7Cut-off Values for the Most Commonly Used Ovarian Reserve Tests
8Assessment of ovarian reserve with anti-Müllerian hormone: a comparison of the predictive value of anti-Müllerian hormone, follicle-stimulating hormone, inhibin B, and ageOBJECTIVE: The objective of this study was to evaluate basal anti-STUDY DESIGN: Frozen basal menstrual cycle day 3 serum samplestreatment.Müllerian hormone as a marker for ovarian responsiveness to fertilitywere evaluated retrospectively for anti-Müllerian hormone, inhibin B,RESULTS: Anti-Müllerian hormone values correlated the best with the(93 patients) and compared with in vitro fertilization records.and follicle-stimulating hormone levels in 123 in vitro fertilization cycles.01), inhibin B (P .05), luteinizing hormone (P .05), and estradiol0.323; P .01), follicle-stimulating hormone (r ; Pnumber of retrieved oocytes (r ; P .001) relative to age (r(r0.190; P .05). Receiver operating characteristic curve analysis0.81; P ) relative to age (r 0.74; P .005), follicle-stimulatinganti-Müllerian hormone had the largest area under the curve (AUCdemonstrated that, for the prediction of 4 oocytes retrieved,oocytes, anti-Müllerian hormone had the largest area under the curve(0.54; P .05). Similarly, for the prediction of 15 retrievedhormone (0.71; P .02), inhibin B (0.66; P .03), and estradiol(0.80; P ) relative to age (0.63; P .02), follicle-stimulatingCONCLUSION: Anti-Müllerian hormone correlates better than age, follicle-(0.58; P .05).hormone (0.64; P .005), inhibin B (r 0.57; P .05), and estradiolcurves estimated that anti-Müllerian hormone accuratelywith the number of retrieved oocytes. Receiver operating characteristicstimulating hormone, luteinizing hormone, inhibin B, and estradiolhigh sensitivity and specificity.predicts ovarian responsiveness to controlled ovarian stimulation withRyan M. Riggs, 2008
9Over rezervini belirleme endikasyonları İleri kadın yaşı (>35 yaş ?)Geçirilmiş over cerrahisiTek overAçıklanamayan infertiliteSigara kullanımıDaha evvelki tedavilerde başarısızlıkAilede erken menopoz hikayesiKemoterapi, radyoterapiEvre III-IV endometriozisHERKESE
10POLYCYSTIC OVARY SYNDROME (PCOS) Sixty-five to 85% of all women with androgen excess are diagnosed as having PCOSThe findings in PCOS are variable, with 40% to 60% of patients obese, 60% to 90% hirsute, 50% to 90% oligoamenorrheic, and 55% to 75% infertile.
11The Hypothalamic–Pituitary–Ovarian Axis and the Role of Insulin. Increased ovarian androgen biosynthesis in the polycystic ovary syndrome results from abnormalities at all levels of the hypothalamic–pituitary–ovarian axis. The increased frequency of luteinizing hormone (LH) pulses in the polycystic ovary syndrome appears to result from anincreased frequency of hypothalamic gonadotropin-releasing hormone (GnRH) pulses. The latter can result from an intrinsic abnormality inthe hypothalamic GnRH pulse generator, favoring the production of luteinizing hormone over follicle-stimulating hormone (FSH) in patientswith the polycystic ovary syndrome, in whom the administration of progesterone can restrain the rapid pulse frequency. By whatever mechanism,the relative increase in pituitary secretion of luteinizing hormone leads to an increase in androgen production by ovarian theca cells. Increasedefficiency in the conversion of androgenic precursors in theca cells leads to enhanced production of androstenedione, which is thenconverted by 17b-hydroxysteroid dehydrogenase (17) to form testosterone or aromatized by the aromatase enzyme to form estrone. Withinthe granulosa cell, estrone is then converted into estradiol by 17. Numerous autocrine, paracrine, and endocrine factors modulate the effectsof both luteinizing hormone and insulin on the androgen production of theca cells; insulin acts synergistically with luteinizing hormoneto enhance androgen production. Insulin also inhibits hepatic synthesis of sex hormone–binding globulin, the key circulating protein thatbinds to testosterone and thus increases the proportion of testosterone that circulates in the unbound, biologically available, or “free,” state.Testosterone inhibits and estrogen stimulates hepatic synthesis of sex hormone–binding globulin. The abbreviation scc denotes side-chaincleavage enzyme, StAR steroidogenic acute regulatory protein, and 3-HSD 3-hydroxysteroid dehydrogenase. Solid arrows denote a higherdegree of stimulation than dashed arrows.David A. Ehrmann, 2005
13Criteria for the diagnosis of polycystic ovary syndrome (PCOS)
14Oligo- or anovulation: Ovulation occurs less than once every 35 days. Hyperandrogenism: Clinical signs include hirsutism, acne, alopecia (male-pattern balding) and frank virilization. Biochemical indicators include raised concentrations of total testosterone and androstendione, and an elevated free androgen index that entails the measurement of total testosterone and sex hormone binding globulin (SHBG). However, the measurement of these biochemical markers for hyperandrogenism has proved markedly inconsistent due to problems with various assays.Polycystic ovaries: The presence of 12 or more follicles in either ovary measuring 2–9 mm in diameter and/or increased ovarian volume (>10 mL).
17Endocrine and metabolic differences among phenotypic expressions of polycystic ovary syndrome according to the 2003 Rotterdam consensus criteriaOBJECTIVE: The Rotterdam criteria extend the phenotypic spectrum ofpolycystic ovary syndrome (PCOS). We characterized endocrine andmetabolic differences among women meeting the National Institutes ofHealth (NIH) definition for PCOS vs two novel phenotypes establishedby the European Society of Human Reproduction and Embryology/American Society for Reproductive Medicine definition.STUDY DESIGN: Endocrine and metabolic data from a retrospectiveanalysis of 160 age- and weight-matched women with PCOS and 23controls were compared. Insulin sensitivity indices were correlatedwith androgens, gonadotropins, and lipids within each phenotype.RESULTS: Ovarian and adrenal androgens were highest in the NIHdefinedPCOS group, lowest in the nonhyperandrogenic PCOSgroup, and intermediate in the hyperandrogenic ovulatory PCOSpopulation. Insulin sensitivity indices, gonadotropins, and lipidswere similar across all PCOS phenotypes. The magnitude of insulinresistance correlated with free testosterone only in the NIH-definedgroup.CONCLUSION: Androgen levels are the major distinguishing endocrinefeature differentiating phenotypic expressions of PCOS. Hyperinsulinemiacorrelates with free testosterone levels only in traditional NIHdefinedwomen with PCOS.In summary, the data presented suggestthat androgen production and secretionis the most prominent endocrineand metabolic factor differentiating phenotypicexpressions of PCOS. In addition,insulin appears to play a moreprominent role in ovarian androgenproduction in the NIH phenotype(HA/OD with or without PCO) than inthe other subpopulations of PCOS patients.From an endocrine and metabolicstandpoint, the OD/PCO phenotype isthe mildest expression of the PCOSspectrum.Robert P. Kauffman, 2008
19Suggested diagnostic evaluation for PCOS In women with oligomenorrhea, in addition to measurement of serum hCG to rule out pregnancy, minimal laboratory testing should include measurements of serum prolactin, thyrotropin, and FSH to rule out hyperprolactinemia, thyroid disease, and ovarian failure, respectively. (See "Etiology, diagnosis, and treatment of secondary amenorrhea", section on Diagnosis).We do not routinely measure serum androgen concentrations in women with mild hirsutism. However, in women with moderate-to-severe hirsutism, we typically measure a total testosterone concentration, and if there are concerns about a possible androgen-secreting tumor causing the hyperandrogenism, we add serum dehydroepiandrosterone sulfate (DHEA-S). (See "Etiology, diagnosis, and treatment of secondary amenorrhea" and see "Evaluation of women with hirsutism").Approximately 45 percent of women with PCOS have IGT or type 2 diabetes. A fasting glucose measurement is a less sensitive test for diagnosing IGT and diabetes in women with PCOS. (See "Clinical manifestations of polycystic ovary syndrome in adults", section on Risk of type 2 diabetes).Once the diagnosis of PCOS is made, we perform an OGTT in all patients. When this is not practical, a fasting glucose along with a hemoglobin A1C can be obtained. If either one is abnormal, an OGTT should be performed to distinguish between IGT and diabetes.Given the high prevalence of lipid abnormalities in PCOS, we suggest measuring a fasting lipid profile in all women with the disorder.An elevation in free testosterone is the most sensitive test to establish the presence of hyperandrogenemia. This is because elevated insulin levels (a frequent concomitant of PCOS) and elevated androgen levels both act to inhibit hepatic production of sex hormone-binding globulin (SHBG) . However, commercially available free testosterone assays are often unreliableOther biochemical findings that are often, but not universally present, may include elevation of serum luteinizing hormone (LH) concentrations, normal serum estradiol, and increased serum estrone concentrations. None of these hormones are part of the diagnostic criteria for PCOS and therefore, do not need to be measured.Richard S. Legro, 2007
20Ovarian hyperthecosis COC ile yanıt alınamayan olgularCC ile başarısız indüksiyonlu hiperandrojenik olgularVirilizm ile birlikte olan olgularİnsülin rezistansı, AN gibi metabolik semptom veren olgularda,LH ve FSH düzeyleri normal ya da düşüktürSerum T düzeyleri tümör sınırlarındadırOvarian hyperthecosis
21ANDROJENLER Testosteron %50 periferik dönüşüm %50 over ve adrenal %80 SHBG, %19 albumine%1 serbest (kadınlarda)DHTEn güçlüT,AD DHTAndrostenodiol glukuronid
22ANDROJENLER DHEAS,DHEA Zayıf Adrenal kaynaklı Gebelikte E3 prekürsörü Puberte başında pubik kıllanmadiğer androjenlerin prekürsörü ADAktif değilOver, adrenal kaynaklıT,DHT’ye dönüşür
23S H B G azaltanlar artıranlar Obesite Androjen fazlalığı KortikosteroidHipotiroidismCushing sendromuAkromegaliKaraciğer hast.ProgestogenHiperinsülinemiÖstrojen fazlalığıOral kontraseptiflerGebelikHipertiroidism
25Which androgen to measure? Free T or free T index were felt to be most sensitive methods of hyperandrogenemiaMeasurement of total T only may not be a sensitive marker of AEA fraction of patients may have DHEAS elevationRoutine assessment of androstenedione is not recommendedESHRE/ASRM Consensus 2003
26Factors that are known to alter serum testosterone concentrations Physiological factorsPulsatile release during the dayDiurnal rhythm: am > pmMenstrual cycle: luteal > follicularSeason (no variation in total testosterone free testosterone shows 30% difference): summer > winterAge (years) in women with and without polycystic ovary syndrome (PCOS): 20s > 40sAnalytical factorsCross reactivity with other endogenous steroidsInterference by endogenous antibodiesPoor performance in the female range: < 8 nmol/lTT concentrations in plasma vary over 3 orders of magnitude depending on age, gender, and the presence of disease.Only 1–3% of T is not bound to plasma proteins, raising questions about whether TT or free T (FT) is the most clinically useful measure.Age- and gender-corrected normal ranges, using a standardized assay, are generally lacking.There is no universally recognized T-calibrating standard.
27Causes of hirsutism. • Polycystic ovary syndrome • Idiopathic • Late-onset congenital adrenal hyperplasia• Cushing's syndrome° Cushing's disease (ACTH-secreting pituitary tumour)° Ectopic ACTH secretion by non-pituitary tumour (bronchus Table, thyroid)° Autonomous cortisol secretion by adrenal or ovarian tumour° Ectopic corticotrophin secretion by tumour (very rare)• Androgen-secreting tumours of the ovary° Sex-cord stromal cell tumours° Adrenal-like tumours of the ovary• Androgen-secreting tumours of the adrenal° Adenomas° Adenocarcinomas• Iatrogenic° Testosterone° Danazol° Glucocorticoids
28Androgen Excess in Women: Experience with Over 1000 Consecutive Patients R. AZZIZ, 2004
29Akantozis NigricansAcanthosis nigricans and hirsutism in a 29-year-old patient with polycystic ovarySyndromeAcanthosis nigricans and skin tags in a 37-year-old Hispanic woman with polycysticovary syndrome.Acanthosis nigricans, a velvety, hyperpigmentation in skin creases arising from the mitogenic action of insulin on the basal cells of the epidermis, is found in the vast majority of these patientsSome patients with PCOS also demonstrate acanthosis nigricans.However, it is important that this syndrome not be confused with PCOS and its milder degree of insulin resistance, since patients with the HAIRAN syndrome tend to have a greater degree of associated morbidity, including NIDDM, hypertension, and CVDandrogen-secretingneoplasmPatients with the HAIRAN syndrome will generally have basal insulin greater than 80 U/mL if fasting, or above 500 U/mL, after glucose administration
30Hyperthecosispreviously considered hyperthecosis to be a variant of PCOS, it should be noted that the term hyperthecosis simply refers to the histopathologic finding of islands of hyperplastic theca cells located between collections of small atretic follicles (i.e., “cysts”).Most women with hyperthecosis demonstrate high circulating androgen levels, and consequently lower circulating LH and FSH levels (4–8 mIU/mL)Androgen-secreting tumor.Over stromasında luteinize teka hücrelerinin bulunmasıdır.Uzun süreli anovülasyon ve amenore.Yavaş fakat giderek artan virilizasyon.T tümör düzeyinde, DHEAS normal.LH/FSH=1/1HAİR-AN sık görülür.Tanı histolojik olarak konur.Fertilizasyon şansı çok azdır.
31Non-Classic Adrenal Hyperplasia (NCAH) 1% to 5% of hyperandrogenic women are deficient in the activity of adrenal enzymes, particularly 21-hydroxylase (21-OHase)autosomal recessive17-hydroxyprogesterone (17-HP)hirsutism, acne, and oligo- and/or amenorrhea
32ACTH Stimülasyon Testi AD 3-7 günleriSabah saat0.25 mg sentetik ACTH (Cortrosyn) IV* IM yapılmamalıBaşlangıçta ve 1 saat sonra kan
34Cushing Syndromeadrenal neoplasm, ectopic ACTH-producing tumor, or pituitary tumor/Cushing diseasecentripetal fat distribution, thinning of the skin with striae, glucose intolerance, osteoporosis, and proximal muscle weaknessmenstrual irregularitiesCushing syndrome is clinically suspected, adrenal corticoid hyperfunction may be ruled out by oral dexamethasone, 1 mg at 11:00 PM, measuring cortisol at 8:00 AM the following morning. The normal response is a level of less than 5 g/dL.Alternatively, a 24-hour free urinary cortisol can be measured and should be less than 100 g/24 hours.If these measures are elevated, a low-dose suppression (2 mg/ day dexamethasonex two days) should be performed and, if abnormal, the diagnosis of hypercortisolemia (Cushing syndrome) is confirmed.
35Androgenic Tumors ovary or adrenal onset of hyperandrogenism is sudden, and when progression is rapid, or when frank virilization is presentVirilizing ovarian tumors, including Sertoli-Leydig cell and lipoid cell tumors, generally exhibit low malignancy potentialIn young women the possibility of an androgen-secreting tumour should be considered with the following:serum testosterone values above 150 ng/dl ;serum-free testosterone values above 2 ng/dl ;serum dehydroepiandrosterone sulphate values above 700 µg per dlIt should be recognized that 20% and 10% of androgen-producing ovarian and adrenal tumors, respectively, may have testosterone levels below this valueAndrogen-producing tumors can be suspected when the circulating testosterone is persistently greater than 200 ng/dL (HAIRAN syndrome, hyperthecosis, or polycystic ovary syndrome)Adrenal tumors can be suspected when the circulating DHEAS level is persistently greater than 7,000 ng/mL
37“Idiopathic” Hirsutism Approximately 15% to 30% of hirsute women do not have ovulatory abnormalities and usually have normal levels of circulating androgensIn many of these patients, skin 5-reductase activity is excessive, leading to higher skin concentrations of the active androgen dihydrotestosteroneIt is important to note that approximately 40% of hirsute women claiming to have “regular menstrual cycles” are actually oligo-ovulatory when evaluated more carefully
38HirsutismThe Endocrine Society Clinical Practice Guidelines recommend biochemical testing in women with moderate or severe hirsutism, or hirsutism of any degree if it is sudden in onset and rapidly progressive, or associated with irregular menses, obesity, or evidence of virilization (clitoromegaly) The Guidelines suggest first measuring an early morning total testosterone concentration. Although a free testosterone concentration is a more sensitive indicator of androgen excess, most available assays are inaccurateAnother approach that many clinicians use, is initial measurement of serum testosterone, prolactin, and DHEA-S, followed by additional testing when indicatedMartin, KA, Chang, RJ, Ehrmann, DA, et al. Evaluation and treatment of hirsutism in premenopausal women: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2008; 93:1105Martin KA, 2008
42PRL hormon biosenteziOrijinal matür PRL RNA sı 227 AA den oluşan sekansı kodlarÜretim sonrası molekül şu etkilere maruz kalır :DegradasyonPolimerizasyonGlikozilasyon (PRL etkinliğinin devamında gereklidir)FosforilasyonBu etkiler sonucu oluşan moleküllerin bioaktiviteleri farklıdırPolimerizasyon oranında bioaktivite düşer (MakroPRL)Monomerik % 80-90Dimerik % 8-20Polimerik % 1-5
43MacroprolactinPRL may form immune complexes, generally with an immunoglobulin G antibody, to produce a biologically inactive form called ‘macroprolactin’, which has a molecular mass of more than 150 kDa. This is registered by most PRL immunoassays and hence serum PRL levels are reported to be high. Since misdiagnosis of hyperprolactinaemia due to the presence of macroprolactin may lead to patient mismanagement, this possibility should be considered in cases with no apparent hyperprolactinaemic symptoms.Polyethylene glycol precipitation is the method of choice to confirm macroprolactinaemia, which in itself has no clinical significance, although it should be remembered that genuine pituitary pathology may co-exist in nearly 5% of such cases.Two causes of hyperprolactinemia due to decreased clearance of prolactin include chronic renal failure (discussed above) and big prolactin. The most common form of prolactin in serum is 23 kD in size and is not glycosylated, but a small amount of a 25 kD glycosylated form can also be detected. In rare cases, glycosylated prolactin, which appears to circulate in aggregates, accounts for most of the prolactin . In this situation the prolactin has been called "big prolactin" and the condition referred to as "macroprolactinemia." The elevated serum prolactin concentration in these patients can be distinguished from hyperprolactinemia of other causes by gel filtration or polyethylene glycol precipitation . In one series of 1106 patients with hyperprolactinemia, approximately 10 percent had macroprolactinemia .The clinical manifestations of macroprolactinemia were described in a series of 55 women ages 18 to 55. None had a history of amenorrhea, eight had oligomenorrhea before age 40, and one had galactorrhea . All subjects had pituitary imaging; no macroadenomas and four microadenomas were seen (consistent with the prevalence of incidentalomas in the normal population). Similar results were seen in a second study of 51 patients . Thus, macroprolactinemia appears to be a benign clinical condition .Equally rare is a raised serum prolactin level due to complexing of normal-sized prolactin with circulating prolactin antibodies . In this situation, the free prolactin concentration is normal and causes no biologic abnormalities.These entities are not of clinical significance directly, but are of clinical significance in an indirect way, because they can be misdiagnosed, and treated, as ordinary hyperprolactinemia . Misdiagnosis can be avoided by asking the laboratory to pretreat the serum with polyethylene glycol to precipitate the macroprolactin before the immunoassay for prolactin.
44James Gibney, 2005 Table 1 summarizes the reported prevalence of macroprolactinaemia in studies in whichall hyperprolactinaemic samples were screened for macroprolactin.
45HiperprolaktinemiPRL ölçümleri stressiz bir zamanda, sabah aç olarak yapılmalıdırTestten hemen önce:Göğüs muayenesiKoitusPelvik muayeneEgzersiz yapılmamalıÇok yüksek PRL düzeyleri immunoassay de yanlış negatif sonuç verebileceği için (hook effect – kanca etkisi) makroadenom takiplerinde 1/100 dilüsyon ile PRL ikinci kez tekrar edilmelidirFizyolojik serum prolaktin düzeyleri 50 ng/ml’in altındadır. Serum prolaktin düzeyleri “two site” immünradyometrik assayler (IRMA) ve kemiluminometrik assayler ( ICMA) ile yüksek duyarlılık ve doğruluk ile ölçülmektedir. Fakat çok büyük prolaktinoması ve çok yüksek serum prolaktin düzeyi olan hastalarda, antikorların satürasyonu prolaktin-antikor sandviçinin oluşumuna engel olabilir. Böylece işaretli antikor düzeyi azalacağından serum prolaktin düzeyi yanlış olarak düşük rapor edilebilir. Kanca etkisi ( hook effect) olarak tanımlanan bu yanılmayı ortadan kaldırmak için makroadenomu olan olgularda prolaktin düzeyleri 1/100 dilüe edilmiş serumda tekrar çalışılmalıdır.Caution should be exercised in interpreting serum prolactin concentrations between 20 and 200 ng/mL (20 to 200 mcg/L SI units) in the presence of a macroadenoma, because of possible artefactually low values due to the "hook effect" [13-15]. This effect occurs when a very high serum prolactin, eg, 5000 ng/mL (5000 mcg/L SI units), saturates both the capture and signal antibodies used in immunoradiometric and chemiluminescent assays, preventing the binding of the two in a "sandwich." The result is an apparent prolactin concentration that is only modestly elevated, suggesting that the macroadenoma is clinically nonfunctioning. The artefact can be avoided by repeating the assay using a 1:100 dilution of serum
46Common causes of primary amenorrhea Bachmann G,1982; Reindollar RH, 1986
47The initial useful laboratory tests are FSH, TSH, and Suggested flow diagram aiding in the evaluation of women with amenorrhea.The initial useful laboratory tests are FSH, TSH, andprolactin.The Practice Committee of the American Society for Reproductive Medicine2008
48Common causes of secondary amenorrhea Reindollar RM, 1981
49STRAW reproductive aging system Lengthdecreases-2 days
50Physiology: perimenopause Variable hormone levelsEstrogen and progesterone levels fluctuate erraticallyVery high serum estrogen levels may resultSlight decline in testosterone with ageSantoro et al. J Clin Endocrinol Metab 2000.Burger et al. J Clin Endocrinol Metab 2000.
51Hyperestrogenism in perimenopause Santoro et al. J Clin Endocrinol Metab 1996.
52The Menopausal Transition A Committee Opinion Revised January 2008 In perimenopausal women, estradiol production fluctuates with FSH levels and can reach higher concentrations than those observed in young women under age. Estradiol levels generally do not decrease significantly until late in the MTDespite continuing regular cyclic menstruation, progesterone levels during the early MT are lower than in women of mid-reproductive age and vary inversely with body mass indexTestosterone levels do not vary appreciably during the MTa decrease in secretion of inhibin A and inhibin B, and a corresponding increase in activin production may favor increased FSH secretion in the absence of any decrease (and perhaps an increase) in estradiol production.Diagnosis of the MT is based on clinical signs and symptoms. Although hormonal changes occur during the MT, hormone measurements are not useful for predicting the stage of MT or the final menstrual period.Practice Committee of the AmericanSociety for Reproductive Medicine