Effect of androgen on adrenal steroidogenesis in normal women

Changes in Adrenal Androgens During Puberty Suppression and Gender-Affirming Hormone Treatment in Adolescents With Gender Dysphoria

INTRODUCTION

Gender-affirming hormone treatment is known to affect adrenal androgen levels in adult individuals with gender dysphoria (GD). This may be clinically relevant because the adrenal gland plays a critical role in many different metabolic processes.

AIM

This study aims to assess the effects of gonadotropin-releasing hormone analogs (GnRHa) treatment and gender-affirming hormone treatment on adrenal androgen levels in adolescents with GD.

METHODS

In this prospective study, dehydroepiandrosterone-sulfate (DHEAS) and androstenedione values were measured every 6 months during 2 years of GnRHa treatment only, and 2 years of GnRHa combined with gender-affirming hormone treatment (estradiol or testosterone) in 73 transgirls and 54 transboys. To determine trends in adrenal androgen levels a linear mixed model was used to approximate androgen levels.

MAIN OUTCOME MEASURES

DHEAS and androstenedione levels were the main outcome measures.

RESULTS

DHEAS levels rose in transboys during GnRHa treatment, which may represent the normal increase during adolescence. In transgirls no change in DHEAS levels during GnRHa treatment was found. Gender-affirming hormone treatment did not affect DHEAS levels in either sex. In transboys androstenedione levels decreased during the first year of GnRHa treatment, which may reflect reduced ovarian androstenedione synthesis, and rose during the first year of gender-affirming hormone treatment, possibly due to conversion of administered testosterone. In transgirls androstenedione levels did not change during either GnRHa or gender-affirming hormone treatment.

CLINICAL IMPLICATIONS

No deleterious effects of treatment on adrenal androgen levels were found during approximately 4 years of follow-up.

STRENGTHS & LIMITATIONS

This is one of the largest cohort of adolescents with GD, treated using a uniform protocol, with standardized follow-up. The lack of a control group is a limitation.

CONCLUSION

The changes in androstenedione levels during GnRHa and gender-affirming hormone treatment in transboys may not be of adrenal origin. The absence of changes in androstenedione levels in transgirls or DHEAS levels in either sex during gender-affirming hormone treatment suggests that gender-affirming hormone treatment does not significantly affect adrenal androgen production. Schagen SEE, Lustenhouwer P, Cohen-Kettenis PT, et al. Changes in Adrenal Androgens During Puberty Suppression and Gender-Affirming Hormone Treatment in Adolescents With Gender Dysphoria. J Sex Med 2018;15:1357-1363.

The prevalence of non-classic adrenal hyperplasia among Turkish women with hyperandrogenism

The prevalence of non-classic adrenal hyperplasia (NCAH) among Turkish women with hirsutism has not been established so far. Thus, we aimed to evaluate the prevalence of 21-hydroxylase (21-OH) deficiency by ACTH stimulation test among hirsute women. The study population consisted of 285 premenopousal women, aged 16-46 years (mean: 23.2 ± 0.3). All were hirsute and hyperandrogenic. Androgen secreting tumors of the ovaries and the adrenal glands were excluded as well as thyroid dysfunction and hyperprolactinemia. All the patients were evaluated by 0.25 mg (i.v.) ACTH stimulation test and 17-OHP responses were obtained at 30 and 60 min. The diagnosis of NCAH due to 21-OH deficiency was considered in patients with the poststimulation 17-OHP level exceed 10 ng/ml. Six (2.1%) of the patients had NCAH due to 21-OH deficiency confirmed by genotyping. The rest of the patients were polycystic ovary syndrome (n = 166, 58.2%) and idiopathic hyperandrogenemia (n = 113, 39.7%). There were no patients with idiopathic hirsutism because patients with normal serum androgen levels were excluded. This first and most extensive national study investigating NCAH prevalence among Turkish population showed that NCAH is not prevalent in this population.

Effect of insulin and testosterone on androgen production and transcription of SULT2A1 in the NCI-H295R adrenocortical cell line

OBJECTIVE

To determine changes in adrenal androgen (AA) production, and transcription of dehydroepiandrosterone (DHEA) sulfotransferase (SULT2A1) in the NCI-H295R human adrenocortical cell line in response to insulin and testosterone, an environment mimicking the polycystic ovary syndrome state.

DESIGN

In vitro experiment using NCI-H295R adrenocortical cell lines.

SETTING

Academic medical center.

PATIENT(S)

NCI-H295R human adrenocortical cell line.

INTERVENTION(S)

The transcriptional activity of SULT2A1 and adrenal steroid production was quantified after exposure to various treatments (e.g., forskolin, insulin, testosterone, and combinations thereof).

MAIN OUTCOME MEASURE(S)

Quantification of mRNA for DHEA sulfotransferase (SULT2A1) by real-time reverse transcription-polymerase chain reaction and measurement of steroid production by radioimmunoassay.

RESULT(S)

Testosterone decreased DHEAS and cortisol, and increased DHEA secretion by H295R cells; the inhibitory effects of testosterone on DHEAS and cortisol production were augmented by insulin. There was a trend toward an increase in the transcription of SULT2A1 by insulin and testosterone.

CONCLUSION(S)

Testosterone and insulin appear to be modulators of adrenal androgen production in this human adrenocortical cell model. These results suggest that testosterone may augment DHEA secretion in the human adrenal, although they do not support the role of this sex steroid or insulin on the elevated DHEAS levels frequently observed in polycystic ovary syndrome.

Evaluation of effects of an oral contraceptive containing ethinylestradiol combined with drospirenone on adrenal steroidogenesis in hyperandrogenic women with polycystic ovary syndrome

OBJECTIVE

To investigate whether the administration of an oral contraceptive containing the new antiandrogenic drospirenone is associated with reduced adrenal androgen synthesis in hyperandrogenic women with diagnosis of polycystic ovary syndrome. Drospirenone, an analogue of spironolactone and aldosterone antagonist, is a novel progestin under clinical development that is similar to the natural hormone progesterone, combining potent progestogenic with antimineralocorticoid and antiandrogenic activities.

DESIGN

Prospective study.

SETTING

Healthy volunteers in University Department of Obstetrics and Gynecology.

PATIENT(S)

Fifteen women ages 18 to 28 years with the diagnosis of polycystic ovary syndrome.

INTERVENTION(S)

Three months of contraceptive use (30 mcg ethinylestradiol, 3 mg drospirenone).

MAIN OUTCOME MEASURE(S)

An adrenocorticotropic hormone test was performed before and after the study.

RESULT(S)

Adrenal production of cortisol was unchanged after therapy with oral contraceptives. An interesting observation was reduced basal concentrations of androgens such as androstenedione, dehydroepiandrosterone sulfate, testosterone, and free testosterone during therapy. The ratios of the areas of substrates to products before and after oral contraceptive administration were compared for differences in 17alpha-hydroxylase (17-hydroxyprogesterone/progesterone) and 17,20-lyase (androstenedione/17-hydroxyprogesterone); activities were significantly reduced, indicating a reduction in the activities of these enzymes.

CONCLUSION(S)

The present results show for the first time that oral contraceptives containing drospirenone affect adrenal steroidogenesis by reducing synthesis and release of androgens in response to adrenocorticotropic hormone, leaving adrenal production of cortisol unchanged.

Production rates of cortisol in men with hypogonadism

Healthy men have a larger endogenous cortisol production rate (PR) than healthy women. To investigate whether this sex-specific difference is maintained in men with low serum testosterone concentrations the endogenous PRs (2 pm to 6 pm) of testosterone, dihydrotestosterone (DHT), and cortisol were simultaneously determined in 10 hypogonadal men. As expected, hypogonadal men were characterized by subnormal PRs of testosterone (19.6 +/- 5.7 microg/h; normal, 180 to 346 microg/h) and of DHT (1.6 +/- 1.1 microg/h; normal, 11 to 20 microg/h). In hypogonadal patients with an intact pituitary-adrenal axis (n = 8), plasma concentrations (7.3 +/- 1.8 microg/dL), metabolic clearance rates (MCRs) (10.0 +/- 4.6 L/h), and endogenous PRs (0.6 +/- 0.2 mg/h) of cortisol were comparable to those seen in eugonadal men. Hence, the sex-specific difference in endogenous cortisol PRs does not depend on the prevailing serum concentrations and on the endogenous PRs of testosterone.

Polymorphisms of the androgen receptor gene and the estrogen receptor beta gene are associated with androgen levels in women

To elucidate the possible role of genetic variation in androgen receptor (AR), estrogen receptor alpha (ER alpha), and ER beta on serum androgen levels in premenopausal women, the CAG repeat polymorphism of the AR gene, the TA repeat polymorphism of the ER alpha gene, and the CA repeat polymorphism of the ER beta gene were studied in a population-based cohort of 270 women. Total testosterone, free testosterone, dehydroepiandrosterone sulfate, androstenedione, 17-hydroxyprogesterone, 3 alpha-androstanediol glucuronide, 17 beta-estradiol, LH, FSH, and sex steroid hormone-binding globulin (SHBG) were measured in serum samples obtained in the follicular phase of the menstrual cycle. Women with relatively few CAG repeats in the AR gene, resulting in higher transcriptional activity of the receptor, displayed higher levels of serum androgens, but lower levels of LH, than women with longer CAG repeat sequences. The CA repeat of the ER beta gene also was associated with androgen and SHBG levels; women with relatively short repeat regions hence displayed higher hormone levels and lower SHBG levels than those with many CA repeats. In contrast, the TA repeat of the ER alpha gene was not associated with the levels of any of the hormones measured. Our results suggest that the serum levels of androgens in premenopausal women may be influenced by variants of the AR gene and the ER beta gene, respectively.

Relationships between dehydroepiandrosterone-sulphate and anthropometric, metabolic and hormonal variables in a large cohort of obese women

OBJECTIVE

The aim of the present study was to measure dehydroepiandrosterone-sulphate (DHEA-S) levels in obesity and assess the relationships between DHEA-S and anthropometric, metabolic and hormonal variables.

SUBJECTS AND METHODS

We evaluated the serum DHEA-S levels in 217 obese but otherwise normal female subjects (age (mean +/- SEM): 39.4 +/- 0.9, range 18-67 years, body mass index (BMI) = 36.1 +/- 0.4, range 27.1-57.1 kg/m2).

RESULTS

DHEA-S levels showed an age-dependent fall similar to that observed in normal women (n = 156, age 46.2 +/- 1.2, range 22-69 years, BMI < 25 kg/m2). Adjusting for age, obese women had mean DHEA-S levels higher than the control group (P < 0.02). In obese patients, DHEA-S levels were directly associated with serum testosterone, androstendione, IGF-I, fT3 levels and 24 h-urinary cortisol. On the other hand, DHEA-S levels were negatively associated with age, total cholesterol, triglycerides levels and systolic blood pressure. No correlation was found with BMI, waist:hip ratio, basal and post-OGTT insulin and glucose, free fatty acids, GH, PRL, fT4, TSH, SHBG levels or diastolic blood pressure. Multiple regression analysis indicated that in obese women, DHEA-S levels were associated negatively to age and positively to testosterone, androstendione and IGF-I levels and daily urinary cortisol. In a subgroup of 20 obese women, DHEA-S levels significantly (P < 0.001) fell after OGTT without any correlation with the insulin response.

CONCLUSIONS

The present results show that dehydroepiandrosterone-sulphate levels are not reduced in obesity, being slightly increased, particularly in young adulthood. Dehydroepiandrosterone-sulphate levels are positively and independently associated with androgen, 24-h urinary cortisol and IGF-I levels but do not seem associated with insulin levels or cardiovascular risk indices.

Polycystic ovary syndrome

Polycystic ovary syndrome is a syndrome and not a disease. It reflects multiple potential etiologies and variable clinical presentations that are reviewed in this article. In addition to menstrual dysfunction and hyperandrogenism, women with polycystic ovary syndrome also may have hypothalamic-pituitary abnormalities, polycystic ovaries on pelvic ultrasonography, infertility, obesity, and insulin resistance. A familial pattern occurs in some cases, suggesting a genetic component to the disorder. The three major pathophysiologic hypotheses that have been proposed to explain the clinical findings of the disorder as well as treatment options are reviewed in this article.

Transient hyperandrogenemia and its relation to ovulation

OBJECTIVE

To study serum androgen levels in relation to ovulation.

DESIGN

Prospective, controlled clinical study.

SETTING

Outpatient endocrine department of a public central hospital.

PATIENT(S)

Forty-eight consecutive young, nonobese, hirsute women.

INTERVENTION(S)

Endocrine evaluation between days 2 and 5 and between days 22 and 25 of a spontaneous menstrual cycle.

MAIN OUTCOME MEASURE(S)

Levels of FSH, LH, E2, P, androstenedione (A), total testosterone (T), DHEAS, and 17alpha-hydroxyprogesterone (17-OHP).

RESULT(S)

Hyperandrogenemia occurred equally in a persistent (56%) or a transient form (44%). Transient hyperandrogenemia was more common in the early follicular phase in ovulatory cycles and in the second phase in delayed or anovulatory cycles (63% and 37% versus 10% and 90%, respectively). In delayed or anovulatory cycles, A, total T, and DHEAS increased significantly during the delayed follicular phase.

CONCLUSION(S)

In delayed or anovulatory cycles, transient hyperandrogenemia occurs late in the follicular phase because of previous ineffective steroidogenesis. In contrast, in ovulatory cycles, transient hyperandrogenemia occurs mainly in the early follicular phase. After ovulation, effective aromatization attenuates the condition. During evaluation and medical treatment of hirsutism, physicians should consider the common occurrence of transient hyperandrogenemia and its relation to ovulation.

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.

Effects of flutamide on pituitary and adrenal responsiveness to corticotrophin releasing factor (CRF)

OBJECTIVE

Flutamide is a non-steroid antiandrogen that specifically blocks the androgen receptor. We have investigated the effect of flutamide treatment on the adrenal androgen response to corticotrophin releasing factor (CRF) in eight patients with polycystic ovary syndrome (PCOS).

PATIENTS

Eight women with moderate to severe hirsutism, ranging in age from 19 to 23 years were enrolled in the study. Basal hormonal pattern showed anovulatory cycles, increased concentrations of LH, androstenedione and testosterone and increased LH/ FSH ratio. A baseline ultrasound scan revealed polycystic ovaries in all patients. Each received 250 mg of Flutamide twice a day for 6 months.

MEASUREMENTS

Before treatment and at the end of the sixth month, women were evaluated for hirsutism score and a CRF test was performed to evaluate ACTH, cortisol and adrenal androgen responses.

RESULTS

Androstenedione (delta 4), DHEA-S, 17-hydroxy-progesterone, testosterone and free-testosterone showed significantly reduced responses after six months of flutamide therapy whereas ACTH and cortisol response were similar to those before treatment. Clinical improvement in the degree of hirsutism was observed in all patients. The Ferriman-Gallwey scores decreased from a mean of 22 +/- 2 to 8 +/- 1.5.

CONCLUSION

Flutamide induces a significant reduction in adrenal androgen response to the CRF test but not in the response of ACTH and cortisol. The finding that flutamide does not alter the pituitary-adrenal axis shows that flutamide acts by reducing adrenal androgens. These results demonstrate that flutamide is not only effective in the treatment of hirsutism but also reduces adrenal androgen secretion.

Postmenopausal virilization in a woman with gonadotropin dependent ovarian hyperthecosis

We report a case of a 66-yr-old woman with progressive hair balding, hirsutism and virilization. Gonadotropins and estradiol levels were in the postmenopausal range; total testosterone (TT), free testosterone (FT) and 17-hydroxyprogesterone (17-OHP) were elevated with dehydroepiandrosterone sulphate, androstendione and cortisol serum levels in the normal range, as 24-hr free urinary cortisol. TT, FT and 17-OHP were normalized, and FSH and LH fell to premenopausal levels on 18th day after a single i.m. injection of the GnRH analogue (GnRHa), triptorelin. Then, a diagnosis of hyperandrogenism of ovarian origin was made and bilateral ovariectomy was performed. Histological study of gonadal tissue revealed diffuse stromal hyperplasia of both ovaries with occasional nests of luteinized cells. With immunoperoxidase techniques these cells stained positively for testosterone and progesterone. One month after surgery, androgen levels were normalized together with regression of most of the clinical signs of virilization. In conclusion, our patient showed a severe virilization developed after menopause; hormonal investigations suggested a gonadotropin dependent ovarian hyperandrogenism, confirmed by histological examination; the presence of luteinized cells in the ovarian stroma was responsible for hyperandrogenism, as confirmed by the immunoperoxidase technique.

A critical review of the origin and control of adrenal androgens

The reticularis and fasciculata zones of the adrenal cortex are the predominant sources of dehydroepiandrosterone (DHEA) and DHEA-sulphate and contribute directly or indirectly 60-75% of androstenedione and testosterone in women. The specific control of adrenal androgens remains unclear. While ACTH stimulates adrenal androgen secretion, the dissociation of cortisol and androgens occurring during adrenarche and under pathological conditions suggests other factors are involved. Recent studies using human adrenal cells in vitro have demonstrated that the ratio of androgen to cortisol produced is substantially independent of the age and gender of the adrenal, indicating that extra-adrenal factors are of greater importance. beta-Endorphin and joining peptide have been shown to stimulate androgen production in human adrenal cells and to influence ACTH-stimulated steroidogenesis in a manner that promotes adrenal androgen production. The activity of these pro-opiomelanocortin-derived peptides may explain the physiological and pathological dissociations of androgens and cortisol.

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.

Overdiagnosis of 21-hydroxylase late onset congenital adrenal hyperplasia: correlation of corticotropin test and human leukocyte antigen typing

OBJECTIVE

To evaluate the reliability of the ACTH test as a means for detection of late onset congenital adrenal hyperplasia (CAH) and discriminating it from polycystic ovary syndrome (PCOS), by repeating the test after 6 months of cyproterone acetate and ethinyl E2 treatment.

DESIGN

Follow-up comparison study.

SETTING

Reproductive Endocrinology in an university tertiary center.

PATIENTS

Thirty-one young women with hirsutism, oligoamenorrhea, and acne, 21 of them detected as late onset CAH, and 10 as non-late onset CAH (PCOS).

INTERVENTION

Cyproterone acetate and ethinyl E2 treatment for > or = 6 months. The ACTH test, before and after 6 months of cyproterone acetate + ethinyl E2 treatment, and human leukocyte antigen (HLA) typing.

MAIN OUTCOME MEASURE

The ACTH test interpretation correlated to HLA typing.

RESULTS

By repeating the ACTH stimulation test in the 31 women (after cyproterone acetate + ethinyl E2 administration), we found a diminution in the rate of accumulation of 17 alpha-hydroxyprogesterone (delta 17-OHP) + P, in all 21-hydroxylase late onset CAH cases. As a result of treatment with cyproterone acetate + ethinyl E2, a decrease in the accumulation rate of 17-OHP + P, below the discriminative value for late onset CAH (6.5 ng/dL per minute), was noted among 12 of 21 women defined primarily as late onset CAH. Among the nine other women, a decrease in the accumulation rate of 17-OHP + P was noted, however not < 6.5 ng/dL per minute.

CONCLUSIONS

The interpretation of delta 17-OHP + P for the diagnosis of late onset CAH may be too sensitive as to the correct clinical diagnosis of late onset CAH. By repeating the ACTH test after 6 months of treatment with cyproterone acetate-ethinyl E2, specificity and accuracy may be improved.

Effects of gonadal androgens and oestrogens on adrenal androgen levels

OBJECTIVE

The physiological role of adrenal androgens in humans remains unclear. Furthermore, there are few data on the relation between sex steroids and adrenal androgen production. We have assessed the effects of sex steroid hormone administration on adrenal androgen levels, by studying a large group of transsexual patients.

DESIGN

A non-randomized intervention.

SETTING

A university teaching hospital.

PATIENTS

Thirty-one male-to-female and 22 female-to-male transsexual patients.

MEASUREMENTS

Plasma levels of adrenal androgens were measured in a group of male-to-female and female-to-male transsexual patients both before and during cross-gender hormone treatment. This treatment involves administration of testosterone esters to women and of ethinyloestradiol and cyproterone acetate to men.

RESULTS

High dose sex steroid administration had marked effects on adrenal androgens levels, which decreased by 27-48% in males treated with ethinyloestradiol and increased by 23-70% in females treated with testosterone.

CONCLUSION

We conclude that administration of high doses of testosterone and oestradiol exert opposing effects on adrenal androgen production.

Raised serum 11-deoxycortisol in men with persistent acne vulgaris

OBJECTIVE

Acne vulgaris is androgen dependent but the hormonal mechanisms are unclear. Although there have been many studies of serum hormones in women with acne there are few studies in men and the results are conflicting. We have therefore carried out a further study in men.

DESIGN AND PATIENTS

Fifty men with acne vulgaris were age-matched against 50 normal men.

MEASUREMENTS

Serum levels of dehydroepiandrosterone sulphate (DHEAS), 17 alpha-hydroxyprogesterone, 11-deoxycortisol, androstenedione and testosterone were measured by radioimmunoassay, sex hormone binding globulin (SHBG) by immunoradiometric assay and LH, FSH and oestradiol by automated ELISA.

RESULTS

The acne patients had higher levels of androstenedione, median 7.35 nmol/l, (interquartile range 2-7) vs 6.05 (2.3), P = 0.004; testosterone, 21.7 nmol/l (7.5) vs 17.55 (7.7), P = 0.04; and free androgen index (FAI) 78.26 (40) vs 65.06 (20), P = 0.007, but also had higher levels of 11-deoxycortisol, 13.65 nmol/l (4.3) vs 12.0 (4.3), P = 0.022. The LH, FSH, 17 alpha-hydroxyprogesterone, DHEAS, oestradiol and SHBG levels were not significantly different. Examination of the Spearman rank correlation coefficient matrices for the serum levels of 17 alpha-hydroxyprogesterone, androstenedione and 11-deoxycortisol showed that the strongest correlation was between androstenedione and 11-deoxycortisol.

CONCLUSION

Although there was overlap between the results of the acne patients and controls the acne patients tended to have higher levels of androstenedione, testosterone, free androgen index and 11-deoxycortisol. The higher levels of 11-deoxycortisol are suggestive of 11 beta-hydroyxlase dysfunction which could be due to a primary adrenal defect or a consequence of raised androgens. Also, a pathway between androstenedione and 11-deoxycortisol has been described in sheep and, although unsubstantiated in man, requires consideration.

Ovarian influence on adrenal androgen secretion in polycystic ovary syndrome

OBJECTIVE

To determine whether the ovary influences adrenal androgen secretion in polycystic ovary syndrome (PCOS).

DESIGN

The adrenal androgen secretion was evaluated before and during ovarian suppression with a long-acting GnRH agonist.

SETTING

Department of Obstetrics and Gynecology, Pisa, Italy.

PARTICIPANTS

Women with PCOS and high (10 subjects) and normal (12 subjects) DHEAS levels and 6 normal women.

INTERVENTIONS

After 1 mg dexamethasone, an ACTH-(1-24) stimulation test was performed in the early follicular phase of the menstrual cycle. The test was repeated after two injections of a long-acting GnRH analogue (GnRH-a).

MAIN OUTCOME MEASURES

Basal plasma levels of gonadotropins, E2, T, androstenedione (A), 17 alpha-hydroxyprogesterone (17-OHP), DHEAS, and cortisol (F) were evaluated before the evening administration of dexamethasone. Serum A, T, 17-OHP, DHEAS, and F were measured 9 hours after dexamethasone and in samples collected 60 and 120 minutes after ACTH IV injection.

RESULTS

In the high DHEAS group the maximum increases in T, A, 17-OHP, and DHEAS in response to ACTH were significantly higher than in normal DHEAS PCOS women and in normal women. The GnRH-a modified the A and T responses to ACTH in the high DHEAS group.

CONCLUSIONS

Ovarian steroids, or other extra-ovarian factors, seem to be responsible for the increased A and T responses to the corticotropin stimulation demonstrated in some PCOS women.

Ovarian suppression reduces clinical and endocrine expression of late-onset congenital adrenal hyperplasia due to 21-hydroxylase deficiency

OBJECTIVE

To determine the effectiveness of GnRH-agonist (GnRH-a) treatment in women with late onset congenital adrenal hyperplasia.

DESIGN

Prospective assessment of GnRH-a treatment in six women with documented late-on-set congenital adrenal hyperplasia who were not preselected. Comparisons were made to previous responses in the same patients receiving dexamethasone. Eight age- and weight-matched ovulatory women served as controls.

SETTING

Academic medical center.

INTERVENTION

Baseline blood determinations before and after i.v. ACTH, before and after 6 months of GnRH-a treatment. Estrogen and progestin replacement was begun in all women after the 3rd month of treatment.

MAIN OUTCOME MEASURES

Serum 17-hydroxyprogesterone (17-OHP), gonadotropin, and androgen levels before and after GnRH-a treatment. Responses of 17-OHP and androgens to ACTH assessment of hirsutism using a modified Ferriman-Gallwey score.

RESULTS

Gonadotropins, estrogen, androgen, and 17-OHP were suppressed with GnRH-a treatment. Levels were similar before and after estrogen and progestin replacement. Responses of 17-OHP after ACTH were blunted but still were elevated compared with responses in controls. Ferriman-Gallwey scores decreased significantly (-8 +/- 1; mean +/- SE). This response was greater than that observed previously with 6 months of dexamethasone (-2 +/- 0.3).

CONCLUSIONS

Suppression of the ovary with GnRH-a treatment was beneficial in these patients with late-onset congenital adrenal hyperplasia. An ovarian influence on the clinical and biochemical findings of the disorder is suggested.

Ovarian suppression with triptorelin and adrenal stimulation with adrenocorticotropin in functional hyperadrogenism: role of adrenal and ovarian cytochrome P450c17 alpha

OBJECTIVES

To validate combined ovarian suppression with triptorelin and adrenal stimulation with ACTH in the diagnosis of female hyperandrogenism and to provide new insights into the adrenal-ovarian relationship present in this disorder.

DESIGN

Comparison of sexual steroids and basal and ACTH-stimulated steroid levels before and after ovarian suppression induced by triptorelin.

SETTING

Department of Endocrinology, Hospital Ramón y Cajal, Madrid, Spain.

PARTICIPANTS

Thirty-nine nonselected women with hyperandrogenism.

MAIN OUTCOME MEASURES

Serum levels of T, 17-hydroxyprogesterone (17-OHP), 17-hydroxy-pregnenolone, DHEA and DHEAS, androstenedione (delta 4-A), 11-deoxycortisol, and cortisol.

RESULTS

Elevated T independent of ovarian suppression pointed to an adrenal disorder in six patients (one with an androgen-producing adenoma, two with late-onset 21-hydroxylase deficiency, three with functional adrenal hyperandrogenism). Nineteen patients had functional ovarian hyperandrogenism as elevated T normalized after ovarian suppression and were subdivided into ovDHEAS+ (n = 7) and ovDHEAS = (n = 12) subgroups depending on the presence of DHEAS hypersecretion. Finally, 14 patients had idiopathic hirsutism according to normal T before and after ovarian suppression. Comparisons of initial hormonal values between groups and with reference values obtained from normal women (n = 11) disclosed in functional adrenal hyperandrogenism an elevation of T and basal and stimulated DHEAS, delta 4-A, and 17-OHP with respect to normal women. These abnormalities were also present in ovDHEAS+ except for basal delta 4-A, which was normal, whereas only T and stimulated 17-OHP were elevated in ovDHEAS =. In the idiopathic group all steroids were normal with the exception of a mild elevation in stimulated DHEAS.

CONCLUSIONS

These results show a continuum of abnormalities in hyperandrogenic women, suggesting an enhanced cytochrome P450c17 alpha activity in the adrenal and the ovary as the shared mechanism between functional adrenal hyperandrogenism and functional ovarian hyperandrogenism.

Testosterone administration increases adrenal response to adrenocorticotrophin

OBJECTIVE

Various studies have demonstrated coexistence of ovarian and adrenal hyperandrogenism in women. This study was designed to determine whether testosterone can increase the response of the adrenal gland to stimulation by adrenocorticotrophin (ACTH).

DESIGN

Non-randomized intervention in a university teaching hospital.

PATIENTS

Twenty androgen-treated female-to-male transsexual patients (10 ovariectomized and 10 non-ovariectomized) and 10 normal female controls.

MEASUREMENTS

ACTH stimulation tests were performed in all subjects. Baseline values and the increase above baseline values after ACTH stimulation were assessed for cortisol and the adrenal androgens androstenedione, dehydroepiandrosterone and dehydroepiandrosterone-sulphate.

RESULTS

Increases in levels of cortisol, androstenedione and dehydroepiandrosterone after administration of ACTH were greater in testosterone-treated transsexual patients than controls.

CONCLUSION

We conclude that testosterone increases the response of the adrenal gland to stimulation by ACTH.

Effect of systemic hyperandrogenism on the adrenal response to adrenocorticotropin hormone

A virilized patient with an androgen-producing ovarian tumor was used to illustrate the effect of chronic hyperandrogenism on the adrenal response to ACTH. The accumulation rates of substrates for 3 beta-ol dehydrogenase, 21-hydroxylase, and 11 beta-hydroxylase remained unchanged after oophorectomy. This suggests that chronic hyperandrogenism does not affect the activity of enzymes involved in adrenal steroidogenesis.

Pituitary-adrenal responses to corticotropin-releasing factor in late onset 21-hydroxylase deficiency

Intravenous corticotropin-releasing factor (CRF) and adrenocorticotropin hormone (ACTH) were administered in patients with adult onset 21-hydroxylase deficiency to compare their diagnostic capability as well as to investigate hypothalamic-pituitary-adrenal function in this disorder. Responses of 17-hydroxyprogesterone, which were markedly elevated compared with controls, were identical with CRF and ACTH. However, intravenous ACTH resulted in higher androstenedione levels in comparison to CRF. Adrenocorticotropin hormone also resulted in decreased cortisol responses, confirming a defect in steroidogenesis, a finding that was not evident with CRF. Plasma ACTH responses to CRF were similar in patients and controls. We conclude that CRF may be as useful as ACTH as a diagnostic test for adult onset 21-hydroxylase deficiency, and that because normal levels of plasma ACTH were evoked by CRF in 21-hydroxylase deficiency, lower doses of exogenous ACTH may be sufficient for making this diagnosis. Although no obvious hypothalamic-pituitary dysfunction could be demonstrated in our patients with 21-hydroxylase deficiency by using CRF, our data confirm the adrenal sensitivity of patients with adult onset 21-hydroxylase deficiency.

Hormonal studies on women with polycystic ovaries diagnosed by ultrasound

Eighty-six patients were diagnosed by ultrasound to have polycystic ovaries. Twelve have fairly regular but anovular cycles (P1), 56 had oligomenorrhoea (P2) and eight had primary or secondary amenorrhoea (P3). The remaining 10 patients had raised progesterone concentrations and were excluded from the hormonal studies. Gonadotrophins, steroid hormones and sex hormone binding globulin (SHBG) were measured in all patients and the results were compared with those of 29 normal women who acted as controls. A high LH:FSH ratio was the most frequently found abnormality (raised in 68.4% of patients) followed by LH (65.8%), free testosterone (FT, calculated from total testosterone (T) and SHBG) (59.2%) and 17-OHP (48.7%). Each of these four estimations was above the normal ranges in 25% of patients: proportionally most of the results outside the normal range occurred in group P3 followed by P2 and P1 respectively. To obtain a quantitative measure of the abnormalities, results were expressed as percentages of the mean control value for each hormone and these percentages were then summated. The four measurements, LH:FSH ratio, LH, FT and 17-OHP gave abnormality scores ranging from a mean of 667 in P1 to 1189 in P3 compared with 405 in controls. Twenty-one of the 76 patients were hirsute with significantly higher androgens than the nonhirsute patients. Their mean abnormality score was 1141 compared with 855 in the non-hirsute group and they all had at least one hormonal abnormality. The study demonstrates that there is a relationship between the degree of hormonal abnormality and the menstrual irregularities and hirsutism in women with PCOS suggesting that there may be a progressive nature to the syndrome.

Reproductive endocrinologic alterations in female asymptomatic obesity

Excess body fat has been clearly associated with an increased risk of oligo-ovulation and endometrial/breast carcinoma. The connection has been assumed to lie within derangements of the metabolic/endocrine compartments, particularly of estrogens and androgens. To differentiate the effect of obesity from its related disease process, an attempt has been made to define the reproductive-endocrinologic alterations encountered in otherwise asymptomatic obese women. Androgen metabolism is accelerated in obesity. It is not clear whether the increased clearance precedes or follows the accelerated production of androgens. A servocontrol mechanism appears to be operative in these asymptomatic individuals, maintaining plasma steroid levels normal. The unbound fraction of T may be somewhat increased in overweight women with predominantly upper body fat deposition. The increased clearance of androgen may arise from an obesity-related depression in SHBG concentration (e.g., for T, E2, delta 5-diol, etc.). Adipose tissue, by virtue of the lipid solubility of most of these steroids, concentrates androgens, estrogens, and progesterone. This steroid sequestration not only contributes to the obesity-related increase in androgen clearance but also leads to an extremely enlarged total body steroid pool. Fat tissue sequestration also increases the concentration of androgens in the vicinity of adipose stromal cells, possibly encouraging their aromatization. Adipose tissue also has a moderate degree of 17-hydroxysteroid dehydrogenase activity, which appears to stimulate the conversion of A to T. Finally, alterations in peripheral and hepatic conjugation and an accelerated urinary excretion may contribute to the elevated clearance of androgens. The accelerated PR of androgens may simply result as compensation for the elevated MCR in obesity. Nonetheless, evidence of alteration(s) in adrenocortical steroidogenesis has been presented suggesting a selective obesity-related enhancement in adrenal androgen secretion. These remain to be confirmed. Nonetheless, adrenocortical abnormalities may arise secondary to the influence of other circulating and intra-adrenal factors, including insulin, prolactin, estrogens, and androgens. It is not known whether the accelerated androgen metabolism or the aberrant adrenal steroidogenesis improve with weight reduction. Excess body fat increases androgen aromatization which, together with an obesity-related decrease in SHBG, is associated with mildly elevated levels of E1 and free E2 in postmenopausal women. Although premenopausal obese individuals have the same tendency, the far greater ovarian estrogen secretion overshadows any differences. The bulk of aromatization activity in fat lies in the stromal comportment. The major substrate for peripheral estrogen production is A. Testosterone also contributes to the estrogen pool via its conversion to E2.(ABSTRACT TRUNCATED AT 400 WORDS)