Metformin and Combined Oral Contraceptive Pills in the Management of Polycystic Ovary Syndrome: A Systematic Review and Meta-analysis

Unraveling the Connection between PCOS and renal Complications: Current insights and Future Directions

Polycystic ovary syndrome (PCOS) represents the most prevalent endocrine disorder among women of reproductive age, affecting approximately 5-18% of females worldwide. Characterized by irregular ovulation, hyperandrogenism, and polycystic ovaries, hyperandrogenism is the defining feature. Recent evidence highlights that, in addition to its notable reproductive and metabolic consequences, PCOS may also contribute to an elevated risk of renal complications. This increased risk is attributed to chronic low-grade inflammation, hormonal dysregulation, and disturbances in lipid metabolism inherent to the condition. However, the pathological mechanisms, clinical manifestations, and progression of secondary renal damage in this cohort remain insufficiently studied. This review consolidates current understanding of the relationship between PCOS and chronic kidney disease (CKD), aiming to clarify potential mechanisms by which PCOS may induce secondary renal dysfunction, encompassing both direct renal impairment and indirect damage mediated through systemic alterations. Furthermore, it advocates for comprehensive management strategies to mitigate renal risks in patients with PCOS, emphasizing the necessity of multidisciplinary approaches and further research to address these critical gaps.

What do users in a polycystic ovary syndrome (PCOS) forum think about the treatments they tried: Analysing treatment sentiment using machine learning

Polycystic ovary syndrome (PCOS) is a heterogenous condition that is estimated to effect up to 21% of reproductive aged people with ovaries. In previous work, a dataset of PCOS features was derived from approximately 100,000 PCOS subreddit users via machine learning. In this study, an exploration of treatment response within the PCOS subreddit was undertaken with the derived dataset. The treatment or symptom features in the dataset had sentiment labels indicating when a treatment was perceived to improve or worsen a condition or symptom. When different features were mentioned within two sentences of each other without conflicting sentiment, it could be assumed that they were related. This assumption allowed for a broad analysis of the perceived effect of popular treatments on the most frequently mentioned symptoms. In general, lifestyle changes and supplements were the most positively regarded, while contraceptives were frequently associated with considerable negative sentiment. For PCOS weight loss, unspecified dieting (RR 5.19, 95% CI 3.28-8.19, n = 99) and intermittent fasting (RR 33.50, 95% CI 8.54-131.34, n = 69) were the most successful interventions. Inositol was associated with a large range of favourable outcomes and was one of the few treatments associated with improved mental health [depression (RR 4.25, 95% CI 1.72-10.51, n = 21), anxiety (RR 5.83, 95% CI 2.76-12.35, n = 41) and mood issues (RR 25.00, 95% CI 3.65-171.10, n = 26)]. Combined oral contraceptive pills as a whole were strongly associated with adverse effects such as worsening depression (RR 0.06, 95% CI 0.02-0.25, n = 33), anxiety (RR 0.10, 95% CI 0.03-0.36, n = 23), fatigue (RR 0, n = 45) and low libido (RR 0.03, 95% CI 0.01-0.24, n = 30). However, combined contraceptives with anti-androgenic progestins were associated with more favourable experiences. This study demonstrates the utility of machine learning to derive measurable patient experience data from an internet forum. While patient experience data derived using machine learning is not a substitute for traditional clinical trials, it is useful for mass validation and hypothesis generation. This paper may serve as the first exploration into this category of clinical internet forum research.

Global burden of polycystic ovary syndrome among women of childbearing age, 1990-2021: a systematic analysis using the global burden of disease study 2021

BACKGROUND

The escalating global incidence of polycystic ovary syndrome (PCOS) necessitates a thorough examination of its epidemiological trends and sociodemographic correlations. Our study bridges this gap by analyzing the global impact of PCOS among women of childbearing age (WCBA) from 1990 to 2021, aiming to inform strategies for enhanced prevention and management.

METHODS

We extracted data from the Global Burden of Disease Study 2021 (GBD 2021), focusing on the burden of PCOS among women aged 15-49 years. We assessed incidence, prevalence, and disability-adjusted life years (DALYs) trends using the estimated annual percentage change (EAPC) and explored the link between PCOS burden and sociodemographic index (SDI).

RESULTS

In 2021, the prevalence cases of PCOS worldwide were 65.77 million, the incidence cases were 1,175.07 thousand, and the DALYs cases were 576.05 thousand. Compared with 1990, the percentage changes were 89, 49, and 87%, respectively. The EAPCs indicated upward trends in prevalence and DALYs rates, with a less pronounced increase in incidence rates. The middle SDI region had the highest PCOS case numbers, and the 45-49 age group in this region experienced the most significant burden increase. A strong positive correlation existed between PCOS prevalent rates and SDI (r = 0.582, p < 0.001).

CONCLUSION

The global burden of PCOS among WCBA has significantly increased over the past three decades, particularly in the 45-49 age group in middle SDI regions. The correlation between PCOS prevalent rates and SDI highlights the role of socio-economic factors in PCOS epidemiology. Tailored prevention and management strategies are crucial for reducing the global burden of PCOS and improving female health outcomes.

International evidence-based recommendations for polycystic ovary syndrome in adolescents

BACKGROUND

During adolescence, accurate diagnostic criteria and/or identification of adolescents "at risk" of polycystic ovary syndrome (PCOS) are critical to establish appropriate screening, treatment, and lifelong health plans. The 2023 International Evidence-Based Guideline for PCOS aimed to provide the most up-to-date evidence-based recommendations to improve health outcomes for individuals with PCOS, emphasizing accurate and timely diagnosis of PCOS from adolescence.

METHODS

The best practice methods following the Appraisal of Guidelines for Research and Evaluation (AGREE-II) criteria were applied. Healthcare professionals and patients/consumers reviewed extensive evidence synthesis/meta-analysis for 55 prioritized clinical questions. Databases (OVID MEDLINE, All EBM, PsycInfo, EMBASE, CINAHL) were searched until August 2022 as part of the 2023 update of the Guideline. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework guided experts on evidence quality, feasibility, acceptability, cost, implementation, and ultimately recommendation strength.

RESULTS

This manuscript focuses on the adolescent-specific recommendations of the 2023 Guideline. The diagnosis is based on the presence of both irregular menstrual cycles (defined according to the time postmenarche) and clinical/biochemical hyperandrogenism following the exclusion of other disorders that mimic PCOS. Adolescents with only one of these features can be considered "at risk" of PCOS requiring the management of symptoms and ongoing follow-up. Polycystic ovarian morphology on pelvic ultrasonography or anti-Müllerian hormone levels should not be used for diagnosis during adolescence. Lifelong health planning is recommended to include healthy lifestyles, screening for depression and metabolic features and the transition to adult care, all underpinned by shared decision-making. Healthcare professionals should explain weight-related health risks to adolescents, while minimizing weight stigma. In adolescents with PCOS or "at risk" of PCOS, combined oral contraceptive pills are indicated for menstrual irregularity and clinical hyperandrogenism, focusing on low dose preparations, and metformin could be considered for metabolic features and cycle regulation. Overall, the evidence is limited in adolescents with PCOS, and recommendations are based on low to moderate certainty evidence.

CONCLUSIONS

Extensive international engagement and rigorous processes generated International Guideline diagnostic criteria for adolescents that differ from adult criteria and clarified appropriate screening and management strategies for PCOS during adolescence.

Diagnosis and Treatment of Adolescent Polycystic Ovary syndrome:A Review

Polycystic ovary syndrome (PCOS) is a prevalent endocrine disorder among women of reproductive age. Diagnosing adolescent PCOS is challenging due to the overlap between adult PCOS diagnostic criteria and normal physiological changes in adolescence. This review examines the diagnosis and treatment strategies for adolescent PCOS. The diagnosis of adolescent PCOS should meet two primary criteria-ovulatory dysfunction and biochemical or clinical hyperandrogenism-after excluding other causes. Defining these criteria accurately aids in early diagnosis and management of adolescent PCOS. However, due to limited research, age-specific diagnostic standards remain lacking. Once diagnosed, timely interventions-such as lifestyle, exercise, and dietary changes, along with targeted treatments like metformin and antiandrogens-should be initiated. In addition, the management of adolescent PCOS presents several challenges, including the absence of standardized medication guidelines, adolescent psychological factors that may impede adherence to dietary and exercise recommendations, and parental concerns about the long-term effects of medication on bone health and metabolism. Therefore, additional research is required to establish optimal management protocols to enhance patients' quality of life and prevent complications.

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

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

The Cardiometabolic Risk in Women with Polycystic Ovarian Syndrome (PCOS): From Pathophysiology to Diagnosis and Treatment

Polycystic Ovarian Syndrome (PCOS) is a prevalent endocrine disorder affecting women of reproductive age, with significant variations in presentation characterized by hyperandrogenism, ovulatory dysfunction, and polycystic ovarian morphology. Beyond reproductive health, it may also pose crucial long-term cardiometabolic risks, especially for women with specific types of PCOS, contributing to early subclinical cardiovascular atherosclerotic alterations such as endothelial dysfunction, increased arterial stiffness, and coronary artery calcium levels, respectively. Moreover, the precise relationship between clinical cardiovascular disease (CVD) and PCOS remains debated, with studies demonstrating an elevated risk while others report no significant association. This review investigates the pathophysiology of PCOS, focusing on insulin resistance and its link to subclinical and clinical cardiovascular disease. Diagnostic challenges and novel management strategies, including lifestyle interventions, medications like metformin and glucagon-like peptide-1 receptor agonists (GLP-1RAs), hormonal contraceptives, and bariatric surgery, are further discussed. Recognizing the cardiometabolic risks associated with PCOS, a comprehensive approach and early intervention should address both the reproductive and cardiometabolic dimensions of the syndrome.

Summary of the 2023 international evidence-based guideline for the assessment and management of polycystic ovary syndrome: an Australian perspective

INTRODUCTION

The Australian-led 2023 International evidence-based guideline for the assessment and management of polycystic ovary syndrome was based on best available evidence, clinical expertise and consumer preference. It followed best practice, involved extensive evidence synthesis and applied relevant frameworks across evidence quality, feasibility, acceptability, cost and implementation. Thirty-nine societies and organisations covering 71 countries were engaged. The evidence in the assessment and management of polycystic ovary syndrome (PCOS) has generally improved in the past five years, but remains of low to moderate quality. The technical evidence report, 52 systematic reviews and analyses (approximately 6000 pages) underpin 77 evidence-based and 54 consensus recommendations, with 123 practice points.

MAIN RECOMMENDATIONS

Changes include: refinement of individual diagnostic criteria, a simplified diagnostic algorithm and inclusion of anti-Müllerian hormone levels as an alternative to ultrasound in adults only, and differentiation of adolescent and adult criteria; strengthening the recognition of broad features of PCOS including metabolic effects, cardiovascular disease, dermatological symptoms, sleep apnoea, a high prevalence of psychological features and a high risk of adverse pregnancy outcomes; emphasising the poorly recognised, diverse burden of disease, the vital need for greater health professional education, evidence-based patient information, improved models of care, shared decision making and research efforts to improve patient experience; maintained emphasis on healthy lifestyle, emotional wellbeing and quality of life, with awareness and consideration of weight stigma; and emphasising evidence-based medical therapy and cheaper and safer fertility management.

CHANGES IN MANAGEMENT AS A RESULT OF THIS GUIDELINE

The 2023 guideline is approved by the National Health and Medical Research Council and provides clinicians and patients with clear advice on best practice in a common and neglected condition, based on the best available evidence, expert multidisciplinary input and consumer preferences. It provides vital, extensive patient and provider resources to enhance evidence-based care. The full guideline is available at www.monash.edu/medicine/mchri/pcos/guideline.

Prevalence, Phenotypes, and Comorbidities of Polycystic Ovary Syndrome Among Indian Women

Importance

The prevalence of polycystic ovary syndrome (PCOS) varies across the globe. Indian studies on PCOS are limited by poor design, small sizes, regional representations, and varying methods.

Objectives

To estimate the nationwide prevalence of PCOS in India, examine the phenotypic spectrum, and assess the magnitude of comorbidities associated with PCOS.

Design, Setting, and Participants

This cross-sectional study recruited 9824 women aged 18 to 40 years from November 1, 2018, to July 31, 2022, across 5 zones of the country. A prevalidated questionnaire dichotomized women into screen-positive and screen-negative groups. Relevant clinical, hormonal, and sonographic assessments categorized women as either women with criteria-based PCOS (ie, National Institutes of Health [NIH] 1990 criteria, Rotterdam 2003 criteria, or Androgen Excess and Polycystic Ovary Syndrome Society [AE-PCOS] criteria), women with partial phenotypes (hyperandrogenism, oligomenorrhea, or polycystic morphology labeled as pre-PCOS), or healthy women, in addition to quantitating various comorbidities.

Main Outcomes and Measures

The prevalence and phenotypes of PCOS among women of reproductive age and the burden of comorbidities associated with PCOS.

Results

A total of 8993 women (mean [SD] age, 29.5 [6.2] years) were enrolled in this study; 196 women were already diagnosed with PCOS, 2251 were categorized as screen positive, and 6546 were categorized as screen negative. The mean (SD) age of screen-positive women (28.1 [6.4] years) was lower than that of screen-negative women (29.7 [6.1] years) (P < .001), and the mean (SD) age at menarche was higher in the former group (13.2 [1.3] vs 13.1 [1.2] years; P < .001). The national prevalence of PCOS was 7.2% (95% CI, 4.8%-10.8%) by NIH 1990 criteria, 19.6% (95% CI, 12.7%-29.2%) by Rotterdam 2003 criteria, and 13.6% (95% CI, 8.4%-21.6%) by AE-PCOS criteria. Overall, PCOS phenotypes C (501 [40.8%]) and D (301 [24.6%]) were the most common, and 492 women (pre-PCOS subgroup) had oligomenorrhea (n = 75), hyperandrogenism (n = 257), or polycystic ovarian morphology (n = 160) only. Among women with PCOS (n = 1224), obesity was present in 529 (43.2%), dyslipidemia in 1126 (91.9%), nonalcoholic fatty liver disease in 403 (32.9%), metabolic syndrome in 305 (24.9%), impaired glucose tolerance in 111 (9.1%), diabetes in 41 (3.3%), and hypertension in 101 (8.3%). The pre-PCOS subgroup (n = 492) displayed similar metabolic aberrations (dyslipidemia: 390 [79.3%]; metabolic syndrome: 78 [15.9%]; nonalcoholic fatty liver disease: 163 [33.1%]; impaired glucose tolerance: 62 [12.6%]; diabetes: 7 [1.4%]; and hypertension: 26 [5.3%]).

Conclusions and Relevance

In this cross-sectional study of reproductive-age women recruited across India, the prevalence of PCOS was high, with phenotype C being predominant. Most of these women had metabolic abnormalities. These findings are crucial for developing preventive and therapeutic strategies, potentially integrating PCOS management into national health programs.

Polycystic Ovarian Syndrome: Exploring Hypertension and Cardiometabolic Implications

Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder affecting women of reproductive age, with significant implications for cardiometabolic health. This review focuses on the relationship between PCOS and hypertension (HTN), an area that remains underexplored despite growing evidence of its importance. PCOS is characterized by hyperandrogenism (HA), ovulatory dysfunction, and polycystic ovarian morphology (PCOM), all of which contribute to a complex metabolic profile that includes insulin resistance (IR), obesity, and dyslipidemia. These factors collectively exacerbate the risk of HTN. Emerging research suggests HA in PCOS may directly influence the renin-angiotensin system (RAS), increasing blood pressure by promoting sodium retention and vascular tone. Additionally, IR, prevalent in both lean and obese women with PCOS, further contributes to HTN by enhancing sympathetic nervous system activity and impairing endothelial function. Despite these associations, the direct link between PCOS and HTN has not been definitively established, warranting further investigation. This review synthesizes current knowledge on the etiology of PCOS and its metabolic consequences, highlighting the need for targeted research to clarify the mechanisms linking PCOS with HTN. Understanding these pathways is crucial for improving the management of PCOS and reducing cardiovascular risks in affected women. By addressing these gaps, this review underscores the importance of considering HTN as a significant comorbidity in PCOS and calls for more comprehensive studies to guide clinical practice.

Topiramate added to metformin for obesity control in women with polycystic ovary syndrome: a randomized clinical trial

CONTEXT

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

OBJECTIVE

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

METHODS

In a randomized, double-blind, placebo-controlled trial, participants with PCOS and body mass index ≥30 kg/m² or ≥27 kg/m² associated with hypertension, type 2 diabetes, or dyslipidemia followed a 20 kcal/kg diet in addition to 850 mg of MTF or a previous MTF regimen. They were randomized to receive either TPM or placebo (P) alongside MTF. Anthropometric measurements, blood pressure, modified Ferriman-Gallwey score (mFGS), and adverse events were assessed every 4 weeks for 6 months.

MAIN OUTCOME MEASURES

The primary endpoint was the percent change in body weight from baseline in both groups. Secondary endpoints included changes in clinical, cardiometabolic, and hormonal parameters and psychosocial features.

RESULTS

Thirty-one participants were in the MTF+P group and 30 in the MTF+TPM group. The MTF+TPM group showed greater mean weight loss at 3 months (-3.4% vs. -1.6%, p=0.03) and 6 months (-4.5% vs. -1.4%, p=0.03). Both groups improved androgens, lipids, and psychosocial scores. Participants with ≥3% weight loss at 6 months improved mFGS (8.4 to 6.5, p=0.026). Paresthesia was more common in the MTF+TPM group (23.3% vs. 3.2%, p=0.026).

CONCLUSIONS

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

METFORMIN: FROM DIABETES TO CANCER TO PROLONGATION OF LIFE

The metformin molecule dates back to over a century, but its clinical use started in the '50s. Since then, its use in diabetics has grown constantly, with over 150 million users today. The therapeutic profile also expanded, with improved understanding of novel mechanisms. Metformin has a major activity on insulin resistance, by acting on the insulin receptors and mitochondria, most likely by activation of the adenosine monophosphate-activated kinase. These and associated mechanisms lead to significant lipid lowering and body weight loss. An anti-cancer action has come up in recent years, with mechanisms partly dependent on the mitochondrial activity and also on phosphatidylinositol 3-kinase resistance occurring in some malignant tumors. The potential of metformin to raise life-length is the object of large ongoing studies and of several basic and clinical investigations. The present review article will attempt to investigate the basic mechanisms behind these diverse activities and the potential clinical benefits. Metformin may act on transcriptional activity by histone modification, DNA methylation and miRNAs. An activity on age-associated inflammation (inflammaging) may occur via activation of the nuclear factor erythroid 2 related factor and changes in gut microbiota. A senolytic activity, leading to reduction of cells with the senescent associated secretory phenotype, may be crucial in lifespan prolongation as well as in ancillary properties in age-associated diseases, such as Parkinson's disease. Telomere prolongation may be related to the activity on mitochondrial respiratory factor 1 and on peroxisome gamma proliferator coactivator 1-alpha. Very recent observations on the potential to act on the most severe neurological disorders, such as amyotrophic lateral sclerosis and frontotemporal dementia, have raised considerable hope.

Comparative efficacy of metformin combined with cabergoline versus metformin alone in patients with PCOS and hyperprolactinemia: A systematic review and meta-analysis of randomized controlled trials

Isntroduction. Polycystic ovary syndrome (PCOS) is a multifaceted endocrine-gynecological condition affecting a substantial number of women during their reproductive years. Metformin (MET) has been shown to improve ovarian function in PCOS-related conditions, while cabergoline is recognized for its powerful and sustained ability to reduce prolactin levels. This study investigates the potential impact of combining cabergoline with metformin while comparing it with metformin alone in the treatment of PCOS alongside hyperprolactinemia.

METHOD

To gather data, we searched PubMed, Google Scholar, ScienceDirect, and Cochrane Central. Eligible studies were randomized controlled trials involving patients with PCOS and hyperprolactinemia. Outcome measures included changes in the levels of prolactin, testosterone, DHEAS, BMI and menstrual irregularities. RevMan version 5.4 was used to analyze outcomes.

RESULT

This study incorporated three Randomized Controlled Trials (RCTs) involving 405 participants in total. Patients receiving a combination of metformin and cabergoline experienced significant reductions in prolactin and testosterone levels (p= <0.0001 and p=<0.0001, respectively). Conversely, alterations in DHEAS levels and BMI did not reach statistical significance (p = 0.19 and p = 0.71, respectively). Notably, women solely prescribed metformin exhibited significantly higher rates of menstrual irregularities compared to those receiving both metformin and cabergoline (p=<0.0001).

CONCLUSION

Our analysis underscores the synergistic effect achieved by pairing metformin and cabergoline in patients with PCOS and hyperprolactinemia. However, we encountered only a restricted number of studies meeting our criteria. It is imperative to consistently assess the combined effects of metformin and cabergoline to gain deeper insights into their effectiveness in addressing PCOS and hyperprolactinemia.

Metformin beyond type 2 diabetes: Emerging and potential new indications

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

Effects of melatonin and metformin on the ovaries of rats with polycystic ovary syndrome

OBJECTIVE

To study the combined and isolated effects of melatonin and metformin in the ovarian tissue of rats with PCOS.

DESIGN

Experimental study using a rat model of PCOS induced by continuous light exposure.

INTERVENTION(S)

Forty adult female rats were divided into 5 groups: physiological estrus phase (Sham); permanente estrus with PCOS induced by continuous lighting exposure for 60 consecutive days (control); with PCOS treated with melatonin; with PCOS treated with metformin; with PCOS treated with melatonin + metformin. After 60 days of treatments, all rats were killed, and ovaries were collected and processed for paraffin-embedding. Formalin-fixed paraffin-embedded sections were stained with hematoxylin and eosin or subjected to immunohistochemistry for proliferation (Ki-67) and apoptosis (cleaved caspase 3) detection markers.

SETTING

Federal University of São Paulo, Brazil.

ANIMALS

Forty adult female Wistar rats (Rattus norvegicus albinus).

MAIN OUTCOME MEASURE(S)

Number of corpus luteum and ovarian cysts, number of ovarian follicles (primary and antral follicles), number of interstitial cells, percentage of ovarian follicles (primary and antral follicles), and of interstitial cells immunostained to cleaved caspase-3 and Ki-67.

RESULTS

Absence of corpus luteum, a higher number of cysts, and increased nuclear volume and area of interstitial cells, along with a decrease in primary and antral follicle numbers, were noticed in the control group compared with the Sham group. Melatonin and metformin treatments attenuated these effects, although the combined treatment did not mitigate the increased number of cysts and ovaries induced by PCOS. An increase in theca interna cell apoptosis was observed in the control group, whereas melatonina and metformin treatments reduced it significantly. A higher percentage of caspase-3-immunostained granulosa cells was noted in the Sham and all treated groups compared with the control group; no aditive effects on ovarian cell apoptosis were observed in the combined treatment. The percentage of Ki-67- immunostained granulosa cells was significantly higher in the control group compared with the Sham group. However, the combined treatment, not melatonin and metformin alone, mitigated this effect. A higher percentage of Ki-67-immunostained interstitial cells was observed in all treated groups compared with the Sham and control groups, whereas no additive effects in that immunoreactivity were observed in the combined treatment.

CONCLUSIONS

Melatonin and metformin may improve ovarian function in rats with PCOS. The combined melatonin and metformin treatment is more effective in attenuating excessive granulosa cell proliferation, but it is not more effective in improving ovarian function than these drugs applied alone in rats with PCOS.

Polycystic ovary syndrome

Despite affecting ~11-13% of women globally, polycystic ovary syndrome (PCOS) is a substantially understudied condition. PCOS, possibly extending to men's health, imposes a considerable health and economic burden worldwide. Diagnosis in adults follows the International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome, requiring two out of three criteria - clinical or biochemical hyperandrogenism, ovulatory dysfunction, and/or specific ovarian morphological characteristics or elevated anti-Müllerian hormone. However, diagnosing adolescents omits ovarian morphology and anti-Müllerian hormone considerations. PCOS, marked by insulin resistance and hyperandrogenism, strongly contributes to early-onset type 2 diabetes, with increased odds for cardiovascular diseases. Reproduction-related implications include irregular menstrual cycles, anovulatory infertility, heightened risks of pregnancy complications and endometrial cancer. Beyond physiological manifestations, PCOS is associated with anxiety, depression, eating disorders, psychosexual dysfunction and negative body image, collectively contributing to diminished health-related quality of life in patients. Despite its high prevalence persisting into menopause, diagnosing PCOS often involves extended timelines and multiple health-care visits. Treatment remains ad hoc owing to limited understanding of underlying mechanisms, highlighting the need for research delineating the aetiology and pathophysiology of the syndrome. Identifying factors contributing to PCOS will pave the way for personalized medicine approaches. Additionally, exploring novel biomarkers, refining diagnostic criteria and advancing treatment modalities will be crucial in enhancing the precision and efficacy of interventions that will positively impact the lives of patients.

View on Metformin: Antidiabetic and Pleiotropic Effects, Pharmacokinetics, Side Effects, and Sex-Related Differences

Metformin is a synthetic biguanide used as an antidiabetic drug in type 2 diabetes mellitus, achieved by studying the bioactive metabolites of Galega officinalis L. It is also used off-label for various other diseases, such as subclinical diabetes, obesity, polycystic ovary syndrome, etc. In addition, metformin is proposed as an add-on therapy for several conditions, including autoimmune diseases, neurodegenerative diseases, and cancer. Although metformin has been used for many decades, it is still the subject of many pharmacodynamic and pharmacokinetic studies in light of its extensive use. Metformin acts at the mitochondrial level by inhibiting the respiratory chain, thus increasing the AMP/ATP ratio and, subsequently, activating the AMP-activated protein kinase. However, several other mechanisms have been proposed, including binding to presenilin enhancer 2, increasing GLP1 release, and modification of microRNA expression. Regarding its pharmacokinetics, after oral administration, metformin is absorbed, distributed, and eliminated, mainly through the renal route, using transporters for cationic solutes, since it exists as an ionic molecule at physiological pH. In this review, particular consideration has been paid to literature data from the last 10 years, deepening the study of clinical trials inherent to new uses of metformin, the differences in effectiveness and safety observed between the sexes, and the unwanted side effects. For this last objective, metformin safety was also evaluated using both VigiBase and EudraVigilance, respectively, the WHO and European databases of the reported adverse drug reactions, to assess the extent of metformin side effects in real-life use.

International evidence-based guideline on assessment and management of PCOS-A Nordic perspective

Polycystic ovary syndrome (PCOS) affects about 12% of women of reproductive age. In 2018, the first evidence-based guideline on assessment and management of PCOS was published, and an updated extended guideline was released in August 2023. These guidelines followed best practice and are endorsed by 39 organizations worldwide, making them the most robust source of evidence to guide clinical practice. In the 2023 guideline, diagnostic criteria have been further refined as polycystic ovary morphology can now be assessed with gynecological ultrasound or elevated anti-Müllerian hormone levels. A healthy lifestyle should be at the focus of care for all women with PCOS; however, with no specific diet or physical exercise recommended. The latest evidence on medical treatments and fertility management are reviewed, including special considerations regarding long-term follow-up of metabolic and psychiatric comorbidities and pregnancy in women with PCOS. Here we summarize the recommendations from a Nordic perspective.