Evaluation of the efficacy of an antioxidant combination for the modulation of metabolic, endocrine, and clinical parameters in patients with polycystic ovary syndrome

Abstract Objective To evaluate the efficacy of dietary supplementation with a combination of antioxidants (lipoic acid, N-acetylcysteine, vitamin B6, and S-adenosyl-L-methionine) for the modulation of metabolic, endocrine, and clinical parameters in comparison with oral contraception in non-diabetic women newly diagnosed with polycystic ovary syndrome (PCOS). Methods This was a prospective, partially randomized, multicenter study in which non-diabetic women with PCOS were recruited under routine clinical practice conditions and distributed in three groups to receive the following regimen for 6 months: 1) antioxidant combination (MN group); 2) oral contraception (OC group); or 3) oral contraception and the antioxidant combination (MN + OC group). General recommendation of healthy diet and regular exercise was given to all patients. Metabolic, endocrine, clinical, and quality of life parameters were recorded at baseline and after 6 months of therapy. Results A total of 96 women with PCOS were included in the study. After 6 months of treatment, the homeostasis model assessment-estimated insulin resistance (HOMA-IR) level was reduced only in the MN group, with a significant mean reduction of −0.92 points. Androstenedione was significantly reduced in all groups. Clinical parameters that significantly improved in all groups were hirsutism, acne, irregular menstruation, and quality of life, with no statistical differences between the groups. Conclusions This study showed that the antioxidant combination might be a suitable therapy for patients with PCOS when oral contraceptive is not indicated, because in all groups clinical parameters, irregular menstruation as well as androstenedione and quality of life were significantly improved with no statistical difference between groups.


Introduction
Polycystic ovary syndrome (PCOS) is recognized to be the most common endocrinopathy among women of reproductive age, with a prevalence of 8%-13% [1,2].Although several theories have been proposed to explain the pathogenic mechanism of PCOS, insulin resistance, together with hyperandrogenism, plays an important role [3].
Oral contraception remains one of the most frequently used therapies in PCOS patients, and it has been found to be beneficial for hirsutism, acne, and menstrual regulation [1].However, the potential cardiometabolic risk associated with these agents has been a concern [4].Metformin is a common insulin-sensitizing agent that has been shown to be beneficial in obese/overweight women with PCOS and in women of normal weight with PCOS and hyperinsulinemia.Specifically, this agent promotes weight loss, menstrual cycle, acne, and glycemic control [5]; thus, despite not being licensed for PCOS, it is widely used.However, metformin may increase severe gastrointestinal adverse events compared with oral contraceptives [6].Given that inositol should currently be considered an experimental therapy in PCOS according to the PCOS guidelines, several dietary interventions are being investigated in parallel [1].
The antioxidants α-lipoic acid (ALA), N-acetylcysteine (NAC), B vitamins (B 6 , B 12 , and folic acid), and S-adenosyl-L-methionine (SAMe) have been evaluated separately in PCOS patients, with positive results in terms of insulin-sensitizing activity, weight loss (abdominal fat), follicular atresia reduction, and oocyte quality improvement [7][8][9][10][11][12].Besides, ALA + NAC + B 6 +SAMe are involved in the transmethylation pathway for the hepatic degradation of several substances including hormones, a potential mechanism of action that should be further explored.We hypothesized that the combination of these four active ingredients in one tablet might represent a potential therapy, alone or in combination with oral contraception, for the metabolic, endocrine, and clinical management of PCOS.
The present study (SOP-DIET, ClinicalTrials.govIdentifier: NCT05340634) evaluated the efficacy of dietary supplementation with the combination of ALA + NAC + B 6 +SAMe for the modulation of metabolic, endocrine, and clinical parameters in non-diabetic women newly diagnosed with PCOS compared with oral contraceptives alone or in combination with antioxidants.

Study design
This was a prospective, partially randomized, multicenter pilot study performed under conditions of routine clinical practice in gynecologic consultations.The main objective was to evaluate the efficacy of the antioxidant combination ALA + NAC + B 6 +SAMe as a dietary supplement in improving metabolic parameters in non-diabetic women with PCOS.The secondary objective was to evaluate the efficacy of this combination in improving endocrine and clinical parameters and the quality of life of the patients.
The protocol was reviewed and approved by the Research Ethics Committee of Fundación Jiménez Díaz (Madrid, Spain), and the study was conducted in accordance with the Declaration of Helsinki.Written informed consent was obtained from all participants before initiating the study.National legislation on data protection was applied.Documents containing patients' personal information were encrypted; only authorized personnel had access to them.

Study population
Patients had to be ≥18 years old and have a new diagnosis of PCOS with at least two of the following symptoms: oligo/anovulation (<21 or >35 days or >90 days any cycle or <8 periods/year), hyperandrogenism (clinical symptomatology or laboratory results), and/or polycystic ovarian ultrasound morphology (according to the National Health and Medical Research Council guideline).
Women were excluded if they had diabetes, adrenal enzyme deficiency, and/or other endocrine disease; if they were pregnant or breastfeeding; if they were being treated with serotonin reuptake inhibitors; or if they had other serious illness or abnormal prolactin levels.

Study procedures
Participation in the study was offered to all patients seen during gynecologic consultation at the participating centers who met the inclusion criteria.Once they had signed the informed consent form, they were randomly assigned (1:1) to a study arm: 1) oral contraception (OC group); and 2) ALA + NAC + B 6 +SAMe and oral contraception (MN + OC group).General recommendation of healthy diet and regular exercise was given to all patients.Patients meeting the inclusion criteria for whom oral contraception was not indicated and those who refused oral contraception or wished to become pregnant were enrolled in a prospective non-randomized group that received ALA + NAC + B 6 +SAMe and were followed up prospectively for 6 months (MN group).
The oral contraception administered was ethinylestradiol 0.02 mg plus drospirenone 3 mg once daily or drospirenone 4 mg once daily (according to physician criteria).Oral antioxidants were administered as two tablets daily.Each tablet included ALA 75 mg, NAC 100 mg, B 6 0.65 mg, and SAMe 200 mg (MetioNac®, Margan Biotech SL).Standard approved dosing was used for both oral contraceptive and antioxidants therapy.
Treatment in the three arms of the study was initiated on the first day of the patient's menstrual period and was administered at the consultation.Patients attended for a checkup at 3 months and at 6 months.At the first visit (3 months), patients who, for whatever reason, did not comply with the treatment (at least 80% of the doses) were withdrawn from the study.Patients for whom the treatment was beneficial at 6 months continued to take it if they wished.

Safety parameters evaluated
Any adverse event that occurred during the observation period was recorded in the electronic data collection platform.Investigators were instructed to report any serious adverse event to the sponsor and to follow up and further report on the outcome.

Statistical analyses
Data analysis was descriptive.Qualitative variables were described by absolute and relative percentage frequencies.Quantitative variables were described by mean and standard deviation if they followed a Gaussian curve or by median and interquartile range if they did not follow a Gaussian curve (Shapiro-Wilks test).Comparison of qualitative variables among groups was done using chi-square tests for contingency tables; for 2 × 2 tables, the Yates's chi-squared test was used, and when any expected frequency was ≤5, Fisher's exact test was applied.Comparison of quantitative variables among groups was done using the Student's t-test or Mann-Whitney U test.All hypothesis tests were bilateral, and those values with a confidence level of 95% (p < 0.05) were considered significant.The data were analyzed using R statistical software v4.1.2.Sample size was calculated assuming a 95% confidence interval (CI) and a mean reduction of HOMA-IR of 0.9 (MN group), with a 1.3 variance and 80% power.
Comparison of metabolic parameters at baseline and after 6 months of treatment is shown in Table 1.HOMA-IR level was reduced only in the MN group, with a significant mean reduction of −0.92 points, from 2.61 ± 3.06 to 1.69 ± 1 (p < 0.05), and a significant median reduction from 1.60 (1.27-2.59) to 1.50 (1.30-1.87)(p < 0.05).Mean Basal HOMA-IR value in MN + OC group was normal before (1.43) and after therapy (1.53) and both in line with normal weight healthy Caucasians women [14].
Comparison of endocrine parameters at baseline and after 6 months of treatment is shown in Table 2. Significant reductions in 17β-estradiol (-18.1 and −53 pg/ml), LH (-2.65 and −3.15 mIU/ml), and LH/FSH (-0.43 and −0.44 mIU/ml) were observed in patients who received oral contraceptives alone or in combination with antioxidants (OC and MN + OC groups, respectively).A significant reduction of −9 nmol/l in SHBG was observed in the OC group, and the MN + OC group had a significant reduction (-1.16 nmol/l) in SDHEA.Androstenedione was significantly reduced in all groups: −1.87 nmol/l, −0.87 nmol/l, and −1.57nmol/l, in MN, OC, and MN + OC, respectively.
Comparison of clinical parameters at baseline and after 6 months of treatment is shown in Table 3.After 6 months of treatment, all groups achieved a quantitative improvement in hirsutism and acne, without differences among them.Only the MN group showed an improvement in the alopecia score.Regarding qualitative parameters, the frequency of acne (neck and back) was significantly reduced only in the MN + OC group.Irregular menstruation improved in all groups.The proportion of patients with an irregular menstrual cycle decreased by 44.8%, 65.4%, and 52.7% in the MN, OC, and MN + OC groups, respectively.
Finally, changes in the patients' self-assessed quality of life before and after treatment were evaluated using the PCOSQ.In all three groups, after 6 months of treatment there was a significant improvement in quality of life.Mean scores decreased by 22.5%, 23.5%, and 26.0% in the MN, OC, and MN + OC groups, respectively (p < 0.01 for all).
There were no significant differences between groups in hormonal parameters except for LH and 17-β-estradiol reduction that was superior for the OC and MN + OC groups compared with MN, and FSH level was higher in MN group compared with OC group after 6 months.There were no significant differences between groups for clinical, metabolic, and quality of life parameters.
All three treatments were well tolerated.No serious adverse events were reported during the study.Twelve patients discontinued therapy (four patients in the MN group discontinued due to pregnancy).

Discussion
Although contraceptive treatment is effective in regulating the menstrual cycle in many patients with PCOS, some are not willing  Quantitative variables were described by mean and standard deviation if they followed a Gaussian curve or by median and interquartile range if they did not follow a Gaussian curve (Shapiro-Wilks test).
to accept treatment and want alternatives.In addition, contraceptive treatment is not an option for young women seeking pregnancy [1].Thus, alternatives may be considered.Besides, we know that an early intervention with oral contraceptive is an efficacious solution in most of the cases but not a complete therapy in the context of a chronic gynecological and endocrinological disease.Interventions with nutraceutical based on antioxidants are generally safe and do provide an additional protection against metabolic pathway of the disease as we have seen in our study using the combination of ALA + NAC + B 6 +SAMe involved in the transmethylation pathway for the hepatic degradation of several substances including hormones.The usefulness of antioxidant administration in modulating the metabolic and endocrine response in PCOS patients is well documented [7][8][9][10][11]15]. Oxidative stress is characterized by a depleted reduced-to-oxidized glutathione index and is associated with anthropometric parameters in women with PCOS [16].The combination of antioxidants ALA + NAC + B 6 +SAMe induce transmethylation and transulfuration hepatic pathways that ultimately result in the novo synthesis of glutathione which level is decreased by 50% in PCOS patients [17].
In our study, a significant improvement of clinical and analytical indicators after 6 months of treatment with ALA + NAC + B 6 +SAMe can be associated with a dual mechanism of action: increasing insulin sensitivity through de novo synthesis of glutathione and modulating androgen action by improving DNA methylation by SAMe.Regarding the first mechanism, the regulation of insulin action depends on hepatic glutathione content.Modulating de novo synthesis of glutathione would help in the prevention of diabetes, as glutathione can block the glucose/ reactive oxygen species-induced β-cell damages [18,19].With respect to the second mechanism, it is known that the promoter region of the androgen receptor is hypo-methylated in granulosa cells of women with PCOS [20].In addition, granulosa cells isolated from PCOS patients show a 25% reduction in the level of 5-methylcytosine [21].DNA methylation is catalyzed by a family of DNA methyltransferases that transfer a methyl group from SAMe to the fifth carbon of a cytosine residue to form 5-methylcytosine [22].This could be related to the antiandrogen response seen in the present study.However, further investigation is required to elucidate the potential of SAMe in epigenetic modulation of the pathogenesis of PCOS.
The combination of ALA + NAC + B 6 +SAMe used in this study (MetioNac ® , Margan Biotech) was previously evaluated by the Nutrition Department of Quironsalud Hospital in Madrid.They conducted a pilot randomized clinical trial comparing a semicustomized weight reduction diet with the same diet, adding the combination of antioxidants in patients with metabolic syndrome.After 3 months, subjects under the diet plus antioxidants regimen showed significant reductions (p < 0.05) in triglycerides and VLDL-cholesterol levels, as well as in total cholesterol, LDL-cholesterol, and glucose levels, improving insulin resistance beyond the diet [23].
SOP-DIET is the first study to assess the efficacy and safety of the antioxidant combination of ALA + NAC + B 6 +SAMe under clinical practice conditions in a randomized controlled setting in comparison with oral contraception in young women with PCOS.As expected, antioxidants did not show an effect on hormonal parameters, with the exception of the androstenedione level.No synergistic effect was observed with the addition of antioxidants to oral contraception.More trials are required with a single OC type for all patients, in order to allow better comparisons.HOMA-IR was reduced by the antioxidant combination (MN group) but not by oral contraception (OC group), with comparable efficacy in terms of quality of life, regularization, and clinical manifestations of PCOS.These results indicate that the antioxidant combination may be beneficial for selected women who are not candidates for oral contraception in order to delay the initiation of pharmacological intervention.
The main limitation of this study is the non-randomization of the MN group.Additional randomized clinical trials are required to confirm these promising results.Another limitation is the absence of a centralized laboratory, which is a requirement for pivotal clinical trials in order to ensure uniform data control and analysis.

Conclusions
This study showed that all treatments provided a significant improvement in the clinical parameters associated with PCOS (hirsutism and acne), a significant reduction in androstenedione levels, and a significant improvement in the quality of life score.The addition of antioxidants to oral contraceptives is not superior to oral contraception alone for the early management of PCOS.Only the combination of antioxidants without oral contraceptives reduced the HOMA-IR index.This study showed that the antioxidant combination might be a suitable therapy for patients with PCOS when oral contraceptive is not indicated, because in all groups androstenedione as well as clinical parameters, irregular menstruation and quality of life were significantly improved with no statistical difference between groups.* The probability value was not considered for the oc and Mn + oc groups, given their small sample sizes.Quantitative variables were described by mean and standard deviation if they followed a Gaussian curve or by median and interquartile range if they did not follow a Gaussian curve (Shapiro-Wilks test).Qualitative variables were described by absolute and relative percentage frequencies.BMi: body mass index; ir: interquartile range; Mn: Metionac ® (α-lipoic acid + N-acetylcysteine + vitamin B 6 + S-adenosyl-l-methionine); oc: oral contraceptives; Sd: standard deviation.
Sign test.

Table 1 .
comparison of metabolic parameters at baseline and after 6 months of treatment.

Table 2 .
comparison of endocrine parameters at baseline and after 6 months of treatment.Quantitative variables were described by mean and standard deviation if they followed a Gaussian curve or by median and interquartile range if they did not follow a Gaussian curve (Shapiro-Wilks test).

Table 3 .
comparison of clinical parameters at baseline and after 6 months of treatment.
a Paired samples Wilcoxon test.b non-parametric Sign test.c Binomial test.