Pathogenesis of Functional Hyperandrogenism in Women With Type 1 Diabetes Mellitus: From Genetic-molecular Mechanisms to Clinical Phenotype.
试验速览
- 阶段
- 不适用
- 状态
- 招募中
- 入组人数
- 60
- 试验地点
- 2
- 主要终点
- Differences in insulin sensitivity between study subgroups
研究概览
简要总结
BACKGROUND Functional ovarian hyperandrogenism, including the polycystic ovary syndrome (PCOS), is very prevalent in women with type 1 diabetes (T1D). The pathogenic mechanisms of this association remain unclear.
HYPOTHESIS Individual factors expose or protect women with T1D to/from the development of androgen excess and PCOS. Such androgen excess in women with T1D may increase their cardiometabolic risk.
MAIN OBJECTIVE Unveiling the pathogenic mechanisms behind functional hyperandrogenism in women with T1D from a sex/gender-medicine and sexual dimorphism perspective.
MATERIAL AND METHOS We have designed a cross-sectional comparative clinical study, including 5 groups of study subjects with 12 participans per group:
i) Women with T1D & PCOS. ii) Women with T1D without PCOS. iii) Men with T1D and normal gonadal function. iv) Women with PCOS without diabetes mellitus v) Non-hyperandrogenic control women without T1D. All groups will show similar age and body mass index. T1D groups will be matched for duration of disease.
OUTCOMES 1.1 Insulin sensitivity (hyperinsulinaemic euglycaemic clamping). 1.2 Body composition (dual-energy x-ray absorptiometry, bioelectrical impedance analysis & sonographic studies).
1.3 Ovarian and adrenal steroidogenesis. 2.1 Differential pattern in genetic variants related with insulin signalling and response, inflammation, adiposity, gonadal function, steroidogenesis, and PCOS itself by whole exome sequencing.
2.2 Microbiopsy studies in deep subcutaneous adipose tissue and skeletal muscle tissue: 2.2.1 Differential DNA methylation patterns in genes associated with PCOS. 2.2.2 Differential transcriptomic pattern in genes associated with PCOS.
2.2.3 Differential proteomic patterns in adipose and muscle tissues. 3. Interaction between T1D and PCOS on parameters of metabolic control (intersticial blood glucose monitoring) and morbidities associated with T1D itself.
详细描述
Functional ovarian hyperandrogenism, and its most frequent phenotypic expression, polycystic ovary syndrome (PCOS), has a worldwide prevalence similar to that of other pandemic metabolic entities such as type 2 diabetes, with figures ranging from 6.5% of women in our environment using strict classical criteria to 17-21% of premenopausal women from Europe and the United States, according to the most recent and inclusive diagnostic criteria. Almost all classic and non-classic cardiovascular risk factors cluster in women with this condition from their early lifespan. Conditions such as obesity, type 2 diabetes, hypertension, or dyslipidaemia, place this prevalent population at a higher risk of cardiovascular events compared to non-hyperandrogenic women. PCOS is a complex syndrome with familial aggregation, in which protective and facilitating environmental factors trigger the onset of the hyperandrogenic phenotype and its metabolic repercussions on a predisposing genotype.
POLYCYSTIC OVARY SYNDROME AND TYPE 1 DIABETES MELLITUS One of the metabolic events inherent to PCOS is a deficient organ-dependent insulin action primarily at the liver. Acting upon this central defect, obesity is the major contributor to peripheral insulin resistance in these women. Since insulin acts as a co-gonadotrophin on theca cells by stimulating various enzymes involved in ovarian and adrenal steroidogenesis, any condition associating endogenous hyperinsulinism, such as obesity or type 2 diabetes, may be associated with PCOS. However, our research group first described the association between PCOS and T1D more than 20 years ago. In that pivotal publication these adolescent and young adult women, who suffered from complete impairment of insulin secretion as the primary mechanism of disease instead of insulin resistance and compensatory hyperinsulinism, had a 3-fold increase in the prevalence of classic PCOS compared with unselected non-hyperandrogenic women from the general population.
This association has been confirmed in subsequent studies conducted by different groups worldwide. In a recent meta-analysis and systematic review by our group, we reported an increased prevalence of PCOS; in its upper range, such prevalence might reach 34% of patients with T1D, tripling the figures observed in the general population for the classic PCOS phenotype, which is the most severe in terms of cardiometabolic consequences. From a pathophysiological view, and given the obvious absence of endogenous hyperinsulinism in T1D, this relationship must be necessarily supported by exogenous subcutaneous insulin delivery. In healthy subjects, insulin directly reaches the liver through the portal circulation after its pancreatic secretion. After exerting its actions at this level, with its subsequent hepatic clearance, insulin passes into the systemic circulation at much lower concentrations than those found in the portal circulation. In PCOS and other insulin-resistant states, insulin resistance is compensated by increased pancreatic insulin secretion, resulting in portal and systemic hyperinsulinism. In contrast, in subjects with T1D, insulin is administered subcutaneously (non-physiologically) and exerts its actions on different organs and tissues, including the gonads and adrenal cortex, before reaching liver tissue at concentrations sufficient to suppress gluconeogenesis; hence, systemic insulin concentrations are necessarily supraphysiological for this reason. In contrast, hepatic insulin levels are not excessive, since this would precipitate hypoglycaemia, and this explains the constant finding of normal levels of sex hormone binding globulin (SHBG) in women with T1D and PCOS. In contrast, in women with PCOS without T1D, SHBG synthesis and secretion is decreased as a consequence of portal hyperinsulinism (certain adipokines secreted by visceral adipose tissue also contribute to this inhibition), a situation that does not occur in women with T1D in the absence of hepatic hyperinsulinism.
A few studies have reported a negative interaction between T1D and PCOS in terms of micro- or macrovascular complications. Nevertheless, the possibility that androgen excess negatively affects adipose tissue distribution in women with T1D and PCOS is plausible, placing them at risk for increased abdominal adiposity and insulin resistance. On the other hand, similarly to those women at high risk of PCOS in the general population - for example, those with obesity, even extreme obesity, or first-degree relatives of women with PCOS - who do not develop characteristics of the syndrome, not all patients with T1D, universally treated with subcutaneous insulin, will develop PCOS, indicating that a predisposition to PCOS is a conditio sine qua non for its occurrence.
DEFECTS IN OVARIAN AND ADRENAL STEROIDOGENESIS Both the fact that PCOS is not universal in women with insulin resistance and hyperinsulinism, and that insulin resistance is not universal in all women with PCOS, suggests that there is a primary defect that favours androgen excess in affected women, and that this is essential for the development of the syndrome in response to insulin or other triggers. The elegant studies conducted by the McAllister's group 20 years ago at the University of Pennsylvania demonstrated that, after several passes in primary culture, theca cells from patients with PCOS produced an excess androgen secretion compared to those of control women without the syndrome. This occurred because an intrinsically increased expression and activity of the enzyme 17α-hydroxylase/17,20-desmolase (P450c17, CYP17), the qualitative regulatory enzyme of sex steroid synthesis that catalyses both the 17α-hydroxylation of pregnenolone and progesterone, and the conversion of 17α-hydroxypregnenolone to dehydroepiandrosterone. The 17,20-desmolase activity of the enzyme is regulated by post-transcriptional mechanisms, including phosphorylation of the serine/threonine residues of the enzyme itself. The same group also demonstrated increased expression in theca cells of women with PCOS of the P450scc enzyme, which is the quantitative regulatory enzyme of ovarian and adrenal steroidogenesis that catalyses the conversion of cholesterol to pregnenolone after cholesterol transfer from the outer to the inner mitochondrial membrane by the steroidogenesis acute regulatory protein (StAR). Since any factor that could influence these theca cells in vivo were, obviously, not present after several culture passes, these alterations place excessive androgen production as a primary ovarian defect in PCOS, corroborating clinical findings such as hyper-responsiveness of 17-hydroxyprogesterone to gonadotrophin stimulation or persistent hyperandrogenemia after suppression of adrenal steroidogenesis.
研究设计
- 研究类型
- Observational
- 观察模型
- Case Control
- 时间视角
- Cross Sectional
入排标准
- 年龄范围
- 18 Years 至 45 Years（Adult）
- 性别
- All
- 接受健康志愿者
- 是
入选标准
- •Non--hyperandrogenic women with type 1 diabetes INCLUSION CRITERIA
- •Premenopausal women between 18 and 45 years old.
- •Diagnosis of type 1a diabetes at least 12 months before inclusion in the study, confirmed by positive autoimmunity and complete insulin deficiency.
- •Treatment with subcutaneous insulin therapy (multiple doses or continuous infusion).
- •Availability of metabolic control data (continuous interstitial blood glucose monitoring) at least in the month prior to study entry.
- •Menarche at least three years prior to study entry.
排除标准
- •Honeymoon period of T1D.
- •Pregnancy or lactation.
- •Thyroid hormone dysfunction or hyperprolactinaemia.
- •Diagnosis of non-classical congenital adrenal hyperplasia or other secondary causes of hyperandrogenism.
- •Diagnosis of other serious chronic disease.
- •Treatment with oral contraceptives or glucocorticoid therapy in the 3 months prior to inclusion in the study.
- •Women with type 1 diabetes and polycystic ovary syndrome INCLUSION CRITERIA
- •Women between 18 and 45 years old.
- •Diagnosis of type 1a diabetes at least 12 months before inclusion in the study, confirmed by positive autoimmunity and complete insulin deficiency.
- •Treatment with subcutaneous insulin therapy (multiple doses or continuous infusion).
- •Availability of metabolic control data (continuous interstitial blood glucose monitoring) at least in the month prior to study entry.
- •Menarche at least three years prior to study entry.
- •PCOS diagnosis based on the 2012 American NIH consensus criteria, including the Rotterdam and AE-PCOS.
- •EXCLUSION CRITERIA
- •Honeymoon period of T1D.
- •Pregnancy/lactation.
- •Thyroid hormone dysfunction or hyperprolactinaemia.
- •Diagnosis of non-classical congenital adrenal hyperplasia or other secondary causes of hyperandrogenism.
- •Diagnosis of other serious chronic disease. reatment with oral contraceptives or glucocorticoid therapy in the 3 months prior to inclusion in the study.
- •Men with T1D and normal gonadal function of similar age, BMI, and duration of diabetes.
- •INCLUSION CRITERIA
- •Age between 18 and 45 years old.
- •Diagnosis of type 1a diabetes at least 12 months before inclusion in the study, confirmed by positive autoimmunity and complete insulin deficiency.
- •Treatment with subcutaneous insulin therapy (multiple doses or continuous infusion).
- •Availability of metabolic control data (continuous interstitial blood glucose monitoring) at least in the month prior to study entry.
- •EXCLUSION CRITERIA
- •Honeymoon period of T1D.
- •Thyroid hormone dysfunction or hyperprolactinaemia.
- •Diagnosis of non-classical congenital adrenal hyperplasia.
- •Diagnosis of male hypogonadism.
- •Women with PCOS of similar age and BMI. INCLUSION CRITERIA
- •Women between 18 and 45 years old.
- •Menarche at least three years prior to study entry.
- •PCOS diagnosis based on the 2012 American NIH consensus criteria, including the Rotterdam and AE-PCOS.
- •EXCLUSION CRITERIA
- •Pregnancy/lactation.
- •Previously known carbohydrate metabolism abnormalities (prediabetes or type 2 diabetes).
- •Thyroid hormone dysfunction or hyperprolactinaemia.
- •Diagnosis of non-classical congenital adrenal hyperplasia or other secondary causes of hyperandrogenism.
- •Diagnosis of other serious chronic disease.
- •Treatment with oral contraceptives or glucocorticoid therapy in the 3 months prior to inclusion in the study.
- •Non-hyperandrogenic control women with regular menses of similar age and BMI. INCLUSION CRITERIA
- •Women between 18 and 45 years old.
- •Menarche at least three years prior to study entry.
- •Presence of regular menses.
- •Lack of signs or symptoms of functional hyperandrogenism. EXCLUSION CRITERIA
- •Pregnancy/lactation.
- •Previously known carbohydrate metabolism disturbances.
- •Thyroid hormone dysfunction or hyperprolactinaemia.
- •Diagnosis of non-classical congenital adrenal hyperplasia or other secondary causes of hyperandrogenism.
- 另有 2 项未显示
研究组 & 干预措施
Women with type 1 diabetes and polycystic ovary syndrome
INCLUSION CRITERIA
- Women between 18 and 45 years old.
- Diagnosis of type 1a diabetes at least 12 months before inclusion in the study, confirmed by positive autoimmunity and complete insulin deficiency.
- Treatment with subcutaneous insulin therapy (multiple doses or continuous infusion).
- Availability of metabolic control data (continuous interstitial blood glucose monitoring) at least in the month prior to study entry.
- Menarche at least three years prior to study entry.
- PCOS diagnosis based on the 2012 American NIH consensus criteria, including the Rotterdam and AE-PCOS.
EXCLUSION CRITERIA
- Honeymoon period of T1D.
- Pregnancy/lactation.
- Thyroid hormone dysfunction or hyperprolactinaemia.
- Diagnosis of non-classical congenital adrenal hyperplasia or other secondary causes of hyperandrogenism.
- Diagnosis of other serious chronic disease. reatment with oral contraceptives or glucocorticoid therapy in the 3 months prior to inclusion in the study.
干预措施: Elevated circulating androgen levels (Other)
Men with T1D and normal gonadal function of similar age, BMI, and duration of diabetes.
INCLUSION CRITERIA
- Age between 18 and 45 years old.
- Diagnosis of type 1a diabetes at least 12 months before inclusion in the study, confirmed by positive autoimmunity and complete insulin deficiency.
- Treatment with subcutaneous insulin therapy (multiple doses or continuous infusion).
- Availability of metabolic control data (continuous interstitial blood glucose monitoring) at least in the month prior to study entry.
EXCLUSION CRITERIA
- Honeymoon period of T1D.
- Thyroid hormone dysfunction or hyperprolactinaemia.
- Diagnosis of non-classical congenital adrenal hyperplasia.
- Diagnosis of male hypogonadism.
干预措施: Elevated circulating androgen levels (Other)
Women with type 1 diabetes and polycystic ovary syndrome
INCLUSION CRITERIA
- Women between 18 and 45 years old.
- Diagnosis of type 1a diabetes at least 12 months before inclusion in the study, confirmed by positive autoimmunity and complete insulin deficiency.
- Treatment with subcutaneous insulin therapy (multiple doses or continuous infusion).
- Availability of metabolic control data (continuous interstitial blood glucose monitoring) at least in the month prior to study entry.
- Menarche at least three years prior to study entry.
- PCOS diagnosis based on the 2012 American NIH consensus criteria, including the Rotterdam and AE-PCOS.
EXCLUSION CRITERIA
- Honeymoon period of T1D.
- Pregnancy/lactation.
- Thyroid hormone dysfunction or hyperprolactinaemia.
- Diagnosis of non-classical congenital adrenal hyperplasia or other secondary causes of hyperandrogenism.
- Diagnosis of other serious chronic disease. reatment with oral contraceptives or glucocorticoid therapy in the 3 months prior to inclusion in the study.
干预措施: Type 1 diabetes mellitus (Other)
Women with type 1 diabetes and polycystic ovary syndrome
INCLUSION CRITERIA
- Women between 18 and 45 years old.
- Diagnosis of type 1a diabetes at least 12 months before inclusion in the study, confirmed by positive autoimmunity and complete insulin deficiency.
- Treatment with subcutaneous insulin therapy (multiple doses or continuous infusion).
- Availability of metabolic control data (continuous interstitial blood glucose monitoring) at least in the month prior to study entry.
- Menarche at least three years prior to study entry.
- PCOS diagnosis based on the 2012 American NIH consensus criteria, including the Rotterdam and AE-PCOS.
EXCLUSION CRITERIA
- Honeymoon period of T1D.
- Pregnancy/lactation.
- Thyroid hormone dysfunction or hyperprolactinaemia.
- Diagnosis of non-classical congenital adrenal hyperplasia or other secondary causes of hyperandrogenism.
- Diagnosis of other serious chronic disease. reatment with oral contraceptives or glucocorticoid therapy in the 3 months prior to inclusion in the study.
干预措施: Sex dimorphism (Other)
Men with T1D and normal gonadal function of similar age, BMI, and duration of diabetes.
INCLUSION CRITERIA
- Age between 18 and 45 years old.
- Diagnosis of type 1a diabetes at least 12 months before inclusion in the study, confirmed by positive autoimmunity and complete insulin deficiency.
- Treatment with subcutaneous insulin therapy (multiple doses or continuous infusion).
- Availability of metabolic control data (continuous interstitial blood glucose monitoring) at least in the month prior to study entry.
EXCLUSION CRITERIA
- Honeymoon period of T1D.
- Thyroid hormone dysfunction or hyperprolactinaemia.
- Diagnosis of non-classical congenital adrenal hyperplasia.
- Diagnosis of male hypogonadism.
干预措施: Type 1 diabetes mellitus (Other)
Men with T1D and normal gonadal function of similar age, BMI, and duration of diabetes.
INCLUSION CRITERIA
- Age between 18 and 45 years old.
- Diagnosis of type 1a diabetes at least 12 months before inclusion in the study, confirmed by positive autoimmunity and complete insulin deficiency.
- Treatment with subcutaneous insulin therapy (multiple doses or continuous infusion).
- Availability of metabolic control data (continuous interstitial blood glucose monitoring) at least in the month prior to study entry.
EXCLUSION CRITERIA
- Honeymoon period of T1D.
- Thyroid hormone dysfunction or hyperprolactinaemia.
- Diagnosis of non-classical congenital adrenal hyperplasia.
- Diagnosis of male hypogonadism.
干预措施: Sex dimorphism (Other)
Women with PCOS of similar age and BMI.
INCLUSION CRITERIA
- Women between 18 and 45 years old.
- Menarche at least three years prior to study entry.
- PCOS diagnosis based on the 2012 American NIH consensus criteria, including the Rotterdam and AE-PCOS.
EXCLUSION CRITERIA
- Pregnancy/lactation.
- Previously known carbohydrate metabolism abnormalities (prediabetes or type 2 diabetes).
- Thyroid hormone dysfunction or hyperprolactinaemia.
- Diagnosis of non-classical congenital adrenal hyperplasia or other secondary causes of hyperandrogenism.
- Diagnosis of other serious chronic disease.
- Treatment with oral contraceptives or glucocorticoid therapy in the 3 months prior to inclusion in the study.
干预措施: Elevated circulating androgen levels (Other)
Non-hyperandrogenic control women with regular menses of similar age and BMI
INCLUSION CRITERIA
- Women between 18 and 45 years old.
- Menarche at least three years prior to study entry.
- Presence of regular menses.
- Lack of signs or symptoms of functional hyperandrogenism. EXCLUSION CRITERIA
- Pregnancy/lactation.
- Previously known carbohydrate metabolism disturbances.
- Thyroid hormone dysfunction or hyperprolactinaemia.
- Diagnosis of non-classical congenital adrenal hyperplasia or other secondary causes of hyperandrogenism.
- Diagnosis of other serious chronic disease.
- Treatment with oral contraceptives or glucocorticoid therapy in the 3 months prior to inclusion in the study.
干预措施: Sex dimorphism (Other)
Women with PCOS of similar age and BMI.
INCLUSION CRITERIA
- Women between 18 and 45 years old.
- Menarche at least three years prior to study entry.
- PCOS diagnosis based on the 2012 American NIH consensus criteria, including the Rotterdam and AE-PCOS.
EXCLUSION CRITERIA
- Pregnancy/lactation.
- Previously known carbohydrate metabolism abnormalities (prediabetes or type 2 diabetes).
- Thyroid hormone dysfunction or hyperprolactinaemia.
- Diagnosis of non-classical congenital adrenal hyperplasia or other secondary causes of hyperandrogenism.
- Diagnosis of other serious chronic disease.
- Treatment with oral contraceptives or glucocorticoid therapy in the 3 months prior to inclusion in the study.
干预措施: Sex dimorphism (Other)
Non--hyperandrogenic women with type 1 diabetes
INCLUSION CRITERIA
- Premenopausal women between 18 and 45 years old.
- Diagnosis of type 1a diabetes at least 12 months before inclusion in the study, confirmed by positive autoimmunity and complete insulin deficiency.
- Treatment with subcutaneous insulin therapy (multiple doses or continuous infusion).
- Availability of metabolic control data (continuous interstitial blood glucose monitoring) at least in the month prior to study entry.
- Menarche at least three years prior to study entry. EXCLUSION CRITERIA
- Honeymoon period of T1D.
- Pregnancy or lactation.
- Thyroid hormone dysfunction or hyperprolactinaemia.
- Diagnosis of non-classical congenital adrenal hyperplasia or other secondary causes of hyperandrogenism.
- Diagnosis of other serious chronic disease.
- Treatment with oral contraceptives or glucocorticoid therapy in the 3 months prior to inclusion in the study.
干预措施: Type 1 diabetes mellitus (Other)
Non--hyperandrogenic women with type 1 diabetes
INCLUSION CRITERIA
- Premenopausal women between 18 and 45 years old.
- Diagnosis of type 1a diabetes at least 12 months before inclusion in the study, confirmed by positive autoimmunity and complete insulin deficiency.
- Treatment with subcutaneous insulin therapy (multiple doses or continuous infusion).
- Availability of metabolic control data (continuous interstitial blood glucose monitoring) at least in the month prior to study entry.
- Menarche at least three years prior to study entry. EXCLUSION CRITERIA
- Honeymoon period of T1D.
- Pregnancy or lactation.
- Thyroid hormone dysfunction or hyperprolactinaemia.
- Diagnosis of non-classical congenital adrenal hyperplasia or other secondary causes of hyperandrogenism.
- Diagnosis of other serious chronic disease.
- Treatment with oral contraceptives or glucocorticoid therapy in the 3 months prior to inclusion in the study.
干预措施: Sex dimorphism (Other)
结局指标
主要结局
Differences in insulin sensitivity between study subgroups
时间窗: At baseline
Study of sensitivity to insulin action by hyperinsulinaemic euglycaemic clamp. Clamping will be conducted in the follicular phase fo women's study participants. In this protocol free fatty acids will be also determined in stored samples.
Fat mass percentage
时间窗: At baseline
Body composition studies: Fat mass percentage with respect to total body weight. Methodology: Bioelectrical impedance analysis by Monitor VitalScan Medeia® System device (United States, CA).
Phase angle 50 KHz
时间窗: At baseline
Methodology: Bioelectrical impedance analysis by Monitor VitalScan Medeia® System device (United States, CA).
Peritoneum-vertebral column fat thickness
时间窗: At baseline
Ultrasound assessment of fat compartments, determined using Toshiba Nemio ZG SSA-580ª ultrasound equipment (Toshiba Medical Systems, S.A., Alcobendas, Madrid) following the protocol previously validated and reported by our research group (PMID: 23386652).
Trunk fat mass %
时间窗: At baseline
Dual energy X-ray absorptiometry (DEXA). Hologic QDR Explorer® equipment.
Differences in ovarian and adrenal steroidogenesis between study subgroups
时间窗: At baseline
The circulating sex steroid profile will be assessed at baseline and at 60 minutes after stimulation of adrenal steroidogenesis with administration of 250 mcg i.v. of 1-24 ACTH. This profile will be determined in serum samples by liquid chromatography followed by tandem mass spectrometry (LC-MS/MS) at the Laboratory of Clinical Biology, Ghent University, Belgium, using a triple-quadrupole mass spectrometer (AB Sciex, Toronto, Canada). The 24h urine steroid metabolomic profile will be analysed by gas chromatography-mass spectrometry (GC-MS). The analytical procedure will be performed by pre-extraction of urine (solid phase extraction with Sep-Pak C18 columns), followed by hydrolysis, solid phase re-extraction and double derivatization of the steroids to their methoxymethyltrimethylsilyl derivatives. The extracts obtained will be injected into the Shimadzu GCMS QP2010 instrument.
次要结局
- Identify genomic variants in genes/proteins related to insulin signalling and action, adiposity, inflammation, steroidogenesis, and PCOS itself(At baseline)
- Description of differential DNA methylation patterns in deep subcutaneous adipose and skeletal muscle tissues (Epigenomics)(At baseline)
- Description of differential gene expression profiles in adipose and muscle tissues (Transcriptomics)(At baseline)
- Description of differential proteomic profiles in adipose and muscle tissue (Proteomics)(At baseline)
研究者
Manuel Luque Ramírez
Clinical researcher
Fundacion para la Investigacion Biomedica del Hospital Universitario Ramon y Cajal