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Abstract
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.
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Affiliation(s)
- Hyejin Lee
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Jee-Young Oh
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Yeon-Ah Sung
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Hyewon Chung
- Department of Obstetrics and Gynecology, Ewha Womans University School of Medicine, Seoul, Korea
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202
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Abstract
Polycystic ovary syndrome, the most common endocrine disorder of reproductive age women, is often associated with insulin resistance and associated disorders. The frequency of type 2 diabetes, hyperlipidemia, cardiac risk markers, structural vascular disease, and clinical disease events are increased in this population of women. PCOS, however, represents a broad spectrum of clinical presentations, as defined by different criteria proposed in Europe and the United States. The role of insulin resistance and hence the risk of cardiometabolic disorders may in part be determined by the definition of PCOS used. Epidemiologic studies and clinical trials support the need to identify women with PCOS to determine their risk of cardiometabolic disorders to prevent and/or treat their serious consequences.
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Affiliation(s)
- Rhoda H Cobin
- The Mount Sinai School of Medicine, New York, NY, USA.
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203
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Oliver-Williams CT, Heydon EE, Smith GCS, Wood AM. Miscarriage and future maternal cardiovascular disease: a systematic review and meta-analysis. Heart 2013; 99:1636-44. [PMID: 23539554 PMCID: PMC3812894 DOI: 10.1136/heartjnl-2012-303237] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Context The 2011 American Heart Association guidelines identified pregnancy complications as a risk factor for cardiovascular disease in women. However, miscarriage was not mentioned within the guidelines, and there is no consensus on the association between miscarriage and future risk of cardiovascular disease. Objective To confirm or refute the association, a meta-analysis of published papers was conducted. Data sources PubMed, Web of Knowledge and Scopus were systematically searched to identify appropriate articles. Reference lists were then hand searched for additional relevant titles. Study Selection To be included, articles had to assess the association between miscarriage and subsequent cardiovascular disease in otherwise healthy women. Only women who had miscarriages were considered exposed. Pooled association measures, using random effects meta-analysis, were calculated for coronary heart disease and cerebrovascular disease. Publication bias and between-study heterogeneity were evaluated. Data Extraction Two authors individually reviewed all studies and extracted data on patient and study characteristics along with cardiovascular outcomes. Results 10 studies were identified, with 517 504 individuals included in the coronary heart disease meta-analysis and 134 461 individuals in the cerebrovascular disease analysis. A history of miscarriage was associated with a greater odds of developing coronary heart disease, OR (95% CI) =1.45 (1.18 to 1.78), but not with cerebrovascular disease, OR=1.11 (0.72 to 1.69). There was a strong association between recurrent miscarriage and coronary heart disease OR=1.99 (1.13 to 3.50). Evidence was found for moderate between-study heterogeneity and publication bias in the coronary heart disease analysis. Conclusions The meta-analysis indicates that a history of miscarriage or recurrent miscarriage is associated with a greater risk of subsequent coronary heart disease.
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204
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Masszi G, Horvath EM, Tarszabo R, Benko R, Novak A, Buday A, Tokes AM, Nadasy GL, Hamar P, Benyó Z, Varbiro S. Reduced estradiol-induced vasodilation and poly-(ADP-ribose) polymerase (PARP) activity in the aortas of rats with experimental polycystic ovary syndrome (PCOS). PLoS One 2013; 8:e55589. [PMID: 23555555 PMCID: PMC3608629 DOI: 10.1371/journal.pone.0055589] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 12/27/2012] [Indexed: 01/03/2023] Open
Abstract
Polycystic ovary syndrome (PCOS) is a complex endocrine disorder characterized by hyperandrogenism and insulin resistance, both of which have been connected to atherosclerosis. Indeed, an increased risk of clinical manifestations of arterial vascular diseases has been described in PCOS. On the other hand endothelial dysfunction can be detected early on, before atherosclerosis develops. Thus we assumed that vascular dysfunction is also related directly to the hormonal imbalance rather than to its metabolic consequences. To detect early functional changes, we applied a novel rodent model of PCOS: rats were either sham operated or hyperandrogenism was achieved by implanting subcutaneous pellets of dihydrotestosterone (DHT). After ten weeks, myograph measurements were performed on isolated aortic rings. Previously we described an increased contractility to norepinephrine (NE). Here we found a reduced immediate relaxation to estradiol treatment in pre-contracted aortic rings from hyperandrogenic rats. Although the administration of vitamin D3 along with DHT reduced responsiveness to NE, it did not restore relaxation to estradiol. Poly-(ADP-ribose) polymerase (PARP) activity was assessed by poly-ADP-ribose immunostaining. Increased PAR staining in ovaries and circulating leukocytes from DHT rats showed enhanced DNA damage, which was reduced by concomitant vitamin D3 treatment. Surprisingly, PAR staining was reduced in both the endothelium and vascular smooth muscle cells of the aorta rings from hyperandrogenic rats. Thus in the early phase of PCOS, vascular tone is already shifted towards vasoconstriction, characterized by reduced vasorelaxation and vascular dysfunction is concomitant with altered PARP activity. Based on our findings, PARP inhibitors might have a future perspective in restoring metabolic disorders in PCOS.
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MESH Headings
- Animals
- Aorta/enzymology
- Aorta/pathology
- Aorta/physiopathology
- Cholecalciferol/pharmacology
- Endothelium, Vascular/enzymology
- Endothelium, Vascular/pathology
- Endothelium, Vascular/physiopathology
- Estradiol/pharmacology
- Estrogens/pharmacology
- Female
- Muscle, Smooth, Vascular/enzymology
- Muscle, Smooth, Vascular/pathology
- Muscle, Smooth, Vascular/physiopathology
- Poly Adenosine Diphosphate Ribose/metabolism
- Poly(ADP-ribose) Polymerases/metabolism
- Polycystic Ovary Syndrome/chemically induced
- Polycystic Ovary Syndrome/metabolism
- Polycystic Ovary Syndrome/pathology
- Polycystic Ovary Syndrome/physiopathology
- Rats
- Rats, Wistar
- Vasoconstriction/drug effects
- Vasodilation/drug effects
- Vitamins/pharmacology
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Affiliation(s)
- Gabriella Masszi
- Cardiology Unit, Bajcsy-Zsilinszky Hospital, Budapest, Hungary
- * E-mail: (GM); (SV)
| | - Eszter Maria Horvath
- Institute of Human Physiology and Clinical Experimental Research, Semmelweis University, Budapest, Hungary
| | - Robert Tarszabo
- Department of Pathophysiology, Semmelweis University, Budapest, Hungary
| | - Rita Benko
- Institute of Human Physiology and Clinical Experimental Research, Semmelweis University, Budapest, Hungary
| | - Agnes Novak
- Cardiology Unit, Bajcsy-Zsilinszky Hospital, Budapest, Hungary
| | - Anna Buday
- Department of Pathophysiology, Semmelweis University, Budapest, Hungary
| | - Anna-Maria Tokes
- Department of Pathology, Semmelweis University, Budapest, Hungary
| | - Gyorgy L. Nadasy
- 2 Department Obstetrical Gynecology Semmelweis University, Budapest, Hungary
| | - Peter Hamar
- Department of Pathophysiology, Semmelweis University, Budapest, Hungary
| | - Zoltán Benyó
- Institute of Human Physiology and Clinical Experimental Research, Semmelweis University, Budapest, Hungary
| | - Szabolcs Varbiro
- 2 Department Obstetrical Gynecology Semmelweis University, Budapest, Hungary
- * E-mail: (GM); (SV)
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205
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Moran LJ, Ko H, Misso M, Marsh K, Noakes M, Talbot M, Frearson M, Thondan M, Stepto N, Teede HJ. Dietary composition in the treatment of polycystic ovary syndrome: a systematic review to inform evidence-based guidelines. J Acad Nutr Diet 2013; 113:520-45. [PMID: 23420000 DOI: 10.1016/j.jand.2012.11.018] [Citation(s) in RCA: 114] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 11/08/2012] [Indexed: 12/20/2022]
Abstract
While lifestyle management is recommended as first-line treatment of polycystic ovary syndrome (PCOS), the optimal dietary composition is unclear. The aim of this study was to compare the effect of different diet compositions on anthropometric, reproductive, metabolic, and psychological outcomes in PCOS. A literature search was conducted (Australasian Medical Index, CINAHL, EMBASE, Medline, PsycInfo, and EBM reviews; most recent search was performed January 19, 2012). Inclusion criteria were women with PCOS not taking anti-obesity medications and all weight-loss or maintenance diets comparing different dietary compositions. Studies were assessed for risk of bias. A total of 4,154 articles were retrieved and six articles from five studies met the a priori selection criteria, with 137 women included. A meta-analysis was not performed due to clinical heterogeneity for factors including participants, dietary intervention composition, duration, and outcomes. There were subtle differences between diets, with greater weight loss for a monounsaturated fat-enriched diet; improved menstrual regularity for a low-glycemic index diet; increased free androgen index for a high-carbohydrate diet; greater reductions in insulin resistance, fibrinogen, total, and high-density lipoprotein cholesterol for a low-carbohydrate or low-glycemic index diet; improved quality of life for a low-glycemic index diet; and improved depression and self-esteem for a high-protein diet. Weight loss improved the presentation of PCOS regardless of dietary composition in the majority of studies. Weight loss should be targeted in all overweight women with PCOS through reducing caloric intake in the setting of adequate nutritional intake and healthy food choices irrespective of diet composition.
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Affiliation(s)
- Lisa J Moran
- The Robinson Institute, Research Centre for Reproductive Health, School of Paediatrics and Reproductive Health, University of Adelaide, Australia.
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206
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Lim SS, Norman RJ, Davies MJ, Moran LJ. The effect of obesity on polycystic ovary syndrome: a systematic review and meta-analysis. Obes Rev 2013; 14:95-109. [PMID: 23114091 DOI: 10.1111/j.1467-789x.2012.01053.x] [Citation(s) in RCA: 304] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 09/02/2012] [Accepted: 09/13/2012] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- S S Lim
- The Robinson Institute, University of Adelaide, Adelaide, South Australia, Australia
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207
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Maliqueo M, Sun M, Johansson J, Benrick A, Labrie F, Svensson H, Lönn M, Duleba AJ, Stener-Victorin E. Continuous administration of a P450 aromatase inhibitor induces polycystic ovary syndrome with a metabolic and endocrine phenotype in female rats at adult age. Endocrinology 2013. [PMID: 23183180 DOI: 10.1210/en.2012-1693] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Studying the mechanisms for the complex pathogenesis of polycystic ovary syndrome (PCOS) requires animal models with endocrine, reproductive, and metabolic features of the syndrome. Hyperandrogenism seems to be a central factor in PCOS, leading to anovulation and insulin resistance. In female rats, continuous administration of letrozole, a nonsteroidal inhibitor of P450 aromatase, at 400 μg/d starting before puberty induces hyperandrogenemia and reproductive abnormalities similar to those in women with PCOS. However, despite high circulating testosterone levels, these rats do not develop metabolic abnormalities, perhaps because of their supraphysiological testosterone concentrations or because estrogen synthesis is completely blocked in insulin-sensitive tissues. To test the hypothesis that continuous administration of lower doses of letrozole starting before puberty would result in both metabolic and reproductive phenotypes of PCOS, we performed a 12-wk dose-response study. At 21 d of age, 46 female Wistar rats were divided into two letrozole groups (100 or 200 μg/d) and a control group (placebo). Both letrozole doses resulted in increased body weight, inguinal fat accumulation, anovulation, larger ovaries with follicular atresia and multiples cysts, endogenous hyperandrogemia, and lower estrogen levels. Moreover, rats that received 200 μg/d had insulin resistance and enlarged adipocytes in inguinal and mesenteric fat depots, increased circulating levels of LH, decreased levels of FSH, and increased ovarian expression of Cyp17a1 mRNA. Thus, continuous administration of letrozole, 200 μg/d, to female rats for 90 d starting before puberty results in a PCOS model with reproductive and metabolic features of the syndrome.
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Affiliation(s)
- Manuel Maliqueo
- Institute of Neuroscience and Physiology, Department of Physiology, Sahlgrenska Academy, Göteborg University, Box 434, SE-405 30 Göteborg, Sweden
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208
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Labruijere S, van Houten ELAF, de Vries R, Musterd-Bagghoe UM, Garrelds IM, Kramer P, Danser AHJ, Villalón CM, Visser JA, Van Den Brink AM. Analysis of the vascular responses in a murine model of polycystic ovary syndrome. J Endocrinol 2013; 218:205-13. [PMID: 23734045 DOI: 10.1530/joe-13-0094] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of there productive age, but the exact pathophysiological mechanisms involved remain unclear. Cardiovascular disease risk is increased in PCOS patients and endothelial damage has been observed. We recently developed a mouse model of PCOS with reproductive and metabolic characteristics resembling those observed in women with PCOS. In this model we studied vascular function with particular emphasis on markers of vascular endothelial function. Animals were treated for 90 days with dihydrotestosterone (DHT; 27.5 mg/day) or placebo using subcutaneous continuous-release pellets. Aortas were isolated for isometric force recordings in organ baths to investigate endothelial and vascular smooth muscle characteristics. Lungs were used to analyze endothelial nitric oxide synthase (eNOS) expression and phosphorylation. Asymmetric dimethylarginine (ADMA) levels were investigated in serum to assess endothelial damage. Expression of androgen receptor (Ar) mRNA was studied in aortas. DHT treatment (compared with placebo) induced i) a significant decrease in acetylcholine-induced aortic relaxations, with no change in calcitonin gene related peptide- or sodium nitroprusside-induced relaxations, as well as 5-hydroxytryptamine-induced contractions; ii) no change in eNOS expression/phosphorylation in lungs or in plasma ADMA levels; and iii) a twofold increase in aortic AR expression. Our results suggest that, in DHT-exposed mice, hyperandrogenemia specifically decreases endothelium dependent vasorelaxation without deterioration of smooth muscle function. This study may initiate further investigations to elucidate underlying mechanism for the phenotype that is present in these animals, as well as in PCOS patients.
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Affiliation(s)
- Sieneke Labruijere
- Division of Vascular Medicine and Pharmacology, Erasmus MC, PO Box 2040, 3000 CA Rotterdam, The Netherlands
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209
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Celik Ö, Yılmaz E, Celik N, Minareci Y, Turkcuoglu I, Simsek Y, Celik E, Karaer A, Aydin S. Salusins, newly identified regulators of hemodynamics and mitogenesis, increase in polycystic ovarian syndrome. Gynecol Endocrinol 2013; 29:83-6. [PMID: 22827297 DOI: 10.3109/09513590.2012.706667] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
In the current study, we aimed to investigate whether serum salusin α and β levels are different in PCOS subjects. Fifty women with PCOS and 50 healthy, age- and body mass index matched controls were included to the prospective cross-sectional study. All subjects underwent venous blood drawing on the early follicular phase after an overnight fasting. Serum salusin α and β levels were measured with EIA, and ELISA respectively. The relationships between serum salusin levels and anthropometric and metabolic parameters were also assessed. Plasma salusin α and β levels were higher in women with PCOS compared to control group. Serum salusin α level correlated positively with salusin β and fasting serum insulin levels. The serum salusin β levels were correlated positively with HOMA-IR, TG, LDL-C, LH, FSH, and total testosterone levels. Our results indicate that salusins, newly identified regulators of hemodynamics and mitogenesis, are increased within the serum of women with PCOS.
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Affiliation(s)
- Önder Celik
- Department of Obstetrics and Gynecology, Inonu University, Medical Faculty, Malatya, Turkey.
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210
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Beller JP, McCartney CR. Cardiovascular risk and combined oral contraceptives: clinical decisions in settings of uncertainty. Am J Obstet Gynecol 2013; 208:39-41. [PMID: 22360920 DOI: 10.1016/j.ajog.2012.01.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Revised: 01/23/2012] [Accepted: 01/31/2012] [Indexed: 11/16/2022]
Abstract
Although generally safe, combined oral contraceptives (COCs) are associated with risks, including an estimated 2-fold increased relative risk of cardiovascular events. For most women taking COCs for contraception, absolute cardiovascular risks are very low, and the overall risks of COCs are outweighed by the risks of unwanted pregnancy. Nonetheless, risks of COCs may be excessive in some women, and both the American College of Obstetricians (ACOG) and the World Health Organization (WHO) have offered contraindications for COC use. Complicating this issue, COCs are commonly used for reasons other than contraception (eg, polycystic ovary syndrome, which is associated with subfertility and cardiovascular risk factors). Thus, in some clinical scenarios, ACOG and WHO guidelines may offer incomplete guidance regarding whether COC use would be associated with an unacceptable risk-benefit ratio. We propose that cardiovascular risk calculators may be helpful in some patients, as an adjunct to ACOG and WHO guidelines, by allowing physicians to estimate the attributable risk of COC-related cardiovascular events.
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Affiliation(s)
- Jennifer P Beller
- Division of Endocrinology and Metabolism, Department of Medicine, Center for Research in Reproduction, University of Virginia Health System, Charlottesville, VA 22908, USA
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211
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Cui L, Zhao H, Zhang B, Qu Z, Liu J, Liang X, Zhao X, Zhao J, Sun Y, Wang P, Li T, Shi Y, Chen ZJ. Genotype–phenotype correlations of PCOS susceptibility SNPs identified by GWAS in a large cohort of Han Chinese women. Hum Reprod 2012. [DOI: 10.1093/humrep/des424] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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212
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Di Domenico K, Wiltgen D, Nickel FJ, Magalhães JA, Moraes RS, Spritzer PM. Cardiac autonomic modulation in polycystic ovary syndrome: does the phenotype matter? Fertil Steril 2012; 99:286-292. [PMID: 23025880 DOI: 10.1016/j.fertnstert.2012.08.049] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Revised: 08/19/2012] [Accepted: 08/22/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess whether heart rate variability (HRV) at rest and during sympathetic stimulation is disturbed in patients with different polycystic ovary syndrome (PCOS) phenotypes in comparison to healthy controls. DESIGN Cross-sectional study. SETTING University hospital. PATIENT(S) Thirty women with classic, anovulatory PCOS, 16 women with ovulatory PCOS, and 23 age-paired women with regular and proven ovulatory cycles. INTERVENTION(S) Anthropometric and hormonal evaluation and analysis of HRV (time and frequency domain HRV indices) at rest and after a mental stress test. MAIN OUTCOME MEASURE(S) Difference between HRV components during rest and stress. RESULT(S) Mean age was 22.80 ± 5.80 years in patients with classic PCOS, 19.81 ± 6.43 years in ovulatory PCOS, and 22.65 ± 5.89 years in controls. During mental stress, patients with classic PCOS showed lower HRV response when compared with the control group, even after adjustment for body mass index (BMI) and age. When patients with classic and ovulatory PCOS were considered together, total T levels were inversely associated with the low frequency component, low frequency/high frequency ratio, and the difference between high frequency response at rest and after the stress test. CONCLUSION(S) Young patients with the classic PCOS phenotype have an impaired autonomic modulation in response to sympathetic stimulation that is typical of considerably older women, or of advanced age.
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Affiliation(s)
- Kristhiane Di Domenico
- Gynecological Endocrinology Unit, Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Denusa Wiltgen
- Gynecological Endocrinology Unit, Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Fabian J Nickel
- Gynecological Endocrinology Unit, Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Jose Antonio Magalhães
- Division of Gynecology and Obstetrics, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Ruy Silveira Moraes
- Division of Cardiology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Poli Mara Spritzer
- Gynecological Endocrinology Unit, Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil; Laboratory of Molecular Endocrinology, Department of Physiology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; National Institute of Hormones and Women's Health, Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Porto Alegre, Brazil.
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213
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Diagnosis and Management of Endometrial Hyperplasia. J Minim Invasive Gynecol 2012; 19:562-71. [DOI: 10.1016/j.jmig.2012.05.009] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Revised: 05/19/2012] [Accepted: 05/28/2012] [Indexed: 11/16/2022]
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214
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215
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Lim SS, Davies MJ, Norman RJ, Moran LJ. Overweight, obesity and central obesity in women with polycystic ovary syndrome: a systematic review and meta-analysis. Hum Reprod Update 2012; 18:618-37. [PMID: 22767467 DOI: 10.1093/humupd/dms030] [Citation(s) in RCA: 482] [Impact Index Per Article: 40.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- S S Lim
- The Robinson Institute, University of Adelaide, Adelaide, Australia
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216
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Baird DT, Balen A, Escobar-Morreale HF, Evers JLH, Fauser BCJM, Franks S, Glasier A, Homburg R, La Vecchia C, Devroey P, Diedrich K, Fraser L, Gianaroli L, Liebaers I, Sunde A, Tapanainen JS, Tarlatzis B, Van Steirteghem A, Veiga A, Crosignani PG, Evers JLH. Health and fertility in World Health Organization group 2 anovulatory women. Hum Reprod Update 2012; 18:586-99. [DOI: 10.1093/humupd/dms019] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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217
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Abstract
Polycystic ovary syndrome (PCOS) has been associated with increased cardiovascular risk (CVR) markers, but population studies have not clarified whether there is an increase in cardiovascular morbidity and mortality. Four different PCOS phenotypes resulted from the Rotterdam criteria that may differ in their CVR potential, thus introducing further complexity. This has led to studies using surrogate CVR markers including biomarkers in blood and imaging such as flow-mediated vasodilatation. In PCOS, both peripheral and central insulin resistance (IR) have been shown. Weight loss has been shown to improve IR and visceral fat, while insulin sensitizer therapies with metformin or thiazolidinediones improve IR and endothelial dysfunction. IR is also found in non-alcoholic fatty liver disease that in turn is very common in PCOS; studies have suggested that IR may be improved by treatment with metformin and omega-3 fish oils. PCOS patients have a more dyslipidemic phenotype that is worse in 'classical PCOS' associated with a higher CVR. Studies with atorvastatin and simvastatin have reported a decrease in the lipid parameters and an improvement in CVR indices including IR, but it is unclear whether this is due to their lipid-lowering action or a pleiotropic effect of the statin. In this expert opinion review, the relevant literature published during the last 2 years was considered. It focuses on some recent important data that has emerged while also exposing the gaps that remain in our knowledge that need to be addressed.
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Affiliation(s)
- T Sathyapalan
- Hull York Medical School, Academic Endocrinology, Diabetes and Metabolism, Michael White Diabetes Centre, 220-236 Anlaby Road, Hull, UK.
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218
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Abstract
Polycystic ovary syndrome (PCOS) is associated with metabolic derangements including insulin resistance, dyslipidemia, systemic inflammation and endothelial dysfunction. There is a growing need to develop pharmacologic interventions to improve metabolic function in women with PCOS. Medications that have been tested in patients with PCOS include metformin, thiazolidinediones, acarbose, naltrexone, orlistat, vitamin D and statins. Metformin decreases hepatic gluconeogenesis and free fatty acid oxidation while increasing peripheral glucose uptake. Early studies in PCOS suggested that metformin indirectly reduces insulin level, dyslipidemia and systemic inflammation; however, recent placebo-controlled trials failed to demonstrate significant metabolic benefit. Thiazolidinediones act primarily by increasing peripheral glucose uptake. Most studies in PCOS have demonstrated that thiazolidinediones reduce insulin resistance; however, effects on dyslipidemia were disappointing. Use of thiazolidinediones is associated with weight gain and major complications. Acarbose reduces digestion of polysaccharides. Studies in PCOS yielded inconsistent effects of acarbose on insulin sensitivity and no significant improvement of dyslipidemia. Naltrexone reduces appetite and modulates insulin release; its use in PCOS may reduce hyperinsulinemia. Orlistat decreases absorption of dietary fats; studies in PCOS suggest beneficial effects on insulin sensitivity. Vitamin D may improve insulin sensitivity but mixed results on lipid profile in PCOS have been reported. Statins are competitive inhibitors of the key enzyme regulating the mevalonate pathway; their effects are related to reduced cholesterol production as well as anti-inflammatory and anti-oxidant properties. In women with PCOS, statins reduce hyperandrogenism, improve lipid profile and reduce systemic inflammation while the effects on insulin sensitivity are variable. Use of statins is contraindicated in pregnancy.
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Affiliation(s)
- Antoni J Duleba
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of California Davis, 4869 Y Street, Suite 2550 ACC, Sacramento, CA 95817, USA.
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219
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Ganie MA, Farooqui KJ, Bhat MA, Mir MM, Shah ZA, Douhath S, Mir SH, Rashid F, Naqshi S, Masoodi MI, Zargar SA, Zargar AH. Pattern of urinary albumin excretion in normotensive young and adolescent Indian women with polycystic ovary syndrome. Indian J Endocrinol Metab 2012; 16:277-282. [PMID: 22470868 PMCID: PMC3313749 DOI: 10.4103/2230-8210.93752] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Polycystic ovarian syndrome (PCOS) is a clinically heterogeneous endocrine disorder affecting up to 4-8% of women of reproductive age. The aim of this study was to evaluate the presence of microalbuminuria in women with PCOS and study its correlation with the various metabolic, clinical, and hormonal parameters. MATERIALS AND METHODS A cross-sectional study involving 69 PCOS women was carried out in a tertiary care center hospital. The diagnosis of PCOS was made according to the Rotterdam criteria. Blood samples were collected in the follicular phase of the menstrual cycle and analyzed for fasting luteinizing hormone (LH), follicle stimulating hormone (FSH), prolactin (PRL), 17-hydroxyprogesterone (17-OHP), total testosterone (T), glucose, insulin, and lipid profile. Urinary albumin was measured in the first void spot urine sample. RESULTS The mean age of the subjects was 22.0 ± 4.1 years and 21.8 ± 4.7 years in normoalbuminuric and microalbuminuric groups, respectively. Urinary albumin excretion (UAE) varied from 5 mg/l to 100 mg/ml, with a median of 5 mg/l. Microalbuminuria was observed in 17/69 (24.6%) of subjects. The mean UAE was 3.65 ± 4.44 mg/l in the normoalbuminuria group versus 45.29 ± 22.74 mg/l in the microalbuminuria group. Upon univariate analysis, hip circumference, diastolic blood pressure, and fasting blood glucose showed significant correlations with urinary albumin concentration (r = 0.264, 0.264, and 0.551, respectively; P = 0.028, 0.029, and 0.000, respectively). No association between UAE and the usual cardiovascular risk factors could be found upon regression analysis. CONCLUSION About 24.6% of women with PCOS showed presence of microalbuminuria in the first void spot urine sample. Screening for the presence of microalbuminuria can help in early identification of a subset of PCOS women with a high risk for future CVD, who can be subjected to preventive strategies at the earliest. However, further studies are needed before recommending routine use of UAE in PCOS cases for the detection of CVD risk.
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Affiliation(s)
- Mohd Ashraf Ganie
- Departments of Endocrinology, Nephrology, and Immunology and Molecular Medicine, Sheri-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
| | - Khalid Jamal Farooqui
- Departments of Endocrinology, Nephrology, and Immunology and Molecular Medicine, Sheri-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
| | - Mohd Ashraf Bhat
- Departments of Endocrinology, Nephrology, and Immunology and Molecular Medicine, Sheri-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
| | - Mohammad Muzzafar Mir
- Department of Gastroenterology, and Clinical Biochemistry, Al Jouf, Aljouf University, KSA
| | - Zaffar Amin Shah
- Departments of Endocrinology, Nephrology, and Immunology and Molecular Medicine, Sheri-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
| | - Syed Douhath
- Department of Clinical Biochemistry, University of Kashmir, Srinagar, Jammu and Kashmir, India
| | - Syed Hussain Mir
- Department of Clinical Biochemistry, University of Kashmir, Srinagar, Jammu and Kashmir, India
| | - Fouzia Rashid
- Department of Clinical Biochemistry, University of Kashmir, Srinagar, Jammu and Kashmir, India
| | - Shazia Naqshi
- Department of Clinical Biochemistry, University of Kashmir, Srinagar, Jammu and Kashmir, India
| | - Mohd Ibrahim Masoodi
- Department of Gastroenterology, and Clinical Biochemistry, Al Jouf, Aljouf University, KSA
| | - S. A. Zargar
- Department of Gastroenterology, and Clinical Biochemistry, Sheri-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
| | - Abdul Hamid Zargar
- Department of Endocrinology, Sheri-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
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220
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Dogan MI, Tasci I, Bulucu F, Aydogdu A, Acar R, Ceyhan T, Koc B, Demir O, Gezer M, Sağlam K. Abdominal Obesity is Associated With a Lower Ankle–Brachial Index in Women With Polycystic Ovary Syndrome. Angiology 2012; 64:105-11. [DOI: 10.1177/0003319711436248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Ilker Tasci
- Department of Internal Medicine, Gulhane School of Medicine, Ankara, Turkey
| | - Fatih Bulucu
- Department of Internal Medicine, Gulhane School of Medicine, Ankara, Turkey
| | - Aydogan Aydogdu
- Department of Endocrinology and Metabolism, Gulhane School of Medicine, Ankara, Turkey
| | - Ramazan Acar
- Department of Internal Medicine, Gulhane School of Medicine, Ankara, Turkey
| | - Temel Ceyhan
- Department of Obstetrics and Gynecology, Gulhane School of Medicine, Ankara, Turkey
| | - Bayram Koc
- Department of Internal Medicine, Gulhane School of Medicine, Ankara, Turkey
| | - Orhan Demir
- Department of Internal Medicine, Gulhane School of Medicine, Ankara, Turkey
| | - Mustafa Gezer
- Department of Internal Medicine, Gulhane School of Medicine, Ankara, Turkey
| | - Kenan Sağlam
- Department of Internal Medicine, Gulhane School of Medicine, Ankara, Turkey
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221
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Bairagi S, Gopal J, Nathan AA, Babu SS, Kumar NP, Dixit M. Glucose-induced increase in circulating progenitor cells is blunted in polycystic amenorrhoeic subjects. Hum Reprod 2012; 27:844-53. [PMID: 22252083 DOI: 10.1093/humrep/der457] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Glucose-induced kinetics of bone marrow-derived stem cells in healthy females is presently unknown. The objectives of this study were to determine whether circulating levels of CD133(+), CD34(+) and CD133(+)CD34(+) cells increase in response to glucose load in healthy females and whether the kinetics is altered in amenorrhoeic women. The other objective of the work was to compare the endothelial differentiation potential of peripheral blood-derived endothelial progenitor cells (EPCs) from healthy versus amenorrhoeic women. METHODS In this case-control study, 44 amenorrhoeic subjects and 36 age-matched females with no menstrual disturbance were recruited at Apollo Hospitals, a Tertiary health care center in Chennai, India. Circulating bone marrow-derived stem cells were measured by two color direct flow cytometry. Cultured progenitor cells were characterized at Day 7 and 14 for expression of endothelial markers and production of nitric oxide (NO) via immunofluoroscence. RESULTS The amenorrhoeic subjects were insulin resistant with homeostatic model of assessment of insulin resistance values of 3.33 ± 0.3 versus 1.75 ± 0.148 observed for controls (P< 0.0001). Among the amenorrhoeic subjects, 38 subjects had polycystic ovaries with no signs of hyperandrogenism. Fasting levels of CD133(+), CD34(+) and CD133(+)CD34(+) cells were reduced in amenorrhoeic subjects (P< 0.001). There was a 1.5 to 2-fold increase in the circulating levels of these cells in response to 75 g oral glucose challenge at 1 and 2 h post-load conditions in controls, which was significantly blunted for CD133(+) (P< 0.001) and CD133(+)CD34(+) (P< 0.001) cells in amenorrhoeic subjects. A positive correlation was observed between estrogen and fasting CD133(+) (r= 0.205, P= 0.070), CD34(+) (r= 0.249, P= 0.027) and CD133(+)CD34(+) (r= 0.217, P= 0.055) cell counts. Additionally, fasting counts for CD34(+) and CD133(+)CD34(+) cells positively correlated with FSH and inversely correlated with LH and C-peptide in the polycystic group. Cultured cells from polycystic subjects exhibited reduced adherence to fibronectin and expressed lower levels of endothelial nitric-oxide synthase and NO. CONCLUSIONS Oral glucose-induced increase in circulating numbers of CD133(+) and CD133(+)CD34(+) cells and endothelial differentiation potential of peripheral blood-derived EPCs is attenuated in insulin resistant amenorrhoeic subjects.
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Affiliation(s)
- Soumi Bairagi
- Laboratory of Vascular Biology, Department of Biotechnology, Indian Institute of Technology Madras, BT 415, Chennai 600036, India
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222
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Fauser BCJM, Bouchard P. Uncertainty remains in women with PCOS regarding the increased incidence of cardiovascular disease later in life, despite the indisputable presence of multiple cardiovascular risk factors at a young age. J Clin Endocrinol Metab 2011; 96:3675-7. [PMID: 22143833 DOI: 10.1210/jc.2011-2935] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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223
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Meyer ML, Malek AM, Wild RA, Korytkowski MT, Talbott EO. Carotid artery intima-media thickness in polycystic ovary syndrome: a systematic review and meta-analysis. Hum Reprod Update 2011; 18:112-26. [PMID: 22108382 DOI: 10.1093/humupd/dmr046] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Polycystic ovary syndrome (PCOS) is a common reproductive endocrine disorder associated with cardiovascular disease (CVD) risk factors and metabolic disturbances. This systematic review and meta-analysis was conducted to determine whether carotid intima-media thickness (CIMT), a marker of subclinical atherosclerosis, is higher in women with PCOS compared with women without PCOS. METHODS Primary articles reporting the mean CIMT in women with PCOS and controls were identified using Ovid MEDLINE, EMBASE and PUBMED. We performed a random-effects meta-analysis and created forest plots of the mean difference in CIMT and conducted tests for heterogeneity and publication bias. Studies were grouped by quality, defined by reporting reproducibility of CIMT and averaging both common carotid arteries versus one side for CIMT. RESULTS From the 36 eligible full-text studies, 8 studies were included in the systematic review and 19 studies were included in the meta-analysis (total n= 1123 women with PCOS, n= 923 controls). The summary mean difference in CIMT among women with PCOS compared with controls was 0.072 mm [95% confidence interval (CI) 0.040, 0.105, P < 0.0001] for highest quality studies, 0.084 mm (95% CI 0.042, 0.126, P = 0.0001) for good quality studies, 0.041 (95% CI -0.038, 0.120, P = 0.310) for fair-quality studies and 0.045 (95% CI -0.020, 0.111, P = 0.173) for lower quality studies. CONCLUSIONS Larger studies with a well-defined PCOS population using rigorous methodology may be required to draw a more robust conclusion. However, these results suggest women with PCOS are at a greater risk of premature atherosclerosis, which emphasizes the importance of screening and monitoring CVD risk factors in women with PCOS.
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Affiliation(s)
- Michelle L Meyer
- Department of Epidemiology, University of North Carolina at Chapel Hill, Bank of America Center, Chapel Hill, NC 27514, USA.
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224
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Ngo D, Chan W, Rajendran S, Heresztyn T, Amarasekera A, Sverdlov A, O’Loughlin P, Morris H, Chirkov Y, Norman R, Horowitz J. Determinants of insulin responsiveness in young women: Impact of polycystic ovarian syndrome, nitric oxide, and vitamin D. Nitric Oxide 2011; 25:326-30. [DOI: 10.1016/j.niox.2011.06.005] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Revised: 06/01/2011] [Accepted: 06/02/2011] [Indexed: 01/04/2023]
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225
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Wehr E, Pilz S, Boehm BO, Grammer TB, März W, Obermayer-Pietsch B. Low free testosterone levels are associated with all-cause and cardiovascular mortality in postmenopausal diabetic women. Diabetes Care 2011; 34:1771-7. [PMID: 21715525 PMCID: PMC3142041 DOI: 10.2337/dc11-0596] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Hyperandrogenemia is associated with cardiovascular risk factors in women but evidence about the relationship of testosterone levels with mortality is sparse. We aimed to evaluate whether total testosterone (TT), free testosterone (FT), and sex hormone-binding globulin (SHBG) are associated with all-cause and cardiovascular mortality in a cohort of postmenopausal women. RESEARCH DESIGN AND METHODS We measured TT and SHBG levels in 875 postmenopausal women who were referred for coronary angiography (during 1997-2000). FT was calculated according to the Vermeulen method. The main outcome measures were Cox proportional hazard ratios (HRs) for mortality from all causes and from cardiovascular causes. RESULTS After a median follow-up time of 7.7 years, 179 women (20.5%) had died. There were 101 deaths due to cardiovascular disease (56.4% of all deaths). We found no association of FT, TT, and SHBG levels with mortality in all postmenopausal women. In postmenopausal diabetic women, multivariable-adjusted HRs (with 95% CIs) in the fourth compared with the first FT quartile for all-cause and cardiovascular mortality were 0.38 (0.08-0.90), P = 0.025, and 0.28 (0.08-0.90), P = 0.032, respectively. We found no association of TT and SHBG with mortality in diabetic postmenopausal women. CONCLUSIONS In postmenopausal diabetic women referred for coronary angiography, low FT levels are independently associated with increased all-cause and cardiovascular mortality.
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Affiliation(s)
- Elisabeth Wehr
- Department of Internal Medicine, Medical UniversityGraz, Graz, Austria.
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226
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Androgens exert sexually dimorphic effects on angiogenesis: novel insight into the relationship between androgens and cardiovascular disease. Asian J Androl 2011; 13:626-7. [PMID: 21666700 DOI: 10.1038/aja.2011.80] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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227
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Yang Z, Kong B, Mosser DM, Zhang X. TLRs, macrophages, and NK cells: our understandings of their functions in uterus and ovary. Int Immunopharmacol 2011; 11:1442-50. [PMID: 21586343 DOI: 10.1016/j.intimp.2011.04.024] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Revised: 04/09/2011] [Accepted: 04/30/2011] [Indexed: 01/07/2023]
Abstract
Inflammation involves multiple changes in many aspects of immune system. Interactions between immune system and female reproductive system strongly impact fertility and reproductive health in general. Many normal events of female reproduction system including ovulation, menstruation, implantation and labor onset are considered as inflammatory process. Emerging evidence reveals that three components of immune system that are critical to initiate and resolve inflammation, Toll-like receptors (TLRs), macrophages, and natural killer (NK) cells, play important roles not only to provide protection against infections by exogenous pathogens but also to regulate essential functions of uterus and ovary. This review will briefly summarize our understanding of the functions of TLRs, macrophages and NK cells in uterus and ovary.
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Affiliation(s)
- Ziyan Yang
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, 107 Wenhuaxi Road, Jinan, Shandong 250012, China
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