Does Spironolactone Normalize Sleep-wake Luteinizing Hormone Pulse Frequency in Pubertal Girls With Hyperandrogenism?
Does Spironolactone Normalize Sleep-wake Luteinizing Hormone Pulse Frequency in Pubertal Girls With Hyperandrogenism?
The purpose of this study is to determine if, in mid- to late pubertal girls with
 hyperandrogenism (HA), androgen-receptor blockade (spironolactone) alone normalizes
 sleep-wake luteinizing hormone (LH) pulse frequency (primary endpoint) and overall LH and
 follicle-stimulating hormone secretion (secondary endpoints).
This is a randomized, placebo-controlled, double-blinded crossover study to test the
 following hypothesis: In mid- to late pubertal girls with hyperandrogenism, spironolactone
 (50 mg twice daily) for 2 weeks will reduce sleep-associated luteinizing hormone (LH) pulse
 frequency compared to placebo treatment. To test this hypothesis, 16 late pubertal girls
 (signified by either [a] post-menarcheal status [Tanner breast stages 2-5] or [b] Tanner
 breast stage of 4 or 5 [whether pre-menarcheal or post-menarcheal], but no more than 4 years
 post-menarcheal) with hyperandrogenism (serum [calculated] free testosterone concentration
 greater than the Tanner stage-specific reference range and/or clinical hirsutism) will
 undergo two clinical research unit (CRU) admissions separated by at least 4 weeks. During
 each admission, blood will be obtained every 10 minutes through an indwelling IV catheter
 from 1600 to 0700 h. This will allow full characterization of pulsatile LH secretion in
 addition to other hormone measurements. Formal polysomnography will be performed during CRU
 admissions. Subjects will be randomized to be pretreated for 2 weeks with either
 spironolactone (an androgen receptor blocker commonly used for hyperandrogenism) or placebo
 prior to the first admission; subjects will be pretreated with the other medication (placebo
 or spironolactone) for 2 weeks before the second admission in accordance with a cross-over
 design. The primary endpoint is LH pulse frequency while asleep. (LH pulse frequency while
 awake is an important secondary endpoint). The sleep-associated LH pulse frequency data from
 the spironolactone and placebo admissions will be analyzed via a hierarchical linear mixed
 model (HLMM). Secondary endpoints will include the relationships between sleep stages and LH
 pulse initiation (analyzed as per Lu et al., Neuroendocrinology 2018 [Epub ahead of print -
 doi: 10.1159/000488110]), and we will test the following hypothesis: In mid- to late pubertal
 girls with hyperandrogenism, spironolactone will enhance the ability of rapid eye movement
 (REM) sleep to inhibit LH pulse initiation.
Inclusion Criteria:

 -  Mid- to late pubertal adolescent girls as signified by either (a) post-menarcheal
 status (Tanner breast stages 2-5) or (b) Tanner breast stage of 4 or 5 (whether
 pre-menarcheal or post-menarcheal) ages 10-17 years.

 -  Hyperandrogenism, defined as a serum (calculated) free testosterone concentration
 greater than the Tanner stage-specific reference range and/or clinical hirsutism

 -  General good health (excepting obesity, hyperandrogenism, PCOS, and adequately-treated
 hypothyroidism)

 -  Willing to strictly avoid pregnancy with use of reliable non-hormonal methods during
 the study period.

 Exclusion Criteria:

 -  Inability/incapacity to provide informed consent

 -  Males will be excluded (hyperandrogenism is unique to females)

 -  Age < 10 or > 17 years (this study is designed to elucidate mechanisms underlying
 emerging PCOS in mid- to late pubertal adolescent girls

 -  Post-menarcheal by > 4 years

 -  Obesity resulting from a well-defined endocrinopathy, or genetic syndrome

 -  To ensure that blood withdrawal is within safe limits, weight < 21.5 kg is an
 exclusion criterion.

 -  Since underweight can alter pulsatile LH secretion, BMI-for-age percentile < 5 is an
 exclusion criterion.

 -  Positive pregnancy test or current lactation. Subjects with a positive pregnancy test
 will be informed of the result by the screening physician. Under Virginia law,
 parental notification is not required for minors. However, the screening physician
 will encourage the subject to tell her parent(s). We will counsel the adolescent about
 the importance of appropriate prenatal care/counseling. We will offer appropriate
 follow-up at the Teen Health Clinic at UVA and/or encourage the adolescent to secure
 prompt care via their primary care physician's office.

 -  Evidence for non-physiologic or non-PCOS causes of hyperandrogenism and/or anovulation

 -  Evidence of virilization (e.g., rapidly progressive hirsutism, deepening of the voice,
 clitoromegaly)

 -  Total testosterone > 150 ng/dl, which suggests the possibility of virilizing ovarian
 or adrenal tumor.

 -  DHEA-S elevation > 1.5 times the upper reference range limit. Mild elevations may be
 seen in adolescent HA and in PCOS, and will be accepted in these groups.

 -  Early morning 17-hydroxyprogesterone > 300 ng/dl measured in the follicular phase,
 which suggests the possibility of congenital adrenal hyperplasia (if elevated during
 the luteal phase, the 17-hydroxyprogesterone will be repeated during the follicular
 phase). NOTE: if a 17-hydorxyprogesterone > 300 ng/dl is confirmed on repeat testing,
 an ACTH stimulated 17-hydroxyprogesterone < 1000 ng/dl performed by the subject's
 personal physician will be required for study participation.

 -  Any abnormal TSH concentration will trigger repeat testing. In many cases when TSH is
 initially abnormal, a repeat TSH will be normal. These subjects will be permitted to
 continue study. If TSH remains abnormal on repeat testing, the subject will be
 referred to her primary medical provider. In some cases, a participant's primary
 medical provider will elect to simply observe a mildly low (> 0.1) or mildly elevated
 (< 10) if stable. In such cases, we will accept a TSH between 0.3 and 7 (inclusive) if
 it has remained stable for at least 6 months-such TSH values are exceedingly unlikely
 to influence the central reproductive axis or to influence the risks of the study.
 Notably, subjects with reasonably-treated primary hypothyroidism-reflected by TSH
 values between 0.3 and 7-on a stable dose of thyroid hormone (i.e., same dose for at
 least 2 months) will not be excluded.

 -  Prolactin concentration > 30 ng/mL (confirmed on repeat). Mild prolactin elevations
 may be seen in adolescents and women with HA/PCOS or obesity.

 -  History and/or physical exam findings suggestive of Cushing's syndrome, adrenal
 insufficiency, or acromegaly.

 -  History and/or physical exam findings suggestive of hypogonadotropic hypogonadism
 (e.g., symptoms of estrogen deficiency) including functional hypothalamic amenorrhea
 (which may be suggested by a constellation of symptoms including restrictive eating
 patterns, excessive exercise, psychological stress, etc.)

 -  Persistent hemoglobin < 11.5 g/dL for non-African American subjects; hemoglobin < 11.0
 g/dL for African American subjects (confirmed on repeat). Importantly, documentation
 of a hemoglobin ≥ 11.0 g/dL for African American subjects or ≥ 11.5 g/dL for
 non-African American subjects in the month prior to the CRU admission is required for
 frequent sampling protocol in the CRU.

 -  Severe thrombocytopenia (platelets < 50,000 cells/microliter) or leukopenia (total
 white blood count < 4,000 cells/microliter)

 -  Previous diagnosis of diabetes, fasting glucose ≥ 126 mg/dl, or a hemoglobin A1c ≥
 6.5%

 -  Persistently abnormal sodium or potassium concentration. Bicarbonate concentrations <
 20 or > 30.

 -  Liver test abnormalities, with two exceptions: (1) mild bilirubin elevations will be
 accepted in the setting of known Gilbert's syndrome or when the subject's primary care
 provider provides a presumptive diagnosis of Gilbert's syndrome and has no plans for
 further work-up; (2) mild transaminase (ALT, AST) elevations may be seen in
 obese/HA/PCOS girls, so stable elevations < 1.5 times the upper limit of normal will
 be accepted in this group.

 -  Absolute contraindications to spironolactone use include history of allergy to
 spironolactone, anuria, acute renal insufficiency, significant impairment of renal
 excretory function, hyperkalemia, primary adrenal insufficiency (Addison's disease),
 and concomitant use of eplerenone

 -  Significant history of cardiac or pulmonary dysfunction (e.g., known or suspected
 congestive heart failure, asthma requiring intermittent systemic corticosteroids,
 etc.)

 -  Decreased renal function evidenced by GFR < 60 ml/min/1.73m2

 -  History of cancer diagnosis and/or treatment (with the exception of basal cell or
 squamous cell skin carcinoma) unless they have remained clinically disease free (based
 on appropriate surveillance) for five years.