Sex hormone levels and subclinical atherosclerosis in postmenopausal women: the Multi-Ethnic Study of Atherosclerosis

Sex and sex steroids as determinants of cardiovascular risk

There are considerable sex differences regarding the risk of cardiovascular disease (CVD), including arterial hypertension, coronary artery disease (CAD) and stroke, as well as chronic renal disease. Women are largely protected from these conditions prior to menopause, and the risk increases following cessation of endogenous estrogen production or after surgical menopause. Cardiovascular diseases in women generally begin to occur at a later age than in men (on average with a delay of 10 years). Cessation of estrogen production also impacts metabolism, increasing the risk of developing obesity and diabetes. In middle-aged individuals, hypertension develops earlier and faster in women than in men, and smoking increases cardiovascular risk to a greater degree in women than it does in men. It is not only estrogen that affects female cardiovascular health and plays a protective role until menopause: other sex hormones such as progesterone and androgen hormones generate a complex balance that differentiates heart and blood vessel function in women compared to men. Estrogens improve vasodilation of epicardial coronary arteries and the coronary microvasculature by augmenting the release of vasodilating factors such as nitric oxide and prostacyclin, which are mechanisms of coronary vasodilatation that are more pronounced in women compared to men. Estrogens are also powerful inhibitors of inflammation, which in part explains their protective effects on CVD and chronic renal disease. Emerging evidence suggests that sex chromosomes also play a significant role in shaping cardiovascular risk. The cardiovascular protection conferred by endogenous estrogens may be extended by hormone therapy, especially using bioidentical hormones and starting treatment early after menopause.

Androgenicity in Young Women and Development of Metabolic Syndrome Before Menopause: The CARDIA and CARDIA Women's Studies

Context

There are no reported data from prospective long-term studies on the relation of androgen levels in young women with development of metabolic syndrome (MetS) before menopause.

Objective

We investigated associations of androgens and SHBG with incident MetS during 23 years of follow-up.

Methods

We included 366 White and 375 Black women ages 20 to 32 years participating in the CARDIA study and CARDIA Women's study, free of MetS at baseline examination (1987-1988), and premenopausal 23 years later. Androgens and SHBG were categorized into quartiles. MetS was defined according to the American Heart Association/National Heart, Lung, and Blood Institute 2009 Joint Scientific Statement. Cox proportional hazards models were used.

Results

By year 23, 30% of women developed MetS. Adjusting for baseline age, race, and education, hazard ratios (95% CI) of developing MetS were 1.46 (1.02-2.10) and 2.22 (1.53-3.21) for women in the highest vs lowest total testosterone (T) and free T quartile, respectively. The hazards of developing MetS were 47%, 59%, and 53% lower for women with SHBG in the second, third, and fourth quartiles (vs lowest quartile), respectively. Associations were attenuated for total T with further adjustments for smoking, physical activity, menstrual status, oral contraceptive/hormone (OCHM) use, insulin level, oligomenorrhea, and age at menarche, but remained statistically significant for free T and SHBG. Associations were similar for both Blacks and Whites, and OCHM nonusers, but not for OCHM users.

Conclusion

High androgenicity in young premenopausal women is associated with higher risk of future MetS, suggesting that early assessment of androgens may contribute to prevention.

Genetically predicted androgenic profiles and adverse cardiac markers: a sex-specific Mendelian randomization study

AIMS

Observational evidence suggests associations between sex hormone levels and heart failure (HF). We used sex-specific genetic variants associated with androgenic sex hormone profiles to investigate the causal relevance of androgenic sex hormone profiles on cardiac structure and function and HF using Mendelian randomization (MR).

METHODS AND RESULTS

Sex-specific uncorrelated genome-wide significant (P < 5 × 10-8 ) variants predicting sex hormone-binding globulin (SHBG), total testosterone, and bioavailable testosterone were extracted from summary statistics of genome-wide association study (GWAS) on 425 097 participants in the UK Biobank. Sex-specific gene-outcome association estimates were computed for left ventricular ejection fraction (LVEF), left ventricular end-diastolic and end-systolic volumes (LVEDV and LVESV, respectively), left ventricular stroke volume (LVSV), cardiac index, and cardiac output in 11 528 female and 14 356 male UK Biobank Imaging Study participants and for incident or prevalent HF in an external cohort of 47 309 cases and 930 014 controls. Inverse-variance weighted MR was the primary analysis method. In females, higher genetically predicted bioavailable testosterone was associated with lower LVEDV [β per nmol/L = -0.11 (-0.19 to -0.03), P = 0.006], lower LVESV [β = -0.09 (-0.17 to -0.01), P = 0.022], lower LVSV [β = -0.11 (-0.18 to -0.03), P = 0.005], lower cardiac output [β = -0.08 (-0.16 to 0.00), P = 0.046], and lower cardiac index [β = -0.08 (-0.16 to -0.01), P = 0.034] and a higher risk of HF [odds ratio 1.10 (1.01-1.19), P = 0.026] on external validation analysis in larger scale, sex-adjusted GWAS data. Higher genetically predicted SHBG was associated with higher LVEDV [β per nmol/L = 0.17 (0.08-0.25), P = 2 × 10-4 ], higher LVESV [β = 0.13 (0.05-0.22), P = 0.003], and higher LVSV [β = 0.18 (0.08-0.28), P = 2 × 10-4 ]. In males, higher genetically predicted total and bioavailable testosterone was associated with lower LVESV [β = -0.07 (-0.12 to -0.02), P = 0.007] and LVEF [β = -0.11 (-0.18 to -0.04), P = 0.003], respectively.

CONCLUSIONS

This study supports a causal effect of pro-androgenic sex hormone profiles in females on adverse markers of left ventricular structure and function typically associated with HF with preserved ejection fraction and with HF. There was weaker evidence of association in males.

Female Reproductive Factors and Risk of New-Onset Heart Failure: Findings From UK Biobank

BACKGROUND

A comprehensive evaluation of woman-specific risk factors in relation to incident heart failure (HF) is limited.

OBJECTIVES

This study sought to investigate the association of multiple female reproductive factors with the risk of HF.

METHODS

Between 2007 and 2010, 229,026 women (mean age: 56.5 years) without prevalent HF from the UK Biobank cohort were included and followed until December 2020. The relation between (self-reported) reproductive factors and HF was analyzed using Cox proportional hazards models with adjustment for potential confounding.

RESULTS

Menarche at age <12 years, compared to age 12-13 years, carried a 9% larger risk of HF (HR: 1.09 [95% CI: 1.01-1.18]). Younger age at menopause was associated with a higher risk of HF (HRage <45 y vs 50-51 y: 1.15 [95% CI: 1.03-1.28]; HRage 45-49 y vs 50-51 y: 1.11 [95% CI: 1.01-1.23]). Younger maternal age at first live birth (HRage <21 y vs 24-26 y: 1.42 [95% CI: 1.28-1.59]; HRage 21-23 y vs 24-26 y: 1.14 [95% CI: 1.03-1.26]) and at last live birth (HRage <26 y vs 29-31 y: 1.19 [95% CI: 1.07-1.33]) were associated with higher risk of HF. Compared to women with 1 or 2 children, having 3 or 4 children (HR: 1.09 [95% CI: 1.02-1.17]) or >4 children (HR: 1.24 [95% CI: 1.05-1.47]) was associated with higher HF risk. Experiencing miscarriages or abortions was not significantly associated with incident HF, whereas experiencing 1 stillbirth and recurrent stillbirths conferred a 20% and 43% larger risk of HF, respectively, compared to no stillbirth.

CONCLUSIONS

The findings emphasize the importance of female reproductive history in the assessment of HF risk.

The association of sex-specific hormones with coronary artery plaque characteristics from Miami Heart (MiHeart) study

Objective

The association of sex-specific hormones with coronary computed tomography angiography(CCTA)-based plaque characteristics in women without cardiovascular disease is not well understood. We investigated the association of sex-specific hormones with coronary artery plaque characteristics in a contemporary multiracial cohort with no clinical coronary artery disease (CAD).

Methods

In this cross-sectional analysis, we utilized data from 2,325 individuals with no clinical CAD from the Miami Heart (MiHeart) study. Multivariable logistic regression models were used to investigate the association of sex hormones: sex hormone binding globulin (SHBG), dehydroepiandrosterone (DHEA), free and total testosterone, estradiol, with plaque characteristics among women and men.

Results

Of the 1,155 women, 34.2% had any plaque and 3.4% had any high-risk plaque features (HRP) while among men (n = 1170), 63.1% had any plaque and 10.4% had HRP. Among women, estradiol and SHBG were associated with lower odds of any plaque after adjusting for age and race-ethnicity (estradiol OR per SD increase: 0.87, 95%CI: 0.76-0.98; SHBG OR per SD increase: 0.82, 95%CI: 0.72-0.93) but the significance did not persist after adjustment of cardiovascular risk factors. High free testosterone was associated with higher odds of HRP (aOR:3.48, 95%CI:1.07-11.26) but null associations for the other sex hormones with HRP, in the context of limited sample size. Among men, there were no significant associations between sex-specific hormones and plaque or HRP.

Conclusion

Among young to middle-aged women with no clinical CAD, increasing estradiol and SHBG were associated with lower odds of any plaque and higher free testosterone was associated with HRP. Larger cohorts may be needed to validate this.

Focusing on testosterone levels in male: A half-longitudinal study of polycyclic aromatic hydrocarbon exposure and diastolic blood pressure in coke oven workers

Polycyclic aromatic hydrocarbons (PAHs) can interfere with testosterone levels, and low levels of testosterone are associated with increased cardiovascular events. To explore the role of testosterone in PAHs exposure and cardiovascular health, we used data from the 2011-2016 National Health and Nutrition Examination Survey (NHANES) and a longitudinal database of 332 male coke oven workers from China. The urine PAHs, tobacco metabolites and plasma testosterone levels of coke oven workers were measured. There were inverse associations between serum (plasma) testosterone concentrations and the risk of dysarteriotony and dyslipidemia among the NHANES participants and coke oven workers. The results of the cross-lagged panel analysis among workers showed that the decrease in testosterone preceded the increase in diastolic blood pressure (DBP), and the absolute value of the path coefficient from baseline testosterone to follow-up DBP (β₂ = -8.162, P = 0.077) was significantly larger than the absolute value of the path coefficient from baseline DBP to follow-up testosterone (β₁ = -0.001, P = 0.781). Results from the half-longitudinal mediation analysis showed that baseline hydroxyfluorene predicted significant decreases in plasma testosterone from baseline to follow-up (path a: 0.71, 95% CI: 1.26, -0.16), whereas plasma testosterone at baseline also predicted significant increments in DBP from baseline to follow-up (path b: 9.22, 95% CI: 17.24, -1.19). The indirect effect of PAHs on DBP via plasma testosterone level was marginally significant (test for indirect effects a*b (P = 0.08)). In conclusion, testosterone level is a longitudinal precursor to increased DBP and plays an essential role in the association between PAHs exposure and damage to the cardiovascular system. Coke oven workers with low plasma testosterone levels are more likely to experience adverse changes in blood pressure and lipid levels after exposure to PAHs.

Cardiovascular Safety and Benefits of Testosterone Implant Therapy in Postmenopausal Women: Where Are We?

We discuss the CV safety and efficacy data for subcutaneous testosterone therapy (STT) in postmenopausal women. We also highlight new directions and applications of correct dosages performed in a specialized center. To recommend STT, we propose innovative criteria (IDEALSTT) according to total testosterone (T) level, carotid artery intima-media thickness, and calculated SCORE for a 10-year risk of fatal cardiovascular disease (CVD). Despite all the controversies, hormone replacement therapy (HRT) with T has gained prominence in treating pre and postmenopausal women in the last decades. HRT with silastic and bioabsorbable testosterone hormone implants has gained prominence recently due to its practicality and effectiveness in treating menopausal symptoms and hypoactive sexual desire disorder. A recent publication on the complications of STT, looking at a large cohort of patients over seven years, demonstrated its long-term safety. However, the cardiovascular (CV) risk and safety of STT in women are still controversial.

Androgen-Induced Cardiovascular Risk in Polycystic Ovary Syndrome: The Role of T Lymphocytes

An estimated 15-20% of reproductive-age women are affected by polycystic ovary syndrome (PCOS). PCOS is associated with substantial metabolic and cardiovascular long-term consequences. In young women with PCOS, several cardiovascular risk factors may be found, including chronic inflammation, high blood pressure, and elevated leukocytes. These women are at an increased risk of cardiovascular diseases (CVD), not only during the reproductive years, but also with aging and menopause; therefore, the early prevention and treatment of future cardiovascular adverse effects are necessary. The fundamental characteristic of PCOS is hyperandrogenemia, which is associated with increased pro-inflammatory cytokines and T lymphocytes. Whether these factors play a role in the pathophysiology of hypertension, a risk factor of CVD, due to PCOS is not well established. This review will briefly discuss how a modest increase in androgens in females is linked to the development of hypertension through pro-inflammatory cytokines and T lymphocyte subsets and the promotion of renal injury. Moreover, it reveals a few existing research gaps in this area, including the lack of specific therapy directed at androgen-induced inflammation and immune activation, thus emphasizing the necessity to explore the systemic inflammation in women with PCOS to halt the inevitable inflammatory process targeting the underlying abnormalities of CVD.

Serum testosterone level correlates with left ventricular hypertrophy in older women

Introduction

Sex hormones may play an important role in age-related cardiac remodeling. However, their impact on cardiac structure and function in females of advanced age still remains unclear. The aim of this study is to evaluate the relationship between sex hormones level and echocardiographic parameters in older women with concomitant cardiovascular diseases.

Materials and Methods

The study group included 52 community-dwelling women with mean age 79.5 ± 2.8 years, consecutive patients of an outpatient geriatric clinic. In all the subjects, a transthoracic echocardiogram was performed and serum testosterone, estradiol, follicle-stimulating hormone, luteinising hormone, dehydroepiandrosterone sulphate, and cortisol levels were determined.

Results

Testosterone level correlated positively with interventricular septum diastolic dimension (IVSd) (rS=0.293, p<0.05), left ventricular mass index (rS=0.285, p<0.05), E/E' ratio (rS=0.301, p<0.05), and negatively with E' (rS=-0.301, p<0.05). Estradiol level showed a positive correlation with the posterior wall dimension (rS=0.28, p<0.05). Besides, no significant correlations between clinical or echocardiographic parameters and other hormones were observed. Female subjects with diagnosed left ventricular hypertrophy (LVH) (n=34) were characterized by a significantly higher rate of hypertension (p=0.011), higher waist-to-height ratio (p=0.009), higher testosterone level (0.82 vs. 0.48 nmol/L, p=0.024), higher testosterone/estradiol ratio (16.4 vs. 9.9, p=0.021), and received more anti-hypertensive drugs (p=0.030). In a multiple stepwise logistic regression, the best determinants of LVH were the presence of hypertension (OR=6.51; 95% CI 1.62-26.1), and testosterone level (OR= 6.6; 95% CI 1.19-36.6).

Conclusions

Higher serum testosterone levels may contribute to pathological cardiac remodeling, especially in hypertensive women. Estradiol, gonadotropins, DHEAS, and cortisol were not related to echocardiographic parameters.

Sex steroids and sex steroid-binding globulin levels amongst middle-aged and elderly men and women from general population

BACKGROUND AND AIMS

Availability of age- and sex-specific reference values for sex steroids and sex steroid-binding globulin (SHBG) levels allows for appropriate interpretation of research findings and their clinical applications. We report the sex-specific distribution and reference levels of sex steroids, including total estradiol, total testosterone and (calculated) free androgen index (cFAI), SHBG and other androgens dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulphate (DHEAS) and androstenedione across age.

METHODS

Using data from 3291 participants from the prospective population-based Rotterdam Study (2006-2008), we visualised the distribution of sex steroids and SHBG levels by calculating and depicting the 5th, 25th, 50th, 75th and 95th percentiles per year and per age-year across 5-year age bands to provide reference value ranges in men and women. Total estradiol and SHBG were measured using automated immunoassay and androgens using liquid chromatography-mass spectrometry (LC-MS/MS).

RESULT

Mean age was 56.8 (range 45.6-79.9) years in men and 56.9 (range 45.7-79.9) years in women. Amongst men, total estradiol and SHBG showed an increasing trend from 45 years onwards. In women, total estradiol and SHBG showed a decreasing trend from 45 years until the age of 60. From 60 years onwards, SHBG showed an increasing trend. For total testosterone, a clear declining trend was observed amongst men but not women. Other androgens showed a similar decreasing trend in both sexes from 45 years onwards.

DISCUSSION AND CONCLUSION

Our study underlines sex-specific trends in sex steroids and SHBG levels with ageing. This warrants taking into account sex- and age-specific reference values for sex steroids and SHBG when investigating their impact on health outcomes to prevent controversial results and allow for their appropriate clinical application.

Caloric restriction-mimetics for the reduction of heart failure risk in aging heart: with consideration of gender-related differences

The literature is full of claims regarding the consumption of polyphenol or polyamine-rich foods that offer some protection from developing cardiovascular disease (CVD). This is achieved by preventing cardiac hypertrophy and protecting blood vessels through improving the function of endothelium. However, do these interventions work in the aged human hearts? Cardiac aging is accompanied by an increase in left ventricular hypertrophy, along with diastolic and systolic dysfunction. It also confers significant cardiovascular risks for both sexes. The incidence and prevalence of CVD increase sharply at an earlier age in men than women. Furthermore, the patterns of heart failure differ between sexes, as do the lifetime risk factors. Do caloric restriction (CR)-mimetics, rich in polyphenol or polyamine, delay or reverse cardiac aging equally in both men and women? This review will discuss three areas: (1) mechanisms underlying age-related cardiac remodeling; (2) gender-related differences and potential mechanisms underlying diminished cardiac response in older men and women; (3) we select a few polyphenol or polyamine rich compounds as the CR-mimetics, such as resveratrol, quercetin, curcumin, epigallocatechin gallate and spermidine, due to their capability to extend health-span and induce autophagy. We outline their abilities and issues on retarding aging in animal hearts and preventing CVD in humans. We discuss the confounding factors that should be considered for developing therapeutic strategies against cardiac aging in humans.

High Prevalence of Asymptomatic Intracranial Atherosclerosis in Elder Women With Tubal Ligation: Result From a Community-Based Study in Shandong, China

Background

In addition to traditional cardiovascular risk factors, gender-specific factors may also contribute to intracranial atherosclerosis. This study aimed to comprehensively investigate the association between asymptomatic intracranial atherosclerosis (aICAS) and menstrual or reproductive history (MRH), namely, menstruation, pregnancy, childbirth, menopause, and contraception.

Methods

Participants in this study were selected from the Kongcun town aICAS study. MRH was collected through structured case report forms, in which menarche age, menstrual regularity, dysmenorrhea, number of pregnancies, number of childbirths, age of first pregnancy, breastfeeding, menopause, menopause age, and contraceptive methods were all involved. All characteristics were compared by chi-squared and nonparametric tests as applicable. Logistic regression model and sensitivity analysis were used to analyze the association between aICAS and MRH.

Results

A total of 1,052 female participants were involved in this study, of which 5.7% had moderate to severe aICAS. Tubal ligation was significantly associated with aICAS in univariate analysis [crude odds ratio (OR), 2.85; 95% CI, 1.22–6.62; P = 0.015]. This association was still significant among female participants over 60 years old after multivariate adjustment (adjusted OR, 4.36; 95% CI, 1.55–12.24; P = 0.005). Sensitivity analysis showed a similar result (adjusted OR, 3.76; 95% CI, 1.24–11.41; P = 0.020). Menopause lost significant association with aICAS after multivariate adjustment (adjusted OR, 1.68; 95% CI, 0.66–4.24; P = 0.275). No other MRH factors were found to be associated with aICAS.

Conclusion

Tubal ligation may be associated with a higher prevalence of aICAS in Chinese elderly women. This provides a new perspective to study the epidemiological characteristics of ICAS.

Sex Hormone-Binding Globulin and Its Association to Cardiovascular Risk Factors in an Italian Adult Population Cohort

Abnormal sex hormone-binding globulin (SHBG) and sex hormone concentrations are the cause or the consequence of cardiometabolic diseases, however, the clinical correlates of SHBG is clearly less understood. In our study we investigate sex- and age-specific serum SHBG levels and their association with cardiovascular risk (CVR) factors and high-risk conditions in an adult cohort of Italian population. Data from 1176 men and 2236 women, aged 20–81 were analyzed and serum SHBG determined in stored samples using an immunoassay. SHBG concentrations, higher in women than in men in the younger age groups, exhibited a curvilinear increase with age in men and a U-shaped curve across the lifespan in women, with a decrease from the 2nd to the 6th decade of age and an increase after the 6th decade when SHBG concentrations were similar in both sexes. Low SHBG serum levels correlated with the traditional CVR factors diabetes, obesity, and hypertension, whereas high level of SHBG correlated with cholesterol HDL. These associations were more numerous in women than in men, in whom decreased with age. The sex- and age specific differences observed in our population-based cohort should be considered in establishing reference ranges and clinical cut-off points to improve CVR score charts and therapeutic approaches.

Associations of endogenous sex hormone levels with the prevalence and progression of valvular and thoracic aortic calcification in the Multi-Ethnic Study of Atherosclerosis (MESA)

BACKGROUND AND AIMS

Sex hormones (SH) may contribute to sex differences in cardiovascular disease (CVD). High free testosterone (T) and low sex hormone binding globulin (SHBG) have been associated with progression of coronary artery calcification in women. We now examined the association of SH with extra-coronary calcification (ECC) prevalence and progression among MESA participants.

METHODS

We studied 2,737 postmenopausal women and 3,130 men free of clinical CVD with baseline SH levels. ECC measurements [ascending and descending thoracic aortic calcification (ATAC, DTAC), mitral annular calcification (MAC), aortic valve calcification (AVC)] were obtained by computed tomography at baseline and after 2.4 ± 0.9 years. We used multivariable Poisson regression to evaluate associations with ECC prevalence and incidence (Agatston scores >0) and linear mixed effects models for ECC progression, per 1-SD increment in log(SH) in women and men separately.

RESULTS

The mean age was 65 ± 9 and 62 ± 10 years for women and men, respectively. In women, greater free T and lower SHBG were associated with MAC incidence in a demographic-adjusted model only. In men, lower free T was associated with MAC prevalence, DTAC incidence and progression, while greater SHBG was associated with MAC prevalence and DTAC progression after further adjusting for CVD risk factors.

CONCLUSIONS

In this diverse cohort free of CVD, we found some associations of SH with ECC measures. In particular, free T was inversely associated with prevalent MAC and DTAC progression in men independent of CVD risk factors. SH may influence vascular calcification, but further work is needed to understand clinical implications of these findings.

Androgens promote vascular endothelial cell proliferation through activation of a ZIP9-dependent inhibitory G protein/PI3K-Akt/Erk/cyclin D1 pathway

While androgens have been reported to mediate cardiovascular endothelial cell proliferation, the potential involvement of membrane androgen receptors (mAR) has not been examined. Here we show ZIP9, a recently characterized mAR, mediates androgen-induced early proliferative events in human umbilical vein endothelial cells (HUVECs). Androgen treatment significantly increased cyclin D1 nuclear localization and proliferation, which were blocked by transfection with siRNA targeting ZIP9 but not the nuclear AR. Testosterone rapidly activated inhibitory G protein signaling, Erk, and Akt, and inhibition of these signaling members abrogated the ZIP9-mediated cyclin D1 and proliferative responses. Erk and Akt modulated cyclin D1 nuclear localization by upregulation of cyclin D1 mRNA and inhibition of GSK-3β activity, respectively. This is the first study to demonstrate a role for ZIP9 in HUVEC proliferation and indicates ZIP9 is a physiologically-relevant androgen receptor in the cardiovascular system that merits further study as a potential therapeutic target for treating cardiovascular disease.

Aging, Cardiovascular Risk, and SHBG Levels in Men and Women From the General Population

AIMS

Prior studies have reported inconsistent results for the association between sex hormone-binding globulin (SHBG) and cardiovascular disease among men and women. Although it is suggested that SHBG levels change with aging, the exact trend of SHBG across age and cardiovascular risk and the underlying mechanisms of these changes remain to be elucidated.

METHODS

Using data of 3264 men and women from a large population-based cohort study, we first visualized the distribution of serum SHBG levels across age. Second, we computed a cardiovascular risk factor sum score and investigated the mean SHBG levels across categories of the risk factor sum score and stratified per age-category. Next, linear regression models were used to investigate the associations between serum SHBG levels and age and potential regulators of SHBG, including body mass index (BMI), fasting insulin, sex steroids, thyroxine, and triglycerides.

RESULTS

Among men, a linear increase in SHBG levels with age and among women a U-shaped pattern was observed. Participants with larger number of cardiovascular risk factors had lower SHBG levels. When stratified by age, older participants had higher SHBG levels. A multivariate model including total testosterone and triglyceride levels in men and total testosterone, triglycerides, BMI, and fasting insulin in women explained, respectively, 46.2% and 31.8% of the variance in SHBG levels.

CONCLUSION

We observed a clear sex-specific pattern for SHBG levels with age. Our findings highlight the importance of taking into account the age-related changes in SHBG levels to avoid controversial results in the assessment of the cardiovascular risk associated with SHBG.

Menopause Per se Is Associated with Coronary Artery Calcium Score: Results from the ELSA-Brasil

Background: Menopause and aging deteriorate the metabolic profile, but little is known about how they independently contribute to structural changes in coronary arteries. We compared a broad cardiometabolic risk profile of women according to their menopausal status and investigated if menopause per se is associated with presence of coronary artery calcium (CAC) in the ELSA-Brasil. Materials and Methods: All participants, except perimenopausal women, who had menopause <40 years or from non-natural causes or reported use of hormone therapy were included. Sample was stratified according to menopause and age categories (premenopause ≤45 years, premenopause >45 years, and postmenopause); their clinical profile and computed tomography-determined CAC were compared using Kruskal-Wallis and chi squared test for frequencies. Associations of CAC (binary variable) with menopause categories adjusted for traditional and nontraditional covariables were tested using logistic regression. Results: From 2,047 participants 51 ± 9 years of age, 1,175 were premenopausal (702 ≤ 45 years) and 872 were postmenopausal women. Mean values of anthropometric variables, blood pressure, lipid and glucose parameters, branched-chain amino acids (BCAA), and homeosthasis model assessment (HOMA-IR), as well as frequencies of morbidities, were more favorable in premenopausal, particularly in younger ones. In crude analyses, CAC >0 was associated with triglyceride-rich lipoprotein remnants, dense low-density lipoprotein, BCAA, and other variables, but not with HOMA-IR. Menopause was independently associated with CAC >0 (odds ratios 2.37 [95% confidence interval 1.17-4.81]) when compared to the younger premenopausal group. Conclusion: Associations of menopause with CAC, independent of traditional and nontraditional cardiovascular risk factors, suggest that hormonal decline per se may contribute to calcium deposition in coronary arteries.

Longitudinal changes over three years in sex steroid hormone levels in women aged 70 years and over

OBJECTIVE

Sex steroid levels in women vary with increasing age from the age of 70 years (70+). Whether this reflects change within individuals with age or a survival advantage is not known. This study aimed to determine the stability of circulating sex steroids and SHBG over time in individual women aged 70+.

DESIGN

A prospective cohort study.

PARTICIPANTS

400 women, aged 70+ not using any sex steroid, anti-androgen/oestrogen or glucocorticoid therapy.

MAIN OUTCOME MEASUREMENTS

Sex steroid concentrations, measured by liquid chromatography-tandem mass spectrometry and sex hormone-binding globulin (SHBG) by immunoassay, in paired blood samples drawn 3 years apart and analysed together.

RESULTS

400 women, median (IQR) age 78.0 (8.6) years, were included in the analysis. Mean testosterone concentrations were statistically significantly higher in follow-up samples compared with baseline. The change was modest (mean change 31 pmol/L, 95% confidence interval (CI) 2.4-59.8; p = .034), and an increase was not observed in all women. There was a statistically significant decline in mean body mass index (mean change -0.4 kg/m² , 95% CI 0.6 to -0.3; p < .001) and a significant increase in the mean serum SHBG concentration (mean change 4.0 nmol/L, 95% CI 2.7-5.4; p < .001). The change observed in testosterone was not explained by the observed change in SHBG. There was no significant change in the mean oestrone or dehydroepiandrosterone concentration.

CONCLUSIONS

Testosterone concentrations in women aged 70+ were more likely to increase than decrease. Whether increasing testosterone concentrations in older women confer a survival advantage needs investigation.

Premature and Early Menopause in Relation to Cardiovascular Disease

Postmenopausal women have an increased risk for cardiovascular diseases. It has been postulated that the loss of ovarian function and subsequent deficiency of endogenous estrogens after menopause contributes to this elevated risk of cardiovascular disease in postmenopausal women. Compared with woman entering menopause at the mean age of 51 years, in women with early menopause or premature ovarian insufficiency the risk for cardiovascular disease is even greater. These women lack the cardioprotective effect of endogenous estrogens for many more years than do women entering natural menopause. The majority of data assessing the risk of cardiovascular disease in relation to age at menopause and specifically premature menopause are derived from large epidemiological cohort studies. In addition, observations in women undergoing bilateral oophorectomy at an early age provide convincing evidence regarding association between early menopause or POI and the development of cardiovascular events and mortality. Moreover, genetic variants associated with earlier age at menopause have also been found to increase the risk of cardiovascular events in women. It has been substantiated that hormone replacement therapy (HRT) decreases the risk for ischemic heart disease and eliminates the increased cardiovascular disease mortality. It is therefore crucial to start HRT as soon as possible, particularly in women with premature ovarian insufficiency.

Pathophysiological effects of androgens on the female vascular system

Sex hormones and their respective receptors affect vascular function differently in men and women, so it is reasonable to assume they play a role in the sex differences in cardiovascular disease states. This review focuses on how the effects of testosterone on arterial vessels impact the female vasculature. In women with androgen-excess polycystic ovary syndrome, and in transgender men, testosterone exposure is associated with high blood pressure, endothelial dysfunction, and dyslipidemia. These relationships suggest that androgens may exert pathophysiological effects on the female vasculature, and these effects on the female vasculature appear to be independent from other co-morbidities of cardiovascular disease. There is evidence that the engagement of androgens with androgen receptor induces detrimental outcomes in the female cardiovascular system, thereby representing a potential causative link with sex differences and cardiovascular regulation. Gender affirming hormone therapy is the primary medical intervention sought by transgender people to reduce the characteristics of their natal sex and induce those of their desired sex. Transgender men, and women with androgen-excess polycystic ovary syndrome both represent patient groups that experience chronic hyperandrogenism and thus lifelong exposure to significant medical risk. The study of testosterone effects on the female vasculature is relatively new, and a complex picture has begun to emerge. Long-term research in this area is needed for the development of more consistent models and controlled experimental designs that will provide insights into the impact of endogenous androgen concentrations, testosterone doses for hormone therapy, and specific hormone types on function of the female cardiovascular system.

No association between postmenopausal time and the prevalence of newly discovered asymptomatic intracranial atherosclerotic stenosis: The APAC study

INTRODUCTION

Asymptomatic intracranial atherosclerotic stenosis (AICAS) is a common cause of stroke. Elderly women were more likely than men to develop AICAS, although it indicated that a lifelong exposure to estrogen could lower the risks of cardiovascular disease (CVDs).

OBJECTIVE

The present study aims to ascertain whether postmenopausal time is a risk factor of AICAS. Fostering a correct perception of menopause is of great significance for the overall well-being of the elderly women.

METHODS

All participants received a questionnaire, physical examination, laboratory testing and transcranial Doppler. The menopausal population (n = 701) was divided into three groups by tertiles of postmenopausal time. Two-tailed testing and trend test were used to reveal the relationship between postmenopausal time and newly discovered AICAS. Other potential risk factors were also analyzed to ascertain whether there was a relation between postmenopausal time and the newly discovered ICAS.

RESULTS

Both mean age and mean postmenopausal time were gradually increased from G0 to G2. The same trend occurred in hypertension, diabetes mellitus, total cholesterol, triglyceride, C-reactive protein and serum homocysteine. Adjusting for various confounding factors, postmenopausal time was not a risk factor for newly discovered AICAS. Multifactor analysis and stratifying analysis showed no correlation between newly discovered AICAS and postmenopausal time.

CONCLUSIONS

Postmenopausal time is not an independent risk factor of AICAS. No relationship was detected between postmenopausal time and newly discovered AICAS, while vigorous control of body weight, blood pressure/glucose/lipids and smoke cessation are vital for preventing the occurrence of AICAS.

Associations of Endogenous Sex Hormones with Carotid Plaque Burden and Characteristics in Midlife Women

CONTEXT

Endogenous sex hormones may be involved in the pathogenesis of cardiovascular disease (CVD) in women. Carotid plaque characteristics, such as echogenicity, an ultrasound measure that reflects plaque composition, may identify unstable plaques that are more likely to rupture, precipitating a CVD event. However, few studies have considered sex steroids in relation to carotid plaque and its characteristics.

OBJECTIVE

To evaluate estrone (E1), estradiol (E2), testosterone (T), sex hormone binding globulin (SHBG), and free T (FT) in relation to carotid plaque in women.

DESIGN, SETTING, AND PARTICIPANTS

In MsHeart, a cross-sectional study of 304 women aged 40 to 60 years, participants underwent a carotid artery ultrasound assessment. The current analysis included MsHeart participants with carotid plaque (n = 141, 46%). E1, E2, and T were assayed using liquid chromatography-tandem mass spectrometry; FT was estimated using ensemble allostery models. Regression models were adjusted for sociodemographic characteristics and CVD risk factors.

MAIN OUTCOMES

Carotid plaque burden (number of plaques, total plaque area [TPA]) and characteristics (calcification, echogenicity) were determined using semi-automated software.

RESULTS

SHBG was inversely related to TPA (odds ratio [OR] 0.39; 95% confidence interval [CI] 0.21, 0.74; multivariable) and higher FTs were associated with greater TPA (OR 2.89; 95% CI 1.31, 6.37; multivariable). Higher E1 was related to echogenicity (OR 2.31; 95% CI 1.26, 4.33; multivariable), characteristic of more stable plaque.

CONCLUSIONS

SHBG and FT are related to TPA while E1 is related to plaque echogenicity, suggesting these hormones have different roles in the development of carotid plaque. Our findings highlight the importance of sex hormones in the development of carotid plaque in midlife women.

Hyperandrogenemia is Common in Asymptomatic Women and is Associated with Increased Metabolic Risk

OBJECTIVE

Women with metabolic syndrome (MetS) have higher endogenous testosterone (T) levels than unaffected women. This study investigated whether hyperandrogenemia (HA) was a marker for increased cardiometabolic risk in reproductively normal premenopausal women.

METHODS

Reproductive hormones and metabolic parameters were assessed in 198 women with regular menses and no clinical hyperandrogenism (eumenorrheic [EM]). Hyperandrogenic EM women were compared with 110 women with NIH criteria polycystic ovary syndrome.

RESULTS

Twenty-two percent of EM women had HA. Levels of non-sex hormone-binding globulin (SHBG)-bound T were elevated in 68% of women, total T levels were elevated in 43% of women, and dehydroepiandrosterone sulfate levels were elevated in 30% of women. The prevalence of HA increased with BMI category (P = 0.01): 12% for BMI < 25 kg/m2 , 22% for BMI of 25 to 30 kg/m2 , and 31% for BMI ≥ 30 kg/m2 . MetS (adjusted odds ratio 2.9; 95% CI: 1.2-6.9) and dysglycemia risks (adjusted odds ratio 2.7; 95% CI: 1.2-5.8) were increased in hyperandrogenic EM women compared with normoandrogenic EM women, with adjustment for BMI. SHBG levels were independently associated with these metabolic end points (P < 0.001), whereas androgen levels were not. A cluster analysis confirmed that there was a discrete subset of EM women with HA and metabolic abnormalities.

CONCLUSIONS

HA is common in EM women and is associated with increased risks for MetS and dysglycemia. However, low SHBG levels rather than elevated androgen levels may be the primary predictor of this relationship with metabolic dysfunction.

Cardiovascular health and menopause in aging women with polycystic ovary syndrome

Introduction: Polycystic ovary syndrome (PCOS) is a common endocrine disorder with heterogeneous clinical manifestations. Current evidence suggests that women with PCOS exhibit an unfavorable metabolic profile which may pose them at increased risk for cardiovascular events later in life.Areas covered: Herein, we present a review of the existing literature relating to PCOS and long-term cardiovascular (CV) health risks in women after menopause. We performed an electronic-based search with the use of PubMed from 1990 to August 2019 and systematically reviewed studies assessing CV events in women with PCOS. We aimed to outline the gaps in the current evidence and suggest areas for future research.Expert opinion: Although there is a clear association between PCOS and cardiometabolic dysfunction, data on actual cardiovascular disease (CVD) events are conflicting. Additional large, prospective cohort studies of well-phenotyped women with PCOS and long-term follow-up into the late menopause are needed to elucidate the true CVD risk in this population.

Endogenous Sex Hormones and Incident Cardiovascular Disease in Post-Menopausal Women

BACKGROUND

Higher androgen and lower estrogen levels are associated with cardiovascular disease (CVD) risk factors in women. However, studies on sex hormones and incident CVD events in women have yielded conflicting results.

OBJECTIVES

The authors assessed the associations of sex hormone levels with incident CVD, coronary heart disease (CHD), and heart failure (HF) events among women without CVD at baseline.

METHODS

The authors studied 2,834 post-menopausal women participating in the MESA (Multi-Ethnic Study of Atherosclerosis) with testosterone, estradiol, dehydroepiandrosterone, and sex hormone binding globulin (SHBG) levels measured at baseline (2000 to 2002). They used Cox hazard models to evaluate associations of sex hormones with each outcome, adjusting for demographics, CVD risk factors, and hormone therapy use.

RESULTS

The mean age was 64.9 ± 8.9 years. During 12.1 years of follow-up, 283 CVD, 171 CHD, and 103 HF incident events occurred. In multivariable-adjusted models, the hazard ratio (95% confidence interval [CI]) associated with 1 SD greater log-transformed sex hormone level for the respective outcomes of CVD, CHD, and HF were as follows: total testosterone: 1.14 (95% CI: 1.01 to 1.29), 1.20 (95% CI: 1.03 to 1.40), 1.09 (95% CI: 0.90 to 1.34); estradiol: 0.94 (95% CI: 0.80 to 1.11), 0.77 (95% CI: 0.63 to 0.95), 0.78 (95% CI: 0.60 to 1.02); and testosterone/estradiol ratio: 1.19 (95% CI: 1.02 to 1.40), 1.45 (95% CI: 1.19 to 1.78), 1.31 (95% CI: 1.01 to 1.70). Dehydroepiandrosterone and SHBG levels were not associated with these outcomes.

CONCLUSIONS

Among post-menopausal women, a higher testosterone/estradiol ratio was associated with an elevated risk for incident CVD, CHD, and HF events, higher levels of testosterone associated with increased CVD and CHD, whereas higher estradiol levels were associated with a lower CHD risk. Sex hormone levels after menopause are associated with women's increased CVD risk later in life.

Classical Cardiovascular Risk Factors and HIV are Associated With Carotid Intima-Media Thickness in Adults From Sub-Saharan Africa: Findings From H3Africa AWI-Gen Study

Background Studies on the determinants of carotid intima-media thickness ( CIMT ), a marker of sub-clinical atherosclerosis, mostly come from white, Asian, and diasporan black populations. We present CIMT data from sub-Saharan Africa, which is experiencing a rising burden of cardiovascular diseases and infectious diseases. Methods and Results The H3 (Human Hereditary and Health) in Africa's AWI-Gen (African-Wits-INDEPTH partnership for Genomic) study is a cross-sectional study conducted in adults aged 40 to 60 years from Burkina Faso, Kenya, Ghana, and South Africa. Cardiovascular disease risk and ultrasonography of the CIMT of right and left common carotids were measured. Multivariable linear and mixed-effect multilevel regression modeling was applied to determine factors related to CIMT. Data included 8872 adults (50.8% men), mean age of 50±6 years with age- and sex-adjusted mean (±SE) CIMT of 640±123μm. Participants from Ghana and Burkina Faso had higher CIMT compared with other sites. Age (β = 6.77, 95%CI [6.34-7.19]), body mass index (17.6[12.5-22.8]), systolic blood pressure (7.52[6.21-8.83]), low-density lipoprotein cholesterol (5.08[2.10-8.06]) and men (10.3[4.75- 15.9]) were associated with higher CIMT. Smoking was associated with higher CIMT in men. High-density lipoprotein cholesterol (-12.2 [-17.9- -6.41]), alcohol consumption (-13.5 [-19.1--7.91]) and HIV (-8.86 [-15.7--2.03]) were inversely associated with CIMT. Conclusions Given the rising prevalence of cardiovascular diseases risk factors in sub-Saharan Africa, atherosclerotic diseases may become a major pan-African epidemic unless preventive measures are taken particularly for prevention of hypertension, obesity, and smoking. HIV -specific studies are needed to fully understand the association between HIV and CIMT in sub-Saharan Africa.

Association of serum androgens and coronary artery calcium scores in women

OBJECTIVE

To determine the association between serum androgens measured by high-resolution liquid chromatography-mass spectrometry and coronary artery calcium (CAC) scores.

DESIGN

Cross-sectional study.

SETTING

Academic institution.

PATIENT(S)

A total of 239 women, aged 40-75 years, with CAC testing and complete cardiovascular disease risk evaluation. Total T, DHEA, and androstenedione were measured using high-resolution liquid chromatography-mass spectrometry, whereas E₂ and sex hormone-binding globulin were measured using commercial assays.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Independent associations between CAC scores and sex steroids.

RESULT(S)

Overall, 164 subjects had a CAC score < 10, 48 had a CAC score between 10 and 100, and 27 had a score > 100. There were no differences in sex hormone levels between women with CAC scores > 10 vs. CAC scores ≤ 10. In multivariable models adjusting for age, body mass index, and low-density lipoprotein cholesterol, a higher T/E₂ ratio was associated with an elevated CAC score, with an unadjusted odds ratio associated with 1-SD change in log-transformed T/E₂ of 1.38 (95% confidence interval 1.01-1.89) and adjusted OR 1.02 (95% confidence interval 1.002-1.04). Total T, DHEA, androstenedione, sex hormone-binding globulin, and E₂ levels were not associated with increased CAC.

CONCLUSION(S)

In the general population, there are mixed reports regarding the relationship between serum androgens and risk factors for cardiovascular disease, and limited information on the relationship between androgens and subclinical atherosclerosis. Our study shows that increased androgens relative to estrogens may have a weak but independent association with subclinical atherosclerosis, as measured by CAC scores.

Genetic polymorphisms of the SHBG gene can be the effect on SHBG and HDL-cholesterol levels in Coronary Heart Disease: a case-control study

Sex hormone binding globulin (SHBG) level is positively associated with the high-density lipoprotein cholesterol (HDL-C) levels. The aim of this study was to investigate the effects of the SHBG gene variations (D356N, rs1799941, and P156L) on SHBG and HDL-C levels and Coronary Heart Disease (CHD) risk. The SHBG D356 N (rs6259,G > A), P156L (rs6258,C > T), and rs1799941(G > A) polymorphisms were determined in 131 male CHD patients and 55 male controls by PCR-RFLP and real-time PCR techniques. SHGB levels were measured by Electro-chemiluminescence immunoassay (ECLIA). In the patients who had SHBG levels lower than threshold 35 nmol/l value, the risk of being HDL-C levels lower than threshold 0.90 mmol/l value was observed statistically significant (p = 0.017; OR 2.522, 95% CI 1.170-5.438). The rs1799941 GG was associated with increased CHD risk when compared with the A allele carriers (GA + AA) (p = 0.019, OR 2.222, 95% CI 1.130-4.371). In addition, the rs1799941 GG genotype and D356 N N allele were associated with lower SHBG in the CHD group (p < 0.01). The logistic regression analysis also revealed the rs1799941 GG genotype was significantly associated with low SHBG in CHD patients. It was observed that Haplotype-1(rs1799941 G allele-P156L P allele-D356 N D allele) was associated with increased CHD risk, while Haplotype-2 (rs1799941 rare A allele-P156L C allele- D356 N G allele) was correlated with the decreased CHD risk (p = 0.0167). Our findings suggest that there is a positive correlation between SHBG and HDL-C levels in CHD patients, and this association might be affected by SHBG gene variations.

Testosterone, myocardial function, and mortality

The cardiovascular system is particularly sensitive to androgens, but some controversies exist regarding the effect of testosterone on the heart. While among anabolic abusers, cases of sudden cardiac death have been described, recently it was reported that low serum level of testosterone was correlated with increased risk of cardiovascular diseases (CVD) and mortality rate. This review aims to evaluate the effect of testosterone on myocardial tissue function, coronary artery disease (CAD), and death. Low testosterone level is associated with increased incidence of CAD and mortality. Testosterone administration in hypogonadal elderly men and women has a positive effect on cardiovascular function and improved clinical outcomes and survival time. Although at supraphysiologic doses, androgen may have a toxic effect, and at physiological levels, testosterone is safe and exerts a beneficial effect on myocardial function including mechanisms at cellular and mitochondrial level. The interaction with free testosterone and estradiol should be considered. Further studies are necessary to better understand the interaction mechanisms for an optimal androgen therapy in CVD.

Differences in association of lower bone mineral density with higher coronary calcification in female and male end-stage renal disease patients

Background

Risk of cardiac events and cardiovascular disease (CVD) in end-stage renal disease (ESRD) patients are predicted by coronary artery calcification (CAC) independently. It is not clear to what extent low bone mineral density (BMD) is associated with higher risk of CAC and if sex interacts. We investigated the sex-specific associations of CAC score with total body BMD (tBMD) as well as with BMD of different skeletal sub-regions.

Methods

In 174 ESRD patients, median age 57 (10th–90th percentiles 29–75) years, 63% males, BMD (measured by dual-energy X-ray absorptiometry; DXA), CAC score (measured by cardiac CT) and circulating inflammatory biomarkers were analysed.

Results

A total of 104 (60%) patients with CAC > 100 AUs were older, had higher prevalence of both clinical CVD and diabetes, higher level of high sensitivity C-reactive protein, tumour necrosis factor, interleukin-6 and lower T-score of tBMD. Female patients had significantly lower tBMD and BMD of all skeletal sub-regions, except head, than male patients. Female patients with high CAC (> 100 AUs) had significantly decreased T-score of tBMD, and lower BMD of arms, legs than those low CAC (≤ 100 AUs); elevated CAC score were associated with tBMD, T-score, Z-score of tBMD and BMD of arms and legs, while no such differences was observed in males. Multivariate generalized linear model (GLM) analysis adjusted for age, diabetes and hsCRP showed that in females per SD higher CAC score (1057 AUs) was predicted by either per SD (0.13 g/cm²) lower tBMD or per SD (0.17 g/cm²) lower BMD at legs. No such associations were found in male ESRD patients.

Conclusions

In female, but not male, lower BMD, in particular sub-regions of legs, was associated with higher CAC score independently. Low BMD has the potential to identify increased risk for high CAC score in ESRD patients.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1235-z) contains supplementary material, which is available to authorized users.

Polycystic ovary syndrome and the risk of cardiometabolic complications in longitudinal studies

The purpose of this study was to perform a review of the longitudinal studies to determine whether polycystic ovary syndrome is associated with higher prevalence of metabolic complications and cardiovascular morbidity and mortality. The primary outcomes included body mass index, metabolic syndrome and its components (waist circumference, lipid profile, arterial hypertension, abnormal glucose metabolism (impaired fasting glucose, impaired glucose tolerance, type 2 diabetes), insulin resistance, and cardiovascular diseases like stroke, angina, and coronary heart disease. Complications in pregnant women were beyond the scope of this review. PubMed database (1992-2018) was searched to identify proper publications. Finally, data from 47 articles were analysed. Studies differed in the design (prospective, retrospective, cohort, observational), research methods, polycystic ovary syndrome diagnostic criteria, studied populations, race, and ethnicity of the participants. Based on the data collected, it appears that women with polycystic ovary syndrome have higher prevalence of obesity, abdominal fat distribution, dyslipidaemia and deterioration of glucose metabolism, but increased prevalence of cardiovascular diseases is not proven.

Cardiovascular Implications of the Menopause Transition: Endogenous Sex Hormones and Vasomotor Symptoms

The menopause transition (MT) is a critical period of women's lives marked by several physiologic changes and menopause-related symptoms that have implications for health. Risk for cardiovascular disease, the leading cause of death in women, increases after menopause, suggesting a contribution of the MT to its development. This article focuses on the relationship between 2 main features of the MT and women's cardiovascular health: (1) dynamic alterations of sex hormones, particularly endogenous estradiol and follicle-stimulating hormone, and (2) vasomotor symptoms, the cardinal symptom of the menopause. Limitations and future directions are discussed.

Association of endogenous sex hormone levels with coronary artery calcium progression among post-menopausal women in the Multi-Ethnic Study of Atherosclerosis (MESA)

BACKGROUND

Sex differences in the incidence and manifestation of cardiovascular disease (CVD) suggest the involvement of sex hormones in disease pathogenesis. Coronary artery calcium (CAC) and its progression, measured by non-contrast cardiac computed tomography, are markers of subclinical atherosclerosis and predict CVD, even among low-risk women. We hypothesized that sex hormone levels were associated with CAC progression among women in the Multi-Ethnic Study of Atherosclerosis.

METHODS

We studied 2759 post-menopausal women (age 65 ± 9 years), free of baseline CVD, with baseline serum sex hormones and CAC measured at Exam 1 (2000-2002). Of this sample, 2427 had ≥1 follow-up CAC measurement through Exam 5 (2010-2012). Using mixed effects linear regression methods, we tested change in log[CAC+1] score by log[sex hormone] levels (continuous, comparing the 90th versus 10th percentiles). Models adjusted for demographics, lifestyle factors, cardiovascular risk factors, hormone therapy, and years since menopause.

RESULTS

At baseline, we found no associations between sex hormones and prevalent CAC. Over a median of 4.7 years, in fully-adjusted models, women with higher free testosterone levels had relatively greater CAC progression [Ratio 1.26 (95% CI 1.01-1.56)], whereas higher sex hormone binding globulin (SHBG) was associated with lower progression risk [0.80 (0.64-0.99). No associations were seen for total testosterone, estradiol, or dehydroepiandrosterone.

CONCLUSION

A more androgenic hormone profile of higher free testosterone and lower SHBG is associated with a greater CAC progression up to 10-years in post-menopausal women. Sex hormone levels may help identify women at increased risk for CVD who may benefit from additional risk-reducing strategies.

Sex differences in endothelial function important to vascular health and overall cardiovascular disease risk across the lifespan

Diseases of the cardiovascular system are the leading cause of morbidity and mortality in men and women in developed countries, and cardiovascular disease (CVD) is becoming more prevalent in developing countries. The prevalence of atherosclerotic CVD in men is greater than in women until menopause, when the prevalence of CVD increases in women until it exceeds that of men. Endothelial function is a barometer of vascular health and a predictor of atherosclerosis that may provide insights into sex differences in CVD as well as how and why the CVD risk drastically changes with menopause. Studies of sex differences in endothelial function are conflicting, with some studies showing earlier decrements in endothelial function in men compared with women, whereas others show similar age-related declines between the sexes. Because the increase in CVD risk coincides with menopause, it is generally thought that female hormones, estrogens in particular, are cardioprotective. Moreover, it is often proposed that androgens are detrimental. In truth, the relationships are more complex. This review first addresses female and male sex hormones and their receptors and how these interact with the cardiovascular system, particularly the endothelium, in healthy young women and men. Second, we address sex differences in sex steroid receptor-independent mechanisms controlling endothelial function, focusing on vascular endothelin and the renin-angiotensin systems, in healthy young women and men. Finally, we discuss sex differences in age-associated endothelial dysfunction, focusing on the role of attenuated circulating sex hormones in these effects.

Reproductive Hormones and Subclinical Cardiovascular Disease in Midlife Women

CONTEXT

Reproductive hormones are important to the pathophysiology of cardiovascular disease (CVD) in women. However, standard estradiol (E2) and testosterone (T) assays lack sensitivity at the levels of postmenopausal women.

OBJECTIVE

Investigate relations of mass spectrometry-assessed estrone (E1), E2, and T and SHBG and subclinical CVD in women.

DESIGN, SETTING, AND PARTICIPANTS

Three hundred and four perimenopausal and postmenopausal women aged 40 to 60 years underwent subclinical CVD measurements. E1, E2, and T were assayed using liquid chromatography-tandem mass spectrometry; free T (FT) was estimated using ensemble allostery models. Regression models were adjusted for CVD risk factors.

MAIN OUTCOME MEASURES

Carotid artery intima media thickness, interadventitial diameter (IAD), and plaque; brachial flow mediated dilation (FMD).

RESULTS

Higher E1 was related to higher FMD [β(SE) = 0.77 (0.37), P = 0.04], indicating better endothelial function. Higher E2 was related to lower IAD [β(SE) = -0.07 (0.02), P = 0.004], indicating less carotid remodeling. Higher SHBG was related to higher FMD [β(SE) = 1.31 (0.40), P = 0.001], yet higher IAD [β(SE) = 0.15 (0.06), P = 0.02] and plaque [OR (95% CI) = 1.84 (1.16 to 2.91), P = 0.009]; FT showed a similar yet inverse pattern of relations as SHBG. Thus, higher SHBG and lower FT were associated with better endothelial function, yet greater carotid remodeling and plaque.

CONCLUSIONS

Endogenous E1 levels were related to endothelial function and E2 to vascular remodeling, suggesting distinct roles of these estrogens. SHBG and FT have complex roles depending on the vessel under study.

High Androgens in Postmenopausal Women and the Risk for Atherosclerosis and Cardiovascular Disease: The Rotterdam Study

CONTEXT

Polycystic ovary syndrome (PCOS) is closely linked to hyperandrogenism (HA). In PCOS, HA has been associated with metabolic disturbances that increase the risk for cardiovascular disease (CVD).

OBJECTIVE

To assess the association of high serum androgen levels, as a postmenopausal remnant of PCOS, with the prevalence of atherosclerosis and incidence of CVD in postmenopausal women.

DESIGN

The Rotterdam Study, a prospective population-based cohort study. Median follow-up was 11.36 years.

SETTING

General community.

PARTICIPANTS

A total of 2578 women aged >55 years. Exclusion criteria were missing informed consent or follow-up data, perimenopausal status, and menopause by surgical intervention or at an unnatural age (age <40 or >62).

INTERVENTION

None.

MAIN OUTCOMES AND MEASURES

Linear, logistic, and Cox regression models assessed the association of top quartiles (P75) of serum testosterone, free androgen index (FAI), dehydroepiandrosterone, and androstenedione and sex hormone-binding globulin with coronary artery calcium, carotid intima-media thickness (IMT), pulse wave velocity, peripheral artery disease, and incidence of coronary heart disease (CHD), stroke, and CVD.

RESULTS

Mean age (standard deviation) was 70.19 (8.71) years, and average time since menopause was 19.85 (9.94) years. Highest quartile FAI was associated with higher pulse wave velocity (β [95% confidence interval (CI)], 0.009 [0.000 to 0.018]). Highest quartile dehydroepiandrosterone [β (95% CI), -0.008 (-0.015 to -0.001)] and androstenedione [β (95% CI), -0.010 (-0.017 to -0.003)] levels were associated with a lower IMT. We found no association between high androgen levels and incident stroke, CHD, or CVD.

CONCLUSION

Postmenopausal high androgen levels were not associated with an elevated risk for CVD. Cardiovascular health in women with PCOS might be better than was anticipated.

Androgens, Irregular Menses, and Risk of Diabetes and Coronary Artery Calcification in the Diabetes Prevention Program

CONTEXT

It is unclear whether relative elevations in androgens or irregular menses (IM) are associated with greater cardiometabolic risk among women who are already overweight and glucose intolerant.

RESEARCH DESIGN AND METHODS

We conducted a secondary analysis of the Diabetes Prevention Program (DPP) and the Diabetes Prevention Program Outcomes Study (DPPOS). Participants included women with sex hormone measurements who did not use exogenous estrogen (n = 1422). We examined whether free androgen index (FAI) or IM was associated with diabetes risk during the DPP/DPPOS or with coronary artery calcification (CAC) at DPPOS year 10. Models were adjusted for menopausal status, age, race or ethnicity, randomization arm, body mass index (BMI), and hemoglobin A1c.

RESULTS

Women had an average age of 48.2 ± 9.9 years. Elevations in FAI and IM were associated with greater BMI, waist circumference, and blood pressure and lower adiponectin. FAI was not associated with diabetes risk during the DPP/DPPOS [hazard ratio (HR) 0.97; 95% confidence interval (CI), 0.93 to 1.02] or increased odds of CAC [odds ratio (OR) 1.06; 95% CI, 0.92 to 1.23]. IM was also not associated with diabetes risk during the DPP/DPPOS (HR 1.07; 95% CI, 0.87 to 1.31) or increased odds of CAC (OR 0.89; 95% CI, 0.53 to 1.49). Women who had both relative elevations in FAI and IM had similar diabetes risk and odds of CAC as women without these conditions. Differences by treatment arm and menopausal status were not observed.

CONCLUSIONS

Among midlife women who were already glucose intolerant and overweight, androgen concentrations and IM did not additionally contribute to increased risk for diabetes or CAC.

Gaps, limitations and new insights on endogenous estrogen and follicle stimulating hormone as related to risk of cardiovascular disease in women traversing the menopause: A narrative review

While it is known that estrogen protects heart health in women prior to menopause, its role after menopause and during the menopause transition is far less apparent. Previous reviews summarizing the literature on the impact of endogenous estrogen on risk of cardiovascular disease (CVD) have focused on postmenopausal women and have not come to a clear conclusion. No previous review has summarized the associations between follicle stimulating hormone (FSH), a proxy measure of the menopause transition, and CVD risk. The main purpose of this narrative review is to highlight gaps and limitations in the literature on endogenous estrogen and FSH as related to CVD risk. Future directions are addressed in light of recent findings in the field. When studying the relationship of estrogen to cardiovascular risk, it is critical to separate endogenously produced estrogen from exogenously administered estrogen. Moreover, other reproductive hormones such as FSH should be assessed, since growing evidence suggests a potential contribution of this hormone. Evaluation of estrogen changes over time allows a separation of women based on their hormone trajectories. These individual trajectories correlate with subclinical CVD and thus indicate that it is much more important to observe a woman over time rather than ascribe risk to a single determination at a single time point. As women progress through menopause and the ovary stops producing estradiol, the nature of the relationship between estrogens and subclinical CVD markers also appears to undergo a switch. Studies are needed to examine the midlife course of endogenous estradiol, FSH and CVD risk. These studies should also consider other hormones, including androgens, with an eye towards helping women modify their cardiovascular risk in midlife, when prevention is most likely possible.

The role of iron in the pathogenesis of atherosclerosis

Ferritin and increased iron stores first appeared on the list of cardiovascular risk factors more than 30 years ago and their causal role in the pathogenesis of atherosclerosis has been heavily discussed since the early 1990s. It seems that besides traditional factors such as hyperlipoproteinemia, hypertension, diabetes mellitus, obesity, physical inactivity, smoking and family history, high iron stores represent an additional parameter that could modify individual cardiovascular risk. The role of iron in the pathogenesis of atherosclerosis was originally primarily associated with its ability to catalyze the formation of highly reactive free oxygen radicals and the oxidation of atherogenic lipoproteins. Later, it became clear that the mechanism is more complex. Atherosclerosis is a chronic fibroproliferative inflammatory process and iron, through increased oxidation stress as well as directly, can control both native and adaptive immune responses. Within the arterial wall, iron affects all of the cell types that participate in the atherosclerotic process (monocytes/macrophages, endothelial cells, vascular smooth muscle cells and platelets). Most intracellular iron is bound in ferritin, whereas redox-active iron forms labile iron pool. Pro-inflammatory and anti-inflammatory macrophages within arterial plaque differ with regard to the amount of intracellular iron and most probably with regard to their labile iron pool. Yet, the relation between plasma ferritin and intracellular labile iron pool has not been fully clarified. Data from population studies document that the consumption of meat and lack of physical activity contribute to increased iron stores. Patients with hereditary hemochromatosis, despite extreme iron storage, do not show increased manifestation of atherosclerosis probably due to the low expression of hepcidin in macrophages.

Androgens and cardiovascular disease in women and men

Cardiovascular disease is the leading cause of death in both women and men. Its pathogenesis is multifactorial, with sex hormones playing an important role. Androgens have both direct and indirect effects on the vasculature. This review summarizes evidence on the association of both endogenous and exogenous androgens with subclinical and overt cardiovascular disease in women and men. Concerning women, both high and low levels of endogenous androgens have been associated with cardiovascular disease, while other studies have reported no association. Adiposity, impaired glucose metabolism, dyslipidemia and estrogen levels may mediate the observed associations. Regarding testosterone therapy in women, there have been no large prospective studies on cardiovascular outcomes. Concerning men, most studies indicate that low levels of circulating testosterone are associated with increased rates of cardiovascular disease in the general population; the causality, however, of this association remains to be proven. Testosterone replacement therapy in men with symptoms of hypogonadism and low serum testosterone merits caution with regard to cardiovascular safety, as evidence is still conflicting.

Androsterone glucuronide to dehydroepiandrosterone sulphate ratio is discriminatory for obese Caucasian women with polycystic ovary syndrome

BACKGROUND

Androsterone glucuronide (ADTG) concentrations have been suggested as a marker of the effects of androgens at the target tissue level. As the mechanism for hyperandrogenemia in obese and nonobese polycystic ovary syndrome (PCOS) may differ, this study compared the different androgen parameters in non-obese compared to obese women with PCOS, and in normal subjects.

METHODS

Eleven non-obese and 14 obese women with PCOS were recruited and compared to 11 control women without PCOS. Total testosterone, dehydroepiandrosterone sulphate (DHEAS), ADTG, and androstenedione were analysed using gold standard tandem mass spectrometry, and the free androgen index (FAI) was calculated.

RESULTS

Total testosterone, ADTG and androstendione levels did not differ between non-obese (body mass index (BMI) ≤25 kg/m²) and obese PCOS (BMI >25 kg/m²) but all were significantly higher than for controls (p < 0.01). The ADTG to DHEAS ratio was significantly elevated 39 ± 6 (p < 0.01) in obese PCOS in comparison to non-obese PCOS and controls (28 ± 5 and 29 ± 4, respectively). The free androgen index (FAI) and insulin resistance (HOMA-IR) were significantly higher in obese PCOS compared to non-obese PCOS and controls (p < 0.01). DHEAS was significantly higher in the non-obese versus obese PCOS (p < 0.01). All androgen parameters were significantly lower and sex hormone binding globulin (SHBG) significantly higher in normal subjects compared to those with obese and non-obese PCOS.

CONCLUSIONS

The ADTG:DHEAS ratio was significantly elevated in obese PCOS compared to non-obese PCOS and controls suggesting that this may be a novel biomarker discriminatory for obese PCOS subjects, perhaps being driven by higher hepatic 5α reductase activity increasing ADTG formation in these women.

Low Levels of Sex Hormone-Binding Globulin Constitute an Independent Risk Factor for Arterial Stiffness in Korean Women

The association between sex hormone-binding globulin (SHBG) and arterial stiffness in women is not conclusive. In addition, obesity might also be involved in the relationship between SHBG and atherosclerosis. The aim of this study was to determine the relationship between SHBG and arterial stiffness in association with central obesity in women. This cross-sectional study included 381 women who participated in the health checkup programs in one hospital. The brachial-ankle pulse wave velocity (baPWV) was measured as a marker for arterial stiffness. A negative correlation was observed between SHBG levels and baPWV (rho = -0.281). The relationship was significant even after adjusting for potential confounders (beta = -0.087 in fully adjusted model). After considering the interaction between central obesity and SHBG levels, the significant association was evident only in obese women (P for interaction = 0.025). Adjustment for a 10-year atherosclerotic cardiovascular disease (ASCVD) risk scores, instead of each cardiovascular risk factor individually, did not affect the significance of the relationship between SHBG levels and baPWV. Serum levels of SHBG were negatively associated with arterial stiffness independent of cardiovascular risk factors or 10-year ASCVD risk scores in Korean women. The relationship may be potentiated by central obesity.

Cardiovascular Risk in Women With Premature Ovarian Insufficiency Compared to Premenopausal Women at Middle Age

CONTEXT

A young age at menopause has been associated with increased cardiovascular disease (CVD) risk.

OBJECTIVE

To compare the cardiovascular risk profile between women with premature ovarian insufficiency (POI) and premenopausal controls of comparable age.

DESIGN

Cross-sectional case control study.

SETTING

Two university medical centers.

PARTICIPANTS

Women above 45 years of age who were previously diagnosed with POI (n = 83) and premenopausal population controls of comparable age (n = 266).

MAIN OUTCOME MEASURES

Blood pressure, body mass index, waist circumference, electrocardiogram, bilateral carotid intima media thickness, estradiol, T, androstenedione, dehydroepiandrosterone sulfate, SHBG, insulin, glucose, lipids, TSH, free T4, N-terminal pro-B-type natriuretic peptide, C-reactive protein, uric acid, creatinine, and homocysteine were measured. Potential associations between POI status and subclinical atherosclerosis were assessed.

RESULTS

Women with POI exhibited an increased waist circumference (β = 5.7; 95% confidence interval [CI], 1.6, 9.9), C-reactive protein (β = 0.75; 95% CI, 0.43, 1.08), free T4 levels (β = 1.5; 95% CI, 0.6, 2.4), and lower N-terminal pro-B-type natriuretic peptide (β = -0.35; 95% CI, -0.62, -0.08), estradiol (β = -1.98; 95% CI, -2.48, -1.48), T (β = -0.21; 95% CI, -0.37, -0.06), and androstenedione (β = -0.54; 95% CI, -0.71, -0.38) concentrations compared to controls, after adjusting for confounders. After adjustment, a trend toward increased hypertension (odds ratio = 2.1; 95% CI, 0.99; 4.56) and decreased kidney function was observed in women with POI (creatinine β = 3.5; 95% CI, -0.05, 7.1; glomerular filtration rate β = -3.5; 95% CI, -7.5, 0.46). Women with POI exhibited a lower mean carotid intima media thickness (β = -0.17; 95% CI, -0.21, -0.13) and decreased odds of plaque presence compared to controls (odds ratio = 0.08; 95% CI, 0.03; 0.26).

CONCLUSIONS

Women with POI exhibited an unfavorable cardiovascular risk profile, including higher abdominal fat, elevated chronic inflammatory factors, and a trend toward increased hypertension and impaired kidney function compared to controls. However, we observed no signs of increased subclinical atherosclerosis in women with POI. Additional studies are required to identify specific determinants of long-term CVD risk in women with POI.

Association of free testosterone and sex hormone binding globulin with metabolic syndrome and subclinical atherosclerosis but not blood pressure in hypertensive perimenopausal women

INTRODUCTION

Data on the role of androgens as potential mediators of increasing cardiovascular risk in women at midlife are controversial. The aim of the study was to analyze the relationship of free testosterone (FT) and sex hormone binding globulin (SHBG) with blood pressure and subclinical organ damage and metabolic syndrome (MS) in middle aged hypertensive women.

MATERIAL AND METHODS

One hundred and fifty-two women with newly diagnosed arterial hypertension were included in the study. In all subjects blood pressure measurements were performed as well as echocardiographic examination with left ventricular structure and function assessment (GE Vivid 7.0), carotid ultrasound with measurement of intima-media thickness (IMT), and carotid-femoral pulse wave velocity (PWV) measurement (Sphygmocor). A fasting blood sample was taken to measure glucose and lipid concentrations. Serum testosterone and SHBG were measured. Free testosterone was calculated according to the Vermeulen formula. Metabolic syndrome was defined following the International Diabetes Federation (IDF) recommendations.

RESULTS

Free testosterone was significantly higher and SHBG lower in women with MS independently of menopausal status. The odds ratio of MS per quartile increment in FT after adjustment for covariates was 2.06 (95% CI: 1.16-3.65). There was no correlation between FT, SHBG and blood pressure. Free testosterone was associated with decreased left ventricular diastolic function (E/A ratio β = -0.19, p = 0.05) and subclinical atherosclerosis (IMT β = 0.34, p = 0.009), but not arterial stiffness.

CONCLUSIONS

Free testosterone and SHBG independently of menopause status are related to MS. Free testosterone is associated with worse metabolic profile, subclinical atherosclerosis and impaired diastolic function of the left ventricle.

Impact of cardiovascular risk factors on carotid intima-media thickness: sex differences

Background and purpose

There has been growing interest in the sex-related differences in the impact of cardiovascular (CV) risk factors on carotid intima–media thickness (CIMT). Therefore, we aimed at examining the influence of CV risk factors on CIMT in men and women and identifying differences between males and females in the risk profiles affecting CIMT.

Patients and methods

The study group consisted of 256 patients (mean age 54.7 years), including 134 females (52%), with the following CV risk factors: arterial hypertension, type 2 diabetes mellitus, dyslipidemia, nicotine addiction, overweight, and obesity. Subjects with the history of any overt CV disease were excluded. CIMT was measured through B-mode ultrasound examination of the right common carotid artery. In the analysis of CIMT values at different ages, the patients were divided into three age groups: 1) <45 years, 2) 45–60 years, and 3) >60 years. Regression analysis was used to examine the influence of CV risk factors on CIMT in men and women.

Results

CIMT increased with age in both men and women. Women had lower values of CIMT than men (0.54 mm vs 0.60 mm, P=0.011). The analysis in three age subgroups revealed that CIMT values were comparable in men and women in group 1 (0.48 mm vs 0.48 mm, P=0.861), but over the age of 45 years, CIMT values became significantly lower in women compared to men (group 2: 0.51 mm vs 0.63 mm, P=0.005; group 3: 0.63 mm vs 0.72 mm, P=0.020). Significant differences were observed between the sexes in terms of risk factor impact on CIMT. In men, only three factors significantly affected CIMT: age (b=+0.009, P<0.0001), hypertension (b=+0.067, P<0.05), and type 2 diabetes (b=+0.073, P<0.05). In women, apart from age (b=+0.008, P<0.0001) and type 2 diabetes (b=+0.111, P<0.01), significant factors were pulse pressure (PP; b=+0.005, P<0.0001), body mass index (b=+0.007, P<0.05), increased waist circumference (b=+0.092, P<0.01), and metabolic syndrome (b=+0.071, P<0.05). In the multiple regression analysis, independent CIMT determinants for the entire group were age (β=0.497, P<0.001) and body mass index (β=0.195, P=0.006). For males, age was the only independent determinant of CIMT (β=0.669, P<0.001). For females, these were PP (β=0.317, P=0.014), age (β=0.242, P=0.03), and increased waist circumference (β=0.207, P=0.048).

Conclusion

CIMT values are lower in women than in men, which is most pronounced over the age of 45 years. There are sex-related differences in the profile of CV risk factors affecting CIMT: in males, CIMT is mostly determined by age, while in females, by age, PP, and increased waist circumference.

Associations of cortisol/testosterone and cortisol/sex hormone-binding globulin ratios with atherosclerosis in middle-age women

BACKGROUND AND AIMS

The cortisol/testosterone (C/T) ratio has been hypothesized to be a better predictor of atherosclerosis than cortisol alone. No study has assessed whether the C/T and C/sex hormone-binding globulin (SHBG) ratios are associated with atherosclerosis in a U.S. population sample.

METHODS

This substudy included 367 women who had both cortisol from year 15 and testosterone and SHBG at year 16 of the Coronary Artery Risk Development in Young Adults study, an ongoing observational cohort in the United States. Of these, intima-media thickness (IMT) was available at follow-up year 20 in 339 (n = 332 with measurement at carotid bulb), and 303 were free of prevalent coronary artery calcium (CAC) at year 15. Area under the curve (AUC) of salivary cortisol was available in 302 individuals. Ratios of AUCs of cortisol to total testosterone, free testosterone, and SHBG were categorized into tertiles. Associations with CAC and IMT were assessed by regression models adjusted for age, race, body mass index, systolic blood pressure, menopause, oral contraceptive use, diabetes, alcohol, and smoking.

RESULTS

Only the highest tertile of the AUC/free testosterone ratio was positively associated with carotid bulb IMT (β = 0.088, P = 0.006). This tertile was also positively associated with new onset CAC between year 15 and 25 (OR 3.45, 95% CI 1.18-10.06). Tertiles of cortisol or testosterone alone were not associated with new onset CAC.

CONCLUSION

AUC/Free testosterone ratio may be more associated with atherosclerosis in women than either indicator alone. The ratio may serve as a suitable biomarker of cortisol-linked stress.

Association of endogenous testosterone with subclinical atherosclerosis in men: the multi-ethnic study of atherosclerosis

OBJECTIVES

Whether endogenous sex hormones play a role in cardiovascular disease (CVD) risk in men is unclear. Few studies have examined associations of sex hormones with atherosclerosis measured by coronary artery calcium score (CACS) and carotid intima-media thickness (cIMT). We evaluated the association of testosterone (T) and other sex hormones with CACS and cIMT.

METHODS

Using the large multi-ethnic cohort of 3164 men without known CVD in the Multi-Ethnic Study of Atherosclerosis (MESA), cross-sectional associations of tertiles of endogenous sex hormones with CACS and cIMT were analysed.

RESULTS

In regard to CAC, there was a significant negative trend (P-trend = 0·02) for CACS>0 over tertiles of free T (FT) with RRs (95% CI) for the lowest to highest tertiles. There was also a marginally significant positive trend (P-trend = 0·06) for CACS>0 over tertiles of sex hormone-binding globulin (SHBG) with RRs for the lowest to highest tertiles. There were no significant associations with CACS >0 for tertiles of TT (Total T), bioavailable T (BT), oestradiol (E2) and dehydroepiandrosterone (DHEA). There was significantly higher log CACS after adjustment for CVD risk factors for lower TT levels, compared to higher levels, using 9·54 and 10·4 nmol/l as cut-off points. In regard to cIMT, there was a significant positive trend (P = 0·003) in mean cIMT over the tertiles of BT, but not for TT, FT, E2, DHEA and SHBG. There was significantly lower cIMT after adjustment for CVD risk factors for lower TT levels compared to higher levels.

CONCLUSION

In a population of male subjects with no known CVD, lower FT is associated with higher RR of CACS>0 and lower TT is associated with higher log CACS. Lower BT and TT are associated with lower cIMT. While these findings support the positive correlation between low T and coronary atherosclerosis, the opposite findings on cIMT warrant further evaluation.

Strategies and methods to study female-specific cardiovascular health and disease: a guide for clinical scientists

BACKGROUND

In 2001, the Institute of Medicine's (IOM) report, "Exploring the Biological Contributions to Human Health: Does Sex Matter?" advocated for better understanding of the differences in human diseases between the sexes, with translation of these differences into clinical practice. Sex differences are well documented in the prevalence of cardiovascular (CV) risk factors, the clinical manifestation and incidence of cardiovascular disease (CVD), and the impact of risk factors on outcomes. There are also physiologic and psychosocial factors unique to women that may affect CVD risk, such as issues related to reproduction.

METHODS

The Society for Women's Health Research (SWHR) CV Network compiled an inventory of sex-specific strategies and methods for the study of women and CV health and disease across the lifespan. References for methods and strategy details are provided to gather and evaluate this information. Some items comprise robust measures; others are in development.

RESULTS

To address female-specific CV health and disease in population, physiology, and clinical trial research, data should be collected on reproductive history, psychosocial variables, and other factors that disproportionately affect CVD in women. Variables related to reproductive health include the following: age of menarche, menstrual cycle regularity, hormone levels, oral contraceptive use, pregnancy history/complications, polycystic ovary syndrome (PCOS) components, menopause age, and use and type of menopausal hormone therapy. Other factors that differentially affect women's CV risk include diabetes mellitus, autoimmune inflammatory disease, and autonomic vasomotor control. Sex differences in aging as well as psychosocial variables such as depression and stress should also be considered. Women are frequently not included/enrolled in mixed-sex CVD studies; when they are included, information on these variables is generally not collected. These omissions limit the ability to determine the role of sex-specific contributors to CV health and disease. Lack of sex-specific knowledge contributes to the CVD health disparities that women face.

CONCLUSIONS

The purpose of this review is to encourage investigators to consider ways to increase the usefulness of physiological and psychosocial data obtained from clinical populations, in an effort to improve the understanding of sex differences in clinical CVD research and health-care delivery for women and men.

Serum androgen concentrations and subclinical measures of cardiovascular disease in men and women

OBJECTIVES

Most of the observed associations of androgens and sex hormone-binding globulin (SHBG) with subclinical cardiovascular disease (CVD) stem from selected study samples with immunoassay-based hormone measurements. Thus, we used a large population-based sample with total testosterone (TT) and androstenedione (ASD) concentrations measured by liquid chromatography-tandem mass spectrometry.

DESIGN

Data of 2140 individuals (mean age: 60,8 years) from the cohort Study of Health in Pomerania were assessed at baseline and 5-year follow-up.

METHODS

Multivariable regression models were implemented to assess cross-sectional and longitudinal associations of TT, free testosterone (fT), ASD, SHBG and dehydroepiandrosterone-sulphate (DHEAS) with measures of subclinical CVD including intima media thickness (IMT), carotid plaques, left ventricular mass (LVM), fractional shortening (FS), relative wall thickness (RWT), and left ventricular geometry.

RESULTS

Cross-sectional analyses yielded an association of TT with IMT in women (β-coefficient per log unit increase: 0.02; 95% CI: 0.007; 0.45) and ASD with FS in both sexes (men: β-coefficient: -2.94; 95% CI: -4.75; -1.12; women: β-coefficient: 1.64; 95% CI: 0.55; 2.73). In longitudinal analyses, DHEAS was positively associated with FS change (β-coefficient: 2.34; 95% CI: -0.59; 4.08). In women, SHBG was positively associated with incident plaques (Q1 vs. Q3 (Ref.): β-coefficient: 1.35; 95% CI: 1.04; 1.74). In both sexes, longitudinal analyses showed no consistent association of TT with subclinical CVD.

CONCLUSIONS

Despite several sex-specific associations of androgens and SHBG with subclinical CVD, the present representative study for the age group ≥45 years among men and women from the general population detected no consistent associations in longitudinal analyses.