Prevalence of impaired glucose tolerance and diabetes in women with polycystic ovary syndrome

Interlukin-22 improves ovarian function in polycystic ovary syndrome independent of metabolic regulation: a mouse-based experimental study

BACKGROUND

Polycystic ovary syndrome (PCOS) is a reproductive endocrine disorder with multiple metabolic abnormalities. Most PCOS patients have concomitant metabolic syndromes such as insulin resistance and obesity, which often lead to the development of type II diabetes and cardiovascular disease with serious consequences. Current treatment of PCOS with symptomatic treatments such as hormone replacement, which has many side effects. Research on its origin and pathogenesis is urgently needed. Although improving the metabolic status of the body can alleviate reproductive function in some patients, there is still a subset of patients with metabolically normal PCOS that lacks therapeutic tools to address ovarian etiology.

METHODS

The effect of IL-22 on PCOS ovarian function was verified in a non-metabolic PCOS mouse model induced by dehydroepiandrosterone (DHEA) and rosiglitazone, as well as granulosa cell -specific STAT3 knockout (Fshrcre+Stat3f/f) mice (10 groups totally and n = 5 per group). Mice were maintained under controlled temperature and lighting conditions with free access to food and water in a specific pathogen-free (SPF) facility. Secondary follicles separated from Fshrcre+Stat3f/f mice were cultured in vitro with DHEA to mimic the hyperandrogenic environment in PCOS ovaries (4 groups and n = 7 per group) and then were treated with IL-22 to investigate the specific role of IL-22 on ovarian function.

RESULTS

We developed a non-metabolic mice model with rosiglitazone superimposed on DHEA. This model has normal metabolic function as evidenced by normal glucose tolerance without insulin resistance and PCOS-like ovarian function as evidenced by irregular estrous cycle, polycystic ovarian morphology (PCOM), abnormalities in sex hormone level. Supplementation with IL-22 improved these ovarian functions in non-metabolic PCOS mice. Application of DHEA in an in vitro follicular culture system to simulate PCOS follicular developmental block and ovulation impairment. Follicles from Fshrcre+Stat3f/f did not show improvement in POCS follicle development with the addition of IL-22. In DHEA-induced PCOS mice, selective ablation of STAT3 in granulosa cells significantly reversed the ameliorative effect of IL-22 on ovarian function.

CONCLUSION

IL-22 can improve non-metabolic PCOS mice ovarian function. Granulosa cells deficient in STAT3 reverses the role of IL-22 in alleviating ovary dysfunction in non-metabolic PCOS mice.

Understanding metabolic patterns in polycystic ovary syndrome: Comparing lean and obese women at a family medicine clinic

Background

Polycystic ovary syndrome (PCOS) is a heterogeneous disorder and various phenotypes have been described. While most women with PCOS are obese, women who are lean also suffer from PCOS. Metabolic derangements often accompany this syndrome. Family physicians, being the first point of contact in the healthcare system, play a vital role in the early diagnosis and management of this condition through diet and lifestyle modifications. The present study was conducted at the Diet and Lifestyle Diseases Management Division of a Family Medicine Clinic.

Methods

We conducted a retrospective analysis of the correlation between body mass index (BMI) and metabolic parameters in women diagnosed with PCOS. The case records of women with PCOS, diagnosed as per modified Rotterdam criteria and who attended the outpatient clinic from January 2020 to December 2022, were chosen. Data on BMI and metabolic parameters were retrieved and statistically analyzed.

Results

Upon analysis of 51 case records, 25.49% of women were in the lean group and 74.51% were overweight or obese. Triglycerides/HDL ratio (1.91 ± 0.47 vs 3.97 ± 5.89) and Vitamin D levels (Median 14.12 vs 16.10 ng/ml) were abnormal in both the obese and the lean women groups. However, there was no significant difference between the groups. Other metabolic parameters were within normal ranges.

Conclusion

The present study indicates that metabolic derangements are associated with PCOS, irrespective of BMI. More robust studies in larger population samples are needed to elucidate the role of metabolic derangements and mainly insulin resistance in the pathophysiology of PCOS and its different phenotypes.

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.

Diagnosis, Management, and Associated Comorbidities of Polycystic Ovary Syndrome: A Narrative Review

Polycystic ovary syndrome (PCOS) is the most widespread and diverse endocrine health issue affecting many adolescent-aged women globally. It is the most frequent illness in reproductive-aged women. According to the Rotterdam criteria, two out of three elements: oligo-anovulation, hyperandrogenism, and polycystic ovaries (defined as having at least one ovary with an ovarian volume > 10 mL and/or 12 or more follicles measuring 2 to 9 mm in diameter) are present in PCOS. Conducted studies show epigenetics, environmental toxins, stress, and food as external factors as well as inflammation, oxidative stress, hyperandrogenism, insulin resistance, and obesity as internal factors related to PCOS. Although a portion of the mechanism associated with the occurrence of PCOS has been identified, there is still much to learn about the exact etiology and pathophysiology. The main debate covers the best ways to diagnose and treat this disease in adolescents. Early detection is crucial because of the disease's long-term effects on metabolic and reproductive health. Before beginning treatment for this group of young women, a firm diagnosis may not be made. Various criteria are used to diagnose PCOS patients. A person with PCOS has a chance of developing several comorbidities and health effects. PCOS patients are at risk of cardiac diseases, metabolic syndromes, resistance to insulin, infertility, and many more. There are numerous medications available for PCOS therapy that need a methodical approach. However, changing one's lifestyle should come first. There is proof in the support of the usage of several medications for PCOS, including mucolytic agents, Hydroxymethylglutaryl-CoA (HMG-CoA) reductase inhibitors, gliptins (oral diabetic medication), glucose-like peptide-1 receptor analogues, glitazones, and sodium-glucose cotransporter protein-2 (SGLT2) inhibitors. A comprehensive, systematic, schematic therapy approach is crucial for the treatment of PCOS.

Association of Fat Mass and Skeletal Muscle Mass with Cardiometabolic Risk Varied in Distinct PCOS Subtypes: A Propensity Score-Matched Case-Control Study

(1) Background: polycystic ovarian syndrome (PCOS) is a heterogeneous syndrome with a constellation of cardiometabolic risk factors. We aimed to investigate if the association of body fat mass (BFM) and skeletal muscle mass (SMM) with cardiometabolic risk differed in PCOS subtypes. (2) Methods: 401 participants (245 PCOS and 156 controls) were assessed for anthropometric measurements, glucose-lipid profiles, reproductive hormones and body composition with propensity score-matched (PSM) analysis. The association of the cardiometabolic risk score (z score, calculated based on levels of obesity and gluco-lipid measurements) with BFM (estimated by trunk BFM/Height2) and SMM (estimated by SMM/Height2) was calculated. (3) Results: Trunk BFM/Height2 and SMM/Height2 were both positively associated with cardiometabolic risk in PCOS (trunk BFM/Height2, OR 2.33, 95% CI 1.49-3.65; SMM/Height2, OR 2.05, 95% CI 1.12-3.76). SMM/Height2 associated with increased cardiometabolic risk in obese PCOS (BMI ≥ 28 kg/m2, OR 2.27, 95% CI 1.15-4.47). For those with lower BMI (<28 kg/m2), trunk BFM/Height2 showed a higher OR in both groups (PCOS, OR 2.12, 95% CI 1.06-4.24; control 2.04, 95% CI 1.04-4.02). Moreover, distinct associations among BMI-stratified groups were validated in hierarchical clustering identifying metabolic and reproductive clusters. (4) Conclusions: BFM and SMM are synergistically associated with higher cardiometabolic risk in PCOS women. Although BFM contributes to increased cardiometabolic risk, SMM also plays a primary role in obese PCOS. Our results highlight the importance of body composition in the management of PCOS.

Bridging the Gap: Integrating Awareness of Polycystic Ovary Syndrome Into Mental Health Practice

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder among women of reproductive age. Individuals with PCOS report reduced quality of life compared with those without PCOS, with possible contributing factors including infertility, hirsutism, irregular menses, and weight gain. Recent literature also supports increased associations between PCOS and co-occurring psychiatric conditions, particularly depression, anxiety, bipolar disorder, and eating disorders. It is concerning that a higher prevalence of suicidal ideation has been observed in individuals with PCOS. Given the high rates of psychiatric burden among those with PCOS, psychiatric care providers are well suited to be on the front lines of screening for psychiatric symptoms as well as initiating treatment. Current interventions include lifestyle changes (improving exercise and nutrition), pharmacological treatments (e.g., insulin-sensitizing agents, oral contraceptives, and psychotropic drugs), and psychotherapeutic interventions (e.g., cognitive-behavioral therapy and mindfulness-based therapy). This review provides an overview of recent research on the prevalence of comorbid psychiatric conditions, a foundation in PCOS-specific symptom screening and diagnosis, and an overview of treatments for psychiatric symptoms among individuals with PCOS.

Sex differences in the association between stroke risk factors and pre-clinical predictors of stroke in the childhood determinants of Adult Health study

BACKGROUND AND AIMS

It is unclear why blood pressure (BP), metabolic markers and smoking increase stroke incidence in women more than men. We examined these associations with carotid artery structure and function in a prospective cohort study.

METHODS

Participants in the Australian Childhood Determinants of Adult Health study at ages 26-36 years (2004-06) were followed-up at 39-49 years (2014-19). Baseline risk factors included smoking, fasting glucose, insulin, systolic and diastolic BP. Carotid artery plaques, intima-media thickness [IMT], lumen diameter and carotid distensibility [CD] were assessed at follow up. Log binomial and linear regression with risk factor × sex interactions predicted carotid measures. Sex-stratified models adjusting for confounders were fitted when significant interactions were identified.

RESULTS

Among 779 participants (50% women), there were significant risk factor × sex interactions with baseline smoking, systolic BP and glucose associated with carotid measures in women only. Current smoking was associated with incidence of plaques (RRunadjusted 1.97 95% CI 1.4, 3.39), which reduced when adjusted for sociodemographics, depression, and diet (RRadjusted 1.82 95% CI 0.90, 3.66). Greater systolic BP was associated with lower CD adjusted for sociodemographics (βadjusted -0.166 95% CI -0.233, -0.098) and hypertension with greater lumen diameter (βunadjusted 0.131 95% CI 0.037, 0.225), which decreased when adjusted for sociodemographics, body composition and insulin (βadjusted 0.063 95% CI -0.052, 0.178). Greater glucose (βunadjusted -0.212 95% CI -0.397, -0.028) was associated with lower CD, which decreased when adjusted for sociodemographics, BP, depression and polycystic ovary syndrome (βadjusted -0.023 95% CI -0.249, 0.201).

CONCLUSIONS

Smoking, SBP and glucose affect carotid structure and function more in women than men with some of this risk due to co-occurring risk factors.

Serum metabolomics probes the molecular mechanism of action of acupuncture on metabolic pathways related to glucose metabolism in patients with polycystic ovary syndrome-related obesity

Polycystic ovary syndrome (PCOS) is a common endocrine syndrome, and obesity is the most common clinical manifestation. Acupuncture is effective in treating PCOS, but the differences in the biological mechanisms of acupuncture therapy and Western medicine treatment have not been determined. Thus, the purpose of this study was to find glucose metabolism-related pathways in acupuncture treatment and differentiate them from Western medical treatment. Sixty patients with PCOS-related obesity were randomly distributed into three groups: patients receiving (1) acupuncture treatment alone, (2) conventional Western medicine treatment, and (3) acupuncture combined with Western medicine treatment. A targeted metabolomics approach was used to identify small molecules and metabolites related to glucose metabolism in the serum of each group, and ultra-high-performance liquid chromatography-tandem mass spectrometry was used to analyze different metabolic fractions. The results showed acupuncture treatment modulates the activity of citric and succinic acids in the tricarboxylic acid cycle, regulates glycolytic and gluconeogenesis pathways, and improves the levels of sex hormones and energy metabolism. The intervention effects on the metabolic pathways were different between patients receiving combination therapy and patients receiving acupuncture therapy alone, suggesting that the dominant modulatory effect of Western drugs may largely conceal the efficacy of acupuncture intervention.

Comparative Assessment of Periodontal Status in Subjects with and without Polycystic Ovary Syndrome and its Correlation with Body Mass Index: A Cross-Sectional Study

New avenues for research have opened, which assess the influence of systemic disease on periodontium and vice versa. To find the correlation between polycystic ovary syndrome (PCOS) and periodontium by assessing clinical parameters [plaque index (PI), probing depth, periodontal disease index (PDI)] and the anthropological parameter [body mass index (BMI)] and to find the correlation between body mass index and periodontal disease index in subjects with and without PCOS. Sixty females comprising 30 with PCOS and 30 without PCOS were selected. Clinical, anthropological, and radiological assessment was done. Double blinding was incorporated. There was a statistically highly significant difference in mean age, mean PI, and mean PDI (P < 0.001) in PCOS group when compared to those without PCOS group by unpaired t-test for inter-group analysis. A statistically significant difference was found in mean probing depth and mean BMI (P < 0.05) in PCOS group when compared to those without PCOS group by unpaired t-test for inter-group analysis. No statistically significant correlation was found between mean PDI and mean BMI in PCOS and non-PCOS group subjects using Spearman's rank correlation. Women suffering from PCOS may be at a heightened risk for developing periodontal disease as our study re-establishes this association with respect to some periodontal parameters. With such a result, general practitioners/gynecologists can be encouraged to refer cases of PCOS to periodontists for early detection, prevention of periodontal disease, and maintenance of periodontal health.

Women with PCOS who undergo IVF: a comprehensive review of therapeutic strategies for successful outcomes

Polycystic ovarian syndrome (PCOS) is a widespread syndrome that poses unique challenges and constraints to the field of assisted reproductive technology. This condition is the most common cause of anovulation among infertile couples. Debate exists over the best therapeutic course of action when patients with PCOS proceed to IVF. In this review, we evaluate the best-performing and safest methods of IVF preparation, ovarian stimulation, trigger method for maturation of stimulated egg growth, and planning for embryo transfer. Pre-IVF considerations include being aware of individual AMH and vitamin D levels as well as BMI prior to selecting an ovarian stimulation protocol. Numerous supplements such as myo-inositol complement the benefits of lifestyle change and may enhance IVF performance including oocyte yield and pregnancy rate. Concerning stimulation protocols, antagonist cycles with the judicious use of GnRH agonist trigger, pre-treatment with metformin and vitamin D repletion may help mitigate the accompanied risk of ovarian hyperstimulation syndrome (OHSS). Following ovarian stimulation, PCOS patients typically undergo programmed frozen embryo transfer (FET) cycles which are more conducive for women with irregular cycles, but likely carry a higher risk of hypertensive disorders of pregnancy. However, newer stimulated FET protocols using Letrozole may offer improved outcomes. Overall, patients with PCOS require careful individual tailoring of their IVF cycle to achieve optimal results.

Assessment of Type 2 Diabetes Risk in Young Women with Polycystic Ovary Syndrome

Women with polycystic ovary syndrome (PCOS) are at increased risk for dysglycemia and type 2 diabetes compared to healthy BMI-matched women of reproductive age: robust evidence exists supporting this notion. The presence of altered glycemic status in young women with the syndrome presents a distinct challenge for the clinician for several reasons. Firstly, the reported incidence of this disorder varies among the limited available studies. Furthermore, there is a lack of consensus on the best screening method, which women to screen, at what frequency, and which strategies need to be implemented to reduce the above risk. We provide data regarding the prevalence of dysglycemia in young women suffering from PCOS and the pathophysiological mechanisms underlying the disorder. In addition, we present evidence suggesting universal screening with the oral glucose tolerance test in young women with the syndrome, irrespective of age or BMI status, to identify and manage glycemic abnormalities in a timely manner. Regarding follow-up, oral glucose testing should be carried out at regular intervals if there are initial abnormal findings or predisposing factors. Finally, the efficacy of a well-balanced diet in conjunction with regular exercise and the use of non-pharmacologic agents in this specific population is discussed.

The Potential of SGLT-2 Inhibitors in the Treatment of Polycystic Ovary Syndrome: The Current Status and Future Perspectives

Polycystic ovary syndrome (PCOS) is the most frequent endocrinopathy during women’s reproductive age. PCOS is a heterogeneous disorder featuring specific cardiometabolic properties. The association between the presence of metabolic disorders and PCOS supports the claim that the regulation of glycemic status is very important in these patients. There is a wide range of therapeutic options (including those treating diabetes mellitus type 2) with potential advantages available for the management of PCOS. Sodium–glucose cotransporter type 2 inhibitors (SGLT-2is) improve glucose metabolism, reduce fat tissue, lower blood pressure, reduce oxidative stress and inflammation, and protect the cardiovascular system. Currently, the use of SGLT-2is is not widespread in PCOS therapy, although these drugs represent a promising new therapeutic approach. Therefore, it is necessary to initiate further study in order to determine more effective therapies for PCOS and investigate the effect of SGLT-2is, both as a monotherapy and in combination with other drugs. It is necessary to understand the mechanisms underlying SGLT-2is in PCOS and their effects on long-term complications, especially since the gold standard treatment for PCOS, such as metformin and oral contraceptives, do not have long-term cardioprotective effects. The effects of SGLT-2is seem to involve cardiac protection, while diminishing endocrine and reproductive abnormalities in PCOS. In the current narrative review, we examine the most recent clinical evidence and discuss the potential applications of SGLT-2is for PCOS therapy.

The polycystic ovary syndrome: the first 150 years of study

The communities of reproductive medicine and reproductive sciences have been witness to an enormous acceleration of interest in polycystic ovary syndrome (PCO) since the mid-19th century. Although progress has been increasingly palpable, the fundamentals of the etiology and pathophysiology of PCO remain as elusive as ever. Particularly lacking is a requisite understanding of events at the cellular and molecular levels. As we cross the millennial divide, it appears appropriate that an interim progress report be crafted. This treatise is attempting to meet this objective. What follows traces the chronology of the recorded history of PCO in 4 parts.

Ketogenic diet restores hormonal, apoptotic/proliferative balance and enhances the effect of metformin on a letrozole-induced polycystic ovary model in rats

OBJECTIVE

Polycystic ovaries (PCO) is a hormonal disorder that is a leading cause of infertility. The formation of multiple persistent cysts and hormonal imbalance are hallmarks of PCO. Recent clinical studies reported a beneficial effect of the ketogenic diet (KD; high-fat, low-carbohydrate) on PCO. The aim of this study was to investigate the effect of the KD alone and in combination with metformin on letrozole-induced PCO in female rats.

METHODS

Female rats were grouped into control and PCO (letrozole; 1 mg/kg for 21 days). The PCO group was subdivided into PCO (non-treated), PCO-metformin (300 mg/kg), PCO rats fed with KD only, and PCO rats treated with metformin and fed with KD. All groups continued to receive letrozole during the 21-day treatment period. At the end of the experiment, serum and ovaries were collected for further analysis.

RESULTS

The untreated-PCO rats showed increased testosterone, LH/FSH ratio, and ovary weights. Disturbed apoptosis and proliferation balance were evident as a low caspase-3 activation and proliferating cell nuclear antigen expression and increased TGF-β expression. The KD improved the letrozole-induced effects, which was comparable to the effect of metformin. Combining the KD with metformin treatment additively enhanced the metformin effect.

CONCLUSION

Our results indicate that the KD has a protective role against PCO in rats, especially when combined with metformin. This study reveals a potential therapeutic role of the KD in PCO, which could prompt valuable future clinical applications.

High density lipoprotein-associated proteins in non-obese women with and without polycystic ovary syndrome

Introduction

Dyslipidemia frequently occurs in women with polycystic ovary syndrome (PCOS), but it is unclear whether dyslipidemia is due to obesity and insulin resistance (IR) or is inherent to PCOS. To address this, proteomic analysis of proteins important in lipid metabolism, particularly for high-density lipoprotein cholesterol (HDL-C), was performed in non-obese, non-insulin resistant PCOS women compared to matched controls.

Methods

Weight and aged-matched non-obese subjects with PCOS (n=24) and without IR were compared with control women (n=24). 19 proteins were measured by Somalogic proteomic analysis: alpha-1-antichymotrypsin, alpha-1-antitrypsin, apolipoproteins A-1, B, D, E, E2, E3, E4, L1, M, clusterin, complement C3, hemopexin, heparin cofactor-II (HCFII), kininogen-1, serum amyloid A-1, amyloid beta A-4 and paraoxonase-1.

Results

Women with PCOS had a higher free androgen index (FAI) (p<0.001) and anti-Mullerian hormone (AMH) (p<0.001), but IR and C-reactive protein (CRP), a marker of inflammation, did not differ from controls (p>0.05). The triglyceride:HDL-cholesterol ratio was elevated (p=0.03) in PCOS. Alpha-1-antitrypsin levels were lower (p<0.05) and complement C3 levels were higher (p=0.001) in PCOS. C3 correlated with body mass index (BMI) (r=0.59, p=0.001), IR (r=0.63, p=0.0005) and CRP (r=0.42, p=0.04) in women with PCOS, though no correlations of these parameters with alpha-1-antitrypsin were found. Total cholesterol, triglycerides, HDL-cholesterol, LDL-cholesterol and levels of the other 17 lipoprotein metabolism-associated proteins did not differ between the two groups (p>0.05). However, in PCOS, alpha-1-antichymotrypsin correlated negatively with BMI (r=-0.40, p<0.04) and HOMA-IR (r=-0.42, p<0.03), apoM correlated positively with CRP (r=0.36, p<0.04) and HCFII correlated negatively with BMI (r=-0.34, p<0.04).

Conclusion

In PCOS subjects, when obesity, IR and inflammation confounders were absent, alpha-1-antitrypsin was lower and complement C3 was higher than in non-PCOS women, suggesting increased cardiovascular risk; however, subsequent obesity related IR/inflammation likely stimulates other HDL-associated protein abnormalities, thus increasing cardiovascular risk further.

The role of obstetrician-gynecologists and reproductive endocrinologists in the blood glucose management of polycystic ovary syndrome

Background: This study aimed to compare the differences between reproductive endocrinologists (Repro-Endo) and obstetricians-gynecologists (Ob-Gyn; non-reproductive medicine specialty) in diagnosing, evaluating, and treating PCOS women with insulin resistance (IR).Methods: Repro-Endo and Ob-Gyn in China participated in this survey, and their responses were analyzed using χ² tests, Fisher exact tests, and multivariable logistic regression analysis.Results: The study analyzed 2412 survey responses (92.3% OB-Gyn; 98.5% women). Physician's age, hospital grade, specialty, and the number of PCOS patients who visit the physicians, revealed that Repro-Endo participants were more likely to suggest an oral glucose tolerance test (OR, 1.727; 95% CI, 1.272-2.345) as their first choice than Ob-Gyn participants. The most common treatments for patients with PCOS were lifestyle modification (>95%) and metformin use (>80%). More Repro-Endo participants prescribed metformin at a dose of 1.5 g/day compared with OB-Gyn (46.5% vs. 23.5%), and more OB-Gyn participants reported being unclear about the appropriate dosage of metformin for patients with obesity and PCOS (12.5% vs. 1.6%).Conclusion: This survey identified knowledge gaps in metabolic screening for patients with IR and PCOS. Similarly, it highlights the need to improve IR management education for physicians caring for PCOS women.

Deconstructing a Syndrome: Genomic Insights Into PCOS Causal Mechanisms and Classification

Polycystic ovary syndrome (PCOS) is among the most common disorders in women of reproductive age, affecting up to 15% worldwide, depending on the diagnostic criteria. PCOS is characterized by a constellation of interrelated reproductive abnormalities, including disordered gonadotropin secretion, increased androgen production, chronic anovulation, and polycystic ovarian morphology. It is frequently associated with insulin resistance and obesity. These reproductive and metabolic derangements cause major morbidities across the lifespan, including anovulatory infertility and type 2 diabetes (T2D). Despite decades of investigative effort, the etiology of PCOS remains unknown. Familial clustering of PCOS cases has indicated a genetic contribution to PCOS. There are rare Mendelian forms of PCOS associated with extreme phenotypes, but PCOS typically follows a non-Mendelian pattern of inheritance consistent with a complex genetic architecture, analogous to T2D and obesity, that reflects the interaction of susceptibility genes and environmental factors. Genomic studies of PCOS have provided important insights into disease pathways and have indicated that current diagnostic criteria do not capture underlying differences in biology associated with different forms of PCOS. We provide a state-of-the-science review of genetic analyses of PCOS, including an overview of genomic methodologies aimed at a general audience of non-geneticists and clinicians. Applications in PCOS will be discussed, including strengths and limitations of each study. The contributions of environmental factors, including developmental origins, will be reviewed. Insights into the pathogenesis and genetic architecture of PCOS will be summarized. Future directions for PCOS genetic studies will be outlined.

Volatilomics as an Emerging Strategy to Determine Potential Biomarkers of Female Infertility: A Pilot Study

Due to its high prevalence, infertility has become a prominent public health issue, posing a significant challenge to modern reproductive medicine. Some clinical conditions that lead to female infertility include polycystic ovary syndrome (PCOS), endometriosis, and premature ovarian failure (POF). Follicular fluid (FF) is the biological matrix that has the most contact with the oocyte and can, therefore, be used as a predictor of its quality. Volatilomics has emerged as a non-invasive, straightforward, affordable, and simple method for characterizing various diseases and determining the effectiveness of their current therapies. In order to find potential biomarkers of infertility, this study set out to determine the volatomic pattern of the follicular fluid from patients with PCOS, endometriosis, and POF. The chromatographic data integration was performed through solid-phase microextraction (SPME), followed by gas chromatography–mass spectrometry (GC-MS). The findings pointed to specific metabolite patterns as potential biomarkers for the studied diseases. These open the door for further research into the relevant metabolomic pathways to enhance infertility knowledge and diagnostic tools. An extended investigation may, however, produce a new mechanistic understanding of the pathophysiology of the diseases.

Circulating Anti-Müllerian hormone in a cohort-study of women with severe obesity with and without polycystic ovary syndrome and the effect of a one-year weight loss intervention

BACKGROUND

Women with polycystic ovary syndrome (PCOS) have high circulating anti-Müllerian hormone (AMH) levels which is correlated with antral follicle count and polycystic ovarian morphology and negatively correlated with body mass index (BMI). Moreover, diet-induced weight loss in women with PCOS and overweight or obesity, reduce or normalize AMH-levels. There is, however, no previous study investigating the circulating AMH levels in women with severe obesity and how a structured diet-induced weight loss program affects circulating AMH levels in these women. Therefore, this study aims to investigate circulating AMH levels in a population of women with severe obesity (BMI ≥ 35 kg/m²) with and without PCOS, as diagnosed by the NIH-criteria, and to investigate the effect of a one-year weight loss program with a very low-energy diet (VLED) on circulating levels of AMH.

METHODS

In a prospective cohort-study, were 246 women with severe obesity were screened for PCOS diagnosis with the NIH-criteria, circulating AMH and anthropometry were measured at baseline and after a 12-month weight loss intervention with very low-energy diet (VLED).

RESULTS

Mean BMI was 39.9 ± 4.7 (PCOS), 39.6 ± 4.3 (non-PCOS) P = 0.960. Circulating AMH was higher in women with PCOS (5.47 ± 4.89 µg/L) compared with non-PCOS (2.66 ± 3.71 µg/L) P < 0.001 and was positively correlated with circulating total testosterone in both groups. Next, we performed ROC-analyses, and show that circulating AMH could not discriminate women with PCOS and severe obesity from non-PCOS women with severe obesity. Finally, a one-year weight reduction program does not affect circulating AMH levels despite significant weight loss neither in women with PCOS, nor without PCOS and severe obesity.

CONCLUSION

Women with severe obesity and PCOS have elevated levels of circulating AMH compared to women without the syndrome. AMH-levels could not discriminate women with PCOS from non-PCOS because of low sensitivity and specificity. Significant weight loss was not associated with changes in circulating AMH levels, neither in women with, nor without PCOS and severe obesity. These results imply that in women with severe obesity, a greater weight loss may be needed to improve reproductive features, independent of PCOS diagnosis.

TRIAL REGISTRATION NUMBER

Clinical trial.gov: NCT01319162.

Ovarian volume as an independent marker for metabolic dysfunction in women with suspected androgen excess

Objective

To determine whether ovarian volume (OV) alone is an independent marker for metabolic dysfunction in women with suspected androgen excess.

Design

Retrospective cohort study.

Setting

Tertiary academic reproductive endocrinology clinic.

Patients

Women aged ≥21 years recruited/referred for symptoms related to androgen excess.

Interventions

Transvaginal ovarian ultrasound, physical and medical evaluation, 2-hour 75-g oral glucose tolerance test (oGTT), and blood sampling.

Main Outcome Measures

Prevalence of hyperandrogenism and metabolic dysfunction.

Results

This study included 666 women, of whom 412 (61.9%) and 254 had OVs of >10 and ≤10 mL, respectively. An OV of >10 mL was associated with a higher prevalence of hirsutism (65.1% vs. 51.5%) than an OV of ≤10 mL. Polycystic ovary syndrome by the National Institutes of Health 1990 criteria was found in 67.3% and 51.4% of women with OVs of >10 and ≤10 mL, respectively. Metabolic parameters, including body mass index, waist circumference, and 1-hour insulin levels during the oGTT (odds ratio, 1.98; 95% confidence interval, 1.18-3.31), were significantly higher in women with an OV of >10 mL than in those with an OV of ≤10 mL. An OV of ≤10 mL had a 76.3% negative predictive value for hyperinsulinemia at 1 hour.

Conclusions

In women with suspected androgen excess, an OV of >10 mL in at least 1 ovary is not associated with metabolic syndrome but is associated with younger age; an increased body mass index and waist circumference; a higher prevalence of hirsutism, oligoovulation, and polycystic ovary syndrome; and a higher 60-minute insulin level during the oGTT. Overall, an increased OV appears to be a good marker for hyperinsulinemia and hyperandrogenism in women suspected of having an androgen excess disorder.

The effect of metformin treatment on leukocyte telomere length in patients with polycystic ovary syndrome: a prospective case-control study

PURPOSE

The study aimed to investigate the effect of metformin treatment on leukocyte telomere length (LTL) and the relationship of LTL with C-reactive protein (CRP), homocysteine, albumin, complete blood count, and HOMA-IR values in patients with polycystic ovary syndrome (PCOS).

MATERIAL AND METHOD

A prospective case-control study consisting of 30 women with PCOS and 30 healthy women without PCOS was performed. The relationship between clinical and laboratory parameters and LTL was analyzed. PCOS patients were treated with metformin (850 mg/day) for three months. Before treatment (BT) and after treatment (AT), each patient's LTL was evaluated and compared with the control group.

RESULTS

In the comparison between PCOS and control groups, the difference was significant for LTL, age, body mass index (BMI), and CRP (p = 0.002; p < 0.001; p = 0.001; p = 0.01, respectively). In PCOS patients, the difference between BT and AT, LTL was not statistically significant (BT: 6.06 ± 2.12; AT: 6.30 ± 1.93; p = 0.623; 95% C.I: - 1.22-0.74); however, the difference for weight was significant (BT: 83.78 ± 15.31; AT: 80.62 ± 15.40; p = 0.02; 95% CI: 1.34-4.99). The logistic regression model established by BMI (group 1: 21-24, group 2: 24-29, group 3: 29-34, group 4: > 34), age, and RDW, which predicted the PCOS group by affecting the LTL level, was statistically significant (p < 0.001/PPV = 96.3%; NPV = 88.5%). Each unit reduction in telomere length increased women's probability of PCOS by 0.4 times (p = 0.013; OR = 0.419, 95% CI: 0.211-0.835).

CONCLUSION

Although statistically insignificant, LTL increased after metformin use in PCOS patients, and the mean weight loss reduction was statistically significant. Telomere shortening increased the likelihood of PCOS 0.4 times.

Adipose mesenchymal stem cell-derived exosomal microRNAs ameliorate polycystic ovary syndrome by protecting against metabolic disturbances

Polycystic ovary syndrome (PCOS) is the most common endocrine and metabolic disorder in women of childbearing age. Adipose mesenchymal stem cells (AMSCs) secrete cytokines involved in the regulation of metabolism and immunity. However, it remains unclear whether exosomes secreted by AMSCs (AMSC-EXOs) can rescue the polycystic phenotype and metabolic dysfunction in PCOS ovaries. Here, we show that AMSC-EXOs can protect against metabolic disturbances, ameliorate ovarian polycystic, and improve fertility in a rat model of PCOS. AMSC-EXOs inhibited the expression of B-cell translocation gene 2 by transferring miR-21-5p to the livers of rats with PCOS, thus activating the IRS1/AKT pathway and increasing hepatic metabolism. The role of AMSC-EXOs in transferring miRNAs to the liver to improve metabolic dysfunction in PCOS and reproduction by rescuing a non-coding RNA pathway was also discovered. This study provides a theoretical basis for the use of rat adipose stem cells and their secreted exosomes to treat PCOS.

Effect of non-pharmacological interventions for overweight/obese women with polycystic ovary syndrome on ovulation and pregnancy outcomes: a protocol for a systematic review and network meta-analysis

INTRODUCTION

Most overweight/obese women with polycystic ovary syndrome (PCOS) have infertility issues which are difficult to treat. Non-pharmacological interventions used for the management of infertility include lifestyle interventions, acupuncture therapies and nutritional supplements. These interventions have been reported to be beneficial in alleviating infertility among overweight women with PCOS. However, effect and safety of these non-pharmacological interventions vary, and there is no standard method of clinical application. Therefore, it is necessary to conduct a systematic review and network meta-analysis (NMA) to rank these non-pharmacological interventions in terms of effect and determine which one is more effective for clinical application.

METHODS AND ANALYSIS

We will retrieve eight databases including Cochrane Library, Medline, Embase, PsycINFO, Chinese National Knowledge Infrastructure, WanFang Data, the Chongqing VIP Database and China Biology Medicine disc from their inceptions onwards. In addition, four clinical trial registries and the related references will be manually retrieved. The primary outcome will be clinical pregnancy. Live birth, ovulation, pregnancy loss, multiple pregnancy and adverse events related to interventions will be considered as the secondary outcomes. STATA software V.15.0 and Aggregate Data Drug Information System V.1.16.8 will be used to conduct pairwise meta-analysis and NMA. The Grading of Recommendations Assessment, Development and Evaluation system will be adopted to evaluate the certainty of evidence.

ETHICS AND DISSEMINATION

Ethical approval will not be required because the study will not include the original information of participants. The results will be published in a peer-reviewed journal or disseminated in relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42021283110.

Outcomes of a Mindfulness-Based Healthy Lifestyle Intervention for Adolescents and Young Adults with Polycystic Ovary Syndrome

STUDY OBJECTIVE

The purpose of this study was to examine the feasibility, acceptability, and preliminary efficacy of a mindfulness-based healthy lifestyle self-management intervention with adolescents and young adults diagnosed with polycystic ovary syndrome (PCOS).

DESIGN

A pilot randomized controlled trial using a pre-post design was used.

SETTING

Central Texas.

PARTICIPANTS

Individuals aged 14-23 with a diagnosis of PCOS.

INTERVENTIONS

The PCOS Kind Mind Program integrates a manualized mindfulness training program (Taming the Adolescent Mind) with health education in 4 key areas of self-management and health promotion: (1) medication adherence, (2) nutrition, (3) physical activity, and (4) sleep.

MAIN OUTCOME MEASURES

Psychological distress, mindfulness, physical activity strategies, nutrition, and exercise self-efficacy.

RESULTS

Linear regression models revealed that those in the PCOS Kind Mind condition reported significantly higher nutrition self-efficacy (β = 6.50, 95% CI, 1.71-11.28, P = 0.013, d = 0.48), physical activity strategies (β = 0.41, 95% CI, 0.04-0.79, P = 0.040, d = 0.67), and physical activity self-efficacy (β = 0.48, 95% CI, 0.07-0.88, P = 0.028, d = 0.46).

CONCLUSION

The PCOS Kind Mind Program improved self-efficacy in the key areas of nutrition and physical activity and increased physical activity strategies in adolescents and young people with PCOS. These findings are encouraging and suggest the need for larger-scale, randomized controlled trials with longer-term follow-up to more robustly evaluate the effects of the PCOS Kind Mind Program on the psychological and physiological health of adolescents and young people with PCOS.

Follicular Fluid: A Powerful Tool for the Understanding and Diagnosis of Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) represents one of the leading causes of anovulatory infertility and affects 5% to 20% of women worldwide. Until today, both the subsequent etiology and pathophysiology of PCOS remain unclear, and patients with PCOS that undergo assisted reproductive techniques (ART) might present a poor to exaggerated response, low oocyte quality, ovarian hyperstimulation syndrome, as well as changes in the follicular fluid metabolites pattern. These abnormalities originate a decrease of Metaphase II (MII) oocytes and decreased rates for fertilization, cleavage, implantation, blastocyst conversion, poor egg to follicle ratio, and increased miscarriages. Focus on obtaining high-quality embryos has been taken into more consideration over the years. Nowadays, the use of metabolomic analysis in the quantification of proteins and peptides in biological matrices might predict, with more accuracy, the success in assisted reproductive technology. In this article, we review the use of human follicular fluid as the matrix in metabolomic analysis for diagnostic and ART predictor of success for PCOS patients.

Nonalcoholic fatty liver disease and obstructive sleep apnea in women with polycystic ovary syndrome

Nonalcoholic fatty liver disease (NAFLD) and obstructive sleep apnea are frequently associated with polycystic ovary syndrome (PCOS) but remain underrecognized. Women with PCOS have a 2-4 times higher risk of NAFLD independent of body mass index than healthy weight-matched controls. Insulin resistance and hyperandrogenemia together play a central role in the pathogenesis of NAFLD. Timely diagnosis of NAFLD is important because its progression can lead to nonalcoholic steatohepatitis and/or advanced liver fibrosis that can eventually result in liver-related mortality. The presence of NAFLD has also been associated with increased risks of type 2 diabetes, cardiovascular events, overall mortality, and extrahepatic cancers. The treatment of NAFLD in PCOS should include lifestyle interventions. Glucagon-like peptide 1 receptor agonists have shown promising results in patients with PCOS and NAFLD, but future randomized trails are needed to confirm this benefit. Likewise, the use of combined oral estrogen-progestin contraceptives may provide a benefit by decreasing hyperandrogenemia. Sleep disordered breathing is common among women with PCOS and is responsible for a number of cardiometabolic derangements. Obstructive sleep apnea is most often found in overweight and obese women with PCOS, but as is the case with NAFLD, its prevalence exceeds that of women who are of similar weight without PCOS. Left untreated, obstructive sleep apnea can precipitate or exacerbate insulin resistance, glucose intolerance, and hypertension.

Prepregnancy Polycystic Ovary Syndrome as a Risk Factor of Subsequent Preterm Labor: A National Population-Based Cohort Study

Background: Preterm labor and the following preterm births, which account for most of the perinatal deaths, are an important issue in public health. The study aims to assess the risk of subsequent preterm labor in pregnant females who have prepregnancy polycystic ovary syndrome (PCOS). Methods: This study has enrolled 1,000,000 randomly sampled females retrieved from the Taiwan National Health Insurance Research Database (NHIRD) during 1998−2012. The study excluded prepregnancy PCOS females who were initially diagnosed at age <15 or >45, and those who had inconsistent diagnoses. Moreover, the medical records of blood hormone tests, gynecologic ultrasonography, pelvic examinations, and tocometers were verified to confirm the accuracy of both diagnoses of PCOS and preterm labor. Among the prepregnancy PCOS females who became pregnant (the case group), each was age-matched to four females without prepregnancy PCOS (the control group). Results: Pregnant females in the case group (n = 1959) had a higher incidence of preterm labor than those in the control group (n = 7836) (42.98% vs. 21.99%, p < 0.0001). Analyzed by using logistic regression, the risk of preterm labor was significantly higher in the case group compared with the control group (crude OR: 2.674; 95% CI: 2.410−2.968, p < 0.0001). After adjustment with covariates, further analysis revealed a similar trend (adjusted OR: 2.405; 95% CI: 2.158−2.680, p < 0.0001). Among 1959 PCOS females in the case group, 196 had undergone metformin treatment. Compared with females without metformin treatment (the non-metformin subgroup), the metformin users (metformin subgroup) presented a reduced risk for preterm labor (adjusted OR: 2.238; 95% CI: 1.657−3.023). The risk of subsequent preterm labor was reduced by about 10% for the metformin subgroup compared with the non-metformin subgroup. Conclusions: Prepregnancy PCOS is an independent and significant risk factor of subsequent preterm labor. Among prepregnancy PCOS females, the risk of preterm labor is lowered by about 10% in metformin users compared with non-metformin females.

Efficacy of Myo-inositol on Anthropometric, Metabolic, and Endocrine Outcomes in PCOS Patients: a Meta-analysis of Randomized Controlled Trial

Polycystic ovary syndrome (PCOS) is a common cause of female infertility, affecting 5-10% of women of reproductive age. Many studies have reported improvement in insulin resistance and thereby intracellular glucose uptake after myo-inositol treatment in PCOS patients, but these studies have a small sample size, varying methodology, and outcome analysis. Therefore, we designed a present meta-analysis of randomized controlled trials to explore the effect of myo-inositol supplementation on anthropometric, metabolic, and endocrine outcomes in PCOS patients. Randomized controlled trials assessing the effectiveness of myo-inositol were identified in electronic databases like PubMed, Cochrane, Embase, MEDLINE, CINAHL, and AMED. Listed references and citations of related articles were also screened manually to identify additional studies. Research papers for which full-text copies were not available on scientific databases were procured from respective authors. Thereafter, data were extracted from included studies and analyzed using RevMan 5.3 of the Cochrane Collaboration. A total of 17 randomized controlled trials with 1083 PCOS patients were included in this meta-analysis. Among the 17 trials, 7 trials compared myo-inositol with folic acid, 8 trials compared myo-inositol with metformin, and 2 trials compared myo-inositol with oral contraceptives. No significant improvement in body mass index, waist-to-hip ratio, fasting insulin, fasting glucose, HOMA, LH, FSH, estradiol, sex hormone-binding globulin, dehydroepiandrosterone, and total testosterone levels were observed after myo-inositol treatment in PCOS patients except androstenedione and prolactin levels. Clinically significant improvement was not observed in anthropometric, metabolic, and endocrine outcomes after myo-inositol treatment in PCOS patients. However, heterogeneity between studies was high.

Can dysglycemia in OGTT be predicted by baseline parameters in patients with PCOS?

Background

Polycystic ovary syndrome (PCOS) is considered a risk factor for the development of type 2 diabetes mellitus (T2DM). However, which is the most appropriate way to evaluate dysglycemia in women with PCOS and who are at increased risk are as yet unclear.

Aim of the study

To determine the prevalence of T2DM, impaired glucose tolerance (IGT), and impaired fasting glucose (IFG) in PCOS women and potential factors to identify those at risk.

Subjects and methods

The oral glucose tolerance test (OGTT), biochemical/hormonal profile, and ovarian ultrasound data from 1614 Caucasian women with PCOS and 362 controls were analyzed in this cross-sectional multicenter study. The data were categorized according to age and BMI.

Results

Dysglycemia (T2DM, IGT, and IFG according to World Health Organization criteria) was more frequent in the PCOS group compared to controls: 2.2% vs 0.8%, P = 0.04; 9.5% vs 7.4%, P = 0.038; 14.2% vs 9.1%, P = 0.002, respectively. OGTT was essential for T2DM diagnosis, since in 88% of them basal glucose values were inconclusive for diagnosis. The presence of either T2DM or IFG was irrespective of age (P = 0.54) and BMI (P = 0.32), although the latter was associated with IGT (P = 0.021). There was no impact of age and BMI status on the prevalence of T2DM or IFG. Regression analysis revealed a role for age, BMI, fat deposition, androgens, and insulin resistance for dysglycemia. However, none of the factors prevailed as a useful marker employed in clinical practice.

Conclusions

One-third of our cohort of PCOS women with either T2DM or IGT displayed normal fasting glucose values but without confirming any specific predictor for dysglycemic condition. Hence, the evaluation of glycemic status using OGTT in all women with PCOS is strongly supported.

Association of Insulin Resistance and Elevated Androgen Levels with Polycystic Ovarian Syndrome (PCOS): A Review of Literature

The polycystic ovary syndrome (PCOS) is the disease featured by elevated levels of androgens, ovulatory dysfunction, and morphological abnormalities. At reproductive stage of women, the rate of PCOS occurrence is measured as 6–10% and the prevalence rate may be double. There are different pathophysiological factors involved in PCOS, and they play a major role in various abnormalities in individual patient. It is clear that there is noteworthy elevation of androgen in PCOS, causing substantial misery and infertility problems. The overexposure of androgen is directly linked with insulin resistance and hyperinsulinaemia. It has been reported previously that PCOS is related to cardiac metabolic miseries and potently increases the risk of heart diseases. Endometrial cancer is also a serious concern which is reported with exceedingly high incidence in women with PCOS. However, the overexposure of androgen has direct and specific influence on the development of insulin resistance. Although many factors are involved, resistance to the insulin and enhanced level of androgen are considered the major causes of PCOS. In the present review, we have focused on the pathophysiology and major revolutions of insulin resistance and excessive levels of androgen in females with PCOS.

Natural history of polycystic ovary syndrome: A systematic review of cardiometabolic outcomes from longitudinal cohort studies

OBJECTIVE

Women with polycystic ovary syndrome (PCOS) have a worsened metabolic profile but the progression of cardiometabolic features over time is unclear. Understanding this natural history is a key priority in PCOS research and vital for guiding the prevention and management of this common condition. We explored cardiometabolic changes that are observed in women with PCOS compared to those without PCOS across the life course.

DESIGN, PATIENTS AND MEASUREMENTS

A systematic review of longitudinal cohort studies was conducted across MEDLINE, EMBASE, Ovid PsycInfo, CINAHL PLUS and EBM reviews between 15 January 2020 and 11 February 2021. Eligible studies included participants with or without PCOS diagnosed according to the 2003 Rotterdam or the 1990 National Institutes of Health (NIH) criteria. We included studies that were published from the year 1990 to 2021 with data on cardiometabolic outcomes as per the PCOS core outcomes set.

RESULTS

There were 31 longitudinal studies with 28,316 participants from four continents. At the start of follow up, participants were aged between 1 year and 49 years with a follow-up period ranging from 2 to 32 years. Changes in BMI and the risk of coronary heart disease were similar in adult women with and without PCOS. Women with PCOS had a higher risk of Type 2 diabetes than their non-PCOS counterparts. Evidence for the majority of all other outcomes was conflicting and with inadequate data.

CONCLUSION

Understanding the natural history of PCOS and particularly changes in cardiometabolic features remains challenging. Existing literature is extensive but heterogeneous and inconsistent. Longitudinal studies in unselected populations are needed to provide high-quality data in this area.

Higher risk of type 2 diabetes in young women with polycystic ovary syndrome: A 10-year retrospective cohort study

BACKGROUND

Polycystic ovary syndrome (PCOS) is a common disorder in women of reproductive age. Over the last few decades, research studies have revealed that PCOS is strongly associated with metabolic disorders, including metabolic syndrome, obesity, insulin resistance and prediabetes. Clinical observation has shown that women with PCOS are expected to have an increased risk of developing type 2 diabetes (T2DM) in the future.

AIM

To assess the hazard ratio (HR) of T2DM between women with/without PCOS.

METHODS

This population-based, retrospective cohort study evaluated data retrieved from the National Health Insurance Research Database. The subjects were women with PCOS (n = 2545) identified on the basis of diagnosis, testing, or treatment codes, and women without PCOS as controls (n = 2545). The HR of T2DM between women with or without PCOS was the main outcome measure analyzed.

RESULTS

Our study found that, during a 10-year follow-up period, the overall incidence of T2DM was 6.25 per 1000 person-years in the PCOS group compared with 1.49 in the control group. After adjustment for potential confounding variables, the overall incidence of T2DM was higher in the PCOS group vs the control group (HR = 5.13, 95%CI: 3.51-7.48, P < 0.0001). The risk of developing T2DM subsequent to PCOS decreased with increasing diagnosis age: the adjusted HR was 10.4 in the 18–24-year age group, 5.28 in the 25-29-year age group, and 4.06 in the 29-34-year age group. However, no such significant association was noted in women older than 35 years.

CONCLUSION

These findings highlight the importance of prompting a more aggressive treatment to prevent diabetes in women diagnosed with PCOS at a young age, and, in contrast, the lessened importance of this type of intervention in women diagnosed with PCOS at a late reproductive age.

Polycystic Ovary Syndrome in Adolescence

Polycystic ovary syndrome (PCOS) is a common, complex, and chronic condition that presents many diagnostic and management challenges for managing clinicians. PCOS diagnosis in adolescents presents a particular challenge for treating clinicians due to the overlap of diagnostic features with normal physiological changes during adolescence. Adolescent diagnostic criteria include well-defined menstrual irregularity according to time postmenarche and hyperandrogenism, but does not require the use of pelvic ultrasound. Adolescents with only one criterion should be considered at risk of PCOS and be followed up around transition to adult care. While PCOS was traditionally considered to be a reproductive disorder, PCOS is now recognized to have major metabolic and cardiovascular health consequences and psychological sequelae that can be present from adolescence. Management of PCOS includes healthy lifestyle, metformin, combined oral contraceptive pill, and/or antiandrogens according to symptoms of concern even in adolescents at risk of PCOS.

PCOS: A Chronic Disease That Fails to Produce Adequately Specialized Pro-Resolving Lipid Mediators (SPMs)

Introduction: Polycystic ovary syndrome (PCOS) is an endocrinological disorder that affects 5–15% of women of their reproductive age and is a frequent cause of infertility. Major symptoms include hyperandrogenism, ovulatory dysfunction, and often obesity and/or insulin resistance. PCOS also represents a state of chronic low-grade inflammation that is closely interlinked with the metabolic features. “Classical” pro-inflammatory lipid mediators such as prostaglandins (PG), leukotrienes (LT), or thromboxanes (TX) are derived from arachidonic acid (AA) and are crucial for the initial response. Resolution processes are driven by four families of so-called specialized pro-resolving mediators (SPMs): resolvins, maresins, lipoxins, and protectins. The study aimed to establish lipid mediator profiles of PCOS patients compared to healthy women to identify differences in their resolutive and pro-inflammatory lipid parameters. Material and Methods: Fifteen female patients (18–45 years) were diagnosed with PCOS according to Rotterdam criteria, and five healthy women, as a comparator group, were recruited for the study. The main outcome measures were: pro-inflammatory lipid mediators (PG, LT, TX) and their precursor AA, SPMs (resolvins, maresins, protectins, lipoxins), their precursors EPA, DHA, DPA, and their active biosynthesis pathway intermediates (18-HEPE, 17-HDHA, 14-HDHA). Results: The level of pro-inflammatory parameters in serum was significantly higher in PCOS-affected women. The ratio (sum of pro-inflammatory molecules)/(sum of SPMs plus hydroxylated intermediates) reflecting the inflammatory state was significantly lower in the group of healthy women. Conclusion: There is a strong pro-inflammatory state in PCOS patients. Further research will clarify whether supplementation with SPMs or their precursors may improve this state.

Association of severity of menstrual dysfunction with hyperinsulinemia and dysglycemia in polycystic ovary syndrome

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.

Polycystic ovary syndrome and type 2 diabetes mellitus: A state-of-the-art review

Polycystic ovary syndrome (PCOS) often coexists with a wide spectrum of dysglycemic conditions, ranging from impaired glucose tolerance to type 2 diabetes mellitus (T2D), which occur to a greater extent compared to healthy body mass index-matched women. This concurrence of disorders is mainly attributed to common pathogenetic pathways linking the two entities, such as insulin resistance. However, due to methodological flaws in the available studies and the multifaceted nature of the syndrome, there has been substantial controversy as to the exact association between T2D and PCOS which has not yet been elucidated. The aim of this review is to present the best available evidence regarding the epidemiology of dysglycemia in PCOS, the unique pathophysiological mechanisms underlying the progression of dysglycemia, the most appropriate methods for assessing glycemic status and the risk factors for T2D development in this population, as well as T2D risk after transition to menopause. Proposals for application of a holistic approach to enable optimal management of T2D risk in PCOS are also provided. Specifically, adoption of a healthy lifestyle with adherence to improved dietary patterns, such the Mediterranean diet, avoidance of consumption of endocrine-disrupting foods and beverages, regular exercise, and the effect of certain medications, such as metformin and glucagon-like peptide 1 receptor agonists, are discussed. Furthermore, the maintenance of a healthy weight is highlighted as a key factor in achievement of a significant reduction of T2D risk in women with PCOS.

Prediction of Insulin Resistance and Impaired Fasting Glucose Based on Sex Hormone-Binding Globulin (SHBG) Levels in Polycystic Ovary Syndrome

OBJECTIVE

Decreased synthesis of sex hormone-binding globulin (SHBG) related to hyperinsulinemia is one of the disturbances characteristic of polycystic ovary syndrome (PCOS). Hyperinsulinemia is a compensatory mechanism for liver insulin resistance (IR); thus, SHBG may be considered as a surrogate marker of liver IR. Therefore, this study aimed to assess the prediction of IR and impaired fasting glucose (IFG) based on SHBG levels in women with PCOS.

METHODS

This analysis included data retrieved from medical records of 854 patients with PCOS hospitalized in the Gynecological Endocrinology Clinic from 2012 to 2019. Data including anthropometric parameters, fasting plasma glucose, insulin, and SHBG levels were analyzed. BMI and HOMA-IR were calculated with standard formulas.

RESULTS

IFG and IR assessed based on HOMA-IR values > 2.0 were found in 19.5% and 47.8% of the study group, respectively. Empirical optimal cutoff values for SHBG levels were ≤41.5 nmol/L typical for IR (AUC 0.711, sensitivity 61.1%, specificity 71.6%, positive predictive value (PPV) 70.7%, and negative predictive value (NPV) 62.1%). The probability of insulin resistance occurrence for SHBG concentration 26.1 nmol/L (the lower normal range) was 61.6% (95% CI: 57.4%-65.8%). The SHBG concentration of 36.4 nmol/L and 8.1 nmol/L was related to a 10% and 20% probability of IFG, respectively.

CONCLUSION

In conclusion, this is the first study estimating the probability of liver IR and IFG occurrence based on SHBG levels in women with PCOS. Despite the low sensitivity, SHBG level below 42 nmol/L should cause closer monitoring for the fatty liver and prediabetes.

Prevalence and Predictors of Impaired Glucose Tolerance and Diabetes Mellitus Type 2 in Patients with Polycystic Ovary Syndrome

Aim: To estimate the prevalence of impaired glucose tolerance (IGT) and diabetes mellitus type 2 (DMT2), as well as the predictors for glucose abnormalities in women with polycystic ovary syndrome (PCOS). Material and methods: A cross-sectional study with 80 consecutive patients with newly diagnosed PCOS who underwent the standard 75g oral glucose tolerance test (OGTT) and the measurement of sex steroid hormone and lipid profile. Results: According to the results from the OGTT, 63% had a normal test (NT), 23% had IGT, and 9% had DMT2. The NT group was younger with lower BMI than IGT and DMT2 groups (25.1 ± 7.3, 31.5 ± 6.5, 37.4 ± 4.0 years, and 29.1 ± 8.3 kg/m2, 31.7 ± 4.6 kg/m2, and 34.5 ± 5.6 kg/m2, respectively). The testosterone levels were highest in the group with a normal test (2.7 ± 0.8 nmol/l) and lowest in the DMT2 group (1.9 ± 0.8 nmol/L), with statistical significance. The sex hormone bounding globulin (SHBG) levels were low in all three groups, with statistically significant differences between NG and IGT, and the NT and DMT2 groups. The multivariate linear regression model identified age, BMI, SHBG and testosterone as major independent predictors for abnormal glucose metabolism. Conclusion: It seems that the prevalence of IGT and DMT2 among PCOS women in our country is not as high as in Western countries. Age, BMI, and SHBG increase the risk for the development of IGT and DMT2. Thus, close monitoring of older, obese women with low SHBG is needed because of the higher risk for the development of IGT and DMT2 in such patients.

Explore the potential molecular mechanism of polycystic ovarian syndrome by protein-protein interaction network analysis

Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders prevailing in reproductive age women, present in 3-15% population of women worldwide. Although there are many studies on PCOS, its underlying mechanism remains to be determined. The present study was to construct protein-protein interaction networks based on the potential disease-causing genes for PCOS and characterize the underlying molecular mechanisms of PCOS using the networks. PCOS-associated genes were extracted from DisGeNet and the protein-protein interaction networks (PPIN) of PCOS were constructed using the String Database. Then we utilized MCODE algorithm to analyse the hub-gene modules from the PPIN. Finally, the major biological functions and signaling pathways involved in the hub modules were explored by functional enrichment analysis. A total of 522 candidate genes associated to PCOS were extracted from DisGeNET database. The PPIN constructed using the genes we have collected above included 488 genes and 2767 interaction relationships. Moreover, seven major gene modules were obtained after analyzing the PPIN with the use of MCODE plug-in. The major modules generated were enriched in certain biological functions such as cancer and cell proliferation and apoptosis, regulation of lipid and glucose metabolism, cell cycle and so on. The integrated analysis performed in the current study revealed that these hub modules and their related genes are closely associated to the pathogenesis of PCOS, which may probably provide novel insights for the treatment of PCOS and the study of its latent pathogenic mechanism. The relationship between several of the key genes including ALB, TOP2A, PTGER3, NPB and BRD2 in the modules and PCOS has not been investigated previously and it remains to be verified by further research of large sample, multi-center and multi-ethnic.

The Risk of Subsequent Miscarriage in Pregnant Women with Prior Polycystic Ovarian Syndrome: A Nationwide Population-Based Study

Objective: To assess the risk of subsequent miscarriage in pregnant women with a prior diagnosis of polycystic ovarian syndrome (PCOS). Methods: Using a nationwide, population-based database (Taiwan National Health Insurance Research Database) during 1998-2012, the study retrieved 1,000,000 randomly-sampled insured citizens as research subjects. The women with a diagnosis of pre-pregnancy PCOS (n = 13,562) who had chromosomal anomalies, artificial abortion, inconsistent diagnoses, and who were initially diagnosed with PCOS at >45 or <15 year-old were excluded, respectively. The records of gynecologic ultrasonography and/or blood tests were checked to verify the accuracy of the diagnoses of both PCOS and miscarriage (ICD-9 CM codes). After pregnancy, every woman with prior PCOS was age-matched to four women without prior PCOS. Results: Pregnant women with prior PCOS (the case group; n = 1926) and those without prior PCOS (the control group; n = 7704) were compared. The incidence of subsequent miscarriage was much higher in the case group compared with the control group (33.80% vs. 4.09%, p < 0.0001). Logistic regression analysis revealed that the risk of subsequent miscarriage was significantly higher in the case group than the control group (odds ratio [OR] 11.98; 95% CI 10.34-13.87, p < 0.0001), and the result remained similar while adjusted with covariates (adjusted OR 11.97; 95% CI 10.27-13.95, p < 0.0001). In the case group, the patient who used metformin had a lower risk of subsequent miscarriage (adjusted OR 9.53; 95% CI 6.69-13.57) when compared with those who did not receive metformin treatment (adjusted OR 12.13; 95% CI 10.38-14.18). Conclusion: For pregnant women, a pre-pregnancy diagnosis of PCOS is an independent and significant risk factor for subsequent miscarriage. The risk of subsequent miscarriage is reduced by about 1/4 for the PCOS patients who undergo metformin treatment compared with those who do not.

Exploring new treatment options for polycystic ovary syndrome: Review of a novel antidiabetic agent SGLT2 inhibitor

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in women of reproductive age associated with long-term metabolic and cardiovascular consequences. A plethora of symptoms and their severity differentiate on an individual level, giving the syndrome numerous phenotypes. Due to menstrual cycle abnormalities, women suffer from irregular menstrual bleeding, difficulty in conception, and infertility. Furthermore, the risk of pregnancy complications such as gestational diabetes mellitus, hypertensive disorders of pregnancy, and preterm birth are higher in women with PCOS than in the general population. Often, women with PCOS have comorbidities such as dyslipidemia, obesity, glucose intolerance or diabetes type 2, non-alcoholic fatty liver disease, and metabolic syndrome, which all influence the treatment plan. Historic insulin-sensitizing agents, although good for some of the metabolic derangements, do not offer long-term cardiovascular benefits; therefore, new treatment options are of paramount importance. Sodium-glucose co-transporter-2 (SGLT-2) inhibitors, a new class of antidiabetic agents with beneficial cardiovascular, bodyweight, and antihyperglycemic effects, although not approved for the treatment of PCOS, might be an attractive therapeutic addition in the PCOS armamentarium. Namely, recent studies with SGLT-2 inhibitors showed promising improvements in anthropometric parameters and body composition in patients with PCOS. It is important to further explore the SGLT-2 inhibitors potential as an early therapeutic option because of the PCOS-related risk of metabolic, reproductive, and psychological consequences.

DeepGP: An Integrated Deep Learning Method for Endocrine Disease Gene Prediction Using Omics Data

Endocrinology is the study focusing on hormones and their actions. Hormones are known as chemical messengers, released into the blood, that exert functions through receptors to make an influence in the target cell. The capacity of the mammalian organism to perform as a whole unit is made possible based on two principal control mechanisms, the nervous system and the endocrine system. The endocrine system is essential in regulating growth and development, tissue function, metabolism, and reproductive processes. Endocrine diseases such as diabetes mellitus, Grave's disease, polycystic ovary syndrome, and insulin-like growth factor I deficiency (IGFI deficiency) are classical endocrine diseases. Endocrine dysfunction is also an increasing factor of morbidity in cancer and other dangerous diseases in humans. Thus, it is essential to understand the diseases from their genetic level in order to recognize more pathogenic genes and make a great effort in understanding the pathologies of endocrine diseases. In this study, we proposed a deep learning method named DeepGP based on graph convolutional network and convolutional neural network for prioritizing susceptible genes of five endocrine diseases. To test the performance of our method, we performed 10-cross-validations on an integrated reported dataset; DeepGP obtained a performance of the area under the curve of ∼83% and area under the precision-recall curve of ∼65%. We found that type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) share most of their associated genes; therefore, we should pay more attention to the rest of the genes related to T1DM and T2DM, respectively, which could help in understanding the pathogenesis and pathologies of these diseases.

The effects of smoking on pregnancy risks in women with polycystic ovary syndrome: a population-based study

STUDY QUESTION

Is there is an association between smoking and pregnancy complications in pregnant women with polycystic ovarian syndrome (PCOS)?

SUMMARY ANSWER

There is an increased risk of developing gestational diabetes mellitus (GDM) among women with PCOS who smoke.

WHAT IS KNOWN ALREADY

Smokers are at increased risk of developing Type 2 Diabetes Mellitus (DM). Given the common pathophysiology and shared risk factors between type 2 DM and GDM, we sought to assess whether an association between smoking and the development of GDM exists.

STUDY DESIGN, SIZE, DURATION

This is a retrospective population-based study utilizing data from the HCUP-NIS over 11 years from 2004 to 2014. Pregnant women with PCOS who did smoke were compared to pregnant women with PCOS who did not smoke. A second comparison was made between pregnant smokers with and without PCOS. Of the 443 590 women who smoked during pregnancy and the 14 882 women with PCOS, 631 women were both smokers and diagnosed with PCOS.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS) is the largest inpatient sample database in the USA and is composed of hospital inpatient stays submitted by hospitals throughout the entire country. Each year, the database provides information relating to 7 million inpatient stays, including patient characteristics, diagnosis and procedures. The data are representative of ∼20% of admissions to US hospitals across 48 states and the District of Columbia.

MAIN RESULTS AND THE ROLE OF CHANCE

There were no differences in the risks of preterm delivery (aOR1.2; CI 0.8-1.9), placental abruption (aOR1.1; CI 0.4-3.2), pregnancy induced hypertension (aOR1.0; CI 0.7-1.5), rate of operative vaginal delivery (aOR1.5; CI 0.9-2.5) and rates of cesarean section (C/S) (aOR1.0; CI 0.7-1.3) between smoking and non-smoking women with PCOS. A significant association between smoking and GDM was observed in women with PCOS (aOR1.5; CI1.01-2.1).

LIMITATIONS, REASONS FOR CAUTION

The limitations of our study are its retrospective nature and the fact that it relies on an administrative database. Data regarding smoking and PCOS diagnosis could be skewed due to patients' underreporting, lack of documentation and documentation differences.

WIDER IMPLICATIONS OF THE FINDINGS

The public health implications of confirming smoking as a risk for GDM among women with PCOS are many. This can lead to earlier screening in pregnancy of smokers for GDM. Earlier initiation of interventions could decrease fetal complications and possibly have an impact on the life and long-term health of the offspring. Future studies are needed in order to assess whether smoking cessation during pregnancy decreases the risk of GDM in that gestation.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was used. The authors report no competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Polycystic Ovary Syndrome Susceptibility Loci Inform Disease Etiological Heterogeneity

Polycystic ovary syndrome (PCOS) is a complex disorder with heterogenous phenotypes and unclear etiology. A recent phenotypic clustering study identified metabolic and reproductive subtypes of PCOS. We hypothesize that the heterogeneity of PCOS manifestations reflects different mechanistic pathways and can be identified using a genetic approach. We applied k-means clustering to categorize the genome-wide significant PCOS variants into clusters based on their associations with selected quantitative traits that likely reflect PCOS etiological pathways. We evaluated the association of each cluster with PCOS-related traits and disease outcomes. We then applied Mendelian randomization to estimate the causal effects between the traits and PCOS. Three categories of variants were identified: adiposity, insulin resistant, and reproductive. Significant associations were observed for variants in the adiposity cluster with body mass index (BMI), waist circumference and breast cancer, and variants in the insulin-resistant cluster with fasting insulin, glucose values, and homeostatic model assessment of insulin resistance (HOMA-IR). Sex hormone binding globulin (SHBG) has strong association with all three clusters. Mendelian randomization suggested a causal role of BMI and SHBG on PCOS. No causal associations were observed for PCOS on disease outcomes.

Chinese herbal medicine for subfertile women with polycystic ovarian syndrome

BACKGROUND

Polycystic ovarian syndrome (PCOS) is characterised by both metabolic and reproductive disorders, and affects 5% to 15% of women of reproductive age. Different western medicines have been proposed for PCOS-related subfertility, such as oral contraceptives, insulin sensitisers and laparoscopic ovarian drilling (LOD). Chinese herbal medicines (CHM) have also been used for subfertility caused by PCOS for decades, and are expected to become an alternative treatment for subfertile women with PCOS.

OBJECTIVES

To assess the efficacy and safety of Chinese herbal medicine (CHM) for subfertile women with polycystic ovarian syndrome (PCOS).

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase and six other databases, from inception to 2 June 2020. In addition, we searched three trials registries, the reference lists of included trials and contacted experts in the field to locate trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing CHM versus placebo, no treatment or conventional (western) therapies for the treatment of subfertile women with PCOS.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened trials for inclusion, assessed the risk of bias in included studies and extracted data. We contacted primary study authors for additional information. We conducted meta-analyses. We used the odds ratios (ORs) to report dichotomous data, with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods.

MAIN RESULTS

We included eight RCTs with 609 participants. The comparisons in the included trials were as follows: CHM versus clomiphene, CHM plus clomiphene versus clomiphene (with or without ethinyloestradiol cyproterone acetate (EE/CPA)), CHM plus follicle aspiration plus ovulation induction versus follicle aspiration plus ovulation induction alone, and CHM plus laparoscopic ovarian drilling (LOD) versus LOD alone. The overall certainty of the evidence for most comparisons was very low. None of the included studies reported the primary outcome, live birth rate. Most studies reported the secondary outcomes, and only one study reported data on adverse events. In trials that compared CHM to clomiphene (with or without LOD in both study arms), we are uncertain of the effect of CHM on pregnancy rates (odds ratio (OR) 1.41, 95% confidence interval (CI) 0.63 to 3.19; I² = 28%; 3 studies, 140 participants; very low certainty evidence). Results suggest that if the chance of pregnancy following clomiphene is assumed to be 21.5%, the chance following CHM would vary between 14.7% and 46.7%. No study reported data on adverse events. When CHM plus clomiphene was compared to clomiphene (with or without EE/CPA), there was low certainty evidence of a higher pregnancy rate in the CHM plus clomiphene group (OR 3.06, 95% CI 2.05 to 4.55; I² = 10%; 6 studies, 470 participants; low certainty evidence). Results suggest that if the chance of pregnancy following clomiphene is assumed to be 31.5%, the chance following CHM plus clomiphene would vary between 48.5% and 67.7%. No data were reported on adverse events. In trials that compared CHM plus follicle aspiration and ovulation induction to follicle aspiration and ovulation induction alone, we are uncertain of the effect of CHM on pregnancy rates (OR 1.62, 95% CI 0.46 to 5.68; 1 study, 44 women; very low certainty evidence). Results suggest that if the chance of pregnancy following follicle aspiration and ovulation induction is assumed to be 29.2%, the chance following CHM with follicle aspiration and ovulation induction would vary between 15.9% and 70%. Reported adverse events included severe luteinised unruptured follicle syndrome (LUFS) (Peto OR 0.60, 95% CI 0.06 to 6.14; 1 study, 44 women; very low certainty evidence), ovarian hyperstimulation syndrome (OHSS) (Peto OR 0.16, 95% CI 0.00 to 8.19; 1 study, 44 women; very low certainty evidence) or multiple pregnancy (Peto OR 0.60, 95% CI 0.06 to 6.14; 1 study, 44 women; very low certainty evidence). These results suggest that if the chances of LUFS, OHSS, and multiple pregnancy following follicle aspiration and ovulation induction are assumed to be 8.3%, 4.2%, and 8.3% respectively, the chances following CHM with follicle aspiration and ovulation induction would be 0.5% to 35.8%, 0% to 26.3% and 0.5% to 35.8% respectively.  In trials that compared CHM plus LOD to LOD alone, we are uncertain if CHM improves pregnancy rates (OR 3.50, 95% CI 0.72 to 17.09; 1 study, 30 women; very low certainty evidence). Results suggest that if the chance of pregnancy following LOD is assumed to be 40%, the chance following CHM with LOD would vary between 32.4% and 91.9%. No data were reported on adverse events. We are uncertain of the results in the comparison groups for all outcomes. The certainty of the evidence for all other comparisons and outcomes was very low. The main limitations in the evidence were failure to report live birth or adverse events, failure to describe study methods in adequate detail and imprecision due to very low event rates and wide CIs.

AUTHORS' CONCLUSIONS

There is insufficient evidence to support the use of CHM for subfertile women with PCOS. No data are available on live birth. We are uncertain of the effect of CHM on pregnancy rates for there is no consistent evidence to indicate that CHM influences fertility outcomes. However, we find that the addition of CHM to clomiphene may improve pregnancy rates, but there is very limited, low certainty evidence for this outcome. Furthermore, there is insufficient evidence on adverse effects to indicate whether CHM is safe. In the future, well-designed, carefully conducted RCTs are needed, with a particular focus on the live birth rate and other safety indexes.

Virilizing doses of testosterone decrease circulating insulin levels and differentially regulate insulin signaling in liver and adipose tissue of females

Transgender men undergoing hormone therapy are at risk for insulin resistance. However, how virilizing testosterone therapy affects serum insulin and peripheral insulin sensitivity in transgender men is unknown. This study assessed the effect of acute, virilizing testosterone on serum insulin concentrations and insulin signaling in liver, skeletal muscle, and white adipose tissue (WAT) of female pigs as a translational model for transgender men. Females received three doses of intramuscular testosterone cypionate (TEST females; 50 mg/day/pig) or corn oil (control) spaced 6 days apart starting on the day of estrus (D0). Fasting blood was collected on D0, D3, D5, D11, and D13, and females were euthanized on D13. On D13, TEST females had virilizing concentrations of serum testosterone with normal concentrations of serum estradiol. Virilizing serum testosterone concentrations (D13) were associated with decreased serum insulin and C-peptide concentrations. Blood glucose and serum glycerol concentrations were not altered by testosterone. Virilizing concentrations of testosterone downregulated AR and ESR1 in subcutaneous (sc) WAT and upregulated transcript levels of insulin-signaling pathway components in WAT and liver. At the protein level, virilizing testosterone concentrations were associated with increased PI3K 110α in liver and increased insulin receptor (INSR) and phospho(Ser256)-FOXO1 in visceral (v) WAT but decreased phospho(Ser473)-AKT in vWAT and scWAT. These results suggest that acute exposure to virilizing concentrations of testosterone suppresses circulating insulin levels and results in increased abundance of proteins in the insulin-signaling pathway in liver and altered phosphorylation of key proteins in control of insulin sensitivity in WAT.NEW & NOTEWORTHY Acute virilizing doses of testosterone administered to females suppress circulating insulin levels, upregulate components of the insulin-signaling pathway in liver, and suppress insulin signaling in white adipose tissue. These results suggest that insulin resistance in transgender men may be due to suppression of the insulin-signaling pathway and decreased insulin sensitivity in white adipose tissue.

Progression to prediabetes or diabetes in young Korean women with polycystic ovary syndrome: A longitudinal observational study

OBJECTIVE

To investigate changes in glycaemic status in women with polycystic ovary syndrome (PCOS).

DESIGN

Longitudinal observational study.

PATIENTS

Women with PCOS who underwent baseline and follow-up screening tests for diabetes (n = 262). Four patients with type 2 diabetes (T2DM) at baseline and 6 patients who were taking drugs at the final follow-up were excluded.

MEASUREMENTS

Changes in glycaemic classification based on fasting glucose, haemoglobin A1c and oral glucose tolerance test.

RESULTS

The median length of follow-up was 2.9 years. The mean age and body mass index in the normoglycaemia group (n = 202) were 23.0 years and 21.6 kg/m² , while it was 23.6 years and 22.9 kg/m² in the prediabetes group (n = 50). In the normoglycaemia group, 38 (18.8%) and 2 (1.0%) developed prediabetes and T2DM, respectively. In the prediabetes group, 22 (44.0%) remained in the same category, 6 (12.0%) developed T2DM, while 22 (44.0%) achieved normoglycaemia. The incidence rate of T2DM was 9.3 per 1,000 person-years, which was significantly higher than that of the female population of similar age, and the incidence was higher in women with fasting glucose ≥ 5.6 mmol/L at baseline than in women with < 5.6 mmol/L.

CONCLUSIONS

About 20% of normoglycaemic women had developed prediabetes or T2DM after a median time of 2.9 years. Meanwhile, nearly half of prediabetes women achieved normoglycaemia. Higher baseline fasting glucose levels were associated with an increased incidence of T2DM. Our results are the first to evaluate glycaemic status changes using all three parameters in patients with PCOS.

Obesity and the Risk of Infertility, Gestational Diabetes, and Type 2 Diabetes in Polycystic Ovary Syndrome

This review describes the relationship between obesity and the most common reproductive (infertility) and metabolic (gestational diabetes mellitus [GDM] and type 2 diabetes mellitus [T2DM]) consequences in polycystic ovary syndrome (PCOS). It also describes the vital role of lifestyle management for PCOS. PCOS is a heterogeneous endocrine disorder common in reproductive-age women. Consensus on the exact etiological mechanisms of PCOS is unreached. Overweight or obesity is present in at least 60% of the PCOS population, but the condition occurs irrespective of BMI, with excess BMI increasing both the prevalence and severity of clinical features. Use of lifestyle therapies (nutrition, physical activity, and/or behavioral) for the prevention and management of excess weight gain, infertility, GDM, and T2DM is a vital component of best-practice PCOS care. Lifestyle management is recommended for all women with PCOS as the first-line treatment with or without medications. Due to a lack of high-quality trials demonstrating the efficacy of specific lifestyle approaches, PCOS lifestyle recommendations are as those for the general population. This review summarizes current knowledge relating to obesity and its impact on fertility, GDM, and T2DM. It also summarizes the lifestyle recommendations to best manage these conditions in women with PCOS and obesity.

Assessment of Early Markers of Cardiovascular Risk in Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is a heterogeneous syndrome, with long-term sequelae from birth to senescence. The long-term effects of PCOS are attributed to several metabolic aberrations ensuing the syndrome. In a systematic review of literature regarding the cardiovascular risk factors that accompany PCOS, we found that macrovascular function has been assessed by flow-mediated dilatation (FMD), microvascular function by venous occlusion plethysmography (VOP), and arterial structure by ultrasonographic assessment of intima-media thickness (IMT) usually of the carotid artery. Contradictory results have been reported; however, in most studies, endothelial dysfunction, an early marker of atherosclerosis assessed either by haemodynamic methods such as FMD or by biochemical methods such as endothelin-1 levels, was found to be impaired. VOP is a less-studied method, with few indices altered. IMT was found to be altered in most of the included studies, but the population was more heterogeneous. Inflammatory markers, including C-reactive protein, were also found to be altered in most studies. On the other hand, a number of interventions have been shown beneficial for the markers of cardiovascular risk, in the context of insulin-sensitizers. However, other interventions such as oral contraceptive pills or statins did not consistently show a similar beneficial effect. In summary, the early identification and eventual treatment of cardiovascular clinical and biochemical risk factors may be used in clinical practice to prevent potential 'silent' triggers of cardiovascular disease.