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European Journal of Endocrinology 10.1530/EJE-17-0516 Accordingly, current strategies forthetreatmentofPCOS andincreasedcardiovascular riskfactors( women explainingtheassociation ofthissyndromewith resistance andobesityare frequentlyfoundinthese syndrome(PCOS)( polycystic excessisamajormechanismleading to Introduction safety andoverallneutraleffects oncardiometabolic riskfactors. Conclusions 95% CI:0.5–2.0).Nomajoradverseeventsoccurredandbiochemicalmarkersweresimilarlysafewithbothtreatments. abnormal glucosetolerance(OR:1.7,95%CI:0.7–4.4),dyslipidemia0.6,0.2–1.8)orhypertension 0.3, frequent withCOCplusspironolactone(OR:0.06,95%CI:0.02–0.23).Nodifferences werefoundinfrequenciesof (5.5 95% CI: 2.6–6.7), totaltestosterone(1.1 with ,COCplusspironolactonecausedlargerdecreasesinhirsutismscore(meandifference 4.6points, Results conducted everythreemonthsanddataweresubmittedtointention-to-treatanalyses. dyslipidemia andhypertension).Acompleteanthropometric,biochemical,hormonalmetabolicevaluation was menstrual dysfunction)andcardiometabolicsafety(changesinthefrequenciesofdisordersglucosetolerance, Methods PCOS (EudraCT2008–004531–38). 150 Design sensitizermetformininwomenwithpolycysticovarysyndrome(PCOS). Objective Abstract *(M AlpañésandFÁlvarez-Blascocontributedequallytothiswork) Centro deInvestigaciónBiomédicaenRedDiabetesyEnfermedadesMetabólicasAsociadasCIBERDEM,Madrid,Spain Universitario RamónyCajal&UniversidaddeAlcaláInstitutoInvestigaciónSanitariaIRYCIS & Diabetes, ObesityandHumanReproductionResearchGroup,DepartmentofEndocrinology&Nutrition, Manuel Luque-Ramírez Macarena Alpañés*, Francisco Álvarez-Blasco*, Elena Fernández-Durán, a one-year randomizedclinicaltrial women withpolycysticovarysyndrome: compared withmetforminin Combined oralcontraceptivesplus DOI: 10.1530/EJE-17-0516 www.eje-online.orgwww.eje- Clinical Study μ nmol/L, 1.8–9.2)anddehydroepiandrosteronesulfate(2.7 g ofdesogestrel)plusspironolactone(100 : We conductedarandomized,parallel,open-label,clinicaltrialcomparing COC(30 : Twenty-four patientswereassigned toCOCplusspironolactoneand22patientsmetformin.Compared online.org : Thecompositeprimaryoutcomeincludedefficacy (ameliorationofhirsutism,androgenexcessand : We aimedtocompareacombinedoralcontraceptive(COC)plusthe antiandrogenspironolactonewiththe : COCplusspironolactonewasmoreeffective thanmetformin forsymptomsofPCOSshowingsimilar

and © 2017EuropeanSociety ofEndocrinology Héctor F Escobar-Morreale and others M Alpañés,FÁlvarez-Blasco nmol/L, 0.4–1.7),freetestosterone(25 1 ); yet,insulin Printed inGreatBritain mg/day) withmetformin(850 2 ). an antiandrogentoCOC may becontroversial( therapy ofPCOS( insulin sensitizerssuchasmetformin ( oral contraceptives(COC) and/orantiandrogensand include amelioration of androgen excess using combined drugs forPCOS Randomized trialofcommon μ Published byBioscientifica Ltd. mol/L, 1.4–4.0).Menstrualdysfunctionwasless COC remain the mainstay of the pharmacological COC remainthemainstay ofthepharmacological mg b.i.d.)foroneyearinwomenwith pmol/L, 12–39), 4 ). Although the practice of adding ). Althoughthepracticeof adding Downloaded fromBioscientifica.com at09/28/202111:28:38PM μ g ofethinylestradioland (2017) Endocrinology European Journal of salud.madrid.org hectorfrancisco.escobar@ Email to HFEscobar-Morreale should beaddressed Correspondence 177 177 : 5 177 3 ). :5 , 399–408

399 –408 4 , 5 via freeaccess ), ), European Journal of Endocrinology impaired glucosetolerance( restrict theuseofthisdrugtowomenwithdocumented for diabetes( with PCOSreceivedmetforminwithoutamedicalclaim United Statesshowedthatasmany30.6%ofwomen Furthermore, arecentreportofcurrentpracticesinthe Spanish AgencyofMedicines andMedicalDevices. approved bythelocalethics committeeandbythe eu/ctr-search/trial/2008-004531-38/ES to comparetreatments( We conducted a non-commercial, parallel, open-label RCT Study design Subjects andmethods risk factorsandadverseevents. focusing onefficacyandsafetyintermsofcardiometabolic year in women with PCOS, plus spironolactone for 1 RCT comparingmetforminwithacombinationofCOC ifunnoticedpregnancyoccurs( , and also to avoid of a male frequent developmentofmenstrualdisturbancesoreven combination withaCOCtheaimofpreventing administered tohyperandrogenicwomenwithPCOSin ( addition ofspironolactone.Thissteroidalantiandrogen with COCmightbeprevented,atleastintheory, bythe this drug( result intohypertension,however, inthewomenreceiving exception ofamildincreaseinbloodpressurethatdidnot and cardiovascularsafetyoftheCOC,withnotable confirmed thesuperiorefficacyandoverallmetabolic acetate asantiandrogenicprogestin( comparing metforminwithaCOCcontainingcyproterone ( a reductioninfastinginsulinandlowertriglyceridelevels the onlyadvantagesofinsulinsensitizerconsisted ing thesuperiorefficacyofCOCovermetforminandthat placed metforminasthetreatmentofchoiceforPCOS( choice forthelong-termmanagementofthesewomen( safety ofCOCexplaintheongoingdebateaboutdrug However, concernsaboutthemetabolicandcardiovascular the dermatologicmanifestationsofPCOSinsomecases( effective fortreatinghirsutismandmaybebeneficial suchasspironolactoneareclinically www.eje-online.org 16 9 ). Similarly, ourpreviousrandomizedclinicaltrial(RCT) Clinical Study ) andantihypertensive( For thereasonsoutlinedabove,wehaveconducteda The increase in blood pressure during treatment This occurreddespiteaCochraneReviewdemonstrat among European endocrinologists recent survey A very 15 ). 8 ), eventhoughcurrentrecommendations https://www.clinicaltrialsregister. 5 ). and others M Alpañés,FÁlvarez-Blasco 17 ) drugisusually 18 ). Thestudywas 10 ). , 11 , 12 , 13 , 14 6 7 3 ). ). ). ). ) -

Therefore, patientsmetallcurrentdefinitionsofPCOS and androgen-secretingtumorshadbeenexcluded. hyperprolactinemia, hypothyroidism, Cushing’s syndrome etiologies suchasnonclassic21-hydroxylasedeficiency, evidence of oligoovulation, provided that specific and/or biochemicalhyperandrogenismtogetherwith spironolactone anddrugoralcoholabuse. contraindication fortheuseofmetformin,COCor diabetes mellitus,orcardiovascularevents,, ofseriousillnessincludinghypertension, months, history profile orcarbohydratemetabolismforthepreviousthree that mightinterferewithbloodpressureregulation,lipid contraceptives, antiandrogens,insulinsensitizersordrugs treatment ofPCOSormedicalwithhormonal seeking fertilityandthosewithprevioussurgical androgen excessoutpatientclinic.We excludedpatients We recruitedwomenwithPCOSreportingtoour Patients after randomization. their armoftreatment.No maskingmethodwasused another (MA)enrolledand assignedtheparticipantsto generated therandomization envelopes,whereas E-M) F obesity ondrugtreatment. Oneinvestigator(H treatment, butnotestimatingthepossibleimpact of BMI andpercentage ofobesepatientsinbotharms aim ofstratificationforobesitywasobtainingsimilar separate blocksfornon-obeseandobesewomen.The mass index(BMI) assignment. Stratificationforobesity, defined byabody fortreatment (five perarmoftreatment)served a one-to-oneratio.Blocksoftensealedopaqueenvelopes patients toCOCplusspironolactoneormetforminin We usedstratifiedblockrandomizationto allocate the Randomization participants ortheirlegalrepresentatives. concentrations: normal menstrual cycles (day 20–24 serum or evidenceoflutealphasedefectinwomenwith dysfunction (menstrualcyclelength: dysfunctionrequiredthepresenceofmenstrual Ovulatory and/or dehydroepiandrosteronesulfate defined by total testosterone score wasdefinedbyamodifiedFerriman–Gallwey ( drugs forPCOS Randomized trialofcommon 1 , 19 Diagnosis ofPCOSrequiredthepresenceclinical Written informedconsent was obtained from allthe ≥ , 20 8 points( ) and showed the classic PCOS phenotype ( ≥ mlL androstendione 35 pmol/L, ≤ 21 12.7 pmol/L). ≥ ). Biochemicalhyperandrogenismwas 30 kg/m Downloaded fromBioscientifica.com at09/28/202111:28:38PM 2 , wasaccomplishedbyusing ≥ 2.3 nmol/L, calculated free 177 ≤ ≥ 6 or 26 :5 9.5 ≥ μ 15.7 nmol/L mol/L ( > 5 days) 35 400 22 19 via freeaccess ). ). European Journal of Endocrinology until assayed. and serumplasmawere separated andfrozenat 60, 90and120 measurement ofseruminsulin andplasmaglucoseat0,30, test (oGTT) was performed, and samples were obtained for concentrations ( total and free testosterone, androstenedione and DHEAS measurement ofanandrogenicprofileconsistinginserum 12-h overnightfasting,basalsampleswereobtainedfor three daysofadietunrestrictedincarbohydratesand a after excludingpregnancyinamenorrheicpatients.After five to ten days after a spontaneous menstrual bleeding or Omron Corp.,Kyoto,Japan).Bloodsampleswereobtained was estimatedusingabodyfatmonitor(OmronBF300; percentage ofbodyfat with respecttototalbodyweight and waist-to-hipratioamongothersnotreportedhere.The recorded includedhirsutismscore,BMI,waistcircumference oftreatment.Variablesafter three,six,nineand12 months anthropometric and physical evaluations at baseline and these strategieswasmadeduringfollow-up. recommended at theinitialvisit, but noemphasison patients droppedoutofthetrial.Lifestylechangeswere monthsunless day.every Drugs were continuedfor 12 andspironolactonewasgiven 28 days every for 21 days resistance andinthelipidprofile( hirsutism wasassociatedwithanimprovementininsulin previous experience,useofthisCOCinwomenwith metabolic variables( with theaimofminimizinganydeleteriousimpacton based on its weak androgenic and activities Alcobendas, Spain). and 100 Merck Sharp&DohmedeEspaña,S.A.Madrid,Spain) of ethinylestradioland150 consisted ofanoralcontraceptivepillcontaining30 study. TheCOCplusspironolactonecombination advised tousebarriercontraceptionthroughoutthe thereafter. Women randomizedtometforminwere side effectsandmaintainedatan850 of treatmentwiththeaimminimizinggastrointestinal Spain) was started at a 425 Metformin (Dianben,Merck, S.L.,MolletdelVallés, administered using commercially available products. excluding pregnancy by propertesting.Drugswere menstrual cycleor, inwomenwithamenorrhea,after Treatment wasstartedonthefirstdayofaspontaneous Procedures Clinical Study Two investigators(MAandFA-B) conductedtheclinical, The choiceofa COC containingdesogestrel was mg/day ofspironolactone(Aldactone,Pfizer, S.L., min. Samples were immediately centrifuged, min. Sampleswereimmediately centrifuged, 22 , 24 ). Then,a75 23 ). Moreover, accordingtoour mg b.i.d. during the first week μ g ofdesogestrel(Microdiol, and others M Alpañés,FÁlvarez-Blasco 24 g oral glucose tolerance g oralglucosetolerance ). TheCOCwasgiven mg doseb.i.d. − 30°C 30°C μ g dysfunction) andcardiometabolicsafety(changesinthe (amelioration ofhirsutism,androgenexcessandmenstrual outcomeincludedefficacy The compositeprimary Outcomes diagnose dyslipidemia( guidelines oftheAndrogenExcessandPCOSSocietyto the AmericanDiabetesAssociation( 0 and120 defined fromthecirculating glucoseconcentrationsat during theoGTT( from thecirculating glucoseandinsulinconcentrations The compositeinsulinsensitivityindexwascalculated were calculatedaccordingtoLevyandcoworkers( model assessmentofinsulinresistance(HOMA2-IR) have beendescribedelsewhere( plasma glucose,lipidsandserumhormonemeasurements decrease withmetformin( RCT, whichconsistedofanincreasewith COCanda infastingglucosetheaforementioned changes observed size calculationsonthetreatment differencesinthe at aone-sided0.05significancelevel. marker ofandrogenexcess( clinically relevanttreatmentdifferencesinthatclinical ending thetrialwouldprovidepowerabove80%todetect Inclusion of46patients(groupratio1:1)and30 3.3 pointsinthehirsutismscorefavorofCOC( ( or metformininanearlier6-monthRCTfromourgroup withCOC the differencesbetweenchangesobserved Regarding efficacyoutcomes,calculationswerebasedon edu/sample_size/size.html Hospital BiostatisticsCenter( We usedtheonlinecalculator of theMassachusetts General Statistical analysis visit. was obtainedatevery including ionsandindexesofrenalhepaticfunction needed to report an adverse event. A serum biochemistry were availableatanytimebytelephoneincasepatients resistance. Regardingsafetyassessment,investigators profiles andindexesofglucosetoleranceinsulin in anthropometricvariables,officebloodpressure,lipid outcomesincludedchanges and ).Secondary frequencies of disorders of glucose tolerance, dyslipidemia drugs forPCOS Randomized trialofcommon 10 , The technicalcharacteristicsoftheassaysemployedfor With respecttosafetyoutcomes,webasedthesample 11 ). The min duringoGTTaccordingtothecriteriaof s . d . ofthedifferencesinthesechangeswere 26 ). Disordersofglucosetolerancewere 28 Downloaded fromBioscientifica.com at09/28/202111:28:38PM ). ) forsamplesizecalculations. 10 ≥ http://hedwig.mgh.harvard. 3 pointsinhirsutismscore), ). Consideringthatthe 22 27 177 , ). We followedthe 24 www.eje-online.org :5 ). Homeostasis 401 10 25 s . via freeaccess d ). ). .

European Journal of Endocrinology www.eje-online.org Table 1 not enrolledinthetrialaresummarized in biochemical characteristics of thepatientsenrolledand criteria, and agreed to participate in the trial. Clinical and women, metinclusioncriteria,didnotshowanyexclusion them, 46patients,including24non-obese and 22obese with 158 patients meeting the classic PCOS criteria. Of attended ourandrogenexcessclinicforthefirsttime, From March 2010toMarch 2014,549consecutivewomen Results (StataCorp). performed usingPASW Statistics18(SPSS)andSTATA 13.1 the previousvisit. in the missingvisitswithrespecttovaluesobserved assumed thatthedependentvariableshadnotchangedat who receivedatleastonedoseofstudydrug.ITTanalysis by intentiontotreat(ITT)includingonlyparticipants primary, andsafetyoutcomeswereperformed secondary different reasons,ormissedintermediatevisits,analysesof between the between-subjects and within-subjects effects. response toeachtreatment,wecalculatedtheinteraction within-subjects effect.To evaluatethedifferencesin as the the visit (baseline, three, six, nine and 12 months) the armoftreatmentasbetween-subjectseffectand to arepeated-measuresgenerallinearmodelincluding metformin usingunpaired randomized toreceiveCOCplusspironolactoneor compared thebaselinecharacteristicsofpatients transformation asneededtoensurenormality. We the Kolmogorov–Smirnovtest,andappliedlogarithmic For continuousvariables,weassessednormalityusing logisticgeneralizedestimatingequationmodels. binary disorders duringthestudywereanalyzedbyunivariate treatment. Thechangesinthefrequenciesofmetabolic baseline differencesinfrequenciesamongthearmsof stated.Weotherwise usedFisher’s exactteststoanalyze as means significance levelwith0.80power. in the changes in glucose at a two-sided 0·05 a clinicallyrelevanttreatmentdifference(0.6 two-treatment parallel-designstudyinordertodetect 44 patientstoenterand28completethe in this trial ( the drop-out rate observed of thechangesinfastingglucosewas0.5 Clinical Study Other than sample size calculations, analyses were Other thansamplesizecalculations,analyseswere Because severalpatientsdiscontinuedtreatmentfor Regarding maincomparativeanalyses,dataareshown (seesectionon ±

s P .

d < .

orrawnumbers(percentages) unless 0.05 wasconsideredstatisticallysignificant. supplementary data supplementary t test.We submittedthedata and others M Alpañés,FÁlvarez-Blasco 10 Supplementary Supplementary ), we needed givenatthe mmol/L and mmol/L) three-month appointment. Another patient in COC plus completing the nine-month visit had also missed the one ofthepatientsonmetforminlosttofollow-upafter metformin, werelosttofollow-up( patients, fiveinCOCplusspironolactoneandsevenon completing thestudyforseveralreasons( and ninepatientsonmetformindroppedoutbefore ( and indexesofglucosetoleranceorinsulinresistance biochemical indexesofandrogenexcess,lipidprofiles anthropometrics, officebloodpressure,clinicaland and the22patientsallocatedtometformininage, the 24patientsrandomizedtoCOCplusspironolactone other relevantdifferencewasfound. frequently obesethanthosenotenteringthetrial,butno end ofthisarticle).Women enrolledinthetrialweremore 2 ofinsulinresistance;LDL,low-density lipoprotein. HDL, high-densitylipoprotein;HOMA2-IR, homeostasismodelassessment Insulin sensitivityindex HOMA2-IR Fasting glucose(mmol/L) Fasting insulin(pmol/L) (mmol/L) HDL (mmol/L) LDL cholesterol(mmol/L) Total cholesterol(mmol/L) (pmol/L) Androstenedione (nmol/L) Sex -binding Free testosterone(pmol/L) Total testosterone(nmol/L) Hirsutism score Diastolic bloodpressure(mmHg) Systolic bloodpressure(mmHg) Waist-to-hip ratio Waist (cm) Body massindex(kg/m Menarche (years) Age (years) statistically significantdifferences werefound. unpaired means pill (COC)plusspironolactoneorwithmetformin.Dataare randomized totreatmentwithacombinedoralcontraceptive Table 1 drugs forPCOS Randomized trialofcommon Table 1 sulfate ( globulin (nmol/L) Six patientsintheCOCplusspironolactonearm We baselinedifferencesbetween didnotobserve ±

s ). . μ t d Baseline characteristicsofthepatientswithPCOS -tests orFisher’s exacttestasappropriate.No mol/L) . unlessotherwisestated.Datawerecomparedby 2 ) Downloaded fromBioscientifica.com at09/28/202111:28:38PM spironolactone 13.8 41.4 44.9 0.78 30.6 184 116 COC plus 6.7 1.6 4.9 1.0 1.3 2.8 4.5 6.5 2.6 89 10 73 87 12 25 ( Fig. 1 n 177 =24) ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± 5.1 1.7 0.4 97 0.5 0.4 0.8 1.0 121 2.4 5.0 21.4 15.9 0.8 5 7 11 0.08 16 7.9 2 5 :5 ). Ofthelatter, Fig. 1 13.8 32.2 46.8 0.78 31.2 Metformin 217 118 7.0 1.3 4.9 1.0 1.3 2.7 4.5 7.2 2.4 ). Twelve 69 13 77 88 12 23 ( n =22) ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±

402 5.5 0.9 0.7 51 0.5 0.2 1.3 1.4 224 3.1 6.4 15.7 23.5 0.8 7 11 16 0.08 18 9.0 2 6 via freeaccess European Journal of Endocrinology difference between arms of treatment in the frequencies of difference betweenarmsoftreatment inthefrequenciesof metformin ( during treatmentwithCOC plus spironolactonethanwith by ITTanalysis).Menstrual dysfunction waslessfrequent COC plusspironolactonehadregularmenses( respectively, oftreatment patients afterthree,six,nineand12 months with metformin(13of19,1017,14and813 (95% CI: 6–65). concentrations, andincreasedDHEASlevelsby35% score, totalandfreetestosteroneorandrostendione metformin didnotshowanydecreaseinhirsutism by 26%(95%CI:15–37).Onthecontrary, womenon androstenedione by46%(95%CI:32–60)andDHEAS 36–72), freetestosteroneby79%(95%CI:67–92), concentrations oftotaltestosteroneby54%(95%CI: hirsutism scoreby68%(95%CI:57–79)andserum treatment values,COCplusspironolactonedecreased with metformin( decreased morewithCOCplusspironolactonethan testosterone andandrostenedioneconcentrations The hirsutismscore,serumtotaltestosterone, free Primary compositeoutcome who completedthestudy( similar comparedwiththatofthesubgroupwomen characteristics ofthepatientsenrolledintrialwere completed alltheothervisits.Clinicalandbiochemical spironolactone missedthenine-monthappointmentbut Clinical Study Menstrual dysfunction persisted in women treated Menstrual dysfunctionpersistedinwomentreated al 3 Table P

= 0.765), whereas all the women treated with 0.765), whereasallthewomentreatedwith Fig. 2 ). We anychangeof didnotobserve and Supplementary Table 1Supplementary Table 2 and others M Alpañés,FÁlvarez-Blasco ). Comparedwithpre- P ). 0.008 =0.008 disorders of abnormal glucose tolerance, dyslipidemia or disorders ofabnormalglucosetolerance,dyslipidemiaor differences betweenarmsof treatment inthemeanvalues . We changes during the trial or did not observe mild urticarial skin rashthatresolvedafter stopping the patient onCOCplusspironolactone whodevelopeda but persistent gastrointestinal disturbances and one drop-out oftwopatientsonmetforminbecausemild The sideeffectsweregenerallymildandresultedinthe Side effects values orintheinsulinsensitivityindex( infastinginsulinconcentrations, in HOMA2-IR observed arm oftreatment,whereasnochangesordifferenceswere glucose levelsdecreasedduringthetrialregardlessof hypertension ( lipoprotein cholesterolconcentrations( in serumtotal and low-density differences were observed but notwithmetformin,whereasnochangesor concentrations increasedwithCOCplusspironolactone, ( mass orsystolic,meananddiastolicbloodpressure circumference, waist-to-hip ratio,percentage offat trial ordifferencesbetweenarmsoftreatmentinwaist ( decreased theirBMIregardlessofthearmtreatment When considered as a whole, patients lost weight and Secondary outcomes drugs forPCOS Randomized trialofcommon i. 3 Fig. 3 Fig. ). BothserumHDLcholesterolandtriglycerides ). We anychangesduringthe didnotobserve Table 3 Flow diagramofthestudy. Figure 1 and Downloaded fromBioscientifica.com at09/28/202111:28:38PM Supplementary Table 2Supplementary 177 www.eje-online.org :5 Fig. 4 i. 4 Fig. ). ). Fasting ). 403 via freeaccess European Journal of Endocrinology www.eje-online.org were submittedtoarepeated-measures generallinearmodel we conductedintention-to-treat statisticalanalyses.Data each visitofthetrial(figures under the excess. Dataaremeans Changes inclinicalandbiochemicalindexesofandrogen Figure 2 Clinical Study ±

s . e . m . ofthepatientsremainingat and others M Alpañés,FÁlvarez-Blasco x -axis) eventhough treatment). metformin (interactionbetween visitevaluationandarmof with COCplusspironolactoneand inthewomentreatedwith during thetrialthatwerenot the sameinwomentreated of thearmtreatment. *Statistically significantchangesduringthetrialirrespective contraceptive pill,DHEAS,dehydroepiandrosteronesulfate. treatment asbetween-subjectseffect. COC,combinedoral including thevisitaswithin-subjectseffect andthearmof concentrations andreducedserumDHEASlevels. serum totalandfreetestosteroneandrostenedione a largedecreaseinthehirsutismscore,normalized menstrual bleeding. COC plusspironolactone induced biochemical hyperandrogenismandrestorationofregular treatment ofPCOSintermsameliorationclinicaland spironolactone was more effectivethan metformin for the In our present RCT, the combination of COC plus Discussion any case. and didnotresultinthewithdrawalfromtrial Table 3Supplementary in individual patients during the trial are summarized in (data notshown).Thefrequenciesofabnormalresults during the trial irrespectiveof the armoftreatment total alkalinephosphataseconcentrationsthatdecreased of safetyserum biochemical indexes with theexceptionof in thegeneralpopulation,thesedrugsshouldbereplaced COC mayworseninsulinresistanceandglucosetolerance and its associated metabolic comorbidities, and because this disorderpresentfrequentlywithinsulinresistance of COCforPCOSwasthat,consideringthatpatientswith argument supportingtheuseofinsulinsensitizersinstead rates in women with PCOS ( androgen excess,menstrualregularityandovulation metformin andotherinsulinsensitizersimproved this common condition ( have beenproposedasanalternativetreatmentfor two decades,insulinsensitizers,particularlymetformin, of choiceforPCOSmanyyears( COC andantiandrogenshavebeenconsideredthedrugs menstrual irregularityinmanypatients. even increasedserumDHEASlevelsanddidnotimprove not improveanyoftheindexesandrogenexcessand menstrual bleeding. On the contrary, metformin did All patientsonCOCplusspironolactonehadregular drugs forPCOS Randomized trialofcommon The importanceofthesefindingsisthat,eventhough . Suchabnormalresultsweremild † Statistically significantchanges Downloaded fromBioscientifica.com at09/28/202111:28:38PM 30 31 ). Compared with placebo, , 32 , 33 29 177 ). But the strongest ), duringthepast :5 404 via freeaccess European Journal of Endocrinology bet n 1 =present. and 0 =absent Dichotomous variableswereanalyzed byunivariatebinarylogisticgeneralizedestimatingequationmodels. *Dichotomousvariableswerecodedas Hypertension Dyslipidemia Frequency ofcardiometabolicdisorders Frequency ofmenstrualdysfunction Dichotomous variables* the components(dichotomousvariables)ofcompositeprimary outcome. Table 3 were comparablygoodatleastduringthe1-yearfollow-up safety profilesofCOCplusspironolactoneandmetformin spironolactone ( in ourpresenttrial,alow-doseCOCwascombinedwith inoneofthesestudieswhen,aswehavedone observed ( decreased or had a neutral effect on these variables pressure and arterial stiffness slightly, whereas metformin cited above,anantiandrogenicCOCincreasedblood two six-monthtrialspublishedaftertheCochraneReview not findahighermetabolicriskswiththelatter( Review of four RCTs comparing metformin with COC did of shortertrialsconductedinthepast.A2007Cochrane profiles ofbothdrugsweresimilarlygood. dyslipidemia duringthetrial.Furthermore,safety not resultinchangesthefrequenciesofpatientswith concentrations with COC plus spironolactone that did high-density lipoprotein cholesterol and triglycerides intheseindexesconsistedofanincreaseboth observed disorders andhypertension.Moreover, theonlychanges lipid profiles,bloodpressureandfrequenciesofmetabolic with metforminonsurrogateindexesofinsulinresistance, metabolic milieuofPCOS,showingnooveralldifferences spironolactone didnotappeartoinfluencenegativelythe that whenassociatedwithlifestyleadvice,COCplus drugs ( by metabolicallysafeandeffectiveinsulinsensitizer Amelioration ofandrogenexcess Continuous variables repeated-measures generallinearmodels. the components(continuousvariables)ofcompositeprimaryoutcome.Continuousvariablesweresubmittedtounivariate Table 2 15 Clinical Study Abnormal glucosetolerance Decrease indehydroepiandrosterone-sulfate(µmol/L) Decrease inandrostenedione(nmol/L) Decrease infreetestosterone(pmol/L) Decrease intotaltestosterone(nmol/L) Decrease inhirsutismscore(points) , Hence, ourstudyconfirmsandexpandsthefindings However, ourpresentresultsprovideevidence 34 6 ). Ofnote,theseunfavorablechangeswerenot ). Differences betweenpatientsallocatedtoCOCplusspironolactonecomparedwithwomenmetformin in Differences betweenpatientsallocatedtoCOCplusspironolactonecomparedwithwomenmetforminin 34 ). Moreover, the cardiometabolic and and others M Alpañés,FÁlvarez-Blasco 9 0.3 0.6 1.7 0.06 ). In

Mean difference 25 2.7 5.5 1.1 4.6 ( COC inbothhealthywomenandpatientswithPCOS mild elevationinbloodpressureassociatedwithother addition ofspironolactonetoCOCmayalsoavoidthe period. In particular, our present results suggest that the and insulin resistance in women with PCOS ( to abdominaladiposity, adiposetissuedysfunction ( latter actually increasing during COC administration regarding bodycompositionandinsulinresistance,the here was superior to treatment with the COC alone metformin alone or in combination with the COC used with androgenconcentrationswithinthenormalrange, of DanishpatientswithPCOS,halfwhompresented to non-hyperandrogenicPCOSphenotypes.Inaseries these drugs in women with the classic PCOS phenotype variables withtheuseofCOCshouldnotlimit a putative worsening in cardiovascular and metabolic antihypertensive properties ( oGTT observed withCOCaloneinan earliertrial( oGTT observed to COCpreventedtheincreaseininsulinlevelsduring women with classicPCOS, the addition of spironolactone sensitivity indexes measured in our study. In agreement, in may accountforthefavorableoutcomesofinsulin response to the antiandrogenic effects of spironolactone may speculatethatameliorationofsuchmechanismin who associatethehighestriskforthesedisorders ( such asthoseincludedinourstudy, whoarepreciselythose

drugs forPCOS Randomized trialofcommon 15 35 ), sincespironolactonehasbothantiandrogen( , However, ourresultsshouldnotbeextrapolated 36 95% confidenceinterval ). Sinceandrogenexcessmaycontributedirectly 0.02–0.23 95% confidenceinterval 0.5–2.0 0.2–1.8 0.7–4.4

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P 0.0001 0.0002 0.0002 0.0001 0.0001 16 28 value 2 405 ), we ) and ). 34 via freeaccess ), European Journal of Endocrinology www.eje-online.org placebo-controlled trials( in earlierproof-of-conceptstudies ( dysfunctionofPCOS hyperandrogenemia andovulatory with ourpresentresults, metformin amelioratedthe metformin doesnotimprovehirsutism( drug wassmall.Whilemostevidencesupportsthat number ofpatientscompletingtreatmentwiththis in improvingmetabolicdysfunction,eventhoughthe of PCOSandwasnotsuperiortoCOCplusspironolactone findings intheDanishstudydescribedearlier( women fromthegeneral population ( may dominatethepicture–ashasbeendescribed in PCOS, thedeleteriouseffectsofCOConinsulinsensitivity women presentingwithnormoandrogenicphenotypesof composition and insulin sensitivity ( shown tobesuperiormetformininimprovingbody and the has been meaning ofthesymbolsandstatistics. pressure. Pleasereferto Changes inanthropometricvariablesandoffice blood Figure 3 Clinical Study In ourstudy, metformindidnotimprovesymptoms Fig. 2 40 fordetailedexplanationsofthe ). However, arecentmeta- and others M Alpañés,FÁlvarez-Blasco 31 , 38 37 32 ) –explainingthe ). In contrast, in 39 ) andshort-term ) inagreement 35 , 36 ). the meaningofsymbolsandstatistics. lipoprotein. Pleasereferto assessment 2ofinsulinresistance;LDL,low-density high-density lipoprotein;HOMA2IR,homeostasismodel Changes inlipidprofileandindexesofinsulinresistance.HDL, Figure 4 populations such as ours; (iii) even being among the evenbeingamongthe populations suchasours; (iii) hyperinsulinemic clamptechniques, particularlyinsmall relatively inaccuratewhen compared witheuglycemic– index derivedfromtheoGTT andthesemethodsare by HOMA2-IRandthecompositeinsulinsensitivity variables studiedhere;(ii)insulinsensitivitywasassessed the impactofpresenceorabsenceobesityon (i) thesmallsamplesize,whichdidnotpermitanalyzing of lifecomparedwithplacebo( clinical andbiochemicalhyperandrogenism, or inquality glucose, lipids andbloodpressure,in under thecurve surrogate markersofinsulinresistance,fastingandarea variables otherthanBMI(thatdecreasedslightly), in metformin inducednodifferencesinanthropometric PCOS, andwhenassociatedwithlifestylemodification, analysis ofthesetrialsconcludedthatinpatientswith drugs forPCOS Randomized trialofcommon Among the limitations of our study we acknowledge: Among thelimitationsofourstudyweacknowledge: Downloaded fromBioscientifica.com at09/28/202111:28:38PM Fig. 2 fordetailedexplanationsof 41 ). 177 :5 406 via freeaccess European Journal of Endocrinology References data collection,analysis,interpretationorwritingofthereport. Regional FEDER,EU.Thefundersofthestudyhadnoroleindesign, de SaludCarlosIII.SupportedinpartbyFondoEuropeoDesarrollo Social ServicesandEquality, Spain.CIBERDEMisaninitiativeofInstituto and EC10–096fromDirecciónGeneraldeFarmacia,MinistryofHealth, from Instituto deSalud Carlos III,MinistryofEconomy and Competitiveness, This study was funded by Grants PI08/0944, PI15/01686 and CM10/00042 Funding perceived asprejudicingtheimpartialityofresearchreported. The authorsdeclarethatthereisnoconflictofinterestcouldbe Declaration ofinterest EJE-17-0516. This islinkedtotheonlineversionofpaperat Supplementary data with classicPCOSnotseekingfertility. pharmacological approachforthetreatmentofpatients COC plusspironolactoneshouldbeconsideredasavalid in termsofmetabolicprofiles.Hence,wesuggestthat manifestations ofclassicPCOS,showingnodisadvantages was moreeffectivethanmetforminfortheclinical highlighting theapplicabilityofourpresentfindings. mimic thoseavailableforroutineclinicalpractice, interests, andthefactthatourlimitedresearch facilities most severePCOSphenotype,theabsenceofcommercial advantages suchastheinclusionofwomensuffering These potentiallimitationsmaybecompensatedby function inthesubsetofwomenallocatedtometformin. ofovulatory we didnotfocusonconfirmingtherecovery at endometrialprotectioninpatientsnotseekingfertility, our designaddressedmenstrualregularityaimingactually the caseforourpre-specifiedsafetyoutcomes;and(v)since andthismightnotbe to improvewithanintervention, single imputation method for a variable, which is expected inITTanalysesisaconservative available observation thelast forward disorders inthesewomen;(iv)carrying about thepossiblelong-termdevelopmentofmetabolic one-year durationofourRCTprecludesanyconclusion longest trialseverconductedinpatientswithPCOS,the 2 1 Clinical Study 2007 syndrome. polycystic ovary and Sterility syndrome:thecompletetaskforcethe polycysticovary report. AE &Witchel SF. TheandrogenexcessandPCOSSociety criteriafor Morreale HF, W, Futterweit JanssenOE,LegroRS, Norman RJ, Taylor Escobar-Morreale HF&SanMillanJL. Abdominaladiposityandthe Azziz R,CarminaE,DewaillyD,Diamanti-KandarakisEscobar- In summary, treatmentwithCOCplusspironolactone 18 266–272. 2009 91 (doi:10.1016/j.tem.2007.07.003) 456–488. Trends inEndocrinology andMetabolism (doi:10.1016/j.fertnstert.2008.06.035) and others M Alpañés,FÁlvarez-Blasco http://dx.doi.org/10.1530/ Fertility Fertility

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