José Sancho

Obesity, and not insulin resistance, is the major determinant of serum inflammatory cardiovascular risk markers in pre-menopausal women

Aims/HypothesisIncreased serum inflammatory markers have been found in obesity and insulin-resistant states, and could play a causative role in insulin resistance, atherosclerosis and cardiovascular disease. The polycystic ovary syndrome represents a human model of insulin resistance because both lean and obese polycystic ovary syndrome patients are insulin-resistant compared with non-hyperandrogenic women. We evaluated whether obesity, insulin resistance, or both, are related to the increased concentrations of inflammatory markers in pre-menopausal women.MethodsWe compared 35 patients with polycystic ovary syndrome and 28 healthy women, paired for BMI, prevalence of obesity and smoking. Measurements included serum inflammatory markers, BMI, waist-to-hip ratio, blood pressure, serum glucose, insulin, lipid and hormone concentrations, and insulin sensitivity index.ResultsThe insulin sensitivity index was reduced in polycystic ovary syndrome patients compared with controls. However, no differences were observed between both groups in C-reactive protein, interleukin 6, tumour necrosis factor-α, soluble type 2 tumour necrosis factor receptor, and soluble intercellular cell adhesion molecule-1. When considering patients and controls as a whole, C-reactive protein and interleukin 6, were increased in obese subjects compared with lean women. Inverse correlations existed between insulin sensitivity index and C-reactive protein, interleukin 6, tumour necrosis factor-α, soluble type 2 tumour necrosis factor receptor, and soluble intercellular cell adhesion molecule-1. Only the weak correlation with C-reactive protein persisted after controlling for BMI.Conclusion/interpretationObesity, and not insulin resistance, is the major determinant of serum inflammatory cardiovascular risk markers in pre-menopausal women.

Role of the pentanucleotide (tttta)n polymorphism in the promoter of the CYP11a gene in the pathogenesis of hirsutism

OBJECTIVE To determine if the (tttta)(n) repeat polymorphism in the promoter region of CYP11a gene is associated with hirsutism and hyperandrogenism in women from Spain. DESIGN Controlled clinical study. SETTING Tertiary-care institutional hospital. PATIENT(S) Ninety-two hirsute women and 33 healthy control women. INTERVENTION(S) Basal and adrenocorticotropin-stimulated serum samples and genomic DNA extracted and purified from whole-blood samples were obtained during the follicular phase of the menstrual cycle. MAIN OUTCOME MEASURE(S) CYP11a (tttta)(n) repeat-polymorphism genotype and serum ovarian and adrenal androgen levels. RESULT(S) None of the CYP11a (tttta)(n) polymorphic alleles was associated with hirsutism. The absence of the four-repeat-units allele (4R-- genotype), which has been reported by other authors to be associated with polycystic ovary syndrome (PCOS), was found in 22.4% of the women studied here and was equally distributed among patients and controls, independently of the presence of PCOS and/or ovarian or adrenal hyperandrogenism. No differences were observed in serum hormone concentrations in 4R-- individuals as compared with subjects with at least one four-repeat-units allele. CONCLUSION(S) The (tttta)(n) repeat polymorphism in the promoter region of CYP11a does not appear to play any significant role in the pathogenesis of hirsutism and hyperandrogenism in women from Spain.

The presence of the 21-hydroxylase deficiency carrier status in hirsute women: phenotype-genotype correlations

OBJECTIVE To determine the role of heterozygosity for mutations in the 21-hydroxylase gene (CYP21) in the pathogenesis of hyperandrogenism. DESIGN Controlled clinical study. SETTING Tertiary care institutional hospital. PATIENT(S) Forty hirsute women and 13 healthy control women. INTERVENTION(S) The source of androgen excess was determined by the changes in serum testosterone levels in response to a single 3.75-mg i.m. dose of triptorelin. MAIN OUTCOME MEASURE(S) CYP21 molecular genetic analysis and serum 17-hydroxyprogesterone levels. RESULT(S) Eight patients and one control were heterozygous carriers of CYP21 mutations. Two patients with adrenal hyperandrogenism and one patient with ovarian hyperandrogenism, who carried the V281L mutation had an increased ACTH-stimulated 17-hydroxyprogesterone level (>4.1 ng/mL) that persisted during gonadal suppression. Another patient with adrenal hyperandrogenism carried the V281L mutation, and her ACTH-stimulated 17-hydroxyprogesterone level was elevated only during gonadal suppression. Four patients (three with idiopathic hirsutism, one with ovarian hyperandrogenism) and one control were carriers of CYP21 mutations typically associated with classic congenital adrenal hyperplasia but had normal basal and ACTH-stimulated 17-hydroxyprogesterone levels. Nine patients without CYP21 mutations had increased ACTH-stimulated 17-hydroxyprogesterone levels; these decreased to normal in six of the patients during gonadal suppression. CONCLUSION(S) The response of serum 17-hydroxyprogesterone to ACTH does not predict CYP21 carrier status. No clear concordance was found between the CYP21 genotype and the functional origin of androgen excess.

Treatment of hirsutism with ethinyl estradiol–desogestrel contraceptive pills has beneficial effects on the lipid profile and improves insulin sensitivity

OBJECTIVE To evaluate the effects on the lipid pattern and insulin sensitivity of hirsute women of an oral contraceptive pill containing 30 microg of ethinyl estradiol and 150 microg of desogestrel. DESIGN Prospective clinical study. SETTING Tertiary care institutional hospital. PATIENT(S) 16 hirsute women. INTERVENTION(S) Women were evaluated at baseline and after receiving six cycles of oral contraceptive therapy. MAIN OUTCOME MEASURE(S) Body mass index (BMI); hirsutism score (nine body areas); serum levels of total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, triglycerides, apolipoprotein B, lipoprotein(a), and serum adrenal and ovarian androgens; and fasting glucose and insulin concentrations. RESULT(S) The mean serum total, HDL, and LDL cholesterol levels increased after six cycles of oral contraceptive therapy. Levels of HDL cholesterol were < 50 mg/dL in 7 of the 16 patients at baseline; these levels normalized in 4 patients after treatment. Serum total and LDL cholesterol remained within the normal range in all patients before and after therapy. No significant changes were observed in serum triglyceride, apolipoprotein B and lipoprotein(a) concentrations. Fasting insulin levels and insulin resistance as analyzed by homeostasis model assessment were reduced significantly after therapy. No changes in BMI were observed. Administration of oral contraceptive pills signifiCantly reduced the hirsutism score and hyperandrogenemia. CONCLUSION(S) Oral contraceptive pills containing low-dose ethinyl estradiol and desogestrel are effective in controlling hyperandrogenism and hirsutism and ameliorate the abnormal metabolic profile of women with hirsutism.

Insulin gene variable number of tandem repeats regulatory polymorphism is not associated with hyperandrogenism in Spanish women

OBJECTIVE To determine if the insulin gene variable number of tandem repeats (VNTR) regulatory polymorphism is associated with hyperandrogenism in a population of Spanish women. DESIGN Controlled clinical study. SETTING Tertiary institutional hospital. PATIENT(S) Ninety-six hyperandrogenic patients and 38 healthy control women. INTERVENTION(S) Whole blood and serum samples were collected during the follicular phase of the menstrual cycle. MAIN OUTCOME MEASURE(S) Insulin gene VNTR regulatory polymorphism genotypes (classes I/I, I/III, and III/III alleles) and serum androgen levels. Insulin resistance was estimated from fasting glucose and insulin levels by using the homeostatic model assessment. RESULT(S) The frequencies of VNTR genotypes were 45.5%, 43.3%, and 11.2% for I/I, I/III, and III/III alleles considering patients and controls as a whole. These frequencies were not statistically different in controls (47.4%, 34.2%, and 18.4%) and in patients (44.8%, 46.9%, and 8.3%). CONCLUSION(S) Hyperandrogenism and the insulin gene VNTR regulatory polymorphism are not associated in Spanish women.

Prospective randomized study comparing the long-acting gonadotropin-releasing hormone agonist triptorelin, flutamide, and cyproterone acetate, used in combination with an oral contraceptive, in the treatment of hirsutism

OBJECTIVE To compare triptorelin, cyproterone acetate (CPA), and flutamide, in combination with an oral contraceptive, in the treatment of hirsutism. DESIGN Prospective randomized study. SETTING(S) Tertiary care hospital. PATIENT(S) Thirty-nine hirsute women with idiopathic or functional ovarian hyperandrogenism. INTERVENTION(S) Patients were randomly assigned to receive triptorelin (3.75 mg IM every 28 days), CPA (100 mg/d orally on days 1-10 of the menstrual cycle), or flutamide (250 mg orally twice daily). All the patients also received a triphasic oral contraceptive. MAIN OUTCOME MEASURE(S) Before and after 3 and 9 months of treatment, the Ferriman-Gallwey score, hepatic function, and gonadal and adrenal steroid profiles were evaluated. RESULTS Thirty-three patients completed the 9-month study period. The Ferriman-Gallwey score decreased in all the groups. In the patients treated with CPA or flutamide, a decrease in the hirsutism score was noted as soon as after 3 months of treatment. This decrease was more pronounced after 9 months of treatment, especially in the patients who received flutamide, who had lower hirsutism scores compared with the other treatment groups. None of the patients had abnormal liver function test results. There was a mild increase in serum lipid concentrations, mostly in the group treated with triptorelin. CONCLUSION(S) Triptorelin, CPA, and flutamide are effective drugs for the treatment of hirsutism. Flutamide results in a greater reduction in the hirsutism score, but CPA also offers satisfactory results at a much lower cost. Triptorelin has no advantages over flutamide and CPA, and is the most expensive of the three drugs tested.

Common single nucleotide polymorphisms in intron 3 of the calpain-10 gene influence hirsutism

OBJECTIVE To study three common polymorphisms in intron 3 of the calpain-10 gene (CAPN10) in hyperandrogenic patients. DESIGN Case-control study. SETTING Academic hospital. PATIENT(S) Ninety-seven hyperandrogenic patients and 37 healthy controls. INTERVENTION(S) Basal and adrenocorticotropin-stimulated serum samples and genomic DNA samples were obtained during the follicular phase of the menstrual cycle. MAIN OUTCOME MEASURE(S) Genotyping of the UCSNP43, UCSNP44, and UCSNP45 polymorphisms in CAPN10 and serum androgen levels. RESULT(S) Sixteen patients had idiopathic hirsutism, defined as normal serum androgen levels and regular menstrual cycles. Eighty-one hyperandrogenic patients (those presenting with hyperandrogenemic hirsutism or the polycystic ovary syndrome) were analyzed further. UCSNP45 alleles were distributed differently among the study groups. Heterozygosity for the uncommon C allele was increased in patients with idiopathic hirsutism (31.3%) and reduced in hyperandrogenic patients (7.4%) compared with controls (16.2%). The UCSNP44 and UCSNP43 alleles were in linkage disequilibrium, and were distributed equally among patients with idiopathic hirsutism, hyperandrogenism, and controls. However, the uncommon A allele at UCSNP43 was associated with higher hirsutism score (mean [+/- SD], 9.9 +/- 6.8, 12.7 +/- 7.7, and 14.6 +/- 8.2 in GG, GA, and AA participants, respectively). No other differences were observed in clinical and biochemical characteristics, including insulin sensitivity, by CAPN10 variant. CONCLUSION(S) The C allele at the UCSNP45 locus in CAPN10 is associated with idiopathic hirsutism, and UCSNP43 influences the hirsutism score.

Role of the follistatin gene in women with polycystic ovary syndrome

OBJECTIVE To search for mutations in the coding exons of the follistatin gene of women diagnosed with polycystic ovary syndrome (PCOS). DESIGN Controlled clinical study. SETTING Tertiary institutional hospital. PATIENT(S) Thirty-four women diagnosed with PCOS and 15 healthy control women. INTERVENTION(S) Whole blood and serum samples were collected during the follicular phase of the menstrual cycle. MAIN OUTCOME MEASURE(S) Circulating total testosterone (T), sex hormone-binding globulin (SHBG), calculated free T (FT), androstenedione (A), dehydroepiandrosterone-sulfate (DHEAS), LH, FSH, E2, and basal and adenocorticotropic hormone (ACTH)-stimulated 17-hydroxyprogesterone (17-OHP) were determined. Insulin resistance was estimated from fasting glucose and insulin levels, using the homeostasis model assessment. The coding regions of the follistatin gene were studied by heteroduplex analysis after polymerase chain reaction amplification. RESULT(S) Women with PCOS presented with higher body-mass index, insulin resistance, T, FT, A, and ACTH-stimulated 17-OHP serum concentrations and lower SHBG serum levels, as compared with controls. No differences were observed among the groups in serum DHEAS, basal 17-OHP, E(2), LH, and FSH. No mutations were found in coding regions of the follistatin gene, with the exception of a G to A change at cDNA position 951, resulting in a silent mutation. This change was present in 2 (5.9%) of 34 patients and 1 (6.7%) of 15 controls. CONCLUSION(S) Mutations in the coding regions of the follistatin gene do not appear to be related to PCOS.

Complete purification of two identical Na+ ‐pump inhibitors isolated from bovine hypothalamus and hypophysis

We have completely purified, in parallel, a low molecular weight, non‐peptidic, non‐lipidic, Na+,K+‐ATPase inhibitory factor from bovine hypothalamic and pituitary tissues. In the final purification step we obtain, from both tissues, a single, homogeneous peak, with a maximal absorbance at 247 nm. This factor, at physiological concentrations of potassium (5–25 mM), inhibits in a dose‐response manner Na+,K+‐ATPase and displaces ouabain from its receptor at the enzyme structure. The factor isolated from both tissues is identical, being the specific activity per weight of tissue higher in hypophysis. No factor was found in cerebral cortex, used as tissue control.

Abnormalities in the serum insulin-like growth factor-1 axis in women with hyperandrogenism

OBJECTIVE To study the insulin-like growth factor-1 (IGF-1) axis in hirsute women. DESIGN Controlled clinical study. SETTING Tertiary care institutional hospital. PATIENT(S) Forty hirsute women and 17 women with normal menstrual cycles. INTERVENTION(S) Basal and ACTH-stimulated samples were obtained, and sampling was repeated 1 (gonadal stimulation) and 21 (gonadal suppression) days after a single 3.75-mg IM dose of triptorelin. Controls did not receive triptorelin for ethical reasons. MAIN OUTCOME MEASURE(S) Serum GH, IGF-1, IGF-binding protein-3 (IGFBP-3), insulin, glucose, total testosterone, sex hormone-binding globulin, E2, and gonadotropin levels. Basal and ACTH-stimulated steroid precursors were measured. RESULT(S) Patients with idiopathic hirsutism were identified by normal serum androgen levels (n=17). Those with functional ovarian hyperandrogenism (n=15) were identified by an increase in the serum testosterone level that normalized during gonadal suppression, whereas those with functional adrenal hyperandrogenism (n=8) were identified by an initial increase in the testosterone level that persisted during gonadal suppression. The adrenal hyperandrogenism group had increased IGF-1 levels compared with the control, idiopathic hirsutism, and ovarian hyperandrogenism groups. Patients with ovarian hyperandrogenism had normal TGF-1 concentrations, but their IGFBP-3 concentrations were lower than those of controls. No differences were observed in GH levels between any of the groups. These results persisted when the influence of age was corrected for. CONCLUSION(S) The IGF-1 axis appears to be involved in the pathogenesis of hyperandrogenism, especially in patients with adrenal hyperandrogenism, who have a clear increase in IGF-1 levels. Moreover, patients with ovarian hirsutism have decreased IGFBP-3 concentrations, which might enhance IGF-1 bioavailability.