Bone mineral density and vitamin D in PCOS and hirsutism

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

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

Bone health and prevalent fractures in women with polycystic ovary syndrome: a meta-analysis and endocrine-context pathophysiology review

INTRODUCTION

Bone health in those with Polycystic Ovary Syndrome (PCOS) is complex, but the general consensus is that cortical areal bone mineral density (aBMD) sites will be higher in PCOS than in age- and BMI-similar controls. However, spine aBMD sites may be lower, especially in non-obese PCOS. Whether or not incident fracture risk is increased in PCOS is currently controversial; no meta-analysis has yet assessed prevalent fractures.

AREAS COVERED

We assessed the bone effects of PCOS-related ovarian hormone alterations, e.g. androgen excess, tonically normal/higher estradiol, and lower-than-normal progesterone levels. We also highlighted evidence that common PCOS medications (e.g. combined hormonal contraceptives [CHC], metformin, and spironolactone) have important bone effects. In adolescents, meta-analysis of CHC showed significant negative aBMD changes. Inflammation has negative PCOS bone effects and is linked with CHC use.

EXPERT OPINION

Is fracture risk altered by PCOS? Our meta-analysis showed a 25% increased risk of prevalent fracture in PCOS versus controls; this did not reach statistical significance. Future prospective research needs to collect and evaluate ovulation characteristics, progesterone exposure, and adolescent CHC use, in addition to the complex variables that may influence risks for prevalent or incident fragility fractures and/or for cortical and cancellous aBMD values in PCOS.

Bone markers and bone mineral density associates with periodontitis in females with poly-cystic ovarian syndrome

INTRODUCTION

Studies suggest an association between poly-cystic ovarian syndrome (PCOS) and chronic periodontitis (CP), both being inflammatory conditions. However, insufficient evidence assesses the impact of this inflammation on bone metabolism and bone turnover markers (BTMs). The present study aimed to determine the association between BTMs, bone mineral density (BMD), and clinical periodontal parameters in PCOS women with CP.

MATERIALS AND METHODS

Three groups, each with 40 newly diagnosed (1) PCOS+CP, (2) PCOS alone, (3) CP alone, and fourth group (n = 20) systemically and periodontally healthy females aged 18-30 years were included in the study. Full mouth clinical periodontal parameters, C-terminal telopeptides of type I collagen (CTX), bone alkaline phosphatase (ALP), BMD and 25-hydroxyvitamin D (VD) were recorded for all.

RESULTS

Low BMD (0.89 ± 0.11 g/cm²), increased CTX levels (2.76 ± 4.64 ng/ml), decreased bone ALP levels (11.09 ± 6.86 ng/ml), higher VD levels (289.02 ± 168.28 nmol/l) and poor clinical periodontal status were observed in PCOS + CP females. BMD-spine showed weak positive correlation with CTX, bone ALP, VD (r = 0.02, r = 0.07, r = 0.15, respectively) in PCOS + CP group. ANCOVA depicted covariates had no confounding effect. Multiple regression model explained 21.0% for BMD-spine and 12.7% for BMD-femur of total variability signifying association with all measured parameters among all groups.

CONCLUSION

Enhanced inflammatory thrust by periodontitis increases CTX levels and decreases bone ALP and BMD levels in women with PCOS. Screening PCOS women for periodontal disease and vice versa may have a direct bearing on overall bone health.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Plasma sclerostin levels are associated with nutritional status and insulin resistance but not hormonal disturbances in women with polycystic ovary syndrome

Objective

The aim of this study was to evaluate the circulating sclerostin levels with nutritional status, insulin resistance and hormonal disturbances in women with polycystic ovary syndrome (PCOS).

Patients and methods

The cross-sectional study involved 98 PCOS inpatients (20 normal weight, 17 overweight and 61 obese) with stable body mass. Body composition was assessed by bioimpedance method in addition to anthropometric measurements (body mass and height). Serum/plasma concentrations of glucose, insulin (with the calculation of homeostatic model assessment insulin resistance—HOMA-IR), estradiol, total testosterone, sex hormone-binding globulin (SHBG) and sclerostin were measured. Free androgen index (FAI) and estradiol/testosterone index were calculated.

Results

Plasma sclerostin levels were significantly higher in obese [0.61 (interquartile range 0.53–0.77) ng/mL] than in overweight [0.53 (0.49–0.57) ng/mL] and normal weight [0.49 (0.42–0.54) ng/mL] groups. Plasma sclerostin levels were significantly higher in the subgroup with insulin resistance [0.65 (interquartile range 0.53–0.77) vs. 0.52 (0.46–0.58) ng/mL; p < 0.001], while similar concentrations were observed in subgroups with FAI below and above median. Plasma sclerostin levels variability were explained by BMI (r = 0.40), the percentage of body fat (r = 0.40) and HOMA-IR values (r = 0.34) in multivariable models.

Conclusions

Circulating sclerostin levels in women with PCOS are related to nutritional status and insulin resistance, but not to sex hormone disturbances.

Obesity and Insulin Resistance, Not Polycystic Ovary Syndrome, Are Independent Predictors of Bone Mineral Density in Adolescents and Young Women

INTRODUCTION

Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders that affects females of reproductive age. The characteristic features of PCOS individually have opposing effects on bone mineral density (BMD); however, their cumulative effect on BMD has not been clearly defined. Adolescence and young adulthood span a crucial period in achieving peak bone mass. Thus, a better understanding of the impact of PCOS on BMD in this age group is needed.

OBJECTIVES

To determine whether BMD is different between young females with PCOS and controls and to identify factors that influence BMD in this population.

METHODS

Data from four cross-sectional studies with a total of 170 females aged 12-25 years with PCOS (n = 123) and controls (n = 47) with a wide range of BMIs (18.7-53.4 kg/m2) were analyzed. Participants had fasting glucose, insulin, and free and total testosterone concentrations measured. HOMA-IR was calculated. Whole-body BMD was assessed by dual-energy X-ray absorptiometry. Multiple regression analysis for predicting BMD included PCOS status, menstrual age, obesity, HOMA-IR, and free testosterone.

RESULTS

HOMA-IR and total and free testosterone were significantly higher in PCOS compared to controls but there was no difference in BMD z-score between PCOS (0.8 ± 1.0) and controls (0.6 ± 1.0) (p = 0.36). Obesity (p = 0.03) and HOMA-IR (p = 0.02) were associated with BMD z-score.

CONCLUSIONS

Obesity status and insulin resistance, but not PCOS status, were each independently associated with BMD in adolescents and young women who spanned a wide range of BMIs.

Socioeconomic status in Danish women with polycystic ovary syndrome: A register-based cohort study

INTRODUCTION

Low socioeconomic status (SES) may be associated with increased risk of polycystic ovary syndrome (PCOS) and vice versa. Possible associations between SES, obesity and ethnicity in PCOS are undetermined.

MATERIAL AND METHODS

National register-based study including women with PCOS aged 25 years or above (PCOS Denmark and an embedded cohort; PCOS Odense University Hospital [OUH]) and one control population. PCOS Denmark (n = 13 891) included women with PCOS in the Danish National Patient Register. Women in PCOS OUH underwent clinical examination (n = 814). Three age-matched controls were included per patient (n = 41 584). The main outcome measure was SES (personal income, occupational status and education).

RESULTS

The median (Q1; Q3) age of women in PCOS Denmark and controls was 33 (29; 39) years. Women with personal income in the lower tertile had a higher probability of a PCOS diagnosis than women in the high-income tertile (adjusted odds ratio [aOR] 1.5, 95% confidence interval [CI] 1.4-1.6). Women who were unemployed or on welfare payment (aOR 1.5, 95% CI 1.4-1.6), or who retired early (OR 1.8, 95% CI 1.7-2.0) had a higher probability of a PCOS diagnosis than women affiliated to the labor market. Women originating from the Middle East more often had PCOS (aOR 3.2, 95% CI 2.8-3.7) compared with women originating from Europe. In PCOS OUH, SES was lower in obese than in normal weight women.

CONCLUSIONS

A diagnosis of PCOS was associated with lower SES. In PCOS, women of foreign origin and women with obesity more often had low SES.

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

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

Correlation of clinical, radiological and serum analysis of hypovitaminosis D with polycystic ovary syndrome: A systematic review and meta-analysis

Objectives

Vitamin D deficiency leads to a myriad of healthcare problems from cardiovascular, metabolic, endocrine, and neurological disorders to cancer. However, the role of vitamin D deficiency in the etiopathogenesis of polycystic ovary syndrome (PCOS) is unclear. This study aimed to measure objectively the impact of vitamin D deficiency on PCOS through a quantitative assessment of the existing literature.

Methods

We conducted a systematic search of published literature on the following online databases using EndnoteX7: MEDLINE, EBSCO, ScienceDirect, and CINAHL. Searches were limited to full-text English-language journal articles published between 2006 and 2016. Eligible clinical studies employed control group data to investigate the association between vitamin D deficiency and PCOS.

Results

We identified 10 studies eligible for this meta-analysis. The summary intervention effect calculated for this meta-analysis yields a value of −0.45 with a confidence interval of −1.68 to 0.79, supporting the hypothesis that lower concentrations of serum vitamin D play a role in the hormonal and metabolic dysregulation seen in PCOS.

Conclusions

Lower concentrations of serum vitamin D are associated with a greater risk of developing PCOS. However, the therapeutic effect of vitamin D in the setting of PCOS remains unclear and must be determined by future interventional studies.

MANAGEMENT OF ENDOCRINE DISEASE: Morbidity in polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is the most prevalent endocrine condition in premenopausal women. The syndrome is characterized by hyperandrogenism, irregular menses and polycystic ovaries when other etiologies are excluded. Obesity, insulin resistance and low vitamin D levels are present in more than 50% patients with PCOS, these factors along with hyperandrogenism could have adverse effects on long-term health. Hyperinflammation and impaired epithelial function were reported to a larger extent in women with PCOS and could particularly be associated with hyperandrogenism, obesity and insulin resistance. Available data from register-based and data linkage studies support that metabolic-vascular and thyroid diseases, asthma, migraine, depression and cancer are diagnosed more frequently in PCOS, whereas fracture risk is decreased. Drug prescriptions are significantly more common in PCOS than controls within all diagnose categories including antibiotics. The causal relationship between PCOS and autoimmune disease represents an interesting new area of research. PCOS is a lifelong condition and long-term morbidity could be worsened by obesity, sedentary way of life, Western-style diet and smoking, whereas lifestyle intervention including weight loss may partly or fully resolve the symptoms of PCOS and could improve the long-term prognosis. In this review, the possible implications of increased morbidity for the clinical and biochemical evaluation of patients with PCOS at diagnosis and follow-up is further discussed along with possible modifying effects of medical treatment.

Fracture Risk Is Decreased in Women With Polycystic Ovary Syndrome: A Register-Based and Population-Based Cohort Study

Hyperandrogenism, obesity, and hyperinsulinemia may protect against osteoporosis, whereas amenorrhea, increased cortisol, and low growth hormone may be associated with higher fracture risk in polycystic ovary syndrome (PCOS). The objective of this study was to investigate fracture risk in PCOS. In the PCOS Denmark study, women with PCOS and/or hirsutism were identified in the Danish National Patient Register (1995-2012). Each patient was assigned three age-matched controls on the index date of PCOS diagnosis. Individuals with a previous endocrine diagnosis were excluded. Within PCOS Denmark, we embedded a well-characterized subcohort of patients, PCOS OUH, diagnosed with PCOS at Odense University Hospital (n = 1217). We identified incident fractures by International Classification of Diseases, 10th Revision (ICD-10) codes and used conditional Cox regression analyses to compare fracture risk. In the PCOS Denmark study, there were 19,199 women with PCOS and 57,483 controls were included, mean age 30.6 years (range, 12-60 years). Fracture rates were decreased in PCOS Denmark (10.3/1000 patient years) versus controls (13.6/1000 patient years). The adjusted ORs were 0.76 (95% CI, 0.71 to 0.80) for all fractures, 0.82 (95% CI, 0.74 to 0.92) for major osteoporotic fractures, and 0.57 (95% CI, 0.47 to 0.70) for fractures of head and face. The risk reduction was more pronounced below the age of 30 years at diagnosis. Women with PCOS had significant more hospital contacts due to strains and sprains. In the PCOS OUH subcohort, the risk reduction of fractures did not differ between PCOS women with elevated versus normal testosterone levels and the risk reduction was nominally smaller in overweight versus normal weight PCOS women. Women with PCOS had reduced risk of fractures, in particular of the appendicular skeleton. The risk reduction was greater in women with younger age at diagnosis suggesting that the skeletal effects of PCOS may be greater in women who have not yet reached peak bone mass. Reduced participation in sports activities was probably not the reason for the reduced risk of fractures.