Natural Molecules for the Therapy of Hyperandrogenism and Metabolic Disorders in PCOS

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European Review for Medical and Pharmacological Sciences 2017; 21 (2 Suppl): 15-29 Natural molecules for the therapy of hyperandrogenism and metabolic disorders in PCOS

V. CAPPELLI1, M.C. MUSACCHIO2, A. BULFONI3, G. MORGANTE1, V. DE LEO1

1Department of Molecular Medicine and Development, University of Siena, Siena, Italy 2Obstetric and Gynaecology, USL 5, Pisa, Italy 3Humanitas-Pio X, Milan, Italy

1 Abstract. – OBJECTIVE: Polycystic ovary syn- tive age and a complex endocrine condition, due drome (PCOS) is the most common endocrinopa- to its heterogeneity and uncertainty about its thy of women of reproductive age and a complex etiology. endocrine condition, due to its heterogeneity and An international meeting in 1990, held at the uncertainty about its etiology. However, PCOS is U.S. National Institute of Health (NIH), was rec- also associated with other metabolic abnormalities such as insulin resistance, impaired glu- ommended that the diagnostic criteria for PCOS cose tolerance, and diabetes. There are few med- should comprise the concomitant presence of an- ications that are approved for the most common ovulation and hyperandrogenaemia biochemical, symptoms of PCOS, leading to the off-label use of clinical (hirsutism/acne) or both1. Subsequently, medications that were approved for other indica- the report of a meeting of experts at a joint ESH- tions. One of the most common medications be- RE/ASRM meeting held in Rotterdam in 2003 ing used off label for PCOS is metformin. proposed that the presence of two of the three Research of other effective therapeutic options has included the utility of inositol. criteria (chronic anovulation, hyperandrogenism PATIENTS AND METHODS: A systematic liter- and polycystic ovaries on ultrasonography) would ature search of PubMed was performed using the be sufficient for PCOS diagnosis2. In 2006, The following combination of terms: ‘PCOS’, ‘hyper- Androgen Excess PCOS Society (AEPCOS) in- androgenism’ ‘inositol’, ‘natural molecules’. On- dicated that PCOS is mainly a hyperandrogenic ly papers published between 2000 and 2016 were disorder and that the second criterion essential for included in our analysis. The present review an- the diagnosis could be either chronic anovulation alyzes all aspects of the choice of natural mole- 3 cules in the treatment of hyperandrogenism and or polycystic ovarian morphology . metabolic disorders in PCOS women. However, PCOS is also associated with other RESULTS: The rationale underlying the use of metabolic abnormalities such as insulin resis- inositols as a therapeutic application in PCOS tance, impaired glucose tolerance, and diabetes4. derives from their activities as insulin mimetic In 2011, the Amsterdam ESHRE/ASMR-spon- agents and their salutary effects on metabolism sored 3rd PCOS Consensus Workshop Group and hyperandrogenism without side effects. CONCLUSIONS: In this review will discuss the identified different phenotype, characterized by role of a number of natural associations between hyperandrogenism and chronic anovulation, from inositol and different substances in the treatment those characterized by ovarian dysfunction and of hyperandrogenic symptoms in PCOS women. polycystic morphology5. This Consensus recommended screening for insulin and glucose tol- Key Words: erance by OGTT (75 g, 0 and 2h values) in the PCOS, Hyperandrogenism, Insulin-resistance, Inosi- tol, Lipoic acid, Monacolin k. presence of phenotype characterized by hyperandrogenism with anovulation, obesity, family history of diabetes5. Introduction There are few medications that are approved for the most common symptoms of PCOS, lead- PCOS and clinical Hyperandrogenism ing to the off-label use of medications that were Polycystic ovary syndrome (PCOS) is the most approved for other indications. One of the most common endocrinopathy of women of reproduc- common medications being used off label for

Corresponding Author: Vincenzo De Leo, MD; e-mail: [email protected] 15 V. Cappelli, M.C. Musacchio, A. Bulfoni, G. Morgante, V. De Leo

PCOS is metformin. A survey of PubMed re- to excess thecal cell development and androgen veals > 30 meta-analyses of a randomized trial production, but in the face of inadequate FSH and > 70 systematic reviews covering the role of stimulation of granulosa cell development and metformin therapy in the management of PCOS, aromatase production, these androgens were including ovulation induction, weight loss, men- not converted to estrogen leading to multiple strual control, miscarriage, and hirsutism6. Also, abnormalities. thiazolidinediones, which are drugs approved for This theory explained the morphology of the treatment of type 2 diabetes, have been used in ovary, hirsutism, and anovulation. Androgen ex- the treatment of PCOS. cess led to an ovarian follicular arrest in the However, side effects such as nausea and di- preantral stage, as estrogen is critical to the devel- arrhea (in the case of metformin) and increased opment and selection of a dominant follicle. The body weight (in the case of pioglitazone) may ovary thus contained multiple small preantral reduce patients compliance and limit the use of follicles due to this ongoing process and also had these drugs7,8. increased central stroma due to excessive thecal Research of other effective therapeutic options and stromal hyperplasia from the disordered go- has included the utility of inositol. The rationale nadotropin exposure. Secondarily this resulted underlying the use of inositols as a therapeutic in the spillover of excess androgens into the cir- application in PCOS derives from their activities culating pool resulting in inappropriate feedback as insulin mimetic agents and their salutary ef- to the hypothalamic pituitary axis and a vicious fects on metabolism and hyperandrogenism with- feedback loop where excess LH leads to excess out side effects. ovarian androgen production which in turn leads The review is organized by pathogenesis of to further LH. Finally, the excess circulating PCOS, common medications used in the treat- androgen led to stimulation of the pilosebaceous ment and the efficacy of inositol and other natural unit increases sebum production, induces termi- molecules used for multiple purposes in PCOS. nal hair differentiation, and in rare instances in the scalp lead to pilosebaceous unit atresia and Pathogenesis of PCOS: Chronic androgenic alopecia. Anovulation, Hyperandrogenism, and Insulin-Resistance Primary Ovarian and Adrenal The PCOS is a multifaceted disease involving Hyperandrogenism genetic/environmental factors but also endocrine Ovarian steroidogenesis is perturbed in the factors, such as disordered gonadotropin secre- syndrome with increased circulating androgen tion, uncontrolled ovarian steroidogenesis, ab- levels frequently noted in women with PCOS. errant insulin signaling and excessive oxidative Further intrafollicular androgen levels tend to be stress. elevated in antral follicles supporting a lack of adequate granulosa aromatase activity10. As noted Primary Disordered Gonadotropin Secretion above, a primary defect in ovarian steroidogenesis The first biochemical abnormality that was could lead through the same feedback loop noted identified in women with PCOS was disordered above to disordered gonadotropin secretion and gonadotropin secretion, with a preponderance stigmata of peripheral hyperandrogenism such as of luteinizing hormone (LH) to follicle stim- acne, hirsutism, and alopecia. Thecal cells from ulating hormone (FSH). Studies of gonado- PCOS women put into long-term culture exhibit tropin secretion in women with PCOS have defects in steroidogenesis including hyperpro- established that women have augmented the duction of androgens, implying alterations of release of LH in response to a gonadotrophin P450c17 activity that increases the 17OHP/A ra- releasing hormone (GnRH) challenge with ap- tio11. Finally, 20-30% of women with PCOS have propriate levels of FSH secretion9. As the two evidence of adrenal hyperandrogenism, primarily cell theory of the ovary evolved, i.e., that the- based on elevated levels of DHEAS an androgen cal cells can only produce androgens under marker of adrenal function12, suggesting that the stimulation of LH, whereas granulosa cells can defect in steroidogenesis is primary, and affects only aromatize androgens from the theca cells both androgen secreting glands, i.e. the ovary and into estrogens under the influence of FSH, this the adrenal. preponderance of LH was thought to be the pri- Other ovarian factors than disordered ste- mary etiology of the syndrome. Excess LH led roidogenesis may contribute to PCOS. For ex-

16 Natural molecules for the therapy of hyperandrogenism and metabolicdisorders in PCOS ample, there appears to be an increased density Also, hyperinsulinemia is linked to ovarian and of small preantral follicles in polycystic ovaries13. adrenal hyperandrogenism for the ability of insu- This could result from increased number of germ lin in certain conditions to stimulate gonadal and cells in the fetal ovary or from decreased loss of adrenal androgen production. Hyperandrogenism oocytes with age, or from decreased rate of loss has been further linked to insulin resistance and of oocytes during late gestation, childhood, and stigmata of the insulin resistance syndrome in puberty. Indeed, there is evidence in vitro to sup- women with PCOS and in PCOS family studies port increased survival and diminished atresia in which have found increasing prevalence of the a PCOS follicle14. metabolic syndrome in family members with increasing androgen levels21. Androgens also in- Primary Disorder of Insulin Resistance duce insulin resistance, best illustrated by the Women with PCOS show multiple abnormali- example of female to male transsexuals who have ties in insulin action. Dynamic studies of insulin increased insulin resistance after supplementa- action, including hyperinsulinemic euglycemic tion with androgens22. In vitro cultures of PCOS clamps and frequently sampled intravenous glu- thecal cells have been found to overproduce an- cose tolerance tests, have shown that women with drogens in response to insulin supplementation23, PCOS are more insulin resistant than weight- by increasing P450 cytochrome expression, LH, matched control women15,16. Early in the ontog- and IGF-1 receptors. Therefore, insulin-resis- eny of the syndrome, as in the ontogeny of type tance increases also adrenal steroidogenesis18. 2 diabetes, this is characterized by increased Further, the use of insulin sensitizing agents, pancreatic beta cell production of insulin to con- including both metformin and troglitazone have trol ambient glucose levels. Thus, many women been associated with both lowering of circulating with PCOS have fasting and meal challenged insulin levels and levels of both adrenal and ovar- hyperinsulinemia17. However, this compensato- ian androgens18. ry response by the pancreatic beta cell is often Finally, increased levels of insulin are associat- inadequate for the degree of peripheral insulin ed with the peripheral availability of sex steroids resistance leading to initially post-prandial hy- through its impact on circulating sex hormone perglycemia in these women and eventually fast- binding globulin (SHBG). SHBG has been found ing hyperglycemia16. to be partially regulated by circulating insulin At the molecular level, impaired insulin sig- levels with an inverse relationship24. Decreasing naling results from mutations or posttranslation- levels of SHBG mean increasing levels of free al modifications of the insulin receptor or any and bioavailable androgens, especially since the of its downstream effectors molecules. Insulin preferred substrate of SHBG are androgens (as resistance could be accounted for by a defect in opposed to estrogens and progestins). Increased insulin binding to its receptor or to a shortage of free androgens mean increased androgen action insulin receptors; however, there is evidence to in the periphery which can mean the piloseba- suggest that insulin resistance is most often due ceous unit or the hypothalamic pituitary axis to a post-binding defect in insulin action18. (Figure 1). The ovaries of these women have a normal response to insulin, probably because the hy- Altered Oxidative Stress and Chronic perinsulinemia acts on the ovary through the Low-Grade Inflammation in PCOS IGF-1 receptor. Furthermore, the insulin level Oxidative stress (OS) reflects an imbalance be- in ovarian uses as the signal mediator also the tween production and scavenging of reactive oxy- inositol-glycan pathway that is different from gen/nitrogen species (ROS/RNS)25, and excess ROS the activated system in other tissues and which accumulated in vivo would induce cell26, protein27, maintains its level in ovarian function also in and lipid damage28. OS is also intimately involved insulin-resistant subjects19. in PCOS pathogenesis, since PCOS patients show Hyperinsulinemia and/or disordered insulin more serious OS compared with the normal29. In action may have perturbed the reproductive ax- addition, OS is involved in the pathological pro- is in multiple ways. First insulin may act at the cesses of IR, hyperandrogenemia, and obesity as hypothalamic pituitary axis to stimulate gonado- well, which accompany PCOS frequently but not tropin production. In animal cell culture models, absolutely30. Abdominal obesity is regarded as a insulin has been found to enhance pituitary go- common complication of PCOS, and the risk of ab- nadotropin secretion20. dominal obesity in PCOS women ranges from 40%

17 V. Cappelli, M.C. Musacchio, A. Bulfoni, G. Morgante, V. De Leo

Figure 1. Hyperinsulinemia stimulates directly cytochrome p450 enzymes in the ovary or indirectly through action of LH or IGF-1, causing hyperandrogenism119. to 80% because of the differences of people and with oxidative stress (OS) markers37. IR encourages nations31. Obese patients are expected to have more OS because hyperglycemia and higher levels of free serious oxidative stress (OS) levels32, and significant fatty acid lead to reactive oxygen species (ROS) correlations of OS markers with obesity indexes, production. In general, insulin receptor substrate such as BMI, are discovered33. Levels of markers (IRS) is the key player of IR pathogenesis38.With that could reflect the degrees of lipid peroxidation the increased OS, various protein kinases are acti- and protein peroxidation, such as oxidized low-den- vated to induce serine/threonine phosphorylation of sity lipoprotein (ox-LDL), malondialdehyde (MDA), IRS and inhibit normal tyrosine phosphorylation of thiobarbituric reactive substances (TBARS), and IRS, reducing the capacity of IRS to combine with advanced oxidation protein products (AOPP), in- insulin receptor, suppressing IRS to activate the crease significantly in the obese patients compared downstream phosphatidyl inositol 3- kinase (PI3K); with the normal, and levels of markers that could and finally insulin signal to the effector via insu- reflect the antioxidant ability, such as glutathione lin receptor (InsR)/IRS/PI3K pathway is altered39. peroxidase (GSHPx) and copper- and zinc-contain- Therefore, studies with antioxidants such as vitamin ing superoxide dismutase (CuZn-SOD), decreased E, a-lipoic acid, and N-acetylcysteine indicate a significantly34. Thus abdominal obesity is directly beneficial impact on insulin sensitivity and offer associated with OS and contributes to the increased the possibility of new treatment approaches for IR40. OS levels in PCOS36. However, obesity is not the on- Moreover, chronic low-grade inflammation is ly factor leading to the more serious oxidative status considered as an important feature of PCOS and of PCOS, and other factors are considered to have has been suggested to participate in the patho- contributions as well, such as insulin-resistance. The genesis and development of PCOS. Inflammatory IR rate of PCOS patients ranges from 50% to 70%36 markers, such as C-reactive protein (CRP), tumor and IR markers of women with PCOS, such as HO- necrosis factor (TNF), interleukin-6 (IL-6), in- MA-IR, increase significantly compared with nor- terleukin-18 (IL-18), monocyte chemotactic pro- mal women and are usually significantly correlated tein-1 (MCP-1), and acute phase serum amyloid A

18 Natural molecules for the therapy of hyperandrogenism and metabolicdisorders in PCOS

(APSAA), increased in women with PCOS com- with PCOS appear to experience a dramatic im- pared with the normal41, 42. Reactive oxygen spe- provement in symptoms after surgery, implying cies (ROS) could induce releasing inflammatory this may be in some subjects a “cure” for the factors and inflammatory response, via activating syndrome50,51. However, these studies are pri- the associated signaling pathways43. marily case series and need further validation in Inflammation has also been demonstrated to prospective studies. be associated with IR in PCOS. As well as OS, inflammation could induce insulin resistance (IR) Combined Hormonal Contraceptives mainly via interfering with post-insulin recep- Combined hormonal contraceptives are the tor signaling pathway, insulin receptor substrate most commonly used medications for the long- 1-phosphatidyl inositol 3 kinase-protein kinase B term treatment of women with PCOS and have (IRS1-PI3K-PKB/Akt) pathway44. been recommended by the Task Force and the Finally, oxidative stress (OS) and inflam- Endocrine Society52, the Australian Alliance53, mation seem to contribute to hyperandrogen- and the PCOS Consensus Group54 as first-line emia in PCOS, but detailed interactions still treatment for hyperandrogenism and menstrual remain unclear. In several studies, OS and cycle irregularities in women with PCOS. inflammation markers are discovered to be They offer benefit through a variety of mech- positively correlated with androgen levels in anisms, including suppression of pituitary LH PCOS patients45. In vitro, OS was reported to secretion, suppression of ovarian androgen secre- enhance the activities of ovarian steroidogene- tion, and increased circulating SHBG levels. sis enzymes, which could stimulate androgen Individual OC preparations may have different generation, and antioxidative chemicals, just as doses and drug combinations and thus have vary- statins, inhibit the activities46. Tumor necrosis ing risk-benefit ratios. Even though guidelines do factor-α (TNF-α), an inflammatory marker as- not specify the use of one OCP over another52,54, sociated with tissue inflammation, was report- the best choice for symptomatic treatment is con- ed to have the ability to promote the synthesis sidered to be low-dose oral contraceptives that of androgen in the rat47. contain anti-androgenic or neutral progestins55. Oral contraceptives may also be associated Therapeutic Options of PCOS with a significant elevation in circulating tri- Treatment of women with PCOS tends to be glycerides as well as in HDL levels, though these symptom based, as there are few therapies which do not appear to progress over time56. There is address the multitude of complaints with which no evidence to suggest that women with PCOS women with PCOS present. Treatment tends to experience more cardiovascular events than the fall into two categories, either the treatment of general population when they use oral contracep- anovulatory infertility or the long-term mainte- tives, though risk factors for adverse events such nance treatment for PCOS related symptoms (i.e. as hypertension, obesity, clotting history, and hirsutism, menstrual disorders, obesity, etc.). smoking must be considered.

Lifestyle Modification Antiandrogens The gold standard for improving insulin sen- A minimum of 6 months of OCP regimen is sitivity in obese PCOS women should be weight usually required to obtain satisfactory results loss, diet, and exercise. Unfortunately, there are against acne and hirsutism55. When this treatment no effective treatments that result in permanent it’s no useful other therapies may be used. weight loss, and it is estimated that 90-95% of patients who experience a weight decrease will Spironolactone relapse. Further, in markedly obese individuals, Spironolactone is primarily used to treat hir- the only treatment that results in sustained and sutism and appears effective, though the evi- significant weight reduction is bariatric sur- dence is weak57. It is a diuretic and aldosterone gery48. The current National Institute of Health antagonist, also binds to the androgen receptors recommendations are to utilize bariatric surgery an antagonist. It has other mechanisms of ac- in patients with a BMI greater than 40 or with tion, including inhibition of ovarian and adrenal a BMI greater than 35 and serious medical steroidogenesis, competition for androgen re- co-morbidities49. It is uncertain whether PCOS ceptors in hair follicles, and direct inhibition of qualifies as a significant comorbidity. Women 5-reductase activity.

19 V. Cappelli, M.C. Musacchio, A. Bulfoni, G. Morgante, V. De Leo

Flutamide proves ovulatory and menstrual frequency61. Met- Flutamide, an androgen-receptor agonist, is formin tends to be the drug of choice to treat another nonsteroidal anti-androgen that has been glucose intolerance and elevated diabetes risk in shown to be effective against hirsutism in smaller women with PCOS because of its favorable safe- trials The most common side effect is dry skin, ty profile and the familiarity a wide number of but its use has been associated with hepatitis in caregivers from varying specialties have with the rare cases. The risk of teratogenicity with this medication. However, there are no long-term stud- compound is significant, and contraception should ies of metformin in women with PCOS to show be used. Flutamide has also been combined with diabetes prevention. Among women with PCOS lifestyle and metformin therapy for treatment of who use metformin, glucose tolerance improves PCOS and may have additive effects58. or stays steady over time62. Metformin also may be Finasteride associated with weight loss in women with PCOS, Finasteride inhibits both forms of the enzyme although the results in other populations are incon- 5-reductase (type 1, predominantly found in the sistent63. Metformin is often used in conjunction skin, and type II, predominantly found in the with lifestyle therapy to treat PCOS. prostate and reproductive tissues). Finasteride is Gastrointestinal symptoms (diarrhea, nausea, better tolerated than other anti-androgens, with vomiting, abdominal bloating, flatulence, and an- minimal hepatic and renal toxicity; however, it orexia) are the most common adverse reactions has a well-documented risk for teratogenicity in and may be ameliorated by starting at a small male fetuses, and adequate contraception should dose and gradually increasing the dose or by us- be used. Overall, randomized trials have found ing the sustained-release version now available in that spironolactone, flutamide, and finasteride to the United States. The dose is usually 1500-2000 have similar efficacy in improving hirsutism57. mg/day given in divided doses. Since metformin and statins administrations Ornithine Decarboxylase Inhibitors are associated with several side effects such as These have been developed for the treatment nausea, vomiting, gastric pain causing the end of of female hirsutism. Ornithine decarboxylase is therapy, combined treatment with natural prod- necessary for the production of polyamines, and ucts: such as monacolin k, inositols, lipoic acid, is also a sensitive and specific marker of androgen glucomannan, and bergamot represents a valid action in the prostate. Inhibition of this enzyme alternative, well tolerated and with a similar limits cell division and function in the piloseba- mode of action64. ceous unit. Recently a potent inhibitor of this enzyme, eflornithine, has been found to be effective Inositol as a facial crème for the treatment of unwanted The stereoisomeric family of 9 inositols in- facial hair59 (Brand name Vaniqa). cludes myo-, cis-, allo-, epi-, muco-, neo, scyllo- and the optical isomers D and L chiro-inositols. Statins Myo-inositol (MI) is the most widely distrib- Another area where there is emerging support uted in nature. Biosynthesized from glucose65, in the literature for a cardiovascular and endo- the cyclase converting the immediate precursor crine benefit in women with PCOS, is the use fructose 6-P to myo-inositol has been cloned66. of statins. They have been shown to improve L-chiro-inositol is the product of epimerizing hy- hyperandrogenemia, lipid levels, and reduce in- droxyl #1 of myo-inositol, while D-chiro-inositol flammation60. However, their long-term effects in (DCI) is the product of epimerizing hydroxyl #3 preventing cardiovascular disease in young wom- of myo-inositol67 (Figure 2). en with PCOS is unknown. There are concerns In nature inositol (and its derivatives: salts, about teratogenicity with the use of this drug in phosphates and associated lipids) are found in reproductive age women, as it is FDA pregnancy many foods (especially fruits and beans)68. In category X. The use of these drugs is still exper- plants, inositol is generally represented in the imental in women with PCOS. form of hexaphosphate, and phytic acid or its salts (phytates). Insulin-Sensitizing Agents MI was once considered as a member of the Metformin is the insulin-sensitizing agent most vitamin B complex; however, it cannot be consid- useful in the long-term maintenance of PCOS. ered a ‘true’ essential nutrient, given that it can Metformin does lower serum androgens, and im- be synthesized by the human body. However, it is

20 Natural molecules for the therapy of hyperandrogenism and metabolicdisorders in PCOS

Figure 2. Structures of myo-, D and L chiro-inositols. Myo-inositol is epimerized in position 1 to form L-chiro-inositol and in position 3 to form D-chiro-inositol67. still a matter of controversy if such biosynthesis the ovary, resulting in an overproduction of DCI may provide amounts considered adequate for and a concomitant depletion of MI75. Also, the good health from glucose69. resulting deficiency of MI could be responsible The two inositol stereoisomers, MI and DCI for the poor oocyte quality and the impairment are chemical mediators of insulin, acting through of the FSH signaling. Clearly, DCI supplementa- different mechanisms70. Both DCI and MI have tion would be ineffective in such women as they similar structures, differing in the stereochem- already have high levels of this molecule in the istry of only one hydroxyl group71. Myo-inositol ovary78. is synthesized from glucose-6-phosphate in two Oral nutritional supplementation with inositol, steps. First, glucose-6-phosphate is isomerized part of the vitamin B complex (B8) and an in- to myo-inositol-1-phosphate, which is then de- tracellular second messenger, was demonstrated phosphorylated by an inositol monophosphatase to enhance insulin sensitivity and improves the enzyme giving free myo-inositol72. In vivo, DCI clinical and hormonal characteristics of PCOS is synthetized by an epimerase that converts patients79,80. Moreover, MI supplementation was myo-inositol into DCI. Larner first demonstrat- shown to restore spontaneous ovulation with the ed a decreased DCI content in urine as well as consequent increase in conception, either alone81 tissues of human subjects and animals with type or when combined with gonadotropins82. 2 diabetes. Moreover, the decrease of DCI in The 2013 International Consensus Conference urine was observed with an increase of myo-ino- on MI and DCI in Obstetrics and Gynecology83 sitol71,73. Additional investigations demonstrated identified opinion leaders in all fields related to that the altered inositol excretion patterns71,73,74 MI and DCI and their involvement, as second were specifically related to the insulin resistance, messengers of insulin, in several insulin-depen- rather than to diabetes. Larner postulated a defect dent processes, such as metabolic syndrome and in the epimerization process that physiologically PCOS. In conclusion, they postulated that the enacts the conversion of MIDCI. treatment of PCOS women, as well as the pre- In addition, MI and DCI function as insulin vention of GDM, seem those clinical conditions second messengers and mediate different actions which take more advantages from MI supplemen- of insulin75. MI is converted to an inositolphos- tation, when used at a dose of 2 g twice/day. The phoglycan (IPG) insulin second messenger (MI- clinical experience with MI is largely superior IPG) involved in cellular glucose uptake, whereas to the one with DCI. However, the existence of DCI is converted to an IPG insulin second mes- tissue-specific ratios, namely in the ovary, has senger (DCI-IPG) involved in glycogen synthe- prompted researchers to recently develop a treat- sis76. On the other hand, at the ovarian level, it ment based on both molecules in the proportion has been shown that MI-based second messenger of 40 (MI) to 1 (DCI)83. is involved in both glucose uptake and FSH In 2015, The International Consensus Con- signaling whereas DCI-based second messen- ference on MI and DCI in Obstetrics and Gyne- ger is devoted to the insulin-mediated androgen cology84 postulated that an imbalance between production77. In women with PCOS, hyperinsu- MI and DCI leads to a reduction in insulin and linemia likely stimulated epimerase activity in FSH signaling, is observed in PCOS patients85,86.

21 V. Cappelli, M.C. Musacchio, A. Bulfoni, G. Morgante, V. De Leo

Indeed, MI depletion induces a defect in glucose valid associations are inositol and monacolin, uptake. This, in turn, reduces glucose availabil- inositol and lipoid acid, inositol and bergamot. ity in the ovary for both oocytes and follicu- These new combinations may oppose the etiopa- lar cells. Although oocytes are characterized by thologies responsible for the onset and deteriora- high glucose consumption, by impairing sugar tion of PCOS-related symptoms. Moreover, these availability oocyte quality will be compromised. natural choices are more accepted by patients and Overall evidence from the literature analyzed by clinicians who consider metformin only an anti- the Conference Scientific Committee points out diabetic drug and then other use are “off-label”91. the beneficial effects of MI treatment in ART, in particular at the level of ovarian response to Inositol and Monacolin K exogenous gonadotropins as well as oocyte and Recently, red yeast rice, a Chinese dietary embryo quality. In this regard, administration supplement, has gained popularity due to its of MI, alone or in combination with DCI (in the properties as a natural statin. It contains varying physiological plasma ratio of 40:1), could be a amounts of natural monacolin K (mevinolin), a predictive factor in improving ART outcomes metabolite of Monascus rubber, which specifi- An important review, published in 201487, an- cally inhibit 3-hydroxy-3-methylglutaryl (HMG)- alyzed data from the literature about inositols in CoA reductase, the rate limiting enzyme in cho- the treatment of PCOS, in conclusion, Di Nicola lesterol synthetic pathway92. Monacolin K was et al87 postulated that despite the relatively high suggested to have a similar effect on lipid metab- number of reports, only a few of them ful- olism, as shown for the mechanism of action of fill the criteria of the randomized clinical trial. pharmacological statins93, and it was demonstrat- Those studies have been extensively reviewed ed to effectively reduce the levels of cholesterol in elsewhere81,88. Among 70 studies focusing on patients with hypercholesterolemia94. Moreover, PCOS treatment using different pharmaceutical its ability to inhibit steroid synthesis was claimed composition incorporating INS, 21 were consid- to be responsible for the observed decrease in ered eligible as they involve MI81. Yet, only six of hyperandrogenism, which may further restore them were randomized controlled clinical trials, ovulation in those PCOS patients, as was already involving more than 300 PCOS patients. Remark- demonstrated following the use of simvastatin ably, in all the studies analyzed, no side effects alone or in combination with metformin95. Fur- were reported. Overall, those studies indicate thermore, the antioxidative properties of statins that MI supplementation improves several of the and monacolin K, may further control cellular hormonal disturbances of PCOS. MI mechanisms proliferation and improve ovulatory function96. of action appear to be mainly based on improving In 2013, our group published about this nat- insulin sensitivity of target tissues, resulting in a ural association97; we studied 60 insulin resis- positive effect on the reproductive axis (MI re- tant PCOS patients. There were 3 groups were stores ovulation and improves oocyte quality) and treated for 6 months with either myo-inositol hormonal functions (MI reduces clinical and bio- and monacolin k, inositol only or metformin and chemical hyperandrogenism and dyslipidemia) they compared clinical, metabolic and hormonal through the reduction of insulin plasma levels87. assessment at the start, after 3 and 6 months of These data are particularly interesting in PCOS treatment. In the present study, we demonstrated women, in fact, an increased activity of epime- that all treatments improved patients’ clinical, rase in theca cells of ovaries of PCOS women hormonal and metabolic profiles, with a tendency is associated with a consistent reduction in the toward better results using the combination of intraovarian ratio of Mi and DCI. This is the hy- myo-inositol and monacolin k. Regarding the lip- pothesis of ovarian paradox postulated by Carlo- id profile, total cholesterol, triglycerides and LDL magno et al in 201089; in this way is fundamental levels were significantly reduced in all groups, to supplement MI and DCI in physiological ratio with a more pronounced reduction in LDL fol- to restore normally ovary function to improve the lowing the combined treatment with myo-inositol oocyte quality90. and monacolin k; the combined treatment with Because of the absence of side effects with the myo-inositol and monacolin k significantly raised administration of these products, the scientific in HDL levels. interest in recent years has been to discover new Since metformin and statins administrations natural associations that represent valid alterna- are associated with several side effects such as tives in the treatment of PCOS symptoms. New nausea, vomiting, gastric pain causing the end

22 Natural molecules for the therapy of hyperandrogenism and metabolicdisorders in PCOS of therapy98, the combined treatment with the of beta-D-glucose and beta-D-mannose with at- natural products: monacolin k and myo-inositol tached acetyl groups in a molar ratio of 1: 1.6 with represent a valid alternative, well tolerated and beta 1-4 linkages106. Because human salivary and with a similar mode of action. pancreatic amylase cannot split beta 1, 4 linkages, glucomannan passes relatively unchanged into Inositol and Lipoic Acid the colon. It has a high molecular weight and can Alpha lipoic acid (LA) is a potent antioxidant, absorb up to 50 times its weight in water, making and controlled release alpha lipoic acid has been it one of the most viscous dietary fibers known107. reported to improve glucose control in type 2 With its low energy density and bulking prop- diabetes patients99, and in women with PCOS, to erties, glucomannan seems to promote weight improve insulin sensitivity and reproductive and loss by displacing the energy of other nutrients metabolic disorders100. Recently, authors showed and producing satiety and satiation as it absorbs that inositol combined with alpha lipoic acid can water and expands in the gastrointestinal tract. be used as a dietary supplement in insulin-re- In addition, glucomannan seems to reduce total sistant patients in order to increase their insulin cholesterol and low-density lipoprotein (LDL) sensitiveness101,103. cholesterol levels by stimulating fecal excretion LA, either as a dietary supplement or a thera- of cholesterol and bile acids and decreasing intes- peutic agent, modulates redox potential because tinal absorption of cholesterol108. Also, glucoman- of its ability to match the redox status between nan may improve glycemic parameters by inhib- different subcellular compartments as well as iting appetite and slowing intestinal absorption extracellularly. Both the oxidized (disulfide) and due to increased viscosity109. Obesity is present in reduced (di-thiol: dihydro-lipoic acid, DHLA) 50-65% of PCOS women; a lot of studies demon- forms of LA show antioxidant properties. LA strated that reduction of body weight and train- exerts antioxidant effects in biological systems ing may improve fertility, and cycle irregularity through ROS quenching but also via an action on through reduce the insulin blood levels. transition metal chelation. Dietary supplementa- The combination between inositol and gluco- tion with LA has been successfully employed in mannan was studied to reducing glucose levels a variety of in vivo models of disease associated and improving insulin sensitivity in PCOS over- with an imbalance of redox status: diabetes and weight patients. In particular, De Leo et al110 in cardiovascular diseases103. 2014 studied this natural association in 40 PCOS Recently it’s studied the association between women with insulin resistance. They concluded myo-inositol, monacolin k and lipoic acid in that this association can improve insulin resis- PCOS patients; the authors recruited 30 women tance in PCOS women with significant results, with PCOS and IR, and they studied lipid profile, in fact, glucomannan can delay absorption of BMI, and androgens before the treatment and glucose in the bowel and can extend the action after 6 months of therapy102. They concluded that of inositol through the delay of absorption of this this association improves lipid parameters and substance. This action should improve inositol hyperandrogenism. action to acquire long-acting function. These data show that this natural association is not only limited to the reduction of total Inositol and Bergamot cholesterol103 but that is also stimulated HDL Pharmacological studies have confirmed the production; the reduction in cholesterol also pos- activities already known in folk medicine, cho- itively affects the levels of androgenic steroids. lesterol lowering action and lipid lowering action The synergy between myo-inositol, monacolin k, of bergamot juice. These actions are mainly due and lipoic acid has produced results through a re- to the flavonoids. Clinical studies have shown duction in plasma insulin levels which no longer that the activity of individual flavonoid com- stimulate the theca cells in androgen production. pounds doesn’t have the same power of action of the entire plant complex. The lipid-lowering Inositol and Glucomannan action carried out by the main bioactive com- Glucomannan is a water-soluble, fermentable pounds (flavonoids) contained in bergamot juice dietary fiber extracted from the tuber or root of was further confirmed in a major clinical RCT the elephant yam, also known as konjac (Amorph- study conducted on 237 patients with hypercho- ophallus konjac or Amorphophallus rivieri). Glu- lesterolemia either associated to hyperglycemia comannan consists of a polysaccharide chain or not111. The results obtained after 30 days have

23 V. Cappelli, M.C. Musacchio, A. Bulfoni, G. Morgante, V. De Leo confirmed that treatment with bergamot extract the synergy between insulin sensitizer (inosi- results in a significant reduction of total and tol) and other product personalized on women LDL-cholesterol, and a significant increase in request. HDL-cholesterol values111. The plant complex Myo-inositol can reduce insulin blood levels to of bergamot has demonstrated in vivo to lower restore physiological menstrual cycle. Restoration triglyceride levels112-114. of the ovulatory cycle can improve mild acne and The association between inositol, monacolin k, hirsutism. The association between myo-inosi- vitamin K2, methylfolate and bergamot juice has tol and monacolin K (3-10 mg/die) can improve been recently studied for its important action on moderate acne and hirsutism after 3, 6 months dyslipidemia115. This association was experiment- of therapy, in fact, monacolin interferes with the ed in 40 perimenopausal women with metabolic production of cholesterol and then with the andro- syndrome, BMI > 25 kg/m2 and insulin resis- gen synthesis97. tance: 20 women were treated and the other 20 Another relevant association is between patients were as the control group. myo-inositol and alpha lipoic acid; with this com- Regarding the lipid profile, total cholester- bination, we can restore ovulatory cycles, and we ol and triglycerides showed a significant de- can interfere with inflammation that character- crease while HDL levels have increased. This ized the onset and maintenance of acne. study demonstrated that the association between In obese PCOS women, the association be- d-chiro-inositol, monacolin-K, bergamot extract, tween inositol and glucomannan; glucomannan methylfolate and vitamin K2 is not limited only is a fibre that can induce a sense of satiety and to the reduction of total cholesterol, but may in- reduce absorption of lipids and carbohydrates crease HDL. The synergic action of nutritional in the bowel with a consequent reduction of cir- components and plant extracts of this new sup- culating insulin, weight reduction and improve plement demonstrated to effectively rebalance hyperandrogenism in these women. the altered functional states of the gluco-lipid In conclusion, MI and its metabolite DCI have metabolism and vascular system. been confirmed as a valid non-pharmacologic alternative to contrast insulin-resistance in PCOS women. Various choices between myo-inositol Conclusions and other natural substances find specific indications depending on the predominant endocrine A growing number of women looking for a and metabolic symptom. mental and physical wellbeing, but at the same It must be remembered that the first improve- time they want to treat their own problems, ments of these symptoms are observed after long in particular, those of an aesthetic nature with treatment (90-120) days. In fact, these therapies non-traditional therapies. should be evaluated in medium and long-term In recent years, many studies was performed associated with an adequate lifestyle. to clarify the involvement of inositols in PCOS It is important to highlight that some studies to improve the ovary function and oocyte quality; we have cited are preliminary and conducted on in fact a large amount of evidence exists to prove a small population, larger sample sizes will also the positive effect of inositol in this way; inositol serve to strengthen future studies. exert important actions in the glucose homeosta- sis and when incorporated into phospho glycans has been shown to serve as second messengers Conflict of interest involved in the signalling-transduction cascade of The authors declare no conflicts of interest. insulin116 and in PCOS patients the metabolism of inositol is dysregulated; these data suggest the relationship between insulin resistance and inositol References deficiency in PCOS women117,118. As expressed in this review, we can assert that exist a lot of natural association to help women 1) Zawadski JK, Dunaif A. Diagnostic criteria for to resolve primary insulin resistance but enough polycystic ovary syndrome: towards a rational a lot of related problems. In particular, the use of approach. In: Dunaif A, Givens JR, Haseltine FP, Merriam GR, editors. Polycystic Ovary Syn- MI or DCI exerts a reduction of metabolic and drome. Boston: Blackwell Scientific Publications, endocrine symptoms in PCOS women through 1992; pp. 377-384.

24 Natural molecules for the therapy of hyperandrogenism and metabolicdisorders in PCOS

2) Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus survival in culture of preantral follicles from poly- Workshop Group, authors. Revised 2003 consen- cystic ovaries. J Clin Endocrinol Metab 2007; 92: sus on diagnostic criteria and long-term health 1975-1978. risks related to polycystic ovary syndrome. Fertil 15) Dunaif A, Segal KR, Futterweit W, Dobrjansky A. Steril 2004; 81: 19-25. Profound peripheral insulin resistance, indepen- 3) Azziz R, Carmina E, Dewailly D, Diamanti-Kandarakis dent of obesity, in polycystic ovary syndrome. E, Escobar-Morreale HF, Futterweit W, Janssen OE, Diabetes 1989; 38: 1165-1174. Legro RS, Norman RJ, Taylor AE, Witchel SF ; Task 16) Dunaif A, Finegood DT. Beta-cell dysfunction in- Force on the Phenotype of the Polycystic Ovary dependent of obesity and glucose intolerance in Syndrome of The Androgen Excess and PCOS the polycystic ovary syndrome. J Clin Endocrinol Society. Task Force on the Phenotype of the Metab 1996; 81: 942-947. Polycystic Ovary Syndrome of The Androgen Chang RJ, Nakamura RM, Judd HL, Kaplan SA Excess and PCOS Society. The Androgen Ex- 17) . cess and PCOS Society criteria for the polycystic Insulin resistance in nonobese patients with poly- ovary syndrome: the complete task force report. cystic ovarian disease. J Clin Endocrinol Metab Fertil Steril 2009; 91: 456-488. 1983; 57: 356-359. De Leo V, la Marca A, Petraglia F. 4) Legro RS, Gnatuk CL, Kunselman AR, Dunaif A. 18) Insulin-lowering Changes in glucose tolerance over time in wom- agents in the management of polycystic ovary en with polycystic ovary syndrome: a controlled syndrome. Endocr Rev 2003; 24: 633-667. study. Clin Endocrinol Metab 2005; 90: 3236- 19) Nestler JE, Jakubowicz DJ, de Vargas AF, Brik C, 3242. Quintero N, Medina F. Insulin stimulates tes- 5) Fauser BC, Tarlatzis BC, Rebar RW, Legro RS, Balen tosterone biosynthesis by human thecal cells AH, Lobo R, Carmina E, Chang J, Yildiz BO, Laven from women with polycystic ovary syndrome JS et al. Consensus on women’s health aspects of by activating its own receptor and using inosi- polycystic ovary syndrome (PCOS): the Amster- tolglycan mediators as the signal transduction dam ESHRE/ASRM-Sponsored 3rd PCOS Con- system. J Clin Endocrinol Metab 1998; 83: sensus Workshop Group. Fertility and Sterility 2001-2005. 2012; 97: 28-38. 20) Adashi EY, Hsueh AJ, Yen SS. Insulin enhancement 6) Vitek W, Alur S, Hoeger KM. Off-label drug use in of luteinizing hormone and follicle-stimulating the treatment of polycystic ovary syndrome. Fertil hormone release by cultured pituitary cells. En- Steril 2015; 103: 605-611. docrinology 1981; 108: 1441-1449. 7) Baillargeon JP, Iuorno MJ, Nestler JE. Insulin sen- 21) Ehrmann DA, Liljenquist DR, Kasza K, Azziz R, Legro sitizers for polycystic ovary syndrome. Clin Ob- RS, Ghazzi MN. Prevalence and predictors of the stet Gynecol 2003; 46: 325-340. metabolic syndrome in women with polycystic 8) Pasquali R, Gambineri A. Insulin-sensitizing agents ovary syndrome. J Clin Endocrinol Metab 2006; in polycystic ovary syndrome. Eur J Endocrinol 91: 48-53. 2006; 154: 763-775. 22) Polderman KH, Gooren LJ, Asscheman H, Bakker A, Heine RJ. 9) Unfer V, Nestler JE, Kamenov ZA, Prapas N, Facchi- Induction of insulin resistance by an- netti F. Effects of Inositol(s) in Women with PCOS: drogens and estrogens. J Clin Endocrinol Metab A Systematic Review of Randomized Controlled 1994; 79: 265-271. Trials. Int J Endocrinol 2016; 2016: 1849162. 23) Willis D, Franks S. Insulin action in human gran- 10) Schneyer AL, Fujiwara T, Fox J, Welt CK, Adams ulosa cells from normal and polycystic ovaries J, Messerlian GM, Taylor AE. Dynamic changes is mediated by the insulin receptor and not the in the intrafollicular inhibin/activin/follistatin axis type-I insulin-like growth factor receptor. J Clin during human follicular development: relationship Endocrinol Metab 1995; 80: 3788-3790. to circulating hormone concentrations. J Clin En- 24) Nestler JE, Powers LP, Matt DW, Steingold KA, docrinol Metab 2000; 85: 3319-3330. Plymate SR, Rittmaster RS, Clore JN, Blackard WG. 11) Diamanti-Kandarakis E. Polycystic ovarian syn- A direct effect of hyperinsulinemia on serum sex drome: pathophysiology, molecular aspects and hormone-binding globulin levels in obese women clinical implications. Expert Rev Mol Med 2008; with the polycystic ovary syndrome. J Clin Endo- 10: e3. crinol Metab 1991; 72: 83-89. 12) Kumar A, Woods KS, Bartolucci AA, Azziz R. Prev- 25) Pisoschi AM, Pop A. The role of antioxidants in the alence of adrenal androgen excess in patients chemistry of oxidative stress: a review. Eur J Med with the polycystic ovary syndrome (PCOS). Clin Chem 2015; 97: 55-74. Endocrinol (Oxf) 2005; 62: 644-649. 26) Hiraku Y, Kawanishi S. Immunohistochemical anal- 13) Webber LJ, Stubbs S, Stark J, Trew GH, Margara R, ysis of 8-nitroguanine, a nitrative DNA lesion, in Hardy K, Franks S. Formation and early develop- relation to inflammation-associated carcinogene- ment of follicles in the polycystic ovary. Lancet sis. Methods Mol Biol 2009; 512: 3-13. 2003; 362: 1017-1021. 27) Dalle-Donne I, Rossi R, Colombo R, Giustarini D, Mil- 14) Webber LJ, Stubbs SA, Stark J, Margara RA, Trew zani A. Biomarkers of oxidative damage in human GH, Lavery SA, Hardy K, Franks S. Prolonged disease. Clin Chem 2006; 52: 601-623.

25 V. Cappelli, M.C. Musacchio, A. Bulfoni, G. Morgante, V. De Leo

28) Tezil T, Basaga H. Modulation of cell death in 43) Touyz RM. Molecular and cellular mechanisms age-related diseases. Curr Pharm Des 2014; 20: in vascular injury in hypertension: role of angio- 3052-3067. tensin II. Curr Opin Nephrol Hypertens 2005; 14: 125-131. 29) Murri M, Luque-Ramírez M, Insenser M, Ojeda-Ojeda M, Escobar-Morreale HF. Circulating markers of 44) Keane KN, Cruzat VF, Carlessi R, De Bittencourt oxidative stress and polycystic ovary syndrome PI, Newsholme P. Molecular events linking oxida- (PCOS): a systematic review and meta-analysis. tive stress and inflammation to insulin resistance Hum Reprod Update 2013; 19: 268-288. and beta-cell dysfunction. Oxid Med Cell Longev 2015; 2015: 181643. 30) Lee JY, Baw C, Gupta S, Aziz N, Agarwal A. Role of oxidative stress in polycystic ovary syndrome. 45) Yang Y, Qiao J, Li R, Li MZ. Is interleukin-18 associ- Curr Women’s Health Rev 2010; 6: 96-107. ated with polycystic ovary syndrome? Reprod Biol Endocrinol 2011; 9: 7. 31) Kirchengast S, Huber J. Body composition charac- Zuo T, Zhu M, Xu W. teristics and body fat distribution in lean women 46) Roles of Oxidative Stress in with polycystic ovary syndrome. Hum Reprod Polycystic Ovary Syndrome and Cancers. Oxid 2001; 16: 1255-1260. Med Cell Longev 2016; 2016: 8589318. Spaczynski RZ, Arici A, Duleba AJ. 32) Holguin F, Fitzpatrick A. Obesity, asthma, and oxi- 47) Tumor necrosis dative stress. J Appl Physiol 2010; 108: 754-759. factor-α stimulates proliferation of rat ovarian theca- interstitial cells. Biol Reprod 1999; 61: 993- Choi HD, Kim JH, Chang MJ, Kyu-Youn Y, Shin WG. 33) 998. Effects of astaxanthin on oxidative stress in over- Sjostrom L, Lindroos AK, Peltonen M, Torgerson J, weight and obese adults. Phytother Res 2011; 25: 48) Bouchard C, Carlsson B, Dahlgren S, Larsson B, 1813-1818. Narbro K, Sjostrom CD, Sullivan M, Wedel H. Life- Couillard C, Ruel G, Archer WR, Pomerleau S, 34) style, diabetes, and cardiovascular risk factors 10 Bergeron J, Couture P, Lamarche B, Bergeron N. years after bariatric surgery. N Engl J Med 2004; Circulating levels of oxidative stress markers and 351: 2683-2693. endothelial adhesion molecules in men with ab- Robinson MK. dominal obesity. J Clin Endocrinol Metab 2005; 49) Surgical treatment of obesity-weigh- 90: 6454-6459. ing the facts. N Engl J Med 2009; 361: 520-521 Escobar-Morreale HF, Botella-Carretero JI, Alva- 35) Kumanyika SK. The obesity epidemic: looking in the 50) rez-Blasco F, Sancho J, San Millan JL. mirror. Am J Epidemiol 2007; 166: 243-245. The polycystic ovary syndrome associated with morbid Legro RS, Finegood D, Dunaif A. 36) A fasting glucose obesity may resolve after weight loss induced by to insulin ratio is a useful measure of insulin sen- bariatric surgery. J Clin Endocrinol Metab 2005; sitivity in women with polycystic ovary syndrome. 90: 6364-6369 J Clin Endocrinol Metab 1998; 83: 2694-2698. 51) Eid GM, Cottam DR, Velcu LM, Mattar SG, Koryt- Mohamadin AM, Habib FA, Elahi TF. 37) Serum para- kowski MT, Gosman G, Hindi P, Schauer PR. Effective oxonase 1 activity and oxidant/antioxidant status treatment of polycystic ovarian syndrome with in Saudi women with polycystic ovary syndrome. Roux-en-Y gastric bypass. Surg Obes Relat Dis Pathophysiology 2010; 17: 189-196. 2005; 1: 77-80. MacLaren R, Cui W, Simard S, Cianflone K. 38) Influ- 52) Legro RS, Arslanian SA, Ehrmann DA, Hoeger KM, ence of obesity and insulin sensitivity on insulin Murad MH, Pasquali R, Welt CK. Endocrine Soci- signaling genes in human omental and subcu- ety. Diagnosis and treatment of polycystic ovary taneous adipose tissue. J Lipid Res 2008; 49: syndrome: an Endocrine Society clinical practice 308-323. guideline. J Clin Endocrinol Metab 2013; 98: 39) Gao D, Nong S, Huang X, Lu Y, Zhao H, Lin Y, Man 4565-4592. Y, Wang S, Yang J, Li J. The effects of palmitate 53) Misso M, Boyle J, Norman R, Teede H. Development on hepatic insulin resistance are mediated by of evidenced-based guidelines for PCOS and NADPH oxidase 3-derived reactive oxygen spe- implications for community health. Semin Reprod cies through JNK and p38MAPK pathways. J Biol Med 2014; 32: 230-240. Chem 2010; 285: 29965-29973. 54) Fauser BC, Tarlatzis BC, Rebar RW, Legro RS, Balen 40) Evans JL, Maddux BA, Goldfine ID. The molecular AH, Lobo R, Carmina E, Chang J, Yildiz BO, Laven basis for oxidative stress-induced insulin resis- JS, Boivin J, Petraglia F, Wijeyeratne CN, Norman RJ, tance. Antiox Redox Signal 2005; 7: 1040-1052. Dunaif A, Franks S, Wild RA, Dumesic D, Barnhart 41) González F. Inflammation in polycystic ovary K. Consensus on women’s health aspects of poly- syndrome: underpinning of insulin resistance cystic ovary syndrome (PCOS): the Amsterdam and ovarian dysfunction. Steroids 2012; 77: ESHRE/ASRM-Sponsored 3rd PCOS Consensus 300-305. Workshop Group. Fertil Steril 2012; 97: 28-38. 42) González F, Nair KS, Daniels JK, Basal E, Schimke 55) Yildiz BO. Oral contraceptives in polycystic ovary JM, Blair HE. Hyperandrogenism sensitizes leu- syndrome: risk-benefit assessment. Semin Re- kocytes to hyperglycemia to promote oxidative prod Med 2008; 26: 111-120. stress in lean reproductive-age women. J Clin 56) Falsetti L, Pasinetti E. Effects of long-term adminis- Endocrinol Metab 2012; 97: 2836-2843. tration of an oral contraceptive containing ethinyl-

26 Natural molecules for the therapy of hyperandrogenism and metabolicdisorders in PCOS

estradiol and cyproterone acetate on lipid metab- 69) Bizzarri M, Carlomagno G. Inositol: history of olism in women with polycystic ovary syndrome. an effective therapy for Polycystic Ovary Syn- Acta Obstet Gynecol Scand 1995; 74: 56-60. drome. Eur Rev Med Pharmacol Sci 2014; 18: 57) Swiglo BA, Cosma M, Flynn DN, Kurtz DM, Labella 1896-1903. ML, Mullan RJ, Erwin PJ, Montori VM. Clinical 70) Larner J, Huang LC, Tang G, Suzuki S, Schwartz CF, review: Antiandrogens for the treatment of hir- Romero G, Roulidis Z, Zeller K, Shen Ty, Oswald AS, sutism: a systematic review and metaanalyses et al. Insulin mediators: structure and formation. of randomized controlled trials. J Clin Endocrinol Cold Spring Harb Symp Quant Biol 1988; 53 pt 2: Metab 2008; 93: 1153-1160. 965-971. 58) Gambineri A, Patton L, Vaccina A, Cacciari M, Mor- 71) Kennington AS, Hill CR, Craig J, Bogardus C, Raz I, selli-Labate AM, Cavazza C, Pagotto U, Pasquali R Ortmeyer HK, Hansen BC, Romero G, Larner J. Low Treatment with flutamide, metformin, and their urinary chiro-inositol excretion in non-insulin- de- combination added to a hypocaloric diet in over- pendent diabetes mellitus. N Engl J Med 1990; weight-obese women with polycystic ovary syn- 323: 373-378. drome: a randomized, 12-month, placebo-con- 72) Loewus MW, Wright RW Jr, Bondioli KR, Bedgar trolled study. J Clin Endocrinol Metab 2006; 91: DL, Karl A. Activity of myo-inositol-1-phosphate 3970-3980. synthase in the epididymal spermatozoa of rams. 59) Wolf JE Jr, Shander D, Huber F, Jackson J, Lin CS, J Reprod Fertil 1983; 69: 215-220. Mathes BM, Schrode K ; Eflornithine HCl Study 73) Ortmeyer HK, Bodkin NL, Lilley K, Larner J, Hansen Group. Randomized, double-blind clinical evalu- BC. Chiroinositol deficiency and insulin resis- ation of the efficacy and safety of topical eflorni- tance. I. Urinary excretion rate of chiroinositol thine HCL 13.9% cream in the treatment of wom- is directly associated with insulin resistance in en with facial hair. Int J Derm 2007; 207: 94-98. spontaneously diabetic rhesus monkeys. Endo- 60) Nestler JE, Jakubowicz DJ. Decreases in ovarian crinology 1993; 132: 640-645. cytochrome P450C17-alpha activity and serum 74) Suzuki S, K awasaki H, Satoh Y, Ohtomo M, Hirai M, free testosterone after reduction of insulin secre- Hirai A, Hirai S, Onoda M, Matsumoto M, Hinokio tion in polycystic ovary syndrome. N Engl J Med Y et al. Urinary chiro-inositol excretion is an 1996; 335: 617-623. index marker of insulin sensitivity in Japan- ese 61) Moghetti P, Castello R, Negri C, Tosi F, Perrone F, type II diabetes. Diabetes Care 1994; 17: 1465- Caputo M, Zanolin E, Muggeo M. Metformin effects 1468. on clinical features, endocrine and metabolic 75) Nestler J, Unfer V. Reflections on inositol(s) for profiles, and insulin sensitivity in polycystic ovary PCOS therapy: steps toward success. Gynecol syndrome: a randomized, double-blind, place- Endocrinol 2015; 31: 501-505. bo-controlled 6-month trial, followed by open, Larner J, Huang LC, Tang G, Suzuki S, Schwartz CF, long-term clinical evaluation. J Clin Endocrinol 76) Romero G, Roulidis Z, Zeller K, Shen TY, Oswald AS, Metab 2000; 85: 139-146. et al. Insulin mediators: structure and formation. Lord JM, Flight IH, Norman RJ 62) . Metformin in poly- Cold Spring Harb Symp Quant Biol 1988; 53: cystic ovary syndrome: systematic review and 965-971. meta-analysis. BMJ 2003; 327: 951-953. 77) Cheang KI, Baillargeon JP, Essah PA, Ostlund RE Lord JM, Flight IH, Norman RJ. 63) Metformin in poly- Jr, Apridonize T, Islam L, Nestler JE. Insulin-stim- cystic ovary syndrome: systematic review and ulated release of D-chiro-inositol-containing meta-analysis. BMJ 2003; 327: 951-953 inositolphosphoglycan mediator correlates with 64) De Leo V, Musacchio MC, Cappelli V, Di Sabatino A, insulin sensitivity in women with polycystic ova- Tosti C, Piomboni P. A combined Treatment with ry syndrome. Metabolism 2008; 57: 1390-1397. Myo-inositol and Monacolin K improve the andro- 78) Carlomagno G, Unfer V, Roseff S. The D-chiroi- gen and lipid profiles of insulin-resistant PCOS nositol paradox in the ovary. Fertil Steril 2011; 95: patients. J Metab Synd 2013; 2: 127. 2515-2516. Daughaday WH, Larner J, Hartnett C. 65) The syn- 79) Gerli S, Mignosa M, Di Renzo GC. Effects of inosi- thesis of inositol in the immature rat and chick tol on ovarian function and metabolic factors in embryo. J Biol Chem 1955; 212: 869-875. women with PCOS: a randomized double blind 66) Dean-Johnson M, Henry SA. Biosynthesis of ino- placebo-controlled trial. Eur Rev Med Pharmacol sitol in yeast. Primary structure of myo-inosi- Sci 2003; 7: 151-159. tol-1-phosphate synthase (EC5.5.1.4) and func- 80) Zacchè MM, Caputo L, Filippis S, Zacchè G, Dindelli tional analysis of its structural gene, the IN01 M, Ferrari A. Efficacy of myo-inositol in the treat- locus. J Biol Chem 1989; 264: 1274-1283. ment of cutaneous disorders in young women 67) Larner J. D-chiro-inositol-its functional role in in- with polycystic ovary syndrome. Gynecol Endo- sulin action and its deficit in insulin resistance. Int crinol 2009; 25: 508-513. J Exp Diabetes Res 2002; 3: 47-60. 81) Papaleo E, Unfer V, Baillargeon JP, Chiu TT. Con- 68) Clements RS Jr, Darnell B. Myo-inositol content of tribution of myo-inositol to reproduction. Eur J common foods: development of a high-myo- ino- Obstet Gynecol Reprod Biol 2009; 147: 120- sitol diet. Am J Clin Nutr 1980; 33: 1954-1967. 123.

27 V. Cappelli, M.C. Musacchio, A. Bulfoni, G. Morgante, V. De Leo

82) Gerli S, Papaleo E, Ferrari A, Di Renzo GC. Ran- and relatively safe alternative approach for dys- domized, double blind placebo-controlled trial: lipidemia. PLoS One 2014; 9: e98611. effects of myo-inositol on ovarian function and 94) Feuerstein JS, Bjerke WS. Powdered red yeast rice metabolic factors in women with PCOS. Eur and plant stanols and sterols to lower cholester- Rev Med Pharmacol Sci 2007; 11: 347-354. ol. J Diet Suppl 2012; 9: 110-115. Facchinetti F, Bizzarri M, Benvenga S, D’Anna R, 83) 95) Kazerooni T, Shojaei-Baghini A, Dehbashi S, Asa- Lanzone A, Soulage C, Di Renzo GC, Hod M, di N, Ghaffarpasand F, Kazerooni Y. Effects of Cavalli P, Chiu TT, Kamenov ZA, Bevilacqua A, metformin plus simvastatin on polycystic ova- Carlomagno G, Gerli S, Oliva MM, Devroey P. ry syndrome: a prospective, randomized, dou- Results from the International Consensus Con- ble-blind, placebo-controlled study. Fertil Steril ference on Myo-inositol and d-chiro-inositol in 2010; 94: 2208-2213. Obstetrics and Gynecology: the link between De Leo V, Musacchio MC, Palermo V, Di Sabatino metabolic syndrome and PCOS. Eur J Obstet 96) A, Morgante G, Petraglia F Gynecol Reprod Biol 2015; 195: 72-76. . Polycystic ovary syndrome and metabolic comorbidities: therapeutic Bevilacqua A, Carlomagno G, Gerli S, Oliva MM, 84) options. Drugs Today (Barc) 2009; 45: 763-775. Devroey P, Lanzone A, Soulange C, Facchinetti F, De Leo V, Musacchio MC, Cappelli V, Di Sabatino Di Renzo GC, Bizzarri M, Hod M, Cavalli P, D’Anna 97) A, Tosti C, Piomboni P. R, Benvenga S, Chiu TT, Kamenov ZA. Results from A Combined Treatment the International Consensus Conference on with Myo-Inositol and Monacolin K Improve the myo-inositol and D-chiro-inositol in Obstetrics Androgen and Lipid Profiles of Insulin-Resistant and Gynecology-assisted reproduction technol- PCOS Patients. J Metabolic Syndr 2013; 2: 2. ogy. Gynecol Endocrinol 2015; 31: 441-446. 98) Practice Committee of American Society for Re- 85) Unfer V, Carlomagno G, Papaleo E, Vailati S, Can- productive Medicine. Use of insulin-sensitizing diani M, Baillargeon JP. Hyperinsulinemia alters agents in the treatment of polycystic ovary syn- myoinositol to D-chiroinositol ratio in the follicu- drome. Fertil Steril 2008; 90(5 Suppl): S69-73. lar fluid of patients with PCOS. Reprod Sci 2014; 99) Evans JL, Heymann CJ, Goldfine ID, Gavin LA. 21: 854-858. Pharmacokinetics, tolerability, and fruc- 86) Heimark D, McAllister J, Larner J. Decreased tosamine-lowering effect of a novel, controlled myo-inositol to chiro-inositol (M/C) ratios and in- release formulation of alpha-lipoic acid. Endocr creased M/C epimerase activity in PCOS theca Pract 2002; 8: 29-35. cells demonstrate increased insulin sensitivity 100) Masharani U, Gjerde C, Evans JL, Youngren JF, compared to controls. Endocr J 2014; 61: 111- Goldfine ID. Effects of controlled-release al- 117. pha lipoic acid in lean, nondiabetic patients 87) Dinicola S, Chiu TT, Unfer V, Carlomagno G, Bi- with polycystic ovary syndrome. J Diabetes Sci zzarri M. The rationale of the myo-inositol and Technol 2010; 4: 359-364. D-chiro-inositol combined treatment for polycys- 101) Capasso I, Esposito E, Maurea N, Montella M, Cris- tic ovary syndrome. J Clin Pharmacol 2014; 54: po A, De Laurentiis M, D’Aiuto M, Frasci G, Botti 1079-1092. G, Grimaldi M, Cavalcanti E, Esposito G, Fucito A, Brillante G, D’Aiuto G, Ciliberto G. 88) Unfer V, Carlomagno G, Dante G, Facchinetti F. Combination Effects of myoinositol in women with PCOS: of inositol and alpha lipoic acid in metabolic a systematic review of randomized controlled syndrome-affected women: a randomized pla- trials. Gynecol Endocrinol 2012; 28: 509-515. cebo-controlled trial. Trials 2013; 14: 273. Cianci A, Panella M, Fichera M, Falduzzi C, Bartolo 89) Carlomagno G, Unfer V, Roseff S. The D-chi- 102) M, Caruso S. ro-inositol paradox in the ovary. Fertil Steril d-chiro-Inositol and alpha lipoic ac- 2011; 95: 2515-2516. id treatment of metabolic and menses disorders in women with PCOS. Gynecol Endocrinol 2015; Papaleo E, Unfer V, Baillargeon JP, Fusi F, Occhi F, 90) 31: 483-486. De Snantis L. Myo-inositol may improve oocyte Rochette L, Ghibu S, Richard C, Zeller M, Cottin Y, quality in intracytoplasmatic sperm injection cy- 103) Vergely C. cles. A prospective, controlled, randomized trial. Direct and indirect antioxidant prop- Fertil Steril 2009; 91: 1750-1754. erties of α-lipoic acid and therapeutic potential. Mol Nutr Food Res 2013; 57: 114-120. 91) Hsia Y, Dawoud D, Sutcliffe AG, Viner RM, Kinra Morgante G, Cappelli V, Di Sabatino A, Massa- S, Wong IC. Unlicensed use of metformin in 104) ro MG, De Leo V children and adolescents in the UK. Br J Clin . Polycystic ovary syndrome Pharmacol 2012; 73: 135-139. (PCOS) and hyperandrogenism: the role of a new natural association. Minerva Ginecol 2015; ) Zacchè MM, Caputo L, Filippis S, Zacchè G, Dindelli 92 67: 457-463. M, Ferrari A. Efficacy of myo-inositol in the treat- De Leo V, Di Sabatino A, Musacchio MC, Morgante ment of cutaneous disorders in young women 105) G, Scolaro V, Cianci A, Petraglia F with polycystic ovary syndrome. Gynecol Endo- . Effect of crinol 2009; 25: 508-513. oral contraceptives on markers of hyperandrogenism and SHBG in women with polycystic Li Y, Jiang L, Jia Z, Xin W, Yang S, Yang Q, Wang 93) ovary syndrome. Contraception 2010; 2: 276- L. A meta-analysis of red yeast rice: an effective 280.

28 Natural molecules for the therapy of hyperandrogenism and metabolicdisorders in PCOS

106) Tye R. Konjac flour: properties and applications. their potential benefits in human hyperlipidemia Food Technology 1991; 45: 11-16. and atherosclerosis: an overview. Mini Rev Med 107) Doi K. Effect of konjac fibre (glucomannan) on Chem 2016; 16: 619-629. glucose and lipids. E J Clin Nutr 1995; 49 Suppl 114) Cha JY, Cho YS, Kim I, Anno T, Rahman SM, Yan- 3: S190-S197. agita T. Effect of hesperetin, a citrus flavonoid, 108) Chen HL, Sheu WH, Tai TS, Liaw Y, Chen Y. on the liver triacylglycerol contentand phos- Konjac supplement alleviated hypercholester- phatidate phosphohydrolase activity in orotic olemia and hyperglycemia in type 2 diabetic acid-fed rats. Plant Foods Hum Nutr 2001; 56: subjects--a randomized double-blind trial. J Am 349-358 Coll Nutr 2003; 22: 36-42. 115) Tosti C, Cappelli V, De Leo V. Role of a new oral 109) Chearskul S, Kriengsinyos W, Kooptiwut S, Sangurai formulation based on D-chiro-inositol / mona- S, Onreabroi S, Churintaraphan M, Semprasert N, colin K / bergamot extract / methylfolate and Nitiyanant W. Immediate and long-term effects Vitamin K2 in perimenopausal women with met- of glucomannan on total ghrelin and leptin in abolic syndrome with a BMI >25 kg / m2. J type 2 diabetesmellitus. Diabetes Res Clin Pract Metab Syndrome 2016; 5: 3. 2009; 83: e40-e42. 116) La Marca A, Grisendi V, Dondi G, Sighinolfi G, 110) De Leo V, Tosti C, Cappelli V, Morgante G, Cianci Cianci A. The menstrual cycle regularization fol- A. Valutazione dell’associazione inositolo-glu- lowing D-chiroinositol treatment in PCOS wom- comannano nel trattamento di donne affette da en: a retrospective study. Gynecol Endocrinol PCOS. Minerva Ginecol 2014; 66: 527-533. 2015; 31: 52-56. 111) Mollace V, Sacco I, Janda E, Malara C, Ventrice D, 117) Genazzani Ad, Santagni S, Rattighieri E, Cicerchia E, Colica C, Visalli V, Muscoli S, Ragusa S, Muscoli C, Despini G, Marini G, Prati A, Simoncini T. Modulato- Rotiroti D, Romeo F. Hypolipemic and hypogly- ry role of dichiroinositol (DCI) on LH and insulin caemic activity of bergamot poyphenols: from secretion in obese PCOS patients. Gynecol animal models to human studies. Fitoterapia Endocrinol 2014; 30: 438-443. 2011; 82: 309-331 118) Huang LC, FontelesMC, Houston DB, Zhang C, 112) Miceli N, Mondello MR, Monforte MT, Sdrafkakis Larner J. Chiroinositol deficiency and insulin re- V, Dugo P, Crupi ML, Taviano MF, De Pasquale sistance. III Acute glycolenic anh hypoglycemic R, Trovato A. Hypolipidemic effects of Citrus effects of two phosphoglycan insulin mediator in bergamia Risso et Poiteau juice in rats fed a normal and streptozotocindiabetic rats in vivo. hypercholesterolemic diet. J Agric Food Chem Endocrinology 1993; 2: 652-657. 2007; 5: 10671-10677 119) De Leo V, Musacchio MC, Cappelli V, Massaro MG, 113) Cappello AR, Dolce V, Iacopetta D, Martello M, Morgante G, Petraglia F. Genetic, hormonal and Fiorillo M, Curcio R, Muto L, Dhanyalayam D. Ber- metabolic aspects of PCOS: an update. Reprod gamot (Citrus bergamia Risso) flavonoids and Biol Endocrinol 2016; 14: 38.