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Li X, Yang J, Blockeel C, Lin M, Tian X, Wu H, Cao Y, Deng L, Zhou X, Xie J, Hu Y, Chen X. Association of severity of menstrual dysfunction with cardiometabolic risk markers among women with polycystic ovary syndrome. Acta Obstet Gynecol Scand 2024; 103:1606-1614. [PMID: 38715377 PMCID: PMC11266638 DOI: 10.1111/aogs.14863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 02/23/2024] [Accepted: 04/13/2024] [Indexed: 07/25/2024]
Abstract
INTRODUCTION Polycystic ovary syndrome (PCOS) is associated with a wide range of unfavorable cardiometabolic risk factors, including obesity, hypertension, insulin resistance, impaired glucose metabolism, dyslipidemia, and metabolic syndrome. Compared with women with regular menstrual cycles, women with a history of irregular menstrual periods have an increased unfavorable cardiometabolic risk. Recently, the association between the severity of oligomenorrhea and hyperinsulinemia and insulin resistance has been demonstrated. However, evidence linking the severity of menstrual cyclicity with cardiometabolic risk in PCOS women is scarce. MATERIAL AND METHODS This work was a prospective cross-sectional study. A total of 154 women diagnosed with PCOS by the Rotterdam criteria were recruited from July 2021 to September 2022. PCOS women with eumenorrheic (eumeno group), oligomenorrhea (oligo group), and amenorrhea (ameno group) underwent history and physical examination, gonadal steroid hormone measurement, lipid profile, oral glucose tolerance test, and homeostasis model assessment of insulin resistance. RESULTS A trend toward an increase in unfavorable cardiometabolic risk markers including obesity, hypertension, prevalence of insulin resistance, prediabetes, dyslipidemia, and metabolic syndrome was observed in the ameno group (n = 57) as compared with the eumeno (n = 24) or oligo group (n = 73). A higher prevalence of insulin resistance (odds ratio [OR]: 3.02; 95% confidence interval [CI]: 1.03-8.81) and prediabetes (OR: 3.94; 95% CI: 1.01-15.40) was observed in the ameno group than in the eumeno group, and a higher proportion of dyslipidemia (OR: 2.44; 95% CI: 1.16-5.15) was observed in the ameno group than in the oligo group in the binary logistic regression analysis after adjusting for confounding factors. CONCLUSIONS PCOS women with amenorrhea show a higher prevalence of insulin resistance, prediabetes, and dyslipidemia compared with those with oligomenorrhea or eumenorrhea. The severity of menstrual dysfunction could be used as a readily obtainable marker for the identification of PCOS women at greatest risk of cardiometabolic diseases.
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Affiliation(s)
- Xuelan Li
- Reproductive Medicine CenterShunde Hospital of Southern Medical University (The First People's Hospital of Shunde)FoshanGuangdongChina
| | - Jie Yang
- Reproductive Medicine CenterShunde Hospital of Southern Medical University (The First People's Hospital of Shunde)FoshanGuangdongChina
| | - Christophe Blockeel
- Brussels, IVF, center for Reproductive MedicineUniversitair Ziekenhuis Brussel, Vrije Universiteit BrusselBrusselsBelgium
| | - Min Lin
- Reproductive Medicine CenterShunde Hospital of Southern Medical University (The First People's Hospital of Shunde)FoshanGuangdongChina
| | - Xiaoyan Tian
- Reproductive Medicine CenterShunde Hospital of Southern Medical University (The First People's Hospital of Shunde)FoshanGuangdongChina
| | - Haocun Wu
- Department of Clinical LaboratoryShunde Hospital of Southern Medical University (The First People's Hospital of Shunde)FoshanGuangdongChina
| | - Yaqi Cao
- College of ScienceMinzu University of ChinaBeijingChina
| | - Ling Deng
- Reproductive Medicine CenterShunde Hospital of Southern Medical University (The First People's Hospital of Shunde)FoshanGuangdongChina
| | - Xianli Zhou
- Reproductive Medicine CenterShunde Hospital of Southern Medical University (The First People's Hospital of Shunde)FoshanGuangdongChina
| | - Jinying Xie
- College of ScienceMinzu University of ChinaBeijingChina
| | - Yunzhao Hu
- Department of CardiologyShunde Hospital of Southern Medical University (The First People's Hospital of Shunde)FoshanGuangdongChina
| | - Xin Chen
- Reproductive Medicine CenterShunde Hospital of Southern Medical University (The First People's Hospital of Shunde)FoshanGuangdongChina
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Łebkowska A, Krentowska A, Adamska A, Uruska A, Rogowicz-Frontczak A, Araszkiewicz A, Ożegowska K, Leśniewska M, Sowa P, Wender-Ożegowska E, Zozulińska-Ziółkiewicz D, Kowalska I. The association of thyroid autoimmunity with ovarian reserve in women with type 1 diabetes with and without polycystic ovary syndrome. Sci Rep 2024; 14:13223. [PMID: 38851814 PMCID: PMC11162496 DOI: 10.1038/s41598-024-63741-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 05/31/2024] [Indexed: 06/10/2024] Open
Abstract
The aim of the study was to investigate the relation between thyroid autoimmunity (TAI), reflected as the presence of thyroid peroxidase antibodies (TPOAb), and parameters of ovarian reserve in women with type 1 diabetes (T1DM) and polycystic ovary syndrome (PCOS). We studied 83 euthyroid women with T1DM (age - 26 ± 5 years, BMI - 24 ± 3 kg/m2) - 12 with PCOS and positive TPOAb (PCOS + TPOAb), 29 with PCOS with negative TPOAb (PCOS + noTPOAb), 18 without PCOS with positive TPOAb (noPCOS + TPOAb), 24 without PCOS with negative TPOAb (noPCOS + noTPOAb). Serum concentrations of anti-Müllerian hormone (AMH), sex hormones, TSH, thyroid hormones and TPOAb were assessed. The prevalence of TAI was comparable between PCOS and noPCOS. We did not observe differences in hormonal profile or AMH concentration between two PCOS groups-PCOS + TPOAb and PCOS + noTPOAb (p > 0.05). Women with PCOS + TPOAb had lower FSH concentration and higher LH/FSH index than noPCOS + noTPOAb (p = 0.027; p = 0.019, respectively). Moreover, PCOS + TPOAb had lower oestradiol level than noPCOS + TPOAb (p = 0.041). AMH concentration was higher in both groups with PCOS, independent of TPOAb presence, than in noPCOS + noTPOAb (both p < 0.001). The presence of positive TPOAb titre was not related to the studied parameters of ovarian reserve - AMH and ovarian follicle number. In multiple linear regression analysis, the only significant predictor of AMH in the whole studied group with T1DM was total daily insulin dose U/kg (β = - 0.264; p = 0.022). The presence of TAI did not affect the hormonal profile or ovarian reserve in women with T1DM with and without PCOS.
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Affiliation(s)
- Agnieszka Łebkowska
- Department of Internal Medicine and Metabolic Diseases, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276, Bialystok, Poland.
| | - Anna Krentowska
- Department of Internal Medicine and Metabolic Diseases, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276, Bialystok, Poland
| | - Agnieszka Adamska
- Department of Endocrinology, Diabetology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Aleksandra Uruska
- Department of Internal Medicine and Diabetology, Poznan University of Medical Sciences, Poznan, Poland
| | - Anita Rogowicz-Frontczak
- Department of Internal Medicine and Diabetology, Poznan University of Medical Sciences, Poznan, Poland
| | - Aleksandra Araszkiewicz
- Department of Internal Medicine and Diabetology, Poznan University of Medical Sciences, Poznan, Poland
| | - Katarzyna Ożegowska
- Department of Infertility and Reproductive Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Monika Leśniewska
- Department of Reproduction and Gynaecological Endocrinology, Medical University of Bialystok, Bialystok, Poland
| | - Paweł Sowa
- Department of Population Medicine and Lifestyle Diseases Prevention, Medical University of Bialystok, Bialystok, Poland
| | - Ewa Wender-Ożegowska
- Department of Reproduction, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Irina Kowalska
- Department of Internal Medicine and Metabolic Diseases, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276, Bialystok, Poland
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Chen S, Guo Z, Yu Q. Genetic evidence for the causal association between type 1 diabetes and the risk of polycystic ovary syndrome. Hum Genomics 2023; 17:100. [PMID: 37957681 PMCID: PMC10641977 DOI: 10.1186/s40246-023-00550-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/07/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Accumulating observational studies have identified associations between type 1 diabetes (T1D) and polycystic ovary syndrome (PCOS). Still, the evidence about the causal effect of this association is uncertain. METHODS We performed a two-sample Mendelian randomization (MR) analysis to test for the causal association between T1D and PCOS using data from a large-scale biopsy-confirmed genome-wide association study (GWAS) in European ancestries. We innovatively divided T1D into nine subgroups to be analyzed separately, including: type1 diabetes wide definition, type1 diabetes early onset, type 1 diabetes with coma, type 1 diabetes with ketoacidosis, type 1 diabetes with neurological complications, type 1 diabetes with ophthalmic complications, type 1 diabetes with peripheral circulatory complications, type 1 diabetes with renal complications, and type 1 diabetes with other specified/multiple/unspecified complications. GWAS data for PCOS were obtained from a large-scale GWAS (10,074 cases and 103,164 controls) for primary analysis and the IEU consortium for replication and meta-analysis. Sensitivity analyses were conducted to evaluate heterogeneity and pleiotropy. RESULTS Following rigorous instrument selection steps, the number of SNPs finally used for T1D nine subgroups varying from 6 to 36 was retained in MR estimation. However, we did not observe evidence of causal association between type 1 diabetes nine subgroups and PCOS using the IVW analysis, MR-Egger regression, and weighted median approaches, and all P values were > 0.05 with ORs near 1. Subsequent replicates and meta-analyses also yielded consistent results. A number of sensitivity analyses also did not reveal heterogeneity and pleiotropy, including Cochran's Q test, MR-Egger intercept test, MR-PRESSO global test, leave-one-out analysis, and funnel plot analysis. CONCLUSION This is the first MR study to investigate the causal relationship between type 1 diabetes and PCOS. Our findings failed to find substantial causal effect of type 1 diabetes on risk of PCOS. Further randomized controlled studies and MR studies are necessary.
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Affiliation(s)
- Shuwen Chen
- Department of Obstetrics and Gynecology, National Clinical Research Center for Obstetric and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital (Dongdan Campus), No.1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Zaixin Guo
- Department of Obstetrics and Gynecology, National Clinical Research Center for Obstetric and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital (Dongdan Campus), No.1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Qi Yu
- Department of Obstetrics and Gynecology, National Clinical Research Center for Obstetric and Gynecologic Diseases, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital (Dongdan Campus), No.1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China.
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Dominic N, Sharma L, Mohindra N, Dabadghao P. Prevalence of polycystic ovary syndrome and its clinical and hormonal profile in young females with type 1 diabetes mellitus: experience from a teaching institution of India. Endocrine 2023; 82:303-310. [PMID: 37615813 DOI: 10.1007/s12020-023-03470-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 07/27/2023] [Indexed: 08/25/2023]
Abstract
OBJECTIVE To investigate the prevalence of polycystic ovary syndrome and its clinical and hormonal profile in females with type 1 diabetes. MATERIALS AND METHODS 65 T1DM females were evaluated for presence of PCOS by Rotterdam ESHRE/ASRM consensus criteria and compared with age and BMI matched females with PCOS without diabetes and females with T1DM without PCOS. RESULTS According to Rotterdam criteria 18/65 (27%) had PCOS. Prevalence of androgen excess, hirsutism, menstrual dysfunction and PCOM was 26%, 3%, 21% and 52%, respectively. Females with T1DM who had PCOS did not differ from females with T1DM without PCOS. When the group of T1DM with PCOS was compared with PCOS females without diabetes, they had significantly lower hirsutism score (median, IQR; 1.5, 0-3 vs. 11.5, 0-16.5, p = 0.04), significantly higher waist hip ratio (0.91, 0.89-0.99 vs. 0.86, 0.80-0.89, p = 0.004) and SHBG (in nmol, 54.4, 38-86.2 vs. 28.3, 20.4-37.4, p = 0.004). CONCLUSION Females with T1DM have a high prevalence of menstrual abnormalities, hyperandrogenism and PCOS which is not related to metabolic control, age of onset of diabetes or insulin dose. Polycystic ovary syndrome, hyperandrogenism, type 1 diabetes, menstrual irregularity, hirsutism.
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Affiliation(s)
- Nibu Dominic
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, India
| | - Lokesh Sharma
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, India
| | - Namita Mohindra
- Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, India
| | - Preeti Dabadghao
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, India.
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Ma Y, Cai J, Liu LW, Hou W, Wei Z, Wang Y, Xu Y. Age at menarche and polycystic ovary syndrome: A Mendelian randomization study. Int J Gynaecol Obstet 2023; 162:1050-1056. [PMID: 37128830 DOI: 10.1002/ijgo.14820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 04/05/2023] [Accepted: 04/12/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE The authors aimed to use a large two-sample Mendelian randomization (MR) study to reveal the causality between age at menarche (AAM) and polycystic ovary syndrome (PCOS) incidence. METHODS The authors collected summary statistics from the hitherto largest genome-wide association studies conducted in AAM and PCOS in the same ancestry. MR with inverse variance weighting was conducted as the main analysis method, while weighted median and MR-Egger regression were used for comprehensive analysis. As for pleiotropy detection, inverse variance weighting, MR-Egger regression, Mendelian Randomization Pleiotropy Residual Sum and Outlier, as well as leave-one-out analysis were used to detect pleiotropy. Risk factor analysis was conducted to investigate the underlying mechanisms linking AAM to PCOS. RESULTS Each standard deviation increment in AAM was associated with a significantly lower incidence of PCOS (odds ratio, 0.86 [95% confidence interval, 0.75-0.98]). After adjustment in horizontal pleiotropy by eliminating four outliers, this pathogenic association was still statistically detected. All pleiotropy indexes were without statistical differences, which suggested the conclusions were robust. It showed the causal association between later AAM and lower body mass index, lower fasting insulin level and insulin resistance. CONCLUSION Our MR analysis verified that a slightly later onset age (15 to 18 years) at menarche could reduce the risk of PCOS. A more comprehensive investigation in a prospective setting is strongly advised.
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Affiliation(s)
- Yuanlin Ma
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sun University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, China
- Clinical Research Center for Obstetrical and Gynecological Diseases of Guangdong Province, Guangzhou, China
| | - Jiahao Cai
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Lok-Wan Liu
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sun University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, China
- Clinical Research Center for Obstetrical and Gynecological Diseases of Guangdong Province, Guangzhou, China
| | - Wenhui Hou
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sun University, Guangzhou, China
- Reproductive Medicine Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zixin Wei
- Department of Pulmonary and Critical Care Medicine, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yizi Wang
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sun University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, China
- Clinical Research Center for Obstetrical and Gynecological Diseases of Guangdong Province, Guangzhou, China
| | - Yanwen Xu
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sun University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, China
- Clinical Research Center for Obstetrical and Gynecological Diseases of Guangdong Province, Guangzhou, China
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Ezeh U, Pisarska MD, Azziz R. Association of severity of menstrual dysfunction with hyperinsulinemia and dysglycemia in polycystic ovary syndrome. Hum Reprod 2022; 37:553-564. [PMID: 35048126 PMCID: PMC8888996 DOI: 10.1093/humrep/deac001] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 12/15/2021] [Indexed: 01/22/2023] Open
Abstract
STUDY QUESTION Is the severity of menstrual cyclicity related to hyperinsulinemia and dysglycemia in women with hyperandrogenic polycystic ovary syndrome (PCOS)? SUMMARY ANSWER Hyperandrogenic PCOS women with amenorrhea, compared to those with oligomenorrhea or eumenorrhea, had a greater risk of post-challenge hyperinsulinemia, which may explain their higher prevalence of dysglycemia. WHAT IS KNOWN ALREADY PCOS is associated with metabolic dysregulation including insulin resistance (IR) and hyperinsulinemia, risk factors for type 2 diabetes mellitus (T2DM) and other vascular-metabolic morbidities. Although the severity of menstrual cyclicity is associated with IR in PCOS, it is unclear whether, and to what extent, it is related to hyperinsulinemia and glycemic abnormalities. STUDY DESIGN, SIZE, DURATION We prospectively compared the degree of menstrual cyclicity with the presence of dysglycemia (elevated 1-h plasma glucose ≥155 mg/dl; abnormal glucose tolerance [AGT], including prediabetes and T2DM; and AUC for glucose [G-AUC]) or dynamic state hyperinsulinemia (peak insulin levels either at 1 or 2 h of the oral glucose tolerance test (oGTT) and AUC for insulin [I-AUC]) in 333 hyperandrogenic PCOS women. PARTICIPANTS/MATERIALS, SETTING, METHODS In a tertiary care setting, hyperandrogenic PCOS participants with ovulatory eumenorrhea (Ov-Eumeno, n = 25), anovulatory eumenorrhea (Anov-Eumeno, n = 33), oligomenorrhea (Oligo, n = 150) and amenorrhea (Ameno, n = 125) underwent comprehensive phenotyping and a 2-h 75 g oGTT. MAIN RESULTS AND THE ROLE OF CHANCE Mean BMI was greater among Ameno women than among Oligo, Anov-Eumeno or Ov-Eumeno women. Adjusting for BMI, the Ameno group demonstrated higher mean 1- and 2-h insulin and glucose, peak insulin and I-AUC and G-AUC, and either had a higher, or tended toward having a higher, prevalence of elevated 1-h glucose level and prevalence of AGT than the Oligo, Anov-Eumeno or Ov-Eumeno groups. In logistic regression, adjusting for BMI, Ameno women were more likely to have: AGT than Oligo women (odds ratio [OR]: 2.3; 95% CI: 1.3 to 4.2); elevated 1-h glucose (OR: 10.2; CI: 1.3-79.7) than those with Ov-Eumeno; and both AGT (OR: 1.7; CI: 1.1-2.6) and elevated 1-h glucose (OR: 1.8; CI: 1.1-2.8) than those with Anov-Eumeno or Ov-Eumeno when combined. Race/ethnicity, age, waist-to-hip ratio, fasting insulin and glucose, and biochemical or clinical measures of hyperandrogenism were similar across the four menstrual categories. LIMITATIONS, REASONS FOR CAUTION Our study was limited by its cross-sectional nature and by studying women affected by PCOS as defined by the Androgen Excess & PCOS Society criteria (i.e. Rotterdam Phenotypes A, B and C) who were identified in the clinical setting. Consequently, extrapolation of the present data to other PCOS phenotypes (e.g. PCOS Phenotype D) should be made with caution. WIDER IMPLICATIONS OF THE FINDINGS In hyperandrogenic PCOS phenotypes, a history of amenorrhea, compared to oligomenorrhea or eumenorrhea, suggests a more severe cardiometabolic risk, including a higher degree of hyperinsulinemia and greater prevalence of glycemic abnormalities. These findings may assist in refining the treatment and screening guidelines for glycemic abnormalities in PCOS. STUDY FUNDING/COMPETING INTEREST(S) This work was supported in part by grants R01-DK073632 and R01-HD29364 from the NIH and an endowment of the Helping Hand of Los Angeles, Inc. (to R.A.). M.D.P. has no competing interests to declare. U.E. is an investor in Concentric Analgesics, Inc. R.A. serves as a consultant for Spruce Biosciences and Fortress Biotech and an advisor for Aurora Forge. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- U Ezeh
- Department Obstetrics & Gynecology, Alta Bates Summit Medical Center/Sutter Health, Berkeley, CA, USA
- Department of Obstetrics & Gynecology, Medical College of Georgia, Augusta University, Augusta, GA, USA
- Department of Obstetrics & Gynecology, and Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - M D Pisarska
- Department of Obstetrics & Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Obstetrics & Gynecology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - R Azziz
- Department of Obstetrics & Gynecology, and Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Health Policy, Management and Behavior, School of Public Health, University at Albany, SUNY, Albany, NY, USA
- Department of Healthcare Organization & Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
- Correspondence address. Womens, Infant & Children, Ste. 10390, 1700 6th Ave, South, Birmingham, AL 35249-7333, USA. Tel: +1-205-934-1030; E-mail:
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OUP accepted manuscript. Hum Reprod Update 2022; 28:501-517. [DOI: 10.1093/humupd/dmac011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 02/06/2022] [Indexed: 11/14/2022] Open
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