Centre for Reproductive Medicine, St. Bartholomew's Hospital, London, UK.
Barts and the London School of Medicine, Queen Mary University of London, London, UK.
Hum Reprod Update. 2019 Mar 1;25(2):243-256. doi: 10.1093/humupd/dmy045.
Polycystic ovary syndrome (PCOS) is a major contributor to subfertility, diabetes and cardiovascular disease in women. The role of non-pharmacological interventions to prevent these outcomes has been reported in many systematic reviews, but robust conclusions have not been made due to variations in the scope, quality and findings of these reviews.
Our aim was to provide an overview of existing evidence on the effects of non-pharmacological interventions in women with PCOS on fertility and non-fertility outcomes by a review of existing systematic reviews.
We reviewed systematic reviews of randomized trials that have evaluated the effects of non-pharmacological interventions, such as lifestyle interventions, nutritional supplements or alternative medicine therapies in women with PCOS on fertility, endocrine, glycaemic and weight-related outcomes. We assessed the quality of systematic reviews with the AMSTAR tool, and reported the outcomes with regard to: fertility (live birth, clinical pregnancy, ovulation and menstrual cycle regularization); endocrine outcomes (Ferriman-Gallwey score, free androgen index, free testosterone and total testosterone levels); and glycaemic (fasting blood insulin, fasting blood glucose, homoeostatic model assessment) and weight-related (BMI) outcomes. We assessed the strength of evidence for significant outcomes as per the grading of recommendations assessment, development and evaluation (GRADE) system.
We found twelve eligible systematic reviews which included between three (143 women) and 27 randomized trials (2093 women). Four reviews assessed the effects of lifestyle interventions (diet, physical activity and/or behavioural interventions); four evaluated nutritional supplements (one each on n-acetylcysteine, omega-3 fatty acids, inositol and vitamin D); and four studied alternative medical therapies (Chinese herbal medicine and acupuncture). All of the included reviews were of high quality and scored between 8 and 11 with the AMSTAR tool (with a maximum score of 11).Randomized evidence is lacking for live birth rate. N-acetylcysteine, inositol and the addition of alternative medicine to ovulation induction agents show preliminary potential to improve fertility (odds ratios (OR) for clinical pregnancy rate range from 1.99 to 4.83). Lifestyle interventions show benefits in improving hirsutism (mean difference (MD): -1.01 to -1.19). Lifestyle interventions (MD: -1.10 to -2.02), inositol (MD: -2.1) and acupuncture (MD: -1.90 to -3.43) all show some evidence of improvement in glycaemic outcomes and there is some evidence of reduced BMI with lifestyle interventions (MD: -0.15 to -1.12). All of these outcomes scored either low or very low quality of evidence on the GRADE score.
Lifestyle interventions in women with PCOS appear to improve glycaemic results, androgenic symptoms and anthropometric outcomes. The role of inositol and N-acetylcysteine in women with PCOS needs further evaluation. Large primary trials on all interventions are needed for an agreed set of core outcomes.
多囊卵巢综合征（PCOS）是导致女性不孕、糖尿病和心血管疾病的主要原因。许多系统评价已经报道了非药物干预措施预防这些结果的作用，但由于这些评价的范围、质量和结果存在差异，因此没有得出可靠的结论。
我们的目的是通过综述现有的系统评价，概述非药物干预措施对 PCOS 女性生育和非生育结局的影响。
我们综述了评估生活方式干预、营养补充剂或替代医学疗法对 PCOS 女性生育、内分泌、血糖和体重相关结局影响的随机试验的系统评价。我们使用 AMSTAR 工具评估系统评价的质量，并报告以下方面的结果：生育结局（活产、临床妊娠、排卵和月经周期正常化）；内分泌结局（Ferriman-Gallwey 评分、游离雄激素指数、游离睾酮和总睾酮水平）；以及血糖相关（空腹胰岛素、空腹血糖、稳态模型评估）和体重相关（BMI）结局。我们根据推荐评估、制定和评价（GRADE）系统对有显著意义的结局进行证据强度评估。
我们发现了 12 项符合条件的系统评价，其中包括 3 项（143 名女性）和 27 项随机试验（2093 名女性）。4 项评价了生活方式干预的效果（饮食、体力活动和/或行为干预）；4 项评估了营养补充剂的效果（分别为 N-乙酰半胱氨酸、ω-3 脂肪酸、肌醇和维生素 D）；4 项研究了替代医学疗法（中药和针灸）。所有纳入的综述均为高质量，使用 AMSTAR 工具评分在 8 到 11 分之间（最高得分为 11 分）。目前尚无关于活产率的随机证据。N-乙酰半胱氨酸、肌醇和将替代医学添加到排卵诱导剂中显示出改善生育能力的初步潜力（临床妊娠率的比值比范围为 1.99 至 4.83）。生活方式干预在改善多毛症方面有获益（均数差值：-1.01 至-1.19）。生活方式干预（均数差值：-1.10 至-2.02）、肌醇（均数差值：-2.1）和针灸（均数差值：-1.90 至-3.43）均显示出改善血糖结局的一些证据，并且生活方式干预显示出降低 BMI 的一些证据（均数差值：-0.15 至-1.12）。所有这些结局在 GRADE 评分上的证据质量均为低或极低。
PCOS 女性的生活方式干预似乎改善了血糖结果、雄激素症状和人体测量学结局。肌醇和 N-乙酰半胱氨酸在 PCOS 女性中的作用需要进一步评估。需要针对所有干预措施开展大型原始试验，以确定一套商定的核心结局。
