Association between polycystic ovary syndrome and the risk of stroke and all-cause mortality: insights from a meta-analysis

Female-specific risk factors for cardiovascular disease: an update

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide. While it was previously believed that men have greater susceptibility to CVD, recent research suggests that women face an increased risk of CVD after the onset of menopause, primarily due to the loss of the protective effects of estrogens. Premature ovarian insufficiency (POI), polycystic ovarian syndrome (PCOS), and gestational factors, such as gestational diabetes mellitus (GDM), recurrent pregnancy loss, preterm delivery, and preeclampsia, are specific reproductive disorders that may contribute to an elevated risk of CVD at earlier ages, i.e., before the onset of menopause. This suggests that women with these conditions should be closely monitored for CVD risk factors even before reaching menopause. Such early intervention may help reduce the incidence of CVD and improve overall cardiovascular health in this population. The precise pathophysiological mechanism underlying the development of CVD in women with menopause, premature POI, PCOS, and gestational factors remains elusive. This review article seeks to elucidate the latest research on the relationship between these conditions and CVD in women, aiming to explore the underlying pathogenic mechanisms contributing to this association.

Polycystic Ovary Syndrome, Insulin Resistance, and Cardiovascular Disease

PURPOSE OF REVIEW

Polycystic ovary syndrome (PCOS) is a prevalent endocrine disorder in women of reproductive age. It has been associated with metabolic, reproductive, and psychiatric disorders. Despite its association with insulin resistance (IR) and cardiovascular disease (CVD) risk factors, the association between PCOS and CVD outcomes has been conflicting. This review reports the updated evidence between PCOS, insulin resistance, and CVD events.

RECENT FINDINGS

IR is highly prevalent occurring in 50 to 95% of general and obese PCOS women. The etiology of PCOS involves IR and hyperandrogenism, which lead to CVD risk factors, subclinical CVD, and CVD outcomes. Multiple studies including meta-analysis confirmed a strong association between PCOS and CVD events including ischemic heart disease, stroke, atrial fibrillation, and diabetes, particularly among premenopausal women, and these associations were mediated by metabolic abnormalities. PCOS is highly familial and has substantial CVD risk and transgenerational effects regardless of obesity. A personalized approach to the CVD risk assessment and management of symptom manifestations should be conducted according to its phenotypes. Lifestyle modifications and reduction in environmental stressors should be encouraged for CVD prevention among PCOS women.

Increased Prevalence of Adverse Health Outcomes Across the Lifespan in Those Affected by Polycystic Ovary Syndrome: A Canadian Population Cohort

Background

Polycystic ovary syndrome (PCOS) is the most common metabolic-endocrine disorder impacting the health and quality of life of women over the lifespan. Evidence-based data on the scope of adverse health outcomes in those affected by PCOS is critical to improve healthcare and quality of life in this population. The aim of this study was to determine the prevalence of adverse health outcomes in those with PCOS compared to age-matched controls.

Methods

We conducted a retrospective observational case-control study in those diagnosed with PCOS and age-matched controls using the Alberta Health Services Health Analytics database and the International Classification of Diseases, for the period from 2002-2018 in Alberta, Canada.

Results

The cohort consisted of n = 16,531 exposed PCOS cases and n = 49,335 age-matched un-exposed controls. The prevalences of hypertension, renal disease, gastrointestinal disease, eating disorders, mental illness, depression-anxiety, rheumatoid arthritis, respiratory infections, and all malignancies were 20%-40% (P < 0.0001) higher in those with PCOS, compared to controls. The prevalence of obesity, dyslipidemia, nonalcoholic fatty liver disease, and type 2 diabetes was 2-3 fold higher in those with PCOS (P < 0.001). Cardiovascular, cerebrovascular, and peripheral vascular disease were 30%-50% higher, and they occurred 3-4 years earlier in those with PCOS (P < 0.0001); a 2-fold higher prevalence of dementia occurred in those with PCOS, compared to controls.

Conclusion

These findings provide evidence that PCOS is associated with a higher prevalence of morbidities over the lifespan, and the potential scope of the healthcare burden in women affected by PCOS.

Metabolic hormones are integral regulators of female reproductive health and function

The female reproductive system is strongly influenced by nutrition and energy balance. It is well known that food restriction or energy depletion can induce suppression of reproductive processes, while overnutrition is associated with reproductive dysfunction. However, the intricate mechanisms through which nutritional inputs and metabolic health are integrated into the coordination of reproduction are still being defined. In this review, we describe evidence for essential contributions by hormones that are responsive to food intake or fuel stores. Key metabolic hormones-including insulin, the incretins (glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1), growth hormone, ghrelin, leptin, and adiponectin-signal throughout the hypothalamic-pituitary-gonadal axis to support or suppress reproduction. We synthesize current knowledge on how these multifaceted hormones interact with the brain, pituitary, and ovaries to regulate functioning of the female reproductive system, incorporating in vitro and in vivo data from animal models and humans. Metabolic hormones are involved in orchestrating reproductive processes in healthy states, but some also play a significant role in the pathophysiology or treatment strategies of female reproductive disorders. Further understanding of the complex interrelationships between metabolic health and female reproductive function has important implications for improving women's health overall.

The Current and Emerging Role of Statins in the Treatment of PCOS: The Evidence to Date

Polycystic ovary syndrome (PCOS) manifests a multifactorial pathology characterized by polycystic ovaries, menstrual cycle disorders, varying degrees of hyperandrogenism, and an ad-verse metabolic risk profile. The position of hyperandrogenism in this syndrome has been extensively studied. A multitude of mechanisms place it in the position of cause but also of consequence; therefore, ongoing research efforts are focused on identifying medications that can effectively reduce levels of androgens in women with PCOS. Moreover, lipid abnormalities are common in this population, with up to 70% of patients having dyslipidemia. Statins may have potential therapeutic benefits for women with PCOS, as they have been shown to improve insulin resistance and reduce the risk of cardiovascular disease. In addition, their role in accelerated steroidogenesis by limiting one source of cholesterol, influencing enzymatic activity, and providing several other beneficial mechanisms is widely investigated. This review aimed to provide a comprehensive overview of the pathogenesis of androgen excess and dyslipidemia in PCOS, as well as the therapeutic potential of statins.

Risk of cardiocerebrovascular diseases is increased in Korean women with polycystic ovary syndrome: a nationwide cohort study

To investigate the relationship between polycystic ovary syndrome (PCOS) and risk of cardiocerebrovascular disease in Korean women. This longitudinal cohort study using data from the Korean National Health Insurance Service included the women aged 15-44 years diagnosed with PCOS between 2002 and 2019, and the controls were matched 1:3 by age group, income, and region of residence. The endpoint outcomes of this study were the occurrence of ischemic heart disease, cerebrovascular diseases, and combined cardiocerebrovascular diseases in the PCOS and control groups. A stratified Cox proportional hazards regression analysis for matched data was performed to evaluate the relative hazard of events in the PCOS group compared to that in the control group. Among a total of 549,400 participants in the cohort, 137,416 women had a diagnosis of PCOS and 412,118 women did not have it. During a median follow-up of 54 months (interquartile range, 30-78 months), the incidence rates of all cardiovascular, ischemic heart, and cerebrovascular diseases were 6.6, 4.0, and 2.9, respectively, per 1000 person-years for women with PCOS, and 4.8, 2.8, and 2.3, respectively, per 1000 person-years for healthy control women. Women with PCOS had a higher hazard ratio of 1.224 (95% confidence interval, 1.18-1.27) of the composite cardiocerebrovascular diseases than those in the controls after propensity score matching for confounding variables, including body mass index, diabetes mellitus, hypertension, dyslipidemia, physical exercise level, alcohol consumption, current smoking, systolic and diastolic blood pressures, total cholesterol, and triglyceride levels. Hazard ratio for ischemic heart and cerebrovascular diseases was higher in women with PCOS than in the control group (hazard ratio, 1.254; 95% confidence interval, 1.20-1.31 and hazard ratio, 1.201; 95% confidence interval, 1.14-1.27, respectively). PCOS is associated with an increased risk of cardiocerebrovascular diseases in Korean women irrespective of their obesity. Counselling on the management of long-term risk of cardiovascular diseases should be offered to women with PCOS in East Asian countries where PCOS is characterized by a relatively low BMI.

Polycystic Ovarian Syndrome: a Risk Factor for Cardiovascular Disease

PURPOSE OF REVIEW

Characterize the risk of cardiovascular disease (CVD) in individuals with polycystic ovarian syndrome (PCOS). Review the pathophysiological pathways that confers CVD risk in individuals with PCOS and interventions to reduce CVD risk.

RECENT FINDINGS

PCOS is a complex syndrome characterized by hyperandrogenism, ovulatory dysfunction, and polycystic ovaries that has metabolic and cardiovascular implications. Intrinsic hormonal dysregulation and chronic low-grade inflammation play an important role in the progression of atherosclerosis in young premenopausal individuals and development of CVD independently of associated traditional risk factors. Management with metformin reduces CVD risk by reducing atherosclerosis progression. PCOS is an important CVD risk factor among individuals of reproductive age. Early detection and interventions are needed to mitigate development of CVD.

Acetate mitigates cardiac mitochondrial dysfunction in experimental model of polycystic ovarian syndrome by modulating GPCR41/43 and PROKR1

The role of short chain fatty acid, acetate in cardiac mitochondrial dysfunction especially in PCOS individuals is unknown. Therefore, the present study investigated the modulatory role of GPCRs (41 and 43) by acetate on cardiac mitochondrial status in PCOS rat model. Eight-week-old female Wistar rats were randomly allotted into four groups (n = 5). Polycystic ovarian syndrome was induced by administering letrozole (1 mg/kg p.o.) once daily for 21 days, thereafter the animals were treated with 200 mg/kg (oral gavage) of acetate for six weeks. Letrozole-induced PCOS rats showed elevated circulating testosterone and anti-mullerian hormone, with multiple ovarian cysts. In addition, these rats also manifested insulin resistance, hyperinsulinemia, and increased plasma triglyceride (TG), TG/HDLc and decreased HDLc, as well as elevated level of cardiac TG, glycogen, glycogen synthase, and plasma/cardiac NF-kB, TNF-α, and SDF-1. Cardiac MDA and caspase-6 increased, while plasma/cardiac NrF2 decreased in PCOS animals. A decrease in mitochondrial ATP synthase, ATP/AMP ratio, CPT2 and SDH, and increased HDAC2 were observed in PCOS rats with decreased level of GPCR 41 and 43 when compared with control. Immunohistochemical evaluation of cardiac tissue also showed decrease expression of PROKR1 in PCOS rats compared with control rats. However, treatment with acetate reversed these systemic, cardiac and mitochondrial anomalies. The present results suggest the therapeutic benefit of acetate, an HDAC2i against cardiac mitochondrial dysfunction in PCOS rat model, by attenuating cardiac inflammation, oxidative stress and apoptosis and these effects are accompanied by modulation of GPCR41 and 43 as well as increased expression of PROKR1.

Obesity and Hyperandrogenemia in Polycystic Ovary Syndrome: Clinical Implications

Polycystic ovary syndrome (PCOS) is often accompanied with metabolic disturbances attributed to androgen excess and obesity, but the contribution of each has not been defined, and the occurrence of metabolic disturbances is usually not investigated. Ninety-nine women with PCOS and forty-one without PCOS were evaluated. The clinical biomarkers of alterations related to glucose (glucose, insulin, and clamp-derived glucose disposal - M), liver (aspartate aminotransferase, alanine aminotransferase, and gamma-glutamyl transferase), and endothelium (arginine, asymmetric dymethylarginine, carotid intima-media thickness, and flow-mediated dilation) metabolism were measured; participants were categorized into four groups according to their obesity (OB) and hyperandrogenemia (HA) status as follows: Healthy (no-HA, lean), HA (HA, lean), OB (no-HA, OB), and HAOB (HA, OB). Metabolic disturbances were very frequent in women with PCOS (≈70%). BMI correlated with all biomarkers, whereas free testosterone (FT) correlated with only glucose- and liver-related indicators. Although insulin sensitivity and liver enzymes were associated with FT, women with obesity showed lower M (coef = 8.56 - 0.080(FT) - 3.71(Ob); p < 0.001) and higher aspartate aminotransferase (coef = 26.27 + 0.532 (FT) + 8.08 (Ob); p = 0.015) than lean women with the same level of FT. Women with obesity showed a higher risk of metabolic disorders than lean women, independent of hyperandrogenemia. Clinicians are compelled to look for metabolic alterations in women with PCOS. Obesity should be treated in all cases, but hyperandrogenemia should also be monitored in those with glucose-or liver-related disturbances.

Added Predictive Value of Female-Specific Factors and Psychosocial Factors for the Risk of Stroke in Women Under 50

BACKGROUND AND OBJECTIVES

Female-specific factors and psychosocial factors may be important in the prediction of stroke but are not included in prediction models that are currently used. We investigated whether addition of these factors would improve the performance of prediction models for the risk of stroke in women younger than 50 years.

METHODS

We used data from the Stichting Informatievoorziening voor Zorg en Onderzoek, population-based, primary care database of women aged 20-49 years without a history of cardiovascular disease. Analyses were stratified by 10-year age intervals at cohort entry. Cox proportional hazards models to predict stroke risk were developed, including traditional cardiovascular factors, and compared with models that additionally included female-specific and psychosocial factors. We compared the risk models using the c-statistic and slope of the calibration curve at a follow-up of 10 years. We developed an age-specific stroke risk prediction tool that may help communicating the risk of stroke in clinical practice.

RESULTS

We included 409,026 women with a total of 3,990,185 person-years of follow-up. Stroke occurred in 2,751 women (incidence rate 6.9 [95% CI 6.6-7.2] per 10,000 person-years). Models with only traditional cardiovascular factors performed poorly to moderately in all age groups: 20-29 years: c-statistic: 0.617 (95% CI 0.592-0.639); 30-39 years: c-statistic: 0.615 (95% CI 0.596-0.634); and 40-49 years: c-statistic: 0.585 (95% CI 0.573-0.597). After adding the female-specific and psychosocial risk factors to the reference models, the model discrimination increased moderately, especially in the age groups 30-39 (Δc-statistic: 0.019) and 40-49 years (Δc-statistic: 0.029) compared with the reference models, respectively.

DISCUSSION

The addition of female-specific factors and psychosocial risk factors improves the discriminatory performance of prediction models for stroke in women younger than 50 years.

The Implication of Mechanistic Approaches and the Role of the Microbiome in Polycystic Ovary Syndrome (PCOS): A Review

As a complex endocrine and metabolic condition, polycystic ovarian syndrome (PCOS) affects women's reproductive health. These common symptoms include hirsutism, hyperandrogenism, ovulatory dysfunction, irregular menstruation, and infertility. No one knows what causes it or how to stop it yet. Alterations in gut microbiota composition and disruptions in secondary bile acid production appear to play a causative role in developing PCOS. PCOS pathophysiology and phenotypes are tightly related to both enteric and vaginal bacteria. Patients with PCOS exhibit changed microbiome compositions and decreased microbial diversity. Intestinal microorganisms also alter PCOS patient phenotypes by upregulating or downregulating hormone release, gut-brain mediators, and metabolite synthesis. The human body's gut microbiota, also known as the "second genome," can interact with the environment to improve metabolic and immunological function. Inflammation is connected to PCOS and may be caused by dysbiosis in the gut microbiome. This review sheds light on the recently discovered connections between gut microbiota and insulin resistance (IR) and the potential mechanisms of PCOS. This study also describes metabolomic studies to obtain a clear view of PCOS and ways to tackle it.

Cardiometabolic Risk, Peripheral Arterial Disease and Cardiovascular Events in Polycystic Ovary Syndrome: Time to Implement Systematic Screening and Update the Management

Polycystic ovary syndrome (PCOS) is a highly prevalent endocrine disorder in women of reproductive age. It presents with gynaecologic, metabolic, and psychologic manifestations. The dominant drivers of pathophysiology are hyperandrogenism and insulin resistance. Both conditions are related to cardiometabolic risk factors, such as obesity, hypertension, dyslipidaemia, hyperglycaemia, type 2 and gestational diabetes, nonalcoholic fatty liver disease and obstructive sleep apnoea. Women with PCOS of reproductive age consistently demonstrated an elevated risk of subclinical atherosclerosis, as indicated by different measurement methods, while findings for menopausal age groups exhibited mixed results. Translation of subclinical atherosclerosis into the increased incidence of peripheral arterial disease and major cardiovascular (CV) events is less clear. Although several expert groups have advised screening, the CV risk assessment and prevention of CV events are frequently underdiagnosed and overlooked aspects of the management of PCOS. A combination of lifestyle management and pharmacotherapy, including the promising new era of anti-obesity medicine, can lead to improvements in cardiometabolic health.

Extensive Arterial and Venous Thrombosis in a Female With a Known Untreated Polycystic Ovarian Syndrome: A Case Report

Polycystic ovarian syndrome (PCOS) is a common heterogeneous endocrine disease associated with a twofold higher risk of stroke and venous thromboembolism (VTE). An 18-year-old female presented to the emergency department (ED) with a one-hour history of right-side body weakness, facial asymmetry, and altered mental status. The patient had poor mentation and was unable to protect her airway. She was intubated and admitted to the intensive care unit (ICU). She was diagnosed with polycystic ovarian syndrome three years ago; however, she was not on active treatment at the time of presentation. She received two doses of the BNT162b2 mRNA COVID-19 vaccine, and her last dose was six months before the current presentation. A workup showed that she had extensive arterial and venous thrombosis. Later during investigations, she was found to have a complex atrial septal defect (ASD) with a left-to-right shunt. This case reports a management approach for a young female with untreated polycystic ovarian syndrome that predisposed her to develop deep vein thrombosis (DVT), pulmonary embolism (PE), and ischemic stroke due to atrial septal defect with possible transient shunt reversal.

Long-term health outcomes in young women with polycystic ovary syndrome: A narrative review

Polycystic ovary syndrome (PCOS) has long been recognized as a common disorder in young women leading to reproductive and cutaneous sequelae. However, the associated health risks are now known to extend beyond these familiar manifestations to a range of longer-term comorbidities. Here we review the evidence for an association of PCOS with adverse long-term health outcomes, discussing the pathophysiological mechanisms involved in addition to opportunities for therapeutic intervention. Cross-sectional and longitudinal studies point to an increased risk of type 2 diabetes, hypertension and dyslipidaemia, with recent data confirming that these translate to an increased risk of cardiovascular events independently of obesity. Obstructive sleep apnoea, nonalcoholic fatty liver disease and endometrial cancer are also more prevalent, while mental health disorders, notably anxiety and depression, are common but under-appreciated associations. Uncertainties remain as to whether these risks are apparent in all patients with PCOS or are confined to particular subtypes, whether risks persist post-menopausally and how risk may be affected by ethnicity. Further work is also needed in establishing if systematic screening and targeted intervention can lead to improved outcomes. Until such data are available, clinicians managing women with PCOS should counsel patients on long-term health risks and invest in strategies that limit progression to metabolic and non-metabolic morbidities.

Circulating microparticles as indicators of cardiometabolic risk in PCOS

Polycystic ovary syndrome (PCOS), the most prevalent endocrine disturbance of the female reproductive system, is associated with several pathologic conditions, such as metabolic syndrome, obesity, diabetes, dyslipidemia, and insulin resistance, all of which are tightly connected to its progression. These factors are associated with a type of extracellular vesicle, ie, microparticles (MPs), released by shedding due to cell activation and apoptosis. Circulating MPs (cMPs) are secreted by a variety of cells, such as platelets, endothelial, leukocytes, and erythrocytes, and contain cytoplasmic substances derived from parent cells that account for their biologic activity. Current evidence has clearly shown that increased cMPs contribute to endothelial dysfunction, diabetes, hypertriglyceridemia, metabolic syndrome, cardiovascular abnormalities as well as PCOS. It has also been reported that platelet and endothelial MPs are specifically increased in PCOS thus endangering vascular health and subsequent cardiovascular disease. Given the importance of cMPs in the pathophysiology of PCOS, we review the role of cMPs in PCOS with a special focus on cardiometabolic significance.

Trends, Predictors, and Outcomes of Cardiovascular Complications Associated With Polycystic Ovary Syndrome During Delivery Hospitalizations: A National Inpatient Sample Analysis (2002-2019)

Background

Women with polycystic ovary syndrome (PCOS) have an increased risk of pregnancy‐associated complications. However, data on peripartum cardiovascular complications remain limited. Hence, we investigated trends, outcomes, and predictors of cardiovascular complications associated with PCOS diagnosis during delivery hospitalizations in the United States.

Methods and Results

We used data from the National Inpatient Sample (2002–2019). International Classification of Diseases, Ninth Revision (ICD‐9), or International Classification of Diseases, Tenth Revision (ICD‐10), codes were used to identify delivery hospitalizations and PCOS diagnosis. A total of 71 436 308 weighted hospitalizations for deliveries were identified, of which 0.3% were among women with PCOS (n=195 675). The prevalence of PCOS, and obesity among those with PCOS, increased during the study period. Women with PCOS were older (median, 31 versus 28 years; P<0.01) and had a higher prevalence of diabetes, obesity, and dyslipidemia. After adjustment for age, race and ethnicity, comorbidities, insurance, and income, PCOS remained an independent predictor of cardiovascular complications, including preeclampsia (adjusted odds ratio [OR], 1.56 [95% CI, 1.54–1.59]; P<0.01), eclampsia (adjusted OR, 1.58 [95% CI, 1.54–1.59]; P<0.01), peripartum cardiomyopathy (adjusted OR, 1.79 [95% CI, 1.49–2.13]; P<0.01), and heart failure (adjusted OR, 1.76 [95% CI, 1.27–2.45]; P<0.01), compared with no PCOS. Moreover, delivery hospitalizations among women with PCOS were associated with increased length (3 versus 2 days; P<0.01) and cost of hospitalization ($4901 versus $3616; P<0.01).

Conclusions

Women with PCOS had a higher risk of preeclampsia/eclampsia, peripartum cardiomyopathy, and heart failure during delivery hospitalizations. Moreover, delivery hospitalizations among women with PCOS diagnosis were associated with increased length and cost of hospitalization. This signifies the importance of prepregnancy consultation and optimization for cardiometabolic health to improve maternal and neonatal outcomes.

A Systematic Review and Meta-Analysis of the Association Between Polycystic Ovary Syndrome and Coronary Artery Calcification

Background: Polycystic ovary syndrome (PCOS) is a common endocrine pathology affecting women of reproductive age characterized by chronic anovulation, hyperandrogenism, and polycystic ovaries. Coronary artery calcification (CAC) is a marker of subclinical atherosclerosis and prognostic of cardiovascular disease (CVD) risk. Some studies have shown that women with PCOS have a greater risk of CAC; however, a few others report contrary findings. The objective of this study is to examine and quantify the association between PCOS and CAC. Materials and Methods: We searched EMBASE, Google Scholar, PubMed, and Web of Science from inception to November 2021 to identify studies that provided information on PCOS and CAC. We used a random-effects model to aggregate the odds ratios (ORs) for CAC (score >0) among women with PCOS compared with controls adjusted for sociodemographic characteristics and CVD risk factors. Results: From the 36 articles reviewed, 3 prospective cohort and 4 cross-sectional studies met the inclusion criteria with a total of 2341 participants. Six studies used CAC > 0 as an outcome and were included in the pooled analysis. Using the Hartung-Knapp-Sidik-Jonkman method, the pooled adjusted ORs for the associations between PCOS and the presence of CAC were 2.48 (95% confidence interval: 2.11-2.84) with no significant heterogeneity (I2 = 0.10%, p = 0.97) for the cohort studies and 1.88 (0.71-3.06) with no significant heterogeneity (I2 = 13.95%, p = 0.87) for the cross-sectional studies. Conclusion: In pooled analyses, women with PCOS had approximately twofold greater odds of having CAC compared with women without PCOS. However, additional prospective studies will be needed to further understand the relationship between PCOS and CAC.

Polycystic ovary syndrome: a "risk-enhancing" factor for cardiovascular disease

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder among women of reproductive age and is hallmarked by hyperandrogenism, oligo-ovulation, and polycystic ovarian morphology. Polycystic ovary syndrome, particularly the hyperandrogenism phenotype, is associated with several cardiometabolic abnormalities, including obesity, dyslipidemia, elevated blood pressure, and prediabetes or type 2 diabetes. Many, but not all, studies have suggested that PCOS is associated with increased risk of cardiovascular disease (CVD), including coronary heart disease and stroke, independent of body mass index and traditional risk factors. Interpretation of the data from these observational studies is limited by the varying definitions and ascertainment of PCOS and CVD across studies. Recent Mendelian randomization studies have challenged the causality of PCOS with coronary heart disease and stroke. Future longitudinal studies with clearly defined PCOS criteria and newer genetic methodologies may help to determine association and causality. Nevertheless, CVD risk screening remains critical in this patient population, as improvements in metabolic profile and reduction in CVD risk are achievable with a combination of lifestyle management and pharmacotherapy. Statin therapy should be implemented in women with PCOS who have elevated atherosclerotic CVD risk. If CVD risk is uncertain, measurement of subclinical atherosclerosis (carotid plaque or coronary artery calcium) may be a useful tool to guide shared decision-making about initiation of statin therapy. Other medications, such as metformin and glucagon-like peptide-1 receptor agonists, also may be useful in reducing CVD risk in insulin-resistant populations. Additional research is needed to determine the best pathways to mitigate PCOS-associated CVD risk.

Cardio-Metabolic Disease and Polycystic Ovarian Syndrome (PCOS): A Narrative Review

Polycystic ovarian syndrome (PCOS) is considered the most common endocrine disorder affecting females in today's world. Although it has been primarily studied and discussed in terms of its reproductive symptoms such as infertility, amenorrhea or oligomenorrhea, acne, hirsutism, and mood disorders, there is yet another unexplored and under-diagnosed category in the PCOS spectrum of diseases: its cardio-metabolic consequences. PCOS patients are prone to these abnormalities from a very young age, increasing their morbidity and mortality rates compared to their regular counterparts. The usual pathogenesis of PCOS is a culmination of several genetic and environmental factors. Regarding its cardio-metabolic aspects, insulin resistance (IR) is said to be the single most important cause of a variety of metabolic risk factors, including type 2 diabetes mellitus (T2DM), metabolic syndrome (MetS), dyslipidemia, obesity, and hypertension (HTN), whereas a few other non-traditional factors such as C-reactive protein (CRP), carotid intima-media thickness (IMT), coronary artery calcification (CAC), and endothelial dysfunction are also said to be increased in PCOS patients, further increasing their risk of complications due to cardiovascular diseases (CVD). A timely diagnosis and adequate treatment of these risk factors by using lifestyle interventions, diet, and/or medications are essential to reduce the burden of PCOS in today's world. This article has highlighted an array of traditional and non-traditional cardio-metabolic consequences PCOS patients are prone to and their systematic pathogenesis. In addition, an outline of recommendations has been given in the pharmacological and non-pharmacological sections of this article, which may benefit doctors in managing this challenging condition.

Suppression of PCSK9/NF-kB-dependent pathways by acetate ameliorates cardiac inflammation in a rat model of polycystic ovarian syndrome

AIM

Endocrinometabolic disorders in women of reproductive age, including polycystic ovarian syndrome (PCOS) has contributed to increased prevalence of cardiovascular disease (CVD) risk and its attendant complications. Acetate, the most abundant endogenously produced short chain fatty acid has been linked to metabolic health. However, the impact of acetate on CVD-driven pathologies in PCOS is unknown. The present study therefore investigated the effects of acetate on cardiometabolic abnormalities associated with PCOS in rat model, and the possible involvement of PCSK9/NF-kB-dependent pathways.

MATERIALS AND METHODS

Eight-week-old female Wistar rats were allotted into four groups (n = 6) and the groups received vehicle, acetate (200 mg/kg), letrozole (1 mg/kg) and letrozole plus acetate respectively. The administrations were done once daily by oral gavage and lasted for 21 days.

KEY FINDINGS

In letrozole-induced PCOS rats characterized with insulin resistance, glucose dysregulation, elevated plasma testosterone and decreased 17-β estradiol as well as degenerated ovarian follicles, there was a significant increase in plasma and cardiac lipid/lipoproteins, lipid peroxidation, inflammatory mediators (NF-kB and TNF-α), γ-glutamyl transferase/lactate dehydrogenase and lactate content, PCSK9 and reduction in plasma and cardiac antioxidants (glutathione peroxidase and reduced glutathione) and plasma nitric oxide synthesis (eNOS and NO) compared with the control rats. In addition, immunohistochemical assessment of cardiac tissue showed severe expression of inflammasome in letrozole-induced PCOS rats compared with the control rats. Nevertheless, supplementation with acetate significantly attenuated these alterations.

SIGNIFICANCE

The present results suggest that acetate protects against cardiac inflammation in a rat model of PCOS by suppression of PCSK9 and NF-kB-dependent mechanisms.

Pregnancy and Reproductive Risk Factors for Cardiovascular Disease in Women

Beyond conventional risk factors for cardiovascular disease, women face an additional burden of sex-specific risk factors. Key stages of a woman's reproductive history may influence or reveal short- and long-term cardiometabolic and cardiovascular trajectories. Early and late menarche, polycystic ovary syndrome, infertility, adverse pregnancy outcomes (eg, hypertensive disorders of pregnancy, gestational diabetes, preterm delivery, and intrauterine growth restriction), and absence of breastfeeding are all associated with increased future cardiovascular disease risk. The menopause transition additionally represents a period of accelerated cardiovascular disease risk, with timing (eg, premature menopause), mechanism, and symptoms of menopause, as well as treatment of menopause symptoms, each contributing to this risk. Differences in conventional cardiovascular disease risk factors appear to explain some, but not all, of the observed associations between reproductive history and later-life cardiovascular disease; further research is needed to elucidate hormonal effects and unique sex-specific disease mechanisms. A history of reproductive risk factors represents an opportunity for comprehensive risk factor screening, refinement of cardiovascular disease risk assessment, and implementation of primordial and primary prevention to optimize long-term cardiometabolic health in women.

Women With Polycystic Ovary Syndrome Have an Increased Risk of Major Cardiovascular Events: a Population Study

CONTEXT

The effects of polycystic ovary syndrome (PCOS) on cardiovascular morbidity and mortality are unclear.

OBJECTIVE

This work aims to establish the relative risk of myocardial infarction (MI), stroke, angina, revascularization, and cardiovascular mortality for women with PCOS.

METHODS

Data were extracted from the Clinical Practice Research Datalink Aurum database. Patients with PCOS were matched to controls (1:1) by age, body mass index (BMI) category, and primary care practice. The primary outcome was the time to major adverse cardiovascular event (MACE); a composite end point incorporating MI, stroke, angina, revascularization and cardiovascular mortality. Secondary outcomes were the individual MACE end points.

RESULTS

Of 219 034 individuals with a diagnosis of PCOS, 174 660 (79.7%) met the eligibility criteria and were matched. Crude rates of the composite end point, MI, stroke, angina, revascularization, and cardiovascular mortality were respectively 82.7, 22.7, 27.4, 32.8, 10.5, and 6.97 per 100 000 patient-years for cases, and 64.3, 15.9, 25.7, 19.8, 7.13, and 7.75 per 100 000 patient-years for controls. In adjusted Cox proportional hazard models (CPHMs), the hazard ratios (HRs) were 1.26 (95% CI, 1.13-1.41), 1.38 (95% CI, 1.11-1.72), 1.60 (95% CI, 1.32-1.94), and 1.50 (95% CI, 1.08-2.07) for the composite outcome, MI, angina, and revascularization, respectively. In a time-dependent CPHM, weight gain (HR 1.01; 1.00-1.01), prior type 2 diabetes mellitus (T2DM) (HR 2.40; 1.76-3.30), and social deprivation (HR 1.53; 1.11-2.11) increased risk of progression to the composite end point.

CONCLUSION

The risk of incident MI, angina, and revascularization is increased in young women with PCOS. Weight and T2DM are potentially modifiable risk factors amenable to intervention.

The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030

Cardiovascular disease is the leading cause of death in women. Decades of grassroots campaigns have helped to raise awareness about the impact of cardiovascular disease in women, and positive changes affecting women and their health have gained momentum. Despite these efforts, there has been stagnation in the overall reduction of cardiovascular disease burden for women in the past decade. Cardiovascular disease in women remains understudied, under-recognised, underdiagnosed, and undertreated. This Commission summarises existing evidence and identifies knowledge gaps in research, prevention, treatment, and access to care for women. Recommendations from an international team of experts and leaders in the field have been generated with a clear focus to reduce the global burden of cardiovascular disease in women by 2030. This Commission represents the first effort of its kind to connect stakeholders, to ignite global awareness of sex-related and gender-related disparities in cardiovascular disease, and to provide a springboard for future research.

An Update on Contraception in Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is a common endocrine disorder in reproductive-aged women, characterized by hyperandrogenism, oligo/anovulation, and polycystic ovarian morphology. Combined oral contraceptives (COCs), along with lifestyle modifications, represent the first-line medical treatment for the long-term management of PCOS. Containing low doses of estrogen and different types of progestin, COCs restore menstrual cyclicity, improve hyperandrogenism, and provide additional benefits such as reducing the risk of endometrial cancer. However, potential cardiometabolic risk associated with these agents has been a concern. COCs increase the risk of venous thromboembolism (VTE), related both to the dose of estrogen and the type of progestin involved. Arterial thrombotic events related to COC use occur much less frequently, and usually not a concern for young patients. All patients diagnosed with PCOS should be carefully evaluated for cardiometabolic risk factors at baseline, before initiating a COC. Age, smoking, obesity, glucose intolerance or diabetes, hypertension, dyslipidemia, thrombophilia, and family history of VTE should be recorded. Patients should be re-assessed at consecutive visits, more closely if any baseline cardiometabolic risk factor is present. Individual risk assessment is the key in order to avoid unfavorable outcomes related to COC use in women with PCOS.

Cardiometabolic Risk in Polycystic Ovary Syndrome: Current Guidelines

Polycystic ovary syndrome is a common endocrine disorder in reproductive-aged women and is associated with an increased risk of metabolic abnormalities, including obesity, impaired glucose tolerance, diabetes, dyslipidemia, metabolic syndrome, venous thromboembolism, and subclinical atherosclerosis. Clinicians and patients alike need to be aware of these increased risks as well as new international guidelines that recommend frequent screening and active management of metabolic abnormalities. Given that the data on risk of cardiovascular events, such as myocardial infarction and stroke, in women with PCOS is mixed, future large-scale, longitudinal studies are needed to clarify these potential risks.

Polycystic Ovary Syndrome and Risk of Type 2 Diabetes, Coronary Heart Disease, and Stroke

Polycystic ovary syndrome (PCOS) has been associated with diabetes and cardiovascular disease; however, whether the relationship is causal is uncertain. We conducted a two-sample Mendelian randomization study to investigate the associations of PCOS with type 2 diabetes, coronary heart disease (CHD), and stroke. Association between PCOS and diabetes risk was examined in European and Asian cohorts, both sex specific and sex combined. Causal effects of PCOS on risks of CHD and stroke were evaluated in European cohorts. Stroke was analyzed as any stroke as well as four subtypes of stroke (ischemic, large artery, cardioembolic, small vessel). We found no association of genetically predicted PCOS with risk of diabetes, CHD, or stroke. This suggests that PCOS in and of itself does not increase the risk of these outcomes. Other features of PCOS (obesity, elevated testosterone, low sex hormone binding globulin) may explain the association between PCOS and cardiometabolic diseases. In light of these results, efforts to prevent cardiometabolic complications in PCOS should focus on women with high-risk features rather than all women with PCOS.

Hypertension in Polycystic Ovary Syndrome: Novel Insights

Polycystic ovary syndrome (PCOS) is a common endocrine disease in women during reproductive age. It was shown that PCOS women are with high risk for dyslipidemia, glucose intolerance, type 2 diabetes and metabolic syndrome. These factors are considered to represent traditional risk factors for the occurrence of cardiovascular disease. Observed increased risk for hypertension in PCOS women seems to be associated with insulin resistance and hyperinsulinemia. Both conditions interfere with the endothelium-dependent vasodilatation mechanisms causing vascular muscle wall hypertrophy. Obesity and insulin resistance are considered key factors for the alteration of blood pressure in PCOS women. Higher cardiovascular risk is implicated in PCOS with aging and its consequent association with both systolic and diastolic blood pressure. The elements of renin-angiotensin-aldosterone system (RAAS) have an impact on endothelial dysfunction as a marker of cardiovascular damage that could be modified is women with PCOS. Androgens and components of RAAS are involved in the process of atherogenesis in PCOS women. Therefore, it is hypothesized that spironolactone treatment could ameliorate endothelial dysfunction in PCOS women. Recently it was shown that telmisartan, angiotensin II receptor antagonist poses insulinsensitizing capacity to activate PPAR gamma and mediate favorable metabolic and reproductive effects in hypertensive PCOS women.

Risk of Cardiovascular and Cerebrovascular Events in Polycystic Ovarian Syndrome Women: A Meta-Analysis of Cohort Studies

Aim: This systematic review and meta-analysis aimed to investigate the risk of cardiovascular disease (CVD) and cerebrovascular disease (CeVD) events in women with polycystic ovary syndrome (PCOS). Methods: We searched the literatures in Pubmed, Embase, and Web of Science to identify cohort studies reporting the association between PCOS and CVD/CeVD events from 1964 to June 1, 2020. Outcome variables, such as all-cause mortality, cardiovascular death, any cardiovascular diseases, myocardial infarction, ischemic heart disease, and stroke, were extracted from the identified literatures, and we reported the outcomes of the association in hazard ratios (HR) and odds ratios (OR). Results: Ten cohort studies comprising 166,682 samples are included in the review. Compared to non-PCOS women, the pooled risk of CVD events in PCOS women (OR: 1.66, 95% CI: 1.32-2.08). In addition, the risk of myocardial infarction (OR: 2.57, 95% CI: 1.37-4.82), ischemic heart disease (OR: 2.77, 95% CI: 2.12-3.61), and stroke (OR: 1.96, 95% CI: 1.56-2.47) are higher in the PCOS group. However, no significant difference in the overall mortality (HR: 1.04, 95% CI: 0.57-1.86) and CVD-related death (HR: 1.49, 95% CI: 0.99-2.23) was observed. Funnel plots of all outcomes are roughly symmetric, and no significant publication bias was found. Conclusion: Though this study identified an increased risk of CVD and CeVD among women with PCOS, including occurrence of myocardial infarction, ischemic heart disease, and stroke, there was no difference in the all-cause or CVD-related mortality observed. Further large-scale studies are warranted to strengthen the association between PCOS and CV events. Our study may require a larger sample size to further verify the conclusions.

Association between the reproductive health of young women and cardiovascular disease in later life: umbrella review

OBJECTIVE

To consolidate evidence from systematic reviews and meta-analyses investigating the association between reproductive factors in women of reproductive age and their subsequent risk of cardiovascular disease.

DESIGN

Umbrella review.

DATA SOURCES

Medline, Embase, and Cochrane databases for systematic reviews and meta-analyses from inception until 31 August 2019.

REVIEW METHODS

Two independent reviewers undertook screening, data extraction, and quality appraisal. The population was women of reproductive age. Exposures were fertility related factors and adverse pregnancy outcomes. Outcome was cardiovascular diseases in women, including ischaemic heart disease, heart failure, peripheral arterial disease, and stroke.

RESULTS

32 reviews were included, evaluating multiple risk factors over an average follow-up period of 7-10 years. All except three reviews were of moderate quality. A narrative evidence synthesis with forest plots and tabular presentations was performed. Associations for composite cardiovascular disease were: twofold for pre-eclampsia, stillbirth, and preterm birth; 1.5-1.9-fold for gestational hypertension, placental abruption, gestational diabetes, and premature ovarian insufficiency; and less than 1.5-fold for early menarche, polycystic ovary syndrome, ever parity, and early menopause. A longer length of breastfeeding was associated with a reduced risk of cardiovascular disease. The associations for ischaemic heart disease were twofold or greater for pre-eclampsia, recurrent pre-eclampsia, gestational diabetes, and preterm birth; 1.5-1.9-fold for current use of combined oral contraceptives (oestrogen and progesterone), recurrent miscarriage, premature ovarian insufficiency, and early menopause; and less than 1.5-fold for miscarriage, polycystic ovary syndrome, and menopausal symptoms. For stroke outcomes, the associations were twofold or more for current use of any oral contraceptive (combined oral contraceptives or progesterone only pill), pre-eclampsia, and recurrent pre-eclampsia; 1.5-1.9-fold for current use of combined oral contraceptives, gestational diabetes, and preterm birth; and less than 1.5-fold for polycystic ovary syndrome. The association for heart failure was fourfold for pre-eclampsia. No association was found between cardiovascular disease outcomes and current use of progesterone only contraceptives, use of non-oral hormonal contraceptive agents, or fertility treatment.

CONCLUSIONS

From menarche to menopause, reproductive factors were associated with cardiovascular disease in women. In this review, presenting absolute numbers on the scale of the problem was not feasible; however, if these associations are causal, they could account for a large proportion of unexplained risk of cardiovascular disease in women, and the risk might be modifiable. Identifying reproductive risk factors at an early stage in the life of women might facilitate the initiation of strategies to modify potential risks. Policy makers should consider incorporating reproductive risk factors as part of the assessment of cardiovascular risk in clinical guidelines.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019120076.

Menstrual cycle regularity and length across the reproductive lifespan and risk of premature mortality: prospective cohort study

OBJECTIVE

To evaluate whether irregular or long menstrual cycles throughout the life course are associated with all cause and cause specific premature mortality (age <70 years).

DESIGN

Prospective cohort study.

SETTING

Nurses' Health Study II (1993-2017).

PARTICIPANTS

79 505 premenopausal women without a history of cardiovascular disease, cancer, or diabetes and who reported the usual length and regularity of their menstrual cycles at ages 14-17 years, 18-22 years, and 29-46 years.

MAIN OUTCOME MEASURES

Hazard ratios and 95% confidence intervals for all cause and cause specific premature mortality (death before age 70 years) were estimated from multivariable Cox proportional hazards models.

RESULTS

During 24 years of follow-up, 1975 premature deaths were documented, including 894 from cancer and 172 from cardiovascular disease. Women who reported always having irregular menstrual cycles experienced higher mortality rates during follow-up than women who reported very regular cycles in the same age ranges. The crude mortality rate per 1000 person years of follow-up for women reporting very regular cycles and women reporting always irregular cycles were 1.05 and 1.23 for cycle characteristics at ages 14-17 years, 1.00 and 1.37 for cycle characteristics at ages 18-22 years, and 1.00 and 1.68 for cycle characteristics at ages 29-46 years. The corresponding multivariable adjusted hazard ratios for premature death during follow-up were 1.18 (95% confidence interval 1.02 to 1.37), 1.37 (1.09 to 1.73), and 1.39 (1.14 to 1.70), respectively. Similarly, women who reported that their usual cycle length was 40 days or more at ages 18-22 years and 29-46 years were more likely to die prematurely than women who reported a usual cycle length of 26-31 days in the same age ranges (1.34, 1.06 to 1.69; and 1.40, 1.17 to 1.68, respectively). These relations were strongest for deaths related to cardiovascular disease. The higher mortality associated with long and irregular menstrual cycles was slightly stronger among current smokers.

CONCLUSIONS

Irregular and long menstrual cycles in adolescence and adulthood are associated with a greater risk of premature mortality (age <70 years). This relation is slightly stronger among women who smoke.

Polycystic Ovary Syndrome and Medical Conditions

Polycystic ovary syndrome is a common endocrinopathy that has been associated with many medical conditions across nearly every specialty. This chapter reviews the current understanding of polycystic ovary syndrome and associated medical conditions.

Gonadal hormones and stroke risk: PCOS as a case study

It is well known that stroke incidence and outcome is sex-dependent and influenced by age and gonadal hormones. In post-menopausal and/or aged females, declining estrogen levels increases stroke risk. However, women who experience early menopause also have an increase in stroke risk. This suggests that, regardless of age, gonadal hormones regulate stroke risk and severity. This review discusses prolonged gonadal hormone dysfunction in a common female endocrine disorder known as polycystic ovarian syndrome, PCOS, and the associated increased risk of stroke due to resulting hyperandrogenism and metabolic comorbidities.

Risk of Psoriasis in Patients with Polycystic Ovary Syndrome: A National Population-Based Cohort Study

Both polycystic ovary syndrome (PCOS) and psoriasis are associated with insulin resistance and metabolic syndrome. Nonetheless, the incidence of psoriasis in patients with PCOS is unclear. We used the Longitudinal Health Insurance Research Database (LHID) in Taiwan from 2000 to 2012 to perform a retrospective population-based cohort study to elucidate the occurrence of psoriasis in PCOS patients. Patients with PCOS without psoriasis in the index year (the year of PCOS diagnosis) were recruited as the PCOS group. Those without PCOS nor psoriasis (control group) were selected using propensity score matching at a ratio of 4:1. Hazard ratios (HRs) were obtained using the Cox proportional hazards regression model. In total, 4707 and 18,828 patients were included in the PCOS and control groups, respectively. The incidence rates of psoriasis in the control and PCOS groups were 0.34 and 0.70 per 1000 person-years, respectively. The risk of psoriasis was higher in the PCOS group by an HR of 2.07 (95% confidence interval [CI] = 1.25–3.43) compared with the control group. In conclusion, the incidence of psoriasis in the PCOS group was higher than that in the control group. Further studies should be conducted to investigate the mechanism underlying the association, and to benefit the long-term management of patients with PCOS.

Infertility and mortality

BACKGROUND

Infertility affects 1 in 10 American reproductive-age women. The impact of this disease beyond the reproductive years is largely unknown.

OBJECTIVE

The objective of the study was to determine the association of infertility history with all-cause and cause-specific mortality.

STUDY DESIGN

This secondary analysis of a multicenter randomized clinical trial included 75,784 women (aged 55-74 years) prospectively enrolled in the Prostate, Lung, Colorectal, and Ovarian cancer-screening trial from 1992 through 2001 and followed up a minimum of 10 years for health-related outcomes and death (856,935 person-years). We examined the association of infertility history (inability to conceive for 1 year or greater) of all-cause and cause-specific mortality using disease risk score-adjusted Cox-proportional hazard regression models.

RESULTS

Infertile women had a 10% increased risk of death (from any cause) during the study period compared with the unexposed (adjusted hazard risk, 1.10, 95% confidence interval, 1.02-1.18, P = .010). This effect was predominantly noted in women at an otherwise low risk of mortality who had a 26% increased risk of death (adjusted hazard risk, 1.26, 95% confidence interval, 1.12-1.42, P < .001). No differences in cardiovascular or diabetic mortality were noted. The risk of cancer death at any time over the study period was increased by 23% in infertile women compared with the unexposed (adjusted hazard risk, 1.23, 95% confidence interval, 1.10-1.37, P < .001). This effect was predominantly noted in women at an otherwise low risk of cancer mortality who had a 47% increased risk of cancer death (adjusted hazard risk, 1.47, 95% confidence interval, 1.25-1.73, P < .001). While no differences are seen in the risk of death from endometrial or ovarian cancer, the risk of death from breast cancer was more than doubled in infertile women at an otherwise low risk of breast cancer death compared with the unexposed (adjusted hazard risk, 2.64, 95% confidence interval, 1.71-4.08, P < .001).

CONCLUSION

Infertility is a harbinger of future morbidity and mortality. Infertile women are at an increased risk of all-cause and cancer-related mortality. Consideration of infertility history in health care maintenance presents an opportunity for screening and early intervention for long-term health outcomes.

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.

Midlife women's health consequences associated with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is one of the most common female endocrinopathies. Its symptoms may appear as early as adolescence and may include irregular menstrual periods, amenorrhea, hirsutism and obesity. Regardless of their phenotypic appearance, women with PCOS are metabolically obese. PCOS is associated with metabolic syndrome, type 2 diabetes, depression, cardiovascular disease and gynecological cancers. The metabolic disorders in obese women with PCOS are invariably due to insulin resistance, while inflammation, oxidative stress and possible interaction with environmental factors are among the features linking women with PCOS alone to metabolic disorders. The current review aims to highlight the relationship between PCOS and midlife women's health complications.

Polycystic ovary syndrome and cardiometabolic risk: Opportunities for cardiovascular disease prevention

Although polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders affecting women, its etiology is not entirely understood. Clinical symptoms of PCOS include acne, amenorrhea or oligomenorrhea, hirsutism, infertility, and mood disorders, which tend to be the primary focus of clinical management. However, the impact of PCOS on future cardiovascular disease (CVD) risk should not be overlooked, and opportunities to implement CVD prevention strategies in these women should be given high priority. The pathogenesis of PCOS commonly involves insulin resistance which leads to several cardiometabolic abnormalities (e.g., dyslipidemia, hypertension, glucose intolerance, diabetes, and metabolic syndrome), thereby putting women at an increased risk for CVD. Prior studies have found that subclinical CVD markers such as coronary artery calcium scores, C-reactive protein, carotid intima-media thickness, and endothelial dysfunction are more likely to be increased in women with PCOS. While the associations between PCOS and cardiometabolic abnormalities have been well established, whether PCOS is associated with subclinical and clinical CVD, independently of these CVD risk factors, is not entirely clear. Lifestyle interventions and weight management may mitigate some of these future CVD risks and should be encouraged. This review summarizes the literature on PCOS and CVD risk factors and provides recommendations that would aid clinicians in the management of these risk factors.

Diagnosis and follow-up of type 2 diabetes in women with PCOS: a role for OGTT?

Polycystic ovary syndrome (PCOS) is common in premenopausal women. The majority of women with PCOS have insulin resistance and the risk of type 2 diabetes mellitus (T2D) is higher in women with PCOS compared to controls. In non-pregnant women with PCOS, glycemic status may be assessed by oral glucose tolerance test (OGTT), fasting plasma glucose (FPG) or HbA1c. OGTT has been reckoned gold standard test for diagnosing T2D, but OGTT is rarely used for diagnostic purpose in other non-pregnant individuals at risk of T2D, apart from PCOS. OGTT has questionable reproducibility, and high sensitivity of the 2-h glucose value is at the expense of relatively low specificity, especially regarding impaired glucose tolerance (IGT). Furthermore, lean women with PCOS are rarely diagnosed with T2D and only few percent of normal-weight women have prediabetes. Glycemic status is necessary at diagnosis and during follow-up of PCOS, especially in women with high risk of T2D (obesity, previous gestational diabetes (GDM)). We suggest that OGTT should be used in the same situations in PCOS as in other patient groups at risk of T2D. OGTT is indicated for diagnosing GDM; however, OGTT during pregnancy may not be indicated in lean women with PCOS without other risk factors for GDM.

Cardiovascular disease in a nationwide population of Danish women with polycystic ovary syndrome

Background

Polycystic ovary syndrome (PCOS) is associated with obesity and low grade inflammation and the risk for cardiovascular disease (CVD) could be increased in PCOS.

Methods

National register-based study including women with PCOS and no previous diagnosis of CVD, hypertension, or dyslipidemia. PCOS Denmark (N = 18,112) included women with PCOS in the Danish National Patient Register. PCOS Odense University Hospital (OUH, N = 1165) was an embedded cohort including premenopausal women with PCOS and clinical and biochemical examination. Three age-matched controls were included per patient in PCOS Denmark (N = 52,769). The main study outcome was CVD events including hypertension and dyslipidemia defined according to nationwide in- and outpatient hospital contact diagnosis codes and/or inferred from filled medicine prescriptions.

Results

The age at inclusion was median (quartiles) 29 (23–35) years and follow up was 11.1 (6.9–16.0) years. The Hazard ratio (95% CI) for development of CVD in PCOS Denmark was 1.7 (1.7; 1.8) (P < 0.001) and the total event rate of CVD was 22.6 per 1000 patient years in PCOS Denmark vs. 13.2 per 1000 patient years in controls (P < 0.001). The median age at diagnosis of CVD was 35 (28–42) years in PCOS Denmark vs. 36 (30–43) years in controls (P < 0.001). Obesity, diabetes, and infertility, and previous use of oral contraceptives were associated with increased risk of development of CVD in PCOS Denmark (P < 0.001). Women in PCOS OUH resembled women in PCOS Denmark regarding risk of CVD. Age, BMI, blood pressure, lipid status, and glycemic status predicted development of CVD in PCOS OUH.

Conclusion

The event rate of CVD including hypertension and dyslipidemia was higher in PCOS compared to controls. The risk of developing CVD must be considered even in young women with PCOS.

Electronic supplementary material

The online version of this article (10.1186/s12933-018-0680-5) contains supplementary material, which is available to authorized users.