Dr Duru Shah is the Director, Gynaecworld – The center for women’s health and fertility , Mumbai, the Founder and President of the PCOS Society India, and a member of Australia’s Centre for Research Excellence in Polycystic Ovary Syndrome’s International Advisory Panel.

Dr Duru Shah

Dr Shah’s co-author on this article is Dr Zeel Shah M.S (OB-GYN) Clinical Associate, Gynaecworld, Mumbai.

 

Beyond Menopause – Polycystic Ovary Syndrome

Polycystic Ovarian Syndrome (PCOS) is the commonest gynaecological  endocrine disorder, affecting upto 10% of women in the reproductive age group,1  characterised by oligo or anovulation, hyperandrogenism and polycystic ovaries on sonography. It  is a complex heterogenous syndrome in which both genetic and environmental influences play an important role in manifestation.2   

Insulin resistance is considered the main pathogenic factor in women with PCOS,3   with  impaired glucose tolerance  seen more often  in the  classical phenotype which  is a predictor of Type 2 Diabetes Mellitus and increased risk of gestational diabetes (GDM).4  Obesity is present in 30-70% of PCOS women 5, mostly central in type which is  known to be positively associated with Insulin Resistance.6,7   Dyslipidemia is the most commonobserved  metabolic abnormality in PCOS irrespective  of BMI.8,9Dyslipidemia leading to   metabolic syndrome which is most severe in hyperandrogenic PCOS  women.10-12

 Menopausal transition is associated with several hormonal and metabolic changes. Weight gain, increased waist circumference, abdominal obesity  and androidal fat distribution occurs in post menopausal women,13-15 which is  attributed to estrogen depletion, chronologic ageing and physical inactivity.16-19 Insulin Resistance  has been demonstrated in post menopausal women,20 which also leads to increased abdominal obesity.  All the above  changes across perimenopause leads to additional physical and psychologic

morbidity.21 All women experience increasing abdominal obesity along with chronic inflammation and dyslipidemia with age and a specific increase in LDL across menopause transition.22 It is therefore possible that metabolic abnormalities will worsen with menopause  in women with PCOS.

 

PCOS is not well defined in the postmenopausal woman due to absence of robust criteria.23 Although PCOS ameliorates with aging24 , elevated androgen levels from both ovarian and adrenal origin continue to persist during early and late menopause.25,26 Results from Shaw et al showed a significant association between menopausal androgen levels and cardiovascular events.27

Dr Zeel Shah

Cross sectional studies have reported that women with PCOS over the age of 35 years have a higher BMI, triglyceride levels, homeostasis model assessment (HOMA) glucose as compared to age matched controls.28,29 It has been proved beyond doubt   that metabolic syndrome occurrs more frequently in women with PCOS compared to controls.30 A  history of irregular periods in PCOS women has been associated with increased risk of cardiovascular disease(CVD) even after adjusting the BMI and other confounders.31A study by Dahlgren et al identified a 7 times higher risk of myocardial infarction in patients with PCOS compared to non PCOS.32   Conversely, a long term  study by Pierpoint et al concluded that PCOS women do not have a higher  cardiovascular mortality rate.33 It has been observed that patients with PCOS have a higher burden of CVD indicators like arterial stiffness, endothelial dysfunction and coronary artery calcification.34,35 The Androgen Excess Society has stated that women with PCOS who are obese, smoke cigarettes, are dyslipidemic or hypertensive  are at risk for CVD whilst  those with metabolic syndrome and diabetes are at higher risk .36   A long term prospective study found a higher prevalence of hypertension and hypertriglyceridemia in women with PCOS.37 However myocardial infarction, stroke, diabetes  and mortality prevalence was similar in BMI-matched PCOS  and control women.37 

Due to lack of clarity, more long term studies are required to demonstrate whether menopause increases the risk of cardiovascular disease in PCOS women compared to non PCOS women.

A meta-analysis done to compare women with PCOS to non PCOS groups for gynaecological cancer concluded that women with PCOS are at increased risk of endometrial cancer, but not of ovarian and breast cancer.38

Conclusion

The change in the hormonal milieu at menopause increases the cardiometabolic risk in postmenopausal women which may be more pronounced in women with PCOS. Whether PCOS exacerbates this cardiovascular risk is still uncertain, and should be evaluated in well designed long term studies of such women.

You will find the references in this article here – References – Beyond Menopause

You can find out more about this work here.