Risks associated with premature ovarian failure in Han Chinese women

Factors influencing premature ovarian insufficiency: a systematic review and meta-analysis

BACKGROUND

Premature ovarian insufficiency (POI) has multiple contributing factors. This study aims to systematically evaluate these factors and their mechanisms, identify high-risk groups, support early intervention, and provide a basis for future research.

METHODS

Following the PRISMA guidelines, a search was conducted across 11 Chinese and English databases, including PubMed, Embase, and the Cochrane Library, up to January 2024. Observational studies on patients with ovarian insufficiency were included. A meta-analysis using Stata 14 was performed to calculate odds ratios (OR) and 95% confidence intervals (CIs) for factors influencing POI.

RESULTS

A total of 38 studies with 4,968 cases and 5,158 controls were included. The following factors were identified as risk factors for POI: abnormal menstruation (OR = 2.707, 95% CI: 1.705-4.299), hair dyeing (OR = 4.725, 95% CI: 2.914-7.660), chemical exposure (OR = 3.314, 95% CI: 2.283-4.811), Type A personality (OR = 6.106, 95% CI: 4.696-7.939), survival stress (OR = 3.292, 95% CI: 2.380-4.555), sleep deprivation (OR = 3.340, 95% CI: 2.363-4.721), bad mood (OR = 4.654, 95% CI: 2.783-7.781), smoking history (OR = 2.748, 95% CI: 1.928-3.917), family history of POI (OR = 4.338, 95% CI: 2.422-7.768), history of mumps (OR = 5.802, 95% CI: 3.460-9.730), number of abortions (OR = 2.292, 95% CI: 1.887-2.785), and history of pelvic surgery (OR = 4.836, 95% CI: 3.066-7.628). Physical exercise (OR = 0.270, 95% CI: 0.106-0.692) and vegetable intake (OR = 0.434, 95% CI: 0.337-0.560) were protective factors. Sensitivity analysis and publication bias tests confirmed robustness.

CONCLUSIONS

POI is related with abnormal menstruation, hair dyeing, chemical exposure, Type A personality, survival stress, sleep deprivation, bad mood, smoking history, family history of POI, history of mumps, number of abortions, and history of pelvic surgery. Physical exercise and vegetable intake may provide protection. These findings inform clinical strategies for early identification and management.

Impaired IL-27 signaling aggravates macrophage senescence and sensitizes premature ovarian insufficiency induction by high-fat diet

Premature ovarian insufficiency (POI) critically affects female reproductive health, with obesity being a significant and recognized risk factor. Interleukin-27 (IL-27), known for its role in immune modulation and inflammation, has garnered attention in metabolic syndrome research. Nonetheless, the role of these immunometabolic factors on the initiation of POI remains to be unraveled. Our investigation delves into the influence of impaired IL-27 signaling on POI induction, particularly under the challenge of a high-fat diet (HFD). We analyzed patients' serum profiles and established a correlation of increased serum triglycerides with decreased IL-27 levels in POI cases. Experiments on C57BL/6 mice lacking the IL-27 receptor alpha (Il27ra-/-) revealed that when subjected to HFD, these mice developed hallmark POI symptoms. This includes escalated lipid deposition in both liver and ovarian tissues, increased ovarian macrophages cellular aging, and diminished follicle count, all pointing to compromised ovarian function. These findings unveil a novel pathway wherein impaired IL-27 signaling potentiates the onset of POI in the presence of HFD. Understanding the intricate interplay between IL-27, metabolic alterations, and immune dysregulation sheds light on potential therapeutic avenues for managing POI, offering hope for improved reproductive health outcomes.

Treatment of ovarian damage induced by chemotherapeutic drugs in female rats with G-CSF and platelet-rich plasma(PRP): an immunohistochemical study correlation with novel marker INSL-3

OBJECTIVE

To assess the impacts of Platelet-Rich Plasma(PRP) and Granulocyte Colony-Stimulating Factor(G-CSF) on a rat model with induced ovarian follicular damage caused by cyclophosphamide(Cy).

MATERIALS AND METHODS

Forty-two Sprague-Dawley rats were randomly allocated into seven distinct groups as; Group 1(control): NaCl intraperitoneal (IP) injection was administered on days D1, D7, and D14. Group 2(Cy):Cy IP injection on D1 + NaCl IP injection on D7 and D14 were administered. Group 3(PRP): PRP IP injection on D1,D7 and D14 were administered. Group 4(Cy + PRP):Cy IP injection on D1 and PRP IP injection on D1, D7 and D14 were administered. Group 5(G-CSF): G-CSF IP injection on D1, D7 and D14 were administered. Group 6(Cy + G-CSF):Cy IP injection on D1+ G-CSF IP injection on D1, D7 and D14 were administered. Group 7(Cy + PRP + G-CSF):Cy IP injection on D1+ PRP IP injection on D1,D7 and D14+ G-CSF IP injection on D1,D7 and D14 were administered. Follicular number, histological scores of AMH and INSL3 stained follicles at different stages of follicular development, and serum Anti-Müllerian hormone(AMH) were evaluated.

RESULTS

The primary, secondary, and antral follicle intensity scores for AMH-positive staining were most prominent in Groups 3 and 5. There was no significant difference between groups 4, 6 and 7 compared to group 1 in terms of follicule counts and AMH staining. The intensity scores of AMH-positive staining follicles were notably reduced in group 2 compared to groups 4, 6, and 7, with a significant difference (p < .01). Among the groups, group 2 exhibited the least intense antral follicle staining for INSL3, displaying a significant difference(p < .01) compared to the remaining groups.

CONCLUSIONS

Autologous PRP and G-CSF might protect ovarian function in the face of ovarian damage caused by Cy-induced effects.

Premature menopausal women and risk of cardiovascular diseases in India: Longitudinal Aging Study in India, 2017-18

Women who have premature menopause are increasing in number and there is a wide regional diversity across the World, including India. However, in India, the relationship between age at menopause and cardiovascular diseases is still unclear. To fill this research gap, we undertook the present study using data from the Longitudinal Aging Study of India (Wave1, 2017-18). Bivariate logistic regression with three different models controlling for socio-economic and demographic characteristics, reproductive history, nutritional status, and co-morbidities of CVDs was used to show the relationship between CVDs and premature menopause. In all three models, the adjusted odds of having CVDs were higher for premature menopausal women than for those who had menopause between the ages of 45-50. There is a need to understand menopausal problems and their risk factors. The government should initiate a reproductive and sexual health awareness program at the macro level and provide treatment for the same.

Transcriptional control of human gametogenesis

The pathways of gametogenesis encompass elaborate cellular specialization accompanied by precise partitioning of the genome content in order to produce fully matured spermatozoa and oocytes. Transcription factors are an important class of molecules that function in gametogenesis to regulate intrinsic gene expression programs, play essential roles in specifying (or determining) germ cell fate and assist in guiding full maturation of germ cells and maintenance of their populations. Moreover, in order to reinforce or redirect cell fate in vitro, it is transcription factors that are most frequently induced, over-expressed or activated. Many reviews have focused on the molecular development and genetics of gametogenesis, in vivo and in vitro, in model organisms and in humans, including several recent comprehensive reviews: here, we focus specifically on the role of transcription factors. Recent advances in stem cell biology and multi-omic studies have enabled deeper investigation into the unique transcriptional mechanisms of human reproductive development. Moreover, as methods continually improve, in vitro differentiation of germ cells can provide the platform for robust gain- and loss-of-function genetic analyses. These analyses are delineating unique and shared human germ cell transcriptional network components that, together with somatic lineage specifiers and pluripotency transcription factors, function in transitions from pluripotent stem cells to gametes. This grand theme review offers additional insight into human infertility and reproductive disorders that are linked predominantly to defects in the transcription factor networks and thus may potentially contribute to the development of novel treatments for infertility.

miRNA-122-5p in POI ovarian-derived exosomes promotes granulosa cell apoptosis by regulating BCL9

This study is to explore the therapeutic effect and potential mechanisms of exosomal microRNAs (miRNAs) derived from the ovaries with primary ovarian insufficiency (POI). The POI mouse model was established by intraperitoneal injection of cyclophosphamide (CTX) and busulfan. The apoptosis of granulosa cells (GCs) incubated with exosomes extracted from ovarian tissues of control and POI groups was analyzed by flow cytometry. Then, high-throughput sequencing was performed to detect the difference of miRNAs profile in ovarian tissue-derived exosomes between the control and POI mice. The effect of differential miRNA on the apoptosis of CTX-induced ovarian GCs was analyzed by flow cytometry. The results showed that POI mouse model was successfully established. Exosomes extracted from ovarian of normal and POI group have different effects on apoptosis of GCs induced by CTX. miRNA-seq found that exosomal miR-122-5p in POI group increased significantly. miR-122-5p as the dominant miRNA targeting BCL9 was significantly upregulated in ovarian tissues of chemotherapy-induced POI group. Exosomes derived from the ovaries in the control group and miR-122-5p inhibitor group attenuated the apoptosis of primary cultured ovarian GCs. In conclusion, exosomal miR-122-5p promoted the apoptosis of ovarian GCs by targeting BCL9, suggested that miR-122-5p may function as a potential target to restore ovarian function.

Prepregnancy adherence to plant-based diet indices and exploratory dietary patterns in relation to fecundability

BACKGROUND

Modest associations have been reported between specific food groups or nutrients and fecundability [measured by time to pregnancy (TTP)]. Examining overall diets provides a more holistic approach towards understanding their associations with fecundability. It is not known whether plant-based diets indices or exploratory dietary patterns are associated with fecundability.

OBJECTIVES

We examine the associations between adherence to 1) plant-based diet indices; and 2) exploratory dietary patterns and fecundability among women planning pregnancy.

METHODS

Data were analyzed from the Singapore Preconception Study of Long-Term Maternal and Child Outcomes (S-PRESTO) study. Prepregnancy diet was assessed using a semi-quantitative FFQ from which the overall, healthful, and unhealthful plant-based diet indices (oPDI, hPDI, and uPDI, respectively) were calculated. Exploratory dietary patterns were derived using factor analysis based on 44 predefined food groups. Participants were categorized into quintiles based on their dietary pattern scores. TTP (expressed in menstrual cycles) was ascertained within a year from the prepregnancy dietary assessment. Discrete-time proportional hazard models, adjusted for confounders, were used to estimate fecundability ratios (FRs) and 95% CIs, with FR > 1 indicating a shorter TTP.

RESULTS

Among 805 women, 383 pregnancies were confirmed by ultrasound scans. Compared with women in the lowest quintile, those in the highest quintile of the uPDI had reduced fecundability (FR of Q5 compared with Q1, 0.65; 95% CI, 0.46-0.91; P trend, 0.009). Conversely, greater adherence to the hPDI was associated with increased fecundability (1.46; 95% CI, 1.02-2.07; P trend, 0.036). The oPDI was not associated with fecundability. Among the 3 exploratory dietary patterns, only greater adherence to the Fast Food and Sweetened Beverages (FFSB) pattern was associated with reduced fecundability (0.61; 95% CI, 0.40-0.91; P trend, 0.018).

CONCLUSIONS

Greater adherence to the uPDI or the FFSB dietary pattern was associated with reduced fecundability among Asian women. Greater adherence to the hPDI may be beneficial for fecundability, though this requires confirmation by future studies.

Epigallocatechin gallate and theaflavins independently alleviate cyclophosphamide-induced ovarian damage by inhibiting the overactivation of primordial follicles and follicular atresia

BACKGROUND

Cyclophosphamide (CTX), which has been used to treat common female cancers for several years, often causes ovarian damage, early menopause and infertility. However, strategies for the effective prevention and treatment of CTX-induced ovarian damage are still lacking. Epigallocatechin gallate (EGCG) and theaflavins (TFs), key molecules derived from green tea or black tea, have been shown to exert preventive effects on many ageing-related diseases.

PURPOSE

We aimed to explore the potential preventive and protective effects of EGCG and TFs on CTX-induced ovarian damage and compare the two compounds.

STUDY DESIGN

Six-week-old female mice were administered a low or high dose of EGCG or TFs. The low dose was equivalent to the average daily amount of tea consumed by a drinker.

METHODS

We determined the oestrous cycle and serum hormone levels to evaluate ovarian endocrine function, and we performed mating tests for reproductivity. We also assessed the follicle count and AMH level to evaluate ovarian reserve, and we performed Masson's trichrome and Sirius red staining to evaluate ovarian fibrosis. We conducted γ-H2AX and TUNEL analyses to evaluate DNA damage, and we also measured the relevant indicators of oxidative stress and follicular activation, including NRF2, HO-1, SOD2, AKT, mTOR and RPS6.

RESULTS

EGCG and TFs treatment independently improved the ovarian endocrine function and reproductivity of mice that were administered CTX. EGCG and TFs also increased the ovarian reserve of these animals. Furthermore, EGCG and TFs alleviated oxidation-induced damage to ovarian DNA in mice by activating the NRF2/HO-1 and SOD2 pathways and reducing the apoptosis of growing follicles. At the same time, EGCG and TFs reduced the overactivation of primordial follicles by inhibiting the AKT/mTOR/RPS6 pathway.

CONCLUSION

The present study showed that EGCG and TFs independently improved ovarian function in mice with CTX-induced ovarian damage, thereby providing useful information for designing a potential clinical strategy that will protect against chemotherapy-induced ovarian damage.

Premature menopause among women in India: Evidence from National Family Health Survey-IV

AIM

Women who experience premature menopause either due to biological or induced reasons have a longer duration of exposure to severe symptoms and adverse health consequences when compared to those who undergo menopause at later age. Despite the fact that premature menopause has a profound effect on the health of women, there has been limited study on this issue. Therefore, this study attempted to determine the prevalence and factors associated with premature menopause among 302 557 women aged 25-39 years in India.

METHODS

This study utilized secondary data from the fourth round of the National Family Health Survey-IV (NFHS-4), conducted during 2015-2016 in India. Descriptive statistics and multinomial logistic regression were used for statistical analyses of the data.

RESULTS

The results revealed that the prevalence of premature menopause in this sample of Indian women was 3.7%, out of which 2.1% of women had experienced natural premature menopause, whereas 1.7% had surgical premature menopause. The prevalence of premature menopause was highest in the southern region of India. Factors like age, education, wealth index, place of residence, smoking status, children ever born, age at first birth, use of hormonal contraception, sterilization, and body mass index were found to be associated with premature menopause in India.

CONCLUSION

A sizeable proportion of women in India are attaining menopause prematurely. Furthermore, the percentage and likelihood of experiencing premature menopause are relatively high among rural women, women with higher parity, early age at childbearing, and women who smoke.

Assessment of premature menopause on the sexual function and quality of life in women

INTRODUCTION

Premature Ovarian Insufficiency (POI) is characterized by ending menstruation in women under 40 years of age. It has a significant effect on women's sexuality and mental health and quality of life. This study aimed to evaluate the sexual function and quality of life of premature menopausal women.

METHODS

This study was a case-control study on 132 people (66 women with a diagnosis of POF and 66 women of reproductive age with normal ovarian function) who were matched in terms of the age, presenting to Women's Clinic in Jahrom in 2019. The WHOQOL-BREF questionnaire and the Female Sexual Function Index (FSFI) questionnaire were used to collect data. p < .05 was considered statistically significant.

RESULTS

The mean score of sexual function in premature menopausal women was 21.35 ± 4.82 and in non-menopausal women was 25.4 ± 6.61 (OR = 0.11, 95% CI = 0.04-0.28). All areas of sexual function; desires disorder (OR = 0.21 95% CI = 0.07-0.56), Arousal disorder(OR = 0.28, 95% CI = 0.08-0.93), orgasm disorder (OR = 0.36 95% CI = 0.16-0.80), lubrication disorder (OR = 0.21 95% CI= 0.05-0.78), satisfaction disorder (OR = 0.11, 95% CI = 0.04-0.28) and quality of life domains: physical health (OR = 0.4 95%CI = 0.06-0.3), mental health (OR = 0.28 95% CI = 0.06-0.1), environmental health (OR = 0.22 95%CI = 0.04-0.6) and social health (OR = 0.28 95%CI = 0.01-0.2) saw a decrease in the premature menopausal women group compared to the control group.

CONCLUSION

The results demonstrated that premature menopausal women are found to be weaker than the control group in all areas of sexual function and quality of life. Among the areas of sexual function, such as libido, arousal, satisfaction, and pain have the most impact on quality of life. Therefore, based on the results from improving sexual function, this issue can improve the quality of life.

Prevalence and Risk Factors of Premature Ovarian Insufficiency/Early Menopause

Premature ovarian insufficiency (POI) and early menopause, defined as loss of ovarian activity prior to 40 years or menopause between the ages of 40 and 45 years, respectively, is associated with significant adverse health impacts. Recent data indicate that the prevalence of POI and early menopause is greater than was previously thought, affecting more than 10% of women. Biopsychosocial risk factors including genetic, autoimmune, reproductive, lifestyle, early-life, social/environmental, and iatrogenic have been associated with POI/early menopause or earlier age at menopause. However, establishing a causal role and the underlying mechanisms remains elusive. Understanding and clarification of these risk factors will facilitate prevention and risk minimization strategies to optimize women's health.

Mapping premature ovarian insufficiency and potential environmental factors: A tool for triggering in-depth research of the problem in Slovenia

Aiming at triggering in-depth research of the problem of Premature Ovarian Insufficiency (POI) in Slovenia, we assessed the regional differences in POI incidence emphasising the relationship with social and physical environmental factors at the population level using a mapping approach. The differences in POI incidence between regions were tested by goodness-of-fit chi-square test, while Pearson correlation coefficient was used to assess the ecological relationship between POI incidence and selected environmental indicators. Significant indicators were mapped. The results showed highly significant interregional differences in POI incidence (p<0.001). Statistically significant ecological relationships were observed between POI incidence and prevalence of active smoking (p=0.001), passive smoking (p=0.017) and consumption of vitamins (p=0.008). The results could be used in diminishing interregional differences in POI. It was concluded that mapping is an effective tool in public health research, especially in triggering new activities.

Impact of hemostatic methods on ovarian reserve and fertility in laparoscopic ovarian cystectomy

Impact of hemostatic methods, electrocoagulation versus suture, on ovarian reserve and fertility in laparoscopic ovarian cystectomy was investigated. Eighty patients with bilateral ovarian cysts who underwent laparoscopic ovarian cystectomy were randomly divided into 2 groups based on the hemostatic methods: 40 in suture group and another 40 in electrocoagulation group. Blood samples were drawn from all patients at roughly three time points: Before the surgery, 1 month and 6 months after the surgery. Radioimmunoassay was performed to measure the serum levels of follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2) and anti-Mullerian hormone (AMH). Moreover, the vaginal ultrasound examination was performed to obtain the ovarian size, peak systolic velocity (PSV) of ovarian stromal blood flow, and antral follicle count (AFC). In terms of postoperative ovarian reserve, the levels of E2 and AMH slightly decreased while the FSH level slightly increased in the suture group at both 1 and 6 months after surgery. In the electrocoagulation group, however, the levels of E2 and AMH decreased significantly while the FSH level increased significantly at 1 month after surgery. Six months after surgery, these levels all returned slightly showing some recovery of ovarian reserve. In comparison between the suture group and the electrocoagulation group, the differences in levels of E2, FSH and AMH were all statistically significant at both 1 and 6 months after surgery (P<0.05). Six months after surgery, the differences in AFC and PSV between the suture group and the electrocoagulation group were statistically significant (P<0.05). In laparoscopic ovarian cystectomy, hemostatic electrocoagulation had a more negative impact on ovarian reserve than hemostatic suture. The use of electrocoagulation for hemostasis should be minimized during the operation, and the suture method should be adopted for hemostasis and shaping of the ovarian wound.

Research on Establishment of Abnormal Phlegmatic Syndrome with Premature Ovarian Failure Rat Model and Effects of Balgham Munziq Treatment

This study aimed to establish and explore the biological basis of abnormal phlegmatic syndrome with premature ovarian failure (POF) model in rats based on the Uighur medicine (UM) in the first place and investigate the effects of unique herbal medicine, Balgham Munziq (BMq). Mature female Wistar rats were fed with spinach and coriander in cold and humid condition for approximately 20 weeks until abnormal phlegmatic syndrome (APS) model was established. When APS model was confirmed by Uighur medical experts, APS with POF disease rats were subdivided into APS with POF disease model group and APS with POF disease treated with BMq group; the rest of them were subdivided into APS model group and APS treated with BMq group. The results show that biological characteristics of animals in the course of modeling period were in accordance with clinical features of abnormal phlegmatic syndrome (APS) in Uighur medicine. Herbal medicine BMq not only reverted reproductive hormone levels disorders but also improved the function of hypothalamic-pituitary-ovarian axis and regulated secretion of monoamine neurotransmitters. APS is most likely to cause pathological changes of hypothalamic-pituitary-ovarian axis and lead to the occurrence of POF and BMq is effective in the treatment of APS with POF disease.

Dietary Protein Intake and Early Menopause in the Nurses' Health Study II

Early menopause, which is the cessation of ovarian function before age 45 years, affects 5%-10% of Western women and is associated with an increased risk of adverse health outcomes. Literature suggests that high levels of vegetable protein intake may prolong female reproductive function. We evaluated the association of long-term intake of vegetable protein, animal protein, and specific protein-rich foods with incidence of early natural menopause in the Nurses' Health Study II cohort. Women included in analyses (n = 85,682) were premenopausal at baseline (1991) and followed until 2011 for onset of natural menopause. Protein intake was assessed via food frequency questionnaire. In Cox proportional hazard models that were adjusted for age, smoking, body mass index, and other factors, women in the highest quintile of cumulatively averaged vegetable protein intake (median, 6.5% of calories) had a significant 16% lower risk of early menopause compared with women in the lowest quintile (3.9% of calories; 95% confidence interval: 0.73, 0.98; P for trend = 0.02). Intake of specific foods, including pasta, dark bread, and cold cereal, was also associated with lower risk (P < 0.05). Conversely, animal protein intake was unrelated to risk. High consumption of vegetable protein, equivalent to 3-4 servings per day of protein-rich foods, is associated with lower incidence of early menopause in US women.

Early menopause: A hazard to a woman's health

Early menopause or premature ovarian insufficiency (POI) is a common cause of infertility in women and affects about one per cent of young women. This disorder has significant psychological sequelae and major health implications. Its relevance has increased in recent years due to the fact that age of motherhood is being delayed in developed countries, with the risk of having either primary ovarian insufficiency or less possibilities of pregnancy. The main characteristics are absence of ovulation, amenorrhoea and high levels of serum gonadothropins (hypergonadotropic hypogonadism). Although the aetiology remains uncertain in most cases, several rare specific causes have been elucidated. Potential causes for POI are iatrogenic (ovarian surgery, radiotherapy or chemotherapy), environmental factors, viral infections, metabolic and autoinmune diseases, and genetic alterations. Because of the association with other autoimmune diseases, close follow up is recommended in patients with POI. The traditional indicators to evaluate ovarian ageing are age, serum hormonal levels, anti-Mullerian hormone, antral follicle count, and ultrasonography of ovaries. Hormone replacement therapy remains the mainstay of treatment, and the best chance of achieving a pregnancy is through oocyte donation. This article aims to present an overview of potential causes, clinical manifestations, and treatment options of POI.

Premature ovarian insufficiency: the context of long-term effects

PURPOSE

Premature ovarian insufficiency (POI) is defined as the cessation of the ovarian function before the age of 40 years. POI aetiology may be related to iatrogenic or endogenous factors and in many cases remains unclear. The aim of this review was to characterize the long-term consequences of POI.

METHODS

The available literature regarding the long-term consequences of POI from MEDLINE has been reviewed.

RESULTS

Lack of ovarian steroids synthesis has serious consequences for women's health. The short-term effects are similar to spontaneous menopause and refer mainly to the climacteric syndrome. In a longer perspective, POI affects a variety of aspects. It obviously and drastically reduces the chances for spontaneous pregnancies. Oestrogen loss leads also to urogenital atrophy. The most common urogenital symptoms include vaginal dryness, vaginal irritation and itching. The urogenital atrophy and hypoestrogenism interferes also with sexual functioning. Patients with POI are threatened by a decrease in bone mineral density (BMD). POI women also experience psychological distress and some studies have shown an increased risk of neurodegenerating diseases. Overall, POI women have a shortened life expectancy, mainly due to cardiovascular disease. Some studies have reported a reduced risk of breast cancer in this group of patients.

CONCLUSIONS

In conclusion there are several well-characterized health risks in POI women. With every patient, an individualized approach is required to properly recognize and prevent these risks.

Akt2/ZEB2 may be a biomarker for exfoliant cells in ascitic fluid in advanced grades of serous ovarian carcinoma

Ovarian cancers present a mild clinical course when diagnosed early but an aggressive pathway when diagnosed in the peri- and postmenopausal periods. However, the predictability of tumor progression is stochastic and is difficult to predict. In the present study, we hypothesized to examine the key pathways that are dysregulated to promote epithelial-mesenchymal transition in serous ovarian carcinoma. Examination of these steps would help to identify ascitic fluid with cells poised for metastasis or otherwise. We focused on examining the Akt2 expression, mainly because of its report as being overamplified in the aggressive variants of ovarian cancer, as well as TGFbeta-sensitivity of Akt2 that forms the key basis for metastasis initiation of most kinds of carcinoma. We obtained primary ovarian carcinoma samples as well as ascitic fluid and distantly metastatic ovarian carcinoma to examine the expression of Akt2. The results of the study demonstrated that in malignant exfoliated ovarian cancer cells, Smad4 expression was tremendously increased in the nuclei, suggesting nuclear translocation of Smad, which thereafter may have activated ZEB2, and thereafter genomically affected the expression of E-cadherin, myosin II, and vimentin, key components for initiating and sustaining metastasis. All of these may have been stimulated by increased cellular expression of Akt2 in metastatic variants of the serous ovarian carcinoma. The reliance on Akt2 and TGF beta signaling may also potentiate the case for Akt inhibitors or small molecule inhibitors of TGFbeta signaling like doxycycline as adjunct chemotherapy in serous ovarian carcinoma, especially the metastatic variants.