Racial Differences in Women with PCOS
Abstract & Commentary
By Michael A. Thomas, MD
Professor, Center for Reproductive Health, University of Cincinnati College of Medicine
Dr. Thomas reports no financial relationships relevant to this field of study.
Synopsis: A retrospective cohort study of 519 women diagnosed with polycystic ovary syndrome demonstrates that black adolescents and reproductive-aged adults have a higher risk for metabolic syndrome and cardiovascular disease compared to their white counterparts.
Source: Hillman JK, et al. Black women with polycystic ovary syndrome (PCOS) have increased risk for metabolic syndrome and cardiovascular disease compared with white women with PCOS. Fertil Steril 2014;101:530-535.
This study consists of 519 total women with polycys-
tic ovary syndrome (PCOS) who were stratified into adult and adolescent groups. Criteria for PCOS was different depending on the group. In the adults, two of three components were necessary to secure the diagnosis of PCOS. These adult criteria included: biochemical or clinical hyperandrogenism, oligomenorrhea, or polycystic appearing ovaries on ultrasound. This is based on the well-accepted Rotterdam criteria.1 However, in the adolescents, PCOS was diagnosed using a previously published modified criteria (of Rotterdam) that is specific for adolescents, which included irregular menstrual cycles with nine or fewer per year for at least 2 years after menarche, polycystic ovaries on transvaginal ultrasound (volume ≥ 10 cm3), and either biochemical hyperandrogenism (total testosterone ≥ 55 ng/mL) or clinical hyperandrogenism (Ferriman-Gallawey score ≥ 8).2
Physical examination and laboratory testing, including fasting glucose and lipids, were performed on all participants. Black adolescents (relative risk [RR], 2.65; 95% confidence interval [CI], 1.29-5.4) and adults (RR, 1.44; 95% CI, 1.21-2.6) were noted to have an increased incidence of metabolic syndrome compared to white girls or women with PCOS. Overall, black PCOS patients had a higher systolic blood pressure (127.33 ± 13.3 vs 121.49 ± 13.3 mmHg), diastolic blood pressure (74.88 ± 8.76 vs 72.04 ± 9.75 mmHg), insulin (23.25 ± 22.31 vs 12.45 ± 14.11 mcU/mL), glucose (88.6 ± 18.8 vs 83.3 ± 11.6), and body mass index (BMI) > 30 kg/m2 (72.3% vs 47%), but lower values for total cholesterol (179.07 ± 38.51 vs 184.49 ± 34.26 mg/dL), high-density lipoprotein (HDL; 49.24 ± 17.19 vs 55.05 ± 15.91 mg/dL), and triglycerides (100.38 ± 83.92 vs 115.47 ± 67.15 mg/dL). When controlling for age and BMI, black adults with PCOS had higher fasting concentrations of low-density lipoproteins and glucose as well as lower HDL in comparison to their white counterparts.
COMMENTARY
PCOS is the most common endocrine disorder in reproductive-aged women with an incidence of 8-12%. Though various diagnostic criteria have been postulated to establish a diagnosis, the classic features of PCOS are hyperandrogenism, oligomenorrhea, and a sonographic finding of a polycystic ovarian morphology. Although the Rotterdam Consensus group in 2004 allowed a diagnosis of PCOS with only two of the three classic criteria,1 many of the experts argued that hyperandrogenism could not be eliminated when making a "definitive" diagnosis.3 Despite these minor diagnostic differences, an association between PCOS and cardiovascular comorbidities (insulin resistance, abnormal glucose metabolism, obesity, and dyslipidemias) has been recognized.4 Metabolic syndrome is a strong predictor of cardiovascular disease and encompasses a constellation of components including abdominal obesity, dyslipidemia, hypertension, and insulin resistance.5 Although the National Health and Nutrition Examination Survey (NHANES) showed no differences in non-Hispanic black men or women compared to non-Hispanic white men or women,6,7 a population of PCOS adolescents and young adults women was not the focus of the study.
This study highlights the racial differences in PCOS patients. Though it was known that PCOS patients are at higher risk for metabolic syndrome and cardiovascular disease, these cardio-metabolic risk factors are much worse in adolescent and adult black women compared to white women. A smaller study examined the potential metabolic differences in black and white women who had PCOS.8 These investigators examined 32 black and 94 white women and noted that the black women had higher HDL cholesterol concentrations and lower non-HDL and triglyceride values. A case-control study of 120 women with PCOS noted that the black cohort also had a more favorable lipid profile than their white counterparts.9
However, these previous studies did not address the issue of overall metabolic differences between the races. Dyslipidemias are only one aspect of metabolic syndrome, which also includes an assessment of abdominal obesity, blood pressure, and insulin resistance. This trial used BMI as a surrogate marker for abdominal obesity, which is one of the potential limitations that the authors expressed.
This study was the first to demonstrate that not all PCOS patients are the same; although white women and girls with PCOS are at risk for increased cardiovascular disease, blacks at all ages are at much higher risk. These black adolescents and adults also demonstrated a higher incidence of obesity, lower HDL cholesterol concentrations, and higher fasting insulin and glucose levels. This is a long-term recipe for cardiovascular events (stroke, myocardial infarction, etc.) or premature death.
The study highlights the need for adequate recruitment of racially diverse populations in trials. Focused attention should be given to recruiting and maintaining women of African, Hispanic, or Asian descent to have a better assessment of their risk. Though this current investigation recruited only from one clinical center, a study from multiple sites should be undertaken to confirm or refute these findings.
Whether aggressive weight loss and dietary intervention at an early age in those diagnosed with PCOS will result in benefit remains to be seen. The National Institutes of Health’s Reproductive Medicine Network is considering funding an aggressive weight loss program for patients diagnosed with PCOS.
It is my hope that racial differences can be assessed during this prospective trial.
References
- Rotterdam ESHRE/ASRM-sponsored PCOS Consensus Workshop Group. Fertil Steril 2004;81:19-25.
- Carmina E, et al. Am J Obstet Gynecol 2010;203:201.e 1-5.
- Azziz R, et al. J Clin Endocrinol Metab 2006;91:4237-45.
- Wild RA, et al. J Clin Endocrinol Metab 2010;95:2038-2049.
- Trevisan M, et al. Am J Epidemiol 1998;148:958-966.
- Ervin RB. Natl Health Stat Rep 2009;5:1-7.
- Walker SE, et al. Nutr Metab Cardiovasc Dis 2012;22:
141-148.
- Koval KW, et al. J Clin Endocrinol Metab 2010;95:E49-53.
- Ladson G, et al. Fertil Steril 2011;96:224-229.
