Polycystic Ovary Syndrome, Obesity and Reproductive Implications

Hyperandrogenism and Cardiometabolic Risk in Pre- and Postmenopausal Women-What Is the Evidence?

Hyperandrogenism in women, such as polycystic ovary syndrome, ovarian hyperthecosis, congenital adrenal hyperplasia, and androgen-secreting tumors, are all associated with increased prevalence of cardiovascular risk factors that include type 2 diabetes, hypertension, dyslipidemia, and metabolic syndrome. However, it is not clear whether this also implies enhanced risk of cardiovascular disease and mortality. Furthermore, the involvement of obesity and menopausal status for cardiometabolic risk in these women has not been elucidated. Based on the most recent systematic reviews and meta-analyses, this review summarizes the latest scientific evidence. To conclude, hyperandrogenism in premenopausal women is associated with enhanced prevalence of cardiovascular risk factors, as well as increased risk of cardiovascular disease and mortality, independently of body mass index. In contrast, elevated cardiovascular risk factors and increased risk of myocardial infarction and stroke in hyperandrogenic postmenopausal women are dependent on obesity. Furthermore, the overall risk of cardiovascular disease and coronary artery disease in hyperandrogenic postmenopausal women is similar to controls. The reason for a reduced cardiometabolic risk after menopause in hyperandrogenic women compared to nonhyperandrogenic women is not clear. It can be speculated that the difference in endocrine balance and metabolic status between women with and without hyperandrogenism might decrease after menopause because hyperandrogenism usually improves with age, whereas menopausal transition itself is associated with androgen dominance and abdominal obesity. Although we have gained increased knowledge about cardiometabolic risks in women with hyperandrogenism, it must be acknowledged that the quality of data is overall low. More research is needed, especially longer and larger follow-up studies in women with hyperandrogenism of different etiologies and phenotypes.

Maternal serum levels of prokineticin-1 related to pregnancy complications and metformin use in women with polycystic ovary syndrome: a post hoc analysis of two prospective, randomised, placebo-controlled trials

OBJECTIVE

Serum prokineticin-1 (s-PROK1) in the second and third trimester of pregnancy is positively correlated to preeclampsia, intrauterine growth restriction (IUGR) and preterm delivery. Women with polycystic ovary syndrome (PCOS) are prone to these adverse pregnancy outcomes. However, the contribution of PROK1 to the development of pregnancy complications and the effect of metformin and hyperandrogenism on s-PROK1 in PCOS have not been studied previously.

DESIGN

This work is a post hoc analysis of two prospective, randomised, placebo-controlled trials.

SETTING

Pregnant women with PCOS were included from 11 study centres in Norway.

PARTICIPANTS

From 313 women, 264 participated in the present study after exclusions due to dropouts or insufficient serum samples.

INTERVENTION

Women with PCOS were randomly administered with metformin or placebo, from first trimester to delivery.

PRIMARY AND SECONDARY OUTCOME MEASURES

s-PROK1 was analysed using ELISA at gestational week 19 and related to pregnancy complications, fasting insulin levels, homoeostatic model assessment for insulin resistance (HOMA-IR), testosterone, or androstenedione levels, metformin use, PCOS phenotype and hyperandrogenism.

RESULTS

Maternal s-PROK1 in the second trimester did not predict pregnancy-induced hypertension, pre-eclampsia or late miscarriage/preterm delivery in women with PCOS. However, s-PROK1 was lower in women who used metformin before inclusion, both in those randomised to metformin and to placebo, compared with those who did not. s-PROK1 was also lower in those who used metformin both at conception and during pregnancy compared with those who used metformin from inclusion or did not use metformin at all. s-PROK1 was lower in hyperandrogenic compared with normo-androgenic women with PCOS.

CONCLUSIONS

Maternal s-PROK1 in the second trimester did not predict pregnancy complications in PCOS. Those who used metformin at conception and/or during pregnancy had lower s-PROK1. PCOS women with hyperandrogenism exhibited lower s-PROK1 compared with normo-adrogenic phenotypes.

TRIAL REGISTRATION NUMBER

NCT03259919 and NCT00159536.

Gut microbiota dysbiosis in polycystic ovary syndrome: Mechanisms of progression and clinical applications

Polycystic ovary syndrome (PCOS) is the most common endocrine diseases in women of childbearing age that leads to menstrual disorders and infertility. The pathogenesis of PCOS is complex and has not yet been fully clarified. Gut microbiota is associated with disorders of lipid, glucose, and steroid hormone metabolish. A large body of studies demonstrated that gut microbiota could regulate the synthesis and secretion of insulin, and affect androgen metabolism and follicle development, providing us a novel idea for unravelling the pathogenesis of PCOS. The relationship between gut microbiota and the pathogenesis of PCOS is particularly important. This study reviewed recent research advances in the roles of gut microbiota in the occurrence and development of PCOS. It is expected to provide a new direction for the treatment of PCOS based on gut microbiota.

Approach to Investigation of Hyperandrogenism in a Postmenopausal Woman

Postmenopausal hyperandrogenism is a condition caused by relative or absolute androgen excess originating from the ovaries and/or the adrenal glands. Hirsutism, i.e., increased terminal hair growth in androgen-dependent areas of the body, is considered the most effective measure of hyperandrogenism in women. Other symptoms can be acne and androgenic alopecia or the development of virilization including clitoromegaly. Postmenopausal hyperandrogenism may also be associated with metabolic disorders like abdominal obesity, insulin resistance and type 2 diabetes. Mild hyperandrogenic symptoms can be due to relative androgen excess associated with menopausal transition or polycystic ovary syndrome, which is likely the most common cause of postmenopausal hyperandrogenism. Virilizing symptoms, on the other hand, can be caused by ovarian hyperthecosis or an androgen-producing ovarian or adrenal tumor that may be potentially malignant. Determination of serum testosterone, preferably by tandem mass spectrometry, is the first step in the endocrine evaluation providing important information on the degree of androgen excess. Testosterone > 5 nmol/L is associated with virilization and requires prompt investigation to rule out an androgen-producing tumor in first instance. To localize the source of androgen excess, imaging techniques are used like transvaginal ultrasound or magnetic resonance imaging (MRI) for the ovaries and computed tomography (CT) and MRI for the adrenals. Bilateral oophorectomy or surgical removal of an adrenal tumor is the main curative treatment and will ultimately lead to a histopathological diagnosis. Mild to moderate symptoms of androgen excess are treated with anti-androgen therapy or specific endocrine therapy depending on diagnosis. This review summarizes the most relevant causes of hyperandrogenism in postmenopausal women and suggests principles for clinical investigation and treatment.

Further delineation of familial polycystic ovary syndrome (PCOS) via whole-exome sequencing: PCOS-related rare FBN3 and FN1 gene variants are identified

AIM

To identify pathogenic rare coding Mendelian/high-effect size variant(s) by whole-exome sequencing in familial polycystic ovary syndrome (PCOS) patients to elucidate PCOS-related pathways.

METHODS

Twenty women and their affected available relatives diagnosed with PCOS according to Rotterdam criteria were recruited. Whole-exome sequencing on germ-line DNA from 31 PCOS probands and their affected relatives was performed. Whole-exome sequencing data were further evaluated by pathway and chemogenomics analyses. In-slico analysis of candidate variants were done by VarCards for functional predictions and VarSite for impact on three-dimensional (3D) structures in the candidate proteins.

RESULTS

Two heterozygous rare FBN3 missense variants in three patients, and one FN1 missense variant in one patient from three different PCOS families were identified.

CONCLUSION

We identified three novel FBN3 and FN1 variants for the first time in the literature and linked with PCOS. Further functional studies may identify causality of these newly discovered PCOS-related variants, and their role yet remains to be investigated. Our findings may improve our understanding of the biological pathways affected and identify new drug targets.

Obesity and oocyte quality: Significant implications for ART and Emerging mechanistic insights

The prevalence of obesity in adults worldwide, and specifically in women of reproductive age, is concerning given the risks to fertility posed by the increased risk of type 2 diabetes, metabolic syndrome and other non-communicable diseases. Obesity has a multi-systemic impact in female physiology that is characterized by the presence of oxidative stress, lipotoxicity, and the activation of pro-inflammatory pathways, inducing tissue-specific insulin resistance and ultimately conducive to abnormal ovarian function. A higher body mass is linked to Polycystic Ovary Syndrome, dysregulated menstrual cycles, anovulation, and longer time to pregnancy, even in ovulatory women. In the context of ART, compared to women of normal BMI, obese women have worse outcomes in every step of their journey, resulting in reduced success measured as live birth rate. Even after pregnancy is achieved, obese women have a higher chance of miscarriage, gestational diabetes, pregnancy complications, birth defects, and most worryingly, a higher risk of stillbirth and neonatal death. The potential for compounding effects of ART on pregnancy complications and infant morbidities in obese women has not been studied. There is still much debate in the field on whether these poorer outcomes are mainly driven by defects in oocyte quality, abnormal embryo development or an unaccommodating uterine environment, however the clinical evidence to date suggests a combination of all three are responsible. Animal models of maternal obesity shed light on the mechanisms underlaying the effects of obesity on the peri-conception environment, with recent findings pointing to lipotoxicity in the ovarian environment as a key driver of defects in oocytes that have not only reduced developmental competence but long-lasting effects in offspring health.

Female Hyperandrogenism in Elite Sports and the Athletic Triad

Essential hyperandrogenism seems to be overrepresented in female elite athletes. This applies to mild forms such as polycystic ovary syndrome, as well as rare differences/disorders of sex development (DSD). The reason is likely a selection bias since there is increasing evidence that androgens are beneficial for athletic performance by potent anabolic effects on muscle mass and bone mass, and stimulation of erythropoiesis. XY DSD may cause a greatly increased production of testosterone in the male range, that is, 10 to 20 times higher than the normal female range. The established regulations concerning the eligibility of female athletes with severe hyperandrogenism to compete in the female classification remain controversial. The most common cause of menstrual disorders in female athletes, however, is probably an acquired functional hypothalamic disturbance due to energy deficiency in relation to energy expenditure, which could lead to low bone mineral density and increased risk of injury. This condition is particularly common in endurance and esthetic sports, where a lean body composition is considered an advantage for physical performance. It is important to carefully evaluate endocrine disturbances and menstrual disorders in athletes since the management should be specific according to the underlying cause.

Médicalisation et autonomie des femmes affectées par le syndrome des ovaires polykystiques

Le syndrome des ovaires polykystiques (SOPK) est un trouble endocrinien répandu qui affecte environ 10% des femmes en âge de procréer. Bien qu’il soit principalement connu pour ses effets sur la fertilité, le SOPK est considéré comme un facteur de risque pouvant mener au diabète de type 2. Il est également associé à des conditions comme les cancers hormono-dépendants, les troubles psychiatriques ou encore les maladies cardio-vasculaires. La volonté de prévenir les conditions associées pourrait pousser à une plus grande médicalisation des femmes atteintes par le SOPK, notamment par d’éventuels dépistages. Cet article examine les facteurs potentiels pouvant contribuer à la médicalisation de ces femmes et la manière dont leur autonomie pourrait être affectée par ce phénomène. Entre autres, l’article met en évidence comment la médicalisation façonne des représentations collectives et individuelles par rapport aux notions de santé, de maladie et de traitement. Dans une perspective relationnelle de l’autonomie, il attire l’attention sur l’importance de reconnaitre comment la médicalisation influence ces représentations et l’impact potentiel que cela pourrait avoir sur les femmes. Encourager la démédicalisation du SOPK par une approche visant à soutenir la santé pousse à interroger ces représentations et fait partie des pistes de solution permettant de favoriser l’autonomie des femmes affectées par le SOPK. Il devient alors possible non seulement de contrôler la maladie, mais aussi de soutenir la santé, voire de faire les deux selon la situation individuelle.

Neurotensin and Xenin Show Positive Correlations With Perceived Stress, Anxiety, Depressiveness and Eating Disorder Symptoms in Female Obese Patients

Objective

Neurotensin and xenin are two closely related anorexigenic neuropeptides synthesized in the small intestine that exert diverse peripheral and central functions. Both act via the neurotensin-1-receptor. In animal models of obesity reduced central concentrations of these peptides have been found. Dysregulations of the acute and chronic stress response are associated with development and maintenance of obesity. Until now, associations of both peptides with stress, anxiety, depressiveness, and eating disorder symptoms have not been investigated. The aim of the present study was to examine associations of neurotensin and xenin with these psychological characteristics under conditions of obesity.

Materials and Methods

From 2010 to 2016 we consecutively enrolled 160 inpatients (63 men and 97 women), admitted due to obesity and its mental and somatic comorbidities. Blood withdrawal und psychometric tests (PSQ-20, GAD-7, PHQ-9, and EDI-2) occurred within one week after admission. We measured levels of neurotensin and xenin in plasma by ELISA.

Results

Mean body mass index was 47.2 ± 9.5 kg/m². Concentrations of neurotensin and xenin positively correlated with each other (women: r = 0.788, p < 0.001; men: r = 0.731, p < 0.001) and did not significantly differ between sexes (p > 0.05). Women generally displayed higher psychometric values than men (PSQ-20: 58.2 ± 21.7 vs. 47.0 ± 20.8, p = 0.002; GAD-7: 9.7 ± 5.8 vs. 7.1 ± 5.3, p = 0.004; PHQ-9: 11.6 ± 6.6 vs. 8.8 ± 5.9, p = 0.008; EDI-2: 50.5 ± 12.8 vs. 39.7 ± 11.9, p < 0.001). Only women showed positive correlations of both neuropeptides with stress (neurotensin: r = 0.231, p = 0.023; xenin: r = 0.254, p = 0.013), anxiety (neurotensin: r = 0.265, p = 0.009; xenin: r = 0.257, p = 0.012), depressiveness (neurotensin: r = 0.281, p = 0.006; xenin: r = 0.241, p = 0.019) and eating disorder symptoms (neurotensin: r = 0.276, p = 0.007; xenin: r = 0.26, p = 0.011), whereas, men did not (p > 0.05).

Conclusion

Neurotensin and xenin plasma levels of female obese patients are positively correlated with perceived stress, anxiety, depressiveness, and eating disorder symptoms. These associations could be influenced by higher prevalence of mental disorders in women and by sex hormones. In men, no correlations were observed, which points toward a sex-dependent regulation.

Significant Role of Dicer and miR-223 in Adipose Tissue of Polycystic Ovary Syndrome Patients

Polycystic ovary syndrome (PCOS) is a chronic metabolic disease that is associated with obesity and adipose tissue dysfunction. This study aimed to explore the roles of Dicer (an enzyme that processes primary microRNAs) and microRNAs in PCOS. Protein levels were detected by western blotting, and mRNA and microRNA levels were detected by RT-PCR. Dicer-deficient pre-adipocytes were established by lentiviral transfection, and an miR-223 mimic and miR-223 inhibitor were used to overexpress and inhibit miR-223, respectively. 3T3-L1 cells were induced to differentiate into mature adipocytes by IBMX, insulin, and dexamethasone. The degree of differentiation was determined by oil red O staining. An insulin resistance model was established by exposing mature adipocytes to excessive glucose and insulin. The protein levels of Dicer and Ago2 in adipose tissues of PCOS patients were significantly lower than those in control females. A Dicer-deficient 3T3-L1 cell model was successfully established, whose proliferation was inhibited significantly. Insulin-resistant mature adipocytes expressed significantly less Dicer protein than control cells. The differentiation of Dicer-deficient 3T3-L1 cells and their expression of miR-223 and marker genes associated with adipose differentiation were reduced significantly. Furthermore, 3T3-L1 cells showed a weaker ability to develop into mature adipocytes when miR-223 expression was inhibited. An miR-223 mimic was used to recover the differentiation block induced by Dicer deficiency. This rescued the expression of genes associated with adipose differentiation, although the differentiation block was not efficiently rescued. It is concluded that insulin resistance may contribute to the decreased levels of Dicer protein in adipose tissue of PCOS patients. This suggests that dysfunction of Dicer plays a significant role in obesity of PCOS patients. miR-223 is a key factor in Dicer-regulated adipose differentiation, and other microRNAs may be involved in the process.

Effects of metformin and Exenatide on insulin resistance and AMPKα-SIRT1 molecular pathway in PCOS rats

AIMS

This study was designed to evaluate the protective effects of AMPKα and SIRT1 on insulin resistance in PCOS rats, and to illuminate the underlying mechanisms.

METHODS

An in vitro PCOS model was established by DHEA (6 mg/(100 g•d)), and the rats were randomly divided into the metformin group (MF group, n = 11), the exenatide group (EX group, n = 11), the PCOS group (n = 10), and the normal control group (NC group, n = 10). The MF group was administered MF 300 mg/(kg•d) daily. The EX group was subcutaneously injected EX 10μg/(kg•d) daily. After 4 weeks of continuous administration, fasting blood glucose and serum androgen, luteinizing hormone and other biochemical indicators were measured. Western and Real-time PCR were used to determine the expression of AMPKα and SIRT1 in the ovaries of each group.

RESULTS

After 4 weeks of drug intervention, compared with untreated PCOS group, EX group and MF group had visibly decreased body weight (222.64 ± 16.57, 218.63 ± 13.18 vs 238.30 ± 12.26 g, P = 0.026), fasting blood glucose (7.71 ± 0.72, 8.17 ± 0.54 vs 8.68 ± 0.47 mmol/L, P < 0.01), HOMA-IR (8.26 ± 2.50, 7.44 ± 1.23 vs 12.66 ± 1.44, P < 0.01) and serum androgen (0.09 ± 0.03, 0.09 ± 0.03 vs 0.53 ± 0.41 ng/ml, P < 0.01) and the expressions of AMPKα and SIRT11 were increased progressively (P < 0.05).

CONCLUSIONS

Both metformin and exenatide can improve the reproductive and endocrine functions of rats with PCOS via the AMPKα-SIRT1 pathway, which may be the molecular mechanism for IR in PCOS and could possibly serve as a therapeutic target.

Association between body mass index and surgical menopausal symptoms in patients with early stage endometrial cancer

OBJECTIVES

Premenopausal women may undergo surgical menopause after staging for their endometrial cancer. Our aim was to determine the association between body mass index (BMI) and surgical menopausal symptoms.

METHODS

We report a retrospective review of endometrial cancer patients whom underwent menopause secondary to their surgical staging procedure. Symptoms were classified as severe if treatment was prescribed, or mild if treatment was offered, but declined. Univariate analysis was performed with ANOVA and Chi-square tests as appropriate. Relative risks (RR) were generated from Poisson regression models.

RESULTS

We identified 166 patients in whom the BMI (kg/m²) distribution was as follows: 33 (19.9%) had BMI <30, 49 (29.5%) had BMI 30-39.9, 50 (30.1%) had BMI 40-49.9, and 34 (20.5%) had BMI ≥50. There were no differences in race, age, or adjuvant treatment among the groups. Overall, 65 (39.2%) women reported symptoms of surgical menopause, including 19 (11.4%) mild and 46 (27.7%) severe. Symptom type did not differ by BMI; however, the prevalence of severe menopausal symptoms decreased with increasing BMI: <30 (45.5%), 30-39.9 (30.6%), 40-49.9 (22%), and ≥ 50 (14.7%); P = 0.002. Multivariate analysis confirmed that symptom prevalence decreased with increasing BMI. Compared to women with a BMI of <30, those with a BMI 40-49.9 (RR = 0.39, 95% CI: 0.17-0.87) or ≥ 50 (RR = 0.24, 95% CI: 0.08-0.70) were significantly less likely to experience menopausal symptoms.

CONCLUSIONS

Women younger than 50 with BMI >40 and stage I endometrial cancer are significantly less likely than women with BMI <30 to experience menopausal symptoms after oophorectomy. This information may assist in peri-operative counseling.

Maternal polycystic ovarian syndrome and early offspring development

STUDY QUESTION

Is maternal polycystic ovarian syndrome (PCOS) associated with developmental delays in offspring?

SUMMARY ANSWER

Offspring of mothers with PCOS were at higher risk of failure on the Ages and Stages Questionnaire (ASQ).

WHAT IS KNOWN ALREADY

There is growing evidence that offspring of mothers with PCOS may be at higher risk for developmental disorders due to potential exposure to hyperandrogenism and insulin resistance. Few studies exist regarding maternal PCOS and early childhood development in the USA.

STUDY DESIGN, SIZE, DURATION

The Upstate KIDS Study is a population-based prospective cohort study of infants born between 2008 and 2010 in New York State (excluding New York City), originally designed to study-and finding no impact of-infertility treatment exposure on child development. Children were followed up to 36 months of age. In all, 4453 mothers completed one or more developmental screening instruments for 5388 children (35.5% twins) up to 36 months of age.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In our study, 458 mothers (10.3%) reported a healthcare provider's diagnosis of PCOS, as well as the related treatment received, on the baseline study questionnaire. Parents completed the ASQ on their child's development at 4, 8, 12, 18, 24, 30 and 36 months of age to assess fine motor, gross motor, communication, personal-social functioning and problem-solving cognitive domains. We used generalized linear mixed models to estimate odds ratios (OR) between PCOS diagnosis and failures in the ASQ adjusted for maternal age, race, BMI, education, marital status, smoking, alcohol consumption, diabetes, insurance and plurality.

MAIN RESULTS AND THE ROLE OF CHANCE

Diagnosis of PCOS was associated with increased risk of the offspring failing the fine motor domain (adjusted odds ratio (aOR) = 1.77; 95% CI: 1.09, 2.89), largely driven by higher risk in female singletons (aOR = 2.23; 1.16, 4.29). Twins of mothers with PCOS had higher risk of failing the communication (aOR = 1.94; 1.19, 3.18) and personal-social functioning (aOR = 1.76; 1.12, 2.77) domains compared to twins born to mothers without PCOS. Compared to offspring of women without PCOS, offspring of women who reported receiving no treatment for their PCOS had a stronger association with failing the ASQ (aOR = 1.68; 0.95, 2.75) than the association among offspring of women who reported PCOS treatment (aOR = 1.16; 0.79, 1.73).

LIMITATIONS, REASONS FOR CAUTION

Further study is needed to confirm the role of maternal PCOS in early offspring development with provider-validated diagnosis of PCOS.

WIDER IMPLICATIONS OF THE FINDINGS

If confirmed, these findings suggest that offspring of women with PCOS may be at increased risk for developmental delay.

STUDY FUNDING/COMPETING INTEREST(S)

Supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD; contracts HHSN275201200005C, #HHSN267200700019C). Authors have no competing interests to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

Maternal Polycystic Ovary Syndrome and Risk for Attention-Deficit/Hyperactivity Disorder in the Offspring

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is the most common childhood neurodevelopmental disorder, and boys are two to three times more likely to develop ADHD. Maternal polycystic ovary syndrome (PCOS), a common metabolic disorder associated with excess circulating androgens, has been associated with increased risk for autism spectrum disorder in the offspring. In this study, we aimed to investigate whether maternal PCOS increases the risk for ADHD in the offspring.

METHODS

We conducted a matched case-control study using health and population data registers for all children born in Sweden from 1984 to 2008. Maternal PCOS was defined by ICD-coded register diagnosis. The outcome of ADHD was defined as an ICD-coded register diagnosis of ADHD and/or registered prescription of medications to treat ADHD. A total of 58,912 ADHD cases (68.8% male) were identified and matched to 499,998 unaffected controls by sex and birth month and year.

RESULTS

Maternal PCOS increased the odds of offspring ADHD by 42% after adjustment for confounders (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.26-1.58). Exclusion of ADHD cases with comorbid autism spectrum disorder attenuated but did not explain the relationship (OR, 1.34; 95% CI, 1.18-1.52). The risk was somewhat elevated for ADHD with comorbid autism spectrum disorder (OR, 1.76; 95% CI, 1.37-2.26). The risk for ADHD was higher among obese mothers with PCOS (OR, 1.68; 95% CI, 1.31-2.17) and was highest among obese mothers with PCOS and other features of metabolic syndrome (OR, 2.59; 95% CI, 1.02-6.58).

CONCLUSIONS

This study provides evidence that maternal PCOS may subtly influence the neurodevelopment of the offspring, resulting in increased risk for neurodevelopmental disorders such as ADHD.

Risks Factors and Treatment Use Related to Infertility and Impaired Fecundity Among Reproductive-Aged Women

INTRODUCTION

Population-level data on infertility and impaired fecundity are sparse. We explored the use of self-reported information provided by reproductive-aged women participating in the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System (BRFSS).

MATERIALS AND METHODS

Three out of 12 questions on reproductive history, family planning, and infertility that seven states included in the 2013 BRFSS were used for this study. In addition to descriptive statistics, we used multinomial logistic regression to identify factors associated with ever experiencing infertility only, difficulty staying pregnant only, and neither infertility nor difficulty staying pregnant. We also explored the association between healthcare coverage and type of treatment received among women ever experiencing infertility only or difficulty staying pregnant only.

RESULTS

Compared with women reporting having never experienced either infertility or difficulty staying pregnant, women who reported ever experiencing difficulty staying pregnant only were significantly more likely to report a history of depressive disorders and smoking (adjusted odds ratio [aOR] = 1.69, 95% confidence interval [CI] = 1.07-2.68 and aOR = 1.98, 95% CI = 1.22-3.20, respectively). Women who ever experienced infertility only were also more likely to report a history of depressive disorders (aOR = 2.02, 95% CI = 1.14-3.59), but less likely to report healthcare coverage (aOR = 0.26, 95% CI = 0.14-0.46). Only 18.9% (95% CI = 11.4-29.9) of women who ever experienced difficulty staying pregnant only reported seeking infertility treatment compared with 49.6% (95% CI = 34.9-64.4) of women who ever experienced infertility only.

CONCLUSIONS

Ongoing public health surveillance systems of state-specific self-reported data, such as BRFSS, provide the opportunity to explore preventable risk factors and treatment use related to infertility and impaired fecundity.

Cytochrome P450 2C19 polymorphisms and valproic acid-induced weight gain

OBJECTIVES

Cytochrome P450 (CYP) 2C19 plays a role in the biotransformation of clinically relevant drugs as well as endogenous compounds, including sex hormones, which are known to be modulators of food intake and energy balance in humans. We attempted to investigate the influence of CYP2C19 polymorphisms on valproic acid (VPA)-induced weight gain.

MATERIALS AND METHODS

This retrospective longitudinal study included 85 VPA-treated and 93 carbamazepine (CBZ)-treated (as a reference) young patients with epilepsy. The body mass index (BMI) gap between the patient's BMI and the cutoff value for being overweight was calculated in each patient during the follow-up period. The longitudinal associations of the CYP2C19 genotype with the BMI gap and risk for becoming overweight during VPA or CBZ therapy were examined retrospectively using the generalized estimating equations approach and the Kaplan-Meier method.

RESULTS

During the follow-up period, the values of the BMI gap were significantly greater (P = 0.002 or P = 0.005) and the cumulative incidence of becoming overweight tended to be higher (P = 0.032) in the VPA-treated female patients with one or two loss-of-function CYP2C19 alleles than in the females without the loss-of-function CYP2C19 alleles. No associations were observed among the VPA-treated male patients and CBZ-treated male and female patients (P > 0.05).

CONCLUSIONS

This is the first report to show a relationship between the CYP2C19 polymorphism and VPA-induced weight gain in female patients with epilepsy. Further investigations are needed to verify these findings.

Effects of aerobic exercise on plasma lipoproteins in overweight and obese women with polycystic ovary syndrome

Background:

Polycystic ovary syndrome (PCOS) is one of the most frequent endocrine disorders. The PCOS manifest by hyperandrogenism, hypertension and cholesterol and lipoprotein improper profiles. Changing the life style, e.g. increasing physical activities is the first approach in controlling PCOS.

Materials and Methods:

Twenty-four women affected by polycystic ovary syndrome (PCOS) after medical screening were divided in to two groups: Experimental group (n = 12) and control group (n = 12), with the average age, weight, height, BMI and WHR of 26.87 ± 4.43 years, 75.71 ± 10.65 kg. 159.29 ± 6.44 cm, 29.86 ± 3.22 kg/m² and 91.75 ± 5.86 respectively. First the body composition such as BMI, WHR, percent body fat, weight and body fat mass were measured. In fasting blood samples the level of HDL, LDL, VLDL, triglyceride and cholesterol were measured. Then the experiment group underwent the effect of an aerobic exercise program. After 12 weeks, all the measured variables before intervention the test were re-measured. Correlated t-test was used for comparing the two groups before and after intervention the test and independent t-test was used for comparing the two groups (P < 0.05).

Results:

The results showed that after 12 weeks of exercise, BMI, WHR, fat rate, weight and fat mass and triglyceride had significant reduction and HDL had significant increase. But no significant changes happened in LDL, VLDL, and cholesterol levels.

Conclusion:

Reducing the weight by aerobic exercise in obese women and affected by PCOS can correct lipoprotein profile and improving health.

Labisia pumila Upregulates Peroxisome Proliferator-Activated Receptor Gamma Expression in Rat Adipose Tissues and 3T3-L1 Adipocytes

Peroxisome proliferator-activated receptor gamma (PPARgamma) is a ligand-activated transcription factor that regulates lipid and glucose metabolism. We investigated the effects of Labisia pumila (LP) standardized water extract on PPARgamma transcriptional activity in adipocytes in vitro and in vivo. We used a rat model of dihydrotestosterone- (DHT-) induced polycystic ovary syndrome (PCOS), a condition characterized by insulin resistance. At 9 weeks of age, the PCOS rats were randomly subdivided into two groups: PCOS-LP (50 mg/kg/day of LP) and PCOS-control (1 mL of deionised water) for 4-5 weeks on the same schedule. Real-time RT-PCR was performed to determine the PPARgamma mRNA levels. LP upregulated PPARgamma mRNA level by 40% in the PCOS rats. Western blot analysis further demonstrated the increased PPARgamma protein levels in parallel with upregulation in mRNA. These observations were further proven by adipocytes culture. Differentiated 3T3-L1 adipocytes were treated with final concentration of 100  μ g/mL LP and compared to untreated control and 10  μ M of rosiglitazone (in type of thiazolidinediones). LP increased PPARgamma expressions at both mRNA and protein levels and enhanced the effect of glucose uptake in the insulin-resistant cells. The data suggest that LP may ameliorate insulin resistance in adipocytes via the upregulation of PPARgamma pathway.

Antidepressants for polycystic ovary syndrome

BACKGROUND

The prevalence of depression in women with polycystic ovary syndrome (PCOS) is high; one study has shown it to be four times that of women without PCOS. Therefore, systematic evaluation of the effectiveness and safety of antidepressants for women with PCOS is important.

OBJECTIVES

To evaluate the effectiveness and safety of antidepressants in treating depression and other symptoms in women with PCOS.

SEARCH METHODS

We searched the following databases from inception to June 2012: the Cochrane Menstrual Disorders and Subfertility Group Trials Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PsycINFO and Chinese National Knowledge Infrastructure, the metaRegister of Controlled Trials (controlled-trials.com), the National Institute of Health Clinical Trials register (clinicaltrials.gov) and the World Health Organization International Trials Registry Platform search portal (www.who.int/trialsearch/Default.aspx).

SELECTION CRITERIA

Only randomised controlled trials (RCTs) studying the effectiveness and safety of antidepressants for women with PCOS were included in this review.

DATA COLLECTION AND ANALYSIS

The methodological quality of the trials was assessed independently by two review authors, in parallel with data extraction. The risk of bias in the included study was assessed in six domains: 1. sequence generation; 2. allocation concealment; 3. blinding of participants, personnel and outcome assessors; 4. completeness of outcome data; 5. selective outcome reporting; 6. other potential sources of bias.

MAIN RESULTS

We found no studies reporting any of our primary review outcomes (depression and allied mood disorder scores, quality of life and adverse events). Only one study with 16 women was eligible for inclusion. This study compared sibutramine versus fluoxetine in women with PCOS, and reported only endocrine and metabolic outcomes. It was unclear whether the participants had psychological problems at baseline. No significant difference was found between the groups for any of the measured outcomes.

AUTHORS' CONCLUSIONS

There is no evidence on the effectiveness and safety of antidepressants in treating depression and other symptoms in women with PCOS.

Uterine morphology and peristalsis in women with polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is associated with chronic oligo-anovulation and high circulating sex hormone levels. Women with PCOS have an increased risk of developing endometrial cancer. In anovulatory women with PCOS a positive relationship between endometrial thickness and endometrial hyperplasia has been observed. Uterine peristalsis, which has been suggested to be of importance for female fertility, has not previously been studied in PCOS.

PURPOSE

To assess whether women with PCOS have altered endometrial thickness, uterine wall morphology, and peristalsis.

MATERIAL AND METHODS

In this prospective case-control study 55 women with PCOS (mean age, 29.5 years ± 4.5 SD) and 28 controls (27.6 ± 3.2) were examined using magnetic resonance imaging (MRI), assessing thickness of endometrium, junctional zone (JZ), and myometrium, and evaluating the occurrence, frequency (waves/min), strength (amplitude), pattern, and direction of peristalsis. Uterine morphology was also assessed by transvaginal ultrasonography (TVUS).

RESULTS

The endometrium was thinner in PCOS with oligo-amenorrhea compared to controls, also after adjustments for age and BMI (adjusted P = 0.043). There was no difference in thickness of the JZ or the myometrium in cases versus controls. Uterine peristalsis was less commonly observed in women with PCOS than in controls (adjusted P = 0.014).

CONCLUSION

There were no differences in myometrial morphology between PCOS and controls, but the endometrium was thinner in PCOS with oligo-amenorrhea. Based on cine MRI, uterine peristalsis was less common in PCOS than in controls.

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.

Effect of maternal obesity on estrous cyclicity, embryo development and blastocyst gene expression in a mouse model

STUDY QUESTION

Does maternal obesity affect estrous cyclicity, embryo development and blastocyst gene expression in mice?

SUMMARY ANSWER

Maternal obesity alters estrous cyclicity and causes the down-regulation of two key metabolite receptors (Slc2a1 and Ldlr) in blastocysts recovered from diet-induced obese females, but embryo development is not affected.

WHAT IS KNOWN ALREADY

Maternal obesity reduces fertility because of effects in the periconception period, but its negative influence is on estrous cyclicity, oocyte quality or embryo development.

STUDY DESIGN, SIZE AND DURATION

This was a randomized study based on a mouse model for obesity. Twenty-one outbred NIH Swiss mice were used and obesity was induced by a diet high in fat administered for 12 weeks prior to breeding to control males.

MATERIAL, SETTING AND METHODS

Females were fed either a control diet (C, n = 9) or a diet high in fat [diet-induced obesity (DiO), n = 12] for 12 weeks, and were then co-housed with fertile males. Mice that failed to breed during 20 consecutive days were considered infertile. Control and diet-induced obese females that demonstrated vaginal plugs were euthanized 3.5 days after mating, blood was sampled for glucose and hormone measurements, corpora lutea counted and embryos recovered; the relative mRNA abundance of 11 candidate genes was determined in blastocysts by qPCR.

MAIN RESULTS AND THE ROLE OF CHANCE

Five DiO females failed to breed and displayed anovulatory ovaries (DiOI), whereas the other seven DiO females (DiOF) could breed, albeit over an extended period compared with controls. DiOF weighed significantly less than DiOI. Both groups had elevated serum insulin compared with C, although blood glucose level was only significantly higher than that in controls in the infertile DiOI group. Adiponectin was lower in the DiOI and leptin higher in both the DiOI and DiOF mice than in C. DiOF ovulated the same number of oocytes as C, and embryo development to blastocyst was normal. The expression of genes encoding metabolic hormone receptors (Insr, Igf1r, Igf2r, Adipor1, Adipor2 and Lepr) and key metabolic enzymes (Gapdh, Cpt1a and Sod2) did not differ between DiOF and C blastocysts, but that of metabolite receptors (Slc2a1 and Ldr) was down-regulated in DiOF. To limit the role of chance, the experiments were conducted in a defined laboratory setting with the proper controls, and the animals were randomly assigned to each experimental group. Moreover, a P-value of < 0.05 was chosen to determine whether the differences observed between the groups were statistically significant.

LIMITATIONS AND REASONS FOR CAUTION

The results obtained may not fully extrapolate to humans. Also, as follicular activity was not monitored while breeding, so the extended breeding period for DiOF group might be explained by behavioral abnormalities occurring in normal cycling animals.

WIDER IMPLICATIONS OF THE FINDINGS

DiO alters the estrous cycle in the mouse model and demonstrates a role of obesity in infertility. The data also suggest that in an outbred, genetically diverse population, such as the human, individual susceptibility to obesity and associated infertility induced by diet exists. The apparently normal development to blastocyst observed in fertile, obese females suggests that preimplantation embryos can resist potentially adverse outcomes caused by an oversupply of fatty acids and glucose under in vivo conditions. This metabolic plasticity may, in part, be due to an ability to down-regulate metabolite transporters, thereby preventing excessive nutrient uptake.

STUDY FUNDING/COMPETING INTEREST(S)

The research was supported by funds from the University of Missouri, grants from the National Institutes of Health and by a fellowship from the Lalor Foundation. There were no competing interests.

TRIAL REGISTRATION NUMBER

Not applicable.

Sex hormones, appetite and eating behaviour in women

Sex hormones play essential roles in the regulation of appetite, eating behaviour and energy metabolism and have been implicated in several major clinical disorders in women. Estrogen inhibits food intake, whereas progesterone and testosterone may stimulate appetite. This review describes recent findings concerning interactions between sex hormones and neuroendocrinological mechanisms in the control of appetite and eating in women. Furthermore, we are gaining insights into the roles played by sex hormones in the development of eating disorders and obesity. For instance, androgens may promote bulimia by stimulating appetite and reducing impulse control, a proposal supported by the observation that antiandrogenic treatment attenuates bulimic behaviour. Androgens are also involved in the pathophysiology of abdominal obesity in women. On the other hand, hormone replacement therapy with estrogen counteracts the weight gain and accumulation of abdominal fat associated with the menopausal transition. In conclusion, sex hormones and/or agents that exhibit similar activities may provide novel strategies for the treatment of eating disorders and android obesity, two of the most serious health problems for women today.

Pioglitazone reduces central obesity in polycystic ovary syndrome women

OBJECTIVE

Based on the role of polycystic ovary syndrome as a cause of metabolic syndrome with chronic anovulation, obesity, hyperinsulinemia and hyperandrogenism, development of effective treatment for its obesity is a priority.

MATERIALS/METHODS

We designed a study, involving 52 patients of 19-36 years of age, to test the pioglitazone in women with polycystic ovary syndrome. Subjects were assigned to receive pioglitazone for 3 months. Body mass index, waist circumference and hip circumference were measured before and after 3 months of pioglitazone prescription.

RESULTS

Fifty patients completed the study. No complication reported during the study period. Waist circumference, hip circumference and waist to height ratio decreased significantly. Body weight and body mass index increased. No significant improvement was seen in acne, acanthosis, hirsutism and menstrual irregularities.

CONCLUSION

Pioglitazone has beneficial effects on central obesity of the patients with polycystic ovary syndrome but other clinical consequences of the syndrome may not improve with the drug.

Sex steroid hormones and reproductive disorders: impact on women's health

The role of sex steroid hormones in reproductive function in women is well established. However, in the last two decades it has been shown that receptors for estrogens, progesterone and androgens are expressed in non reproductive tissue /organs (bone, brain, cardiovascular system) playing a role in their function. Therefore, it is critical to evaluate the impact of sex steroid hormones in the pathophysiology of some diseases (osteoporosis, Alzheimer, atherosclerosis). In particular, women with primary ovarian insufficiency, polycystic ovary syndrome, endometriosis and climacteric syndrome may have more health problems and therefore an hormonal treatment may be crucial for these women.

Randomized comparison of the influence of dietary management and/or physical exercise on ovarian function and metabolic parameters in overweight women with polycystic ovary syndrome

OBJECTIVE

To compare the influence of dietary management and/or physical exercise on ovarian function and metabolic variables in women with polycystic ovary syndrome (PCOS).

DESIGN

Randomized 4-month trial with three interventions and a long-term follow-up.

SETTING

Women's health clinical research unit at a university hospital.

PATIENT(S)

Fifty-seven overweight/obese women with PCOS.

INTERVENTION(S)

Dietary management, physical exercise, or both, using programs individually adapted and supervised by a dietician and/or a physical therapist.

MAIN OUTCOME MEASURE(S)

Ovarian function, endocrinologic, and metabolic status and body composition.

RESULT(S)

On average, body mass index was reduced 6% by the dietary management, 3% by the exercise, and 5% by the combined interventions. Lower body fat and lean body mass were significantly decreased in the dietary groups, whereas upper body fat was lowered and lean body mass maintained by exercise alone. The menstrual pattern was significantly improved in 69% and ovulation confirmed in 34% of the patients, with no differences among the groups. The strongest predictor of resumed ovulation was a high serum level of insulin-like growth factor-binding protein 1 after the intervention. Follow-up of one-half of the patients for a median of 2.8 years revealed sustained weight reduction and improvement in menstrual pattern.

CONCLUSION(S)

Dietary management and exercise, alone or in combination, are equally effective in improving reproductive function in overweight/obese women with PCOS. The underlying mechanisms appear to involve enhanced insulin sensitivity. Supportive individualized programs for lifestyle change could exert long-term beneficial effects.

Nonmalignant diseases and treatments associated with primary ovarian failure: an expanded role for fertility preservation

Cancer treatments can be detrimental to fertility; recent literature has focused on the efforts of fertility preservation for this patient population. It should be recognized, however, that several nonmalignant medical conditions and therapeutic interventions could be similarly hazardous to fertility. Some of these nonmalignant diseases and their treatments that can adversely impact the reproductive axis are gastrointestinal diseases, rheumatologic disorders, nonmalignant hematologic conditions, neurologic disorders, renal disorders, gynecologic conditions, and metabolic diseases. Their negative effects on reproductive function are only now being appreciated and include impaired ovarian function, endocrine function, or sexual function and inability to carry a pregnancy to term. Complications and comorbidities associated with certain diseases may limit the success of established fertility preservation options. Recent advances in fertility preservation techniques may provide these patients with new options for childbearing. Here, we review several fertility-threatening conditions and treatments, describe current established and experimental fertility preservation options, and present three initiatives that may help minimize the adverse reproductive effects of these medical conditions and treatments by raising awareness of the issues and options: (1) increase awareness among practitioners about the reproductive consequences of specific diseases and treatments, (2) facilitate referral of patients to fertility-sparing or restorative programs, and (3) provide patient education about the risk of infertility at the time of diagnosis before initiation of treatment.

Insulin and hyperandrogenism in women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a very common endocrine disorder characterized by chronic anovulation, clinical and/or biochemical hyperandrogenism, and/or polycystic ovaries. But most experts consider that hyperandrogenism is the main characteristic of PCOS. Several theories propose different mechanisms to explain PCOS manifestations: (1) a primary enzymatic default in the ovarian and/or adrenal steroidogenesis; (2) an impairment in gonadotropin releasing hormone (GnRH) secretion that promotes luteal hormone (LH) secretion; or (3) alterations in insulin actions that lead to insulin resistance with compensatory hyperinsulinemia. However, in the past 20 years there has been growing evidence supporting that defects in insulin actions or in the insulin signalling pathways are central in the pathogenesis of the syndrome. Indeed, most women with PCOS are metabolically insulin resistant, in part due to genetic predisposition and in part secondary to obesity. But some women with typical PCOS do not display insulin resistance, which supports the hypothesis of a genetic predisposition specific to PCOS that would be revealed by the development of insulin resistance and compensatory hyperinsulinemia in most, but not all, women with PCOS. However, these hypotheses are not yet appropriately confirmed, and more research is still needed to unravel the true pathogenesis underlying this syndrome. The present review thus aims at discussing new concepts and findings regarding insulin actions in PCOS women and how it is related to hyperandrogenemia.

Genetic basis of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is associated with obesity and manifests with reproductive, hyperandrogenic and metabolic features. Although the etiology of PCOS is complex and incompletely understood, genetics plays an important role (heritability: ∼70%). Potential problems with studying the genetics of PCOS include the heterogeneity of the condition and associated sub-fertility. A candidate gene approach has been used in over 70 published studies on PCOS, most of which have been inadequately powered to detect a statistically meaningful association. Furthermore, these studies often fail to replicate prior published studies on the same candidate gene in different populations. The first genome-sequence variant (identified from a genome-wide association study in subjects with Type 2 diabetes mellitus) to be studied in PCOS (FTO gene) has been shown by our group to associate with susceptibility for the development of PCOS. This is the first genetic corroboration of a link between PCOS and obesity. Future directions include a genome-wide association study in PCOS.