Highly Atherogenic Lipid Particles are Associated with Preeclampsia After Successful Fertility Treatment for Obese Women who have Unexplained Infertility.

Atherogenic dyslipidemia-before or during pregnancy-may contribute to preeclampsia and subsequent cardiovascular disease risk. We performed a nested case-control study to further understand dyslipidemia associated with preeclampsia. The cohort consisted of participants in the randomized clinical trial "Improving Reproductive Fitness Through Pretreatment with Lifestyle Modification in Obese Women with Unexplained Infertility" (FIT-PLESE). FIT-PLESE was designed to study the effect of a pre-fertility treatment 16-week randomized lifestyle intervention program (Nutrisystem diet + exercise + orlistat vs. training alone) on improvement in live birth rate among obese women with unexplained infertility. Of the 279 patients in FIT-PLESE, 80 delivered a viable infant. Maternal serum was analyzed across five visits: before and after lifestyle interventions and also at three pregnancy visits (16, 24, and 32 weeks gestation). Apolipoprotein lipids were measured in a blinded fashion using ion mobility. Cases were those who developed preeclampsia. Controls also had a live birth but did not develop preeclampsia. Generalized linear and mixed models with repeated measures were used to compare the mean lipoprotein lipid levels of the two groups across all visits. Complete data were available for 75 pregnancies, and preeclampsia developed in 14.5% of the pregnancies. Cholesterol/high-density lipoprotein (HDL) ratios (p < 0.003), triglycerides (p = 0.012), and triglyceride/HDL ratios, all adjusted for BMI, were worse in patients with preeclampsia (p < 0.001). Subclasses a, b, and c of highly atherogenic, very small, low-density lipoprotein (LDL) particles were higher during pregnancy for the preeclamptic women (p < 0.05). Very small LDL particle subclass d levels were significantly greater only at 24 weeks (p = 0.012). The role of highly atherogenic, very small LDL particle excess in the pathophysiology of preeclampsia awaits further investigation.

Proprotein Convertase Subtilisin Kexin 9 (PCSK9) and nonHDL particles rise during normal pregnancy and differ by BMI.

BACKGROUND: Serum lipids, including total cholesterol (TC), triglycerides (TG), and low-density lipoprotein cholesterol (LDL-c), increase during pregnancy. Serum Proprotein Convertase Subtilisin Kexin 9 (PCSK9) is a vital regulator in lipoprotein metabolism. Circulating PCSK9 downregulates the LDL receptor on the surface of liver cells inhibiting clearance of LDL-c. OBJECTIVE: To determine the influence of weeks of pregnancy and obesity on circulating levels of essential lipid lipoproteins and PCSK9 in women with normal, uncomplicated pregnancies and deliveries. METHODS: We performed a comprehensive lipid and lipoprotein profile during each trimester of pregnancy in 70 mostly Caucasian women with uncomplicated normal pregnancies and deliveries. Based on their first trimester BMI, we placed them into one of three categories: (<25 kg/m2 n=23, 25-30 kg/m2 n=25, or >30 n=22) kg/m2. Cholesterol, triglycerides, LDL cholesterol (LDL-c), non-HDL particles, and lipoprotein(a) were measured by spectrophotometry, ion mobility, and immunoturbidimetric assays. Elisa assay determined PCSK9 (active and total). Homeostatic Model Assessment (HOMA-IR) assessed insulin resistance in the second and third trimesters of pregnancy. RESULTS: Total and active PCSK9, LDL-c, and nonHDL particle concentrations were higher than reported for non-pregnant normal values, increased after the first trimester of pregnancy, and were highest from mid-gestation to the last trimester of pregnancy in the overweight and the obese. CONCLUSION: PCSK9 levels rise as normal pregnancy progresses. Levels are higher in persons who are obese, even after adjustment for insulin resistance. Defining normal PCSK9 levels during pregnancy must adjust for gestational age and BMI.

Lipoprotein lipid concentrations and cardiovascular risk in women with polycystic ovary syndrome.

Twenty-nine patients with polycystic ovary syndrome (PCOS) and 30 normal women had lipoprotein lipid and androgen profiles compared after a 12-h fast. Both PCOS and normal women were evaluated in the proliferative phase of the cycle. PCOS patients had higher serum LH to FSH ratios [2.0 +/- 1.3 (+/- SEM) vs. 0.6 +/- 0.1), higher testosterone (T; 66 +/- 5 vs. 33 +/- 2 ng/ml), higher free T (1.1 +/- 1 vs. 0.4 +/- 0.02 ng/dl), and higher dehydroepiandrosterone sulfate (291 +/- 28 vs. 140 +/- 12 micrograms/dl) levels, and lower T-estrogen-binding globulin-binding capacity (1.5 +/- 0.2 vs. 2.2 +/- 0.1 micrograms/dl) than normal women (all P less than 0.05). The PCOS patients had higher mean serum triglycerides [122 +/- 11 (+/- SEM) 63 +/- 3 mg/dl] and very low density lipoprotein cholesterol levels (24 +/- 2 vs. 13 +/- 1 mg/dl), but lower high density lipoprotein cholesterol levels (43 +/- 2 vs. 58 +/- 2 mg/dl; P less than 0.05). While PCOS patients were heavier and more sedentary and their diets were higher in saturated fat and lower in fiber (P less than 0.01, respectively), the differences in lipoprotein lipid concentrations could not be attributed to body weight. T-estrogen-binding globulin-binding capacity correlated with high density lipoprotein cholesterol in PCOS patients (r = 0.42; P = 0.025) after adjusting for weight. We conclude that hyperandrogenemia in women may result in a male pattern of lipoprotein lipid concentrations. These findings suggest that PCOS patients may have increased atherogenic potential.

The effects of hormone replacement therapy and raloxifene on C-reactive protein and homocysteine in healthy postmenopausal women: a randomized, controlled trial.

C-Reactive protein and homocysteine are independent risk factors for the development of cardiovascular disease. This study compared the effects of hormone replacement therapy (HRT) and raloxifene on serum C-reactive protein and homocysteine levels as markers of cardiovascular risk in healthy postmenopausal women. Healthy postmenopausal women (n = 390) were enrolled in a double blind, randomized, placebo-controlled, 6-month trial at eight out-patient sites in the United States. Women were randomly assigned to receive continuous combined HRT (0.625 mg/day conjugated equine estrogen and 2.5 mg/day medroxyprogesterone acetate), raloxifene (60 or 120 mg/day), or placebo for 6 months. C-Reactive protein and homocysteine were measured in baseline and 6-month serum samples. HRT increased C-reactive protein levels by 84% (P<0.001), whereas raloxifene (60 and 120 mg/day) had no significant effect (-6% and -4%;, respectively; P>0.2). Raloxifene (60 and 120 mg/day) significantly lowered serum levels ofhomocysteine by 8% (P = 0.014) and 6% (P = 0.024), respectively, similar to the 7% (P = 0.014) reduction obtained with HRT. We conclude that HRT and raloxifene lower serum homocysteine levels to a comparable extent in postmenopausal women. Whereas cardiovascular risk predicted by C-reactive protein in healthy postmenopausal women is not influenced by raloxifene, the relationship between elevated C-reactive protein levels with HRT and cardiovascular disease events requires further study.

Obesity, lipids, cardiovascular risk, and androgen excess.

Several lines of evidence suggest that a subset of women may be at increased risk of cardiovascular disease because of unfavorable alterations in insulin action and/or production, accompanying altered apolipoprotein metabolism and altered androgenicity and/or estrogenicity. A number of cardiovascular disease risk factors, including central obesity, insulin resistance (with associated hyperinsulinemia), dyslipidemia, and/or diabetes mellitus, tend to cluster in these women. Another common ovarian morphology in women with hyperandrogenism is polycystic ovaries, which cluster with hirsutism, anovulation, infertility, gonadotropin secretion abnormalities, android fat distribution, and many important cardiovascular disease risk factors. Studies indicate that androgen excess may be a signal of increased risk for coronary artery disease, even in younger women. If androgenicity and insulin resistance are early warning signs of increasing risk of morbidity and mortality, these patients are prime candidates for preventive medicine. It is important that primary care providers begin to recognize these androgen disorders as a clue to the existence of a complex, lifelong pattern potentially placing women at risk for premature morbidity and mortality and initiate preventive treatment before irreversible thresholds are crossed.

Estrogen: effects on the cardiovascular tree.

My objective is to review the current literature with respect to basic science aspects concerning the effects of both endogenous and exogenous sex steroids on the vascular system. For simplification in this complex, burgeoning field, generalizations are made and mechanisms are highlighted. Major landmark studies in the English language over the past 25 years are reviewed. Cardiovascular, endocrinologic, and gynecologic references are targeted. Investigations by leading authorities are emphasized with an intent to bridge clinical significance with in vitro studies, in vivo data (both animal and human), and current epidemiologic information. Study results indicate that atherosclerotic lesions can stabilize, and occlusion can regress. The combined effects of estrogen in preventing atherosclerosis and maintaining arterial tone and integrity indicate that the circulatory system is a major target for estrogen action. A number of direct and indirect effects of estrogen have been shown to be beneficial.

Serum progesterone levels as an aid in the diagnosis of ectopic pregnancy.

Progesterone levels in 29 women with ectopic pregnancies and 20 women with early intrauterine pregnancies were evaluated using a new direct radioimmunoassay that offers results within four hours. Patients with normal intrauterine pregnancies had serum progesterone levels greater than 20 ng/mL (mean = 30.9 ng/mL) while all patients with ectopic pregnancies had progesterone levels less than 15 ng/mL (mean = 5.7 ng/mL). The incorporation of the progesterone assay into the workup of a patient with suspected ectopic pregnancy can be a useful clinical adjunct to the conventional methods of evaluation.

Virilizing paraovarian tumors: a consequence of Nelson's syndrome?

In a patient with Nelson's syndrome, elevated peripheral concentrations of androgens usually associated with neoplasm prompted ovarian vein catheterization. Androgen excess was limited to the right ovary. However, laparotomy revealed bilateral multiple paraovarian nodules with histologic appearance of adrenocortical tissue. The occurrence of virilization from ectopic adrenal tissue with markedly elevated ACTH concentrations is exceedingly rare.

Autoantibodies associated with endometriosis: can their detection predict presence of the disease?

To evaluate the usefulness of autoantibody detection as a nonoperative method of diagnosing endometriosis, we tested 221 sera from 215 patients from the infertility, gynecology, and gynecologic oncology services by an indirect immunofluorescence assay using monolayer cultures of an endometrial carcinoma cell line. The assay showed positive cytoplasmic staining, demonstrating a sensitivity of 83% in the patients with laparoscopically confirmed endometriosis. The specificity of the assay was 65% for the infertility patients and 76% for the infertility and gynecology patients combined. Several gynecologic cancer patients showed either nuclear or nuclear and cytoplasmic staining, but few showed exclusive cytoplasmic staining. These initial results suggest that detection of antibodies might be useful for the diagnosis of endometriosis.

Metabolic impact of adding medroxyprogesterone acetate to conjugated estrogen therapy in postmenopausal women. The Menopause Study Group.

OBJECTIVE: To evaluate the impact of different dosages of medroxyprogesterone acetate (MPA) on metabolism and hemostasis in postmenopausal women treated with conjugated estrogens. METHODS: In this prospective, double-blind study, 525 women were randomized to five treatment groups at 26 sites in the United States and Europe. All participants received 0.625 mg conjugated estrogens daily for up to 13 cycles; four groups also received MPA, either 2.5 or 5.0 mg/day continuously or 5.0 or 10.0 mg/day for the last 14 days of each cycle. Effects on lipid and carbohydrate metabolism and coagulation were evaluated. RESULTS: Beneficial changes in plasma lipid levels occurred in all groups, but were greatest with conjugated estrogens alone (P < or = .05). Fasting glucose and insulin levels were significantly lower and the insulin response to glucose challenge was significantly blunted in all groups (P < or = .05). No major changes of clinical significance occurred in hemostatic levels. CONCLUSIONS: Metabolic levels were not affected adversely by the addition of MPA to conjugated estrogens, but some beneficial changes were greater with conjugated estrogens alone. Hemostatic levels were not affected.

Basal body temperature and endometriosis.

This investigation examined the association between pelvic endometriosis and altered basal body temperature (BBT). The study population consisted of infertile women who have been diagnosed as having endometriosis. A significant association was found between the presence of pelvic endometriosis (without previous treatment) and the appearance of a late decline in BBT during the early follicular phase of the menstrual cycle. A temperature greater than 97.8 degrees F on the first 3 days of menses is associated with pelvic endometriosis. The findings of this study support the early clinical diagnosis of endometriosis in infertile women. Basal body temperature chart analysis may be useful as a clinical adjunct when endometriosis is suspected.

Detection of antiendometrial antibodies in patients with endometriosis: methodological issues.

OBJECTIVE: To determine if methodological reasons explain previous inability of a single investigator to detect antiendometrial antibodies in patients with endometriosis by indirect immunofluorescence (IIF). DESIGN: Sera of selected patients were tested by standard IIF and recently reported methodology. Alternate diluent experiments were conducted to explain discordant results. SETTING: Sera were obtained preoperatively, and testing was completed in an institutional research laboratory. Results are compared with surgical findings. PATIENTS/PARTICIPANTS: Patients, seven with endometriosis and six without endometriosis, 40 years of age or less who are presenting for gynecological surgery. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Indirect immunofluorescence was graded according to the presence or absence of cytoplasmic staining, intensity of the staining, and the lowest dilution at which staining was observed. RESULTS: The standard IIF method repeatedly demonstrated the presence of cytoplasmic staining for the presence of antiendometrial antibodies in patients with endometriosis, whereas modified methods did not produce similar positive staining results. During the alternate dilution experiments, when fluorescein isothiocyanate conjugate (FITC) was diluted in animal sera, negative results were obtained. CONCLUSIONS: The variations used in alternate methodology and failure to titrate FITC reported by other investigators are possible reasons for false-negative results reported.

Evaluation of endometrial tissue specific complement activation in women with endometriosis.

OBJECTIVE: To determine if endometrial tissue specific complement (C) activation occurs in patients with endometriosis. DESIGN: Prospective. SETTING: University of Oklahoma Health Sciences Center, a tertiary care referral center. PATIENTS: Twenty-six women, 9 with endometriosis and 17 without endometriosis. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Uterine and ectopic endometria were evaluated by the immunofluorescence assay for the presence of activated products of the initial (C3d) and terminal (C5b-9) C pathway, C3 regulatory proteins (decay-accelerating factor and membrane cofactor protein), and terminal C regulatory proteins (clusterin and vitronectin). RESULTS: The initial (C3d) and terminal (C5b-9) C components were deposited on blood vessel walls in uterine and/or ectopic endometria of women with and without endometriosis. In the stromal compartment at both sites, C deposition was colocalized with terminal C inhibitors/cell-cell attachment factors, clusterin and vitronectin on elastic fibers. No specific staining for C proteins was detected on the glandular epithelium of uterine and ectopic endometrial tissues examined. Furthermore, intense staining of endometrial epithelium for C3 regulatory proteins, decay-accelerating factor, and membrane cofactor protein was noted on endometrial glands from women with and without endometriosis. CONCLUSIONS: Our findings demonstrate a lack of specific deposition of C in the glandular epithelial cells of endometria of women with endometriosis. The localization of C3 regulatory proteins, decay-accelerating factor, and membrane cofactor protein on glandular epithelium may suggest the involvement of intrinsic protective mechanisms on these cells from autologous C attack in vivo.

F(ab')2 segment is the active component of immunoglobulin G autoantibody generation in patients with endometriosis.

OBJECTIVE: To determine if the low titer antiendometrial antibody detection by indirect immunofluorescence (IIF) in the sera of patients with endometriosis is because of specific antigen-antibody interactions. DESIGN: Sera of selected patients subjected to separation of immunoglobulin fragments by ammonium sulfate precipitation and pepsin digestion and tested by IIF. In a comparative method, a fragment, crystallizable (Fc) flooding technique was used to determine the active component. SETTING: Sera obtained preoperatively in the outpatient and results matched with surgical findings. PATIENTS/PARTICIPANTS: Patients 45 years of age or less presenting for gynecological surgery who had signed an informed consent for the drawing of preoperative blood. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Indirect immunofluorescence was graded according to the intensity of staining and the lowest dilution at which staining occurred. RESULTS: All of the sera of the 11 patients with endometriosis exhibited F(ab')2 specific staining but none exhibited Fc fragment staining. None of the 7 control patients displayed F(ab')2 or Fc fragment staining. CONCLUSIONS: F(ab')2 fragment is the active component of an immunologically specific interaction when antiendometrial antibodies are detected in the sera of patients with endometriosis.

Subtle variations in tubal anatomy in infertile women.

The frequency of tubal variations was recorded in 100 infertile and 100 fertile women at cesarean section. The infertile women had significantly more tubal/pelvic anatomical variation than did their fertile counterparts. Fimbrial agglutinations (25%), accessory tubes (13%), accessory ostia (10%), phimoses (13%), and sacculations (7%) were found more commonly in the infertile women. Paratubal cysts were found with equal numbers in both groups. There was no statistical difference in history of sexually transmitted disease/pelvic inflammatory disease (PID) or endometriosis. No significant relationship between a positive PID history and fimbrial agglutination was found; the majority of agglutinations were present with no associated adhesions.

Vulvar acanthosis nigricans: a marker for insulin resistance in hirsute women.

OBJECTIVE: To determine the frequency of acanthosis nigricans (AN) in a group of hirsute, hyperandrogenic women and to determine the body site most frequently affected. DESIGN: Cross-sectional observational study. SETTING: University teaching hospital. PATIENTS, PARTICIPANTS: Reproductive age, nonhypertensive, nondiabetic women referred for evaluation of hirsutism, documented to have hyperandrogenism, without medications known to influence lipid, carbohydrate, or hormonal metabolism. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Presence of AN. Insulin resistance was assessed by measuring fasting glucose, fasting insulin, and nadir glucose after a 0.1 U/kg i.v. insulin bolus in both obese and nonobese, hirsute, hyperandrogenic women. RESULTS: Twenty-four of 43 women were found to have AN. Although AN was identified at several body sites including the axilla (n = 14), on the nape of the neck (n = 13), below the breasts (n = 7), and on the inner thigh (n = 7), it was always present on the vulva in women who displayed one or more lesions. Acanthosis nigricans was found only in the obese, hirsute, hyperandrogenic women. These women were the most insulin resistant. CONCLUSIONS: Acanthosis nigricans and insulin resistance are found frequently in obese, hirsute, hyperandrogenic women. The vulva is the most likely place to find this marker.

Effect of tumor necrosis factor-alpha on adhesion of human endometrial stromal cells to peritoneal mesothelial cells: an in vitro system.

OBJECTIVE: To assess the effects of tumor necrosis factor-alpha (TNF-alpha) on adhesion of endometrial stromal cells to peritoneal mesothelial cells, a possible step leading to endometriosis. DESIGN: Analysis of cell adhesion in vitro. SETTING: University research laboratory. PATIENTS: Peritoneal fluid and biopsies were obtained from volunteers with regular cycles without endometriosis or endometrial pathology. INTERVENTIONS: Tumor necrosis factor-alpha (0.1 to 1,000 U/mL) was added to nutrient media with the following supplements: 10% fetal calf serum, epidermal growth factor 20 ng/mL, and gentamicin 10 ng/mL. MAIN OUTCOME MEASURES: Radioactivity of chromium-51 was used as a reflection of adherent stromal cells. RESULTS: The adherence of endometrial stromal cells to mesothelial cells was significantly increased by pretreatment of mesothelial cells with TNF-alpha. CONCLUSIONS: Tumor necrosis factor-alpha may play a facilitory role in the development of endometriosis.

Antibodies to carbonic anhydrase in endometriosis: prevalence, specificity, and relationship to clinical and laboratory parameters.

OBJECTIVE: To investigate the presence and clinical association of serum autoantibodies to carbonic anhydrase (CA) in women with and without endometriosis. DESIGN: Sera were tested in an ELISA against human and bovine CAI and/or CAII isoenzymes and by Western immunoblotting of trypsin-digested fragments of human CAII as antigens. The ELISA positivity was defined as mean + 2 SD of 100 control sera. Positive sera also were tested for the presence of antiendometrial antibodies and antinuclear antibodies (ANA) by indirect immunofluorescence assays (IFA) on endometrial (ECC) and HEp-2 cells, antibodies to single-stranded (ss) and double-stranded (ds) DNA by the Farr-type RIA and Crithidia IFA, and extractable nuclear antigens (Sm, nRNP, Ro, and La) by an ELISA. PATIENTS: Sera from 319 patients with laparoscopic diagnosed pelvic endometriosis (100 stage I, 95 stage II, 67 stage III, and 57 stage IV), 100 with other gynecologic disorders, and 100 control women were used. RESULTS: In the ELISA, 113 of 319 (35.4%) endometriosis sera had elevated immunoglobulin G antibodies against nondenatured CA isoenzymes. The reactivity of sera from the endometriosis group was significantly higher (35%) in all four subgroups of patients than each of the nonendometriosis sera (< 12% and < 6%, respectively). No stage-dependent variation of an autoantibody pattern was evident. However, anti-CA autoantibodies were present in 66.3% of women with endometriosis-associated infertility. The frequency of anti-CA autoantibodies was significantly higher (by 51.7%) in women with antiendometrial antibodies detectable by IFA. In addition, in sera positive for anti-CA antibodies, the frequency of ANA also was increased (20/113 [17.6%]) with titers of 1:40 to 1:1,080. The ANA-positive sera were negative for anti-ssDNA, anti-dsDNA, anti-Sm, anti-nRNP, and anti-La. However, three sera were positive for anti-Ro antibodies. Immunoblotting study of autoantibody reactivity with trypsin-digested subfragments of human CAII revealed consistent immunoreactivity with 14 to 6.2-kd range CAII peptides. CONCLUSIONS: [1] A subgroup of patients with endometriosis have autoantibodies directed to native and linear epitopes of the CA protein. [2] Prevalence of anti-CA antibodies was associated with antiendometrial antibodies and ANA. [3] Anti-CA antibodies were associated with a higher predictive value of the disease when all patient subgroups were considered together.

Endometrial antibodies versus CA-125 for the detection of endometriosis.

Detection of endometrial antibodies using an indirect immunofluorescence method along with a well-established human endometrial carcinoma cell line was evaluated and compared with CA-125 for detecting endometriosis. Two hundred two patient sera from the infertility, gynecological, and gynecological oncology services were evaluated. The sensitivity for antibody testing was 83.1% with a specificity of 78.8%, in contrast to a sensitivity of 27.3% and a specificity of 82.6% for CA-125. These preliminary findings offer promise that antibody detection methods may be a useful adjunct in the diagnosis of endometriosis.

Clinical signs of androgen excess as risk factors for coronary artery disease.

Women with androgen excess have been found to have higher triglycerides and lower high-density lipoprotein cholesterol concentrations than nonhirsute women and are presumed to be at increased risk of coronary artery disease. However, definitive data linking androgen excess with coronary artery disease is lacking. We evaluated 102 women coming to coronary artery catheterization for signs and symptoms of androgen excess. Hirsutism was found more commonly in those women with confirmed coronary artery disease (chi 2 = 10.11). Waist:hip ratio (an index of android fat distribution) was associated with hirsutism (by ANOVA, F-test) and with coronary artery disease (t-test). The strongest associations were found in older women (aged greater than or equal to 60). Androgen excess in women may signal risk for coronary artery disease.