Prevalence of endocrine diseases and abnormal glucose tolerance tests in 340 caucasian premenopausal women with hirsutism as the referral diagnosis

REPRODUCTIVE ENDOCRINOLOGY

FERTILITY AND STERILITY威 VOL. 82, NO. 6, DECEMBER 2004 Copyright ©2004 American Society for Reproductive Medicine Published by Elsevier Inc. Printed on acid-free paper in U.S.A.

Prevalence of endocrine diseases and abnormal glucose tolerance tests in 340 Caucasian premenopausal women with hirsutism as the referral diagnosis Dorte Glintborg, M.D.,a Jan Erik Henriksen, M.D., Ph.D.,a Marianne Andersen, M.D., Ph.D.,a Claus Hagen, M.D., Dr.Sci.,a Jørgen Hangaard, M.D., Ph.D.,a Per Emil Rasmussen, M.D.,b Karoline Schousboe, M.D., Ph.D.,a and Anne Pernille Hermann, M.D., Ph.D.a Odense University Hospital, Odense, Denmark

Objective: To perform an audit on the examination of hirsute patients and to establish a rational routine examination program in an outpatient endocrine clinic. Design: Systematic, retrospective audit. Setting: Academic tertiary-care medical center. Patient(s): Three hundred forty women with hirsutism as the referral diagnosis. Intervention(s): Hormone analyses and ACTH tests during cycle days 2– 8, 2 hours of oral glucose tolerance test (OGTT), and vaginal ultrasound. Main Outcome Measure(s): End diagnosis, fasting, 30-, 60-, and 120-minute oral glucose–stimulated levels of insulin and capillary blood glucose. Result(s): Two hundred one patients were diagnosed as having idiopathic hirsutism (IH) and 134 as having polycystic ovary syndrome (PCOS). End diagnosis: prolactinoma: n ⫽ 1, Cushing’s syndrome: n ⫽ 1, androgen-producing ovarian tumor: n ⫽ 1, late-onset 21-hydroxylase defects: n ⫽ 2. During OGTT, 4.9% (13 of 263) had previously undiagnosed diabetes; no significant difference in diabetes prevalence was found between idiopathic hirsutism and PCOS. For 50.8%, fasting insulin values were in the upper quartile for a reference population. Conclusion(s): Initial evaluation of hirsute patients with irregular menses should include serum (s)-17␣hydroxyprogesterone, s-prolactin, s-Testosterone (T), and s-sex hormone-binding globulin. Further evaluation is needed in patients with markedly elevated s-T or with clinical Cushing’s syndrome. Hirsute patients have a high risk of diabetes, although this could be due to the high number of overweight patients among this population. (Fertil Steril威 2004;82:1570 –9. ©2004 by American Society for Reproductive Medicine.) Key Words: Hirsutism, PCOS, evaluation, endocrine disease, oral glucose tolerance test, diabetes Received October 17, 2003; revised and accepted June 16, 2004. Reprint requests: Dorte Glintborg, M.D., Kløvervaenget 6, 3.sal, Odense C. 5000, Denmark (FAX: 45-66-11-33-71; E-mail: dorte.glintborg@ ouh.fyns-amt.dk). a Department of Endocrinology and Metabolism. b Fertility Clinic. 0015-0282/04/$30.00 doi:10.1016/j.fertnstert.2004. 06.040

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Hirsutism is caused by increased androgenicity due to high androgen concentrations or increased androgen sensitivity in the pilosebaceous gland. The prevalence of hirsutism is 5%–25% in premenopausal women (1). Of hirsute patients, 95% are diagnosed as having either polycystic ovary syndrome (PCOS) or idiopathic hirsutism (IH). However, hirsutism can be the early manifestation of Cushing’s syndrome, androgen-producing tumors, or the adrenogenital syndrome (2). There is currently no agreement as to the optimal

design of an evaluation program to ensure that these potentially serious diseases are not overlooked. We used an extensive diagnostic program to clarify the prevalence of endocrine diseases among patients referred to our outpatient clinic. In particular, we wanted to clarify the prevalence of insulin resistance and abnormal glucose tolerance among our population. The aim of the study was to establish a rational evaluation program for patients attending with hirsutism.

MATERIALS AND METHODS Patients All premenopausal Caucasian women referred to the outpatient clinic at the Department of Endocrinology from 1997 to 2002 with a referral diagnosis of hirsutism were included in the audit. Patients attending only for clinical evaluation were excluded because no hormonal or metabolic parameters were measured during these evaluations. Women aged ⬍15 years were referred to the department of Pediatrics at Odense University Hospital, and patients with both hirsutism and infertility were referred to the Department of Fertility. All patients suspended taking oral contraceptives for at least 3 months before evaluation.

Methods Medical history, including cycle history, was recorded in all patients with a standard scheme prepared for hirsute patients. Hirsutism was assessed with the Ferriman-Gallwey score (3). Routine evaluation included basal blood samples, an ACTH test, an oral glucose tolerance test (OGTT), and vaginal ultrasound (US). The 0.25-mg ACTH test (Synachten 0.25 mg/mL; Novartis Healthcare, Copenhagen, Denmark) was performed in the follicular phase (cycle days 2– 8) in patients with a cycle length ⬍3 months; patients with cycle length ⬎3 months had the test performed on a random day. The ACTH tests were performed between 8:00 AM and 10:00 AM. Serum (s)-cortisol and s-17-hydroxyprogesterone (17-OHP) were measured at baseline and at 30 minutes and 60 minutes. At baseline, androgens (s-total T, s-free T, s-serum hormone-binding globulin [SHBG], s-DHEAS), s-LH, s-FSH, s-PRL, and s-E2 were also measured. The OGTT was performed at 8:00 AM on a random day of the cycle. P-insulin, c-peptide, and capillary blood glucose (CBG) were measured at baseline and at 30 minutes, 60 minutes, and 120 minutes after oral ingestion of 75 g glucose dissolved in water. The OGTT was performed in 263 patients, excluding 6 patients with established diabetes diagnosis. In the remaining patients OGTT was not performed because these patients did not want the test. Ultrasound examinations were performed at the Fertility Clinic, Odense University Hospital, and polycystic ovaries were defined according to Adams (4). Two measurements of 24-hour urinary cortisol— or a short dexamethasone suppression test involving 2 days of Decadron (1 mg)—were performed in patients with a clinical suspicion of Cushing’s syndrome. In this group of hirsute women, PCOS was diagnosed in those with irregular menses and no other diagnosis during the workup (5). Idiopathic hirsutism was diagnosed in the patients with regular menses, because no other measures of ovulation were available. We did, however, divide patients with IH into subgroups according to levels of free T index. FERTILITY & STERILITY威

Assays Luteinizing hormone, FSH, insulin, c-peptide, and E2 were analyzed by time-resolved fluoroimmunoassay with commercial kits (AutoDELFIA; Wallac Oy, Turku, Finland). Intraassay variations were as follows: FSH 1.0%–1.4%, LH 1.8%– 9.4%, E2 3.1%–5.2%, insulin 2.1%–3.7%, and c-peptide 3.1%– 5.0%. Interassay variations were as follows: FSH 2.1%–3.7%, LH 2.0%–3.9%, E2 1.8%– 8.5%, insulin 3.4%– 4.0%, and cpeptide 1.9%–3.0%. 17-hydroxyprogesterone was analyzed by radioimmunoassay with a commercial kit (Coat-A-Count; Diagnostic Products, Los Angeles, CA). Intra- and interassay variations were 3.5%–7.1% and 5.0%–11%, respectively. From 1997 to 2000, total and free T and SHBG were analyzed with the specific radioimmunoassays and extraction methods described previously (6). For this method, the intra-assay variation for total T was 8.2% and for SHBG was 5.2%. The interassay variation for total T was 13.8% and for SHBG was 7.5%. From 2000 to 2002, total T and SHBG were analyzed by time-resolved immunoassay with a commercial kit (AutoDELFIA). For AutoDELFIA, the intraassay variations for total T were 2.1%– 4.2% and for SHBG were 3.3%–5.2%. The interassay variations for total T were 5.2%–7.3% and for SHBG were 4.0%–5.7%. Blood glucose was measured on capillary ear blood with Hemo Cue (HemoCue, Denmark A/S DK-2950 Vedback). Homeostasis model insulin resistance index (HOMA-r) was calculated as HOMA-r ⫽ fasting insulin ⫻ fasting blood gluTABLE 1 Clinical and paraclinical data from patients with IH and PCOS.

Age (y) Total FG BMI (kg/m2) SHBG (nmol/L) FTI DHEAS (␮mol/L) 17-OHP (nmol/L) LH/FSH Fasting insulin (pmol/L) AUC insulin (104 pmol/L) HOMA-r (pmol mmol L⫺2) Fasting glucose (mmol/L) 2-h glucose (mmol/L)

IH (n ⫽ 201)

PCOS (n ⫽ 134)

34 (27–39) 12 (7–15) 25.2 (22.3–29.4) 60 (43–86) 0.036 (0.020–0.059) 5.7 (4.2–7.8) 12.0 (9.0–15.0) 0.77 (0.54–1.04) 50 (33–78) 3.7 (2.2–5.7) 10.0 (6.4–15.4) 4.5 (4.2–4.9) 5.7 (5.0–6.7)

29 (23–34)* 12 (7–16) 28.8 (23.7–35.4)* 47 (36–71)* 0.059 (0.037–0.088)* 6.1 (4.3–7.9) 12.6 (9.5–15.0) 1.42 (0.86–1.8)* 61 (41–113)* 4.8 (3.1–7.6)* 12.3 (8.2–21.7)† 4.4 (4.2–4.8) 6.0 (4.8–6.8)

Note: Values listed as median (25th–75th percentile). 17-OHP ⫽ maximum ACTH-stimulated 17-␣-hydroxyprogesterone; AUC ⫽ area under curve; BMI ⫽ body mass index; FG ⫽ Ferriman-Gallwey score; FTI ⫽ free T index; HOMA-r ⫽ fasting insulin ⫻ fasting glucose/22.5; IH ⫽ idiopathic hirsutism; PCOS ⫽ polycystic ovary syndrome; SHBG ⫽ serum hormonebinding globulin. * P⬍.001. † P⬍.05. Glintborg. Endocrine disease and OGTT in hirsutism. Fertil Steril 2004.

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TABLE 2 Clinical and paraclinical data from patients with IH and PCOS, grouped according to BMI. IH

Age (y) BMI (kg/m2) Total FG SHBG (nmol/L) FTI DHEAS (␮mol/L) 17-OHP (nmol/L) LH/FSH Fasting insulin (pmol/L) AUC insulin (104 pmol/L) HOMA-r (pmol mmol L–2) Fasting glucose (mmol/L) 2-h glucose (mmol/L)

PCOS

BMI ⱕ 25 (n ⫽ 94)

BMI ⬎ 25 (n ⫽ 99)

BMI ⱕ 25 (n ⫽ 43)

BMI ⬎ 25 (n ⫽ 82)

34 (29–40) — 11 (6–15) 71 (55–99) 0.026 (0.015–0.044) 5.5 (4.1–6.9) 12.0 (8.7–15.0) 0.8 (0.5–1.1) 40 (26–50) 2.4 (1.8–3.8) 8.4 (5.3–10.4) 4.5 (4.2–4.8) 5.5 (4.8–6.4)

33 (27–39) 29.2 (26.5–33.1) 12 (8–15) 52 (38–70)‡ 0.044 (0.026–0.063)‡ 5.9 (4.3–8.0) 11.4 (9.5–15.0) 0.8 (0.6–1.0) 68 (44–92)‡ 4.6 (3.2–7.5)‡ 13.3 (8.6–19.0)‡ 4.5 (4.3–4.9) 5.9 (5.1–7.2)†

27 (21–33)* — 10 (6–14) 66 (43–87) 0.041 (0.025–0.068)* 5.8 (4.0–8.2) 10.1 (8.1–14.0) 1.3 (0.9–1.8)* 42 (35–56) 3.1 (2.7–3.5) 8.9 (6.8–11.2) 4.6 (4.2–4.8) 6.0 (4.6–6.7)

29 (25–35)* 32.2 (28.8–37.4)* 12 (8–17)† 41 (33–56)*‡ 0.072 (0.052–0.109)*‡ 6.2 (4.4–7.7) 13 (10–16)‡§ 1.4 (0.9–1.8)* 86 (52–122)‡§ 5.8 (4.0–8.3)‡ 17.7 (9.7–25.1)‡§ 4.4 (4.1–4.9) 6.0 (4.9–7.0)

Note: Values listed as median (25th–75th percentile). 17-OHP ⫽ maximum ACTH-stimulated 17-␣-hydroxyprogesterone; AUC ⫽ area under curve; BMI ⫽ body mass index; FG ⫽ Ferriman-Gallwey score; FTI ⫽ free T index; HOMA-r ⫽ fasting insulin ⫻ fasting glucose/22.5; IH ⫽ idiopathic hirsutism; PCOS ⫽ polycystic ovary syndrome; SHBG ⫽ serum hormone-binding globulin. * P⬍.001 vs. patients with IH in same weight group. ‡ P⬍.001 vs. normal-weight patients in same patient group. † P⬍.05 vs. normal-weight patients in same patient group. § P⬍.05 vs. patients with IH in same weight group. Glintborg. Endocrine disease and OGTT in hirsutism. Fertil Steril 2004.

cose (CBG)-binding globulin/22.5 (7), reference ⬍15 pmol mmol L–2. Area under the curve for insulin during OGTT was calculated with the trapezium rule. Reference intervals in the follicular phase were as follows: s-FSH 2.2– 6.5 U/L, s-LH 1.6 –9.3 U/L, s-E2 80 –790 pmol/L, s-total T 0.55–1.8 nmol/L, s-free T 0.006 – 0.034 nmol/L, and s-SHBG 41–170 nmol/L. The reference interval for s-cortisol was 200 –700 nmol/L. Free T index (FTI) was calculated as s-total T/s-SHBG, reference interval 0.003– 0.04.

Statistical Methods Parameters were not normally distributed and were described as medians and quartiles. The Mann-Whitney test was used to compare differences between two groups. The ␹2 test was used to test for differences in frequencies between groups. During multiple regression analysis, the dependent variables were logarithmically transformed. We used commercial software (SPSS version 11.5; SPSS, Chicago, IL) for our calculations. P values ⬍.05 were considered significant.

RESULTS Characteristics All patients had hirsutism during clinical examination, and in all cases the Ferriman-Gallwey score was ⬎2. We grouped patients according to diagnosis: IH (n ⫽ 201) and PCOS (n ⫽ 134). Patient characteristics are presented in 1572 Glintborg et al.

Endocrine disease and OGTT in hirsutism

Table 1. Tables 2 and 3 show the values for patients grouped according to body mass index (BMI) and levels of FTI. Significantly more patients with PCOS (26.0%, 34 of 131) had low SHBG values (⬍37 nmol/L) than patients with IH (14.8%, 29 of 196) (P⬍.05). Among patients with IH, 43.6% (86 of 196) had FTI above the reference interval, and 24.6% (48 of 196) had total T levels above the reference interval. Corresponding values in patients with PCOS were 72.8% (96 of 131) and 49.6% (64 of 130), in both cases P⬍.001 for patients with PCOS compared with patients with IH. Twenty-nine hirsute patients had DHEAS levels above the reference interval. As regards the normal-weight patients, the subgroup of patients with PCOS had significantly higher levels of FTI and LH/FSH than patients with IH (Table 2). The subgroup of patients with IH and elevated FTI had significantly higher BMI and significantly lower SHBG levels than IH patients with FTI within reference (Table 3). Vaginal US examinations were performed on 303 patients, and of these, 169 were described as normal, whereas 111 were described as PCO or possible PCO (USPCO). The vaginal US results in 23 patients were described as inconclusive. The association between menstrual history and vaginal US is presented in Table 4. Of the patients whose US results were normal, 23% had irregular periods. The correVol. 82, No. 6, December 2004

TABLE 3 Clinical and paraclinical data from patients with IH and PCOS, grouped according to free T index. IH

Age (y) Total FG BMI (kg/m2) SHBG (nmol/L) FTI DHEAS (␮mol/L) 17-OHP (nmol/L) LH/FSH Fasting insulin (pmol/L) AUC insulin (104 pmol/L) HOMA-r (pmol mmol L–2) Fasting glucose (mmol/L) 2-h glucose (mmol/L)

PCOS

FTI normal (n ⫽ 110)

FTI high (n ⫽ 86)

FTI normal (n ⫽ 35)

FTI high (n ⫽ 96)

35 (30–40) 10 (6–14) 23.6 (22.1–27.0) 73 (55–100) 0.021 (0.012–0.029) 5.1 (3.6–6.7) 11.0 (8.7–15.0) 0.8 (0.6–1.0) 42 (27–64) 3.2 (1.9–5.2) 8.4 (5.6–12.9) 4.6 (4.2–4.9) 5.6 (4.8–6.5)

33 (25–37) 13 (9–16)† 28.0 (23.7–32.5)† 50 (35–63) 0.060 (0.049–0.079)† 6.6 (5.0–8.5)† 12.2 (9.7–15.0) 0.8 (0.5–1.1) 56 (43–82)† 4.1 (2.5–6.5)‡ 11.0 (8.6–16.61)† 4.5 (4.3–4.9) 5.9 (5.2–7.2)

32 (23–37)* 11 (8–14) 23.5 (21.4–29.8) 78 (59–103) 0.028 (0.019–0.035)* 5.2 (3.6–6.4) 11.0 (8.3–13.0) 1.1 (0.7–1.8)* 44 (35–63) 3.0 (2.4–5.4) 9.2 (6.9–12.5) 4.6 (4.2–5.0) 6.0 (4.3–7.1)

28 (22–32) 12 (7–16) 30.4 (25.8–37.1)*† 42 (32–52)† 0.073 (0.054–0.107)† 6.3 (4.4–8.3) 13.0 (9.9–16.0)‡ 1.4 (0.9–1.8)† 78 (48–116)*‡ 5.2 (3.4–7.8)*‡ 14.2 (9.4–22.3)‡ 4.4 (4.2–4.8) 6.0 (5.0–6.7)

Note: Values listed as median (25th–75th percentile). 17-OHP ⫽ maximum ACTH-stimulated 17-␣-hydroxyprogesterone; AUC ⫽ area under curve; BMI ⫽ body mass index; FG ⫽ Ferriman-Gallwey score; FTI ⫽ free T index; HOMA-r ⫽ fasting insulin ⫻ fasting glucose/22.5; IH ⫽ idiopathic hirsutism; PCOS ⫽ polycystic ovary syndrome; SHBG ⫽ serum hormone-binding globulin. * P⬍.05 vs. patients with IH in same weight group. † P⬍.001 vs. normal-weight patients in same patient group. ‡ P⬍.05 vs. normal-weight patients in same patient group. Glintborg. Endocrine disease and OGTT in hirsutism. Fertil Steril 2004.

sponding prevalence in patients with USPCO was 70% (P⬍.001).

calculations of OGTT responses and are not included in patients with IH and PCOS diagnoses.

End Diagnosis

OGTT

Eight patients had PRL values above the reference interval (23–70 ␮g/L). Of these, one patient had a pituitary microadenoma diagnosed by magnetic resonance scan. This patient had regular periods, but a transvaginal US revealed PCO. Prolactin values in the remaining seven patients normalized without treatment within a few months. Ultrasound examinations were performed in five patients with hyperprolactinemia, and PCOS were observed in three cases. Cushing’s syndrome was diagnosed in one patient, who showed amenorrhea and typical appearance. In this patient, the 24-hour urinary cortisol excretions were highly elevated (1251 and 1597 nmol per 24 hours, reference 50 –270 nmol per 24 hours) and a magnetic resonance scan revealed a pituitary adenoma. One patient with hirsutism, amenorrhea, and deepening of the voice was diagnosed as having an androgen-producing ovarian tumor. Total T in this patient was 10.9 nmol/L, and US examination showed an ovarian tumor. Late-onset 21-hydroxylase defects were found in two patients with baseline elevated 17-OHP (23 nmol/L and 89 nmol/L, respectively). During the ACTH test, the 17-OHP responses were also elevated (maximum values 130 nmol/L and 600 nmol/L, respectively). Genetic evaluation of the CYP21 gene is being performed for these patients. The above-mentioned five patients were excluded from further FERTILITY & STERILITY威

Diabetes and Impaired Glucose Tolerance World Health Organization criteria were applied to the diagnosis of diabetes and impaired glucose tolerance (IGT) (8). Six patients had previously been diagnosed as having diabetes, prevalence 1.8% (6 of 340). Thirty-two patients did not attend the OGTT, and diabetes could not be confirmed or rejected because only one measurement of fasting CBG or plasma glucose (FPG) was carried out by their general practitioners. We determined that FPG ⬍7.0 mmol/L or fasting

TABLE 4 Correlations between cycle history and vaginal ultrasound.

Regular cycles Irregular cycles Total

Vaginal US, normal

Vaginal US, PCO

Total

130 39 169

33 78 111

163 117 280

Note: Cycle history in patients with normal vaginal ultrasound (US) and vaginal US described as polycystic ovary (PCO)/possible PCO. P⬍.001 (␹2 test). Glintborg. Endocrine disease and OGTT in hirsutism. Fertil Steril 2004.

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TABLE 5 Percentage (number) of patients with elevated fasting insulin or abnormal glucose tolerance during OGTT. IH

Elevated fasting insulin IGT Diabetes

PCOS

BMI ⱕ 25

BMI ⬎ 25

BMI ⱕ 25

BMI ⬎ 25

20.0 (13/65) 9.7 (5/72) 1.4 (1/72)

61.6 (45/73)* 8.8 (7/80) 6.2 (5/80)

27.6 (8/29) 10.0 (3/30) 0

73.9 (51/69)† 8.3 (6/72) 9.7 (7/72)†

Note: BMI ⫽ body mass index; IGT ⫽ impaired glucose tolerance; IH ⫽ idiopathic hirsutism; OGTT ⫽ oral glucose tolerance test; PCOS ⫽ polycystic ovary syndrome. * P⬍.05 vs. normal-weight patients in same patient group. † P⬍.001 vs. normal-weight patients in same patient group. Glintborg. Endocrine disease and OGTT in hirsutism. Fertil Steril 2004.

CBG ⬍6.1 mmol/L excluded the diagnosis of diabetes. One patient had an FPG of 7.2 mmol/L measured by her general practitioner, and OGTT was not performed on this patient. The OGTT was performed in 263 patients (IH: 155, PCOS: 108). During OGTT, 13 patients fulfilled the criteria of diabetes, and of these, 8 had elevated fasting CBG. The distribution of patients was IH: 6 of 155, PCOS: 7 of 108 (P⫽NS). Table 5 shows the distribution of normal-weight and overweight patients with abnormal glucose tolerance. In a few cases, BMI was not recorded. Patients with BMI ⬎25 kg/m2 and ⬎30 kg/m2 had diabetes prevalences of 7.9% and 11.7%, respectively, during OGTT. Of the normal-weight patients, one had diabetes (fasting CBG 6.4 mmol/L). The 2-hour CBG level in this patient was 7.9 mmol/L. The prevalence of previously undiagnosed diabetes was 4.7% (14 of 296), resulting in a total diabetes prevalence of 6.6% (20 of 302). Of hirsute patients, 8% were diagnosed as having IGT during OGTT (21 of 263). We found no significant differences in fasting and 120-minute CBG values between patient groups (Tables 1 and 3). The data were compared with those of a population of 780 healthy, Danish, female twins (Karoline Schousboe, personal correspondence, August 2003) with an age of 37 years (29 – 45 years), BMI 24.0 kg/m2 (22.1–26.3 kg/m2) (median [25th–75th percentile]). Among these twins, the prevalence of newly diagnosed diabetes was 1.2% and of IGT was 10.0%. The prevalence of diabetes in the population of hirsute patients was significantly higher than among the twins (P⬍.01). Individuals were stratified according to weight (normal-weight and overweight). After subgrouping individuals, we found significantly higher diabetes prevalence in overweight hirsute patients than in overweight twins (P⬍.05), with prevalences of 7.9% and 2.2%, respectively. Insulin Resistance Fasting insulin values were significantly higher in the PCOS group than among IH patients (P⬍.001) and correlated significantly to BMI (r ⫽ 0.65, P⬍.001). Polycystic 1574 Glintborg et al.

Endocrine disease and OGTT in hirsutism

ovary syndrome patients had significantly higher HOMA-r (P⬍.001) and higher area-under-the-curve insulin (P⬍.001) than IH patients (Table 1). Among normal-weight hirsute patients, the prevalence of fasting insulin ⬎55 pmol/L was 22.3% (Table 5). Overweight patients with PCOS had significantly higher levels of fasting insulin and HOMA-r than overweight patients with IH (Table 2). However, PCOS patients in the overweight group were significantly more obese than overweight patients with IH (P⬍.001). Because of the importance of BMI for insulin resistance, we performed multiple regression analysis correcting for BMI. After correcting metabolic parameters for BMI, no significant difference remained between patients with PCOS and those with IH (Table 6). However, the observed differences in FTI and LH/FSH between the patient groups remained significant. Significantly greater mean fasting insulin values were found in the population of hirsute patients than in the twin population mentioned above: median (25th–75th quartiles) insulin in twins 34.0 pmol/L (25.0 – 47.0 pmol/L) vs. patients 55.0 pmol/L (37.0 – 88.5 pmol/L) (P⬍.001). In this comparison, we adjusted for correlation in twin pairs. The significant differences between fasting insulin values remained significant after stratifying individuals into normal and overweight groups.

DISCUSSION Although hirsutism is a frequent disorder, there is currently no agreement concerning a standard evaluation program for these patients. As a result, patients are examined differently in departments of endocrinology, gynecology, dermatology, or fertility, depending on current interests or traditions within the department. In this study, only a few patients suffered from serious hormonal conditions other than PCOS, although a considerable proportion displayed insulin resistance or abnormal glucose tolerance. Vol. 82, No. 6, December 2004

TABLE 6 Multiple regression analysis showing the effect of BMI and patient group on metabolic and hormonal parameters. Dependent variable Log Log Log Log Log Log Log

FTI LH/FSH fasting insulin (pmol/L) AUC insulin (pmol/L) HOMA-r (pmol mmol 1⫺2) fasting glucose (mmol/L) 120-min glucose (mmol/L)

BMI 0.019 (0.013, 0.024)* ⫺0.002 (⫺0.007, 0.003) 0.03 (0.025, 0.034)* 0.027 (0.022, 0.033) 0.032 (0.027, 0.037)* 0.002 (0.001, 0.003) 0.006 (0.003, 0.009)

Patient group (IH and PCOS)

R2

0.215 (0.143, 0.287)* 0.23 (0.169, 0.292) 0.013 (⫺0.043, 0.069) 0.023 (⫺0.049, 0.096) ⫺0.002 (⫺0.063, ⫺0.059) ⫺0.016 (⫺0.032, 0.001) ⫺0.001 (⫺0.035, 0.033)

0.258 0.162 0.461 0.337 0.449 0.047 0.076

Note: Multiple regression analysis with body mass index (BMI) and patient group as explanatory variables. Data presented as B-value (95% confidence interval). The R2 value for the regression model is presented for each value. AUC ⫽ area under curve; FTI ⫽ free T index; HOMA-r ⫽ fasting insulin ⫻ fasting glucose/22.5; IH ⫽ idiopathic hirsutism; PCOS ⫽ polycystic ovary syndrome. * P⬍.001. Glintborg. Endocrine disease and OGTT in hirsutism. Fertil Steril 2004.

Polycystic ovary syndrome was defined according to the criteria proposed by the National Institutes of Health (5). The evaluation of T levels in females with commercial immunoassay kits is known to constitute a major challenge in daily clinical work, and levels of T have therefore not been included in the diagnosis of patients with IH (9, 10). In the present study, the main issue was to assess the prevalence of serious hormonal disorders and abnormal glucose tolerance. To facilitate the application of the results in daily practice, patients with IH were simply defined as hirsute patients with regular menses. It has, however, been established that an appreciable proportion of patients with regular periods might be anovulatory, and a precise diagnosis of idiopathic hirsutism would have to include assessment of ovulation (11).

Referral of Hirsute Patients Among patients referred with hirsutism, the number of patients with endocrine diseases varies according to the number of patients referred and the knowledge and interests of the referring doctors in the region. Because patients were offered cosmetic treatment in this period, we could expect an increased number of patients with only cosmetic distress. Despite these potential reservations, the prevalence of endocrine disease we observed corresponded to previous studies in hirsute patients (2, 12, 13). O’Driscoll et al. (2) examined a British population of 350 female patients referred because of hirsutism or androgen alopecia. Of these patients, 8 were diagnosed as having endocrine disease: 3 with adrenal enzyme defects, 1 with hepatic enzyme defect, 1 with adrenal tumor, 1 with prolactinoma, 1 with acromegaly, and 1 with ovarian tumor. The T levels in patients diagnosed with ovarian and adrenal tumors were 13 nmol/L and 50 nmol/L, respectively. In a study by Moran et al. (12) of 250 women referred with irregular periods, hirsutism, infertility, or galactorrhea, there were 8 patients with endocrine diseases: 5 with enzyme defects, 2 with ovarian tumor, and 1 with Cushing’s syndrome. Zargar et al. (13) examined FERTILITY & STERILITY威

142 Indian female patients with hirsutism and found adrenal tumors in 3 and enzyme defects in 2. Postmenopausal women were included in the studies by O’Driscoll et al. and Zargar et al.

Cushing’s Syndrome One patient with typical appearance and highly elevated 24-hour urinary cortisol was diagnosed as having Cushing’s syndrome. In the same period, 24-hour urinary cortisol or short dexamethasone suppression tests were performed on 130 hirsute patients. Of these, 7 displayed abnormal results and were admitted for further evaluation and extended dexamethasone suppression tests at the department. None of these patients was diagnosed as having Cushing’s syndrome. During the period 1997–2002, 25 patients at the department were diagnosed as having Cushing’s syndrome. All patients were referred because of hypertension and/or suspicion of Cushing’s syndrome. These data suggest a precise referral diagnosis from the general practitioners and that screening for Cushing’s syndrome should only be performed for patients with typical clinical signs of this disease.

21-Hydroxylase Defects In classic adrenogenital syndrome, ACTH-stimulated 17OHP exceeds 300 nmol/L. Nonclassic adrenogenital syndrome is traditionally diagnosed by 17-OHP ⬎15 nmol/L and/or ACTH-stimulated 17-OHP ⬎30 nmol/L (14). CYP21 carriers most often have elevated ACTH-stimulated 17-OHP values of 13–30 nmol/L (15). However, recent studies have questioned these cut-off levels because patients with nonclassic adrenogenital syndrome most often have ACTH-stimulated 17-OHP values ⬎45 nmol/L (14). Stimulated 17-OHP values in 21-hydroxylase deficiency carriers have been recorded at levels as high as 45 nmol/L, and the cut-off values currently applied might result in an overestimation of the prevalence of patients with nonclassic adrenogenital syndrome (16). Because 17-OHP is produced in both ovaries 1575

and adrenals, elevated basal 17-OHP concentrations can be caused by ovarian androgen production (17). In this study, two patients had basal and ACTH-stimulated 17-OHP values corresponding to nonclassic adrenogenital syndrome. Two patients had borderline 17-OHP values (basal, stimulated values: 17 nmol/L, 26 nmol/L and 5 nmol/L, 32 nmol/L, respectively) and were not diagnosed as having nonclassic adrenogenital syndrome. Genetic evaluation of the CYP21 gene in these patients is ongoing. New recommendations concerning PCOS diagnosis include 17-OHP measurement to exclude adrenogenital syndrome. Testing of ACTH is recommended when basal 17OHP is elevated (18 –21). Recent studies have shown higher ACTH-stimulated 17OHP responses in PCOS patients than in controls (22–24). In the present study, 110 of 298 patients had 17-OHP responses ⬎13 nmol/L during ACTH testing. No significant difference was found between patients with IH (60 of 175) and those with PCOS (73 of 123). High 17-OHP responses can be caused by unspecific adrenal hyperresponsiveness, as well as by enzyme defects. The correspondence between basal and increased ACTHstimulated 17-OHP responses to 21-hydroxylase defects is still to be clarified, and the indication for 17-OHP measurements awaits clarification of this point.

Hyperprolactinemia Of eight patients with PRL above the reference interval, only one patient was diagnosed as having prolactinoma. Prolactinoma seems to occur only rarely in patients with hirsutism. Therefore, s-PRL should only be measured in hirsute patients who display symptoms relevant for this diagnosis.

Androgen-Producing Tumors The patient with an androgen-producing tumor was not virilized upon clinical examination but had, however, consulted her doctor because of hirsutism and changes in her voice. The strongly elevated T level (10.9 nmol/L) raised suspicions of an androgen-producing tumor. Because of the low incidence of these tumors, Waggoner et al. (25) suggest that diagnosis should predominantly depend on clinical examination. These investigators examined 478 consecutive patients referred because of hirsutism, irregular periods, and/or hyperandrogenemia. Of these patients, only 1 of 11 with T level ⬎8.7 nmol/L was diagnosed as having an androgen-producing tumor. Because these tumors are potentially life-threatening, most investigators suggest that as a minimum, T levels be established in patients with irregular menses (18, 19, 26). The limit of T, above which androgen-producing tumors should be excluded, varies between 5–7 nmol/L in these studies. Dehydroepiandrosterone sulfate is produced by the adrenals, and increased levels of DHEAS were previously used to distinguish between adrenal and ovarian tumors. How1576 Glintborg et al.

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ever, elevated levels of adrenal androgens are observed in 25%– 60% of patients with PCOS, and although the mechanisms are still unclear, a substantial adrenal– ovarian interaction is believed to exist in PCOS (17). In previous studies, dexamethasone treatment was used for patients with high levels of adrenal androgens and PCOS (27–29). In these studies, dexamethasone treatment was associated with a significant suppression of T. However, patients might experience a significant weight gain, thus limiting the relevance of using glucocorticoids for the treatment of hyperandrogenism (28). DHEAS was previously used to differentiate between malignant (high levels) and benign (low levels) adrenal tumors. However, the value of differentiation was too low to be of clinical value (30). In our population, 29 patients had DHEAS above the reference; none of these patients were diagnosed as having an adrenal tumor. The value of DHEAS measurement in hirsutism therefore seems low. In a previous study, SHBG values of ⬍37 nmol/L were considered to be the best predictor of PCOS (31). In the present study, overweight patients had significantly lower SHBG values than normal-weight patients. We expect patients with low levels of SHBG to respond better to treatment with oral contraceptives and/or weight loss than patients with higher levels. Interestingly, SHBG levels correlate well to the degree of insulin resistance measured in euglycemic hyperinsulinemic clamp (32).

Oral Glucose Tolerance Test Insulin Resistance We found a high prevalence of insulin resistance in our population. As expected, insulin resistance correlated to BMI, and among normal-weight patients, 24.4% had fasting insulin values ⬎55 pmol/L. Compared with healthy female twins, hirsute patients had significantly higher fasting insulin levels, which remained significant after subgrouping patients and controls according to BMI. After correction for BMI, we found no significant differences in metabolic parameters between patients with IH and PCOS. Our data indicate that in a group of hirsute patients, overweight rather than irregular periods is the main predictor of insulin resistance. Nevertheless, the question of whether hirsute patients as a group are more insulin-resistant than weight- and age-matched healthy female subjects remains to be reconfirmed. Insulin resistance in IH has been examined in few studies (33, 34). These studies have found higher levels of insulin and c-peptide in patients with IH than in controls. It is speculated that IH is caused by a local activation of T in the hair follicle. Similar processes in other tissues, such as muscle tissue, might explain the insulin resistance observed in patients with IH (34). However, recent studies found adrenal hyperresponsiveness in patients with IH, and the exact mechanism for IH remains unclear (35, 36). Idiopathic Vol. 82, No. 6, December 2004

FIGURE 1 Suggested evaluation program for patients with a primary diagnosis of hirsutism. Medical history: periods, fertility, age of debut, duration of symptoms, galactorrhea. Clinical examination: body mass index (BMI), blood pressure, waist– hip ratio, FerrimanGallwey score, virilization, Cushing’s syndrome. Metabolism: fasting glucose, fasting insulin, fasting lipid profile. Hormone status: total T, serum hormone-binding globulin, LH, FSH, PRL, TSH.

Glintborg. Endocrine disease and OGTT in hirsutism. Fertil Steril 2004.

hirsutism should perhaps not be considered a local phenomenon but rather as caused in part by the same mechanisms as PCOS. In previous studies on PCOS patients, fasting insulin and insulin responses during OGTT were significantly higher in patients than in weight-matched controls (37– 40). In PCOS, insulin probably causes hormonal changes through the enzyme p450c17alfa in the ovary. This enzyme increases the production of 17-OHP and, as a result, the production of androgens (41, 42). It is not clear how insulin resistance originates PCOS, but some patients have insulin postreceptor defects, including reduced tyrosine and increased serine phosphorylation (43). These defects might inhibit tyrosin kinase activity in the insulin receptor and thereby inhibit FERTILITY & STERILITY威

insulin effects. In addition, postreceptor defects can induce the reduced GLUT4 expression that is also observed in PCOS (44). IGT and Diabetes The total prevalence of diabetes in our population was 6.6%. In the Danish Glostrup study (45), 2.0% of 60-yearold women (mean BMI 26.4%) had newly diagnosed diabetes, and the total diabetes prevalence was 6.8%. These data indicate that hirsute women might develop diabetes at a younger age than healthy women. However, the two populations differed according to BMI, and different measurement methods of glucose were used. Traditionally, the prevalence of diagnosed and undiagnosed diabetes is believed to 1577

be of approximately the same size. In our population, however, 6 patients were previously diagnosed with diabetes, and 14 patients had previously undiagnosed diabetes. Surprisingly, we found no significant difference in the frequency of IGT or diabetes between patients with IH and those with PCOS, and our data indicate that BMI is the major determinant for developing diabetes in hirsute patients. Only one patient with BMI ⬍25 kg/m2 was diagnosed as having diabetes during OGTT. To our knowledge, no previously published studies have focused on larger groups of wellcharacterized patients with IH. Future studies are needed to establish whether patients with IH have metabolic disorders, which increases the risk of future diabetes. In the subgroup of patients with PCOS, we found 6.9% with previously undiagnosed diabetes. In previous studies including patients with PCOS, the prevalence of diabetes has been established at 1.5%–10% and that of IGT at 10.3%– 36% (37, 38, 40, 46). As expected, the highest prevalence is observed in patients with a high BMI. The prevalence of abnormal OGTT was ⬎30% in two studies on patients with mean BMI values 38 kg/m2 (38) and 40 kg/m2 (37). The variance of BMI in different studies makes it difficult to compare data. Overweight patients with PCOS have a high risk of diabetes, and previous studies have indicated that this risk is higher than in weight-matched controls. It remains unclear whether patients with IH have a lower diabetes risk than patients with PCOS.

Suggested Evaluation Program Figure 1 presents our suggested evaluation program in hirsute patients. Patients with regular menses during a period of 6 months–1 year are unlikely to suffer from serious endocrine diseases. Most often, patients with irregular menses have PCOS. Diabetes in normal-weight patients is rare, and we suggest that metabolic parameters only be measured in overweight patients. However, hirsute patients might have a higher prevalence of insulin resistance than healthy female subjects. The indication for OGTT in hirsute patients remains unclear, although OGTT might be needed, especially in obese hirsute patients. General practitioners can perform a major part of the evaluation program and will be able to exclude serious endocrine diseases that require treatment at a specialist center. Patients with total T values ⬎5 nmol/L, with suspected Cushing’s syndrome or infertility, should be referred to a specialist center for further evaluation. References 1. Barth JH. Investigations in the assessment and management of patients with hirsutism. Curr Opin Obstet Gynecol 1997;9:187–92. 2. O’Driscoll JB, Mamtora H, Higginson J, Pollock A, Kane J, Anderson DC. A prospective study of the prevalence of clear-cut endocrine disorders and polycystic ovaries in 350 patients presenting with hirsutism or androgenic alopecia. Clin Endocrinol (Oxf) 1994;41:231– 6. 3. Ferriman D, Gallwey JD. Clinical assessment of body hair growth in women. J Clin Endocrinol 1961;21:1440 –7. 4. Adams J, Polson DW, Franks S. Prevalence of polycystic ovaries in women with anovulation and idiopathic hirsutism. Br Med J (Clin Res Ed) 1986;293:355–9.

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40. Morin-Papunen LC, Vauhkonen I, Koivunen RM, Ruokonen A, Tapanainen JS. Insulin sensitivity, insulin secretion, and metabolic and hormonal parameters in healthy women and women with polycystic ovarian syndrome. Hum Reprod 2000;15:1266 –74. 41. Nestler JE, Jakubowicz DJ. Decreases in ovarian cytochrome P450c17 alpha activity and serum free testosterone after reduction of insulin secretion in polycystic ovary syndrome. N Engl J Med 1996;335:617–23. 42. Dunaif A. Insulin resistance and the polycystic ovary syndrome: mechanism and implications for pathogenesis. Endocr Rev 1997;18:774 – 800. 43. Dunaif A, Xia J, Book CB, Schenker E, Tang Z. Excessive insulin receptor serine phosphorylation in cultured fibroblasts and in skeletal muscle. A potential mechanism for insulin resistance in the polycystic ovary syndrome. J Clin Invest 1995;96:801–10. 44. Rosenbaum D, Haber RS, Dunaif A. Insulin resistance in polycystic ovary syndrome: decreased expression of GLUT-4 glucose transporters in adipocytes. Am J Physiol 1993;264:E197–202. 45. Drivsholm T, Ibsen H, Schroll M, Davidsen M, Borch-Johnsen K. Increasing prevalence of diabetes mellitus and impaired glucose tolerance among 60-year-old Danes. Diabet Med 2001;18:126 –32. 46. Weerakiet S, Srisombut C, Bunnag P, Sangtong S, Chuangsoongnoen N, Rojanasakul A. Prevalence of type 2 diabetes mellitus and impaired glucose tolerance in Asian women with polycystic ovary syndrome. Int J Gynaecol Obstet 2001;75:177– 84.

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