HYPOTHALAMIC-PITUITARY GONADAL AXIS

Introduction
Following decades of research into understanding the intricate regulation of gonadal function, a
decapeptide (initially termed Luteinizing hormone releasing factor) Gonadotrophin releasing
hormone GnRH was identified as the key regulator of gonadal function. In recognition of their
work, Schally and Guilleman were awarded the Nobel prize in medicine in 1977. The
hypothalamus and anterior pituitary gland work in synergy to regulate the functions of the
gonads in males and females.

HYPOTHALAMUS
The hypothalamus is derived from the forebrain tissue on either side of the third ventricle and
links the nervous system to the endocrine system through the pituitary gland. The
hypothalamus directly innervates the posterior lobe of the pituitary gland (neurohypophysis),
and hypothalamic stimulation leads to release of stored peptide hormones such as arginine
vasopressin(AVP) and oxytocin. In contrast, the anterior lobe of the pituitary gland
(adenohypophysis) responds to hypothalamic derived neuropeptides, which when released
directly into the pituitary portal circulation cause the release of corresponding pituitary
hormones.
The hypothalamus secretes a number of hormones and other chemical agents that pass
through the hypothalamo-hypophyseal portal blood vessels to the pituitary gland where they
regulate the release of anterior pituitary hormones. The hormones produced by the target
glands controlled by the hormones of the anterior pituitary may exert a negative-feedback
control on the secretion of the corresponding hypothalamic or pituitary hormone. Hormones
secreted by the hypothalamus with effects on the pituitary hormone secretion includes;
corticotrophin releasing hormone(CRH), gonadotrophin releasing hormone(GnRH), thyrotropin
releasing hormone(TRH), growth hormone releasing hormone(GHRH), somatostatin and
dopamine.
Gonadotrophin releasing hormone(GnRH) effect on hormone release from the anterior
pituitary gland (FSH and LH) modulates the function of the gonads in males and females.
PITUITARY GLAND
The pituitary gland is made up of two lobes which are embryologically related and functionally
distinct. The pituitary gland is connected to the hypothalamus by the pituitary stalk.

Hormones secreted by the anterior pituitary gland that regulate gonadal function includes
follicle stimulating hormones and luteinizing hormone. Other hormones that may affect
gonadal function in pathologic states includes prolactin and thyroid stimulating hormone. This
is important when evaluating disorders of the hypothalamic- pituitary -gonadal axis. Although
each hypothalamic releasing factor has a targeted hormone, some integration of hormone
release does occur. For example, thyrotropin releasing hormone (TRH) causes synthesis and
release of not only TSH but prolactin as well.

GONADOTROPHIN RELEASING HORMONE(GnRH)

GnRH is a decapeptide produced by the hypothalamus in pulses into the hypothalamic-
hypophyseal portal circulation. It stimulates the release of the gonadotrophins; follicle
stimulating hormone(FSH) and luteinizing hormone(LH) from the anterior pituitary gland. The
GnRH secreting neurons are not located in a discrete nucleus, but instead are diffusely
distributed in the hypothalamus. About 7000 GnRH neurons in the medial basal hypothalamus
establish contact with capillaries of the pituitary portal system in the median eminence. GnRH
binds to its receptor in the anterior pituitary gland and stimulates the biosynthesis and
secretion of LH and FSH, which in turn regulate gonadal steroidogenesis and gametogenesis.
Steroid hormones (such as testosterone and estrogen), inhibins, activins, produced by the
gonads, stress hormones, leptin and the opiod system modulate the secretion of GnRH and
gonadotrophins.
GnRH stimulates the release of FSH and LH from the anterior pituitary gland. FSH and LH are
dimeric glycoproteins and are released in pulses of approximately 90 minutes. This pulsatile
release is essential for the gonadotrophins to exert their physiologic actions. Of all the pituitary
hormones influenced by pulsatile release, the gonadotrophins are the most affected.

HYPOTHALAMIC- PITUITARY- TESTICULAR AXIS

The hypothalamic –pituitary-testicular axis.

Control of gonadal function in males begins with pulsatile release of GnRH from the
hypothalamus to stimulate release of FSH and LH from the anterior pituitary gland. LH binds to
plasma membrane receptors on the Leydig cells of the testes to stimulate synthesis and
secretion of testosterone. Due to the pulsatile nature of LH secretion with a half-life of 30
minutes, plasma LH concentrations vary widely in men and a single plasma sample may not
provide an accurate estimate of mean LH levels.
FSH binds to receptors on Sertoli cells of the testes where it has several effects, which includes
increased synthesis of androgen-binding protein, and aromatase binding complex which
converts testosterone to estradiol, and increased production of inhibin. FSH has a longer half-
life (4 hours) in comparison with LH.
The functions of the testes are to synthesize sperm and androgens. Sertoli and Leydig cells play
key roles in this process. Sertoli cells in the seminiferous tubules of the testes play a critical role
in sperm maturation and secretes inhibin, a glycoprotein that inhibits the pituitary secretion of
FSH. Surrounding the seminiferous tubules are the interstitial Leydig cells which are primarily
responsible for androgen production. The principal androgen in men is testosterone which is
required for (1) sexual differentiation, (2) spermatogenesis, and (3) promotion and
maintenance of sexual maturity at puberty.
GnRH is synthesized in the hypothalamus and transported to the anterior pituitary where it
stimulates release of both follicle stimulating hormone and luteinizing hormone. In adult men,
(1) GnRH, (2) LH, and (3) FSH, are secreted in pulsatile patterns with higher concentrations
found in the early morning hours and lower concentrations in the late evening. LH acts on
Leydig cells to convert cholesterol to pregnenolone, which is subsequently converted to
testosterone. FSH acts on the Sertoli cells and spermatocytes and is central to the initiation (in
puberty) and maintenance (in adulthood) of spermatogenesis.
LH secretion is inhibited by testosterone and its metabolites, estradiol(E2) and
dihydrotestosterone. Inhibin B secreted by Sertoli cells inhibits secretion of FSH via a negative
feedback control of the anterior pituitary gland.
Testis is the primary site of androgen production in men, and the major circulating androgen is
testosterone. The rate limiting step in testosterone synthesis is conversion of cholesterol to
pregnenolone. Luteinizing hormone regulates the rate of this enzymatic reaction and thus
controls the overall rate of testosterone synthesis. A diurnal rhythm in circulating testosterone
levels is seen in adult men, with highest levels in the early morning, and very low levels late at
night. Although testosterone is the major hormone produced, small amounts of
dihydrotestosterone(DHT), androstenedione, pregnenolone and estradiol are secreted by the
testes.
Testosterone and dihydrotestosterone(DHT) circulate in plasma freely (approximately 3%) or
bound to plasma proteins. Binding proteins include the specific sex hormone binding globulin
(SHBG), and the non-specific proteins such as albumin. Biologically active fraction includes free
testosterone and possibly albumin bound testosterone. SHBG bound testosterone is not
biologically active
Circulating testosterone serves as a precursor for the formation of DHT by the enzyme 5α-
reductase. Testosterone can also be converted to estrogen by the enzyme aromatase. DHT is
thought to be (1) the essential androgen responsible for the formation of primary sex
characters in males during embryogenesis, (2) for development of male secondary sex
characteristics at puberty, and (3) for adult male function. The concentration of testosterone
remains low (˂50 ng/Dl) until puberty, when concentrations of testosterone rises to 500 – 700
ng/dl. Testosterone remains at high concentrations through adulthood.
Most of the estrogens in the circulation of adult males is derived from aromatization of
testosterone to 17β-estradiol and androstenedione to estrone. Estrogen formation requires
sequential hydroxylation, oxidation and removal of carbon position 19 and aromatization of the
A ring of testosterone. The aromatase enzyme complex is active in many tissues, including
muscle, liver and kidney, but the most significant site is adipose tissue.
Early in fetal development, exposure of testosterone to the Wolffian duct leads to
differentiation of the various components of the male genital tract. Testicular function is
reactivated during puberty in development of secondary sexual characteristics. Testosterone
acting with FSH has paracrine effects on the seminiferous tubules and Sertoli cells to induce
spermatogenesis

Stages in spermatogenesis
Sertoli cells secretes the following substances:
1. Anti-Mullerian hormone (AMH) - secreted during the early stages of fetal life
2. Inhibin and Activin - secreted after puberty, and work together to regulate FSH
secretion.
3. Androgen binding protein (also called testosterone binding globulin) increases
testosterone concentration in the seminiferous tubules to stimulate spermiogenesis.
4. Estradiol – aromatase from Sertoli cells convert testosterone to 17β-estradiol to direct
spermatogenesis. In the testes, spermatogenesis is modulated at every level by
estrogen.

HYPOTHALAMIC-PITUITARY-OVARIAN AXIS

Formation of the gonads occurs early in fetal development; primordial germ cells can be
identified in the 5-day-old human blastocyst. The developmental process is similar in
male and female embryos. By 42 days of gestation, sexual dimorphism becomes
apparent. Male embryos developing gonad switch to the male pattern under the control
of a gene for testicular differentiation that is located on the Y chromosome. At this
point, seminiferous ducts can be identified in the testes. In the absence of the testicular
differentiation gene, ovarian development occurs; however, it takes about 70 days for
developing ovarian tissue to become histologically identifiable.
The ovary is composed of three principal cell types; (1) granulosa cells, (2) mesenchymal
cells, and (3) primordial germ cells (oogonia).
At birth, there are about 1 million germ cells in the ovary, but this number decreases to
400,000 at menarche, with only a few remaining at menopause.
Cyclical ovarian function depends on appropriately timed secretion of the anterior
pituitary gonadotrophins, FSH and LH in response to hypothalamic GnRH. Coordination
of the menstrual cycle in adult females depends on positive- and negative-feedback
relationship between the ovarian hormones; estradiol and progesterone in concert with
GnRH, FSH and LH.
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Constant pulsatile secretion of GnRH from the hypothalamus is critical for the release of
pituitary FSH and LH. GnRH regulates (1) synthesis and storage of gonadotrophins, (2)
movement of gonadotrophins from a reserve pool ready for secretion, and (3)
immediate release of FSH and LH. The release of FSH and LH is affected both positively
and negatively by estradiol and progesterone. Estradiol exerts its inhibitory effect on
both the hypothalamus and the pituitary gland. Progesterone in high concentrations
inhibits gonadotrophin secretion through suppression of hypothalamic GnRH release.
Female gonadal steroids also have positive feedback effect on pituitary gonadotrophin
secretion. Positive feedback is triggered by a sharp rise in plasma estradiol levels and is
crucial for promotion of “LH surge” required for initiation of ovulation.
Neural stimuli from the central nervous system can also impact hypothalamic-pituitary
regulation of ovarian function. The hypothalamus receives both neural and hormonal
signals which can affect GnRH secretion and the menstrual cycle leading to anovulation
and amenorrhoea. These manifestations may be observed in situations of chronic stress
and weight loss.

The female reproductive system consists of a (1) vagina, (2) uterus, (3) fallopian tubes,
and (4) ovaries. The ovaries produce ova and secrete the sex hormones, progesterone
and estrogen. Estrogens are produced mainly by the ovaries in females. The three most
biologically active estrogens in order of potency are, (1) estrone, (2) estradiol, and (3)
estriol. Estradiol is the most active estrogen in non-pregnant women. Estrogens are
secreted by the (1) ovarian follicles, (2) corpus luteum, and (3) placenta. The adrenal
glands and testes (in men) are also believed to secrete minute quantities of estrogens.
The ovary synthesizes estrogen via aromatization of androgens.
Estrogens are responsible for the development and maintenance of the female sex
organs and female secondary sexual characteristics. In the adult female, estrogens cause
proliferation of the endometrium. It also increases; the thickness of the vaginal
epithelium, the vascularity of the cervix, cervical mucous elasticity to allow sperm
penetration, and dilates the cervical os.
The progestogens include pregnenolone, progesterone, and 17-hydroxyprogesterone.
Pregnenolone is the precursor of all ovarian steroid hormones. Progesterone is the
primary secretory product of the corpus luteum and is required for the induction of
secretory activity in an estrogen primed uterus, implantation of a fertilized ovum, and
maintenance of early pregnancy. The corpus luteum also secretes 17-
hydroxyprogesterone; however, this steroid has little or no biological activity.

All steroid hormones are derived from cholesterol. Cholesterol may be synthesized de
novo within the ovary, or it may be derived from pre-formed sources. Little hormone is
stored in the ovary, so secretory activity is closely related to synthetic requirement and
substrate availability. Granulosa cells of the ovary produce estradiol, while theca and
stromal cells secrete progesterone and 17-hydroxyprogesterone. Both FSH and LH are
required for the synthesis of estrogen. The rate-limiting step in ovarian steroidogenesis
is conversion of cholesterol to pregnenolone. This process is regulated by luteinizing
hormone. Follicle stimulating hormone controls conversion of androgens to estrogens.
Gonadal steroids circulate in a free form or bound to plasma proteins. These binding
proteins include sex hormone–binding globulin (SHBG), and albumin. Approximately
60% of plasma estradiol is weakly bound to albumin and 38% to SHBG, 2-3% is free.
Progesterone binds strongly to cortisol –binding globulin(CBG) and weakly to albumin.
Biological activity of steroid hormones is proportional to the concentration of free
hormone in plasma, and not to the concentration of protein –bound hormone.

Plasma estradiol is converted rapidly in the liver to estrone. It is further converted to

estriol, conjugated and the excreted by the kidneys. Progesterone is rapidly cleared and
has a half-life of about 5 minutes. It is converted to pregnanediol, conjugated to
glucuronic acid, and excreted via the kidneys.
MENSTRUAL CYCLE
The menstrual cycle is usually divided into two phases; the follicular or proliferative
phase, and the luteal or secretory phase. The length of the menstrual cycle is defined as
the period dating from the onset of one menstrual bleed (day 1) until the onset of the
next bleed.

The average normal cycle length is 28 days. Variation of the length of the cycle between
women is as a result of variability of the follicular phase. The luteal phase duration is
remarkably constant (approximately 14 days).

FOLLICULAR PHASE
Initiation of follicular phase begins during the last few days of the luteal phase of the
preceding menstrual cycle. Concentration of FSH is elevated during the early follicular
phase, but declines up until ovulation. FSH stimulates the growth of new follicles and
estradiol secretion. Many follicles are recruited during day 1- 4 of the menstrual cycle in
response to FSH. Selection of the dominant follicle occurs between day 5 and 7. This
follicle continues to grow and release factors that reduce the growth of other follicles.
Estradiol concentration increases with follicular growth and exerts a negative feedback
control on the pituitary and hypothalamic hormone secretion of FSH, and a positive
feedback on LH release by mid-follicular phase which causes a rise in LH concentration.
Follicular phase terminates at ovulation.
 OVULATION
Estrogen concentration increases just before ovulation which positively stimulates the
hypothalamus and triggers the LH surge. The LH surge occurs 34 to 36 hours before
release of the ovum from the follicles. The peak LH levels occurs about 10 to 12 hours
before ovulation. Ovulation usually occurs around day 14 in a 28-day cycle. The precise
mechanism of follicular rupture is unknown.

LUTEAL PHASE
After ovulation, the ruptured follicle undergoes changes in structure and function to
become the corpus luteum. The corpus luteum is the site of steroid secretion by the
ovary during the luteal phase; progesterone and some estradiol are primarily produced.
Progesterone produced by the corpus luteum inhibits LH secretion. It reaches a
maximum peak 8 to 9 days after the LH peak. Estradiol concentration also increase
during the luteal phase and, together with progesterone cause a reduction in FSH and
LH concentrations.
In the last few days of luteal phase, as the corpus luteum begins to regress, the levels of
estradiol and progesterone decrease. Loss of negative feedback results in elevation of
FSH once more, and the recruitment of a new batch of follicles for the next cycle.

PERIMENOPAUSE/MENOPAUSE
Perimenopause is the time from the start of irregular menstrual cycles until at least 1
year after periods have ceased. The menopausal transmission takes about 2 – 8 years
with the menopause occurring at an average age of about 51 years. Menopause can
only be defined retrospectively when 12 months have elapsed since the last menstrual
cycle. The primary underlying pathophysiology of the menopause is the loss of ovarian
follicles. In the post-menopausal state, a 10- to 15-fold increase in circulating FSH levels
is seen, along with a 4-5 –fold increase in LH and a more than 90% decrease in
circulating estradiol. FSH levels are higher than LH levels because LH is cleared from the
blood much faster (half-lives are about 30 minutes for LH and 4 hours for FSH).
Gonadotrophin levels reach a maximum about 1 to 3 years after the final menses, and
elevated levels of both FSH and LH provide conclusive evidence of ovarian failure.