United States

OBJECTIVE: Polycystic ovary syndrome (PCOS), is associated with reduced health-related quality of life (QOL) and increased risk for depression and anxiety. These associations are partly due to the stressful and stigmatizing nature of PCOS symptoms, including hirsutism and negative body image stemming from BMI. However, the impact of the cumulative wear and tear in the stress response system (i.e. allostatic load (AL)), and of metabolic syndrome on these QOL outcomes is unknown. We assessed how AL and metabolic syndrome relate to physical and mental health related QOL in women with PCOS. 
METHODS: We performed a secondary analysis of baseline data from a randomized control trial (OWL-PCOS) in women with PCOS defined by Rotterdam criteria. Physical and mental health related QOL were assessed by the SF36 and PCOSQ. AL was calculated using the 12 factors: IGF-1, HDL, LDL, triglycerides, fasting glucose, fasting insulin, creatinine, systolic blood pressure, diastolic blood pressure, heart rate, waist-to-hip ratio, and BMI. High risk categories were calculated as the 75th percentile for all factors except for HDL in which the 25th percentile was used. An AL index was calculated for each participant as the sum of the number of factors in the risk category (0-12), with higher scores indicating more physiological dysregulation in the stress response system. We defined a high level of AL as an ALI of 4, based on convention. Metabolic syndrome was classified as meeting 3 of 5 NIH criteria. Wilcoxon rank sum tests were used to assess differences in QOL measures between high vs low AL, and with vs without metabolic syndrome. All analyses were performed in RStudio version 2022.07.1.
RESULTS: Among 90 women with PCOS, the mean age was 29 years old, the majority of which were White (84%), non-Hispanic (93%), nulliparous (83%) and not on any medications for depression (97%) or anxiety (98%). Thirty-six women had high AL and 27 women had metabolic syndrome. Women with high AL, had significantly higher summary scores on the SF36 Mental Component (p = 0.012) and lower scores on the SF36 Physical Component (p = 0.001), indicating higher mental health QOL and lower physical health QOL. On the PCOSQ, women with high AL had higher Emotional Wellbeing scores (p = 0.013), but no differences in Physical Wellbeing and General Wellbeing scores. Women with metabolic syndrome had lower SF36 Physical Component summary scores (p=0.039), indicating lower physical health related QOL. 
CONCLUSION: These findings suggest that among the constellation of symptoms experienced by women with PCOS, AL and metabolic syndrome are not primary drivers of adverse mental health outcomes in this population. 


AE-PCOS 2022

Do allostatic load and metabolic syndrome contribute to mental health outcomes in women with polycystic ovary syndrome?

allostatic load

metabolic syndrome

quality of life

Dear Delegates, 

On behalf of the organizing committee at UCF Rosen College of Hospitality Management and Elsevier, I have the greatest pleasure to welcome you to the **6th World Research Summit for Tourism and Hospitality: Resilience, Adaptability, and Innovation.** 

Though we cannot host you this year owing to Covid-19 at our beautiful resort-like campus in Orlando, Florida, we believe this virtual and live-streamed conference will provide an interactive, dynamic, and shared international platform for global academics and practitioners to discuss how to enhance research applications and knowledge management through resilience, adaptability, digital intelligence, innovation, and smart knowledge in bringing our industry and research back to normal. This summit particularly offers unique opportunities to unfold and embrace various repercussions of COVID-19 pandemic with various stakeholders, including academic researchers, industry professionals, and government officials, through dialogues on how to better utilize research outputs for the benefits of the industry, in a resilient, intelligent and innovative way. 

I hope you will agree that we have put together a wonderful program including keynote speeches, panel discussions, concurrent presentations, poster sessions, and best paper recognition and award ceremony. We hope you will take advantage of these activities and engage yourself with great learning and sharing opportunities during the two days of the Summit. Thank you for joining us and we look forward to our discussions! 

Sincerely, 
Dr. Youcheng Wang 
Dean and Preeminent Chair Professor

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TOUR 2021

This conference provides an interactive, dynamic, and shared international platform for global academics and practitioners to discuss how to enhance research applications and knowledge management through resilience, adaptability, digital intelligence, innovation, and smart knowledge in bringing our industry and research back to normal. This summit particularly offers unique opportunities to unfold and embrace various repercussions of COVID-19 pandemic with various stakeholders, including academic researchers, industry professionals, and government officials, through dialogues on how to better utilize research outputs for the benefits of the industry, in a resilient, intelligent and innovative way.

poster

### Welcome to the AE-PCOS Society's 20th Annual Meeting!


The AE-PCOS Society’s 20th Annual Meeting's theme will be Reflections and Directions. The meeting will aim to incorporate the perspectives of both long-time, contributing members of the Society and newer members of the Society, while highlighting the latest research findings in PCOS-related clinical and basic research.

The recorded content will be available to registrants only for three months after the meeting. 


To gain access to this event page you are required to register. 

For tickets to the event, please register [here](https://secure.ae-society.org/np/clients/aesociety/eventRegistration.jsp?forwardedFromSecureDomain=1&event=2). 

Please register for the AE-PCOS 2022 Conference to join the event.

The AE-PCOS Society’s 20th Annual Meeting's theme are Reflections and Directions. The meeting aims to incorporate the perspectives of both long-time, contributing members of the Society and newer members of the Society, while highlighting the latest research findings in PCOS-related clinical and basic research.

OBJECTIVE: Polycystic ovary syndrome (PCOS) is the most prevalent reproductive endocrinopathy in women. Symptoms and complications place a significant burden on servicewomen, negatively influencing health, and hindering military operational and worldwide readiness. Despite Congressional recognition of the seriousness of PCOS, research in military PCOS populations is limited. Furthermore, current military policies do not address specific healthcare needs and challenges experienced by women with PCOS. Our purpose was to explore and describe servicewomen’s experience of living with PCOS.
METHODS: Qualitative descriptive design using focus groups and individual interviews. Women with PCOS were recruited from military locations. Data were analyzed using constant comparative content analysis with Nvivo12.
RESULTS: Air Force, Army, Navy, and Marine Corps women (N = 23) from 20 different occupational specialties participated. Three major themes emerged: (1) PCOS symptoms: PCOS was all-consuming, impacting every aspect of their lives, (2) Navigating the military healthcare system: challenges and facilitators within the military healthcare system, and (3) navigating PCOS as a servicemember: how the military environment including policies and work environment influenced their experience with PCOS. Thirteen sub-themes revealed challenges with accurate, timely diagnosis, access, trust, and continuity of healthcare, self-esteem and body image issues, and workplace harassment resulting in mental stress, due to symptoms such as facial hair, acne, painful, unpredictable menstrual cycles, and weight. A determination to “push through” to complete their unit mission was also identified. 
CONCLUSIONS: Servicewomen living with PCOS have similar experiences regardless of duty title or service branch. Unlike their civilian counterparts, servicewomen face significant career-limiting consequences. Weight is a major stress-point for servicewomen. Time to diagnosis (months to years) and managing onerous symptoms negatively influence health and unit cohesiveness, degrading mission readiness. Future studies are needed to further elucidate military-specific challenges experienced by servicewomen with PCOS. Research is also needed to facilitate development of evidence-based policies and identify effective strategies that support the health and readiness of servicewomen.
(Tri-Service Nursing Research Program: N18-B05)
Disclaimer: The views expressed are solely those of the authors and do not reflect the official policy or position of the US Army, US Navy, US Air Force, the Department of Defense, or the US Government.
Hopkins, D.1, Walker, S.1, Siaki, L.2, Philips, A. 3, Wilson, C.4, Wallen, G.5
(1) Clinical Investigation Facility, David Grant Medical Center, Travis Air Force Base, CA
(2) Center for Nursing Science and Clinical Inquiry, Regional Health Command-Pacific, Tripler Army Medical Center, Honolulu HI
(3) Malcolm Grow Medical Clinics and Surgery Center, Joint Base Andrews, MD
(4) Graduate School of Nursing, Uniformed Services University, Bethesda, MD
(5) Branch Chief and Senior Investigator, Translational Biobehavioral and Health Disparities Branch, National Institutes of Health, Clinical Center, Bethesda, MD


The Experience of Living with Polycystic Ovary Syndrome in the Military

OBJECTIVE: Polycystic ovary syndrome (PCOS) is associated with increased risk for depression and anxiety, partly driven by BMI, hirsutism, and genetic factors. Although PCOS increases the odds of hypertension (HTN) by 1.5, the co-occurrence of PCOS + HTN in relation to symptoms of depression and anxiety is not well understood. Furthermore, few studies focus solely on these symptoms in Black women with PCOS. Here, we examine the impact of HTN on depression, anxiety, and fatigue symptoms in Black women with PCOS. 
METHODS: We preformed preliminary data analysis of a single cohort study of symptoms in adult Black women with PCOS or with PCOS + HTN. Both diagnoses were obtained from medical records. Depressive symptoms were measured by the PROMIS Depression short-form and the CESD-10. Anxiety was measured by the PROMIS Anxiety short-form and the state scale of the State-Trait Anxiety Inventory (STAI). Fatigue was measured by the PROMIS Fatigue short-form and the Multidimensional Fatigue Inventory (MFI). Wilcoxon rank sum tests were used to assess differences in symptoms between PCOS vs PCOS + HTN. All analyses were performed in RStudio version 2022.07.1.
RESULTS: Among 32 Black women with PCOS, the mean age was 34.7 years old, and the mean BMI was 39.8. Nine of the 32 women had PCOS + HTN. Women with PCOS + HTN demonstrated higher fatigue on the MFI (p = 0.015), more severe depression on the PROMIS Depression (p = 0.039) and CESD-10 (p = 0.046), and more severe anxiety symptoms on the STAI (p = 0.007). For those with PCOS + HTN, mean scores exceed cut points for clinical depression on the CESD-10 and clinical anxiety on the STAI. Women with PCOS + HTN also demonstrated a trend for higher fatigue on the PROMIS Fatigue as well as higher anxiety on the PROMIS Anxiety. 
CONCLUSION: Our findings highlight that the co-occurrence of HTN and PCOS in Black women may contribute to the severity of depression, anxiety, and fatigue symptoms. Our study also points toward the need to better understand the symptom experience of minority groups with PCOS, including racial, ethnic, sex, and gender. 
(Funding: 1P30NR-18090 [Pilot PI: LN])

Depression, Anxiety & Fatigue Among Black Women With Pcos With and Without Hypertension

WOMEN WITH PCOS EXPERIENCE DIFFERENT MENSTRUAL CYCLE EXPERIENCES THAN CONTROL DURING THE PANDEMIC. 

Prior, JC (1,3), Nelson, K (2,3), Shirin, S (3). 

(1) Department of Medicine Division of Endocrinology 
(2) University of British Columbia, Graduate Programme Vancouver, BC 
(3) Centre for Menstrual Cycle and Ovulation Research, Division of Endocrinology UBC, Canada 

OBJECTIVE: 
Although increasing studies now report reproduction in women with Polycystic Ovary Syndrome (PCOS), none have described menstrual cycle-related experiences. Our objective was to explore this by standardized daily Menstrual Cycle Diary©. Specifically, we compared PCOS “cases” with matched controls. We hypothesized in PCOS vs controls: greater levels of depression and lower levels of self-worth but similar levels of outside stress. 

METHODS: 
This is a single-cycle prospective case-control study using data from 112 community-dwelling women ages 19-35 years with approximately month-apart, spontaneous (not on hormonal contraception) menstrual cycles in the Menstruation Ovulation Study 2 (MOS2); all data were collected early in the SARS-CoV-2 pandemic. Six women self-reported PCOS. We matched them with random participants in a 3:1 ratio within five years of age and by BMI category. We did not adjust for ovulatory characteristics, given that 63% of all MOS2 cycles had ovulatory disturbances1. We described data while testing hypotheses by Mann-Whitney U and Chi-Square Tests. We also described Principal Component Analysis (PCA) patterns versus published mean 11-month data in normally ovulatory normal-weight women2. Data were analyzed using SPSS version 28. 

RESULTS: 
As expected, women living with PCOS (n=6) and controls (n=18) were similarly aged in the early 30s, with non-different mean BMIs in the low overweight range. PCOS women were more white with non-East Asian other ethnicities. Mean menstrual flow (ml/day) was significantly higher in controls than PCOS (p=0.009), with no difference in days of flow (p>0.721). There was also no significant difference in the duration of cramps (p>0.812), cramp intensity (p>0.415) or front breast tenderness (p>0.250). 

Our hypotheses of lower feelings of self-worth and higher feelings of depression with similar perceived outside stresses were not confirmed. Women with PCOS had significantly higher (p>0.001) feelings of depression than controls. There was no significant difference in feelings of self-worth; however, women with PCOS experienced significantly greater (p>0.001) outside stressors than controls. 

PCA patterns showed six rather than the expected five ‘Factors’, except for “Negative Moods” in Factor 1, which differed importantly in Factor loading structure from previous data in ovulatory women. Most interesting is that cramps and flow were not on the same factor but that “stretchy” cervical mucus loaded positively with interest in sex. 

CONCLUSIONS 
In conclusion, women with PCOs experience less menstrual flow/day than matched controls. They also experienced greater outside stresses and had more depression and similar feelings of self-worth as did the controls during the SARS-CoV-2 pandemic. 

REFERENCES 
Prior JC, Shirin S, Bos C, et al. Epidemic of Subclinical Ovulatory Disturbances During SARS-COV2 Pandemic—an Experiment of Nature. Endocrine Society podium presentation, Atlanta, Georgia, June, 2022. 

Allison B. Macbeth, Azita Goshtasebi, G. William Mercer & Jerilynn C. Prior (2021) Does Interest in Sex Peak at Mid-Cycle in Ovulatory Menstrual Cycles of Healthy, Community-Dwelling Women? An 11-Month Prospective Observational Study, Women's Reproductive Health, 8:2, 79-91, DOI: 10.1080/23293691.2021.1901519

Experiences of Women Living with Polycystic Ovary Syndrome: ​a case-control single-cycle daily Menstrual Cycle Diary © study during the SARS-CoV-2 pandemic.​

The aim was to investigate if AMH could be used as a surrogate for polycystic ovarian morphology in a large data set when diagnosing women with polycystic ovarian syndrome. In our data set the prevalence of PCOS was 13.6% when AMH was used as part of Rotterdam criteria. The hormonal and metabolic profile was typical for PCOS whe assesing AMH-indueced phenotypes.

Anti-Müllerian hormone is a useful tool in polycystic ovary syndrome diagnostics in large datasets

Objective: Polycystic ovary syndrome (PCOS) is associated with psychological morbidity including depression and anxiety and diminished sexual satisfaction. As vitamin D (vit D) deficiency has been linked to symptoms of PCOS, we explored the association of baseline total 25-hydroxyvitamin D (25[OH]D) and bioavailable 25- hydroxyvitamin D (bio-25[OH]D) with sexual dysfunction (SDy) and the impact of vit D replacement.
Methods: Reproductive age women with PCOS and SDy, using the Female Sexual Functioning Index (FSFI), and without severe depression, using the Beck Depression Inventory (BDI), were eligible. Subjects with SDy (FSFI <26.55) were allowed to choose either vit D 600U daily plus hormonal contraceptive (HC) (n=18) or vit D 600IU daily and non-HC (n=10). FSFI, BDI, and serum total and bio-25[OH]D were determined at baseline and at study completion. Initial comparisons between those with and without SDy to total and bio-25[OH]D status and changes in FSFI after treatment were analyzed and correlations between FSFI with demographics, pre-treatment total and free testosterone (tT and fT) levels, total and bio-25[OH]D, HC use, and BDI were performed.
Results: A total of 42 women without severe depression completed the FSFI with 28 (66.7%) having SDy. All FSFI domains including arousal, lubrication, orgasm, and pain were significantly lower compared to women without SDy at baseline and with no associations with respect to demographics, tT and fT, or total 25[OH]D and bio-25[OH]D. Vit D replacement was initiated with HC (n=18) or non-HC (n-10), and for those completing the study, FSFI (>26.5) improved in 61% (11/18), regardless of the treatment group. A time-treatment effect showed a significant change for the domain of orgasm, suggesting that HC had more of an impact than Vit D replacement on this scale. Improvement in sexual function as a dichotomous variable was not associated with age, BMI, other demographics, tT and fT, total and bio-25[OH]D, or HC use. 
Discussion: Vit D level was not associated with SDy or BDI, and while HC appeared to have more of an impact, standard Vit D supplementation could not account for the noted improvement in FSFI in women with PCOS.
Support: Grant from Patty Brisben Foundation, Cincinnati, OH

Total & Bioavailable 25-Hydroxyvitamin D is not associated with Improved Sexual Dysfunction Following Vitamin D Supplementation in Women with Polycystic Ovarian Syndrome

Aim: To summarize the effects of metformin treatment on markers of hyperandrogenism in patients diagnosed with PCOS.
Data source: A systematic review, with meta-analysis, of randomized placebo-controlled clinical trials that evaluated the effects of metformin treatment in adult patients with PCOS on the levels of hyperandrogenism markers from the recommendations of The Cochrane Handbook for Systematic Reviews of Interventions.
Data extraction: The literature search, data extraction, risk of bias, and the assessment of certainty of evidence were performed independently by two reviewers using a structured form. The results were combined by applying the random effect and the effect measure presented as a standardized mean difference (SMD). Significant values were considered as p<0.05 with 95% CI. Furthermore, sensitivity analyzes were performed in order to explore possible heterogeneity between studies.
Data synthesis: Were included 18 studies in the quantitative evaluation. A significant reduction in total testosterone levels was seen in the metformin-treated group when compared to the control group after combining the results [SMD: -0.46 (95% CI: -0.89 to -0.02)]. Therefore, metformin proved to be effective in reducing total testosterone levels, a finding confirmed by the sensitivity analysis, and the same was observed for FAI values – a measure influenced by testosterone levels.
Conclusion: We showed that metformin proved to be effective in reducing total testosterone levels, a finding confirmed by the sensitivity analysis, and the same was observed for FAI values – a measure influenced by testosterone levels. The protocol of this study was registered at Prospero (CRD42021235761).

Influence of metformin on hyperandrogenism in women with Polycystic Ovary Syndrome: a systematic review and meta-analysis of randomized clinical trials

OBJECTIVE: Diagnosis of polycystic ovary syndrome (PCOS) is a time- and resource-consuming process. Circulating miRNAs associated with PCOS might serve as diagnostic biomarkers. The aim of this study is the validation of 5 miRNAs with the highest diagnostic potential identified previously by our group and test their diagnostic accuracy for PCOS in a larger clinical series of patients and controls.

METHODS: We studied 71 women with PCOS and 69 control women selected as to be similar in terms of body mass index. We used miRCURY LNA™ Universal RT microRNA PCR to analyze the 5 miRNAS showing the strongest associations with PCOS in a much smaller pilot study from our group

RESULTS: Only the expression of 2 miRNAs of the 5 studied here (miR-142-3p and miR-598-3p) was different between subjects with PCOS and non-hyperandrogenic controls. The diagnostic accuracy of the combination of these circulating miRNAs was fairly good [area under the ROC curve (AUC) 0.801; 95% confidence interval (95CI) 0.720-0.882] and turned to excellent when adding the waist-to-hip ratio (WHR, AUC 0.834, 95CI 0.756-0.912), the luteinizing hormone to follicle-stimulating hormone ratio (LH/FSH ratio, AUC 0.869, 95CI: 0.804-0.934) or both (AUC 0.895, 95CI 0.835-0.954).

CONCLUSION: Models based on circulating miR-142-3p and miR-598-3p expression show excellent discrimination among women with or without PCOS, particularly when coupled with easily available measurements such as WHR and LH/FSH ratio.

(Funded by grants PI15/01686, PIE16/00050, PI18/01122 and PI21/00116 from ISCIII. CIBERDEM IRYCIS & EDRF).

Validation Of Circulating Micrornas In Polycystic Ovary Syndrome (Pcos) Diagnosis

OBJECTIVE: Metabolomics is a powerful tool to characterize the organism phenotypes and can facilitate the identification of altered metabolites and molecular pathways in pathophysiological states. Metabolites are small intermediates or end products of cellular metabolism which reflect the response to endogenous and exogenous factors. In this regard, sex hormones and obesity are important modulators of whole-body metabolism, and obese individuals and women with polycystic ovary syndrome (PCOS) present with metabolic alterations that may also manifest in the postprandial period. Hence, we investigated the effect of obesity and sex hormones on the serum metabolomics profile after single macronutrient challenges in a series of young adults. 
METHODS: Seventeen non-hyperandrogenic control women, 19 women with PCOS, and 19 healthy men —equally distributed in obese and non-obese subgroups— were submitted to isocaloric oral glucose, lipid and protein loads. Serum samples were obtained at baseline, 1h and 2h after glucose and protein ingestion, or at 2h and 4h in the lipid challenge. Thirty-five low-molecular-weight polar metabolites were determined by 1H-NMR. Postprandial net changes were expressed as areas under the curve (AUC). The influence of macronutrient, group (women, PCOS, men), obesity, and their interactions on each metabolite were evaluated by univariate GLM for repeated measures analysis.
RESULTS: Twelve metabolites (glycine, alanine, proline, threonine, serine, asparagine, glutamine, glutamic acid, ornithine, isobutyric acid, citrate and glycerol) showed different AUCs among macronutrient loads, although neither obesity nor sex hormones exerted any influence. In contrast, the AUCs of 3-hydroxybutyric and pyroglutamic acids were lower in men compared with either control or PCOS women. Remarkably, we observed numerous interactions between group, and/or obesity, and/or macronutrient for several molecules, indicating that the effect of obesity was different (or even the opposite) in control and PCOS women compared with men, and depending on the type of macronutrient. These metabolites included, among others, branched-chain and aromatic amino acids, lysine, methylhystidine, beta-glucose and acetone. Furthermore, patients with PCOS exhibited a specific and unique response —different from that of women and men— for pyruvate, tryptophan, creatine and betaine. Finally, five metabolites (2-oxoisovaleric acid, creatinine, carnitine, acetate and choline) showed no differences among the distinct macronutrient challenges and no effect of obesity, sex or PCOS.
CONCLUSION: Altered postprandial metabolomic profiles in women with PCOS point to worse metabolic flexibility that is exacerbated by obesity.


Serum Metabolomics Profile After Oral Macronutrient Challenges: Influence Of Obesity And Polycystic Ovary Syndrome

OBJECTIVE: The original description of PCOS was based on the cystic morphology of the ovaries. Serum Anti Mullerian Hormone (AMH) concentration reflects follicular reserve of the ovaries and high AMH concentrations correlate with PCO morphology. The presence of three different definitions and four different phenotypes of PCOS indicates heterogeneity of the syndrome. Our goal was to examine if phenotyping based on serum AMH can help to understand the mechanisms underlying the clinical heterogeneity. 
METHODS: 
Subjects: The EPIC EMR was used to retrospectively review the charts of 123 patients who were referred to the PCOS clinic at the UC Davis Medical Center. Patients who did not meet the Rotterdam Criteria for PCOS, who were on were on hormonal contraception, or diagnosed with a different pathology (i.e. congenital adrenal hyperplasia, pituitary tumor, premature ovarian failure) were excluded. The remaining 92 patients were included in the final analysis. Variables: Anthropometric data (age, BMI), sex/adrenal steroids (testosterone, SHBG, bio-available-T, free-T, DHEA-S,17OHP), pituitary hormones (LH, FSH, prolactin) and metabolic (HgA1C, total-cholesterol, HDL-C, LDL-C and triglyceride) were collected.
RESULTS: 
The distribution for AMH was skewed to right and therefore a rank-based quartile classification was used. AMH concentrations (ng/mL) in these quartiles were: 1st: 2.4±1.3 (n = 31); 2nd: 5.2±0.6 (n = 14); 3rd: 7.8±0.9 (n = 24) and 4th: 18.9±10.7 (n = 23). Age did not differ among groups. The following variables differed significantly (p < 0.05) in the highest AMH group (4th) when compared with the other quartiles (1st, 2nd, or 3rd) using non-parametric pairwise tests: BMI: Highest AMH group was thinner (BMI:27.1±5.9) vs. (range:28.9±6.2 to 30.5±6.5); had higher testosterone (ng/dL): (52.6±27.8) vs (29.6±13.4 to 34.9±17.7); had higher free-testosterone (ng/dL): (8.0±6.8) vs. (4.9±±2.7 to 5.4±3.0); had higher 17OHP (ng/dL): (86.7±58.8) vs. (36.8±22.2 to 46.2±39.2); had higher HDL-C (mg/dL): (56.7±13.6) vs. (44.4±5.8 to 46.4±8.7).
CONCLUSIONS:
The phenotyping based on serum AMH concentrations demonstrated that the PCOS women with highest serum AMH differ from the rest: They are thinner, have higher androgen levels. They appear to have more favorable metabolic profiles. AMH-based phenotyping may help to understand the differences between various clinical presentations of PCOS, and potentially guide the treatment approaches.

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