Evidence for heterogeneous etiologies of adrenal dysfunction in polycystic ovary syndrome

Objective: To examine the hypothesis that, in polycystic ovary syndrome (PCOS), ovarian steroids induce adrenal enzyme dysfunction or adrenal androgen hyperresponsiveness to ACTH. Design: Prospective controlled clinical study. Setting: Reproductive endocrinology unit of an academic medical center. Patients: Twelve women with PCOS who, had adrenal androgen excess were compared with five weight-matched ovulatory women. In half of the women with PCOS, prestudy screening was suggestive of mild 3 beta-hydroxysteroid dehydrogenase (HSD) deficiency. Interventions: Basal and adrenal dynamic blood sampling before and after GnRH agonist (GnRH-a) administration for 6 months. Main Outcome Measures: Basal E(2) and androgen levels as well as dexamethasone-suppressed. ACTH-stimulated 17 alpha-hydroxyprogesterone, 17 alpha-hydroxypregnenolane, and androgen levels before and after ovarian suppression. Results: Although none of the subjects with PCOS proved to have mild 3 beta-HSD deficiency, the majority of them (58%) met the criteria for 17,20 lyase hyperactivity before and after GnRH-a therapy. As a group, the remaining subjects with PCOS exhibited an elevated DHEAS response to ACTH before GnRH-a treatment, which may have normalized after GnRH-a treatment. Conclusion: Adrenal androgen excess in PCOS may be heterogeneous in etiology, whereas 17,20 lyase hyperactivity appears to be an intrinsic adrenal disorder, adrenal androgen hyperresponsiveness to ACTH mag be ovarian induced. Reliance on historical controls may lead to overdiagnosis of mild 3 beta-HSD deficiency.