THE ASSOCIATION of ovarian dysfunction and infertility with evidence of increased

Transcription

1 Effects of Low-dosage Steroid Therapy on 17-ketosteroid Fractions in Infertility WILLIAM McK. JEFFERIES, M.D. THE ASSOCIATION of ovarian dysfunction and infertility with evidence of increased androgenicity has been recognized for many years More recently, there have been reports of increased amounts of androgen in the urine 13 and of the production of androgen by incubated slices of ovarian tissue in women with hirsutism and ovarian dysfunction of the Stein-Leventhal type. Most women with ovarian dysfunction and infertility do not have the Stein-Leventhal syndrome, however, and many have no evidence of excessive androgen production or excretion. Because the administration of relatively small doses of cortisone or related steroids is accompanied by improvement of ovarian function in many cases, regardless of the presence of androgenicity,5. 7 studies have been made of the effect of this therapy upon the urinary 17-ketosteroid (17-KS) fractions of patients, of whom some improved and some did not. By comparing these responses, it was hoped that further understanding of the nature of the disorder responsible for the clinical picture and of the nature of the effect of the steroid medication might be obtained. This report includes the results of such studies on 8 subjects. MATERIALS AND METHODS Seven women, aged 0-40 years, with infertility associated with ovarian dysfunction, were studied prior to and while receiving cortisone acetate'" or hydrocortisonet orally in dosages varying between.5 and 5 mg. given 4 times From the Infertility Clinic of the Maternal Health Association of Cleveland and the Department of Medicine, Western Reserve University School of Medicine, Cleveland, Ohio. Presented at the 18th annual meeting of the American Society for the Study of Sterility, Mar. 30-Apr. 1, 196, Chicago, Ill. The author is indebted to Mrs. Susan Czegesi, Mrs. Louise Faulkner, and Miss Phyllis Disbro for 17-ketosteroid determinations and fractionations. *Cortone, supplied by Merck, Sharp & Dohme, West Point, Pa. tcortef, supplied by The Upjohn Company, Kalamazoo, Mich. 34

2 VOL. 14, No.3, 1963 INFERTILITY THERAPY 343 daily. Five of these women had mild to moderate degrees of hirsutism or acne; the other had no physical evidence of androgenic changes. The presence of tumor or other organic cause of their symptoms had been carefully excluded by appropriate examinations or roentgenograms. Similar studies were performed on a normal, nonhirsute, ovulating, fertile woman. Twenty-four-hour urine collections were made before treatment and at approximately monthly intervals during treatment. The specimens were promptly frozen, and fractionations were later performed on those that seemed of greatest interest on the basis of clinical developments. Creatinine determinations were made on each 4-hr. urine specimen to verify the completeness of the collection. Total neutral urinary 17 -KS were determined by a modification of the method of Callow, as described previously.7 Fractionation of urinary 17-KS from an aliquot of a 4-hr. urine specimen was performed by gradient elution from an alumina column after initial extraction of the conjugates followed by hydrolysis of the glucuronides by,a-glucuronidase and sulfates with ethyl acetate, according to a standardized technic also described previously.6 Four fractions were identified, corresponding to dehydroepiandrosterone (DHA), androsterone (A), etiocholanolone (E), and the ll-oxygenated 17-ketosteroids (1l-oxy-17-KS). RESULTS The results of studies performed on the normal woman appear in Fig. 1. This 6-year-old housewife had no hirsutism nor acne, was ovulating regularlyon the basis of basal body temperature (BBT) charts, with menses every 8 days, and had had normal pregnancies without difficulty. Fractionations were made of the 17-KS in 4-hr. urines collected during the pre- and postovulatory phases of her cycle before treatment, after 3 weeks of cortisone Fig.!. Urinary 17-KS fractionation N. C. TotaI17-KS, 9.8 mg./4 hr. 8 7 ~ 6 :I: ~ 5... '" E 4 3 I 0-0 Pre-Rx ---- Cortisone, 5 mg Q 8 Hrs. x 3 Wks.... Placebo, x 3 Wks. x... x I Mo. After Rx ---;-~-,...:. * ---.e ", -, g...; ~.::..~.::.. _o~ x,, ~ " :~ " " DHA A E

3 344 JEFFERIES FERTILITY & STERILITY acetate, 5 mg. every 8 hr., after 3 weeks of the same schedule of placebo tablets indistinguishable from the cortisone tablets, and 3 weeks after cessation of all treatment. All fractionation patterns were remarkably similar except for the decrease of DHA on cortisone therapy. Urinary 17-KS fractionation patterns of other normal women may show considerable variation in the DHA, A, and E fractions between individuals,6, 9,11 but this patient's pattern approximates that of the average normal woman. In Fig. are shown the results of studies performed on a 31-year-old housewife with a history of regular menses from 10 to 16 years of age, followed by irregular cycles, several episodes of metropathia hemorrhagica, the appearance of moderate acne and hirsutism, and infertility for 9 years. BBT charts revealed no evidence of ovulation. Two pretreatment fractionations were performed on 4-hr. urine specimens obtained 9 days apart. The Similarity of these two patterns and the difference from those of the subject in Fig. 1 are impressive. After the ingestion of hydrocortisone, 5 mg. every 8 hr., for 4 weeks, the DHA, A, and E fractions decreased significantly. Subsequent fractionations on treatment showed no further change. The absence of significant change in the 1l-oxy-17-KS fraction is not surprising, because this fraction consists largely of excretory products of hydrocortisone. In spite of the impressive change in the pattern of urinary 17-KS excretion, this patient has not ovulated after more than 6 months of continuous therapy. The pretreatment pattern of the patient whose results are shown in Fig. 3 is quite similar to that in Fig., but this patient had a different clinical picture and response to therapy. This 0-year-old housewife had moderate acne and a high urinary 17-KS excretion, but her menses were regular and she had no difficulty in conceiving. Her presenting complaint was that she had been unable to carry a pregnancy to term, having had miscarriages, each at 4~~ months of gestation. BBT charts revealed regular ovulatory rises, but the ~ :I: 5 ~ ~ 4 E Pre-Rx o~:::::::.: ----.~ o --.~ x' OL----D~H-A------~A~------E~--~I~I-~O~X~~-=17~-K~S Fig.. Urinary 17-KS fractionation J. K. Total 17-KS, 1B.1 mg'; 4 hr.

4 VOL. 14, No.3, 1963 INFERTILITY THERAPY 345 postovulatory phases were relatively long (up to 19 days). After hydrocortisone, 5 mg. every 8 hr. for a month, not only did her fractionation pattern show interesting changes, DHA excretion dropping most, A next, and E least, but her postovulatory phases became more normal and her acne cleared dra- Fig. 3. Urinary 17-KS fractionation K. M. Total 17-KS: before treatment, 0.9 mg.j4 hr.; during treatment, 1.8 mg.j4 hr Pre-Rx I _.-. Hydrocortisone, 5 mg. Q BH x J m~ 6 lq 5 :r: ~... 4 go 3 OL- ~ ~ -L L- DHA A E J J-OXY-J7KS. matically. She became pregnant again and this time carried her baby to term uneventfully, with no hormonal treatment other than the hydrocortisone, which was continued up to the time of delivery. The next patient (Fig. 4), a 5-year-old woman, had a fractionation pattern quite similar to that of the normal subject in Fig. 1, and yet she had had irregular menses since her late menarche (at age 16), had moderate hirsutism, and had been trying unsuccessfully to become pregnant for a year. BBT charts revealed ovulatory rises preceding the irregular periods. Fractionations performed on specimens collected in the pre- and postovulatory phases before treatment and after 10 we~ks of cortisone acetate,.5 mg. 4 times daily, showed no significant changes, and yet 1 days after the last fractionation, while still taking the cortisone, she conceived and went on to have a normal pregnancy. Fig. 4. Urinary 17-KS fractionation L. K. Total 17-KS: before ovulation, 8.0 mg.j4 hr.; after ovulation, 9.4 mg.j4 hr Pre- Rx - Pre-Ov Pre-Rx - Post-Ov.. 5 f- ~---. Cortisone.5mg. 4xd x JOwks. - Pre-Ov. Ul a: ~4f- N... go3f _...-_... "......"'..,'4 -- "" ", =- ---Q~ ",~~... " ~ (~~... OL- ~ ~y ~J ~J ~J DHA A E JJ-OXY-J7Ks'

5 346 JEFFERIES FERTILITY & STERILITY Patient J. M. (Fig. 5), a 6-year-old woman, had had regular 8-day menstrual cycles until age 3, when they became irregular. She had a normal pregnancy at 5, followed by amenorrhea for the year prior to study. At age 3 she had received prednisolone for facial acne, which had subsided without l o_pre-rx 6 I- _.-. Cortisone, 5mg. Q SH, for IOwks. I fq 5 I ~ 4 "- go 3./o~ ~ ~ o~ ' I I I DHA A E II-OXY-17KS. Fig. 5. Urinary 17-KS fractionation J. M. FSH, 8 M.U.j4 hr.; total 17-KS: before treatment, 1.0 mg.j4 hr.; during treatment, 7.1 mg.j4 hr. recurrence. A few coarse hairs were present. Skull X-rays and 4-hr. urinary gonadotropin excretion were normal. Her urinary 17-KS excretion and fractionation pattern were within normal limits, but the administration of cortisone acetate, 5 mg. every 8 hr., produced a significant and comparable change in all three fractions (DHA, A, and E). Nine weeks after beginning cortisone therapy, she ovulated, and a month later she conceived. Patient M. B. (Fig. 6), a 5-year-old subject, had a fractionation pattern practically identical with that of J. M. (Fig. 5) and a similar response to steroid therapy, with a comparable fall of the three fractions, but there were interesting differences between these women. M. B. was having menses every 8-37 days, but she had been infertile for a total of 6 years during marriages. BBT charts revealed biphasic curves with sluggish postovulatory rises and prolonged luteal phases (up to 17 days). She also had moderate 0-0 I Pre-Rx - Pre-Ov. 6 l.o Pre - Rx - Post - Ov.!!i 5...". Hydrocortisone,5mg QSHx3Mo.,Pre-Ov. :i:... " "" x3mo.,post-ov. ~ 4 "... E 3 Fig. 6. Urinary 17-KS fractionation M. B. Total 17-KS: before ovulation, 13.6 mg.j4 hr.; after ovulation, 15.5 mg.j4 hr. DHA A E II-OXY-17-KS

6 VOL. 14, No.3, 1963 INFERTILITY THERAPY 347 hirsutism and mild acne. After 4~~ months on hydrocortisone, 5 mg. every 8 hr., treatment was changed to cortisone acetate, 5 mg. 4 times daily. Although there was no further change in her fractionation pattern, she conceived after 4 months of the second regimen. Fig. 7. Urinary 17-KS fractionation J. B. Total 17-KS: before therapy, 7.7 mg.j4 hr.; on thyroid, 7.5 mg.j4 hr.; on cortisone, 4.6 mg.j4 hr. 6!Q 5 :x: ~ 4 " ḡo 3 0_0 Pre-Rx 0 0 Thyroid, gr.m I d. for I yr. _._. Cortisone,.5 mg. 4xd, for I mo. Patient J. B. (Fig. 7), 1 years old, who had had secondary amenorrhea for 5 years, had no evidence of androgenicity whatsoever. Menarche had occurred at age 1, with regular cycles until age 15, when menses stopped abruptly while she was losing weight on a diet. She was married at 19 but was unable to conceive. Tests of thyroid function were normal (PBI, 5.8 /Lg.%, 4-hr. p31 uptake 17%), and for a year prior to study she had been given desiccated thyroid in doses up to gr. III daily without benefit. Cyclic injections of a progestational agent had produced withdrawal bleeding but no ovulations. The last injection had been administered 6 months before the study. The first fractionation was performed while she was still taking thyroid, gr. III daily, her serum PBI being 8.1 /Lg.j100 ml. This medication was then tapered and stopped over a 6-week period. Three weeks later, another fractionation was performed, revealing an impressive decrease in A and increase in E. Cortisone acetate,.5 mg. 4 times daily, was then administered, and a Fig. 8. Urinary 17-KS fractionation E. M. Total 17-KS: before treatment, 1. mg.j4 hr.; on thyroid, 11.7 mg.j4 hr.; on cortisone, 10.0 mg.j4 hr. 0 0 Pre-Rx Thyroid, gr. n/d for I mo. _._ moo +Cortisone, 5 mg Q 8H for 3 mo.!q 5 :x: ~ 4 " ḡ' 3 DHA A

7 348 JEFFERIES FERTILITY & STERILITY month later a further decrease in A and E had occurred. Two weeks later, she ovulated and conceived. Patient E. M. (Fig. 8), a 7-year-old woman, also showed no evidence of androgenicity and received thyroid, but she had a small, nontoxic, diffuse thyroid enlargement associated with irregular menses and infertility of 7 year's duration. The results of serum PBI and p3l uptake studies were invalidated by recent salpingograms. Her pretreatment pattern was also quite similar to that of the normal subject, but on thyroid therapy A did not change while E decreased significantly. With the addition of cortisone acetate, 5 mg. every 8 hr., the excretion of A decreased slightly. Four months after the initiation of cortisone therapy, a month after her third fractionation, she conceived. DISCUSSION A previous report6 has indicated that treatment with cortisone acetate or hydrocortisone in the dosages employed in this study may produce significant changes in the patterns of excretion of urinary 17-KS of women with ovarian dysfunction. It also appears that each person has his or her own characteristic pattern of urinary 17-KS excretion.s The observations made in this study help to clarify some of the questions that have arisen regarding the relationship of fractionation patterns to clinical pictures and the relationship between changes in these patterns and response to low-dosage corticosteroid therapy in patients with ovarian dysfunction and infertility. It is apparent from comparison of Fig. and 3, Fig. 1, 4, and 6, and Fig. 5 and 6 that women with similar patterns of urinary 17 -KS excretion may have quite different clinical pictures. It is also evident from Fig. 4-6 that androgenic changes may be present in patients with fractionation patterns well within the normal range. Patient J. K. (Fig. ) demonstrated that cortico :steroid therapy may produce significant change in pattern without clinical improvement in ovarian dysfunction. Furthermore, comparison of her patterns with those of K. M. (Fig. 3) reveals that the same dose of steroid for the same period of time may produce different degrees of change in pattern in different subjects. Patients K. M., L. K., and M. B. (Fig. 3, 4, and 6, respectively) demonstrate that the occurrence of regular ovulatory cycles does not preclude the presence of a functional disorder that may respond favorably to corticosteroid therapy. L. K. and M. B. also revealed that improvement in ovarian function with treatment may occur without a significant change in fractionation pattern. In M. B. the administration of hydrocortisone, 5 mg. every 8 hr., and cortisone acetate, 5 mg. 4 times daily, resulted in identical fractionation patterns. The evidence does not permit any conclusions as to why this patient

8 VOL. 14, No.3, 1963 INFERTILITY THERAPY 349 conceived on the latter treatment and not on the former, but it is possible that the success of the second regimen may have been related to the greater ease with which the 4-times daily schedule was followed. Most patients stated that they could remember to take a dose of medication 4 times daily (upon arising, before lunch, before supper, and at bed time) more readily than every 8 hr. (e.g., 7 A.M., 3 P.M., and 11 P.M.). The observations made on Patients J. B. and E. M. (Fig. 7 and 8) indicate that improvement in ovarian dysfunction may occur with corticosteroid therapy in patients having no androgenic changes and normal excretion of 17-KS. They also show the increase in A to E ratio with thyroid therapy that was first reported by Bradlow and his associates in studies of the effect of administration of relatively large doses of triiodothyronine upon urinary 17-KS fractions. Whether this effect of thyroid therapy influences ovarian dysfunction favorably or adversely cannot be stated on the basis of these studies, although there was no indication that thyroid alone helped the ovarian function of either of these women. Hence, although most cases of ovarian dysfunction are associated with androgenic changes and/or increase in 17-KS excretion, from the observations made on these 8 subjects it is apparent that disorders of ovarian function are not necessarily related to the presence of either of these factors. Furthermore, although response to corticosteroid therapy is often accompanied by changes in these factors, it does not necessarily depend upon such changes. The occurrence of androgenic changes with normal 17-KS excretion may be explained by the production of small, but biologically effective quantities of a potent androgen such as testosterone, which may not alter significantly the 17-KS excretion pattern, but this would not account for the occurrence of ovarian dysfunction in women with no androgenic changes. An excessive production of estrogen by the adrenals or ovaries may be a factor in some cases. This possibility must be investigated further, but clinical observations suggest that this would be a relatively infrequent cause of ovarian dysfunction, and that most cases result from some other disorder. When all of the observations made upon patients with ovarian dysfunction of the types manifested in these subjects are considered, certain features stand out: (1) The androgenic changes, when they occur, usually appear after the onset of ovarian function at adolescence, and sometimes not until several years later. () Evidence of ovarian dysfunction, although sometimes present with the onset of menses, also often does not occur until several years later. (3) The appearance of androgenic changes and/or ovarian dysfunction is often related to a period of increased stress. (4) In some patients, wedge resection of the ovaries may restore normal ovarian function, at least temporarily,15 and decrease 17 -KS excretion. 4 (5) Administration of small doses of cor-

9 350 JEFFERIES FERTILITY & STERILITY tis one tends to restore a normal pattern of 17 -KS excretion and often restores normal ovarian function, even in patients with the Stein-Leventhal syndrome who have previously had temporary improvement after wedge resection of the ovaries. This behavior suggests that there may be a reciprocal relationship between the adrenals and the ovaries, possibly in the nature of a competition of some sort, so that when this disorder is present, a decrease in the activity of either gland may result in improved function of the other. The recent demonstrations that many of the steps in the production of ovarian hormones are identical with steps in the production of adrenal steroids makes such a hypothesis reasonable. Presumably the disorder could result from a relative deficiency of one or more factors necessary for the normal activity of one or more enzymatic steps common to the function of the two pairs of glands. Under some circumstances the supply may be adequate for normal function of both glands, at least in some persons, but at times of emotional strain, severe illness, pregnancy, or similar stresses, the supply may be inadequate, and evidence of dysfunction would appear. If the defect occurred at some step prior to the production of androgen, no androgenic changes would occur, whereas a defect beyond this point would result in excessive production of androgen with associated clinical changes. Because. of its greater importance in body health and economy, hydrocortisone would presumably be produced preferentially, and the production of other normal steroids would suffer first. Although this hypothesis remains to be proved, it seems to be the most logical explanation of all of the observations made in this field to date. It, of course, does not preclude the possibility that specific defects in steroid metabolism in either the adrenals or the ovaries may occur in some cases, a situation that is obviously present in congenital adrenal hyperplasia. SUMMARY AND CONCLUSIONS Urinary 17-ketosteroid fractionation patterns were determined in 5 women with hirsutism, acne, or both, associated with ovarian dysfunction and infertility, in women with ovarian dysfunction and infertility without accompanying androgenic changes, and in a normal fertile woman before and while receiving cortisone acetate or hydrocortisone in small doses. The results led to the following conclusions: 1. Similar 17-ketosteroid fractionation patterns may be associated with different clinical pictures in different patients.. Androgenic changes may occur with fractionation patterns well within the normal range.. 3. The administration of the same dosage of steroid for the same length of

10 VOL. 14, No.3, 1963 INFERTILITY THERAPY 351 time to women with similar patterns may result in different changes of pattern. 4. The occurrence of regular ovulatory cycles in an infertile woman does not preclude the presence of a functional disorder that may respond favorably to corticosteroid therapy. All patients of this type observed so far had evidence of abnormal luteal phases on the basis of basal temperature records. 5. In some patients improvement in ovarian function may occur without significant changes in fractionation patterns, and conversely, in some a change in pattern may occur without improvement in ovarian function. 6. Improvement in ovarian dysfunction may occur with corticosteroid therapy in patients having no androgenic changes and normal 17-ketosteroid patterns. 7. Hence, although hirsutism and/or acne often occur in association with ovarian dysfunction and infertility, they may not be directly related. University Hospitals Gleveland 6, Ohio REFERENCES 1. BISSELL, G. W., and WILLIAMS, R. H. Hirsutism in females; a clinical study of its etiology, course and treatment. Ann. Int. Med. :783, BRADLOW, H. L., et al. Interaction of hormonal effects: Influence of triiodothyronine on androgen metabolism. Science 14: 106, BROOKSBANK, B. W. L. Endocrinological aspects of hirsutism. Physiol. Rev. 41:63, HERRMANN, W., BUCKNER, F., and MORRIS, J. M. The problem of "mild" adrenal hyperplasia. Fertil. & Steril. 11:74, JEFFERIES, W. McK. Further experience with small doses of cortisone and related steroids in infertility associated with ovarian dysfunction. Fertil. & Steril. 11: 100, JEFFERIES, W. McK. Effect of small doses of cortisone upon urinary 17-ketosteroid fractions in patients with ovarian dysfunction. ]. Glin. Endocrinol. :55, JEFFERIES, W. McK., and LEVY, R. P. Treatment of ovarian dysfunction with small doses of cortisone or hydrocortisone. ]. Glin. Endocrinol. 19: 1069, JEFFERIES, W. McK., and MICHELAKIS, A. M. Studies of individual patterns of urinary 17-ketosteroid fractions. ]. Lab. & Glin. Med. 58:831, KAPPAS, A., and GALLAGHER, T. F. Studies in steroid metabolism. XXVIII. The a-ketosteroid excretion pattern in normal females and the response to ACTH. J. Glin. Invest. 84: 1566, LANTHIER, A., and SANDOR, T. "In vitro" production of androgenic steroids by human normal and "Stein-Leventhal" type ovarian slices. Metabolism 9:861, LIPSETT, M. B., and RITER, B. Urinary ketosteroids and pregnanetriol in hirsutism. ]. Glin. Endocrinol. 0:180, LUFT, R. A study on hirsutism, Cushing's syndrome, and precocious puberty. Acta med. scandinav. 149 Suppl.: 1-119, O'DONNELL, V. J., and MCCAIG, J. G. Biosynthesis of steroids by human ovaries. Biochem. J. 71:11, ROCCA, D. Z. Obesidad e hypertricosis. Semana med. 108:864, STEIN, 1. F. Bilateral polycystic ovaries. Am. J. Obst. & Gynec. 50:385, WARREN, J. C., and SALHANlCK, H. A. Steroid biosynthesis in the human ovary. J. Glin. Endocrinol. 1:118,1961.