Androgen Excess as a Cause for Adipogenic Dysfunction in PCOS Women
Condition: Polycystic Ovary Syndrome (PCOS)
MeSH terms: Polycystic Ovary Syndrome; Hyperandrogenism
Study type: Interventional
Phase: Phase 2

Summary: 
      The purpose of this research study is to collect specimen samples and study medical
      information from women with Polycystic Ovary Syndrome (PCOS) and women without PCOS. The goal
      is to learn more about the changes that take place in the body that result in PCOS.

      We anticipate that 32 women will take part in this study (16 without PCOS and 16 with PCOS).
      All patients will undergo a physical exam, blood tests, and ultrasound of their ovaries. If
      they meet the criteria for this study, they will then undergo additional blood tests, removal
      of a small amount of subcutaneous abdominal fat, measurement of regional body fat (i.e., DXA
      scan) and a modified frequently-sampled intravenous glucose tolerance test (FSIGTT). The
      women without PCOS will complete the study at this point.

      The women with PCOS will be randomized to receive the drug flutamide 125 mg/day or placebo.
      They will take the drug every day for six 28-day cycles. They will be asked to collect and
      store a urine sample once a week. They will also be asked to complete a pill diary and
      menstrual diary. Once a month while they are taking the flutamide/placebo, they will return
      to the clinic and bring their frozen urine samples. At that time they will undergo a physical
      exam, toxicity assessment, and blood draw.

      Quality of Life assessments will be done at the beginning of the study for all participants.
      Women with PCOS who are taking the flutamide or placebo will be asked to repeat the Quality
      of Life assessments during the study and at the end of the study.

      After the six 28-day cycles are completed they will then undergo additional blood tests,
      removal of a small amount of subcutaneous abdominal fat, measurement of regional body fat
      (i.e., DXA scan) and a modified frequently-sampled intravenous glucose tolerance test
      (FSIGTT).

      Six months following the completion of all study protocol procedures, participants who
      received flutamide/placebo will be contacted by phone to check on the status of their health.
      They will be asked if they have experienced any health problems or have become pregnant since
      they completed the study procedures.
    

Detailed description: 
      Aim 1. Examine mechanisms of subcutaneous abdominal adipose (fat) development in
      normal-weight PCOS women vs. BMI- and age-matched normal (control) women.

      Subjects and clinical assessment: We will recruit 16 lean (18.5-25 kg/M2) PCOS subjects and
      16 age- and BMI-matched controls. Subjects will complete a standardized questionnaire
      emphasizing menstrual dating, abnormal hair growth and acne. The questionnaire also will
      annotate age, smoking status, medications, surgical history and family histories of excess
      hair growth in female relatives and of diabetes in parents or siblings for exclusion criteria
      and for inclusion of some basic traits as covariates. Subjects also will undergo a physical
      examination; hirsutism will be scored by the modified Ferriman-Gallwey (mFG) method.
      Transvaginal sonography (TVUS) will be performed to determine the presence or absence of
      polycystic ovaries. A screening blood sample will be obtained for determinations of steroid
      hormones, SHBG, TSH, and prolactin.

      Women of any ethnicity between the ages of 18 and 35 years will be recruited. PCOS patients
      will be diagnosed by 1990 NIH criteria. Controls will have regular menstrual cycles at 21 to
      35 day intervals, a luteal phase progesterone (P4) level > 3 ng/mL, and no evidence of
      hirsutism, acne, alopecia, polycystic ovaries or endocrine dysfunction. Exclusion criteria
      are: present/past history (<1 year) of smoking, cancer, alcohol abuse, drug addiction, severe
      depression, or post traumatic stress; diabetes; uncontrolled hypertension (≥ 165/100);
      clinically significant hepatic or renal disease, or other major medical illness; signs or
      symptoms of infection; recent (within 30 days) use of an experimental device; recent (within
      3 months) use of androgens, anabolic steroids or non-steroidal anti-inflammatory drugs;
      recent (within 3 months) use of hormonal agents (including birth control pills or insulin
      sensitizers); use of the drug warfarin.

      Studies will be conducted in the follicular phase in controls and during amenorrhea in PCOS
      women. All subjects will undergo a modified frequently-sampled intravenous glucose tolerance
      test (FSIGTT). Glucose in the form of a 50% solution (0.3 g/kg) and regular human insulin
      (0.03 units/kg) will be injected through an intravenous line at 0 and 20 min, respectively.
      Blood will be collected at -20, -15, -5, 0, 2, 4, 8, 19, 22, 30, 40, 50, 70, 90, and 180 min
      for glucose and insulin determinations. Mathematical modeling of serial glucose and insulin
      determinations will calculate: insulin sensitivity index (SI, i.e. the action of insulin to
      accelerate glucose uptake and suppress glucose production), glucose effectiveness index (SG,
      i.e. the combined effect of glucose to enhance glucose uptake and suppress endogenous glucose
      production at basal insulin levels) and the acute response to glucose (AIRG).

      Adipocytes isolation and culture: Approximately 1-2 gms of fat will be obtained from the
      lower SC abdomen using standard procedures under local anesthesia. Adipocytes (fat cells) and
      surrounding fat tissue will be isolated to measure adipocyte cell number and diameter, lipid
      accumulation and function, adiponectin, and stem cell development.

      Procedures: All procedures will be performed in normal and PCOS women at the start of study.

      i). Venipuncture: Fasting blood will be collected for blood count, chemistry panel, LH, FSH,
      total/free T, DHT, A4, DHEAS, E1, E2, anti-mullerian hormone (AMH), SHBG, adiponectin,
      leptin, IL-6, lipid profile and free fatty acids (FFAs).

      ii ). Body composition: Body composition will be assessed by BMI, waist-to-hip circumference
      and DEXA scanning. Girths will be measured at the waist (narrowest section of the torso
      between ribs and umbilicus) and hips (largest protrusion of the hip region, above the gluteal
      fold). For total body fat and regional fat distribution, whole body scans will be performed,
      utilizing DEXA imaging.

      iii). Body fat distribution: Total body DEXA will measure abdominal fat (i.e., the area
      between the dome of the diaphragm and the top of the hip. Total body DEXA images also will
      determine % body fat; fat-free body mass; total body, abdominal, and leg fat; and abdomen/leg
      fat mass ratio. The leg region is that area below the top of the hip bone (greater
      trochanter).

      iv). Ovarian testing: Transvaginal ultrasound will be performed in the follicular phase in
      controls and during amenorrhea in PCOS women. Ovarian volume will be calculated. Antral
      follicle number, defined as the total follicle number (2-9 mm in diameter) of both ovaries,
      will be determined by 1 investigator (D.A.D.). Polycystic ovaries will be identified, with
      one such ovary sufficient to define PCO

      Aim 2. Determine the role of androgen in SC abdominal ASC dysfunction and its relation to
      metabolism in normal-weight PCOS women through androgen. antagonism by clinical use of
      flutamide vs. placebo.

      Modified FSIGTT and Adipogenic studies: The modified FSIGTT and all adipogenic studies
      performed at study initiation will be repeated at the end of the 6-month flutamide vs.
      placebo intervention in PCOS women.

      Procedures: All procedures performed at study initiation also will be repeated at the end of
      the six 28-day cycles of flutamide vs. placebo intervention in PCOS women. In addition,
      monthly liver function studies will be performed to detect possible elevations of serum
      transaminase levels above the normal range during flutamide vs. placebo therapy.

      Menstrual records: Ovulatory frequency will be determined by having subjects keep a daily
      menstrual record and collect weekly first morning urine samples for possible progesterone and
      creatinine determinations. Urine samples will be frozen for later analysis to determine
      evidence of ovulation, as necessary.

      Aim 3. Identify epigenetic changes that underlie SC abdominal ASC dysfunction in
      normal-weight PCOS women vs. BMI- and age-matched controls.

      Subcutaneous abdominal adipose stem cells from PCOS and control women will be grown into
      newly-formed fat cells (adipocytes) in the laboratory. Cells will be studied before and after
      6-month treatment with placebo vs flutamide for changes in the cell epigenome (methylation,
      RNA sequences and histone modification).
    

Intervention name(s): Flutamide; Placebo
Intervention type(s): Drug; Other
Intervention description(s): Flutamide 125 mg orally each 28 day cycle for 6 cycles; Placebo orally each 28 day cycle for 6 cycles
Other intervention name(s): Euflex
Intervention MeSH terms: Flutamide
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Triple (Participant, Investigator, Outcomes Assessor)
Primary purpose: Treatment
Keywords: polycystic ovary syndrome; hirsutism; anovulation; oligomenorrhea; amenorrhea; hyperandrogenism; antiandrogen effect