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| Name | Class |
|---|---|
| Instituto de Salud Carlos III | OTHER_GOV |
| University of Alcala | OTHER |
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Reproduction requires from women enough energy depots to warrant an adequate nutritional supply to the fetus. Hence, adipose tissue is able to communicate with female hypothalamic-pituitary-ovary axis. The hypothesis of the project is that abnormalities in the quantity (absolute and relative to lean body mass), distribution and/or function of adipose tissue are associated with functional forms of female gonadal dysfunction in predisposed women, in a spectrum of anomalies that go from hypothalamic amenorrhea to the polycystic ovary syndrome (PCOS). To challenge this hypothesis, the investigators will study 5 groups of 10 women each: women with exercise-associated hypothalamic amenorrhea, women without ovulatory dysfunction that exercise equally, non-hyperandrogenic patients with PCOS, hyperandrogenic patients with PCOS, and healthy control women comparable to those with PCOS. The aims of the study will be:
Primary objective: To identify novel signalling factors originating from adipose tissue and muscle using targeted and nontargeted evaluation of the proteome and of gene expression of superficial subcutaneous fat, deep subcutaneous fat (which mimics visceral adipose tissue) and skeletal muscle.
Secondary objectives:
2.1, Sex steroid profiles.
2.2. Classic cardiovascular risk factors: carbohydrate metabolism, lipid profiles and blood pressure.
2.3 Markers of low-grade chronic inflammation.
2.4. Oxidative stress markers.
2.5. Cardiovascular autonomic function.
2.6. Surrogate markers of subclinical atherosclerosis.
2.7. Circulating concentrations of endocrine disruptors.
2.8. Oral and gut microbiome.
The results will provide a better understanding of the mechanisms linking body energy depots with the female reproductive axis and, hopefully, the identification of potential biomarkers for the diagnosis and treatment of the disorders studied here.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| I- Hypothalamic amenorrhea | 10 women with exercise-associated hypothalamic amenorrhea |
| |
| II- Hyperandrogenic polycystic ovary syndrome | 5 lean women with hyperandrogenic polycystic ovary syndrome. 5 women with weight excess and hyperandrogenic polycystic ovary syndrome. |
| |
| III- Non-hyperandrogenic polycystic ovary syndrome | 5 lean women with non-hyperandrogenic polycystic ovary syndrome 5 women with weight excess and non-hyperandrogenic polycystic ovary syndrome |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Anthropometric and physical examination | Diagnostic Test |
|
| Measure | Description | Time Frame |
|---|---|---|
| Adipokine and myokine signaling identification | Up to 5 years |
| Measure | Description | Time Frame |
|---|---|---|
| Circulating adipokine profile | At fasting and after an oral glucose challenge: Circulating concentrations of Leptin, Adiponectin, Chemerin, Lipocalin-2, Adipsin, Plasminogen Activator Inhibitor (PAI)-1, Monocyte Chemoattractant Protein (MCP)-1, and Soluble Leptin Receptor by multianalyte profiling on the Luminex Magpix system (Luminex Technologies, Austin, USA.). | Up to 5 years |
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Inclusion Criteria
Group I
Group II:
Group III:
Group IV:
Group V:
Exclusion Criteria (Groups I-V)
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Patients with exercise-associated functional amenorrhea and polycystic ovary syndrome will be consecutively recruited from our Reproductive Endocrinolgy clinic. Those premenopausal adult women are referred to clinic because of symptoms of functional androgen excess such as hirsutism or menstrual dysfunction.
The control group (Groups IV and V) will include healthy female volunteers recruited - contemporarily with the recruitment of patients - from the hospital's staff and overweight or obese women seeking medical attention in our department.
| Name | Role | Phone | Extension | |
|---|---|---|---|---|
| Alejandra Quintero Tobar | Contact | 34913369029 | mariaalejandra.quintero@salud.madrid.org | |
| Sara de Lope Quiñones | Contact | 34913369029 | sara.lope@salud.madrid.org |
| Name | Affiliation | Role |
|---|---|---|
| Héctor F Escobar-Morreale, PhD, MD | Diabetes, Obesity and Human Reproduction Research Group (CIBERDEM), Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain | Principal Investigator |
| Manuel Luque-RamÃrez, PhD, MD |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Endocrinology and Nutrition | Recruiting | Madrid | Madrid | 28034 | Spain |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 30710572 | Background | Ortiz-Flores AE, Luque-Ramirez M, Fernandez-Duran E, Alvarez-Blasco F, Escobar-Morreale HF. Diagnosis of disorders of glucose tolerance in women with polycystic ovary syndrome (PCOS) at a tertiary care center: fasting plasma glucose or oral glucose tolerance test? Metabolism. 2019 Apr;93:86-92. doi: 10.1016/j.metabol.2019.01.015. Epub 2019 Jan 30. | |
| 30229887 |
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The investigators will deposit any datasets and supplemental materials to a generalist repository. The investigators will refer to the deposited material as an item in the bibliography of any manuscript and number the reference appropriately within the text.
Data will become available at the time of the first manuscript submission.
Public access
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Serum Plasma Whole blood samples Subcutaneous adipose tissue by percutaneous biopsy Muscle tissue by percutaneous biopsy Feces Oral smear
| IV- Trained women without ovulatory dysfunction | 10 women who exercise as intensively as women with exercise-associated hypothalamic amenorrhea but with normal ovulatory cycles. |
|
| V- Non-hyperandrogenic healthy women | 10 women matched by age and body mass index with women with polycystic ovary syndrome who do not perform physical activity on a regular basis |
|
| Indirect calorimetry, accelerometer and seven-day dietary recall | Diagnostic Test | Energy availability assessment. |
|
| Biochemical, hormonal and metabolic phenotyping | Diagnostic Test |
|
|
| Sonographic studies | Diagnostic Test |
|
|
| 24-hour Ambulatory blood pressure monitoring | Diagnostic Test | A&D TM2430EX oscillometric devices (A&D Company Limited, Tokyo, Japan). |
|
| Percutaneous biopsy | Procedure | Subcutaneous fat tissue and muscle tissue for proteomics an gene expression studies. |
|
| Cardiovascular autonomic function studies | Diagnostic Test | Parasympathetic and sympathetic responses to deep breathing, Valsalva's maneuver and orthostatism. |
|
| Oral smear and feces specimen | Diagnostic Test | Microbiome studies. |
|
| Appetite regulation hormonal profile | At fasting and after an oral glucose challenge: Circulating concentrations of Amylin, C-Peptide, Ghrelin, Gastric Inhibitory Peptide (GIP), Glucagon-Like Peptide (GLP)-1, Glucagon, IL-6, Insulin, Pancreatic Polypeptide (PP), Peptide YY, Tumor Necrosis Factor (TNF)-α by multianalyte profiling on the Luminex Magpix system (Luminex Technologies, Austin, USA.). | Up to 5 years |
| Association between body mass index and sex steroids | Body mass index in in kg/m^2. Sex steroids (including circulating total testosterone, estradiol, androstenedione, dehydroepiandrosterone-sulphate and estrone) measured by liquid chromatography tandem mass spectrometry (LC-MS/MS). Free testosterone will be calculated from total testosterone and sex hormone binding globulin levels. | Up to 5 years |
| Association between percentage of fat mass with respect to total body weight and sex steroids | Fat mass% by bioelectric impedanciometry and DEXA. Sex steroids (including circulating total testosterone, estradiol, androstenedione, dehydroepiandrosterone-sulphate and estrone) measured by liquid chromatography tandem mass spectrometry (LC-MS/MS). Free testosterone will be calculated from total testosterone and sex hormone binding globulin levels. | Up to 5 years |
| Association between percentage of lean mass with respect to total body weight and sex steroids | Lean mass% by bioelectric impedanciometry and DEXA. Sex steroids (including circulating total testosterone, estradiol, androstenedione, dehydroepiandrosterone-sulphate and estrone) measured by liquid chromatography tandem mass spectrometry (LC-MS/MS). Free testosterone will be calculated from total testosterone and sex hormone binding globulin levels. | Up to 5 years |
| Association between body fat depots and sex steroids | Adipose tissue depots will be estimated using a Toshiba Nemio XG SSA-580A Diagnostic Ultrasound System. Minimum sc and preperitoneal fat thicknesses will be measured at the level of the xyphoid process. Maximum sc fat thickness will be measured at the level of the umbilicus. Intraperitoneal fat thickness will be measured placing a probe transversally in the midline of abdomen, 2 cm above the umbilicus. Three measures of ip fat thickness will be obtained: the distance from the fascia of rectus abdominis muscle to the vertebral column, the distance from the peritoneum to the vertebral column, and the distance from the linea alba to the vertebral column. Perirenal fat thickness will be estimated as the distance from the perirenal fascia to the renal surface. Sex steroids will be measured as previously described. | Up to 5 years |
| Association between body composition, sex steroids, and insulin resistance. | Fat mass, lean mass and body fat depots will be measured as previously described. Fasting glucose and insulin levels will be used for calculating the homeostasis model assessment of insulin resistance (HOMA-IR), and the composite insulin sensitivity index will be estimated from the glucose and insulin concentrations measured during the oral glucose tolerance test. Sex steroids will be measured as previously described. | Up to 5 years |
| Association between body composition, sex steroids, and lipids. | Fat mass, lean mass and body fat depots will be measured as previously described. Circulating HDL-cholesterol and phospholipid levels will be measured by enzymatic methods after precipitation of plasma with phosphotungstic acid and Mg2+. Total cholesterol and triglyceride levels will be determined by enzymatic methods. LDL-cholesterol concentrations will be estimated by Friedewald's equation. Circulating apolipoprotein (Apo) AI, Apo B100, and lipoprotein (a) levels will be determined by kinetic immunonephelometry. Sex steroids will be measured as previously described. | Up to 5 years |
| Association between body composition, sex steroids, and office blood pressure. | Fat mass, lean mass and body fat depots will be measured as previously described. Office blood pressure will be determined as the mean of three manual sphygmomanometer readings in the sitting position. Sex steroids will be measured as previously described. | Up to 5 years |
| Association between body composition, sex steroids, and ambulatory blood pressure monitoring parameters. | Fat mass, lean mass and body fat depots will be measured as previously described. Twenty-four-hour ambulatory blood pressure monitoring will be performed using an A&D TM2430EX oscillometric device (A&D Co., Ltd., Tokyo, Japan). The cuff (12 × 22 cm for lean participants, 14 × 30 cm for overweight or obese participants) will placed on the nondominant arm in every woman. The period from 0700 to 2300 h will be considered daytime, and from 2300 until 0700 h the next day will be considered nighttime, reflecting the usual sleeping habits of Spaniards. Systolic, diastolic, and mean blood pressure as well as heart rate will be measured every 20 min during daytime and every 30 min during nighttime. Sex steroids will be measured as previously described. | Up to 5 years |
| Association between body composition, sex steroids, and cardiovascular autonomic function tests. | Fat mass, lean mass and body fat depots will be measured as previously described. Cardiovascular autonomic function will be assessed by the blood pressure and heart rate responses to active standing, and Ewing and Clarke's tests. Sex steroids will be measured as previously described. | Up to 5 years |
| Association between body composition, sex steroids, and carotid intima-media thickness. | Fat mass, lean mass and body fat depots will be measured as previously described. Imaging will be conducted using a high-resolution 7.5-MHz phased-array transducer by the same trained operator in all the participants. Sex steroids will be measured as previously described. | Up to 5 years |
| Association between body composition, sex steroids, and oxidative stress. | Fat mass, lean mass and body fat depots will be measured as previously described. Oxidative stress profile will be measured by enzymatic assays: Plasma thiobarbituric acid reactive substances, total antioxidant capacity, nitrotyrosine, protein carbonyl groups and erythrocyte glutathione peroxidase levels. Sex steroids will be measured as previously described. | Up to 5 years |
| Association between body composition, sex steroids, and microbiome | Participants will be instructed to collect fecal and salivary samples. DNA samples wil be used for massive sequencing of 16S ribosomal DNA (rDNA) amplicons in a MiSeq platform (Illumina). The bacterial diversity will be estimated by using Shannon, Chao 1, Jaccard, and Sorensen indexes with their SDs. Taxonomic affiliations will be assigned by using the RDP_classifier from the Ribosomal Database Project (RDP), and readings with RDP score value <0.8 will be assigned to the upper taxonomic rank, leaving the last rank as unidentified. Sex steroids will be measured as previously described. | Up to 5 years |
| Diabetes, Obesity and Human Reproduction Research Group (CIBERDEM), Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain |
| Principal Investigator |
| Luque-Ramirez M, Jimenez-Mendiguchia L, Garcia-Cano A, Fernandez-Duran E, de Dios Rosa V, Nattero-Chavez L, Ortiz-Flores AE, Escobar-Morreale HF. Certified testosterone immunoassays for hyperandrogenaemia. Eur J Clin Invest. 2018 Dec;48(12):e13029. doi: 10.1111/eci.13029. Epub 2018 Oct 8. |
| 29897462 | Background | Insenser M, Murri M, Del Campo R, Martinez-Garcia MA, Fernandez-Duran E, Escobar-Morreale HF. Gut Microbiota and the Polycystic Ovary Syndrome: Influence of Sex, Sex Hormones, and Obesity. J Clin Endocrinol Metab. 2018 Jul 1;103(7):2552-2562. doi: 10.1210/jc.2017-02799. |
| 29569621 | Background | Escobar-Morreale HF. Polycystic ovary syndrome: definition, aetiology, diagnosis and treatment. Nat Rev Endocrinol. 2018 May;14(5):270-284. doi: 10.1038/nrendo.2018.24. Epub 2018 Mar 23. |
| 29224112 | Background | Escobar-Morreale HF. The Role of Androgen Excess in Metabolic Dysfunction in Women : Androgen Excess and Female Metabolic Dysfunction. Adv Exp Med Biol. 2017;1043:597-608. doi: 10.1007/978-3-319-70178-3_26. |
| 28722287 | Background | Montes-Nieto R, Insenser M, Murri M, Fernandez-Duran E, Ojeda-Ojeda M, Martinez-Garcia MA, Luque-Ramirez M, Escobar-Morreale HF. Plasma thiobarbituric acid reactive substances (TBARS) in young adults: Obesity increases fasting levels only in men whereas glucose ingestion, and not protein or lipid intake, increases postprandial concentrations regardless of sex and obesity. Mol Nutr Food Res. 2017 Nov;61(11). doi: 10.1002/mnfr.201700425. Epub 2017 Aug 29. |
| 26874912 | Background | Escobar-Morreale HF, Martinez-Garcia MA, Montes-Nieto R, Fernandez-Duran E, Temprano-Carazo S, Luque-Ramirez M. Effects of glucose ingestion on circulating inflammatory mediators: Influence of sex and weight excess. Clin Nutr. 2017 Apr;36(2):522-529. doi: 10.1016/j.clnu.2016.01.015. Epub 2016 Jan 29. |
| 26671973 | Background | Insenser M, Montes-Nieto R, Martinez-Garcia MA, Escobar-Morreale HF. A nontargeted study of muscle proteome in severely obese women with androgen excess compared with severely obese men and nonhyperandrogenic women. Eur J Endocrinol. 2016 Mar;174(3):389-98. doi: 10.1530/EJE-15-0912. Epub 2015 Dec 15. |
| 25479351 | Background | Borruel S, Molto JF, Alpanes M, Fernandez-Duran E, Alvarez-Blasco F, Luque-Ramirez M, Escobar-Morreale HF. Surrogate markers of visceral adiposity in young adults: waist circumference and body mass index are more accurate than waist hip ratio, model of adipose distribution and visceral adiposity index. PLoS One. 2014 Dec 5;9(12):e114112. doi: 10.1371/journal.pone.0114112. eCollection 2014. |
| 25304109 | Background | Luque-Ramirez M, Escobar-Morreale HF. Polycystic ovary syndrome as a paradigm for prehypertension, prediabetes, and preobesity. Curr Hypertens Rep. 2014 Dec;16(12):500. doi: 10.1007/s11906-014-0500-6. |
| 25104855 | Background | Escobar-Morreale HF, Alvarez-Blasco F, Botella-Carretero JI, Luque-Ramirez M. The striking similarities in the metabolic associations of female androgen excess and male androgen deficiency. Hum Reprod. 2014 Oct 10;29(10):2083-91. doi: 10.1093/humrep/deu198. Epub 2014 Aug 7. |
| 24684164 | Background | Murri M, Insenser M, Luque M, Tinahones FJ, Escobar-Morreale HF. Proteomic analysis of adipose tissue: informing diabetes research. Expert Rev Proteomics. 2014 Aug;11(4):491-502. doi: 10.1586/14789450.2014.903158. Epub 2014 Mar 31. |
| 24368231 | Background | Murri M, Insenser M, Escobar-Morreale HF. Metabolomics in polycystic ovary syndrome. Clin Chim Acta. 2014 Feb 15;429:181-8. doi: 10.1016/j.cca.2013.12.018. Epub 2013 Dec 22. |
| 24324038 | Background | Luque-Ramirez M, Marti D, Fernandez-Duran E, Alpanes M, Alvarez-Blasco F, Escobar-Morreale HF. Office blood pressure, ambulatory blood pressure monitoring, and echocardiographic abnormalities in women with polycystic ovary syndrome: role of obesity and androgen excess. Hypertension. 2014 Mar;63(3):624-9. doi: 10.1161/HYPERTENSIONAHA.113.02468. Epub 2013 Dec 9. |
| 24275746 | Background | Escobar-Morreale HF. Reproductive endocrinology: Menstrual dysfunction--a proxy for insulin resistance in PCOS? Nat Rev Endocrinol. 2014 Jan;10(1):10-1. doi: 10.1038/nrendo.2013.232. Epub 2013 Nov 26. No abstract available. |
| 24087928 | Background | Insenser M, Escobar-Morreale HF. Proteomics and polycystic ovary syndrome. Expert Rev Proteomics. 2013 Oct;10(5):435-47. doi: 10.1586/14789450.2013.837665. Epub 2013 Oct 3. |
| 23791845 | Background | Murri M, Insenser M, Bernal-Lopez MR, Perez-Martinez P, Escobar-Morreale HF, Tinahones FJ. Proteomic analysis of visceral adipose tissue in pre-obese patients with type 2 diabetes. Mol Cell Endocrinol. 2013 Aug 25;376(1-2):99-106. doi: 10.1016/j.mce.2013.06.010. Epub 2013 Jun 18. |
| 23559188 | Background | Luque-Ramirez M, Martinez-Garcia MA, Montes-Nieto R, Fernandez-Duran E, Insenser M, Alpanes M, Escobar-Morreale HF. Sexual dimorphism in adipose tissue function as evidenced by circulating adipokine concentrations in the fasting state and after an oral glucose challenge. Hum Reprod. 2013 Jul;28(7):1908-18. doi: 10.1093/humrep/det097. Epub 2013 Apr 4. |
| 23422073 | Background | Insenser M, Montes-Nieto R, Murri M, Escobar-Morreale HF. Proteomic and metabolomic approaches to the study of polycystic ovary syndrome. Mol Cell Endocrinol. 2013 May 6;370(1-2):65-77. doi: 10.1016/j.mce.2013.02.009. Epub 2013 Feb 17. |
| 23386652 | Background | Borruel S, Fernandez-Duran E, Alpanes M, Marti D, Alvarez-Blasco F, Luque-Ramirez M, Escobar-Morreale HF. Global adiposity and thickness of intraperitoneal and mesenteric adipose tissue depots are increased in women with polycystic ovary syndrome (PCOS). J Clin Endocrinol Metab. 2013 Mar;98(3):1254-63. doi: 10.1210/jc.2012-3698. Epub 2013 Feb 5. |
| 23348399 | Background | Montes-Nieto R, Insenser M, Martinez-Garcia MA, Escobar-Morreale HF. A nontargeted proteomic study of the influence of androgen excess on human visceral and subcutaneous adipose tissue proteomes. J Clin Endocrinol Metab. 2013 Mar;98(3):E576-85. doi: 10.1210/jc.2012-3438. Epub 2013 Jan 24. |
| 21609197 | Background | Alvarez-Blasco F, Luque-Ramirez M, Escobar-Morreale HF. Diet composition and physical activity in overweight and obese premenopausal women with or without polycystic ovary syndrome. Gynecol Endocrinol. 2011 Dec;27(12):978-81. doi: 10.3109/09513590.2011.579658. Epub 2011 May 24. |
| 22104628 | Background | Insenser M, Escobar-Morreale HF. Application of proteomics to the study of polycystic ovary syndrome. J Endocrinol Invest. 2011 Dec;34(11):869-75. doi: 10.3275/8108. Epub 2011 Nov 21. |
| 22427353 | Background | Escobar-Morreale HF, Samino S, Insenser M, Vinaixa M, Luque-Ramirez M, Lasuncion MA, Correig X. Metabolic heterogeneity in polycystic ovary syndrome is determined by obesity: plasma metabolomic approach using GC-MS. Clin Chem. 2012 Jun;58(6):999-1009. doi: 10.1373/clinchem.2011.176396. Epub 2012 Mar 16. |
| 22796336 | Background | Insenser M, Montes-Nieto R, Vilarrasa N, Lecube A, Simo R, Vendrell J, Escobar-Morreale HF. A nontargeted proteomic approach to the study of visceral and subcutaneous adipose tissue in human obesity. Mol Cell Endocrinol. 2012 Nov 5;363(1-2):10-9. doi: 10.1016/j.mce.2012.07.001. Epub 2012 Jul 14. |
| 23303572 | Background | Murri M, Luque-Ramirez M, Insenser M, Ojeda-Ojeda M, Escobar-Morreale HF. Circulating markers of oxidative stress and polycystic ovary syndrome (PCOS): a systematic review and meta-analysis. Hum Reprod Update. 2013 May-Jun;19(3):268-88. doi: 10.1093/humupd/dms059. Epub 2013 Jan 9. |
| 23337724 | Background | Martinez-Garcia MA, Montes-Nieto R, Fernandez-Duran E, Insenser M, Luque-Ramirez M, Escobar-Morreale HF. Evidence for masculinization of adipokine gene expression in visceral and subcutaneous adipose tissue of obese women with polycystic ovary syndrome (PCOS). J Clin Endocrinol Metab. 2013 Feb;98(2):E388-96. doi: 10.1210/jc.2012-3414. Epub 2013 Jan 21. |
| 42359269 | Derived | Luque-Ramirez M, de Lope Quinones S, Quintero-Tobar A, Martinez-Garcia MA, Insenser M, Nattero-Chavez L, Garriga M, Michael Fernandez AC, Escobar-Morreale HF. Evidence of early subclinical atherosclerosis in women with exercise-induced hypothalamic amenorrhea. Hum Reprod Open. 2026 Jun 3;2026(3):hoag055. doi: 10.1093/hropen/hoag055. eCollection 2026. |
| ID | Term |
|---|---|
| D011085 | Polycystic Ovary Syndrome |
| D009043 | Motor Activity |
| D017588 | Hyperandrogenism |
| ID | Term |
|---|---|
| D010048 | Ovarian Cysts |
| D003560 | Cysts |
| D009369 | Neoplasms |
| D010049 | Ovarian Diseases |
| D000291 | Adnexal Diseases |
| D005831 | Genital Diseases, Female |
| D052776 | Female Urogenital Diseases |
| D005261 | Female Urogenital Diseases and Pregnancy Complications |
| D000091642 | Urogenital Diseases |
| D000091662 | Genital Diseases |
| D006058 | Gonadal Disorders |
| D004700 | Endocrine System Diseases |
| D001519 | Behavior |
| D058489 | 46, XX Disorders of Sex Development |
| D012734 | Disorders of Sex Development |
| D014564 | Urogenital Abnormalities |
| D047808 | Adrenogenital Syndrome |
| D052801 | Male Urogenital Diseases |
| D000013 | Congenital Abnormalities |
| D009358 | Congenital, Hereditary, and Neonatal Diseases and Abnormalities |
Not provided
Not provided
| ID | Term |
|---|---|
| D010808 | Physical Examination |
| D018660 | Blood Pressure Monitoring, Ambulatory |
| ID | Term |
|---|---|
| D019937 | Diagnostic Techniques and Procedures |
| D003933 | Diagnosis |
| D001795 | Blood Pressure Determination |
| D003935 | Diagnostic Techniques, Cardiovascular |
| D018670 | Monitoring, Ambulatory |
| D008991 | Monitoring, Physiologic |
Not provided
Not provided