The Cycle disturbances, OLigomenorrhea and Amenorrhea (COLA) Study

Women of reproductive age consult the gynaecologist often for cycle
disturbances, such as oligomenorrhea or amenorrhea. Most frequently
(approximately 80%), women with cycle disturbances present with chronic
anovulation along with normal gonadotropin serum concentrations and normal
estradiol serum concentrations. Normogonadotropic normo-estrogenic anovulation
is classified as World Health Organization (WHO) class II {Rowe PJ, 1993 171
/id}. Polycystic ovary syndrome (PCOS) is a specific subgroup of WHO class II.
PCOS is diagnosed if at least two of the following criteria are present: (i)
oligo-/anovulation, (ii) clinical and/ or biochemical hyperandrogenism, or
(iii) polycystic ovaries on ultrasonography {Rotterdam ESHRE/ASRM-sponsored
PCOS consensus workshop group, 2004 1272 /id}. The prevalence of PCOS is 91% of
all women with WHO II status {Broekmans, 2006 1276 /id}.

Cycle disturbances may also be associated with elevated gonadotropins and
hypoestrogenism, suggesting that the primary defect resides within the ovary,
which is classified as WHO class III {Rowe PJ, 1993 171 /id}. The typical form
of WHO class III is menopause. Menopause is defined as the permanent cessation
of menstrual cycles due to ovarian follicle pool depletion. On average,
menopause occurs at the age of 51 years, along with a WHO III status {Treloar,
1981 232 /id}. However, in 10% to 15% of women menopause occurs before the age
of 45 (early menopause, EMP) {Luoto, 1994 139 /id} and in 1% to 2% it occurs
before the age of 40 (primary ovarian insufficiency, POI) {Coulam, 1986 7 /id}.
Ovarian follicle pool depletion or dysfunction may even occur before menarche,
as is the case in most Turner (45,X0) patients. This phenomenon is referred to
as primary hypergonadotropic hypoestrogenic amenorrhea, or primary gonadal
failure {Reynaud, 2004 1274 /id}. The final groups of women with WHO III status
involve women with incipient (IOF) or transitional ovarian failure (TOF). In
these women, elevated basal FSH serum concentrations are identified, along with
regular (IOF) or irregular cycles (TOF) before the age of 40 yrs.

Finally, women presenting with cycle abnormalities show a hypogonadotropic
hypoestrogenic, i.e. WHO I, status {Rowe PJ, 1993 171 /id}. Functional
hypogonadotropic amenorrhea, also known as a hypothalamic amenorrhea, is mostly
reversible and may be triggered by stressors such as excessive exercise,
nutritional deficits (incl. anorexia nervosa) or psychological factors
{Perkins, 2001 1297 /id}.

This research proposal has multiple aims for research in women with WHO I, II
or III status, including extended care and general health assessment,
diagnosis/etiology, assessment of best approach/treatment, cardiovascular risk
assessment, and complication prediction (regarding pregnancies, children, and
future health). These include the aims of the original protocols for cycle
disturbances (METC protocols 04-263 and 05-047).

Up until now we have collected data, serum and DNA samples according to the
METC protocols 04-263 and 05-047:
- WHO II status: 998 women, of whom 804 women with PCOS (81%)
- WHO III status: 1317 women, of whom 477 women with POI (36%), 392 women with
IOF (30%), 227 women with TOF (17%), 105 women with early menopause (8%), 68
women with poor response (5%), and 48 women with hypergonadotropic primary
amenorrhea (4%) (Multicenter collaboration).

The collection of these data and samples has already led to the publication of
a series of papers by our group regarding the phenotype and genotype of PCOS .
Since the writing of the previous research protocols, however, it has become
clear that much larger cohorts of well-phenotyped patients are needed to
perform genetic studies focusing on small genetic variations (e.g. using
genome-wide association studies and possibly *next generation sequencing*
studies in the near future), and findings of such studies need to be
replicated. Moreover, there is a need for continued cardiovascular follow-up
and the follow-up of children born in women with PCOS. This can only be
performed adequately when a thorough initial screening is performed.

Despite the association of premature cessation of ovarian function and short
term health problems such as decreased fertility and climacteric symptoms in
women with POI, there is a lack of both baseline and prospective follow up data
for CVD, osteoporosis, cognition, emotional well-being, and sexual health.
Moreover, the mechanism for CVD in women with POI is undiscovered. Finally,
there is a lack of prospective follow-up data and hard clinical endpoints to
substantiate the current advice or hormone substitution therapy in women with
POI. We will especially focus on cardiovascular health to investigate a
possible relationship with the occurrence of early reproductive ageing.
While the association between PCOS and CVD seems relatively better understood,
CVD risk and events have not been studied in a Dutch population. From recent
studies persued by our group, it has become clear that Dutch women with PCOS
may have an altered profile compared to other (mostly North-American) study
populations. Furthermore, long term follow-up of these women beyond the
cessation of fertility is indicated, because unfavorable hormonal, metabolic
and inflammatory alterations may persist after menopause in PCOS. This will be
studied in a separate protocol that is now under construction.

Design
This proposed study part, focusing on the first, second and third primary
objectives, is designed as a prospective cohort study for evaluating phenotype
and genotype characteristics of women with WHO I, II, or III status. The COLA
study protocol is in line with previous protocols 04-263 and 05-047.

Duration of the study
This study was originally initiated in 2004. We expect to need at least five
more years to complete inclusion. Moreover, research towards the identification
of genes and variants associated with complex genetic traits is still
developing. One can imagine that ongoing research projects and newer techniques
will enable us to continue our work for some decades.

Setting of the study
This study will be performed at the department of Reproductive Medicine and
Gynaecology, division Woman & Baby, University Medical Center Utrecht (UMCU).
In addition, collaboration will be established with the following centers for
the inclusion of women with cycle disturbances (similar to protocol 04-263):
Erasmus Medical Center (Rotterdam) and Vrije Universiteit Medical Center
(Amsterdam). Furthermore, collaboration will be established with the following
centers for the inclusion of women with WHO III status (similar to protocol
05-047): Erasmus Medical Center (Rotterdam), Medical Center Alkmaar, University
Medical Center Groningen, Leiden University Medical Center, Medisch Spectrum
Twente (Enschede), Isala Clinics (Zwolle), University Medical Center St.
Radboud (Nijmegen), Amphia Hospital (Breda), Deventer Hospital, Catharina
Ziekenhuis (Eindhoven), Amsterdam Medical Center, Maastricht University Medical
Center.

If collaboration can be affirmed the necessary documents will be added in an
addendum.

With this observational study we intend to identify phenotypic and genetic
factors related to the phenotype and the pathophysiology of cycle disturbances.
Moreover, we aim at developing predictive models for ovarian ageing, cycle
abnormalities and the probability to conceive in the future. Results will not
be analyzed and interpreted individually. As such, the participants will not
benefit from the results of this study. However, women with cycle disturbances
could benefit from this study as it aims to decipher the yet unknown etiology
behind these disturbances. Knowing the etiology of the cycle disturbance may
help identify whether the children of these women are at risk for developing
identical phenotypes.
The burden associated with participating in this study will be mostly originate
from the collection of two extra blood vials when blood is drawn during routine
medical care. Venapuncture is generally accepted to be minimally invasive.
Therefore the risks and burdens for the participating patients of this study
are negligible.