Ovarian influence on adrenal androgen secretion in polycystic ovary syndrome

Estrogen Biosynthesis and Signal Transduction in Ovarian Disease

Estrogen mainly binds to estrogen receptors (ERs) to regulate menstrual cycles and reproduction. The expression of ERalpha (ERα), ERbeta (ERβ), and G-protein-coupled estrogen receptor (GPER) mRNA could be detected in ovary, suggesting that they play an important role in estrogen signal transduction in ovary. And many studies have revealed that abnormal expression of estrogen and its receptors is closely related to ovarian disease or malignant tumors. With the continuous development and research of animal models, tissue-specific roles of both ERα and ERβ have been demonstrated in animals, which enable people to have a deeper understanding of the potential role of ER in regulating female reproductive diseases. Nevertheless, our current understanding of ERs expression and function in ovarian disease is, however, incomplete. To elucidate the biological mechanism behind ERs in the ovary, this review will focus on the role of ERα and ERβ in polycystic ovary syndrome (PCOS), ovarian cancer and premature ovarian failure (POF) and discuss the major challenges of existing therapies to provide a reference for the treatment of estrogen target tissue ovarian diseases.

High DHEAS/free testosterone ratio is related to better metabolic parameters in women with PCOS

AIMS

To demonstrate the effects of DHEAS/free testosterone (DHEAS/FT) ratio on metabolic parameters in women with and without polycystic ovary syndrome (PCOS).

METHODS

The data of 91 women with PCOS and 66 women in the control group were collected retrospectively.

RESULTS

DHEAS/FT of the control group was higher than that of PCOS group (684.93 ± 300.54 to 517.2 ± 300.8, p < 0.001). DHEAS/FT correlated with BMI (r = -0.352, p = 0.001), WHR (r = -0.371, p = 0.0219), LDL (r = -0.227, p = 0.031), HOMA-IR (r = -0.36, p = 0.001) and FAI (r = -0.639, p = 0.001) negatively and with HDL (r = 0.344, p = 0.001) and SHBG (r = 0.646, p = 0.001) positively. In the control group, DHEAS/FT correlated with BMI (r = -0.334, p = 0.007), CRP (r = -0.297, p = 0.016) and FAI (r = -0.399, p = 0.01) negatively.

CONCLUSIONS

High DHEAS/FT ratios are related to a better metabolic phenotype in women with PCOS and low levels can be used to detect women with PCOS that have a higher risk of metabolic problems.

Association between Hypoadiponectinemia and Low Serum Concentrations of Calcium and Vitamin D in Women with Polycystic Ovary Syndrome

Objective. To investigate the possible association of calcium and vitamin D deficiency with hypoadiponectinemia in women with PCOS. Subjects and Methods. In this case-control study, 103 PCOS cases and 103 controls included. The concentrations of calcium, 25-OH-vitamin D (25OHD), adiponectin, insulin, glucose, total cholesterol, HDL-cholesterol, triglyceride (TG), and androgens were measured in fasting blood samples. Results. Adiponectin (8.4 ± 2.7 ng/mL versus 13.6 ± 5 ng/mL in control group, P : 0.00), calcium (2 ± 0.1 mmol/L versus 2.55 ± 0.17 mmol/L in controls, P : 0.00), and 25-OH-Vit D (30 ± 2.99 nmol/L versus 43.7 ± 5.2 nmol/L in control group, P : 0.00) levels were decreased in women with PCOS. Subjects with PCOS had higher concentrations of TG (1.4 ± 0.77 mmol/L versus 1.18 ± 0.75 mmol/L in control group, P : 0.019) and dehydroepiandrosterone sulfate (DHEA-S) (10.7 ± 11 mmol/L versus 9.7 ± 10.4, P : 0.02 in control group). There were significant correlations between adiponectin concentrations with calcium (r : 0.78, P : 0.00) and 25OHD levels (r : 0.82, P : 0.00). The association of hypoadiponectinemia and PCOS was not significant considering 25OHD as a confounding factor. Conclusion. The present findings indicate that the association of hypoadiponectinemia with PCOS is dependent on vitamin D. A possible beneficiary effect of vitamin D on the metabolic parameters in PCOS may be suggested.

Steroidogenic alterations and adrenal androgen excess in PCOS

BACKGROUND

This cross-sectional study was undertaken to improve our understanding of the steroidogenic alterations leading to adrenal hyperandrogenism in polycystic ovarian syndrome (PCOS).

METHODS

Two-hundred and thirty-four women with clinical and biochemical features suggestive of PCOS underwent metabolic and hormonal evaluation. We used the androstenedione/DHEAS ratio as a surrogate for the level of ovarian 3betaHSD activity. We then selected the 90th percentile for the ratio in those with elevated DHEAS (>9 micromol/l) as the cut-off level beyond which excess DHEAS production will be minimized by excess ovarian 3betaHSD activity. This cut-off level was at a ratio of 1.5 and all PCOS women were then divided into two groups, the higher (>1.5) being the group with excess ovarian 3betaHSD activity. We hypothesized that women with a high ratio would be unlikely to have DHEAS excess due to the rapid conversion of DHEA to androstenedione. Those with a low ratio (concordant ovarian and adrenal steroidogenesis) could then either have high DHEAS or normal DHEAS, depending on whether CYP17 activity was higher or lower respectively.

RESULTS

Insulin resistance was found to be associated with decreased CYP17 activity while irregular cycles and neuroendocrine dysfunction were determined to be associated with higher ovarian 3betaHSD activity.

CONCLUSION

Adrenal androgen excess in PCOS seems to be related to insulin sensitivity as well as decreased activity of 3betaHSD, the latter being preferentially present in those women with regular cycles or without neuroendocrine dysfunction.

Reduction of dehydroepiandrosterone sulfate synthesis in women with polycystic ovary syndrome by human menopausal gonadotropin but not purified urinary follicle stimulating hormone: a comparative pilot study

We aimed to compare the effects of two different gonadotropins on steroid production in patients with polycystic ovary syndrome (PCOS). The study group comprised 20 infertile patients diagnosed with PCOS who were accepted into in vitro fertilization-embryo transfer and gamete intra-Fallopian transfer programs. Ten patients were consecutively allocated to a purified urinary follicle stimulating hormone (FSH) administration group while the other ten received human menopausal gonadotropin (hMG). All patients were pretreated with a gonadotropin releasing hormone-agonist. The patients were followed by daily vaginal ultrasonography until at least two follicles reached a diameter of 17 mm or an estradiol value of at least 100 pg/ml per follicle. To induce ovulation, human chorionic gonadotropin was given. On the 3rd day of menstruation, serum estradiol, luteinizing hormone (LH), FSH, total testosterone, androstenedione, dehydroepiandrosterone sulfate (DHEAS), insulin-like growth factor-I and insulin were measured. These same parameters were measured again on the day of follicle aspiration in both serum and follicular fluid. In both groups, the serum levels of estradiol and androstenedione were raised significantly, and on aspiration day the serum level of DHEAS was significantly raised in the FSH group but not in the hMG group. Our findings suggest that in PCOS patients exogenous hMG induces a different steroid synthesis pattern compared to pure FSH, hypothetically by reduction of the delta-5 steroid synthesis pathway in the adrenals and/or in the ovary.

Glucose action and adrenocortical biosynthesis in women with polycystic ovary syndrome

OBJECTIVE

To determine if insulin or glucose action plays a role in adrenocortical steroidogenesis in the polycystic ovary syndrome (PCOS).

DESIGN

Prospective cohort study.

SETTING

Academic medical center.

PATIENT(S)

Nine reproductive-aged patients with PCOS and nine age-, race-, and body mass index-matched controls.

MAIN OUTCOME MEASURE(S)

Insulin-modified frequently sampled intravenous glucose tolerance testing and an acute 60-minute ACTH-(1-24) stimulation test. From the glucose tolerance test, glucose and insulin were measured and the insulin sensitivity index, glucose effectiveness, and acute insulin response to glucose were determined. Dehydroepiandrosterone sulfate (DHEAS) basally and 17-hydroxypregnenolone, 17-hydroxyprogesterone, DHEA, androstenedione, and cortisol during ACTH testing at 0 and 60 minute (steroid(0) and steroid(60)) were determined. The net change in steroid during the ACTH test was calculated.

RESULT(S)

The insulin sensitivity index had limited correlation with adrenocortical variables in both groups. In patients with PCOS, glucose effectiveness was positively associated with DHEAS, cortisol(0), cortisol(60), change in cortisol, DHEA(0), DHEA(60), change in DHEA, 17-hydroxyprenenolone(60), change in 17-hydroxypregnenolone, DHEA(0), androstenedione(0), 17-hydroxyprenenolone(0), 17-hydroxyprogesterone(0), 17-hydroxyprenenolone(60), and 17-hydroxyprogesterone(60).

CONCLUSION(S)

Adrenocortical biosynthesis, basally and in response to ACTH, appears to be closely associated with glucose effectiveness in PCOS. A common factor determining both the effectiveness of glucose to control its own production or uptake and adrenocortical biosynthesis may be aberrant in PCOS.

The role of the adrenal cortex in polycystic ovary syndrome

Adrenal androgen excess affects approximately 25% of PCOS patients. The exact etiology of this excess in PCOS patients is unclear. Some evidence that adrenal androgen excess may be a genetic trait. The adrenal androgen response to ACTH is highly individualized, and the relative response seems to be constant over time. In addition, there is a strong familial component to adrenal androgen levels in normal individuals and PCOS patients. It is possible that the tendency to overproduce adrenal androgens is an inherited risk factor for the development of PCOS. Overall, few hyperandrogenic patients actually have isolated deficiencies of 3 beta-hydroxysteroid dehydrogenase, 21-hydroxylase, and 11-hydroxylase. The ovarian hormonal secretion in PCOS can affect adrenal androgen secretion and metabolism, although this factor accounts for only part of this abnormality. More likely, the adrenal androgen excess results from a generalized hyperresponsiveness of the adrenal cortex to ACTH, but without an increase in CRH or ACTH sensitivity. Although glucocorticoid administration may improve the ovulatory function of these patients, the results are modest and cannot be predicted by the circulating androgen levels.

Adrenal dynamic responses to physiologic and pharmacologic adrenocorticotropic hormone stimulation before and after ovarian steroid modulation in women with polycystic ovary syndrome

OBJECTIVE

To test the hypothesis that in women with polycystic ovary syndrome (PCOS), adrenal cytochrome P450c 17alpha activity is different after physiologic vs. pharmacologic ACTH stimulation and that ovarian activity promotes adrenal hyperactivity that is different after physiologic vs. pharmacologic ACTH stimulation.

DESIGN

Prospective controlled pilot study.

SETTING

Reproductive endocrinology unit of an academic medical center.

PATIENT(S)

Six women with PCOS who had adrenal hyperandrogenism were compared with four women with normal ovulation.

INTERVENTION(S)

Adrenal dynamic blood sampling was performed before and after 6 months of GnRH agonist administration.

MAIN OUTCOME MEASURE(S)

Comparison of physiologic and pharmacologic ACTH-stimulated levels of progesterone, 17-hydroxyprogesterone, and androgens before and after ovarian steroid modulation.

RESULT(S)

In women with PCOS, exaggerated responses of androstenedione and 11beta-hydroxyandrostenedione as well as elevated ratios of 17-hydroxyprogesterone to progesterone and of androstenedione to 17-hydroxyprogesterone after physiologic ACTH stimulation did not persist after GnRH-agonist administration. Three of the six women with PCOS had an increased response of androstenedione and a ratio of androstenedione to 17-hydroxyprogesterone that were >2 SD above the mean of those in the women with normal ovulation after pharmacologic ACTH stimulation; this finding persisted after GnRH-agonist administration.

CONCLUSION(S)

In women with PCOS, increases in adrenal androgen sensitivity after physiologic ACTH stimulation reflected in both arms of cytochrome P450c 17alpha activity may be influenced by ovarian activity. However, 17,20-lyase hyperactivity in a subset after pharmacologic ACTH stimulation may be an intrinsic adrenal disorder.

Adrenal androgenic response to 2-hour ACTH stimulation test in women with PCOS

Adrenal function may be abnormal in women with polycystic ovary syndrome (PCOS). This study aims to evaluate adrenal steroid response to the adrenocorticotropic hormone (ACTH) stimulation test and to find out the effect of high serum testosterone levels on adrenal response. We have also investigated any subtle enzyme deficiency by extending blood sampling to 2 h with 30 min intervals following ACTH administration. Twenty-eight women with PCOS and 18 healthy controls without hirsutism and oligomenorrhea were included in the study. After determining their serum basal levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH), testosterone, dehydroepiandrosterone sulfate (DHEAS), 17-hydroxyprogesterone (17-OHP), and progesterone, ACTH stimulation test was performed. The change in serum 17-OHP and the summed rate of change in serum 17-OHP and progesterone levels were estimated and 95th percentile for each value was computed. Women with PCOS were heavier and more hirsute than controls (p < 0.01, p < 0.001, respectively). Serum basal LH, LH:FSH ratio, testosterone (p < 0.001, for all), DHEAS (p < 0.01), and 17-OHP (p < 0.05) were higher in women with PCOS. All of the 17-OHP measurements, including basal and each 30 min interval after the administration of ACTH, were higher in women with PCOS than those of healthy controls (p < 0.05, p < 0.002, p < 0.001, p < 0.015, p < 0.018, respectively). However, the incremental changes in serum 17-OHP30-0, 17-OHP60-0, 17-OHP90-0, 17-OHP120-0, and the summed rate of change in serum 17-OHP and progesterone in women with PCOS were not different from those in healthy controls. The incremental response in terms of serum progesterone, DHEAS, and testosterone levels to the ACTH stimulation test for each 30 min interval was not different in women with PCOS than in healthy controls. We were not able to show any critical value for serum basal testosterone and DHEAS levels that would effect response to ACTH stimulation in terms of 17-OHP levels. We have concluded that extending the duration of blood sampling up to 2 h has no advantage in evaluating adrenal steroid response to ACTH stimulation. Since serum 17-OHP levels remain within normal limits in response to ACTH stimulation, the origin of elevated serum basal 17-OHP levels may be polycystic ovaries. Elevated serum testosterone level does not have any adverse effect on adrenal function. Serum progesterone measurement seems to have no place in the diagnosis of 21-hydroxylase deficiency. Adrenal androgenic response to ACTH stimulation is normal in women with PCOS.

Role of the ovary in the adrenal androgen excess of hyperandrogenic women

OBJECTIVE

To test the hypothesis that ovarian hormones in women with hyperandrogenism alter adrenocortical steroidogenesis.

DESIGN

Combination of two prospective studies.

SETTING

Academic medical centers.

PATIENT(S)

Eighteen hyperandrogenic patients demonstrating hirsutism with either hyperandrogenemia, oligomenorrhea, or both. Eighteen healthy nonhirsute eumenorrheic untreated women served as controls.

INTERVENTIONS

Blood sampling basally and after acute adrenal stimulation with ACTH, before and after 20-24 weeks of leuprolide administration. Nine patients also received 0.625 mg/d of oral conjugated esterified estrogens and 10 mg of medroxyprogesterone acetate days 1-12 of the month (i.e., estrogen replacement therapy [ERT]), whereas the remaining nine did not.

MAIN OUTCOME MEASURE(S)

Before and after the administration of the GnRH agonist (GnRH-a), the basal concentrations of DHEAS; and the levels of androstenedione (A4), DHEA, androstenediol, 11 beta-hydroxyandrostenedione (11-OHA4), and cortisol before and 60 minutes after acute adrenal stimulation, were measured.

RESULT(S)

Levels of DHEAS, androstenediol, and 11-OHA4 decreased by 15%-30%, regardless of whether patients initially had or did not have DHEAS excess. However, only hyperandrogenic patients with elevated levels of DHEAS showed a significant decrease in basal DHEA levels. No statistically significant difference in the response of either androgen to ACTH (1-24) stimulation was noted with ovarian suppression, regardless of initial DHEAS level or use of ERT.

CONCLUSION(S)

We found no evidence that ovarian hormone secretion affected adrenal steroidogenesis, and those women with the highest adrenal androgen levels had the least response to GnRH-a suppression. These findings further support the concept of an intrinsic, and possibly primary, abnormality of adrenocortical steroidogenesis in a subset of hyperandrogenic women that is independent of ovarian abnormalities.

Late endocrine effects of ovarian electrocautery in women with polycystic ovary syndrome

OBJECTIVE

To examine the duration of the changes in endocrine indices produced by ovarian electrocautery in women with polycystic ovary syndrome (PCOS).

DESIGN

Long-term observational study.

SETTING

University hospital.

PATIENT(S)

Infertile women with PCOS.

INTERVENTION(S)

Ovarian electrocautery was performed through the laparoscope. Blood was sampled before the operation and at defined intervals thereafter. After the establishment of regular cycles, sampling was performed 1 week before the menstrual period.

MAIN OUTCOME MEASURE(S)

The patients were observed before and at defined intervals for up to 20 years after ovarian electrocautery. Serum concentrations of hypophyseal and ovarian hormones were determined, including sex hormone-binding globulin (SHBG).

RESULT(S)

There was a clear shift from anovulation to ovulatory cycles and a significant decrease in androgens and gonadotropins. The concentration of SHBG increased. These effects lasted for many years; after 18-20 years, two thirds of the women were still ovulating.

CONCLUSION(S)

Ovarian electrocautery for PCOS normalizes ovarian function, including androgen production, and the results seem to be stable for 18-20 years.

Lack of an ovarian function influence on the increased adrenal androgen secretion present in women with functional ovarian hyperandrogenism

OBJECTIVE

To evaluate whether ovarian function might have an influence on the adrenal hyperandrogenism present in patients with functional ovarian hyperandrogenism.

DESIGN

Controlled clinical study.

SETTING

Tertiary institutional hospital.

PATIENT(S)

Twenty-nine hirsute women with functional ovarian hyperandrogenism and 12 normal controls.

INTERVENTION(S)

The ACTH and GnRH tests were performed before and during triptorelin-induced ovarian suppression in patients. The normal women served as controls for the ACTH test.

MAIN OUTCOME MEASURE(S)

Basal and ACTH-stimulated steroid values.

RESULT(S)

All patients presented elevated T and free androgen index, which normalized after triptorelin. Patients with functional ovarian hyperandrogenism and adrenal hyperandrogenism, defined by elevated basal DHEAS (n = 10), presented enhanced delta 4-17, 20-lyase activity, which persisted during ovarian suppression. delta 4-17,20-lyase activity was normal in the functional ovarian hyperandrogenism patients without adrenal hyperandrogenism (n = 19). No correlation was observed between the any of the indexes of the adrenal enzymatic activities evaluated and plasma E2 or T.

CONCLUSION(S)

Increased adrenal delta 4-17,20-lyase activity is present in functional ovarian hyperandrogenism women with adrenal hyperandrogenism. No influence of the excess ovarian androgens or estrogens was found on any of the adrenal enzymatic pathways explored.

Polycystic ovarian disease: current insights into an old problem

Recent studies have led to significant advances in the understanding of the pathogenesis of polycystic ovary syndrome (PCOS), as well as to improvements in the treatment of the commonly associated symptoms. New data continue to implicate etiologic alterations in the hypothalamic-pituitary axis, beginning in the perimenarcheal period, as well as derangements in insulin and insulin-like growth factor metabolism. Current observations also support a role for an increase in adrenal androgen production and an increase in adrenal sensitivity to trophic hormone stimulation in the development of PCOS. Therapeutic regimens for those patients unsuccessfully treated with traditional approaches have been further validated, including the use of flutamide or gonadotropin-releasing hormone agonist-steroidal "add back" for the treatment of hirsutism. Novel approaches to the treatment of infertility are likewise discussed.

Clinical and hormonal effects of gonadotropin-releasing hormone agonist plus an oral contraceptive in severely hirsute patients with polycystic ovary disease

OBJECTIVE

To evaluate the therapeutic effects of a GnRH agonist (GnRH-a), leuprolide acetate (LA) plus a pill containing ethinyl E2 plus cyproterone acetate (CPA) in a group of women with severe hirsutism who were unresponsive to oral contraceptive (OC) therapy.

DESIGN

Twenty-four patients suffering from severe hirsutism secondary to polycystic ovary disease (PCOD) were treated for 12 months with 3.75 mg IM LA every 28 days in association with 0.035 mg/d ethinyl E2 plus 2 mg/d CPA (Diane; Schering, Berlin, Germany) for 21 d/mo.

SETTING

Patients were recruited in the Institute of Obstetrics and Gynecology, St. Bambino Hospital, University of Catania, Catania, Italy. Hormonal assays were performed in the Hormone Laboratories of St. Bambino Hospital, University of Catania, Catania, Italy.

MAIN OUTCOME MEASURES

Every 3 months the hirsutism score was evaluated. Mean serum concentrations of LH, FSH, E2, total and free T, androstenedione (A), sex hormone-binding globulin (SHBG), and DHEAS were determined. Every 6 months a vaginal ultrasound examination was performed.

RESULTS

In all patients after 6 and 12 months of treatment with LA plus OC, the hirsutism score improved significantly. Serum levels of LH, FSH, E2, total and free T, A, and DHEAS decreased significantly, whereas SHBG showed a marked increase. A significant reduction in the ovarian size was observed.

CONCLUSION

Gonadotropin-releasing hormone agonist, associated with a pill containing CPA, reduced the hirsutism in severely affected women with PCOD who are unresponsive to OC treatment alone.