Women with polycystic ovary syndrome are burdened with multimorbidity and medication use independent of body mass index at late fertile age: A population-based cohort study

[Multimorbidity in endocrinological diseases: Clinical implications of PCOS]

Polycystic ovary syndrome (PCOS) is one of the most common endocrinological disorders in women of reproductive age. It affects up to 15% of this population worldwide and is characterized by a complex hormonal, metabolic and reproductive dysfunction. In this article, the multimorbidity of PCOS is reviewed, with a particular focus on the clinical implications and management of this complex disorder.

Roxadustat alleviates metabolic traits in letrozole-induced PCOS mice

Polycystic ovary syndrome (PCOS) is a highly prevalent disorder in women that is commonly accompanied by metabolic syndrome. Activation of the hypoxia-inducible factor (HIF) pathway is known to alleviate metabolic defects. Hence, this study utilized a preclinical PCOS mouse model to investigate the effects of chemically induced HIF activation on the metabolic traits of PCOS. Prepubertal letrozole treatment was used to generate a PCOS mouse model in the C57Bl6/J strain, and PCOS mice were orally treated with vehicle or roxadustat for six weeks from age 12 weeks onwards to induce HIF activation. Although the PCOS mice showed impaired glucose tolerance, increased insulin resistance, elevated blood lipids, and reduced muscle glycogen content, there was no difference in histological evaluations of white adipose tissue (WAT) or liver or in organ weights. Roxadustat treatment resulted in significant improvement in glucose tolerance (27 % reduction in area under the curve (AUC) values, p < 0.0001), fasting glucose levels (4.59 ± 0.83 mmol/l vs 3.05 ± 0.62 mmol/l, p < 0.0001) and insulin resistance (46 % reduction in homeostasis model assessment-insulin resistance (HOMA-IR) values, 6.76 ± 3.72 vs 3.64 ± 2.44, p = 0.019) compared to vehicle-treated mice without altering the body weight. Gene expression analyses with real-time quantitative polymerase chain reaction (RT-qPCR) and RNA sequencing revealed significant differences in gene expression in the tissues of PCOS mice compared to control mice, whereas the transcriptomic effects of roxadustat were mainly transient. However, immunohistochemistry revealed increased uncoupling protein 1 (UCP1) expression in WAT, which may indicate WAT browning related to HIF pathway activation.

Chronotypes in middle-aged women with polycystic ovary syndrome: A population-based study

INTRODUCTION

Circadian rhythm disruption has been associated with the risk of polycystic ovary syndrome (PCOS), as the evening chronotype (EC) shares several traits with PCOS, including metabolic disorders, cardiovascular diseases, and psychiatric disorders. It has been suggested that the biological clock could be targeted with new, preventive, and therapeutic strategies for PCOS in women with biorhythm disorders. We evaluated inner circadian rhythmicity in middle-aged women with PCOS in a population-based setting, focusing on whether women with PCOS and an EC have a specific subtype in relation to their clinical characteristics.

MATERIAL AND METHODS

The data derived from the Northern Finland Birth Cohort, a population-based longitudinal birth cohort of 12 058 individuals born in 1966. We compared the circadian phenotype between 314 women with PCOS (according to the Rotterdam criteria) and 1248 women without PCOS at age 46 years using the validated Finnish shortened 6-item Morningness-Eveningness Questionnaire (sMEQ) and the single-item self-assessed morningness-eveningness question.

RESULTS

PCOS was not associated with the EC by the sMEQ (p = 0.495) or self-assessment (p = 0.303). The self-assessed morningness-eveningness values differed from the sMEQ chronotype distribution (p < 0.001), nevertheless, the most frequent chronotype was the intermediate chronotype (IC) determined by both chronotyping methods (sMEQ PCOS 47.7% vs. 45.2% non-PCOS; self-assessment PCOS 66.5% vs. 68.4% non-PCOS). The hyperandrogenic PCOS phenotypes A-C did not differ from the non-hyperandrogenic phenotype D as for the chronotype (p = 0.271). The EC was associated in both groups with depressive and anxiety symptoms (PCOS p = 0.012, non-PCOS p < 0.001) and the use of sleep medication (PCOS p = 0.017, non-PCOS p < 0.001).

CONCLUSIONS

The EC was not over-represented in middle-aged women with PCOS or in the hyperandrogenic PCOS phenotypes A-C in our study. This does not support the need for chronotyping in the comprehensive assessment of women with PCOS. However, as chronotypes tend to change with aging, cross-sectional studies in different age groups are warranted to draw conclusions on the role of chronotypes in PCOS and the associated metabolic risks.

Optimized polycystic ovarian disease prognosis and classification using AI based computational approaches on multi-modality data

Polycystic Ovarian Disease or Polycystic Ovary Syndrome (PCOS) is becoming increasingly communal among women, owing to poor lifestyle choices. According to the research conducted by National Institutes of Health, it has been observe that PCOS, an endocrine condition common in women of childbearing age, has become a significant contributing factor to infertility. Ovarian abnormalities brought on by PCOS carry a high risk of miscarriage, infertility, cardiac problems, diabetes, uterine cancer, etc. Ovarian cysts, obesity, menstrual irregularities, elevated amounts of male hormones, acne vulgaris, hair loss, and hirsutism are some of the symptoms of PCOS. It is not easy to determine PCOS because of its different combinations of symptoms in different women and various criteria needed for diagnosis. Taking biochemical tests and ovary scanning is a time-consuming process and the financial expenses have become a hardship to the patients. Thus, early prognosis of PCOS is crucial to avoid infertility. The goal of the proposed work is to analyse PCOS symptoms based on clinical data for early diagnosis and to classify into PCOS affected or not. To achieve this objective, clinical features dataset and ultrasound imaging dataset from Kaggle is utilized. Initially 541 instances of 45 clinical features such as testosterone, hirsutism, family history, BMI, fast food, menstrual disorder, risk etc. are considered and correlation-based feature extraction method is applied to this dataset which results in 17 features. The extracted features are applied to various machine learning algorithms such as Logistic Regression, Naïve Bayes and Support Vector Machine. The performance of each method is evaluated based on accuracy, precision, recall, F1-score and the result shows that among three models, Support Vector Machine model achieved high accuracy of 94.44%. In addition to this, 3856 ultrasound images are analysed by CNN based deep learning algorithm and VGG16 transfer learning algorithm. The performance of these models is evaluated using training accuracy, loss and validation accuracy, loss and the result depicts that VGG16 outperforms than CNN model with validation accuracy of 98.29%.

Exploring the Role of Pituitary Adenylate Cyclase-Activating Polypeptide (PACAP) and Kynurenine Pathway Dysregulation in Migraine Pathophysiology Among Women With Polycystic Ovary Syndrome (PCOS)

A narrative review was undertaken to explore the current understanding of the relationship between polycystic ovary syndrome and migraine headaches, with a focus on the potential roles of pituitary adenylate cyclase-activating polypeptide and the kynurenine pathway in the shared pathophysiology of these conditions. Emerging evidence suggests that pituitary adenylate cyclase-activating polypeptide may be a key player in the development of migraine headaches, with potential implications for the higher incidence of migraine observed in women with polycystic ovary syndrome. Additionally, dysregulation of the kynurenine pathway and altered levels of kynurenine metabolites have been linked to both migraine and polycystic ovary syndrome, indicating a complex interplay between hormonal, metabolic, and neurological factors in the comorbid presentation of these disorders. Further research is needed to elucidate the specific mechanisms underlying these associations and to develop targeted therapeutic approaches for managing migraine in the context of polycystic ovary syndrome.

Prospective risk of Type 2 diabetes in 99 892 Nordic women with polycystic ovary syndrome and 446 055 controls: national cohort study from Denmark, Finland, and Sweden

STUDY QUESTION

What is the prospective risk of Type 2 diabetes (T2D) in Nordic women with polycystic ovary syndrome (PCOS) compared to controls?

SUMMARY ANSWER

A diagnosis of PCOS and BMI ≥30 kg/m2 is a high-risk phenotype for a prospective risk of T2D diagnosis across Nordic countries.

WHAT IS KNOWN ALREADY

The risk of T2D in women with PCOS is increased. The risk of T2D is related to BMI and the magnitude of risk in normal weight women with PCOS has been discussed. However, prospective data regarding risk of T2D in population-based cohorts of women with PCOS are limited.

STUDY DESIGN, SIZE, DURATION

This national register-based study included women with PCOS and age-matched controls. The main study outcome was T2D diagnosis occurring after PCOS diagnosis. T2D was defined according to ICD-10 diagnosis codes and/or filled medicine prescriptions of anti-diabetic medication excluding metformin.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The study cohort included women originating from Denmark (PCOS Denmark, N = 27 016; controls, N = 133 994), Finland (PCOS Finland, N = 20 467; controls, N = 58 051), and Sweden (PCOS Sweden, N = 52 409; controls, N = 254 010). The median age at cohort entry was 28 years in PCOS Denmark, Finland, and Sweden with a median follow-up time (interquartile range) in women with PCOS of 8.5 (4.0-14.8), 9.8 (5.1-15.1), and 6.0 (2.0-10.0) years, respectively. Cox regression analyses were adjusted for BMI and length of education.

MAIN RESULTS AND THE ROLE OF CHANCE

The crude hazard ratio (HR, 95% CI) for T2D diagnosis in women with PCOS was 4.28 (3.98-4.60) in Denmark, 3.40 (3.11-3.74) in Finland, and 5.68 (5.20-6.21) in Sweden. In adjusted regression analyses, BMI ≥30 vs <25 kg/m2 was associated with a 7.6- to 11.3-fold risk of T2D. In a combined meta-analysis (PCOS, N = 99 892; controls, N = 446 055), the crude HR for T2D in PCOS was 4.64 (3.40-5.87) and, after adjustment for BMI and education level, the HR was 2.92 (2.32-3.51).

LIMITATIONS, REASONS FOR CAUTION

Inclusion of more severe cases of PCOS in the present study design could have lead to an overestimation of risk estimates in our exposed population. However, some women in the control group would have undiagnosed PCOS, which would lead to an underestimation of T2D risk in women with PCOS. BMI data were not available for all participants. The present study should be repeated in study cohorts with higher background risks of T2D, particularly in populations of other ethnicities.

WIDER IMPLICATIONS OF THE FINDINGS

The prospective risk for diagnosis of T2D is increased in women with PCOS, and the risk is aggravated in women with BMI ≥30 kg/m2.

STUDY FUNDING/COMPETING INTEREST(S)

Funding in Denmark was from the Region of Southern Denmark, Overlægerådet, Odense University Hospital. Funding in Finland was from Novo Nordisk Foundation, Finnish Research Council and Sigrid Juselius Foundation, the National Regional Fund, Sakari Alhopuro Foundation and Finnish Diabetes Research Foundation. E.E. has received a research grant from Ferring Pharmaceuticals (payment to institution) and serves as medical advisor for Tilly AB, not related to this manuscript. The remaining authors declare no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Polycystic ovary syndrome presents as a multimorbid condition by age 50: birth cohort linkage to national register data

OBJECTIVE

This population-based follow-up study investigated register-based disease diagnoses and medication use up till age of 50 years among women with polycystic ovary syndrome (PCOS) that were identified from a population-based birth cohort.

DESIGN

Population-based longitudinal cohort study.

PATIENTS

Women reporting oligo/amenorrhea and hirsutism at age 31 and/or who were diagnosed with PCOS by a physician by age 46 (n = 244) and women without PCOS symptoms or diagnosis (n = 1556) in the Northern Finland Birth Cohort 1966.

MAIN OUTCOME MEASURES

National register data on diagnosed diseases (International Statistical Classification of Diseases [ICD]-8-10) and medication use (Anatomical Therapeutic Chemical) until the age of 50.

RESULTS

Women with PCOS had a 26% higher risk for any registered diagnosis (risk ratio [RR]: 1.26 [1.09-1.46]) and a 24% higher risk for medication use (RR: 1.24 [1.05-1.46]) compared with non-PCOS women, even after adjusting for several confounders. Several main ICD categories were more prevalent among women with PCOS versus non-PCOS controls, eg, endocrine, metabolic, nervous system, musculoskeletal, and genitourinary diseases in addition with different symptoms and injuries. Surprisingly, even though the overall morbidity was only increased in women with PCOS with a body mass index (BMI) ≥ 25 kg/m2, there were several ICD main categories that showed higher comorbidity risk especially in women with PCOS with a BMI < 25 kg/m2. Several medications were prescribed more often to women with PCOS versus non-PCOS controls, eg, medications related to the alimentary tract and metabolism, the cardiovascular system, genitourinary system drugs and sex hormones, dermatologic and hormonal preparations, and medications to treat the musculoskeletal, nervous, and respiratory systems.

CONCLUSION

Women with PCOS are burdened with multimorbidity and higher medication use, independent of BMI and other confounders. Accordingly, preventive strategies are needed to alleviate the disease burden and improve the health outcomes of women with PCOS.

Dissecting the shared genetic architecture between endometriosis and polycystic ovary syndrome

Background

Previous study suggested evidence for coexistence and similarities between endometriosis and polycystic ovary syndrome (PCOS), but it is unclear regarding the shared genetic architecture and causality underlying the phenotypic similarities observed for endometriosis and PCOS.

Methods

By leveraging summary statistics from public genome-wide association studies regarding endometriosis (European-based: N=470,866) and PCOS (European-based: N=210,870), we explored the genetic correlation that shared between endometriosis and PCOS using linkage disequilibrium score regression. Shared risk SNPs were derived using PLACO (Pleiotropic analysis under composite null hypothesis) and FUMA (Functional Mapping and Annotation of Genetic Associations). The potential causal association between endometriosis and PCOS was investigated using two-sample Mendelian randomization (MR). Linkage disequilibrium score for the specific expression of genes analysis (LDSC-SEG) were performed for tissue enrichment analysis. The expression profiles of the risk gene in tissues were further examined.

Results

A positive genetic association was observed between endometriosis and PCOS. 12 significant pleiotropic loci shared between endometriosis and PCOS were identified. Genetic associations between endometriosis and PCOS were particularly enriched in uterus, endometrium and fallopian tube. Two-sample MR analysis further indicated a potential causative effect of endometriosis on PCOS, and vice versa. Microarray and RNA-seq verified the expressions of SYNE1 and DNM3 were significantly altered in the endometrium of patients with endometriosis or PCOS compared to those of control subjects.

Conclusion

Our study indicates the genetic correlation and shared risk genes between PCOS and endometriosis. These findings provide insights into the potential mechanisms behind their comorbidity and the future development of therapeutics.

Associations between Polycystic Ovary Syndrome (PCOS) and Antibiotic Use: Results from the UAEHFS

Women with polycystic ovary syndrome (PCOS) have a higher susceptibility to infections compared to those without PCOS. Studies evaluating antibiotic use based on PCOS status are scarce. Therefore, we aimed to (i) assess the associations between self-reported PCOS and antibiotic use, and (ii) whether PCOS treatment and the age at PCOS diagnosis modified the associations above. This cross-sectional analysis used the United Arab Emirates Healthy Future Study (UAEHFS) conducted from February 2016 to March 2023 involving 2063 Emirati women aged 18-62 years. We performed ordinal logistic regressions under unadjusted and demographic-health-characteristic-adjusted models to obtain the odds ratios (ORs) and 95% confidence intervals (CIs) to analyze PCOS and antibiotic use. Subgroup analyses were performed by treatment status and age at diagnosis. We found that women with PCOS were 55% more likely to frequently take a course of antibiotics in the past year (aOR 1.55; 95% CI 1.26-1.90). Similar likelihoods were also found among those being treated for PCOS and those without treatment but with a PCOS diagnosis at ≤25 years. Our study suggests that PCOS was associated with an increased use of antibiotics among Emirati women. Understanding the frequent antibiotic use susceptibility among those with PCOS may improve antibiotic use surveillance and promote antibiotic stewardship in these at-risk individuals.

Polycystic ovary syndrome

Despite affecting ~11-13% of women globally, polycystic ovary syndrome (PCOS) is a substantially understudied condition. PCOS, possibly extending to men's health, imposes a considerable health and economic burden worldwide. Diagnosis in adults follows the International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome, requiring two out of three criteria - clinical or biochemical hyperandrogenism, ovulatory dysfunction, and/or specific ovarian morphological characteristics or elevated anti-Müllerian hormone. However, diagnosing adolescents omits ovarian morphology and anti-Müllerian hormone considerations. PCOS, marked by insulin resistance and hyperandrogenism, strongly contributes to early-onset type 2 diabetes, with increased odds for cardiovascular diseases. Reproduction-related implications include irregular menstrual cycles, anovulatory infertility, heightened risks of pregnancy complications and endometrial cancer. Beyond physiological manifestations, PCOS is associated with anxiety, depression, eating disorders, psychosexual dysfunction and negative body image, collectively contributing to diminished health-related quality of life in patients. Despite its high prevalence persisting into menopause, diagnosing PCOS often involves extended timelines and multiple health-care visits. Treatment remains ad hoc owing to limited understanding of underlying mechanisms, highlighting the need for research delineating the aetiology and pathophysiology of the syndrome. Identifying factors contributing to PCOS will pave the way for personalized medicine approaches. Additionally, exploring novel biomarkers, refining diagnostic criteria and advancing treatment modalities will be crucial in enhancing the precision and efficacy of interventions that will positively impact the lives of patients.

Fertility treatment pathways and births for women with and without polycystic ovary syndrome-a retrospective population linked data study

OBJECTIVE

To study the fertility treatment pathways used by women with and without polycystic ovary syndrome (PCOS) and which pathways were more likely to result in a birth.

DESIGN

This retrospective national community-based cohort study used longitudinal self-report survey data (collected 1996-2022; aged 18-49 years) from women born in 1973-1978 who are participants in the Australian Longitudinal Study on Women's Health. The study also used linked administrative data on fertility treatments (1996-2021).

PATIENTS

Of the 8,463 eligible women, 1,109 accessed fertility treatment and were included.

EXPOSURE

Polycystic ovary syndrome diagnosis was self-reported.

MAIN OUTCOME MEASURE

use of ovulation induction (OI), intrauterine insemination, and/or in vitro fertilization (IVF) was established through linked administrative data. Births were self-reported.

RESULTS

One in 10 of the eligible participants had PCOS (783/7,987, 10%) and 1 in 4 of the women who used fertility treatment had PCOS (274/1,109, 25%). Women with PCOS were 3 years younger on average at first fertility treatment (M = 31.4 years, SD = 4.18) than women without PCOS (M = 34.2 years, SD = 4.56). Seven treatment pathways were identified and use differed by PCOS status. Women with PCOS were more likely to start with OI (71%; odds ratio [OR] 4.20, 95% confidence interval [CI]: 2.91, 6.07) than women without PCOS (36%). Of the women with PCOS who started with OI, 46% required additional types of treatment. More women without PCOS ended up in IVF (72% vs. 51%). Overall, 63% (701/1,109) had an attributed birth, and in adjusted regressions births did not vary by last type of treatment (IVF: 67%, reference; intrauterine insemination: 67%, OR 0.94 95% CI: 0.56, 1.58; OI: 61%, OR 0.71, 95% CI: 0.52, 0.98), or by PCOS status (OR 1.27, 95% CI: 0.91, 1.77). By age, 74% of women under 35 years (471/639) and 49% of women 35 years or older had a birth.

CONCLUSION

More women with PCOS used fertility treatment but births were equivalent to women without PCOS. Most women followed clinical recommendations. Births did not differ between pathways, so there was no disadvantage in starting with less invasive treatments (although there may be financial or emotional disadvantages).

Induced Pluripotent Stem Cells as a Possible Approach for Exploring the Pathophysiology of Polycystic Ovary Syndrome (PCOS)

Polycystic ovary syndrome (PCOS) is the most prevalent endocrine condition among women with pleiotropic sequelae possessing reproductive, metabolic, and psychological characteristics. Although the exact origin of PCOS is elusive, it is known to be a complex multigenic disorder with a genetic, epigenetic, and environmental background. However, the pathogenesis of PCOS, and the role of genetic variants in increasing the risk of the condition, are still unknown due to the lack of an appropriate study model. Since the debut of induced pluripotent stem cell (iPSC) technology, the ability of reprogrammed somatic cells to self-renew and their potential for multidirectional differentiation have made them excellent tools to study different disease mechanisms. Recently, researchers have succeeded in establishing human in vitro PCOS disease models utilizing iPSC lines from heterogeneous PCOS patient groups (iPSCPCOS). The current review sets out to summarize, for the first time, our current knowledge of the implications and challenges of iPSC technology in comprehending PCOS pathogenesis and tissue-specific disease mechanisms. Additionally, we suggest that the analysis of polygenic risk prediction based on genome-wide association studies (GWAS) could, theoretically, be utilized when creating iPSC lines as an additional research tool to identify women who are genetically susceptible to PCOS. Taken together, iPSCPCOS may provide a new paradigm for the exploration of PCOS tissue-specific disease mechanisms.

A policy brief on improving the lifestyle of women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) in women is a significant public health issue. We searched the relevant databases using the sensitive keywords to receive the available evidence for successful lifestyle interventions among PCOS women. The systematic reviews related to PCOS were evaluated for an effective lifestyle intervention that was identified. The lifestyle interventions include three components: weight management, physical exercise, and behavioral coaching or combined interventions for developing exercise and modifying diet. Evidence shows that the impact of starting lifestyle intervention as the first-line management to improve obstetric and reproductive outcomes is high. There is evidence that proves health coaching can improve health behaviors and lifestyle. Thus, it is recommended to improve the lifestyle of women with PCOS.

PCOS during the menopausal transition and after menopause: a systematic review and meta-analysis

BACKGROUND

Current knowledge about the consequences of PCOS during the late reproductive years and after menopause is limited.

OBJECTIVE AND RATIONALE

We performed a systematic review and meta-analysis of data on the pathophysiology, clinical manifestations, diagnosis, prognosis, and treatment of women ≥45 years of age-peri- or postmenopausal-with PCOS.

SEARCH METHODS

Studies published up to 15 April 2023, identified by Entrez-PubMed, EMBASE, and Scopus online facilities, were considered. We included cross-sectional or prospective studies that reported data from peri- or postmenopausal patients with PCOS and control women with a mean age ≥45 years. Three independent researchers performed data extraction. Meta-analyses of quantitative data used random-effects models because of the heterogeneity derived from differences in study design and criteria used to define PCOS, among other confounding factors. Sensitivity analyses restricted the meta-analyses to population-based studies, to studies including only patients diagnosed using the most widely accepted definitions of PCOS, only menopausal women or only women not submitted to ovarian surgery, and studies in which patients and controls presented with similar indexes of weight excess. Quality of evidence was assessed using the GRADE system.

OUTCOMES

The initial search identified 1400 articles, and another six were included from the reference lists of included articles; 476 duplicates were deleted. We excluded 868 articles for different reasons, leaving 37 valid studies for the qualitative synthesis, of which 28 studies-published in 41 articles-were considered for the quantitative synthesis and meta-analyses. Another nine studies were included only in the qualitative analyses. Compared with controls, peri- and postmenopausal patients with PCOS presented increased circulating total testosterone (standardized mean difference, SMD 0.78 (0.35, 1.22)), free androgen index (SMD 1.29 (0.89, 1.68)), and androstenedione (SMD 0.58 (0.23, 0.94)), whereas their sex hormone-binding globulin was reduced (SMD -0.60 (-0.76, -0.44)). Women with PCOS showed increased BMI (SMD 0.57 (0.32, 0.75)), waist circumference (SMD 0.64 (0.42, 0.86)), and waist-to-hip ratio (SMD 0.38 (0.14, 0.61)) together with increased homeostasis model assessment of insulin resistance (SMD 0.56 (0.27, 0.84)), fasting insulin (SMD 0.61 (0.38, 0.83)), fasting glucose (SMD 0.48 (0.29, 0.68)), and odds ratios (OR, 95% CI) for diabetes (OR 3.01 (1.91, 4.73)) compared to controls. Women with PCOS versus controls showed decreased HDL concentrations (SMD -0.32 (-0.46, -0.19)) and increased triglycerides (SMD 0.31 (0.16, 0.46)), even though total cholesterol and LDL concentrations, as well as the OR for dyslipidaemia, were similar to those of controls. The OR for having hypertension was increased in women with PCOS compared with controls (OR 1.79 (1.36, 2.36)). Albeit myocardial infarction (OR 2.51 (1.08, 5.81)) and stroke (OR 1.75 (1.03, 2.99)) were more prevalent in women with PCOS than controls, the ORs for cardiovascular disease as a whole, coronary artery disease as a whole, breast cancer and age at menopause, were similar in patients and controls. When restricting meta-analysis to studies in which women with PCOS and controls had a similar mean BMI, the only difference that retained statistical significance was a decrease in HDL-cholesterol concentration in the former and, in the two studies in which postmenopausal women with PCOS and controls had similar BMI, patients presented with increased serum androgen concentrations, suggesting that hyperandrogenism persists after menopause, regardless of obesity.

WIDER IMPLICATIONS

Hyperandrogenism appeared to persist during the late-reproductive years and after menopause in women with PCOS. Most cardiometabolic comorbidities were driven by the frequent coexistence of weight excess and PCOS, highlighting the importance of targeting obesity in this population. However, the significant heterogeneity among included studies, and the overall low quality of the evidence gathered here, precludes reaching definite conclusions on the issue. Hence, guidelines derived from adequately powered prospective studies are definitely needed for appropriate management of these women.

Bone health and prevalent fractures in women with polycystic ovary syndrome: a meta-analysis and endocrine-context pathophysiology review

INTRODUCTION

Bone health in those with Polycystic Ovary Syndrome (PCOS) is complex, but the general consensus is that cortical areal bone mineral density (aBMD) sites will be higher in PCOS than in age- and BMI-similar controls. However, spine aBMD sites may be lower, especially in non-obese PCOS. Whether or not incident fracture risk is increased in PCOS is currently controversial; no meta-analysis has yet assessed prevalent fractures.

AREAS COVERED

We assessed the bone effects of PCOS-related ovarian hormone alterations, e.g. androgen excess, tonically normal/higher estradiol, and lower-than-normal progesterone levels. We also highlighted evidence that common PCOS medications (e.g. combined hormonal contraceptives [CHC], metformin, and spironolactone) have important bone effects. In adolescents, meta-analysis of CHC showed significant negative aBMD changes. Inflammation has negative PCOS bone effects and is linked with CHC use.

EXPERT OPINION

Is fracture risk altered by PCOS? Our meta-analysis showed a 25% increased risk of prevalent fracture in PCOS versus controls; this did not reach statistical significance. Future prospective research needs to collect and evaluate ovulation characteristics, progesterone exposure, and adolescent CHC use, in addition to the complex variables that may influence risks for prevalent or incident fragility fractures and/or for cortical and cancellous aBMD values in PCOS.

The impact of metformin with or without lifestyle modification versus placebo on polycystic ovary syndrome: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Available evidence has shown that metformin improves insulin sensitivity and weight management in polycystic ovary syndrome (PCOS). Nevertheless, key knowledge gaps remain regarding its efficacy and the specific outcomes in this population. This review evaluates the effectiveness of metformin and lifestyle modification compared with placebo in the management of PCOS and will inform the forthcoming, 2023 evidence-based PCOS guidelines.

DESIGN

Systematic review and meta-analysis of the literature.

METHODS

A search was performed in MEDLINE, EMBASE, PsycINFO, All EBM, and CINAHL. The review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and included randomized controlled trials published in English through July 2022.

RESULTS

Moderate certainty of evidence showed a larger reduction of body mass index (BMI) (mean difference [MD] -0.53, 95% confidence interval [CI] -0.95 to -0.12 kg/m2), homeostatic model assessment for insulin resistance (MD -0.50, 95% CI -0.91 to -0.09) (critical outcomes), and fasting glucose (MD -0.13, 95% CI -0.19 to -0.07 mmol/L) with metformin compared to placebo with increased mild gastrointestinal adverse effects (odds ratio [OR] 7.67, 95% CI 2.74-21.46). Low certainty of evidence showed a larger reduction of waist-hip ratio (MD -0.02, 95% CI -0.03 to -0.00), total cholesterol (MD -0.24, 95% CI -0.43 to -0.05 mmol/L), low-density lipoprotein (MD -0.16, 95% CI -0.30 to -0.01 mmol/L), and triglycerides (MD -0.11, 95% CI -0.20 to -0.02 mmol/L) with metformin than placebo.

CONCLUSIONS

Metformin should be considered an efficacious adjunct to lifestyle interventions in adults with PCOS, especially for those with a higher BMI, to improve weight loss, insulin resistance, and lipids.

Exome sequencing to explore the possibility of predicting genetic susceptibility to the joint occurrence of polycystic ovary syndrome and Hashimoto's thyroiditis

A large body of evidence indicates that women with polycystic ovary syndrome (PCOS) have a higher risk of developing Hashimoto's thyroiditis (HT) than healthy individuals. Given the strong genetic impact on both diseases, common predisposing genetic factors are possibly involved but are not fully understood. Here, we performed whole-exome sequencing (WES) for 250 women with sporadic PCOS, HT, combined PCOS and HT (PCOS+HT), and healthy controls to explore the genetic background of the joint occurrence of PCOS and HT. Based on relevant comparative analyses, multivariate logistic regression prediction modeling, and the most informative feature selection using the Monte Carlo feature selection and interdependency discovery algorithm, 77 variants were selected for further validation by TaqMan genotyping in a group of 533 patients. In the allele frequency test, variants in RAB6A, GBP3, and FNDC7 genes were found to significantly (padjusted < 0.05) differentiated the PCOS+HT and PCOS groups, variant in HIF3A differentiated the PCOS+HT and HT groups, whereas variants in CDK20 and CCDC71 differentiated the PCOS+HT and both single disorder groups. TaqMan genotyping data were used to create final prediction models, which differentiated between PCOS+HT and PCOS or HT with a prediction accuracy of AUC = 0.78. Using a 70% cutoff of the prediction score improved the model parameters, increasing the AUC value to 0.87. In summary, we demonstrated the polygenic burden of both PCOS and HT, and many common and intersecting signaling pathways and biological processes whose disorders mutually predispose patients to the development of both diseases.

Association Between Self-Reported Polycystic Ovary Syndrome with Chronic Diseases Among Emiratis: A Cross-Sectional Analysis from the UAE Healthy Future Study

Purpose

This study aimed to assess the prevalence of self-reported polycystic ovary syndrome (PCOS) among Emiratis and examine bi-directional associations of PCOS with self-reported chronic diseases, namely: diabetes, asthma, high cholesterol, and high blood pressure.

Patients and Methods

A cross-sectional analysis was performed using the UAE Healthy Future Study (UAEHFS) data collected from February 2016 to April 2022 involving 1040 Emirati women aged 25-67 years from recruitment centers in the United Arab Emirates (UAE). The bi-directional associations between self-reported PCOS and self-reported chronic diseases were evaluated by establishing temporality based on reported age-at-diagnoses. Firstly, the associations between PCOS (diagnosed at ≥25 years) and chronic diseases (diagnosed at <25 years) were examined, followed by PCOS (diagnosed at <25 years) and chronic diseases (diagnosed at ≥25 years). Finally, a Poisson regression under unadjusted and age-and-body mass index (BMI) adjusted models was performed to obtain the risk ratio (RR) and its 95% confidence interval (CI).

Results

The prevalence of PCOS in this study was 25.9%. Those with asthma and high cholesterol diagnosed at <25 years had increased risks of PCOS diagnosed at ≥25 years (RR = 1.79, 95% CI: 1.17-2.76 for asthma; and RR = 1.61, 95% CI: 1.01-2.59 for high cholesterol), compared to those respective healthier counterparts, after adjusting for age and BMI. No significant association was observed between PCOS diagnosed at <25 years and respective chronic diseases diagnosed at ≥25 years.

Conclusion

PCOS prevalence among Emirati women was high. Asthma and high cholesterol in earlier life were associated with PCOS in later life. Understanding how chronic disease conditions and PCOS are associated in bi-directional ways may improve the surveillance of chronic disease conditions among women with PCOS and may also contribute to more targeted PCOS prevention strategies.

Mitochondrial Dysfunction in Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is a multi-causal condition. Among the genetic causes, variations in the mitochondrial DNA (mtDNA) are increasingly recognised as causative. PCOS not only occurs in known syndromic mitochondrial disorders due to pathogenic variants in the mtDNA but also in non-syndromic mitochondrial disorders. Additionally, mtDNA variants not causing a multi-system mitochondrial disorder but exclusively PCOS have been reported. Among the syndromic mitochondrial disorders, PCOS has been described in myoclonic epilepsy with ragged-red fibre (MERRF) syndrome. Among the non-syndromic mitochondrial disorders, PCOS has been described in association with insulin resistance. Several other studies suggest that mtDNA point mutations or mtDNA deletions can be associated with PCOS without manifesting in organs other than the ovaries. Evidence from animal studies suggests that function, morphology, and biogenesis of mitochondria in ovarian tissue are generally impaired in PCOS patients. In conclusion, there is increasing evidence that mtDNA variants play a pathophysiological role in the development of PCOS. Further studies are needed to establish the causal link between mtDNA variants and PCOS.

Polycystic Ovarian Syndrome in Aging Women: An Observational Study

Background: Polycystic ovarian syndrome (PCOS) in aging women has not been extensively studied, although it is a very common disorder. Most of the research has been conducted on women of the reproductive age group, although PCOS is a disease occurring in all age groups. This study aims to provide an idea of the PCOS pattern prevalent in aging women presenting at a tertiary care center in Eastern India.

Methods: This was a prospective, single-center, observational cohort study conducted over three years, from October 2016 to September 2019. A total of 36 patients between 35 and 65 years of age were found to have PCOS according to Rotterdam’s criteria during this period. These patients were prospectively followed up to study their demographic characteristics, symptoms, management, and outcomes.

Results: A total of 80% of the women were below 40 years of age, while only 20% were above 40. In total, 70% of the women were overweight or obese. Infertility was seen in 75% of patients below 40 years of age and 28% of patients above 40. Among these, 23 (95%) conceived successfully after proper management. The main presenting complaints were infertility and menstrual irregularities. With aging, diabetes increased from 24%, in below 40, to 28%, in above 40; hypertension increased from 13% to 28%. The occurrence of impaired oral glucose tolerance test (OGTT) and impaired lipid profile increased with age: from 48% to 57% and 13% to 28%, respectively.

Conclusion: PCOS in aging women causes considerable morbidity and greatly affects the quality of life, although it is less understood. Further research in this field is very much needed to understand and appropriately manage the problems in aging women, to improve their quality of life.

Women with polycystic ovary syndrome have poorer work ability and higher disability retirement rate at midlife: a Northern Finland Birth Cohort 1966 study

OBJECTIVE

Polycystic ovary syndrome (PCOS) presents with multiple comorbidities potentially affecting function. This was the first general population-based study to evaluate work ability, participation in working life, and disability retirement in middle-aged women with and without PCOS.

DESIGN

This is a cohort study.

METHODS

Women with PCOS (n = 280) and women without PCOS symptoms or diagnosis (n = 1573) were identified in the Northern Finland Birth Cohort in 1966 and were evaluated for self-rated work ability and potential confounders at age 46. Next, incidence rate ratios (IRRs) for disability and unemployment days were extracted from national registers during a prospective 2-year follow-up. Lastly, we assessed hazard ratios (HRs) for disability retirement between 16 and 52 years of age from national registers.

RESULTS

The women with PCOS reported poorer ability to work at age 46, especially due to poorer health. During the 2-year follow-up period, the affected women gained on average an additional month of disability and unemployment days, corresponding to an approximately 25% higher risk for both disability (IRR (95% CI): 1.25 (1.22-1.27)) and unemployment days (IRR (95% CI): 1.26 (1.23-1.28)) in models adjusted for health and socioeconomic factors. Lastly, we found a two-fold higher cumulative risk for disability retirement by age 52 compared to non-PCOS women (HR (95% CI): 1.98 (1.40-2.80)), which remained after adjusting for confounding factors (aHR (95% CI): 1.55 (1.01-2.38)).

CONCLUSIONS

PCOS is associated with lower participation in working life already in midlife. Acknowledging PCOS-related multimorbidity, concerted efforts are needed to support sustainable careers for women with PCOS.