REPRODUCTIVE

ENDOCRINOLOGY
AMIR, BAUTISTA, CALUAG, CHUA , GARCIA , GUDULUR,
KALANGEG , LIMPAYOS , MANALAYSAY, MARAMBA ,
ORIRE, PALISOC, RODRIGUEZ, SALES, SAMSON
Objectives
1. To review the anatomy involved in Reproductive
Neuroendocrinology
2. To review the physiology and different
hormones in Reproductive Neuroendocrinology
3. At the end of the lecture, we will be able to
integrate basic sciences (biochemistry,
physiology, anatomy, pharmacology) to
understand the clinical correlations involved in
reproductive neuroendocrinology
Outcome
Lecture Outline

Part I
Reproductive Neuroendocrine Anatomy
Part II
1. Reproductive Neuroendocrine Physiology
2. Menstrual Cycle
Part III
Clinical Correlations
ANATOMY
The Hypothalamus
and Pituitary Gland
Transport of GnRH to the
Anterior Pituitary
Transport of GnRH to the
Anterior Pituitary
Link between Olfactory and
Reproductive Development
The Ovaries
PHYSIOLOGY
The Hypothalamus
and GnRH
The reproductive process starts in the brain,
through the activation of the initial
hormonal signal that will release the
gonadotropins from the pituitary gland.
This hormone released by the hypothalamus
is gonadotropin-releasing hormone (GnRH).
The GnRH Pulse Generator
Studies have shown that GnRH is characteristically released
intermittently, in a pulsatile fashion.
Hence comes the concept of the GnRH pulse generator
responsible for the pulsatile release of the hormone.
GnRH pulses occur at about hourly intervals.
The rising edge of each GnRH pulse is abrupt, such that
GnRH can increase by a factor of 50 within 1 minute.
Each GnRH pulse is preceded by an increase in multiunit
activity within the area of the arcuate nucleus.
Mechanisms Responsible for
GnRH Pulsatility
The cellular basis and the mechanisms that
determine the timing of the increase in multiunit
activity resulting in pulsatile GnRH activity are still
under study.
First, there is a growing consensus that pulsatile
activity originates from an inherent pace-making
activity of the GnRH neuron itself.
Second, recent evidence suggests a key role of
kisspeptin (KISS1), a product of the KISS1 gene, and
its receptor (GPR54 or KISS1R) in the regulation of
GnRH release.
Modulatory influences on
GnRH pulsatility
Modulatory influence on the frequency and
amplitude of GnRHpulses is exerted by the ovarian
steroid hormones through their feedback loop
actions.
In general, estradiol is known to decrease GnRH
pulse amplitude, whereas progesterone decreases
GnRH pulse frequency.
Numerous other studies suggest that the
spontaneous activity of the GnRH pulse generator
may also be modulated by avariety of additional
stimulatory and inhibitory afferent neural signals.
Stimulatory inputs to GnRH release may originate
from neurons using the biogenic amine
neuroepinephrine (NE), the amino acid glutamate
and the peptide neuropeptide Y (NPY).
Inhibitory inputs may come from amino acid
gamma aminobutyric acid (GABA), the biogenic
amine dopamine (DA), the endogenous opioid b-
endorphin, and the neurosecretory peptide
corticotropin-releasing hormone (CRH) neurons.
These systems may affect the GnRH pulse
generator either tonally or conditionally.
Metabolic influences and
GnRH release
There is good clinical evidence linking energy homeostasis
and reproductive function in a human.
A functional reproductive system requires an accurate
integration of energy balance, and a significant imbalance
may lead to reproductive dysfunction and amenorrhea.
Nutritional deprivation and abnormal eating habits are
known to interfere with the normal reproductive process
Leptin also appears to function as one of the metabolic cues
regulating the GnRH pulse generator.
Another example is the orexigenic peptide, neuropeptide Y
(NPY), which is synthesized in the arcuate nucleus.
Anterior Pituitary
gland and the
Gonadotropins
Anterior Pituitary gland and
the Gonadotropins
Activation of the GnRH Receptor:
GnRH activation of the receptor requires the
release of constraining intramolecular bonds,
which maintain the receptor in an inactive
configuration.
Once activated, the GnRH receptor stimulates
cellular production of specific membrane-
associated lipid-like diacylglycerols, which, acting as
a second messenger, activate several cellular
proteins.
Estrogens and the GnRH
Receptor
The number of GnRH-R also varies with the
hormonal environment, with highest
number of receptors expressed when high
concentrations of estrogens are present.
This leads to an increase in the overall Ca2++
response and a significantly amplified
gonadotropin response to a GnRH pulse.
GnRH Pulse Frequency and
Gonadotropin Release
A low GnRH pulse frequency favors FSH
synthesis, whereas a high GnRH pulse
frequency favors LH synthesis.
This phenomenon may play a role during the
luteal phase of the menstrual cycle and in
the changing FSH:LH ratio that occurs during
the passage from one menstrual cycle to
another.
GnRH Receptor Desentization
Sustained exposure of the GnRH-R to
constant GnRH concentrations drastically
reduces the response of the gonadotrope to
subsequent stimulation with GnRH. This
phenomenon is referred to as homologous
desensitization or downregulation of the
receptor.
GnRH Analogues and the GnRH
Receptors

Following administration of these GnRH

agonists, there is an initial stimulation of
gonadotropin release (flare), followed by the
process of desensitization blocking the
releasing effect on the gonadotropins.
 Gonadotropins
2 distinct gonadotropins: LH (Luteinizing Hormone) has a -subunit
of 121 amino acids, a structure that is responsible for the
specificity of the interaction with the LH receptor.
FSH (Follicle Stimulating Hormone)
hCG (Chorionic Gonadotropin) produced in the primate by
the placenta
LH and FSH are glycoproteins of high molecular weight.
They are heterodimers, containing two monomeric units (subunits)
are each encoded by a separate gene.
Both LH and FSH have a similar -subunit, the structure (92 amino
acids) of which is highly conserved.
The biologic half-life of LH is 20 minutes, much
shorter than that of FSH (3 to 4 hours). (The
half-life of hCG is 24 hours.)
Both gonadotropins act synergistically in the
female, FSH acts primarily on the granulosa
cells of the ovarian follicles to stimulate
follicular growth, whereas LH acts primarily on
the theca cells of these follicles as well as on
the luteal cells to stimulate ovarian steroid
hormone production.
OVARY AND ITS
HORMONES
 GONADOTROPIN RECEPTORS
Two gonadotropins acts synergistically in the female
namely:
FSH (acts on granulosa cells)=follicular growth
LH (acts in theca cells)= steroidogenesis.
They are transmembrane G protein coupled receptors
which possess seven membrane-spanning domains.
 OVARIAN STEROID:
BIOSYNTHESIS
Primary function of ovary: secretion of ovarian
steroids.
Secretes 3 primary hormones namely estradiol(primary
estrogen, progesterone and androstenedione.
Also secretes, in varying amounts, estrone (a less
potent estrogen), pregnenolone, 17-
hydroxyprogesterone, testosterone, and
dehydroepiandrosterone (DHEA).
does not synthesize mineralo- or glucocorticoids
All steroids are derived from acetate (a two-carbon compound),
which, in a series of complex reactions, is transformed into
cholesterol (a 27-carbon steroid).
The sex steroids (as well as the corticosteroids) are then derived
from a stepwise transformation of the cholesterol molecule into
steroids with
21 carbon atoms (the corticosteroids, pregnenolone, 17-hydroxy
pregnenolone, progesterone, and 17-hydroxyprogesterone),
19 carbon atoms (androgens such as DHEA, androstenedione,
and testosterone),
18 carbon atoms (estrogens such as estradiol and estrone)
AROMATASE ENZYME:
Converts androgens to estrogen, estrone or estradiol.
Aromatic or phenol ring is characteristics of the estrogens.
Complex enzyme which consist of two proteins:
P450arom (also a member of the cytochrome P450
superfamily of genes), catalyzes the reactions required for
the formation of the phenolic A ring.
NADPH-cytochrome P450 reductase, a ubiquitous protein
required for transferring reducing equivalents from NADPH
to any microsomal form of cytochrome P450 with which it
comes into contact.
AROMATASE ENZYME:
It is found in tissues like gonads, endometrium, brain,
placenta, bone, skin etc.

Aromatase deficiency syndrome-mutation of CYP 19

(Autosomal recessive)
OVARIAN STEROIDS: BLOOD
TRANSPORT AND METABOLISM
After release into the circulation, sex steroids bind to a
steroid-specific transport protein, sex hormonebinding
globulin (SHBG) (a -globulin synthesized by the liver), to
the nonsteroid-specific albumin, or circulate in an
unbound or free form.

Free and loosely albumin-bound steroids are believed to be

the most biologically important fractions.
SHBG binds primarily dihydrotestosterone, testosterone,
and estradiol, in order of decreasing affinity.
The metabolic clearance rate of sex steroids is inversely
related to their affinity to SHBG.
Major sites of steroid metabolism are the liver and kidney.
Prostaglandins
Subclass of eicosanoids and prostanoids
Mediators of inflammatory and anaphylactic
reactions.
Their most abundant precursor is arachidonic acid.
Biosynthesis can be inhibited by several groups of
compounds, including the nonsteroidal anti-
inflammatory drugs (NSAIDs) type 1 (aspirin and
indomethacin), which inhibit endoperoxide
formation (the immediate precursor of
eicosanoids), and type 2 (phenylbutazone), which
inhibits the action of endoperoxidase isomerase
and reductase.
Corticosteroids also can inhibit prostaglandins
synthesis.
They are produced intracellularly shortly before
they are released and generally act locally.
One important effect is their ability to modulate
the responses of endogenous stimulators and
inhibitors, such as ovarian stimulation by LH.
Prostaglandins play an important role in ovarian
physiology.
May help regulate myometrial contractility and
may also play a role in regulating the process of
menstruation.
COMMUNICATION
WITHIN THE
HYPOTHALAMIC-
PITUITARY-OVARIAN
ENDOCRINE AXIS
STEROID RECEPTORS
OVARIAN-HYPOTHALAMIC-
PITUITARY FEEDBACK LOOPS
FSH and LH ovaries
Folliculogenesis
Corpus luteum

Granulosa and thecal cell

17 estradiol
progesterone
OVARIAN-HYPOTHALAMIC-
PITUITARY FEEDBACK LOOPS
Essential component to the physiology of
reproductive cycle
Negative
Positive
Ovarian peptides
NEGATIVE FEEDBACK LOOP
Major ovarian to brain-pituitary feedback loop
Inhibitory
Estradiol 17
Potent physiologic inhibitor of GnRH and
gonadotropin secretion
Progesterone
Affects the GnRH pulse generator
POSITIVE FEEDBACK LOOP
Dependent on rapidly rising estradiol levels, in
combination with a small but significant
progesterone rise, both produced by the mature
dominant follicle and responsible for the
generation of the preovulatory LH and FSH surge.
OVARIAN PEPTIDES FEEDBACK
LOOP
Nonsteroid ovarian factors
Inhibin
Activin
 Menstrual Cycle
The menstrual cycle is the regular
natural change that occurs in
the female reproductive
system (specifically
the uterus and ovaries) that
makes pregnancy possible.
Essential to the coordination of
these events is the communication
between the ovaries and the
hypothalamic-pituitary unit
through the hormonal feedbacks.
Menstrual Cycle
The primate menstrual cycle is divided into two
phases: the follicular phase followed by the luteal
phase.
It is separated by an ovulatory period
The mean duration of the menstrual cycle is 28 7
days.
Follicular phase
Three phases:
Recruitment of a cohort of antral follicles
Selection of a dominant follicle
Growth of the dominant follicle
 Follicular phase
Recruitment of a cohort of antral follicles
Begins during the early antral stage of follicles
FSH provides the critical signal for the recruitment of a cohort
of preantral follicles.
Ovarian reserve:
the number of antral follicles in the ovaries. It can be
measured by three ways:
(1) by a measurement of FSH on day 2 to 3 of the cycle
(2) by a sonographic antral follicle count;
(3) by the measurement of inhibin B on day 2 to 3 of the
cycle
(4) by the measurement of anti-mllerian hormone (AMH)
Follicular phase
Selection of a dominant follicle
The process of selection is not well understood but is
postulated to be brought by the competitive advantage of
the dominant follicle (eg, well-vascularized)
The negative feedback of estradiol to FSH also begins
during this phase.
This phase is usually completed by day 5.
Follicular phase
Growth of the dominant follicle
Requires an optimal GnRH pulse frequency of 1 pulse/90
minutes
Aromatase enzyme is produced
Theca cell layer appears
LH receptors in the theca interna appear and contribute
further into the production of estradiol
The antrum is seen, and the oocyte becomes surrounded
by the zona pellucida
Ovulatory Gonadotropin surge
During this stage, a high level of Estradiol causes a
positive feedback response to the Hypothalamus,
causing an increase in GnRH and in effect, LH and
FSH.
This gonadotropin surge is the absolute
requirement for further maturation and rupture of
the follicle
Ovulation
Also known as follicular rupture, it occurs about 32
hours following the initial rise of the LH surge.
It is proposed that the LH surge induces an acute
inflammatory reaction within the follicle (Eg,
release of prostaglandin and plasmin)
Luteal phase
This phase occurs after the extrusion of the oocyte
from the follicle.
The follicular wall becomes convoluted, and the
diameter and volume of the follicle decrease. The
newly formed structure is now called the Corpus
luteum. The formation of this structure is due to:
Hypertrophy of the granulosa and theca cells;
Disruption of the basal lamina that separate
these layers
Luteal phase
Endocrine factors
The Corpus luteum primarily depends on LH
stimulation to perform its function, which is
mainly progesterone release
Progesterone release acts a negative feedback for
GnRH release in the hypothalamus, decreasing its
levels
Progesterone also causes an increase in basal
body temperature by affecting the hypothalamic
regulatory system
Luteal phase
Luteolysis
The life span of the Corpus luteum is about 14
days. It slowly degenerates within this period.
Only hCG (if conception occurs) can rescue the
Corpus luteum from luteolysis
Luteal-Follicular transition
Luteolysis ultimately leads to a decrease in release
of Progesterone, Estradiol and Inhibin A by the
Corpus Luteum
This causes an increase of FSH levels (Primarily due
to estradiol and Inhibin A decrease) and GnRH
increase (due to Progesterone decrease)
The increasing levels of FSH allows the stimulation
of new follicles, and thus a new cycle.
Menstrual Cycle and the
Endometrium
Changes in the endometrium occur with
synchronicity to the hormonal changes discussed.
This ensures an appropriate environment for the
conceptus, if ever conception occurs.
Has three phases:
Proliferative phase
Secretory phase
Menstruation
Proliferative phase
Coincides with the Follicular phase in the ovaries
Changes that occur in the endometrium include:
Increase in estradiol receptors
Proliferation of both glands and stroma of
stratum functionale
Straight glands become tortuous and voluminous
Appearance of subnuclear vacuoles at the base
of the cells lining the glands
 Secretory phase
Coincides with the Luteal phase in the ovaries
Changes that occur in the endometrium include:
well-developed subnuclear glycogen-rich vacuoles
appear in every cell of a given gland
The Glycogen-rich substance is secreted in the uterine
lumen
Glycodelin
IGFBP-1
Homeobox A10
Leukemia Inhibitory Factor
Secretory phase
After the first week of the luteal phase, the stroma
becomes more edematous
Endothelial proliferation occurs in the upper
stratum functionale producing vascular clusters
Predecidual stromal cells develop
Menstruation
Occurs when there is no implantation of blastocyst in the
endometrium
The following events occur in the endometrium occurs
during menstruation:
Collapse
Infiltration of PMNs and Monocytes
Autolysis of stratum functionale
Desquamation
The metalloproteinase family of enzymes is mainly
responsible for eliminating the endometrial functional layer
Menstruation
Regular menstruation usually lasts for 3 to 5 days,
but anywhere from 2 to 7 days is considered
normal
Menstrual intervals vary depending of age and time
of initiation of the premenopause period
The average blood loss is 35 mL with 10 to 80 mL
considered within the normal range.
Menstrual Cycle and the
Cervical Glands
Changes in the production and property of mucus
secreted by the cervical glands are closely
correlated to changes in estradiol and progesterone
during the menstrual cycle.
High estradiol levels induces the production of
copious amounts of Cervical mucus.
Progesterone thickens this cervical mucus later
on the menstrual cycle
Hormone assay techniques
Labeled Immunoassays are the most common techniques
used in measurements of hormones because of their high
sensitivity and specificity
This is achieved by production of highly specific antibodies
that are able to bind the hormones
Different labels can be used for quantification. These
includes Radiolabels, Enzymes, Fluorescent &
Chemiluminescent substances.
Competitive and noncompetitive types of immunoassays
have also been developed.
CLINICAL
CORRELATES
Relationship of the Olfactory and
GnRH Systems in Early Fetal Life
Resultant lack of
Failure of GnRH establishment of
neuron migration. functional
connections.

KALLMANN
SYNDROME
Mechanisms Responsible for
GnRH Pulsatility
Targeted deletions
Mutations of of KISS1 and/or its
KISS1 gene.. receptor (GPR54 or
KISS1R).

Hypogonadotropic
Hypogonadism
Kisspeptin
Has been used to induce egg maturation in
women undergoing in vitro fertilization
therapy, with subsequent fertilization of the
mature eggs, embryo transfer into the
uterus, and successful human pregnancy.
 Comparison between Kallmann
Syndrome versus KISS1 gene
mutation/deletion

Kallmann Syndrome KISS1 Gene Mutation

Hypogonadotropic Hypogonadotropic
hypogonadism hypogonadism
Anosmia
Modulatory Influences on
GnRH Pulsatility
Administration of alpha adrenergic blockers has
been shown to reduce pulse frequency in animals,
in accord with the postulated tonal stimulatory role
for norepinephrine.

The role of GABA as a tonal inhibitor may be more

prominent during the prepubertal period, at which
time a diminishing inhibitory GABA tone may
activate puberty and the resumption of GnRH
pulsatile release.
GnRH Pulsatility
Dopamine infusions in women are associated with
a decrease in circulating LH and prolactin.

In patients with hypothalamic amenorrhea in which

there appears to be an increase in dopamine tone,
administration of dopaminergic blocker may return
the LH pulse frequency to normal.
Certain drugs such as methyl dopa, TCAs, SSRIs,
and SNRIs may interfere the specific effects of
neurotransmitters on GnRH neurons.
Alterations in Hyperprolactinemia
GnRH Secretion

Oligomenorrhea or
Galactorrhea
Energetics And Reproduction

Suppression of
Dietary
pulsatile LH
Restriction
release
Metabolic Influences and
GnRH Release
Nutritional deprivation and abnormal eating habits
are known to interfere with normal reproductive
process.

Anorexia nervosa is a well-known and extreme

example of how alteration in food intake can result
in the suppression of the menstrual cycle.
Metabolic Influences and
GnRH Release
Hypogonadot
ropic state,
and in
extreme
Amenorrhea, cases, a
Anorexia weightloss, regression to
behavioral a prepubertal
Nervosa changes pattern of LH
secretion,
with
hypoestrogen
ism.
Prolactin Elevation
dec. Kisspeptin

Anovulation
Elevations Inhibits
And
in GnRH
Hypoestrogeni
Prolactin Release c amenorrhea
GnRH Receptor
Females with GnRH-R mutations typically present
with incomplete or absent pubertal development
and primary amenorrhea. Although reproductive
function is compromised, conception may be
successfully obtained following gonadotropin
treatment.
 Aromatase Enzyme

Aromatase
CYP19
Deficiency
Mutation
Syndrome
Aromatase Enzyme
In female patients, accumulation of androgens
during pregnancy may cause virilization at birth.
Female patients also have primary amenorrhea.
Patients have abnormal pubertal maturation and
are tall due to absence or deficiency of estrogen to
affect epiphyseal closure.
Aromatase inhibition leads to profound
hypoestrogenism.
Useful in the management of patients with
estrogen receptor positive tumors.
 Ovarian Steroids: Blood Transport
and Metabolism
Metabolic clearance rate of sex steroids is inversely
related to their affinity to sex hormone-binding
globulin (SHBG ).
Various clinical conditions may influence the level
of SHBG.

Increase Decrease
Estrogen Androgen
in in
and s and
circulating circulating
Thyroid hypothyro
levels of levels of
Hormone idism
SHBG SHBG
 Cyclic Dysfunction
Related to Lifestyle and Stress

Lifestyle Functional
variables Significant
Decrease Hypothala
such as reduction in mic
psychogeni in the frequenc Amenorrhe
c stress, activity of y of a or
exercise- the GnRH pulsatile Functional
related or pulse LH hypothala
diet-related generator . mic chronic
causes.
release. anovulation
 Abnormalities of the
Pituitary

Prolactin Amenorrhea-
Secreting- galactorrhea
Adenoma syndrome.
Abnormality of the Corpus
Luteum

Blunted
progesterone Inadequate
secretion Luteal Phase
throughout the
luteal phase. Syndrome.
GnRH Pulse Frequency and
Gonadotropin Release
An increase in FSH:LH ratio is a characteristic of
women with polycystic ovary syndrome.
Polycystic Ovary Syndrome

Rotterdam consensus in 2003 revised the

diagnostic criteria (Ref. 4), with two of the
three following criteria declared as
prerequisites for PCOS:
-Chronic anovulation or oligomenorrhea
-Clinical or biochemical hyperandrogenism
-Polycystic ovarian morphology.
Polycystic Ovary Syndrome
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