Overweight women with polycystic ovary syndrome have evidence of subclinical cardiovascular disease

Assessing the intersection of cardiovascular disease, venous thromboembolism, and polycystic ovary syndrome

INTRODUCTION

No study has examined how the relationship between polycystic ovary syndrome (PCOS) and atherosclerotic cardiovascular diseases (aCVD), of ischemic stroke (ISCH), acute myocardial infarction (AMI), and peripheral vascular disease (PAD), differ in the presence of venous thromboembolism (VTE).

MATERIALS AND METHODS

We performed a cross-sectional analysis using Truven Health Analytics MarketScan® Commercial databases from 2004-2011. The association between women aged 18-64 years with and without PCOS, and aCVD was assessed using VTE-stratified multivariable logistic regression models.

RESULTS

Overall, women with PCOS were more likely to have aCVD, (aOR, 1.27; 95% CI, 1.10-1.46) especially ISCH (aOR, 1.56; 95% CI, 1.30-1.88), than women without PCOS. When stratified by VTE status, women with PCOS and a VTE diagnosis had a decreased odds of having any aCVD (aOR 0.67; 95% CI, 0.46-0.98), and VTE diagnosis more often preceded the occurrence of ISCH and AMI among women with PCOS compared with women without PCOS.

CONCLUSIONS

Overall, women with PCOS were more likely to have aCVD, with stroke being the most prevalent manifestation. Although VTE often occurred before any aCVD, it appeared to have an inverse association with the development of ISCH, AMI, and PAD among women with PCOS, suggesting that aggressively treating VTE or aCVD early may limit the chances of developing the other thrombogenic condition among women with PCOS.

Biomarkers and insulin sensitivity in women with Polycystic Ovary Syndrome: Characteristics and predictive capacity

OBJECTIVE

Polycystic ovary syndrome (PCOS) is a common endocrine disorder associated with metabolic complications. Metabolic biomarkers with roles in obesity, glycaemic control and lipid metabolism are potentially relevant in PCOS. The aim was to investigate metabolic biomarkers in lean and overweight women with and without PCOS and to determine whether any biomarker was able to predict insulin resistance in PCOS.

DESIGN

Cross-sectional study.

PATIENTS

Eighty-four women (22 overweight and 22 lean women with PCOS, 18 overweight and 22 lean women without PCOS) were recruited from the community and categorized based on PCOS and BMI status.

MEASUREMENTS

Primary outcomes were metabolic biomarkers [ghrelin, resistin, visfatin, glucagon-like peptide-1 (GLP-1), leptin, plasminogen activator inhibitor -1 (PAI-1), glucose-dependent insulinotropic polypeptide (GIP) and C-Peptide] measured using the Bio-Plex Pro Diabetes assay and insulin sensitivity as assessed by glucose infusion rate on euglycaemic-hyperinsulinaemic clamp.

RESULTS

The biomarkers C-peptide, leptin, ghrelin and visfatin were different between overweight and lean women, irrespective of PCOS status. The concentration of circulating biomarkers did not differ between women with PCOS diagnosed by the Rotterdam criteria or National Institute of Health criteria. PAI-1 was the only biomarker that significantly predicted insulin resistance in both control women (P = 0.04) and women with PCOS (P = 0.01).

CONCLUSIONS

Biomarkers associated with metabolic diseases appear more strongly associated with obesity rather than PCOS status. PAI-1 may also be a novel independent biomarker and predictor of insulin resistance in women with and without PCOS.

Hypertension in Reproductive-Aged Women With Polycystic Ovary Syndrome and Association With Obesity

BACKGROUND

Polycystic ovary syndrome (PCOS) is a common disorder with metabolic complications, yet the prevalence of hypertension is unclear. We aim to assess hypertension prevalence and the impact of obesity in women reporting PCOS compared to those not reporting PCOS.

METHODS

This is a cross-sectional analysis of data from a large longitudinal study, the Australian Longitudinal Study on Women's Health (ALSWH). Women from the general community were randomly selected from the national health insurance database. Standardized data collection occurred at 6 survey time points. Data from Survey 4 in 2006 (n = 8,612, age: 28-33 years) were examined for this study. The main outcome measures studied were self-reported PCOS and hypertension.

RESULTS

Reported PCOS prevalence was 5.8% (95% confidence interval (CI): 5.3%-6.4%). Women with PCOS had higher body mass index (BMI). Hypertension prevalence was 5.5% (95% CI: 3.3-7.7) in women reporting PCOS and 2.0% (95% CI: 1.6-2.3) in women not reporting PCOS (P < 0.001). Hypertension was associated with BMI (odds ratio: 1.07, 95% CI: 1.05-1.10, P < 0.001) with a trend towards an association with PCOS (P = 0.09). On subgroup analysis, hypertension was not associated with BMI in women reporting PCOS but was associated in those not reporting PCOS.

CONCLUSIONS

In this large community-based cohort, we note increased prevalence of hypertension and higher BMI in young women reporting PCOS. BMI association with hypertension appeared clear in women not reporting PCOS. Yet in women with PCOS, hypertension appeared to not be associated with BMI, akin to observations on diabetes risk in PCOS, suggesting that metabolic abnormalities in PCOS may be independent of BMI.

Oxidative stress and cardiovascular complications in polycystic ovarian syndrome

Polycystic ovarian syndrome (PCOS) is a complex endocrine condition which is associated with metabolic and cardiovascular complications. It is elevated to a metabolic disorder with significant long term health ramification due to the high prevalence of insulin resistance (IR), impaired glucose tolerance, type 2 diabetes (T2D), dyslipidemia and numerous cardiovascular risk factors in PCOS women. This article concentrates on the recent developments in the regulation of oxidative stress (OS) in PCOS and on the association between PCOS and CVD outcomes. The prognostic events that define the severity of PCOS and involvement of cardiovascular risk in PCOS include endothelial dysfunction (ED) and impaired cardiac structure. Fact is that, in PCOS women, the circulating biomarkers of OS are in abnormal levels that are independent of overweight, which depicts the participation of OS in the pathophysiology of this common derangement. In addition, hyperglycemia (HG) per se, promotes reactive oxygen species (ROS) generation in PCOS. When the destructive ROS outbalances the concentration of physiological antioxidants, OS occurs. The resultant OS, directly stimulates hyperandrogenism and causes extensive cellular injury, DNA damage and/or cell apoptosis. To further the burden, the total serum antioxidant level in PCOS women is compromised, which diminishes the body's defense against an oxidative milieu. Thus, it is evident that OS regulates several cellular mechanisms in PCOS. Improving our understanding about the regulation of OS, critical role of ROS and protein biomarkers in PCOS should lead to novel therapeutic strategies in addressing PCOS-induced CVD. Besides, it is possible that the beneficial effects of dietary or therapeutic antioxidants have significant clinical relevance in PCOS.

Mindfulness-based stress reduction for overweight/obese women with and without polycystic ovary syndrome: design and methods of a pilot randomized controlled trial

Mindfulness-based stress reduction (MBSR) may be beneficial for overweight/obese women, including women with polycystic ovary syndrome (PCOS), as it has been shown to reduce psychological distress and improve quality of life in other patient populations. Preliminary studies suggest that MBSR may also have salutary effects on blood pressure and blood glucose. This paper describes the design and methods of an ongoing pilot randomized controlled trial evaluating the feasibility and effects of MBSR in PCOS and non-PCOS women who are overweight or obese. Eighty six (86) women with body mass index ≥25 kg/m², including 31 women with PCOS, have been randomized to 8 weeks of MBSR or health education control, and followed for 16 weeks. The primary outcome is mindfulness assessed with the Toronto Mindfulness Scale. Secondary outcomes include measures of blood pressure, blood glucose, quality of life, anxiety and depression. Our overall hypothesis is that MBSR will increase mindfulness and ultimately lead to favorable changes in blood pressure, blood glucose, psychological distress and quality of life in PCOS and non-PCOS women. This would support the integration of MBSR with conventional medical treatments to reduce psychological distress, cardiovascular disease and diabetes in PCOS and non-PCOS women who are overweight or obese.

Female obesity and infertility

Infertility affects one in seven couples, and its rate is on the increase. Ovulatory defects and unexplained causes account for >50% of infertile aetiologies. It is postulated that a significant proportion of these cases are either directly or indirectly related to obesity. The prevalence of overweight and obese men and women has topped 50% in some developed countries. Obesity is on the increase worldwide; in turn, the consequences in terms of the associated morbidity and mortality have also been increasing. Obesity is associated with various reproductive sequelae including anovulation, subfertility and infertility, increased risk of miscarriage and poor neonatal and maternal pregnancy outcomes. Thus, the combination of infertility and obesity poses some very real challenges in terms of both the short- and long-term management of these patients. The mechanism with which obesity impacts female reproductive function is summarised in this review.

Screening for glucose intolerance in polycystic ovary syndrome: hemoglobin A1C, fasting blood glucose or oral glucose tolerance test?

Polycystic ovary syndrome (PCOS) is a chronic condition with many reproductive, metabolic and psychological manifestations. Insulin resistance puts women with PCOS at an increased risk for developing impaired glucose tolerance (IGT) and diabetes (T2D). An oral glucose tolerance test is the preferred IGT/T2D screening test, since it is most sensitive for detecting early glucose abnormalities. The goals in detecting IGT in these women are to avoid progression to T2D, modify cardiovascular risk and prevent gestational diabetes. Periodic IGT/T2D rescreening is necessary, given their propensity for more rapid deterioration in glucose tolerance. Lifestyle intervention is first-line therapy for PCOS women with IGT. Metformin is an option if lifestyle intervention fails to have an impact, while bariatric surgery is reserved for a select set of morbidly obese patients.

Prospective association of polycystic ovary syndrome with coronary artery calcification and carotid-intima-media thickness: the Coronary Artery Risk Development in Young Adults Women's study

OBJECTIVE

To study the independent associations of polycystic ovary syndrome (PCOS), and its 2 components, hyperandrogenism and anovulation, with coronary artery calcification (CAC) and carotid artery intima-media thickness (IMT).

APPROACH AND RESULTS

At the year 20 of the Coronary Artery Risk Development in Young Adults (CARDIA) study, a population-based multicenter cohort of young adults, women (mean age, 45 years) with information on menses and hirsutism in their twenties were assessed for CAC (n=982) and IMT (n=988). We defined PCOS as women who had both irregular menses and hyperandrogenism (n=55); isolated oligomenorrhea (n=103) as women who only had irregular menses; and isolated hyperandrogenism (n=156) as women who had either hirsutism or increased testosterone levels. Logistic regressions and general linear models were used to estimate the associations between components of PCOS and subclinical CVD. The prevalence of CAC was 10.3% overall. Women with PCOS had a multivariable adjusted odds ratio of 2.70 (95% confidence interval, 1.31-5.60) for CAC. Women with either isolated oligomenorrhea or isolated hyperandrogenism had no increased risk of CAC when compared with unexposed women. Women with PCOS had significantly increased bulb and internal carotid-IMT measurements; however, no significant differences were noted in bulb or internal carotid artery IMT among women with either isolated oligomenorrhea or isolated hyperandrogenism when compared with unexposed women. There were no differences in common carotid-IMT among the 4 study groups.

CONCLUSIONS

In this study, women with PCOS, manifested as both anovulation and hyperandrogenism, but not women with one of these manifestations alone, were at increased risk for the development of subclinical CVD.

Nonobese Young Females with Polycystic Ovary Syndrome have Nutritive Microvascular Dysfunction: A Pilot Study

OBJECTIVE

To investigate nutritive microvascular function in young nonobese females with polycystic ovary syndrome (PCOS) and to correlate microvascular reactivity with sex steroids, inflammatory markers, and metabolic variables.

METHODS

Fourteen nonobese females with PCOS (24.6 ± 2.7 years, body mass index [BMI] 23.7 ± 3.1 kg/m2) and 13 age- and BMI-matched controls (22.8 ± 2.3 years, 22.5 ± 3.4kg/m2) underwent anthropometric, hormonal, and microvascular evaluations. The main outcome measures were capillary density, red blood cell velocity (RBCV) at resting and peak during postocclusive reactive hyperemia (RBCVmax), and time taken to reach RBCVmax (TRBCVmax).

RESULTS

Subjects with PCOS had lower RBCV and higher TRBCVmax compared to controls, respectively (0.237 [0.220-0.324] vs. 0.362 [0.297-0.382] mm/s, P<.01) and (5 [5-6] vs. 4 [3-5] s, P<.05]. The free androgen index (FAI) and sex hormone-binding globulin (SHBG) level were different between groups. FAI correlated to RBCVmax (ρ = -0.49, P<.05) and to TRBCVmax (ρ = 0.41, P<.05). SHBG correlated with RBCVmax (ρ = 0.52, P<.01) while estradiol (E2) levels correlated with RBCV (ρ = 0.80, P<.001) and RBCVmax (ρ = 0.46, P<.05).

CONCLUSION

Microvascular dysfunction characterized by reduced RBCVmax and prolonged TRBCVmax was present in young, nonobese PCOS subjects. FAI was associated with observed impairments, suggesting a possible common mechanism linking sex hormones and microvascular dysfunction.

Brachial-to-ankle pulse wave velocity as an independent prognostic factor for ovulatory response to clomiphene citrate in women with polycystic ovary syndrome

Background

Polycystic ovary syndrome (PCOS) has a risk for cardiovascular disease. Increased arterial stiffness has been observed in women with PCOS. The purpose of the present study was to investigate whether the brachial-to-ankle pulse wave velocity (baPWV) is a prognostic factor for ovulatory response to clomiphene citrate (CC) in women with PCOS.

Methods

This study was a retrospective cohort study of 62 women with PCOS conducted from January 2009 to December 2012 at the university hospital, Yamagata, Japan. We analyzed 62 infertile PCOS patients who received CC. Ovulation was induced by 100 mg CC for 5 days. CC non-responder was defined as failure to ovulate for at least 2 consecutive CC-treatment cycles. The endocrine, metabolic, and cardiovascular parameters between CC responder (38 patients) and non-responder (24 patients) groups were analyzed.

Results

In univariate analysis, waist-to-hip ratio, level of free testosterone, percentages of patients with dyslipidemia, impaired glucose tolerance, and diabetes mellitus, blood glucose and insulin levels at 60 min and 120 min, the area under the curve of glucose and insulin after 75-g oral glucose intolerance test, and baPWV were significantly higher in CC non-responders compared with responders. In multivariate logistic regression analysis, both waist-to-hip ratio (odds ratio, 1.77; 95% confidence interval, 2.2–14.1; P = 0.04) and baPWV (odds ratio, 1.71; 95% confidence interval, 1.1–2.8; P = 0.03) were independent predictors of ovulation induction by CC in PCOS patients. The predictive values of waist-to-hip ratio and baPWV for the CC resistance in PCOS patients were determined by the receiver operating characteristic curves. The area under the curves for waist-to-hip ratio and baPWV were 0.76 and 0.77, respectively. Setting the threshold at 0.83 for waist-to-hip ratio offered the best compromise between specificity (0.65) and sensitivity (0.84), while the setting the threshold at 1,182 cm/s for baPWV offered the best compromise between specificity (0.80) and sensitivity (0.71).

Conclusions

Both metabolic and cardiovascular parameters were predictive for CC resistance in PCOS patients. The measurement of baPWV may be a useful tool to predict ovulation in PCOS patients who receive CC.

Zinc and homocysteine levels in polycystic ovarian syndrome patients with insulin resistance

In this study, our objective was to evaluating the value of serum zinc levels as an etiologic and prognostic marker in patients with polycystic ovarian syndrome. We conducted a prospective study, including 53 women with polycystic ovarian syndrome and 33 healthy controls. We compared serum zinc levels, as well as clinical and metabolic features, of the cases. We also compared serum zinc levels between patients with polycystic ovarian syndrome with insulin resistance. Mean zinc levels were found to be significantly lower in patients with polycystic ovarian syndrome than healthy controls. Multiple logistic regression analysis of significant metabolic variables between polycystic ovarian syndrome and control groups (serum zinc level, body mass index, the ratio of triglyceride/high-density lipoprotein cholesterol, and homocysteine) revealed that zinc level was the most significant variable to predict polycystic ovarian syndrome. Mean serum zinc levels tended to be lower in patients with polycystic ovarian syndrome with impaired glucose tolerance than patients with normal glucose tolerance, but the difference was not statistically significant. In conclusion, zinc deficiency may play a role in the pathogenesis of polycystic ovarian syndrome and may be related with its long-term metabolic complications.

Arterial stiffness is increased in asymptomatic nondiabetic postmenopausal women with a polycystic ovary syndrome phenotype

OBJECTIVE

The metabolic dysfunction accompanying the polycystic ovary syndrome (PCOS) may increase the risk of hypertension and cardiovascular disease (CVD). Although menopause per se may be an additional risk factor of CVD, the association between PCOS in postmenopausal women and cardiovascular risk has not been adequately investigated. We aimed to evaluate the effect of PCOS on markers of subclinical atherosclerosis in nondiabetic postmenopausal women.

METHODS

This cross-sectional study included 286 postmenopausal women with intact ovaries. PCOS phenotype was defined if three of the following were present: insulin resistance, current hyperandrogenism or history of clinical androgen excess, history of infertility, central obesity and history of irregular menses. Traditional CVD risk factors, as well as indices of arterial structure (intima-media thickness, atheromatous plaques presence) and function [flow-mediated dilation, pulse wave velocity (PWV), augmentation index] were compared between women with a PCOS phenotype and the rest of the sample, who served as controls.

RESULTS

Women with the PCOS phenotype (N=43) had higher SBP and triglycerides and lower high-density lipoprotein (HDL)-cholesterol than controls. Mean values of PWV differed significantly between PCOS cases and controls (9.46±1.74 vs. 8.60±1.51 m/s, P=0.001, univariate). Multivariate regression analysis showed that the PCOS phenotype, age and SBP were the only independent predictors of PWV.

CONCLUSION

Arterial stiffness is increased in asymptomatic, nondiabetic women with a putative PCOS phenotype, independently of age, BMI or blood pressure. This might present one mechanism through which PCOS increases the risk of CVD and hypertension later in life.

Physical activity and mental health in women with polycystic ovary syndrome

Background

Physical activity is prescribed as a component of primary management for Polycystic Ovary Syndrome (PCOS). This study investigates the association between physical activity and mental health as well as the exercise barriers, motivators and support providers for younger women with and without PCOS to assist in physical activity uptake and prescription for these women.

Methods

Women aged 18-50 years with (n = 153) and without PCOS (n = 64) completed a questionnaire at one time point. The questionnaire included the Hospital Anxiety and Depression Scale and a survey regarding levels of physical activity, physical activity barriers, motivators and supports. A MANCOVA assessed associations between physical activity, PCOS and mental health (specifically depression and anxiety). Descriptive and Chi square goodness of fit statistics assessed the differences in perceived barriers, motivators and support providers amongst women with and without PCOS.

Results

Women with PCOS displayed higher severity of depression (F(1,210) = 8.32, p = 0.004) and anxiety (F(1,210) = 17.37, p < 0.001) symptoms compared to controls. Overall, for physically active women, depression was significantly less severe than in their inactive counterparts (F(2,210) = 13.62, p < 0.001). There were no differences in anxiety by physical activity status and no interaction effects between PCOS and activity status for depression or anxiety. Women with PCOS were more likely to report a lack of confidence about maintaining physical activity (Χ² = 3.65; p = 0.046), fear of injury (Χ² = 4.08; p = 0.043) and physical limitations (Χ² = 11.92; p = 0.001) as barriers to physical activity and were more likely to be motivated to be active to control a medical condition (Χ² = 7.48; p = 0.006). Women with PCOS identified more sources of support compared to women without PCOS.

Conclusions

Physical activity is associated with lower depression in women with PCOS and differences exist in the self-reported physical activity barriers, motivators and support providers, compared to controls. Being more active may offer mental health benefits in managing PCOS. Prescribing physical activity to women with PCOS should be individualized and consider both common and PCOS-specific barriers and motivators for successful engagement.

Cardiovascular disease risk in young Indian women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is associated with significant risk factors for cardiovascular disease (CVD) like insulin resistance, hyperinsulinism, hypertension and dyslipidemia. We studied CVD risk in young women (18-35 years age) with PCOS using carotid intima media thickness (CIMT) and brachial artery flow mediated dilation (FMD) which are markers of subclinical atherosclerosis. Fifty women with PCOS (age: 24.3 ± 4 years; body mass index [BMI]: 24.6 ± 4 kg/m(2)) were compared with 50 age and BMI matched healthy controls (age: 24.6 ± 5 years; BMI: 23.9 ± 4 kg/m(2)). CIMT was significantly higher (0.55 ± 0.09 mm versus 0.40 ± 0.1 mm, p value <0.0001) and FMD was significantly lower (9.39 ± 4.36% versus 13.89 ± 4.77%, p value <0.0001) in cases as compared to controls. These differences in CIMT and FMD remained significant when subgroup were analyzed, obese PCOS versus obese controls and non obese PCOS versus non-obese controls. In stepwise linear regression PCOS was associated with CIMT and FMD independent of age, BMI and blood pressure. Young women with PCOS irrespective of their BMI have evidence for increased CVD risk as shown by increased CIMT and a lower FMD.

Sex hormone binding globulin, but not testosterone, is associated with the metabolic syndrome in overweight and obese women with polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is associated with hyperandrogenism and an increased risk of Type 2 diabetes and cardiovascular disease. Decreased SHBG and elevated testosterone are associated with metabolic syndrome and glucose intolerance in women.

AIM

The aim of this study was to assess the relationship between SHBG and testosterone and metabolic syndrome and glucose intolerance in PCOS.

MATERIAL/SUBJECTS AND METHODS

Cross-sectional study in overweight and obese premenopausal non-diabetic women with PCOS (no.=178: no.=55 metabolic syndrome, no.=16 glucose intolerance). Data were analyzed by multiple regression with metabolic syndrome, oral glucose tolerance test (OGTT) glucose or SHBG as dependent variables and reproductive hormones, insulin resistance, glucose tolerance, lipids or C-reactive protein as independent variables.

RESULTS

Metabolic syndrome was independently associated with body mass index [odds ratio (OR) 1.084 95% confidence interval (CI) 1.034-1.170, p=0.015] and SHBG (OR 0.961 95% CI 0.932-0.995, p=0.018). Glucose tolerance was independently associated with OGTT insulin (β=0.418, p<0.001), age (β=0.154, p=0.033) and PRL (β=-0.210, p=0.002). SHBG was independently associated with OGTT insulin (β=-0.216, p=0.014) and PCOS diagnostic criteria (β=0.197, p=0.010).

CONCLUSIONS

SHBG, but not testosterone, is independently associated with metabolic syndrome in overweight women with PCOS and is associated with insulin resistance and PCOS diagnostic criteria.

Diagnosis and treatment of polycystic ovary syndrome: an Endocrine Society clinical practice guideline

OBJECTIVE

The aim was to formulate practice guidelines for the diagnosis and treatment of polycystic ovary syndrome (PCOS).

PARTICIPANTS

An Endocrine Society-appointed Task Force of experts, a methodologist, and a medical writer developed the guideline.

EVIDENCE

This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe both the strength of recommendations and the quality of evidence.

CONSENSUS PROCESS

One group meeting, several conference calls, and e-mail communications enabled consensus. Committees and members of The Endocrine Society and the European Society of Endocrinology reviewed and commented on preliminary drafts of these guidelines. Two systematic reviews were conducted to summarize supporting evidence.

CONCLUSIONS

We suggest using the Rotterdam criteria for diagnosing PCOS (presence of two of the following criteria: androgen excess, ovulatory dysfunction, or polycystic ovaries). Establishing a diagnosis of PCOS is problematic in adolescents and menopausal women. Hyperandrogenism is central to the presentation in adolescents, whereas there is no consistent phenotype in postmenopausal women. Evaluation of women with PCOS should exclude alternate androgen-excess disorders and risk factors for endometrial cancer, mood disorders, obstructive sleep apnea, diabetes, and cardiovascular disease. Hormonal contraceptives are the first-line management for menstrual abnormalities and hirsutism/acne in PCOS. Clomiphene is currently the first-line therapy for infertility; metformin is beneficial for metabolic/glycemic abnormalities and for improving menstrual irregularities, but it has limited or no benefit in treating hirsutism, acne, or infertility. Hormonal contraceptives and metformin are the treatment options in adolescents with PCOS. The role of weight loss in improving PCOS status per se is uncertain, but lifestyle intervention is beneficial in overweight/obese patients for other health benefits. Thiazolidinediones have an unfavorable risk-benefit ratio overall, and statins require further study.

[Biological insulin resistance in Congolese woman with polycystic ovary syndrome (PCOS)]

OBJECTIVES

Metabolic features of polycystic ovary syndrome (PCOS) have been poorly investigated in African women where environmental factors are different from those occurring in developed countries. This study aimed to determine the frequency and features of insulin resistance (IR) in Congolese women affected by polycystic ovary syndrome (PCOS).

PATIENTS AND METHODS

This was a case-control study conducted in women received in three hospital institutions in Kinshasa from 2006-2007. Blood samples were taken to measure HDL and LDL cholesterol, triglycerides, fasting insulin and glucose levels, and the homeostatic model (HOMA-IR) was used to assess IR under basal conditions.

RESULTS

Fifty-five Congolese women with PCOS and forty-four normal women (mean age 24 ± 6.8 years) were included in the study. Although body mass index was not statistically different between PCOS and control women, IR evaluated by the HOMA-IR was detected in 39.3% of PCOS women. Fasting insulin level was the most significant determinant of IR in the Congolese women with PCOS (OR 2.134 [1.360-3.348]; P<0.001).

CONCLUSIONS

Nearly one in two women from Congo affected by PCOS is IR and this feature is independent of overweight and central fat distribution. HOMA-IR is the most suitable index than the clinical parameters for detecting IR in these women.

Follistatin and activins in polycystic ovary syndrome: relationship to metabolic and hormonal markers

OBJECTIVE

Polycystic ovary syndrome (PCOS) is common and has reproductive and metabolic manifestations. Activin A and follistatin levels remain controversial and activin B levels are unstudied in PCOS. The aim of this study was to evaluate activin A, activin B and follistatin levels and to examine their associations with metabolic status in overweight and obese women with and without PCOS.

MATERIALS AND METHODS

Cross-sectional study assessing overweight and obese, premenopausal women with PCOS (n=51, n=26 National Institutes of Health (NIH) and n=25 non-NIH) and without PCOS (n=25 controls). Outcomes included activin A, activin B, follistatin and activin A/follistatin ratio and the association of the activins and follistatin with metabolic variables.

RESULTS

Activin A, activin B and activin A/follistatin ratio were not significantly different and follistatin was elevated for PCOS versus controls (P=0.01) independent of age or BMI. Follistatin levels were significantly different across the PCOS phenotypes (p=0.05), however this was a non-significant trend (after correction for age and BMI) for women with NIH PCOS or non-NIH PCOS to have elevated levels in comparison to controls. Activin A was most strongly predicted by low density lipoprotein/high density lipoprotein (r(2)=0.192, p<0.001), follistatin by triglycerides and highly sensitive C-reactive protein (r(2)=0.340, p<0.001) and the activin A/follistatin ratio by insulin area under the curve and mean arterial pressure (r(2)=0.289, p<0.001).

CONCLUSIONS

Follistatin is elevated and activins A and B are not different between PCOS and controls. Follistatin and activin A are related to metabolic parameters in women with and without PCOS. Follistatin may potentially act as a marker of or be involved in the pathophysiology of both reproductive and metabolic features of PCOS.

Prevalence of polycystic ovary syndrome in women in China: a large community-based study

STUDY QUESTION

What is the prevalence of polycystic ovary syndrome (PCOS) in Han Chinese women from different communities?

SUMMARY ANSWER

The prevalence of PCOS in Chinese women aged 19-45 years is 5.6%.

WHAT IS KNOWN ALREADY

The prevalence of PCOS is reported to range from 5 to 10% but to the best of our knowledge the Han Chinese population has not been studied.

STUDY DESIGN, SIZE, DURATION

A large-scale epidemiological study was carried out between October 2007 and September 2011 in 15 924 Han Chinese women of reproductive age (19-45 years) from the 10 provinces and municipalities in China.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 16 886 women from 152 cities and 112 villages were involved in the study. All study participants received a questionnaire and underwent a physical and transvaginal ultrasound examination. Blood samples were collected from a subsample of women (n = 3565) for analysis of metabolic markers and hormones. Based on the Rotterdam PCOS criteria, we assessed hyperandrogenism (H), chronic anovulation (O) and polycystic ovaries (P). Following diagnosis, women with PCOS were assigned to one of four different phenotypes. Finally, the prevalence and related risks of PCOS among Chinese women were estimated based on all the data sources.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 16 886 women were initially involved in the study and 15 924 eligible participants then completed the study; the overall response rate was 94.3% (15 924/16 886). The prevalence of PCOS in the Chinese community population was 5.6% (894/15 924). Blood samples were analyzed from 833 of these women who were assigned to the four PCOS phenotypes as follows: 19% H + O, 37% H + P, 15% O + P and 29% H + O + P. Comparing the 833 women with PCOS to 2732 women without PCOS indicated that PCOS occurs in younger women (P < 0.05) and these women were prone not only to menstrual problems, hyperandrogenism, PCO and infertility but also metabolic syndrome (MS) and insulin resistance (IR). However, there was no significant difference in the rate of hypertension or hyperlipemia between the two groups. Obese patients with PCOS had a higher rate of MS (16 versus 48%), IR (7 versus 28%), hypertension (8 versus 30%) and hyperlipemia (48 versus 73%) compared with non-obese patients (all P < 0.05), respectively. The rates of metabolic complications in patients with PCOS increased with age.

LIMITATIONS, REASONS FOR CAUTION

Age and ethnic origin contribute to the differing manifestations of PCOS; therefore, sampling is one of the most important issues in epidemiological research into PCOS. Owing to the mobility of the Chinese population, the survey among resident populations caused a certain deviation in the age distribution.

WIDER IMPLICATIONS OF THE FINDINGS

The prevention and treatment of PCOS, particularly in those who are obese, are essential in Chinese women of reproductive age.

Antidepressants for polycystic ovary syndrome

BACKGROUND

The prevalence of depression in women with polycystic ovary syndrome (PCOS) is high; one study has shown it to be four times that of women without PCOS. Therefore, systematic evaluation of the effectiveness and safety of antidepressants for women with PCOS is important.

OBJECTIVES

To evaluate the effectiveness and safety of antidepressants in treating depression and other symptoms in women with PCOS.

SEARCH METHODS

We searched the following databases from inception to June 2012: the Cochrane Menstrual Disorders and Subfertility Group Trials Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PsycINFO and Chinese National Knowledge Infrastructure, the metaRegister of Controlled Trials (controlled-trials.com), the National Institute of Health Clinical Trials register (clinicaltrials.gov) and the World Health Organization International Trials Registry Platform search portal (www.who.int/trialsearch/Default.aspx).

SELECTION CRITERIA

Only randomised controlled trials (RCTs) studying the effectiveness and safety of antidepressants for women with PCOS were included in this review.

DATA COLLECTION AND ANALYSIS

The methodological quality of the trials was assessed independently by two review authors, in parallel with data extraction. The risk of bias in the included study was assessed in six domains: 1. sequence generation; 2. allocation concealment; 3. blinding of participants, personnel and outcome assessors; 4. completeness of outcome data; 5. selective outcome reporting; 6. other potential sources of bias.

MAIN RESULTS

We found no studies reporting any of our primary review outcomes (depression and allied mood disorder scores, quality of life and adverse events). Only one study with 16 women was eligible for inclusion. This study compared sibutramine versus fluoxetine in women with PCOS, and reported only endocrine and metabolic outcomes. It was unclear whether the participants had psychological problems at baseline. No significant difference was found between the groups for any of the measured outcomes.

AUTHORS' CONCLUSIONS

There is no evidence on the effectiveness and safety of antidepressants in treating depression and other symptoms in women with PCOS.

Effects of drospirenone-ethinylestradiol and/or metformin on CD4(+)CD28(null) T lymphocytes frequency in women with hyperinsulinemia having polycystic ovary syndrome: a randomized clinical trial

OBJECTIVE

To evaluate the long-term effects of drospirenone (DRSP)/ethinylestradiol (EE) alone, metformin alone, and DRSP/EE-metformin on CD4(+)CD28(null) T lymphocytes frequency, a cardiovascular risk marker, in patients with hyperinsulinemic polycystic ovary syndrome (PCOS).

DESIGN

Randomized clinical trial.

INTERVENTIONS

Ninety three patients with hyperinsulinemic PCOS were age matched and body mass index matched and randomized to receive a 6 months daily treatment with DRSP (3 mg)/EE (0.03 mg), or metformin (1500 mg), or DRSP/EE combined with metformin.

MAIN OUTCOME MEASURES

CD4(+)CD28(null) T-cell frequencies.

RESULTS

The DRSP/EE and metformin groups did not show any significant change in the CD4(+)CD28(null) frequency compared to the baseline. Interestingly, a statistically significant decrease in CD4(+)CD28(null) frequency occurred after 6 months of DRSP/EE-metformin (median 3-1.5; P < .01). Of note, this statistically significant association was confirmed after adjusting for baseline values in DRSP/EE-metformin group by analysis of covariance (P < .05).

CONCLUSIONS

In women with hyperinsulinemic PCOS, combined therapy with DRSP/EE and metformin may reduce cardiovascular risk.

Is insulin resistance an intrinsic defect in asian polycystic ovary syndrome?

PURPOSE

Approximately 50% to 70% of women with polycystic ovary syndrome (PCOS) have some degree of insulin resistance, and obesity is known to worsen insulin resistance. Many metabolic consequences of PCOS are similar to those of obesity; therefore, defining the cause of insulin resistance in women can be difficult. Our objective was to clarify the factors contributing to insulin resistance in PCOS.

MATERIALS AND METHODS

We consecutively recruited 144 women with PCOS [age: 26±5 yr, body mass index, body mass index (BMI): 24.4±4.0 kg/m2] and 145 controls (age: 25±5 yr, BMI: 23.0±3.6 kg/m2), and divided them into overweight/obese (ow/ob, BMI≥23 kg/m2) and lean (BMI<23 kg/m2) groups. Anthropometric measures and a 75-g oral glucose tolerance test were performed, and insulin sensitivity index (ISI) was calculated as an index of insulin sensitivity. Factors predictive of ISI were determined using regression analysis.

RESULTS

ISI was significantly lower in both lean and ow/ob women with PCOS compared to BMI-matched controls (p<0.05). Increasing BMI by 1 kg/m2 decreased ISI by 0.169 in PCOS patients (p<0.05) and by 0.238 in controls (p<0.05); there was no significant difference between these groups. In lean PCOS patients and lean controls, BMI had no effect on ISI. Multiple regression analysis revealed that PCOS status (β=-0.423, p<0.001) and BMI (β=-0.375, p<0.001) were significantly associated with ISI.

CONCLUSION

Insulin resistance is an intrinsic defect of PCOS, and a high BMI could exacerbate insulin resistance in all women, irrespective of whether they have PCOS.

Polycystic ovary syndrome and obesity do not affect vascular parameters related to early atherosclerosis in young women without glucose metabolism disturbances, arterial hypertension and severe abnormalities of lipid profile

The aim of this study was to evaluate the influence of polycystic ovary syndrome (PCOS) and obesity on vascular parameters related to early atherosclerosis (VP-EA) [brachial flow-mediated dilation (FMD), carotid intima-media thickness (CIMT) and carotid arterial compliance (CAC)] in women with minor cardiovascular risk factors (CVRFs). Twenty-five young women with PCOS and 23 eumenorrheic women matched for body mass index (BMI) were studied. The women were subdivided according to BMI and PCOS status, and comparisons were done between PCOS and Control group, regardless of BMI, and between Obese and Lean group, regardless of the presence of PCOS. Insulin resistance was higher in PCOS-group than in control-group and in obese-group than in lean-group. The median of all VP-EA evaluated were similar between PCOS-group and Control-group [FMD: 6.6 versus 8.4% (p = NS); CIMT: 48.0 versus 47.0 mm.10-2 (p = NS); CAC: 6.2 versus 5.6N-1.m4.10-10 (p = NS)] and between obese-group and lean-group [FMD: 7.8 versus 6.6% (p = NS); CIMT: 48.0 versus 47.0 mm.10-2 (p = NS); CAC: 5.7 versus 6.3N-1.m4.10-10 (p = NS)]. These results suggest that PCOS and obesity do not affect VP-EA in women with minor CVRFs.

Endothelial function measured using flow-mediated dilation in polycystic ovary syndrome: a meta-analysis of the observational studies

OBJECTIVE

Women with polycystic ovary syndrome (PCOS) demonstrate an increased prevalence of cardiovascular disease (CVD) risk factors. Previous researchers have compared flow-mediated dilation (FMD), an early marker of CVD, in women with and without PCOS. Evidence for a PCOS-mediated reduction in FMD remains equivocal, potentially because of study differences in cohort-matching and measurement approaches. The aims of this systematic review and meta-analysis were to examine to what extent FMD is impaired in PCOS and to explore the influence of potential moderators of FMD reduction, such as age and BMI.

DESIGN

A systematic review and meta-analysis of published observational studies comparing FMD in PCOS with control women.

PATIENTS

Twenty-one published studies were included (PCOS, n = 908; controls, n = 566). A subanalysis, using tighter inclusion criteria, involved seven studies (PCOS, n = 402; control, n = 251).

MEASUREMENTS

Mean differences in FMD between PCOS and controls were synthesized. The subanalysis was delimited to the inclusion of age and BMI-matched controls. These factors were then explored as moderators using meta-regression.

RESULTS

The pooled mean FMD was 3.4% (95% CI=1.9, 4.9) lower in PCOS compared with control women, with substantial heterogeneity between studies. In the subanalysis, the PCOS-mediated reduction in FMD was 4.1% (95% CI=2.7, 5.5). Heterogeneity remained substantial (I(2) =81%). Subsequent meta-regression indicated that the magnitude of FMD difference was not influenced by BMI (P = 0.17) nor age (P = 0.38).

CONCLUSIONS

This systematic research synthesis indicates that endothelial function is compromised in PCOS women, even if they are young and nonobese.

The effect of obesity on polycystic ovary syndrome: a systematic review and meta-analysis

While many women with polycystic ovary syndrome (PCOS) are overweight, obese or centrally obese, the effect of excess weight on the outcomes of PCOS is inconsistent. The review aimed to assess the effects of overweight, obesity and central obesity on the reproductive, metabolic and psychological features of PCOS. MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL) and PSYCINFO were searched for studies reporting outcomes according to body mass index categories or body fat distribution. Data were presented as mean difference or risk ratio (95% confidence interval). This review included 30 eligible studies. Overweight or obese women with PCOS had decreased sex hormone-binding globulin (SHBG), increased total testosterone, free androgen index, hirsutism, fasting glucose, fasting insulin, homeostatic model assessment-insulin resistance index and worsened lipid profile. Obesity significantly worsened all metabolic and reproductive outcomes measured except for hirsutism when compared to normal weight women with PCOS. Overweight women had no differences in total testosterone, hirsutism, total-cholesterol and low-density lipoprotein-cholesterol compared to normal weight women and no differences in SHBG and total testosterone compared to obese women. Central obesity was associated with higher fasting insulin levels. These results suggest that prevention and treatment of obesity is important for the management of PCOS.

Women with polycystic ovary syndrome have intrinsic insulin resistance on euglycaemic-hyperinsulaemic clamp

STUDY QUESTION

What is the prevalence of insulin resistance (IR) and the contributions of intrinsic and extrinsic IR in women diagnosed with polycystic ovary syndrome (PCOS) according to the Rotterdam criteria?

SUMMARY ANSWER

We report novel clamp data in Rotterdam diagnosed PCOS women, using World Health Organization criteria for IR showing that women with PCOS have a high prevalence of IR, strengthening the evidence for an aetiological role of IR in both National Institutes of Health (NIH) and Rotterdam diagnosed PCOS in lean and overweight women.

WHAT IS KNOWN ALREADY

PCOS is a complex endocrine condition with a significant increased risk of gestational diabetes and type 2 diabetes.

STUDY DESIGN, SIZE, DURATION

Using a cross-sectional study design, 20 overweight and 20 lean PCOS (Rotterdam criteria), 14 overweight and 19 lean body mass index (BMI)-matched control non-PCOS women underwent clinical measures of IR after a 3-month withdrawal of insulin sensitizers and the oral contraceptive pill.

MATERIALS, SETTING, METHODS

In an academic clinic setting, glucose infusion rate (GIR) on euglycaemic-hyperinsulinaemic clamp was investigated as a marker of insulin sensitivity.

MAIN RESULTS AND THE ROLE OF CHANCE

PCOS women were more IR than BMI-matched controls (main effect for BMI and PCOS; P < 0.001). IR was present in 75% of lean PCOS, 62% of overweight controls and 95% of overweight PCOS. Lean controls (mean ± SD; GIR 339 ± 76 mg min⁻¹ m⁻²) were less IR than lean PCOS (270 ± 66 mg min⁻¹ m⁻²), overweight controls (264 ± 66 mg min⁻¹ m⁻²) and overweight PCOS (175 ± 96 mg min⁻¹ m⁻²). The negative relationship between BMI and IR reflected by GIR was more marked in PCOS (y = 445.1 - 7.7x, R² = 0.42 (P < 0.0001) than controls (y = 435.5 - 4.6x, R² = 0.04 (P < 0.01)).

LIMITATIONS, REASONS FOR CAUTION

The study did not use glucose tracer techniques to completely characterize the IR, as well as the lack of matching for body composition and age.

WIDER IMPLICATIONS OF THE FINDINGS

IR is exacerbated by increased BMI, supporting intrinsic IR in PCOS. BMI impact on IR is greater in PCOS, than in controls, irrespective of visceral fat, prioritizing lifestyle intervention and the need for effective therapeutic interventions to address intrinsic IR and prevent diabetes in this high-risk population.

STUDY FUNDING/COMPETING INTEREST(S)

This investigator-initiated trial was supported by grants from the National Health & Medical Research Council (NHMRC) Grant number 606553 (H.J.T., N.K.S. and S.K.H.) as well as Monash University and The Jean Hailes Foundation. H.J.T. is an NHMRC Research Fellow. N.K.S. is supported through the Australian Government's Collaborative Research Networks (CRN) programme. A.E.J. is a Jean Hailes and NHMRC scholarship holder. The authors declare that there is no conflict of interest associated with this manuscript.

Risk of venous thromboembolism in women with polycystic ovary syndrome: a population-based matched cohort analysis

BACKGROUND

There is an increased risk of venous thromboembolism among women taking oral contraceptives. However, whether there is an additional risk among women with polycystic ovary syndrome (PCOS) is unknown.

METHODS

We developed a population-based cohort from the IMS LifeLink Health Plan Claims Database, which includes managed care organizations in the United States. Women aged 18-46 years taking combined oral contraceptives and who had a claim for PCOS (n = 43 506) were matched, based on a propensity score, to control women (n = 43 506) taking oral contraceptives. Venous thromboembolism was defined using administrative coding and use of anticoagulation. We used Cox proportional hazards models to assess the relative risk (RR) of venous thromboembolism among users of combined oral contraceptives with and without PCOS.

RESULTS

The incidence of venous thromboembolism among women with PCOS was 23.7/10 000 person-years, while that for matched controls was 10.9/10 000 person-years. Women with PCOS taking combined oral contraceptives had an RR for venous thromboembolism of 2.14 (95% confidence interval [CI] 1.41-3.24) compared with other contraceptive users. The incidence of venous thromboembolism was 6.3/10 000 person-years among women with PCOS not taking oral contraceptives; the incidence was 4.1/10 000 person-years among matched controls. The RR of venous thromboembolism among women with PCOS not taking oral contraceptives was 1.55 (95% CI 1.10-2.19).

INTERPRETATION

We found a 2-fold increased risk of venous thromboembolism among women with PCOS who were taking combined oral contraceptives and a 1.5-fold increased risk among women with PCOS not taking oral contraceptives. Physicians should consider the increased risk of venous thromboembolism when prescribing contraceptive therapy to women with PCOS.

Study of early atherosclerotic markers in women with polycystic ovary syndrome

OBJECTIVE

Women with polycystic ovary syndrome (PCOS) may represent a large underappreciated segment of female population who is at increased cardiovascular risk because of the presence of cluster of metabolic abnormalities. The aim of our study was to assess atherosclerotic risk factors in women with PCOS.

MATERIALS AND METHODS

In a cross-sectional study, 50 women with PCOS and 50 age and weight-matched healthy controls were enrolled. Endothelial dysfunction by flow-mediated dilatation (FMD) of brachial artery, highly sensitive C-reactive protein (hs CRP), and carotid intima media thickness (CIMT) were measured in both cases and control groups.

RESULTS

The mean age of women with PCOS was 26.82 ± 3.26 years and Body-mass index (BMI) of 26.2 ± 4.8 kg/ m(2). Thirty-six (72%) patients were overweight or obese,54% had central obesity and 12% had impaired glucose tolerance. Among the markers of atherosclerosis, hsCRP levels were nonsignificantly higher in patients with PCOS than in controls. The FMD was 12.18 ± 2.3% vs 8.3 ± 2.23% in patients with PCOS and controls respectively (P=0.01). CIMT was significantly different in two study groups (0.68 ± 0.11 in PCOS vs 0.52 ± 0.02 in normal subjects, (P=0.01). FMD had significant negative correlation with homeostasis model assessment (HOMA) index (r = -0.32, P=0.02) and hs CRP (r = -0.37, P=0.04) while hs CRP was correlated with BMI (r = 0.54, P=0.005), HOMA (r = 0.38, P=0.02) and FMD (r = -0.33, P=0.01). CIMT was significantly different in women with PCOS and control subjects, and it had significant correlation with age (r = 0.42, P=0.03), BMI (r = 0.36, P=0.01), waist circumference (r = 0.52, P=0.001) and HOMA (r = 0.31, P=0.04).

CONCLUSION

Women with PCOS definitely have increased risk for future cardiovascular events. Clinicians should consider early cardiovascular screening and interventions to control all modifiable cardiovascular risk factors.

Evaluation of adverse outcome in young women with polycystic ovary syndrome versus matched, reference controls: a retrospective, observational study

CONTEXT

Polycystic ovary syndrome (PCOS) is associated with insulin resistance, hyperandrogenism, and dyslipidemia, but the effects of these disturbances on long-term health are not fully understood.

AIM

Our aim was to determine the relative risk of type 2 diabetes, cancer, large-vessel disease (LVD), and all-cause mortality for women diagnosed with PCOS.

DESIGN

Data were extracted from the General Practice Research Database, a longitudinal, anonymized research database derived from nearly 600 primary-care practices in the United Kingdom. Patients with a diagnosis of PCOS between 1990 and 2010 were selected. Patients were matched to two sets of controls. The first set was matched according to primary-care practice and age, and the second was also matched on body mass index. Primary outcome was first incident record of diabetes. Crude rates for diabetes were presented, and time to diabetes was analyzed using Cox proportional hazard models. Secondary outcomes (cancer, LVD, and mortality) were also modeled.

RESULTS

Of 53,303 identified with a diagnosis of PCOS, 21,740 (40.8%) met the eligibility criteria. Median follow-up was 4.7 yr (interquartile range = 2.0-8.6 yr) in those with PCOS and 5.8 yr (2.7-9.6) in the reference group. Crude rates of diabetes were 5.7 and 1.7 per 1000 patient-years for cases and controls, respectively. The corresponding adjusted hazard ratio was 3.015 (95% confidence interval = 2.733-3.327). Of cases matched by body mass index, crude rates of diabetes were 4.7 and 2.4 per 1000 patient-years, respectively. The corresponding adjusted hazard ratio was 1.752 (1.514-2.028). No significant difference in BMI-adjusted risk was evident for cancer, LVD, or all-cause mortality.

CONCLUSIONS

During this follow-up period, women with PCOS were not at increased risk of LVD, cancer, or death, but they had increased risk of type 2 diabetes.

Overweight, obesity and central obesity in women with polycystic ovary syndrome: a systematic review and meta-analysis

BACKGROUND Polycystic ovary syndrome (PCOS) is closely associated with obesity but the prevalence of obesity varies between published studies. The objective of this research was to describe the prevalence of overweight, obesity and central obesity in women with and without PCOS and to assess the confounding effect of ethnicity, geographic regions and the diagnostic criteria of PCOS on the prevalence. METHODS MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL) and PSYCINFO were searched for studies reporting the prevalence of overweight, obesity or central obesity in women with and without PCOS. Data were presented as prevalence (%) and risk ratio (RR) [95% confidence interval (CI)]. Random-effect models were used to calculate pooled RR. RESULTS This systematic review included 106 studies while the meta-analysis included 35 studies (15129 women). Women with PCOS had increased prevalence of overweight [RR (95% CI): 1.95 (1.52, 2.50)], obesity [2.77 (1.88, 4.10)] and central obesity [1.73 (1.31, 2.30)] compared with women without PCOS. The Caucasian women with PCOS had a greater increase in obesity prevalence than the Asian women with PCOS compared with women without PCOS [10.79 (5.36, 21.70) versus 2.31 (1.33, 4.00), P < 0.001 between subgroups). CONCLUSIONS Women with PCOS had a greater risk of overweight, obesity and central obesity. Although our findings support a positive association between obesity and PCOS, our conclusions are limited by the significant heterogeneity between studies and further studies are now required to determine the source of this heterogeneity. Clinical management of PCOS should include the prevention and management of overweight and obesity.

Ethinylestradiol30μg-drospirenone and metformin: could this combination improve endothelial dysfunction in polycystic ovary syndrome?

BACKGROUND

We are hereby investigating for the first time the effect of the association ethinylestradiol30μg-drospirenone 3mg (DRP/EE30μg) plus metformin and weight loss on endothelial status and C-reactive protein (hsCRP) levels in polycystic ovary syndrome (PCOS).

METHODS

25 young women with PCOS (mean age 22.76 ± 0.83 years, body mass index (BMI): 28.44 ± 6.23) who completed the study were prospectively evaluated. The oral contraceptive- DRP/EE30μg (21 days/month) and metformin (1700 mg daily) were administered for 6 months to the PCOS group. Additionally, the 15 overweight and obese patients (BMI > 25 kg/m2) were instructed in a diet of no more than 1500 cal daily. Primary outcome measures were surrogate markers of cardiovascular disease and included endothelial function, i.e. flow-mediated dilatation (FMD) on the brachial artery and endothelin-1 levels, as well as hsCRP concentrations, body composition (measured by whole-body dual-energy X-ray-absorptiometry) and insulin resistance. Variables were assessed at baseline, as well as after our medical intervention.

RESULTS

The combination between DRP/EE30μg plus metformin combined with weight loss triggered a significant improvement in the FMD values (FMD-PCOSbasal 3.48 ± 1.00 vs FMD-PCOS6 months7.43 ± 1.04, p = 0.033), as well as body composition and insulin insensitivity (p < 0.05). Regarding hsCRP levels, there was no significant intragroup (PCOS6months - PCOSbasal) difference.

CONCLUSION

A 6-month course of metformin- DRP/EE30μg (associated with weight loss) improves the endothelial dysfunction in PCOS and shows neutral effects on hsCRP concentrations as an inflammation marker. These data demand for reevaluation of the medical therapy in PCOS, particularly in women with additional metabolic and cardiovascular risk factors (ClinicalTrials.gov Identifier: NCT01459445).

The effect of diet and exercise on markers of endothelial function in overweight and obese women with polycystic ovary syndrome

BACKGROUND

Women with polycystic ovary syndrome (PCOS) present with vascular abnormalities, including elevated markers of endothelial dysfunction. There is limited evidence for the effect of lifestyle modification and weight loss on these markers. The aim of this study was to determine if 20 weeks of a high-protein energy-restricted diet with or without exercise in women with PCOS could improve endothelial function.

METHODS

This is a secondary analysis of a subset of 50 overweight/obese women with PCOS (age: 30.3 ± 6.3 years; BMI: 36.5 ± 5.7 kg/m(2)) from a previous study. Participants were randomly assigned by computer generation to one of three 20-week interventions: diet only (DO; n = 14, ≈ 6000 kJ/day), diet and aerobic exercise (DA; n = 16, ≈ 6000 kJ/day and five walking sessions/week) and diet and combined aerobic-resistance exercise (DC; n = 20, ≈ 6000 kJ/day, three walking and two strength sessions/week). At Weeks 0 and 20, weight, markers of endothelial function [vascular cell adhesion molecule-1 (sVCAM-1), inter-cellular adhesion molecule-1 (sICAM-1), plasminogen activator inhibitor-1 (PAI-1) and asymmetric dimethylarginine (ADMA)], insulin resistance and hormonal profile were assessed.

RESULTS

All three treatments resulted in significant weight loss (DO 7.9 ± 1.2%, DA 11.0 ± 1.6%, DC 8.8 ± 1.1; P < 0.001 for time; P = 0.6 time × treatment). sVCAM-1, sICAM-1 and PAI-1 levels decreased with weight loss (P≤ 0.01), with no differences between treatments (P ≥ 0.4). ADMA levels did not change significantly (P = 0.06). Testosterone, sex hormone-binding globulin and the free androgen index (FAI) and insulin resistance also improved (P < 0.001) with no differences between treatments (P ≥ 0.2). Reductions in sVCAM-1 were correlated to reductions in testosterone (r = 0.32, P = 0.03) and FAI (r = 0.33, P = 0.02) as well as weight loss (r= 0.44, P = 0.002). Weight loss was also associated with reductions in sICAM-1 (r= 0.37, P = 0.008).

CONCLUSIONS

Exercise training provided no additional benefit to following a high-protein, hypocaloric diet on markers of endothelial function in overweight/obese women with PCOS.

Effect of exercise training on insulin sensitivity, mitochondria and computed tomography muscle attenuation in overweight women with and without polycystic ovary syndrome

AIMS/HYPOTHESIS

Polycystic ovary syndrome (PCOS) is an insulin resistant (IR) state. Increased skeletal muscle lipid content and impaired mitochondrial biogenesis have been implicated in the pathogenesis of IR. We investigated whether differences in these variables explain the IR of women affected by PCOS and whether improvements in IR with exercise are reflected by changes in these variables.

METHODS

Sixteen PCOS and 13 non-PCOS overweight women were assessed, and eight PCOS and seven non-PCOS women were reassessed after 12 weeks of moderate and vigorous exercise training. Outcomes included insulin sensitivity (glucose infusion rate [GIR]), skeletal muscle gene expression and protein abundance, enzyme activity of selected mitochondrial components, and computed tomography (CT) attenuation-estimated muscle lipid.

RESULTS

GIR was lower in women with PCOS versus those without (p = 0.01) and increased with exercise in both groups. Baseline CT muscle attenuation suggested a trend to less muscle lipid in PCOS, which increased with exercise training, with a difference in the change in muscle lipid (p = 0.01, age-corrected), compared with non-PCOS women. GIR correlated with PGC1A gene expression across the whole group; skeletal muscle expression of mitochondrial biogenesis markers was not different between groups at baseline, or after training. Neither lipid changes nor mitochondrial changes correlated with changes in GIR.

CONCLUSIONS/INTERPRETATION

Differences in IR in women with and without PCOS were not explained by differences in skeletal muscle lipid or mitochondrial parameters. Improvements in IR with exercise were dissociated from mitochondrial parameters. CT muscle attenuation suggested a differential capacity of PCOS muscle to store lipid compared with non-PCOS.

TRIAL REGISTRATION

Clinicaltrials.gov ISRCTN84763265.

FUNDING

National Health & Medical Research Council (Grant number 606553), Monash University and The Jean Hailes Foundation.

Ultrasonographic and laboratory markers of metabolic and cardiovascular disease risk in obese women with polycystic ovary syndrome

OBJECTIVE

To evaluate whether the presence of polycystic ovary syndrome (PCOS) alters multiple ultrasonographic and laboratory markers of metabolic and cardiovascular disease risk in obese women without any other health condition that could interfere with combined oral contraceptive (COC) eligibility criteria.

METHODS

This was a case-control study evaluating 90 obese women (body mass index (BMI) ≥ 30.0 kg/m(2) and < 40 kg/m(2)) aged between 18 and 40 years without any other health condition that could interfere with COC eligibility criteria, of whom 45 had PCOS and 45 were age-matched controls. BMI, waist and hip circumference, arterial blood pressure, fasting insulin and glucose, quantitative insulin sensitivity check index (QUICKI), high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, total cholesterol, triglycerides, testosterone, sex hormone-binding globulin, free androgen index (FAI), carotid stiffness index, intima media thickness, flow-mediated dilatation (FMD) of the brachial artery and non-alcoholic fatty liver disease (NAFLD) were assessed.

RESULTS

In women with PCOS, we observed a higher frequency of NAFLD (73.3 vs. 46.7%, P < 0.01) and higher FAI (10.4 vs. 6.8%, P < 0.01). We also observed a trend towards increased insulin levels (10.06 ± 6.66 vs. 7.45 ± 5.88 µIU/mL, P = 0.05), decreased QUICKI (0.36 ± 0.06 vs. 0.39 ± 0.07, P = 0.05) and decreased FMD (7.00 ± 3.87 vs. 8.41 ± 3.79%, P = 0.08). No other significant difference was observed.

CONCLUSIONS

NAFLD is frequent in obese women without any other health condition that could interfere with COC eligibility criteria, especially in those with PCOS. This should be considered when choosing the best contraceptive option.

The impact of intensified exercise training on insulin resistance and fitness in overweight and obese women with and without polycystic ovary syndrome

OBJECTIVE

  To evaluate mechanisms of insulin resistance (IR) in overweight and obese women with and without polycystic ovary syndrome (PCOS) and explore relationships between IR, fitness and body mass index (BMI) at baseline and following exercise intervention.

DESIGN

  Prospective controlled intensified exercise intervention study.

PATIENTS

  A total of 20 overweight (BMI > 25 kg/m(2) ) and obese (>30 kg/m(2) ), reproductive-aged PCOS women and 13 non-PCOS overweight, healthy controls of comparable BMI and age were studied at baseline. Measures were repeated in 13 PCOS and eight control women following three 1-h exercise sessions per week over 12 weeks.

MEASUREMENTS

  Insulin resistance was measured by glucose infusion rate on euglycaemic hyperinsulinaemic clamp, and fitness was assessed by VO(2max) .

RESULTS

  At baseline, PCOS women were 46% more insulin resistant than controls (175·6 vs 257·2 mg/m(2) /min, P < 0·05) with IR independently associated with VO(2max) and BMI in the PCOS group only (P < 0·01). Postexercise IR improved across both groups (P < 0·01). In PCOS women, IR improved by 16% (P < 0·05) but was not restored to the same level as controls (P < 0·05). Improvement in IR and in VO(2max) was related to the PCOS group (r(2)  = 0·85, P < 0·05), yet change in IR and in fitness was not related. No associations were found in controls.

CONCLUSIONS

  While intensified exercise improves IR in PCOS women, a higher IR persisted following exercise in PCOS women, and a clear relationship between improved IR and improved fitness was not found. Therefore, other mechanisms of, and therapies for, IR must be explored in PCOS as IR remains higher than observed in non-PCOS controls.

Cardiovascular Risk in Women With PCOS

Polycystic ovary syndrome (PCOS), or Stein-Leventhal syndrome, is a common endocrine disorder defined by two of the three following features: i) oligoovulation or anovulation, ii) clinical and/or biochemical signs of hyperandrogenism, or iii) polycystic ovaries, once the related endocrinological and gynaecological disorders have been excluded. PCOS does not exclusively involve the reproductive apparatus , it has a complex number of systemic relevancy symptoms. It leads to Metabolic Syndrome, with severe consequences on the cardiovascular apparatus. Many clinical studies have underlined the connection between PCOS and the cardiovascular risk profile of such female patients, due to a lipid/glucose altered metabolism, hypertension, systemic inflammatory condition (assessable by markers such as VES, TNF-alfa, citokines and C-reactive protein (hsPCR) levels), and vascular injuries. Considering the early onset of the disease, PCOS could be considered as a real cardiovascular risk factor which affects the quality of life seriously. The current review aimed to point out the main connections between PCOS and cardiovascular risk factors according to the latest findings coming from literature data analysis, and try to depict the great influences that such a common disease can have on the patients' health integrity.

Arteriolar insulin resistance in a rat model of polycystic ovary syndrome

OBJECTIVE

To investigate the vascular dysfunction caused by insulin resistance in polycystic ovary syndrome (PCOS) and the effectiveness of vitamin D in an animal model.

DESIGN

Controlled experimental animal study.

SETTING

Animal laboratory at a university research institute.

ANIMAL(S)

Thirty female Wistar rats.

INTERVENTION(S)

Rats were divided into groups at age 21-28 weeks. Twenty of them were subjected to dihydrotestosterone (DHT) treatment (83 μg/d); ten of them also received parallel vitamin D treatment (120 ng/100 g/wk). Oral glucose tolerance tests with insulin level measurements were performed. Gracilis arterioles were tested for their contractility as well as their nitric oxide (NO)-dependent and insulin-induced dilation using pressure arteriography.

MAIN OUTCOME MEASURE(S)

Several physiologic parameters, glucose metabolism, and pressure arteriography.

RESULT(S)

DHT treatment increased the passive diameter of resistance arterioles, lowered norepinephrine-induced contraction (30.1 ± 4.7% vs. 8.7 ± 3.6%) and reduced acetylcholine-induced (122.0 ± 2.9% vs. 48.0 ± 1.4%) and insulin-induced (at 30 mU/mL: 21.7 ± 5.3 vs. 9.8 ± 5.6%) dilation. Vitamin D treatment restored insulin relaxation and norepinephrine-induced contractility; in contrast, it failed to alter NO-dependent relaxation.

CONCLUSION(S)

In DHT-treated rats, in addition to metabolically proven insulin resistance, decreased insulin-induced vasorelaxation was observed and was improved by vitamin D treatment without affecting NO-dependent relaxation. The reduction in insulin-induced dilation of arterioles is an important as yet undescribed pathway of vascular damage in PCOS and might explain the clinical effectiveness of vitamin D treatment.

Current perspectives of insulin resistance and polycystic ovary syndrome

AIMS

To review the relationship between insulin resistance and polycystic ovary syndrome.

METHODS

A literature review.

RESULTS

Insulin resistance likely plays a central pathogenic role in polycystic ovary syndrome and may explain the pleiotropic presentation and involvement of multiple organ systems. Insulin resistance in the skeletal muscle of women with polycystic ovary syndrome involves both intrinsic and acquired defects in insulin signalling. The cellular insulin resistance in polycystic ovary syndrome has been further shown to involve a novel post-binding defect in insulin signal transduction. Treatment of insulin resistance through lifestyle therapy or with a diabetes drug has become mainstream therapy in women with polycystic ovary syndrome. However, effects with current pharmacologic treatment with metformin tend to be modest, with limited benefit as an agent to treat infertility. Insulin resistance contributes to increased risk for pregnancy complications, diabetes and cardiovascular disease risk profile in polycystic ovary syndrome, which is further exacerbated by obesity. While numerous studies demonstrate increased prevalence of cardiovascular disease risk factors in women with polycystic ovary syndrome, there are limited data showing that women with polycystic ovary syndrome are at increased risk for cardiovascular disease events.

CONCLUSIONS

Insulin resistance is linked to polycystic ovary syndrome. Further study of lifestyle and pharmacologic interventions that reduce insulin resistance, such as metformin, are needed to demonstrate that they are effective in reducing the risk of diabetes, endometrial abnormalities and cardiovascular disease events in women with polycystic ovary syndrome.

Evaluation of early atherosclerotic findings in women with polycystic ovary syndrome

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BACKGROUND

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in women of childbearing age, and it seems better to consider it as an ovarian manifestation of metabolic syndrome. The aim of the current study was to evaluate early atherosclerotic findings in patients with PCOS.

METHODS

We enrolled 46 women with PCOS and 45 normal control subjects who were referred to our hospital's endocrinology outpatient clinic. Carotid intima media thickness (CIMT) and flow-mediated dilatation (FMD) were performed in both cases and matched controls.

RESULTS

Patients with PCOS showed an increased mean CIMT (0.63 ± 0.16 mm) when compared with the control subjects (0.33 ± 0.06 mm). This difference was statistically significant (p = 0.001). The mean FMD in young patients with PCOS was 10.07 ± 1.2%, while it was 6.5 ± 2.06% in normal subjects. This difference was also statistically significant (p = 0.001).

CONCLUSION

Our findings suggest that PCOS is related with early atherosclerotic findings.

Systemic inflammation, cellular influx and up-regulation of ovarian VCAM-1 expression in a mouse model of polycystic ovary syndrome (PCOS)

PCOS, a major cause of anovulatory sterility, is associated with obesity, insulin resistance and chronic inflammation. New evidence suggests that the immune system aggravates the clinical features of PCOS. Our aim was to study the immune, metabolic and endocrine features of a mouse model of PCOS elicited by androgenisation using dehydroepiandrosterone (DHEA). We observed a significant weight gain and insulin resistance in DHEA-androgenised mice, coupled with the formation of ovarian follicular cysts. DHEA up-regulated the expression of vascular cell adhesion molecule (VCAM)-1 and intercellular adhesion molecule (ICAM)-1 in the granulosa cell layer of the majority of cysts, and VCAM-1 expression in the theca cell layer of all follicles and cysts. The expression of these markers was low in control tissue. Peritoneal cells from PCOS-mice showed enhanced production of inflammatory cytokines, suggesting an association between chronic inflammation and PCOS. In addition, DHEA-androgenisation induced the activation of CD4(+) cells both in vivo and in vitro, and their expression of the respective ligands for VCAM-1 and ICAM-1, VLA-4 and LFA-1, as assessed in vitro. CD4(+) cells were present in androgenised ovaries, especially in the granulosa cell layer of cysts with high VCAM-1 expression. Herein, we present novel evidence that the immune system is activated systemically and locally in a mouse model for PCOS. We propose that VCAM-1 is involved in aggravating PCOS symptoms by promoting leukocyte recruitment to the ovaries and perpetuating local inflammation. These findings offer novel therapeutic opportunities for PCOS, such as blockage of VCAM-1 expression.

Lifestyle changes in women with polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) affects 4% to 18% of reproductive-aged women and is associated with reproductive, metabolic and psychological dysfunction. Obesity worsens the presentation of PCOS and weight management (weight loss, maintenance or prevention of excess weight gain) is proposed as an initial treatment strategy, best achieved through lifestyle changes incorporating diet, exercise and behavioural interventions.

OBJECTIVES

To assess the effectiveness of lifestyle treatment in improving reproductive, anthropometric (weight and body composition), metabolic and quality of life factors in PCOS.

SEARCH STRATEGY

Electronic databases (Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, PsycINFO, CINAHL, AMED) (date of last search 7/9/2010), controlled trials register, conference abstracts, relevant journals, reference lists of relevant papers and reviews and grey literature databases, with no language restrictions applied.

SELECTION CRITERIA

Randomised controlled trials comparing lifestyle treatment (diet, exercise, behavioural or combined treatments) to minimal or no treatment in women with PCOS.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials, assessed methodological quality and risk of bias and extracted data.

MAIN RESULTS

Six studies were included with n=164 participants. Three studies compared physical activity to minimal dietary and behavioural advice or no advice. Three studies compared combined dietary, exercise and behavioural interventions to minimal intervention. Risk of bias varied with 4/6 having adequate sequence generation and clinician or outcome assessor blinding and 3/6 having adequate allocation concealment, complete outcome data and being free of selective reporting.  There were no studies assessing the fertility primary outcomes of pregnancy, live birth and miscarriage and no data for meta-analysis on ovulation or menstrual regularity. Lifestyle intervention provided benefits when compared to minimal treatment for secondary reproductive, anthropometric and reproductive outcomes. These included endpoint values for total testosterone (mean difference (MD) -0.27 nmol/L, 95% confidence interval (CI) -0.46 to -0.09, P = 0.004), hirsutism or excess hair growth by the Ferriman-Gallwey score (MD -1.19, 95% CI -2.35 to -0.03, P = 0.04), weight (MD -3.47 kg, 95% CI -4.94 to -2.00, P < 0.00001), waist circumference (MD -1.95 cm, 95% CI -3.34 to -0.57, P = 0.006) and fasting insulin (MD -2.02 µU/mL, 95% CI -3.28 to -0.77, P = 0.002). There was no evidence of effect of lifestyle for body mass index, free androgen index, sex hormone binding globulin, glucose or cholesterol levels; and no data for quality of life, patient satisfaction or acne.

AUTHORS' CONCLUSIONS

Lifestyle intervention improves body composition, hyperandrogenism (high male hormones and clinical effects) and insulin resistance in women with PCOS. There was no evidence of effect for lifestyle intervention on improving glucose tolerance or lipid profiles and no literature assessing clinical reproductive outcomes, quality of life and treatment satisfaction.

Oxidative stress markers are not valuable markers in lean and early age of polycystic ovary syndrome patients

BACKGROUND

Early atherosclerosis and increased risk of cardiovascular diseases (CVD) have been reported in patients with polycystic ovary syndrome (PCOS). Oxidative stress is an accepted risk factor for the development of CVD.

AIM

To evaluate the association between oxidative stress markers [ischemia-modified albumin (IMA), total antioxidant status (TAS), and total oxidant status (TOS) levels], carotid intima- media thickness (CIMT), endocrine and metabolic parameters in patients with PCOS. MATERIALS, SUBJECTS, AND METHODS: We studied 52 patients with PCOS and 36 age- and body mass index (BMI)-matched controls. The diagnosis of PCOS was made according to the Rotterdam criteria. Metabolic, hormonal parameter and IMA, TAS, TOS levels were measured.

RESULTS

No statistically significant difference was determined in relation to age, BMI and waist-hip ratio, IMA, TAS, and TOS levels between groups. Mean IMA level was higher in PCOS patients, however, statistical significant difference was not observed. Mean CIMT and homeostasis model assessment of insulin resistance levels were significantly higher in patients with PCOS than in control subjects.

CONCLUSION

Our study has shown that although CIMT levels, showing CVD risk, were higher in PCOS patients, TAS and TOS oxidative stress markers were found to be similar between groups, IMA was higher in PCOS patients however the difference was not reach statistical significant. The present results suggest that CIMT increases before the state of ischemia and shows preischemic state of vasculature, while oxidative stress markers are considered to be indicators of ischemia and reperfusion injury in progressive vascular disease. Further studies are needed to show the association between oxidative stress markers, CVD and PCOS.

Ovarian hypertension: polycystic ovary syndrome

Hypertension is a significant contributor to the risk for cardiovascular disease. The increased prevalence of hypertension in women with polycystic ovary syndrome (PCOS) may contribute to the increased risk of cardiovascular disease in these women. Whether hypertension is associated with PCOS independent of obesity remains controversial. Nevertheless, detection and subsequent treatment of hypertension in this population should decrease the adverse sequelae from hypertensive cardiovascular disease. Treatment of risk factors inherent to PCOS, such as hyperandrogenism, insulin resistance, and obesity, may minimize the risk not only for the development of hypertension but also for incident cardiovascular disease independent of hypertension.

Meta-analysis of cardiovascular disease risk markers in women with polycystic ovary syndrome

BACKGROUND

The relation between polycystic ovary syndrome (PCOS) and cardiovascular disease (CVD) remains unclear. In an attempt to provide high-quality evidence on the relation between PCOS and CVD, relevant literature for CVD risk markers [C-reactive protein (CRP), homocysteine (Hcy), tumor necrosis factor-alpha (TNF-α), plasminogen activator inhibitor-1 (PAI-1), lipoprotein (a) [Lp(a)], advanced glycation end-products (AGEs), vascular endothelial growth factor (VEGF), interleukin-6 (IL-6), asymmetric dimethylarginine (ADMA), endothelin-1 (ET-1) and fibrinogen] in women with PCOS was reviewed and analyzed.

METHODS

A systematic search was conducted electronically using specific eligibility criteria. Weighted mean differences (WMDs) and 95% confidence intervals (CIs) were calculated and combined appropriately. To ensure synthesis of the best available evidence, sensitivity analyses were performed. RESULTS A total of 130 data sets were included in 11 different outcomes, involving 7174 and 5076 CVD markers in women with PCOS and controls, respectively. Women with PCOS demonstrated significantly elevated CRP [WMD (95% CI) 0.99 (0.77-1.21)], Hcy [2.25 (1.46-3.03)], PAI-1 antigen [16.96 (7.25-26.28)], PAI-1 activity [0.71 (0.18-1.23)], VEGF [1.72 (0.96-2.48)], ADMA [0.19 (0.08-0.3)], AGEs [3.91 (2.36-5.45)] and Lp(a) [0.81 (0.58-1.04)] concentrations compared with controls, yet with significant between-study heterogeneity. Borderline significance (not robust in the sensitivity analyses) was detected for TNF-α [0.75 (0.07-1.44)], ET-1 [1.06 (0.52-1.59)] and fibrinogen [0.20 (0.01-0.39)], whereas no difference was detected for IL-6 [0.71 (-0.16 to 1.59)]. CONCLUSIONS Women with PCOS have increased serum concentrations of CVD risk markers compared with controls. Whether this apparent risk is translated into increased incidence of CVD in later life remains to be elucidated.