Ind ian Journa l of Expcrimental Biology Vol. 41. July 2003, pp. 694-700

Endocrine characteristics of polycystic ovary syndrome (peaS)

A Szilagyi & I Szabo

Dcpartmcnt of Obstctri cs and Gyneco logy. Uni vcrsity of Pecs, 17 Edcsanyak st, H-7624 Pecs, Hungary

Polycystic ovary syndromc (peOS) is probably the Illos t prcvalent cndocrinopathy in women and thc most common causc of anovulatory in ferti lit y. Patients with peos havc c lini ca l and biochemica l features consistent with th e ul lrJsound diagnosis and thcy arc li kely to face thc problems of hyperandrogcnism, subfcrtility and rccurrcn t misca rriage . Thc aim or th ' present review is to sUllllllJri ze our prcsent knowledgc on the hormonal background or thi s very prcvalelll sy ndro illc and to give some cl ini cal examplcs how the prcscnt knowlcdge can bc appli cd to trca t peos paticnts accord ing to their cu rrent probleill. such as mcnstrual cyclc disorder. hirsuti sm, inrcrtilit y or to prcvcnt latc conscquences as diabctes mcllitus. Thc et iology an pathogcnesis of peos is still a matter of controversies, but it i ~; apparent that ilnppropriatc g.onadotropin sccretion . obcsity, hyperinsulini sm and insulin resistancc arc thc major determi,ning factors in the developmen t or ovarian hyperandrogcnism an chron ic anovulation. Revcrsal of insulin rcs istance in peos eunstitutcs the fundamental goa l in thc managemcnt of hypcrandrogenic anovu latory infertility and in thc prevention of long-tcrlll conscquenccs. The va luc of the insulin sen siti zcr ll1etfonnin therapy awaits rurther cvaluation and it should be intcgrated in the spcct rum of thcrapcutical opt ions that include thc di scusscd surg.ical methods and GnRH analogues as wc l l.

Kcywords : Anovulatory in fertility. Endocrinopathy. peos. Polycystic llvary syndromc

Polycystic ovary syndrome (peOS) is probably the most preva lent enclocrinopathy in women and the most common cause of anovu latory infertility'. More recent studies, although based on modifi~d criteria of peos. also report high preva lence from 4% to 9% in the female population of fertile age2.1 . Pol ycys tic ovaries (peO) seen by ultrasound is an even more frequent finding. It has been shown that one women in five has polycystic ovaries that can be demonstrated on ultrasound examinati on4

. According to some further large studi es the prevalence of peo in healthy vo lunteer populations may range up to 33%5. Women representing sy mptoms of oligo-amenorrhea with hyperandrogenism have polycystic ovaries in 87% of the cases t

•

The aim of thi s rev iew is to summari ze our present knowledge on the hormonal background of this very prevalent syndrome and to give some clinical examples how the present knowledge can be applied to treat peos patients according to their current problem, e.g. menstrual cycle disorder, hirsutism, infertility or prevention of late consequences as diabetes mellitus.

Diagnosis peos has been defined clini ca ll y, biochemically,

and by ultrasound. The predominantl y European

* Addrcss for corrcspondancc: E- Ill~il: andras.szilagyi @aok .ptc.hu Phonc: +36 72 536360 or +36 30 9693710 Fax: +36 72 536370 or +36 72 2 13352

diagnos is of peos is based on clinical signs of menstrual di sturbance andlor hyperandrogenism (hirsuti sm, acne or alopec ia) and establi shed by transvagi nal ultrasound examination of the ovaries characteri zing the ovarian morphology. According to the criteria of Adams(" polycystic ovaries (peO) should be diagnosed when more than eight descrete follicles of <10 mm diameter are seen in the ovary, usually peripherally arrayed around an enlarged, hyperechogen ic, cen tral stroma. Most of the patients with peo have a clinical or biochemical feature consisten t w ith the ultrasound diagnosis and they are likely to face the problems of hyperandrogenism, subrertilit y and recurrent miscarri age. As 1'01' the predominantly North American view, the 1990 National Institute of H ealth (N TH ) conference on peos 7 recommended that diagnostic criteria should include biochemical ev idence of hyperandrogenism and ovartan dysfunction without regardin g the morphological diagnosis of peo by ultrasound as an assential part o f the diagnosis. A recent proposa l by Homburg~ attempts to bridge the gap bet ween predominant ly American biochemical marker-based diagnos is and predominantly European reliance on ultrasound as a sine qua non for diagnosi~, .

Pathophysiology The pathophys iology o f the disorder ha ' been

thorou ghly in vesti gated, but its etiology is still unse ttl ed. There are theories supporting a primary

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SZILAGYI & SZABO: .EN DOCRINOLOGY OF PCOS 695

hypothalamic-pituitary defect , a primary ovarian steroidogeni c defect , a primary adrenal steroidogenic defect and a primary defect of insulin res istaneeY

- '2, Furtheremore, the ex isting literature provides a strong bas is for arguing that PCOS clusters in famili es. However, the mode of inheritance of the di sorder is still uncertain . Several loci have have been proposed as PCOS genes including CYPII A, the insulin gene, and a region near the in sulin receptor 13

. Whatever the pathogenes is of PCOS , the endpoint is an ovary secret ing excess ive amount of androgens.

Hormonal and biochemical characteristic Excessive ovarian androgen production is

characteri sti c of most women with the typi cal ovarian morphology. PCOS patients have hi gher serum concentrati ons of testosterone, free tes tosterone and androstened ione 'o. The source of the excessive ovarian and rogen production is a key ques tion. The rate limiting enzy mes in androgen biosy nthesis are 17-hydroxylase and 17/20 lyase activiti es that are di sordered in PCOS I~ . In response to a single dose of GnRH anal ogue, wo men with PCOS have an exaggerated increase in both 17-hydroxyprogesterone and androstendi onel 4

. The 17-hydroxylase and 17/20 lyase belong to the enzy me complex cy tochrome P450 17a, and the act ivity of thi s enzy me compl ex may be increased by several pathways in PCOS.

Among the candidates LH , insulin-like growth fac tor-l (IGF-I ) and insulin itse lf can be li sted. LH is hypersecreted in 40-50% of PCOS patients IS. It is a unique feature of PCOS that the LH secretion is di sproportionately increased over that of FSH , resulting in an elevated (>2: I) LH :FSH rati o ' 6, The increased mean LH level is due to the increased GnRH-LH pu lse freq uency that may be ex plained by the reduced opioidergic inhibition of GnRH in PCOS

. 17 0 . d' 18 h I patients. ur prev Ious stu les suggest t at centra op ioidergic and dopaminergic control of gonadotropin secretion is impaired in PCOS and rema ins unaffected by ovari an surgery, evc n when menstrual cyclicity is resumed. Accord ig to in vitro studi es the and rogen production by theca-stromal cell s respond readily to LH stimulati on with an increased expression of cytochrome P450 17a acti vity l4, with a sy nergistic effect occuring in the presence of IGF- I or in sulin I9.2o. Furtheremore, IGFBP-I the binding globuline of IG F­I is suppressed first of all in obese PCOS patients20

,

and in thi s way the potenti al of IGF- I is increased to act sy nergistica lly with LH to stimulate the theca and interstiti al ce lls of the ovary to produce androgens2 1

.

It has been proven that hyperinsulinemia and insulin res istance playa key ro le in the pathophysiology of hyperandrogen ism and probably the pathogenesis of PCOS7.9. Insulin receptors are present in the ovar/2

and insulin may also bind to IGF-I receptors and acts as a gonadotrophic hormone, enhancing inducti on of ovari an LH receptors and LH binding capacit/',

Apart from the ovarian androgens, several observers have noted that a characteri stic adrenal androgen, dehydroepiandrosterone sulfate (DHEAS), is found in hi gh concentrati on in the blood of patients with PCOS and there is an enhanced responsiveness of adrenal androgens to stimulat ion. Furtheremore, in many pati ents the entire sy ndrome can be corrected by parti al adrenal suppress i on~3 . We have also fo und elevated DH EAS leve l in PCOS that was reduced afte r ovari an wedge resecti o n2~,

A further characteristic hormonal dev iati on in PCOS is hyperprolactinemia . It can be explailled by estrogen priming at the pituitary level or by decreased central dopaminergic tone25. Even in normal basa l prolactin level, an exaggerated prolact in response to metoclopramide26

, or to th yro id releas ing hormone (TRH) admini stration25.27 was observed in PCOS. According to our studies, the increased prolactin response to metoclopramide remains unaltered by ovari an surgival manipulations (wedge resection or lase r vaporization) in PCOS indicati ng a persistent aberrati on in the dopaminergic contro l of prolactin secret ion'S.

There are also characteri stic featu res in the urinary stero id excretion of PCOS patients that can be profil ed by gas chromatography. PCOS is characteri zed by increased 5a- reductase enzy me ac ti vit/ s. This enzy me converts testosterone to the biologicall y active 5a-d ihydrotestosterone in androgen-dependent target organs; increased activit{ of thi s enzy me in th e skin causes hirsuti sm2

'.

Increased Sa-reductase enzyme acti vity increases the production of not onl y the Sa-androgen metabolites (androsterone), but enhances hepatic corti so l metabolism, too (increased 5a-tetrahydrocorti sol-a­THF production)28 . In thi s way rati os of 5a- to 5B­steroids (androsterone/ctiocholanolone-An/Et and a­THF/THF) is characteri stically increased in PCOS, as well as the increased ratio of androgene metabolites (A M) to corti sol metabolites (CM),

Cap ill ary gas chromatographic profi ling of urinary steroids may also be used to detect late onset stero id 2 I-hydroxy lase defic iency, the most freq uent enzyme deficiency th at causes hirsuti sm, and th at should be differenti ated from PCOS30

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696 INDIA N J EXP SIOl, JULY 2003

Hormonal changes after the.-apeutical interventions There is no single effective treatment for PCOS .

Management of PCOS depends on the requirements of the patient. Infertility is treated with ovul ation inducti on or by surgical ovarian manipulations (wedge resec ti on or more recentl y laparoscopic electrocoagul ation. laser vapori zati on of the ovari es). If the complains focus on the hyperandrogenemic sy mptoms, first of all excess ive hair growth , suppression of the ovarian androgene production should be achieved. Hyperinsulinemia, insulin resistance as a principa l facto r in the pathogenes is of PCOS has led to the use of in sulin-l owering agents also ca lled in sulin sensiti zers . The most extens ively studi ed insulin-l owering agent in the treatment of PCOS is metformin: an oral antihyperglycemi c agent used initially in the treatment of type 2 diabetes mellitus. Metformin can be used alone or in combination with agents admini stered for ovu lati on induction. Furtheremore, metformin also appears to induce cardioprotective effects on serum lipids as well as plasminogen inhibitor (PAI )-I and may decrease the ri sk of deve lopment of type 2 diabetes3l

·32

. The high ly promiss ing therapeutic profi le of metfo rmin deserves further studies and app licati on.

In the followin g chapter of the rev iew the author's data on the hormona l effects of ovarian surge ry to achieve res um ption of the menstrual cyc le and infertility and the effects of long term GnRH analogue trea tment on serum and urinary steroid hormones will be summari zed. On one hand the clinica l and hormon;}1 effects of long term gonadotropin-releas ing hormone (Gn RH ) ana logue treatment was studied in hirsute PCOS patients and on the other hand in fert il e, clomiphene citrate resistent PCOS pati en ts were surgica ll y treated to ach ieve resumption of the menstrual cycle and ferti I ity. Hormonal changes before and after surgery was evaluated, too .

GIlR H analogue t.reatmellt oj hyperalldrogellemic peas patients

GnRH analogues exert a profound and prolonged suppress ion of pituitary gonadotropin sec retion whi ch accounts for the marked suppression of ovari an functi on33 Short term studies performed on PCOS patients utili zing a short-acting GnRH agoni st for 4 weeks proved marked suppress ion of ovarian steroidogenesis34

. Later on, it became evident that long ter~ GnRH analogue treatment should be considered among the va rious therapeu tic modalities offered in the contex t of hirsutism35

. Several studies

have aimed to measure serum gonadotropin and androge n levels during GnRH analogue treatment in . PCQS36, but the efficacy of gas chromatographic profiling of urinary steroids in monitoring GnRH analogue therapy has not been studi ed yet. although the effect of Gn RH analogue stimubtion test on urinary steroid excreti on wa~ reported in a swdy)7

PGlients and methods A long acti ng GnRH analogue (Decapeptyl

Depot®-Ferring, Germany) was admi ni stered as monthly intramuscul ar injection for 6 months in 8 PCOS patients. Cl ini cal and hormonal effects were measured. Serum LH , FSH, prolactin , testostero ne, est radiol levels were determ ined monthly and profi ling uri nary steroids by coloumn gas chromatography of 24 hI' urine samples was performed before and in the third and sixth month of treatment accord ing to Shackleton and Homok i 3 X .3~ . To evalu ate Sa-red uctase enzy me activity in the li ver and skin of [he patients, the ratios of androsterone (An) to etiocholanulone (Et) and Sa-tetrahydrocort isol (a-THF) to tetrahydrocorti so l (THF) were ca lcul ated in urine samples before and after the GnRH analogue therapy. Changes in the rati o of androgen metabolites (A M) to corti so l metabolites (CM) dL ring trea tment were evaluated, too. Degree of hirsuti sm was assessed before and after treatment by Ferriman Gallwey

.jO score .

Resulls LH has decreased significantl y following the first

inj ec ti on of the GnRH analogue (from 11 ,9 ± 2,9 (0

1,05 ± 0,5 U/I). FSH and vrolact in leve ls have not changed duri ng treatment. Testosterone levels were normali zed «3 nmol/l) , estrad iol was suppres. ed near to postmenopausal levels (50-100 pmolll).

An/Et and a-THF/THF ratios in the urine samples have decreased sign ificantly during t erapy (An/Et from 2. 1 ±0 .2S to 1.6 ±0.2, a-THF/THF from 1.1 ± 0.1 to 0.8±0. 1), but they were still higher th an that of in hea lthy fe males (normal rat ios: An/Et I, a­THF/THF 0,6). The elevated rati o of androgen metabolites to cort isol metabolites characteristi c of PCOS has decreased during treatment to normal va lues (A M/CM from 0.8 ± 0.2 to 0.5 ± 0.1 ) Clini cally, all the PCOS patients became amenorrheic during GnRH agoni st treatment, and 6 out of the 8 pati ents complained of mild hot flu shes. Hirsuti sm assessed by Ferriman Gallwey score was dimini shed, but not significantly.

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SZILAG YI & SZABO : .ENDOCRINOLOGY OF PCOS 697

Conclusiolls of the chronic GnRH analogue treatment study:

Long acting GnRH analogue treatment in peos is effecti ve in reducing serum LH , estrad iol and androgen levels. Gas chromatographic profiling of urinary steroids by using spec ifi c rat ios is a sensiti ve tool for monitoring changes in steroid hormone production during GnRH analogue administrat ion. Use of specific ratios may help to avo id errors of urine collect ion . Increased Sa -reductase enzyme acti vity characteristi c for peos41 is di mi nished during treatment, but it remains still higher than that of in healthy females. Product ion of androgen

metabo lites is reduced, too. The finding that Sa­reductase ac ti vity (ratios of An/Et and a-THF/THF) in our peos patients could be diminished, but not absolutely normalised raises the poss ibility that some di sorders in peos are irremediable as it was found in a study concern ing the inappropriate hypothalamic opioidergic and dopaminergic control of gonadotropin and prolactin secretion in peos patientslH .

Degree of hirsutism Improves during GnRH analogue admini strati on, but for a significant improvement probably a longer or combined trea tment would be required. Our data on chronic GnRH analogue treatment in peos were publi shed in detail s recent l/ 2

.

Surgical treatm.en! of peDS associated illfertility For the treatment of infertility assoc iated with

peos ovulation induction is the most appropri ate trea tment. Clomiphene citrate in doses of SO-200 mg/day from day 4 or S of the cycle for S days may be the simpliest method to achieve ovu lation in 80% of the cases, however, the overall pregnancy rate is on ly 30-40%. Thi s di screpancy may partl y be ex plained by the an ti es trogenic effect of clomiphene citrate on the cervica l mucus and endometrium, and the increased LH concentrati ons during clomiphene citrate action that may seri ously compromise pregnancy rates in I . 1141 If I . I f' ' 1 t l ese patients " . c om lp l ene trealmental s to

induce ovulation ("c lomiphene fa ilures") the nex t step may be stimulati on of the ovari es wi th exogenous gonadotrop ins or surgical manipul ati on of the ovari es.

Surgica l treatment, ori ginall y by bilateral wedge resecti on of the ovaries·14

, or later by laparoscopic approaches (e lectrocautery, laser photodiathermy, laser drilling) is found to be effec tive in restoring ovulation for at least 6 months, but the benefit 01"

I I t· I 4S 46 Illonopo ar cu rrent may ast or severa years " . As a consequence of profound changes in the gonadotropin

secretion in response to ovari an surgery , resumption of normal menstrual cyc lici ty with subsequent

I · h ~~ ovu atlOn as been observed- ' . Although wcdge resection by laparotomy has not been performed for IS -20 years, our data are avai lable on the hormonal effects of thi s procedure. The aim of the study was to compare the hormonal and cl ini ca l effects of ovari an wedge resection, electrocoagu lati on and laser vapori sati on In patients with polycysti c ovary syndrome.

Pmiellls and l1lethods The diagnosis of peos was based on the clini ca l

manifestations of chronic hyperandrogenemia, such as menstrual disturbances (oligo- to amenorrhea), hirsuti sm and infertility. Endocrinological features compri sed elevated serum LH w ith normal or subnormal FSH concentrations and the finding of elevated serum testosterone. androstenedione and/or dehydroepiandrosterone sulfate (DHEAS) leve ls. The presence of enlarged ovaries w ith multiple subcapsular cysts was sonographicall y confirmed in all peos women . All pati ents had failed to ovulate in response to clomiphene citrate regimens ( 100 mg/day for S days) administered for at leas t 3 months.

Nine patients underwent classica l wedge resecti on of the ovaries, I I patients were treated by laparoscopic Nd:Y AG laser vapori sa ti on (contact approach for the laser beam, continuous wave mode), and in S6 patients laparoscop ic multiple point elec trocoagulati on of the ovari es by monopolar current was performed.

Results A significant decrease in serum LH five days after

surgery cou ld be ach ieved only after the laparoscop ic approaches ( laser or elec trocoagulati on). On the other hand. laparoscopic procedures induced an increase in serum FSH that may be favourab le in initiating menst rll al cyc l icit y .

Serum tes tosterone has decreased five days after surgery in some wedge resected patients, but a pronou nced decrease cou ld be ach ieved only by the laparoscopic methods.

Changes in the pul satile pattern of LH and FS H were studied by multiple (every ten minutes fo r 6 hours) blood samplings before and after laser surgery. LH pul se amplitudes, but not pulse frequency have decreased sign i fi cantl y after laser surgery. Practi ca ll y all the pat ients follow ing the different surgical procedures had ovulatory cyc les proved by basa l body

698 INDIAN J EXP B IOl, JUl Y 2003

temperature charts and progesterone determinations in the luteal phase. Pregnancy rates in the different study groups in one year after surgery were as follows: wedge resection 2/9, Nd:Y AG laser 4111 , electro­coagulati on 15/56.

COllclusions oI the ova riall surgical manipulatioll studies

A ll the surgica l methods are effecti ve in restoring menstrual cycl icity, but laparoscopic methods have higher pregnancy rates. The rapid recovery without adhesions following laparoscopic surgery is favou rable. Laser surgery or elec trocoagulation are more effecti ve in reducing circulating androgen and LH levels than wedge resection. Decrease in LH leve l after laser surgery is due to reduced pul se amplitudes.

Our results are in accordance with the literary data that laparoscopic surgica l methods in clomiphene resistent peos patients are effecti ve to restore ferti lit y. Interest i ngl y, restoration of menstrual cyc licity and fert ility in peos pati ents by normali zed gonadotropin secretion is not accompanied by altera ti ons in central dopaminergic and opioidergic control of gonadotropin and prolactin secreti on IS. It may indicate that some central endocrine abnormalities in peos are inremcdiablc.

A further advantage of surgica l therapy of peos related infel1ility is that stimulation with gonadotropins fo llow ing ovari an surgery gives an enhanced ovari an response compared with the pre-surgery (pre­diathermy) response48

.

Summary 'and future perspectives The etiology and pathogenesis of peos is st ill a

matter of con troversies, but it is apparent that inappropriate gonadotropin secretion, obesity, hyperin sulini sm and insulin res istance are major determining factors in the deve lopment of ovari an hyperandrogenism and chronic anovulati on. Follow up studies have also shown an increase in the incidence of diabetes in peos evaluated at peri menopausal age. Thus reversa l of insulin resistance in peos constitutes the fundamental goa l in the management of hyperandrogenic anovulatory infertility and in the prevention of long-term consequences. The value of the insu lin sensiti zer metforlllin therapy awaits further evaluation and it should be integrated in the spectrum of therapeutica l

. 49 options .

Final ly, we may in fer that our resu lts support the not ion that peos may successfull y be managed

depending on the goals of the treatment and the requirements of the patients. Hyperancirogenemia, hirsuti sm may effecti ve ly te treated by long acti ng GnRH analogues that accordi ng to literary data may be combined with oral contracept ives to enhance the therapeutic effect and to re uce the ri sk of bone loss during a prolonged treatmentSO

.5 I. On the other hand, surgical manipu lations of the ovari es are not effective in reducing hirsuti sm4

'i ,52 . T he laparoscopic ovari n surgery is indicated only in infertile patients if conven ti onal ovulation induction fai ls to restore ferti lity.

The therapeutic interventions and their hormonal effects are in accordance WIth our knowledge on the endocrine background of peos. Our presen t knowledge on the pathophysiology of peos can be applied at the clinica l level to help peas pati ents according to their requirements and to prevent long term consequences of thi s syndrome.

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