Cardiovascular disease risk in women with premature ovarian insufficiency: A systematic review and meta-analysis

Expression profiles of circular RNA in granulosa cells from women with biochemical premature ovarian insufficiency

Aim: To identify the expression profiles and potential functions of circular RNAs (circRNAs) in granulosa cells (GCs) from women with biochemical premature ovarian insufficiency (bPOI). Patients & methods: CircRNAs microarray analysis was performed to GCs from 8 patients with bPOI and 8 control women, followed by qRT-PCR in 15 paired samples. CircRNA-miRNA networks and the prediction of their enriched signaling pathways were conducted by bioinformatics analysis. Results: A total of 133 upregulated and 424 downregulated circRNAs was identified in women with bPOI. We constructed circRNA-miRNA networks and found that the most predominantly enriched signaling pathways were the FoxO signaling pathway and cellular senescence. Conclusion: CircRNAs are differentially expressed in bPOI, which might contribute to the pathogenesis of bPOI.

The Use of Sex-Specific Factors in the Assessment of Women's Cardiovascular Risk

Cardiovascular disease (CVD) is the leading cause of death among women in the United States. As compared with men, women are less likely to be diagnosed appropriately, receive preventive care, or be treated aggressively for CVD. Sex differences between men and women have allowed for the identification of CVD risk factors and risk markers that are unique to women. The 2018 American Heart Association/American College of Cardiology Multi-Society cholesterol guideline and 2019 American College of Cardiology/American Heart Association guideline on the primary prevention of CVD introduced the concept of risk-enhancing factors that are specific to women and are associated with an increased risk of incident atherosclerotic CVD in women. These factors, if present, would favor more intensified lifestyle interventions and consideration of initiation or intensification of statin therapy for primary prevention to mitigate the increased risk. In this primer, we highlight sex-specific CVD risk factors in women, stress the importance of eliciting a thorough obstetrical and gynecological history during cardiovascular risk assessment, and provide a framework for how to initiate appropriate preventive measures when sex-specific risk factors are present.

Impact of preventive screening and lifestyle interventions in women with a history of preeclampsia: A micro-simulation study

BACKGROUND

Preeclampsia is a female-specific risk factor for the development of future cardiovascular disease. Whether early preventive cardiovascular disease risk screenings combined with risk-based lifestyle interventions in women with previous preeclampsia are beneficial and cost-effective is unknown.

METHODS

A micro-simulation model was developed to assess the life-long impact of preventive cardiovascular screening strategies initiated after women experienced preeclampsia during pregnancy. Screening was started at the age of 30 or 40 years and repeated every five years. Data (initial and follow-up) from women with a history of preeclampsia was used to calculate 10-year cardiovascular disease risk estimates according to Framingham Risk Score. An absolute risk threshold of 2% was evaluated for treatment selection, i.e. lifestyle interventions (e.g. increasing physical activity). Screening benefits were assessed in terms of costs and quality-adjusted-life-years, and incremental cost-effectiveness ratios compared with no screening.

RESULTS

Expected health outcomes for no screening are 27.35 quality-adjusted-life-years and increase to 27.43 quality-adjusted-life-years (screening at 30 years with 2% threshold). The expected costs for no screening are €9426 and around €13,881 for screening at 30 years (for a 2% threshold). Preventive screening at 40 years with a 2% threshold has the most favourable incremental cost-effectiveness ratio, i.e. €34,996/quality-adjusted-life-year, compared with other screening scenarios and no screening.

CONCLUSIONS

Early cardiovascular disease risk screening followed by risk-based lifestyle interventions may lead to small long-term health benefits in women with a history of preeclampsia. However, the cost-effectiveness of a lifelong cardiovascular prevention programme starting early after preeclampsia with risk-based lifestyle advice alone is relatively unfavourable. A combination of risk-based lifestyle advice plus medical therapy may be more beneficial.

The difference in referencing in Web of Science, Scopus, and Google Scholar

AIMS

How often a medical article is cited is important for many people because it is used to calculate different variables such as the h-index and the journal impact factor. The aim of this analysis was to assess how the citation count varies between Web of Science (WoS), Scopus, and Google Scholar in the current literature.

METHODS

We included the top 50 cited articles of four journals ESC Heart Failure; Journal of cachexia, sarcopenia and muscle; European Journal of Preventive Cardiology; and European Journal of Heart Failure in our analysis that were published between 1 January 2016 and 10 October 2019. We recorded the number of citations of these articles according to WoS, Scopus, and Google Scholar on 10 October 2019.

RESULTS

The top 50 articles in ESC Heart Failure were on average cited 12 (WoS), 13 (Scopus), and 17 times (Google Scholar); in Journal of cachexia, sarcopenia and muscle 37 (WoS), 43 (Scopus), and 60 times (Google Scholar); in European Journal of Preventive Cardiology 41 (WoS), 56 (Scopus), and 67 times (Google Scholar); and in European Journal of Heart Failure 76 (WoS), 108 (Scopus), and 230 times (Google Scholar). On average, the top 50 articles in all four journals were cited 41 (WoS), 52 (Scopus, 26% higher citations count than WoS, range 8-42% in the different journals), and 93 times (Google Scholar, 116% higher citation count than WoS, range 42-203%).

CONCLUSION

Scopus and Google Scholar on average have a higher citation count than WoS, whereas the difference is much larger between Google Scholar and WoS.

Relation between platelet coagulant and vascular function, sex-specific analysis in adult survivors of childhood cancer compared to a population-based sample

Female sex is a risk factor for long-term adverse outcome in cancer survivors, however very little is known for the underlying pathophysiological mechanisms rendering the increased risk. This study investigated sex-specifically the relation between thrombin generation (TG) with and without presence of platelets and vascular function in 200 adult survivors of a childhood cancer compared to 335 population-based control individuals. TG lag time, peak height and endogenous thrombin potential (ETP) measured in presence and absence of platelets were correlated to reflection index (RI) and stiffness index (SI). A sex-specific correlation analysis showed a negative relation in female survivors for platelet-dependent peak height and/or ETP and RI only. An age adjusted linear regression model confirmed the negative association between RI and platelet-dependent ETP (beta estimate: −6.85, 95% confidence interval: −12.19,−1.51) in females. Adjustment for cardiovascular risk factors resulted in loss of the association, whereby arterial hypertension and obesity showed the largest effects on the observed association. No other relevant associations were found in male and female cancer survivors and all population-based controls. This study demonstrates a link between platelet coagulant and vascular function of resistance vessels, found in female cancer survivors, potentially mediated by the presence of arterial hypertension and obesity.

Association of Premature Natural and Surgical Menopause With Incident Cardiovascular Disease

IMPORTANCE

Recent guidelines endorse using history of menopause before age 40 years to refine atherosclerotic cardiovascular disease risk assessments among middle-aged women. Robust data on cardiovascular disease risk in this population are lacking.

OBJECTIVE

To examine the development of cardiovascular diseases and cardiovascular risk factors in women with natural and surgical menopause before age 40 years.

DESIGN, SETTING, AND PARTICIPANTS

Cohort study (UK Biobank), with adult residents of the United Kingdom recruited between 2006 and 2010. Of women who were 40 to 69 years old and postmenopausal at study enrollment, 144 260 were eligible for inclusion. Follow-up occurred through August 2016.

EXPOSURES

Natural premature menopause (menopause before age 40 without oophorectomy) and surgical premature menopause (bilateral oophorectomy before age 40). Postmenopausal women without premature menopause served as the reference group.

MAIN OUTCOMES AND MEASURES

The primary outcome was a composite of incident coronary artery disease, heart failure, aortic stenosis, mitral regurgitation, atrial fibrillation, ischemic stroke, peripheral artery disease, and venous thromboembolism. Secondary outcomes included individual components of the primary outcome, incident hypertension, hyperlipidemia, and type 2 diabetes.

RESULTS

Of 144 260 postmenopausal women included (mean [SD] age at enrollment, 59.9 [5.4] years), 4904 (3.4%) had natural premature menopause and 644 (0.4%) had surgical premature menopause. Participants were followed up for a median of 7 years (interquartile range, 6.3-7.7). The primary outcome occurred in 5415 women (3.9%) with no premature menopause (incidence, 5.70/1000 woman-years), 292 women (6.0%) with natural premature menopause (incidence, 8.78/1000 woman-years) (difference vs no premature menopause, +3.08/1000 woman-years [95% CI, 2.06-4.10]; P < .001), and 49 women (7.6%) with surgical premature menopause (incidence, 11.27/1000 woman-years) (difference vs no premature menopause, +5.57/1000 woman-years [95% CI, 2.41-8.73]; P < .001). For the primary outcome, natural and surgical premature menopause were associated with hazard ratios of 1.36 (95% CI, 1.19-1.56; P < .001) and 1.87 (95% CI, 1.36-2.58; P < .001), respectively, after adjustment for conventional cardiovascular disease risk factors and use of menopausal hormone therapy.

CONCLUSIONS AND RELEVANCE

Natural and surgical premature menopause (before age 40 years) were associated with a small but statistically significant increased risk for a composite of cardiovascular diseases among postmenopausal women. Further research is needed to understand the mechanisms underlying these associations.

Women's Reproductive History and Pre-Clinical Peripheral Arterial Disease in Late Life: The San Diego Population Study

Objective: Reproductive events have been linked with increased cardiovascular risk in women, but whether they are associated with pre-clinical peripheral arterial disease (PAD) has been understudied. We evaluated associations between reproductive factors and later-life ankle-brachial index (ABI), femoral artery intima-media thickness (fIMT), and femoral plaques. Methods: Cross-sectional analysis of 707 multiethnic women who participated in a follow-up exam of the San Diego Population Study in 2007-2011. To assess associations between reproductive factors (age at menarche, parity, age at menopause, surgical menopause, hormone therapy) with ABI, and Doppler ultrasound measurements of common and superficial fIMT, linear regression was used; for femoral plaque presence, logistic regression was used. Models were adjusted for age, race/ethnicity, and cardiometabolic factors. We tested interactions of reproductive factors with menopause type (natural vs. surgical). Results: Women were on average 71 years old, and 56% were non-Hispanic White. Reproductive factors were not associated with fIMT, femoral plaque presence, or ABI. There were significant interactions between menopause type (surgical vs. natural) and oral contraceptive use (-β: 0.04, p = 0.03) for ABI, as well as between menopause type and parity (β: 0.11, p = 0.05) and age at menopause (β: 0.001, p = 0.05) for fIMT. Among women with natural menopause, oral contraceptive use was associated with higher ABI (β: 0.03, p = 0.007) and older age at natural menopause was related to greater fIMT (β: 0.009, p = 0.06). Among women with surgical menopause, nulliparity was marginally associated with greater fIMT (β: 0.33, p = 0.07). Conclusions: Reproductive history may not be independently associated with later-life lower extremity atherosclerosis in women. Studies are necessary to confirm findings and examine pregnancy-related exposures in relation to pre-clinical PAD.

Selected persistent organic pollutants associated with the risk of primary ovarian insufficiency in women

Although some persistent organic pollutants (POPs) may not be currently in production, many of these chemicals still exist ubiquitously in the environment and continue to represent significant environmental health concern. One of the important concerns of POPs exposure may lead to the adverse reproductive consequences including primary ovarian insufficiency (POI), but the limited evidence has been reported so far. Our case-control study was performed to explore the association between serum levels of selected POPs and risk for POI in a Chinese female population, including 157 cases and 217 healthy controls. Serum concentrations of polychlorinated biphenyls (PCBs), organochlorine pesticides (OCPs), polybrominated diphenyl ethers (PBDEs) and serum levels of reproductive hormones [follicle-stimulating hormone (FSH), luteinizing hormone (LH), anti-Mullerian hormone (AMH) and estradiol] were measured. The medians of dioxin-like PCBs (DL-PCBs) and p,p'-dichlorodiphenyltrichloroethane (p,p'-DDT) were significantly higher in case sera than in controls. Higher concentrations of DL-PCBs and p,p'-DDT were significantly associated with elevated risk of POI. A dose-response relationship was observed between the sum of DL-PCBs (Σ₆ DL-PCBs) and the risk of POI (p for trend = 0.003), with odds ratios for the second and third tertiles, compared with the first, of 1.31- (95% CIs: 0.67-2.57) and 3.15-fold (95% CIs: 1.63-6.10), respectively. Similar results were observed for the sum of p,p'-DDT and its metabolites (Σ₂ p,p'-DDTs). In control women, FSH levels were negatively associated with PCBs exposure, while LH had a positive association with OCPs. In patients with POI, exposure to PCBs was correlated with higher levels of LH, whereas exposure to OCPs was associated with lower levels of AMH. To the best of our knowledge, this study for the first provided evidence that exposure to PCBs and DDT could be the potential risk factors for POI in women.

Endogenous sex hormones and risk of venous thromboembolism in young women

BACKGROUND

The risk of venous thromboembolism (VTE) in young women can predominantly be attributed to exogenous hormone use. The influence of (abnormalities in) endogenous sex hormones, as in polycystic ovary syndrome (PCOS) or primary ovarian insufficiency (POI), on VTE risk is uncertain.

OBJECTIVES

Th assess the association between endogenous sex hormone levels and VTE risk.

METHODS

Women aged ≤45 years from the MEGA case-control study who provided a blood sample in the absence of exogenous hormone exposure or pregnancy were included. Sex hormone-binding globulin (SHBG), estradiol, follicle-stimulating hormone (FSH) and testosterone were measured. The free androgen index (FAI) and estradiol to testosterone ratio (E:T) were calculated. VTE risk was assessed according to quartiles (Qs) of levels and clinical cut-offs as proxies for PCOS (FAI > 4.5) and POI (FSH > 40 U/L). Logistic regression models were used to estimate adjusted odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

Six hundred and sixty-five women (369 cases; 296 controls) were eligible for the analyses. Testosterone and FSH levels, E:T and POI (FSH > 40 U/L vs FSH ≤ 40 U/L) were not associated with VTE risk. For estradiol, VTE risk was increased with levels in Q4 vs Q1 (OR 1.6; 95% CI 1.0-2.5). There was a dose-response relationship between SHBG levels and VTE risk, with the highest OR at Q4 vs Q1: 2.0 (95% CI 1.2-3.3). FAI > 4.5 (PCOS proxy) vs FAI ≤ 4.5 was associated with increased VTE risk (OR 3.3; 95% CI 0.9-11.8).

CONCLUSIONS

Estradiol, SHBG and FAI were associated with VTE risk, suggesting a role for endogenous sex hormones in the pathophysiology of VTE in young women.

Tailored hormonal approach in women with premature ovarian insufficiency

Premature ovarian insufficiency (POI) is probably one of the most devastating diagnoses for women of reproductive age. The major implications for fertility, climacteric symptoms, and quality of life, the great impact of long-term consequences such as bone loss and cardiovascular health, and the lack of a coherent and shared clinical approach make the choice for the right hormonal therapy challenging. In this review we propose an integrated and patient-based hormonal approach for women with POI, from puberty to late reproductive age.

Preeclampsia: The Relationship between Uterine Artery Blood Flow and Trophoblast Function

Maternal uterine artery blood flow is critical to maintaining the intrauterine environment, permitting normal placental function, and supporting fetal growth. It has long been believed that inadequate transformation of the maternal uterine vasculature is a consequence of primary defective trophoblast invasion and leads to the development of preeclampsia. That early pregnancy maternal uterine artery perfusion is strongly associated with placental cellular function and behaviour has always been interpreted in this context. Consistently observed changes in pre-conceptual maternal and uterine artery blood flow, abdominal pregnancy implantation, and late pregnancy have been challenging this concept, and suggest that abnormal placental perfusion may result in trophoblast impairment, rather than the other way round. This review focuses on evidence that maternal cardiovascular function plays a significant role in the pathophysiology of preeclampsia.

Climacteric Status at the Age of 46: Impact on Metabolic Outcomes in Population-Based Study

CONTEXT

Menopausal transition is associated with increased cardiovascular risks. Available data on the effect of earlier climacterium on these risks are limited.

OBJECTIVE

To compare cardiovascular risk-associated parameters at the ages of 14, 31, and 46 in relation to climacteric status at the age of 46.

DESIGN, SETTING, AND PARTICIPANTS

A prospective cohort study including 2685 women from the Northern Finland Birth Cohort 1966.

MAIN OUTCOME MEASURES

Follicle-stimulating hormone, body mass index (BMI), waist circumference, waist-to-hip ratio (WHR), blood pressure (BP), body composition, cholesterol levels, testosterone (T) levels, free androgen index (FAI), high-sensitivity C-reactive protein (hs-CRP), and liver enzymes.

RESULTS

Women who were climacteric at the age of 46 had lower BMIs (P = 0.029), T levels (P = 0.018), and FAIs (P = 0.009) at the age of 31. At the age of 46, they had less skeletal muscle (P < 0.001), a higher fat percentage (P = 0.016), higher cholesterol levels [total cholesterol (P < 0.001), low-density lipoprotein cholesterol (P < 0.001), high-density lipoprotein cholesterol (HDL-C; P = 0.022), and triglycerides (P = 0.008)], and higher alanine aminotransferase (P = 0.023) and γ-glutamyltransferase (P < 0.001) levels compared with preclimacteric women. Waist circumference, WHR, BP, and hs-CRP levels did not differ between the groups. Of the climacteric women, 111/381 were using hormone-replacement therapy (HRT). In subanalysis that excluded the HRT users, triglycerides, HDL-C, and body fat percentage did not differ among the groups.

CONCLUSIONS

Earlier climacterium is associated with mainly unfavorable metabolic changes.

Association of serum androgens and coronary artery calcium scores in women

OBJECTIVE

To determine the association between serum androgens measured by high-resolution liquid chromatography-mass spectrometry and coronary artery calcium (CAC) scores.

DESIGN

Cross-sectional study.

SETTING

Academic institution.

PATIENT(S)

A total of 239 women, aged 40-75 years, with CAC testing and complete cardiovascular disease risk evaluation. Total T, DHEA, and androstenedione were measured using high-resolution liquid chromatography-mass spectrometry, whereas E₂ and sex hormone-binding globulin were measured using commercial assays.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Independent associations between CAC scores and sex steroids.

RESULT(S)

Overall, 164 subjects had a CAC score < 10, 48 had a CAC score between 10 and 100, and 27 had a score > 100. There were no differences in sex hormone levels between women with CAC scores > 10 vs. CAC scores ≤ 10. In multivariable models adjusting for age, body mass index, and low-density lipoprotein cholesterol, a higher T/E₂ ratio was associated with an elevated CAC score, with an unadjusted odds ratio associated with 1-SD change in log-transformed T/E₂ of 1.38 (95% confidence interval 1.01-1.89) and adjusted OR 1.02 (95% confidence interval 1.002-1.04). Total T, DHEA, androstenedione, sex hormone-binding globulin, and E₂ levels were not associated with increased CAC.

CONCLUSION(S)

In the general population, there are mixed reports regarding the relationship between serum androgens and risk factors for cardiovascular disease, and limited information on the relationship between androgens and subclinical atherosclerosis. Our study shows that increased androgens relative to estrogens may have a weak but independent association with subclinical atherosclerosis, as measured by CAC scores.

Sex-Specific Risk of Cardiovascular Disease in Autoimmune Addison Disease-A Population-Based Cohort Study

CONTEXT

Little is known of cardiovascular disease (CVD) in autoimmune Addison disease (AAD). Inadequate glucocorticoid replacement might potentially increase CVD risk.

OBJECTIVE

To examine CVD in AAD in subgroups of ischemic heart disease (IHD) and cerebrovascular disease (CeVD) and investigate the effects of glucocorticoid and mineralocorticoid dosing.

DESIGN, SETTING, AND PATIENTS

In this cohort-control study, we used Swedish health registries from 1964 to 2013 to identify 1500 subjects with AAD and 13,758 matched controls. Incident CVD was analyzed from 2006 to 2013. Adjusted hazard ratios (aHRs) were calculated using Cox proportional hazard models. Glucocorticoid and mineralocorticoid doses were stratified to examine dose-related risks.

RESULTS

During 8807 person-years (PY), 94 events of first CVD (10.7/1000 PY) in patients with AAD occurred compared with 563 events during 80,163 PY (7.0/1000 PY) in controls. IHD was significantly more common in women (aHR, 2.15; 95% CI, 1.49 to 3.10) but not men (aHR, 1.16; 95% CI, 0.75 to 1.78) with AAD compared with controls. No increase in CeVD risk was detected (aHR, 0.88; 95% CI, 0.56 to 1.37, women; aHR, 0.88; 95% CI 0.53 to 1.50, men). CVD was associated with greater glucocorticoid and mineralocorticoid replacement doses in women but not men.

CONCLUSION

The risk of IHD but not CeVD is increased in AAD, especially in women. The risk of CVD independently correlated with greater glucocorticoid and mineralocorticoid replacement doses in women. Our data suggest that close monitoring and early treatment of risk factors for CVD, among women in particular, might be warranted.

The Use of Risk Enhancing Factors to Personalize ASCVD Risk Assessment: Evidence and Recommendations from the 2018 AHA/ACC Multi-society Cholesterol Guidelines

PURPOSE OF REVIEW

In 2018, the AHA/ACC multi-society Cholesterol Guidelines introduced the novel concept of risk-enhancing factors to be used as a supplement to the pooled cohort risk equations to personalize atherosclerotic cardiovascular disease risk assessment in primary prevention. In this review, we discuss the rationale and evidence behind each of the risk- enhancing factors to help clinicians perform a more personalized cardiovascular risk assessment.

RECENT FINDINGS

The risk-enhancing factors are high-risk features that may guide the use of lipid-lowering therapy particularly in intermediate and select borderline risk patients. For the purpose of this review, these factors are divided into 5 categories: (i) race and genetics, (ii) conditions specific to women (iii) lipid related risk, (iv) concurrent high-risk medical conditions, and (v) biomarkers.

SUMMARY

The addition of the risk-enhancing factors to the pooled cohort equations provides a more individualized and comprehensive approach to cardiovascular disease risk assessment.

Sex-Specific Physiology and Cardiovascular Disease

Sex differences in cardiovascular diseases can be classified as those which are specific to one sex and those that differ in incidence, prevalence, etiology, symptomatology, response to treatment, morbidity, and mortality in one sex compared to the other. All sex differences in cardiovascular conditions have their basis in the combined expression of genetic and hormonal differences between women and men. This chapter addresses how understanding basic mechanisms of hormone responses, imaging diagnostics, and integration of genomics and proteomics has advanced diagnosis and improved outcomes for cardiovascular conditions, apart from those related to pregnancy that are more prevalent in women. These conditions include obstructive coronary artery disease, coronary microvascular dysfunction, spontaneous coronary artery dissection, diseases of the cardiac muscle including heart failure and takotsubo cardiomyopathy, and conditions related to neurovascular dysregulation including hot flashes and night sweats associated with menopause and effects of exogenous hormones on vascular function. Improvement in technologies allowing for noninvasive assessment of neuronally mediated vascular reactivity will further improve our understanding of the basic etiology of the neurovascular disorders. Consideration of sex, hormonal status, and pregnancy history in diagnosis and treatment protocols will improve prevention and outcomes of cardiovascular disease in women as they age.

Childhood experiences of parenting and age at menarche, age at menopause and duration of reproductive lifespan: Evidence from the English Longitudinal Study of Ageing

OBJECTIVES

The parent-child relationship is critical for human development, yet little is known about its association with offsprings' reproductive health outside the context of abuse and neglect. We investigated whether childhood experiences of poor-quality parenting (characterized as decreased parental care and increased parental overprotection) are associated with women's reproductive timing and lifespan.

STUDY DESIGN

Observational study of 2383 women aged 55-89 years in 2007 from the English Longitudinal Study of Ageing (ELSA). Multinomial logistic regression models were estimated.

MAIN OUTCOME MEASURES

Self-reported ages at menarche and menopause and duration of reproductive lifespan.

RESULTS

Increasing maternal and paternal overprotection were associated with later menarche (≥16 years) after adjustment for age and childhood socioeconomic position (relative risk ratio (RRR) 1.11, 95% CI 1.02-1.21 and 1.11, 95% CI 1.01-1.21, respectively, per unit increase in the predictor). Increasing parental overprotection and decreasing paternal care were associated with earlier menarche (≤10 years). However, these associations were marginally non-significant. Maternal and paternal overprotection were also inversely associated with age at natural menopause after adjustment for age, childhood socioeconomic position and age at menarche (p value for linear trend = 0.041 and 0.004, respectively). Further, increasing paternal overprotection was associated with a shorter reproductive lifespan (≤33 years) (RRR 1.09 (1.01-1.18), per unit increase in the predictor) after adjustment for age and childhood socioeconomic position. Adjustment for additional childhood and adult factors did not explain these associations.

CONCLUSIONS

Women who experienced poor-quality parenting in childhood, especially increased levels of parental overprotection, might be at increased risk of an unfavourable reproductive health profile that is characterized by late or early menarche, premature menopause and a shorter reproductive lifespan.

[Gender differences in stroke risk factors]

Currently, there are a lot of studies on gender-related risk factors for stroke. However, contradictory data and the lack of a common view on the problem of gender-based approach to stroke prevention determine the importance of this problem. The most significant sex-non-specific stroke risk factors are hypertension, cardiac conditions, including atrial fibrillation, smoking, glucose and lipid metabolism disorders, excessive alcohol consumption, overweight, low physical activity and sedentary lifestyle, emotional stress. However, the incidence and significance of each stroke risk factor in women are different compared with men, due to women's reproductive status. Hypertension, atrial fibrillation, diabetes mellitus, abdominal obesity, migraine with aura, emotional stress and depression are more common risk factors in women compared to men. The stroke risk factors unique to women are the timing of age at menarche, pregnancy, gestational diabetes mellitus, preeclampsia, hormonal status disturbances, the use of combined oral contraceptives and hormone replacement therapy.

The role of ADAMTS4 and ADAMTS9 in cardiovascular disease in premature ovarian insufficiency and idiopathic hypogonadotropic hypogonadism

PURPOSE

We aimed to determine the relation of a disintegrin and metalloproteinase with thrombospondin motifs-4 (ADAMTS4), and a disintegrin and metalloproteinase with thrombospondin motifs-9 (ADAMTS9) with cardiovascular disease (CVD) risk, in ovarian dysfunction patients with premature ovarian insufficiency (POI), and idiopathic hypogonadotropic hypogonadism (IHH).

METHODS

43 IHH and 44 POI patients were enrolled to this case-control study. Serum hormonal parameters, lipid profiles, ADAMTS4 and ADAMTS9 levels were measured. Lipid accumulation product (LAP) index, visceral adiposity index (VAI), and homeostasis model assessment of insulin resistance (HOMA-IR) were calculated. The patients with at least two out of the four following criteria were accepted to have increased CVD risk; waist-to-hip ratio (WHR) ≥ 0.8, waist circumference (WC) ≥ 79 cm, triglycerides (TG) ≥ 150 mg/dL, high-density lipoprotein cholesterol (HDL-C) < 50 mg/dL. Serum ADAMTS4 and ADAMTS9 levels were measured by enzyme-linked immunosorbent assay (ELISA).

RESULTS

ADAMTS4 and ADAMTS9 levels were significantly higher in the IHH group than the POI group (p = 0.002, and p = 0.013, respectively). IHH group had significantly higher levels of insulin, HOMA-IR index, and LAP index (p = 0.006, p = 0.005, and p = 0.013, respectively). The mean age of patients in the IHH group (23.60 ± 5.64 years) was significantly lower than the POI group (31.05 ± 6.03 years), (p < 0.001). Odds ratios (OR) were 1.236 (95% CI 1.055-1.447) and 1.002 (95% CI 1.000-1.004) for LAP index and ADAMTS4, respectively, in the IHH group. These two parameters found to have high predictivity for CVD risk in the IHH group (p = 0.009 and p = 0.028, respectively).

CONCLUSION

The lower levels of ADAMTS4 in the POI group, when compared with the IHH patients pointed out that even limited hormone secretion and ovulation in the POI group, may have protective effect on cardiovascular system. The higher levels of ADAMTS4 and LAP index in the IHH group demonstrated the increased risk of these patients for CVD.

Rationale and design of a cohort study on primary ovarian insufficiency in female survivors of Hodgkin's lymphoma: influence on long-term adverse effects (SOPHIA)

INTRODUCTION

Hodgkin's lymphoma (HL) has become the prototype of a curable disease. However, many young survivors suffer from late adverse effects of treatment. Both chemotherapy (CT) and radiotherapy (RT) may induce primary ovarian insufficiency (POI), which has been associated with reduced bone mineral density (BMD), neurocognitive dysfunction and possibly cardiovascular disease (CVD). While the general assumption is that POI increases CVD risk, other hypotheses postulate reverse causality, suggesting that cardiovascular risk factors determine menopausal age or that biological ageing underlies both POI and CVD risk. None of these hypotheses are supported by convincing evidence. Furthermore, most studies on POI-associated conditions have been conducted in women with early natural or surgery-induced menopause with short follow-up times. In this study, we will examine the long-term effects of CT-induced and/or RT-induced POI on BMD, cardiovascular status, neurocognitive function and quality of life in female HL survivors.

METHODS AND ANALYSIS

This study will be performed within an existing Dutch cohort of HL survivors. Eligible women were treated for HL at ages 15-39 years in three large hospitals since 1965 and survived for ≥8 years after their diagnosis. Women visiting a survivorship care outpatient clinic will be invited for a neurocognitive, cardiovascular and BMD assessment, and asked to complete several questionnaires and to provide a blood sample. Using multivariable regression analyses, we will compare the outcomes of HL survivors who developed POI with those who did not. Cardiovascular status will also be compared with women with natural POI.

ETHICS AND DISSEMINATION

This study has been approved by the Institutional Review Board of the Netherlands Cancer Institute and has been registered at 'Toetsingonline' from the Dutch Central Committee on Research involving Human Subjects (file no. NL44714.031.13). Results will be disseminated through peer-reviewed publications and will be incorporated in follow-up guidelines for HL survivors.

Cardiovascular health in patients with premature ovarian insufficiency. Management of long-term consequences

Cardiovascular diseases (CVDs) represent the world’s leading cause of death among women. Women with premature ovarian insufficiency (POI) may be at higher risk of cardiovascular disease, such as myocardial infarction or stroke, than women with normal menopause. The increased burden may be mediated by a worsening of cardiovascular risk factors, such as lipid profiles, with accompanying loss of ovarian function. In contrast, the increased burden may be caused by factors that precede and potentially contribute to both CVD events and ovarian decline, such as smoking. Women with X chromosome-related POI like Turner syndrome (TS) are a distinct group with unique medical needs. Regardless of the cause, women with POI may serve as an important population to target for CVD screening and prevention strategies. These strategies should include the use of CVD risk stratification tools to identify women who may benefit from lifestyle modification and pharmacological therapy to prevent CVD.

Ischemic stroke across sexes: What is the status quo?

Stroke prevalence is expected to increase in the next decades due to the aging of the Western population. Ischemic stroke (IS) shows an age- and sex-dependent distribution in which men represent the most affected population within 65 years of age, being passed by post-menopausal women in older age groups. Furthermore, a sexual dimorphism concerning risk factors, presentation and treatment of IS has been widely recognized. In order to address these phenomena, a number of issue have been raised involving both socio-economical and biological factors. The latter can be either dependent on sex hormones or due to intrinsic factors. Although women have poorer outcomes and are more likely to die after a cerebrovascular event, they are still underrepresented in clinical trials and this is mirrored by the lack of sex-tailored therapies. A greater effort is needed in the future to ensure improved treatment and quality of life to both sexes.

NAMS 3rd Utian Translational Science Symposium, October 2016, Orlando, Florida A conversation about hormone therapy: is there an appropriate dose, route, and duration of use?

The North American Menopause Society (NAMS) held the 3rd Utian Translational Symposium on October 4, 2016, in Orlando, Florida, to answer questions about the benefits and risks of hormone therapy (HT) for postmenopausal women. This report is a record of the proceedings of that symposium.The maxim about HT for the past 15 years since the publication of the initial results of the Women's Health Initiative (WHI) has been to prescribe the "lowest dose for the shortest period of time." With new clinical trials, observational data, and further analysis of the WHI and the cumulative 13 years' follow-up, it was time to hold a conversation about the state of the evidence and recommendations for HT dose, route, and duration of use.The symposium brought together experts in the field of HT to speak on these topics, organized by session, after which working groups gathered to synthesize the presentations into areas of what still needs to be known and how to proceed with areas of needed research. After the presentations, there was consensus that postmenopausal women aged younger than 60 years or within 10 years of menopause onset without contraindications and who desire to take HT for relief of vasomotor symptoms or prevention of bone loss if at elevated risk can safely do so.The working groups raised the possibility that the use of "Big Data" (pharmacy and cancer databases) would allow answers that cannot be found in clinical trials. This could lead to more appropriate FDA labeling and patient package inserts reflecting the true risks associated with various types and formulations of HT, with differences among estrogen alone, estrogen with a progestogen, and estrogen plus a selective estrogen-receptor modulator for the younger women most likely to initiate these therapies for symptom relief. Differences were found for potential risk among estrogen alone, estrogen with synthetic progestins contrasted to progesterone, lower doses, nonoral doses, and low-dose vaginal estrogen.With all of the available routes and dosages, including vaginal estrogen alone for genitourinary symptoms, there are many options when considering the most appropriate type, dose, formulation, route of administration, and duration of use, taking into account the age of the woman at initiation of HT and the time from menopause.

Ischemic stroke across sexes: what is the status quo?

Stroke prevalence is expected to increase in the next decades due to the aging of the Western population. Ischemic stroke (IS) shows an age- and sex-dependent distribution in which men represent the most affected population within 65 years of age, being passed by post-menopausal women in older age groups. Furthermore, a sexual dimorphism concerning risk factors, presentation and treatment of IS has been widely recognized. In order to address these phenomena, a number of issue have been raised involving both socio-economical and biological factors. The latter can be either dependent on sex hormones or due to intrinsic factors. Although women have poorer outcomes and are more likely to die after a cerebrovascular event, they are still underrepresented in clinical trials and this is mirrored by the lack of sex-tailored therapies. A greater effort is needed in the future to ensure improved treatment and quality of life to both sexes.

Reprint of: Proteomics in cardiovascular diseases: Unveiling sex and gender differences in the era of precision medicine

Cardiovascular diseases (CVDs) represent the most important cause of mortality in women and in men. Contrary to the long-standing notion that the effects of the major risk factors on CVD outcomes are the same in both sexes, recent evidence recognizes new, potentially independent, sex/gender-related risk factors for CVDs, and sex/gender-differences in the clinical presentation of CVDs have been demonstrated. Furthermore, some therapeutic options may not be equally effective and safe in men and women. In this context, proteomics offers an extremely useful and versatile analytical platform for biomedical researches that expand from the screening of early diagnostic and prognostic biomarkers to the investigation of the molecular mechanisms underlying CDVs. In this review, we summarized the current applications of proteomics in the cardiovascular field, with emphasis on sex and gender-related differences in CVDs.

SIGNIFICANCE

Increasing evidence supports the profound effect of sex and gender on cardiovascular physio-pathology and the response to drugs. A clear understanding of the mechanisms underlying sexual dimorphisms in CVDs would not only improve our knowledge of the etiology of these diseases, but could also inform health policy makers and guideline committees in tailoring specific interventions for the prevention, treatment and management of CVDs in both men and women.

Estrogen deprivation and cardiovascular disease risk in primary ovarian insufficiency

OBJECTIVE

To evaluate the association between estrogen (E) exposure and deficiency and cardiovascular disease (CVD) risk among women with primary ovarian insufficiency (POI).

DESIGN

Cross-sectional study conducted between 1996 and 2016.

SETTING

Tertiary referral centers.

PATIENT(S)

A total of 385 women with POI, defined by amenorrhea and FSH levels ≥40 IU/L before 40 years of age, were recruited.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Women underwent a standardized intake questionnaire including data on menstrual cyclicity. Lifetime E exposure and E-free period were assessed. Serum was analyzed for endocrine and CVD profiles. The Framingham 30-year risk of CVD was calculated.

RESULT(S)

Lifetime E exposure (mean ± SD) was 19.3 ± 7.0 years, E-free period was 3.1 ± 4.1 years, and age at screening was 34.8 ± 7.4 years. In multivariate models E-free interval associated positively with estimated risk of hard and general CVD events (β 0.18 [95% confidence interval 0.08, 0.29]; 0.20 [0.05, 0.35], respectively), and lifetime E exposure associated negatively with estimated risk of hard and general CVD events (-0.15 [-0.24, -0.05]; -0.16 [-0.29, -0.03], respectively), as well as low density lipoprotein cholesterol (-0.03 [-0.06, 0.00]) and non-high density lipoprotein cholesterol (-0.04 [-0.07, 0.00]).

CONCLUSION(S)

Prolonged E deprivation is associated with an increased estimated risk of CVD, whereas prolonged E exposure is associated with a reduced estimated risk. These results support the policy of early and continued use of E replacement therapy in women with POI.

CLINICAL TRIAL REGISTRATION NUMBER

NCT0230904.

Proteomics in cardiovascular diseases: Unveiling sex and gender differences in the era of precision medicine

Cardiovascular diseases (CVDs) represent the most important cause of mortality in women and in men. Contrary to the long-standing notion that the effects of the major risk factors on CVD outcomes are the same in both sexes, recent evidence recognizes new, potentially independent, sex/gender-related risk factors for CVDs, and sex/gender-differences in the clinical presentation of CVDs have been demonstrated. Furthermore, some therapeutic options may not be equally effective and safe in men and women. In this context, proteomics offers an extremely useful and versatile analytical platform for biomedical researches that expand from the screening of early diagnostic and prognostic biomarkers to the investigation of the molecular mechanisms underlying CDVs. In this review, we summarized the current applications of proteomics in the cardiovascular field, with emphasis on sex and gender-related differences in CVDs.

SIGNIFICANCE

Increasing evidence supports the profound effect of sex and gender on cardiovascular physio-pathology and the response to drugs. A clear understanding of the mechanisms underlying sexual dimorphisms in CVDs would not only improve our knowledge of the etiology of these diseases, but could also inform health policy makers and guideline committees in tailoring specific interventions for the prevention, treatment and management of CVDs in both men and women.

Cardiovascular RiskprofilE - IMaging and gender-specific disOrders (CREw-IMAGO): rationale and design of a multicenter cohort study

Background

Reproductive disorders, such as polycystic ovary syndrome (PCOS), primary ovarian insufficiency (POI) and hypertensive pregnancy disorders (HPD) like pre-eclampsia (PE), are associated with an increased risk of cardiovascular disease (CVD). Detection of early signs of cardiovascular disease (CVD), as well as identification of risk factors among women of reproductive age which improve cardiovascular risk prediction, is a challenge and current models might underestimate long-term health risks. The aim of this study is to assess cardiovascular disease in patients with a history of a reproductive disorder by low-dose computed tomography (CT).

Methods

Women of 45 - 55 years, who experienced a reproductive disorder (PCOS, POI, HPD), are invited to participate in this multicenter, prospective, cohort study. Women will be recruited after regular cardiovascular screening, including assessment of classical cardiovascular risk factors. CT of the coronary arteries (both coronary artery calcium scoring (CACS), and contrast-enhanced coronary CT angiography (CCTA)) and carotid siphon calcium scoring (CSC) is planned in 300 women with HPD and 300 women with PCOS or POI. In addition, arterial stiffness (non-invasive pulse wave velocity (PWV)) measurement and cell-based biomarkers (inflammatory circulating cells) will be obtained.

Discussion

Initial inclusion is focused on women of 45 - 55 years. However, the age range (40 - 45 years and/or ≥ 55 years) and group composition may be adjusted based on the findings of the interim analysis. Participants can potentially benefit from information obtained in this study concerning their current cardiovascular health and expected future risk of cardiovascular events. The results of this study will provide insights in the development of CVD in women with a history of reproductive disorders. Ultimately, this study may lead to improved cardiovascular prediction models and will provide an opportunity for timely adjustment of preventive strategies. Limitations of this study include the possibility of overdiagnosis and the average radiation dose of 3.5 mSv during coronary and carotid siphon CT, although the increased lifetime malignancy risk is negligible.

Trial registration

Netherlands Trial Register, NTR5531. Date registered: October 21st, 2015.

Pregnancy: An Underutilized Window of Opportunity to Improve Long-term Maternal and Infant Health-An Appeal for Continuous Family Care and Interdisciplinary Communication

Physiologic adaptations during pregnancy unmask a woman's predisposition to diseases. Complications are increasingly predicted by first-trimester algorithms, amplify a pre-existing maternal phenotype and accelerate risks for chronic diseases in the offspring up to adulthood (Barker hypothesis). Recent evidence suggests that vice versa, pregnancy diseases also indicate maternal and even grandparent's risks for chronic diseases (reverse Barker hypothesis). Pub-Med and Embase were reviewed for Mesh terms "fetal programming" and "pregnancy complications combined with maternal disease" until January 2017. Studies linking pregnancy complications to future cardiovascular, metabolic, and thrombotic risks for mother and offspring were reviewed. Women with a history of miscarriage, fetal growth restriction, preeclampsia, preterm delivery, obesity, excessive gestational weight gain, gestational diabetes, subfertility, and thrombophilia more frequently demonstrate with echocardiographic abnormalities, higher fasting insulin, deviating lipids or clotting factors and show defective endothelial function. Thrombophilia hints to thrombotic risks in later life. Pregnancy abnormalities correlate with future cardiovascular and metabolic complications and earlier mortality. Conversely, women with a normal pregnancy have lower rates of subsequent diseases than the general female population creating the term: "Pregnancy as a window for future health." Although the placenta works as a gatekeeper, many pregnancy complications may lead to sickness and earlier death in later life when the child becomes an adult. The epigenetic mechanisms and the mismatch between pre- and postnatal life have created the term "fetal origin of adult disease." Up to now, the impact of cardiovascular, metabolic, or thrombotic risk profiles has been investigated separately for mother and child. In this manuscript, we strive to illustrate the consequences for both, fetus and mother within a cohesive perspective and thus try to demonstrate the complex interrelationship of genetics and epigenetics for long-term health of societies and future generations. Maternal-fetal medicine specialists should have a key role in the prevention of non-communicable diseases by implementing a framework for patient consultation and interdisciplinary networks. Health-care providers and policy makers should increasingly invest in a stratified primary prevention and follow-up to reduce the increasing number of manifest cardiovascular and metabolic diseases and to prevent waste of health-care resources.

Irresponsible and responsible resource management in obstetrics

Low budgets constrain and high budgets stimulate choices. In high-income countries, this economic reality may lead to overuse of healthcare services and pose unnecessary risks for mothers and infants. Options for improvement can be created at different levels of healthcare systems. Pregnancy provides an effective opportunity to profile maternal risks and represents a vulnerable but potentially modifiable period from prenatal life to adulthood. In response to system-inherent false incentives, professional responsibility requires obstetricians to strive to improve the future health of families and their offspring despite disincentives for doing so. This chapter addresses professionally responsible resource management in obstetrics and identifies implications for patients, care givers, communities, policy makers, and academic faculties.

Poor Compliance to Hormone Therapy and Decreased Bone Mineral Density in Women with Premature Ovarian Insufficiency

Premature ovarian insufficiency leads to through infertility and estrogen deficiency. Optimal management encompasses estrogen replacement therapy. Long-term outcome of women with POI is not known. We design a study to evaluate the medical care, hormone replacement therapy compliance and bone mineral density (BMD) in POI women with at least a five-year follow-up after the first evaluation. One hundred and sixty-two patients (37.3±8.0 years) were evaluated (follow-up 7.9±2.8 years). Sixty-nine patients (42.6%) had stopped their hormone replacement therapy (HRT) for at least one year during the follow up period. BMD determination at initial evaluation and at follow-up visit was completed in 92 patients. At first evaluation, 28 patients (30%) had osteopenia and 7 (8%) had osteoporosis. At follow up, 31 women (34%) had BMD impairment with osteopenia in 61% and osteoporosis in 5%. In univariate analysis and multivariate analysis, there was a significant loss of femoral BMD in women who had stopped their HRT for over a year. In conclusion, this first study concerning long-term follow-up of POI patients shows the poor compliance to their HRT, despite its importance in the prevention of bone demineralization. This study reinforces the need for follow up and specific care for POI women.

Cardiovascular Risk in Women With Premature Ovarian Insufficiency Compared to Premenopausal Women at Middle Age

CONTEXT

A young age at menopause has been associated with increased cardiovascular disease (CVD) risk.

OBJECTIVE

To compare the cardiovascular risk profile between women with premature ovarian insufficiency (POI) and premenopausal controls of comparable age.

DESIGN

Cross-sectional case control study.

SETTING

Two university medical centers.

PARTICIPANTS

Women above 45 years of age who were previously diagnosed with POI (n = 83) and premenopausal population controls of comparable age (n = 266).

MAIN OUTCOME MEASURES

Blood pressure, body mass index, waist circumference, electrocardiogram, bilateral carotid intima media thickness, estradiol, T, androstenedione, dehydroepiandrosterone sulfate, SHBG, insulin, glucose, lipids, TSH, free T4, N-terminal pro-B-type natriuretic peptide, C-reactive protein, uric acid, creatinine, and homocysteine were measured. Potential associations between POI status and subclinical atherosclerosis were assessed.

RESULTS

Women with POI exhibited an increased waist circumference (β = 5.7; 95% confidence interval [CI], 1.6, 9.9), C-reactive protein (β = 0.75; 95% CI, 0.43, 1.08), free T4 levels (β = 1.5; 95% CI, 0.6, 2.4), and lower N-terminal pro-B-type natriuretic peptide (β = -0.35; 95% CI, -0.62, -0.08), estradiol (β = -1.98; 95% CI, -2.48, -1.48), T (β = -0.21; 95% CI, -0.37, -0.06), and androstenedione (β = -0.54; 95% CI, -0.71, -0.38) concentrations compared to controls, after adjusting for confounders. After adjustment, a trend toward increased hypertension (odds ratio = 2.1; 95% CI, 0.99; 4.56) and decreased kidney function was observed in women with POI (creatinine β = 3.5; 95% CI, -0.05, 7.1; glomerular filtration rate β = -3.5; 95% CI, -7.5, 0.46). Women with POI exhibited a lower mean carotid intima media thickness (β = -0.17; 95% CI, -0.21, -0.13) and decreased odds of plaque presence compared to controls (odds ratio = 0.08; 95% CI, 0.03; 0.26).

CONCLUSIONS

Women with POI exhibited an unfavorable cardiovascular risk profile, including higher abdominal fat, elevated chronic inflammatory factors, and a trend toward increased hypertension and impaired kidney function compared to controls. However, we observed no signs of increased subclinical atherosclerosis in women with POI. Additional studies are required to identify specific determinants of long-term CVD risk in women with POI.