PCOS: Cardiovascular, Fatty Liver and Sleep Apnea Complications

By Yemi Adesanya-Famuyiwa, MD

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder among women of reproductive age, affecting 5-13% of women.

It can present as four varying combinations of hyperandrogenemia (excessive androgen levels), ovulatory dysfunction (that can manifest as irregular menstrual cycles), and polycystic ovary morphology as noted on ultrasound. PCOS, particularly the hyperandrogenism phenotype, is associated with several cardiometabolic abnormalities, including obesity, dyslipidemia, elevated blood pressure, and prediabetes or type 2 diabetes. Many, but not all, studies have suggested that PCOS is associated with increased risk of cardiovascular disease (CVD), including coronary heart disease and stroke. This increased risk for cardiovascular events is independent of body mass index and other risk factors.

The predilection for cardiovascular risk can be noted as early as in adolescents. A recent study showed overweight adolescents have an incidence of PCOS of 22%. In this population there is increased incidence of hyperinsulinism, which is one of the risk factors for cardiovascular events. Hyperinsulinemia increases with androgen production. Girls with polycystic ovary syndrome and obesity have a higher insulin resistance as well as three times higher incidence of type 2 diabetes than adults with polycystic ovary syndrome. Adolescents with PCOS and BMI greater than 25 had higher triglycerides and LDL cholesterol levels in addition to having lower HDL.

Polycystic ovary syndrome is associated with inflammatory cytokines that results in a state of chronic low-grade inflammation. The association of the chronic inflammatory state and the excess production of cytokines results in increased insulin resistance. Insulin resistance and hyperandrogenemia have been associated with the development of nonalcoholic fatty liver disease.

Polycystic ovary syndrome has also been associated with the development of nonalcoholic fatty liver disease. Polycystic ovary syndrome especially in patients with high BMI is also associated with obstructive sleep apnea. The development of nonalcoholic fatty liver disease and obstructive sleep apnea frequently present in PCO S patients and usually go undiagnosed for a while.

Early diagnosis of nonalcoholic fatty liver disease is especially important because this can progress to nonalcoholic steatohepatitis and or advanced liver fibrosis that can lead to increased liver related mortality. Treatment of nonalcoholic Fatty liver disease should include lifestyle intervention. Doychena et al. recognition in treatment of sleep obstructive apnea is especially important because this can compound the cardiovascular risks associated with polycystic ovary syndrome.