Effects of androgen excess and body mass index on endothelial function in women with polycystic ovary syndrome

Polycystic ovary syndrome potentiates blood pressure and vascular responses to the cold pressor test

Polycystic ovary syndrome (PCOS) predisposes women to cardiovascular diseases. Blood pressure (BP) responses to the cold pressor test (CPT) predict future cardiovascular risk but have yet to be characterized in PCOS. Therefore, we compared BP responses to the CPT between females with PCOS [n = 10; age: 22 ± 3 yr, body mass index (BMI): 23.9 ± 3 kg/m2] and healthy controls (CTRL; n = 10; age: 22 ± 2 yr, BMI: 22.1 ± 2 kg/m2). BP (finger photoplethysmography calibrated to manual sphygmomanometry-derived values), femoral blood flow (duplex ultrasound), and vascular resistance [FVR; mean arterial pressure (MAP)/blood flow] were measured continuously at baseline and across a 3-min hand CPT. Venous blood samples were used to quantify the free androgen index (FAI; total testosterone/sex hormone binding globulin × 100). Baseline MAP was not different between PCOS and CTRL (87 ± 7 vs. 82 ± 11 mmHg, respectively; P = 0.25), nor was systolic BP (SBP; 109 ± 9 vs. 106 ± 7 mmHg; P = 0.42). Across the CPT, MAP and SBP were higher in PCOS than CTRL (main effects of group, both P < 0.05). Peak CPT induced increases in MAP (+12 ± 5 vs. +7 ± 4 mmHg; P = 0.04) and corresponding changes in SBP (+13 ± 7 vs. +7 ± 3 mmHg; P = 0.04) and FVR (+0.17 ± 0.08 vs. +0.02 ± 0.13 mmHg/mL/min; P = 0.01) were larger in PCOS than CTRL. Within-group regressions indicated that FAI was positively associated with relative increases in peak MAP (R2 = 0.72, P < 0.01) and corresponding changes in FVR (R2 = 0.83, P < 0.01) in females with PCOS but not in CTRL (MAP: R2 = 0.03, P = 0.62; FVR: R2 = 0.12, P = 0.41). Young, lean females with PCOS demonstrate exaggerated BP and vascular responses to the CPT that may be indicative of elevated cardiovascular risk mediated in part by the detrimental effects of elevated androgens.NEW & NOTEWORTHY Young, lean, and otherwise healthy females with polycystic ovary syndrome (PCOS) demonstrated exaggerated blood pressure responses to the cold pressor test (CPT) relative to controls. CPT responses were associated with bioavailable androgens, suggesting that hyperandrogenism contributes to exaggerated responses to the CPT in PCOS. Given associations between CPT responsiveness and the subsequent development of hypertension, these findings add to mounting evidence for increased cardiovascular risk even in lean females with PCOS.

Metabolic Syndrome, Hepatic Steatosis and Testosterone: A Matter of Sex

Hepatic steatosis is considered the hepatic manifestation of metabolic disorders. Its global prevalence is a growing public health concern, estimated to affect over 30% of the population. Steatosis is strictly linked to metabolic dysfunction, leading to the revised terminology of MASLD (metabolic dysfunction-associated steatotic liver disease). The disease often progresses in conjunction with metabolic syndrome components, significantly increasing cardiovascular and overall mortality risks. The interplay between sex hormones and metabolic dysfunction is crucial, with male hypogonadism and female hyperandrogenism exacerbating the risk and severity of hepatic steatosis. In men, testosterone deficiency is associated with increased visceral adiposity and insulin resistance, creating a vicious cycle of metabolic deterioration. Conversely, in women, hyperandrogenism, particularly in conditions like polycystic ovary syndrome, may lead to severe metabolic disturbances, including hepatic steatosis. Estrogen deficiency also contributes to central adiposity and metabolic syndrome. The aim of this paper is to discuss this complex sex-dimorphic relationship.

Hyperandrogenism and Cardiometabolic Risk in Pre- and Postmenopausal Women-What Is the Evidence?

Hyperandrogenism in women, such as polycystic ovary syndrome, ovarian hyperthecosis, congenital adrenal hyperplasia, and androgen-secreting tumors, are all associated with increased prevalence of cardiovascular risk factors that include type 2 diabetes, hypertension, dyslipidemia, and metabolic syndrome. However, it is not clear whether this also implies enhanced risk of cardiovascular disease and mortality. Furthermore, the involvement of obesity and menopausal status for cardiometabolic risk in these women has not been elucidated. Based on the most recent systematic reviews and meta-analyses, this review summarizes the latest scientific evidence. To conclude, hyperandrogenism in premenopausal women is associated with enhanced prevalence of cardiovascular risk factors, as well as increased risk of cardiovascular disease and mortality, independently of body mass index. In contrast, elevated cardiovascular risk factors and increased risk of myocardial infarction and stroke in hyperandrogenic postmenopausal women are dependent on obesity. Furthermore, the overall risk of cardiovascular disease and coronary artery disease in hyperandrogenic postmenopausal women is similar to controls. The reason for a reduced cardiometabolic risk after menopause in hyperandrogenic women compared to nonhyperandrogenic women is not clear. It can be speculated that the difference in endocrine balance and metabolic status between women with and without hyperandrogenism might decrease after menopause because hyperandrogenism usually improves with age, whereas menopausal transition itself is associated with androgen dominance and abdominal obesity. Although we have gained increased knowledge about cardiometabolic risks in women with hyperandrogenism, it must be acknowledged that the quality of data is overall low. More research is needed, especially longer and larger follow-up studies in women with hyperandrogenism of different etiologies and phenotypes.

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.

Guidelines on the use of sex and gender in cardiovascular research

In cardiovascular research, sex and gender have not typically been considered in research design and reporting until recently. This has resulted in clinical research findings from which not only all women, but also gender-diverse individuals have been excluded. The resulting dearth of data has led to a lack of sex- and gender-specific clinical guidelines and raises serious questions about evidence-based care. Basic research has also excluded considerations of sex. Including sex and/or gender as research variables not only has the potential to improve the health of society overall now, but it also provides a foundation of knowledge on which to build future advances. The goal of this guidelines article is to provide advice on best practices to include sex and gender considerations in study design, as well as data collection, analysis, and interpretation to optimally establish rigor and reproducibility needed to inform clinical decision-making and improve outcomes. In cardiovascular physiology, incorporating sex and gender is a necessary component when optimally designing and executing research plans. The guidelines serve as the first guidance on how to include sex and gender in cardiovascular research. We provide here a beginning path toward achieving this goal and improve the ability of the research community to interpret results through a sex and gender lens to enable comparison across studies and laboratories, resulting in better health for all.

Is polycystic ovary syndrome associated with elevated muscle sympathetic nerve activity?

Polycystic ovary syndrome (PCOS) is a complex disorder characterized by reproductive abnormalities, cardiometabolic disturbances and a heightened risk of cardiovascular disease. A small but compelling body of research demonstrates that females with PCOS present with elevated muscle sympathetic nerve activity (MSNA) at rest. Heightened MSNA is present in lean, overweight and obese females with PCOS, but limited evidence suggests that androgens may be more strongly linked to elevated MSNA in lean females with PCOS than in obese females with PCOS. Although the specific mechanisms underlying elevated MSNA in PCOS remain elusive, sympathetic activation is implicated in the progression of several cardiovascular diseases and may contribute to the cardiovascular pathophysiology of PCOS. Encouragingly, MSNA appears responsive to non-pharmacological intervention, making the sympathetic nervous system a promising therapeutic target to mitigate cardiovascular risk in PCOS. This brief review summarizes the existing evidence regarding elevated MSNA, cardiovascular risk profile and vascular function, as well as the potential for clinical intervention and future research directions in females with PCOS. NEW FINDINGS: What is the topic of this review? The presence of elevated muscle sympathetic nerve activity in females with polycystic ovary syndrome and the implications for cardiovascular health. What advance does it highlight? The sympathetic nervous system likely contributes to elevated cardiovascular disease risk in females with polycystic ovary syndrome. Moreover, it presents as a promising therapeutic target for mitigating cardiovascular disease and merits further investigation.