Metformin for Ectopic Fat Deposition and Metabolic Markers in Polycystic Ovary Syndrome (PCOS)
Metformin for Ectopic Fat Deposition and Metabolic Markers in Polycystic Ovary Syndrome (PCOS)
This project, "A double-blind placebo-controlled randomized clinical trial assessing the
 efficacy of metformin for hepatic fat in adolescents and young adults with polycystic ovary
 syndrome", proposes exploring the use of novel and noninvasive methodologies in an at-risk
 adolescent and young adult population with polycystic ovary syndrome (PCOS) who may gain
 long-term health benefits from early detection and treatment of non-alcoholic fatty liver
 disease (NAFLD). PCOS is a common condition that frequently presents in adolescence and young
 adulthood and is defined by elevated androgens (male hormones) in the blood leading to 1.
 hirsutism and acne and 2. menstrual abnormalities or amenorrhea. Affected individuals are at
 increased risk of developing insulin resistance (a precursor of diabetes), NAFLD and lipid
 (cholesterol) abnormalities.These features are all associated with the metabolic syndrome, a
 rising major public health concern. Recently, an association between PCOS and NAFLD has been
 noted but has only been superficially studied in the adolescent and young adult population.
 The susceptibility of certain PCOS patients to developing NAFLD is theorized to be due to
 having underlying insulin resistance, elevated androgen levels, and a genetic predisposition.
 Metformin is an insulin sensitizing medication widely used to treat type 2 diabetes mellitus
 that may have beneficial effects on insulin resistance-related conditions including PCOS and
 NAFLD. Although widely used in PCOS, its effect on NAFLD in this group has not been
 previously studied.

 The primary aims of this proposal are: 1) To determine whether PCOS with liver fat >/=4.8%
 treated with metformin for six months will have a decline in percentage liver fat compared to
 a placebo group. 2) To measure the association of the PNPLA3 I148M allele with NAFLD in PCOS
 at baseline (n=40). 2b) To measure the association of percentage liver fat with biomarkers of
 NAFLD, dyslipidemia, insulin resistance and body composition at baseline (n=40) and after a
 placebo-controlled intervention with metformin in PCOS with liver fat >4.8% (n=20).

 The goal of this research proposal is to explore the use of novel and noninvasive
 technologies in a young and at risk population. Dr. Sopher hopes to use the results of this
 research to lay the groundwork for the prevention and treatment of NAFLD and other metabolic
 disorders in adolescents and young adults with PCOS and to prevent lifelong morbidity
 associated with PCOS.
PCOS subjects will be screened by questionnaire for eligibility with the goal of recruiting
 40 subjects who are 14 to 25 years, BMI between the 10th and 95th percentile for age (<20
 years) and 18.5 - 29.9 kg/m2 (20 years or older), and at least two years post-menarche.
 Oligomenorrheic subjects will complete the protocol during the early follicular phase of the
 menstrual cycle (days one through seven) and amenorrheic subjects will complete the protocol
 on any day. The protocol will comprise: a) History and physical exam: Height, weight, body
 mass index (BMI) (percentile and z-score for <20 years), blood pressure, physical exam,
 Ferriman-Gallwey hirsutism scoring, smoking, alcohol and family history; b) Laboratory
 evaluation will be between 0800 and 0900 after an overnight fast via a 21 gauge intravenous
 catheter for: 1) General endocrine panel: Thyroid function, prolactin,
 17-hydroxyprogesterone; 2) PCOS panel: luteinizing hormone (LH), follicle stimulating hormone
 (FSH), estradiol, sex hormone binding globulin, testosterone, free testosterone,
 androstenedione, dehydroepiandrosterone; 3) Liver panel: Liver enzymes (alanine
 aminotransferase (ALT), aspartate aminotransferase (AST), gamma glutamyl-transpeptidase
 (GGT)), apoptosis markers (Fas, cytokeratin-18 fragments, M30), pancreatic polypeptide; 4)
 Cardiovascular risk panel: Cholesterol, triglycerides, HDL, LDL, free fatty acids, c-reactive
 protein; 5) IR evaluation: hemoglobin A1C, glucose, insulin, c-peptide and two-hour oral
 glucose tolerance test (OGTT) after a 75 gram glucose challenge with measurement of glucose
 and insulin at 30, 60, 90 and 120 minutes. IR will be determined by age- and BMI- specific
 homeostatic measure of insulin resistance (HOMA-IR) cutoffs based on a National Health and
 Nutrition Examination Survey (NHANES) study of 1,164 nonobese adolescents 12 to 19 years old.
 Other IR indices that will be evaluated are whole body insulin sensitivity (WBIS) and insulin
 area under the curve; 6) Genetic evaluation: A blood sample for the PNPLA3 I148M allele
 (baseline only). c) Magnetic resonance spectroscopy (MRS) of the liver for intrahepatic lipid
 content acquired using standard point resolved spectroscopy sequence (PRESS). Percentage
 liver fat will be calculated. d) Total body magnetic resonance imaging (MRI) with 10 mm
 slices and 40 mm interslice gaps for total body adipose tissue and VAT. e) Dual-energy x-ray
 absorptiometry (DXA): Total body DXA will be performed for total body lean and fat mass and
 percentage body fat. f) Randomization: Subjects whose liver fat is 4.8% or greater (n≈20)
 will be randomized to placebo or extended-release metformin 1000 mg (2 tablets) daily.
 Randomization will be double-blind and will be performed by randomly selected permuted size 2
 and size 4 blocks determined by the Columbia University Medical Center (CUMC) Research
 Pharmacy with the guidance of a statistician. g) Intervention: All subjects will receive
 identically appearing pill bottles labeled "Study Medication" containing their first
 three-month supply of either metformin or placebo. Subjects will be instructed to take pills
 with dinner and to take one pill once a day for one week and subsequently two pills once a
 day for the remainder of the first three months. Subjects will be asked to call with any side
 effects that they may experience. They will receive weekly calls from a research coordinator
 and will be asked to bring their empty pill bottles to their follow-up studies do to ensure
 compliance. h) Brief interim evaluation: After three months of the intervention phase,
 subjects will be seen for a general health assessment, which includes weight, blood pressure
 and a physical examination, and will receive their second three-month supply of their
 assigned intervention. i) Follow-up exam: At the end of six months, subjects will undergo
 laboratory and body composition testing identical to those performed in the baseline testing.
Inclusion Criteria:

 -  Healthy adolescent girls and young women 13 - 25 years old

 -  At least 2 years postmenarche

 -  With clinical hyperandrogenism and/or hyperandrogenemia, menstrual dysfunction
 (oligomenorrhea or amenorrhea) and exclusion of other known disorders. PCOS will be
 diagnosed using NIH 1990 criteria.

 Exclusion Criteria:

 -  Past or present history of a medical disorder or medication known to affect body
 composition

 -  Insulin secretion and sensitivity, or the GH-IGF-I axis (e.g. steroid hormone or
 thyroid replacement)

 -  Any diseases affecting bone metabolism (collagen disorders, primary
 hyperparathyroidism, nephrolithiasis, untreated hyperthyroidism) indwelling hardware

 -  History of current or past pregnancy

 -  Hormonal contraceptive or metformin use within 3 months of enrollment

 -  Nonclassical congenital adrenal hyperplasia (CAH) - early morning
 17-hydroxyprogesterone level less than 200 ng/dL