The androgenic sex hormone profile is an essential feature of metabolic syndrome in premenopausal women: a controlled community-based study

Relationship between Serum Total Testosterone Concentration and Metabolic Syndrome in Premenopausal Obese Women

BACKGROUND

Men with low testosterone levels are at an increased risk of developing metabolic syndrome, irrespective of age or obesity. However, the relationship between metabolic syndrome and testosterone levels in women remains unclear. We compared the total testosterone concentrations between premenopausal obese women with and without metabolic syndrome and identified the factors affecting these concentrations.

METHODS

A single-center retrospective analysis was conducted using the medical records of 580 premenopausal women with obesity. The diagnostic criteria for metabolic syndrome were established using the National Cholesterol Education Program Adult Treatment Panel III guidelines.

RESULTS

The mean±standard deviation age, weight, and body mass index were 38.8±8.4 years, 78.0±11.8 kg, and 30.0±4.1 kg/m2, respectively. The mean total testosterone concentration was lower in the metabolic syndrome group than in the non-metabolic syndrome group (n=385 vs. n=195; 0.22±0.10 ng/mL vs. 0.24±0.11 ng/mL; P<0.001). In a model adjusted for age, body mass index, skeletal muscle mass, body fat mass, and body fat percentage, the odds ratio for metabolic syndrome with respect to the total testosterone level was 0.128 (P=0.028). Testosterone concentration was negatively correlated with age (r=-0.334), systolic blood pressure (r=-0.084), and triglyceride concentration (r=-0.093) but positively correlated with weight (r=0.144), body mass index (r=0.140), waist circumference (r=0.133), body fat mass (r=0.167), and body fat percentage (r=0.167). Stepwise regression analysis revealed that age (β=-0.004, P<0.001), body mass index (β=0.003, P=0.004), and high-density lipoprotein cholesterol concentration (β=0.001, P=0.019) were independently associated with total testosterone concentration (adjusted R2=12.6%).

CONCLUSION

Metabolic syndrome and obesity may be independently associated with testosterone levels in premenopausal women with obesity.

Associations of sex hormone ratios with metabolic syndrome and inflammation in US adult men and women

Background

Sex hormones play a critical role in sex differences and cardiovascular disease risk associated with metabolic syndrome (MS) and inflammation. However, the associations of sex hormone ratios with metabolic and inflammatory markers are unclear according to sex and age differences. We evaluated the associations of sex hormone ratios with MS and inflammation among males and females.

Methods

A retrospective cross-sectional study was conducted by including all adults from the National Health and Nutrition Examination Survey cycles 2013-2016 and excluding any pregnant women, heart disease, diabetes, and those currently taking insulin. MS was defined using the National Cholesterol Education Program criteria and a high-sensitivity C-reactive protein (CRP) level>3 mg/L was defined as a high CRP. Measures of MS components and CRP concentrations were also analyzed. The primary exposures were testosterone to estradiol (excess androgen index), testosterone to sex hormone-binding globulin (free androgen index), and estradiol to sex hormone-binding globulin (free estradiol index). The adjusted associations were summarized with a relative risk (RR) and 95% confidence interval (CI).

Results

This study included 9167 subjects with 4360 males and 4807 females. Increases in free estradiol index were positively associated with MS (RR=1.48; 95%CI: 1.39, 1.58; RR=1.31; 95%CI: 1.22, 1.40) and high CRP (RR=1.49; 95%CI: 1.25, 1.77; RR=1.26; 95%CI: 1.06, 1.50) in men with age<50 years and age≥50 years, respectively. Similarly, higher free estradiol index was also robustly associated with increased prevalence of MS (RR=1.22; 95%CI: 1.15, 1.28) and high CRP (RR=1.68; 95%CI: 1.48, 1.90) in women with age ≥50 years. Among women with age<50 years, a higher free androgen index was associated with MS (RR=1.34; 95%CI: 1.25, 1.42) and high CRP (RR=1.13; 95%CI: 1.02, 1.25). These associations were unchanged even after adjusting for all sex hormones.

Conclusion

Free estradiol index was consistently and positively associated with MS and high CRP in males of all ages and older females. Free androgen index was positively associated with MS and high CRP in females with age<50 years.

Androgenicity in Young Women and Development of Metabolic Syndrome Before Menopause: The CARDIA and CARDIA Women's Studies

Context

There are no reported data from prospective long-term studies on the relation of androgen levels in young women with development of metabolic syndrome (MetS) before menopause.

Objective

We investigated associations of androgens and SHBG with incident MetS during 23 years of follow-up.

Methods

We included 366 White and 375 Black women ages 20 to 32 years participating in the CARDIA study and CARDIA Women's study, free of MetS at baseline examination (1987-1988), and premenopausal 23 years later. Androgens and SHBG were categorized into quartiles. MetS was defined according to the American Heart Association/National Heart, Lung, and Blood Institute 2009 Joint Scientific Statement. Cox proportional hazards models were used.

Results

By year 23, 30% of women developed MetS. Adjusting for baseline age, race, and education, hazard ratios (95% CI) of developing MetS were 1.46 (1.02-2.10) and 2.22 (1.53-3.21) for women in the highest vs lowest total testosterone (T) and free T quartile, respectively. The hazards of developing MetS were 47%, 59%, and 53% lower for women with SHBG in the second, third, and fourth quartiles (vs lowest quartile), respectively. Associations were attenuated for total T with further adjustments for smoking, physical activity, menstrual status, oral contraceptive/hormone (OCHM) use, insulin level, oligomenorrhea, and age at menarche, but remained statistically significant for free T and SHBG. Associations were similar for both Blacks and Whites, and OCHM nonusers, but not for OCHM users.

Conclusion

High androgenicity in young premenopausal women is associated with higher risk of future MetS, suggesting that early assessment of androgens may contribute to prevention.

Age-Dependent Changes in the Effects of Androgens on Female Metabolic and Body Weight Regulation Systems in Humans and Laboratory Animals

In recent years, the effects of androgens on metabolic and body weight regulation systems and their underlying mechanisms have been gradually revealed in females. In women and experimental animals of reproductive age, androgen excess can adversely affect metabolic functioning, appetite, and body weight regulation. In addition, excess androgens can increase the risk of metabolic disorders, such as obesity, insulin resistance, and diabetes. These unfavorable effects of androgens are induced by alterations in the actions of hypothalamic appetite-regulatory factors, reductions in energy expenditure, insulin resistance in skeletal muscle, and β-cell dysfunction. Interestingly, these unfavorable effects of androgens on metabolic and body-weight regulation systems are neither observed nor evident in ovariectomized animals and post-menopausal women, indicating that the adverse effects of androgens might be dependent on the estrogen milieu. Recent findings may provide novel sex- and age-specific strategies for treating metabolic diseases.

The Roles of Androgens in Humans: Biology, Metabolic Regulation and Health

Androgens are an important and diverse group of steroid hormone molecular species. They play varied functional roles, such as the control of metabolic energy fate and partition, the maintenance of skeletal and body protein and integrity and the development of brain capabilities and behavioral setup (including those factors defining maleness). In addition, androgens are the precursors of estrogens, with which they share an extensive control of the reproductive mechanisms (in both sexes). In this review, the types of androgens, their functions and signaling are tabulated and described, including some less-known functions. The close interrelationship between corticosteroids and androgens is also analyzed, centered in the adrenal cortex, together with the main feedback control systems of the hypothalamic-hypophysis-gonads axis, and its modulation by the metabolic environment, sex, age and health. Testosterone (T) is singled out because of its high synthesis rate and turnover, but also because age-related hypogonadism is a key signal for the biologically planned early obsolescence of men, and the delayed onset of a faster rate of functional losses in women after menopause. The close collaboration of T with estradiol (E2) active in the maintenance of body metabolic systems is also presented Their parallel insufficiency has been directly related to the ravages of senescence and the metabolic syndrome constellation of disorders. The clinical use of T to correct hypoandrogenism helps maintain the functionality of core metabolism, limiting excess fat deposition, sarcopenia and cognoscitive frailty (part of these effects are due to the E2 generated from T). The effectiveness of using lipophilic T esters for T replacement treatments is analyzed in depth, and the main problems derived from their application are discussed.

The effects of androgens on metabolic functions in females

The metabolic effects of androgens and their underlying mechanisms in females have been revealed by recent studies. An excess of androgens can have adverse effects on feeding behavior and metabolic functions and induce metabolic disorders / diseases, such as obesity, insulin resistance, and diabetes, in women and experimental animals of reproductive age. Interestingly, these effects of androgens are not observed in ovariectomized animals, indicating that their effects might be dependent on the estrogen milieu. Central and peripheral mechanisms, such as alterations in the activity of hypothalamic factors, reductions in energy expenditure, skeletal muscle insulin resistance, and β-cell dysfunction, might be related to these androgens' effects. J. Med. Invest. 68 : 228-231, August, 2021.

Association of Changes in Metabolic Syndrome Status With the Incidence of Thyroid Nodules: A Prospective Study in Chinese Adults

Although several cross-sectional studies have shown an association of metabolic syndrome (MetS) with nodular thyroid disease, related prospective studies are scarce. This study investigated the association of MetS with thyroid nodule (TN) incidence in Chinese adults, and explored whether the development of or recovery from MetS is associated with changes in the risk of developing TNs. A total of 4,749 Chinese aged 18-65 years were involved in this 6-year prospective study. The association of MetS with TN prevalence was examined. TN-free individuals at baseline (n = 3,133) were further examined. TN incidence rates in groups with different MetS statuses (MetS-free, MetS-developed, MetS-recovery and MetS-chronic) were analyzed. Of all participants, 18.21 and 31.65% had MetS and TNs, respectively. MetS patients had a higher TN prevalence than the non-MetS group (31.08 vs. 19.81% in males, p < 0.01; 59.52 vs. 39.59% in females, p < 0.01). Sex, age and MetS were independent risk factors for TNs. At a median follow up of 5.94 years, the MetS-chronic group (4.37/100 person-years) had a higher risk of TNs (adjusted incidence rate ratio [IRR] = 1.288 [95% CI 1.014-1.636]) compared with the MetS-free group (2.72/100 person-years) in the whole cohort. In males, the MetS-chronic group (3.76/100 person-years) had a higher risk of TNs (adjusted IRR = 1.367 [95% CI 1.017-1.835]) compared with the MetS-free group (2.31/100 person-years). In females, the risk of TNs was significantly higher in the MetS-chronic (6.44/100 person-years) and MetS-developed (6.31/100 person-years) groups compared with the MetS-free group (3.23/100 person-years).

Androgens sensitise mice to glucocorticoid-induced insulin resistance and fat accumulation

AIMS/HYPOTHESIS

Chronic glucocorticoid therapy causes insulin resistance, dyslipidaemia, abnormal fat accumulation, loss of muscle mass and osteoporosis. Here we describe a hitherto unknown sexual dimorphism in the metabolic response to chronic glucocorticoid exposure in mice. This led us to investigate whether glucocorticoid-induced insulin resistance and obesity were dependent on sex hormones.

METHODS

Male and female CD1 mice were treated for 4 weeks with supraphysiological doses (~250 μg/day) of corticosterone, the main glucocorticoid in rodents, or equivalent volume of vehicle (drinking water without corticosterone). To investigate the effects of sex hormones, a separate group of mice were either orchidectomised or ovariectomised prior to corticosterone treatment, with or without dihydrotestosterone replacement. Body composition was determined before and after corticosterone treatment, and insulin tolerance was assessed after 7 and 28 days of treatment. Adipocyte morphology was assessed in white and brown adipose tissues by immunohistochemistry, and fasting serum concentrations of NEFA, triacylglycerols, total cholesterol and free glycerol were measured using colorimetric assays. Obesity- and diabetes-related hormones were measured using multiplex assays, and RNA and protein expression in adipose tissues were measured by RT-PCR and immunoblotting, respectively.

RESULTS

Chronic corticosterone treatment led to insulin resistance, fasting hyperinsulinaemia, increased adiposity and dyslipidaemia in male, but not female mice. In males, orchidectomy improved baseline insulin sensitivity and attenuated corticosterone-induced insulin resistance, but did not prevent fat accumulation. In androgen-deficient mice (orchidectomised males, and intact and ovariectomised females) treated with dihydrotestosterone, corticosterone treatment led to insulin resistance and dyslipidaemia. In brown adipose tissue, androgens were required for corticosterone-induced intracellular lipid accumulation ('whitening'), and dihydrotestosterone specifically exacerbated corticosterone-induced accumulation of white adipose tissue by increasing adipocyte hypertrophy. Androgens also suppressed circulating adiponectin concentrations, but corticosterone-induced insulin resistance did not involve additional suppression of adiponectin levels. In white adipose tissue, androgens were required for induction of the glucocorticoid target gene Gilz (also known as Tsc22d3) by corticosterone.

CONCLUSIONS/INTERPRETATION

In mice, androgens potentiate the development of insulin resistance, fat accumulation and brown adipose tissue whitening following chronic glucocorticoid treatment.

High-free androgen index is associated with increased risk of non-alcoholic fatty liver disease in women with polycystic ovary syndrome, independent of obesity and insulin resistance

BACKGROUND/OBJECTIVE

Central obesity and insulin resistance (IR) are common conditions in women with polycystic ovary syndrome (PCOS) and in subjects with non-alcoholic fatty liver disease (NAFLD). However, few studies have addressed the association between hyperandrogenism (HA) and NAFLD. We aimed to determine whether variations in the free androgen index (FAI) might be associated with NAFLD prevalence.

SUBJECTS/METHODS

A cross-sectional study was performed including 400 Chinese women with PCOS and 100 age, and body mass index (BMI)-matched women. The anthropometric and serum biochemical parameters related to sex steroids, glucose and lipid profiles were examined. Liver fat content (LFC) was measured by quantitative ultrasound.

RESULTS

The prevalence of NAFLD was 56.23% in PCOS patients and 38% in controls (P=0.001), and this prevalence increased with FAI quartile independently of obesity and homeostasis model assessment of insulin resistance (HOMA-IR). The FAI level increased from non-NAFLD group to NAFLD group. The FAI was positively associated with the metabolic parameters LFC, BMI, waist circumference, alanine aminotransferases, aspartate, triglyceride, total cholesterol and low-density lipoprotein cholesterol, and was negatively associated with high-density lipoprotein. Moreover, in multivariate logistic regression analysis BMI, high-sensitivity C-reactive protein (hsCRP), FAI, LFC and HOMA-IR were significantly associated with NAFLD. The cut-off values of FAI, LFC, BMI and hsCRP to predict NAFLD were 9.86%, 17.19%, 24.38% and 0.72%, respectively. The area under the curve for predicting NAFLD in PCOS patients showed comparable sensitivity and specificity between BMI and a new index combining FAI with hsCRP.

CONCLUSIONS

A higher FAI level is associated with increased LFC and NAFLD prevalence independent of obesity and IR.

AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS, AMERICAN COLLEGE OF ENDOCRINOLOGY, AND ANDROGEN EXCESS AND PCOS SOCIETY DISEASE STATE CLINICAL REVIEW: GUIDE TO THE BEST PRACTICES IN THE EVALUATION AND TREATMENT OF POLYCYSTIC OVARY SYNDROME - PART 2

Polycystic ovary syndrome (PCOS) is recognized as the most common endocrine disorder of reproductive-aged women around the world. This document, produced by the collaboration of the American Association of Clinical Endocrinologists and the Androgen Excess Society aims to highlight the most important clinical issues confronting physicians and their patients with PCOS. It is a summary of current best practices in 2014. Insulin resistance is believed to play an intrinsic role in the pathogenesis of PCOS. The mechanism by which insulin resistance or insulin give rise to oligomenorrhea and hyperandrogenemia, however, is unclear. Hyperinsulinemic-euglycemic clamp studies have shown that both obese and lean women with PCOS have some degree of insulin resistance. Insulin resistance is implicated in the ovulatory dysfunction of PCOS by disrupting the hypothalamic-pituitary-ovarian axis. Given the association with insulin resistance, all women with PCOS require evaluation for the risk of metabolic syndrome (MetS) and its components, including type 2 diabetes, hypertension, hyperlipidemia, and the possible risk of clinical events, including acute myocardial infarction and stroke. Obese women with PCOS are at increased risk for MetS with impaired glucose tolerance (IGT; 31 to 35%) and type 2 diabetes mellitus (T2DM; 7.5 to 10%). Rates of progression from normal glucose tolerance to IGT, and in turn to T2DM, may be as high as 5 to 15% within 3 years. Data suggest the need for baseline oral glucose tolerance test every 1 to 2 years based on family history of T2DM as well as body mass index (BMI) and yearly in women with IGT. Compared with BMI- and age-matched controls, young, lean PCOS women have lower high-density lipoprotein (HDL) size, higher very-low-density lipoprotein particle number, higher low-density lipoprotein (LDL) particle number, and borderline lower LDL size. Statins have been shown to lower testosterone levels either alone or in combination with oral contraceptives (OCPs) but have not shown improvement in menses, spontaneous ovulation, hirsutism, or acne. Statins reduce total and LDL cholesterol but have no effect on HDL, C-reactive protein, fasting insulin, or homeostasis model assessment of insulin resistance in PCOS women, in contrast to the general population. There have been no long-term studies of statins on clinical cardiac outcomes in women with PCOS. Coronary calcification is more prevalent and more severe in PCOS than in controls. In women under 60 years of age undergoing coronary angiography, the presence of polycystic ovaries on sonography has been associated with more arterial segments with >50% stenosis, but the relationship between PCOS and actual cardiovascular events remains unclear. Therapies for PCOS are varied in their effects and targets and include both nonpharmacologic as well as pharmacologic approaches. Weight loss is the primary therapy in PCOS--reduction in weight of as little as 5% can restore regular menses and improve response to ovulation- inducing and fertility medications. Metformin in premenopausal PCOS women has been associated with a reduction in features of MetS. Clamp studies using ethinyl estradiol/drosperinone combination failed to reveal evidence of an increase in either peripheral or hepatic insulin resistance. Subjects with PCOS have a 1.5-times higher baseline risk of venous thromboembolic disease and a 3.7-fold greater effect with OCP use compared with non-PCOS subjects. There is currently no genetic test to screen for or diagnose PCOS, and there is no test to assist in the choice of treatment strategies. Persistent bleeding should always be investigated for pregnancy and/or uterine pathology--including transvaginal ultrasound exam and endometrial biopsy--in women with PCOS. PCOS women can have difficulty conceiving. Those who become pregnant are at risk for gestational diabetes (which should be evaluated and managed appropriately) and the microvascular complications of diabetes. Assessment of a woman with PCOS for infertility involves evaluating for preconceptional issues that may affect response to therapy or lead to adverse pregnancy outcomes and evaluating the couple for other common infertility issues that may affect the choice of therapy, such as a semen analysis. Women with PCOS have multiple factors that may lead to an elevated risk of pregnancy, including a high prevalence of IGT--a clear risk factor for gestational diabetes--and MetS with hypertension, which increases the risk for pre-eclampsia and placental abruption. Women should be screened and treated for hypertension and diabetes prior to attempting conception. Women should be counseled about weight loss prior to attempting conception, although there are limited clinical trial data demonstrating a benefit to this recommendation. Treatment for women with PCOS and anovulatory infertility should begin with an oral agent such as clomiphene citrate or letrozole, an aromatase inhibitor.

Comparison of prevalence of periodontal disease in women with polycystic ovary syndrome and healthy controls

BACKGROUND

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder among women of reproductive age, affecting 4-18% of them. Previous studies also showed that periodontal diseases are associated with different components of the metabolic syndrome. The aim of this study is to determine the association between PCOS and periodontal diseases.

MATERIALS AND METHODS

A total of 196 women (98 with PCOS and 98 healthy controls) were enrolled. PCOS diagnosis was confirmed by history, clinical signs, physical examination, laboratory parameters, and ultrasound studies. Both cases and controls were examined by the same periodontist. Periodontal parameters including bleeding on probing (BOP), probing depth, clinical attachment loss (CAL), plaque index, and tooth loss were investigated in all participants. Pregnant women, smokers, individuals with a history of malignancy or osteoporosis, and those taking prophylactic antibiotics for dental procedures or receiving periodontal treatment during the 6-month period before examination were excluded. Data were analyzed using t-test, Chi-square test, and linear regression. Statistical significance was set at P < 0.05.

RESULTS

CAL and sites with BOP were significantly higher in women with PCOS (P < 0.05). However, no significant difference was observed in the tooth loss rate between PCOS and non-PCOS participants (P = 0.384).

CONCLUSION

The prevalence of periodontal disease seems to be higher in women with PCOS. This may be related to the role of chronic systemic inflammation in the pathophysiology of both PCOS and periodontal diseases.

Complications and challenges associated with polycystic ovary syndrome: current perspectives

Polycystic ovary syndrome (PCOS) represents the most common endocrine dysfunction in fertile women and it is considered a heterogeneous and multifaceted disorder, with multiple reproductive and metabolic phenotypes which differently affect the early- and long-term syndrome’s risks. Women with PCOS present an adverse reproductive profile, including a high risk of pregnancy-induced hypertension, preeclampsia, and gestational diabetes mellitus. Patients with PCOS present not only a higher prevalence of classic cardiovascular risk factors, such as hypertension, dyslipidemia, and type-2 diabetes mellitus, but also of nonclassic cardiovascular risk factors, including mood disorders, such as depression and anxiety. Moreover, at the moment, clinical data on cardiovascular morbidity and mortality in women with PCOS are controversial. Finally, women with PCOS show an increased risk of endometrial cancer compared to non-PCOS healthy women, particularly during premenopausal period. Currently, we are unable to clarify if the increased PCOS early- and long-term risks are totally due to PCOS per se or mostly due to obesity, in particular visceral obesity, that characterized the majority of PCOS patients. In any case, the main endocrine and gynecological scientific societies agree to consider women with PCOS at increased risk of obstetric, cardiometabolic, oncology, and psychological complications throughout life, and it is recommended that these women be accurately assessed with periodic follow-up.

Serum sex hormone levels in different severity of male adult obstructive sleep apnea-hypopnea syndrome in East Asians

Obstructive sleep apnea-hypopnea syndrome (OSAHS) is a serious health issue, which can impact the hormone secretion. The aim of this study is to analyze the relationship between serum sex hormone concentrations and different severity degree of OSAHS, and to evaluate the influence of OSAHS on sex hormone levels. We enrolled 116 subjects who were subjected to polysomnography (PSG). They were divided into three groups: control group (n=10) [apnea hypopnea index (AHI) <5/h], mild-moderate OSAHS group (n=15) (5≤AHI<30/h), and severe OSAHS group (n=91) (AHI≥30/h). The patients in OSAHS group were subdivided into obesity and non-obesity subgroups. The parameters such as AHI, body mass index (BMI), lowest oxygen saturation (LSaO2), and mean oxygen saturation (MSaO2) were recorded. Serum levels of testosterone, polactin, estradiol, follicle stimulating hormone (FSH) and luteinizing hormone (LH) were determined in the morning immediately after waking up. Mean levels of hormones were compared among groups. The correlation between hormone levels and sleep-breathing parameters was analyzed. No significant differences in serum sex hormone levels were found among control, mild-moderate OSAHS, and severe OSAHS groups (P>0.05). There was no correlation between AHI and sex hormone levels (P>0.05). Testosterone was significantly negatively correlated with BMI (P<0.05). These results suggested that BMI might have a direct effect on testosterone level, and it might be an important factor affecting testosterone level in male OSAHS patients, and there may be no correlation between severity of OSAHS and sex hormones levels.

High DHEAS/free testosterone ratio is related to better metabolic parameters in women with PCOS

AIMS

To demonstrate the effects of DHEAS/free testosterone (DHEAS/FT) ratio on metabolic parameters in women with and without polycystic ovary syndrome (PCOS).

METHODS

The data of 91 women with PCOS and 66 women in the control group were collected retrospectively.

RESULTS

DHEAS/FT of the control group was higher than that of PCOS group (684.93 ± 300.54 to 517.2 ± 300.8, p < 0.001). DHEAS/FT correlated with BMI (r = -0.352, p = 0.001), WHR (r = -0.371, p = 0.0219), LDL (r = -0.227, p = 0.031), HOMA-IR (r = -0.36, p = 0.001) and FAI (r = -0.639, p = 0.001) negatively and with HDL (r = 0.344, p = 0.001) and SHBG (r = 0.646, p = 0.001) positively. In the control group, DHEAS/FT correlated with BMI (r = -0.334, p = 0.007), CRP (r = -0.297, p = 0.016) and FAI (r = -0.399, p = 0.01) negatively.

CONCLUSIONS

High DHEAS/FT ratios are related to a better metabolic phenotype in women with PCOS and low levels can be used to detect women with PCOS that have a higher risk of metabolic problems.

Circulating 5α-dihydrotestosterone, abdominal obesity and adipocyte characteristics in women

Abstract Background: The association between circulating androgen levels and fat distribution in women has been widely inconsistent among existing studies.

OBJECTIVE

We sought to investigate the relation between plasma adrenal and gonadal androgen levels and body fat distribution, as well as abdominal adipocyte characteristics.

METHODS

Paired omental and subcutaneous adipose tissue samples were surgically obtained from 60 women (age, 47±5 years; body mass index, 26±5 kg/m2) undergoing gynecological surgery. Body composition and fat distribution were measured by dual-energy X-ray absorptiometry and computed tomography, respectively. Adipocyte diameter, basal lipolysis, and heparin-releasable lipoprotein lipase activity were measured. Steroids were quantified using high-performance gas chromatography and mass spectrometry.

RESULTS

Significant negative associations were found between plasma dihydrotestosterone (DHT) levels and total adiposity (body mass index, r=-0.35, p<0.05; fat mass, r=-0.31, p<0.05) as well as computed tomography assessments of abdominal adiposity (r=-0.30, p<0.05 and r=-0.44, p<0.005 for subcutaneous and visceral adipose tissue area, respectively). The association between DHT levels and visceral adipose tissue area was independent of total body fat mass. A significant negative association was also observed between plasma DHT and omental adipocyte diameter (r=-0.27, p<0.05). When expressed as the omental/subcutaneous ratio, heparin-releasable lipoprotein lipase activity was negatively and significantly related to plasma DHT, androstenedione, and dehydroepiandrosterone (DHEA) levels.

CONCLUSION

Abdominally obese women with large, metabolically active omental adipocytes appear to be characterized by reduced endogenous levels of DHT. The assumption that high androgen levels are associated with an android body fat distribution pattern in women should be critically re-examined.

Prevalence of metabolic syndrome is higher among non-obese PCOS women with hyperandrogenism and menstrual irregularity in Korea

Background

Hyperandrogenism (HA) has been linked with several components of metabolic syndrome (MetS). Few studies in Asian women have evaluated the important risk factors for and prevalence of MetS according to PCOS subtype. In this study, we investigated differences in metabolic parameters and the prevalence of MetS in two major phenotypic subgroups of PCOS in Korea. Furthermore, we investigated the relationship between HA-associated parameters and MetS.

Materials and Methods

This cross-sectional observational study was conducted from May 2010 to December 2011 in Korea. A total of 837 females with PCOS, aged 15–40, were recruited from Departments of Obstetrics and Gynecology at 13 hospitals. Of those, 700 subjects with either polycystic ovaries (PCO)+HA+oligomenorrhea/amenorrhea (O) or PCO+O were eligible for this study. MetS was diagnosed according to the modified National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III guidelines and the International Diabetes Federation (IDF) criteria.

Results

MetS was more prevalent in the PCO+HA+O group (19.7%) than in the PCO+O (11.9%) group. There were statistically significant trends for an increased risk of MetS in the PCO+HA+O group compared to the PCO+O group. After adjustment for age, the odds ratio of MetS was 2.192 in non-obese subjects with PCO+HA+O compared to those with PCO+O, whereas the risk of MetS was not different in obese patients. Multivariate logistic regression analysis showed that high free androgen index and low sex hormone-binding globulin were significantly associated with MetS in non-obese women with PCOS, with odds ratios of 4.234 (95% CI, 1.893–9.474) and 4.612 (95% CI, 1.978–10.750), respectively. However, no associations were detected between MetS and SHBG and FAI in obese PCOS subjects.

Conclusions

Our results indicate that HA and its associated parameters (FAI and SHBG) are significantly associated with MetS in non-obese PCOS subjects, whereas this association was not observed in obese subjects.

Childhood obesity and its impact on the development of adolescent PCOS

Obesity exacerbates the reproductive and metabolic manifestations of polycystic ovary syndrome (PCOS). The symptoms of PCOS often begin in adolescence, and the rising prevalence of peripubertal obesity has prompted concern that the prevalence and severity of adolescent PCOS is increasing in parallel. Recent data have disclosed a high prevalence of hyperandrogenemia among peripubertal adolescents with obesity, suggesting that such girls are indeed at risk for developing PCOS. Obesity may impact the risk of PCOS via insulin resistance and compensatory hyperinsulinemia, which augments ovarian/adrenal androgen production and suppresses sex hormone-binding globulin (SHBG), thereby increasing androgen bioavailability. Altered luteinizing hormone (LH) secretion plays an important role in the pathophysiology of PCOS, and although obesity is generally associated with relative reductions of LH, higher LH appears to be the best predictor of increased free testosterone among peripubertal girls with obesity. Other potential mechanisms of obesity-associated hyperandrogenemia include enhanced androgen production in an expanded fat mass and potential effects of abnormal adipokine/cytokine levels. Adolescents with PCOS are at risk for comorbidities such as metabolic syndrome and impaired glucose tolerance, and concomitant obesity compounds these risks. For all of these reasons, weight loss represents an important therapeutic target in obese adolescents with PCOS.

Modification of abdominal fat distribution after aromatase inhibitor therapy in breast cancer patients visualized using 3-D computed tomography volumetry

INTRODUCTION/BACKGROUND

The purpose of this study was to describe modification of subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) distributions in breast cancer patients after aromatase inhibitor (AI) therapy using computed tomography (CT) volumetric measurement of abdominal body fat distribution.

PATIENTS AND METHODS

Sixty-four consecutive patients who were receiving adjuvant AI therapy were included in this study. Patients were evaluated using CT before and after at least 6 months of AI therapy with imaging follow-up of 4.3 ± 2.2 years. Abdominal fat distribution was automatically calculated using a workstation that obtained total abdominal adipose tissue (TAAT) area (mm(3)). SAT was manually segmented and VAT was determined as TAAT - SAT. Percentages were calculated for change of TAAT, VAT, and SAT. VAT/SAT ratio was calculated.

RESULTS

Percentage of TAAT after AI therapy was increased by a mean of 9.1% from baseline (16,280.3 ± 6953.3 mm(3)) to (17,763.6 ± 6850.8 mm(3)). Two groups of patients were observed; those with an increase in TAAT and those with a decrease. Modification of VAT/SAT ratio was observed (from 1.38 to 1.69) in all subjects, reflecting a relative increased volume of VAT (mean, 18%) and slight mean reduction of SAT (mean 1.9%).

CONCLUSION

In our study, therapy with AI in breast cancer patients was accompanied with a change in fat distribution to relatively greater VAT/SAT ratio in patients, regardless of whether they gained or lost weight after therapy. Because this pattern of fat distribution is associated with metabolic disorders, attention must be paid to these clinical manifestations in patients during their follow-up management.

Sex differences in type 2 diabetes: focus on disease course and outcomes

BACKGROUND

Women with type 2 diabetes (T2D) are less likely to reach the goals for hemoglobin A1c compared with men, and have higher all-cause mortality. The risk of cardiovascular disease is elevated among both men and women with T2D, however, the risk has declined among men over recent years while it remains stationary in women. Reasons for these sex differences remain unclear, and guidelines for diabetes treatment do not differentiate between sexes. Possible causes for varying outcome include differences in physiology, treatment response, and psychological factors. This review briefly outlines sex differences in hormonal pathophysiology, and thereafter summarizes the literature to date on sex differences in disease course and outcome.

METHODS

Systematic searches were performed on PubMed using "sex", "gender", and various glucose-lowering therapies as keywords. Earlier reviews are summarized and results from individual studies are reported. Reference lists from studies were used to augment the search.

RESULTS

There is an increased risk of missing the diagnosis of T2D when screening women with only fasting plasma glucose instead of with an oral glucose tolerance test. The impact of various risk factors for complications may differ by sex. Efficacy and side effects of some glucose-lowering drugs differ between men and women. Men with T2D appear to suffer more microvascular complications, while women have higher morbidity and mortality in cardiovascular disease and also fare worse psychologically.

CONCLUSION

Few studies to date have focused on sex differences in T2D. Several questions demand further study, such as whether risk factors and treatment guidelines should be sex-specific. There is a need for clinical trials designed specifically to evaluate sex differences in efficacy and outcome of the available treatments.

Endogenous sex hormones and their associations with cardiovascular risk factors in post-menopausal women

AIMS

Our aim was to understand the relationship between endogenous sex hormones and cardiovascular disease (CVD) risk factors in post-menopausal women.

MATERIALS AND METHODS

Eighty-three post-menopausal women from a previous prospectively designed study were included. We analyzed endogenous sex hormones and biochemical parameters.

RESULTS

Levels of estradiol and free testosterone were higher in patients with metabolic syndrome. Estradiol correlated positively with interleukin-6 (IL-6), weight, body mass index (BMI), insulin, homocysteine, and homeostasis model assessment of insulin resistance (HOMA-IR). Free testosterone correlated positively with weight, waist circumference (WC), BMI, insulin, HOMA-IR and negatively with HDL and SHBG. DHEAS correlated only with HDL. FSH correlated negatively with age, weight, WC, hip circumference, BMI, systolic blood pressure, diastolic blood pressure, duration of menopause, fasting glucose, HDL, C-reactive protein, and insulin. LH correlated negatively with IL-6, age, WC, duration of menopause and SHBG.

CONCLUSIONS

We identified endogenous estradiol and free testosterone as the strongest links to CVD risk. They can be used as biomarkers for CVD risk estimation.

SHBG and endothelial function in older subjects

BACKGROUND

Endothelial dysfunction is predictor of cardiovascular diseases that have different prevalence in men and women before menopause. Sex hormones and sex hormone binding globulin (SHBG), novel risk factors for diabetes and cardiovascular diseases even in older individuals, might explain this difference. However, the relationship between these hormones and endothelial function has never been addressed in the elderly.

METHODS AND RESULTS

430 men and,424 women 70 years older of Prospective Study of the Vasculature in Uppsala Seniors study, with complete data on SHBG, testosterone(T), estradiol(E2), endothelium-independent vasodilation (EIDV), endothelium-dependent vasodilation(EDV), flow-mediated vasodilation (FMD) and the pulse wave analysis (reflection index, RI) were evaluated. Multivariate regression analysis adjusted for confounders was used to assess the relationship between T, E2, SHBG and endothelial function. In men we found a positive relationship between SHBG and EDV (β ± SE 3.60 ± 0.83, p<0.0001), EIDV (2.42 ± 0.58, p<0.0001) but not with FMD. The relationship between SHBG and EDV and EIDV was maintained after adjustment for sex (1.64 ± 0.47, p<0.001 and 1.79 ± 0.35, p<0.0006, respectively). After adjustment for confounders, the relationship between SHBG and EDV and EIDV was still statistically significant (2.63 ± 0.90 and 1.86 ± 0.63, p = 0.004 for both). In women SHBG and EIDV were positively associated (1.58 ± 0.46; p = 0.0007), and this relationship was independent of sex (1.79 ± 0.35; p<0.001). No significant interaction SHBG * SEX was found for EIDV (p = 0.72). In a combined analysis in two sexes, SHBG and EIDV were positively associated (1.13 ± 0.45; p = 0.01). SHBG was not associated with EDV, FMD and RI. No significant relationship was found between T or E2 and EDV, EIDV, FMD or RI in both sexes.

CONCLUSIONS

In older men SHBG, but not T and E2, is positively and independently associated with EDV in resistance arteries. In both sexes, SHBG was positively and independently associated with EIDV.

The complex interaction between obesity, metabolic syndrome and reproductive axis: a narrative review

The aim of this narrative review is to provide current evidence for the interaction between obesity, metabolic syndrome (MS) and reproductive axis. Gonadotropin-releasing hormone (GnRH) pulses and, consequently, normal function of reproductive (hypothalamus-pituitary-gonadal) axis depend on normal energy balance, which presupposes sufficient food intake, reasonable energy consumption and average thermoregulatory costs. In case of an energy imbalance, reproductive dysfunction may occur. In young women, excessive leanness is accompanied by puberty delay, whereas premature puberty might be a manifestation of obesity. In a similar way, obesity in men affects fertility. Excess adipose tissue results in increased conversion of testosterone to estradiol, which may lead to secondary hypogonadism through reproductive axis suppression. Moreover, oxidative stress at the level of the testicular micro-environment may result in decreased spermatogenesis and sperm damage. Products of the adipocyte, such as leptin, adiponectin and resistin, and gut peptides, such as ghrelin, are considered to be crucial in the interaction between energy balance and reproduction. Finally, an indirect evidence for the interplay between MS and reproductive axis is the fact that when treating components of one, parameters of the other can be improved as well. These therapeutic interventions include lifestyle modifications, pharmacological agents, such as sex hormone replacement therapy, and surgical procedures. Although many issues remain unclear, the elucidation of the complex interaction between MS and reproductive axis will have obvious clinical implications in the therapeutic approach of both entities.

Cardiovascular and metabolic risks associated with PCOS

Polycystic ovary syndrome, the most common endocrine disorder of reproductive age women, is often associated with insulin resistance and associated disorders. The frequency of type 2 diabetes, hyperlipidemia, cardiac risk markers, structural vascular disease, and clinical disease events are increased in this population of women. PCOS, however, represents a broad spectrum of clinical presentations, as defined by different criteria proposed in Europe and the United States. The role of insulin resistance and hence the risk of cardiometabolic disorders may in part be determined by the definition of PCOS used. Epidemiologic studies and clinical trials support the need to identify women with PCOS to determine their risk of cardiometabolic disorders to prevent and/or treat their serious consequences.

Association between polycystic ovarian syndrome, overweight, and metabolic syndrome in adolescents

PURPOSE

Polycystic syndrome (PCOS) is associated with multiple metabolic abnormalities. Studies in the adolescent population are still limited and the results have been much different. The aim of this study was to investigate the association between PCOS, overweight, and metabolic syndrome in adolescents.

METHODS

30 PCOS adolescents were randomly selected from a PCOS population with NIH 1990 criteria and 71 adolescents from the normal adolescents. Anthropometric, hormonal and metabolic parameters were evaluated in four sub-groups including obese and non-obese PCOS and obese and non-obese normal adolescents.

RESULTS

The prevalence of overweight and metabolic syndrome in adolescents with PCOS was 52% and 33.3% respectively vs 22.4% (P = 0.005) and 11.26% in control (normal) adolescents (P = 0.0001). Among all subjects, including obese and non-obese adolescents with or without PCOS, the prevalence of insulin resistance, hypercholesterolemia, central obesity, and metabolic syndrome was higher in obese PCOS with 61.5%, 46.2%, 53.8%, and 69.2%, respectively.

CONCLUSIONS

Obesity and IR are important risk factors for metabolic syndrome in PCOS. Considering the long-term health risks, it is necessary to identify metabolic disorders in adolescents with PCOS as early as possible.

Consensus on women's health aspects of polycystic ovary syndrome (PCOS): the Amsterdam ESHRE/ASRM-Sponsored 3rd PCOS Consensus Workshop Group

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in females, with a high prevalence. The etiology of this heterogeneous condition remains obscure, and its phenotype expression varies. Two widely cited previous ESHRE/ASRM sponsored PCOS consensus workshops focused on diagnosis (published in 2004) and infertility management (published in 2008), respectively. The present third PCOS consensus report summarizes current knowledge and identifies knowledge gaps regarding various women's health aspects of PCOS. Relevant topics addressed-all dealt with in a systematic fashion-include adolescence, hirsutism and acne, contraception, menstrual cycle abnormalities, quality of life, ethnicity, pregnancy complications, long-term metabolic and cardiovascular health, and finally cancer risk. Additional, comprehensive background information is provided separately in an extended online publication.

Spectrum of metabolic dysfunction in relationship with hyperandrogenemia in obese adolescent girls with polycystic ovary syndrome

OBJECTIVE

Polycystic ovary syndrome (PCOS) in adult women is associated with increased risk of metabolic syndrome (MS) and atherosclerosis. We evaluated the spectrum of metabolic dysfunction in relationship with hyperandrogenemia (HA) in adolescent girls with PCOS.

MATERIALS AND METHODS

Ovulatory function, acne, hirsutism (HS), body mass index (BMI), body composition, fasting lipids, glucose, insulin, free testosterone (FT), high-sensitivity C-reactive protein (hs-CRP), and HbA1c were evaluated in 103 girls. The homeostatic assessment model equations (HOMA-IR and HOMA-%B) were used for determination of insulin resistance and beta-cell function respectively.

RESULTS

The oligo-ovulation (Oligo)+HA+HS (n=44), Oligo+HA (n=28), and Oligo+HS (n=31) phenotypes had similar BMI. However, hyperandrogenemic phenotypes had higher prevalence of acanthosis nigricans (AN) and acne (P<0.01) and higher insulin, HOMA-IR, HOMA-%B, HbA1c, and hs-CRP levels than Oligo+HS group (P<0.01). Serum FT was correlated with HOMA-IR (r=0.38, P<0.01), HOMA-%B (r=0.49, P<0.01), hs-CRP (r=0.42, P<0.01), AN (r=0.39, P<0.01), and HbA1c (r=0.27, P<0.01). Furthermore, 34% of girls met diagnostic criteria for MS displaying higher BMI, FT, HOMA-%B, HOMA-IR, hs-CRP, and HbA1c than subjects without MS (P<0.01). Using combined HOMA-IR>or=4.0 and hs-CRP>3.0 cut-off values, 71.4% of MS versus 23.5% non-MS group were considered at risk of diabetes and atherosclerosis (P<0.0001).

CONCLUSIONS

Hyperandrogenemic PCOS phenotypes have greatest degree of insulin resistance and inflammation. The use of insulin resistance and inflammatory markers may help identify adolescent girls with PCOS at risk of cardiometabolic syndrome.

Association between androgens, intima-media thickness and the metabolic syndrome in obese adolescent girls

BACKGROUND

While an association between androgens and the metabolic syndrome (MS) is well established in obese women, studies concerning this relationship are scarce in obese adolescent girls. Therefore, we analysed the relationships between androgens, MS and intima-media thickness (IMT) in this age-group.

METHODS

In 160 obese girls (aged 12-18 years, mean BMI: 32.6 +/- 5.0 kg/m((2))), androgens [testosterone, dehydroepiandrosterone sulphate (DHEA-S), androstenedione], SHBG and the components of MS (waist circumference, blood pressure (BP), lipids, uric acid, insulin, glucose, 2 h glucose in oral glucose tolerance test (oGTT)) were studied. Furthermore, IMT was determined in a subgroup of 71 randomly chosen girls.

RESULTS

Testosterone correlated significantly to systolic BP (r = 0.20), diastolic BP (r = 0.24), 2 h glucose in oGTT (r = 0.30), triglycerides (r = 0.19), uric acid (r = 0.17), waist circumference (r = 0.25) and IMT (r = 0.54). These relationships (except for waist circumference and uric acid) were independent of BMI and insulin resistance index homeostasis model assessment. In contrast to testosterone, DHEA-S, androstenedione and SHBG showed no or weaker correlations to any parameter of MS. The 48 girls with MS demonstrated significantly higher testosterone (1.8 +/- 0.7 nmol/l; P = 0.025) and DHEA-S (4.7 +/- 2.3 micromol/l; P = 0.008) concentrations as compared with the 112 girls without MS (mean testosterone 1.5 +/- 0.7 nmol/l, mean DHEA-S 3.6 +/- 2.3 micromol/l).

CONCLUSIONS

Testosterone was significantly related to MS and its components in obese adolescent girls independently of BMI and insulin resistance. As IMT was significantly associated with testosterone, this supports the clinical relevance of this finding.

Metabolic syndrome and polycystic ovary syndrome... and vice versa

The metabolic syndrome (MS) and the polycystic ovary syndrome (PCOS) appear to be interrelated, although they are distinct entities. Women with PCOS appear to be commonly affected by MS, while women with MS may display reproductive or endocrine features of PCOS. These clinical observations appear to be only partly attributable to the association of both syndromes with obesity and imply a reciprocal pathophysiologic relationship between PCOS and MS with potentially significant clinical sequelae. Adult women with MS are at a greater risk of developing cardiovascular disease; women with PCOS also appear to carry such an increased risk in their postmenopausal life. Conversely, women with MS may experience reproductive disturbances, reminiscent of PCOS, more commonly than their counterparts from the general population. This review presented the current epidemiology of MS in adults and adolescents with PCOS, as well as the limited amount of data on the prevalence of features of PCOS among women with MS or MS features. We also discuss the potential pathophysiologic mechanisms underlying the relationship between these interweaving, but distinct, syndromes.

Effects of androgens on adipocyte differentiation and adipose tissue explant metabolism in men and women

OBJECTIVE

To examine the effects of aromatizable or nonaromatizable androgens on abdominal subcutaneous (SC) and omental (OM) adipose tissue lipid metabolism and adipogenesis in men and women.

DESIGN AND SUBJECTS

Primary organ and preadipocyte cultures were established from surgical samples obtained in men (n = 22) and women undergoing biliopancreatic diversions (n = 12) or gynaecological surgeries (n = 8). Cultures were treated with testosterone, dihydrotestosterone (DHT) and methyltrienolone (R1881).

MEASUREMENTS

Heparin-releasable lipoprotein lipase (HR-LPL) activity, glycerol release, adiponectin secretion, glycerol-3-phosphate dehydrogenase activity and lipid accumulation were measured.

RESULTS

In organ cultures from men, DHT had a statistically significant inhibitory effect on HR-LPL activity in the OM compartment. Testosterone significantly inhibited HR-LPL activity in SC and OM cultures. In women, high DHT concentrations tended to inhibit HR-LPL activity in OM cultures. Minor androgenic effects were observed for basal and isoproterenol-stimulated lipolysis as well as adiponectin release in men. On the other hand, adipocyte differentiation was significantly and dose-dependently inhibited by DHT, testosterone and R1881 in SC and OM cultures from both sexes. These effects did not differ according to adipose tissue depot but appeared to be more pronounced in women than in men.

CONCLUSIONS

Androgens slightly decreased HR-LPL activity in adipose tissue organ cultures, but markedly inhibited adipogenesis in SC and OM primary preadipocyte cultures in both sexes. Androgenic effects on adipose tissue in men vs. women may not differ in terms of direction but in the magnitude of their negative impact on adipogenesis and lipid synthesis.

Increased androgen bioavailability is associated with non-alcoholic fatty liver disease in women with polycystic ovary syndrome

BACKGROUND

Increased prevalence of abnormal aminotransferase levels and/or ultrasonographic evidence of hepatic steatosis (HS) have been found in women with polycystic ovary syndrome (PCOS). However, factors associated with non-alcoholic fatty liver disease (NAFLD) in PCOS are still under investigation. The aim of this case-control study was to investigate the presence of NAFLD and to assess factors associated with this condition in PCOS patients.

METHODS

A prospective study of 57 premenopausal PCOS patients and 60 age- and weight-matched control women, with a history of no or minimal alcohol consumption was conducted. Anthropometric variables, biochemical and hormonal parameters were determined and NAFLD was evaluated by abdominal ultrasonography and biochemical testing, after excluding causes of secondary liver disease. Insulin resistance was assessed by homeostasis model assessment of insulin resistance (HOMA-IR) and free androgen index (FAI) was calculated.

RESULTS

PCOS patients had an increased prevalence of HS [21/57 patients (36.8%) versus 12/60 controls (20.0%), P < 0.05] and abnormal (> or =40 IU/l) serum aminotransferase levels [13/57 patients (22.8%) versus 2/60 controls (3.3%), P < 0.01] than controls. All patients and controls with metabolic syndrome had HS. Factors associated with HS were PCOS diagnosis, older age, increased BMI, waist circumference (WC), HOMA-IR and FAI values and decreased high-density lipid cholesterol and sex hormone binding globulin levels. PCOS patients had an OR of 3.55 (95% CI: 1.02-5.35) for HS versus controls, after adjustment for age, BMI and WC.

CONCLUSIONS

NAFLD is common in PCOS patients and increased androgen bioavailability may be implicated, in combination with metabolic abnormalities. Liver evaluation is proposed in PCOS patients, especially in those with metabolic syndrome.

High prevalence of metabolic syndrome in first-degree male relatives of women with polycystic ovary syndrome is related to high rates of obesity

CONTEXT

Women with polycystic ovary syndrome (PCOS) have twice the risk for metabolic syndrome (MetS) compared to women from the general population. Mothers and sisters of affected women also have an increased prevalence of MetS.

OBJECTIVE

The aim of the study was to determine the prevalence of MetS in fathers and brothers of women with PCOS compared to men from the general population.

DESIGN AND SETTING

We conducted a cross-sectional observational study at academic medical centers.

PARTICIPANTS

A total of 211 fathers and 58 brothers of women with PCOS were studied and compared to 1153 and 582 Third National Health and Nutrition Survey (NHANES III) men of similar age and race/ethnicity, respectively.

MAIN OUTCOME MEASURE

We measured MetS prevalence.

RESULTS

The prevalence of MetS was increased in fathers (42 vs. 32%; P = 0.006) and brothers (22 vs. 9%; P = 0.001) compared to NHANES III men. Fathers and brothers had higher body mass index (BMI) than NHANES III men (P < 0.0001). MetS rates were similar in fathers and brothers compared to NHANES III groups after adjusting for BMI. Total testosterone was inversely related to MetS in both fathers and brothers, but this relationship was also accounted for by the higher BMI in male relatives.

CONCLUSION

Male relatives of women with PCOS had increased prevalence rates of MetS and obesity compared to the general U.S. male population from NHANES III. In contrast to women with PCOS and their female relatives, the higher prevalence of MetS in male relatives was accounted for by elevated BMI. These findings suggest that the high rates of MetS in male relatives of women with PCOS are related to higher rates of obesity than the general population.

Sex hormones and metabolic syndrome in children and adolescents

Cardiovascular risk starts early in life, yet the patterns of changes in metabolic syndrome (MS) during puberty and normal development have not been completely defined. Sex hormones are shown to play a pivotal role in the modulation of insulin resistance and MS. Our aim is to clarify the relation between sex hormones and MS in normal children and adolescents. This is a cross-sectional study of 365 (8-12 and 14-18 years old) school students. We analyzed the associations of sex hormones (testosterone, free androgen index, estradiol, free estradiol index [FEI], and sex hormone-binding globulin [SHBG]) with cardiovascular risk factors and MS. Prevalence of MS varied depending on the definition, and 33 (9%) students had MS based on at least 1 definition of MS. Frequency of MS doubled among 14- to 18-year-old adolescents compared with 8- to 12-year-old children (12.4% vs 5.6%, P = .02). Adolescent boys and girls with MS had significantly lower SHBG levels compared with controls. Adolescent boys with MS also had significantly higher FEI levels compared with controls. Logistic regression analysis was performed to find the predictors of MS. Among covariates of age, estradiol, testosterone, free androgen index, and FEI, SHBG was the only significant predictor of MS (B = -0.3, odds ratio = 0.8, 95% confidence interval for odds ratio are 0.64 and 0.92, P = .005, Nagelkarke R(2) = 0.48) in adolescent boys. In conclusion, sex hormone levels and androgen/estrogen balance may play an important role in determining MS and future cardiovascular risk among children and adolescents.

Androgen receptor antagonism and an insulin sensitizer block the advancement of vaginal opening by high-fat diet in mice

Reduced hypothalamic sensitivity to steroid negative feedback may contribute to the onset of puberty. In high fat-fed rodents, the timing of vaginal opening (VO) is advanced, suggesting that puberty begins earlier. Because obesity can increase androgens, which interfere with normal steroid feedback in adult females, we hypothesized that androgens reduce hypothalamic sensitivity to negative feedback during puberty and that blocking androgen action would prevent advanced VO in high fat-fed mice. Age at VO was examined in mice fed high-fat or low-fat diets from weaning and treated with the androgen receptor antagonist flutamide or vehicle (controls). VO was advanced in high-fat vs. low-fat controls, and flutamide blocked this advancement. VO was also delayed in low fat-fed flutamide-treated females, suggesting involvement of androgens in the timing of normal puberty. We next investigated if high-fat diet-induced insulin resistance contributes to early VO, as elevated insulin can stimulate androgen production. VO was examined in mice on either diet treated with the insulin sensitizer metformin. Metformin blocked high-fat advancement of VO but did not alter the timing of VO in low fat-fed mice. Insulin was elevated in high fat-fed females that had undergone VO compared with age-matched low fat-fed or metformin-treated animals on either diet that had not undergone VO. Together, these data suggest a model in which metabolic changes induced by high-fat diet, including transient increased circulating insulin, act in part by increasing androgen action to influence the timing of puberty in females.

Role of androgen excess on metabolic aberrations and cardiovascular risk in women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is associated with a clustering of metabolic and cardiovascular risk factors. Insulin resistance is implicated as the major player in the metabolic abnormalities and contributes to the increased cardiovascular risk associated with the syndrome. However, androgen excess appears to participate as an independent parameter, which further aggravates the cardiovascular and metabolic aberrations in affected women with PCOS. The resultant impact of hyperandrogenemia possibly acquires clinical significance for women's health in the context of PCOS, particularly since recent data support an increased incidence of coronary artery disease and of cardiovascular events directly related to androgen levels in women with the syndrome.

Long-term follow-up of patients with polycystic ovary syndrome: reproductive outcome and ovarian reserve

BACKGROUND

The purpose of the present study was to examine long-term reproductive outcome and ovarian reserve in an unselected population of women with polycystic ovary syndrome (PCOS). METHODS A total of 91 patients with confirmed PCOS and 87 healthy controls were included in the study. Patients had been diagnosed between 1987 and 1995 and at the time of the follow-up, subjects were 35 years of age or older.

RESULTS

Among women who had attempted a pregnancy, 86.7% of PCOS patients and 91.6% of controls had given birth to at least one child. Among PCOS patients who had given birth, 73.6% had done so following a spontaneous conception. Mean ovarian volume and the number of antral follicles in PCOS patients were significantly greater than in control women (P < 0.001, respectively). PCOS patients also had higher serum concentrations of anti-Müllerian hormone and lower follicle-stimulating hormone levels.

CONCLUSIONS

Most women with PCOS had given birth, and the rate of spontaneous pregnancies was relatively high. Together with the ultrasound findings and the hormonal analyses, this finding could imply that PCOS patients have a good fecundity, and an ovarian reserve possibly superior to women with normal ovaries.

Androgen dependence of hirsutism, acne, and alopecia in women: retrospective analysis of 228 patients investigated for hyperandrogenism

Hirsutism, acne, alopecia, and oligo-amenorrhea are clinical expressions of hyperandrogenism, one of the most frequent endocrine disorders in women of reproductive age. Women referred to our endocrine clinics for skin symptoms of hyperandrogenism underwent a laboratory workup to evaluate hormone measurements and received antiandrogen therapy. We retrospectively analyzed the outcome of 228 consecutive patients investigated over 6 years.Patients with hirsutism had higher levels of androstenedione, dehydroepiandrosterone sulfate (DHEAS), and salivary testosterone; lower levels of sex hormone-binding globulin (SHBG); and a higher prevalence of oligo-amenorrhea than patients with alopecia, while patients with acne showed intermediate values. Hirsutism score correlated positively with androstenedione, DHEAS, and salivary testosterone, and correlated negatively with SHBG; salivary testosterone showed the highest correlation coefficient. Total testosterone was not significantly different among patients with hirsutism, alopecia, or acne, and did not significantly correlate with hirsutism score. Hirsutism and oligo-amenorrhea were the most sensitive symptoms of hyperandrogenism, and no androgenic parameter alone allowed us to identify all cases of hyperandrogenism.Patients of central European origin sought consultation with milder hirsutism scores than patients of southern European origin. There was, however, no difference in the clinical-biological correlation between these groups, arguing against differences in skin sensitivity to androgens.Polycystic ovary syndrome, defined as hyperandrogenism (hirsutism or elevated androgens) and oligo-amenorrhea, was diagnosed in 63 patients (27.6%), an underestimate compared with other reports that include systematic ovarian ultrasound studies. Neither pelvic ultrasound, used in a limited number of cases, nor the luteinizing hormone/follicle-stimulating hormone ratio helped to distinguish patients with polycystic ovary syndrome from the other diagnostic groups. These included hyperandrogenism (hirsutism or elevated androgens) and eumenorrhea (101 patients; 44.3%); normal androgens (acne or alopecia and eumenorrhea) (51 patients; 22.4%); isolated low SHBG (7 patients; 3.1%); nonclassical congenital adrenal hyperplasia (4 patients; 1.8% of total, 4.9% of patients undergoing cosyntropin stimulation tests); and ovarian tumor (2 patients; 0.9%).Ethinylestradiol and high-dose cyproterone acetate treatment lowered the hirsutism score to 53.5% of baseline at 1 year, and was also effective in treating acne and alopecia. The clinical benefit is ascribed to the peripheral antiandrogenic effect of cyproterone acetate as well as the hormone-suppressive effect of this combination. Salivary testosterone showed the most marked proportional decrease of all the androgens under treatment. Cost-effectiveness and tolerance of ethinylestradiol and high-dose cyproterone acetate compared well with other antiandrogenic drug therapies for hirsutism. The less potent therapy with spironolactone only, a peripheral antiandrogen without hormone-suppressive effect, was effective in treating isolated alopecia in patients with normal androgens.

Effects of androgens on insulin action in women: is androgen excess a component of female metabolic syndrome?

Hyperinsulinemia as a consequence of insulin resistance causes hyperandrogenemia in women. The objective was to review evidence for the converse situation, i.e. whether androgens adversely influence insulin action. Androgen excess could potentially contribute to the pathogenesis of insulin resistance in women with polycystic ovary syndrome (PCOS), metabolic syndrome/type 2 diabetes, and in obese peripubertal girls. An Entrez-PubMed search was conducted to identify studies addressing the relationship of androgens with metabolic syndrome/type 2 diabetes in women. Studies reporting outcomes of androgen administration, interventions to reduce androgen effects in hyperandrogenemic women, and basic studies investigating androgen effects on insulin target tissues were reviewed. Multiple studies showed associations between serum testosterone and insulin resistance or metabolic syndrome/type 2 diabetes risk in women, but their cross-sectional nature did not allow conclusions about causality. Androgen administration to healthy women was associated with development of insulin resistance. Intervention studies in women with hyperandrogenism were limited by small subject numbers and use of indirect methods for assessing insulin sensitivity. However, in three of the seven studies using euglycemic hyperinsulinemic clamps, reduction of androgen levels or blockade of androgen action improved insulin sensitivity. Testosterone administration to female rats caused skeletal muscle insulin resistance. Testosterone induced insulin resistance in adipocytes of women in vitro. In conclusion, the metabolic consequences of androgen excess in women have been under-researched. Studies of long-term interventions that lower androgen levels or block androgen effects in young women with hyperandrogenism are needed to determine whether these might protect against metabolic syndrome/type 2 diabetes in later life.

Transient prenatal androgen exposure produces metabolic syndrome in adult female rats

Androgen exposure during intrauterine life in nonhuman primates and in sheep results in a phenocopy of the reproductive and metabolic features of polycystic ovary syndrome (PCOS). Such exposure also results in reproductive features of PCOS in rodents. We investigated whether transient prenatal androgen treatment produced metabolic abnormalities in adult female rats and the mechanisms of these changes. Pregnant dams received free testosterone or vehicle injections during late gestation, and their female offspring were fed regular or high-fat diet (HFD). At 60 days of age, prenatally androgenized (PA) rats exhibited significantly increased body weight; parametrial and subcutaneous fat; serum insulin, cholesterol and triglyceride levels; and hepatic triglyceride content (all P < 0.0125). There were no significant differences in insulin sensitivity by intraperitoneal insulin tolerance test or insulin signaling in liver or skeletal muscle. HFD had similar effects to PA on body weight and composition as well as on circulating triglyceride levels. HFD further increased hepatic triglyceride content to a similar extent in both PA and control rats. In PA rats, HFD did not further increase circulating insulin, triglyceride, or cholesterol levels. In control rats, HFD increased insulin levels, but to a lesser extent than PA alone ( approximately 2.5- vs. approximately 12-fold, respectively). We conclude that transient prenatal androgen exposure produces features of the metabolic syndrome in adult female rats. Dyslipidemia and hepatic steatosis appear to be mediated by PA-induced increases in adiposity, whereas hyperinsulinemia appears to be a direct result of PA.

Body shape and size and insulin resistance as early clinical predictors of hyperandrogenic anovulation in ethnic minority adolescent girls

PURPOSE

To determine whether key associated features of hyperandrogenic anovulation (HA) in predominately Caribbean Hispanic (CH) adolescent girls can be combined to improve the early diagnosis of HA.

METHODS

Unselected observational sample of females aged 12 to 21 years (mean 17.5 +/- 2.4 years), (64% CH, 28% African American). One hundred twenty subjects provided a menstrual history, had a physical examination, and a follicular phase fasting blood drawn for LH, FSH, testosterone, sex hormone binding globulin (SHBG), 17-OH progesterone (17-OHP), androstenedione (Delta(4)A), glucose, and insulin. We prospectively categorized subjects into four groups: G I (n = 42) had normal menses and normal physical exam; G II (n = 41) had normal menses and abnormal physical exam, that is, signs indicating possible hyperandrogenism and/or insulin resistance, including at least one of obesity, hirsutism, acne, or acanthosis nigricans; G III (n = 15) had abnormal menses and normal physical exam, and G IV (n = 22) had HA with BOTH abnormal menses and abnormal physical exam, that is, girls most likely to develop polycystic ovary syndrome. Hormonal levels and additional clinical and physical characteristics of interest were compared among the four groups.

RESULTS

Group IV subjects had significantly higher waist circumference measurements, independent of overweight status, than all other groups. As hypothesized, Group IV subjects had significantly higher androgen levels and significantly lower SHBG levels than all other groups. FAI, SHBG, and waist circumference had the highest diagnostic accuracy for predicting Group IV status (i.e., HA phenotype).

CONCLUSIONS

Markers of insulin resistance and hyperandrogenemia, including waist circumference, FAI, and SHBG, best associate with irregular menstrual cycles and the HA phenotype in ethnic minority adolescent girls.

Does insulin resistance, visceral adiposity, or a sex hormone alteration underlie the metabolic syndrome? Studies in women

Insulin resistance, obesity, and a sex hormone alteration have each been suggested as the underlying link for the constellation of risk factors for myocardial infarction (MI) commonly referred to as the metabolic syndrome or the insulin resistance syndrome. In an attempt to identify in women which of these variables is the most likely link, insulin, adiposity variables, sex hormones, and risk factors for MI were measured and their relationships analyzed statistically in 58 premenopausal and 20 postmenopausal healthy women. On controlling for age, visceral adipose tissue (VAT) correlated more strongly with risk factors for MI, insulin, and free testosterone (FT) than did total adipose tissue or subcutaneous adipose tissue. VAT, therefore, was used as the adiposity variable for further data analysis. Waist circumference was a better surrogate of VAT than was waist-hip ratio, which was a poor surrogate of VAT. VAT correlated positively with insulin, FT, triglyceride, and glucose, and negatively with high-density lipoprotein and sex hormone-binding globulin. On controlling for age, FT and insulin correlated with risk factors for MI and with each other, but on controlling for age and VAT, all of their correlations lost statistical significance except for FT-triglyceride and FT-insulin in the postmenopausal women. In conclusion, VAT accumulation in women, independently of other measures of adiposity, may largely explain the correlations of insulin, obesity, and sex hormones with risk factors for MI and may be the immediate underlying factor that links risk factors for MI to form the metabolic syndrome. Insulin resistance, which has been generally accepted to be the underlying factor, may be a component of the syndrome rather than its underlying link. We hypothesize that in women FT may effect preferential VAT accumulation and induce insulin resistance directly, as well as via VAT accumulation, so that a sex hormone alteration may underlie VAT accumulation and thus ultimately underlie the metabolic syndrome (with insulin resistance as a component).

Metabolic syndrome is associated with self-perceived depression

OBJECTIVE

To study the association between metabolic syndrome (MetS) and self-perceived depression.

DESIGN

A cross-sectional community-based study.

SETTING

Semi-rural community of Lapinlahti in eastern Finland in 2005.

SUBJECTS

A total of 416 subjects in eight adult birth cohorts (55%) with complete Beck Depression Inventory (BDI-21) questionnaire data.

MAIN OUTCOME MEASURES

The values of the 21 BDI items and the BDI-21 total score with a cut-off point of 14/15 were used to study the association between MetS and depression. National Cholesterol Education Programme (NCEP) 2005 criteria were used for MetS classification.

RESULTS

The total BDI-21 score was significantly higher in the subjects with MetS than in the subjects without MetS (p=0.020). Men with MetS were significantly worse off than men without MetS in the BDI-21 items of irritability (p=0.008), work inhibition (p=0.008), fatigability (p=0.037), weight loss (p=0.045), and loss of libido (p=0.014), while women were only so on the item of loss of libido (p=0.007). In a logistic regression analysis using a BDI-21 cut-off point of 14/15 adjusted for age, marital status, vocational education, and working status, significant association was retained between perceived depression and elevated blood glucose among men (OR=1.697) and large waist circumference among women (OR=1.066).

CONCLUSION

Elevated plasma glucose in men and central obesity in women are associated with self-perceived depression. This co-occurrence deserves attention in clinical practice.

Serum sex hormone-binding globulin, a determinant of cardiometabolic disorders independent of abdominal obesity and insulin resistance in elderly men and women

Serum sex hormone-binding globulin (SHBG) is related to cardiometabolic disorders; but whether or not this relationship is purely secondary to hyperinsulinemia and/or obesity, which down-regulates SHBG, is unknown. The aim of the study was to investigate the association of SHBG and total testosterone with atherogenic dyslipidemias, metabolic syndrome (MS), and diabetes among predominantly elderly Turkish adults. After appropriate exclusions, 777 randomly selected male and female subjects with available measurements of both variables were eligible and were analyzed cross-sectionally, with diabetic subjects analyzed separately. Free testosterone was calculated. Metabolic syndrome was identified by the modified criteria of the Adult Treatment Panel III. Metabolic syndrome was identified in half the sample, which had a median age of 58 years. The odds of low SHBG concentrations (<45 nmol/L in men, <55 nmol/L in women) for the likelihood of 2 types of dyslipidemias, MS, and diabetes were examined by regression analyses in standard models including age, smoking status, presence of abdominal obesity, and insulin resistance (homeostasis model assessment of insulin resistance). In both sexes, low SHBG was associated independently with high triglyceride/low high-density lipoprotein dyslipidemia and with MS, at significant 2.2- to 4.5-fold odds ratios, independent of waist circumference or homeostasis model assessment of insulin resistance index. Low SHBG among women was additionally associated with the likelihood of hypertriglyceridemia with elevated apolipoprotein B and-at borderline significance-with that of diabetes, again when adjusted for the same confounders. In an elderly population with prevalent MS, low SHBG levels significantly associate with high triglyceride/low high-density lipoprotein dyslipidemia, MS, and, in women alone, diabetes and a dyslipidemia marking small dense low-density lipoprotein particles, all independent of abdominal obesity and insulin resistance. Low SHBG may be an important independent factor for cardiometabolic risk, particularly in women.