Genomic and proteomic evidence for hormonal and metabolic foundations of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) and its underlying features remain poorly understood. In this genetic and proteomic study, we expand the number of genetic loci from 19 to 29, and identify 31 associated plasma proteins. Many risk-increasing loci were associated with later age at menopause, underscoring the reproductive longevity related to a larger functional ovarian reserve. Hormonal regulation in the aetiology of this condition, through metabolic and reproductive features, was emphasised. The proteomic analysis highlighted perturbations of metabolically-related biology that are typical in women with PCOS. A PCOS polygenic risk score was associated with adverse cardio-metabolic outcomes, with differing contributions of testosterone and BMI in women and men. Finally, while oligo- and anovulatory infertility are characteristic features of PCOS, we observed no impact of PCOS susceptibility on childlessness. We suggest that PCOS susceptibility confers balanced pleiotropic influences on fertility in women, and life-long adverse metabolic consequences in both sexes. ### Competing Interest Statement Members of the 23andMe Research team are employees of and hold stock or stock options in 23andMe, Inc. SB reports ownerships in Intomics A/S, Hoba Therapeutics Aps, Novo Nordisk A/S, Lundbeck A/S, ALK abello A/S and managing board memberships in Proscion A/S and Intomics A/S. GT, UT, KS, and US are employees of deCODE genetics/Amgen Inc. MIM serves on advisory panels for Pfizer and NovoNordisk. MIM has received honoraria from Pfizer, NovoNordisk and EliLilly, and has received research funding from Pfizer, NovoNordisk, EliLilly, AstraZeneca, Sanofi Aventis, Boehringer Ingelheim, Merck, Roche, Janssen, Takeda, and Servier. MIM is now an employee of Genentech and a holder of Roche stock. JL has received consultancy fees from Danone, Metagenics inc., Titus Healthcare, Roche and Euroscreen. RA has received consultancy fees from Spruce Biosciences, Fortress Biotech, Rani Therapeutics, Core Access Surgical Technologies, and Arora Forge Advisors; and has equity in Martin Imaging. MOG has served on an advisory board for Nestle Health Science. BCJM Fauser has received fees and/or grant support during the last 4 years from the following organisations (in alphabetic order); Bain Capital, Controversies in Obstetrics & Gynecology (COGI), Dutch Heart Foundation (Nederlandse Hartstichting), Elsevier, European Society of Human Reproduction and Embryology (ESHRE), Ferring, International Federation of Fertility Societies (IFFS), London Womens Clinic, Myovant, Netherlands Organisation for Health Research and Development (ZonMW), Pantharei Bioscience, Partners Group, PregLem/Gideon Richter, Shieldler, Reproductive Biomedicine Online (RBMO), UpToDate. Co-founder and shareholder of Zoe Ltd (TDS). ### Funding Statement The WGHS is supported by the NHLBI (HL043851 and HL080467) and the NCI (CA047988 and UM1CA182913). This work has been supported by F32 HD103317, K08 HD110723 from the National Institute of Child Health and Human Development, 23CDA1054471 from the American Heart Association, Pediatric Endocrine Society Clinical Scholar Award and Boston Childrens Hospital Office of Faculty Development Career Development Fellowship (JZ), MATER Marie Sklodowska-Curie which received funding from the European Union's Horizon 2020 research and innovation program under grant agreement No. 813707 (NPG), MRC grant MC_U106179472 YZ, KAK, FRD, KKO, JRBP), Samuel Oschin Comprehensive Cancer Institute Developmental Funds, Center for Bioinformatics and Functional Genomics and Department of Biomedical Sciences Developmental Funds (MRJ), Novo Nordisk Foundation (grants NNF17OC0027594 and NNF14CC0001 (KB and SB), NCI P30CA177558 (CH), NIDDK R01DK075787 (JNH), NCI UM1CA186107 (PK), European Regional Development Fund (Project No. 2014-2020.4.01.15-0012) and the European Union Horizon 2020 research and innovation program under grant agreements No 692065 (TL, RM, AS) and 692145 (RM), Estonian Research Council grant PRG1076 (AS), Horizon 2020 innovation grant ERIN grant EU952516 (AS), Horizon Europe NESTOR grant 101120075 (AS), NICHD R01HD065029 (RS), Estonian Ministry of Education and Research (grant IUT34-16 to TL), NICHD R01HD057450 (MU), NICHD R01HD100630 (MU, RL, MGH, CW), NICHD P50HD044405 (AD), NICHD R01HD057223 (AD), R01HD085227 (MGH, AD) and R01 HD100812 (AD) from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, deCode Genetics (GT, UT, KS, US), NHMRC Ideas Grant 2003629 and DoH Western Australia Merit Award 1186046 (BHM), SCGOPHCG RAC 2015-16/034 (SGW, BGAS), 2016-17/018 (BGAS), NIHR BRC, Wellcome Trust, MRC (TDS), Eris M. Field Chair in Diabetes Research (MOG), NIDDK P30 DK063491 (MOG), NIDDK U01DK094431, U01DK048381 (DE), NICHD U10HD38992 (RL), Estonian Ministry of Education and Research (grant IUT34-16), Enterprise Estonia (grant EU48695); the EU-FP7 Marie Curie Industry-Academia Partnerships and Pathways (IAPP, grant SARM, EU324509 to AS), Wellcome (090532, 098381, 203141); European Commission (ENGAGE: HEALTH-F4-2007-201413 to MIM), MRC G0802782, MR/M012638/1 (SF), Li Ka Shing Foundation, WT-SSI/John Fell Funds, NIHR Biomedical Research Centre, Oxford, Widenlife and NICHD 5P50HD028138-27 (CML), NICHD R01HD065029, ADA 1-10-CT-57, Harvard Clinical and Translational Science Center, from the National Center for Research Resources 1UL1 RR025758 (CKW). Novo Nordisk Foundation Data Science Investigator grant NNF20OC0062294 (TK). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: All research involving human participants has been approved by the author Institutional Review Board (IRB) or an equivalent committee, and all clinical investigation was conducted according to the principles expressed in the Declaration of Helsinki. Written informed consent was obtained from all participants. The Boston cohort was approved by the Partners IRB (# 2002P001924 and 2012P002417) and the University of Utah IRB (IRB 00076659). The deCODE cohort was approved by the National Bioethics Committee of Iceland (VSN 03/007), which was conducted in agreement with conditions issued by the Data Protection Authority of Iceland. Personal identities of the participant data and biological samples were encrypted by a third party system (Identity Protection System), approved and monitored by the Data Protection Authority. The UK cohort was approved by the Parkside Health Authority (Now NHS Health Research Authority, NRES Committee West London & GTAC, UK, London, UK) under EC2359 “The Molecular Genetics of Polycystic Ovaries.” The Rotterdam PCOS cohort, the COLA study, was approved by institutional review board (Medical Ethics Committee) of the PCOS genetics metaanalysis PLOS Genetics | https://doi.org/10.1371/journal.pgen.1007813 December 19, 2018 10 / 20 Erasmus Medical Center (04/263). Controls from the Rotterdam Study were approved by the Medical Ethics Committee of the Erasmus MC (registration number MEC 02.1015) and by the Dutch Ministry of Health, Welfare and Sport (Population Screening Act WBO, license number 1071272/159521/PG). The Rotterdam Study Personal Registration Data collection is filed with the Erasmus MC Data Protection Officer under registration number EMC1712001. The Rotterdam Study has been entered into the Netherlands National Trial Register (NTR; www. trialregister.nl) and into the WHO International Clinical Trials Registry Platform (ICTRP; www.who.int/ictrp/network/primary/en/) under shared catalogue number NTR6831. The Chicago PCOS cohort was approved by the Northwestern IRB (# STU00008096). The control subjects from the NUgene study were approved by the Northwestern IRB (# STU00010003). The Estonia cohort was approved by the Research Ethics Committee of the University of Tartu approved the study (198T/18). The Twins UK study was approved by the St Thomas Hospital Research Ethics Committee (EC04/015). The Nurses Health Study (NHS I and II) was approved by the Partners Human Research Committee (#1999/P/011114). Patients and control subjects in FinnGen provided informed consent for biobank research, based on the Finnish Biobank Act. Alternatively, older research cohorts, collected prior the start of FinnGen (in August 2017), were collected based on study specific consents and later transferred to the Finnish biobanks after approval by the National Supervisory Authority for Welfare and Health, Fimea. Recruitment procedures followed the biobank protocols approved by Fimea. The Coordinating Ethics Committee of the Hospital District of Helsinki and Uusimaa (HUS) approved the FinnGen study protocol (Nr HUS/990/2017). The FinnGen study was approved by Finnish Institute for Health and Welfare (permit numbers: THL/2031/6.02.00/2017, THL/1101/5.05.00/2017, THL/341/6.02.00/2018, THL/2222/6.02.00/2018, THL/283/6.02.00/2019, THL/1721/5.05.00/2019, THL/1524/5.05.00/2020, and THL/2364/14.02/2020); Digital and population data service agency (permit numbers: VRK43431/2017/3, VRK/6909/2018/3, VRK/4415/2019/3); the Social Insurance Institution (permit numbers: KELA 58/522/2017, KELA 131/522/2018, KELA 70/522/2019, KELA 98/522/2019, KELA 138/522/2019, KELA 2/522/2020, KELA 16/522/2020); and Statistics Finland (permit numbers: TK/53/1041/17 and TK/53/90/20). The Biobank access decisions for FinnGen samples and data utilized in the FinnGen Data Freeze 6 include: THL Biobank BB2017/55, BB2017/111, BB2018/19, BB/2018/34, BB/2018/67, BB2018/71, BB2019/7, BB2019/8, BB2019/26, BB2020/1, Finnish Red Cross Blood Service Biobank 7.12.2017, Helsinki Biobank HUS/359/2017, Auria Biobank AB17/5154, Biobank Borealis of Northern Finland/2017/1013, Biobank of Eastern Finland 1186/2018, Finnish Clinical Biobank Tampere MH0004, Central Finland Biobank 1/2017, and Terveystalo Biobank STB 2018001. Analyses in the EstBB were carried out under ethical approval 1.1/12/624 from the Estonian Committee on Bioethics and Human Research and data release N05 from the EstBB. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data produced will either be available online or upon reasonable request to the authors after peer-reviewed publication of the manuscript.