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Helmy H, Hamid Sadik NA, Badawy L, Sayed NH. Mechanistic insights into the protective role of eugenol against stress-induced reproductive dysfunction in female rat model. Chem Biol Interact 2022; 367:110181. [PMID: 36108715 DOI: 10.1016/j.cbi.2022.110181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/05/2022] [Accepted: 09/08/2022] [Indexed: 11/17/2022]
Abstract
The challenging and highly demanding life rhythm nowadays subjects people to unavoidable chronic stress. Chronic stress is associated with a wide array of serious health complications including neuroendocrine dysregulations. Women are more prone to chronic stress-related hormonal disturbances and their physical and psychological consequences, especially reproductive impairment. Eugenol is a natural phenolic anti-oxidant that has several beneficial biological activities. The current study intended to scrutinize the potential protective effect of eugenol in female Wistar rats exposed to chronic unpredictable mild stress (CUMS). Rats were randomly allocated into 4 groups; group 1 received olive oil, group 2 received eugenol in olive oil, groups 3 and 4 were subjected to CUMS protocol for 8 weeks, with pre- and concomitant treatment with eugenol (50 mg/kg/day; p.o.) in group 4. The results showed that CUMS exposure led to weight loss and depressive-like behaviours. CUMS induced hypothalamic-pituitary-adrenal axis activation with subsequent elevation of serum corticosterone level which, in turn, caused decline in ovarian release of estradiol and antimullerian hormones together with an increased production of follicle-stimulating and luteinizing hormones by the anterior pituitary, leading to reproductive disturbances. In ovaries, CUMS imposed oxidative stress, insulin resistance and molecular damage. Intriguingly, all these adverse effects were significantly mitigated by the administration of eugenol that improved animals' behaviours, corrected corticosterone upsurge, tempered hormonal disturbances, and amended ovarian damage. All biochemical results were further confirmed by hippocampal and ovarian histopathological examinations. In conclusion, the current study highlights the prophylactic role of eugenol against reproductive disturbances induced by chronic stress in female rats.
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Affiliation(s)
- Hebatullah Helmy
- Department of Biochemistry, Faculty of Pharmacy, Cairo University, Cairo, Egypt.
| | | | | | - Noha H Sayed
- Department of Biochemistry, Faculty of Pharmacy, Cairo University, Cairo, Egypt.
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Acute stress anticipates and amplifies the Luteinizing Hormone pre-ovulatory surge in rats: role of noradrenergic neurons. Brain Res 2022; 1781:147805. [DOI: 10.1016/j.brainres.2022.147805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 01/21/2022] [Accepted: 01/25/2022] [Indexed: 11/17/2022]
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Phumsatitpong C, Wagenmaker ER, Moenter SM. Neuroendocrine interactions of the stress and reproductive axes. Front Neuroendocrinol 2021; 63:100928. [PMID: 34171353 PMCID: PMC8605987 DOI: 10.1016/j.yfrne.2021.100928] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 06/17/2021] [Accepted: 06/19/2021] [Indexed: 01/27/2023]
Abstract
Reproduction is controlled by a sequential regulation of the hypothalamo-pituitary-gonadal (HPG) axis. The HPG axis integrates multiple inputs to maintain proper reproductive functions. It has long been demonstrated that stress alters fertility. Nonetheless, the central mechanisms of how stress interacts with the reproductive system are not fully understood. One of the major pathways that is activated during the stress response is the hypothalamo-pituitary-adrenal (HPA) axis. In this review, we discuss several aspects of the interactions between these two neuroendocrine systems to offer insights to mechanisms of how the HPA and HPG axes interact. We have also included discussions of other systems, for example GABA-producing neurons, where they are informative to the overall picture of stress effects on reproduction.
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Affiliation(s)
- Chayarndorn Phumsatitpong
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI, United States
| | - Elizabeth R Wagenmaker
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI, United States
| | - Suzanne M Moenter
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI, United States; Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States.
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Phumsatitpong C, De Guzman RM, Zuloaga DG, Moenter SM. A CRH Receptor Type 1 Agonist Increases GABA Transmission to GnRH Neurons in a Circulating-Estradiol-Dependent Manner. Endocrinology 2020; 161:5892962. [PMID: 32798220 PMCID: PMC7547842 DOI: 10.1210/endocr/bqaa140] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 08/06/2020] [Indexed: 12/15/2022]
Abstract
GnRH neurons are central regulators of reproduction and respond to factors affecting fertility, such as stress. Corticotropin-releasing hormone (CRH) is released during stress response. In brain slices from unstressed controls, CRH has opposite, estradiol-dependent effects on GnRH neuron firing depending on the CRH receptor activated; activating CRHR-1 stimulates whereas activating CRHR-2 suppresses activity. We investigated possible direct and indirect mechanisms. Mice were ovariectomized and either not treated further (OVX) or given a capsule producing high positive feedback (OVX + E) or low negative feedback (OVX + low E) physiologic circulating estradiol levels. We tested possible direct effects on GnRH neurons by altering voltage-gated potassium currents. Two types of voltage-gated potassium currents (transient IA and sustained IK) were measured; neither CRHR-1 nor CRHR-2 agonists altered potassium current density in GnRH neurons from OVX + E mice. Further, neither CRH nor receptor-specific agonists altered action potential generation in response to current injection in GnRH neurons from OVX + E mice. To test the possible indirect actions, GABAergic postsynaptic currents were monitored. A CRHR-1 agonist increased GABAergic transmission frequency to GnRH neurons from OVX + E, but not OVX, mice, whereas a CRHR-2 agonist had no effect. Finally, we tested if CRH alters the firing rate of arcuate kisspeptin neurons, which provide an important excitatory neuromodulatory input to GnRH neurons. CRH did not acutely alter firing activity of these neurons from OVX, OVX + E or OVX + low E mice. These results suggest CRH increases GnRH neuron activity in an estradiol-dependent manner in part by activating GABAergic afferents. Mechanisms underlying inhibitory effects of CRH remain unknown.
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Affiliation(s)
| | | | | | - Suzanne M Moenter
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI, US
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, US
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, US
- Correspondence: Suzanne M. Moenter; 7725 Med Sci II; 1137 E Catherine St; Ann Arbor, MI 48109-5622. E-mail:
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McCosh RB, Breen KM, Kauffman AS. Neural and endocrine mechanisms underlying stress-induced suppression of pulsatile LH secretion. Mol Cell Endocrinol 2019; 498:110579. [PMID: 31521706 PMCID: PMC6874223 DOI: 10.1016/j.mce.2019.110579] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 08/30/2019] [Accepted: 09/10/2019] [Indexed: 12/21/2022]
Abstract
Stress is well-known to inhibit a variety of reproductive processes, including the suppression of episodic Gonadotropin releasing hormone (GnRH) secretion, typically measured via downstream luteinizing hormone (LH) secretion. Since pulsatile secretion of GnRH and LH are necessary for proper reproductive function in both males and females, and stress is common for both human and animals, understanding the fundamental mechanisms by which stress impairs LH pulses is of critical importance. Activation of the hypothalamic-pituitary-adrenal axis, and its corresponding endocrine factors, is a key feature of the stress response, so dissecting the role of stress hormones, including corticotrophin releasing hormone (CRH) and corticosterone, in the inhibition of LH secretion has been one key research focus. However, some evidence suggests that these stress hormones alone are not sufficient for the full inhibition of LH caused by stress, implicating the additional involvement of other hormonal or neural signaling pathways in this process (including inputs from the brainstem, amygdala, parabrachial nucleus, and dorsomedial nucleus). Moreover, different stress types, such as metabolic stress (hypoglycemia), immune stress, and psychosocial stress, appear to suppress LH secretion via partially unique neural and endocrine pathways. The mechanisms underlying the suppression of LH pulses in these models offer interesting comparisons and contrasts, including the specific roles of amygdaloid nuclei and CRH receptor types. This review focuses on the most recent and emerging insights into endocrine and neural mechanisms responsible for the suppression of pulsatile LH secretion in mammals, and offers insights in important gaps in knowledge.
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Affiliation(s)
- Richard B McCosh
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA, 92093-0674, USA
| | - Kellie M Breen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA, 92093-0674, USA
| | - Alexander S Kauffman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA, 92093-0674, USA.
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Phumsatitpong C, Moenter SM. Estradiol-Dependent Stimulation and Suppression of Gonadotropin-Releasing Hormone Neuron Firing Activity by Corticotropin-Releasing Hormone in Female Mice. Endocrinology 2018; 159:414-425. [PMID: 29069304 PMCID: PMC5761586 DOI: 10.1210/en.2017-00747] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 10/17/2017] [Indexed: 11/19/2022]
Abstract
Gonadotropin-releasing hormone (GnRH) neurons are the final central regulators of reproduction, integrating various inputs that modulate fertility. Stress typically inhibits reproduction but can be stimulatory; stress effects can also be modulated by steroid milieu. Corticotropin-releasing hormone (CRH) released during the stress response may suppress reproduction independent of downstream glucocorticoids. We hypothesized CRH suppresses fertility by decreasing GnRH neuron firing activity. To test this, mice were ovariectomized (OVX) and either implanted with an estradiol capsule (OVX+E) or not treated further to examine the influence of estradiol on GnRH neuron response to CRH. Targeted extracellular recordings were used to record firing activity from green fluorescent protein-identified GnRH neurons in brain slices before and during CRH treatment; recordings were done in the afternoon when estradiol has a positive feedback effect to increase GnRH neuron firing. In OVX mice, CRH did not affect the firing rate of GnRH neurons. In contrast, CRH exhibited dose-dependent stimulatory (30 nM) or inhibitory (100 nM) effects on GnRH neuron firing activity in OVX+E mice; both effects were reversible. The dose-dependent effects of CRH appear to result from activation of different receptor populations; a CRH receptor type-1 agonist increased firing activity in GnRH neurons, whereas a CRH receptor type-2 agonist decreased firing activity. CRH and specific agonists also differentially regulated short-term burst frequency and burst properties, including burst duration, spikes/burst, and/or intraburst interval. These results indicate that CRH alters GnRH neuron activity and that estradiol is required for CRH to exert both stimulatory and inhibitory effects on GnRH neurons.
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Affiliation(s)
- Chayarndorn Phumsatitpong
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan 48109
| | - Suzanne M. Moenter
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan 48109
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan 48109
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan 48109
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Stress and the HPA Axis: Balancing Homeostasis and Fertility. Int J Mol Sci 2017; 18:ijms18102224. [PMID: 29064426 PMCID: PMC5666903 DOI: 10.3390/ijms18102224] [Citation(s) in RCA: 174] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 10/17/2017] [Accepted: 10/21/2017] [Indexed: 12/25/2022] Open
Abstract
An organism’s reproductive fitness is sensitive to the environment, integrating cues of resource availability, ecological factors, and hazards within its habitat. Events that challenge the environment of an organism activate the central stress response system, which is primarily mediated by the hypothalamic–pituitary–adrenal (HPA) axis. The regulatory functions of the HPA axis govern the cardiovascular and metabolic system, immune functions, behavior, and reproduction. Activation of the HPA axis by various stressors primarily inhibits reproductive function and is able to alter fetal development, imparting a biological record of stress experienced in utero. Clinical studies and experimental data indicate that stress signaling can mediate these effects through direct actions in the brain, gonads, and embryonic tissues. This review focuses on the mechanisms by which stress activation of the HPA axis impacts fertility and fetal development.
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Sominsky L, Hodgson DM, McLaughlin EA, Smith R, Wall HM, Spencer SJ. Linking Stress and Infertility: A Novel Role for Ghrelin. Endocr Rev 2017; 38:432-467. [PMID: 28938425 DOI: 10.1210/er.2016-1133] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 07/24/2017] [Indexed: 12/23/2022]
Abstract
Infertility affects a remarkable one in four couples in developing countries. Psychological stress is a ubiquitous facet of life, and although stress affects us all at some point, prolonged or unmanageable stress may become harmful for some individuals, negatively impacting on their health, including fertility. For instance, women who struggle to conceive are twice as likely to suffer from emotional distress than fertile women. Assisted reproductive technology treatments place an additional physical, emotional, and financial burden of stress, particularly on women, who are often exposed to invasive techniques associated with treatment. Stress-reduction interventions can reduce negative affect and in some cases to improve in vitro fertilization outcomes. Although it has been well-established that stress negatively affects fertility in animal models, human research remains inconsistent due to individual differences and methodological flaws. Attempts to isolate single causal links between stress and infertility have not yet been successful due to their multifaceted etiologies. In this review, we will discuss the current literature in the field of stress-induced reproductive dysfunction based on animal and human models, and introduce a recently unexplored link between stress and infertility, the gut-derived hormone, ghrelin. We also present evidence from recent seminal studies demonstrating that ghrelin has a principal role in the stress response and reward processing, as well as in regulating reproductive function, and that these roles are tightly interlinked. Collectively, these data support the hypothesis that stress may negatively impact upon fertility at least in part by stimulating a dysregulation in ghrelin signaling.
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Affiliation(s)
- Luba Sominsky
- School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria 3083, Australia
| | - Deborah M Hodgson
- School of Psychology, Faculty of Science and IT, The University of Newcastle, New South Wales 2308, Australia
| | - Eileen A McLaughlin
- School of Biological Sciences, Faculty of Science, The University of Auckland, Auckland 1010, New Zealand.,School of Environmental & Life Sciences, Faculty of Science and IT, The University of Newcastle, New South Wales 2308, Australia
| | - Roger Smith
- Mothers and Babies Research Centre, Hunter Medical Research Institute, Lookout Road, New Lambton Heights, New South Wales 2305, Australia.,Priority Research Centre in Reproductive Science, The University of Newcastle, New South Wales 2308, Australia
| | - Hannah M Wall
- School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria 3083, Australia
| | - Sarah J Spencer
- School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria 3083, Australia
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Barra de la Tremblaye P, Plamondon H. Alterations in the corticotropin-releasing hormone (CRH) neurocircuitry: Insights into post stroke functional impairments. Front Neuroendocrinol 2016; 42:53-75. [PMID: 27455847 DOI: 10.1016/j.yfrne.2016.07.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 07/04/2016] [Accepted: 07/06/2016] [Indexed: 10/21/2022]
Abstract
Although it is well accepted that changes in the regulation of the hypothalamic-pituitary adrenal (HPA) axis may increase susceptibility to affective disorders in the general population, this link has been less examined in stroke patients. Yet, the bidirectional association between depression and cardiovascular disease is strong, and stress increases vulnerability to stroke. Corticotropin-releasing hormone (CRH) is the central stress hormone of the HPA axis pathway and acts by binding to CRH receptors (CRHR) 1 and 2, which are located in several stress-related brain regions. Evidence from clinical and animal studies suggests a role for CRH in the neurobiological basis of depression and ischemic brain injury. Given its importance in the regulation of the neuroendocrine, autonomic, and behavioral correlates of adaptation and maladaptation to stress, CRH is likely associated in the pathophysiology of post stroke emotional impairments. The goals of this review article are to examine the clinical and experimental data describing (1) that CRH regulates the molecular signaling brain circuit underlying anxiety- and depression-like behaviors, (2) the influence of CRH and other stress markers in the pathophysiology of post stroke emotional and cognitive impairments, and (3) context and site specific interactions of CRH and BDNF as a basis for the development of novel therapeutic targets. This review addresses how the production and release of the neuropeptide CRH within the various regions of the mesocorticolimbic system influences emotional and cognitive behaviors with a look into its role in psychiatric disorders post stroke.
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Affiliation(s)
- P Barra de la Tremblaye
- School of Psychology, Behavioral Neuroscience Program, University of Ottawa, 136 Jean-Jacques Lussier, Vanier Building, Ottawa, Ontario K1N 6N5, Canada
| | - H Plamondon
- School of Psychology, Behavioral Neuroscience Program, University of Ottawa, 136 Jean-Jacques Lussier, Vanier Building, Ottawa, Ontario K1N 6N5, Canada.
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Goldstein JM, Handa RJ, Tobet SA. Disruption of fetal hormonal programming (prenatal stress) implicates shared risk for sex differences in depression and cardiovascular disease. Front Neuroendocrinol 2014; 35:140-58. [PMID: 24355523 PMCID: PMC3917309 DOI: 10.1016/j.yfrne.2013.12.001] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 10/31/2013] [Accepted: 12/04/2013] [Indexed: 12/19/2022]
Abstract
Comorbidity of major depressive disorder (MDD) and cardiovascular disease (CVD) represents the fourth leading cause of morbidity and mortality worldwide, and women have a two times greater risk than men. Thus understanding the pathophysiology has widespread implications for attenuation and prevention of disease burden. We suggest that sex-dependent MDD-CVD comorbidity may result from alterations in fetal programming consequent to the prenatal maternal environments that produce excess glucocorticoids, which then drive sex-dependent developmental alterations of the fetal hypothalamic-pituitary-adrenal (HPA) axis circuitry impacting mood, stress regulation, autonomic nervous system (ANS), and the vasculature in adulthood. Evidence is consistent with the hypothesis that disruptions of pathways associated with gamma aminobutyric acid (GABA) in neuronal and vascular development and growth factors have critical roles in key developmental periods and adult responses to injury in heart and brain. Understanding the potential fetal origins of these sex differences will contribute to development of novel sex-dependent therapeutics.
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Affiliation(s)
- J M Goldstein
- Departments of Psychiatry and Medicine, Harvard Medical School, Boston, MA, USA; Brigham and Women's Hospital (BWH), Connors Center for Women's Health & Gender Biology, 1620 Tremont St. BC-3-34, Boston, MA 02120, USA; BWH, Departments of Psychiatry and Medicine, 1620 Tremont St. BC-3-34, Boston, MA 02120, USA.
| | - R J Handa
- Department of Basic Medical Sciences, University of Arizona College of Medicine, 425 N. Fifth Street, Phoenix, AZ 85004, USA
| | - S A Tobet
- Department of Biomedical Sciences and School of Biomedical Engineering, Colorado State University, 1617 Campus Delivery, Fort Collins, CO 80523, USA
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Fukushima A, Furuta M, Kimura F, Akema T, Funabashi T. Testosterone exposure during the critical period decreases corticotropin-releasing hormone-immunoreactive neurons in the bed nucleus of the stria terminalis of female rats. Neurosci Lett 2013; 534:64-8. [DOI: 10.1016/j.neulet.2012.11.065] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2012] [Revised: 10/16/2012] [Accepted: 11/16/2012] [Indexed: 11/25/2022]
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Kageyama K. Regulation of gonadotropins by corticotropin-releasing factor and urocortin. Front Endocrinol (Lausanne) 2013; 4:12. [PMID: 23431022 PMCID: PMC3576618 DOI: 10.3389/fendo.2013.00012] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Accepted: 01/30/2013] [Indexed: 02/05/2023] Open
Abstract
While stress activates the hypothalamic-pituitary-adrenal (HPA) axis, it suppresses the hypothalamic-pituitary-gonadal (HPG) axis. Corticotropin-releasing factor (CRF) is a major regulatory peptide in the HPA axis during stress. Urocortin 1 (Ucn1), a member of the CRF family of peptides, has a variety of physiological functions and both CRF and Ucn1 contribute to the stress response via G protein-coupled seven transmembrane receptors. Ucn2 and Ucn3, which belong to a separate paralogous lineage from CRF, are highly selective for the CRF type 2 receptor (CRF(2) receptor). The HPA and HPG axes interact with each other, and gonadal function and reproduction are suppressed in response to various stressors. In this review, we focus on the regulation of gonadotropins by CRF and Ucn2 in pituitary gonadotrophs and of gonadotropin-releasing hormone (GnRH) via CRF receptors in the hypothalamus. In corticotrophs, stress-induced increases in CRF stimulate Ucn2 production, which leads to the inhibition of gonadotropin secretion via the CRF(2) receptor in the pituitary. GnRH in the hypothalamus is regulated by a variety of stress conditions. CRF is also involved in the suppression of the HPG axis, especially the GnRH pulse generator, via CRF receptors in the hypothalamus. Thus, complicated regulation of GnRH in the hypothalamus and gonadotropins in the pituitary via CRF receptors contributes to stress responses and adaptation of gonadal functions.
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Affiliation(s)
- Kazunori Kageyama
- *Correspondence: Kazunori Kageyama, Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan. e-mail:
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