The pathophysiology of polycystic ovary syndrome

Assessment of the Effect of Leonurine Hydrochloride in a Mouse Model of PCOS by Gene Expression Profiling

Polycystic ovary syndrome (PCOS) is an endocrine disease commonly associated with metabolic disorders in females. Leonurine hydrochloride (Leo) plays an important role in regulating immunity, tumours, uterine smooth muscle, and ovarian function. However, the effect of Leo on PCOS has not been reported. Here, we used dehydroepiandrosterone to establish a mouse model of PCOS, and some mice were then treated with Leo by gavage. We found that Leo could improve the irregular oestros cycle of PCOS mice, reverse the significantly greater serum testosterone (T) and luteinising hormone (LH) levels, significantly reduce the follicle-stimulating hormone (FSH) level, and significantly increase the LH/FSH ratio of PCOS mice. Leo could also change the phenomenon of ovaries in PCOS mice presented with cystic follicular multiplication and a lacking corpus luteum. Transcriptome analysis identified 177 differentially expressed genes related to follicular development between the model and Leo groups. Notably, the cAMP signalling pathway, neuroactive ligand-receptor interactions, the calcium signalling pathway, the ovarian steroidogenesis pathway, and the Lhcgr, Star, Cyp11a, Hsd17b7, Camk2b, Calml4, and Phkg1 genes may be most related to improvements in hormone levels and the numbers of ovarian cystic follicles and corpora lutea in PCOS mice treated by Leo, which provides a reference for further study of the mechanism of Leo.

The effects of pro-, pre-, and synbiotics supplementation on polycystic ovary syndrome: an umbrella review of meta-analyses of randomized controlled trials

Background

Synbiotics, refer to a combination of probiotics and prebiotics in a form of synergism that beneficially affect the host's health by alternating the composition and/or function of the gut microbiota. Numerous meta-analyses of randomized clinical trials have proven that pro, pre-, and synbiotics supplementation has health outcomes in women with polycystic ovary syndrome (PCOS). However, the strength and quality of this evidence in aggregate have not yet been synthesized in great detail.

Methods

PubMed, Scopus, Web of Sciences, and Google Scholar were searched up to March 2023. We pooled the mean difference and its 95% confidence interval (CI) by applying a random-effects model.

Results

Overall, nine meta-analyses including a total of 12 trials were identified. The results of the present study indicated that probiotic supplementation significantly reduced the homeostatic model assessment for insulin resistance (HOMA-IR; WMD: -0.29, 95% CI: -0.57 to -0.02, p = 0.03, n = 4; moderate certainty) and fasting glucose concentration (FGC; WMD: -7.5 mg/dL, 95% CI: -13.60 to -0.51, p = 0.03; n = 4; low certainty). Moreover, synbiotic supplementation had beneficial effects on glycemic control, lipid profile, and hormonal parameters, but the certainty of the evidence was rated as low to very low. However, supplementation with pro-/synbiotics did not affect inflammation and oxidative stress in women with PCOS. Furthermore, waist/hip circumference, fasting glucose concentration, lipid profile, dehydroepiandrosterone sulfate, high-sensitivity C-reactive protein, and hirsutism score were significantly reduced after prebiotics supplementation with low certainty of evidence.

Conclusion

Although pro-, pre-, and synbiotics supplementation had beneficial effects on some PCOS-related outcomes, the certainty of the evidence was rated as low to very low. Therefore, further well-designed RCTs might help to confirm our findings in women with PCOS.

The effects of low-level laser therapy on polycystic ovarian syndrome in rats: three different dosages

The main objective of this in vivo study was to investigate the effect of different low-level laser therapy (LLLT) doses on polycystic ovary syndrome (PCOS). In the present experimental study, a single dosage of estradiol valerate (EV) was administered to induce PCOS in female rats. After administration of the EV for induction of PCOS, rats were divided into 5 groups (n = 8/group): C group (animals that were not exposed to any form of procedure), PC group (no treatment following EV induction), L1 group (1 J/cm2 LLLT treatment following EV induction), L2 group (2 J/cm2 LLLT treatment following EV induction), L3 group (6 J/cm2 LLLT treatment following EV induction). The results indicated that no significant difference was found in the serum levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH), and progesterone (P4) between the C and L2 groups (p < 0.05). Although the serum levels of testosterone (T) were significantly higher in the C group compared with other groups (p < 0.05), the L2 group was determined to be the closest to the C group. Additionally, the LH, FSH, and T receptor level of the L2 group was closest to the C group. In conclusion, a 2 J/cm2 dosage of LLLT (L2 group) can be considered the most potentially effective treatment of PCOS in the rat. However, more studies are needed to determine the optimal dose of LLLT for the treatment of PCOS.

Therapeutic exploration of polyherbal formulation against letrozole induced PCOS rats: A mechanistic approach

Objective

This study aimed to develop an effective alternative medicine with multi potential herbs against polycystic ovarian syndrome (PCOS) in rats induced by letrozole treatment.

Materials and method

Polyherbal syrup was prepared with a combination of S. asoca bark, G. sylvestre leaves, P. daemia aerial parts, C. zeylanium stem bark, C. bonduc seeds, and W. somnifera roots ethanolic extract. In vitro cell viability study, adenosine monophosphate-activated protein kinase (AMPK), and glucose transporter 4 (GLUT4) gene expression assay were carried out on the Chinese Hamster Ovarian (CHO) cell line. For the PCOS induction letrozole (1 mg/kg p. o.) was given for 21 consecutive days. The PCOS induction was confirmed by measuring estrus irregularity, insulin resistance by oral glucose tolerance test (OGTT), and hyperandrogenism by measuring serum total testosterone level 21 days after completion of letrozole treatment. After induction of PCOS, metformin (155 mg/kg p. o.), and polyherbal syrup (100 mg/kg, 200 mg/kg, and 400 mg/kg p. o.) were administered for further 28 days. The treatment efficacy was measured by measuring serum lipid profile, fasting insulin level, sex hormones level, ovarian steroidogenic enzymes, ovarian tissue insulin receptor, AMPK, and GLUT4 protein expression levels, and histomorphological studies. The post-treatment effect was confirmed by reproductive performance studies.

Results

Letrozole-induced PCOS rats showed significant estrus irregularity, abnormal sex hormones levels, and hyperandrogenism indicated by showing increased free androgenic index and decreased sex hormones binding globulin (SHBG) level. The insulin resistance in PCOS rats was indicated by increased fasting glucose levels with impaired glucose clearance in the OGT test. Homeostasis Model Assessment Index of Insulin Resistance (HOMA-IR) increased level, also decreases INSR, GLUT4, and AMPK mRNA expression in ovarian cells confirming the insulin resistance in PCOS rats. Ovarian histology in PCOS rats also showed many follicular cysts, atretic follicles, and the absence of corpus luteum. The administration of polyherbal syrup, in a dose-dependent manner, effectively restored these alterations. The treatment of polyherbal formulation 400 mg/kg possesses highly significant efficacy over the treatment of metformin in PCOS rats. It mainly acts by reducing peripheral and ovarian hyperandrogenism and improves insulin sensitivity via activating the insulin receptor and AMP-activated kinase-mediated transcription and translation of GLUT4 from the cytoplasm to the ovarian membrane improves glucose uptake and promotes the follicular development and ovulation. The higher fertility rate, delivery index, and survival of delivered pups confirm the broader and superior efficacy of PCOS. These beneficial actions are mainly attributable to the formulation's inclusion of the key secondary metabolites flavonoids and phytosterols. In conclusion, the prepared polyherbal syrup was found to be the safest and most effective alternative medicine for both endocrinal and metabolic complications of PCOS women.

Effects of androgen excess and body mass index on endothelial function in women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is associated with endothelial dysfunction; whether this is attributable to comorbid hyperandrogenism and/or obesity remains to be established. Therefore, we 1) compared endothelial function between lean and overweight/obese (OW/OB) women with and without androgen excess (AE)-PCOS and 2) examined androgens as potential modulators of endothelial function in these women. The flow-mediated dilation (FMD) test was applied in 14 women with AE-PCOS (lean: n = 7; OW/OB: n = 7) and 14 controls (CTRL; lean: n = 7, OW/OB: n = 7) at baseline (BSL) and following 7 days of ethinyl estradiol supplementation (EE; 30 µg/day) to assess the effect of a vasodilatory therapeutic on endothelial function; at each time point we assessed peak increases in diameter during reactive hyperemia (%FMD), shear rate, and low flow-mediated constriction (%LFMC). BSL %FMD was attenuated in lean AE-PCOS versus both lean CTRL (5.2 ± 1.5 vs. 10.3 ± 2.6%, P < 0.01) and OW/OB AE-PCOS (5.2 ± 1.5 vs. 6.6 ± 0.9%, P = 0.048). A negative correlation between BSL %FMD and free testosterone was observed in lean AE-PCOS only (R² = 0.68, P = 0.02). EE increased %FMD in both OW/OB groups (CTRL: 7.6 ± 0.6 vs. 10.4 ± 2.5%, AE-PCOS: 6.6 ± 0.9 vs. 9.6 ± 1.7%, P < 0.01), had no impact on %FMD in lean AE-PCOS (5.17 ± 1.5 vs. 5.17 ± 1.1%, P = 0.99), and reduced %FMD in lean CTRL (10.3 ± 2.6 vs. 7.6 ± 1.2%, P = 0.03). Collectively, these data indicate that lean women with AE-PCOS exhibit more severe endothelial dysfunction than their OW/OB counterparts. Furthermore, endothelial dysfunction appears to be mediated by circulating androgens in lean but not in OW/OB AE-PCOS, suggesting a difference in the endothelial pathophysiology of AE-PCOS between these phenotypes.NEW & NOTEWORTHY We present evidence for marked endothelial dysfunction in lean women with androgen excess polycystic ovary syndrome (AE-PCOS) that is 1) associated with free testosterone levels, 2) impaired relative to overweight/obese women with AE-PCOS, and 3) unchanged following short-term ethinyl estradiol supplementation. These data indicate an important direct effect of androgens on the vascular system in women with AE-PCOS. Our data also suggest that the relationship between androgens and vascular health differs between phenotypes of AE-PCOS.

Serum anti-Müllerian hormone as a predictor of polycystic ovarian syndrome among women of reproductive age

BACKGROUND

Polycystic ovarian syndrome (PCOS) affects up to one-fifth of women of reproductive age and causes anovulatory subfertility. Some studies have recommended that an anti-Müllerian hormone (AMH) level greater than 3.8-5 ng/mL can be used for diagnosing PCOS. This study aims to analyse serum AMH levels among PCOS women of reproductive age to use AMH as a biomarker predictor along with other Rotterdam criteria.

METHODS

In this cross-sectional study, a total of 98 women visiting the fertility center of a private hospital in Lahore, Pakistan, were screened. Data were obtained from 51 PCOS newly diagnosed women aged 28.24 years (SD ± 4.84 years) meeting at least two of the Rotterdam criteria and specific inclusion criteria. Baseline variables, menstrual cycle length, ovarian morphology on ultrasound, hirsutism, sex hormones, gonadotropin, and serum AMH levels were analysed during the follicular phase (1-5 days) of the menstrual cycle. Serum AMH was measured by an enzyme-linked immunosorbent assay.

RESULTS

A high serum AMH level (7.23 ± 4.67 ng/ml) was recorded with normal sex hormone levels. Women with oligo-/amenorrhea had a significant mean difference for luteinizing hormone (p = 0.02) and AMH levels (p = 0.03) when compared with women of normal menstrual cycle length. PCOS women with high AMH levels (≥ 3.9 ng/ml) showed a significant difference in ovarian morphology (p < 0.05) when compared with the normal AMH group.

CONCLUSIONS

An elevated serum AMH level can be used as a strong predictor to reflect the certainty of PCOS diagnosis among women of reproductive age when study concurrently with the other Rotterdam criteria.

Effect of vitamin E supplementation on cardiometabolic risk factors, inflammatory and oxidative markers and hormonal functions in PCOS (polycystic ovary syndrome): a systematic review and meta-analysis

Polycystic ovary syndrome (PCOS) is a common endocrinopathy among reproductive-age women. Various therapeutical approaches are currently used to manage or control symptoms associated with PCOS. This systematic review intended to assess the effects of Vit E supplementation on cardiometabolic risk factors, inflammatory and oxidative markers, and hormonal functions in PCOS women based on the clinical trial's results. The databases including PubMed, Scopus, Cochrane, Web of Science, and Embase were used to find all relevant studies. The authors reviewed all relevant clinical trials via systematic evaluation of abstracts and titles. Searches were conducted on August 1, 2020. After the initial search and reading of the article's title and abstract, 353 articles were reviewed; finally, 12 articles met the inclusion criteria. Vitamin E supplementation improves lipid profile, decreases insulin and HOMA-IR levels. Furthermore, while Vitamin E supplementation decreases LH and testosterone concentrations, it increases FSH and progestrone concentrations. The following meta-analysis showed that vitamin E supplementation made statistically significant improvements in triglyceride (TG) and low-density lipoproteins (LDL) levels, meanwhile, pooled mean difference for waist circumference (WC) and HOMA-IR were also statistically significant. Supplementary regimens containing vitamin E can positively affect metabolic and hormonal parameters in women with PCOS.

Polycystic ovary syndrome and risks for COVID-19 infection: A comprehensive review : PCOS and COVID-19 relationship

This comprehensive review aimed to evaluate the relationship between SARS-CoV-2 infection (the cause of coronavirus disease 2019, or COVID-19) and the metabolic and endocrine characteristics frequently found in women with polycystic ovary syndrome (PCOS). In the general population, COVID-19 is more severe in subjects with dyslipidemia, obesity, diabetes mellitus, and arterial hypertension. Because these conditions are comorbidities commonly associated with PCOS, it was hypothesized that women with PCOS would be at higher risk for acquiring COVID-19 and developing more severe clinical presentations. This hypothesis was confirmed in several epidemiological studies. The present review shows that women with PCOS are at 28%-50% higher risk of being infected with the SARS-CoV-2 virus at all ages and that, in these women, COVID-19 is associated with increased rates of hospitalization, morbidity, and mortality. We summarize the mechanisms of the higher risk of COVID-19 infection in women with PCOS, particularly in those with carbohydrate and lipid abnormal metabolism, hyperandrogenism, and central obesity.

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.

Sleep disturbances, sleep quality, and cardiovascular risk factors in women with polycystic ovary syndrome: Systematic review and meta-analysis

OBJECTIVES

(1) To establish the prevalence of sleep disorders in women with PCOS. (2) To establish the association between sleep disturbance and cardiovascular risk factors in women with PCOS.

METHODS

The electronic databases PubMed and EMBASE were searched for observational studies of individuals with PCOS published in English from inception to 21 October 2021. The dichotomous outcome measure was presented as odds ratio (OR) and 95% confidence interval (CI). The mean difference (MD) in continuous variables was expressed for each study.

RESULTS

A total of 18 articles were included in this meta-analysis, with a total of 16,152 participants from nine different countries. Women with PCOS had a high prevalence of sleep disturbance (OR = 6.22; 95% CI: 2.77, 13.97; p < 0.001), higher PSQI scores (MD = 2.10; 95% CI: 0.29, 3.90; p = 0.02), and shorter duration of sleep (MD = -15.65 min; 95% CI: -27.18, -4.13; p = 0.008). We found that body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), low-density lipoprotein cholesterol (LDL-c), fasting glucose, 2-h glucose, and waist circumference (WC) levels were significantly higher and high-density lipoprotein cholesterol (HDL-c) was significantly lower in PCOS with sleep disturbance than in PCOS without sleep disturbance.

CONCLUSIONS

The current study shows a high prevalence of sleep disturbance in women with PCOS and provides evidence of an association between cardiovascular risk factors and sleep disturbance among this population. Increased attention should be paid to sleep management in clinical guidelines for PCOS.

Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022298040.

Role of Oxidative Stress in Obese and Nonobese PCOS Patients

OBJECTIVE

The aim of this study was to evaluate the relationship between the oxidant-antioxidant status, endothelial dysfunction, lipid metabolism, and metabolic syndrome risk in women with polycystic ovary syndrome (PCOS).

MATERIALS AND METHODS

Forty-five obese (BMI >30 kg/m2) woman diagnosed with PCOS in the study, forty-five nonobese (BMI <30 kg/m²) PCOS diagnosis working groups, and forty-nine healthy control groups were created with patients. Serum malondialdehyde (MDA) levels with antioxidant activities, such as SOD, GSH, GPx, and CAT activities, were measured by spectrophotometry.

RESULTS

There was a statistically significant difference in the mean serum MDA level in the obese PCOS group compared to the nonobese group and the control group (p < 0.001). When the antioxidant parameters, such as SOD, GPx, GSH, and CAT, were compared with the healthy control group, nonobese, and obese PCOS groups, the difference between the groups was statistically significant (p < 0.001). A positive correlation was observed between MDA and BMI, triglyceride, LDL, SBP, DBP, and HOMA-IR in the PCOS patient group.

CONCLUSION

Oxidative stress and decreased antioxidant parameters in PCOS patients were correlated with hyperinsulinemia, hypertension, and dyslipidemia findings, and we think that this oxidative stress condition may contribute to metabolic syndrome and cardiovascular diseases in PCOS patients.

Kisspeptin neurons as an integration center of reproductive regulation: Observation of reproductive function based on a new concept of reproductive regulatory nervous system

Background

Regulation of the reproductive system has been explained by the actions and feedback of gonadotropin releasing hormone‐luteinizing hormone/follicle stimulating hormone (GnRH‐LH/FSH) ‐sex steroids; however, the discovery of kisspeptin neurons and a kisspeptin‐GnRH‐LH/FSH axis has prompted this regulation to be reviewed.

Methods

We investigated changes in kisspeptin neurons and associated changes in the hypothalamic‐pituitary‐gonadal (HPG) axis under various situations and experimental conditions using histochemical methods.

Main findings (Results)

Kisspeptin neurons play an important role in receiving and integrating information from internal and external environmental factors and communicating it to the conventional HPG axis.

Conclusion

The recently described Kisspeptin‐GnRH‐LH/FSH‐gonad system regulates reproductive function via mechanisms that until recently were not completely understood.

Effects of oxytocin and antagonist antidote atosiban on body weight and food intake of female mice, Mus musculus

Growing evidence suggests that oxytocin (OT) plays an important factor for the control of food intake, body weight, and energy metabolism in human and non-human animals. It has reported previously, the downregulation in oxytocin receptors (OTRs) expression is linked with the development of obesity, but exogenous OT reverse body weight and food intake in obese animal model. It is important to know that, whether intraperitoneal administration crosses blood brain barrier. Therefore, in the present experiment, we study the impact of intraperitoneal administration of synthetic OT 0.0116 mg/kg and antagonist atosiban (OTA) 1 mg/kg on food intake, and body weight of female mice, Mus musculus for different duration i.e. 30, 60, and 90 days. In this study, it was observed that there was significant decrease (p<0.001, one-way analysis of variance [ANOVA]) in the body weight (BW), food intake, and gonadosmatic indices (GSI) after the intraperitoneal exposure of OT at dose 0.0116 mg/kg up to 90 days and inhibits via antagonist atosiban. These results indicates that intraperitoneal administration of OT can be used for treatment for longer duration without any side effects and maintains homeostasis in physiologic system regulates body weight and gonadal weight in female mice, which represent an important therapeutic tool for the obesity and metabolic disorder in female.

PCOS and Depression: Common Links and Potential Targets

PCOS or polycystic ovary syndrome is a common endocrine disorder that occurs during the reproductive age in females. It manifests in the form of a wide range of symptoms including (but not limited to) hirsutism, amenorrhea, oligomenorrhea, obesity, acne vulgaris, infertility, alopecia, and insulin resistance. The incidence of depression in PCOS population is increasing as compared to the general population. Increased depression in PCOS significantly alters the quality of life (QOL) of affected females. Also, self-esteem is found to be low in both depression and PCOS. The loss in self-esteem in such patients can be largely attributed to the associated factors including (but not limited to) obesity, acne, androgenic alopecia, and hirsutism. The reason behind the occurrence of depression in PCOS remains elusive to date. Literature suggests that there is an overlap of clinical symptoms between depression and PCOS. As the symptoms overlap, there is a possibility of common associations between depression, PCOS, and PCOS-associated abnormalities including insulin resistance (IR), obesity, CVD, and androgen excess. Studies demonstrate that depression is an inflammatory disorder marked with increased levels of inflammatory markers. On the other hand, PCOS is also regarded as a pro-inflammatory state that is characterized by increased levels of pro-inflammatory markers. Thus, there is a possibility of an inflammatory relationship existing between depression and PCOS. It is also possible that the inflammatory markers in PCOS can cross the blood-brain barrier (BBB) leading to the development of depression. Through the present review, we have attempted to shed light on common associations/shared links between depression and PCOS with respect to the levels of cortisol, androgen, vitamin D, neurotransmitters, monoaminoxidase (MAO), and insulin-like growth factor-1 (IGF-1). Tracking down common associations between depression and PCOS will help find potential drug therapies and improve the QOL of females with depression in PCOS.

Glucocorticoid signaling and lipid metabolism disturbances in the liver of rats treated with 5α-dihydrotestosterone in an animal model of polycystic ovary syndrome

PURPOSE

Polycystic ovary syndrome (PCOS) is a complex reproductive disorder often associated with obesity, insulin resistance, and dyslipidemia. Hormonal changes in PCOS may also include altered glucocorticoid signaling. Our aim was to examine whether alterations in hepatic glucocorticoid signaling are associated with disturbances of glucose and lipid metabolism in animal model of PCOS.

METHODS

Female rats, 3 weeks old, were subcutaneously implanted with 5α-dihydrotestosterone (DHT) or placebo pellets for 90 days to induce PCOS. Expression of 11β-hydroxysteroid dehydrogenase 1 (11βHSD1) and A-ring reductases (5α and 5β), as well as intracellular distribution of glucocorticoid receptor (GR) and expression of its regulated genes were examined in the liver. Proteins of hepatic lipid and carbohydrate metabolism and markers of inflammation were also assessed.

RESULTS

DHT treatment induced increase in body and liver mass, as well as in triglycerides and free fatty acids levels in plasma. Elevation of 11βHSD1 and reduction of 5α-reductase expression was observed together with increased hepatic corticosterone concentration and nuclear GR activation. Induced expression of Krüppel-like factor 15 and decreased expression of genes for proinflammatory cytokines and de novo lipogenesis (DNL) were detected in the liver of DHT-treated rats, while DNL regulators and proinflammatory markers were not changed. However, increased mRNA levels of stearoyl-CoA desaturase and apolipoprotein B were observed in DHT animals.

CONCLUSIONS

DHT treatment stimulated hepatic glucocorticoid prereceptor metabolism through increased corticosterone availability which is associated with enhanced GR activation. This does not affect gluconeogenesis and DNL, but could be linked to stimulated triglyceride synthesis and hypertriglyceridemia.

Metformin treatment before and during IVF or ICSI in women with polycystic ovary syndrome

BACKGROUND

The use of insulin-sensitising agents, such as metformin, in women with polycystic ovary syndrome (PCOS) who are undergoing ovulation induction or in vitro fertilisation (IVF) cycles has been widely studied. Metformin reduces hyperinsulinaemia and suppresses the excessive ovarian production of androgens. It is suggested that as a consequence metformin could improve assisted reproductive techniques (ART) outcomes, such as ovarian hyperstimulation syndrome (OHSS), pregnancy, and live birth rates.

OBJECTIVES

To determine the effectiveness and safety of metformin as a co-treatment during IVF or intracytoplasmic sperm injection (ICSI) in achieving pregnancy or live birth in women with PCOS.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group Specialised Register, CENTRAL via the Cochrane Register of Studies Online (CRSO), MEDLINE, Embase, PsycINFO, LILACS, the trial registries for ongoing trials, and reference lists of articles (from inception to 13 February 2020).

SELECTION CRITERIA

Types of studies: randomised controlled trials (RCTs) comparing metformin treatment with placebo or no treatment in women with PCOS who underwent IVF or ICSI treatment.

TYPES OF PARTICIPANTS

women of reproductive age with anovulation due to PCOS with or without co-existing infertility factors. Types of interventions: metformin administered before and during IVF or ICSI treatment.

PRIMARY OUTCOME MEASURES

live birth rate, incidence of ovarian hyperstimulation syndrome.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the studies, extracted the data according to the protocol, and assessed study quality. We assessed the overall quality of the evidence using the GRADE approach.

MAIN RESULTS

This updated review includes 13 RCTs involving a total of 1132 women with PCOS undergoing IVF/ICSI treatments. We stratified the analysis by type of ovarian stimulation protocol used (long gonadotrophin-releasing hormone agonist (GnRH-agonist) or short gonadotrophin-releasing hormone antagonist (GnRH-antagonist)) to determine whether the type of stimulation used influenced the outcomes. We did not perform meta-analysis on the overall (both ovarian stimulation protocols combined) data for the outcomes of live birth and clinical pregnancy rates per woman because of substantial heterogeneity. In the long protocol GnRH-agonist subgroup, the pooled evidence showed that we are uncertain of the effect of metformin on live birth rate per woman when compared with placebo/no treatment (risk ratio (RR) 1.30, 95% confidence interval (CI) 0.94 to 1.79; 6 RCTs; 651 women; I2 = 47%; low-quality evidence). This suggests that if the chance for live birth following placebo/no treatment is 28%, the chance following metformin would be between 27% and 51%. Only one study used short protocol GnRH-antagonist and reported live birth rate. Metformin may reduce live birth rate compared with placebo/no treatment (RR 0.48, 95% CI 0.29 to 0.79; 1 RCT; 153 women; low-quality evidence). This suggests that if the chance for live birth following placebo/no treatment is 43%, the chance following metformin would be between 13% and 34% (short GnRH-antagonist protocol). We found that metformin may reduce the incidence of OHSS (RR 0.46, 95% CI 0.29 to 0.72; 11 RCTs; 1091 women; I2 = 38%; low-quality evidence). This suggests that for a woman with a 20% risk of OHSS without metformin, the corresponding risk using metformin would be between 6% and 14%. Using long protocol GnRH-agonist stimulation, metformin may increase clinical pregnancy rate per woman compared with placebo/no treatment (RR 1.32, 95% CI 1.08 to 1.63; 10 RCTs; 915 women; I2 = 13%; low-quality evidence). Using short protocol GnRH-antagonist, we are uncertain of the effect of metformin on clinical pregnancy rate per woman compared with placebo/no treatment (RR 1.38, 95% CI 0.21 to 9.14; 2 RCTs; 177 women; I2 = 87%; very low-quality evidence). We are uncertain of the effect of metformin on miscarriage rate per woman when compared with placebo/no treatment (RR 0.86, 95% CI 0.56 to 1.32; 8 RCTs; 821 women; I2 = 0%; low-quality evidence). Metformin may result in an increase in side effects compared with placebo/no treatment (RR 3.35, 95% CI 2.34 to 4.79; 8 RCTs; 748 women; I2 = 0%; low-quality evidence). The overall quality of evidence ranged from very low to low. The main limitations were inconsistency, risk of bias, and imprecision.

AUTHORS' CONCLUSIONS

This updated review on metformin versus placebo/no treatment before or during IVF/ICSI treatment in women with PCOS found no conclusive evidence that metformin improves live birth rates. In a long GnRH-agonist protocol, we are uncertain whether metformin improves live birth rates, but metformin may increase the clinical pregnancy rate. In a short GnRH-antagonist protocol, metformin may reduce live birth rates, although we are uncertain about the effect of metformin on clinical pregnancy rate. Metformin may reduce the incidence of OHSS but may result in a higher incidence of side effects. We are uncertain of the effect of metformin on miscarriage rate per woman.

Evaluation of efficacy of QR 678 and QR678 neo hair growth factor formulation for the treatment of female pattern alopecia in patients with PCOS-A prospective study

BACKGROUND

Hair is an essential identity of women. Femininity, sexuality, attractiveness, and personality are symbolically linked to a woman's hair. Female pattern hair loss is found in 20%-30% of patients with polycystic ovary syndrome (PCOS).

AIM

The aim of the present study was to evaluate the efficacy of QR678^® and QR678 Neo^® therapy in the treatment of female alopecia with PCOS.

METHOD

A total of 20 females diagnosed with PCOS in the age 25-50 years, with complaints of female pattern alopecia with Ludwig, grades I, and II were selected for the study. At each visit, 1.5 ml solution of QR678^® was injected in the scalp skin of patients. A total of eight sessions were performed at an interval of 3 week each. All the patients were evaluated with standard global photography at baseline, 4th and 8th session, and 2 months after 8th session.

RESULT

Marked improvement was seen in the global photographic assessment score (mean = 8) which was maintained for over 1 year. In videomicroscopic assessment, after four sessions the patients had 8.07 fewer vellus hair, 6.07 more terminal hair, and average hair shaft diameter was 0.82 μm wider. After eight sessions, they had 11.66 fewer vellus hair, 13.77 more terminal hair, and hair shaft diameter was 2.86 μm wider than at baseline.

CONCLUSION

Intra-dermal injections of QR 678^® hair growth factor formulation is an effective option for female pattern alopecia with PCOS. This is the first of its kind study using QR678^® and QR678 Neo^® in PCOS patients.

Apelin/Apelin receptor: A new therapeutic target in Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is an endocrinopathy, and it accounts for 75% of non-ovulatory infertile in women of childbearing age. It is clear that obesity, insulin resistance, dyslipidaemia coexist in PCOS. Apelin, as an endogenous ligand of the previously orphan receptor, is an adipokine that secreted by adipose tissue. Apelin and apelin receptors are expressed in many tissues and organ to regulate their physiological functions. Studies have shown that Apelin/apelin-receptor also expressed in ovary such as follicles, granulosa cells. Furthermore, Apelin/apelin-receptor play roles in vascular establishment and hormone metabolism in ovary. These indicate that the Apelin/apelin-receptor play an important role in the development of follicle. Apelin/apelin-receptor are increased in ovary of PCOS, which are associated with abnormal ovarian hormones and function. These are important causes of menstrual cycle disorders and anovulation. Moreover, apelin now appears clearly as a new player in energy metabolism. Apelin can regulate glucose and lipid metabolism but also modulate insulin secretion. And plasma apelin concentrations are elevated in obesity and type 2 diabetes patients. Interestedly, obesity and type 2 diabetes are also companied with polycystic ovary syndrome patients. We speculate apelin/apelin-receptor may play a vital role in pathogenesis of polycystic ovary syndrome, but the underlying mechanisms remain under exploration. Here, we review apelin/apelin-receptor, as a new therapeutic target, have effects on ovarian function and energy metabolism in polycystic ovary syndrome.

Pathophysiological roles of chronic low-grade inflammation mediators in polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is the most common hormonal imbalance disease in reproductive-aged women. Its basic characteristics are ovulatory dysfunction and ovarian overproduction of androgens that lead to severe symptoms such as insulin resistance, hirsutism, infertility, and acne. Notwithstanding the disease burden, its underlying mechanisms remain unknown, and no causal therapeutic exists. In recent years, further studies showed that inflammation processes are involved in ovulation and play a key role in ovarian follicular dynamics. Visceral adipose tissue can cause inflammatory response and maintenance of the inflammation state in adipocytes by augmented production of inflammatory cytokines, monocyte chemoattractant proteins, and recruitment of the immune cell. Therefore, the PCOS can be related to a low-grade inflammation state and inflammatory markers. Investigating the inflammatory processes and mediators that contribute to the commencement and development of PCOS can be a critical step for better understanding the pathophysiology of the disease and its treatment through inhibition or control of related pathways. In the present review, we discuss the pathophysiological roles of chronic low-grade inflammation mediators including inflammasome-related cytokines, interleukin-1β (IL-1β), and IL-18 in PCOS development.

Follicular localization of growth differentiation factor 8 and its receptors in normal and polycystic ovary syndrome ovaries

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of reproductive age and its etiology has not been characterized. Growth differentiation factor 8 (GDF8) is a member of the transforming growth factor-β superfamily that plays a critical role in the regulation of ovarian functions. However, the expression pattern of GDF8 in the human ovary is not yet clear. This study examined the cellular distribution of GDF8 and its putative cellular receptors (ACVR2A, ACVR2B, and ALK5) in a series of normal (n = 34) and PCOS ovaries (n = 14). The immunostaining of GDF8, ACVR2A, ACVR2B, and ALK5 was detected in the oocytes regardless of the developmental stage. All these proteins were localized in antral follicles in normal and PCOS ovaries, and the expression of these proteins increased with increasing follicle diameter. A significantly higher expression of GDF8 was detected in the granulosa cells than in the matched theca cells (TCs). These proteins were also localized in the luteal cells of the corpus luteum. Granulosa cells and TCs of large antral follicles in PCOS ovaries display a higher expression of these proteins. The higher expression levels of GDF8 and its functional receptors (ACVR2A, ACVR2B, and ALK5) in antral follicles of PCOS ovaries than those in normal ovaries suggest the possible involvement of dysregulated GDF8 in the pathogenesis of PCOS.

Serum retinol-binding protein 4 levels in polycystic ovary syndrome

OBJECTIVE

Serum levels of retinol-binding protein 4 (RBP4), an adipokine thought to affect systemic insulin sensitivity, were compared between women with polycystic ovary syndrome (PCOS) and non-PCOS controls to evaluate the association of RBP4 with clinical, hormonal and metabolic parameters of PCOS.

SUBJECTS AND METHODS

Serum RBP4 levels were analysed in 278 women with PCOS (age range 18-57 years) and 191 non-PCOS controls (age 20-53 years) by enzyme-linked immunosorbent assay.

RESULTS

Serum levels of RBP4 were increased in women with PCOS compared with control women in the whole population (45.1 ± 24.0 (s.d.) vs 33.5 ± 18.3 mg/L, P < 0.001). Age-stratified analysis showed that serum RBP4 levels were increased in women with PCOS aged ≤30 years compared with controls (47.7 ± 23.5 vs 27.1 ± 10.4 mg/L, P < 0.001), whereas no significant differences were seen in the other age groups. No significant correlations of RBP4 were seen with either steroids or indices of insulin resistance.

CONCLUSIONS

Although serum RBP4 levels were increased in younger women with PCOS compared with age-matched non-PCOS controls, RBP4 does not seem to be a good marker of insulin resistance or other metabolic derangements in women with PCOS.

Myo-inositol and D-chiro-inositol (40:1) reverse histological and functional features of polycystic ovary syndrome in a mouse model

Mice exposed to continuous light undergo functional and histological changes that mimic those of human Polycystic Ovary Syndrome (PCOS). We herein induced the syndrome by exposing 30-day-old females to 10 weeks of permanent light. Ovarian morphology and histology, as well as reproductive parameters (time of observed pregnancy/delivery) were investigated. Ovaries of PCOS-modeled mice showed lack of tertiary follicles and corpora lutea, altered ovarian architecture, and increased thickness of the theca layer. When mice were returned to a normal light-dark regimen for 10 days, a slight, spontaneous improvement occurred, whereas a quick and almost complete recovery from PCOS signs and symptoms was obtained by treating animals with a daily supplementation of 420 mg/kg myo-inositol and D-chiro-inositol (MyoIns/DCIns) in a 40:1 molar ratio. Namely, ovaries from mice treated by this protocol recovered normal histological features and a proper ratio of theca/granulosa cell layer thickness (TGR), suggesting that the androgenic phenotype was efficiently reversed. Indeed, we identified TGR as a useful index of PCOS, as its increase in PCOS-modeled mice correlated linearly with reduced reproductive capability ( r = 0.75, p < 0.0001). Mice treated with a 40:1 formula regained low TGR values and faster recovery of their fertility, with a physiological delivery time after mating. On the other hand, a higher D-chiro-inositol treatment formula, such as MyoIns versus DCIns 5:1, was ineffective or even had a negative effect on clinical-pathological outcomes.

Kisspeptin and Polycystic Ovary Syndrome

Although the pathogenesis of Polycystic Ovary Syndrome (PCOS) is still unclear, the disturbance of hypothalamic-pituitary-gonadal (HPG) axis is suspected to be the main culprit in the development of PCOS. Kisspeptin, a hypothalamic peptide encoded by the KISS1 gene, is widely reported as a key factor in the regulation of luteinizing hormone (LH)/ follicular-stimulating hormone (FSH) secretion, which may be potentially involved with the development of PCOS. Objective: The objective of this study is to summarize the existing knowledge in the literature in terms of the circulating kisspeptin concentration in PCOS women, kisspeptin and metabolic profiles in PCOS women and kisspeptin expression in PCOS animal models. Method: A systematic literature search was conducted using "Pubmed," "Embase," "Web of Science" for all English language articles published up to July 2018 with the terms "PCOS," "Stein-Leventhal Syndrome," "Polycystic ovary syndrome," "metastins" and "kisspeptin". Conclusion: Overall, kisspeptin levels are higher in the PCOS population, which supports the hypothesis that an over-active KISS1 system leads to enhanced HPG-axis activity, thereby causing irregular menstrual cycles and excessive androgen release in PCOS women.

Animal models of polycystic ovary syndrome: A review of hormone-induced rodent models focused on hypothalamus-pituitary-ovary axis and neuropeptides

BACKGROUND

Polycystic ovary syndrome (PCOS) is a common endocrine disorder among women of reproductive age and a major cause of infertility; however, the pathophysiology of this syndrome is not fully understood. This can be addressed using appropriate animal models of PCOS. In this review, we describe rodent models of hormone-induced PCOS that focus on the perturbation of the hypothalamic-pituitary-ovary (HPO) axis and abnormalities in neuropeptide levels.

METHODS

Comparison of rodent models of hormone-induced PCOS.

MAIN FINDINGS

The main method used to generate rodent models of PCOS was subcutaneous injection or implantation of androgens, estrogens, antiprogestin, or aromatase inhibitor. Androgens were administered to animals pre- or postnatally. Alterations in the levels of kisspeptin and related molecules have been reported in these models.

CONCLUSION

The most appropriate model for the research objective and hypothesis should be established. Dysregulation of the HPO axis followed by elevated serum luteinizing hormone levels, hyperandrogenism, and metabolic disturbance contribute to the complex etiology of PCOS. These phenotypes of the human disease are recapitulated in hormone-induced PCOS models. Thus, evidence from animal models can help to clarify the pathophysiology of PCOS.

Androgens drive microvascular endothelial dysfunction in women with polycystic ovary syndrome: role of the endothelin B receptor

KEY POINTS

Polycystic ovary syndrome (PCOS) is a complex syndrome with cardiovascular risk factors, including obesity and insulin resistance. PCOS is also associated with high androgens, increases the risk of cardiovascular dysfunction in women. Due to the complexity of PCOS, had it has been challenging to isolate specific causes of the cardiovascular dysfunction. Our measure of cardiovascular dysfunction (endothelial dysfunction) was most profound in lean women with PCOS. The endothelin-1-induced vasodilation in these PCOS subject, was dependent on the ET_B R but was not NO-dependent. We also demonstrated oestrogen administration improved endothelial function in lean and obese women with PCOS likely because oestrogen increased NO availability. Our studies indicate a primary role for androgens in cardiovascular dysfunction in PCOS.

ABSTRACT

Endothelin-1 (ET-1) is an indicator of endothelial injury and dysfunction and is elevated in women with androgen excess polycystic ovary syndrome (AE-PCOS). The endothelin B receptor (ET_B R) subtype mediates vasodilatation, but is blunted in women with PCOS. We hypothesized that androgen drives endothelial dysfunction in AE-PCOS women and oestradiol (EE) administration reverses these effects. We assessed microvascular endothelial function in women with (7 lean and 7 obese) and without AE-PCOS (controls, 6 lean, 7 obese). Only obese AE-PCOS women were insulin resistant (IR). We evaluated cutaneous vascular conductance (%CVC_max ) with laser Doppler flowmetry during low dose intradermal microdialysis ET-1 perfusions (1, 3, 4, 5 and 7 pmol) with either lactated Ringer solution alone, or with ET_B R (BQ-788), or nitric oxide (NO) inhibition (l-NAME). Log[ET-1]-%maxCVC dose-response curves demonstrated reduced vasodilatory responses to ET-1 in lean AE-PCOS (logED₅₀ , 0.59 ± 0.08) versus lean controls (logED₅₀ , 0.49 ± 0.09, P < 0.05), but not compared to obese AE-PCOS (logED₅₀ , 0.65 ± 0.09). ET_B R inhibition decreased ET-1-induced vasodilatation in AE-PCOS women (logED₅₀ , 0.64 ± 0. 22, P < 0.05). This was mechanistically observed at the cellular level, with ET-1-induced, DAF-FM-measurable endothelial cell NO production, which was abrogated by dihydrotestosterone in an androgen receptor-dependent manner. EE augmented the cutaneous vasodilating response to ET-1(logED₅₀ 0.29 ± 0.21, 0.47 ± 0.09, P < 0.05 for lean and obese, respectively). Androgens drive endothelial dysfunction in lean and obese AE-PCOS. We propose that the attenuated ET-1-induced vasodilatation in AE-PCOS is a consequence of androgen receptor-mediated, suppressed ET_B R-stimulated NO production, and is reversed with EE.

Antioxidant effect of genistein on ovarian tissue morphology, oxidant and antioxidant activity in rats with induced polycystic ovary syndrome

Background

Oxidative stress is the most frequent cause of female infertility disorders including polycystic ovary syndrome (PCOS). Genistein as a major component of soybean isoflavone scavenges free radicals by antioxidant activities.

Objective

The present study examines the antioxidant effects of genistein on ovarian tissue following experimental PCOS in rats.

Materials and Methods

Twenty female Wistar rat were randomly divided into the following groups (n=5 each group): (I) control group (no treatment); (II) induced PCOS (injection of estradiol valerate); (III) genistein-treated non-PCOS (received genistein); and (IV) genistein-treated PCOS groups. The weight of rats were measured and the blood samples collected and centrifuged. The oxidant and antioxidant activity of plasma and ovaries were measured. All rats were sacrificed under anesthesia, and ovaries were collected and weighted. Histological examination and follicular quality were assessed by staining.

Results

In histological observation, the induced PCOS rats displayed more number of atretic follicles and the follicular quality in genistein-treated rats was similar to the control groups. The plasma and ovaries malondialdehyde levels significantly increased in PCOS rats (p < 0.001), while the total antioxidant capacity levels, glutathione peroxidase, and superoxide dismutase activities significantly decreased (p < 0.001). The plasma and ovary malondialdehyde levels significantly decreased in PCOS rats that were treated with genistein (p < 0.001) and the total antioxidant capacity (p < 0.05), glutathione peroxidase, and superoxide dismutase activities significantly increased (p < 0.001).

Conclusion

Treatment with genistein preserved follicular quality by increasing antioxidant activities and scavenging oxidant levels in PCOS rats.

Effect of "DXB-2030," a Polyherbal Formulation, on Experimental Polycystic Ovary Syndrome Associated with Hyperandrogenism

The objective of the present study was to evaluate “DXB-2030,” a polyherbal combination of Trigonella foenum-graecum, Aloe vera, Sphaeranthus indicus, Nardostachys jatamansi, and Symplocos racemosa extracts in an experimental model of testosterone propionate (TP), induced polycystic ovary syndrome (PCOS) in female rats. Thirty animals were divided into 3 groups of 10 each; group 1 served as normal control; group 2 was administered with TP and served as positive control; along with TP, group 3 was treated with “DXB-2030” at a dose of 100 mg/kg p.o., for 60 days. At the end of the study period, the animals were subjected for the estimation of serum testosterone levels, oral glucose tolerance test (OGTT), weight of the ovaries, estrous cycle, and histopathological evaluation. An in vitro assay on GLUT4 expression was carried out to understand the effect of “DXB-2030” on insulin resistance. Results showed that treatment with “DXB-2030” reversed the TP-induced changes by increasing the GLUT4 expression and decreasing the body weight, testosterone levels, AUC of glucose in OGTT, and the cystic follicles of the ovaries, thus indicating its beneficial effect in PCOS by ameliorating the metabolic dysfunction and reproductive impairment, which are the pathophysiological conditions associated with PCOS. From the results obtained, it can be concluded that “DXB-2030” was effective in the management of experimental PCOS and hence may be recommended in the treatment of PCOS.

Effect of synbiotic pomegranate juice on glycemic, sex hormone profile and anthropometric indices in PCOS: A randomized, triple blind, controlled trial

BACKGROUND AND AIMS

Polycystic Ovarian Syndrome is a common reproductive, endocrine, and metabolic disease in women. Pomegranate juice, known as a rich source of phytochemicals with high antioxidant activity, enriched with probiotic may improve PCOS.

METHODS AND RESULTS

A randomized, controlled, triple-blinded, parallel trial study was performed in PCOS patients (n = 92). Three treatment groups (23 patients each) received 2 L of synbiotic pomegranate juice (SPJ), pomegranate juice (PJ), and synbiotic beverage (SB) weekly. The control group (23 patients) received 2 L of placebo beverage weekly. Primary outcome was any change in insulin resistance and secondary outcomes were fasting blood sugar (FBS), insulin sensitivity, testosterone, luteinizing hormone (LH), follicle stimulating hormone (FSH), body mass index (BMI), waist and hip circumference, from baseline to the end of the trial. At the end of the study, 86 patients were analyzed. There was significant change in insulin resistance in the SPJ and SB groups. Insulin sensitivity increased significantly in the SPJ and SB groups. Insulin also changed significantly in the SPJ and SB groups. BMI, weight and waist circumference decreased significantly in the SPJ and SB groups. Testosterone level also decreased significantly in the SPJ and SB groups. There was no significant change in FPG, LH and FSH in any of the groups.

CONCLUSION

SPJ in the form of a new beverage can improve insulin resistance, insulin, testosterone level, BMI, weight and waist circumference in PCOS. This trial was registered in Iranian Registry of Clinical Trials, with number: 25272.

Assessment of oxytocin level, glucose metabolism components and cutoff values for oxytocin and anti-mullerian hormone in infertile PCOS women

OBJECTIVE

Comparing oxytocin level and some other parameters between infertile women with or without polycystic Ovary Syndrome (PCOS), to evaluate the correlation between oxytocin with anti-mullerian hormone (AMH), Body Mass Index (BMI) and insulin resistance (IR).

MATERIALS AND METHODS

This cross-sectional study was performed on 80 PCOS and 81 non-PCOS women as the control group. Oxytocin, various hormones, Oral glucose tolerance test (OGTT) and Homeostatic model assessment of insulin resistance (HOMA-IR) were compared between two groups. Correlations between parameters were assessed by the spearman's rank correlation coefficient. Cutoff values for oxytocin and AMH in PCOS were calculated by the ROC-Curve and DeLong method.

RESULTS

The mean oxytocin level was statistically lower in the case group (p ≤ 0.001). The mean BMI, AMH, HOMA-IR, fasting insulin and insulin 2-h after 75-g glucose were significantly higher in the PCOS group. Oxytocin was negatively correlated to AMH when evaluated for all participants or only among controls. Moreover oxytocin was negatively correlated to HOMA-IR among all participants. However the relationship between oxytocin and BMI was not statistically significant. The calculated cutoff value for oxytocin was 125 ng/L and for AMH was 3.6 ng/mL in the PCOS group.

CONCLUSION

The mean oxytocin level in the PCOS infertile women was lower than non-PCOS women. Oxytocin showed a significant reverse correlation with AMH and HOMA-IR.

The obesogen tributyltin induces features of polycystic ovary syndrome (PCOS): a review

Polycystic ovary syndrome (PCOS) is a heterogeneous syndrome characterized by abnormal reproductive cycles, irregular ovulation, and hyperandrogenism. This complex disorder has its origins both within and outside the hypothalamic-pituitary-ovarian axis. Cardio-metabolic factors, such as obesity and insulin resistance, contribute to the manifestation of the PCOS phenotype. Polycystic ovary syndrome is one of the most common endocrine disorders among women of reproductive age. Growing evidence suggested an association between reproductive and metabolic features of PCOS and exposure to endocrine-disrupting chemicals (EDC), such as bisphenol A. Further, the environmental obesogen tributyltin (TBT) was shown to induce reproductive, metabolic and cardiovascular abnormalities resembling those found in women and animal models of PCOS. However, the causal link between TBT exposure and PCOS development remains unclear. The objective of this review was to summarize the most recent research findings on the potential association between TBT exposure and development of PCOS-like features in animal models and humans.

Chromium supplementation does not improve weight loss or metabolic and hormonal variables in patients with polycystic ovary syndrome: A systematic review

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in women of reproductive age, and recently, chromium was discussed as an adjuvant way to manage it. Herein, a systematic review was conducted which centered on the effects of chromium on ovarian physiology with a focus on body mass index, as well as hormonal and metabolic dysfunctions in women suffering from PCOS. This review was performed using the guidelines from Preferred Reporting Items for Systematic Reviews. Clinical trials investigating chromium in women with PCOS with outcome measures related to metabolic and hormonal status were included. The search was conducted using PubMed, Scopus, and Google Scholar databases for clinical trials in the English language from the inception of the resources until May 2017 with the terms: chromium, chromium picolinate, CrP, polycystic ovary syndrome, PCOS, and sclerocystic ovary syndrome. The search resulted in 89 articles, and after inclusion and exclusion criteria were applied, 6 articles were selected for analysis. Two studies that evaluated the effect of chromium on body weight or body mass index reported no effect. Another study reported the beneficial effect of chromium on weight reduction. It seems that the effect of chromium in the reduction of blood glucose is insignificant, and results are inconsistent in relation to dyslipidemia. With regard to the effects of chromium on concentrations of sex hormones, a longer duration of treatment is needed to produce significant changes. The articles reviewed demonstrated that chromium supplementation has limited effects on weight reduction, glucose control, lipid profile, and hormonal disturbance of women with PCOS; however, more studies are needed due to the clinical changes observed in patients with PCOS after chromium supplementation.

Is there a role for kisspeptin in pathogenesis of polycystic ovary syndrome?

AIM

To investigate association of kisspeptin levels in infertile women with different ovarian reserve patterns.

MATERIALS AND METHODS

In this prospective cross-sectional study, 157 participants were recruited. The women were divided into three groups: (i) adequate ovarian reserve (AOR) (n = 57), (ii) high ovarian reserve (PCOS) (n = 60), (iii) diminished ovarian reserve (DOR) (n = 40). Weight, height, waist circumference (WC), hip circumference (HC), body mass index (BMI), waist/hip ratio (WHR) were measured. The blood samples were analyzed for estradiol (E2), follicle-stimulating hormone (FSH), luteinizing hormone (LH), total testosterone (TT), 17-hydroxy progesterone (17OHP), dehydroepiandrosterone sulfate (DHEAS), antimullerian hormone (AMH), kisspeptin measurements.

RESULTS

FSH concentration was higher and AMH concentration was lower in DOR group (p < .001, p < .001, respectively). The mean LH, TT and DHEAS levels were higher in PCOS group (p = .001, p < .00 and p = .003, respectively). The 17OHP level did not differ among the groups (p = .15). Women with PCOS possessed the highest kisspeptin level (p = .01). The kisspeptin level was negatively correlated with FSH level (r = -0.18, p = .02) and positively correlated with TT and DHEAS levels (r = 0.17, p = .02 and r = 0.23, p = .003, respectively).

CONCLUSIONS

Women with PCOS had increased serum kisspeptin levels. Kisspeptin concentrations were negatively correlated with serum FSH and positively correlated with serum TT and DHEAS levels.

Amitriptyline plays important roles in modifying the ovarian morphology and improving its functions in rats with estradiol valerate-induced polycystic ovary

Previous studies demonstrated that depression is more prevalent in women with polycystic ovary syndrome (PCOS). In this study, we aimed to determine whether amitriptyline (AMT), an antidepressant drug, plays a role in preventing PCOS. The results showed that AMT modified ovarian morphology improved the ovarian functions and estrus cycle in estradiol valerate (EV)-induced polycystic ovary (PCO). AMT restored the levels of estradiol (E₂), testosterone (T) and progesterone (P₄) to normal, and elevated the level of luteinizing hormone (LH) in EV-induced PCO. No significant changes in follicle stimulating hormone (FSH) levels were observed in rats with EV or AMT treatment. The restoration of norepinephrine (NE) level was detected in rats with EV-induced PCO. AMT also altered the expression levels of steroidogenesis genes and beta2-adrenoceptor (beta2-AR) in EV-induced PCO. Our data revealed that AMT improves the ovarian morphology and modifies ovarian expression of beta2-AR and steroidogenesis genes in rats with EV-induced rat PCO. Our data provide support for the hypothesis that AMT is considered as a candidate drug for preventing and treating PCOS along with depression.

Association between biochemical hyperandrogenism parameters and Ferriman-Gallwey score in patients with polycystic ovary syndrome: A systematic review and meta-regression analysis

BACKGROUND AND OBJECTIVE

A limited number of studies have evaluated the relationship between clinical and biochemical hyperandrogenism (HA). This study aimed to evaluate the association between biochemical hyperandrogenism parameters (BHPs) and Ferriman-Gallwey (FG) score in patients with polycystic ovary syndrome (PCOS).

METHODS

We searched PubMed, Scopus, Google Scholar, ScienceDirect and Web of Sciences databases (2000-2015) to identify studies investigating clinical and biochemical parameters of HA in PCOS patients. In this meta-analysis, both fixed and random effect models were applied to estimate pooled effect size. To assess the relationships between BHPs and FG score, meta-regression analysis was used.

RESULTS

Fifty-five study groups with a total of 6593 PCOS patients were analysed. Meta-regression analysis of pooled data from all eligible studies showed significant positive relationships of FG score with androstenedione (A4) (P=.034) and dehydroepiandrosterone sulphate (DHEAS) (P=.012), whereas it showed no association with total testosterone (tT), free testosterone (fT), sex hormone bonding globulin (SHBG) and free androgen index (FAI). The results did not change after adjusting for quality assessment or method of assay. Nor did the associations between A4 and FG score remain after adjusting for age and BMI, diagnostic criteria for PCOS and study design or the association between DHEAS and FG score remain after adjusting for ethnicity.

CONCLUSION

This meta-analysis confirmed the associations of some BHPs, including A4 and DHEAS with FG score, indicating that measurement of these parameters can be useful for managing PCOS patients with hirsutism.

Myo-inositol administration positively effects ovulation induction and intrauterine insemination in patients with polycystic ovary syndrome: a prospective, controlled, randomized trial

Objectıve: The aim of the study is to investigate the effect of myo-inositol (MYO) on pregnancy rates of patients diagnosed with polycystic ovary syndrome (PCOS) who undergone controlled ovulation induction and intrauterine insemination (IUI).

METHODS

A total of 196 infertile patients diagnosed with PCOS and admitted to Dokuz Eylul University Faculty of Medicine were included in the study between March 2013 and May 2016. The patients in group 1 (n = 98) were given 4 g MYO and 400 μg folic acid before and during ovulation induction. The patients undergone controlled ovarian hyperstimulation (COH) with recombinant FSH and IUI. The patients in group 2 (n = 98), were given recombinant FSH directly and 400 μg folic acid. The primary outcome measure of this study was the clinical pregnancy rate.

RESULTS

In group 1, 9 patients conceived spontaneous pregnancy. During COH + IUI treatment three cycles were canceled in group 1 and 8 cycles in group 2. Total rFSH dose and cycle duration were significantly lower and clinical pregnancy rates were higher in group 1. The pregnancy rate for group 1 was %18.6 and for group 2 was %12.2. Conclusıons: This study shows that MYO should be considered in the treatment of infertile PCOS patients. MYO administration increases clinical pregnancy rates, lowers total rFSH dose and the duration of the ovulation induction.

The Effects of Omega-3 Fatty Acids and Vitamin E Co-Supplementation on Indices of Insulin Resistance and Hormonal Parameters in Patients with Polycystic Ovary Syndrome: A Randomized, Double-Blind, Placebo-Controlled Trial

This study was conducted to determine the effects of omega-3 fatty acids and vitamin E co-supplementation on indices of insulin resistance and hormonal parameters in women with polycystic ovary syndrome (PCOS). This randomized double-blind, placebo-controlled trial was done on 68 women diagnosed with PCOS according to the Rotterdam criteria aged 18-40 years old. Participants were randomly assigned into 2 groups to receive either 1 000 mg omega-3 fatty acids from flaxseed oil containing 400 mg α-Linolenic acid plus 400 IU vitamin E supplements (n=34) or placebo (n=34) for 12 weeks. Hormonal parameters were quantified at the beginning of the study and after 12-week intervention. After 12 weeks of intervention, compared to the placebo, omega-3 fatty acids and vitamin E co-supplementation resulted in a significant decrease in insulin (-1.0±3.5 vs. +2.7±6.6 µIU/mL, P=0.004), homeostasis model of assessment-estimated insulin resistance (-0.2±0.8 vs. +0.6±1.5, P=0.005), homeostasis model of assessment-estimated B cell function (-4.3±14.3 vs. +10.5±24.5, P=0.004) and a significant increase in quantitative insulin sensitivity check index (+0.006±0.02 vs. -0.01±0.04, P=0.008). Supplementation with omega-3 fatty acids plus vitamin E led to significant reductions in serum total testosterone (-0.5±0.7 vs. -0.1±0.5 ng/mL, P=0.008) and free testosterone (-1.2±2.1 vs. -0.2±1.7, P=0.04) compared to the placebo group. We did not observe any significant effect of omega-3 fatty acids and vitamin E co-supplementation on fasting plasma glucose and other hormonal profiles. Omega-3 fatty acids and vitamin E co-supplementation for 12 weeks in PCOS women significantly improved indices of insulin resistance, total and free testosterone.

Hormonal alterations in PCOS and its influence on bone metabolism

According to the World Health Organization (WHO) polycystic ovary syndrome (PCOS) occurs in 4-8% of women worldwide. The prevalence of PCOS in Indian adolescents is 12.2% according to the Indian Council of Medical Research (ICMR). The National Institute of Health has documented that it affects approximately 5 million women of reproductive age in the United States. Hormonal imbalance is the characteristic of many women with polycystic ovarian syndrome (PCOS). The influence of various endocrine changes in PCOS women and their relevance to bone remains to be documented. Hormones, which include gonadotrophin-releasing hormone (GnRH), insulin, the leutinizing/follicle-stimulating hormone (LH/FSH) ratio, androgens, estrogens, growth hormones (GH), cortisol, parathyroid hormone (PTH) and calcitonin are disturbed in PCOS women. These hormones influence bone metabolism in human subjects directly as well as indirectly. The imbalance in these hormones results in increased prevalence of osteoporosis in PCOS women. Limited evidence suggests that the drugs taken during the treatment of PCOS increase the risk of bone fracture in PCOS patients through endocrine disruption. This review is aimed at the identification of the relationship between bone mineral density and hormonal changes in PCOS subjects and identifies potential areas to study bone-related disorders in PCOS women.

An inverse association between serum soluble receptor of advanced glycation end products and hyperandrogenism and potential implication in polycystic ovary syndrome patients

BACKGROUND

Studies found that AGE-RAGE system is closely related to insulin resistance and hyperandrogenemia, which are two core pathophysiological processes in polycystic ovary syndrome (PCOS). This study is to investigate the relationship among advanced glycation end-products/soluble receptor of advanced glycation end-products (AGEs/sRAGE) and anthropometric evaluation, homeostatic model assessment-insulin resistance (HOMA-IR), free androgen index (FAI) in reproductive-aged PCOS patients.

METHODS

One hundred and forty-eight Chinese women with PCOS were enrolled in this study. Subgroups were divided according to body mass index (BMI), waist circumference (WC), quartile intervals of HOMA-IR and androgen levels. The relationships between AGEs/sRAGE and above clinical markers were assessed by Pearson's correlation analyses.

RESULTS

Serum AGEs showed a gradually increased tendency with BMI and WC. It reached statistical significant between the normal weight group (BMI < 24 kg/m²) and the obesity group (BMI ≥ 28 kg/m²) . The sRAGE levels gradually decreased with increasing BMI, WC, HOMA-IR and FAI respectively. Furthermore, the differences between each group were statistical significant. The correlation analysis showed a positive correlation between BMI and serum AGEs levels. On the contrary, the sRAGE levels showed significantly inverse correlations with BMI, WC, HOMA-IR and FAI. The optimal point of sRAGE for the presence of insulin resistance was 704.097 pg/ml by ROC curve analysis.

CONCLUSIONS

Along with the body fat accumulation, the serum levels of AGEs were increased, whereas, the serum levels of sRAGE were reduced in obese PCOS patients. The serum levels of sRAGE, which is a decoy receptor, dramatically decreased in the patients with more severe insulin resistant states and higher FAI, which might be a potential biomarker and a promising therapeutic target in the treatment of PCOS, especially in obese subjects.

COMPARISON OF FINASTERIDE, METFORMIN, AND FINASTERIDE PLUS METFORMIN IN PCOS

The effects of finasteride on insulin resistance and of metformin on hyperandrogenism in patients with polycystic ovary syndrome (PCOS) are not clear. This study therefore compared the effects of finasteride, metformin, and finasteride plus metformin treatments on hormone levels, insulin resistance, and hirsutism score in women with PCOS. Fifty-two patients with PCOS were randomly assigned to receive finasteride 5 mg/day, metformin 1700 mg/day or finasteride plus metformin for 12 months. Body mass index (BMI), Ferriman Gallway score (FGS), serum concentrations of estradiol, sex hormone-binding globulin, free testosterone, dehydroepiandrosterone sulfate (DHEAS), androstenedione, and homeostasis model assessment of insulin resistance (HOMA-IR) index and areas under the curve (AUC) for insulin and glucose were evaluated before and after 12 months of treatment. Reductions in FGS, free testosterone, DHEAS, androstenedione, HOMA-IR, AUC-insulin, and AUC-glucose were significant within each group, whereas BMI and estradiol were not. Comparisons of changes in parameters in the 3 groups did not clearly show the superiority of any treatment modality. The treatment with finasteride alone significantly reduced both androgen levels and parameters of insulin resistance. In addition, metformin alone was effective, and not inferior to finasteride, in the treatment of hyperandrogenism.

Contribution of real-time elastography in diagnosis of polycystic ovary syndrome

PURPOSE

We aimed to assess the feasibility and reproducibility of real-time elastography (RTE) for displaying the effects of morphological changes in the ovary in polycystic ovary syndrome (PCOS).

METHODS

Forty-eight patients diagnosed with PCOS and 48 healthy women were enrolled in the study. Ultrasonography and RTE were performed on the 3rd day of the menstrual cycle. Evaluations were performed independently by two radiologists. Ovarian volume, number of follicles, elasticity pattern, and strain ratio were measured. Elasticity patterns were assessed as hard (type 1; blue or blue-green), moderate (type 2; green or green-yellow) or soft (type 3; red or orange-red).

RESULTS

Both radiologists determined the elasticity pattern as mostly type 1 in the PCOS group and type 3 in the control group (P < 0.01). The mean strain ratios obtained by the first and second radiologist were 6.1±1.8 (2.7-10.1) and 6.0±1.5 (3.0-9.0) in PCOS and 3.3±1.2 (1.7-7.2) and 3.2±0.9 (1.7-6.8) in the control group, respectively (P < 0.001). Interobserver agreement was moderate for the elasticity pattern (κ=0.48) and good for the strain ratio (intraclass correlation coefficient, 0.77). A strain ratio of 3.8 was determined as the optimized cutoff point by receiver operating curve analysis. Strain ratio was correlated with the ovarian volume and the number of detected follicles (P < 0.001).

CONCLUSION

Elasticity pattern and strain ratio can help identify morphological changes that make PCOS ovaries stiffer than normal ovaries.

A story of metformin-butyrate synergism to control various pathological conditions as a consequence of gut microbiome modification: Genesis of a wonder drug?

The most widely prescribed oral anti-diabetic agent today in the world today is a member of the biguanide class of drugs called metformin. Apart from its use in diabetes, it is currently being investigated for its potential use in many diseases such as cancer, cardiovascular diseases, Alzheimer's disease, obesity, comorbidities of diabetes such as retinopathy, nephropathy to name a few. Numerous in-vitro and in-vivo studies as well as clinical trials have been and are being conducted with a vast amount of literature being published every day. Numerous mechanisms for this drug have been proposed, but they have been unable to explain all the actions observed clinically. It is of interest that insulin has a stimulatory effect on cellular growth. Metformin sensitizes the insulin action but believed to be beneficial in cancer. Like -wise metformin is shown to have beneficial effects in opposite sets of pathological scenario looking from insulin sensitization point of view. This requires a comprehensive review of the disease conditions which are claimed to be affected by metformin therapy. Such a comprehensive review is presently lacking. In this review, we begin by examining the history of metformin before it became the most popular anti-diabetic medication today followed by a review of its relevant molecular mechanisms and important clinical trials in all areas where metformin has been studied and investigated till today. We also review novel mechanistic insight in metformin action in relation to microbiome and elaborate implications of such aspect in various disease states. Finally, we highlight the quandaries and suggest potential solutions which will help the researchers and physicians to channel their research and put this drug to better use.