Introduction
Polycystic ovary syndrome (PCOS), a complex gynaecological endocrine and metabolic disorder, is characterized by polycystic ovarian morphology (PCOM), infrequent ovulation or anovulation, clinical or biochemical hyperandrogenism, and at least 2 of 3 features are needed to establish a diagnosis [
1,
2]. PCOS is also associated with several metabolic disturbances, such as insulin resistance (IR), increased risk of type 2 diabetes mellitus (T2DM) and obesity [
1,
3]. The prevalence of PCOS is between 8 and 13% according to the population studied and the definitions used [
4].
Studies have found that metabolic factors play important roles in PCOS pathological mechanisms. Some PCOS related genes were found to be related to carbohydrate metabolism and steroid synthesis pathway [
5]. Metabolic imbalance could lead to PCOS development [
6]. Several studies have shown that PCOS patients have abnormal metabolite composition, including bile acids, short-chain fatty acids and branched-chain amino acids [
7,
8]. In addition, gut microbiota (GM) dysbiosis was also found in PCOS development. The GM plays a key role in human and animal health, and maintains a dynamic balance to prevent the development of various diseases. In recent years, evidence has been provided on the correlation between the GM and the development of metabolic diseases, such as obesity and T2DM [
9], which accordingly leads to the hypothesis that the GM is closely associated with the aetiology and pathological mechanisms of PCOS [
6,
10,
11]. Many studies have investigated this relationship. For example, compared with healthy women, PCOS patients had lower α diversity of the GM, which correlated with the increase in androgens [
12]. Sun et al. found that plasma dimethylamine, a product of choline metabolism by the GM, was significantly increased in PCOS patients, demonstrating that GM growth was increased in the group of women with PCOS [
13]. In addition, it seems that abnormal short-chain fatty acid (SCFA) metabolism caused by an abnormal GM is associated with IR and hyperandrogenaemia in PCOS patients [
14]. These studies have confirmed the close relationship between the GM, metabolites and PCOS.
Over 50% of PCOS cases are overweight [
15]. Evidence implies that obesity worsens some features of PCOS, such as infertility, hyperandrogenaemia and IR [
16‐
18]. Obesity prevention and treatment will benefit patients with PCOS [
18]. Weight loss is the first-line treatment for overweight women with PCOS [
19]. Orlistat, an anti-obesity drug approved by the U.S. FDA, has been used to improve or reverse the pathological characteristics of PCOS [
20]. Kumar et al. found that orlistat in PCOS is as effective as metformin in reducing weight with improvement in the lipid profile and pregnancy rates [
21]. Orlistat could also combine with a low-calorie diet to improve IR and reduce circulating androgens [
22]. There is relatively little research on the mechanism by which orlistat improves PCOS. Considering the relationship between the GM, metabolites and PCOS, in the current study, we therefore aimed to compare the characteristics of the gut microbiota and their metabolite profiles between the PCOS and ORL-PCOS groups, which could help to better understand the mechanism of the effect of orlistat on PCOS.
Discussion
Orlistat exerts an anti-obesity effect by inhibiting the absorption of triglycerides. Multiple clinical studies have proven its effect on weight loss [
27,
28]. A recent study found that orlistat treatment has beneficial effects on body weight in HFD-induced obese mice by modifying the composition of the gut microbiota, presenting as reduced total microbial abundance and obviously upregulated bacteria [
29]. In addition, 5% weight loss of initial body weight has been shown to increase ovulation frequency and fertility, and to improve testosterone and lipid levels in PCOS patients [
30‐
32]. In this study, the gut microbiota and its metabolite profiles were first compared between PCOS mice and orlistat-treated PCOS mice, highlighting the critical role of microbiota and microbiota metabolites in controlling PCOS development, which could help to better understand the interaction between orlistat and PCOS.
Studies have shown that the gut microbiota is related to obesity or PCOS, and several phyla of microbiota may be involved in the occurrence and development of obesity or PCOS [
14,
29,
33].
Firmicutes and
Bacteroidetes are the two most abundant bacterial phyla in the human gut [
34]. It has been found that the fecal community of obese mice/humans or PCOS patients/mouse models is characterized by an increased ratio of
Firmicutes to
Bacteroidetes (F/B) [
35‐
37]. Changes in the F/B ratio were found during PCOS treatment. For example, Lin et al
. observed a reduced abundance of
Firmicutes and an elevated abundance of
Bacteroidetes in response to sleeve gastrectomy in a dehydroepiandrosterone-induced PCOS rat model [
38]. Additionally, flaxseed oil intervention modulated the gut microbiota and ameliorated PCOS in rats by decreasing the ratio of F/B [
39]. A recent study found that orlistat could further decrease the F/B ratio in HFD-induced obese mice, exerting beneficial effects on body weight [
29]. Consistently, in this study, we also found that the ORL-PCOS had significant changes in the composition of the gut microbiota, such as an increase in the abundance of
Bacteroidetes and a decrease in
Firmicutes.
Bacteroidetes exert immunomodulatory effects on the host, and its elevation has been shown to be associated with weight loss in humans and animal models [
40,
41]. Additionally, the
Bacteroides genus belonging to the
Bacteroidetes phylum was negatively associated with T2DM [
42].
Firmicutes, which is closely related to obesity and metabolic syndrome, play a role in energy resorption and facilitate fat storage in the host body [
11]. A previous study showed that orlistat is a reversible gastric and pancreatic lipase inhibitor and could promote weight loss by partially preventing intestinal fat absorption [
43]. Weight loss is associated with changes in the gut microbiota [
44]. Therefore, we speculated that orlistat may exert beneficial effects on body weight by modifying the gut microbiota, such as the decreased abundance of
Firmicutes, which may help reduce fat storage and weight loss.
At the family level, we observed that orlistat treatment led to a significant decrease in the relative abundance of
Ruminococcaceae and
Lactobacillaceae, and an elevation of
Muribaculaceae and
Bacteroidaceae. Previous studies have found that the relative abundance of
Ruminococcaceae was higher in obese patients with PCOS and letrozole-induced PCOS rat models [
37,
45,
46]. Furthermore, the
Ruminococcaceae abundance was reported to be associated with diabetes and testosterone levels. Mokkala et al. revealed that the relative abundance of
Ruminococcaceae increased twofold in women with gestational diabetes compared to healthy controls [
47]. The
Ruminococcus genus can increase inflammatory cytokine production, which is positively associated with T2DM [
42]. Eyupoglu et al. reported that
Ruminococcaceae appears to be associated with clinical androgen excess in patients with PCOS [
45].
Lactobacillaceae can ferment carbohydrates, including pectin and glucose, to produce formic acid, lactic acid, acetic acid and ethanol. Although
Lactobacillaceae is commonly used as a probiotic, studies have shown that
Lactobacillaceae is positively correlated with weight gain, and a higher level of
Lactobacillaceae was detected in obese children and adults than in lean control individuals [
48,
49], suggesting that the effect of
Lactobacillaceae on metabolism may be species and strain specific [
50]. Moreover, a significantly increased relative abundance of the
Lactobacillus genus was observed in PCOS with insulin resistance rat models [
46]. A lower level of
Lactobacillaceae could alleviate obesity in HFD-induced obese mice. Ye et al. suggested that ripened pu-erh tea serves as a great candidate to alleviate obesity by increasing the abundance of
Bacteroidaceae,
Muribaculaceae and decreasing the abundance of
Lactobacillaceae in HFD-induced obese mice [
51], which is consistent with the results of the present study.
Bacteroidaceae could promote cytokine production and have a potential role in inhibiting autoimmune disease [
51]. Obese adolescents with PCOS had a lower relative abundance of the family
Bacteroidaceae, which conferred a 4.4-fold higher likehood ratio of taxa predictive of PCOS diagnosis [
52].
Muribaculaceae could degrade dietary components and polysaccharides to produce short chain fatty acids (SCFAs) that play key roles in anti-inflammatory and glycolipid homeostasis balance [
53]. PCOS has been proven to be a chronic inflammatory disease, and obesity, insulin resistance, T2DM and hyperandrogenemia are common symptoms [
26]. In the present study, we speculated that orlistat may improve the above PCOS symptoms by changing the gut microbiota composition, indicating that these bacteria might be the most efficient taxa contributing to preventing the development of PCOS.
Lipid metabolism is dysregulated in women with PCOS. Lipids are involved in various metabolic pathways, such as steroid hormone biosynthesis, and fatty acid metabolism [
54]. In this study, based on the KEGG enrichment analysis, steroid hormone biosynthesis was the pathway in which the differential metabolites were most significantly enriched, such as DHEAS, dihydrotestosterone (DHT), progesterone and tetrahydrocorticosterone. The levels of DHEAS and DHT were significantly downregulated 0.40-fold and 0.16-fold respectively in orlistat treated PCOS mice compared with the control group. Correlation analysis revealed that both were negatively correlated with the abundance of
Bacteroides, and positively correlated with the abundance of
Ruminococcaceae_UCG_014,
Ruminococcaceae_UCG_005 and
Pseudomonas. In a study on the fecal metabolites and gut microbiota in obese patients with PCOS, several fecal metabolites were used as characteristic metabolites, including DHEAS, which was significantly and positively correlated with the serum testosterone level and negatively correlated with body mass index (BMI) or fasting insulin among PCOS patients [
26,
55]. DHEAS is a kind of androgen mainly secreted by the adrenal cortex, and found to be high in 22–25% of patients with PCOS [
56]. Higher DHEAS could increase incidence of degenerated oocytes and early miscarriage rates in women with PCOS [
57]. In addition, the prevalence of adrenal hyperandrogenaemia, which is defined as elevated circulating DHEAS levels, in women with PCOS is 15% to 45% [
58]. Similar to DHEAS, the concentration of DHT, a potent androgen, was significantly higher in PCOS patients [
59]. The DHT-induced PCOS model is one of the three typically used androgen-based PCOS models [
60]. DHT exposure could cause the key reproductive characteristics (aperiodic, anovulatory and multifollicular ovaries) and metabolic characteristics (increased body weight and visceral adiposity) of PCOS [
61]. Moreover, in this study, the level of progesterone was significantly upregulated by 6.74-fold in orlistat treated PCOS mice. Progesterone was positively correlated with the abundance of
Bacteroides, and
Desulfovibrio and negatively correlated with the abundance of
Ruminococcaceae_UCG_014 and
Ruminococcaceae_UCG_005 by correlation analysis. Progesterone is a key steroid hormone and is absolutely required for uterine implantation, decidualization, and maintenance of pregnancy [
62]. PCOS women have lower progesterone levels during the luteal phase which overstimulates the immune system that produces more estrogen [
63]. The chronic anovulation seen in PCOS implies long-term oestrogen excess or a lack of progesterone [
64]. PCOS is a state of altered steroid hormone production and activity, and there is a close relationship between gut microbiota and sex hormones in PCOS [
65]. Therefore, we speculated that orlistat may modify the gut microbiota of obese rats with PCOS, which has an impact on sex hormones, including decreased levels of DHEAS, and DHT and increased progesterone levels, to improve the steroid hormone state in PCOS.
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