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Kolnikaj TS, Herman R, Janež A, Jensterle M. The Current and Emerging Role of Statins in the Treatment of PCOS: The Evidence to Date. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:244. [PMID: 38399531 PMCID: PMC10890374 DOI: 10.3390/medicina60020244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 01/18/2024] [Accepted: 01/23/2024] [Indexed: 02/25/2024]
Abstract
Polycystic ovary syndrome (PCOS) manifests a multifactorial pathology characterized by polycystic ovaries, menstrual cycle disorders, varying degrees of hyperandrogenism, and an ad-verse metabolic risk profile. The position of hyperandrogenism in this syndrome has been extensively studied. A multitude of mechanisms place it in the position of cause but also of consequence; therefore, ongoing research efforts are focused on identifying medications that can effectively reduce levels of androgens in women with PCOS. Moreover, lipid abnormalities are common in this population, with up to 70% of patients having dyslipidemia. Statins may have potential therapeutic benefits for women with PCOS, as they have been shown to improve insulin resistance and reduce the risk of cardiovascular disease. In addition, their role in accelerated steroidogenesis by limiting one source of cholesterol, influencing enzymatic activity, and providing several other beneficial mechanisms is widely investigated. This review aimed to provide a comprehensive overview of the pathogenesis of androgen excess and dyslipidemia in PCOS, as well as the therapeutic potential of statins.
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Affiliation(s)
- Tea Shehu Kolnikaj
- Department of Endocrinology, Diabetes and Metabolic Diseases, University of Medicine Tirana, 1000 Tirana, Albania;
| | - Rok Herman
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia; (R.H.); (A.J.)
- Department of Internal Medicine, Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Andrej Janež
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia; (R.H.); (A.J.)
- Department of Internal Medicine, Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Mojca Jensterle
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia; (R.H.); (A.J.)
- Department of Internal Medicine, Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
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Zhou YY, Wu YQ, Chong CJ, Zhong SM, Wang ZX, Qin XH, Liu ZQ, Liu JY, Song JL. Irpex lacteus polysaccharide exhibits therapeutic potential for ovarian fibrosis in PCOS rats via the TGF- β1/smad pathway. Heliyon 2023; 9:e18741. [PMID: 37554783 PMCID: PMC10405015 DOI: 10.1016/j.heliyon.2023.e18741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 07/10/2023] [Accepted: 07/26/2023] [Indexed: 08/10/2023] Open
Abstract
Polycystic ovarian syndrome (PCOS) is one of the commonest endocrinopathies in childbearing women. The research was conducted to assess the impact of Irpex lacteus polysaccharide (ILP, 1000 mg/kg) on the letrozole (1 mg/kg)-induced PCOS model in female rats. Metformin (Met, 265 mg/kg) as the positive control. The study suggested that ILP restored the estrous cycle in rats with PCOS as well as lowered relative ovarian weight and body weight, in comparison to normal. Rats with PCOS showed improvement in ovarian structure and fibrosis when given ILP. ILP decreased the testosterone (T), low-density lipoprotein cholesterol (LDL-C), triglyceride (TG), total cholesterol (TC), luteinizing hormone (LH), homeostasis model assessment-insulin resistance (HOMA-IR), fasting blood glucose (FBG), and insulin (INS) levels and elevated the follicle-stimulating hormone (FSH) and estrogen (E2) levels in PCOS rats. In addition, ILP increased the content of superoxide dismutase (SOD) in serum and the antioxidant enzymes (Prdx3, Sod1, Gsr, Gsta4, Mgst1, Gpx3, Sod2 and Cat) expression levels in the ovaries and decreased the serum expression of malondialdehyde (MDA). In addition, ILP treatment slowed down the process of the fibrosis-associated TGF-β1/Smad pathway and downregulated α-smooth muscle actin (α-SMA) and connective tissue growth factor (CTGF) levels in PCOS rats ovaries. According to these findings, ILP may be able to treat letrozole-induced PCOS in rats by ameliorating metabolic disturbances, sex hormone levels, oxidative stress, and ovarian fibrosis.
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Affiliation(s)
- Yan-Yuan Zhou
- Department of Pharmacy, School of Pharmacy, Guilin Medical University, Guilin, 541199, China
| | - Ya-Qi Wu
- Department of Pharmacy, School of Pharmacy, Guilin Medical University, Guilin, 541199, China
| | - Chao-Jie Chong
- Department of Pharmacy, School of Pharmacy, Guilin Medical University, Guilin, 541199, China
| | - Shu-Mei Zhong
- Department of Nutrition and Food Hygiene, School of Public Health, Guilin Medical University, Guilin, 541199, China
| | - Zi-Xian Wang
- Department of Nutrition and Food Hygiene, School of Public Health, Guilin Medical University, Guilin, 541199, China
| | - Xiao-Hui Qin
- Department of Pharmacy, School of Pharmacy, Guilin Medical University, Guilin, 541199, China
| | - Zhi-Qiang Liu
- Department of Pharmacy, School of Pharmacy, Guilin Medical University, Guilin, 541199, China
| | - Jun-Yang Liu
- Department of Nutrition and Food Hygiene, School of Public Health, Guilin Medical University, Guilin, 541199, China
| | - Jia-Le Song
- Department of Nutrition and Food Hygiene, School of Public Health, Guilin Medical University, Guilin, 541199, China
- Department of Clinical Nutrition, Second Hospital Affiliated to Guilin Medical University, Guilin, 541100, China
- Guangxi Key Laboratory of Environmental Exposomics and Entire Lifecycle Health, Guilin Medical University, Guilin, 541199, China
- South Asia Branch of National Engineering Research Center of Dairy Health for Maternal and Child Health, Guilin University of Technology, Guilin, 541004, China
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Xia Q, Xie L, Wu Q, Cong J, Ma H, Li J, Cai W, Wu X. Elevated baseline LH/FSH ratio is associated with poor ovulatory response but better clinical pregnancy and live birth in Chinese women with PCOS after ovulation induction. Heliyon 2023; 9:e13024. [PMID: 36711322 PMCID: PMC9876966 DOI: 10.1016/j.heliyon.2023.e13024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 01/10/2023] [Accepted: 01/12/2023] [Indexed: 01/19/2023] Open
Abstract
Background What is the association between elevated baseline LH/FSH ratio and reproductive outcomes, especially ovulatory response, among Chinese women with polycystic ovary syndrome (PCOS) after ovulation induction. Methods This was a secondary analysis of a multicenter randomized trial in 1000 women with PCOS from 21 sites (27 hospitals) in Mainland China. LH and FSH levels before ovulation induction and the main outcomes including ovulation, biochemical pregnancy, clinical pregnancy, miscarriage, and live birth were measured. A linear regression model, logistic regression models and Cox proportional hazard regression model were used to estimate the association between LH/FSH ratios and reproductive outcomes in PCOS. Results LH/FSH ratio was significantly associated with age, body mass index (BMI), total testosterone (TT), estradiol (E2), free testosterone (FT), and antimullerian hormone (AMH). Anovulatory women had significantly higher LH/FSH ratio than ovulatory women (P = 0.003), especially in women with young age (P = 0.023), high BMI (P = 0.002), low E2 (P = 0.002), FT (P = 0.010), TT (P < 0.001) and AMH(P = 0.032). Women with elevated LH/FSH ratio were associated with lower ovulation (LH/FSH≥1 OR = 0.42, 95% CI, 0.26-0.68; LH/FSH≥2 OR = 0.32, 95% CI, 0.20-0.54; LH/FSH≥3 OR = 0.40, 95% CI 0.21-0.74) when compared with LH/FSH<1. The association was held after adjustment for treatment with or without the confounding factors. Although no association between LH/FSH ratio and biochemical pregnancy, women with 1 ≤ LH/FSH<2 were associated with higher clinical pregnancy (OR = 1.71; 95% CI, 1.09-2.67) and live birth (OR = 1.73; 95% CI, 1.09-2.75) compared to women with LH/FSH<1. Women with 2 ≤ LH/FSH<3 were associated with lower miscarriage rate (OR = 0.38; 95% CI, 0.16-0.93). Conclusions Elevated baseline LH/FSH ratio in women with PCOS was associated with poor ovulatory response, but women were more likely to achieve clinical pregnancy and live birth than women with normal LH/FSH. It suggests LH and FSH in women with PCOS may play a role in successful pregnancy despite of negative impact in ovulation.
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Affiliation(s)
- Qing Xia
- Department of Obstetrics and Gynaecology, Heilongjiang University of Chinese Medicine, Harbin 150001, China,Department of Obstetrics and Gynaecology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100010, China
| | - Liangzhen Xie
- Department of Obstetrics and Gynaecology, Heilongjiang University of Chinese Medicine, Harbin 150001, China
| | - Qi Wu
- Department of Obstetrics and Gynaecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200000, China,Department of Obstetrics and Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong City 999077, Hong Kong
| | - Jing Cong
- Department of Obstetrics and Gynaecology, Heilongjiang University of Chinese Medicine, Harbin 150001, China
| | - Hongli Ma
- Department of Obstetrics and Gynaecology, Heilongjiang University of Chinese Medicine, Harbin 150001, China
| | - Jian Li
- Department of Obstetrics and Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong City 999077, Hong Kong,Department of Obstetrics and Gynecology, The Affiliated Hospital, Gui Zhou Medical University, Gui Zhou 550000, China
| | - Wangyu Cai
- Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu 322000, China
| | - Xiaoke Wu
- Department of Obstetrics and Gynaecology, Heilongjiang University of Chinese Medicine, Harbin 150001, China,Heilongjiang Provincial Hospital, Harbin Institute of Technology, Harbin 150001, China,Corresponding author. First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, China.
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Pirtea P, Ayoubi JM, Desmedt S, T’Sjoen G. Ovarian, breast, and metabolic changes induced by androgen treatment in transgender men. Fertil Steril 2021; 116:936-942. [DOI: 10.1016/j.fertnstert.2021.07.1206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 07/27/2021] [Accepted: 07/28/2021] [Indexed: 01/15/2023]
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Homer MV, Rosencrantz MA, Shayya RF, Chang RJ. The effect of estradiol on granulosa cell responses to FSH in women with polycystic ovary syndrome. Reprod Biol Endocrinol 2017; 15:13. [PMID: 28187771 PMCID: PMC5303291 DOI: 10.1186/s12958-017-0230-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 02/08/2017] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The influence of estradiol (E2) on granulosa cell (GC) function has not been tested clinically in women with polycystic ovary syndrome (PCOS). The objective of this study is to determine if E2 influences GC responses to FSH in women with PCOS. METHODS This is a two phase, single cohort study conducted over a 2-year period at a single academic center. Nine women with PCOS according to NIH criteria. In Phase 1, FSH stimulation of GC responses as measured by E2 and Inhibin B (Inh B) were assessed before and at 5 and 6 weeks after GnRH agonist administration. In Phase 2, the same protocol was employed with the addition of an aromatase inhibitor (letrozole, LET) administered daily beginning at week 4 for 2 weeks. RESULTS In Phase 1, recovery of FSH, E2 and Inh B from ovarian suppression occurred at 5 and 6 weeks after GnRH agonist injection and preceded resumption of LH and androgen secretion. In Phase 2, hormone recovery after GnRH agonist was characterized by elevated FSH and suppressed E2 levels whereas recovery of LH and androgen levels were unchanged. In Phase 1, FSH stimulated E2 and Inh B responses were unaltered during recovery from ovarian suppression. In Phase 2, E2 and Inh B fold changes after FSH were significantly reduced at weeks 5 (p < 0.04) and 6 (p < 0.01), respectively. CONCLUSION In anovulatory women with PCOS, chronic, unopposed E2 secretion may contribute, at least in part, to enhanced ovarian responsiveness to FSH. TRIAL REGISTRATION NCT02389088.
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Affiliation(s)
- Michael V. Homer
- 0000 0001 2107 4242grid.266100.3Reproductive Medicine, University of California, 200 West Arbor Drive MC: 8710, San Diego, CA 92103 USA
| | - Marcus A. Rosencrantz
- Reproductive Endocrinology and Infertility, Southern California Permanente Medical Group, 6650 Alton Parkway, Irvine, CA 92618 USA
| | - Rana F. Shayya
- Obstetrics and Gynecology, Southern California Permanente Medical Group, 250 Travelodge Drive, El Cajon, CA 92020 USA
| | - R. Jeffrey Chang
- 0000 0001 2107 4242grid.266100.3Reproductive Medicine, University of California, 200 West Arbor Drive MC: 8710, San Diego, CA 92103 USA
- 9500 Gilman Drive #0633 La Jolla, San Diego, CA 92093 USA
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Mahalingaiah S, Diamanti-Kandarakis E. Targets to treat metabolic syndrome in polycystic ovary syndrome. Expert Opin Ther Targets 2015; 19:1561-74. [PMID: 26488852 DOI: 10.1517/14728222.2015.1101067] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Metabolic syndrome is comprised of a combination of the following states: increased insulin resistance, dyslipidemia, cardiovascular disease, and increased abdominal obesity. Women with polycystic ovary syndrome (PCOS) have an increased risk of developing metabolic syndrome over the course of their lives. Metabolic syndrome increases risk of major cardiovascular events, morbidity, quality of life, and overall health care costs. Though metabolic syndrome in women with PCOS is an area of great concern, there is no effective individual medical therapeutic to adequately treat this issue. AREAS COVERED This article will review key aspects of metabolic syndrome in PCOS. We will discuss classic and novel therapeutics to address metabolic syndrome in women with PCOS. We will conclude with the importance of developing strategic interventions to increase the compliance to lifestyle and dietary modification, in addition to appreciation of the emerging pharmaceutical therapeutics available. EXPERT OPINION Innovation in lifestyle modification, including diet, exercise, with and without dedicated stress reduction techniques is the future in treatment of metabolic syndrome in PCOS. Application of novel interventions, such as group medical care, may improve future adherence to lifestyle modification recommendations, in addition to or in combination with pharmaceutical therapeutics.
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Affiliation(s)
- Shruthi Mahalingaiah
- a Department of Obstetrics and Gynecology , Boston University School of Medicine , Boston , MA 02118 , USA
| | - Evanthia Diamanti-Kandarakis
- b Department of Endocrinology, Diabetes & Metabolism , University of Athens Medical School , Athens 11521 , Greece
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Abstract
Alterations of ovarian follicle morphology and function have been well documented in women with PCOS. These include increased numbers of growing preantral follicles, failure of follicle growth beyond the mid-antral stage, evidence of granulosa call degeneration, and theca cell hyperplasia. Functional abnormalities include paradoxical granulosa cell hyperresponsiveness to FSH which is clinically linked to ovarian hyperstimulation during ovulation induction. In addition, there is likely a primary theca cell defect that accounts for the majority of excess androgen production in this disorder. The precise mechanisms responsible for altered follicle function are not completely clear. However, several factors appear to influence normal advancement of follicle development as well as impair ovarian steroidogenesis. These include intra- as well as extraovarian influences that distort normal ovarian growth and disrupt steroid production by follicle cells.
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Affiliation(s)
- R Jeffrey Chang
- Division of Reproductive Endocrinology, Department of Reproductive Medicine, University of California, San Diego, School of Medicine, 9500 Gilman Drive, La Jolla, CA 92093-0633, United States.
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Will MA, Palaniappan M, Peegel H, Kayampilly P, Menon KMJ. Metformin: direct inhibition of rat ovarian theca-interstitial cell proliferation. Fertil Steril 2012; 98:207-14. [PMID: 22608319 DOI: 10.1016/j.fertnstert.2012.04.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Revised: 04/10/2012] [Accepted: 04/10/2012] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To determine whether metformin has direct effects on ovarian theca-interstitial (T-I) cell proliferation through activation of adenosine monophosphate-activated protein kinase (AMPK). DESIGN In vitro experimental study. SETTING Academic medical center laboratory. ANIMAL(S) Immature Sprague-Dawley female rats. INTERVENTION(S) Ovarian T-I cells were isolated, purified, and cultured in the absence (control) or presence of insulin (1 μg/mL) with or without metformin or other activators/inhibitors of AMPK (AICAR, compound C). MAIN OUTCOME MEASURE(S) Proliferation assessed by determination of expression levels of proteins involved in cell cycle progression, cyclin D3, and cyclin-dependent kinase 4 (CDK4) with Western blot analysis, and determination of DNA synthesis with bromodeoxyuridine (BrdU) incorporation assay; activation of AMPK, Erk1/2, and S6K1 determined by Western blot analysis with the use of antibodies specific for the phosphorylated (activated) forms. RESULT(S) Metformin inhibited insulin-induced ovarian T-I cell proliferation and the up-regulation of the cell cycle regulatory proteins, cyclin D3 and CDK4. Metformin independently activated AMPK in a dose-dependent manner. Treatment with metformin inhibited insulin-induced activation of Erk1/2 and S6K1. This effect was reversed with the addition of compound C, a known AMPK inhibitor. CONCLUSION(S) Metformin directly inhibits proliferation of ovarian T-I cells via an AMPK-dependent mechanism. These findings further validate the potential benefits of metformin in the treatment of conditions associated with hyperinsulinemia and excessive growth of ovarian T-I cells (such as polycystic ovary syndrome).
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Affiliation(s)
- Matthew A Will
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, Michigan, USA.
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Rosencrantz MA, Wachs DS, Coffler MS, Malcom PJ, Donohue M, Chang RJ. Comparison of inhibin B and estradiol responses to intravenous FSH in women with polycystic ovary syndrome and normal women. Hum Reprod 2009; 25:198-203. [PMID: 19850592 DOI: 10.1093/humrep/dep373] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Inhibin B (Inh B) is produced by pre-antral and early antral follicles whereas estradiol (E(2)) is a product of follicles undergoing antrum formation. This temporal distinction is evident in the patterns of Inh B and E(2) release earlier and later during the follicular phase of the menstrual cycle, respectively. However, in previous studies of women with polycystic ovary syndrome (PCOS) and normal controls, release of these granulosa cell (GC) products appears to be simultaneous in response to FSH stimulation. In order to reconcile these disparate findings, we conducted dose-response studies in both PCOS women and normal controls to determine whether GC product responses were due to the amount of FSH administered. In addition, we compared FSH-stimulated responses in PCOS women at various stages of recovery following ovarian suppression with a long-acting GnRH agonist to examine whether Inh B and E(2) responses reflected the level of ovarian follicle activity (i.e. circulating E(2) levels). METHODS Women with PCOS, 18-35 years (n = 23), and normal ovulatory controls, 18-35 years (n = 10) were recruited for study. Dose-responses were assessed over 24 h following intravenous administration of 0 (saline), 37.5, 75 and 150 IU of recombinant human FSH (r-hFSH) in PCOS and normal women. In addition, E(2) and Inh B responses to 150 IU of r-hFSH were assessed at baseline and 4, 6 and 8 weeks following suppression of ovarian steroidogenesis by a long-acting GnRH agonist in PCOS women. RESULTS In PCOS women and normal controls, serum Inh B and E(2) exhibit similar and simultaneous dose-responsiveness to FSH stimulation. During recovery from ovarian suppression, basal and stimulated Inh B release appear to be restored earlier than that of E(2) in PCOS women. CONCLUSIONS These findings are consistent with the notion that, in PCOS women, the level of ovarian follicle activity largely determines the earlier release of Inh B compared with E(2).
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Affiliation(s)
- Marcus A Rosencrantz
- Departments of Reproductive Medicine, University of California, San Diego, School of Medicine, 9500 Gilman Drive, La Jolla, CA 92093-0633, USA
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Wachs DS, Coffler MS, Malcom PJ, Chang RJ. Comparison of follicle-stimulating-hormone-stimulated dimeric inhibin and estradiol responses as indicators of granulosa cell function in polycystic ovary syndrome and normal women. J Clin Endocrinol Metab 2006; 91:2920-5. [PMID: 16720653 DOI: 10.1210/jc.2006-0442] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
CONTEXT Follicular phase secretion of inhibin B, like that of estradiol (E(2)), correlates with the quantity and quality of developing follicles. However, it has not been established whether inhibin B responses to gonadotropin stimulation parallel those of E(2) as a reflection of granulosa cell functional capacity. OBJECTIVE Our objective was to determine whether inhibin B responses to FSH stimulation are similar to those of E(2) in women with polycystic ovary syndrome (PCOS) and normal women. DESIGN AND SETTING We conducted a prospective study to compare ovarian responses in two groups of women at a general clinical research center in a tertiary academic medical center. PATIENTS Women with PCOS, 18-35 yr (n = 19), and normal ovulatory controls, 18-35 yr (n = 7), were recruited for study. INTERVENTIONS Serum samples were measured over a 24-h period after an iv injection of recombinant human FSH, 150 IU. MAIN OUTCOME MEASURES Serum E(2), inhibin A, and inhibin B responses after FSH administration were assessed. RESULTS In PCOS women, the 24-h production of inhibin B and E(2) after FSH was significantly greater than that of normal controls. Within the PCOS group, the fold change in inhibin B was significantly greater than that of E(2). Inhibin A responses between groups were similar and of markedly lower magnitude. CONCLUSIONS FSH-stimulated inhibin B responses may be employed to assess the functional capacity of granulosa cells in PCOS and normal women.
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Affiliation(s)
- Deborah S Wachs
- Department of Reproductive Medicine, School of Medicine, University of California-San Diego, 9500 Gilman Drive, La Jolla, CA 92093-0633, USA
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Abstract
Polycystic ovary syndrome (PCOS) is a medical condition that has brought multiple specialists together. Gynecologists, endocrinologists, cardiologists, pediatricians, and dermatologists are all concerned with PCOS patients and share research data and design clinical trials to learn more about the syndrome. Insulin resistance is a common feature of PCOS and is more marked in obese women, suggesting that PCOS and obesity have a synergistic effect on the magnitude of the insulin disorder. Hyperinsulinemia associated with insulin resistance has been causally linked to all features of the syndrome, such as hyperandrogenism, reproductive disorders, acne, hirsutism, and metabolic disturbances. Women with PCOS should be evaluated for cardiovascular risk factors, such as lipid profile and blood pressure. Modification of diet and lifestyle should be suggested to those who are obese. Several insulin-lowering agents have been tested in the management of PCOS. In particular, metformin is the only drug currently in widespread clinical use for treatment of PCOS. In a high percentage of patients, treatment with metformin is followed by regularization of menstrual cycle, reduction in hyperandrogenism and in cardiovascular risk factors, and improvement in response to therapies for induction of ovulation.
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Affiliation(s)
- Vincenzo De Leo
- Department of Pediatrics, Obstetrics, and Reproductive Medicine, Institute of Obstetrics and Gynecology, University of Siena, 53100 Siena, Italy.
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Shalev E, Leung PCK. Gonadotropin-releasing hormone and reproductive medicine. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2003; 25:98-113. [PMID: 12577127 DOI: 10.1016/s1701-2163(16)30206-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The hypothalamic gonadotropin-releasing hormone (GnRH) is a key regulator of the reproductive system, mainly through its effects on pituitary luteinizing hormone (LH) and follicle-stimulating hormone (FSH) release. Gonadotropin-releasing hormone analogues are modifications of the natural decapeptide, being either agonists (GnRHa) or antagonists. GnRHa may imitate the native hormone and induce an endogenous LH surge; however, sustained treatment with GnRHa results in complete refractoriness of LH and FSH production. This aspect of GnRHa action is the main application of the GnRHa in reproduction today. The hypogonadotropic hypogonadal state that results from the sustained treatment is the basis for additional applications of the GnRHa. The agonists appear to be effective, to some extent, for the treatment of endometriosis and were proved to be beneficial prior to surgery for fibroma uteri. GnRHa is used in assisted reproduction for both induction of an endogenous LH surge and for induction of ovulation, and its capacity to cause refractoriness of the pituitary may be used to avoid a premature LH surge. It is suggested that the GnRHa have a direct effect on ovarian steroidogenesis, which is independent of its action on the pituitary. This unwanted effect and other possible drawbacks of the agonists are thought to be eliminated with the use of the antagonists. The mechanism of action of these antagonists is through competitive blocking of the GnRH receptor, which results in a rapid but reversible suppression of gonadotropin secretion. As for GnRHa, GnRH antagonists have been proven effective to prevent the LH surge and to reduce the incidence of severe ovarian hyperstimulation syndrome in controlled ovarian stimulation cycles.
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Affiliation(s)
- Eliezer Shalev
- Department of Obstetrics and Gynecology, Haemek Hospital, Afula, affiliated with the Faculty of Medicine, the Technion Israel Institute of Technology, Haifa, Israel
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Barontini M, García-Rudaz MC, Veldhuis JD. Mechanisms of hypothalamic-pituitary-gonadal disruption in polycystic ovarian syndrome. Arch Med Res 2001; 32:544-52. [PMID: 11750729 DOI: 10.1016/s0188-4409(01)00325-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Although the pathogenesis of polycystic ovarian syndrome (PCOS) is still controversial, a series of investigations has demonstrated an array of neuroendocrine abnormalities as a major component of the syndrome. From a neuroendocrine perspective, patients with PCOS exhibit an accelerated frequency and/or higher amplitude of LH pulses, augmentation of LH secretory burst mass, and a more disorderly LH release. Elevated in vitro LH bioactivity and a preponderance of basic LH isoforms, which correlate positively with elevated serum 17-hydroxyprogesterone, androstenedione, and testosterone concentrations, also characterize adolescents with PCOS. Heightened GnRH drive of gonadotropin secretion and a steroid-permissive milieu appear to jointly promote elevated secretion of basic LH isoforms. Positive feedback is implied, because hypersecretion of highly bioactive LH in PCOS probably contributes to inordinate androgen output. However, the precise nature of feedback disruption remains uncertain. Indeed, recent data suggest that PCOS is marked by anomalies of both feedforward and feedback signaling between GnRH/LH and ovarian androgens. From a single hormone perspective, the individual patterns of LH and androstenedione release are consistently more irregular in patients with PCOS. Bihormonal analysis has disclosed concomitant uncoupling of the pairwise synchrony of LH and testosterone, LH and androstenedione, and testosterone and androstenedione secretion. The foregoing ensemble of findings points to deterioration of both orderly uniglandular and coordinate bihormonal output in PCOS. Additional studies are needed to establish the primary pathophysiologic mechanisms underlying this disorder.
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Affiliation(s)
- M Barontini
- Centro de Investigaciones Endocrinologicas (CEDIE), Hospital de Niños R. Gutiérrez, Buenos Aires, Argentina.
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Abstract
Current treatment of polycystic ovary syndrome (PCOS) in women is essentially symptomatic. However, there is growing evidence that this disorder is an evolving condition and that it may be associated with major medical outcomes later in life. As a consequence, effective treatments should be instituted as soon as PCOS is diagnosed. Insulin resistance with associated hyperinsulinaemia and increased luteinising hormone (LH)-dependent androgen secretion from the ovary seem to play a central role in the pathogenesis of PCOS. Accordingly, the effects of attenuation of hyper-insulinaemia, LH excess or hyperandrogenism were recently assessed, with promising results. A consistent finding was that attenuation of insulin resistance and hyperinsulinaemia may correct the entire spectrum of endocrine, metabolic and reproductive abnormalities of PCOS in many subjects.
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Affiliation(s)
- P Moghetti
- Divisione di Endocrinologia e Malattie del Metabolismo, Ospedale Maggiore, University of Verona, I-37126 Verona, Italy.
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Ravhon A, Aurell R, Lawrie H, Margara R, Winston RM. The significance of delayed suppression using buserelin acetate and recombinant follicle-stimulating hormone in a long protocol in vitro fertilization program. Fertil Steril 2000; 73:325-9. [PMID: 10685537 DOI: 10.1016/s0015-0282(99)00521-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine whether the time taken to achieve ovarian suppression has an impact on ovarian responsiveness and the outcome of IVF-ET. DESIGN Retrospective analysis. SETTING An assisted reproduction unit at a university center. PATIENT(S) Patients undergoing a long protocol of IVF-ET that included buserelin acetate therapy initiated on day 2 of the cycle and recombinant FSH. INTERVENTION(S) Patients were divided into two groups according to the duration of buserelin acetate therapy required to achieve pituitary and ovarian suppression (group 1 = 2 weeks, n = 172; group 2 = > or =3 weeks, n = 337). MAIN OUTCOME MEASURE(S) Number of recombinant FSH ampules administered, duration of ovarian stimulation (days), ovarian response, and IVF outcome. RESULT(S) The patients in group 2 had lower mean E2 levels after 5 days and 9 days of stimulation than the patients in group 1. The number of recombinant FSH ampules administered and the number of days of stimulation required were higher in group 2 than in group 1. These differences were prominent in the subgroups of older patients (> or =36 years) and patients who had no evidence of polycystic ovaries on ultrasound examination. The number of oocytes retrieved and fertilized, the cancelation rate, and the pregnancy rate were similar in the two groups. CONCLUSION(S) Prolonged administration of a GnRH agonist to achieve suppression leads to a reduced ovarian response, particularly in women > or =36 years of age, but does not affect the success rate of IVF-ET.
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Affiliation(s)
- A Ravhon
- Department of Reproductive Medicine and Science, Imperial College School of Medicine, Hammersmith Hospital, London, United Kingdom.
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Toscano V. Polycystic ovary syndrome: What is it? Pathogenetic enigma and therapeutic dilemma. J Endocrinol Invest 1998; 21:546-50. [PMID: 9856408 DOI: 10.1007/bf03350779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- V Toscano
- Department of Medical Physiopathology, Università La Sapienza, Policlinico Umberto I, Rome, Italy
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Affiliation(s)
- J C Marshall
- Department of Internal Medicine, University of Virginia, Charlottesville 22908, USA
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Affiliation(s)
- P Moghetti
- Division of Endocrinology and Metabolic Diseases, University of Verona, Italy
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Evidence for heterogeneous etiologies of adrenal dysfunction in polycystic ovary syndrome*†*Supported in part by a Research Competition Award from the University of Buffalo Research Foundation, Buffalo, New York (F.G.).†Presented in part at the 41st Annual Meeting of the Society for Gynecologic Investigation, Chicago, Illinois, March 22 to 26, 1994. Fertil Steril 1996. [DOI: 10.1016/s0015-0282(16)58500-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Rittmaster RS, Arab DM, Lehman L. Dose-response effect of depot leuprolide acetate on serum androgens in hirsute women. Fertil Steril 1996; 65:912-5. [PMID: 8612847 DOI: 10.1016/s0015-0282(16)58259-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To determine the dose of leuprolide acetate (LA) needed to maximally suppress serum androgens in hirsute women. DESIGN Prospective, dose-escalation study. SETTING Outpatient endocrinology clinic. PATIENTS Eight hyperandrogenic women with moderate to severe hirsutism. INTERVENTIONS A LA dose-response study was done in women receiving depot LA plus estrogen-progestin replacement. MAIN OUTCOME MEASURES Serum concentrations of T, androstenedione (A), and basal and GnRH-stimulated LH. RESULTS The lowest LA dose (3.75 mg/mo) suppressed serum T by 62% +/- 6% and A by 56% +/- 7%. No further decrease in serum androgens was seen with doses up to 15 mg/mo. Maximal suppression of basal and stimulated LH was also seen with the lowest dose of LA. CONCLUSIONS As opposed to results previously published in children with precocious puberty, the 3.75 mg dose of depot LA is sufficient to maximally suppress serum androgens in hyperandrogenic women.
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Affiliation(s)
- R S Rittmaster
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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Hughes E, Collins J, Vandekerckhove P. WITHDRAWN: Gonadotrophin-releasing hormone analogue as an adjunct to gonadotropin therapy for clomiphene-resistant polycystic ovarian syndrome. Cochrane Database Syst Rev 1996; 1996:CD000097. [PMID: 17636588 PMCID: PMC10866100 DOI: 10.1002/14651858.cd000097.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Elevation of endogenous LH levels may result in premature luteinization. This may also be associated with the increased rate of spontaneous abortion. Gonadotropin releasing hormone analogue (GnRHa) used prior to human menopausal gonadotropin (hMG/FSH) administration may improve the outcome of ovulation induction. OBJECTIVES To assess if GnRHa pre-treatment plus FSH/hMG increase the rate of clinical pregnancy and/or decrease the rate of spontaneous abortion in women with WHO group two ovulatory dysfunction, compared with hMG/FSH alone. SEARCH STRATEGY The Cochrane Subfertility Review Group specialised register of controlled trials was searched. SELECTION CRITERIA All relevant published and unpublished RCTs were selected. Three RCTs were identified comparing these two approaches. DATA COLLECTION AND ANALYSIS DATA EXTRACTION A diverse search strategy was employed, including hand-search of 43 core journals from 1966 to the present, bibliographies of relevant trials, MEDLINE database, abstracts from North American and European meetings and contact with authors of relevant papers. Relevant data were extracted independently by two reviewers using the standardised data extraction sheet. Validity was assessed in terms of method of randomisation, completeness of follow-up, presence or absence of crossover and co-intervention. DATA SYNTHESIS Two by two tables were generated for all relevant outcomes. Odds ratios were generated using the Peto modified Mantel-Haenszel technique. Statistical heterogeneity was assessed using by two. MAIN RESULTS Studies were clinically and statistically homogenous. Common odds ratios for pregnancy per treatment cycle and moderate to severe ovarian hyperstimulation syndrome (OHSS) were 1.50 (0.72-3.12) and 1.40 (0.5-3.92) respectively. AUTHORS' CONCLUSIONS These studies are too small to clearly demonstrate clinically significant differences in pregnancy rate between the two approaches. However, data from IVF studies suggest that there may be an increased risk of OHSS associated with GnRHa use. In the absence of evidence suggesting a benefit of GnRHa augmentation for PCOS, it should not be recommended as a standard treatment for this patient group. Further studies assessing live birth and OHSS rates are warranted.
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Affiliation(s)
- E Hughes
- McMaster University, Rm HSC-4F7, Dept of Obstetrics & Gynecol, 1200 Main St West, Hamilton, Ontario, Canada, L8N 3Z5.
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Scheele F, van der Meer M, Lambalk CB, Schoute E, Schoemaker J, Hompes PG. Exploring the recovery phase after treatment with a gonadotrophin-releasing hormone-agonist for ovulation induction in polycystic ovary syndrome: three pilot trials. Eur J Obstet Gynecol Reprod Biol 1995; 62:221-4. [PMID: 8582500 DOI: 10.1016/0301-2115(95)02182-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Guided by the favorable results of pulsatile gonadotrophin-releasing hormone (GnRH) in the recovery phase after GnRH agonist (GnRH-a) in PCOS, two hypotheses concerning the recovery phase were tested: (1) The resistance to clomiphene citrate will be broken in the recovery phase. (2) Stimulation with (i) a fixed dose of follicle stimulating hormone (FSH) or (ii) with the GnRH-a itself is equally effective in inducing ovulation as pulsatile GnRH. DESIGN After discontinuation of a 17-21 days GnRH-a treatment, ovulation induction was attempted with clomiphene citrate (CC) or with a fixed dose of FSH or with GnRH-a itself in three separate pilot trials. A previously reported group of 12 patients, treated with pulsatile GnRH in the recovery phase served as control. PATIENTS Three groups of six patients having PCOS. The group treated with CC was a selected CC-resistant group. RESULTS No CC-treated patient ovulated. After FSH stimulation two patients ovulated, and one patient ovulated on stimulation with a low dose of the GnRH-a. Endocrine observations in the recovery phase showed an early rise of FSH as compared to the rise of LH and androgens. CONCLUSION This study could not demonstrate any effect of the recovery phase with respect to facilitation of follicular growth in PCOS. Both tested hypotheses were rejected: (1) The resistance to CC appeared not to be broken by the GnRH-a treatment and (2) subsequent stimulation with FSH or with the GnRH-a itself were not as effective as stimulation with pulsatile GnRH. An extensive further study of the mentioned modalities did not seem feasible.
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Affiliation(s)
- F Scheele
- Department of Obstetrics and Gynaecology, Diakonessenhuis, Utrecht, The Netherlands
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23
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Stevens MJ, Bell DR, Blome SA, Begbie SD. Prolonged hypogonadism after pulsed gonadotropin-releasing hormone agonist for prostate cancer. Lancet 1994; 344:274-5. [PMID: 7913195 DOI: 10.1016/s0140-6736(94)93043-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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24
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Goni MH, Markussis V, Tolis G. Octreotide effect on ovarian morphology in insulin-resistant PCOS patients following six-month decapeptyl treatment. Am J Reprod Immunol 1994; 31:104-11. [PMID: 8049019 DOI: 10.1111/j.1600-0897.1994.tb00854.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
PROBLEM Regulation of ovarian folliculogenesis involves bidirectional communication between the immune and endocrine systems. Somatostatin analogues have been reported to acutely suppress elevated androgens in polycystic ovary syndrome (PCOS). The aim of our study was to analyze the morphologic and hormonal-metabolic response to octreotide therapy for one month in insulin-resistant PCOS patients in whom luteinizing hormone (LH) effect had formerly been separated by a six-month GnRH-agonist (GnRH-a) course. METHOD Fifteen PCOS patients were studied two months after completing a six-month GnRH-a (decapeptyl 3.75 mg monthly injection) course. Seven of the patients (group A), who were insulin-resistant and gave hyperinsulinemic response to a glucose challenge, received a 50-micrograms subcutaneous injection of octreotide twice a day for one month. The nonhyperinsulinemic patients (group B) received placebo injections. Hormonal measurements, oral glucose tolerance test (OGTT), and transvaginal ovarian ultrasound were performed before and toward the end of the treatment period. RESULTS After octreotide ovarian volume dropped significantly in group A (x +/- SD) (19.2 +/- 5.1 versus 14.7 +/- 5.5 cc, P = .02). LH levels increased (3.25 +/- 1.22 versus 5.95 +/- 4.34 mu/ml, P = .05) as did E2 levels (38.0 +/- 11.4 versus 55.1 +/- 12.7 pg/ml, P = .005). There was no change in follicle-stimulating hormone, 17-hydroxy-progesterone, free testosterone, or androstenedione levels. Insulin secretion during OGTT dropped significantly (555 +/- 294 versus 68 +/- 29 mu u/ml/hr, P = .002). Glucose tolerance was not affected. In contrast, the placebo-treated group B patients showed an increase in ovarian volume (10.9 +/- 3.5 versus 14.8 +/- 3.3 cc, P = .001) while their gonadotropin and steroid profile relapsed, similarly to our patients receiving octreotide. CONCLUSIONS Octreotide has an adjunctive beneficial effect to GnRH-a on ovarian morphology although, at the dose used, there was no suppression of gonadotropin or ovarian steroid levels. The changes in ovarian morphology are probably mediated through suppression of insulin levels and/or other ovarian growth factors.
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Affiliation(s)
- M H Goni
- Department of Endocrinology, Hippokration Hospital, Athens, Greece
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25
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Abstract
GnRH and its analogues have led to exciting new avenues of therapy in virtually every subspecialty of internal medicine as well as in gynecology, pediatrics, and urology. Since their discovery in 1971, it has been demonstrated that GnRH and its analogues enable medical professionals to influence the hypothalamic-pituitary-gonadal axis in two distinct classes of therapeutic applications. The first provides natural sequence GnRH in a pulsatile fashion via portable infusion pumps to mimic the normal physiology of hypothalamic GnRH secretion and restores reproductive potential to infertile men and women with disorders of endogenous GnRH secretion. The second mode uses long-acting GnRH agonists administered in a depot delivery to produce a paradoxical desensitization of pituitary gonadotropin secretion which, in turn, results in a complete ablation of the reproductive axis. This biochemical castration induced by GnRH agonist administration is a safe, effective, complete, and reversible method of removing the overlay of gonadal steroids from a variety of diseases which they are known to exacerbate. These diseases include endometriosis and uterine fibroids in women, prostate cancer in men, and precocious puberty in both sexes. This review examines the physiologic and pharmacologic principles underlying the advances produced by these agents, the mechanism of action of GnRH and its analogues at the cellular level, and the individual therapeutic applications to which these analogues have been applied. Because virtually every subspecialty of medicine will be touched by the GnRH analogues, this review provides an overview and background of their use.
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Affiliation(s)
- P M Conn
- Department of Pharmacology, University of Iowa College of Medicine, Iowa City 52242
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26
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Markussis V, Goni MH, Tolis G. Therapeutic use of gonadotropin-releasing hormone agonists in polycystic ovarian syndrome. Ann N Y Acad Sci 1993; 687:242-9. [PMID: 8323179 DOI: 10.1111/j.1749-6632.1993.tb43872.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Polycystic ovarian syndrome is a heterogeneous disorder characterized by abnormal function of the hypothalamic-pituitary-gonadal axis, excessive production of androgens, aberrant intermediary metabolism, and structural changes in ovarian morphology. Long-term administration of the GnRH agonistic analogues brings about pituitary gonadotroph down-regulation after an initial period of stimulation of FSH/LH release. The resulting decrease in LH output and ovarian androgen production exerts beneficial effects on the clinical and biochemical parameters of the PCO syndrome. Ovarian volume and stroma usually decrease, but the results of treatment are not permanent, since relapse of the syndrome is usually observed a few months after cessation of the agonist. There are no serious side effects, and a small decrease in bone mineral content is recovered after discontinuation of the treatment. Possible indications for this regime include patients with very large ovaries and resistant hyperandrogenemia. On the other hand, the use of GnRH agonists in the preparation of PCOS patients for ovulation induction is already established.
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Affiliation(s)
- V Markussis
- Department of Endocrinology, Hippokrateion Hospital, Athens, Greece
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Cedars MI, Steingold KA, de Ziegler D, Lapolt PS, Chang RJ, Judd HL. Long-term administration of gonadotropin-releasing hormone agonist and dexamethasone: assessment of the adrenal role in ovarian dysfunction. Fertil Steril 1992; 57:495-500. [PMID: 1531463 DOI: 10.1016/s0015-0282(16)54890-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To examine the possible impact of abnormal adrenal steroidogenesis on the ovarian dysfunction seen in polycystic ovarian disease (PCOD). DESIGN Prospective analysis of blood sampling monthly for 6 months, then three times weekly for 90 days. SETTING Tertiary institutional outpatient care. PARTICIPANTS Six anovulatory women with a diagnosis of PCOD. INTERVENTION Six-month suppression with gonadotropin-releasing hormone agonist (GnRH-a) followed by suppression with dexamethasone (DEX) for 90 days. MAIN OUTCOME MEASURES Serum levels of testosterone (T), androstenedione (A), dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEAS), cortisol, estradiol (E2), progesterone (P), follicle-stimulating hormone (FSH), luteinizing hormone (LH) and bioactive LH. RESULTS Gonadotropin-releasing hormone agonist administration suppressed greater than 60% of the circulating levels of T and A, suggesting an ovarian origin. Minimal changes of DHEA, DHEAS, and cortisol were seen. With the addition of DEX, there was greater than 90% suppression of the total circulating A, T, DHEA, DHEAS, and cortisol, supporting the adrenal origin of the non-GnRH-a suppressible androgens. Excessive ovarian T and A secretion returned during the 90-day recovery study period in spite of rises of FSH concentrations that changed the ratio of FSH to LH in all subjects. Four of the six women failed to ovulate. In comparison of the women who did and did not ovulate during recovery, no differences in absolute levels or changes in concentrations of steroids or gonadotropins could be detected. CONCLUSIONS Using sequential and simultaneous administration of GnRH-a and DEX, we were able to delineate the contributions of the ovaries and adrenals to the abnormal steroidogenesis seen in PCOD. Despite prolonged suppression of ovarian and then adrenal steroidogenesis, ovarian dysfunction, evidenced by abnormal androgen production, returned with cessation of agonist administration.
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Affiliation(s)
- M I Cedars
- Department of Obstetrics and Gynecology, University of California Los Angeles Center
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28
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Abstract
In this review article evidence is assembled from the neuroendocrinology of women with polycystic ovary-like syndrome (PCOS), to argue that the central dysregulation of gonadotropin secretion as found in the syndrome is not the cause of its development. The increased amplitude of luteinizing hormone (LH) pulses is explained by an increased pituitary sensitivity to gonadotropin releasing hormone (GnRH) due to prolonged unopposed estrogen exposure of the gonadotropic cells. The increase in pulse frequency cannot be used in the argument because it may be the cause for, as well the result of, the pathological status of the ovary. A good argument for a pathogenetic involvement of central factors, however, is the reversed day/night rhythm in adolescent girls with PCOS. A critical review of the literature does not give evidence of involvement of either obesity or catecholamines in the central abnormalities. Therefore they cannot cause PCOS via central feedback systems. The response of the gonadotropins to progesterone is the same as it is in normally cycling women. Androgens exert a variable effect on LH secretory patterns, although they do induce the typical change of PCOS in the ovaries. This argues for an ovarian rather than for a central cause. Endogenous opiates seem to be increased in PCOS. It can be argued that this should suppress both LH secretion and adrenal androgen secretion. It should also stimulate insulin-like growth factor (IGF)-binding proteins, thereby binding more IGF with less stimulatory action on the theca cells to produce androgens. Therefore endogenous opiates do not seem to be involved in the pathogenesis of PCOS either. Studies in PCOS during the recovery from GnRH agonist treatment show that the luteinizing hormone/follicle stimulating hormone (LH/FSH) ratio is quite normal for some time during the recovery phase. However, PCOS always develops again. This therefore does not give a clue either. In pulsatile GnRH stimulation of PCOS patients, the LH and FSH secretory patterns completely normalize. However, the symptoms of PCOS continue under this stimulation and the clinical pattern does not change dramatically. This gives the best argument that PCOS is caused by one or more peripheral factors, which may be ovarian in origin, rather than by central factors.
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Affiliation(s)
- J Schoemaker
- Department of Obstetrics and Gynecology, Free University Hospital, Amsterdam, The Netherlands
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Gonzalez F, Hatala DA, Speroff L. Adrenal and ovarian steroid hormone responses to gonadotropin-releasing hormone agonist treatment in polycystic ovary syndrome. Am J Obstet Gynecol 1991; 165:535-45. [PMID: 1832519 DOI: 10.1016/0002-9378(91)90280-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
It has been postulated that in polycystic ovary syndrome ovarian steroids can influence adrenal steroidogenesis. To test this hypothesis, basal and dexamethasone-suppressed-corticotropin-stimulated steroid hormone responses were compared among three groups of women before, during, and after gonadotropin-releasing hormone agonist treatment for 3 months. The groups were characterized as follows: (1) women with polycystic ovary syndrome with high dehydroepiandrosterone sulfate levels (greater than 400 micrograms/dl), (2) women with polycystic ovary syndrome with normal dehydroepiandrosterone sulfate levels (less than 300 micrograms/dl), and (3) normal ovulatory women. In response to gonadotropin-releasing hormone agonist, basal serum luteinizing hormone, follicle-stimulating hormone, estradiol, estrone, 17-hydroxyprogesterone, androstenedione, and testosterone in all three groups were suppressed to similar levels. Basal serum dehydroepiandrosterone sulfate levels in the group with high levels declined, but they did not reach the normal, unaltered concentrations in the other two groups. Two subjects with polycystic ovary syndrome in this group with high levels, who showed the greatest declines in basal serum dehydroepiandrosterone sulfate levels (34%, 40%), also had evidence of 3 beta-hydroxysteroid dehydrogenase deficiency before treatment, which was resolved by the end of treatment. In both groups with polycystic ovary syndrome, the increase in maximum incremental rise of dehydroepiandrosterone and dehydroepiandrosterone sulfate levels in response to a pharmacologic dose of corticotropin from a dexamethasone-suppressed baseline (adrenal androgen capacity) remained unaltered during gonadotropin-releasing hormone agonist administration. We conclude that ovarian steroids may promote excessive adrenal androgen secretion in women with polycystic ovary syndrome, may induce 3 beta-hydroxysteroid dehydrogenase deficiency as a mechanism for adrenal involvement in some women with polycystic ovary syndrome, and do not influence adrenal androgen capacity.
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Affiliation(s)
- F Gonzalez
- Department of Reproductive Biology, School of Medicine, Case Western Reserve University, Cleveland, Ohio
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31
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Affiliation(s)
- P M Conn
- Department of Pharmacology, University of Iowa College of Medicine, Iowa City 52242-1109
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Filicori M, Flamigni C, Campaniello E, Meriggiola MC, Michelacci L, Valdiserri A, Ferrari P. Polycystic ovary syndrome: abnormalities and management with pulsatile gonadotropin-releasing hormone and gonadotropin-releasing hormone analogs. Am J Obstet Gynecol 1990; 163:1737-42. [PMID: 2122730 DOI: 10.1016/0002-9378(90)91438-i] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Ovulation induction with pulsatile gonadotropin-releasing hormone achieves high ovulatory and pregnancy rates in hypogonadotropic hypogonadism while limiting the occurrence of ovarian hyperstimulation and multiple pregnancy. However, this form of therapy is apparently less effective in polycystic ovary syndrome. The administration of a gonadotropin-releasing hormone analog for 4 to 8 weeks before the initiation of pulsatile gonadotropin-releasing hormone ovulation induction can temporarily correct endocrine abnormalities of polycystic ovary syndrome, such as excessive luteinizing hormone and androgen secretion, and improve ovulatory and pregnancy rates in these patients. For optimal results, this pretreatment should probably be repeated before each pulsatile gonadotropin-releasing hormone ovulation induction cycle. Obesity is associated with a lower success rate, and spontaneous abortion remains a prominent complication in polycystic ovary syndrome even after gonadotropin-releasing hormone analog suppression. With this regimen the risks of ovarian hyperstimulation and multiple pregnancy are virtually abolished. Thus, pulsatile gonadotropin-releasing hormone appears to be highly effective and safe for ovulation induction in patients with polycystic ovary syndrome also, provided that this treatment is preceded by pituitary-ovarian suppression with a gonadotropin-releasing hormone analog.
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Affiliation(s)
- M Filicori
- Center for Chronobiology of Reproduction, University of Bologna, Italy
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Bachus KE, Hughes CL, Haney AF, Dodson WC. The luteal phase in polycystic ovary syndrome during ovulation induction with human menopausal gonadotropin with and without leuprolide acetate. Fertil Steril 1990; 54:27-31. [PMID: 2113488 DOI: 10.1016/s0015-0282(16)53631-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Little data exist on the effects of adjunctive therapy with leuprolide acetate (LA) in the luteal phase of women with polycystic ovary syndrome (PCOS) undergoing ovulation induction with human menopausal gonadotropin (hMG). Additionally, it is not known whether gonadal steroid concentrations in the luteal phase of induced cycles in PCOS are predictive of pregnancy. In this prospective, randomized study comparing cycles using hMG alone (n = 26) with cycles using hMG with LA (n = 33), no differences were noted between treatment groups in progesterone (P), estradiol (E2), and P:E2 ratios on luteal days 3, 6, and 9. When all treatment cycles were pooled, there were no differences in P, E2, or P:E2 ratios, comparing conception and nonconception cycles. We conclude that adjunctive therapy with LA in PCOS patients undergoing ovulation induction with hMG does not alter the luteal phase concentrations of P, E2, and P:E2. Furthermore, no correlation was found between the serum concentrations of these luteal phase steroids and cycle fecundity.
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Affiliation(s)
- K E Bachus
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
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