Heterogeneity of the polycystic ovary syndrome: clinical, endocrine and ultrasound features in 556 patients

Hepatokines: the missing link in the development of insulin resistance and hyperandrogenism in PCOS?

The liver plays a critical role in several metabolic pathways, including the regulation of glucose and lipid metabolism. Non-alcoholic fatty liver disease (NAFLD), the most common chronic liver disease worldwide, is closely associated with insulin resistance (IR) and metabolic syndrome (MetS). Hepatokines, newly discovered proteins secreted by hepatocytes, have been linked to the induction of these metabolic dysregulations. Polycystic ovary syndrome (PCOS), the most common endocrine disorder in women of reproductive age, has been associated with NAFLD and IR, while hyperandrogenism additionally appears to be implicated in the pathogenesis of the latter. However, the potential role of hepatokines in the development of metabolic disorders in PCOS has not been fully investigated. Therefore, the aim of this review is to critically appraise the current evidence regarding the interplay of hepatokines with NAFLD, hyperandrogenism, and IR in PCOS.

Role and mechanism of miR-335-5p in the pathogenesis and treatment of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a common endocrine disorder of unknown etiology that occurs in women of reproductive age. Despite being considered to affect up to one-fifth of women in this cohort, the condition lacks generally accepted diagnostic biomarkers and options for targeted therapy. Hereby, we analyzed the diagnostic, therapeutic, and functional potential of a recently discovered miR-335-5p that was observed to be reduced in the follicular fluid (FF) of PCOS patients as compared with healthy women. We found miR-335-5p to be significantly decreased in the serum and FF samples of PCOS patients (n = 40) vs healthy women (n = 30), as well as in primary human granulosa cells (hGCs), and in 3 different hormonally induced PCOS-like murine models vs. wild-type (WT) mice. The level of circulating miR-335-5p was found to significantly correlate with the impaired endocrine and clinical features associated with PCOS in human patients. Ovarian intrabursal injection of the miR-335-5p antagomir in WT mice ovaries induced a PCOS-like reproductive phenotype. Treatment with the miR-335-5p agomir rescued the dihydrotestosterone-induced PCOS-phenotype in mice, thereby providing a functional link between miR-335-5p and PCOS. We identified SP1 as a miR-335-5p target gene by using the dual-luciferase reporter assay. Both the luciferase reporter assay and chromatin immunoprecipitation assay showed that SP1 bound to the promoter region of human CYP19A1 and inhibited its transcription. miR-335-5p increased the production of estradiol via the SP1/CYP19A1 axis in hGCs, thereby suggesting its mechanistic pathway of action. In conclusion, these results provide evidence that miR-335-5p may function as a mediator in the etiopathogenesis of PCOS, as well as has the potential as both a novel diagnostic biomarker and therapeutic target for PCOS.

Polycystic Ovary Syndrome and the Neuroendocrine Consequences of Androgen Excess

Polycystic ovary syndrome (PCOS) is a major endocrine disorder strongly associated with androgen excess and frequently leading to female infertility. Although classically considered an ovarian disease, altered neuroendocrine control of gonadotropin-releasing hormone (GnRH) neurons in the brain and abnormal gonadotropin secretion may underpin PCOS presentation. Defective regulation of GnRH pulse generation in PCOS promotes high luteinizing hormone (LH) pulsatile secretion, which in turn overstimulates ovarian androgen production. Early and emerging evidence from preclinical models suggests that maternal androgen excess programs abnormalities in developing neuroendocrine circuits that are associated with PCOS pathology, and that these abnormalities are sustained by postpubertal elevation of endogenous androgen levels. This article will discuss experimental evidence, from the clinic and in preclinical animal models, that has significantly contributed to our understanding of how androgen excess influences the assembly and maintenance of neuroendocrine impairments in the female brain. Abnormal central gamma-aminobutyric acid (GABA) signaling has been identified in both patients and preclinical models as a possible link between androgen excess and elevated GnRH/LH secretion. Enhanced GABAergic innervation and drive to GnRH neurons is suspected to contribute to the pathogenesis and early manifestation of neuroendocrine derangement in PCOS. Accordingly, this article also provides an overview of GABA regulation of GnRH neuron function from prenatal development to adulthood to discuss possible avenues for future discovery research and therapeutic interventions. © 2022 American Physiological Society. Compr Physiol 12:3347-3369, 2022.

Polycystic ovarian syndrome-current pharmacotherapy and clinical implications

Polycystic ovary syndrome (PCOS), the most common endocrinopathy in women is characterized by polycystic ovaries, chronic anovulation and hyperandrogenism. The treatment in PCOS is mainly symptomatic and involves lifestyle interventions and medications such as Metformin, Oral contraceptives and Antiandrogens. However, the management of PCOS is challenging and current interventions are not able to deal with outcomes of this syndrome. This review encompasses latest pharmacotherapeutic and non-pharmacotherapeutic interventions currently in use to tackle various symptomatic contentions in PCOS. Our focus has been mainly on novel therapeutic modalities for treatment/management of PCOS, like use of newer insulin sensitizers viz., Inositols, Glucagon-like peptide-1(GLP-1) agonists, Dipeptidyl pepdidase-4 (DPP-4) inhibitors, and sodium-glucose transport protein 2 (SGLT2) inhibitors. Also, evidence suggesting the use of vitamin D, statins, and Letrozole as emerging therapies in PCOS have been summarized in this review. Additionally, novel cosmetic techniques like electrolysis, laser and use of topically applied eflornithine to tackle the most distressing feature of facial hirsutism associated with PCOS, non-pharmacological therapy like acupuncture and the role of herbal medicine in PCOS management have also been discussed.

A review of the hormones involved in the endocrine dysfunctions of polycystic ovary syndrome and their interactions

Polycystic ovary syndrome (PCOS) affects up to 20% of women but remains poorly understood. It is a heterogeneous condition with many potential comorbidities. This review offers an overview of the dysregulation of the reproductive and metabolic systems associated with PCOS. Review of the literature informed the development of a comprehensive summarizing 'wiring' diagram of PCOS-related features. This review provides a justification for each diagram aspect from the relevant academic literature, and explores the interactions between the hypothalamus, ovarian follicles, adipose tissue, reproductive hormones and other organ systems. The diagram will provide an efficient and useful tool for those researching and treating PCOS to understand the current state of knowledge on the complexity and variability of PCOS.

Continuum of Symptoms in Polycystic Ovary Syndrome (PCOS): Links with Sexual Behavior and Unrestricted Sociosexuality

Symptoms of polycystic ovary syndrome (PCOS) exist on a continuum, are associated with hyperandrogenism, and have fertility implications. The present study investigated the relationship between PCOS symptoms and sociosexuality in young women with a continuum of symptoms ranging from none to clinical levels. Given that unrestricted sociosexuality, or one's orientation toward uncommitted sexual activity, is associated with hyperandrogenism, we hypothesized that women experiencing more symptoms of PCOS, and a greater likelihood of androgen excess, would have a more unrestricted sociosexual orientation. Women completed questionnaires about PCOS symptoms, sociosexuality, and sexuality. Unrestricted sociosexuality, unrestricted desire, romantic interest in women, and masturbation frequency were all positively associated with PCOS symptoms (including male pattern hair growth). The sexuality scores were also higher in women who scored above (versus below) the cutoff on a self-report PCOS screening questionnaire. In addition, attraction to women was higher in participants reporting a past diagnosis of PCOS. The findings are in line with theories that androgens play a role in sociosexuality and sexual orientation. Future research should examine sociocultural explanations, and whether the continuum of PCOS symptoms (e.g., hirsutism) is a useful model for studying the effects of androgen exposure, hyperandrogenism, or androgen responsiveness on women's behavior.

Differential Effects of Various Androgens on Polycystic Ovary Syndrome

The hyperandrogenism in polycystic ovary syndrome (PCOS) is associated with the risk for the future development of the cardiovascular disease. The objective of the study is to verify whether different androgens have the same harmful effect. This cross-sectional study enrolled 823 women with PCOS: 627 (76.2%) with biochemical hyperandrogenism and 196 (23.8%) with normal androgen levels. The role of individual androgen was evaluated using univariate and multivariate logistic regression. In normoandrogenemic PCOS (NA-PCOS), free androgen index (FAI) predicted significant abnormality in visceral adipose index (VAI, OR=9.2, p=0.002) and dehydroepiandrosterone (DHEA) predicted against alteration in β-cell function (OR=0.5, p=0.007). In hyperandrogenemic PCOS (HA-PCOS), FAI predicted derangements in waist triglyceride index (WTI), VAI, and lipid accumulation product (LAP) (OR ranging from 1.6 to 5.8, p<0.05). DHEA weakly predicted against VAI (OR 0.7, p=0.018), dehydroepiandrosterone sulfate (DHEAS) tended to predict against the conicity index (OR=0.7, p=0.037). After multiple regression, FAI retained significant strength to predict various anthropometric and metabolic abnormalities (OR ranging from 1.1 to 3.0, p<0.01), DHEA was kept as a protector factor against WTI, LAP, and VAI (OR ranging from 0.6 to 0.9; p<0.01) and DHEAS against the conicity index (OR=0.5, p<0.001). In conclusion, the free androgen index was the most powerful predictor of anthropometric and metabolic abnormalities of polycystic ovary syndrome. Conversely, DHEA and DHEAS demonstrated protective effects against disorders in some markers of obesity and abnormal metabolism.

Individual and combined effects of 5-year exposure to hyperandrogenemia and Western-style diet on metabolism and reproduction in female rhesus macaques

STUDY QUESTION

What is the impact of prolonged exposure to hyperandrogenemia (T), Western-style diet (WSD) and the combination on metabolic and reproductive function in female rhesus macaques, particularly in the post-partum period?

SUMMARY ANSWER

Combined T + WSD worsened measures of insulin sensitivity and parameters of cyclicity following prolonged (5 years) exposure, but there was no effect on post-partum metabolic function.

WHAT IS KNOWN ALREADY

Women with hyperandrogenemia due to polycystic ovary syndrome are at higher risk for gestational diabetes and Type 2 diabetes post-partum, but it is unknown if this is related to hyperandrogenemia. Hyperandrogenemia in the presence of a WSD worsens metabolic function in female nonhuman primates.

STUDY DESIGN, SIZE, DURATION

Female rhesus macaques began treatment near menarche (roughly 2.5 years of age) consisting of either cholesterol (control; C) or testosterone (T) implants (average serum levels 1.4 ng/ml) and exposure to standard monkey chow or a WSD (15 vs 36% of calories from fat, respectively). The four groups were maintained on treatment for 3 years, underwent a fertility trial in Year 4 and continued with treatments through Year 5.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Metabolic measurements (glucose tolerance tests and double X-ray absorptiometry scans) were performed yearly, and results from 5 years of treatment are reported for all animals. Animals were bled daily for 30 days at 5 years to capture changes in ovarian cycle hormones, and ultrasound measurements were performed during the early follicular and luteal phase.

MAIN RESULTS AND THE ROLE OF CHANCE

After 5 years of treatment, WSD exposure moderately increased body weight and body fat, although control animals also had a high body mass index due to ad libitum feeding. Animals in the T + WSD group had increased fasting insulin and insulin secretion during an intravenous glucose tolerance test. WSD exposure also altered ovarian cycles, delaying the time to the E2 surge, decreasing progesterone and anti-Müllerian hormone levels and increasing the number of antral follicles present by ultrasound. Longitudinal assessment of metabolic function for only those animals that became pregnant in Year 4 of treatment revealed no differences in post-partum metabolism between groups, although WSD resulted in overall elevated weights, body fat and measures of insulin resistance.

LARGE SCALE DATA

None.

LIMITATIONS, REASONS FOR CAUTION

The small sample size and heterogeneity in metabolic effects observed in the T + WSD group are limitations of the current study, with only a subset of animals in this group showing impaired insulin resistance relative to controls. In addition, obesity in the C group prevented comparisons to lean animals.

WIDER IMPLICATIONS OF THE FINDINGS

Hyperandrogenemia combined with WSD had a greater impact on insulin sensitivity and ovarian function than either treatment alone.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by NIH grant P50 HD071836 to C.T.R., J.H. and C.T. and P51 OD011092 for support of the Oregon National Primate Research Center. All authors declare no competing interests.

Inositols in PCOS

(1) Background: Myoinositol (MI) and D-chiro-inositol (DCI) are involved in a number of biochemical pathways within oocytes having a role in oocyte maturation, fertilization, implantation, and post-implantation development. Both inositols have a role in insulin signaling and hormonal synthesis in the ovaries. (2) Methods: Literature search (with key words: inositols, myo-inositol, d-chiro-inositol, PCOS) was done in PubMed until Sept. 2020 and 197 articles were identified, of which 47 were of clinical trials (35 randomized controlled trials). (3) Results: Many studies have demonstrated that in patients with polycystic ovarian syndrome (PCOS) MI treatment improved ovarian function and fertility, decreased the severity of hyperandrogenism including acne and hirsutism, positively affected metabolic aspects, and modulated various hormonal parameters deeply involved in the reproductive axis function and ovulation. Thus treating with MI has become a novel method to ameliorate PCOS symptoms, improve spontaneous ovulation, or induce ovulation. The current review is focused on the effects of MI and DCI alone or in combination with other agents on the pathological features of PCOS with focus on insulin resistance and adverse metabolic outcomes. (4) Conclusions: The available clinical data suggest that MI, DCI, and their combination in physiological ratio 40:1 with or without other compound could be beneficial for improving metabolic, hormonal, and reproductive aspects of PCOS.

Ultrasonographic and biochemical assessments as early prediction of polycystic ovarian syndrome in obese women

Background

Polycystic ovary syndrome (PCOS) is considered as a common cause of hormonal disturbance and obesity. The diagnosis of PCOS was done by different methods including clinical signs as anovulation, hyperandrogenism, biochemical markers and ultrasounographic investigation. This study investigated comparative outcomes of ultrasonographic and biochemical markers for early prediction of PCOS in obese women.

Subjects and methods

Seventy-five patients were clinically diagnosed with obese, PCOS and obese with PCOS and twenty-five normal age matched subjects were enrolled as control. Abdominal and transvaginal ultrasonographic for assessment of ovarian properties. In addition, BMI, serum free testosterone, dehydroepiandrosterone (DHEA), insulin, glycosylated hemoglobin (HbA1c) and LDL-c levels were evaluated.

Result

In obese patients with PCOs (20%) ovaries revealed normal appearance in morphology while the rest (80%) showed PCOs in the form of cysts of 2–8 mm in diameter peripherally arranged around stroma. A significant elevation of free testosterone, DHEA and insulin in obese with or without PCOS compared with obese group (p<0.001). A positive correlation with hormonal abnormalities of increased HA1c, LDL-c, free testosterone, DHEA and insulin compared with obese only.

Conclusion

According to our study findings, ovarian morphology combined with biochemical markers is more reliable for early prediction and diagnosis of PCOS for interpretation and management.

Is the presence of Demodex folliculorum increased with impaired glucose regulation in polycystic ovary syndrome?

Demodex parasites may cause skin and eyelash lesions by settling on the pilosebaceous unit. This parasite plays a role in the pathophysiology of acne in polycystic ovarian syndrome (PCOS). We aimed to examine the relationship between Demodex folliculorum and blood glucose control in patients with PCOS with skin and eyelash lesions. Forty-four patients with PCOS with skin lesions were enrolled in the study. At least two specimens were taken from the skin lesions using the standard method and at least six epilated eyelashes were taken from both eyes under a biomicroscope and evaluated using a light microscope. The demographic characteristics, body mass index (BMI) and clinical parameters of the patients were recorded. Demodex folliculorum was present at a rate of 59.1% in the skin lesions of the patients with PCOS, 40.9% in eyelash samples and 43.18% in both skin and lashes. Homeostasis model assessment of insulin resistance (HOMA-IR), glycosylated haemoglobin (HB A1c) concentrations, and BMIs were significantly higher in the patients who had D. folliculorum in skin samples than in those without (p = .010, p = .007 and p = .02). Impaired glucose regulation may explain the pathophysiology of the increased D. folliculorum presence in the skin lesions of patients with PCOS.Impact statementWhat is already known on this subject? Although several studies on Demodex folliculorum and PCOS have been conducted, we have not yet found a study that examines D. folliculorum parasites in the eyelashes and skin correlating with glucose regulation in PCOS. This study presents new information about the relationship between the presence of D. folliculorum and impaired glucose regulation in women with PCOS.What do the results of this study add? D. folliculorum is seen more commonly in skin lesions in patients with PCOS with impaired blood glucose regulation.What are the implications of these findings for clinical practice and/or further research? D. folliculorum is present in both skin and eyelash lesions in patients with PCOS. These lesions may be prevented by avoiding unregulated glucose levels and obesity. In future studies, the investigation of the resorption of D. folliculorum parasites in skin lesions with the continuation of normal glucose levels in patients with PCOS will reveal a more interesting linkage.

Female Pattern Hair Loss and Androgen Excess: A Report From the Multidisciplinary Androgen Excess and PCOS Committee

OBJECTIVE

To determine the current state of knowledge and provide evidence-based recommendations that could be valid for all specialists taking care of female pattern hair loss (FPHL), a common form of hair loss in women that is characterized by the reduction of hair density in the central area of the scalp, whereas the frontal hairline is generally well conserved.

PARTICIPANTS

An expert task force appointed by the Androgen Excess and PCOS Society, which included specialists from dermatology, endocrinology, and reproductive endocrinology.

DESIGN

Levels of evidence were assessed and graded from A to D. Peer-reviewed studies evaluating FPHL published through December 2017 were reviewed. Criteria for inclusion/exclusion of the published papers were agreed on by at least two reviewers in each area and arbitrated by a third when necessary.

CONCLUSIONS

(i) The term "female pattern hair loss" should be used, avoiding the previous terms of alopecia or androgenetic alopecia. (ii) The two typical patterns of hair loss in FPHL are centrifugal expansion in the mid scalp, and a frontal accentuation or Christmas tree pattern. (iii) Isolated FPHL should not be considered a sign of hyperandrogenism when androgen levels are normal. (iv) The assessment of patients with FPHL is primarily clinical. (v) In all patients with FPHL, assessment of a possible androgen excess is mandatory. Measurement of vitamin D, iron, zinc, thyroid hormones, and prolactin are optional but recommended. (vi) Treatment of FPHL should start with minoxidil (5%), adding 5α-reductase inhibitors or antiandrogens when there is severe hair loss or hyperandrogenism.

Anti-Müllerian Hormone as a Diagnostic Marker in Egyptian Infertile Polycystic Ovary Syndrome Females: Correlations with Vitamin D, Total Testosterone, Dyslipidemia and Anthropometric Parameters

BACKGROUND

Recent studies have highlighted the role of anti-Müllerian hormone (AMH) in numerous ovarian disorders. Polycystic Ovary Syndrome (PCOS) is one of the major causes of infertility in Egypt. Several reports have linked PCOS with vitamin D deficiency. This investigation illustrates the possibility of using serum AMH for PCOS diagnosis in infertile Egyptian females, determines the variables affecting it and correlates it with serum 25(OH)D, testosterone, dyslipidemia and anthropometric parameters.

METHODS

All parameters were assessed either with ELISA or colorimetrically in 53 infertile PCOS women and 17 age matched apparently healthy controls diagnosed according to Rotterdam consensus.

RESULTS

Serum AMH, total testosterone, triacylglycerol (TG) levels and BMI were significantly higher in PCOS group compared to healthy controls (p=0.0239, p=0.0381, p=0.0457, and p=0.0067, respectively), while serum 25(OH)D levels and HDL-cholesterol (HDL-C) were significantly lower (p=0.0397 and p=0.0443, respectively). No significant correlation existed between AMH and 25(OH) D, BMI and dyslipidemia markers. AMH was found to have a significant negative correlation with age and a highly significant positive one with total testosterone in PCOS group (r=-0.303, p=0.027 and r=0.370, p=0.008, respectively). In the receiver operating characteristic curve of AMH, the cut-off value was 42.63 pmol/L with a specificity of 59% and a sensitivity of 82%. Multivariate regression analysis showed total testosterone to be the only determinant for AMH (β=0.381 and p=0.038).

CONCLUSIONS

There should be a future trend of using AMH as a diagnostic marker for PCOS in Egyptian females. The variation in serum AMH levels is determined by total testosterone.

Phenotypic variation in anti-Mullerian hormone (AMH) production per follicle in women with polycystic ovary syndrome (PCOS) and isolated polycystic ovarian morphology (PCOM): an observational cross-sectional study

This observational study compares the ratio of serum anti-Mullerian hormone (AMH) to the total antral follicle count (AFC) (as a marker of AMH production per follicle) in the various phenotypes of women with polycystic ovary syndrome (PCOS) and isolated polycystic ovarian morphology (PCOM). Two hundred and sixty-two women were recruited. Women with PCOS were divided into four phenotypes based on the diagnostic inclusion criteria of oligo-anovulation (OA), hyperandrogenism (HA) and polycystic ovarian morphology (PCOM). These included Group A (OA + HA + PCOM), Group B (OA + HA), Group C (HA + PCOM) and Group D (OA + PCOM). A ratio of serum AMH to total AFC was calculated and expressed as the AMH/AFC ratio which was compared in the phenotypes of PCOS and isolated PCOM. The median AMH/AFC ratios in PCOS-A, PCOS-D, PCOS-C and PCOM were 1.5, 1.6, 1.2 and 1.1, respectively. There were significant differences in the groups compared [F(3, 238) = 6.14, p = 0.000)]. The ratios were significantly higher in the oligo-anovulatory phenotypes PCOS-A and PCOS-D than the PCOM (p = 0.004 and 0.002, respectively). There was no significant difference in the ratio between ovulatory phenotype PCOS-C and PCOM (p = 0.59). The role of androgens and LH in per-follicle AMH production remains limited. The findings support the hypothesis of a key role for AMH in the mechanism of anovulation in PCOS.

Differential DNA methylation patterns of polycystic ovarian syndrome in whole blood of Chinese women

As a universally common endocrinopathy in women of reproductive age, the polycystic ovarian syndrome is characterized by composite clinical phenotypes reflecting the contributions of reproductive impact of ovarian dysfunction and metabolic abnormalities with widely varying symptoms resulting from interference of the genome with the environment through integrative biological mechanisms including epigenetics. We have performed a genome-wide DNA methylation analysis on polycystic ovarian syndrome and identified a substantial number of genomic sites differentially methylated in the whole blood of PCOS patients and healthy controls (52 sites, false discovery rate < 0.05 and corresponding p value < 5.68e–06), highly consistently replicating biological pathways extensively implicated in immunity and immunity-related inflammatory disorders (false discovery rate < 0.05) that were reportedly regulated in the DNA methylome from ovarian tissue under PCOS condition. Most importantly, our genome-wide profiling focusing on PCOS patients revealed a large number of DNA methylation sites and their enriched functional pathways significantly associated with diverse clinical features (levels of prolactin, estradiol, progesterone and menstrual cycle) that could serve as novel molecular basis of the clinical heterogeneity observed in PCOS women.

Single Nucleotide Polymorphisms in CD14 and Toll-like Receptor 4 Genes in Patients with Polycystic Ovarian Syndrome

Introduction

Polycystic ovary syndrome (PCOS) is a complex disease having genetic, immunologic, and environmental components, and candidate genes on innate immunity have been hypothesized to be involved in its etiology. We examined the possible association of CD14 and toll-like receptor 4 (TLR4) polymorphisms with PCOS.

Materials and methods

A total of 219 women with PCOS and 272 healthy women were recruited in the study. Their samples were genotyped for the polymorphism of CD14 and TLR4 genes.

Results

The distributions of genotypes of both polymorphisms were found to be significant in women with PCOS compared with controls. The distributions of alleles were also found to be predominant in PCOS compared with controls.

Conclusion

Polymorphisms in CD14-159C>T and TLR4-299A>G significantly increased susceptibility to PCOS. Further studies with larger sample sizes are warranted to confirm these findings.

How to cite this article

Allauddin N, Rozati R. Single Nucleotide Polymorphisms in CD14 and Toll-like Receptor 4 Genes in Patients with Polycystic Ovarian Syndrome. J South Asian Feder Obst Gynae 2017;9(4):304-307.

Adiponectin Deficiency Leads to Female Subfertility and Ovarian Dysfunctions in Mice

Adipose tissue plays an important role in regulating female fertility, owing to not only its energy stores but also the endocrine actions of secreted adipokines. As one of the adipokines, adiponectin is almost exclusively secreted from the fat, and its circulating concentration is paradoxically reduced in obesity. Although recent studies implied a purported positive role of adiponectin in ovarian functions, definitive in vivo evidence has been sorely lacking. We have consistently observed subfertility in female adiponectin null mice and therefore postulated a protective role of adiponectin in ovarian functions. Female adiponectin null mice displayed impaired fertility, reduced retrieval of oocytes, disrupted estrous cycle, elevated number of atretic follicles, and impaired late folliculogenesis. Analysis of their sera revealed a significant decrease in estradiol and FSH but an increase in LH and testosterone at proestrus. In addition, we found marked reduction of progesterone levels at diestrus, a significant decrease in LH receptor expression as well as in the number of GnRH immunoreactive neurons. Adiponectin deficiency also altered the peak concentrations of LH surge and led to lower expression of Cytochrome P450 family 11 subfamily A member 1 (P450scc), an enzyme critical for progesterone synthesis, as well as an increase in BCL2 associated X, apoptosis regulator and Insulin like growth factor binding protein 4 in atretic follicles. These physiological and molecular events were independent of insulin sensitivity. Thus, we have revealed a novel mechanism linking adiponectin and female fertility that entails regulation of reproductive hormone balance and ovarian follicle development.

The epigenomics of polycystic ovarian syndrome: from pathogenesis to clinical manifestations

Polycystic ovarian syndrome (PCOS) is a complex condition of ovarian dysfunction and metabolic abnormalities with widely varying clinical manifestations resulting from interference of the genome and the environment through integrative biological mechanisms with the emerging field of epigenetics offering an appealing tool for studying the nature and nurture of the disease. We review the current literature of epigenetic studies on PCOS from disease development to the association analysis of the DNA methylome and to exploratory studies on the molecular mechanisms of disease heterogeneity and comorbidity. Recent data based on profiling of the DNA methylome of PCOS in different tissues provided consistent molecular evidence in support of epidemiological findings on disease comorbidity suggesting a possible autoimmune basis in the pathogenesis of the disease. We show that the field of epigenetics and epigenomics could serve to link molecular regulatory mechanisms with disease development and disease manifestation which could contribute to PCOS prevention and treatment and eventually promote reproductive health in fertile age women. We summarize the up-to-date findings and discuss the implications of various studies and point to new avenues of research on PCOS in the rapidly developing field of epigenetics and epigenomics.

Relationship between Advanced Glycation End Products and Steroidogenesis in PCOS

BACKGROUND

Women with PCOS have elevated levels of the harmful Advanced Glycation End Products (AGEs), which are highly reactive molecules formed after glycation of lipids and proteins. Additionally, AGEs accumulate in the ovaries of women with PCOS potentially contributing to the well-documented abnormal steroidogenesis and folliculogenesis.

MAIN BODY

A systematic review of articles and abstracts available in PubMed was conducted and presented in a systemic manner. This article reports changes in steroidogenic enzyme activity in granulosa and theca cells in PCOS and PCOS-models. It also described the changes in AGEs and their receptors in the ovaries of women with PCOS and presents the underlying mechanism(s) whereby AGEs could be responsible for the PCOS-related changes in granulosa and theca cell function thus adversely impacting steroidogenesis and follicular development. AGEs are associated with hyperandrogenism in PCOS possibly by altering the activity of various enzymes such as cholesterol side-chain cleavage enzyme cytochrome P450, steroidogenic acute regulatory protein, 17α-hydroxylase, and 3β-hydroxysteroid dehydrogenase. AGEs also affect luteinizing hormone receptor and anti-Mullerian hormone receptor expression as well as their signaling pathways in granulosa cells.

CONCLUSIONS

A better understanding of how AGEs alter granulosa and theca cell function is likely to contribute meaningfully to a conceptual framework whereby new interventions to prevent and/or treat ovarian dysfunction in PCOS can ultimately be developed.

The significance of anthropometric and endocrine parameters in ovulation induction with clomiphene citrate in women with polycystic ovary syndrome

Objectives:

To investigate factors associated with the response to ovarian stimulation in patients with polycystic ovary syndrome.

Methods:

The records of patients with polycystic ovary syndrome and infertility who underwent ovulation induction with clomiphene citrate were reviwed between January 2011 and December 2014 in Etlik Zübeyde Hanim Women’s Health Training and Research Hospital Ankara, Turkey. The anthropometric and endocrine factors of patients who were resistant to treatment at a dose of 150 mg/day (n=84) were compared with those who responded with growth of at least one graaffian follicle at a dose of 50 mg/day (n=342).

Results:

Of the parameters examined, body mass index, luteinizing hormone level, and luteinizing hormone/follicle stimulating hormone ratio were significantly higher in the clomiphene citrate-resistant group compared with the responsive group.

Conclusion:

Reproductive treatment in patients with polycystic ovary syndrome show different outcomes. Significantly higher body mass index, luteinizing hormone level, and luteinizing hormone/follicle stimulating hormone ratio observed in clomiphene citrate resistant group can be a possible explanation for this impedance.

Chromium picolinate reduces insulin resistance in polycystic ovary syndrome: Randomized controlled trial

AIM

To investigate the effect of chromium picolinate (CrP) on insulin resistance (IR) in polycystic ovary syndrome (PCOS).

METHODS

This double blinded randomized controlled trial was conducted in the Gynecology outpatient clinics at Ain Shams University Women's Hospital. Using closed and randomly mixed envelopes, 100 women were selected out of 400 PCOS patients. Eighty-five patients finished the study and were analyzed, 44 in group I and 41 in group II. They were randomly allocated to 6 months of either 1000 μg CrP (50 patients), or placebo capsules (50 patients). Patients were seen monthly to encourage similar diet control and physical exercise plans. The primary outcome was fasting glucose insulin ratio (FGIR), secondary outcomes included ovulation, regularity of the cycle, body mass index (BMI), fasting blood sugar (FBS), fasting serum insulin (FSI), and serum testosterone level.

RESULTS

There were no significant differences between women of both groups regarding pretreatment levels of FBS, FSI, FGIR, and serum testosterone. Use of CrP for 6 months was associated with significant reduction of BMI (P < 0.001) and FSI (P = 0.007), and significant rise in FGIR (P = 0.045). CrP significantly increased the chances of ovulation (P = 0.011) and regular menstruation (P = 0.002) by almost twofold after the fifth month of treatment.

CONCLUSION

Chromium picolinate is useful in PCOS to reduce IR and stimulate ovulation.

Correlation of Skin Changes with Hormonal Changes in Polycystic Ovarian Syndrome: A Cross-sectional Study Clinical Study

Background:

Polycystic ovarian syndrome (PCOS) is a heterogenous collection of signs and symptoms that when gathered, form a spectrum of disorder with disturbance of reproductive, endocrine and metabolic functions.

Aim:

The aim of this study is to correlate the skin manifestations with hormonal changes and to know the incidence and prevalence of skin manifestations in patients with PCOS.

Materials and Methods:

A total of 40 patients with PCOS were examined during 1 year time period from May 2008 P to May 2009. Detailed clinical history was taken from each patient. PCOS was diagnosed on the basis of ultrasonography. Hormonal assays included fasting blood sugar, postprandial blood sugar, follicle-stimulating hormone, luteinizing hormone, thyroid stimulating hormone, dehydroepiandrostenedione, prolactin, free testosterone, fasting lipid profile and sex hormone binding globulin. The results obtained were statistically correlated.

Results:

In our study, the prevalence of cutaneous manifestations was 90%. Of all the cutaneous manifestations acne was seen in highest percentage (67.5%), followed by hirsutism (62.5%), seborrhea (52.5%), androgenetic alopecia (AGA) (30%), acanthosis nigricans (22.5%) and acrochordons (10%). Fasting insulin levels was the most common hormonal abnormality seen in both acne and hirsutism, whereas AGA was associated with high testosterone levels.

Conclusion:

The prevalence of cutaneous manifestations in PCOS was 90%. Hirsutism, acne, seborrhea, acanthosis nigricans and acrochordons were associated with increased levels of fasting insulin, whereas AGA showed higher levels of serum testosterone.

Importance of cannulated prolactin test in the definition of hyperprolactinaemia

PURPOSE

Recent guidelines suggest that a single prolactin measurement is adequate to confirm hyperprolactinaemia. This may lead to unnecessary investigation of artefactual hyperprolactinaemia. Prolactin measurement drawn from an indwelling cannula after rest removes stress as a confounding variable. The objective was to determine the frequency of true hyperprolactinaemia amongst patients referred following a single prolactin measurement.

METHODS

A cannulated study was considered if prolactin on referral ('Referral Prolactin') was <5,500 mU/L (260 ng/mL) but >410 mU/L (19 ng/mL) in males or >510 mU/L (24 ng/mL) in females, irrespective of clinical context. Case-notes of 267 patients undergoing cannulated prolactin measurement over a 10-year period (2000-2010) were reviewed. Pre-existing pituitary disease, dopamine antagonist use, and macroprolactinaemia were excluded. Morning ante-cubital vein cannulation was followed immediately by withdrawal of 'Repeat Prolactin' sample. After 120-min bed-rest, 'Resting Prolactin' was withdrawn through the cannula.

RESULTS

235 patients were included for analysis. 64 (27%) were within normal range; following Repeat Prolactin in 41 (17%) and Resting Prolactin in 23 (9%) cases. Referral Prolactin was higher in patients with true hyperprolactinaemia, 1,637 ± 100 mU/L (77.2 ± 4.7 ng/mL) than with artefactual hyperprolactinaemia, 1,122 ± 68 mU/L (52.9 ± 3.2 ng/mL; P < 0.001) but there was substantial overlap. 21 out of 171 cases (12%) with true hyperprolactinaemia had a macroadenoma. Presenting symptoms did not predict true hyperprolactinaemia. Referral Prolactin of 2,000 mU/L (94 ng/mL) had 97% specificity to identify true hyperprolactinaemia.

CONCLUSIONS

Reliance on a single, non-rested prolactin value may lead to over-diagnosis of hyperprolactinaemia. A resting sample should be considered with random values <2,000 mU/L (94 ng/mL).

Herbal medicine for the management of polycystic ovary syndrome (PCOS) and associated oligo/amenorrhoea and hyperandrogenism; a review of the laboratory evidence for effects with corroborative clinical findings

BACKGROUND

Polycystic ovary syndrome (PCOS) is a prevalent, complex endocrine disorder characterised by polycystic ovaries, chronic anovulation and hyperandrogenism leading to symptoms of irregular menstrual cycles, hirsutism, acne and infertility. Evidence based medical management emphasises a multidisciplinary approach for PCOS, as conventional pharmaceutical treatment addresses single symptoms, may be contra-indicated, is often associated with side effects and not effective in some cases. In addition women with PCOS have expressed a strong desire for alternative treatments. This review examines the reproductive endocrine effects in PCOS for an alternative treatment, herbal medicine. The aim of this review was to identify consistent evidence from both pre-clinical and clinical research, to add to the evidence base for herbal medicine in PCOS (and associated oligo/amenorrhoea and hyperandrogenism) and to inform herbal selection in the provision clinical care for these common conditions.

METHODS

We undertook two searches of the scientific literature. The first search sought pre-clinical studies which explained the reproductive endocrine effects of whole herbal extracts in oligo/amenorrhoea, hyperandrogenism and PCOS. Herbal medicines from the first search informed key words for the second search. The second search sought clinical studies, which corroborated laboratory findings. Subjects included women with PCOS, menstrual irregularities and hyperandrogenism.

RESULTS

A total of 33 studies were included in this review. Eighteen pre-clinical studies reported mechanisms of effect and fifteen clinical studies corroborated pre-clinical findings, including eight randomised controlled trials, and 762 women with menstrual irregularities, hyperandrogenism and/or PCOS. Interventions included herbal extracts of Vitex agnus-castus, Cimicifuga racemosa, Tribulus terrestris, Glycyrrhiza spp., Paeonia lactiflora and Cinnamomum cassia. Endocrine outcomes included reduced luteinising hormone (LH), prolactin, fasting insulin and testosterone. There was evidence for the regulation of ovulation, improved metabolic hormone profile and improved fertility outcomes in PCOS. There was evidence for an equivalent effect of two herbal medicines and the pharmaceutical agents bromocriptine (and Vitex agnus-castus) and clomiphene citrate (and Cimicifuga racemosa). There was less robust evidence for the complementary combination of spirinolactone and Glycyrrhiza spp. for hyperandrogenism.

CONCLUSIONS

Preclinical and clinical studies provide evidence that six herbal medicines may have beneficial effects for women with oligo/amenorrhea, hyperandrogenism and PCOS. However the quantity of pre-clinical data was limited, and the quality of clinical evidence was variable. Further pre-clinical studies are needed to explain the effects of herbal medicines not included in this review with current clinical evidence but an absence of pre-clinical data.

Polycystic ovary syndrome: a review for dermatologists: Part I. Diagnosis and manifestations

Polycystic ovary syndrome (PCOS) is a common endocrine disorder among women who are of reproductive age. The pathogenesis involves several associated hormonal pathways that culminate in metabolic, reproductive, and cardiovascular effects. The hallmark features of hyperandrogenism and hyperinsulinemia have systemic long-term implications. Dermatologists frequently evaluate and manage the cutaneous manifestations of PCOS (ie, acanthosis nigricans, hirsutism, acne, and alopecia), and therefore play a key role in its diagnosis and management. In part I of this continuing medical education article, we review the definition, etiology, pathogenesis, and clinical features of PCOS.

Physical activity and mental health in women with polycystic ovary syndrome

Background

Physical activity is prescribed as a component of primary management for Polycystic Ovary Syndrome (PCOS). This study investigates the association between physical activity and mental health as well as the exercise barriers, motivators and support providers for younger women with and without PCOS to assist in physical activity uptake and prescription for these women.

Methods

Women aged 18-50 years with (n = 153) and without PCOS (n = 64) completed a questionnaire at one time point. The questionnaire included the Hospital Anxiety and Depression Scale and a survey regarding levels of physical activity, physical activity barriers, motivators and supports. A MANCOVA assessed associations between physical activity, PCOS and mental health (specifically depression and anxiety). Descriptive and Chi square goodness of fit statistics assessed the differences in perceived barriers, motivators and support providers amongst women with and without PCOS.

Results

Women with PCOS displayed higher severity of depression (F(1,210) = 8.32, p = 0.004) and anxiety (F(1,210) = 17.37, p < 0.001) symptoms compared to controls. Overall, for physically active women, depression was significantly less severe than in their inactive counterparts (F(2,210) = 13.62, p < 0.001). There were no differences in anxiety by physical activity status and no interaction effects between PCOS and activity status for depression or anxiety. Women with PCOS were more likely to report a lack of confidence about maintaining physical activity (Χ² = 3.65; p = 0.046), fear of injury (Χ² = 4.08; p = 0.043) and physical limitations (Χ² = 11.92; p = 0.001) as barriers to physical activity and were more likely to be motivated to be active to control a medical condition (Χ² = 7.48; p = 0.006). Women with PCOS identified more sources of support compared to women without PCOS.

Conclusions

Physical activity is associated with lower depression in women with PCOS and differences exist in the self-reported physical activity barriers, motivators and support providers, compared to controls. Being more active may offer mental health benefits in managing PCOS. Prescribing physical activity to women with PCOS should be individualized and consider both common and PCOS-specific barriers and motivators for successful engagement.

Polycystic ovary syndrome: current status and future perspective

Polycystic ovary syndrome (PCOS) is a widespread reproductive disorder that encompasses many associated health conditions and has an impact on various metabolic processes. PCOS is depicted by hyperandrogenism, polycystic ovaries, and anovulation. It increases the risk of insulin resistance (IR), type 2 diabetes, obesity, and cardiovascular disease. The etiology of the disease remains unclear, and the subjective phenotype makes a united diagnosis difficult among physicians. It seems to be a familial genetic syndrome caused by a combination of environmental and genetic factors. It can be linked with metabolic disorders in first-degree family members. PCOS is the cause of up to 30% of infertility in couples seeking treatment. Currently, there is no cure for PCOS. Despite the growing incidence of this syndrome, limited research has been done that encompasses the entirety of PCOS spectrum. In this review, the current status and possible future perspective will be discussed.

Insulin resistance and the polycystic ovary syndrome revisited: an update on mechanisms and implications

Polycystic ovary syndrome (PCOS) is now recognized as an important metabolic as well as reproductive disorder conferring substantially increased risk for type 2 diabetes. Affected women have marked insulin resistance, independent of obesity. This article summarizes the state of the science since we last reviewed the field in the Endocrine Reviews in 1997. There is general agreement that obese women with PCOS are insulin resistant, but some groups of lean affected women may have normal insulin sensitivity. There is a post-binding defect in receptor signaling likely due to increased receptor and insulin receptor substrate-1 serine phosphorylation that selectively affects metabolic but not mitogenic pathways in classic insulin target tissues and in the ovary. Constitutive activation of serine kinases in the MAPK-ERK pathway may contribute to resistance to insulin's metabolic actions in skeletal muscle. Insulin functions as a co-gonadotropin through its cognate receptor to modulate ovarian steroidogenesis. Genetic disruption of insulin signaling in the brain has indicated that this pathway is important for ovulation and body weight regulation. These insights have been directly translated into a novel therapy for PCOS with insulin-sensitizing drugs. Furthermore, androgens contribute to insulin resistance in PCOS. PCOS may also have developmental origins due to androgen exposure at critical periods or to intrauterine growth restriction. PCOS is a complex genetic disease, and first-degree relatives have reproductive and metabolic phenotypes. Several PCOS genetic susceptibility loci have been mapped and replicated. Some of the same susceptibility genes contribute to disease risk in Chinese and European PCOS populations, suggesting that PCOS is an ancient trait.

Study of Omentin1 and Other Adipokines and Hormones in PCOS Patients

OBJECTIVES

Polycystic ovary syndrome (PCOS) is associated with insulin resistance and obesity. Recent studies have shown that plasma omentin-1 levels decrease with obesity. Currently, no data exists on the relative correlation between omentin-1 with other adipokines or the expression and regulation of omentin-1 in the serum of women with PCOS. The objective of this study is to evaluate the role of omentin-1 levels or omentin-1 /adipokines ratio in the serum of women with PCOS compared with matched control subjects.

METHODS

The study involved 60 patients with PCOS and 30 women without PCOS who were used as controls. To examine the relationship between fasting serum omentin-1 and serum interleukin-6 (IL-6), interleukin-8 (IL-8), resistin, ghrelin, leptin RBP-4 and tumor necrosis factor-a (TNF-a) levels in infertile PCOS and non-PCOS subjects. Also, insulin and other hormones were measured in both groups. All these factors were measured by enzyme-linked immunosorbent assays.

RESULTS

From the total of 60 cases, there was a significant increase (p<0.001) in PCOS patients when compared to the control group in fasting serum, serum interleukin-6 (IL-6), interleukin-8 (IL-8), resistin, leptin RBP-4, tumor necrosis factor-a (TNF-a) levels and insulin. A significant decrease in omentin-1 and ghrelin (p<0.001) was observed. The results also showed that 93.33% and 98.30% in PCOS patients had abnormal omentin1: Insulin ratio and omentin1: Resistin ratio respectively according to the cut off values ≤27.42 and ≤31.35. Moreover, 81.67% of PCOS patients had abnormal omentin1:IL-6 ratio according to the cut of value (≤66.09).

CONCLUSION

This is the first time the role of plasma omentin1 has been investigated with respect to its implication in PCOS. Usually, LH/FSH ratio and FAI (ratio of total testosterone to SHBG) are the important factors used for the diagnosis of PCOS in all previous literature, but none of them referred to the parameters discussed in this report. Also, the percentage of sensitivity and the difference between range of these parameters in PCOS patients and the controls may give a different perspective in trying to understand the etiology of PCOS. Therefore, these parameters may be used for future diagnosis of PCOS. This study also suggested that omentin/resistin ratio may play a crucial paracrine or endocrine role in modulating insulin sensitivity.

Hair loss and hyperprolactinemia in women

In the literature of the past 30 years there are only some publications concerned with hair loss and hyperprolactinemia in women. Therefore, the relevance of hyperprolactinemia was evaluated in 40 women with diffuse alopecia.Hair loss was assessed by clinical appearance and the pluck trichogram. 82.5% of the female patients had diffuse hair loss and 17.5% had androgenetic alopecia.The highest prolactin values measured were 1390 ng/ml and 255 ng/ml. Six patients had values between 150-80.4 ng/ml and 10 between 79.1-51.7 ng/ml. All others had prolactin values below 50 ng/ml. Fifteen untreated patients with elevated prolactin levels could be followed up. Without any prolactin-inhibiting drugs, reductions and normalizations beside moderate fluctuations could be detected.Thyroid-specific diagnostics showed in 95% of the patients a normal thyroid function. 2.5% had a slight hyperthyreoidism and 2.5% had a slight hypothyreoidism. No female patient had clinical signs of androgenization and the determined androgens testosterone, androstendione and dihydroepiandrostendione were in the normal range.According to these results, moderate elevated prolactin levels in association with diffuse or androgenetic hair loss can be neglected as causative for the hair loss, because there is no evidence that they have an influence to the pattern, the extent or the duration of the hair loss. These results are supported by investigations of other authors who described only in high doses of prolactin an inhibiting effect on human hair follicles in vitro. Nevertheless, moderate constantly elevated prolactin levels should induce further diagnostics to exclude a prolactin-producing tumor of the pituitary gland.

Different diagnostic power of anti-Mullerian hormone in evaluating women with polycystic ovaries with and without hyperandrogenism

PURPOSE

The aim of this study is to compare the secretory profiles and diagnostic power of anti-Mullerian hormone (AMH) for the PCOS patient with and without hyperandrogenism.

METHODS

One hundred and thirty-one PCOS patients with oligomenorrhea or amenorrhea were recruited into the study. Sixty-two and sixty-nine patients had and did not have hyperandrogenism (HA+) hyperandrogenism (HA-), respectively. Sera were collected for determining the levels of AMH, basal sexual hormones, glucose and lipid metabolic indicators.

RESULTS

The AMH serum levels of PCOS patients were significantly higher than the control group, with the highest AMH serum level in the HA+ group. The cut-off value for predicting PCOS patients of all types was 3.92 ng/mL, with a sensitivity of 65 %, and specificity of 62 %. The cut-off value for predicting PCOS patients in the HA+ group was 4.23 ng/mL, with a sensitivity of 82 %, and specificity of 64 %. The cut-off value for predicting PCOS patients in the HA- group was 3.76 ng/mL, with a sensitivity of 64 %, and specificity of 62 %. In the HA+ group, AMH was negatively associated with FSH and positively associated with LH. In the HA- group, AMH was negatively associated with HDL and positively associated with BMI, fasting glucose and LDL.

CONCLUSIONS

AMH is only suitable for predicting the PCOS patients with hyperandrogenism. The diagnostic power of AMH is limited when used to predict patients without hyperandrogenism. It reflects the differences in pathophysiology and severity of disrupted folliculogenesis between the two subtypes.

Effectiveness of GnRH antagonist multiple dose protocol applied during early and late follicular phase compared with GnRH agonist long protocol in non-obese and obese patients with polycystic ovary syndrome undergoing IVF/ICSI

Objective

To evaluate the effectiveness of GnRH antagonist multiple dose protocol applied during early and late follicular phase (MDP-EL) in comparison with standard GnRH agonist luteal long protocol (LP) in each non-obese and obese polycystic ovary syndrome (PCOS) women undergoing IVF.

Methods

Two hundred eleven infertile women with PCOS were recruited and randomized to undergo either GnRH antagonist MDP-EL (antagonist group) or standard GnRH agonist luteal LP (agonist group). IVF cycle outcomes were compared between the two groups.

Results

Total dose and days of recombinant human follicle stimulating hormone (rhFSH) administered were significantly fewer in the antagonist group than in the agonist group. Incidence of severe ovarian hyperstimulation syndrome was significantly lower in the antagonist group. However, IVF and pregnancy outcomes were similar in the two groups. When all subjects were divided into non-obese and obese subgroups, in non-obese PCOS subgroup, IVF and pregnancy outcomes were comparable in the antagonist and agonist groups but total dose and days of rhFSH were also significantly fewer in the antagonist group. Similar findings were also observed in obese PCOS subgroup.

Conclusion

GnRH antagonist MDP-EL is at least as effective as GnRH agonist LP and may be a more patient-friendly alternative in controlled ovarian stimulation for PCOS patients undergoing IVF, independent of body mass index.

Polycystic Ovary Syndrome and Chronic Inflammation: Pharmacotherapeutic Implications

Objective:

To examine the relationship between polycystic ovary syndrome (PCOS), cardiovascular risk factors, cardiovascular disease (CVD), and chronic inflammation and analyze data regarding pharmacologic therapies that are recommended to reduce CVD risk in PCOS and the impact of those therapies on chronic inflammation.

Data Sources:

A search of MEDLINE (1950-October 2011) was conducted to identify clinical studies pertaining to the identification and treatment of CVD and chronic low-grade inflammation in PCOS, Search terms included polycystic ovary syndrome, cardiovascular disease, inflammation, metformin, thiazolidinedione, and statin. Bibliographies of these studies and review articles were also examined.

Study Selection and Data Extraction:

English-language clinical studies evaluating the effect of metformin, thiazolidinediones, and statins on inflammatory markers, endothelial function, adhesion molecules, fibrinolysis, cytokines, and adipokines in PCOS were included.

Data Synthesis:

Women with PCOS have an increased prevalence of many cardiovascular risk factors including obesity, android fat distribution, insulin resistance, impaired glucose tolerance, diabetes, dyslipidemia, hypertension, and metabolic syndrome. Markers of chronic low-grade inflammation, which are associated with an increased risk of CVD, are also elevated in PCOS. Clinical guidelines recommend the use of insulin sensitizers and statins to prevent CVD in some patients with PCOS. Current literature indicates that each of these medication classes has beneficial effects on inflammation, as well. Although there are currently no studies to determine whether these treatments decrease CVD in PCOS, it can be hypothesized that drugs impacting chronic inflammation may reduce cardiovascular risk. Some studies show that metformin, thiazolidinediones, and statins have beneficial effects on inflammatory markers in PCOS; however, the data are inconsistent.

Conclusions:

There is insufficient information to recommend any pharmacologic therapies for their antiinflammatory effects in PCOS in the absence of other indications such as diabetes and dyslipidemia.

Statins for women with polycystic ovary syndrome not actively trying to conceive

BACKGROUND

Statins, as lipid-lowering agents with pleiotropic actions, are likely not only to improve the dyslipidaemia associated with polycystic ovary syndrome but may also exert other beneficial metabolic and endocrine effects.

OBJECTIVES

To assess the efficacy and safety of statin therapy for women with polycystic ovary syndrome (PCOS) who are not actively trying to conceive.

SEARCH STRATEGY

We searched the following databases (from inception to week 1, July 2011): the Cochrane Menstrual Disorders and Subfertility Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and CINAHL. We handsearched relevant conference proceedings and references of the identified articles for additional studies. We also contacted experts for further studies in progress.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing a statin versus placebo or statin in combination with another drug versus another drug alone in women with PCOS.

DATA COLLECTION AND ANALYSIS

Two review authors performed data collection and analysis independently.

MAIN RESULTS

Four trials fulfilled the criteria for inclusion. They comprised a total of 244 women with PCOS receiving 12 weeks or 6 weeks of treatment. Two trials (184 women randomised) studied the effects of simvastatin and two trials (60 women randomised) studied the effects of atorvastatin. There was no good evidence that statins improved menstrual regularity, spontaneous ovulation rate, hirsutism or acne, either alone or in combination with the combined oral contraceptive pill (OCP). Nor were there any significant effects on body mass index (BMI). Statins were effective in lowering testosterone levels (nmol/L) (mean difference (MD) -0.90, 95% CI -1.18 to -0.62, P < 0.00001, 3 RCTs, 105 women) when used alone or with the OCP. Statins also improved total cholesterol, low-density lipoprotein (LDL) and triglycerides but had no significant effect on high-density lipoprotein (HDL) levels, high sensitivity (HS) C-reactive protein (HS-CRP), fasting insulin or homeostatic model assessment (HOMA) insulin resistance. No serious adverse events were reported in any of the included studies.

AUTHORS' CONCLUSIONS

Although statins improve lipid profiles and reduce testosterone levels in women with PCOS, there is no evidence that statins improve resumption of menstrual regularity or spontaneous ovulation, nor is there any improvement of hirsutism or acne. There is a need for further research to be performed with large sample sizes and well-designed RCTs to assess clinical outcomes.

Hirsutism Score and the Severity of Hyperandrogenism Associated with Polycystic Ovary Syndrome in the South-Eastern Region of Turkey

This study investigated the severity of hirsutism and its correlation with serum total testosterone (tT) levels in 87 patients with polycystic ovary syndrome (PCOS) and 85 healthy control subjects from the south-eastern region of Turkey. A wide range of variability exists in both hirsutism and modified Ferriman—Gallwey (mFG) scores. Similar mFG scores and serum tT levels were found compared with previous studies of general populations, but lower scores than those previously reported from Turkey. The incidence of hirsutism was lower in hyperandrogenic PCOS patients compared with non-hyperandrogenic PCOS patients. There was no correlation between serum tT levels and the rate of hirsutism in patients with PCOS. Heritability, testosterone receptor sensitivity, 5α reductase activity or environmental/socioeconomic factors may play a role in the development of clinical hirsutism. Larger scale studies are needed to clarify which other factors may be responsible and to confirm these results.

Prevalence of polycystic ovarian syndrome in Indian adolescents

BACKGROUND

PCOS is a common female endocrine disorder with prevalence ranging from 2.2% to 26%. Most reports have studied adult women with age ranged from 18 to 45 years. The aim of this study was to find the prevalence of PCOS in Indian adolescents.

METHOD

We prospectively studied 460 girls aged 15 to 18 years from a residential college in Andhra Pradesh, South India, who underwent clinical examination. Out of which 72 girls with oligomenorrhea and/or hirsutism were invited for biochemical, hormonal, and ultrasonographic evaluation for diagnosis of PCOS by Rotterdam criteria. PCOS was defined as the presence of any two of the three features: (1) Oligo/amenorrhea: absence of menstruation for 45 days or more and/or ≤8 menses per year. (2) Clinical hyperandrogenism: Modified Ferriman and Gallway (mFG) score of 6 or higher. (3) Polycystic ovaries: presence of >10 cysts, 2-8 mm in diameter, usually combined with increased ovarian volume of >10 cm(3), and an echo-dense stroma in pelvic ultrasound scan.

RESULTS

Out of 460 girls, one (0.22%) had oligo/amenorrhea with clinical hyperandrogenism, 29 (6.30%) had oligomenorrhea with polycystic ovaries, one (0.22%) had polycystic ovaries with clinical hyperandrogenism and 11 (2.39%) had oligomenorrhea with polycystic ovaries in the presence of clinical hyperandrogenism. Thus 42 (9.13%) girls satisfied Rotterdam's criteria for PCOS, which increased to 50.46 (10.97%) when imputed data were included.

CONCLUSION

Prevalence of PCOS in Indian adolescents is 9.13%.This draws attention to the issue of early diagnosis in adolescent girls.

Exogenous hCG activity, but not endogenous LH activity, is positively associated with live birth rates in anovulatory infertility

Objective

To evaluate, retrospectively, the roles of endogenous and exogenous luteinising hormone (LH) activity on live birth rate in ovulation induction cycles.

Methods

Associations between LH activity at baseline, end of stimulation and live birth rate were analysed in relation to patient characteristics, baseline and end of stimulation variables in WHO group II anovulatory women (n=155) stimulated with recombinant follicle-stimulating hormone (rFSH) or highly purified human menopausal gonadotrophin (HP-hMG). HP-hMG provides FSH and exogenous LH activity mainly in the form of human chorionic gonadotrophin (hCG).

Results

Serum LH concentrations at baseline or end of stimulation were not predictive of live birth rate in the rFSH group (n=79) or HP-hMG group (n=76). Serum hCG concentration at end of stimulation was a significant positive predictor in HP-hMG-treated women. Other variables were not independently predictive of live birth in either of the groups, except for a negative association between serum FSH concentrations at the start of stimulation and live birth in the rFSH-treated group.

Conclusions

Endogenous LH concentrations are not predictive of live birth in anovulatory WHO group II patients undergoing ovulation induction with rFSH or HP-hMG. On the other hand, exogenous hCG activity during HP-hMG stimulation is positively associated with treatment outcome.

Serum vaspin and C-reactive protein levels in women with polycystic ovaries and polycystic ovary syndrome

OBJECTIVE

Our aim was to evaluate C-reactive protein (CRP) and serum vaspin levels in women with polycystic ovary syndrome (PCOS) or polycystic ovaries (PCO).

DESIGN

Twenty-four women with PCOS and 23 women with PCO constituted the study groups. The control group comprised 24 healthy women.

METHODS

Homeostatic model assessment for insulin resistance (HOMA-IR), CRP and serum vaspin levels were measured. The receiver-operating characteristic curve (ROC) of vaspin for prediction of women with increased diabetogenic risk was constructed.

RESULTS

The three groups did not significantly differ in age and body mass index. HOMA-IR was significantly higher in the PCOS and PCO groups than in control group. Median CRP levels in the control, PCO and PCOS groups were 0.66, 1.28 and 3.2 mg/l, respectively (p = 0.0001). Women with PCOS had significantly higher serum vaspin levels than the healthy controls [3.52 ± 1.38 vs. 0.36 ± 0.19 ng/ml, p = 0.0001]. Serum vaspin could differentiate between women with and without increased diabetogenic risk at a cut-off value of 1.82 ng/ml with a sensitivity of 83.3% and a specificity of 66.1%.

CONCLUSION

The results of our study showed that the presence of the increased vaspin, CRP and higher HOMA-IR levels in women with PCOS and PCO could contribute to increased diabetogenic and atherogenic risk in these patients.

Use of metformin in the treatment of polycystic ovary syndrome

Metformin is quite an old drug, but it is optimal for the control of glycemia in Type 2 diabetes. It was reported, 15 years ago, that insulin resistance was abnormally high in most polycystic ovary syndrome (PCOS) patients. Starting from that moment, increasing numbers of studies were performed to demonstrate the efficacy of metformin in controlling and/or modulating several aspects of PCOS, which is the most common cause of menstrual irregularity, inesthetisms and infertility. Metformin induces higher glucose uptake, thus inducing a lower synthesis/secretion of insulin. Such an effect permits the possible restoration of the normal biological functions that are severely affected by the compensatory hyperinsulinemia reactive to the increased peripheral insulin resistance. These are the basis of the many positive effects of this drug, such as the restoration of menstrual cyclicity, ovulatory cycles and fertility, because abnormal insulin levels affect the hypothalamus-pituitary-ovarian function, as well as the use of glucose in peripheral tissues. Metformin improves the impairments typically observed in hyperinsulinemic PCOS patients, reducing the possible evolution towards metabolic syndrome and Type 2 diabetes; and when pregnancy occurs, it consistently reduces the risk of gestational diabetes, eclampsia and hypertension. PCOS seems to be the perfect physiopathological condition that might have higher benefits from metformin administration, obviously after Type 2 diabetes. This review focuses on the many aspects of PCOS and on the possible issues of this disease for which metformin might be a putative optimal treatment.

Insulin resistance and the long-term consequences of polycystic ovary syndrome

In a significant number of women with the polycystic ovary syndrome there is impaired insulin metabolism with hypersecretion of insulin. Insulin resistance is defined as a diminution in the glucose response to a given amount of insulin. Insulin resistance has been implicated in the pathogenesis of many aspects of the syndrome. Hyperinsulinaemia leads to increased production of androgens resulting in anovulatory infertility. Women and particularly obese women with insulin resistance and the polycystic ovary syndrome have an increased risk of developing gestational diabetes and also type 2 diabetes and cardiovascular disease in later life. The women should be counselled about long-term health risks, and obese women with the polycystic ovary syndrome should be periodically screened. Lifestyle modification to reduce weight in obese women and treatment with insulin-sensitising drugs such as metformin in women with glucose intolerance result in the improvement of some metabolic abnormalities and hyperandrogenic disorders with the consequent restoration of normal menstrual and ovulatory function in a significant number of women with polycystic ovaries.

Antiepileptic drugs, sex hormones, and PCOS

Reproductive endocrine dysfunction in women with epilepsy is an important issue, and in recent years there is growing evidence to support the effect on sex hormones of both epilepsy per se and various antiepileptic drugs (AEDs). Focal epileptic discharges from the temporal lobe may have a direct influence on the function of the hypothalamic-pituitary axis, thereby altering the release of sex steroid hormones. The role of laterality and severity of epilepsy is still conflicting. The use of the liver enzyme-inducing AEDs--such as phenobarbital, phenytoin, and carbamazepine--can increase serum sex hormone-binding globulin concentrations, leading to diminished bioactivity of testosterone (T) and estradiol. Valproic acid, an enzyme inhibitor, has been associated with the occurrence of reproductive endocrine disorders characterized by high serum T, free androgen index, androstenedione, dehydroepiandrosterone sulfate concentrations, and with polycystic changes in ovaries and menstrual disorders. A better understanding of the effects of AEDs on sex hormones is key to selecting the appropriate AEDs and is crucial for reproductive health in female patients.

Obesity and polycystic ovary syndrome: association with androgens, leptin and its genotypes

Obesity and hyperandrogenaemia are key features of polycystic ovary syndrome (PCOS). The aim of this study was to investigate whether leptin and androgens are associated with obesity in PCOS subjects and identify whether there exist any genetic alterations in leptin gene in women with PCOS. The results reveal that leptin levels are elevated in women with PCOS and associate with BMI. However, irrespective of the obesity status leptin levels are higher in PCOS cases indicating that increased BMI/obesity may not be the only factor contributing to elevated levels of leptin. With regard to testosterone and androstenedione, the levels were increased in obese individuals irrespective of PCOS status. No correlation between leptin and androstenedione or testosterone was observed in controls and PCOS subjects. The single-nucleotide polymorphism G19A detected in the untranslated exon 1 of leptin gene was not associated with PCOS and does not contribute to elevated levels of leptin. The results overall suggest that androgen and leptin levels are increased in PCOS and obesity. It demonstrates that obesity is a confounding factor for hyperandrogenaemia irrespective of their PCOS status. The study rules out role of obesity status and leptin genotype in increase in leptin levels observed in PCOS cases.

Obesity-related lipid profile and altered insulin incretion in adolescents with polycystic ovary syndrome

PURPOSE

The objective of this study was evaluate influence of body mass index (BMI), hyperinsulinemia and/or insulin resistance (IR), and androgens on the lipid profile of adolescent polycystic ovary syndrome (PCOS).

METHODS

A total of 71 PCOS and 94 healthy adolescent girls from a Southern Italian region were included in the study. At day 5-8 of menstrual cycle, patients underwent a 75-g oral glucose tolerance test to evaluate insulin levels; lipid and homocysteine levels were also assessed, baseline hormonal assays and ultrasound examination performed, and anthropometric characteristics measured.

RESULT

No differences were observed in the incidence of overweight or obesity and total cholesterol, high-density lipoprotein (HDL) cholesterol level, low-density lipoprotein cholesterol level; triglycerides and homocysteine levels did not differ between PCOS and control groups. All fasting metabolic indexes were similar, whereas insulin secretion after glucose load (I-AUC) was significantly higher in PCOS subjects. Total cholesterol levels were significantly related to waist-hip ratio (WHR). Low-density lipoprotein level was positively correlated with BMI, waist, WHR, and homeostasis model assessment (HOMA) but not I-AUC. Findings obtained for HDL correlated negatively to the same parameters, being also negatively correlated to both fasting insulin and HOMA, but not I-AUC. Moreover, HDL was positively correlated to circulating androstenedione (A) and negatively to circulating testosterone (T) levels. Triglycerides seemed to correlate positively with body BMI, waist, and WHR, and negatively with A levels. Homocysteine levels correlated positively with plasma triglyceride content.

CONCLUSION

In the adolescent population studied, no differences were revealed in lipid profile between PCOS and controls. The PCOS is not a discriminant factor. The anthropometric characteristics resulted in the primary factor influencing the lipid derangement, confirming the importance of treating obesity at an early age to reduce morbidity rates. Hyperinsulinemia and IR, peculiarities of PCOS capable of influencing long-term evolution into cardiovascular diseases and diabetes mellitus, are not associated with worse lipid profile. Young patients should be encouraged and motivated to change their lifestyle, with the aim of losing weight and thus reducing risk of onset of overt dyslipidemia.