Metformin improves polycystic ovary syndrome symptoms irrespective of pre-treatment insulin resistance

Asprosin levels in women with and without the polycystic ovary syndrome: a systematic review and meta-analysis

Objective: This systematic review and meta-analysis aimed at summarizing the evidence concerning circulating asprosin, and related endocrine and metabolites in women with and without the polycystic ovary syndrome (PCOS).Method: We performed a comprehensive literature search in Pubmed, Web of Science, Scielo, and Chinese National Knowledge Infrastructure for studies published until May 20, 2022, that evaluated circulating asprosin levels in women with and without PCOS, regardless of language. The quality of studies was assessed with the Newcastle-Ottawa Scale. Random-effects models were used to estimate mean differences (MD) or standardized MD (SMD) and their 95% confidence interval (CI).Results: We evaluated eight studies reporting 1,050 PCOS cases and 796 controls of reproductive age. Participants with PCOS were younger (MD = -2.40 years, 95% CI -2.46 to -2.33), with higher values of asprosin (SMD = 2.57, 95% CI 1.64-3.50), insulin (SMD = 2.73, 95% CI 1.18-4.28), homeostatic model assessment of insulin resistance (SMD = 2.70, 95% CI 0.85-4.55), luteinizing hormone (SMD = 2.33, 95% CI 0.60-4.06), total testosterone (SMD = 4.06, 95% CI 1.89-6.22), dehydroepiandrosterone sulfate (SMD = 2.38, 95% CI 0.37-4.40), and triglycerides (SMD = 1.20, 95% CI 0.13 to 2.27). Moreover, PCOS women had lower circulating levels of sex hormone-binding globulin (SMD = -3.36, 95% CI -4.92 to -1.80), and high-density lipoprotein-cholesterol (SMD = -0.85, 95% CI -1.69 to -0.01); with no significant differences observed for glucose, total cholesterol, and low-density lipoprotein-cholesterol levels.Conclusion: Circulating asprosin levels were significantly higher in women with PCOS as compared to those without the syndrome.

Comprehensive Management of Polycystic Ovary Syndrome: Effect of Pharmacotherapy, Lifestyle Modification, and Enhanced Adherence Counseling

Introduction Polycystic ovary syndrome (PCOS) is a common endocrine disorder in women of childbearing age in India, which often presents as menstrual irregularities, infertility, acanthosis nigricans, etc. Metabolic disturbances associated with PCOS predispose patients to cardiovascular diseases, which may be avoided by effective management. The aim of the current study was to evaluate the role of lifestyle modification (LSM) and metformin in PCOS management. Methods This is a retrospective cohort study conducted among 130 PCOS patients who attended the outpatient department of the tertiary care hospital in central India from October 2019 to March 2020. The study describes the effect of a combined package of LSM (physical exercise and dietary changes) and metformin on anthropometric, clinical, and biochemical parameters at three and six months. Results Out of the total 130 women, 12 were lost to follow-up and were omitted from further analysis. At six months of the treatment package (LSM, metformin, and enhanced adherence counseling (EAC)), a significant decrease was seen in body mass index, blood sugar, follicle-stimulating hormone, luteinizing hormone, and insulin. Following the intervention, the menstruation cycle became regular in 91% of the women while volume, theca, and appearance of polycystic ovaries on ultrasound decreased in 86% of women. Insulin resistance (IR) and hyperinsulinemia are the major causes of pathophysiological changes associated with PCOS. Metformin along with LSM primarily acts by decreasing IR, while EAC ensures treatment compliance. Conclusion Metformin along with LSM in the form of calories restricted, high-protein diet, and physical activity reduce IR and hyperandrogenaemia, resulting in improved anthropometric, glycemic indices, hormonal profiles, and features of hyperandrogenaemia. The combined therapy is beneficial to 85-90% of women with PCOS.

Metformin: Sex/Gender Differences in Its Uses and Effects—Narrative Review

Metformin (MTF) occupies a major and fundamental position in the therapeutic management of type 2 diabetes mellitus (T2DM). Gender differences in some effects and actions of MTF have been reported. Women are usually prescribed lower MTF doses compared to men and report more gastrointestinal side effects. The incidence of cardiovascular events in women on MTF has been found to be lower to that of men on MTF. Despite some promising results with MTF regarding pregnancy rates in women with PCOS, the management of gestational diabetes, cancer prevention or adjunctive cancer treatment and COVID-19, most robust meta-analyses have yet to confirm such beneficial effects.

Licogliflozin versus placebo in women with polycystic ovary syndrome: A randomized, double-blind, phase 2 trial

Polycystic ovary syndrome (PCOS) is characterized by hyperandrogenism and insulin resistance. The dual sodium-glucose co-transporter 1/2 inhibitor (SGLT1/2i) licogliflozin (LIK066) ameliorates hyperinsulinism in patients with diabetes and obesity. This study examines the effect of licogliflozin on androgens in women with PCOS. In a multicentre, randomized, placebo-controlled, double-blind, 2-week trial, patients with PCOS received licogliflozin 50 mg or placebo three times a day (TID). Changes in free testosterone (FT), other androgens and variables of insulin resistance were analysed. Concentration of FT did not change (TR_LIK066 :TR_PCB [FT]: 0.88; 90% CI: 0.70-1.11; P = .353). Licogliflozin reduced androstendione (A4) by 19% (TR_LIK066 :TR_PCB [A4]: 0.81; 90% CI: 0.68-0.99; P = .089) and dehydroepiandrosteron sulphate (DHEAS) by 24% (TR_LIK066 :TR_PCB [DHEAS]: 0.76; 90% CI: 0.65-0.89; P = .008). Hyperinsulinaemia was reduced by 70% by licogliflozin (highest insulin concentration [MAXI]; TR_LIK066 :TR_PCB [MAXI]: 0·26; 90% CI:0.20-0.34; P < .001 and area under the curve insulin [AUCI]; TR_LIK066 :TR_PCB [AUCI]: 0.32; 90% CI: 0.25-0.41; P < .001). Diarrhoea and nausea occurred as common adverse events. Dual inhibition of SGLT1/2 ameliorates hyperinsulinaemia and hyperandrogenaemia in women with PCOS. Licogliflozin may represent a promising novel treatment option for PCOS.

Effects of Metformin and Exercise in Polycystic Ovary Syndrome: Systematic Review and Meta-Analysis

Polycystic ovary syndrome (PCOS) is a common endocrine disorder in women of reproductive age. Metformin is introduced for treatment of women with PCOS, and the beneficial effects of exercise in women with PCOS are found for a range of outcomes. Our aim is to compare the effects of metformin plus exercise with exercise intervention in PCOS on clinical, anthropometric, metabolic, and psychological parameters. MEDLINE, EMBASE, Web of Science and China National Knowledge Infrastructure were searched for studies. Nine studies were considered eligible for inclusion. The meta-analysis reveals that metformin offers additive benefits to exercise, leading to modest improvements in menstrual cycles, hyperandrogenism, and abdominal fat.

Effect of metformin on adiponectin in PCOS: A meta-analysis and a systematic review

BACKGROUND

Conflicting results have been reported regarding the effect of metformin on adiponectin levels in women with polycystic ovary syndrome (PCOS). This meta-analysis reviewed all studies comparing adiponectin levels before and after metformin treatment in PCOS women. Additionally, changes in other indicators, including long-term complications associated with PCOS, such as inflammatory, metabolism factors and hormonal profile, were investigated following metformin treatment. We conducted subgroup analysis based on body mass index (BMI) stratification and appropriate pooling.

METHODS

We searched literature in PUBMED, EMBASE, the Cochrane Library, and CNKI databases. The main meta-analysis included 11 studies containing data on 353 subjects.

RESULTS

Metformin treatment was associated with significantly increased serum adiponectin concentrations [10 studies, random-effects SMD (95% CI) -0.58 [-1.03, -0.13]; I² = 86%; P = 0.01]. Additionally, the meta-analysis revealed that circulating tumor necrosis factor-α(TNF-α) and C-reactive protein (CRP) concentrations were significantly decreased after metformin treatment, with corresponding SMDs of 1.01 (95% CI: 0.74-1.28, P＜0.00001) and 0.48(95% CI: 0.35-0.60, P＜0.00001).

CONCLUSION

Following metformin administration, serum adiponectin concentrations of PCOS women were found to be significantly increased, accompanied by a significant improvement in other indicators. Further investigation with a larger sample size should be conducted to validate optimal dose and duration of metformin.

Metformin Therapy for Acne in Patients with Polycystic Ovary Syndrome: A Systematic Review and Meta-analysis

BACKGROUND

Acne is one of the cutaneous manifestations of polycystic ovary syndrome (PCOS). There is limited evidence on metformin use for treatment of acne in PCOS patients.

OBJECTIVE

Our aim was to conduct a systematic review and meta-analysis to evaluate the efficacy of metformin for treatment of PCOS-related acne.

METHODS

On November 23, 2019, we searched PubMed, the Cochrane Library, and Embase databases for human clinical studies in any language. The keywords included 'acne' and 'polycystic ovary syndrome' combined with 'metformin,' 'biguanide,' or 'glucophage.' We included randomized controlled trials (RCTs), non-randomized controlled trials (NRCTs), and open-label studies on patients with PCOS treated with metformin. We calculated standardized mean differences (SMDs) for acne scores and odds ratios (ORs) for presence of acne, with 95% confidence intervals (CIs). Quality assessment was performed using the Cochrane Collaboration risk of bias instrument for RCTs. NRCTs and open-label studies were assessed using the adapted methodological index for nonrandomized studies (MINORS).

RESULTS

We included 51 studies on 2405 PCOS patients. Metformin as adjuvant therapy led to greater improvement of acne scores than the same therapy without metformin (SMD - 0.256; 95% CI - 0.439 to - 0.074). Pooling pre- and post-metformin therapy data showed significant decrease of acne scores after metformin use (SMD - 0.712; 95% CI - 0.949 to - 0.476). Presence of acne decreased significantly after metformin treatment (OR 0.362; 95% CI 0.271 to 0.485).

LIMITATIONS

There was heterogeneity across some studies due to different acne assessment scales, metformin dosages, and treatment durations.

CONCLUSIONS

For PCOS patients, metformin as stand-alone or adjuvant therapy was associated with improvement of acne. More randomized controlled trials are needed to validate these results.

REGISTRATION

PROSPERO registration number CRD42020159656.

Liraglutide: New Perspectives for the Treatment of Polycystic Ovary Syndrome

Polycystic ovary syndrome is a complex and heterogenous disorder involving multiple organ systems and different molecular pathways. It is tightly associated with obesity and especially abdominal obesity. As body weight reduction is the main modifiable risk factor for polycystic ovary syndrome, therapeutic approaches in overweight or obese women with polycystic ovary syndrome have been developed. Liraglutide is a glucagon-like peptide-1 receptor agonist that promotes sustained weight loss, as well as abdominal fat reduction, in individuals with obesity, prediabetes, and type 2 diabetes mellitus. The majority of current clinical studies have demonstrated that liraglutide therapy achieved significant reductions in body weight, body mass index, and abdominal circumference in overweight and obese women with polycystic ovary syndrome. Liraglutide therapy promoted significant improvements in free testosterone and sex hormone-binding globulin levels in some studies. Important metabolic and hormonal improvements were also reported after the combination of liraglutide with metformin. Increased menstrual frequency, as well as potential positive effects in reproduction, were described. However, the small number of participants, short duration, and low daily liraglutide dose are some of the main limitations of these studies. Larger and longer, multi-centred, double-blind, placebo-controlled trials of liraglutide monotherapy or combination therapy, with prolonged post-interventional monitoring, are crucially anticipated. Metabolic, hormonal, and reproductive primary outcomes should be uniformly addressed, to tailor future targeted treatment approaches, according to the patient phenotype and needs. This will improve long-term therapeutic outcomes in this population.

Biguanides Induce Acute de novo Lipogenesis in Human Primary Sebocytes

Introduction

Acne arises during puberty, in part, due to elevated hormones and growth factors which stimulate de novo lipogenesis (DNL) in primary sebocytes to significantly increase sebum production. Oral isotretinoin is an effective acne therapy, reducing sebum production through inducing apoptosis in sebocytes. However, isotretinoin is teratogenic and has additional unwanted side effects, including an initial acne flare-up, which limits its utility. The biguanide, metformin has been found to alleviate severe acne in women with polycystic ovary syndrome (PCOS) through normalization of their insulin and androgen hormone levels. Metformin’s broader effectiveness to improve acne in non-PCOS populations lacks significant clinical support. In an effort to determine whether biguanides directly affect sebogenesis, we investigated their ability to alter DNL in cell-based assays in vitro.

Methods

De novo lipogenesis was measured in human primary sebocytes using [14C]-acetate labeling. Lipid species analysis was performed by extracting newly synthesized lipids and subjecting them to thin layer chromatography. Gene expression changes in sebocytes were identified through qPCR analysis of isolated RNA. Metabolic parameters including oxygen consumption rate, lactate production and activation of adenosine monophosphate-dependent protein kinase (AMPK) were assessed in human primary sebocytes.

Results

Using human primary sebocytes, we found that biguanides, isotretinoin and azithromycin induced an acute dose and time-dependent increase in [14C]-acetate labeling of neutral lipids, while AICAR, an AMPK activator, inhibited this DNL response. Biguanides did not activate AMPK in sebocytes, however, they significantly reduced oxygen consumption rate and increased lactate production. Treatment with biguanides, but not isotretinoin, significantly upregulated ACSS2 gene expression in primary sebocytes and showed synergism with lipogenic activators to induce DNL genes.

Discussion

These changes are consistent with an acute increase in sebocyte lipogenesis and support the potential of biguanides to cause an initial flare-up in patients suffering from severe acne.

l-Carnitine plus metformin in clomiphene-resistant obese PCOS women, reproductive and metabolic effects: a randomized clinical trial

To evaluate the reproductive and metabolic effects of L-carnitine plus metformin in clomiphene citrate (CC) resistant obese polycystic ovary syndrome (PCOS) women. A double-blinded randomized controlled clinical trial, clomiphene-citrate resistant obese women were allocated randomly to receive CC plus metformin and L-carnitine (n = 138) or CC plus metformin and placebo (n = 136). The primary outcome was clinical pregnancy rate. The secondary outcomes were hormonal and metabolic profile changes in addition to ovulation and first trimester (13 weeks) miscarriage rates. Clomiphene-citrate, L-carnitine, and metformin group showed significant improvement in the menstrual regularity, ovulation rate, and pregnancy rate compared to CC plus metformin and placebo group (29% vs. 9%, 34.7% vs.11%, and 28.2% vs. 6.6%, respectively). No statistically significant difference in the miscarriage rate between the two groups (p = .08). After three months of treatment, the reduction in body mass index (BMI) was non-significant (p = .061) between both groups. The hormonal and metabolic parameters were more significantly improved in the L-carnitine group compared with the placebo group. l-Carnitine may act synergistically with metformin for improvement of reproductive performance, insulin resistance, and lipid profile in clomiphene-resistant obese PCOS women.

Randomised controlled trial to study the efficacy of exercise with and without metformin on women with polycystic ovary syndrome

OBJECTIVES

1. To study the efficacy of exercise in improving clinical symptoms, anthropometry, glucose tolerance and laboratory profile in women with Polycystic ovarian syndrome. 2. To study the combined efficacy of exercise and metformin on above parameters in women with polycystic ovary syndrome.

STUDY DESIGN

A Randomised double blinded placebo controlled trial was performed at a district hospital in New Delhi. Sixty six women were included in the study. Block randomisation was done to divide the women into two groups. Women were treated with fixed exercise schedule along with oral placebo in Group A and exercise with oral metformin in Group B. Outcomes stated in objectives were studied and statistically analysed. Quantitative variables were compared using unpaired t-test and Paired t-test within the groups across follow-ups. Qualitative variable has been compared using Chi-Square test /Fisher's exact test.

RESULTS

In Group A and B significant improvement was noted in menstrual cycles, mean waist circumference, mean waist-hip ratio and body mass index. The mean weight loss was 0.78 ± 0.19 kg and 1.71 ± 0.19 kg in group A and B respectively after 3 months. The mean weight loss was 1.08 ± 0.30 kg and 1.71 ± 0.19 kg in group A and B respectively. The mean difference in modified Ferriman Gallwey score at 0, 3 and 6 months were statistically significant in both groups. On comparing group A with group B at 6 months, significant improvement was found in menstrual cycle symptoms (55.17% vs 83.33%), mean weight loss (1.08 kg vs 2.5 kg), waist circumference reduction (2.56 cm vs 4.75 cm) and change in mean waist hip ratio (0.02 vs 0.04). Significant changes were noted in OGTT and Serum testosterone level at 6 months in Group B, but not in Group A. Statistically no significant differences were found in acne, acanthosis nigricans and other biochemical parameters.

CONCLUSION

Regular exercise should be recommended for the women with PCOS. It results in statistically significant improvement in menstrual cycle pattern, hirsutism, body mass index, weight, waist circumference waist-hip ratio. Addition of metformin resulted in added benefits on menstrual cycle, hirsutism, weight, body mass index, waist circumference, waist hip ratio, serum testosterone and Oral Glucose Tolerance Test (OGTT).

Polycystic Ovary Syndrome: Implication for Drug Metabolism on Assisted Reproductive Techniques-A Literature Review

Polycystic ovary syndrome (PCOS) affects 6-10% of women and could be considered one of the most common endocrine alterations in women of reproductive age. The syndrome is characterized by several hormonal and metabolic alterations, including insulin resistance and hyperandrogenism, which play a severe detrimental role in the patient's fertility. We aimed to offer an overview about drug metabolism in the PCOS population. Nevertheless, we did not find any study that directly compared drug metabolism between PCOS and healthy women. We therefore decided to summarize briefly how hormonal and insulin sensitizer drugs act differently in healthy and PCOS women, who show altered steroidogenesis by theca cells and metabolic imbalance, focusing especially on assisted reproductive techniques. To date, data about drug metabolism in the PCOS population appears to be extremely limited. This important gap could have significant implications for therapeutic approaches and future perspectives: the dosage of drugs commonly used for the treatment of PCOS women should be tailored according to each patient's characteristics; we should implement new clinical trials in order to identify the best pharmacologic strategy for PCOS patients undergoing in vitro fertilization (IVF); it would be advisable to create an international expert panel to investigate the drug metabolism in the PCOS population.

Insulin Sensitizers Modulate GnRH Receptor Expression in PCOS Rats

BACKGROUND

Insulin sensitizers like metformin and pioglitazone are clinically used since last decades for the treatment of PCOS, but their efficacy and possible role in PCOS patients remains questionable. Also, the mechanism by which these insulin sensitizers show effect is not clear.

AIM OF THE STUDY

To evaluate the effect of metformin and pioglitazone on leutinizing hormone and follicle stimulating hormone receptor mRNA expression, hyperandrogenism and insulin resistance in high fat diet induced and letrozole induced PCOS in rats.

METHODS

Pre-pubertal female rats were divided into four groups: group I received normal pellet diet and group II, III and IV received high fat diet. After 105 d of dietary manipulation, metformin and pioglitazone treatment was given to group III and group IV animals respectively for 21 d. Similarly, adult female rats were divided into four groups: group I received 1% carboxymethyl cellulose (CMC) and group II, III, IV received letrozole for 21 d. After 21 d of letrozole administration, metformin and pioglitazone treatment was given to group III and group IV animals respectively for 21 d. Oral glucose tolerance test, lipid profile, fasting glucose, insulin, estrus cycle, hormonal profile, ovary weight, leutinizing hormone receptor and follicle stimulating hormone receptor mRNA expression was measured. Polycystic ovarian morphology was assessed through histopathological changes of ovary.

RESULTS AND CONCLUSION

Metformin and pioglitazone treatment improve both metabolic and reproductive parameters of PCOS including hyperinsulinemia and hyperandrogenism. LH receptor and FSH receptor mRNA expression were altered by pioglitazone and metformin treatment.

DPP4 INHIBITOR SITAGLIPTIN AS A POTENTIAL TREATMENT OPTION IN METFORMIN-INTOLERANT OBESE WOMEN WITH POLYCYSTIC OVARY SYNDROME: A PILOT RANDOMIZED STUDY

OBJECTIVE

Metformin has an established role in the management of polycystic ovary syndrome (PCOS). Some patients cannot tolerate it due to associated gastrointestinal adverse events. The present study evaluated the dipeptidyl peptidase 4 inhibitor sitagliptin as a potential treatment option in metformin-intolerant PCOS.

METHODS

We conducted a 12-week, prospective, randomized, open-label study with 30 obese metformin-intolerant women with PCOS (age 35.0 ± 7.2 years; body mass index, 36.9 ± 5.5 kg/m²). After metformin withdrawal, they were randomized to lifestyle intervention and sitagliptin 100 mg daily (SITA) or lifestyle intervention alone as controls (CON). All participants underwent anthropometric and endocrine measurements and oral glucose tolerance testing. Model-derived indexes of insulin resistance and beta-cell function were calculated.

RESULTS

SITA improved beta-cell function as assessed by the homeostasis model assessment for beta-cell function index (HOMA-B) of 45.9 ± 35.8 ( P = .001), modified beta-cell function index (MBCI) of 7.9 ± 7 ( P = .002), and quantitative insulin-sensitivity check index (QUICKI) of -0.03 ± 0.03 ( P = .002). By contrast, beta-cell function decreased in CON. The between-group differences were significant for HOMA-B ( P = 0.001), MBCI ( P = .010), and QUICKI ( P = .025). The conversion rate to impaired glucose homeostasis was prevented in SITA: 3 of 15 subjects had impaired glucose tolerance (IGT) before and after the study. In CON, none had type 2 diabetes (T2D), and 4 had IGT at the beginning. After 12 weeks, IGT was observed in 2 and T2D in 3 subjects.

CONCLUSION

SITA improved beta-cell function and prevented a conversion to IGT and T2D in metformin-intolerant obese PCOS patients.

ABBREVIATIONS

BMI = body mass index; DPP-4 = dipeptidyl peptidase-4; DXA = dual energy X-ray absorptiometry; GIP = glucose-dependent insulinotropic peptide; GLP-1 = glucagon-like peptide-1; HOMA-B = homeostasis model assessment for beta-cell function; HOMA-IR = homeostasis model assessment of insulin resistance; IAI = insulin action index; IGT = impaired glucose tolerance; IR = insulin resistance; MBCI = modified beta-cell function index; OGTT = oral glucose tolerance test; QUICKI = quantitative insulin sensitivity check index; PCOS = polycystic ovary syndrome; SHBG = sex hormone-binding globulin; T2D = type 2 diabetes.

Metabolic and androgen profile in underweight women with polycystic ovary syndrome

INTRODUCTION

Polycystic ovary syndrome (PCOS) is a disorder associated with insulin resistance and obesity. Aim of our study is to clarify the prevalence of underweight in PCOS patients and whether metabolic and androgen profiles of PCOS differ depending on normal or low body weight.

METHODS

Out of 1269 consecutive patients with PCOS recruited from the Department of Endocrinology and Metabolism at the University of Duisburg-Essen, 19 patients (1.5%) were underweight and were compared to 375 lean PCOS subjects (29.6%). Clinical and endocrine parameters were evaluated. Insulin resistance was assessed by 3-h oral glucose tolerance test (OGTT).

RESULTS

Prevalence of type 2 diabetes and free androgen index did not differ between the two groups. Total cholesterol and low density lipoprotein levels were significantly lower in the group of underweight patients. While no significant difference was found for the Homeostasis model assessment (HOMA) index at fasting state, the HOMA-M120, calculated 2 h after glucose intake in OGTT, was significantly higher in underweight patients. Underweight patients also showed significantly higher postprandial insulin secretion after glucose intake in OGTT. Six underweight PCOS patients received metformin treatment for oligomenorrhea. An improvement of the menstrual cycle was observed in three cases, while two patients were lost to follow up and one discontinued therapy due to side effects.

CONCLUSIONS

The prevalence of underweight in patients with PCOS is very low. Underweight in PCOS is associated with higher postprandial insulin levels. Several of our underweight patients were able to achieve regular menstrual cycle under metformin therapy.

Clinical outcome of various metformin treatments for women with polycystic ovary syndrome

Aim

Polycystic ovary syndrome (PCOS) is an ovulatory disorder and insulin resistance and diabetes are involved in its pathophysiology. Metformin, an anti-diabetic agent, has been reported to be useful to induce ovulation.

Methods

Metformin treatment was classified into four types: (1) clomiphene-metformin combination treatment for clomiphene-resistant patients; (2) clomiphene-metformin combination for clomiphene-sensitive patients; (3) clomiphene-metformin combination for naïve patients; and (4) metformin monotherapy. The patients underwent physical, endocrinological, and clinical examinations for their ovulation rates, pregnancy rates, and follicular development.

Results

The ovulation rates, pregnancy rates, and single follicular development were not significantly different among the clomiphene-metformin combination treatment groups. In the Body Mass Index (BMI) subanalysis, the pregnancy rate was higher in the BMI≥30 kg/m2 group than in the other three groups with a BMI of ≤30 kg/m2 in both cycles and cases. The ovulation rates and pregnancy rates were significantly higher in the group with a fasting insulin of ≥15 μU/mL than in the groups with a fasting insulin of <15 μU/mL in both cycles and cases.

Conclusion

Clomiphene-metformin combination treatment appears to be useful, at least for clomiphene-resistant patients, and a BMI of >30 kg/m2 and a fasting insulin of ≥15 μU/mL appear to be predictors of a good result with this treatment.

Therapeutic effects of metformin and clomiphene in combination with lifestyle intervention on infertility in women with obese polycystic ovary syndrome

Objective:

To evaluate the therapeutic effects of metformin and clomiphene in combination with lifestyle adjustment on infertility in women with obese polycystic ovarian syndrome (PCOS).

Methods:

A total of 101 infertile women with obese PCOS admitted to our hospital from July 2013 to July 2015 were randomly divided into an observation group (n=51) and a control group (n=50). The control group was treated with metformin plus clomiphene, based on which the observation group was also subjected to lifestyle adjustment. The body weight, body mass index (BMI) and waist-to-hip ratio (WHR) were measured before and after treatment. The changes of reproductive hormones, ovaries and endometrium were detected, and the rates of menstrual recovery, ovulation and pregnancy were observed.

Results:

The body weight and BMI of the observation group after treatment were significantly lower than those before treatment and of the control group (P<0.05). There was no significant difference in WHR between the two groups. In the observation group, there were significant differences in LH, T, LH/FSH, FINS and TG levels before and after treatment and from those of the control group after treatment (P<0.05). Both the left and right ovarian volumes of the observation group after treatment were significantly lower than those before treatment and of the control group after treatment (P<0.05). The menstrual recovery, ovulation and pregnancy rates of the observation group were significantly higher than those of the control group (P<0.05).

Conclusion:

Lifestyle adjustment combined with metformin and clomiphene can improve the reproductive endocrine and lipid metabolism of obese PCOS patients, decrease the volumes of left and right ovaries, and increase the menstrual recovery, ovulation and pregnancy rates.

Metformin - For the dermatologist

Metformin though primarily an antidiabetic drug, has found to play an important role in a number of cutaneous disorders. Because of its role in improving hyperinsulinemia, it has proven beneficial in hormonal acne, hidradenitis suppurativa (HS) and acanthosis nigricans. Its antiandrogenic properties further serve as an add-on to the conventional management of hirsutism associated with polycystic ovarian syndrome. Very recently, systemic usage of metformin for psoriasis and cutaneous malignancies has shown promising results. Interestingly, metformin has also been topically used in hyperpigmentary disorders with pertinent levels of improvement and happens to be the most recent addition to the list of dermatologic indications. Though an oral hypoglycemic agent to begin with, metformin today has proven to be a boon for dermatologists.

Debates Regarding Lean Patients with Polycystic Ovary Syndrome: A Narrative Review

Polycystic ovary syndrome (PCOS) is a complex syndrome showing the clinical features of an endocrine/metabolic disorder, including hyperinsulinemia and hyperandrogenism. Two phenotypes are present, either lean or obese, with different biochemical, hormonal, and metabolic profiles. Evidence suggests many treatment modalities that can be applied. However, many of these modalities were found to be not suitable for the lean phenotype of PCOS. Much contradictory research was found regarding lean patients with PCOS. The aim of this narrative review is to shed light on the debate prevailing regarding characteristics, as well as metabolic, hematological, and potential management modalities. Literature review was performed from January 1, 2000 to March 31, 2017 with specific word search such as lean PCOS, hormonal abnormalities in lean PCOS, and the management of lean PCOS. All retrieved articles were carefully assessed, and data were obtained. We could conclude that the debate is still prevailing regarding this specific lean population with PCOS, especially with regard to their characteristics and management modalities. Further studies are still required to resolve this debate on the presence of PCOS in lean women.

The role of anti-Mullerian hormone and inhibin B in the assessment of metformin therapy in women with polycystic ovarian syndrome

Objectives:

To evaluate the role of anti-Mullerian hormone (AMH) and inhibin B in the evaluation of the effectiveness of short- (3 months) and long-term (6 months or more) metformin therapy in Iraqi women with polycystic ovarian syndrome (PCOS).

Methods:

This cross-sectional study was carried out at the Biochemistry Department, College of Medicine, University of Baghdad, Baghdad, Iraq from June 2010 to May 2011. It included 38 volunteers of women patients with PCOS, aged 18-38 years, who were classified into: Group I (GI, n=20); Group II included women in GI that were followed up after they were treated with metformin hydrochloride tablet 500 mg 3 times daily for 3 months; and GIII included 18 women that were already on metformin hydrochloride treatment 500 mg tablet 3 times daily for 6 months to 3 years. Investigations included serum measurement of insulin, AMH, inhibin B, androgen hormones using enzyme-linked immunosorbent assay, and mini Vidus techniques.

Results:

The mean ± standard error of the mean value of serum AMH levels was significantly decreased in post metformin treatment women (3 months; GII) compared with those before treatment (GI), and those women on prolonged treatment (GIII) (p<0.01 for both). However, there was no significant difference in serum AMH between GI and GIII. With respect to serum inhibin B, both women of GI and GII had significant decrease compared with GIII, with no significant changes between GI and GII.

Conclusion:

This study showed the efficacy of serum AMH measurement as a prognostic biochemical marker in the follow up of metformin treatment of PCOS women.

Nutrition and skin: Kids are not just little people

There has been a surge of new data regarding the pathophysiology of skin diseases. We are appreciating the sophisticated interplay among the skin, the immune system, and the environment. More elegant and highly specific medicines have been designed to target certain immune mediators of the adaptive immune system. In parallel fashion, we are learning more about the elegance of the innate immune system and how nutrition as early as the prenatal period can affect the priming of other immune cells. Concerns about the long-term impact of new immune-modulating medicines-especially in the pediatric population-have patients asking their dermatologists for nutritional alternatives to medical therapies. Nutrients and nutritional therapies appear to play a role at different ages for different dermatoses. Probiotics are showing promise as a therapeutic option for patients older than 1 year for atopic dermatitis. Systemic contact allergens appear to be a bigger burden on the adult population with atopic dermatitis. Obesity is a growing concern for both children and adults with psoriasis. Milk and high glycemic foods have a strong impact on the teenage acne population. Vitamins A and D are addressed as piece of the alopecia areata puzzle. Zinc and homeopathy are presented finally as possible treatments to the everlasting wart.

Potential use of durian fruit (Durio zibenthinus Linn) as an adjunct to treat infertility in polycystic ovarian syndrome

Infertility due to polycystic ovarian syndrome (PCOS) is a worldwide problem that is increasing at alarming rates. Insulin resistance, the prime factor of PCOS, induces comorbid metabolic syndrome as well. Durian (Durio zibenthinus Linn), a fruit of Southeast Asia, is used as a natural supplement in healthy diets. This paper is a short literature review that examines the fruit's effects against various components of metabolic syndrome and its fertility-enhancing properties in PCOS. Various published literature was reviewed to learn of the anti-inflammatory, anti-oxidant, anti-obesity, anticholesterol, and antihypoglycaemic nature of the fruit. The literature search was done using PubMed, Google Scholar and library databases. The keywords used were polycystic ovarian syndrome, infertility, metabolic syndrome and Durian zibenthinus Linn. Reviewed studies showed that the fruit is effective against various components of metabolic syndrome, but the mechanisms of action against anovulation and menstrual disturbances in PCOS have yet to be studied. The traditional use of durian as a fertility-enhancing agent needs to be validated scientifically by isolating its various components and ascertaining its fertility enhancing properties.

Impact of Treatment with Metformin on Adipocytokines in Patients with Polycystic Ovary Syndrome: A Meta-Analysis

Background

Metformin is effective for the treatment of polycystic ovary syndrome, but conflicting results regarding its effect on adipocytokine levels (adiponectin, resistin, visfatin, and leptin) in patients with polycystic ovary syndrome receiving metformin treatment have been reported. To provide high-quality evidence about the effect of metformin treatment on adipocytokines in patients with polycystic ovary syndrome, relevant studies that assessed the levels of adipocytokines (adiponectin, resistin, visfatin, and leptin) in patients with polycystic ovary syndrome receiving treatment with metformin administration were reviewed and analyzed.

Methods

A literature search was conducted in the SCI, PUBMED, EMBASE, and Elsevier databases, and personal contact was made with the authors. Standard mean differences and 95% confidence intervals were calculated and combined appropriately. To ensure synthesis of the best available evidence, sensitivity analyses were performed.

Results

A total of 34 data sets were included in 4 different outcomes, involving 744 women with polycystic ovary syndrome and adipocytokine levels measured both before and after metformin administration. Metformin treatment was associated with significantly elevated serum adiponectin concentrations (standard mean differences [95% confidence interval], −0.43 [−0.75 to −0.11]) and decreased serum leptin concentrations (0.65 [0.26 to 1.04]), whereas no significant difference in resistin level (−0.01 [−0.49 to 0.45]) or visfatin level (−0.04 [−1.55 to 1.46]) was found.

Conclusions

Metformin administration was associated with increased serum adiponectin concentrations and decreased serum leptin levels. Further study is needed to elucidate whether this apparent effect decreases the incidence of type 2 diabetes and other metabolic diseases in patients with polycystic ovary syndrome later in life.

Insulin resistance in nonobese Japanese women with polycystic ovary syndrome is associated with poorer glucose tolerance, delayed insulin secretion, and enhanced insulin response

Purpose

To determine the prevalence of insulin resistance (IR) and impaired glucose tolerance (IGT) in PCOS patients, the optimal screening method, and to compare our findings between nonobese and obese Japanese women with PCOS.

Methods

Ninety-eight PCOS patients were included in this research from 2006 to 2013. Glucose tolerance test (OGTT) was performed. Serum glucose and insulin concentration were assayed before and 30, 60, and 120 min after taking 75 g of glucose.

Results

All examined metabolic parameters were significantly favorable in the nonobese subjects, below 25 kg/m². HOMA-IR, fasting insulin, glucose₁₂₀, and insulin₁₂₀ showed strong correlations with BMI. A total of 1.4 % of nonobese women had IR based on fasting insulin or HOMA-IR. However, 15.5 % (11/71) of nonobese women had IR as determined by a continuous increase of serum insulin level in OGTT. In comparison, the prevalence of IR among the obese women ranged from 41 to 59 %. AUC_glucose, glucose₆₀, glucose₁₂₀, and insulin₁₂₀ in nonobese women with a continuous insulin increase were higher than those without such a continuous increase.

Conclusions

All examined metabolic parameters were significantly correlated with BMI. As the presence of a continuous increase of insulin level reflects to some degree poorer glucose tolerance, delayed insulin secretion, and enhanced insulin response compared with non-continuous insulin increase, OGTT might not been excluded to determine IR and IGT for nonobese women with PCOS.

Liver Injury Indicating Fatty Liver but Not Serologic NASH Marker Improves under Metformin Treatment in Polycystic Ovary Syndrome

Objective. Polycystic ovary syndrome (PCOS) is associated with obesity and insulin resistance (IR), key features of nonalcoholic steatohepatitis (NASH). Cytokeratin 18 fragments (M30) have been established as a serum marker for NASH. The insulin sensitizer metformin improves hepatic IR. This study evaluates the influence of MF on serologic NASH (sNASH) in patients with PCOS. Patients and Methods. In 89 patients, metabolic parameters, liver injury indicating fatty liver (LIFL), and M30 were assessed at baseline and after metformin treatment. Patients with initial IR were subdivided into dissolved (PCOS-exIR) and persistent IR (PCOS-PIR) after treatment and compared to an initially insulin sensitive PCOS group (PCOS-C). Results. Improvement of LIFL prevalence could be seen in PCOS-C and PCOS-exIR compared to PCOS-PIR (-19.4, resp., -12.0% versus 7.2%, Chi(2) = 29.5, P < 0.001) without change in sNASH prevalence. In PCOS-PIR, ALT levels increased significantly accompanied by a nominal, nonsignificant M30 increase. Conclusions. Metformin improves LIFL in subgroups of patients with PCOS without influencing sNASH. This could either indicate a missing effect of metformin on NAFLD or slowed disease progression. Further studies are needed to elucidate NAFLD in the context of PCOS and potential therapeutic options.

The Role of Metformin in Metabolic Disturbances during Pregnancy: Polycystic Ovary Syndrome and Gestational Diabetes Mellitus

Maintenance of gestation implicates complex function of multiple endocrine mechanisms, and disruptions of the global metabolic environment prompt profound consequences on fetomaternal well-being during pregnancy and postpartum. Polycystic Ovary Syndrome (PCOS) and gestational diabetes mellitus (GDM) are very frequent conditions which increase risk for pregnancy complications, including early pregnancy loss, pregnancy-induced hypertensive disorders, and preterm labor, among many others. Insulin resistance (IR) plays a pivotal role in the pathogenesis of both PCOS and GDM, representing an important therapeutic target, with metformin being the most widely prescribed insulin-sensitizing antidiabetic drug. Although traditional views neglect use of oral antidiabetic agents during pregnancy, increasing evidence of safety during gestation has led to metformin now being recognized as a valuable tool in prevention of IR-related pregnancy complications and management of GDM. Metformin has been demonstrated to reduce rates of early pregnancy loss and onset of GDM in women with PCOS, and it appears to offer better metabolic control than insulin and other oral antidiabetic drugs during pregnancy. This review aims to summarize key aspects of current evidence concerning molecular and epidemiological knowledge on metformin use during pregnancy in the setting of PCOS and GDM.

Therapeutic effects of metformin and laparoscopic ovarian drilling in treatment of clomiphene and insulin-resistant polycystic ovary syndrome

OBJECTIVE

To compare the therapeutic effects of metformin (Met) and laparoscopic ovarian drilling (LOD) in clomiphene and insulin-resistant patients with polycystic ovary syndrome (CIRPCOS).

METHODS

A total of 110 patients were randomly divided into two groups. One group was administered Met (n = 55), while the other group underwent LOD (n = 55). Rates of ovulation, pregnancy, and abortion were compared between both groups.

RESULTS

Rates of normal menstruation, ovulation, and pregnancy in the LOD group were higher than in the Met group: 76.4% (42/55) vs. 58.2% (32/55), P < 0.04; 50.8% (11/258) vs. 33.5% (94/281), P < 0.001; 38.2% (21/55) vs. 20.0% (11/55), P < 0.03. The difference in the early abortion rate between both groups was not statistically significant.

CONCLUSIONS

Although Met can significantly improve a patient's insulin resistance, we found that in patients diagnosed with CIRCPOS, LOD can be much more effective in improving rates of normal menstruation, ovulation, and pregnancy.

Effects of insulin-sensitizing agents and insulin resistance in women with polycystic ovary syndrome

Objective

The aim of this study was to investigate the effect of insulin sensitizing agents on hormonal and metabolic parameters as well as menstrual patterns in women with polycystic ovary syndrome (PCOS).

Methods

One hundred and twenty-three patients with PCOS were included. Metformin was administered to patients at 1,500 mg or 1,700 mg daily for 3 months. If the patients had no improvement of the menstrual cycle or metformin-related adverse effects developed, the patients changed medication to a daily dose of either 15 mg pioglitazone or up to 45 mg. Then resumption of a regular menstrual cycle or recovery of ovulation was evaluated. Hormonal and metabolic profiles were compared between the response and non-response group to insulin sensitizing agents.

Results

One hundred and five patients with PCOS were treated with metformin for 3 months. Forty-eight patients (45.7%) showed improvement of menstrual cycle regularity after 3 months of metformin use, whereas 57 patients (54.3%) had no change. The mean free testosterone measured after 3 months of treatment was significantly lower in metformin responders than in non-responders. The other parameters did not differ between the groups. Of the 23 patients who used pioglitazone for 3 to 6 months, 19 patients (82.6%) showed improvement in their menstrual cycles.

Conclusion

Metformin treatment seems to be effective for the improvement of menstrual cyclicity irrespective of insulin resistance in women with PCOS. When metformin related adverse effect occurred, pioglitazone would be effective for aiding the resumption of the menstrual cycle.

Effect of metformin and spironolactone therapy on OGTT in patients with polycystic ovarian syndrome - a retrospective analysis

BACKGROUND

Metformin (an insulin sensitizer) and spironolactone (an antiandrogen) are both used for treatment of polycystic ovary syndrome. We analyzed the effect of 6 months of therapy with these drugs on body weight and glucose tolerance.

RESULTS

This was a retrospective analysis of polycystic ovarian syndrome (PCOS) cases on treatment. There were 88 patients with PCOS-42 were on metformin 1 g daily and 46 were taking spironolactone 50-75 mg daily. 21 of 42 had abnormal glucose tolerance (AGT) in the metformin group and 13 of 46 had AGT in the spironolactone group. Patients on metformin reported a greater reduction in body weight, whereas there was no change in body weight with spironolactone therapy (67.6-63.7 versus 59.6-59.2 kg). There was a significant reduction in the 1 and 2 h glucose and insulin levels with metformin therapy in those with AGT. However, fasting glucose increased in those with normal glucose tolerance. There was no change in either body weight or insulin levels with spironolactone. But, there was a significant reduction in both the 0 and 2 h glucose with spironolactone also in those with AGT.

CONCLUSION

Spironolactone and metformin had similar effect in reducing the glucose levels in PCOS patients with AGT. PCOS patients with normal glucose tolerance had higher fasting plasma glucose at the end of 6 months of metformin therapy inspite of weight reduction.

Effect of different doses of metformin on serum testosterone and insulin in non-diabetic women with breast cancer: a randomized study

This is a randomized controlled trial to test the effect of different doses of metformin in patients with breast cancer and without diabetes, with the aim of modifying the hormonal and metabolic parameters linked to breast cancer prognosis. Analysis of the results suggest that the dose of 1500 mg/d of metformin causes a significant reduction of insulin and testosterone serum levels.

BACKGROUND

Serum levels of insulin and testosterone may affect both breast cancer (BC) incidence and prognosis. Metformin reduces hyperglycemia and insulin levels in patients with diabetes. In women without diabetes and with polycystic ovary syndrome, metformin lowers both insulin and testosterone levels. Patients with diabetes who are treated with metformin showed a lower risk of cancer; a protective effect of metformin also was observed for BC. Recently, studies on metformin use for prevention or treatment of BC have been proposed in patients who are not diabetic. The aim of the present study was to test the effect of different doses of metformin on serum levels of insulin and testosterone in those postmenopausal patients with breast cancer and without diabetes who have basal testosterone levels ≥0.28 ng/mL (median value).

PATIENTS AND METHODS

A total of 125 eligible women were initially invited to take metformin 500 mg/d for 3 months. The 108 women who completed the first 3 months were invited to continue the study with metformin 1000 mg/d (500 mg twice a day [b.i.d.]) for 1 month. The women were then randomized into 2 groups, and, for the subsequent 5 months, 1 group increased the dose by taking metformin 1500 mg/d (500 mg 3 times a day [t.i.d.]), and the other group continued with metformin 1000 mg /d (500 [b.i.d.]).

RESULTS

A total of 96 women completed the study: 43 women received 1500 mg/d, and 53 women received 1000 mg/d. The women who took 1500 mg/d showed a significant reduction of insulin level, HOMA-IR index (homeostasis model assessment-insulin resistance index), testosterone level, and free androgen index compared with women treated with 1000 mg/d. After treatment with 1500 mg/d, the insulin level decreased by 25% and the testosterone level decreased by 23%.

CONCLUSION

Both these changes might have a prognostic importance.

Effect of lifestyle modification and metformin therapy on emerging cardiovascular risk factors in overweight Indian women with polycystic ovary syndrome

INTRODUCTION

Polycystic ovarian syndrome (PCOS) is common among women of reproductive age. Although traditional cardiac risk factors are known to be altered and improved with short-term metformin therapy, not much is known about novel cardiac risk factors.

OBJECTIVE

The aim of this study was to evaluate the effects of lifestyle modification and short-term metformin therapy on the fasting serum lipids, homeostasis model assessment of insulin resistance (HOMA-IR), serum high-sensitivity C-reactive protein (hsCRP), and serum homocysteine.

METHODS

Native overweight [body mass index (BMI) >23 kg/m(2)] Indian women diagnosed with PCOS were evaluated and subjected to an oral glucose tolerance test and determination of insulin, homocysteine, hsCRP, and fasting lipids levels. They were started on maximally tolerated doses of metformin along with lifestyle modification. Following 3 months of therapy, they were resampled.

RESULTS

Out of 36 consecutive patients included, 25 women completed 3 months of metformin treatment and were eligible for repeat evaluation. The age of study group was 22.2 ± 5 years. Twenty-two (61%) women were obese (BMI >25 kg/m(2)). Improvement was seen in body weight, BMI, serum total cholesterol, triglycerides, high-density lipoprotein cholesterol (HDL-C), hsCRP, and serum testosterone on metformin therapy. However, no improvement was seen in serum fasting insulin, HOMA-IR, or homocysteine.

CONCLUSION

Serum hsCRP improved with lifestyle modification and metformin therapy for 3 months in overweight subjects from India with PCOS, along with serum total cholesterol, triglycerides, and HDL-C. However, markers of insulin resistance and serum homocysteine did not improve.

Use of metformin in the treatment of polycystic ovary syndrome

Metformin is quite an old drug, but it is optimal for the control of glycemia in Type 2 diabetes. It was reported, 15 years ago, that insulin resistance was abnormally high in most polycystic ovary syndrome (PCOS) patients. Starting from that moment, increasing numbers of studies were performed to demonstrate the efficacy of metformin in controlling and/or modulating several aspects of PCOS, which is the most common cause of menstrual irregularity, inesthetisms and infertility. Metformin induces higher glucose uptake, thus inducing a lower synthesis/secretion of insulin. Such an effect permits the possible restoration of the normal biological functions that are severely affected by the compensatory hyperinsulinemia reactive to the increased peripheral insulin resistance. These are the basis of the many positive effects of this drug, such as the restoration of menstrual cyclicity, ovulatory cycles and fertility, because abnormal insulin levels affect the hypothalamus-pituitary-ovarian function, as well as the use of glucose in peripheral tissues. Metformin improves the impairments typically observed in hyperinsulinemic PCOS patients, reducing the possible evolution towards metabolic syndrome and Type 2 diabetes; and when pregnancy occurs, it consistently reduces the risk of gestational diabetes, eclampsia and hypertension. PCOS seems to be the perfect physiopathological condition that might have higher benefits from metformin administration, obviously after Type 2 diabetes. This review focuses on the many aspects of PCOS and on the possible issues of this disease for which metformin might be a putative optimal treatment.

Insulin-sensitizing agents in the treatment of polycystic ovary syndrome: an update

PURPOSE OF REVIEW

Polycystic ovary syndrome (PCOS) is the most frequent endocrinopathy in reproductive-aged women, mainly characterized by oligoanovulation and hyperandrogenism. Insulin resistance represents a major pathophysiological feature of the syndrome and, therefore, insulin-sensitizing agents (metformin and thiazolidinediones) have been applied in PCOS women. However, the clinical use of insulin sensitizers in PCOS has been debated. The aim of the current review was to update the knowledge regarding the role of metformin and thiazolidinediones in PCOS treatment, focusing on recently published studies.

RECENT FINDINGS

Several clinical trials examined metformin effectiveness on lipids, atherosclerosis and inflammatory markers, hormone levels, menstrual irregularities, ovulation induction, fertility, hirsutism, obesity parameters and quality of life in PCOS women. Metformin treatment was shown to improve these features, although conflicting results were also reported. Only one study investigated pioglitazone effect on PCOS, reporting an improved IVF outcome in clomiphene citrate-resistant PCOS patients. Finally, both metformin and pioglitazone, as a part of a low-dose polytherapy, exerted beneficial effects on lipids, androgen levels, hirsutism and markers of atherosclerosis in nonobese PCOS women.

SUMMARY

Further research, including larger randomized controlled trials and meta-analyses, is needed to clarify the role of metformin and thiazolidinediones in the treatment of clinical and biochemical PCOS characteristics.

A functional GNAQ promoter haplotype is associated with altered Gq expression and with insulin resistance and obesity in women with polycystic ovary syndrome

OBJECTIVES

The G-protein Gq, encoded by GNAQ, is involved in glucose metabolism. The GNAQ promoter harbours three polymorphisms. The TT(-695/-694)GC polymorphism was already shown to affect Gq transcription. Accordingly, we (i) characterized the GNAQ promoter polymorphisms G(-173)A and G(-168)A, (ii) investigated potential influences upon the TT(-695/-694)GC polymorphism and (iii) studied the associations with metabolic abnormalities in polycystic ovary syndrome (PCOS).

METHODS

Characterization of the polymorphisms was performed with electrophoretic mobility shift assays and reporter assays. Inhibition of lipolysis and Gq expression were measured in adipocytes isolated from female mammary tissue. We genotyped 266 healthy Caucasians, 265 women with PCOS, and 293 healthy, age-matched female controls to associate GNAQ promoter polymorphisms and haplotypes with anthropometric and metabolic variables.

RESULTS

The A(-168) allele was associated with significantly decreased transcriptional activity and altered transcription factor binding, whereas the G(-173)A polymorphism appeared functionally silent. Linkage and haplotype frequencies analysis resulted in four common haplotypes. In adipose tissue, a 44% higher Gq mRNA concentration was observed in homozygous GC(-695/-694)-G(-168) haplotypes compared with homozygous TT(-695/-694)-G(-168) haplotypes (P=0.046). This was associated with increased insulin inhibition of lipolysis in isolated adipocytes. In PCOS patients, the homozygous GC-G haplotype was associated with decreased insulin resistance and body mass index (BMI) compared with the homozygous TT-G haplotype (homeostatic model assessment of insulin resistance: 3.4+/-0.4 vs. 5.6+/-0.7 mmol/l x mmol/l2, P=0.001; fasting insulin: 86.6+/-11.9 vs. 128.8+/-16.5 pmol/l, P=0.003; BMI: 29.3+/-1.2 vs. 33.9+/-1.3 kg/m2, P=0.002). No association with BMI was found in healthy women.

CONCLUSION

G(-168)A is functionally relevant and in linkage with TT(-695/-694)GC. GNAQ promoter diplotypes are associated with insulin resistance and obesity in PCOS.

Prenatal androgenization of female mice programs an increase in firing activity of gonadotropin-releasing hormone (GnRH) neurons that is reversed by metformin treatment in adulthood

Prenatal androgenization (PNA) of female mice with dihydrotestosterone programs reproductive dysfunction in adulthood, characterized by elevated luteinizing hormone levels, irregular estrous cycles, and central abnormalities. Here, we evaluated activity of GnRH neurons from PNA mice and the effects of in vivo treatment with metformin, an activator of AMP-activated protein kinase (AMPK) that is commonly used to treat the fertility disorder polycystic ovary syndrome. Estrous cycles were monitored in PNA and control mice before and after metformin administration. Before metformin, cycles were longer in PNA mice and percent time in estrus lower; metformin normalized cycles in PNA mice. Extracellular recordings were used to monitor GnRH neuron firing activity in brain slices from diestrous mice. Firing rate was higher and quiescence lower in GnRH neurons from PNA mice, demonstrating increased GnRH neuron activity. Metformin treatment of PNA mice restored firing activity and LH to control levels. To assess whether AMPK activation contributed to the metformin-induced reduction in GnRH neuron activity, the AMPK antagonist compound C was acutely applied to cells. Compound C stimulated cells from metformin-treated, but not untreated, mice, suggesting that AMPK was activated in GnRH neurons, or afferent neurons, in the former group. GnRH neurons from metformin-treated mice also showed a reduced inhibitory response to low glucose. These studies indicate that PNA causes enhanced firing activity of GnRH neurons and elevated LH that are reversible by metformin, raising the possibility that central AMPK activation by metformin may play a role in its restoration of reproductive cycles in polycystic ovary syndrome.

Polycystic Ovary Syndrome

Polycystic ovary syndrome is the most common endocrine disorder in women of reproductive age. It affects 6% to 7% of the population and is characterized by hyperandrogenism and ovarian dysfunction. Women with the disorder often present with insulin resistance and obesity, making it importance for health care providers to monitor closely for signs and symptoms of metabolic syndrome and type 2 diabetes. Treatments are targeted toward improving insulin tolerance, reducing signs and symptoms of hyperandrogenism (hirsutism, anovulation, etc), restoring normal menstrual cycle function, and restoring fertility. Major treatment should include weight management through diet and exercise, regardless of body mass index and might include concurrent drug therapy. It is important that pharmacists understand the underlying pathophysiology of the disease and the available treatments, in addition to the importance of reducing risk of metabolic syndrome/type 2 diabetes, and cardiovascular disease in these patients.

Comparison of effects of 3 mg drospirenone plus 20 μg ethinyl estradiol alone or combined with metformin or cyproterone acetate on classic metabolic cardiovascular risk factors in nonobese women with polycystic ovary syndrome

OBJECTIVE

To evaluate the effects of a pill with drospirenone (3 mg) plus ethinyl E(2) (20 μg) (DRP/20EE) alone or associated with metformin or cyproterone acetate (CPA) on some metabolic cardiovascular risk factors in women with polycystic ovary syndrome (PCOS).

DESIGN

Randomized, open-label clinical trial.

SETTING

Academic medical clinic.

PATIENT(S)

Forty-eight hirsute women with PCOS.

INTERVENTION(S)

Patients were randomized to treatment with DRP/20EE or with DRP/20EE plus metformin (1,500 mg/d) or with DRP/20EE plus CPA (12.5 mg/d, 10 days per cycle) for 6 months.

MAIN OUTCOME MEASURE(S)

Blood pressure, lipid profile, and indexes of glucose tolerance and insulin sensitivity were assessed before and after 6 months of treatment.

RESULT(S)

Body mass index and blood pressure were not modified by any treatment. Treatment with DRP/EE20 did not change the lipid profile; DRP/EE20 plus metformin significantly increased high-density lipoprotein cholesterol concentrations; DRP/EE20 plus CPA significantly increased triglycerides and total cholesterol. The area under the curve for insulin was significantly decreased by DRP/EE20 and DRP/EE20 plus metformin, but it was significantly increased by DRP/EE20 plus CPA. Treatment with DRP/EE20 plus CPA significantly increased the homeostasis model assessment of insulin resistance index and significantly reduced the glucose to insulin ratio index. Treatment with DRP/EE20 significantly increased the glucose to insulin ratio index.

CONCLUSION(S)

Treatment with DRP/EE20 improved insulin sensitivity in hirsute women with PCOS, with no deterioration of lipid profile. This effect was not ameliorated by the addition of metformin. The positive metabolic effects of DRP are abolished by the concomitant use of CPA.

Insulin and hyperandrogenism in women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a very common endocrine disorder characterized by chronic anovulation, clinical and/or biochemical hyperandrogenism, and/or polycystic ovaries. But most experts consider that hyperandrogenism is the main characteristic of PCOS. Several theories propose different mechanisms to explain PCOS manifestations: (1) a primary enzymatic default in the ovarian and/or adrenal steroidogenesis; (2) an impairment in gonadotropin releasing hormone (GnRH) secretion that promotes luteal hormone (LH) secretion; or (3) alterations in insulin actions that lead to insulin resistance with compensatory hyperinsulinemia. However, in the past 20 years there has been growing evidence supporting that defects in insulin actions or in the insulin signalling pathways are central in the pathogenesis of the syndrome. Indeed, most women with PCOS are metabolically insulin resistant, in part due to genetic predisposition and in part secondary to obesity. But some women with typical PCOS do not display insulin resistance, which supports the hypothesis of a genetic predisposition specific to PCOS that would be revealed by the development of insulin resistance and compensatory hyperinsulinemia in most, but not all, women with PCOS. However, these hypotheses are not yet appropriately confirmed, and more research is still needed to unravel the true pathogenesis underlying this syndrome. The present review thus aims at discussing new concepts and findings regarding insulin actions in PCOS women and how it is related to hyperandrogenemia.

Large effects on body mass index and insulin resistance of fat mass and obesity associated gene (FTO) variants in patients with polycystic ovary syndrome (PCOS)

Background

The polycystic ovary syndrome (PCOS), a common endocrine disorder in women of child-bearing age, mainly characterised by chronic anovulation and hyperandrogenism, is often associated with insulin resistance (IR) and obesity. Its etiology and the role of IR and obesity in PCOS are not fully understood. We examined the influence of validated genetic variants conferring susceptibility to obesity and/or type 2 diabetes mellitus (T2DM) on metabolic and PCOS-specific traits in patients with PCOS.

Methods

We conducted an association study in 386 patients with PCOS (defined by the Rotterdam-criteria) using single nucleotide polymorphisms (SNPs) in or in proximity to the fat mass and obesity associated gene (FTO), insulin-induced gene-2 (INSIG2), transcription factor 7-like 2 gene (TCF7L2) and melanocortin 4 receptor gene (MC4R). To compare the effect of FTO obesity risk alleles on BMI in patients with PCOS to unselected females of the same age range we genotyped 1,971 females from the population-based KORA-S4 study (Kooperative Gesundheitsforschung im Raum Augsburg, Survey 4).

Results

The FTO risk allele was associated with IR traits and measures of increased body weight. In addition, the TCF7L2 SNP was associated with body weight traits. For the SNPs in the vicinity of INSIG2 and MC4R and for the other examined phenotypes there was no evidence for an association. In PCOS the observed per risk allele effect of FTO intron 1 SNP rs9939609 on BMI was +1.56 kg/m², whereas it was +0.46 kg/m² in females of the same age range from the general population as shown previously.

Conclusion

The stronger effect on body weight of the FTO SNP in PCOS might well have implications for the etiology of the disease.

Targeting insulin sensitivity in the treatment of polycystic ovary syndrome

Targeting insulin resistance may result in a list of benefits for women with PCOS, including hormonal, metabolic and ovulatory (and fertility) improvements. The therapeutic strategy to treat PCOS should however depend on the clinical situation, the phenotype, the degree of androgen excess, age, the presence of infertility and the woman's desire to conceive, the presence of obesity and, finally, the spectrum of metabolic abnormalities and the need to treat or prevent long-term associated comorbidities. According to the needs, therapeutic options include, alone or in combination, lifestyle management, particularly in the presence of obesity, the use of insulin sensitizers, metformin and thiazolidinediones, antiandrogens or estro-progestins.