Acute Progesterone Suppression of Wake vs. Sleep Luteinizing Hormone Pulse Frequency in Pubertal Girls With and Without Hyperandrogenism
Acute Progesterone Suppression of Wake vs. Sleep Luteinizing Hormone Pulse Frequency in Pubertal Girls With and Without Hyperandrogenism
The purpose of this study is two-fold. (1) We will determine if in mid- to late pubertal
 girls without hyperandrogenism (HA), progesterone (P4) acutely reduces waking luteinizing
 hormone (LH) frequency to a greater extent than sleep-associated LH frequency. (2) We will
 determine if in mid- to late pubertal girls with HA, P4 will acutely suppress waking LH
 frequency to a lesser degree than it does in girls without HA.
This is a randomized, placebo-controlled, double-blinded crossover study to test the
 following hypotheses: (1) In normal mid- to late pubertal girls without hyperandrogenism
 (HA), progesterone acutely suppresses waking LH pulse frequency more than sleep-associated LH
 pulse frequency; and (2) compared to normal mid- to late pubertal girls without HA, acute
 progesterone suppression of waking LH pulse frequency is impaired in mid- to late pubertal
 girls with HA. Studies will be performed in mid- to late pubertal girls (at least Tanner
 breast stage 3 but no more than 2 years postmenarcheal). Subjects will complete two 18-hour
 Clinical Research Unit (CRU) admissions in separate menstrual cycles. Immediately before and
 during the first CRU admission, either oral micronized progesterone (0.8 mg/kg/dose) or
 placebo (randomized) will be given at 0700, 1500, 2300, and 0700 h. During the 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. A second CRU admission (performed at least 2 months later given blood
 withdrawal limits) will be identical to the first except that placebo will exchanged for
 progesterone or vice versa (treatment crossover). The primary endpoint is LH pulse frequency
 while awake. (LH pulse frequency while asleep is an important secondary endpoint.) Results in
 pubertal girls without HA were recently published (Kim et al, J Clin Endocrinol Metab
 2018;103:1112-1121). Data from girls with HA will be compared to recently-published results
 in girls without HA. Mean LH pulse frequency while awake will be analyzed via a hierarchical
 linear mixed model (HLMM). HA status (HA vs. non-HA), sleep status (wake vs. sleep), and
 treatment (progesterone vs. placebo) will represent fixed-effects, along with all associated
 interactions. Random effects will be used to account for hierarchical variance-covariance
 structure of the crossover study design. With regard to hypothesis testing, the association
 between HA status and wake LH pulse frequency will be evaluated via linear contrasts of HLMM
 least squares pulse frequency means. The differential impact of exogenous progesterone on
 wake LH pulse frequency in pubertal girls with and without HA (primary analysis) will be
 evaluated via the same testing method. Using published and preliminary data, we determined
 that, if 16 pubertal girls with HA complete both admissions, we should have at least an 80%
 chance of detecting a 0.2 pulse/hour differential effect of P4 on wake LH pulse frequency
 between the HA and the non-HA groups 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)

 -  For girls without hyperandrogenism: serum (calculated) free testosterone concentration
 within the Tanner stage-specific reference range and the absence of hirsutism

 -  For girls with hyperandrogenism: 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: Mild prolactin elevations may be seen in 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.)

 -  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 such girls.

 -  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.

 -  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).