High Androgens in Postmenopausal Women and the Risk for Atherosclerosis and Cardiovascular Disease: The Rotterdam Study

Genetically predicted high serum sex hormone-binding globulin levels are associated with lower ischemic stroke risk: A sex-stratified Mendelian randomization study

OBJECTIVE

Cross-sectional and cohort studies have found insufficient evidence of a causal relationship between sex hormone-binding globulin and ischemic stroke, only associations. Here, we performed a sex-stratified, bidirectional, two-sample Mendelian randomization analysis to evaluate whether a causal relationship exists between sex hormone-binding globulin and ischemic stroke.

METHODS

Single-nucleotide polymorphisms associated with sex hormone-binding globulin and ischemic stroke were screened from genome-wide association studies summary data as instrumental variables to enable a bidirectional, two-sample Mendelian randomization study design. Inverse-variance weighted analysis was used as the main method to evaluate potential causality, and additional methods, including the weighted median and MR-Egger tests, were used to validate the Mendelian randomization results. Cochran's Q statistic, MR-Egger intercept test, and Mendelian Randomization-Pleiotropy Residual Sum and Outlier global test were used as sensitivity analysis techniques to assure the reliability of the results. Multivariable analysis was used to show the robustness of the results with key theorized confounders.

RESULTS

Inverse-variance weighted analysis showed that genetically predicted higher serum sex hormone-binding globulin levels were associated with significantly decreased risk of ischemic stroke in males (odds radio = 0.934, 95 % confidence interval = 0.885-0.985, P = 0.012) and females (odds radio = 0.924, 95 % confidence interval = 0.868-0.983, P = 0.013). In an analysis of ischemic stroke subtypes, genetically predicted higher serum sex hormone-binding globulin levels were also associated with significantly decreased risk of small-vessel occlusion in both males (odds radio = 0.849, 95 % confidence interval = 0.759-0.949, P = 0.004) and females (odds radio = 0.829, 95 % confidence interval = 0.724-0.949, P = 0.006). The association remained in sensitivity analyses and multivariable analyses. The reverse analysis suggested an association between genetically predicted risk of cardioembolism and increased serum sex hormone-binding globulin in females (Beta = 0.029 nmol/L, Standard Error = 0.010, P = 0.003).

CONCLUSION

Our findings provide new insight into the etiology of ischemic stroke and suggest that modulating serum sex hormone-binding globulin may be a therapeutic strategy to protect against ischemic stroke.

Testosterone therapy in females is not associated with increased cardiovascular or breast cancer risk: a claims database analysis

BACKGROUND

Testosterone therapy (TTh) has been shown to improve libido in women with sexual dysfunction, but its utilization has been limited due to concern for cardiovascular events and past studies reporting highly variable results.

AIM

To assess the association of TTh in women with major adverse cardiac events (MACEs), including heart attack, stroke, or death, using a large database.

METHODS

The TriNetX Diamond Network was queried from 2009 to 2022. Our study cohort included adult females with ≥3 systemic testosterone prescriptions within a year. Our control cohort excluded females with any testosterone prescriptions, polycystic ovary syndrome, or androgen excess. Both cohorts excluded females with prior heart failure, unstable angina, intersex surgery (female to male), personal history of sex reassignment, or gender identity disorders. Propensity matching between the cohorts was performed. A subanalysis by age was conducted (18-55 and >55 years).

OUTCOMES

We evaluated the association of TTh to the following: MACE, upper or lower emboli or deep vein thrombosis (DVT), pulmonary embolism (PE), breast neoplasm, and hirsutism within 3 years of TTh.

RESULTS

When compared with propensity-matched controls, adult females with TTh had a lower risk of MACE (risk ratio [RR], 0.64; 95% CI, 0.51-0.81), DVT (RR, 0.61; 95% CI, 0.42-0.90), PE (RR, 0.48; 95% CI, 0.28-0.82), and malignant breast neoplasm (RR, 0.48; 95% CI, 0.37-0.62). Similarly, females aged 18 to 55 years with TTh had a lower risk of MACE (RR, 0.49; 95% CI, 0.28-0.85) and DVT (RR, 0.48; 95% CI, 0.25-0.93) and a similar risk of malignant breast neoplasm (RR, 0.62; 95% CI, 0.34-1.12). Females aged ≥56 years with TTh had a similar risk of MACE (RR, 0.84; 95% CI, 0.64-1.10), DVT (RR, 0.82; 95% CI, 0.50-1.36), and PE (RR, 0.52; 95% CI, 0.26-1.05) and a significantly lower risk of malignant breast neoplasm (RR, 0.51; 95% CI, 0.38-0.68). Risk of hirsutism was consistently higher in those with TTh as compared with propensity-matched controls.

CLINICAL IMPLICATIONS

Our results contribute to safety data on TTh, a therapy for sexual dysfunction in women.

STRENGTHS AND LIMITATIONS

The TriNetX Diamond Network allows for significant generalizability but has insufficient information for some factors.

CONCLUSIONS

We found a decreased risk of MACE among women with TTh as compared with matched controls and a similar risk of MACE in postmenopausal women while demonstrating a similar or significantly lower risk of breast cancer on age-based subanalysis.

Increased Prevalence of Adverse Health Outcomes Across the Lifespan in Those Affected by Polycystic Ovary Syndrome: A Canadian Population Cohort

Background

Polycystic ovary syndrome (PCOS) is the most common metabolic-endocrine disorder impacting the health and quality of life of women over the lifespan. Evidence-based data on the scope of adverse health outcomes in those affected by PCOS is critical to improve healthcare and quality of life in this population. The aim of this study was to determine the prevalence of adverse health outcomes in those with PCOS compared to age-matched controls.

Methods

We conducted a retrospective observational case-control study in those diagnosed with PCOS and age-matched controls using the Alberta Health Services Health Analytics database and the International Classification of Diseases, for the period from 2002-2018 in Alberta, Canada.

Results

The cohort consisted of n = 16,531 exposed PCOS cases and n = 49,335 age-matched un-exposed controls. The prevalences of hypertension, renal disease, gastrointestinal disease, eating disorders, mental illness, depression-anxiety, rheumatoid arthritis, respiratory infections, and all malignancies were 20%-40% (P < 0.0001) higher in those with PCOS, compared to controls. The prevalence of obesity, dyslipidemia, nonalcoholic fatty liver disease, and type 2 diabetes was 2-3 fold higher in those with PCOS (P < 0.001). Cardiovascular, cerebrovascular, and peripheral vascular disease were 30%-50% higher, and they occurred 3-4 years earlier in those with PCOS (P < 0.0001); a 2-fold higher prevalence of dementia occurred in those with PCOS, compared to controls.

Conclusion

These findings provide evidence that PCOS is associated with a higher prevalence of morbidities over the lifespan, and the potential scope of the healthcare burden in women affected by PCOS.

Testosterone and the heart: friend or foe?

Cardiovascular disease (CVD) is the leading cause of death in women aged 65 years and older. Sex hormones have been implicated as having a critical role in the evolution of CVD, with the focus mainly on estrogens in women. Available data also indicate that low testosterone blood levels may be detrimental to cardiovascular function in women. At blood concentrations considered normal for premenopausal women, testosterone has favorable effects on blood vessel function (relaxation and contraction), much of which is determined by the endothelial cells that line the inside of blood vessels. Testosterone enhances endothelium-dependent and independent brachial artery vasodilation and has an acute systolic blood pressure-lowering effect in postmenopausal women. Advantageous effects of testosterone in animal models have been seen for myocardial function and cardiac electrical signaling. Human data are mainly limited to observational and mechanistic studies, which mostly demonstrate beneficial effects of testosterone on cardiovascular health. Few studies of testosterone use in women, with cardiovascular endpoints as primary outcomes, have been published.

No association effect of genetic polymorphism was observed between polycystic ovary syndrome and cardiovascular diseases risk: a mendelian randomization study

OBJECTIVE

Polycystic ovary syndrome (PCOS) is one of the risk factors for cardiovascular diseases (CVDs). However, the possible association between PCOS and common CVDs remains inconclusive. The aim of this study was to explore the potential relationship between PCOS and CVDs using genetic polymorphisms.

METHODS

We conducted two-sample Mendelian randomization (MR) analyses. In our study, 14 single nucleotide polymorphisms (SNPs) in Europeans and another 13 SNPs in Asians were applied as instrumental variables for PCOS. The largest published meta-genome-wide association studies of European ancestry and the BioBank Japan Project of Asian ancestry were used to collect the outcome data. MR analysis was performed using inverse variance weighting as the primary method. Several sensitivity analyses and instrumental variable strength evaluations were also performed to verify the reliability of results.

RESULTS

Our analysis revealed that any potential causal association between genetically-predicted PCOS and the risk of CVDs do not exist. These CVDs include peripheral artery disease, atrial fibrillation, arrhythmia, cardiovascular diseases, heart failure, peripheral vascular disease, hypertension, ischemic stroke, myocardial infarction and venous thromboembolisms. Associations could not be found even after the SNPs linked to these possible confounders (body mass index, waist-to-hip ratio, and serum testosterone) were deleted. Sensitivity analysis demonstrated no presence of horizontal pleiotropy or heterogeneity.

CONCLUSION

The present mendelian randomization study suggests that genetically-predicted PCOS may not be associated with the risk of CVDs.

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

BACKGROUND

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

OBJECTIVE AND RATIONALE

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

SEARCH METHODS

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

OUTCOMES

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

WIDER IMPLICATIONS

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

Cardiovascular disease risk in women with hyperandrogenism, oligomenorrhea/menstrual irregularity or polycystic ovaries (components of polycystic ovary syndrome): a systematic review and meta-analysis

Aims

Prior meta-analyses indicate polycystic ovary syndrome (PCOS) is associated with cardiovascular diseases (CVDs), but have high statistical heterogeneity, likely because PCOS is a heterogenous syndrome diagnosed by having any two of the three components: hyperandrogenism, oligomenorrhea/menstrual irregularity or polycystic ovaries. Several studies report higher risk of CVDs from individual PCOS components, but a comprehensive assessment of how each component contributes to CVD risk is lacking. This study aims to assess CVD risk for women with one of the PCOS components.

Methods and results

A systematic review and meta-analysis of observational studies was conducted. PubMed, Scopus, and Web of Science were searched without restrictions in July 2022. Studies meeting inclusion criteria examined the association between PCOS components and risk of a CVD. Two reviewers independently assessed abstracts and full-text articles, and extracted data from eligible studies. Where appropriate, relative risk (RR) and 95% confidence interval (CI) were estimated by random-effects meta-analysis. Statistical heterogeneity was assessed using the I² statistic. Twenty-three studies, including 346 486 women, were identified. Oligo-amenorrhea/menstrual irregularity was associated with overall CVD (RR = 1.29, 95%CI = 1.09-1.53), coronary heart disease (CHD) (RR = 1.22, 95%CI = 1.06-1.41), and myocardial infarction (MI) (RR = 1.37, 95%CI = 1.01-1.88) but not cerebrovascular disease. These results were broadly consistent even after further adjustment for obesity. There was mixed evidence for the role of hyperandrogenism in CVDs. No studies examined polycystic ovaries as an independent exposure for CVD risk.

Conclusion

Oligo-amenorrhea/menstrual irregularity is associated with greater risk of overall CVD, CHD, and MI. More research is needed to assess the risks associated with hyperandrogenism or polycystic ovaries.

Androgen-Induced Cardiovascular Risk in Polycystic Ovary Syndrome: The Role of T Lymphocytes

An estimated 15-20% of reproductive-age women are affected by polycystic ovary syndrome (PCOS). PCOS is associated with substantial metabolic and cardiovascular long-term consequences. In young women with PCOS, several cardiovascular risk factors may be found, including chronic inflammation, high blood pressure, and elevated leukocytes. These women are at an increased risk of cardiovascular diseases (CVD), not only during the reproductive years, but also with aging and menopause; therefore, the early prevention and treatment of future cardiovascular adverse effects are necessary. The fundamental characteristic of PCOS is hyperandrogenemia, which is associated with increased pro-inflammatory cytokines and T lymphocytes. Whether these factors play a role in the pathophysiology of hypertension, a risk factor of CVD, due to PCOS is not well established. This review will briefly discuss how a modest increase in androgens in females is linked to the development of hypertension through pro-inflammatory cytokines and T lymphocyte subsets and the promotion of renal injury. Moreover, it reveals a few existing research gaps in this area, including the lack of specific therapy directed at androgen-induced inflammation and immune activation, thus emphasizing the necessity to explore the systemic inflammation in women with PCOS to halt the inevitable inflammatory process targeting the underlying abnormalities of CVD.

Low serum dehydroepiandrosterone levels are associated with diabetic retinopathy in patients with type 2 diabetes mellitus

AIMS

This cross-sectional study assessed the association of serum dehydroepiandrosterone levels with the risk of diabetic retinopathy in patients with type 2 diabetes mellitus in China.

MATERIALS AND METHODS

Patients with type 2 diabetes mellitus were included in a multivariate logistic regression analysis to assess the association of dehydroepiandrosterone with diabetic retinopathy after adjusting for confounding factors. A restricted cubic spline was also used to model the association of serum dehydroepiandrosterone level with the risk of diabetic retinopathy and to describe the overall dose-response correlation. Additionally, an interaction test was conducted in the multivariate logistic regression analysis to compare the effects of dehydroepiandrosterone on diabetic retinopathy among age, sex, obesity status, hypertension, dyslipidemia, and glycosylated hemoglobin level subgroups.

RESULTS

In total, 1,519 patients were included in the final analysis. Low serum dehydroepiandrosterone was significantly associated with diabetic retinopathy in patients with type 2 diabetes mellitus after adjustment for confounding factors (odds ratio [quartile 4 vs quartile 1]: 0.51; 95% confidence interval: 0.32-0.81; P = 0.012 for the trend). Additionally, the restricted cubic spline indicated that the odds of diabetic retinopathy decreased linearly as the dehydroepiandrosterone concentration increased (P-overall = 0.044; P-nonlinear = 0.364). Finally, the subgroup analyses showed that the dehydroepiandrosterone level stably affected diabetic retinopathy (all P for interaction >0.05).

CONCLUSIONS

Low serum dehydroepiandrosterone levels were significantly associated with diabetic retinopathy in patients with type 2 diabetes mellitus, suggesting that dehydroepiandrosterone contributes to the pathogenesis of diabetic retinopathy.

Approach to Investigation of Hyperandrogenism in a Postmenopausal Woman

Postmenopausal hyperandrogenism is a condition caused by relative or absolute androgen excess originating from the ovaries and/or the adrenal glands. Hirsutism, i.e., increased terminal hair growth in androgen-dependent areas of the body, is considered the most effective measure of hyperandrogenism in women. Other symptoms can be acne and androgenic alopecia or the development of virilization including clitoromegaly. Postmenopausal hyperandrogenism may also be associated with metabolic disorders like abdominal obesity, insulin resistance and type 2 diabetes. Mild hyperandrogenic symptoms can be due to relative androgen excess associated with menopausal transition or polycystic ovary syndrome, which is likely the most common cause of postmenopausal hyperandrogenism. Virilizing symptoms, on the other hand, can be caused by ovarian hyperthecosis or an androgen-producing ovarian or adrenal tumor that may be potentially malignant. Determination of serum testosterone, preferably by tandem mass spectrometry, is the first step in the endocrine evaluation providing important information on the degree of androgen excess. Testosterone > 5 nmol/L is associated with virilization and requires prompt investigation to rule out an androgen-producing tumor in first instance. To localize the source of androgen excess, imaging techniques are used like transvaginal ultrasound or magnetic resonance imaging (MRI) for the ovaries and computed tomography (CT) and MRI for the adrenals. Bilateral oophorectomy or surgical removal of an adrenal tumor is the main curative treatment and will ultimately lead to a histopathological diagnosis. Mild to moderate symptoms of androgen excess are treated with anti-androgen therapy or specific endocrine therapy depending on diagnosis. This review summarizes the most relevant causes of hyperandrogenism in postmenopausal women and suggests principles for clinical investigation and treatment.

Polycystic ovary syndrome and leukocyte telomere length: cross-sectional and longitudinal changes

OBJECTIVE

Telomeres are DNA-protein complexes that protect chromosome ends from DNA damage and are surrogate biomarkers of cellular aging. Current evidence, almost entirely from cross-sectional observations, supports negative associations between leukocyte telomere length (LTL) and adverse lifestyle factors and cardiometabolic risk factors. Polycystic ovary syndrome (PCOS), the most common gynecological endocrine disorder, is associated with inflammation and oxidative stress, both factors associated with accelerated telomere attrition. We therefore hypothesized that LTL would be shorter and decrease more rapidly in women with PCOS in comparison to a control population.

DESIGN

This is a population-based cohort study comprising women of Northern Finland Birth Cohort 1966, with clinical examinations at ages 31 and 46. The sample included self-reported PCOS (age 31, n = 190; age 46, n = 207) and referent women (age 31, n = 1054; age 46, n = 1324) with data on LTL.

METHODS

The association between LTL and PCOS at ages 31 and 46 was analyzed by linear regression models adjusted for BMI, smoking, alcohol consumption and socioeconomic status at the corresponding age.

RESULTS

Women with PCOS had similar mean LTL at ages 31 and 46 (P > 0.4 for both). The mean LTL change between ages 31 and 46 did not differ between groups (P = 0.19). However, we observed a significant LTL attrition between ages 31 and 46 in the reference population (P < 0.001), but not in women with PCOS (P = 0.96).

CONCLUSIONS

This finding may suggest a difference in the LTL attrition rate in women with PCOS, an unexpected finding that might affect their risk of age-related disease. Further research is needed to clarify the underlying mechanisms.

The impact of ageing and menopause in women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a common hormonal, metabolic and reproductive disorder. Women with PCOS at reproductive age have increased risk and prevalence of prediabetes and diabetes and have multiple risk factors for cardiometabolic disease and other comorbidities such as obstructive sleep apnoea, endometrial cancer and mood disorders, which contribute to the overall health burden of the syndrome. However, little is known about the impact of PCOS on long-term health in ageing women. In this review, we aimed to give an updated overview regarding the long-term health outcomes of PCOS and their clinical implications in peri- and postmenopause. The PCOS phenotype ameliorates with ageing and limited available data suggest that there is no further deterioration in cardiometabolic profile in women with PCOS after menopause. Accordingly, the risk of cardiovascular disease in ageing women with PCOS seems to be no different from those without PCOS and lower than previously anticipated based on their risk during reproductive years. Regarding other comorbidities including sleep apnoea, mood disorders and endometrial cancer, it is difficult to determine the true risk in older women with PCOS due to the confounding factors and lack of long-term cohort studies. Large, prospective studies on community-based and well-phenotyped PCOS cohorts with extended follow-up into late menopause are needed to confirm these findings.

Changes in eating behavior through lifestyle treatment in women with polycystic ovary syndrome (PCOS): a randomized controlled trial

BACKGROUND

Eating behaviors like emotional eating, external eating and restrained eating play an important role in weight gain and weight loss in the general population. Improvements in eating behavior are important for long-term weight. This has not yet been studied in women with Polycystic Ovary Syndrome (PCOS). The aim of this study is to examine if a three-component lifestyle intervention (LI) is effective for improving disordered eating behavior in women with PCOS.

METHODS

Women diagnosed with PCOS (N = 183), with a body mass index (BMI) > 25 kg/m² and trying to achieve a pregnancy were either assigned to 1 year of 20 group sessions of cognitive behavioral therapy (CBT) combined with nutritional advice and exercise with or without additional feedback through Short Message Service (SMS) or Care As Usual (CAU), which includes the advice to lose weight using publicly available services.

RESULTS

The Eating Disorder Examination Questionnaire (EDEQ) scores worsened in CAU (47.5%) and improved in the LI (4.2%) at 12 months. The difference between the LI and CAU was significant (P = 0.007) and resulted in a medium to large effect size (Cohen's d: - 0.72). No significant differences were observed in EDEQ scores between LI with SMS compared to LI without SMS (Cohen's d: 0.28; P = 0.399). Also, weight loss did not mediate the changes in eating behavior. An overall completion rate of 67/183 (36.6%) was observed.

CONCLUSIONS

A three-component CBT lifestyle program resulted in significant improvements in disordered eating behavior compared to CAU. Changes in disordered eating behavior are important for long-term weight loss and mental health.

TRIAL REGISTRATION

NTR, NTR2450. Registered 2 August 2010, https://www.trialregister.nl/trial/2344.

Cardiometabolic biomarkers in women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of reproductive age. Apart from the reproductive problems, PCOS is also associated with metabolic disturbances, and therefore, it also affects adolescents and postmenopausal women with PCOS as well as their offspring and other first-degree relatives. Adolescents with PCOS show unfavorable cardiometabolic biomarkers more often than controls, such as overweight/obesity and hyperandrogenism, and studies also suggest an unfavorable lipid profile. During reproductive age, women with PCOS develop additional cardiometabolic biomarkers, such as hypertension, insulin resistance, and metabolic syndrome. Growing evidence also supports the important role of inflammatory cytokines in cardiovascular health in these women. During menopausal transition, some PCOS characteristics ameliorate, whereas other biomarkers increase, such as body mass index, insulin resistance, type 2 diabetes, and hypertension. Offspring of women with PCOS have a lower birth weight and a higher body mass index later in life than controls. In addition, fathers, mothers, and siblings of women with PCOS show unfavorable cardiometabolic biomarkers. Therefore, cardiovascular screening and follow-up of women with PCOS and their offspring and siblings are of utmost importance.

Subclinical cardiovascular disease and polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) impacts approximately 6%-10% of women worldwide, with hallmark features of hyperandrogenism, irregular menses, infertility, and polycystic appearing ovaries on ultrasound. In addition, PCOS is associated with several endocrine and metabolic disorders, including obesity, insulin resistance and diabetes mellitus, hypertension, dyslipidemia and metabolic syndrome, which all increase the risk for subclinical cardiovascular disease (CVD), the presence of altered vascular endothelium without overt CVD. In this review, we summarize the most recent literature regarding subclinical CVD in women with PCOS, including markers such as flow-mediated dilation, arterial stiffness, coronary artery calcium scores, carotid intima-media thickness and visceral and epicardial fat.

Aging versus youth: Endocrine aspects of vulnerability for COVID-19

Coronavirus Disease 2019 (COVID-19) is characterized with a wide range of clinical presentations from asymptomatic to severe disease. In patients with severe disease, the main causes of mortality have been acute respiratory distress syndrome, cytokine storm and thrombotic events. Although all factors that may be associated with disease severity are not yet clear, older age remains a leading risk factor. While age-related immune changes may be at the bottom of severe course of COVID-19, age-related hormonal changes have considerable importance due to their interactions with these immune alterations, and also with endothelial dysfunction and comorbid cardiometabolic disorders. This review aims to provide the current scientific evidence on the pathogenetic mechanisms underlying the pathway to severe COVID-19, from a collaborative perspective of age-related immune and hormonal changes together, in accordance with the clinical knowledge acquired thus far.

Morbidity and mortality in PCOS: A prospective follow-up up to a mean age above 80 years

OBJECTIVE

Despite the clear evidence of increased cardiovascular disease (CVD) risk factors, the long-term effect on CVD and mortality is still uncertain in women with PCOS, especially in the elderly. Studies in elderly women with PCOS are lacking. The objective was to study morbidity/mortality in PCOS women compared with a reference group up to a mean age above 80 years.

STUDY DESIGN

A well-defined cohort of women with PCOS, examined in 1987 and 2008, was re-examined 32 years later in 2019 (age range 72-91 years), in parallel with an age-matched reference group. For deceased women register data was used, for women alive interviews were done, and medical records studied. Blood pressure and blood tests were analyzed. Morbidity and mortality data was available in 35/36 women with PCOS, and in 99/118 women in the reference group.

RESULTS

At mean age 81 years there was no difference in all-cause mortality (HR 1.1, ns), CVD-related mortality (HR 1.7, ns), all CVD (HR 1.2, ns), hypertension (HR 1.8, ns), type 2 diabetes (HR 1.7, ns), in levels of blood lipids, glucose, insulin or thyroid hormones. Comparing baseline data from the deceased and living women with PCOS, no differences were found regarding age, menopausal age, BMI, HOMA-IR, FAI, total testosterone or SHBG. However, deceased women with PCOS had a higher WHR (0.87 vs. 0.80; p-value < 0.01) at baseline.

CONCLUSIONS

No evidence of increased all-cause mortality or CVD was found in women with PCOS. The elevated testosterone levels and CVD risk profile in PCOS present during perimenopause do not seem to be associated with increased CVD morbidity/mortality risk later in life.

Associations between blood sex steroid concentrations and risk of major adverse cardiovascular events in healthy older women in Australia: a prospective cohort substudy of the ASPREE trial

BACKGROUND

Blood testosterone concentrations in women decline during the reproductive years and reach a nadir in the seventh decade, after which concentrations increase and are restored to those of reproductive-aged women early in the eighth decade. We aimed to establish the association between the concentration of testosterone in the blood and risk of major adverse cardiovascular events (MACE) and all-cause mortality in healthy older women.

METHODS

SHOW was a prospective cohort substudy of the longitudinal randomised ASPREE trial. Eligible participants were women aged at least 70 years from Australia with unimpaired cognition, no previous MACE, and a life expectancy of at least 5 years. Participants who were receiving hormonal or steroid therapy were ineligible for inclusion. We measured serum concentrations of sex steroids with liquid chromatography-tandem mass spectrometry and of SHBG with immunoassay. We compared lower concentrations of sex hormones with higher concentrations using four quartiles. Primary endpoints were risk of MACE and all-cause mortality, the associations of which with sex steroid concentrations were assessed using Cox proportional hazards regression that included age, body-mass index, smoking status, alcohol consumption, diabetes, hypertension, dyslipidaemia, impaired renal function, and treatment allocation in the ASPREE trial (aspirin vs placebo). ASPREE is registered with ClinicalTrials.gov, NCT01038583.

FINDINGS

Of the 9180 women recruited to the ASPREE trial between March 10, 2010, and Dec 31 2014, 6358 participants provided sufficient biobank samples at baseline and 5535 were included in the final analysis. Median age at entry was 74·0 years (IQR 71·7-77·7). During a median 4·4 years of follow-up (24 553 person-years), 144 (2·6%) women had a first MACE (incidence 5·9 per 1000 person-years). During a median 4·6 years of follow-up (3·8-5·6), 200 women died (7·9 per 1000 person-years). In the fully adjusted models, higher concentrations of testosterone were associated with a lower incidence of MACE (quartile 4 vs quartile 1: hazard ratio 0·57 [95% CI 0·36-0·91]; p=0·02), as were higher concentrations of DHEA (quartile 4 vs quartile 1: 0·61 [0·38-0·97]; p=0·04). For oestrone, a lower risk of MACE was seen for concentrations in quartile 2 only, compared with quartile 1 (0·55 [0·33-0·92]; p=0·02). In fully adjusted models, no association was seen between SHBG and MACE, or between any hormone or SHBG and all-cause mortality.

INTERPRETATION

Blood concentrations of testosterone and DHEA above the lowest quartile in older women were associated with a reduced risk of a first-ever MACE. Given that the physiological effects of DHEA are mediated through its steroid metabolites, if the current findings were to be replicated, trials investigating testosterone therapy for the primary prevention of ischaemic cardiovascular disease events in older women would be warranted.

FUNDING

The National Health and Medical Research Council of Australia, US National Institute on Aging, the Victorian Cancer Agency, the Commonwealth Scientific and Industrial Research Organisation, and Monash University.

Low Serum Dehydroepiandrosterone and Dehydroepiandrosterone Sulfate Are Associated With Coronary Heart Disease in Men With Type 2 Diabetes Mellitus

AIMS

Sex hormones play an important role in the pathogenesis of cardiovascular disease (CVD). This cross-sectional study aimed to explore the associations of dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulfate (DHEAS) with coronary heart disease (CHD) and stroke in middle-aged and elderly patients with type 2 diabetes mellitus (T2DM).

MATERIALS AND METHODS

A total of 995 patients with T2DM were included in the study analysis. Serum levels of DHEA and DHEAS were quantified using liquid chromatography-tandem mass spectrometry. Binary logistic regression analyses were performed to assess the associations of DHEA and DHEAS with CHD and stroke. Receiver operating characteristic (ROC) curve analysis was performed to determine the optimal DHEA and DHEAS cutoff values for the detection of CHD in men with T2DM.

RESULTS

In men with T2DM, after adjustment for potential confounders in model 3, the risk of CHD decreased with an increasing serum DHEA level [odds ratio (OR) = 0.38, quartile 4 vs. quartile 1; 95% confidence interval (CI) = 0.16-0.90; p = 0.037 for trend). Consistently, when considered as a continuous variable, this association remained significant in the fully adjusted model (OR = 0.59, 95% CI = 0.40-0.87, p < 0.05). When taken as a continuous variable in model 3, serum DHEAS level was also inversely related to the risk of CHD among men (OR = 0.56, 95% CI = 0.38-0.82, p < 0.05). Similarly, this relationship remained statistically significant when DHEAS was categorized into quartiles (OR = 0.27, quartile 4 vs. quartile 1; 95% CI = 0.11-0.67; p = 0.018 for trend). ROC curve analyses revealed that the optimal cutoff values to detect CHD in men with T2DM were 6.43 nmol/L for DHEA and 3.54 μmol/L for DHEAS. In contrast, no significant associations were found between DHEA and DHEAS on the one hand and stroke on the other in men and women with T2DM (all p > 0.05).

CONCLUSIONS

Serum DHEA and DHEAS were significantly and negatively associated with CHD in middle-aged and elderly men with T2DM. This study suggests potential roles of DHEA and DHEAS in CHD pathogenesis.

An overview of polycystic ovary syndrome in aging women

The manifestations of polycystic ovary syndrome (PCOS), a ubiquitous reproductive disorder, may vary significantly depending on the severity of a number of endocrine and metabolic changes. Although no diagnostic criteria are presently available for PCOS for perimenopausal and menopausal women, the condition can still be suspected in case of a previous diagnosis of the condition, a chronic history of irregular menstrual cycles and hyperandrogenism, and/or polycystic ovarian morphology during the reproductive period. PCOS is associated with long-term health risks, including obesity, diabetes, hypertension, dyslipidemia, metabolic syndrome and cardiovascular risk factors during reproductive age, especially in patients possessing classic phenotypes. The aim of this review was to outline the available data about the impact of PCOS on long-term health risks after reproductive age in patients with PCOS. Previously, it was assumed that women with PCOS would be more prone to develop cardiometabolic diseases after reproductive age but current data suggest that in accordance with the healing in the phenotypic characteristics of PCOS, no deterioration appears to occur in cardiometabolic health in these patients. While there is substantial evidence for a greater prevalence of abnormal subclinical atherosclerotic markers among younger patients with PCOS, data for older women are insufficient. However, there is also support for an increased risk of endometrial cancer in PCOS patients. Extensive prospective cohort studies in which healthy controls as well as patients with defining PCOS phenotypes are observed and monitored from the early reproductive period into the late postmenopausal period should now be performed in order to clarify morbidities and mortality in aging women with PCOS.

Effects of testosterone treatment on clitoral haemodynamics in women with sexual dysfunction

PURPOSE

To explore the effects of 6-month systemic testosterone (T) administration on clitoral color Doppler ultrasound (CDU) parameters in women with female sexual dysfunction (FSD).

METHODS

81 women with FSD were retrospectively recruited. Data on CDU parameters at baseline and after 6 months with four different treatments were available and thus further longitudinally analyzed: local non-hormonal moisturizers (NH group), n = 37; transdermal 2% T gel 300 mcg/day (T group), n = 23; local estrogens (E group), n = 12; combined therapy (T + E group), n = 9. Patients underwent physical, laboratory, and genital CDU examinations at both visits and completed different validated questionnaires, including the Female Sexual Function Index (FSFI).

RESULTS

At 6-month visit, T therapy significantly increased clitoral artery peak systolic velocity (PSV) when compared to both NH (p < 0.0001) and E (p < 0.0001) groups. A similar increase was found in the T + E group (p = 0.039 vs. E). In addition, T treatment was associated with significantly higher FSFI desire, pain, arousal, lubrication, orgasm, and total scores at 6-month visit vs. baseline. Similar findings were observed in the T + E group. No significant differences in the variations of total and high-density lipoprotein-cholesterol, triglycerides, fasting glycemia, insulin and glycated hemoglobin levels were found among the four groups. No adverse events were observed.

CONCLUSION

In women complaining for FSD, systemic T administration, either alone or combined with local estrogens, was associated with a positive effect on clitoral blood flow and a clinical improvement in sexual function, showing a good safety profile.

TRIAL REGISTRATION NUMBER

NCT04336891; date of registration: April 7, 2020.

Androgens promote vascular endothelial cell proliferation through activation of a ZIP9-dependent inhibitory G protein/PI3K-Akt/Erk/cyclin D1 pathway

While androgens have been reported to mediate cardiovascular endothelial cell proliferation, the potential involvement of membrane androgen receptors (mAR) has not been examined. Here we show ZIP9, a recently characterized mAR, mediates androgen-induced early proliferative events in human umbilical vein endothelial cells (HUVECs). Androgen treatment significantly increased cyclin D1 nuclear localization and proliferation, which were blocked by transfection with siRNA targeting ZIP9 but not the nuclear AR. Testosterone rapidly activated inhibitory G protein signaling, Erk, and Akt, and inhibition of these signaling members abrogated the ZIP9-mediated cyclin D1 and proliferative responses. Erk and Akt modulated cyclin D1 nuclear localization by upregulation of cyclin D1 mRNA and inhibition of GSK-3β activity, respectively. This is the first study to demonstrate a role for ZIP9 in HUVEC proliferation and indicates ZIP9 is a physiologically-relevant androgen receptor in the cardiovascular system that merits further study as a potential therapeutic target for treating cardiovascular disease.

Associations of serum androgens with coronary heart disease and interaction with age: The Henan Rural Cohort Study

BACKGROUND AND AIMS

We aimed to investigate the associations of testosterone and androstenedione with coronary heart disease, and the interaction effect of testosterone or androstenedione and age on coronary heart disease.

METHODS AND RESULTS

A total of 6178 participants were included in this study. Serum testosterone and androstenedione were detected by liquid chromatography-tandem mass spectrometry. Logistic regression and restricted cubic splines were used to assess the independent effects of testosterone and androstenedione on coronary heart disease. Interactive plots were employed to examine the interaction effects of testosterone or androstenedione with age on coronary heart disease. After adjusting for multiple variables, serum testosterone and androstenedione levels were negatively associated with coronary heart disease in males (tertile 3 vs tertile 1, odd ratio (OR) = 0.56, 95% confidence interval (CI) (0.33, 0.96), and OR = 0.40, 95% CI (0.22, 0.74)). Per 1 unit increase in ln-testosterone and ln-androstenedione was associated with a 24% (OR = 0.76, 95% CI (0.63, 0.91)) and 30% (OR = 0.69, 95% CI (0.55, 0.86)) lower risk of coronary heart disease, respectively. Additionally, the positive association of age with coronary heart disease was attenuated by increasing concentrations of ln-testosterone and ln-androstenedione concentration in males.

CONCLUSIONS

The results indicated that serum testosterone and androstenedione were negatively associated with coronary heart disease risk in Chinese rural males. To some extent, this study supports the application of hormone therapy in males with coronary heart disease, which can contribute to reducing the burden of coronary heart disease and related cardiovascular disease.

Biomediators in Polycystic Ovary Syndrome and Cardiovascular Risk

Polycystic ovary syndrome (PCOS) is extremely heterogeneous in terms of clinical manifestations. The variability of the syndrome's phenotype is derived from the genetic and molecular heterogeneity, with a great deal of environmental factors that may have long-term health consequences, such as metabolic and cardiovascular (CV) diseases. There is no doubt that women with PCOS suffer from metabolic complications more than their age-matched counterparts in the general population and at an earlier age. Obesity, low steroid hormone-binding globulin (SHBG), hyperandrogenemia, insulin resistance, and compensatory hyperinsulinemia are biomediators and early predictors of metabolic complications in PCOS. Doubts remain about the real risk of CV diseases in PCOS and the molecular mechanisms at the basis of CV complications. Based on that assumption, this review will present the available evidence on the potential implications of some biomediators, in particular, hyperandrogenism, estrogen-progesterone imbalance, insulin resistance, and low SHBG, in the processes leading to CV disease in PCOS, with the final aim to propose a more accurate CV risk assessment.

Women With Polycystic Ovary Syndrome Have an Increased Risk of Major Cardiovascular Events: a Population Study

CONTEXT

The effects of polycystic ovary syndrome (PCOS) on cardiovascular morbidity and mortality are unclear.

OBJECTIVE

This work aims to establish the relative risk of myocardial infarction (MI), stroke, angina, revascularization, and cardiovascular mortality for women with PCOS.

METHODS

Data were extracted from the Clinical Practice Research Datalink Aurum database. Patients with PCOS were matched to controls (1:1) by age, body mass index (BMI) category, and primary care practice. The primary outcome was the time to major adverse cardiovascular event (MACE); a composite end point incorporating MI, stroke, angina, revascularization and cardiovascular mortality. Secondary outcomes were the individual MACE end points.

RESULTS

Of 219 034 individuals with a diagnosis of PCOS, 174 660 (79.7%) met the eligibility criteria and were matched. Crude rates of the composite end point, MI, stroke, angina, revascularization, and cardiovascular mortality were respectively 82.7, 22.7, 27.4, 32.8, 10.5, and 6.97 per 100 000 patient-years for cases, and 64.3, 15.9, 25.7, 19.8, 7.13, and 7.75 per 100 000 patient-years for controls. In adjusted Cox proportional hazard models (CPHMs), the hazard ratios (HRs) were 1.26 (95% CI, 1.13-1.41), 1.38 (95% CI, 1.11-1.72), 1.60 (95% CI, 1.32-1.94), and 1.50 (95% CI, 1.08-2.07) for the composite outcome, MI, angina, and revascularization, respectively. In a time-dependent CPHM, weight gain (HR 1.01; 1.00-1.01), prior type 2 diabetes mellitus (T2DM) (HR 2.40; 1.76-3.30), and social deprivation (HR 1.53; 1.11-2.11) increased risk of progression to the composite end point.

CONCLUSION

The risk of incident MI, angina, and revascularization is increased in young women with PCOS. Weight and T2DM are potentially modifiable risk factors amenable to intervention.

The role of androgens in women's health and wellbeing

Androgens in women, as well as in men, are intrinsic to maintenance of (i) reproductive competency, (ii) cardiac health, (iii) appropriate bone remodeling and mass retention, (iii) muscle tone and mass, and (iv) brain function, in part, through their mitigation of neurodegenerative disease effects. In recognition of the pluripotency of endogenous androgens, exogenous androgens, and selected congeners, have been prescribed off-label for several decades to treat low libido and sexual dysfunction in menopausal women, as well as, to improve physical performance. However, long-term safety and efficacy of androgen administration has yet to be fully elucidated. Side effects often observed include (i) hirsutism, (ii) acne, (iii) deepening of the voice, and (iv) weight gain but are associated most frequently with supra-physiological doses. By contrast, short-term clinical trials suggest that the use of low-dose testosterone therapy in women appears to be effective, safe and economical. There are, however, few clinical studies, which have focused on effects of androgen therapy on pre- and post-menopausal women; moreover, androgen mechanisms of action have not yet been thoroughly explained in these subjects. This review considers clinical effects of androgens on women's health in order to prevent chronic diseases and reduce cancer risk in gynecological tissues.

Long-term cardiometabolic disease risk in women with PCOS: a systematic review and meta-analysis

BACKGROUND

Polycystic ovary syndrome (PCOS) is associated with cardiometabolic disease, but recent systematic reviews and meta-analyses of longitudinal studies that quantify these associations are lacking.

OBJECTIVE AND RATIONALE

Is PCOS a risk factor for cardiometabolic disease?

SEARCH METHODS

We searched from inception to September 2019 in MEDLINE and EMBASE using controlled terms (e.g. MESH) and text words for PCOS and cardiometabolic outcomes, including cardiovascular disease (CVD), stroke, myocardial infarction, hypertension (HT), type 2 diabetes (T2D), metabolic syndrome and dyslipidaemia. Cohort studies and case–control studies comparing the prevalence of T2D, HT, fatal or non-fatal CVD and/or lipid concentrations of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) and triglycerides (TGs) between women with and without PCOS of ≥18 years of age were eligible for this systematic review and meta-analysis. Studies were eligible regardless of the degree to which they adjusted for confounders including obesity. Articles had to be written in English, German or Dutch. Intervention studies, animal studies, conference abstracts, studies with a follow-up duration less than 3 years and studies with less than 10 PCOS cases were excluded. Study selection, quality assessment (Newcastle–Ottawa Scale) and data extraction were performed by two independent researchers.

OUTCOMES

Of the 5971 identified records, 23 cohort studies were included in the current systematic review. Women with PCOS had increased risks of HT (risk ratio (RR): 1.75, 95% CI 1.42 to 2.15), T2D (RR: 3.00, 95% CI 2.56 to 3.51), a higher serum concentration of TC (mean difference (MD): 7.14 95% CI 1.58 to 12.70 mg/dl), a lower serum concentration of HDL-C (MD: −2.45 95% CI −4.51 to −0.38 mg/dl) and increased risks of non-fatal cerebrovascular disease events (RR: 1.41, 95% CI 1.02 to 1.94) compared to women without PCOS. No differences were found for LDL-C (MD: 3.32 95% CI −4.11 to 10.75 mg/dl), TG (MD 18.53 95% CI −0.58 to 37.64 mg/dl) or coronary disease events (RR: 1.78, 95% CI 0.99 to 3.23). No meta-analyses could be performed for fatal CVD events due to the paucity of mortality data.

WIDER IMPLICATIONS

Women with PCOS are at increased risk of cardiometabolic disease. This review quantifies this risk, which is important for clinicians to inform patients and to take into account in the cardiovascular risk assessment of women with PCOS. Future clinical trials are needed to assess the ability of cardiometabolic screening and management in women with PCOS to reduce future CVD morbidity.

An Update on Contraception in Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is a common endocrine disorder in reproductive-aged women, characterized by hyperandrogenism, oligo/anovulation, and polycystic ovarian morphology. Combined oral contraceptives (COCs), along with lifestyle modifications, represent the first-line medical treatment for the long-term management of PCOS. Containing low doses of estrogen and different types of progestin, COCs restore menstrual cyclicity, improve hyperandrogenism, and provide additional benefits such as reducing the risk of endometrial cancer. However, potential cardiometabolic risk associated with these agents has been a concern. COCs increase the risk of venous thromboembolism (VTE), related both to the dose of estrogen and the type of progestin involved. Arterial thrombotic events related to COC use occur much less frequently, and usually not a concern for young patients. All patients diagnosed with PCOS should be carefully evaluated for cardiometabolic risk factors at baseline, before initiating a COC. Age, smoking, obesity, glucose intolerance or diabetes, hypertension, dyslipidemia, thrombophilia, and family history of VTE should be recorded. Patients should be re-assessed at consecutive visits, more closely if any baseline cardiometabolic risk factor is present. Individual risk assessment is the key in order to avoid unfavorable outcomes related to COC use in women with PCOS.

Testosterone and sex hormone-binding globulin in dysglycemic women at high cardiovascular risk: A report from the Outcome Reduction with an Initial Glargine Intervention trial

AIMS

Total and free testosterone and sex hormone-binding globulin may affect cardiovascular prognosis in women. The objective was to study the association between sex hormones and prognosis in women with dysglycemia and high cardiovascular risk.

METHODS

This epidemiological report included dysglycemic women from the Outcome Reduction with an Initial Glargine Intervention trial (n = 2848) with baseline total testosterone and sex hormone-binding globulin. Free testosterone was calculated with the Vermeulen formula. Cox regression analyses adjusted for variables including age, previous diseases and pharmacological treatments were used to estimate the association between these levels and the composite cardiovascular outcome (death from cardiovascular causes, nonfatal myocardial infarction or nonfatal stroke) and all-cause mortality per one standard deviation.

RESULTS

Patients (73% post-menopausal) were followed for a median of 6.1 years during which 377 cardiovascular events and 389 deaths occurred. In Cox analyses, total and free testosterone were not associated with any outcomes, but sex hormone-binding globulin was related to all-cause mortality in age adjusted (HR 1.15; 95% CI 1.06-1.24; p < 0.01) and fully adjusted analyses (HR 1.14; 95% CI 1.05-1.24; p < 0.01).

CONCLUSIONS

Increasing levels of baseline sex hormone-binding globulin were associated with an increased risk of all-cause mortality in dysglycemic women at high cardiovascular risk.

TRIAL REGISTRATION

ClinicalTrials.gov no. NCT00069784.

Reproductive Hormones and Anthropometry: A Follow-Up of PCOS and Controls From Perimenopause to Older Than 80 Years

CONTEXT

There is a lack of knowledge about hormonal and anthropometric changes in women with polycystic ovary syndrome (PCOS) after the menopause.

OBJECTIVE

This work aimed to study reproductive hormones and anthropometry in women with PCOS older than 80 years.

DESIGN AND SETTING

This prospective cohort study was conducted at a university hospital.

PATIENTS

A well-defined cohort of women with PCOS, previously examined in 1987 and 2008 (21 years) was reexamined in 2019 (11 years). Of the original cohort (n = 37), 22 women were still alive and 21 (age range, 72-91 years) participated. Comparisons were made with age-matched controls (n = 55) from the original control cohort (body mass index [BMI] similar to PCOS women). The results were compared with results from 1987 and 2008.

INTERVENTIONS

Hormonal measurements and a physical examination were performed.

MAIN OUTCOME MEASURES

Follicle-stimulating hormone (FSH), luteinizing hormone (LH), testosterone, sex hormone-binding globulin (SHBG), free androgen index (FAI), hirsutism score, BMI, and waist to hip ratio (WHR) were measured.

RESULTS

At mean age 81 years, FSH levels were lower in women with PCOS (50 vs 70 IU/L) who were still more hirsute than controls (33% vs 4%). No differences were found in FAI, testosterone, SHBG or LH levels, BMI, or WHR. From perimenopausal age until the present age, levels of testosterone and FAI continued to decline in women with PCOS. SHBG levels continued to increase with age. FSH had not changed over time during the last 11 years.

CONCLUSIONS

Women with PCOS at age 72 to 91 had lower FSH levels, remained clinically hyperandrogenic, and had similar FAI and body composition as controls.

Sex steroids and markers of micro- and macrovascular damage among women and men from the general population

AIMS

The contribution of sex hormones to micro- and macrovascular damage might differ among women and men. In particular, little is known about the association between sex hormones and small vessel disease. Therefore, we examined the association of total oestradiol, total testosterone, free-androgen index (FAI), dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEAS), and androstenedione levels with micro- and macrovascular diseases.

METHODS AND RESULTS

This cross-sectional study included 2950 women and 2495 men from the population-based Rotterdam Study. As proxy of microvascular damage, we measured diameters of retinal arterioles and venules. Markers of macrovascular damage included carotid intima-media thickness and carotid plaque, coronary artery calcification (CAC), and peripheral artery disease. Linear and logistic regression models were used and adjusted for age, cardiovascular risk factors, and years since menopause. Associations with microvasculature: In women, total testosterone [mean difference per 1-unit increase in natural-log transformed total testosterone (95% confidence interval, CI): 2.59 (0.08-5.09)] and androstenedione [4.88 (1.82-7.95)] and in men DHEAS [2.80 (0.23-5.37)] and androstenedione [5.83 (2.19-9.46)] were associated with larger venular caliber. Associations with markers of large vessel disease: In women, higher total testosterone [-0.29 (-0.56 to -0.03)], FAI [-0.33 (-0.56 to -0.10)], and androstenedione levels [-0.33 (-0.64 to -0.02)] were associated with lower CAC burden and FAI [odds ratio (95% CI): 0.82 (0.71-0.94)] was associated with lower prevalence of plaque.

CONCLUSION

A more androgenic profile was associated with more microvascular damage in both women and men. Among women, however, higher androgen levels were also associated with less macrovascular damage. Our findings suggest that androgens might have distinct effects on the vasculature, depending on the vascular bed and stages of the atherosclerosis process.

Sex-Specific Associations of Testosterone and Genetic Factors With Health Span

BACKGROUND

Previous studies have suggested associations between testosterone, genetic factors, and a series of complex diseases, but the associations with the lifespan phenotype, such as health span, remain unclear.

METHODS

In this prospective cohort study, we analyzed 145,481 men and 147,733 women aged 38-73 years old from UK Biobank (UKB) to investigate the sex-specific associations of total testosterone (TT), free testosterone (FT), or polygenic risk score (PRS) with health span termination (HST) risk. At baseline, serum testosterone levels were measured. HST was defined by eight events strongly associated with longevity. PRS, an efficient tool combining the effect of common genetic variants to discriminate genetic risk of complex phenotypes, was constructed by 12 single-nucleotide polymorphisms related to health span from UKB (P ≤ 5.0 × 10^-8). We used multivariable Cox regression models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

With a median follow-up time of 7.70 years, 26,748 (18.39%) men and 18,963 (12.84%) women had HST. TT was negatively associated with HST in men [HR per standard deviation (SD) increment of log-TT: 0.92, 95% CI: 0.88-0.97]. Inversely, both TT (HR per SD increment of log-TT: 1.05, 95% CI: 1.02-1.08) and FT (HR per SD increment of log-FT: 1.08, 95% CI: 1.05-1.11) presented an increased risk of HST in women. PRS was positively associated with HST risk (quintile 5 versus quintile 1, men, HR: 1.19, 95% CI: 1.15-1.24; women, HR: 1.21, 95% CI: 1.16-1.27). Moreover, men with high TT and low genetic risk showed the lowest HST risk (HR: 0.80, 95% CI: 0.73-0.88), whereas HST risk for women with both high TT and genetic risk increased obviously (HR: 1.32, 95% CI: 1.19-1.46). Similar joint effects were observed for FT in both genders.

CONCLUSIONS

We observed sex-specific associations that testosterone was negatively associated with HST risk in men and positively associated with HST risk in women. Genetic factors increased the HST risk, suggesting that participants with both high genetic risk and abnormal testosterone levels (high level in women or low level in men) should be the target for early intervention. Although our findings highlight the associations between testosterone and health span, further mechanistic studies and prospective trials are warranted to explore the causation behind.

Impact of Increased Oxidative Stress on Cardiovascular Diseases in Women With Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is a complex disorder that affects around 5% to 10% of women of childbearing age worldwide, making it the most common source of anovulatory infertility. PCOS is defined by increased levels of androgens, abnormal ovulation, irregular menstrual cycles, and polycystic ovarian morphology in one or both ovaries. Women suffering from this condition have also been shown to frequently associate certain cardiovascular comorbidities, including obesity, hypertension, atherosclerosis, and vascular disease. These factors gradually lead to endothelial dysfunction and coronary artery calcification, thus posing an increased risk for adverse cardiac events. Traditional markers such as C-reactive protein (CRP) and homocysteine, along with more novel ones, specifically microRNAs (miRNAs), can accurately signal the risk of cardiovascular disease (CVD) in PCOS women. Furthermore, studies have also reported that increased oxidative stress (OS) coupled with poor antioxidant status significantly add to the increased cardiovascular risk among these patients. OS additionally contributes to the modified ovarian steroidogenesis, consequently leading to hyperandrogenism and infertility. The present review is therefore aimed not only at bringing together the most significant information regarding the role of oxidative stress in promoting CVD among PCOS patients, but also at highlighting the need for determining the efficiency of antioxidant therapy in these patients.

Risk of Cardiovascular and Cerebrovascular Events in Polycystic Ovarian Syndrome Women: A Meta-Analysis of Cohort Studies

Aim: This systematic review and meta-analysis aimed to investigate the risk of cardiovascular disease (CVD) and cerebrovascular disease (CeVD) events in women with polycystic ovary syndrome (PCOS). Methods: We searched the literatures in Pubmed, Embase, and Web of Science to identify cohort studies reporting the association between PCOS and CVD/CeVD events from 1964 to June 1, 2020. Outcome variables, such as all-cause mortality, cardiovascular death, any cardiovascular diseases, myocardial infarction, ischemic heart disease, and stroke, were extracted from the identified literatures, and we reported the outcomes of the association in hazard ratios (HR) and odds ratios (OR). Results: Ten cohort studies comprising 166,682 samples are included in the review. Compared to non-PCOS women, the pooled risk of CVD events in PCOS women (OR: 1.66, 95% CI: 1.32-2.08). In addition, the risk of myocardial infarction (OR: 2.57, 95% CI: 1.37-4.82), ischemic heart disease (OR: 2.77, 95% CI: 2.12-3.61), and stroke (OR: 1.96, 95% CI: 1.56-2.47) are higher in the PCOS group. However, no significant difference in the overall mortality (HR: 1.04, 95% CI: 0.57-1.86) and CVD-related death (HR: 1.49, 95% CI: 0.99-2.23) was observed. Funnel plots of all outcomes are roughly symmetric, and no significant publication bias was found. Conclusion: Though this study identified an increased risk of CVD and CeVD among women with PCOS, including occurrence of myocardial infarction, ischemic heart disease, and stroke, there was no difference in the all-cause or CVD-related mortality observed. Further large-scale studies are warranted to strengthen the association between PCOS and CV events. Our study may require a larger sample size to further verify the conclusions.

Polycystic Ovary Syndrome: Menopause and Malignancy

Polycystic ovary syndrome (PCOS) has been extensively studied in reproductive-aged women. However, accumulating research shows that PCOS can have lifelong effects on multiple aspects of women's health. PCOS can affect the onset and course of menopause and cardiovascular health in perimenopausal and postmenopausal patients. Moreover, PCOS may increase a woman's risk for both gynecologic and nongynecologic malignancies. When treating older PCOS patients, physicians should be cognizant of the syndrome's long-term effects and consider the unique needs of these women.

The Effect of Whole Blood Lead (Pb-B) Levels on Changes in Peripheral Blood Morphology and Selected Biochemical Parameters, and the Severity of Depression in Peri-Menopausal Women at Risk of Metabolic Syndrome or with Metabolic Syndrome

The aim of our study was to assess the impact of whole blood lead (Pb-B) levels on changes in peripheral blood morphology and selected biochemical parameters, and the severity of depression in peri-menopausal women at risk of metabolic syndrome (pre-MetS) or with metabolic syndrome (MetS). The study involved 233 women from the general population of the West Pomeranian Province (Poland) aged 44–65 years. The intensity of menopausal symptoms and the severity of depression was examined using the Blatt–Kupperman Index (KI) and the Beck Depression Inventory (BDI). C-reactive protein (CRP), insulin, glucose, glycated hemoglobin (HbA1C), high-density lipoprotein (HDL) and low-density lipoprotein (LDL) cholesterol, triglyceride levels (TG), cortisol, morphology of blood cells and homeostasis model assessment for insulin resistance (HOMA-IR) and Pb-B was measured. Women with MetS had higher levels of glucose, HbA1C, HDL, LDL, TG, cortisol, insulin and higher HOMA-IR. No significant differences in Pb-B were observed between pre-MetS and the control group, and between pre-MetS and the MetS group. A significant correlation was noticed between Pb-B vs. the percentage of monocytes in blood, and blood cortisol levels in women with MetS; Pb-B vs. lymphocyte count and HbA1C in the pre-MetS group, as well as in the BDI scores between the MetS and pre-MetS group. We cannot clearly state that exposure to Pb is an environmental factor that can be considered as a risk factor for MetS in this studied group.

Animal Models to Understand the Etiology and Pathophysiology of Polycystic Ovary Syndrome

More than 1 out of 10 women worldwide are diagnosed with polycystic ovary syndrome (PCOS), the leading cause of female reproductive and metabolic dysfunction. Despite its high prevalence, PCOS and its accompanying morbidities are likely underdiagnosed, averaging > 2 years and 3 physicians before women are diagnosed. Although it has been intensively researched, the underlying cause(s) of PCOS have yet to be defined. In order to understand PCOS pathophysiology, its developmental origins, and how to predict and prevent PCOS onset, there is an urgent need for safe and effective markers and treatments. In this review, we detail which animal models are more suitable for contributing to our understanding of the etiology and pathophysiology of PCOS. We summarize and highlight advantages and limitations of hormonal or genetic manipulation of animal models, as well as of naturally occurring PCOS-like females.

Menopausal Hormone Therapy: a Comprehensive Review

PURPOSE OF REVIEW

For decades the medical community recommended menopausal hormone therapy (MHT) for prevention of atherosclerotic cardiovascular disease (ASCVD) and osteoporosis in addition to relieving unpleasant vasomotor and genitourinary symptoms. These recommendations were largely based on observational studies. Several large randomized placebo-controlled trials led to the surprising finding that postmenopausal women were at higher risk of cardiovascular disease (CVD) events compared with women in the placebo group. For the next decade, women were less frequently prescribed MHT and more often declined MHT.

RECENT FINDINGS

Today, there are more evidence-based guidelines utilizing sex-specific ASCVD risk factors to assess risk in women. More recent studies have shed new light on safety and potential benefits for women initiating MHT earlier with newer options for route of administration, dosing, and combinations. Recent studies suggest MHT safety in younger women, women within 10 years of menopause, and women who use low-dose MHT for short durations for menopause symptom relief. Transdermal, newer low-dose oral therapies and SERM therapies may also have lower risk and be reasonable considerations for women. Healthcare providers need to be aware of the current options for MHT, current indications, contraindications, long-term ASCVD risks, and nonhormonal options for high-risk women.

Objectives, design and main findings until 2020 from the Rotterdam Study

The Rotterdam Study is an ongoing prospective cohort study that started in 1990 in the city of Rotterdam, The Netherlands. The study aims to unravel etiology, preclinical course, natural history and potential targets for intervention for chronic diseases in mid-life and late-life. The study focuses on cardiovascular, endocrine, hepatic, neurological, ophthalmic, psychiatric, dermatological, otolaryngological, locomotor, and respiratory diseases. As of 2008, 14,926 subjects aged 45 years or over comprise the Rotterdam Study cohort. Since 2016, the cohort is being expanded by persons aged 40 years and over. The findings of the Rotterdam Study have been presented in over 1700 research articles and reports. This article provides an update on the rationale and design of the study. It also presents a summary of the major findings from the preceding 3 years and outlines developments for the coming period.

Carotid intima-media thickness in polycystic ovary syndrome and its association with hormone and lipid profiles

Objective

Polycystic ovary syndrome (PCOS) has been associated with an increased risk of metabolic disturbances and cardiovascular disease. Intima-media thickness of the common carotid artery (CIMT) represents a valid surrogate marker of early systemic atherosclerosis. This study aimed to investigate if CIMT is increased in PCOS patients compared to healthy controls and if there is an association with hormone and metabolic profiles.

Methods

In this prospective cross-sectional study, past medical history, anthropometrical measurements and hormonal, lipidemic and glycemic parameters were obtained in 41 PCOS patients and 43 age-matched healthy controls of similar body mass index (BMI) and frequency of smokers. B-mode ultrasound enabled CIMT measurement at the far wall of the left and right common carotid artery.

Results

Patients with PCOS showed significantly increased CIMT values compared to healthy controls (0.49±0.04mm vs. 0.37±0.04mm respectively, P<0.001). They featured a generally increased cardiovascular risk profile. Correlation analysis showed a positive association between CIMT and the adverse metabolic risk profile. The diagnosis of PCOS was the strongest predictor of CIMT, even after multiple adjustments for BMI, age and smoking status (β = 0.797, P<0.001, R² = 0.73). A model among oligomenorrhoic patients revealed a relationship between CIMT and the suspected duration of disease (β = 0.373, P = 0.021, R² = 0.14).

Conclusions

PCOS patients are likely to feature signs of premature systemic atherosclerosis at a young age. Early exposure to adverse cardiovascular risk factors may possibly have long-term consequences on the vascular system. An early vessel screening might thus already be beneficial in these patients at a younger age.

Characteristics of polycystic ovary syndrome throughout life

Polycystic ovary syndrome is the most common endocrine disorder in women of reproductive age. It is a complex disease in which genetic, endocrine, environmental, and behavioral factors are intertwined, giving rise to a heterogeneous phenotype with reproductive, metabolic, and psychological characteristics. Polycystic ovary syndrome affects women’s health and their quality of life across the life course. During different life stages, the polycystic ovary syndrome phenotype can change, which requires a personalized diagnostic approach and treatment. Polycystic ovary syndrome is a major cause of anovulatory infertility; this disorder is also associated with hirsutism and acne. Diagnosing polycystic ovary syndrome during adolescence is challenging because the polycystic ovary syndrome criteria include normal physiological events that occur during puberty. With increasing age, the syndrome evolves from a reproductive disease to a more metabolic disorder. Along with metabolic disturbances, including insulin resistance and abnormalities of energy expenditure, polycystic ovary syndrome is recognized as a major risk factor for the development of type 2 diabetes and cardiovascular disease in later life. Moreover, there is evidence for familial clustering of endocrine and metabolic features of polycystic ovary syndrome. Environmental factors such as diet and obesity appear to contribute to the phenotype. Treatment should be tailored to the specific concerns and needs of the individual patient and involves restoring fertility, treatment of the metabolic complaints, treatment of androgen excess, and providing endometrial protection. The complexity of the disorder, and the impact on quality of life, requires a timely diagnosis, screening for complications, and management strategies for the long-term health issues associated with polycystic ovary syndrome. The syndrome remains underdiagnosed, and women experience significant delays to diagnosis.

Risk of hypertension in women with polycystic ovary syndrome: a systematic review, meta-analysis and meta-regression

BACKGROUND

A limited number of publications have assessed the prevalence of hypertension (HTN) in polycystic ovary syndrome (PCOS) patients with inconclusive results. Since in general populations the occurrence of hypertension is related to age per se, we investigated the prevalence (P) / relative risk (RR) of HTN in pooled patients with PCOS, vs control population among reproductive age women with PCOS, compared to menopause/aging patients.

METHODS

PubMed, Scopus, ScienceDirect, web of science, and Google scholar were systematically searched for retrieving observational studies published from inception to April 2019 investigating the HTN in patients with PCOS. The primary outcome of interest was pooled P and RR of HTN in reproductive and menopausal/aging women with PCOS compared to control population.

RESULTS

The pooled prevalence of HTN in reproductive and menopausal/aging women with PCOS was higher than in the control population [(Pooled P: 0.15, 95% CI: 0.12-0.18 vs. Pooled P: 0.09, 95% CI: 0.08-0.10) and (Pooled P: 0.49, 95% CI: 0.28-0.70 vs. Pooled P: 0.40, 95% CI: 0.22-0.57), respectively]. Compared to the control population, pooled relative risk (RR) of HTN patients was increased only in reproductive age PCOS (1.70-fold, 95% CI: 1.43-2.07) but not in menopausal/aging patients who had PCOS during their reproductive years. The same results were obtained for subgroups of population-based studies. Meta-regression analysis of population-based studies showed that the RR of HTN in reproductive age PCOS patients was 1.76-fold than menopausal/aging PCOS patients (P = 0.262).

CONCLUSION

This meta-analysis confirms a greater risk of HTN in PCOS patients but demonstrates that this risk is increased only in reproductive age women with PCOS, indicating that after menopause, having a history of PCOS may not be as an important predisposing factor for developing HTN.

The cardiovascular risk profile of middle-aged women with polycystic ovary syndrome

OBJECTIVES

Contradictory results have been reported regarding the association between polycystic ovary syndrome (PCOS) and cardiovascular disease (CVD). We assessed the cardiometabolic phenotype and prevalence of CVD in middle-aged women with PCOS, compared with age-matched controls from the general population, and estimated 10-year CVD risk and cardiovascular health score.

DESIGN

A cross-sectional study.

PARTICIPANTS

200 women aged >45 with PCOS, and 200 age-matched controls.

MEASUREMENTS

Anthropometrics, insulin, lipid levels, prevalence of metabolic syndrome and type II diabetes. Ten-year Framingham risk score and the cardiovascular health score were calculated, and carotid intima-media thickness (cIMT) was measured.

RESULTS

Mean age was 50.5 years (SD = 5.5) in women with PCOS and 51.0 years (SD = 5.2) in controls. Increased waist circumference, body mass index and hypertension were more often observed in women with PCOS (P < .001). In women with PCOS, the prevalence of type II diabetes and metabolic syndrome was not significantly increased and lipid levels were not different from controls. cIMT was lower in women with PCOS (P < .001). Calculated cardiovascular health and 10-year CVD risk were similar in women with PCOS and controls.

CONCLUSIONS

Middle-aged women with PCOS exhibit only a moderately unfavourable cardiometabolic profile compared to age-matched controls, even though they present with an increased BMI and waist circumference. Furthermore, we found no evidence for increased (10-year) CVD risk or more severe atherosclerosis compared with controls from the general population. Long-term follow-up of women with PCOS is necessary to provide a definitive answer concerning long-term risk for CVD.

Cardiovascular events among reproductive and menopausal age women with polycystic ovary syndrome: a systematic review and meta-analysis

This study aimed to evaluate the prevalence (P)/hazard ratio (HR) of cardiovascular (CV) events among reproductive age and menopausal age women with polycystic ovary syndrome (PCOS) in comparison with healthy controls. PubMed, Scopus, ScienceDirect, Web of science, and Google scholar were searched for retrieving observational studies published up to April 2018 investigating CV events in patients with PCOS. The primary outcomes were a composite outcome of CV events [including coronary arterial disease (CAD), cardiovascular disease (CVD), myocardial infarction (MI), angina, heart failure, and ischemic heart disease] and mortality due to CV events; secondary outcomes were specific CVD events, including cerebrovascular disease, CAD, CVD, MI, angina, heart failure, ischemic heart disease, and stroke. In this meta-analysis, both fixed and random effect models were used. Potential sources of heterogeneity were explored by meta-regression and subgroup analyses. Sixteen studies including 12 population-based were analyzed for the meta-analysis. Results showed that the pooled HRs of CV events in PCOS patients of reproductive age and in menopausal/aging women were higher than healthy controls (pooled HR: 1.38, 95% CI: 1.12-1.71) and (pooled HR: 1.53, 95% CI: 1.15, 2.04), respectively. Compared to healthy controls, analysis of population-based studies revealed that the HR of CV events increased only in reproductive age PCOS patients (1.43-fold, 95% CI: 1.27, 1.61), whereas the difference was not statistically significant when comparing menopausal/aging PCOS patients to healthy controls (1.03-fold, 95% CI: 0.41, 2.59). Sufficient data were not available for comparing the HRs of mortality due to CV events between the two PCOS age groups. Mainly based on population-based study, we found a greater risk of CV events in reproductive aged but not in menopausal/aging PCOS women, suggesting that having a history of PCOS during reproductive ages may not be an important risk factor for developing events in later life. This is a preliminary assumption and needs to be reevaluated by further comprehensive cohort studies of longer duration, initiated in the reproductive period, considering all known CVD risk factors.

Cardiovascular health and menopause in aging women with polycystic ovary syndrome

Introduction: Polycystic ovary syndrome (PCOS) is a common endocrine disorder with heterogeneous clinical manifestations. Current evidence suggests that women with PCOS exhibit an unfavorable metabolic profile which may pose them at increased risk for cardiovascular events later in life.Areas covered: Herein, we present a review of the existing literature relating to PCOS and long-term cardiovascular (CV) health risks in women after menopause. We performed an electronic-based search with the use of PubMed from 1990 to August 2019 and systematically reviewed studies assessing CV events in women with PCOS. We aimed to outline the gaps in the current evidence and suggest areas for future research.Expert opinion: Although there is a clear association between PCOS and cardiometabolic dysfunction, data on actual cardiovascular disease (CVD) events are conflicting. Additional large, prospective cohort studies of well-phenotyped women with PCOS and long-term follow-up into the late menopause are needed to elucidate the true CVD risk in this population.