Ovarian Morphology and Theca Cell Androgen Production in Women With Polycystic Ovary Syndrome (PCOS)

In women with polycystic ovary syndrome (PCOS), the major abnormality is excessive ovarian
androgen production marked by increased serum testosterone (T) and androstenedione (A)
levels. Studies to determine the alteration in ovarian steroidogenesis that lead to abnormal
production of ovarian androgens have revealed increased CYP17 gene expression with
accentuated 17-hydroxylase activity leading to exaggerated 17-hydroxyprogesterone (17P)
responses to LH stimulation. In contrast, T and A responses did not distinguish between PCOS
and normal women, although these androgens were clearly greater in the former compared to the
latter group. As a result, 17P responsiveness has been employed to determine the functional
capacity of the ovary to produce androgen. Stimulatory agents have included GnRH agonist,
Lupron, at a dose of 10 microgram per kilogram, or hCG at a dose of 10,000 IU.

The investigators recently showed that hCG administered intravenously in a dose-response
fashion revealed gradual increases of 17P and a non-dose dependent increase of serum T and A.
The pattern of steroid hormone production revealed the predominant pathway by which androgens
are generated in women with PCOS. Extending these studies, the investigators selected the
mid-maximal dose of hCG to stimulate ovarian androgens and included morphometric measures of
the ovary, such as ovarian follicle number (as determined by ultrasound) and related
hormones, such as anti-mullerian hormone and inhibin B, both products of the ovarian
follicle. The results showed that increased androgen and 17P responses in PCOS women were
associated with increased antral follicle number and greater AMH levels compared to normal
women. Inhibin B levels were similar between groups.

Based on responses observed in normal women, the PCOS women were divided into two groups.
Those with 17P responses that did not exceed the normal mean plus 2 standard deviations
(normal responder PCOS; NR-PCOS) and those that did exceed the normal response (high
responder PCOS; HR-PCOS). This separation occurred at a rate of 50%. Notably, serum AMH
levels were 2-fold higher in NR-PCOS compared to HR-PCOS. This finding was puzzling as serum
AMH levels have been shown to correlate to the number of small follicles present in ovaries
suggesting that AMH may be a surrogate for small follicle number. However, both PCOS
subgroups had equivalent follicle numbers. The investigators hypothesize that the NR-PCOS
have greater number of small follicles compared to HR-PCOS. To address this issue the
investigators propose to assess the number of small follicles in NR- and HR-PCOS women and
normal controls.

In a secondary consideration the HR-PCOS group was heavier than the NR-PCOS. This implies
that the HR-PCOS women may have had greater insulin resistance and hyperinsulinemia that may
have contributed to the significantly higher 17P responses to hCG. As a result, the
investigators will also perform an oral glucose tolerance test in all subjects.

Power Analysis Results of the investigators' pilot study have shown that approximately 50% of
PCOS women will exhibit 17OHP responses to hCG stimulation similar to those of normal women.
Consequently, a sample size of 20 subjects in each group has an 80% power to detect a
difference in the means of 0.820 ng/ml (the difference between the average 17OHP expression
level in high responder PCOS women (HR-PCOS), 2.840 ng/ml, and that of normal responder PCOS
(NR-PCOS) women, 2.02 ng/ml), which is a 33% increase. In the proposed study, the
investigators believe that HR-PCOS (n=20) will show significantly greater (33% more) 17OHP
production in response to hCG stimulation than NR-PCOS (n=20) at a power of 0.8 and a type I
error rate of 0.05. The investigators will recruit 25 subjects in each group to allow for
subject drop out. A secondary analysis will be performed between women with PCOS and normal
controls (n=20).

Inclusion Criteria:

1. Subjects will be determined to have PCOS based on clinical history of irregular menses
and clinical or laboratory evidence of hyperandrogenism and polycystic ovaries on
ultrasound

2. Subjects should not have been on any hormonal therapy or metformin for at least 2
months prior to study start

3. Subjects will be determined to be normal controls if they have a clinical history of
regular periods

Exclusion Criteria:

1. Women with hemoglobin less than 11 gm/dl at screening evaluation

2. Women with untreated thyroid abnormalities

3. Pregnant women or women who are nursing

4. Women with BMI > 37

5. Women with known sensitivity to the agents being used

6. Women with diabetes, or renal, liver, or heart disease