Environment May Influence Hormonal, Metabolic Differences in US Women Living With PCOS

Hormonal and metabolic differences between Alabama and California women living with polycystic ovary syndrome (PCOS) suggest that environment may impact the disease.

A prospective cohort study published in the Journal of Clinical Endocrinology & Metabolism compared hormonal and metabolic data between Alabama women and California women with polycystic ovary syndrome (PCOS). Regardless of race, the study found that Alabama women with PCOS were more likely to be hirsute with metabolic dysfunction, whereas California women with PCOS were more likely to demonstrate hyperandrogenemia.

“Environmental exposures are an area of ongoing public health concern, given their potential to impact chronic disease, including PCOS,” the researchers wrote.

The study included a total of 1610 women and adolescents (14 years and older) who presented for evaluation of androgen excess at tertiary care–based specialty clinics at the University of Alabama at Birmingham or Cedars-Sinai Medical Center in Los Angeles between 1987 and 2010.

Of all the women included, 1300 (80.7%) self-identified as White; 201 (12.5%) self-identified as Black; 86 (5.3%) self-identified as Asian, mixed, or other race; and 23 (1.4%) did not specify their race.

Women with PCOS in Alabama were younger (mean [SD] age, 28.0 [7.6] years vs 29.5 [7.3] years; P = .0001) and had a higher mean (SD) body mass index (BMI) (33.1 [9.3] vs 30.1 [8.3]; P < .001) than women with PCOS in California.

Women with PCOS in Alabama were more likely to be hirsute (84.6% vs 72.8%; P < .001) and had a higher mean (SD) modified Ferriman-Gallwey score measuring hirsutism (7.9 [4.9] vs 6.7 [5.1]; P < .001) than women with PCOS in California. Even after adjusting for BMI and age, Alabama women were still more likely to be hirsute (adjusted odds ratio [aOR], 1.8; 95% CI, 1.4-2.4; P < .001).

Alabama women with PCOS were also more likely to have elevated glucose and insulin levels than California women with PCOS at each timepoint of a 2-hour glucose tolerance test.

Additionally, Alabama women had a higher mean (SD) Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) score than women with PCOS in California (8.25 [8.15] vs 3.37 [8.60]; P < .001). These findings remained even after adjusting for age and BMI (adjusted beta coefficient, 3.6; 95% CI, 1.61-5.5; P < .001).

Women with PCOS in California were more likely to have elevated free testosterone, total testosterone, and dehydroepiandrosterone sulfate (DHEA-S; a male sex hormone) values than women with PCOS in Alabama.

These findings persisted after adjusting for age and BMI: elevated free testosterone (aOR, 0.14; 95% CI, 0.11-9.18; P < .001), elevated total testosterone (aOR, 0.41; 95% CI, 0.33-0.51; P < .001), and elevated DHEA-S (aOR, 0.07; 95% CI, 0.05-0.09; P < .001).

“Overall results were similar when stratified by race, with some exceptions including the lack of differences in BMI among Black women with PCOS based on geographic location yet continued variation in androgen profiles and metabolic dysfunction based on regional differences,” the researchers noted.

However, they wrote that more study is needed to identify the precise contributors to geographic differences in PCOS presentation.

“Throughout an individual’s lifetime, factors such as geography, diet and nutrition, socioeconomic status, and environmental toxins have also been identified as environmental modulators of PCOS development and progression,” the researchers wrote.

These factors were not measured or reported in this study.

Additionally, the study was limited by only surveying women with a PCOS diagnosis based on the National Institute of Health criteria, which is less generalized to women with PCOS phenotypes reliant on ultrasound findings. Additionally, the women presented for evaluation of symptoms, so selection bias may have played a role. Differences in access to the 2 specialty clinics may also have led to selection bias.

“Ongoing research is needed to identify modifiable environmental risk factors for PCOS that may be race and ethnic specific to bring precision medicine to the management of PCOS,” the researchers concluded.


VanHise K, Chan JL, Wertheimer S, et al. Regional variation in hormonal and metabolic parameters of White and Black women with PCOS in the United States. J Clin Endocrinol Metab. Published online October 11, 2022. doi:10.1210/clinem/dgac515

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