N-acetyl-cysteine treatment for polycystic ovary syndrome

Nutritional and dietary aspects in polycystic ovary syndrome: insights into the biology of nutritional interventions

Polycystic Ovary Syndrome (PCOS) is a complex endocrine disorder, which affects 5-17% of reproductive age women and is often associated with obesity and metabolic impairment. Common treatment strategies are based on exercise, diet and nutrient supplementation since PCOS is often linked with obesity and metabolic impairment. Studies have recommended that nutrition is a key factor in the health maintenance of women with PCOS, however, little is known about the subject in the context of such a disease. This narrative review aims to identify dietary and nutritional aspects of PCOS and discuss the role of nutrients in management of polycystic ovary syndrome in view of clinical trials.

N-Acetylcysteine as an Adjuvant to Letrozole for Induction of Ovulation in Infertile Patients with Polycystic Ovary Syndrome

Background:

This study was aimed to evaluate the influence of oral N-acetylcysteine (NAC) application as an adjuvant to letrozole on induced ovulation outcomes in patients with polycystic ovary syndrome (PCOS).

Materials and Methods:

This was a placebo-controlled double-blind randomized clinical trial with 130 PCOS patients who were infertile. First, patients were randomly divided into two groups. Patients in Group 1 were administered letrozole 5 mg/d plus NAC 1.2 g/d and patients in Group 2 were administered letrozole plus placebo for 5 days starting at the 3^rd day of the menstruation period. On the 12^th day of the cycle, ultrasound evaluation was performed, and in whom at least one follicle with an 18–20 mm diameter was found, 10,000 unit human chorionic gonadotropin (hCG) was prescribed, and 36 h after hCG injection, timed intercourse was advised. On the 16^th day, after hCG injection, serum β-hCG level was evaluated.

Results:

The number of follicles >18 mm was significantly higher in the letrozole + NAC group (P = 0.007). The ovulation and pregnancy rates were also significantly higher in the letrozole + NAC group (P = 0.045). No adverse side effects and no cases of ovarian hyperstimulation syndrome were observed in NAC group.

Conclusion:

NAC is demonstrated to be a safe and well-tolerated adjuvant to letrozole and can increase the pregnancy rates in PCOS patients.

Infertility and the presence of insulin resistance are associated with increased oxidative stress in young, non-obese Turkish women with polycystic ovary syndrome

STUDY OBJECTIVE

To investigate the relationship between both insulin resistance and fertility and the oxidant/antioxidant system in young, non-obese patients diagnosed with polycystic ovary syndrome (PCOS).

DESIGN

Case-control study.

SETTING

Department of Obstetrics and Gynecology, Ege University, Izmir, Turkey.

PARTICIPANTS

PCOS patients without insulin resistance (IR-) (n = 33), PCOS patients with insulin resistance (IR+) (n = 27), and healthy controls (n = 30). Patients with PCOS and regular sexual intercourse were further divided into infertile (n = 14) and fertile (n = 15) groups.

MAIN OUTCOME MEASURES

The malondialdehyde (MDA) and thiol levels as well as the catalase (CAT) and superoxide dismutase (SOD) enzyme activities.

RESULTS

Both IR+ and IR- PCOS patients had higher MDA levels and lower thiol levels when compared to the controls (each P < .001). However, only IR- patients had significantly higher SOD (3700.81 ± 410.13 vs 2614.19 ± 611.80 U/g Hb; P < .001) and CAT (7565.06 ± 628.27 vs 6819.61 ± 539.2 U/g Hb; P < .001) activities when compared to the controls. Infertile PCOS patients had significantly higher MDA levels (347.5 ± 22.8 vs 278.6 ± 42.6 nmol/g Hb, P < .001) and lower thiol levels (498.5 ± 56.2 vs 568.5 ± 38.6 μmol/l, P = .001) when compared to fertile patients.

CONCLUSIONS

The results of this study demonstrated an imbalance in the oxidative-antioxidative system of PCOS patients. This imbalance was worse in IR+ and infertile PCOS patients.

N-acetylcysteine for polycystic ovary syndrome: a systematic review and meta-analysis of randomized controlled clinical trials

Objective. To review the benefits and harms of N-acetylcysteine (NAC) in women with polycystic ovary syndrome (PCOS). Method. Literature search was conducted using the bibliographic databases, MEDLINE (Ovid), CINAHL, EMBASE, Scopus, PsyInfo, and PROQUEST (from inception to September 2013) for the studies on women with PCOS receiving NAC. Results. Eight studies with a total of 910 women with PCOS were randomized to NAC or other treatments/placebo. There were high risk of selection, performance, and attrition bias in two studies and high risk of reporting bias in four studies. Women with NAC had higher odds of having a live birth, getting pregnant, and ovulation as compared to placebo. However, women with NAC were less likely to have pregnancy or ovulation as compared to metformin. There was no significant difference in rates of the miscarriage, menstrual regulation, acne, hirsutism, and adverse events, or change in body mass index, testosterone, and insulin levels with NAC as compared to placebo. Conclusions. NAC showed significant improvement in pregnancy and ovulation rate as compared to placebo. The findings need further confirmation in well-designed randomized controlled trials to examine clinical outcomes such as live birth rate in longer follow-up periods. Systematic review registration number is CRD42012001902.

Circulating markers of oxidative stress and polycystic ovary syndrome (PCOS): a systematic review and meta-analysis

BACKGROUND Oxidative stress might be associated with polycystic ovary syndrome (PCOS), but relatively small studies published to date do not permit reaching a definitive conclusion. We aimed at conducting a systematic review and meta-analysis of studies evaluating circulating markers of oxidative stress in patients with PCOS. METHODS We conducted a systematic review of studies reporting circulating markers of oxidative stress in women with PCOS and controls published up to June 2012, using Entrez PubMed and EMBASE online facilities. Meta-analysis calculated standardized mean differences (SMDs) and 95% confidence intervals (95CI). RESULTS From 1633 potential studies identified electronically, 68 studies, including 4933 PCOS patients and 3671 controls, were selected. For each of nine circulating markers of oxidative stress, an individual meta-analysis was conducted. Compared with control women, patients with PCOS presented higher circulating concentrations of homocysteine (23% increase, SMD 0.6, 95CI, 0.4-0.8), malondialdehyde (47% increase, SMD 1.9, 95CI 1.2-2.6) and asymmetric dimethylarginine (36% increase, SMD 1.1, 95CI 0.6-1.6), and increased superoxide dismutase activity (34% increase, SMD 1.0, 95CI 0.5-1.4) and decreased glutathione levels (50% decrease, SMD -3.7, 95CI -6.2 to -1.2) and paraoxonase-1 activity (32% decrease, SMD -0.9, 95CI -1.3 to -0.4). Similar results were found when restricting the analyses to studies in which patients and controls were matched for age and body mass index. CONCLUSIONS Circulating markers of oxidative stress are abnormal in women with PCOS independent of weight excess. This finding suggests that oxidative stress may participate in the pathophysiology of this common disorder.

Metformin and N-acetyl Cysteine in Polycystic Ovarian Syndrome–-A Comparative Study

Objective

To compare the effects of Metformin with N-acetyl cysteine in polycystic ovarian syndrome (PCOS).

Methods

A prospective, randomised controlled study was conducted in the Department of Obstetrics and Gynaecology in a Medical College and General Hospital. Total 115 cases of polycystic ovarian syndrome presenting with different complaints were selected for the study. Fifty nine cases were treated with Metformin (Group-M) and other 56 with N-acetyl cysteine (Group-N). Primary outcome measures are improvement in clinical features and biochemical profile, where as secondary outcome measures are improvement in hormonal profile and ultrasonographic findings. Statistical analysis was done by Z test and Chi square test.

Results

From each group, 50 patients were ultimately evaluated. There was significant improvement in some of the clinical features like weight gain, acne and hirsutism in group-N ( P < 0.05), but there was no significant change in other features like oligomenorrhea, amenorrhoea and infertility. The biochemical markers of insulin resistance like fasting insulin, fasting glucose/insulin ratio and HOMA-IR were significantly reduced in group-N. Hormone levels like serum LH, FSH, TT and LH/FSH ratio was significantly decreased in group-N, but FT, FT/TT ratio and SHBG were similar in both the groups. Ultrasonographic findings were similar in both the groups.

Conclusion

N-acetyl Cysteine had better improvement in clinical, biochemical and hormonal profile than Metformin in PCOS patients. It can be used as a substitute for insulin reducing medications in treatment of PCOS patients, considering its limited adverse effects.

Effect of N-acetyl-cysteine after ovarian drilling in clomiphene citrate-resistant PCOS women: a pilot study

The aim of this randomized double-blind placebo-controlled pilot study was to evaluate N-acetyl-cysteine (NAC) as an adjunctive therapy following unilateral laparoscopic ovarian drilling (LOD) for clomiphene citrate-resistant women with polycystic ovary syndrome (PCOS). A total of 60 patients with clomiphene citrate-resistant PCOS who underwent unilateral LOD were assigned randomly to receive either NAC 1.2 g/d (group A=30) or placebo (group B=30) for 5 days starting at day 3 of the cycle for 12 consecutive cycles. The primary outcome was pregnancy rate; secondary outcomes were ovulation rates, endometrial thickness and pregnancy outcome. Baseline clinical, endocrine, and sonographic characteristics were similar in the two groups. A significant increase in both ovulation and pregnancy rates was observed in the NAC group, compared with placebo [87% versus 67% (RR 1.3; 95% CI 1.2-2.7) and 77% versus 57% (RR 1.4; 95% CI 1.1-2.7), respectively, P<0.01]. Moreover, miscarriage rates were significantly lower and live birth rates were significantly higher in the NAC group [8.7% versus 23.5% (RR 0.4; 95% CI 0.1-3.7) and 67% versus 40% (RR 1.7; 95% CI 0.3-3.5), respectively, P<0.01]. In conclusion, NAC is a novel adjuvant therapy after unilateral LOD which might help improve overall reproductive outcome.

Prolonged treatment with N-acetylcysteine and L-arginine restores gonadal function in patients with polycystic ovary syndrome

Nitric oxide (NO) plays a wide spectrum of biological actions including a positive role in oocyte maturation and ovulation. Free radicals levels have been shown elevated in polycystic ovary syndrome (PCOS) and therefore would be responsible for quenching NO that, in turn, would play a role in determining oligo- or amenorrhea connoting PCOS. Eight patients with PCOS displaying oligo-amenorrhea from at least 1 yr underwent a combined treatment with N-acetylcysteine (NAC) (1200 mg/die) plus L-arginine (ARG) (1600 mg/die) for 6 months. Menstrual function, glucose and insulin levels, and, in turn, homeostasis model assessment (HOMA) index were monitored. Menstrual function was at some extent restored as indicated by the number of uterine bleedings under treatment (3.00, 0.18-5.83 vs 0.00, 0.00-0.83; p<0.02). Also, a well-defined biphasic pattern in the basal body temperature suggested ovulatory cycles. The HOMA index decreased under treatment (2.12, 1.46-4.42 vs 3.48, 1.62-5.95; p<0.05). In conclusion, this preliminary, open study suggests that prolonged treatment with NAC+ARG might restore gonadal function in PCOS. This effect seems associated to an improvement in insulin sensitivity.

Clomiphene citrate plus N-acetyl cysteine versus clomiphene citrate for augmenting ovulation in the management of unexplained infertility: a randomized double-blind controlled trial

OBJECTIVE

To compare clomiphene citrate with N-acetyl cysteine vs. clomiphene citrate alone for augmenting ovulation in management of unexplained infertility.

DESIGN

Prospective randomized double-blind controlled trial.

SETTING

Department of obstetrics and gynecology in a university medical faculty in Egypt.

PATIENT(S)

Four hundred four patients as a study group (clomiphene citrate plus N-acetyl cysteine group) and 400 patients as a control group (clomiphene citrate-alone group). All women had unexplained infertility.

INTERVENTION(S)

Patients in the study group were treated with clomiphene citrate (50-mg tablets) twice per day and with N-acetyl cysteine (1,200 mg/d orally) for 5 days starting on day 2 of the cycle. Patients in the control group were treated with clomiphene citrate with sugar powder.

MAIN OUTCOME MEASURE(S)

The primary outcomes were number and size of growing follicles, serum E(2), serum P, and endometrial thickness. The secondary outcome was the occurrence of pregnancy.

RESULT(S)

There were no statistically significant differences between the two groups in the number of follicles sized >18 mm, mean E(2) levels, serum P, or endometrial thickness. Pregnancy rate was comparable in both groups (22.2% vs. 27%). Miscarriage rate was comparable in both groups (6.7% in the study group vs. 7.4% in the control group).

CONCLUSION(S)

N-Acetyl cysteine is ineffective in inducing or augmenting ovulation in patients with unexplained infertility and cannot be recommended as an adjuvant to clomiphene citrate in such patients.