Body mass index and ovarian function are associated with endocrine and metabolic abnormalities in women with hyperandrogenic syndrome

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1 European Journal of Endocrinology (2008) ISSN CLINICAL STUDY Body mass index and ovarian function are associated with endocrine and metabolic abnormalities in women with hyperandrogenic syndrome S Cupisti, N Kajaia, R Dittrich, H Duezenli, M W Beckmann and A Mueller Department of Obstetrics and Gynecology, Erlangen University Hospital, Universitaetsstrasse 21-23, D Erlangen, Germany (Correspondence should be addressed to A Mueller; andreas.mueller@uk-erlangen.de) Abstract Background: The aim of this study was to evaluate associations of clinical features, such as hirsutism, polycystic ovaries (PCOs), ovulatory dysfunction, and body mass index (BMI) R25 kg/m 2, with metabolic abnormalities in hyperandrogenic women. Methods: Hirsutism was based on the modified Ferriman Gallwey score. Ovulatory function was classified as eumenorrhea, oligomenorrhea and amenorrhea, and PCOs were assessed using the ultrasound criteria recommended in the Rotterdam definition. An oral glucose tolerance test was performed. Different insulin resistance (IR) indices were calculated. Results: Hirsute women had significantly higher BMI, DHEA sulfate (DHEAS) and free androgen index (FAI), and significantly lower values for sex hormone-binding globulin (SHBG). Women with amenorrhea were younger in comparison to women with eumenorrhea and had significantly higher values for fasting insulin (FI) and 1- and 2-h insulin levels; lower values for glucose to insulin ratio (GIR), quantitative insulin sensitivity check index (QUICKI), and SHBG. Women with PCO had significantly higher levels of LH and low-density lipoprotein (LDL), whereas high-density lipoprotein (HDL) levels were significantly lower. Women with a BMI R25 kg/m 2 had significantly higher values for age, fasting plasma glucose, FI, and 1- and 2-h glucose and insulin levels, homeostatic model for assessment of IR (HOMA-IR), homeostatic model for assessment of B-cell function (HOMA-B), and FAI, whereas their GIR, insulin sensitivity index, QUICKI, SHBG, and HDL were significantly lower. Conclusions: In women with hyperandrogenic syndrome, BMIR25 kg/m 2 and amenorrhea appear to be associated with severe endocrine and metabolic abnormalities. European Journal of Endocrinology Introduction The most common endocrine disorder seen in gynecological practice, with the clinical and biochemical features of hyperandrogenemia, is known as polycystic ovary syndrome (PCOS). It affects w4 6% of women of reproductive age (1). The syndrome is associated with gynecological, endocrine, dermatological, and metabolic changes. It is a collection of signs and features in which no single phenomenon is diagnostically relevant on its own (2). The issue of how to define the syndrome appropriately has continued to generate significant controversy (2, 3). The definition of PCOS has altered since 1844, when it was first described by Chereau 1844 (4) and Rokitanski 1844 (5). The heterogeneity of the syndrome was evident even in the initial descriptions in 1935 (6). The definition of PCOS used today was developed at an expert conference sponsored by the National Institutes of Health (NIH) in April 1990, leading to the publication of the NIH criteria (7). Another expert conference was organized in Rotterdam in May 2003 (8, 9). On the basis of these definitions of PCOS, completely different phenotypes are possible (2, 3). It has become evident in recent years that both definitions lead to problems in practical use, resulting in subsets of women that differ too widely and have different metabolic risk profiles, consequently requiring different treatment approaches. The different phenotypes are also difficult to compare in clinical research, due to the heterogeneity of their metabolic risk profiles (2, 3). The Androgen Excess Society recently suggested that the original NIH criteria should be accepted with some modifications, including the Rotterdam recommendation of ultrasound evidence of polycystic ovaries (PCOs), with PCOS being defined as an androgen excess syndrome or hyperandrogenic syndrome after other androgen excess or related disorders have been excluded; the four features of ovulatory dysfunction, hirsutism, hyperandrogenemia, and PCOs should be taken into consideration (2). q 2008 Society of the European Journal of Endocrinology DOI: /EJE Online version via

2 712 S Cupisti and others EUROPEAN JOURNAL OF ENDOCRINOLOGY (2008) 158 Despite the controversy over the definition, w50 70% of women with PCOS have been described as having hyperinsulinemic insulin resistance, which may play a major pathological role in the development of the syndrome (10, 11). Moreover, insulin resistance plays a causative role in the development of the metabolic syndrome (10, 12), with severe endocrine and metabolic disturbances leading to several complications later in life (13 16). Diagnosing PCOS or hyperandrogenic syndrome thus implies an increased risk for these complications later in life. Lean and obese hyperandrogenic women in particular may have completely different metabolic risk profiles and may need different treatment approaches in relation to several complications that may develop later in life. The aim of the present study was to evaluate possible associations of clinical features such as hirsutism, PCO, and ovulatory dysfunction (expressed in the form of menstrual disturbances, as an easily assessed marker) with metabolic and endocrine disturbances in hyperandrogenic women. By definition, all of the women included fulfilled the PCOS criteria in accordance with the revised Rotterdam 2003 criteria and the proposal by the Androgen Excess Society that PCOS should be defined as a predominately hyperandrogenic syndrome. In addition, the association of BMI R25 kg/m 2 with metabolic and endocrine disturbances in these women was assessed. Patients and methods Patients During the study period (January 2005 December 2006), 214 women were referred to the Division of Gynecological Endocrinology and Reproductive Medicine at our hospital for the evaluation of possible androgen excess or hyperandrogenism. The inclusion criteria were hirsutism, hyperandrogenemia, PCO, and ovulatory dysfunction (expressed in the form of menstrual disturbances), in the absence of other endocrine abnormalities also affecting ovulatory function, for example, hyperprolactinemia, functional hypothalamic amenorrhea, or thyroid dysfunction. The exclusion criteria were: 21-hydroxylase-deficient non-classical adrenal hyperplasia (NCAH), hyperandrogenic insulin resistance and acanthosis nigricans (HAIRAN) syndrome, or an androgen-secreting neoplasm. All of the women included thus met the definition of PCOS provided by the Rotterdam criteria as well as the NIH criteria. Women who had been receiving hormonal therapy, including oral contraceptive pills or steroid medications within 3 months of their initial visit were not included. The study was approved by the local ethics committee. All of the patients provided written informed consent and completed a uniform medical history questionnaire with an emphasis on menstrual dates and regularity, hirsutism, acne, gynecological history, history of infertility, medications, and family history. Procedures All of the women underwent a complete screening panel, including physical examination, weight and height measurement, ultrasound examination of the ovaries, and their body mass index (BMI) was calculated. Hirsutism was scored in accordance with the modified Ferriman Gallwey score (17). PCOs were diagnosed on ultrasound when at least one ovary had a volume above 10 ml or there were 12 or more follicles measuring 2 9 mm in diameter. The interval between bleeding episodes was assessed. The major clinical signs, such as oligomenorrhea or amenorrhea, vary in duration but are generally unambiguous (18). Women with regular bleeding episodes between 26 and 32 days were categorized as eumenorrheic. Women with cycles longer than 32 days were categorized as oligomenorrheic. In those women, serum was obtained between days 3 and 5 of their menstrual cycle. Women with amenorrhea within the previous year were categorized as anovulatory without further testing, and blood was taken for hormonal analysis at random. Women with cycles of less than 26 days were not included in the study. Calculation of insulin resistance All the patients were on an unrestricted diet. An oral glucose (75 g) tolerance test was carried out, with glucose (mg/dl) and insulin (miu/ml) measured at 0, 60, and 120 min. After glucose and insulin levels had been measured, the following mathematical models were used to assess insulin resistance The glucose to insulin ratio (GIR) was calculated using the formula described by Legro et al. (19). The homeostatic model for assessment of insulin resistance (HOMA-IR) was calculated using the following formula (20): FG (mmol/l)!fi (mu/ml)/22.5. The homeostatic model for assessment of B-cell function (HOMA-B) was calculated using the formula (20): 20!FI (mu/ml)/(fg (mmol/l) 3.5). The quantitative insulin sensitivity check index (QUICKI) was calculated using the formula (21): 1/(log (FI) (mu/ml)clog (FG) (mg/dl)). The Matsuda insulin sensitivity index (ISI) was calculated using the formula (22): /O(FG (mg/dl)!fi (mu/ml)!g (mg/dl)!i (mu/ml)) (FG, fasting plasma glucose; FI, fasting plasma insulin; G, mean plasma glucose concentration; and I, mean insulin concentration during the oral glucose tolerance test).

3 EUROPEAN JOURNAL OF ENDOCRINOLOGY (2008) 158 Exclusion of related disorders For evaluation of an androgen-secreting neoplasm, the total testosterone cut off value used was above 7 nmol/l, at which point computed tomography of the adrenal gland is normally carried out at our institution to exclude an androgen-secreting neoplasm. To exclude 21-hydroxylase deficiency in patients with a 17-hydroxyprogesterone (17-HP) level above 6 nmol/l, 17-HP levels stimulated by adrenocorticotropic hormone (ACTH) were measured (23, 24). In brief, all tests were started between 0800 and 0900 h with the patients in the fasting state. A baseline sample was obtained, and thereafter 0.25 mg ACTH (Synacthen, Novartis, Germany) was administered intravenously over 60 s and blood was sampled after 60 min. Both the baseline and 60-min samples were assayed for 17-HP levels. If the stimulated 17-HP level was above 30 nmol/l, the woman was considered to have 21-hydroxylase-deficient nonclassical adrenal hyperplasia. Biochemical measurements All of the assays were carried out in our routine diagnostic endocrinology laboratory using established commercial assays routinely monitored by participation in external quality control programs. Total testosterone (TT), DHEA sulfate (DHEAS), and sex hormone-binding globulin (SHBG) were measured with chemiluminescent enzyme immunoassays (Immulite 2000, Diagnostic Products Corporation, Los Angeles, CA, USA). The calibration range of the TT assay was nmol/l with an analytical sensitivity of 0.5 nmol/l. The cross-reaction with 5a-dihydrotestosterone was 2%. The calibration range of the DHEAS assay was mmol/l with an analytical sensitivity of 0.08 mmol/l. No cross-reactivity with other compounds was known. The calibration range of the SHBG assay was up to 180 nmol/l with an analytical sensitivity of 0.02 nmol/l. The inter- and intra-assay coefficients of variation (CVs) were always below 11% at mid-range concentrations. No cross-reactivity with other compounds was known. Estradiol was measured using a solid-phase competitive chemiluminescent enzyme immunoassay (Immulite 2000, Diagnostic Products Corp). The calibration range of the assay was pmol/l with an analytical sensitivity of 55 pmol/l. The intra-assay CVs were 9.9, 7.8, and 4.3% at the levels of 327, 660, and 1692 pmol/l respectively. The corresponding interassay CVs were 16, 11, and 6.7%. The cross-reactivity with 17b-estradiol valerate was 1.14%. Prolactin was measured using an immunometric assay (Immulite 2000, Diagnostic Products Corp). The calibration range of the assay was up to 3180 miu/l with an analytical sensitivity of 3.4 miu/l. The intraassay CVs were 2.8, 3.6, and 2.3% at the levels of 186.6, 402.6, and miu/l respectively. The corresponding interassay CVs were 8.2, 7.4, and 5.9%. No cross-reactivity with other compounds is known. Lutinizing hormone (LH) was measured with an immunometric assay (Immulite 2000, Diagnostic Products Corp). The calibration range of the assay was up to 200 miu/ml with an analytical sensitivity of 0.05 miu/ml. The intra-assay CVs were 3.04, 3.71, and 3.6% at the levels of 1.04, 1.89, and 8.7 miu/ml respectively. The corresponding inter-assay CVs were 6.6, 6.2, and 6.7%. The cross-reactivity with human chorionic gonadotropin was 0.20%. FSH was measured with an immunometric assay (Immulite 2000, Diagnostic Products Corp). The calibration range of the assay was up to 170 miu/ml with an analytical sensitivity of 0.1 miu/ml. The intra-assay CVs were 2.5, 2.9, and 2.1% at the levels of 4, 9.1, and 40 miu/ml respectively. The corresponding inter-assay CVs were 6.3, 5.5, and 4.3%. The cross-reactivity with thyrotrophin was 0.01%. Plasma insulin was determined using a solid-phase two-site chemiluminescent immunometric assay (Immulite 2000, Diagnostic Products Corp). The calibration range of the assay was up to 300 miu/ml with an analytical sensitivity of 2 miu/ml. The intraassay CVs were 5.5, 4.0, 3.3, 3.9, 3.8, and 3.7% at the levels of 7.67, 12.5, 17.2, 26.4, 100, and 291 miu/ml respectively. The corresponding inter-assay CVs were 7.3, 4.9, 4.1, 5.0, 4.2, and 5.3%. The cross-reactivity with proinsulin was 8%. Plasma concentration was measured with the glucose oxidase method using an automatic biochemical analyzer (Immulite 2000, Diagnostic Products Corp). Total cholesterol (Ch), low-density cholesterol (LDL), high-density cholesterol (HDL), and triglycerides (TGs) were regularly measured after an overnight fasting period of 12 h, using routine clinical chemistry methods and then documented. Calculation of the free androgen index (FAI) The FAI was obtained as the quotient 100!total testosterone (TT)/SHBG (24, 25). Statistical analysis Metabolic risks in hyperandrogenic women 713 Numerical variables are presented as meangs.d. unless otherwise noted. We employed non-parametric statistical tests that are based on ranks of observations and require no assumptions about the underlying distribution of data. All hypothesis tests were two sided. For bivariate analysis, two-sample Wilcoxon tests (i.e., Wilcoxon rank-sum tests) were used to compare parameters between hyperandrogenic women with and without specific categorical variables (hirsutism, PCO, oligomenorrhea, amenorrhea, and BMIO25 kg/m 2 ). Afterwards, we explored the possible influence of

4 714 S Cupisti and others EUROPEAN JOURNAL OF ENDOCRINOLOGY (2008) 158 categorical variables (hirsutism, PCO, amenorrhea, and BMI O25 kg/m 2 ) of the other endocrine and metabolic parameters using a multivariate ANOVA, and a P value!0.05 was considered statistically significant. All statistical analyses were carried out using the Statistical Program for the Social Sciences (SPSS version 13.0 for Windows; SPSS Inc., Chicago, IL, USA). Results A total of 214 women with clinical or biochemical signs of hyperandrogenemia presented for the evaluation of possible androgen excess or hyperandrogenism at the Division of Gynecological Endocrinology and Reproductive Medicine in Erlangen University Hospital between January 2005 and December Twenty women were not included, as they had been receiving hormonal treatment within 3 months of their initial visit. Eight women had hyperprolactinemic oligo-ovulation/anovulation and two women showed evidence of 21-OH-deficient NCAH. All of the women included in the study had at least one androgen level increased. No ovarian tumors were identified using ultrasonography in any of the women, and none of them had HAIRAN syndrome. The study population thus consisted of 184 women with hyperandrogenic syndrome. Comparison of hyperandrogenic women with hirsutism with hyperandrogenic women without hirsutism Women classified as hirsute had significantly higher BMI, DHEAS, and FAI values. They showed significantly lower values forshbg. The results are shown intable 1. Comparison of hyperandrogenic women with amenorrhea or oligomenorrhea with hyperandrogenic women with regular menses Women classified as having oligomenorrhea showed no significant differences in comparison with women with eumenorrhea. However, women classified as having amenorrhea were younger in comparison with women with eumenorrhea and had significantly higher values for fasting insulin and 1- and 2-h insulin levels. They had lower values for GIR and QUICKI. They also had significantly lower values for SHBG than hyperandrogenic women with eumenorrhea. The results are shown in Table 2. Comparison of hyperandrogenic women with ultrasound criteria of PCOs with hyperandrogenic women with normal ovarian morphology Women with ultrasound evidence of PCOs had significantly higher levels of LH and LDL, whereas Table 1 The differences between endocrine and metabolic variables in the group of women with hirsutism in comparison with the group of women without hirsutism. Hirsutism (nz102) No hirsutism (nz82) HDL was significantly lower. The results are shown in Table 3. Comparison of overweight hyperandrogenic women (BMI R25 kg/m 2 ) with normal weight hyperandrogenic women (BMI!25 kg/m 2 ) Hyperandrogenic women with BMI R25 kg/m 2 had significantly higher values for age, FG, FI, and 1- and 2-h glucose and insulin levels, HOMA-IR, HOMA-B, and FAI, whereas GIR, ISI, QUICKI, SHBG, and HDL were significantly lower. The results are shown in Table 4. Results of the multivariate ANOVA P value Age (years) 28.22G G6.89 NS BMI (kg/m 2 ) 30.38G G FG (mg/dl) 87.72G G7.90 NS G 1 h (mg/dl) G G NS G 2 h (mg/dl) G G NS FI (mu/ml) 12.42G G9.82 NS I1h(mU/ml) G G80.66 NS I2h(mU/ml) 87.89G G90.59 NS GIR 10.64G G8.80 NS HOMA-IR 2.75G G2.48 NS HOMA-B G G NS ISI 5.65G G5.45 NS QUICKI 0.34G G0.04 NS LH (IU/l) 7.51G G6.36 NS FSH (IU/l) 6.55G G10.51 NS PRL (ng/ml) 11.36G G7.94 NS E (pmol/l) G G NS TT (nmol/l) 2.64G G1.24 NS DHEAS (pmol/l) 7.52G G SHBG (nmol/l) 34.03G G FAI 10.80G G Ch (mg/dl) G G40.30 NS TG (mg/dl) G G81.59 NS HDL (mg/dl) 46.67G G23.35 NS LDL (mg/dl) G G57.59 NS BMI, body mass index; Ch, cholesterol; DHEAS, dehydroepiandrosterone sulfate; E, estrogen; FAI, free androgen index; FG, fasting plasma glucose; FI, fasting plasma insulin; FSH, follicle-stimulating hormone; G 1 h, mean plasma glucose concentration after 1 h; G 2 h, mean plasma glucose concentration after 2 h; GIR, glucose to insulin ratio; HDL, high-density lipoprotein; HOMA-B, homeostatic model for assessment of B-cell function; HOMA-IR, homeostatic model for assessment of insulin resistance; I 1 h, mean plasmainsulinafter 1 h; I2 h, meanplasmainsulinafter2 h; ISI, insulinsensitivity index; LDL, low-density lipoprotein; LH, lutinizing hormone; PRL, prolactin; QUICKI, quantitative insulin sensitivity check index; SHBG, sex hormonebinding globulin; TG, triglycerides; TT, total testosterone; NS, not significant. Bivariate analysis showed no difference between women classified as having oligomenorrhea in comparison with women with eumenorrhea. Therefore, oligomenorrhea as a possible predictive value was excluded from further multivariate analysis.

5 EUROPEAN JOURNAL OF ENDOCRINOLOGY (2008) 158 Metabolic risks in hyperandrogenic women 715 Table 2 The differences between endocrine and metabolic variables in the group of women with oligomenorrhea in comparison with the group of women with eumenorrhea, and the differences in the group of women with amenorrhea in comparison with the group of women eumenorrhea. Eumenorrhea (nz44) Oligomenorrhea (nz64) P value Amenorrhea (nz76) P value Age (years) 30.39G G6.76 NS 27.45G BMI (kg/m 2 ) 27.34G G6.67 NS 30.78G7.73 NS FG (mg/dl) 85.47G G8.37 NS 85.78G8.85 NS G 1 h (mg/dl) G G NS G47.39 NS G 2 h (mg/dl) G G NS G36.50 NS FI (miu/ml) 9.48G G7.85 NS 13.79G I1h(mIU/ml) 83.91G G69.03 NS G I2h(mIU/ml) 67.02G G72.85 NS G GIR 14.02G G7.88 NS 10.00G HOMA-IR 2.13G G1.92 NS 3.03G2.62 NS HOMA-B G G97.70 NS G NS ISI 7.49G G5.46 NS 5.58G4.53 NS QUICKI 0.36G G0.04 NS 0.34G LH (IU/l) 6.03G G5.17 NS 9.62G6.71 NS FSH (IU/l) 6.05G G2.82 NS 7.88G12.69 NS PRL (ng/ml) 12.11G G7.73 NS 10.07G8.86 NS E (pmol/l) G G NS G NS TT (nmol/l) 2.18G G1.18 NS 2.70G1.32 NS DHEAS (pmol/l) 7.18G G4.24 NS 7.19G4.12 NS SHBG (nmol/l) 47.64G G23.24 NS 33.13G FAI 7.24G G5.79 NS 10.54G8.23 NS Ch (mg/dl) G G28.82 NS G31.36 NS TG (mg/dl) G G47.82 NS G82.51 NS HDL (mg/dl) 56.36G G6.19 NS 44.50G14.60 NS LDL (mg/dl) G G20.53 NS G27.80 NS BMI, body mass index; Ch, cholesterol; DHEAS, dehydroepiandrosterone sulfate; E, estrogen; FAI, free androgen index; FG, fasting plasma glucose; FI, fasting plasma insulin; FSH, follicle-stimulating hormone; G 1 h, mean plasma glucose concentration after 1 h; G 2 h, mean plasma glucose concentration after 2 h; GIR, glucose to insulin ratio; HDL, high-density lipoprotein; HOMA-B, homeostatic model for assessment of B-cell function; HOMA-IR, homeostatic model for assessment of insulin resistance; I 1 h, mean plasma insulin after 1 h; I 2 h, mean plasma insulin after 2 h; ISI, insulin sensitivity index; LDL, low-density lipoprotein; LH, lutinizing hormone; PRL, prolactin; QUICKI, quantitative insulin sensitivity check index; SHBG, sex hormone-binding globulin; TG, triglycerides; TT, total testosterone; NS, not significant. The possible influences of the other categorical variables (hirsutism, PCO, amenorrhea, and BMI O25 kg/m 2 ) of the endocrine and metabolic variables are described as follows. In women with BMI O25 kg/m 2 HOMA-IR was significantly increased, while after adjustment with BMI O25 kg/m 2, the clinical features hirsutism, PCO, and amenorrhea had no influence (Table 5). In women with BMI O25 kg/m 2 or amenorrhea, HOMA-B was significantly increased, while after adjustment with BMI O25 kg/m 2 and amenorrhea, the clinical features hirsutism and PCO had no influence (Table 6). In women with BMI O25 kg/m 2, ISI was significantly decreased, while after adjustment with BMI O25 kg/m 2, the clinical features hirsutism, PCO, and amenorrhea had no influence (Table 7). In women with BMI O25 kg/m 2, QUCKI was significantly decreased while after adjustment with BMI O25 kg/m 2, the clinical features hirsutism, PCO, and amenorrhea had no influence (Table 8). In women with BMI O25 kg/m 2 or hirsutism or amenorrhea, SHBG levels were significantly decreased while after adjustment with BMI O25 kg/m 2, the clinical features hirsutism and amenorrhea, PCO showed no influence of SHBG levels (Table 9). Discussion The aim of this study was to evaluate possible associations of the clinical features hirsutism, PCO, and ovulatory dysfunction with metabolic changes or risk factors in hyperandrogenic women. By definition, all of the women included met the PCOS criteria in accordance with the revised Rotterdam 2003 criteria and the proposal made by the Androgen Excess Society (3). Additionally, we assessed the association of BMI R25 kg/m 2 with metabolic changes, as an elevated BMI has been described as increasing the risk for adverse health consequences, especially among patients with metabolic syndrome or IR (26). In the study population, the incidence of BMI R25 kg/m 2 and amenorrhea as a marker of chronic anovulation, which is the most severe form of disturbance in ovarian function (18) was associated with the most severe changes in the endocrine and metabolic profile in hyperandrogenic women, whereas the incidences of hirsutism, PCO, and oligomenorrhea were associated only with minor or no changes in metabolic parameters in the women studied. IR in particular is known to be a prominent feature associated with the risk of the metabolic syndrome and

6 716 S Cupisti and others EUROPEAN JOURNAL OF ENDOCRINOLOGY (2008) 158 Table 3 The differences between endocrine and metabolic variables in the group of women with polycystic ovaries (PCO) in comparison with the group of women without PCO. PCO (nz98) No PCO (nz86) P value Age (years) 27.71G G8.11 NS BMI (kg/m 2 ) 27.96G G8.93 NS FG (mg/dl) 85.40G G9.63 NS G 1 h (mg/dl) G G45.32 NS G 2 h (mg/dl) G G39.63 NS FI (mu/ml) 11.05G G10.26 NS I1h(mU/ml) G G96.39 NS I2h(mU/ml) 82.67G G98.34 NS GIR 11.65G G8.62 NS HOMA-IR 2.40G G2.58 NS HOMA-B 186.4G G163.8 NS ISI 6.41G G5.26 NS QUICKI 0.35G G0.04 NS LH (IU/l) 9.40G G FSH (IU/l) 6.38G G12.14 NS PRL (ng/ml) 11.39G G8.52 NS E (pmol/l) G G NS TT (nmol/l) 2.66G G1.33 NS DHEAS (pmol/l) 2.67G G4.07 NS SHBG (nmol/l) 40.54G G24.44 NS FAI 8.73G G9.82 NS Ch (mg/dl) G G36.74 NS TG (mg/dl G G NS HDL (mg/dl) 39.95G G LDL (mg/dl) G G BMI, body mass index; Ch, cholesterol; DHEAS, dehydroepiandrosterone sulfate; E, estrogen; FAI, free androgen index; FG, fasting plasma glucose; FI, fasting plasma insulin; FSH, follicle-stimulating hormone; G 1 h, mean plasma glucose concentration after 1 h; G 2 h, mean plasma glucose concentration after 2 h; GIR, glucose to insulin ratio; HDL, high-density lipoprotein; HOMA-B, homeostatic model for assessment of B-cell function; HOMA-IR, homeostatic model for assessment of insulin resistance; I 1 h, mean plasmainsulinafter 1 h; I2 h, meanplasmainsulinafter2 h; ISI, insulinsensitivity index; LDL, low-density lipoprotein; LH, lutinizing hormone; PRL, prolactin; QUICKI, quantitative insulin sensitivity check index; SHBG, sex hormonebinding globulin; TG, triglycerides; TT, total testosterone; NS, not significant. the development of type 2 diabetes. The urgent need for a simple way of measuring insulin resistance has led to the creation of a large number of insulin sensitivity indices that have been reviewed elsewhere (22, 27 29). However, Moltz showed recently that it is possible to determine IR using defined cut off points for glucose (102 mg/dl) and insulin (13 mu/ml) when screening for the metabolic syndrome (30). Insulin sensitivity indices that use fasting glucose and insulin values may not provide greater objectivity in assessing insulin resistance than fasting values for glucose and insulin itself (31 33). The advantage of using GIR, HOMA-IR, Table 4 The differences between endocrine and metabolic variables in the group of women with BMI R25 kg/m 2 in comparison with the group of women with BMI!25 kg/m 2. BMI R25 kg/m 2 (nz110) BMI!25 kg/m 2 (nz74) P value Age (years) 29.23G G BMI (kg/m 2 ) 33.30G G2.05 FG (mg/dl) 87.85G G8.10! G 1 h (mg/dl) G G G 2 h (mg/dl) G G FI (mu/ml) 14.54G G2.89! I1h(mU/ml) G G30.31! I2h(mU/ml) G G31.89! GIR 8.91G G8.89! HOMA-IR 3.22G G0.65! HOMA-B G G101.27! ISI 4.60G G5.48! QUICKI 0.33G G0.03! LH (IU/l) 7.89G G5.91 NS FSH (IU/l) 8.01G G3.06 NS PRL (ng/ml) 10.67G G7.68 NS E (pmol/l) G G NS TT (nmol/l) 2.57G G1.13 NS DHEAS (pmol/l) 6.85G G4.20 NS SHBG (nmol/l) 30.03G G23.1! FAI 11.34G G4.28! Ch (mg/dl) G G24.97 NS TG (mg/dl) G G52.88 NS HDL (mg/dl) 44.00G G LDL (mg/dl) G G22.98 NS BMI, body mass index; Ch, cholesterol; DHEAS, dehydroepiandrosterone sulfate; E, estrogen; FAI, free androgen index; FG, fasting plasma glucose; FI, fasting plasma insulin; FSH, follicle-stimulating hormone; G 1 h, mean plasma glucose concentration after 1 h; G 2 h, mean plasma glucose concentration after 2 h; GIR, glucose to insulin ratio; HDL, high-density lipoprotein; HOMA-B, homeostatic model for assessment of B-cell function; HOMA-IR, homeostatic model for assessment of insulin resistance; I 1 h, mean plasmainsulinafter 1 h; I2 h, meanplasmainsulinafter2 h; ISI, insulinsensitivity index; LDL, low-density lipoprotein; LH, lutinizing hormone; PRL, prolactin; QUICKI, quantitative insulin sensitivity check index; SHBG, sex hormonebinding globulin; TG, triglycerides; TT, total testosterone; NS, not significant. HOMA-B, and QUICKI may therefore be questionable. The Matsuda ISI is the only index that incorporates 1- and 2-h levels for OGTT into the calculation model, and it has been reported that the Matsuda ISI is best able to predict the risk of insulin resistance and provides the best relative sensitivity and specificity rates in comparison with other markers (31, 33). Recently, reference values have also been established for the Matsuda ISI in order to distinguish between patients with insulin resistance and those who are insulin sensitive (31). In this study, Matsuda ISI showed a significant negative Table 5 Homeostatic model for assessment of insulin resistance (HOMA-IR), multivariate ANOVA. Hirsutism K PCO K0.23 K K Amenorrhea K BMI ! Constant nz184, R 2 Z0.22. CI, confidence intervals.

7 EUROPEAN JOURNAL OF ENDOCRINOLOGY (2008) 158 Metabolic risks in hyperandrogenic women 717 Table 6 Homeostatic model for assessment of B-cell function (HOMA-B), multivariate ANOVA. Hirsutism K PCO K5.11 K K Amenorrhea BMI ! Constant ! nz184, R 2 Z0.12. CI, confidence intervals. Table 7 Insulin sensitivity index (ISI), multivariate ANOVA. Hirsutism K1.18 K K PCO K0.66 K K Amenorrhea K0.69 K K BMI K5.11 K7.60!0.001 K6.44 K3.78 Constant ! nz184, R 2 Z0.31. CI, confidence intervals. correlation with the incidence of three (out of five) clinical features. However, the ISI values were significantly lower only in women with BMI R25 kg/m 2. In general, BMI R25 kg/m 2 was significantly associated with changes in all of the insulin sensitivity indices and may therefore serve as a predictive marker of IR in hyperandrogenic women. The increase in fasting insulin and glucose values in hyperandrogenic women was also significantly associated and correlated with BMI R25 kg/m 2. This result appears to be in accordance with the results reported by Moltz (30). Furthermore, amenorrhea may also serve as a possible predictive marker of IR in hyperandrogenic women. However, we found that only an alteration in QUICKI, FI, 1-, and 2-h insulin values was significantly associated with the incidence of amenorrhea. All insulin values and all of the insulin sensitivity indices (except for QUICKI) correlated significantly with the incidence of amenorrhea. Overall, a diagnostic advantage for the calculated insulin sensitivity indices that use fasting glucose and insulin values was also not observed in this study, although investigating this was not the aim of the study. In addition, it may be difficult to use the cut off points for the selected indices, and it should be noted that these indices are not absolutely strict for the diagnosis of impaired carbohydrate metabolism, although they may help identify women who have the highest risk for Table 8 Quantitative insulin sensitivity check index (QUICKI), multivariate ANOVA. Hirsutism K K K K PCO K K K Amenorrhea K K K BMI K K8.22!0.001 K K Constant ! nz184, R 2 Z0.35. CI, confidence intervals. Table 9 Sex hormone-binding globulin (SHBG), multivariate ANOVA. Hirsutism K9.50 K K15.33 K3.65 PCO K1.37 K K Amenorrhea K7.35 K K13.19 K1.51 BMI K21.33 K6.92!0.001 K27.42 K15.25 Constant ! nz184, R 2 Z0.35. CI, confidence intervals.

8 718 S Cupisti and others EUROPEAN JOURNAL OF ENDOCRINOLOGY (2008) 158 developing diabetes (31). Recently, SHBG was found to be a predictive marker of insulin resistance (34), which showed a significant negative correlation with the incidence of hirsutism, amenorrhea, and BMI R25 kg/m 2 and was also significantly altered in patients with amenorrhea or BMI R25 kg/m 2. Diagnosing insulin resistance in women with hyperandrogenemic syndrome or androgen excess may help identify endocrine and metabolic risk factors and identify individuals for targeted treatment with insulin sensitizers, in order to improve treatment approaches and prevent complications later in life (35, 36). In the hyperandrogenic women studied, each specific clinical feature appears to be related to extensive differences in the endocrine and metabolic profiles. The definitions of PCOS have changed in recent years, and completely different phenotypes have been described (2, 3). It has become evident in recent years that all of the current definitions lead to problems in practical use, resulting in subsets of women with excessively different characteristics who have different metabolic risk profiles and require different treatment approaches. The term PCOS, therefore, does not describe a uniform population and covers a wide range of metabolic changes in different individuals (2, 3). It may be asked whether continued use of the term PCOS takes sufficient account of more recently identified aspects of the etiology and pathogenesis of this complex syndrome. Using the misleading and simplified term PCOS, which comprises a variety of different entities, involves a risk of misinterpretation and of underestimation or overestimation of symptoms, as well as overlooking contraindications (37). However, classifications of hyperandrogenism in women are available that take greater account of ovarian function, obesity, and hyperinsulinemic insulin resistance as the key clinical factors leading to different therapy approaches. Geisthovel and Rabe have proposed a classification with five different subsets: functional cutaneous androgenization and functional androgenizing syndrome I IV (37, 38). It may be necessary to implement a classification with strictly defined therapy-targeted concepts and diagnostic procedures for female functional androgenization (37), particularly since obese hyperandrogenic women with insulin resistance may benefit from participation in weight reduction programs, exercise instruction, and possibly treatment with insulin-sensitizing drugs as part of their individual treatment regimens (26). The Androgen Excess Society recently suggested that the syndrome should be defined as a predominantly hyperandrogenic syndrome. The task force considered that PCOS was defined by all of the component phenotypes that potentially signal an increased risk for insulin resistance and the resulting metabolic abnormalities, and consideration of the following four features was suggested: ovulatory dysfunction, hirsutism, hyperandrogenemia, and PCOs (3). In the population included in this study, the clinical features of hirsutism and PCOs were not associated with significant changes in the metabolic variables used. PCO was only associated with an alteration in lipoproteins as described previously by Chen et al. (39). However, it is questionable whether these features can serve as predictive markers of metabolic abnormalities in hyperandrogenic women. If these features are useful at all, then perhaps only when they are together with other clinical symptoms. However, ovulatory dysfunction appearing as amenorrhea was associated with the most severe metabolic abnormalities and may serve as a predictive marker of metabolic abnormalities. In our opinion, the BMI needs to be incorporated into any definition if the aim is to identify hyperandrogenic women with metabolic abnormalities. In summary, women with hyperandrogenic syndrome can be classified in relation to their clinical characteristics into subgroups with different endocrine and metabolic profiles and associated metabolic risks. These subgroups require different treatment approaches and ovarian function, and increased BMI associated with hyperinsulinemic insulin resistance, in particular, should be given special consideration. Acknowledgements Research for this paper was supported by a grant from the Katholischer Akademischer Austauschdienst (KAAD). We thank Mrs H Niggemann for her independent statistical review of the data and the statistical analysis. References 1 Ovalle F & Azziz R. Insulin resistance, polycystic ovary syndrome, and type 2 diabetes mellitus. Fertility and Sterility Azziz R, Carmina E, Dewailly D, Diamanti-Kandarakis E, Escobar-Morreale HF, Futterweit W, Janssen OE, Legro RS, Norman RJ, Taylor AE & Witchel SF. Excess society position statement: criteria for defining polycystic ovary syndrome as a predominantly hyperandrogenic syndrome: an androgen excess society guideline. Journal of Clinical Endocrinology and Metabolism Azziz R. Controversy in clinical endocrinology: diagnosis of polycystic ovarian syndrome: the Rotterdam criteria are premature. Journal of Clinical Endocrinology and Metabolism Chereau A. Mémoires pour servir à l étude des maladies des Ovaires Paris: Fortin, Masson, Rokitansky C 1844 A manual of pathological anatomy, vol 2. Philadelphia: Blanchard, Lea, 1855:246 (trans. by Edward Sieveking from original German edition of 1844). 6 Stein IF & Leventhal ML. Amenorrhea associated with bilateral polycystic ovaries. American Journal of Obstetrics and Gynaecology Zawadzki JK & Dunaif A. Diagnostic criteria for polycystic ovary syndrome: towards a rational approach. In Polycystic Ovary Syndrome, pp Eds A Dunaif, JR Givens, FP Haseltine & GR Merriam, Boston: Blackwell Scientific, 1992.

9 EUROPEAN JOURNAL OF ENDOCRINOLOGY (2008) Rotterdam 8, ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertility and Sterility Rotterdam 9, ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Human Reproduction Eckel RH, Eckel SM & Grundy PZ. The metabolic syndrome. Lancet Dunaif A. A insulin resistance and the polycystic ovary syndrome: mechanism and implications for pathogenesis. Endocrine Reviews Reaven GM. Banting lecture Role of insulin resistance in human disease. Diabetes Isomaa B, Almgren P, Tuomi T, Forsen B, Lahti K, Nissen M, Taskinen MR & Groop L. Cardiovascular morbidity and mortality associated with the metabolic syndrome. Diabetes Care Meigs JB, Rutter MK, Sullivan LM, Fox CS, D Agostino RB Sr & Wilson PW. Impact of insulin resistance on risk of type 2 diabetes and cardiovascular disease in people with metabolic syndrome. Diabetes Care Economic consequences of diabetes mellitus in the US. In American Diabetes Association. Diabetes Care 1997, 21, Alberti KG. The costs of non-insulin-dependent diabetes mellitus. Diabetic Medicine Archer JS & Chang RJ. Hirsutism and acne in polycystic ovary syndrome. Best Practice and Research. Clinical Obstetrics and Gynaecology Norman RJ, Dewailly D, Legro RS & Hickey TE. Polycystic ovary syndrome. Lancet Legro RS, Finegood D & Dunaif A. Fasting glucose to insulin ratio is a useful measure of insulin sensitivity in women with polycystic ovary syndrome. Journal of Clinical Endocrinology and Metabolism Matthews DR, Hosker JP, Rudenski AS, Naylor BA, Treacher DF & Turner RC. Homeostasis model assessment: insulin resistance and beta-cell function from fasting plasma glucose and insulin concentrations in man. Diabetologia Katz A, Nambi SS, Mather K, Baron AD, Follmann DA, Sullivan G & Quon MJ. Quantitative insulin sensitivity check index: a simple, accurate method for assessing insulin sensitivity in humans. Journal of Clinical Endocrinology and Metabolism Matsuda M & DeFronzo RA. Insulin sensitivity indices obtained from oral glucose tolerance testing: comparison with the euglycemic insulin clamp. Diabetes Care Azziz R, Sanchez LA, Knochenhauer ES, Moran C, Lazenby J, Stephens KC, Taylor K & Boots LR. Androgen excess in women: experience with over 1000 consecutive patients. Journal of Clinical Endocrinology and Metabolism Souter I, Sanchez LA, Perez M, Bartolucci AA & Azziz R. The prevalence of androgen excess among patients with minimal unwanted hair growth. American Journal of Obstetrics and Gynaecology Mathur RS, Moody LO, Landgrebbe S & Williamson HO. Plasma androgens and sex hormone binding globulin in the evaluation of hirsute patients. Fertility and Sterility Meigs JB, Wilson PW, Fox CS, Vasan RS, Nathan DM, Sullivan LM & D Agostino RB. Body mass index, metabolic syndrome, and risk of type 2 diabetes or cardiovascular disease. Journal of Clinical Endocrinology and Metabolism StumvollM, Van Haeften T, Fritsche A & Gerich J. Oral glucose tolerance test indexes for insulin sensitivity and secretion based on various availabilities of sampling times. Diabetes Care Hanley AJ, Williams K, Gonzalez C, DAgostino RB Jr, Wagenknecht LE, Stern MP & Haffner SM. San Antonio Heart Study; Mexico City Diabetes Study; Insulin Resistance Atherosclerosis Study Prediction of type 2 diabetes using simple measures of insulin resistance: combined results from the San Antonio Heart Study, the Mexico City Diabetes Study, and the Insulin Resistance Atherosclerosis Study. Diabetes (erratum in: Diabetes 2003; 52:1306). 29 Radikova Z. Assessment of insulin sensitivity/resistance in epidemiological studies. Endocrine Regulations Moltz L. Prevalence of insulin resistance in relation to body weight importance for primary prevention of cardiovascular diseases. Geburtshilfe und Frauenheilkunde Radikova Z, Koska J, Huckova M, Ksinantova L, Imrich R, Vigas M, Trnovec T, Langer P, Sebokova E & Klimes I. Insulin sensitivity indices: a proposal of cut-off points for simple identification of insulin-resistant subjects. Experimental and Clinical Endocrinology and Diabetes Szurkowska M, Szafraniec K, Gilis-Januszewska A, Szybinski Z & Huszno B. Insulin resistance indices in population-based study and their predictive value in defining metabolic syndrome. Przeglad Epidemiologiczny Penesova A & Radikova Z. Comparison of insulin sensitivity indices calculated from standard 3-sampled and frequently sampled oral glucose tolerance test. Endocrine Regulations Kajaia N, Binder H, Dittrich R, Oppelt PG, Flor B, Cupisti S, Beckmann MW & Mueller A. Low sex hormone-binding globulin as a predictive marker for insulin resistance in women with hyperandrogenic syndrome. European Journal of Endocrinology Ehrmann DA, Barnes RB, Rosenfield RL, Cavaghan MK & Imperial J. Prevalence of impaired glucose tolerance and diabetes in women with polycystic ovary syndrome. Diabetes Care Dahlgren E, Johansson S, Lindstedt G, Knutsson F, Oden A, Janson PO, Mattson LA, Crona N & Lundberg PA. Women with polycystic ovary syndrome wedge resected in 1956 to 1965: a long-term follow-up focusing on natural history and circulating hormones. Fertility and Sterility Geisthovel F & Rabe T. The ESHRE/ASRM consensus on polycystic ovary syndrome (PCOS) an extended critical analysis. Reproductive BioMedicine Online Geisthovel F. Functional hyperandrogenism-classification, etiology, diagnosis and therapy; in German. Therapeutische Umschau Chen MJ, Yang WS, Yang JH, Hsiao CK, Yang YS & Ho HN. Low sex hormone-binding globulin is associated with low high-density lipoprotein cholesterol and metabolic syndrome in women with PCOS. Human Reproduction Received 31 January 2008 Accepted 1 February 2008 Metabolic risks in hyperandrogenic women 719