Hyperandrogenemia and Altered Day-night LH Pulse Patterns
Hyperandrogenemia and Altered Day-night LH Pulse Patterns
The purpose of this study is to determine if, in mid- to late pubertal girls with
 hyperandrogenism, androgen-receptor blockade (spironolactone) improves the ability of
 progesterone to acutely reduce waking luteinizing hormone pulse frequency (primary endpoint).
This is a randomized, placebo-controlled, double-blinded crossover study to test the
 following hypothesis: In mid- to late pubertal girls with hyperandrogenism (HA), acute
 progesterone suppression of waking LH pulse frequency is greater after 2 weeks of
 spironolactone pretreatment compared to after 2 weeks of placebo pretreatment. We will only
 study mid- to late pubertal girls with HA (i.e., girls who would be candidates for
 therapeutic spironolactone use). Subjects will complete two 18-hour Clinical Research Unit
 (CRU) admissions in separate menstrual cycles. Subjects will be randomized to be pretreated
 for 2 weeks with either oral spironolactone (50 mg twice daily) or placebo prior to the first
 CRU admission. Immediately before and during each CRU admission, oral micronized progesterone
 (0.8 mg/kg/dose) will be given at 0700, 1500, 2300, and 0700 h. During each CRU admission,
 blood will be obtained every 10 minutes through an indwelling iv catheter from 1800 to 1200
 h. This will allow full characterization of pulsatile LH secretion in addition to other
 hormone measurements. Formal polysomnography will be performed during CRU admissions. A
 second CRU admission (performed at least 2 months later given blood withdrawal limits) will
 be identical to the first except that placebo pretreatment will exchanged for spironolactone
 pretreatment or vice versa (treatment crossover). The primary endpoint is LH pulse frequency
 while awake. (LH pulse frequency while asleep is an important secondary endpoint.) The wake
 LH pulse frequency data from the spironolactone and placebo admissions will be analyzed via a
 hierarchical linear mixed model (HLMM). The admission (spironolactone vs. placebo) will
 represent the fixed effect factor of the HLMM. Random effects will be utilized to account for
 the hierarchical variance-covariance structure of the two-period cross-over design. Wake LH
 pulse frequency in response to exogenous progesterone will be compared between the
 spironolactone admission and the placebo admission via a linear contrast of the HLMM least
 squares LH pulse frequency means. A similar analysis will be performed for sleep-related LH
 pulse frequency. Using published and preliminary data, we determined that, if 16 mid- to late
 pubertal girls with HA complete both admissions, we should have at least an 80% chance of
 detecting a 0.35 pulse/hour mean within-subject difference in wake LH pulse frequency between
 the spironolactone and placebo admissions with a two-sided false positive rejection rate of
 no more than 0.05.
Inclusion Criteria:

 -  Mid- to late pubertal adolescent girl (at least Tanner breast stage 3, but no more
 than 2 years postmenarcheal)

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

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

 -  Capable of and willing to provide informed assent (adolescents under age 16 years)
 and/or consent (adolescents over age 16 years; custodial parents or guardians of all
 adolescent volunteers)

 -  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)

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

 -  Positive pregnancy test or current lactation

 -  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 > 200 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-hydroxyprogesterone > 200 ng/dl is confirmed on repeat testing,
 an ACTH stimulated 17-hydroxyprogesterone < 1000 ng/dl will be required for study
 participation.

 -  Abnormal thyroid stimulating hormone (TSH): Note that subjects with stable and
 adequately treated primary hypothyroidism, reflected by normal TSH values, will not be
 excluded.

 -  Hyperprolactinemia > 20% higher than the upper limit of normal. Mild prolactin
 elevations may be seen in adolescents and women with HA/PCOS, and elevations within
 20% higher than the upper limit of normal will be accepted in this group.

 -  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 hematocrit < 36% and hemoglobin < 12 g/dl.

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

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

 -  Persistent liver panel abnormalities, with two exceptions. Mild bilirubin elevations
 will be accepted in the setting of known Gilbert's syndrome. Also, mild transaminase
 elevations may be seen in obesity/HA/PCOS; therefore, elevations < 1.5 times the upper
 limit of normal will be accepted in this group.

 -  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

 -  A personal history of breast, ovarian, or endometrial cancer

 -  History of any other 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

 -  History of allergy to micronized progesterone or spironolactone

 -  Body mass index (BMI)-for-age percentile < 5% (underweight)

 -  Due to the amount of blood being drawn, adolescent volunteers with body weight < 25 kg
 will be excluded.

 -  Restrictions on use of other drugs or treatments: No medications known to affect the
 reproductive system, glucose metabolism, lipid metabolism, or blood pressure can be
 taken in the 2 months prior to the screening visit and in the 3 months prior to the
 start of the study medications. Such medications include oral contraceptive pills,
 progestins, metformin, systemic glucocorticoids, some antipsychotic medications, and
 sympathomimetics/stimulants (e.g., methylphenidate).