Hyperinsulinemic Androgen Excess Research Articles

ERah: A Computational Tool Integrating Spectral Deconvolution and Alignment with Quantification and Identification of Metabolites in GC/MS-Based Metabolomics.

Gas chromatography coupled to mass spectrometry (GC/MS) has been a long-standing approach used for identifying small molecules due to the highly reproducible ionization process of electron impact ionization (EI). However, the use of GC-EI MS in untargeted metabolomics produces large and complex data sets characterized by coeluting compounds and extensive fragmentation of molecular ions caused by the hard electron ionization. In order to identify and extract quantitative information on metabolites across multiple biological samples, integrated computational workflows for data processing are needed. Here we introduce eRah, a free computational tool written in the open language R composed of five core functions: (i) noise filtering and baseline removal of GC/MS chromatograms, (ii) an innovative compound deconvolution process using multivariate analysis techniques based on compound match by local covariance (CMLC) and orthogonal signal deconvolution (OSD), (iii) alignment of mass spectra across samples, (iv) missing compound recovery, and (v) identification of metabolites by spectral library matching using publicly available mass spectra. eRah outputs a table with compound names, matching scores and the integrated area of compounds for each sample. The automated capabilities of eRah are demonstrated by the analysis of GC-time-of-flight (TOF) MS data from plasma samples of adolescents with hyperinsulinaemic androgen excess and healthy controls. The quantitative results of eRah are compared to centWave, the peak-picking algorithm implemented in the widely used XCMS package, MetAlign, and ChromaTOF software. Significantly dysregulated metabolites are further validated using pure standards and targeted analysis by GC-triple quadrupole (QqQ) MS, LC-QqQ, and NMR. eRah is freely available at http://CRAN.R-project.org/package=erah .

Metabolomics reveals impaired maturation of HDL particles in adolescents with hyperinsulinaemic androgen excess.

Hyperinsulinaemic androgen excess (HIAE) in prepubertal and pubertal girls usually precedes a broader pathological phenotype in adulthood that is associated with anovulatory infertility, metabolic syndrome and type 2 diabetes. The metabolic derangements that determine these long-term health risks remain to be clarified. Here we use NMR and MS-based metabolomics to show that serum levels of methionine sulfoxide in HIAE girls are an indicator of the degree of oxidation of methionine-148 residue in apolipoprotein-A1. Oxidation of apo-A1 in methionine-148, in turn, leads to an impaired maturation of high-density lipoproteins (HDL) that is reflected in a decline of large HDL particles. Notably, such metabolic alterations occur in the absence of impaired glucose tolerance, hyperglycemia and hypertriglyceridemia, and were partially restored after 18 months of treatment with a low-dose combination of pioglitazone, metformin and flutamide.

IS-062 Endocrine And Metabolic Consequences Of Low Weight At Birth

About 3% of human fetuses are born small for gestational age (SGA). More than 90% of those SGA infants catch-up growth and normalise their body size by the age of 2 yr. Longitudinal studies have disclosed that SGA-catch-up children tend to become hyperinsulinemic, viscerally adipose and to show an abnormal adipokine profile by 4–6 years of age, even if not obese. Between 6 and 8 years, their circulating levels of sex hormone binding globulin (SHBG) start to be low, and those of dehydroepiandrosterone-sulphate (DHEAS) start to be high; in girls, precocious pubarche (pubic hair < 8 yr) may emerge as clinical marker. A mismatch between early adipogenesis and later lipogenesis, accounting for lipotoxicity, dys-adipokinemia and insulin resistance, seems to encompass this sequence; postnatal overweight amplify these risks. Beyond the age of 8 years, such SGA children tend to experience an early onset of puberty with rapid progression, that may lead to a lower adult stature; low birthweight girls with precocious pubarche are also at increased risk for developing hyperinsulinemic androgen excess in adolescence. In these girls, insulin sensitisation with metformin started in prepuberty and maintained throughout puberty appears to decrease visceral and hepatic adiposity, and to have normalising effects on serum insulin, lipids, leptin and adipokines, on the tempo of puberty, on final stature, and on the prevalence of androgen excess in adolescence.

Correction: Hyperinsulinaemic androgen excess in adolescent girls

Nat. Rev. Endocrinol. 10, 499–508 (2014); 10.1038/nrendo.2014.58 In the version of this article originally published online and in print, there was an error in Figure 1. The dotted blue line in the bottom panel should have extended down to the axis. This has now been corrected in the HTML and PDF versions of the article.

Hyperinsulinaemic androgen excess in adolescent girls.

Hyperinsulinaemic androgen excess is the most common cause of hirsutism, acne and menstrual irregularity in adolescent girls. Here, we propose that the disorder frequently originates from an absolute or relative excess of lipids in adipose tissue, and from associated changes in insulin sensitivity, gonadotropin secretion and ovarian androgen release. Girls from populations with genotypes attuned to nutritionally harsh conditions seem to be particularly vulnerable to the development of hyperinsulinaemic androgen excess in today's obesogenic environment. We propose that hirsutism, hyperandrogenaemia and menstrual irregularity (≥2 years after menarche) is used as a diagnostic triad for the disorder. No pharmacological therapy has been approved for girls with androgen excess; however, lifestyle intervention is essential to reduce adiposity. In girls without obesity who are not sexually active, insulin sensitization has more broadly normalizing effects than estradiol-progestogen combinations. The early recognition of girls at risk of developing hyperinsulinaemic androgen excess might enable prevention in childhood.

Oral Contraception vs Insulin Sensitization for 18 Months in Nonobese Adolescents With Androgen Excess: Posttreatment Differences in C-Reactive Protein, Intima-Media Thickness, Visceral Adiposity, Insulin Sensitivity, and Menstrual Regularity

An oral estro-progestagen is the standard medication given to adolescent girls with androgen excess, even when those girls are not at risk of pregnancy. The aim of this study was to compare on-treatment and post-treatment effects of intervention with an oral contraceptive vs an insulin-sensitizing treatment for androgen excess in nonobese adolescents. This was a randomized, open-label trial. Subjects were nonobese adolescent girls with hyperinsulinemic androgen excess and without risk of pregnancy (mean age, 16 years; body mass index, 23 kg/m²; n = 34). The effects of treatment with ethinylestradiol-cyproteroneacetate (EE-CA) vs a low-dose combination of pioglitazone (7.5 mg/d), flutamide (62.5 mg/d), and metformin (850 mg/d) (PioFluMet) for 18 months were studied. Posttreatment follow-up was for 6 months. Androgen excess (hirsutism and acne scores and serum testosterone), glucose-stimulated insulinemia, circulating C-reactive protein, carotid intima media thickness, body composition (absorptiometry), abdominal fat partitioning (magnetic resonance imaging), and menstrual regularity were measured. EE-CA and PioFluMet attenuated androgen excess similarly but had divergent, and even opposing, effects on other outcomes. Six months posttreatment, the PioFluMet-treated girls had a lower glucose-induced insulinemia, a lower C-reactive protein level, and a thinner intima media than the EE-CA-treated girls, and they were viscerally less adipose, had a higher lean mass, and were more likely to have regular cycles. The on-treatment and post-treatment effects of PioFluMet compared favorably with those of oral contraception in nonobese adolescents with androgen excess. The intervention whereby androgen excess is reduced in adolescence influences the post-treatment phenotype. PioFluMet-like interventions in adolescence may thus hold the potential to prevent part of the androgen-excess phenotype in adulthood, including adiposity and subfertility.

Ethinyl Estradiol-Cyproterone AcetateVersusLow-Dose Pioglitazone-Flutamide-Metformin for Adolescent Girls with Androgen Excess: Divergent Effects onCD163,TWEAKReceptor,ANGPTL4, andLEPTINExpression in Subcutaneous Adipose Tissue

The aim was to compare the effects of a traditional therapy (an oral estroprogestagen) to those of a novel treatment (a low-dose combination of generics) in adolescent girls with androgen excess. In an open-label trial over 1 yr, 34 adolescents (age, 16 yr; body mass index, 23 kg/m2) with hyperinsulinemic androgen excess and without pregnancy risk were randomized to receive daily ethinyl estradiol-cyproterone acetate (EE-CA; Diane 35 Diario) or a low-dose combination of pioglitazone 7.5 mg/d, flutamide 62.5 mg/d, and metformin 850 mg/d (PioFluMet). Markers of androgen excess, C-reactive protein, high molecular weight adiponectin, lipids, carotid intima media thickness, body composition (absorptiometry), abdominal fat partitioning (magnetic resonance imaging), and gene expression in longitudinal biopsies of sc adipose tissue at the abdominal level (RT-PCR) were assessed at baseline and after 1 yr. EE-CA and low-dose PioFluMet reduced androgen excess comparably, but had divergent effects on C-reactive protein, high molecular weight adiponectin, lipids, carotid intima media thickness, lean mass, abdominal and visceral fat, and on the expression of CD163, leptin, TNF-like weak inducer of apoptosis receptor, and angiopoietin-like protein 4, respectively, related to macrophage activation, fat accretion, inflammation, and lipoprotein metabolism in adipose tissue. All these divergences pointed to a healthier condition on low-dose PioFluMet. EE-CA and PioFluMet are similarly effective in reversing androgen excess over 1 yr, but low-dose PioFluMet is superior in reversing inflammatory, metabolic, and cardiovascular anomalies that are often associated with androgen excess.

Treatment of Androgen Excess in Adolescent Girls

Objective: The aim was to perform a first comparison between the effects of a classic therapy and those of a novel treatment for androgen excess in adolescent girls. Design and Setting: We conducted a randomized, open-labeled trial at a university hospital. Participants: Thirty-four adolescents with hyperinsulinemic androgen excess and without risk of pregnancy participated in the study. Interventions: Ethinyl estradiol-cyproterone acetate (EE-CA) vs. a low-dose combination of pioglitazone, flutamide, and metformin (PioFluMet) was administered for 6 months. Main Outcome Measures: We assessed hirsutism and acne scores; androgen excess; fasting insulin, lipid profile, C-reactive protein, high molecular-weight adiponectin, leptin, follistatin; carotid intima-media thickness; body composition (absorptiometry); and abdominal fat partitioning (magnetic resonance imaging). Results: EE-CA and PioFluMet attenuated the androgen excess comparably but had divergent effects on fasting insulinemia; on circulating chole...

Treatment of Androgen Excess in Adolescent Girls: Ethinylestradiol-Cyproteroneacetate Versus Low-Dose Pioglitazone-Flutamide-Metformin

The aim was to perform a first comparison between the effects of a classic therapy and those of a novel treatment for androgen excess in adolescent girls. We conducted a randomized, open-labeled trial at a university hospital. Thirty-four adolescents with hyperinsulinemic androgen excess and without risk of pregnancy participated in the study. Ethinyl estradiol-cyproterone acetate (EE-CA) vs. a low-dose combination of pioglitazone, flutamide, and metformin (PioFluMet) was administered for 6 months. We assessed hirsutism and acne scores; androgen excess; fasting insulin, lipid profile, C-reactive protein, high molecular-weight adiponectin, leptin, follistatin; carotid intima-media thickness; body composition (absorptiometry); and abdominal fat partitioning (magnetic resonance imaging). EE-CA and PioFluMet attenuated the androgen excess comparably but had divergent effects on fasting insulinemia; on circulating cholesterol, triglycerides, C-reactive protein, high molecular-weight adiponectin, leptin, and follistatin; on carotid intima-media thickness; on lean mass; and on abdominal, visceral, and hepatic fat, with all these divergences pointing to a healthier condition on low-dose PioFluMet. Low-dose PioFluMet compared favorably to EE-CA in adolescents with androgen excess and without pregnancy risk. The efficacy and safety of low-dose PioFluMet remain to be studied over a longer term and in larger cohorts.

Divergent effects of ethinylestradiol–drospirenone and flutamide–metformin on follistatin in adolescents and women with hyperinsulinemic androgen excess

Randomized studies have disclosed that ethinylestradiol–drospirenone and flutamide–metformin have divergent effects on the body adiposity and adipokines of adolescents and young women with hyperinsulinemic androgen excess. We have now tested in 41 patients from those original studies whether the divergent effects on body adiposity could be mediated by divergent levels of follistatin, an adipokine that promotes subcutaneous adipogenesis. Circulating follistatin was measured, at study start and after 9 months, with an enzyme-linked immunosorbent assay. Treatment with ethinylestradiol–drospirenone was accompanied by a more adipose body composition and by a nearly 4-fold rise of follistatinemia (P < 0.0001). In contrast, treatment with low-dose flutamide–metformin did not increase body adiposity and did not alter follistatinemia detectably. Finally, combined treatment with ethinylestradiol–drospirenone and flutamide–metformin was accompanied by an intermediate (2- to 3-fold) rise of follistatinemia (P < 0.005). In conclusion, the principle that ethinylestradiol–drospirenone and flutamide–metformin exert diverging effects on adipokines is herewith broadened to include circulating follistatin. Hyperfollistatinemia may be among the mechanisms whereby oral contraceptives aggravate the body adiposity of adolescents and young women with hyperinsulinemic androgen excess.

Low-dose pioglitazone, flutamide, metformin plus an estro-progestagen for non-obese young women with polycystic ovary syndrome: increasing efficacy and persistent safety over 30 months

Context. Therapy of androgen excess should not only confer cosmetic benefit, but also improve long-term markers of endocrine-metabolic and cardiovascular health. Here we report on our pilot experience with a low-dose polytherapy for 30 months.Design, Patients, Intervention. Unblinded extension (24–30 months) of a double-placebo study exploring low-dose polytherapy over 24 months. Between 24 and 30 months, women with hyperinsulinemic androgen excess (N = 36; mean age: 19.4 year; BMI: 23.7 kg/m2) received metformin (850 mg/day), flutamide (62.5 mg/day), pioglitazone (7.5 mg/day), ethinylestradiol (20 μg/day) plus drospirenone (3 mg/day) for 24/28 days.Main Outcomes. Carotid IMT, body composition (by absorptiometry), abdominal fat (by magnetic resonance), hirsutism score, fasting glycaemia, insulin, androgens, HDL cholesterol, C-reactive protein and hepatic safety indices.Results. Low-dose polytherapy for 30 months was not accompanied by a change in body weight or bone mineral density, but it was associated with a marked rise of insulin sensitivity (p < 0.00001), with a loss of visceral fat (mean: −27%; p < 0.00001) and with a lowering of IMT (−0.16 mm; p < 0.00001). Aspartate aminotransferase, gamma-glutamyl transferase and lactate dehydrogenase levels decreased slightly over 30 months.Conclusion. Low-dose polytherapy (24/28 day) with pioglitazone, flutamide, metformin and estro-progestagen was found to improve, without changing weight, a spectrum of long-term health markers in young women with hyperinsulinemic androgen excess.

Early Origins of Polycystic Ovary Syndrome: Hypotheses May Change without Notice

Polycystic ovary syndrome (PCOS) is an evolving concept, as illustrated by its consecutive definitions. In 2004, the definition of PCOS in women changed from the classic National Institutes of Health (NIH) definition (clinical and/or biochemical androgen excess plus oligoovulation, with exclusion of specific etiologies such as hyperprolactinemia and 21-hydroxylase deficiency) (1) to the more inclusive Rotterdam definition (any two of the following three criteria, after similar exclusions: clinical and/or biochemical androgen excess, oligoor anovulation, and polycystic morphology on ultrasound) (2). In 2009, the Androgen Excess Society launched a new definition that considers PCOS primarily as a disorder of clinical and/or biochemical androgen excess, plus either chronic oligoovulation and/or polycystic ovaries, still with exclusion of specific etiologies (3). The core of the consecutive PCOS populations, however, changed little over the past decades because it continues to consist of women with hyperinsulinemic androgen excess (4–6). This core still constitutes the majority of PCOS women diagnosed by the latest definition, which, just as the earlier definitions, remains to be validated in adolescent girls (3). A better insight into the (epi-)genetics, early origins, and natural history of hyperinsulinemic androgen excess may sharpen the perspective of PCOS prevention and is therefore a priority in the current research agenda for PCOS.

Adipose tissue expandability and the early origins of PCOS

The most prevalent phenotypes of polycystic ovary syndrome (PCOS) are characterized by insulin resistance and androgen excess. The adipose tissue (AT) expandability hypothesis explains the development of insulin resistance in obesity and in cases of AT deficit. In line with this hypothesis, we propose that hyperinsulinemic androgen excess in PCOS is often underpinned by exhaustion of the capacity to expand subcutaneous AT in a metabolically safe way. Such exhaustion might occur when a positive energy imbalance meets a normal fat-storage capacity and/or when a normal energy balance faces a low fat storage capacity. This concept thus explains how PCOS phenotypes might result from obesity, prenatal growth restraint or a genetic lipodystrophy, or, experimentally, from prenatal androgen excess.

Low‐dose pioglitazone and low‐dose flutamide added to metformin and oestro‐progestagens for hyperinsulinaemic women with androgen excess: add‐on benefits disclosed by a randomized double‐placebo study over 24 months

Metformin plus oestro-progestagen is a combination treatment for non-obese women with hyperinsulinaemic androgen excess. We explored whether low-dose pioglitazone (Pio) and flutamide (Flu) has readily detectable add-on effects. Randomized, double-placebo pilot study over 24 months; 38 women with hyperinsulinaemic androgen excess (mean age 20 years; BMI 23.7 kg/m(2)); all women received metformin and an oestro-progestagen for 24 months, and add-on Flu (62.5 mg/day; 21/28 days) for 18 months. A first randomization was performed at start of the study, for Pio (7.5 mg/day; 21/28 days) vs. Pio-placebo, with a cross-over of Pio subgroups at 18 month. A second randomization was performed at 18 months, for Flu vs. Flu-placebo until 24 months. Intima media thickness (IMT); body composition by absorptiometry; abdominal fat partitioning by magnetic resonance; circulating glucose, insulin, IGF-I, androgens, LDL : HDL ratio, RBP4, vaspin. Add-on effects of Pio included a gain of lean mass (mirrored by a loss of fat) and an accelerated lowering of IMT (P <or= 0.001). Add-on effects of flutamide included a further reduction of androgen excess. Between 0 and 18 months, women lost a quarter of their visceral fat (P < 0.001; independently of Pio); beyond 18 months, a rebound of visceral fat occurred in women who had stopped Pio and Flu. Between 0 and 24 months, insulin sensitivity increased, as did circulating RBP-4 and vaspin (all P = 0.001). Low-dose Pio and Flu further improve long-term markers - such as IMT, lean mass and visceral fat - when jointly added to a treatment of metformin plus an oestro-progestagen in non-obese women with hyperinsulinaemic androgen excess.

Metformin Treatment for Four Years to Reduce Total and Visceral Fat in Low Birth Weight Girls with Precocious Pubarche

A low birth weight (LBW) tends to be followed by overweight due to an excess of fat, including visceral fat. LBW girls with precocious pubarche (PP) (pubic hair < 8 yr) are at high risk for developing an adipose state of hyperinsulinemic androgen excess that leads toward early menarche. We explored the effects of insulin sensitization with metformin in LBW-PP girls. SETTING, DESIGN, PATIENTS, INTERVENTION: Prepubertal LBW girls with PP (mean body weight 2.4 kg; age 7.9 yr; body mass index 18.4 kg/m(2)) were studied. Girls were randomly assigned to remain untreated (n=19) or receive metformin for 4 yr (n = 19; 425 mg/d for 2 yr, then 850 mg/d for 2 yr). At the start and after 4 yr, height, weight, fasting insulin, glucose, IGF-I, testosterone, lipids, leptin, high molecular weight adiponectin, body composition by absorptiometry, abdominal fat partitioning (only 4 yr) by magnetic resonance imaging, and menarcheal status were determined. Metformin-treated girls gained on average 5.5 kg (or approximately 50%) less fat, after 4 yr were less insulin resistant and less hyperandrogenic, had lower IGF-I levels and a less atherogenic lipid profile, and were less likely to be post-menarcheal than untreated girls, whereas their gain in height, lean mass, and bone mineral density were similar. After 4 yr, untreated girls had more visceral fat, a higher ratio of visceral-to-sc fat, and a higher leptin-to-high molecular weight adiponectin ratio (all approximately 50% higher) than metformin-treated girls. Long-term metformin treatment appears to reduce total and visceral fat in LBW-PP girls, and to delay menarche without attenuating linear growth, thereby opening the perspective that adult height may be increased.

Pioglitazone (7·5 mg/day) added to flutamide–metformin in women with androgen excess: additional increments of visfatin and high molecular weight adiponectin

Low-dose pioglitazone (Pio), flutamide (Flu), metformin (Met) plus an oestro-progestagen is a novel polytherapy lowering total and visceral adiposity, and reducing carotid intima media thickness (IMT) in hyperinsulinaemic women with androgen excess, without changing their body mass index (BMI). In a search for mediators of PioFluMet's actions, we measured serum levels of visfatin and high molecular weight (HMW) adiponectin. In a double-blind study, we enrolled 38 young women with hyperinsulinaemic androgen excess [mean BMI: 23.7 kg/m(2)], all of whom started on Flu (62.5 mg/day), Met (850 mg/day) and a transdermal oestro-progestagen, each for 21/28 days over 1 year. Patients were randomly assigned to receive, in addition, placebo (n = 19) or Pio (7.5 mg/day; n = 19) on the same 21/28 days. Serum concentrations of visfatin and HMW adiponectin, visceral fat by magnetic resonance imaging, carotid IMT by ultrasound, all carried out during study start and after 1 year. PioFluMet raised visfatin by a mean 84% and HMW adiponectin by 157% (P < 0.001), and reduced visceral fat and IMT by a mean 22% and 31% (both P < 0.001). Low-dose Pio accounted for about half of the PioFluMet effects on IMT, visfatin and HMW adiponectin. In hyperinsulinaemic women with androgen excess, low-dose polytherapy with PioFluMet evoked striking rises in both circulating visfatin and HMW adiponectin, while lowering IMT and reducing visceral adiposity within 1 year.