Polycystic Ovary Syndrome and Cardiovascular Risk

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PCOS is associated with an increase in cardiovascular risk factors (189). In addition to obesity that is commonly present and independently associated with increased cardiovascular risk, women with PCOS have dyslipedemia, hypertension and elevated PAI-1 levels. Obesity is a prominent feature in women with PCOS as about half of the patients are obese. Also, obesity appears to confer an additive and synergistic effect on the mani festations of the syndrome and additionally, it is one of the strongest risk factors for diabetes. The obesity is usually of the android type with an increased waist to hip ratio that may further contribute to diabetes risk.

Women with PCOS have higher serum triglycerides, total and LDL cholesterol and lower HDL cholesterol levels than weight-matched regularly menstruating women (190). These findings however, vary and depend on the weight, diet and ethnic background. In a large study of non-Hispanic white women, elevated LDL-C was the predominant lipid abnormality in women with PCOS (191). An additional parameter contributing to the elevated cardiovascular risk is hypertension. Obese women with PCOS have an increased incidence of hypertension and sustained hypertension is threefold more likely in later life in women with PCOS (192). It is not clear whether this increase in hypertension is because of the PCOS status, obesity or both.

PAI-1 concentrations in blood are higher in women with PCOS as compared to those not affected. PAI-1 levels have been shown to be positively correlated with triglycerides, basal insulin and abdominal obesity (193). It was shown that impaired fibrinolysis and particularly the high levels of PAI-1 in selected groups of patients with CHD, is not a consequence of the coronary disease itself but it is rather related to the metabolic risk factors of atherosclerosis (194).

PCOS has also been associated with endothelial dysfunction. In the past several years it has been become evident that endothelial dysfunction may play the central pathogenetic role in the development of diabetes complications and CVDs. In a study that included 12 obese women with PCOS, endothelium-dependent vasodilation was found to be impaired (195). Additionally, it was shown that endothelial dysfunction was associated with both elevated androgen levels and insulin resistance.

Furthermore, in women with PCOS, mean carotid intima-media wall thickness (IMT) was found to be greater as compared to age-matched women without PCOS (196). Greater IMT is associated with an adverse cardiovascular risk profile that includes hyperlipi-demia, central adiposity, hypertension and hyperinsulinemia, which is the profile of the dysmetabolic syndrome (syndrome X). Also, increases in the thickness of the carotid intima and media has been shown to be a reliable measure of atherosclerosis elsewhere and directly associated with increased risk of cerebrovascular events and MI in older adults (197).

In addition to above, women with PCOS were found to have more extensive coronary artery disease (198). This was shown in a study that examined patients that underwent coronary angiography for the assessment of chest pain or valvular disease. Polycystic ovaries were present in 42% of the women and coronary lesions were associated with hirsutism, previous hysterectomy, low HDL, higher free testosterone, triglycerides, and C-peptide levels.

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