PCOS: an ovarian disorder that leads to dysregulation in the hypothalamic–pituitary–adrenal axis?

Allopregnanolone in the pathogenesis of the psychiatric comorbidities of polycystic ovarian syndrome

Polycystic ovarian syndrome (PCOS) is an endocrine disorder affecting 10-15 % of women of reproductive age, with significant implications for both physical and mental health. Several recent research studies have examined the connection between PCOS and psychiatric disorders; however, the mechanism linking the two is not fully understood. Allopregnanolone is a neurosteroid that modulates GABAA receptors and is naturally affected by the pathophysiology of PCOS. It is thought to play a role in mood disorders, including premenstrual dysphoric disorder and postpartum depression. Recent research has begun to focus on the relationship between PCOS and allopregnanolone. A literature review was conducted using databases, including PubMed, MEDLINE, and Cochrane Library. Keywords included "PCOS," "psychiatric disorders," "allopregnanolone," and "neurosteroids." Articles were selected based on relevance to psychiatric implications of PCOS, with a focus on high-quality, original research studies. Quality assessment of the sources was informed using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) Handbook criteria. The literature review revealed a growing body of evidence suggesting a strong association between PCOS and an increased risk of psychiatric disorders, particularly depression, anxiety, and mood disorders. The role of allopregnanolone, a neurosteroid, was identified as an important factor in this relationship, with some studies indicating its potential impact on mood regulation in PCOS patients. There is a dire need for clinicians to consider the mental health implications of PCOS during diagnosis and management. The integration of psychiatric screening in PCOS management could lead to earlier detection and improved outcomes. Future research should focus on the therapeutic potential of allopregnanolone and other neurosteroids in treating psychiatric disorders associated with PCOS.

An endocrinological perspective on polycystic ovarian syndrome

Polycystic ovarian syndrome (PCOS) is a complex endocrinological disorder that involves dysfunctions across multiple endocrine axes, including the hypothalamic-pituitary-gonadal (HPG), hypothalamic-pituitary-adrenal (HPA) and hypothalamic-pituitary-thyroid (HPT) axes. Our review focuses on understanding the pathophysiology of PCOS through an endocrinological perspective, emphasizing the complex interactions between multiple endocrine axes. We have discussed the roles of the HPG, HPA, and HPT axes in PCOS. Dysregulation of the HPG axis, particularly the altered gonadotropin-releasing hormone pulse frequency resulting in elevated ratio of luteinizing hormone to follicle stimulating hormone, is central to the hyperandrogenism and anovulation, observed in PCOS. We have further highlighted the contributions of the HPA and HPT axes, where elevated adrenal androgen levels and hypothyroidism intensifies the phenotypes of PCOS. Additionally, insulin resistance and hyperinsulinemia, commonly associated with PCOS, aggravates hormonal disturbances and heighten the risk of metabolic complications such as type 2 diabetes and cardiovascular diseases. Elevated levels of anti-Müllerian hormone have also been emphasized as a key factor in inhibiting follicular growth, leading to impaired ovarian function and hyperandrogenism. This review further supports that PCOS is a multifactorial condition involving complex feedback mechanisms between the endocrine, metabolic, and reproductive systems. Furthermore, there remains a huge scope for deciphering the precise molecular interactions between the HPG, HPA, and HPT axes in PCOS, which could pave the way for targeted therapies for better management of both the endocrine and metabolic aspects of this disorder. This review will benefit researchers to get an endocrine perspective on PCOS.

The Cardiometabolic Risk in Women with Polycystic Ovarian Syndrome (PCOS): From Pathophysiology to Diagnosis and Treatment

Polycystic Ovarian Syndrome (PCOS) is a prevalent endocrine disorder affecting women of reproductive age, with significant variations in presentation characterized by hyperandrogenism, ovulatory dysfunction, and polycystic ovarian morphology. Beyond reproductive health, it may also pose crucial long-term cardiometabolic risks, especially for women with specific types of PCOS, contributing to early subclinical cardiovascular atherosclerotic alterations such as endothelial dysfunction, increased arterial stiffness, and coronary artery calcium levels, respectively. Moreover, the precise relationship between clinical cardiovascular disease (CVD) and PCOS remains debated, with studies demonstrating an elevated risk while others report no significant association. This review investigates the pathophysiology of PCOS, focusing on insulin resistance and its link to subclinical and clinical cardiovascular disease. Diagnostic challenges and novel management strategies, including lifestyle interventions, medications like metformin and glucagon-like peptide-1 receptor agonists (GLP-1RAs), hormonal contraceptives, and bariatric surgery, are further discussed. Recognizing the cardiometabolic risks associated with PCOS, a comprehensive approach and early intervention should address both the reproductive and cardiometabolic dimensions of the syndrome.

Impact of dehydroepiandrosterone sulfate and free androgen index on pregnancy and neonatal outcomes in PCOS patients

BACKGROUND

Polycystic ovary syndrome (PCOS) is a prevalent endocrine disorder associated with infertility and pregnancy complications. The pathogenesis of PCOS and its impact on reproductive function may be influenced by the source of androgens, including testosterone, free androgen, dehydroepiandrosterone sulfate (DHEAS). However, the differential effects of these androgen on pregnancy and neonatal outcomes and the cut-off value of East Asian population with PCOS remain unclear.

METHODS

A retrospective cohort study was conducted at the Reproductive Medicine Center of the First Affiliated Hospital of Sun Yat-sen University from January 2015 to November 2022, involving 636 cycles of in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI). Subgroup analyses were performed using cut-off values of 6.4 for free androgen index (FAI), 9.5 µmol/L for DHEAS. Pregnancy and neonatal outcomes were compared between groups. Restricted cubic spline (RCS) was used to identify significant cut-off values affecting pregnancy.

RESULTS

Higher FAI levels (> 6.4) were associated with decrease in clinical pregnancy rate (PR) (50.61% vs. 41.66%, p = 0.024), live birth rate (LBR) (42.42% vs. 32.35%, p = 0.011). When DHEAS levels exceeded 9.5 µmol/L, there was a significant decrease in clinical PR (51.27% vs. 42.73%, P = 0.039), LBR (42.73% vs. 32.73%, P = 0.012). Negative correlations were also observed between DHEAS levels and cumulative pregnancy rate (70.57% vs 56.62% p = 0.002) and cumulative live birth rate (CLBR) (59.35% vs 43.37%, p = 0.0007). Both FAI and DHEAS elevated is associated with the lowest clinical pregnancy rate (37.84%). Conversely, when solely FAI is elevated, the pregnancy rate increases to 52.38%, while an elevation in DHEAS alone is associated with a pregnancy rate of, both of which are lower than when neither FAI nor DHEAS are elevated (60.68%). The live birth rates exhibit a similar trend (30.00% vs 40.00% vs 41.83% vs 44.48%). RCS revealed a significant decrease in CPR and CLBR when DHEA levels exceeded 7.69 umol/L, while the cut-off value of FAI was 6.36 for CPR and CLBR.

CONCLUSION

In conclusion, PCOS patients with biochemical hyperandrogenism show unsatisfactory clinical PR and CLBR when undergoing assisted reproductive technology (ART). This may be attributed to the influence of both adrenal-derived DHEAS and ovarian-derived FAI on the unfavorable pregnancy outcomes.

Reduced PATL2 Impairs the Proliferation of Ovarian Granulosa Cells by Decreasing ADM2 Expression in Patients with PCOS

It is recognized that PCOS patients are often accompanied with aberrant follicular development, which is an important factor leading to infertility in patients. However, the relevant regulatory mechanisms of abnormal follicular development are not well understood. In the present study, by collecting human ovarian granulosa cells (GCs) from PCOS patients who underwent in vitro fertilization (IVF), we found that the proliferation ability of GCs in PCOS patients was significantly reduced. Surprisingly, PATL2 and adrenomedullin 2 (ADM2) were obviously decreased in the GCs of PCOS patients. To further explore the potential roles of PATL2 and ADM2 on GC, we transfected PATL2 siRNA into KGN cells to knock down the expression of PATL2. The results showed that the growth of GCs remarkably repressed after knocking down the PATL2, and ADM2 expression was also weakened. Subsequently, to study the relationship between PATL2 and ADM2, we constructed PATL2 mutant plasmid lacking the PAT construct and transfected it into KGN cells. The cells showed the normal PATL2 expression, but attenuated ADM2 expression and impaired proliferative ability of GCs. Finally, the rat PCOS model experiments further confirmed our findings in KGN cells. In conclusion, our study suggests that PATL2 promoted the proliferation of ovarian GCs by stabilizing the expression of ADM2 through "PAT" structure, which is beneficial to follicular development, whereas, in the ovary with polycystic lesions, reduction of PATL2 could result in the decreased expression of ADM2, subsequently weakened the proliferation ability of GCs and finally led to the occurrence of aberrant follicles.

Clinical Phenotypes of PCOS: a Cross-Sectional Study

This cross-sectional study examines the Doi-Alshoumer PCOS clinical phenotype classification in relation to measured clinical and biochemical characteristics of women with polycystic ovary syndrome (PCOS). Two cohorts of women (Kuwait and Rotterdam) diagnosed with PCOS (FAI > 4.5%) were examined. These phenotypes were created using neuroendocrine dysfunction (IRMA LH/FSH ratio > 1 or LH > 6 IU/L) and menstrual cycle status (oligo/amenorrhea) to create three phenotypes: (A) neuroendocrine dysfunction and oligo/amenorrhea, (B) without neuroendocrine dysfunction but with oligo/amenorrhea, and (C) without neuroendocrine dysfunction and with regular cycles. These phenotypes were compared in terms of hormonal, biochemical, and anthropometric measures. The three suggested phenotypes (A, B, and C) were shown to be sufficiently distinct in terms of hormonal, biochemical, and anthropometric measures. Patients who were classified as phenotype A had neuroendocrine dysfunction, excess LH (and LH/FSH ratio), irregular cycles, excess A4, infertility, excess T, highest FAI and E2, and excess 17αOHPG when compared to the other phenotypes. Patients classified as phenotype B had irregular cycles, no neuroendocrine dysfunction, obesity, acanthosis nigricans, and insulin resistance. Lastly, patients classified as phenotype C had regular cycles, acne, hirsutism, excess P4, and the highest P4 to E2 molar ratio. The differences across phenotypes suggested distinct phenotypic expression of this syndrome, and the biochemical and clinical correlates of each phenotype are likely to be useful in the management of women with PCOS. These phenotypic criteria are distinct from criteria used for diagnosis.

Aberrant BMP15/HIF-1α/SCF signaling pathway in human granulosa cells is involved in the PCOS related abnormal follicular development

AIMS

To investigate the regulatory mechanism of SCF expression in human GCs of PCOS related follicles.

MATERIALS AND METHODS

SCF, BMP15 and HIF-1α were evaluated in human serums, follicular fluids (FFs) and GCs, which were collected from 69 PCOS patients and 74 normal ovulatory patients. KGN cell line was used in this study.

RESULTS

Our results showed that the rate of MII oocyte and 2PN fertilization was lower in PCOS group, though PCOS patients retrieved much more oocytes. The level of BMP15 in FF and the level of SCF in serum and FF were also lower in PCOS patients. We found a weakened expression of HIF-1α and SCF in GCs from PCOS patients when compared with the non-PCOS patients. The expression of HIF-1α and SCF was significantly increased in KGN cells after treating cells with rhBMP15, however, this promotion effects of BMP15 on HIF-1α and SCF expression were obviously abolished by co-treatment with BMP-I receptor inhibitor (DM). Moreover, knock down of HIF-1α expression in KGN cells significantly reduced the expression of SCF in human GCs, in spite of activating BMP15 signaling pathway.

CONCLUSIONS

The present study suggest that BMP15 could induce SCF expression by up-regulating HIF-1α expression in human GCs, the aberrance of this signaling pathway might be involved in the PCOS related abnormal follicular development.

Partially purified non-polar phytocomponents from Aloe barbadensis Mill. gel restores metabolic and reproductive comorbidities in letrozole-induced polycystic ovary syndrome rodent model- an "in-vivo" study

ETHNOPHARMACOLOGICAL RELEVANCE

In India, Kumaryasava, a popular Aloe barbadensis Mill. gel preparation has therapeutic value in treatment of female reproductive disorders like menstrual disturbances and menopausal problems. Despite their widespread use, only a limited number of studies have probed into the scientific evidence for their varied bioactivities. In this regard, studies have demonstrated that Aloe vera gel has the potential to modulate steroidogenic activity in letrozole induced polycystic ovary syndrome (PCOS) rat. However, isolation and identification of the bioactive molecule/s from Aloe vera gel and studying their molecular targets will underpin the treatment regime for PCOS.

MATERIAL AND METHODS

The Partially Purified Non-Polar Phytocomponents (PPNPP)- LP1 and LP3 were isolated from the petroleum ether extract of Aloe vera gel by column chromatography. Based upon the GC-MS analysis, LP1 and LP3 comprised of n-Hexadecanoic acid and Campesterol acetate with an abundance of 97.07%, and 96.07% respectively. For evaluation of their bioactivities, eighty 3-4 months female Balb/c mice were classified as 10 groups with 8 animals in each group. Groups were control (C), PCOS (0.5 mg/kg/day Letrozole orally for 21days), PCOS treated orally for 60 days with Aloe vera gel (AVG) (10 mg/kg/day) (PCOS + AVG), PCOS treated orally for 60 days with petroleum ether extract (PE) of Aloe vera gel (25 μg/kg/day) (PCOS + PE), PCOS treated orally for 60 days with LP1 (0.5 μg/kg/day) (PCOS + LP1), PCOS treated orally for 60 days with commercially available pure compound-n-Hexadecanoic acid (HA) (0.5 μg/kg/day) (PCOS + HA), PCOS treated orally for 60 days with LP3 (0.01 μg/kg/day) (PCOS + LP3), PCOS treated orally for 60 days with commercially available pure compound- Campesterol acetate (CA) (0.01 μg/kg/day) (PCOS + CA), PCOS treated orally for 60 days with Metformin (100 mg/kg/day) (PCOS + Metformin) and PCOS treated orally for 60 days with DMSO (Vehicle) (PCOS + DMSO). Body weight, Oral glucose tolerance test, lipid profile, fasting glucose, insulin, estrus cycle, hormonal profile, gene expression of gonadotropin receptors (Fshr and Lhr), steroid receptors (Ar, Esr1, Esr2 and Pgr) and steroidogenic markers (Star, Hsd3b1, Cyp19a1 and Amh) were analysed in the ovaries. Polycystic ovarian morphology was assessed through histopathological changes of ovary. Toxicity markers- SGOT, SGPT and creatinine were also measured at the end of the study.

RESULTS

Mice treated with letrozole demonstrated significant increase in body weight, glucose intolerance, fasting insulin levels, HOMA-IR, triglycerides levels as well as testosterone levels, and a significant decline in the progesterone levels as compared to the control animals. PCOS animals also exhibited arrested estrus cyclicity, disrupted ovarian histopathology with the presence of multiple peripheral cysts and abnormal gene expression of gonadotropin receptor, steroid receptor and steroid markers. Oral administration of AVG, PE extract of AVG, LP3 and metformin greatly alleviated these complications in PCOS animals.

CONCLUSION

The above findings indicate the effectiveness of LP3, isolated from Aloe vera gel against letrozole induced PCOS in mice and may be used in the treatment of PCOS as an alternative to metformin.

A review of the hormones involved in the endocrine dysfunctions of polycystic ovary syndrome and their interactions

Polycystic ovary syndrome (PCOS) affects up to 20% of women but remains poorly understood. It is a heterogeneous condition with many potential comorbidities. This review offers an overview of the dysregulation of the reproductive and metabolic systems associated with PCOS. Review of the literature informed the development of a comprehensive summarizing 'wiring' diagram of PCOS-related features. This review provides a justification for each diagram aspect from the relevant academic literature, and explores the interactions between the hypothalamus, ovarian follicles, adipose tissue, reproductive hormones and other organ systems. The diagram will provide an efficient and useful tool for those researching and treating PCOS to understand the current state of knowledge on the complexity and variability of PCOS.

The first report of clonidine in vivo/in vitro effects on infertile women with polycystic ovary syndrome (in vivo/in vitro study)

The sympathetic nervous system (SNS) is hyperactive in women with polycystic ovary syndrome (PCOS). This study was designed in two sections: in vivo/in vitro with clonidine as the alpha-2 adrenoceptor (ADR-α₂) agonist for modulating this hyperactivity. Eighty women with PCO participated in this randomised clinical trial (in vivo). A clonidine (0.1 mg) tablet was given twice a day for two months. Polycystic ovary morphology (PCOM) and pregnancy rate were the main outcome measurements. In the candidates for in vitro fertilisation (IVF), clonidine was added to the culture medium during IVF for two study groups (PCO-clonidine/PCO-without) and two control groups (egg donors-clonidine/egg donors-without). Our results showed that the pregnancy rate significantly was higher in the study group (p = .002). The mRNA expression of ADR-α₁ and ADR-β₂ in PCO was higher than control group (p value <.001). But ADR-α₁ expression in PCO-clonidine group decreased (p value = .042), the same as ADR-α₂ expression. The intensity of this effect showed a pattern for ADR-α₁<ADR-β₂<ADR-α₂. Increase of antral follicle count (AFC) growth and pregnancy rate indicate the significant role of ADR-α₂ in PCOS. Clonidine reduced gene expression and protein levels, confirming the above results. These results would aid in pharmacological treatments, as well as assisted reproductive technologies (ARTs).Impact StatementWhat is already known on this subject? In women with PCOS, sympathetic nerve activity is higher than in healthy women. Clonidine is widely used as an alpha-2 presynaptic adrenoceptor (autoreceptor) agonist to modulate the output of the sympathetic nervous system (SNS). Our in vivo/in vitro results showed that the optimal dose of clonidine can increase the oocyte maturity and pregnancy rate in PCO women. This finding was also confirmed by the results in cumulus cell culture.What do the results of this study add? The results of administration of 0.2 mg of clonidine (in vivo) for oocyte maturation and pregnancy rate confirms the in vitro response in the cumulus cell culture of PCO women's follicle.What are the implications of these findings for clinical practice and/or further research? These findings can be used in pharmacological treatment of anovulation and assisted reproductive technology (ART).

Pregnancy outcome of freeze thaw cycles of polycystic ovary syndrome patients regarding the anti-Müllerian hormone percentile

Patients with polycystic ovary syndrome display increased levels of anti-Müllerian hormone. Frozen-thawed embryo transfer (FET) prevents ovarian hyperstimulation and results in better pregnancy outcome in PCOS patients. Therefore, we aimed to evaluate the effect of serum AMH levels on the pregnancy outcome of FET cycles in PCOS patients. 110 infertile women with PCOS who were recommended for embryo cryopreservation followed by FET. The patients' AMH levels were evaluated, and the age-related AMH percentiles were determined. The patients were then grouped according to AMH percentiles, namely, 75th-90th percentile (Group 1) and higher than the 90th percentile (Group 2).A total of 110 PCOS patients who conceived in Frozen Embryo Transfer (FET)-In-vitro Fertilisation (IVF) cycles were included in this study. The preterm delivery rates in FET cycles were higher in the group of PCOS patients with AMH levels greater than the 90th percentile than in patients in the 75th-90th percentile group (50% vs 28.8%, p = .024). In conclusion, PCOS patients with AMH levels higher than the 90^th percentile had substantially higher preterm delivery rates than those with AMH levels at the 75^th-90^th percentile, suggesting the need for closer follow-up. Further studies are needed to elucidate the underlying mechanisms behind this correlation.IMPACT STATEMENTWhat is already known on this subject? The association of AMH levels with the risk of adverse pregnancy outcomes has been previously investigated. In women with PCOS, substantially elevated AMH levels were significantly associated with preterm birth.What do the results of this study add? Results showed that the PCOS patients with higher AMH levels and underwent assisted reproductive treatment demonstrated an increased risk of preterm labour than the PCOS patients with lower AMH levels.What are the implications of these findings for clinical practice and/or further research? In women with PCOS, substantially elevated AMH levels were significantly related to preterm birth, suggesting the need for closer follow-up in this population and the need for further studies to elucidate the underlying mechanisms behind this correlation.

Expression of ADR-α1, 2 and ADR-β2 in cumulus cell culture of infertile women with polycystic ovary syndrome and poor responder who are a candidate for IVF: the novel strategic role of clonidine in this expression

OBJECTIVE

Alpha and beta-adrenoceptors (ADR-α1, 2, and β2) play a regulatory role in the folliculogenesis and steroidogenesis in the ovarian follicles. This study aimed to measure these adrenoceptors mRNA and its protein levels in cumulus cells (CCs) culture of poor ovarian reserve (POR) and polycystic ovarian syndrome (PCOS) infertile women (IVF candidate) and the effect of clonidine treatment at CCs culture.

METHODS

This case/control study was conducted in 2017 includes a control (donation oocytes) and two studies (PCO and POR) groups. The ovulation induction drugs were prescribed in all groups. After the oocyte puncture, the follicular fluid was collected and CCs were isolated were cultured. RNA was extracted and cDNA was synthesized and designed the primer for the ADR-α1, 2 and ADR-β2 gene expression. The protein levels were investigated by Western Blot.

RESULTS

The results showed a high level of three adrenergic expressions in PCO women compared to the control group (p-value <.001), which can be reduced by clonidine. POR group showed a significant decrease in the gene expression of ADR-α1 (p-value = .004) and ADR-α2 (p-value = .003) compared to the control group and clonidine treatment had no effect.

CONCLUSION

The significant increase of three adrenoceptors gene expression and protein levels in CCs culture indicate to the hyperactivity of the ovarian sympathetic nervous system at the receptor levels in women with PCOS, and clonidine confirmed it by reducing this expression. In POR women, the reduction of ADR-α1, 2 expressions maybe lead to the aging process in the ovary.

Dehydroepiandrosterone stimulates inflammation and impairs ovarian functions of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is one of the most common causes of infertility in child-bearing-age women. It is characterized by ovulation dysfunction, polycystic ovaries, and hyperandrogenism. Inflammation is likely to be a crucial contributor to the pathogenesis of PCOS. However, the association between the inflammatory cytokines and the development of PCOS has not been reported. To explore the relationship between the inflammatory cytokines and PCOS, alterations of serum proteins in dehydroepiandrosterone (DHEA)-induced PCOS rats were screened by protein array, and the concentration of IFN-γ was further measured by using enzyme-linked immunosorbent assay (ELISA). DHEA-induced PCOS rats had a decreased level of IFN-γ compared with the control rats, which was restored partly in flutamide (an androgen receptor antagonist)-treated rats. Moreover, the level of IFN-γ in serum of patients with PCOS was also lower than that in healthy women. Using the ovarian granulosa cells (KGN), we demonstrated that DHEA downregulated the expression and secretion of IFN-γ in dose- and time-dependent manners, which could be restored to some extent by treating with flutamide. Furthermore, flutamide ameliorated the inhibitory effect on cell proliferation and promotive effect on cell apoptosis by DHEA. The results also revealed that IFN-γ promoted the proliferation but inhibited the apoptosis of KGN cells, which was suppressed by DHEA via activating the downstream PI3K/AKT signaling pathway. Taken together, these results showed that DHEA inhibited the proliferation and promoted the apoptosis of ovarian granulosa cells through downregulating the expression of IFN-γ which could be restored by flutamide, and IFN-γ may serve as a potential inflammatory biomarker for PCOS detection.

Peri-ovarian adipose tissue contributes to intraovarian control during folliculogenesis in mice

Peri-ovarian adipose tissue (POAT) is a kind of intra-abdominal white adipose tissue that is present surrounding the ovaries in rodents. Recent studies demonstrated that POAT-deficient mice displayed a phenotype of delayed antral follicular development, for which decreases in serum estrogen, serum FSH and FSHR levels were responsible. However, folliculogenesis is regulated by endocrine signals and also modulated by a number of locally produced intraovarian factors whose acts are both autocrine and paracrine. Here, we used a model of surgical removal of POAT unilaterally and contralateral ovaries as controls, as both were under the same endocrine control, to assess the paracrine effect of the POAT on folliculogenesis. Surgical removal of unilateral POAT resulted in delayed antral follicular development and the increased number of atretic follicles, accompanied by decreased levels of intraovarian adipokines and growth factors, lipid accumulation and steroidogenic enzyme expression. POAT-deficient ovaries displayed compensatory increased expressions of intraovarian genes, such as Vegf and Adpn for angiogenesis, Acc, Fasn, and Gapdh involved in lipogenesis and Fshr in response to FSH stimulation. Furthermore, we demonstrated that removal of POAT promoted follicular apoptosis, caused retention of cytoplasmic YAP and inhibited PTEN-AKT-mTOR activation. These alterations were observed only in the POAT-deficient ovaries but not in the contralateral ovaries (with POAT), which suggests that a paracrine interaction between POAT and ovaries is important for normal folliculogenesis.

Role of the PI3K-Akt Signaling Pathway in the Pathogenesis of Polycystic Ovary Syndrome

This review aimed to focus on the recent progress of the understanding of the role of phosphatidylinositol 3-kinase (PI3K) in polycystic ovary syndrome (PCOS). In recent years, it has been increasingly recognized that PI3K plays an important role in PCOS whose pathogenesis is unclear. However, research continues into revealing the details of how PI3Ks are involved in developing PCOS. Previous studies have shown that activation of the PI3K-protein kinase B (Akt) signaling pathway has important effects on insulin resistance and endometrial cancer. Knowledge of the action of PI3K in PCOS might provide valuable information to further validate the pathogenesis of PCOS and suggest new methods of treatment.

The Predictive Role of Serum Cystatin C Levels in Polycystic Ovary Syndrome in Adolescents

STUDY OBJECTIVE

To evaluate the correlation between serum cystatin levels and clinical parameters in adolescents with polycystic ovary syndrome (PCOS). DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: This prospective case-control study included 89 adolescents with PCOS. Demographic characteristics and hormonal and biochemical parameters were compared between study (89 patients with PCOS) and control (84 subjects without PCOS) groups. Risk factors recorded were age, body mass index (BMI), waist to hip ratio (WHR), Ferriman-Gallwey score, triglyceride, total cholesterol, high-density lipoprotein, low-density lipoprotein (LDL), high-sensitivity C-reactive protein, cystatin C, follicle stimulating hormone, luteinizing hormone, estradiol, dehydroepiandrosterone sulfate, homeostatic model assessment insulin resistance index, free testosterone, and progesterone levels.

RESULTS

BMI, WHR, Ferriman-Gallwey score, and triglyceride, LDL, total cholesterol, estradiol, dehydroepiandrosterone sulfate, free testosterone, luteinizing hormone, high-sensitivity C-reactive protein, and cystatin C levels, and homeostatic model assessment insulin resistance index scores were significantly higher, and high-density lipoprotein levels were lower in the PCOS patients compared with healthy subjects (P < .05). We also found positive correlations between the cystatin C levels and BMI, WHR, estradiol, high-sensitivity C-reactive protein, and LDL levels in the study group.

CONCLUSION

The serum cystatin C level is a promising marker for diagnosing adolescent patients with PCOS and suggests an inflammatory etiology for these patients. Further studies with more participants should examine this potential association with inflammation.

Study of the association of the T869C polymorphism of the transforming growth factor-β1 gene with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a common multifactorial disorder characterized by hyperandrogenism, insulin resistance and chronic oligoanovulation. In addition, a number of females with PCOS have ovaries with multiple cysts, an irregular or no menstrual cycle and an imbalance of female hormones compared with normal controls. The transforming growth factor β1 (TGF‑β1) gene is one of the genes associated with obesity and type 2 diabetes, which are characteristic symptoms of PCOS. The present study, therefore, investigated the association between the T869C polymorphism of the TGF‑β1 gene, a single nucleotide polymorphism (SNP) of TGF‑β1 and PCOS. The genomic DNA from 285 patients with PCOS and 129 healthy control individuals was used in the present study. P<0.05 was considered to indicate a statistically significant difference between the groups. The present study findings suggested that the frequency of genotypes provided no significant association between the T869C polymorphism in the TGF‑β1 gene and patients with PCOS. Although the present study concluded that the T869C polymorphism in the TGF‑β1 gene is not associated with the pathogenesis of PCOS, further studies regarding the correlation between other SNPs of the TGF‑β1 gene and PCOS are required.

Effects of metformin on the adrenal cortex of androgenized rats

OBJECTIVE

To evaluate the sex steroid profile and histomorphometry of the adrenal cortical zones of androgenized rats (wistar) with polycystic ovary syndrome treated with metformin.

STUDY DESIGN

Thirty animals were divided into three groups: GC (regular estrous cycle), GPE (permanent estrus), and GPEM (permanent estrus + metformin 28 mg/kg for 50 days). At the end of this period, blood was collected for hormone measurement. The width of the adrenal cortical zones and the nuclear volumes were analyzed by histomorphometry. The ANOVA test was used in the statistical analysis.

RESULTS

The adrenal glands of the androgenized animals were larger and more intensely vascularized than those of the other groups. The concentration of androstenedione in GPE was higher than that in the other groups (0.4 ± 0.1*>= 0.2 ± 0.1 = 0.2 ± 01, *p < 0.05). The width of the zona glomerulosa and of the zona reticularis and their nuclear volumes were greater in GPE compared to those of the other groups (GPE* > GPEM = GC, *p < 0.05).

CONCLUSION

Metformin treatment may decrease the serum levels of androstenedione as well as the width and the nuclear volumes of the zona glomerulosa and of the zona reticularis in androgenized animals.

A macrophage activation marker chitotriosidase in women with PCOS: does low-grade chronic inflammation in PCOS relate to PCOS itself or obesity?

OBJECTIVE

Polycystic ovary syndrome (PCOS) is described as a low-grade chronic inflammatory state where the macrophage infiltration increased in visceral fat play the major role. The aim of this study was to assess chitotriosidase (ChT) activity (an activated macrophage marker) in women with PCOS and controls and to evaluate its correlation with anthropometric and biochemical parameters.

STUDY DESIGN

Seventy-nine women with PCOS and 60 healthy controls were included in the study. PCOS and controls were divided into two subgroups according to body mass indexes (BMIs) as normoweight (<25 kg/m(2)) and overweight (≥25 kg/m(2)). ChT activity, biochemical (free testosterone, luteinizing hormone, insulin resistance index, etc.) and clinical parameters [BMI, waist-to-hip ratio, modified Ferriman-Gallwey scores (mFG)] were analyzed according to groups.

RESULTS

Serum ChT activity was significantly (p < 0.001) higher in women with PCOS than controls (normoweight, 87.1 ± 90.1 vs. 18.4 ± 9.0 nmol/ml/h; overweight, 92.0 ± 96.7 vs. 17.9 ± 12.1 nmol/ml/h PCOS and controls, respectively). No statistically significant difference was noted between ChT activity of normoweight and overweight PCOS subgroups. A positive correlation was found between ChT activity and PCOS status (r 0.598, p < 0.001), mFG scores (r 0.525, p < 0.001), free testosterone (r 0.402, p 0.001) and total testosterone (r 0.168, p 0.048) for the combined groups (PCOS + controls). In multivariant linear regression analysis participants' PCOS status (presence or absence) and LH levels were the main predictors of ChT activity in the whole study population (p 0.002 and p 0.041, respectively).

CONCLUSION

ChT activity elevates in PCOS independent of obesity. Our findings support the concept of PCOS is a state of low-grade chronic inflammation where the macrophages could play the major role. Hyperandrogenism might also be related to this inflammatory state and can be a subject of further trials.

Impact of obesity on reproductive outcomes after ovarian ablative therapy in PCOS: a collaborative meta-analysis

Obesity is known to interfere with reproductive outcomes in polycystic ovary syndrome. There is no consensus regarding the impact of obesity on reproductive outcomes after ovarian ablative therapy (OAT) and there is no level I evidence to answer this question. This systematic review and meta-analysis assessed the strength of the association between obesity and ovulation or pregnancy rates after OAT. MEDLINE and several other databases were searched from 2000 to September 2011 for studies reporting on OAT and reproductive outcomes. Data were synthesized to determine the relative risk of reproductive outcomes (ovulation and pregnancy) in lean (body mass index <25 kg/m(2)) compared with overweight or obese women. The study obtained 15 data sets (14 articles) for analysis, which included 905 subjects in the obese group and 879 subjects in the lean group. Lean women had increased ovulation rates (RR 1.43, 95% CI 1.22-1.66) compared with obese women. Pregnancy rates also showed a similar trend (RR 1.73, 95% CI 1.39-2.17). Reproductive outcomes were generally better in younger women, more recent studies and randomized controlled trials. It is concluded that lean women respond better to OAT than their obese counterparts. These epidemiological observations indicate that obesity alters reproductive outcomes after OAT negatively. Obesity is known to interfere with reproductive outcomes in polycystic ovary syndrome. There is no consensus regarding the impact of obesity on ovarian ablative therapy (OAT) and there is no level I evidence to answer this question. We therefore undertook a systematic review and meta-analysis to assess the strength of the association between obesity and ovulation or pregnancy rates after OAT. We searched MEDLINE and several other databases from 2000 to September 2011 for studies reporting on OAT and reproductive outcomes. Data were synthesized to determine the risk ratio of reproductive outcomes (ovulation and pregnancy) in lean (BMI <25 kg/m(2)) as opposed to overweight or obese women. We obtained 15 datasets (14 articles) for analysis, which included 905 subjects in the obese group and 879 subjects in the lean group. Lean women had increased ovulation rates (RR 1.43, 95% CI 1.22-1.66) as compared to obese women. Pregnancy rates also showed a similar trend (RR 1.73, 95% CI 1.39-2.17). Reproductive outcomes were generally better in younger women, more recent studies and randomized controlled trials. We conclude that lean women respond better to OAT than their obese counterparts. These epidemiological observations indicate that obesity alters reproductive outcomes after OAT negatively.

Neonatal androgenization exacerbates alcohol-induced liver injury in adult rats, an effect abrogated by estrogen

Alcoholic liver disease (ALD) affects millions of people worldwide and is a major cause of morbidity and mortality. However, fewer than 10% of heavy drinkers progress to later stages of injury, suggesting other factors in ALD development, including environmental exposures and genetics. Females display greater susceptibility to the early damaging effects of ethanol. Estrogen (E2) and ethanol metabolizing enzymes (cytochrome P450, CYP450) are implicated in sex differences of ALD. Sex steroid hormones are developmentally regulated by the hypothalamic-pituitary-gonadal (HPG) axis, which controls sex-specific cycling of gonadal steroid production and expression of hepatic enzymes. The aim of this study was to determine if early postnatal inhibition of adult cyclic E2 alters ethanol metabolizing enzyme expression contributing to the development of ALD in adulthood. An androgenized rat model was used to inhibit cyclic E2 production. Control females (Ctrl), androgenized females (Andro) and Andro females with E2 implants were administered either an ethanol or isocalorically-matched control Lieber-DeCarli diet for four weeks and liver injury and CYP450 expression assessed. Androgenization exacerbated the deleterious effects of ethanol demonstrated by increased steatosis, lipid peroxidation, profibrotic gene expression and decreased antioxidant defenses compared to Ctrl. Additionally, CYP2E1 expression was down-regulated in Andro animals on both diets. No change was observed in CYP1A2 protein expression. Further, continuous exogenous administration of E2 to Andro in adulthood attenuated these effects, suggesting that E2 has protective effects in the androgenized animal. Therefore, early postnatal inhibition of cyclic E2 modulates development and progression of ALD in adulthood.

Expression of growth differentiation factor-9 and bone morphogenetic protein-15 in oocytes and cumulus granulosa cells of patients with polycystic ovary syndrome

OBJECTIVE

To evaluate the effect of growth differentiation factor-9 (GDF-9) and bone morphogenetic protein-15 (BMP-15) on the development of follicles among patients with polycystic ovary syndrome (PCOS).

DESIGN

Case-control study.

SETTING

University Hospital.

PATIENT(S)

Twenty-two oocytes were obtained from 15 patients with PCOS and 67 oocytes from 58 controls. Cumulus granulosa cells (GC) were obtained from 16 patients with PCOS and controls treated with intracytoplasmic sperm injection.

INTERVENTION(S)

Immunofluorescence combined with laser scanning confocal microscopy and immunocytochemistry were used to analyze the expression of GDF-9 and BMP-15 in oocytes and cumulus GCs.

MAIN OUTCOME MEASURE(S)

To detect the protein expression levels.

RESULT(S)

No significant difference was found in the expression of GDF-9 and BMP-15 in the oocytes and BMP-15 in the cumulus GCs of patients with PCOS and controls. However, the expression of GDF-9 in cumulus GCs of patients with PCOS was decreased significantly compared with controls (8.88 +/- 1.52 vs. 5.01 +/- 0.83).

CONCLUSION(S)

The expression of GDF-9 and BMP-15 in the oocytes of patients with PCOS who received ovulation induction treatment was in the normal range, but the GDF-9 expression in cumulus GCs from patients with PCOS was significantly lower than the normal. Reduced GDF-9 expression in cumulus GCs of patients with PCOS appears to be associated with decreased long-term developmental potential of the oocytes of patients with PCOS.

Naltrexone treatment in clomiphene resistant women with polycystic ovary syndrome

BACKGROUND

Endogenous opiates may affect various aspects of reproductive and metabolic function in patients with polycystic ovary syndrome (PCOS). This study evaluated long-term inhibition of the opioid system using naltrexone in clomiphene citrate (CC)-resistant women with PCOS.

METHODS

A group of 30 infertile females with PCOS were evaluated; all subjects were obese, hyperandrogenic and hyperinsulinemic; 16 patients were amenorrhic and 14 were oligomenorrhic. All subjects received natrexone (50 mg p.o. daily) for 6 months. Patients who did not ovulate after 12 weeks of naltrexone monotherapy, also received CC (starting at 50 mg/day for 5 days and, for non-responders, increasing it up to 150 mg/day).

RESULTS

Of the 30 women, 3 ovulated during naltrexone monotherapy and 19 of the remaining 27 ovulated during naltrexone + CC therapy. There were no conceptions during naltrexone monotherapy, but 9 of 27 women (33.3%) conceived during naltrexone + CC; there was one missed abortion at 9 weeks, one preterm delivery at 34 weeks and seven term live births. Naltrexone therapy was also followed by significant reductions in BMI, fasting serum insulin, luteinizing hormone (LH), LH/follicle-stimulating hormone ratio and testosterone.

CONCLUSIONS

In this preliminary trial, naltrexone improved endocrine and metabolic function in women with CC-resistant PCOS. Furthermore, naltrexone restored CC sensitivity in the majority of subjects, resulting in a significant number of pregnancies.

Le syndrome des ovaires polykystiques (SOPK)

Polycystic ovaries syndrome (PCOS) is one of the most common female hormonal disorders. Its multiple components--reproductive, metabolic, neoplasic and cardiovascular--have a major impact on the public health. Androgen excess and resistance to insulin, probably from genetic origin, are responsible for most of the clinical symptomatology. Resistance to insulin seems to be accompanied by a greater risk of glucose intolerance, type 2 diabetes, lipidic anomalies and can involve the development of cardiovascular diseases. In addition, sleep apnea syndrome is more progressively described in PCOS. Infertility, menses disorders and hirsutism often push these patients to consult their physician. A better understanding of the physiopathological mechanisms led to the emergence of new therapeutic options increasing the sensitivity to insulin. Besides the pregnancy wishes, cares aim to attenuate the marks of the hyper-androgenism (hormonal treatment and cosmetic) and to correct cardiovascular, respiratory and gynaecological risk factors. In case of infertility by anovulation, cares must be performed by trained experts to minimize the risk of ovarian hyper-stimulation syndrome and multiple pregnancies. A gradation from loose weight to clomiphene citrate ovulation induction, ovarian drilling, low dose gonadotropin, in vitro fertilisation, or in vitro maturation of oocytes should bring back good reproduction potential.

Eating behaviour and body image in overweight adolescent girls with or without hyperandrogenicity

We addressed the question of whether a combination of obesity and hyperandrogenicity has a more severe influence on psychosocial behaviours, as reflected by eating behaviour and body image, compared to obesity alone.

AIM

To study eating behaviour and body image in age-, pubertal- and BMI-matched overweight adolescent girls with and without hyperandrogenicity, and to compare the data with those from a control group of normal weight girls.

METHODS

Overweight adolescent girls in late puberty with (n=10) and without hyperandrogenicity (n=8) and a control group of normal weight girls (n=9) were studied. The Eating Disorder Inventory for children (EDI-C) questionnaire was used to obtain information on eating behaviours and psychological characteristics, and silhouettes were used to evaluate body image.

RESULTS

The girls with overweight but without hyperandrogenicity showed more disturbed eating behaviour and more psychological problems than did the girls with both overweight and hyperandrogenicity as compared to the healthy controls. The overweight group also had more feelings of ineffectiveness than the hyperandrogenic group. Both the overweight and the hyperandrogenic girls estimated themselves as being significantly larger and their ideal shape as being significantly smaller than their current shape. However, all overweight girls considered their current shape to be significantly smaller than it was objectively.

CONCLUSIONS

The girl with overweight alone seemed to have more disturbed eating behaviour and more psychological problems than girls with combined overweight and hyperandrogenicity. This could indicate that different therapeutic interventions might be needed in attempts to reduce weight in the two groups.

Plasma adrenomedullin levels in patients with polycystic ovary syndrome

OBJECTIVE

To evaluate adrenomedullin levels in patients with polycystic ovary syndrome (PCOS).

DESIGN

Prospective study.

SETTING

Department of obstetrics and gynecology in a university hospital.

PATIENT(S)

Thirty-eight women with PCOS and 29 healthy control subjects were enrolled in the study.

INTERVENTION(S)

Plasma adrenomedullin, serum androstenedione, free T, T, DHEAS, SHBG, thyrotropin, PRL, FSH, LH, and E2 were measured in each subject. Insulin resistance was estimated by fasting insulin level, fasting glucose:insulin ratio and 75-g glucose tolerance test for 2 hours.

MAIN OUTCOME MEASURE(S)

Plasma adrenomedullin levels and correlations among adrenomedullin and gonadotropins, female sex steroids, androgens, and insulin resistance.

RESULT(S)

There was no significant difference concerning plasma adrenomedullin concentrations between the groups. In patients with PCOS, fasting glucose, fasting insulin, body mass index, and free T were inversely correlated with the plasma adrenomedullin. Plasma adrenomedullin was significantly correlated with glucose:insulin ratio. After controlling for body mass index, there were no significant correlations between the above-mentioned parameters.

CONCLUSION(S)

Adrenomedullin may play a role in regulating the insulin metabolism in patients with PCOS.

Steroidogenic alterations and adrenal androgen excess in PCOS

BACKGROUND

This cross-sectional study was undertaken to improve our understanding of the steroidogenic alterations leading to adrenal hyperandrogenism in polycystic ovarian syndrome (PCOS).

METHODS

Two-hundred and thirty-four women with clinical and biochemical features suggestive of PCOS underwent metabolic and hormonal evaluation. We used the androstenedione/DHEAS ratio as a surrogate for the level of ovarian 3betaHSD activity. We then selected the 90th percentile for the ratio in those with elevated DHEAS (>9 micromol/l) as the cut-off level beyond which excess DHEAS production will be minimized by excess ovarian 3betaHSD activity. This cut-off level was at a ratio of 1.5 and all PCOS women were then divided into two groups, the higher (>1.5) being the group with excess ovarian 3betaHSD activity. We hypothesized that women with a high ratio would be unlikely to have DHEAS excess due to the rapid conversion of DHEA to androstenedione. Those with a low ratio (concordant ovarian and adrenal steroidogenesis) could then either have high DHEAS or normal DHEAS, depending on whether CYP17 activity was higher or lower respectively.

RESULTS

Insulin resistance was found to be associated with decreased CYP17 activity while irregular cycles and neuroendocrine dysfunction were determined to be associated with higher ovarian 3betaHSD activity.

CONCLUSION

Adrenal androgen excess in PCOS seems to be related to insulin sensitivity as well as decreased activity of 3betaHSD, the latter being preferentially present in those women with regular cycles or without neuroendocrine dysfunction.

Molecular mechanisms of insulin resistance and associated diseases

Insulin resistance is a state in which higher than normal concentrations of insulin are required for normal response. The most common underlying cause is central obesity, although primary insulin resistance in normal-weight individuals is also possible. Excess abdominal adipose tissue has been shown to release increased amounts of free fatty acids which directly affect insulin signalling, diminish glucose uptake in muscle, drive exaggerated triglyceride synthesis and induce gluconeogenesis in the liver. Other factors presumed to play the role in insulin resistance are tumour necrosis factor alpha, adiponectin, leptin, IL-6 and some other adipokines. Hyperinsulinaemia which accompanies insulin resistance may be implicated in the development of many pathological states, such as hypertension and hyperandrogenaemia. Insulin resistance underlies metabolic syndrome and is further associated with polycystic ovary syndrome and lipodystrophies. When beta-cells fail to secrete the excess insulin needed, diabetes mellitus type 2 emerges, which is, besides coronary heart disease, the main complication of insulin resistance and associated diseases.

Ovarian steroids modulate neuroendocrine dysfunction in polycystic ovary syndrome

OBJECTIVE

Neuroendocrine dysfunction in polycystic ovary syndrome (PCOS) was addressed by studying the steroid hormone changes in women with PCOS with either high or normal LH levels leading to inferences regarding the primacy of elevated LH in the pathophysiology of PCOS.

METHODS

A cross-sectional study was designed in an academic clinical facility involving 234 women with PCOS. Patients were divided into two groups based on an LH/FSH ratio < or >1 and hormonal and metabolic studies were performed in both groups. Factors were determined by binomial logistic regression that predicted group membership of these women.

RESULTS

Higher follicular phase estradiol (E2) and androstenedione (A4) levels as well as greater insulin sensitivity were the only factors that predicted the presence of neuroendocrine dysfunction with elevated A4 being necessary for neuroendocrine dysfunction.

CONCLUSIONS

It was concluded that uncoupling of hypothalamic E2 inhibition by elevated ovarian A4 associated with E2 related sensitization of pituitary LH leads to neuroendocrine dysfunction in PCOS.

Irregular cycles and steroid hormones in polycystic ovary syndrome

BACKGROUND

This cross-sectional study was undertaken to evaluate the factors that relate to menstrual status (oligo-amenorrhoea versus eumenorrhoea) in polycystic ovary syndrome (PCOS).

METHODS

A total of 234 women with clinical and biochemical features suggestive of PCOS underwent metabolic and hormonal evaluation. A forward stepwise logistic regression model was created based on the results to determine variables related to ovulatory status.

RESULTS

Only follicular phase progesterone and estradiol (E(2)) were retained in the final model. This model correctly classified 80% of PCOS women by ovulatory status. Univariate analysis revealed no difference in progesterone between ovulatory groups but E(2) was higher in anovulatory groups. This suggested interaction between progesterone and E(2) and the single interaction variable (progesterone/E(2)) also classified 80% of women by ovulatory status correctly.

CONCLUSION

The results suggest that a low ratio of progesterone to E(2) is associated with menstrual irregularity and ovulatory status in PCOS.