Serotonergic changes in specific areas of rat brain associated with activity--stress gastric lesions

Disruption of running activity rhythm following restricted feeding in female mice: Preventive effects of antidepressants

Biological rhythms are critical in the etiology of mood disorders; therefore, effective mood disorder treatments should address rhythm disturbances. Among the variables synchronized with the light-dark cycle, spontaneous activity in rodents is useful for investigating circadian rhythms. However, previous studies have focused only on the increase of wheel-running activity under restricted feeding conditions, while little information is available on circadian rhythm of running activity. In this study, chronometrical analysis was used to assess whether circadian rhythms during wheel-running are altered by restricted feeding and affected by antidepressant drugs. Wheel revolutions were automatically recorded and analyzed using cosinor-rhythmometry in 8-week old ICR albino mice. When feeding was restricted to 1 h per day (21:00-22:00), wheel-running rhythms were reliably disrupted. Female mice exhibited marked alterations in the pattern and extent of wheel-running beginning on day 1. Subchronic treatment with imipramine or paroxetine, as well as tandospirone and (-)-DOI, prevented wheel-running rhythm disruption. Thus, altering the circadian activity rhythms of female mice on a 1-h feeding schedule may be useful for investigating disturbances in biological rhythms.

Neurobiology of stress-induced hyperalgesia

The intensity and severity of perceived pain does not correlate consistently with the degree of peripheral or central nervous system tissue damage or with the intensity of primary afferent or spinal nociceptive neurone activity. In this respect, the modulation of pain by emotion and context is now widely recognized. In particular, stress, fear and anxiety exert potent, but complex, modulatory influences on pain. Stress can either suppress pain (stress-induced analgesia) or exacerbate it (stress-induced hyperalgesia; SIH) depending on the nature, duration and intensity of the stressor. Herein, we review the methods and models used to study the phenomenon of SIH in rodents and humans and then present a detailed discussion of our current understanding of neural substrates and neurobiological mechanisms. The review provides perspectives and challenges for the current and future treatment of pain and the co-morbidity of pain with stress-related psychiatric disorders including anxiety and depression.

The effects of palm vitamin E on stress hormone levels and gastric lesions in stress-induced rats

INTRODUCTION

This study examines the effects of palm vitamin E (PVE) or α-tocopherol (α-TF) supplementation on adrenocorticotropin hormone (ACTH), corticosterone and gastric lesions in rats exposed to water-immersion restraint stress (WIRS).

MATERIAL AND METHODS

Sixty male Sprague-Dawley rats (200-250 g) were divided into three groups. Group I: 20 rats as a control group were given a normal diet. Group II: 20 rats received oral supplementation of PVE at 60 mg/kg body weight. Group III: 20 rats received oral supplementation of α-TF at 60 mg/kg body weight. After the treatment period of 28 days, each group was further subdivided into two groups: 10 rats not exposed to stress, and the other 10 rats subjected to WIRS for 3.5 h. Blood samples were taken to measure the ACTH and corticosterone levels. The rats were then sacrificed and the stomach excised and opened along the greater curvature and examined for lesions.

RESULTS

Rats exposed to WIRS had lesions in their stomach mucosa. Our findings showed that dietary supplementation of PVE or α-TF was able to reduce gastric lesions significantly in comparison to the stressed controls. The WIRS increased plasma ACTH and corticosterone significantly. Palm vitamin E and α-TF treatments reduced these parameters significantly compared to the stressed controls.

CONCLUSIONS

Supplementation with either PVE or α-TF reduces the formation of gastric lesions, probably by inhibiting the elevation of ACTH and corticosterone levels induced by stress.

The selective serotonin reuptake inhibitor fluvoxamine suppresses post-feeding hyperactivity induced by food restriction in rats

Previous studies demonstrated that rats allowed access to running wheel with food restriction schedules run excessively. This hyperactivity consisted of a pre-feeding activity (an increase in running activity before the feeding time, also termed food-anticipatory activity: FAA) and a post-feeding activity (an increase in running activity after the feeding time, succeeding activity: SA). Here we evaluated the effect of fluvoxamine, a selective serotonin reuptake inhibitor, on food restriction-induced hyperactivity in rats. Furthermore, the effect of fluvoxamine on each of the FAA and the SA was also investigated. Rats were individually housed in a running-wheel cage under food restriction for 3 h per day, and running activity was measured for 7 consecutive days. This restricted feeding significantly increased the running activity and decreased body weight. Simultaneous administration of fluvoxamine (50 mg/kg/day, p.o.) for 7 days suppressed the increase in running activity (P<0.05) with no modification of the decrease in body weight or food intake. Analysis of each activity revealed that fluvoxamine's efficacy was observed only in the SA (p<0.01). These results suggest that repeated treatment with fluvoxamine attenuates the hyperactivity, which is exclusively dependent on the substantial reduction in the SA.

Telemetry provides new insights into entrainment of activity wheel circadian rhythms and the role of body temperature in the development of ulcers in the activity-stress paradigm

Two methods of monitoring the circadian rhythm of activity in rodents: (1) an activity wheel cage, which detects the number of wheel revolutions, and (2) an internal radio transmitter, which records gross motor activity (GMA) of the animal, were compared in both normal circadian cycles and during the development of activity-stress ulcers. Rats were implanted with a biotelemetry transmitter that detected GMA and body temperature (BT) and placed in activity wheel cages. A 12 hour/12 hour light/dark cycle was maintained throughout the experiment. Subjects were subdivided into two groups: (1) unlimited access to activity wheel (AW) cages and (2) locked activity wheel (LW) cages. Following an ad-libitum habituation period, animals were allowed food access for 1 hour/day during the light. In the habituation period, the animals showed higher GMA and BT during the dark phase when housed in AW cages than in LW cages. Both GMA and number of wheel revolutions increased dramatically after the onset of food restriction for the AW animals. There was a deleterious drop in BT in AW animals as the food-restricted period continued and a significant correlation existed between severity of ulcerations and BT. The findings of this experiment demonstrate that the activity wheel imposes an alternation of the circadian cycle, which, in turn, influences rhythmicity through reentrainment. Additionally, in the activity-stress paradigm, a significant drop in BT correlates with severity of ulcerations. A disrupted circadian cycle, involving hypothermia, is proposed as the mechanism underlying the demise of animals in the activity-stress paradigm.

Long-lasting delayed hyperalgesia after subchronic swim stress

Rats subjected to an inescapable subchronic stress, consisting of 10-20 min of forced swimming for 3 days, showed a thermal hyperalgesia and an enhanced nociceptive behavior to the subcutaneous administration of formalin 24 and 48 h, respectively, after the last swim session. Hyperalgesia to thermal and chemical stimulants was still present 8 and 9 days after the last swim session, respectively. Chemical, but not thermal, nociception was negatively correlated with the swim effort or struggle times during the last swim session. The serotonin-selective reuptake inhibitors clomipramine (2.5 mg/kg/day, i.p., started 3 or 7 days before stress) and fluoxetine (0.25 mg/kg/day, i.p., started 7 days before stress), or serotonin precursor tryptophan (3 mg/kg/day, i.p., 24 h before each swim stress) blocked the development of both the thermal and the chemical hyperalgesia and increased swim effort times compared to vehicle-treated rats. These treatments did not affect nociceptive responses in control rats subjected to sham swimming. These findings suggest that repeated stress can produce a long-lasting increase in pain sensitivity to both phasic or tonic noxious stimuli by diminishing central serotonin activity. This model may help elucidate the underlying neural mechanisms that mediate the effects of repeated stress on pain sensitivity and affective states.

Exercise and brain neurotransmission

Physical exercise influences the central dopaminergic, noradrenergic and serotonergic systems. A number of studies have examined brain noradrenaline (norepinephrine), serotonin (5-hydroxytryptamine; 5-HT) and dopamine with exercise. Although there are great discrepancies in experimental protocols, the results indicate that there is evidence in favour of changes in synthesis and metabolism of monoamines during exercise. There is a possibility that the interactions between brain neurotransmitters and their specific receptors could play a role in the onset of fatigue during prolonged exercise. The data on the effects of branched chain amino acid (BCAA) supplementation and 'central fatigue' seem to be conflicting, although recent studies suggest that BCAA supplementation has no influence on endurance performance. There are numerous levels at which central neurotransmitters can affect motor behaviour; from sensory perception, and sensory-motor integration, to motor effector mechanisms. However, the crucial point is whether or not the changes in neurotransmitter levels trigger or reflect changes in monoamine release. Until recently most studies were done on homogenised tissue, which gives no indication of the dynamic release of neurotransmitters in the extracellular space of living organisms. Recently, new techniques such as microdialysis are voltammetry were introduced to measure in vivo release of neurotransmitters. Microdialysis can collect virtually any substance from the brain of a freely moving animal with a limited amount of tissue trauma. This method allows measurement of local neurotransmitter release during on-going behavioural changes such as exercise. The results of the first studies using these methods indicate that the release of most neurotransmitters is influenced by exercise. Although the few studies that have been published to date show some discrepancies, we feel that these recently developed and more sophisticated in vivo methods will improve our insight into the relationship between the monoamine and other transmitters during exercise. Continued quantitative and qualitative research needs to be conducted so that a further understanding of the effects of exercise on brain neurotransmission can be gained.

Caudal raphe-dorsal vagal complex peptidergic projections: role in gastric vagal control

Subpopulations of raphe pallidus (Rpa) and raphe obscurus (Rob) neurons containing TRH, serotonin (5-HT), and substance P contribute projections to the dorsal vagal complex (DVC). Activation of Rpa and Rob neurons induces a vagal cholinergic-dependent stimulation of gastric secretory and motor function and modulates resistance of the gastric mucosa to gastric injury in rats and cats. The caudal raphe nuclei-DVC pathways containing TRH/5-HT are involved in mediating cold-induced vagal stimulation of gastric function and erosion formation. These results suggest that Rpa/Rob-DVC projections containing TRH/5-HT may be an important pathways in the medullary regulation of vagal activity to the viscera.

Potentiating interactions between medullary serotonin and thyrotropin-releasing hormone-induced gastric erosions in rats

The central interaction between 5-HT and exogenous and endogenous thyrotropin-releasing hormone (TRH)-induced gastric lesions was investigated in conscious rats. Intracisternal injection (i.c.) of the TRH analog, RX 77368, (2.5 nmol) in indomethacin (2 mg/kg, i.p.)-treated rats produced 1.4 +/- 0.1% of gastric corpus mucosal lesions which were aggravated by 30 and 208% by simultaneous i.c. injection 5-HT at 10 and 100 nmol, respectively, whereas i.v. 5-HT (100 nmol) had no effect. The 5-HT2/1c antagonist, ketanserin, given i.c. at 10 or 100 nmol reduced by 44 and 76%, respectively, cold restraint stress-induced 3.4 +/- 0.6% gastric lesions in indomethacin-pretreated rats whereas, when given i.v. (100 nmol), it was inactive. Ketanserin or 5-HT (100 nmol, i.c.) alone did not modify the gastric mucosa. The present data suggest a potentiating interaction between endogenous 5-HT and TRH which has implication in the understanding of medullary mechanisms involved in gastric lesion formation induced by cold restraint.

Effects of amygdaloid lesions on gastric erosion formation during exposure to activity-stress

To examine the role of the amygdala in the production of gastric ulcers induced by activity-stress, electrolytic lesions were placed in the centromedial (CENT) and medial (MED) amygdaloid nuclei, as well as in the intra-amygdaloid division of the bed nucleus of the stria terminalis (BNST). As compared to sham-operated controls (CONT), gastric ulceration was attenuated in rats with CENT lesions and exacerbated in rats with lesions located in the BNST or MED. Wheel running did not differ significantly between control animals and lesioned rats, but did differ within lesioned groups. Rats with MED lesions ran more than rats with CENT or BNST lesions. Results support the view that the integrity of the centromedial amygdala is critical for the maintenance of the viscera and demonstrate that neurogenic factors contribute to the development of gastric erosions during exposure to activity-stress.

Response suppression induced with selective 5-HT agonists can be differentially blocked with LY53857 in an animal model of depression

Studies from this laboratory have demonstrated that administration of the selective 5-HT2/1C antagonist LY53857 can block 5-HTP-induced response suppression. To further investigate the serotonergic mechanisms involved in this effect, we decided to test the capacity of LY53857 to block response suppression induced with two selective 5-HT agonists. After a 15 minute baseline period, rats trained to press a lever for milk reinforcement on a VI 1' schedule were given IP injections of 1.0 mg/kg DOI, or 1.0 mg/kg 8-OH-DPAT to induce response suppression. Subsequently, rats were injected with 1.0 mg/kg LY53857 1 hour prior to DOI- or 8-OH-DPAT-induced response suppression. Preinjections with LY53857 resulted in a 100% blockade of DOI-induced response suppression whereas the same dose did not block response suppression induced with 8-OH-DPAT. These results indicate that the 5-HTP-induced response suppression shows some pharmacological similarity to DOI-induced response suppression and may be mediated through 5-HT2 and/or 5-HT1C receptors.

Differential effect of 5-hydroxytryptophan on approach and avoidance behavior in rats

The current hypersensitive postsynaptic serotonin receptor theory of depression developed and expanded by Aprison and Hingtgen was based on an animal model of behavior in which food-reinforced approach behavior was suppressed following 5-hydroxytryptophan (5-HTP) administration. In this paper, data are presented to show that when the same animal is taught to emit, alternatingly, approach and avoidance behavior, and the serotonin precursor, 5-HTP, is administered, only the approach behavior is affected. Adult, male Wistar rats were trained on Sidman avoidance (RS20:SS10) and food-reinforced approach (VI 1) schedules. During the first part of this study, rats received separately 50-min sessions for approach and avoidance responding. For the second part, both schedules were given in the same experimental chamber. In the third part, 10-min alternating approach and avoidance components were combined in the same 50-min sessions. Significant behavioral suppression of approach responding was observed following administration of L-5-HTP (50 mg/kg IP), as well as after D,L-5-HTP (25 and 50 mg/kg IP) in a dose-dependent relationship, whereas no significant effect was seen for Sidman avoidance responding during this type of session. These results support the role of serotonin in food-reinforced approach behavior and suggest that suppression of Sidman avoidance behavior may be mediated by other neurotransmitter systems.

Multiple neurochemical and behavioral consequences of stressors: implications for depression

Animal models of clinical depression have frequently focused on the contribution of stressors to the induction of behavioral impairments and pharmacological intervention in the amelioration of these disturbances. Stressors provoke various behavioral disturbances and influence the activity of central neurotransmitters implicated in depression. It is our contention that those variables which favor the provocation of amine depletions or prevent the development of a neurochemical adaptation will increase vulnerability to behavioral disturbances. It is essential to consider, however, that marked interindividual and interstrain differences exist in the behavioral and neurochemical response to stressors, and in the effectiveness of antidepressant treatments.

Activity-wheel stress and serotonergic hypersensitivity in rats

Adult male Wistar rats were subjected to activity wheel stress: unlimited access to an activity wheel for up to twelve days and food for 30 to 60 min each day. Each treated rat was paired with a control, the latter being housed in home cages and given sufficient food to maintain a weight similar to the stressed partner. All rats were previously trained on a variable interval schedule for milk reinforcement. When the activity of the stressed rat increased rapidly then decreased suddenly, the pair was decapitated for biochemical analysis. Levels of the serotonin metabolite, 5-hydroxyindoleacetic acid, decreased by 50%, and the Bmax for ketanserin binding increased by 19% in frontal cortical homogenates from the stressed rats when compared to controls. These data support the concept that stress increases the sensitivity of central serotonin receptors.

i.r. Beta-endorphin, corticosterone, cholesterol and triglyceride concentrations in rat plasma after stress, cingulotomy or both

Plasma i.r. beta-endorphin, corticosterone, cholesterol and triglyceride concentrations were determined in male Sprague-Dawley rats after exposure to running or swimming stressors or after surgical ablation of the cingulum bundle. While cingulotomy alone altered only the plasma triglyceride concentrations, the combination of cingulotomy plus running stress significantly increased plasma i.r. beta-endorphin and triglyceride concentrations above those seen in animals receiving only a running stress. Triglyceride concentrations in cingulotomy plus swimming stress were significantly elevated above those in animals receiving a severe stress only. While the exposure to running and swimming increased plasma beta-endorphin significantly above control levels, plasma corticosterone was not affected by these stressors. Changes in plasma cholesterol and triglycerides were also differentially affected by cingulotomy or stress exposure. These results indicate that various stress hormones are affected differentially by exposure to various experimental procedures which are employed as stressors.

Response suppression in rats after bilateral microinjection of 5-hydroxytryptophan in lateral hypothalamus

Studies using the 5-hydroxytryptophan (5-HTP) animal model of depression have led to the development of the hypersensitive postsynaptic serotonin receptor theory of depression. To demonstrate more clearly that the 5-HTP-induced suppression is a centrally mediated phenomenon, rats were implanted with bilateral cannulae in the lateral hypothalamus and received microinjections of D,L-5-HTP (100-500 ng) 15 min after the start of a VI operant session (milk reinforcement). Significant decreases in responding were observed that were comparable to those obtained after a systemic injection of 50 mg/kg D,L-5-HTP. Rats receiving a microinjection of 5-HTP in the posterior hypothalamus did not exhibit a behavioral effect. Rats working on shock-avoidance schedules did not demonstrate response suppression following microinjection of 5-HTP into the lateral hypothalamus, which is the same result as that following systemic 5-HTP administration. These data support the important role previously assigned to central 5-HT mechanisms in the 5-HTP animal model of depression.

Neuroendocrine correlates of sustained stress: the activity-stress paradigm

Rats sacrificed after 4 days in the activity-stress paradigm or after 4 days of food restriction had significantly elevated levels of plasma corticosterone as compared to control rats. The approximately 5 fold increase in corticosterone in the stressed treatment groups was consistently found in all experiments. ACTH levels were elevated in activity-stress and food-restricted groups in some experiments but these increases were not statistically significant. Prolactin levels were significantly elevated in food-restricted group rats as compared to controls or activity-stress group animals in one experiment but this finding was not repeated in further experiments. In a second series of experiments, rats from activity-stressed and food-restricted treatment groups and controls were exposed to an acute stressor for 15 min prior to sacrifice to assess the effects of prior sustained stress on hormonal responses to an acute stressor. Exposure to 15 min of immobilization or intermittent footshock immediately prior to sacrifice increased plasma levels of corticosterone, ACTH and prolactin in control, food-restricted and activity-stressed rats. Generally, hormonal responses to the acute stress were similar in all treatment groups. However, in two experiments where the resting levels of corticosterone were especially elevated in the activity-stress group, the acute stress-induced rise in corticosterone was less than that seen for the other two treatment groups. In another experiment, administration of dexamethasone suppressed acute stress-evoked levels of ACTH and corticosterone in control, activity-stressed and food-restricted rats. Thus, rats exposed to 4 days of sustained stress were found to have consistently elevated resting levels of corticosterone.(ABSTRACT TRUNCATED AT 250 WORDS)

The phenomenon of stress: concepts and mechanisms associated with stress-induced responses of the neuroendocrine system

'Stress', 'stressors' and the 'stress response' are terms which represent concepts rather than being precisely definable. No single theory of stress has been universally accepted. Selye's General Adaptation Syndrome of stress remains the primary theory for the basis of stress research in food-producing animals; however, other concepts and theories have been developed. This paper reviews current theories and suggests that the complexity of research on stress in food-producing animals can be attributed to the lack of concrete theories and concepts regarding identifiable stressors, the endocrine responses stimulated by potential stressors and the complex and integrated biological changes in the neuro-endocrine system resulting from exposure to hypothesized stressors.

Neurochemical and behavioral consequences of mild, uncontrollable shock: effects of PCPA

The present experiments examined the role of the serotonergic system in the behavioral deficit produced by uncontrollable shock. In Experiment 1: Establishment of model, the behavioral potential of the Sprague-Dawley rat was defined. When exposed to mild uncontrollable stress such as a 0.8 mA electric footshock, a significant percentage of rats developed a shock escape deficit which was evident when subsequently placed in a shock escape paradigm. Serotonin depletion was produced by chronic treatment with p-chlorophenylalanine. Biogenic amine levels and 5-HT levels were monitored in various brain areas using HPLC. Following chronic treatment with PCPA, the shock escape capability of the Sprague-Dawley rat was assessed. The severe depletion of 5-HT in various brain regions was highly correlated with a dramatic improvement in the shock escape scores. Thus, the detrimental effects of exposure to a mild course of inescapable shock can be prevented by chronic treatment with PCPA. These experiments implicate the serotonergic system as a possible mediator of the "learned helplessness" phenomenon.

Inhibition of GABA uptake in the rat hippocampal slice

Pharmacological manipulations known to inhibit GABA uptake prolonged GABA-evoked conductance increases in CA1 pyramidal cells in the rat hippocampal slice preparation. Treatments included reduction of extracellular sodium and exposure to cis-4-OH-nipecotic acid, nipecotic acid or L-2,4-diaminobutyric acid (all at 1 mM). These effects contrast with the results obtained with 4-OH-isonipecotic acid, an inactive structural analog of nipecotic acid, which had no effect on the time-course of GABA responses. 4,5,6,7-Tetrahydroisoxazolo[4,5-c]pyridine-3-ol (THPO), an impotent but selective inhibitor of GABA uptake into glia, did not prolong GABA-evoked responses. The effect of sodium reduction depended on the distance between the source of GABA and its receptors, as predicted for an uptake-limited response. GABA-receptor agonists that are poor substrates for GABA uptake (muscimol, thiomuscimol, piperidine-4-sulphonic acid, isoguvacine and 4,5,6,7-tetrahydroisoxazolo[5,4-c]pyridine-3-ol (THIP) evoked very long conductance changes that were not further prolonged by uptake inhibitors. These results demonstrate the presence of a functional GABA uptake system in the hippocampal slice. The accessibility of hippocampal GABAergic synapses and the known susceptibility of the hippocampus to epileptiform events suggest that the hippocampal slice could be a valuable CNS preparation to study the role of GABA uptake in synaptic physiology.

Medical psychology in exercise and sport

Several psychological outcomes that accompany acute and chronic exercise have medical significance. Transient reductions in somatic tension and subjective anxiety appear most reliable. Symptom abatement in moderate depression can occur with chronic exercise in a manner comparable to psychotherapy and may offer a better prognosis in some instances. Other cognitive, behavioral, and perceptual events associated with exercise may assist in managing mental health, and exercise has been successfully used as a therapeutic adjunct in a variety of psychiatric disorders. Regular exercise may also complement treatments designed to manage aspects of coronary-prone behavior and psychoendocrine responsivity to mental stress. The lack of strict experimental control or effective placebo contrasts in most exercise studies precludes a convincing argument that exercise causes the psychological outcomes observed. Rather, expectancy of benefits, generalized treatment or attention effects, social reinforcement, and past history or selection bias represent likely alternatives. These competing explanations do not discount, however, that many individuals benefit in a clinically significant way. Exercise offers a low-cost alternative or adjunct with side effects that appear largely health-related. Although the effective psychological dosage or modality has not been quantified, current physiologic guidelines of the American College of Sports Medicine (large muscle rhythmic activity, for 20 to 60 minutes, 3 to 5 days per week at 60 to 80 per cent age-adjusted maximal heart rate), or a weekly caloric cost of 2000 kcal, should be effective with little medical risk. However, no evidence confirms that an increase in metabolic or psychoendocrine tolerance to exercise is necessary or sufficient for psychological outcomes to occur. Although biologic adaptations are known to follow exercise training and subside with diminished activity, there is currently no objective evidence that habitual exercise leads to dependence. If exercise has use in managing subjective or somatic symptoms, these may return during periods of exercise abstinence. Moreover, despite popular hypotheses concerning endorphins and biogenic amines, no direct relationships have yet been shown between exercise-induced mood swings and peripheral biochemical events. A proportion of habitual runners have reported acute episodes of euphoria-like states during or following exercise, but this remains a subjective and unpredictable event that may be related to psychophysiologic relaxation or acute changes in self-esteem.(ABSTRACT TRUNCATED AT 400 WORDS)

Learned helplessness: Effects on brain monoamines and the pituitary-gonadal axis

The effect of the learned helplessness paradigm, a model of depression, on biogenic amines in eight brain regions, and on the serum levels of luteinizing hormone, corticosterone, and testosterone in male rats was determined. Rats which were exposed to uncontrollable and unpredictable shocks (HY-rats) had hormone levels similar to those in appropriate control animals. However, HY-rats had higher levels of 5-HIAA in the pons/medulla oblongata and lower levels of 5-HT in the cortex than rats which could escape the shocks (HE-rats). Furthermore, striatal levels of NE were higher in HY-rats when compared to HE-rats and non-shocked controls (HC-rats). Shock treatment per se resulted in lower NE levels in the hippocampus. These data implicate the serotonergic and noradrenergic systems as possible mediators of the learned helplessness phenomenon, but do not support the view that this behavior is associated with impaired pituitary-gonadal function.