A systematic review and meta-analysis of the association between maternal polycystic ovary syndrome and neuropsychiatric disorders in children

The early development of offspring born to women with polycystic ovary syndrome: Insights from a prospective birth cohort study in Southwestern China

PURPOSE

This prospective cohort study aimed to investigate the effect of maternal polycystic ovary syndrome (PCOS) on the offspring early development.

METHODS

A total of 91 mother-child pairs, consisting of 33 PCOS and 58 non-PCOS, were recruited. Peripheral blood tests were performed during 12-16, 24-28, and 32-36 weeks of gestation. Ages & Stages Questionnaires (ASQ) were utilized to assess the motor development of offspring at 27 months of age. Logistic regression models were employed to compare groups and control confounding variables.

RESULTS

Women with PCOS had a higher level of testosterone and free androgen index than the non-PCOS group in all three detection windows. There were no intergroup differences in any of the five domains of specific ASQ domain scores or the body measurements of the offspring at 27 months old. Stratification by sex of offspring suggested that no significant differences were detected in the male offspring. However, in the female offspring, the PCOS group exhibited lower gross motor scores in female offspring than the non-PCOS group (48.1 ± 11.8 vs. 55.2 ± 8.1, P = 0.027), as well as lower fine motor scores (48.5 ± 8.5 vs. 53.6 ± 11.0, P = 0.028). The gross motor score of female offspring in the PCOS group remained lower even after adjustments. Each 1 ng/mL increase in testosterone at 12-16 weeks of gestation was associated with a decrease in gross motor score of female offspring by 12.2 (95% CI = -23.3 to -1.0, P = 0.038). The highest tertile of testosterone at 12-16 weeks of gestation was associated with a 7.75-point decrease in gross motor score of female offspring compared to the lowest tertile of testosterone (95% CI = -14.9 to -0.6, P = 0.040), with a significant linear trend observed (P for trend = 0.031).

CONCLUSIONS

The findings of this study suggest that maternal PCOS could exert a negative influence on the gross motor development of female offspring, potentially associated with intrauterine androgen exposure during the early stages of pregnancy.

Polycystic ovary syndrome

Despite affecting ~11-13% of women globally, polycystic ovary syndrome (PCOS) is a substantially understudied condition. PCOS, possibly extending to men's health, imposes a considerable health and economic burden worldwide. Diagnosis in adults follows the International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome, requiring two out of three criteria - clinical or biochemical hyperandrogenism, ovulatory dysfunction, and/or specific ovarian morphological characteristics or elevated anti-Müllerian hormone. However, diagnosing adolescents omits ovarian morphology and anti-Müllerian hormone considerations. PCOS, marked by insulin resistance and hyperandrogenism, strongly contributes to early-onset type 2 diabetes, with increased odds for cardiovascular diseases. Reproduction-related implications include irregular menstrual cycles, anovulatory infertility, heightened risks of pregnancy complications and endometrial cancer. Beyond physiological manifestations, PCOS is associated with anxiety, depression, eating disorders, psychosexual dysfunction and negative body image, collectively contributing to diminished health-related quality of life in patients. Despite its high prevalence persisting into menopause, diagnosing PCOS often involves extended timelines and multiple health-care visits. Treatment remains ad hoc owing to limited understanding of underlying mechanisms, highlighting the need for research delineating the aetiology and pathophysiology of the syndrome. Identifying factors contributing to PCOS will pave the way for personalized medicine approaches. Additionally, exploring novel biomarkers, refining diagnostic criteria and advancing treatment modalities will be crucial in enhancing the precision and efficacy of interventions that will positively impact the lives of patients.

New insights into the interaction between polycystic ovary syndrome and psychiatric disorders: A narrative review

Polycystic ovary syndrome (PCOS) is a prevalent endocrine disease characterized by hyperandrogenism, ovulatory dysfunction, and ovarian polycystic changes, which combines with reproductive problems, metabolic disorders, and psychological disorders to exhibit a far-reaching impact on the physical and mental health of women. We reviewed previous research and discovered that psychiatric disorders are more common in PCOS patients and their children, potentially exacerbating the condition and creating a vicious loop. To understand the reasons, relevant articles were collected following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines from PubMed, Web of Science, and Cochrane Library, through December 2022. Evidence suggested that PCOS-related clinical manifestations, hyperandrogenism, insulin resistance, obesity, gut dysbiosis, and other variables may increase the risk of psychiatric disorders in patients. In turn, psychiatric disorders may aggravate the pathologic process of PCOS and increase the difficulty of the treatment. We systematically reported the mechanisms underlying the psychiatric disorders-PCOS interactions, intending to provide potential ways to break the vicious cycle and lay the groundwork for future research. However, research on PCOS and psychiatric disorders were still in initial stages, which limited the scope of this review. More studies are needed to further verify our findings.

Maternal Thyroid Dysfunction During Pregnancy as an Etiologic Factor in Autism Spectrum Disorder: Challenges and Opportunities for Research

Background: Autism spectrum disorder (ASD) is a neurodevelopmental condition with unknown etiology. Both genetic and environmental factors have been associated with ASD. Environmental exposures during the prenatal period may play an important role in ASD development. This narrative review critically examines the evidence for a relationship between maternal thyroid dysfunction during pregnancy and ASD in the child. Summary: Studies that assessed the associations of hypothyroidism, hyperthyroidism, hypothyroxinemia, thyroid hormone concentrations, or autoimmune thyroid disease with ASD outcomes were included. Most research focused on the relationship between hypothyroidism and ASD. Multiple population-based studies found that maternal hypothyroidism was associated with higher likelihood of an ASD diagnosis in offspring. Associations with other forms of maternal thyroid dysfunction were less consistent. Findings may have been affected by misclassification bias, survival bias, or publication bias. Studies using medical records may have misclassified subclinical thyroid dysfunction as euthyroidism. Two studies that assessed children at early ages may have misclassified those with ASD as typically developing. Most studies adjusted for maternal body mass index (BMI) and/or mental illness, but not interpregnancy interval or pesticide exposure, all factors associated with fetal survival and ASD. Most studies reported a combination of null and statistically significant findings, although publication bias is still possible. Conclusions: Overall, evidence supported a positive association between maternal thyroid dysfunction during pregnancy and ASD outcomes in the child, especially for hypothyroidism. Future studies could reduce misclassification bias by using laboratory measures instead of medical records to ascertain thyroid dysfunction and evaluating children for ASD at an age when it can be reliably detected. Survival bias could be further mitigated by adjusting models for more factors associated with fetal survival and ASD. Additional research is needed to comprehensively understand the roles of maternal levothyroxine treatment, iodine deficiency, or exposure to thyroid-disrupting compounds in the relationship between maternal thyroid dysfunction and child ASD outcomes.

Sex and gender in neurodevelopmental conditions

Health-related conditions often differ qualitatively or quantitatively between individuals of different birth-assigned sexes and gender identities, and/or with different gendered experiences, requiring tailored care. Studying the moderating and mediating effects of sex-related and gender-related factors on impairment, disability, wellbeing and health is of paramount importance especially for neurodivergent individuals, who are diagnosed with neurodevelopmental conditions with uneven sex/gender distributions. Researchers have become aware of the myriad influences that sex-related and gender-related variables have on the manifestations of neurodevelopmental conditions, and contemporary work has begun to investigate the mechanisms through which these effects are mediated. Here we describe topical concepts of sex and gender science, summarize current knowledge, and discuss research and clinical challenges related to autism, attention-deficit/hyperactivity disorder and other neurodevelopmental conditions. We consider sex and gender in the context of epidemiology, behavioural phenotypes, neurobiology, genetics, endocrinology and neighbouring disciplines. The available evidence supports the view that sex and gender are important contributors to the biological and behavioural variability in neurodevelopmental conditions. Methodological caveats such as frequent conflation of sex and gender constructs, inappropriate measurement of these constructs and under-representation of specific demographic groups (for example, female and gender minority individuals and people with intellectual disabilities) limit the translational potential of research so far. Future research and clinical implementation should integrate sex and gender into next-generation diagnostics, mechanistic investigations and support practices.

Steroid hormone pathways, vitamin D and autism: a systematic review

The origins of the male preponderance in autism incidence remain unclear. The idea that perinatal factors associated with sex differentiation (e.g., steroid hormone pathways) may increase the possibility of the emergence of autism is complementary to the hypothesis that female individuals are intrinsically less likely to develop autism. Empirical evidence for the mechanistic roles of in utero steroid hormones in autism etiology is accumulating but inconsistent. We conducted a systematic review using rigorous criteria for the measurements of steroids and vitamin D exposure, to summarize the potential contributing roles of prenatal and early postnatal steroids and vitamin D alterations to the emergence of autism. We searched PubMed, PsychInfo, Scopus, and included 22 studies for qualitative synthesis. Among them, six studies examined the association of autism diagnoses in offspring and levels of steroids and precursor steroid hormones in the fetal environment, eight studies examined the associations between autism and maternal and fetal blood vitamin D levels during pregnancy and at birth, and eight studies examined the associations between offspring autism diagnoses and maternal hyperandrogenemia diagnosed before pregnancy. We identified promising and complex results regarding the relations between steroid metabolism and autism. The interpretation of findings was limited by the mostly observational study designs, insufficient investigation of the effects of offspring sex, confounders and their cumulative effects on the development of the child, and unclear impact of the timing of steroids exposure and their effects on fetal neurodevelopment.

Association between maternal polycystic ovary syndrome and attention-deficit/hyperactivity disorder in offspring aged 3-6 years: A Chinese population-based study

Background

Maternal polycystic ovary syndrome (PCOS) may increase the risk of attention-deficit/hyperactivity disorder (ADHD) in offspring; however, their association remains unexplored in Asian populations. Hence, this study aimed to investigate the association between maternal PCOS and ADHD in offspring aged 3-6 years and whether it differed by offspring sex.

Methods

This was a district-wide population-based study of 87,081 preschoolers from 234 kindergartens in Longhua District, Shenzhen, China. The parents were invited to complete a self-administrated questionnaire covering information on socio-demographics, maternal disease history, and child behavior. ADHD symptoms were measured with the parent-rating 26-item Swanson, Nolan, and Pelham Rating Scale (SNAP-IV). Logistic regression was performed to examine the associations between maternal PCOS and ADHD symptoms in offspring.

Results

The response rate was 80% and 63,390 mother-child pairs were included. Of the mothers, 1,667 (2.6%) reported PCOS diagnoses. The mean age of children at ADHD assessment was 4.86 ± 0.84[SD] years, and 53.6% were boys. Children with maternal PCOS had a higher risk of developing ADHD symptoms than other children (12.0 vs. 9.4%, adjusted odds ratio [OR] = 1.32, 95% CI: 1.13-1.54). The risk estimate was significant in boys (adjusted OR = 1.38, 95% CI: 1.14-1.66) but not in girls (adjusted OR = 1.23, 95% CI: 0.94-1.57, P for interaction = 0.391). Treatment of PCOS tended to be associated with a lower risk of ADHD symptoms than untreated PCOS albeit risk confidence intervals were overlapped (treated: adjusted OR = 1.28, 95% CI: 1.06-1.54 vs. untreated: adjusted OR = 1.14, 95% CI: 1.08-1.83).

Conclusion

Maternal PCOS increases the risk of developing ADHD in offspring, especially boys. Further studies are warranted to confirm our findings, and early neurodevelopmental screening may be needed in children born to mothers with PCOS.

Anti-Müllerian Hormone and Polycystic Ovary Syndrome in Women and Its Male Equivalent

This article reviews the main findings on anti-Müllerian hormone (AMH) and its involvement in the pathogenesis of polycystic ovary syndrome (PCOS) and its male equivalent. In women, AMH is produced by granulosa cells from the mid-fetal life to menopause and is a reliable indirect marker of ovarian reserve. AMH protects follicles from atresia, inhibits their differentiation in the ovary, and stimulates gonadotrophin-releasing hormone neurons pulsatility. AMH overexpression in women with PCOS likely contributes to the increase of the follicle cohort and of androgen levels, leading to follicular arrest and anovulation. In the male, AMH is synthesized at high levels by Sertoli cells from fetal life to puberty when serum AMH falls to levels similar to those observed in women. AMH is involved in the differentiation of the genital tract during fetal life and plays a role in Sertoli and Leydig cells differentiation and function. Serum AMH is used to assess Sertoli cell function in children with disorders of sex development and various conditions affecting the hypothalamic–pituitary–testicular axis. Although the reproductive function of male relative of women with PCOS has been poorly investigated, adolescents have elevated levels of AMH which could play a detrimental role on their fertility.

Maternal polycystic ovarian syndrome and pubertal development in daughters and sons: a population-based cohort study

STUDY QUESTION

Does maternal polycystic ovarian syndrome (PCOS) affect the timing of pubertal development in daughters and sons?

SUMMARY ANSWER

Maternal PCOS was associated with earlier adrenarche in daughters.

WHAT IS KNOWN ALREADY

Female adolescents with PCOS often experience earlier adrenarche compared to adolescents without PCOS, due to hyperandrogenism. Likewise, they usually have hyperandrogenism during pregnancy, which might potentially affect the development of the foetus, including its future reproductive health.

STUDY DESIGN, SIZE, DURATION

In this population-based cohort study, we included 15 596 mothers-child pairs from the Danish National Birth Cohort (DNBC) Puberty Cohort, who were followed from foetal life until full sexual maturation or 18 years of age.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Using register-based and self-reported information on maternal PCOS and menstrual irregularities, collected during pregnancy, we categorized the mothers as having PCOS (n = 251), oligomenorhoea (n = 134), 'other menstrual irregularities' (n = 2411) or no menstrual abnormalities (reference group, n = 12 800). The children provided self-reported information on pubertal development every 6 months from the age of 11 years. The main outcome measures were adjusted mean age differences (in months) at attaining several individual pubertal milestones using an interval-censored regression model, as well as the average difference in age at attaining all pubertal milestones combined into a single estimate using Huber-White robust variance estimation.

MAIN RESULTS AND THE ROLE OF CHANCE

We found that maternal PCOS was associated with an accelerated pubertal development in daughters with an overall average difference of -3.3 (95% CI: -6.3; -0.4) months based on all pubertal milestones compared to the reference group. When further looking into the average difference for adrenarche only (pubarche, axillary hair and acne), the average difference was -5.4 (95% CI: -8.7; -2.1) months compared to the reference group; whereas thelarche and menarche did not occur earlier in daughters of mothers with PCOS (average difference: -0.8 (95% CI: -3.9; 2.4) months). Oligomenorrhoea and 'other menstrual irregularities' were not associated with pubertal development in daughters. Neither PCOS, oligomenorrhoea nor 'other menstrual irregularities' were associated with pubertal development in sons.

LIMITATIONS, REASONS FOR CAUTION

We expect some degree of non-differential misclassification of maternal PCOS and menstrual irregularities as well as pubertal development in the children.

WIDER IMPLICATIONS OF THE FINDINGS

Maternal PCOS might accelerate adrenarche in daughters. Whether this is due to genetics, epigenetics or prenatal programming by hyperandrogenism in foetal life remains unsolved. The results from the present study can be generalized to Caucasian populations.

STUDY FUNDING/COMPETING INTEREST(S)

The study is funded by the Faculty of Health at Aarhus University. The authors have no financial relationships or competing interests to disclose.

TRIAL REGISTRATION NUMBER

N/A.