Metformin in normal-weight hirsute women with polycystic ovary syndrome with normal insulin sensitivity

Efficacy and safety of dietary polyphenol administration as assessed by hormonal, glycolipid metabolism, inflammation and oxidative stress parameters in patients with PCOS: a meta-analysis and systematic review

BACKGROUND

The current knowledge about the efficacy and safety of dietary polyphenol administration in patients with polycystic ovarian syndrome (PCOS) is divergent.

OBJECTIVE

To evaluate the pooled efficacy and safety of dietary polyphenol administration in the treatment of patients with PCOS.

METHODS

The pubmed, Embase, Scopus, Cochrane Library, and Web of Science databases were searched for randomized controlled trials (RCTs) of dietary polyphenol administration for the treatment of PCOS. English-language RCTs involving adults with PCOS were thoroughly searched in electronic databases from the time of their establishment to May 2024. Random-effects models were used because heterogeneity was derived from differences in intervention materials and study duration, among other confounding factors. The effect sizes of the outcomes in the pooled analysis are expressed as weighted mean differences (WMDs) and 95% confidence intervals (CIs).

RESULTS

A total of 15 RCTs involving 934 patients were finally included. Compared with control treatments, dietary polyphenol administration significantly reduced luteinizing hormone (LH) (WMD: -0.85, 95% CI [-1.32 to -0.38], p = 0.00), and prolactin levels (WMD: -3.73, 95% CI [-6.73 to -0.74], p = 0.01). Dietary polyphenol administration significantly reduced insulin levels (WMD: -0.85, 95% CI [-1.32 to -0.38], p = 0.00). Regarding lipid metabolism, dietary polyphenol administration only reduced triglyceride levels (WMD: -8.96, 95% CI [-16.44 to -1.49], p = 0.02). Malondialdehyde (MDA) (WMD: -0.65, 95% CI [-0.68 to -0.62], p = 0.00), tumor necrosis factor (TNF-α) (WMD: -1.39, 95% CI [-2.41 to -0.37], p = 0.01) concentrations were significantly reduced by dietary polyphenol administration. None of the interventions significantly affected weight, body mass index (BMI), waist circumference (WC), homeostatic model-insulin resistance (HOMA-IR), fasting blood sugar (FBS), glycated hemoglobin (HBA1c), follicle-stimulating hormone (FSH), testosterone (T), dehydroepiandrosterone (DHEA), estradiol (E2), anti-Müllerian hormone (AMH), quantitative insulin-sensitivity check index (QUICKI), sex hormone-binding globulin (SHBG), total antioxidant capacity (TAC), C-peptide, C-reactive protein (CRP), high-density lipoprotein (HDL), low-density lipoprotein (LDL), cholesterol, cholesterol/HDL, acne score, thyroid-stimulating hormone (TSH), aspartate aminotransferase (AST), alanine aminotransferase (ALT) or alkaline phosphatase (ALP).

CONCLUSION

Dietary polyphenol administration was efficacious in patients with PCOS in our study. This review might provide new insight into the treatment of patients with PCOS and the potential of daily polyphenol supplementation in patients with PCOS. Nevertheless, these results must be interpreted carefully as a result of the heterogeneity and risk of bias among the studies and we expect that more high-quality RCTs evaluating the efficacy and safety of dietary polyphenol adnimistration in patients with PCOS will be conducted in the future.

SYSTEMATIC REVIEW REGISTRATION

CRD42024498494.

Efficacy and safety of cangfu daotan decoction as an adjuvant treatment of Diane-35 for polycystic ovary syndrome: A systematic review and meta-analysis

Objective

Cangfu Daotan decoction is a classic traditional Chinese medicine formula that has been found to be beneficial for treating polycystic ovarian syndrome (PCOS) in animal models. This systematic review aimed to assess the efficacy and safety of Cangfu Daotan decoction as an adjuvant treatment to Diane-35 for PCOS in humans.

Methods

Seven electronic databases were searched up to June 22, 2024, to identify randomized controlled trials (RCTs) that evaluated Cangfu Daotan decoction combined with Diane-35 versus Diane-35 alone for the treatment of PCOS. The effects of individual RCTs were combined via meta-analysis and were measured as relative risks (RRs) or weighted mean differences (WMDs).

Results

Twenty-five RCTs with a moderate to high risk of bias were included, involving 1845 patients with PCOS. Meta-analyses indicated that compared with Diane-35 alone, the combination of Diane-35 and Cangfu Daotan decoction significantly improved the response rate (RR 1.19, 95 % confidence interval [CI] 1.14 to 1.24), pregnancy rate (RR 1.57, 95 % CI 1.18 to 2.09), ovulation rate (RR 1.22, 95 % CI 1.11 to 1.35), and ovarian volume (WMD -1.43 cm3, 95 % CI -2.46 to -0.39). Cangfu Daotan decoction also significantly reduced the luteinizing hormone (LH) level, LH:FSH ratio, testosterone level, prolactin level, body mass index (BMI) and hirsutism and acne scores but had no significant effect on the follicle-stimulating hormone (FSH) level. All adverse events were mild and not related to Cangfu Daotan decoction treatment.

Conclusions

The findings suggest that Cangfu Daotan decoction, as an adjuvant therapy to Diane-35 for the treatment of PCOS, can reduce multiple sex hormone levels and BMI, relieve hyperandrogenism signs, and ultimately improve pregnancy outcomes, with good safety. The effect of Cangfu Daotan decoction on FSH remains uncertain. Due to limitations of risk of bias and heterogeneity, the quality of evidence was rated as moderate to very low.

Comprehensive Management of Polycystic Ovary Syndrome: Effect of Pharmacotherapy, Lifestyle Modification, and Enhanced Adherence Counseling

Introduction Polycystic ovary syndrome (PCOS) is a common endocrine disorder in women of childbearing age in India, which often presents as menstrual irregularities, infertility, acanthosis nigricans, etc. Metabolic disturbances associated with PCOS predispose patients to cardiovascular diseases, which may be avoided by effective management. The aim of the current study was to evaluate the role of lifestyle modification (LSM) and metformin in PCOS management. Methods This is a retrospective cohort study conducted among 130 PCOS patients who attended the outpatient department of the tertiary care hospital in central India from October 2019 to March 2020. The study describes the effect of a combined package of LSM (physical exercise and dietary changes) and metformin on anthropometric, clinical, and biochemical parameters at three and six months. Results Out of the total 130 women, 12 were lost to follow-up and were omitted from further analysis. At six months of the treatment package (LSM, metformin, and enhanced adherence counseling (EAC)), a significant decrease was seen in body mass index, blood sugar, follicle-stimulating hormone, luteinizing hormone, and insulin. Following the intervention, the menstruation cycle became regular in 91% of the women while volume, theca, and appearance of polycystic ovaries on ultrasound decreased in 86% of women. Insulin resistance (IR) and hyperinsulinemia are the major causes of pathophysiological changes associated with PCOS. Metformin along with LSM primarily acts by decreasing IR, while EAC ensures treatment compliance. Conclusion Metformin along with LSM in the form of calories restricted, high-protein diet, and physical activity reduce IR and hyperandrogenaemia, resulting in improved anthropometric, glycemic indices, hormonal profiles, and features of hyperandrogenaemia. The combined therapy is beneficial to 85-90% of women with PCOS.

DPP4 INHIBITOR SITAGLIPTIN AS A POTENTIAL TREATMENT OPTION IN METFORMIN-INTOLERANT OBESE WOMEN WITH POLYCYSTIC OVARY SYNDROME: A PILOT RANDOMIZED STUDY

OBJECTIVE

Metformin has an established role in the management of polycystic ovary syndrome (PCOS). Some patients cannot tolerate it due to associated gastrointestinal adverse events. The present study evaluated the dipeptidyl peptidase 4 inhibitor sitagliptin as a potential treatment option in metformin-intolerant PCOS.

METHODS

We conducted a 12-week, prospective, randomized, open-label study with 30 obese metformin-intolerant women with PCOS (age 35.0 ± 7.2 years; body mass index, 36.9 ± 5.5 kg/m²). After metformin withdrawal, they were randomized to lifestyle intervention and sitagliptin 100 mg daily (SITA) or lifestyle intervention alone as controls (CON). All participants underwent anthropometric and endocrine measurements and oral glucose tolerance testing. Model-derived indexes of insulin resistance and beta-cell function were calculated.

RESULTS

SITA improved beta-cell function as assessed by the homeostasis model assessment for beta-cell function index (HOMA-B) of 45.9 ± 35.8 ( P = .001), modified beta-cell function index (MBCI) of 7.9 ± 7 ( P = .002), and quantitative insulin-sensitivity check index (QUICKI) of -0.03 ± 0.03 ( P = .002). By contrast, beta-cell function decreased in CON. The between-group differences were significant for HOMA-B ( P = 0.001), MBCI ( P = .010), and QUICKI ( P = .025). The conversion rate to impaired glucose homeostasis was prevented in SITA: 3 of 15 subjects had impaired glucose tolerance (IGT) before and after the study. In CON, none had type 2 diabetes (T2D), and 4 had IGT at the beginning. After 12 weeks, IGT was observed in 2 and T2D in 3 subjects.

CONCLUSION

SITA improved beta-cell function and prevented a conversion to IGT and T2D in metformin-intolerant obese PCOS patients.

ABBREVIATIONS

BMI = body mass index; DPP-4 = dipeptidyl peptidase-4; DXA = dual energy X-ray absorptiometry; GIP = glucose-dependent insulinotropic peptide; GLP-1 = glucagon-like peptide-1; HOMA-B = homeostasis model assessment for beta-cell function; HOMA-IR = homeostasis model assessment of insulin resistance; IAI = insulin action index; IGT = impaired glucose tolerance; IR = insulin resistance; MBCI = modified beta-cell function index; OGTT = oral glucose tolerance test; QUICKI = quantitative insulin sensitivity check index; PCOS = polycystic ovary syndrome; SHBG = sex hormone-binding globulin; T2D = type 2 diabetes.

Clinical outcome of various metformin treatments for women with polycystic ovary syndrome

Aim

Polycystic ovary syndrome (PCOS) is an ovulatory disorder and insulin resistance and diabetes are involved in its pathophysiology. Metformin, an anti-diabetic agent, has been reported to be useful to induce ovulation.

Methods

Metformin treatment was classified into four types: (1) clomiphene-metformin combination treatment for clomiphene-resistant patients; (2) clomiphene-metformin combination for clomiphene-sensitive patients; (3) clomiphene-metformin combination for naïve patients; and (4) metformin monotherapy. The patients underwent physical, endocrinological, and clinical examinations for their ovulation rates, pregnancy rates, and follicular development.

Results

The ovulation rates, pregnancy rates, and single follicular development were not significantly different among the clomiphene-metformin combination treatment groups. In the Body Mass Index (BMI) subanalysis, the pregnancy rate was higher in the BMI≥30 kg/m2 group than in the other three groups with a BMI of ≤30 kg/m2 in both cycles and cases. The ovulation rates and pregnancy rates were significantly higher in the group with a fasting insulin of ≥15 μU/mL than in the groups with a fasting insulin of <15 μU/mL in both cycles and cases.

Conclusion

Clomiphene-metformin combination treatment appears to be useful, at least for clomiphene-resistant patients, and a BMI of >30 kg/m2 and a fasting insulin of ≥15 μU/mL appear to be predictors of a good result with this treatment.

Voluntary Exercise Improves Estrous Cyclicity in Prenatally Androgenized Female Mice Despite Programming Decreased Voluntary Exercise: Implications for Polycystic Ovary Syndrome (PCOS)

Prenatal androgen (PNA) exposure in mice produces a phenotype resembling lean polycystic ovary syndrome. We studied effects of voluntary exercise on metabolic and reproductive parameters in PNA vs vehicle (VEH)-treated mice. Mice (8 wk of age) were housed individually and estrous cycles monitored. At 10 weeks of age, mice were divided into groups (PNA, PNA-run, VEH, VEH-run, n = 8-9/group); those in the running groups received wheels allowing voluntary running. Unexpectedly, PNA mice ran less distance than VEH mice; ovariectomy eliminated this difference. In ovary-intact mice, there was no difference in glucose tolerance, lower limb muscle fiber types, weight, or body composition among groups after 16 weeks of running, although some mitochondrial proteins were mildly up-regulated by exercise in PNA mice. Before running, estrous cycles in PNA mice were disrupted with most days in diestrus. There was no change in cycles during weeks 1-6 of running (10-15 wk of age). In contrast, from weeks 11 to 16 of running, cycles in PNA mice improved with more days in proestrus and estrus and fewer in diestrus. PNA programs reduced voluntary exercise, perhaps mediated in part by ovarian secretions. Exercise without weight loss improved estrous cycles, which if translated could be important for fertility in and counseling of lean women with polycystic ovary syndrome.

Insulin resistance in nonobese Japanese women with polycystic ovary syndrome is associated with poorer glucose tolerance, delayed insulin secretion, and enhanced insulin response

Purpose

To determine the prevalence of insulin resistance (IR) and impaired glucose tolerance (IGT) in PCOS patients, the optimal screening method, and to compare our findings between nonobese and obese Japanese women with PCOS.

Methods

Ninety-eight PCOS patients were included in this research from 2006 to 2013. Glucose tolerance test (OGTT) was performed. Serum glucose and insulin concentration were assayed before and 30, 60, and 120 min after taking 75 g of glucose.

Results

All examined metabolic parameters were significantly favorable in the nonobese subjects, below 25 kg/m². HOMA-IR, fasting insulin, glucose₁₂₀, and insulin₁₂₀ showed strong correlations with BMI. A total of 1.4 % of nonobese women had IR based on fasting insulin or HOMA-IR. However, 15.5 % (11/71) of nonobese women had IR as determined by a continuous increase of serum insulin level in OGTT. In comparison, the prevalence of IR among the obese women ranged from 41 to 59 %. AUC_glucose, glucose₆₀, glucose₁₂₀, and insulin₁₂₀ in nonobese women with a continuous insulin increase were higher than those without such a continuous increase.

Conclusions

All examined metabolic parameters were significantly correlated with BMI. As the presence of a continuous increase of insulin level reflects to some degree poorer glucose tolerance, delayed insulin secretion, and enhanced insulin response compared with non-continuous insulin increase, OGTT might not been excluded to determine IR and IGT for nonobese women with PCOS.

Plasma adiponectin levels in women with polycystic ovary syndrome: impact of metformin treatment in a case-control study

OBJECTIVE

An interaction between adiponectin, steroid synthesis or action and measures of insulin resistance (IR) have been reported in the pathogenesis of polycystic ovary syndrome (PCOS). The present study was done to determine plasma adiponectin concentration (PAC) in women with and without PCOS and to assess its correlation to the hormonal and metabolic parameters including measures of IR. The effect of Metformin for 6 months in PCOS was also evaluated.

PATIENTS

In total, 72 selected women were classified as follows: 17 obese (body mass index (BMI))>25 kg/m(2) with PCOS; 19 normal weight (BMI) 18-22.9 kg/m(2) with PCOS; 17 obese (BMI)>25 kg/m(2) without PCOS and 19 normal weight (BMI) 18-22.9 kg/m(2) without PCOS.

INTERVENTIONS

Blood samples were collected from all women with PCOS between 0800 and 1100 h, after an overnight fast.

MAIN OUTCOME MEASURES

Serum level of LH, FSH, TSH, total T4, testerosterone, 17-α-hydroxyprogesterone (17OHP), DHEAS, insulin, adiponectin and glucose. Measures of IR included fasting serum insulin (FSI), glucose-to-insulin ratio, and homeostasis model assessment (HOMA).

RESULT AND CONCLUSION

Waist-hip ratio (WHR), insulin, and HOMA index were significantly higher in the lower adiponectin group than in the higher adiponectin group. By using stepwise multiple regression analysis, in model 1 (including BMI, FSI, fasting plasma glucose (FPG) with other variables such serum as testerosterone and DHEAS), the weight and contributions from other variables, namely FSI and FPG were significant independent determinants of fasting PAC (adjusted r(2)=0.66); and in model 2 (including BMI, HOMA, FPG only as an index of IR with other variables such as serum testerosterone and DHEAS), BMI, and HOMA were significant independent determinants of fasting PAC (adjusted r(2)=0.59). FPG, HOMA index and FSI were significantly lower after Metformin treatment in both obese and non-obese PCOS while adiponectin levels increased significantly.

Metformin versus lifestyle changes in treating women with polycystic ovary syndrome

OBJECTIVE

To compare the efficacy of metformin with that of lifestyle changes in patients with polycystic ovary syndrome (PCOS).

DESIGN

Prospective, randomized clinical trial of 40 women with PCOS to analyze the effects of metformin and lifestyle intervention treatments on menstrual pattern and hormone and metabolic profile. The duration of treatment was 6 months. Statistical analysis was done using Student's t-test.

RESULTS

Fifteen women in the metformin group and 12 in the lifestyle changes group completed the study. The menstrual pattern improved by ~67% in both groups. There was a significant decrease in waist circumference in the lifestyle changes group (101.8 ± 3.9 and 95.1 ± 3.6, at baseline and at 6 months of treatment, respectively; p < 0.001) and in body mass index (BMI) in both groups. The predictor of menstrual pattern improvement was BMI.

CONCLUSIONS

Both metformin and lifestyle changes may increase the number of menstrual cycles in PCOS. This effect was related to a decrease in BMI.

Relationship of obesity-related disturbances with LH/FSH ratio among post-menopausal women in the United States

OBJECTIVES

Although luteinizing hormone to follicular stimulating hormone (LH/FSH) ratio is a controversial criterion for identifying a sub-group of infertile women with polycystic ovary syndrome (PCOS) and abnormalities at the level of the hypothalamic-pituitary-ovarian axis, an elevated LH/FSH ratio is frequently observed in PCOS cases. Obesity and insulin resistance are highly prevalent among PCOS women. To date, no studies have examined the associations of LH/FSH ratio with these co-morbid conditions outside the context of pre- and peri-menopausal PCOS women. The objective of this study is to evaluate whether the LH/FSH ratio is associated with obesity, insulin resistance, metabolic disturbances and chronic inflammation among post-menopausal U.S. women, 35-60 years of age.

STUDY DESIGN

Cross-sectional study of 693 women who participated in the 1999-2002 National Health and Nutrition Examination Survey.

MAIN OUTCOME MEASURES

Body mass index, waist circumference, triglycerides, high-density lipoprotein (HDL) cholesterol, systolic and diastolic blood pressures, fasting glucose, metabolic syndrome, Homeostasis Model Assessment for Insulin Resistance and C-reactive protein (CRP).

RESULTS

Age- and hysterectomy-adjusted regression models suggest that CRP level is positively associated with LH/FSH ratio and LH/FSH>1, high glucose level and LH/FSH>2 are inversely related and HDL<50mg/dL is positively associated with both LH/FSH>1 and LH/FSH>2.

CONCLUSIONS

In a nationally representative sample of post-menopausal women, markers of chronic inflammation and dyslipidemia which are characteristics of PCOS-associated morbidities were also significantly associated with LH/FSH ratio, meriting further investigation.

Evidence-based and potential benefits of metformin in the polycystic ovary syndrome: a comprehensive review

Metformin is an insulin sensitizer widely used for the treatment of patients affected by type 2 diabetes mellitus. Because many women with polycystic ovary syndrome (PCOS) are insulin resistant, metformin was introduced in clinical practice to treat these patients also. Moreover, metformin's effect has other targets beside its insulin-sensitizing action. The present review was aimed at describing all evidence-based and potential uses of metformin in PCOS patients. In particular, we will analyze the uses of metformin not only for the treatment of all PCOS-related disturbances such as menstrual disorders, anovulatory infertility, increased abortion, or complicated pregnancy risk, hyperandrogenism, endometrial, metabolic and cardiovascular abnormalities, but also for the prevention of the syndrome.

Use of metformin in polycystic ovary syndrome

Women with polycystic ovary syndrome (PCOS) have a myriad of phenotypic and clinical features that may guide therapeutic options for metabolic protection and ovulation induction. The use of metformin may prove beneficial in a subset of the population of women with PCOS. Hyperinsulinemia, as demonstrated by elevated insulin levels on a 2-hour 75-g load glucose tolerance test, is an important parameter in deciding whether or not to initiate metformin therapy to women with PCOS with the hope of preventing or delaying the onset of type 2 diabetes mellitus (DM). Cardiovascular risk factors including markers of subclinical inflammation, and dyslipidemia may also be improved by metformin therapy. For ovulation induction, metformin is not as effective as clomiphene citrate as first-line therapy for women with PCOS. There are no clear data to suggest that metformin reduces pregnancy loss or improves pregnancy outcome in PCOS, and it is currently recommended that metformin be discontinued with the first positive pregnancy test result, unless there are other medical indications (eg, type 2 DM). This review addresses practical management guidelines for the uses of metformin in women with PCOS.

Metformin improves polycystic ovary syndrome symptoms irrespective of pre-treatment insulin resistance

OBJECTIVE

Insulin resistance (IR) and obesity are common features of the polycystic ovary syndrome (PCOS). Insulin-sensitizing agents have been shown to improve both reproductive and metabolic aspects of PCOS, but it remains unclear whether it is also beneficial in lean patients without pre-treatment IR. The aim of this study was to determine the influence of metformin on the clinical and biochemical parameters of PCOS irrespective of the presence of basal obesity and IR.

DESIGN

The effect of 6 months of metformin treatment was prospectively assessed in 188 PCOS patients, divided into three groups according to body mass index (BMI; lean: BMI<25 kg/m2, overweight: BMI 25-29 kg/m2, and obese: BMI30 kg/m2). Outcome parameters, which were also assessed in 102 healthy controls, included body weight, homeostasis model assessment for IR (HOMA-IR), fasting glucose and insulin levels, area under the curve of insulin response (AUCI), hyperandrogenism, and menstrual irregularities.

RESULTS

In comparison with the respective BMI-appropriate control groups, only obese but not lean and overweight PCOS patients showed differences in fasting insulin and HOMA-IR. Metformin therapy significantly improved all outcome parameters except fasting glucose levels. Subgroup analyses revealed that in the group of lean PCOS patients without pre-treatment IR, metformin significantly improved HOMA-IR (1.7+/-1.0 vs 1.1+/-0.7 micromol/lxmmol/l2) and fasting insulin levels (7.7+/-4.2 vs 5.4+/-3.9 mU/l), in addition to testosterone levels (2.6+/-0.9 vs 1.8+/-0.7 nmol/l), anovulation rate (2.3 vs 59.5%), and acne (31.8 vs 11.6%; all P<0.017). In the overweight and obese PCOS groups, metformin also showed the expected beneficial effects.

CONCLUSION

Metformin improves parameters of IR, hyperandrogenemia, anovulation, and acne in PCOS irrespective of pre-treatment IR or obesity.