kuhr DL, Nobles CJ, Connell MT, Schisterman EF. Adiposity is associated with anovulation independent of serum free testosterone: A prospective cohort study. Paediatr Perinat Epidemiol 2021; 35:174-183. [PMID: 33107110 PMCID: PMC7878298 DOI: 10.1111/ppe.12726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 07/13/2020] [Accepted: 08/16/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Obesity, a body mass index (BMI) ≥30 kg/m2 , is linked to infertility, potentially through a greater risk of anovulation due to elevated androgens. Yet, previous studies have not directly assessed the impact of adiposity, or body fat, on anovulation in the absence of clinical infertility. OBJECTIVE To characterise the associations between adiposity and anovulation among women menstruating on a regular basis. METHODS Women from the EAGeR trial (n = 1200), a randomised controlled trial of low-dose aspirin and pregnancy loss among women trying to conceive, were used to estimate associations between adiposity and incident anovulation. Participants completed baseline questionnaires and anthropometry, and provided blood specimens. Women used fertility monitors for up to six consecutive menstrual cycles, with collection of daily first morning voids for hormone analysis in the first two menstrual cycles for prospective assessment of anovulation. Anovulation was assessed by urine pregnanediol glucuronide or luteinising hormone concentration or the fertility monitor. Weighted mixed-effects log-binomial regression was used to estimate associations between measures of adiposity and incident anovulation, adjusted for free (bioavailable) testosterone, anti-Mullerian hormone (AMH), serum lipids, and demographic and life style factors. RESULTS 343 (28.3%) women experienced at least one anovulatory cycle. Anovulation risk was higher per kg/m2 greater BMI (relative risk [RR] 1.03, 95% confidence interval (CI) 1.01, 1.04), cm waist circumference (RR 1.01, 95% CI 1.00, 1.02), mm subscapular skinfold (RR 1.02, 95% CI 1.01, 1.03), and mm middle upper arm circumference (RR 1.04, 95% CI 1.01, 1.06) adjusted for serum free testosterone, AMH, lipids, and other factors. CONCLUSIONS Adiposity may be associated with anovulation through pathways other than testosterone among regularly menstruating women. This may account in part for reported associations between greater adiposity and infertility among women having menstrual cycles regularly. Understanding the association between adiposity and anovulation might lead to targeted interventions for preventing infertility.
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Affiliation(s)
- Michael S. Bloom
- Departments of Environmental Health Sciences and Epidemiology and Biostatistics, University at Albany, State University of New York, Rensselaer, NY
- Department of Global and Community Health, George Mason University, Fairfax, VA (author’s current institution)
| | - Neil J. Perkins
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | - Lindsey A. Sjaarda
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | - Sunni L. Mumford
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | - Aijun Ye
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | - Keewan Kim
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | - Daniel L. Kuhr
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
- Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH (author’s current institution)
| | - Carrie J. Nobles
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | - Matthew T. Connell
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | - Enrique F. Schisterman
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
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Ding H, Zhang J, Zhang F, Zhang S, Chen X, Liang W, Xie Q. Resistance to the Insulin and Elevated Level of Androgen: A Major Cause of Polycystic Ovary Syndrome. Front Endocrinol (Lausanne) 2021; 12:741764. [PMID: 34745009 PMCID: PMC8564180 DOI: 10.3389/fendo.2021.741764] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 09/22/2021] [Indexed: 01/27/2023] Open
Abstract
PCOS has a wide range of negative impacts on women's health and is one of the most frequent reproductive systemic endocrine disorders. PCOS has complex characteristics and symptom heterogeneity due to the several pathways that are involved in the infection and the absence of a comm14on cause. A recent study has shown that the main etiology and endocrine aspects of PCOS are the increased level of androgen, which is also known as "hyperandrogenemia (HA)" and secondly the "insulin resistance (IR)". The major underlying cause of the polycystic ovary is these two IR and HA, by initiating the disease and its severity or duration. As a consequence, study on Pathogenesis is crucial to understand the effect of "HA" and "IR" on the pathophysiology of numerous symptoms linked to PCOS. A deep understanding of the pattern of the growth in PCOS for HA and IR can help ameliorate the condition, along with adjustments in nutrition and life, as well as the discovery of new medicinal products. However, further research is required to clarify the mutual role of IR and HA on PCOS development.
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Affiliation(s)
- Haigang Ding
- Department of Gynecology, Shaoxing Maternity and Child Health Care Hospital, Shaoxing, China
- Obstetrics and Gynecology Hospital of Shaoxing University, Shaoxing, China
| | - Juan Zhang
- Department of Gynecology, Shaoxing Maternity and Child Health Care Hospital, Shaoxing, China
- Obstetrics and Gynecology Hospital of Shaoxing University, Shaoxing, China
| | - Feng Zhang
- Department of Gynecology, Shaoxing Maternity and Child Health Care Hospital, Shaoxing, China
- Obstetrics and Gynecology Hospital of Shaoxing University, Shaoxing, China
| | - Songou Zhang
- College of Medicine, Shaoxing University, Shaoxing, China
| | - Xiaozhen Chen
- College of Medicine, Shaoxing University, Shaoxing, China
| | - Wenqing Liang
- Medical Research Center, Zhoushan Hospital of Traditional Chinese Medicine Affiliated to Zhejiang Chinese Medical University, Zhoushan, China
- *Correspondence: Qiong Xie, ; Wenqing Liang,
| | - Qiong Xie
- Department of Gynecology, Zhoushan Hospital of Traditional Chinese Medicine Affiliated to Zhejiang Chinese Medical University, Zhoushan, China
- *Correspondence: Qiong Xie, ; Wenqing Liang,
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Eubanks AA, Nobles CJ, Hill MJ, DeCherney AH, Kim K, Sjaarda LA, Perkins NJ, Ye A, Zolton JR, Silver RM, Schisterman EF, Mumford SL. Recalled maternal lifestyle behaviors associated with anti-müllerian hormone of adult female offspring. Reprod Toxicol 2020; 98:75-81. [PMID: 32916273 DOI: 10.1016/j.reprotox.2020.08.015] [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: 05/19/2020] [Revised: 08/18/2020] [Accepted: 08/27/2020] [Indexed: 11/17/2022]
Abstract
Anti-müllerian hormone (AMH) is an established marker of ovarian reserve that decreases with age. Though the pool of ovarian follicles is established during fetal development, impacts of in utero exposures on AMH are uncertain. Thus, we sought to evaluate associations of in utero exposures with AMH of adult daughters with a prospective cohort study of adult daughters at university medical centers. Women noted their mother's reported use of diethylstilbestrol (DES), vitamins, tobacco, alcohol, and caffeine during pregnancy, and their mother's occupation during pregnancy. All participants were reproductive age women (18-40 years) enrolled in the Effects of Aspirin in Gestation and Reproduction (EAGeR) trial. Serum AMH concentrations were measured at baseline prior to conception and categorized using clinical guidelines. Multinomial regression models estimated associations between each exposure and high (>3.5 ng/mL) and low (<1.0 ng/mL) versus normal AMH (1.0-3.5 ng/mL), adjusting for participant's age, mother's age, mother's history of fertility treatment, and mother's use of vitamins. In 1202 women with available data, maternal caffeine use was associated with an increased risk of low AMH, compared to normal (relative risk [RR] 1.90, 95 % confidence interval [CI] 1.09, 3.30). Vitamins were associated with an increased risk of high AMH compared to normal (RR 1.93, 95 % CI 1.24, 3.00). Other exposures were not associated with AMH concentrations in offspring. Maternal caffeine and vitamin use during pregnancy may be associated with ovarian reserve in adult offspring, highlighting the potential importance of pregnancy lifestyle on the reproductive health of daughters.
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Affiliation(s)
- Allison A Eubanks
- Department of Obstetrics and Gynecology, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20852, United States
| | - Carrie J Nobles
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
| | - Micah J Hill
- Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
| | - Alan H DeCherney
- Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
| | - Keewan Kim
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
| | - Lindsey A Sjaarda
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
| | - Neil J Perkins
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
| | - Aijun Ye
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
| | - Jessica R Zolton
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States; Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Room 2B200 SOM, 50 North Medical Drive, Salt Lake City, UT, 84132, United States
| | - Enrique F Schisterman
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States.
| | - Sunni L Mumford
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
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Wang J, Wu D, Guo H, Li M. Hyperandrogenemia and insulin resistance: The chief culprit of polycystic ovary syndrome. Life Sci 2019; 236:116940. [PMID: 31604107 DOI: 10.1016/j.lfs.2019.116940] [Citation(s) in RCA: 147] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 09/23/2019] [Accepted: 10/06/2019] [Indexed: 02/07/2023]
Abstract
Polycystic ovary syndrome (PCOS) is one of the most common systemic reproductive endocrine diseases, which has a variety of effects on a woman's health. Because of the involvement of multiple pathways and the lack of common clues, PCOS demonstrates multifactorial properties and heterogeneity of symptoms. Recent studies have demonstrated that the core etiology and primary endocrine characteristics of PCOS are hyperandrogenemia (HA) and insulin resistance (IR). HA and IR are the main causes of PCOS and they can interplay each other in the occurrence and development of PCOS. Just because of this, the study about the effects of HA and IR on pathophysiology of various related symptoms of PCOS is very important to understand the pathogenesis of PCOS. This paper reviews the main symptoms of PCOS, including neuroendocrine disorders, reproductive processes, dyslipidemia, obesity, hypertension, nonalcoholic fatty liver disease (NAFLD), and sleep disordered breathing, which seriously affect the physical and mental health of PCOS women. The increasing knowledge of the development pattern of HA and IR in PCOS suggests that changes in diet and lifestyle, and the discovery of potential therapeutic agents may improve PCOS. However, further studies are needed to clarify the mutual influence and relation of HA and IR in development of PCOS. This review provides an overview of the current knowledge about the effects of HA and IR on PCOS.
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Affiliation(s)
- Juan Wang
- Department of Histology and Embryology, University of South China, Institute of Clinical Anatomy & Reproductive Medicine, Hengyang, 421001, Hunan, China
| | - Daichao Wu
- Department of Histology and Embryology, University of South China, Institute of Clinical Anatomy & Reproductive Medicine, Hengyang, 421001, Hunan, China
| | - Hui Guo
- Department of Histology and Embryology, University of South China, Institute of Clinical Anatomy & Reproductive Medicine, Hengyang, 421001, Hunan, China
| | - Meixiang Li
- Department of Histology and Embryology, University of South China, Institute of Clinical Anatomy & Reproductive Medicine, Hengyang, 421001, Hunan, China.
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Dreno B, Bagatin E, Blume-Peytavi U, Rocha M, Gollnick H. Akne bei erwachsenen Frauen: Physiologische und psychologische Erwägungen und Management. J Dtsch Dermatol Ges 2019; 16:1185-1196. [PMID: 30300500 DOI: 10.1111/ddg.13664_g] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 03/06/2018] [Indexed: 01/03/2023]
Affiliation(s)
- Brigitte Dreno
- Department of Dermatology, University of Nantes, Frankreich
| | - Edileia Bagatin
- Department of Dermatology, Federal University of São Paulo - UNIFESP, São Paulo, Brasilien
| | - Ulrike Blume-Peytavi
- Klinik für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin
| | - Marco Rocha
- Department of Dermatology, Federal University of São Paulo - UNIFESP, São Paulo, Brasilien
| | - Harald Gollnick
- Klinik für Dermatologie und Venerologie, Otto-von-Guericke-Universität, Magdeburg
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Mumford SL, Browne RW, Kim K, Nichols C, Wilcox B, Silver RM, Connell MT, Holland TL, Kuhr DL, Omosigho UR, Perkins NJ, Radin R, Sjaarda LA, Schisterman EF. Preconception Plasma Phospholipid Fatty Acids and Fecundability. J Clin Endocrinol Metab 2018; 103:4501-4510. [PMID: 30124893 PMCID: PMC6220440 DOI: 10.1210/jc.2018-00448] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 08/09/2018] [Indexed: 12/30/2022]
Abstract
CONTEXT Fatty acids (FAs) are important for reproductive processes, including steroidogenesis, though associations with fecundability, as measured by time to pregnancy (TTP), are unclear. OBJECTIVE To investigate the relationship between preconception plasma phospholipid FA (PPFA) levels and time to human chorionic gonadotropin-pregnancy among women with prior pregnancy loss. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort of 1228 women attempting pregnancy (aged 18 to 40 years, with one or two prior pregnancy losses) followed for up to six cycles at four US university medical centers during 2006 to 2012. PPFA levels were measured at baseline. MAIN OUTCOME MEASURES Associations with fecundability overall and by body mass index (BMI) group after adjusting for confounders were estimated using fecundability odds ratios (FORs) and 95% CIs. False discovery rate (FDR) was used to account for multiple comparisons. RESULTS Monounsaturated fatty acids (MUFAs) were associated with increased fecundability or shorter TTP [FOR, 1.08 (95% CI, 1.01 to 1.16) per unit increase in percentage of total FAs], whereas polyunsaturated fatty acids (PUFAs) were associated with decreased fecundability or longer TTP [FOR, 0.95 (95% CI, 0.91 to 1.00) per 1% change], though associations only remained significant after FDR adjustment among women with BMI <25 kg/m2. Saturated FA and trans FA were not associated with fecundability. Omega-3 FAs and omega-6 linoleic acid were not associated with fecundability. CONCLUSION We observed associations between preconception MUFA and PUFA levels and fecundability among women with normal BMI, highlighting the importance of FA composition among normal-weight women with prior pregnancy loss.
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Affiliation(s)
- Sunni L Mumford
- Epidemiology Branch, DIPHR, NICHD, National Institutes of Health, Bethesda, Maryland
- Correspondence and Reprint Requests: Sunni L. Mumford, PhD, Earl Stadtman Investigator, Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 6710B Rockledge Drive, MSC7004, Bethesda, Maryland 20817. E-mail:
| | - Richard W Browne
- Biotechnical and Clinical Laboratory Sciences, University at Buffalo, State University of New York, Buffalo, New York
| | - Keewan Kim
- Epidemiology Branch, DIPHR, NICHD, National Institutes of Health, Bethesda, Maryland
| | - Christina Nichols
- Epidemiology Branch, DIPHR, NICHD, National Institutes of Health, Bethesda, Maryland
| | - Brian Wilcox
- Department of Clinical Sciences, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania
| | - Robert M Silver
- Department of Family and Preventive Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Matthew T Connell
- Epidemiology Branch, DIPHR, NICHD, National Institutes of Health, Bethesda, Maryland
| | - Tiffany L Holland
- Epidemiology Branch, DIPHR, NICHD, National Institutes of Health, Bethesda, Maryland
| | - Daniel L Kuhr
- Epidemiology Branch, DIPHR, NICHD, National Institutes of Health, Bethesda, Maryland
- Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, Ohio
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Ukpebo R Omosigho
- Epidemiology Branch, DIPHR, NICHD, National Institutes of Health, Bethesda, Maryland
| | - Neil J Perkins
- Epidemiology Branch, DIPHR, NICHD, National Institutes of Health, Bethesda, Maryland
| | - Rose Radin
- Epidemiology Branch, DIPHR, NICHD, National Institutes of Health, Bethesda, Maryland
| | - Lindsey A Sjaarda
- Epidemiology Branch, DIPHR, NICHD, National Institutes of Health, Bethesda, Maryland
| | - Enrique F Schisterman
- Epidemiology Branch, DIPHR, NICHD, National Institutes of Health, Bethesda, Maryland
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Dreno B, Bagatin E, Blume-Peytavi U, Rocha M, Gollnick H. Female type of adult acne: Physiological and psychological considerations and management. J Dtsch Dermatol Ges 2018; 16:1185-1194. [PMID: 30248242 DOI: 10.1111/ddg.13664] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 03/06/2018] [Indexed: 12/12/2022]
Abstract
Today we see more cases of acne after adolescence, with a greater prevalence in females than males. Adult female acne has a distinct clinical presentation and is associated with a number of specific pathophysiological features and gender-specific triggers. The psychological impact of acne is generally significant and largely underestimated; stress during professional and private life, anxiety and sleep quality, in particular, have a reciprocal relationship with disease susceptibility and severity. It is essential to compare with males. Acne in females often causes greater distress in adults than in adolescents. The impact of disease may therefore be greater for female patients, triggering higher levels of psychosocial anguish and increasing the likelihood of sequelae such as skin picking and the risks of cutaneous superinfection, scarring and PIH and acne recurrence. The management of adult female acne should encompass not just medical treatment of the symptoms, but also a comprehensive, holistic approach to the patient as a whole, her individual lifestyle factors and the impact of acne on her quality of life. Future management of this disease should aim to improve patient adherence to therapy and to develop validated outcomes of treatment regarding overall skin appearance and quality of life.
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Affiliation(s)
| | - Edileia Bagatin
- Department of Dermatology, Federal University of São Paulo - UNIFESP, São Paulo, Brazil
| | - Ulrike Blume-Peytavi
- Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Germany
| | - Marco Rocha
- Department of Dermatology, Federal University of São Paulo - UNIFESP, São Paulo, Brazil
| | - Harald Gollnick
- Department of Dermatology and Venereology, Otto-von-Guericke Universität, Magdeburg, Germany
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Association of testosterone and antimüllerian hormone with time to pregnancy and pregnancy loss in fecund women attempting pregnancy. Fertil Steril 2018; 109:540-548.e1. [PMID: 29428315 DOI: 10.1016/j.fertnstert.2017.11.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 11/13/2017] [Accepted: 11/14/2017] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To examine whether higher T and/or antimüllerian hormone (AMH) was associated with anovulation, time to pregnancy (TTP), or pregnancy loss risk among healthy, fecund women without diagnosed polycystic ovary syndrome. DESIGN Prospective cohort study conducted as a secondary analysis from the Effects of Aspirin in Gestation and Reproduction randomized trial. SETTING University medical centers. PATIENT(S) A total of 1,198 healthy, eumenorrheic women aged 18-40 years attempting spontaneous pregnancy with one to two prior pregnancy losses were included. Women were categorized by baseline antimüllerian hormone (AMH), as a surrogate marker of antral follicle count, and T concentrations; the highest quartile for each was "high," and below the top quartile (i.e., lower 75% of values) was "norm," forming four groups: norm T/norm AMH (n = 742), norm T/high AMH (n = 156), high T/norm AMH (n = 157), and high T/high AMH (n = 143). INTERVENTION(S) Not applicable. MAIN OUTCOME MEASURE(S) Anovulation, pregnancy incidence, TTP, and pregnancy loss incidence. RESULT(S) Women with high T/high AMH had a greater anovulation risk (risk ratio 1.58, 95% confidence interval 1.13-2.22) compared with women with norm T/norm AMH, but with imprecise differences in incidence of pregnancy, TTP, or pregnancy loss. CONCLUSION(S) Women with higher T and AMH had more frequent anovulatory cycles but with marginal impacts on TTP or pregnancy loss. A continuum of mild inefficiency in reproductive function may be related to higher T and AMH, including in fecund women with normal menstrual cycles and no clinical diagnosis of polycystic ovary syndrome, but with unclear effects on fecundability and pregnancy loss. CLINICAL TRIAL REGISTRATION NUMBER NCT00467363.
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Abbott DH, Rayome BH, Dumesic DA, Lewis KC, Edwards AK, Wallen K, Wilson ME, Appt SE, Levine JE. Clustering of PCOS-like traits in naturally hyperandrogenic female rhesus monkeys. Hum Reprod 2017; 32:923-936. [PMID: 28333238 DOI: 10.1093/humrep/dex036] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 02/09/2017] [Indexed: 11/13/2022] Open
Abstract
Study question Do naturally occurring, hyperandrogenic (≥1 SD of population mean testosterone, T) female rhesus monkeys exhibit traits typical of women with polycystic ovary syndrome (PCOS)? Summary answer Hyperandrogenic female monkeys exhibited significantly increased serum levels of androstenedione (A4), 17-hydroxyprogesterone (17-OHP), estradiol (E2), LH, antimullerian hormone (AMH), cortisol, 11-deoxycortisol and corticosterone, as well as increased uterine endometrial thickness and evidence of reduced fertility, all traits associated with PCOS. What is known already Progress in treating women with PCOS is limited by incomplete knowledge of its pathogenesis and the absence of naturally occurring PCOS in animal models. A female macaque monkey, however, with naturally occurring hyperandrogenism, anovulation and polyfollicular ovaries, accompanied by insulin resistance, increased adiposity and endometrial hyperplasia, suggests naturally occurring origins for PCOS in nonhuman primates. Study design, size, duration As part of a larger study, circulating serum concentrations of selected pituitary, ovarian and adrenal hormones, together with fasted insulin and glucose levels, were determined in a single, morning blood sample obtained from 120 apparently healthy, ovary-intact, adult female rhesus monkeys (Macaca mulatta) while not pregnant or nursing. The monkeys were then sedated for somatometric and ultrasonographic measurements. Participants/materials, setting, methods Female monkeys were of prime reproductive age (7.2 ± 0.1 years, mean ± SEM) and represented a typical spectrum of adult body weight (7.4 ± 0.2 kg; maximum 12.5, minimum 4.6 kg). Females were defined as having normal (n = 99) or high T levels (n = 21; ≥1 SD above the overall mean, 0.31 ng/ml). Electronic health records provided menstrual and fecundity histories. Steroid hormones were determined by tandem LC-MS-MS; AMH was measured by enzymeimmunoassay; LH, FSH and insulin were determined by radioimmunoassay; and glucose was read by glucose meter. Most analyses were limited to 80 females (60 normal T, 20 high T) in the follicular phase of a menstrual cycle or anovulatory period (serum progesterone <1 ng/ml). Main results and the role of chance Of 80 monkeys, 15% (n = 12) exhibited classifiable PCOS-like phenotypes. High T females demonstrated elevations in serum levels of LH (P < 0.036), AMH (P < 0.021), A4 (P < 0.0001), 17-OHP (P < 0.008), E2 (P < 0.023), glucocorticoids (P < 0.02-0.0001), the serum T/E2 ratio (P < 0.03) and uterine endometrial thickness (P < 0.014) compared to normal T females. Within the high T group alone, anogenital distance, a biomarker for fetal T exposure, positively correlated (P < 0.015) with serum A4 levels, while clitoral volume, a biomarker for prior T exposure, positively correlated (P < 0.002) with postnatal age. Only high T females demonstrated positive correlations between serum LH, and both T and A4. Five of six (83%) high T females with serum T ≥2 SD above T mean (0.41 ng/ml) did not produce live offspring. Large scale data N/A. Limitations, reasons for caution This is an initial study of a single laboratory population in a single nonhuman primate species. While two biomarkers suggest lifelong hyperandrogenism, phenotypic expression during gestation, prepuberty, adolescence, mid-to-late reproductive years and postmenopause has yet to be determined. Wider implications of the findings Characterizing adult female monkeys with naturally occurring hyperandrogenism has identified individuals with high LH and AMH combined with infertility, suggesting developmental linkage among traits with endemic origins beyond humans. PCOS may thus be an ancient phenotype, as previously proposed, with a definable pathogenic mechanism(s). Study funding/competing interest(s) Funded by competitive supplement to P51 OD011106 (PI: Mallick), by P50 HD028934 (PI: Marshall) and by P50 HD044405 (PI: Dunaif). The authors have no potential conflicts of interest.
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Affiliation(s)
- D H Abbott
- Department of Obstetrics and Gynecology, University of Wisconsin, Madison, WI, USA.,Wisconsin National Primate Research Center, University of Wisconsin, Madison, WI, USA
| | - B H Rayome
- Wisconsin National Primate Research Center, University of Wisconsin, Madison, WI, USA
| | - D A Dumesic
- Department of Obstetrics and Gynecology, University of California, Los Angeles, CA, USA
| | | | - A K Edwards
- Wisconsin National Primate Research Center, University of Wisconsin, Madison, WI, USA
| | - K Wallen
- Division of Developmental & Cognitive Neuroscience, Yerkes National Primate Research Center, USA.,Department of Psychology, Emory University, Atlanta, GA, USA
| | - M E Wilson
- Division of Developmental & Cognitive Neuroscience, Yerkes National Primate Research Center, USA
| | - S E Appt
- Department of Pathology, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - J E Levine
- Wisconsin National Primate Research Center, University of Wisconsin, Madison, WI, USA.,Department of Neuroscience, University of Wisconsin, Madison, WI, USA
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Kushnir VA, Seifer DB, Barad DH, Sen A, Gleicher N. Potential therapeutic applications of human anti-Müllerian hormone (AMH) analogues in reproductive medicine. J Assist Reprod Genet 2017; 34:1105-1113. [PMID: 28643088 PMCID: PMC5581791 DOI: 10.1007/s10815-017-0977-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 06/07/2017] [Indexed: 11/25/2022] Open
Abstract
Members of the transforming growth factor-beta (TGF-beta) superfamily are key regulators of various physiological processes. Anti-Müllerian hormone (AMH) which is also commonly known as Müllerian-inhibiting substance (MIS) is a member of the TGF-beta superfamily and an important regulator of reproductive organ differentiation and ovarian follicular development. While AMH has been used for diagnostic purposes as a biomarker for over 15 years, new potential therapeutic applications of recombinant human AMH analogues are now emerging as pharmacologic agents in reproductive medicine. Therapeutic uses of AMH in gonadal tissue may provide a unique opportunity to address a broad range of reproductive themes, like contraception, ovulation induction, onset of menopause, and fertility preservation, as well as specific disease conditions, such as polycystic ovarian syndrome (PCOS) and cancers of the reproductive tract. This review explores the most promising therapeutic applications for a novel class of drugs known as AMH analogues with agonist and antagonist functions.
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Affiliation(s)
- Vitaly A Kushnir
- Center for Human Reproduction, 21 East 69th Street, New York, NY, 10021, USA.
- Department of Obstetrics and Gynecology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | - David B Seifer
- Geisel School of Medicine at Dartmouth, Hanover, NH, United States
| | - David H Barad
- Center for Human Reproduction, 21 East 69th Street, New York, NY, 10021, USA
- Foundation for Reproductive Medicine, New York, NY, USA
| | - Aritro Sen
- Center for Human Reproduction, 21 East 69th Street, New York, NY, 10021, USA
- Division of Endocrinology & Metabolism, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Norbert Gleicher
- Center for Human Reproduction, 21 East 69th Street, New York, NY, 10021, USA
- Foundation for Reproductive Medicine, New York, NY, USA
- Department of Obstetrics and Gynecology, University of Vienna School of Medicine, Vienna, Austria
- The Rockefeller University, New York, NY, USA
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Tal R, Seifer DB. Ovarian reserve testing: a user's guide. Am J Obstet Gynecol 2017; 217:129-140. [PMID: 28235465 DOI: 10.1016/j.ajog.2017.02.027] [Citation(s) in RCA: 232] [Impact Index Per Article: 33.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 02/08/2017] [Accepted: 02/14/2017] [Indexed: 10/20/2022]
Abstract
Ovarian reserve is a complex clinical phenomenon influenced by age, genetics, and environmental variables. Although it is challenging to predict the rate of an individual's ovarian reserve decline, clinicians are often asked for advice about fertility potential and/or recommendations regarding the pursuit of fertility treatment options. The purpose of this review is to summarize the state-of-the-art of ovarian reserve testing, providing a guide for the obstetrician/gynecologist generalist and reproductive endocrinologist. The ideal ovarian reserve test should be convenient, be reproducible, display little if any intracycle and intercycle variability, and demonstrate high specificity to minimize the risk of wrongly diagnosing women as having diminished ovarian reserve and accurately identify those at greatest risk of developing ovarian hyperstimulation prior to fertility treatment. Evaluation of ovarian reserve can help to identify patients who will have poor response or hyperresponse to ovarian stimulation for assisted reproductive technology. Ovarian reserve testing should allow individualization of treatment protocols to achieve optimal response while minimizing safety risks. Ovarian reserve testing may inform patients regarding their reproductive lifespan and menopausal timing as well as aid in the counselling and selection of treatment for female cancer patients of reproductive age who receive gonadotoxic therapy. In addition, it may aid in establishing the diagnosis of polycystic ovary syndrome and provide insight into its severity. While there is currently no perfect ovarian reserve test, both antral follicular count and antimüllerian hormone have good predictive value and are superior to day-3 follicle-stimulating hormone. The convenience of untimed sampling, age-specific values, availability of an automated platform, and potential standardization of antimüllerian hormone assay make this test the preferred biomarker for the evaluation of ovarian reserve in women.
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Dewailly D. Diagnostic criteria for PCOS: Is there a need for a rethink? Best Pract Res Clin Obstet Gynaecol 2016; 37:5-11. [DOI: 10.1016/j.bpobgyn.2016.03.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 03/08/2016] [Accepted: 03/09/2016] [Indexed: 10/22/2022]
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Balen AH, Morley LC, Misso M, Franks S, Legro RS, Wijeyaratne CN, Stener-Victorin E, Fauser BCJM, Norman RJ, Teede H. The management of anovulatory infertility in women with polycystic ovary syndrome: an analysis of the evidence to support the development of global WHO guidance. Hum Reprod Update 2016; 22:687-708. [PMID: 27511809 DOI: 10.1093/humupd/dmw025] [Citation(s) in RCA: 351] [Impact Index Per Article: 43.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 06/01/2016] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Here we describe the consensus guideline methodology, summarise the evidence-based recommendations we provided to the World Health Organisation (WHO) for their consideration in the development of global guidance and present a narrative review on the management of anovulatory infertility in women with polycystic ovary syndrome (PCOS). OBJECTIVE AND RATIONALE The aim of this paper was to present an evidence base for the management of anovulatory PCOS. SEARCH METHODS The evidence to support providing recommendations involved a collaborative process for: (i) identification of priority questions and critical outcomes, (ii) retrieval of up-to-date evidence and exiting guidelines, (iii) assessment and synthesis of the evidence and (iv) the formulation of draft recommendations to be used for reaching consensus with a wide range of global stakeholders. For each draft recommendation, the methodologist evaluated the quality of the supporting evidence that was then graded as very low, low, moderate or high for consideration during consensus. OUTCOMES Evidence was synthesized and we made recommendations across the definition of PCOS including hyperandrogenism, menstrual cycle regulation and ovarian assessment. Metabolic features and the impact of ethnicity were covered. Management includes lifestyle changes, bariatric surgery, pharmacotherapy (including clomiphene citrate (CC), aromatase inhibitors, metformin and gonadotropins), as well as laparoscopic surgery. In-vitro fertilization (IVF) was considered as were the risks of ovulation induction and of pregnancy in PCOS. Approximately 80% of women who suffer from anovulatory infertility have PCOS. Lifestyle intervention is recommended first in women who are obese largely on the basis of general health benefits. Bariatric surgery can be considered where the body mass index (BMI) is ≥35 kg/m2 and lifestyle therapy has failed. Carefully conducted and monitored pharmacological ovulation induction can achieve good cumulative pregnancy rates and multiple pregnancy rates can be minimized with adherence to recommended protocols. CC should be first-line pharmacotherapy for ovulation induction and letrozole can also be used as first-line therapy. Metformin alone has limited benefits in improving live birth rates. Gonadotropins and laparoscopic surgery can be used as second-line treatment. There is no clear evidence for efficacy of acupuncture or herbal mixtures in women with PCOS. For women with PCOS who fail lifestyle and ovulation induction therapy or have additional infertility factors, IVF can be used with the safer gonadotropin releasing hormone (GnRH) antagonist protocol. If a GnRH-agonist protocol is used, metformin as an adjunct may reduce the risk of ovarian hyperstimulation syndrome. Patients should be informed of the potential side effects of ovulation induction agents and of IVF on the foetus, and of the risks of multiple pregnancy. Increased risks for the mother during pregnancy and for the child, including the exacerbating impact of obesity on adverse outcomes, should also be discussed. WIDER IMPLICATIONS This guidance generation and evidence-synthesis analysis has been conducted in a manner to be considered for global applicability for the safe administration of ovulation induction for anovulatory women with PCOS.
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Affiliation(s)
- Adam H Balen
- Leeds Centre for Reproductive Medicine, Leeds Teaching Hospitals, Leeds LS14 6UH, UK
| | - Lara C Morley
- Leeds Centre for Reproductive Medicine, Leeds Teaching Hospitals, Leeds LS14 6UH, UK
| | - Marie Misso
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Monash Medical Centre, 43-51 Kanooka Grove, Clayton, VIC 3168, Australia
| | - Stephen Franks
- Institute of Reproductive & Developmental Biology, Hammersmith Hospital, London, UK
| | - Richard S Legro
- Penn State College of Medicine, 500 University Drive, H103, Hershey, PA 17033, USA
| | | | | | - Bart C J M Fauser
- Department of Reproductive Medicine & Gynaecology, University Medical Center, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Robert J Norman
- The Robinson Institute, University of Adelaide, Norwich House, 55 King William Street, North Adelaide, SA 5005, Australia
| | - Helena Teede
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Monash Medical Centre, 43-51 Kanooka Grove, Clayton, VIC 3168, Australia
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Balen AH, Morley LC, Misso M, Franks S, Legro RS, Wijeyaratne CN, Stener-Victorin E, Fauser BC, Norman RJ, Teede H. The management of anovulatory infertility in women with polycystic ovary syndrome: an analysis of the evidence to support the development of global WHO guidance. Hum Reprod Update 2016. [DOI: 10.1093/humupd/dmw025 [last accessed on 26.11.19]] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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21
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Rosenfield RL, Ehrmann DA. The Pathogenesis of Polycystic Ovary Syndrome (PCOS): The Hypothesis of PCOS as Functional Ovarian Hyperandrogenism Revisited. Endocr Rev 2016; 37:467-520. [PMID: 27459230 PMCID: PMC5045492 DOI: 10.1210/er.2015-1104] [Citation(s) in RCA: 727] [Impact Index Per Article: 90.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 07/20/2016] [Indexed: 02/06/2023]
Abstract
Polycystic ovary syndrome (PCOS) was hypothesized to result from functional ovarian hyperandrogenism (FOH) due to dysregulation of androgen secretion in 1989-1995. Subsequent studies have supported and amplified this hypothesis. When defined as otherwise unexplained hyperandrogenic oligoanovulation, two-thirds of PCOS cases have functionally typical FOH, characterized by 17-hydroxyprogesterone hyperresponsiveness to gonadotropin stimulation. Two-thirds of the remaining PCOS have FOH detectable by testosterone elevation after suppression of adrenal androgen production. About 3% of PCOS have a related isolated functional adrenal hyperandrogenism. The remaining PCOS cases are mild and lack evidence of steroid secretory abnormalities; most of these are obese, which we postulate to account for their atypical PCOS. Approximately half of normal women with polycystic ovarian morphology (PCOM) have subclinical FOH-related steroidogenic defects. Theca cells from polycystic ovaries of classic PCOS patients in long-term culture have an intrinsic steroidogenic dysregulation that can account for the steroidogenic abnormalities typical of FOH. These cells overexpress most steroidogenic enzymes, particularly cytochrome P450c17. Overexpression of a protein identified by genome-wide association screening, differentially expressed in normal and neoplastic development 1A.V2, in normal theca cells has reproduced this PCOS phenotype in vitro. A metabolic syndrome of obesity-related and/or intrinsic insulin resistance occurs in about half of PCOS patients, and the compensatory hyperinsulinism has tissue-selective effects, which include aggravation of hyperandrogenism. PCOS seems to arise as a complex trait that results from the interaction of diverse genetic and environmental factors. Heritable factors include PCOM, hyperandrogenemia, insulin resistance, and insulin secretory defects. Environmental factors include prenatal androgen exposure and poor fetal growth, whereas acquired obesity is a major postnatal factor. The variety of pathways involved and lack of a common thread attests to the multifactorial nature and heterogeneity of the syndrome. Further research into the fundamental basis of the disorder will be necessary to optimally correct androgen levels, ovulation, and metabolic homeostasis.
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Affiliation(s)
- Robert L Rosenfield
- Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, The University of Chicago Pritzker School of Medicine, Chicago, Illinois 60637
| | - David A Ehrmann
- Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, The University of Chicago Pritzker School of Medicine, Chicago, Illinois 60637
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22
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Schliep KC, Schisterman EF, Wactawski-Wende J, Perkins NJ, Radin RG, Zarek SM, Mitchell EM, Sjaarda LA, Mumford SL. Serum caffeine and paraxanthine concentrations and menstrual cycle function: correlations with beverage intakes and associations with race, reproductive hormones, and anovulation in the BioCycle Study. Am J Clin Nutr 2016; 104:155-63. [PMID: 27225433 PMCID: PMC4919523 DOI: 10.3945/ajcn.115.118430] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 04/25/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Clinicians often recommend limiting caffeine intake while attempting to conceive; however, few studies have evaluated the associations between caffeine exposure and menstrual cycle function, and we are aware of no previous studies assessing biological dose via well-timed serum measurements. OBJECTIVES We assessed the relation between caffeine and its metabolites and reproductive hormones in a healthy premenopausal cohort and evaluated potential effect modification by race. DESIGN Participants (n = 259) were followed for ≤2 menstrual cycles and provided fasting blood specimens ≤8 times/cycle. Linear mixed models were used to estimate associations between serum caffeine biomarkers and geometric mean reproductive hormones, whereas Poisson regression was used to assess risk of sporadic anovulation. RESULTS The highest compared with the lowest serum caffeine tertile was associated with lower total testosterone [27.9 ng/dL (95% CI: 26.7, 29.0 ng/dL) compared with 29.1 ng/dL (95% CI: 27.9, 30.3 ng/dL), respectively] and free testosterone [0.178 ng/mL (95% CI: 0.171, 0.185 ng/dL) compared with 0.186 ng/mL (95% CI: 0.179, 0.194 ng/dL), respectively] after adjustment for age, race, percentage of body fat, daily vigorous exercise, perceived stress, depression, dietary factors, and alcohol intake. The highest tertiles compared with the lowest tertiles of caffeine and paraxanthine were also associated with reduced risk of anovulation [adjusted RRs (aRRs): 0.39 (95% CI: 0.18, 0.87) and 0.40 (95% CI: 0.18, 0.87), respectively]. Additional adjustment for self-reported coffee intake did not alter the reproductive hormone findings and only slightly attenuated the results for serum caffeine and paraxanthine and anovulation. Although reductions in the concentrations of total testosterone and free testosterone and decreased risk of anovulation were greatest in Asian women, there was no indication of effect modification by race. CONCLUSION Caffeine intake, irrespective of the beverage source, may be associated with reduced testosterone and improved menstrual cycle function in healthy premenopausal women.
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Affiliation(s)
- Karen C Schliep
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, MD; Department of Family and Preventive Medicine, University of Utah Health Sciences Center, Salt Lake City, UT
| | - Enrique F Schisterman
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, MD
| | - Jean Wactawski-Wende
- Department of Epidemiology and Environmental Health, University at Buffalo, Buffalo, NY; and
| | - Neil J Perkins
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, MD
| | - Rose G Radin
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, MD
| | - Shvetha M Zarek
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, MD; Program of Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | - Emily M Mitchell
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, MD
| | - Lindsey A Sjaarda
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, MD
| | - Sunni L Mumford
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, MD;
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Pelusi C, Stancampiano M, Fanelli F, Pariali M, Gambineri A, Pasquali R. Anti-müllerian hormone and insulin-like 3 levels in healthy normal-weight ovulatory and anovulatory eumenorrheic late adolescent females: potential early biomarkers of ovarian dysfunction? Eur J Obstet Gynecol Reprod Biol 2015; 195:188-192. [PMID: 26579638 DOI: 10.1016/j.ejogrb.2015.09.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 09/08/2015] [Accepted: 09/28/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate differences in anti-müllerian hormone (AMH) and insulin-like 3 (INSL3) levels and their association with gonadotropin and ovarian steroid hormones, as expression of ovarian function, between healthy normal-weight ovulatory and anovulatory eumenorrheic late adolescent females. STUDY DESIGN This study analyzed AMH and INSL3 levels in forty healthy eumenorrheic late adolescent females (aged 16-19 ys), selected from a cross-sectional epidemiological study performed on the prevalence of hyperandrogenic states. The subjects were divided into ovulatory (n: 28) and anovulatory (n: 12) groups in accordance to a previous cluster analysis based on progesterone (P) distribution measured once in the latter part of the cycle. Both groups were compared for anthropometric, biochemical and hormonal parameters. RESULTS INSL3 and AMH were detectable in all samples. Testosterone (P=0.01), the free-androgen index (FAI) (P=0.051), gonadotropins (LH: P=0.02; FSH: P=0.004) and AMH (P=0.02) levels were significantly higher in the anovulatory group with respect to their ovulatory counterpart. A trend toward significantly higher INSL3 concentrations (P=0.08) was also shown in the anovulatory group. A positive correlation between INSL3 levels and androgens such as androstenedione (r=0.38; P=0.02), testosterone (r=0.44; P=0.004) and FAI (r=0.42; P=0.006) and a negative borderline significant correlation (r=-0.30; P=0.055) between AMH and P were shown in all subjects. CONCLUSION Healthy eumenorrheic late adolescent females with sporadic anovulation display higher AMH and INSL-3 blood concentrations in association with higher androgen levels compared with age- and BMI-matched subjects with ovulatory cycle, suggesting evidence of an earlier ovarian dysfunction.
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Affiliation(s)
- Carla Pelusi
- Division of Endocrinology, Department of Medical and Surgical Science (DIMEC), and Center of Applied Biomedical Research (CRBA), S. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Bologna, Italy
| | - Marianna Stancampiano
- Division of Endocrinology, Department of Medical and Surgical Science (DIMEC), and Center of Applied Biomedical Research (CRBA), S. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Bologna, Italy
| | - Flaminia Fanelli
- Division of Endocrinology, Department of Medical and Surgical Science (DIMEC), and Center of Applied Biomedical Research (CRBA), S. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Bologna, Italy
| | - Milena Pariali
- Division of Endocrinology, Department of Medical and Surgical Science (DIMEC), and Center of Applied Biomedical Research (CRBA), S. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Bologna, Italy
| | - Alessandra Gambineri
- Division of Endocrinology, Department of Medical and Surgical Science (DIMEC), and Center of Applied Biomedical Research (CRBA), S. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Bologna, Italy
| | - Renato Pasquali
- Division of Endocrinology, Department of Medical and Surgical Science (DIMEC), and Center of Applied Biomedical Research (CRBA), S. Orsola-Malpighi Hospital, University Alma Mater Studiorum, Bologna, Italy.
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24
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Zarek SM, Mitchell EM, Sjaarda LA, Mumford SL, Silver RM, Stanford JB, Galai N, White MV, Schliep KC, DeCherney AH, Schisterman EF. Is Anti-Müllerian Hormone Associated With Fecundability? Findings From the EAGeR Trial. J Clin Endocrinol Metab 2015; 100:4215-21. [PMID: 26406293 PMCID: PMC4702454 DOI: 10.1210/jc.2015-2474] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE The objective of the study was to evaluate whether anti-Müllerian hormone (AMH) is associated with fecundability among women with proven fecundity and a history of pregnancy loss. DESIGN This was a prospective cohort study within a multicenter, block-randomized, double-blind, placebo-controlled clinical trial ( clinicaltrials.gov , number NCT00467363). SETTING The study was conducted at four US medical centers (2006-2012). PARTICIPANTS Participating women were aged 18-40 years, with a history of one to two pregnancy losses who were actively attempting pregnancy. MAIN OUTCOME MEASURES Time to human chorionic gonadotropin detected and clinical pregnancy were assessed using Cox proportional hazard regression models to estimate fecundability odds ratios (fecundability odds ratios with 95% confidence interval [CI]) adjusted for age, race, body mass index, income, low-dose aspirin treatment, parity, number of previous losses, and time since most recent loss. Analyses examined by preconception AMH levels: low (<1.00 ng/mL, n = 124); normal (referent 1.00-3.5 ng/mL, n = 595); and high (>3.5 ng/mL, n = 483). RESULTS Of the 1202 women with baseline AMH levels, 82 women with low AMH (66.1%) achieved an human chorionic gonadotropin detected pregnancy, compared with 383 with normal AMH (65.2%) and 315 with high AMH level (65.2%). Low or high AMH levels relative to normal AMH (referent) were not associated with fecundability (low AMH: fecundability odds ratios 1.13, 95% CI 0.85-1.49; high AMH: FOR 1.04, 95% CI 0.87-1.24). CONCLUSIONS Lower and higher AMH values were not associated with fecundability in unassisted conceptions in a cohort of fecund women with a history of one or two prior losses. Our data do not support routine AMH testing for preconception counseling in young, fecund women.
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Affiliation(s)
- Shvetha M Zarek
- Epidemiology Branch (S.M.Z., E.M.M., L.A.S., S.L.M., K.C.S., E.F.S.), Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, Maryland 20854; Program in Reproductive and Adult Endocrinology (S.M.Z., A.H.D.), Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland 20982; Department of Obstetrics and Gynecology (R.M.S., J.B.S.), University of Utah and Intermountain HealthCare, Salt Lake City, Utah 84111; Department of Statistics (N.G.), University of Haifa, Haifa 3498838, Israel; and Department of Family, Community, and Rural Health (M.V.W.), The Commonwealth Medical College, Scranton, Pennsylvania 18509
| | - Emily M Mitchell
- Epidemiology Branch (S.M.Z., E.M.M., L.A.S., S.L.M., K.C.S., E.F.S.), Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, Maryland 20854; Program in Reproductive and Adult Endocrinology (S.M.Z., A.H.D.), Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland 20982; Department of Obstetrics and Gynecology (R.M.S., J.B.S.), University of Utah and Intermountain HealthCare, Salt Lake City, Utah 84111; Department of Statistics (N.G.), University of Haifa, Haifa 3498838, Israel; and Department of Family, Community, and Rural Health (M.V.W.), The Commonwealth Medical College, Scranton, Pennsylvania 18509
| | - Lindsey A Sjaarda
- Epidemiology Branch (S.M.Z., E.M.M., L.A.S., S.L.M., K.C.S., E.F.S.), Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, Maryland 20854; Program in Reproductive and Adult Endocrinology (S.M.Z., A.H.D.), Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland 20982; Department of Obstetrics and Gynecology (R.M.S., J.B.S.), University of Utah and Intermountain HealthCare, Salt Lake City, Utah 84111; Department of Statistics (N.G.), University of Haifa, Haifa 3498838, Israel; and Department of Family, Community, and Rural Health (M.V.W.), The Commonwealth Medical College, Scranton, Pennsylvania 18509
| | - Sunni L Mumford
- Epidemiology Branch (S.M.Z., E.M.M., L.A.S., S.L.M., K.C.S., E.F.S.), Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, Maryland 20854; Program in Reproductive and Adult Endocrinology (S.M.Z., A.H.D.), Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland 20982; Department of Obstetrics and Gynecology (R.M.S., J.B.S.), University of Utah and Intermountain HealthCare, Salt Lake City, Utah 84111; Department of Statistics (N.G.), University of Haifa, Haifa 3498838, Israel; and Department of Family, Community, and Rural Health (M.V.W.), The Commonwealth Medical College, Scranton, Pennsylvania 18509
| | - Robert M Silver
- Epidemiology Branch (S.M.Z., E.M.M., L.A.S., S.L.M., K.C.S., E.F.S.), Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, Maryland 20854; Program in Reproductive and Adult Endocrinology (S.M.Z., A.H.D.), Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland 20982; Department of Obstetrics and Gynecology (R.M.S., J.B.S.), University of Utah and Intermountain HealthCare, Salt Lake City, Utah 84111; Department of Statistics (N.G.), University of Haifa, Haifa 3498838, Israel; and Department of Family, Community, and Rural Health (M.V.W.), The Commonwealth Medical College, Scranton, Pennsylvania 18509
| | - Joseph B Stanford
- Epidemiology Branch (S.M.Z., E.M.M., L.A.S., S.L.M., K.C.S., E.F.S.), Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, Maryland 20854; Program in Reproductive and Adult Endocrinology (S.M.Z., A.H.D.), Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland 20982; Department of Obstetrics and Gynecology (R.M.S., J.B.S.), University of Utah and Intermountain HealthCare, Salt Lake City, Utah 84111; Department of Statistics (N.G.), University of Haifa, Haifa 3498838, Israel; and Department of Family, Community, and Rural Health (M.V.W.), The Commonwealth Medical College, Scranton, Pennsylvania 18509
| | - Noya Galai
- Epidemiology Branch (S.M.Z., E.M.M., L.A.S., S.L.M., K.C.S., E.F.S.), Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, Maryland 20854; Program in Reproductive and Adult Endocrinology (S.M.Z., A.H.D.), Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland 20982; Department of Obstetrics and Gynecology (R.M.S., J.B.S.), University of Utah and Intermountain HealthCare, Salt Lake City, Utah 84111; Department of Statistics (N.G.), University of Haifa, Haifa 3498838, Israel; and Department of Family, Community, and Rural Health (M.V.W.), The Commonwealth Medical College, Scranton, Pennsylvania 18509
| | - Mark V White
- Epidemiology Branch (S.M.Z., E.M.M., L.A.S., S.L.M., K.C.S., E.F.S.), Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, Maryland 20854; Program in Reproductive and Adult Endocrinology (S.M.Z., A.H.D.), Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland 20982; Department of Obstetrics and Gynecology (R.M.S., J.B.S.), University of Utah and Intermountain HealthCare, Salt Lake City, Utah 84111; Department of Statistics (N.G.), University of Haifa, Haifa 3498838, Israel; and Department of Family, Community, and Rural Health (M.V.W.), The Commonwealth Medical College, Scranton, Pennsylvania 18509
| | - Karen C Schliep
- Epidemiology Branch (S.M.Z., E.M.M., L.A.S., S.L.M., K.C.S., E.F.S.), Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, Maryland 20854; Program in Reproductive and Adult Endocrinology (S.M.Z., A.H.D.), Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland 20982; Department of Obstetrics and Gynecology (R.M.S., J.B.S.), University of Utah and Intermountain HealthCare, Salt Lake City, Utah 84111; Department of Statistics (N.G.), University of Haifa, Haifa 3498838, Israel; and Department of Family, Community, and Rural Health (M.V.W.), The Commonwealth Medical College, Scranton, Pennsylvania 18509
| | - Alan H DeCherney
- Epidemiology Branch (S.M.Z., E.M.M., L.A.S., S.L.M., K.C.S., E.F.S.), Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, Maryland 20854; Program in Reproductive and Adult Endocrinology (S.M.Z., A.H.D.), Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland 20982; Department of Obstetrics and Gynecology (R.M.S., J.B.S.), University of Utah and Intermountain HealthCare, Salt Lake City, Utah 84111; Department of Statistics (N.G.), University of Haifa, Haifa 3498838, Israel; and Department of Family, Community, and Rural Health (M.V.W.), The Commonwealth Medical College, Scranton, Pennsylvania 18509
| | - Enrique F Schisterman
- Epidemiology Branch (S.M.Z., E.M.M., L.A.S., S.L.M., K.C.S., E.F.S.), Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, Maryland 20854; Program in Reproductive and Adult Endocrinology (S.M.Z., A.H.D.), Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland 20982; Department of Obstetrics and Gynecology (R.M.S., J.B.S.), University of Utah and Intermountain HealthCare, Salt Lake City, Utah 84111; Department of Statistics (N.G.), University of Haifa, Haifa 3498838, Israel; and Department of Family, Community, and Rural Health (M.V.W.), The Commonwealth Medical College, Scranton, Pennsylvania 18509
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Sjaarda LA, Schisterman EF, Schliep KC, Plowden T, Zarek SM, Yeung E, Wactawski-Wende J, Mumford SL. Dietary Carbohydrate Intake Does Not Impact Insulin Resistance or Androgens in Healthy, Eumenorrheic Women. J Clin Endocrinol Metab 2015; 100:2979-86. [PMID: 26066675 PMCID: PMC4524988 DOI: 10.1210/jc.2015-1957] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Diet is proposed to contribute to androgen-related reproductive dysfunction. OBJECTIVE This study evaluated the association between dietary macronutrient intake, carbohydrate fraction intake, and overall diet quality on androgens and related hormones, including anti-Müllerian hormone (AMH) and insulin, in healthy, regularly menstruating women. DESIGN This was a prospective cohort study from 2005 and 2007. SETTING The study was conducted at the University at Buffalo, western New York State, USA. PARTICIPANTS Participants were 259 eumenorrheic women without a self-reported history of infertility, polycystic ovary syndrome (PCOS), or other endocrine disorder. MAIN OUTCOME MEASURES A 24-hour dietary recall was administered 4 times per menstrual cycle, and hormones were measured 5 to 8 times per cycle for 1 (n = 9) or 2 (n = 250) cycles per woman (n = 509 cycles). Associations between the dietary intake of carbohydrates (starch, sugar, sucrose, and fiber), macronutrients, overall diet quality and hormones (insulin, AMH, and total and free testosterone), as well as the relationship of dietary intake with occurrences of high total testosterone combined with high AMH (fourth quartile of each), ie, the "PCOS-like phenotype," were assessed. RESULTS No significant relationships were identified between dietary intake of carbohydrates, percent calories from any macronutrient or overall diet quality (ie, Mediterranean diet score) and relevant hormones (insulin, AMH, and total and free testosterone). Likewise, no significant relationships were identified between dietary factors and the occurrence of a subclinical PCOS-like phenotype. CONCLUSIONS Despite evidence of a subclinical continuum of a PCOS-related phenotype of elevated androgens and AMH related to sporadic anovulation identified in previous studies, dietary carbohydrate and diet quality do not appear to relate to these subclinical endocrine characteristics in women without overt PCOS.
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Affiliation(s)
- Lindsey A Sjaarda
- Division of Intramural Population Health Research (L.A.S., E.F.S., K.C.S., T.P., S.M.Z., E.Y., S.L.M.) and Program of Reproductive and Adult Endocrinology (T.P., S.M.Z.), Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892; and Department of Epidemiology and Environmental Health (J.W.W.), School of Public Health and Health Professions, University at Buffalo, Buffalo, New York 14214
| | - Enrique F Schisterman
- Division of Intramural Population Health Research (L.A.S., E.F.S., K.C.S., T.P., S.M.Z., E.Y., S.L.M.) and Program of Reproductive and Adult Endocrinology (T.P., S.M.Z.), Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892; and Department of Epidemiology and Environmental Health (J.W.W.), School of Public Health and Health Professions, University at Buffalo, Buffalo, New York 14214
| | - Karen C Schliep
- Division of Intramural Population Health Research (L.A.S., E.F.S., K.C.S., T.P., S.M.Z., E.Y., S.L.M.) and Program of Reproductive and Adult Endocrinology (T.P., S.M.Z.), Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892; and Department of Epidemiology and Environmental Health (J.W.W.), School of Public Health and Health Professions, University at Buffalo, Buffalo, New York 14214
| | - Torie Plowden
- Division of Intramural Population Health Research (L.A.S., E.F.S., K.C.S., T.P., S.M.Z., E.Y., S.L.M.) and Program of Reproductive and Adult Endocrinology (T.P., S.M.Z.), Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892; and Department of Epidemiology and Environmental Health (J.W.W.), School of Public Health and Health Professions, University at Buffalo, Buffalo, New York 14214
| | - Shvetha M Zarek
- Division of Intramural Population Health Research (L.A.S., E.F.S., K.C.S., T.P., S.M.Z., E.Y., S.L.M.) and Program of Reproductive and Adult Endocrinology (T.P., S.M.Z.), Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892; and Department of Epidemiology and Environmental Health (J.W.W.), School of Public Health and Health Professions, University at Buffalo, Buffalo, New York 14214
| | - Edwina Yeung
- Division of Intramural Population Health Research (L.A.S., E.F.S., K.C.S., T.P., S.M.Z., E.Y., S.L.M.) and Program of Reproductive and Adult Endocrinology (T.P., S.M.Z.), Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892; and Department of Epidemiology and Environmental Health (J.W.W.), School of Public Health and Health Professions, University at Buffalo, Buffalo, New York 14214
| | - Jean Wactawski-Wende
- Division of Intramural Population Health Research (L.A.S., E.F.S., K.C.S., T.P., S.M.Z., E.Y., S.L.M.) and Program of Reproductive and Adult Endocrinology (T.P., S.M.Z.), Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892; and Department of Epidemiology and Environmental Health (J.W.W.), School of Public Health and Health Professions, University at Buffalo, Buffalo, New York 14214
| | - Sunni L Mumford
- Division of Intramural Population Health Research (L.A.S., E.F.S., K.C.S., T.P., S.M.Z., E.Y., S.L.M.) and Program of Reproductive and Adult Endocrinology (T.P., S.M.Z.), Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892; and Department of Epidemiology and Environmental Health (J.W.W.), School of Public Health and Health Professions, University at Buffalo, Buffalo, New York 14214
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26
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Marcondes RR, Carvalho KC, Duarte DC, Garcia N, Amaral VC, Simões MJ, Lo Turco EG, Soares JM, Baracat EC, Maciel GAR. Differences in neonatal exposure to estradiol or testosterone on ovarian function and hormonal levels. Gen Comp Endocrinol 2015; 212:28-33. [PMID: 25623143 DOI: 10.1016/j.ygcen.2015.01.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 01/03/2015] [Accepted: 01/14/2015] [Indexed: 10/24/2022]
Abstract
Exposure to an excess of androgen or estrogen can induce changes in reproductive function in adult animals that resemble polycystic ovary syndrome in humans. However, considerable differences exist among several types of animal models. Little is known about the molecular features of steroidogenesis and folliculogenesis in the ovaries of rats exposed to different sex steroids as neonates. Here, we evaluated the impact of androgen and estrogen exposure on the ovaries of adult female rats during their neonatal period in the gene expression of Lhr and Cyp17a1, two key players of steroidogenesis. We also assessed hormone levels, folliculogenesis and the theca-interstitial cell population. The study was performed on the second postnatal day in thirty female Wistar rats that were sorted into the following three intervention groups: testosterone, estradiol and vehicle (control group). The animals were euthanized 90 days after birth. The main outcomes were hormone serum levels, ovary histomorphometry and gene expression of Lhr and Cyp17a1 as analyzed via quantitative real-time PCR. We found that exposure to excess testosterone in early life increased the LH and testosterone serum levels, the LH/FSH ratio, ovarian theca-interstitial area and gene expression of Lhr and Cyp17a1 in adult rats. Estrogen induced an increase in the ovarian theca-interstitial area, the secondary follicle population and gene expression of Lhr and Cyp17a1. All animals exposed to the sex steroids presented with closed vaginas. Our data suggest that testosterone resulted in more pronounced reproductive changes than did estrogen exposure. Our results might provide some insight into the role of different hormones on reproductive development and on the heterogeneity of clinical manifestations of conditions such as polycystic ovary syndrome.
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Affiliation(s)
- Rodrigo R Marcondes
- Disciplina de Ginecologia, Laboratório de Ginecologia Estrutural e Molecular (LIM 58), Faculdade de Medicina da Universidade de São Paulo, 01246903 São Paulo, Brazil.
| | - Kátia C Carvalho
- Disciplina de Ginecologia, Laboratório de Ginecologia Estrutural e Molecular (LIM 58), Faculdade de Medicina da Universidade de São Paulo, 01246903 São Paulo, Brazil
| | - Daniele C Duarte
- Disciplina de Ginecologia, Laboratório de Ginecologia Estrutural e Molecular (LIM 58), Faculdade de Medicina da Universidade de São Paulo, 01246903 São Paulo, Brazil
| | - Natália Garcia
- Disciplina de Ginecologia, Laboratório de Ginecologia Estrutural e Molecular (LIM 58), Faculdade de Medicina da Universidade de São Paulo, 01246903 São Paulo, Brazil
| | - Vinícius C Amaral
- Disciplina de Ginecologia, Laboratório de Ginecologia Estrutural e Molecular (LIM 58), Faculdade de Medicina da Universidade de São Paulo, 01246903 São Paulo, Brazil
| | - Manuel J Simões
- Departamento de Morfologia e Genética, Disciplina de Histologia e Biologia Estrutural, Universidade Federal de São Paulo, 04023900 São Paulo, Brazil
| | - Edson G Lo Turco
- Departamento de Cirurgia, Disciplina de Urologia, Setor de Reprodução Humana, Universidade Federal de São Paulo, 04024002 São Paulo, Brazil
| | - José M Soares
- Disciplina de Ginecologia, Laboratório de Ginecologia Estrutural e Molecular (LIM 58), Faculdade de Medicina da Universidade de São Paulo, 01246903 São Paulo, Brazil
| | - Edmund C Baracat
- Disciplina de Ginecologia, Laboratório de Ginecologia Estrutural e Molecular (LIM 58), Faculdade de Medicina da Universidade de São Paulo, 01246903 São Paulo, Brazil
| | - Gustavo A R Maciel
- Disciplina de Ginecologia, Laboratório de Ginecologia Estrutural e Molecular (LIM 58), Faculdade de Medicina da Universidade de São Paulo, 01246903 São Paulo, Brazil.
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Konishi S, Nishihama Y, Iida A, Yoshinaga J, Imai H. Association of antimüllerian hormone levels with menstrual-cycle type and dysmenorrhea in young asymptomatic women. Fertil Steril 2014; 102:1439-43. [DOI: 10.1016/j.fertnstert.2014.07.1255] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 07/31/2014] [Accepted: 07/31/2014] [Indexed: 11/30/2022]
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28
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Prasad A, Mumford SL, Buck Louis GM, Ahrens KA, Sjaarda LA, Schliep KC, Perkins NJ, Kissell KA, Wactawski-Wende J, Schisterman EF. Sexual activity, endogenous reproductive hormones and ovulation in premenopausal women. Horm Behav 2014; 66:330-8. [PMID: 24954690 PMCID: PMC4127088 DOI: 10.1016/j.yhbeh.2014.06.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 06/10/2014] [Accepted: 06/11/2014] [Indexed: 01/28/2023]
Abstract
We investigated whether sexual activity was associated with reproductive function in the BioCycle Study, a prospective cohort study that followed 259 regularly menstruating women aged 18 to 44years for one (n=9) or two (n=250) menstrual cycles in 2005-2007. Women were not attempting pregnancy nor using hormonal contraceptives. History of ever having been sexually active was assessed at baseline and frequency of sexual activity, defined as vaginal-penile intercourse, was self-reported daily throughout the study. Serum concentrations of estradiol, luteinizing hormone (LH), follicle-stimulating hormone (FSH), progesterone, and testosterone were measured up to 8times/cycle. Sporadic anovulation was identified using peak progesterone concentration. Linear mixed models were used to estimate associations between sexual activity and reproductive hormone concentrations and generalized linear models were used to estimate associations with sporadic anovulation. Models were adjusted for age, race, body mass index, perceived stress, and alcohol consumption and accounted for repeated measures within women. Elevated concentrations of estrogen (+14.6%, P<.01), luteal progesterone (+41.0%, P<.01) and mid-cycle LH (+23.4%, P<.01), but not FSH (P=.33) or testosterone (P=.37), were observed in sexually active women compared with sexually inactive women (no prior and no study-period sexual activity); sexually active women had lower odds of sporadic anovulation (adjusted odds ratio=0.34, 95% confidence interval: 0.16-0.73). Among sexually active women, frequency of sexual activity was not associated with hormones or sporadic anovulation (all P>.23). Findings from our study suggest that ever having been sexually active is associated with improved reproductive function, even after controlling for factors such as age.
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Affiliation(s)
- Ankita Prasad
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 6100 Executive Blvd., Rockville, MD 20852, USA.
| | - Sunni L Mumford
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 6100 Executive Blvd., Rockville, MD 20852, USA.
| | - Germaine M Buck Louis
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 6100 Executive Blvd., Rockville, MD 20852, USA.
| | - Katherine A Ahrens
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 6100 Executive Blvd., Rockville, MD 20852, USA.
| | - Lindsey A Sjaarda
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 6100 Executive Blvd., Rockville, MD 20852, USA.
| | - Karen C Schliep
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 6100 Executive Blvd., Rockville, MD 20852, USA.
| | - Neil J Perkins
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 6100 Executive Blvd., Rockville, MD 20852, USA.
| | - Kerri A Kissell
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 6100 Executive Blvd., Rockville, MD 20852, USA; Program of Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA.
| | - Jean Wactawski-Wende
- Department of Social and Preventive Medicine, University at Buffalo, The State University of New York, 270C Farber Hall, Buffalo, NY 14214, USA.
| | - Enrique F Schisterman
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 6100 Executive Blvd., Rockville, MD 20852, USA.
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