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1、胰岛素抵抗与多囊卵巢综合征,北京大学深圳医院生殖医学中心李蓉,一、胰岛素与卵巢功能的关系,胰岛素通过IGF-1受体刺激卵巢分泌雌激素，雄激素及 孕酮(细胞色素 p-450c 17 17-羟化酶)胰岛素抑制肝脏分泌SHBG 雄激素的效应胰岛素抑制肝脏合成 IGFBP-1 IGF-1的效应同 Gn相互作用抑制卵泡的凋亡 闭锁上调 IGF-1受体,Figure 1.Possible Mechanisms of Insulin Stimulation of Ovarian Cytochrome P450c17 Activity and Androgen production.In theca cell
2、s,insulin may directly stimulate(plus signs)ovarian cytochrome P450c17,resulting in increased 17-hydroxylase and,to a lesser extent,17,20-lyase activity.This would lead to increased production of androstenedione,which is then converted to testosterone by the enzyme 17-reductase.Alternatively or in c
3、onjunction with this,insulin may stimulate ovarian androgen production indirectly by enhancing the amplitude of serum luteinizing hormone(LH)pulses,and luteinizing hormone may then stimulate ovarian cytochrome P450c17 activity.,二、胰岛素抵抗与PCOS,胰岛素及其受体的结构,胰岛素是胰腺Langerhans小岛上的-细胞产生多肽，由A链(21AAs)和B链(30AAs)
4、构成。胰岛素受体由两个-亚单位（135 kDa）和两个-亚单位(95 kDa)构成的异构四聚体。-亚单位：存在于细胞膜外，富含半胱氨酸，是胰岛素的结合位点；-亚单位：三种类型：细胞膜外、细胞膜、细胞浆内，后者含有ATP 结合位点和几个酪氨酸自动磷酸化位点。,胰岛素的作用机理（1）,胰岛素受体-亚单位的酪氨酸位点磷酸化,胰岛素,胰岛素受体-亚单位,获得激酶活性，细胞内蛋白磷酸化,胰岛素受体底物（IRS）,突变,胰岛素抵抗,基因,OGTTPCOS,高胰岛素血症,FIG 1.The IR is a heterotetramer consisting of two a,b-dimers linked
5、by disulfide bonds.The a-subunit contains the ligand-binding site,and the b-subunit contains a ligand-activated tyrosine kinase.Tyrosine autophosphorylation increases the receptor s tyrosine kinase activity whereas serine phosphorylation inhibits it.,胰岛素的作用机理（2）,胰岛素抵抗的机理(1),受体与胰岛素的结合或者受体亲和力无改变50%PCO
6、S-ser:IR 酪氨酸磷酸化 或 IR 丝氨酸磷酸化 50%PCOS-nl:IR下游信号传导受阻(IRS-1 的磷酸化；PI3-K的活性）,Figure 9.The tyrosine-phosphorylated IR phosphorylates intracellular substrates,such as IR substrate(IRS)-1 and IRS-2,initiating signal transduction and the plieotropic actions of insulin.The activation of PI3-K(PI3-kinase)by tyr
7、osine-phosphorylated IRS-1 appears to be the pathway for insulin-mediated glucose transport.The Ras-MAP kinase pathway appears to regulate cell growth and glycogen synthesis.,胰岛素抵抗的机理（2）,IR 丝氨酸磷酸化因子IR 酪氨酸激酶抑制因子膜糖蛋白 PC-1/TNF-a,胰岛素抵抗的机理（3）,抑制 IR 酪氨酸激酶活性,Figure 14.Insulin resistance in 50%of PCOS women
8、 appears to be secondary to a cell membrane-associated factor,presumably a serine/threonine kinase,that serine-phosphorylates the IR-inhibiting signaling.Serine phosphorylation of IRS-1 appears to be the mechanism for TNF-mediated insulin resistance.The membrane glycoprotein PC-1 also inhibits IR ki
9、nase activity,but it does not cause serine phosphorylation of the receptor.These are examples of a recently appreciated mechanism for insulin resistance secondary to factors regulating the receptors tyrosine kinase activity.,胰岛素抵抗的机理（4）,FIG.2.a normal(control),a PCOS woman with normal insulin-stimul
10、ated tyrosine phosphorylation(PCOS-nl)and a PCOS woman with high basal autophosphorylation on serine residues(PCOS-ser);S-serine,Y-tyrosine.Basal autophosphorylation is increased and there is minimal further insulin-stimulated phosphorylation in the PCOS-ser b-subunits.The high basal phosphorylation
11、 represents phosphoserine,and phosphotyrosine content does not increase in response to insulin in the PCOS-ser b-subunits.,FIG.3.a striking increase in phosphoserine content and a marked decrease in insulin-stimulated phosphotyrosine content after mixing hIR with PCOS-ser lectin eluates as compared
12、with mixing hIR with control lectin eluates or in the absence of mixing.,NIDDM IR 数目/IR磷酸化/葡萄糖转运 胰岛素刺激的肌糖原合成 高血糖症代偿,PCOS 与NIDDM的关系(1),PCOS IR 传导信号起始阶段异常 IR磷酸化独特类型 PCOS-相关的胰岛素抵抗 与其它 NIDDM 基因相区别,PCOS 与NIDDM的关系（2）,PCOS 是 NIDDM的一个独特的亚型,对患有PCOS的绝经后妇女，PCOS 及葡萄糖不耐受的研究显示 PCOS-相关的胰岛素抵抗使患NIDDM的危险显著增加。,降低雄激素水平
13、不能完全恢复胰岛素敏感性。雄激素不引起或引起轻度胰岛素抵抗。,雄激素能引起胰岛素抵抗?,高胰岛素血症能引起高雄激素血症？,在PCOS病人，高胰岛素血症能增加雄激素水平。胰岛素通过IR直接介导，而不是占据了IGF-I 受体。类固醇合成异常。降低胰岛素水平却未改变高雄激素 的异常。,FIG.6 A single factor that causes serine phosphorylation of the IR and serine phosphorylation of P450c17,the key regulatory enzyme controlling androgen biosynth
14、esis,could produce both the insulin resistance and the hyperandrogenism characteristic of PCOS.It is also possible that the insulin resistance and the reproductive abnormalities reflect separate genetic defects and that the insulin resistance unmasks the syndrome in genetically susceptible women.Rec
15、ent studies suggest that insulin acting through its own receptor augments steroidogenesis and LH release.Androgens amplify the associated insulin resistance.,三、PCOS的诊断,PCOS的定义(1)（1990年NIH标准）,慢性无排卵（Chronic anovalation）高雄激素血症（Hyperandrogenism）（临床或生化）(clinical or biochemical)排除其他代谢异常（Exclusion of other
16、 etiologies）,PCOS的定义(2)（2003年标准）,少或无排卵（Oligo and/or anovulation）高雄激素血症（Hyperandrogenism）(clinical and/or biochemical)多囊卵巢（Polycystic ovaries）(2 out of 3 criteria)排除其他代谢异常（Exclusion of other etiologies）,PCOS的定义(3),高雄激素血症（Hyperandrogenism）卵巢功能异常（Ovulatory dysfunction）排除其他代谢异常（The exclusion of specific
17、 disorders）PCO不是必需的诊断要求LH/FSH 比值也不是必需的诊断要求,胰岛素抵抗的诊断,餐后2小时胰岛素水平100U/ml GLU/INS 4.5 INS/GLU0.3重叠临床检测与胰岛素水平并不完全相关 所有的 PCOS病人 所有的肥胖妇女,四、胰岛素抵抗的处理,双胍类药物二甲双胍(如格华止)血管紧张素转换酶抑制剂(如开博通、蒙诺)胰岛素增敏剂(如罗格列酮)饮食和运动,降低胰岛素抵抗的方法,饮食和运动疗法,限制热量或减轻体重的饮食胰岛素敏感性Gn 和 雄激素代谢P450 和 17-羟化酶活性,肥胖和缺乏运动胰岛素抵抗,-葡萄糖苷酶抑制剂的作用机理,延缓碳水化合物及二糖的消化,
18、葡萄糖的吸收,葡萄糖苷酶抑制剂的用法,阿卡波糖:100mg tid，3-6月（之前或同时服用格华止/胰岛素）,增加血管平滑肌的 IR酪氨酸激酶活性;降低循环血中的胰岛素;增加 SHBG、LH 和雄激素;降低 17-OHP 对 GnRH的过度反应;抑制雄激素;降低高胰岛素血症;降低垂体 LH分泌、膜细胞雄激素分泌及SHBG的增加。,Metformin 的作用机理,500 mg,tid,3-6月 同时服用 CC/Gn，或者行 ART 2.肥胖、多毛妇女要求低热量饮食(1500 kcal/天)，及 850 mg metformin/天,Metformin 的用法,高亲和力配体 PPAR-g,PPAR-g 一种类固醇核受体超家族,通过激活其受体影响胰岛素的敏感性。治疗 TNF-a-引起的胰岛素抵抗 降低瘦素,Troglitazone的作用机理,Troglitazone的用法,同格华止一起使用单独使用,
