Milder forms of atherogenic dyslipidemia in ovulatory versus anovulatory polycystic ovary syndrome phenotype

The Cardiometabolic Risk in Women with Polycystic Ovarian Syndrome (PCOS): From Pathophysiology to Diagnosis and Treatment

Polycystic Ovarian Syndrome (PCOS) is a prevalent endocrine disorder affecting women of reproductive age, with significant variations in presentation characterized by hyperandrogenism, ovulatory dysfunction, and polycystic ovarian morphology. Beyond reproductive health, it may also pose crucial long-term cardiometabolic risks, especially for women with specific types of PCOS, contributing to early subclinical cardiovascular atherosclerotic alterations such as endothelial dysfunction, increased arterial stiffness, and coronary artery calcium levels, respectively. Moreover, the precise relationship between clinical cardiovascular disease (CVD) and PCOS remains debated, with studies demonstrating an elevated risk while others report no significant association. This review investigates the pathophysiology of PCOS, focusing on insulin resistance and its link to subclinical and clinical cardiovascular disease. Diagnostic challenges and novel management strategies, including lifestyle interventions, medications like metformin and glucagon-like peptide-1 receptor agonists (GLP-1RAs), hormonal contraceptives, and bariatric surgery, are further discussed. Recognizing the cardiometabolic risks associated with PCOS, a comprehensive approach and early intervention should address both the reproductive and cardiometabolic dimensions of the syndrome.

Gut Microbes in Polycystic Ovary Syndrome and Associated Comorbidities; Type 2 Diabetes, Non-Alcoholic Fatty Liver Disease (NAFLD), Cardiovascular Disease (CVD), and the Potential of Microbial Therapeutics

Polycystic ovary syndrome (PCOS) is one of the most common endocrine anomalies among females of reproductive age, highlighted by hyperandrogenism. PCOS is multifactorial as it can be associated with obesity, insulin resistance, low-grade chronic inflammation, and dyslipidemia. PCOS also leads to dysbiosis by lowering microbial diversity and beneficial microbes, such as Faecalibacterium, Roseburia, Akkermenisa, and Bifidobacterium, and by causing a higher load of opportunistic pathogens, such as Escherichia/Shigella, Fusobacterium, Bilophila, and Sutterella. Wherein, butyrate producers and Akkermansia participate in the glucose uptake by inducing glucagon-like peptide-1 (GLP-1) and glucose metabolism, respectively. The abovementioned gut microbes also maintain the gut barrier function and glucose homeostasis by releasing metabolites such as short-chain fatty acids (SCFAs) and Amuc_1100 protein. In addition, PCOS-associated gut is found to be higher in gut-microbial enzyme β-glucuronidase, causing the de-glucuronidation of conjugated androgen, making it susceptible to reabsorption by entero-hepatic circulation, leading to a higher level of androgen in the circulatory system. Overall, in PCOS, such dysbiosis increases the gut permeability and LPS in the systemic circulation, trimethylamine N-oxide (TMAO) in the circulatory system, chronic inflammation in the adipose tissue and liver, and oxidative stress and lipid accumulation in the liver. Thus, in women with PCOS, dysbiosis can promote the progression and severity of type 2 diabetes, non-alcoholic fatty liver disease (NAFLD), and cardiovascular diseases (CVD). To alleviate such PCOS-associated complications, microbial therapeutics (probiotics and fecal microbiome transplantation) can be used without any side effects, unlike in the case of hormonal therapy. Therefore, this study sought to understand the mechanistic significance of gut microbes in PCOS and associated comorbidities, along with the role of microbial therapeutics that can ease the life of PCOS-affected women.

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.

Metabolome implies increased fatty acid utilization and histone methylation in the follicles from hyperandrogenic PCOS women

Well-balanced metabolism is essential for the high-quality of oocytes, and metabolic fluctuations of follicular microenvironment potentially encourage functional changes in follicle cells, ultimately impacting the developmental potential of oocytes. Here, the global metabolomic profiles of follicular fluid from PCOS women with ovarian hyperandrogenism and nonhyperandrogenism were depicted by untargeted metabolome and transcriptome. In parallel, functional methods were employed to evaluate the possible impact of dysregulated metabolites on oocyte and embryo development. Our findings demonstrated that PCOS women exhibited distinct metabolic features in follicles, such as the increase in fatty acid utilization and the downregulation in amino acid metabolism. And intrafollicular androgen levels were positively correlated with contents of multiple fatty acids, suggesting androgen as one of the contributing factors to the metabolic abnormalities in PCOS follicles. Moreover, we further demonstrated that elevated levels of α-linolenic acid and H3K27me3 could hinder oocyte maturation, fertilization, and early embryo development. Hopefully, our data serve as a broad resource on the metabolic abnormalities of PCOS follicles, and advances in the relevant knowledge will allow the identification of biomarkers that predict the progression of PCOS and its poor pregnancy outcomes.

Astaxanthin supplementation impact on insulin resistance, lipid profile, blood pressure, and oxidative stress in polycystic ovary syndrome patients: A triple-blind randomized clinical trial

Astaxanthin (ASX) is a natural carotenoid compound found in several of microorganisms and seafood. It may have numerous therapeutic benefits for polycystic ovarian syndrome (PCOS) patients. The aim of this study was to investigate the effect of ASX on lipid profile, insulin resistance (IR), blood pressure (BP), and oxidative stress (OS) levels in infertile PCOS patients. Overall, 58 infertile women with diagnosed PCOS participated in this triple-blind randomized clinical trial. They were randomly assigned to two groups, taking either a placebo or ASX (2 × 6 mg/day) for 8 weeks. Blood serum samples were collected from patients before and after the intervention. Fasting Insulin (FI), fasting blood glucose (FBS), OS markers (malondialdehyde [MDA], superoxide dismutase [SOD], and total antioxidant capacity [TAC]), and lipid profiles were evaluated in serum. Moreover, based on the relevant formula, several indices associated with IR were calculated. BP was also assessed at the start and end of the study. After 8 weeks of ASX consumption, a significant reduction was observed in fasting blood sugar, HOMA-IR, FI, MDA, low-density lipoprotein-cholesterol, and TC/HDL-C. Conversely, ASX significantly increased TAC, HDL-C, and QUICKI. After adjusting the analysis for the baseline values of age, body mass index, and biochemical parameters, non-significant values were obtained for QUICKI and FI, along with no changes in other findings. Overall, ASX appears to be an effective and safe supplement that alleviates insulin metabolism, lipid profile parameters, and OS in infertile PCOS patients.

Plasma Lipoprotein(a) Levels in Polycystic Ovary Syndrome: A Systematic Review and Meta-analysis

INTRODUCTION

The polycystic ovary syndrome (PCOS) may represent an important model of lipid alterations. Lipoprotein(a) [Lp(a)] has emerged as a new marker of cardiovascular risk.

AIM

The main objective of this meta-analysis was to analyze the available evidence on Lp(a) levels in patients with PCOS compared to a control group.

METHODS

This meta-analysis was performed according to PRISMA guidelines. A literature search was performed to detect studies that have quantified Lp(a) levels in women with PCOS compared to a control group. The primary outcome was Lp(a) levels expressed in mg/dL. Random effects models were used.

RESULTS

Twenty-three observational studies including 2,337 patients were identified and considered eligible for this meta-analysis. In the overall analysis, the quantitative analysis showed that patients with PCOS have a higher Lp(a) levels (SMD: 1.1 [95% CI: 0.7 to 1.4]; I²=93%) compared to the control group. The results were similar in the analysis of the subgroups of patients according to body mass index (normal weight group: SMD: 1.2 [95% CI: 0.5 to 1.9], I²=95%; overweight group: SMD: 1.2 [95% CI: 0.5 to 1.8], I²=89%). Sensitivity analysis showed that the results were robust.

CONCLUSIONS

This meta-analysis shows that women with PCOS had higher levels of Lp(a) compared to healthy women used as a control group. These findings were observed in both overweight and non-overweight women.

Endocrine Disrupting Chemicals in Polycystic Ovary Syndrome: The Relevant Role of the Theca and Granulosa Cells in the Pathogenesis of the Ovarian Dysfunction

Polycystic ovary syndrome (PCOS) is the most common heterogeneous endocrine disorder among women of reproductive age. The pathogenesis of PCOS remains elusive; however, there is evidence suggesting the potential contribution of genetic interactions or predispositions combined with environmental factors. Among these, endocrine disrupting chemicals (EDCs) have been proposed to potentially contribute to the etiology of PCOS. Granulosa and theca cells are known to cooperate to maintain ovarian function, and any disturbance can lead to endocrine disorders, such as PCOS. This article provides a review of the recent knowledge on PCOS pathophysiology, the role of granulosa and theca cells in PCOS pathogenesis, and the evidence linking exposure to EDCs with reproductive disorders such as PCOS.

Management of Dyslipidemia in Endocrine Diseases

Most endocrine disorders are chronic in nature, and thus even a minor effect to increase risk for cardiovascular disease can lead to a significant impact over prolonged duration. Although robust therapies exist for many endocrine disorders (eg suppression of excess hormone amounts, or replacement of hormone deficiencies), the therapies do not perfectly restore normal physiology. Thus, individuals with endocrine disorders are at potential increased cardiovascular disease risk, and maximizing strategies to reduce that risk are needed. This article reviews various endocrine conditions that can impact lipid levels and/or cardiovascular disease risk.

Effects of endocrine disorders on lipids and lipoproteins

Endocrine diseases may be associated with dyslipidaemia and may increase atherosclerotic cardiovascular disease (ASCVD) risk. This chapter describes changes in lipids and lipoproteins in diseases of the pituitary, thyroid, adrenal glands, ovaries, and testes, the mechanisms for these changes, ASCVD risk in these endocrine disorders, and whether treatment of the endocrine disorder improves the lipid profile and reduces ASCVD risk. Acromegaly, GH deficiency, Cushing syndrome, chronic glucocorticoid replacement, hypothyroidism, PCOS and male hypogonadism can increase LDL-C and/or TG. Marked reductions in LDL-C are associated with hyperthyroidism, and extremely low HDL-C levels with testosterone and/or other anabolic steroid abuse. Acromegaly, GH deficiency, Cushing syndrome, and chronic glucocorticoid replacement are associated with increased ASCVD risk. Treatment of acromegaly, GH deficiency, hypothyroidism, Cushing syndrome, and testosterone deficiency reduce LDL-C, although statin therapy may still be needed. Effects on ASCVD are not known.

Effect of pharmacological interventions on lipid profiles and C-reactive protein in polycystic ovary syndrome: A systematic review and meta-analysis

CONTEXT

Polycystic ovary syndrome (PCOS) is a heterogeneous condition affecting women of reproductive age. It is associated with dyslipidaemia and elevated plasma C-reactive protein (CRP), which increase the risks of cardiovascular disease (CVD).

OBJECTIVE

To review the existing evidence on the effects of different pharmacological interventions on lipid profiles and CRP of women with PCOS.

DATA SOURCES

We searched PubMed, MEDLINE, Scopus, Embase, Cochrane Library, and Web of Science in April 2020 and updated the results in March 2021.

STUDY SELECTION

The study included randomized controlled trials (RCTs) and follows the 2020 Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA).

DATA EXTRACTION

Two independent researchers extracted data and assessed for risk of bias using the Cochrane risk of bias tool. Covidence systematic review software were used for blinded screening and study selection.

DATA SYNTHESIS

In 29 RCTs, there were significant reductions in triglycerides with atorvastatin versus placebo [mean difference (MD): -0.21 mmol/L; 95% confidence interval (CI): -0.39, -0.03, I²  = 0%, moderate grade evidence]. Significant reductions were seen for low-density lipoprotein cholesterol (LDL-C) with metformin versus placebo [standardized mean difference (SMD): -0.41; 95% CI: -0.85, 0.02, I²  = 59%, low grade evidence]. Significant reductions were also seen for total cholesterol with saxagliptin versus metformin (MD: -0.15 mmol/L; 95% CI: -0.23, -0.08, I²  = 0%, very low grade evidence). Significant reductions in C-reactive protein (CRP) were seen for atorvastatin versus placebo (MD: -1.51 mmol/L; 95% CI: -3.26 to 0.24, I²  = 75%, very low-grade evidence).

CONCLUSION

There were significant reductions in the lipid parameters when metformin, atorvastatin, saxagliptin, rosiglitazone and pioglitazone were compared with placebo or other agents. There was also a significant reduction of CRP with atorvastatin.

The Prevalence of Polycystic Ovary Syndrome, Its Phenotypes and Cardio-Metabolic Features in a Community Sample of Iranian Population: Tehran Lipid and Glucose Study

Objectives

The aim of the present study was to evaluate the prevalence of polycystic ovary syndrome (PCOS), its phenotypical and cardio-metabolic features in a community sample of the Iranian population in comparison to healthy eumenorrheic, non-hirsute women without polycystic ovaries. The second aim was to assess the cardio-metabolic characteristics of women who suffered from one criteria of PCOS compared to those healthy eumenorrheic, non-hirsute women.

Methods

In this cross-sectional population-based study, a total of 1,960 eligible women, aged (18-45 years) were recruited from the Tehran-Lipid and Glucose-Study participants and were classified as the three groups of (i) women with PCOS by the Rotterdam criteria, (ii) non-PCOS women with one criteria of PCOS and (iii) healthy eumenorrheic, non-hirsute women without polycystic ovaries morphology (PCOM) as the control group. Further PCOS women were extended to four phenotypes of hyperandrogenism, oligo-anovulation, polycystic ovaries (phenotype A), hyperandrogenism, oligo/anovulation (phenotype B), hyperandrogenism, polycystic ovaries (phenotype C) and oligo-anovulation, polycystic ovaries (phenotype D). Cardio-metabolic profiles and the prevalence of comorbidities of metabolic syndrome (MetS) and lipid abnormalities were compared among these groups linear, and the median regression models adjusted for age and body mass index.

Results

The prevalence of PCOS according to the diagnostic criteria of the NIH, Rotterdam and AE-PCOS Society were 13.6, 19.4, and 17.8, respectively. Among those who met the Rotterdam criteria, 23.9, 46.3, 21.6, and 8.2% had phenotypes A, B, C, and D, respectively. Among the remaining 1,580 women who did not fulfil the PCOS criteria, 108 (6.8%) suffered from only oligo/anovulation, 332 (21%) only hyperandrogenism/hyperandrogenemia, 159 (16.2%) only PCOM in ultrasound and 981 (62%) were healthy eumenorrheic, non-hirsute women without PCOM. The study revealed that some adiposity indices and lipid abnormalities in PCOS phenotypes with hyperandrogenism (A, B, and C) were worse than in healthy women. By contrast, women with phenotype D did not differ from the healthy ones in terms of adiposity and lipid abnormalities. However, the respective values for other cardio-metabolic profiles and MetS rates in different phenotypes of PCOS were similar to the healthy women. Only the prevalence of MetS in phenotype A was significantly higher than in the healthy women. There were no statistically significant differences between participants with one criteria of PCOS and healthy counterparts in terms of most adiposity indexes, cardio-metabolic factors, and comorbidity of MetS and its components. However, women with hyperandrogenism had a significantly higher level of the waist to height ratio (WHtR) and hypertriglyceridemia than their healthy counterparts.

Conclusion

PCOS, mainly classical phenotypes A and B, are common among Iranian women of reproductive age. Women with PCOS who had androgen excess exhibited the worst lipid profile, and those who had full three criteria of the syndrome exhibited the higher rate of MetS. However, women with only ovulatory dysfunction and only PCOM had similar cardio-metabolic characteristics, compared to healthy subjects. These data suggest that routine screening for metabolic disturbances may be needed in the prevention of cardio-metabolic disorders in patients with more serious phenotypes of PCOS.

Effects of Androgen Excess-Related Metabolic Disturbances on Granulosa Cell Function and Follicular Development

Polycystic ovary syndrome (PCOS) is a common reproductive endocrine disease in women of reproductive age. Ovarian dysfunction including abnormal steroid hormone synthesis and follicular arrest play a vital role in PCOS pathogenesis. Hyperandrogenemia is one of the important characteristics of PCOS. However, the mechanism of regulation and interaction between hyperandrogenism and ovulation abnormalities are not clear. To investigate androgen-related metabolic state in granulosa cells of PCOS patients, we identified the transcriptome characteristics of PCOS granulosa cells by RNA-seq. Gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis of differentially expressed genes (DEGs) revealed that genes enriched in lipid metabolism pathway, fatty acid biosynthetic process and ovarian steroidogenesis pathway were abnormally expressed in PCOS granulosa cells in comparison with that in control. There are close interactions among these three pathways as identified by analysis of the protein-protein interaction (PPI) network of DEGs. Furthermore, in vitro mouse follicle culture system was established to explore the effect of high androgen and its related metabolic dysfunction on follicular growth and ovulation. RT-qPCR results showed that follicles cultured with dehydroepiandrosterone (DHEA) exhibited decreased expression levels of cumulus expansion-related genes (Has2, Ptx3, Tnfaip6 and Adamts1) and oocyte maturation-related genes (Gdf9 and Bmp15), which may be caused by impaired steroid hormone synthesis and lipid metabolism, thus inhibited follicular development and ovulation. Furthermore, the inhibition effect of DHEA on follicle development and ovulation was ameliorated by flutamide, an androgen receptor (AR) antagonist, suggesting the involvement of AR signaling. In summary, our study offers new insights into understanding the role of androgen excess induced granulosa cell metabolic disorder in ovarian dysfunction of PCOS patients.

Serum sclerostin level and its relation to subclinical atherosclerosis in the polycystic ovary syndrome phenotypes: A prospective controlled study

Objective

We aim to study the relationship between atherosclerosis and serum sclerostin levels in different phenotypes of polycystic ovary syndrome (PCOS).

Materials and Methods

A total of 134 women with PCOS and 33 age-matched controls participated in this study. Women with PCOS were further divided into subgroups based on their PCOS phenotypes: phenotype A (n=35), phenotype B (n=33), phenotype C (n=31), and phenotype D (n=35). Metabolic parameters, hormonal parameters, carotid intima-media thickness (CIMT), and sclerostin levels were compared among the PCOS phenotypes.

Results

Statistically significant differences occurred among groups regarding follicle-stimulating hormone, luteinizing hormone, estradiol, total cholesterol, low-density lipoprotein, Ferriman-Gallwey score, total testosterone, and free androgen index. The mean CIMT was statistically higher in all PCOS phenotypes than in controls. In subgroup comparison, phenotypes A and B had a higher body mass index (BMI) adjusted CIMT than other phenotypes, respectively (p=0.005). Serum sclerostin levels were higher in PCOS patients than in controls. A concentration of ≥6.297 ng/mL showed a sensitivity of 56% and a specificity of 69.7% to predict PCOS. The BMI-adjusted sclerostin level was significantly higher in phenotype C (20.3±0.7 ng/mL) than in other phenotypes.

Conclusion

Patients with phenotypes A and B seem to have an increased risk for atherosclerosis. Although sclerostin was higher in PCOS patients, we could not demonstrate the relation between sclerostin and atherosclerosis in different PCOS phenotypes.

Effect of vitamin D on experimental model of polycystic ovary syndrome in female rats

AIMS

Vitamin D plays an important role in the regulation of ovulatory dysfunction. We aimed to study the effect of vitamin D on letrozole-induced PCOS in female rats.

MATERIAL & METHODS

40 non-pregnant Wistar rats were divided into four groups: group I control (received 1 ml of 1% aqueous solution of (CMC)/d orally), group II letrozole-induced PCOS group (received letrozole 200 μg/d orally), group III vitamin D-treated group (received vitamin D 1000 IU/kg/d), group IV letrozole and vitamin D treated group (received letrozole and vitamin D as group II and group III for 90 days. BMI, ovarian weight, serum vitamin D, biochemical metabolic and oxidative stress markers were evaluated, ovarian tissues glutathione, malondialdehyde levels and caspase-3 activity were measured. Histopathological examination of the ovary and coronary artery were done.

KEY FINDINGS

Letrozole-induced typical PCOS with significant decrease in vitamin D and coronary vasculopathy. Group II shows insignificant change in all parameters but there is significant increase in vitamin D and decrease in triglyceride and glutathione. In group VI all parameters were significantly improved but coronary vasculopathy was partly improved. Vitamin D was significantly negatively correlated with all parameters but significantly positively correlated with estradiol, insulin sensitivity, and HDL and insignificantly correlated with glutathione. Both Insulin resistance and testosterone were significantly positively correlated with all parameters but significantly negatively correlated with estradiol, insulin sensitivity, HDL and glutathione.

SIGNIFICANCE

These results holding the promise of beneficial impact of vitamin D administration to PCOS and its associated cardiovascular disorders.

Elucidating the impact of obesity on hormonal and metabolic perturbations in polycystic ovary syndrome phenotypes in Indian women

Polycystic ovary syndrome is a complex endocrinopathy with heterogeneous presentation and multifactorial etiology. We have undertaken this case-control study to compare metabolic and endocrine characteristics in different phenotypic subgroups of women with PCOS and the impact of obesity on them. Women with PCOS (n = 489) were classified into 4 phenotypes according to Rotterdam criteria. Comparisons of clinical, biochemical and hormonal parameters were performed across all phenotypic groups of PCOS and with controls (n = 270) by Welch’s ANOVA with subsequent Games-Howell post-hoc test. We found maximum prevalence of normoandrogenic phenotype D, which is milder form of PCOS in terms of insulin resistance, gonadotropin levels and dyslipidemia, followed by phenotype A, in our total study population. After classification of the study group into lean and obese groups, only few insulin and lipid-related traits showed marked differences between phenotypes. Further, we noted that obese women showed adverse metabolic but not androgenic traits compared to lean counterparts in the same phenotype. Metabolic syndrome frequency is increased in hyperandrogenic phenotypes with HDL-C and waist circumference being most predominant contributing factors in total, lean and obese groups. We demonstrate that in our study population there is greater occurrence of phenotype D of PCOS. Our study highlights the importance of clinicians concurrently employing Rotterdam criteria along with obesity status for ascertaining accurate PCOS status and formulating suitable therapeutic intervention.

Lipid Management in Patients with Endocrine Disorders: An Endocrine Society Clinical Practice Guideline

OBJECTIVE

This guideline will provide the practicing endocrinologist with an approach to the assessment and treatment of dyslipidemia in patients with endocrine diseases, with the objective of preventing cardiovascular (CV) events and triglyceride-induced pancreatitis. The guideline reviews data on dyslipidemia and atherosclerotic cardiovascular disease (ASCVD) risk in patients with endocrine disorders and discusses the evidence for the correction of dyslipidemia by treatment of the endocrine disease. The guideline also addresses whether treatment of the endocrine disease reduces ASCVD risk.

CONCLUSION

This guideline focuses on lipid and lipoprotein abnormalities associated with endocrine diseases, including diabetes mellitus, and whether treatment of the endocrine disorder improves not only the lipid abnormalities, but also CV outcomes. Based on the available evidence, recommendations are made for the assessment and management of dyslipidemia in patients with endocrine diseases.

Mitochondrial dysfunction: An emerging link in the pathophysiology of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a common endocrine disorder characterized by irregular menstrual cycles, hyperandrogenism and subfertility. Due to its complex manifestation, the pathogenic mechanism of PCOS is not well defined. Cumulative effect of altered genetic and epigenetic factors along with environmental factors may play a role in the manifestation of PCOS leading to systemic malfunction. With failure of genome-wide association study (GWAS) and other studies performed on nuclear genome to provide any clue for precise mechanism of PCOS pathogenesis, attention has been diverted to mitochondria. Mitochondrion plays an important role in cellular metabolic functions and is linked to Insulin Resistance (IR). Recently, increasing reports suggest that mitochondrial dysfunction may be a contributing factor in the pathogenesis of PCOS. Hence, in this review, we have discussed mitochondrial biology in brief and emphasizes on genetic and epigenetic aspects of mitochondrial dysfunction studied in PCOS women and PCOS-like animal models. We also highlight underlying mechanism behind mitochondrial dysfunction contributing to PCOS and its related complications such as obesity, diabetes, cardiovascular diseases, metabolic syndrome, non-alcoholic fatty liver disease (NAFLD) and cancer. Furthermore, contrasting remarks against involvement of mitochondrial dysfunction in PCOS pathophysiology have also been presented. This review enhances our understanding in relation to mitochondrial dysfunction in the etiology of PCOS and stimulates further research to explore a clear link between mitochondrial dysfunction and PCOS pathogenesis and progression. Understanding pathogenic mechanisms underlying PCOS will open new windows to develop promising therapeutic strategies against PCOS.

Dyslipidemia involvement in the development of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is widely accepted as the most common endocrine abnormality in women of childbearing age and may be accompanied by dyslipidemia, hyperandrogenism, hyperinsulinemia, oxidative stress and infertility. Dyslipidemia is now known to play an important role in the development of PCOS. Lipid abnormalities, including elevated low-density lipoprotein and triglyceride levels and reduced high-density lipoprotein levels, are often found in women with PCOS and play an important role in PCOS; therefore, we summarize the effect of lipid abnormalities on hyperandrogenism, insulin resistance, oxidative stress and infertility in PCOS and review the effects of common lipid-lowering drugs on patients with PCOS. The purpose of this article is to elucidate the mechanisms of lipid metabolism abnormalities in the development of PCOS.

Criteria, phenotypes and prevalence of polycystic ovary syndrome

Polycystic ovarian syndrome (PCOS) is known as one of the most frequent endocrine diseases in women worldwide. However, this term does not completely capture the diversity of clinical signs associated with this syndrome e.g., menstrual irregularity and clinical features of androgen excess, which are though commonplace in women with PCOS, they are not included under the definition of PCOS, limited to polycystic ovarian morphology (PCOM). Utilizing the most globally accepted criterion used today in the diagnosis of PCOS, the authors of this article review and discuss the historical and current context of evidence as well as their limitations. This review addresses the phenotypic approach and age-dependent aspects of PCOS in adolescents, adult and peri/postmenopausal women, as presented in the NIH (1990, 2012), Rotterdam (2003), AE-PCOS Society (2006) consensuses and in the latest evidence-based international guideline (2018). Global data on the epidemiology of PCOS, including prevalence and distribution of polycystic ovarian syndrome phenotypes, is also analyzed in the article. Lastly, the authors discuss the importance and current need to perform more epidemiological studies focused on PCOS.

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.

Relation of NT-probnp levels and cardiovascular disease risk factors in lean women with polycystic ovary syndrome

Women with polycystic ovary syndrome (PCOS) often have cardiovascular disease (CVD) risk factors. N-terminal fragment of brain natriuretic peptide (Nt-probnp) is used as a diagnostic and prognostic marker for CVD. The aim of this study was to evaluate whether Nt-probnp is increased in lean PCOS patients. A total of 110 lean (BMI < 25 kg/m²) PCOS patients and 80 age and BMI matched healthy lean controls were included in this study. Serum Homeostatic Model Assessment-Insulin Resistance (HOMA-IR), Matsuda insulin sensitivity index (ISI), Nt-probnp, C-reactive protein (CRP), androgen and lipid levels were measured. Serum Nt-probnp levels were significantly higher in the PCOS group. Hyperandrogenic PCOS patients had higher Nt-probnp levels. There were significant correlations between serum Nt-probnp and total testosterone, total cholesterol, HOMA and Matsuda levels. Linear regression analysis showed that Matsuda ISI and fasting insulin levels significantly affected the Nt-probnp levels (R² of the model = 0.763; p<.0001). IMPACT STATEMENT What is already known on this subject? Many risk factors for cardiovascular disease (CVD) including insulin resistance, dyslipidaemia, hypertension and hyperandrogenism may be found in young women with polycystic ovary syndrome (PCOS), although evidence for CVD in lean women with PCOS is limited. N-terminal fragment of brain natriuretic peptide (NT-probnp) is a high predictive marker regarding of CVD, especially in patients without overt CVD. There have been contradictory results regarding Nt-probnp levels in PCOS patients and there have not been any effective studies regarding the relation between CVD risk factors and Nt-probnp levels for lean PCOS patients. What the results of this study add? This study found increased Nt-probnp levels in lean PCOS patients, which may indicate a positive correlation with risk for CVD. Strong relations were also found between Nt-probnp levels and increased insulin resistance, dyslipidaemia, decreased insulin sensitivity and hyperandrogenism. Lean PCOS patients have increased risk factors for CVD, and these risk factors are correlated with Nt-probnp levels. Nt-probnp is more affected by increased fasting insulin and decreased insulin sensitivity. What the implications are of these findings for clinical practice and/or further research? Lean PCOS patients should be evaluated for CVD. Further prospective controlled studies are needed in order to predict the long-term risk of developing CVD in lean PCOS patients.

Metabolic and carbohydrate characteristics of different phenotypes of polycystic ovary syndrome

OBJECTIVE

To compare the prevalence of various metabolic and cardiovascular risk factors and insulin resistance between polycystic ovary syndrome (PCOS) patients with or without hyperandrogenism.

MATERIAL AND METHODS

This is a retrospective cross-sectional study involving women with PCOS as diagnosed according to the Androgen Excess (AE) Society definition (n=504) and women with normoandrogenemic PCOS (n=183). Anthropometrics, lipid profile, glucose, insulin, oral glucose tolerance test (OGTT), and reproductive hormone levels were evaluated.

RESULTS

Women with PCOS diagnosed according to the AE Society had a significantly higher prevalence of metabolic syndrome compared with the normoandrogenemic PCOS phenotype: odds ratio (OR) 2.95 [95% confidence interval (CI) 1.21-7.21]. There was no significant difference in the prevalence glucose intolerance test between the groups [OR: 2.15, 95% CI 0.71-6.56]. The prevalence of low high density lipoprotein (HDL)-cholesterol in the group under the AE-PCOS Society criteria was higher than that of the normoandrogenemic PCOS group [OR: 2.82, 95%CI 1.29-3.36].

CONCLUSION

The risks of metabolic syndrome and cardiovascular disease may vary among the phenotypes of PCOS based on the Rotterdam criteria. This new data may be of reference in informing women with PCOS, although further prospective studies are needed to validate this proposition.

[Does hyperandrogenic statute in the polycystic ovary syndrome constitute an obstacle to the success of in vitro fertilization?]

OBJECTIVES

The aim of this study was to evaluate the impact of initial androgenic statute of women with polycystic ovary syndrome (SOPK) on the expected results of in vitro fertilization (FIV).

MATERIALS AND METHODS

It is about an exploratory study carried out in 61 unfertile SOPK patients, having profited all from a cycle of FIV/ICSI (intracytoplasmic sperm injection). We have divided our population in two groups according to their hormonal androgenic statute: groups with hyperandrogenism and without hyperandrogenism. We proceeded to note the anthropometric and hormonal parameters as well as results of FIV for each of the two groups.

RESULTS

SOPK patients with hyperandrogenism are more obese than their counterparts. Also, they have more oocytes collected after ovarian induction. In addition, we did not reveal any significant differences between our two study groups concerning parameters defining FIV response.

CONCLUSION

Our findings suggest that hyperandrogenism statute in SOPK infertile women does not seem to compromise the results of FIV. On the contrary, it would make it possible to optimize the chances to puncture more significant number of oocytes.

Criteria, prevalence, and phenotypes of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a highly prevalent disorder effecting reproductive-aged women worldwide. This article addresses the evolution of the criteria used to diagnosis PCOS; reviews recent advances in the phenotypic approach, specifically in the context of the extended Rotterdam criteria; discusses limitations of the current criteria used to diagnosis, particularly when studying adolescents and women in the peri- and postmenopause; and describes significant strides made in understanding the epidemiology of PCOS. This review recognizes that although there is a high prevalence of PCOS, there is increased variability when using Rotterdam 2003 criteria, owing to limitations in population sampling and approaches used to define PCOS phenotypes. Last, we discuss the distribution of PCOS phenotypes, their morbidity, and the role that referral bias plays in the epidemiology of this syndrome.

Poly Cystic Ovarian Syndrome: An Updated Overview

Poly Cystic Ovarian Syndrome (PCOS) is one of the most common metabolic and reproductive disorders among women of reproductive age. Women suffering from PCOS present with a constellation of symptoms associated with menstrual dysfunction and androgen excess, which significantly impacts their quality of life. They may be at increased risk of multiple morbidities, including obesity, insulin resistance, type II diabetes mellitus, cardiovascular disease (CVD), infertility, cancer, and psychological disorders. This review summarizes what the literature has so far provided from guidelines to diagnosis of PCOS. It will also present a general overview about the morbidities associated with this disease, specifically with its more severe classic form. Finally, the review will stress on the various aspects of treatment and screening recommendations currently used in the management of this condition.

Lipoprotein(a) and apolipoprotein(a) in polycystic ovary syndrome

OBJECTIVE

Levels of lipoprotein(a), Lp(a), an independent risk factor for cardiovascular disease (CVD), are affected by sex hormones. Women with polycystic ovary syndrome (PCOS) have elevated androgen levels and are at increased CVD risk. We investigated the impact of PCOS-related hormonal imbalance on Lp(a) levels in relation to apo(a) gene size polymorphism, a major regulator of Lp(a) level.

DESIGN

Cross-sectional.

PATIENTS

Forty-one Caucasian women with PCOS based on the NIH criteria.

MEASUREMENTS

(1) Apo(a) gene size polymorphism measured as Kringle (K) 4 repeat number; (2) total plasma Lp(a) level; (3) allele-specific apo(a) level assessing the amount of Lp(a) carried by an individual apo(a) allele/isoform; and (4) sex hormone levels.

RESULTS

The mean age was 32 ± 6 years, and the mean BMI was 35 ± 8 with 66% of women classified as obese (BMI >30 kg/m² ). LDL cholesterol was borderline high (3·37 mmol/l), and HDL cholesterol was low (1·06 mmol/l). The distribution of Lp(a) level was skewed towards lower levels with a median level of 22·1 nmol/l (IQR: 6·2-66·5 nmol/l). Lp(a) levels were not correlated with age, body weight or BMI. The median allele-specific apo(a) level was 10·6 nmol/l (IQR: 3·1-31·2 nmol/l), and the median apo(a) size was 27 (IQR: 23-30) K4 repeats. Allele-specific apo(a) levels were significantly and inversely correlated with K4 repeats (r = -0·298, P = 0·007). Neither Lp(a) nor allele-specific apo(a) levels were significantly associated with testosterone or dehydroepiandrosterone sulphate levels.

CONCLUSIONS

The apo(a) genetic variability remains the major regulator of plasma Lp(a) levels in women with PCOS.

Body Mass Index below Obesity Threshold Implies Similar Cardiovascular Risk among Various Polycystic Ovary Syndrome Phenotypes

OBJECTIVE

The aim of this study was to determine the cardiometabolic risk factors in different polycystic ovary syndrome (PCOS) phenotypes.

SUBJECTS AND METHODS

This cross-sectional study was performed between 2010 and 2011. Eighty-nine patients with PCOS and 25 age- and weight-matched healthy controls were included in the study. Patients were grouped using the Rotterdam 2003 criteria as: group 1, oligomenorrhea and/or anovulation (ANOV) and hyperandrogenemia (HA) and/or hyperandrogenism (n = 23); group 2, ANOV and polycystic ovaries (PCO; n = 22); group 3, HA and PCO (n = 22); group 4, ANOV, HA and PCO (n = 22); group 5, controls (n = 25). Laboratory blood tests for diagnosis and cardiometabolic risk assessments were performed. Insulin resistance (IR) was calculated in all patients with the homeostasis model assessment of IR (HOMA-IR) formula. An euglycemic hyperinsulinemic clamp test was performed on 5 randomly selected cases in each subgroup, making 25 cases in total, and indicated as the 'M' value (mg/kg/min), which is the total body glucose disposal rate.

RESULTS

The mean BMl values of the groups were: group 1, 26.1 ± 5.3; group 2, 27.9 ± 5.2; group 3, 24.3 ± 4.2; group 4, 27.9 ± 7.5; group 5, 24.7 ± 5.2 (p > 0.05). There were no differences in the lipid profile, plasma glucose, HOMA-IR, insulin and M values between the groups (p > 0.05). Phenotypes with oligomenorrhea/anovulation (groups 1, 2 and 4) were more obese than group 3 (p = 0.039).

CONCLUSIONS

The cardiometabolic risk profile was similar among the PCOS subgroups. This finding could be attributed to the mean BMl values, which, being below 30, were not within the obesity range. Obesity appeared to be an important determinant of high cardiovascular risk in PCOS.

Lipoprotein Particles in Adolescents and Young Women With PCOS Provide Insights Into Their Cardiovascular Risk

CONTEXT

Adult women with polycystic ovarian syndrome (PCOS) have an increased risk for cardiovascular disease, but the evidence for this is controversial in adolescents and young women with PCOS. Measurement of low-density lipoprotein (LDL) particle number, measured by nuclear magnetic resonance spectroscopy is a novel technology to assess cardiovascular risk.

OBJECTIVE

The objective of the study was to evaluate lipoprotein particle number and size in young women with PCOS and its relationship with insulin resistance and hyperandrogenism.

DESIGN

This was a cross-sectional case control study.

SETTING

The study was conducted at a clinical research center.

PARTICIPANTS

Women with PCOS (n = 35) and normal controls (n = 20) participated in the study.

INTERVENTIONS

Blood samples and anthropometric measures were obtained.

MAIN OUTCOME MEASURES

LDL particle size and number were measured using nuclear magnetic resonance spectroscopy. A secondary outcome was to investigate the correlation of LDL particle number with high-sensitivity C-reactive protein, waist to hip ratio, hyperandrogenism, insulin resistance, and adiponectin.

RESULTS

Women with PCOS had higher LDL particle number when compared with healthy controls (935 ± 412 vs 735 ± 264, P = .032); LDL particle number correlated strongly with high-sensitivity C-reactive protein (r = 0.37, P = .006) and waist-to-hip (r = 0.57, P = .0003). The higher LDL particle number was driven mainly due to differences in the small LDL particle number (sLDLp), with PCOS patients having more sLDLp (348 ± 305 vs 178 ± 195, P = .015). The sLDLp correlated with the Matsuda index (r = -0.51, P = .0001), homeostasis model assessment index of insulin resistance (r = 0.41, P = .002), and adiponectin (r = -0.46, P = .0004) but not with T.

CONCLUSION

Adolescent and young women with PCOS have an atherogenic lipoprotein profile suggestive of increased cardiovascular risk that appears to be driven by the degree of visceral adiposity and insulin resistance.

Scientific Statement on the Diagnostic Criteria, Epidemiology, Pathophysiology, and Molecular Genetics of Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is a heterogeneous and complex disorder that has both adverse reproductive and metabolic implications for affected women. However, there is generally poor understanding of its etiology. Varying expert-based diagnostic criteria utilize some combination of oligo-ovulation, hyperandrogenism, and the presence of polycystic ovaries. Criteria that require hyperandrogenism tend to identify a more severe reproductive and metabolic phenotype. The phenotype can vary by race and ethnicity, is difficult to define in the perimenarchal and perimenopausal period, and is exacerbated by obesity. The pathophysiology involves abnormal gonadotropin secretion from a reduced hypothalamic feedback response to circulating sex steroids, altered ovarian morphology and functional changes, and disordered insulin action in a variety of target tissues. PCOS clusters in families and both female and male relatives can show stigmata of the syndrome, including metabolic abnormalities. Genome-wide association studies have identified a number of candidate regions, although their role in contributing to PCOS is still largely unknown.

Psoriasis and polycystic ovary syndrome: a new link in different phenotypes

OBJECTIVE

Women affected by PCOS and psoriasis are more likely to have insulin-resistance, hyperinsulinemia, reduced HDL cholesterol levels and a more severe degree of skin disease than those with psoriasis alone. The mechanism underlying this association between PCOS and psoriasis is currently unknown. The aim of the present study was to evaluate the features of psoriasis and the psoriasis severity scores in the different PCOS phenotypes and in age and body mass index (BMI)-matched psoriatic control patients.

STUDY DESIGN

A cross-sectional study was performed on 150 psoriatic patients: 94 PCOS and 56 age- and BMI-matched controls. PCOS patients were diagnosed and divided into four phenotypes according to Rotterdam criteria: A - patients with complete phenotype with hyperandrogenism (H) plus oligoamenorrhea (O) plus polycystic ovary (PCO) on ultrasound examination; B - patients with H plus O (without PCO); C - patients with H plus PCO (ovulatory phenotype); D - patients with O plus PCO (without H). The patient's Psoriasis Area and Severity Index (PASI) as well as the Physician's Global Assessment (PGA) were calculated. A PASI score ≥10 was correlated with common indicator of severe disease. A PGA ≥4 was considered as a condition of moderate to severe disease.

RESULTS

Among the four phenotypes investigated, the group with complete phenotype (H plus O plus PCO) had a higher prevalence of patients with patient's PASI ≥10 compared to controls (Odds Ratio (OR) 4.71, 95% confidence intervals (CI) 1.59-13.95). The group with O plus PCO had a higher prevalence of patients with PGA ≥4 compared to controls (OR 26.79, 95% CI 3.40-211.02) while the ovulatory group had a lower prevalence of patients with PGA ≥4 (OR 0.06, 95% CI 0.01-0.51).

CONCLUSIONS

The ovulatory phenotype displays a milder psoriasis form than other phenotypes while the phenotypes with oligoamenorrhea presented higher severity scores of disease than other phenotypes and control group.

Association of anti-Mullerian hormone and small-dense low-density lipoprotein cholesterol with hepatosteatosis in young lean women with and without polycystic ovary syndrome

OBJECTIVE

To study the association of anti-Mullerian hormone (AMH) and small-dense low-density lipoprotein cholesterol (sd-LDL) with hepatosteatosis among young, lean, polycystic ovary patients.

STUDY DESIGN

A prospective, case control study was carried out including 79 young lean women. Fifty-eight women with polycystic ovary syndrome (PCOS) and 21 age-and BMI-matched healthy controls were recruited. Anthropometric variables, biochemical and hormonal parameters, insulin-resistance indices, lipid profiles including sd-LDL levels and serum AMH levels were determined. Hepatic lipid content was evaluated by abdominal ultrasonography (USG). Determining the best predictor(s) which discriminate normal USG and hepatosteatosis was analyzed by multiple logistic regression analyses. Adjusted odds ratios and 95% confidence intervals were also calculated.

RESULTS

PCOS patients had an increased prevalence of hepatosteatosis by 41.4% (P = 0.006) and they had significantly higher levels of sd-LDL and AMH when compared with the control group (P < 0.001). AMH and sd-LDL levels were positively and significantly associated with hepatosteatosis in young lean women with and without PCOS (OR: 2.877, 95%CI: 1.453-5.699, P: 0.02 and OR: 1.336, 95%CI: 1.083-1.648, P: 0.007, respectively). AMH and sd-LDL levels were positively correlated in PCOS patients (r = 0.626, P < 0.001). Both sd-LDL and AMH levels were the most predictive parameters for the determination of hepatosteatosis within the PCOS group. (OR: 3.347, 95%CI: 1.348-8.313, P = 0.009 and OR: 1.375, 95%CI: 1.072-1.764, P = 0.012, respectively). Statistically significant higher levels of AMH were associated with hepatosteatosis both in insulin resistance (IR) positive and IR negative PCOS patients (P < 0.001).

CONCLUSION

Hepatosteatosis is common in young lean PCOS patients. Increased AMH and sd-LDL levels may independently predict hepatosteatosis in young lean women with and without PCOS.

Metabolic risk in PCOS: phenotype and adiposity impact

Polycystic ovary syndrome (PCOS) is a common condition in reproductive-aged women, with reproductive, cardiometabolic, and psychological features. The heterogeneity in insulin resistance, obesity, and cardiometabolic features has led to controversy on the independent contributions of PCOS status, diagnostic criteria, phenotype, and adiposity. It now appears that women with PCOS have an increased risk of insulin resistance and cardiometabolic features, which is independent of, but worsened by, adiposity and central adiposity, and is unrelated to reproductive phenotype. Obesity may be more prevalent in the more severe phenotypes, which suggests either an exacerbation of the reproductive features or a more likely diagnosis in overweight women with PCOS. Therefore, all women with PCOS should be targeted for prevention, screening, and management of cardiometabolic features.

Serum Uric Acid Concentration in Overweight and Obese Women with Polycystic Ovary Syndrome / Nivelul acidului uric la femeile supraponderale și obeze cu sindromul ovarelor polichistice

Background: Women with polycystic ovary syndrome (PCOS) are at high risk for the development of diabetes mellitus, hypertension and coronary heart disease. Due to the inverse correlation between serum uric acid and insulin sensitivity, the measurement of uric acid may provide a marker of insulin resistance. Objective: To establish the relationship between uric acid and markers of insulin resistance in obese and overweight women with PCOS. Methods: Serum uric acid levels were measured in 38 PCOS obese and overweight patients and 30 controls matched for age and body mass index (BMI). Anthropometric variables, plasma glucose and insulin levels were measured. Insulin resistance was evaluated by homeostasis model assessment (HOMA-IR). Results: No statistically significant differences in uric acid levels between PCOS and non-PCOS women were found. Serum uric acid levels were positively correlated with BMI, waist circumference, insulin and HOMA. Following the use of stepwise linear regression analysis, BMI was the only parameter retained by the regression model, responsible for 42.1% of the variability of serum uric acid levels. Conclusions: In PCOS women obesity seems to be the main determinant of plasma uric acid levels. Insulin and HOMA are also involved to a lesser extent, but their role remains to be clarified by further studies.

The prevalence of metabolic disorders in various phenotypes of polycystic ovary syndrome: a community based study in Southwest of Iran

BACKGROUND

Polycystic ovary syndrome (PCOS) is a common endocrinopathy, associated with metabolic abnormalities. Metabolic features of various phenotypes of this syndrome are still debatable. The aim of present study hence was to evaluate the metabolic and hormonal features of PCOS phenotypes in comparison to a group of healthy control.

METHODS

A total of 646 reproductive-aged women were randomly selected using the stratified, multistage probability cluster sampling method. The subjects were divided into five phenotypes: A (oligo/anovulation + hyperandrogenism + polycystic ovaries), B (oligo/anovulation + hyperandrogenism), C (hyperandrogenism + polycystic ovaries) and D (oligo/anovulation + polycystic ovaries). Hormonal and metabolic profiles and the prevalence of metabolic syndrome among these groups were compared using ANCOVA adjusted for age and body mass index.

RESULTS

Among women with PCOS (n = 85), those of groups A and C had higher serum levels of insulin and homeostatic model assessment for insulin resistance (HOMA-IR), compared to PCOS women of group D. Serum concentrations of cholesterol, low density lipoprotein, triglycerides and glucose in group A were higher than in other phenotypes, whereas the metabolic syndrome was more prevalent among group B.

CONCLUSIONS

Women who had all three components of the syndrome showed the highest level of metabolic disturbances indicating that metabolic screening of the severest phenotype of PCOS may be necessary.

Decreased cholesterol efflux capacity and atherogenic lipid profile in young women with PCOS

CONTEXT

Women with polycystic ovary syndrome (PCOS) have a high prevalence of cardiovascular disease (CVD) risk factors including dyslipidemia. Lipoproteins are heterogeneous, and measurement of serum lipids provides only the size of the pool and does not predict their function or composition. Recently, high-density lipoprotein cholesterol (HDL-C) function, as determined by cholesterol efflux capacity from macrophages, has been shown to be an independent predictor of subclinical CVD.

OBJECTIVE

The aim of the study was to comprehensively evaluate lipoprotein profile including lipid particle size and number and cholesterol efflux capacity in PCOS to better define CVD risk.

DESIGN AND SETTING

A case control study was performed at an academic PCOS center.

PATIENTS

Women with PCOS (n = 124) and geographically matched controls (n = 67) were included in the study.

MAIN OUTCOME MEASURES

The primary outcome was to measure HDL-C efflux capacity by an ex vivo system involving the incubation of macrophages with apolipoprotein (Apo) B-depleted serum from subjects, and the secondary outcome was to measure lipid particle size and number using nuclear magnetic resonance spectroscopy.

RESULTS

Women with PCOS had significantly higher body mass index and blood pressure but similar HDL-C and low-density lipoprotein cholesterol levels compared to controls. The mean ApoA1 levels were lower, and the ApoB/ApoA1 ratio was higher in PCOS subjects compared to controls (P < .01). There were no differences in ApoB levels. Women with PCOS had an 7% decrease in normalized cholesterol efflux capacity compared to controls (P < .003). Cholesterol efflux capacity in PCOS correlated with body mass index, ApoA1, HDL-C, and the presence of metabolic syndrome. In a multivariable regression model, PCOS was significantly associated with diminished cholesterol efflux. PCOS was also associated with an atherogenic profile including an increase in large very low-density lipoprotein particles, very low-density lipoprotein (VLDL) size, and small low-density lipoprotein cholesterol particles (P < .01).

CONCLUSIONS

Our novel findings of decreased cholesterol efflux and an atherogenic lipid particle number and size pattern in women with PCOS, independent of obesity, further substantiate the increased risk of CVD in this population.

Polycystic ovary syndrome: do endocrine-disrupting chemicals play a role?

Polycystic ovary syndrome (PCOS) is a heterogeneous disorder characterized by multiple endocrine disturbances, and its underlying causes, although uncertain, are likely to be both genetic and environmental. Recently, there has been interest in whether endocrine-disrupting chemicals (EDCs) in the environment, particularly Bisphenol A (BPA), may contribute to the disorder. In animal models, exposure to BPA during the perinatal period dramatically disrupts ovarian and reproductive function in females, often at doses similar to typical levels of human exposure. BPA also appears to have obesogenic properties, disrupting normal metabolic activity and making the body prone to overweight. In humans, cross-sectional data suggest that BPA concentrations are higher in women with PCOS than in reproductively healthy women, but the direction of causality has not been established. As this research is in its infancy, additional work is needed to understand the mechanisms by which EDCs may contribute to PCOS as well as the critical periods of exposure, which may even be transgenerational. Future research should also focus on translating the promising work in animal models into longitudinal human studies and determining whether additional EDCs, beyond BPA, may be important to consider.

Reciprocal Action of Pentraxin-3 and CRP in Women with Polycystic Ovary Syndrome

The aim of this study was to investigate the relationship between pentraxin-3 and other biochemical parameters in women with polycystic ovary syndrome (PCOS). We compared 58 women with PCOS to 34 body mass index- and age-matched normally menstruating healthy controls. Women with PCOS had significantly higher DHEA-S, free testosterone, LH and FAI, but lower pentraxin-3 levels when compared to healthy controls (0.86±0.21 and 0.91±0.14 respectively, p=0.014). Levels of CRP and lipoprotein-a were higher in the PCOS group. Overweight PCOS had significantly higher insulin, HOMA-IR, FAI, free testosterone and CRP and statistically significantly lower HDL and SHBG levels when compared to controls. Pentraxin-3 levels of obese and normal weight PCOS were similar. CRP and pentraxin-3 might contribute reciprocally to metabolic events and chronic low-grade inflammation in women with PCOS.

Diabetes and cardiovascular events in women with polycystic ovary syndrome: a 20-year retrospective cohort study

OBJECTIVE

Women with polycystic ovary syndrome (PCOS) are potentially at increased risk of cardiovascular (CV) diseases due to well-established risk factors, including insulin resistance, obesity and type 2 diabetes mellitus (T2DM). However, data showing excess CV events in this population are still lacking. We investigated the incidence and prevalence of CV events in a cohort of women with PCOS.

DESIGN

Retrospective cohort study (total follow-up >12,000 person-years).

SETTING

Leicester, Leicestershire and Rutland (Total Female population of 434,859), UK.

PARTICIPANTS

Two thousand three hundred and one women with PCOS (mean age = 29.6 years) attending a speciality clinic in Leicestershire, UK.

MAIN OUTCOMES MEASURES

T2DM, myocardial infarction (MI), angina, heart failure (HF), stroke and CV-related death.

RESULTS

Incidence of T2DM, MI, angina, HF, stroke and CV death was respectively 3.6, 0.8, 1.0, 0.3, 0.0 and 0.4 per 1000 person-years. At the end of follow-up, the prevalence of MI in the age groups 45-54, 55-64 and >65 years was 1.9%, 6.0% and 27.3% and of angina was 2.6%, 6.0% and 27.3%, respectively. Age-group-specific odds ratios for the prevalence of MI and angina compared to the local female population ranged between 2.6 (95% CI: 1.0-6.3) and 12.9 (CI: 3.4-48.6) with the highest ratio being for MI in the group >65 years old. Age, history of hypertension and smoking had significant correlations with CV outcomes in the PCOS patients.

CONCLUSION

We have shown a high incidence and age-group-specific prevalence of T2DM, MI and angina in the women with PCOS, with over a quarter having had MI or angina in those >65 years. These findings should be considered in the treatment strategies and long-term planning for women with PCOS.

Influence of obesity on atherogenic dyslipidemia in women with polycystic ovary syndrome

BACKGROUND

Obesity is known to underlie, at least partially, dyslipidemia in polycystic ovary syndrome (PCOS), but it is unclear whether PCOS status per se increases the risk of alterations of lipoprotein subfractions, which differ in size and atherogenic potential. Our objective was to evaluate whether PCOS influences lipoprotein profile and LDL and HDL subfractions and to study the impact of obesity on these parameters.

MATERIALS AND METHODS

This was a case-control study conducted in an academic medical centre. The study population consisted of 54 women of fertile age with PCOS and 60 controls adjusted for age and BMI. Biochemical lipid profile and LDL and HDL lipoprotein subfractions (measured using Lipoprint System).

RESULTS

Lean PCOS women exhibited lower HDL cholesterol and apolipoprotein AI levels than controls, although these differences were not associated with alterations of lipoprotein subfractions. All obese subjects, whether PCOS or controls, displayed lipid parameters typical of atherogenic dyslipidemia, although the former group had lower levels of large HDL, higher levels of small HDL subfractions and a higher percentage of VLDL than the latter. These differences were associated with a greater prevalence of non-A LDL pattern (25.0%) in obese PCOS subjects than in obese controls (4.3%).

CONCLUSIONS

PCOS does not constitute an additional risk factor for cardiovascular disease in lean women, but leads to a lipid profile characteristic of atherogenic dyslipidemia and an altered pattern of lipoprotein subfraction when associated with obesity.

Dyslipidemia in women with polycystic ovary syndrome

Dyslipidemia is a very common metabolic abnormality in women with polycystic ovary syndrome (PCOS). Insulin resistance is a key pathophysiology of PCOS, thus dyslipidemia in women with PCOS may be consistent with those found in an insulin resistant state. In recent meta-analysis, triglycerides and low-density lipoprotein (LDL) cholesterol levels were 26 mg/dL and 12 mg/dL higher, and high-density lipoprotein cholesterol concentration was 6 mg/dL lower in women with PCOS than those of controls. Alterations in LDL quality also have been reported in women with PCOS: women with PCOS have an increased proportion of atherogenic small dense LDL or decreased mean LDL particle size. However, in a recent Korean study, non-obese Korean women with PCOS had no significant quantitative or qualitative changes in LDL cholesterol profile. Lipoprotein (a) has been identified as an independent risk factor for coronary heart disease, and its elevation in PCOS patients has been consistently reported in diverse studies including non-obese Korean population. Some studies have investigated apolipoprotein (Apo) A-I and ApoC-I levels in women with PCOS and levels of ApoA-I, which has cardio-protective effects, were significantly lower in women with PCOS than those of controls. ApoC-I is known to increase the postprandial serum lipid level that is common in coronary artery disease patients, and one study reported that such an elevation may be the earliest variation of lipid abnormality in women with PCOS. In conclusion, women with PCOS should receive a complete lipid test, and lifestyle modification, including diet and exercise, is the first line therapy for all women with PCOS and is particularly important for those with dyslipidemia.

Divergences in insulin resistance between the different phenotypes of the polycystic ovary syndrome

CONTEXT/OBJECTIVE

Current diagnostic criteria for polycystic ovary syndrome (PCOS) have generated distinct PCOS phenotypes, based on the different combinations of diagnostic features found in each patient. Our aim was to assess whether either each single diagnostic feature or their combinations into the PCOS phenotypes may predict insulin resistance in these women.

PATIENTS/DESIGN

A total of 137 consecutive Caucasian women with PCOS, diagnosed by the Rotterdam criteria, underwent accurate assessment of diagnostic and metabolic features. Insulin sensitivity was measured by the glucose clamp technique.

RESULTS

Among women with PCOS, 84.7% had hyperandrogenism, 84.7% had chronic oligoanovulation, and 89% had polycystic ovaries. According to the individual combinations of these features, 69.4% of women had the classic phenotype, 15.3% had the ovulatory phenotype, and 15.3% had the normoandrogenic phenotype. Most subjects (71.4%) were insulin resistant. However, insulin resistance frequency differed among phenotypes, being 80.4%, 65.0%, and 38.1%, respectively, in the 3 subgroups (P < .001). Although none of the PCOS diagnostic features per se was associated with the impairment in insulin action, after adjustment for covariates, the classic phenotype and, to a lesser extent, the ovulatory phenotype were independently associated with insulin resistance, whereas the normoandrogenic phenotype was not. Metabolic syndrome frequency was also different among phenotypes (P = .030).

CONCLUSIONS

There is a scale of metabolic risk among women with PCOS. Although no single diagnostic features of PCOS are independently associated with insulin resistance, their combinations, which define PCOS phenotypes, may allow physicians to establish which women should undergo metabolic screening. In metabolic terms, women belonging to the normoandrogenic phenotype behave as a separate group.

Lipoprotein subfractions in metabolic syndrome and obesity: clinical significance and therapeutic approaches

Small, dense low density lipoprotein (sdLDL) represents an emerging cardiovascular risk factor, since these particles can be associated with cardiovascular disease (CVD) independently of established risk factors, including plasma lipids. Obese subjects frequently have atherogenic dyslipidaemia, including elevated sdLDL levels, in addition to elevated triglycerides (TG), very low density lipoprotein (VLDL) and apolipoprotein-B, as well as decreased high density lipoprotein cholesterol (HDL-C) levels. Obesity-related co-morbidities, such as metabolic syndrome (MetS) are also characterized by dyslipidaemia. Therefore, agents that favourably modulate LDL subclasses may be of clinical value in these subjects. Statins are the lipid-lowering drug of choice. Also, anti-obesity and lipid lowering drugs other than statins could be useful in these patients. However, the effects of anti-obesity drugs on CVD risk factors remain unclear. We review the clinical significance of sdLDL in being overweight and obesity, as well as the efficacy of anti-obesity drugs on LDL subfractions in these individuals; a short comment on HDL subclasses is also included. Our literature search was based on PubMed and Scopus listings. Further research is required to fully explore both the significance of sdLDL and the efficacy of anti-obesity drugs on LDL subfractions in being overweight, obesity and MetS. Improving the lipoprotein profile in these patients may represent an efficient approach for reducing cardiovascular risk.

Lipoprotein subfractions in metabolic syndrome and obesity: clinical significance and therapeutic approaches

Small, dense low density lipoprotein (sdLDL) represents an emerging cardiovascular risk factor, since these particles can be associated with cardiovascular disease (CVD) independently of established risk factors, including plasma lipids. Obese subjects frequently have atherogenic dyslipidaemia, including elevated sdLDL levels, in addition to elevated triglycerides (TG), very low density lipoprotein (VLDL) and apolipoprotein-B, as well as decreased high density lipoprotein cholesterol (HDL-C) levels. Obesity-related co-morbidities, such as metabolic syndrome (MetS) are also characterized by dyslipidaemia. Therefore, agents that favourably modulate LDL subclasses may be of clinical value in these subjects. Statins are the lipid-lowering drug of choice. Also, anti-obesity and lipid lowering drugs other than statins could be useful in these patients. However, the effects of anti-obesity drugs on CVD risk factors remain unclear. We review the clinical significance of sdLDL in being overweight and obesity, as well as the efficacy of anti-obesity drugs on LDL subfractions in these individuals; a short comment on HDL subclasses is also included. Our literature search was based on PubMed and Scopus listings. Further research is required to fully explore both the significance of sdLDL and the efficacy of anti-obesity drugs on LDL subfractions in being overweight, obesity and MetS. Improving the lipoprotein profile in these patients may represent an efficient approach for reducing cardiovascular risk.

C-reactive protein and lipoprotein-a as markers of coronary heart disease in polycystic ovary syndrome

OBJECTIVE

The aim of this study was to investigate the risk factors of coronary heart disease, CRP and Lipoprotein-a in polycystic ovary syndrome patients.

MATERIAL AND METHODS

Prospectively collected data of polycystic ovary syndrome patients (n=62) and control group (n=40) were compared.

RESULTS

PCOS patients had higher HOMA-IR, CRP, DHEAS, free testosterone, FAI, LH and prolactin levels when compared to the control group. Lipoprotein-a levels did not differ between the groups. The obese PCOS group had statistically significantly higher fasting blood glucose, total cholesterol, triglyceride, free testosterone, insulin, CRP and HOMA-IR and statistically significantly lower HDL and SHBG when compared to normal weight PCOS persons. Fasting blood glucose, total cholesterol, LDL, SHBG, CRP, Lipoprotein-a, FSH, LH, TSH, DHEAS and prolactin levels did not differ between the normal weight and obese control groups.

CONCLUSION

CRP levels increase in polycystic ovary syndrome patients and can be used as a marker of coronary heart disease. Future studies can be directed at treatments to decrease CRP levels, including antiinflammatory treatments.

Cardiac autonomic modulation in polycystic ovary syndrome: does the phenotype matter?

OBJECTIVE

To assess whether heart rate variability (HRV) at rest and during sympathetic stimulation is disturbed in patients with different polycystic ovary syndrome (PCOS) phenotypes in comparison to healthy controls.

DESIGN

Cross-sectional study.

SETTING

University hospital.

PATIENT(S)

Thirty women with classic, anovulatory PCOS, 16 women with ovulatory PCOS, and 23 age-paired women with regular and proven ovulatory cycles.

INTERVENTION(S)

Anthropometric and hormonal evaluation and analysis of HRV (time and frequency domain HRV indices) at rest and after a mental stress test.

MAIN OUTCOME MEASURE(S)

Difference between HRV components during rest and stress.

RESULT(S)

Mean age was 22.80 ± 5.80 years in patients with classic PCOS, 19.81 ± 6.43 years in ovulatory PCOS, and 22.65 ± 5.89 years in controls. During mental stress, patients with classic PCOS showed lower HRV response when compared with the control group, even after adjustment for body mass index (BMI) and age. When patients with classic and ovulatory PCOS were considered together, total T levels were inversely associated with the low frequency component, low frequency/high frequency ratio, and the difference between high frequency response at rest and after the stress test.

CONCLUSION(S)

Young patients with the classic PCOS phenotype have an impaired autonomic modulation in response to sympathetic stimulation that is typical of considerably older women, or of advanced age.

CD4(+)CD28(null) T lymphocyte frequency, a new marker of cardiovascular risk: relationship with polycystic ovary syndrome phenotypes

OBJECTIVE

To study the frequency of CD4(+)CD28(null) T cells, which are aggressive T lymphocytes associated with recurrent coronary instability and type 2 diabetes mellitus, in different polycystic ovary syndrome (PCOS) phenotypes and in age- and body mass index-matched healthy women.

DESIGN

Retrospective cohort observational study.

SETTING

Unit of human reproductive pathophysiology, university hospital.

PATIENT(S)

A total of 167 PCOS patients and 102 control subjects.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

CD4(+)CD28(null) T cell frequency, high-sensitive C-reactive protein levels, and other glucose-metabolic parameters.

RESULT(S)

CD4(+)CD28(null) frequency was significantly higher in all PCOS groups than in control subjects. CD4(+)CD28(null) frequency was significantly higher in nonhyperandrogenic phenotype (5.7%, range 3.2-7.1) than in phenotypes with hyperandrogenism (H) + oligoamenorrhea (O) + polycystic ovary (PCO) (3.5%, range 1-5.8), H + O (3%, range 1.8-4.7), and H + PCO (2.63%, range 1.2-4.1). The relative risk of non-H phenotype for PCOS women in the highest quartile for CD4(+)CD28(null) frequency compared with PCOS women with the lowest quartile was 3.2 (95% confidence interval 1.9-5.8).

CONCLUSION(S)

Cardiovascular risk evaluation should be performed in all PCOS phenotypes. In particular, we demonstrated that the non-H phenotype has potentially increased cardiovascular risk in terms of CD4(+)CD28(null) frequency.

Oxidative stress and small, dense low-density lipoproteins: current and future perspectives

Small, dense low-density lipoproteins (LDLs) are more susceptible to oxidation than their larger, more buoyant counterparts and therefore the biological modification of these LDL particles may, in part, be responsible for their atherogenic properties. Kotani et al. found that at multiple regression analysis there was an independent and significant inverse correlation between the mean LDL particle size and the oxidative stress status; notably, the authors adjusted not only for the traditional cardiovascular risk factors, but also for drug treatments. Higher levels of small, dense LDL concentrations significantly contribute to atherosclerosis, and lipoprotein size and subfractions may refine cardiovascular disease risk assessment.