胰岛素抵抗与多囊卵巢综合征ppt课件

胰岛素抵抗与多囊卵巢综合征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v1921年， Achard 和 Their首先发现糖代谢异常与高雄激素血症有关 ;v1935年， Stein and Leventhal首先提出PCOS;v1976年， Kahn 和同事发现高雄激素血症、胰岛素抵抗和黑棘皮症有关 ;v1980年， Burghen 首先提出 PCOS与高雄激素血症、高胰岛素血症有关 ;背 景Figure 2. Section of a polycystic ovary with multiple subscapular follicular cysts and stromal hypertrophy (left panel). At higher power (x100) islands of luteinized theca cells are visible in the stroma (right panel). This morphological change is called stromal hyperthecosis and appears to be directly correlated with circulating insulin levels. 一、胰岛素与卵巢功能的关系v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 )v胰岛素抑制肝脏分泌 SHBG 雄激素的效应v胰岛素抑制肝脏合成 IGFBP-1 IGF-1的效应v同 Gn相互作用v抑制卵泡的凋亡 闭锁v上调 IGF-1受体Figure 1. Possible Mechanisms of Insulin Stimulation of Ovarian Cytochrome P450c17 Activity and Androgen production. In theca cells, 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 conjunction 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及其受体的结构v 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)构成。v 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（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 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（胰岛素的作用机理（ 2）胰岛素抵抗的机理胰岛素抵抗的机理 (1)v受体与胰岛素的结合或者受体亲和力 无 改变v50% PCOS-ser : IR 酪氨酸磷酸化 或 IR 丝氨酸磷酸化 v50% 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 tyrosine-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（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（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 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 kinase 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（胰岛素抵抗的机理（ 4）FIG.2. a normal (control), a PCOS woman with normal insulin-stimulated 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 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 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) PCOSIR 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。v降低雄激素水平不能完全恢复胰岛素敏感性。v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？v在 PCOS病人， 高胰岛素血症能增加雄激素水平 。v胰岛素通过 IR直接介导，而不是占据了 IGF-I 受体。v类固醇合成异常。v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 biosynthesis, 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. Recent 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的定义的定义 (1)（ 1990年年 NIH标准）标准）v 慢性无排卵（ Chronic anovalation）v 高雄激素血症（ Hyperandrogenism）（临床或生化） (clinical or biochemical)v 排除其他代谢异常（ Exclusion of other etiologies）PCOS的定义的定义 (2)（ 2003年标准）年标准）v 少或无排卵（ Oligo and/or anovulation）v 高雄激素血症（ Hyperandrogenism）(clinical and/or biochemical)v 多囊卵巢（ Polycystic ovaries）(2 out of 3 criteria)v 排除其他代谢异常（ Exclusion of other etiologies）PCOS的定义的定义 (3)v高雄激素血症（ Hyperandrogenism） v卵巢功能异常（ Ovulatory dysfunction）v排除其他代谢异常（ The exclusion of specific