Obesity and the Risk of Infertility, Gestational Diabetes, and Type 2 Diabetes in Polycystic Ovary Syndrome

This review describes the relationship between obesity and the most common reproductive (infertility) and metabolic (gestational diabetes mellitus [GDM] and type 2 diabetes mellitus [T2DM]) consequences in polycystic ovary syndrome (PCOS). It also describes the vital role of lifestyle management for PCOS. PCOS is a heterogeneous endocrine disorder common in reproductive-age women. Consensus on the exact etiological mechanisms of PCOS is unreached. Overweight or obesity is present in at least 60% of the PCOS population, but the condition occurs irrespective of BMI, with excess BMI increasing both the prevalence and severity of clinical features. Use of lifestyle therapies (nutrition, physical activity, and/or behavioral) for the prevention and management of excess weight gain, infertility, GDM, and T2DM is a vital component of best-practice PCOS care. Lifestyle management is recommended for all women with PCOS as the first-line treatment with or without medications. Due to a lack of high-quality trials demonstrating the efficacy of specific lifestyle approaches, PCOS lifestyle recommendations are as those for the general population. This review summarizes current knowledge relating to obesity and its impact on fertility, GDM, and T2DM. It also summarizes the lifestyle recommendations to best manage these conditions in women with PCOS and obesity.

An Update on Contraception in Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is a common endocrine disorder in reproductive-aged women, characterized by hyperandrogenism, oligo/anovulation, and polycystic ovarian morphology. Combined oral contraceptives (COCs), along with lifestyle modifications, represent the first-line medical treatment for the long-term management of PCOS. Containing low doses of estrogen and different types of progestin, COCs restore menstrual cyclicity, improve hyperandrogenism, and provide additional benefits such as reducing the risk of endometrial cancer. However, potential cardiometabolic risk associated with these agents has been a concern. COCs increase the risk of venous thromboembolism (VTE), related both to the dose of estrogen and the type of progestin involved. Arterial thrombotic events related to COC use occur much less frequently, and usually not a concern for young patients. All patients diagnosed with PCOS should be carefully evaluated for cardiometabolic risk factors at baseline, before initiating a COC. Age, smoking, obesity, glucose intolerance or diabetes, hypertension, dyslipidemia, thrombophilia, and family history of VTE should be recorded. Patients should be re-assessed at consecutive visits, more closely if any baseline cardiometabolic risk factor is present. Individual risk assessment is the key in order to avoid unfavorable outcomes related to COC use in women with PCOS.

Effect of body mass index (BMI) on phenotypic features of polycystic ovary syndrome (PCOS) in Singapore women: a prospective cross-sectional study

Background

A diagnosis of Polycystic Ovary Syndrome (PCOS) and its related phenotypic features including increased hair growth can affect a woman’s social and emotional well-being. We aim to determine firstly, if excess body weight affects menstrual cycle length, excessive hair growth and other phenotypic features in healthy women without PCOS and secondly, whether having PCOS exacerbates the effects of high body mass index (BMI).

Methods

A prospective cross-sectional study involving healthy women (21–45 years) recruited at an annual health screen for hospital staff and volunteers from the university community, and PCOS cases referred to tertiary gynecological clinics in Singapore. To dissect the independent and/or combinatorial effects of PCOS and BMI on the phenotypic features, subjects were divided into four categories: non-PCOS (normal BMI), non-PCOS (high BMI), PCOS (normal BMI), and PCOS (high BMI). General linear modelling was performed to compare clinical, ovarian, hormonal and metabolic parameters across these four categories.

Results

Of 389 participants, 134 (34.4%) were classified as PCOS and the remaining 255 (65.6%), as the non-PCOS population. Overall 45.2% of women had high BMI (≥ 23). Compared to non-PCOS subjects, women with PCOS had a higher BMI (mean (SD): 25.14 ± 6.46 vs 23.08 ± 4.36, p < 0.001). Women with PCOS and high BMI had increased hair growth with modified Ferriman-Gallwey (mFG) scores that were 2.96-fold higher versus healthy-normal BMI women (mean difference; 1.85, 95% CI 0.80–2.90). Compared to healthy-high BMI women, PCOS women with high BMI had significantly higher mean differences in mFG scores (1.79, 95% CI 0.64–2.93). In PCOS women, having high BMI also significantly increased mFG scores by 1.85-fold (mean difference; 1.82. 95% CI 0.52–3.12). This effect was mirrored by the additive effect of BMI and PCOS on free androgen index. No independent effect of high BMI on rates of oligomenorrhoea, antral follicle count, ovarian volume or serum androgens were observed.

Conclusions

We observed an additive effect of body weight to increase hair growth in women with PCOS. Maximum mFG scores were present in PCOS women with high BMI. Such increases in mFG score may affect the self-esteem of women with PCOS.

Psychological Issues and Sexual Function in Women with Different Infertility Causes: Focus on Polycystic Ovary Syndrome

The objectives of this study are to assess the prevalence of psychological complaints and changes in sexual function in infertile PCOS women compared with patients with other infertility causes (tubal and male infertility factors) and to identify the predisposing factors. An observational study with three cohorts of infertile women was designed including 37 PCOS patients, 36 women with tubal factor, and 31 women with male factor. Clinical history and physical examination were carried out in all patients. All subjects completed the Hamilton Anxiety Rating Scale, the Beck Depression Inventory, and the Female Sexual Function Index questionnaires. Women with infertility due to PCOS showed a significantly higher prevalence of depressive (48.6 vs 19.4 and 12.9%, p < 0.01) and anxiety symptoms (21.6 vs 5.6 and 3.2%, p = 0.041) than respondents of reference groups. Sexual function in PCOS subjects was impaired in the areas orgasm and satisfaction (p < 0.01 for both) compared to patients of reference groups. Clinical, biochemical hyperandrogenism, and overweight were associated with a higher incidence of depressive and anxiety symptoms in the infertile PCOS group (p < 0.01 for all). Besides, the severity of anxiety symptoms was associated with the number of medically assisted reproduction attempts (p = 0.014). Weight gain and age (p = 0.04 and p = 0.047) were associated with impaired sexual functioning. The relation between reduced sexuality and depressive/anxiety symptoms was found (p = 0.038 and p = 0.012, respectively). Infertile PCOS patients showed the highest prevalence of psychological complaints and some impairment in their sexual functioning. Mental health and sexual functioning need to be part of the routine clinical screening of every PCOS patient. The study was registered at clinicaltrials.gov (identifier: NCT03306459) https://clinicaltrials.gov/ct2/show/NCT03306459?cond=PCOS&cntry=ES&city=Barcelona&draw=2&rank=3.

Update on PCOS: Consequences, Challenges, and Guiding Treatment

Polycystic ovary syndrome (PCOS) is one of the most common reproductive endocrine disorders in women and despite this, diagnostic challenges, delayed diagnosis, and less-than-optimal treatment regimens plague the condition. The International PCOS network, consisting of geographically diverse international experts in PCOS as well as consumers, engaged in a multi-year international evidence-based guideline development process that was jointly sponsored by the European Society for Human Reproduction and Embryology (ESHRE) and the American Society of Reproductive Medicine (ASRM). The guideline was published in 2018 and endorsed by more than 40 international societies involved in PCOS. Translation of this evidence-based guideline to medical practice and consumer groups remains a priority. However, there remain many challenges to both understanding the diagnosis and treatment of PCOS. Evidence suggests that both clinicians and consumers are not satisfied with the timeliness of diagnosis and treatment options. This review summarizes the important findings for diagnosis and treatment from the guidelines and expands on recent developments in the literature since its publication. Special attention to diagnosis at the ends of the reproductive spectrum are discussed and remaining areas of controversy are noted. Additionally, the review highlights some of the remaining challenges in the understanding and management of PCOS to help guide clinicians and investigators in this perplexing condition.

Risk of developing major depressive disorder in polycystic ovary syndrome: a retrospective cohort study

This study aimed to investigate the risk of developing major depressive disorder (MDD) in women with polycystic ovary syndrome (PCOS). As a population-based retrospective cohort study based on the Korean National Health Insurance Claims Database and National Health Information Database, newly diagnosed 26,251 women with PCOS with age matched 131,480 women without PCOS from 2007 to 2010 were followed longitudinally and the subsequent occurrence of newly onset MDD was evaluated. The risk of developing MDD in women with PCOS after adjusting for various confounding variables was higher compared to women without PCOS (hazard ratio [HR]1.34, 95% confidence intervals [CI] 1.29-1.40, p<.0001). Stratified by the body mass index, the risk of being admitted to the hospital due to MDD was the highest in the overweight PCOS (HR 2.53, 95% CI 1.71-3.76, p<.0001). The risk of developing MDD was higher in women with PCOS compared to women without PCOS. Maintenance of the appropriate body weight should be emphasised as the hazard ratio of developing MDD was higher in overweight women with PCOS.Impact statementWhat is already known on this subject? PCOS is a multisystem disorder associated with various comorbidities including diabetes mellitus, infertility and endometrial cancer.What do the results of this study add? Women with PCOS showed a higher risk of developing MDD compared to age matched women without PCOS in this multivariate analysis after adjusting for body-mass-index, smoking habit, socio-economic status, residential area, blood glucose, and blood cholesterol. The risk of being admitted to hospital due to MDD was the highest in PCOS with BMI ≥ 25.What are the implications of these findings for clinical practice and/or further research? PCOS should not be considered as a condition confined to ovulatory dysfunction and dermatologic problems, but the higher risk of developing MDD should be recognised. The importance of maintaining an appropriate BMI should be emphasised, as the risk of being admitted to the hospital due to MDD increased in overweight and obese women with PCOS.

Postpartum complications increased in women with polycystic ovary syndrome

BACKGROUND

Women with polycystic ovary syndrome are at a higher risk of cardiometabolic and psychiatric comorbidities and preconception and antepartum complications, but the impact of polycystic ovary syndrome during the postpartum period is unknown.

OBJECTIVE

This study aimed to investigate the risk of postpartum cardiovascular disease complications and perinatal and postpartum depression.

STUDY DESIGN

This was a retrospective cohort study conducted using a United States insurance claims database. Women with and without polycystic ovary syndrome aged 18 to 50 years enrolled continuously in a single health plan during the preconception, antepartum, and postpartum periods between 2000 and 2016 were included. The primary outcome was postpartum cardiovascular disease and depression (perinatal and postpartum). Multivariable logistic regression was used to adjust for covariates including age, geographic location, preterm delivery, assisted reproductive technology use, multiple births, prepregnancy depression, prepregnancy diabetes, prepregnancy hypertension, gestational diabetes, gestational hypertension, obesity, history of hyperlipidemia, smoking, and race.

RESULTS

We identified 42,391 unique women with polycystic ovary syndrome and 795,480 women without polycystic ovary syndrome. In multivariable models, women with polycystic ovary syndrome had significantly higher odds of cardiovascular disease complications, including postpartum preeclampsia (adjusted odds ratio, 1.30; 95% confidence interval, 1.17-1.45), eclampsia (adjusted odds ratio, 1.45; 95% confidence interval, 1.14-1.86) cardiomyopathy (adjusted odds ratio, 1.26; 95% confidence interval, 1.03-1.54), hypertensive heart disease (adjusted odds ratio, 1.32: 95% confidence interval, 1.07-1.64), thrombotic disease (adjusted odds ratio, 1.50; 95% confidence interval, 1.20-1.87), congestive heart failure (adjusted odds ratio, 1.35; 95% confidence interval, 1.13-1.61), and cerebrovascular accidents (adjusted odds ratio, 1.21; 95% confidence interval, 1.14-1.29), than those without polycystic ovary syndrome, as well as both perinatal (adjusted odds ratio, 1.27; 95% confidence interval, 1.22-1.33) and postpartum depression (adjusted odds ratio, 1.46; 95% confidence interval, 1.36-1.57). Nonobese women with polycystic ovary syndrome had higher odds of postpartum eclampsia (adjusted odds ratio 1.72; 95% confidence interval, 1.31-2.26), peripartum cardiomyopathy (adjusted odds ratio, 1.43; 95% confidence interval, 1.14-1.79), and cerebrovascular accidents (adjusted odds ratio, 1.28; 95% confidence interval, 1.19-1.38) than nonobese women without polycystic ovary syndrome. In the group of women without prepregnancy depression, the odds of perinatal depression (adjusted odds ratio, 1.32; 95% confidence interval, 1.26-1.39) and postpartum depression (adjusted odds ratio, 1.50; 95% confidence interval, 1.39-1.62) were higher in women with polycystic ovary syndrome than those without polycystic ovary syndrome.

CONCLUSION

In a large United States cohort, our study found that women with polycystic ovary syndrome are at increased risk of both cardiovascular and psychiatric complications during the postpartum period. Polycystic ovary syndrome should be recognized as an at-risk condition; our findings underscore the need for routine screening and early interventions for these major comorbidities.

The mental health of Chinese women with polycystic ovary syndrome is related to sleep disorders, not disease status

BACKGROUND

Mental health disorders are highly prevalent in polycystic ovary syndrome (PCOS) cases. The etiology for anxiety/depression in women with PCOS still remains unclear, due to conflicting results.

AIM

To examine whether an association exists between the mental health of Chinese women with PCOS and various indicators such as their disease characteristics, biochemistry results and sleep status.

METHODS

During July 2018 and January 2020, our study included a total of 433 women diagnosed with PCOS at Chongqing Hospital of Traditional Chinese Medicine. Sleep-related variables were evaluated by the Pittsburgh Sleep Quality Index (PSQI), anxiety and depression values were quantified by the Hospital Anxiety and Depression Scale (HADS), and biochemistry results were collected from the medical records of the patients.

RESULTS

26.6% patients resulted as positive anxiety and 23.6% as positive depression. We found significant associations between anxiety/depression status and sleep conditions of PCOS patients. More specifically, anxiety significantly associated with sleep quality OR (95%CI) = 1.611 (1.147-2.261), sleep disturbance 2.326 (1.468-3.685) and daytime dysfunction 1.457 (1.122-1.891). Similarly, depression significantly associated with sleep quality 1.467 (1.043-2.063), sleep disturbance 1.624 (1.030-2.561) and daytime dysfunction 1.406 (1.077-1.836). There was no association detected between mental health and disease characteristics, as well as reproductive and metabolic indicators in PCOS.

LIMITATION

Cross-sectional nature of the data prevents causal associations, selection bias of a hospital-based population.

CONCLUSIONS

Sleep-related disorders might be involved in the etiology and development of the anxiety/depression observed in PCOS cases. We propose that management of sleep disorders should be an integral part of the disease management of women with PCOS.

Cardiometabolic Risk in Polycystic Ovary Syndrome: Current Guidelines

Polycystic ovary syndrome is a common endocrine disorder in reproductive-aged women and is associated with an increased risk of metabolic abnormalities, including obesity, impaired glucose tolerance, diabetes, dyslipidemia, metabolic syndrome, venous thromboembolism, and subclinical atherosclerosis. Clinicians and patients alike need to be aware of these increased risks as well as new international guidelines that recommend frequent screening and active management of metabolic abnormalities. Given that the data on risk of cardiovascular events, such as myocardial infarction and stroke, in women with PCOS is mixed, future large-scale, longitudinal studies are needed to clarify these potential risks.

Assessment of Optimism in Women with Polycystic Ovary Syndrome: A Case Control-Study

Polycystic ovary syndrome (PCOS) is a chronic endocrinopathy characterized by hyperandrogenism and anovulation that may pervade psychological dimensions such as dispositional optimism. Considering how PCOS influences mental health and the lack of studies on this matter, this research was aimed at assessing optimism and associated factors in PCOS. A case–control study of 156 patients with PCOS and 117 controls was conducted. All woman filled out the Life Orientation Test-Revised (LOT-R), a self-report questionnaire for measuring dispositional optimism. Medication, pain severity, gynecological, and sociodemographic information was also collected. Lower optimism was found in patients with PCOS compared to controls, even after covariate adjustment (LOT-R global scores: 14.1 vs. 15.9, p = 0.020). Our study provides evidence that a personality characteristic with important implications in illness prognosis may be affected in PCOS. We propose to assess dispositional optimism with the LOT-R scale in the gynecological appointment and tailor medical attention accordingly as a way to improve the comprehensive care of these patients within a multidisciplinary team.

Why are Women With Polycystic Ovary Syndrome at Increased Risk of Depression? Exploring the Etiological Maze

Polycystic ovary syndrome (PCOS) is a complex and common multisystemic disorder. Women with PCOS have up to eight times higher prevalence of depression than control groups. This paper aims to explore the underlying risk factors for developing depression in this high-risk group. Studies indicate an interplay of multiple mechanisms that place women with PCOS at an increased risk for depression. The pathophysiology thought to play a role includes disturbances in the endocrine axes and changes to the metabolic pathway. The risk of depression is independently linked to insulin resistance and obesity in this population. However, rates of depression were still higher than control groups when accounting for these variables, demonstrating that they are not the only mechanism causing depression. The clinical manifestations of hyperandrogenism and menstrual abnormalities may compound negative views and lower self-esteem and negatively impact mood. Many of these women also struggle with infertility, and due to the added external pressures like societal beliefs and culture, they may be further negatively impacted and worsen their depressive symptoms. The prevalence of depression in women with PCOS is high; thus, this paper highlights the essential understanding of the underlying mechanisms at play. This is to better aid in addressing the fundamental cause of depression in this high-risk group effectively.

Twelve-month Continuation of the Etonogestrel Implant in Adolescents With Polycystic Ovary Syndrome

STUDY OBJECTIVE

To identify why adolescents with polycystic ovary syndrome (PCOS) chose the etonogestrel (ENG) contraceptive implant, to determine the 12-month continuation rate, and to characterize factors related to discontinuation.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective chart review of adolescents seen at a tertiary care children's hospital between July 1, 2008, and August 30, 2019, with PCOS diagnosis confirmed per National Institutes of Health criteria and ≥12-month ENG follow-up.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Demographic characteristics, reasons for ENG insertion and removal, and information on other hormonal/contraceptive therapies were collected. Patients were categorized as ENG continuers (use ≥12 months) or discontinuers (removal at <12 months), and groups were compared.

RESULTS

A total of 96 patients met inclusion criteria (age 17.7 ± 2.2 years, body mass index 34.8 ± 8 kg/m²). Reasons for ENG were documented in 74% (51% contraception, 32% ease of use, 15% other, 13% estrogen avoidance). In all, 27% had never been sexually active, and 67% had had prior sexual activity. Treatments prior to ENG placement included 74% combined hormonal contraception, 20% medroxyprogesterone acetate withdrawal, and 17% depot medroxyprogesterone. A total of 77% continued ENG at 12 months. The main reasons for discontinuation were bleeding (41%), concern about weight gain (23%), and mood changes (18%). No preimplantation characteristics were independently predictive of continuation, although 100% of patients with type 2 diabetes (n = 11) continued. Patients who sought additional care, including telephone calls (41% vs 12%, P = .006) and clinic visits (64% vs 20%, P < .001) were more likely to discontinue.

CONCLUSIONS

The ENG implant was well tolerated in adolescents with PCOS and similar to published 12-month continuation rates.

Acupuncture for polycystic ovary syndrome: An overview of a protocol for systematic reviews and meta analyses

BACKGROUND

As the results of previous systematic reviews and meta-analyses on acupuncture for polycystic ovary syndrome (PCOS) have provided inconsistent evidence. This overview of systematic reviews (SRs) and meta-analyses will aim to critically appraise the methodology and reporting quality of the relevant SRs and meta-analyses with the aim of identifying whether acupuncture could provide an effective treatment for patients with PCOS or not.

METHODS

Electronic databases including MEDLINE via Ovid, EMBASE, PubMed, Cochrane library, China National Knowledge Infrastructure (CNKI), Chinese Scientific Journal Database (VIP database), and Wanfang Database will be searched for related SRs and meta-analyses from inceptions to the search date without language restrictions. Two reviewers will independently select SRs and meta-analyses and collect related data, and a third reviewer will be introduced if any disagreement happened during the assessing. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) and the latest Assessment of Multiple Systematic Reviews 2 (AMSTAR2) checklists will be employed to evaluate the reporting and methodology quality.

RESULTS

This overview will be published in a peer-reviewed journal.

CONCLUSION

This overview will identify related SRs and meta-analyses of acupuncture for treating PCOS.

ETHICS AND DISSEMINATION

Ethics approval and patient consent are not required as this study is an overview based on published systematic reviews and meta-analyses.

Are Dietary Indices Associated with Polycystic Ovary Syndrome and Its Phenotypes? A Preliminary Study

Polycystic ovary syndrome (PCOS) is a complex hormonal disorder which impairs ovarian function. The adherence to healthy dietary patterns and physical exercise are the first line of recommended treatment for PCOS patients, but it is yet unclear what type of diet is more adequate. In this case-control study, we explored associations between adherence to five dietary quality indices and the presence of PCOS. We enrolled 126 cases of PCOS and 159 controls living in Murcia (Spain). Diagnostic of PCOS and its phenotypes were established following the Rotterdam criteria (hyperandrogenism (H), oligoanovulation (O), polycystic ovaries morphology (POM)). We used a validated food frequency questionnaires to calculate the scores of five dietary indices: alternate Healthy Eating index (AHEI), AHEI-2010, relative Mediterranean Dietary Score (rMED), alternate Mediterranean Dietary Score (aMED) and Dietary Approaches to Stop Hypertension (DASH). We used multivariable logistic regression to estimate adjusted odds ratios and confidence intervals. In the multivariable analysis, AHEI-2010 index was inversely associated with Hyperandrogenism + Oligoanovulation PCOS phenotype (OR_Q3 vs. _Q1 = 0.1; 95% CI: (0.0; 0.9); P_{for trend} = 0.02). We did not find any statistical significant association between dietary indices and total anovulatory or ovulatory PCOS. However, further studies with higher sample sizes exploring these associations among the diverse phenotypes of PCOS are highly warranted.

Prenatal androgen exposure causes a sexually dimorphic transgenerational increase in offspring susceptibility to anxiety disorders

If and how obesity and elevated androgens in women with polycystic ovary syndrome (PCOS) affect their offspring's psychiatric health is unclear. Using data from Swedish population health registers, we showed that daughters of mothers with PCOS have a 78% increased risk of being diagnosed with anxiety disorders. We next generated a PCOS-like mouse (F₀) model induced by androgen exposure during late gestation, with or without diet-induced maternal obesity, and showed that the first generation (F₁) female offspring develop anxiety-like behavior, which is transgenerationally transmitted through the female germline into the third generation of female offspring (F₃) in the androgenized lineage. In contrast, following the male germline, F₃ male offspring (mF₃) displayed anxiety-like behavior in the androgenized and the obese lineages. Using a targeted approach to search for molecular targets within the amygdala, we identified five differentially expressed genes involved in anxiety-like behavior in F₃ females in the androgenized lineage and eight genes in the obese lineage. In mF₃ male offspring, three genes were dysregulated in the obese lineage but none in the androgenized lineage. Finally, we performed in vitro fertilization (IVF) using a PCOS mouse model of continuous androgen exposure. We showed that the IVF generated F₁ and F₂ offspring in the female germline did not develop anxiety-like behavior, while the F₂ male offspring (mF₂) in the male germline did. Our findings provide evidence that elevated maternal androgens in PCOS and maternal obesity may underlie the risk of a transgenerational transmission of anxiety disorders in children of women with PCOS.

The Prevalence and Factors Associated With Anxiety-Like and Depression-Like Behaviors in Women With Polycystic Ovary Syndrome

Increasing evidence shows that polycystic ovary syndrome (PCOS) patients are particularly vulnerable to anxiety/depression-like behaviors. This study sought to determine the prevalence of anxiety/depression-like behaviors among women with PCOS and to identify factors associated with these behaviors. This study was a secondary analysis of three studies performed on Chinese women who were aged 18 to 40 and diagnosed with PCOS according to the modified Rotterdam criteria. We obtained 802 useable responses for the self-rating anxiety scale and 798 responses for the self-rating depression scale. The prevalence of anxiety-like and depression-like behaviors among women with PCOS was 26.1% (209/802) and 52.0% (415/798), respectively. Anxiety-like behaviors were associated with age, body image-related factors (including body mass index and waist-to-hip ratio), and hyperandrogenism-related factors (including free androgen index and hirsutism). Depression-like behaviors were associated with age, body image-related factors, hyperandrogenism-related factors, and metabolic factors (including fasting insulin, fasting plasma glucose, and homeostatic model assessment of insulin resistance). Body image-related factors and hyperandrogenism-related factors were related to both anxiety-like behaviors and depression-like behaviors in both infertile and fertile PCOS patients.

Circulating steroids and mood disorders in patients with polycystic ovary syndrome

Aberrant androgen metabolism is a characteristic feature of polycystic ovary syndrome (PCOS). Various androgens as well as their precursors and metabolites can accumulate in the blood of PCOS patients. Although these steroids include neuroactive steroids, such as allopregnanolone and androstenedione (Δ4A), it remains unknown whether altered blood steroid levels contribute to the high risk of mood disorders in PCOS. In this study, we measured blood levels of 11 steroids in 25 PCOS patients using liquid chromatography-tandem mass spectrometry and chemiluminescent enzyme immunoassay, and assessed the psychological status of these patients using the Hospital Anxiety and Depression Scale (HADS) questionnaire. We also examined age and the degree of metabolic abnormalities of each patient. Steroid values of the patients were compared to our previous data from 31 eumenorrheic women. As a result, 20 patients exhibited aberrant blood levels of one or more of the 11 tested steroids. In most cases, Δ4A and allopregnanolone levels were within or close to the reference ranges. Levels of four steroids were negatively correlated with patients' age, while no correlation was observed between steroid values and metabolic conditions. Seven patients showed high HADS scores. HADS scores were correlated with blood Δ4A levels even after stratifying by body mass indexes, but not with the levels of other steroids or clinical data. These results indicate that the high frequency of anxiety and depression in PCOS patients cannot be ascribed to altered blood levels of a specific steroid, although there may be a weak association between circulating Δ4A levels and psychological conditions of the patients.

Depressive and Anxiety Symptom Assessment in Adults with Polycystic Ovarian Syndrome

BACKGROUND

Polycystic ovarian syndrome (PCOS) is an endocrinopathic disorder commonly affecting women in the reproductive age. These women have a possibility of developing depression and anxiety due to biochemical changes, concerns regarding physical appearance, and social pressure from infertility. Thus, the connection between PCOS, anxiety, and depression has a possible impact on patients' quality of life. This study is aimed at assessing depression and anxiety symptoms among PCOS patients and their association with different socioeconomic aspects.

METHODS

A cross-sectional study was conducted to assess depression and anxiety symptoms on 250 PCOS patients which were selected through consecutive sampling technique. Arabic versions of the HAM-A and HAM-D questionnaires were used alongside a demographic sheet to determine the socioeconomic and fertility status.

RESULTS

Prevalence of anxiety symptoms was reported among 100 (40%) of women and was found to be significantly higher in single women with a prevalence of 59 (48%) (χ2 = 5.8, p value <0.01). Also, lower-income status and unemployment were associated with a significantly higher prevalence of anxiety 18 (67%) (χ2 = 10.3, p value =0.03) and 71 (45%) (χ2 = 4.5, p value =0.03) women, respectively. Depressive symptoms were reported among 122 (49%) participants.

CONCLUSION

Single marital status, low income, and unemployment were predictors of anxiety. Tension was noted to be the most common anxiety symptom among participants while depressed mood and psychological anxiety were the most reported depressive symptoms. It is important to note the link between anxiety, PCOS, and depression when deciding treatment plans for affected women.

Perceived Stress Scale Among Adolescents with Polycystic Ovary Syndrome

Introduction

Polycystic ovary syndrome (PCOS) is a common disorder that affects women during their reproductive age. Previous studies have suggested that PCOS may be linked to some mental disorders.

Aim

The study aimed to estimate the perceived stress among adolescents with PCOS and investigate the relationship between PCOS symptoms and perceived stress scale (PSS) in adolescents.

Methods

This was a case control study with 72 participants (between 11 and 19 years); 36 adolescents with PCOS and 36 matched controls were recruited from family medicine and gynecological outpatient clinics at Cairo University hospitals. They participated in a structured interview using a pre-designed questionnaire. Full general examination was conducted, including anthropometric measures, acne staging, and hirsutism staging using the Ferriman–Gallwey score. We assessed the severity of stress over the previous month of interview using the 10-item perceived stress scale (PSS-10).

Results

There was a statistically significant difference in PSS scores among adolescents with and without PCOS; most cases with severe PSS scores were found to have PCOS. The mean score of PSS was higher in PCOS adolescents (20.416) than in the non-PCOS control group (18.8), but with no statistical significance. There was no significant correlation between the severity of PSS in PCOS adolescents and BMI, WC, acne or hirsutism severity; there was only weak positive correlation between PSS score and DBP (r=0.167).

Conclusion

PCOS adolescents have higher incidence of severe perceived stress; however, degree of PSS was independent of BMI, WC, acne or hirsutism severity and shows only weak correlations with DBP. Our results urge the need for implementing a holistic approach that should include stress reduction programs to help adolescents get ready for their adult life.

Clinical Obstetrics & Gynecology: Polycystic Ovary Disease Ethnicity, Diversity, and Psychosocial Ramifications

Polycystic ovary disease is a heterogenous disorder that presents differently in each individual. Some of this variation is due to racial and ethnic differences, which has been shown to affect hirsutism scores, metabolic comorbidities, cardiovascular risk factors, and long-term health outcomes. Psychosocial factors, including mental health diagnoses, body image distress measures, and disordered eating behaviors have also been shown to affect women with polycystic ovarian syndrome at a higher rate than the general population, and contribute to a decreased quality of life among many patients with this chronic condition.

Chinese herbal medicine on treating obese women with polycystic ovary syndrome: A systematic review and meta-analysis protocol

INTRODUCTION

Known as an endocrine disorder, Polycystic ovary syndrome (PCOS) has posed an influence on 6% to 20% reproductive females worldwide. The commonly used pharmaceutical agents currently are Oral Contraceptives (OCs) and insulin-sensitizing agents. However, OCs is not appropriate for females pursuing pregnancy. Furthermore, some of insulin-sensitizing agents are found to be related to a high incidence of gastrointestinal adverse effects. In this regard, the effectiveness of Chinese herbal medicine in handling reproductive and metabolic defects simultaneously has been proved by extensive evidence. In this research, the effectiveness and safety of Chinese herbal medicine for obese females with PCOS were examined.

METHODS AND ANALYSIS

In the systematic review, we searched databases of AMED, Science Online, EMbase, WorldSciNet, the Cochrane Library, PubMed, Nature, MEDLINE, China National Knowledge Infrastructure, the Wanfang Databse and China Biology Medicine Disc and the Chongqing VIP Chinese Science and Technology Periodical Database, to find out the papers published in Chinese or English by September 25, 2020 in this field. In addition, potential reference lists, relevant conference proceedings, qualified studies, related system reviews and other resources were also considered. Two researchers were responsible for independently selecting the research papers, collecting data, and evaluating research quality. Moreover, the data were synthesized with the combination of a fixed-effects or random-effects model with the heterogeneity test. According to the objective and self-reported assessment, the primary outcomes will be Nausea and vomiting were primary outcomes. RevMan 5 software was used to analyze the collected data, the evidence level of which was evaluated by GRADE. The selection between the fixed-effects and random-effects models was determined by the heterogeneity level. In addition to the 95% Confidence Interval (CI), odds ratio (OR), or risk ratio (RR) was applied to the 2 categories. Moreover, 95% CI and standardized mean difference (SMD) or the weighted mean difference (WMD) were taken as the continuous variables. When existing meaningful heterogeneity could not be explained by any assessment such as subgroup analysis, we would not conduct a meta-analysis. During the subgroup analysis, each subgroup in specific cases should be comprehensively considered.

ETHICS AND DISSEMINATION

The evaluation of rights or personal information of patients was not involved in the systematic review. Hence, we need not gain approval from ethical institutions. This paper will be present at related conferences for communication and published in journals.

REGISTRATION

Open Science Framework (OSF) Preregistration: osf.io/yp86h.

Sexual Function in Women With Polycystic Ovary Syndrome: Design of an Observational Prospective Multicenter Case Control Study

INTRODUCTION

The prevalence of polycystic ovary syndrome (PCOS) is 10-15% in women of reproductive age. Its characteristics are (i) clinical or biochemical hyperandrogenism, (ii) oligomenorrhea or amenorrhea, and (iii) polycystic ovaries on ultrasound. PCOS is associated with lower quality of life, depression, anxiety, diabetes, and cardiovascular disease. Treatment commonly entails oral contraceptive use to lower endogenous androgen levels. Androgen levels and comorbidities may affect sexual function. Previous studies have addressed a limited range of possible contributing factors. We will assess sexual function as well as genital and self-reported sexual arousal in a laboratory setting in women with PCOS compared to an age-matched healthy control group. Modulation by biopsychosocial factors mentioned will be studied.

METHODS

This is a multicenter prospective case control study. The study population includes healthy women with and without PCOS, aged 18-40 years, in a stable heterosexual relationship for at least 6 months. Power is calculated at 67 participants in each group. Anticipating a drop out of 10%, 150 participants will be recruited.

MAIN OUTCOME MEASURES

The main outcomes measured are sexual function using the Female Sexual Function Index, Sexual Desire Inventory, and Female Sexual Distress Scale-Revised; genital sexual arousal measured as vaginal pulse amplitude; and self-reported sexual arousal in response to erotic stimuli in a laboratory setting. The mediators that will be investigated include testosterone, free androgen levels, oral contraceptive use, sensitivity to androgens (using CAG repeat length), body mass index, body image, mental health, and self-esteem.

CONCLUSION

Strengths of this study are the inclusion of a broad range of biopsychosocial outcome measures including DNA analysis, a healthy control group, and standardized assessment of genital and self-reported sexual arousal in a laboratory setting. With the design of this study we aim to provide an insight into which biopsychosocial factors associated with PCOS are related to sexual function, and how sexual function may be affected by treatment. These new insights may help to improve clinical management of PCOS while improving the quality of life. Pastoor H, Both S, Timman R, et al. Sexual Function in Women With Polycystic Ovary Syndrome: Design of an Observational Prospective Multicenter Case Control Study. Sex Med 2020;8:718-729.

A safety evaluation of current medications for adult women with the polycystic ovarian syndrome not pursuing pregnancy

INTRODUCTION

The polycystic ovary syndrome (PCOS) is a very prevalent disorder in premenopausal women. Cardiovascular risk factors cluster in these patients, raising concern about the safety of the drugs commonly used to ameliorate symptoms of androgen excess in in this population at risk of cardiovascular morbidity.

AREAS COVERED

This review summarizes the clinical efficacy and safety profiles of drugs commonly used for the management of hyperandrogenic symptoms and endometrial protection in adult women with PCOS who do not seek pregnancy.

EXPERT OPINION

Antiandrogenic drugs usually used in adult women with PCOS carry a low risk of severe side effects. In spite of the cardiovascular risk profile of women with PCOS, and that individualized risk assessment is of paramount importance, there is no solid evidence supporting that the use of combined oral contraceptives in these women increases the risk of cardiovascular or thromboembolic events compared with the general population. However, virtually all these drugs are used in an off-label fashion. Large, high-quality studies addressing the long-term safety of pharmacological treatments in women with PCOS are definitely needed.

Lifestyle modifications alone or combined with hormonal contraceptives improve sexual dysfunction in women with polycystic ovary syndrome

OBJECTIVE

To describe the prevalence of female sexual dysfunction in a well-defined polycystic ovary syndrome (PCOS) population, and to assess the impact of common PCOS treatments on sexual function.

DESIGN

Secondary analysis of a randomized controlled trial, oral contraceptive pills and weight loss in PCOS.

SETTING

Two academic medical centers.

PATIENTS

Women with PCOS (N = 114) defined by the Rotterdam criteria.

INTERVENTIONS

Continuous oral contraceptive pill (OCP) or intensive lifestyle modification (Lifestyle) or the combination (Combined) for 16 weeks.

MAIN OUTCOME MEASURES

Change in Female Sexual Function Index (FSFI) and Female Sexual Distress Scale-Revised (FSDS-R) scores after 16 weeks.

RESULTS

There was no change in total FSFI or FSDS-R score in any treatment group; however, an increase in the FSFI desire domain subscore was observed in the Lifestyle and Combined treatments, indicating improved sexual desire over the 16-week period. Overall, 33 participants (28.9%) met criteria for sexual dysfunction by FSFI criteria (baseline score ≤26.55). Among this group, FSFI score improved after 16 weeks of Lifestyle and Combined treatments. There was no change in prevalence of sexual dysfunction in treatment groups at 16 weeks. Use of OCPs did not alter FSFI scores.

CONCLUSION(S)

Female sexual dysfunction is highly prevalent among women with PCOS. Our findings suggest that common treatments for PCOS, including intensive lifestyle modification and the combination of intensive lifestyle modification and OCPs, have the potential to improve sexual function in these women; the mechanism for these improvements is likely multifactorial.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00704912.

Differential expression profile of plasma exosomal microRNAs in women with polycystic ovary syndrome

OBJECTIVE

To examine different expression profiles of plasma exosomal microRNA (miRNA) in polycystic ovary syndrome (PCOS) patients and controls, and their potential roles in PCOS pathogenesis.

DESIGN

Experimental study.

SETTING

Center for reproductive medicine.

PATIENT(S)

Seventy-five PCOS patients and 75 age-matched controls.

INTERVENTION(S)

Plasma exosomes miRNAs sequenced from 15 PCOS patients and 15 controls.

MAIN OUTCOME MEASURE(S)

Plasma exosomal miRNA expression and the correlation between PCOS phenotypes and miRNA expression.

RESULT(S)

The sequenced plasma exosomes miRNAs were further determined by quantitative reverse transcriptase polymerase chain reaction (qRT-PCR) in a larger cohort, followed by Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses. Correlation analysis and receiver operating characteristic (ROC) curve analysis were used to determine the association between PCOS phenotypes and miRNA expression. The miRNA sequencing revealed 34 exosomal miRNAs were differentially expressed between PCOS patients and controls. Via qRT-PCR, five differentially expressed miRNAs (miR-126-3p, miR-146a-5p, miR-20b-5p, miR-106a-5p, and miR-18a-3p) were identified. The GO and KEGG analyses predicted their target functions included axon guidance, mitogen-activated protein kinase (MAPK) signaling, endocytosis, circadian rhythms, and cancer pathways. The expression of these miRNAs correlated with menstrual cycle, antral follicle count, hormone level, and combined yielded a ROC curve area of 0.781 in discriminating PCOS patients from the controls.

CONCLUSION(S)

Differential expression of plasma exosomal miRNAs may confer a risk of PCOS and may be helpful in distinguishing PCOS patients from controls. Certain miRNA expression may associated to the disease progression, which could help in an epigenetic understanding of the pathophysiology of PCOS.

"The whole package deal": experiences of overweight/obese women living with polycystic ovary syndrome

BACKGROUND

Polycystic Ovary Syndrome (PCOS) is a common female reproductive disorder with multiple manifestations. There are relatively few qualitative studies exploring the nature of living with PCOS despite its high prevalence. Qualitative research can enhance clinical practice via the provision of patient insights into the experience of living with their condition.

METHODS

We conducted two focus groups and three semi-structured interviews of Australian overweight/obese women with PCOS aged 18-46 years between March and April 2017 who were recruited through social media advertising. Interviews and focus groups were audio recorded and transcribed verbatim. Thematic analysis was applied to the data, using the method of constant comparison.

RESULTS

Ten women contributed data from two focus groups and two semi-structured interviews. Five themes emerged from the data: complexity of the condition with its multiple manifestations, difficulties with delayed diagnosis and lack of information provided after diagnosis, negative experiences on social media and online forums and the need for support, frustration over lack of a "cure"; and the impact of symptoms and concern about long-term sequelae.

CONCLUSIONS

Living with PCOS appears to generate a significant degree of anxiety about the future, dissatisfaction with current treatment models, and loss of feminine identity. Gaps in timely diagnosis, information and support provision need to be addressed. This includes supporting weight management as a fundamental concern for women with PCOS.

Knowledge of PCOS in physicians-in-training: identifying gaps and educational opportunities

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in reproductive-aged women. A recent study found that many obstetrics and gynecology (ObGyn) practicing physicians are unaware of the Rotterdam criteria recommended for diagnosis. Our objective was to identify gaps in trainee knowledge of PCOS diagnostic criteria and management. An online survey was sent out to US ObGyn physicians-in-training in 2018. The primary outcomes were identification of at least one component of each Rotterdam criteria (Rot-3): (1) oligomenorrhea/amenorrhea, (2) clinical or biochemical hyperandrogenism, and (3) ovarian volume or antral follicle count, and identification of all five components (Rot-5). Secondary outcomes were identification of comorbidities and management of PCOS. Multivariable logistic regression was used controlling for gender, seniority (PGY) status, program type, completion of an REI rotation, and number of PCOS patients seen. 85.4% of 347 trainees completing the survey reported using Rotterdam criteria to diagnose PCOS. However, only 55% identified Rot-3 and less than 10% identified Rot-5. Seniority (PGY4 OR 2.2; 95% CI: 1.2-4.1; p = .01) and completion of REI rotation (OR 1.8 95% CI: 1.2, 1.8; p = .006) were associated with identifying Rot-3. Similar findings were noted with identifying Rot-5. Our study identified significant gaps in knowledge regarding PCOS, suggesting an urgent need for improving strategies for trainee education to increase patient satisfaction and provide comprehensive care.

Intertwined reproductive endocrinology: Puberty and polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a heterogeneous familial disorder often emerging during the peri-pubertal years concomitantly with the onset of gonadarche and adrenarche. Both gonadarche and PCOS reflect functional changes in the hypothalamic-pituitary-ovarian axis. During this transition, normal girls manifest features consistent with PCOS such as irregular menses, mild hyperandrogenism, and multi-follicular ovary morphology. Themes common to puberty and PCOS, neuroendocrine features, androgen exposure, and insulin sensitivity, will be considered to address the possibility that PCOS interferes with the normal pubertal transition.

Endocrinological disorders and inflammatory skin diseases during COVID-19 outbreak: a review of the literature

INTRODUCTION

In the next future, dermatologists, endocrinologist and physicians may cope with the impact of extent SARS-CoV-2 (COVID-19) infection over chronic inflammatory skin diseases and their treatment. COVID-19 pandemic obliged many countries to impose social restrictions, resulting in the need to adapt daily lifestyle habits and working activities. These changes have drastically reduced physical activity and social interactions, with the possible increase of anxiety, eating disorders and weight gain.

EVIDENCE ACQUISITION

We searched for relevant studies (trials, real-life studies and case reports, meta-analysis, pooled data analysis, reviews) on endocrine disorders and inflammatory skin diseases. The database used was PubMed. The studies included were those published in the English language between January 1, 2018 and May 5, 2020.

EVIDENCE SYNTHESIS

Several studies have been previously showed the association of overweight and obesity, with the metabolic syndrome and insulin-resistance. It has been demonstrated how these conditions correlate with the worsening of such chronic inflammatory skin diseases, such as psoriasis, hidradenitis suppurativa and acne. Many evidences suggest an important role of adipose tissue in the production of pro-inflammatory cytokines (Leptin, adiponectin, TNFα, IL-6, MCP-1, PAI-1), involved in the pathogenesis and the exacerbations of these skin diseases. In addition, we should expect an increasing incidence rate of hypovitaminosis D in the next future due to reduced sun exposure caused by isolation at home and missed holidays. Scientific evidences already show the important immunomodulating role of vitamin D in inflammatory skin diseases.

CONCLUSIONS

Our study pays attention on medium-long term effects of COVID-19 outbreak on inflammatory skin disorders, due to the lifestyle changes. In such context this review considers how a multidisciplinary approach, involving dermatologists, nutritionists and endocrinologists, may lead to a better management of dermatologic patients.

Association between depression risk and polycystic ovarian syndrome in young women: a retrospective nationwide population-based cohort study (1998-2013)

STUDY QUESTION

Is polycystic ovarian syndrome (PCOS) in women associated with the increasing incidence of depression in an East Asian population?

SUMMARY ANSWER

Younger PCOS patients (aged 15-29 years), but not middle-aged patients, have an increased risk of depression in Taiwan.

WHAT IS KNOWN ALREADY

During reproductive age, 6-10% of women have PCOS. Among them, ~40% experience depression, mostly at young ages.

STUDY DESIGN, SIZE, DURATION

This is a retrospective population-based cohort study analysing depression risk in Taiwanese women using data from a nationwide database containing 1998-2013 data of nearly 1 million people.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We included 15- to 50-year-old women newly diagnosed with PCOS during 1998-2013 from the Taiwan National Health Insurance Research Database as the PCOS cohort (n = 7684) and then randomly matched them 4 : 1 by sex, age and index year with women without PCOS as the comparison cohort (n = 30 736). We used multivariable Cox proportional hazard regression analysis to determine the association between PCOS and depression risk [hazard ratio (HR) with 95% confidence interval (CI)].

MAIN RESULTS AND THE ROLE OF CHANCE

The incidence of depression was higher in the PCOS group than in the comparison group (6.67 vs. 4.82 per 1000 person-years; adjusted HR = 1.28, 95% CI = 1.12-1.46). PCOS patients aged 15-29 years had a significantly higher depression risk (adjusted HR = 1.39, 95% CI = 1.18-1.65); no such significant association was noted among patients aged 30-39 years and 40-50 years.

LIMITATIONS, REASONS FOR CAUTION

A history of malignancy, which may increase depression, could not be obtained for our study patients. Moreover, we could not obtain a family history of depression, a relevant risk factor for depression. Finally, the database has no records of body mass index, which may influence depression outcome.

WIDER IMPLICATIONS OF THE FINDINGS

In Taiwan, younger PCOS patients (15-29 years), but not the middle-aged patients, have an increased risk of depression. Our findings provide vital information to patients, clinicians, the Taiwan Government and other developing Asian countries to improve the PCOS treatment strategies in the future. Routine screening for depression in PCOS patients may be implemented into the health practice.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported in part by the Taiwan Ministry of Health and Welfare Clinical Trial Center (MOHW108-TDU-B-212-133 004), China Medical University Hospital, Academia Sinica Stroke Biosignature Project (BM10701010021), MOST Clinical Trial Consortium for Stroke (MOST 107-2321-B-039 -004-), Tseng-Lien Lin Foundation, Taichung, Taiwan and Katsuzo and Kiyo Aoshima Memorial Funds, Japan. No competing interest existed.

TRIAL REGISTRATION NUMBER

N/A.

Risk of psychological burden in polycystic ovary syndrome: A case control study in Riyadh, Saudi Arabia

BACKGROUND

While increased risk of psychiatric burden in patients with polycystic ovarian syndrome (PCOS) is reported in the literature, there is dearth of reports from Saudi Arabia on occurrence of psychological burden in women with PCOS. This study aimed to compare the sociodemographic and clinical features of PCOS cases with non-PCOS control and explore the prevalence of depression, anxiety and stress in PCOS and non-PCOS women.

MATERIALS AND METHODS

This is a case-control study carried out in PSMMC, Riyadh, Saudi Arabia from March 2019 to June 2019. Samples were recruited by convenience sampling and simple random method in PCOS cases (82) and control group (85), respectively. Depression, Anxiety and Stress Scale-21 (DASS-21) was used to measure the presence of psychological burden.

RESULTS

High percentage of participants were in an age group of 26-35 years (51%) and university educated (64%). Significantly (P = 0.001) high proportion of PCOS cases found with irregular menses, hirsutism, infertility and presence of acne (P = 0.001) when compared to control group. The odds of developing depression (P = 0.006), anxiety (P = 0.028) and stress (P = 0.000) was significantly higher in PCOS cases compared to control participants. Further, among the three parameters, the occurrence of stress (odds ratio, OR=10.45) in women with PCOS was more common than depression (OR=2.675) and anxiety (OR=2.056).

LIMITATIONS

Recall bias and inclusion of only one hospital.

CONCLUSION

In conclusion, most of the PCOS cases had stress, depression and anxiety compared to control group. Meeting the psychological need of the PCOS women will help in improving their quality of life.

Comorbid depression in medical diseases

Depression is one of the most common comorbidities of many chronic medical diseases including cancer and cardiovascular, metabolic, inflammatory and neurological disorders. Indeed, the prevalence of depression in these patient groups is often substantially higher than in the general population, and depression accounts for a substantial part of the psychosocial burden of these disorders. Many factors can contribute to the occurrence of comorbid depression, such as shared genetic factors, converging biological pathways, social factors, health behaviours and psychological factors. Diagnosis of depression in patients with a medical disorder can be particularly challenging owing to symptomatic overlap. Although pharmacological and psychological treatments can be effective, adjustments may need to be made for patients with a comorbid medical disorder. In addition, symptoms or treatments of medical disorders may interfere with the treatment of depression. Conversely, symptoms of depression may decrease adherence to treatment of both disorders. Thus, comprehensive treatment plans are necessary to optimize care.

Hormonal Treatments for Major Depressive Disorder: State of the Art

Major depressive disorder is a common psychiatric disorder associated with marked suffering, morbidity, mortality, and cost. The World Health Organization projects that by 2030, major depression will be the leading cause of disease burden worldwide. While numerous treatments for major depression exist, many patients do not respond adequately to traditional antidepressants. Thus, more effective treatments for major depression are needed, and targeting certain hormonal systems is a conceptually based approach that has shown promise in the treatment of this disorder. A number of hormones and hormone-manipulating compounds have been evaluated as monotherapies or adjunctive treatments for major depression, with therapeutic actions attributable not only to the modulation of endocrine systems in the periphery but also to the CNS effects of hormones on non-endocrine brain circuitry. The authors describe the physiology of the hypothalamic-pituitary-adrenal (HPA), hypothalamic-pituitary thyroid (HPT), and hypothalamic-pituitary-gonadal (HPG) axes and review the evidence for selected hormone-based interventions for the treatment of depression in order to provide an update on the state of this field for clinicians and researchers. The review focuses on the HPA axis-based interventions of corticotropin-releasing factor antagonists and the glucocorticoid receptor antagonist mifepristone, the HPT axis-based treatments of thyroid hormones (T₃ and T₄), and the HPG axis-based treatments of estrogen replacement therapy, the progesterone derivative allopregnanolone, and testosterone. While some treatments have largely failed to translate from preclinical studies, others have shown promising initial results and represent active fields of study in the search for novel effective treatments for major depression.

Health-related quality of life in women with polycystic ovary syndrome attending to a tertiary hospital in Southeastern Spain: a case-control study

BACKGROUND

Polycystic ovary syndrome (PCOS) is a chronic condition with symptoms affecting many women at reproductive age and evaluating their health-related quality of Life (HRQoL) is an important issue. Moreover, differences in the HRQoL between women with different PCOS phenotypes have never been analyzed. Therefore, the aim of our study was to compare the HRQoL between women with PCOS -and its phenotypes- and controls attending to a tertiary hospital.

METHODS

A group of 117 women with PCOS and 153 controls were studied between 2014 and 2016. Controls were women without PCOS attending the gynecological outpatient clinic for routine examinations. Cases were women attending the same setting and diagnosed with PCOS. PCOS diagnose was performed following the Rotterdam Criteria and women were further classified by anovulatory or ovulatory phenotypic subtype. Women underwent physical and gynecological exams and completed health questionnaires including the Short Form-12v2. Eight scales and two component summary scores [Physical (PCS) and Mental (MCS), respectively] were calculated. Bivariate and multivariate analyses were performed to assess differences in HRQoL between women with PCOS and controls.

RESULTS

All women with PCOS and anovulatory PCOS presented lower score in PCS compared to controls [mean (95%CI): 53.7 (52.5-54.9) and 52.9 (51.5-54.4) vs. 55.8 (54.8-56.8); p-values< 0.01], as well as lower scores for five out of the eight scales (p-values < 0.05) after adjusting by age, body mass index, infertility, educational level and current occupation. No significant differences were observed for the MCS between women with or without PCOS or its phenotypic subtypes.

CONCLUSIONS

HRQoL was significantly decreased in adult women with PCOS and its anovulatory phenotype compared to controls attending the outpatient clinic of a tertiary hospital. These results may have implications for the clinical practice and suggest the need for specific interventions in women with PCOS.

Lifestyle management of polycystic ovary syndrome: a single-center study in Bosnia and Herzegovina

BACKGROUND

Polycystic ovary syndrome (PCOS) is a complex endocrinopathy affecting up to 20% of pre-menopausal women. The most recent international guidelines set lifestyle management as the cornerstone of the PCOS treatment. Still, there is a paucity of data on the implementation of lifestyle management in clinical practice. This cross-sectional study aimed to explore physicians-reported practices in PCOS lifestyle management in the Sarajevo Canton, Bosnia and Herzegovina (BiH). The profession of dietetics is not legally recognized in BiH. Nutritional interventions in health promotion and disease treatment are provided by medical professionals.

METHODS

Data were collected by a paper-based questionnaire distributed during March-May 2018 in the Public Institution Health Centre of Sarajevo Canton.

RESULTS

Forty-six physicians (response rate of 80.7%) completed the questionnaire. An initial treatment plan based solely on lifestyle measures (diet + physical activity), as recommended by current guidelines was reported by 34.8% of physicians. Although dietary interventions were rated as highly relevant in PCOS management by the vast majority of physicians, only one-half reported recording patients' adherence and 45.7% of physicians were unsure of the effectiveness of the lifestyle interventions in their patients.

CONCLUSION

PCOS lifestyle management in the study setting is sub-optimal. Additional education on effective PCOS lifestyle management strategies would be beneficial, especially for physicians with less than 15 years in practice. Possible obstacles to better physicians' engagement in PCOS lifestyle management should be further investigated.

Animal Models to Understand the Etiology and Pathophysiology of Polycystic Ovary Syndrome

More than 1 out of 10 women worldwide are diagnosed with polycystic ovary syndrome (PCOS), the leading cause of female reproductive and metabolic dysfunction. Despite its high prevalence, PCOS and its accompanying morbidities are likely underdiagnosed, averaging > 2 years and 3 physicians before women are diagnosed. Although it has been intensively researched, the underlying cause(s) of PCOS have yet to be defined. In order to understand PCOS pathophysiology, its developmental origins, and how to predict and prevent PCOS onset, there is an urgent need for safe and effective markers and treatments. In this review, we detail which animal models are more suitable for contributing to our understanding of the etiology and pathophysiology of PCOS. We summarize and highlight advantages and limitations of hormonal or genetic manipulation of animal models, as well as of naturally occurring PCOS-like females.

Exploratory study of a screening measure for polycystic ovarian syndrome, quality of life assessment, and neuropsychological evaluation

Background

The universally adopted 2018 PCOS medical diagnostic and treatment guidelines for Polycystic Ovarian Syndrome (PCOS) cites the need for a brief screening measure that can be easily administered in the clinical care setting. We evaluate a 12-item questionnaire emphasizing the medical symptoms of PCOS with a group of women with PCOS as well as comparison samples of college women not diagnosed with PCOS.

Method

Of 120 undergraduate psychology women 18 to 41 years of age, 86 screened negative on a 12-item PCOS symptoms inventory. They were compared to a group of PCOS patients diagnosed medically in a manner consistent with the Teede et al. (2018) evidence-based diagnostic guidelines. The screen-positive, screen-negative, and PCOS-confirmed groups were compared on the PCOS Quality-of-Life (QoL) questionnaire, Zung Self-Rating Depression Scale (ZDS), Spielberg State-Trait Anxiety Inventory (STAI), Fatigue Symptom Inventory (FSI), Spiritual well-being and Spiritual Beliefs Inventories, the computerized Automated Neuropsychological Assessment Metric (ANAM) battery, and an experimental tachistoscopic Bilateral Perceptual Asymmetries Letter and Dots Matching Bilateral Field Advantage (BFA) test (to evaluate the effects of early brain androgenization possible from PCOS). For each questionnaire and neuropsychological performance principal outcome, the Linear Mixed Effects (LME) model was employed to evaluate the predictive significance of demographic characteristics and group membership (confirmed cases, screen negative and screen positive cases) for these outcomes.

Results

The PCOS-confirmed women scored more poorly than the screen-negative (reference) and screen-positive groups on all the measures of physical, emotional, social, and spiritual well-being measures. On the ANAM neuropsychological battery, PCOS-confirmed women did more poorly on Sternberg Memory and Stimulus Response throughput measures. They also had slower correct response speed for both the unilateral and bilateral dot- and letter-matching tachistoscopic stimulus presentations. However, the bilateral field advantage throughput performance ratio did not differ among groups, which is a global measure of bilateral versus unilateral brain/behavior asymmetries.

Conclusion

PCOS screening can be a feasible and important part of women’s healthcare. PCOS-confirmed women should receive not only the medical standard of care from the 2018 guidelines, but also comprehensive psychosocial and neurocognitive support to enhance their quality of life.

New insights into anti-Müllerian hormone role in the hypothalamic-pituitary-gonadal axis and neuroendocrine development

Research into the physiological actions of anti-Müllerian hormone (AMH) has rapidly expanded from its classical role in male sexual differentiation to the regulation of ovarian function, routine clinical use in reproductive health and potential use as a biomarker in the diagnosis of polycystic ovary syndrome (PCOS). During the past 10 years, the notion that AMH could act exclusively at gonadal levels has undergone another paradigm shift as several exciting studies reported unforeseen AMH actions throughout the Hypothalamic–Pituitary–Gonadal (HPG) axis. In this review, we will focus on these findings reporting novel AMH actions across the HPG axis and we will discuss their potential impact and significance to better understand human reproductive disorders characterized by either developmental alterations of neuroendocrine circuits regulating fertility and/or alterations of their function in adult life. Finally, we will summarize recent preclinical studies suggesting that elevated levels of AMH may potentially be a contributing factor to the central pathophysiology of PCOS and other reproductive diseases.

Mini-Review on the Possible Interconnections between the Gut-Brain Axis and the Infertility-Related Neuropsychiatric Comorbidities

Both the gut-brain axis (GBA) and the hypothalamic–pituitary–adrenal (HPA) axis remain an intriguing yet obscure network with a strong influence over other systems of organs. Recent reports have sought to describe the multitude of harmful stressors that may impact the HPA axis along with the interconnections between these. This has improved our knowledge of how the underlying mechanisms working to establish homeostasis are affected. A disruption to the HPA axis can amplify the chances of gastrointestinal deficiencies, whilst also increasing the risk of a wide spectrum of neuropsychiatric disorders. Thus, the influence of microorganisms found throughout the digestive tract possess the ability to affect both physiology and behaviour by triggering responses, which may be unfavourable. This is sometimes the case in of infertility. Numerous supplements have been formulated with the intention of rebalancing the gut microflora. Accordingly, the gut flora may alter the pharmacokinetics of drugs used as part of fertility treatments, potentially exacerbating the predisposition for various neurological disorders, regardless of the age and gender.

Psychological Experiences of Adolescent Girls with Polycystic Ovary Syndrome: A Qualitative Study

Background

Polycystic Ovary Syndrome (PCOS) is one of the most common endocrine disorders in the women of reproductive age. In addition to multiple physical problems, this syndrome has many psychological manifestations. Thus, the present research was conducted aimed at investigating the psychological experiences of the adolescent girls with PCOS.

Materials and Methods

This research was conducted using the qualitative content analysis method. A total of 18 adolescent girls with PCOS and 15 healthcare providers were selected by the purposive sampling method. The data were collected through in-depth interviews, focus group discussions, and field notes, which were analyzed using the conventional content analysis method.

Results

After analyzing, three main categories and seven subcategories were extracted. First, the psychological experiences related to the disease symptoms had three subcategories: "psychological experiences related to hirsutism, alopecia, and acne," "psychological experiences related to obesity," and "psychological experiences related to menstrual disorders." Second, the psychological experiences related to disease complications had two subcategories: "psychological experiences related to infertility" and "psychological experiences related to disease progression." Third, the psychological experiences related to treatment of the disease had two subcategories: "psychological experiences related to prolongation of the treatment and uncertain fate of the disease" and "psychological experiences related to the complications of the medical treatment."

Conclusions

Results of the study showed that adolescent girls with PCOS were exposed to multiple concerns endangering their psychological health. Therefore, it is recommended to provide adequate and appropriate information about the disease and its consequences, as well as psychosocial supports and regular assessment of psychological state by the team of healthcare providers in the adolescent girls with PCOS.

Depression in Girls With Obesity and Polycystic Ovary Syndrome and/or Type 2 Diabetes

OBJECTIVES

Polycystic ovary syndrome (PCOS) is a common reproductive/metabolic condition associated with obesity, type 2 diabetes (T2D) and depression in adult women. Depression in adults is related to PCOS dermatologic manifestations. Adolescents with obesity with or without T2D have elevated depression symptoms, but data from youth with PCOS and obesity with/without T2D are limited.

METHODS

Our study included girls, aged 11 to 17 years, with obesity and PCOS, PCOS+T2D or T2D, who were newly seen in an obesity complications clinic after March 2016. All participants had Center for Epidemiologic Studies-Depression (CES-D, 20 items) scores obtained within 6 months of PCOS or T2D diagnosis. Data on history of psychiatric diagnosis and treatment, metabolic syndrome and severity of acne and hirsutism were collected through chart review.

RESULTS

One hundred five girls (47 with PCOS, 14 with PCOS+T2D, 44 with T2D) had similar age (15±1.8 years) and body mass index z scores (2.2±0.4). CES-D scores ≥16, indicating elevated depression symptoms, and CES-D scores ≥24, indicating severe depression symptoms, were observed in 60% and 30% of girls with PCOS, 78% and 71% of those with PCOS+T2D and 39% and 21% of those with T2D, respectively (p<0.0001 for both cutpoints). A higher CES-D score was not associated with severity of hirsutism or acne (p>0.05 for both).

CONCLUSIONS

Adolescents with PCOS and obesity have higher rates of elevated depression symptoms compared with girls with T2D, which is not related to worse dermatologic symptoms. Because depression may impact both PCOS and T2D management and adherence to therapy, greater efforts should be made to screen for and address mental health in adolescents with PCOS and obesity, especially if T2D is present.

Population-based Data at Ages 31 and 46 Show Decreased HRQoL and Life Satisfaction in Women with PCOS Symptoms

CONTEXT

Polycystic ovary syndrome (PCOS) is associated with decreased health-related quality of life (HRQoL), but longitudinal data beyond the reproductive years are lacking, and the impact of isolated PCOS symptoms is unclear.

OBJECTIVE

To study generic HRQoL using the 15D questionnaire, life satisfaction, and self-reported health status in women with PCOS symptoms at ages 31 and 46 years.

DESIGN

A longitudinal assessment using the Northern Finland Birth Cohort 1966.

SETTING

General community.

PARTICIPANTS

The 15D data were available for women reporting isolated oligo-amenorrhea (OA; at age 31 years, 214; and 46 years, 211), isolated hirsutism (H; 31 years, 211; and 46 years, 216), OA + H (PCOS; 31 years, 74; and 46 years, 75), or no PCOS symptoms (controls; 31 years, 1382; and 46 years, 1412). Data for life satisfaction and current health status were available for OA (31 years, 329; and 46 years, 247), H (31 years, 323; and 46 years, 238), PCOS (31 years, 125; and 46 years, 86), control (31 years, 2182; and 46 years, 1613) groups.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

15D HRQoL, questionnaires on life satisfaction, and self-reported health status.

RESULTS

HRQoL was lower at ages 31 and 46 in women with PCOS or H than in the controls. PCOS was an independent risk factor for low HRQoL, and the decrease in HRQoL in PCOS was similar to that of women with other chronic conditions, such as asthma, migraine, rheumatoid arthritis, and depression. The risk for low HRQoL in PCOS remained significant after adjusting for body mass index, hyperandrogenism, and socioeconomic status. Mental distress was the strongest contributing factor to HRQoL. PCOS was also associated with a risk for low life satisfaction and a 4-fold risk for reporting a poor health status.

CONCLUSIONS

Women with PCOS present with low HRQoL, decreased life satisfaction, and a poorer self-reported health status up to their late reproductive years. Assessments and interventions aiming to improve HRQoL in PCOS should be targeted beyond the fertile age.

Long-term effects of a three-component lifestyle intervention on emotional well-being in women with Polycystic Ovary Syndrome (PCOS): A secondary analysis of a randomized controlled trial

Many women with Polycystic Ovary Syndrome (PCOS) report high depression rates. The relationship between PCOS and these high depression rates is unclear. Two-component lifestyle interventions have revealed short-term effects on depression scores in this group of women. In general, 3-component interventions including diet, exercise, and cognitive behavioral therapy (CBT) are more effective in the long-term to improve emotional well-being. This has not yet been studied in women with PCOS. This study examined the effect of 20 CBT lifestyle (LS) sessions combined with a healthy diet and physical therapy with or without 9 months additional feedback through Short Message Service (SMS) via mobile phone, compared to care as usual (CAU, involving advice to lose weight). In this secondary analysis, 155 women with PCOS and a BMI above 25 kg/m2 were eligible. Depression scores decreased significantly in the LS programme compared to CAU (P = 0.045). In both the LS programme without SMS (P = 0.036) and the LS programme with SMS (P = 0.011) depression scores decreased while no change was observed in CAU (P = 0.875). Self-esteem scores improved significantly in the LS programme compared to CAU (P = 0.027). No differences in body image scores were observed in LS participants compared to CAU (P = 0.087), although body image improved significantly in both the LS without SMS (P = 0.001) and with SMS (P = 0.008) study arms. We found no significant mediating role by androgens in the relationship between LS participants and emotional well-being. Only weight-loss mediated the relationship between LS and self-esteem. To conclude, a three-component lifestyle intervention programme with or without additional SMS resulted in significant improvements in depression and self-esteem compared to CAU, in women with PCOS, obesity, and a wish to achieve a pregnancy. Testosterone, androstenedione, DHEA, insulin, HOMA-IR, and cortisol did not mediate this effect. Weight loss mediated the effects on self-esteem but not on depression and body-image. This suggests that lifestyle treatment independent of weight loss can reduce depression and body-image, but both lifestyle treatment and weight loss can improve self-esteem. Thus, a three-component lifestyle intervention based on CBT could prove successful in improving mood in women with PCOS who are overweight or obese and attempting to become pregnant.

Overview of systematic reviews of non-pharmacological interventions in women with polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is a major contributor to subfertility, diabetes and cardiovascular disease in women. The role of non-pharmacological interventions to prevent these outcomes has been reported in many systematic reviews, but robust conclusions have not been made due to variations in the scope, quality and findings of these reviews.

OBJECTIVE AND RATIONALE

Our aim was to provide an overview of existing evidence on the effects of non-pharmacological interventions in women with PCOS on fertility and non-fertility outcomes by a review of existing systematic reviews.

SEARCH METHODS

We reviewed systematic reviews of randomized trials that have evaluated the effects of non-pharmacological interventions, such as lifestyle interventions, nutritional supplements or alternative medicine therapies in women with PCOS on fertility, endocrine, glycaemic and weight-related outcomes. We assessed the quality of systematic reviews with the AMSTAR tool, and reported the outcomes with regard to: fertility (live birth, clinical pregnancy, ovulation and menstrual cycle regularization); endocrine outcomes (Ferriman-Gallwey score, free androgen index, free testosterone and total testosterone levels); and glycaemic (fasting blood insulin, fasting blood glucose, homoeostatic model assessment) and weight-related (BMI) outcomes. We assessed the strength of evidence for significant outcomes as per the grading of recommendations assessment, development and evaluation (GRADE) system.

OUTCOMES

We found twelve eligible systematic reviews which included between three (143 women) and 27 randomized trials (2093 women). Four reviews assessed the effects of lifestyle interventions (diet, physical activity and/or behavioural interventions); four evaluated nutritional supplements (one each on n-acetylcysteine, omega-3 fatty acids, inositol and vitamin D); and four studied alternative medical therapies (Chinese herbal medicine and acupuncture). All of the included reviews were of high quality and scored between 8 and 11 with the AMSTAR tool (with a maximum score of 11).Randomized evidence is lacking for live birth rate. N-acetylcysteine, inositol and the addition of alternative medicine to ovulation induction agents show preliminary potential to improve fertility (odds ratios (OR) for clinical pregnancy rate range from 1.99 to 4.83). Lifestyle interventions show benefits in improving hirsutism (mean difference (MD): -1.01 to -1.19). Lifestyle interventions (MD: -1.10 to -2.02), inositol (MD: -2.1) and acupuncture (MD: -1.90 to -3.43) all show some evidence of improvement in glycaemic outcomes and there is some evidence of reduced BMI with lifestyle interventions (MD: -0.15 to -1.12). All of these outcomes scored either low or very low quality of evidence on the GRADE score.

WIDER IMPLICATIONS

Lifestyle interventions in women with PCOS appear to improve glycaemic results, androgenic symptoms and anthropometric outcomes. The role of inositol and N-acetylcysteine in women with PCOS needs further evaluation. Large primary trials on all interventions are needed for an agreed set of core outcomes.

Pioglitazone Metformin Complex Improves Polycystic Ovary Syndrome Comorbid Psychological Distress via Inhibiting NLRP3 Inflammasome Activation: A Prospective Clinical Study

Objective

This study aimed at investigating the therapeutic effect and mechanism of pioglitazone metformin complex preparation (PM) in polycystic ovary syndrome (PCOS) comorbid psychological distress.

Methods

Seventy-five patients with PCOS comorbid psychological distress were randomly allocated into the PM, metformin, and placebo groups. The primary efficacy measure was the change from baseline to week 12 on the Symptom Checklist 90-R (SCL-90-R) scores. NLRP3 inflammasome, IL-1β, IL-6, TNF-α, and biochemical parameters were determined at baseline and at week 12. The participants were required to meet the criteria for PCOS (Rotterdam, NIH) and psychological distress (any factor scores of SCL − 90 − R > 2).

Results

The participants had significantly high scores on the SCL-90-R scales of anxiety and depression. PM significantly decreased anxiety and depression symptom severity (from 2.31 ± 0.75 to 1.65 ± 0.38, p < 0.001, and from 2.08 ± 0.74 to 1.61 ± 0.46, p = 0.010, at week 12, respectively). PM significantly decreased the expression of NRPL3 and caspase-1. Patients in the PM group experienced a significant reduction in IL-1β (from 98.42 ± 14.38 to 71.76 ± 13.66, p = 0.02), IL-6 (from 87.51 ± 8.74 to 71.98 ± 15.87, p = 0.02), and TNF-α (from 395.33 ± 88.55 to 281.98 ± 85.69, p = 0.04). PM was superior to metformin in reducing total testosterone (2.24 ± 0.74 versus 3.06 ± 0.83, p = 0.024, at week 12).

Conclusions

This study is the first to reveal that PM alleviates psychological distress via inhibiting NLRP3 inflammasome and improves several markers, including total testosterone.

Exercise and insulin resistance in PCOS: muscle insulin signalling and fibrosis

OBJECTIVE

Mechanisms of insulin resistance in polycystic ovary syndrome (PCOS) remain ill defined, contributing to sub-optimal therapies. Recognising skeletal muscle plays a key role in glucose homeostasis we investigated early insulin signalling, its association with aberrant transforming growth factor β (TGFβ)-regulated tissue fibrosis. We also explored the impact of aerobic exercise on these molecular pathways.

METHODS

A secondary analysis from a cross-sectional study was undertaken in women with (n = 30) or without (n = 29) PCOS across lean and overweight BMIs. A subset of participants with (n = 8) or without (n = 8) PCOS who were overweight completed 12 weeks of aerobic exercise training. Muscle was sampled before and 30 min into a euglycaemic-hyperinsulinaemic clamp pre and post training.

RESULTS

We found reduced signalling in PCOS of mechanistic target of rapamycin (mTOR). Exercise training augmented but did not completely rescue this signalling defect in women with PCOS. Genes in the TGFβ signalling network were upregulated in skeletal muscle in the overweight women with PCOS but were unresponsive to exercise training except for genes encoding LOX, collagen 1 and 3.

CONCLUSIONS

We provide new insights into defects in early insulin signalling, tissue fibrosis, and hyperandrogenism in PCOS-specific insulin resistance in lean and overweight women. PCOS-specific insulin signalling defects were isolated to mTOR, while gene expression implicated TGFβ ligand regulating a fibrosis in the PCOS-obesity synergy in insulin resistance and altered responses to exercise. Interestingly, there was little evidence for hyperandrogenism as a mechanism for insulin resistance.