• 1.
  

  a) T b) F c) F d) T e) T

There is growing evidence to demonstrate the strong association among PCOS, NAFLD and NASH. Most of the endocrine and metabolic characteristics of women with PCOS, including elevated androgen levels, insulin resistance, dyslipidemia, and elevated low-grade inflammation levels are considered to contribute to the presence and progression of NAFLD. Due to their common characteristics, including obesity, insulin resistance, and metabolic syndrome, women with liver biopsy or ultrasound-proved NAFLD were not surprisingly found to have higher prevalence of PCOS. It has been reported that modest weight loss and exercise can improve the NASH in women with PCOS by liver biopsy documentation. It has also been reported that intrahepatic fat is more closely related to the metabolic complications of obesity than visceral fat that might be represented by waist circumference or waist-to-hip ratio – central obesity. Furthermore, lots of studies showed that the prevalence of NAFLD is increased in young women with PCOS, independent of coexisting metabolic features and obesity. Such findings might suggest a more close relationship between NAFLD and PCOS rather than sharing risk factors of obesity and metabolic syndrome. Liver enzymes such as alanine aminotransferase (ALT) and aspartate aminotransferase (AST) are cytosolic enzymes and are thought to be specific markers of liver damage. However, ALT levels can be normal in patients with NAFLD. Previous studies demonstrated that amongst a total of 48/88 (55%) women with PCOS who had NAFLD proven by ultrasonography, only 7 (15%) had elevated aminotransferase levels. Therefore, elevated ALT levels in women with PCOS may represent a higher severity of liver cell injury. Not only aminotransferase levels, but also some innovative markers as the caspase 3-cleaved fragment of cytokeratin 18, have been found to also represent the progressive hepatocyte injury in women with PCOS.

• 2.
  

  a) T b) T c) T d) T e) F

Women with PCOS were reported to have a higher prevalence of NAFLD and NASH diagnosed by liver biopsy, magnetic resonance spectroscopy, computed tomography and abdominal ultrasonography.

• 3.
  

  a) F b) F c) F d) T e) T

Statins are effective in reducing chronic inflammation, lipid profiles and biochemical hyperandrogenemia in women with PCOS. Meta-analysis revealed that statins might improve serum liver enzymes (aminotransferase levels) as well as ultrasound findings in NAFLD and NASH. However, there were no available studies regarding the beneficial effects of statins on the histological changes, liver-related morbidity or mortality of patients with NAFLD. Women with PCOS are characterized by having either elevated ovarian or adrenal androgen levels including decreased SHBG levels, increased testosterone and/or DHEAS levels. Testosterone levels, which mainly come from ovarian origin, highly associate with the presence of a higher prevalence of obesity, metabolic syndrome, dyslipidemia and NAFLD in women with PCOS. On the contrary, DHEAS/DHEA, which mainly comes from adrenal glands, has been reported to have opposing effects from testosterone regarding obesity, insulin resistance and metabolic syndrome in women with PCOS. DHEAS levels are inversely associated with the presence of NAFLD and NASH. Flutamide, a non-steroidal anti-androgen, is commonly used in the treatment of acne and hirsutism. Though two prospective studies of 190 and 230 hyperandrogenic girls or young women, respectively, who took a low dose of flutamide for range of period for 3-54 months in one study, and 10 years in another study revealed no cases of hepatotoxicity, there was still a case series study reporting severe hepatotoxicity after treatments in the same population. Though OCP has been reported to have an adverse impact on lipid profiles and being metabolized in the liver, might potentially increase the severity of NAFLD, according to a population-based study, current OCP usage was associated with a reduced risk of NAFLD. The protective effect of OCP usage on NAFLD might be secondary to the effect of androgen reduction, but was attenuated after adjusting for the confounding effect of adiposity. Spironolactone, another common anti-androgen used to treat acne and hirsutism in women with PCOS, was recently found to exhibit favourable effects on serum insulin and insulin resistance in patients with NAFLD.

• 4.
  

  a) T b) F c) F d) T e) T

Options a), d), and e) are true as the criteria to diagnose PCOS based on the available guidelines/consensus statements such as the NIH 1990 criteria, Rotterdam criteria 2003 and AES-PCOS 2006 include the presence of clinical/biochemical evidence of androgen excess such as hirsutism and raised levels of testosterone including polycystic ovarian morphology on transvaginal ultrasonography such as > 12 follicles measuring 2 – 9 mm and/or ovarian volume > 10 cm ³ . Options b) and c) are false as these factors are not part of the diagnostic criteria for PCOS. They form part of the criteria to diagnose metabolic syndrome which include elevated blood pressure, dyslipidaemia and raised glucose levels.

• 5.
  

  a) T b) T c) T d) F e) T

The diagnostic criteria for PCOS in accordance to the 1993 Japanese Society for Obstetrics and Gynecology requires the presence of all the following three criteria: anovulation, the presence of polycystic ovarian morphology, and high serum LH levels. Measurement of luteinizing hormone (LH) was chosen instead of hyperandrogenism. Serum testosterone level is used only as a “referential factor”. The Japanese criteria can impact on the number of women diagnosed with PCOS in the Japanese population. Additionally, other studies in other ethnicities utilised the NIH or Rotterdam criteria do not require any ultrasound evidence of polycystic ovarian morphology to make a diagnosis of PCOS. Current studies in Caucasian women show the prevalence of PCOS remains higher (up to 15%) when compared to East Asian women (up to 5.7%). Option (c) is true as evidenced by a large Chinese population study of > 15, 000 women. The Rotterdam criteria is the broadest and most inclusive when compared to the NIH 1990 criteria or the AE-PCOS criteria. The wide range of reported prevalence of PCOS is likely due to differences such as subjective variation in clinical assessment of hirsutism, lack of reference standards for androgen assays, and inter-observer differences in the measurement of ovarian morphology.

• 6.
  

  a) T b) T c) F d) T e) F

Options (a) and (b) are true as the mFG score to diagnose hirsutism is > 3 in Thai women based on the current studies, this is the lowest score for hirsutism amongst other ethnicities such as Chinese and Japanese women. In South Asians, women were reported to have a higher mean mFG score and in one particular study the mean score can be as high as 18. Option (c) is false as a study comparing Middle Eastern and Caucasian women with PCOS shows that Middle Eastern women are found to be more hirsute. NIH criteria 1990 and AES-PCOS 2006 criteria both indicated that clinical/biochemical evidence of hyperandrogenism is an essential requirement to diagnose PCOS.

• 7.
  

  a) F b) F c) T d) T e) T

Studies are still inconclusive on the threshold value of ovarian volume required to diagnose PCOS in Asian women and the best threshold appeared to be less than 6.3 cm ³ for ovarian volume and 10 follicles for mean follicular number to diagnose PCOS in Chinese women based on one study. Polycystic ovarian morphology was not part of the diagnostic criteria of NIH criteria 1990. NIH 1990 criteria specifies that the presence of clinical/biochemical of androgen excess and menstrual irregularities (oligo-anovulation) are required before woman are diagnosed with PCOS. Based on available studies, East Asian women with PCOS had a higher incidence of polycystic ovarian morphology on ultrasound when compared to Caucasian women with PCOS (92.9% versus 69.9%). Ovarian volume is observed to increase through childhood and achieves its maximum volume shortly after puberty and declines significantly with each decade of life from age 30 to age 70 in the physiological state. The rate of follicle loss per year was significantly slower in women with PCOS compared with that in women with normal ovaries; comparing both groups, the fastest period of follicle loss was between the ages of 18 and 30 years while the average follicle loss was 0.8 follicles/year in women with PCOS and 1.7 follicles/year in those without PCOS (P < 0.001).

• 8.
  

  a) T b) T c) F d) F e) F

Increased number of pre-antral and antral follicles is the characteristic morphological feature of polycystic ovaries. Histopathological studies observed 2-3 fold increased density of growing follicles in the ovaries of PCOS patients. Diagnostic test studies have confirmed that FNPO has the best diagnostic power to distinguish between PCOS patients and healthy women with highest sensitivity and specificity. Increased ovarian volume is an important feature of PCOM. Women with PCOS have been found to have significantly greater ovarian volume compared with normal controls. Although priority should be given to FNPO to define PCOM, measurement of ovarian volume serves as a good surrogate marker with higher level of reliability. Increased stromal echogenicity is a key ultrasonographic finding of a typical polycystic ovary. Several parameters have been tried to assess the echogenicity including stromal index (mean stromal echogenicity/mean echogenicity of entire ovary) and 3D mean greyness (MG) of the ovary. However, these methods are still controversial since the assessment of the stromal echogenicity is highly dependent on the setting of the ultrasound machine and the patient’s body habitus. Stromal hypertrophy is one of the morphological features observed in histopathological studies and it may be the main cause of ovarian enlargement in polycystic ovaries. But since total ovarian volume and stromal volume are well correlated and ovarian volume is more easily and reliably measured in routine practice than ovarian stroma, the assessment of stroma volume is at present not required to define PCOM. Stromal blood flow has been evaluated by a number of studies using 2D colour Doppler measurement and 3D power Doppler angiography. Lower stromal artery resistance index and higher vascularization indices have been reported. However due to the lack of standardized method for measurement and uniform data to substantiate the finding of increase stromal blood flow in PCOS patients, it is not included in the criteria of PCOM.

• 9.
  

  a) T b) F c) F d) F e) F

The AEPS task force recommends increasing the FNPO threshold to ≥25 follicles for the definition of PCOM after critical systemic review and analysis of the recent literature. Meanwhile, the guideline emphasizes the updated threshold fit with modern ultrasound technology that affords optimal resolution. There is still significant debate regarding the sensitivity of diagnostic cut-off of >10 cm ³ for discriminating between normal and polycystic ovaries. The different ovarian volume threshold values proposed by a number of studies may be related to the difference in the ethnicity and metabolic characteristics of the population studied. Therefore an internal reference normal value is highly recommended. If it is not available, the task force recommends using the existing threshold conservatively. The follicular distribution is at present not a part of the diagnostic criteria for a polycystic ovary. There is not an easy and objective method to evaluate this feature. But it is intriguing that the peripheral distribution of small ovarian follicles which constitute a classic polycystic ovary appearance of “string of pearls” may indicate a specific patho-physiological process that defines PCOM which warrants further investigation. The ratio of ovarian stroma to total ovarian size >0.32 was found to be the best significant predictor of hyperandrogenemia. However, there are few studies evaluating its diagnostic potential. It remains unclear whether the quantitative assessment of the stroma yields any additional information to define PCOM accurately. Performing follicle count in a single cross section is a feasible method for evaluating the density of follicle populations in the ovaries. The threshold of FNPS ≥ 9 follicles was proposed in diagnosing PCOM. However, the selection of a single cross-sectional view optimal for defining polycystic ovaries is heavily reliant on the operator’s skills and experience. The method of counting the follicles throughout the entire ovary may be more reliable than the single cross-sectional approach.

• 10.
  

  a) F b) T c) T d) T e) F

Ovarian volume changes with age. The available data have shown that the ovarian volume increases through childhood, reaches a maximum during adolescence (1.3-3.8 years post-menarche), slowly declining during adulthood and rapidly shrinking after the menopause. Given the changing pattern of ovarian volume with age, the cut-off value of 10 cm ³ may not be suitable for diagnosing PCOM in adolescence and women over 40 years old. This formula is the most commonly used in clinical practice. Since polycystic ovaries appear to be more irregular, a number of different ultrasound formulae were proposed, such as the equations of prolate spheroid and spherical volume. Although it was suggested that the formula should be modified in PCOS ovaries and 3D software for the calculation was introduced, there is currently no consensus on the most suitable method of estimating ovarian volume. FNPO has the best discriminatory performance in the diagnosis of PCOS. But in contrast to follicle count, the measurement of ovarian volume is associated with higher levels of inter- and intra-observer agreement. It is a helpful ultrasound parameter in evaluating the ovarian morphology in PCOS patients when a reliable follicle count is not possible due to reduced image quality. Ovarian volume may be related to different ethnic background and metabolic characteristics of different populations. It has been found to vary with ethnicity, body mass index and insulin levels. Although the exact associations have not be established, this may be one of the reasons explaining the differences in the upper limits of the normal ovarian volume reported from different centres. Although 3D methods of volume estimate provide more spatial information and allow for correction for any surface irregularities, its validity and reproducibility have not been confirmed due to its technical limitations. Up to now, the widely accepted 2D measurement of ovarian volume using the prolate ellipsoid formula is still the standard method for the ultrasound diagnosis.

• 11.
  

  a) T b) T c) T d) F e) T

There is a paucity of data on FNPO and ovarian volume in normal and PCOS adolescents due to the lack of an easy non-invasive imaging method for the accurate assessment of ovarian morphology. Until more data are collected and validated, the criteria for PCOM in adolescence cannot be established. In adolescents, the ultrasound examination is typically carried out abdominally rather than vaginally. Accurate assessment of the ovarian morphology is often difficult due to the suboptimal image quality, especially in obese girls. There is a fair amount of overlap in ovarian morphological findings, which tends to be heterogeneous, between PCOS and normal girls. The difficulty in discriminating between normal ovarian features of puberty and features of PCOS makes it a challenge to establish the diagnosis of PCOM in adolescence. Polycystic ovaries appear to be inherited as an autosomal dominant trait and early clinical manifestations of PCOS may emerge in some girls during the peri-pubertal years. An enlarged ovarian volume has been found to be present in daughters of women with PCOS before the onset of puberty. Due to the difficulties in diagnosis, there is a high prevalence of failure in the early detection of PCOS in young girls. Multicystic ovary is defined by the presence of larger follicles distributed throughout the ovary. It does not have a relationship with hyper-androgenism and should not be considered a pathological finding. However small follicles may not be visualized in transabdominal scan and the suboptimal image quality may make it difficult to differentiate it from a polycystic ovary.

• 12.
  

  a) T b) T c) F d) F e) T

The NCEP ATP III criteria for MbS are BP ≥130/85 mmHg, fasting TG ≥1.7 mmol/L, fasting glucose ≥5.5 mmol/L, HDL-C <1.3 mmol/L, and WC ≥88 cm in Caucasians or ≥80 cm in Asians. HDL is a protective lipid due to its capacity to remove cholesterol from peripheral tissues thereby decreasing atherogenesis. HDL-C levels are closely related to insulin sensitivity and HDL-C is reduced in conditions of IR such as MbS and PCOS. PCOS is not a MbS criterion, although MbS is highly prevalent amongst both lean and overweight/obese PCOS women.

• 13.
  

  a) T b) T c) T d) T e) F

BP should be measured at every visit as part of the assessment of cardiovascular risk and prevention of cardiovascular disease in women with the polycystic ovary syndrome, although the frequency may be reduced to annual measurement in lean PCOS women. Obesity, particularly central adiposity, increases the risk of PCOS-associated metabolic complications. WC and BMI should be measured at every visit because of changes in the degree and distribution of obesity with time. OGTT should be performed at baseline and then every 1-5 years to screen for IGT and T2DM in PCOS. Guidelines differ as to whether the initial OGTT should be performed in all PCOS women, or only PCOS women with additional T2DM risk factors. Insulin levels may be useful in academic settings, however there is currently no role for insulin measurement in clinical practice.

• 14.
  

  a) F b) T c) F d) F e) F

Metabolic and reproductive benefits may be achieved with as little 5% weight loss. Weight loss results in significant improvement in pregnancy and ovulation rates in anovulatory obese women. Even in the absence of weight changes, aerobic exercise results in metabolic benefits such as reduced IR and serum TG. Studies in both general and PCOS populations have failed to demonstrate improved weight loss with modifications in fat, protein and carbohydrate content in hypocaloric diets. Though the benefits of lifestyle intervention are mostly derived from studies of overweight/obese PCOS women, exercise and dietary advice should be extended to lean PCOS women to prevent weight gain particularly as weight gain is more common in PCOS. An exercise-based study of overweight women with and without PCOS found that only PCOS women achieved reductions in IR and serum TG suggesting that PCOS women may preferentially benefit from exercise.

• 15.
  

  a) F b) T c) T d) F e) F

Evidence to date suggests that pregnancy following bariatric surgery is safe, and may be preferable to pregnancy in the setting of untreated obesity. Indeed, the PCOS Australian Alliance suggests consideration of bariatric surgery in obese PCOS women who remain anovulatory despite lifestyle intervention. Reduced BMI and adiposity, as well as increased menstrual frequency, were observed with metformin in a recent meta-analysis. Metformin is suggested in PCOS women undergoing IVF for the benefit of OHSS risk reduction. Hormonal contraceptives e.g. the OCP are recommended as first-line pharmacotherapy in PCOS women where lifestyle intervention has failed and metformin is currently only recommended if hormonal contraceptives cannot be used. It remains to be seen if this recommendation is changed by a recent RCT demonstrating increased MbS prevalence at the end of 16 weeks of OCP therapy. Thiazolidinediones are not recommended in PCOS women due to general population studies demonstrating risks of weight gain, worsening heart failure, increased cardiovascular events, and osteoporosis and bladder cancer.

• 16.
  

  a) T b) T c) T d) T e) T

It has been suggested that AMH could be used interchangeably with the AFC as a diagnostic criterion for PCOS. There is a significant correlation between serum AMH and the antral follicle count. However there are several AMH assays and their interpretation needs to be assay specific due to significantly different values. It is hence necessary to have an international standardisation of AMH results before a cut off value can be used for diagnosis.

• 17.
  

  a) T b) T c) T d) T e) F

Serum AMH values are significantly higher in women with anovulatory PCOS. This is important as AMH is hypothesized to play a key role in the pathophysiology of anovulation seen in PCOS. This is postulated to be due to the heightened inhibitory function of AMH leading to a reduced sensitivity of the antral follicles to the action of FSH.

• 18.
  

  a) F b) T c) F d) F e) F

TT levels are elevated in 22 – 85% PCOS patients; however, only one-third of samples in PCOS demonstrate an abnormal value. FT levels are elevated in 70% of PCOS subjects, which is the single most sensitive test for hyperandrogenemia. FT can be calculated based on TT and SHBG values. Only 10% of patients demonstrate isolated DHEAS elevation. Only 9% of cases demonstrate isolated elevation of A4.

• 19.
  

  a) T b) F c) T d) T e) F

Women with non-classic 21-hydroxylase deficient adrenal hyperplasia, over-secrete 17-hydroprogesterone and adrenal androgens. Women with this disorder usually have clinical hyperandrogenic signs and symptoms that are often indistinguishable from PCOS. Women with hypogonadotropic hypogonadism usually have a low to normal androgen levels with no obvious sign of androgen excess. Androgen-secreting neoplasms are usually associated with severe progressive androgen excess, including signs of virilization, hirsutism, and male pattern balding, although generally more severe than that in garden-variety PCOS. The features of Cushing’s disease are often similar to PCOS, as they result from a generalized adrenocorticoid excess secondary to increased pituitary secretion of ACTH, with signs and symptoms including central obesity, menstrual irregularities, hirsutism, and acne. 5α-reductase deficiency usually presents with ambiguous genitalia at birth as there is a partial, or sometimes total, inability to convert testosterone to dihydro-testosterone.

• 20.
  

  a) T b) F c) F d) T e) F

Combination hormonal contraceptives (HCs) are more effective than placebo or no treatment for the treatment of mild to moderate hirsutism, and are recommended as first line therapy. In more severe cases, or if there is insufficient response after 6 months of treatment, combination with anti-androgens is recommended. The progestins in the HC cause LH suppression and subsequent decrease in androgen production by the ovarian theca cells. The estrogen in the HC causes an increase in hepatic SHBG production with subsequent reduction in circulating free testosterone. Insulin sensitizers have an indirect effect on androgens by reducing insulin levels, however, other treatments are considered much more effective for the treatment of hirsutism (antiandrogens, HCs) and insulin sensitizers are therefore not recommended for routine clinical treatment of hirsutism. Antiandrogen therapy includes androgen receptor blockers (e.g. spironolactone, flutamide) and 5α-reductase inhibitors (e.g. finasteride). These drugs are very effective, alone or in combination (e.g. with HCs) in treating hirsutism. Due to their teratogenic potential on a male fetus, they are usually prescribed in combination with an HC or a secure contraceptive in reproductive age women. There are no 5α-reductase agonists used clinically. Glucocorticoids (GCs) have a pronounced effect in suppressing adrenal androgens, but tend to minimally effective in treating hirsutism as compared to antiandrogens or HCs. GCs are not recommended for the routine treatment of hirsutism.

• 21.
  

  a) F b) T c) F d) T e) T

The total number of primordial follicles is the same in polycystic ovaries and in normal control ovaries. However, there is a significant increase in the percentage of early growing (primary) follicles and a reciprocal reduction in the proportion of primordial follicles compared with normal control ovaries. GDF-9 is an oocyte derived growth factor that is critical for normal follicular development beyond the primary follicle. It also has a critical role in granulosa cell (GC) and thecal cell (TC) growth, as well as in the differentiation and maturation of the oocyte. Decreased levels in the polycystic ovary have been associated with impaired follicular development. AMH expression is reduced in primordial and primary follicles from polycystic ovaries. The role of AMH is to regulate the progression of early follicles beyond this stage. As a consequence of reduced expression, higher numbers of follicles enter the pre-antral stage in PCOS. Once the antral follicle stage has been achieved, the expression of AMH is greatly elevated in polycystic ovaries. The overall serum level is greater because there are more antral follicles present, each capable of producing AMH. Furthermore, the GCs themselves have a greater output of AMH compared with the GCs from antral follicles from normal ovaries. There is an increase in expression of VEGF in the dense hyperethecotic stroma of polycystic ovaries, which is likely to be responsible for increased ovarian stromal blood flow.

• 22.
  

  a) T b) F c) F d) T e) T

Excess insulin binds to the IGF-1 receptors, which enhances the TCs androgen production in response to LH stimulation. Hyperinsulinaemia decreases the hepatic synthesis of SHBG. Therefore, there is an increase in serum free-testosterone concentration, with consequent peripheral androgen action. Hyperinsulinaemia inhibits the hepatic secretion of IGFBP-1 resulting in elevated concentrations of IGF-1 and IGF-2, which are important regulators of ovarian follicular maturation and steroidogenesis. In combination with more TC IGF-2 secretion, IGF-1 and IGF-2 further augment ovarian androgen synthesis by acting on IGF-1 receptors. LH acts in synergy with insulin on TC androgen synthesis, and because of this action, it has been described as a “co-gonadotrophin”. Hyperinsulinaemia results in increased cytochrome P450c17α enzyme activity, which is essential in the steroidogenesis pathway in both the ovary and the adrenal, and in turn leads to higher levels of androgen synthesis.

• 23.
  

  a) F b) T c) F d) F e) F

Changes in the pulsatility of GnRH are thought to alter the ratio of secretion of FSH and LH throughout the menstrual cycle. FSH secretion predominates when GnRH pulsatility is low, whereas LH secretion predominates with rapid pulsations. The kiss 1 system, which incorporates the kisspeptin, neurokinin B and dynorphin neurones, acts as the GnRH pulse generator, and is located in the arcuate nucleus of the hypothalamus. Kisspeptin acts upstream of GnRH and signals directly to the GnRH neurones. Elevated serum concentrations of LH (>95 ^th percentile of normal) are observed in 40-60% of women with PCOS. LH levels are influenced by temporal relation to ovulation, which causes a transient normalisation of LH secondary to the suppressive effect of ovulatory progesterone. Also, lean women with PCOS have higher levels of LH. Androgens do not directly influence LH pulsatility. However, androgens influence the regulatory activity of oestradiol and progesterone on LH release. Endogenous opioid tone is important in the regulation of LH and prolactin secretion, and inhibits GnRH release. Reduced hypothalamic opioid and dopaminergic tone in women with PCOS is associated with inappropriate gonadotrophin secretion, and ultimately tonic LH hypersecretion as well as prolactin secretion.

• 24.
  

  a) F b) T c) F d) T e) T

The women with PCOS present with at least three to five-fold risk for endometrial cancer. The risk is present also independent of BMI, but obesity aggravates the risk significantly. In non-PCOS women, the increased cancer risk is commonly related to obesity and postmenopausal amenorrhea (high estrogen effect especially if obese with no counteracting progesterone action). In women with PCOS oligo/amenorrhea often starts already at young age, thus the endometrium is being exposed to stress for a long time, sometimes even from puberty onwards. The endometrial cancer incidence is increased especially in women with PCOS <50 years.

• 25.
  

  a) F b) F c) T d) F e) T

During the proliferative phase estrogen drives endometrial growth and proliferation through estrogen receptor (ER) activation and the ER expression is highest during the late proliferative phase of the menstrual cycle. During the secretory phase progesterone counteracts estrogen by downregulating the ERs especially in the epithelium. The downregulation is not complete in the stroma thus estrogen does have some effects also during the secretory phase. In cases of hyperinsulinemia, ERs, and thus estrogen, synergize with insulin through the MAPK pathway.

• 26.
  

  a) T b) F c) F d) T e) T

Previous studies have implied women with PCOS having an altered steroid hormone response showing low HOXA10 and IGFBP-1 expression in secretory phase endometrium or in decidualized endometrial stromal cells. In recent studies several pathologies have been found in the histological examinations of placentas in women with PCOS, even in normal pregnancies, implying impaired trophoblast invasion and decreased placental growth. Women with PCOS have reported to have an increased inflammatory profile during the proliferative phase of the menstrual cycle and the poor response to progesterone seems to coincide with an increased cytokine/chemokine response. These findings may imply impaired development of the feto-maternal interface resulting from impaired endometrial cell function and response to non-optimal embryos in women with PCOS and may explain pregnancy complications reported in affected women.

• 27.
  

  a) F b) F c) T d) T e) T

So far, there are no specific endometrial markers related to PCOS per se that can predict any clinical outcomes. Thus, no recommendations for regular screening can be advised at this point. In order to be able to have a screening program more studies should be established with clear end points determined, if any of the endometrial findings/markers so far, or new ones, are able to predict clinical outcomes (preeclampsia, preterm birth, endometrial cancer) in women with PCOS. There is no doubt that PCOS is a risk factor for endometrial cancer and that the risk is aggravated with obesity and metabolic derangements. In clinical practice, the women should be screened for endometrial cancer if women present with several risk factors (amenorrhea, obesity, abnormal glucose tolerance) or abnormal bleeding episodes. It should also be noted, that the irregular bleeding episodes, common in women with PCOS, may also mask cancer-related bleeding. The women should be consulted about the risk related to endometrial cancer in order to motivate life style interventions and medical treatments to increase endometrial health.

• 28.
  

  a) T b) T c) T d) T e) T

There are great number of studies indicating that parental nutrition and other lifestyle factors during the peri-conceptual period can affect reproductive performance and health of the offspring. Moreover, obesity has been shown to associate with early miscarriage and poor pregnancy outcomes. As women with PCOS often have several metabolic derangements with a high incidence of type 2 diabetes (all risk factors also for endometrial cancer) the women should be informed about the risks and the outcomes especially for the offspring and also motivate them to make some life style changes in order to lose weight. Some previous results also indicate that lifestyle modifications could have beneficial effects on endometrial function in women with PCOS. Progestins are commonly used to prevent and treat endometrial hyperplasia in women with oligo/amenorrhea as they counteract the estrogen that has mitogenic and proliferative effects. Metformin has been shown to have beneficial effects on endometrial health as well, although the data as regards pregnancy outcomes and cancer survival are still somewhat conflicting. No common guidelines exist as to how often progestins should be prescribed in order to guarantee endometrial protection against prolonged estrogen effects. It has been suggested that some women with PCOS are progesterone resistant, and thus it might be that progestins alone are not sufficient for endometrial protection in these women. Further studies are warranted in this area.

• 29.
  

  a) T b) F c) F d) F e) F

This P450 side chain cleavage enzyme (CYP11A) catalyzes the first reaction in the steroidogenesis pathway, which is the conversion of cholesterol to pregnenolone. This process involves three chemical reactions, the 22-hydroxylation of cholesterol, 20-hydroxylation of 22(R)-hydroxycholesterol, and oxidative scission of the C20-22 bond of 20(R),22(R)-dihydroxycholesterol (the side-chain cleavage event), to yield pregnenolone and isocaproaldehyde. Of these three reactions, the binding of cholesterol and 22-hydroxylation are rate limiting, as the efficiencies (kcat/Km ratios) are much higher for the subsequent reactions, and the high KD of ∼3000 nM drives the dissociation of pregnenolone from P450scc. The overall side-chain cleavage reaction catalyzed by P450scc is slow, and is also limited by cholesterol availability. These three reactions occur on a single active site that is in contact with the inner mitochondrial membrane. The steroidogenic acute regulatory protein, commonly referred to as StAR, is a transport protein that regulates cholesterol transfer from the outer to the inner mitochondria. Often times, this step is also considered to be the rate limiting step in steroidogenesis as the rate of transport of cholesterol to the inner mitochondria limits the availability of cholesterol for steroid biosynthesis. However, it is important to note that StAR is a transport protein and it does not mediate any enzymatic reaction to convert cholesterol to any of the intermediates. 3β-hydroxysteroid dehydrogenase type 2 (HSD3B2) catalyzes the biosynthesis of progesterone from pregnenolone, 17α-hydroxyprogesterone from 17α-hydroxypregnenolone, and androstenedione from dehydroepiandrosterone (DHEA). Thus it is a critical enzyme in the steroidogenesis pathway. However, it is not a rate limiting enzyme. Aromatase converts testosterone to estradiol, and it is a rate limiting enzyme for estradiol biosynthesis. Cytochrome P450 17A1 (CYP17A1) catalyzes two distinct types of substrate oxidation. Through its hydroxylase activity, it catalyzes the 17α-hydroxylation of pregnenolone or progesterone to 17α-hydroxypregnenolone or 17α-hydroxyprogesterone respectively. Subsequently, through its C17, 20 lyase activity, it can further convert 17α-hydroxypregnenolone or 17α-hydroxyprogesterone to the androgens dehydroepiandrosterone or androstenedione respectively, which are precursors to the more potent androgens testosterone, and dihydrotestosterone. CYP17A1 is regarded as the rate-limiting enzyme for androgen biosynthesis.

• 30.
  

  a) F b) F c) F d) T e) F

LH stimulation of adenylyl cyclase activity via G protein coupled receptors occurs at the gonads, specifically at the theca cells in the ovary, and at the Leydig cells of the testis. 8Br-cAMP’s primary function is to activate cAMP-dependent protein kinase A (PKA) and subsequently increase steroidogenic gene transcription. Protein phosphorylation by PKA activates transcription of genes encoding steroidogenic enzymes. This results in an increase in steroidogenic capacity. In the NCI-H295R cellular model, there is no feedback loop that exists, as observed in the physiological state, which can modulate GnRH hormone release. In the physiological state increased estrogen levels can suppress GnRH release from the hypothalamus. In the physiological state, ACTH stimulation of adenylyl cyclase activity via G protein coupled receptors results in increased cAMP which activates the steroidogenesis pathway. Thus 8Br-cAMP is added to mimic this effect and activate the steroidogenesis pathway. 8Br-cAMP is not a substrate for the StAR enzyme. However, it does induce the expression of StAR, which is critical for importing cholesterol into the mitochondria for steroidogenesis.