Cardiovascular disease risk in women with premature ovarian insufficiency: A systematic review and meta-analysis

Causal associations between premature ovarian insufficiency and cardiovascular diseases: a Mendelian randomization study

To date, there remains a paucity of prospective studies examining the association between premature ovarian insufficiency (POI) and cardiovascular diseases (CVD). The objective of this study was to investigate the potential association between POI and CVD utilizing the method of Mendelian randomization (MR). MR analyses utilized summary statistics from the most extensive genome-wide association studies (GWAS) on POI and CVD extracted from European ancestry cohorts and the FinnGen biobank. The inverse variance-weighted (IVW) method was the primary MR analysis technique. Supplementary analyses were performed using MR-Robust Adjusted Profile Score (MR-RAPS). Cochran's Q statistic, MR-Egger, and weighted median MR models were employed to further assess heterogeneity and horizontal pleiotropy. Causal effects of POI on coronary heart disease (odds ratio [OR] = 1.048, 95% confidence interval [CI]: 1.006-1.091; p = 0.023)] and ischemic stroke (OR = 1.010, 95% CI: 1.000-1.020; p = 0.0498) were found. However, we did not observe a significant correlation between POI and hypertension (OR = 0.999, 95% CI: 0.994-1.004, p = 0.691), heart failure (OR = 1.009, 95% CI: 0.999-1.020, p = 0.0725), atrial fibrillation (OR = 0.995, 95% CI: 0.986-1.004, p = 0.3035), and myocardial infarction (OR = 1.002, 95% CI: 0.991-1.013, p = 0.7061). POI was causally associated with coronary heart disease and ischemic stroke, with no apparent impact on hypertension, heart failure, atrial fibrillation, or myocardial infarction. The causal relationship between POI and CVD underscores the imperative for proactive cardiovascular risk management in individuals with POI.

Frontiers of premature ovarian insufficiency research: an analysis from the top 100 most influential articles in the field

Objectives: Premature ovarian insufficiency (POI) is a serious condition that affects women worldwide, In recent years, the number of research publications on POI has increased over the last decades because of the advancement of cutting-edge research in gynecology and the deepening of disciplinary interactions. At the same time, there is a more urgent need to systematically analyze and review existing studies to generalize the research paradigm and disciplinary structure of the field under technological changes.

Materials and methods: We selected the top 100 most cited papers in the Web of Science (WOS) SCI-Expanded database. Knowledge graphs were constructed through the VOS viewer, Cite Space, and Scimago Graphica software, and then relevant information retrieved from the literature was edited using Excel to assess research priorities and trends in the field.

Results: A total of 53 periodicals from 34 different nations and regions published the 100 most-cited publications between 1999 and 2024. The Journal of Clinical Endocrinology & Metabolism published the majority of the papers, while The Lancet had the highest average number of citations per piece. The United States of America produced the highest contribution in terms of publications, with China and France closely trailing after. In terms of total publications, Erasmus MC, Shanghai Jiao Tong University, and Shandong University each contributed the highest number of papers. The main categories were obstetrics and gynecology, endocrinology and metabolism, and reproductive biology. The top five keywords were: failure, women, ANTI-MULLERIAN HORMONE, NATURAL MENOPAUSE, and AGE. The study of HERITAGE AND GENETICS, CARDIOVASCULAR DISEASES, and CELL BIOLOGY AND IMMUNOGENETICS is becoming more and more popular in POI, as shown by cluster analysis.

Conclusions: Bibliometric analysis enables POI researchers to efficiently and visibly pinpoint the cutting-edge areas and focal points of their study. Potential topics of future study may include genetic and molecular biological pathways, cardiovascular pathology, and immunology.

Lipid metabolism in women: A review

The menopausal transition, defined by the cessation of menstruation due to declining ovarian follicular function, results in a marked decrease in endogenous estrogen levels. This phase is associated with significant metabolic changes and a shift towards a more atherogenic lipid profile. Specifically, there are increases in total cholesterol, low-density lipoprotein cholesterol, and triglycerides and unfavorable alterations in high-density lipoprotein cholesterol and lipoprotein(a) levels. These lipid changes, which contribute to an increased risk of atherosclerotic cardiovascular disease, are influenced by diminished estrogen levels and chronological aging. However, the specific mechanisms driving this increased risk are not fully understood. A thorough understanding of these lipid profile alterations is important for developing strategies to reduce cardiovascular disease risk in women. This review provides an overview of how lipid metabolism is affected during the menopausal transition and the resulting implications for cardiovascular risk.

No increased arterial stiffness after premenopausal risk-reducing salpingo-oophorectomy (RRSO)

OBJECTIVE

Women at high familial risk of ovarian cancer are recommended to undergo premenopausal risk-reducing salpingo-oophorectomy (RRSO). The procedure leads to immediate surgical menopause, and while early natural menopause is associated with an increase in the risk of cardiovascular disease (CVD), evidence on CVD risk after surgical menopause is inconsistent.

MAIN OUTCOME MEASURES

To investigate the long-term CVD risk after surgical menopause we conducted a cross-sectional study comparing a group of women who underwent a premenopausal RRSO (≤45 years) with a group who underwent postmenopausal RRSO (≥54 years). We assessed arterial stiffness, measured by pulse wave velocity (PWV). Increased PWV has been shown to be an independent predictor for CVD. Age differences between the pre- and postmenopausal RRSO groups were accounted for by restricting analyses to women aged 60-70 at study visit (n = 307). Within the premenopausal RRSO group (n = 461), we also examined the effect of timing of premenopausal RRSO on PWV (RRSO<41 vs RRSO 41-45 years). In addition, we assessed the association between PWV and coronary artery calcium (CAC) in women who underwent premenopausal RRSO.

RESULTS

In women aged 60-70 at study visit, PWV levels were significantly lower in the premenopausal RRSO group compared with the postmenopausal RRSO group (β: -0.87, 95 % CI, -1.45, -0.28 for PWV level; RR: 0.47, 95 % CI, 0.24, 0.93 for being in the upper PWV quintile). The timing of premenopausal RRSO did not influence PWV. Among all women who underwent premenopausal RRSO, having a PWV in the upper quintile was an independent predictor of the presence of CAC (RR 1.32, 95 % CI, 1.04-1.68 for CAC > 0).

CONCLUSION

Our study does not support a long-term adverse effect of premenopausal RRSO on arterial stiffness, but increased arterial stiffness is associated with the presence of CAC in women who have undergone a premenopausal RRSO.

CLINICAL TRIAL REGISTRATION

The pre-registered clinical trial number is .

Menopause-related changes in vascular signaling by sex hormones

Cardiovascular disease (CVD), such as hypertension and coronary artery disease, involves pathological changes in vascular signaling, function, and structure. Vascular signaling is regulated by multiple intrinsic and extrinsic factors that influence endothelial cells, vascular smooth muscle, and extracellular matrix. Vascular function is also influenced by environmental factors including diet, exercise, and stress, as well as genetic background, sex differences, and age. CVD is more common in adult men and postmenopausal women than in premenopausal women. Specifically, women during menopausal transition, with declining ovarian function and production of estrogen (E2) and progesterone, show marked increase in the incidence of CVD and associated vascular dysfunction. Mechanistic research suggests that E2 and E2 receptor signaling have beneficial effects on vascular function including vasodilation, decreased blood pressure, and cardiovascular protection. Also, the tangible benefits of E2 supplementation in improving menopausal symptoms have prompted clinical trials of menopausal hormone therapy (MHT) in CVD, but the results have been inconsistent. The inadequate benefits of MHT in CVD could be attributed to the E2 type, dose, formulation, route, timing, and duration as well as menopausal changes in E2/E2 receptor vascular signaling. Other factors that could affect the responsiveness to MHT are the integrated hormonal milieu including gonadotropins, progesterone, and testosterone, vascular health status, preexisting cardiovascular conditions, and menopause-related dysfunction in the renal, gastrointestinal, endocrine, immune, and nervous systems. Further analysis of these factors should enhance our understanding of menopause-related changes in vascular signaling by sex hormones and provide better guidance for management of CVD in postmenopausal women. SIGNIFICANCE STATEMENT: Cardiovascular disease is more common in adult men and postmenopausal women than premenopausal women. Earlier observations of vascular benefits of menopausal hormone therapy did not materialize in randomized clinical trials. Further examination of the cardiovascular effects of sex hormones in different formulations and regimens, and the menopausal changes in vascular signaling would help to adjust the menopausal hormone therapy protocols in order to enhance their effectiveness in reducing the risk and the management of cardiovascular disease in postmenopausal women.

Endogenous sex hormone levels are associated with the revised Framingham Stroke Risk Profile in postmenopausal women: a longitudinal study in a Swedish cohort

BACKGROUND

Endogenous sex hormones in postmenopausal women have been associated with risk of cardiovascular diseases. The aim of this study was to determine the association between endogenous sex hormones and the revised Framingham Stroke Risk Profile (rFSRP) in postmenopausal women.

METHODS

This is an observational cross-sectional study on the Vara-Skövde cohort, a Swedish population-based study for longitudinal surveillance of the development and progress of type 2 diabetes and hypertension. The participants were physically examined in 2002-2005 and sex hormones were analysed with liquid chromatography-tandem mass spectrometry assay (LC-MS/MS). Women who were ≥55 years old, with estradiol levels below 20 pg/mL, not using hormonal therapy, and with no self-reported history of stroke, were included (N = 133). The outcome variable was rFSRP. Regression analyses of log-transformed rFSRP were fitted against levels of sex hormones (17-α-OH-progesterone, estrone, estradiol, progesterone, dihydrotestosterone, dehydroepiandrosterone, testosterone and androstenedione), adjusting for body mass index (BMI) or waist-to-hip ratio (WHR), C-reactive protein (CRP) and cholesterol level.

RESULTS

Levels of estrone and estradiol were positively associated with rFSRP in the crude model (estrone β = 0.208, 95% CI = 0.081;0.336, P = 0.002; estradiol β = 0.170, CI = 0.034;0.305, P = 0.015). Adjustments for BMI revealed significant positive associations between progesterone (β = 0.155 95% CI = 0.025;0.285, P = 0.020), estrone (β = 0.167, 95% CI = 0.037;0.297, P = 0.013) and 17-α-OH-progesterone (β = 0.146, 95% CI = 0.014; 0.277, P = 0.030) and rFSRP, and adjustments for WHR revealed a significant positive association between testosterone and rFSRP (β = 0.152, CI = 0.026;0.278, p = 0.018).

CONCLUSIONS

Increase of estrone was associated with higher rFSRP, also in the fully adjusted model, whereas progesterone, 17-α-OH-progesterone and testosterone were significant only in the models adjusting for BMI and WHR respectively. Larger studies studying stroke events are warranted to confirm these findings.

CLINICAL TRIAL NUMBER

Not applicable.

Cardiovascular Health Considerations for Primary Care Physicians Treating Breast Cancer Survivors

Breast cancer (BC) survivors are at increased risk for cardiovascular disease (CVD) and require their primary care physicians to manage their long-term general medical care, including cardiovascular (CV) health. Yet, evidence exists that some primary care physicians possess insufficient knowledge about survivorship care. With the goal of bridging these knowledge gaps, a PubMed review was conducted from July 7, 2020, through October 2, 2020, with an updated PubMed review from January 3, 2024, through April 28, 2024, focusing on CV health considerations in the primary care of BC survivors. Search terms included variations of "breast cancer survivors" and "cardiovascular." In total, 152 publications were included. Breasts cancer survivors may have increased CVD risk because some anticancer therapies are cardiotoxic and risk factors for BC often also increase the risk for CVD. Multiple risk factors overlap for BC and CVD such as older age, Western diet, early menarche, physical inactivity, high body mass index, and smoking. In this review, results are summarized from studies that report the presence of CV risk factors and CVD in BC survivors. Also described are the CV effects of BC therapies (chemotherapy, hormonal agents, targeted therapies, and radiotherapy) and the type of CV evaluation (cardiac imaging and measurement of biomarkers) that these patients may need. Primary care physicians have an important role in managing the CV health of BC survivors from preventing, assessing, and managing CV risk factors to referring patients to appropriate specialists when needed.

Network Pharmacology, Molecular Docking, and Experimental Validation on Guiluoshi Anzang Decoction Against Premature Ovarian Insufficiency

BACKGROUND AND OBJECTIVES

Premature Ovarian Insufficiency (POI) is a disease suffered by women under the age of 40 when ovarian function has declined, seriously affecting both the physical and mental health of women. Guiluoshi Anzang decoction (GLSAZD) has been used for a long time and has a unique therapeutic effect on improving ovarian function. This study aims to investigate the mechanism of GLSAZD in treating POI through network pharmacology, molecular docking, and experimental verification.

METHODS

In this study, the active ingredients of Guiluoshi Anzang Decoction and the targets of POI were obtained from TCMSP, BATMANN-TCM, Uniprot, GeneCards, and other databases, and network pharmacology analysis was performed. Molecular docking was conducted to validate the affinity of the main active ingredient of GLSAZD to key POI targets. A POI SD rat model was established, and HE staining, ELISA, Real-time PCR, and Western blot experiments were performed to verify the predicted core targets and the therapeutic effects.

RESULTS

10 core targets and the top 5 ingredients were screened out. Molecular docking showed core targets AKT1, CASP3, TNF, TP53, and IL6 had stable binding with the core 5 ingredients quercetin, kaempferol, beta-sitosterol, luteolin, and Stigmasterol. GO and KEGG enrichment analysis demonstrated the mechanism involved in the positive regulation of gene expression, PI3K-AKT signaling pathway, and apoptosis signaling pathways. Animal experiments indicated GLSAZD could up-regulate the protein expression of p-PI3K and p-AKT1 and the mRNA expression of STAT3 and VEGF, down-regulate TP53 and Cleaved Caspase-3 protein expression in rat`s ovarian tissues and serum TNF-α and IL-6 protein levels, activate PI3K-AKT signaling pathway and inhibit the apoptosis signaling pathway.

CONCLUSION

GLSAZD treats POI through multi-component, multi-target, and multi-pathway approaches. This study provided evidence for its clinical application in treating POI and shed light on the study of traditional medicine of the Guangxi Zhuang Autonomous Region in China.

Female-specific risk factors for cardiovascular disease: an update

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide. While it was previously believed that men have greater susceptibility to CVD, recent research suggests that women face an increased risk of CVD after the onset of menopause, primarily due to the loss of the protective effects of estrogens. Premature ovarian insufficiency (POI), polycystic ovarian syndrome (PCOS), and gestational factors, such as gestational diabetes mellitus (GDM), recurrent pregnancy loss, preterm delivery, and preeclampsia, are specific reproductive disorders that may contribute to an elevated risk of CVD at earlier ages, i.e., before the onset of menopause. This suggests that women with these conditions should be closely monitored for CVD risk factors even before reaching menopause. Such early intervention may help reduce the incidence of CVD and improve overall cardiovascular health in this population. The precise pathophysiological mechanism underlying the development of CVD in women with menopause, premature POI, PCOS, and gestational factors remains elusive. This review article seeks to elucidate the latest research on the relationship between these conditions and CVD in women, aiming to explore the underlying pathogenic mechanisms contributing to this association.

Impaired IL-27 signaling aggravates macrophage senescence and sensitizes premature ovarian insufficiency induction by high-fat diet

Premature ovarian insufficiency (POI) critically affects female reproductive health, with obesity being a significant and recognized risk factor. Interleukin-27 (IL-27), known for its role in immune modulation and inflammation, has garnered attention in metabolic syndrome research. Nonetheless, the role of these immunometabolic factors on the initiation of POI remains to be unraveled. Our investigation delves into the influence of impaired IL-27 signaling on POI induction, particularly under the challenge of a high-fat diet (HFD). We analyzed patients' serum profiles and established a correlation of increased serum triglycerides with decreased IL-27 levels in POI cases. Experiments on C57BL/6 mice lacking the IL-27 receptor alpha (Il27ra-/-) revealed that when subjected to HFD, these mice developed hallmark POI symptoms. This includes escalated lipid deposition in both liver and ovarian tissues, increased ovarian macrophages cellular aging, and diminished follicle count, all pointing to compromised ovarian function. These findings unveil a novel pathway wherein impaired IL-27 signaling potentiates the onset of POI in the presence of HFD. Understanding the intricate interplay between IL-27, metabolic alterations, and immune dysregulation sheds light on potential therapeutic avenues for managing POI, offering hope for improved reproductive health outcomes.

Vaginal microbiome of women with premature ovarian insufficiency: a descriptive cross-sectional study

OBJECTIVE

This study aimed to describe the vaginal microbiome of women with premature ovarian insufficiency (POI) receiving systemic hormone therapy (HT).

METHODS

Forty women with POI receiving systemic HT for at least 6 months, who were sexually active, were included in the descriptive cross-sectional study. Vaginal secretion was collected for DNA extraction followed by pyrosequencing of the 16S rRNA. The samples were pooled into phylogenetic groups (Ravel groups I-V).

RESULTS

Women had mean age of 37.13 (± 7.27) years and POI diagnosis at age 27.90 (± 8.68) years, and a mean HT duration of 8.20 (± 8.73) years. It was observed that 33.4% of the women presented group I flora, with a predominance of Lactobacillus crispatus; 9% group II flora, with a predominance of Lactobacillus gasseri; 33.4% group III flora, with a predominance of Lactobacillus iners; 15.2% group IV flora, with a predominance of anaerobic bacteria; and 9% group V flora, with a predominance of Lactobacillus jensenii.

CONCLUSION

Women with POI receiving HT presented a vaginal microbiome with a predominance of lactobacilli in the composition of the vaginal flora, specifically L. crispatus and L. iners when evaluated by molecular biology through pyrosequencing of 16S rRNA.

Coronary Artery Calcium Scores After Prophylactic Premenopausal Bilateral Salpingo-Oophorectomy

Background

Premenopausal risk-reducing salpingo-oophorectomy (RRSO) in women at high familial risk of ovarian cancer leads to immediate menopause. Although early natural menopause is associated with increased cardiovascular disease risk, evidence on long-term cardiovascular disease risk after early surgical menopause is scarce.

Objectives

We sought to determine the long-term influence of the timing of RRSO on the development of coronary artery calcium (CAC), an established marker for cardiovascular disease risk.

Methods

We conducted a cross-sectional study (N = 733) nested in a nationwide cohort of women at high familial risk of ovarian cancer. In women aged 60-70 years (n = 328), we compared CAC scores between women with a premenopausal RRSO (age ≤45 years) and women with a postmenopausal RRSO (age ≥54 years), using multivariable Poisson analyses. Within the premenopausal RRSO group (n = 498), we also examined the effect of age at RRSO. In addition, we compared the premenopausal RRSO group with an external reference cohort (n = 5,226).

Results

Multivariable analyses showed that the prevalence rates of any CAC (CAC >0), at least moderate CAC (CAC >100), and severe CAC (CAC >400) were comparable between the premenopausal and postmenopausal RRSO groups (relative risk [RR]: 0.93; 95% CI: 0.75-1.15 for any CAC; RR: 0.71; 95% CI: 0.43-1.17 for at least moderate CAC; RR: 0.81; 95% CI: 0.30-2.13 for severe CAC). There was no difference in CAC between the premenopausal RRSO group and a similar aged reference cohort. Timing of premenopausal RRSO (early premenopausal RRSO [<41 years] vs late premenopausal RRSO [41-45 years]) did not affect the outcomes.

Conclusions

Our results do not show a long-term adverse effect of surgical menopause on the development of CAC.

Living a Cancer Surveillance Life: A Meta-Ethnographic Synthesis of Everyday Experiences and Ambivalences for Women Living With Hereditary Risk of Breast and/or Ovarian Cancer

OBJECTIVE

Women with or at risk of hereditary breast- and ovarian cancer (HBOC) often live a surveillance-focused life from young adulthood. As they navigate a life of heightened medical vigilance, or a "cancer surveillance life," we explore how women with HBOC, as well as their partners and families, experience this particular kind of living through a thorough literature review of existing qualitative research.

METHODS

We performed Boolean searches in PubMed, EMBASE, EBSCOhost, PSYCHinfo, Scopus, and Web of Science from April-May 2022, identifying 506 relevant articles. After eliminating duplicates and quantitative studies, we systematically analyzed 53 articles. Articles examining all aspects of living with HBOC were eligible for inclusion. Following quality assessment by a verified appraisal tool, 28 articles were included in this review. We undertook an "a-lines-of-argument synthesis," and identified key similarities across studies to highlight generalizable aspects of living with HBOC.

RESULTS

We discovered five central themes which capture the ambivalences experienced by women living with HBOC: (1) an unresolved balancing act regarding genetic testing (2) burdens of relaying genetic information within the family (3) experienced risk discrepancies (4) preservation of the self and: (5) unsettled reproductive feelings.

CONCLUSIONS

Living with HBOC is filled with ambivalences, which are critical for decision making concerning disclosing risks to family members and children, choosing between risk-reducing surgeries or surveillance, and family planning. Healthcare professionals should be aware of these findings when counseling women and families with HBOC to provide the best support possible in navigating their unique kind of living.

Menstrual cycle and the protective effects of remote ischemic preconditioning against endothelial ischemia/reperfusion injury: comparison with postmenopausal women

The aim of this study was to determine whether the capacity of remote ischemic preconditioning (IPC) against endothelial ischemia/reperfusion (I/R) injury changes across the menstrual cycle in premenopausal women and to compare IPC responses to postmenopausal women. Thirty-five women were studied (22 premenopausal/13 postmenopausal). Changes in endothelial function were determined during the early follicular vs. the late follicular phase (after positive urine ovulation test; Study 1), vs. the mid-luteal phase (after positive urine progesterone test; Study 2), and vs. estrogen-deficient postmenopausal women; Study 3). Endothelium-dependent vasodilation was assessed by the forearm blood flow (FBF) to reactive hyperemia with/without I/R injury with remote IPC (3 × 5 min cycles of upper arm ischemia). In the premenopausal women, peak FBF responses during the early follicular phase were blunted 20% (P < 0.0001) with I/R injury (from baseline: 23.4 ± 6.2 to 19.5 ± 4.9 mL/100 mL tissue/min) compared with the late follicular/mid-luteal phases despite IPC. In postmenopausal women, peak FBF was diminished (from: 21.1 ± 5.1 to 17.2 ± 4.4 mL/100 mL tissue/min), and total FBF (area under the curve) was decreased a third (-32%; P < 0.001) with I/R injury. Protection from I/R injury was preserved during the late follicular (from baseline: 21.7 ± 5.3 to 24.8 ± 5.9 mL/100 mL tissue/min; P = 0.109) and mid-luteal phases (from: 25.1 ± 3.9 to 27.2 ± 5.7 mL/100 mL tissue/min; P = 0.267). Reduced estrogen during the early follicular phase and the rise in estrogen associated with ovulation and the mid-luteal phase may contribute to changes in IPC-mediated protection in premenopausal women and shed light on how cardioprotection may change with ovarian hormone deficiency with the menopause transition.NEW & NOTEWORTHY The capacity of remote ischemic preconditioning to protect against vascular endothelial ischemia/reperfusion injury varies widely across the phases of the menstrual cycle in healthy premenopausal women. Robust protection was afforded during the late follicular and mid-luteal phases. In contrast, weakened protection was demonstrated during the early follicular phase, with a level of impairment similar to estrogen-deficient postmenopausal women.

Mesenchymal stem cell-derived extracellular vesicles therapy for primary ovarian insufficiency: a systematic review and meta-analysis of pre-clinical studies

BACKGROUND

Primary ovarian insufficiency (POI) manifests with hormonal imbalances, menstrual irregularities, follicle loss, and infertility. Mesenchymal stem cell-derived extracellular vesicles (MSC-EVs) are emerging as a promising treatment for POI. This systematic review aims to assess the effects of MSC-EVs on follicle number, hormonal profile, and fertility in POI animal models.

METHODS

A systematic search of PubMed, Scopus, and Web of Science databases up to December 14th, 2023 was conducted. Two reviewers independently conducted screening, risk of bias assessment, and data extraction. Meta-analysis was performed to analyze treatment versus control outcomes using a random effects model. Publication bias was assessed using Egger's regression test and sensitivity analysis was assessed using the leave-one-out method. Subgroup analyses and meta-regressions were conducted based on EV source, induction model, type of animal, study quality, administration route, administration frequency and route, and dose.

RESULTS

a total of 29 studies were included. MSC-EVs treatment significantly increased total follicle count (SMD, (95CI), p-value; 3.56, (0.91, 6.21), < 0.001), including primordial (SMD, (95CI), p-value; 2.86, (1.60, 4.12), < 0.001), primary (SMD, (95CI), p-value; 3.17, (2.28, 4.06), < 0.001), mature (SMD, (95CI), p-value; 2.26, (1.02, 3.50), < 0.001), and antral follicles (SMD, (95CI), p-value; 2.44, (1.21, 3.67), < 0.001). Administration frequency and route did not affect this outcome, but EV source affected primordial, primary, secondary and antral follicle count. Additionally, MSC-EVs treatment elevated anti-müllerian hormone (SMD, (95CI); 3.36, (2.14, 4.58)) and estradiol (SMD, (95CI); 3.19, (2.20, 4.17)) levels while reducing follicle stimulating hormone levels (SMD, (95CI); -2.68, (-4.42, -0.94)). Unlike EV source, which had a significant impact on all three hormones, administration frequency, route, and EV dose did not affect this outcome. Moreover, treatment increased offspring number (SMD, (95CI); 3.70, (2.17, 5.23)) and pregnancy odds (OR, (95CI); 10.25, (4.29, 24.46)) compared to controls. Publication bias and a high level of heterogeneity was evident in all analyses, except for the analysis of the pregnancy odds. However, sensitivity analysis indicated that all of the analyses were stable.

CONCLUSION

MSC-EVs therapy shows promise for POI treatment, potentially facilitating clinical translation. However, Further research is warranted to optimize methodology and assess side effects.

Bushen Huoxue formula attenuates lipid accumulation evoking excessive autophagy in premature ovarian insufficiency rats and palmitic acid-challenged KGN cells by modulating lipid metabolism

Introduction

Premature ovarian insufficiency (POI) has affected about 3.7% of women of reproductive age and is a major factor contributing to infertility. Bushen Huoxue formula (BHF), a traditional Chinese medicine prescription, is clinically used to treat POI in China. This study aims to investigate the potential mechanisms of BHF in combating POI using corticosterone-induced rats and palmitic acid (PA)-challenged human ovarian granulosa cells (GCs).

Methods

Initially, ultra performance liquid chromatography tandem mass spectrometry was employed to analyze the components of BHF. The pharmacodynamic parameters evaluated included body weight, ovaries index, and serum hormone in rats. Follicle numbers were observed using H&E staining. Additionally, PCNA and TUNEL staining were used to assess GCs proliferation and apoptosis, respectively. Lipid accumulation and ROS levels were examined using Oil Red O and ROS staining. Protein expressions were determined by western blot. To probe mechanisms, cell viability and E2 levels in BHF-treated, PA-stimulated GCs were determined using MTT and ELISA, respectively. Cell apoptosis and ROS levels were assessed using TUNEL and ROS staining. Proteins related to lipid metabolism and autophagy in PA-stimulated GCs were studied using agonists.

Results

Our results shown that BHF effectively normalized serum hormone levels, including follicle-stimulating hormone (FSH), anti-Müllerian hormone (AMH), estradiol (E2), and luteinizing hormone (LH). Concurrently, BHF also significantly reduced follicular atresia and promoted cell proliferation while inhibiting apoptosis in POI rats. Furthermore, BHF mitigated ovarian lipid accumulation by modulating lipid metabolism, which included reducing lipid synthesis (expression of peroxisome proliferator-activated receptor γ and CCAAT/enhancer binding protein α), increasing lipid catabolism (expression of adipose triglyceride lipase), and enhancing lipid oxidation (expression of carnitine palmitoyl transferase 1A). Mechanistically, the therapeutic effects of BHF on POI were linked with alleviation of lipid deposition-induced reactive oxygen species (ROS) accumulation and excessive autophagy, corroborating the results in PA-challenged GCs. After treatment with elesclomol (a ROS inducer) and rapamycin (an autophagy inducer) in GCs, the effects of BHF were almost counteracted under model conditions.

Conclusion

These findings suggest that BHF alleviates the symptoms of POI by altering lipid metabolism and reducing lipid accumulation-induced ROS and autophagy, offering evidence for BHF's efficacy in treating POI clinically.

Metabolic benefits afforded by estradiol and testosterone in both sexes: clinical considerations

Testosterone (T) and 17β-estradiol (E2) are produced in male and female humans and are potent metabolic regulators in both sexes. When E2 and T production stops or decreases during aging, metabolic dysfunction develops and promotes degenerative metabolic and vascular disease. Here, we discuss the shared benefits afforded by E2 and T for metabolic function human females and males. In females, E2 is central to bone and vascular health, subcutaneous adipose tissue distribution, skeletal muscle insulin sensitivity, antiinflammatory immune function, and mitochondrial health. However, T also plays a role in female skeletal, vascular, and metabolic health. In males, T's conversion to E2 is fundamental to bone and vascular health, as well as prevention of excess visceral adiposity and the promotion of insulin sensitivity via activation of the estrogen receptors. However, T and its metabolite dihydrotestosterone also prevent excess visceral adiposity and promote skeletal muscle growth and insulin sensitivity via activation of the androgen receptor. In conclusion, T and E2 are produced in both sexes at sex-specific concentrations and provide similar and potent metabolic benefits. Optimizing levels of both hormones may be beneficial to protect patients from cardiometabolic disease and frailty during aging, which requires further study.

Assessment of left ventricular myocardial systolic dysfunction in premature ovarian insufficiency patients using echocardiographic layer-specific myocardial strain imaging

BACKGROUND

Due to the lack of oestrogen, premature ovarian insufficiency (POI) is an independent risk factor for ischaemic heart disease and overall cardiovascular disease. This study aimed to apply layer-specific myocardial strain for early quantitative evaluation of subclinical left ventricular myocardial systolic function changes in patients with POI.

METHODS

Forty-eight newly diagnosed, untreated patients with POI (POI group) and fifty healthy female subjects matched for age, height and weight (control group) were enrolled. Standard transthoracic echocardiography was used to measure conventional parameters and layer-specific strain parameters.The layer-specific strain parameters included subendomyocardial global longitudinal strain (GLSendo), mid-layer myocardial global longitudinal strain (GLSmid), subepimyocardial global longitudinal strain (GLSepi), subendomyocardial global circumferential strain (GCSendo), mid-layer myocardial global circumferential strain (GCSmid), and subepimyocardial global circumferential strain (GCSepi).

RESULTS

There were no significant differences in age, body mass index (BMI), blood pressure, or left ventricular ejection fraction (LVEF) between the two groups. The end-diastolic interventricular septal thickness (IVST) was greater in the POI group (8.29 ± 1.32 vs. 7.66 ± 0.82, P = 0.008), and the POI group had lower E, E/A, and lateral e' (all P < 0.05). As for systolic functions,the POI group had lower GLSendo, GLSmid, GLSepi, GCSendo, GCSmid, and GCSepi (all P < 0.05).The intraobserver and interobserver coefficients of GLSendo, GLSmid, GLSepi, GCSendo, GCSmid, and GCSepi were greater than 0.900.

CONCLUSIONS

POI patients with normal LVEF may suffer from subclinical left ventricular myocardial systolic dysfunction. Echocardiography of layer-specific myocardial strain could more sensitively detect subclinical impairment of left ventricular systolic function in POI patients.

Introducing a value-based healthcare approach for women with premature ovarian insufficiency (POI): Recommendations for patient-centered outcomes in clinical practice

OBJECTIVE

To establish a set of clinician and patient-reported outcome measures (PROMs) and present the initial findings of a value-based healthcare (VBHC) program in patients with premature ovarian insufficiency (POI).

METHODS

Employing a four-phase approach, we identified the most crucial domains for patients with POI and translated these into PROMs. Prior to each visit, patients completed questionnaires to evaluate: depression (BDI-II), menopausal symptoms (GCS), work ability (WAS) and infertility (FertiQoL). During the visits, cardiovascular health assessments and dual-energy X-ray absorptiometry (DEXA) scans to measure bone mineral density were performed. Data at intake is presented, and comparisons are drawn between women using and those not using hormone replacement therapy (HRT). Patient-reported experience measures (PREMs) were evaluated by a questionnaire.

RESULTS

A total of 267 POI patients completed the PROM questionnaires, of whom 58.1 % were using HRT at intake. Over half of the patients (53.5 %), had a BDI-II score of 14 or higher, indicating mild to severe depression. The mean total GCS score was 20.9 (SD 11.3). The median work ability score was 7.5 (IQR 6.0-8.0) and the mean FertiQoL score 63.9 (SD 15.7). Additionally, 22.7 % of patients presented with hypertension, 6.2 % with hypercholesterolemia, and almost 50 % had low bone mass. Patients rated the VBHC program with a mean of 8.6 (SD 1.2).

CONCLUSIONS

These findings underscore the necessity of a multidisciplinary VBHC program incorporating standardized screening and psychological treatment. We advocate for the implementation of patient-centered outcomes for clinical practice, which have been found to be highly relevant by patients with POI.

Update on sex specific risk factors in cardiovascular disease

Cardiovascular disease (CVD) is the leading cause of death worldwide and accounts for roughly 1 in 5 deaths in the United States. Women in particular face significant disparities in their cardiovascular care when compared to men, both in the diagnosis and treatment of CVD. Sex differences exist in the prevalence and effect of cardiovascular risk factors. For example, women with history of traditional cardiovascular risk factors including hypertension, tobacco use, and diabetes carry a higher risk of major cardiovascular events and mortality when compared to men. These discrepancies in terms of the relative risk of CVD when traditional risk factors are present appear to explain some, but not all, of the observed differences among men and women. Sex-specific cardiovascular disease research-from identification, risk stratification, and treatment-has received increasing recognition in recent years, highlighting the current underestimated association between CVD and a woman's obstetric and reproductive history. In this comprehensive review, sex-specific risk factors unique to women including adverse pregnancy outcomes (APO), such as hypertensive disorders of pregnancy (HDP), gestational diabetes mellitus, preterm delivery, and newborn size for gestational age, as well as premature menarche, menopause and vasomotor symptoms, polycystic ovarian syndrome (PCOS), and infertility will be discussed in full detail and their association with CVD risk. Additional entities including spontaneous coronary artery dissection (SCAD), coronary microvascular disease (CMD), systemic autoimmune disorders, and mental and behavioral health will also be discussed in terms of their prevalence among women and their association with CVD. In this comprehensive review, we will also provide clinicians with a guide to address current knowledge gaps including implementation of a sex-specific patient questionnaire to allow for appropriate risk assessment, stratification, and prevention of CVD in women.

Prevalence of Sex-Specific Cardiovascular Disease Risk Factors, Medical Risk, and Engagement in Health-Promoting Behaviours in Premenopausal Females

Background

Several sex-specific risk factors (SS-RFs) increase a women's risk for cardiovascular disease (CVD) but are often overlooked during risk assessment. The purpose of this study was to identify the prevalence of SS-RFs and assess CVD risk, knowledge, perceptions and behaviours in premenopausal Canadian women.

Methods

An online survey was distributed across Canada to premenopausal biological females (19-49 years of age). The survey gathered demographics, medical history, engagement in health-promoting behaviours, and knowledge and perceptions of CVD risk. CVD risk was calculated using medical risk and SS-RFs were tabulated from medical history.

Results

A total of 2559 participants (33 ± 8 years) completed the survey. The majority of our sample (82%) was classified as low medical risk. Of those classified as low risk, 35% had at least 1 SS-RF. Of high-risk individuals, 70% underestimated their risk, 21% of whom perceived themselves as low risk. Engagement in health behaviours was suboptimal. Knowledge of traditional CVD risk factors and prevention was relatively high; however, less than one-half were aware of SS-RFs such as early menopause (39.4%).

Conclusions

Considering both traditional and SS-RFs, 47% of premenopausal Canadian women may be at risk for developing CVD. Of those deemed low medical risk for developing CVD, more than one-third reported having at least 1 SS-RF. Canadian women have poor knowledge of the risks associated with SS-RFs, lack sufficient awareness of the need for prevention of CVD, and are not engaging in sufficient health-promoting behaviours to mitigate future CVD risk.

Cardiovascular health and the menopause, metabolic health

Estrogen depletion following menopause predisposes to increased risk of cardiovascular disease (CVD), mainly due to ischemic heart disease. This is mostly evident in cases with premature menopause. The pathophysiological basis for this atherosclerotic process is the accumulation of several risk factors, such as abdominal obesity, atherogenic dyslipidemia, insulin resistance and arterial hypertension. The presence of vasomotor symptoms may further augment this risk, especially in women younger than 60 years. Menopausal hormone therapy (MHT) exerts many beneficial effects on lipid profile and glucose homeostasis as well as direct arterial effects, and may reduce CVD risk if initiated promptly (i.e.,<60 years or within ten years of the final menstrual period). Transdermal estradiol and micronized progesterone or dydrogesterone are the safest regimens in terms of venous thromboembolic events (VTE) and breast cancer risk. In any case, an individualized approach, taking into account the patient's total CVD, VTE and breast cancer risk, is recommended.

Premature ovarian insufficiency, early menopause, and induced menopause

Premature ovarian insufficiency (POI) is a condition in which there is a decline in ovarian function in women who are younger than 40 years resulting in a hypo-oestrogenic state with elevated gonadotrophins and oligomenorrhoea/amenorrhoea. This leads to short term complications of menopausal symptoms and long-term effects on bone and cardiovascular health, cognition as well as the impact of reduced fertility and sexual function associated with this condition. It is managed by sex steroid replacement either with HRT or combined hormonal contraception until the age of natural menopause (51) and this can provide a beneficial role with both symptom control and minimising the long-term adverse effects associated with this condition. Women who undergo a menopause between 40 and 45 years are deemed to have an "early menopause". The limited data available for this group suggest that they also have an increased morbidity if not adequately treated with hormone therapy. As such, women who have an early menopause should be managed in a similar way to those with POI, with the recommendation that they should take HRT at least until the natural age of menopause. This is the same for induced menopause that is caused by medical or surgical treatment that impacts the ovaries. It is important to ensure early diagnosis and access to specialist care to help support and manage these patients to reduce the symptoms and risks of long-term complications. This review looks at the diagnosis, causes, short and long-term complications and management of POI, early and induced menopause.

Sex differences in lipids: A life course approach

Differences between men and women in lipids and lipoproteins are observed in distribution and trajectory from infancy to adulthood in the general population. However, these differences are more pronounced in hereditary lipid disorders such as familial hypercholesterolemia (FH) when absolute cholesterol levels are higher from birth onwards. In the early life course, girls compared to boys have higher low-density lipoprotein cholesterol (LDL-C) levels and total cholesterol, while high-density lipoprotein cholesterol (HDL-C) levels are similar. In early adulthood to middle-age, women have lower LDL-C and higher HDL-C levels, as LDL-C levels increase and HDLC levels decrease in men. In the elderly, all lipids - total cholesterol, LDL-C, HDL-C and triglyceride levels decrease but are more pronounced in men. Lipid levels are also affected by specific transitions in girls/women such as the menstrual cycle, pregnancy, breastfeeding and menopause. Lipid levels fluctuate during the menstrual cycle. During pregnancy a physiological increase of LDL-C and even a larger increase in triglyceride levels are observed. Pregnancy has a double impact on LDL-C accumulation in women with FH as they have to stop statins, and the absolute increase in LDL-C is higher than in women without FH. In the menopausal transition, women develop a more adverse lipid profile. Therefore, it is important to take into account both sex and the life course when assessing a lipid profile.

Women, lipids, and atherosclerotic cardiovascular disease: a call to action from the European Atherosclerosis Society

Cardiovascular disease is the leading cause of death in women and men globally, with most due to atherosclerotic cardiovascular disease (ASCVD). Despite progress during the last 30 years, ASCVD mortality is now increasing, with the fastest relative increase in middle-aged women. Missed or delayed diagnosis and undertreatment do not fully explain this burden of disease. Sex-specific factors, such as hypertensive disorders of pregnancy, premature menopause (especially primary ovarian insufficiency), and polycystic ovary syndrome are also relevant, with good evidence that these are associated with greater cardiovascular risk. This position statement from the European Atherosclerosis Society focuses on these factors, as well as sex-specific effects on lipids, including lipoprotein(a), over the life course in women which impact ASCVD risk. Women are also disproportionately impacted (in relative terms) by diabetes, chronic kidney disease, and auto-immune inflammatory disease. All these effects are compounded by sociocultural components related to gender. This panel stresses the need to identify and treat modifiable cardiovascular risk factors earlier in women, especially for those at risk due to sex-specific conditions, to reduce the unacceptably high burden of ASCVD in women.

Early menopause is associated with increased risk of heart failure and atrial fibrillation: A systematic review and meta-analysis

OBJECT

Menopause is linked to a higher risk of cardiovascular disease. However, it is unclear whether premature menopause (defined as menopause before the age of 40 years) or early menopause (defined as menopause before the age of 45 years) is associated with an increased risk of heart failure or atrial fibrillation. This study aimed to examine the most reliable evidence on the relationship between early menopause and the risk of heart failure and atrial fibrillation.

METHODS

A comprehensive literature search was performed in three online databases, Embase, Web of Science, and PubMed, from database establishment to April 1, 2023. The results were presented as hazard ratios with 95 % confidence intervals. The I2 statistic was employed to assess heterogeneity, and the Egger's test was used to determine publication bias.

RESULTS

Nine cohort studies were included in the analysis, with a total of 6,255,783 postmenopausal women. Women with premature and early menopause had an increased risk of heart failure (HR: 1.39, 95 % CI: 1.31-1.47; HR: 1.23, 95 % CI: 1.10-1.37, respectively) and atrial fibrillation (HR: 1.15, 95 % CI: 1.01-1.31; HR: 1.08, 95 % CI: 1.04-1.13, respectively) when compared with women who had undergone menopause after the age of 45 years. Subgroup analysis showed that, compared with early menopause, premature menopause has a stronger association with an increased risk of heart failure and atrial fibrillation.

CONCLUSIONS

Women who undergo premature menopause or early menopause have a higher risk of heart failure and atrial fibrillation compared with women who undergo menopause in the normal age range. These reproductive factors need to be considered for measures that might reduce the risk of heart failure and atrial fibrillation.

Review of mendelian randomization studies on age at natural menopause

Menopause marks the end of the reproductive phase of life. Based on epidemiological studies, abnormal age at natural menopause (ANM) is thought to contribute to a number of adverse outcomes, such as osteoporosis, cardiovascular disease, and cancer. However, the causality of these associations remains unclear. A powerful epidemiological method known as Mendelian randomization (MR) can be used to clarify the causality between ANM and other diseases or traits. The present review describes MR studies that included ANM as an exposure, outcome and mediator. The findings of MR analyses on ANM have revealed that higher body mass index, poor educational level, early age at menarche, early age at first live birth, early age at first sexual intercourse, and autoimmune thyroid disease appear to be involved in early ANM etiology. The etiology of late ANM appears to be influenced by higher free thyroxine 4 and methylene tetrahydrofolate reductase gene mutations. Furthermore, early ANM has been found to be causally associated with an increased risk of osteoporosis, fracture, type 2 diabetes mellitus, glycosylated hemoglobin, and the homeostasis model of insulin resistance level. In addition, late ANM has been found to be causally associated with an increased systolic blood pressure, higher risk of breast cancer, endometrial cancer, endometrioid ovarian carcinoma, lung cancer, longevity, airflow obstruction, and lower risk of Parkinson's disease. ANM is also a mediator for breast cancer caused by birth weight and childhood body size. However, due to the different instrumental variables used, some results of studies are inconsistent. Future studies with more valid genetic variants are needed for traits with discrepancies between MRs or between MR and other types of epidemiological studies.

Anti-Mullerian hormone and cardiometabolic status: a systematic review

BACKGROUND

To summarise the relationship between Anti-mullerian hormone (AMH) levels and cardiometabolic status in different populations.

METHODS

PubMed, Scopus, and Embase were searched for retrieving observational studies published up to February 2022 investigating the relationship between AMH level and cardiometabolic status.

RESULTS

Of 3,643 studies retrieved from databases, a total of 37 observational studies were included in this review. The majority of the included studies revealed an inverse association between AMH and lipid profiles, including triglycerides (TG), total cholesterol (TC), low-density lipoprotein (LDL), and a positive correlation with high-density lipoprotein (HDL). While some studies have revealed a significant inverse association between AMH and glycemic parameters, including fasting plasma glucose (FPG), fasting insulin, and HOMA-IR, others found no such relationships. There is also an inconsistency among studies regarding the association of AMH with adiposity indices and blood pressure. Evidence indicates a significant association between AMH and some vascular markers, such as intima-media thickness and coronary artery calcification. Of 3 studies evaluating the relationship between AMH and cardiovascular events, two studies showed an inverse relationship between AMH levels and cardiovascular (CVD), whereas another study showed no significant association.

CONCLUSIONS

The results of this systematic review suggest that serum AMH levels can be associated with CVD risk. This may provide new insight into the use of AMH concentrations as a predictive marker for assessing the risk of cardiovascular disease, although more well-design longitudinal studies are still necessary for this area. Future studies on this topic will hopefully provide an opportunity to run a meta-analysis; it will increase the persuasiveness of this interpretation.

Reproduction as a window to future health in women

Cultivating awareness for reproduction as a window to future health presents an opportunity for early identification and modification of risk factors that can affect both individual and population-level morbidity and mortality. Infertility could serve as both a window into future health as well as a pathway to future pathology. The underlying mechanisms of infertility may share common pathways with long-term risk for health and well-being. Making this identification early in the disease process may improve opportunities for intervention, and deepen our understanding of long-term risk. Additionally, fertility treatments may increase individual risk. Only by making these associations and designing studies to understand how disease and treatment risk impact health can we truly fulfill our goal of building healthy families. The aim of this review is to discuss the short-term impact of fertility challenges and treatment, long-term associations of infertility with morbidity and mortality, and the role of parity in modifying these risk associations.

Added Predictive Value of Female-Specific Factors and Psychosocial Factors for the Risk of Stroke in Women Under 50

BACKGROUND AND OBJECTIVES

Female-specific factors and psychosocial factors may be important in the prediction of stroke but are not included in prediction models that are currently used. We investigated whether addition of these factors would improve the performance of prediction models for the risk of stroke in women younger than 50 years.

METHODS

We used data from the Stichting Informatievoorziening voor Zorg en Onderzoek, population-based, primary care database of women aged 20-49 years without a history of cardiovascular disease. Analyses were stratified by 10-year age intervals at cohort entry. Cox proportional hazards models to predict stroke risk were developed, including traditional cardiovascular factors, and compared with models that additionally included female-specific and psychosocial factors. We compared the risk models using the c-statistic and slope of the calibration curve at a follow-up of 10 years. We developed an age-specific stroke risk prediction tool that may help communicating the risk of stroke in clinical practice.

RESULTS

We included 409,026 women with a total of 3,990,185 person-years of follow-up. Stroke occurred in 2,751 women (incidence rate 6.9 [95% CI 6.6-7.2] per 10,000 person-years). Models with only traditional cardiovascular factors performed poorly to moderately in all age groups: 20-29 years: c-statistic: 0.617 (95% CI 0.592-0.639); 30-39 years: c-statistic: 0.615 (95% CI 0.596-0.634); and 40-49 years: c-statistic: 0.585 (95% CI 0.573-0.597). After adding the female-specific and psychosocial risk factors to the reference models, the model discrimination increased moderately, especially in the age groups 30-39 (Δc-statistic: 0.019) and 40-49 years (Δc-statistic: 0.029) compared with the reference models, respectively.

DISCUSSION

The addition of female-specific factors and psychosocial risk factors improves the discriminatory performance of prediction models for stroke in women younger than 50 years.

Cardiovascular Risk Factors in Premature Ovarian Insufficiency using Hormonal Therapy

OBJECTIVE

 Premature ovarian insufficiency (POI) is characterized by early hypoestrogenism. An increased risk of cardiovascular (CV) disease is a long-term consequence of POI. A challenge of hormone therapy (HT) is to reduce the CV risk.

METHODS

 Cross-sectional study with lipid profile analysis (total cholesterol, LDL-C, HDL-C, VLDL-C and triglycerides), blood glucose levels and arterial blood pressure of women with POI using HT, compared with age and BMI-matched women with normal ovarian function (controls).

RESULTS

 The mean age and BMI of 102 POI patients using HT and 102 controls were 37.2 ± 6.0 and 37.3 ± 5.9 years, respectively; 27.0 ± 5.2 and 27.1 ± 5.4 kg/m². There wasn't difference between groups in arterial systolic and diastolic blood pressure, blood glucose levels, total cholesterol, LDL-C, VLDL-C and triglycerides. HDL-C levels were significantly higher in the POI group (56.3 ± 14.6 and 52 ± 13.9mg/dL; p = 0.03). Arterial hypertension was the most prevalent chronic disease (12% in the POI group, 19% in the control group, p = ns), followed by dyslipidemia (6 and 5%, in POI and control women).

CONCLUSION

 Women with POI using HT have blood pressure levels, lipid and glycemic profile and prevalence of hypertension and dyslipidemia similar to women of the same age and BMI with preserved gonadal function, in addition to better HDL levels.

Does the addition of serum antimüllerian hormone concentrations to the Framingham Risk Score and Pooled Cohort Equations improve the prediction of cardiovascular disease?

The present study revealed that the addition of serum antimüllerian hormone concentrations to Framingham Risk Score and Pooled Cohort Equations could potentially improve the risk prediction of cardiovascular disease.

Objective

The current study aimed to examine the added value of serum antimüllerian hormone (AMH) concentration to the Framingham Risk Score (FRS) and Pooled Cohort Equations (PCE) in predicting the risk of cardiovascular disease (CVD) in women of reproductive age.

Methods

Women 30 years and older were considered eligible for this population-based prospective study. The univariate and multivariate Cox proportional hazard models were used to evaluate the association between the serum concentrations of AMH and the risk of CVD.

Results

In the enhanced model, which integrated AMH into FRS and PCE and was adjusted for family history of premature CVD, AMH showed a significant association with the risk of CVD during a 19-year follow-up of 800 women (hazard ratio, 0.77 [95% CI, 0.60-0.99] and hazard ratio, 0.64 [95% CI, 0.48-0.84], respectively). According to the likelihood-ratio test, the addition of AMH measurements to FRS and PCE could significantly improve the risk prediction of CVD (P = 0.02 and P < 0.001, respectively); however, the integration of this biomarker did not improve the classification of risk categories.

Conclusions

The present findings revealed that the addition of serum AMH concentrations to FRS and PCE could potentially improve the risk prediction of CVD.

The global prevalence of premature ovarian insufficiency: a systematic review and meta-analysis

OBJECTIVE

The objective of this review was to answer the global prevalence of premature ovarian insufficiency (POI), and explore the associated factors including etiopathology and regions with POI.

METHODS

The search was conducted on reports from a total of eight databases that comprised Chinese National Knowledge Infrastructure (CNKI), Wanfang, China BioMedical Literature Database (CBM), PubMed, the Cochrane Library, Embase, Web of Science and Ovid MEDLINE^® between 1946 and 2021. To analyze the source of heterogeneity, we performed subgroup analysis based on different etiologies and regions. Meta-analysis was carried out by Stata14.0 software.

RESULTS

The results showed that the global overall prevalence of POI among women was 3.5%. By subgroup analysis, the prevalence of POI among women with iatrogenic etiology was 11.2%, followed by autoimmunity (10.5%); the prevalence of POI by region was 11.3% at the highest in North America followed by South America (5.4%); and the prevalence of POI was 5.3% in a developing country, higher than 3.1% in a developed country. The trend of prevalence of POI over the past 20 years was on the rise (although p > 0.05).

CONCLUSION

We recommend that health and medical institutions strengthen public health awareness, achieve health-education goals related to POI and increase women's awareness of and attention to POI.

All-cause and cardiovascular mortality after hysterectomy and oophorectomy in a large cohort (HUNT2)

INTRODUCTION

Hysterectomy and bilateral oophorectomy are common major surgical procedures that have been associated with increased mortality risk. We aimed to assess the association of hysterectomy and/or bilateral oophorectomy with all-cause and cardiovascular mortality in a Norwegian population.

MATERIAL AND METHODS

Cohort study with data from The Trøndelag Health Study (HUNT2) linked to the Norwegian Cause of Death Registry, with follow-up from 1996 until 2014 or death. The unexposed group (n = 18 673) included women with both their ovaries and uterus intact, while the two exposed groups included women with hysterectomy alone (n = 1199), or bilateral oophorectomy with or without hysterectomy (n = 907). We compared mortality in exposed vs unexposed groups and adjusted for relevant covariates by Cox regression. Further, we performed analyses stratified by age at surgery (≤39, 40-52, ≥53 years) and subgroup analyses among women ≤52 years of age at inclusion.

RESULTS

Among the 47 312 women in HUNT2 (1995-1997), 20 779 provided complete information regarding gynecological surgery and previous health. The hysterectomy group had increased all-cause mortality (hazard ratio [HR] 1.30, 95% confidence interval [CI] 1.06-1.58) and cardiovascular mortality (HR 1.47, 95% CI 1.09-1.97). We found no significant association between bilateral oophorectomy and all-cause or cardiovascular mortality in the total population. However, among women ≤52 years at inclusion, cardiovascular mortality was increased in the hysterectomy group (HR 2.71, 95% CI 1.19-6.17) with a similar, but less precise estimate in the bilateral oophorectomy group (HR 2.42, 95% CI 0.84-6.93).

CONCLUSIONS

Hysterectomy was associated with increased all-cause and cardiovascular mortality, whereas bilateral salpingo-oophorectomy was not. Among women ≤52 years at inclusion, both hysterectomy and bilateral oophorectomy were associated with a twofold increased risk of cardiovascular mortality, but the results were imprecise. Women after hysterectomy and/or bilateral salpingo-oophorectomy constitute a group with increased cardiovascular mortality that may need closer attention to cardiovascular disease risk from the healthcare system to ensure timely and effective preventive interventions.

Premature Ovarian Insufficiency

Natural menopause typically occurs between the ages of 46 to 55 years. Premature ovarian insufficiency or premature menopause refers to compromised ovarian follicular activity, occurring spontaneously or because of medical interventions, prior to the age of 40 years. The premature loss of estrogen leads to bothersome menopause symptoms and predisposes the women to multiple long-term health risks including a higher mortality risk. Hormone replacement therapy used until the natural age of menopause can help manage the symptoms effectively and can mitigate the long-term risk of estrogen deprivation to some extent. However, hormone replacement therapy is underutilized in this population due to the inappropriate extrapolation of potential risks that have been demonstrated with hormone therapy use in women after natural menopause. There is a large unmet need for educating patients and providers regarding the impact of premature ovarian insufficiency and the compelling need for its appropriate management.

The risk of long-term cardiometabolic disease in women with premature or early menopause: A systematic review and meta-analysis

Background

Transition into menopause is associated with an increased risk of cardiovascular disease (CVD). However, it is unclear whether the association exists between premature menopause (defined as age at menopause 40 years) or early menopause (defined as age at menopause 40-45 years) and CVD or cardiovascular risk factors. The aim of this review was to comprehensively evaluate and meta-analyze the most reliable evidence about the relationship between menopausal age and the risk of long-term cardiometabolic disease.

Methods

A comprehensive literature search of the PubMed, Web of Science, and Embase databases from inception to October 1, 2022, for titles and abstracts with a restriction to English language papers led to the discovery of the studies. Data are expressed as the Hazard Ratio (HR) with 95% confidence intervals (CI). The degree of heterogeneity was measured using the I-square (I ²) index.

Results

921,517 participants from 20 cohort studies published between 1998 and 2022 were considered. Compared to women with menopause at age >45 years, women with premature menopause (PM) or early menopause (EM) had a higher risks of type 2 diabetes (RR: 1.32, 95% CI: 1.08-1.62; RR: 1.11, 95% CI: 0.91-1.36, respectively), hyperlipidemia (RR: 1.21, 95% CI: 1.05-1.39; RR: 1.17, 95% CI: 1.02-1.33, respectively), coronary heart disease (RR: 1.52, 95% CI: 1.22-1.91; RR: 1.19, 95% CI: 1.07-1.32, respectively), stroke (RR: 1.27, 95% CI: 1.02-1.58; RR: 1.13, 95% CI: 0.97-1.32, respectively) and total cardiovascular event (RR: 1.36, 95% CI: 1.16-1.60; RR: 1.14, 95% CI: 0.97-1.35, respectively). No difference was found for hypertension in PM or EM women (RR: 0.98, 95% CI: 0.89-1.07; RR: 0.97, 95% CI: 0.91-1.04, respectively). Additionally, we also found that PM women, but not EM women, were linked with an increased risk of ischemic and hemorrhagic stroke. However, this is not in line with the conclusion that both PM and EM had a higher risk of total stroke.

Conclusion

Women with PM or EM have a higher risk of developing long-term CVD, compared to women with menopause at age >45 years. Therefore, we recommend early lifestyle interventions (e.g., maintaining a healthy lifestyle) and medical treatments (e.g., timely initiation of menopausal hormone therapy) to decrease the risk of cardiometabolic disease in early or premature menopausal women.

Systematic Review Registration

PROSPERO, identifier CRD42022378750.

Defining preventive cardiology: A clinical practice statement from the American Society for Preventive Cardiology

Remarkable transformations in science and healthcare have resulted in declines in mortality from cardiovascular disease over the past several decades, largely driven by progress in prevention and treatment of persons at risk. However, these trends are now beginning to stall, as our county faces increases in cardiovascular risk factors including overweight and obesity, type 2 diabetes mellitus, and metabolic syndrome. Furthermore, poor long-term adherence to a healthy lifestyle and lifesaving pharmacotherapy have exacerbated these trends, with recent data suggesting unprecedented increases in cardiovascular morbidity and mortality. A paradigm shift is needed to improve the cardiovascular health of our nation. Preventive cardiology, a growing subspecialty of cardiovascular medicine, is the practice of primordial, primary, and secondary prevention of all cardiovascular diseases. Preventive cardiologists and preventive cardiology specialists are well equipped with the knowledge and skill-set necessary to reduce deaths related to the growing burden of heart disease and its risk factors. Despite dedicated efforts, cardiovascular disease remains the leading killer of men and women in the United States. Although there is little debate regarding the importance of prevention, many healthcare professionals question the need for preventive cardiology as a distinct subspecialty. Additionally, the field's growth has been hampered by a lack of organization and standardization, and variability of training within programs across the country. The purpose of this document is to delineate the key attributes that define the field of preventive cardiology according to the American Society for Preventive Cardiology.

Cardiovascular Disease in Women: Does Menopause Matter?

It is known that the menopause transition (MT) is a complex period during a woman's life, but there has been ongoing debate on whether the increase in cardiovascular disease (CVD) during midlife is due to chronological aging or ovarian aging. The purpose of this review is to summarize the recent findings on the role of ovarian aging versus chronological aging on cardiovascular disease (CVD) outcomes and its risk factors in women. Recent data from longitudinal studies have shown that menopause-related factors, such as earlier age at menopause and surgical menopause are associated with higher CVD outcomes. The MT is also associated with detrimental changes in vascular health as well as cardiometabolic risk factors including body composition, visceral fat accumulation, lipids/lipoproteins, blood pressure and the metabolic syndrome. The robust evidence from recent research indicating increases in CVD risk over the MT beyond aging call for immediate efforts to rise awareness among women and their health care providers of CVD risk acceleration accompanying the MT. Efforts should also be directed toward developing and testing novel preventive approaches that target women during this time period to counteract the expected increase in CVD risk.

Age at Menopause and Suicidal Ideation in Menopausal Women: A Study of Korea National Health and Nutrition Examination Survey Data

BACKGROUND

Although menopause is considered a risk factor for depression, no association has been established between the risk of suicidal ideation and age at menopause. This study aimed to evaluate the association between age at menopause and suicidal ideation in middle-aged menopausal Korean women.

METHODS

This cross-sectional study used data from the Korea National Health and Nutrition Examination Survey (2013-2018). Women aged 40-65 years were divided into the following three categories: primary ovarian insufficiency (POI), early menopause, and menopause, according to age at natural menopause (< 40, 40-45, and > 45 years, respectively). Depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9).

RESULTS

Among 2,232 menopausal women, 25 (1.1%) experienced POI and 114 (5.1%) experienced early menopause. The PHQ-9 items that pertained to low self-esteem and suicidal ideation scored higher in women with POI than in those who experienced menopause after 45 years of age. The prevalence of suicidal ideation differed significantly according to age at menopause (POI, 30.0%; early menopause, 12.7%; menopause, 8.0%; P = 0.016). Logistic regression analysis revealed that POI was significantly associated with suicidal ideation after the adjustment for age, body mass index, and education, household income, and walking levels (odds ratio, 4.2; 95% confidence interval, 1.0-17.7).

CONCLUSION

Korean middle-aged women with POI were more likely to have suicidal ideation than those who experienced menopause at 45 years or above, despite not being diagnosed with major depressive disorder.

Trajectories of metabolic parameters after bilateral oophorectomy in premenopausal women

OBJECTIVE

To study the trajectories of metabolic parameters after bilateral oophorectomy.

STUDY DESIGN

This population-based cohort study included a random sample of all premenopausal women who underwent bilateral oophorectomy at or before age 45 years from 1988 to 2007 in Olmsted County, Minnesota, and their age-matched (±1 year) referent women who did not undergo bilateral oophorectomy.

MAIN OUTCOME MEASURES

The medical records of all women were reviewed to collect the metabolic parameters over a 10-year period. We compared three groups of women: 1) referent women (n = 270), 2) women who underwent bilateral oophorectomy and received estrogen therapy (n = 163), and 3) women who underwent bilateral oophorectomy and did not receive estrogen therapy (n = 107).

RESULTS

Over 10 years of follow-up, the three groups had significantly different mean values of diastolic blood pressure, weight, body mass index (BMI), total cholesterol, triglycerides, and high-density lipoprotein cholesterol (HDL-C). However, women with and without bilateral oophorectomy were already different at baseline for hyperlipidemia, systolic blood pressure, weight, and BMI. Nevertheless, the trajectories of change over 10 years were significant for weight (group by time interaction p = 0.03), BMI (p = 0.03), and HDL-C (p = 0.004). The changes occurred primarily in the initial 4-5 years. Women who received estrogen therapy after bilateral oophorectomy were comparable to the referent women with respect to the weight and BMI trends, and they experienced an increase in HDL-C over time.

CONCLUSION

Women who underwent bilateral oophorectomy before menopause experienced unfavorable changes in some metabolic parameters possibly increasing their cardiovascular risk.

The effect of cognitive-behavioral therapy on stress and anxiety of women with premature ovarian insufficiency: A randomized controlled trial

TRIAL REGISTRATION

Iranian Registry of Clinical Trials (IRCT): IRCT20120718010324N64. Date of registration: 14/02/2021. URL: https://en.irct.ir/user/trial/52024/view; date of first registration: 17/02/2021.

Risks of Stroke and Heart Disease Following Hysterectomy and Oophorectomy in Chinese Premenopausal Women

BACKGROUND

Little is known about the long-term risks of stroke and ischemic heart disease (IHD) in women who had a hysterectomy alone (HA) or with bilateral oophorectomy (HBO) for benign diseases, particularly in China where the burden of cardiovascular diseases (CVD) is high. We assessed mean levels of cardiovascular risk factors and relative risks of stroke and IHD in Chinese women who had a HA or HBO.

METHODS

A total of 302 510 women, aged 30 to 79 years were enrolled in the China Kadoorie Biobank from 2004 to 2008 and followed up for a mean of 9.8 years. The analysis involved premenopausal women without prior cardiovascular disease or cancer at enrollment. We calculated adjusted hazard ratios for incident cases of CVD and their pathological types (ischemic stroke, hemorrhagic stroke, and IHD) after HA and HBO. Analyses were stratified by age and region and adjusted for levels of education, household income, smoking status, alcohol consumption, physical activity, body mass index, systolic blood pressure, diabetes, self-reported health, and number of pregnancies.

RESULTS

Among 282 722 eligible women, 8478 had HA, and 1360 had HBO. Women who had HA had 9% higher risk of CVD after HA (hazard ratio, 1.09 [95% CI, 1.06-1.12]) and 19% higher risk of CVD after HBO (1.19 [95% CI, 1.12-1.26]) compared with women who did not. Both HA and HBO were associated with higher risks of ischemic stroke and IHD but not with hemorrhagic stroke. The relative risks of CVD associated with HA and HBO were more extreme at younger age of surgery.

CONCLUSIONS

Women who had either HA or HBO have higher risks of ischemic stroke and IHD, and these risks should be evaluated when discussing these interventions. Additional screening for risk factors for CVD should be considered in women following HA and HBO operations, especially if such operations are performed at younger age.

Metabolic differences in women with premature ovarian insufficiency: a systematic review and meta-analysis

Objective

This review aimed to investigate the metabolic profile of women with premature ovarian insufficiency (POI) compared relative to women with normal ovarian functioning.

Methods

A systematic search of PubMed, EMBASE, and the Web of Science for observational studies published up until the 6^th of July 2021 that compared the metabolic profile of POI women with a healthy control group were assessed. Mean differences (MD) and 95% confidence interval (CI) were pooled using the fixed or random effect models.

Results

A total of 21 studies involving 1573 women with POI and 1762 control women were included. POI patients presented significantly higher waist circumference, total cholesterol, low-density lipoprotein, high-density lipoprotein, triglycerides, and fasting glucose. Additionally, POI patients had marginally higher insulin level. However, the differences in systolic, and diastolic blood pressure were non-significant relative to the control group.

Conclusions

POI is associated with alterations in certain metabolic parameters compared to control women. This finding highlights the importance of early screening and the lifelong management of metabolic health for women with POI.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13048-022-01041-w.

Age at Menarche and Menopause, Reproductive Lifespan, and Risk of Cardiovascular Events Among Chinese Postmenopausal Women: Results From a Large National Representative Cohort Study

Background

At present, the association between age at menarche and menopause, reproductive lifespan, and cardiovascular disease (CVD) risk among Chinese postmenopausal women is not clear, and some related researches are contradictory.

Methods

A total of 6,198 Chinese postmenopausal women with a mean age of 63.6 years were enrolled at baseline in 2012-2015 and followed up for 5 years. A standardized questionnaire was used to collect relevant information by well-trained interviewers. Physical examination of the participants was performed by trained medical staff. CVD events were observed during follow-up. Cox proportional hazards models were used to estimate hazard ratios between reproductive characteristics and CVD events.

Results

Age at menarche was positively associated with CVD events (HR, 1.106; 95%CI, 1.047-1.167). There was a negative association between age at menopause and CVD risk in postmenopausal women with comorbidity (HR, 0.952; 95%CI, 0.909-0.996). Reproductive lifespan was negatively associated with CVD events (HR, 0.938; 95%CI, 0.880-0.999). The CVD risk increased by 10.6% for every 1-year increase in age at menarche. The CVD risk reduced by 6.2% for every 1-year increase in age at menopause in women with comorbidity. The CVD risk reduced by 3.8% for every 1-year increase in reproductive lifespan.

Conclusions

Based on the large prospective study with a nationally representative sample, Chinese postmenopausal women with late age at menarche and shorter reproductive lifespan have higher risk of CVD events.

MicroRNA-4516 in Urinary Exosomes as a Biomarker of Premature Ovarian Insufficiency

Premature ovarian insufficiency (POI) is a typical disorder of amenorrhea that lasts for a minimum of four months in women < 40 years old and is typically characterized by reduced estrogen levels and elevated serum concentrations of follicle-stimulating hormone. We collected urine samples from two participant cohorts from Gil Hospital of Gachon University (Incheon, Korea): a sequencing cohort of 19 participants (seven patients with POI (POI patients without Turner syndrome), seven patients with Turner syndrome (POI patients with Turner syndrome), and five control individuals (age-matched controls with confirmed ovarian sufficiency)) and a validation cohort of 46 participants (15 patients with POI, 11 patients with Turner syndrome, and 20 control individuals). Among differentially expressed miRNAs, hsa-miR-4516 was significantly upregulated in patients with POI in both cohorts, independent of the presence of Turner syndrome. Moreover, the upregulation of miR-4516 was confirmed in the ovary—but not in the uterus—of a cyclophosphamide and busulfan-induced POI mouse model. This was accompanied by a decrease in STAT3 protein level, a predicted target of miR-4516, via miRTarBase2020. Our study provides compelling evidence that miR-4516 is highly expressed in patients with POI and POI mouse models, suggesting that miR-4516 is a diagnostic marker of POI.

Sex differences in hypertension. Do we need a sex-specific guideline?

Hypertension is the most prevalent cardiovascular disorder and the leading cause of death worldwide in both sexes. The prevalence of hypertension is lower in premenopausal women than in men of the same age, but sharply increases after the menopause, resulting in higher rates in women aged 65 and older. Awareness, treatment, and control of hypertension are better in women. A sex-pooled analysis from 4 community-based cohort studies found increasing cardiovascular risk beginning at lower systolic blood pressure thresholds for women than men. Hormonal changes after the menopause play a substantial role in the pathophysiology of hypertension in postmenopausal women. Female-specific causes of hypertension such as the use of contraceptive agents and assisted reproductive technologies have been identified. Hypertensive disorders in pregnancy are associated with increased risk of maternal, fetal, and neonatal morbidity and mortality, as well as with a greater risk of developing cardiovascular disease later in life. Hypertension-mediated organ damage was found to be more prevalent in women, thus increasing the cardiovascular risk. Sex differences in pharmacokinetics have been observed, but their clinical implications are still a matter of debate. There are currently no sufficient data to support sex-based differences in the efficacy of antihypertensive treatment. Adverse drug reactions are more frequently reported in women. Women are still underrepresented in large clinical trials in hypertension, and not all of them report sex-specific results. Therefore, it is of utmost importance to oblige scientists to include women in clinical trials and to consider sex as a biological variable.