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

Metabolic and endocrine status associate with obstructive sleep apnea risk among patients with polycystic ovary syndrome

STUDY OBJECTIVES

Risk of obstructive sleep apnea (OSA) appears to be increased among patients with polycystic ovary syndrome (PCOS), but the underlying physiology is unclear. We sought to identify predictors of OSA risk among patients with PCOS.

METHODS

A cross-sectional analysis of patients evaluated for PCOS at a single tertiary center from 2017-2022 was completed. Inclusion criteria included patients 18-44 years of age who had Rotterdam criteria for PCOS and had completed a Berlin Questionnaire (BQ) for OSA risk assessment. All patients underwent standardized anthropometric, ultrasound, endocrine, and metabolic phenotyping.

RESULTS

Of the 572 patients screened during the study period, 309 patients with PCOS met inclusion criteria, and 104 (33.7%) had a high-risk BQ. Those with a high-risk BQ, compared with those without, had significantly (P < .05) higher waist:hip ratio, low-density-lipoprotein cholesterol, triglycerides, fasting insulin, 2-hour insulin, fasting glucose, 2-hour glucose, homeostatic model assessment for insulin resistance, hemoglobin A1C, C-reactive protein, free testosterone, and free androgen index and had lower high-density-lipoprotein cholesterol and sex hormone binding globulin. In multivariable modeling controlling for all significantly differing variables in univariate analyses, hemoglobin A1C (β [standard error] 1.05 [0.45], P = .02), C-reactive protein (0.09 [0.04], P = .01), and sex hormone binding globulin (-0.02 [0.01], P = .02) associated with high-risk BQ.

CONCLUSIONS

Dysglycemia, inflammation, and androgen status independently associate with predicted OSA risk by BQ. Future studies are needed to comprehensively assess the impact of treatment of OSA on these outcomes among patients with PCOS to better clarify the directionality and clinical implications of these associations.

CITATION

Christ JP, Shinkai K, Corley J, Pasch L, Cedars MI, Huddleston HG. Metabolic and endocrine status associate with obstructive sleep apnea risk among patients with polycystic ovary syndrome. J Clin Sleep Med. 2024;20(6):871-877.

Effect of obstructive sleep apnea on in vitro fertilization outcomes in women with polycystic ovary syndrome

STUDY OBJECTIVES

Polycystic ovary syndrome (PCOS) confers a high risk of obstructive sleep apnea (OSA). Here we investigated the effect of OSA on first in vitro fertilization (IVF) cycle metrics and outcomes in patients with PCOS.

METHODS

This was a prospective cohort study of patients with PCOS undergoing their first IVF at a single tertiary center between October 1, 2021, and September 30, 2022. Patients were screened for OSA before IVF and grouped accordingly. Clinical and IVF cycle data were compared between groups.

RESULTS

OSA was found in 37.2% of 156 patients with PCOS, with longer infertility duration (4.3 ± 2.5 vs. 3.4 ± 2.0 years) and lower levels of anti-Müllerian and luteinizing hormones than patients without OSA (6.44 ± 2.96 vs 8.69 ± 4.03 µg/L and 6.30 ± 5.02 vs 8.46 ± 6.09 U/L). Antral follicle count was lower in patients with OSA (28.9 ± 12.4 vs 33.2 ± 12.9). During ovarian stimulation, patients with OSA required significantly higher doses of gonadotropin (2080.8 ± 1008.7 vs 1682.8 ± 619.9 U) and had lower peak estradiol level (4473.5 ± 2693.0 vs 5455.7 ± 2955.1 pmol/L) and fewer retrieved oocytes, high-quality, and available embryos (17.8 ± 7.2 vs 21.9 ± 10.5, 4.5 ± 4.4 vs 6.2 ± 4.6, 5.2 ± 4.3 vs 7.4 ± 5.0). Eleven patients were excluded for having no embryos or missing transfer. Therefore, we analyzed the outcome of the first embryo transfer in 145 patients. The biochemical and clinical pregnancy rates were lower in patients with OSA than patients without OSA (51.9% vs 66.7% and 42.3% vs 60.2%). OSA was independently associated with clinical pregnancy rate after controlling for several confounders (P = .043).

CONCLUSIONS

OSA impairs female fertility in patients with polycystic ovary syndrome, suggesting an adverse effect on in vitro fertilization cycle stimulation characteristics and clinical outcomes.

CITATION

Zhang Q, Wang Z, Ding J, et al. Effect of obstructive sleep apnea on in vitro fertilization outcomes in women with polycystic ovary syndrome. J Clin Sleep Med. 2024;20(1):31-38.

How is Obstructive Sleep Apnea Associated with High Blood Pressure and Diabetes Mellitus Type 2? Clues from a Two-Step Mendelian Randomized Study

Background

Obstructive sleep apnea (OSA), high blood pressure (HBP), and type 2 diabetes mellitus (T2DM) have a close clinical relationship, but whether and how OSA affects HBP and T2DM is unclear.

Study Design and Methods

Two-step, two-sample Mendelian randomization techniques were applied using single-nucleotide polymorphisms as genetic instruments for exposure and mediators, thus minimizing bias due to confounding factors and reverse causality. The total effect of OSA on HBP and T2DM was categorized into direct and mediating effects based on the mediating factors.

Results

Two-sample MR analysis showed that OSA increased the risk of HBP (odds ratio [OR] = 1.010, 95% confidence interval [CI], 1.002-1.018; P = 0.0121) and T2DM (OR = 1.140, 95% CI, 1.059-1.228; P = 0.0005). In the process of OSA caused by HBP, sex hormone-binding globulin (SHBG) (female, 4.47% mediation; male, 2.76% mediation), total testosterone (TT) (male, 3.72% mediation), bioavailable testosterone (BioT) (female, 7.74% mediation), high-density lipoprotein cholesterol (HDL-C) (3.25% mediation), and apolipoprotein A1 (ApoA1) (1.31% mediation) were individual contributors. SHBG (female, 4.10% mediation; male, 1.58% mediation), TT (male, 3.69% mediation), BioT (female, 2.58% mediation), HDL-C (3.32% mediation), ApoA1 (2.14% mediation), and omega-6 fatty acids (2.33% mediation) may have mediating roles to varying degrees in the process of OSA caused by T2DM.

Interpretation

This MR study showed that OSA is a risk factor for HBP and T2DM, and the evaluation of mediators may help further reveal the specific mechanism by which OSA causes HBP and T2DM.

Beyond Counting Sheep: Exploring the Link between Polycystic Ovary Syndrome and Sleep Health

Polycystic ovary syndrome (PCOS) is a common hormonal condition with reproductive, metabolic, and psychological sequelae that affects 8 to 13% of reproductive-aged women and 3 to 11% of adolescent girls. Sleep is often compromised in women with PCOS due to increased rates of sleep problems, with the most established problem being obstructive sleep apnea (OSA). OSA is highly prevalent in reproductive-aged adult women with PCOS, but not so in adolescence. The international evidence-based PCOS guideline to improve health outcomes in women with PCOS indicated routine screening to identify and alleviate symptoms of OSA. The guidelines, however, did not weigh other multidimensional constructs of sleep health such as sleep disturbances (e.g., sleep quality and quantity), beyond OSA. This is perhaps due to the lack of research and existing mixed findings in the area of PCOS and sleep health. This narrative review summarizes the current knowledge about OSA and expands further to include the limited knowledge about other sleep problems in PCOS among reproductive-aged women and adolescent girls. We broadly cover the prevalence, risk factors, and mechanisms of sleep problems in PCOS and their relationship with cardiometabolic and psychological health. A brief summary on treatment and intervention strategies for sleep problems in PCOS and future recommendations will be deliberated.

Polycystic ovary syndrome and adipose tissue

Polycystic ovary syndrome (PCOS) is the most common endocrine metabolic disorder in women of reproductive age. Typically, it is associated with ovulatory dysfunction: dysovulation or anovulation, and symptoms of hyperandrogenism. It incurs risk of metabolic disorders such as diabetes, dyslipidemia and fatty liver. As a key endocrine organ in metabolic homeostasis, adipose tissue is often implicated in these complications. Studies of white adipose tissue (WAT) in PCOS have focused on the mechanism of insulin resistance in this tissue. Clinically, abnormalities in WAT distribution are seen, with decreased waist-to-hip ratio and increased ratio of adipose to lean mass. Such abnormalities are greater when total circulating androgens are elevated. At tissue level, white adipocyte hyperplasia occurs, along with infiltration of macrophages. Secretion of adipokines, cytokines and chemo-attractant proteins is increased in a pro-inflammatory manner, leading to reduced insulin sensitivity via alteration of glucose transporters, and hence decreased glucose uptake. The kinetics of non-esterified fatty acids (or free fatty acids) is also altered, leading to lipotoxicity. In recent years, brown adipose tissue (BAT) has been studied in women with PCOS. Although abundance is low in the body, BAT appears to play a significant role in energy expenditure and metabolic parameters. Both supra-clavicular skin temperature, which reflects BAT activity, and BAT mass are reduced in women with PCOS. Moreover, BAT mass and body mass index (BMI) are inversely correlated in patients. In the adipocyte, increased total circulating androgen levels reduce expression of uncoupling protein 1 (UCP1), a key protein in the brown adipocyte, leading to reduced biogenesis and mitochondrial respiration and hence a reduction in post-prandial thermogenesis. BAT is currently being investigated as a possible new therapeutic application.

Nonalcoholic fatty liver disease and obstructive sleep apnea in women with polycystic ovary syndrome

Nonalcoholic fatty liver disease (NAFLD) and obstructive sleep apnea are frequently associated with polycystic ovary syndrome (PCOS) but remain underrecognized. Women with PCOS have a 2-4 times higher risk of NAFLD independent of body mass index than healthy weight-matched controls. Insulin resistance and hyperandrogenemia together play a central role in the pathogenesis of NAFLD. Timely diagnosis of NAFLD is important because its progression can lead to nonalcoholic steatohepatitis and/or advanced liver fibrosis that can eventually result in liver-related mortality. The presence of NAFLD has also been associated with increased risks of type 2 diabetes, cardiovascular events, overall mortality, and extrahepatic cancers. The treatment of NAFLD in PCOS should include lifestyle interventions. Glucagon-like peptide 1 receptor agonists have shown promising results in patients with PCOS and NAFLD, but future randomized trails are needed to confirm this benefit. Likewise, the use of combined oral estrogen-progestin contraceptives may provide a benefit by decreasing hyperandrogenemia. Sleep disordered breathing is common among women with PCOS and is responsible for a number of cardiometabolic derangements. Obstructive sleep apnea is most often found in overweight and obese women with PCOS, but as is the case with NAFLD, its prevalence exceeds that of women who are of similar weight without PCOS. Left untreated, obstructive sleep apnea can precipitate or exacerbate insulin resistance, glucose intolerance, and hypertension.