Sleep disorders in polycystic ovary syndrome: influence of obesity and hyperandrogenism

Metabolic and endocrine status associate with obstructive sleep apnea risk among patients with polycystic ovary syndrome

STUDY OBJECTIVES

Risk of obstructive sleep apnea (OSA) appears to be increased among patients with polycystic ovary syndrome (PCOS), but the underlying physiology is unclear. We sought to identify predictors of OSA risk among patients with PCOS.

METHODS

A cross-sectional analysis of patients evaluated for PCOS at a single tertiary center from 2017-2022 was completed. Inclusion criteria included patients 18-44 years of age who had Rotterdam criteria for PCOS and had completed a Berlin Questionnaire (BQ) for OSA risk assessment. All patients underwent standardized anthropometric, ultrasound, endocrine, and metabolic phenotyping.

RESULTS

Of the 572 patients screened during the study period, 309 patients with PCOS met inclusion criteria, and 104 (33.7%) had a high-risk BQ. Those with a high-risk BQ, compared with those without, had significantly (P < .05) higher waist:hip ratio, low-density-lipoprotein cholesterol, triglycerides, fasting insulin, 2-hour insulin, fasting glucose, 2-hour glucose, homeostatic model assessment for insulin resistance, hemoglobin A1C, C-reactive protein, free testosterone, and free androgen index and had lower high-density-lipoprotein cholesterol and sex hormone binding globulin. In multivariable modeling controlling for all significantly differing variables in univariate analyses, hemoglobin A1C (β [standard error] 1.05 [0.45], P = .02), C-reactive protein (0.09 [0.04], P = .01), and sex hormone binding globulin (-0.02 [0.01], P = .02) associated with high-risk BQ.

CONCLUSIONS

Dysglycemia, inflammation, and androgen status independently associate with predicted OSA risk by BQ. Future studies are needed to comprehensively assess the impact of treatment of OSA on these outcomes among patients with PCOS to better clarify the directionality and clinical implications of these associations.

CITATION

Christ JP, Shinkai K, Corley J, Pasch L, Cedars MI, Huddleston HG. Metabolic and endocrine status associate with obstructive sleep apnea risk among patients with polycystic ovary syndrome. J Clin Sleep Med. 2024;20(6):871-877.

The Relationship Between Mood and Sleep in Different Female Reproductive States

Mood and sleep are tightly interrelated. Mood and sleep symptoms and disorders are more common in women than in men and often associated with reproductive events. This article reviews the current literature on the reciprocal relationships between mood and sleep across reproductive phases in women, such as menstrual cycle and related disorders, pregnancy, climacteric, and use of hormonal contraception and hormone replacement therapy. Mood and sleep symptoms seem to covary in relation to physiologic and pathologic reproductive conditions, although the relationship seems more clear for subjective than objective sleep.

The stress of losing sleep: Sex-specific neurobiological outcomes

Sleep is a vital and evolutionarily conserved process, critical to daily functioning and homeostatic balance. Losing sleep is inherently stressful and leads to numerous detrimental physiological outcomes. Despite sleep disturbances affecting everyone, women and female rodents are often excluded or underrepresented in clinical and pre-clinical studies. Advancing our understanding of the role of biological sex in the responses to sleep loss stands to greatly improve our ability to understand and treat health consequences of insufficient sleep. As such, this review discusses sex differences in response to sleep deprivation, with a focus on the sympathetic nervous system stress response and activation of the hypothalamic-pituitary-adrenal (HPA) axis. We review sex differences in several stress-related consequences of sleep loss, including inflammation, learning and memory deficits, and mood related changes. Focusing on women's health, we discuss the effects of sleep deprivation during the peripartum period. In closing, we present neurobiological mechanisms, including the contribution of sex hormones, orexins, circadian timing systems, and astrocytic neuromodulation, that may underlie potential sex differences in sleep deprivation responses.

Beyond Counting Sheep: Exploring the Link between Polycystic Ovary Syndrome and Sleep Health

Polycystic ovary syndrome (PCOS) is a common hormonal condition with reproductive, metabolic, and psychological sequelae that affects 8 to 13% of reproductive-aged women and 3 to 11% of adolescent girls. Sleep is often compromised in women with PCOS due to increased rates of sleep problems, with the most established problem being obstructive sleep apnea (OSA). OSA is highly prevalent in reproductive-aged adult women with PCOS, but not so in adolescence. The international evidence-based PCOS guideline to improve health outcomes in women with PCOS indicated routine screening to identify and alleviate symptoms of OSA. The guidelines, however, did not weigh other multidimensional constructs of sleep health such as sleep disturbances (e.g., sleep quality and quantity), beyond OSA. This is perhaps due to the lack of research and existing mixed findings in the area of PCOS and sleep health. This narrative review summarizes the current knowledge about OSA and expands further to include the limited knowledge about other sleep problems in PCOS among reproductive-aged women and adolescent girls. We broadly cover the prevalence, risk factors, and mechanisms of sleep problems in PCOS and their relationship with cardiometabolic and psychological health. A brief summary on treatment and intervention strategies for sleep problems in PCOS and future recommendations will be deliberated.

Different sleep pattern in over-weight/obese women with polycystic ovary syndrome

CONTEXT

Sleep duration and sleep quality have important health implications although our knowledge of objectively measured sleep variables in women with Polycystic Ovary Syndrome (PCOS) is limited.

OBJECTIVE

To compare sleep variables assessed by actigraphy in over-weight/obese women with PCOS and controls, and to assess sleep variables after behavioral modification intervention in comparison with minimal intervention in a randomized trial.

DESIGN

Randomized controlled trial, and a control group.

SETTING

Outpatient gynecological clinic at a university hospital in Sweden.

PARTICIPANTS

39 women fulfilling all Rotterdam PCOS criteria, randomized to behavioral modification intervention or minimal intervention and 21 controls with no other metabolic disease, all aged 18-40 years with a BMI ≥ 27 kg/m².

INTERVENTION

A four-month behavioral modification intervention including weekly group meetings focusing on behavioral and healthy lifestyle aspects. Minimal intervention reflecting standard care.

MAIN OUTCOME MEASURE

Sleep durations and sleep efficiency assessed by actigraphy.

RESULTS

Compared to the control group, women with PCOS had significantly shorter time in bed (501 vs 548 min, p= 0.049), sleep time over 24 hours (448 vs 567 min, p=0.005) and sleep time at night (434 vs 511 min, p=0.002), poorer sleep efficiency (87 vs 93%, p<0.001), and longer wakefulness after sleep onset (64 vs 38 min, p<0.001). However, total sleep time at night for women with PCOS (7.2hrs) was within the normal range. Following behavioral modification intervention, the reduction from baseline in sleep over 24 hours and in the daytime sleep were significant compared to the minimal intervention group (78 min, p=0.009 and 43 min, p=0.003 respectively).

CONCLUSIONS

We found over-weight/obese women with PCOS to have normal sleep duration, but worse sleep efficiency than controls. Behavioral modification intervention seems to reduce the amount of daytime sleep, suggesting improved sleep behavior.

CLINICAL TRIALS REGISTRATION

https://doi.org/10.1186/ISRCTN48947168, identifier ISRCTN48947168.

Sleep disturbances, sleep quality, and cardiovascular risk factors in women with polycystic ovary syndrome: Systematic review and meta-analysis

OBJECTIVES

(1) To establish the prevalence of sleep disorders in women with PCOS. (2) To establish the association between sleep disturbance and cardiovascular risk factors in women with PCOS.

METHODS

The electronic databases PubMed and EMBASE were searched for observational studies of individuals with PCOS published in English from inception to 21 October 2021. The dichotomous outcome measure was presented as odds ratio (OR) and 95% confidence interval (CI). The mean difference (MD) in continuous variables was expressed for each study.

RESULTS

A total of 18 articles were included in this meta-analysis, with a total of 16,152 participants from nine different countries. Women with PCOS had a high prevalence of sleep disturbance (OR = 6.22; 95% CI: 2.77, 13.97; p < 0.001), higher PSQI scores (MD = 2.10; 95% CI: 0.29, 3.90; p = 0.02), and shorter duration of sleep (MD = -15.65 min; 95% CI: -27.18, -4.13; p = 0.008). We found that body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), low-density lipoprotein cholesterol (LDL-c), fasting glucose, 2-h glucose, and waist circumference (WC) levels were significantly higher and high-density lipoprotein cholesterol (HDL-c) was significantly lower in PCOS with sleep disturbance than in PCOS without sleep disturbance.

CONCLUSIONS

The current study shows a high prevalence of sleep disturbance in women with PCOS and provides evidence of an association between cardiovascular risk factors and sleep disturbance among this population. Increased attention should be paid to sleep management in clinical guidelines for PCOS.

Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022298040.

Hot flashes, insomnia, and the reproductive stages: a cross-sectional observation of women from the EPISONO study

STUDY OBJECTIVES

To investigate the association of hot flashes and insomnia in women in premenopause and postmenopause.

METHODS

The study was performed using data from the São Paulo Epidemiological Sleep Study. Women in premenopause were classified as having regular menstrual cycles, being anovulatory, or using hormonal contraceptives. Women in menopause were classified as being in perimenopause, early postmenopause, or late postmenopause. Women reporting frequent insomnia symptoms and relevant daytime complaints were classified as having insomnia disorder. Polysomnography alterations suggestive of insomnia were also identified.

RESULTS

The frequency of hot flashes was 42% among women in postmenopause (mainly in early postmenopause) and 9% among women in premenopause (mainly anovulatory; P < .01). Approximately 18.7% had insomnia disorder, 48% had isolated insomnia symptoms, and 32.4% had polysomnography alterations. Comparing women in menopause with those in premenopause, the diagnosis of insomnia was similar (premenopause: 18.9% vs menopause: 17.5%), but women in menopause had more frequent isolated insomnia symptoms (premenopause: 43.9% vs menopause: 55.9%; P = .02) and polysomnography correlates of insomnia (premenopause: 26.5% vs menopause: 42.6%; P < .01). Hot flashes were more frequent among women with insomnia disorders (25.5%) and with isolated insomnia symptoms (23.0%) when compared with good sleepers (12.6%) in the entire sample (P = .01). Among women in late menopause, the prevalence of hot flashes was higher in both women with insomnia disorders (42.1%) and with isolated insomnia symptoms (37.5%) when compared with women who were good sleepers (14.3%; P = .05).

CONCLUSIONS

Hot flashes are associated with insomnia and polysomnography alterations suggestive of insomnia. The prevalence of hot flashes among women with insomnia disorder is especially high among women in late postmenopause.

CITATION

Hachul H, Castro LS, Bezerra AG, et al. Hot flashes, insomnia, and the reproductive stages: a cross-sectional observation of women from the EPISONO study. J Clin Sleep Med. 2021;17(11):2257-2267.

Investigation of common risk factors between polycystic ovary syndrome and Alzheimer's disease: a narrative review

BACKGROUND

The most common endocrine and metabolic disorders in premenopausal women is polycystic ovary syndrome (PCOS), characterized by hyperandrogenism, chronic anovulation, and/or ultrasound evidence of small ovarian cysts. Obesity and insulin resistance are also the main factors influencing the clinical manifestations of this syndrome. Alzheimer's disease (AD) is the most typical progressive neurodegenerative disorder of the brain, and recent studies suggest a relationship between endocrinal dysregulation and neuronal loss during AD pathology.

AIM

This study aimed to evaluate the common risk factors for Alzheimer's and PCOS based on previous studies. Knowing the common risk factors and eliminating them may prevent neurodegenerative Alzheimer's disease in the future.

METHOD

In this narrative review, international databases, including Google Scholar, Scopus, PubMed, and the Web of Science, were searched to retrieve the relevant studies. The relevant studies' summaries were categorized to discuss the possible pathways that may explain the association between Alzheimer's and PCOS signs/symptoms and complications.

RESULTS

According to our research, the factors involved in Alzheimer's and PCOS disorders may share some common risk factors. In patients with PCOS, increased LH to FSH ratio, decreased vitamin D, insulin resistance, and obesity are some of the most important factors that may increase the risk of Alzheimer's disease.

Poor sleep is associated with higher blood pressure and uterine artery pulsatility index in pregnancy: a prospective cohort study

Objective

To elucidate the association between sleep disturbances and blood pressure as well as uterine artery Doppler during pregnancy in women with no pre‐existing hypertension.

Design

Prospective cohort study.

Setting

Outpatient specialist clinics at KK Women’s and Children’s Hospital, Singapore.

Population

Women with viable singleton pregnancies confirmed by ultrasonography at less than 14 weeks of amenorrhoea at first visit.

Methods

In all, 926 subjects were recruited for this study in the outpatient specialist clinics at KK Women’s and Children’s Hospital, Singapore, between 1 September 2010 and 31 August 2014. They were followed up throughout pregnancy with sleep quality, blood pressure and uterine artery Doppler assessed at each visit.

Main outcome measures

Sleep quality, blood pressure and uterine artery Doppler.

Results

Sleep progressively worsened as pregnancy advanced. Shorter sleep duration and poorer sleep efficiency were associated with higher blood pressure, especially in the first trimester. Mixed model analysis demonstrated an overall positive association between sleep quality represented by Pittsburgh Sleep Quality Index (PSQI) score and diastolic blood pressure (DBP) (P < 0.001) and mean arterial pressure (MAP) (P = 0.005) during pregnancy after considering all trimesters. Sleep duration was found to be negatively associated with both systolic blood pressure (SBP) (P = 0.029) and DBP (P = 0.002), whereas sleep efficiency was negatively correlated with DBP (P = 0.002) only. Overall poor sleep during pregnancy was also found to be associated with a higher uterine artery pulsatility index.

Conclusion

Our prospective study demonstrated that poor sleep quality is significantly associated with higher blood pressure and uterine artery pulsatility index during pregnancy.

Tweetable abstract

Poor sleep quality is significantly associated with higher blood pressure and higher uterine artery pulsatility index during pregnancy.

Poor sleep quality is significantly associated with higher blood pressure and higher uterine artery pulsatility index during pregnancy.

Lifestyle and environmental contributions to ovulatory dysfunction in women of polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is the most common reason of anovulatory infertility. Environmental factor is one of the main causes of PCOS, but its contribution to ovulatory dysfunction in PCOS remains unknown.

METHODS

A total of 2217 infertile women diagnosed as PCOS according to Rotterdam criteria were recruited, including 1979 women with oligo-anovulation (OA group) and 238 women with normal -anovulation (non OA group). Besides, 279 healthy control women of reproductive age were enrolled as controls.

RESULTS

Frequencies of snoring (PCOS-OA group, PCOS-non-OA group, control group: 29.30% vs 18.10% vs 11.50%, P < 0.01), smoking (37.70% vs 28.10% vs 12.20%, P < 0.01), plastic tableware usage (38.30% vs 28.10% vs 25.40%, P < 0.01) and indoor decoration (32.10% vs 24.80% vs 16.80%, P < 0.01) were highest in PCOS-OA group. After adjusted for multivariable, difference remained significant between PCOS-OA group and the other two groups. PCOS-OA women preferred a meat favorable diet compared to PCOS-non-OA group (54.60% vs 41.30%, P < 0.01). There was no difference between three groups in exercise, frequency of insomnia, and alcohol consumption.

CONCLUSIONS

Smoking, snoring, hyper-caloric diet, plastic tableware usage and indoor decoration were found to be associated with an increased risk for ovulatory dysfunction in women suffering from PCOS.