The Journal of Clinical Endocrinology & Metabolism

ContextPolycystic ovary syndrome (PCOS) is a heterogeneous endocrine disorder associated with reproductive dysfunction and long-term cardiometabolic risk. Traditional phenotype classifications based on diagnostic criteria may not fully capture the multidimensional biological variability underlying endocrine and metabolic risk profiles, particularly in young women. ObjectiveTo identify data-driven endocrine-metabolic phenotypes in young women with PCOS and evaluate their association with established cardiometabolic risk markers. Design and SettingCross-sectional study conducted at a tertiary Gynecological Endocrinology Clinic in Poland between January 2018 and May 2025. ParticipantsA total of 1300 young women diagnosed with PCOS according to Rotterdam criteria were included. The primary analytic cohort comprised 1032 participants aged 16-25 years with complete endocrine-metabolic biomarker data. Main Outcome MeasuresEndocrine-metabolic phenotypes were derived using principal component analysis followed by Gaussian mixture model clustering. Cardiometabolic risk endpoints included impaired glucose tolerance (2-hour plasma glucose during an oral glucose tolerance test [≥]140 mg/dL), an atherogenic lipid profile (triglycerides (TG)/high-density lipoproteins (HDL-C) ratio >3.50), elevated non-HDL cholesterol ([≥]130 mg/dL), and a composite outcome of any abnormality. ResultsPrincipal component analysis retained 10 components explaining 81.9% of total variance. Unsupervised clustering identified two stable phenotypes (silhouette = 0.392; ARI = 0.842). Cluster 0 (n=954; 92.4%) represented a mixed endocrine-metabolic profile, whereas cluster 1 (n=78; 7.6%) was enriched for thyroid/autoimmune features, with higher anti-thyroid peroxidase antibody levels and higher thyroid-stimulating hormone. Cluster 1 showed a higher prevalence of an atherogenic lipid profile compared with cluster 0, while differences in glucose intolerance and non-HDL cholesterol were modest. Logistic regression analyses suggested phenotype-specific variation in cardiometabolic risk markers. ConclusionsIn a large cohort of young women with PCOS, data-driven analysis identified two reproducible endocrine-metabolic phenotypes, including a distinct thyroid/autoimmune-enriched subgroup. These findings highlight clinically relevant heterogeneity beyond traditional diagnostic phenotypes and support the potential value of integrated endocrine-metabolic profiling for early risk stratification in PCOS.

BackgroundThyroid autoimmunity (TAI) is frequently reported in women with polycystic ovary syndrome (PCOS), yet its clinical relevance for cardiometabolic and androgenic severity remains uncertain. We evaluated whether TAI identifies a metabolically or androgenically more severe PCOS phenotype using pre-specified exposure definitions and cardiometabolic endpoints. MethodsThis cross-sectional study included 1,300 women with confirmed PCOS in the source dataset. Thyroid autoimmunity was defined a priori using three definitions: anti-thyroid peroxidase antibodies above the laboratory upper limit of normal (TAI_A, primary definition), anti-TPO positivity combined with thyroid-stimulating hormone >4.0 mIU/L (TAI_B), and high-titer anti-TPO >100 IU/mL (TAI_C). The primary endpoint was triglyceride-to-high-density lipoprotein cholesterol ratio (TG/HDL-C) >3.5. Secondary endpoints included non-HDL-C [≥]130 mg/dL and 120-minute oral glucose tolerance test (OGTT) glucose [≥]140 mg/dL. Associations were assessed using age-adjusted Firth logistic regression models in complete-case cohorts. Sensitivity analyses included restriction to euthyroid participants, alternative TAI definitions, trimming of extreme values (1-99%), and bootstrap-based confidence intervals. Exploratory hormonal comparisons were adjusted using the Benjamini-Hochberg false discovery rate. ResultsTAI_A was not significantly associated with the primary endpoint (TG/HDL >3.5) (OR 0.77, 95% CI 0.21-1.67). No significant associations were observed for secondary endpoints including non-HDL-C [≥]130 mg/dL (OR 1.09, 95% CI 0.61-1.76) or impaired glucose tolerance on OGTT (OR 1.27, 95% CI 0.63-2.18). Results remained directionally consistent across alternative TAI definitions and sensitivity analyses, including restriction to euthyroid women and trimming of extreme values. In exploratory analyses, thyroid-stimulating hormone levels differed between TAI-positive and TAI-negative women, while no androgenic or cardiometabolic parameters remained significant after false discovery rate correction. Model diagnostics did not indicate major violations of model assumptions. ConclusionIn this large cross-sectional cohort of women with PCOS, thyroid autoimmunity was not associated with an adverse cardiometabolic or androgenic phenotype. Anti-TPO positivity alone therefore does not appear to identify a metabolically high-risk PCOS subgroup under the studied conditions. Prospective studies are needed to clarify the longitudinal implications of thyroid autoimmunity in PCOS.

Cushings disease is caused by the overproduction of cortisol. The effects of this disease are well known in a general population, including high blood pressure, diabetes, and weight gain. Cushings disease causes both obesity and metabolic related symptoms, and it can be difficult to discern the obesity-dependent from the obesity-independent mechanisms of Cushings disease. To identify patients with Cushings disease, we identified 476 Michigan Medicine patients between January 1st 2000-2025 along with propensity-matched control cases. We stratified our participants by obesity status and into a Cushings disease group and a control group. As expected, the Cushings group had an elevated BMI compared to the control group (34 kg/m2 vs 29 kg/m2). We found a higher proportion of females diagnosed with Cushings compared to males (287 vs 72). Cushings disease was associated with an increase in the fasting glucose levels in both non-obese and obese patients. In both the obese, and non-obese patients, there was an increase in ALT and AST levels regardless of Cushings disease status, but the increase due to Cushings disease was much greater in the patients with obesity (73.4 vs 35.1 mg/dL). Cushings disease also had a moderating effect on blood pressure, with participants a BMI under 30 kg/m2 increasing by 12.6 mmHg and participants with obesity increasing by only 7.9 mmHg. These findings highlight the need to consider obesity status when evaluating the effects of Cushings disease.

BackgroundObesity is a chronic multifactorial disease characterized by substantial interindividual variability in weight loss after lifestyle intervention and bariatric surgery. Thyroid hormones play a key role in energy homeostasis, but their influence on postoperative weight outcomes remains insufficiently studied. ObjectiveTo evaluate the association between preoperative thyroid status and changes in body mass index (BMI) after lifestyle intervention and bariatric surgery over a five-year follow-up. MethodsWe conducted a retrospective cohort study including adults with class II or III obesity enrolled in the Obesite Severe et Epigenetique (OBESEPI) study. All participants underwent preoperative lifestyle intervention followed by bariatric surgery. Thyroid status was classified as euthyroid or hypothyroid based on clinical and biochemical criteria. BMI was assessed at baseline and at nine postoperative time points over five years. ResultsAmong 435 included patients, 71 (16.8%) had hypothyroidism. Baseline BMI was similar between groups, whereas diabetes was more frequent in hypothyroid patients (52.1% vs 37.7%; p = 0.022). Hypothyroid patients had significantly higher BMI at 6-24 months after surgery, but differences were no longer significant beyond three years. BMI trajectories and magnitude of weight regain were comparable between groups. Higher preoperative TSH levels were independently associated with BMI regain (OR 1.32, 95% CI 1.00-1.72; p = 0.047). Higher baseline BMI, younger age, and female sex were also associated with greater BMI regain. ConclusionsHypothyroidism was associated with lower early postoperative weight loss but did not influence long-term BMI trajectories. Higher preoperative TSH levels were independently associated with BMI regain. KEYPOINTSO_LIPreoperative hypothyroidism is associated with reduced early weight loss during the first two years after bariatric surgery. C_LIO_LILong-term BMI trajectories and weight regain patterns are similar between hypothyroid and euthyroid patients beyond three years of follow-up. C_LIO_LIHigher preoperative TSH levels independently predict BMI regain. C_LIO_LIBaseline BMI, younger age, and female sex remain key determinants of the magnitude of BMI regain after bariatric surgery. C_LI

ObjectivesSex hormone-binding globulin (SHBG) and testosterone are differentially associated with type 2 diabetes (T2D) risk. We investigated whether these associations differ by HIV and menopausal status in Black South African women living with (WLWH) and without HIV (WLWOH). DesignCross-sectional observational. MethodsEighty one premenopausal (57 WLWOH, 24 WLWH) and 280 postmenopausal (236 WLWOH, 44 WLWH) women from the Middle-Aged Soweto Cohort (MASC) completed the following measures: circulating SHBG and sex hormones, body composition (dual energy x-ray absorptiometry), oral glucose tolerance test to estimate insulin sensitivity (Matsuda index), secretion (insulinogenic index, IGI) and clearance, and beta-cell function (disposition index, DI). Dysglycaemia was defined as either impaired fasting or postprandial glucose or T2D. ResultsSHBG was higher and total and free testosterone were lower in postmenopausal WLWH than WLWOH (all p<0.023). Irrespective of HIV serostatus, SHBG was positively associated with Matsuda index, insulin clearance and DI and inversely with HOMA-IR (all p<0.011). The association between SHBG and Matsuda index was stronger in premenopausal than postmenopausal women (p=0.043 for interaction). Free testosterone (and not total testosterone) was only negatively associated with basal insulin clearance (p=0.021), and positively associated with HOMA-IR in premenopausal and not post-menopausal women (p=0.015 for interaction). ConclusionsWe show for the first time that midlife African WLWH have higher SHBG and lower total and free testosterone than WLWOH, which corresponded to their higher beta-cell function, suggesting a putative protective effect of SHBG on T2D risk in WLWH. Significance statementThis study in midlife Black African women suggest that higher sex hormone binding protein (SHBG) and lower free testosterone in women living with HIV (WLWH) may be associated with reduced risk of type 2 diabetes (T2D) compared to women living without HIV. Further, this study provides a putative mechanism underlying the lower prevalence of T2D in WLWH and obesity compared to women living with obesity but without HIV. However, longitudinal studies are required to understand the clinical implications of these findings.

ContextPolycystic ovary syndrome (PCOS) is characterized by hyperandrogenism and frequent metabolic disturbances, including insulin resistance (IR), and is commonly accompanied by chronic low-grade inflammation. Complete blood count (CBC)-derived indices provide inexpensive markers reflecting systemic inflammatory and hematologic status; however, their relationships with androgen-related features in PCOS remain incompletely characterized. ObjectiveTo evaluate associations between androgen-related biomarkers and CBC-derived indices in young women with PCOS and to determine whether these associations persist after accounting for insulin resistance. DesignCross-sectional observational study. SettingSingle-center Gynecological Endocrinology Clinic in Katowice, Poland. ParticipantsWomen aged 16-25 years diagnosed with PCOS (Rotterdam criteria) between 2018 and 2025 (N = 1,300). Available-case and complete-case analyses were performed. Main Outcome MeasuresNeutrophil-to-lymphocyte ratio (NLR), red cell distribution width (RDW), and platelet-to-lymphocyte ratio (PLR). Associations with free androgen index (FAI), total testosterone, and dehydroepiandrosterone sulfate (DHEAS) were assessed using Spearman correlation and multivariable linear regression models adjusted for age and log-transformed HOMA-IR with heteroskedasticity-consistent (HC3) standard errors. False discovery rate (FDR) correction was applied. ResultsFAI was positively associated with NLR in both available-case and complete-case analyses (Spearman {rho} = 0.201; FDR-adjusted q < 0.001). DHEAS showed a positive association with NLR in complete-case analysis (q = 0.040). In multivariable models adjusted for age and log(HOMA-IR) (n = 885-888 depending on outcome), higher FAI was independently associated with lower RDW ({beta} = -0.075; 95% CI -0.141 to -0.009; q = 0.032) and lower PLR ({beta} = -2.37; 95% CI -4.60 to -0.14; q = 0.042). Higher DHEAS was independently associated with lower RDW ({beta} = -0.00056; 95% CI -0.00109 to -0.00004; q = 0.042). In complete-case analysis, total testosterone was inversely associated with PLR ({beta} = -3.91; 95% CI -7.58 to -0.24; q = 0.038). Associations between androgen markers and NLR were attenuated after adjustment. ConclusionsAmong young women with PCOS, androgen-related biomarkers are independently associated with selected CBC-derived indices, particularly RDW and PLR, whereas associations with NLR appear partly explained by shared metabolic correlates. These findings suggest that androgen excess may be linked to subtle hematologic alterations in early-stage PCOS beyond insulin resistance.

PurposeInfants and toddlers with classical congenital adrenal hyperplasia (CAH) are at high risk for adrenal crisis and associated sequelae. To better understand acute illness at this early age, we determined the frequency and severity of acute illness and hospitalizations between 0-4 years of age, both within CAH and compared to controls. We also evaluated the impact of pre-hospital stress-dose hydrocortisone on Emergency Department (ED) visits and hospitalizations. MethodsWe performed a retrospective study of 40 CAH youth and 27 age-matched controls at a tertiary center. Characteristics of acute illnesses during the first 4 years of life were recorded, including fever, vomiting, diarrhea, ED visits, hospitalizations, abnormal electrolytes, and stress-dose hydrocortisone usage. ResultsCAH youth had more frequent illnesses requiring stress-dosing when they were younger than 2 years old [4.0 (1.0-6.0)] compared to when they were 2-4 years old [3.0 (1.0-4.0), P < 0.05], with the most illnesses during their first year of life. As well, CAH infants and toddlers had more hospitalizations younger than 2 years old compared to 2-4 years old (36 vs 2). 25% (3/12) of CAH youth with abnormal electrolytes in the ED did not receive any stress-dosing (oral/IM) prior to the ED, and only 25% (3/12) had received intramuscular hydrocortisone at home. CAH youth had more frequent ED visits (7.4 times as many) and hospitalizations (38 to 0) compared to controls. ConclusionsVery young children with classical CAH are at high risk for acute illness and hospitalizations during their first 2 years of life, and do not receive adequate stress-dosing prior to the ED despite appropriate education. Our findings underscore the need for earlier recognition of acute illness in this vulnerable population and improved education regarding administration of stress-dose hydrocortisone to prevent morbidity.

BackgroundCongenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency (21OHD) is characterized by a broad clinical spectrum, ranging from salt-wasting to nonclassical forms. Genotype-phenotype correlations based on predicted residual enzymatic activity have been widely studied, but data from Latin American populations remain scarce. Additionally, the influence of mutational burden on phenotype prediction has not been fully explored. ObjectiveTo evaluate the genotype-phenotype correlation and the impact of mutational burden on predictive accuracy in a Colombian cohort of patients with CAH. MethodsWe conducted a cross-sectional study of patients with confirmed CAH enrolled in a specialized rare disease program. Genotypic classification was based on predicted residual enzymatic activity (Null, A, B, C), and clinical phenotype was categorized as salt-wasting (SW), simple virilizing (SV), or nonclassical (NC). Genotype-phenotype concordance was defined as exact category agreement. Mutational burden was defined as the total number of pathogenic variants, dichotomized as low ([&le;]2 mutations) or high (>2). Penalized logistic regression (Firth method) was used to evaluate associations between mutational burden, sex, and concordance. ResultsAmong 48 patients with available genetic data, genotype-phenotype concordance was highest in severe genotypes: 100% in Null and 85.7% in Group A. In contrast, concordance declined in Group B (33.3%) and Group C (44.4%). Individuals with high mutational burden had significantly lower odds of concordance (OR = 0.18; 95% CI: 0.03-0.94). No significant interaction between sex and mutational burden was observed. More than one-third of Group C patients exhibited more severe phenotypes than predicted. ConclusionsOur findings support established genotype-phenotype correlations in CAH, particularly for severe genotypes. However, increased mutational burden was associated with reduced predictive accuracy, suggesting the need to consider total mutation load in clinical assessment and genetic counseling.

BackgroundThe reproductive and sexual disorders commonly occur in patient with Cushings syndrome (CS), but only few clinical studies focused on the hypothalamus-pituitary-gonad (HPG) axis status in women with CS. A comprehensive spectrum of the impairment on HPG axis in women with CS of different tensity and causes is needed. MethodThis retrospective study analyzed the status of HPG axis in 137 women with different CS causes diagnosed between 2007 and May 2024, and the correlation between reproductive hormones and the tensity of hypercortisolism. Receiver operating characteristic (ROC) analysis was performed in 45 women with available data of plasma steroids by tandem mass spectrometry (LC-MS/MS) as well. ResultsWomen with ectopic adrenocorticotropin (ACTH) secretion (EAS) had significantly higher levels of serum cortisol, 24h urinary-free cortisol (UFC), ACTH, with marked increase in testosterone and decrease in Luteinizing hormone (LH) and Follicle-stimulating hormone (FSH) (P<0.001).The serum cortisol and ACTH were positively associated with testosterone, while negatively associated with LH and FSH, especially in postmenopausal women. Further investigation of steroid profiles found plasma androgen including testosterone, Androstenedione (A2), dehydrospiandrostenedione (DHEA) and dehydrospiandrostenedione sulfate (DHEAS) had high sensitivity and specificity in discriminating CD from adrenal CS. Additional analysis of thyroid axis found hypercortisolism had less influence on TSH compared with LH and FSH. ConclusionExcessive cortisol caused by CS can impair the HPG axis in women, which were especially intense in EAS. The degrees of impairment were associated with the intensity and the underlying causes of hypercortisolism.

BackgroundObesity affects hormone metabolisms and contributes to gallstone disease more strongly in women than in men. This study assessed the sex-specific associations between serum levels of sex hormone-binding globulin (SHBG) and testosterone and risk of cholecystectomy, and their mediation role in the obesity-cholecystectomy association. MethodsIncluded were 176,909 men and 160,147 women from the UK Biobank. Serum SHBG and total testosterone were measured by immunoassay. Incident cases of cholecystectomy for gallstone disease were identified using hospital inpatient records. Multivariable Cox proportional hazards models were used to calculate hazard ratios (HR) with 95% confidence interval (CI) of cholecystectomy associated with the serum hormones. A mediation analysis was performed to estimate the proportion of the obesity-cholecystectomy association potentially mediated by the two sex hormones. ResultsA total of 2877 men and 4607 women underwent cholecystectomies during the follow-up. Regardless of sex, higher levels of SHBG were associated with a lower risk of cholecystectomy. The HRs of cholecystectomy comparing the highest with the lowest quartiles of SHBG were 0.68 (95% CI: 0.59-0.77) in men (P-trend <0.001) and 0.39 (95% CI: 0.36-0.53) in women (P-trend <0.001). Higher levels of testosterone were associated with a higher risk of cholecystectomy in women (HRQ4 vs. Q1 = 1.28; 95% CI: 1.18-1.39; P-trend <0.001) but not in men (P-trend = 0.12). In women, it was estimated that 14.71% and 2.74% of the association between obesity and cholecystectomy was significantly medicated by SHBG and testosterone, respectively. ConclusionsSHBG levels are inversely associated with risk of cholecystectomy in both sexes, whereas higher testosterone levels are associated with a higher risk of cholecystectomy only in women. Both hormones mediate the obesity-cholecystectomy association in women.

Background Glucagon-like peptide-1 receptor agonists (GLP1 RAs) are first-line pharmacotherapy for obesity and metabolic dysfunction-associated steatotic liver disease (MASLD); however, 20% to 35% of patients fail to achieve clinically meaningful weight loss despite guideline-directed therapy. Whether this GLP1 refractory obesity (GRO) phenotype is associated with distinct hepatic molecular abnormalities or influences bariatric surgical outcomes remains unknown. Objectives To characterize the hepatic histological, ultrastructural, and molecular phenotype of GRO at bariatric surgery, determine its recovery following surgery, and identify preoperative hepatic biomarkers associated with postoperative weight loss. Setting Academic tertiary referral bariatric surgery center. Methods Intraoperative liver biopsies were obtained from lean controls (n=3), GLP1 naive obese patients (GNO; n=10), and GLP1-refractory obese patients (GRO; n=10) undergoing Roux-en-Y gastric bypass. GRO was defined as <5% total weight loss after 12 months of guideline-directed GLP1 RA therapy. Paired liver biopsies were obtained six months postoperatively from subsets of GNO (n=5) and GRO (n=5). Histological, ultrastructural, and molecular analyses were performed, and preoperative hepatic protein expression was correlated with postoperative total weight loss. Results Compared with GNO, GRO patients exhibited more advanced hepatic steatosis, fibrosis, lipid accumulation, and mitochondrial ultrastructural disruption at surgery (all P<0.05). Despite equivalent Body mass index, GNO patients maintained lean-equivalent hepatic pCREB, pAMPK, pACC, and oxidative phosphorylation (OXPHOS) protein expression, whereas GRO patients demonstrated marked suppression of GLP1R downstream signaling (75 to 85%) and OXPHOS complex subunits (38 to 55%; all P<0.001). Six months after surgery, histological and molecular recovery remained significantly attenuated in GRO. GRO patients achieved less postoperative weight loss than GNO patients (25.2% vs. 29.51% total weight loss; P<0.001). Across the pooled cohort, several hepatic molecular markers correlated with postoperative weight loss; however, no individual biomarker independently predicted postoperative weight loss within the GRO subgroup. Conclusions GLP1 refractory obesity is associated with a distinct hepatic phenotype characterized by impaired GLP1R signaling, mitochondrial dysfunction, and attenuated hepatic recovery following bariatric surgery. The coordinated suppression of hepatic energy-sensing, mitochondrial biogenesis, and oxidative phosphorylation pathways supports the concept that GLP1 refractory obesity represents a biologically distinct metabolic phenotype. Larger prospective studies are required to determine the prognostic utility of hepatic molecular profiling for postoperative outcomes. Keywords: GLP1 receptor agonist refractoriness; bariatric surgery; hepatic steatosis; MASLD; AMPK; pCREB; mitochondrial dysfunction; OXPHOS; weight loss outcomes; biomarker

ImportanceDiagnosis of polycystic ovary syndrome (PCOS) in adolescence is challenging because menstrual irregularity and hyperandrogenism are common in adolescents. Recent international guidelines highlighted an at risk for PCOS category based on either menstrual regularity or hyperandrogenism; however, its population prevalence and genetic correlates remain unknown. ObjectiveTo estimate the prevalence of PCOS and at risk for PCOS in adolescence and evaluate associations with genetic risk for PCOS. Design, Settings, and ParticipantsPopulation-based analysis of 1,533 adolescents from the Avon Longitudinal Study of Parents and Children (ALSPAC) with sufficient reproductive data. ExposurePolygenic score (PGS) for PCOS derived from the largest genome-wide association study in European women. Main Outcomes and MeasuresGuideline-defined PCOS (presence of both irregular menses and hyperandrogenism) and at risk for PCOS (presence of one feature). ResultsPCOS prevalence was 3.2%, while 27.2% met criteria for being at risk for PCOS. A higher PCOS PGS was associated with hyperandrogenism (OR per SD increase in PGS: 1.22; 95% CI, 1.07-1.39; P=4x10-3) but not irregular menses. Conclusions and RelevanceOver one-fourth of adolescents met criteria for being at risk for PCOS. Genetic risk for PCOS was associated with hyperandrogenism but not isolated menstrual irregularity, suggesting that androgen excess is a more specific early manifestation of inherited PCOS liability.

Context Polyendocrine metabolic ovarian syndrome (PMOS), formerly known as polycystic ovary syndrome (PCOS), is a biologically heterogeneous disorder, yet previous clustering studies have reported inconsistent phenotype structures. Whether these discrepancies reflect methodological variability or genuine multidimensional disease biology remains unknown. Objective To determine whether independently derived endocrine, metabolic, inflammatory, and thyroid phenotypes represent the same underlying biological structure or capture distinct dimensions of PMOS heterogeneity. Design Cross-sectional observational study using a cross-space phenotyping framework. Setting Tertiary referral outpatient endocrinology and gynecology clinic. Participants A total of 1,286 women were diagnosed with PCOS according to the Rotterdam criteria. Methods Four predefined biological spaces (endocrine, metabolic, inflammatory, and thyroid) were analyzed independently. Within each space, standardized preprocessing, dimensionality reduction, and unsupervised clustering were performed. Cluster robustness was evaluated using bootstrap resampling, while agreement between independently derived phenotypes was quantified using the adjusted Rand index (ARI). Biological relevance was assessed using independent non-circular validation with variables excluded from phenotype derivation. Sensitivity analyses compared complete-case and imputed datasets. Results All four biological spaces produced highly stable clustering solutions (bootstrap ARI: endocrine 0.915, metabolic 0.964, inflammatory 0.930, thyroid 0.990). Despite this robustness, agreement between independently derived phenotypes remained consistently low. The highest concordance was observed between metabolic and inflammatory phenotypes (ARI = 0.208), followed by endocrine and metabolic phenotypes (ARI = 0.159), whereas agreement involving thyroid phenotypes was close to zero. Independent non-circular validation confirmed that all identified phenotypes represented biologically coherent patient subgroups beyond the variables used for clustering. Sensitivity analyses demonstrated high agreement between complete-case and imputed solutions, supporting the robustness of the findings. Conclusions Stable biological phenotypes exist within individual physiological domains of PMOS but do not converge into a single overarching biological phenotype. These findings support a multidimensional model of PMOS heterogeneity in which endocrine, metabolic, inflammatory, and thyroid systems describe complementary rather than interchangeable aspects of disease biology. Cross-space phenotyping provides a general framework for investigating biological heterogeneity in complex disorders and may facilitate future precision medicine approaches.

IntroductionThe bidirectional relationship between depression and type 2 diabetes (T2D) is well-established. Women are disproportionately affected by their co-occurrence, particularly during midlife, yet sex- and age-specific studies on phenotypic and mechanistic factors underlying risk for their co-occurrence are limited. The purpose of this study was to identify combined risk profiles (i.e., depression, T2D) in women during midlife and to determine if microRNAs (miRs) that are associated with high-risk profiles provide mechanistic insights into multimorbidity. Materials and MethodsThis study included baseline data from women during midlife (ages 40-64 years) who participated in the Diabetes Prevention Program (DPP) (n = 603). Unsupervised k-means clustering was used to identify multimorbid risk profiles. Clinical characteristics included for risk profiling included Beck Depression Inventory (BDI-I), age, BMI, waist circumference, triglycerides, high HDL, FBG, and HbA1c. Associations between risk profiles and individual miRs and principal components of co-expressed miRs were determined via logistic regression models adjusted for participant race and ethnicity. False discovery rate (q< 0.05) was used to control for multiple comparisons. ResultsTwo distinct profiles were identified, with the high-risk profile characterized by younger age yet higher adiposity, glycemic biomarkers, and depression symptom burden compared to the low-risk profile. MiR-320a and miR-320c were associated with increased odds of high-risk profile assignment, and a co-expression cluster enriched for miRs belonging to the miR-320 family (PC3) was significantly associated with increased odds of high-risk profile assignment. Across all models, Black race demonstrated at least threefold higher odds of high-risk profile assignment. DiscussionThese findings highlight distinct multimorbid risk profiles in women during midlife, emphasizing the potential utility of integrated, multidimensional approaches for risk stratification. Findings also revealed mechanisms that may underly risk for co-occurrence of T2D and depression in women during midlife and potential therapeutic targets for prevention and treatment.

ContextThe body has evolved homeostatic mechanisms to maintain free levels of Ca+2 and 1,25-dihydroxyvitamin D [1,25(OH)2D] within narrow physiological ranges. Clinical guidelines emphasize important contributions of PTH in maintaining this homeostasis. ObjectiveTo investigate mechanisms of homeostatic regulation of vitamin D (VitD) metabolism and to apply mechanistic insights to improve clinical assessment of VitD status. DesignCrossover clinical trial studying participants before and after VitD3-supplementation. SettingCommunity. Participants11 otherwise healthy individuals with VitD-deficiency (25-hydroxyvitamin D [25(OH)D] [&le;]20 ng/mL). InterventionsVitD3-supplements (50,000 IU once or twice a week depending on BMI, for 4-6 weeks) were administered to achieve 25(OH)D[&ge;]30 ng/mL. ResultsVitD3-supplementation significantly increased mean 25(OH)D by 2.7-fold and 24,25-dihydroxyvitamin D [24,25(OH)2D] by 4.3-fold. In contrast, mean levels of PTH, FGF23, and 1,25(OH)2D did not change. Mathematical modeling suggested that 24-hydroxylase activity was maximal for 25(OH)D[&ge;]50 ng/mL and achieved a minimum ([~]90% suppression) with 25(OH)D<10-20 ng/mL. The 1,25(OH)2D/24,25(OH)2D ratio better predicted modeled 24-hydroxylase activity (h) ({rho}=-0.85; p=0.001) compared to total plasma 25(OH)D ({rho}=0.51; p=0.01) and the 24,25(OH)2D/25(OH)D ratio ({rho}=0.37; p=0.3). ConclusionsSuppression of 24-hydroxylase provides a first line of defense against symptomatic VitD-deficiency by decreasing metabolic clearance of 1,25(OH)2D. The 1,25(OH)2D/24,25(OH)2D ratio provides a useful index of VitD status since it incorporates 24,25(OH)2D levels and therefore, provides insight into 24-hydroxylase activity. When VitD availability is limited, this suppresses 24-hydroxylase activity - thereby decreasing the level of 24,25(OH)2D and increasing the 1,25(OH)2D/24,25(OH)2D ratio. Thus, an increased 1,25(OH)2D/24,25(OH)2D ratio signifies triggering of homeostatic regulation, which occurs at early stages of VitD-deficiency.

BackgroundThis study was designed to investigate the relationship between visceral fat metabolic score (METS-VF), lipid accumulation product (LAP), visceral adiposity index (VAI) and thyroid function. MethodsUtilizing data from the National Health and Nutrition Examination Survey (NHANES) 2007-2012, participants were excluded if they lacked data on METS-VF, LAP, VAI or thyroid function, or were under 18 years of age. Multiple linear regression, smooth curve fitting, and subgroup analyses were performed to determine the independent relationship between lipid accumulation and thyroid function. ResultsAfter full covariate adjustment, all three visceral adiposity indices showed significant positive associations with FT3 (LAP: {beta}=0.028, VAI: {beta}=0.024, METS-VF: {beta}=0.026; all P<0.001), FT3/FT4 ratio, TT3, TT4, and TgAb. LAP and VAI demonstrated inverse associations with FT4 ({beta}=-0.218 and -0.183, respectively; both P<0.001), while VAI and METS-VF were positively associated with TSH ({beta}=0.149, P=0.041; {beta}=0.167, P=0.025). Quartile analyses confirmed dose-dependent relationships, with Q4 participants showing elevated FT3, FT3/FT4, TT3, TT4, and reduced FT4 compared to Q1. RCS analyses revealed distinct non-linear patterns: LAP exhibited non-linearity with FT3, TSH, TT3, and TT4 (all P-nonlinear<0.05) but linear inverse associations with FT4. VAI displayed reverse L-shaped curves for FT3, TSH, and TT3 with plateaus at higher levels, while TT4 showed an inverted U-shape. METS-VF demonstrated non-linear increases for FT3 and TT3, linear associations with TSH and TT4, and an inverted U-curve for FT4. Stratified analyses identified age, race, and smoking as consistent modifiers of FT3/FT4 associations across all indices (interaction P<0.05), with stronger effects in younger/older adults, males, White participants, and high-income groups. TT3 and TT4 modification patterns varied by index. Thyroid autoantibodies showed minimal associations across all indices. ConclusionVisceral lipid accumulation is closely associated with thyroid dysfunction, and this association exhibits significant non-linear characteristics, which are modulated by factors such as age, race, and lifestyle habits. These findings provide new perspectives for the early identification and intervention of obesity-related thyroid dysfunction.

BackgroundAlterations in levels of 25-Hydroxyvitamin D have been associated with the risk of thyroid disease. This study uses Mendelian randomization (MR) to infer the possible causal association of 25-Hydroxyvitamin D with hypothyroidism. MethodsWe performed two-sample MR using the summary statistics data from genome-wide association studies (GWAS) from populations with European ancestry to infer the causality of genetically controlled levels of 25-Hydroxyvitamin D on the risk of hypothyroidism, Hashimotos thyroiditis, as well as biochemical parameters of thyroid diseases. The inverse-variance method (IVW) was used as the primary method to calculate the combined effect of all SNPs. Other methods were adopted to evaluate the stability and reliability of the results. Comprehensive sensitivity analyses were conducted to ensure that none of the MR analysiss primary assumptions were violated. ResultsThe results of the IVW analysis revealed a significant causal association between higher levels of 25-Hydroxyvitamin D and lower risk of hypothyroidism (beta = -0.197, 95% CI (- 0.301, -0.093); SE = 0.053, Pbeta = 2.256x10-4) as well as increased levels of free T4 (beta = 0.204, 95% CI (0.305, 0.094); SE = 0.056, Pbeta = 3.0506x10-4). On the other hand, no significant causality was determined for higher levels of 25-Hydroxyvitamin D in association with Hashimotos thyroiditis (beta=-0.047, 95% CI (-0.245, 0.151), p=0.641) and TSH levels (beta = -0.024, 95% CI (-0.099, - 0.051); Pbeta = 0.524). ConclusionThe results of this two-sample MR study provide evidence supporting the potential of 25-Hydroxyvitamin D supplementation in reducing the risk of hypothyroidism.

PurposeTo investigate the effect of sex and age on the timing of a type 2 diabetes (T2D) diagnosis and the influence T2D-related genes, parental history of T2D, and obesity on T2D development. MethodsIn this case-control study, 1012 T2D cases and 1008 healthy subjects were selected from the Diabetes in Mexico Study database. Participants were stratified by sex and age at T2D diagnosis (early, [&le;]45 years; late, [&ge;]46 years). Seventy T2D-associated SNPs were explored and the percentage contribution (R2) of T2D-related genes, parental history of T2D, and obesity (body mass index [BMI] and waist-hip ratio [WHR]) on T2D development was calculated using univariate and multivariate logistic regression models. ResultsT2D-related genes influenced T2D development most in males who were diagnosed early (R2 = 23.5%; females diagnosed early, R2 = 13.5%; males and females diagnosed late, R2 = 11.9% and R2 = 7.3%, respectively). With an early diagnosis, insulin production genes were more influential in males (76.0% of R2) whilst peripheral insulin resistance genes were more influential in females (52.3% of R2). With a late diagnosis, insulin production genes from chromosome region 11p15.5 notably influenced males while peripheral insulin resistance and inflammation genes notably influenced females. Influence of parental history was higher among those diagnosed early (males, 19.9%; females, 17.5%) versus late (males, 6.4%; females, 5,3%). Unilateral maternal T2D history was more influential than paternal T2D history. BMI influenced T2D development for all, while WHR exclusively influenced males. ConclusionsThe influence of T2D-related genes, maternal T2D history, and fat distribution on T2D development was greater in males than females.

Polycystic ovary syndrome (PCOS) is a complex, multi-system, heritable endocrinopathy that is a common cause of anovulatory infertility in reproductive-aged women. While insulin resistance (IR) is not a diagnostic feature, it is widespread in women with PCOS, and often more severe than in women of similar age and BMI. Conversely, women with rare Mendelian disorders of IR also present with features of PCOS. We hypothesize that PCOS is driven by underlying IR, which can be evaluated through a genetic approach. We curated and stratified 310 genes related to three mechanisms of IR using molecular and clinical criteria. We evaluated protein-altering genetic variation in 102 insulin signaling genes, 29 obesity genes, and 22 dyslipidemia genes from whole-exome sequencing data from 675 PCOS patients. 40 insulin signaling genes, 12 obesity genes, and 10 dyslipidemia genes were significantly enriched for protein-altering variation in PCOS cases compared to healthy population controls. Variants in these 62 significantly enriched genes affected 51% of PCOS cases in our study cohort. The 15 highest ranked genes were selected for follow-up: LMNA, LEPR, KCNJ11, BSCL2, ACACA, NTRK2, GCK, ABCC8, SLC2A2, POMC, MC4R, TBC1D4, INSR, NR0B2, and GCKR. 50% of variants identified in these 15 genes were pathogenic, 35% were likely pathogenic, and only 15% were variants of uncertain significance. These findings support IR as a central pathway in PCOS. Furthermore, this study demonstrates that a candidate pathway approach with sufficient pre-processing can successfully identify functionally relevant variants and genes underlying complex traits.

Context: Polycystic ovary syndrome (PCOS) is a heterogeneous endocrine disorder involving complex interactions among endocrine, metabolic, inflammatory, and thyroid pathways. However, the systems-level organization of these interactions remains poorly understood. Objective: To reconstruct the endocrine-metabolic biomarker network in women with PCOS and identify bridge biomarkers integrating distinct physiological domains. Design: Retrospective cross-sectional study. Setting: Single tertiary referral center. Participants: A total of 1,286 women diagnosed with PCOS according to the revised Rotterdam criteria. Methods: Twenty-nine routinely measured laboratory biomarkers representing endocrine, metabolic, hematological/inflammatory, and thyroid domains were analyzed. Sparse Gaussian graphical models were estimated using Graphical LASSO with Extended Bayesian Information Criterion model selection. Network topology, node centrality, bridge centrality, bootstrap resampling, and predefined sensitivity analyses were performed. Results: The reconstructed network comprised 29 biomarkers connected by 73 conditional dependency edges (network density, 0.18), demonstrating a modular but highly integrated endocrine-metabolic architecture. Conventional centrality analysis primarily identified biomarkers organizing local physiological modules, whereas bridge-centrality analysis revealed biomarkers coordinating communication between biological domains. Sex hormone-binding globulin exhibited the highest bridge strength, followed by fasting insulin, triglycerides, and high-density lipoprotein cholesterol. Additional reproducible bridge biomarkers included free thyroxine, white blood cell count, 2-hour plasma glucose, absolute neutrophil count, androstenedione, and anti-thyroglobulin antibodies. The leading bridge biomarkers remained stable across bootstrap resampling, complete-case reconstruction, and alternative network specifications. Conclusions: PCOS is characterized by an integrated endocrine-metabolic network organized around a limited number of reproducible bridge biomarkers linking multiple physiological systems. Network analysis provides complementary systems-level information beyond conventional biomarker evaluation and may facilitate future biological phenotyping and precision medicine approaches in PCOS.