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

Topiramate Added to Metformin for Obesity Control in Women With Polycystic Ovary Syndrome

CONTEXT

Polycystic ovary syndrome (PCOS) is often linked with obesity, and weight management can improve endocrine and cardiometabolic features.

OBJECTIVE

This work aimed to evaluate the effects of adding topiramate (TPM) to metformin (MTF) on weight control and hormonal and metabolic outcomes in women with PCOS.

METHODS

In a randomized, double-blind, placebo-controlled trial, participants with PCOS and body mass index of 30 or greater, or 27 or greater associated with hypertension, type 2 diabetes, or dyslipidemia followed a 20 kcal/kg diet in addition to 850 mg of MTF or a previous MTF regimen. They were randomly assigned to receive either TPM or placebo (P) alongside MTF. Anthropometric measurements, blood pressure, modified Ferriman-Gallwey score (mFGS), and adverse events were assessed every 4 weeks for 6 months. The primary end point was the percentage change in body weight from baseline in both groups. Secondary end points included changes in clinical, cardiometabolic, and hormonal parameters and psychosocial features.

RESULTS

Thirty-one participants were in the MTF + P group and 30 in the MTF + TPM group. The MTF + TPM group showed greater mean weight loss at 3 months (-3.4% vs -1.6%; P = .03) and 6 months (-4.5% vs -1.4%; P = .03). Both groups had improved androgens, lipids, and psychosocial scores. Participants with 3% or greater weight loss at 6 months had improved mFGS (8.4 to 6.5; P = .026). Paresthesia was more common in the MTF + TPM group (23.3% vs 3.2%; P = .026).

CONCLUSION

Combining TPM with MTF and a low-calorie diet may be an effective, low-cost, easy-to-use, and safe strategy for weight management in women with PCOS, with mild adverse effects.

Pharmacological and Non-Pharmacological Interventions for Polycystic Ovary Syndrome (PCOS) in Indian Women: A Systematic Review and Meta-Analysis

Background: Polycystic ovary syndrome (PCOS) is an endocrine disorder prevalent in women of reproductive age. Treatment or management of this syndrome includes several pharmacological and non-pharmacological treatment approaches for different manifestations of the disease that vary with the patient's age, symptoms, requirements, and geographical location. Objective: This systematic review aims to conduct a comprehensive and evidence-based analysis of the various available treatment options and identify knowledge gaps in PCOS management in India. Methods: A comprehensive search was conducted in PubMed, Scopus, and Embase databases from January 2010 till February 2024. We included randomized control trials (RCTs) using any pharmacological drugs (e.g., insulin sensitizers, anti-androgens, anti-obesity drugs, oral contraceptive pills, ovulation induction drugs, etc.) or non-pharmacological intervention (e.g., yoga, diet, herbal supplements, etc.) with Indian PCOS patients for improving common manifestations of PCOS and written in the English language. Studies were screened by two authors independently in a two-level process. Data extraction was also performed by two authors. Risk of bias was performed using the RoB 2 Tool. Subgroup analysis and meta-analysis were performed using the RevMan tool. Results: Thirty RCTs on pharmacological and eight on non-pharmacological interventions were included in the study. However, all the RCTs were so heterogeneous in terms of intervention used, subject recruited, and outcomes measured that meta-analysis was possible for only three subgroups (metformin vs. inositol, metformin vs. metformin+ inositol, and letrozole vs. clomiphene citrate), with only two or three studies per analysis. Most studies were single-centric and small-sized and had a high risk of bias, limiting their generalizability. Conclusions: This systematic review synthesized existing research and evaluated the effectiveness and safety of existing treatments. Limitations and gaps in the current research were identified, which may inform future research for better understanding and management of PCOS in the Indian context.

Bridging gap in treatment of polycystic ovarian syndrome through drug repurposing: what we achieved and where we are?

Polycystic ovarian syndrome (PCOS) is one of the chief causes of infertility in women of reproductive age. Several drugs belonging to the oral contraceptive class have been approved for the treatment of PCOS. Nonetheless, the capability to target only a few symptoms of PCOS and fatal side effects are key hurdles to their use. Therefore, repurposing existing drugs can be promising in managing PCOS efficiently. Drugs from different pharmacological classes like antidiabetics (metformin, rosiglitazone, pioglitazone, and semaglutide), statins (simvastatin and atorvastatin), antiandrogen drugs (finasteride and flutamide), etc. demonstrated significant potential in managing PCOS. The present review offers a comprehensive overview of all the medications examined as potential repurposed options for the efficient treatment of PCOS. The pathogenesis of PCOS, existing therapies for PCOS and their challenges, drug repurposing and its significance is also explained. The small-molecular drugs from various pharmacological classes and different phytoceuticals repurposed against PCOS are discussed along with their anti-PCOS activity mechanisms. Moreover, novel drug targets responsible for PCOS and opportunities for drug repurposing are briefed. The repurposed drugs in clinical trials for PCOS and drug repurposing challenges are discussed. Thus, drug repurposing can serve as a potential way to effectively treat PCOS, reducing the extent of infertility and improving the quality of life of women.

The Molecular Basis of Polycystic Ovary Syndrome and Its Cardiometabolic Correlates: Exploring the Intersection and Its Clinical Implications-A Narrative Review

Recent studies have highlighted the association between polycystic ovary syndrome (PCOS) and cardiometabolic diseases, leading to an improved understanding of the underlying mechanistic factors. PCOS significantly increases cardiovascular risk by predisposing individuals to various subclinical and clinical conditions, including atherosclerosis and type 2 diabetes mellitus. Additionally, it interacts synergistically with other traditional cardiovascular risk factors, such as obesity, hyperlipidemia, and insulin resistance. Several molecular mechanisms involving genetics, epigenetics, adipokine secretion, hyperandrogenemia, and hyperinsulinemia play a role in the relationship between PCOS and these comorbidities. For instance, androgen excess has been implicated in the development of hypertension, type 2 diabetes mellitus, endothelial dysfunction, and ultimately, broader cardiovascular disease. A deeper understanding of these underlying mechanisms facilitates the development of diagnostic, preventative, and therapeutic strategies directed at reducing cardiometabolic morbidity. This narrative review summarizes the current evidence, explores the potential clinical implications of these findings, and discusses emerging therapies to reduce cardiometabolic morbidity in women with PCOS.

Reproductive Endocrine Disorders: A Comprehensive Guide to the Diagnosis and Management of Infertility, Polycystic Ovary Syndrome, and Endometriosis

Reproductive endocrine disorders, including infertility, polycystic ovary syndrome (PCOS), and endometriosis, significantly impact women's reproductive health and overall well-being. This comprehensive review explores the diagnosis and management strategies for these prevalent conditions. Infertility, affecting millions globally, is often linked to ovulatory dysfunction, PCOS, and endometriosis. PCOS is characterized by hyperandrogenism, menstrual irregularities, and insulin resistance, contributing to anovulation and infertility. The Rotterdam criteria are widely used for PCOS diagnosis, and management includes lifestyle modifications, pharmacological treatments like ovulation inducers, and, in some cases, surgical interventions. Endometriosis, caused by the presence of endometrial-like tissue outside the uterus, leads to chronic pain and infertility through inflammation, adhesions, and impaired ovarian function. Laparoscopy remains the gold standard for diagnosing endometriosis, and treatment focuses on pain relief, fertility preservation, and reducing recurrence. In cases of endometriosis-related infertility, assisted reproductive technologies (ARTs) like in vitro fertilization (IVF) are often recommended. In addition, the role of diet and lifestyle changes in managing these conditions is gaining recognition. This review emphasizes the complexity of reproductive endocrine disorders and underscores the need for individualized treatment plans, combining medical, surgical, and lifestyle approaches to improve fertility outcomes and enhance the quality of life for affected women. The review also highlights the importance of early diagnosis and advances in therapeutic interventions to ensure optimal patient care in the management of infertility, PCOS, and endometriosis.

Pharmacological and non-pharmacological interventions for improving endometrial receptivity in infertile patients with polycystic ovary syndrome: a comprehensive review of the available evidence

Direct and indirect evidence suggests that endometrial receptivity may play a crucial role in the reduced fertility rate of women with polycystic ovary syndrome (PCOS). Various pharmacological and non-pharmacological strategies with potential effects on endometrial receptivity in patients with PCOS have been proposed. The aim of this study was to summarize the rationale and the clinical and experimental evidence of interventions tested for improving endometrial receptivity in infertile patients with PCOS. A systematic review was conducted by consulting electronic databases. All interventions with a potential influence on endometrial receptivity in infertile patients with PCOS were evaluated, and their main biological mechanisms were analysed. In total, 24 interventions related to endometrial receptivity were identified. Notwithstanding a strong biological rationale, no intervention aimed at improving endometrial receptivity in women with PCOS is supported by an adequate body of evidence, limiting their use in clinical practice. Further high-quality research is needed in this field to limit potentially ineffective and unsafe add-on treatments in infertile patients with PCOS.

Recent developments in drug treatment strategies for infertility in patients with polycystic ovary syndrome

INTRODUCTION

Infertility related to polycystic ovary syndrome (PCOS) represents a significant challenge for women of reproductive age. Over the last few years, evidence-based medicine has driven new approaches for treating infertility in patients with PCOS, changing rapidly and deeply the clinical practice.

AREAS COVERED

The authors provide an in-depth examination of recent developments in drug treatment strategies that have impacted the clinical practice and changed the previous approach to infertility in patients with PCOS.

EXPERT OPINION

The authors identify four primary areas of interest that have impacted clinical practice in the last few years. Specifically, they discuss the current role of metformin administration in women with PCOS and infertility, the choice for using clomiphene citrate or letrozole as first-line treatment for ovulation induction, the use of new gonadotropin formulations for in vitro fertilization (IVF) program, and the elective embryo transfer in IVF cycles as golden standard treatment for patients with PCOS at high-risk for ovarian hyperstimulation syndrome.

Efficacy of WeChat-Based Digital Intervention Versus Metformin in Women With Polycystic Ovary Syndrome: Randomized Controlled Trial

BACKGROUND

The first-line treatment for polycystic ovary syndrome (PCOS) is lifestyle modification. However, it is currently unknown whether digital medicine can assist patients with PCOS in maintaining a healthy lifestyle while alleviating PCOS symptoms.

OBJECTIVE

This study aims to evaluate the efficacy of WeChat-based digital intervention versus metformin treatment in women with PCOS and insulin resistance.

METHODS

A total of 80 women with PCOS and insulin resistance were recruited from an endocrinology clinic and randomly assigned to receive either a WeChat-based digital intervention (n=40, 50%) or metformin (n=40, 50%) for 12 weeks. The WeChat-based digital intervention consisted of 3 modules; a coach assisted the patients in using the intervention. The primary outcome was the change in a homeostatic model assessment for insulin resistance. At baseline and after the 12-week intervention, anthropometric parameters, menstruation frequency, sex hormone levels, metabolic factors, and body fat distribution were measured in the clinic. Furthermore, self-assessed web-based questionnaires on diet, exercise, sleep, anxiety, and depression were obtained.

RESULTS

A total of 72 participants completed the follow-up (for a 90% follow-up rate), including 35 of 40 (88%) participants from the digital intervention group and 37 of 40 (93%) participants from the metformin group. The homeostatic model assessment for insulin resistance in the digital intervention group was significantly improved after 12 weeks of treatment with a mean change of -0.93 (95% CI -1.64 to -0.23), but no statistical difference was observed between the groups (least squares mean difference -0.20; 95% CI -0.98 to 0.58; P=.62). Both digital intervention and metformin treatment significantly improved menstruation frequency (digital intervention: P<.001; metformin: P<.001) and reduced body weight (digital intervention: P<.001; metformin: P<.001) and total fat mass (digital intervention: P<.001; metformin: P<.001). Furthermore, the digital intervention had a significant advantage over metformin in improving waist circumference (least squares mean difference -1.84; 95% CI -3.44 to -0.24; P=.03), waist-to-hip ratio (least squares mean difference -0.02; 95% CI -0.03 to 0.00; P=.03), total fat mass (least squares mean difference -1.59; 95% CI -2.88 to -0.30; P=.02), and dehydroepiandrosterone sulfate (least squares mean difference -69.73; 95% CI -129.70 to -9.75; P=.02). In terms of safety, the main adverse events were sensations of hunger in the digital intervention group (2/40, 5%) and gastrointestinal adverse events in the metformin group (12/40, 30%).

CONCLUSIONS

Our data suggest that digital intervention is an effective treatment option for patients with PCOS, with an efficacy comparable to that of metformin, and that it can also alleviate the negative effects of medications and make it easier and more efficient to adhere to lifestyle treatments. WeChat-based digital interventions have the potential to provide a new path for the improvement and health of women with PCOS in China.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05386706; https://clinicaltrials.gov/study/NCT05386706.

Achilles tendon thickness and serum asprosin level significantly increases in patients with polycystic ovary syndrome

Aim

In our study, we aimed to investigate the Achilles tendon thickness (ATT) and asprosin levels in patients with polycystic ovary syndrome (PCOS) and to evaluate the relationship of these parameters, which may be related to cardio-metabolic diseases.

Methods

In our prospective cross-sectional study, 45 female patients with PCOS and 30 female healthy individuals similar in age were included. Serum dehydroepiandrosterone sulfate (DHEAS), total testosterone, anti-Müllerian hormone (AMH) and asprosin levels were measured using appropriate kits and homeostatic model assessment of insulin resistance (HOMA-IR), luteinizing hormone (LH) to follicle-stimulating hormone (FSH) ratio was calculated. ATT measurements were performed by two radiologists using a high-resolution ultrasound doppler system.

Results

Serum DHEAS, total testosterone, AMH and asprosin levels, HOMA-IR value, LF/FSH ratio, and ATT values were higher in patients with PCOS compared to healthy controls. Correlation analysis was performed between ATT and other parameters in patients with PCOS. In univariate analysis, parameters associated with ATT were detected as asprosin, DHEAS and AMH. In the linear regression analysis performed with significant parameters, asprosin and DHEAS levels were found to be associated with ATT.

Conclusion

ATT values and serum asprosin levels were found to be significantly increased in patients with PCOS, and there is a very close positive relationship between ATT and serum asprosin levels. For this reason, it was thought that ATT measurement could be a cheap, simple and non-invasive monitoring parameter that can be used in the routine cardiometabolic follow-up of patients with PCOS.

Metformin beyond type 2 diabetes: Emerging and potential new indications

Metformin is best known as a foundational therapy for type 2 diabetes but is also used in other contexts in clinical medicine with a number of emerging and potential indications. Many of its beneficial effects may be mediated by modest effects on weight loss and insulin sensitivity, but it has multiple other known mechanisms of action. Current clinical uses beyond type 2 diabetes include: polycystic ovarian syndrome; diabetes in pregnancy/gestational diabetes; prevention of type 2 diabetes in prediabetes; and adjunct therapy in type 1 diabetes. As metformin has been in clinical use for almost 70 years, much of the underpinning evidence for its use in these conditions is, by definition, based on trials conducted before the advent of contemporary evidence-based medicine. As a result, some of the above-established uses are 'off-label' in many regulatory territories and their use varies accordingly in different countries. Going forward, several current 'repurposing' investigational uses of metformin are also being investigated: prevention of cancer (including in Li Fraumeni syndrome), renal protection, Alzheimer's disease, metabolic dysfunction-associated steatotic liver disease and promotion of healthy ageing. Despite the longevity of metformin and its important current roles beyond type 2 diabetes in clinical medicine, it has further potential and much research is ongoing.