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Hookana I, Holmström L, Eskuri MAE, Pakanen L, Ollila MM, Kiviniemi AM, Kenttä T, Vähätalo J, Tulppo M, Lepojärvi ES, Piltonen T, Perkiömäki J, Tikkanen JT, Huikuri H, Junttila MJ. Characteristics of women with ischemic sudden cardiac death. Ann Med 2023; 55:2258911. [PMID: 37795698 PMCID: PMC10557538 DOI: 10.1080/07853890.2023.2258911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 09/11/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Sudden cardiac death (SCD) is a significant mode of death causing 15-20% of all deaths in high-income countries. Coronary artery disease (CAD) is the most common cause of SCD in both sexes, and SCD is often the first manifestation of underlying CAD in women. This case-control study aimed to determine the factors associated with SCD due to CAD in women. METHODS The study group consisted of women with CAD-related SCD (N = 888) derived from the Fingesture study conducted in Northern Finland from 1998 to 2017. All SCDs underwent medicolegal autopsy. The control group consisted of women with angiographically verified CAD without SCD occurring during the 5-year-follow-up (N = 610). To compare these groups, we used medical records, autopsy findings, echocardiograms, and electrocardiograms (ECGs). RESULTS Subjects with SCD were older (73.2 ± 11.3 vs. 68.8 ± 8.0, p < 0.001) and were more likely to be smokers or ex-smokers (37.1% vs. 27.6%, p = 0.045) compared to control patients. The proportion of subjects with prior myocardial infarction (MI) was higher in controls (46.9% vs. 41.4% in SCD subjects, p = 0.037), but in contrast, SCD subjects were more likely to have underlying silent MI (25.6% vs. 2.4% in CAD controls, p < 0.001). Left ventricular hypertrophy (LVH) was more common finding in SCD subjects (70.9% vs. 55.1% in controls, p < 0.001). Various electrocardiographic abnormalities were more common in subjects with SCD, including higher heart rate, atrial fibrillation, prolonged QTc interval, wide or fragmented QRS complex and early repolarization. The prevalence of Q waves and T inversions did not differ between the groups. CONCLUSIONS Underlying LVH and previous MI with myocardial scarring are common and often undiagnosed in women with CAD-related SCD. These results suggest that untreated CAD with concomitant myocardial disease is an important factor in SCD in women.
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Affiliation(s)
- I. Hookana
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu and Biocenter Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - L. Holmström
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu and Biocenter Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - M. A. E. Eskuri
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu and Biocenter Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - L. Pakanen
- Forensic Medicine Unit, Finnish Institute for Health and Welfare, Oulu, Finland
- Department of Forensic Medicine, Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - M. M. Ollila
- Department of Obstetrics and Gynecology, Research Unit of Clinical Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - A. M. Kiviniemi
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu and Biocenter Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - T. Kenttä
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu and Biocenter Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - J. Vähätalo
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu and Biocenter Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - M. Tulppo
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu and Biocenter Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - E. S. Lepojärvi
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu and Biocenter Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - T. Piltonen
- Department of Obstetrics and Gynecology, Research Unit of Clinical Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - J. Perkiömäki
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu and Biocenter Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - J. T. Tikkanen
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu and Biocenter Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - H. V. Huikuri
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu and Biocenter Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - M. J. Junttila
- Research Unit of Biomedicine and Internal Medicine, Medical Research Center Oulu and Biocenter Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
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Ollila MM, Arffman RK, Korhonen E, Morin-Papunen L, Franks S, Junttila J, Piltonen TT. Women with PCOS have an increased risk for cardiovascular disease regardless of diagnostic criteria - a prospective population-based cohort study. Eur J Endocrinol 2023:lvad077. [PMID: 37436934 DOI: 10.1093/ejendo/lvad077] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 05/23/2023] [Accepted: 05/31/2023] [Indexed: 07/14/2023]
Abstract
OBJECTIVE Polycystic ovary syndrome (PCOS) is associated with many cardiovascular disease (CVD) risk factors, such as obesity, type 2 diabetes mellitus and hypertension. However, it remains debatable whether the presence of multiple CVD risk factors translates to increased CVD events. DESIGN A prospective, population-based Northern Finland Birth Cohort 1966. METHODS Individuals with an expected date of birth in 1966 in Northern Finland have been followed from birth. Women in the cohort were classified as having PCOS according to either the National Institute of Health (NIH) criteria (n=144) or the Rotterdam criteria (n=386) at age 31, and they were compared to women without any PCOS features. The study population was re-examined at age 46, and the incidence of major adverse cardiovascular events (MACE), including myocardial infarction (MI), stroke, heart failure and cardiovascular mortality, was recorded up to age 53. RESULTS During the 22-year follow-up, both women with NIH-PCOS and women with Rotterdam-PCOS had a significantly higher risk for cardiovascular events than control women. The BMI-adjusted hazard ratio (HR) for MACE in the Rotterdam-PCOS group and the NIH-PCOS group was 2.33 (1.26-4.30) and 2.47 (1.18-5.17), respectively. The cumulative hazard curves in both diagnostic categories began to diverge at age 35. Regarding the individual CVD endpoints, MI was significantly more prevalent in both women with NIH-PCOS (p=0.010) and women with Rotterdam-PCOS (p=0.019), when compared to control women. CONCLUSIONS PCOS should be considered a significant risk factor for CVD. Future follow-up will show how the risk of CVD events develops after menopausal age.
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Affiliation(s)
- M M Ollila
- Department of Obstetrics and Gynaecology, Medical Research Center Oulu, Research Unit of Clinical Medicine, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - R K Arffman
- Department of Obstetrics and Gynaecology, Medical Research Center Oulu, Research Unit of Clinical Medicine, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - E Korhonen
- Department of Obstetrics and Gynaecology, Medical Research Center Oulu, Research Unit of Clinical Medicine, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - L Morin-Papunen
- Department of Obstetrics and Gynaecology, Medical Research Center Oulu, Research Unit of Clinical Medicine, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - S Franks
- Institute of Reproductive and Developmental Biology, Imperial College London, United Kingdom
| | - J Junttila
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - T T Piltonen
- Department of Obstetrics and Gynaecology, Medical Research Center Oulu, Research Unit of Clinical Medicine, University of Oulu and Oulu University Hospital, Oulu, Finland
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Tuorila K, Ollila MM, Järvelin MR, Tapanainen J, Franks S, Puukka K, Piltonen T, Morin-Papunen L. O-163 Hyperandrogenaemia in early adulthood is an independent risk factor for abnormal glucose metabolism in later life. Hum Reprod 2021. [DOI: 10.1093/humrep/deab127.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Study question
What is the role of androgen excess as a contributing factor to insulin resistance and abnormal glucose metabolism (AGM) in women?
Summary answer
There was a positive association between early adulthood hyperandrogenaemia with AGM. Serum SHBG levels could help identifying women at risk for disordered glucose metabolism.
What is known already
It is commonly recognised that insulin resistance induces compensatory hyperinsulinaemia which promotes ovarian androgen secretion. Studies in rodents have also suggested that testosterone causes prolonged activation of androgen receptor in pancreatic islet β-cells, inducing insulin hypersecretion and eventually secondary β-cell failure, thus predisposing to type 2 diabetes (T2D). However, the exact physiology behind the association between androgens, insulin resistance and T2D in women is not well understood. Many previously published studies are limited by cross-sectional study design, unrepresentative clinic populations, as well as variying steroid hormone measurement methods and definitions of androgen excess.
Study design, size, duration
A prospective longitudinal population-based cohort (n = 5,889) to investigate whether serum levels of testosterone (T, measured using LC-MS/MS) and free androgen index (FAI) at ages 31 and 46 associated with AGM at age 46 years. After exclusion of pregnant women, users of hormonal intrauterine device, contraceptive pills, hormone therapy, minipills and statins, there were 4,421 women at age 31 and 4,457 women at age 46. At age 46 a two-hour OGTT was performed in 2,780 women.
Participants/materials, setting, methods
Serum fasting glucose and insulin, insulin resistance (HOMA–IR) and pancreatic β-cell function (HOMA–B) assessments were performed at ages 31 and 46. Elevated T levels (age 31: >2.3nmol/l; age 46: >1.7nmol/l) were defined according to the 97.5% percentile. T2D diagnoses were gathered from postal questionnaire at age 46, and verified and completed from the hospital discharge and national medication reimbursement registers. Impaired fasting glucose, impaired glucose tolerance or T2D were categorised as AGM.
Main results and the role of chance
At age 31, hyperandrogenic (HA) women displayed increased insulin resistance estimated by HOMA-IR (1.35±0.96 vs. 1.03±0.44, P = 0.05), increased insulin secretion estimated by HOMA-B (115.05±34.67 vs. 99.25±25.47, P = 0.006), and higher fasting insulin level (10.48±7.54 mU/l vs. 7.93±3.42 mU/l, P = 0.034) compared with normoandrogenic (NA) women, after BMI adjustment. At age 46, HA women had comparable HOMA-B levels (98.04±60.03 vs. 96.27±65.89, P = 0.93) but their fasting glucose (5.57±1.06 mmol/l vs. 5.37±0.77 mmol/, P = 0.07) and glycated haemoglobin levels (37.47±7.83 mmol/mol vs. 36.18±4.99 mmol/mol, P = 0.07) tended to be higher.
Women in the highest T quartile (Q4
odds ratio [OR]=1.77, 95%CI: [1.14–2.76]) and in the two highest FAI quartiles at age 31 (Q4: OR = 3.61 [2.16–6.03] and Q3: OR = 2.11 [1.24–3.59]) had increased risk for AGM at age 46, independently of BMI, when compared with women in the lowest quartile. Similarly, women in the two highest FAI quartiles at age 46 had increased risk for AGM (Q4: OR = 2.91 [1.82–4.64]) when compared with women in the lowest quartile, after BMI adjustment. The three highest sex hormone-binding globulin (SHBG) quartiles inversely associated with AGM, both at ages 31 and 46, independently of BMI (at age 31: Q4: OR = 0.38 [0.24–0.62], at age 46: Q4: OR = 0.27 [0.17–0.44]).
Limitations, reasons for caution
We used only serum T as a marker of HA, even though other androgens, such as androstenedione and adrenal androgens have a place in the evaluation of androgenicity in women. Further studies of other large populations are needed to confirm our results.
Wider implications of the findings
This is the first longitudinal, general population based study to confirm a positive association between early adulthood hyperandrogenaemia with AGM in middle adulthood independently of confounding factors. Our results further suggest that SHBG levels could help to identify women at risk for AGM.
Trial registration number
NA
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Affiliation(s)
- K Tuorila
- University of Oulu and Oulu University Hospital- Medical Research Center- PEDEGO Research Unit, Department of Obstetrics and Gynecology, Oulu, Finland
| | - M M Ollila
- University of Oulu and Oulu University Hospital- Medical Research Center- PEDEGO Research Unit, Gynaecology and Obstetrics, Oulu, Finland
| | - M R Järvelin
- University of Oulu- Faculty of Medicine- Imperial College London- Oulu University Hospital- Brunel University London, Center for Life Course Health Research- MRC-PHE Centre for Environment and Health- Department of Epidemiology and Biostatistics- Schoo
| | - J Tapanainen
- University of Oulu and Oulu University Hospital- Medical Research Center- PEDEGO Research Unit- University of Helsinki and Helsinki University Hospital, Department of Obstetrics and Gynecology, Oulu, Finland
| | - S Franks
- Imperial College London, Institute of Reproductive and Developmental Biology, London, United Kingdom
| | - K Puukka
- University of Oulu and Oulu University Hospital- Medical Research Center Oulu, NordLab Oulu- Department of Clinical Chemistry, Oulu, Finland
| | - T Piltonen
- University of Oulu and Oulu University Hospital- Medical Research Center- PEDEGO Research Unit, Department of Obstetrics and Gynecology, Oulu, Finland
| | - L Morin-Papunen
- University of Oulu and Oulu University Hospital- Medical Research Center- PEDEGO Research Unit, Department of Obstetrics and Gynecology, Oulu, Finland
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Ollila MM, West S, Keinänen-Kiukaaniemi S, Jokelainen J, Auvinen J, Puukka K, Ruokonen A, Järvelin MR, Tapanainen JS, Franks S, Piltonen TT, Morin-Papunen LC. Overweight and obese but not normal weight women with PCOS are at increased risk of Type 2 diabetes mellitus-a prospective population-based cohort study. Hum Reprod 2017; 32:968. [PMID: 28333219 DOI: 10.1093/humrep/dex030] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- M M Ollila
- Department of Obstetrics and Gynaecology, Oulu University Hospital, University of Oulu, Medical Research Center Oulu and PEDEGO Research Unit, FI, OYS, Oulu, Finland
| | - S West
- Department of Obstetrics and Gynaecology, Oulu University Hospital, University of Oulu, Medical Research Center Oulu and PEDEGO Research Unit, FI, OYS, Oulu, Finland
| | - S Keinänen-Kiukaaniemi
- Center for Life Course Health Research, University of Oulu, FI, Oulu, Finland.,Unit of Primary Health Care, Oulu University Hospital, FI, Oulu, Finland
| | - J Jokelainen
- Center for Life Course Health Research, University of Oulu, FI, Oulu, Finland.,Unit of Primary Health Care, Oulu University Hospital, FI, Oulu, Finland
| | - J Auvinen
- Center for Life Course Health Research, University of Oulu, FI, Oulu, Finland.,Unit of Primary Health Care, Oulu University Hospital, FI, Oulu, Finland
| | - K Puukka
- NordLab Oulu, Department of Clinical Chemistry, Oulu University Hospital, University of Oulu and Medical Research Center, FI, Oulu, Finland
| | - A Ruokonen
- NordLab Oulu, Department of Clinical Chemistry, Oulu University Hospital, University of Oulu and Medical Research Center, FI, Oulu, Finland
| | - M-R Järvelin
- Center for Life Course Health Research, University of Oulu, FI, Oulu, Finland.,Department of Children, Young People and Families, National Institute for Health and Welfare, FI, Oulu, Finland.,Department of Epidemiology and Biostatistics, MRC-PHE Centre for Environment & Health, School of Public Health, Imperial College London,London, UK
| | - J S Tapanainen
- Department of Obstetrics and Gynaecology, Oulu University Hospital, University of Oulu, Medical Research Center Oulu and PEDEGO Research Unit, FI, OYS, Oulu, Finland.,Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, FI, Helsinki, Finland
| | - S Franks
- Institute of Reproductive and Developmental Biology, Imperial College London, Hammersmith Hospital, London, UK
| | - T T Piltonen
- Department of Obstetrics and Gynaecology, Oulu University Hospital, University of Oulu, Medical Research Center Oulu and PEDEGO Research Unit, FI, OYS, Oulu, Finland
| | - L C Morin-Papunen
- Department of Obstetrics and Gynaecology, Oulu University Hospital, University of Oulu, Medical Research Center Oulu and PEDEGO Research Unit, FI, OYS, Oulu, Finland
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Ollila MM, West S, Keinänen-Kiukaanniemi S, Jokelainen J, Auvinen J, Puukka K, Ruokonen A, Järvelin MR, Tapanainen JS, Franks S, Piltonen TT, Morin-Papunen LC. Overweight and obese but not normal weight women with PCOS are at increased risk of Type 2 diabetes mellitus-a prospective, population-based cohort study. Hum Reprod 2016; 32:423-431. [PMID: 28031324 DOI: 10.1093/humrep/dew329] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 11/29/2016] [Accepted: 12/16/2016] [Indexed: 12/15/2022] Open
Abstract
STUDY QUESTION What are the respective roles of polycystic ovary syndrome (PCOS), long-term weight gain and obesity for the development of prediabetes or Type 2 diabetes mellitus (T2DM) by age 46 years? SUMMARY ANSWER The risk of T2DM in women with PCOS is mainly due to overweight and obesity, although these two factors have a synergistic effect on the development of T2DM. WHAT IS KNOWN ALREADY PCOS is associated with an increased risk of prediabetes and T2DM. However, the respective roles of PCOS per se and BMI for the development of T2DM have remained unclear. STUDY DESIGN, SIZE, DURATION In a prospective, general population-based follow-up birth cohort 1966 (n = 5889), postal questionnaires were sent at ages 14 (95% answered), 31 (80% answered) and 46 years (72% answered). Questions about oligoamenorrhoea and hirsutism were asked at age 31 years, and a question about PCOS diagnosis at 46 years. Clinical examination and blood sampling were performed at 31 years in 3127 women, and at 46 years in 3280 women. A 2-h oral glucose tolerance test (OGTT) was performed at 46 years of age in 2780 women. PARTICIPANTS/MATERIALS, SETTING, METHODS Women reporting both oligoamenorrhoea and hirsutism at age 31 years and/or diagnosis of PCOS by 46 years were considered as women with PCOS (n = 279). Women without any symptoms at 31 years and without PCOS diagnosis by 46 years were considered as controls (n = 1577). The level of glucose metabolism was classified according to the results of the OGTT and previous information of glucose metabolism status from the national drug and hospital discharge registers. MAIN RESULTS AND THE ROLE OF CHANCE PCOS per se significantly increased the risk of T2DM in overweight/obese (BMI ≥ 25.0 kg/m2) women with PCOS when compared to overweight/obese controls (odds ratio: 2.45, 95% CI: 1.28-4.67). Normal weight women with PCOS did not present with an increased risk of prediabetes or T2DM. The increase in weight between ages 14, 31 and 46 years was significantly greater in women with PCOS developing T2DM than in women with PCOS and normal glucose tolerance, with the most significant increase occurring in early adulthood (between 14 and 31 years: median with [25%; 75% quartiles]: 27.25 kg [20.43; 34.78] versus 13.80 kg [8.55; 20.20], P < 0.001). LIMITATIONS, REASONS FOR CAUTION The diagnosis of PCOS was based on self-reporting, and the questionnaire at 46 years did not distinguish between polycystic ovaries only in ultrasonography and the syndrome. Ovarian ultrasonography was not available to aid the diagnosis of PCOS. WIDER IMPLICATIONS OF THE FINDINGS These results emphasize weight management already during adolescence and early adulthood to prevent the development of T2DM in women with PCOS, as the period between 14 and 31 years seems to be a crucial time-window during which the women with PCOS who are destined to develop T2DM by 46 years of age experience a dramatic weight gain. Furthermore, our results support the view that, particularly in times of limited sources of healthcare systems, OGTT screening should be targeted to overweight/obese women with PCOS rather than to all women with PCOS. STUDY FUNDING/COMPETING INTERESTS Finnish Medical Foundation; North Ostrobothnia Regional Fund; Academy of Finland (project grants 104781, 120315, 129269, 1114194, 24300796, Center of Excellence in Complex Disease Genetics and SALVE); Sigrid Juselius Foundation; Biocenter Oulu; University Hospital Oulu and University of Oulu (75617); Medical Research Center Oulu; National Institute for Health Research (UK); National Heart, Lung, and Blood Institute (grant 5R01HL087679-02) through the STAMPEED program (1RL1MH083268-01); National Institute of Health/National Institute of Mental Health (5R01MH63706:02); ENGAGE project and grant agreement HEALTH-F4-2007-201413; EU FP7 EurHEALTHAgeing-277849 European Commission and Medical Research Council, UK (G0500539, G0600705, G1002319, PrevMetSyn/SALVE) and Medical Research Center, Centenary Early Career Award. The authors have no conflicts of interests. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- M M Ollila
- Department of Obstetrics and Gynaecology, Oulu University Hospital, University of Oulu, Medical Research Center Oulu and PEDEGO Research Unit, FI-90029, OYS, Oulu, Finland
| | - S West
- Department of Obstetrics and Gynaecology, Oulu University Hospital, University of Oulu, Medical Research Center Oulu and PEDEGO Research Unit, FI-90029, OYS, Oulu, Finland
| | - S Keinänen-Kiukaanniemi
- Center for Life Course Health Research, University of Oulu, FI-90014, Oulu, Finland.,Unit of Primary Health Care, Oulu University Hospital, FI-90220, Oulu, Finland
| | - J Jokelainen
- Center for Life Course Health Research, University of Oulu, FI-90014, Oulu, Finland.,Unit of Primary Health Care, Oulu University Hospital, FI-90220, Oulu, Finland
| | - J Auvinen
- Center for Life Course Health Research, University of Oulu, FI-90014, Oulu, Finland.,Unit of Primary Health Care, Oulu University Hospital, FI-90220, Oulu, Finland
| | - K Puukka
- NordLab Oulu, Department of Clinical Chemistry, Oulu University Hospital, University of Oulu and Medical Research Center Oulu, FI-90220, Oulu, Finland
| | - A Ruokonen
- NordLab Oulu, Department of Clinical Chemistry, Oulu University Hospital, University of Oulu and Medical Research Center Oulu, FI-90220, Oulu, Finland
| | - M-R Järvelin
- Center for Life Course Health Research, University of Oulu, FI-90014, Oulu, Finland.,Department of Children, Young People and Families, National Institute for Health and Welfare, FI-90101, Oulu, Finland.,Department of Epidemiology and Biostatistics, MRC-PHE Centre for Environment & Health, School of Public Health, Imperial College London, W2 1PG, London, UK
| | - J S Tapanainen
- Department of Obstetrics and Gynaecology, Oulu University Hospital, University of Oulu, Medical Research Center Oulu and PEDEGO Research Unit, FI-90029, OYS, Oulu, Finland.,Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, FI-00014, Helsinki, Finland
| | - S Franks
- Institute of Reproductive and Developmental Biology, Imperial College London, Hammersmith Hospital, W12 0NN, London, UK
| | - T T Piltonen
- Department of Obstetrics and Gynaecology, Oulu University Hospital, University of Oulu, Medical Research Center Oulu and PEDEGO Research Unit, FI-90029, OYS, Oulu, Finland
| | - L C Morin-Papunen
- Department of Obstetrics and Gynaecology, Oulu University Hospital, University of Oulu, Medical Research Center Oulu and PEDEGO Research Unit, FI-90029, OYS, Oulu, Finland
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