Lipoprotein subclass patterns in women with polycystic ovary syndrome (PCOS) compared with equally insulin-resistant women without PCOS

Overweight and obesity in polycystic ovary syndrome: association with inflammation, oxidative stress and dyslipidaemia

Polycystic ovary syndrome (PCOS) is associated with altered lipid profile and increased small, dense LDL particles (sdLDL). Considering that paraoxonase 1 (PON1) is an antioxidative enzyme located on HDL particles, the aim of this study was to investigate the connection between oxidative stress (OS) and PON1 activity with lipoprotein subclasses in PCOS depending on obesity. In 115 PCOS patients, lipoprotein subclasses distributions were determined by gradient gel electrophoresis. OS status was assessed by total oxidative status (TOS), advanced oxidation protein products, malondialdehyde (MDA), prooxidant-antioxidant balance (PAB), total antioxidative status (TAS) and superoxide dismutase (SOD) and PON1 activity. Overweight/obese PCOS patients (n 55) had increased OS compared with normal weight patients (n 60). In addition, overweight/obese group had lower HDL size and higher proportion of HDL 3a subclasses (P < 0·05). PAB was in negative correlation with HDL 2a (P < 0·001), whereas MDA and SOD correlated positively with HDL 3 subclasses (P < 0·05). Serum PON1 activity was positively associated with proportions of PON1 activity on HDL 2b (P < 0·05) and 2a (P < 0·01), but negatively with the proportion on HDL 3 particles (P < 0·01). LDL B phenotype patients had increased TAS, SOD and PON1 activity on HDL 2b, but decreased PON1 activity on HDL 3 subclasses. OS is associated with altered lipoprotein subclasses distribution in PCOS patients. Obesity in PCOS affects the profile of HDL subclasses, reflected through the reduced proportion of PON1 activity on HDL 3 subclasses in the presence of sdLDL particles.

Markers of insulin resistance in Polycystic ovary syndrome women: An update

Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders, affecting 5%-10% of women of reproductive age. The importance of this syndrome lies in the magnitude of associated comorbidities: infertility, metabolic dysfunction, cardiovascular disease (CVD), plus psychological and oncological complications. Insulin resistance (IR) is a prominent feature of PCOS with a prevalence of 35%-80%. Without adequate management, IR with compensatory hyperinsulinemia contributes directly to reproductive dysfunction in women with PCOS. Furthermore, epidemiological data shows compelling evidence that PCOS is associated with an increased risk of impaired glucose tolerance, gestational diabetes mellitus and type 2 diabetes. In addition, metabolic dysfunction leads to a risk for CVD that increases with aging in women with PCOS. Indeed, the severity of IR in women with PCOS is associated with the amount of abdominal obesity, even in lean women with PCOS. Given these drastic implications, it is important to diagnose and treat insulin resistance as early as possible. Many markers have been proposed. However, quantitative assessment of IR in clinical practice remains a major challenge. The gold standard method for assessing insulin sensitivity is the hyperinsulinemic euglycemic glucose clamp. However, it is not used routinely because of the complexity of its procedure. Consequently, there has been an urgent need for surrogate markers of IR that are more applicable in large population-based epidemiological investigations. Despite this, many of them are either difficult to apply in routine clinical practice or useless for women with PCOS. Considering this difficulty, there is still a need for an accurate marker for easy, early detection and assessment of IR in women with PCOS. This review highlights markers of IR already used in women with PCOS, including new markers recently reported in literature, and it establishes a new classification for these markers.

Metabolic syndrome and its components in different phenotypes of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy affecting reproductive-age women. Important factors in its pathogenesis are hyperinsulinaemia and insulin resistance, which lead to higher risk of metabolic syndrome (MetS) and its complications. With the implementation of the Rotterdam diagnostic criteria in 2003, the group of PCOS patients became highly heterogeneous, with varying metabolic risk reported for different phenotypes of the syndrome. The aim of the present review is to assess the prevalence and severity of MetS and its components in patients with the four phenotypes of PCOS. A comprehensive search of Pubmed database was performed to identify studies comparing metabolic characteristics between PCOS patients with different phenotypes of the syndrome. The results of 60 studies published between 2004 and 2020 were retrieved and analysed. More adverse metabolic profile was observed in PCOS patients with hyperandrogenic phenotypes in comparison to normoandrogenic patients, as well as in classic phenotypes, defined by National Institutes of Health criteria, in comparison to newer phenotypes introduced by the Rotterdam criteria. In the majority of observations, normoandrogenic PCOS patients did not differ significantly from controls in terms of metabolic characteristics, although some East Asian studies reported more adverse metabolic profile in normoandrogenic phenotype in comparison to healthy women. In conclusion, metabolic abnormalities in PCOS seem to be associated with joint effects of hyperandrogenism, insulin resistance and visceral obesity. The differences observed between the four phenotypes of PCOS underline the need for individualised diagnostic and therapeutic approach.

Cardiovascular Risk Factors and Subclinical Atherosclerosis in Greek Adolescents with Polycystic Ovary Syndrome: Its Relationship with Body Mass Index

Polycystic ovary syndrome (PCOS) is the most common endocrine condition affecting 6–18% of adolescents and is strongly associated with obesity and cardiovascular risk factors, enhancing the risk of atherosclerosis. Thirty-two adolescents with newly diagnosed PCOS were evaluated for lipid profile disorders, insulin resistance, inflammation, non-alcoholic fatty liver disease (NAFLD), and subclinical atherosclerosis through measurements of carotid intima–media thickness (cIMT). The relationships of the above markers with increased body mass index and abdominal obesity were investigated. Twenty-three adolescents (72%) were overweight (OW) or obese (OB). The OW/OB group had significantly higher insulin, HOMA-IR, high-sensitive C-reactive protein (hsCRP), visceral adiposity index (VAI), and lipid accumulation product (LAP) levels; and lower glucose-per-insulin ratios and HDL-C levels compared to the healthy weight group. The cIMT and small dense low-density lipoprotein cholesterol (sdLDL-C) levels did not differ between the two groups. Similarly, cIMT and sdLDL-C levels did not differ between PCOS-adolescents and healthy controls. CIMT was positively correlated with systolic blood pressure and waist circumference per height ratio. In conclusion, OW/OB PCOS-adolescents have a cluster of adverse factors predisposing them to atherosclerotic cardiovascular disease. Therefore, early cardiovascular risk assessment, as well as timely and targeted interventions, are necessary for prevention.

Why does Polycystic Ovary Syndrome (PCOS) Need Long-term Management?

BACKGROUND

Polycystic ovary syndrome (PCOS) is a frequent female reproductive endocrine disease. It has been associated with a number of severe reproductive and metabolic abnormalities. However, there are still open questions especially regarding the best long-term management.

METHODS

We summarized the literature focused on the symptoms and negative long-term consequences of untreated PCOS and the existing options for the treatment. We reviewed the Pubmed and China National Knowledge Infrastructure databases and the relevant literature for the last 20 years. Included in this review also are new results of own (published) research and own experience from treating daily more than 100 PCOS patients.

RESULTS

Obesity is one of the most common findings. It can cause abnormal ovulations which can lead to infertility. Important long-term consequences can be adverse pregnancy outcomes. There is an agreement that the risk of endometrial cancer can be increased. Insulin resistance, important within the pathophysiology of PCOS, predisposes patients to metabolic dysfunction and increased risk of type 2 diabetes mellitus. Lifestyle modifications including dietary changes, exercise and weight loss are first-line interventions for many patients. Well known drug treatments such as metformin, oral contraceptives, etc. should be selected according to the individual situation and patients' needs. Regarding newer methods in the long-term management of PCOS, we found that orlistat may help to achieve weight loss and to improve lipid and glucose metabolism.

CONCLUSION

In addition to pharmacological interventions, long-term standardized individualized management of PCOS patients is needed to achieve fertility and to reduce the risk of metabolic related diseases.

Investigation of galectin-3, lipocalin 2, retinol binding protein (RBP), small dense low-density lipoprotein (sdLDL) in patients with hirsutism

Introduction

Hirsutism is defined as excessive terminal hair in androgen-dependent areas in women. Adipose tissue is no longer regarded as a storage site for triglycerides or as a source of free fatty acids but is currently emerging as a key constituent of energy metabolism secreting numerous enzymes, cytokines, growth factors, and hormones.

Aim

To evaluate serum levels of galectin-3 (Gal3), lipocalin-2 (LCN2), retinol binding protein (RBP), and small dense low-density lipoprotein (sdLDL) in patients with hirsutism and patients co-presenting with polycystic ovary syndrome (PCOS) and hirsutism.

Material and methods

The study included 90 patients that were divided into three groups: (I) patients with idiopathic hirsutism (IH) (n = 30), (II) PCOS patients with hirsutism (H-PCOS) (n = 30), and (III) the control group (n = 30). Informed consent was obtained from each participant. Idiopathic hirsutism was scored using the modified Ferriman-Gallwey (mFG) scoring system and the diagnosis of PCOS was established based on the modified Rotterdam criteria. Human Gal3, LCN2, RBP, and sdLDL levels were analysed using a commercially available double-antigen sandwich enzyme-linked immunosorbent assay.

Results

No significant difference was found between the three groups with regard to serum Gal3, LCN2, RBP, and sdLDL levels (p > 0.05). Median values were higher in the H-PCOS group than in the other two groups: body weight (median: 76.5 kg) (p < 0.001), waist circumference (median: 82.5 cm) (p = 0.001).

Conclusions

No significant correlation was found between the adipokines that play a role in the aetiology of numerous diseases and some mediators of the lipid metabolism and hirsutism.

In women with PCOS, waist circumference is a better surrogate of glucose and lipid metabolism than disease status per se

OBJECTIVE

Cardiometabolic abnormalities are recognized in polycystic ovary syndrome (PCOS). However, over-emphasis on PCOS as a risk factor potentially results in over-investigation and treatment of some women with and under-recognition of cardiometabolic risk in obese women without PCOS. Our objective was to explore the association between waist circumference (WC) and indices of glucose and lipid metabolism in women with and without PCOS.

DESIGN, PATIENTS AND MEASUREMENTS

(i) An exploratory cross-sectional study investigating association of potential cardiometabolic risk markers (PCOS status, anthropometric measures, hsCRP, HOMA-IR, SHBG, testosterone) with indices of glucose (frequently sampled intravenous glucose tolerance test) and lipid metabolism (postprandial studies and lipoprotein particle size) in 61 women with (n = 29) and without (n = 32) PCOS; (ii) a cross-sectional study in 103 PCOS women and 102 BMI-matched controls to explore if between-group differences in indices of lipid and glucose metabolism persist after adjusting for WC. NIH criteria were used for PCOS diagnosis.

RESULTS

Study 1: Univariate correlations and stepwise regression modelling identified waist circumference (WC), as a better surrogate than PCOS status, independently predicting multiple variables of glucose and lipid metabolism. Study 2: Fasting insulin and triglyceride, hsCRP and insulin resistance (according to HOMA-IR and SiM [Avignon index]) were greater, while fasting HDL was lower in women with PCOS compared to BMI-matched women without PCOS. None of these differences persisted when a subset of 80 women with PCOS was compared with 80 women without PCOS, pair-matched for WC.

CONCLUSION

Some cardiometabolic abnormalities in PCOS are related to central obesity, and following adjustment for WC does not differ from normal subjects. Waist circumference measurement has potential to take precedence over PCOS status as part of the assessment of cardiometabolic risk in reproductive-age women.

Metabolic syndrome enhances endoplasmic reticulum, oxidative stress and leukocyte-endothelium interactions in PCOS

OBJECTIVE

Polycystic ovary syndrome (PCOS) is associated with insulin resistance, which can lead to metabolic syndrome (MetS). Oxidative stress and leukocyte-endothelium interactions are related to PCOS. Our aim was to evaluate whether the presence of MetS in PCOS patients can influence endoplasmic reticulum (ER) and oxidative stress and leukocyte-endothelium interactions.

MATERIAL AND METHODS

This was a prospective controlled study conducted in an academic medical center. The study population consisted of 148 PCOS women (116 without/32 with MetS) and 112 control subjects (87 without / 25 with MetS). Metabolic parameters, reactive oxygen species (ROS) production, ER stress markers (GRP78, sXBP1, ATF6), leukocyte-endothelium interactions, adhesion molecules (VCAM-1, ICAM-1, E-Selectin), TNF-α and IL-6 were determined.

RESULTS

Total ROS, inflammatory parameters and adhesion molecules were enhanced in the presence of MetS (p<0.05), and the PCOS+MetS group showed higher levels of IL-6 and ICAM-1 than controls (p<0.05). Increased adhesion and leukocyte rolling flux were observed in PCOS and PCOS+MetS groups vs their respective controls (p<0.05). GRP78 protein expression was higher in the PCOS groups (p<0.05 vs controls) and sXBP1 was associated with the presence of MetS (p<0.05 vs controls without MetS). Furthermore, PCOS+MetS patients exhibited higher GRP78 and ATF6 levels than controls and PCOS patients without MetS (p<0.05). In PCOS women, HOMA-IR was positively correlated with ICAM-1 (r=0.501; p<0.01), ROS (r=0.604; p<0.01), rolling flux (r=0.455;p<0.05) and GRP78 (r=0.574; p<0.001).

CONCLUSION

Our findings support the hypothesis of an association between altered metabolic status, increased ROS production, ER stress and leukocyte-endothelium interactions in PCOS, all of which are related to vascular complications.

Metabolic profiling of polycystic ovary syndrome reveals interactions with abdominal obesity

Background:

Polycystic ovary syndrome (PCOS) is a common reproductive disorder associated with metabolic disturbances including obesity, insulin resistance and diabetes mellitus. Here we investigate whether changes in the metabolic profile of PCOS women are driven by increased tendency to obesity or are specific features of PCOS related to increased testosterone levels.

Design and methods:

We conducted an NMR metabolomics association study of PCOS cases (n=145) and controls (n=687) nested in a population-based birth cohort (n=3127). Subjects were 31 years old at examination. The main analyses were adjusted for waist circumference (WC) as a proxy measure of central obesity. Subsequently, metabolite concentrations were compared between cases and controls within pre-defined WC strata. In each stratum, additional metabolomics association analyses with testosterone levels were conducted separately among cases and controls.

Results:

Overall, women with PCOS showed more adverse metabolite profiles than the controls. Four lipid fractions in different subclasses of very low density lipoprotein (VLDL) were associated with PCOS, after adjusting for WC and correction for multiple testing (P<0.002). In stratified analysis the PCOS women within large WC strata (⩾98 cm) had significantly lower high density lipoprotein (HDL) levels, Apo A1 and albumin values compared with the controls. Testosterone levels were significantly associated with VLDL and serum lipids in PCOS cases with large WC but not in the controls. The higher testosterone levels, adjusted for WC, associated adversely with insulin levels and HOMA IR in cases but not in the controls.

Conclusions:

Our findings show that both abdominal obesity and hyperandrogenism contribute to the dyslipidaemia and other metabolic traits of PCOS which all may negatively contribute to the long-term health of women with PCOS.

Distinguishing characteristics of metabolically healthy versus metabolically unhealthy obese adolescent girls with polycystic ovary syndrome

OBJECTIVE

To investigate the key physical, metabolic, hormonal and cardiovascular characteristics of metabolically healthy obese (MHO) versus unhealthy obese (MUHO) girls with polycystic ovary syndrome (PCOS).

DESIGN

Cross-sectional study.

SETTING

Research center.

PATIENT(S)

Seventy obese girls with PCOS were divided into 19 MHO and 51 MUHO based on cutoff points for in vivo insulin sensitivity (within and < 2 SDs of the mean of the insulin sensitivity of the normal-weight girls, respectively).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Body composition, abdominal fat, in vivo insulin sensitivity and secretion (hyperinsulinemic-euglycemic and hyperglycemic clamps respectively), hormonal profile, and cardiovascular disease risk markers.

RESULT(S)

MUHO-PCOS girls had higher waist circumference, visceral adipose tissue, leptin, and free testosterone, lower SHBG and E2, higher non-high-density lipoprotein (HDL) cholesterol and atherogenic lipoprotein particle concentrations, smaller HDL particle size, and higher high-sensitivity C-reactive protein compared with MHO-PCOS girls. Hepatic and peripheral insulin sensitivity were lower with higher first- and second-phase insulin secretion, but β-cell function relative to insulin sensitivity was lower in MUHO versus MHO. Pair matching of MHO and MUHO regarding age and body mass index revealed similar findings. MUHO-PCOS girls had larger visceral adiposity, lower insulin sensitivity and β-cell function, worse hormonal profile, and severely atherogenic lipoprotein concentrations compared with MHO-PCOS girls.

CONCLUSION(S)

MHO-PCOS girls have favorable physical, metabolic, hormonal, and cardiovascular disease (CVD) characteristics and lower risk biomarkers for type 2 diabetes compared with their MUHO-PCOS peers. A greater understanding of the contrast in this risk phenotype in obese girls with PCOS may have important implications for therapeutic interventions, their outcomes, and their durability.

Lipoprotein Particles in Adolescents and Young Women With PCOS Provide Insights Into Their Cardiovascular Risk

CONTEXT

Adult women with polycystic ovarian syndrome (PCOS) have an increased risk for cardiovascular disease, but the evidence for this is controversial in adolescents and young women with PCOS. Measurement of low-density lipoprotein (LDL) particle number, measured by nuclear magnetic resonance spectroscopy is a novel technology to assess cardiovascular risk.

OBJECTIVE

The objective of the study was to evaluate lipoprotein particle number and size in young women with PCOS and its relationship with insulin resistance and hyperandrogenism.

DESIGN

This was a cross-sectional case control study.

SETTING

The study was conducted at a clinical research center.

PARTICIPANTS

Women with PCOS (n = 35) and normal controls (n = 20) participated in the study.

INTERVENTIONS

Blood samples and anthropometric measures were obtained.

MAIN OUTCOME MEASURES

LDL particle size and number were measured using nuclear magnetic resonance spectroscopy. A secondary outcome was to investigate the correlation of LDL particle number with high-sensitivity C-reactive protein, waist to hip ratio, hyperandrogenism, insulin resistance, and adiponectin.

RESULTS

Women with PCOS had higher LDL particle number when compared with healthy controls (935 ± 412 vs 735 ± 264, P = .032); LDL particle number correlated strongly with high-sensitivity C-reactive protein (r = 0.37, P = .006) and waist-to-hip (r = 0.57, P = .0003). The higher LDL particle number was driven mainly due to differences in the small LDL particle number (sLDLp), with PCOS patients having more sLDLp (348 ± 305 vs 178 ± 195, P = .015). The sLDLp correlated with the Matsuda index (r = -0.51, P = .0001), homeostasis model assessment index of insulin resistance (r = 0.41, P = .002), and adiponectin (r = -0.46, P = .0004) but not with T.

CONCLUSION

Adolescent and young women with PCOS have an atherogenic lipoprotein profile suggestive of increased cardiovascular risk that appears to be driven by the degree of visceral adiposity and insulin resistance.

Targets to treat metabolic syndrome in polycystic ovary syndrome

INTRODUCTION

Metabolic syndrome is comprised of a combination of the following states: increased insulin resistance, dyslipidemia, cardiovascular disease, and increased abdominal obesity. Women with polycystic ovary syndrome (PCOS) have an increased risk of developing metabolic syndrome over the course of their lives. Metabolic syndrome increases risk of major cardiovascular events, morbidity, quality of life, and overall health care costs. Though metabolic syndrome in women with PCOS is an area of great concern, there is no effective individual medical therapeutic to adequately treat this issue.

AREAS COVERED

This article will review key aspects of metabolic syndrome in PCOS. We will discuss classic and novel therapeutics to address metabolic syndrome in women with PCOS. We will conclude with the importance of developing strategic interventions to increase the compliance to lifestyle and dietary modification, in addition to appreciation of the emerging pharmaceutical therapeutics available.

EXPERT OPINION

Innovation in lifestyle modification, including diet, exercise, with and without dedicated stress reduction techniques is the future in treatment of metabolic syndrome in PCOS. Application of novel interventions, such as group medical care, may improve future adherence to lifestyle modification recommendations, in addition to or in combination with pharmaceutical therapeutics.

Low-density lipoprotein receptor affects the fertility of female mice

Low-density lipoprotein receptor (LDLR) has been demonstrated to play a central role in lipoprotein metabolism, with Ldlr-deficient (Ldlr–/–) mice developing severe dyslipidemia. In the present study we investigated whether Ldlr knockout could harm female reproduction and explored the mechanisms involved. The results indicate that although the number of litters born to Ldlr–/– mice did not differ significantly from that born to controls, the number of pups per litter was significantly lower in the former group. Interestingly, although Ldlr–/– mice were obese, the weight of their ovaries was lower than that in control mice. Serum cholesterol levels was significantly higher in Ldlr–/– mice than in their wild-type counterparts. In contrast, there were significant decreases in cholesterol, triglyceride and total lipid levels in ovaries of Ldlr–/– mice. Both ovarian lipid deposition, as detected by Oil red O staining, and lipid droplets, as evaluated by transmission electron microscopy, supported decreased lipid levels in ovaries from Ldlr–/– mice. In addition, Ldlr–/– mice had fewer ovarian follicles, more atretic follicles, lower oestrogen levels and spent significantly less time in oestrus than did the controls. Superovulation assays indicated immature Ldlr–/– mice ovulated fewer ova than controls. These results indicate that lack of Ldlr results in dyslipidaemia and poor fertility.

Decreased cholesterol efflux capacity and atherogenic lipid profile in young women with PCOS

CONTEXT

Women with polycystic ovary syndrome (PCOS) have a high prevalence of cardiovascular disease (CVD) risk factors including dyslipidemia. Lipoproteins are heterogeneous, and measurement of serum lipids provides only the size of the pool and does not predict their function or composition. Recently, high-density lipoprotein cholesterol (HDL-C) function, as determined by cholesterol efflux capacity from macrophages, has been shown to be an independent predictor of subclinical CVD.

OBJECTIVE

The aim of the study was to comprehensively evaluate lipoprotein profile including lipid particle size and number and cholesterol efflux capacity in PCOS to better define CVD risk.

DESIGN AND SETTING

A case control study was performed at an academic PCOS center.

PATIENTS

Women with PCOS (n = 124) and geographically matched controls (n = 67) were included in the study.

MAIN OUTCOME MEASURES

The primary outcome was to measure HDL-C efflux capacity by an ex vivo system involving the incubation of macrophages with apolipoprotein (Apo) B-depleted serum from subjects, and the secondary outcome was to measure lipid particle size and number using nuclear magnetic resonance spectroscopy.

RESULTS

Women with PCOS had significantly higher body mass index and blood pressure but similar HDL-C and low-density lipoprotein cholesterol levels compared to controls. The mean ApoA1 levels were lower, and the ApoB/ApoA1 ratio was higher in PCOS subjects compared to controls (P < .01). There were no differences in ApoB levels. Women with PCOS had an 7% decrease in normalized cholesterol efflux capacity compared to controls (P < .003). Cholesterol efflux capacity in PCOS correlated with body mass index, ApoA1, HDL-C, and the presence of metabolic syndrome. In a multivariable regression model, PCOS was significantly associated with diminished cholesterol efflux. PCOS was also associated with an atherogenic profile including an increase in large very low-density lipoprotein particles, very low-density lipoprotein (VLDL) size, and small low-density lipoprotein cholesterol particles (P < .01).

CONCLUSIONS

Our novel findings of decreased cholesterol efflux and an atherogenic lipid particle number and size pattern in women with PCOS, independent of obesity, further substantiate the increased risk of CVD in this population.

Trends in serum lipids and hypertension prevalence among non-pregnant reproductive-age women: United States National Health and Nutrition Examination Survey 1999-2008

Cardiovascular disease is one of the leading causes of death among reproductive-age women. In this study, we examine trends in the prevalence of dyslipidemia, hypertension, and related clinicians' advice among reproductive-age women. We conducted trend analysis of these factors among non-pregnant women aged 20-49 years (n = 5,768) using National Health and Nutrition Examination Survey (NHANES) data obtained between 1999 and 2008. Multiple linear regression and logistic regression analyses were used to examine linear trends over a 10-year period after adjusting for covariates. A downward trend was observed for the proportion of women with abnormal levels of low density lipoprotein (LDL; P = 0.038) and high density lipoprotein (HDL; P = 0.008) cholesterol from 1999 to 2008. In contrast, no significant changes were observed in the prevalence of abnormal total cholesterol (P = 0.948) and triglyceride levels (P = 0.300), or hypertension (P = 0.632). Based on the self-reported data, upward trends were observed in the rates of cholesterol checking (P = 0.002), high cholesterol (P = 0.012), receiving clinicians' advice to use lipid-lowering agents (P < 0.001) and patients' compliance with their advice (P < 0.001). Although rates of self-reported hypertension did not change over time (P = 0.120), receiving clinicians' advice to use antihypertensive medications (P = 0.003) and patients' compliance with these medications (P = 0.015) also increased significantly. Overall improvements in LDL and HDL cholesterol over this time period could be due to increases in related awareness, receiving advice to use medications, and patients' compliance with this advice. Use of antihypertensive medication has also increased among reproductive-age women in the US.

Testosterone and progesterone, but not estradiol, stimulate muscle protein synthesis in postmenopausal women

CONTEXT

The effect of the female sex steroids, estradiol and progesterone, on muscle protein turnover is unclear. Therefore, it is unknown whether the changes in the hormonal milieu throughout the life span in women contribute to the changes in muscle protein turnover and muscle mass (eg, age associated muscle loss).

OBJECTIVE

The objective of this study was to provide a comprehensive evaluation of the effect of sex hormones on muscle protein synthesis and gene expression of growth-regulatory factors [ie, myogenic differentiation 1 (MYOD1), myostatin (MSTN), follistatin (FST), and forkhead box O3 (FOXO3)].

SUBJECTS AND DESIGN

We measured the basal rate of muscle protein synthesis and the expression of muscle growth-regulatory genes in 12 premenopausal women and four groups of postmenopausal women (n=24 total) who were studied before and after treatment with T, estradiol, or progesterone or no intervention (control group). All women were healthy, and pre- and postmenopausal women were carefully matched on body mass, body composition, and insulin sensitivity.

RESULTS

The muscle protein fractional synthesis rate was approximately 20% faster, and MYOD1, FST, and FOXO3 mRNA expressions were approximately 40%-90% greater (all P<.05) in postmenopausal than premenopausal women. In postmenopausal women, both T and progesterone treatment increased the muscle protein fractional synthesis rate by approximately 50% (both P<.01), whereas it was not affected by estradiol treatment and was unchanged in the control group. Progesterone treatment increased MYOD1 mRNA expression (P<.05) but had no effect on MSTN, FST, and FOXO3 mRNA expression. T and estradiol treatment had no effect on skeletal muscle MYOD1, MSTN, FST, and FOXO3 mRNA expression.

CONCLUSION

Muscle protein turnover is faster in older, postmenopausal women compared with younger, premenopausal women, but these age-related differences do not appear to be explained by the age- and menopause-related changes in the plasma sex hormone milieu.

Influence of obesity on atherogenic dyslipidemia in women with polycystic ovary syndrome

BACKGROUND

Obesity is known to underlie, at least partially, dyslipidemia in polycystic ovary syndrome (PCOS), but it is unclear whether PCOS status per se increases the risk of alterations of lipoprotein subfractions, which differ in size and atherogenic potential. Our objective was to evaluate whether PCOS influences lipoprotein profile and LDL and HDL subfractions and to study the impact of obesity on these parameters.

MATERIALS AND METHODS

This was a case-control study conducted in an academic medical centre. The study population consisted of 54 women of fertile age with PCOS and 60 controls adjusted for age and BMI. Biochemical lipid profile and LDL and HDL lipoprotein subfractions (measured using Lipoprint System).

RESULTS

Lean PCOS women exhibited lower HDL cholesterol and apolipoprotein AI levels than controls, although these differences were not associated with alterations of lipoprotein subfractions. All obese subjects, whether PCOS or controls, displayed lipid parameters typical of atherogenic dyslipidemia, although the former group had lower levels of large HDL, higher levels of small HDL subfractions and a higher percentage of VLDL than the latter. These differences were associated with a greater prevalence of non-A LDL pattern (25.0%) in obese PCOS subjects than in obese controls (4.3%).

CONCLUSIONS

PCOS does not constitute an additional risk factor for cardiovascular disease in lean women, but leads to a lipid profile characteristic of atherogenic dyslipidemia and an altered pattern of lipoprotein subfraction when associated with obesity.

Dyslipidemia in women with polycystic ovary syndrome

Dyslipidemia is a very common metabolic abnormality in women with polycystic ovary syndrome (PCOS). Insulin resistance is a key pathophysiology of PCOS, thus dyslipidemia in women with PCOS may be consistent with those found in an insulin resistant state. In recent meta-analysis, triglycerides and low-density lipoprotein (LDL) cholesterol levels were 26 mg/dL and 12 mg/dL higher, and high-density lipoprotein cholesterol concentration was 6 mg/dL lower in women with PCOS than those of controls. Alterations in LDL quality also have been reported in women with PCOS: women with PCOS have an increased proportion of atherogenic small dense LDL or decreased mean LDL particle size. However, in a recent Korean study, non-obese Korean women with PCOS had no significant quantitative or qualitative changes in LDL cholesterol profile. Lipoprotein (a) has been identified as an independent risk factor for coronary heart disease, and its elevation in PCOS patients has been consistently reported in diverse studies including non-obese Korean population. Some studies have investigated apolipoprotein (Apo) A-I and ApoC-I levels in women with PCOS and levels of ApoA-I, which has cardio-protective effects, were significantly lower in women with PCOS than those of controls. ApoC-I is known to increase the postprandial serum lipid level that is common in coronary artery disease patients, and one study reported that such an elevation may be the earliest variation of lipid abnormality in women with PCOS. In conclusion, women with PCOS should receive a complete lipid test, and lifestyle modification, including diet and exercise, is the first line therapy for all women with PCOS and is particularly important for those with dyslipidemia.

Atherogenic changes in low-density lipoprotein particle profiles were not observed in non-obese women with polycystic ovary syndrome

STUDY QUESTION

Is a preponderance of small dense low-density lipoprotein-cholesterol (LDL-C) observed in non-obese women with polycystic ovary syndrome (PCOS)?

SUMMARY ANSWER

Non-obese Korean women with PCOS have no quantitative or qualitative changes in LDL-C profiles.

WHAT IS KNOWN ALREADY

Small dense LDL particles (sd-LDL) are more atherogenic than large buoyant ones and are strongly associated with coronary artery disease independent of other risk factors. Many investigators have found an increased proportion of atherogenic sd-LDL or a decreased mean LDL particle size in women with PCOS, but all of these studies have been based primarily on obese or overweight women with PCOS.

STUDY DESIGN, SIZE, DURATION

This was a case-control study evaluating complete lipid and lipoprotein profiles in 64 PCOS patients and 64 age- and BMI-matched controls. All women with PCOS in our study population were not obese. To determine the differences in the LDL particle profiles between PCOS phenotypes, the patients with PCOS were divided into two subgroups according to the presence of clinical or biochemical hyperandrogenism.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Using the Rotterdam criteria, we recruited 64 women (18-40 years) with PCOS who were attending a tertiary university hospital. A total of 64 premenopausal control women were matched with patients based on exact age and BMI (± 1.0 kg/m(2)). All the participants fell within the non-obese range of the BMI (<25 kg/m(2)) according to the definition of obesity for Asians. The LDL subfraction was analyzed by 3% polyacrylamide gel tube electrophoresis. Seven LDL subclasses were quantified and LDL subclasses 3-7 were small LDL subfractions. LDL subfraction scores were calculated based on the following weighted scoring system developed by the manufacturer: scores of <5.5 were categorized as phenotype A (large, buoyant LDLs), and those >5.5 were categorized as non-A phenotype (sd-LDLs). The system also determined the mean LDL particle size diameter.

MAIN RESULTS AND THE ROLE OF CHANCE

There were no differences in the absolute level of LDL-C, mean LDL diameter or percentage of atherogenic sd-LDLs between PCOS patients and controls or between hyperandrogenic and non-hyperandrogenic PCOS subgroups. Also, none of the subjects showed a non-A LDL phenotype. The most notable finding of our study was the difference in the lipoprotein (a) levels and prevalence of its elevation in PCOS patients versus controls (P = 0.002 and P = 0.004, respectively), and between PCOS subgroups (P = 0.030 and P = 0.047, respectively).

LIMITATIONS, REASONS FOR CAUTION

Inclusion of only non-obese subjects, small sample size and lack of information on other potential confounding factors, such as differences in diet and/or exercise patterns.

WIDER IMPLICATIONS OF THE FINDINGS

Although our findings suggest that non-obese women with PCOS have no significant quantitative or qualitative changes in LDL-C profile, data on obese Korean women with PCOS could offer complementary findings about the possible relationship between the magnitude of obesity and LDL phenotype. Further investigations are needed to determine whether a change in lipoprotein (a) in non-obese women with PCOS is also found in other ethnic groups.

STUDY FUNDING/COMPETING INTEREST(S)

No conflict of interest exists. This study was supported by a grant of the Korean Health Technology R&D Project, Ministry of Health & Welfare, Republic of Korea (A100624).

TRIAL REGISTRATION NUMBER

N/A.

Cholesterol screening for women: who is "at-risk"?

BACKGROUND

High cholesterol often precedes cardiovascular disease (CVD) and guidelines recommend cholesterol screening among at-risk women. Definitions of CVD risk vary and prevalence of dyslipidemia (abnormal total cholesterol, high-density lipoprotein (HDL-C), or non-HDL-C) among at-risk women may vary by age and definition of CVD risk.

METHODS

This study used 2007-2008 National Health and Nutrition Examination Survey data (n=1,781), a representative sample of the U.S. civilian, non-institutionalized population, to estimate the proportion of women without previous dyslipidemia diagnosis who are U.S. Preventive Services Task Force (USPSTF) at-risk and American Heart Association (AHA) at-risk. We also report dyslipidemia prevalence stratified by age.

RESULTS

Over half (55.0%) of younger women (20-44 years) and 74.2% of older women (≥45 years) were USPSTF at-risk, while nearly all younger and older women had at least one AHA risk factor (99.5% and 99.6%, respectively). Dyslipidemia prevalence among younger women was 47.3% (95% confidence interval [CI]: 42.2-52.5) for USPSTF-at-risk and 39.5% (95% CI: 35.7-43.4) for AHA at-risk. Among older women, it was 65.5% (95% CI: 60.8-69.9) for USPSTF at-risk and 63.3% (95% CI: 59.0-67.4) for AHA at-risk.

CONCLUSIONS

The AHA risk definition identified 45% more young women and 25% more older women than the USPSTF risk definition; however, both definitions of at-risk identified similar prevalence estimates of dyslipidemia among women. Given a high prevalence of dyslipidemia among younger women, future research is needed to assess whether identification and treatment of young women with dyslipidemia will decrease CVD mortality among them later in life.

Leucocytosis in women with polycystic ovary syndrome (PCOS) is incompletely explained by obesity and insulin resistance

OBJECTIVES

Low-grade chronic inflammation predicts cardiovascular outcomes and is observed in women with polycystic ovary syndrome (PCOS). Whether this is entirely a cause or consequence of insulin resistance (IR) is unknown.

METHODS

Seventy pairs of women with and without PCOS, matched for age, body mass index (BMI) and IR (HOMA, QUICKI and Avignon index), were generated from a larger cohort of 103 women with and 104 BMI-matched women without PCOS. Women with PCOS were studied in the follicular phase of the menstrual cycle. White cell count (WCC), high-sensitivity CRP (hsCRP) and a series of 12 cytokines and growth factors were measured. These inflammatory markers were also compared between women with PCOS and 10 normal women studied in the follicular, peri-ovulatory and luteal stages.

RESULTS

When all subjects were compared, WCC (6.75 × 10(9) vs 5.60 × 10(9 ) g/l, P < 0.005), hsCRP (4.04 vs 2.90 mg/l, P < 0.05) and IL-6 (1.11 vs 0.72 pg/ml, P < 0.05) were greater in women with PCOS. Pair-matching for IR eliminated between-group differences in hsCRP and cytokines but did not alter the difference in WCC (6.60 × 10(9) vs 5.60 × 10(9 ) g/l, P < 0.005). WCC was greater in PCOS compared to normal women at all stages of the menstrual cycle.

CONCLUSIONS

Low-grade inflammation occurs in PCOS. Increased hsCRP and cytokines are associated with IR, but increased WCC is observed even when IR is accounted for. The explanation for this and its clinical significance is unknown.

Effects of thiazolidinediones on polycystic ovary syndrome: a meta-analysis of randomized placebo-controlled trials

INTRODUCTION

Thiazolidinedione (TZD) is one of the therapy options for polycystic ovary syndrome (PCOS) patients; however, the effectiveness of TZD in the treatment of PCOS remains controversial. The aim of this metaanalysis was to clarify the role that TZDs play in the treatment of PCOS.

METHODS

The authors searched the following databases for any date up to June 2012 for randomized controlled trials on PCOS treatment in which interventions for the experimental and control groups were TZDs and placebo, respectively: Medline, Embase, and the Cochrane library.

RESULTS

The search strategy identified 173 potential publications, eight of which were included. In the treatment of PCOS, the insulin-lowering effects of TZDs were superior to placebo (95% CI -1.50 to -0.12; P=0.021), and the lowering of fasting blood glucose was superior to placebo (95% CI -1.06 to -0.05; P=0.031). There was no difference in reduction of the Ferriman-Gallwey scores or the androgen levels between TZDs and placebo (95% CI -0.57 to 0.10; P=0.169 and 95% CI -0.64 to 0.09; P=0.141, respectively). The effects of TZDs on body weight reduction were inferior to placebo (95% CI 0.13 to 0.66; P=0.003). Significant between-study heterogeneity was detected for several variables assessed.

CONCLUSION

This is the first meta-analysis to evaluate the role that TZDs plays in the treatment of PCOS compared with placebo. The currently available data showed that TZDs can effectively reduce insulin and fasting blood glucose levels in patients with PCOS, but TZDs may not effectively reduce the Ferriman-Gallwey score or androgen levels and may increase body weight.

A systematic review and meta-analysis of randomized controlled trials comparing pioglitazone versus metformin in the treatment of polycystic ovary syndrome

OBJECTIVE

Evidence indicates that metformin and pioglitazone both improve insulin resistance and hirsutism among patient with polycystic ovarian syndrome (PCOS). However, the effectiveness of pioglitazone versus metformin in the treatment of PCOS remains controversial. To summarize the relative efficacy of pioglitazone and metformin in PCOS patients, a systematic review and meta-analysis of randomized controlled trials (RCTs) was performed.

METHODS

The authors searched MEDLINE, EMBASE, CNKI and WANFANG DATA for articles published up to November 2011 to identify those comparing pioglitazone versus metformin as a treatment for PCOS.

RESULTS

Of the 161 studies retrieved, six trials were included in this analysis, including a total of 278 women with PCOS. Pioglitazone was found to be significantly more effective than metformin at reducing fasting insulin level (P = 0.002, standardized mean differences [SMD] = -0.37, 95% confidence interval [CI] [-0.61, -0.13]). Similarly, pioglitazone was found to be significantly more effective than metformin at improving the HOMA-IR index (P = 0.014, SMD = -0.32, 95% CI [-0.57, -0.06]). However, pioglitazone was significantly less effective than metformin at reducing body mass index (BMI; P = 0.038, SMD = 0.25, 95% CI [0.01, 0.49]). The effect of pioglitazone on fasting glucose levels, testosterone levels, and Ferriman-Gallwey scores was not significantly different from that of metformin (P greater than 0.05 for all).

CONCLUSION

This systematic review and meta-analysis suggests that pioglitazone was more suitable for treating hyperinsulinemia and insulin resistance among PCOS patients, while metformin was more effective in reducing body weight. Well designed RCTs are needed to provide better evidence.

Testosterone increases the muscle protein synthesis rate but does not affect very-low-density lipoprotein metabolism in obese premenopausal women

Men and women with hyperandrogenemia have a more proatherogenic plasma lipid profile [e.g., greater triglyceride (TG) and total and low-density lipoprotein-cholesterol and lower high-density lipoprotein-cholesterol concentrations] than healthy premenopausal women. Furthermore, castration of male rats markedly reduces testosterone availability below normal and decreases plasma TG concentration, and testosterone replacement reverses this effect. Testosterone is, therefore, thought to be an important regulator of plasma lipid homeostasis. However, little is known about the effect of testosterone on plasma TG concentration and kinetics. Furthermore, testosterone is a potent skeletal muscle protein anabolic agent in men, but its effect on muscle protein turnover in women is unknown. We measured plasma lipid concentrations, hepatic very low density lipoprotein (VLDL)-TG and VLDL-apolipoprotein B-100 secretion rates, and the muscle protein fractional synthesis rate in 10 obese women before and after trandermal testosterone (1.25 g of 1% AndroGel daily) treatment for 3 wk. Serum total and free testosterone concentrations increased (P < 0.05) by approximately sevenfold in response to testosterone treatment, reaching concentrations that are comparable to those in women with hyperandrogenemia, but lower than the normal range for eugonadal men. Except for a small (∼10%) decrease in plasma high-density lipoprotein particle and cholesterol concentrations (P < 0.04), testosterone therapy had no effect on plasma lipid concentrations, lipoprotein particle sizes, and hepatic VLDL-TG and VLDL-apolipoprotein B-100 secretion rates (all P > 0.05); the muscle protein fractional synthesis rate, however, increased by ∼45% (P < 0.001). We conclude that testosterone is a potent skeletal muscle protein anabolic agent, but not an important regulator of plasma lipid homeostasis in obese women.

Hormonal and metabolic effects of polyunsaturated fatty acids in young women with polycystic ovary syndrome: results from a cross-sectional analysis and a randomized, placebo-controlled, crossover trial

BACKGROUND

Polycystic ovary syndrome (PCOS) is characterized by an adverse metabolic profile. Although dietary changes are advocated, optimal nutritional management remains uncertain. Polyunsaturated fatty acids (PUFAs), particularly long-chain (LC) n-3 (omega-3) PUFAs, improve metabolic health, but their therapeutic potential in PCOS is unknown.

OBJECTIVES

We aimed to determine the associations between plasma PUFAs and metabolic and hormonal aspects of PCOS to investigate the efficacy of LC n-3 PUFA supplementation and to support the findings with mechanistic cellular studies.

DESIGN

We selected a cross-sectional PCOS cohort (n = 104) and conducted a principal component analysis on plasma fatty acid profiles. Effects of LC n-3 PUFA supplementation on fasting and postprandial metabolic and hormonal markers were determined in PCOS subjects (n = 22) by a randomized, crossover, placebo-controlled intervention. Direct effects of n-6 (omega-6) compared with n-3 PUFAs on steroidogenesis were investigated in primary bovine theca cells.

RESULTS

Cross-sectional data showed that a greater plasma n-6 PUFA concentration and n-6:n-3 PUFA ratio were associated with higher circulating androgens and that plasma LC n-3 PUFA status was associated with a less atherogenic lipid profile. LC n-3 PUFA supplementation reduced plasma bioavailable testosterone concentrations (P < 0.05), with the greatest reductions in subjects who exhibited greater reductions in plasma n-6:n-3 PUFA ratios. The treatment of bovine theca cells with n-6 rather than with n-3 PUFAs up-regulated androstenedione secretion (P < 0.05).

CONCLUSIONS

Cross-sectional data suggest that PUFAs modulated hormonal and lipid profiles and that supplementation with LC n-3 PUFAs improves androgenic profiles in PCOS. In bovine theca cells, arachidonic acid modulated androstenedione secretion, which suggests an indirect effect of n-3 PUFAs through the displacement of or increased competition with n-6 PUFAs. This trial was registered at clinicaltrials.gov as NCT01189669.

Metabolic and hormonal aspects of polycystic ovary syndrome: the impact of diet

Polycystic ovary syndrome (PCOS) is a common, chronic endocrine condition affecting young women of reproductive age. It is characterised by hyperandrogenaemia, and profound menstrual and ovulatory dysfunction with consequent sub-fertility. A clustering of metabolic aberrations is commonly associated with this condition and these include insulin resistance, disordered lipid metabolism and chronic low-grade inflammation. Overweight and obesity, as well as a degree of adipose tissue dysfunction, are present in a large proportion of women with PCOS, and where present, magnify the inherent hyperandrogenaemia characteristic of the condition, in addition to worsening the metabolic profile. Diet and lifestyle interventions are among the first-line treatments for PCOS, and weight reduction through energy restriction has been shown to exert positive influences on both metabolic and hormonal aspects of this condition. Alterations in carbohydrate amount and type have also been investigated, and more recently, dietary fatty acids, with a particular emphasis on PUFA, have been shown to have a positive impact within this population group. Although it is likely that diet is not the root cause of PCOS, it represents a modifiable variable with the potential to improve the health of women with this condition. Work to date has provided insights into the role of diet in PCOS; however, further work is required to determine the role of nutrients specifically within the context of PCOS, in order to develop more effective, evidence-based dietary guidelines for this condition.