HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Gambineri, A. Articles by Pasquali, R. Search for Related Content PubMed PubMed Citation Articles by Gambineri, A. Articles by Pasquali, R. Social Bookmarking                What's this?

Glucose Intolerance in a Large Cohort of Mediterranean Women With Polycystic Ovary Syndrome

Phenotype and Associated Factors

From the Division of Endocrinology, Department of Internal Medicine and Gastroenterology, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy

	ABSTRACT

TOP ABSTRACT RESEARCH DESIGN AND METHODS RESULTS DISCUSSION REFERENCES

 
The aim of this study was to investigate the phenotypic parameters and associated factors characterizing the development of glucose intolerance in polycystic ovary syndrome (PCOS). Among the 121 PCOS female subjects from the Mediterranean region, 15.7 and 2.5% displayed impaired glucose tolerance and type 2 diabetes, respectively. These subjects were included in a single group of overweight or obese subjects presenting with glucose intolerance (GI) states. PCOS women with normal glucose tolerance (81.8%) were subdivided into two groups: those who were overweight or obese and those of normal weight. Metabolic and hormonal characteristics of the GI group included significantly higher fasting and glucose-stimulated insulin levels, more severe insulin resistance, hyperandrogenemia, and significantly higher cortisol and androstenedione responses to 1–24 ACTH stimulation. One important finding was that lower birth weight and earlier age of menarche were associated with GI in PCOS women. Frequency of hirsutism, oligomenorrhea, acne, and acanthosis nigricans did not characterize women with GI. Our findings indicate that PCOS patients with GI represent a subgroup with specific clinical and hormonal characteristics. Our observations may have an important impact in preventative and therapeutic strategies.

Studies in American and Asian subjects have shown that, compared with the general population, women with PCOS have an increased risk for impaired glucose tolerance (IGT) and type 2 diabetes (4–6), with a tendency toward early development of glucose intolerance (GI) states (7). However, to our knowledge, no studies have been performed on subjects from the Mediterranean region. The strong connection between PCOS and GI states is further emphasized by the high prevalence of polycystic ovarian morphology found on ultrasound scans in premenopausal women with type 2 diabetes (8) and those with previous gestational diabetes (9).

As has been seen in the general population (10), there is evidence that insulin resistance may play a major pathophysiological role in the development of GI in PCOS women (11,12). The decreased insulin sensitivity in PCOS women appears in fact quite similar to that found in type 2 diabetic patients and to be relatively independent of obesity, fat distribution, and lean body mass (13). On the other hand, there is strong evidence that obesity per se, particularly the abdominal phenotype, represents an important independent risk factor for GI in PCOS women (7). An impaired early-phase insulin secretion also seems to play a role in obese PCOS women (14,15), particularly in women with a family history of diabetes (14,16). However, no other potential specific pathophysiological factors involved in the development of diabetes have been described, thus emphasizing the need for more information on clinical characteristics and hormonal and metabolic abnormalities of women presenting with IGT or type 2 diabetes. Moreover, to improve the understanding of the pathophysiology of GI states in PCOS, it is mandatory to search for associated factors. Therefore, using a large cohort of Mediterranean obese and normal weight women with PCOS, this study aimed at characterizing the specific clinical, hormonal, and metabolic parameters of those presenting with GI and investigating factors associated with GI development.

	RESEARCH DESIGN AND METHODS

TOP ABSTRACT RESEARCH DESIGN AND METHODS RESULTS DISCUSSION REFERENCES

 
This study included 121 women with PCOS, all in the reproductive age (range 14–37 years), who consecutively attended the Endocrine Unit of S. Orsola-Malpighi Hospital, Bologna, Italy, in the previous 3 years. The diagnosis of PCOS was made by the presence of chronic anovulation, hyperandrogenemia (defined by supranormal total testosterone levels according to our reference value of 1.35 ± 0.62 nmol/l, and polycystic ovarian morphology at ultrasound examination, according to previously defined criteria (17) Other causes of hyperandrogenism, such as hyperprolactinemia, Cushing syndrome, and congenital adrenal hyperplasia, were excluded by specific laboratory analysis, as previously described (18). None of the subjects included in the study had thyroid, cardiovascular, renal, or liver dysfunctions based on clinical examination and routine laboratory findings; had taken any medication known to affect glucose or sex hormone metabolism during the 3 months prior to the study; or were dieting. The study protocol was approved by the local ethics committee, and all subjects enrolled in the study signed an informed consent.

On the first day of the study, anthropometric measurements, clinical and family history, and information on dietary habits and habitual physical activity were obtained from each subject. Baseline blood samples were also obtained for androgen and SHBG determinations. An oral glucose tolerance test (OGTT) (75 g, Curvosio; Sclavo, Cinisello Balsamo, Italy) was performed, with blood samples taken at baseline and 30, 60, 90, 120, and 180 min after the glucose load for glucose measurement and at baseline and 60, 120, and 180 min for insulin and C-peptide determinations. Normal glucose tolerance (NGT), IGT, and type 2 diabetes were defined using glucose levels during the OGTT, according to the criteria proposed by the World Health Organization (WHO) (19).

On the second day, starting at 8:00–8:30 A.M., a standard 1–24 ACTH test (250 µg cosyntropin [Synacthen] i.v.) was performed; samples for cortisol, dehydroepiandrosterone (DHEA), androstenedione, and 17-hydroxyprogesterone (17-OHP) determinations were drawn at baseline and 60 min thereafter. All samples were immediately chilled on ice and centrifuged; serum or plasma aliquots were frozen at –80°C until assayed. All PCOS women were investigated after a 12-h overnight fast, provided they had followed a 3-day diet containing >250–300 g carbohydrate/day, had mild oligomenorrhea within the first 10 days after the last menstruation, or had severe oligomenorrhea or amenorrhea regardless of the menstrual cycle.

Anthropometry, clinical and family history, dietary habits, and habitual physical activity.
Height, weight, waist and hip circumferences, and the waist-to-hip ratio (WHR) were measured according to standardized procedures (20). BMI was calculated as weight in kilograms divided by square meters of height in centimeters and was used to classified the study population as normal weight (BMI 18.5 and <25 kg/m²), overweight (BMI 25 and <30 kg/m²), or obese (BMI 30 kg/m²), according to WHO classification (21). Waist circumference 80 cm and WHR >0.85 were also used as indexes of abdominal body fat distribution (21). Hirsutism was estimated using the Ferriman-Gallwey score (22). Menstrual status was evaluated in the 6 months before the study. Oligomenorrhea was defined as cycle lengths >35 days and amenorrhea as no cycles occurring during the previous 6 months. An anovulatory state was defined as progesterone levels 2 ng/ml (6.4 nmol/l), measured every 10 days throughout the last cycle (23). The presence of acne and acanthosis nigricans was evaluated by a careful clinical examination (24,25). A questionnaire regarding personal and family history was given to each subject enrolled in the study and was filled in at home under the supervision of the subjects’ parents and, finally, of the investigator. The questionnaire addressed body weight at birth, age of menarche, and familiarity of diabetes and obesity. A subject was considered to have a positive family history for type 2 diabetes and obesity if at least one first-degree relative (parent or sibling) was or had been affected. To assess the reliability of the data related to birth weight, we compared the values reported in the questionnaire with those registered in the personal pediatric record, if available at home. This comparison was done in 88 patients. No significant difference was observed between the two sources of birth weight evaluations (P < 0.001; range of difference –0.1 to 0.1 kg) and they correlated well (r = 0.998, P < 0.001), documenting a good accordance between the values described in the questionnaire and those reported in the pediatric record. Dietary intake was evaluated by the dietitian attending our unit according to a previously defined method, including quantitative information on daily energy intake and macronutrient composition of the diet. Finally, physical activity was investigated by using a self-administered questionnaire proposed by Baecke et al. (26) that made it possible to distinguish three meaningful factors (scored from 1 to 5): physical activity at work (work index), sport during leisure time (sport index), and physical activity during leisure time, excluding sport (leisure index).

Hormone assay and data analysis.
Plasma glucose levels were determined by the glucose oxidase technique immediately after blood was drawn. Levels for insulin, total testosterone, DHEA and its sulfate (DHEA-S), androstenedione, 17-OHP, SHBG, and cortisol were determined as previously described (18,27,28). The intra-assay coefficients of variation in our laboratory were 3.0% for insulin, 7.0% for total testosterone, 9.0% for DHEA, 5.9% for DHEA-S, 6.0% for androstenedione, 13.0% for 17-OHP, 6.5% for SHBG, and <8.0% for cortisol. Free testosterone was calculated as the ratio between total testosterone and SHBG, according to the method of Vermeulen et al. (29). To investigate insulin sensitivity in the basal condition and after the glucose challenge, the Quantitative Insulin-Sensitivity Check Index (QUICKI) and the homeostasis model assessment (HOMA) applied to the OGTT (HOMA_OGTT) were calculated, as previously proposed (30,31).

Statistical analysis.
All data are expressed as means ± SD and frequencies (percent). Glucose, insulin, and C-peptide response to the OGTT are expressed as the area under the curve (AUC), calculated by the trapezoidal method, whereas hormonal response to the ACTH test is expressed as values, calculated as the difference () between peak values and basal values of each hormone measured.

Continuous data were compared among the three groups by ANCOVA, using age as the covariate. Category data were analyzed using ² testing. ANOVA and linear regression were used to compare birth records with self-reported birth weights. Two-tailed P values <0.05 were considered statistically significant. Statistical analysis was performed by running the SPSS/PC+ (SPSS, Chicago, IL) software package (32).

	RESULTS

TOP ABSTRACT RESEARCH DESIGN AND METHODS RESULTS DISCUSSION REFERENCES

 
Definition of the groups.
According to the glucose tolerance status, 2.5% (3 of 121) of the PCOS women had type 2 diabetes, 15.7% (19 of 121) had IGT, and 81.8% (99 of 121) had NGT. All women with IGT and type 2 diabetes (the GI group) were overweight or obese, whereas among NGT women, 80.8% (80 of 99) were overweight or obese (the OB-NGT group) and 19.2% (19 of 99) were normal weight (the NW-NGT group). The three women with type 2 diabetes were included in the same group as those with IGT (the GI group), as they had fasting glucose values <126 mg/dl (114, 110, and 114 mg/dl) and glucose levels at 120 min of the OGTT (243, 209, and 204 mg/dl) slightly exceeding the WHO threshold of 200 mg/dl (19). In addition, the overlapping age and similar abdominal obesity phenotype were also reasons to pool the type 2 diabetes and IGT subjects.

Anthropometry, clinical and family history, dietary habits, and habitual physical activity.
Subject characteristics are given in Table 1. PCOS women included in the GI group were significantly older compared with the other two groups (P < 0.05); therefore, statistical analyses among the groups were performed after adjusting for age. No significant difference in anthropometric parameters was found between the GI and OB-NGT groups; as expected, however, both groups had significantly higher values of body weight (P < 0.001), WHR (P < 0.001), and waist circumference (P < 0.001) with respect to the NW-NGT group. The hirsutism score was similar in all the groups. No difference was present in the frequency of oligomenorrhea between PCOS women with GI and those of the OB-NGT group, but in both groups oligomenorrhea was significantly more frequent than in the NW-NGT group (P < 0.05). Conversely, the frequency of acne was negligible (5%) in the GI group, whereas it was present in 25% of the OB-NGT group (P < 0.05 vs. GI) and 58% of the NW-NGT group (P < 0.001 vs. GI and P < 0.01 vs. OB-NGT). Finally, about half of the women in the GI and the OB-NGT groups had acanthosis nigricans, whereas none of the NW-NGT women were affected (P < 0.001).

Glucose and insulin levels and indexes of insulin resistance.
Table 2 shows subjects’ values related to glucose tolerance and insulin resistance. The GI group had significantly higher fasting glucose and glucose_AUC values with respect to the other two groups (P < 0.001). In addition, compared with the two NGT groups, the GI group had significantly higher fasting insulin (P < 0.05 vs. OB-NGT group and P < 0.001 vs. NW-NGT group), insulin_AUC (P < 0.001), and C-peptide_AUC (P < 0.01 vs. OB-NGT group and P < 0.001 vs. NW-NGT group) values. However, fasting C-peptide values were similar between the GI and the OB-NGT groups and significantly higher than in the NW-NGT group (P < 0.01). Finally, compared with the other two groups, the GI women had significantly lower QUICKI (P < 0.01 vs. OB-NGT group and P < 0.001 vs. NW-NGT group) and HOMA_OGTT (P < 0.001) values. However, among PCOS women with NGT, those included in the OB-NGT group had significantly higher fasting insulin (P < 0.01), C-peptide (P < 0.01), and C-peptide_AUC (P < 0.05) values and significantly lower QUICKI (P < 0.001) and HOMA_OGTT (P < 0.001) indexes.

View larger version (24K): [in this window] [in a new window]   FIG. 1. Cortisol and sex hormone responsiveness to 1–24 ACTH administration, expressed as values (means ± SD) in PCOS women with GI states () and obese (OB-NGT; ) and normal-weight (NW-NGT; &;) PCOS women with NGT. P values refer to OB-NGT and NW-NGT vs. GI and OB-NGT vs. NW-NGT groups. A, androstenedione.

	DISCUSSION

TOP ABSTRACT RESEARCH DESIGN AND METHODS RESULTS DISCUSSION REFERENCES

Although all PCOS women with GI investigated in this study were obese, it is noteworthy that nearly 80% of obese PCOS subjects had NGT. Surprisingly, there was no difference in the frequency of the abdominal phenotype among these groups. Therefore, although obesity appears to be an important prerequisite for the development of GI in PCOS (4–6), additional pathogenetic factors need to be taken into consideration. Notably, we found that PCOS women presenting with GI were significantly more insulin resistant and had higher insulin blood levels than those with NGT, regardless of body weight or fat distribution. These data confirm and extend the results of the only long-term follow-up study performed by our group in PCOS women, demonstrating that insulin sensitivity, measured by means of insulin and glucose values during an OGTT, tends to worsen markedly over time, particularly in those with obesity, and is associated with the appearance of GI in many of these women (27). Taken together, these findings strongly support the concept that insulin resistance, worsening in time, may play a major role in the development of GI in obese PCOS women (35). On the other hand, in the presence of insulin resistance, pancreatic ß-cell insulin secretion increases in a compensatory fashion and type 2 diabetes develops when this compensation is no longer sufficient to maintain euglycemia (36). Under normal circumstances, the relation between ß-cell function and insulin sensitivity is constant (36). Previous studies have shown that several obese PCOS women may be characterized by impaired early-phase insulin secretion (15), which may play a contributory role in the development of GI. In this study, we found that PCOS women with GI had higher fasting and glucose-stimulated insulin and C-peptide concentrations. Although we cannot rule out the possibility that subtle defects in insulin secretion may be present in these women, our data nevertheless emphasize that more severe hyperinsulinemia in obese PCOS women is associated with a worsened insulin resistance state, even in the presence of GI.

This study also attempted to identify early markers of the development of GI in PCOS women, which can be important in clinical practice to plan preventive and therapeutic strategies. Two new interesting factors emerged from our investigation. The first was represented by the presence of lower birth weight in the GI group with respect to the two NGT groups, confirming the close asso-ciation of this feature with insulin resistance and susceptibility to developing type 2 diabetes (37). The mechanisms responsible for this association are still speculative; it has been hypothesized that although undernourished fetuses make a metabolic adaptation from which they benefit in the short-term by increasing fuel availability, in time this condition becomes damaging, leading to insulin resistance (37). The second factor was the earlier menarche age found in PCOS women with GI in comparison with those with NGT. These data are in line with those observed in a different group of patients where a precocious pubarche was related to hyperinsulinemia and low birth weight (38). At variance with this finding, a positive family history for diabetes was similar in all groups, regardless of the glucose tolerance state. Therefore, these data do not seem to support the concept that a family history positive for diabetes may predict the development of IGT or type 2 diabetes. However, this observation could be attributable to the fact that all our GI subjects were included in the same group. Indeed, when considered separately, a positive family history for diabetes was present in all diabetic women and in approximately half of those presenting with IGT, making these results similar to those reported in other studies (5,6).

After having defined the factors associated with the development of GI in PCOS, we tried to characterize the phenotype of our cohort. We found that hyperandrogenemia was more severe in PCOS women with GI than in the other groups due to the significantly lower SHBG concentrations and, consequently, the increased free testosterone fraction. It is likely that hyperinsulinemia represents the major contributing factor, as hepatic SHBG synthesis is negatively regulated by insulin (39). In addition, PCOS women with GI were characterized by a higher response of cortisol and androstenedione to ACTH stimulation in comparison with the OB-NGT group and, particularly, the NW-NGT group, suggesting an adrenal hyperresponsiveness in obese PCOS subjects, particularly those with coexisting GI (40). Baseline cortisol levels in both GI and OB-NGT groups were, however, significantly lower than in these groups’ normal-weight counterparts. The lower fasting cortisol levels suggest increased cortisol clearance in obese PCOS women and, therefore, adrenal hyperresponsiveness to ACTH may be viewed as a compensatory mechanism used to maintain normal cortisol levels (41,42). Increased cortisol clearance may be secondary to an increased activity of the 5-reductase (42) and/or of the 11 ß-hydroxysteroid dehydrogenase (41), which convert cortisol to inactive -tetrahydroderivatives and cortisone, respectively, in both the adipose tissue and the liver. As suggested by Rodin et al. (41), increased androgen production, due to compensatory adrenal hyperfunction, may be partly involved in the hyperandrogenic state in PCOS, particularly when obesity is present. Hyperinsulinemia may be partly responsible for this (43). Alternatively, insulin might exert a direct modulation of adrenal steroidogenesis, an idea supported by in vitro studies where insulin administration reinforced the responsiveness of the enzymes involved in the adrenal synthesis to ACTH stimulation (3), and also by in vivo studies performed in PCOS patients showing that the amelioration of insulin resistance and related hyperinsulinemia by insulin sensitizer administration was associated with a decrease of adrenal androgen blood levels (44).

Despite different blood androgen levels among the groups, the hirsutism score was similar, suggesting that hirsutism may depend on the excess androgen per se, rather than on the degree of hyperandrogenemia or on some differences in the peripheral biological action of androgens, which may vary among PCOS women. Surprisingly, however, the frequency of acne was very high in the normal-weight PCOS women but significantly lower in the OB-NGT group and negligible in the GI group, where acne was found in only one patient. This suggests that acne in PCOS women may not be related to obesity or to the severity of insulin resistance and may be relatively independent of circulating androgen levels, as suggested by other studies (45). Moreover, the important difference in the frequency of acne despite a low difference in age among the three groups, together with the evidence that the two NGT groups with a similar age had a significant difference in the frequency of acne, make it unlikely that age is a confounding factor in the evaluation of acne in our study.

Conversely, acanthosis nigricans was clearly related to the presence of a mild-to-moderate insulin resistant state, as otherwise expected (46). The fact that oligomenorrhea was significantly more frequent in obese PCOS women, regardless of the subjects’ glucose tolerance state, than in their normal weight counterparts further confirmed the well-known negative impact of obesity and associated more severe insulin resistance and hyperadrogenemia on menstrual cycles in PCOS.

Finally, the finding of a lack of significant difference in energy and macronutrient intake and in physical activity between PCOS subjects with GI versus those with NGT in this study was intriguing. Although the limitations of the low number of patients belonging to each group, particularly the GI and NW-NGT groups, and therefore the low analytical power (P < 0.42) of these parameters must be considered, our data suggest that lifestyle habits are probably not relevant for defining the categories of subjects susceptible to developing GI, at least in those with PCOS. On the other hand, our findings do not exclude the possibility that women with PCOS may have specific alterations of dietary intake, as several other studies seem to suggest (rev. in 47). This latter possibility has not been adequately investigated in well-done epidemiological studies.

In conclusion, this study showed, in a large cohort from the Mediterranean region, that GI states are common in relatively young PCOS women and are associated with the presence of obesity. Moreover, our results clearly indicate that PCOS women with GI are characterized by more severe insulin resistance, insulin hypersecretion, and hyperandrogenemia. Other than a positive history for diabetes, lower birth weight and early menarche appear to be important factors associated with the development of GI later in life. This may be relevant from the clinical point of view while planning both preventive and therapeutic strategies.

	ACKNOWLEDGMENTS

 
The study was supported by a grant, "Ricerca Fondamentale Orientata ex quota 60%," from the University of Bologna.

We thank Susan West for reviewing the manuscript for English usage.

Address correspondence and reprint requests to Renato Pasquali, MD, U.O. di Endocrinologia, Dipartimento di Medicina Interna e Gastroenterologia, Policlinico Sant’ Orsola-Malpighi, via Massarenti 9, 40138 Bologna, Italy. E-mail: renato.pasquali{at}unibo.it

Received for publication November 11, 2003 and accepted in revised form June 1, 2004

Abbreviations: DHEA, dehydroepiandrosterone; DHEA-S, DHEA sulfate; GI, glucose intolerance; HOMA, homeostasis model assessment; IGT, impaired glucose tolerance; NGT, normal glucose tolerance; OGTT, oral glucose tolerance test; 17-OHP, 17-hydroxyprogesterone, PCOS, polycystic ovary syndrome; QUICKI, Quantitative Insulin-Sensitivity Check Index; SHBG, sex hormone–binding globulin; WHO, World Health Organization; WHR, waist-to-hip ratio

	REFERENCES

TOP ABSTRACT RESEARCH DESIGN AND METHODS RESULTS DISCUSSION REFERENCES

 

1. Franks S: Polycystic ovary syndrome. N Engl J Med333 :853 –861,1995[Free Full Text]
2. Knochenhauer ES, Key TJ, Kahsar-Miller M, Waggoner W, Boots LR, Azziz R: Prevalence of the polycystic ovary syndrome in unselected black and white women of the southwestern United States: a prospective study. J Clin Endocrinol Metab83 :3078 –3082,1998[Abstract/Free Full Text]
3. Gambineri A, Pelusi C, Vicennati V, Pagotto U, Pasquali R: Obesity and the polycystic ovary syndrome. Int J Obes Relat Metab Disord26 :883 –896,2002[Medline]
4. Legro RS, Kunselman AR, Dodson WC, Dunaif A: Prevalence and predictions of the risk of type 2 diabetes mellitus and impaired glucose tolerance in polycystic ovary syndrome: a prospective, controlled study in 254 affected women. J Clin Endocrinol Metab84 :165 –169,1999[Abstract/Free Full Text]
5. Ehrmann DA, Barnes RB, Rosenfield RL, Cavaghan MK, Imperial J: Prevalence of impaired glucose tolerance and diabetes in women with polycystic ovary syndrome. Diabetes Care22 :141 –146,1999[Abstract/Free Full Text]
6. 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 Obstet75 :177 –184,2001[Medline]
7. Dunaif A: Insulin resistance and polycystic ovary syndrome: mechanism and implication for pathogenesis. Endocr Rev18 :774 –800,1997[Abstract/Free Full Text]
8. Conn JJ, Jacobs HS, Conway GS: The prevalence of polycystic ovaries in women with type 2 diabetes mellitus. Clin Endocrinol (Oxf)52 :81 –86,2000[Medline]
9. Holte J, Gennarelli G, Wide L, Lithell H, Berne C: High prevalence of polycystic ovaries and associated clinical, endocrine, and metabolic features in women with previous gestational diabetes mellitus. J Clin Endocrinol Metab83 :1143 –1150,1998[Abstract/Free Full Text]
10. De Fronzo RA, Ferrannini E: Insulin resistance: a multifaceted syndrome responsible for NIDDM, obesity, hypertension, dyslipidemia, and atherosclerotic cardiovascular disease. Diabetes Care14 :173 –194,1991[Abstract]
11. Warram JH, Martin BC, Krolewski AS, Soeldner JS, Kahn CR: Slow glucose removal rate and hyperinsulinemia precede the development of type II diabetes in the offspring of diabetic parents. Ann Intern Med113 :909 –915,1990
12. Lillioja S, Mott D, Spraul M, Ferraro R, Foley JE, Ravussin E, Knowler WC, Bennett PH, Bogardus C: Insulin resistance and insulin secretory dysfunction as precursors of non-insulin-dependent diabetes mellitus. N Engl J Med329 :1988 –1992,1993[Abstract/Free Full Text]
13. Dunaif A, Segal KR, Futterweit W, Dobrjansky A: Profound peripheral insulin-resistance, independent of obesity, in polycystic ovary syndrome. Diabetes38 :1165 –1174,1989[Abstract]
14. Ehrmann DA, Sturis J, Byrne MM, Karrison T, Rosenfield RL, Polonsky KS: Insulin secretory defects in polycystic ovary syndrome: relationship to insulin sensitivity and family history of non-insulin-dependent diabetes mellitus. J Clin Invest96 :520 –527,1995
15. Dunaif A, Finegood DT: Beta-cell dysfunction independent of obesity and glucose intolerance in the polycystic ovary syndrome. J Clin Endocrinol Metab81 :942 –947,1996[Abstract]
16. Colilla S, Cox NJ, Ehrmann DA: Heritability of insulin secretion and insulin action in women with polycystic ovary syndrome and their first degree relatives. J Clin Endocrinol Metab86 :2027 –2031,2001[Abstract/Free Full Text]
17. Pache TD, Wladimiroff JW, Hop WC, Fauser BC: How to discriminate between normal and polycystic ovaries: transregional U.S. study. Radiol183 :421 –423,1992
18. Pasquali R, Gambineri A, Biscotti D, Vicennati V, Gagliardi L, Colitta D, Fiorini S, Cognini GE, Filicori M, Morselli-Labate AM: Effect of long-term treatment with metformin added to hypocaloric diet on body composition, fat distribution, and androgen and insulin levels in abdominally obese women with and without the polycystic ovary syndrome. J Clin Endocrinol Metab85 :2767 –2774,2000[Abstract/Free Full Text]
19. Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care20 :1183 –1197,1997[Medline]
20. World Health Organization: Measuring Obesity-Classification and Description of Anthropometric Data. Copenhagen, World Health Org.,1988 (Eur/ICP/NUT 125-0612v)
21. World Health Organization: Obesity: Preventing and Managing the Global Epidemic. Report of a WHO Consultation on Obesity. Geneva, World Health Org.,1997 (Tech. Rep. Ser., no. 894)
22. Ferriman D, Gallwey JD: Clinical assessment of body hair growth in women. J Clin Endocrinol Metab21 :1440 –1447,1961
23. Nestler JE, Jakubowicz DJ, Evans WS, Pasquali R: Effects of metformin on spontaneous and clomiphene-induced ovulation in the polycystic ovary syndrome. N Engl J Med338 :1876 –1880,1998[Abstract/Free Full Text]
24. Pochi PE, Shalita AR, Strauss JS, Webster SB, Cunliffe WJ, Katz HI, Kligman AM, Leyden JJ, Lookingbill DP, Plewig G, et al: Report of the consensus conference on acne classification, Washington DC, March 24 and 25,1990 . J Am Acad Dermatol24 :495 –500, 1991[Medline]
25. Rogers DL: Acanthosis nigricans. Semin Dermatol10 :160 –163,1991[Medline]
26. Baecke JAH, Burema J, Frijters JER: A short questionnaire for the measurement of habitual physical activity in epidemiological studies. Am J Clin Nutr36 :939 –942,1982
27. Pasquali R, Gambineri A, Anconetani B, Vicennati V, Colitta D, Caramelli E, Casimirri F, Morselli-Labate AM: The natural history of the metabolic syndrome in young women with the polycystic ovary syndrome and the effect of long-term oestrogen-progestagen treatment. Clin Endocrinol (Oxf)50 :517 –527,1999[Medline]
28. Vicennati V, Pasquali R: Abnormalities of the hypothalamic-pituitary-adrenal axis in nondepressed women with abdominal obesity and relations with insulin resistance: evidence for a central and peripheral alteration. J Clin Endocrinol Metab85 :4093 –4098,2000[Abstract/Free Full Text]
29. Vermeulen A, Verdonck L, Kaufman JM: A critical evaluation of simple methods for the estimation of free testosterone in serum. J Clin Endocrinol Metab84 :3666 –3672,1999[Abstract/Free Full Text]
30. Mather KJ, Hunt AE, Steinberg HO, Paradisi G, Hook G, Kats A, Quon MJ, Baron AD: Repeatability characteristic of simple indices of insulin resistance: implications for research applications. J Clin Endocrinol Metab86 :5457 –5464,2001[Abstract/Free Full Text]
31. Matusda M, De Fronzo RA: Insulin sensitivity indices obtained from oral glucose tolerance testing. Diabetes Care22 :1462 –1470,1999[Abstract/Free Full Text]
32. SPSS/PC+: Base System User’s Guide. Version 5.0. Chicago, IL, SPSS,1992
33. Harris MI, Hadden WC, Knowler WC, Bennett PH: Prevalence of diabetes and impaired glucose tolerance and plasma glucose levels in U.S. population aged 20–74 yr. Diabetes36 :523 –534,1987[Abstract]
34. Norman RJ, Masters L, Milner CR, Wang JX, Davies MJ: Relative risk of conversion from normoglycaemia to impaired glucose tolerance or non-insulin dependent diabetes mellitus in polycystic ovarian syndrome. Hum Reprod16 :1995 –1998,2001[Abstract/Free Full Text]
35. Legro RS: Diabetes prevalence and risk factors in polycystic ovary syndrome. Obstet Gynecol Clin North Am28 :99 –109,2001[Medline]
36. Bergman RN, Phillips LS, Cobelli C: Physiologic evaluation of factors controlling glucose tolerance in man: measurement of insulin sensitivity and ß-cell glucose sensitivity from the response to intravenous glucose. J Clin Invest68 :1456 –1467,1981
37. Phillips DI, Barker DJ, Hales CN, Hirst S, Osmond C: Thinness at birth and insulin resistance in adult life. Diabetologia37 :150 –154,1994[Medline]
38. Ibanez L, Potau N, Francois I, de Zegher F: Precocious pubarche, hyperinsulinism, and ovarian hyperandrogenism in girls: relation to reduced fetal growth. J Clin Endocrinol Metab83 :3558 –3562,1998[Abstract/Free Full Text]
39. Plymate SR, Matej LA, Jones RE, Friedl KE: Inhibition of sex hormone-binding globulin production in the human hepathoma (HepG2) cell line by insulin and prolactin. J Clin Endocrinol Metab67 :460 –464,1988[Abstract]
40. Moran C, Knochenhauer E, Boots LR, Azziz R: Adrenal androgen excess in hyperandrogenism: relation to age and body mass. Fertil Steril71 :671 –674,1999[Medline]
41. Rodin A, Thakkar H, Taylor N, Clayton R: Hyperandrogenism in polycystic ovary syndrome: evidence of dysregulation of 11 ß-hydroxysteroid dehydrogenase. N Engl J Med330 :460 –465,1994[Abstract/Free Full Text]
42. Rodin A, Stewart PM, Shackleton CHL, Beastall GM, Edwards CRW: 5-Reductase activity in polycystic ovary syndrome. Lancet335 :431 –433,1990[Medline]
43. Stewart PM, Boulton A, Kumar S, Clark PM, Shackleton CH: Cortisol metabolism in human obesity: impaired cortisone–>cortisol conversion in subjects with central adiposity. J Clin Endocrinol Metab84 :1022 –1027,1999[Abstract/Free Full Text]
44. Azziz R, Hermann DA, Legro RS, Fereshetian AG, O’ Keefe M, Ghazzi MN, PCOS/Troglitazone Study Group: Troglitazone decreases adrenal androgen levels in women with polycystic ovary syndrome. Fertil Steril79 :932 –937,2003[Medline]
45. Shaw JC: Acne: effect of hormones on pathogenesis and management. Am J Clin Dermatol3 :571 –578,2002[Medline]
46. Pugeat M, Ducluean PH, Mallion-Donadieu M: Association of insulin resistance with hyperandrogenemia in women. Horm Res54 :322 –326,2000[Medline]
47. Pasquali R, Gambineri A: Treatment of the polycystic ovary syndrome with lifestyle intervention. Curr Opin Endocrinol Diab9 :459 –468,2002

CiteULike

Del.icio.us

Digg

Reddit

Technorati

This article has been cited by other articles:

				D. M. Sloboda, R. Hart, D. A. Doherty, C. E. Pennell, and M. Hickey Age at Menarche: Influences of Prenatal and Postnatal Growth J. Clin. Endocrinol. Metab., January 1, 2007; 92(1): 46 - 50. [Abstract] [Full Text] [PDF]

				R. Azziz, E. Carmina, D. Dewailly, E. Diamanti-Kandarakis, H. F. Escobar-Morreale, W. Futterweit, O. E. Janssen, R. S. Legro, R. J. Norman, A. E. Taylor, et al. Criteria for Defining Polycystic Ovary Syndrome as a Predominantly Hyperandrogenic Syndrome: An Androgen Excess Society Guideline J. Clin. Endocrinol. Metab., November 1, 2006; 91(11): 4237 - 4245. [Abstract] [Full Text] [PDF]

				R. Pasquali and A. Gambineri Insulin-sensitizing agents in polycystic ovary syndrome. Eur. J. Endocrinol., June 1, 2006; 154(6): 763 - 775. [Abstract] [Full Text] [PDF]

				A. Gambineri, V. Vicennati, S. Genghini, F. Tomassoni, U. Pagotto, R. Pasquali, and B. R. Walker Genetic Variation in 11{beta}-Hydroxysteroid Dehydrogenase Type 1 Predicts Adrenal Hyperandrogenism among Lean Women with Polycystic Ovary Syndrome J. Clin. Endocrinol. Metab., June 1, 2006; 91(6): 2295 - 2302. [Abstract] [Full Text] [PDF]

				E. L. Ding, Y. Song, V. S. Malik, and S. Liu Sex Differences of Endogenous Sex Hormones and Risk of Type 2 Diabetes: A Systematic Review and Meta-analysis JAMA, March 15, 2006; 295(11): 1288 - 1299. [Abstract] [Full Text] [PDF]

				M. Mohlig, J. Spranger, M. Ristow, A. F H Pfeiffer, T. Schill, H. W Schlosser, L. Moltz, G. Brabant, and C. Schofl Predictors of abnormal glucose metabolism in women with polycystic ovary syndrome Eur. J. Endocrinol., February 1, 2006; 154(2): 295 - 301. [Abstract] [Full Text] [PDF]

				E Carmina, N Napoli, R A Longo, G B Rini, and R A Lobo Metabolic syndrome in polycystic ovary syndrome (PCOS): lower prevalence in southern Italy than in the USA and the influence of criteria for the diagnosis of PCOS Eur. J. Endocrinol., January 1, 2006; 154(1): 141 - 145. [Abstract] [Full Text] [PDF]

				M.A. Checa, A. Requena, C. Salvador, R. Tur, J. Callejo, J.J. Espinos, F. Fabregues, J. Herrero, and (Reproductive Endocrinology Interest Group of the Insulin-sensitizing agents: use in pregnancy and as therapy in polycystic ovary syndrome Hum. Reprod. Update, July 1, 2005; 11(4): 375 - 390. [Abstract] [Full Text] [PDF]

				J. Vrbikova and D. Cibula Combined oral contraceptives in the treatment of polycystic ovary syndrome Hum. Reprod. Update, May 1, 2005; 11(3): 277 - 291. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Gambineri, A. Articles by Pasquali, R. Search for Related Content PubMed PubMed Citation Articles by Gambineri, A. Articles by Pasquali, R. Social Bookmarking                What's this?