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Departments of Internal Medicine (T.A., P.A.E., M.J.I., J.E.N.) and Obstetrics and Gynecology (J.E.N.), Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia 23298-0111
Address all correspondence and requests for reprints to: John E. Nestler, M.D., Medical College of Virginia, P.O. Box 980111, Richmond, Virginia 23298-0111. E-mail: nestler{at}hsc.vcu.edu.
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Abstract |
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We conducted a retrospective chart review of all women with PCOS seen over a 3-yr period at an endocrinology clinic. Of the 161 PCOS cases reviewed, 106 met the inclusion criteria. The women were divided into two groups: 1) women with PCOS and the MBS (n = 46); and 2) women with PCOS lacking the MBS (n = 60).
Prevalence of the MBS was 43%, nearly 2-fold higher than that reported for age-matched women in the general population. Women with PCOS had persistently higher prevalence rates of the MBS than women in the general population, regardless of matched age and body mass index ranges. Acanthosis nigricans was more frequent in women with PCOS and the MBS. Women with PCOS and the MBS had significantly higher levels of serum free testosterone (P = 0.002) and lower levels of serum SHBG (P = 0.001) than women with PCOS without the MBS. No differences in total testosterone were observed between the groups.
We conclude that the MBS and its components are common in women with PCOS, placing them at increased risk for cardiovascular disease. Women with PCOS and the MBS differ from their counterparts lacking the MBS in terms of increased hyperandrogenemia, lower serum SHBG, and higher prevalence of acanthosis nigricans, all features that may reflect more severe insulin resistance.
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Introduction |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Insulin resistance also appears to play a pathogenic role in the metabolic syndrome (MBS) (16, 17). The National Cholesterol Education Program Adult Treatment Panel (NCEP ATP III) (18) guidelines define the MBS as having three or more of the following abnormalities: waist circumference in females greater than 88 cm; fasting serum glucose at least 110 mg/dl; fasting serum triglycerides at least 150 mg/dl; serum HDL-C less than 50 mg/dl; and blood pressure at least 130/85 mm Hg. The MBS is associated with a heightened risk for developing DM2 (19) and cardiovascular disease (20), as well as with cardiovascular mortality (21). The NCEP ATP III criteria were used to ascertain the prevalence of the MBS in a representative U.S. adult sample, using data from the Third National Health and Nutrition Examination Survey (NHANES III) (22). In this sample, the prevalence of the MBS among women in age groups 20–29 and 30–39 yr was 6 and 15%, respectively (23).
Cardiovascular and DM2 risk factors defining the MBS are prevalent in PCOS (14, 23). Recently, some studies assessed the prevalence of metabolic abnormalities or MBS in women with PCOS. Korhonen et al. (24) conducted a cross-sectional population-based study and reported that serum concentrations of some sex hormones differed between premenopausal women with and without ATP III-defined MBS. Glueck et al. (25) studied prevalence of the MBS, using ATP III criteria, in 138 PCOS patients and found it to be 46%. Legro et al. (26) compared metabolic abnormalities and cardiovascular risk factors between women with PCOS and control women and reported them to be more frequent in the former group.
To date, however, no study has evaluated whether in PCOS, women with the MBS differ phenotypically and hormonally from those without the MBS. We hypothesized that the MBS is more prevalent in PCOS than in age-matched women in the general population. We also hypothesized that the presence of the MBS would reflect more severe insulin resistance, and as a consequence, women with PCOS and the MBS would be more hyperandrogenic and suffer from more severe menstrual cycle irregularity than women with PCOS without the MBS. To test this hypothesis, we conducted a retrospective medical chart review of women with PCOS seen in our Endocrine Clinic. The results confirmed that the MBS is more prevalent in women with PCOS than in the general U.S. population, even when matched for both age and body mass index (BMI), and indicated that women with PCOS who have the MBS have a higher degree of hyperandrogenism.
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Subjects and Methods |
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We reviewed the charts of all women with PCOS seen by two of the investigators (J.E.N., M.J.I.) in the private academic endocrine practice at the Virginia Commonwealth University Health System for routine clinical care during the period from December 2000 to December 2003. Women were referred from a wide range of sources, including self-referral, obstetrics-gynecology clinics, primary care clinics, and subspecialty clinics, both at the academic center and in the community. Inclusion criteria for the study required the presence of the following information in the medical record: 1) BMI and/or waist circumference, blood pressure, fasting lipid profile, fasting plasma glucose oral glucose tolerance test, and androgens all assessed at baseline; 2) use of no medications known to affect sex steroid metabolism, such as oral contraceptives, or insulin-sensitizing drugs for at least 3 months before enrollment; and 3) recorded history of menses while off oral contraceptives and other hormonal agents known to affect menstrual cyclicity.
We identified a total of 161 women evaluated during the specified time period. Of these, 106 women fulfilled the inclusion criteria. From records of these 106 patients, we collected data on the following variables: age; race; BMI; age of menarche; menstrual history; presence or absence of hirsutism and acanthosis nigricans; a family history of heart disease, diabetes, or PCOS in first-degree relatives; a fasting lipid profile [serum total cholesterol, HDL-C, low-density lipoprotein cholesterol (LDL-C), and triglycerides]; a fasting glucose and 2-h oral glucose tolerance test; serum concentrations of 17 
-hydroxyprogesterone; total and free testosterone; SHBG; dehydroepiandrosterone sulfate (DHEAS); prolactin; and TSH.
Patients who were excluded (n = 57) did not differ from the study cohort (n = 106), with regard to clinical characteristics (age, BMI, age at menarche, and menstruation frequency) and hormonal variables (total testosterone, free testosterone, SHBG, percentage free testosterone, DHEAS, and 17 -hydroxyprogesterone). The majority of patients excluded (n = 50; 88%) were excluded due to missing fasting plasma glucose values. Other reasons for exclusion were absent levels of serum triglycerides (n = 15), HDL-C (n = 23), and BMI determinations (n = 2). Many of the excluded women (44%) had two or more parameters missing.
Women were diagnosed with PCOS using criteria adopted at the 1990 National Institute of Child Health and Human Development conference on PCOS (27). That is, women were diagnosed as having PCOS if they had chronic oligomenorrhea (eight or fewer menstrual periods annually) and hyperandrogenism (either clinical hirsutism or elevated serum total or free testosterone) and if the diagnoses of hypothyroidism, hyperthyroidism, hyperprolactinemia, and nonclassical adrenal hyperplasia had been excluded (27). Hirsutism was clinically assessed by the endocrinologist caring for the patient, and acanthosis nigricans was determined by the presence of the characteristic pigmentary changes on the posterior neck or axillary region (28).
In the present study, we used the NCEP ATP III criteria for MBS with one modification. Because waist circumference measurements were not taken on all the patients, we used BMI as a surrogate for waist circumference. Studies have shown that at least 50% of PCOS women are overweight or obese, and the majority of them have abdominal adiposity (29). To determine the cutoff value of BMI corresponding to a waist circumference of 88 cm that would be relevant for PCOS, we used data from women with PCOS enrolled in previous studies at our university, because they were derived from the same pool of clinic patients. We analyzed (Fig. 1
) the correlation between BMI and waist circumference in these PCOS women (n = 75; age range, 20–40 yr) and found that a waist circumference of 88 cm corresponded to a BMI of 32 kg/m2 (r = 0.82; P < 0.0001). These previously studied 75 PCOS patients were matched by age and BMI with 106 women with PCOS in our study.
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Laboratory analyses
All laboratory analyses were performed by either the Clinical Chemistry Laboratory of the Virginia Commonwealth University Health System hospital or the Laboratory Corporation of America Holdings (LabCorp, Burlington, NC). Serum total cholesterol and glucose concentrations were measured by standard assays. Triglycerides were measured with a glycerol-blanked assay to avoid false elevations by endogenous glycerol. HDL-C and LDL-C were measured with homogeneous assays specific for HDL-C and LDL-C, respectively. All of the above were done with Roche reagents on a Hitachi 717 analyzer (Hitachi High-Technologies Corp., Tokyo, Japan). Prolactin and TSH were measured on a standard automated immunoassay system (Immulite 2000, Diagnostic Products Corporation, Los Angeles, CA). Free testosterone was analyzed by equilibrium dialysis. Total testosterone, SHBG, and DHEAS were measured by automated immunoassay at LabCorp.
Statistical analysis
Results are reported as the means with 95% confidence intervals or percentages, if not indicated otherwise. We assessed the normality of the distribution of all variables using the normal quintile plot method. For comparison of continuous variables, the analysis of covariance model was used to adjust for BMI and age differences between the two groups. Demographic and historic dichotomous variables were compared by 
2 analysis using the Pearson test. The nominal logistic regression was used to adjust for the differences in BMI and age covariates between the two groups when comparing the dichotomous outcome variables (acanthosis and hirsutism).
Evaluation of trend between age groups was analyzed using the Cochran-Armitage trend test. Prevalence of the MBS by age and BMI from the NHANES data was analyzed for nonpregnant women at least 20 yr of age who attended the medical examination and fasted at least 8 h before the exam. Analysis of NHANES III data included sampling weights to produce nationally representative estimates, as described previously (30). Statistical significance was defined by P values < 0.05. All statistical analyses were performed with JMP statistical software (version 4.0, SAS Institute Inc., Cary, NC), including calculation of weighted percentages to adjust for the complex NHANES III sampling design.
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Results |
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Prevalence of the NCEP ATP III-defined MBS within this cohort of PCOS patients was 43%, occurring in 46 of 106 subjects (Table 1). Figure 2 presents age-stratified prevalence of the MBS in the study, compared with the age-stratified prevalence of the MBS in U.S. females at least 20 yr of age (23). In the 20- to 29-yr-old group, women with PCOS had a nearly 8-fold greater prevalence than women in the general population (44.8 vs. 5.9%, respectively). Similarly, women with PCOS aged 30–39 had a nearly 4-fold increased prevalence of the MBS compared with similarly aged women in the general population. With age, the prevalence of the MBS increased in our study, from 23% of PCOS women less than 20 yr old to 45% of women aged 20–29 yr, and then to 53% of PCOS women aged 30–39 yr, representing a significant trend (P < 0.001).
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, the prevalence of the MBS continued to differ markedly between women with PCOS and women in the general U.S. population.
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, and prevalence of one or more abnormalities of the MBS is shown in Table 4. The most prevalent of the MBS factors among the study subjects were high BMI (67%) and low serum HDL-C (68%). The least prevalent factor was a high fasting serum glucose level (3.8%). Among these PCOS patients, the most prevalent combination was the presence of three MBS abnormalities (30.2%), with only 9.4% of the women having no MBS factors.
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Using the 1997 criteria of the American Diabetes Association (31, 32), the prevalence of impaired fasting glucose (IFG), impaired glucose tolerance, and DM2 in our study was 0.9% (1 of 106), 11% (12 of 106), and 8% (7 of 106), respectively (Table 1
). In the U.S. female population aged 20–39 yr, prevalence of IFG and DM2 is 0.6 and 1.1%, respectively (32), hence revealing that the prevalence of DM2 was 8-fold greater in the women with PCOS. If one were to apply the new 2003 guideline for IFG of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus (33), which is a fasting serum glucose greater than 100 mg/dl, to the patients in our study, the prevalence of IFG increased from 0.9% (1 of 106) to 10% (11 of 106).
Anthropometric and clinical characteristics of MBS in PCOS
As shown in Table 5, PCOS patients with the MBS had a significantly higher mean BMI compared with women without the MBS (39.3 vs. 33.7 kg/m2; P = 0.001). Because insulin resistance correlates positively with BMI and may be confounded by age, we adjusted for both BMI and age when comparing variables between these two groups of women.
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Clinically, PCOS women with the MBS tended to present more often with symptoms of hirsutism, although this difference was not significant (P = 0.24; Table 6). Acanthosis nigricans, after adjusting for BMI and age differences between the groups, was statistically more prevalent among PCOS patients with the MBS compared with their non-MBS counterparts (50 vs. 23%; P = 0.03). Family history of heart disease, hypertension, lipid abnormalities, DM2, and PCOS was similar between the two groups.
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Women with PCOS and the MBS were more hyperandrogenic than women with PCOS lacking the MBS after adjustment for age and BMI (Table 5). Serum total testosterone levels were higher, although not statistically, in the MBS women compared with the non-MBS women (72.1 vs. 60.1 ng/dl; P = 0.09). Levels of serum free testosterone were statistically higher in the MBS patients compared with the non-MBS patients (1.61 vs. 1.07 ng/dl; P = 0.002). Accordingly, serum SHBG concentrations were significantly lower in the MBS group than in the non-MBS patients (26.2 vs. 36.5 nmol/liter; P = 0.001).
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Discussion |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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In our study, the prevalence of the MBS in women with PCOS was 43%, which is nearly 2-fold higher than the age-adjusted prevalence rate of 24% in women nationally, based on data obtained from women who participated in the NHANES III survey (23). In fact, the prevalence rate of the MBS in our women with PCOS under age 40 was comparable to the 44% rate reported for women aged 60–69 in the general population. Because the presence of the MBS correlates with cardiovascular disease risk, this finding of a markedly high prevalence of the MBS in young women with PCOS lends support to previous reports suggesting that women with PCOS manifest increased atherosclerosis (13, 14, 15) and a 7-fold increased risk of cardiovascular disease (34).
Importantly, the higher prevalence of the MBS in women with PCOS compared with the NHANES III database persisted even when stratified by both age and BMI. This indicates that obesity by itself does not account for the age-related differences in the prevalence of the MBS between these two groups of women. As shown in Table 2, women with PCOS had a higher prevalence of MBS at all ranges of BMI compared with women in the general population. This finding suggests that the presence of PCOS by itself confers increased risk of the MBS, perhaps secondary to the intrinsic insulin resistance of PCOS.
Women with concurrent PCOS and MBS presented more frequently with the phenotypic feature of acanthosis nigricans, a putative biomarker of insulin resistance, than women with PCOS only. They also suffered from more severe hyperandrogenemia, manifested as higher serum free testosterone and lower serum SHBG concentrations, than PCOS women without the MBS. Notably, this again may reflect more severe insulin resistance in the women with the MBS, because SHBG has been noted to correlate inversely with insulin sensitivity.
The high prevalence of the MBS in our cohort of women with PCOS (43%) is in very close agreement with the 46% incidence of MBS reported in newly referred women with confirmed PCOS reported by Glueck et al. (25). When patients in our study (the majority of whom were between ages 30 and 39) were stratified by age, the prevalence of MBS was 45% in women with PCOS between ages 20 and 29 yr and 53% in women 30 or older. As shown in Fig. 2, these rates are substantially higher than the rates of 6% for women aged 20–29 yr and 15% for women aged 30–39 yr reported in the general population (23).
In further evaluating the MBS in PCOS, it was noteworthy that the majority of women with PCOS had at least one abnormality of the MBS present (91%). Other than elevated BMI, 69% of women with PCOS had two or more of the abnormalities present. Conversely, only 9% of these women lacked any metabolic abnormalities.
Of the abnormalities present in affected women with PCOS, low HDL-C occurred most frequently (68%), followed in descending order by elevated BMI (67%), high blood pressure (45%), hypertriglyceridemia (35%), and high fasting serum glucose (4%). These findings are consistent with those of Legro et al. (26) who also reported a high prevalence (91%) of low serum HDL-C (<35 mg/dl) and a low prevalence of IFG (3%) in women with PCOS. Low serum HDL-C levels are known to predict an increased risk of cardiovascular disease independently of serum LDL-C (35), and recent studies have suggested that serum HDL-C may provide cardiovascular protection by direct endothelial effects via nitric oxide synthase (36, 37, 38).
Another contributing factor to cardiovascular disease is hyperandrogenemia. Our results found serum free testosterone levels to be significantly higher in women with PCOS and the MBS compared with women with PCOS without the MBS (P = 0.002). Likewise, SHBG levels were significantly lower in PCOS in the presence of the MBS compared with PCOS lacking the MBS (P = 0.001). Studies have shown that SHBG may be a surrogate marker of insulin resistance such that the lower the level of SHBG, the greater the degree of insulin resistance (39). Therefore, the significantly lower serum concentration of SHBG observed in PCOS women with the MBS compared with those without the MBS suggests a central role of insulin resistance in the MBS.
We find a significant difference (P = 0.04), although slight, in menstrual cycle frequency between PCOS women with and without the MBS. The only phenotypical difference between the PCOS patients with and without the MBS in our study was the presence of acanthosis nigricans in the former group. Acanthosis nigricans is reported to be highly associated with insulin resistance (40). This finding supports our hypothesis that the MBS would reflect greater insulin resistance.
There were some limitations to our study. The main limitation was that data for the study were not collected prospectively, but the study was based on retrospective clinical data. Therefore, direct waist circumference measurements and formal hirsutism scores were not available. BMI was used as a surrogate for waist circumference, an approach validated by the strong positive correlation of BMI with waist circumference in women with PCOS. Meigs et al. (41) compared the prevalence of the MBS in the San Antonio Heart Study cohort using BMI vs. waist circumference as part of the ATP III criteria, noting that waist circumference is not uniformly used in clinical care. They reported that prevalence was similar when BMI was substituted for waist circumference. In addition, insulin resistance was not measured directly in our study. However, because measurement of insulin resistance directly by techniques such as the hyperinsulinemic clamp is not "standard of care" in PCOS, this study could not include this data. Other caveats include the relatively small sample size and the potential for recall bias in terms of history of menstrual cycle irregularity and reporting of family history.
Despite these limitations, the findings of this study, conducted in an academic clinical endocrine practice, have significant clinical implications. The women in this study were not preselected, making them more likely to be representative of typical patients with PCOS managed in clinical endocrine practices. These women with PCOS had a high prevalence of the MBS, at a rate of 43%, and, notably, the findings indicate an association between PCOS and the MBS that is independent of obesity. Excluding elevated BMI, 69% of women with PCOS had two or more of the abnormalities present. The MBS confers increased risk for cardiovascular disease, and the presumed increased insulin resistance of women with PCOS and MBS should confer increased risk for glucose intolerance. Because PCOS affects up to 10% of the 50 million reproductive-aged women in the United States, if the prevalence of the MBS in PCOS is approximately 40%, then nearly 2 million women may be affected with concurrent PCOS and the MBS. These findings support the idea that PCOS should be considered a general health disorder with serious public health implications and indicate that physicians should comprehensively screen all women with PCOS for the MBS.
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Footnotes |
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First Published Online December 28, 2004
Abbreviations: BMI, Body mass index; DHEAS, dehydroepiandrosterone sulfate; DM2, type 2 diabetes mellitus; HDL-C, high-density lipoprotein cholesterol; IFG, impaired fasting glucose; LDL-C, low-density lipoprotein cholesterol; MBS, metabolic syndrome; NCEP ATP III, National Cholesterol Education Program Adult Treatment Panel; NHANES III, Third National Health and Nutrition Examination Survey; PCOS, polycystic ovary syndrome.
Received June 2, 2004.
Accepted December 16, 2004.
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