Hyperandrogenemia in polycystic ovary syndrome: exploration of the role of free testosterone and androstenedione in metabolic phenotype

An overview on androgen-mediated actions in skeletal muscle and adipose tissue

Androgens are a class of steroid hormones primarily associated with male sexual development and physiology, but exert pleiotropic effects in either sex. They have a crucial role in various physiological processes, including the regulation of skeletal muscle and adipose tissue homeostasis. The effects of androgens are mainly mediated through the androgen receptor (AR), a ligand-activated nuclear receptor expressed in both tissues. In skeletal muscle, androgens via AR exert a multitude of effects, ranging from increased muscle mass and strength, to the regulation of muscle fiber type composition, contraction and metabolic functions. In adipose tissue, androgens influence several processes including proliferation, fat distribution, and metabolism but they display depot-specific and organism-specific effects which differ in certain context. This review further explores the potential mechanisms underlying androgen-AR signaling in skeletal muscle and adipose tissue. Understanding the roles of androgens and their receptor in skeletal muscle and adipose tissue is essential for elucidating their contributions to physiological processes, disease conditions, and potential therapeutic interventions.

Randomized control trial to compare effects of ultra-low dose (Ethinylestradiol 20 μg or 15 μg) with low dose (Ethinylestradiol 30 μg) hormonal pills on lipid discordance in non-obese PCOS women

OBJECTIVE

Regular users of hormonal contraceptive pills show marked heterogeneity in metabolic effects with variations in compositions. This might be due to choice of outcome variables for comparison. Total cholesterol-high-density lipoprotein ratio (TC/HDL) discordance with low-density lipoprotein (LDL-C) has now become an established marker of future risk for atherosclerotic cardiovascular disease and stable to variations in user.

METHODS

The present study was a randomized controlled trial to compare prevalence of TC/HDL and LDL discordance among non-obese women with polycystic ovarian syndrome (PCOS) treated with hormonal pills. Women were randomized into three arms, two arms received ultra-low dose pills (Ethinylestradiol [EE] 20 μg with drosperinone 3 mg or EE 15 μg with gestodene 60 μg) and one arm received low dose pill (EE 30 μg with desogestrel 150 μg). The role of baseline participant features and pill composition on discordance was determined.

RESULTS

Discordance was observed in more than a quarter of the participants before intervention. After 1 year of treatment, less than a fifth of the participants were discordant. Ultralow-dose pill users had lower discordance, LDL, and TC than low-dose pill users after 1 year of treatment. The random forest, a non-linear classifier, showed the highest accuracy in predicting discordance. The baseline Parameters with the maximal impact on the occurrence of discordance were triglyceride, homeostatic model assessment for insulin resistance, body mass index, and high density lipoprotein.

CONCLUSION

Non-obese PCOS women on ultra-low dose pill have a lower risk of acquiring future atherosclerotic cardiovascular disease.

The PCOS-NAFLD Multidisease Phenotype Occurred in Medaka Fish Four Generations after the Removal of Bisphenol A Exposure

As a heterogeneous reproductive disorder, polycystic ovary syndrome (PCOS) can be caused by genetic, diet, and environmental factors. Bisphenol A (BPA) can induce PCOS and nonalcoholic fatty liver disease (NAFLD) due to direct exposure; however, whether these phenotypes persist in future unexposed generations is not currently understood. In a previous study, we observed that transgenerational NAFLD persisted in female medaka for five generations (F4) after exposure to an environmentally relevant concentration (10 μg/L) of BPA. Here, we demonstrate PCOS in the same F4 generation female medaka that developed NAFLD. The ovaries contained immature follicles, restricted follicular progression, and degenerated follicles, which are characteristics of PCOS. Untargeted metabolomic analysis revealed 17 biomarkers in the ovary of BPA lineage fish, whereas transcriptomic analysis revealed 292 genes abnormally expressed, which were similar to human patients with PCOS. Metabolomic-transcriptomic joint pathway analysis revealed activation of the cancerous pathway, arginine-proline metabolism, insulin signaling, AMPK, and HOTAIR regulatory pathways, as well as upstream regulators esr1 and tgf signaling in the ovary. The present results suggest that ancestral BPA exposure can lead to PCOS phenotypes in the subsequent unexposed generations and warrant further investigations into potential health risks in future generations caused by initial exposure to EDCs.

Marrow adipose tissue is increased in overweight and obese women with PCOS independently of hyperandrogenism related obesity and metabolic disorders

Purpose

This study aimed to investigate the increase in bone marrow adipose tissue (BMAT) in overweight and obese women with polycystic ovary syndrome (PCOS) and its relationship with hyperandrogenism, obesity, and metabolic disorders.

Methods

The study included 87 overweight or obese women with PCOS (mean age 29 ± 4 years), as well as 87 age-matched controls recruited from a separate population study. All PCOS patients were measured for anthropometric features, abdominal adipose tissue areas, BMAT, biochemistry, and sex hormones. BMAT was compared between the PCOS patients and controls. In PCOS patients, subgroup comparisons of BMAT and its associations with body adiposity indices, biochemistry, and sex hormones were analyzed. The odds ratios (ORs) of elevated BMAT (defined as BMAT ≥ 38%) were calculated.

Results

On average BMAT was increased by 5.6% ( ± 11.3%) in PCOS patients compared to controls. BMAT were significantly higher in the upper tertiles of total cholesterol (TC) and low density lipoprotein-cholesterol (LDL-C). BMAT was not correlated with abdominal adiposity indices or biochemistry except for LDL-C (r = 0.253-0.263, p = 0.014-0.018). LDL-C was not significantly different between the normal and abnormal androgen PCOS subgroups (p = 0.10-0.887). LDL-C, follicle stimulating hormone (FSH), and total testosterone (TT) were risk factors for elevated BMAT, with ORs of 1.899 (p = 0.038-0.040), 1.369 (p = 0.030-0.042), and 1.002 (p = 0.040-0.044) for each unit increase, respectively.

Conclusion

BMAT was increased in overweight and obese PCOS patients, but the increase in BMAT was not associated with the hyperandrogenism related obesity or metabolic disorders.

A model combining testosterone, Androstenedione and free testosterone index improved the diagnostic efficiency of polycystic ovary syndrome

OBJECTIVE

Hyperandrogenism is frequently observed in patients with polycystic ovary (PCOS). The purpose of this study was to develop an easy-to-use tool for predicting polycystic ovary syndrome (PCOS) and to evaluate and compare the value of androstenedione (Andro) and other hormone indicators in the diagnosis of patients with hyperandrogenic PCOS.

METHODS

This study included 139 women diagnosed with hyperandrogenic PCOS according to the Rotterdam criteria and 74 healthy control women from Shanghai Tenth People's Hospital. The serum hormone levels of the patients and controls were measured using a chemiluminescence immunoassay (CLIA) and incorporated for further analysis.

RESULTS

Total testosterone (TT), Andro, Dehydroepiandrosterone sulfate (DHEAS), and Free androgen index (FAI) were significantly higher in the PCOS group than the control group. Further, Andro, FSH, LH, TT, FAI and LH/FSH in the hyper-androstenedione (HA) group were higher than the normal Andro (NA) group. The Youden index was the highest for Andro (0.65), with 81.82% sensitivity and 83.16% specificity. Correlation analysis showed that FSH, LH, TT, FAI, Insulin Sensitivity Index (ISI), and LH/FSH were positively correlated with Andro, while Fasting blood glucose (FPG) and two-hour postprandial blood glucose (2h PG) were negatively correlated with Andro.

CONCLUSIONS

The model using Andro, TT, FAI may help to identifying women with undiagnosed PCOS. Serum Andro is a meaningful biomarker for hyperandrogenism in PCOS patients and may further aid disease diagnosis.

Non-Alcoholic Fatty Liver Disease in Patients with Polycystic Ovary Syndrome: A Systematic Review, Meta-Analysis, and Meta-Regression

BACKGROUND

The metabolic effects of polycystic ovary syndrome (PCOS) may increase the risk of non-alcoholic fatty liver disease (NAFLD). However, the burden of NAFLD in PCOS has not been unequivocally defined. This systematic review (SR), meta-analysis (MA) assessed NAFLD's prevalence, and risk factors in patients with PCOS.

METHODS

A literature search was performed in MEDLINE, Scopus, and Scielo. First, we performed a MA of proportions to estimate the prevalence of NAFLD in PCOS. Second, we performed meta-analyses of precalculated adjusted odds ratios to examine NAFLD risk factors. Finally, we performed a meta-regression to model how the estimated prevalence changed with changes in prespecified variables.

RESULTS

We identified 817 articles from the database searches. Thirty-six were included. MA of proportions found a pooled NAFLD prevalence of 43% (95% CI, 35-52%) with high heterogeneity (I² = 97.2%). BMI, waist circumference, ALT values, HOMA-IR values, free androgen index levels, hyperandrogenism, and triglycerides were associated with significantly higher risk-adjusted odds of NAFLD among patients with PCOS. Meta-regression showed that rises in NAFLD prevalence were mediated through increases in metabolic syndrome prevalence and higher levels of HOMA-IR, free androgen index, and total testosterone.

CONCLUSION

The prevalence of NAFLD (43%) among PCOS patients is high despite their average young age, with several metabolic and PCOS-specific factors influencing its occurrence. Screening programs may aid in detecting metabolic-associated fatty liver disease and prevent its consequences. Further work is required to establish the burden of liver-related outcomes once NAFLD has progressed in the PCOS population.

The role of kisspeptin in the pathogenesis of a polycystic ovary syndrome

Hypothalamic-pituitary gonadal (HPG) axis is responsible for the development and regulation of the female reproductive system. In polycystic ovary syndrome (PCOS), there is a disturbance in the HPG axis. Kisspeptin, a neuropeptide produced by the KISS1 gene, plays a vital role in the regulation of HPG axis by binding with its receptors KISS1R/GPR54, and stimulates gonadotropin secretion from the hypothalamus into pituitary to release luteinizing hormone (LH) and follicle stimulating hormone (FSH). Polymorphisms or mutations in the KISS1 gene can cause disturbance in the kisspeptin signaling pathway and is thought to disrupt HPG axis. Altered signaling of kisspeptin can cause abnormal secretion of GnRH pulse, which leads to increased LH/FSH ratio, thereby affecting androgen levels and ovulation. The increased levels of androgen worsen the symptoms of PCOS. In the present article, we review the molecular physiology and pathology of kisspeptin and how it is responsible for the development of PCOS. The goal of this review article is to provide an overview and metabolic profile of kisspeptin in PCOS patients and the expression of kisspeptin in PCOS animal models. In the present article, we also review the molecular physiology and pathology of kisspeptin and how it is responsible for the development of PCOS.

Multiomics Analysis-Based Biomarkers in Diagnosis of Polycystic Ovary Syndrome

Polycystic ovarian syndrome is an utmost communal endocrine, psychological, reproductive, and metabolic disorder that occurs in women of reproductive age with extensive range of clinical manifestations. This may even lead to long-term multiple morbidities including obesity, diabetes mellitus, insulin resistance, cardiovascular disease, infertility, cerebrovascular diseases, and ovarian and endometrial cancer. Women affliction from PCOS in midst assemblage of manifestations allied with menstrual dysfunction and androgen exorbitance, which considerably affects eminence of life. PCOS is recognized as a multifactorial disorder and systemic syndrome in first-degree family members; therefore, the etiology of PCOS syndrome has not been copiously interpreted. The disorder of PCOS comprehends numerous allied health conditions and has influenced various metabolic processes. Due to multifaceted pathophysiology engaging several pathways and proteins, single genetic diagnostic tests cannot be supportive to determine in straight way. Clarification of cellular and biochemical pathways and various genetic players underlying PCOS could upsurge our consideration of pathophysiology of this syndrome. It is requisite to know pathophysiological relationship between biomarker and their reflection towards PCOS disease. Biomarkers deliver vibrantly and potent ways to apprehend the spectrum of PCOS with applications in screening, diagnosis, characterization, and monitoring. This paper relies on the endeavor to point out many candidates as potential biomarkers based on omics technologies, thus highlighting correlation between PCOS disease with innovative technologies. Therefore, the objective of existing review is to encapsulate more findings towards cutting-edge advances in prospective use of biomarkers for PCOS disease. Discussed biomarkers may be fruitful in guiding therapies, addressing disease risk, and predicting clinical outcomes in future.

Role of sex hormone-binding globulin in the free hormone hypothesis and the relevance of free testosterone in androgen physiology

According to the free hormone hypothesis, biological activity of a certain hormone is best reflected by free rather than total hormone concentrations. A crucial element in this theory is the presence of binding proteins, which function as gatekeepers for steroid action. For testosterone, tissue exposure is governed by a delicate equilibrium between free and total testosterone which is determined through interaction with the binding proteins sex hormone-binding globulin and albumin. Ageing, genetics and various pathological conditions influence this equilibrium, hereby possibly modulating hormonal exposure to the target tissues. Despite ongoing controversy on the subject, strong evidence from recent in vitro, in vivo and human experiments emphasizes the relevance of free testosterone. Currently, however, clinical possibilities for free hormone diagnostics are limited. Direct immunoassays are inaccurate, while gold standard liquid chromatography with tandem mass spectrometry (LC-MS/MS) coupled equilibrium dialysis is not available for clinical routine. Calculation models for free testosterone, despite intrinsic limitations, provide a suitable alternative, of which the Vermeulen calculator is currently the preferred method. Calculated free testosterone is indeed associated with bone health, frailty and other clinical endpoints. Moreover, the added value of free testosterone in the clinical diagnosis of male hypogonadism is clearly evident. In suspected hypogonadal men in whom borderline low total testosterone and/or altered sex hormone-binding globulin levels are detected, the determination of free testosterone avoids under- and overdiagnosis, facilitating adequate prescription of hormonal replacement therapy. As such, free testosterone should be integrated as a standard biochemical parameter, on top of total testosterone, in the diagnostic workflow of male hypogonadism.

Hypoxia Differentially Affects Healthy Men and Women During a Daytime Nap With a Dose-Response Relationship: a Randomized, Cross-Over Pilot Study

Context: The use of daytime napping as a countermeasure in sleep disturbances has been recommended but its physiological evaluation at high altitude is limited. Objective: To evaluate the neuroendocrine response to hypoxic stress during a daytime nap and its cognitive impact. Design, Subject, and Setting: Randomized, single-blind, three period cross-over pilot study conducted with 15 healthy lowlander subjects (8 women) with a mean (SD) age of 29(6) years (Clinicaltrials identifier: NCT04146857, https://clinicaltrials.gov/ct2/show/NCT04146857?cond=napping&draw=3&rank=12). Interventions: Volunteers underwent a polysomnography, hematological and cognitive evaluation around a 90 min midday nap, being allocated to a randomized sequence of three conditions: normobaric normoxia (NN), normobaric hypoxia at FiO2 14.7% (NH15) and 12.5% (NH13), with a washout period of 1 week between conditions. Results: Primary outcome was the interbeat period measured by the RR interval with electrocardiogram. Compared to normobaric normoxia, RR during napping was shortened by 57 and 206 ms under NH15 and NH13 conditions, respectively (p < 0.001). Sympathetic predominance was evident by heart rate variability analysis and increased epinephrine levels. Concomitantly, there were significant changes in endocrine parameters such as erythropoietin (∼6 UI/L) and cortisol (∼100 nmol/L) (NH13 vs. NN, p < 0.001). Cognitive evaluation revealed changes in the color-word Stroop test. Additionally, although sleep efficiency was preserved, polysomnography showed lesser deep sleep and REM sleep, and periodic breathing, predominantly in men. Conclusion: Although napping in simulated altitude does not appear to significantly affect cognitive performance, sex-dependent changes in cardiac autonomic modulation and respiratory pattern should be considered before napping is prescribed as a countermeasure.

Adrenal Androgen Predictive Effects on Clinical and Metabolic Abnormalities of Polycystic Ovary Syndrome

OBJECTIVE

 To examine the possible effects of adrenal prohormones in the prediction of clinical and metabolic abnormalities in women with polycystic ovary syndrome (PCOS).

METHODS

 The present study enrolled 299 normal cycling non-PCOS, 156 normoandrogenemic, and 474 hyperandrogenemic women with PCOS. Baseline characteristics were compared using a chi-squared test or analysis of variance (ANOVA) as appropriate. The roles of adrenal prohormones and their ratios with total testosterone in predicting co-occurring morbidities in women PCOS were evaluated using univariate and multivariate logistic regression analyses.

RESULTS

 Adrenal hyperandrogenism per dehydroepiandrosterone sulfate (DHEAS) levels were found in 32% of women with PCOS. In non-PCOS women, dehydroepiandrosterone (DHEA) and its sulfate had no predictive role concerning clinical, anthropometric, and metabolic parameters. In PCOS women, mainly in the hyperandrogenemic group, DHEA showed to be a significant predictor against most anthropometric-metabolic index abnormalities (odds ratio [OR] = 0.36-0.97; p < 0.05), and an increase in triglycerides (TG) levels (OR = 0.76; p = 0.006). Dehydroepiandrosterone sulfate presented a few predictive effects regarding PCOS-associated disorders. In controls, DHEAS predicted against the increase in estimated average glucose (OR= 0.38; p = 0.036). In the normoandrogenic group, it predicted against elevation in the waist/hip ratio (WHR) (OR= 0.59; p = 0.042), and in hyperandrogenemic PCOS women, it predicted against abnormality in the conicity index (CI) (OR = 0.31; p = 0.028).

CONCLUSION

 Dehydroepiandrosterone was shown to be a better predictor of abnormal anthropometric and biochemical parameters in women with PCOS than DHEAS. Thus, regarding adrenal prohormones, DHEA measurement, instead of DHEAS, should be preferred in PCOS management. The effects of androgen prohormones on the prediction of PCOS abnormalities are weak.

Levels of Trace Elements in Erythrocytes as Endocrine Disruptors in Obese and Nonobese Women with Polycystic Ovary Syndrome

Introduction: Polycystic ovary syndrome (PCOS) is one of the most commonly recognized endocrinopathies in women. The literature lacks clear data that allow any meaningful conclusions to be drawn about the influence of trace elements in erythrocytes on the biochemical parameters of PCOS. Materials and methods: This study was conducted among 47 women meeting the Rotterdam criteria for the diagnosis of polycystic ovary syndrome. The research groups included women with PCOS with different BMI values (body mass index): obese women with PCOS (PCOS with BMI ≥ 30, mean BMI index 35.4 ± 4.4 kg/m²), nonobese PCOS women (PCOS with BMI < 30, mean BMI index 25.2 ± 2.8 kg/m²), and healthy control group (CG) with a mean BMI of 23.57 ± 0.9 kg/m². The contents of trace elements in erythrocytes were determined with an inductively coupled plasma atomic emission spectrometer. Results: The only trace element showing significant differences in concentration between the studied groups was nickel (Ni). The level of nickel in the obese women with PCOS (BMI ≥ 30) was significantly higher than in nonobese women (BMI < 30). The content of other trace elements in erythrocytes did not differ significantly between the studied groups. Several significant correlations were found within each of the studied PCOS groups: in the group of obese women, the content of zinc (Zn) in erythrocytes positively correlated with prolactin, the content of magnesium (Mg) positively correlated with testosterone, and the content of manganese (Mn) negatively correlated with thyroid-stimulating hormone. In the group of nonobese women, Zn content correlated positively with testosterone, Ni with luteinizing hormone (LH) and estradiol, and Mg negatively correlated with estradiol. Conclusions: The relationship between the level of trace elements and the level of hormones suggests that, in obese women with PCOS, nickel may play a role in inhibiting the processes of folliculogenesis and ovulation. Research on trace elements and their relationship to ovulatory cycles and the development of PCOS may contribute to reducing the consequences of PCOS and, therefore, should be extended.

Cutaneous Manifestations and Hormonal Changes Among Polycystic Ovary Syndrome Patients at a Tertiary Care Center

Background: Polycystic ovary syndrome (PCOS) is a highly prevalent endocrine disorder affecting 5%-10% of women worldwide. PCOS patients usually present with cutaneous manifestations of hyperandrogenism, such as acne, hirsutism, and androgenic alopecia.

Objective: To estimate the prevalence of dermatological manifestations and their association with hormonal changes in PCOS patients. In addition, this study aimed to estimate the prevalence of comorbidities associated with PCOS and to demonstrate the referral pattern among Dermatology, Gynecology, and Primary Health Care (PHC).

Methods: This is a cross-sectional study conducted at King Abdulaziz Medical City (KAMC) in Jeddah, Saudi Arabia. All PCOS patients who attended KAMC from 2016 to 2021 were included. Data were collected through a retrospective chart review of the electronic medical record system (BestCare) and by utilizing a structured data collection sheet.

Results: A total of 447 female patients were diagnosed with PCOS with a median age of 29 years and a median BMI of 28.76 kg/m².The prevalence of cutaneous manifestations among patients was 68%. Hirsutism (47.3%), acne vulgaris (40.6%), and androgenic alopecia (20.3%) were the most common manifestations. The most common hormonal abnormalities were raised luteinizing hormone (LH) levels in 220 (49.1%) patients and raised LH/follicle-stimulating hormone (FSH) ratio in 159 (35.5%) patients. FSH, LH/FSH ratio, and age were significant predictors for acne vulgaris (P-value=0.01, 0.04, and 0.01, respectively). Obesity (44.20%), infertility (25.70%), and dyslipidemia (17%) were the most common comorbidities in our sample. Most patients' first visits and follow-ups were in PHC. 

Conclusion: The prevalence of cutaneous manifestations among PCOS patients is relatively high and plays a significant role in making the diagnosis. Therefore, physicians across multiple specialties need to be more aware of the full spectrum of PCOS presentations to alleviate it from its under-diagnosed status.

Multicenter Evaluation of a New, Fully Automated Androstenedione Electrochemiluminescence Immunoassay: Precision Analysis, Method Comparison, and Determination of Reference Ranges

BACKGROUND

Androstenedione (ASD) levels can aid diagnosis of hyperandrogenism together with other clinical/laboratory findings. We evaluated performance of the new, automated Elecsys® ASD assay vs an ASD isotope dilution-liquid chromatography-tandem mass spectrometry (ID-LC-MS/MS) reference measurement procedure and determined reference ranges.

METHODS

Repeatability/intermediate precision were assessed using 3 control levels and 5 human serum pools (n = 75 each; Clinical and Laboratory Standards Institute EP05-A3). Method comparisons vs commercially available immunoassays [IMMULITE ASD (Siemens) and LIAISON ASD (DiaSorin)] and an ID-LC-MS/MS measurement procedure method were conducted using 421 serum samples; Passing-Bablok regression and Pearson's correlation coefficients were calculated. Reference ranges and distribution of values associated with polycystic ovary syndrome (PCOS) were determined in five clinical cohorts using samples from several sites/vendors.

RESULTS

Repeatability/intermediate precision coefficients of variation across all sites were 2.01% to 3.91% and 2.43% to 4.30%, respectively (mean ASD: 7.80-34.7 nmol/L). The Elecsys ASD assay showed poor agreement with IMMULITE ASD (slope = 0.459; r = 0.856; n = 320), fair agreement with LIAISON ASD (slope = 0.625; r = 0.984; n = 327), and very good agreement with ID-LC-MS/MS (slope = 1.040; r = 0.996; n = 332). Reference ranges (2.5th-97.5th percentiles) were: children (≤8 years; n = 140), <0.525 to 1.81 nmol/L; males (≥18 years; n = 138), 0.979 to 5.32 nmol/L; and postmenopausal females (n = 140), 0.654 to 3.74 nmol/L. Reference range (5th-95th percentiles) for females with fertile cycle (≥18 years; n = 84) was 1.71 to 4.58 nmol/L. The distribution of values (2.5th-97.5th percentiles) in females with PCOS (n = 125) was 2.26 to 12.1 nmol/L.

CONCLUSIONS

Elecsys ASD assay demonstrated excellent precision and very good agreement with ID-LC-MS/MS. Reference ranges were established to support results interpretation in routine practice.

Aberrant H19 Expression Disrupts Ovarian Cyp17 and Testosterone Production and Is Associated with Polycystic Ovary Syndrome in Women

As one of the most common endocrine disorders affecting women, polycystic ovary syndrome (PCOS) is associated with serious conditions including anovulation, endometrial cancer, infertility, hyperandrogenemia, and an increased risk for obesity and metabolic derangements. One contributing etiology to the pathophysiology of hyperandrogenemia associated with PCOS is an intrinsic alteration in ovarian steroidogenesis, leading to enhanced synthesis of androgens including testosterone. Studies have suggested that the increased testosterone synthesis seen in PCOS is driven in part by increased activity of CYP17A1, the rate-limiting enzyme for the formation of androgens in the gonads and adrenal cortex, which represents a critical factor driving enhanced testosterone secretion in PCOS. In this work, we evaluated the hypothesis that dysregulation of the noncoding RNA H19 results in aberrant CYP17 and testosterone production. To achieve this, we measured Cyp17 in ovarian tissues of H19 knockout mice, and quantified serum testosterone levels, in comparison with wild-type controls. We also evaluated circulating and ovarian H19 expression and correlated results with the presence or absence of PCOS in a group of women undergoing evaluation and treatment for infertility. We found that the loss of H19 in a mouse model results in decreased ovarian Cyp17, along with decreased serum testosterone in female mice. Moreover, utilizing serum samples and cumulus cells from women with PCOS, we showed that circulating and ovarian levels of H19 are increased in women with PCOS compared to controls. Findings from our multimodal experimental strategy, involving both a mouse model of dysregulated H19 expression and clinical serum and ovarian cellular samples from women with PCOS, suggest that the loss of H19 may disrupt androgen production via a Cyp17-mediated mechanism. Conversely, excess H19 may play a role in the pathogenesis of PCOS-associated hyperandrogenemia.

Diagnostik und Therapie bei Haarausfall und Hirsutismus

Kaum ein Symptom kann so irritierend sein wie die unwillentliche Veränderung des Behaarungsmusters. Haarverlust an sich ist ein Phänomen, das durch die asynchron verlaufenden Wachstumsphasen der einzelnen Haarfollikel physiologisch zum Verlust von etwa 100 Kopfhaaren pro Tag führt. Die Ursachen für einen darüber hinausgehenden Haarausfall sind vielfältig: Sie können hormonell, psychosomatisch oder autoimmunologisch sein, aber auch alimentär oder paraneoplastisch. In diesem Beitrag werden die unterschiedlichen Formen von Haarausfall (Alopezien) erläutert, ergänzend wird auch das unerwünscht vermehrte Haarwachstum bei Frauen (Hirsutismus) erklärt. Die Behandlung der jeweiligen Alopezie ist aufgrund der unterschiedlichen Ursachen nicht in einen allgemeingültigen Algorithmus zu fassen.

Biomediators in Polycystic Ovary Syndrome and Cardiovascular Risk

Polycystic ovary syndrome (PCOS) is extremely heterogeneous in terms of clinical manifestations. The variability of the syndrome's phenotype is derived from the genetic and molecular heterogeneity, with a great deal of environmental factors that may have long-term health consequences, such as metabolic and cardiovascular (CV) diseases. There is no doubt that women with PCOS suffer from metabolic complications more than their age-matched counterparts in the general population and at an earlier age. Obesity, low steroid hormone-binding globulin (SHBG), hyperandrogenemia, insulin resistance, and compensatory hyperinsulinemia are biomediators and early predictors of metabolic complications in PCOS. Doubts remain about the real risk of CV diseases in PCOS and the molecular mechanisms at the basis of CV complications. Based on that assumption, this review will present the available evidence on the potential implications of some biomediators, in particular, hyperandrogenism, estrogen-progesterone imbalance, insulin resistance, and low SHBG, in the processes leading to CV disease in PCOS, with the final aim to propose a more accurate CV risk assessment.

Lower sexual satisfaction in women with polycystic ovary syndrome and metabolic syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is a multi-symptom disorder linked with a range of metabolic and hormonal disturbances. Psychological and sexual aspects of PCOS also need to be considered.

OBJECTIVE OF THE STUDY

This study aimed to assess sexual satisfaction (SS) in PCOS patients and eumenorrheic controls (CON). The relationships between SS, depressive symptoms, health-related quality of life (HRQoL), and hormonal and metabolic profiles were evaluated.

METHODS

In this study, 190 patients with PCOS (mean age 26.34 ± 5.47 years) and 197 age-matched CON (mean age 27.12 ± 4.97 years) were enrolled. All subjects completed Polish version of the Sexual Satisfaction Questionnaire (SSQ), WHO Quality of Life-BREF (WHOQOL-BREF), and the Center for Epidemiologic Studies Depression Scale-Revised (CESD-R) questionnaire. Fasting blood samples were collected to assess hormonal, lipid, and glucose profiles. Anthropometric measures were collected. Metabolic syndrome (MS) was evaluated according to the IDF-AHA/NHLBI criteria.

RESULTS

Patients with PCOS and MS had lower SS vs non-MS-PCOS. There were no significant differences in the level of SS, presence of depressive symptoms, or HRQoL between PCOS and CON (P > 0.05). Negative correlations were found between the SS level and BMI, waist circumference, and waist-to-height ratio in PCOS women. However, overweight or obese PCOS women did not differ in SS levels vs normal-weight PCOS patients. The social dimension of WHOQOL-BREF was the only significant predictor of SS in PCOS patients.

CONCLUSIONS

SS in PCOS women appears to be undisturbed. However, MS in PCOS patients could negatively influence SS. The level of SS should be assessed in PCOS women, especially if MS is present.

Cardiovascular, anthropometric, metabolic and hormonal profiling of normotensive women with polycystic ovary syndrome with and without biochemical hyperandrogenism

PURPOSE

Women with polycystic ovary syndrome (PCOS) present with or without biochemical hyperandrogenism (HAPCOS or non-HAPCOS, respectively). Cardiometabolic and hormonal abnormalities have been reported in women with PCOS, particularly those with hypertension. However, no direct comparison between normotensive (blood pressure <140/90 mmHg) patients with HAPCOS and non-HAPCOS has been made. This study compared different cardiovascular (CV), anthropometric, metabolic and hormonal features between normotensive patients with HAPCOS and non-HAPCOS and healthy women.

METHODS

We consecutively recruited 249 normotensive patients with PCOS and 85 healthy eumenorrheic women to a case-control observational study. Based on blood androgen concentration, patients with PCOS were divided into HAPCOS (n = 69) or non-HAPCOS (n = 180) groups.

RESULTS

Although within normal ranges, patients with HAPCOS had significantly (p < 0.05) higher peripheral and central systolic blood pressure and pulse pressure, C-reactive protein, low-density lipoprotein cholesterol, triglycerides, glucose, and insulin than subjects with non-HAPCOS, and healthy women. They also had lower N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) concentration. In contrast, their body mass index (BMI) was higher of over 4 kg/m² than patients with non-HAPCOS and nearly 6 kg/m² than in healthy participants. Except for BMI, statistical differences in the cardiometabolic profile were of little clinical relevance.

CONCLUSIONS

Young normotensive women with HAPCOS have a worse cardiometabolic profile but lower NT-proBNP concentration than patients with non-HAPCOS. Features of this profile in both PCOS groups are within ranges typical for healthy women. Increased BMI is the only clinically relevant feature differentiating hyperandrogenic from non-hyperandrogenic patients with PCOS, and healthy women.

Role of shear wave elastography in predicting the metabolic and androgenic alterations in patients with polycystic ovary syndrome

AIM

To evaluate the variation in tissue stiffness caused by the changes in ovarian volume and stroma in polycystic ovary syndrome (PCOS) using a novel method of ultrasonography, that is shear wave elastography (SWE). The current study also aimed to evaluate the potential applications of this method in predicting the metabolic and androgenic alterations in patients with PCOS.

METHODS

The present study included 33 patients with PCOS. The blood samples for the metabolic and androgenic parameters and SWE values pertaining to the patients were obtained on the same day during the early follicular phase. The predictive ability of SWE to reflect the metabolic and androgenic abnormalities was evaluated using the receiver operating characteristic curve (ROC) analysis.

RESULTS

The mean SWE value pertaining to the group with higher total testosterone levels was significantly lower, compared to the group with normal testosterone levels (p = 0.041). The ROC analysis revealed that the predictive potential of SWE was statistically significant in regard to the serum testosterone levels alone (area under the curve [AUC] = 0.755, 95% confidence interval [CI]: 0.573-0.938, p = 0.041). There was no significant relationship between the SWE values and metabolic parameters.

CONCLUSIONS

Based on the results of the present study, decreased SWE values appear to be associated with increased serum testosterone levels. However, the present study did not observe any significant relationship between the SWE values and metabolic parameters. SWE can be used as a practical and non-invasive method to predict the serum testosterone levels during the follow-up evaluations of the patients with PCOS.

Differential Effects of Various Androgens on Polycystic Ovary Syndrome

The hyperandrogenism in polycystic ovary syndrome (PCOS) is associated with the risk for the future development of the cardiovascular disease. The objective of the study is to verify whether different androgens have the same harmful effect. This cross-sectional study enrolled 823 women with PCOS: 627 (76.2%) with biochemical hyperandrogenism and 196 (23.8%) with normal androgen levels. The role of individual androgen was evaluated using univariate and multivariate logistic regression. In normoandrogenemic PCOS (NA-PCOS), free androgen index (FAI) predicted significant abnormality in visceral adipose index (VAI, OR=9.2, p=0.002) and dehydroepiandrosterone (DHEA) predicted against alteration in β-cell function (OR=0.5, p=0.007). In hyperandrogenemic PCOS (HA-PCOS), FAI predicted derangements in waist triglyceride index (WTI), VAI, and lipid accumulation product (LAP) (OR ranging from 1.6 to 5.8, p<0.05). DHEA weakly predicted against VAI (OR 0.7, p=0.018), dehydroepiandrosterone sulfate (DHEAS) tended to predict against the conicity index (OR=0.7, p=0.037). After multiple regression, FAI retained significant strength to predict various anthropometric and metabolic abnormalities (OR ranging from 1.1 to 3.0, p<0.01), DHEA was kept as a protector factor against WTI, LAP, and VAI (OR ranging from 0.6 to 0.9; p<0.01) and DHEAS against the conicity index (OR=0.5, p<0.001). In conclusion, the free androgen index was the most powerful predictor of anthropometric and metabolic abnormalities of polycystic ovary syndrome. Conversely, DHEA and DHEAS demonstrated protective effects against disorders in some markers of obesity and abnormal metabolism.

Natural autoantibodies to the gonadotropin-releasing hormone receptor in polycystic ovarian syndrome

CONTEXT

Polycystic ovarian syndrome (PCOS) is a complex disease with different subtypes and unclear etiology. Among the frequent comorbidities are autoimmune diseases, suggesting that autoantibodies (aAb) may be involved in PCOS pathogenesis.

OBJECTIVE

As the gonadal axis often is dysregulated, we tested the hypothesis that aAb to the gonadotropin-releasing hormone receptor (GnRH-R) are of diagnostic value in PCOS.

DESIGN

An in vitro assay for quantifying aAb to the GnRH-R (GnRH-R-aAb) was established by using a recombinant fusion protein of full-length human GnRH-R and firefly luciferase. A commercial rabbit antiserum to human GnRH-R was used for standardization. Serum samples of control subjects and different cohorts of European PCOS patients (n = 1051) were analyzed.

RESULTS

The novel GnRH-R-aAb assay was sensitive, and signals were linear on dilution when tested with the commercial GnRH-R antiserum. Natural GnRH-R-aAb were detected in one control (0.25%) and two PCOS samples (0.31%), and 12 samples were slightly above the threshold of positivity. The identification of samples with positive GnRH-R-aAb was reproducible and the signals showed no matrix interferences.

CONCLUSION

Natural GnRH-R-aAb are present in a very small fraction of adult control and PCOS subjects of European decent. Our results do not support the hypothesis that the GnRH-R constitutes a relevant autoantigen in PCOS.

Risk of Insulin Resistance and Metabolic Syndrome in Women with Hyperandrogenemia: A Comparison between PCOS Phenotypes and Beyond

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in premenopausal women, with a wide spectrum of possible phenotypes, symptoms and sequelae according to the current clinical definition. However, there are women who do not fulfill at least two out of the three commonly used "Rotterdam criteria" and their risk of developing type 2 diabetes or obesity later in life is not defined. Therefore, we addressed this important gap by conducting a retrospective analysis based on 750 women with and without PCOS. We compared four different PCOS phenotypes according to the Rotterdam criteria with women who exhibit only one Rotterdam criterion and with healthy controls. Hormone and metabolic differences were assessed by analysis of variance (ANOVA) as well as logistic regression analysis. We found that hyperandrogenic women have per se a higher risk of developing insulin resistance compared to phenotypes without hyperandrogenism and healthy controls. In addition, hyperandrogenemia is associated with developing insulin resistance also in women with no other Rotterdam criterion. Our study encourages further diagnostic and therapeutic approaches for PCOS phenotypes in order to account for varying risks of developing metabolic diseases. Finally, women with hyperandrogenism as the only symptom should also be screened for insulin resistance to avoid later metabolic risks.

Common endocrine disorders associated with the polycystic ovary syndrome

Introduction

Screening of polycystic ovary syndrome (PCOS) women for hypothyroidism and hyperprolactinemia was suggested, because the undiagnosed hypothyroidism and hyperprolactinemia can aggravate the PCOS symptoms.

Aim of the study

To determine whether the insulin resistance (IR), hypothyroidism, and hyperprolactinemia are common endocrine disorders associated with the PCOS.

Material and methods

One hundred and twenty PCOS women were compared to 120 non-PCOS controls in this study. Participants' day 2-3 hormonal profile and insulin resistance (IR) using the fasting glucose and fasting insulin were evaluated. Collected data were analyzed to determine whether the IR, hypothyroidism, and hyperprolactinemia are common endocrine disorders associated with the PCOS.

Results

TSH and prolactin were significantly high in PCOS women (6.4 ±4.2 and 934 ±102.3, respectively) than controls (3.5 ±3.3 and 445 ±77.5 mIU/ml, respectively) (p = 0.004 and 0.001, respectively). The PCOS women had significantly high relative risk of IR (RR 3.0 (95% CI: 1.9-4.7) p < 0.0001), hypothyroidism (RR 3.4; 95% CI: 1.7-6.9) (p = 0.0005), and hyperprolactinaemia (RR 3.15; 95% CI: 1.8-5.6) (p = 0.0001) than controls. The PCOS women had higher odds of IR (OR 4.8; 95% CI: 2.6-8.8) (p < 0.0001), hypothyroidism (OR 4.29; 95% CI: 1.9-9.4) (p = 0.0003), and hyperprolactinaemia (OR 4.27; 95% CI: 2.1-8.5) (p < 0.0001) than controls.

Conclusions

TSH and prolactin were significantly high in studied PCOS women, and 47.5% of the studied PCOS women had IR. The PCOS women had significantly higher odds and relative risks of IR, hypothyroidism, and hyperprolactinemia than controls. IR, hypothyroidism, and hyperprolactinemia are common endocrine disorders associated with PCOS.

Characterizing the Clinical and Genetic Spectrum of Polycystic Ovary Syndrome in Electronic Health Records

CONTEXT

Polycystic ovary syndrome (PCOS) is one of the leading causes of infertility, yet current diagnostic criteria are ineffective at identifying patients whose symptoms reside outside strict diagnostic criteria. As a result, PCOS is underdiagnosed and its etiology is poorly understood.

OBJECTIVE

We aim to characterize the phenotypic spectrum of PCOS clinical features within and across racial and ethnic groups.

METHODS

We developed a strictly defined PCOS algorithm (PCOSkeyword-strict) using the International Classification of Diseases, ninth and tenth revisions and keywords mined from clinical notes in electronic health records (EHRs) data. We then systematically relaxed the inclusion criteria to evaluate the change in epidemiological and genetic associations resulting in 3 subsequent algorithms (PCOScoded-broad, PCOScoded-strict, and PCOSkeyword-broad). We evaluated the performance of each phenotyping approach and characterized prominent clinical features observed in racially and ethnically diverse PCOS patients.

RESULTS

The best performance came from the PCOScoded-strict algorithm, with a positive predictive value of 98%. Individuals classified as cases by this algorithm had significantly higher body mass index (BMI), insulin levels, free testosterone values, and genetic risk scores for PCOS, compared to controls. Median BMI was higher in African American females with PCOS compared to White and Hispanic females with PCOS.

CONCLUSIONS

PCOS symptoms are observed across a severity spectrum that parallels the continuous genetic liability to PCOS in the general population. Racial and ethnic group differences exist in PCOS symptomology and metabolic health across different phenotyping strategies.

Impact of Increased Oxidative Stress on Cardiovascular Diseases in Women With Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is a complex disorder that affects around 5% to 10% of women of childbearing age worldwide, making it the most common source of anovulatory infertility. PCOS is defined by increased levels of androgens, abnormal ovulation, irregular menstrual cycles, and polycystic ovarian morphology in one or both ovaries. Women suffering from this condition have also been shown to frequently associate certain cardiovascular comorbidities, including obesity, hypertension, atherosclerosis, and vascular disease. These factors gradually lead to endothelial dysfunction and coronary artery calcification, thus posing an increased risk for adverse cardiac events. Traditional markers such as C-reactive protein (CRP) and homocysteine, along with more novel ones, specifically microRNAs (miRNAs), can accurately signal the risk of cardiovascular disease (CVD) in PCOS women. Furthermore, studies have also reported that increased oxidative stress (OS) coupled with poor antioxidant status significantly add to the increased cardiovascular risk among these patients. OS additionally contributes to the modified ovarian steroidogenesis, consequently leading to hyperandrogenism and infertility. The present review is therefore aimed not only at bringing together the most significant information regarding the role of oxidative stress in promoting CVD among PCOS patients, but also at highlighting the need for determining the efficiency of antioxidant therapy in these patients.

Hyperandrogenism by Liquid Chromatography Tandem Mass Spectrometry in PCOS: Focus on Testosterone and Androstenedione

The identification of hyperandrogenism in polycystic ovary syndrome (PCOS) is concerning because of the poor accuracy of the androgen immunoassays (IA) and controversies regarding which androgens should be measured. The aim of our study was to evaluate the impact of the assessment of testosterone (T) and androstenedione (A) by liquid chromatography in tandem with mass spectrometry (LC/MS-MS), in the diagnosis of PCOS. We evaluated 131 patients referred for suspected PCOS. Fourteen patients in total were excluded, some because of other diagnosis (n = 7) or incomplete diagnostic workup (n = 7). We measured T and A both by IA and LC-MS/MS in the 117 subjects included. We calculated free T (fT) by the Vermeulen formula and recorded clinical and metabolic data. 73 healthy females served as controls to derive immunoassays (IA) and LC-MS/MS reference intervals for T, fT and A. PCOS was confirmed in 90 subjects by IA and in 93 (+3.3%) by LC-MS/MS. The prevalence of biochemical hyperandrogenism in PCOS by LC-MS/MS increased from 81.7% to 89.2% if A was also considered. The most frequently elevated androgens were fT (73.1%) and A (64.5%) and they had similar levels of accuracy in differentiating PCOS and controls (0.34 ng/dL, Sn 91% Sp 89%; 1.16 ng/mL, Sn 91% Sp 88%, respectively). Free testosterone correlated with body mass index (BMI), homeostatic model assessment (HOMA)-index, glycated hemoglobin (HbA1c), and sex-binding globulin (SHBG). The results confirm that LC-MS/MS is slightly more sensitive than IA in the diagnosis of PCOS with LC-MS/MS detecting higher levels of fT and A. Moreover, assessment of fT and A by LC-MS/MS had a similar level of accuracy in discriminating between PCOs and control subjects. Lastly, fT by LC-MS/MS correlates with adverse metabolic parameters.

Effect of Central Obesity and Hyperandrogenism on Selected Inflammatory Markers in Patients with PCOS: A WHtR-Matched Case-Control Study

White blood cell counts (WBC), lymphocyte-to-monocyte ratio (LMR), and monocyte-to-high-density lipoprotein cholesterol ratio (MHR) are used as chronic inflammation markers. Polycystic ovary syndrome (PCOS) is a constellation of systemic inflammation linked to central obesity (CO), hyperandrogenism, insulin resistance, and metabolic syndrome. The waist-to-height ratio (WHtR) constitutes a highest-concordance anthropometric CO measure. This study aims to access WBC, LMR, and MHR in PCOS and healthy subjects, with or without CO. Establishing relationships between complete blood count parameters, high-sensitivity C-reactive protein (hsCRP), and hormonal, lipid and glucose metabolism in PCOS. To do this, WBC, LMR, MHR, hsCRP, anthropometric, metabolic, and hormonal data were analyzed from 395 women of reproductive age, with and without, PCOS. Correlations between MHR, and dysmetabolism, hyperandrogenism, and inflammation variables were examined. No differences were found in WBC, LMR, MHR, and hsCRP between PCOS and controls (p > 0.05). PCOS subjects with CO had higher hsCRP, MHR, and WBC, and lower LMR vs. those without CO (p < 0.05). WBC and MHR were also higher in controls with CO vs. without CO (p < 0.001). MHR correlated with anthropometric, metabolic, and endocrine parameters in PCOS. WHtR appeared to strongly predict MHR in PCOS. We conclude that PCOS does not independently influence WBC or MHR when matched for CO. CO and dysmetabolism may modify MHR in PCOS and control groups.

Endocrine Insights into the Pathophysiology of Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a class of neurodevelopmental disorders that affects males more frequently than females. Numerous genetic and environmental risk factors have been suggested to contribute to the development of ASD. However, no one factor can adequately explain either the frequency of the disorder or the male bias in its prevalence. Gonadal, thyroid, and glucocorticoid hormones all contribute to normal development of the brain, hence perturbations in either their patterns of secretion or their actions may constitute risk factors for ASD. Environmental factors may contribute to ASD etiology by influencing the development of neuroendocrine and neuroimmune systems during early life. Emerging evidence suggests that the placenta may be particularly important as a mediator of the actions of environmental and endocrine risk factors on the developing brain, with the male being particularly sensitive to these effects. Understanding how various risk factors integrate to influence neural development may facilitate a clearer understanding of the etiology of ASD.

Gonadal hormones and stroke risk: PCOS as a case study

It is well known that stroke incidence and outcome is sex-dependent and influenced by age and gonadal hormones. In post-menopausal and/or aged females, declining estrogen levels increases stroke risk. However, women who experience early menopause also have an increase in stroke risk. This suggests that, regardless of age, gonadal hormones regulate stroke risk and severity. This review discusses prolonged gonadal hormone dysfunction in a common female endocrine disorder known as polycystic ovarian syndrome, PCOS, and the associated increased risk of stroke due to resulting hyperandrogenism and metabolic comorbidities.

Elevated and diagnostic androgens of polycystic ovary syndrome

Introduction

A genetic variation at the level of aromatase enzyme and/or androgen receptors was suggested in polycystic ovary syndrome (PCOS).

Aim of the study

To determine the androgens elevated and diagnostic for PCOS.

Material and methods

A total of 120 PCOS women were compared to non-PCOS controls in this study. The studied women were evaluated thoroughly, including: day 2-3 hormonal profile and any hormonal change confirmed by two laboratory results eight weeks apart. Collected data were analysed to determine the androgens elevated and diagnostic for PCOS.

Results

The luteinising hormone (LH) and LH/follicle stimulating hormone (FSH) ratio were significantly high in the studied PCOS group compared to controls (p = 0.02 and 0.01, respectively). In addition, total and free testosterone and androstenedione were significantly high in the studied PCOS group compared to controls (p = 0.001, 0.003, and 0.02, respectively).The studied PCOS group had higher relative risk (RR) and odds ratio (OR) of elevated total testosterone (2.4 and 5.7, respectively), elevated free testosterone (2.9 and 4.9, respectively), and elevated androstenedione (3.0 and 4.8, respectively), compared to controls.

Conclusions

Testosterone (both total and free testosterone) and androstenedione were the main elevated androgens and were diagnostic for excess ovarian androgens in the studied PCOS women, whereas dehydroepiandrosterone (DHEA) was not elevated and/or diagnostic for excess ovarian androgens in the studied PCOS women.

Prevalence of metabolic syndrome in four phenotypes of PCOS and its relationship with androgenic components among Iranian women: A cross-sectional study

BACKGROUND

Polycystic ovary syndrome (PCOS) increases the risk of metabolic syndrome (MetS). Insulin resistance (IR) plays a major role in the pathophysiology of both PCOS and MetS.

OBJECTIVE

This study was designed to compare the prevalence of MetS among different phenotypes of PCOS and its relationship with androgenic components.

MATERIALS AND METHODS

182 participants eligible for this five-group comparative study were selected by convenience sampling method. They were classified according to the Rotterdam criteria: clinical and/or biochemical hyperandrogenism (H) + PCOS on ultrasound (P) + ovulation disorders (O) (n = 41), clinical and/or biochemical H + PCOS on P (n = 33), PCOS on P + O (n = 40), clinical and/or biochemical H + O (n = 37), and control (without PCOS) (n = 31). MetS was measured based on the National Cholesterol Education Program Adult Treatment Panel III criteria. Androgenic components included free-androgen-index (FAI), total-testosterone (TT) level and sex-hormone-binding-globulin (SHBG).

RESULTS

A significant difference was observed between the study groups in terms of MetS prevalence (p = 0.01). In phenotype H+P+O, there was a statistically significant positive association between TG and TT, and a significant negative association between SBP and DBP with SHBG. In phenotype O+P, WC was inversely associated with SHBG. In phenotype H+O, FBS and TG were positively associated with FAI but HDL was inversely associated with FAI. Moreover, WC and DBP were positively associated with TT in phenotype H+O. No associations were detected between MetS parameters and androgenic components in other PCOS subjects (phenotype H+P) and in the control group. TT was significantly higher in the PCOS group suffering from MetS (p = 0.04).

CONCLUSION

According to the research results, hyperandrogenic components are potent predictors of metabolic disorders. Thus, we suggest that MetS screening is required for the prevention of MetS and its related complications in PCOS women.

Vaginal bleeding and spotting in transgender men after initiation of testosterone therapy: A prospective cohort study (ENIGI)

BACKGROUND

Previous studies have cross-sectionally described amenorrhea in cohorts of transgender men on intramuscular or subcutaneous testosterone injections. It remains uncertain which testosterone preparations most effectively suppress vaginal bleeding and when amenorrhea occurs after testosterone initiation.

AIM

To investigate the clinical effects of various testosterone preparations on vaginal bleeding and spotting in transgender men.

METHODS

This prospective cohort study was part of the European Network for the Investigation of Gender Incongruence (ENIGI). Data on the persistence and intensity of vaginal bleeding and spotting, serum sex steroid levels and body composition were prospectively and cross-sectionally assessed in 267 transgender men during a three-year follow-up period, starting at the initiation of various testosterone preparations.

RESULTS

After three months of testosterone, 17.9% of transgender men reported persistent vaginal bleeding and 26.8% reported spotting. The percentages reporting vaginal bleeding and spotting decreased over the first year of testosterone (bleeding 4.7% and spotting 6.9% at 12 months, respectively), with no participants reporting vaginal bleeding or spotting after 18 months of testosterone. Factors associated with vaginal bleeding or spotting included lower serum testosterone levels and being on testosterone gel as compared to injections (e.g., esters or undecanoate preparations). If vaginal bleeding persisted, starting progestogens at three months resulted in a decrease in the intensity of vaginal bleeding and spotting.

DISCUSSION

Transgender men and hormone-prescribing providers can be reassured that vaginal bleeding and spotting usually stop within three months after testosterone initiation. If not, serum testosterone levels should be measured and testosterone dose adjusted to achieve serum testosterone levels in the physiologic male range. Adding a progestin can be considered after three to six months if bleeding persists. Providers should be aware that cessation of bleeding can be more difficult to achieve in transgender men with lower serum testosterone levels or those on testosterone gel.

Supervised exercise training and increased physical activity to reduce cardiovascular disease risk in women with polycystic ovary syndrome: study protocol for a randomized controlled feasibility trial

BACKGROUND

Polycystic ovary syndrome (PCOS) affects up to 20% of women and is characterised by higher amounts of visceral fat, obesity, insulin resistance, dyslipidemia and reproductive and cardiometabolic complications. Increased oxidised low-density lipoprotein (LDL) concentrations have been associated with an increased risk of cardiovascular disease (CVD)-related events. Oxidised LDL is rarely used as a marker for CVD risk in PCOS-related studies despite its widely accepted role in atherogenesis and the increased risk factors associated with PCOS. Additionally, prolonged periods of sedentary behaviour can negatively affect metabolic health. No studies have specifically examined the effects of reducing sedentary behaviour on CVD risk in PCOS with a lifestyle physical activity intervention. The aim of the current study is to measure the feasibility of a randomised controlled trial (RCT) examining the effects of supervised exercise and reducing sedentary behaviour in women with PCOS on CVD risk.

METHODS/DESIGN

A feasibility, exploratory RCT will be conducted. Fifty-one pre-menopausal females will be randomly allocated between an exercise group (EG), a lifestyle physical activity group (LPAG) and a control group. Participants in the EG will undertake a 12-week supervised aerobic exercise programme. The LPAG will aim to increase daily physical activity and reduce sedentary behaviour for 12 weeks. The control group will not take part in any intervention. Primary outcomes are feasibility and acceptability of the intervention and procedures. Secondary outcomes are oxidised LDL, aerobic fitness, blood lipid profile, fasting glucose and insulin, testosterone and inflammatory markers.

DISCUSSION

PCOS is associated with various increased risk factors for CVD, including hypertension, dyslipidemia, abdominal obesity, insulin resistance, and inflammation. Whether oxidised LDL has a role in this increased risk is not yet known. The present study aims to measure the feasibility of implementing structured exercise training and/or increased lifestyle physical activity in women with PCOS, so that a subsequent adequately powered RCT can be designed. The results from the study will be used to refine the interventions and determine the acceptability of the study design. A limitation is that some self-monitoring in the lifestyle physical activity group may not be reliable or replicable, for example inputting information about time spent cleaning/gardening.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03678714. Registered 20 September 2018.

Pig Hsd17b3: Alternative splice variants expression, insertion/deletion (indel) in promoter region and their associations with male reproductive traits

Hydroxysteroid 17-Beta Dehydrogenase 3 (Hsd17b3), primarily expressed in Leydig cells (LCs) of the mammalian testes, is essential for testosterone biosynthesis and male fertility. The aim of our study was to profile the expression, splice variants (SV) and novel insertion/deletion (indel) of Hsd17b3 in boars. Quantitative analysis showed that the expression level of Hsd17b3 in the testis was significantly highest. Among different testicular cell types, the Hsd17b3 mRNA expression level of LCs was significantly higher than that of SSCs (spermatogonial stem cells) and SCs (Sertoli cells). Furthermore, the SV was firstly identified in pigs and it was highly expressed in LCs comparing with SSCs and SCs. In addition, two mutations were identified in pig Hsd17b3 gene promotor and intron, respectively, which were associated with male reproductive traits (P <  0.05). In conclusion, both transcripts of Hsd17b3 gene were highly expressed in pig testes and LCs; the two novel indel variants of Hsd17b3 gene can be used as potential DNA makers for the marker-assisted selection in pigs. All these findings would enrich the study of Hsd17b3 gene in pig genetic breeding.

Abdelazim and Sakiyeva endocrinopathy associated with polycystic ovary syndrome: Case reports

Polycystic ovary syndrome (PCOS) is a multiple endocrine disorder associated with significant reproductive and metabolic manifestations. A genetic variation at the level of aromatase enzyme gene (CYP19 gene) and/or androgen receptors with subsequent increased ovarian androgen was suggested in PCOS. Recently, researchers noted that 56% of the PCOS women had evidence of hypothyroidism and this report represents three case of PCOS with hypothyroidism and hyperprolactinemia (Abdelazim and Sakiyeva endocrinopathy associated with PCOS) to highlight the hypothyroidism and hyperprolactinemia as a common endocrinopathy associated with PCOS. PCOS women should be screened for the endocrinopathy associated with PCOS especially the hypothyroidism and hyperprolactinemia because the undiagnosed endocrinopathy aggravates the PCOS symptoms.

Hyperandrogenism and Metabolic Syndrome Are Associated With Changes in Serum-Derived microRNAs in Women With Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) remains one of the most common endocrine disorder in premenopausal women with an unfavorable metabolic risk profile. Here, we investigate whether biochemical hyperandrogenism, represented by elevated serum free testosterone, resulted in an aberrant circulating microRNA (miRNAs) expression profile and whether miRNAs can identify those PCOS women with metabolic syndrome (MetS). Accordingly, we measured serum levels of miRNAs as well as biochemical markers related to MetS in a case-control study of 42 PCOS patients and 20 Controls. Patients were diagnosed based on the Rotterdam consensus criteria and stratified based on serum free testosterone levels (≥0.034 nmol/l) into either a normoandrogenic (n = 23) or hyperandrogenic (n = 19) PCOS group. Overall, hyperandrogenic PCOS women were more insulin resistant compared to normoandrogenic PCOS women and had a higher prevalence of MetS. A total of 750 different miRNAs were analyzed using TaqMan Low-Density Arrays. Altered levels of seven miRNAs (miR-485-3p, -1290, -21-3p, -139-3p, -361-5p, -572, and -143-3p) were observed in PCOS patients when compared with healthy Controls. Stratification of PCOS women revealed that 20 miRNAs were differentially expressed between the three groups. Elevated serum free testosterone levels, adjusted for age and BMI, were significantly associated with five miRNAs (miR-1290, -20a-5p, -139-3p, -433-3p, and -361-5p). Using binary logistic regression and receiver operating characteristic curves (ROC), a combination panel of three miRNAs (miR-361-5p, -1225-3p, and -34-3p) could correctly identify all of the MetS cases within the PCOS group. This study is the first to report comprehensive miRNA profiling in different subgroups of PCOS women with respect to MetS and suggests that circulating miRNAs might be useful as diagnostic biomarkers of MetS for a different subset of PCOS.

The effects of exercise on cardiometabolic outcomes in women with polycystic ovary syndrome not taking the oral contraceptive pill: protocol for a systematic review and meta-analysis

BACKGROUND

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy, affecting 4-12% of reproductive-aged women. Women with PCOS often exhibit many metabolic abnormalities that are associated with an increased cardiovascular disease (CVD) risk, independent of obesity. Exercise interventions from 12 to 24 weeks have been shown to have positive effects on blood lipid profile, ovulation and insulin resistance in women with PCOS. However, no consensus on which exercise interventions are effective (i.e. duration, type of exercise, frequency), including for different phenotypes, currently exists. The aim of this systematic review and meta-analysis is to define effective types of exercise interventions to improve cardiometabolic profile, across the range of phenotypes of PCOS.

METHODS

We will conduct electronic database searches, including randomised-controlled trials (RCT), quasi-RCT and clinical trials. Primary outcomes sought will be lipid profile, carotid-intima media thickness, fasting blood glucose, %HbA1c, blood pressure, waist circumference, waist-to-hip ratio, abdominal adiposity and inflammation markers. Secondary outcomes sought will be free and total testosterone, sex hormone binding globulin and insulin resistance. The Cochrane Risk Assessment Tool will be used to assess study quality. Data will be analysed in RevMan. Analysis of heterogeneity will be undertaken using the I2 statistic. Significant heterogeneity will be explored, and sensitivity analyses carried out as appropriate. A subgroup analysis based on androgen profile will be undertaken if data are sufficient.

DISCUSSION

A large proportion of women are affected by PCOS. It is prudent to examine how CVD risk can be mitigated in this high-risk population, and this review aims to provide evidence-driven recommendations on the types of exercise interventions that are effective for this. The review will seek to provide recommendations regarding type, frequency and duration of exercise interventions to improve cardiometabolic profile in PCOS. The subgroup analysis may be able to highlight difference in intervention effects between normo-androgenic and hyper-androgenic profile. Limitations include heterogeneity across studies and a scarcity of clinical trials involving a PCOS control group not undertaking any intervention.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018086117.

Androgens drive microvascular endothelial dysfunction in women with polycystic ovary syndrome: role of the endothelin B receptor

KEY POINTS

Polycystic ovary syndrome (PCOS) is a complex syndrome with cardiovascular risk factors, including obesity and insulin resistance. PCOS is also associated with high androgens, increases the risk of cardiovascular dysfunction in women. Due to the complexity of PCOS, had it has been challenging to isolate specific causes of the cardiovascular dysfunction. Our measure of cardiovascular dysfunction (endothelial dysfunction) was most profound in lean women with PCOS. The endothelin-1-induced vasodilation in these PCOS subject, was dependent on the ET_B R but was not NO-dependent. We also demonstrated oestrogen administration improved endothelial function in lean and obese women with PCOS likely because oestrogen increased NO availability. Our studies indicate a primary role for androgens in cardiovascular dysfunction in PCOS.

ABSTRACT

Endothelin-1 (ET-1) is an indicator of endothelial injury and dysfunction and is elevated in women with androgen excess polycystic ovary syndrome (AE-PCOS). The endothelin B receptor (ET_B R) subtype mediates vasodilatation, but is blunted in women with PCOS. We hypothesized that androgen drives endothelial dysfunction in AE-PCOS women and oestradiol (EE) administration reverses these effects. We assessed microvascular endothelial function in women with (7 lean and 7 obese) and without AE-PCOS (controls, 6 lean, 7 obese). Only obese AE-PCOS women were insulin resistant (IR). We evaluated cutaneous vascular conductance (%CVC_max ) with laser Doppler flowmetry during low dose intradermal microdialysis ET-1 perfusions (1, 3, 4, 5 and 7 pmol) with either lactated Ringer solution alone, or with ET_B R (BQ-788), or nitric oxide (NO) inhibition (l-NAME). Log[ET-1]-%maxCVC dose-response curves demonstrated reduced vasodilatory responses to ET-1 in lean AE-PCOS (logED₅₀ , 0.59 ± 0.08) versus lean controls (logED₅₀ , 0.49 ± 0.09, P < 0.05), but not compared to obese AE-PCOS (logED₅₀ , 0.65 ± 0.09). ET_B R inhibition decreased ET-1-induced vasodilatation in AE-PCOS women (logED₅₀ , 0.64 ± 0. 22, P < 0.05). This was mechanistically observed at the cellular level, with ET-1-induced, DAF-FM-measurable endothelial cell NO production, which was abrogated by dihydrotestosterone in an androgen receptor-dependent manner. EE augmented the cutaneous vasodilating response to ET-1(logED₅₀ 0.29 ± 0.21, 0.47 ± 0.09, P < 0.05 for lean and obese, respectively). Androgens drive endothelial dysfunction in lean and obese AE-PCOS. We propose that the attenuated ET-1-induced vasodilatation in AE-PCOS is a consequence of androgen receptor-mediated, suppressed ET_B R-stimulated NO production, and is reversed with EE.

Relationship Between Steroid Hormones and Metabolic Profile in Women With Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is commonly associated with a higher cardiometabolic risk. The relationship between steroid hormones and cardiometabolic profile in PCOS has been evaluated, but no single hormonal predictor of this association has been identified to determine. To determine the relationship between steroid hormones and cardiometabolic risk factors in PCOS women. Study included 64 women diagnosed with PCOS. Fasting blood samples were analyzed for biochemical, metabolic parameters and sex steroid hormones. PCOS women with BMI≥27 had significantly higher serum free testosterone (FT), free androgen index (FAI), estrone (E1) (p=0.014, p=0.02, p=0.01) than those with normal weight. In all subjects E1 positively correlated with BMI (p=0.0067), serum insulin (p=0.0046), HOMA-IR (p=0.0125) and negatively with HDL-cholesterol (p=0.009). FAI positively correlated with serum cholesterol (p=0.0457), triacylglycerols (TAG) (p=0.0001), HOMA-IR (p=0.037), and glycemia (p=0.0001), negatively with HDL-cholesterol (p=0.029). In multiple linear regression model E1 most significantly predicted HOMA-IR, whereas FT/FAI predicted HDL-cholesterol and BMI. We conclude that PCOS women with marked overweight or obesity have higher FT, FAI and E1 as compared with nonobese PCOS subjects. E1 and FT may predict worse cardiometabolic profile in PCOS.

Association Between Vitamin D and Adrenal Parameters with Metabolic and Inflammatory Markers in Polycystic Ovary Syndrome

Vitamin D deficiency has been related with metabolic alterations in polycystic ovary syndrome (PCOS). As well, hyperactivation of adrenal axis can be programmed early in life and could be related later with PCOS development. Our aim was to establish the relationship between vitamin D and adrenal parameters with metabolic alterations and inflammation markers in PCOS. In 73 patients and 33 controls, 25-hydroxyvitamin D (25-OH-D), total and bioavailable testosterone (TT and bioT), androstenedione (A4), SHBG, cortisol, insulin, and C-reactive protein (hs-CRP) were determined; HOMA and lipid accumulation product (LAP) index were calculated. All parameters were higher in patients than in controls, except for SHBG and 25-OH-D which were lower. Binary regression analysis showed that differences in TT, bioT, A4, insulin and HOMA were independent of body mass index and waist circumference but SHBG, hs-CRP, LAP and 25-OH-D were related to body weight and fat distribution. Binary logistic regression analysis showed that cortisol and 25-OH-D could be associated to PCOS development. Correlations found between LAP and insulin, HOMA and hs-CRP confirm it is a good indicator of metabolic complications. Vitamin D and cortisol association to PCOS development justifies future research to understand the role of vitamin D in PCOS and analyze patient's perinatal history and its possible relationship with hyperactivation of adrenal axis in adult life.

Differential activity of the corticosteroidogenic enzymes in normal cycling women and women with polycystic ovary syndrome

The phenotypic complex of patients with definitive diagnosis of polycystic ovary syndrome may include patients with normal and high serum androgen levels. Patients with hyperandrogenemia seem to present higher risk of changes to the glucose and lipid metabolism and, eventually, of earlier development of cardiovascular diseases than normoandrogenemic patients or healthy women. From a laboratory and clinical point of view, it is important to check androgen levels in patients with polycystic ovary syndrome. The identification of partial insufficiency of a given corticosteroidogenic enzyme is also relevant to understand the physiopathology of androgen increase in polycystic ovary syndrome. Therefore, the present review analyzes the functions of the different enzymes involved in the ovary and adrenal steroidogenesis in normal cycling women and in patients with polycystic ovary syndrome. In addition, it emphasizes appropriate reason for investigating eventual enzyme deficiency to provide rationale for prescription and follow-up of women with polycystic ovary syndrome.

Prevalence of glucose intolerance and metabolic syndrome within one year following delivery of a pregnancy complicated by gestational diabetes

Background

Women with a history of gestational diabetes (GDM) are at risk for development of both overt Type 2 diabetes (T2DM) and cardiovascular disease (CVD) at higher rates and at earlier ages than control women. Current guidelines recommend longitudinal testing of glucose tolerance for women with prior GDM, but no formal assessments of cardiovascular disease are suggested. This study estimated the prevalence of metabolic syndrome in women with GDM in recent pregnancy who were followed for at least 1 year postpartum to quantify their cardiovascular risks.

Methods

This is a retrospective study of women who were diagnosed with GDM in a public hospital and followed for at least 1 year after delivery and who had tests performed at a minimum 4–12 weeks postpartum and 6 and 12 months postpartum. Primary outcomes were prevalence of glucose tolerance abnormalities and metabolic syndrome (MetS) defined by two prevailing sets of diagnostic criteria.

Results

One hundred fifty-one indigent, primarily Latina women who had been diagnosed in their last pregnancy with GDM comprised the study population. At the first visit postpartum, 4.7% were found to have overt diabetes and between 24 and 31% met the criteria for MetS. By the end of 12 months, another 14.5% were diagnosed with overt diabetes, and 38.5% had prediabetes. An additional 12–25% of the woman who had not had MetS at baseline developed MetS by the end of the 1-year follow-up.

Conclusions

Given the high prevalence of MetS among women with recent history of GDM immediately postpartum and its rapid development in the following year, further research is needed to enable the development of practice guidelines that will define appropriate short and long-term evaluations needed to assess risk for cardiovascular disease in these women.

New perspectives on the definition and management of polycystic ovary syndrome

BACKGROUND

There is a growing debate on the opportunity of improving the understanding in the diagnosis and management of polycystic ovary syndrome (PCOS).

OBJECTIVE

This review article summarizes recent research related to the definition of polycystic ovary syndrome (PCOS).

METHODS

Review of the recent literature on the topic.

RESULTS

New ideas on the definition of hyperandrogenism, based on new scientific data and clinical perspectives are presented. (i) In fact, recent studies have pointed out the need to improve the concept of androgen excess by using a larger androgen profile, rather than simply measuring the testosterone blood levels. (ii) Due to the poor correlation between androgen blood levels and the degree of hirsutism, it is proposed that the definition of hyperandrogenism should be based on the presence of blood androgen excess and hirsutism, considered separately, because their pathophysiological mechanisms may differ according to the different phenotypes of PCOS. (iii) The potential role of obesity in favoring the development of PCOS during adolescence is also discussed and the concept of "PCOS secondary to obesity" is developed. (iv) Finally, the need for greater appropriateness in the evaluation of possible coexistence is highlighted, in patients with PCOS who have fasting or glucose-stimulated very high insulin levels, or severe insulin-resistant states.

CONCLUSIONS

Based on what was discussed in this review, we believe that there are margins for modifying some of the current criteria that define the various PCOS phenotypes.

New Biomarkers to Evaluate Hyperandrogenemic Women and Hypogonadal Men

Androgens can have variable effects on men and women. Women may be evaluated for androgen excess for several reasons. Typically, young premenopausal women present with clinical symptoms of hirsutism, alopecia, irregular menses, and/or infertility. The most common cause of these symptoms is polycystic ovary syndrome. After menopause, even though ovaries stop producing estrogen, they continue to produce androgen, and women can have new onset of hirsutism and alopecia. Laboratory evaluation involves measurement of the major ovarian and adrenal androgens. In women, age, phase of the menstrual cycle, menopausal status, obesity, metabolic health, and sex hormone-binding proteins significantly affect total-androgen levels and complicate interpretation. This review will summarize the clinically relevant evaluation of hyperandrogenemia at different life stages in women and highlight pitfalls associated with interpretation of commonly used hormone measurements. Hypogonadism in men is a clinical syndrome characterized by low testosterone and/or low sperm count. Symptoms of hypogonadism include decreased libido, erectile dysfunction, decreased vitality, decreased muscle mass, increased adiposity, depressed mood, osteopenia, and osteoporosis. Hypogonadism is a common disorder in aging men. Hypogonadism is observed rarely in young boys and adolescent men. Based on the defects in testes, hypothalamus, and/or pituitary glands, hypogonadism can be broadly classified as primary, secondary, and mixed hypogonadism. Diagnosis of hypogonadism in men is based on symptoms and laboratory measurement. Biomarkers in use/development for hypogonadism are classified as hormonal, Leydig and Sertoli cell function, semen, genetic/RNA, metabolic, microbiome, and muscle mass-related. These biomarkers are useful for diagnosis of hypogonadism, determination of the type of hypogonadism, identification of the underlying causes, and therapeutic assessment. Measurement of serum testosterone is usually the most important single diagnostic test for male hypogonadism. Patients with primary hypogonadism have low testosterone and increased luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Patients with secondary hypogonadism have low testosterone and low or inappropriately normal LH and FSH. This review provides an overview of hypogonadism in men and a detailed discussion of biomarkers currently in use and in development for diagnosis thereof.

Elevated androstenedione in young adult but not early adolescent prenatally androgenized female rats

Background

Elevated testosterone (T) is routinely reported as a marker of hyperandrogenemia in rodent models for polycystic ovary syndrome (PCOS). In women with PCOS, elevated serum androstenedione (A4) is associated with more severe phenotypes, including a positive correlation with serum T, DHEAS, free androgen index (FAI), LH, and LH/FSH ratio. Furthermore, A4, along with calculated free T and FAI, was identified as one of the best predictors of PCOS in adult women of all ages (18 to > 50 y).

Objective

The objective of this study was to investigate serum A4 levels in early adolescent and young adult prenatally androgenized (PNA) female rats, a model for PCOS.

Methods

Pregnant rats were injected with 5 mg T daily during gestational days 16–19 (PNA rats, experimental group) or an equal volume of vehicle (control group). Female offspring of both groups had tail vein blood drawn for serum analysis at 8 and 16 weeks of age. ELISAs were used to quantify serum A4 and T levels.

Results

Serum A4 and T were elevated in 16-week-old PNA rats compared to controls. There was no significant difference in either hormone at 8 weeks of age.

Conclusions

The PNA rats demonstrated elevated serum A4 and T in young adulthood, as has been observed in women with PCOS, further validating this as a model for PCOS and underscoring the importance of serum A4 elevation as a parameter inherent to PCOS and a rodent model for the disorder. Significant A4 elevation develops between early adolescence and early adulthood in this PNA rat model.

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

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