Long-Term Effects of Treatment Modalities on Metabolic

Health, Fertility Outcomes, and Cardiovascular Risks in

Lean Women with Polycystic Ovary Syndrome (PCOS): A
Systematic Review
Abstract
Oligomenorrhea with different degrees of follicular and adrenal hyperandrogenism are the
hallmarks of the condition of polycystic ovary syndrome (PCOS). For some of the women of
their reproductive years, this endocrine illness is incredibly prevalent and comprises a variety of
disorders. There are set of symptoms such as hirsutism, acne, and insulin resistance for
identification of characteristics of PCOS. Various treatment modalities have been opted over the
years for the treatment and management of this condition among which metformin and flutamide
are the most prevalent, along with lifestyle modifications as prevalent recommendations to
patients. Weight management for obese patients is the most challenging aspect of PCOS
management. Still, similar findings are found in women with lean physiology or normal BMI
indicating that PCOS symptoms prevail and occur irrespective of the BMI but obese or
overweight face more problems.We determined the long term effects of treatment modalities on
PCOS symptoms and their improvement. Metformin was reported to primarily increase the
blood levels of glucose as well as BMI. Blood pressure was also maintained among various
researchers and DHEAS levels also altered along with serum sex hormone-binding globulin in
the plasma of patients undergoing treatments specific for PCOS patients in normal BMI or lean
PCOS. Further studies with more extensive parameters being employed needs to be conducted
for the determination of exact mechanism and cause of the disease to ease the treatment process.

Keywords: Polycystic Ovary Syndrome (PCOS), Lean PCOS, Treatments for PCOS, PCOS
intervention, metformin,Flutamide
Introduction
In the United States of America States (1) and around the globe, PCOS impacts between five and
ten percent of women of age at reproduction (2,3). The existence of more than one of the
recently updated Rotterdam parameters, which make it one of the most prevalent hormonal
illnesses in premenopausal women, allows for a diagnosis: Anovulation/oligomenorrhea, medical
or biochemical hyperandrogenism, and/or ultrasound-detected polycystic-looking ovaries are
some examples of these conditions (4). The hormone androgen Excess-PCOS society eventually
issued updated specifications for the characterization of PCOS, which include the two of the two
additional specifications: the existence of elevated testosterone levels (biochemical and/or
clinical) and abnormal ovarian function (oligoanovulation and/or polycystic ovaries), with the
expulsion of associated disorders. This was done in light of the essential part that a high level of
androgens plays with regard to the indications of this syndrome (5).
The periods that tend to be unpredictable (usually less than nine per year), hirsutism, fertility
problems, overweight and obesity, male-pattern baldness, and acne-related symptoms are all
typical indications of PCOS in women that cause them to visit a gynecologist for evaluation.
Additionally, women experiencing PCOS frequently have concomitant conditions such as
elevated blood pressure, dyslipidemia, the metabolic syndrome (MS), impaired tolerance to
glucose (IGT), and developing type 2 diabetes mellitus (DM), which may raise their risk of
developing coronary artery disease (CAD). In addition to being obese with adiposity in the
center, over 60% of people with PCOS are fat (6). However, the exact extent of
CVD susceptibility in women with PCOS is mainly unclear because there aren't enough long-
term investigations that monitor these women throughout their peri- and postmenopausal years,
when deaths from cardiovascular disease are most likely to take place.

Four to eight percent of women of reproductive age have PCOS, a heterogeneous

endocrinopathy (7-10). Approximately 90-95% of women experiencing infertility caused by
anovulatory cycles who visit infertility medical facilities have the syndrome as well as which is
the most frequent contributing factor to the condition (11). Periodic irregularities, a state
of hyperandrogenism and ovaries with multiple cysts are defining characteristics. Hirsutism, or
excessive hair growth on the body, can be noticed in as many as 70% of hyperandrogenic
females. An uncommon yet less definitive indicator of hyperandrogenism is acne (12).
Despite the fact that most women with PCOS are obese or overweight, an insignificant but
substantial minority of those with the disorder have an average body mass index (BMI; 25
kg/M2), thereby rendering the diagnosis process and the treatment strategy more challenging.
Lean PCOS refers to certain situations. In these situations, other hormonal and genetic illnesses
exhibiting identical clinical manifestations must be ruled out before physicians can develop a
proper therapeutic strategy (13).
Contrary to popular belief PCOS patients frequently exhibit signs of insulin resistance even in
settings when they are not obese (2). The outcomes of this study in non-obesity females with
PCOS are contentious regardless of the fact that it is commonly acknowledged that obese PCOS
individuals exhibit insulin resistance and that their tolerance to insulin is diminished than that of
non-obese PCOS women. The condition manifestation as well as progression are influenced by
variations in the genetic code. Ethnic background, dietary habits, the environment, and their way
of life (14). DHEAS levels were substantially much higher in non-obesity PCOS cases than in
obese PCOS patients, according to research by Moran et al. (15).
The investigation conducted demonstrated that PCO is an important contributor to risk for the
eventual occurrence of non-insulin-dependent diabetes mellitus in obese women as well as that
these women have significant anomalies in the response to insulin. Women with PCO who are
not fat show elevated insulin levels triggered by glucose but not during the practice of fasting
(16, 17).
The production of estradiol uses androgens as more than just necessary intermediates in the
process Additionally, they have complex implications on the development of follicles (18),
which include an increase in the activity of aromatase (19). The production of estrogen and
ovarian secretion of androgen must be synchronized for optimal ovulation in order to enable the
female reproductive system to operate. The coordinated functioning of the follicles in the ovary
depends on a range of intrafollicular modulators, despite the fact that these mechanisms are
highly reliant on LH and FSH concentration levels (20).
PCOS-afflicted women have a 40% incident rate of poor ability to tolerate glucose or frank
diabetes and are at high risk of developing type 2 diabetes mellitus. The progression of type 2
diabetes mellitus onset is also influenced by overweight and obesity, a trait that is usually but not
necessarily present in PCOS (21). Insulin resistance (IR) varies in severity in women with
PCOS, and problems with the generation of insulin and functionality play an integral role in the
underlying causes of this hormonal disorder. PCOS options for treatment in the past remained
limited (22). However, during the past ten years, the advantages of insulin-sensitizing treatment
for PCOS have been well-established. Glucophage has been shown to decrease the plasma levels
of insulin and testosterone (23,24), and to stimulate natural ovulation.10 Rosiglitazone,
pioglitazone, and troglitazone have all been demonstrated to reduce hyperandrogenism and
promote ovulation, as have pioglitazone and rosiglitazone ( 25,26) respectively. Clinical
investigations using thiazolidinediones (TZDs) have reported iron deficiency modestly increased
weight, and edema in the extremities (27,28)
In an extensive study together with 11,035 PCOS women, those experiencing the condition had a
higher risk of elevated blood pressure than controllers who were assigned to groups for both
weight and age (odds ratio [OR] 1.41; the 95% confidence interval [CI], 1.31 to 1.51) (29).
Furthermore, regardless of controlling for age, resistance to insulin, overweight and obesity, or
high cholesterol levels in a cross-sectional examination of 151 women with PCOS,
hyperandrogenemia along with elevated blood pressure were found to be associated (30).
Fig 1. Female Reproductive System
According to multiple research investigations, the overall incidence of metabolic syndrome is
more significant (15 to 44%) among people with PCOS (31,32). According to a single research
project, women with PCOS had an eleven times greater likelihood of developing the condition
metabolic syndrome than women with age-matched controls (33).
Multiple research studies indicate that women with a probable diagnosis of PCOS are at a greater
likelihood of developing CAD. The Nurses' Health study findings, which was a significant
prospective cohort investigation with 82,439 female nurses who have been monitored for a
period of fourteen years, provided the sole prospective evidence. After accounting for a number
of conventional CV risk variables, it was found that women presenting typically inconsistent and
highly variable menstrual periods had a higher risk for nonfatal or deadly coronary artery disease
(age-adjusted relative risks (RR), 1.25; 95% confidence interval (CI), 1.07 to 1.47; and RR, 1.67;
1.35 to 2.06) when compared to women revealing having a record of regular cycles of
menstruation. Women with highly unpredictable periods of menstruation did not have a higher
cumulative stroke risk (RR, 1.30; 95% CI, 0.97 to 1.74) (34).
Aims & Objectives
 To assess the lean PCOS and modes of treatments
 To evaluate long term effects of treatments modalities such as ovulation, fertility,
cardiovascular diseases
 Provide emerging medical professionals with a better understanding to opt the best
treatment and intervention for PCOS
Methodology:
We included cohort and observational studies along with randomized control trials due to the
distinctive features of the study and the lack of data on the lean PCOS. The Medical Subject
Headings (MeSH) terms and keywords utilized for the search were Polycystic Ovary Syndrome
(PCOS), Thinness, Lean Body Weight Treatment Outcome OR Therapeutics, Fertility outcomes,
Ovulation and Cardiovascular risks among numerous other research terms were employed in an
electronic search on Elsevier, PubMed Online, NIH, Wiley, Frontier, EBSCO and Scopus along
with google scholar. The literature-based systemic review for the most recent research employed
the PRISMA strategy. To determine if every component met the criteria for inclusion, it was
thoroughly reviewed and analyzed. It was evaluated and examined. If they satisfied all inclusion
criteria, they were simply included in the research.
Inclusion criteria:
1. Study participants must be lean women diagnosed with polycystic ovary syndrome (PCOS).
2. The study must involve different treatment modalities, including any therapeutic interventions
or treatment options.
3. The outcomes of interest should be assessed over the long term, considering the effects on
metabolic health, fertility outcomes, and cardiovascular risks.
5. The study design should be randomized controlled trials (RCTs) or prospective cohort studies.
6. Studies must be published in peer-reviewed journals.
Exclusion criteria:
1. Studies with participants who do not meet the criteria for lean women with PCOS.
2. Studies that focus on treatment modalities not relevant to PCOS.
3. Studies with inadequate sample sizes or poor study design (e.g., retrospective studies, case
reports).
5. Studies with short-term follow-up (less than 4 months).
6. non-English language studies (unless they are deemed crucial for inclusion).
7. Studies with incomplete or unavailable data for the outcomes of interest.
We identified 265 research papers from electronic searches of databases, i.e., Scopus, EBSCO,
Elsevier, Springer, PubMed and BMC. We started screening studies by removing the duplicate
research, which left us with 127 articles. We further filtered the articles on the absence of desired
components in research and availability of the full text of articles. After the screening process,
we were left with 68 researches which were narrowed down to 5 after a thorough research study.
The total number of participants, their mean age along with other parameters were noted.
tifi

tio
en

ca
Id

n
Records identified through PubMed Additional records identified
database searching through other sources
n=198 Google Scholar= 67

Records after duplicates

removed
en
Sc
re

in
g

n=127

Records screened (on Records excluded

basis of language& full n=59
text availability)
n=68
gib

Full-text articles
ilit
Eli

Full-text articles assessed

y

for eligibility excluded, with

incomplete variables of
n=34
study
n=29
ud
ed
In
cl

Studies included in
qualitative synthesis Fig.2 PRISMA
n=5
Table 1. CASP checklist to assess the quality of studies
Simmond Baillargeon Underdal Palomba Sahin et
s et al. J.P et al. M.O et al. et al. (38) al. (39)
(35) (36) (37)
Did the review address a
* * * * *
focused question?
Did the authors look for
* * * * *
the correct type of papers?
Do you think all the
essential, relevant studies * * * * *
were included?
Did the review’s authors
do enough to assess the
* * * * *
quality of the included
studies?
If the review results have
been combined, was it * * * * *
reasonable to do so?
What are the overall
* * * * *
results of the review?
How precise are the
* * * * *
results?
Can the results be applied
* * * * *
to the local population?
Were all important
* * * * *
outcomes considered?
Are the benefits worth the
* * * * *
harms and costs?
Results Good Good Good Good Good
The asterisk sign (*) indicates ‘yes.’
 Results & Discussion:
Table 2. Characteristics of studies

Study Ye Regio N Age Wei BM Treatme Time Outcome Criteria

ar n (year ght I nt Perio for
s) (kg) (kg/ d Diagnos
m2) is
Simm 20 Austra T=1 29 ± 68.7 24. Ethinyloe 1-9 Cardiovascular Rotterda
onds 16 lia 3 8 ± 9 ± stradiols years health profile m
et al. 14.8 5.4 Biguanid similar to criteria
(35) e / healthy control.
salbutam Increased blood
ol (n=4) viscosity in
PCOS, which
might act as a
risk factor for
CVD and
endothelial
dysfunction
along with
thromboembolis
m.
C=1 31 ± 64.5 23. Salbutam 1-6
3 11 ± 8 ± ol (n=2) years
10.4 4.2
Baillar 20 Ameri T1= 27.7 62.1 24. Metformi 6 Weight (61.4 0.3 Rotterda
geon 04 ca 28 ± 0.9 ± 0.6 6 ± n mont kg) and BMI m
J.P et 0.2 hs (24.3 ±0.1 criteria
al. kg/m2) reduced
(36) with decreased
systolic blood
pressure (119.5 ±
0.7 from 123.6
mmHg) and
decreased
DHEAS levels in
blood (303 39
from 394)
T2= 27.9± 61.5 24. Rosiglita Weight and BMI
22 1.1 ± 0.7 3 ± zone increased along
0.3 with decreased
serum sex
hormone-binding
globulin (g/dL)
and blood
pressure.
 T3= 27.5 62.1 24. A Weight increased
20 ± 1.1 ± 0.7 6 ± combinat from 62.0kg to
0.3 ion of 62.3kg and BMI
Metformi shifted from 24.5
n and kg/m2 to
rosiglitaz 24.3kg/m2.
one Blood pressure
showed minimal
to no changes,
but serum sex
hormone-binding
globulin (g/dL)
decreased from
6.9 to 6.7.
P=3 27.2 62.3 24. Minimal to no
0 ± 0.9 ± 0.6 6 changes were
±0. noted in blood
2 pressure, BMI
and fasting
glucose-to-
insulin ratio
among
participants.
Under No 2018 T=6 29.5 79.9 28. Metformi 7.7 Weight gain 2.1 Rotterda
dal rw 6 ± 3.9 ± 7 ± n years ± 10.5 among m
M.O et ay 19.5 6.9 pregnant ladies criteria
al. and reduction of
(37) cholesterol as
well as
triglycerides.
Elevation in
fasting blood
glucose
measured no
change in blood
pressure.
P=6 30.1 80.1 28. No change in
5 ± 4.1 ± 5 ± weight with
17.7 6.2 minimal change
in blood pressure
and elevation in
cholesterol
levels.
Palom Ital 2007 T=1 24.3 22. Metformi 2 BMI remained Rotterda
ba et y 4 ± 3.1 4 ± n years unaltered with m
al. 2.7 elevated levels criteria
(38) of DHEAS and
decreased serum
sex hormone-
binding globulin
concentration.
LDL-cholesterol
levels increase
after 24 months
of intervention.
P=1 24.8 22. Placebo A decrease in the
3 ± 2.7 7 ± level of DHEAS
1.9 was reported.
C=1 25.6 21. Nothing A decrease in the
0 ± 2.7 7 ± concentration of
2.1 DHEAS level
occurred with a
reduction in
levels of
cholesterol-LDL.
Sahin Tu 2004 T1= 23.33 66.7 26. Metformi 4 Weight and BMI Rotterda
et al. rke 15 ± 3 ± 58 n mont reduced with m
(39) y 4.47 12.6 ± hs decreased levels criteria
9 3.2 of DHEAS and
6 testosterone
observed and
increased LH
and FSH levels
in individuals.
Cortisol levels
were also
reduced.
T2 23.2± 65.4 25. Flutamid Weight
=15 4.36 ± 01± e decreased up to 2
11.6 3.9 kg with increase
8 6 observed in BMI
with elevated
levels of FSH.
LH levels were
diminished as
well as
testosterone and
DHEAS levels
reduced.
C=1 24.84 64.3 26. Nothing
5 ± ± 36
5.26 13.9 ±
 1 2.1
8
T= Treatment group
C= Control group
P= Placebo group
DHEAS= dehydroepiandrosterone sulfate
BMI= Body Mass Index
FSH= Follicle Stimulating Hormone
LH= Luteinizing Hormone
HDL= High Density Lipoprotein
LDL= Low Density Lipoprotiein
The research investigation describes how PCOS individuals, regardless of weight, exhibit
clinical symptoms including periods that are not regular, breakouts and hirsutism as well as
hormonal imbalances anomalies such elevated LH/FSH, LH, , and testosterone levels (40).
Metabolic abnormalities, such as a poor GTT, aberrant lipid profile, raised fasting/2-hour insulin
levels, and increased insulin resistance, are also seen in women with PCOS, but they were
noticeably more prevalent in PCOS with increased BMI. Similar results from earlier
investigations have been noted (41). Additionally, it has been shown that PCOS patients, whether
they're physically lean or overweight or obese, are innately insulin intolerant with adaptive
elevated insulin levels, and this is a key factor in the etiology of PCO.
Metformin
By increasing glucose absorption and utilization in the peripheral tissues and lowering the
manufacturing of glucose in the liver, the insulin-sensitizing drug metformin lowers blood sugar
concentrations (42). The primary mechanism that operates of glucophage/metformin is to
decrease the production of glucose in the liver (43), perhaps via increasing hepatic
responsiveness to insulin. Fasting elevated insulin levels and systemic insulin intolerance are
indicators of hepatic insulin resistance in non-diabetics (44). Slim women having PCOS had
better results using metformin to restore cycles of menstruation (55%) and fertilization (45%)
than their obese equivalents. Particularly lean phenotypes showed substantial decreases in the
resistance to insulin, the hormone testosterone, and fasting blood glucose levels (45). Even
among PCOS individuals who were underweight, therapy with metformin was linked to
improvements in irregular menstrual periods (46). The circulatory SHBG levels in PCOS-
afflicted women have been demonstrated to be suppressed by insulin (47,48), and the
administration of metformin caused a 60% increase in the concentration in the blood of this
adhering protein.
Metformin therapy for PCOS in women resulted in lower blood concentrations of estrogen. The
lack of thecal androgens, an intermediate for converting androgenic substances to estrogens,
might have served as the cause of occurrence. On the other hand, research indicates that insulin
promotes the aromatase enzyme production within human granulosa cell lines (49,50), and the
decline in blood estradiol could potentially be connected to the decline in ovulation aromatase
function.
In accordance of the "metabolic memory" hypothesis, early severe diabetes management is
recommended for people with type 2 diabetes in order to stop elevated levels of plasma glucose
from initiating the established vascular damage pathways such as oxidative damage,
nonenzymatic protein glycation, epigenetic alterations, and prolonged inflammation. Despite
other medications used to avoid the long-term consequences of high blood sugar levels,
metformin has been shown in studies conducted in vitro to have a potent suppressive impact on
both the generation and accumulation of complex end products of glycation following
nonenzymatic glycation (51).
Flutamide
Contrasting information exists on flutamide's impact on non-obese PCOS woman's metabolic
profile and their susceptibility to insulin resistance (52-54). According to specific reports,
flutamide decreases the production both of the adrenal and ovarian androgens, reinstates the
process of ovulation, and improves the metabolic condition of hyperandrogenic women (55,56).
However, additional studies assert that flutamide has no or minimal impact on circulation
androgen levels, blood lipid levels, or insulin responsiveness (57, 54).
Androgens are widely recognized to have a role in the feedback-mediated regulation of
gonadotropin biosynthesis and secretion (58–60). Flutamide, was also recently demonstrated to
boost gonadotropin production in men (61,62) by blocking specific androgen receptors and
negating the effects of androgen. The Gonadotropin release is changed in PCOS69, and a
significant number of patients exhibit higher-than-normal plasma concentrations of LH and
persistently frequent, fast LH (GnRH) pulses secretion70–(63), for unknown reasons. Studies on
the impact of flutamide on gonadotropin levels in PCOS-affected women have produced
conflicting findings, which may be related to the variety of the communities examined. Some
studies claim it has little influence on FSH and LH levels whereas other research claims it lowers
FSH and LH75 or lowers LH and raises FSH (64).
This relationship can be demonstrated by restoring older women's GnRH pulse generators'
sensitivity to sexual hormones, such as progesterone and estrogen, by inhibiting androgen
activity with antiandrogens. Additionally, it has been proposed that blocking or reducing
increased androgen production could serve as a critical component in reinstating regular ovarian
control of the release of GnRH in PCOS and could have a significance for therapy protocols
intended to induce periodic menstruation in PCOS patients (65).
The prevalent endocrine ailment polycystic ovarian syndrome (PCOS) is linked to a number of
concurrent medical conditions, including diabetes, high cholesterol levels, hypertension, and the
metabolic syndrome, each of whom puts PCOS-affected women at risk for developing
cardiovascular disease at an early age lifetime. Additionally, subclinical cardiovascular disease is
more common in women with PCOS and is demonstrated by altered function of endothelial
cells, elevated arterial intimal-medial size, and coronary arteries hardening. According to
preliminary evidence, women with PCOS have aberrant levels of blood indicators for
cardiovascular risk including high-sensitivity C-reactive protein, homocysteine, and adiponectin.
However, there is little information on blood coagulation and fibrinolytic pathway anomalies.
According to research by Baldani et al, obese PCOS individuals exhibit a lesser likelihood of
hirsutism along with pimples compared with non-obese people yet have a greater possibility of
oligomenorrhea. Obese women also had higher rates of hyperandrogenemia, glucose intolerance,
hypercholestrolemia, and hypertriglyceridemia (66).
Siddiqui et al. stated that there had been no statistically meaningful variation in the measurement
of waist to hip proportion or hirsutism grade comparing obese and non-obese individuals, but
that there was a statistically significant increase in the diastolic and systolic pressures in obese
patients (67).

Fig 3. Physiological Appearance and Dysfunction in Ovaries

According to Alpanes et al., inadequate amounts of both total and HDL cholesterol and impaired
responsiveness to insulin are both symptoms of adrenal hyperandrogenemia. Differences in
cholesterol levels among studies are slightly impacted by these parameters since insulin is one of
the main moderators of the activity of lipoprotein lipase and excessive androgen production has
an autonomous role in cholesterol and metabolism of lipids (68). Both LDL and cholesterol
levels have been reported to experience reduction aftertreatment with metformin (31).
Furthermore, DHEAS and the resistance to insulin were found to be negatively correlated in
those who are type 2 diabetic (69) In the research by Chen et al., a higher amount of DHEAS
was positively correlated with a more favorable metabolic profile, encompassing obesity in the
abdominal region, insulin resistance, and high cholesterol levels (70). According to Lerchbaum
et al., women with PCOS with a reduced ratio of testosterone liberated to DHEAS have a worse
metabolic condition than PCOS women with an elevated ratio (71).
Diet and Lifestyle
It has been established that a variety of nutritional guidelines or dietary practices which involves
the diet known as the Mediterranean diet, the ketogenic program, Dietary Approaches to Stop
Hypertension, and other dietary regimens, have a significant influence on reducing body weight
and elevated insulin levels (IR), as well as enhance the functioning of reproduction. Women
with PCOS benefit from meals that reduce their risk of weight gain and insulin resistance;
nevertheless, early detection of the condition is necessary to establish a customized and long-
lasting nutritional intervention (72). The dietary changes have been proved to be beneficial for
PCOS-positive slim women. Reduced levels of luteinizing hormone, androgen, and "high-
sensitivity C-reactive protein," which plays an integral part in inflammatory processes, were seen
after treatment (73). Glucose tolerance was also improved. The medication is believed to reduce
the resistance to insulin by functioning as an insulin signaling a messenger program, so
enhancing the peripheral metabolism of glucose. In PCOS women, hormonal equilibrium and
ovulation were reestablished (73,74).
Different dietary and pharmaceutical treatment therapies have been opted by healthcare
professionals to procure an optimal outcome of patients suffering from PCOS. Yet there is
limited evidence on the effectiveness of intervention for lean PCOS. There is need to develop
longitudinal studies till perimenopausal, post-menopausal or till the death of women consuming
a certain medication or opting a specific diet or lifestyle pattern for the management of the
disease for a better, concise and clear image of treatment side effects as well as indication of
successful interventions to recommend patients. Vitamin D as well as fish oil or good fats in the
form of PUFAS and MUFAS are recommended to the patients suffering from PCOS for better
heart health as well as proper functioning of metabolic processes. Exercise and lifestyle
modifications are considered as promising interventions to start for management of disease as
well as diminishing of symptoms suffered by the females. Exercise reduces the systemic
inflammation and decreases the likelihood of weight gain and deposition of fats in the body as
endocrinal disorder affected is prone to weight gain and obesity which can further lead to severe
complications.

Conclusion
PCOS has been prevalently reported in women of reproductive age with disrupted periods,
hirsutism, acne and hyperinsulinemia as characteristic symptoms observed among women
suffering from this lifelong condition. Various medicinal and therapeutic interventions opted
during recent years are limited with metformin and flutamide as vastly consumed drugs. They
have been linked with various health benefits for PCOS by reducing the production of excessive
androgen and decreasing the circulating excessive sugar levels and free lipids that in turn
provides benefit to consistent ovulation and fertilization as well as menstruation which is the
primary goal. Further studies with more extensive parameters being employed needs to be
conducted for the determination of exact mechanism and cause of the disease to ease the
treatment process.

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