Association between adverse life events, DNA methylation and risk of premature ovarian insufficiency

Background: Premature ovarian insufficiency (POI) has serious physical and psychological consequences due to estrogen deprivation, leading to increased morbidity and mortality. Previous research has predominately focused on genetic, autoimmune, iatrogenic and infectious factors. However, the causes of most POI cases remain unknown. This is the first study to explore adverse life events as a potential cause of POI disease. Methods: A novel, mixed-methods study was conducted in an obstetric and gynecologic hospital located in Shanghai between 2018 and 2019. In the qualitative component, we recruited women newly- diagnosed with idiopathic POI (FSH levels >40 IU/L) in the hospital to participate in semi-structured interviews through convenience sampling. The main questions covered by the topic guide were designed to explore adverse life events prior to POI diagnosis. Data was audio recorded and transcribed verbatim before thematic analysis using QDA Miner Lite. Quantitatively, we then evaluated genome-wide patterns of DNA methylation in whole blood-derived DNA obtained from a sub-sample comprising the interview participants diagnosed with POI (n=20, mean age=34 years) and healthy women (comparison group) with regular menstrual cycles and a FSH level <8.8 IU/L (n=20, mean age= 34 years) using an Illumina850K microarray. Finally, a theoretical disease model was proposed by integrating findings of qualitative and quantitative studies. Findings: A total of 43 women (mean age=33·8 years) participated in the qualitative study. A number of stressful life events prior to POI diagnosis were discussed by them as important factors influencing their health and well-being. Three core themes emerged: 1) persistent exposure to workplace stress. 2) persistent exposure to family-related adverse life events, and 3) sleep problem/disturbance. In the quantitative study, we found that genome wide DNA-methylation profiles of patients with POI were different from women who experienced regular menses. Our analysis identified 5,582 differential methylated sites (DMSs), including 4,722 hypermethylated sites and 860 hypomethylated sites. Functional enrichment analysis identified differentially methylated sites (DMSs) were significantly associated with genes related to “stress response” and “circadian entrainment pathway”. An explanatory disease model was proposed to illustrate that long-term cumulative adverse experiences might interact with various genetic alterations and play a role in pathogenesis of POI. Interpretation: Persistent exposures to adverse life events related to work stress, family stress and sleep disturbance exist in idiopathic POI patients. The altered DNA methylation in POI patients who experienced adverse life events indicates that social adversity may affect ovarian function through a genetic process. Future research should investigate how social environmental factors influence POI disease risks, and whether provision of tailored interventions (i.e. preventing or mitigating impact of adverse life events) aimed at high-risk populations may help prevent new POI cases and improve conditions of existing POI patients. Funding Statement: This study was supported by National Key Research and Development Program of China (No.2018YFC1004800, 2018YFC1004802); The National Natural Science Foundation of China (No. 81971334); The Shanghai Municipal Education Commission—Gaofeng Clinical Medicine (No. 20152236). Declaration of Interests: All authors declare no competing interests. Ethics Approval Statement: Ethical approval was obtained from International Peace Maternity and Child Health Hospital (IPMCH) Ethic Committee.

ObjectivesTo reveal the characteristics of vaginal microbiota in premature ovarian insufficiency (POI) patients and their relationship with ovarian function.Materials and MethodsIn this case-control study, the vaginal bacterial composition of 30 POI patients and 26 healthy women of comparable age was assessed by 16S rRNA gene sequencing targeting the V3-V4 hypervariable regions. The metabolic functions of vaginal microflora were preliminarily predicted through the PICRUSt2 analysis. Redundancy analysis and Spearman’s correlation analyzed the relationships between vaginal microbiota and ovarian function indicators.Results Actinobacteria, Atopobium, and Gardnerella were significantly increased in POI patients. Their increments were significantly negatively correlated with anti-müllerian hormone (AMH) and inhibin B, and positively correlated with follicle-stimulating hormone (FSH) and luteinizing hormone (LH). While Bifidobacterium was significantly decreased in POI patients. Its relative abundance was significantly positively correlated with AMH and negatively correlated with FSH and LH. Then, POI patients included in this study were divided into POI (25 < FSH ≤ 40) (n = 9) and premature ovarian failure (POF) (FSH > 40) (n = 21) subgroups according to serum FSH levels. Compared with the controls, Firmicutes and Lactobacillus were significantly decreased only in POF (FSH > 40) patients, while no difference was observed in POI (25 < FSH ≤ 40) patients. Lactobacillus was negatively correlated with FSH. Firmicutes was significantly reduced and Actinobacteria was significantly increased in POF (FSH > 40) patients compared with POI (25 < FSH ≤ 40) patients. The key bacterial taxa Gardnerella and Atopobium showed potency in predicting POI.ConclusionsHere we demonstrated significant changes in the vaginal microbiota of POI patients, and these changes were significantly correlated with reduced ovarian reserve, endocrine disruption, and symptoms of perimenopausal syndrome. Differences in vaginal microbiota between POI (25 < FSH ≤ 40) and POF (FSH > 40) patients were also identified. These findings may provide new evidence for the relationship between vaginal microbiota and ovarian function.

Background and PurposePrimary ovarian insufficiency (POI) has serious physical and psychological consequences due to estradiol deprivation, leading to increased morbidity and mortality. However, the causes of most POI cases remain unknown. Psychological stress, usually caused by stressful life events, is known to be negatively associated with ovarian function. It is important to explore high-frequency adverse life events among women with POI for future interventions.MethodsForty-three women (mean age=33·8 years) were recruited who were newly- diagnosed with idiopathic POI (FSH levels >40 IU/L) to participate in semi-structured interviews through convenience sampling. The main questions covered by the topic guide were designed to explore adverse life events prior to POI diagnosis. Interviews were audio recorded, transcribed and analyzed thematically. Data were analyzed from June 2019 to August 2020.ResultsAmong the women with POI, mean age at diagnosis of POI was 33·8 years (range from 19 to 39 years), and the average time between the onset of irregular menstruation and POI diagnosis was 2.3 years. These women with POI had a relatively normal menstrual cycle before the diagnosis. A number of stressful life events prior to POI diagnosis were discussed by them as important factors influencing their health. Four core themes emerged: 1) persistent exposure to workplace stress, 2) persistent exposure to family-related adverse life events, 3) sleep problem/disturbance existed in women with POI before diagnosis, and 4) participants’ general cognition and concerns about POI.ConclusionsPersistent exposures to adverse life events related to work stress, family stress and sleep problem existed in women with POI. Our findings are consistent with the hypothesis that adverse life events play a role in the development of POI. Future research should investigate how social environmental factors influence POI disease risks, and whether provision of tailored interventions (i.e. preventing or mitigating impact of adverse life events) aimed at high-risk populations may help prevent new POI cases and improve conditions of women with POI. We gained an in-depth understanding of the experiences of these women via 1:1 qualitative method, and find adverse life events are frequent in women with POI prior to the diagnosis.

Another step towards improving oncofertility counselling of young women with Hodgkin's lymphoma.

The N6-methyladenosine (m6A) modification plays a central role in epigenetic regulation of the mammalian transcriptome. m6A can be demethylated by the fat mass- and obesity-associated (FTO) protein and the α-ketoglutarate-dependent dioxygenase alkB homolog 5 (ALKBH5) protein. Much less is known about that whether m6A content is involved in POI (premature ovarian insufficiency) disease. In this case-controlled study, 69 POI and 53 tubal occlusion patients were recruited from the reproduction centers in our hospital. For the POI animal model experiment, ovarian tissue was obtained from ten POI and nine healthy mice. An m6A test kit was developed to determine the m6A content in the RNA, and qPCR and western blot were used to examine the mRNA and protein expression levels of FTO and ALKBH5. FACS was used to measure the levels of proliferation and apoptosis, and siRNA was used to establish FTO and ALKBH5 knockdown cell lines. Our results showed that the m6A content in the RNA from POI patients and POI mice was significantly higher than control groups and that POI was characterized by the content of m6A. The mRNA and protein expression levels of FTO were significantly lower in the POI patients than control group and were associated with a risk of POI. These data suggest that the decreased mRNA and protein expression levels of FTO may be responsible for the increase in m6A in POI, which may further increase the risk of complications of POI. High m6A should be investigated further as a novel potential biomarker of POI.

The aim of the study was to compare demographic, hormonal and clinical parameters in patients with premature ovarian insufficiency (POI) and women with early menopause in Greece. One hundred thirty-nine women of Greek origin, aged 14–45 years, referring for oligomenorrhea and having elevated FSH concentrations were divided into three groups regarding the age of menstrual disturbances onset [POI1: </=30 years (n = 42); POI2: 31–39 years (n = 36); early menopause: 40–45 years (n = 61)]. The mean age of menstrual disturbances onset and that of diagnosis in all POI and early menopause patients were 28.7 years (28.7 ± 7.7) versus 42.1 years (42.1 ± 1.5) and 33.8 years (33.8 ± 7.2) versus 43.3 years (43.3 ± 1.4), respectively. POI patients and women with early menopause were diagnosed, respectively, five years and approximately four to six months later than the age of menstrual disturbances onset. Moreover, FSH2 (second confirmatory FSH measurement at 4-to-6-weeks interval) was greater in all POI patients than in early menopause women (55.4 ± 33.9 vs. 32.4 ± 19.4; p < .05) whereas mean age of menarche was greater in early menopause women than in POI patients (13 ± 1.3 vs. 12 ± 2.2; p < .05). Furthermore, FSH2 was increased in all POI and decreased in early menopause patients.

BackgroundAlthough vitamin A is known to play an important role in ovarian function, its association with ovarian insufficiency has not been reported yet. Therefore, the aim of the study was to explore the association between serum vitamin A levels and premature ovarian insufficiency (POI).MethodsThis cross-sectional survey included women with POI (n = 47) and normo-ovulatory controls (n = 67) who were enrolled between December 2016 and May 2018 in Zhejiang, China. The serum levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), anti-Müllerian hormone (AMH), vitamin A, and total cholesterol (TC) were measured for each participant. The association of TC-adjusted vitamin A levels with the risk of POI was assessed using binary logistic regression analysis.ResultsSerum vitamin A levels appeared to be slightly higher in the POI group than in the control group, but there was no evidence of a statistically significant difference (728.00 ± 176.00 µg/L vs. 503.93 ± 145.64 µg/L, p = 0.13). After adjustment for serum lipid levels, the serum vitamin A/TC ratio was significantly lower in the POI group than in the control group (143.14 ± 35.86 vs. 157.56 ± 35.21 µg/mmol, p = 0.04). Further, the serum vitamin A/TC ratio was significantly and inversely associated with POI risk (unadjusted odds ratio [OR] = 0.988, 95% confidence interval [CI]: 0.977–0.999, p = 0.04). The association remained after adjusting for confounding factors (age, BMI, annual household income, and education) (OR = 0.986, 95% CI: 0.972–0.999, p = 0.04).ConclusionsSerum vitamin A/TC ratio was inversely associated with POI risk. Therefore, the serum vitamin A/TC ratio may serve as a predictive factor for POI, and vitamin A supplementation may play help prevent or treat POI.

BackgroundDue to the lack of oestrogen, premature ovarian insufficiency (POI) is an independent risk factor for ischaemic heart disease and overall cardiovascular disease. This study aimed to apply layer-specific myocardial strain for early quantitative evaluation of subclinical left ventricular myocardial systolic function changes in patients with POI.MethodsForty-eight newly diagnosed, untreated patients with POI (POI group) and fifty healthy female subjects matched for age, height and weight (control group) were enrolled. Standard transthoracic echocardiography was used to measure conventional parameters and layer-specific strain parameters.The layer-specific strain parameters included subendomyocardial global longitudinal strain (GLSendo), mid-layer myocardial global longitudinal strain (GLSmid), subepimyocardial global longitudinal strain (GLSepi), subendomyocardial global circumferential strain (GCSendo), mid-layer myocardial global circumferential strain (GCSmid), and subepimyocardial global circumferential strain (GCSepi). ResultsThere were no significant differences in age, body mass index (BMI), blood pressure, or left ventricular ejection fraction (LVEF) between the two groups. The end-diastolic interventricular septal thickness (IVST) was greater in the POI group (8.29 ± 1.32 vs. 7.66 ± 0.82, P = 0.008), and the POI group had lower E, E/A, and lateral e′ (all P < 0.05). As for systolic functions,the POI group had lower GLSendo, GLSmid, GLSepi, GCSendo, GCSmid, and GCSepi (all P < 0.05).The intraobserver and interobserver coefficients of GLSendo, GLSmid, GLSepi, GCSendo, GCSmid, and GCSepi were greater than 0.900. ConclusionsPOI patients with normal LVEF may suffer from subclinical left ventricular myocardial systolic dysfunction. Echocardiography of layer-specific myocardial strain could more sensitively detect subclinical impairment of left ventricular systolic function in POI patients.Graphical abstract

FSHR polymorphisms are associated with premature ovarian insufficiency development

Premature ovarian insufficiency (POI) is associated with an increased risk of neurodegenerative diseases, but the underlying mechanisms remain unclear. Here, we integrated DNA methylome profiling of peripheral blood leukocytes and circulating steroid hormone analysis to identify potential mechanism linking POI to neurogenerative risk. Methylome analysis revealed distinct epigenetic signatures in POI patients, including hypomethylation at the SOAT1 promoter, a gene critical for cholesterol homeostasis. Gene set enrichment analysis (GSEA) implicated suppressed steroid biosynthesis, supported by significantly reduced circulating levels of steroids, including androstenedione, dehydroepiandrosterone (DHEA), aldosterone, cortisol, and cortisone in POI patients. Notably, neuroprotective steroids DHEA and pregnenolone exhibited an age-dependent decline exclusively in the POI group. Our findings suggest that SOAT1-mediated cholesterol dysmetabolism leads to steroidogenesis suppression and depletion of neuroprotective steroids. Epigenetic dysregulation of SOAT1 and steroidogenic genes, coupled with depletion of DHEA and pregnenolone might contribute to the elevated neurodegenerative risk in POI.

Laparoscopic ovarian surgery to induce follicular response in patients with premature ovarian insufficiency, diminished ovarian reserve, or resistant ovary syndrome

Premature ovarian insufficiency (POI) is poorly understood, with causes identified in only 25% of cases. Emerging evidence suggests links between trace elements (TEs) and POI. This study is the first to compare concentrations of manganese (Mn), copper (Cu), zinc (Zn), selenium (Se), molybdenum (Mo), arsenic (As), cadmium (Cd), mercury (Hg), and lead (Pb) across urine, serum, and whole blood in women with POI compared to healthy controls (HC), aiming to explore their distribution and potential associations with POI. This cross-sectional-case-control study enrolled 81 participants (40 POI patients and 41 healthy controls) at the University Medical Centre Ljubljana, Slovenia. Blood and urine samples were collected to quantify basic biochemical parameters using standard clinical chemistry methods and concentrations of Mn, Cu, Zn, Se, Mo, As, Cd, Hg, and Pb using inductively coupled plasma-mass spectrometry (ICP-MS). Participants also completed questionnaires on socio-demographics, medical history, lifestyle, and nutrition. Data was analyzed using the Mann-Whitney U test, Student's t-tests, Fisher exact test, logistic regression models adjusted on body mass index (BMI), age, hematocrit, and Kendall's tau correlation. Women with POI had significantly higher BMI and red blood cell (RBC) indices, including hemoglobin, hematocrit, and red cell distribution width (RDW), compared to controls. A larger proportion of POI patients resided in rural agricultural areas. Liver and kidney function assessments showed no significant differences between the groups. Adjusted models revealed that POI patients had significantly lower urinary levels of Cu, Zn, Se, Mo, Cd, Hg, and Pb than controls, while whole blood Mn levels were higher. Serum Cu levels were significantly elevated in POI patients, whereas Pb, Cd, and Hg were lower. No significant differences were observed for As. Correlation analysis showed several strong to moderate associations among TEs across biofluids, but only weak correlations were found between TEs and demographic or biochemical factors. This study suggests potential associations between TEs and POI in women. Notably, most TEs (Zn, Se, Cu, Mo, Cd, Hg, Pb) were significantly lower in the urine of the POI group, while Cu, Cd, Hg, and Pb showed significant differences in both urine and serum.

BackgroundCurrently, evidence on the role of stressful life events in fatigue among the Chinese working adults is lacking. This study aimed at exploring the prospective associations between stressful life events and chronic fatigue among Chinese government employees.MethodsFrom January 2018 to December 2019, a total of 16206 government employees were included at baseline and they were followed-up until May 2021. A digital self-reported questionnaire platform was established to collect information on participants' health and covariates. Life events were assessed by the Life Events Scale (LES), fatigue was assessed by using a single item, measuring the frequency of its occurrence. Binary logistic regression analysis was used for the data analysis.ResultsOf the included 16206 Chinese government employees at baseline, 60.45% reported that they experienced negative stressful life events and 43.87% reported that they experienced positive stressful life events over the past year. Fatigue was reported by 7.74% of the sample at baseline and 8.19% at follow-up. Cumulative number of life events at baseline, and cumulative life events severity score at baseline were positively associated with self-reported fatigue at follow up, respectively. After adjusting sociodemographic factors, occupational factors and health behavior related factors, negative life events at baseline (OR: 2.06, 95% CI: 1.69–2.51) were significantly associated with self-reported fatigue at follow-up. Some specific life events including events related to work and events related to economic problems were significantly associated with self-reported fatigue. Specifically, work stress (OR = 1.76, 95%CI: 1.45–2.13), as well as not satisfied with the current job (OR = 1.95, 95%CI: 1.58–2.40), in debt (OR = 1.75, 95%CI: 1.40–2.17) were significantly associated with self-reported fatigue. The economic situation has improved significantly (OR = 0.62, 95%CI: 0.46–0.85) at baseline was significantly associated with lower incidence of self-reported fatigue.ConclusionNegative stressful life events were associated with fatigue among Chinese government employees. Effective interventions should be provided to employees who have experienced negative stressful life events.

Objective This study aimed to investigate the characteristics of bone mineral density (BMD) in patients with premature ovarian insufficiency (POI), compare BMD between iatrogenic POI and idiopathic POI patients, and investigate the factors affecting BMD in POI patients. Method This cross-sectional study recruited a total of 88 iatrogenic POI patients, 45 idiopathic POI patients and 45 normal reproductive-age women, all of whom met the study criteria and were treated at the Department of Gynecological Endocrinology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University from 1 January 2023 to 30 June 2024. Medical history was collected for all patients, and follicle stimulating hormone (FSH), estradiol (E2), total testosterone (TT), free testosterone (FT), biologically active testosterone (BioT), dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulfate (DHEAS) were measured. Height and weight were measured, and the body mass index (BMI) was calculated. BMD of the lumbar spine and left femur was measured in POI patients. Multiple linear regression analyses were performed to determine the correlation between characteristics and BMD. Results The incidence of osteoporosis was significantly higher in iatrogenic POI patients than in idiopathic POI patients (40.9% vs. 20.0%, p < 0.05). The femoral shaft BMD, greater trochanter BMD t-score, total femoral BMD and total femoral BMD t-score were significantly lower in iatrogenic POI patients compared to idiopathic POI patients (all p < 0.05). Multiple linear regression analysis revealed that delay in diagnosis negatively affected the lumbar BMD t-score (p < 0.05) and the BMI and DHEAS positively affected the total femur BMD t-score in iatrogenic POI patients (p < 0.05). No significant correlations were found in idiopathic POI patients. Conclusion The incidence of osteopenia and osteoporosis in POI patients is high, especially in iatrogenic POI patients, who experience more severe bone loss and a higher incidence of osteoporosis. BMI and a delay in diagnosis significantly affected BMD in iatrogenic POI patients. This, to our knowledge, is the first study showing that DHEAS positively affects BMD in iatrogenic POI patients, which, however, needs further studies for confirmation.

STUDY QUESTIONWhat is the incidence of premature ovarian insufficiency (POI), has the incidence of POI changed over time, and what is the risk of POI among relatives of POI women?SUMMARY ANSWERThe incidence of POI increased among females aged 15–19 years from 2007 onwards and decreased in older age groups, and among relatives of women with POI the risk of POI is significantly increased.WHAT IS KNOWN ALREADYSo far, there has been no good quality, nationwide studies of the incidence of POI. Early menopause has been associated with the elevated risk of early menopause among relatives, but the knowledge of the familial risk of POI is scarce. Lower socioeconomic status has been associated with lower age at natural menopause.STUDY DESIGN, SIZE, DURATIONPopulation-based study with 5011 women diagnosed with POI in 1988–2017. The data were collected from national registries and covers POI subjects in entire Finland.PARTICIPANTS/MATERIALS, SETTING, METHODSWomen with hormone replacement therapy reimbursement for POI were identified from Social Insurance Institution (SII). We calculated POI incidence in different age groups and studied the changes in the incidence rate over time in 5-year segments. Four population-based controls were selected from the Digital and Population Data Services Agency (DVV) for each POI woman. Family members of the POI cases and controls were identified from the DVV and linked to SII reimbursement data to identify POI diagnoses among them. The familial risk of POI was estimated with a logistical regression model.MAIN RESULTS AND THE ROLE OF CHANCEThe incidence was highest in the 35–39 age group, ranging from 73.8/100 000 women-years in 1993–1997 to 39.9/100 000 women-years in 2013–2017. From 2007, the incidence among 15- to 19-year-olds rose from 7.0 to 10.0/100 000 women-years in 2015–2017. Cumulative incidence of POI for women under 40 years in 1988–2017 was 478/100 000 women. The relative risk of POI among relatives of women with POI was 4.6 (95% CI 3.3–6.5) compared to relatives of women without POI. POI women tended to have slightly lower socioeconomic status and level of education compared to controls.LIMITATIONS, REASONS FOR CAUTIONFor some women with POI, diagnosis or reimbursement may be lacking. However, we presume that these women represent a minority due to the nature of the disease and the economic benefits of reimbursement. Some changes in the incidence of POI can reflect changes in clinical practice and changing treatments and reimbursement criteria.WIDER IMPLICATIONS OF THE FINDINGSThe risk of developing POI is significantly higher in women who have first-degree relatives diagnosed with POI. Raising awareness of the increased risk might lead to earlier diagnosis and initiation of hormonal replacement therapy, possibly preventing adverse effects of low oestrogen levels, such as osteoporosis.STUDY FUNDING/COMPETING INTEREST(S)This work was financially supported by the Oulu University Hospital. H.S. received a grant from Finnish Menopause Society. S.M.S. received a grant from the Finnish Menopause Society, the Finnish Medical Foundation and the Juho Vainio Foundation. The authors do not have any competing interests to declare.TRIAL REGISTRATION NUMBERN/A.