Consensus on androgen testing in polycystic ovary syndrome

doi:10.3969/j.issn.1673-8640.2023.03.001

Abstract

Abstract:

Polycystic ovary syndrome（PCOS） is one of the most common endocrine disorders in reproductive-age females，frequently leading to female infertility. Hyperandrogenemia plays a role in the pathogenesis of PCOS. Hyperandrogenemia can be evaluated by biochemical tests or clinical signs. At present，there are some limitations of immunology-based testing methods for androgen，such as cross-reaction，poor accuracy in low-concentration samples and lack of comparability among different reagent manufacturers，leading to false positivity. With the advantages of high sensitivity，high specificity，wide linear range and the capability of simultaneous determination of multiple molecules，liquid chromatography-tandem mass spectrometry（LC-MS/MS） becomes a good choice for androgen testing. On the basis of published clinical and laboratory evidence，Beijing Obstetrics and Gynecology Hospital of Capital Medical University，China Association for Promotion of Health Science and Technology-Fertility Protection and Preservation Committee，along with the experts in the clinical laboratory，gynecological endocrinology and mass spectrometry application relevant field made this consensus，in order to provide professional guidance in PCOS androgen testing in clinical laboratories. The consensus includes recommendations on types and methods of androgen testing for PCOS and challenges of androgen testing with LC-MS/MS.

Key words: Polycystic ovary syndrome, Hyperandrogenemia, Liquid chromatography-tandem mass spectrometry

CLC Number:

R446.1

Expert Group on the Consensus on Androgen Testing in Polycystic Ovary Syndrome China Association for Promotion of Health Science and Technology-Fertility Protection and Preservation Committee. Consensus on androgen testing in polycystic ovary syndrome[J]. Laboratory Medicine, 2023, 38(3): 203-208.

Figures/Tables 1

References 34

[1]	中国医师协会内分泌代谢科医师分会. 多囊卵巢综合征诊治内分泌专家共识[J]. 中华内分泌代谢杂志, 2018, 34(1):1-7.
[2]	LEGRO R S, ARSLANIAN S A, EHRMANN D A, et al. Diagnosis and treatment of polycystic ovary syndrome:an endocrine society clinical practice guideline[J]. J Clin Endocrinol Metab, 2013, 98(12):4565-4592. DOI URL
[3]	CONWAY G, DEWAILLY D, DIAMANTI-KANDARAKIS E, et al. The polycystic ovary syndrome:a position statement from the European Society of Endocrinology[J]. Eur J Endocrinol, 2014, 171(4):P1-P29. DOI URL
[4]	WITCHEL S F, OBERFIELD S, ROSENFIELD R L, et al. The diagnosis of polycystic ovary syndrome during adolescence[J]. Horm Res Paediatr, 2015.
[5]	中华医学会妇产科学分会内分泌学组及指南专家组. 多囊卵巢综合征中国诊疗指南[J]. 中华妇产科杂志, 2018, 53(1):2-6.
[6]	LIZNEVA D, GAVRILOVA-JORDAN L, WALKER W, et al. Androgen excess:investigations and management[J]. Best Pract Res Clin Obstet Gynaecol, 2016, 37:98-118. DOI URL
[7]	赵丽, 蔡昭炜, 李雪玲, 等. 抗缪勒氏管激素联合性激素检查在诊断多囊卵巢综合征的价值[J]. 现代诊断与治疗, 2020, 31(2):269-270.
[8]	ESCOBAR-MORREALE H F. Polycystic ovary syndrome:definition,aetiology,diagnosis and treatment[J]. Nat Rev Endocrinol, 2018, 14(5):270-284. DOI URL
[9]	KEEVIL B G, ADAWAY J. Assessment of free testosterone concentration[J]. J Steroid Biochem Mol Biol, 2019, 190:207-211. DOI URL
[10]	VERMEULEN A, VERDONCK L, KAUFMAN J M. A critical evaluation of simple methods for the estimation of free testosterone in serum[J]. J Clin Endocrinol Metab, 1999, 84(10):3666-3672. DOI URL
[11]	叶雅萍, 李萍. 性激素结合球蛋白在生殖医学中的应用研究进展[J]. 生殖医学杂志, 2022, 31(2):273-277.
[12]	KEEVIL B G, ADAWAY J, FIERS T, et al. The free androgen index is inaccurate in women when the SHBG concentration is low[J]. Clin Endocrinol(Oxf), 2018, 88(5):706-710. DOI URL
[13]	O'REILLY M W, TAYLOR A E, CRABTREE N J,et al. Hyperandrogenemia predicts metabolic phenotype in polycystic ovary syndrome:the utility of serum androstenedione[J]. J Clin Endocrinol Metab, 2014, 99(3):1027-1036. DOI URL
[14]	CHEN F, CHEN M, ZHANG W, et al. Comparison of the efficacy of different androgens measured by LC-MS/MS in representing hyperandrogenemia and an evaluation of adrenal-origin androgens with a dexamethasone suppression test in patients with PCOS[J]. J Ovarian Res, 2021, 14(1):32. DOI PMID
[15]	牛静云, 侯丽辉, 寇丽辉, 等. 不同高雄激素血症表型多囊卵巢综合征患者临床特征分析[J]. 实用妇产科杂志, 2018, 34(4):286-290.
[16]	GOODMAN N F, COBIN R H, FUTTERWEIT W, et al.. American Association of Clinical Endocrinologists,American College of Endocrinology,and Androgen Excess and PCOS Society disease state clinical review:guide to the best practices in the evaluation and treatment of polycystic ovary syndrome-part 1[J]. Endocr Pract, 2015, 21(11):1291-1300. DOI URL
[17]	GOODARZI M O, CARMINA E, AZZIZ R. DHEA, DHEAS and PCOS[J]. J Steroid Biochem Mol Biol, 2015, 145:213-225. DOI URL
[18]	夏曦, 邓玉颖, 顾俊婕, 等. 超高压液相色谱-质谱联用技术联合分析血清睾酮和硫酸脱氢表雄酮提高多囊卵巢综合征的诊断率[J]. 中华内分泌代谢杂志, 2018, 34(2):136-140.
[19]	CAO Z, LU Y, CONG Y, et al. Simultaneous quantitation of four androgens and 17-hydroxyprogesterone in polycystic ovarian syndrome patients by LC-MS/MS[J]. J Clin Lab Anal, 2020, 34(12):e23539.
[20]	TOSI F, FIERS T, KAUFMAN J M, et al. Implications of androgen assay accuracy in the phenotyping of women with polycystic ovary syndrome[J]. J Clin Endocrinol Metab, 2016, 101(2):610-618. DOI PMID
[21]	KEEVIL B. Steroid mass spectrometry for the diagnosis of PCOS[J]. Med Sci(Basel), 2019, 7(7):78.
[22]	AMBROZIAK U, KPCZYSKA-NYK A, KURYLOWICZ A, et al. LC-MS/MS improves screening towards 21-hydroxylase deficiency[J]. Gynecol Endocrinol, 2015, 31(4):296-300. DOI PMID
[23]	HANDELSMAN D J, WARTOFSKY L. Requirement for mass spectrometry sex steroid assays in the Journal of Clinical Endocrinology and Metabolism[J]. J Clin Endocrinol Metab, 2013, 98(10):3971-3973. DOI URL
[24]	WIERMAN M E, AUCHUS R J, HAISENLEDER D J, et al. Editorial:the new instructions to authors for the reporting of steroid hormone measurements[J]. Mol Endocrinol, 2014, 28(12):1917. DOI URL
[25]	TEEDE H J, MISSO M L, COSTELLO M F, et al. Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome[J]. Hum Reprod, 2018, 33(9):1602-1618. DOI URL
[26]	ZHAO M, BAKER S D, YAN X, et al. Simultaneous determination of steroid composition of human testicular fluid using liquid chromatography tandem mass spectrometry[J]. Steroids, 2004, 69(11-12):721-726. PMID
[27]	OLIVEIRA L R, LONGUI C A, GUARAGNA-FILHO G, et al. Androgens by immunoassay and mass spectrometry in children with 46,XY disorder of sex development[J]. Endocr Connect, 2020, 9(11):1085-1094. DOI PMID
[28]	SHIRAISHI S, LEE P W, LEUNG A, et al. Simultaneous measurement of serum testosterone and dihydrotestosterone by liquid chromatography-tandem mass spectrometry[J]. Clin Chem, 2008, 54(11):1855-1863. DOI PMID
[29]	YARROW J F, BECK D T, CONOVER C F, et al. Invalidation of a commercially available human 5α-dihydrotestosterone immunoassay[J]. Steroids, 2013, 78(12-13):1220-1225. DOI PMID
[30]	KEEFE C C, GOLDMAN M M, ZHANG K, et al. Simultaneous measurement of thirteen steroid hormones in women with polycystic ovary syndrome and control women using liquid chromatography-tandem mass spectrometry[J]. PLoS One, 2014, 9(4):e93805. DOI URL
[31]	FANELLI F, BELLUOMO I, DI LALLO V D, et al. Serum steroid profiling by isotopic dilution-liquid chromatography-mass spectrometry:comparison with current immunoassays and reference intervals in healthy adults[J]. Steroids, 2011, 76(3):244-253. DOI URL
[32]	医疗器械监督管理条例[EB/OL].(2021-03-19)[2021-04-01]. https://www.nmpa.gov.cn/xxgk/fgwj/flxzhfg/20210319202057136.html.
[33]	Clinical and Laboratory Standards Institute. Liquid chromatography-mass spectrometry methods[S]. C62-A,CLSI, 2014.
[34]	Clinical and Laboratory Standards Institute. Defining, establishing, and verifying reference intervals in the clinical laboratory[S]. EP28-A3c,CLSI, 2010.

分析物名称	测定方法	检测效能
TT	CLIA、 LC-MS/MS	LC-MS/MS与CLIA测定TT的相关性较差（r=0.362，P<0.01）；采用LC-MS/MS和CLIA测定TT，诊断PCOS的曲线下面积分别为0.850和0.805，且CLIA的TT测定值整体偏高^[18]
DHEA-S	CLIA、 LC-MS/MS	在PCOS的诊断中，采用LC-MS/MS测定DHEA-S的效能（曲线下面积为0.789）显著优于采用CLIA测定DHEA-S（曲线下面积为0.661）（P<0.01）；LC-MS/MS对低浓度样本（pg/mL或ng/mL水平）和因分子结构相似导致的交叉反应严重且基质干扰大的分析物具有显著优势^[11]
DHEA	ELISA、 RIA、 LC-MS/MS	1）LC-MS/MS较RIA定量限更低、测量范围更宽、准确性更高^[26] 2）ELISA与LC-MS/MS测定DHEA的相关性一般（r=0.631，P<0.001）；一致性分析发现ELISA存在低估DHEA水平的趋势^[27]
DHT	ELISA、 RIA、 LC-MS/MS	1）RIA测定的血清DHT水平明显高于LC-MS/MS的测定结果 ^[28] 2）ELISA与LC-MS/MS的DHT测定结果成非线性，且一致性分析发现ELISA存在低估DHT水平的趋势^[27]，原因主要在于DHT的血清浓度远低于其他雄激素，免疫法的抗体灵敏度较低，且测量范围窄，无法准确定量DHT 3）RIA检测血清DHT会受前体睾酮对映体干扰，导致DHT测定值显著升高^[29]
A4	ELISA、 RIA、 CLIA、 LC-MS/MS	1）LC-MS/MS与RIA测定A4的相关性一般（r=0.632，P<0.01），LC-MS/MS测定的A4水平低于RIA的测定结果，在卵泡期偏差更大^[30] 2）ELISA与LC-MS/MS测定A4的相关性一般（r=0.735，P<0.001），且一致性分析发现ELISA存在高估A4水平的趋势^[25,27,31]

分析物名称	测定方法	检测效能
TT	CLIA、 LC-MS/MS	LC-MS/MS与CLIA测定TT的相关性较差（r=0.362，P<0.01）；采用LC-MS/MS和CLIA测定TT，诊断PCOS的曲线下面积分别为0.850和0.805，且CLIA的TT测定值整体偏高^[18]
DHEA-S	CLIA、 LC-MS/MS	在PCOS的诊断中，采用LC-MS/MS测定DHEA-S的效能（曲线下面积为0.789）显著优于采用CLIA测定DHEA-S（曲线下面积为0.661）（P<0.01）；LC-MS/MS对低浓度样本（pg/mL或ng/mL水平）和因分子结构相似导致的交叉反应严重且基质干扰大的分析物具有显著优势^[11]
DHEA	ELISA、 RIA、 LC-MS/MS	1）LC-MS/MS较RIA定量限更低、测量范围更宽、准确性更高^[26] 2）ELISA与LC-MS/MS测定DHEA的相关性一般（r=0.631，P<0.001）；一致性分析发现ELISA存在低估DHEA水平的趋势^[27]
DHT	ELISA、 RIA、 LC-MS/MS	1）RIA测定的血清DHT水平明显高于LC-MS/MS的测定结果 ^[28] 2）ELISA与LC-MS/MS的DHT测定结果成非线性，且一致性分析发现ELISA存在低估DHT水平的趋势^[27]，原因主要在于DHT的血清浓度远低于其他雄激素，免疫法的抗体灵敏度较低，且测量范围窄，无法准确定量DHT 3）RIA检测血清DHT会受前体睾酮对映体干扰，导致DHT测定值显著升高^[29]
A4	ELISA、 RIA、 CLIA、 LC-MS/MS	1）LC-MS/MS与RIA测定A4的相关性一般（r=0.632，P<0.01），LC-MS/MS测定的A4水平低于RIA的测定结果，在卵泡期偏差更大^[30] 2）ELISA与LC-MS/MS测定A4的相关性一般（r=0.735，P<0.001），且一致性分析发现ELISA存在高估A4水平的趋势^[25,27,31]