The anion exchanger 1 (AE1), traditionally known for its role in erythrocyte anion transport and acid–base homeostasis, has recently been identified in non-erythroid tissues, suggesting broader physiological functions. In the present study, we investigated for the first time the expression and potential role of AE1 in human ovarian granulosa cells (GCs) obtained from women with endometriosis (ENDO-GCs) or male factor infertility controls (MF-GCs). Cells were cultured in the presence of follicular fluid derived from control (FF-MF) or endometriosis patients (FF-ENDO), and DIDS-sensitive anion exchange activity was pharmacologically inhibited using 4,4′-diisothiocyanatostilbene-2,2′-disulfonic acid (DIDS). AE1 expression was evaluated at both protein and transcript levels together with markers of proliferation, inflammation, and steroidogenesis. The results demonstrate that AE1 is constitutively expressed in GCs and may contribute to granulosa cell homeostasis. Inhibition of DIDS-sensitive anion exchange activity inhibited cell proliferation, shifted cell morphology toward a fibroblast-like phenotype, and reduced estradiol and progesterone secretion and inflammatory (IL-6) gene transcription. Notably, MF-GCs cultured in FF-MF exhibited compensatory upregulation of AE1, whereas ENDO-GCs and cells exposed to FF-ENDO showed impaired adaptive responses and generalized transcriptional suppression. These findings provide preliminary evidence supporting a role for DIDS-sensitive anion exchange activity in granulosa cell physiology and warrant further studies to clarify the specific contribution of AE1 to follicular dysfunction associated with endometriosis. However, the specific mechanistic contribution of AE1 could not be established and will require further functional and genetic investigations.

Endometriosis (ENDO) and poor ovarian response (POR) represent challenging conditions in assisted reproduction. Both, associated with altered follicular fluid (FF) composition, specifically impact on granulosa cell (GC) function in an incompletely understood way. GCs from male factor (MF, n = 30), ENDO (n = 38), and POR (n = 27) patients were cultured in media supplemented with FF from each group (FF-MF, FF-ENDO, FF-POR). Proliferation, morphology, and secretory activity (cortisol, estradiol, progesterone, IL-6) were assessed. GC proliferation depended primarily on FF origin, being highest with FF-ENDO, intermediate with FF-POR, and lowest with FF-MF. Morphological analysis revealed enrichment of muscle-like and fibroblast-like morphologies under FF-ENDO and FF-POR, suggestive of dysregulated luteinization and extracellular matrix remodeling. Secretory activity reflected a complex interplay between GC origin and FF type: IL-6 was strongly induced by FF-MF and FF-POR but consistently suppressed by FF-ENDO; cortisol and estradiol were generally consumed, while progesterone synthesis was largely confined to MF-GCs, with only variable induction in ENDO-GCs exposed to FF-POR. These findings indicate that pathological FF milieus reprogram GC behavior in distinct ways, with potential consequences for luteal function and oocyte competence. Identifying the molecular mediators of these alterations may guide tailored strategies to improve ART outcomes in ENDO and POR patients.

Endometriosis is a complicated condition characterized by inflammation, low oocyte quality, and decreased uterus receptivity, associated with fertility issues. This study aims to better understand the reduced pregnancy outcome in endometriosis by analyzing both the granulosa cells (GCs) and the follicular fluids (FFs) obtained during the assisted reproductive technology (ART)-related oocyte pick-up. Seventy patients, approaching our ART Center with the diagnosis of infertility for Age-Idiopathic Factor (AIF) (n = 36), endometriosis (ENDO) (n = 23), or male factor (MF) (n = 11), were enrolled in this study. GCs from each group were separately analyzed for morphology, replication, and expression of Connexin-43 and Follicle-Stimulating Hormone Receptor (FSHR) by microscopy, flow cytometry, and immunocytochemistry. Results show that FF in a culture medium allowed GCs to survive and replicate. Upon culturing GCs from each group with ENDO follicular fluid, increases were observed in both population doublings and in the development of fibroblast-like and muscle-like morphologies. Despite undergoing morphological changes, GCs consistently expressed FSHR. However, exposure to ENDO follicular fluid led to an upregulation of Connexin-43 expression across all GC groups. These findings suggest that in endometriosis, FF contains unidentified factors that can induce aberrant replication, morphological differentiation, and overexpression of Connexin-43, potentially contributing to follicular dysfunction.

Poor adherence to hypertension therapy has been associated with cardiovascular and metabolic complications, increased healthcare expenditures, and death [1]. The evaluation of adherence to the treatment includes direct and indirect measurement methods, although there is no gold-standard method to measure medication adherence. Numerous variables can influence the follow-up of these patients and especially their willingness to follow recommended therapies. Other variables may involve personal motivations, factors related to the staff following up patients, organizational factors, and factors related to the therapy itself. All these factors are described as Hawthorne effect and must be considered for possible bias in the studies of hypertension [2]. The Hawthorne effect refers to the set of changes in a phenomenon, or behavior, that occur because of the presence of observers, but do not last over time. Peeters and collaborators [3] compared two types of approaches to evaluate resistant hypertension (RH): one based only on standard care (SoC) and the other one based on SoC plus an intervention, consisting in the evaluation of antihypertensive drugs (AHD) concentrations using a dried blood spot (DBS) sampling method. This randomized controlled trial included patients with established RH based on a 24-h arterial blood pressure (BP) measurement. The Authors reported the results after 3- and 12-months evaluation and found a significant improvement in both RH and BP in the intervention + SoC arm and SoC alone arm and a significant difference in AHD adherence between the arms after 12 months of follow-up. No differences were determined in the prevalence of RH or BP values between the intervention + SoC arm and the SoC arm after 12 months. Given that most patients had uncontrolled BP for years before participation, the Authors reported that it is highly unlikely that the observed improvements would have been achieved without their participation in this study and concluded that personalized feedback conversations improved AHD adherence, but did not reduce the prevalence of RH. The study evaluated AHD adherence with an accurate assessment and its effect on BP reduction was larger compared to most other intervention trials [4]. Personalized feedback conversations based on DBS-derived AHD concentrations improved AHD adherence, but did not reduce the prevalence of RH compared with the SoC group. A recent study evaluated RH-related problems and concluded that nonadherence to AHD must be excluded before RH is diagnosed [5]. The reduction of RH cases after the two evaluation approaches might suggest that more precise initial diagnosis is necessary for RH. In the study of Peeters [3], most patients had uncontrolled BP for years before participation, but the nonadherence was not evaluated before the study. The study shows that both types of evaluation improve compliance to AHD by making patients both aware of the usefulness of therapy and more adherent because of the knowledge that their BP and therapy will be monitored. This type of control, on the other hand, did not show a difference on the prevalence of RH after 12 months unlike after 3 months. The Authors calculated the defined daily dosage (DDD) for each used AHD, and they found that the DDD of AHD decreased in the intervention + SoC arm. This factor is important considering that both assessment methods showed a reduction in RH cases, but the difference was not statistically significant. The AHD has a role in the BP values, but other factors may influence the pressure measurement, such as the 'white-coat effect' and the possible stress associated with measurement, especially in patients who had not followed therapy exactly and who feared being caught at the visit [5]. An important factor to evaluate is the difference between men and women. It is known that pressure values and response to therapy are gender-different and a separate evaluation would have been useful in the actual study, since the percentage of males was higher. Since most of the patients were obese, the value of body mass index (BMI) varies in the sexes and perhaps the awareness of the importance of therapy is greater in females. Almost all the patients were also taking diets and other therapies in addition to AHD, and it cannot be ruled out that such therapies could be assessed during the BP evaluation in the two groups of patients. For example, statins, metformin, a low-calorie diet can induce a reduction in BMI, BP and in the dosage of medications. Although the difference was not significant in the two groups, it cannot be ruled out that the BP response and thus the prevalence of RH could have changed. For example, in diabetic patients with renal failure, the diabetic therapy could have improved renal function and consequently BP values and induced adjustment of AHD. Evaluation of RH must also take into account the initial diagnosis, considering that a significant proportion of patients with RH have primary hyperaldosteronism (PA). In this case, therapy must be targeted including mineralocorticoid receptor blockers, which have been considered in the measurement of AHD, but may not have been used in undiagnosed cases of PA making hypertension resistant. Patients with PA are erroneously considered RH when not treated with mineralocorticoid receptor blockers. The Authors have included of spironolactone in the AHD measurement, but there is no information of the prevalence of PA. Finally, other points to be considered are: 1. the patients do not only get their information from physicians, but almost always give importance to personal web searches and many sites provide inaccurate or even counterproductive information. This aspect also reduces the confidence in doctors. An important finding supporting the value of this study was the detection of DBS on a drop of blood; however, a possible limitation of this minimally invasive method is that it detects the presence or absence of the drugs, but not their concentration. The half-life of the drugs and consequently the distance since the last administration could make some drugs with short half-lives nondetectable; 2. patients with reduced AHD adherence might be interested in hiding compliance by taking the appropriate therapy only in the previous days, and thus the values found might be affected by this behavior; 3. average number and amount of drugs used in RH is elevated, demonstrating the complexity of patients' clinical pictures and the concomitance of other diseases that perhaps make patients more aware of the various associated problems by improving medication adherence. In conclusion, personalized feedback conversations based on DBS-derived AHD concentrations improved AHD adherence, but did not reduce the prevalence of RH. The study shows that any method of informing the patient can be useful to improve the compliance in patients with RH. Future studies on RH should consider the presence of associated metabolic factors (obesity, insulin resistance, associated endocrine dysfunction), the careful evaluation of all causes of secondary hypertension, and the possible influence of associated therapy in the treatment of RH. ACKNOWLEDGEMENTS Disclosure Statement: The authors have nothing to disclose. Conflicts of interest There are no conflicts of interest.

Papillary thyroid cancer (PTC) is the 8th most common cancer among women overall. Licorice contains over 300 active compounds, many of them with anti-cancer properties. Glycyrrhetinic acid (GA) is a major component of licorice. The aim of this study was to investigate the potential anti-proliferative effects of licorice and GA on PTC cell cultures. Licorice extract (LE) was produced from the root and tested on BCPAP and K1 cell lines, as well as GA and aldosterone. We used the MTT test to investigate the anti-proliferative activity, the wound healing test for the migratory activity, and finally, we analyzed cell cycle distribution, apoptosis, and oxidative stress after LE, GA, or aldosterone incubation. Both LE and GA reduced cell viability at 48 h and cell migration at 24 h in both PTC cultures. Aldosterone reduced cell migration only in K1 cells. LE and GA induced cell cycle arrest in the G0/G1 phase in the BCPAP cell line, while LE and aldosterone induced it in the K1 culture. GA but not LE increased the apoptosis rate in both cell lines, whereas LE but not GA increased oxidative stress in both cultures. This study presents the first evidence of the in vitro anti-proliferative and anti-migratory activity of LE and GA on PTC.

Aldosterone (Aldo) exerts its action through binding with the mineralocorticoid receptor (MR). Clinically, a link between primary aldosteronism (PA) and thyroid diseases has been hypothesised. However, the presence and activity of MR on the thyroid have not yet been demonstrated. We investigated the gene/protein expression and activation of MR in primary thyroid cell cultures (normal rat thyroid [FRTL-5] and human papillary thyroid cancer [PTC] cell lines, BCPAP and K1) through qRT-PCR analysis, immunofluorescence, and confocal microscopy. We also studied the effects of Aldo on thyroid-specific and inflammation genes in vitro. Paired human normal and neoplastic thyroid tissues were also studied. We demonstrated both gene and protein expression and activation of MR in normal rat thyroid and human PTC lines. Incubation with Aldo induced an acute increase in IL-6 expression in both the FRTL-5 and BCPAP lines, which was antagonised by spironolactone, and an acute and late upregulation of thyroid-specific genes in FRTL-5. MR was also expressed at both gene and protein levels in normal human thyroid tissues and in PTC, with a progressive decline during neoplastic tumourigenesis, particularly in more aggressive histotypes. We present the first evidence of MR gene and protein expression in both normal and pathological thyroid cells and tissues. We have shown that MR is present and functionally activated in thyroid tissue. Binding of Aldo to MR induces the expression of inflammatory and thyroid-specific genes, and the thyroid may thus be considered a novel mineralocorticoid target tissue.

Pseudohyperaldosteronism (PHA) is characterized by hypertension, hypokalemia, and a decrease in plasma renin and aldosterone levels. It can be caused by several causes, but the most frequent is due to excess intake of licorice. The effect is mediated by the active metabolite of licorice, glycyrrhetinic acid (GA), which acts by blocking the 11-hydroxysteroid dehydrogenase type 2 and binding to the mineralocorticoid receptor (MR) as an agonist. The management of licorice-induced PHA depends on several individual factors, such as age, gender, comorbidities, duration and amount of licorice intake, and metabolism. The clinical picture usually reverts upon licorice withdrawal, but sometimes mineralocorticoid-like effects can be critical and persist for several weeks, requiring treatment with MR blockers and potassium supplements. Through this case series of licorice-induced PHA, we aim to increase awareness about exogenous PHA, and the possible risk associated with excess intake of licorice. An accurate history is mandatory in patients with hypertension and hypokalemia to avoid unnecessary testing. GA is a component of several products, such as candies, breath fresheners, beverages, tobacco, cosmetics, and laxatives. In recent years, the mechanisms of action of licorice and its active compounds have been better elucidated, suggesting its benefits in several clinical settings. Nevertheless, licorice should still be consumed with caution, considering that licorice-induced PHA is still an underestimated condition, and its intake should be avoided in patients with increased risk of licorice toxicity due to concomitant comorbidities or interfering drugs.

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

L’ipertensione arteriosa in gravidanza è una condizione sempre più comune, per l’aumento dell’età media della prima gravidanza e dei fattori di rischio cardiovascolare (quali obesità e diabete) tra le donne in età fertile ed è gravata da complicanze materno-fetali anche gravi. Pur trattandosi di una problematica gestita principalmente dal ginecologo, anche l’endocrinologo ha un suo ruolo importante, per gli interventi di prevenzione nelle pazienti a maggior rischio di sviluppare ipertensione in gravidanza e per il corretto inquadramento diagnostico-terapeutico dei casi insorti prima o durante la gravidanza, al fine di escludere cause endocrine di ipertensione.

Thermoablation is an increasing local therapeutic procedure in the treatment of metastases or small localized tumors. It has been recently used also for the treatment of functioning adrenocortical adenomas, such as aldosterone-producing adenoma (APA). A recent study used an in vitro model of steroidogenic adrenocortical cell lines to evaluate the in vivo effect of thermoablation in APA. The purpose of this procedure is the destruction of the tumor, preserving the integrity and function of adjacent normal adrenal tissue. In this commentary we discuss some pitfalls that should be considered to improve the translation from in vitro assessments to in vivo models.

OBJECTIVE:Hyperandrogenic skin disorders, such as hirsutism, acne and alopecia, affect approximately 10-20% of women of reproductive age, reducing quality of life and causing psychological impairment. Spironolactone is a commonly used antiandrogen, especially in women who are not sexually active or have contraindications to hormonal contraceptives. The aim of this study was to evaluate the effects of spironolactone, especially after its withdrawal, in patients with hyperandrogenic skin disorders.METHODS:Retrospective analysis of 63 women with hyperandrogenic skin symptoms due to polycystic ovary syndrome (PCOS), treated with spironolactone for at least 6 months as first-line treatment.RESULTS:After a mean time of treatment of 25.7 months, all patients reported a significant improvement in hyperandrogenic skin disorders; only 5 patients were dissatisfied and required the addition of an oral contraceptive. The therapy was well tolerated and the most frequent side-effect was intermestrual bleeding in 68.2% of cases, affecting mainly classic PCOS phenotype. Thirthyeight patients showed prolonged effects 33.7 months after spironolactone withdrawal, whereas 20 relapsed 17.5 months after discontinuation. No significant difference in clinical and biochemical parameters was observed between these two groups both at baseline and after spironolactone treatment. Ovulatory PCOS patients were treated for a shorter time and reported earlier relapse than classic PCOS patients.CONCLUSION:Spironolactone is an effective and safe treatment for hyperandrogenic skin disorders, showing long-lasting effects even several months after its discontinuation.

Endometriosis is a chronic inflammatory disease associated with pelvic pain, infertility, and increased cardiovascular risk. Recent studies suggest a possible role of aldosterone as a pro-inflammatory hormone in the pathogenesis of the disease. Cortisol is also an important mediator of stress reaction, but its role is controversial in endometriosis. The aim of this study was to evaluate aldosterone and cortisol levels and blood pressure values in women with endometriosis. We measured blood pressure, plasma aldosterone, renin, cortisol, and dehydroepiandrosterone sulfate (DHEAS) in 20 women with untreated minimal or mild pelvic endometriosis compared with 20 healthy controls matched for age and body mass index. Aldosterone values were similar in the two groups, while renin was significantly lower and the aldosterone to renin ratio was significantly higher in patients with endometriosis than in controls. Systolic blood pressure was in the normal range, but significantly higher in patients with endometriosis. Morning plasma cortisol was normal, but significantly lower in patients with endometriosis compared with controls, while DHEAS to cortisol ratio was similar in the two groups. These preliminary results are evidence of increased biological aldosterone activity and dysregulation of the hypothalamic-pituitary-adrenal axis in early stages of endometriosis. These alterations could play a role in disease development, suggesting new therapeutic targets for aldosterone receptor blockers.

The study by Yan and co-workers1 sought to review the literature reports on diagnostic criteria and biochemical and clinical success after surgery in patients with unilateral hyperaldosteronism. Primary aldosteronism is a syndrome, that includes various pathologies that have certain signs and symptoms in common. Since the discovery of the disease, many studies have tried to establish the criteria for diagnosis and operability of unilateral forms. With the availability of computerized tomography (CT) and magnetic resonance (MRI) and with the advance in methods to evaluate selective aldosterone secretion in the adrenal veins (AVS), the criteria have been refined and numerous guidelines have been made by various societies. The initial guidelines of the Endocrine Society and the Japan Endocrine Society2, 3 recommend AVS in all patients diagnosed with primary aldosteronism who are willing to have surgery when necessary. Subsequently, new guidelines considered that in some cases catheterization was not necessary if an adenoma was evident in a young patient with low serum potassium.4 The modification of the guidelines demonstrates that many points remain unclear and may influence the follow-up after unilateral adrenalectomy. The difficulty to create homogeneous guidelines is probably related to the fact that primary aldosteronism is a syndrome and not a defined disease with numerous underlying factors (genetic, autoimmune, family, etc.).5 The Primary Aldosteronism Surgical Outcome (PASO) study6 emphasized that the duration of hypertension is a key factor in both the outcome of the intervention of future cardiovascular risk. Establishing the duration of hypertension is not always easy. We are dealing with hypertensive patients at diagnosis and sometimes it is difficult to establish the duration of hypertension, considering that not everyone has had their blood pressure measured and the aldosterone to renin ratio evaluated before they first noticed blood pressure was high. This point is important because we must always consider that increased aldosterone can cause permanent damage to the arteries and metabolic complications, and thus be a negative prognostic factor after unilateral adrenalectomy. It is true that the aldosterone to renin ratio often normalizes, but possible vascular damage and cardiovascular risk is a consequence of both the direct effect of aldosterone at the level of vascular wall and, in a lesser extent, of any other cause of hypertension. It is still unclear whether PA arises ex novo on a normotensive patient or overlaps in an already hypertensive patient. Recently, aldosterone has been shown to be the major proinflammatory and profibrotic hormone, and this must be considered in both the collection of the patient's history and the therapy to be performed The publication of Yan and collaborators1 considered the literature studies performed to assess the biochemical and clinical effect of AVS or CT, evaluating the result of the surgery. The accuracy of diagnosis by imaging tests such as CT or MRI are not always precise, so all guidelines have recommended AVS, as morphological examinations are unable to detect small adenomas. The differential diagnosis between unilateral and bilateral forms has always been critical. A recent meta-analysis evaluated the accuracy of adrenal imaging examinations for the evaluation of unilateral forms, considering the result of AVS. The analysis ascertained a sensitivity of 68% and specificity of 57% for CT/MRI in identifying unilateral forms The parameters were higher considering patients with age < 40 years (71 and 79%). The study concluded that CT/MRI are not efficient tests as an alternative to AVS even in young patients,7 but the literature studies are non-homogeneous.8, 9 An important consideration in the evaluation of the studies in the literature is that usually CT/MRI and AVS are performed in the same patient and sometimes the decision to do AVS is made just based on the CT image. AVS can sometimes give problems of interpretation both for the difficulty of cannulating the right adrenal vein and for the presence of anatomical variants of the adrenal veins that can dilute the blood. Other problems may be stress-related particularly in situations of technical difficulty during catheterization. Stress evoked by the procedure may activate ACTH, cortisol, and aldosterone, interfering with lateralization. Also, the pulsatile pattern of secretion of cortisol and aldosterone can generate time-related variability in hormone concentrations in the adrenal vein blood. For this reason, some authors prefer to associate ACTH stimulation to minimize the time-related variability compared with sequential sampling without stimulation.10 These factors and the evaluation of other clinical parameters must be considered to decide on the intervention and to predict its success. Resolution of hypertension occurs in only 30–60% of cases.1 Chronic therapy with aldosterone receptor blockers alone or with other hypotensive agents is recommended if the patient refuses surgery or if there is a risk of surgery (eg, advanced age or associated diseases) or if the patient has already had surgery. Conversely, medical management with spironolactone or eplerenone is an alternative treatment of cases of primary aldosteronism, so the choice of medical management should always be considered. Recent guidelines recommend doing the surgery directly in young patients with a marked hypokalemia, but we must always keep in mind the possibility of non-secreting incidentalomas in patients not treated before surgery with aldosterone receptor blockers.11 Most of the centers prefer to perform surgery even in cases where the CT scan does not show an adenoma and the AVS shows lateralization, but in these cases, we believe to be preferable to perform the therapy with aldosterone receptors blockers and reserve another AVS later especially if the patient is not well controlled with the therapy. Given that in these cases hypertension often persists even after surgery, sometimes associated with persistent increase of aldosterone to renin ratio, it would be more appropriate to first treat the patient with anti-aldosterone therapy and then reconsider the possibility of surgery. Normalization of blood pressure and serum potassium during aldosterone receptor blockers before surgery can sometimes be a criterion for the presumption of complete clinical and biochemical recovery. Both the persistence of hyperaldosteronism due to incorrect interpretation of biochemical and morphological tests, and the persistence of hypertension even in the presence of resolution of primary aldosteronism should be evaluated in relation to the future risk not only of cardiovascular accidents, but also metabolic ones, such as diabetes. The authors have reported correctly that the prognosis after adrenalectomy guided by CT versus AVS is heterogeneous consistent with the opportunity of a more accurate assessment prior to intervention with presumption of both clinical and biochemical success. Therapy including anti-aldosterone drugs even in some cases not operated could be appropriate considering the classic Pitt studies12 that have shown that such therapy protects from the risk of cardiovascular relapse regardless of the pressure and aldosterone values. It is known that aldosterone is a factor that exacerbates cardiovascular risk because of its proinflammatory and profibrotic actions.13 Hundemer and collaborators14 showed that cardiovascular risk is greater in patients treated with mineralocorticoid receptor blockers compared with essential hypertensive patients treated with conventional therapies. Considering the Pitt's studies12 probably the risk is dependent on the duration of hypertension and should also take in mind the much greater risk that would have occurred if patients had not been treated with aldosterone receptor blockers. An important factor to be considered will also be the direct action of spironolactone at the adrenal level of blocking aldosterone synthase. A similar effect after long-term treatment with aldosterone receptors blockers in patients with primary aldosteronism could lead to a restoration of proper functioning of the renin-angiotensin-aldosterone system as demonstrated in cases of idiopathic hyperaldosteronism that have recovered from the condition after prolonged treatment with anti-aldosteronics.15 Clinical and biochemical success is not a sufficient criterion to understand the future of these patients, as pointed in the reference study.1 Most of the guidelines have focused on biochemical or clinical parameters assessment after surgery, but future studies will need to assess subsequent long-term cardiovascular risk comparing the long-term effects of adrenalectomy and those of chronic therapy with aldosterone receptors blockers combined with other hypotensive agents. These studies should consider that about 60% of operated patients are hypertensive after surgery1 and that sometimes primary aldosteronism can persist even after surgery in cases that were not correctly evaluated. The authors declare that there are no funders for this work. The authors have no competing interests.

Polycystic ovary syndrome (PCOS) is a heterogeneous and extremely common disease with symptoms that vary with the age of the patient, typically characterized by hyperandrogenism, chronic oligo-anovulation, and/or several metabolic disorders. The syndrome includes various phenotypes, and the pathogenesis is multifactorial, often involving insulin resistance. This feature is closely related to ovarian dysfunction, inflammation, hyperandrogenism, and metabolic disorders, which characterize and complicate the syndrome. Therapy currently considers both lifestyle improvements and medications, and must be tailored on a case-by-case basis. To date, the published studies have not arrived at a definition of the most suitable therapy for each individual case and many of the drugs used are still off-label. In this review, we discuss some controversial diagnostic and therapeutic aspects of PCOS, such as the role of insulin resistance, inflammation, and hyperandrogenism. We also evaluated the advantages and disadvantages of contraceptive therapy and antiandrogens.

In a recent paper, Subramanian and collaborators reported a 52% increased risk of COVID-19 infection in women with polycystic ovary syndrome (PCOS) and an incidence nearly twice that of women without PCOS. The authors focused, as important factors of the increased prevalence of infection, both the inflammatory characteristic of PCOS and the increase in androgens that facilitate the entry of the virus into the cells of the target organs. We asked 200 consecutive, unvaccinated women with PCOS who had been followed with spironolactone for more than 4 months, about COVID-19 infection and found only four patients who were infected. None of the infected patients were hospitalized and only one had fever and other manifestations of the syndrome, but these symptoms resolved in a few days. The other three reported only mild or minimal symptoms. This observation needs confirmation with specific studies, considering the possibility that many other patients may have been infected by being asymptomatic and not swabbing for COVID-19. Spironolactone can increase the circulating angiotensin-converting enzyme 2 and antagonize the androgen receptor, preventing activation of transmembrane protease serine 2 in cells of the respiratory tract and other tissues. Drug also has potent anti-inflammatory and antithrombotic actions by antagonizing the mineralocorticoid receptor in target tissues and inflammatory cells. From Subramanian's study and reported observations, a proper evaluation of the use of spironolactone in COVID-19 in both PCOS and the general population is urged.

The FDA recommends that we should not have more than 2 g of sodium per day (one teaspoon).1 This rate represents a level of sodium considered safe and adequate for the general population of adults, including children aged 15 years and over and pregnant or lactating women. Only for infants and children sodium intake should be reduced, based on their age and energy requirement: 0.2 g/day is proposed for infants aged 7–11 months, 1.1 g/day for children aged 1–3 years, 1.3 g/day for children aged 4–6 years and 1.7 g/day for children aged 7–15 years. However, the average intake of sodium for most Americans is more than 3 g per day and similar results are reported in oriental countries, where salt is added to many foods.2 The purpose of these recommendations is to progressively reduce the daily salt intake of Americans improving their quality of life and increasing lifespan itself. The improvement will be reflected especially in the reduction of hypertension and cardiovascular diseases. Currently, 40% of the adult population and 10% of children are hypertensive. Hypertension involves genetic, racial, and quality-of-life factors. In the recent study of Hussain and coll.,3 the authors conclude that most popular websites provide either information or guidance on dietary sodium reduction, but rarely both. The two most relevant tools that evaluate information on sites dealing with sodium restriction are the DISCERN4 and the JHU-SALT.3 The Authors conclude that consumers seeking information and guidance online will find that most easily accessible websites offer accurate but limited information and provide insufficient guidance on how to lower sodium intake. The doctor-patient relationship very often is conditioned by the Web. Currently, people search for news of some possible disease or nutritional recommendations. Even the choice of a specialist is often based on web searches. Often patients have no idea of their salt intake and might seek information about salt intake either because of their interest in healthier living or because they have hypertension or another chronic disease. Many sites report that salt restriction is critical for maintaining regular blood pressure and reducing cardiovascular risk and suggest that everyone should follow a low-salt diet. Unfortunately, those seeking information on the Internet lack knowledge of the complex mechanisms of water and electrolyte regulation and perhaps follow incorrect instructions for their case. Often the low-sodium diet is recommended on sites to normotensive patients, or it is not explained that in all cases an evaluation of the cause of possible alterations should be sought before taking unnecessary and even harmful diets and supplements. Each pathology must be considered in relation to possible implications in sodium secretion or excretion and to associated current therapies, which are often complex and include medications that clearly affect hydro-electrolyte balance. This demonstrates how an inexperienced or out-of-date patient on this topic might be misled when examining websites that recommend salt reduction. The patient's history should always investigate possible incorrect sources of information, especially on the current topic about salt or sodium intake. The same applies to water intake that is strictly related to salt. It is known that sodium is the basic element in the body and is regulated by various factors, such as water intake, activity of the renin-angiotensin aldosterone system (RAAS), antidiuretic hormone (ADH), natriuretic hormones, cortisol, body mass index, insulin resistance, and many other factors.5 Any alteration in sodium and volume must be compensated by regulatory mechanisms, as happens throughout all the endocrine system. An exaggerated intake of water can dilute sodium but also has a suppressing action on renin production and thus aldosterone, accentuating fluid excretion to restore a physiological balance. The opposite occurs in cases of fluid loss or reduced water intake as frequently happens in the elderly. This condition leads to a hemoconcentration and stimulates the RAAS and ADH, both to conserve outputs and to improve water and electrolyte balance (Figure 1). Searching websites for information about low-sodium foods and diets could be dangerous, leading to an activation of the RAAS. It is known that aldosterone has a potent inflammatory and fibrotic action when produced in excess. A similar situation has been demonstrated in patients taking furosemide and thiazides, which on the one hand reduce blood pressure, but on the other hand accentuate the inflammatory state and cardiovascular risk.6 Therefore, it is always recommended to combine a potassium-sparing drug such as spironolactone and its derivatives.7 These considerations show how important the intervention of the specialist is in deciding on both diet and medication needed in the treatment of hypertension. Estimation of salt intake is very complex and current studies give conflicting results, especially because the actual criteria are still inadequate and involve many factors that are difficult for the patient to assess and must be explained and evaluated by the specialist. Some studies have considered sodium intake either by questionnaires or by assessment of 24-h sodium excretion, while others have assessed sodium excretion in a spot urine sample.8 All these assessments can be a source of error both for eventual treatments and for genetic differences in the body's response to salt intake. The nature and quality of nutrient intake ascertainment are diverse. Some foods, consumed especially by young people, contain exaggerated amounts of salt, such as sandwiches, pancakes, energy drinks, chips, soup. Self-reported measures may be essential for some purposes but intrinsically suffer from both random errors and systematic biases. Biomarkers of intake, which are more objective, can replace self-report for some purposes, but have only been developed for a few nutrients. Currently, no one single approach accurately measures dietary intakes in a comprehensive manner for all nutrients. We believe that the web information cannot be accurate because the sites do not know the history and eating habits of each individual person seeking information about salt intake and possible correlated diseases. Through this commentary, we want to point out that JCH readers, who are doctors involved in hypertension, need to understand that often patients before going to the doctor inform themselves by looking for websites that explain the issue. The problem is that the sites may not have information about the specific problem of the readers and therefore they propose standard diets and therapy that in specific cases could be harmful. Even some doctors write on the web their considerations related to the issue and in each case, the conclusions cannot always be correct. The study of Hussain and coll.3 is interesting since it highlights this issue. It would be important that the conclusions of this study could be available not only to JCH readers who may be experts on the issue, but also to the media to urge them to always contact specialists before deciding whether to undertake a low-salt diet. The most important Scientific Societies involved in hypertension and cardiovascular disorders should periodically share simple and clear information about some burning issues, such as salt intake, licorice abuse, and endocrine causes of hypertension. Family doctors need to know the patients' sources of information and they should encourage patients to consider only these official websites. The physician's role is therefore critical in order to discuss and alert patients to the positive effects and risks of a low-sodium diet. Changes of life-style and nutritional habits should always be considered according to patients’ history and concomitant disorders. It is known that some populations abuse salt and other populations are predisposed to hypervolemia such as African American patients in whom low-renin essential hypertension is easily found.9 Genetic predisposition to hypertension and alterations of parameters linked to plasma volume regulation must always be considered by physicians to give appropriate advice to each individual case. The patient's history should always include an assessment of inappropriate diets, exaggerated fluid intake, or unnecessary salt reduction. Such data are also important to interpret any altered laboratory data. The authors have no competing interests.

INTRODUCTION:An adrenal incidentaloma (AI) is an adrenal neoplasm incidentally discovered during an imaging unrelated to suspected adrenal disease. The aim of the present review is to offer practical guidance on the multidisciplinary approach of AIs.Areas covered:The prevalence of AI is high in the aging population (up to 5-8%); however, hormonally active or malignant conditions are rare. After the discovery of an AI, it is suggested to assess in parallel if the mass is potentially malignant and functionally active. The answer to the former question is mainly based on medical history (extra-adrenal malignancies, new-onset of signs or symptoms) and imaging (conventional radiology and/or nuclear medicine). The answer to the latter question is a complete endocrine evaluation of both cortical (glucocorticoids, mineralocorticoids) and medullary (catecholamines) secretion.Expert opinion:A multidisciplinary discussion is suggested for patients with adrenal disease, after the exclusion of nonfunctioning benign cortical adenoma, in order to plan a close and tailored follow-up for the suspected malignant or functioning forms. Surgery is advised for patients with malignant disease (adrenocortical cancer) or with clinically relevant secreting neoplasm (primary aldosteronism, Cushing's syndrome, and pheochromocytoma).

Endometriosis, an estrogen-dependent chronic gynecological disease, is characterized by a systemic inflammation that affects circulating red blood cells (RBC), by reducing anti-oxidant defenses. The aim of this study was to investigate the potential beneficial effects of licorice intake to protect RBCs from dapsone hydroxylamine (DDS-NHOH), a harmful metabolite of dapsone, commonly used in the treatment of many diseases. A control group (CG, n = 12) and a patient group (PG, n = 18) were treated with licorice extract (25 mg/day), for a week. Blood samples before (T0) and after (T1) treatment were analyzed for: i) band 3 tyrosine phosphorylation and high molecular weight aggregates; and ii) glutathionylation and carbonic anhydrase activity, in the presence or absence of adjunctive oxidative stress induced by DDS-NHOH. Results were correlated with plasma glycyrrhetinic acid (GA) concentrations, measured by HPLC–MS. Results showed that licorice intake decreased the level of DDS-NHOH-related oxidative alterations in RBCs, and the reduction was directly correlated with plasma GA concentration. In conclusion, in PG, the inability to counteract oxidative stress is a serious concern in the evaluation of therapeutic approaches. GA, by protecting RBC from oxidative assault, as in dapsone therapy, might be considered as a new potential tool for preventing further switching into severe endometriosis.