Diabetes risk may worsen for women with ‘string of pearls’ PCOS appearance

Key takeaways:

• Women with a “string of pearls” follicular distribution in polycystic ovary syndrome may be at higher risk for type 2 diabetes.
• Ovarian morphology did not worsen risk for other chronic conditions.

DENVER — Reproductive-age women with polycystic ovary syndrome that presents as a “string of pearls” follicular formation may be more likely to develop type 2 diabetes compared with women with other PCOS phenotypes, according to a speaker.

One diagnostic criteria for PCOS is the number of follicles 2 mm to 9 mm in diameter seen in the ovary on ultrasound; a string-of-pearls appearance of follicles arranged peripherally in the ovary has been associated with more severe metabolic disturbances among reproductive-age women, Nir Kugelman, MD, a fellow in gynecologic reproductive endocrinology and infertility at McGill University Health Centre in Montreal, said during a presentation at the ASRM Scientific Congress & Expo. However, long-term data on health outcomes such as chronic morbidity and mortality for women with this ovarian follicular distribution are lacking, Kugelman said.

For the prospective study, researchers analyzed data from 340 women with PCOS enrolled in a long-term study between 1987 and 2005 who had sonographic information, including 189 women with the string-of-pearls follicular distribution and 151 with a more random follicular distribution. Researchers assessed hormone levels and CV risk markers at enrollment and followed patients until 2024. Primary outcomes were mortality and chronic morbidity including diabetes, dyslipidemia, hypertension, ischemic heart disease, autoimmune conditions and nine cancer types in the two groups.

At enrollment, women with the string-of-pearls follicular formation were younger (mean age, 28 years vs. 33 years; P < .001), had a higher BMI (mean, 27.2 kg/m² vs. 25.3 kg/m²; P = .004) and had higher levels of serum luteinizing hormone, follicle-stimulating hormone, androgens, fasting insulin, total cholesterol and triglycerides (P for all < .001).

During follow-up of more than 30 years, there were seven deaths among women with the string-of-pearls follicular distribution and nine deaths among women with the random follicular distribution (P = .33). Women in the string-of-pearls group on average died younger (mean age, 54.3 years vs. 70.8 years; P = .037).

Women in the string-of-pearls group had higher rates of noninsulin-dependent diabetes compared with women with the random follicular distribution (23.8% vs. 9.2%; P < .001). In analyses adjusted for age at recruitment, BMI, fasting insulin, cholesterol and triglyceride levels, the only condition associated with the string-of-pearls follicular formation was noninsulin-dependent diabetes, with an OR of 2.92 (95% CI, 1.37-6.21).

Women in the string-of-pearls group also had a numerically higher rate of hypertension that did not reach statistical significance (34.3% vs. 25.1%; P = .066).

“Interestingly, women in the string-of-pearls group had lower rates of hypothyroidism ... with a P value that nearly reached statistical significance,” Kugelman said.

There were no between-group differences for any other chronic conditions or cancers, Kugelman said.

“Despite more severe metabolic derangements when younger, no significant differences were observed in the rates of most chronic conditions, mortality or cardiovascular diseases between the string-of-pearls and nonstring-of-pearls groups at the end of the study, when [women] were older,” Kugelman said. “This also confirms that a string-of-pearls appearance is a marker for a more severe metabolic dysfunction in PCOS patients. However, aging may have reduced earlier metabolic disparities, by increasing disturbance in the nonstring-of-pearls group, or the follow-up period was insufficient to capture disease differences. Therefore, longer follow-up is needed to better understand long-term health outcomes in PCOS patients.”