We investigated a possible influence on birth weight in Turner's syndrome of many clinical, hormonal, genetic and immunogenetic variables. We considered 97 patients with Turner's syndrome. Patients with parents with identical GM (Gamma heavy chains Marker) phenotype had a significantly lower birth weight than those with parents with different GM phenotype. Karyotype other than 45,X, HLA (Human Leukocyte Antigen) parental sharing, mother-patient compatibility and elevated 17-hydroxyprogesterone (<em>17OHP</em>) serum level after adrenocorticotropin hormone (ACTH) and absence of heart and kidney malformations and lymphedema were associated with a lower birth weight, but not significantly. Multiple interactions showed that the presence of an identical GM phenotype in parents, together with other conditions (karyotype other than 45,X, adrenal dysfunction, HLA parental sharing, mother-child compatibility, KM(3) [Kappa light chains Marker] phenotype) resulted in a further decrease of birth weight. These data might suggest a negative effect of genetic similarity on intrauterine growth in Turner's syndrome.

Precocious pubarche (PP) is most often a benign condition secondary to the early appearance of adrenarche. However, PP may be a manifestation of nonclassical adrenal hyperplasia. The incidence of nonclassical adrenal hyperplasia in patients with PP ranges from about 0-40% of cases. Controversy exists as to whether all children with PP should undergo an ACTH stimulation test. The aim of this study was 1) to determine the frequency of mild adrenal enzyme defects in a very large and ethnically homogeneous group of children with isolated PP (typical pubarche); 2) to determine whether clinical data, in particular bone age, and basal hormonal values can help to distinguish patients who are at risk for having adrenal enzymatic defects and thus should have an ACTH test; and 3) to determine which patients diagnosed as having a mild adrenal enzyme defect might require treatment. We studied 171 subjects (135 girls and 36 boys), aged 7 +/- 1.2 (SD) yr, with isolated PP. Thirty-eight normal subjects (18 age-matched and 20 pubertal) were studied as controls. An ACTH stimulation test (Synacthen, 0.25-mg iv bolus) was performed. Blood samples were drawn at baseline and 1 h postinjection. 17 alpha-Hydroxyprogesterone (<em>17OHP</em>), 17 alpha-hydroxypregnenolone (17PGN), dehydroepiandrosterone, androstenedione, testosterone, 11-deoxycortisol, and cortisol were evaluated. Haplotype (HLA) typing was performed in the patients who were diagnosed with nonclassical 21-hydroxylase deficiency (NC21OHD). Using published nomogram standards for the serum <em>17OHP</em> response to ACTH, 10 patients (5.8%) were diagnosed as having NC21OHD. Seven of 112 patients (6.2%) were diagnosed as having nonclassical 3 beta-hydroxysteroid dehydrogenase deficiency (NC3HSD) on the basis of the following three criteria: stimulated 17PGN levels and stimulated 17PGN/<em>17OHP</em> and 17PGN/cortisol ratios higher than 2 SD above the mean for pubertal controls. None of the patients had stimulated 11-deoxycortisol values greater than 2 SD above the mean of pubertal controls. Nineteen patients (11%) had a stimulated <em>17OHP</em> response characteristic of the heterozygotes for 21-hydroxylase deficiency. One hundred and thirty-five of 171 patients with no biochemical evidence of an adrenal biosynthetic defect were diagnosed as having precocious adrenarche. Bone age was advanced >> 2 SD for chronological age) in 80% of the patients with NC21OHD, in 71.4% of the patients with NC3HSD, in 58% of the patients classified as heterozygotes, and in 32.6% of the patients with precocious adrenarche. Basal hormone levels were helpful in detecting NC21OHD, but not NC3HSD. All patients with NC21OHD and only 1 with NC3HSD underwent glucocorticoid suppression treatment.(ABSTRACT TRUNCATED AT 400 WORDS)

OBJECTIVE

Early diagnosis and treatment of testicular adrenal rest tumors (TART) is important for gonadal functions and fertility protection in boys with congenital adrenal hyperplasia (CAH). In this descriptive study, we investigated the prevalence of TART in boys with 21-hydroxylase deficient (21OHD) CAH followed in our pediatric endocrine clinic.

METHODS

The study group consisted of 14 male patients with a mean age of 9.6 ± 5.1 (range: 0.8-18.3) years. Six (42.9%) of the 14 patients were diagnosed as having salt-wasting type (SW) and eight (57.1%) patients - as having the simple virilizing (SV) form of 21OHD. Mean age at diagnosis was 2.9 ± 2.7 (range: 0.03-6.3) years. Two different radiologists performed scrotal ultrasonography. Chronological age, bone age, and anthropometric measurements were evaluated. Serum adrenocorticotropic hormone (ACTH), 17-alpha-hydroxyprogesterone (<em>17OHP</em>) and androstenedione levels were also evaluated in all patients during the follow-up period.

RESULTS

Scrotal ultrasonography revealed bilateral TART in two patients (14.3%) and testicular microlithiasis (TM) in four patients (28.6%). One patient had both TART and TM bilaterally. During the follow-up period, the mean serum adrenocorticotropic hormone, <em>17OHP</em> and androstenedione levels in the total group of patients were 130.0 ± 179.1 pg/mL (21.7-726.5), 5.8 ± 3.3 ng/mL (0.8-11.4) and 4.3 ± 4.1 (0.2-11.0) ng/mL, respectively.

CONCLUSIONS

Microlithiasis or TART may be frequently encountered during the follow-up of patients with CAH. In order to prevent late complications including infertility, we suggest that ultrasonographic evaluations be performed yearly in all male CAH patients.

OBJECTIVE

Premature androgenic alopecia has been suggested as a feature of the male equivalent of the syndrome of polycystic ovary. However, the hormonal pattern of men with premature balding has been investigated in only a few studies with inconsistent results.

METHODS

We examined 37 men with premature balding (defined as frontoparietal and vertex hair loss before the age of 30 years with alopecia defined as grade 3 vertex or more on the alopecia classification scale of Hamilton with Norwood modification). The plasma concentrations of total testosterone, dihydrotestosterone, epitestosterone, androstenedione, cortisol, 17-OH-progesterone (<em>17OHP</em>), estradiol, LH, FSH, prolactin, SHBG and TSH and free thyroxine were measured.

RESULTS

The frequency of subnormal values in SHBG, FSH, testosterone and epitestosterone (but not in free androgen index) was significant in the balding men. A borderline significant trend was recorded with respect to increased levels in 17OH-P and prolactin.

CONCLUSIONS

The hormonal pattern of a substantial number of men with premature balding resembles in some respects the hormonal pattern of women with polycystic ovary syndrome.

Premature adrenarche refers to the presence of secondary sexual hair in girls younger than 8 years old and boys younger than 9 years old. It is a relatively common presentation to paediatricians and is more frequent in girls than boys. It is a benign diagnosis, but other causes of androgen excess such as congenital adrenal hyperplasia or adrenal tumours should be excluded first. In conjunction with history and clinical examination, first line investigations should include determination of serum androgen concentrations, along with bone age, proceeding to synacthen stimulation test (for <em>17OHP</em> levels) and adrenal ultrasound if indicated. The phenotype of premature adrenarche varies considerably between populations but may be associated with low birth weight, insulin resistance, adverse cardio-metabolic risk and progression to polycystic ovarian syndrome in some populations. In the majority of cases, no specific treatment is recommended, but where there is a history of low birth weight, with associated insulin resistance, intervention with the insulin sensitising agent metformin may be considered on a case by case basis.

Elevated blood 17alpha-hydroxyprogesterone (<em>17OHP</em>) level, although widely used for the screening of classical 21-hydroxylase deficiency (21OHD) in neonates, has frequently been found in some neonates without classical 21OHD, particularly preterm neonates. We studied the diagnostic value of the metabolite of 21-deoxycortisol (pregnanetriolone, Ptl) and the metabolite of <em>17OHP</em> (pregnanetriol, PT) in identifying 21OHD in term and preterm neonates with elevated blood <em>17OHP</em> on the newborn screening. Spot urine samples from 59 classical 21OHD neonates (50 term, 9 preterm), 83 neonates without 21OHD having transiently elevated blood <em>17OHP</em> (non-21OHD) (49 term, 34 preterm), and 62 control term neonates were studied using gas chromatography/mass spectrometry in selected ion monitoring analysis for Ptl, PT, 5beta-tetrahydrocortisone (betaTHE), and 5alpha-tetrahydrocortisone (alphaTHE). Ptl and Ptl/(betaTHE+alphaTHE) showed no overlap between 21OHD and non-21OHD, and 21OHD and controls, respectively (Ptl was 0.46-124 mg/g creatinine in 21OHD term, 0.80-26.9 mg/g creatinine in 21OHD preterm, < or = 0.08 mg/g creatinine in non-21OHD term, < or =0.06 mg/g creatinine in non-21OHD preterm, and < or = 0.07 mg/g creatinine in controls). PT and PT/(betaTHE+alphaTHE) showed significant overlap between 21OHD and non-21OHD. The above data indicate that spot urine Ptl is a highly specific marker of 21OHD with a cutoff value of 0.1 mg/g creatinine, yielding an unambiguous separation between 21OHD and non-21OHD in term and preterm neonates.

17-Hydroxyprogesterone (17-OHP) is an intermediate steroid in the adrenal biosynthetic pathway from cholesterol to cortisol and is the substrate for steroid 21-hydroxylase. An inherited deficiency of 21-hydroxylase leads to greatly increased serum concentrations of 17-OHP, while the absence of cortisol synthesis causes an increase in adrenocorticotrophic hormone. The classical congenital adrenal hyperplasia (CAH) presents usually with virilisation of a girl at birth. Affected boys and girls can have renal salt loss within a few days if aldosterone production is also compromised. Diagnosis can be delayed in boys. A non-classical form of congenital adrenal hyperplasia (NC-CAH) presents later in life usually with androgen excess. Moderately raised or normal 17-OHP concentrations can be seen basally but, if normal and clinical suspicion is high, an ACTH stimulation test will show 17-OHP concentrations (typically >30 nmol/L) above the normal response. NC-CAH is more likely to be detected clinically in females and may be asymptomatic particularly in males until families are investigated. The prevalence of NC-CAH in women with androgen excess can be up to 9% according to ethnic background and genotype. Mutations in the 21-hydroxylase genes in NC-CAH can be found that have less deleterious effects on enzyme activity. Other less-common defects in enzymes of cortisol synthesis can be associated with moderately elevated 17-OHP. Precocious puberty, acne, hirsutism and subfertility are the commonest features of hyperandrogenism. 17-OHP is a diagnostic marker for CAH but opinions differ on the role of <em>17OHP</em> or androstenedione in monitoring treatment with renin in the salt losing form. This review considers the utility of 17-OHP measurements in children, adolescents and adults.

OBJECTIVE

To investigate association of kisspeptin levels in infertile women with different ovarian reserve patterns.

METHODS

In this prospective cross-sectional study, 157 participants were recruited. The women were divided into three groups: (i) adequate ovarian reserve (AOR) (n = 57), (ii) high ovarian reserve (PCOS) (n = 60), (iii) diminished ovarian reserve (DOR) (n = 40). Weight, height, waist circumference (WC), hip circumference (HC), body mass index (BMI), waist/hip ratio (WHR) were measured. The blood samples were analyzed for estradiol (E2), follicle-stimulating hormone (FSH), luteinizing hormone (LH), total testosterone (TT), 17-hydroxy progesterone (<em>17OHP</em>), dehydroepiandrosterone sulfate (DHEAS), antimullerian hormone (AMH), kisspeptin measurements.

RESULTS

FSH concentration was higher and AMH concentration was lower in DOR group (p < .001, p < .001, respectively). The mean LH, TT and DHEAS levels were higher in PCOS group (p = .001, p < .00 and p = .003, respectively). The <em>17OHP</em> level did not differ among the groups (p = .15). Women with PCOS possessed the highest kisspeptin level (p = .01). The kisspeptin level was negatively correlated with FSH level (r = -0.18, p = .02) and positively correlated with TT and DHEAS levels (r = 0.17, p = .02 and r = 0.23, p = .003, respectively).

CONCLUSIONS

Women with PCOS had increased serum kisspeptin levels. Kisspeptin concentrations were negatively correlated with serum FSH and positively correlated with serum TT and DHEAS levels.

OBJECTIVE

Adrenal incidentalomas (AIs) may be due to congenital adrenal hyperplasia (CAH) due to homozygous CYP21A2 mutations, or perhaps from heterozygous carrier status. It is unclear if genetic or biochemical testing of CYP21A2 status in AI is justified, despite its potential for avoiding adrenal crises in those referred for adrenalectomy.

METHODS

We systematically searched PubMed/MEDLINE for articles published up to October 19, 2015 containing all terms associated with adrenal tumors and CAH. Meta-analyses were used to estimate the CAH or carrier prevalence in AI and assess clinical factors that may guide testing.

RESULTS

Thirty-six publications were included. Of AI patients biochemically screened for CAH, 58/990 (5.9%) were diagnosed with CAH. Genetic screening of all AIs revealed only 2/252 (0.8%) with clear CAH. The carrier prevalence was 10.2% (36/352). The rate of 0.8% (8/1,000) genetically confirmed CAH is higher than the 1/15,000 affected by classic CAH or 1/1,000 by nonclassic CAH in the Caucasian population. The rate of heterozygous CYP21A2 mutation frequency is similar to those in reported in population studies. Levels of both basal and stimulated 17-hydroxyprogesterone positively correlated with AI diameter. Although bilateral incidentalomata were frequent in CAH, their presence did not predict CYP21A2 status.

CONCLUSIONS

The presence of an AI does not increase the probability of detection of CAH or CYP21A2 carrier status to the extent routine genetic testing is justified. Screening with 17-hydroxyprogesterone levels appears to lack specificity in the setting of an AI. CYP21A2 mutation analysis is probably the only reliable method for CAH diagnosis in AIs.

BACKGROUND

ACC = adrenocortical carcinoma ACTH = adrenocorticotropic hormone AI = adrenal incidentaloma CAH = congenital adrenal hyperplasia NCAH = nonclassic congenital adrenal hyperplasia <em>17OHP</em> = 17-hydroxyprogesterone SV = simple virilizing.

We have analyzed the kinetics of salivary cortisol (F) and 17-hydoxyprogesterone (<em>17OHP</em>) after a single oral administration of hydrocortisone (HC; 10 mg; 0700 h) in healthy male volunteers (n = 10; 18-29 yr) and in patients with congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency (males, n = 7; females, n = 3; 8.5-20.4 yr). The HC doses, related to body surface area, ranged from 6.3-9.2 mg/m(2) in controls and from 4.2-10.7 mg/m(2) in CAH patients. Saliva was collected over 5 h (at intervals of 15-30 min), and the steroids were measured with adapted RIAs. In healthy controls, maximal cortisol values (250.3 +/- 35.9 nmol/liter) were reached after 30 min. Values showed a monophasic decrease. A t(1/2) of 94.5 min was calculated. The proportion of the HC dose in the total area under the curve was 71.2 +/- 3.2%. For <em>17OHP</em>, a monophasic decrease was found, with a minimum level of 48 +/- 27 pmol/liter after 300 min. In CAH patients the salivary steroid profiles showed individual kinetics (maximal cortisol values ranged from 107-726 nmol/liter). Here a monophasic decrease was found with a shorter t(1/2) of 56.4 min. The HC dose proportion in the area under the curve was 88.3 +/- 6%. <em>17OHP</em> showed biphasic courses with a decrease to the minimum <em>17OHP</em> level after 210 min at the latest and a subsequent gradual increase. Our findings of limited normalization of the adrenal cortex by oral HC administration underlines the necessity of optimizing therapy control and indicates the usefulness of kinetic studies for the judgement of therapy in CAH patients.

BACKGROUND

Congenital adrenal hyperplasia caused by classic 21-hydroxylase deficiency (21OHD) is an autosomal recessive disorder with a high prevalence of asymptomatic heterozygote carriers (HTZ) in the general population, making case detection desirable by routine methodology. HTZ for classic and nonclassic (NC) forms have basal and ACTH-stimulated values of 17-hydroxyprogesterone (<em>17OHP</em>) that fail to discriminate them from the general population. 21-Deoxycortisol (21DF), an 11-hydroxylated derivative of <em>17OHP</em>, is an alternative approach to identify 21OHD HTZ.

OBJECTIVE

To determine the discriminating value of basal and ACTH-stimulated serum levels of 21DF in comparison with <em>17OHP</em> in a population of HTZ for 21OHD (n = 60), as well as in NC patients (n = 16) and in genotypically normal control subjects (CS, n = 30), using fourth generation tandem mass spectrometry after HPLC separation (LC-MS/MS).

RESULTS

Basal 21DF levels were not different between HTZ and CS, but stimulated values were increased in the former and virtually nonresponsive in CS. Only 17·7% of the ACTH-stimulated 21DF levels overlapped with CS, when compared to 46·8% for <em>17OHP</em>. For 100% specificity, the sensitivities achieved for ACTH-stimulated 21DF, <em>17OHP</em> and the quotient [(21DF + <em>17OHP</em>)/F] were 82·3%, 53·2% and 87%, using cut-offs of 40, 300 ng/dl and 46 (unitless), respectively. Similar to <em>17OHP</em>, ACTH-stimulated 21DF levels did not overlap between HTZ and NC patients. A positive and highly significant correlation (r = 0·846; P < 0·001) was observed between 21DF and <em>17OHP</em> pairs of values from NC and HTZ.

CONCLUSIONS

This study confirms the superiority of ACTH-stimulated 21DF, when compared to <em>17OHP</em>, both measured by LC-MS/MS, in identifying carriers for 21OHD. Serum 21DF is a useful tool in genetic counselling to screen carriers among relatives in families with affected subjects, giving support to molecular results.

BACKGROUND

To investigate the effect of pioglitazone on adrenal steroidogenesis in polycystic ovary syndrome (PCOS), we studied 11 obese (two with BMI >25 kg/m(2); nine with BMI >27 kg/m(2)) PCOS women before and after 6 months of treatment at a dose of 45 mg/day.

METHODS

During the early follicular phase, ultrasonography and hormonal assays were performed. On separate days, all women underwent an oral glucose tolerance test (OGTT), a euglycaemic hyperinsulinaemic clamp and an adrenocorticotrophin hormone (ACTH) test. The same protocol was repeated after therapy.

RESULTS

Pioglitazone treatment significantly reduced the insulin response to OGTT and improved the insulin sensitivity indices (P < 0.01 and P = 0.03 respectively). A significant decrease was found in LH (P < 0.05) and androstenedione (P < 0.01) levels after therapy, whereas the other hormonal parameters improved but not significantly. Pioglitazone administration reduced the response of 17alpha-hydroxyprogesterone (<em>17OHP</em>) and androstenedione to ACTH (P < 0.01 and P < 0.02 respectively), most likely through an inhibition of cytochrome P450. The same treatment was able to rebalance the relative activity of 17,20-lyase, as documented by an increase in the androstenedione:<em>17OHP</em> ratio (P < 0.05) after ACTH stimulation.

CONCLUSIONS

Our data support the contention that insulin enhances ACTH-stimulated steroidogenesis, while inducing a relative impairment of 17,20-lyase activity. Whether the beneficial effects of pioglitazone on this imbalance could be related to the ameliorated glyco-insulinaemic metabolism or to a direct effect on the adrenal glands remains to be determined.

We have followed nine adult patients with congenital adrenal hyperplasia (CAH) for between 7-77 months on dexamethasone (DXM) 0.5 mg mane and 0.25 mg nocte, reducing to 0.5 mg mane. Twenty-four hour profiles of ACTH, 17-hydroxyprogesterone (<em>17OHP</em>), and androstenedione were performed; the areas under the curves (AUC) and the heights of the morning peaks were used to assess biochemical control. Comparisons were made between treatment before DXM (pre-DXM), 0.75 mg for 2 weeks (DXM-ST), 0.75 mg for at least 3 months (DXM-LT), and 0.5 mg for at least 3 months (DXM-0.5). None of the three males suffered any significant side-effects. All women had menstrual disturbance but in three ovulation was induced. One female developed Cushing's syndrome and two developed hirsutism which resolved on stopping DXM. Overall there was no significant difference between DXM-ST and DXM-LT (mean AUCs for ACTH: DXM-ST 660, DXM-LT 383, for <em>17OHP</em>: DXM-ST 1177, DXM-LT 587, for androstenedione DXM-ST 232, DXM-LT 121). Reduction of the dose from 0.75 mg to 0.5 mg led to significant deterioration in control (Mean AUC's for ACTH DXM-0.5, 1123 (P less than 0.02), for <em>17OHP</em> DXM-0.5, 2068 (P less than 0.002), for androstenedione DXM-0.5, 213 (P less than 0.5). We conclude that DXM is a satisfactory regime but the dose must be adjusted for each patient.

The purpose of this study was to ascertain whether the pituitary-adrenal responses to human corticotropin-releasing hormone (hCRH) in "non-functioning" adrenocortical adenoma would uncover a functional activity in these adrenal nodules. Eleven patients with incidentally discovered "silent" adrenocortical adenoma and eleven controls were studied. The initial clinical and laboratory examination, including an overnight 1 mg dexamethasone suppression test, revealed no abnormalities in any of the subjects. IR-ACTH and serum steroids (F, S, P, <em>17OHP</em>, 18OHB, and aldosterone) were normal in both controls and patients. After pulse IV injection of 100 micrograms hCRH, the cortisol response was significantly exaggerated (P = 0.01). Stimulated plasma ACTH levels were, however, significantly lower in patients than in controls (P = 0.01), indicating counter-feedback regulation of cortisol. The peak cortisol/peak ACTH ratio (Fmax/ACTHmax) in the patients was significantly elevated (26.8 +/- 4.37 nmol/ng vs. 14.6 +/- 2.16 nmol/ng, P = 0.02). Two further patients with incidentally discovered "pre-Cushing's" adrenocortical adenoma displayed an even higher ratio (43.5 and 45.5 nmol/ng). In established Cushing's syndrome due to an autonomous adrenocortical adenoma, suppression of ACTH and of the ACTH response to hCRH occurs with a very high basal cortisol/basal ACTH ratio. Our findings suggest some functional activity even in clinically "silent" adrenocortical adenoma. Response to hCRH uncovers a continuous spectrum between adrenocortical adenoma, "pre-Cushing's", and Cushing's syndrome.

OBJECTIVE

To evaluate weight-adjusted strategy for levels of neonatal-<em>17OHP</em> in order to improve newborn screening (NBS) efficiency.

METHODS

Blood samples collected between 2-7 days of age from 67,640 newborns were evaluated. When N<em>17OHP</em> levels were ≥ 20 ng/mL, and a second sample was requested. We retrospectively analyzed neonatal-<em>17OHP</em> levels measured by Auto DELFIA- B024-112 assay, grouped according to birth-weight: G1: < 1,500 g, G2: 1,501-2,000 g, G3: 2,000-2,500 g and G4:>> 2,500 g. <em>17OHP</em> cutoff values were determined for each group using the 97.5(th), 99(th), 99.5(th) and 99.8(th) percentiles.

RESULTS

0.5% of newborns presented false-positive results using the cutoff level ≥ 20 ng/mL for all groups. Neonates of low birthweight made up 69% of this group. Seven full-term newborns presented congenital adrenal hyperplasia (CAH) and, except for one of them, <em>17OHP</em> levels were>> 120 ng/mL. Only the 99.8(th) percentile presented higher predictive positive value (2%), and lower rate of false-positives in all groups.

CONCLUSIONS

We suggest the use of 99.8(th) percentile obtained by weight-adjusted N<em>17OHP</em> values of healthy newborns to reduce the rate of false-positive results in NBS.

BACKGROUND

Information on the concentrations of steroids in ovarian follicular fluid (FF) from regularly menstruating (RM) women has been limited because of the absence of methods for the simultaneous quantification of multiple steroids in small volumes of FF. We studied steroid profiles in FF during the early follicular phase of the menstrual cycle and after ovarian stimulation for in vitro fertilization (IVF), and compared concentrations with published values obtained by immunoassay (IA).

METHODS

We used liquid chromatography-tandem mass spectrometry (LC-MS/MS) to measure 13 steroids in 40-microL aliquots of FF samples from 21 RM women and from 5 women after ovarian stimulation for IVF. Relationships between concentrations of steroids and their ratios (representations of the enzyme activities) were evaluated within and between subgroups.

RESULTS

The concentrations of testosterone (Te), androstenedione (A4), and estradiol (E2) measured by LC-MS/MS were lower than those previously reported in studies with IAs. In RM women, androgens were the most abundant class of steroids, with A4 being the major constituent. The concentrations of 17-hydroxyprogesterone (<em>17OHP</em>), total androgens, and estrogens were 200- to 1000-fold greater in FF than in serum. Compared with RM women, FF samples from women undergoing ovarian stimulation had significantly higher concentrations of E2 (P = 0.021), pregnenolone (P = 0.0022), <em>17OHP</em> (P = 0.0007), and cortisol (F) (P = 0.0016), and significantly higher ratios of F to cortisone (P = 0.0006), E2 to estrone (P = 0.0008), and E2 to Te (P = 0.0013).

CONCLUSIONS

The data provide the first MS-based concentration values for 13 steroids in ovarian FF from RM women, from estrogen- and androgen-dominant follicles, and from women after ovarian stimulation for IVF.

Preterm birth is the leading cause of neonatal mortality and morbidity and long-term disability of non-anomalous infants. Previous studies have identified a prior early spontaneous preterm birth as the risk factor with the highest predictive value for recurrence. Two recent double blind randomized placebo controlled trials reported lower preterm birth rate with the use of either intramuscular 17 alpha-hydroxyprogesterone caproate (IM <em>17OHP</em>-C) or intravaginal micronized progesterone suppositories in women at risk for preterm delivery. However, it is still unclear which high-risk women would truly benefit from this treatment in a general clinical setting and whether socio-cultural, racial and genetic differences play a role in patient's response to supplemental progesterone. In addition the patient's acceptance of such recommendation is also in question. More research is still required on identification of at risk group, the optimal gestational age at initiation, mode of administration, dose of progesterone and long-term safety.

To evaluate the temporal coupling between spontaneous kisspeptin and luteinizing hormone (LH) pulsatile releases in polycystic ovary syndrome (PCOS) patients.

We examined 71 patients diagnosed with PCOS. A 2 h pulsatility study was performed to evaluate serum kisspeptin and LH pulse frequency and concentration, sampled every 10 min; baseline follicle-stimulating hormone (FSH), estradiol (E2), prolactin (PRL), cortisol, 17-hydroksy-progesterone (<em>17OHP</em>), testosterone (T), free testosterone index (FTI, and insulin levels were also measured. Detect and Specific Concordance (SC) algorithms were used to evaluate the temporal coupling associations between spontaneous episodic secretion of kisspeptin and LH.

All PCOS patients demonstrated LH and kisspeptin pulsatile secretions. When the SC index was calculated across the sample of PCOS patients (n = 71), no temporal coupling was observed between kisspeptin and LH pulses. When PCOS patients were subdivided according to their menstrual cyclicity, oligomenorrheic patients demonstrated elevated kisspeptin pulse frequency. Additionally, the SC index reveled a temporal coupling between kisspeptin and LH secretory peaks only in eumenorrheic patients (n = 30, intermenstrual interval < 45 days). Oligomenorrheic PCOS patients (intermenstrual interval>> 45 days) did not demonstrate temporal coupling between kisspeptin and LH secretory peaks.

The study of the endogenous kisspeptin and LH pulsatile release revealed the temporal coupling of kisspeptin with LH secretory pulses only in eumenorrheic. This data supports the hypothesis that neuroendocrine impairments in PCOS affect the coupling of kisspeptin with LH pulses and potentially worsen as the disease progresses, becoming unequivocally evident in oligomenorrheic PCOS patients.

OBJECTIVE

As nonclassic congenital adrenal hyperplasia (NCCAH) needs to be taken into account in women with hyperandrogenism, we aimed to assess whether the recommended level of poststimulated <em>17OHP</em> ≥30 nmol/l confirms NCCAH.

METHODS

Forty, consecutive women with biochemical and/or clinical hyperandrogenism (aged 25·4, 18-38) suspected of having NCCAH were recruited to the study. In patients with <em>17OHP</em> level between 5·1 and 29·9 nmol/l an ACTH stimulation test was performed. In patients with basal or poststimulated <em>17OHP</em> ≥30 nmol/l, twenty-four-hour urinary steroid profile (USP) analysis was performed and CYP21A2 mutation was assessed. In selected patients with poststimulated <em>17OHP</em> <30 nmol/l USP was also performed.

RESULTS

The group was divided into two subgroups with basal or poststimulated <em>17OHP</em> ≥30 nmol/l (group A) and with poststimulated <em>17OHP</em> <30 nmol/l (group B). Among 40 patients, basal or poststimulated <em>17OHP</em> ≥30 nmol/l was found in 21, but NCCAH was confirmed by USP followed by genetic testing only in 5 (24%). Four patients were diagnosed as heterozygotes, and in twelve, no CYP21A2 mutation was detected.

CONCLUSIONS

The diagnosis of NCCAH based only on serum <em>17OHP</em> measurements (basal or poststimulated) may lead to false-positive diagnosis when performed by immunoassay with a cut-off value of ≥30 nmol/l. The definitive diagnosis can be established based on USP and/or genetic testing.

C-reactive protein (CRP) is a risk marker for type 2 diabetes mellitus and cardiovascular diseases. In polycystic ovary syndrome (PCOS), limited data are available on high-sensitivity C-reactive protein (hs-CRP) levels and its relationship with components of PCOS especially in Indian women. The objective was to determine serum hs-CRP concentration in adolescent women with and without PCOS and to assess possible correlations of serum hs-CRP levels with components of PCOS in Indian women. One hundred and sixty women with PCOS and sixty non-PCOS women having normal menstrual cycles were included. Clinical assessment included anthropometry, Ferriman-Gallwey (FG) score and blood pressure (BP) measurement. Laboratory evaluation included estimation of T4, TSH, LH, FSH, total testosterone, prolactin, cortisol, <em>17OHP</em>, hs-CRP, lipid profile, and insulin, and glucose after 2-h oral glucose tolerance test. Homeostasis Model Assessment Insulin resistance index (HOMA-IR) and Quantitative Insulin Sensitivity Check Index (QUICKI) and glucose intolerance was calculated. FG score, LH, FSH, total Testosterone, HOMA-IR and QUICKI were significantly different among women with or without PCOS (p < 0.01). Although hs-CRP levels showed a higher trend in women having PCOS, there was no significant difference between the groups (p>> 0.05). A significant and positive correlation was found between hs-CRP and body mass index (BMI) (r = 0.308, p < 0.01) among PCOS group. The results in Indian adolescent women suggest that hs-CRP levels may not per se be associated with PCOS, rather can be related to fat mass in this subset of subjects.

The main purpose of the study was to identify the principal gonadal steroids synthesized by male and female sea lampreys, Petromyzon marinus. To achieve this, we used high performance liquid chromatography to separate the steroids in the serum of sexually mature animals, and to separate the steroids produced by gonadal tissue incubated in the presence of radiolabelled precursor steroids, as a means of identifying the major steroidogenic pathways. We were unable to detect evidence of the 'classical' steroids, such as 17beta-estradiol (E(2)) or testosterone (T) in the serum of either male or female lampreys. Instead, the principal chromatographic peaks contained very polar compounds that had elution times consistent with 15alpha-hydroxylated estrogens and androgens, and there were sex-specific differences in the chemical nature and the quantity of these compounds. Testis fragments or ovarian follicles co-incubated with tritium-labelled pregnenolone ([3H]P(5)), 17-hydroxyprogesterone ([3H]<em>17OHP</em>(4)), or androstenedione ([3H]A(4)), provided additional confirmation that the gonads synthesize a range of very polar steroids, and the metabolites found were consistent with the presence of a 15alpha-hydroxylated (15alphaOH) metabolic pathway common to testis and ovary. For ovarian tissue, the major 'end product' metabolites from all three precursors were 15alphaOH-estrogens, and for testis tissue 15alpha-hydroxyprogesterone (15alphaOHP(4)) and 15alpha-hydroxytestosterone (15alphaOHT) and small amounts of 15alphaOH estrogen. Small amounts of E(2) were also produced by both ovarian (all substrates) and testicular tissue (some substrates). Although it was assumed that the E(2) was synthesized via the aromatization of T, [3H]T was not found as an intermediate metabolite. The study suggests that the principal gonadal steroids in sea lamprey are 15alpha-OH compounds, and that only small amounts of E(2) or T are synthesized by the gonads at this stage of reproductive development. There was no direct evidence of progesterone (P(4)) synthesis from [3H]P(5), although the metabolites synthesized by both testis and ovary were indicative of a metabolic pathway that involved P(4) as an intermediate.

The dose of 250 microg used in the standard short synacthen test is supraphysiological and lower doses may provide a more sensitive test. We examined steroid responses to 125ng/m2, 250ng/m2 and 500 ng/m2 (1-24)ACTH in 6 normal males, looking at effects of dose and the within- and between-subject coefficients of variation (CV). Subjects were given each dose 3 times, blood samples were taken at 10 minute intervals. There was a dose response relationship between dose of (1-24)ACTH and peak values for cortisol and <em>17OHP</em> (p<0.05). There was no difference between peaks of A4 at different doses and no clear peaks were reached for DHEAS. 86% of the peaks for <em>17OHP</em>, 63% for A4 and 25% for cortisol were at 10 minutes and 14%, 29% and 65% respectively at 20 mins (p=0.001). Within-subject CV for cortisol was 12.6% and between subject 10.1%. Tests of adrenal function using low doses of (1-24)ACTH have acceptable between- and within-subject CV for peak values with a dose as low as 125 ng/m2 (1-24)ACTH. Protocols for low dose synacthen tests, with traditional sampling at zero, 30 and 60 minutes or even as shown here at 10 minute intervals, fail to fully define the changes in steroid levels following adrenal stimulation. More frequent blood sampling will be needed to accurately detect peak levels in particular of <em>17OHP</em> and A4.

In an effort to elucidate the aetiology of female-to-male transsexualism (FM-TS) 12 out of an annual sample of 16 untreated female-to-male transsexuals (FMT), aged 19 years 7 months (19;7) to 44 years 8 months (44;8) [median age (M) 27;5] were assessed by means of sexual-medical questionnaires, physical and endocrinological examination. The control group consisted of 15 healthy women (CF), aged 19 years 2 months (19;2) to 36 years 1 month (36;1) (M 22;7) without gender identity disorder, who were not under hormonal medication (including contraceptives). Baseline levels of testosterone (T; ng/dl), androstenedione (A4; ng/dl), dehydroepiandrosterone sulfate (DHEAS; ng/ml), luteinizing hormone (LH; IU/l), follicle stimulating hormone (FSH; IU/l), and sex-hormone binding globuline (SHBG; microgram/dl) were measured. A standard single-dose ACTH stimulation test (250 micrograms ACTH IV; Synacthen) was performed with all subjects. Aldosterone (ALDO), corticosterone (B), deoxycorticosterone (DOC), progesterone (PROG), 17-hydroxyprogesterone (<em>17OHP</em>), 11-deoxycortisol (S), cortisol (F), cortisone (E), pregnenolone (PREG) and 17-hydroxypregnenolone (OHPREG) were assessed before and 60 min after ACTH stimulation. Transvaginal ultrasound was performed in nine out of 12 FMT (20;11 to 44;8, M 27;5; m 29.1 +/- 7.5) but not in CF. Results showed that 10 FMT (83.3%) and five CF (33.3%) were above normal values for at least one of the measured androgens. Baseline levels of T and A4 were significantly higher in FMT than in CF (T: 54.0 +/- 13.8 vs. 41.1 +/- 12.8; A4: 244.8 +/- 73.0 vs. 190.5 +/- 49.3; p < .05), whereas DHEAS, SHBG, LH and FSH did not differ between the groups. Unbound T (T/SHBG ratio) was higher in FMT (72.0 +/- 67.6) than in CF (26.4 +/- 15.1). Baseline levels of <em>17OHP</em>, OHPREG and DOC were higher in FMT than in CF (p < .05). After ACTH stimulation <em>17OHP</em> and OHPREG remained higher in FMT than in CF (p < .05). Single case analysis of ACTH stimulation test together with physical examination revealed symptoms for non-classical congenital adrenal hyperplasia (NC-CAH) in six FMT (50%) and two CF (13.3%). Eight out of nine FMT who were assessed by means of transvaginal ultrasound (i.e. 88.9%; 50.0% of 16) had polycystic ovaries (PCO). Oligomenorrhoea or menstrual dysregularities (81.7% of 16 FMT vs. 0% of CF), hirsutism (56.2% of 16 FMT vs. 13.3% of 15 CF) and adiposity (25.0% vs. 0%) were frequent in FMT, but not in CF. Hyperandrogenism with polycystic ovarian syndrome (PCOS) and adrenocortical hyperresponsiveness to ACTH seems to be a common finding in FMT. This offers support for a hormonal factor in the genesis of FM-TS. Because the prevalence of PCOS and NC-CAH in the female population is higher than FM-TS, the true nature of this factor and its interaction with environmental influences remains unknown.

OBJECTIVE

To investigate melatonin production in hyperandrogenic women before and during treatment with cyproterone acetate and ethinyl estradiol (Diane 35).

METHODS

We studied 10 women with late onset adrenal hyperplasia due to 21-hydroxylase deficiency (LOCAH) and 10 women with idiopathic hirsutism (IH). Patients were treated with Diane 35 for four months. Fasting blood samples for the determination of luteinizing hormone (LH), follicle-stimulating hormone (FSH), testosterone and dihydroepiandrosterone sulfate (DHEAS) and 24-hour urine collections for the determination of 6-sulfatoxymelatonin (aMT6s) excretion were obtained from all patients at baseline and after 4 months of treatment. Results were compared with those obtained in 15 control women.

RESULTS

At baseline, women with LOCAH had significantly higher serum testosterone, 17-hydroxyprogesterone (<em>17OHP</em>) and ACTH stimulated <em>17OHP</em> values than IH and control women. Their aMT6s values (51.0+/-20.5 mg/24h) were significantly higher than the values in IH (34.3+/-7.1) and control women (30.5+/-6.5) (p< 0.001). Diane 35 treatment significantly decreased serum LH, FSH and testosterone levels and aMT6s values in LOCAH patients (29.8+/-16.6 mg/24h) (p<0.0001) in LOCAH patients.

CONCLUSIONS

These results indicate that hyperandrogenic women with LOCAH have increased melatonin production. The normalization of aMT6s and testosterone values during cyproterone acetate-ethinyl estradiol treatment, suggest that sex steroids either directly or through the suppression of gonadotropin, modulate melatonin secretion in these patients.