Ovarian volume and PCOS: a controversial issue

The effects of pro-, pre-, and synbiotics supplementation on polycystic ovary syndrome: an umbrella review of meta-analyses of randomized controlled trials

Background

Synbiotics, refer to a combination of probiotics and prebiotics in a form of synergism that beneficially affect the host's health by alternating the composition and/or function of the gut microbiota. Numerous meta-analyses of randomized clinical trials have proven that pro, pre-, and synbiotics supplementation has health outcomes in women with polycystic ovary syndrome (PCOS). However, the strength and quality of this evidence in aggregate have not yet been synthesized in great detail.

Methods

PubMed, Scopus, Web of Sciences, and Google Scholar were searched up to March 2023. We pooled the mean difference and its 95% confidence interval (CI) by applying a random-effects model.

Results

Overall, nine meta-analyses including a total of 12 trials were identified. The results of the present study indicated that probiotic supplementation significantly reduced the homeostatic model assessment for insulin resistance (HOMA-IR; WMD: -0.29, 95% CI: -0.57 to -0.02, p = 0.03, n = 4; moderate certainty) and fasting glucose concentration (FGC; WMD: -7.5 mg/dL, 95% CI: -13.60 to -0.51, p = 0.03; n = 4; low certainty). Moreover, synbiotic supplementation had beneficial effects on glycemic control, lipid profile, and hormonal parameters, but the certainty of the evidence was rated as low to very low. However, supplementation with pro-/synbiotics did not affect inflammation and oxidative stress in women with PCOS. Furthermore, waist/hip circumference, fasting glucose concentration, lipid profile, dehydroepiandrosterone sulfate, high-sensitivity C-reactive protein, and hirsutism score were significantly reduced after prebiotics supplementation with low certainty of evidence.

Conclusion

Although pro-, pre-, and synbiotics supplementation had beneficial effects on some PCOS-related outcomes, the certainty of the evidence was rated as low to very low. Therefore, further well-designed RCTs might help to confirm our findings in women with PCOS.

How to Choose the Optimal Starting Dose of Clomiphene Citrate (50 or 100 mg per Day) for a First Cycle of Ovulation Induction in Anovulatory PCOS Women?

RESEARCH QUESTION

Clomiphene citrate (CC) is one of the first-line treatments for ovulation induction in women with anovulatory polycystic ovary syndrome (PCOS). However, nearly 1 out of 2 women is resistant to 50 mg/day of CC. The objective of this study is to investigate the clinical, biological, and/or ultrasound factors that may predict the resistance to 50 mg/day of CC in the first cycle of treatment in women with anovulatory PCOS. This would make it possible to identify PCOS patients to whom the dose of 100 mg/day would be offered as of the first cycle.

DESIGN

A retrospective and monocentric study was conducted on 283 women with anovulatory PCOS who required the use of ovulation induction with CC (903 cycles).

RESULTS

During the first cycle of treatment, 104 patients (36.8%) were resistant to 50 mg/day of CC. Univariate regression analysis showed that patients who resisted 50 mg/day of CC had significantly higher BMI, waist circumference, serum levels of AMH, total testosterone, Δ4-androstenedione, 17-OHP, and insulin (p < 0.05), compared to patients ovulating with this dose. Serum levels of SHBG were significantly lower in patients resistant to 50 mg/day (p < 0.05). After multivariate analysis, only AMH and SHBG remained statistically significant (p = 0.01 and p = 0.001, respectively). However, areas under the ROC curves were weak (0.59 and 0.68, respectively).

CONCLUSION

AMH and SHBG are the only two parameters significantly associated with the risk of resistance to 50 mg/day of CC. However, no satisfactory thresholds have been established to predict resistance to 50 mg CC.

Is There Still a Place for Surgery in Patients with PCOS? A Review

OBJECTIVE

The surgical management of polycystic ovary syndrome (PCOS) represents an unclear option compared to medical therapy, and it is necessary to deepen the role of minimally invasive surgery, represented by laparoscopic ovarian drilling (LOD) and transvaginal hydrolaparoscopy (THL), for the treatment of PCOS in infertile women resistant to drug therapy and to establish its success in terms of ovulation and pregnancy rates.

METHODS

A search was performed in the main electronic databases (MEDLINE, EMBASE, Web of Science, PubMed, and the Cochrane Library) from 1994 to October 2022 in order to evaluate the role of surgery in patients with PCOS resistant to pharmacological treatment. Only original scientific articles in English were included.

RESULTS

Seventeen studies were analyzed in this review. In all analyzed studies, more than 50% of the population underwent spontaneous ovulation after surgical treatment without great differences between the two surgical techniques (LOD and THL). More than 40% of patients delivered, with a higher rate after LOD, although eight ectopic pregnancies and sixty-three miscarriages were reported. A lower risk of adhesion formation after THL has been reported. No clear data regarding the effect of surgery on the regularization of the menstrual cycle has been described. A reduction in LH and AMH serum levels as well as the LH/FSH ratio compared to preoperative levels for both surgical techniques has been described.

CONCLUSIONS

Despite the scarcity and heterogeneity of data, surgical therapy could be considered an effective and safe approach in the management of PCOS patients with resistance to pharmacological treatment who desire to become pregnant.

Differentiating Polycystic Ovary Syndrome from Adrenal Disorders

Although polycystic ovary syndrome (PCOS) is primarily considered a hyperandrogenic disorder in women characterized by hirsutism, menstrual irregularity, and polycystic ovarian morphology, an endocrinological investigation should be performed to rule out other hyperandrogenic disorders (e.g., virilizing tumors, non-classical congenital adrenal hyperplasia (NCAH), hyperprolactinemia, and Cushing’s syndrome) to make a certain diagnosis. PCOS and androgen excess disorders share clinical features such as findings due to hyperandrogenism, findings of metabolic syndrome, and menstrual abnormalities. The diagnosis of a woman with these symptoms is generally determined based on the patient’s history and rigorous clinical examination. Therefore, distinguishing PCOS from adrenal-originated androgen excess is an indispensable step in diagnosis. In addition to an appropriate medical history and physical examination, the measurement of relevant basal hormone levels and dynamic tests are required. A dexamethasone suppression test is used routinely to make a differential diagnosis between Cushing’s syndrome and PCOS. The most important parameter for differentiating PCOS from NCAH is the measurement of basal and ACTH-stimulated 17-OH progesterone (17-OHP) when required in the early follicular period. It should be kept in mind that rapidly progressive hyperandrogenic manifestations such as hirsutism may be due to an androgen-secreting adrenocortical carcinoma. This review discusses the pathophysiology of androgen excess of both adrenal and ovarian origins; outlines the conditions which lead to androgen excess; and aims to facilitate the differential diagnosis of PCOS from certain adrenal disorders.

Ovarian Drilling: Back to the Future

Polycystic ovary syndrome (PCOS) is the leading cause of anovulatory infertility. The complex metabolic dysregulation at the base of this syndrome often renders infertility management challenging. Many pharmacological strategies have been applied for the induction of ovulation with a non-negligible rate of severe complications such as ovarian hyperstimulation syndrome and multiple pregnancies. Ovarian drilling (OD) is currently being adopted as a second-line treatment, to be performed in case of medical therapy. Laparoscopic ovarian drilling (LOD), the contemporary version of ovarian wedge resection, is considered effective for gonadotropins in terms of live birth rates, but without the risks of iatrogenic complications in gonadotropin therapy. Its endocrinal effects are longer lasting and, after the accomplishment of this procedure, ovarian responsiveness to successive ovulation induction agents is enhanced. Traditional LOD, however, is burdened by the potential risks of iatrogenic adhesions and decreased ovarian reserve and, therefore, should only be considered in selected cases. To overcome these limits, novel tailored and mini-invasive approaches, which are still waiting for wide acceptance, have been introduced, although their role is still not well-clarified and none of them have provided enough evidence in terms of efficacy and safety.

The interplay between PCOS pathology and diet on gut microbiota in a mouse model

The gut microbiome has been implicated in polycystic ovary syndrome (PCOS) pathophysiology. PCOS is a disorder with reproductive, endocrine and metabolic irregularities, and several studies report that PCOS is associated with a decrease in microbial diversity and composition. Diet is an important regulator of the gut microbiome, as alterations in macronutrient composition impact the balance of gut microbial communities. This study investigated the interplay between macronutrient balance and PCOS on the gut microbiome of control and dihydrotestosterone (DHT)-induced PCOS-like mice exposed to diets that varied in protein (P), carbohydrate (C) and fat (F) content. The amount of dietary P, C and F consumed significantly altered alpha (α) and beta (β) diversity of the gut microbiota of control and PCOS-like mice. However, α-diversity between control and PCOS-like mice on the same diet did not differ significantly. In contrast, β-diversity was significantly altered by PCOS pathology. Further analysis identified an operational taxonomic unit (OTU) within Bacteroides (OTU3) with 99.2% similarity to Bacteroides acidifaciens, which is inversely associated with obesity, to be significantly decreased in PCOS-like mice. Additionally, this study investigated the role of the gut microbiome in the development of PCOS traits, whereby PCOS-like mice were transplanted with healthy fecal microbiota from control mice. Although the PCOS gut microbiome shifted toward that of control mice, PCOS traits were not ameliorated. Overall, these findings demonstrate that while diet exerts a stronger influence over gut microbiota diversity than PCOS pathology, overall gut microbiota composition is affected by PCOS pathology.

Association of Polycystic Ovary Syndrome Phenotypes With Adverse Pregnancy Outcomes After In-Vitro Fertilization/Intracytoplasmic Sperm Injection

OBJECTIVE

This study aims to evaluate the association between polycystic ovary syndrome (PCOS) phenotypes and adverse perinatal outcomes, comparing the characteristics, ovarian response, and assisted reproductive outcomes in patients with various PCOS phenotypes after in-vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI).

METHODS

This study comprised 6,732 patients who underwent the first cycle of IVF/ICSI treatment in our outpatient department from January 2017 to July 2018. Propensity score matching (PSM) was used in PCOS and non-PCOS groups to balance the influence of intergroup confounding factors. After the PSM procedure, 1,186 patients were included in the two groups, and the PCOS patients were further divided into four PCOS phenotype groups based on the Rotterdam criteria.

RESULTS

Patients with various PCOS phenotypes had similar rates of biochemical pregnancy, clinical pregnancy, and live birth (all P-values > 0.05). The overall incidence of adverse pregnancy outcomes (including ectopic pregnancy, miscarriage, preterm birth) was significantly higher in PCOS phenotype A and D groups than in the control group (44% and 46.4% vs. 28.7%, P = 0.027). The rates of hypertensive disorder of pregnancy (HDP) were significantly higher in PCOS phenotype A and C groups than in the control group (9.3% and 12.5% vs. 3.1%, P = 0.037). After adjustment for potential confounders, the differences in adverse pregnancy outcomes persisted (P = 0.025).

CONCLUSIONS

The overall incidence of adverse pregnancy outcomes is higher in women with PCOS phenotypes A and D than in women with non-PCOS.

Body Composition and Its Impact on the Hormonal Disturbances in Women with Polycystic Ovary Syndrome

We investigated the relationship between selected body composition (BC) parameters and included 55 women diagnosed with PCOS and 29 women in which PCOS was excluded. Hormone concentration and BC parameters were assessed during hospitalization. Women with PCOS had higher concentration of luteinizing hormones, total testosterone, androstenedione, and Anti-Müllerian hormones compared to women that were not diagnosed with PCOS. We did not observe any significant differences in the BC parameters between both groups as well as between four PCOS phenotype subgroups. Only in the group of women with PCOS was the concentration of sex hormone binding globulin and free testosterone correlated with all investigated BC parameters. Correspondence analysis did not confirm unambiguously associations between phenotypes of PCOS and the value of BC parameters, while logistic regression revealed that increased Anti-Müllerian hormone concentration and the value of body mass index could be useful parameters in differentiating women with PCOS and women with other disorders. The ROC analysis performed on the entire group of women also confirmed that the concentration of Anti-Müllerian hormones could be a powerful parameter to categorize women as suffering from PCOS.

Microbiome and PCOS: State-of-Art and Future Aspects

Polycystic ovary syndrome (PCOS) is a complex and heterogeneous endocrine disease. The hypothesis that alterations in the microbiome are involved in the genesis of PCOS has been postulated. Aim of this review is to summarize the available literature data about the relationship between microbiome and PCOS. A search on PubMed and Medline databases was performed from inception to November 20Most of evidence has focused on the connection of intestinal bacteria with sex hormones and insulin-resistance: while in the first case, a relationship with hyperandrogenism has been described, although it is still unclear, in the second one, chronic low-grade inflammation by activating the immune system, with increased production of proinflammatory cytokines which interfere with insulin receptor function, causing IR (Insulin Resistance)/hyperinsulinemia has been described, as well as the role of gastrointestinal hormones like Ghrelin and peptide YY (PYY), bile acids, interleukin-22 and Bacteroides vulgatus have been highlighted. The lower genital tract microbiome would be affected by changes in PCOS patients too. The therapeutic opportunities include probiotic, prebiotics and synbiotics, as well as fecal microbiota transplantation and the use of IL-22, to date only in animal models, as a possible future drug. Current evidence has shown the involvement of the gut microbiome in PCOS, seen how humanized mice receiving a fecal transplant from women with PCOS develop ovarian dysfunction, immune changes and insulin resistance and how it is capable of disrupting the secondary bile acid biosynthesis. A future therapeutic approach for PCOS may involve the human administration of IL-22 and bile acid glycodeoxycholic acid.

Correlation between anti-Mullerian hormone levels and antral follicle counts in polycystic ovary and metabolic syndromes

Anti-Mullerian hormone (AMH) is expressed by the granulosa cells of the pre-antral and small antral follicles in the ovary. AMH serum levels are significantly higher in women with polycystic ovary syndrome (PCOS) due to an increased antral follicle counts (AFC) and a higher production of AMH per antral follicle. This research is a cohort study design with a sample size of 60 female patients with (n = 30) and without PCOS (n = 30) in which the relationship between AMH serum level and other hormonal markers was explored. The following measurements were taken from the patients on the fifth day of the menstrual cycle: AMH, glucose, index of insulin resistance (HOMA/IR), body mass index (BMI), testosterone and cholesterol, lipoproteins, and triglycerides. The study proposes diagnostic criteria for PCOS. A twofold increase in the AMH serum levels was observed in the PCOS group when compared to the control group. The following incremental increases were seen in AMH serum levels: testosterone (18.4%); fasting blood glucose (18%); fasting insulin (83.86%); HOMA/IR (64.23%); mean cholesterol (30%); mean triglycerides (17%); and BMI (26.75%). All differences were considered significant at p ˂ 0.005. The results from the study concluded that monitoring the level of AMH allows for the prediction of ovarian hyperstimulation syndrome (OHSS) during ovulation induction and assisted reproductive technology cycles. Monitoring of anti-Mullerian hormone levels may provide an additional marker for determining treatment strategies when presented with additional risks associated with overweight, hirsutism, type II diabetes, infertility, and cardiovascular disease.

Gestational diabetes mellitus: Prevention, diagnosis and treatment. A fresh look to a busy corner

BACKGROUND

Gestational diabetes mellitus (GDM) is a common pregnancy complication characterized by hyperglycaemia with onset or first recognition during pregnancy. Risk factors include family history of diabetes, previous GDM, genetic predisposition for GDM/type 2 diabetes, insulin resistance conditions such as overweight, obesity and ethnicity. Women with GDM are at high risk for fetal macrosomia, small for gestational age, neonatal hypoglycaemia, operative delivery and caesarean delivery. The aim of this narrative review is to summarize the most recent findings of diagnosis and treatment of GDM in order to underline the importance to promote adequate prevention of this disease, especially through lifestyle interventions such as diet and physical activity.

METHODS

The research was conducted using the following electronic databases, MEDLINE, EMBASE, Web of Science, Scopus, ClinicalTrial.gov, OVID and Cochrane Library, including all published randomized and non-randomized studies as well as narrative and systematic reviews.

RESULTS

The lack of universally accepted criteria makes the definition of diagnosis and prognosis of this condition difficult. Early diagnosis and glucose blood level control may improve maternal and fetal short and long-term outcomes. Treatment strategies include nutritional interventions and exercise. Medical treatment can be necessary if these strategies are not effective. Moreover, novel non-pharmacologic agents such as myo-inositol seem to be effective and safe both in the prevention and the treatment of GDM.

CONCLUSIONS

It is important to promote adequate prevention of GDM. Further studies are needed in order to better define the most appropriate strategies for the clinical management of women affected by GDM.

2-D and 3-D ultrasonographic characteristics of the ovary in women with PCOS and multifollicular ovaries

In this prospective study, seventy-six patients (PCOS group; n = 36, multifollicular ovary group; n = 40) were evaluated by 2-D and 3-D ultrasonography. VOCAL programme, echogenicity, number of follicles and blood flow parameters were evaluated. The patients with PCOS had a higher total ovarian volume, mean stromal volume and stromal echogenicity (18.6 ± 4.75 to 10.2 ± 3.4 p < .01; 12.23 ± 2.53 to 5.02 ± 2.44 p = .02; score 1:28 to 10 p < .01, respectively). There was no statistically significant difference in terms of mean RI and PI values between the groups (p > .05). 3 D power Doppler parameters included VI, FI, and VFI values of the patients with PCOS were higher when compared to those of the patients with multifollicular ovary (3.82 ± 2.65 to 1.78 ± 1.2, p < .01; 50.76 ± 4.45 to 40.6 ± 3.64, p = .03; and 2.34 ± 1.02 to 1.12 ± 0.65, p = .02, respectively). Our results revealed that total ovarian volume, stromal volume and echogenicity; VFI, VI, and FI could be useful for differential diagnosis in women with PCOS and multifollicular ovaries.Impact statementWhat is already known on this subject? Ultrasonography is considered the new diagnostic tool for PCOS. Enlarged ovaries with multiple small follicles peripherally located around increased ovarian stroma with increased stromal echogenicity are the sonographic features of polycystic ovaries.What do the results of this study add? 3-D Doppler ultrasonography may be more specific in the determination of multifollicular and polycystic ovaries when compared to RI and PI in 2-D Doppler ultrasonography. Moreover, 3-D power Doppler ultrasonography could be useful for differential diagnosis in women with PCOS and multifollicular ovaries.What are the implications of these findings for clinical practice and/or further research? In clinical practice, the differentiation of multifollicular ovaries and polycystic ovaries (PCO) is difficult with the use of 2-D sonography alone. Therefore, 3-D ultrasound and power Doppler may also be used in addition to 2-D ultrasound for the differentiation of multifollicular ovaries and PCO.

Current and experimental drug therapy for the treatment of polycystic ovarian syndrome

INTRODUCTION

Polycystic ovary syndrome (PCOS) is an endocrine disorder that affects 8-13% of reproductive-age women. Irregular periods, hirsutism, or infertility are the most common clinical presentations of patients affected by PCOS. This syndrome is also linked to metabolic abnormalities such as type 2 diabetes, insulin resistance and obesity. The optimal therapeutic approach is still unknown.

AREAS COVERED

This narrative review offers an overview of the literature on current and experimental pharmacological options for treating PCOS and highlights ongoing clinical trials. Several electronic databases were searched and current research registers were analyzed to the present year. The papers selected for this review were critically analyzed, and all data available were summarized, organized, and explored to derive key information.

EXPERT OPINION

The main goal of PCOS treatment is to obtain a metabolic and hormonal balance. Optimal PCOS therapy should be direct to the reproductive abnormalities and the entire spectrum of endocrine and metabolic complications that appear to have a long-term negative impact on PCOS patient health, as in post-menopausal period. The discovery of new mechanisms in PCOS pathogenesis will offer the possibility of testing new drug classes.