Polycystic ovaries - beyond menopause

Effects of hormone replacement therapy on glucose and lipid metabolism in peri- and postmenopausal women with a history of menstrual disorders

BACKGROUND

Previous studies have indicated that women with a history of menstrual disorders have an increased risk of metabolic and cardiovascular diseases. This has been attributed to the high proportion of polycystic ovary syndrome (PCOS) among this group. The favorable effects of hormone replacement therapy (HRT) on serum lipid profiles and glucose homeostasis in postmenopausal women is widely accepted. Whether HRT can also show positive effects on metabolic homeostasis in menopausal women with prior menstrual disorders (a putative PCOS phenotype) has not been reported yet. The aim of the study was to compare the effects of HRT on glucose and lipid metabolism in peri- and postmenopausal women with prior menstrual disorders and controls who did not have prior menstrual disorders.

METHODS

A retrospective multicenter study was conducted including 595 peri- and postmenopausal women who received HRT at four hospitals in the Zhejiang Province from May 31, 2010 to March 8, 2021. Participants were divided into the Normal menstruation group and the Menstrual disorders group according to their prior usual menstrual cycle pattern. Glucose and lipid metabolism indicators were assessed at baseline and after HRT. The results were compared between and within the groups, and data from peri- and postmenopausal women were analyzed separately.

RESULTS

HRT significantly decreased fasting insulin and homeostasis model assessment of insulin resistance in perimenopausal users, and fasting plasma glucose levels in postmenopausal users with prior menstrual disorders, compared with baseline. Furthermore, HRT decreased low-density lipoprotein cholesterol, total cholesterol, fasting insulin, fasting plasma glucose and homeostasis model assessment of insulin resistance in both peri- and postmenopausal controls, compared with baseline. Nevertheless, no significant differences were observed in any of the glucose or lipid metabolism indicators at baseline and follow-up, as well as changes from baseline levels between menopausal women with and without prior menstrual disorders.

CONCLUSIONS

HRT shows more obvious within-group improvements in glucose and lipid metabolism in controls, but there is no significant between-group difference. Further prospective studies are required for confirmation.

Postmenopausal hyperandrogenism

Postmenopausal hyperandrogenism is a state of relative or absolute androgen excess originating from the adrenal glands and/or ovaries clinically manifested by the presence of terminal hair in androgen-dependent areas of the body, and other manifestations of hyperandrogenism such as acne and alopecia or the development of virilization. In such circumstances, physicians must exclude the possibility of rare but serious androgen-producing tumors of the adrenal glands or ovaries. Worsening of undiagnosed hyperandrogenic disorders such as polycystic ovary syndrome, congenital adrenal hyperplasia, ovarian hyperthecosis, Cushing syndrome and iatrogenic hyperandrogenism should be considered for differential diagnosis. Elevated serum testosterone not only causes virilizing effects, but also will lead to hypercholesterolemia, insulin resistance, hypertension and cardiac disease. An ovarian androgen-secreting tumor, which is diagnosed in 1-3 of 1000 patients presenting with hirsutism, comprises less than 0.5% of all ovarian tumors. Adrenal tumors, including non-malignant adenomas and malignant carcinomas, are less common than ovarian tumors but cause postmenopausal virilization. Measurement of serum testosterone, sex hormone-binding globulin, dehydroepiandrosterone sulfate, androstenedione and inhibin B is necessary in postmenopausal women with the complaints and signs of hyperandrogenism. Some tests to discard Cushing syndrome should also be done. After an etiological source of androgen hypersecretion has been suspected, we recommend performing magnetic resonance imaging of the adrenal glands or ovaries. Medical management with gonadotropin-releasing hormone agonist/analogues or antagonists has been reported for women who are either unfit for surgery or in whom the source of elevated testosterone is unidentified.

Polycystic Ovarian Syndrome and Menopause in Forty Plus Women

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of reproductive age group, but it affects women's health and quality of life across the life course. During different stages of life, the PCOS phenotype can change, which requires a personalized diagnostic approach and treatment. With increasing age, the syndrome evolves from a reproductive disease to a more metabolic disorder. Along with various metabolic disturbances like insulin resistance and abnormalities of energy expenditure, PCOS is recognized as a major risk factor for the development of type 2 diabetes and cardiovascular disease (CVD) in later life. The aim of the current review was to conduct a nonsystematic review of published literature and research that has been presented so far regarding menopausal women with PCOS as well as the associated changes in hormone profile, their lipid profile, and various metabolic changes that occur. The current review may also contribute to raise awareness about the risk of hypertension and CVDs in postmenopausal women with PCOS.

Blood pressure in postmenopausal women with a history of polycystic ovary syndrome

Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder at reproductive age, affecting 6-10% of females in this group. The aetiology of this syndrome is not fully understood. Genetics, endocrinology factors, and the influence of the environment are possible causes of this syndrome. PCOS is characterised by menstrual disorders, hyperandrogenism, and abnormalities in ovarian morphology as well as metabolic disorders. PCOS increases the risk of overweight and obesity, diabetes, endometrial cancer, and cardiovascular diseases such as hypertension along with all its long-term consequences. There are limited studies about cardiovascular disorders, especially hypertension, in postmenopausal women with a history of PCOS. The presented paper is an attempt to briefly summarise literature data concerning the influence of this disease on the incidence of hypertension and blood pressure control in postmenopausal women. Women with PCOS more often present features of metabolic syndrome and have increased cardiovascular risk factors including hypertension. The prevalence of hypertension is 2.5 times higher than in corresponding healthy peers. Furthermore, hyperandrogenaemia is associated with elevated blood pressure independent of the patient's age, insulin resistance, obesity, and dyslipidaemia. In view of this, these patients should be thoroughly screened for hypertensive disorders and educated about the lifestyle modifications that could prevent hypertension later in life.

Recent advances in the understanding and management of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a multifaceted condition characterized by chronic anovulation and excess ovarian activity, in contrast to other causes of anovulation that involve ovarian dormancy or primary insufficiency. Recent studies indicated that PCOS is associated with low-grade chronic inflammation and that women with PCOS are at increased risk of non-alcoholic fatty liver disease. The inflammatory and metabolic derangements associated with PCOS are explained in part by the coexistence of insulin resistance and obesity but are further fueled by the androgen excess. New insights into the regulation of hormones and cytokines in muscle and fat tissue support the concept that PCOS is a systemic syndrome. The therapeutic plan should be tailored to the patient phenotype, complaints, and reproductive desire. Of note, the aromatase inhibitor letrozole seems to be more effective than the reference drug clomiphene citrate to treat infertility due to PCOS. Integral management by a multidisciplinary team may help the patients to adhere to lifestyle interventions and thereby reduce body adiposity and recover their metabolic and reproductive health.

Androgens and Blood Pressure Control: Sex Differences and Mechanisms

The role that androgens play in mediating elevated blood pressure is unclear. Low levels of androgens in men and increased levels of androgens in women, as occurs with polycystic ovary syndrome (PCOS), are both associated with increased risk for cardiovascular disease and elevated blood pressure. We have used animal models to evaluate the potential mechanisms by which men and women have differential responses to androgens that affect regulation of blood pressure and the implications these may have for the health of men and women.

The Association between Oligomenorrhea, Onset of Menopause and Metabolic Syndrome in Thai Postmenopausal Women

Objectives

This study explored the association between a history of oligomenorrhea and onset of menopause and metabolic parameters.

Methods

The study population was 605 postmenopausal women who were patients at the Menopause Clinic, Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand between February 2015 and December 2015. A questionnaire was used to ask all women about their history of oligomenorrhea. The study also collected medical data, including weight, height, waist circumference, blood pressure, and blood glucose and lipid profile.

Results

Of the 231 postmenopausal women with a complete data record, 31 had a history of oligomenorrhea and 200 did not. The age of onset of menopause was around 48 years in both groups. Prevalence of metabolic syndrome was 12.1%. More women with a waist circumference larger than 80 cm had a history of oligomenorrhea at the interview than women who had not, but a history of oligomenorrhea did not relate to other metabolic parameters. The adjusted odds ratio of a history of oligomenorrhea to waist circumference was 3.69 (95% confidence interval, 1.17–11.64).

Conclusions

A history of oligomenorrhea did not affect the age at menopause, but was associated with waist circumference during menopause.

Addressing the unique healthcare needs of women: Opportunity for change exists at the intersection of precision health and learning health systems

INTRODUCTION

Women have unique healthcare needs that are not well addressed by our current healthcare system and with healthcare transformation underway the opportunity exists to avoid weaving these age-old problems into the fabric of the new healthcare design. myAva is an example of a learning health system integrated into a cloud-based precision health platform. The goal of myAva is to integrate the tools of precision health and principals of a learning health system to improve care for women, starting with polycystic ovary syndrome (PCOS).

METHODS

Putting patients at the center in designing a new style of healthcare has been an important concept underlying the development of myAva since inception. Understanding the needs of patients and providers is key to the development of myAva. Surveys were collected from members of the PCOS patient community and patient and medical advisory boards were recruited. For the pilot group comprehensive omic data, biometric and self-reported data were collected and integrated into a personalized health dashboard enabling providers to formulate personalized treatment plans. The ongoing collection of data will create continuous improvement of healthcare.

RESULTS

Precision health for chronic issues faced is in its infancy and although myriad challenges exist the potential to improve health outcomes is great. myAva's providers, patients, and advisors are encouraged by the early outcomes of the program with improved health outcomes and an increased sense of empowerment reported. It is clear that designing and implementing this type of care requires collaboration, the involvement of all stakeholders, with patients at the center.

Metabolic profile in women with polycystic ovary syndrome across adult life

OBJECTIVE

To assess insulin sensitivity, insulin secretion and metabolic profile in women with polycystic ovary syndrome (PCOS) in different stages of reproductive life.

MATERIALS AND METHODS

In a cross-sectional study, 190 PCOS women (PCOSw) and 99 controls (Cw) aged between 18 and 55years were included. PCOSw and Cw were distributed into 3 stages of reproductive life: early reproductive age (18-34years old), late reproductive age (35-40years old) and perimenopausal period (41-55years old). Waist circumference (WC), body mass index (BMI) and blood pressure (BP) were recorded. An oral glucose tolerance test (OGTT) with measurement of glucose and insulin was performed. Sex steroids and lipid profile were also determined in the fasting sample. Insulin sensitivity was assessed by HOMA-IR and ISI composite, and insulin secretion by HOMA-β and insulinogenic index. Visceral adiposity index (VAI) and lipid accumulation product (LAP) were also calculated. Metabolic syndrome (MS) was assessed by the IDF and ATPIII criteria.

RESULTS

At early reproductive age, PCOSw showed higher BMI, WC, and VAI and a higher prevalence of MS compared to Cw (p<0.05). In addition, at late reproductive age PCOSw also showed elevated total cholesterol, triglycerides, insulin secretion, LAP and BP. At perimenopausal period, these parameters were not different between Cw and PCOSw. Within the PCOSw group, HOMA-β was lower at late reproductive and perimenopausal periods compared to the early reproductive age. Regarding control women, a deterioration of anthropometric and metabolic parameters was observed in perimenopausal women compared to early and late reproductive women.

CONCLUSIONS

Our results suggest that metabolic derangements associated with PCOS are more evident at the early and late reproductive ages. On the other hand, during perimenopause, there is no further deterioration of metabolic parameters. Nevertheless, a disruption in pancreatic β-cell function is evidenced at this stage.

A case of postmenopausal androgen excess

Ovarian steroid cell tumors are very rare but potentially life-threatening neoplasms. They represent less than 0.1% of all ovarian tumors, typically present in premenopausal women and frequently manifest with virilization. Signs of hyperandrogenism may appear in postmenopausal women due to tumorοus and non-tumorοus adrenal and ovarian causes as well due to the normal aging process. In any case, steroid cell tumor should be suspected in postmenopausal women who present with rapid progressive androgen excess symptoms. This report describes a case of a 67-year-old postmenopausal woman with signs of hyperandrogenism, where an ovarian steroid cell tumor was diagnosed and treated by laparoscopic bilateral salpingo-oophorectomy and synchronous hysterectomy.

Metabolic disorders in menopause

Metabolic disorders occurring in menopause, including dyslipidemia, disorders of carbohydrate metabolism (impaired glucose tolerance - IGT, type 2 diabetes mellitus - T2DM) or components of metabolic syndrome, constitute risk factors for cardiovascular disease in women. A key role could be played here by hyperinsulinemia, insulin resistance and visceral obesity, all contributing to dyslipidemia, oxidative stress, inflammation, alter coagulation and atherosclerosis observed during the menopausal period. Undiagnosed and untreated, metabolic disorders may adversely affect the length and quality of women's life. Prevention and treatment preceded by early diagnosis should be the main goal for the physicians involved in menopausal care. This article represents a short review of the current knowledge concerning metabolic disorders (e.g. obesity, polycystic ovary syndrome or thyroid diseases) in menopause, including the role of a tailored menopausal hormone therapy (HT). According to current data, HT is not recommend as a preventive strategy for metabolic disorders in menopause. Nevertheless, as part of a comprehensive strategy to prevent chronic diseases after menopause, menopausal hormone therapy, particularly estrogen therapy may be considered (after balancing benefits/risks and excluding women with absolute contraindications to this therapy). Life-style modifications, with moderate physical activity and healthy diet at the forefront, should be still the first choice recommendation for all patients with menopausal metabolic abnormalities.

An interesting cause of hyperandrogenemic hirsutism

Mild clinical signs of hyperandrogenism such as hirsutism may appear during the menopausal transition as part of the normal aging process, but the development of frank virilization suggests a specific source of androgen excess. We report a case of a 68-year-old woman with signs of virilization that had started 6 months before. Clinical analyses revealed high levels of serum testosterone for a postmenopausal woman. Pelvic MRI and abdomen CT showed no evidence of ovarian and adrenal tumor. Postmenopausal hyperandrogenism can be the result of numerous etiologies ranging from normal physiologic changes to ovarian or rarely adrenal tumors. Our patient was found to have iatrogenic hyperandrogenism. This condition is rarely reported cause of virilization.

Clinical and Biochemical Profiles according to Homeostasis Model Assessment-insulin Resistance (HOMA-IR) in Korean Women with Polycystic Ovary Syndrome

Objectives

The aim of this study was to investigate the clinical and biochemical profiles according to homeostasis model assessment of insulin resistance (HOMA-IR) in Korean polycystic ovary syndrome (PCOS) patients.

Methods

In 458 PCOS patients diagnosed by the Rotterdam European Society for Human Reproduction and Embryology (ESHRE) criteria, measurements of somatometry, blood test of hormones, glucose metabolic and lipid profiles, and transvaginal or transrectal ultrasonogram were carried out. HOMA-IR was then calculated and compared with the clinical and biochemical profiles related to PCOS. The patients were divided into 4 groups by quartiles of HOMA-IR.

Results

The mean level of HOMA-IR was 2.18 ± 1.73. Among the four groups separated according to HOMA-IR, body weight, body mass index (BMI), waist-to-hip ratio (WHR), triglyceride (TG), total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, lipid accumulation product (LAP) index, high-sensitivity C-reactive protein (hs-CRP), Apoprotein B, free testosterone, and sex hormone binding globulin (SHBG) were found to be significantly different. TG, LAP index, glucose metabolic profiles, and hs-CRP were positively correlated with HOMA-IR after adjustment for BMI.

Conclusion

Our results suggest that the clinical and biochemical profiles which are applicable as cardiovascular risk factors are highly correlated with HOMA-IR in Korean women with PCOS.