Functional ovarian hyperandrogenism and polycystic ovary syndrome in prepubertal girls with obesity and/or premature pubarche

Evaluation of Glucose Metabolism and Cardiovascular Risk Factors in Prepubertal Girls with Premature Pubarche

OBJECTIVE

Premature pubarche (PP) is a risk factor for metabolic syndrome (MS). The aim was to evaluate if glucose-insulin metabolism, cardiovascular risk factors, familial cardiovascular risk factors (FCVRF) created a risk for insulin resistance (IR) and if PP was a risk factor alone for MS in normal weight prepubertal girls with PP.

METHODS

Thirty-five prepubertal, non-obese girls with PP with normal birth weight and 35 age-matched control girls were evaluated for FCVRF, anthropometric measurements, blood pressure, lipid profile, fasting blood glucose-insulin, hemoglobin A1c (HbA1c), sex hormone binding globulin (SHBG), leptin, adiponectin, tumor necrosis factor-alpha (TNF-α), androgen levels, and bone age. Oral glucose tolerance test was performed in PP participants. Homeostasis model of assessment of IR (HOMA-IR), fasting glucose/insulin ratio, atherogenic index (AI), and free androgen index (FAI) were calculated. PP participants were further stratified by FCVRF.

RESULTS

HbA1c, lipid profile, testosterone, leptin, adiponectin, TNF-α, HOMA-IR, glucose/insulin ratio, AI, and fasting glucose-insulin levels were similar. In the PP group FAI was significantly higher (p=0.001), whereas SHBG was significantly lower (p=0.010) than the control group. Leptin levels of FCVRF+ and FCVRF- subgroups were 15.2±9.1 and 9.7±7.2 ng/mL, respectively and the difference was significant (p=0.016).

CONCLUSION

As PP does not appear to be a risk factor alone for impaired glucose metabolism and IR in prepubertal non-obese girls with normal birth weight, it is our opinion that it is unnecessary to examine in detail such cases before puberty. Low SHBG levels in the PP group and high leptin levels in FCVRF+ subgroup might suggest that these may be predictive for MS in the future.

11-Oxygenated androgens in health and disease

The adrenal gland is a source of sex steroid precursors, and its activity is particularly relevant during fetal development and adrenarche. Following puberty, the synthesis of androgens by the adrenal gland has been considered of little physiologic importance. Dehydroepiandrosterone (DHEA) and its sulfate, DHEAS, are the major adrenal androgen precursors, but they are biologically inactive. The second most abundant unconjugated androgen produced by the human adrenals is 11β-hydroxyandrostenedione (11OHA4). 11-Ketotestosterone, a downstream metabolite of 11OHA4 (which is mostly produced in peripheral tissues), and its 5α-reduced product, 11-ketodihydrotestosterone, are bioactive androgens, with potencies equivalent to those of testosterone and dihydrotestosterone. These adrenal-derived androgens all share an oxygen atom on carbon 11, so we have collectively termed them 11-oxyandrogens. Over the past decade, these androgens have emerged as major components of several disorders of androgen excess, such as congenital adrenal hyperplasia, premature adrenarche and polycystic ovary syndrome, as well as in androgen-dependent tumours, such as castration-resistant prostate cancer. Moreover, in contrast to the more extensively studied, traditional androgens, circulating concentrations of 11-oxyandrogens do not demonstrate an age-dependent decline. This Review focuses on the rapidly expanding knowledge regarding the implications of 11-oxyandrogens in human physiology and disease.

11-Ketotestosterone Is the Dominant Circulating Bioactive Androgen During Normal and Premature Adrenarche

CONTEXT

Adrenarche refers to the rise of dehydroepiandrosterone sulfate (DHEA-S) associated with the development of a functional adrenal zona reticularis. Clinical features of adrenarche include onset of body odor, axillary hair, and pubic hair, which reflect increased androgen action. An early rise in adrenal androgens, or premature adrenarche (PremA), is a risk factor for adverse metabolic profiles in adolescence and adulthood. The bioactive androgens associated with adrenarche and PremA remain poorly understood. The adrenal gland is a potential source of testosterone (T) and the 11-oxygenated derivatives 11β-hydroxytestosterone (11OHT) and 11-ketotestosterone (11KT).

OBJECTIVE

The objective of this study was to characterize the adrenal androgen biome contributing to adrenarche and PremA.

PARTICIPANTS AND METHODS

With the use of mass spectrometry, 19 steroids including the 11-oxygenated derivatives of T were measured in sera obtained from girls with PremA (n = 37; 4 to 7 years) and age-matched girls (n = 83; 4 to 10 years).

RESULTS

In reference population girls, dehydroepiandrosterone, DHEA-S, androstenediol-3-sulfate, T, and 11KT all increased at the onset of adrenarche (6 to 8 years) and beyond (9 to 10 years) (P < 0.05 vs younger subjects 4 to 5 years). T, 11OHT, and 11KT were further elevated in PremA vs age-matched girls (P < 0.001). Circulating concentrations of 11KT during adrenarche and PremA exceeded those of T and 11OHT (11KT > T ≥ 11OHT). Androgen receptor activity and nuclear translocation studies demonstrated that 11KT is a potent androgen similar to T.

CONCLUSIONS

Our findings suggest that 11KT is the dominant bioactive androgen in children during adrenarche and PremA. Its androgenic capacity suggests that it may be responsible for the phenotypic changes seen in these phenomena.

Correlations of Insulin Resistance and Serum Testosterone Levels with LH:FSH Ratio and Oxidative Stress in Women with Functional Ovarian Hyperandrogenism

Functional ovarian hyperandrogenism (FOH) is a form of polycystic ovary syndrome (PCOS) characterized by elevated circulating levels of androgens derived from the ovary. Insulin resistance (IR) is the most common etiological factor in women with FOH. IR causes the generation of increased oxidative stress (OS) and diminished antioxidant status. OS is directly correlated with both IR and testosterone levels, which consequently contribute to endocrine and biochemical alterations in FOH women. In the current study, elevations in total testosterone, free testosterone and luteinizing hormone (LH) levels accompanied by a decrease in follicle stimulating hormone (FSH) level leading to higher LH:FSH ratio were the prominent endocrine changes observed in women with FOH. A significant increase in fasting blood levels of glucose and insulin, as well as an elevated IR were also seen in FOH women, as compared to their age matched controls. Women with FOH have higher pro-oxidant and lower anti-oxidant levels in blood than their age matched controls. In FOH women, elevations in LH:FSH ratio and OS are correlated more with hyperandrogenemia than with IR. Of the androgens, free rather than total testosterone has better positive correlations with elevated LH:FSH ratio and OS, and hence, the former is a better predictive marker for the development of biochemical PCOS in women with FOH.

Current status of childhood obesity and its associated morbidities in Turkey

As a transitional society, rapid changes have occurred in the social, economic, nutritional and lifestyle aspects of the Turkish population over the last three decades. As a result, the prevalence of overweight and obesity has shown a dramatic increase in the adult Turkish population, reaching figures as high as 30-40%. Although there is no nationwide figure regarding the prevalence of overweight and obesity in Turkish children and adolescents, several local studies performed between 2000 and 2010 in different regions of the country have demonstrated varying prevalence rates of 10.3%-17.6% and 1.9%-7.8% for overweight and obesity, respectively, in children aged 6-16 years. The differences in the figures obtained in these regions are thought to be due to variations in the subject sampling. The figures appear to vary depending on residential (urban vs. rural) and economic conditions. Belonging to a high-income family, living in a large city, having obese parents, being of high birth weight, consuming sugar-sweetened beverages (soft drinks, juice drinks, etc.), and spending time in front of TV and PC were identified as the most common risk factors. Complications and co-morbidities of obesity have also started to appear in our pediatric population. Metabolic syndrome, diagnosed according to the International Diabetes Federation criteria, was found in 2.3% of Turkish schoolchildren aged 10-19 years. This rate was 28% in obese children. Preventive public measures have started to be implemented by the State and other bodies to control the rising trends in obesity.

Adrenal function during childhood and puberty in daughters of women with polycystic ovary syndrome

CONTEXT

In some patients, PCOS may develop as a consequence of an exaggerated adrenarche during pubertal development.

OBJECTIVE

The aim of the study was to assess adrenal function during childhood and pubertal development in daughters of women with PCOS (PCOSd).

DESIGN

We included 98 PCOSd [64 during childhood (ages 4-8 yr) and 34 during the peripubertal period (ages 9-13 yr)] and 51 daughters of control women (Cd) [30 during childhood and 21 during the peripubertal period]. In both groups, an acute ACTH-(1-24) stimulation test (0.25 mg) and an oral glucose tolerance test were performed. Bone age and serum concentrations of cortisol, androstenedione, 17-hydroxyprogesterone, dehydroepiandrosterone (DHEA), DHEA sulfate (DHEAS), glucose, and insulin were determined.

RESULTS

PCOSd and Cd were similar in age and body mass index. During the peripubertal period, basal and poststimulated DHEAS concentrations were higher in PCOSd compared to Cd. Among PCOSd, 12.5% of girls in childhood and 32.4% in peripuberty presented biochemical evidence of exaggerated adrenarche. Stimulated insulin was higher in PCOSd compared to Cd during childhood (P = 0.03) and peripuberty (P = 0.03). An advancement of 8 months between bone and chronological age was observed in peripubertal PCOSd compared to Cd.

CONCLUSIONS

In PCOSd, basal and stimulated DHEAS concentrations were higher during the onset of puberty. Around 30% of the PCOSd demonstrated an exacerbated adrenarche, which may reflect increased P450c17 activity. In addition, a modest advance in bone age was observed, probably secondary to the hyperinsulinemia and/or adrenal hyperandrogenism.