Polycystic Ovary Syndrome - part 8 pps

Precursors of PCOS 109 and FSH occurs during ovulatory cycles (11). A pulsatile GnRH stimulus is essential for gonadotropin synthesis, and more rapid frequencies, one pulse every hour, favor LH synthesis and secretion, whereas slower pulses, one pulse every 3–4 h, favor FSH secretion. The effects of GnRH pulse frequency are modulated at the level of the LH- and FSH- gene, and frequency directly stimulates gene transcription (12). In addition, GnRH frequency modulates the complex gonadotrope mechanism whereby follistatin production (increased by rapid pulses) can inactivate intragonadotrope activin, reducing FSH- transcription and mRNA expression (13). In women, modulation of GnRH pulse frequency is effected predominantly by ovarian hormones, with major regulation occurring during the luteal phase (14). Proges- terone from the corpus luteum acts to enhance hypothalamic opioid activity, which in turn slows GnRH pulse secretion to one pulse every 3–4 h (15). As noted above, this favors FSH synthesis and constitutes an important part of the mechanisms favoring preferential FSH secretion in the late luteal phase, which in turn stimulates the next wave of cyclic ovarian follicular maturation. In humans, the maximum GnRH pulse frequency is approximately one pulse per hour, a frequency that is initially achieved during pubertal maturation. In adult women during the follicular phase, inhibition of the slow luteal GnRH frequency is gradually released (16), so that by the mid- cycle LH surge GnRH pulses occur approximately once per hour. Indeed one pulse per hour appears to be the intrinsic GnRH frequency in adult women, and reduction of this frequency is predominately effected by luteal progesterone. Estradiol plays a permissive role, in that it is required for expression of hypothalamic progesterone receptors (17). In addition, estradiol, in concert with inhibin A from the corpus luteum, acts to directly suppress gonadotrope FSH synthesis and release during the mid- luteal phase. Estradiol in the concentrations seen in the late follicular phase can also elicit positive feedback, enabling marked enhancement of LH release in response to GnRH. Thus, the ability to secrete GnRH at a frequency of one pulse per hour is achieved during pubertal maturation. Thereafter, the predominant regulation of GnRH secretion appears to be the combined effects of luteal progesterone and estradiol to inhibit GnRH frequency, thus favoring FSH production. As FSH release is restrained by both estradiol and inhibin A in the luteal phase, gonadotrope FSH stores are enhanced, providing a pool for release following the demise of the corpus luteum. The monotropic FSH stimulus facilitates recruitment of the next cohort of ovarian follicles, and GnRH pulse frequency gradually rises during the follicular phase, reflecting the gradual loss of the restraining influence of prior exposure to luteal progesterone (11). 2.2. GnRH and Gonadotropin Secretion in Adult Women with PCOS When recent spontaneous ovulation has been excluded, abnormal gonadotropin secretion is commonly observed in adult women with PCOS. Taylor et al. (18) demon- strated that 75% of women had elevated LH levels and over 90% had an elevated LH/FSH ratio. Spontaneous LH pulse amplitude is increased and LH responses to exogenous GnRH exaggerated while plasma FSH levels are relatively low (19,20). 110 Marshall et al. Fig. 1. Luteinizing hormone (LH) pulse amplitude and frequency during ovulatory cycles and in women with polycystic ovarian syndrome (PCOS). Spontaneous ovulation had not occurred within the week prior to study in women with PCOS. These abnormalities appear to reflect a persistently, rapid GnRH pulse frequency (21) with LH (GnRH) pulses occurring approximately one per hour. The normal luteal slowing seen during ovulatory cycles does not occur (Fig. 1). This, in turn, favors LH secretion while FSH is restrained by the consistent presence of plasma estradiol. Measured against the background of the normal variations seen during ovulatory cycles, the persistent rapid frequency of GnRH pulse secretion appears to reflect failure to suppress the inherent post-pubertal GnRH pulse generator firing of one pulse per hour. 2.3. Etiology of Abnormal Gonadotropin Secretion Convincing evidence of abnormalities of hypothalamic function in women is lacking, and the majority of studies have not shown consistent abnormalities of neurotransmitter function. 2.3.1. Hypothalamic Neurotransmitters Animal studies indicated that noradrenergic neurons were stimulatory, whereas dopamine and opioid neurons inhibited GnRH secretion. Studies in humans have attempted to define abnormalities of these central pathways. Investigations are by necessity indirect in women and reflect the use of medications that inhibit or stimulate these pathways. Initial studies suggested that diminished dopaminergic tone may be a factor, based on the moderate degree of hyperprolactinemia commonly present in women with PCOS. However, use of dopamine agonists did not improve clinical or biochemical function and results have been inconclusive (22). Recognition that slowing of GnRH pulses during the luteal phase reflected the action of opioids suggested dimin- ished hypothalamic opioid tone as a factor in the persistently rapid GnRH secretion Precursors of PCOS 111 (23). In primates, hypophyseal-portal endorphin concentrations are increased during the luteal phase (24). However, evidence showing that progesterone administration can slow GnRH pulses in women with PCOS suggested that progesterone induction of enhanced opioid tone was not significantly impaired in PCOS (25). Other studies have assessed both noradrenergic and GABAergic pathways following administration of thymoxamine (-1-adreno receptor antagonist) or valproate to increase GABA, but studies have not documented consequent changes in mean LH or LH pulse frequency (26,27). Thus, evidence to date has failed to identify a primary hypothalamic abnor- mality and suggests that the observed abnormalities of GnRH secretion are secondary to the abnormal hormonal milieu in plasma. 2.3.2. Estrogens The observation that estrogens could enhance LH secretion at mid-cycle suggested that excess androstenedione, peripherally aromatized to estrone, could enhance LH secretion (28). Estrone levels are increased in PCOS, but administration of exogenous estrone or the use of a peripheral aromatase inhibitor did not augment GnRH-stimulated LH secretion or reduce LH pulse frequency (29). 2.3.3. Hyperinsulinemia A majority of obese and, to a lesser degree, lean women with PCOS exhibit insulin resistance with consequent compensatory increase of insulin secretion (3,4,30). Type II diabetes is significantly more prevalent in women with PCOS compared to age- and weight-matched controls (31). As noted, excess insulin acts synergistically with LH to stimulate ovarian androgen production and to suppress hepatic production of SHBG, resulting in elevated free testosterone. Reduction of insulin resistance following treatment with metformin, or thiazolidinediones, results in moderate reduction in hyperandrogenemia and improved ovulatory function (32–34). Thus, in vivo evidence, together with in vitro data showing a direct effect on steroidogenesis, clearly indicates a role for hyperinsulinemia in the pathogenesis of PCOS. However, its potential role in the neuroendocrine abnormalities is unclear, and insulin does not augment gonadotrope responses to GnRH nor do insulin infusions alter LH secretion (35,36). In a similar vein, insulin sensitization with metformin or pioglitazone did not result in reduced LH secretion (37) despite evidence of improved insulin sensitivity. In sum, the data do not provide evidence that hyperinsulinemia directly causes neuroendocrine abnormalities but may play a role through its action of increasing hyperandrogenemia. 2.3.4. Progesterone Chronic anovulation in PCOS results in reduced progesterone in plasma, which removes the predominant agent that slows GnRH pulse secretion during ovulatory cycles. Although low progesterone associated with anovulation clearly plays a role in the persistently rapid GnRH pulse secretion in PCOS, it does not appear to account for the neuroendocrine abnormalities. Anovulatory cycles can occur in otherwise normally cycling women, and spontaneous infrequent ovulation occurs in PCOS. In the latter circumstance, progesterone transiently reduces LH pulse frequency, but LH levels are again elevated with rapid frequency, some 10–14 days after progesterone falls (18). In addition, adolescents with hyperandrogenemia exhibit abnormally rapid LH/GnRH 112 Marshall et al. pulse secretion, even before menarche when ovulatory cycles have not yet been estab- lished (38). However, as progesterone is the major physiologic inhibitor of GnRH pulse frequency, the abnormalities of GnRH pulse secretion in PCOS suggest the possi- bility of reduced sensitivity to progesterone feedback. This concept is supported by evidence following oral contraceptive therapy, which slowed LH pulses in hyperandro- genemic women but not to the same degree as normal controls (39). Subsequent studies have administered luteal concentrations of estradiol and progesterone to women with PCOS and carefully monitored GnRH pulse frequency before and after exposure to ovarian steroids. Women with PCOS require higher concentrations of progesterone to suppress GnRH frequency to the same degree as ovulatory controls (40). The reduced sensitivity to progesterone reflects the actions of elevated androgens, as pretreatment with the androgen receptor blocker, flutamide, can restore normal progesterone sensi- tivity, indicating that the impaired progesterone sensitivity is a reversible hypothalamic abnormality (41). Of interest, similar observations have recently been made in some adolescents with hyperandrogenemia (see Subheading 3.1). 2.3.5. Hyperandrogenemia Elevated plasma androgens appear to be an important factor in modulating normal neuroendocrine responses. While early in vitro evidence suggested that androgens increased GnRH pulse frequency, data in women did not confirm this observation. Basal LH pulsatility was not changed by androgen infusion or blockade of androgen action (41,42). However, as noted above, flutamide can restore normal hypothalamic sensitivity to progesterone, and longer term administration has restored regular cyclical regulation in some women with PCOS (43). Exposure to excess androgens during fetal life, however, appears to exert significant effects on hypothalamic function during subsequent pubertal maturation. Exposure to high concentrations of androgens during early fetal life in monkeys, sheep, and rats results in increased LH secretion and GnRH pulse frequency during subsequent pubertal maturation (44–47). In addition, in sheep models of fetal hyperandrogenemia, sensitivity to progesterone was impaired as seen in women. In rodent models, reduced basal and estradiol induction of hypotha- lamic progesterone receptors have been reported (47). Similarly, in mice, prenatal exposure to androgen enhances GABAergic drive to GnRH neurons that can be reversed by flutamide (48). These animal models provide compelling evidence that prenatal androgen exposure can markedly modify neuroendocrine regulation during subsequent puberty. However, few data are available in women though androgen exposure may be increased during pregnancy in women with PCOS (49), perhaps reflecting genetic causes, the latter suggested by PCOS clustering in certain families (50). Overall, androgens appear to exert significant modulation of normal endocrine function, particularly impairment of hypothalamic progesterone sensitivity. The latter may reflect reduced availability of hypothalamic progesterone receptors, resulting in reduced responsiveness to lower concentrations of progesterone. It is of interest that the consequences of prenatal androgenization are manifest during subsequent pubertal maturation, suggesting that the earlier exposure to androgen excess may have perma- nently modified the normal set points for regulation of GnRH pulse secretion by ovarian steroids. Precursors of PCOS 113 3. GONADOTROPIN SECRETION IN NORMAL PUBERTY AND ADOLESCENTS WITH HYPERANDROGENEMIA 3.1. Regulation During Normal Pubertal Maturation During the first 6 months of life, the GnRH pulse generator is active with plasma gonadotropins approximating adult values. Subsequently, LH and FSH levels fall, and GnRH pulses occur at low amplitude every 4–6 h, resulting in a relative predominance of FSH over LH during childhood (51). The resumption of GnRH activity occurs several years before clinical evidence of puberty is manifested (52–54). Initially, increased LH pulse amplitude and frequency occur during sleep, with associated overnight increases in sex steroids, testosterone, progesterone, and to a lesser degree, estradiol (55,56) (Fig. 2). With the progression of maturation, daytime LH pulse secretion increases, and sleep- associated increases in LH pulsatility are less evident. The mechanisms governing the diurnal changes in GnRH secretion in early puberty are unclear. The close association of increased LH secretion with the onset of sleep (57) suggests higher central nervous system (CNS) center activation, but this may be modified by the overnight changes in sex steroids. The latter may facilitate modified higher CNS functions or may directly impair GnRH pulse generator activity during daytime (awake) hours. Evidence to support a role for the small increases in sex steroids in daytime inhibition of GnRH secretion is found in studies of diurnal changes in LH pulse frequency in girls with and without ovarian function. The increased frequency in association with sleep is not seen in girls with gonadal dysgenesis. LH pulse frequencies are similar before and during the onset of sleep, suggesting that GnRH frequency was not suppressed during the daytime hours (51) (Fig. 3). These data suggest the influence of an ovarian factor(s) in modulating the day–night difference in early pubertal GnRH pulse secretion. In addition, estradiol infusion in early pubertal girls reduces the nocturnal increase in LH (58), and while data are not Fig. 2. Overnight changes in ovarian steroids in normal early pubertal girls (Tanner stages I–III). See insert for color figure. 114 Marshall et al. Fig. 3. Day/night luteinizing hormone (LH) (GnRH) pulse frequency in normal early pubertal girls and girls with gonadal dysgenesis. Reproduced with permission (51). available in girls, testosterone exerts similar actions in boys (59). These studies suggest a role for gonadal steroids at the early stages of pubertal maturation, and they may be involved in the relative quiescence of GnRH pulse secretion during childhood. The hypothalamus is very sensitive to sex steroid feedback during childhood, but sensitivity appears to be lost during maturation (60,61). The etiology of the decreasing sensitivity to feedback is uncertain, but analogy to studies in adults suggests that it may reflect an action of the gradual increase in androgen secretion. In pre- and early-pubertal girls, plasma testosterone concentrations exceed those of estradiol and remain so until later stages of puberty (56). Thus, the progressive increase in testosterone during normal female puberty may modulate a reduced sensitivity of the GnRH pulse generator to inhibition by estradiol and progesterone. While the above concept remains to be proven, hyperandrogenism during adoles- cence has been shown to modify progesterone inhibition of GnRH secretion in some girls during puberty. Chhabra et al. (62) showed that approximately 50% of hyperan- drogenemic adolescents exhibit relative insensitivity of GnRH secretion to the feedback actions of progesterone and estradiol (Fig. 4). These studies mimic earlier observa- tions in adults (41) and again suggest a role for androgens in the evolution of GnRH and gonadotropin secretion during puberty. This is supported by studies showing elevated LH, LH pulse frequency, and amplitude in hyperandrogenic adolescents (63). In addition, hyperandrogenic girls have higher daytime GnRH pulse frequency, and the diurnal variation is less evident (64). Detailed studies have suggested that the daytime increase of LH secretion is advanced by some 2 years in the presence of elevated plasma androgens (38). Taken together, the data suggest that ovarian steroids may play significant roles, either by direct action on the GnRH pulse generator or by modifying higher CNS centers, during both the period of childhood quiescence and the evolution of diurnal changes during subsequent puberty. The predominance of androgens in early pubertal blood in normal girls suggests that androgens may play a role in reducing hypothalamic Precursors of PCOS 115 Fig. 4. The suppression of GnRH pulse frequency by progesterone in normal and hyperandrogenemic adolescent girls. Girls received estradiol (orally in a constant daily dosage) and variable amounts of oral progesterone suspension every 8 h for 7 days. The reduction in luteinizing hormone (LH) (GnRH) pulse frequency, during 11 h runs of q 10-min sampling in day 1 and day 7, is shown as a function of the mean plasma progesterone on day 7. T, mean total testosterone for the group; T 1 and T 3 , indicate subjects at Tanner stages I and III, whereas the remaining subjects were at pubertal stage IV or V on the Tanner scale. Reproduced with permission (62). sensitivity to ovarian steroid feedback, resulting in the elevated LH and ovarian steroid concentrations seen later in puberty and adult women. 3.2. The Origin and Role of Excess Androgens and the Pubertal Evolution of PCOS Data from animal studies, particularly those in monkeys (46), clearly indicate that fetal exposure to excess androgens can modify neuroendocrine function during subse- quent pubertal maturation. In several regards—elevated LH, rapid GnRH pulses, and impaired progesterone feedback (45)—the changes observed are similar to those seen in hyperandrogenic adolescents and women with PCOS. Although data in humans are lacking, the potential for excess exposure to androgens in fetal life may be a factor in the evolution of these disorders. Similarly, in prepubertal girls, excess androgens are associated with increased risk of PCOS in adulthood (65). Some studies have suggested that this may reflect precocious adrenarche, which appears to be more common in some girls with low birth weight. The mechanisms are unclear, but a “catch-up” phenomenon is proposed in which hyperinsulinemia may be a factor. Studies in normal girls clearly indicate that androgen secretion exceeds that of estrogen during early puberty and thus may form part of the mechanism for reducing sensitivity to estradiol and proges- terone regulation of GnRH pulse secretion during pubertal maturation. Few detailed studies are available in adolescent girls, but analogy to the effects of progesterone in adults suggests that this may be part of the mechanisms allowing increased GnRH, gonadotropin, and steroid secretion during maturation. In addition, the abnormalities of GnRH and LH secretion in hyperandrogenic adolescents resemble those seen in adult 116 Marshall et al. women with PCOS. Thus, it is feasible that excess androgens from any cause, during fetal life, associated with premature adrenache (65), obesity (66,67), hyperinsulinemia (68), or reflecting inherent abnormalities of ovarian steroidogenesis (6), may lead to feedback abnormalities in the diurnal control of pulsatile GnRH secretion by ovarian steroids. As the effect would be to impair inhibition of GnRH secretion, the persistently fast GnRH pulse secretion would favor increased LH, relatively decreased FSH, and further contribute to ovarian androgen production and ovulatory dysfunction. In this regard, the increased prevalence of obesity in pre- and pubertal girls over the last quarter century may be a significant factor (69,70). Studies (66,67) have emphasized the hyperandrogenemia associated with obesity (Fig. 5). Although the exact mechanisms remain to be elucidated, this may reflect the synergistic action of hyperinsulinemia augmenting early pubertal gonadotropin stimulation of the ovary. Together, these data suggest a sequence that results in impaired regulation of diurnal changes in GnRH pulse frequency. Analogy to studies in adults and rodents suggests that the slow prepubertal GnRH pulse stimulation would favor FSH secretion during childhood. The augmentation of GnRH frequency and amplitude during sleep would gradually favor a change to LH synthesis, with the latter acting to enhance ovarian steroid secretion. In early pubertal girls, the overnight increase in ovarian steroids may in turn mediate the subsequent decline in GnRH secretion during the next day. We propose that exposure to excess androgens at a stage prior to or during the pubertal maturational process results in perturbation of these normal regulatory mechanisms. The net effect would be to diminish ovarian steroid inhibition of GnRH pulse frequency, resulting in increasing LH and decreasing FSH synthesis and secretion. This in turn Fig. 5. Total plasma testosterone, sex hormone-binding globulin (SHBG), calculated free testos- terone, as a function of BMI in early (Tanner I–III) and late (Tanner IV and V) stages of pubertal maturation. Open square, Tanner I–III subjects; closed square, Tanner IV and V. Precursors of PCOS 117 will be reflected by enhanced ovarian production of androgen and impaired follicular maturation—circumstances that could be the forerunner of PCOS in adults. In sum, present evidence is incomplete, but existing data suggest that hyperandro- genemia may play a central role in the evolution of altered hypothalamic sensitivity to ovarian steroid feedback during normal pubertal maturation. In turn, this would suggest that exposure to excess androgens might accelerate this process, resulting in earlier increase in daytime GnRH pulse secretion and a more rapid progression to the adult pattern. This concept is supported by available evidence to date, and further studies are required to elucidate the precise nature of this interaction. Establishing the role of androgens during pubertal maturation is of import, as it offers the potential for reversing or ameliorating the proposed sequence leading to PCOS in adults. Data using androgen blockade in adults have demonstrated that sensitivity to progesterone can be restored following administration of flutamide (41). By analogy, it would suggest that early recognition and reduction in androgen production, or blockade of androgen action, during early puberty may lead to normalization of the pubertal transition, potentially preventing the evolution of the full neuroendocrine abnormalities seen in adult women with PCOS. In this regard, efforts to reduce the increased prevalence in childhood obesity may be particularly important, as recent data suggest that this is a potent cause of elevated androgens in a majority of girls. However, the degree of hyperan- drogenemia associated with obesity varies, and not all girls with hyperandrogenemia exhibit impaired sensitivity to steroid feedback (62). Thus, factors that determine the degree and the effects of hyperandrogenemia may well vary in individual adolescent girls, and further study to elucidate factors determining these changes will allow more complete understanding of the cause and effects of pubertal hyperandrogenemia. ACKNOWLEDGMENTS We recognize the important contributions of clinical fellows in these research studies and thank S. Chhabra, MD, C. A. Eagleson, MD, C. L. Pastor, MD, and K. A. Prendergast, MD for their contributions. In addition, the invaluable assistance of research coordinators A. Bellows, PhD and C. Chopra is recognized as are the contributions of the GCRC staff and nurses and the availability of the Ligand Core Lab of the Center for Research in Reproduction at the University of Virginia. This work was supported by NIH grants: R01 HD34179 and R01 HD33039 (JCM), K23 HD044742 (CRM), and T32 HD-07382 (SKB). We also recognize the support of the Specialized Cooperative Centers Program in Research in Reproduction and Infertility through grant U54 HD28934 (JCM) and the GCRC grant M01 RR00847. REFERENCES 1. Zawadski J, Dunaif A. Diagnostic criteria for polycystic ovary syndrome: towards a rational approach. In: Dunaif A, Givens J, Haseltine F, Merriam G, eds. Polycystic Ovary Syndrome. 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