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Kujanpää L, Arffman RK, Pesonen P, Hurskainen E, Järvelin MR, Franks S, Tapanainen JS, Morin-Papunen L, Piltonen TT. Polycystic ovary syndrome presents as a multimorbid condition by age 50: birth cohort linkage to national register data. Eur J Endocrinol 2024; 190:409-420. [PMID: 38781435 DOI: 10.1093/ejendo/lvae057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 03/03/2024] [Accepted: 05/22/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVE This population-based follow-up study investigated register-based disease diagnoses and medication use up till age of 50 years among women with polycystic ovary syndrome (PCOS) that were identified from a population-based birth cohort. DESIGN Population-based longitudinal cohort study. PATIENTS Women reporting oligo/amenorrhea and hirsutism at age 31 and/or who were diagnosed with PCOS by a physician by age 46 (n = 244) and women without PCOS symptoms or diagnosis (n = 1556) in the Northern Finland Birth Cohort 1966. MAIN OUTCOME MEASURES National register data on diagnosed diseases (International Statistical Classification of Diseases [ICD]-8-10) and medication use (Anatomical Therapeutic Chemical) until the age of 50. RESULTS Women with PCOS had a 26% higher risk for any registered diagnosis (risk ratio [RR]: 1.26 [1.09-1.46]) and a 24% higher risk for medication use (RR: 1.24 [1.05-1.46]) compared with non-PCOS women, even after adjusting for several confounders. Several main ICD categories were more prevalent among women with PCOS versus non-PCOS controls, eg, endocrine, metabolic, nervous system, musculoskeletal, and genitourinary diseases in addition with different symptoms and injuries. Surprisingly, even though the overall morbidity was only increased in women with PCOS with a body mass index (BMI) ≥ 25 kg/m2, there were several ICD main categories that showed higher comorbidity risk especially in women with PCOS with a BMI < 25 kg/m2. Several medications were prescribed more often to women with PCOS versus non-PCOS controls, eg, medications related to the alimentary tract and metabolism, the cardiovascular system, genitourinary system drugs and sex hormones, dermatologic and hormonal preparations, and medications to treat the musculoskeletal, nervous, and respiratory systems. CONCLUSION Women with PCOS are burdened with multimorbidity and higher medication use, independent of BMI and other confounders. Accordingly, preventive strategies are needed to alleviate the disease burden and improve the health outcomes of women with PCOS.
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Affiliation(s)
- Linda Kujanpää
- Research Unit of Clinical Medicine, University of Oulu, 90220 Oulu, Finland
- Medical Research Center Oulu (MRC Oulu), University of Oulu, 90220 Oulu, Finland
- Department of Obstetrics and Gynecology, Oulu University Hospital, 90220 Oulu, Finland
| | - Riikka K Arffman
- Research Unit of Clinical Medicine, University of Oulu, 90220 Oulu, Finland
- Medical Research Center Oulu (MRC Oulu), University of Oulu, 90220 Oulu, Finland
- Department of Obstetrics and Gynecology, Oulu University Hospital, 90220 Oulu, Finland
| | - Paula Pesonen
- Infrastructure for Population Studies, Faculty of Medicine, University of Oulu, 90220 Oulu, Finland
| | - Elisa Hurskainen
- Research Unit of Clinical Medicine, University of Oulu, 90220 Oulu, Finland
- Medical Research Center Oulu (MRC Oulu), University of Oulu, 90220 Oulu, Finland
- Department of Obstetrics and Gynecology, Oulu University Hospital, 90220 Oulu, Finland
| | - Marjo-Riitta Järvelin
- Center for Life-Course Epidemiology, Faculty of Medicine, University of Oulu, 90220 Oulu, Finland
| | - Stephen Franks
- Institute of Reproductive and Developmental Biology, Imperial College London, SW7 2BT London, United Kingdom
| | - Juha S Tapanainen
- Department of Obstetrics and Gynecology, Oulu University Hospital, 90220 Oulu, Finland
- Department of Obstetrics and Gynecology, University of Helsinki, Helsinki University Hospital, 00014 Helsinki, Finland
- Department of Obstetrics and Gynecology, HFR-Cantonal Hospital of Fribourg, University of Fribourg, 79085 Fribourg, Switzerland
| | - Laure Morin-Papunen
- Research Unit of Clinical Medicine, University of Oulu, 90220 Oulu, Finland
- Medical Research Center Oulu (MRC Oulu), University of Oulu, 90220 Oulu, Finland
- Department of Obstetrics and Gynecology, Oulu University Hospital, 90220 Oulu, Finland
| | - Terhi T Piltonen
- Research Unit of Clinical Medicine, University of Oulu, 90220 Oulu, Finland
- Medical Research Center Oulu (MRC Oulu), University of Oulu, 90220 Oulu, Finland
- Department of Obstetrics and Gynecology, Oulu University Hospital, 90220 Oulu, Finland
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Nelson K, Shirin S, Kalidasan D, Prior JC. Experiences of women living with Polycystic Ovary Syndrome: A pilot case-control, single-cycle, daily Menstrual Cycle Diary study during the SARS-CoV-2 pandemic. PLoS One 2023; 18:e0296377. [PMID: 38157371 PMCID: PMC10756515 DOI: 10.1371/journal.pone.0296377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 12/11/2023] [Indexed: 01/03/2024] Open
Abstract
Polycystic Ovary Syndrome (PCOS) affects many people and is often distressing. Much medical literature about diagnosis and treatment exists, but little is known about PCOS menstrual cycle-related experiences except that cycles tend to be far-apart and unpredictable. Our purpose was to examine the menstrual cycle and daily life experiences in those with PCOS having approximately month-apart cycles compared with age and BMI-matched cohort controls using data from the Menstruation & Ovulation Study 2 (MOS2) during the first 1.5 years of SARS-CoV-2 pandemic. We hypothesized that those with PCOS would experience lower self-worth and more negative moods. This is a single-cycle prospective case-control study in community-dwelling women ages 19-35 years. Eight reported physician-diagnosed PCOS and were matched (1:3 ratio) with controls by age (within .6 years) and BMI (within .19 BMI units). Experiences were recorded daily (Menstrual Cycle Diary©, Diary). All kept daily morning temperatures to assess luteal phase lengths by the validated Quantitative Basal Temperature© analysis method. From 112 in MOS2, 32 women were compared: eight with PCOS versus 24 controls. Demographic, socioeconomic, comorbidities and lifestyle variables were not different between the two groups. Cycle lengths were similar in PCOS and controls (one PCOS and control each had oligomenorrhea; most lengths were 21-35 days, P = .593). Unexpectedly, luteal phase lengths were also similar between PCOS and controls (P = .167); anovulation occurred in 5 with PCOS, and in 9 controls. There were no significant Diary differences between the two groups except for greater "outside stress" in the PCOS group (P = .020). In contrast to our hypotheses, there were no significant differences in feelings of self-worth, anxiety nor depression. The SARS-CoV-2 pandemic was a stressful time for women. MOS2 captured granular menstrual cycles, ovulation and daily experiences in women with PCOS compared with age- and BMI-matched controls. These pilot data in women with milder PCOS are the first of more research required to understand the daily experiences in those living with PCOS.
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Affiliation(s)
- Kaitlin Nelson
- Centre for Menstrual Cycle and Ovulation Research, Division of Endocrinology and Metabolism, Department of Medicine, University of British Columbia, Vancouver, Canada
- BC Women’s Health Research Institute, Vancouver, Canada
- Experimental Medicine, MSc Programme, University of British Columbia, Vancouver, Canada
| | - Sonia Shirin
- Centre for Menstrual Cycle and Ovulation Research, Division of Endocrinology and Metabolism, Department of Medicine, University of British Columbia, Vancouver, Canada
- BC Women’s Health Research Institute, Vancouver, Canada
| | - Dharani Kalidasan
- Centre for Menstrual Cycle and Ovulation Research, Division of Endocrinology and Metabolism, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Jerilynn C. Prior
- Centre for Menstrual Cycle and Ovulation Research, Division of Endocrinology and Metabolism, Department of Medicine, University of British Columbia, Vancouver, Canada
- BC Women’s Health Research Institute, Vancouver, Canada
- Division of Endocrinology and Metabolism, Department of Medicine, University of British Columbia, Vancouver, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
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3
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Liu J, Teng Z, Xie H, Yuan H, Liu M, Chen J, Tang H, Xiang H, Wu H, Huang J. Prevalence and characteristics of polycystic ovarian syndrome in patients with bipolar disorder. J Affect Disord 2023; 340:387-395. [PMID: 37544485 DOI: 10.1016/j.jad.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 08/01/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Bipolar disorder (BD) is frequently accompanied by endocrine disturbances. We compared the prevalence of polycystic ovary syndrome (PCOS) and related reproductive disorders between drug-naïve BD patients and matched healthy controls (HCs) and between drug-naïve BD patients and BD patients with long-term medication, as well as the clinical metabolic correlates among BD patients. METHODS 72 drug-naïve BD patients, 98 HCs, and 72 BD patients with long-term medication were recruited in the study. Menstruation was recorded, reproductive hormone levels and metabolic indicators were measured, and a pelvic ultrasound examination was performed via transvaginal sensor for each participant. PCOS was defined using the Rotterdam criteria. RESULTS After controlling for demographic variables, drug-naïve BD patients presented higher rates of PCOS than the HCs (OR: 3.02, 95 % CI: 1.09-8.36). Regression analysis showed that long-term treatment with valproate (OR: 3.89, 95 % CI: 1.13-13.37), age (OR: 0.37, 95 % CI: 0.14-0.95), and insulin resistance index (OR: 1.73, 95 % CI: 1.10-12.71) were correlated with PCOS in BD patients. CONCLUSIONS Drug-naïve BD patients are susceptible to developing PCOS, and valproate is correlated with increased occurrence and development of PCOS. Therefore, PCOS in BD patients, especially those who use valproate, needs to be investigated and monitored closely by medical personnel.
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Affiliation(s)
- Jieyu Liu
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, China National Technology Institute on Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China; Department of Ultrasound Diagnosis, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China
| | - Ziwei Teng
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, China National Technology Institute on Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China
| | - Haiqing Xie
- Department of Ultrasound Diagnosis, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China
| | - Hui Yuan
- Department of Stomatology, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China
| | - Minghui Liu
- Department of Ultrasound Diagnosis, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China
| | - Jindong Chen
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, China National Technology Institute on Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China
| | - Hui Tang
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, China National Technology Institute on Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China
| | - Hui Xiang
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, China National Technology Institute on Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China
| | - Haishan Wu
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, China National Technology Institute on Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China
| | - Jing Huang
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, China National Technology Institute on Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha 410011, Hunan, China.
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Piltonen T, Morin-Papunen L, Ollila MM, Tapanainen J, Arffman R, Järvelin MR, Franks S. Women self-reporting PCOS symptoms should not be overlooked. Hum Reprod 2023; 38:189-190. [PMID: 36433765 DOI: 10.1093/humrep/deac251] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Terhi Piltonen
- Department of Obstetrics and Gynaecology, Medical Research Center Oulu, PEDEGO Research Unit, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Laure Morin-Papunen
- Department of Obstetrics and Gynaecology, Medical Research Center Oulu, PEDEGO Research Unit, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Meri-Maija Ollila
- Department of Obstetrics and Gynaecology, Medical Research Center Oulu, PEDEGO Research Unit, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Juha Tapanainen
- Department of Obstetrics and Gynaecology, Medical Research Center Oulu, PEDEGO Research Unit, University of Oulu and Oulu University Hospital, Oulu, Finland.,Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Riikka Arffman
- Department of Obstetrics and Gynaecology, Medical Research Center Oulu, PEDEGO Research Unit, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Marjo-Riitta Järvelin
- Center for Life Course Health Research, Faculty of Medicine, University of Oulu, Oulu, Finland.,Unit of Primary Care, Oulu University Hospital, Oulu, Finland.,MRC Centre for Environment and Health, Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK.,Department of Life Sciences, College of Health and Life Sciences, Brunel University London, London, UK
| | - Stephen Franks
- Institute of Reproductive and Developmental Biology, Imperial College London, London, UK
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Impact of social isolation during COVID-19 pandemic on health behaviors and weight management in women with polycystic ovary syndrome. Eat Weight Disord 2022; 27:2407-2413. [PMID: 35195885 PMCID: PMC8865179 DOI: 10.1007/s40519-022-01369-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 01/18/2022] [Indexed: 11/25/2022] Open
Abstract
PURPOSE COVID-19 pandemic has far-reaching psychosocial implications for chronic health conditions. We aimed to investigate whether COVID-19 associated social isolation affects lifestyle and weight control in women with polycystic ovary syndrome (PCOS). METHODS We conducted an online survey involving 232 women with PCOS and 157 healthy controls on weight changes, physical activity, sleep and eating patterns using Three-Factor Eating Questionnaire (TFEQ-18), Pittsburgh Sleep Quality Index (PSQI), and International Physical Activity Questionnaire Short Form (IPAQ-SF). PCOS-related quality of life questionnaire (PCOSQ) was also completed by the patients. RESULTS While 48.5% of all participants gained weight, 13.9% maintained a stable weight, and 37.6% lost weight during the 14-week social isolation. The distribution of weight change was similar between groups (p = 0.44). All participants reported a decrease in physical activity (p < 0.001). While eating behavior showed no significant change in both groups, reduced sleep quality was found only in the PCOS group (p < 0.001). In women with weight gain, increase in BMI values was higher in patients (1.3 ± 1 kg/m2) than controls (1.0 ± 0.6 kg/m2; p = 0.01). Among those who gained weight, delta BMI values showed positive correlations with delta sleep induction time (r = 0.25, p = 0.001), delta PSQI (r = 0.24, p = 0.004) and delta TFEQ-18 scores (r = 0.25, p = 0.001). CONCLUSION Weight changes during social isolation are similar in women with PCOS and healthy women. However, within those who gain weight, increase in BMI is more pronounced in women with PCOS. Weight gain appears to be related to alterations in sleep quality and eating habits rather than reduced physical activity. LEVEL III Evidence obtained from cohort or case-control analytic studies.
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6
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Peña AS, Codner E, Witchel S. Criteria for Diagnosis of Polycystic Ovary Syndrome during Adolescence: Literature Review. Diagnostics (Basel) 2022; 12:diagnostics12081931. [PMID: 36010282 PMCID: PMC9406411 DOI: 10.3390/diagnostics12081931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/05/2022] [Accepted: 08/06/2022] [Indexed: 11/11/2022] Open
Abstract
Polycystic ovary syndrome (PCOS) is one of the most common endocrine conditions in women. PCOS may be more challenging to diagnose during adolescence due to an overlap with the physiological events of puberty, which are part of the diagnostic criteria in adult women. This review focuses on the evidence available in relation to PCOS diagnostic criteria for adolescents. Adolescent PCOS should be diagnosed using two main criteria irregular -menstrual cycles (relative to number of years post-menarche) and hyperandrogenism (clinical and/or biochemical); after excluding other conditions that mimic PCOS. Accurate definitions of the two main criteria will decrease challenges/controversies with the diagnosis and provide timely diagnosis during adolescence to establish early management. Despite the attempts to create accurate diagnostic criteria and definitions, this review highlights the limited research in this area, especially in the follow up of adolescents presenting with one diagnostic feature that are called “at risk of PCOS”. Studies in adolescents continue to use the Rotterdam diagnostic criteria that uses pelvic ultrasound. This is inappropriate, because previous and emerging data that show many healthy adolescents have polycystic ovarian morphology in the early years post-menarche. In the future, anti-Müllerian hormone levels might help support PCOS diagnosis if adolescents meet two main criteria.
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Affiliation(s)
- Alexia S. Peña
- Discipline of Paediatrics, The University of Adelaide Robinson Research Institute, 72 King William Road, Adelaide, SA 5006, Australia
- Endocrinology and Diabetes Department, Women’s and Children’s Hospital, 72 King William Road, Adelaide, SA 5006, Australia
- Correspondence: ; Tel.: +61-881618134
| | - Ethel Codner
- Institute of Child and Maternal Research, School of Medicine, University of Chile, Santiago 836-0160, Chile
| | - Selma Witchel
- UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA 15224, USA
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Bell RJ, Islam RM, Skiba MA, Herbert D, Martinez Garcia A, Davis SR. Substituting serum anti-Müllerian hormone for polycystic ovary morphology increases the number of women diagnosed with polycystic ovary syndrome: a community-based cross-sectional study. Hum Reprod 2021; 37:109-118. [PMID: 34741176 DOI: 10.1093/humrep/deab232] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 09/15/2021] [Indexed: 12/19/2022] Open
Abstract
STUDY QUESTION Can serum anti-Müllerian hormone (AMH) replace polycystic ovary morphology (PCOM) determined by ultrasound as a diagnostic component of polycystic ovary syndrome (PCOS)? SUMMARY ANSWER Despite good correlations between serum AMH and PCOM, the use of a high serum AMH as a proxy for PCOM resulted in the reclassification of PCOS in 5% of study participants, with the main effect being more women identified, although some women previously classified as having PCOS were no longer classified as such. WHAT IS KNOWN ALREADY AMH has been proposed as an alternative to PCOM as a diagnostic component of PCOS. Previous studies are limited by poorly defining PCOS, use of infertile women as comparators, measurement of hormones by immunoassay that lack precision in the female range, low-resolution ovarian ultrasound and inconsistent handling and storage of serum samples. STUDY DESIGN, SIZE, DURATION This is an Australian cross-sectional study of 163 non-healthcare-seeking women. PARTICIPANTS/MATERIALS, SETTING, METHODS Serum AMH was measured by both the Ansh picoAMH assay and the Beckman Coulter Access 2 (BA2) assay, in parallel with androgens measured by liquid chromatography-tandem mass spectrometry, in blood samples of women, not pregnant, breast feeding or using systemic steroids, who also underwent high-resolution ovarian ultrasound. PCOS was determined by the Rotterdam criteria with PCOM defined by the Androgen Excess-PCOS Taskforce recommendation of ≥25 follicles in at least one ovary. Cut-off serum concentrations that best identified women as having PCOM were identified by receiver operator characteristic (ROC) curves. MAIN RESULTS AND THE ROLE OF CHANCE A total of 163 women, mean (SD) age 32.5 (5.5) years, who provided a blood sample and had both ovaries visualized on ultrasound were included in the analysis. Women with isolated PCOM had higher median (range) Ansh AMH and BA2 AMH concentrations than those with no PCOS characteristics [56.9 pmol/l (34.6, 104.2) versus 18.7 (3.2, 50.9), P = 0.002 and 38.5 pmol/l (22.2, 100.2) versus 16.7 (3.5, 38.9), P = 0.002, respectively]. An AMH ≥ 44.0 pmol/l, suggested by the ROC curve, identified 80.6% of women with PCOM, falsely identified 15.2% of women without PCOM as having PCOS and had a positive predictive value of 55.6%. The negative predictive value was 94.9%. An AMH BA2 assay cut-off of ≥33.2 pmol/l provided a sensitivity of 80.6%, a specificity of 79.5% and a positive predictive value for PCOM of 48.1%. The negative predictive value was 94.6% for PCOM. When serum AMH was used in the place of PCOM as a diagnostic criterion for PCOS, the Ansh assay resulted in an additional seven women classified as having PCOS and no longer classified one woman as having PCOS. For the BA2 assay, eight additional and two fewer women were classified as having PCOS. Overall, both assays resulted in six more women being classified as having PCOS. LIMITATIONS, REASONS FOR CAUTION Women with functional hypogonadotrophic hypogonadism were not excluded and may have been misclassified as having an oligo-amenorrhoea-PCOM phenotype. As study participants were predominantly Caucasian/White, our findings cannot be generalized to women of other ethnicities. WIDER IMPLICATIONS OF THE FINDINGS Although serum AMH reflects the number of developing ovarian follicles, the absolute values vary between assays and specific reference ranges for individual assays are required. Irrespective of the assay used, replacing PCOM with serum AMH to diagnose PCOS in a community-based sample altered the number of women classified as having or not having PCOS. Consequently, although overall the risk of women being identified as having PCOS would be increased, some women would no longer be classified as having this condition. STUDY FUNDING/COMPETING INTEREST(S) The study was supported by the Norman Beischer Research Foundation and the Grollo-Ruzzene Foundation. S.R.D. is an NHMRC Senior Principal Research Fellow (Grant No. 1135843). S.R.D. reports unrelated support that includes grants from the NHMRC Australia, personal fees for educational activities from Besins Healthcare, Abbott Chile, BioFemme and Pfizer Australia, personal Advisory Board/consultancy fees from Theramex, Abbott Laboratories, Astellas, Mayne Pharmaceuticals, Roche Diagnostics, Lawley Pharmaceuticals and Que Oncology and has received institutional grant funding from Que Oncology and Ovoca research. The other authors declare no conflicts of interest. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- Robin J Bell
- Women's Health Research Program, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rakibul M Islam
- Women's Health Research Program, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Marina A Skiba
- Women's Health Research Program, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Dilinie Herbert
- Women's Health Research Program, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Alejandra Martinez Garcia
- Women's Health Research Program, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Department of Endocrinology, Division of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Susan R Davis
- Women's Health Research Program, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Chin HB, Marsh EE, Hall JE, Baird DD. Prevalence of Hirsutism Among Reproductive-Aged African American Women. J Womens Health (Larchmt) 2021; 30:1580-1587. [PMID: 34520248 DOI: 10.1089/jwh.2021.0125] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Hirsutism is the most common clinical symptom of hyperandrogenism, but racial and ethnic-specific thresholds have not been established. Our objective was to characterize hirsutism using self-report of hair growth in a large sample of African American women. Materials and Methods: The Study of Environment, Lifestyle, and Fibroids is a prospective community-based cohort study of African American women (23-34 at recruitment). A total of 1568 participants received the modified Ferriman-Gallwey (mFG) pictorial assessment and were asked if they were ever bothered by excess hair. We estimated the prevalence of hirsutism (mFG score ≥8) and associations of acne, polycystic ovary syndrome (PCOS), and menstrual cycle characteristics with hirsutism. We also explored hirsutism defined by the 95th percentile of scores in our cohort (mFG = 11) and a newly recommended criterion, mFG = 4. Results: We could determine hirsutism status in 1556 women. Thirty-seven percent reported being bothered by excess hair, and 10% met the mFG criterion for hirsutism. History of severe facial acne was positively associated with hirsutism (prevalence ratio: 1.90; 95% confidence interval [CI]: 1.30-2.76), as was physician-diagnosed PCOS (2.22, 95% CI: 1.30-3.81). Women with irregular menstrual cycles were also more likely to report hirsutism (1.78, 95% CI: 1.00-3.18). Results were similar using mFG ≥11 and attenuated using mFG ≥4. Conclusions: Hirsutism prevalence was 10% in this community sample of African American women and was associated with PCOS, severe acne, and irregular menstrual cycles suggesting this represented hirsutism caused by hyperandrogenism. Ethnically diverse, population-based studies assessing the association between mFG score and androgen levels are needed to better understand the hirsutism threshold as a clinical marker of hyperandrogenism.
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Affiliation(s)
- Helen B Chin
- Department of Global and Community Health, College of Health and Human Services, George Mason University, Fairfax, Virginia, USA.,Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, North Carolina, USA
| | - Erica E Marsh
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Janet E Hall
- Clinical Research Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, North Carolina, USA
| | - Donna D Baird
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, North Carolina, USA
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Piltonen TT, Arffman RK, Joham AE. Natural History of Polycystic Ovary Syndrome and New Advances in the Epidemiology. Semin Reprod Med 2021; 39:94-101. [PMID: 34464984 DOI: 10.1055/s-0041-1735211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in women, affecting up to 15% of the female population. The natural history of the syndrome is complex, including both androgen exposure in early life and adiposity-driven dysfunction involving also dysregulated, also involving altered hypothalamus-ovarian crosstalk. The manifestations can arise as early as childhood or puberty onward, suggesting that genetic susceptibility is an important etiological factor. In adulthood, women with PCOS present with reproductive, metabolic, and psychological health issues at a population-based level. Epidemiological studies on large datasets offer an excellent opportunity to evaluate health effects and costs related to the syndrome. Hospital or insurance-based datasets are also available; however, the results are not representative of the female population in the community. More longitudinal studies spanning from early childhood to late adulthood are needed to assess the long-term health impact and early manifestations of PCOS. Moreover, the identification of women with PCOS from large datasets can be expensive. Self-reported symptoms or PCOS diagnosis may offer a feasible approach.
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Affiliation(s)
- Terhi T Piltonen
- PEDEGO Research Unit, Department of Obstetrics and Gynecology, Medical Research Center, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Riikka K Arffman
- PEDEGO Research Unit, Department of Obstetrics and Gynecology, Medical Research Center, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Anju E Joham
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Department of Diabetes and Vascular Medicine, Monash Health, Melbourne, Australia
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Skiba MA, Bell RJ, Herbert D, Garcia AM, Islam RM, Davis SR. Use of community-based reference ranges to estimate the prevalence of polycystic ovary syndrome by the recognised diagnostic criteria, a cross-sectional study. Hum Reprod 2021; 36:1611-1620. [PMID: 33846715 DOI: 10.1093/humrep/deab069] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 01/13/2021] [Indexed: 12/14/2022] Open
Abstract
STUDY QUESTION Does the application of reference ranges for sex steroids and the modified Ferriman-Gallwey (mFG) scale established in the community from which the study sample was drawn, combined with the most conservative polycystic ovary morphology (PCOM) criteria to the recognised diagnostic criteria for polycystic ovary syndrome (PCOS) improve the certainty of diagnosis of PCOS in non-healthcare-seeking women? SUMMARY ANSWER Despite application of the stringent definitions of the elements used to diagnose PCOS in a non-healthcare seeking community-based sample, the risk of diagnostic uncertainty remains. WHAT IS KNOWN ALREADY There is heterogeneity in prevalence estimates for PCOS due, in part, to lack of standardisation of the elements comprising the recognised National Institutes of Health (NIH), Rotterdam and Androgen Excess Society (AE-PCOS) diagnostic criteria. The AE-PCOS Society proposed refinements to the definitions of biochemical androgen excess and PCOM that can now be incorporated into these sets of diagnostic criteria to estimate PCOS prevalence. STUDY DESIGN, SIZE, DURATION An Australian cross-sectional study of 168 non-healthcare-seeking women. PARTICIPANTS/MATERIALS, SETTING, METHODS The 168 included women were aged 18-39 years, euthyroid and normoprolactinemic, not recently pregnant, breast feeding or using systemic hormones. Each provided menstrual history and assessment of the mFG, had measurement of sex steroids by liquid chromatography, tandem mass spectrometry, and a pelvic ultrasound. The presence of PCOS was determined using modified (m) NIH, Rotterdam, and AE-PCOS criteria according to AE-PCOS Society recommendations. MAIN RESULTS AND THE ROLE OF CHANCE Overall, 10.1% of the included participants met the mNIH PCOS criteria, which requires the presence of menstrual dysfunction, while 18.5% met the mRotterdam and 17.5% the AE-PCOS criteria, with the latter requiring hyperandrogenism. Eight of the 27 participants with menstrual dysfunction, 10 of 31 women with PCOM, and 39 of 68 women with hyperandrogenism had no other feature of PCOS. Of the 19 participants with hyperandrogenaemia, 10 met the mNIH criteria (52.5%) and 14 met both the mRotterdam and AE-PCOS criteria (78.9%). Women who had the combination of hyperandrogenism and PCOM explained the greatest discrepancy between the mNIH and the other criteria. LIMITATIONS, REASONS FOR CAUTION Clinical androgenisation relied on participant self-assessment, which has been shown to be valid when compared with clinician assessment. The sample size was a function of both the strict inclusion criteria and the requirements of non-healthcare-seeking women having a blood draw and pelvic ultrasound which may have introduced a selection bias. WIDER IMPLICATIONS OF THE FINDINGS Despite applying stringent cut-offs for serum androgens, the mFG scale and the ovarian follicle count, these criteria remain arbitrary. Accordingly, healthy women may be captured by these criteria, and misidentified as having PCOS, while women with the condition may be missed. Consequently, PCOS remains a diagnosis to be made with care. STUDY FUNDING/COMPETING INTEREST(S) The study was supported by the Grollo-Ruzzene Foundation. Dr S.R.D. is an NHMRC Senior Principal Research Fellow (Grant no. 1135843). S.R.D. has been paid for developing and delivering educational presentations for Besins Healthcare, BioFemme and Pfizer Australia, has been on Advisory Boards for Theramex, Abbott Laboratories, Mayne Pharmaceuticals and Roche and a consultant to Lawley Pharmaceuticals and Que Oncology and has received has received institutional grant funding for Que Oncology research; there are no other relationships or activities that could appear to have influenced the submitted work. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- Marina A Skiba
- Women's Health Research Program, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Robin J Bell
- Women's Health Research Program, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Dilinie Herbert
- Women's Health Research Program, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Alejandra Martinez Garcia
- Women's Health Research Program, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Division of Medicine, Department of Endocrinology, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Rakibul M Islam
- Women's Health Research Program, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Susan R Davis
- Women's Health Research Program, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Caanen MR, Peters HE, van de Ven PM, Jüttner AMFM, Laven JSE, van Hooff MHA, Lambalk CB. Anti-Müllerian Hormone Levels in Adolescence in Relation to Long-term Follow-up for Presence of Polycystic Ovary Syndrome. J Clin Endocrinol Metab 2021; 106:e1084-e1095. [PMID: 33351079 PMCID: PMC7947839 DOI: 10.1210/clinem/dgaa949] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Indexed: 11/20/2022]
Abstract
CONTEXT Anti-Müllerian hormone (AMH) measured in adolescence as biomarker for prediction of adult polycystic ovary syndrome (PCOS) is doubtful but not substantiated. OBJECTIVE To investigate whether serum AMH levels and other PCOS-associated features in adolescence can predict the presence of PCOS in adulthood. DESIGN AND SETTING A long-term follow-up study based on a unique adolescent study on menstrual irregularities performed between 1990 and 1997. PARTICIPANTS AND INTERVENTIONS AMH was assayed in 271 adolescent girls. Data on PCOS features were combined with AMH levels. In 160 of the 271 (59%) participants, we collected information in adulthood about their menstrual cycle pattern and presence of PCOS (features) by questionnaire 2 decades after the initial study. RESULTS AMH was higher in adolescent girls with oligomenorrhea compared with girls with regular cycles, median (interquartile range): 4.6 (3.1-7.5) versus 2.6 (1.7-3.8) μg/L (P < 0.001). Women with PCOS in adulthood had a higher median adolescent AMH of 6.0 compared with 2.5 μg/L in the non-PCOS group (P < 0.001). AMH at adolescence showed an area under the receiver operating characteristic curve for PCOS in adulthood of 0.78. In adolescent girls with oligomenorrhea the proportion developing PCOS in adulthood was 22.5% (95% CI, 12.4-37.4) against 5.1% (95% CI, 2.1-12.0) in girls with a regular cycle (P = 0.005). Given adolescent oligomenorrhea, adding high AMH as factor to predict adult PCOS or adult oligomenorrhea was of no value. CONCLUSIONS Adolescent AMH either alone or adjuvant to adolescent oligomenorrhea does not contribute as prognostic marker for PCOS in adulthood. Therefore, we do not recommend routine its use in clinical practice.
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Affiliation(s)
- Mirte R Caanen
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit, HV Amsterdam, the Netherlands
- Correspondence: Mirte Caanen, Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit, 1081 HV Amsterdam, the Netherlands. E-mail:
| | - Henrike E Peters
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit, HV Amsterdam, the Netherlands
| | - Peter M van de Ven
- Clinical Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit, HV Amsterdam, the Netherlands
| | - Anne M F M Jüttner
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit, HV Amsterdam, the Netherlands
| | - Joop S E Laven
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Erasmus University Medical Center, CA Rotterdam, The Netherlands
| | - Marcel H A van Hooff
- Department of Obstetrics and Gynaecology, Sint Franciscus Hospital, PM Rotterdam, The Netherlands
| | - Cornelis B Lambalk
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit, HV Amsterdam, the Netherlands
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12
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Lüll K, Arffman RK, Sola-Leyva A, Molina NM, Aasmets O, Herzig KH, Plaza-Díaz J, Franks S, Morin-Papunen L, Tapanainen JS, Salumets A, Altmäe S, Piltonen TT, Org E. The Gut Microbiome in Polycystic Ovary Syndrome and Its Association with Metabolic Traits. J Clin Endocrinol Metab 2021; 106:858-871. [PMID: 33205157 DOI: 10.1210/clinem/dgaa848] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Indexed: 12/11/2022]
Abstract
CONTEXT Despite the gut microbiome being widely studied in metabolic diseases, its role in polycystic ovary syndrome (PCOS) has been scarcely investigated. OBJECTIVE Compare the gut microbiome in late fertile age women with and without PCOS and investigate whether changes in the gut microbiome correlate with PCOS-related metabolic parameters. DESIGN Prospective, case-control study using the Northern Finland Birth Cohort 1966. SETTING General community. PARTICIPANTS A total of 102 PCOS women and 201 age- and body mass index (BMI)-matched non-PCOS control women. Clinical and biochemical characteristics of the participants were assessed at ages 31 and 46 and analyzed in the context of gut microbiome data at the age of 46. INTERVENTION (s): None. MAIN OUTCOME MEASURE(S) Bacterial diversity, relative abundance, and correlations with PCOS-related metabolic measures. RESULTS Bacterial diversity indices did not differ significantly between PCOS and controls (Shannon diversity P = .979, unweighted UniFrac P = .175). Four genera whose balance helps to differentiate between PCOS and non-PCOS were identified. In the whole cohort, the abundance of 2 genera from Clostridiales, Ruminococcaceae UCG-002, and Clostridiales Family XIII AD3011 group, were correlated with several PCOS-related markers. Prediabetic PCOS women had significantly lower alpha diversity (Shannon diversity P = .018) and markedly increased abundance of genus Dorea (false discovery rate = 0.03) compared with women with normal glucose tolerance. CONCLUSION PCOS and non-PCOS women at late fertile age with similar BMI do not significantly differ in their gut microbial profiles. However, there are significant microbial changes in PCOS individuals depending on their metabolic health.
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Affiliation(s)
- Kreete Lüll
- Institute of Genomics, Estonian Genome Centre, University of Tartu, Tartu, Estonia
- Department of Biotechnology, Institute of Molecular and Cell Biology, University of Tartu, Tartu, Estonia
| | - Riikka K Arffman
- Department of Obstetrics and Gynecology, PEDEGO Research Unit, Medical Research Centre, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Alberto Sola-Leyva
- Department of Biochemistry and Molecular Biology, Faculty of Sciences, University of Granada, Granada, Spain
- Instituto de Investigación Biosanitaria ibs GRANADA, Granada, Spain
| | - Nerea M Molina
- Department of Biochemistry and Molecular Biology, Faculty of Sciences, University of Granada, Granada, Spain
- Instituto de Investigación Biosanitaria ibs GRANADA, Granada, Spain
| | - Oliver Aasmets
- Institute of Genomics, Estonian Genome Centre, University of Tartu, Tartu, Estonia
- Department of Biotechnology, Institute of Molecular and Cell Biology, University of Tartu, Tartu, Estonia
| | - Karl-Heinz Herzig
- Research Unit of Biomedicine, Medical Research Center, University of Oulu, Oulu University Hospital, Oulu, Finland
- Department of Paediatric Gastroenterology and Metabolic Diseases, Poznań University of Medical Sciences, Poznań, Poland
| | - Julio Plaza-Díaz
- Department of Biochemistry and Molecular Biology II, Faculty of Pharmacy, University of Granada, Granada, Spain
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Stephen Franks
- Faculty of Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
| | - Laure Morin-Papunen
- Department of Obstetrics and Gynecology, PEDEGO Research Unit, Medical Research Centre, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Juha S Tapanainen
- Department of Obstetrics and Gynecology, PEDEGO Research Unit, Medical Research Centre, Oulu University Hospital, University of Oulu, Oulu, Finland
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Andres Salumets
- Department of Obstetrics and Gynaecology, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Competence Centre on Health Technologies, Tartu, Estonia
| | - Signe Altmäe
- Department of Biochemistry and Molecular Biology, Faculty of Sciences, University of Granada, Granada, Spain
- Instituto de Investigación Biosanitaria ibs GRANADA, Granada, Spain
- Department of Obstetrics and Gynaecology, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Terhi T Piltonen
- Department of Obstetrics and Gynecology, PEDEGO Research Unit, Medical Research Centre, Oulu University Hospital, University of Oulu, Oulu, Finland
- Department of Obstetrics and Gynecology, Reproductive Endocrinology and IVF Unit, Oulu, University Hospital, University of Oulu, Oulu, Finland
| | - Elin Org
- Institute of Genomics, Estonian Genome Centre, University of Tartu, Tartu, Estonia
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Rantakallio JSS, Nevalainen JE, West SI, Ollila MM, Puukka K, Bloigu AH, Järvelin MR, Tapanainen JS, Franks S, Dunkel L, Piltonen TT, Vääräsmäki MS, Morin-Papunen LC. Association of Self-Reported Polycystic Ovary Syndrome, Obesity, and Weight Gain From Adolescence to Adulthood With Hypertensive Disorders of Pregnancy: A Community-Based Approach. Hypertension 2021; 77:1010-1019. [PMID: 33517680 DOI: 10.1161/hypertensionaha.120.15702] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The purpose of this prospective, population-based cohort study was to evaluate the roles of polycystic ovary syndrome (PCOS), obesity, weight gain, and hyperandrogenemia in the development of hypertensive disorders of pregnancy (HDP) through fertile age both in PCOS and in non-PCOS women. The study population-NFBC1966 (Northern Finland Birth Cohort 1966)-allowed a long-term follow-up of women from age 14 until 46 years who developed HDP (n=408) or did not (n=3373). HDP diagnosis was confirmed by combining hospital discharge records, data from Finnish Medical Birth Registers, and the questionnaire data at age 46. Women with self-reported PCOS (srPCOS; n=279), defined by both oligo-amenorrhea and hirsutism at age 31 or with PCOS diagnosis by age 46, were compared with women without reported PCOS (n=1577). Women with srPCOS had an increased HDP risk (odds ratio, 1.56 [95% CI, 1.03-2.37]), but the association disappeared after adjustment for body mass index. In women with srPCOS and HDP, body mass index increased from age 14 to 46 significantly more than in srPCOS women without HDP (median [interquartile range], 9.82 [6.23-14.6] and 7.21 [4.16-10.5] kg/m2, respectively; P<0.001). Also, in non-PCOS women, the increase was higher in women with (7.54 [5.32-11.62] kg/m2; P<0.001) than without HDP (6.33 [3.90-9.33] kg/m2; P<0.001). Increase in waist circumference between ages 31 and 46 years was associated with HDP but not with PCOS. Hyperandrogenemia at 31 or 46 years did not associate with HDP (1.44 [0.98-2.11]). In conclusion, obesity, especially abdominal obesity, and weight gain from adolescence to age 46, but not srPCOS or hyperandrogenemia, were associated with an increased risk of HDP.
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Affiliation(s)
- Juhani S S Rantakallio
- From the Department of Obstetrics and Gynecology, PEDEGO Research Unit (J.S.S.R., J.E.N., S.I.W., M.-M.E.O., A.H.B., J.S.T., T.T.P., M.S.V., L.C.M.-P.), Medical Research Center, Oulu University Hospital, University of Oulu, Finland
| | - Jaana E Nevalainen
- From the Department of Obstetrics and Gynecology, PEDEGO Research Unit (J.S.S.R., J.E.N., S.I.W., M.-M.E.O., A.H.B., J.S.T., T.T.P., M.S.V., L.C.M.-P.), Medical Research Center, Oulu University Hospital, University of Oulu, Finland
| | - Sammeli I West
- From the Department of Obstetrics and Gynecology, PEDEGO Research Unit (J.S.S.R., J.E.N., S.I.W., M.-M.E.O., A.H.B., J.S.T., T.T.P., M.S.V., L.C.M.-P.), Medical Research Center, Oulu University Hospital, University of Oulu, Finland
| | - Meri-Maija Ollila
- From the Department of Obstetrics and Gynecology, PEDEGO Research Unit (J.S.S.R., J.E.N., S.I.W., M.-M.E.O., A.H.B., J.S.T., T.T.P., M.S.V., L.C.M.-P.), Medical Research Center, Oulu University Hospital, University of Oulu, Finland
| | - Katri Puukka
- NordLab Oulu, Department of Clinical Chemistry (K.P.), Medical Research Center, Oulu University Hospital, University of Oulu, Finland
| | - Aini H Bloigu
- From the Department of Obstetrics and Gynecology, PEDEGO Research Unit (J.S.S.R., J.E.N., S.I.W., M.-M.E.O., A.H.B., J.S.T., T.T.P., M.S.V., L.C.M.-P.), Medical Research Center, Oulu University Hospital, University of Oulu, Finland
| | - Marjo-Riitta Järvelin
- MRC-PHE Centre for Environment and Health, Department of Epidemiology and Biostatistics, School of Public Health (M.-R.J.), Imperial College London, United Kingdom
- Center for Life Course Health Research, Faculty of Medicine, University of Oulu, Finland (M.-R.J.)
| | - Juha S Tapanainen
- From the Department of Obstetrics and Gynecology, PEDEGO Research Unit (J.S.S.R., J.E.N., S.I.W., M.-M.E.O., A.H.B., J.S.T., T.T.P., M.S.V., L.C.M.-P.), Medical Research Center, Oulu University Hospital, University of Oulu, Finland
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Finland (J.S.T.)
| | - Stephen Franks
- Institute of Reproductive and Developmental Biology (S.F.), Imperial College London, United Kingdom
| | - Leo Dunkel
- Centre for Endocrinology, William Harvey Research Institute, Barts and The London Medical School, United Kingdom (L.D.)
| | | | - Marja S Vääräsmäki
- From the Department of Obstetrics and Gynecology, PEDEGO Research Unit (J.S.S.R., J.E.N., S.I.W., M.-M.E.O., A.H.B., J.S.T., T.T.P., M.S.V., L.C.M.-P.), Medical Research Center, Oulu University Hospital, University of Oulu, Finland
| | - Laure C Morin-Papunen
- From the Department of Obstetrics and Gynecology, PEDEGO Research Unit (J.S.S.R., J.E.N., S.I.W., M.-M.E.O., A.H.B., J.S.T., T.T.P., M.S.V., L.C.M.-P.), Medical Research Center, Oulu University Hospital, University of Oulu, Finland
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