Polycystic ovarian syndrome, insulin resistance and thickness of the endometrium

Risk of endometrial cancer in patients with polycystic ovarian syndrome: A meta‑analysis

While existing literature suggests an association between polycystic ovarian syndrome (PCOS) and endometrial cancer, the sparsity and inconsistency of current evidence indicates a lack of clarity regarding the exact strength of this association. It also remains uncertain whether the degree of risk of disease is affected by confounding factors, such as age and body mass index (BMI). The present meta-analysis is aimed to quantify the risk of endometrial cancer in female subjects with PCOS compared to those without PCOS. PubMed, MEDLINE, EMBASE, Scopus and Cochrane were searched from inception to October 31, 2022, to identify peer-reviewed case-control, cohort and cross-sectional studies that assessed the association between endometrial cancer and PCOS and contained original data. Two researchers independently extracted data and performed quality assessment using the Newcastle-Ottawa criteria. Pooled odds ratios (ORs) were calculated using the random-effect model and inverse variance. The degree of heterogeneity was assessed using I² statistics. A total of 10 relevant studies were identified and included in the meta-analysis (comprising 12,248 female patients with PCOS and 54,120 controls). Females with PCOS had a significantly increased odds of developing endometrial cancer as compared to those without PCOS [OR, 4.07; 95% confidence interval (CI), 2.13-7.78; P<0.0001]. When postmenopausal subjects (age, >54 years) were excluded from the meta-analysis, the odds increased further (OR, 5.14; 95% CI, 3.22-8.21; P<0.00001). Patients with PCOS are up to 5 times more likely to develop endometrial cancer compared to those without PCOS. Larger, prospective studies that are well-controlled for confounding factors, such as BMI, are required.

Evaluation of the Association of Endometrial Thickness, Insulin Resistance, and Menstrual Patterns in Adolescent Females with Polycystic Ovarian Syndrome

STUDY OBJECTIVE

To evaluate endometrial stripe (EMS) thickness and its association with menstrual pattern and insulin resistance in adolescent females with or at risk for polycystic ovarian syndrome (PCOS) METHODS: This was a retrospective case-control study of adolescent females ranging between 12 and 21 years old evaluated in the Adolescent Gynecology & Endocrinology Clinic (AGEC) at a tertiary children's hospital between 2017 and 2021. Transabdominal pelvic ultrasound (US) was obtained for evaluation of PCOS or acute pelvic pain. Unadjusted comparisons were performed between imaging measurements in the PCOS and control (girls without PCOS with acute pelvic pain) groups, as well as analysis of the PCOS group adjusted for age, body mass index, race, and biochemical values. This study was approved by the Institutional Review Board.

RESULTS

In our study, 54 subjects met the inclusion criteria for the PCOS group and 42 for the control group. EMS thickness was thinner in the PCOS group than in the control (0.55 ± 0.31 cm vs 0.70 ± 0.23 cm; P < .001). There was no difference in EMS thickness in the PCOS group when stratified by intermenstrual interval, insulin resistance, and other biochemical factors.

CONCLUSION

Our findings support recommendations by the 2018 International Guidelines to avoid use of US for the establishment of PCOS diagnosis in adolescents. These results highlight the unique pathophysiology of adolescent PCOS in contrast to PCOS in adult women. Further large-scale prospective studies are needed to understand the role of EMS thickness as a prognostic marker in adolescent PCOS.

The impact of anti-Müllerian hormone on endometrial thickness in gonadotropin stimulation/intrauterine insemination cycles: is there an effect on pregnancy outcomes?

PURPOSE

To study the association, if any, between anti-Müllerian hormone (AMH) and pre-ovulatory endometrial thickness (ET) in gonadotropin/intrauterine insemination (IUI) cycles.

METHODS

This retrospective cohort study included a total of 964 patients undergoing 1926 gonadotropin/IUI cycles at an academic fertility center. Primary outcome measure was the association between serum AMH and measured ET on the day of and the day before human chorionic gonadotropin hormone (hCG) ovulation trigger. The effect of a model combining AMH and ET on early pregnancy outcomes was a secondary measure.

RESULTS

In 52.8% of cycles, ET was last assessed and recorded on the day of hCG administration, while in the remaining 47.2% on the day prior to trigger. In unadjusted regression models, AMH was weakly correlated with ET on hCG trigger day [bAMH (95%CI) = 0.032 (- 0.008, 0.070), p = 0.015]. When adjusting for potential confounders, the positive correlation became significant [0.051 (0.006, 0.102), p = 0.047]. Similar findings were observed when assessing the correlation between AMH and ET on the day prior to hCG trigger. ET was non-significantly associated with the odds of clinical pregnancy, when adjusting for potential confounders, except for when restricting the analysis to couples with idiopathic infertility [OR (95%CI), p-value: 0.787 (0.623, 0.993), 0.044].

CONCLUSION

Our findings support an effect of serum AMH on endometrial development in gonadotropin induced cycles, even when adjusting for the diagnosis of PCOS. ET was not associated with the odds of achieving a clinical pregnancy, except for couples with idiopathic infertility.

Exploring the Dominant Features and Data-driven Detection of Polycystic Ovary Syndrome through Modified Stacking Ensemble Machine Learning Technique

Polycystic ovary syndrome (PCOS) is the most frequent endocrinological anomaly in reproductive women that causes persistent hormonal secretion disruption, leading to the formation of numerous cysts within the ovaries and serious health complications. But the real-world clinical detection technique for PCOS is very critical since the accuracy of interpretations being substantially dependent on the physician's expertise. Thus, an artificially intelligent PCOS prediction model might be a feasible additional technique to the error prone and time-consuming diagnostic technique. In this study, a modified ensemble machine learning (ML) classification approach is proposed utilizing state-of-the-art stacking technique for PCOS identification with patients' symptom data; employing five traditional ML models as base learners and then one bagging or boosting ensemble ML model as the meta-learner of the stacked model. Furthermore, three distinct types of feature selection strategies are applied to pick different sets of features with varied numbers and combinations of attributes. To evaluate and explore the dominant features necessary for predicting PCOS, the proposed technique with five variety of models and other ten types of classifiers is trained, tested and assessed utilizing different feature sets. As outcomes, the proposed stacking ensemble technique significantly enhances the accuracy in comparison to the other existing ML based techniques in case of all varieties of feature sets. However, among various models investigated to categorize PCOS and non-PCOS patients, the stacking ensemble model with 'Gradient Boosting' classifier as meta learner outperforms others with 95.7% accuracy while utilizing the top 25 features selected using Principal Component Analysis (PCA) feature selection technique.

Hyperandrogenism and Polycystic ovary syndrome: Effects in pregnancy and offspring development

Polycystic ovary syndrome (PCOS) is one of the major endocrine disorders affecting women of reproductive age. Its etiology remains unclear. It is suggested that environmental factors, and particularly the intrauterine environment, play key roles in PCOS development. Besides the role of androgens in PCOS pathogenesis, exposure to endocrine disruptors, as is Bisphenol A, could also contribute to its development. Although PCOS is considered one of the leading causes of ovarian infertility, many PCOS patients can get pregnant. Some of them by natural conception and others by assisted reproductive technique treatments. As hyperandrogenism (one of PCOS main features) affects ovarian and uterine functions, PCOS women, despite reaching pregnancy, could present high-risk pregnancies, including implantation failure, an increased risk of gestational diabetes, preeclampsia, and preterm birth. Moreover, hyperandrogenism may also be maintained in these women during pregnancy. Therefore, as an altered uterine milieu, including hormonal imbalance, could affect the developing organisms, monitoring these patients throughout pregnancy and their offspring development is highly relevant. The present review focuses on the impact of androgenism and PCOS on fertility issues and pregnancy-related outcomes and offspring development. The evidence suggests that the increased risk of pregnancy complications and adverse offspring outcomes of PCOS women would be due to the factors involved in the syndrome pathogenesis and the related co-morbidities. A better understanding of the involved mechanisms is still needed and could contribute to a better management of these women and their offspring. This article is categorized under: Reproductive System Diseases > Molecular and Cellular Physiology Reproductive System Diseases > Environmental Factors.

DNA methylation of AMHRII and INSR gene is associated with the pathogenesis of Polycystic Ovary Syndrome (PCOS)

BACKGROUND:

Polycystic ovary syndrome (PCOS) is a common gynecologic endocrinopathy, characterized by menstrual disorders, ovulation disorders, polycystic ovary, hyperandrogen syndrome and insulin resistance. At present, the etiology and exact pathogenesis of PCOS are still unclear. Anti-Müllerian hormone is a local regulator secreted by ovarian granulosa cells, and participates in regulating the occurrence and development of PCOS. Insulin resistance is another important pathophysiological feature of PCOS. Although the expression of anti-müllerian hormone receptor (AMHR) and insulin receptor (INSR) in PCOS have been previously reported, the DNA methylation of the genes have not been well characterized.

OBJECTIVE:

To study AMHR II/INSR and its role in gene methylation in Ovarian and endometrial pathology of PCOS subjects.

METHODS:

We recruited seventy-five women with PCOS as cases and twenty healthy women as controls, using immunohistochemical method, study localization, distribution and expression of MHRII/INSR in ovary and endometrium and then discover the correlation of AMHRII/INSR gene methylation.

RESULTS:

Different clinical features in PCOS group AMHRII gene methylation level and insulin resistance relations have significant differences (r= 0.532, P= 0.000); INSR gene methylation level and insulin resistance relations have significant differences (r= 0.281, P= 0.03).

CONCLUSIONS:

The analysis of DNA methylation suggested that methylation of AMHRII and INSR genes was associated with basic clinical characteristics and insulin resistance of PCOS. These results provide evidence for AMHRII and INSR genes, and their methylation levels are intimately associated with the pathogenesis of PCOS.

Clinical and biochemical discriminants between functional hypothalamic amenorrhoea (FHA) and polycystic ovary syndrome (PCOS)

BACKGROUND

Secondary oligo/amenorrhoea occurs in 3%-5% of women of reproductive age. The two most common causes are polycystic ovary syndrome (PCOS) (2%-13%) and functional hypothalamic amenorrhoea (FHA) (1%-2%). Whilst both conditions have distinct pathophysiology and their diagnosis is supported by guidelines, in practice, differentiating these two common causes of menstrual disturbance is challenging. Moreover, both diagnoses are qualified by the need to first exclude other causes of menstrual disturbance.

AIM

To review clinical, biochemical and radiological parameters that could aid the clinician in distinguishing PCOS and FHA as a cause of menstrual disturbance.

RESULTS

FHA is uncommon in women with BMI > 24 kg/m² , whereas both PCOS and FHA can occur in women with lower BMIs. AMH levels are markedly elevated in PCOS; however, milder increases may also be observed in FHA. Likewise, polycystic ovarian morphology (PCOM) is more frequently observed in FHA than in healthy women. Features that are differentially altered between PCOS and FHA include LH, androgen, insulin, AMH and SHBG levels, endometrial thickness and cortisol response to CRH. Other promising diagnostic tests with the potential to distinguish these two conditions pending further study include assessment of 5-alpha-reductase activity, leptin, INSL3, kisspeptin and inhibin B levels.

CONCLUSION

Further data directly comparing the discriminatory potential of these markers to differentiate PCOS and FHA in women with secondary amenorrhoea would be of value in defining an objective probability for PCOS or FHA diagnosis.

Decreased Endometrial Thickness Is Associated With Higher Risk of Neonatal Complications in Women With Polycystic Ovary Syndrome

PURPOSE

To evaluate the association of endometrial thickness (EMT) with obstetric and neonatal outcomes in women with polycystic ovary syndrome (PCOS).

METHODS

A total of 1755 subfertile PCOS women with singleton livebirths after frozen-thawed embryo transfer were included between January 2009 and September 2019. Main obstetric outcomes were hypertensive disorders in pregnancy and abnormal placentation. Main neonatal outcomes were preterm birth (PTB), low birthweight (LBW) and small-for-gestational age (SGA). Crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were estimated by univariate and multivariate logistic regression analyses.

RESULTS

Each millimeter decrease in EMT was related to a 9% (adjusted OR 1.09, 95% CI 1.00-1.19; P = 0.053), 14% (adjusted OR 1.14, 95% CI 1.02-1.28; P = 0.002) and 22% (adjusted OR 1.22, 95% CI 1.07-1.38; P = 0.003) higher risk of PTB, LBW and SGA, respectively. Compared to women with EMT >13 mm, women with EMT ≤8 mm also had significantly higher risk of PTB (adjusted OR 3.79, 95% CI 1.53-9.39; P = 0.004), LBW (adjusted OR 4.33, 95% CI 1.39-13.50; P = 0.012) and SGA (adjusted OR 6.38, 95% CI 1.78-22.83; P = 0.004). These associations remained consistent in further subgroup analysis by endometrial preparation regimen and in sensitivity analyses among nulligravida women or women without adverse obstetric outcomes. No significant differences were found in the incidence of several pregnancy complications across EMT categories.

CONCLUSION

Decreased EMT was independently associated with increased risk of PTB, LBW and SGA in women with PCOS.

The Menstrual Disturbances in Endocrine Disorders: A Narrative Review

CONTEXT

Menstrual cycle is considered the fifth vital sign among women. This study aimed to summarize the menstrual disturbances in different endocrine disorders.

EVIDENCE ACQUISITION

In this narrative review, relevant studies (up to December 2019) were searched based on the MeSH keywords diabetes, polycystic ovary syndrome, Cushing's syndrome, thyroid dysfunction, hyperprolactinemia, menstrual cycle, uterine bleeding, and menstruation. Databases used for searching articles included Google Scholar, Scopus, PubMed, and Web of science for observational, experimental, and review studies.

RESULTS

Endocrine disorders trigger the onset of menstrual disturbance across the reproductive lifespan of women. Endocrine glands (pituitary, thyroid, pancreas, adrenal, and ovaries) have a functional role in endocrine regulation of the menstrual cycle. According to available evidence, oligomenorrhea (cycles longer than 35 days) is the most common menstrual disturbance among endocrine disorders (thyrotoxicosis, hypothyroidism, polycystic ovary syndrome, Cushing's syndrome, and diabetes). Complex endocrine pathways play an essential role in a women's menstrual calendar.

CONCLUSIONS

The menstrual cycle length and amount of bleeding can be indicative of endocrine disorders. Further studies are needed to identify the unknowns about the association between endocrine disorders and the menstrual cycle.

Baseline Endometrial Thickness or Endometrial Thickness Change in Response to Estrogen Is Not Predictive of Frozen Embryo Transfer Success in Medicated Cycles

There is some consensus that endometrial thickness (EMT) needs to be at least 7 mm on day of embryo transfer. However, the predictive role of baseline EMT and EMT change in response to estrogen is largely unknown. The objective of this study was to evaluate the role of endometrial thickness in frozen embryo transfer (FET) cycles. We analyzed the association of baseline endometrial thickness (EMTb-Day 3 of cycle) and endometrial thickness change (EMTΔ-from baseline to start of progesterone supplementation) with FET success in 121 cycles. We also investigated whether baseline estradiol levels and body mass index (BMI) are associated with EMTb. No difference was observed in EMTb and EMTΔ in cycles resulting in clinical pregnancy compared to unsuccessful transfers (5.1 ± 2.2 mm vs 5.0 ± 1.9 mm; p = 0.92, and 4.7 ± 2.4 mm vs. 4.4 ± 2.4 mm; p = 0.56). When 7 mm cut-off was used, endometrial thickness on the day of start of progesterone supplementation (EMTp) was also not different between groups (9.8 ± 2.9 mm vs. 9.4 ± 2.5 mm; p = 0.50). Multivariable logistic regression models did not demonstrate any predictive value of EMTb, EMTp, or EMTΔ in predicting success of FET cycles (p = 0.92, p = 0.80, and p = 0.84, respectively). There was no significant correlation between EMTb and baseline estradiol levels (r = -0.001; p = 0.985). BMI showed statistically significant weak positive linear relationship with EMTb (r = +0.29; p = 0.002). Our study did not demonstrate any significant relationship between baseline endometrial thickness or endometrial thickness change and clinical pregnancy rates in frozen embryo transfer cycles. Significant positive linear relationship of BMI with baseline endometrial thickness, despite no correlation between baseline estradiol and EMTb, points to the role of possible other mechanism affecting EMT besides estradiol in obese patients.

Elevated insulin levels compromise endometrial decidualization in mice with decrease in uterine apoptosis in early-stage pregnancy

Women with hyperinsulinism and insulin resistance have reduced fertility, but the underlying mechanism is still poorly understood. Aberrant endometrial decidualization in early pregnancy was linked to pregnancy complications. In this study, we aimed to test whether elevated insulin levels compromise decidualization in early-stage pregnancy. C57BL/6J mice in high insulin-exposed group were given a subcutaneous injection of recombinant insulin at a concentration of 0.05 IU daily. During decidualization in early pregnancy, serum levels of insulin, E2, P4, LH, FSH and blood glucose were significantly altered in mice treated with high insulin levels. The number of embryo implantation sites and endometrial decidual markers BMP2, ER, PR was significantly decreased by high insulin levels in vivo. Artificial decidual induction in primary mouse endometrial stromal cells and immortal human endometrial stromal cells line were all compromised after treated with 100 nmol/L insulin levels. All these results on flow cytometry, transmission electron microscopy and western blotting of Bax, Bcl2, cleaved Caspase3, cleaved PARP proteins level showed that decidual cells apoptosis was significantly decreased. Mitochondrial transmembrane potential also significantly increased by the influence of high insulin levels. PI3K and p-Akt were much higher after insulin exposure and the compromised decidualization by high insulin treatment was rescued by PI3K/Akt inhibitor LY294002 both in vitro and in vivo. In conclusion, we demonstrated that elevated insulin levels could compromise mice decidualization in early-stage pregnancy and PI3K/p-Akt-regulated apoptosis was essential for this role. It provides a clue for future investigation on compromised reproduction in women with hyperinsulinemia.

Endometrial neoplasia in reproductive-aged Thai women with polycystic ovary syndrome

OBJECTIVE

To determine the risk of endometrial neoplasia in relation to endometrial thickness and to evaluate factors influencing endometrial thickness in reproductive-aged Thai women with polycystic ovary syndrome (PCOS).

METHODS

The present cross-sectional study was done at the Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand, between October 1, 2010, and January 31, 2013. We recruited women (aged ≥18 years) with PCOS diagnosed according to the revised 2003 Rotterdam criteria. Data were collected for physical examinations, pelvic ultrasonography, hormonal profiles, and carbohydrate metabolic profiles. Endometrial tissue was obtained using a disposable endometrial-suctioning device.

RESULTS

The final analysis included 122 women. Six (4.9%) patients had endometrial neoplasia. All six women had an endometrial thickness of 7 mm or more, representing a risk of 8.7% (6/69) in this group. The endometrial thickness was significantly but weakly associated with body mass index (r=0.227, P=0.012), 2-hour blood glucose (r=0.323, P=0.001), fasting glucose to insulin ratio (r=0.185, P=0.042), homeostatic model assessment of insulin resistance (r=0.183, P=0.044), and free testosterone (r=0.236, P=0.009). No categorical risk factors for an endometrial thickness of 7 mm or more were identified.

CONCLUSION

Thai women with PCOS and a thick endometrium (≥7 mm) had an 8.7% risk of endometrial neoplasia. Invasive endometrial surveillance for the prevention of endometrial cancer is recommended in these women.

Clustering of PCOS-like traits in naturally hyperandrogenic female rhesus monkeys

Study question

Do naturally occurring, hyperandrogenic (≥1 SD of population mean testosterone, T) female rhesus monkeys exhibit traits typical of women with polycystic ovary syndrome (PCOS)?

Summary answer

Hyperandrogenic female monkeys exhibited significantly increased serum levels of androstenedione (A4), 17-hydroxyprogesterone (17-OHP), estradiol (E2), LH, antimullerian hormone (AMH), cortisol, 11-deoxycortisol and corticosterone, as well as increased uterine endometrial thickness and evidence of reduced fertility, all traits associated with PCOS.

What is known already

Progress in treating women with PCOS is limited by incomplete knowledge of its pathogenesis and the absence of naturally occurring PCOS in animal models. A female macaque monkey, however, with naturally occurring hyperandrogenism, anovulation and polyfollicular ovaries, accompanied by insulin resistance, increased adiposity and endometrial hyperplasia, suggests naturally occurring origins for PCOS in nonhuman primates.

Study design, size, duration

As part of a larger study, circulating serum concentrations of selected pituitary, ovarian and adrenal hormones, together with fasted insulin and glucose levels, were determined in a single, morning blood sample obtained from 120 apparently healthy, ovary-intact, adult female rhesus monkeys (Macaca mulatta) while not pregnant or nursing. The monkeys were then sedated for somatometric and ultrasonographic measurements.

Participants/materials, setting, methods

Female monkeys were of prime reproductive age (7.2 ± 0.1 years, mean ± SEM) and represented a typical spectrum of adult body weight (7.4 ± 0.2 kg; maximum 12.5, minimum 4.6 kg). Females were defined as having normal (n = 99) or high T levels (n = 21; ≥1 SD above the overall mean, 0.31 ng/ml). Electronic health records provided menstrual and fecundity histories. Steroid hormones were determined by tandem LC-MS-MS; AMH was measured by enzymeimmunoassay; LH, FSH and insulin were determined by radioimmunoassay; and glucose was read by glucose meter. Most analyses were limited to 80 females (60 normal T, 20 high T) in the follicular phase of a menstrual cycle or anovulatory period (serum progesterone <1 ng/ml).

Main results and the role of chance

Of 80 monkeys, 15% (n = 12) exhibited classifiable PCOS-like phenotypes. High T females demonstrated elevations in serum levels of LH (P < 0.036), AMH (P < 0.021), A4 (P < 0.0001), 17-OHP (P < 0.008), E2 (P < 0.023), glucocorticoids (P < 0.02-0.0001), the serum T/E2 ratio (P < 0.03) and uterine endometrial thickness (P < 0.014) compared to normal T females. Within the high T group alone, anogenital distance, a biomarker for fetal T exposure, positively correlated (P < 0.015) with serum A4 levels, while clitoral volume, a biomarker for prior T exposure, positively correlated (P < 0.002) with postnatal age. Only high T females demonstrated positive correlations between serum LH, and both T and A4. Five of six (83%) high T females with serum T ≥2 SD above T mean (0.41 ng/ml) did not produce live offspring.

Large scale data

N/A.

Limitations, reasons for caution

This is an initial study of a single laboratory population in a single nonhuman primate species. While two biomarkers suggest lifelong hyperandrogenism, phenotypic expression during gestation, prepuberty, adolescence, mid-to-late reproductive years and postmenopause has yet to be determined.

Wider implications of the findings

Characterizing adult female monkeys with naturally occurring hyperandrogenism has identified individuals with high LH and AMH combined with infertility, suggesting developmental linkage among traits with endemic origins beyond humans. PCOS may thus be an ancient phenotype, as previously proposed, with a definable pathogenic mechanism(s).

Study funding/competing interest(s)

Funded by competitive supplement to P51 OD011106 (PI: Mallick), by P50 HD028934 (PI: Marshall) and by P50 HD044405 (PI: Dunaif). The authors have no potential conflicts of interest.

Small leucine-rich proteoglycans (SLRPs) in the endometrium of polycystic ovary syndrome women: a pilot study

Background

Small leucine-rich proteoglycans (SLRPs) play an important role in tissue homeostasis and cell proliferation since these proteoglycans sequester multiple growth factors. However, the content of SLRPs in the endometrium of polycystic ovary syndrome (PCOS) women is unknown. Our purpose was to test the hypothesis that excessive endometrial proliferation in PCOS may be partly related to abnormalities in SLRPs.

Methods

In a cross section study a total of 20 endometrial samples were collected from 10 patients with PCOS and 10 ovulatory women during their proliferative (pre-ovulatory) phase. The study subjects were matched for age, body mass index and race. The age range was 20 to 35 years. All volunteers were evaluated in reproductive endocrinology clinic, Gynecology Division, Clinics Hospital, University of São Paulo Medical School Profile and concentration of small leucine-rich proteoglycans (decorin, lumican, fibromodulin and biglycan) were determined by immunohistochemical testing and Western blotting.

Results

Decorin and lumican demonstrated higher immunoreactivity and relative expression in the endometrium of women with PCOS compared to that of women with regular menstrual cycles.

Conclusion

Our data suggests that the endometrium of PCOS women demonstrate a greater content of SLRP than controls; decorin and lumican, in particular, were found in higher concentrations in the endometrium of PCOS women during the proliferative phase. These differences may, in part, explain the excess of endometrial proliferation frequently observed in PCOS. Further studies are warranted.

Relationships between Serum Luteinizing Hormone Level, Endometrial Thickness and Body Mass Index in Polycystic Ovary Syndrome Patients with and without Endometrial Hyperplasia

Background

The endometrial hyperplasia measured by ultrasound in polycystic ovary syndrome (PCOS) women is strongly related to pathologic endometrial thickness, but there is no consensus on the relation between serum luteinizing hormone (LH) and either of these factors: pathologic endometrial hyperplasia and body mass index (BMI).

Materials and Methods

In this observational cross-sectional study, three hundred fifty infertile PCOS women were involved in this research. An endometrial biopsy was taken by using a pipelle instrument, regardless of menstrual cycle’s day and all samples were reported by the same pathologist. Basal serum LH level was compared between two subgroups (hyperplasia and non-hyperplasia). The intended population was divided into three groups according to BMI and basal serum LH, later on the comparison was made in three groups. Chi-square test was applied to compare nominal variables between groups. Mann-Whitney U, and one way ANOVA tests were used to compare means on the basis of the result of normality test.

Results

The frequency of endometrial hyperplasia was 2.6%. Endometrial thickness in the patients with endometrial hyperplasia was significantly higher than that of a normal endometrium (10.78 ± 3.70 vs. 7.90 ± 2.86 respectively, P=0.020). There was no relation between endometrial hyperplasia and serum LH (P=0.600). The ANOVA test showed serum LH levels were not the same among three BMI groups (P=0.007). Post hoc test was also performed. It showed that the LH level in normal BMI group was significantly higher than those of other groups (P=0.005 and P=0.004), but there was no statistical difference between overweight and obese groups (P=0.8). We found no relationship between BMI and endometrial thickness in PCOS patients (P=0.6).

Conclusion

Sonographic endometrial stripe thickness is predictive for endometrial hyperplasia in PCOS women. We could not find out any relationship between serum LH level and BMI with endometrial thickness in PCOS patients. However, our study confirmed a diverse relationship between serum LH level and BMI in PCOS patients.

Endometrial thickness and risk of breast and endometrial carcinomas in the prostate, lung, colorectal and ovarian cancer screening trial

Postmenopausal women with higher circulating estrogen levels are at increased risk of developing breast and endometrial carcinomas. In the endometrium, excess estrogen relative to progesterone produces a net proliferative stimulus, which may result in endometrial thickening. Therefore, the hypothesis that endometrial thickness is a biological marker of excess estrogen stimulation that is associated with risk of breast and endometrial carcinomas was tested. Endometrial thickness was measured in 1,272 postmenopausal women, aged 55-74 years, who underwent transvaginal ultrasound (TVU) screening as part of the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial. Serial endometrial thickness measurements were available for a subset of women at 1 year (n = 1,018), 2 years (n = 869) and 3 years (n = 641) after baseline. The associations between endometrial thickness and breast (n = 91) and endometrial (n = 14) carcinoma were evaluated by estimating relative risks (RRs) and 95% confidence intervals (CIs) using Cox proportional hazards regression with age as the time metric. Models incorporating baseline endometrial thickness and as a time-varying covariate using all measurements were examined. Median follow-up among study participants was 12.5 years (range: 0.3-13.8 years). Compared to baseline endometrial thickness of 1.0-2.99 mm, women with baseline endometrial thickness greater than or equal to 5.0 mm had an increased risk of breast (RR = 2.00, 95% CI = 1.15-3.48) and endometrial (RR = 5.02, 95% CI = 0.96-26.36) carcinomas in models adjusted for menopausal hormone use and BMI. These data suggest that increased endometrial thickness as assessed by TVU was associated with increased risk of breast and endometrial carcinomas.

Endometrial thickness in women with ovulatory dysfunction

This study is designed to evaluate the relationship between endometrial thickness and clinical/biochemical parameters in women with chronic anovulation. One hundred and twenty women with ovulatory dysfunction were prospective included, endometrial thickness and endocrine and metabolic parameters were measured. The interval between the examination day and the day of the most recent menstrual bleeding (the anovulatory interval) for the studied subject was an average of 145 ± 186 days. The endometrial thickness averaged 7.1 ± 3.2 mm. Correlation analyses revealed that the endometrial thickness was positively correlated with body mass index but was not correlated with age, serum androgens, or estradiol (E2) levels. We further classified the subjects into two groups based on endometrial thickness: Group A, endometrial thickness <7 mm and Group B, endometrial thickness ≥7 mm. The anovulatory interval, follicle-stimulating hormone, luteinizing hormone, E2 and androgen levels were not significantly different between Groups A and B. Group B had higher body weight and more risk for metabolic syndrome. We concluded that endometrial thickness in women with ovulatory dysfunction is positively correlated with body weight status but is not correlated with serum androgens or E2 levels.

Is polycystic ovary syndrome, a state of relative estrogen excess, a real risk factor for estrogen-dependant malignancies?

Polycystic ovary syndrome (PCOS) is a common endocrinopathy affecting women of fertile age. It is associated with several risk factors and long-term health consequences. Chronic anovulation combined with relative estrogen excess and consequent prolonged stimulatory effect on the endometrium can lead to the pathogenesis of hormonal dependant carcinoma. PCOS is thus traditionally reported to be associated with increased risk of endometrial, as well as breast and ovarian cancers. This article provides a critical literature review of the relationship between PCOS and the incidence of estrogen-dependant gynecological tumours, and it then discusses whether the commonly cited risk factor association can be substantiated by high quality studies which comply with the requirements of "evidence-based medicine."

Uterine morphology and peristalsis in women with polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is associated with chronic oligo-anovulation and high circulating sex hormone levels. Women with PCOS have an increased risk of developing endometrial cancer. In anovulatory women with PCOS a positive relationship between endometrial thickness and endometrial hyperplasia has been observed. Uterine peristalsis, which has been suggested to be of importance for female fertility, has not previously been studied in PCOS.

PURPOSE

To assess whether women with PCOS have altered endometrial thickness, uterine wall morphology, and peristalsis.

MATERIAL AND METHODS

In this prospective case-control study 55 women with PCOS (mean age, 29.5 years ± 4.5 SD) and 28 controls (27.6 ± 3.2) were examined using magnetic resonance imaging (MRI), assessing thickness of endometrium, junctional zone (JZ), and myometrium, and evaluating the occurrence, frequency (waves/min), strength (amplitude), pattern, and direction of peristalsis. Uterine morphology was also assessed by transvaginal ultrasonography (TVUS).

RESULTS

The endometrium was thinner in PCOS with oligo-amenorrhea compared to controls, also after adjustments for age and BMI (adjusted P = 0.043). There was no difference in thickness of the JZ or the myometrium in cases versus controls. Uterine peristalsis was less commonly observed in women with PCOS than in controls (adjusted P = 0.014).

CONCLUSION

There were no differences in myometrial morphology between PCOS and controls, but the endometrium was thinner in PCOS with oligo-amenorrhea. Based on cine MRI, uterine peristalsis was less common in PCOS than in controls.

Endometrial abnormality in women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy associated with infertility and metabolic disorder in women of reproductive age. Although the clinical and biochemical features are heterogeneous with individuals, the most widely accepted clinical characteristics of PCOS are oligo- or anovulation combined with hyperandrogenism. With the higher rate of implantation failure after induction of ovulation or higher risk of spontaneous miscarriage after pregnancy, the reduced fertility is apparently attributed not only to anovulation but also to endometrial dysfunction in patients with PCOS. Here we review the features of the endometrial abnormalities in women with PCOS. The ability to improve the endometrial functions is of potential therapeutic targets to increase reproductive outcome of women with PCOS.

State of the Art Review: Emerging Therapies: The Use of Insulin Sensitizers in the Treatment of Adolescents with Polycystic Ovary Syndrome (PCOS)

PCOS, a heterogeneous disorder characterized by cystic ovarian morphology, androgen excess, and/or irregular periods, emerges during or shortly after puberty. Peri- and post-pubertal obesity, insulin resistance and consequent hyperinsulinemia are highly prevalent co-morbidities of PCOS and promote an ongoing state of excess androgen. Given the relationship of insulin to androgen excess, reduction of insulin secretion and/or improvement of its action at target tissues offer the possibility of improving the physical stigmata of androgen excess by correction of the reproductive dysfunction and preventing metabolic derangements from becoming entrenched. While lifestyle changes that concentrate on behavioral, dietary and exercise regimens should be considered as first line therapy for weight reduction and normalization of insulin levels in adolescents with PCOS, several therapeutic options are available and in wide use, including oral contraceptives, metformin, thiazolidenediones and spironolactone. Overwhelmingly, the data on the safety and efficacy of these medications derive from the adult PCOS literature. Despite the paucity of randomized control trials to adequately evaluate these modalities in adolescents, their use, particularly that of metformin, has gained popularity in the pediatric endocrine community. In this article, we present an overview of the use of insulin sensitizing medications in PCOS and review both the adult and (where available) adolescent literature, focusing specifically on the use of metformin in both mono- and combination therapy.

Endometrial histology and predictable clinical factors for endometrial disease in women with polycystic ovary syndrome

OBJECTIVE

This study was aimed to investigate endometrial histology and to find predictable clinical factors for endometrial disease (hyperplasia or cancer) in women with polycystic ovary syndrome (PCOS).

METHODS

We investigated the endometrial histology and analyzed the relationship between endometrial histology and clinical parameters, such as LH, FSH, estradiol, testosterone, fasting and 2 hours postprandial glucose and insulin, insulin resistance, body mass index, endometrial thickness, menstrual status from 117 women with PCOS. Statistical analysis was performed with chi square and t-test, p-value<0.05 was considered as statistically significant. And receiver operating characteristic curve was used to find predictable clinical factors for endometrial disease and to decide the cuff off values.

RESULTS

In 117 women with PCOS, endometrial histologic profiles are as follows: proliferative phase in 90 women (76.9%), endometrial hyperplasia in 25 women (21.4%), and endometrial cancer in 2 women (1.7%). Of 25 women with endometrial hyperplasia, simple hyperplasia without atypia, complex hyperplasia without atypia and complex hyperplasia with atypia were diagnosed in 15 (12.8%), 6 (5.1%), 4 (3.4%) women, respectively. Age and endometrial thickness were significantly related with endometrial disease, p=0.013 and p=0.001, respectively. At the cut off level of 25.5 years in age, sensitivity and specificity predicting for endometrial disease were 70.4% and 55.6%, respectively (p=0.023). At the cut off level of 8.5 mm in endometrial thickness, sensitivity and specificity were 77.8% and 56.7%, respectively (p=0.000).

CONCLUSION

In women with PCOS, the incidence of endometrial hyperplasia and cancer were 21.4% and 1.7%. The age and endometrial thickness may be used as clinical determining factors for endometrial biopsy.

Oncological repercussions of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a highly prevalent endocrine disorder that has been associated with insulin resistance and metabolic syndrome. Evidence has suggested that PCOS may be associated with the appearance of certain types of cancer, particularly endometrial, ovarian and breast cancer. The objective of this review was to collect further evidence of these correlations and to identify their possible mechanisms.

Reproductive ecology and the endometrium: physiology, variation, and new directions

Endometrial function is often overlooked in the study of fertility in reproductive ecology, but it is crucial to implantation and the support of a successful pregnancy. Human female reproductive physiology can handle substantial energy demands that include the production of fecund cycles, ovulation, fertilization, placentation, a 9-month gestation, and often several years of lactation. The particular morphology of the human endometrium as well as our relative copiousness of menstruation and large neonatal size suggests that endometrial function has more resources allocated to it than many other primates. The human endometrium has a particularly invasive kind of hemochorial placentation and trophoblast that maximizes surface area and maternal-fetal contact, yet these processes are actually less efficient than the placentation of some of our primate relatives. The human endometrium and its associated processes appear to prioritize maximizing the transmission of oxygen and glucose to the fetus over efficiency and protection of maternal resources. Ovarian function controls many aspects of endometrial function and thus variation in the endometrium is often a reflection of ecological factors that impact the ovaries. However, preliminary evidence and literature from populations of different reproductive states, ages and pathologies also suggests that ecological stress plays a role in endometrial variation, different from or even independent of ovarian function. Immune stress and psychosocial stress appear to play some role in the endometrium's ability to carry a fetus through the mechanism of inflammation. Thus, within reproductive ecology we should move towards a model of women's fecundity and fertility that includes many components of ecological stress and their effects not only on the ovaries, but on processes related to endometrial function. Greater attention on the endometrium may aid in unraveling several issues in hominoid and specifically human evolutionary biology: a low implantation rate, high rates of early pregnancy loss, prenatal investment in singletons but postnatal support of several dependent offspring at once, and higher rate of reproductive and pregnancy-related pathology compared to other primates, ranging from endometriosis to preeclampsia. The study of the endometrium may also complicate some of these issues, as it raises the question of why humans have a maximally invasive placentation method and yet slow fetal growth rates. In this review, I will describe endometrial physiology, methods of measurement, variation, and some of the ecological variables that likely produce variation and pregnancy losses to demonstrate the necessity of further study. I propose several basic avenues of study that leave room for testable hypotheses in the field of reproductive ecology. And finally, I describe the potential of this work not just in reproductive ecology, but in the resolution of broader women's health issues.