Evaluation of serum androgen levels in women with premature ovarian failure

Women with premature ovarian failure (POF) did not show the same androgen profile as postmenopausal women. We observed that serum DHEA and DHEAS levels are significantly higher in women with POF than in postmenopausal women. Women with premature ovarian failure (POF) did not show the same androgen profile as postmenopausal women. We observed that serum DHEA and DHEAS levels are significantly higher in women with POF than in postmenopausal women. Women with premature ovarian failure (POF) may be candidates for androgen replacement (1Davis S. Androgen replacement in women: a commentary.J Clin Endocrinol Metab. 1999; 84: 1886-1891Crossref PubMed Google Scholar). Premature ovarian failure causes serious repercussions in women's lives and should therefore receive individualized attention. It should not be viewed as “premature menopause” nor should women with POF be assessed in the same way as postmenopausal women. The aim of this study was to evaluate the androgen profile of a group of women with POF.A cross-sectional study was performed at the Department of Obstetrics and Gynecology, School of Medicine, Universidade Estadual de Campinas, Brazil. The Institutional Review Board approved the study and all women signed an informed consent form prior to enrollment. The study group consisted of 30 women who had been diagnosed with POF. The inclusion criteria consisted of women aged ≤40 years, who had a spontaneous menarche before age 16, whose last menstrual period had occurred at least 12 months prior to inclusion in the study, who had two serum FSH measurements ≥40 mIU/mL obtained on separate dates, and who had not taken hormonal medication for 3 months or more prior to entering the study.The first control group consisted of 30 regularly menstruating women with cycles of 24 to 35 days, who were paired by age (±1 year) to women diagnosed with POF, as well as by the same category of body mass index (BMI) (kg/m2): BMI <20: underweight; 20–25: normal; 26–30: overweight; >30: obese. The second control group consisted of 30 women who had undergone natural menopause after age 50. They were paired with the POF group according to the number of years of amenorrhea up to the date of inclusion in the study.Exclusion criteria consisted of previous hysterectomy and/or oophorectomy, chronic illnesses, previous radiation or chemotherapy, and previous use of medication that could modify hormone production.In all three groups, serum levels of free testosterone (FT), androstenedione (A), DHEA, DHEAS, and 17-hydroxyprogesterone (17-OHP) were measured. All samples were analyzed by radioimmunoassay (RIA) using commercial kits (Diagnostic Systems Laboratories, Webster, TX). The interassay coefficients of variation were 7.3%–9.7% for FT, 6.0%–9.8% for A, 3.8%–8.6% for DHEA, 4.8%–5.3% for DHEAS, and 3.2%–7.5% for 17-OHP. Testosterone (T) was measured by electrochemiluminescent assay (Elecsys analyzer; Roche, Basel, Switzerland) and the coefficient of variation was 5.6%. Sex hormone binding globulin (SHBG) was measured by time-resolved immunofluorometry (Delfia; Perkins Elmer, Basel, Switzerland), whose interassay coefficient varied from 8.2% to 10.1%. Samples from menstruating women were collected between the 3rd and 9th days of the menstrual cycle. Serum was frozen at −20°C until analysis.Comparisons between the three groups were carried out using analysis of variance (ANOVA), followed by the Tukey test when a significant difference was detected. The Kruskal-Wallis nonparametric test, followed by the Mann-Whitney test when there was a significant difference, was used for data that did not follow a normal distribution. Simple correlation analysis (Pearson) was used to study the association between variables in each group. The level of significance was set at P<.05.The age of women with POF was 34.4 ± 5.2 years (mean ± SD), BMI was 24.7 ± 5.0, and duration of amenorrhea was 5.4 ± 3.8 years. The age of regularly menstruating women was 34.5 ± 5.5 years and their BMI was 24.4 ± 4.6. The age of postmenopausal women was 55.1 ± 3.9 years and duration of amenorrhea was 5.4 ± 3.8 years.Androgen levels in the group of women with POF, in the group of regularly menstruating women, and in the group of postmenopausal women were, respectively (mean ± SD): T (ng/dL): 22.8 ± 10.2, 26.6 ± 12.5, 17.5 ± 7.7; FT (pg/mL): 0.9 ± 0.4, 0.9 ± 0.4, 0.8 ± 0.3; A (ng/mL): 1.3 ± 0.5, 1.6 ± 0.8, 1.0 ± 0.4; DHEAS (ng/mL): 723.7 ± 332.1, 838.4 ± 421.2, 432.5 ± 207.5; DHEA (ng/mL): 6.0 ± 2.8, 7.3 ± 4.5; 3.6 ± 1.9; 17-OHP (ng/mL): 0.9 ± 0.5, 1.0 ± 0.6, 1.0 ± 0.9; SHBG (nmol/L): 64.1 ± 37.9, 67.0 ± 30.2, 58.1 ± 26.6; SHBG/T: 3.58 ± 3.08, 3.17 ± 2.32, 6.00 ± 8.91.T and A levels were significantly higher in regularly menstruating women than in postmenopausal women (P=.0055 and P=.0007, respectively); however, there were no statistically significant differences between POF and the 2 control groups. The levels of DHEAS and DHEA were significantly higher (P=.00001 and P=.0001, respectively) in the POF group and in the group of regularly menstruating women compared to the postmenopausal group. No differences were observed between the groups when comparing the levels of the other androgens (FT, 17-OHP) or in the SHBG and SHBG/T ratio (Table 1).TABLE 1Mean values of measurements performed in groups of women with POF, regularly menstruating women, and postmenopausal women (n = 30 in each group).Women with POFRegularly menstruating womenPostmenopausal womenP valueMeanSDMeanSDMeanSDT (ng/dL)22.810.226.6aSignificant difference between groups.12.617.5aSignificant difference between groups.7.7.0055FT (pg/mL)0.90.40.90.40.80.3NSA (ng/mL)1.30.51.6aSignificant difference between groups.0.81.0aSignificant difference between groups.0.4.0007DHEAS (ng/mL)723.7bSignificant difference between groups.332.1838.4aSignificant difference between groups.421.2432.5aSignificant difference between groups.,bSignificant difference between groups.207.5.00001DHEA (ng/mL)6.0bSignificant difference between groups.2.87.3aSignificant difference between groups.4.53.6aSignificant difference between groups.,bSignificant difference between groups.1.9.000117-OHP (ng/mL)0.90.51.00.61.00.9NSSHBG (nmol/L)64.137.967.030.258.126.6NSSHBG/T3.583.083.172.326.008.91NSNote: NS = not significant.a Significant difference between groups.b Significant difference between groups. Open table in a new tab In the simple correlation analysis (Pearson) between the variables studied, in the POF group an inverse correlation was observed between the duration of amenorrhea and the levels of DHEA (R = −0.38; P=.036) and 17-OHP (R = −0.46; P=.01). Levels of 17-OHP and DHEA in these women decreased as the length of time that had elapsed since gonadal failure increased. In addition, an inverse correlation between BMI and SHBG levels (R = −0.58; P=.001) was observed (data not shown).When the groups in which age was a differentiating factor were analyzed together, the correlation analysis showed that among women in the POF and postmenopausal groups, age was a significant variable that influenced DHEA (R = −0.59; P<.001) and DHEAS (R = −0.53; P<.001). When the group of regularly menstruating women was analyzed together with the group of postmenopausal women, age was significantly associated with decrease in DHEA (R = −0.45; P<.001) and DHEAS (R = −0.44; P<.001).The use of androgen replacement therapy in postmenopausal women has been the subject of debate, primarily because this association could theoretically improve the results of estrogen therapy. Androgen replacement is usually indicated for selected groups of patients, including women with POF (1Davis S. Androgen replacement in women: a commentary.J Clin Endocrinol Metab. 1999; 84: 1886-1891Crossref PubMed Google Scholar, 2Davis S. Testosterone deficiency in women.J Reprod Med. 2001; 46: 291-296PubMed Google Scholar, 3Mazer A. Testosterone deficiency in women: etiologies, diagnosis, and emerging treatments.Int J Fertil Women Med. 2002; 47: 77-86PubMed Google Scholar). However, there is limited knowledge regarding serum androgen levels in patients with POF.In this study, women with POF showed no difference in T levels when compared to the other two groups. The present results are partially in conflict with the results of two previous studies (4Bermudez J.A. Moran C. Herrera J. Barahona E. Perez M.C. Zarate A. Determination of the steroidogenic capacity in premature ovarian failure.Fertil Steril. 1993; 60: 668-671PubMed Scopus (20) Google Scholar, 5Hartmann B.W. Kirchengast S. Albrech A. Laml T. Söregi G. Huber J.C. Androgen serum levels in women with premature ovarian failure compared to fertile and menopausal controls.Gynecol Obstet Invest. 1997; 44: 127-131Crossref PubMed Scopus (35) Google Scholar) that showed lower T levels in women with POF when compared to regularly menstruating women, and no difference between women with POF and postmenopausal women. However, our results are in agreement with data (6Elias A.N. Pandian M.R. Rojas F.J. Serum levels of androstenedione, testosterone and dehydroepiandrosterone sulfate in patients with premature ovarian failure to age-matched menstruating controls.Gynecol Obstet Invest. 1997; 43: 47-48Crossref PubMed Scopus (29) Google Scholar) from another study that compared 29 women with POF to 29 age-matched fertile women and obtained similar T levels in both groups.Analysis of serum T levels and of the other variables studied in women with POF revealed no correlation between age, BMI, and the duration of gonadal failure. This would seem to indicate that ovarian production of this androgen did not decrease as the time since gonadal failure increased, at least during the period evaluated.No statistically significant differences were detected in free T levels among the groups in this study.In women with POF, serum A levels did not differ from those in the other two groups. These findings are in agreement with data reported from previous studies (5Hartmann B.W. Kirchengast S. Albrech A. Laml T. Söregi G. Huber J.C. Androgen serum levels in women with premature ovarian failure compared to fertile and menopausal controls.Gynecol Obstet Invest. 1997; 44: 127-131Crossref PubMed Scopus (35) Google Scholar, 6Elias A.N. Pandian M.R. Rojas F.J. Serum levels of androstenedione, testosterone and dehydroepiandrosterone sulfate in patients with premature ovarian failure to age-matched menstruating controls.Gynecol Obstet Invest. 1997; 43: 47-48Crossref PubMed Scopus (29) Google Scholar, 7Doldi N. Belvisi L. Bassan M. Fusi F.M. Ferrari A. Premature ovarian failure: steroid synthesis and autoimmunity.Gynecol Endocrinol. 1998; 12: 23-28Crossref PubMed Scopus (40) Google Scholar). However, in this study, postmenopausal women showed a 36% decrease in A levels compared to the group of regularly menstruating women.In our study, women with POF had higher DHEA levels than postmenopausal women, but there was no statistically significant difference between this group and the group of regularly menstruating women. DHEA levels were 50% lower in the postmenopausal group compared to the group of regularly menstruating women and 40% lower compared to women with POF. Because women with POF are younger, adrenal DHEA production would be greater in women with POF than in older postmenopausal women.Our results show that women with POF presented 70% higher levels of DHEAS than postmenopausal women but showed no statistically significant differences when compared to regularly menstruating women. The decrease in DHEAS in the postmenopausal group was 48% compared to regularly menstruating women. These results revealed lower adrenal production in postmenopausal women, who comprise an older age group.The correlation between age and levels of DHEA and DHEAS reflects the influence of the patient's age on the production of these hormones. The age variable was analyzed in relation to the group of regularly menstruating women together with the postmenopausal women, and also in relation to the group formed by the women with POF and the postmenopausal women. In both of these groups, age was the only statistically significant variable that influenced DHEA and DHEAS. While evaluating a wider age range, a negative correlation was observed. A decrease in the two primary adrenal products was seen throughout a lifetime, and this is in agreement with previous reports (8Vermeulen A. Plasma androgens in women.J Reprod Med. 1998; 43: 725-733PubMed Google Scholar, 9Orentreich N. Brind J.L. Rizer R.L. Vogelman J.H. Age changes and sex differences in serum dehydroepiandrosterone sulfate concentration throughout adulthood.J Clin Endocrinol Metab. 1984; 59: 551-555Crossref PubMed Scopus (1257) Google Scholar). Our data do not permit an analysis of when this occurs or within which age range this decrease is relevant.Our results do not imply that androgen deficiency is related to the diagnosis of POF, but rather quantify this reduction in order to differentiate this group of women from women who have undergone natural menopause. The potential worsening of androgen deficiency due to estrogen therapy should also be evaluated. While prudence is needed when treating eventual androgen deficiency, it should also be understood that androgens exert important biologic effects in women. There is evidence of several benefits derived from this form of hormone therapy, particularly during the postmenopausal period (10Sarrel P.M. Androgen deficiency: menopause and estrogen-related factor.Fertil Steril. 2002; 77: S63-S67Abstract Full Text Full Text PDF PubMed Google Scholar). From this perspective, our conclusions may contribute towards helping women with POF receive differentiated attention. In conclusion, women with POF did not show the same androgen profile as postmenopausal women. From the androgens evaluated in this study, we observed that serum DHEA and DHEAS levels were significantly higher in women with POF than in postmenopausal women. Women with premature ovarian failure (POF) may be candidates for androgen replacement (1Davis S. Androgen replacement in women: a commentary.J Clin Endocrinol Metab. 1999; 84: 1886-1891Crossref PubMed Google Scholar). Premature ovarian failure causes serious repercussions in women's lives and should therefore receive individualized attention. It should not be viewed as “premature menopause” nor should women with POF be assessed in the same way as postmenopausal women. The aim of this study was to evaluate the androgen profile of a group of women with POF. A cross-sectional study was performed at the Department of Obstetrics and Gynecology, School of Medicine, Universidade Estadual de Campinas, Brazil. The Institutional Review Board approved the study and all women signed an informed consent form prior to enrollment. The study group consisted of 30 women who had been diagnosed with POF. The inclusion criteria consisted of women aged ≤40 years, who had a spontaneous menarche before age 16, whose last menstrual period had occurred at least 12 months prior to inclusion in the study, who had two serum FSH measurements ≥40 mIU/mL obtained on separate dates, and who had not taken hormonal medication for 3 months or more prior to entering the study. The first control group consisted of 30 regularly menstruating women with cycles of 24 to 35 days, who were paired by age (±1 year) to women diagnosed with POF, as well as by the same category of body mass index (BMI) (kg/m2): BMI <20: underweight; 20–25: normal; 26–30: overweight; >30: obese. The second control group consisted of 30 women who had undergone natural menopause after age 50. They were paired with the POF group according to the number of years of amenorrhea up to the date of inclusion in the study. Exclusion criteria consisted of previous hysterectomy and/or oophorectomy, chronic illnesses, previous radiation or chemotherapy, and previous use of medication that could modify hormone production. In all three groups, serum levels of free testosterone (FT), androstenedione (A), DHEA, DHEAS, and 17-hydroxyprogesterone (17-OHP) were measured. All samples were analyzed by radioimmunoassay (RIA) using commercial kits (Diagnostic Systems Laboratories, Webster, TX). The interassay coefficients of variation were 7.3%–9.7% for FT, 6.0%–9.8% for A, 3.8%–8.6% for DHEA, 4.8%–5.3% for DHEAS, and 3.2%–7.5% for 17-OHP. Testosterone (T) was measured by electrochemiluminescent assay (Elecsys analyzer; Roche, Basel, Switzerland) and the coefficient of variation was 5.6%. Sex hormone binding globulin (SHBG) was measured by time-resolved immunofluorometry (Delfia; Perkins Elmer, Basel, Switzerland), whose interassay coefficient varied from 8.2% to 10.1%. Samples from menstruating women were collected between the 3rd and 9th days of the menstrual cycle. Serum was frozen at −20°C until analysis. Comparisons between the three groups were carried out using analysis of variance (ANOVA), followed by the Tukey test when a significant difference was detected. The Kruskal-Wallis nonparametric test, followed by the Mann-Whitney test when there was a significant difference, was used for data that did not follow a normal distribution. Simple correlation analysis (Pearson) was used to study the association between variables in each group. The level of significance was set at P<.05. The age of women with POF was 34.4 ± 5.2 years (mean ± SD), BMI was 24.7 ± 5.0, and duration of amenorrhea was 5.4 ± 3.8 years. The age of regularly menstruating women was 34.5 ± 5.5 years and their BMI was 24.4 ± 4.6. The age of postmenopausal women was 55.1 ± 3.9 years and duration of amenorrhea was 5.4 ± 3.8 years. Androgen levels in the group of women with POF, in the group of regularly menstruating women, and in the group of postmenopausal women were, respectively (mean ± SD): T (ng/dL): 22.8 ± 10.2, 26.6 ± 12.5, 17.5 ± 7.7; FT (pg/mL): 0.9 ± 0.4, 0.9 ± 0.4, 0.8 ± 0.3; A (ng/mL): 1.3 ± 0.5, 1.6 ± 0.8, 1.0 ± 0.4; DHEAS (ng/mL): 723.7 ± 332.1, 838.4 ± 421.2, 432.5 ± 207.5; DHEA (ng/mL): 6.0 ± 2.8, 7.3 ± 4.5; 3.6 ± 1.9; 17-OHP (ng/mL): 0.9 ± 0.5, 1.0 ± 0.6, 1.0 ± 0.9; SHBG (nmol/L): 64.1 ± 37.9, 67.0 ± 30.2, 58.1 ± 26.6; SHBG/T: 3.58 ± 3.08, 3.17 ± 2.32, 6.00 ± 8.91. T and A levels were significantly higher in regularly menstruating women than in postmenopausal women (P=.0055 and P=.0007, respectively); however, there were no statistically significant differences between POF and the 2 control groups. The levels of DHEAS and DHEA were significantly higher (P=.00001 and P=.0001, respectively) in the POF group and in the group of regularly menstruating women compared to the postmenopausal group. No differences were observed between the groups when comparing the levels of the other androgens (FT, 17-OHP) or in the SHBG and SHBG/T ratio (Table 1). Note: NS = not significant. In the simple correlation analysis (Pearson) between the variables studied, in the POF group an inverse correlation was observed between the duration of amenorrhea and the levels of DHEA (R = −0.38; P=.036) and 17-OHP (R = −0.46; P=.01). Levels of 17-OHP and DHEA in these women decreased as the length of time that had elapsed since gonadal failure increased. In addition, an inverse correlation between BMI and SHBG levels (R = −0.58; P=.001) was observed (data not shown). When the groups in which age was a differentiating factor were analyzed together, the correlation analysis showed that among women in the POF and postmenopausal groups, age was a significant variable that influenced DHEA (R = −0.59; P<.001) and DHEAS (R = −0.53; P<.001). When the group of regularly menstruating women was analyzed together with the group of postmenopausal women, age was significantly associated with decrease in DHEA (R = −0.45; P<.001) and DHEAS (R = −0.44; P<.001). The use of androgen replacement therapy in postmenopausal women has been the subject of debate, primarily because this association could theoretically improve the results of estrogen therapy. Androgen replacement is usually indicated for selected groups of patients, including women with POF (1Davis S. Androgen replacement in women: a commentary.J Clin Endocrinol Metab. 1999; 84: 1886-1891Crossref PubMed Google Scholar, 2Davis S. Testosterone deficiency in women.J Reprod Med. 2001; 46: 291-296PubMed Google Scholar, 3Mazer A. Testosterone deficiency in women: etiologies, diagnosis, and emerging treatments.Int J Fertil Women Med. 2002; 47: 77-86PubMed Google Scholar). However, there is limited knowledge regarding serum androgen levels in patients with POF. In this study, women with POF showed no difference in T levels when compared to the other two groups. The present results are partially in conflict with the results of two previous studies (4Bermudez J.A. Moran C. Herrera J. Barahona E. Perez M.C. Zarate A. Determination of the steroidogenic capacity in premature ovarian failure.Fertil Steril. 1993; 60: 668-671PubMed Scopus (20) Google Scholar, 5Hartmann B.W. Kirchengast S. Albrech A. Laml T. Söregi G. Huber J.C. Androgen serum levels in women with premature ovarian failure compared to fertile and menopausal controls.Gynecol Obstet Invest. 1997; 44: 127-131Crossref PubMed Scopus (35) Google Scholar) that showed lower T levels in women with POF when compared to regularly menstruating women, and no difference between women with POF and postmenopausal women. However, our results are in agreement with data (6Elias A.N. Pandian M.R. Rojas F.J. Serum levels of androstenedione, testosterone and dehydroepiandrosterone sulfate in patients with premature ovarian failure to age-matched menstruating controls.Gynecol Obstet Invest. 1997; 43: 47-48Crossref PubMed Scopus (29) Google Scholar) from another study that compared 29 women with POF to 29 age-matched fertile women and obtained similar T levels in both groups. Analysis of serum T levels and of the other variables studied in women with POF revealed no correlation between age, BMI, and the duration of gonadal failure. This would seem to indicate that ovarian production of this androgen did not decrease as the time since gonadal failure increased, at least during the period evaluated. No statistically significant differences were detected in free T levels among the groups in this study. In women with POF, serum A levels did not differ from those in the other two groups. These findings are in agreement with data reported from previous studies (5Hartmann B.W. Kirchengast S. Albrech A. Laml T. Söregi G. Huber J.C. Androgen serum levels in women with premature ovarian failure compared to fertile and menopausal controls.Gynecol Obstet Invest. 1997; 44: 127-131Crossref PubMed Scopus (35) Google Scholar, 6Elias A.N. Pandian M.R. Rojas F.J. Serum levels of androstenedione, testosterone and dehydroepiandrosterone sulfate in patients with premature ovarian failure to age-matched menstruating controls.Gynecol Obstet Invest. 1997; 43: 47-48Crossref PubMed Scopus (29) Google Scholar, 7Doldi N. Belvisi L. Bassan M. Fusi F.M. Ferrari A. Premature ovarian failure: steroid synthesis and autoimmunity.Gynecol Endocrinol. 1998; 12: 23-28Crossref PubMed Scopus (40) Google Scholar). However, in this study, postmenopausal women showed a 36% decrease in A levels compared to the group of regularly menstruating women. In our study, women with POF had higher DHEA levels than postmenopausal women, but there was no statistically significant difference between this group and the group of regularly menstruating women. DHEA levels were 50% lower in the postmenopausal group compared to the group of regularly menstruating women and 40% lower compared to women with POF. Because women with POF are younger, adrenal DHEA production would be greater in women with POF than in older postmenopausal women. Our results show that women with POF presented 70% higher levels of DHEAS than postmenopausal women but showed no statistically significant differences when compared to regularly menstruating women. The decrease in DHEAS in the postmenopausal group was 48% compared to regularly menstruating women. These results revealed lower adrenal production in postmenopausal women, who comprise an older age group. The correlation between age and levels of DHEA and DHEAS reflects the influence of the patient's age on the production of these hormones. The age variable was analyzed in relation to the group of regularly menstruating women together with the postmenopausal women, and also in relation to the group formed by the women with POF and the postmenopausal women. In both of these groups, age was the only statistically significant variable that influenced DHEA and DHEAS. While evaluating a wider age range, a negative correlation was observed. A decrease in the two primary adrenal products was seen throughout a lifetime, and this is in agreement with previous reports (8Vermeulen A. Plasma androgens in women.J Reprod Med. 1998; 43: 725-733PubMed Google Scholar, 9Orentreich N. Brind J.L. Rizer R.L. Vogelman J.H. Age changes and sex differences in serum dehydroepiandrosterone sulfate concentration throughout adulthood.J Clin Endocrinol Metab. 1984; 59: 551-555Crossref PubMed Scopus (1257) Google Scholar). Our data do not permit an analysis of when this occurs or within which age range this decrease is relevant. Our results do not imply that androgen deficiency is related to the diagnosis of POF, but rather quantify this reduction in order to differentiate this group of women from women who have undergone natural menopause. The potential worsening of androgen deficiency due to estrogen therapy should also be evaluated. While prudence is needed when treating eventual androgen deficiency, it should also be understood that androgens exert important biologic effects in women. There is evidence of several benefits derived from this form of hormone therapy, particularly during the postmenopausal period (10Sarrel P.M. Androgen deficiency: menopause and estrogen-related factor.Fertil Steril. 2002; 77: S63-S67Abstract Full Text Full Text PDF PubMed Google Scholar). From this perspective, our conclusions may contribute towards helping women with POF receive differentiated attention. In conclusion, women with POF did not show the same androgen profile as postmenopausal women. From the androgens evaluated in this study, we observed that serum DHEA and DHEAS levels were significantly higher in women with POF than in postmenopausal women.