Homocysteine levels in women with polycystic ovary syndrome treated with metformin versus rosiglitazone: a randomized study

The Effect of Thiazolidinediones in Polycystic Ovary Syndrome: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

INTRODUCTION

Polycystic ovary syndrome (PCOS) is a complex endocrine condition affecting women of reproductive age. It is characterised by insulin resistance and is a risk for type 2 diabetes mellitus (T2DM). The aim of this study was to review the literature on the effect of pioglitazone and rosiglitazone in women with PCOS.

METHODS

We searched PubMed, MEDLINE, Scopus, Embase, Cochrane Library and the Web of Science in April 2020 and updated in March 2023. Studies were deemed eligible if they were randomised controlled trials (RCTs) reporting the effect of pioglitazone and rosiglitazone in PCOS. The study follows the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Two reviewers independently extracted data and assessed the risk of bias using the Cochrane risk of bias tool.

RESULTS

Out of 814 initially retrieved citations, 24 randomised clinical trials (RCTs) involving 976 participants were deemed eligible. Among women with PCOS, treatment with rosiglitazone compared to metformin resulted in a significant increase in the mean body weight (mean difference (MD) 1.95 kg; 95% CI 0.03-3.87, p = 0.05). Metformin treatment was associated with a reduction in mean body mass index (BMI) compared to pioglitazone (MD 0.85 kg/m2; 95% CI 0.13-1.57, p = 0.02). Both pioglitazone compared to placebo (MD 2.56 kg/m2; 95% CI 1.77-3.34, p < 0.00001) and rosiglitazone compared to metformin (MD 0.74 kg/m2; 95% CI 0.07-1.41, p = 0.03) were associated with a significant increase in BMI. Treatment with pioglitazone compared to placebo showed a significant reduction in triglycerides (MD - 0.20 mmol/L; 95% CI - 0.38 to - 0.03, p = 0.02) and fasting insulin levels (MD - 11.47 mmol/L; 95% CI - 20.20, - 2.27, p = 0.01). Rosiglitazone compared to metformin was marginally significantly associated with a reduction in the luteinising hormone (LH) (MD - 0.62; 95% CI - 1.25-0.00, p = 0.05).

CONCLUSION

Both pioglitazone and rosiglitazone were associated with significant increases in body weight and BMI when compared with metformin or placebo. Pioglitazone significantly reduced triglycerides and fasting insulin when compared with placebo while rosiglitazone showed a modest reduction of LH when compared with metformin.

PROSPERO REGISTRATION NO

CRD42020178783.

Effects of different insulin sensitisers in the management of polycystic ovary syndrome: A systematic review and meta-analysis

OBJECTIVE

Characteristic features of polycystic ovary syndrome (PCOS) include insulin resistance and an increased risk for type 2 diabetes. To promote improved insulin sensitivity, insulin sensitisers have been used in PCOS. However, direct comparisons across these agents are limited. This study compared the effects of metformin, rosiglitazone and pioglitazone in the management of PCOS to inform the 2023 International Evidence-based PCOS Guideline.

DESIGN

Systematic review and meta-analysis of the literature.

PATIENTS

Women with PCOS and treatment with insulin sensitisers.

MEASUREMENTS

Hormonal and clinical outcomes, as well as side effects.

RESULTS

Of 1660 publications identified, 13 randomised controlled trials were included. Metformin was superior in lowering weight (mean difference [MD]: -4.39, 95% confidence interval [CI]: -7.69 to -1.08 kg), body mass index (MD: -0.95, 95% CI: -1.41 to -0.49 kg/m2 ) and testosterone (MD: -0.10, 95% CI: -0.18 to -0.03 nmol/L) versus rosiglitazone, whereas there was no difference when comparing metformin to pioglitazone. Adding rosiglitazone or pioglitazone to metformin did not improve metabolic outcomes. However, rosiglitazone seemed superior to metformin in lowering lipid concentrations.

CONCLUSIONS

Metformin should remain the first-line insulin sensitising treatment in adults with PCOS for the prevention and management of weight and metabolic features. The addition of thiazolidinediones appears to offer little benefit.

Comparison of Serum Vitamin B12 Levels Among Drug-Naïve and Metformin-Treated Patients With Polycystic Ovary Syndrome

Background

Metformin is frequently prescribed for polycystic ovary syndrome (PCOS). There is a well-established causal relationship between metformin use in type 2 diabetes and vitamin B12 deficiency; such a relationship is seldom studied in PCOS. We conducted this study to compare vitamin B12 levels among newly diagnosed and metformin-treated patients with PCOS.

Methodology

This cross‑sectional comparative study was conducted from July 2021 to June 2022, among patients with PCOS attending a specialized endocrinology clinic of a tertiary hospital in Mymensingh, Bangladesh. A total of 50 patients newly diagnosed with PCOS and 52 with PCOS who had received metformin for at least six months were evaluated. The serum vitamin B12 level was measured by utilizing the chemiluminescent microparticle immunoassay principle.

Results

The new drug-naïve and metformin-treated subjects with PCOS had similar clinical and laboratory parameters except for the metformin group’s lower hemoglobin levels and higher plateletcrit. Metformin receivers had lower serum vitamin B12 levels than the drug-naïve subjects (385.5 pg/mL [interquartile range, or IQR, 298.7-535.2] vs. 272.0 pg/mL [IQR 217.0-395.7]; P < 0.001). The metformin group had higher frequencies of B12 deficiency and borderline deficiency (15.4% vs. 6% and 42.3% vs. 18%, respectively; P = 0.003).

Conclusions

This study observed lower serum B12 levels in PCOS patients using metformin than in the newly diagnosed ones. Large-scale data are needed to recommend routine periodic screening for B12 levels in metformin-treated PCOS.

Impact of pharmacological interventions on anthropometric indices in women with polycystic ovary syndrome: A systematic review and meta-analysis of randomized controlled trials

CONTEXT

Polycystic ovary syndrome (PCOS) is a heterogeneous condition affecting women of reproductive age and is associated with increased body weight.

OBJECTIVE

To review the literature on the effect of different pharmacological interventions on the anthropometric indices in women with PCOS.

DATA SOURCES

We searched PubMed, MEDLINE, Scopus, Embase, Cochrane library, and the Web of Science in April 2020 with an update in PubMed in March 2021.

STUDY SELECTION

The study followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA)2020.

DATA EXTRACTION

Reviewers extracted data and assessed the risk of bias using the Cochrane risk of bias tool.

RESULTS

80 RCTs were included in the meta-analysis. Metformin vs placebo showed significant reduction in the mean body weight (MD: -3.13 kg; 95% confidence interval [CI]: -5.33 to -0.93, I² = 5%) and the mean body mass index (BMI) (MD: -0.75 kg/m² ; 95% CI: -1.15 to -0.36, I² = 0%). There was a significant reduction in the mean BMI with orlistat versus placebo (MD: -1.33 kg/m²; 95% CI: -2.16 to -0.66, I² = 0.0%), acarbose versus metformin (MD: -1.26 kg/m²; 95% CI: -2.13 to -0.38, I² = 0%), and metformin versus pioglitazone (MD: -0.91 kg/m²; 95% CI: -1.62 to -0.19, I² = 0%). A significant increase in the mean BMI was also observed in pioglitazone versus placebo (MD: + 2.59 kg/m²; 95% CI: 1.78-3.38, I² = 0%) and in rosiglitazone versus metformin (MD: + 0.80 kg/m²; 95% CI: 0.32-1.27, I² = 3%). There was a significant reduction in the mean waist circumference (WC) with metformin versus placebo (MD: -1.21 cm; 95% CI: -3.71 to 1.29, I² = 0%) while a significant increase in the mean WC with pioglitazone versus placebo (MD: + 5.45 cm; 95% CI: 2.18-8.71, I² = 0%).

CONCLUSION

Pharmacological interventions including metformin, sitagliptin, pioglitazone, rosiglitazone orlistat, and acarbose have significant effects on the anthropometric indices in women with PCOS.

Impact of pharmacological interventions on insulin resistance in women with polycystic ovary syndrome: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Polycystic ovary syndrome (PCOS) is a complex endocrine condition affecting women of reproductive age. It is characterized by insulin resistance and is a major risk factor for type 2 diabetes mellitus (T2DM). The objective was to review the literature on the effect of different pharmacological interventions on insulin resistance in women with PCOS.

DESIGN

We searched PubMed, MEDLINE, Scopus, Embase, Cochrane library and the Web of Science in April 2020 and updated in March 2021. The study follows the 2020 Preferred Reporting Items for Systematic reviews and Meta-ana. Reviwers extracted data and assessed the risk of bias using the Cochrane risk of bias tool.

RESULTS

In 58 randomized controlled trials there were significant reductions in the fasting blood glucose (FBG) with metformin versus placebo (standardized mean difference [SMD]: -0.23; 95% confidence interval [CI]: -0.40, -0.06; I² = 0%, low-grade evidence), and acarbose versus metformin (mean difference [MD]: -10.50 mg/dl; 95% CI: -15.76, -5.24; I² = 0%, low-grade evidence). Significant reductions in fasting insulin (FI) with pioglitazone versus placebo (SMD: -0.55; 95% CI: -1.03, -0.07; I² = 37%; p = .02, very-low-grade evidence). A significant reduction in homoeostatic model assessment of insulin resistance (HOMA-IR) was seen with exenatide versus metformin (MD: -0.34; 95% CI: -0.65, -0.03; I² = 0%, low-grade evidence). No effect on homoeostatic model assessment of beta cells (HOMA-B) was observed.

CONCLUSIONS

Pharmacological interventions, including metformin, acarbose, pioglitazone and exenatide have significant effects on FBG, FI, HOMA-IR but not on HOMA-B.

The effect of metformin on homocysteine levels in patients with polycystic ovary syndrome: A systematic review and meta-analysis

PURPOSE

Metformin is widely used as an insulin sensitizer in polycystic ovary syndrome (PCOS) patients. However, previous studies have found that the effect of metformin on the level of homocysteine were not consistent in PCOS patients. The aim of this review was to analyze the effect of metformin on homocysteine levels in patients with PCOS patients.

METHODS

The Cochrane Library, Pubmed, and Web of Science were searched according to predefined search terms. There is no restriction for publication time and language.

RESULTS

Eleven studies were included and the data were extracted. The homocysteine level in PCOS patients was significantly increased after taking metformin (mean difference [MD] -1.33; 95% confidence interval [CI] -2.16 to -0.49, p = 0.002). Subgroup analysis showed that the level of homocysteine was generally increased in PCOS patients with body mass index (BMI) ≥25 after taking metformin alone (MD -1.82; 95% CI -2.56 to -1.07, p < 0.00001). There was no significant change in homocysteine level in PCOS patients with BMI <25 (MD 0.69; 95% CI -0.41 to 1.79, p = 0.22). Subgroup analysis showed that there was no significant difference when taking metformin >3 months or taking metformin ≤3 months (p = 0.84). Taking metformin ≥1700 mg/days significantly increased homocysteine levels in PCOS patients (MD -2.05; 95% CI -2.40 to -1.70, p < 0.00001). When taking metformin <1700 mg/days, there was no significant difference in homocysteine level in PCOS patients (MD 0.15; 95% CI -1.06 to 1.37, p = 0.80). The difference between the two subgroups was significant (p = 0.0006). There was no significant difference in vitamin B12 level before and after metformin treatment (MD 24.70; 95% CI -22.54 to 71.93, p = 0.31). There was a decrease in serum folic acid level after metformin administration (MD 1.03; 95% CI 0.80 to 1.26, p < 0.00001).

CONCLUSION

Taking metformin alone increased homocysteine levels and decreased folic acid levels in nonpregnant PCOS patients. And, it was suggested that the dosage of metformin should be less than 1700 mg/days. The supplement of folic acid and B vitamins during metformin administration may be essential in nonpregnant PCOS patients. We should pay much attention to the potential effect of metformin in PCOS patients.

The correlation between plasma total homocysteine level and gestational diabetes mellitus in a Chinese Han population

To assess the correlation between plasma total homocysteine (tHcy) level and gestational diabetes mellitus (GDM) in a Chinese Han population. This case–control study included 350 GDM patients and 346 gestational week-matched normal glucose tolerance (NGT) pregnant women. Plasma tHcy and insulin levels were analyzed by HPLC and ELISA respectively. Logistic regression analysis was used to investigate the correlation between plasma tHcy level and risk of GDM. Women with GDM had a higher plasma tHcy level than NGT women (6.61 ± 1.32 vs. 6.17 ± 1.29 μmol/L, P = 0.001)). The GDM risk was 1.79 (OR = 1.79, 95% CI 1.18–2.72, P = 0.006) times higher in women whose plasma tHcy level was ≥ 7.29 μmol/L compared to women with plasma tHcy level < 5.75 μmol/L. Stratified analysis showed the GDM risk were much higher when HOMA-IR index ≥ 2 (OR = 5.42, 95% CI 2.51–11.74, P < 0.001), age ≥ 30 years (OR = 5.14, 95% CI 2.78–9.52, P < 0.001), or women with a family history of type 2 diabetes mellitus (T2DM) (OR = 4.13, 95% CI 1.78–9.56, P = 0.001). In the Chinese Han population, an elevated plasma tHcy level may increase the overall risk of GDM especially in women with a high HOMA-IR index, increasing age or with family history of T2DM.

Significance of Homocysteine Levels in the Management of Polycystic Ovarian Syndrome: A Literature Review

Polycystic ovarian syndrome (PCOS) is a complex disorder involving cardiovascular, metabolic, endocrine, and reproductive systems. Even though the exact etiology is not clear, many studies suggest genetic and environmental factors play a role. Homocysteine (Hcy) is considered to be an independent risk factor for atherogenic and thrombotic components of various systems. Many studies in the past have evaluated Hcy levels in the PCOS population. This article aims to elaborate on the importance of Hcy levels in the overall management of PCOS. We conducted a PubMed data search using combined keywords PCOS and homocysteine levels and manually screened relevant articles for the review while avoiding duplication of data. After the literature review, we analyzed the relationship between homocysteine levels and various components of PCOS. Most of the studies identified a statistically significant elevation in Hcy levels in PCOS women with insulin resistance, androgen excess, elevated markers of cardiovascular risk, recurrent pregnancy loss, and metformin treatment. We also examined studies that focused on treating hyperhomocysteinemia (Hhcy) in PCOS women. However, because of the limited sample sizes and various inclusion criteria used for subjects in the studies, their clinical implication is unclear in routine practice. Furthermore, we encourage clinicians to follow up on Hcy levels in PCOS women at high risk for any complications in their management course. We believe an observational study on a larger scale in a well-defined PCOS population would be useful to uncover the prevalence of elevated Hcy levels in PCOS women, which would help pave the way for establishing treatment guidelines on serum Hcy levels in PCOS management.

Comparison of the efficacy between NAC and metformin in treating PCOS patients: a meta-analysis

Our aim is to evaluate the clinical effectiveness and safety by comparing N-acetyl-cysteine (NAC) with metformin administrated by polycystic ovary syndrome (PCOS) patients. Systematic review and meta-analysis of randomized clinical trials (RCTs). MEDLINE, EMBASE, Web of Science and China National Knowledge Infrastructure were searched for studies. 10 studies were considered eligible for inclusion. NAC significantly reduced BMI and total testosterone, there was no significant difference in pregnancy rate, serum LH level, fasting insulin, and LH/FSH ratio. In conclusions, NAC may be considered as an alternative supplement to metformin, but large-scale randomized controlled trials are needed to assess the efficacy and safety of NAC in PCOS patients.

The effect of nutrient supplementation in the management of polycystic ovary syndrome-associated metabolic dysfunctions: A critical review

Polycystic ovary syndrome (PCOS) is complex heterogeneous disorder that has several aspects in terms of pathology such as metabolic, endocrine, reproductive, and psychological. However, the etiology of PCOS remains poorly understood. Several studies suggest that insulin resistance and hyperandrogenism play a central role in the progression of PCOS pathophysiology. Therefore, common treatment strategies of PCOS are based on lifestyle modification, which include exercise, diet, and nutrient supplementation therapy. Recent studies have recommended some nutrients such as vitamins, minerals, and vitamin-like nutrients for the therapy of PCOS because each has at least one functional property in PCOS-induced pathways. Therefore, it is claimed that the cause of PCOS could be vitamin or mineral deficiency. This review aims to provide a critical literature survey on nutritional supplementation for the treatment of PCOS-associated endocrine and metabolic dysfunctions and discuss the role of nutrients in the management of PCOS in view of the clinical trials and experimental studies.

Proton Pump Inhibitors, H2-Receptor Antagonists, Metformin, and Vitamin B-12 Deficiency: Clinical Implications

There is clear evidence that proton-pump inhibitors (PPIs), H2-receptor antagonists (H2RAs), and metformin can reduce serum vitamin B-12 concentrations by inhibiting the absorption of the vitamin. However, it is unclear if the effects of these drugs on serum vitamin B-12 are associated with increased risk of biochemical or functional deficiency (as is indicated by elevated blood concentrations of homocysteine and methylmalonic acid) or clinical deficiency (including megaloblastic anemia and neurologic disorders such as peripheral neuropathy and cognitive dysfunction). This review provides an overview of vitamin B-12 absorption and biochemistry and the mechanisms by which PPIs, H2RAs, and metformin affect these functions. It also summarizes the literature relating the use of these drugs to the risk of vitamin B-12 deficiency. Also discussed is that strategies for assessing vitamin B-12 status and diagnosing vitamin B-12 deficiency have evolved in recent years beyond solely measuring serum total vitamin B-12. Multiple analyte testing, a strategy in which ≥2 of 4 biomarkers of vitamin B-12 status-serum total vitamin B-12, holotranscobalamin, homocysteine, and methylmalonic acid-are measured, increases sensitivity and specificity for diagnosing vitamin B-12 deficiency. It is concluded that randomized controlled trials are now needed that use the strategy of multiple analyte testing to determine if PPIs, H2RAs, and metformin do indeed increase the risk of vitamin B-12 deficiency. Until these studies are conducted, a reasonable recommendation for physicians and their patients who are taking these drugs is to monitor vitamin B-12 status and to provide vitamin B-12 supplements if altered blood biomarkers or clinical signs consistent with low or deficient vitamin B-12 status develop.

Comparison of metformin and N-acetyl cysteine, as an adjuvant to clomiphene citrate, in clomiphene-resistant women with polycystic ovary syndrome

OBJECTIVE

To evaluate the effects of short- and long-term treatment with metformin and NAC, in an adjuvant to clomiphene citrate (CC), on the improvement of hormonal profile (SHBG, total testosterone, FBS, and fasting insulin) and fertility status in CC-resistant women with PCOS.

MATERIALS AND METHODS

One hundred and eight CC-resistant PCOS patients participated in the study and received either metformin (1500mg/day) or NAC (1800mg/day) with 100mg/day of CC for 8 and 12 weeks. Mean BMI, hirsutism score, LH/FSH ratio, endometrial thickness, mature follicle number, and serum concentrations of LH, FSH, E2, fasting insulin, total testosterone and FBS were evaluated before and after short- and long-term treatment. Furthermore, ovulation and pregnancy rates in the first and second cycles were also determined in treated patients.

RESULTS

There was no significant difference in all variables before and 8 weeks after treatment with metformin and NAC. The BMI- and insulin-lowering effects of metformin were significantly higher than NAC after long-term treatment. However, the reducing-effect of NAC on hirsutism score and FBS levels was significantly more than metformin after 12 weeks. Treatment with metformin and NAC significantly increased ovulation and pregnancy rates in CC-resistant PCOS patients. In the first and second cycles, ovulation and pregnancy rates in patients treated with NAC were slightly higher than those received metformin.

CONCLUSIONS

Compared with metformin, administration of NAC in an adjuvant to CC is recommended for improving of hormonal profile and treatment of anovulatory infertility in hyperinsulinemic patients especially women with PCOS who are CC-resistant.

Metformin Treatment and Homocysteine: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

The aim of this systematic review is to assess whether metformin could change the concentration of serum homocysteine (Hcy) with and without simultaneous supplementation of B-group vitamins or folic acid. A literature search was conducted in PubMed, EmBase, and Cochrane Central Register of Controlled Trials (CENTRAL) to identify randomized controlled trials (RCTs) reporting the concentration of serum Hcy in metformin-treated adults. Meta-analysis was applied to assess the association between metformin and the changes of Hcy concentration. Twelve publications were included in this study. In the overall analysis, metformin administration was not statistically associated with the change of Hcy when compared with the control treatment (mean difference (MD), 0.40 μmol/L; 95% confidence interval (CI), -0.07~0.87 μmol/L, p = 0.10). In the subgroup analysis, metformin was significantly associated with an increased concentration of Hcy in the absence of exogenous supplementation of folic acid or B-group vitamins (MD, 2.02 μmol/L; 95% CI, 1.37~2.67 μmol/L, p < 0.00001), but with a decreased concentration of serum Hcy in the presence of these exogenous supplementations (MD, -0.74 μmol/L; 95% CI, -1.19~-0.30 μmol/L, p = 0.001). Therefore, although the overall effect of metformin on the concentration of serum Hcy was neutral, our results suggested that metformin could increase the concentration of Hcy when exogenous B-group vitamins or folic acid supplementation was not given.

The role of metformin on vitamin B12 deficiency: a meta-analysis review

Metformin is the only biguanide oral hypoglycemic drug, that is used to treat patients with type-2 diabetes mellitus. There are some reports of metformin being associated with decreased serum levels of vitamin B12 (VB12). The objective of this study is to systematically analyze the impact of metformin on the frequency of VB12 deficiency and serum levels of VB12. A search of various databases provided 18 retrospective cohort studies and 11 randomized controlled trials. Pooled estimates of odds ratio with 95% confidence interval using random effect model were conducted. Studies were examined for heterogeneity, publication bias and sensitivity analysis. Separate analysis of randomized control trials (RCTs) including both low-risk and high-risk bias was also conducted. 29 studies were selected with a total of 8,089 patients. 19 studies were rated intermediate or high quality. Primary outcome suggested increased incidence of VB12 deficiency in metformin group (OR = 2.45, 95% CI 1.74-3.44, P < 0.0001.) Heterogeneity was relatively high (I(2) = 53%), with minor publication bias. Secondary outcome suggested lower serum VB12 concentrations in metformin group (Mean difference = -65.8, 95% CI -78.1 to -53.6 pmol/L, P < 0.00001) with high heterogeneity (I(2) = 98%,) and low publication bias. RCTs analysis of low-and high-risk group revealed similar trends. We conclude that metformin treatment is significantly associated with an increase in incidence of VB12 deficiency and reduced serum VB12 levels.

Vitamin B12 status in metformin treated patients: systematic review

Objective

Randomized controlled trials and observational studies have yielded inconsistent results on the effects of metformin on vitamin B₁₂ reduction. We therefore performed a systematic review to analyze the effects of metformin on vitamin B₁₂ concentration.

Methods

PubMed, Medline, Embase, and the Cochrane central registry of controlled trials were searched to identify randomized controlled trials and observational studies exploring the association between metformin and vitamin B₁₂ concentration in patients with type 2 diabetes mellitus or polycystic ovary syndrome. The main outcome measure was changes in serum vitamin B₁₂ concentration after 6–208 weeks of treatment with metformin, as compared with placebo or other anti-hyperglycemic therapy.

Results

Six randomized controlled trials met the inclusion criteria. Serum vitamin B₁₂ concentrations were significantly lower in patients treated with metformin than in those who received placebo or rosiglitazone (mean difference [MD], −53.93 pmol/L; 95% confidence interval [CI], −81.44 to −26.42 pmol/L, P = 0.0001). Subgroup analysis identified four trials in which patients received a lower dose of metformin (<2000 mg/d) and two in which they received a higher dose (≥2000 mg/d), with MDs in vitamin B₁₂ concentration after metformin treatment of −37.99 pmol/L (95% CI, −57.44 to −18.54 pmol/L, P = 0.0001) and −78.62 pmol/L (95% CI, −106.37 to −50.86 pmol/L, P<0.00001), respectively.

Conclusions

The reduction of vitamin B₁₂ may be induced by metformin in a dose dependent manner.

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.

Influence of oral contraceptive pills on homocysteine and nitric oxide levels: as risk factors for cardiovascular disease

PURPOSE

Elevation of homocysteine levels have been involved as a remarkable risk factor for cardiovascular disease. Decreased bioavailability of nitric oxide (NO) may result in abnormal reactions between the vessel wall and platelets and is thus involved in the initiation and progression of atherosclerosis. We aimed to assess the effect of a low dose oral contraceptive pills on homocysteine and NO levels which may influence the individual cardiovascular risk by regulation of endothelial function and development of atherosclerosis.

METHODS

The study was conducted in 50 healthy women with normal menstrual cycles as control group and 50 healthy women receiving oral contraceptive pill for at least three menstrual cycles. Homocysteine concentration was assayed by an enzyme immunoassay method and a colorimetric assay was used for determination of NO levels.

RESULTS

After 3 months of treatment, homocysteine levels were significantly increased (P = 0.027), and there was a significant and considerable decrease (P = 0.048) in NO concentration of oral contraceptive pill (OCP) consumers.

CONCLUSIONS

Our data indicates that OCPs increase the homocysteine (HCY) and reduce the NO levels. These findings warrant a possible implication of OCP in change of risk of development of coronary heart disease.

Effect of lifestyle modification and metformin therapy on emerging cardiovascular risk factors in overweight Indian women with polycystic ovary syndrome

INTRODUCTION

Polycystic ovarian syndrome (PCOS) is common among women of reproductive age. Although traditional cardiac risk factors are known to be altered and improved with short-term metformin therapy, not much is known about novel cardiac risk factors.

OBJECTIVE

The aim of this study was to evaluate the effects of lifestyle modification and short-term metformin therapy on the fasting serum lipids, homeostasis model assessment of insulin resistance (HOMA-IR), serum high-sensitivity C-reactive protein (hsCRP), and serum homocysteine.

METHODS

Native overweight [body mass index (BMI) >23 kg/m(2)] Indian women diagnosed with PCOS were evaluated and subjected to an oral glucose tolerance test and determination of insulin, homocysteine, hsCRP, and fasting lipids levels. They were started on maximally tolerated doses of metformin along with lifestyle modification. Following 3 months of therapy, they were resampled.

RESULTS

Out of 36 consecutive patients included, 25 women completed 3 months of metformin treatment and were eligible for repeat evaluation. The age of study group was 22.2 ± 5 years. Twenty-two (61%) women were obese (BMI >25 kg/m(2)). Improvement was seen in body weight, BMI, serum total cholesterol, triglycerides, high-density lipoprotein cholesterol (HDL-C), hsCRP, and serum testosterone on metformin therapy. However, no improvement was seen in serum fasting insulin, HOMA-IR, or homocysteine.

CONCLUSION

Serum hsCRP improved with lifestyle modification and metformin therapy for 3 months in overweight subjects from India with PCOS, along with serum total cholesterol, triglycerides, and HDL-C. However, markers of insulin resistance and serum homocysteine did not improve.

Medical management of metabolic dysfunction in PCOS

Polycystic ovary syndrome (PCOS) is associated with metabolic derangements including insulin resistance, dyslipidemia, systemic inflammation and endothelial dysfunction. There is a growing need to develop pharmacologic interventions to improve metabolic function in women with PCOS. Medications that have been tested in patients with PCOS include metformin, thiazolidinediones, acarbose, naltrexone, orlistat, vitamin D and statins. Metformin decreases hepatic gluconeogenesis and free fatty acid oxidation while increasing peripheral glucose uptake. Early studies in PCOS suggested that metformin indirectly reduces insulin level, dyslipidemia and systemic inflammation; however, recent placebo-controlled trials failed to demonstrate significant metabolic benefit. Thiazolidinediones act primarily by increasing peripheral glucose uptake. Most studies in PCOS have demonstrated that thiazolidinediones reduce insulin resistance; however, effects on dyslipidemia were disappointing. Use of thiazolidinediones is associated with weight gain and major complications. Acarbose reduces digestion of polysaccharides. Studies in PCOS yielded inconsistent effects of acarbose on insulin sensitivity and no significant improvement of dyslipidemia. Naltrexone reduces appetite and modulates insulin release; its use in PCOS may reduce hyperinsulinemia. Orlistat decreases absorption of dietary fats; studies in PCOS suggest beneficial effects on insulin sensitivity. Vitamin D may improve insulin sensitivity but mixed results on lipid profile in PCOS have been reported. Statins are competitive inhibitors of the key enzyme regulating the mevalonate pathway; their effects are related to reduced cholesterol production as well as anti-inflammatory and anti-oxidant properties. In women with PCOS, statins reduce hyperandrogenism, improve lipid profile and reduce systemic inflammation while the effects on insulin sensitivity are variable. Use of statins is contraindicated in pregnancy.

Homocysteine metabolism in polycystic ovary syndrome

Homocysteine, a sulfur-containing amino acid formed during the metabolism of methionine, exert cytotoxic effects on vascular endothelium. Molecular mechanisms of homocysteine-induced cellular dysfunction include increased inflammatory cytokine expression, altered nitric oxide bioavailability, induction of oxidative stress, activation of apoptosis and defective methylation. Hyperhomocysteinemia is associated with an increased risk of atherosclerotic and thromboembolic disorders, as well as hyperinsulinemia and may partially account for increased risk of cardiovascular disease associated with insulin resistance. Women with PCOS are more likely to develop components of the metabolic syndrome such as disturbances of carbohydrate metabolism, obesity, hypertension and dyslipidemia, which in turn are risk factors for cardiovascular disease. A number of studies confirmed the presence of increased serum homocysteine concentration in PCOS patients and the possible determinants of this observation are still debated. PCOS treatment options can influence homocysteine levels.

Inflammatory-metabolic parameters in obese and nonobese normoandrogenemic polycystic ovary syndrome during metformin and oral contraceptive treatment

Our aim was to evaluate the optimal treatment strategy addressing cardiovascular risk in obese and nonobese patients with polycystic ovary syndrome (PCOS). We planned a prospectıve randomized clinical study. Normoandrogenemic and oligoamenorrheic women with PCOS and impaired glucose tolerance (n = 96) were enrolled in the study. Six months of treatment with metformin HCL or oral contraceptive pills (OCPs) were given to the patients. Group 1 were obese and receiving metformin. Group 2 were obese and receiving OCPs. Group 3 were nonobese and receiving metformin, and Group 4 were nonobese receiving OCPs. ADMA, homocysteine, high sensitive C-reactive protein (hs-CRP) and homeostasis model assessment estimate of insulin resistance (HOMA-IR) were investigated. ADMA, homocysteine, hs-CRP and HOMA-IR were similar in obese and nonobese groups before the treatment. After 6 months of treatment, a significant decrease was observed in ADMA, homocysteine and HOMA-IR levels in Groups 1 and 3. An increase in ADMA and hs-CRP levels was observed in Groups 2 and 4. In this study, metformin treatment leads to improvement in hormonal and metabolic parameters and decreases ADMA and homocysteine levels possibly independent of BMI. However, the use of oral contraceptives in obese and nonobese patients with PCOS with impaired glucose tolerance increases ADMA and hs-CRP levels and creates an increase in the metabolic risk.

Metformin vs thiazolidinediones for treatment of clinical, hormonal and metabolic characteristics of polycystic ovary syndrome: a meta-analysis

OBJECTIVES

Insulin-sensitizing drugs (ISDs) have been advocated for the long-term treatment of polycystic ovary syndrome (PCOS). It is therefore important to compare the efficacy and safety of ISDs such as metformin and thiazolidinediones (TZDs) for the treatment of this syndrome.

METHODS

A meta-analysis to assess the effectiveness and safety of metformin vs TZDs (including pioglitazone and rosiglitazone) in the treatment of PCOS was conducted, using MEDLINE (1966-May 2010) and EMBASE (1988-May 2010) to select randomized controlled trials comparing clinical, hormonal and metabolic results.

RESULTS

Ten trials were included. TZDs were superior to metformin in reducing serum levels of free testosterone (P=0.03) and dehydroepiandrosterone sulfate (DHEA) (P=0.002) after 3 months treatment. Decreases in triglyceride levels were more pronounced with metformin after 6 months (P<0.0001). Decreases in body mass index (BMI) were greater with metformin treatment as assessed at 3 and 6 months (P<0.00001). There were no significant between-group differences concerning improvements in ovulation, pregnancy rate, menstrual patterns or insulin sensitivity, or changes in serum levels of androstenedione, luteinizing hormone, follicle-stimulating hormone, total cholesterol, low-density lipoprotein C or insulin. Metformin caused a significantly higher incidence of side effects such as nausea, diarrhoea and abdominal cramping (P<0.00001). Significant between-study heterogeneity was detected for several variables assessed.

CONCLUSIONS

The findings from this meta-analysis do not indicate that metformin is superior to TZD's for the treatment of PCOS or vice versa. Between studies, heterogeneity was a major confounder. A large scale, well-designed, randomized, controlled trial is needed to further address this issue.

Thiazolinedione treatment in PCOS--an update

Polycystic ovary syndrome (PCOS) is characterised by anovulation, hyperandrogenism, and polycystic ovaries. Fifty percent of patients fulfil the criteria for the metabolic syndrome. The pathogenesis of PCOS may be looked as a vicious cycle involving hyperandrogenemia, central obesity, and insulin resistance and medical treatment should aim at breaking this cycle. Lifestyle intervention, oral contraceptives, and insulin sensitises such as metformin are the most commonly used treatment modalities. The thiazolidinediones rosiglitazone and pioglitazone were recently applied as insulin sensitising treatment in patients with PCOS. Thiazolidinediones activate the transcription of genes that affect glucose and lipid metabolism mediating decreased free fatty acid levels and decreased visceral fat mass. In the present article, we give an overview of the diverse effects of glitazone treatment in patients with PCOS. We review the studies comparing glitazone versus metformin and oral contraceptive treatment and recommend which patients should be treated with glitazones in daily praxis.

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.

Effects of metformin with or without supplementation with folate on homocysteine levels and vascular endothelium of women with polycystic ovary syndrome

OBJECTIVE

To evaluate whether the administration of metformin exerts any effects on serum homocysteine (Hcy) levels in patients with polycystic ovary syndrome (PCOS) and whether supplementation with folate enhances the positive effects of metformin on the structure and function of the vascular endothelium.

RESEARCH DESIGN AND METHODS

A total of 50 patients affected by PCOS, without additional metabolic or cardiovascular diseases, were enrolled in a prospective nonrandomized placebo-controlled double-blind clinical study. They were grouped into two treatment arms that were matched for age and BMI. Patients were treated with a 6-month course of metformin (1,700 mg daily) plus folic acid (400 microg daily; experimental group, n = 25) or placebo (control group, n = 25). Complete hormonal and metabolic patterns, serum Hcy, folate, vitamin B12, endothelin-1 levels, brachial artery diameter at the baseline (BAD-B) and after reactive hyperemia (BAD-RH), flow-mediated dilation, and intima-media thickness in both common carotid arteries were evaluated.

RESULTS

After treatment, a significant increase in serum Hcy levels was observed in the control group compared with the baseline values and the experimental group. A beneficial effect was observed in the concentrations of BAD-B, BAD-RH, flow-mediated dilation, intima-media thickness, and serum endothelin-1 in both groups. However, the results were improved more significantly in the experimental group than in the control subjects.

CONCLUSIONS

Metformin exerts a slight but significant deleterious effect on serum Hcy levels in patients with PCOS, and supplementation with folate is useful to increase the beneficial effect of metformin on the vascular endothelium.

Targeting insulin sensitivity in the treatment of polycystic ovary syndrome

Targeting insulin resistance may result in a list of benefits for women with PCOS, including hormonal, metabolic and ovulatory (and fertility) improvements. The therapeutic strategy to treat PCOS should however depend on the clinical situation, the phenotype, the degree of androgen excess, age, the presence of infertility and the woman's desire to conceive, the presence of obesity and, finally, the spectrum of metabolic abnormalities and the need to treat or prevent long-term associated comorbidities. According to the needs, therapeutic options include, alone or in combination, lifestyle management, particularly in the presence of obesity, the use of insulin sensitizers, metformin and thiazolidinediones, antiandrogens or estro-progestins.

The role of insulin-sensitizing agents in the treatment of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) represents a heterogeneous spectrum of disorders, mainly characterized by chronic oligoanovulation and hyperandrogenism. Although not included in the diagnostic criteria, insulin resistance is recognized as a fundamental pathogenetic factor of the syndrome. Thus, the use of insulin-sensitizing drugs, such as metformin and thiazolidinediones, has been proposed for PCOS treatment. These agents are unique because they exert both metabolic and endocrine/ovarian beneficial effects. In this review the results of up-to-date clinical studies and meta-analyses on the possible gynaecological actions of insulin sensitizers are discussed. It has been shown that, as well as favourable metabolic influences, such as improvement in glucose, lipid and proinflammatory profiles, these agents also exert beneficial endocrine and ovarian effects, including amelioration of reproductive abnormalities, restoration of ovulation and menstrual cycles, increase in pregnancy rates and reduction of androgen production. Therefore, current data support the use of insulin sensitizers, along with lifestyle measures and/or other agents, in women with PCOS, especially in the presence of insulin- or clomifene-resistance.

Effects of an antiandrogenic oral contraceptive pill compared with metformin on blood coagulation tests and endothelial function in women with the polycystic ovary syndrome: influence of obesity and smoking

OBJECTIVE

To study the blood clotting tests and endothelial function of polycystic ovary syndrome (PCOS) patients and non-hyperandrogenic women, and their changes during PCOS treatment, as a function of the presence of obesity and smoking.

DESIGN

Case-control study followed by a randomized clinical trial.

METHODS

Blood clotting and endothelial function were analyzed in 40 PCOS patients and 20 non-hyperandrogenic women. Thirty-four PCOS women were randomized to an oral contraceptive containing 35 microg ethinyl-estradiol plus 2 mg cyproterone acetate (Diane(35)Diario) or metformin (850 mg twice daily), monitoring the changes on these parameters during 24 weeks of treatment. The influence of obesity and smoking was also analyzed.

RESULTS

Blood clotting and endothelial function tests were similar among PCOS patients and controls with the exception of a higher platelet count in the former. Obesity increased circulating fibrinogen levels, prothrombin activity and platelet counts, and reduced prothrombin and activated partial thromboplastin times. Smoking increased fibrinogen levels, platelet counts, and prothrombin activity, and reduced prothrombin time, in relation to the larger waist circumference of smokers. Irrespective of the treatment received, PCOS patients showed a decrease in prothrombin time and an increase in prothrombin activity, with a parallel increase in homocysteine levels in metformin users. The activated partial thromboplastin time decreased markedly in the patients treated with Diane(35)Diario. Finally, flow-mediated dilation improved in non-smokers irrespective of the drug received, but worsened in smokers.

CONCLUSIONS

Oral contraceptives and metformin may exert deleterious effects on blood clotting tests of PCOS women, yet the effects of metformin appear to be milder. Because smoking potentiates some of these effects and deteriorates endothelial function, smoking cessation should be promoted in PCOS patients.

The effects of insulin sensitizers on the cardiovascular risk factors in women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in pre-menopausal women characterized by menstrual cycle disturbances, chronic anovulation, and clinical and/or biochemical hyperandrogenism. Although, the primary etiology of PCOS remains unknown, insulin resistance/hyperinsulinemia plays a pivotal role in the pathogenesis of the syndrome. A growing body of recent data support that women with PCOS have displayed an increased prevelance of cardiovascular disease (CVD) risk factors putting potentially at a hight risk for heart disease. Most of these CVD risk factors are etiologically correlated with insulin resistance/hyperinsulinemia, highlighting the role of insulin sensitizers in the therapeutic quiver for the chronic treatment of PCOS. In this review, we discuss the current literature on the CVD risk factors in PCOS and the influence of insulin sensitizers upon these risk factors.

Insulin sensitizing drugs for weight loss in women of reproductive age who are overweight or obese: systematic review and meta-analysis

BACKGROUND

Women of reproductive age, who are overweight or obese, are prone to infertility. Weight loss in these women leads to increased fecundity, higher chances of conception after infertility treatment and improved pregnancy outcome. In spite of the advantages, most patients have difficulty in losing weight and often regain lost weight over time. This review assesses whether treatment with insulin sensitizing drugs contributes to weight loss, compared with diet or a lifestyle modification programme.

METHODS

After a systematic search of the literature, only randomized controlled trials (RCTs), investigating the effect of insulin sensitizing drugs on weight loss compared with placebo and diet and/or a lifestyle modification programme, were included. Subjects were restricted to women of reproductive age. The main outcome measure was change in body mass index (BMI).

RESULTS

Only 14 trials, unintentionally all but two on women with polycystic ovary syndrome (PCOS) only, were included in the analysis. Treatment with metformin showed a statistically significant decrease in BMI compared with placebo (weighted mean difference, -0.68; 95% CI -1.13 to -0.24). There was some indication of greater effect with high-dose metformin (>1500 mg/day) and longer duration of therapy (>8 weeks). Limitations were power, low use of intention-to-treat analysis and heterogeneity of the studies.

CONCLUSION

A structured lifestyle modification programme to achieve weight loss should still be the first line treatment in obese women with or without PCOS. Adequately powered RCTs are required to confirm the findings of this review and to assess whether the addition of high-dose metformin therapy to a structured lifestyle modification programme might contribute to more weight loss.

Comparative effects of atorvastatin and simvastatin on the plasma total homocysteine levels in women with polycystic ovary syndrome: a prospective randomized study

OBJECTIVE

To test the hypothesis that statins improve hyperhomocysteinemia in women with polycystic ovary syndrome (PCOS).

DESIGN

A prospective randomized study.

SETTING

University Hospital.

PATIENT(S)

Fifty-two women with PCOS and 52 women matched for age and body mass index as controls.

INTERVENTION(S)

Patients were randomly divided into two groups for treatment: group 1, atorvastatin, 20 mg daily (n = 26), and group 2, simvastatin, 20 mg daily (n = 26). Blood samples were obtained before and after treatment.

MAIN OUTCOME MEASURE(S)

Serum homocysteine levels.

RESULT(S)

After 12 weeks of treatment, serum homocysteine levels in group 1 had decreased from 14.3 +/- 2.9 to 10.6 +/- 1.7 micromol/L; in group 2, the levels decreased from 13.6 +/- 2.1 to 11.1 +/- 1.9 micromol/L. Both two groups, free testosterone and total testosterone declined statistically significantly (38.3% and 36.5%; and 40.6% and 46.0%, respectively). In group 1, vitamin B(12) increased from 362.1 +/- 107 to 478.7 +/- 267 pg/mL; in group 2, it increased from 391.3 +/- 107 to 466 +/- 211 pg/mL, but the change did not reach statistical significance. There was a considerable decline in the homeostatic model assessment index in group 1 (40.0% to 32.1%).

CONCLUSION(S)

Treatment with statins in women with PCOS leads to decreases in serum homocysteine levels.

Cardiovascular risk in normal weight, eumenorrheic, nonhirsute daughters of patients with polycystic ovary syndrome: a pilot study

OBJECTIVE

To verify whether healthy daughters with polycystic ovaries (PCO) of patients with polycystic ovary syndrome (PCOS) have an increased risk of cardiovascular disease in comparison with healthy controls.

DESIGN

Prospective observational study.

SETTING

University hospital.

PATIENT(S)

Seventeen eumenorrheic daughters with PCO of patients with PCOS (group 1) and 20 healthy volunteers (group 2) with regular ovulatory cycles.

INTERVENTION(S)

Fasting blood sampling, ultrasonographic and Doppler analyses, 24-hour ambulatory blood pressure monitoring.

MAIN OUTCOME MEASURE(S)

Medical examination; blood measurement of nitrites and nitrates, biochemical and hormonal parameters; utero-ovarian ultrasonographic analysis and color Doppler evaluation of uterine and stromal ovarian arteries; brachial artery flow-mediated vasodilatation; 24-hour ambulatory blood pressure monitoring. An oral glucose tolerance test was performed to analyze glucose, insulin, and C-peptide levels.

RESULT(S)

At Doppler analysis a significantly higher uterine and a lower ovarian artery pulsatility index was found in group 1 compared with group 2. The brachial artery diameter, after the reactive hyperemia, showed a greater vasodilatation in controls in comparison with women with PCO. The 24-hour blood pressure monitoring demonstrated that patients with PCO have significant higher 24-hour, daytime, and nighttime diastolic and mean arterial pressure values than controls. The nitrites and nitrates plasma levels were lower in group 1 compared with group 2. The glucose and insulin plasma values were higher in patients with PCO than in controls.

CONCLUSION(S)

Eumenorrheic nonhirsute daughters of patients with PCOS who have PCO appearance on ultrasound have an increased cardiovascular risk.

Drug insight: insulin-sensitizing drugs in the treatment of polycystic ovary syndrome--a reappraisal

The recognition that insulin resistance has a pivotal role in the pathogenesis of polycystic ovary syndrome (PCOS) revolutionized our understanding of this complex disorder. PCOS causes major metabolic and reproductive morbidities, including substantially increased risk for type 2 diabetes mellitus and the metabolic syndrome. Insulin-sensitizing drugs (ISDs) ameliorate reproductive abnormalities, restore ovulation and regular menses, increase pregnancy rates and reduce androgenic symptoms in affected women with PCOS. Accordingly, ISDs, specifically metformin, have been widely adopted as therapy for this condition. A recent, large, randomized, multicenter, clinical trial that assessed live-birth rates rather than surrogate end points suggested that metformin alone is inferior to clomiphene citrate in treating infertility associated with PCOS. There is, furthermore, no evidence to support the use of metformin during pregnancy to prevent spontaneous abortions or gestational diabetes mellitus in women with PCOS. Renewed safety concerns about thiazolidinediones followed recent studies that reported increased cardiovascular morbidity with these agents. These concerns might preclude thiazolidinedione use in otherwise healthy women with PCOS. Finally, although ISDs improve insulin action and cardiovascular disease risk, there is no evidence that they provide long-term health benefits in PCOS. This article discusses the role of ISDs in PCOS in light of these new data.

Polycystic ovarian syndrome: pathophysiology, molecular aspects and clinical implications

Polycystic ovarian syndrome (PCOS) is universally recognised as the commonest endocrinopathy of women. The definition and the aetiological hypotheses of PCOS are continuously evolving to accommodate expanding knowledge on the syndrome, which is now known to be more complex than purely a reproductive disorder. Increased androgen synthesis, disrupted folliculogenesis and insulin resistance lie at the pathophysiological core of PCOS. An intriguing concept involves the perpetuation of a vicious circle with endocrine/reproductive and metabolic components. An unfavourable metabolic environment may unmask genetic traits of ovarian dysfunction, and the unfolding endocrine derangement could further aggravate the metabolic disarray. This article reviews the molecular mechanisms known to underlie the ovarian and metabolic abnormalities characterising PCOS. The putative interdependence between reproductive and metabolic aspects of PCOS, and therapeutic implications for the management of PCOS, are also discussed.

How should we manage atherogenic dyslipidemia in women with polycystic ovary syndrome?

Despite their young age, women with polycystic ovary syndrome (PCOS) have increased cardiovascular risk. Besides normal concentrations of low-density lipoprotein (LDL) cholesterol, dyslipidemia is very common and includes elevated triglyceride levels and low high-density lipoprotein cholesterol concentrations. Recent findings also showed that women with PCOS have qualitative LDL alterations, with increased levels of atherogenic small, dense LDL particles. Such lipid abnormalities constitute a common form of dyslipidemia, the so-called atherogenic lipoprotein phenotype (ALP), associated with a greater cardiovascular risk. Weight reduction and increased physical activity may constitute first-line therapy for ALP in PCOS, and lipid lowering drugs, particularly nicotinic acid and fibrates, should be used in patients with severe dyslipidemia. Statins have usually a lower impact on ALP, and their beneficial effect is often moderate. Insulin-sensitizing medications favorably alter each component of ALP and combined therapy with these agents remains an option; in particular, the combination pioglitazone plus metformin seems to be particularly beneficial.

Peroxisome proliferator-activated receptors: new players in the field of reproduction

Peroxisome proliferator-activated receptors (PPAR) are members of the nuclear hormone receptor superfamily. Synthetic ligands to one family member, PPARgamma, are currently widely used as treatment for chronic diseases such as diabetes type II and other insulin resistances, e.g. as seen in polycystic ovary syndrome (PCOS). Moreover, novel approaches employing knock-out mice demonstrated that PPARgamma seems to play a key role in placental and fetal development. This review describes recent insights into the role of PPARs in human reproduction with specific reference to infertility, placental maturation and fetal development as well as disturbed pregnancy. Further, we highlight the current knowledge on synthetic ligands to PPARgamma used as a treatment in women with PCOS.

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.

Homocysteine and cardiovascular disease: a review of the evidence

Elevated homocysteine (HCY) levels can be caused by a number of factors, including folate and B-vitamin deficiency, pre-existing atherosclerotic disease, diabetes and various drugs. Epidemiological evidence, as well as data from retrospective and prospective studies, supports an association between elevated HCY levels and increased risk of cardiovascular disease (CVD). However, whether lowering HCY levels by administration of folate and vitamins B6 and B12 is associated with any significant decrease in vascular risk remains the subject of ongoing debate. Although the major studies that have reported to date show that vitamin supplementation was associated with a decrease in HCY levels, this failed to have any significant effect on cardiovascular risk. Furthermore, although some lipid-modifying treatments have been shown to increase HCY levels, there is no evidence that this attenuates or compromises the beneficial effects of such treatments on cardiovascular risk. Taken together, these data suggest that HCY is a marker, rather than a cause, of CVD and therefore do not provide support for routine screening for and treatment of elevated HCY to prevent CVD. Data from ongoing clinical trials are awaited to clarify this issue.

Prospective, randomized trial of metformin and vitamins for the reduction of plasma homocysteine in insulin-resistant polycystic ovary syndrome

One hundred and two women with insulin-resistant polycystic ovary syndrome were randomized to treatment with a vitamin B preparation, metformin, or both, in conjunction with standard infertility treatment. Plasma homocysteine levels were significantly reduced by both B vitamins and metformin, but to a greater degree by B vitamins, and higher pregnancy rates were associated with vitamin B treatment.

Effects of metformin or rosiglitazone on serum concentrations of homocysteine, folate, and vitamin B12 in patients with type 2 diabetes mellitus

OBJECTIVES

Metformin is widely used in patients with type 2 diabetes but may decrease vitamin B(12) levels and increase levels of homocysteine (Hcy), a cardiovascular risk factor. Rosiglitazone, a peroxisome proliferator-activated receptor-gamma agonist, may reduce markers of inflammation. We investigated whether 6 weeks' treatment with metformin or rosiglitazone affects serum concentrations of Hcy, folate, or vitamin B(12) in subjects with newly diagnosed type 2 diabetes compared with controls.

METHODS

We examined 165 patients with type 2 diabetes. Fasting blood samples, a physical examination, and a complete medical history were performed at the beginning and at the end of the treatment. All blood samples were obtained after a 12-h fast.

RESULTS

After treatment, metformin use was associated with an increase in levels of Hcy by 2.36 micromol/l and decreases in folate and vitamin B(12) concentrations by -1.04 ng/ml and -20.17 pg/ml. During rosiglitazone treatment, Hcy levels decreased by -0.92 micromol/l; folate and vitamin B(12) levels remained unchanged. Metformin and rosiglitazone significantly decreased levels of triglyceride (TG), low-density lipoprotein (LDL), total cholesterol (total-C), HbA1c, insulin, and homeostasis model assessment (HOMA). Metformin also significantly decreased body weight. In controls, there was no change in Hcy, folic acid, vitamin B(12), TG, LDL, total-C, HbA1c, insulin, or HOMA levels. Homocysteine change did not correlate with insulin, folate, or vitamin B(12) changes in the metformin and rosiglitazone groups.

CONCLUSIONS

In patients with type 2 diabetes, metformin reduces levels of folate and vitamin B(12) and increases Hcy. Conversely, rosiglitazone decreases Hcy levels in this time period. The clinical significance of these findings remains to be investigated.

Impact of folate and homocysteine metabolism on human reproductive health

Folates belong to the vitamin B group and are involved in a large number of biochemical processes, particularly in the metabolism of homocysteine. Dietary or genetically determined folate deficiency leads to mild hyperhomocysteinemia, which has been associated with various pathologies. Molecular mechanisms of homocysteine-induced cellular dysfunction include increased inflammatory cytokine expression, altered nitric oxide bioavailability, induction of oxidative stress, activation of apoptosis and defective methylation. Whereas the involvement of folate metabolism and homocysteine in ageing-related diseases, in several developmental abnormalities and in pregnancy complications has given rise to a large amount of scientific work, the role of these biochemical factors in the earlier stages of mammalian reproduction and the possible preventive effects of folate supplementation on fertility have, until recently, been much less investigated. In the present article, the possible roles of folates and homocysteine in male and female subfertility and related diseases are systematically reviewed, with regard to the epidemiological, pathological, pharmacological and experimental data of the literature from the last 25 years.

Polycystic ovarian syndrome: the next cardiovascular dilemma in women?

All known risks for cardiovascular disease are increased in women with polycystic ovary syndrome, which features amenorrhea, hirsutism, and obesity. Epidemiologic studies in these patients and their families have revealed a familial predisposition not only to polycystic ovary syndrome, but also diabetes, hypertension, and cardiovascular disease. The heterogeneity of phenotypes (clinically and biochemically) leads to difficulty in achieving a precise diagnosis, defining a single underlying pathogenesis, and selecting a homogeneous population for much needed prospective studies. The authors believe that while insulin resistance plays and important role in some cases of polycystic ovarian syndrome, it is the overall milieu created by the co-existence of several cardiovascular risk factors in polycystic ovarian syndrome patients which could be an important target for preventative strategies and therapy.

Metformin versus rosiglitazone in the treatment of polycystic ovary syndrome

OBJECTIVE

The aim of our study is to investigate and compare the clinical, biochemical and hormonal changes during application of insulin-sensitizers from two different groups.

STUDY DESIGN

This prospective, open clinical study lasted 3 months and included 30 women with PCOS, divided in two groups of 15 women each. Group 1 received 850 mg metformin twice a day and group 2 was treated with rosiglitazone 4 mg a day. Serum levels of testosterone, immune reactive insulin (IRI), sex hormone binding globulin (SHBG), dehydroepiandrosterone sulfate (DHEAS) and lipid metabolism parameters were measured before the treatment, and on the 3rd month. Free androgen index (FAI) and homeostasis model assessment of insulin resistance (HOMA-IR) were calculated. Body mass index (BMI) and waist-to-hip ratio (WHR) were assessed at baseline and at the end of therapy.

RESULTS

Two parameters change significantly in the 3rd month in our study--testosterone and insulin. Much better decrease in the level of testosterone and free androgen index was established in group treated with metformin, while the indices of insulin resistance were better influenced in the group treated with rosiglitazone.

CONCLUSION

Application of insulin sensitizers from both groups has a favorable influence on the basic hormonal deviations in PCOS--the hyperandrogenemia and the insulin resistance. In cases with PCOS metformin treatment influences better hyperandrogenemia, while rosiglitazone affects more pronouncedly insulin resistance and hyperinsulinemia.