Prolactin levels in functional hypothalamic amenorrhea: a retrospective case-control study

GnRH ability to release FSH and LH in women with functional hypothalamic amenorrhea: a retrospective cohort study about women with and without polycystic ovarian morphology

Nearly 50% of women with functional hypothalamic amenorrhea (FHA) reveal polycystic ovarian morphology (PCOM), a known risk factor for ovarian hyperstimulation syndrome. However, gonadotropin releasing hormone-agonist (GnRH-a) triggers are not recommended in FHA, since an inadequate endogenous surge in luteinizing hormone (LH) is expected. We aimed to challenge this concept and evaluated LH levels after GnRH stimulation in FHA-women with and without PCOM. In a retrospective cohort study, 82 women with FHA, who underwent a GnRH stimulation test, were included. Thirty-five women revealed PCOM (42.7%). Twenty minutes after GnRH stimulation, there was an increase of serum LH levels in FHA-PCOM (median basal: 2.7 mIU/mL, IQR 1.1-4.6 versus median stimulated: 13.5 mIU/mL, IQR 7.8-21.6, p < 0.001) and in FHA-nonPCOM patients (median basal: 2.5 mIU/mL, IQR 0.5-3.9 versus median stimulated: 5.7 mIU/mL, IQR 2.4-13.9, p < 0.001). Overall, positive correlations (p < 0.001) were found between basal and stimulated LH levels. In FHA-PCOM patients, 42.9% of patients revealed stimulated LH levels >15 mIU/mL, while this was the case in 19.1% of FHA-nonPCOM patients (p = 0.034). In women with FHA-PCOM, ovulation induction with a GnRH-a trigger might be feasible. Future research should focus on the prediction of an adequate response to GnRH triggers in the IVF setting.

Frequency of polycystic ovarian morphology and other ultrasonographic findings in Iranian female athletes

OBJECTIVES

Polycystic ovary morphology and ovarian cysts are frequent and usually asymptomatic in young female individuals. The present study is the first to examine ovarian sonographic findings in asymptomatic female athletes from Iran. This study aimed to evaluate the frequency of such sonographic findings in healthy female athletes on a screening basis.

METHODS

In this cross-sectional observational study, 455 females from 16 provinces of Iran were evaluated by trans-abdominal sonography during their routine pre-participation medical evaluation.

RESULTS

The mean age of participants was 21.8 years (SD 5.3). The mean age at the beginning of exercise was 14.20 years (SD = 4.25). Menarche occurred at 11-20 years with a mean of 13.5 years (SD 1.5). Judokas had the lowest (12.1 years), and football players had the highest menarche age (14.6 years; as compared to 12.8 years in the Iranian female population). In 87.5 % of participants, the sonographic findings were within normal limits. 4.8 % of all examinations revealed polycystic ovary morphology (PCOM), 5.7 % of participants had a simple cyst(s), and 20.8 % of cysts had diameters >49 mm. In those athletes who began regular performance-oriented training before menarche, PCOM was found in only 2.4 %. There was a significant positive linear association between BMI groups and PCOM (p = 0.003), but not for simple cysts. Frequency of PCOM (p < 0.001) as well as ovarian cysts (p = 0.012) were significantly different among studied sport types. There was a significant positive correlation between delayed menarche status and PCOM (p = 0.017). However, no such relationship was found for simple cysts.

CONCLUSIONS

Maintaining a healthy body mass index and beginning regular exercise before menarche may have a preventative effect for polycystic ovary morphology in female athletes.

Re-embarking in ART while still breastfeeding: an unresolved question

Infertile women may request to embark on a new course of Assisted Reproductive Technologies (ART) in pursuit of a second child while still breastfeeding their first child. Breastfeeding is a time of profound hormonal changes that may interfere with ovarian physiology and uterine receptivity. Prolactin and oxytocin can mediate a plethora of potential detrimental effects. However, robust evidence to advise in favor or against ART during breastfeeding is lacking. In this narrative review, we reviewed the literature with the intent to shed light on this neglected issue. Possible adverse effects on ART success emerged for ovulatory mechanisms, folliculogenesis, uterine contractions, uterine peristalsis, and early embryo development. A negative impact of exogeneous hormones on infant health might be considered only for stimulation cycles. Overall, most concerns can be claimed for the clinical setting of ovarian stimulation, followed by the one of embryo transfer in a natural cycle and, finally, by the embryo transfer in a hormone replacement treatment preparation. However, in general, it seems wise to wait for breastfeeding to be discontinue before re-embarking on IVF, also considering that a too short interpregnancy interval may be deleterious to pregnancy outcomes. On the other hand, one must also recognize that available evidence is insufficient to deny access to treatments for women requesting earlier access. These women must be informed regarding the non-fully reassuring evidence.

Functional hypothalamic amenorrhoea and polycystic ovarian morphology: a narrative review about an intriguing association

BACKGROUND

Functional hypothalamic amenorrhoea (FHA) is responsible for 20-35% of all cases of secondary amenorrhoea and, thus, is the second most common cause of secondary amenorrhoea after polycystic ovary syndrome (PCOS). A high number of patients with FHA reveal polycystic ovarian morphology (PCOM) on ultrasound. The combination of amenorrhoea and PCOM can lead to confusion. First, amenorrhoeic women with PCOM fulfil the revised Rotterdam criteria and, thus, can easily be misdiagnosed with PCOS. Moreover, it has been claimed that some women with FHA and concomitant PCOM differ from those without PCOM in terms of endocrine regulation and metabolic traits.

OBJECTIVE AND RATIONALE

The main focus of this article was on studies about FHA, which differentiated between patients with or without PCOM. The aim was to estimate the prevalence of PCOM and to look if it has an impact on pathophysiologic, diagnostic and therapeutic issues as well as on long-term consequences.

SEARCH METHODS

Peer review original and review articles were selected from PubMed searches for this review. Searches were performed using the search terms 'polycystic AND functional hypothalamic amenorrhoea'. The reference lists of publications found were searched for relevant additional studies. The inclusion criteria for publications were: English language, patients' age ≥ 18 years, year of publication >1980, original studies, validated diagnosis of FHA, and validated diagnosis of PCOM using transvaginal ultrasound.

OUTCOMES

The prevalence of PCOM in women with FHA varied from 41.9% to 46.7%, which is higher than in healthy non-PCOS controls. Hypothetically, the high prevalence might be due to a mixture of silent PCOM, as in the general population, and pre-existing PCOS. Several differences in metabolic and hormonal parameters were found between FHA-PCOM and FHA-non-PCOM patients. While oestrogen deficiency is common to both groups of patients, FHA-PCOM patients have a higher BMI, higher levels of anti-Müllerian hormone (AMH) and testosterone, a higher increase in LH in the course of a GnRH test, and lower sex hormone binding globulin (SHBG) levels than FHA-non-PCOM patients. The differential diagnosis between FHA-PCOM and PCOS, especially PCOS phenotype D (PCOM and oligo-/anovulation without hyperandrogenism), can be challenging. Several parameters have been suggested, which are helpful though not absolutely reliable. They include the typical causes for FHA (excessive exercise, energy deficit, and/or psychological stress), the serum levels of LH, testosterone, and SHBG, as well as the progestin challenge test. Whether FHA-PCOM has a different risk profile for long-term consequences concerning patients' metabolic and cardiovascular situation as well as their bone mass, is unclear. Concerning therapeutic aspects, there are only few data about FHA-PCOM compared to FHA-non-PCOM. To treat anovulation, the use of pulsatile GnRH treatment seems to be equally effective in both groups. Similar to FHA-non-PCOM patients, pulsatile GnRH therapy would be more efficient than exogenous gonadotropins in FHA-PCOM patients.

WIDER IMPLICATIONS

Women with FHA-PCOM present a special sub-population of FHA patients. The diagnostic pitfall of FHA-PCOM should be emphasized in clinical guidelines about FHA and PCOS. The fact that almost half of the women with FHA have an ovarian follicle excess (i.e. PCOM) in face of low gonadotropin serum levels suggests that the intra-ovarian regulation of folliculogenesis is subject to individual variations, for unknown reasons, either genetic or epigenetic. Further studies are needed to investigate this hypothesis.

REGISTRATION NUMBER

Not applicable.

A Retrospective Study in Trans Individuals Undergoing Gender Affirming Testosterone Treatment: Can Changes in Prolactin Counteract the Negative Effects on the Lipid Profile?

Background/Objectives: Gender-affirming hormone therapy (GAHT) is known to influence the lipid profiles of trans men and transmasculine individuals. Recent data show that moderate prolactin (PRL) elevations might exert beneficial metabolic effects ("HomeoFIT-PRL model"). The aim of this study is to investigate changes in PRL levels and possible associations between PRL and lipid profiles in this population after a year of GAHT. Methods: In a retrospective cohort study, 97 participants, who received GAHT with testosterone, were included. Blood lipids, PRL, and sex steroid hormone levels were evaluated prior to and at 10-14 months after treatment started. Results: The difference in PRL levels between baseline and follow-up was significant (p = 0.007) with a median difference of +2.3 ng/mL. Concerning blood lipids, the decline in high-density lipoprotein cholesterol (HDL-C) reached statistical significance (median 56 mg/dL versus 50 mg/dL; p < 0.001), and low-density lipoprotein cholesterol (LDL-C) and triglyceride levels increased (p = 0.023 and p = 0.045, respectively). Individuals with a PRL > 25 ng/mL at follow-up (n = 20, 20.6%) revealed increases in total cholesterol and LDL-C significantly less often. Overall, participants frequently displayed unfavorable changes in their lipid profile after 10-14 months of GAHT, as well as a slight but significant increase in PRL. About 20% of patients showed mild-to-moderate hyperprolactinemia (PRL > 25 ng/mL). However, such changes were associated with potentially beneficial dynamics in the lipid profile, at least for triglycerides. Conclusions: These findings seem in line with the HomeoFIT-PRL model suggesting that moderate elevations in PRL levels might exert beneficial metabolic effects. Increases in PRL after testosterone were common.

Changes in Prolactin and Insulin Resistance in PCOS Patients Undergoing Metformin Treatment: A Retrospective Study

Background: Prolactin levels have been shown to influence metabolic outcomes, including insulin resistance. Metformin is known to be beneficial in polycystic ovary syndrome (PCOS) patients. PCOS women might react differently to metformin treatment depending on their baseline prolactin levels. Methods: In this retrospective study, the homeostasis model assessment for insulin resistance (HOMA-IR), prolactin, luteinizing hormone (LH), follicle-stimulating hormone (FSH), the LH:FSH ratio, and total testosterone and sex hormone-binding globulin (SHBG) were measured in 75 obese/overweight women with PCOS and insulin resistance before initiation of metformin treatment and after 6-8 months. Results: At baseline, HOMA-IR was inversely correlated to SHBG (r = -0.408; p < 0.001) and prolactin (r = -0.402; p < 0.001). After 6-8 months of metformin treatment, the LH:FSH ratio and the HOMA-IR declined significantly (p < 0.05). A significant positive correlation could be shown between basal prolactin and the difference in the HOMA-IR (r = 0.233; p = 0.044). Women with lower baseline prolactin (≤14.9 ng/mL) revealed a sharper decline in HOMA-IR (-0.8, IQR -1.0; -0.5 vs. -0.6, IQR -0.8; -0.3; p = 0.049) as well as an increase in prolactin at follow-up (1.6 ng/mL, IQR -0.2;3.8 vs. -1.3, IQR -4.6;3.2; p = 0.003) compared to patients with a baseline prolactin > 14.9 ng/mL. Conclusions: In overweight/obese, insulin-resistant PCOS women, lower baseline prolactin levels are associated with higher baseline HOMA-IR levels as well as with a better response to metformin treatment. More data are necessary to prove these observations in larger populations.

The LH:FSH Ratio in Functional Hypothalamic Amenorrhea: An Observational Study

BACKGROUND

In functional hypothalamic amenorrhea (FHA), luteinizing hormone and follicle-stimulating hormone levels show high interindividual variability, which significantly limits their diagnostic value in differentiating FHA from polycystic ovary syndrome (PCOS). Our aim was to profile the LH:FSH ratio in a large sample of patients with well-defined FHA.

METHODS

This observational study included all consecutive patients with FHA presenting to the Department of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Vienna, between January 2017 and August 2023. The main parameters of interest were the LH level, the FSH level, and the LH:FSH ratio. In a subgroup analysis, we compared the LH:FSH ratio of patients with PCO morphology (PCOM) on ultrasound with that of patients without PCOM.

RESULTS

A total of 135 patients were included. Only a minority of patients revealed FSH and LH levels ≤ 2.0 mIU/mL (13% and 39%, respectively). Most patients (81.5%) had an LH:FSH ratio ≤ 1.0, while a minority (2.2%) had a ratio ≥ 2.1. The LH:FSH ratio was similar in patients with and without PCOM.

CONCLUSION

In a well-defined FHA sample, the LH:FSH ratio was ≤ 1 in most patients. The LH:FSH ratio may prove useful in distinguishing FHA from PCOS but needs further investigation.