Total Antioxidant Capacity Status In Non-Obese Adolescent Females With PCOS: A cross section study

doi:10.21203/rs.3.rs-5195369/v1

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Total Antioxidant Capacity Status In Non-Obese Adolescent Females With PCOS: A cross section study

https://doi.org/10.21203/rs.3.rs-5195369/v1

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published 12 Nov, 2024

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Background

The endocrine disease polycystic ovarian syndrome (PCOS) has a number of complications. Teenagers all over the globe are becoming increasingly concerned about the syndrome. It has been suggested that oxidative stress plays a significant role in the pathogenesis of PCOS.

Aim

The purpose of the present work was to estimate Total antioxidant capacity (TAC) in non –obese adolescents and decide if the TAC could be a potential marker for the prediction and diagnosis of PCOS.

Methods

Serum samples were collected to assess the levels of follicle stimulant hormone (FSH), luteinizing hormone (LH), serum lipids, serum total antioxidant capacity (TAC) in 50 non-obese patients with PCOS and 50 controls; correlation analysis was made between serum lipid, hormonal parameters and TAC.

Results

Adolescents with PCOS had significantly lower levels of TAC compared with controls and showed significant higher values of LH, FSH and LH/FSH ratio. There were significant negative correlations between TAC levels with LH, FSH and LH/FSH. Linear regression analysis revealed statistically significant correlations between TAC and LH and FSH levels in non-obese adolescents with PCOS.

Conclusion

Serum TAC level was diminished in non-obese PCOS patients and was related to increase of LH/FSH ratio. So, quantification of TAC activity in serum could be of value in assessment of cases at higher risk for development of PCOS, suggesting its possible role in regulating sex hormones and could have potential roles in the etiopathogenesis of PCOS in non-obese adolescent females.

Polycystic ovary

total antioxidant capacity

oxidative stress

adolescent females

Public health is impacted by the prevalent disease known as PCOS. Reproductive, metabolic, and psychological alterations are the results. Women with PCOS symptomatize with features of hirsutism, hyperandrogenism and amenorrhea, or oligo and anovulation. The etiology of PCO is still unknown till nowadays especially the pathophysiology of the disease. Some theories explain it to be as an oxidative stress, endothelial injury, genetic mechanisms and inflammatory state [1]. A high majority of females with PCOS (55–75%) have a raised LH to FSH ratio that is likely owing to increased secretion of LH rather than decreased FSH secretion. Furthermore, some anomalies in progesterone (P4) synthesis have been found in PCOS patients, which may be linked to a high rate of abortion [2]. PCOS is a complex disorder involving multiple organ systems with onset during the early pubertal years. Intrauterine hyperandrogen exposure has been proposed as a key factor causing the reprogramming of multiple genes contributing to the development of PCOS, which affects the hypothalamus-pituitary axis and metabolic disturbance, increasing LH secretion and abdominal fat accumulation and elevating insulin resistance risks at puberty and adolescence [1]. The list of factors involved in the pathophysiology continues to expand including oxidative stress and trace elements [3]. Reports relating to the prevalence of PCOS in adolescents are rare but some studies concluded that the prevalence rate could be between 5 to 11% [4].

Oxidative stress (OS) is defined as the excessive production of reactive oxidants, often in combination with insufficient antioxidant values that cause DNA damage and/or cell apoptosis. Toxic effects that harm the cell can result from disruptions in the normal oxidation reaction of cells and the generation of free radicals and peroxides [5]. OS has been related to a variety of pathological cardiovascular disorders as type 2 diabetes, insulin resistance, MS, obesity, coronary heart disease and PCOS as well as further conditions such as female infertility [6]. An imbalance between antioxidants and oxidants in living biological systems can lead to infertile PCOS women [7]. The reduction in oxidative stress is positively correlated with further developed oocytes [8]. OS could play role in widespread atherosclerotic lesions in the ovarian arteries which could affect different ovarian pathologies [9]. As a result, using anti-oxidative medicines to treat PCOS is becoming more common [10]. Total antioxidant capacity (TAC) evaluating the antioxidant capacity of biological samples by measuring the quantity of free radicals scavenged.

Few studies concurrently examined the systemic and local OS status of PCOS and how that relates to oocyte and embryo quality [11]. In a prior PCOS investigation, it was discovered that PCOS women had much higher insulin resistance and oxidative stress than healthy women. Previous researchers have found a link between circulating oxidative stress markers and PCOS, implying that oxidative stress has a role in PCOS pathogenesis. The particular mechanisms of action, on the other hand, are still unknown. PCOS and Metabolic Syndrome share a number of characteristics that interact. The link between PCOS and oxidative stress may have role in the inhibition of female reproductive function in addition to other endocrine complications [12].

Studies have demonstrated a relationship between food consumption and PCOS [13]. Deficits in trace elements are typically linked to absorption problems or to chronic diseases. In this respect, chronic hyperglycemia may be mentioned because it has the potential to significantly alter the status of some micronutrients, some of which are directly involved in the regulation of glucose homeostasis. Vitamin E, zinc, vitamin C, beta-carotene, and selenium are antioxidants that have a negative relationship with PCOS. Selenium and zinc play significant roles in the control of insulin metabolism and glucose homeostasis and act as cofactors of antioxidant enzymes [14]. Regrettably, there is an insufficient data on PCOS and TAC correlation. Consequently, this finding encouraged us to design a case-control study to examine the relationship of dietary TAC and the odds of PCOS.

The goal of this study is to compare TAC levels in PCOS patients and healthy females and investigate the relation between TAC, hormonal and biochemical markers in non-obese adolescents.

Study Design

A cross-sectional study was conducted on 50 PCOS and 50 healthy adolescent (non obese, BMI between 18.5 and 29.9 kg/m²) volunteer controls (study group aged 16–18 years).

The inclusion and exclusion criteria:

Inclusion criteria included candidates that should have oligomenorrhea/amenorrhea, clinical and/or biochemical signs of hyperandrogenism (ie, hirsutism, acne, male pattern balding, elevated serum androgens).

Criteria for exclusion were used to exclude PCOS cases with endocrine disorders: diabetes, hypothyroidism, hyperprolactinemia, Cushing syndrome, androgen secreting neoplasms, and other adrenal disorders, hypertension, smoking, drugs (e.g. fertility drugs, oral anti-diabetic agents, oral contraceptive pills, and any ovarian pathology.

Outcome measures

All candidates were subjected to full history taking, for amenorrhea, oligomenorrhea or anovulation. oligo/amenorrhea was defined as irregular and inconsistent menstrual blood flow in a woman with the length of menstrual cycle greater than 35 days or four to nine menstrual cycles in a year. Menstrual flow should be normal before the development of oligomenorrhea [15]. Girls should be at least one year away from menarche with regular cycles [16].
General and gynecological examination were done to assess the prevalence of hyperandrogenism as acne, hirsutism, male pattern balding, including a modified Ferriman − Gallwey(mF-G) score (is defined as an mF-G score of > 4 [or ≥ 2 in the lower abdomen, thighs, and upper lip] with/without acne [17].
Pelvic ultrasound scan is not included in the diagnostic criteria of PCOS in adolescent yet it was done for all candidates to exclude any other pathologies and also to assess the number and size of follicles. The Sonographic examination was done using (GE, HD, Volusion P 8). It was performed during the early follicular phase (between the 3rd and 5th days of the menstrual cycle). All females were examined at the same time of the day to avoid the circadian rhythm of the ovarian blood flow, by the same sonographic specialist doctor, as the following: Pelvic assessment was performed using a 4.5 MHz abdominal transducer with full bladder. The largest longitudinal, antero-posterior and transverse diameters of each ovary were measured, and the ovarian volume was calculated using the ellipse formula (length × width × height × 0.523). Twelve or more follicles measuring 2–9 mm in diameter is considered a positive finding. Transabdominal US may provide useful information in the evaluation of PCOS during adolescence, even in obese adolescents.
Body weight (in kg) and height (in cm) measurements were performed using standard procedures. Body mass index (BMI) was calculated as follows: weight (kg)/height2 (m2). BMI reference values were defined as normal, overweight, and obese at 18.5–24.9, 25.0–29.9, and ≥ 30.0 kg/m2, respectively.

• Biochemical assays

A total of 5 mL of venous blood was withdrawn into a plain tube. Blood samples were collected between days 1 and 5 of the menstrual cycle (i.e. follicular phase), according to the NHS guidelines. The rest of the biochemical blood samples needed has been obtained at the same day to save time and to decrease the number of visits for the patient since there is no relation between the rest of the laboratory exams and the hormonal cycle of the menstruation:

• Total Antioxidant Capacity (TAC)

Total antioxidant capacity (TAC) was measured in serum using a colorimetric kit obtained from Biodiagnostic (Egypt). This assay measures antioxidant capacity by the reaction of antioxidants in the sample with a defined amount of exogenously provided hydrogen peroxide. The anti-oxidants eliminate a certain amount of peroxide. The residual peroxide is determined colorimetrically by an enzymatic reaction that involves the conversion of 3, 5-dichloro-2- hydroxybenzenesulfate to a colored product.

• Hormonal assay

Serum luteinizing hormone (LH) and follicle stimulating hormone (FSH) were determined by enzyme-linked immunosorbent Assay (ELISA) kit (R & D Systems, Minneapolis, USA).

• Statistical analysis

All statistical analysis was performed using the SPSS version 20.0 (SPSS Inc., Chicago, IL, USA). Student’s t-test was used for comparison of means. Spearman correlation coefficient was used to test the strength of associations between different variables. Data are expressed as mean ± SD. P values < 0.05 were considered statistically significant. Linear regression analysis was used to determine the predictive effect of investigated TAC on hormonal parameters and the standard errors of the beta coefficients was also calculated. Correlation analysis was used by bivariate analysis (Pearson correlation for normal distribution variables or Spearman correlation for non-normal distribution variables). To compare anthropometric, hormonal and metabolic parameters of PCOS with those of control group, the post-hoc analysis of Tukey's test, was used to compare those indicators of the former groups with control groups. Linear regression was used to control for confounding factors with a stepwise method, entry significance level was set to 0.05 and removal significance level was set to 0.1. TAC was regarded as dependent variables, and the factors which showed statistically significant differences were set as independent variables.

Demographic characteristics showed no significant difference between two groups regarding age, BMI and serum lipids, while TAC showed significant lesser values in PCOS group than in the healthy group. On the other hand, LH, FSH and LH/FSH were higher in the PCOS than controls (p < 0.05). Age, serum biochemical and hormonal features of groups were shown in Tables 1 and 2.

In PCOS patients, negative correlations were observed between TAC and LH (r=-0.852; P < 0.001), FSH (r=-0.725; P < 0.002) and LH/FSH ratio concentration levels and significant positive correlations were found between TAC and total cholesterol (r = 0.452; P < 0.035) and triglycerides concentration levels (r = 0.0410; P < 0.05), (Table 3).

Table 4: In order to investigate the hormonal relationship between TAC and PCOS in adolescent girls, a linear regression analysis was conducted. The levels of LH and FSH significantly correlated negatively with TAC.

Table 1

Clinical features in groups of patients with PCOS and healthy controls
Anthropometric parameters	Group	Mean ± SD	Median	P value
Age(years)	PCOS	17.15 ± 2.6	17.12	NS
Age(years)	Controls	16.09 ± 1.6	16.42
BMI (kg/m²)	PCOS	20.50 ± 1.74	19.56	NS
BMI (kg/m²)	Controls	20.75 ± 1.50	18.75	NS

Table 2

Biochemical parameters in groups of patients with PCOS and healthy controls.
Biochemical parameters	Controls	20.75 ± 1.50	18.75
	Group	Mean ± SD	Normal ranges for lab values
TAC (µM)	PCOS	0.8154 ± 0.44	0.5-2	< 0.05
TAC (µM)	Controls	1.99 ± 0.27	0.5-2	< 0.05
LH (IU/l)	PCOS	5.00 ± 0.53	4–8	< 0.05
LH (IU/l)	Controls	1.90 ± 0.63	4–8	< 0.05
FSH (IU/l)	PCOS	3.10 ± 0.89	4–8	< 0.05
FSH (IU/l)	Controls	1.48 ± 0.25	4–8	< 0.05
LH/FSH	PCOS	1.71 ± 0.45	1–2	< 0.05
LH/FSH	Controls	1.25 ± 0.63	1–2	< 0.05
LDL-C(mg/dl)	PCOS	178.93 ± 19.55	40–150	NS
LDL-C(mg/dl)	Controls	140.91 ± 20.80	40–150	NS
TG (mg/dl)	PCOS	107.09 ± 29.958	50–150	NS
TG (mg/dl)	Controls	74.36 ± 27.178	50–150	NS
HDL-C (mg/dl)	PCOS	50.55 ± 10.921	35–85	NS
HDL-C (mg/dl)	Controls	49.36 ± 13.50	35–85	NS
Total cholesterol (mg/dl)	PCOS	250.88 ± 30.77	70–200	NS
Total cholesterol (mg/dl)	Controls	178.36 ± 34.12	70–200	NS
FBG (mg/dl)	PCOS	81.36 ± 14.05	60–110	NS
FBG (mg/dl)	Controls	81.09 ± 8.51	60–110	NS

Table 3

The correlation between TAC with serum lipids, hormonal parameters and BMI in PCOS group.
Variables	R	P value
Total cholesterol	0.452	< 0.035
Triglycerides	0.410	< 0.05
LDL	0.412	0.064
HDL	− .105	0.61
LH	-0.852	< 0.001
FSH	-0.725	< 0.002
LH/FSH	-0.625	< 0.001
BMI	0.228	0.89

Table 4

Identify the important hormonal determinants of independent variables that affect serum TAC levels in PCOS girls, linear regression analysis was used (dependent variable)
		Unstandardized Coefficients		Standardized Coefficients	P
		B	Std. Error	Beta	P
1	(Constant)	2.729	.260		0.001
	FSH	− .123	.162	− .174	0.046
	LH	− .307	.098	− .719	0.009
a. Dependent Variable: TAC

P values derived from linear regression models that evaluated the association of LH and FSH variables (independent) with TAC (dependent).

The body composition is greatly impacted by the chronic, complex disorder polycystic ovarian syndrome. [18]. Oxidative stress is now recognized to play a central role in the pathophysiology of many different disorders, including PCOS. The present study concentrated on TAC as an antioxidant biomarker and studied their levels in serum of blood. The correlation between it and PCO development in early stages and we investigated the relation between TAC, hormonal and biochemical markers in non-obese PCO adolescents. The assessment of antioxidant biomarkers and oxidative stress have been recommended as beneficial tools in evaluating the risk of oxidative damage and related diseases [19, 20] and assist in the management and prevention of oxidative diseases.

The extracellular matrix (ECM), which is essential for tissue morphogenesis, offers the physical microenvironment for the cells. Additionally, the ECM is in charge of delivering signals from the environment to cells so they can divide and proliferate. The phases of follicle development and regression necessitate reorganizing the ovarian ECM on a regular basis. States of altered hormone secretion may be accompanied by abnormal ovarian ECM composition, such as postmenopausal or PCOS [21]. Oxidative stress has a significant effect at a systemic & a local level. Follicular fluid delivers a direct and local microenvironment for development of oocyte and affected by the serum levels of micronutrients [22]

In our present study we found that TAC showed significant lesser values in PCOS group than in the healthy group and also, we found negative correlations were observed between TAC and hormonal parameters for diagnosis of PCO. This result is in agreement with many preceding researches [23–25]. They all found that cases of PCO have low levels of TAC. Although there are still conflicting results regarding this issue in literature as there are results of altered researches concerning antioxidant levels showed that there was no relation between TAC and PCO pathogenesis. In 2013 Murri and his research group in a systemic review studied similar studies done over a total 470 women including 260 women with PCOS. They found that when compared to controls, TAC levels in PCOS women were the same. [6].

Some studies found that not only using superoxide dismutase, glutathione and chief markers that reflect nonenzymatic antioxidant capacity, levels of lipid pro-oxidative, and enzyme antioxidant capacity, respectively, but also, they use TAC and total oxidant capacity (TOC) to reveal overall antioxidant and oxidation levels in follicular fluid [6, 11, 26]. Nevertheless, these studies did not conclude a result regarding TAC levels in follicular fluid in correlation with PCO but what we understand that there is an imbalance between antioxidants and oxidants in systemic and follicular fluid of PCOS that could be contributed in the pathogenic mechanisms of PCOS.

In order to have a better understanding about the correlation between PCO and TAC, we chose the non-obese girls. Obesity has been shown to worsen the body's low-grade persistent inflammation that is linked to OS. Also, Montero et al. demonstrated that there is a connection between OS and obesity in adolescents. [27]. As young as 10 years old, the perimenarcheal stage of PCOS has been documented[28]Similarities between the pathological features of PCOS and the physiological changes of puberty have been renowned, like menstrual irregularity, increased ovarian and adrenal steroidogenesis, the hyperpulsatile gonadotropin secretion, hyperinsulinemia, diminished levels of Sex Hormone Binding Globulin (SHBG), Insulin-like growth factor binding protein-1(IGFBP-1) and insulin resistance[29]. TAC could be a predictive aid for differentiation between the two conditions.

The increased FSH and LH concentrations of the non-obese compared with the obese PCOS group is steady with other reports in the adult inhabitants of diminished LH pulse amplitude in obese PCOS. It was postulated that, in obese PCOS, the hyperinsulinemia might be accountable for the reduced levels of LH[30]. Researchers discovered differences in androgen and gonadotropin concentrations between non- obese healthy adolescents and non-obese PCOS.

The Androgen Excess and PCOS Society and the American College of Obstetricians and Gynecologists both advise that all PCOS patients undergo a thorough fasting lipid and lipoprotein examination as part of their cardiovascular risk assessment. [31]. A Nigerian study was done in 2019 studied lipid profiles and oxidative stress markers of patients with polycystic ovary syndrome. In agreement with our study, they concluded that PCO women have a lower TAC and a Higher Total cholesterol and triglycerides levels than in healthy controls [32]. PCOS is associated with oxidative stress and a wide variety of endocrine and metabolic issues, including obesity, hyperinsulinemia, and dyslipidemia, which may be responsible for the oxidative stress related to PCOS. [33]. Hyperlipidemia increases the likelihood of oxidative stress. It reveals a novel facet of leukocyte activation and oxidative stress in hyperlipidemia that leukocyte ROS production is positively correlated with triglycerides. [34]. Also, a Chinese study concluded that the imbalance between oxidant and antioxidant ratio is present in hyperlipidemia cases [35].

One drawback of our research was the small sample size, which was caused by the high cost of performing the biomarker testing. As a result, there are a finite number of markers that can be used in the regression analysis. Our results only show the OS level at the moment the sample was taken; they do not show the physiological OS level over the course of the entire menstrual cycle. Unfortunately, the diagnostic criteria for PCOS are so open-ended that many teenagers who appear with temporary functional hyperandrogenism and menstrual irregularities during puberty run the risk of being misdiagnosed. In conclusion, decreased serum TAC levels could be a potential positive predictive marker for an elevated LH, and LH/FSH levels among non-obese PCOS and appear to contribute in the pathogenic mechanisms of PCOS in non-obese adolescents, it is probable to prevent the progress or development of oxidative stress by routine assessment of TAC levels in serum in PCOS patients.

Ethical Approval and consent to participate:

The study was approved by local ethics committee of the National Research Centre (No: 13176); the purpose of the protocol was explained to both the patients and control adolescents, and written informed consent was obtained from them and from their parents for girls below 18 years old before the beginning of the study.

Consent for publication

All authors shared in design of the work and final approval of the version to be published.

Availability of data and material

All participants 100 adolescents (50 PCOS and 50 healthy) were attended to the outpatient clinic at the Medical Research Centre of Excellence– National Research Centre Cairo, Egypt through year 2022 and 2023.

Funding

None

Conflict of interest

Authors have no conflict of interest

Acknowledgments

Authors are grateful to all patients who participated in this study.

Author contribution

Moushira Zaki: Analysis and interpretation of the data. Sondos M. Salem: Clinical assessment &Acquisition of the data. Ehab Salama: Drafting the work &Acquisition of the data. Mina Wassef Girgiss: Design and Drafting the work. Tamer Elnahas: Clinical assessment. Safenaz Y. El Sherity (corresponding author): Acquisition of the ultrasonographic data and Eman Refaat Youness: Revising the work critically for important intellectual content.

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No competing interests reported.

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Total Antioxidant Capacity Status In Non-Obese Adolescent Females With PCOS: A cross section study

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Abstract

Background

Aim

Methods

Results

Conclusion

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Introduction

Subjects and Methods

The inclusion and exclusion criteria:

Outcome measures

• Biochemical assays

• Total Antioxidant Capacity (TAC)

• Hormonal assay

• Statistical analysis

Results

Discussion

Declarations

References

Additional Declarations

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Journal Publication

Version 1