Prevalence of polycystic ovaries in women with anovulation and idiopathic hirsutism

Effect of metformin on anti-mullerian hormone levels in women with polycystic ovarian syndrome: a systematic review and meta-regression analysis of randomized controlled trials with

BACKGROUND

Several interventional studies have evaluated the potential anti-Mullerian hormone (AMH)-reduction effect of metformin. However, the results are still contradictory. In order to obtain a better viewpoint from them, this study aimed to comprehensively investigate the effects of metformin on AMH in the women with with polycystic ovarian syndrome (PCOS).

METHODS

Scopus, PubMed/Medline, Web of Science, Cochrane, and Embase databases were searched using standard keywords to identify all controlled trials investigating the AMH levels following metformin administration. Pooled weighted mean difference and 95% confidence intervals were achieved by random-effects model analysis for the best estimation of outcomes.

RESULTS

Sixteen studies with 484 participants' were included in this article. The pooled findings showed that AMH levels in the single arm clinical trials were significantly reduced (pooled WMD of -3.06 ng/ml; 95% confidence interval [CI] -4.03 to -2.10; P < 0.001) after use of metformin. Furthermore, compared to the control group, in randomized clinical trials, a reduced significant effect on AMH levels was observed following use of metformin (pooled WMD of -3.47 ng/ml; 95% CI -7.14 to -0.19; P = 0.047). Furthermore, higher reduction in the AMH levels with a metformin dosage ≤ 1500 mg/day and duration of treatment ≤ 12 weeks when compared to higher dosages and duration of intervention, observed in this meta-analysis.

CONCLUSIONS

In conclusion, results this meta-analysis of clinical trials confirms the beneficial effect of the treatment with metformin in the reduction of the AMH levels in women.

Letrozole use in vitrified single-blastocyst transfer cycles is associated with lower risk of large for gestational age infants in patients with polycystic ovary syndrome

PURPOSE

To evaluate the obstetric and perinatal outcomes of three routine endometrial preparation protocols in women with PCOS who underwent frozen embryo transfer (FET).

METHODS

This was a retrospective study in women with PCOS who underwent FET in an academic reproductive medical center. A total of 2710 cycles were enrolled and classified into three groups according to different endometrial preparation protocols; human menopausal gonadotropin (HMG), letrozole + HMG, or hormone replacement therapy (HRT).

RESULTS

The stimulation groups had reduced risks of hypertensive disorders of pregnancy (HDP), large for gestational age (LGA) infants, and cesarean delivery than the HRT group. After adjustment for different confounder combinations in the two models, the frequencies of LGA and HDP in the letrozole + HMG group and the HMG group were still significantly lower than those in the HRT group. The letrozole + HMG group exhibited a reduced risk of LGA than HMG group after adjustment of confounders. A trend toward risk reductions in HDP and LGA was observe in turns of HRT, HMG, and letrozole + HMG groups, and the trends were statistically significant (Ptrend = 0.031 and 0.001).

CONCLUSION

In patients with PCOS, ovarian stimulation protocols for endometrial preparation are associated with reduced risks of HDP and LGA compared to HRT cycles. The use of letrozole could further reduce risk of LGA compared to HMG only protocol. We propose that ovarian stimulation protocols can be used widely for endometrial preparation in FET cycles in women with PCOS, especially with the use of letrozole.

Clinical Phenotypes of PCOS: a Cross-Sectional Study

This cross-sectional study examines the Doi-Alshoumer PCOS clinical phenotype classification in relation to measured clinical and biochemical characteristics of women with polycystic ovary syndrome (PCOS). Two cohorts of women (Kuwait and Rotterdam) diagnosed with PCOS (FAI > 4.5%) were examined. These phenotypes were created using neuroendocrine dysfunction (IRMA LH/FSH ratio > 1 or LH > 6 IU/L) and menstrual cycle status (oligo/amenorrhea) to create three phenotypes: (A) neuroendocrine dysfunction and oligo/amenorrhea, (B) without neuroendocrine dysfunction but with oligo/amenorrhea, and (C) without neuroendocrine dysfunction and with regular cycles. These phenotypes were compared in terms of hormonal, biochemical, and anthropometric measures. The three suggested phenotypes (A, B, and C) were shown to be sufficiently distinct in terms of hormonal, biochemical, and anthropometric measures. Patients who were classified as phenotype A had neuroendocrine dysfunction, excess LH (and LH/FSH ratio), irregular cycles, excess A4, infertility, excess T, highest FAI and E2, and excess 17αOHPG when compared to the other phenotypes. Patients classified as phenotype B had irregular cycles, no neuroendocrine dysfunction, obesity, acanthosis nigricans, and insulin resistance. Lastly, patients classified as phenotype C had regular cycles, acne, hirsutism, excess P4, and the highest P4 to E2 molar ratio. The differences across phenotypes suggested distinct phenotypic expression of this syndrome, and the biochemical and clinical correlates of each phenotype are likely to be useful in the management of women with PCOS. These phenotypic criteria are distinct from criteria used for diagnosis.

Analysis of the effect of hashimoto's thyroiditis and insulin resistance on ovarian volume in patients with polycystic ovary syndrome

OBJECTIVE

In this study, patients were divided into two groups. Patients with polycystic ovary syndrome (PCOS) and patients with polycystic ovary syndrome + Hashimoto's Thyroid (PCOS + HT). The effect of insulin resistance on ovarian volume in patients divided into two groups and the change in ovarian volume with the addition of HT to PCOS will be investigated.

MATERIAL AND METHODS

46 PCOS patients and 46 PCOS patients diagnosed with HT were included in this study. A detailed medical history was taken from all participants. Polycystic ovary image was evaluated as below or above 10 ml and antral follicles were counted by transvaginal ultrasound. Insulin resistance of the patients was evaluated according to the fasting insulin (HOMA) index.

RESULTS

Insulin resistance was found to be associated with fasting insulin, HOMA index, body mass index and right ovarian volume in patients diagnosed with PCOS. Among the patients diagnosed with PCOS + HT, insulin resistance was found to be significantly correlated with fasting insulin, HOMA index, (BMI), (SHBG) and left ovarian volume. An increase in right ovarian volume was found in 37.5% of patients with PCOS without insulin resistance and in 76.3% of patients with insulin resistance. An increase in left ovarian volume was found in 35.7% of patients without insulin resistance diagnosed with PCOS + HT and in 68.8% of patients with insulin resistance.

CONCLUSIONS

This study shows that ovarian volume should be evaluated in every PCOS patient in order to predict insulin resistance, which causes long-term metabolic diseases, and that all PCOS patients with increased ovarian volume should be investigated for insulin resistance. In addition, it has been observed that insulin resistance affects left ovarian volume in patients with PCOS + HT, whereas insulin resistance affects the volume of the right ovary more in patients with PCOS. At least one ovary has been found to be affected by long-term metabolic diseases. While there was a greater increase in ovarian volume with the addition of insulin resistance, no significant change was observed in the number of patients with increased ovarian volume (PCOS-58, PCOS + HT-57) with the addition of HT finding.

Evaluation of socio-demographic and clinical characteristics of PCOS patients attending a tertiary care institute in Colombo

BACKGROUND AND OBJECTIVES

Polycystic ovary syndrome (PCOS) is a common endocrine disorder with heterogeneous aetiology. It is characterized by irregular menses and or oligo/anovulation, hyper-androgenism, and polycystic ovaries. The prevalence and diagnosis of PCOS changes depending on which clinical criteria are utilized to confirm the diagnosis. The prevalence can be high as 8-13% when the Rotterdam criteria are used. However, there is significant inter-individual variation in presentation. We have studied the socio-demographic and clinical characteristics of PCOS patients attending the Endocrinology clinic in a tertiary care institute in Sri Lanka.

METHODS

A descriptive cross sectional study was conducted from September 2019 to September 2020 at the Endocrinology Unit of the National Hospital of Sri Lanka. All the patients who met the inclusion and exclusion criteria and who has a diagnosis of PCOS made according to Rotterdam criteria were recruited in to the study. After obtaining informed written consent, the data was collected using an interviewer administered questionnaire. HOMA-IR was calculated using the fasting insulin and blood glucose level.

RESULTS

The study enrolled sixty females. The mean age was 26.7 years (range 18-44). The mean weight was 64.8 (SD = 11.9) kg and BMI was 27.1 (SD = 4.8) kg/m^-2. According to Asian BMI cut-offs, 1 (1.7%) patient was underweight and 13 (21.7%) had normal weight. Forty six (76.7%) had their weight in the overweight or obese category. Fifty four (90.0%) patients had clinical or biochemical evidence of hyperandrogenism while 24 (40%) had polycystic ovaries on trans-abdominal ultrasound scan and 50 (83.3%) had irregular menstrual cycles. According to the body fat percentage assessed by the whole body DEXA scan 4.1% normal body fat, while 50.0% and 45.8% had overweight and obesity respectively. HOMA-IR detected 61.1% to have high insulin resistance. Out of the patients who had USS of the abdomen 27.5% had co-existent non-alcoholic fatty liver. Fifty four percent of the patients had sub/infertility.

CONCLUSIONS

The majority of the population were overweight or obese and had higher prevalence of insulin resistance and non-alcoholic fatty liver. Out of the clinical characteristics used to make the diagnosis of PCOS, the presence of clinical or biochemical evidence of hyperandrogenism and irregular menstrual cycles are more common than the detection of polycystic ovaries on trans-vaginal USS. The higher prevalence of overweight, obesity, insulin resistance and NAFLD associated with PCOS makes the diagnosis and management of the disease crucial to prevent long term consequences of the disease.

Menstrual Cycle Regularity and Length Across the Reproductive Lifespan and Risk of Cardiovascular Disease

Importance

Menstrual cycle characteristics may be associated with an increased risk of cardiovascular disease (CVD). However, existing studies are limited, and few have explored the mediating role of established CVD risk factors.

Objective

To explore the associations of menstrual cycle characteristics across the reproductive lifespan with the risk of CVD and to what extent these associations were mediated by hypercholesterolemia, chronic hypertension, and type 2 diabetes.

Design, Setting, and Participants

This cohort study prospectively followed Nurses' Health Study II participants between 1993 and 2017 who reported menstrual cycle regularity and length for ages 14 to 17 years and 18 to 22 years at enrollment in 1989 and updated current cycle characteristics in 1993 (at ages 29 to 46 years). Data analysis was performed from October 1, 2019, to January 1, 2022.

Exposures

Menstrual cycle regularity and length across the reproductive lifespan.

Main Outcomes and Measures

Incident CVD events of interest, including fatal and nonfatal coronary heart disease (CHD; myocardial infarction [MI] or coronary revascularization) and stroke.

Results

A total of 80 630 Nurses' Health Study II participants were included in the analysis, with a mean (SD) age of 37.7 (4.6) years and body mass index of 25.1 (5.6) at baseline. Over 24 years of prospective follow-up, 1816 women developed their first CVD event. Multivariable Cox proportional hazards models showed that, compared with women reporting very regular cycles at the same ages, women who had irregular cycles or no periods at ages 14 to 17, 18 to 22, or 29 to 46 years had hazard ratios for CVD of 1.15 (95% CI, 0.99-1.34), 1.36 (95% CI, 1.06-1.75), and 1.40 (95% CI, 1.14-1.71), respectively. Similarly, compared with women reporting a cycle length of 26 to 31 days, women reporting a cycle length 40 days or more or a cycle too irregular to estimate from ages 18 to 22 or 29 to 46 years had hazard ratios for CVD of 1.44 (95% CI, 1.13-1.84) and 1.30 (95% CI, 1.09-1.57), respectively. Mediation analyses showed that subsequent development of hypercholesteremia, chronic hypertension, and type 2 diabetes only explained 5.4% to 13.5% of the observed associations.

Conclusions and Relevance

In this cohort study, both irregular and long menstrual cycles were associated with increased rates of CVD, which persisted even after accounting for subsequently established CVD risk factors.

DO ANDROGENS PREDICT CARDIOVASCULAR RISK INCLUDING CARDIOTROPHIN-1 LEVELS in PATIENTS WITH OBESE and LEAN POLYCYSTIC OVARY SYNDROME

Introduction

We aimed to investigate Cardiotrophin-1 (CT-1) levels along with other markers of cardiovascular disease and the association of androgen levels with these parameters in both lean and overweight or obese PCOS patients.

Material and Methods

The study included 90 overweight or obese PCOS patients with metabolic syndrome (MS) and 80 lean PCOS patients without MS. The control group consisted of 140 healthy females. Anthropometric measurements, plasma glucose, insulin, lipid and hormone profile, homocysteine, hs-CRP, CT-1 levels and carotid-IMT were evaluated in all study subjects.

Results

Fasting insulin, HOMA values were significantly higher in obese PCOS patients. Total testosteron levels were higher in both PCOS groups with respect to both controls. Serum homocysteine, hs-CRP, CT-1 and carotid-IMT values were significantly higher in both PCOS groups compared to controls (p=0.001, pCIMT: 0.005). CT-1 was positively correlated with insulin, HOMA, total testosterone, homocysteine, hs-CRP and carotid IMT. After multiple regression analysis, CT-1 was significantly positively correlated with total testosterone, hs-CRP and carotid IMT.

Conclusions

CT-1 was associated with other cardiovascular risk markers and its use as a cardiovascular risk marker might be suggested. Cardiovascular risk was increased even in lean PCOS patients without MS and it might be associated with elevated androgen levels.

Challenges in diagnosis and understanding of natural history of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy affecting 8%-13% of reproductive-aged women. The aetiology of the syndrome is complex, with genetic susceptibility, androgen exposure in early life and adiposity related dysfunction leading to perturbance in hypothalamic-ovarian function. PCOS clinical features are heterogeneous, with manifestations arising even in early adolescence, developing into multisystem reproductive, metabolic and psychological manifestations in adulthood. In this review, we will discuss challenges in the diagnosis of PCOS and understanding of the natural history of PCOS.

Investigating the active components of Huatan Tongjing Decoction for the treatment of polycystic ovary syndrome via network pharmacology

BACKGROUND

Polycystic ovary syndrome (PCOS) is a common endocrine disease in women, potentially causing ovarian infertility for women at gestational age. Huatan Tongjing Decoction is commonly used to treat PCOS, however the involved molecular mechanism has not been fully understood.

METHODS

In this study, the active components of Huatan Tongjing Decoction and potentially targeted proteins were downloaded from the Traditional Chinese Medicine Systems Pharmacology (TCMSP) database. PCOS-related genes were accessed from Malacards database. STRING database was utilized to construct a protein-protein interaction (PPI) network based on the PCOS-related genes and the predicted targets. Subsequently, the PPI network was subjected to Random walk with restart (RWR). Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses were performed on top 50 genes with the high affinity scores to the drug targets. Subsequently, based on the predicted drug components and targets, a component-gene interaction network was constructed. Finally, the most central drug targets were selected, and the corresponding compounds were subjected to molecular docking and dynamic simulations to examine their bindings.

RESULTS

The 122 main active components and 246 potential targets of Huatan Tongjing Decoction were obtained from TCMSP, and a total of 259 nodes and 1,919 interactions were acquired from the PPI network. The top 50 genes were mainly enriched in response to peptide hormone function and PI3K-Akt signaling pathway in RWR analysis. Molecular docking and dynamic simulations predicted that MMP-quercetin interaction played an important role in the treatment of PCOS using Huatan Tongjing Decoction.

CONCLUSIONS

Luteolin and quercetin in Huatan Tongjing Decoction potentially bound MMP9 and served as active compornants. This study preliminarily suggested the efficacy of Huatan Tongjing Decoction against PCOS in molecular degreee.

Follicular Fluid: A Powerful Tool for the Understanding and Diagnosis of Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) represents one of the leading causes of anovulatory infertility and affects 5% to 20% of women worldwide. Until today, both the subsequent etiology and pathophysiology of PCOS remain unclear, and patients with PCOS that undergo assisted reproductive techniques (ART) might present a poor to exaggerated response, low oocyte quality, ovarian hyperstimulation syndrome, as well as changes in the follicular fluid metabolites pattern. These abnormalities originate a decrease of Metaphase II (MII) oocytes and decreased rates for fertilization, cleavage, implantation, blastocyst conversion, poor egg to follicle ratio, and increased miscarriages. Focus on obtaining high-quality embryos has been taken into more consideration over the years. Nowadays, the use of metabolomic analysis in the quantification of proteins and peptides in biological matrices might predict, with more accuracy, the success in assisted reproductive technology. In this article, we review the use of human follicular fluid as the matrix in metabolomic analysis for diagnostic and ART predictor of success for PCOS patients.

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: A Complex Disease with a Genetics Approach

Polycystic ovarian syndrome (PCOS) is a complex endocrine disorder affecting females in their reproductive age. The early diagnosis of PCOS is complicated and complex due to overlapping symptoms of this disease. The most accepted diagnostic approach today is the Rotterdam Consensus (2003), which supports the positive diagnosis of PCOS when patients present two out of the following three symptoms: biochemical and clinical signs of hyperandrogenism, oligo, and anovulation, also polycystic ovarian morphology on sonography. Genetic variance, epigenetic changes, and disturbed lifestyle lead to the development of pathophysiological disturbances, which include hyperandrogenism, insulin resistance, and chronic inflammation in PCOS females. At the molecular level, different proteins and molecular and signaling pathways are involved in disease progression, which leads to the failure of a single genetic diagnostic approach. The genetic approach to elucidate the mechanism of pathogenesis of PCOS was recently developed, whereby four phenotypic variances of PCOS categorize PCOS patients into classic, ovulatory, and non-hyperandrogenic types. Genetic studies help to identify the root cause for the development of this PCOS. PCOS genetic inheritance is autosomal dominant but the latest investigations revealed it as a multigene origin disease. Different genetic loci and specific genes have been identified so far as being associated with this disease. Genome-wide association studies (GWAS) and related genetic studies have changed the scenario for the diagnosis and treatment of this reproductive and metabolic condition known as PCOS. This review article briefly discusses different genes associated directly or indirectly with disease development and progression.

The role of polymorphism in various potential genes on polycystic ovary syndrome susceptibility and pathogenesis

Polycystic ovary syndrome (PCOS) is the most common endocrinopathies affecting the early reproductive age in women, whose pathophysiology perplexes many researchers till today. This syndrome is classically categorized by hyperandrogenism and/or hyperandrogenemia, menstrual and ovulatory dysfunction, bulky multi follicular ovaries on Ultrasonography (USG), and metabolic abnormalities such as hyperinsulinemia, dyslipidemia, obesity. The etiopathogenesis of PCOS is not fully elucidated, but it seems that the hypothalamus-pituitary-ovarian axis, ovarian, and/or adrenal androgen secretion may contribute to developing the syndrome. Infertility and poor reproductive health in women's lives are highly associated with elevated levels of androgens. Studies with ovarian theca cells taken from PCOS women have demonstrated increased androgen production due to augmented ovarian steroidogenesis attributed to mainly altered expression of critical enzymes (Cytochrome P450 enzymes: CYP17, CYP21, CYP19, CYP11A) in the steroid hormone biosynthesis pathway. Despite the heterogeneity of PCOS, candidate gene studies are the widely used technique to delineate the genetic variants and analyze for the correlation of androgen biosynthesis pathway and those affecting the secretion or action of insulin with PCOS etiology. Linkage and association studies have predicted the relationship between genetic variants and PCOS risk among families or populations. Several genes have been proposed as playing a role in the etiopathogenesis of PCOS, and the presence of mutations and/or polymorphisms has been discovered, which suggests that PCOS has a vital heritable component. The following review summarizes the influence of polymorphisms in crucial genes of the steroidogenesis pathway leading to intraovarian hyperandrogenism which can result in PCOS.

The Effect of Ageing on Clinical, Hormonal and Sonographic Features Associated with PCOS-A Long-Term Follow-Up Study

The knowledge of polycystic ovary syndrome (PCOS) natural history is limited. Our objective was to assess the effect of aging on clinical, hormonal and sonographic ovarian PCOS features and additionally to identify parameters that impact the course of PCOS. A secondary aim was to supply additional information on the reproductive outcome in women with previously diagnosed PCOS. A longitudinal cohort study with a median follow-up of 120.9 months was conducted, and 31 Caucasian women previously diagnosed with PCOS according to the Rotterdam criteria were re-examined at a median age of 35. Clinical examinations; transvaginal ultrasound scans; and lipid, E-selectin and sex hormone assessments were performed at the beginning and at the end of the follow-up. It was observed that menstrual cycles became regular and sonographic morphology of ovaries was normalized in 55% and 49% of the participants, respectively (all p < 0.05). At the final assessment, 55% of the women no longer met the criteria for PCOS (p < 0.05). The age, follicle-stimulating hormone (FSH) and E-selectin assessed at the baseline were the most important predictors of the PCOS persistence into later years (respectively, OR = 0.84, OR = 0.39, OR = 1.08, all p < 0.05). Ninety-five percent of the patients who had ever been trying to conceive became pregnant a minimum of once. The women with persistent PCOS had worse metabolic and reproductive parameters compared to the women with resolved PCOS. Positive correlations were found between the number of miscarriages and ovarian volume, LH, androstenedione, 17-hydroxyprogesterone and an increase in E-selectin during the follow-up (R = 0.46, R = 0.59, R = 0.54, R = 0.49, R = 0.47, all p < 0.05). In conclusion, progressing from the third to the fourth decade is connected with a reduction in PCOS features, which seems to have a great impact on fertility of women with a previous diagnosis of PCOS. FSH and E-selectin, as determined at the initial PCOS diagnosis, had an impact on the disappearance of the syndrome years after.

Homeopathic Treatment in Patients with Polycystic Ovarian Syndrome: A Case Series

BACKGROUND AND OBJECTIVES

 Polycystic ovary syndrome (PCOS) is a common heterogeneous endocrine disorder in women of reproductive age. It is characterized by various clinical presentations such as ovulatory dysfunction, polycystic ovaries, and hyperandrogenism. Considering the side effects associated with conventional treatment and the patients who fail to respond to these measures, there is a demand for a complementary therapy that would alleviate symptoms of PCOS without side effects. Homeopathy is a complementary system of medicine that has been successfully used in different disease conditions, including PCOS. A case series of PCOS is hereby presented, to demonstrate some positive results of individualized homeopathic treatment.

METHODS

 Seven cases of young women with PCOS were treated with individualized homeopathic medicines. Each case was followed up with clinical and ultrasonographic evidence and was reported according to the criteria set out in the HOM-CASE guidelines. The assessment of causal attribution of homeopathic treatment effect was carried out using the Modified Naranjo Criteria.

RESULTS

 Marked improvement was observed in all seven cases of PCOS. The irregular menstrual cycles and other associated symptoms became normal, along with a resolution of cysts in ovaries as evidenced by ultrasonography. All cases improved within 4 to 12 months of treatment. The Modified Naranjo Criteria total score was +9/13 for each case, which indicates a positive causal attribution of homeopathy in relieving the symptoms of PCOS.

CONCLUSION

 This case series suggests a significant role of individualized homeopathic medicines in PCOS by regularizing the menstrual cycle along with the resolution of cysts and associated symptoms.

Polycystic ovary syndrome and reproductive health of women: a curious association

Reproductive health is a broad concept that encompasses mortality, morbidity, and quality of life associated with the reproductive system, mechanism, and incidents encountered at all ages by men and women. Orthodox Indian society finds the conversation on reproductive health to be a taboo and discourages open conversations about it. Polycystic ovary syndrome (PCOS) is a reproductive-age metabolic endocrine disorder found in females. Females suffering from PCOS are prone to reproductive, metabolic, and cardiovascular disorders. In this paper, we will systematically review about effect of PCOS on Reproductive Health of Women. The numerous electronic databases such as: BMJ, LANCET, PUBMED, Unicef Website, WHO Website and Google Scholar have been comprehensively searched for studies linked to PCOS, its various effects and effect on women's reproductive health. For additional analyses, we have reviewed reference lists of reviews and collected papers. The effects of PCOS on women's reproductive health have been verified by several scientific reports worldwide. PCOS is a hormonal condition, as per multiple reports, with the ability to lead to different outcomes. It still appears to be a common cause among females of infertility. An integral aspect of the treatment of this disease is the early diagnosis of long-term morbidities by effective screening tests. In the future, studies must concentrate on the missing holes in our growing perception of this disease. Several studies have confirmed that reproductive morbidity, including irregular uterine bleeding, abortion, miscarriage, and other risk of pregnancy during reproductive years, is associated with PCOS. PCOS is an amalgam of physiological and psychosocial dysfunction, not just an endocrine disorder.

Anti-Müllerian Hormone Levels in Adolescence in Relation to Long-term Follow-up for Presence of Polycystic Ovary Syndrome

CONTEXT

Anti-Müllerian hormone (AMH) measured in adolescence as biomarker for prediction of adult polycystic ovary syndrome (PCOS) is doubtful but not substantiated.

OBJECTIVE

To investigate whether serum AMH levels and other PCOS-associated features in adolescence can predict the presence of PCOS in adulthood.

DESIGN AND SETTING

A long-term follow-up study based on a unique adolescent study on menstrual irregularities performed between 1990 and 1997.

PARTICIPANTS AND INTERVENTIONS

AMH was assayed in 271 adolescent girls. Data on PCOS features were combined with AMH levels. In 160 of the 271 (59%) participants, we collected information in adulthood about their menstrual cycle pattern and presence of PCOS (features) by questionnaire 2 decades after the initial study.

RESULTS

AMH was higher in adolescent girls with oligomenorrhea compared with girls with regular cycles, median (interquartile range): 4.6 (3.1-7.5) versus 2.6 (1.7-3.8) μg/L (P < 0.001). Women with PCOS in adulthood had a higher median adolescent AMH of 6.0 compared with 2.5 μg/L in the non-PCOS group (P < 0.001). AMH at adolescence showed an area under the receiver operating characteristic curve for PCOS in adulthood of 0.78. In adolescent girls with oligomenorrhea the proportion developing PCOS in adulthood was 22.5% (95% CI, 12.4-37.4) against 5.1% (95% CI, 2.1-12.0) in girls with a regular cycle (P = 0.005). Given adolescent oligomenorrhea, adding high AMH as factor to predict adult PCOS or adult oligomenorrhea was of no value.

CONCLUSIONS

Adolescent AMH either alone or adjuvant to adolescent oligomenorrhea does not contribute as prognostic marker for PCOS in adulthood. Therefore, we do not recommend routine its use in clinical practice.

How polycystic ovary syndrome came into its own

Polycystic ovary syndrome (PCOS) is a disorder whose definition and diagnosis have been evolving over the past 85 years since Stein and Leventhal made their original description of the triad of amenorrhea, polycystic ovaries, and hyperandrogenism in 1935. Although much progress in characterizing the disorder was accomplished from the late 1950s through the late 1980s, much confusion remained in the field, as there were no agreed-upon diagnostic criteria. This deficiency began to be addressed with a conference held at the National Institutes of Health (NIH) in April 1990, which, through a survey of meeting participants, defined what is today known as "classic" PCOS. Following the NIH 1990 conference, many of our European colleagues, who relied more exclusively on the ultrasound detection of polycystic ovaries for the diagnosis of PCOS, organized a second expert conference in Rotterdam in May 2003, where the diagnostic criteria were expanded. Finally, the Androgen Excess Society (now the Androgen Excess and PCOS Society) published its recommendations for diagnosis in November 2006, principally rooted in associating the criteria for PCOS with the risks of metabolic and other long-term morbidities. A breakthrough in our understanding of PCOS came when we realized that PCOS could be classified into 4 phenotypes (A-D) based on 3 features (clinical and/or biochemical hyperandrogenism, oligoanovulation, and polycystic ovaries) and that the Rotterdam 2003 and the Androgen Excess Society 2006 criteria were simply expansions of the NIH 1990 criteria. Having a clearer definition of PCOS has allowed us to establish PCOS as a globally prevalent disorder, affecting between 1 in 10 and 1 in 7 women, the most common endocrine disorder of women, and the most common cause of infertility, among other findings. However, it is critical that we understand that much of the work on the criteria and definition of PCOS has arisen through the process of scientific dialog, debate, and "consensus," although many would argue that "consensus science" is not science at all. Despite the significant progress made over the past 50 years, much remains to be studied and advocated for when it comes to the care of women with PCOS.

C-Reactive Protein, Fibrinogen, Leptin, and Adiponectin Levels in Women with Polycystic Ovary Syndrome

Background and Aim

We aimed to compare the levels of clinical, biochemical, hormonal, and metabolic parameters as well as serum CRP, fibrinogen, leptin, and adiponectin in cases with PCOS and control group to investigate whether they play a role in the etiology of the syndrome.

Materials and Methods

The present study included a total of 90 subjects, 45 subjects were diagnosed with PCOS (n = 45) and 45 subjects served as control group (n = 45). Serum CRP, fibrinogen, leptin, and adiponectin levels were analyzed for each subject.

Results

Serum CRP, fibrinogen, and leptin were found to be higher (statistically significant) in the group with PCOS as compared to the control group (p < 0.05). Serum Adiponectin was higher in the control group (statistically significantly) as compared with the patients in the PCOS group (p < 0.05).

Conclusion

CRP and fibrinogen (cardiac risk factor markers) increase in women with PCOS. The levels of leptin which affects metabolism increase, whereas the levels of adiponectin decrease.

Clinical Presentation and Frequency of Metabolic Syndrome in Women With Polycystic Ovary Syndrome: An Experience From a Tertiary Care Hospital in Pakistan

Introduction: Polycystic ovary syndrome (PCOS) is a common endocrine disorder affecting women of reproductive age. The aim of this study was to determine the variations in the clinical presentation and frequency of metabolic syndrome (MetS) in women with PCOS.

Methods: This cross-sectional study was conducted at the Baqai Institute of Diabetology and Endocrinology, Baqai Medical University, Karachi, Pakistan, from April 2019 to March 2020. Women attending the endocrine clinic who satisfied the Rotterdam criteria of PCOS and agreed to participate in the study were included. Detailed personal and family history of menstrual cycle, hirsutism, diabetes, hypertension, dyslipidemia and obesity was noted along with measurement of vitals, anthropometric measures and calculation of the body mass index. Physical examination performed for signs of hyperandrogenism, insulin resistance and biochemical and hormonal evaluation was also carried out in recruited participants. Statistical analysis was done using the Statistical Package for the Social Sciences (SPSS) version 20 (IBM Corp., Armonk, NY).

Results: A total of 153 participants with mean age of 27.2±8.13 years were included in this study. Regarding clinical presentation, menstrual irregularity (oligomenorrhea 39.85%, amenorrhea 38.9%), followed by hirsutism 52.3%, was the most common presentation. Polycystic appearance of ovaries was noted in 33.3% of our study participants. MetS was identified in 46.4% participants (obesity was noted at the highest frequency at 82.4% followed by dyslipidemia at 56.2%).

Conclusion: We observed a high frequency of MetS in females presenting with PCOS. There is a need to evaluate women with PCOS for various components of MetS to prevent potential complications.

The insulin signaling pathway is dysregulated in cumulus cells from obese, infertile women with polycystic ovarian syndrome with an absence of clinical insulin resistance

Methods:

This is a cohort study, conducted at a university-based reproductive medicine center and private reproductive medicine center that aimed to evaluate granulosa cumulus cell gene expression in the insulin signaling pathway in Polycystic Ovary Syndrome (PCOS) patients undergoing in vitro fertilization (IVF) treatment and to compare the cumulus gene expression between normal weight and obese women without clinical insulin resistance. Fifteen PCOS patients, nine normal weight patients and six obese patients presenting normal HOMA IR (Homeostasis Model Assessment–Insulin Resistance), participated. Patients underwent oocyte retrieval for IVF and after the procedure, granulosa cumulus cells were removed from the oocytes for RNA extraction. Quantitative polymerase chain reaction (PCR) array analysis of 84 genes from insulin signaling pathway was conducted. The results were expressed as fold up- or fold down-expression in obese patients compared with normal weight patients. Any fold change ⩾3 or ⩽3 and any p ⩽ 0.05 were considered statistically significant.

Results:

There were 10 genes that were overexpressed in obese compared with normal weight women, BCL2L1, BRAF, CBL, DOK1, FBP1, FRS2, MTOR, PCK2, RPS6KA1, and SORBS1, that had a fold change ⩾3 and p ⩽ 0.05.

Discussion:

In the obese group, the overexpressed genes are mainly responsible for the proliferation and differentiation of cumulus cells during oocyte maturation, insulin resistance, apoptosis regulation, and glucose metabolism during early embryogenesis, suggesting that in the follicular environment, insulin resistance is present even in the absence of clinical signs.

Conclusion:

Together, our findings and the related literature suggest that those alterations may be associated with the worse prognosis of follicular development and oocyte maturation observed in PCOS obese women.

Long-Term Follow-Up and Treatment of a Female With Complete Estrogen Insensitivity

CONTEXT

We previously reported the first female with a causative ESR1 gene variant, who exhibited absent puberty and high estrogens. At age 15 years, she presented with lower abdominal pain, absent breast development, primary amenorrhea, and multicystic ovaries. The natural history of complete estrogen insensitivity (CEI) in women is unknown.

OBJECTIVE

The purpose of this report is to present the neuroendocrine phenotype of CEI, identify potential ligands, and determine the effect of targeted treatment.

DESIGN

We have characterized gonadotropin pulsatility and followed this patient's endocrine profile and bone density over 8 years. Seventy-five different compounds were tested for transactivation of the variant receptor. A personalized medicine approach was tailored to our patient.

SETTING

Academic medical center.

PATIENT OR OTHER PARTICIPANTS

A 24-year-old adopted white female with CEI.

INTERVENTION(S)

The patient was treated with diethylstilbestrol (DES) for approximately 2.5 years.

MAIN OUTCOME MEASURE(S)

Induction of secondary sexual characteristics.

RESULTS

Luteinizing hormone (LH) pulse studies demonstrated normal pulsatile LH secretion, elevated mean LH, and mildly elevated mean follicle-stimulating hormone (FSH) in the presence of markedly increased estrogens. DES transactivated the variant ESR1 in vitro. However, DES treatment did not induce secondary sexual characteristics in our patient.

CONCLUSIONS

Treatment with DES was not successful in our patient. She remains hypoestrogenic despite the presence of ovarian cysts with a hypoestrogenic vaginal smear, absent breast development, and low bone mineral mass. Findings suggest additional receptor mechanistic actions are required to elicit clinical hormone responses.

Effect of amlodipine on blood flow of preovulatory follicle in women with clomiphene resistant polycystic ovaries: a randomized controlled trial

OBJECTIVE

To detect whether amlodipine could increase pre-ovulatory follicular blood flow, thus enhancing ovulation and creating a better chance of conception in women with PCOS.

METHODS

165 women were screened of which 124 were qualified and women were equally randomized to 62 receiving clomiphene citrate and amlodipine and 62 receiving clomiphene citrate and placebo. The primary outcome was to detect if amlodipine can improve pre-ovulatory follicle blood flow studied by colour and power Doppler Pulsatility index of ovarian arteries, with drug administration. The secondary outcomes were endometrial thickness and clinical pregnancy.

RESULTS

The mean value of the ovarian arteries Pulsatility Index was significantly lower in the amlodipine group when compared to those of the placebo group (1.36 and 1.82, respectively, with P value 0.002). Mean endometrial thickness, for all women in both groups, on the day of detecting a mature follicle was significantly higher in the amlodipine group compared to the placebo group (8.99 and 7.0, respectively, with P value 0.003), and clinical pregnancy increased from 11% to 37% in the amlodipine group compared to the placebo group.

CONCLUSION

Amlodipine improves ovarian blood flow and increases the chances of conception.

TRIAL REGISTRATION

Pan African Clinical Trial Registry (http://www.pactr.org). Trial No: PAC TR201708002485292.

Laparoscopic ovarian drilling for ovulation induction in women with anovulatory polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is a common condition affecting 8% to 13% of reproductive-aged women. In the past clomiphene citrate (CC) used to be the first-line treatment in women with PCOS. Ovulation induction with letrozole should be the first-line treatment according to new guidelines, but the use of letrozole is off-label. Consequently, CC is still commonly used. Approximately 20% of women on CC do not ovulate. Women who are CC-resistant can be treated with gonadotrophins or other medical ovulation-induction agents. These medications are not always successful, can be time-consuming and can cause adverse events like multiple pregnancies and cycle cancellation due to an excessive response. Laparoscopic ovarian drilling (LOD) is a surgical alternative to medical treatment. There are risks associated with surgery, such as complications from anaesthesia, infection, and adhesions.

OBJECTIVES

To evaluate the effectiveness and safety of LOD with or without medical ovulation induction compared with medical ovulation induction alone for women with anovulatory polycystic PCOS and CC-resistance.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group (CGFG) trials register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL and two trials registers up to 8 October 2019, together with reference checking and contact with study authors and experts in the field to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of women with anovulatory PCOS and CC resistance who underwent LOD with or without medical ovulation induction versus medical ovulation induction alone, LOD with assisted reproductive technologies (ART) versus ART, LOD with second-look laparoscopy versus expectant management, or different techniques of LOD.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed risks of bias, extracted data and evaluated the quality of the evidence using the GRADE method. The primary effectiveness outcome was live birth and the primary safety outcome was multiple pregnancy. Pregnancy, miscarriage, ovarian hyperstimulation syndrome (OHSS), ovulation, costs, and quality of life were secondary outcomes.

MAIN RESULTS

This updated review includes 38 trials (3326 women). The evidence was very low- to moderate-quality; the main limitations were due to poor reporting of study methods, with downgrading for risks of bias (randomisation and allocation concealment) and lack of blinding. Laparoscopic ovarian drilling with or without medical ovulation induction versus medical ovulation induction alone Pooled results suggest LOD may decrease live birth slightly when compared with medical ovulation induction alone (odds ratio (OR) 0.71, 95% confidence interval (CI) 0.54 to 0.92; 9 studies, 1015 women; I² = 0%; low-quality evidence). The evidence suggest that if the chance of live birth following medical ovulation induction alone is 42%, the chance following LOD would be between 28% and 40%. The sensitivity analysis restricted to only RCTs with low risk of selection bias suggested there is uncertainty whether there is a difference between the treatments (OR 0.90, 95% CI 0.59 to 1.36; 4 studies, 415 women; I² = 0%, low-quality evidence). LOD probably reduces multiple pregnancy rates (Peto OR 0.34, 95% CI 0.18 to 0.66; 14 studies, 1161 women; I² = 2%; moderate-quality evidence). This suggests that if we assume the risk of multiple pregnancy following medical ovulation induction is 5.0%, the risk following LOD would be between 0.9% and 3.4%. Restricting to RCTs that followed women for six months after LOD and six cycles of ovulation induction only, the results for live birth were consistent with the main analysis. There may be little or no difference between the treatments for the likelihood of a clinical pregnancy (OR 0.86, 95% CI 0.72 to 1.03; 21 studies, 2016 women; I² = 19%; low-quality evidence). There is uncertainty about the effect of LOD compared with ovulation induction alone on miscarriage (OR 1.11, 95% CI 0.78 to 1.59; 19 studies, 1909 women; I² = 0%; low-quality evidence). OHSS was a very rare event. LOD may reduce OHSS (Peto OR 0.25, 95% CI 0.07 to 0.91; 8 studies, 722 women; I² = 0%; low-quality evidence). Unilateral LOD versus bilateral LOD Due to the small sample size, the quality of evidence is insufficient to justify a conclusion on live birth (OR 0.83, 95% CI 0.24 to 2.78; 1 study, 44 women; very low-quality evidence). There were no data available on multiple pregnancy. The likelihood of a clinical pregnancy is uncertain between the treatments, due to the quality of the evidence and the large heterogeneity between the studies (OR 0.57, 95% CI 0.39 to 0.84; 7 studies, 470 women; I² = 60%, very low-quality evidence). Due to the small sample size, the quality of evidence is not sufficient to justify a conclusion on miscarriage (OR 1.02, 95% CI 0.31 to 3.33; 2 studies, 131 women; I² = 0%; very low-quality evidence). Other comparisons Due to lack of evidence and very low-quality data there is uncertainty whether there is a difference for any of the following comparisons: LOD with IVF versus IVF, LOD with second-look laparoscopy versus expectant management, monopolar versus bipolar LOD, and adjusted thermal dose versus fixed thermal dose.

AUTHORS' CONCLUSIONS

Laparoscopic ovarian drilling with and without medical ovulation induction may decrease the live birth rate in women with anovulatory PCOS and CC resistance compared with medical ovulation induction alone. But the sensitivity analysis restricted to only RCTs at low risk of selection bias suggests there is uncertainty whether there is a difference between the treatments, due to uncertainty around the estimate. Moderate-quality evidence shows that LOD probably reduces the number of multiple pregnancy. Low-quality evidence suggests that there may be little or no difference between the treatments for the likelihood of a clinical pregnancy, and there is uncertainty about the effect of LOD compared with ovulation induction alone on miscarriage. LOD may result in less OHSS. The quality of evidence is insufficient to justify a conclusion on live birth, clinical pregnancy or miscarriage rate for the analysis of unilateral LOD versus bilateral LOD. There were no data available on multiple pregnancy.

Proliferation of Ovarian Granulosa Cells in Polycystic Ovarian Syndrome Is Regulated by MicroRNA-24 by Targeting Wingless-Type Family Member 2B (WNT2B)

Background

Polycystic ovarian syndrome (PCOS) is a common endocrine disorder causing infertility among reproductive-age women. The molecular mechanisms underlying the development of PCOS are not well understood, and effective treatment options and therapeutic targets for PCOS are not available. This study was designed to investigate the role and therapeutic potential of miR-324 in PCOS.

Material/Methods

We used quantitative real time-polymerase chain reaction (qRT-PCR) to assess expression. Cell viability was determined by [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide] (MTT) assay. Acridine orange/ethidium bromide (AO/EB) and annexin V/PI staining were performed to examine apoptosis. Western blot analysis was used to determine protein expression.

Results

Results showed that the expression of miR-324 was aberrantly and significantly downregulated in PCOS ovarian tissues and KGN ovarian granulosa cells. Nonetheless, ectopic expression of miR-324 expression inhibited the viability of KGN cells via induction of apoptotic cell death. In silico analysis showed Wingless-Type family member 2B (WNT2B) to be the target of miR-324, which was also validated by dual-luciferase reporter assay. We also found that the expression of WNT2B was upregulated in the KGN cells, and overexpression of miR-324 inhibited WNT2B expression. Similar to WNT2B overexpression, WNT2B silencing decreased the viability of the KGN. Furthermore, overexpression of WNTB2 in KGN partially reversed the growth-inhibitory effects of miR-324 overexpression.

Conclusions

miR-324 regulates the proliferation of KGN cells in PCOs and be essential in the management of PCOS.

Gonadotrophins for ovulation induction in women with polycystic ovary syndrome

BACKGROUND

Ovulation induction with follicle stimulating hormone (FSH) is a second-line treatment in women with polycystic ovary syndrome (PCOS) who do not ovulate or conceive on clomiphene citrate.

OBJECTIVES

To compare the effectiveness and safety of gonadotrophins as a second-line treatment for ovulation induction in women with clomiphene citrate-resistant polycystic ovary syndrome (PCOS), and women who do not ovulate or conceive after clomiphene citrate.

SEARCH METHODS

In January 2018, we searched the Cochrane Gynaecology and Fertility Group Specialised Register of Controlled Trials, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, the World Health Organisation clinical trials register, Clinicaltrials.gov, LILACs, and PubMed databases, and Google Scholar. We checked references of in all obtained studies. We had no language restrictions.

SELECTION CRITERIA

All randomised controlled trials reporting data on clinical outcomes in women with PCOS who did not ovulate or conceive on clomiphene citrate, and undergoing ovulation induction with urinary-derived gonadotrophins, including urofollitropin (uFSH) in purified FSH (FSH-P) or highly purified FSH (FSH-HP) form, human menopausal gonadotropin (HMG) and highly purified human menopausal gonadotrophin (HP-HMG), or recombinant FSH (rFSH), or continuing clomiphene citrate. We included trials reporting on ovulation induction followed by intercourse or intrauterine insemination. We excluded studies that described co-treatment with clomiphene citrate, metformin, luteinizing hormone, or letrozole.

DATA COLLECTION AND ANALYSIS

Three review authors (NW, EK, and MvW) independently selected studies for inclusion, assessed risk of bias, and extracted study data. Primary outcomes were live birth rate per woman and multiple pregnancy per woman. Secondary outcomes were clinical pregnancy, miscarriage, incidence of ovarian hyperstimulation syndrome (OHSS) per woman, total gonadotrophin dose, and total duration of stimulation per woman. We combined data using a fixed-effect model to calculate the risk ratio (RR). We summarised the overall quality of evidence for the main outcomes using GRADE criteria.

MAIN RESULTS

The review included 15 trials with 2387 women. Ten trials compared rFSH with urinary-derived gonadotrophins (three compared rFSH with human menopausal gonadotrophin, and seven compared rFSH with FSH-HP), four trials compared FSH-P with HMG. We found no trials that compared FSH-HP with FSH-P. One trial compared FSH with continued clomiphene citrate.Recombinant FSH (rFSH) versus urinary-derived gonadotrophinsThere may be little or no difference in the birth rate between rFSH and urinary-derived gonadotrophins (RR 1.21, 95% confidence interval (CI) 0.83 to 1.78; five trials, N = 505; I² = 9%; low-quality evidence). This suggests that for the observed average live birth per woman who used urinary-derived FSH of 16%, the chance of live birth with rFSH is between 13% and 28%. There may also be little or no difference between groups in incidence of multiple pregnancy (RR 0.86, 95% CI 0.46 to 1.61; eight trials, N = 1368; I² = 0%; low-quality evidence), clinical pregnancy rate (RR 1.05, 95% CI 0.88 to 1.27; eight trials, N = 1330; I² = 0; low-quality evidence), or miscarriage rate (RR 1.20, 95% CI 0.71 to 2.04; seven trials, N = 970; I² = 0; low-quality evidence). We are uncertain whether rFSH reduces the incidence of OHSS (RR 1.48, 95% CI 0.82 to 2.65, ten trials, n=1565, I² = 0%, very low-quality evidence).Human menopausal gonadotrophin (HMG) or HP-HMG versus uFSHWhen compared to uFSH, we are uncertain whether HMG or HP-HMG improves live birth rate (RR 1.28, 95% CI 0.65 to 2.52; three trials, N = 138; I² = 0%; very low quality evidence), or reduces multiple pregnancy rate (RR 2.13, 95% CI 0.51 to 8.91; four trials, N = 161; I² = 0%; very low quality evidence). We are also uncertain whether HMG or HP-HMG improves clinical pregnancy rate (RR 1.31, 95% CI 0.66 to 2.59; three trials, N = 102; I² = 0; very low quality evidence), reduces miscarriage rate (RR 0.33, 95% CI 0.06 to 1.97; two trials, N = 98; I² = 0%; very low quality evidence), or reduces the incidence of OHSS (RR 7.07, 95% CI 0.42 to 117.81; two trials, N = 53; very low quality evidence) when compared to uFSH.Gonadotrophins versus continued clomiphene citrateGonadotrophins resulted in more live births than continued clomiphene citrate (RR 1.24, 95% CI 1.05 to 1.46; one trial, N = 661; I² = 0%; moderate-quality evidence). This suggests that for a woman with a live birth rate of 41% with continued clomiphene citrate, the live birth rate with FSH was between 43% and 60%. There is probably little or no difference in the incidence of multiple pregnancy between treatments (RR 0.89, 95% CI 0.33 to 2.44; one trial, N = 661; I² = 0%; moderate-quality evidence). Gonadotrophins resulted in more clinical pregnancies than continued clomiphene citrate (RR 1.31, 95% CI 1.13 to 1.52; one trial, N = 661; I² = 0%; moderate-quality evidence), and more miscarriages (RR 2.23, 95% CI 1.11 to 4.47; one trial, N = 661; I² = 0%; moderate-quality evidence). None of the women developed OHSS.

AUTHORS' CONCLUSIONS

There may be little or no difference in live birth, incidence of multiple pregnancy, clinical pregnancy rate, or miscarriage rate between urinary-derived gonadotrophins and recombinant follicle stimulating hormone in women with polycystic ovary syndrome. For human menopausal gonadotropin or highly purified human menopausal gonadotrophin versus urinary follicle stimulating hormone we are uncertain whether one or the other improves or lowers live birth, incidence of multiple pregnancy, clinical pregnancy rate, or miscarriage rate. We are uncertain whether any of the interventions reduce the incidence of ovarian hyperstimulation syndrome. We suggest weighing costs and convenience in the decision to use one or the other gonadotrophin. In women with clomiphene citrate failure, gonadotrophins resulted in more live births than continued clomiphene citrate without increasing multiple pregnancies.

Can Amlodipine Improve the Pre-ovulatory Follicle Blood Flow in Women with Polycystic Ovarian Syndrome?

BACKGROUND

A reduction in intra-ovarian vascular resistance is necessary to achieve pregnancy in a natural cycle. The aim of this RCT was to detect whether a vasodilator calcium channel blocker, amlodipine, could increase the pre-ovulatory follicular blood flow, enhance follicular maturation in women with PCOS and improve ovulatory outcome.

METHODS

Sixty women received induction by clomiphene citrate (CC); thirty were given amlodipine (Amlodipine group) and the other 30 women were given placebo (Placebo group). The pattern of pre-ovulatory follicle blood flow was studied by color and power Doppler ultrasonography pre and post drug administration. Independent t-test was used to compare mean values of the 2 groups. The p<0.05 is considered statistically significant.

RESULTS

When comparing the Doppler effect of amlodipine versus placebo in the treatment cycle, it was found that mean value of ovarian arteries (OA) pulsatility index was lower in amlodipine group but it didn't reach statistical significance (p= 0.063); however, the mean value of OA resistance index reached statistical significance (p=0.028) in amlodipine group. Moreover, in the second cycle, endometrial thickness was significantly higher (p=0.006) in women of the amlodipine group when compared to those of the placebo group. At least one sonographically detectable mature follicle (≥18 mm) was observed in 54.5% (36/66) during the first cycle. At the second cycle, this proportion significantly rose to 86.7% (26/30) in the amlodipine group, but marginally and non-significantly to 56.7% (17/30) in the placebo group.

CONCLUSION

Amlodipine as calcium channel blocker was proved to have a role in improving ovarian blood flow at the time of ovulation and enhancing follicular maturation and thus, it may increase the chances of conception.

Polycystic Ovary Syndrome and NC-CAH: Distinct Characteristics and Common Findings. A Systematic Review

Background: Twenty-one-hydroxylase-deficient non-classic adrenal hyperplasia (NC-CAH) is a very common autosomal recessive syndrome with prevalence between 1:1,000 and 1:2,000 individuals and the frequency varies according to ethnicity. On the other hand, polycystic ovary syndrome has a familial basis and it is inherited under a complex hereditary trait. This syndrome affects 6 to 10% of women in reproductive age and it is the most common endocrine disorder in young women. Our aim was to investigate, through a systematic review, the distinct characteristics and common findings of these syndromes. Methods: The search period covered January 1970 to November 2018, using the scientific databases PubMed. Inclusion criteria were adult women patients with PCOS or NC-CAH. Search terms were "polycystic ovary syndrome," "PCOS," "non-classical adrenal hyperplasia," "NC-CAH," "21-hydroxylase deficiency." From an initial 16,255 titles, the evaluations led to the final inclusion of 97 papers. Results: The clinical features of NC-CAH are hirsutism and ovulatory and menstrual dysfunction therefore; differentiation between these two syndromes is difficult based on clinical grounds only. Additionally, NC-CAH and PCOS are both associated with obesity, insulin resistance, and dyslipidaemia. Reproductive abnormalities are also common between these hyperandrogenemic disorders since in patients with NC-CAH polycystic ovarian morphology and subfertility are present as they are in women with PCOS. The diagnosis of PCOS, is confirmed once other disorders that mimic PCOS have been excluded e.g., conditions that are related to oligoovulation or anovulation and/or hyperandrogenism, such as hyperprolactinaemia, thyroid disorders, non-classic congenital adrenal hyperplasia, and androgen-producing neoplasms. Conclusions: The screening tool to distinguish non-classic adrenal hyperplasia from PCOS is the measurement of 17-hydroxyprogesterone levels. The basal levels of 17-hydroxyprogesterone may overlap, but ACTH stimulation testing can distinguish the two entities. In this review these two common endocrine disorders are discussed in an effort to unveil their commonalities and to illuminate their shadowed distinctive characteristics.

Higher luteinizing hormone levels associated with antimüllerian hormone in postmenarchal daughters of women with polycystic ovary syndrome

OBJECTIVE

To study the reproductive and metabolic differences between daughters of women with polycystic ovary syndrome (PCOSd) and control women (Cd) after menarche.

DESIGN

Case-control study.

SETTING

Clinical endocrinology unit.

PATIENT(S)

We studied 43 PCOSd and 28 Cd 1.5-6 years after menarche.

INTERVENTION(S)

Determination of anthropometry, pubertal development, hirsutism, oral glucose tolerance test, and GnRH analogue test.

MAIN OUTCOME MEASURE(S)

Ferriman score, sex steroids, gonadotropins, antimüllerian hormone (AMH), ovarian volumes, and glucose and insulin levels.

RESULT(S)

The groups were similar in chronologic, gynecologic, and menarchal ages and anthropometric variables. Ferriman score, ovarian volumes, and AMH were higher in PCOSd. Propensity score analysis showed that there were significant differences in LH, LH-FSH ratio, T and free androgen index, post-stimulated LH and LH-FSH ratio, and 2-hour insulin that could be attributed only to the fact of being a PCOS daughter. The generalized linear model showed that higher LH levels were positively associated with AMH and T levels.

CONCLUSION(S)

We found that higher LH, androgen, and insulin levels are present in PCOSd during the postmenarchal period, which may establish the basis for the development of PCOS during adulthood. Moreover, LH levels were associated with AMH levels, which supports that the neuroendocrine feedback proposed for AMH and LH is present in humans and that this feature is probably programed in utero, as recently shown in mice.

Obesity as an effect modifier of the association between menstrual abnormalities and hypertension in young adult women: Results from Project ELEFANT

BACKGROUND

The menstrual cycle is regulated by reproductive hormones such as estrogen which has been implicated in the pathogenesis of hypertension and is associated with obesity. However, to date there has scant study of hypertension in relation to menstrual characteristics and abnormalities. We hypothesize that adverse menstrual characteristics are associated with an increase the prevalence of hypertension and that this relationship is exacerbated by obesity.

METHODS

Our study leverages 178,205 healthy female participants (mean age = 29) in a population-based cross-sectional study in Tianjin, China. Menstrual characteristics including menstrual cycle length and regularity, menstrual bleeding length, menstrual blood loss and dysmenorrhea were assessed by self-reported questionnaires, and hypertension was diagnosed by physician. Multiple logistic regression models were used to assess the relationships between menstrual characteristics and hypertension.

RESULTS

Normal length menstrual cycle (OR = 1.21, 95% CI: 1.03-1.41), oligomenorrhea (OR = 1.54, 95% CI: 1.12-2.07), irregular cycle (OR = 1.54, 95% CI: 1.22-1.93), and light menstrual blood loss (OR = 1.36, 95% CI: 1.06-1.72) were associated with hypertension among women who are overweight or obese, but not among women who are normal weight. Longer menstrual bleeding duration (OR = 1.44, 95% CI: 1.24-1.67) and dysmenorrhea were associated with increased prevalence of hypertension (OR = 1.20, 95% CI: 1.14-1.41) in all young women.

CONCLUSIONS

The prevalence of hypertension is higher among women with menstrual abnormalities, and this association is modified by overweight and obesity.

Effects of orlistat on serum androgen levels among iranian obese women with polycystic ovarian syndrome

Introduction

Polycystic ovary syndrome is one of the most common endocrinopathies in young women, and it affects 6% to 8% of women in reproductive age. Hyperandrogenism is the hallmark of polycystic ovary syndrome. The aim of the present study was to evaluate the effects of orlistat on weight loss and serum androgen levels among Iranian women with polycystic ovary syndrome.

Methods

The present study was carried out in the clinic of Infertility and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Thirty-two patients with polycystic ovary syndrome were randomly enrolled. We measured serum androgens (Testosterone, 17α-hydroxyprogesterone, dehydroepiandrosterone and sex hormone-binding globulin) before and after 12 weeks of treatment with orlistat. We used the Rotterdam Criteria for all patients and transvaginal sonography was performed.

Results

The mean age of patients was 27.75±6.22 and the mean body mass index was 32.69±0.94 kg/m². Comparing with baseline, treatment with orlistat resulted in a significant reduction in weight, BMI, and waist circumference (p=0.001). We also found a remarkable reduction in total testosterone levels (p>0.001). Treatment improved the sex hormone-binding globulin plasma levels, but the improvement was not statistically significant. There was no reduction in other androgen levels.

Conclusion

This study showed a significant reduction of weight and total testosterone level - the most important androgen in polycystic ovary syndrome - after 12 weeks of treatment with orlistat. Therefore, it seems that a short course of orlistat can be useful in the management of patients with polycystic ovary syndrome.

Steroid-depleted polycystic ovarian syndrome serum promotes in vitro oocyte maturation and embryo development

In vitro maturation (IVM) of immature oocytes obtained from patients with polycystic ovarian syndrome (PCOS) is considered as a novel strategy in order to reduce clinical side effects and cost of in vitro fertilization (IVF) technique. The aim of this study was to evaluate the effects of PCOS whole and steroid-depleted serums on in vitro oocyte maturation indices. Patients with PCOS were selected according to the Rotterdam criteria. Cumulus-oocyte complexes and blood serums were collected and pooled. Cumulus cells and immature oocytes were treated with 10% whole or steroid-depleted serums. Stearoyl-CoA desaturase-1 (SCD1) and cyclooxygenase-2 (COX2) expression levels in cumulus cells were evaluated by quantitative PCR. Fatty acid composition of cumulus cells was analyzed using gas-liquid chromatography. Polar body observation was considered as the oocyte maturation index. Oleate (1.28-fold, p = .006), SCD1 expression (450-fold, p = .001), and COX2 expression (35-fold, p = .02) in cumulus cell, as well as oocyte maturation (p < .001) and in vitro embryo development (p < .05) were significantly higher in treatment with steroid-depleted serum compared to that of whole serum. Steroid depletion of PCOS serum improved its capacity to increase success rate of oocyte maturation, intra-cytoplasmic sperm injection and early embryo development.

The peripheral blood transcriptome identifies dysregulation of inflammatory response genes in polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a common endocrine disorder in women, resulting in ovulation failure and other metabolic problems. However, the underlying mechanisms of it remain largely uncertain due to the complexity of clinical manifestations. This systemic disorder is involved in endocrine, metabolism, immune system and many organs, and few studies have explored peripheral blood transcriptome in patients with PCOS. We performed gene expression profiling of peripheral blood from 8 PCOS patients and eight healthy women with microarray. The significance analysis of microarray (SAM) software was employed to screen the differentially expressed genes (DEGs) and gene ontology (GO) was used for functional enrichment analysis. In total, 181 DEGs with fold-changes >2.0 and q-values <0.05 were identified between the two groups. Among them, 149 were up-regulated and 32 down-regulated in PCOS. Unsupervised clustering of expressed genes could readily differentiate PCOS from control. More importantly, inflammatory response pathway including 14 dysregulated genes was highly enriched in PCOS. Furthermore, 10 DEGs were validated using quantitative reverse-transcription PCR (qRT-PCR) assays. Our study provides independent evidence for the involvement of systemic inflammatory response in PCOS and it may facilitate a greater understanding of this complex disease.

Polycystic Ovary Syndrome in Bipolar Affective Disorder: A Hospital-based Study

BACKGROUND

Preliminary studies suggest a multidimensional relationship of mood pathology with endocrine disturbances. Studies have found an increased risk of mood disorders in polycystic ovary syndrome (PCOS), and conversely, many of the medications commonly used in the treatment of bipolar affective disorder (BPAD) can have deleterious effects on blood levels of reproductive hormones and consequently on the hypothalamic-pituitary-gonadal (HPG) axis and reproductive function. Furthermore, there is evidence of reproductive dysfunction in women with BPAD before treatment.

OBJECTIVES

To assess the comorbidity of PCOS in patients of BPAD and to study risk factors associated with this comorbidity.

MATERIALS AND METHODS

Two hundred female patients with the Diagnostic and Statistical Manual of Mental Disorders, 4^th Edition diagnosis of BPAD, between ages of 15 and 45 years, were evaluated by an endocrinologist. Patients reporting menstrual disturbances or having any stigmata of PCOS were further subjected to hormonal analysis, which included luteinizing hormone, follicle-stimulating hormone, prolactin, and testosterone, in the early follicular phase of menstrual cycle. Diagnosis of PCOS was made as per the NIH criteria.

RESULTS

Of 200 patients, 46 (23%) were diagnosed as having PCOS. Forty-five percent (n = 90) reported menstrual disturbances while 27% (n = 54) had polycystic ovaries on ultrasonography. 19.2% of the patients diagnosed as PCOS had a history of valproate intake while 27.90% patients had no such history (P = 0.15). No significant difference (P = 0.07) was found in the prevalence of PCOS among various drug groups (including group on multiple mood stabilizers).

CONCLUSION

A higher prevalence of PCOS is seen in BPAD, irrespective of pharmacotherapy, suggesting a common link between the disorders which might be in the form of disturbance in HPG axis.

The Ovarian Cycle

The "ovarian cycle" is an exquisite and dynamic endocrine system that includes ovarian events, hypothalamic-pituitary interactions, uterine endometrial and myometrial changes during implantation and pregnancy, cervical alterations in structure, and breast development. The ovarian cycle and the steroid hormones produced by the ovary also impact epithelial cancer development in the ovary, uterus, cervix, and breast. This chapter provides a personal view of recent developments that occur in this complex endocrine environment.

Effect of metformin on the anti-Müllerian hormone level in infertile women with polycystic ovarian syndrome

Background

Polycystic ovary syndrome (PCOS) is the major cause of anovulatory infertility in women. The level of serum Anti-Mullerian Hormone (AMH) in patients can be 2–3 times higher than in healthy women. The aim of this study was to assess the effect of metformin on AMH level in PCOS patients suffering from infertility.

Methods

In this pre and post clinical trial, 30 infertile patients with PCOS were enrolled according to the Rotterdam criteria. The serum AMH level was recorded before and after 8 weeks of treatment with metformin (1500 mg daily). We used SPSS version 17 and paired samples t-test, multiple linear regression and ANCOVA test for data analysis.

Results

Serum AMH level was significantly decreased after 8 weeks of treatment with metformin [10±3.75 (ng/ml) versus 7.8±3.7 (ng/ml)] (p=0.008, 95% CI: 0.60–3.75). Also, AMH level change was directly associated to BMI in PCOS patients. In other words, in these patients, a higher BMI led to more decrease in AMH level after metformin treatment.

Conclusion

Eight weeks’ treatment with metformin would significantly decrease AMH. AMH level change was directly associated to BMI.

Clinical trial registration

The trial was registered at the Iranian Registry of Clinical Trials (http://www.irct.ir) with the Irct ID: 201403132967N5

Funding

This study was funded by the Department of Gynecology and Obstetrics, School of Medicine, Kashan University of Medical Sciences (Grant Number: 9322).

Ovarian surgery for symptom relief in women with polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is a common endocrine condition, affecting approximately one in 10 women. PCOS is defined by two of three features: oligo- or anovulation, clinical or biochemical hyperandrogenism or both, or polycystic ovaries.Women with PCOS can have a wide range of health problems, including infrequent and irregular periods, unwanted hair growth and acne, and subnormal fertility. Long-term health concerns include an increased risk of heart disease, diabetes and the development of precancerous disease of the womb.

OBJECTIVES

To assess the effectiveness and harms of ovarian surgery as a treatment for symptomatic relief of hirsutism, acne and menstrual irregularity in PCOS.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group specialized register, CENTRAL, MEDLINE, Embase and PsycINFO (from inception to 17 October 2016). We handsearched citation lists, registers of ongoing trials and conference proceedings.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) of women undergoing ovarian drilling in comparison to no treatment, medical treatment, or other forms of surgical treatment for the symptoms of PCOS.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. The primary outcome measures were improvement in menstrual regularity and androgenic symptoms of PCOS (hirsutism, acne); the secondary outcome measures included harms, change of body mass index (BMI), waist circumference, androgen levels, metabolic measures and quality of life. We assessed the quality of the evidence using GRADE methods.

MAIN RESULTS

We included 22 RCTs (2278 women analyzed) of participants with PCOS and symptoms of acne, hirsutism or irregular menstrual cycles, all of which included laparoscopic ovarian drilling (LOD) as an intervention.Two studies reported their funding source (Farquhar 2002 - supported in part by the Auckland Medical Research Foundation; Sarouri 2015 - the authors thank the Vice Chancellor for Research of Guilan University of Medical Sciences for funding this project).The quality of the evidence ranged from very low to moderate quality. The main limitations were imprecision associated with the low number of studies, inconsistency and risk of bias associated with the inability to blind participants. There were too few studies to assess risk of publication bias. Menstrual RegularityTwo studies compared LOD versus metformin (n=226) but no conclusions could be drawn with regard to menstrual regularity, as their findings were inconsistent and they were unsuitable for pooling. There appeared to be little or no difference in the rate of women reporting improvement in menstrual regularity when LOD was compared with medical treatment including metformin + clomiphene (OR 1.02, 95% CI 0.64 to 1.64, 2 studies, 332 women, I² = 13%, low-quality evidence), letrozole (OR 1.08, 95% CI 0.64 to 1.84, 1 study, 260 women, low-quality evidence), or metformin + letrozole (OR 0.95, 95% CI 0.49 to 1.81, 1 study, 146 women, low-quality evidence). However, one study reported that LOD was superior to gonadotrophin (OR 19.2, 95% CI 3.17 to 116.45, 1 study, 35 women, very low-quality evidence).There appeared to be little or no difference in the rate of women reporting improvement in menstrual regularity when bilateral unipolar LOD was compared to unilateral LOD (OR 1.51, 95% CI 0.62 to 3.71, 2 studies, 104 women, I² = 0%, moderate-quality evidence), transvaginal ultrasound-guided LOD (OR 1.23, 95% CI 0.64 to 2.37, 1 study, 147 women, low-quality evidence), LOD using adjusted thermal dose in accordance with the ovarian volume (OR 0.42, 95% CI 0.16 to 1.14, 1 study, 115 women, low-quality evidence) or bipolar LOD (OR 1.00, 95% CI 0.05 to 18.57, 1 study, 18 women, low-quality evidence).Four to five punctures per ovary may improve the rate of women reporting menstrual regularity compared with two or fewer (OR 16.04, 95% CI 4.19 to 61.34, 2 studies, 73 women, I² = 0%, low-quality evidence). Androgenic SymptomsThere was probably little or no difference in improvement in androgenic symptoms when LOD was compared to metformin (OR 1.00, 95% CI 0.42 to 2.37, 1 study, 126 women, moderate-quality evidence) or gonadotrophins; acne (OR 3.20, 95% CI 0.33 to 30.94, 1 study, 25 women, low-quality evidence), hirsutism (OR 2.31, 95% CI 0.22 to 23.89, 1 study, 25 women, low-quality evidence).There appeared to be little or no difference in improvement of androgenic symptoms when LOD was compared to transvaginal ultrasound-guided LOD, with respect to hirsutism (OR 1.09, 95% CI 0.30 to 3.91, 1 study, 39 women, low-quality evidence) or acne (OR 0.84, 95% CI 0.20 to 3.50, 1 study, 31 women, low-quality evidence). HarmsLOD was associated with fewer gastrointestinal side effects than metformin plus clomiphene (OR 0.05, 95% CI 0.01 to 0.36, 2 studies, 332 women, I² = 0%, moderate-quality evidence). One study suggested little or no difference in rates of ovarian hyperstimulation syndrome between LOD and gonadotrophins (OR 0.08, 95% CI 0.00 to 1.61, 1 study, 33 women, low-quality evidence).There were fewer adhesions with transvaginal hydrolaparoscopy compared to LOD (OR 0.10, 95% CI 0.05 to 0.18, 1 study, 246 women, moderate-quality evidence). There appeared to be little or no difference in adhesions when variable energy LOD was compared with standard LOD (OR 0.96, 95% CI 0.32 to 2.88, 1 study, 64 women, low-quality evidence). Another study (44 women) reported that none of the women who returned for surgery following either traditional or unilateral LOD were found to have adhesions.

AUTHORS' CONCLUSIONS

There was no clear evidence that LOD improves menstrual regularity or the androgenic symptoms of PCOS, compared to most of the medical treatments used in the included studies. LOD was associated with fewer gastrointestinal side effects compared to metformin and clomiphene.There was also no clear evidence of different effectiveness between types of LOD, except that LOD with four to five punctures per ovary may be more effective than two or fewer punctures. There was little evidence comparing LOD with different types of surgery, although one study concluded that transvaginal hydrolaparoscopy had a lower risk of adhesions than LOD.There was evidence from one small study of benefit from LOD compared to gonadotrophins for menstrual regulation. However, gonadotrophins are seldom used for this indication.

Reproductive and metabolic features during puberty in sons of women with polycystic ovary syndrome

CONTEXT

Intrauterine life may be implicated in the origin of polycystic ovary syndrome (PCOS) modifying the endocrine and metabolic functions of children born to PCOS mothers independently of the genetic inheritance and gender. The aim of the present study was to evaluate the reproductive and metabolic functions in sons of women with PCOS during puberty.

METHODS

Sixty-nine PCOS sons (PCOSs) and 84 control sons of 7-18 years old matched by the Tanner stage score were studied. A complete physical examination was conducted including anthropometric measurements (weight, height, waist, hip and body mass index). An oral glucose tolerance test was performed and circulating concentrations of luteinizing hormone, follicle-stimulating hormone (FSH), sex hormone-binding globulin, testosterone, androstenedione (A4), 17α-hydroxyprogesterone (17-OHP) and AMH were determined in the fasting sample.

RESULTS

Waist-to-hip ratio, FSH and androstenedione levels were significantly higher in the PCOSs group compared to control boys during the Tanner stage II-III. In Tanner stages II-III and IV-V, PCOSs showed significantly higher total cholesterol and LDL levels. Propensity score analysis showed that higher LDL levels were attributable to the PCOSs condition and not to other metabolic factors. AMH levels were comparable during all stages. The rest of the parameters were comparable between both groups.

CONCLUSIONS

Sons of women with PCOS show increased total cholesterol and LDL levels during puberty, which may represent latent insulin resistance. Thus, this is a group that should be followed and studied looking for further features of insulin resistance and cardiovascular risk markers. Reproductive markers, on the other hand, are very similar to controls.

Myo-inositol effects in women with PCOS: a meta-analysis of randomized controlled trials

Myo-inositol (MI) supplementation in women with polycystic ovary syndrome (PCOS) has been evaluated over the last years. Many hormonal and reproductive impairments associated with this disorder seem relieved by the supplement. The objective of the meta-analysis was to assess the effects of MI alone or combined with d-chiro-inositol (DCI) on the endocrine and metabolic abnormalities of women with PCOS. Literature was retrieved from selected databases, MEDLINE, EMBASE, PubMed and Research Gate (up to November 2016). Only randomized controlled trials (RCTs) investigating the effects of MI alone or combined with DCI were reviewed. Nine RCTs involving 247 cases and 249 controls were included. Significant decreases in fasting insulin (SMD = -1.021 µU/mL, 95% CI: -1.791 to -0.251, P = 0.009) and homeostasis model assessment (HOMA) index (SMD = -0.585, 95% CI: -1.145 to -0.025, P = 0.041) were identified after MI supplementation. The trial sequential analysis of insulin meta-analysis illustrates that the cumulative z-curve crossed the monitoring boundary, providing firm evidence of the intervention effect. A slight trend toward a reduction of testosterone concentration by MI with respect to controls was found (SMD = -0.49, 95% CI: -1.072 to 0.092, P = 0.099), whereas androstenedione levels remained unaffected. Throughout a subgroup's meta-analysis, a significant increase in serum SHBG was observed only in those studies where MI was administered for at least 24 weeks (SMD = 0.425 nmol/L, 95% CI: 0.050-0.801, P = 0.026). These results highlight the beneficial effect of MI in improving the metabolic profile of women with PCOS, concomitantly reducing their hyperandrogenism.

Healthy eating index in women with polycystic ovary syndrome: A case-control study

BACKGROUND

Despite many effort to identify and control the factors involved in polycystic ovary syndrome (PCOS), there are no available reports indicating the association of healthy eating index (HEI) and PCOS.

OBJECTIVE

The present study has been conducted to examine the relationship between HEI and PCOS.

MATERIALS AND METHODS

In this case-control study, the study population comprised 297 women aged 20-40 yr referred to Baqiyatallah Hospital Clinics, Tehran, Iran in two groups: case group (n=99) and control group (n=198). The usual dietary data were collected using a validated 168-item semi-quantitative food frequency questionnaire. Standard anthropometric measurements (height, weight, and waist circumference) were also taken. Unconditional logistic regression was used to analyze the relationship between the PCOS and the HEI.

RESULTS

The mean age and body mass index of case and control groups were 29±5.5 vs. 29.5±6 yr and 26.6±4.8 vs. 26±4.2 kg/m², respectively (p=0.752, p=0.822). Mean HEI scores for the case and control groups were found to be 61 and 65, respectively. In final model and after adjustment for confounders, the prevalence of PCOS in subjects in the highest tertile HEI score was significantly (50%) less than those in the lowest tertile HEI score (OR=0.50; 95% CI: 0.25-0.74, p=0.001).

CONCLUSION

Our results suggest that HEI score is inversely associated with the risk of PCOS in adult women.

[Quality of oocytes and embryos from women with polycystic ovaries syndrome: State of the art]

The frequency of polycystic ovary syndrome (PCOS) and the consequent fertility disorders cause many difficulties in the management of the assisted reproductive technics. Some studies are focused on different additional treatments, stimulation protocols or techniques that could optimize the in vitro fertilization cycles. The quality of the oocytes and embryos of these patients is also an outstanding issue. They remain difficult to actually evaluate during management, and none of the few published studies on this subject demonstrated any inferiority, compared to control patients. However, many differences have been highlighted, studying intra- and extra-ovarian factors. The advent of new genetic techniques could allow a better understanding of the pathophysiological mechanisms of the syndrome, as well as refining the evaluation of oocytes and embryos, in order to better predict the results of in vitro fertilization attempts. Pregnancy and birth rates, however, appear to be comparable to those of the general population.

Long-term use of clomiphene citrate in induction of ovulation in PCO patients with clomiphene citrate resistance

OBJECTIVE

The aim of our study to evaluate the effect of extended clomiphene citrate treatment on the ovulation rate, pregnancy rate, and hormonal profile of clomiphene resistant PCOS.

METHODOLOGY

This a prospective study conducted in Maternity Hospital Minia University, 200 patients with PCOS recruited in the study during the period from September 2015 till February 2016 (6 months was duration of the study), they were diagnosed as PCO with clomiphene resistance before being recruited in the study. They received 150mg clomiphene citrate for 10 days start in 2nd day of cycle for three consecutive cycles, and followed up for another three months without treatment, last follow-up cycle was on February. We studied the effect of extended treatment with CC in ovulation rate, pregnancy rate and hormonal profile in patients before and after treatment.

RESULTS

There was significant improvement in ovulation rate in the patients after extended CC treatment for 3 months and 3 months follow-up (as 12 cases in the first cycle and 32 cases in the second cycle and increased to 76 cases in the third cycle) while no ovulation documented before treatment pregnancy rate was 17% itis generally low but it highly significant when compared with was zero preceding treatment.

CONCLUSION

Extended CC treatment is good method to improve ovulation and pregnancy rate in CC resistant PCOS but further multi-center studies are needed to provide more powerful evidence.

The Effect of Metformin Treatment on the Serum Levels of Homocysteine, Folic Acid, and Vitamin B12 in Patients with Polycystic Ovary Syndrome

Background and Objective:

Hyperhomocysteinemia is a well-known risk factor for cardiovascular disease. Although metformin therapy can increase homocysteine (Hcy) levels, it frequently is used as an oral medicine in women with polycystic ovary syndrome (PCOS), who might be at risk of catching diabetes mellitus. The aim of this study was to investigate the effect of metformin on the levels of serum Hcy, vitamin B12 (vit B12), and folic acid in patients with PCOS.

Materials and Methods:

An interventional study was designed with 18 patients with PCOS at the Fatemehzahra infertility Hospital in Babol, Iran. Metformin treatment (500 mg twice daily) was initiated in all patients for a period of consecutive 6 months. The levels of serum Hcy, vit B12, and folic acid were measured in the participants before and after metformin treatment.

Results:

The mean vit B12 level showed a significant decrease in patients after 6 months of metformin treatment (P = 0.002). However, there was no significant difference in serum folic acid levels. The mean Hcy levels increased after treatment, but this difference not was statistically significant. When patients were stratified into four subgroups by their insulin sensitivity and body mass index (BMI), relatively similar results were obtained in the subgroups, except that Hcy levels in the overweight/obesity group (BMI > 25 kg/m²) after treatment showed a significant increase (P = 0.01).

Conclusion:

These findings indicate that metformin increases the serum Hcy concentration in patients with PCOS especially in the women with BMI > 25 kg/m². The possible mechanism for this effect would be the obvious reduction in the levels of vit B12.

Management of Polycystic Ovary Syndrome

Polycystic ovary syndrome is a common endocrinological problem in women of reproductive age. Polycystic ovary syndrome is a heterogenous disorder and patients may attend different clinics depending on the main complaint. The exact pathophysiology of polycystic ovary syndrome remains obscure, although there have been insights that have thrown light on this condition. Consensus on the definition of the syndrome has only been recently achieved. The management of polycystic ovary syndrome poses a challenge to the physician as responses to the different treatment regimes have proved to be inconsistent. Diet and lifestyle advice, restoration of menstrual cycle regularity, treatment of hyperandrogenism, treatment of infertility and prevention of long-term consequences form the basis of polycystic ovary syndrome management. This review aims to provide the reader with the latest evidence in the treatment of polycystic ovary syndrome, as well as focus on some of the controversies surrounding its management.