Determinants of low bone mineral density in premenopausal polycystic ovary syndrome patients

Contrasting Bone Profiles in PCOS Are Related to BMI: A Systematic Review and Meta-analysis

CONTEXT

Controversial results have emerged regarding whether polycystic ovary syndrome (PCOS) is protective or increases the risk of bone frailty.

OBJECTIVE

This study investigated whether the PCOS condition affects bone parameters of premenopausal women. This is an update for a previous meta-analysis published in 2019.

DATA SOURCES

We searched MEDLINE and Embase.

STUDY SELECTION

Studies were considered eligible for the update if published in English between October 1, 2018, and December 31, 2023. The diagnosis of PCOS should be based on National Institutes of Health criteria, the Rotterdam Consensus, Androgen Excess & PCOS Society criteria, or International Classification of Diseases codes in women over 18 years old. Only records with the Newcastle-Ottawa Scale ≥ 6 were selected for data extraction.

DATA EXTRACTION

Data were extracted by 2 independent reviewers.

DATA SYNTHESIS

We identified 31 studies that met the inclusion criteria for qualitative analysis from 3322 studies in the whole period (1990-2023). Overall, cross-sectional studies included 1822 individuals with PCOS and 1374 controls, while cohort studies incorporated 30 305 women with PCOS and 10,1907 controls. Contrasting profiles emerged after stratification using a body mass index (BMI) cutoff of 27 kg/m2. Individuals with PCOS and a BMI <27 kg/m2 exhibited lower vertebral and nonvertebral bone density, reduced bone turnover marker (osteocalcin), and increased bone resorption marker (C-terminal type I collagen) levels. Conversely, individuals with PCOS and a BMI ≥27 kg/m2 exhibited increased vertebral and nonvertebral bone mineral density, with no significant changes in bone formation and resorption markers (except osteocalcin).

CONCLUSION

The findings of this study alert for a low bone mass, low bone formation, and increased bone resorption PCOS with a BMI <27 kg/m2.

Characteristics of bone mineral density in patients with functional hypothalamic amenorrhoea and its association with reproductive hormones and body composition

OBJECTIVE

Bone mineral density (BMD) is typically reduced in patients with female athlete triad (FAT) and anorexia nervosa (AN). However, bone health in most patients with functional hypothalamic amenorrhoea (FHA), who may not suffer from severe energy deficiency, has not received adequate attention in clinical practice. This study aimed to investigate BMD and its association with clinical and endocrine features in individuals with FHA and to provide clinical evidence for improving bone loss and preventing osteoporosis in FHA.

DESIGN

To assess the bone status of patients with FHA and investigate its association with various clinical and endocrinological characteristics.

PATIENTS

We retrospectively analysed 80 patients with FHA who attended the Obstetrics and Gynecology Hospital of Fudan University from January 2022 to March 2023.

MEASUREMENTS

The levels of reproductive hormones, including luteinising hormone (LH), follicle-stimulating hormone, oestradiol (E2 ) and total testosterone (TT), were examined at the time of initial diagnosis, and a body composition analyser was used to measure body fat percentage (BF%), lean body mass (LBM) and segmental muscle/fat. Dual-emission X-ray absorptiometry was used to measure lumbar spine BMD and femoral neck BMD in patients with FHA, and the Z score was calculated.

RESULTS

The study cohort consisted of 80 female patients with FHA. The average age of the patients was 24.64 ± 6.02 years, and their body mass index (BMI) was 19.47 ± 2.86 kg/m2 . The duration of weight loss was 12 (6, 24) months, while the duration of oligo/amenorrhoea was 12 (4.5, 24) months. The mean degree of weight loss was 18.39 ± 9.53%. Low BMD were present in 15% of patients with FHA at the lumbar spine and/or femoral neck; 12.5% and 10% had low bone mass at the lumbar spine and femoral neck, respectively. The low bone mass group experienced a longer period of weight loss than the normal group [24 (16.5, 60) vs. 12 (4.5, 24) months, p = .037]. In addition, the abnormal group had a lower BMR (basal metabolic rate, BMR) [1158 ± 85 vs. 1231 ± 91 kcal/day, p = .011] and lower bone mineral content [2.15 ± 0.26 vs. 2.43 ± 0.31 kg, p = .009] than the normal group. Both LBMD and femoral neck BMD (Fn BMD) were positively correlated with BMI, BF%, LBM, and regional muscle/fat mass (all p < .05). There was also a positive correlation between LBMD and basal LH levels (p = .009) and waist-to-hip ratio (p = .034), whereas Fn BMD was positively correlated with TT levels (p = .029). Multiple linear regression analysis showed that LBM was positively associated with LBMD (β = .007, 95% confidence interval [CI] = 0.004-0.009, p < .001), while trunk muscle mass was positively associated with Fn BMD (β = .046, 95% CI = 0.013-0.080, p = .008).

CONCLUSION

Fifteen percent of the patients with FHA exhibited low bone mass, a condition associated with prolonged weight loss. The basal LH and TT levels showed positive correlations with LBMD and Fn BMD, respectively. Meanwhile, BMR levels, BMI, BF%, and muscle mass were all positively correlated with LBMD and Fn BMD. Clinically, we should be attentive to suboptimal bone health in patients with FHA and take early screening, diagnosis and intervention measures, especially appropriate muscle mass gain, to prevent the onset of osteoporosis and fragility fractures in the long term.

Bone strength is reduced in a neonatal androgenized rat model

Background

Whether polycystic ovary syndrome (PCOS) affects bone health during a woman's lifespan remains controversial. An androgenized rodent model replicated many metabolic and reproductive features of women with PCOS, and we aimed to use it to investigate the impact of androgens on microarchitecture (by micro-CT), bone mechanical strength, bone formation and resorption markers in rats with intact ovaries (SHAM) who underwent oophorectomy.

Methods

Wistar rats (Rattus norvegicus albinus) were employed for the experiments in this study. The protocol of androgenization consisted of the application of 1.25 mg s.c. testosterone propionate beteween days 2-5 of life, while the controls received the same amount of corn oil s.c. as previously established. Androgenized SHAM rats exhibited chronic anovulation identified by vaginal cytology and a reduction in the proportion of corpus luteum in the ovary in comparison to control SHAM rats. The realization of the ovariectomy or SHAM procedure occurred on Day 100 of life. All groups (n = 8) were followed-up for 180 days to address the study endpoints.

Results

Micro-CT from androgenized female rats (SHAM) showed a divergence between the trabecular and cortical bone profiles. Compared to SHAM controls, these rats had an increase in trabecular bone mass with a diminution in bone resorption C-terminal telopeptide of type 1 collagen (CTX) (p < 0.05), a concomitant decrease in cortical area and thickness in the femur, and a reduction in the strength of the femur on the mechanical test (p < 0.01).

Conclusions

Our results suggest that a reduction in the cortical thickness and cortical area observed in PCOS model rats was associated with a reduced strength of the femur, despite increased trabecular formation. Ovariectomy in the androgenized OVX group limited the progression rate of cortical bone loss, resulting in bone resistance and cortical thickness comparable to those observed in the control OVX group.

Altered Vitamin D Status and Bone Mineral Density in Obese and Non-obese Patients With Polycystic Ovary Syndrome: A Cross-Sectional Study in Turkey

Background  Polycystic ovary syndrome (PCOS) is the most common endocrinological disease in women of reproductive age. In addition to providing the basis for comorbidities such as metabolic and cardiovascular diseases, it also affects bone metabolism. This study aimed to determine whether there is a relationship between bone mineral density (BMD), vitamin D status, insulin resistance, sex hormones, and calcium metabolism disorders in women with PCOS. Methodology Fifty-six non-obese women with PCOS, 67 obese women with PCOS, and 45 normal weight controls participated in the study. Circulating levels of gonadotropins, estradiol, prolactin, dehydroepiandrosterone sulfate, total testosterone, thyroid stimulating hormone, sex hormone-binding globulin, insulin, glucose, and calcium metabolism parameters were assessed. We used the Homeostatic Model Assessment-Insulin Resistance Index to detect insulin resistance. BMD values in the various body regions were measured by dual X-ray absorptiometry. Results Women with PCOS had significantly lower vitamin D values and lumbar spine BMD than controls (p <0.001 and p <0.05, respectively). Among the patients with PCOS subgroups, vitamin D deficiency (VDD) was more frequent in obese PCOS patients (67.1%) than in non-obese patients (58.9%). We found significantly lower BMD at all sites only in the subgroup of the non-obese PCOS women than in controls (p <0.001). Conclusions VDD is prevalent in PCOS women in those with obesity and hyperandrogenemia. Non-obese PCOS women have significantly lower BMD measurements than healthy controls, but obese PCOS women have BMD values comparable with normal-weight eumenorrheic controls. Body mass index is the most important factor determining BMD in women with PCOS.

Association Between Plasma Sclerostin Levels and Body Mass Index in Women With Polycystic Ovary Syndrome

Background Polycystic ovary syndrome (PCOS) is recognized as one of the most common endocrine pathologies in females of reproductive age worldwide. This study investigated the relationship between serum sclerostin levels and body mass index (BMI) in women with PCOS. Methods Women aged 18-40 years who presented to our clinic between January 1, 2019, and January 1, 2020, and were diagnosed with PCOS were included in this study. The patients' clinical and laboratory data were recorded, and waist circumference, hip circumference, and BMI values were calculated. The patients with a BMI of >25 kg/m2 were evaluated as Group I, those with a BMI of <18.5 kg/m2 as Group II, and those with a BMI of 18.5-25 kg/m2 as Group III. Serum sclerostin levels were compared between the BMI groups. Results The study included 90 patients. The mean BMI values were 32.2±2.1, 17.0±0.9, and 22.9±2.1 kg/m2 for Groups I, II, and III, respectively. We detected a statistically significant difference in serum sclerostin levels between Group II and Group I (p<0.005). There was a significant, positive correlation between the sclerostin level and BMI (r=0.258, p=0.014), weight (r=0.237, p=0.044), waist measurement (r=0.225, p=0.045), and hip measurement (r=0.225, p=0.033). Conclusion This study revealed that abnormal body composition in PCOS could alter circulating sclerostin levels.

Determinants of Bone Mineral Density in Iranian Women with Polycystic Ovary Syndrome

Background

Whether the endocrine aberrations caused by polycystic ovary syndrome (PCOS) might influence bone density in women of reproductive age is controversial.

Objectives

The present study aimed to compare PCOS women to a control group matched in terms of age and body mass index (BMI) regarding bone indices and to clarify the potential relationship between their hormonal changes and bone density.

Methods

This case-control study consisted of 61 PCOS patients, and 35 women with normal ovulatory function served as controls. Bone parameters, including bone mineral content (BMC) and bone mineral density (BMD) in addition to T- and Z-scores, were measured at the lumbar vertebrae, neck of the left femur, hip, and distal part of the radial bone, using dual-energy X-ray absorptiometry. Blood samples were taken to be tested for biochemical parameters and serum concentrations of insulin, osteocalcin, parathyroid hormone (PTH), vitamin D, follicle-stimulating hormone (FSH), luteinizing hormone (LH), total testosterone, dehydroepiandrosterone sulfate (DHEAS), and estradiol were measured. Insulin resistance was evaluated through the homeostatic model assessment of insulin resistance (HOMA-IR).

Results

The results revealed greater levels of HOMA-IR and total testosterone in PCOS women than in controls. Nevertheless, the two groups were comparable in terms of bone parameters. In the control group, BMI was the only determinant of bone density at most of the skeletal sites. Nonetheless, BMI and HOMA-IR were independently and positively associated with bone indices at the femoral neck (FN) and total hip in the PCOS group. Parathyroid hormone and vitamin D concentrations were not different in the two groups. However, phosphate levels were higher in PCOS patients (P = 0.025). Osteocalcin was inversely correlated to BMI, and both groups had a negative correlation between DHEAS and PTH. Serum phosphate was inversely and independently associated with estrogen in the PCOS group (r = -0.377, P = 0.004).

Conclusions

Body mass index and HOMA-IR were independent and positive determinants of FN and total hip bone density in the PCOS subjects. Nonetheless, in the non-PCOS women, BMI was the only independent determinant of bone density at most of the skeletal sites. Additionally, osteocalcin was inversely correlated with BMI in both groups.

Association of Endogenous Hormones and Bone Mineral Density in Postmenopausal Women

Aim

The aim of this study was to examine the association between endogenous hormones and bone mineral density (BMD) in postmenopausal women.

Materials and Methods

This was a cross-sectional study of 798 postmenopausal women aged 47-85 years. Data were collected on age, age at menopause, years since menopause, smoking status, body mass index, adiposity, BMD, physical activity, and Vitamin D supplementation. Measured hormonal parameters were: follicle-stimulating hormone (FSH), estradiol, testosterone, dehydroepiandrosterone sulfate, ∆4-androstenedione, cortisol, insulin-like growth factor-1, 25-hydroxyvitamin D, and parathormone (PTH) levels. BMD was measured at the lumbar spine, femoral neck, and total hip using dual-energy X-ray absorptiometry. A directed acyclic graph was used to select potential confounding variables.

Results

Multivariable analysis showed significant associations between cortisol and femoral neck BMD (β: -0.02, 95% confidence interval [CI]: -0.03--0.00), and PTH with femoral neck BMD (β: -0.01, 95% CI: -0.02--0.01) and total hip BMD (β: -0.01, 95% CI: -0.01--0.00). Hormonal factors more likely associated with a higher risk of low BMD (osteopenia or osteoporosis) were FSH (odds ratio [OR]: 1.02, 95% CI: 1.01-1.03) and PTH (OR: 1.02, 95% CI: 1.01-1.04).

Conclusions

Higher cortisol and PTH levels were inversely associated with BMD. Postmenopausal women with higher FSH or PTH levels were likely to have low BMD.

Effects of distinct Polycystic Ovary Syndrome phenotypes on bone health

Polycystic Ovary Syndrome (PCOS) is a highly prevalent and heterogenous endocrinopathy affecting 5-18% of women. Although its cardinal features include androgen excess, ovulatory dysfunction, and/or polycystic ovarian morphology, women often display related metabolic manifestations, including hyperinsulinaemia, insulin resistance, and obesity. Emerging data reveal that the hormonal alterations associated with PCOS also impact bone metabolism. However, inconsistent evidence exists as to whether PCOS is a bone-protective or bone-hindering disorder with an accumulating body of clinical data indicating that hyperandrogenism, hyperinsulinaemia, insulin resistance, and obesity may have a relative protective influence on bone, whereas chronic low-grade inflammation and vitamin D deficiency may adversely affect bone health. Herein, we provide a comprehensive assessment of the endocrine and metabolic manifestations associated with PCOS and their relative effects on bone metabolism. We focus principally on clinical studies in women investigating their contribution to the alterations in bone turnover markers, bone mineral density, and ultimately fracture risk in PCOS. A thorough understanding in this regard will indicate whether women with PCOS require enhanced surveillance of bone health in routine clinical practice.

The influence of ESR1 polymorphisms on selected hormonal, metabolic and mineral balance markers in women with hyperandrogenism

Hyperandrogenism is the most common endocrine disorder in women, characterized by an imbalance in normal estrogen and androgen levels in the blood. Androgens influence bone mineral density, body mass composition, muscle mass, mental state, and the regulation of sexual function.. The aim of the study was to assess the effect of estrogen receptor α gene (ESR1) polymorphisms on selected markers of bone metabolism and hormonal parameters in women with hyperandrogenism. The study group included 80 young women with hyperandrogenism who underwent measurements of bone mineral density (BMD), and determination of hormonal and metabolic parameters. Enzyme immunoassays were used to measure leptin, sRANKL (soluble receptor activator of nuclear factor-kB ligand), osteoprotegerin and 25-OH vitamin D total levels. An analysis of ESR1 gene polymorphisms was performed using the real-time PCR method. A relationship was demonstrated between the concentration of free estradiol (FEI) and the concentration of 17-OH-progesterone, and the ESR1 gene polymorphisms: rs3020314 (p = 0.031, p = 0.026 respectively) and rs1884051 (p = 0.033, p = 0.026 respectively). In conclusion, the ESR gene polymorphisms may be associated with hormonal disturbances in the concentration of estrogens and androgens, in hyperandrogenism in young women which may indirectly affect bone mineral density. However, no statistically significant relationships between the studied polymorphisms and the selected parameters of mineral metabolism have been demonstrated..

Bone Health in Women With Polycystic Ovary Syndrome: A Narrative Review

Bone as an active connective and endocrine tissue is influenced by hormones, physical activity, inflammatory factors, minerals, dietary components, and body weight. Bone fractures are a major cause of decreased quality of life and mortality in humans. Polycystic ovary syndrome (PCOS), is one of the most common endocrine disorders in women of reproductive age worldwide. PCOS is associated with disturbances in androgen and estrogen levels, insulin resistance (IR), obesity, as well as low-grade chronic inflammation, and gut microbiota (GM) dysbiosis, all of which may negatively or positively affect bone metabolism. However, it has not yet been well clarified whether PCOS is bone-protective or bone-destructive. This study aimed to review the association between bone health and PCOS, and summarize its related factors. PubMed, Scopus, and Web of Science databases were searched to retrieve relevant English publications investigating the relationship between bone health and PCOS. Several disorders associated with PCOS can negatively or positively affect bone metabolism. Despite some positive effects of insulin, androgens, estrogens, and obesity on bone, IR, estrogen deficiency, low-grade chronic inflammation, and GM dysbiosis may adversely affect the bone metabolism in PCOS women. Studies comparing bone mineral density or bone metabolism and the risk of bone fractures in women with PCOS have controversial results. Further studies are required to understand the mechanisms underlying bone metabolism in PCOS subjects. Moreover, prospective studies are needed to estimate the risk of bone fractures and osteoporosis in PCOS subjects.

Bone mass density in lean and overweight women with polycystic ovary syndrome

INTRODUCTION

Polycystic ovary syndrome is a condition characterized by hormonal and metabolic disturbances that may affect bone health. The purpose of this study was to investigate the effect of polycystic ovary syndrome on bone mineral density and to examine which clinical characteristics of the syndrome could influence bone mineral density.

MATERIALS AND METHODS

We examined 183 premenopausal women: 158 women with polycystic ovary syndrome and 25 healthy age- and body mass index matched controls. Bone mineral density and body composition were investigated by whole-body dual energy X-ray absorption. Total and free testosterone, sex hormone binding globulin, luteinizing hormone, follicle stimulating hormone, estradiol, fasting insulin and glucose, parathyroid hormone, calcium and 25-OH-cholecalciferol were measured. The effect of polycystic ovary syndrome on bone mineral density was analyzed by statistical two-way analysis of variance tests and multiple linear regressions for investigating the connection between bone mineral density and selected clinical parameters.

RESULTS

Women with polycystic ovary syndrome had significantly lower bone density in the lumbar vertebrae L1-L4 compared to healthy controls, independently of body mass index. We found that total lean body mass was the most important associating factor for bone mineral density and these were strongly correlated throughout all regression analyzes. We found no connection between lumbar bone density and androgen status, hyperinsulinemia, estradiol or calcium homeostasis.

CONCLUSIONS

Premenopausal women with polycystic ovary syndrome have lower bone mineral density in the lumbar vertebrae L1-L4 compared to healthy controls. Total lean body mass and polycystic ovary syndrome are significantly associated to this finding.

Polycystic ovary syndrome and obesity: clinical aspects and nutritional management

INTRODUCTION

Polycystic Ovary Syndrome (PCOS) is a multifactorial endocrine and metabolic disorder characterized by androgen excess, oligo-anovulatory infertility, polycystic ovaries in ultrasound examination, insulin resistance, and cardiometabolic disorders, with overweight/obesity and visceral adiposity. This review aims to provide an overview of the clinical characteristics and nutritional therapy of PCOS and obesity.

METHODS

The authors analyzed the updated and relevant publications found on Pubmed about clinical aspects and nutritional management of PCOS and obesity in studies done in animal and human models.

DISCUSSION

It is crucial an early detection and intervention in PCOS patients to avoid the more challenging control of the onset of more impaired-health conditions that this pathology causes. It is presented evidence that clearly shows the close interaction among oxidative stress, low-grade inflammation, and PCOS. It is also analyzed the relevance of treating metabolic and nutritional correlations of PCOS with a complete therapeutic strategy that includes individualized medication, diet, and healthy habits.

CONCLUSIONS

By an integral approach and treatment that includes not only medications for PCOS symptoms, supplementation of minerals and vitamins to control PCOS complications but an antiinflammatory diet, nutritional education, exercise individualized program, lifestyle changes, it is possible to improve insulin resistance, sustained weight loss, ovulation rates, among other goals for the management of this disease. Further studies are needed to clarify mechanisms, beneficial effects, and doses of supplements and precise medication to determine the best combination of diets and exercise programs according to these patients' specific requirements.

Vitamin D, Bone Metabolism, and Fracture Risk in Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder among premenopausal women. PCOS may have reproductive, metabolic, cardiovascular, and psychological implications. Vitamin D deficit is often encountered in PCOS women and may contribute to the pathophysiology of this disorder. As of the key role of vitamin D in bone and mineral metabolism, and because the vitamin D status appears to be closely linked with the PCOS manifestations including insulin resistance, obesity, ovulatory and menstrual irregularities, oxidative stress and PTH elevation, hypovitaminosis D may directly and indirectly via the different facets of PCOS impair bone health in these women. Although limited data are available on life-long fracture risk in women with PCOS, the importance of preserving bone health in youth and adults to prevent osteoporosis and related fractures is also recognized in PCOS women. Evidence of the association between vitamin D and the clinical hallmarks of PCOS are summarized and discussed. Vitamin D arises as a cornerstone in women with PCOS and contributes to the pathophysiological link between PCOS and bone metabolism.

The Relationship Between Polycystic Ovarian Syndrome, Periodontal Disease, and Osteoporosis

Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder to affect women in their reproductive years. There has been growing concern that women with PCOS may suffer from long-term metabolic consequences due to the high degree of insulin resistance that is often present in PCOS. However, few longitudinal studies exist in this area and there is a paucity of data on whether women with PCOS are at risk of other chronic diseases as they age. Specifically, current evidence suggests that reproductive-age women with PCOS may be at increased risk for both osteoporosis and periodontal disease (PD)-both these chronic diseases can have serious implications for health and quality of life. However, few studies have addressed how risk factors for osteoporosis and PD may be altered by aging in PCOS. The PCOS phenotype of women beyond reproductive years is poorly understood, and it is not known whether the metabolic profile of older women with PCOS results in an increased risk of osteoporosis and PD. The objective of this review is to discuss the relationships between PCOS, osteoporosis, and PD, and how these relationships could be impacted during aging. The long-term goal of this review is to provide direction for future research that is needed to more clearly elucidate these relationships and eventually provide a basis for evidence-based health recommendations.

Osteosarcopenia in Reproductive-Aged Women with Polycystic Ovary Syndrome: A Multicenter Case-Control Study

CONTEXT

Osteosarcopenia (loss of skeletal muscle and bone mass and/or function usually associated with aging) shares pathophysiological mechanisms with polycystic ovary syndrome (PCOS). However, the relationship between osteosarcopenia and PCOS remains unclear.

OBJECTIVE

We evaluated skeletal muscle index% (SMI% = [appendicular muscle mass/weight (kg)] × 100) and bone mineral density (BMD) in PCOS (hyperandrogenism + oligoamenorrhea), and contrasted these musculoskeletal markers against 3 reproductive phenotypes (i): HA (hyperandrogenism + eumenorrhea) (ii); OA (normoandrogenic + oligoamenorrhea) and (iii), controls (normoandrogenic + eumenorrhea). Endocrine predictors of SMI% and BMD were evaluated across the groups.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter case-control study of 203 women (18-48 years old) in New York State.

RESULTS

PCOS group exhibited reduced SMI% (mean [95% confidence interval (CI)]; 26.2% [25.1,27.3] vs 28.8% [27.7,29.8]), lower-extremity SMI% (57.6% [56.7,60.0] vs 62.5% [60.3,64.6]), and BMD (1.11 [1.08,1.14] vs 1.17 [1.14,1.20] g/cm2) compared to controls. PCOS group also had decreased upper (0.72 [0.70,0.74] vs 0.77 [0.75,0.79] g/cm2) and lower (1.13 [1.10,1.16] vs 1.19 [1.16,1.22] g/cm2) limb BMD compared to HA. Matsuda index was lower in PCOS vs controls and positively associated with SMI% in all groups (all Ps ≤ 0.05). Only controls showed associations between insulin-like growth factor (IGF) 1 and upper (r = 0.84) and lower (r = 0.72) limb BMD (all Ps < 0.01). Unlike in PCOS, IGF-binding protein 2 was associated with SMI% in controls (r = 0.45) and HA (r = 0.67), and with upper limb BMD (r = 0.98) in HA (all Ps < 0.05).

CONCLUSIONS

Women with PCOS exhibit early signs of osteosarcopenia when compared to controls likely attributed to disrupted insulin function. Understanding the degree of musculoskeletal deterioration in PCOS is critical for implementing targeted interventions that prevent and delay osteosarcopenia in this clinical population.

Negative impact of polycystic ovary syndrome on bone health: a systematic review and meta-analysis

BACKGROUND

Polycystic ovary syndrome (PCOS) has reproductive and metabolic aspects that may affect bone health. Controversial results from different studies regarding the risk of fractures, bone mineral density (BMD) or bone markers led to uncertainty whether PCOS might improve or deteriorate bone health.

OBJECTIVE AND RATIONALE

This study aimed to investigate the impact of PCOS on bone markers, BMD and fracture risk.

SEARCH METHODS

A systematic review and a meta-analysis were carried out. PubMed, EMBASE and Cochrane databases were searched for eligible studies from 1st of January of 1990 to 9th of October of 2018. Eligible studies enrolled women older than 18 years with PCOS, which should be diagnosed according to the Rotterdam Consensus, the Androgen Excess Society, the National Institutes of Health Consensus or the International Classification of Diseases. The studies were grouped according to patient mean BMI: <27 kg/m2 or ≥27 kg/m2. The results were polled as mean difference (MD), standardized MD (SMD) and hazard ratio (HR).

OUTCOMES

Overall, 921 studies were retrieved, and 31 duplicated studies were removed. After screening the titles and abstracts, 80 studies were eligible for full text reading. Of those, 23 studies remained for qualitative synthesis. With the exception of one study, all studies were considered high quality based on the Newcastle-Ottawa scale (NOS; score ≥6). Meta-analysis was performed in 21 studies, with a total of 31 383 women with PCOS and 102 797 controls. Women with PCOS with BMI <27 kg/m2 had lower BMD of the total femur (MD, -0.04; 95% CI, -0.07 to 0.00; I2 = 31%; P = 0.22) and spine (MD, -0.07; 95% CI, -0.13 to -0.01; I2 = 70%; P < 0.01) when compared with the control group, whereas for women with BMI ≥27 kg/m2 no difference was observed (femur: MD, 0.02; 95% CI, -0.02 to 0.05; I2 = 20%, P = 0.29; spine: MD, 0.02; 95% CI, -0.06 to 0.05; I2 = 0%; P = 0.84). Osteocalcin was remarkably reduced in women with PCOS with BMI <27 kg/m2 (SMD, -2.68; 95% CI, -4.70 to -0.67; I2 = 98%; P < 0.01), but in women with BMI ≥27 kg/m2, there were no differences between PCOS and controls. Few studies (n = 3) addressed the incidence of bone fractures in women with PCOS. The HR for total bone fractures did not identify differences between women with PCOS and controls.

WIDER IMPLICATIONS

On the basis of the available evidence, it is possible to assume that PCOS in women with BMI <27 kg/m2 is associated with reduced BMD in the spine and femur, and decreased bone formation, as manifested by lower levels of circulating osteocalcin. These findings suggest that bone parameters in PCOS may be linked, to some extent, to adiposity. These studies included premenopausal women, who have already achieved peak bone mass. Hence, further prospective studies are necessary to clarify the existence of increased risk of fractures in women with PCOS.

Androgens and Androgen Receptor Actions on Bone Health and Disease: From Androgen Deficiency to Androgen Therapy

Androgens are not only essential for bone development but for the maintenance of bone mass. Therefore, conditions with androgen deficiency, such as male hypogonadism, androgen-insensitive syndromes, and prostate cancer with androgen deprivation therapy are strongly associated with bone loss and increased fracture risk. Here we summarize the skeletal effects of androgens—androgen receptors (AR) actions based on in vitro and in vivo studies from animals and humans, and discuss bone loss due to androgens/AR deficiency to clarify the molecular basis for the anabolic action of androgens and AR in bone homeostasis and unravel the functions of androgen/AR signaling in healthy and disease states. Moreover, we provide evidence for the skeletal benefits of androgen therapy and elucidate why androgens are more beneficial than male sexual hormones, highlighting their therapeutic potential as osteoanabolic steroids in improving bone fracture repair. Finally, the application of selective androgen receptor modulators may provide new approaches for the treatment of osteoporosis and fractures as well as building stronger bones in diseases dependent on androgens/AR status.

Increased risk of fractures in patients with polycystic ovary syndrome: a nationwide population-based retrospective cohort study

Polycystic ovary syndrome (PCOS) is a complex disorder; various features of this disorder may influence bone metabolism and skeletal mass. The contribution of PCOS to lower bone mineral density has been recognized. However, the impact of PCOS on the long-term risks for fractures remains inconclusive. The aim of this study was to determine the risk of overall fracture and fractures at different anatomic sites in patients with PCOS. Using a nationwide health insurance claims database, we included 11,106 subjects, aged 15-80 years, with newly diagnosed PCOS (ICD-9-CM: 254.4X) during 2000-2012. Patients with PCOS and respective age-matched (1:4) controls without PCOS were enrolled. The occurrence of fracture was monitored until the end of 2013. Cox regression and computed hazard ratios (HR) with 95% confidence intervals (95% CI) were used to determine the risk of PCOS among women with fractures. The PCOS and non-PCOS groups were comprised of 11,106 patients with PCOS and 44,424 participants without PCOS, respectively. Patients with PCOS had a higher incidence of any fractures compared with non-PCOS group (10.16 versus 8.07 per 1000 person-years) and a greater risk of any fractures [adjusted hazard ratio (aHR) = 1.23, 95% CI = 1.13-1.33], osteoporotic fractures (aHR = 1.33, 95% CI = 1.15-1.54), spine fractures (aHR = 1.36, 95% CI = 1.11-1.66) and forearm fractures (aHR = 1.39, 95% CI = 1.07-1.80), but the risk for femur or hip fracture, humerus, wrist and non-osteoporotic fractures were not increased. In conclusion, the PCOS group had a higher occurrence rate of fractures than the non-PCOS group. These results provide evidence for the adverse effects of PCOS on the risk of fractures.

An update on PCOS in adolescents

PURPOSE OF REVIEW

Polycystic ovarian syndrome (PCOS) is a common endocrinopathy which can be difficult to treat in adolescents. Fortunately, early identification and treatment can help mitigate some of the metabolic complications. In this review, we reflect on recent literature regarding PCOS diagnosis, associated complications, and treatment options.

RECENT FINDINGS

Although there are three well known criteria to diagnose PCOS, they can be difficult to translate to adolescence. Newer diagnostic tools under study include anti-Mullerian hormone and revised ultrasound criteria. More is known about the many complications associated with PCOS, and new treatment options are on the horizon.

SUMMARY

PCOS frequently will present during adolescence. These young women may already have symptoms of metabolic comorbidities. Providers caring for these patients must be aware of the many related complications and common treatment options. Newer diagnostic techniques and treatment options are under active study in adults, and may soon be translated to adolescence. A comprehensive approach allows treatment of patients' concerns, and also prevention of metabolic complications.