ORIGINAL ARTICLE

Effect of Metformin on Microvascular

Endothelial Function in Polycystic
Ovary Syndrome
Behnam Heidari, MD, MPH; Amir Lerman, MD; Antigoni Z. Lalia, MD;
Lilach O. Lerman, MD, PhD; and Alice Y. Chang, MD, MSc

Abstract

Objective: To investigate the factors that are associated with the effect of metformin on endothelial
dysfunction in polycystic ovary syndrome (PCOS).
Patients and Methods: From March 24, 2014, to November 18, 2016, 48 women with PCOS were
randomly assigned to 1500 mg/d of metformin (N¼29) or no treatment (N¼13) for 3 months; 42
patients (29 in the initial treatment group and 13 in the no treatment group) completed the study.
Study variables were measured at baseline and after 3 months. Participants who did not receive
metformin initially were then treated with metformin for another 3 months, and study variables were
measured again. Endothelial function was measured as reactive hyperemiaeperipheral arterial
tonometry (RH-PAT) from the index finger.
Results: The age and baseline endothelial function (mean  SD) of the participants were 32.76.9 years
and 1.80.5, respectively. No notable change was observed in endothelial function after 3 months with
metformin compared with no treatment. However, after stratifying participants who received metformin
based on baseline endothelial function, there was a significant improvement following metformin
treatment in participants with abnormal baseline endothelial function (1.30.3 vs 1.70.3; P<.001) but
not in those with normal baseline endothelial function (2.10.4 vs 2.00.5; P¼.11).
Conclusion: Metformin improves endothelial function in women with PCOS and endothelial
dysfunction independent of changes in glucose metabolism, dyslipidemia, or presence of prediabetes.
Metformin has a direct effect on endothelial function in PCOS, and measurement of endothelial
function can stratify and follow response to metformin treatment in PCOS.
Trial Registration: clinicaltrials.gov Identifier: NCT02086526.
ª 2019 Mayo Foundation for Medical Education and Research n Mayo Clin Proc. 2019;94(12):2455-2466

P
olycystic ovary syndrome (PCOS) is a calcification, greater carotid intima-media For Limelight, see
highly prevalent endocrine disorder thickness,7-9 and endothelial dysfunction page 2369
affecting up to 19.9% of women of compared with healthy controls.7,8
From the Department of
reproductive age.1 The combination of Metformin treatment improves ovulatory Cardiovascular Medicine
increased androgens and insulin resistance frequency and can improve both insulin (B.H., A.L.), Department
of Internal Medicine, Divi-
in PCOS results in an increased risk for the resistance and hyperandrogenism.9 Metfor- sion of Endocrinology,
cardiometabolic syndrome.2,3 Impaired min treatment is also associated with weight Diabetes, Metabolism, and
glucose tolerance (IGT), type 2 diabetes mel- loss and improved plasma lipid profile in Nutrition (A.Z.L., A.Y.C.),
and Division of
litus, obesity, dyslipidemia, metabolic PCOS,9,10 although this is not universally Nephrology and Hyper-
syndrome, and nonalcoholic fatty liver observed in all women with PCOS.11 There tension (L.O.L.), Mayo
Clinic, Rochester, MN.
disease have been found to be more preva- is also mixed evidence regarding metformin’s
lent in PCOS than in healthy controls.4-6 effect on endothelial function.7,12,13 Differ-
Subsequently, PCOS has also been associated ences seen between studies could be related
with biomarkers of subclinical athero- to greater effect seen specifically with macro-
sclerosis such as coronary and aortic vascular vs microvascular endothelial

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 MAYO CLINIC PROCEEDINGS

function or due to the heterogeneous pheno- enrolled in this study. The diagnosis of
types of PCOS and specific factors related to PCOS was made by an endocrinologist at
these phenotypes.11 Mayo Clinic using Rotterdam criteria.15
We sought to determine whether specific Criteria of both oligoanovulation and
metabolic, hormonal, or phenotypic features androgen excess were required for inclusion
of PCOS might be associated with metfor- in the study to increase the likelihood of in-
min’s effect in PCOS on peripheral microvas- sulin resistance. Oligoanovulation was
cular endothelial function or if metformin defined as less than 9 menses per year or
can improve endothelial function in women the absence of a progesterone increase above
with PCOS and endothelial dysfunction. 10 ng/mL (to convert to nmol/L, multiply by
The use of digital measurement of microvas- 3.18) in the luteal phase (days 20-22 of
cular endothelial function could be more menstrual cycle) in women with monthly
clinically relevant in the treatment of PCOS menses. Androgen excess was defined as
because it is less dependent on expertise elevated testosterone or dehydroepiandros-
required for the measurement of macrovascu- terone sulfate, severe acne, androgenic
lar flow-mediated dilation and interpretation alopecia, or clinical hirsutism (Ferriman-
of the data.14 Gallwey score >8). Exclusion criteria
included elevated prolactin level, untreated
PATIENTS AND METHODS hypothyroidism or hyperthyroidism, Cush-
ing syndrome, congenital adrenal hyperpla-
Study Design and Treatment Allocation sia, diabetes, creatinine level greater than
We conducted an open-label study of 1.5 mg/dL (to convert to mmol/L, multiply
women with PCOS randomized to metfor- by 88.4), pregnancy, breastfeeding, smok-
min vs no treatment at Mayo Clinic in ing, taking oral contraceptive pills or other
Rochester, Minnesota, from March 24, medications that would affect androgen
2014, to November 18, 2016 (clinicaltrials. levels, insulin sensitivity, or endothelial
gov Identifier: NCT02086526). The study function.
protocol was approved by the Institutional Body mass index was calculated as
Review Board of Mayo Clinic. Written weight in kilograms divided by height in me-
informed consent was obtained from each ters squared. Homeostasis model assessment
participant before study enrollment. Partici- of insulin resistance (HOMA-IR) was calcu-
pants could not be taking any other medica- lated by multiplying fasting plasma glucose
tions for the treatment of PCOS for at least 3 (mg/dL) by fasting plasma insulin (U/L)
months before screening and enrollment. divided by 405.16
We randomly assigned 48 women with Endothelial function values of more than
the diagnosis of PCOS to metformin (1500 1.6 were considered normal, and those less
mg daily, extended-release) or no treatment than or equal to 1.6 were considered
(delayed start, Figure 1A). Metformin dosage abnormal (endothelial dysfunction).17
was titrated to 1500 mg weekly during the Impaired fasting glucose was defined as
first 3 weeks of the trial. Participants ran- fasting glucose levels of 100 to 125 mg/dL
domized to the no treatment arm had the op- (5.6 to 6.9 mmol/L), and IGT was defined
tion to continue the study for an additional 3 as 2-hour glucose levels of 140 to
months, during which they received metfor- 199 mg/dL (7.8 to 11.0 mmol/L) following
min and completed an additional set of study a 75-g oral glucose tolerance test (OGTT).
measurements after metformin treatment Impaired fasting glucose and IGT are predia-
(Figure 1B). betic states of hyperglycemia, associated
with insulin resistance and increased risk
Definitions and Procedures of cardiovascular pathology, and thus pa-
Premenopausal women aged 18 to 50 years tients with impaired fasting glucose and
with a body mass index (BMI) of 25 or IGT are an important target group for
greater who had a diagnosis of PCOS were primary prevention.18
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METFORMIN FOR ENDOTHELIAL DYSFUNCTION IN PCOS

48 Patients randomized allocation

15 Assigned to no treatment 33 Assigned to metformin

3 Became pregnant
1 Moved to another
1 Excluded due to
state
gastrointestinal
1 Became pregnant
complications

13 Completed trial and were 29 Completed trial

assigned to metformin

1 Did not complete

therapy

12 Completed therapy
A

Metformin
0 3 months

Randomization First visit and Second visit and

laboratory tests laboratory tests

Delayed start Metformin

0 3 months 6 months

First visit and Second visit and Third visit and

laboratory tests laboratory tests laboratory tests
B

FIGURE 1. Participants’ assignments to immediate or delayed metformin treatment. A, Number of par-

ticipants in each step and treatment received. B, Timing of follow-up visits and workups.

Participants’ height and weight were endothelial function, correlates well with
measured with light clothing without shoes. coronary endothelial function, and has
Waist circumference was measured in the good reproducibility17,19-22 Finger reactive
midpoint between the iliac crest and the hyperemia (RH)eperipheral arterial tonom-
lower rib after normal expiration. Hip etry (PAT), which measures flow-mediated
circumference was measured as the widest dilation, was used to assess endothelial func-
diameter of the hips. A standard mercury tion. The measurement methods have been
sphygmomanometer was used to measure published previously.17,20,23 Briefly, the
systolic and diastolic blood pressure after EndoPAT 2000 device uses finger probes
10 minutes of resting in a sitting position. that record and analyze the volume of blood.
Before placement of intravenous access, Two finger probes were placed on 2 index
an EndoPAT 2000 device (Itamar Medical fingers of each participant to continuously
Ltd) was used to assess endothelial function. record the blood volume changes accompa-
As previously described, it is a noninvasive nying pulse waves. A standard blood pres-
method for the assessment of the peripheral sure cuff was placed on one arm. At first, 5

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 MAYO CLINIC PROCEEDINGS

minutes of PAT recording was done for (metformin vs no treatment). Next, all par-
equilibration. Next, while the PAT recording ticipants treated with metformin (including
was still continuing, the cuff was inflated to those in the metformin group and those in
higher than systolic pressure and held for 5 the delayed start group) were divided into
minutes. After 5 minutes, the cuff was 2 groups according to their baseline endo-
deflated, and the PAT recording continued thelial functiondnormal or endothelial
for another 5 minutes. The recordings from dysfunction as defined previously. Baseline
the other index finger were used as a control characteristics of the participants are pre-
for each measurement. The recorded sented as mean  SD for normally distrib-
RH-PAT data were analyzed by computer uted continuous variables, median and
software through an operator-independent interquartile range for nonnormally distrib-
process. The RH-PAT index was obtained uted continuous variables, and number (per-
as a measure of RH. It was calculated as centage) for dichotomous variables. The
the average PAT signal amplitude during 1 Kolmogorov-Smirnov test was used to assess
minute starting from 1.5 minutes after cuff normality in the study variables. The inde-
deflation divided by the average PAT signal pendent sample t test was used to compare
amplitude during the 2.5 minutes before means for normally distributed variables
cuff inflation. and the Mann-Whitney U test for nonnor-
Venous blood samples were collected af- mally distributed variables at baseline. The
ter 12 hours of overnight fasting for mea- c2 test was used to compare the dichoto-
surements of fasting plasma glucose, mous variables between study groups at
hemoglobin A1c, C-peptide, fasting plasma baseline. A paired t test was used to compare
insulin, total cholesterol, high-density lipo- means for normally distributed variables and
protein cholesterol, low-density lipoprotein the Wilcoxon signed rank test for nonnor-
cholesterol, triglycerides, C-reactive protein, mally distributed variables within each study
leptin, adiponectin, estradiol, dehydroepian- group before and after treatment. The McNe-
drosterone sulfate, and total testosterone. Af- mar test was used to compare the dichoto-
ter baseline samples were obtained, a 75-g mous variables within each study group
OGTT was performed. After the participant before and after treatment. Linear regression
ingested 75 g of glucose, blood samples analysis was used to assess predictors of
were collected every 10 minutes for the change in RH-PAT index following metfor-
following 3 hours to measure plasma glucose min treatment. With the sample size of 42,
and insulin levels. The OGTT samples were our study had the power of 80% to detect
collected via a retrograde venous catheter the mean difference of 0.3 in RH index
with the hand being placed within a heating before and after treatment with metformin.
box and warmed to approximately 60 C to SPSS statistical software, version 22 (IBM
collect arterialized blood. Corp) was used for data analysis. Two-
Study variables were measured twice for sided P<.05 was considered statistically
those initially assigned to metformin, once significant.
before and once after 3 months of treatment.
For control participants who were in the no RESULTS
treatment group and received metformin In this study, 48 women with PCOS were
treatment later on (delayed start group), var- randomly assigned to metformin (33 pa-
iables were measured 3 times: 2 times before tients) or no treatment (15 patients). Four
metformin therapy (day 1 and day 90) and participants in the metformin treatment
once after metformin therapy (after 6 group (12.1%) and 2 participants in the no
months) (Figure 1B). treatment group (13.3%) did not complete
the trial (Figure 1A). Of the participants in
Statistical Analyses the no treatment group who completed the
The study participants were first grouped trial, 13 continued the study to take metfor-
based on the randomized treatment min for 3 months (delayed start group).
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METFORMIN FOR ENDOTHELIAL DYSFUNCTION IN PCOS

Among those, 12 participants completed adjusted for other variables. Table 3 shows
therapy. the univariable and multivariable regression
Table 1 shows the characteristics of the analysis considering the individual change
metformin and no treatment groups at base- in endothelial function as the dependent var-
line and after 3 months. The mean  SD age iable. Impaired baseline endothelial function
of the participants was 32.76.9 years. The was the only variable that was significantly
participants were obese (BMI, 36.89.4 associated with improved endothelial func-
kg/m2). Mean baseline endothelial function tion following treatment with metformin in
was 1.80.5 for the study population. the univariable analysis (b¼.519; P¼.001).
Table 1 also shows the characteristics of Because we had improvements of endothelial
the delayed start and metformin groups at function in 23 participants, we could include
baseline and after 3 months. There was no only 2 variables in the multivariable model.
notable difference between baseline charac- Since we observed consistent significant
teristics in the two groups. There was no changes in HOMA-IR following metformin
notable change in study variables in the treatment (Table 1 [P<.01] and Table 2
delayed start group after 3 months. In [P<.01]) and it has been reported to be
metformin-treated participants, there was a significantly associated with impaired endo-
significant decrease in body weight thelial function,24 we included HOMA-IR
(P<.05), fasting plasma glucose (P<.01), and baseline endothelial function in the final
fasting plasma insulin (P<.05), HOMA-IR multivariable model (Table 3). As shown,
(P<.05), total plasma cholesterol (P<.05), baseline endothelial dysfunction remained
and testosterone (P<.001) after 3 months the single significant predictor of change in
of treatment. There was no notable change endothelial function following adjustment
in endothelial function in the 2 groups dur- for HOMA-IR (b¼.518; P¼.002).
ing this period.
To further explore the effect of metfor- DISCUSSION
min therapy on endothelial function, all The current study documents that treatment
study participants who received metformin with metformin can improve peripheral
were stratified according to baseline endo- endothelial function, but specifically in the
thelial function (normal vs endothelial subset of women with PCOS and endothelial
dysfunction) (Figure 2). Table 2 compares dysfunction. This improvement in endothe-
the characteristics of the study participants lial function was not mediated through
stratified by baseline endothelial function changes in androgens, glucose metabolism,
before and after 3 months of treatment or insulin resistance. In addition, endothelial
with metformin. As shown in Table 2, the dysfunction was highly prevalent in our
group with endothelial dysfunction did not study populationd15 of 42 women with
have significantly different concentrations PCOS (35.7%) had endothelial dysfunction
of fasting glucose (P<.01), insulin (P<.05), (Table 2).
and C-peptide (P<.05) compared with the To our knowledge, only one previously
normal group. There was no significant published study has assessed the effect of
change in endothelial function in partici- metformin on peripheral microvascular
pants with baseline normal endothelial func- endothelial function in PCOS.7 That study
tion following 3 months of metformin found that although endothelial function
treatment (2.10.4 vs 2.00.5; P¼.11) was decreased in women with PCOS
(Table 2). In contrast, there was a significant compared with healthy controls, 3 months
improvement in participants with abnormal of metformin treatment did not notably
baseline endothelial function (1.30.3 vs change endothelial function in the women
1.70.3; P<.001). with PCOS.7 The 2 factors that distinguish
Next, we assessed what factors can pre- our study is that (1) Lowenstein et al7 had
dict the improvement of endothelial function a lean sample of women with PCOS whereas
following metformin treatment when our patients were obese and (2) they did not
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 MAYO CLINIC PROCEEDINGS

TABLE 1. Characteristics of the Study Population at Baseline and After 3 Monthsa,b,c,d

Metformin group (N¼29) Delayed treatment group (N¼13)
Variable Baseline Month 3 Baseline Month 3
Age (y) 32.47.5 NA 33.15.9 NA
Height (cm) 166.16.9 166.27 165.45.5 165.76.7
Weight (kg) 103.430.8 102.331.6e 104.720.9 100.919.7
2
BMI (kg/m ) 37.19.1 36.210.3 38.48.3 37.78.1
Waist circumference (cm) 107.618.8 106.818.4 111.415.7 113.121.5
Hip circumference (cm) 12318.4 120.214 124.414.4 123.915.1
Waist to hip circumference 0.90.1 0.90.1 0.90.1 0.90.1
SBP (mm Hg) 120.714.5 117.912.1 120.217.9 118.816.4
DBP (mm Hg) 72.810.2 69.79.1 73.514.1 71.312.2
Hypertension 4 (13.8) 2 (6.9) 2 (15.4) 2 (15.4)
FPG (mg/dL) 94.411.1 87.59.4f 89.88.1 91.39.2
IFG 5 (17.2) 2 (6.7) 1 (7.7) 1 (7.7)
2-h Glucose OGTT (mg/dL) 143.523.5 142.328.3 14323 136.431.8
IGT 13 (44.8) 11 (37.9) 6 (46.2) 7 (53.8)
HbA1c (%) 5.30.3 NA 5.30.3 NA
C-peptide (ng/mL) 1.1 (0.74-1.3) 0.93 (0.59-1.2) 0.93 (0.59-1.2) 0.86 (0.54-1)
Insulin (mIU/mL) 13.7 (9.8-24.1) 10.2 (5.9-16)e 10 (7.75-22.75) 11.2 (5.4-17.9)
HOMA-IR 3.2 (2.4-5.5) 2.1 (1.1-3.5)f 2.1 (1.6-5.6) 3.6 (1.4-6.5)
IR (%) 63.3 46.7 58.3 58.3
e
Total cholesterol (mg/dL) 177.730.3 169.426.2 17027.4 170.824.3
HDL-C (mg/dL) 45.613.7 45.712.1 47.813.4 5121.7
Adiponectin (mg/dL) 6046.72786.4 5946.92928.5 6122.22478.1 6413.72499.4
Leptin (mg/L) 47.423.3 48.423.2 45.815.1 43.218.3
LDL-C (mg/dL) 104.131.6 101.819.8 100.825.5 100.620.2
TG (mg/dL) 123.175.7 109.747.9 106.643.8 95.630.3
Estradiol (pg/mL) 49.6 (35-98.7) 42.4 (33.4-56.5) 61.6 (40-121.5) 58.9 (46-71)
DHEAS (mg/dL) 147 (73.4-257.5) 123 (75.1-246) 150 (99.3-164) 126 (98.5-150)
Total testosterone (ng/dL) 33 (23.5-37) 24 (15.5-35.5)g 31 (24-61) 27.5 (21.3-44)
CRP (mg/L) 2.3 (1.2-5.4) 3.1 (1.4-6.2) 5.1 (1.4-11.3) 7.2 (4.3-11.1)
RHI 1.90.6 1.90.5 1.70.4 1.80.5
a
BMI ¼ body mass index; CRP ¼ C-reactive protein; DBP ¼ diastolic blood pressure; DHEAS ¼ dehydroepiandrosterone sulfate; FPG ¼ fasting plasma glucose; HDL-C ¼
high-density lipoprotein cholesterol; HOMA-IR ¼ homeostasis model assessment of insulin resistance; IFG ¼ impaired fasting glucose; IGT ¼ impaired glucose tolerance;
IR ¼ insulin resistance; LDL-C ¼ low-density lipoprotein cholesterol; NA ¼ not applicable; OGTT ¼ oral glucose tolerance test; RHI ¼ reactive hyperemia index; SBP ¼
systolic blood pressure; TG ¼ triglycerides.
b
Data are presented as mean  SD for normally distributed continuous variables, median (interquartile range) for nonnormally distributed continuous variables, and No.
(percentage) for dichotomous variables.
c
SI conversion factors: To convert glucose values to mmol/L, multiply by 0.0555; to convert HbA1c values to proportion of total hemoglobin, multiply by 0.01; to convert C-
peptide values to nmol/L, multiply by 0.331; to convert insulin values to pmol/L, multiply by 6.945; to convert cholesterol values to mmol/L, multiply by 0.0259; to
convert triglyceride values to mmol/L, multiply by 0.0113; to convert estradiol values to pmol/L, multiply by 3.671; to convert DHEAS values to mmol/L, multiply by 0.027;
to convert testosterone values to nmol/L, multiply by 0.0347; to convert CRP values to nmol/L, multiply by 9.524.
d
There was no significant difference between the 2 groups at baseline.
e
P<.05, comparing values at baseline and after 3 months.
f
P<.01, comparing values at baseline and after 3 months.
g
P<.001, comparing values at baseline and after 3 months.

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METFORMIN FOR ENDOTHELIAL DYSFUNCTION IN PCOS

have any data about glucose metabolism or

insulin resistance. Their study concluded
Before treatment
that the shorter duration of treatmentd3 After treatment
2.25
monthsdwas not long enough to produce
an observable effect and overlooked the
additional possibility that their sample was 2.00

Endothelial function
also different because they were not over-
weight or obese compared with patients in 1.75
previous studies. In our study, over
one-third of the women with PCOS had
1.50
endothelial dysfunction, and similar to the
aforementioned study, we did not see a
notable improvement in endothelial function 1.25
after 3 months of metformin therapy in the
whole study population. However, stratified 1.00
by baseline endothelial function, we found
that those with abnormal baseline endothe- Normal Abnormal
lial dysfunction had notable improvement Baseline endothelial function
whereas those with normal baseline endo-
FIGURE 2. Change in endothelial function following treatment with met-
thelial function did not. Our study results
formin. Error bars represent 95% CIs of the mean.
support the majority of studies in PCOS
that reported improvement of macrovascular
flow-mediated dilation following metformin treatment of PCOS to improve ovulatory fre-
administration.12,13,25 We know that both quency and prevent the development of type
flow-mediated dilation and RH-PAT measure 2 diabetes. However, its mechanism of action
endothelial function and are associated with is not fully understood, and studies reveal a
unfavorable cardiovascular outcomes. How- plethora of pleiotropic effects that are not al-
ever, the magnitude of their correlation ways related.9 Metformin might improve
regarding the prediction of future cardiovas- endothelial function directly by multiple po-
cular events is not yet elucidated and they tential mechanisms. Although metformin is
are discussed as separate concepts in the cur- a glucose-lowering agent, it is currently
rent literature.14 Therefore, this study estab- known as an antiaging medication that tar-
lishes that a notable effect of metformin on gets several pathways of aging. It has been
peripheral microvascular endothelial func- found to be effective in increasing the life
tion can be observed even in obese women span in animal models and delays
with PCOS as early as 3 months after age-related diseases as well. The effect of
treatment. metformin on aging includes multiple
The improvement of endothelial function mechanisms such as increasing adenosine
in our study was independent of the effect of monophosphateeactivated protein kinase,
metformin on other cardiometabolic factors, which results in increased nitric oxide pro-
including glucose metabolism, insulin resis- duction in the endothelium and subse-
tance, and dyslipidemia. This result is quently better vascular relaxation.
similar to that from a previous study docu- Metformin decreases mammalian target of
menting that metformin improved macro- rapamycin, which can subsequently increase
vascular endothelial dysfunction in women nitric oxide. It decreases inflammation and
with PCOS independent of changes in insu- oxidative stress, which may subsequently
lin sensitivity.12 Insulin resistance and result in better endothelial function and
glucose intolerance are hallmarks of PCOS. vascular dilation.26,27 It has a protective ef-
Metformin is an antidiabetic agent with fect against inflammation and can reduce
insulin-sensitizing properties that has endothelial cell damage and apoptosis
become increasingly accepted in the caused by mitochondrial membrane damage.
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 MAYO CLINIC PROCEEDINGS

TABLE 2. Characteristics of the Study Population at Baseline and After 3 Months of Metformin Therapy, Stratified by Baseline Endothelial
Function Statusa,b,c
Normal baseline endothelial function (N¼26) Endothelial dysfunction (N¼15)
Variable Baseline Month 3 Baseline Month 3
Age (y) 33.86.9 NA 30.66.7 NA
Height (cm) 165.35 165.86.4 166.98.6 166.68.7
Weight (kg) 104.428.8 102.831.4d 102.727.2 100.725.9
BMI (kg/m2) 37.99.2 37.59.9 36.78.4 35.09.7
d
Waist circumference (cm) 107.615.4 111.824.3 110.921.9 109.919.9
Hip circumference (cm) 119.428 122.614.7 117.813.1 117.312.4
Waist to hip circumference 0.80.2 0.90.1 0.90.1 0.90.1
SBP (mm Hg) 121.212.5 119.412.5 119.416.4 116.114.0
DBP (mm Hg) 73.311.9 70.78.9 72.510.5 69.111.2
Hypertension 4 (15.4) 2 (7.7) 2 (13.3) 2 (13.3)
FPG (mg/dL) 93.710.4 85.67.6e 91.710.7 91.39.2
IFG (%) 3 (11.5) 1 (3.8) 3 (20) 1 (6.7)
2-h OGTT glucose (mg/dL) 141.525.3 138.730.6 146.519 145.225.7
IGT 11 (42.3) 10 (38.5) 8 (53.3) 6 (40.0)
HbA1c (%) 5.30.3 NA 5.30.3 NA
C-peptide (ng/mL) 0.99 (0.76-1.2) 0.83 (0.75-1.15)d 0.99 (0.57-1.4) 0.82 (0.51-1.3)
Insulin (mIU/mL) 11.6 (9-20.3) 11.6 (8.1-16.1)d 11.9 (7.5-24.6) 6.9 (3.3-16.2)
HOMA-IR 2.9 (2.2-4.9) 2.7 (1.6-3.6)e 2.7 (1.5-6.0) 1.7 (0.6-4.1)d
Total cholesterol (mg/dL) 175.427.5 168.323.9 175.133.3 172.529.5
HDL-C (mg/dL) 44.112.5 44.110.5 50.114.6 51.418.4
Adiponectin (mg/dL) 6084.72382.6 5836.12095.2 60443202 6924.13615.4
Leptin (mg/L) 46.620.2 47.221.6 47.623.4 46.823.3
LDL-C (mg/dL) 102.631.9 101.720.2 103.825.8 101.418.9
TG (mg/dL) 124.976 111.952.5 105.747.8 98.326.3
Estradiol (pg/mL) 47 (33.1-96.3) 46.6 (34.3-55.1) 51 (42-149) 46.1 (38.8-145)
DHEAS (mg/dL) 95.4 (72.8-164) 121 (74.7-217) 164 (149-308)f 173.5 (114.1-307.7)
g
Total testosterone (ng/dL) 29 (22-42) 22 (15.5-30.5) 35 (28-50) 30 (21-43)
CRP (mg/L) 3.4 (1.1-5.1) 2.2 (1.2-5.4) 5.3 (1.4-11.2) 5.3 (1.1-9.2)
RHI 2.10.4 2.00.5 1.30.3h 1.70.3g
a
BMI ¼ body mass index; CRP ¼ C-reactive protein; DBP ¼ diastolic blood pressure; DHEAS ¼ dehydroepiandrosterone sulfate; FPG ¼ fasting plasma glucose; HDL-C ¼
high-density lipoprotein cholesterol; HOMA-IR ¼ homeostasis model assessment of insulin resistance; IGT ¼ impaired glucose tolerance; IFG ¼ impaired fasting glucose;
LDL-C ¼ low-density lipoprotein cholesterol; NA ¼ not applicable; OGTT ¼ oral glucose tolerance test; RHI ¼ reactive hyperemia index; SBP ¼ systolic blood pressure;
TG ¼ triglycerides.
b
Data are presented as mean  SD for normally distributed continuous variables, median (interquartile range) for nonnormally distributed continuous variables, and No.
(percentage) for dichotomous variables.
c
SI conversion factors: To convert glucose values to mmol/L, multiply by 0.0555; to convert HbA1c values to proportion of total hemoglobin, multiply by 0.01; to convert C-
peptide values to nmol/L, multiply by 0.331; to convert insulin values to pmol/L, multiply by 6.945; to convert cholesterol values to mmol/L, multiply by 0.0259; to
convert triglyceride values to mmol/L, multiply by 0.0113; to convert estradiol values to pmol/L, multiply by 3.671; to convert DHEAS values to mmol/L, multiply by 0.027;
to convert testosterone values to nmol/L, multiply by 0.0347; to convert CRP values to nmol/L, multiply by 9.524.
d
P<.05, comparing values at baseline and after 3 months inside each group.
e
P<.01, comparing values at baseline and after 3 months inside each group.
f
P<.05, comparing values between two groups at baseline.
g
P<.001, comparing values at baseline and after 3 months inside each group.
h
P<.001, comparing values between two groups at baseline.

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METFORMIN FOR ENDOTHELIAL DYSFUNCTION IN PCOS

TABLE 3. Linear Regression Analysis Considering Endothelial Function Change After Metformin Administration
Dependent Variable
Univariable Multivariable
Variable b P value b P value
Baseline endothelial .519 .001 .518 .002
dysfunction
Age .004 .76 NA NA
BMI .002 .81 NA NA
Hypertension .161 .61 NA NA
FPG .003 .71 NA NA
IGT .114 .49 NA NA
Insulin .001 .87 NA NA
HOMA-IR .007 .833 .001 .92
Estradiol .002 .15 .002 .15
Total testosterone .004 .46 NA NA
CRP .127 .51 NA NA
DHEAS .001 .15 NA NA
Total cholesterol .001 .61 NA NA
HDL-C .010 .09 NA NA
Adiponectin .001 .25 NA NA
Leptin .001 .8 NA NA
LDL-C .001 .7 NA NA
TG .001 .27 NA NA
BMI ¼ body mass index; CRP ¼ C-reactive protein; DHEAS ¼ dehydroepiandrosterone sulfate; FPG ¼ fasting plasma glucose; HDL-C ¼
high-density lipoprotein cholesterol; HOMA-IR ¼ homeostasis model assessment of insulin resistance; IGT ¼ impaired glucose tolerance;
LDL-C ¼ low-density lipoprotein cholesterol; NA ¼ not applicable; TG ¼ triglycerides.

It might reduce vascular remodeling and protein and the adipose tissue hormones adi-
fibrosis. Also, by inhibiting the renin- ponectin and leptin. Similarly, a previous
angiotensin system, it can cause vascular study12 in overweight women with PCOS
relaxation as well as a decrease in systolic did not find notable changes in glucose
blood pressure and skin hyperemia.28 In metabolism and insulin response during an
addition, metformin can increase production OGTT after 6 months of metformin treat-
of nitric oxide in the endothelial cells and ment. It is also possible that in obese women
improve its effect on vasodilation.29 it is more difficult to see the effect with 3
Although the current study did not identify months of treatment. It might be that the
a specific mechanism of action or pathway criterion standard hyperinsulinemic-
through which metformin improves endo- euglycemic clamp is needed to formally mea-
thelial function, the aforementioned clinical sure changes in insulin resistance that have
and laboratory studies provide possible ex- been demonstrated previously with metfor-
planations through which metformin exerts min. It has also been found that the meta-
a direct protective effect on vascular bolic abnormalities in PCOS do not
endothelium.28,29 necessarily change together. As an instance,
In this sample of obese women with differences in serum low-density lipoprotein
PCOS studied for 3 months, metformin had cholesterol levels in these patients are at
no major effect on body weight, waist least partially independent of BMI.9 Interest-
circumference, cholesterol and triglyceride ingly, a recent study has reported that endo-
concentrations, or markers of chronic sub- thelial function in PCOS is not associated
clinical inflammation, including C-reactive with cardiometabolic factors of obesity and
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 MAYO CLINIC PROCEEDINGS

insulin resistance.8 Lambert et al8 found that dysfunction can benefit from taking metfor-
women with PCOS have lower endothelial min, whereas metformin did not have any
function and higher sympathetic activation notable effect on those with normal baseline
compared with matched controls with a endothelial function. Our study suggests a
similar metabolic profile. Both observed potential beneficial role for the measurement
findings were associated with PCOS but of endothelial function to individualize the
not cardiometabolic variables such as BMI, treatment approaches in women with PCOS.
glucose level, insulin concentration, or lipid In addition to its prognostic value, endo-
profile.8 This finding suggests that endothe- thelial function can be targeted for treatment
lial dysfunction is at least partially indepen- to reduce future cardiovascular events. As an
dent of prevalent cardiometabolic risk example, a study by Kitta et al33 found that
factors in PCOS.8 Thus, improvement of improvement of endothelial dysfunction
endothelial function in PCOS following met- can reduce future adverse outcomes in pa-
formin administration can be mediated tients with coronary artery disease. Another
through mechanisms other than weight study reported that improved endothelial
reduction, change in plasma glucose and in- function following antihypertensive treat-
sulin levels, or lipid profile as documented in ment in postmenopausal women is associ-
previous studies.28,29 Endothelial dysfunc- ated with more favorable cardiovascular
tion could thus be an independent abnor- outcomes.34 These findings further highlight
mality or an early factor in the course of the value of targeting endothelial function
the metabolic dysregulation, leading to for prevention of coronary heart disease.
increased cardiovascular risk in women Although a higher long-term risk of cardio-
with PCOS. These data suggest that vascular events in PCOS remains to be
screening for endothelial dysfunction can further clarified,9 several studies have estab-
be done independently and in addition to lished the higher prevalence of cardiometa-
the metabolic risk profile in women with bolic risk factors in PCOS that raises
PCOS to help decision making regarding concerns about their future risk of adverse
possible treatment strategies. cardiovascular events.2-6,9,35-37 Therefore,
Polycystic ovary syndrome is a heteroge- screening for cardiometabolic risk factors is
neous disorder with various presentations currently recommended in all women with
and ongoing challenges in treatment strate- PCOS.3,9 Heart disease is still the leading
gies.2,9 Metformin can have variable effects cause of death for women, with the develop-
in women with PCOS, at least partially ment of type 2 diabetes notably increasing a
because different subtypes of PCOS have woman’s risk for heart disease to the equiva-
different cardiometabolic profiles and should lent of a prior cardiovascular event. Our
be considered as separate subpopulations for study results suggest that screening for
therapeutic approaches.9,30 This issue high- endothelial dysfunction might be a prom-
lights the need for individualized treatment, ising method to screen for higher-risk indi-
especially in patients with PCOS. We have viduals who could receive the greatest
previously proposed that measuring endo- benefit from metformin or other therapies
thelial function can be a useful tool for indi- independent of their glucose tolerance and
vidualized medicine.31,32 Assessing cardiovascular risk factor profile. Future
endothelial function provides information studies are needed to further validate this
about the atherosclerosis itself rather than strategy.
quantifying risk factors that may have vari- The strengths of the current study are
able effects from person to person. Hence, the use of a control group to assess endothe-
it can be used as a tool for individualized lial function in a randomized manner and
risk assessment and provides an opportunity the inclusion of detailed dynamic measure-
to control atherosclerosis at earlier ments of glucose metabolism and insulin
stages.31,32 In the current study, we found secretion using the 2-hour OGTT. The null
that women with PCOS and endothelial correlations of metformin’s effect with
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METFORMIN FOR ENDOTHELIAL DYSFUNCTION IN PCOS

changes in these metabolic parameters are Grant Support: This study was supported in part by a St.
important indicators that metformin could Jude Medical Foundation Career Development Award in
Cardiovascular Research, National Institutes of Health Build-
have a direct effect on the endothelium and ing Interdisciplinary Careers in Women’s Health Award
reinforces the dialogue to pursue other K12HD065987, and the National Center for Advancing
mechanistic routes of metformin in future Translational Sciences.
studies. Besides the novel findings, our study Potential Competing Interests: Dr Amir Lerman is a
has some limitations. Similar to most studies consultant for Itamar Medical Ltd, Shahal Medical Services
of the effect of metformin in women with Ltd, and Volcano Corporation/Philips Healthcare. Dr Lilach
PCOS,30 we do not have a long follow-up Lerman is a consultant for WeiJian Technology Co, Ltd.
to establish metformin’s effect on hard car- Correspondence: Address to Alice Y. Chang, MD, MSc,
diovascular end points of morbidity and Department of Internal Medicine, Division of Endocrinology,
mortality. Studies with long-term follow-up Diabetes, Metabolism, and Nutrition, Mayo Clinic, 200 First
St SW, Rochester, MN 55905 ([email protected]).
would be needed to assess whether this
improvement in endothelial function can
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