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Vadan RL, Varela N, Zhuravko N, Ogidan NO, Adedara VO, Keku E. Comparative Management Methods for Adolescents With Polycystic Ovarian Syndrome: A Systemic Review. Cureus 2024; 16:e55876. [PMID: 38595887 PMCID: PMC11003559 DOI: 10.7759/cureus.55876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2024] [Indexed: 04/11/2024] Open
Abstract
Polycystic ovarian syndrome (PCOS) is a common endocrinological disorder affecting many adolescents and women of reproductive age worldwide. A diagnosis of PCOS in adolescence relies upon investigating each medical history independently and noting commonly associated symptoms, including obesity, insulin resistance, acne, menstrual abnormalities, and hirsutism. Many researchers are aiming to discover a methodology to help manage the symptoms associated with PCOS, especially in adolescents. This review will investigate management methods possible for adolescents with PCOS. Although the most preferred way to help reduce symptoms is through lifestyle modifications such as vigorous exercise and dietary regimens low in carbohydrates, pharmaceuticals are also offering promising results to adolescents with PCOS. Metformin, oral contraceptives, gonadotropin-releasing hormone (GnRH) antagonists, and other alternatives, including finasteride, eflornithine, fibroblast growth factors (FGFs), and vitamin D, are all shown to help improve insulin sensitivity and regulate menstrual cycles and reduce hirsutism. Epilatory and surgical measurements are also available; however, they are reserved for when all other methods fail and once adulthood or an appropriate age is reached. Although there are many pharmaceuticals available, it is necessary to evaluate each adolescent with PCOS uniquely and prescribe the appropriate pharmacotherapy regarding their symptoms.
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Affiliation(s)
- Roberta L Vadan
- Medicine, St. George's University School of Medicine, St. George's, GRD
| | - Nanette Varela
- Medicine, St. George's University School of Medicine, St. George's, GRD
| | - Nikita Zhuravko
- Medicine, St. George's University School of Medicine, St. George's, GRD
| | - Noreena O Ogidan
- Medicine, St. George's University School of Medicine, St. George's, GRD
| | - Victor O Adedara
- Medicine, St. George's University School of Medicine, St. George's, GRD
| | - Emmanuel Keku
- Public Health & Preventive Medicine, St. George's University School of Medicine, St. George's, GRD
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Alesi S, Forslund M, Melin J, Romualdi D, Peña A, Tay CT, Witchel SF, Teede H, Mousa A. Efficacy and safety of anti-androgens in the management of polycystic ovary syndrome: a systematic review and meta-analysis of randomised controlled trials. EClinicalMedicine 2023; 63:102162. [PMID: 37583655 PMCID: PMC10424142 DOI: 10.1016/j.eclinm.2023.102162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/27/2023] [Accepted: 07/27/2023] [Indexed: 08/17/2023] Open
Abstract
Background Anti-androgens and combined oral contraceptive pills (COCPs) may mitigate hyperandrogenism-related symptoms of polycystic ovary syndrome (PCOS). However, their efficacy and safety in PCOS remain unclear as previous reviews have focused on non-PCOS populations. To inform the 2023 International Evidence-based Guideline in PCOS, we conducted the first systematic review and meta-analysis investigating the efficacy and safety of anti-androgens in the management of hormonal and clinical features of PCOS. Methods We systematically searched MEDLINE, Embase, PsycInfo, All EBM reviews, and CINAHL up to 28th June 2023 for randomised controlled trials (RCTs) examining oral anti-androgen use, alone or in combination with metformin, COCPs, lifestyle, or other interventions, in women of any age, with PCOS diagnosed by Rotterdam, National Institutes of Health or Androgen Excess & PCOS Society criteria, and using a form of contraception. Non-English studies and studies of less than 6 months duration or which used the same anti-androgen regimen in both/all groups were excluded in order to establish efficacy for the clinical outcomes of interest. Three authors screened articles against selection criteria and assessed risk of bias and quality using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework. Critical outcomes (prioritised during guideline development for GRADE purposes) included weight, body mass index (BMI), irregular cycles, hirsutism, liver function, and quality of life. Random effects meta-analyses were conducted where appropriate. This study is registered with PROSPERO, CRD42022345640. Findings From 1660 studies identified in the search, 27 articles comprising 20 unique studies were included. Of these, 13 studies (n = 961) were pooled in meta-analysis. Seven studies had a high risk of bias, nine moderate and four low. Anti-androgens included finasteride, flutamide, spironolactone, or bicalutamide. In meta-analysis, anti-androgens + lifestyle were superior to metformin + lifestyle for hirsutism (weighted mean difference [WMD] [95% CI]: -1.59 [-3.06, -0.12], p = 0.03; I2 = 74%), SHBG (7.70 nmol/l [0.75, 14.66], p = 0.03; I2 = 0%), fasting insulin and fasting insulin: glucose ratio (-2.11 μU/ml [-3.97, -0.26], p = 0.03; I2 = 0% and -1.12 [-1.44, -0.79], p < 0.0001, I2 = 0%, respectively), but were not superior to placebo + lifestyle for hirsutism (-0.93, [-3.37, 1.51], p = 0.45; I2 = 76%) or SHBG (9.72 nmol/l [-0.71, 20.14], p = 0.07; I2 = 31%). Daily use was more effective for hirsutism than use every three days (-3.48 [-4.58, -2.39], p < 0.0001, I2 = 1%), and resulted in lower androstenedione levels (-0.30 ng/ml [-0.50, -0.10], p = 0.004; I2 = 0%). Combination treatment with anti-androgens + metformin + lifestyle resulted in lower testosterone compared with metformin + lifestyle (-0.29 nmol/l [-0.52, -0.06], p = 0.01; I2 = 61%), but there were no differences in hirsutism when anti-androgens + metformin + lifestyle were compared with either anti-androgens + lifestyle or metformin + lifestyle. In limited meta-analyses (n = 2 trials), combining anti-androgens with COCP resulted in poorer lipid profiles compared with COCP ± placebo, with no differences in other outcomes. Interpretation Current evidence does not support the use of anti-androgens preferentially to COCPs to treat hyperandrogenism in PCOS. Anti-androgens could be considered to treat hirsutism in PCOS, where COCPs are contraindicated, poorly tolerated, or present a sub-optimal response after a minimum 6-month period, with consideration of clinical context and individual risk factors and characteristics. Funding National Health and Medical Research Council (NHMRC) of Australia Monash University.
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Affiliation(s)
- Simon Alesi
- Monash Centre for Health Research and Implementation (MCHRI), Monash University, Clayton, VIC, Australia
| | - Maria Forslund
- Monash Centre for Health Research and Implementation (MCHRI), Monash University, Clayton, VIC, Australia
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Johanna Melin
- Monash Centre for Health Research and Implementation (MCHRI), Monash University, Clayton, VIC, Australia
- Department of Obstetrics and Gynecology, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Daniela Romualdi
- Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Alexia Peña
- Discipline of Paediatrics, The University of Adelaide and Robinson Research Institute, Adelaide, Australia
| | - Chau Thien Tay
- Monash Centre for Health Research and Implementation (MCHRI), Monash University, Clayton, VIC, Australia
| | - Selma Feldman Witchel
- Division of Paediatric Endocrinology, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Helena Teede
- Monash Centre for Health Research and Implementation (MCHRI), Monash University, Clayton, VIC, Australia
| | - Aya Mousa
- Monash Centre for Health Research and Implementation (MCHRI), Monash University, Clayton, VIC, Australia
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Du Y, Zhu YJ, Zhou YX, Ding J, Liu JY. Metformin in therapeutic applications in human diseases: its mechanism of action and clinical study. MOLECULAR BIOMEDICINE 2022; 3:41. [PMID: 36484892 PMCID: PMC9733765 DOI: 10.1186/s43556-022-00108-w] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 11/18/2022] [Indexed: 12/13/2022] Open
Abstract
Metformin, a biguanide drug, is the most commonly used first-line medication for type 2 diabetes mellites due to its outstanding glucose-lowering ability. After oral administration of 1 g, metformin peaked plasma concentration of approximately 20-30 μM in 3 h, and then it mainly accumulated in the gastrointestinal tract, liver and kidney. Substantial studies have indicated that metformin exerts its beneficial or deleterious effect by multiple mechanisms, apart from AMPK-dependent mechanism, also including several AMPK-independent mechanisms, such as restoring of redox balance, affecting mitochondrial function, modulating gut microbiome and regulating several other signals, such as FBP1, PP2A, FGF21, SIRT1 and mTOR. On the basis of these multiple mechanisms, researchers tried to repurpose this old drug and further explored the possible indications and adverse effects of metformin. Through investigating with clinical studies, researchers concluded that in addition to decreasing cardiovascular events and anti-obesity, metformin is also beneficial for neurodegenerative disease, polycystic ovary syndrome, aging, cancer and COVID-19, however, it also induces some adverse effects, such as gastrointestinal complaints, lactic acidosis, vitamin B12 deficiency, neurodegenerative disease and offspring impairment. Of note, the dose of metformin used in most studies is much higher than its clinically relevant dose, which may cast doubt on the actual effects of metformin on these disease in the clinic. This review summarizes these research developments on the mechanism of action and clinical evidence of metformin and discusses its therapeutic potential and clinical safety.
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Affiliation(s)
- Yang Du
- grid.13291.380000 0001 0807 1581Department of Biotherapy, Cancer Center, State Key Laboratory of Biotherapy, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Ya-Juan Zhu
- grid.13291.380000 0001 0807 1581Department of Biotherapy, Cancer Center, State Key Laboratory of Biotherapy, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Yi-Xin Zhou
- grid.13291.380000 0001 0807 1581Department of Biotherapy, Cancer Center, State Key Laboratory of Biotherapy, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Jing Ding
- grid.54549.390000 0004 0369 4060Department of Medical Oncology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan China
| | - Ji-Yan Liu
- grid.13291.380000 0001 0807 1581Department of Biotherapy, Cancer Center, State Key Laboratory of Biotherapy, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
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Soldat-Stankovic V, Popovic Pejicic S, Stankovic S, Jovanic J, Bjekic-Macut J, Livadas S, Ognjanovic S, Mastorakos G, Micic D, Macut D. THE EFFECT OF MYOINOSITOL AND METFORMIN ON CARDIOVASCULAR RISK FACTORS IN WOMEN WITH POLYCYSTIC OVARY SYNDROME: A RANDOMIZED CONTROLLED TRIAL. ACTA ENDOCRINOLOGICA (BUCHAREST, ROMANIA : 2005) 2021; 17:241-247. [PMID: 34925574 PMCID: PMC8665246 DOI: 10.4183/aeb.2021.241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
CONTEXT Cardiovascular risk is increased in women with polycystic ovary syndrome (PCOS). Do insulin sensitizing agents such as metformin (MET) and myoinositol (MI) ameliorate biomarkers of cardiovascular risk? OBJECTIVE To compare the effects of MET and MI on blood pressure, lipid profile and high sensitive C-reactive protein (hs-CRP) in women with PCOS in respect to their body mass index (BMI). DESIGN Open label, parallel randomized, single center study. SUBJECTS AND METHODS Sixty six women with PCOS (33 normal-weight and 33 overweight/obese) were randomized to either MI (4 g/day) or MET (1500 mg/day) for a period of 6 months. Serum concentration of hormones, lipid profile, oxidized LDL (ox-LDL), hs-CRP, blood pressure measurement and clinical assessment of BMI, waist circumference (WC) and Ferriman Gallwey score (FG score) were performed before and after treatment. RESULTS Thirty patients in each group completed the trial. Compared with MET, MI significantly decreased diastolic blood pressure (DBP) (p=0.036) and significantly increased serum hs-CRP (p=0.043). No differences between groups in total cholesterol (TC), HDL-cholesterol, LDL-cholesterol, ox-LDL and triglycerides were reported after 6 months. Treatment with MI reduced BMI (p=0.037), WC (p=0.005), DBP (p=0.021) and TC (p=0.008). During MET treatment a significant decrease in BMI (p=0.005), WC (p=0.004), FG score (p=0.001), testosterone (p=0.013) and free androgen index (FAI) (p=0.006) was observed. CONCLUSIONS Our study showed an advantage of MI in reduction of DBP and TC thus predicting favorable metabolic and cardiovascular outcomes in PCOS women. MET more effectively decrease indices of hyperandrogenism.
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Affiliation(s)
- V. Soldat-Stankovic
- University Clinical Centre of the Republic of Srpska - Internal medicine, Bosnia and Herzegovina
| | - S. Popovic Pejicic
- University Clinical Centre of the Republic of Srpska - Internal medicine, Bosnia and Herzegovina
| | - S. Stankovic
- University Clinical Centre of the Republic of Srpska - Nuclear medicine, Bosnia and Herzegovina
| | - J. Jovanic
- University Clinical Centre of the Republic of Srpska - Internal medicine, Bosnia and Herzegovina
- University Clinical Centre of the Republic of Srpska - Cardiology, Banja Luka, Republika Srpska, Bosnia and Herzegovina
| | - J. Bjekic-Macut
- Klinicko Bolnicki Centar Bezanijska kosa - Department of Endocrinology, Belgrade, Serbia
- University of Belgrade, Faculty of Medicine - Internal Medicine, Belgrade, Serbia
| | - S. Livadas
- Metropolitan Hospital Athens - Endocrinology Unit, Athens, Greece
| | - S. Ognjanovic
- University of Belgrade, Faculty of Medicine -Clinic of Endocrinology, Diabetes and Diseases of Metabolism, Belgrade, Serbia
| | - G. Mastorakos
- National and Kapodistrian University of Athens - Endocrinology Unit, Athens, Greece
| | - D. Micic
- Serbian Academy of Sciences and Arts - Department of Medical Sciences, Belgrade, Serbia
| | - D. Macut
- University of Belgrade, Faculty of Medicine -Clinic of Endocrinology, Diabetes and Diseases of Metabolism, Belgrade, Serbia
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Shpakov AO. Improvement Effect of Metformin on Female and Male Reproduction in Endocrine Pathologies and Its Mechanisms. Pharmaceuticals (Basel) 2021; 14:ph14010042. [PMID: 33429918 PMCID: PMC7826885 DOI: 10.3390/ph14010042] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/02/2021] [Accepted: 01/06/2021] [Indexed: 02/07/2023] Open
Abstract
Metformin (MF), a first-line drug to treat type 2 diabetes mellitus (T2DM), alone and in combination with other drugs, restores the ovarian function in women with polycystic ovary syndrome (PCOS) and improves fetal development, pregnancy outcomes and offspring health in gestational diabetes mellitus (GDM) and T2DM. MF treatment is demonstrated to improve the efficiency of in vitro fertilization and is considered a supplementary drug in assisted reproductive technologies. MF administration shows positive effect on steroidogenesis and spermatogenesis in men with metabolic disorders, thus MF treatment indicates prospective use for improvement of male reproductive functions and fertility. MF lacks teratogenic effects and has positive health effect in newborns. The review is focused on use of MF therapy for restoration of female and male reproductive functions and improvement of pregnancy outcomes in metabolic and endocrine disorders. The mechanisms of MF action are discussed, including normalization of metabolic and hormonal status in PCOS, GDM, T2DM and metabolic syndrome and restoration of functional activity and hormonal regulation of the gonadal axis.
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Affiliation(s)
- Alexander O Shpakov
- I.M. Sechenov Institute of Evolutionary Physiology and Biochemistry of Russian Academy of Sciences, 194223 Saint Petersburg, Russia
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Pharmacological Approaches to Controlling Cardiometabolic Risk in Women with PCOS. Int J Mol Sci 2020; 21:ijms21249554. [PMID: 33334002 PMCID: PMC7765466 DOI: 10.3390/ijms21249554] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/12/2020] [Accepted: 12/13/2020] [Indexed: 12/12/2022] Open
Abstract
Polycystic ovary syndrome (PCOS) is characterized by elevated androgen production and subclinical changes in cardiovascular and metabolic risk markers. Total cholesterol, high-density lipoprotein (HDL) cholesterol, fasting glucose, and fasting insulin appear to increase specifically in PCOS compared with fertile women. PCOS also confers an increased risk of cardiometabolic disease in later life. Novel biomarkers such as serum’s cholesterol efflux capacity and blood-derived macrophage activation profile may assist in more accurately defining the cardiometabolic risk profile in these women. Aldosterone antagonists, androgen receptor antagonists, 5α-reductase inhibitors, and synthetic progestogens are used to reduce hyperandrogenism. Because increased insulin secretion enhances ovarian androgen production, short-term treatment with metformin and other hypoglycemic agents results in significant weight loss, favorable metabolic changes, and testosterone reduction. The naturally occurring inositols display insulin-sensitizing effects and may be also used in this context because of their safety profile. Combined oral contraceptives represent the drug of choice for correction of androgen-related symptoms. Overall, PCOS management remains focused on specific targets including assessment and treatment of cardiometabolic risk, according to disease phenotypes. While new options are adding to established therapeutic approaches, a sometimes difficult balance between efficacy and safety of available medications has to be found in individual women.
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