Adrenal function in subgroups of the PCO syndrome assessed by a long ACTH test

Classification of polycystic ovary syndrome into three types according to response to human corticotropin-releasing hormone

OBJECTIVE

To evaluate disturbances of the hypothalamic-pituitary-adrenal axis in women with polycystic ovary syndrome (PCOS).

DESIGN

Retrospective cohort study.

SETTING

Yokohama City University, Yokohama, Japan.

PATIENT(S)

Sixty women with PCOS and 19 women with normal menstruation.

INTERVENTION(S)

Administration of human corticotropin-releasing hormone (hCRH), dexamethasone suppression testing, and stimulation of ovulation with clomiphene citrate.

MAIN OUTCOME MEASURE(S)

Plasma cortisol and ACTH levels, plasma androstenedione and DHEAS levels, and ovulation rates.

RESULT(S)

In women with PCOS, plasma ACTH and cortisol levels were significantly higher and the plasma ACTH level after the administration of hCRH was higher than in controls. Based on the response to hCRH, patients with PCOS could be classified into three categories: those with a normal response to hCRH (group 1), those with an exaggerated response of ACTH to hCRH (group 2), and those with a high basal level of cortisol and a poor response to hCRH (group 3). In groups 2 and 3, DHEAS levels were significantly higher, suppression of androstenedione by dexamethasone was significantly greater, and ovulation rates with clomiphene citrate were significantly lower than in group 1.

CONCLUSION(S)

This classification provides insight into the underlying cause of PCOS and thus is useful in selecting appropriate treatment.

Somatostatin treatment reduces the exaggerated response of adrenocorticotropin hormone and cortisol to corticotropin-releasing hormone in polycystic ovary syndrome

OBJECTIVE

To evaluate the influence of somatostatin analogue (octreotide) in the function of hypothalamic-pituitary-adrenal (HPA) axis in women with polycystic ovary syndrome (PCOS).

SETTING

Women referred to the Department of Obstetrics and Gynecology, Università Cattolica del Sacro Cuore.

PATIENT(S)

Twelve PCOS women and 12 normo-ovulatory controls.

INTERVENTION(S)

In early follicular phase, I microgram/kg human corticotrophin-releasing hormone (CRH) was injected at 9:00 A.M. and blood samples were collected for 90 minutes after stimulus; ACTH and cortisol plasma levels were measured. The following day at 8:00 A.M., PCOS patients received an ACTH test (250 micrograms IV) and samples were collected 60 minutes after injection. After 6 weeks of octreotide treatment (100 mg s.c. twice daily), PCOS patients repeated the same study.

MAIN OUTCOME MEASURE(S)

Plasma cortisol and ACTH concentrations.

RESULT(S)

The ACTH and cortisol baseline levels were similar in PCOS and control patients. The responses to human CRH of ACTH (incremental area = 437.86 +/- 188.7 versus 175.78 +/- 87.6 pmol/L; mean +/- SD) and cortisol (incremental area = 17,293.6 +/- 4,320.3 versus 5,885 (912.1 nmol/L) were significantly greater in PCOS with respect to control subjects. After octreotide treatment, ACTH response significantly decreased and no difference was observed with respect to controls (incremental area = 176.94 +/- 91.4). Cortisol responses were decreased by treatment. However, they remained significantly higher than in controls. Treatment did not modify adrenal response to IV ACTH.

CONCLUSION(S)

Data suggest that, in the HPA axis, hyperfunction of PCOS somatostatin could be involved partially.

Corticotropin-releasing hormone induces an exaggerated response of adrenocorticotropic hormone and cortisol in polycystic ovary syndrome

OBJECTIVE

To evaluate pituitary-adrenal responsive to corticotropin-releasing hormone (CRH) stimulus in polycystic ovary syndrome (PCOS).

DESIGN

Controlled clinical study.

PATIENTS

Twelve women aged 17 to 32 years, who had been diagnosed as having PCOS, were studied. Fifteen appropriately age- and weight-matched ovulatory patients served as the control.

INTERVENTION

In the early follicular phase or after progestin-induced menses, human CRH was injected at 8:00 A.M. and blood samples were collected at 0, 15, 30, 60, and 90 minutes after stimulus. Plasma levels of ACTH and cortisol were measured.

RESULTS

Baseline levels of ACTH and cortisol were similar in PCOS and control patients. Both ACTH and cortisol response to CRH were markedly greater in the PCOS population as compared with controls. Moreover, ACTH- and cortisol-stimulated secretion was prolonged for the whole period of the study in hyperandrogenic patients with respect to controls, where baseline levels were attained 60 minutes after the stimulus.

CONCLUSIONS

Our results are consistent with the hypothesis that women with PCOS may demonstrate hyperfunction of the hypothalamic-pituitary-adrenal axis, which may be involved in the physiopathologic events leading to the complexity of the syndrome.

The hypothalamo-pituitary-adrenal axis across the normal menstrual cycle and in polycystic ovary syndrome

OBJECTIVE

We explored the hypothesis that activation of the hypothalamo-pituitary-adrenal axis is involved in the pathogenesis of hyperandrogenism in the polycystic ovary syndrome.

PATIENTS

Seven women with polycystic ovary syndrome (mean age 27.6 +/- 1.6 (SEM) years) (hirsutism, oligo/amenorrhoea and elevated serum testosterone and dehydroepiandrosterone sulphate) and nine normal female controls (mean age 24.6 +/- 1.5 years) were studied. To exclude anovulation as a confounding factor, four of these normal women were studied in both the follicular and luteal phase of the menstrual cycle.

DESIGN AND MEASUREMENTS

Plasma ACTH and cortisol levels were measured at 15-minute intervals between 0600 h and 1800 h. ACTH and cortisol mean levels, pulse number and amplitude were calculated using established computer software, programmed to identify ACTH and cortisol peaks.

RESULTS

With the exception of mean plasma levels of ACTH over the 12-hour period, which were reduced in the luteal phase of the menstrual cycle (1.8 +/- 0.3 pmol/l) compared to the follicular phase (2.3 +/- 0.2 pmol/l, P < 0.05), there were no differences in the pattern of ACTH or cortisol secretion across the normal cycle. In polycystic ovary syndrome, 12-hour ACTH pulse frequency was reduced (3.6 +/- 0.7) compared with controls (5.9 +/- 0.6, P < 0.05), but cortisol pulsatility and ACTH and cortisol mean levels were similar in both groups.

CONCLUSION

The hyperandrogenism of polycystic ovary syndrome cannot be explained by enhanced ACTH secretion. Normal circulating cortisol levels, yet elevated dehydroepiandrosterone sulphate levels, suggests that polycystic ovary syndrome is yet another example of discrepant adrenal glucocorticoid and androgen secretion, and provides further evidence for a putative adrenal androgen stimulating factor.

Differential androgen response to adrenocorticotropic hormone stimulation in polycystic ovarian syndrome: relationship with insulin secretion

OBJECTIVE

To investigate the relationship between insulin and adrenal androgens in patients with polycystic ovarian disease (PCOD).

DESIGN

Patients with PCOD and a group of volunteers who attended the department during a period of 6 months were studied.

SETTING

Department of Gynaecology and Obstetrics, Università Cattolica del Sacro Cuore, Roma, Italy.

PARTICIPANTS

Healthy women with ovulatory cycles (hospital personnel, n = 8) and women affected by PCOD (n = 32) were studied on day 5 to 6 of their follicular phase.

INTERVENTIONS

All women had an oral glucose tolerance test (OGTT) (75 g) on day 5 to 6 of the cycle. Then plasma samples were collected at 7.00 A.M.; at 11.00 P.M., 2 mg of dexamethasone (DEX) were orally administered with blood samples collected the day after at 7.00 A.M. (effect of DEX). Then adenocorticotropic hormone (ACTH, Synacten; Ciba-Geigy, Varese, Italy) 250 micrograms was injected intravenously (IV) and samples collected 60 minutes later (effect of ACTH).

MAIN OUTCOME MEASURES

Plasma glucose and insulin concentration were assayed on OGTT samples collected at time 0, 30, 60, 90, 120, 180, and 240 minutes after glucose ingestion. Data are expressed as area under the curve. Cortisol, 17 alpha-hydroxyprogesterone (17-OHP), testosterone (T), androstenedione (A), and dehydroepiandrosterone sulphate (DHEAS) plasma levels were evaluated on the samples collected before and after DEX or ACTH administration. Data are expressed as absolute concentrations and percent increase in respect to values before the treatment.

RESULTS

According to the OGTT response, 21 patients were classified as hyperinsulinemic and 11 as normoinsulinemic. The ideal body weight was greater in hyperinsulinemic patients. No differences in baseline hormone levels were found between the two groups. Only sex hormone binding globulin levels were significantly greater in normoinsulinemic patients (P less than 0.05). Also, the plasma concentration of all steroids after DEX were similar in both groups. Intravenous injection of ACTH significantly increased plasma androgens levels. Cortisol, DHEAS, and T enhancement did not differ in normoinsulinemic and hyperinsulinemic patients, whereas significantly greater A (P less than 0.01) and 17-OHP (P less than 0.05) plasma concentrations were observed after ACTH injection in hyperinsulinemic when compared with normoinsulinemic PCOD subjects. Control group after IV ACTH showed an increase of A and 17-OHP similar to those found in normoinsulinemic PCOD group.

CONCLUSIONS

These data suggest that insulin could be involved in the androgen production by adrenal gland and it could influence the responsiveness of adrenal to its trophic hormones.

Assessment of the adrenal-ovarian contribution by short-term dexamethasone and ACTH tests in hyperandrogenized patients

Fifty-four hyperandrogenized women were studied to evaluate the importance of the adrenal or ovarian contribution to androgen secretion. Forty-six had the polycystic ovarian (PCOD) syndrome. Eight normal women represented a control group. The endocrine study was performed during the follicular phase. The plasma samples were collected at 7.00 am (A1) and at 11.00 pm (A3). Dexamethasone 2 mg was administered orally at 11.30 pm and blood samples were collected the day after, at 7.00 am (B). The adrenocorticotropic hormone (ACTH) was injected, 250 micrograms i.v. and samples were collected after 60 min. Cortisol dehydroepiandrosterone-sulfate (DHEAS), androstenedione, testosterone and 17-hydroxyprogesterone (17OHP) were measured. The hyperandrogenized patients had A1 androgen levels higher than the controls (p less than 0.01). 17OHP and androstenedione A3 values showed a cortisol-related decrease. After dexamethasone, androgen levels, since DHEAS, were normalized in all patients. We found that baseline androgen levels and circadian and dexamethasone-inhibited amounts were strongly correlated (p less than 0.01). The ACTH test revealed five cases of enzymatic adrenal deficiencies. Moreover, the amplitude of the response of 17OHP and androstenedione to ACTH is predictable in relation to both circadian and dexamethasone-inhibited amounts (p less than 0.01). In conclusion, our study confirms and makes quantifiable the importance of the adrenal contribution to androgen secretion in hyperandrogenized patients. The ACTH test is important for detecting the presence of mild enzymatic adrenal defects.

5 alpha-reductase activity in polycystic ovary syndrome

11 patients with polycystic ovary syndrome (hirsutism and oligomenorrhoea), but with no deficiency of 21-hydroxylase or 3 beta-hydroxysteroid dehydrogenase, had abnormal cortisol metabolism. The high ratio of 5 alpha to 5 beta cortisol metabolites in the urine is consistent with enhanced activity of 5 alpha-reductase. Urinary total cortisol metabolites were higher in patients than controls. Increased 5 alpha-reductase activity in liver and skin enhances hepatic cortisol metabolism at the expense of androgen excess and may be the underlying abnormality in polycystic ovary syndrome.

Pituitary and adrenal response to ovine corticotropin-releasing hormone in women with polycystic ovarian syndrome

It has been hypothesized that there is an adrenal abnormality in the polycystic ovary syndrome (PCO). This study was undertaken to examine this hypothesis in a more physiological way, by enhancing the ACTH secretion in response to ovine corticotropin releasing hormone (oCRH) injection so that adrenal androgen and glucocorticoid responsiveness to endogenous stimulation could be examined. Plasma ACTH and the ACTH and cortisol (F) response to oCRH were normal. The plasma T and dehydroepiandrosterone (DHEA) responses were also normal. The androstenedione (A) response, however, was exaggerated. This study supports the hypothesis that the adrenal gland in patients with PCO produces increased amounts of androstenedione in response to ACTH stimulation.

Adrenal cortex and type II polycystic ovary syndrome

The aim of this study was to investigate whether the adrenal gland participates in the pathogenesis of type II polycystic ovary syndrome (PCO), and, if so, to see if an altered pattern of ACTH secretion might be responsible. Circadian secretion and pulsatility (morning and evening) of ACTH, and adrenal and pituitary responsiveness to exogenous ACTH and GnRH, respectively, were evaluated in 10 women with type II PCO and 10 normally menstruating women. After the patients had been administered oral dexamethasone (0.5 mg each night) for 3 months, studies were repeated. Mean plasma values of PRL, testosterone, DHA-S and 17-OH progesterone (17-P) measured by RIA were significantly higher (p less than 0.05) in patients than in controls. FSH and sex hormone binding globulin (SHBG) were significantly lower (p less than 0.05). Cortisol and 17-P responses to ACTH, and the LH/FSH ratio (both in basal conditions and after GnRH stimulation) were significantly higher (p less than 0.05) in patients. ACTH circadian secretion and pulsatility were similar in both groups. Treatment with dexamethasone significantly reduced plasma values of testosterone, DHA-S, androstenedione (adione), cortisol and the LH/FSH ratio (basal and after GnRH), but adrenal hyperresponsiveness to ACTH was maintained. ACTH pulsatility and secretion were significantly (p less than 0.05) reduced in the morning. Our results suggest that there are abnormalities at the adrenal level in type II PCO. Given that ACTH secretion appears to be normal and that adrenal hyperresponsiveness is still observed after treatment with dexamethasone, it is tempting to speculate that excessive trophic stimulation of the gland by a factor other than ACTH could exist in such patients.

Increased DHEAs levels in PCO syndrome: evidence for the existence of two subgroups of patients

In 49 patients affected by PCO syndrome the serum levels of dehydroepiandrosterone-sulphate (DHEAs) were determined and correlated with the clinical presentation and the endocrine pattern. Twenty-three patients (47%) had high DHEAs levels (h-DHEAs patients). They presented a milder clinical presentation (low incidence of amenorrhea) than PCO patients with normal DHEAs levels (n-DHEAs patients). In h-DHEAs patients the finding of a normal DHEAs response to ACTH and of slightly increased 170HP serum levels suggested that the elevation of serum DHEAs was not due to an adrenal enzymatic deficiency but to a tonic hyperstimulation of the adrenals. Two subgroups of h-DHEAs patients were identified: in the first subgroup, PRL and estrone levels were increased and probably explained the DHEAs hypersecretion; in the second subgroup, the endocrine pattern was very similar to that observed in n-DHEAs patients and a clear explanation for DHEAs increase was not found, although the possibility of an exaggerated secretion of some pituitary hormones with adrenal androgen stimulating activity must be considered.

The effect of endogenous progesterone on serum levels of 5 alpha-reduced androgens in hirsute women

This study was to examine indirectly the effect of endogenous progesterone, a known competitor for 5 alpha-reductase, on androgen metabolism in target organs in hirsute women. Serum levels of progesterone, testosterone (T), androstenedione (A), dihydrotestosterone (DHT) and 5 alpha-androstane 3 alpha 17 beta-diol (3 alpha-diol) and sex hormone binding globulin (SHBG) were assessed serially over a four week period in normal women, six hirsute women with regular menstrual cycles, eight hirsute women with oligomenorrhoea (and presumptive polycystic ovaries) and seven non-hirsute women with oligomenorrhoea. Serum T and A levels were significantly higher than normal in both hirsute and non-hirsute women with oligomenorrhoea, while serum SHBG was significantly lower than normal in the two groups of hirsute women. The calculated free T level was higher than normal in all three groups of patients. DHT levels were not significantly different from normal in any of the three groups of patients. The 3 alpha-diol level showed considerable overlap with normal in all groups of patients and was only significantly higher than normal in hirsute women with oligomenorrhoea (P less than 0.05). There was a small fall in DHT in the late luteal phase of the cycle of those women with a sustained rise in serum progesterone in the second half of the cycle, but no change in serum 3 alpha-diol. These studies suggest that serum 3 alpha-diol may not be as good an indicator of peripheral androgen metabolism in hirsute women as previously reported and that a rise in serum progesterone has only a minimal effect on circulating levels of the active 5 alpha-reduced androgen metabolites. Although in vitro 3 alpha-diol has been shown to be a potent inhibitor of 5 alpha-reductase this casts doubt on its role in this regard in vivo.

Acth function in women with the polycystic ovarian syndrome

Serum androgen levels, including dehydroepiandrosterone sulphate (DHAS) which is thought to be solely of adrenal origin, are elevated in women with the polycystic ovarian syndrome. We have investigated the possibility that this may be due to a mild form of congenital adrenal hyperplasia by measuring basal and stimulated levels of ACTH in women with this condition and have compared them to levels in normal women. We found no difference in the diurnal rhythm of ACTH between patients and normal subjects nor any difference in stimulated levels achieved after a single-dose oral metyrapone test. Thus there is no evidence from this study to support the idea that these patients might have congenital adrenal hyperplasia. There are two alternative hypotheses to explain the elevated DHAS levels. They may be associated with the high oestrogen levels, which interfere with the enzyme 3 beta-hydroxysteroid dehydrogenase, or there may be alteration of the factors controlling adrenal androgen secretion.

Adrenal abnormalities in idiopathic hirsutism

The possibility that abnormal adrenal androgen production may be present in patients with idiopathic hirsutism was examined. Plasma testosterone, dihydrotestosterone and androstenedione levels were elevated in hirsute patients. In response to exogenous alpha 1-24 ACTH the increments in plasma androstenedione, dehydroepiandrosterone (DHA) and cortisol were significantly greater in hirsute patients than in normal subjects. The testosterone response was exaggerated following endogenous stimulation induced by metyrapone. Treatment with dexamethasone, 0.5 mg each night for 3 months, corrected both the androgen excess and the exaggerated androgen responses but not the excessive cortisol response to stimulation. These observations indicate adrenal abnormalities in idiopathic hirsutism. The dissociation of cortisol and adrenal androgen responsiveness following dexamethasone suggests that the abnormalities observed may be due to excessive adrenal androgen production stimulated by a dexamethasone-suppressible factor other than ACTH. Excess adrenal androgen production may be the primary disorder leading to the development of idiopathic hirsutism.