Practice patterns of screening for sleep apnea in physicians treating PCOS patients

Analysis of the proportion and clinical characteristics of obstructive sleep apnea in women with polycystic ovary syndrome

PURPOSE

To investigate the proportion and clinical characteristics of obstructive sleep apnea (OSA) in Chinese patients with polycystic ovarian syndrome (PCOS) through home sleep apnea test (HSAT) and to evaluate the reproductive endocrine and metabolic characteristics in these patients.

METHODS

The study was a cross-sectional analysis of infertile PCOS patients who underwent sleep respiratory monitoring between January and December 2019 at Peking University Third Hospital Reproductive Medical Center and respiratory and critical care medicine department. The prevalence of OSA, body mass index (BMI), menstruation, reproductive endocrine, and metabolic characteristics were collected in patients with PCOS. Logistic regression was performed to identify significant relationships among these factors and OSA.

RESULTS

Amont 328 patients with PCOS, the prevalence of OSA was 40% (131/328), and six cases (5%) were severe. Univariate analysis showed that BMI and blood pressure were significantly higher in patients with OSA than in those without OSA (P < 0.05), whereas the anti-Mullerian hormone was lower than that in patients without OSA. In terms of glucose and lipid metabolism, the glycosylated hemoglobin (HbA1c), fasting plasma glucose, and fasting insulin levels were significantly higher in patients with PCOS and comorbid OSA than in those without OSA (all P < 0.05). Patients with OSA also had higher triglyceride, low-density lipoprotein cholesterol, and high-sensitivity C-reactive protein levels and lower high-density lipoprotein cholesterol levels (P < 0.05). Logistic regression analysis revealed that higher BMI, elevated serum testosterone, and decreased high-density lipoprotein cholesterol (HDL-C) are correlated with occurrence of OSA (P < 0.05).

CONCLUSION

OSA in patients with PCOS was associated with multiple alterations in indexes of reproductive endocrine and metabolic disorders.

Understanding polycystic ovary syndrome from the patient perspective: a concept elicitation patient interview study

BACKGROUND

The aim of this study was to explore the need for a new disease-specific patient reported outcome (PRO) measure for use in clinical trials of drugs designed to target the underlying causes of polycystic ovary syndrome (PCOS), and in the process contribute to our understanding of the symptoms and impacts that define the patient experience with PCOS.

METHODS

Semi-structured interviews were conducted in 20 women diagnosed with PCOS according to the Rotterdam criteria who had not menstruated in the previous month. The relative importance of PCOS symptoms and impact concepts to patients was determined by analyzing the frequency of their expression in the interview transcripts. These insights were compared to clinicians' perceptions of PCOS.

RESULTS

Pain- and discomfort-related symptoms accounted for the highest proportion (27.6%) of the 735 patient expressions, although clinicians did not consider pain to be important to patients with PCOS. The most frequently expressed individual symptoms were cramping (70% of patients; 14.7% of concepts), irregular menstruation (95% of patients; 12.2% of concepts), facial hair growth (75% of patients; 10.6% of concepts), heavy bleeding (70% of patients; 8.8% of concepts), infertility (70% of patients; 5.4% of concepts), and bloating (60% of patients; 5.2% of concepts). Cramping, heavy bleeding, and bloating were not identified by clinicians as being important to patients with PCOS. The impacts most frequently reported by patients with PCOS related to emotional well-being (e.g. anxiety/stress) and coping behaviors (e.g. acne medication, hair removal).

CONCLUSIONS

The only validated PCOS-specific PRO, the PCOSQ, does not capture some key PCOS symptoms and impacts expressed by patients with PCOS, most notably those related to pain and discomfort, bleeding intensity and coping behaviours. Furthermore, some key PCOS symptoms may be under-recognized in the clinic.

Effect of metformin on sleep disorders in adolescent girls with polycystic ovarian syndrome

OBJECTIVE

Patients with polycystic ovarian syndrome (PCOS) have a high prevalence of sleep disorders. Metformin is an antidiabetic drug that may have a role in treatment of the manifestations of PCOS. The aim of this study was to assess the presence of sleep disorders in adolescent girls with PCOS and to study the effects of using metformin on sleep disorders in these girls.

METHODS

This study was carried out on 90 adolescent girls aging from 12 to 18 years who were divided into 3 equal groups: control untreated group, untreated PCOS group, and PCOS + metformin group. Body weight, height, body mass index, hirsutism score, fasting and postprandial blood glucose, fasting serum insulin, Homeostatic Model Assessment (HOMA) index, sleep disturbances scale, and Epworth sleepiness scale were measured.

RESULTS

Metformin administration resulted in significant decrease in the body weight, body mass index, hirsutism score, fasting and postprandial blood glucose, fasting serum insulin, HOMA index, sleep disturbances scale, and Epworth sleepiness scale compared to the untreated PCOS group.

CONCLUSION

Metformin can reduce the incidence of sleep disorders and excessive daytime sleepiness in adolescent girls with PCOS.

Diabetes, sleep apnea, obesity and cardiovascular disease: Why not address them together?

Obesity, sleep apnea, diabetes and cardiovascular diseases are some of the most common diseases encountered by the worldwide population, with high social and economic burdens. Significant emphasis has been placed on obtaining blood pressure, body mass index, and placing importance on screening for signs and symptoms pointing towards cardiovascular disease. Symptoms related to sleep, or screening for sleep apnea has been overlooked by cardiac, diabetic, pulmonary and general medicine clinics despite recommendations for screening by several societies. In recent years, there is mounting data where obesity and obstructive sleep apnea sit at the epicenter and its control can lead to improvement and prevention of diabetes and cardiovascular complications. This editorial raises questions as to why obstructive sleep apnea screening should be included as yet another vital sign during patient initial inpatient or outpatient visit.

Sleep and cardiometabolic function in obese adolescent girls with polycystic ovary syndrome

OBJECTIVE

To compare the polysomnography findings and cardiometabolic function among adolescent girls with polycystic ovary syndrome (PCOS) and matched female and male controls.

METHOD

Retrospective chart review of electronic medical records of 28 girls with PCOS (age: 16.8±1.9 years, body mass index (BMI) Z-score 2.4±0.4), 28 control females (age: 17.1±1.8, BMI Z-score 2.4±0.3) and 28 control males (age: 16.6±1.6, BMI Z-score 2.5±0.5) in a tertiary care centre.

RESULTS

The prevalence of obstructive sleep apnoea (OSA) was higher in girls with PCOS compared to control females (16/28 (57%) vs. 4/28(14.3%), p<0.01); however, it was comparable to that of the control males (16/28(57%) vs. 21/28(75%), p=0.4). Girls with PCOS had a significantly higher prevalence of insulin resistance compared to control females and control males (20/28 (71.4%) vs. 9/22 (41.0%) (p=0.04) vs. 8/23 (34.8%) (p=0.01). Among girls with PCOS, those with OSA had significantly higher proportions of metabolic syndrome (MetS) (9/16 (56.3%) vs. 1/12 (8.3%) p=0.03), higher insulin resistance (14/16 (87.5%) vs. 6/12 (50%), p=0.04), elevated daytime systolic blood pressure (128.4±12.8 vs. 115.6±11.4, p<0.01), lower high-density lipoprotein (HDL) (38.6±8.7 vs. 49±10.9, p=0.01) and elevated triglycerides (TG) (149.7±87.7 vs. 93.3±25.8, p=0.03) compared to those without OSA.

CONCLUSIONS

We report a higher prevalence of OSA and metabolic dysfunction in a selected group of obese girls with PCOS referred with sleep-related complaints compared to BMI-matched control girls without PCOS. We also report higher prevalence of cardiometabolic dysfunction in girls with PCOS and OSA compared to girls with PCOS without OSA.

Longitudinal analyses of polysomnographic variables, serum androgens, and parameters of glucose metabolism in obese adolescents with polycystic ovarian syndrome

PURPOSE

The prevalence of obstructive sleep apnea syndrome (OSAS) is clearly increased in adults with polycystic ovarian syndrome (PCOS), whereas OSAS does not seem to be frequent in adolescents with PCOS, pointing towards the fact that some patients with PCOS develop OSAS in the further course of the disease. We therefore aimed to analyze the changes of polysomnographic variables in obese adolescents with PCOS in a longitudinal analysis.

METHODS

Fifteen adolescents with PCOS (age 15.3 years ± 1.2, BMI 32.9 kg/m(2) ± 6.4, SDS-BMI 2.5 ± 0.8) underwent overnight 12-channel polysomnography at baseline and after a mean duration of 28 ± 6 months (age 17.8 years ± 1.1, BMI 32.7 kg/m(2) ± 7.0, SDS-BMI 2.1 ± 0.9). After performing the initial polysomnography, we treated hyperandrogenemia and insulin resistance in the study group. We determined parameters of body weight/body composition, parameters of glucose metabolism, and serum androgens in all patients at baseline and follow-up. At follow-up, we compared the polysomnographic variables of the study group to those of healthy female adults.

RESULTS

The polysomnographic variables, the parameters of body weight/body composition, and the parameters of glucose metabolism in the study group did not change significantly during the observation period. The serum levels of total testosterone and sex hormone binding globulin increased significantly, whereas free androgen index decreased significantly. At follow-up, the polysomnographic variables of the study group did not differ from those of healthy female adults.

CONCLUSIONS

OSAS does not seem to develop in adolescents with PCOS being treated for hyperandrogenism and insulin resistance. The pathogenesis of OSAS in PCOS needs to be examined in larger controlled studies.

Screening for sleep-disordered breathing and excessive daytime sleepiness in adolescent girls with polycystic ovarian syndrome

OBJECTIVE

To determine the prevalence and clinical and metabolic correlates of sleep-disordered breathing (SDB) and excessive daytime sleepiness (EDS) in adolescent girls with polycystic ovarian syndrome (PCOS).

STUDY DESIGN

Standardized questionnaires were administered to participants with PCOS and age-, sex-, ethnicity-, and body mass index (BMI) z score-matched controls. Medical records were reviewed for anthropometric and metabolic data.

RESULTS

We studied 103 participants with PCOS (16.9 ± 1.5 years) and 90 controls (16.8 ± 1.7 years). Compared with controls, girls with PCOS had a higher prevalence of SDB (45.6% vs 27.8%; P = .01) and EDS (54.4% vs 35.6%; P < .01). Within PCOS, those with SDB had higher BMI z score (2.1 ± 0.5 vs 1.7 ± 0.6; P < .01), higher homeostatic model assessment index (5.1 ± 2.3 vs 4.1 ± 3.5; P < .01), and higher prevalence of the metabolic syndrome (MetS) (42.6% vs 16.1%; P = .003) compared with those without SDB. Similarly, participants with PCOS and EDS had a higher BMI z score (2.0 ± 0.6 vs 1.7 ± 0.6; P = .03), higher homeostatic model assessment index (5.1 ± 2.9 vs 3.8 ± 3.1; P = .01), and higher rate of MetS (39.3% vs. 14.9%; P < .01) compared with those without EDS. MetS was independently associated with SDB (OR, 3.2; 95% CI, 1.0-10.1) and EDS (OR, 4.5; 95% CI, 1.2-16).

CONCLUSIONS

SDB and EDS are highly prevalent in adolescent girls with PCOS compared with matched controls. The MetS is independently associated with SDB and EDS in this group.

A comparison of polysomnographic variables between adolescents with polycystic ovarian syndrome with and without the metabolic syndrome

BACKGROUND

We aimed to determine the differences in polysomnographic variables between obese adolescents with polycystic ovarian syndrome (PCOS) with and without metabolic syndrome, as the prevalence of obstructive sleep apnea syndrome (OSAS) is increased in adults with PCOS, OSAS has been regarded as a manifestation of the metabolic syndrome, and the prevalence of metabolic syndrome is increased in patients with PCOS.

METHODS

Fourteen obese adolescents with PCOS and metabolic syndrome [15.7 years ± 1.9, body mass index (BMI) 36.2 kg/m(2) ± 6.2], 14 obese adolescents with PCOS without metabolic syndrome (15.7 years ± 1.1, BMI 33.8 kg/m(2) ± 6.2), 19 healthy, obese adolescents without PCOS or metabolic syndrome (15.3 years ± 1.0, BMI 34.4 kg/m(2) ± 6.5), and 14 healthy, normal-weight adolescents (15.4 years ± 0.7, BMI 21.1 kg/m(2) ± 2.2) underwent polysomnography to compare transcutaneous arterial oxygen saturation (Sat O(2)), apnea index (AI), hypopnea index (HI), apnea-hypopnea index (AHI), the absolute number of obstructive apneas (NOA), percentage sleep stages 3 and 4 of non REM-sleep (stages 3 and 4), percentage of rapid eye movement (REM) sleep (%REM), sleep-onset latency, and sleep efficiency.

RESULTS

We found no differences among the four groups concerning AI, HI, AHI, NOA, and stages 3 and 4. Significant differences among the groups were found regarding Sat O(2) (P = 0.04), %REM (P = 0.03), sleep-onset latency (P = 0.002), and sleep efficiency (P = 0.01).

CONCLUSIONS

Weight status, PCOS, and metabolic syndrome do not seem to have significant effects on respiratory polysomnographic variables in adolescent girls with PCOS, suggesting that the pathomechanisms leading to OSAS in patients with PCOS develop in the later course of the disease.

The impact of insulin resistance and hyperandrogenemia on polysomnographic variables in obese adolescents with polycystic ovarian syndrome

PURPOSE

We aimed to determine the impact of insulin resistance and hyperandrogenemia on polysomnographic variables in obese adolescents with polycystic ovarian syndrome (PCOS), as studies in adults with PCOS suggest that parameters of glucose metabolism and serum androgens are related to respiratory polysomnographic variables (RPV), and the symptoms of PCOS usually begin around menarche.

METHODS

We divided our study group of obese adolescents with PCOS according to HOMA-index and in a second analysis according to free androgen index (FAI). Study group A consisted of 14 girls with HOMA-index <4, study group B of 17 girls with HOMA-index >4. Study group C consisted of 19 girls with FAI <10, and study group D of 18 girls with FAI >10. The control group for both analyses consisted of 19 healthy obese adolescents without PCOS. All girls underwent overnight 12-channel polysomnography.

RESULTS

In both analyses, we found no differences between the groups concerning the RPV. Study group B demonstrated a significantly lower percentage of REM-sleep than the control group (p = 0.02). Study group D demonstrated a significantly lower percentage sleep stages 3 and 4 of non-REM-sleep than study group C and the controls (p = 0.008). Study group D demonstrated significantly lower sleep efficiency than the controls (p = 0.03).

CONCLUSIONS

Insulin resistance and hyperandrogenemia do not seem to have a significant impact on RPV in obese adolescents with PCOS. Differences in sleep architecture found between patients with PCOS and controls, however, are possibly influenced by insulin resistance and/or serum androgens.

A comparison of polysomnographic variables between obese adolescents with polycystic ovarian syndrome and healthy, normal-weight and obese adolescents

PURPOSE

The purpose of this study was to determine the differences in polysomnographic variables between obese adolescents with polycystic ovarian syndrome (PCOS) and healthy, normal-weight and obese controls, as the prevalence of obstructive sleep apnea syndrome (OSAS) is increased in adults with PCOS.

METHODS

Twenty-two obese adolescents with PCOS (mean age 15.2 +/- 1.3 years, mean BMI 31.7 +/- 6.2 kg/m(2)), 18 healthy, normal-weight adolescents (mean age 15.0 +/- 0.9 years, mean BMI 20.6 +/- 2.3 kg/m(2)), and 11 healthy, obese adolescents (mean age 15.0 +/- 1.0 years, mean BMI 34.8 +/- 8.7 kg/m(2)) underwent polysomnography to compare mean transcutaneous arterial oxygen saturation (Sat O(2)), apnea index (AI), hypopnea index (HI), apnea-hypopnea index (AHI), the absolute number of obstructive apneas (NOA), percentage sleep stages 3 and 4 of non-REM sleep (stages 3 and 4), percentage of REM sleep (%REM), sleep-onset latency, and sleep efficiency.

RESULTS

We found no differences between the three groups concerning Sat O(2), AI, HI, AHI, NOA, and stages 3 and 4. The girls with PCOS differed from normal-weight and obese controls regarding sleep-onset latency and sleep efficiency and from the normal-weight controls regarding %REM.

CONCLUSIONS

OSAS does not seem to be more prevalent in adolescents with PCOS. Concerning the respiratory variables, adolescents with PCOS do not seem to differ from healthy controls; however, there seem to be differences concerning sleep architecture.

Effects of poor and short sleep on glucose metabolism and obesity risk

The importance of sleep to hormones and glucose metabolism was first documented more than four decades ago. Since then, sleep curtailment has become an endemic behavior in modern society. In addition, the prevalence of sleep disorders, particularly obstructive sleep apnea (OSA), has increased. OSA is very common in endocrine and metabolic disorders, but often remains undiagnosed. This Review summarizes the laboratory and epidemiologic evidence that suggests how sleep loss, either behavioral or disease-related, and poor quality of sleep might promote the development of obesity and diabetes mellitus, and exacerbate existing endocrine conditions. Treatment of sleep disorders has the potential to improve glucose metabolism and energy balance. Screening for habitual sleep patterns and OSA might be critically important for patients with endocrine and metabolic disorders.

Impact of obstructive sleep apnea on insulin resistance and glucose tolerance in women with polycystic ovary syndrome

CONTEXT

Insulin resistance, impaired glucose tolerance, and type 2 diabetes are common in women with polycystic ovary syndrome (PCOS). Obstructive sleep apnea (OSA) has been linked to metabolic dysfunction. We studied women with and without PCOS to determine the extent to which OSA is responsible for insulin resistance and glucose intolerance in PCOS.

METHODS

In a prospective design, 52 women with PCOS and 21 women without PCOS of similar age and body mass index had an overnight polysomnogram and a 75-g oral glucose tolerance test.

RESULTS

Twenty-nine women (56%) with PCOS had OSA compared with four controls (19%) (adjusted odds ratio 7.1; 95% confidence interval, 1.7-45.7; P = 0.01). PCOS women with OSA were more insulin resistant than those without OSA [homeostasis model assessment (HOMA) index 5.7 +/- 0.4 vs. 3.5 +/- 0.4; P = 0.006] after controlling for age, body mass index, and ethnicity. Impaired glucose tolerance was found in 16 of 29 (55%) PCOS women with OSA and only six of 23 (26%) of those without OSA (unadjusted P = 0.049). Insulin resistance and glucose intolerance were highly correlated with the presence and severity of OSA. Among PCOS women with normal glucose tolerance, the presence of OSA was associated with a nearly 2-fold higher fasting insulin level and HOMA index. The severity of OSA was a highly significant predictor of the fasting concentrations of glucose and insulin as well as the 2-h glucose concentration and HOMA index.

CONCLUSIONS

OSA is a highly prevalent and important determinant of insulin resistance, glucose intolerance, and type 2 diabetes in PCOS.

Polycystic Ovary Syndrome and Obstructive Sleep Apnea

Polycystic ovary syndrome (PCOS), the most common endocrine disorder of pre-menopausal women, is characterized by chronic hyperandrogenism, oligoanovulation, obesity and insulin resistance. Importantly, PCOS women are at increased risk for glucose intolerance, type 2 diabetes and cardiovascular disorders. Recent reports indicate an unexpectedly high prevalence of obstructive sleep apnea (OSA) in PCOS. Alterations in sex steroids (i.e. high androgen and low estrogen levels) and increased visceral adiposity in PCOS could potentially contribute to the increased prevalence of OSA in this disorder. There is some evidence to suggest that there may be strong associations between the presence and severity of OSA and the metabolic disturbances that characterize PCOS. Causal mechanisms in the link between PCOS and OSA remain to be elucidated. Clinicians who manage PCOS patients should be aware of the high prevalence of OSA in these patients and systematically evaluate these women for sleep disturbances.