Update on PCOS: Consequences, Challenges, and Guiding Treatment

Potential role of endoplasmic reticulum stress in the pathophysiology of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is an endocrine disorder that affects million women worldwide, presenting a complex pathophysiology that has not been fully elucidated yet. Recently, it has been suggested that PCOS triggers the endoplasmic reticulum (ER) stress, thus being associated with unfolded protein response (UPR) activation. Indeed, the UPR response has been associated with several pathological conditions, including in the reproductive system. Several studies demonstrated that ovarian UPR markers are upregulated in PCOS, being associated with worst ovarian outcomes, and this was ameliorated by ER stress inhibition. In this review, we aim to summarize the main findings from previous studies covering this topic, in an attempt to clarify the potential role of ER stress and the UPR response in the pathophysiology of PCOS.

Proteomics and bioinformatics analysis of follicular fluid from patients with polycystic ovary syndrome

Objectives: Polycystic ovary syndrome (PCOS) is a common endocrine and metabolic disorder with heterogeneous manifestations and complex etiology. We used quantitative proteomics analysis based on mass spectrometry to identify the differences in proteomics profiles for follicular fluid obtained from patients with or without PCOS and explore possible mechanisms underlying PCOS.

Methods: Follicular fluid samples were collected from infertile patients with (n = 9) or without (n = 9) PCOS. Total protein was extracted, quantitatively labeled with a tandem mass tag (TMT), and analyzed using liquid chromatography-mass spectrometry (LC‐MS). TMT-based proteomics and bioinformatics analysis were used to determine the differentially expressed proteins (DEPs) and understand the protein networks. The analysis included protein annotation, unsupervised hierarchical clustering, functional classification, functional enrichment and clustering, and protein-protein interaction analysis. Selected DEPs were confirmed by ELISA, and correlation analysis was performed between these DEPs and the clinical characteristics.

Results: In this study, we have identified 1,216 proteins, including 70 DEPs (32 upregulated proteins, 38 downregulated proteins). Bioinformatics analysis revealed that the inflammatory response, complement and coagulation cascades, activation of the immune response, lipid transport, and regulation of protein metabolic processes were co-enriched in patients with PCOS. Based on ELISA results, insulin-like growth factor binding protein 1 (IGFBP1) and apolipoprotein C2 (APOC2) were differentially expressed between patients with and without PCOS. Follicular IGFBP1 showed a positive correlation with the serum levels of high-density lipoprotein cholesterol (HDL-C) (r = 0.3046, p = 0.0419), but negatively correlated with the serum levels of anti-Müllerian hormone (AMH) (r = –0.2924, p = 0.0354) and triglycerides (r = –0.3177, p = 0.0246). Follicular APOC2 was negatively correlated with the serum apolipoprotein A1 (APOA1) levels (r = 0.4509, p = 0.0002).

Conclusion: Our study identified DEPs in the follicular fluid of patients with PCOS. Inflammatory response, complement and coagulation cascades, activation of the immune response, lipid transport, and regulation of protein metabolic process were deregulated in PCOS, which may play essential roles in the pathogenesis of PCOS.

Serum-Derived Exosomal microRNAs in Lipid Metabolism in Polycystic Ovary Syndrome

The crosstalk between obesity and insulin resistance (IR) in polycystic ovary syndrome (PCOS) may be related to miRNA regulation secreted by exosomes. However, the underlying mechanism remains to be explored. A model of PCOS with IR was constructed in mice with dehydroepiandrosterone (DHEA) and a high-fat diet (HFD). Serum exosomes were extracted and characterized using transmission electron microscopy (TEM) and western blot analysis (for CD9, CD63, and CD81). The expression of miR-20b-5p and miR-106a-5p in serum exosomes was detected by qRT-PCR. The effects of serum exosomal miR-20b-5p and miR-106a-5p on lipid metabolism and ovary histological structure in PCOS model with IR were also explored. Serum exosomal miR-20b-5p and miR-106a-5p overexpression could inhibit adipocyte differentiation in 3T3-L1 cells with IR and PCOS mice model. Furthermore, the predicted targets of miR-20b-5p and miR-106a-5p were also analyzed with bioinformatics. In DHEA + HFD serum-derived exosomes, the miR-20b-5p and miR-106a-5p levels were markedly decreased. Overexpression of miR-20b-5p and miR-106a-5p alleviated adipocyte differentiation-related genes and triglyceride content in 3T3-L1 cells and liver steatosis in mice. Bioinformatics analysis of miR-20b-5p and miR-106a-5p predicted targets indicated that miR-20b-5p and miR-106a-5p were highly related to lipid metabolism. Serum-derived exosome miR-20b-5p and miR-106a-5p inhibited adipocyte differentiation during the process of PCOS with IR, which might be a novel therapeutic target.

Clinical Characteristics of Hyperandrogenism Include Hirsutism, Polycystic Ovary Syndrome, and Acne: Association with Psychiatric Disease in Women -A Nationwide Population-Based Cohort Study in Taiwan

Objective

Previous studies have shown an increased in psychiatric disorders in women with disorders associated with hyperandrogenism, but few nationwide cohorts have studied this phenomenon. Therefore, this study is aimed to examine the association between the clinical manifestations of hyperandrogenism and subsequent psychiatric disorders.

Methods

Based on the National Health Insurance Research Database, 49,770 enrolled participants were matched for age and index date between January 1, 2000, and December 31, 2015. Hirsutism, polycystic ovary syndrome, and acne are characterized by hyperandrogenism. After adjusting for confounding factors, we used Cox proportional analysis to compare the risk of psychiatric disorders during the 16 years of follow-up.

Results

Of all the participants, 1319 (13.25%) had psychiatric disorders in the study group, whereas only 3900(9.80%) had psychiatric disorders in the control group. After adjusting for age, and monthly income, the Cox regression analysis showed that the study patients were more likely to develop psychiatric disorders (hazard ratio [HR]: 2.004, 95% confidence interval [CI] = 1.327–2.724, P < 0.001). The results demonstrated that women aged 20–29 years had a more significant risk.

Conclusion

Women with clinical characteristics of hyperandrogenism have a higher risk of developing psychiatric disorders, especially those aged 20–29 years.

Implications of endocrine-disrupting chemicals on polycystic ovarian syndrome: A comprehensive review

Polycystic ovarian syndrome (PCOS) is a complex multifactorial disorder of unknown pathogenesis in which genetic and environmental factors contribute synergistically to its phenotypic expressions. Endocrine-disrupting chemicals (EDCs), a group of widespread pollutants freely available in the environment and consumer products, can interfere with normal endocrine signals. Extensive evidence has shown that EDCs, environmental contributors to PCOS, can frequently induce ovarian and metabolic abnormalities at low doses. The current research on environmental EDCs suggests that there may be link between EDC exposure and PCOS, which calls for more human bio-monitoring of EDCs using highly sophisticated analytical techniques for the identification and quantification and to discover the underlying pathophysiology of the disease. This review briefly elaborated on the general etiology of PCOS and listed various epidemiological and experimental data from human and animal studies correlating EDCs and PCOS. This review also provides insights into various analytical tools and sample preparation techniques for biomonitoring studies for PCOS risk assessment. Furthermore, we highlight the role of metabolomics in disease-specific biomarker discovery and its use in clinical practice. It also suggests the way forward to integrate biomonitoring studies and metabolomics to underpin the role of EDCs in PCOS pathophysiology.

Changes in the prevalence of polycystic ovary syndrome in China over the past decade

BACKGROUND

Polycystic ovary syndrome (PCOS) has become a major international public health concern. However, because of controversy about the diagnostic criteria and patient selection, estimates of its absolute prevalence and change with time vary greatly.

METHODS

We conducted two consecutive nationwide epidemiological surveys of the prevalence of PCOS in representative samples of reproductive-aged women in China in 2010 and 2020. Face-to-face interviews were performed by trained interviewers in each survey. All participants completed a questionnaire and underwent a physical examination, blood sampling, and transvaginal pelvic ultrasound. We assessed hyperandrogenism (H), chronic anovulation (O), and polycystic ovaries (P) to classify the presence of PCOS using the Rotterdam criteria. The prevalence of PCOS among reproductive-aged women was estimated after consideration of differential probabilities of selection and population distribution. We conducted a logistic regression analysis by using the probability of PCOS as a function of the survey year to acquire the trend information across the years.

FINDINGS

28,739 respondents completed the survey, including 15,924 in the previously published 2010 survey and 12,815 in the new 2020 survey. In 2020, 826 participants could be diagnosed as having PCOS, with a weighted prevalence of 7.8% (95%CI: 7.0%, 9.0%) among women aged 20-49 years, leading to an estimate of 24.0 million women of reproductive age affected by this condition in China as a whole. The estimated prevalence in 2020 was higher than that of a decade ago despite identical research methods suggesting a two-thirds increase over the study period. Women with PCOS in 2020 also appeared to have a more severe phenotype overall than those of a decade ago, possibly reflecting a significantly higher prevalence of obesity, hyperandrogenism, and infertility.

INTERPRETATION

The prevalence of PCOS in Chinese women has increased significantly over the past 10 years. PCOS is a significant public health problem in women of reproductive age in China and national policy and guidelines should be re-examined in the light of the current data.

FUNDING

National Key R&D Program of China and the National Natural Science Foundation of China.

The Translational Role of miRNA in Polycystic Ovary Syndrome: From Bench to Bedside—A Systematic Literature Review

MicroRNAs (miRNAs) are small, non-coding RNAs that are essential for the regulation of post-transcriptional gene expression during tissue development and differentiation. They are involved in the regulation of manifold metabolic and hormonal processes and, within the female reproductive tract, in oocyte maturation and folliculogenesis. Altered miRNA levels have been observed in oncological and inflammatory diseases, diabetes or polycystic ovary syndrome (PCOS). Therefore, miRNAs are proving to be promising potential biomarkers. In women with PCOS, circulating miRNAs can be obtained from whole blood, serum, plasma, urine, and follicular fluid. Our systematic review summarizes data from 2010–2021 on miRNA expression in granulosa and theca cells; the relationship between miRNAs, hormonal changes, glucose and lipid metabolism in women with PCOS; and the potential role of altered miRNAs in fertility (oocyte quality) in PCOS. Furthermore, we discuss miRNAs as a potential therapeutic target in PCOS and as a diagnostic marker for PCOS.

Metformin Improves the Hepatic Steatosis Index in Non-Obese Patients with Polycystic Ovary Syndrome

Non-alcoholic fatty liver disease (NAFLD) is a common yet little recognized health problem in women with polycystic ovary syndrome (PCOS). In a retrospective setting, we investigated the effects of metformin treatment on the hepatic steatosis index (HSI) as a readily available biomarker panel for NAFLD. HSI values of >36 are considered to be highly suggestive for NAFLD. In our cohort, HSI values indicating NAFLD were found in 60/81 (74.1%) women at baseline. The mean HSI improved significantly after the metformin treatment from 43.2 ± 1.0 to 41.0 ± 1.1. Subgroup analyses of non-obese (body mass index (BMI) < 30 kg/m2), obese (BMI 30−35 kg/m2) and very obese (BMI > 35 kg/m2) women yielded mean baseline HSI values of 35.5 ± 4.5, 41.2 ± 2.7 and 51.2 ± 4.7, respectively. A significant improvement in the HSI of 1.5 ± 2.1 was observed after metformin treatment in non-obese women but not in the obese subgroups. The data suggest a new aspect of metformin treatment in non-obese PCOS patients, namely, a possible improvement in NAFLD. This study highlighted hepatic steatosis as a common comorbidity in PCOS patients that can severely affect their long-term health, and therefore, deserves more attention in the management of PCOS patients.

Polycystic ovary syndrome is associated with nonalcoholic steatohepatitis in women of reproductive age

Polycystic ovary syndrome (PCOS) occurs in approximately 10% of all reproductive-age women, with over 50% of these patients having imaging-confirmed nonalcoholic fatty liver disease (NAFLD). Whether PCOS increases the risk for more clinically relevant disease, such as nonalcoholic steatohepatitis (NASH), is unclear. Such findings are relevant to prognosticating risk of progressive liver disease in the growing population of young adults with NAFLD. Using weighted discharge data from the United States National Inpatient Sample from 2016 to 2018, we evaluated the association of PCOS with the presence of NASH among reproductive-age women with NAFLD. The association of PCOS with NASH was assessed by logistic regression, adjusting for demographic and comprehensive metabolic comorbidities. Other causes of hepatic steatosis and chronic liver diseases were excluded. Our analysis included 189,440 reproductive-age women with NAFLD, 9415 of whom had PCOS. Of those with PCOS, 1390 (15%) had a distinct code for NASH. Women with PCOS were younger (median age, 33 vs. 40 years; p < 0.001) and more likely to have diabetes (37.0% vs. 34.0%), obesity (83.0% vs. 58.0%), dyslipidemia (26.0% vs. 21.0%), and hypertension (38.0% vs. 35.0%) (all p ≤ 0.01). On adjusted analysis accounting for these metabolic comorbidities, PCOS remained independently associated with an increased prevalence of NASH (adjusted odds ratio, 1.22; 95% confidence interval, 1.05-1.42; p = 0.008). Conclusions: Among reproductive-age women with NAFLD, metabolic risk factors were more common in those with PCOS. Despite adjustment for these metabolic comorbidities, PCOS remained associated with a 22% higher odds of having NASH. These findings support efforts to increase NAFLD screening in young women with PCOS and highlight the potential "head start" in progressive liver disease among young women with PCOS.

Resveratrol regulates the inflammation and oxidative stress of granulosa cells in PCOS via targeting TLR2

Polycystic ovary syndrome (PCOS) is featured as a common endocrine disorder in reproductive-aged women, while its pathophysiology is not fully illustrated. This study examined potential actions of resveratrol in PCOS cellular model and explored the underlying interaction between resveratrol and toll-like receptor 2 (TLR2). This study performed the bioinformatics analysis on two microarray datasets (GSE34526 and GSE138518). We found that TLR2 was one of potential hub genes that may be associated with PCOS. Further examination showed that TLR2 was highly expressed in granulosa cells from PCOS group compared with control. The in vitro studies showed that LPS intervention caused an increased expression of TLR2 and the pro-inflammatory mediators, and induced oxidative stress in the granulosa cells, which was concentration-dependently antagonized by resveratrol treatment. TLR2 silence significantly attenuated LPS-induced increase TNF-α, IL-1β, IL-6 and IL-8 expression and oxidative stress of granulosa cells. Furthermore, TLR2 overexpression promoted inflammatory response and oxidative stress in the granulosa cells, which was antagonized by resveratrol treatment. In conclusion, resveratrol could attenuate LPS-induced inflammation and oxidative stress in granulosa cells, and the underlying mechanisms may be related to the inhibitory effect of resveratrol on TLR2 expression in granulosa cells.

The therapeutic effects and mechanisms of action of resveratrol on polycystic ovary syndrome: A comprehensive systematic review of clinical, animal, and in vitro studies

BACKGROUND

Polycystic ovary syndrome (PCOS) is one of the most important and common polygenic endocrine disorders among women of reproductive age. Resveratrol, a natural phenol, is involved in various biological activities, including antioxidant, antiseptic, anti-inflammatory, anti-aging, and anti-cancer effects.

METHODS

This systematic review aimed to investigate the therapeutic effects and mechanisms of actions of resveratrol in PCOS. The present study was conducted according to the guidelines of the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statements. We searched PubMed, Science Direct, Google Scholar, Scopus, ISI Web of Science, ProQuest, and Embase databases up to August 2021 by using the relative keywords. Original studies published in the English language that assessed the effects of resveratrol on PCOS and its associated complications were considered. Out of 417 records screened, only 24 articles met the inclusion criteria: 10 in vitro, 10 animal, and 4 human studies.

RESULTS

The results obtained in the present study showed that resveratrol supplementation might be effective in improving PCOS-related symptoms by reducing insulin resistance, alleviating dyslipidemia, improving ovarian morphology and anthropometric indices, regulating the reproductive hormones, and reducing inflammation and oxidative stress by affecting biological pathways.

CONCLUSION

According to the available evidence, resveratrol may reduce the complications of PCOS. However, further studies are recommended for a comprehensive conclusion on the exact mechanism of resveratrol in PCOS patients. This article is protected by copyright. All rights reserved.

Conversion of Classical and 11-Oxygenated Androgens by Insulin-Induced AKR1C3 in a Model of Human PCOS Adipocytes

Polycystic ovary syndrome (PCOS) is the most prevalent endocrinopathy in women. A common symptom of PCOS is hyperandrogenism (AE); however, the source of these androgens is uncertain. Aldo-keto reductase family 1 member C3 (AKR1C3) catalyzes the formation of testosterone (T) and 5α-dihydrotestosterone (DHT) in peripheral tissues, which activate the androgen receptor (AR). AKR1C3 is induced by insulin in adipocytes and may be central in driving the AE in PCOS. We elucidated the conversion of both classical and 11-oxygenated androgens to potent androgens in a model of PCOS adipocytes. Using high-performance liquid chromatography (HPLC) discontinuous kinetic assays to measure product formation by recombinant AKR1C3, we found that the conversion of 11-keto-Δ4-androstene-3,17-dione (11K-4AD) to 11-ketotestosterone (11K-T) and 11-keto-5α-androstane-3,17-dione (11K-5AD) to 11-keto-5α-dihydrotestosterone (11K-DHT) were superior to the formation of T and DHT. We utilized a stable isotope dilution liquid chromatography high resolution mass spectrometric (SID-LC-HRMS) assay for the quantification of both classical and 11-oxygenated androgens in differentiated Simpson-Golabi-Behmel syndrome adipocytes in which AKR1C3 was induced by insulin. Adipocytes were treated with adrenal derived 11β-hydroxy-Δ4-androstene-3,17-dione (11β-OH-4AD), 11K-4AD, or Δ4-androstene-3,17-dione (4AD). The conversion of 11β-OH-4AD and 11K-4AD to 11K-T required AKR1C3. We also found that once 11K-T is formed, it is inactivated to 11β-hydroxy-testosterone (11β-OH-T) by 11β-hydroxysteroid dehydrogenase type 1 (HSD11B1). Our data reveal a unique role for HSD11B1 in protecting the AR from AE. We conclude that the 11-oxygenated androgens formed in adipocytes may contribute to the hyperandrogenic profile of PCOS women and that AKR1C3 is a potential therapeutic target to mitigate the AE of PCOS.

Metabolomics combined with network pharmacology to explore the mechanisms of modified Guishen pill to ameliorate polycystic ovary syndrome

BACKGROUND

The modified Guishen pill (MGP) has a prominent therapeutic effect on polycystic ovary syndrome (PCOS). However, its mechanism is still unclear. This study aimed to uncover the mechanism of MGP for PCOS treatment through a comprehensive strategy integrating metabolomics and network pharmacology.

METHODS

A letrozole-induced PCOS model was used to evaluate ovarian function in rats. Plasma metabolomics was used to authenticate differential metabolites and enriched related pathways using the MetaboAnalyst platform. Network pharmacology was utilized to explore the endogenous targets of MGP treatment for PCOS. Finally, the potential targets and related biological functions were verified experimentally.

RESULTS

MGP improved PCOS symptoms by regulating abnormal levels of sex hormones and alleviating ovarian pathological changes in rats; fifty-four potential differential metabolites involved in MGP treatment for PCOS, and the hub genes derived from network pharmacology were consistent with the metabolomic analysis results to varying degrees. The comprehensive analysis identified that a key novel target for endothelial nitric oxide synthase (eNOS/NOS3), five key metabolites (ornithine, citrulline, l-glutamic acid, acetylornithine, and hydroxyproline), and one pathway (arginine and proline metabolism) were related to the therapy of PCOS with MGP. Subsequently, we verified the localization and expression of eNOS in the ovaries, and it significantly improved insulin resistance, apoptosis, and oxidative stress in letrozole-induced PCOS rats.

CONCLUSION

Our work reveals the complex mechanism of MGP therapy for PCOS. This study is a successful paradigm for elucidating the pharmacological mechanism of the traditional Chinese medicine compound.

Reconsidering the Polycystic Ovary Syndrome (PCOS)

Though likely the most common clinical diagnosis in reproductive medicine, the Polycystic Ovary Syndrome (PCOS) is still only poorly understood. Based on previously published research, and here newly presented supportive evidence, we propose to replace the four current phenotypes of PCOS with only two entities—a hyperandrogenic phenotype (H-PCOS) including current phenotypes A, B, and C, and a hyper-/hypoandrogenic phenotype (HH-PCOS), representing the current phenotype D under the Rotterdam criteria. Reclassifying PCOS in this way likely establishes two distinct genomic entities, H-PCOS, primarily characterized by metabolic abnormalities (i.e., metabolic syndrome) and a hyperandrogenic with advancing age becoming a hypoandrogenic phenotype (HH-PCOS), in approximately 85% characterized by a hyperactive immune system mostly due to autoimmunity and inflammation. We furthermore suggest that because of hypoandrogenism usually developing after age 35, HH-PCOS at that age becomes relatively treatment resistant to in vitro fertilization (IVF) and offer in a case-controlled study evidence that androgen supplementation overcomes this resistance. In view of highly distinct clinical presentations of H-PCOS and HH-PCOS, polygenic risk scores should be able to differentiate between these 2 PCOS phenotypes. At least one clustering analysis in the literature is supportive of this concept.

Prevalence and associated risk factors for mental health problems among patients with polycystic ovary syndrome in Bangladesh: A nationwide cross-Sectional study

BACKGROUND

Polycystic ovary syndrome (PCOS) is a common female reproductive endocrine problem worldwide. The prevalence of mental disorder is increasing among PCOS patients due to various physical, psychological, and social issues. Here we aimed to evaluate the mental health and associated factors among women suffering from PCOS in Bangladesh.

METHODS

We performed an online cross-sectional survey among 409 participants with PCOS using Google Forms. We used structured questionnaires to collect socio-demographic information and lifestyle-related factors. Also, we applied patient health questionnaire (PHQ-9), generalized anxiety disorder (GAD-7) scale, and UCLA loneliness (UCLA-3) scale for psychometric assessment of the participants. Finally, we applied several statistical tools and performed data interpretations to evaluate the prevalence of mental health disorders and associated factors among patients with PCOS in Bangladesh.

RESULTS

Prevalence of loneliness, generalized anxiety disorder and depressive illness among the women with PCOS were 71%, 88%, and 60%, respectively. Among the mental illness, mild, moderate, and severe cases were 39%, 18%, and 14% for loneliness; 39%, 23% and 26% for generalized anxiety disorder; and 35%, 18%, and 7% for depressive disorder. According to the present findings, obesity, financial condition, physical exercise, mealtime, food habit, daily water consumption, birth control method, and long-term oral contraceptive pills contribute to developing mental health disorders among females with PCOS in Bangladesh.

CONCLUSION

According to present study results, high proportion of women suffering from PCOS experience several mental disorders in Bangladesh. Although several socio-demographic and lifestyle-related factors were found to be associated with the poor mental health of women with PCOS; however, PCOS itself is a condition that favors poor physical and psychological health. Therefore, we recommend proper treatment, public awareness, and a healthy lifestyle to promote the good mental health of women suffering from PCOS.

Value of ultrasonography parameters in diagnosing polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a common endocrinopathy among women of reproductive age associated with hyperandrogenism, oligo-amenorrhea, and infertility. Symptoms and their severity vary among the individuals. If the manifestation is mild, PCOS may remain undiagnosed. In more severe cases, it results in a spectrum of symptoms of metabolic syndrome, insulin resistance, and cardiovascular diseases. The diagnosis is established after a physical examination and evaluating the patient's hormonal profile. In addition to these required methods, ultrasonographic assessment of the patient's ovaries is another non-invasive, cheap, and time-saving tool, making the examination more profound and leading to the correct diagnosis. Specific ultrasonographic parameters are used to tell the healthy and polycystic ovaries apart: the ovarian volume (OV), ovarian follicle count, follicle distribution pattern, ovarian stromal echogenicity, and the resistance and pulsatility indices assessed using the Doppler function. This review evaluated the selected articles and ascertained the ultrasonographic parameters that accurately predict PCOS. This systematic review showed that the most valuable ultrasonographic parameters in diagnosing PCOS are the OV and follicle number per ovary.

Integrated Network Pharmacology and Clinical Study to Reveal the Effects and Mechanisms of Bushen Huoxue Huatan Decoction on Polycystic Ovary Syndrome

Objective

Bushen Huoxue Huatan Decoction (BHHD) is a classic prescription for treating polycystic ovary syndrome (PCOS). This study aims to explore the effects and possible mechanisms of BHHD on PCOS by integrating network pharmacology and clinical study.

Methods

The components and potential drug targets of BHHD were analysed using the TCMSP platform, and the potential pathogenesis targets for PCOS were analysed using the GeneCards and OMIM databases. Subsequently, a disease-compound-target network diagram was established to identify the targets of BHHD treatment on PCOS. In addition, protein-protein interaction analysis, KEGG pathway analysis, and Gene Ontology biological analysis were carried out to reveal the mechanisms of BHHD. To further validate the analysis, a clinical trial involving 62 PCOS patients was conducted. All patients were treated with BHHD for 3 months and the ovulation rate, anthropometric indicators, clinical symptoms, and serological indicators were measured and compared before and after treatment.

Results

The network pharmacology analysis showed that quercetin, luteolin, and kaempferol are the most significant active components in BHHD; STAT3, Jun, AKT1, MAPK3, MAPK1, and TP53 are the most critical drug targets; regulating hormones, reversing insulin (INS) resistance, exerting anti-inflammatory effects, and improving fertility might be the most important mechanisms of BHHD in the treatment of PCOS. After BHHD administration, the cyclic ovulation rate and the clinical symptoms including acanthosis nigricans and acne of patients were obviously improved. The serum endocrine levels of luteinising hormone (LH), LH/follicle-stimulating hormone, testosterone, dehydroepiandrosterone sulphate, insulin (INS), and area under the INS curve were evidently reversed, and the serum inflammatory factors levels including human interleukin (IL)-18, IL-16, IL-1β, IL-8, macrophage migration inhibitory factor, and human leukocyte differentiation antigen CD40 ligand were greatly reduced.

Conclusion

BHHD has a good therapeutic effect on PCOS, and its mechanisms may be related to regulating hormone levels, improving insulin resistance, alleviating inflammation, and promoting pregnancy.

Osteosarcopenia: A Narrative Review on Clinical Studies

Osteosarcopenia (OS) is defined by the concurrent presence of osteopenia/osteoporosis and sarcopenia. The pathogenesis and etiology of OS involve genetic, biochemical, mechanical, and lifestyle factors. Moreover, an inadequate nutritional status, such as low intake of protein, vitamin D, and calcium, and a reduction in physical activity are key risk factors for OS. This review aims to increase knowledge about diagnosis, incidence, etiology, and treatment of OS through clinical studies that treat OS as a single disease. Clinical studies show the relationship between OS and the risk of frailty, falls, and fractures and some association with Non-communicable diseases (NCDs) pathologies such as diabetes, obesity, and cardiovascular disease. In some cases, the importance of deepening the related mechanisms is emphasized. Physical exercise with adequate nutrition and nutritional supplementations such as proteins, Vitamin D, or calcium, represent a significant strategy for breaking OS. In addition, pharmacological interventions may confer benefits on muscle and bone health. Both non-pharmacological and pharmacological interventions require additional randomized controlled trials (RCT) in humans to deepen the synergistic effect of exercise, nutritional interventions, and drug compounds in osteosarcopenia.

'I'm usually being my own doctor': women's experiences of managing polycystic ovary syndrome in Canada

BACKGROUND

Polycystic ovary syndrome (PCOS) is a complex, chronic condition characterized by anovulation, polycystic ovarian morphology and hyperandrogenism that requires lifelong management. To reduce the risk of comorbidity and to manage symptoms, lifestyle management and pharmaceuticals such as oral contraceptives are the most common forms of treatment and should be tailored to the individual patient. The literature to date has shown PCOS patients to experience widespread dissatisfaction with the amount and quality of information they receive from providers, along with lower levels of trust in physicians. Little is known about the lived experiences of women managing PCOS in Canada, across age groups.

METHODS

In-depth remote interviews explored women's lived experiences managing PCOS and the barriers and facilitators they encountered in their management journeys. Data were analyzed using thematic analysis and interpretive description methodology.

RESULTS

Twenty-five in-depth, telephone interviews conducted with participants (aged 18-63 y) across Canada revealed participants lacking sufficient information and guidance from physicians, especially in primary care. Areas in need of more guidance included lifestyle management and mental health. Lack of empathy and weight bias among physicians were also perceived by participants. Older participants received little guidance on treatment options postmenopause. Loss of trust and withdrawal from seeking medical care were prominent themes, along with greater self-reliance on self-management, including self-educating and self-experimenting with treatments.

CONCLUSIONS

Most women in this study were frustrated with the level of involvement and information provision from their doctors. Key recommendations are identified for the provision of care to younger and older patients with PCOS. Improved education for physicians may be needed to improve the quality of healthcare provision for PCOS.

Evaluation of Formulated Herbal Syrup (Containing Fennel, Anise, and Celery) on the Letrozole-Induced Polycystic Ovary Syndrome Model

Background: Polycystic ovary syndrome (PCOS) is a complex endocrine disorder associated with irregular menstrual cycles, hyperandrogenism, obesity, and reduced fertility. Objectives: The present study aimed to formulate herbal syrup based on Iranian traditional medicine (ITM) and evaluate its effect on the letrozole-induced PCOS model in female rats. Methods: The herbal syrup contains anise, fennel, and celery seed extracts. Five different formulations were made with different percentages of additive components. Quality control and stability tests were performed on the selected formulation. During the in vivo step, 6 groups of rats were evaluated: The control group (received carboxymethyl cellulose 1% as a vehicle) and the other 5 groups (received letrozole 1 mg/kg orally for 21 days). During 21 days, daily vaginal smears were examined to detect irregularities of the estrous cycle. After induction of PCOS, rats were orally administered with herbal syrup (1, 2, 4 mL/kg) or metformin (200 mg/kg) for 28 days. Moreover, body and ovarian weights, serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, progesterone, and testosterone were measured. Finally, ovarian tissues were isolated for histological examination. Results: The best formulation of the syrup contained the plant extract (totally 10%), sugar (50%), sodium benzoate (0.1%), and potassium sorbate (0.1%). Body weight was significantly increased in all groups compared to the control group, and after treatment, a significant weight reduction was seen in the metformin and 1-mL/kg dose group. Following PCOS induction, ovary weight was significantly increased, while after treatment, it showed a significant decrease. After 21 days of letrozole administration, induction of PCOS was confirmed by the irregularities in estrous cycles and an increase in testosterone and LH levels. After treatments with the syrup, LH levels significantly decreased in all groups (P < 0.05), and serum testosterone and FSH levels significantly decreased in the 2-mL/kg dose group compared to the PCOS group (P < 0.05). Estradiol and progesterone levels significantly increased in the treatment groups in a dose-dependent manner. Histological studies of metformin and herbal syrup groups exhibited normal follicular development with fewer and smaller cystic follicles compared to the PCOS group. Conclusions: The herbal syrup made from anise, fennel, and celery seed extracts improved serum levels of sex hormones, recovered the ovarian morphology in PCOS-induced rats, and can be a good candidate for further clinical trials.

What can be done to improve polycystic ovary syndrome (PCOS) healthcare? Insights from semi-structured interviews with women in Canada

BACKGROUND

Polycystic ovary syndrome (PCOS) is a common and perplexing condition affecting metabolic, reproductive, cardiovascular, and psychological health in women. Previous studies point to widespread dissatisfaction and frustration in women with the information and care they receive. Studies have found delays with the diagnosis of PCOS and gaps in knowledge in physicians regarding the diagnosis and management of PCOS. Little has been heard from women on what they think can be improved with PCOS care, especially in Canada. This qualitative study explores women's experiences navigating the healthcare system and their insights on what could be improved based on their lived experiences.

METHODS

Twenty-five participants were interviewed remotely over the phone by the first author between October and December 2018.Interviews were semi-structured and in-depth. Data were analyzed using thematic analysis and interpretive description methodology.

RESULTS

Twenty-five in-depth interviews conducted with participants across Canada (ages 18-63) revealed three overall areas in need of improvement. First, women emphasized a need for greater knowledge and awareness of PCOS in primary care physicians (PCPs) as well as the need for the medical community to prioritize women's health. Second, participants advocated for greater PCOS awareness and de-stigmatization in the general community and in women and girls, and any individuals with female reproductive systems. Third, participants brought up several needed resources, such as the need for more PCOS research to be funded and undertaken, more PCOS specialists and experts to be available, credible doctor-provided information (e.g., pamphlets, websites), and age-specific support groups and mental health supports to be available. Participants were generally unaware of existing PCOS organizations and brought up the need for established PCOS organizations to aid in the training and retraining of doctors and local awareness-building in communities.

CONCLUSIONS

Participants believed that PCPs in Canada needed to be well-versed on how to diagnose and manage PCOS to prevent delays in diagnosis and provide easier access to care. Further, greater awareness and de-stigmatization in the general community are needed so women can identify symptoms early and have access to support from those around them. Overall, PCOS may be an overlooked and under-prioritized condition, both in the Canadian healthcare system and general community.

Burden of polycystic ovary syndrome in the Middle East and North Africa region, 1990-2019

Polycystic ovary syndrome (PCOS) is one of the most important contributing factors to infertility. In this study, we report the burden of PCOS by age and sociodemographic index (SDI) for the 21 countries in the Middle East and North Africa (MENA) region. Publicly available data on the point prevalence, incidence and years lived with disability (YLDs), from 1990 to 2019, were retrieved from the Global Burden of Disease (GBD) 2019 study for the 21 countries in MENA. The results are presented with age-standardised numbers and rates per 100,000 population, along with their corresponding 95% uncertainty intervals (UIs). In 2019, the age-standardised point prevalence and incidence rate for PCOS in the MENA region were 2079.7 (95% UI: 1392.0 to 2812.3) and 77.2 (95% UI: 51.6 to 105.4) per 100,000, respectively, which represents a 37.9% (95% UI: 31.7 to 45.0) and a 33.7% (95% UI: 27.7 to 40.3) increase since 1990, respectively. Also in 2019, the age-standardised YLD rate of PCOS in this region was 18.7 (95% UI: 7.8 to 37.9) per 100,000 women, which has increased by 36.1% (95% UI: 29.4 to 43.4) since 1990. Kuwait [25.4 (10.7, 51.2)] had the highest age-standardised YLD rate, while Afghanistan [10.8 (10.1, 49.2)] had the lowest. Moreover, the largest increase in the YLD rate, from 1990 to 2019, was seen in Sudan [90.3% (64.1, 120.9)], whereas no country decreased during the measurement period. The total prevalent number and point prevalence of PCOS (per 100,000) were both highest in the 20-24 age group. The prevalence of PCOS was highest among women of reproductive age, but decreased rapidly after 45 years of age. Moreover, at the country level there was a positive association between SDI and the age-standardised YLD rates of PCOS. The growing prevalence and burden of PCOS in the MENA region highlights the need to implement cost-effective preventive programs, especially for women in their third decade of life, and in MENA countries with higher SDI levels.

Mediterranean Diet Combined With a Low-Carbohydrate Dietary Pattern in the Treatment of Overweight Polycystic Ovary Syndrome Patients

Objectives

To determine the therapeutic effect of a Mediterranean diet (MED) combined with a low-carbohydrate (LC) dietary model in overweight polycystic ovary syndrome (PCOS) patients.

Methods

In this 12-week randomized controlled clinical trial, 72 overweight patients with PCOS were randomly assigned to one of two energy-restricted dietary models: the MED/LC diet or the Low fat (LF) diet. After the intervention, the number of the two groups returned to normal menstruation was counted. Body weight, body mass index (BMI), waist circumference, waist-hip ratio (WHR), body fat percentage (BF%), serum fasting insulin(FINS), fasting plasma glucose(FPG), insulin resistance index (HOMA-IR), quantitative insulin sensitivity index (QUIKI), total cholesterol (TC) and high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), triglyceride (TG), total testosterone (TT), luteinizing hormone (LH), follicle-stimulating hormone (FSH), and prolactin (PRL) were compared between 2 groups before and after intervention.

Results

MED/LC group had more significant reduction trend in weight (−6.10 ± 1.52 kg vs −4.79 ± 0.97 kg, P < 0.05), BMI (−2.12 ± 0.57 kg/m² vs −1.78 ± 0.36 kg/m², P < 0.05), WC (−6.12 ± 5.95 cm vs −3.90 ± 1.58 cm, P < 0.05), WHR (−0.06 ± 0.02 vs −0.03 ± 0.02, P < 0.05), BF% (−2.97% ± 1.78% vs −1.19% ± 0.91%, P < 0.05), TT (−0.20 ± 0.24 ng/mL vs 0.08 ± 0.11 ng/Ml, P < 0.001), LH (−5.28 ± 3.31 mIU/mL vs −3.39 ± 3.64 mIU/mL, P < 0.05), and LH/FSH (−1.18 ± 0.75 vs -0.66 ± 1.05, P < 0.05) compared with the LF group. In addition, FPG (0.05 ± 0.38 mmol/mL vs -0.50 ± 1.01 mmol/mL, P < 0.001), FINS (−4.88 ± 6.11 μU/mL vs −8.53 ± 5.61 μU/mL, P < 0.01), HOMA-IR index (−1.11 ± 1.51 vs −2.23 ± 0.25, P < 0.05), and QUIKI index (0.014 ± 0.016 vs 0.028 ± 0.019, P < 0.05) decreased significantly in the MED/LC group compared with the LF group. Comparing the changes in lipid parameters between the two groups (LF vs MED/LC), significant differences in TG (−0.33 ± 0.32 mmol vs −0.76 ± 0.97 mmol, P < 0.05), TC (−0.40 ± 1.00 mmol vs −1.45 ± 2.00 mmol, P < 0.05), and LDL-C (−0.41 ± 1.05 mmol vs −0.73 ± 0.76 mmol, P < 0.05) were observed.

Conclusion

The results of this study suggest that the MED/LC diet model is a good treatment for overweight PCOS patients, significantly restoring their menstrual cycle, improving their anthropometric parameters and correcting their disturbed endocrine levels, and its overall effectiveness is significantly better than the LF diet model. Therefore, this study recommends that the MED/LC diet model can be used in the clinical treatment of patients with overweight PCOS.

Controversies in the Pathogenesis, Diagnosis and Treatment of PCOS: Focus on Insulin Resistance, Inflammation, and Hyperandrogenism

Polycystic ovary syndrome (PCOS) is a heterogeneous and extremely common disease with symptoms that vary with the age of the patient, typically characterized by hyperandrogenism, chronic oligo-anovulation, and/or several metabolic disorders. The syndrome includes various phenotypes, and the pathogenesis is multifactorial, often involving insulin resistance. This feature is closely related to ovarian dysfunction, inflammation, hyperandrogenism, and metabolic disorders, which characterize and complicate the syndrome. Therapy currently considers both lifestyle improvements and medications, and must be tailored on a case-by-case basis. To date, the published studies have not arrived at a definition of the most suitable therapy for each individual case and many of the drugs used are still off-label. In this review, we discuss some controversial diagnostic and therapeutic aspects of PCOS, such as the role of insulin resistance, inflammation, and hyperandrogenism. We also evaluated the advantages and disadvantages of contraceptive therapy and antiandrogens.

Insulin-like growth factor 2 mRNA-binding protein 2-regulated alternative splicing of nuclear factor 1 C-type causes excessive granulosa cell proliferation in polycystic ovary syndrome

Objectives

Polycystic ovary syndrome (PCOS) is a common reproductive endocrine disorder. Insulin‐like growth factor 2 mRNA‐binding protein 2 (IGF2BP2) serves as an HMGA2 target gene to promote the proliferation of granulosa cells (GCs). However, it is still unclear whether IGF2BP2 participates in the pathogenesis of PCOS as RNA binding protein (RBP). In this study, we aimed to elucidate IGF2BP2‐interacting transcripts, global transcriptome together with alternative splicing in GCs to eventually uncover potential mechanisms of PCOS pathogenesis.

Materials and Methods

The expression of IGF2BP2 in GCs from PCOS patients was detected using quantitative reverse transcription PCR (RT‐qPCR) and western blot. We captured IGF2BP2‐interacting transcripts, global transcriptome together with alternative splicing by RNA immunoprecipitation sequencing (RIP‐seq) and RNA sequencing (RNA‐seq). KGN cells transfected with IGF2BP2 overexpressing plasmids and nuclear factor 1 C‐type (NFIC) siRNAs, were applied to CCK‐8, EdU and TUNEL assays.

Results

IGF2BP2 was highly expressed in GCs from PCOS patients. As an RBP, it preferentially bound to the 3′and 5′UTRs of mRNAs with GGAC motif and a newly found GAAG motif. The overexpression of IGF2BP2 changed the transcriptome profile of KGN cells. IGF2BP2 functioned to regulate alternative splicing events and promote cell proliferation through inhibiting exon skipping events of NFIC.

Conclusion

In conclusion, we demonstrated that IGF2BP2 promotes GC proliferation via regulating alternative splicing of NFIC in PCOS. The findings help to better understand the roles of IGF2BP2 in the pathogenesis of PCOS.

A Randomized Cohort Study: Is It Worth the Time to Receive Antiandrogenic Pretreatment Before Ovulation Induction for Women With Polycystic Ovary Syndrome?

Objective

To assess the effect of antiandrogenic pretreatment using combined oral contraceptives (COCs) before ovulation induction in infertile patients with polycystic ovary syndrome (PCOS) with hyperandrogenism.

Design

Prospective, randomized open-labeled cohort study.

Setting

Multicenter.

Patients

PCOS patients with hyperandrogenism and requiring infertility treatments.

Interventions

Randomization to direct ovulation induction of letrozole (letrozole group) or ethinylestradiol/cyproterone acetate (EE/CPA) for 3 months and subsequent letrozole-induced ovulation (EE/CPA+ letrozole group). The maximum number of ovulation induction cycle was three to four.

Main Outcome Measures

Ovulation rate, conception rate, ongoing pregnancy rate, and live birth rate were the main outcomes of the study.

Results

There were no significant differences in the cumulative ovulation, conception, ongoing pregnancy, and live birth rates between the letrozole and EE/CPA+ letrozole groups (cumulative ovulation: 206/254 [81.10%] vs. 169/205 [82.44%], risk ratio [RR]= 1.09 [0.68,1.76], P=0.713; conception: 44/90 [48.89%] vs. 42/76 [55.26%], RR= 1.29 [0.70,2.38], P=0.413; ongoing pregnancy: 33/90 [36.67%] vs. 33/76 [43.42%], RR=1.33 [0.71,2.47], P=0.376; and live birth: 32/90 [35.56%] vs. 31/76 [40.79%], RR=1.25 [0.67, 2.34], P=0.489).

Conclusions

The results of this study showed that COC pretreatment was not superior to direct letrozole-induced ovulation therapy in improving ovulation and pregnancy results in women with PCOS. There is no benefit to perform antiandrogenic therapy before ovulation induction in patients with PCOS in clinical practice.

Clinical Trial Registration

www.clinicaltrials.gov, identifier ChiCTR1900022839.

"I felt like she didn't take me seriously": a multi-methods study examining patient satisfaction and experiences with polycystic ovary syndrome (PCOS) in Canada

Background

Polycystic ovary syndrome (PCOS) is a common and complex condition affecting metabolic, reproductive, cardiovascular, and psychological health in women. Previous studies point to widespread dissatisfaction and delays with the diagnosis of PCOS and a lack of information provision by doctors, with few studies on Canadian populations. This multi-methods study explored the perceptions and experiences of PCOS diagnosis in Canada using an online-distributed survey and follow-up, in-depth, semi-structured phone interviews.

Methods

The online questionnaire was completed by 296 women aged 18–60 with a self-reported diagnosis of PCOS. The survey measured time to diagnosis, number of doctors seen, and information provided. Descriptive statistics, Chi-square tests, Fisher’s exact tests, and Spearman’s rank correlations were used to analyze the sample characteristics and correlations between the demographic factors and the outcome measures. Twenty-five follow-up interviews were held over the phone and analyzed using thematic analysis and interpretive description methodology.

Results

Survey respondents were dissatisfied with the information provided about PCOS (66%), lifestyle management (34%), and medical therapy (38%) at the time of diagnosis. Approximately 34% of respondents waited for more than 2 years and 41% saw 3 or more doctors before attaining diagnosis. Many did not receive any information about lifestyle management (42%) or medical therapy (28%). Interview participants encountered doctors who lacked sufficient knowledge on PCOS to diagnose, chronically dismissed concerns, and did not provide necessary medical information about the condition. Women described benefitting from self-advocation to receive the care they needed from doctors, and self-educating about PCOS using materials they could find online. Younger interview participants whose symptoms began in adolescence would often not understand the significance of symptoms until much later in life, contributing to delayed diagnoses.

Conclusions

Greater education on PCOS for physicians, particularly in primary care, is needed to prevent delayed diagnoses and ensure that patients are provided with reliable medical information about their condition. Greater awareness of PCOS may be necessary for the general population to help women identify symptoms, especially for adolescents and their parental figures.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01630-3.

Polycystic ovarian syndrome-current pharmacotherapy and clinical implications

Polycystic ovary syndrome (PCOS), the most common endocrinopathy in women is characterized by polycystic ovaries, chronic anovulation and hyperandrogenism. The treatment in PCOS is mainly symptomatic and involves lifestyle interventions and medications such as Metformin, Oral contraceptives and Antiandrogens. However, the management of PCOS is challenging and current interventions are not able to deal with outcomes of this syndrome. This review encompasses latest pharmacotherapeutic and non-pharmacotherapeutic interventions currently in use to tackle various symptomatic contentions in PCOS. Our focus has been mainly on novel therapeutic modalities for treatment/management of PCOS, like use of newer insulin sensitizers viz., Inositols, Glucagon-like peptide-1(GLP-1) agonists, Dipeptidyl pepdidase-4 (DPP-4) inhibitors, and sodium-glucose transport protein 2 (SGLT2) inhibitors. Also, evidence suggesting the use of vitamin D, statins, and Letrozole as emerging therapies in PCOS have been summarized in this review. Additionally, novel cosmetic techniques like electrolysis, laser and use of topically applied eflornithine to tackle the most distressing feature of facial hirsutism associated with PCOS, non-pharmacological therapy like acupuncture and the role of herbal medicine in PCOS management have also been discussed.

Effectiveness of Lifestyle Modification in Polycystic Ovary Syndrome Patients with Obesity: A Systematic Review and Meta-Analysis

(1) Background: Polycystic ovary syndrome (PCOS) is the most common cause of anovulatory infertility and endocrine disorders among women of reproductive age. Previous studies have employed lifestyle interventions to manage anovulatory infertility and endocrine disorders. However, the effect of lifestyle interventions on the metabolic index remains ambiguous; (2) Methods: Data were obtained through a systematic search of the Ovid-Medline, Ovid-EMBASE, and Cochrane Library databases. Two reviewers independently reviewed the literature in two stages. A consensus was achieved through discussions regarding the final selection of the literature; (3) Results: This study observed that the group that underwent lifestyle modifications displayed significant improvement in reproductive function compared to the control group. Combination therapy with diet and exercise resulted in improved fasting insulin levels, compared to monotherapy with diet or exercise. Moreover, moderate weight loss (a minimum of 5%) resulted in an improved metabolic index. The subgroup analysis revealed that the group that underwent lifestyle modifications had a significantly higher number of patients with improved menstrual cycles, compared to the control groups; (4) Conclusions: Lifestyle modification using combination therapy is a promising therapeutic approach that can be employed in the management of PCOS patients with obesity. This scenario warrants further studies with larger sample sizes to develop ideal treatment protocols.

A bibliometric analysis of polycystic ovary syndrome research in Southeast Asia: Insights and implications

BACKGROUND AND AIMS

There has been an increased understanding in the pathophysiology and management of polycystic ovary syndrome (PCOS) in recent years. This study aimed to evaluate the trends and characteristics of PCOS publications in Southeast Asia (SEA) through a bibliometric analysis.

METHODS

Systematic review of literature on PCOS in SEA countries between 1975 and 2020 was performed using the Scopus database. All published studies on PCOS conducted in or published by authors from any of the countries in SEA were included in this analysis. Bibliographic information was obtained, and visualization of collaboration networks of countries and keywords was conducted using VOSviewer software.

RESULTS

A total of 260 articles were included in this analysis. The number of PCOS publications in SEA continued to increase through the years. The country with the highest number of publications was Thailand while Singapore produced the most publications with the greatest impact. The focus of research in SEA was on PCOS prevalence, risk factors, infertility, and metabolic complications. A country's fertility rate, research and development expenditures (%GDP), number of researchers per million people, and international research collaborations significantly correlated with PCOS research impact in SEA.

CONCLUSION

This is the first bibliometric analysis in PCOS research in SEA. Despite the continuing increase in PCOS publications in SEA, it still lags compared to other regions. Countries in SEA should consider policies and strategies directed at increasing research support and encouraging international collaborations for local researchers to produce more meaningful publications and augment PCOS knowledge in the region.

Prevalence, Risk Factors, and Pathophysiology of Nonalcoholic Fatty Liver Disease (NAFLD) in Women with Polycystic Ovary Syndrome (PCOS)

Background: Polycystic Ovary Syndrome (PCOS) is one of the most common endocrine disorders in women's reproductive period of life. The presence of nonalcoholic fatty liver disease NAFLD, one of the leading causes of chronic liver disease in the Western world, is increased in women with PCOS. This review aims to present current knowledge in epidemiology, pathophysiology, diagnostics, and treatment of NAFLD in PCOS with an emphasis on the molecular basis of development of NAFLD in PCOS women. Methods: Authors investigated the available data on PCOS and NAFLD by a MEDLINE and Pub Med search during the years 1990-2021 using a combination of keywords such as "PCOS", "NAFLD", "steatohepatitis", "insulin resistance", "hyperandrogenaemia", "inflammation", "adipose tissue", and "obesity". Peer-reviewed articles regarding NAFLD and PCOS were included in this manuscript. Additional articles were identified from the references of relevant papers. Results: PCOS and NAFLD are multifactorial diseases, The development of NAFLD in PCOS women is linked to insulin resistance, hyperandrogenemia, obesity, adipose tissue dysfunction, and inflammation. There is the possible role of the gut microbiome, mitochondrial dysfunction, and endocannabinoid system in the maintenance of NAFLD in PCOS women. Conclusions: There is a need for further investigation about the mechanism of the development of NAFLD in PCOS women. New data about the molecular basis of development of NAFLD in PCOS integrated with epidemiological and clinical information could influence the evolution of new diagnostic and therapeutic approaches of NAFLD in PCOS.

Quantitative Proteomics Reveals That a Prognostic Signature of the Endometrium of the Polycystic Ovary Syndrome Women Based on Ferroptosis Proteins

OBJECTIVE

We aimed to study the relationship between ferroptosis proteins and reproductive outcomes of infertile patients with PCOS and construct the related prognostic model.

METHODS

These endometrium samples of the study were collected from 33 women with PCOS and 7 control women with successful pregnancies at the Reproductive Center of Lanzhou University Second Hospital, September 2019 to September 2020. The 40 patients' endometrium was identified the differentially expressed proteins (DEPs) using liquid chromatography tandem mass spectrometry. The Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis and Gene Ontology (GO) showed that the DEPs related pathways and functions between PCOS and controls. Subsequently, univariate Cox regression analysis and Lasso regression were used to identifying independent prognostic ferroptosis proteins, which were utilized to establish a prognostic model. Then the performance of the prognostic model was evaluated by receiver operating characteristic curve (ROC) and decision curve analysis (DCA). Then clinical data and prognostic model were used to predict the reproductive outcomes of PCOS patients by constructing the nomograms. Finally, we performed the single sample gene set enrichment analysis (ssGSEA) to explore the correlation between risk scores and immune status.

RESULTS

A total of 5331 proteins were identified, 391 proteins were differentially expressed in the PCOS and controls. The KEGG analysis revealed that the ferroptosis pathway was significantly different between PCOS and controls. 5 ferroptosis proteins (GPX4, DPP4, G6PD, PCBP1, and PCBP2) prognostic model (FerSig) was constructed via Cox regression and Lasso regression. Patients were separated into high and low-risk groups according to the FerSig. Kaplan-Meier curve showed that patients in the low-risk group had much better reproductive outcomes than those in the high-risk group. The DCA showed that the risk score was an independent predictive factor for reproductive outcomes. Compared with clinical data, ROC curve analysis indicated the FerSig proteins as a potential diagnostic and prognostic factor in PCOS patients. Functional analysis revealed that the FerSig proteins and immune microenvironment were correlated to the prognosis of PCOS.

CONCLUSION

The prognostic model focused on the FerSig proteins could predict the reproductive outcomes of PCOS patients with decreased endometrial receptivity, and provided theoretical basis for individualized treatment.

Elevated circulating GPHB5 levels in women with insulin resistance and polycystic ovary syndrome: A cross-sectional study and multiple intervention studies

OBJECTIVE

GPHB5 has been found to be associated with glucose and lipid metabolism in animal studies. However, the association of GPHB5 with IR and metabolic disorders remains unknown, and there is a lack of research in humans. Our aim in this study was to investigate the relationship between circulating GPHB5 and metabolic disorders in humans.

METHODS

Bioinformatics analysis was performed to understand the relationship between GPHB5 and metabolic disorders. GPHB5 mRNA expression in mice and rats was determined using RT-qPCR. Circulating GPHB5 concentrations were measured with an ELISA kit. EHC and OGTT were performed in humans.

RESULTS

Bioinformatics analysis shows that GPHB5 is associated with metabolic disorders and PCOS. GPHB5 mRNA expression levels in the metabolic-related tissues of HFD-fed mice, db/db and ob/ob mice, and PCOS rats were significantly higher than those of WT mice or rats. In human studies, we find that circulating GPHB5 levels were significantly higher in women with IR and PCOS. GPHB5 levels were positively correlated with age, BMI, WHR, BP, FBG, 2 h-BG, FIns, 2 h-Ins, TC, LDL-C, HbA1c, and FFA, but negatively correlated with adiponectin. Furthermore, GPHB5 was positively correlated with DHEAS and FAI, while negatively correlated with SHBG, FSH, SHBG and FSH. The increased GPHB5 concentration was related to IR and PCOS. After the treatment of metformin, GLP-1RA (Lira), and TZDs, circulating GPHB5 levels were decreased.

CONCLUSIONS

Our results reveal that circulating GPHB5 could be a biomarker and potential therapeutic target for IR and PCOS in women.

Modified Cangfu Daotan decoction ameliorates polycystic ovary syndrome with insulin resistance via NF-κB/LCN-2 signaling pathway in inflammatory microenvironment

This study explored the possible connection between the insulin resistance-targeting protein adipokine lipocalin-2 (LCN-2) and NF-κB signaling pathway in the inflammatory microenvironment in PCOS-IR model rats to determine the pharmacological mechanism of modified Cangfu Daotan decoction (MCDD) intervention for PCOS-IR. We used a high-fat diet (42 days) combined with letrozole (1 mg/kg/day, 42 days) to establish a PCOS-IR rat model. From the third week after modeling, the rats were given continuous administration of MCDD (high dose with 31.68 g/kg, medium dose with 15.84 g/kg, and low dose with 7.92 g/kg) for 28 days. Serum, ovarian tissue, liver, and adipose tissue were collected after the last gavage. Enzyme-linked immunosorbent assay, hematoxylin-eosin (HE) staining, Masson staining, qRT-PCR, and Western blot experiments were performed to detect various indicators. Our results showed that MCDD could reduce body weight and abdominal fat weight; restore normal estrous cycle and ovarian function; alleviate fatty liver; regulate HOMA-IR and OGTT index; reduce serum inflammatory factor levels, LCN-2 level, and gene expression; and regulate the insulin signal transduction and NF-κB pathways in PCOS-IR rats. Thus, MCDD may play a role in improving ovarian function in PCOS-IR rats by downregulating NF-κB/LCN-2 proteins and upregulating the gene expression of Insr/Irs-1/Glut4 in the insulin signaling pathway in the inflammatory environment.

Life Modifications and PCOS: Old Story But New Tales

Polycystic ovary syndrome (PCOS) is defined as a kind of endocrine and metabolic disorder that affects female individuals of reproductive age. Lifestyle modifications, including diet modifications, exercise, and behavioral modification, appear to alleviate the metabolic dysfunction and improve the reproductive disorders of PCOS patients (particularly in obese women). Therefore, lifestyle modifications have been gradually acknowledged as the first-line management for PCOS, especially in obese patients with PCOS. However, the mechanism of lifestyle modifications in PCOS, the appropriate composition of diet modifications, and the applicable type of exercise modifications for specific female populations are rarely reported. We conducted a systematic review and enrolled 10 randomized controlled trials for inclusion in a certain selection. In this review, we summarized the existing research on lifestyle modifications in PCOS. We aimed to illustrate the relationship between lifestyle modifications and PCOS (referring to hyperandrogenism, insulin resistance as well as obesity) and also considered the priorities for future research. These results might be an invaluable tool to serve as a guide in lifestyle modifications as the intervention for PCOS and other related endocrine disorders.

Reproductive outcomes after bariatric surgery in women

The presence of obesity may significantly influence female fertility through various mechanisms. Impairment of the hypothalamic-pituitary-ovarian axis in obese women may induce anovulation and infertility. Obesity may have an effect on women’s spontaneous and assisted conception rates, increased miscarriage rates, premature labor, stillbirth and perinatal risks, and menstrual irregularity. It has been suggested that weight loss improves reproductive outcomes due to fertility amelioration and an improvement in menstrual irregularity and ovulation. It is still not known which weight reduction procedures (changes in lifestyle, pharmacological management or bariatric intervention) result in optimal outcome on infertility. Currently, bariatric surgery is defined as the best available method for the management of obesity and its associated diseases.

We have analyzed literature facts about effects of bariatric surgery on the function of the hypothalamic-pituitary-ovarian axis, polycystic ovary syndrome (PCOS), anti-Mullerian hormone (AMH) and sexual dysfunction in obesity and pregnancy in obesity. Immediate positive effects of bariatric surgery are evident at the moment, while for long-term outcomes more prolonged follow-up investigations should be done.

Elevated plasma pentraxin-3 in polycystic ovary syndrome is associated with hyperandrogenism: a case-control study

BACKGROUND

Pentraxin 3 (PTX3) - a crucial humoral innate immunity component - is related to obesity and cardiovascular complications in women who suffer from polycystic ovary syndrome (PCOS). However, the circulating PTX3 level in PCOS is still debated. In this study, we aimed to evaluate PTX3 plasma levels in PCOS women of childbearing age, and find possible endocrine/metabolic factors that could affect this level.

METHODS

A total of 360 women were enrolled: 120 PCOS women and 240 body mass index (BMI) matched normally ovulating women. Blood samples were collected on the third day of natural menstrual cycle or from the bleeding after progesterone withdrawal. The PTX3 concentration was measured by immunoassay.

RESULTS

The PTX3 plasma level was significantly higher in PCOS women compared to controls. There was a positive correlation between PTX3 plasma level and PCOS diagnosis, overweight, cycle length, serum LH to FSH ratio, estradiol, total testosterone (TT) on the third day of menstrual cycle, antral follicle count (AFC), as well as uric acid. Multivariant linear regression analysis indicated that participants' serum PTX3 levels were proportional to the circulating TT level, existence of PCOS, basal estradiol level and AFC.

CONCLUSIONS

Overall, the circulating PTX3 level was elevated in PCOS women and significantly associated with the presence of hyperandrogenism. This study provided the basis for further in-depth researches regarding PTX3 role in PCOS pathophysiology.

Associations between dyslipidaemia and pregnancy outcomes in the first complete cycle of IVF/ICSI: a real-world analysis

RESEARCH QUESTION

Are there associations between dyslipidaemia and pregnancy outcomes in the first complete cycle of IVF/intracytoplasmic sperm injection (ICSI)?

DESIGN

This long-term, retrospective real-world analysis involved 5030 infertile women who underwent a first complete IVF/ICSI cycle between January 2015 and October 2020. They were categorized into dyslipidaemia (n = 1903) and control (n = 3127) groups according to serum lipid concentrations before ovarian stimulation. Propensity score matching and multivariable logistic regression were used to control for confounding variables.

RESULTS

In the raw cohort, women with dyslipidaemia had a significantly increased late miscarriage rate (P = 0.039), decreased term birth rate (P = 0.002) and decreased live birth rate (P = 0.005) compared with non-dyslipidaemic women. In the propensity score-matched cohort, the term birth rate (P = 0.038) and live birth rate (P = 0.044) were significantly lower in the dyslipidaemia group (n = 1686) than the controls (n = 1686). Multivariable logistic regression indicated that infertile women with dyslipidaemia (P = 0.026) and elevated serum total cholesterol concentrations (total cholesterol ≥5.20 mmol/l; P = 0.028) were significantly less likely to have a live birth. Rates of late miscarriage (P = 0.027), term birth (P = 0.003) and live birth (P = 0.010) differed significantly among women with normal, borderline increased and increased serum lipid concentrations. Compared with controls, women with increased serum lipid concentrations had a significantly higher late miscarriage rate, lower term birth rate and lower live birth rate. Women with increased serum lipid concentrations were significantly less likely than controls to have a live birth.

CONCLUSIONS

Dyslipidaemia, total cholesterol ≥5.20 mmol/l and degrees of elevated serum lipid concentrations are negatively associated with live birth rate in the first complete IVF/ICSI cycle in infertile women.

Unravelling Polycystic Ovary Syndrome and Its Comorbidities

Polycystic ovary syndrome (PCOS) is a chronic multisystem endocrine disorder that affects women of reproductive age. In the ovary, the dynamic balance between dormant and growing follicles that culminates in ovulation becomes dysfunctional in the presence of excessive androgen production (ovarian/adrenal/peripheral). Moreover, hyperandrogenicity in pregnancy affects fetal development in utero and is linked to maternal pregnancy complications. Hormonal imbalance, ovarian dysfunction, and central obesity often emerge in these patients during adolescence. Once disordered physiological changes develop in PCOS, a vicious cycle ensues, leading to reproductive, metabolic, and psychological comorbidities. With the alarming increase of the number of young adults with a high degree of obesity in Korea, the prevalence of PCOS has also considerably increased. Timely and accurate screening, multicomponent healthy lifestyle modifications for both patients and family members, and comprehensive medical interventions based on international evidence-based guidelines are essential for curtailing PCOS and its comorbidities.

Effectiveness of a 6-Month Lifestyle Intervention on Diet, Physical Activity, Quality of Life, and Markers of Cardiometabolic Health in Women with PCOS and Obesity and Non-PCOS Obese Controls: One Size Fits All?

Little is known about the difference in effectiveness of lifestyle intervention between women with PCOS and non-PCOS women. In a post hoc longitudinal analysis of a randomized, controlled trial, we aimed to investigate whether infertile women with PCOS and obesity (N = 87) responded differently to a 6-month lifestyle intervention program than infertile non-PCOS obese controls (N = 172). We evaluated several aspects of the intervention such as changes in diet, physical activity, and dropout rate, as well as the effect on weight, quality of life (QoL), and cardiometabolic outcomes. Multilevel analyses were used, and analyses were adjusted for baseline characteristics such as age, education, and smoking. Although BMI in both groups significantly decreased at 3 months and 6 months, there were no significant differences between the groups at 3 months (adjusted B: −0.3, 95% CI: −0.9 to 0.3, p = 0.35) and 6 months (adjusted B: 0.5, 95% CI: −0.4 to 1.4, p = 0.29). Women with PCOS and non-PCOS women had similar compliance with the lifestyle intervention in terms of actual change in diet and physical activity. Mental QoL scores were not different at either 3 or 6 months. Physical QoL scores were lower in women with PCOS compared with non-PCOS women at 3 months (adjusted B: −2.4, 95% CI: −4.8 to −0.06, p = 0.045) but not at 6 months. Cardiometabolic parameters did not differ between the groups. Our results showed that infertile women with PCOS and obesity and non-PCOS obese controls responded largely similarly to our lifestyle intervention and achieved the same level of improvement in markers of cardiometabolic health.

Involvement of Kisspeptin in androgen-induced hypothalamic endoplasmic reticulum stress and its rescuing effect in PCOS rats

Endoplasmic reticulum (ER) stress, with adaptive unfolded protein response (UPR), is a key link between obesity, insulin resistance and type 2 diabetes, all of which are often present in the most common endocrine-metabolic disorder in women of reproductive age, polycystic ovary syndrome (PCOS), which is characterized with hyperandrogenism. However, the link between excess androgen and Endoplasmic reticulum (ER) stress/insulin resistance in patients with polycystic ovary syndrome (PCOS) is unknown. An unexpected role of kisspeptin was reported in the regulation of UPR pathways and its involvement in the androgen-induced ER stress in hypothalamic neuronal cells. To evaluate the relationship of kisspeptin and ER stress, we detected Kisspeptin and other factors in blood plasm of PCOS patients, rat models and hypothalamic neuronal cells. We detected higher testosterone and lower kisspeptin levels in the plasma of PCOS than that in non-PCOS women. We established a PCOS rat model by dihydrotestosterone (DHT) chronic exposure, and observed significantly downregulated kisspeptin expression and activated UPR pathways in PCOS rat hypothalamus compared to that in controls. Inhibition or knockdown of kisspeptin completely mimicked the enhancing effect of DHT on UPR pathways in a hypothalamic neuronal cell line, GT1-7. Kp10, the most potent peptide of kisspeptin, effectively reversed or suppressed the activated UPR pathways induced by DHT or thapsigargin, an ER stress activator, in GT1-7 cells, as well as in the hypothalamus in PCOS rats. Similarly, Kisspeptin attenuated thapsigargin-induced Ca²⁺ response and the DHT- induced insulin resistance in GT1-7 cells. Collectively, the present study has revealed an unexpected protective role of kisspeptin against ER stress and insulin resistance in the hypothalamus and provided a new treatment strategy targeting hypothalamic ER stress and insulin resistance with kisspeptin as a potential therapeutic agent.

Increased uterine androgen receptor protein abundance results in implantation and mitochondrial defects in pregnant rats with hyperandrogenism and insulin resistance

Abstract

In this study, we show that during normal rat pregnancy, there is a gestational stage-dependent decrease in androgen receptor (AR) abundance in the gravid uterus and that this is correlated with the differential expression of endometrial receptivity and decidualization genes during early and mid-gestation. In contrast, exposure to 5α-dihydrotestosterone (DHT) and insulin (INS) or DHT alone significantly increased AR protein levels in the uterus in association with the aberrant expression of endometrial receptivity and decidualization genes, as well as disrupted implantation. Next, we assessed the functional relevance of the androgen-AR axis in the uterus for reproductive outcomes by treating normal pregnant rats and pregnant rats exposed to DHT and INS with the anti-androgen flutamide. We found that AR blockage using flutamide largely attenuated the DHT and INS-induced maternal endocrine, metabolic, and fertility impairments in pregnant rats in association with suppressed induction of uterine AR protein abundance and androgen-regulated response protein and normalized expression of several endometrial receptivity and decidualization genes. Further, blockade of AR normalized the expression of the mitochondrial biogenesis marker Nrf1 and the mitochondrial functional proteins Complexes I and II, VDAC, and PHB1. However, flutamide treatment did not rescue the compromised mitochondrial structure resulting from co-exposure to DHT and INS. These results demonstrate that functional AR protein is an important factor for gravid uterine function. Impairments in the uterine androgen-AR axis are accompanied by decreased endometrial receptivity, decidualization, and mitochondrial dysfunction, which might contribute to abnormal implantation in pregnant PCOS patients with compromised pregnancy outcomes and subfertility.

Key messages

The proper regulation of uterine androgen receptor (AR) contributes to a normal pregnancy process, whereas the aberrant regulation of uterine AR might be linked to polycystic ovary syndrome (PCOS)-induced pregnancy-related complications.

In the current study, we found that during normal rat pregnancy there is a stage-dependent decrease in AR abundance in the gravid uterus and that this is correlated with the differential expression of the endometrial receptivity and decidualization genes Spp1, Prl, Igfbp1, and Hbegf.

Pregnant rats exposed to 5α-dihydrotestosterone (DHT) and insulin (INS) or to DHT alone show elevated uterine AR protein abundance and implantation failure related to the aberrant expression of genes involved in endometrial receptivity and decidualization in early to mid-gestation.

Treatment with the anti-androgen flutamide, starting from pre-implantation, effectively prevents DHT + INS-induced defects in endometrial receptivity and decidualization gene expression, restores uterine mitochondrial homeostasis, and increases the pregnancy rate and the numbers of viable fetuses.

This study adds to our understanding of the mechanisms underlying poor pregnancy outcomes in PCOS patients and the possible therapeutic use of anti-androgens, including flutamide, after spontaneous conception.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00109-021-02104-z.

The Emerging Roles and Therapeutic Potential of Extracellular Vesicles in Infertility

Infertility is becoming much more common and affects more couples. The past years witnessed the rapid development of the diagnosis and treatment upon infertility, which give numerous coupled more opportunities become parents. Extracellular vesicles are known as nano-sized membrane vesicles to play a major role in intracellular communication. In recent years, several basic and clinical studies have tried to investigate the correlation between the reproductive health/disorder and extracellular vesicles. However, the mechanism is still unclear. In this review, we reviewed the relationship between reproductive physiology and extracellular vesicles, and then collectively focused on the recent findings on the relationship between extracellular and infertility, and its consequent influence on the novel insight regarding the therapeutic strategies for infertility in the future clinical practice.

LEAP-2: An Emerging Endogenous Ghrelin Receptor Antagonist in the Pathophysiology of Obesity

Liver-expressed antimicrobial peptide 2 (LEAP-2), originally described as an antimicrobial peptide, has recently been recognized as an endogenous blocker of growth hormone secretagogue receptor 1a (GHS-R1a). GHS-R1a, also known as ghrelin receptor, is a G protein-coupled receptor (GPCR) widely distributed on the hypothalamus and pituitary gland where it exerts its major functions of regulating appetite and growth hormone (GH) secretion. The activity of GHS-R1a is controlled by two counter-regulatory endogenous ligands: Ghrelin (activation) and LEAP-2 (inhibition). Ghrelin activates GHS-R1a on the neuropeptide Y/Agouti-related protein (NPY/AgRP) neurons at the arcuate nucleus (ARC) to promote appetite, and on the pituitary somatotrophs to stimulate GH release. On the flip side, LEAP-2, acts both as an endogenous competitive antagonist of ghrelin and an inverse agonist of constitutive GHS-R1a activity. Such a biological property of LEAP-2 vigorously blocks ghrelin's effects on food intake and hormonal secretion. In circulation, LEAP-2 displays an inverse pattern as to ghrelin; it increases with food intake and obesity (positive energy balance), whereas decreases upon fasting and weight loss (negative energy balance). Thus, the LEAP-2/ghrelin molar ratio fluctuates in response to energy status and modulation of this ratio conversely influences energy intake. Inhibiting ghrelin's activity has shown beneficial effects on obesity in preclinical experiments, which sheds light on LEAP-2's anti-obesity potential. In this review, we will analyze LEAP-2's effects from a metabolic point of view with a focus on metabolic hormones (e.g., ghrelin, GH, and insulin), and discuss LEAP-2's potential as a promising therapeutic target for obesity.

ANGPTL4 Expression in Ovarian Granulosa Cells Is Associated With Polycystic Ovary Syndrome

OBJECTIVES

This study aims to characterize the expression of ANGPTL4 in ovarian granulosa cells (GCs) and its association with polycystic ovary syndrome (PCOS).

METHODS

This study included 104 PCOS patients and 112 women in control group undergoing in vitro fertilization-embryo transfer (IVF-ET) from the reproductive hospital affiliated with Shandong University from 2019 to 2021. By reverse transcription and real-time quantitative (RT-q) PCR, the mRNA expression of ANGPTL4 in GCs was assessed, and clinical information for these patients were then reviewed and analyzed.

RESULTS

The RT-qPCR results showed that ANGPTL4 expression in the control group was significantly lower than that in the PCOS group (p = 0.000) and had positive association with AMH (r = 0.211), HOMA-IR (r = 0.174), LDL/HDL (r = 0.176), ApoB/ApoAI (r = 0.155), and TC/HDL (r = 0.189). Additionally, the high expression of ANGPTL4 in the ovarian granulosa cells might be an independent predictor in PCOS (OR: 3.345; 95% CI: 1.951-5.734) with a close contact with incidence of PCOS (AUC: 0.704; 95% CI: 0.633-0.774, p < 0.001).

CONCLUSIONS

Our study revealed higher ANGPTL4 expression in ovarian GCs with PCOS. Its association with glucose and lipid metabolism showed that ANGPTL4 might play an important role in PCOS metabolism and pathogenesis.