Conditions: PCOS
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 12
Healthy volunteers: no

Brief summary:
To exam in the effect of a combination of low dose Metformin and Spironolactone on functional brain MRI, menstrual regulation and metabolism in adolescents with PCOS.

Detailed description:
Polycystic Ovarian Syndrome (PCOS) is the most common endocrinopathy in adolescent females and also one of the most complex. Patients experience an exaggerated ovarian/adrenal androgen production in response to physiologic and supra-physiologic elevations in insulin. The hormonal dysregulation is not only associated with acne, hirsutism, and menstrual irregularity, but also with perpetuated insulin resistance, central adiposity, and clinical depression.

In the proposed study, we aim to treat a hormonally and metabolically well-defined group of adolescent girls with PCOS with a combination of two pharmacological agents: metformin (insulin sensitizer) and spironolactone (anti-androgen) for 6 months. Although hyperandrogenism is a fundamental component of PCOS and responsible for the perpetuation of insulin resistance, adiposity and anovulation, there are few pediatric studies that have examined the benefits of treating both insulin resistance and hyperandrogenism simultaneously. Preliminary studies in adults, however, suggest synergistic effect of both spironolactone and metformin (spiro-met) with near normalization of the metabolic and ovulatory dysfunction. Therefore, we hypothesize that spiro-met will improve adolescent metabolism, body composition, ovarian morphology/function. We anticipate that our study will generate key pilot data for further randomized, double blind placebo controlled trials using both agents.

We also plan to examine functional brain MRI before and after the spiro-met intervention. This will allow us to inspect the effects of the hyperinsulinemic/androgenic hormonal milieu in PCOS on structural and functional brain MRI. We hypothesis, that the hormonal environment in PCOS affects centers of appetite and mood.

Arms:
arm 1: Treatment with Metformin and Spironolactone

Interventions: intervention 1: Metformin and Spironolactone
Intervention descriptions: intervention 1: Oral Metformin tablet (500 mg/tablet) twice daily for 6 months. Oral Spironolactone tablet (50 mg/tablet) once daily for 6 months.

Protocol document:
Prot_SAP_000.pdf: 
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Version 17Jan2019 
 
 
 
Metabolic and Neuro-Endocrine Effect of Treating 
PCOS in Adolescents 
 
 
IRB#: 16010020 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Tania Burgert 
Pediatric Endocrinology 
Children’s Mercy Hospitals & Clinics 
Kansas City, MO 
 


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TABLE OF CONTENTS 
 
INTRODUCTION/LITERATURE REVIEW 
 
 
 
 
 
Page 3 
 
STUDY PROTOCOL 
 
 
 
 
 
 
 
 
Page 4 
 
STUDY AIMS  
 
 
 
 
 
 
 
 
Page 5 
 
POPULATION  
 
 
 
 
 
 
 
 
Page 5 
INCLUSION CRITERIA 
EXCLUSION CRITERIA 
 
RECRUITMENT 
 
 
 
 
 
 
 
 
Page 6 
 
INFORMED CONSENT  
 
 
 
 
 
 
 
Page 7 
 
DATA COLLECTION  
 
 
 
 
 
 
 
Page 8 
 
PHONE CALL 
 
STUDY VISIT 
 
 
 
 
 
 
 
 
 
 
MISCELLANEOUS CONSIDERATIONS 
 
 
 
 
 
Page 11 
ADVERSE EVENTS 
BENEFITS TO PARTICIPANTS 
REIMBURSEMENT 
CONFIDENTIALITY 
 
HYPOTHESES  
 
 
 
 
 
 
 
 
Page 12 
 
STATSITCAL CONSIDERATIONS 
 
 
 
 
 
 
Page 12 
 
DATA ANALYSIS 
 
 
 
 
 
 
 
 
Page 12 
 
SAMPLE SIZE  
 
 
 
 
 
 
 
 
Page 12 
 
DATA DISCLOSURE/PUBLICATION 
 
 
 
 
 
 
Page 13 
 
STUDY RESOURCES  
 
 
 
 
 
 
 
Page 13 
ESTIMATED COST 
RESEARCH STAFF TIME 
 
STUDY TIMELINE 
 
 
 
 
 
 
 
 
Page 14 
 
REFERENCES  
 
 
 
 
 
 
 
 
Page 15 
 
APPENDIX A 
 
 
 
 
 
 
 
 
 
Page 17 
 


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RESEARCH PLAN  
 
A) SPECIFIC AIMS 
 
Treatment recommendations for polycystic ovary syndrome (PCOS) in adolescent girls are based on very few studies and 
mainly expert opinion.1 Therefore more studies are needed on therapeutic regimens that improve the wellbeing of 
adolescent girls suffering from this condition. Targeted intervention that addresses the core metabolic disturbance in 
PCOS may also provide much needed information about the interconnectivity between signs, symptoms, and diagnostic 
parameters. The current proposal will provide preliminary data on a novel treatment paradigm for adolescent PCOS as 
well as important pilot information on neuro-endocrine connection in PCOS.   
 
Hypothesis:  A 6-month trial of synergistic combination drug therapy with low dose insulin sensitizer (metformin) and 
anti-androgen (spironolactone) will significantly improve metabolic profile and clinical manifestations of PCOS in 
adolescents.  
 
Specific Aim 1: To examine the effects of a 6-month drug intervention with combined low dose metformin (500mg orally 
BID) and spironolactone (50 mg orally QD) in adolescent PCOS on biochemical markers of insulin resistance such as the 
whole-body insulin sensitivity index (WBISI). The WBISI will be calculated from glucose and insulin values obtained 
during the oral glucose tolerance testing (OGTT) before and after drug intervention.    
While improving insulin resistance is an important metabolic target, most patients are concerned with central 
adiposity, which is linked to insulin resistance. To this end, studies have demonstrated reduction in body mass 
index (BMI), and an improvement in waist-hip circumference in women treated with metformin 2. Therefore, 
secondary treatment outcomes will not only include lipid profile and other biochemical markers of PCOS but also 
include changes in body composition as assessed by bio-impedance scale.  Further clinical outcome measures will 
include menstrual cycle regularity, ovarian morphology changes as assessed by trans-abdominal ultrasound, 
hirsutism scores and resting blood pressure.   
 
Specific Aim 2: To examine structural and functional brain changes associated with adolescent PCOS before and after 
drug intervention designed to improve insulin resistance.  
In adolescents, improving insulin resistance with metformin was recently attributed to reduced food intake with 
decreased perceived hunger 3. Therefore, our second aim may lead to a mechanistic understanding of why 
adolescent with PCOS often improve BMI with improved insulin resistance. Indeed, it has been postulated that 
insulin resistance not only affects diabetes and cardiovascular disease but exerts a significant impact on central 
nervous system (CNS) function regarding neuro-functional responses to food-related cues. Insulin resistant 
women with PCOS show a differential brain response to glucose challenge testing. These authors hypothesize this 
could lead to increased caloric intake and eating past the point of satiety (non-homeostatic eating) 4. Since food 
intake is also a function of mood, a standard depression questionnaire will be administered. 
 
 
B) BACKGROUND AND SIGNIFICANCE 
 
PCOS is the most common and complex endocrinopathies in the female population. At the core of the condition lies an 
exaggerated ovarian/adrenal androgen production in response to physiologic and supra-physiologic elevations in insulin. 
Clinically, this hyperandrogenism is linked to acne, hirsutism, and menstrual irregularity. Additionally, hyperandrogenism 
positively feeds back onto insulin resistance, thereby perpetuating hyperinsulinemia. This becomes a vicious cycle, and it 
is this perpetuated insulin resistance that is deemed responsible for the detrimental metabolic sequelae of PCOS. Adverse 
outcomes include Type 2 diabetes, cardiovascular disease, depression, and obstructive sleep apnea (OSA). Adolescent 
PCOS treatment focuses on treating insulin resistance (i.e., metformin) with or without symptomatic/cosmetic relief 
through oral contraceptive hormones. However, studies seeking significant metabolic improvement by targeting both 
hyperandrogenism and insulin resistance are lacking.  
 
Without treating hyperandrogenism in PCOS patients, insulin resistance remains. This is because the driving force behind 
the metabolic downward spiral is not shut down. Therefore, simultaneously targeting both insulin resistance and 
hyperandrogenism should be highly effective in improving biochemical markers of insulin resistance in adolescents with 


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PCOS. Indeed, reports in adolescents 5 indicate that hyperandrogenism is an important treatment target in the goal of 
improving metabolic health parameters. A recent study in adult women with PCOS demonstrated that the drug 
combination of low dose anti-androgen (spironolactone) and low dose insulin sensitizer (metformin) is superior to either 
drug alone in improving all metabolic parameters of PCOS 6. Remarkably, the metformin dose and spironolactone dose 
used in this study was lower than the usual recommended dose for mono-therapy in adolescents with PCOS.  
 
Spironolactone has been used for decades as a potassium sparing diuretic and was found to have anti-androgenic effect in 
the 1970’s 7. Its anti-androgenic effect is carried out through a dual mechanism of androgen receptor blockade, and via 
spironolactone’s inhibition of 5-alpha reductase, thus reducing the conversion of testosterone to its biologically more 
potent metabolite, di-hydrotestosterone. The concern with studying spironolactone in adolescent girls has always been the 
potential effect of the drug to under-virilize a male embryo through transplacental exposure of the drug, should an 
unplanned pregnancy occur. However, unlike the widely prescribed OC, spironolactone does not pose a serious health risk 
(i.e thrombo-embolic events) to the patient herself 8 and therefore is the safer drug for the subject, especially if she is 
overweight and has a family history of thrombo-embolism events.  Furthermore, a recent study in adolescent girls with 
hirsutism, demonstrated that a carefully designed study does not need to preclude adolescents from receiving anti-
androgen therapy 9. In this study, adolescent girls with hirsutism were treated with the potent anti-androgen finasteride for 
6 months and were not on oral contraceptive pills. In our proposed study, risk will be reduced by precluding sexually 
active teens from partaking in the study.  Furthermore, all participants, even if not sexually active will be required to take 
a monthly pregnancy test for the duration of the study.  This would likely safeguard against any inadvertent exposure of a 
male conceptus to spironolactone, as study drug would be discontinued immediately in the event of a positive pregnancy 
test.  Lastly there has been a case report on a young woman treated with spironolactone (200-400mg daily) throughout 
each of her pregnancies due to Bartter Syndrome. In the case description she delivered two normal male infants and one 
normal female10. At the time of the report one of the males had entered puberty at a physiologic time. While the 
teratogenic concern remains based on some, but not all animal studies11,12 carefully selected subjects and stringent 
protocol adherence should allow this very beneficial drug to be examined in adolescents with PCOS.  
 
Metformin is well known for its insulin sensitizing effect at the level of the liver and its beneficial effect on diabetes 
prevention 13. In a double- blind placebo-controlled study in obese youth the principal investigator of the current proposal 
has shown that metformin is well tolerated in youth and has beneficial effects on BMI and autonomic control of the heart 
14. Metformin use, especially in adolescents, is becoming an increasingly preferred treatment over oral contractive pills 
unless the patient is sexually active. In their 2013 guidelines on treating PCOS in adolescents, the Endocrine Society 
states that metformin has shown to restore menstrual regularity, improve hyperandrogenism and glucose tolerance in 
obese and non-obese patients 1. However, due to a lack of sufficient adolescent studies, the Endocrine Society’s first line 
treatment recommendation remains oral contraceptive pills for PCOS in adolescents.  The safety profile of metformin is 
excellent and the risk for lactic acidosis in patients with normal kidney function is no longer a concern for the medical 
community. Gastrointestinal side effects are not uncommon but can be overcome by taking the metformin with food and 
by starting with a low dose that is incrementally increased, titrated to tolerance.  
 
C) PRELIMINARY STUDIES/EVIDENCE OF CAPABILITY 
 
The principal investigator has a longstanding history in clinical research in the field of adolescent obesity as it relates to 
metabolic and cardiovascular disease. She has specifically performed drug interventions with metformin 14 and studied 
adolescent girls with PCOS 15, giving her great expertise in proposed area of study. She has a track-record of publishing as 
first and senior author and has obtained NIH funding (K23).   
 
At her prior employment she established and directed a successful multi-specialty adolescent PCOS program which 
allowed her to recruit 100 subjects for her study on oral glucose tolerance in adolescents with PCOS. Since her arrival at 
CMH last year, she has recreated a similar program at CMH’s Broadway location. For the program Dr. Burgert has 
established collaborations with adolescent medicine, radiology and nutrition services. All patients seen in her program 
have OGTT and ovarian ultrasound performed at the same day of their initial consultation. Patients and families enjoy the 
“one stop” complete evaluation. This model not only allows for streamline care but also makes it easier to offer studies 
that require these examinations.  
 


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Dr. Burgert is becoming a nationally recognized expert in PCOS and was just selected to give the “Year in Review in 
PCOS” at the upcoming annual PES/PAS meeting.  She has written chapters and reviews on the topic and is the education 
chair for the AES-PCOS society. She recently returned from presenting her data on ovarian ultrasound in adolescent 
PCOS at the AES-PCOS society in Italy.   
 
Dr. Bruce is a licensed clinical psychologist with advanced training in cognitive neuroscience and functional neuro-
imaging. Her laboratory investigates how the human brain weighs risks and benefits of choices about food (i.e. pediatric 
eating behaviors), purchasing decisions (i.e., neuroeconomics), and adherence to medical regimens (i.e., pharmacologic 
interventions in neurologic populations). 
Her research has revealed that obese youth demonstrate differential brain structural and functional profiles when 
compared to healthy weight youth. Specifically, in response to appetitive stimuli including food images, obese children 
exhibiting increased reactivity to food cues in limbic and paralimbic cortical regions16. Equally disconcerting, these 
differences also extend to food advertising cues (i.e., fast food brand logos) with obese children having a more limbic 
response and lean children demonstrating more reactivity in the prefrontal cortex (PFC), a cortical region associated with 
self-control 17. Even in the resting state (without stimulatory food cues) the brain’s neurofunctional connectivity of obese 
children differs from that of lean children, with obese children demonstrate increased connectivity between cortical 
regions associated with reward and valuation. In regards of applying Dr. Bruce’s findings to PCOS, nothing is known 
about neurofunctional response to external appetitive cues in PCOS.  Even less is known as to how pharmacologic 
treatment (i.e. metformin and spironolactone), can directly or indirectly impact brain structure and function.  
 
 
RESEARCH DESIGN AND METHODS 
 
Research Design and Procedures:  
The overall objective of this proposal is to determine if metabolic improvements occurs in adolescents with PCOS after a 
6-month open label intervention with a low dose synergistic drug regimen of metformin (insulin sensitizer) and 
spironolactone (anti-androgen). 
 
 
Initial data will be collected as part of the patient’s routine PCOS health care.  Should a patient consent to the study this 
data will be used as baseline analysis. During the 6- month intervention study the subject will have a safety monitoring 
visit at 3 months into the intervention which will include blood work, complete examination and compliance history. All 
baseline examinations will be covered by insurance. All post intervention biochemical or other testing will be covered by 
study funds and Dr. Bruce’s neuro-imaging start- up funds.  
 
For complete study design:  see flow chart at end of the RESEARCH DESIGN AND METHODS section.   
 
Study Design: 
This is a single center clinical research study to obtain pilot data.  
It is a non-controlled open label drug intervention study in a convenient sample of adolescent girls attending a PCOS 
clinic.   
 
Patients/Subjects: 
The sample will include 20 adolescent females (ages 13-21) of all ethnic backgrounds referred to the CMH adolescent 
PCOS program for evaluation and management of PCOS.  
Patient risks and safeguards are extensively described in PROTECTION OF HUMAN SUBJECTS 
 
Inclusion Criteria: Generally healthy; Meeting Androgen Excess Society (AES) diagnostic criteria of PCOS:  Menstrual 
Dysfunction or PCO ovaries on ultrasound AND clinical or biochemical hyperandrogenism. 
Normal liver and kidney function. No chronic illnesses except for stable, treated hypothyroidism. 
 
Exclusion Criteria: Use of metformin and/or spironolactone within the last 6 months. Currently on either oral hormonal 
contraception or other forms of hormonal contraception such as Depo-ProveraR, NuvaRingR 


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Current or past pregnancy; Currently sexually active; Psychiatric disorder based on self/parental report; type 2 diabetes 
(blood glucose > 200mg/dl on OGTT); Anemia (Hct < 35); Baseline creatinine > 1.0 mg; Abnormal liver transaminases > 
2 x the upper limit of normal range, potassium elevated outside the reference range (in non-hemolyzed blood sample).  
 
Drugs/Experimental Intervention:  
Subjects with receive 6 months combination drug therapy with a combination of low dose metformin and spironolactone.  
 
Intervention – Metformin:  The investigational pharmacy will distribute the metformin. The study dose will be 500 mg/tab 
orally BID, to be taken with food at breakfast and dinner.  In order to improve tolerability of the regimen, the drug will be 
started sub-therapeutically. The first 4 days only ½ tablet will be taken with dinner and then increased to 1 tab for the next 
3 days with dinner. The second week ½ tablet will be added to breakfast for four days and then the next 3 days the 
breakfast dose is increased to 1 tablet. After two weeks the subject will be on 500 mg BID from which time the 6- month 
intervention is counted.  Long term use of metformin may lead to vitamin B12 deficiency.  Therefore, vitamin B12 levels 
will be measured in the study and balanced diet is recommended.  
 
Intervention - Spironolactone: The investigational pharmacy with distribute the spironolactone. The subject will take one 
tablet (50mg/tab orally QD) with breakfast once the metformin dose has been titrated up to 500 mg BID, approximately 2 
weeks into the study. The 6-month intervention counts from the first dose of spironolactone taken.   
 
 
Observation and Measurements: 
 
Whole Body Insulin Sensitivity Index (WBISI): This determinant of insulin sensitivity has been validated against the 
euglycemic clamp as an accurate measure of insulin sensitivity in adolescents by the PI’s former research group.18.The 
WBISI is calculated based on the area under the curve (AUC) for glucose and insulin during an oral glucose tolerance test. 
While the original WBISI (also known as Matsuda Index)19 requires a  3 hour glucose tolerance, calculating the index 
during a 2 hour glucose tolerance test has become common practice with good results 20. 
Procedure: After an overnight fast, an 18-22 gauge intravenous catheter will be placed to allow easy access and minimize 
discomfort during repeated blood sampling. All hormone labs and baseline metabolic labs (including the 0- minute 
glucose and insulin) will be drawn immediately after placement of the indwelling catheter. The subject will be asked to 
drink 8 oz of a cola or orange flavored glucose solution (containing 75grams of glucose) to start the OGTT.  Blood 
sampling during the OGTT will occur at the 30-, 60- and 120- minute time points and include blood for glucose and 
insulin so that the AUC can be calculated for WBISI. The baseline OGTT will be billed to insurance, the post intervention 
OGTT will be covered by study funds. 
 
Ovarian Ultrasound: This ultrasound will be performed trans-abdominally through a full bladder on the same day of the 
OGTT in the Endocrine clinic office on Broadway. The radiology tech will use a portable ultrasound for patient 
convenience. The first ultrasound will be billed to insurance, the post intervention ultrasound will be covered by study 
funds.   
 
Bio-impedance Scale: Body composition will be measured through the bio-impedance scale available in the Endocrine 
Clinic.  
 
Depression Scale: The Hospital Anxiety and Depression (HADS) assessment will be used. The instrument has adequate 
psychometric properties and is considered a valid and reliable tool for screening adolescents for depression.  A member of 
the MAPP research/clinical team has successfully implemented this tool in her examination of overweight insulin-
resistant adolescents 21.  
 
Data Analysis:  
 
Primary Outcome:  Insulin Sensitivity as assessed by the whole- body insulin sensitivity index (WBISI) also known as the 
Madsuda index. This is calculated from the Oral Glucose tolerance test and is a better parameter of insulin sensitivity than 
HOMA (based on fasting glucose and insulin values). 


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Power Analysis: Based on published research studies, a sample size of N = 20 patients per group, shows sufficient power. 
Metformin + Spironolactone group (n = 62):  WBISI improved from 4.7+- 2.71 to 8.04 +- 4.03.   
When the sample size is 20, a paired t-test with a 0.05 two-sided significance level will have 93% power to detect the 
difference between a before treatment WBISI of 4.700 and after-treatment WBISI mean of 8.000, assuming that the 
standard deviation of change in WBISI is 4.0. 
 
PROTECTION OF HUMAN SUBJECTS 
 
Subject Population Recruitment 
 
The study population will include adolescent females (age 13 to 21 years old) referred to Children’s Mercy Adolescent 
PCOS Program.  Prior to her first visit, the patient and her family will receive a letter about the voluntary research studies 
available through the PCOS Program. The patient may decline hearing about our research during her initial visit or any 
visits to the PCOS Program.  If she declines participation, she will continue to receive standard of care in the Adolescent 
PCOS Program. 
 
Medical Information Technology (MIT) will provide a list of qualified candidates.  Potential subjects will be identified 
after a review of medical records through Cerner or other CMH sources (databases, billing records, pathology reports, 
admission logs).  This may involve access to records by individuals not involved in the patient’s care. 
 
All subjects diagnosed with PCOS and treated at the CMH Diabetes Clinic will be identified by ICD-9 diagnostic codes. 
In accordance with 45 CFR 164.512(i)(1)(ii), (see http://www.hhs.gov/hipaafaq/permitted/research/317.html), qualifying 
patients will be identified initially by creation of a PCOS pre-screening log. This information is to be used solely for work 
preparatory to research (in this case the identification of qualifying subjects for targeted screening). No pre-screening 
information will be removed from CMH. This is necessary in order for the investigator, sub-investigator(s) and research 
coordinator(s) to effectively approach the entire clinic population for recruitment into the study. With the assistance of the 
IT department, all current CMH patients with type 1 diabetes [defined by (1) any patient visit tagged the diagnostic codes 
for PCOS from the prior 24 months will be identified. A password-protected pre-screening log of qualifying subjects and 
their next scheduled clinic appointment to the CMH diabetes center will be maintained to aid in subject identification. 
This will be updated quarterly. This will aid the key study personnel in efficiently and effectively attending particular 
clinic days/locations for optimal recruitment. The type 1 diabetes pre-screening log will contain subject names, medical 
record numbers and future clinic dates, as well as coordinator/investigator notes regarding eligibility. The entire screening 
log will be destroyed upon completion of targeted enrollment. 
 
Qualified patients may also be identified by review of the daily clinic schedule, via review of Cerner data and billing 
records provided by MIT.  Whether by phone or in person, only study personnel will give details about the study to 
subjects and families.   
 
At their clinic visit, the study will be explained briefly, and subjects/parents will be asked whether or not they are 
interested in participating.  All interested subjects and parents will have the study (including the risks and benefits) 
thoroughly explained using the written consent.  They will be given copies of the consent to review without staff present, 
in order to allow them time to discuss with each other.  They will be given an opportunity to ask additional questions after 
they have read the consent. If subject and parent agree to participate the appropriate child or adult consent will be signed.  
 
Alternatively, subjects and parents will be given the opportunity to take consents home for further reading, discussion, and 
decision-making at a later date. These families may enroll at their next scheduled visit or another time convenient for 
them. No pressure will be placed on any subject or family to enroll. These families may be contacted by phone to ask if 
they want to participate. 
 
Refusal to participate will be notated in the Research Prescreening Log.  These patients will not be approached additional 
times for participation in this study. 
 
A password-protected pre-screening log of qualifying subjects and their next scheduled clinic appointment to the CMH 
diabetes center will be maintained to aid in subject identification. This will aid the study personnel in efficiently and 


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effectively attending particular clinic days/locations for optimal recruitment. The PCOS pre-screening log will contain 
subject names, medical record number, date of birth, clinic visit date, clinic location, clinic provider appointment time as 
well as coordinator/investigator notes regarding eligibility. For those individuals not interested in participating, the 
minimum amount of PHI will be retained to ensure they are not approached again regarding participation in this study.  
Only their name and MRN will be retained.  The remainder of the information will be deleted from the file.  The entire 
screening log will be destroyed upon completion of targeted enrollment. 
 
INFORMED CONSENT 
 
If the subject is between the ages of 13-21 on the date of the clinic appointment/study visit and parent agree to participate 
in the study, written informed consent/assent will be obtained before the extraction of any CMH EMR data. 
 
Consent/assent will be obtained from research staff at the time of a routine clinical follow-up for T1DM.  The study will 
again be explained to the family/patient and informed consent will be obtained in accordance with CMH Policy, IRB 
Protocols and Health and Human Services Regulation 45 CFR 46.116. 
 
For those patients scheduled to see a provider participating the study, consent/assent and enrollment will be undertaken by 
a research assistant or alternative provider (and not the medical staff participating in the patient’s clinical cares). 
 
If the subject wishes to have more time to consider participating in the study, we will follow-up with a phone call and 
consent them over the phone at that time if they want to participate in the study. 
 
 
DATA Collection 
 
Research material will be obtained through from their medical record for laboratory test results including OGTT, 
anthropometric measures, ultrasound data, vital signs, physical examination, including hirsutism score and birth history, 
medical history, family history and menstrual history will also be collected.  Further materials include a depression score.  


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VISIT FLOW 
 
 
 
 
 
 
 
 
 
Bio-impedance Scale  
BMI, Blood Pressure, Complete 
PE 
Detailed Menstrual History/ 
Family History  
Depression scale 
Nutrition Assessment /Dietary 
Counseling  
Study offered to patients meeting 
inclusion criteria 
Informed consent performed  
OGTT  
Ovarian Ultrasound  
Baseline Hormone Labs  
 
Did not qualify for study 
Declined participation 
The clinical data, bio-
impedance – body 
composition, OGTT, Ovarian 
US and Hormone Labs from 
the first MAPP visit will be 
used for baseline study data 
and entered into study.  
STUDY VISIT 1:  
(Completed after informed 
consent) 
Depression score (HADS) 
Distribution of 3 month supply of 
study drug 
Distribution of 6 urine pregnancy 
test kits 
STUDY VISIT 2:   
Monitor & Compliance Visit (12 
Weeks from Visit 1 +/- 2 weeks) 
Distribution of 2nd 3 month supply 
of study drug 
PE, menstrual Hx, BMI, BP 
Labs: Safety profile: LFTs, CBC, 
Lytes, serum HCG 
STUDY VISIT 3:  
End of Study Visit Part 1 (24 
weeks from Visit 1 +/- 2 weeks) 
OGTT, Hormone labs, safety labs  
Ovarian Ultrasound 
Bio-impedance Scale  
PE, menstrual Hx, BMI, BP 
Depression score (HADS) 
On the first visit to the PCOS 
Program (unless performed within 
the last year) 
First Visit MAPP Clinic Visit 
Continued routine clinical 
management and service as 
MAPP patient  
Twice: at 4 wk and 8 wk time 
point of intervention the study 
coordinator will contact 
subject to discuss compliance 
and inquire about urine 
pregnancy test results.  
Twice: at 16 wk and 20 wk 
time point of intervention the 
study coordinator will contact 
subject to discuss compliance 
and inquire about urine 
pregnancy test results.  


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Risks and Inconveniences:  
 
1.  Phlebotomy/OGTT 
While many patients with PCOS would potentially have an OGTT as part of their regular evaluation, most would not have 
repeat OGTT at 6 months.  The OGTT will require venipuncture/i.v. insertion at the commencement of the OGTT.  This 
can be painful may not succeed on first attempt.  Bruising and tenderness can occur after venipuncture/i.v. insertion.  Some 
also can feel faint or dizzy during venipuncture.  After drinking the standard 75g of glucola on an empty stomach some 
patients may feel nauseated. 
   
2.  Ultrasound  
Transabdominal ultrasound evaluation of the ovaries requires a full bladder which may cause subjects discomfort as they 
are avoiding urination.  Furthermore, pressing the ultrasound probe on a full bladder may be uncomfortable for some.  There 
is no radiation or contrast involved in this test.  
 
3.  Metformin  
The main side effect of metformin is gastrointestinal discomfort such as flatulence, queasiness, and loose bowel movements. 
Metformin therapy can cause malabsorption of vitamin B12 in the distal ileum after long-term use for several years. 
Therefore, vitamin B12 levels will be monitored in the study.  Subjects will be recommended to stay on a well-balanced 
diet. Lactic acidosis is a rare but potentially fatal metabolic consequence of metformin treatment.  However nearly all reports 
of lactic acidosis are related to treatment in a patient in which metformin therapy was contraindicated due to renal and liver 
dysfunction.  In the absence of contraindications lactic acidosis is not of concern in otherwise healthy people.  
 
4. Spironolactone 
In generally this drug is very well tolerated and poses no health risk in low dose. Given that spironolactone is a potassium-
sparing diuretic it may elevate potassium levels in those with underlying kidney disease or excessive potassium intake. In 
the absence of contraindications like renal failure and in a presence of healthy well-balanced diet, spironolactone is unlikely 
to increase potassium levels outside the normal range. Should a subject not maintain a normal hydration status she may feel 
dizzy/lightheaded. This can be avoided by normal fluid intake. The main concern is the potential of this drug to under-
virilize a male conceptus. Therefore, sexually active teenagers are excluded from the study. Nevertheless, every subject will 
be monitored with monthly urine pregnancy tests to assure that the study drug is not continued beyond the first two weeks 
post conception should an unexpected pregnancy occur. Study drugs will be immediately discontinued should a positive 
pregnancy test have occurred.  
 
5. Anxiety and Depression Survey risks: 
The survey asks sensitive questions about mental health.  To reduce discomfort while answering questions, you 
will answer questions in a private room.  Participants are free to not answer any questions.  Confidentiality risks 
are minimal and unlikely to occur. Your child’s confidentiality will be protected to the greatest extent possible.  
If subject reports any concerning symptoms, we will provide referrals and information on how to get help. 
 
Protection of Human Subjects 
 
All studies will be performed under the direct supervision of either the PI or co-investigators.  Phlebotomy discomfort will 
be minimized by personnel skilled in venipuncture of children and obese patients.   
Gastrointestinal side effects with metformin will be minimized by slow incremental dose increases over the course of two 
weeks.  The PI has extensive experience with metformin and has used it in a clinical trial published in 2008. In terms of 
spironolactone treatment, potential subjects will be interviewed separately from their parents with our Adolescent 
Medicine co-investigators regarding their sexual activity.  A patient who is sexually active will be excluded from 
participating in the study. Furthermore, subjects will be counseled on the potential teratogenic effects of spironolactone 
and the requirements of monthly pregnancy tests.  Should a subject not comply with monthly pregnancy testing, then she 
will be discontinued from the study. Should a patient decide to become sexually active during the study, she will also be 


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discontinued from the study. Should a subject’s pregnancy test turn positive then she will be discontinued of both 
intervention drugs. At that point the principal investigator will meet with the IRB to discuss recommendations in terms of 
following pregnancy outcome.    
Prior to commencing spironolactone/metformin the PI will assess kidney functions and examine electrolytes with 
attention to potassium levels. Any abnormalities in one or both of these areas will prohibit entry into the trial.  Subjects 
will be given the number of the principal investigator and the RA.  They will also be given an emergency number that is 
available at all times through the section of Pediatric Endocrinology.  All on call staff will be aware of the study.   
 
Data and Safety Monitoring Plan  
 
The proposed study poses moderate risk to the subjects.  However, it offers the prospect of direct benefits to the subjects.  
The definition of moderate risk is as follows: Risks are recognized as being greater than minimal, but not high, and there is 
adequate surveillance and protections to discover adverse events promptly and to keep their effects minimal. 
 
Attribution of Adverse Events 
 
• 
Definite:  
Adverse event(s) will clearly be related to investigational agent(s) or other intervention. 
• 
Probable:  
Adverse event(s) will likely be related to investigational agent(s). 
• 
Possible:  
Adverse event(s) may be related to investigational agent(s). 
• 
Unlikely:  
Adverse event(s) will doubtfully be related to investigational agent(s). 
• 
Unrelated: 
Adverse event(s) will clearly not be related to the investigational agents(s). 
 
Plan for Grading Adverse Events 
0 
No adverse event or within normal limits 
1 
Mild adverse event 
2 
Moderate adverse event 
3 
Severe adverse event resulting in hospitalization or prolongation of existing hospitalization, a 
persistent or significant disability/incapacity, or a congenital anomaly/birth defect. 
4 
Life-threatening or disabling adverse event 
5 
Fatal adverse event 
 
Plan for Reporting and Reviewing Serious Adverse Events 
 
Serious unanticipated adverse events will be reported immediately to the IRB. Serious anticipated adverse events where 
magnitude or frequency exceeds expectations will be reported to the IRB immediately. 
 
 
 
 
  
The principal investigator will evaluate the adverse event and determine whether the adverse event affects the Risk/Benefit 
ratio of the study and whether modifications to the protocol (at Risks to Subjects, or in Procedures) or consent form (at 
Risks and Inconveniences) are required. 
 
Plan for Reviewing and Reporting Non-Serious Unanticipated and Anticipated Adverse Events. 
 
The principal investigator will conduct a review of all adverse events at the half-way point through the study. The principal 
investigator will evaluate the frequency and severity of the adverse events and determine if modifications to the protocol or 
consent form are required. 
 
A summary of the adverse events will be reported to the IRB periodically or, at minimum, when re-approval of the protocol 
is sought.  The summary will include number of subjects enrolled and a summary of graded adverse events to date.   
 
 
Attribution 
Grade 1 
Grade 2 
Grade 3 
Grade 4 
Grade 5 


Page 12 of 16 
Version 17Jan2019 
UNA
TP 
ATP 
UNA
TP 
ANT 
UNA
TP 
ANT 
UNA
TP 
ANT 
UNA
TP 
ANT 
Unrelated 
 
 
 
 
 
 
 
 
 
 
Unlikely 
 
 
 
 
 
 
 
 
 
 
Possible 
 
 
 
 
 
 
 
 
 
 
Probable 
 
 
 
 
 
 
 
 
 
 
Definite 
 
 
 
 
 
 
 
 
 
 
Totals 
 
 
 
 
 
 
 
 
 
 
Total Subjects Enrolled to Date 
 
 
Data Monitoring and Safety Reviews 
 
The principal investigator (TSB) is responsible for monitoring the data and conducting safety reviews. Either the principal 
investigator or the IRB have the authority to stop or modify the study.   
 
The principal investigator will conduct a data and safety review at least semi-annually or at the time of re-approval and at 
any time a serious adverse event occurs. During the review process, the principal investigator will evaluate whether the 
study should continue unchanged, require modification/amendment, continue or close to enrollment. 
 
Confidentiality  
 
The identification of all subjects will be kept confidential and will not be divulged in any publication emanating from this 
work.  Data will be released only upon written consent of the patient. 
The study will comply with HIPAA guidelines regarding confidentiality of patient data. All data are labeled with a study 
ID, including forms and specimens. All data transferred to the database identify the patient only with the study ID. A file 
on each patient that includes personal identifiers, linking name and contact information to the study ID will be kept.  Patient 
files are kept in secure locations and the clinical center is responsible for taking every other reasonable measure (those set 
by the state, the site, and the study) to ensure and maintain record confidentiality and patient privacy. 
 
 Potential Benefits 
The study may have direct benefit to the subjects. Some subjects may experience clinical benefits with the drug intervention 
such as regularization of menses, reduction in BMI and decrease in acne and hirsutism. Mood may also improve with 
treatment.  
 
 
 
 
 


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REFERENCES 
 
RESEARCH PLAN:  
 
1. 
Legro RS, Arslanian SA, Ehrmann DA, et al. Diagnosis and treatment of polycystic ovary syndrome: an 
Endocrine Society clinical practice guideline. The Journal of clinical endocrinology and metabolism. 
Dec 2013;98(12):4565-4592. 
2. 
Glintborg D, Altinok ML, Mumm H, Hermann AP, Ravn P, Andersen M. Body composition is 
improved during 12 months' treatment with metformin alone or combined with oral contraceptives 
compared with treatment with oral contraceptives in polycystic ovary syndrome. J Clin Endocrinol 
Metab. Jul 2014;99(7):2584-2591. 
3. 
Adeyemo MA, McDuffie JR, Kozlosky M, et al. Effects of metformin on energy intake and satiety in 
obese children. Diabetes, obesity & metabolism. Apr 2015;17(4):363-370. 
4. 
Van Vugt DA, Krzemien A, Alsaadi H, Frank TC, Reid RL. Glucose-induced inhibition of the appetitive 
brain response to visual food cues in polycystic ovary syndrome patients. Brain research. Apr 16 
2014;1558:44-56. 
5. 
Alemzadeh R, Kichler J, Calhoun M. Spectrum of metabolic dysfunction in relationship with 
hyperandrogenemia in obese adolescent girls with polycystic ovary syndrome. European journal of 
endocrinology / European Federation of Endocrine Societies. Jun 2010;162(6):1093-1099. 
6. 
Ganie MA, Khurana ML, Nisar S, et al. Improved efficacy of low-dose spironolactone and metformin 
combination than either drug alone in the management of women with polycystic ovary syndrome 
(PCOS): a six-month, open-label randomized study. J Clin Endocrinol Metab. Sep 2013;98(9):3599-
3607. 
7. 
Stripp B, Taylor AA, Bartter FC, et al. Effect of spironolactone on sex hormones in man. J Clin 
Endocrinol Metab. Oct 1975;41(4):777-781. 
8. 
Shaw JC, White LE. Long-term safety of spironolactone in acne: results of an 8-year followup study. 
Journal of cutaneous medicine and surgery. Nov-Dec 2002;6(6):541-545. 
9. 
Tartagni MV, Alrasheed H, Damiani GR, et al. Intermittent low-dose finasteride administration is 
effective for treatment of hirsutism in adolescent girls: a pilot study. Journal of pediatric and adolescent 
gynecology. Jun 2014;27(3):161-165. 
10. 
Groves TD, Corenblum B. Spironolactone therapy during human pregnancy. American journal of 
obstetrics and gynecology. May 1995;172(5):1655-1656. 
11. 
Hecker A, Hasan SH, Neumann F. Disturbances in sexual differentiation of rat foetuses following 
spironolactone treatment. Acta endocrinologica. Dec 1980;95(4):540-545. 
12. 
Rose LI, Regestein Q, Reckler JM. Lack of effect of spironolactone on male genital development. 
Investigative urology. Sep 1975;13(2):95-96. 
13. 
Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with 
lifestyle intervention or metformin. The New England journal of medicine. Feb 7 2002;346(6):393-403. 
14. 
Burgert TS, Duran EJ, Goldberg-Gell R, et al. Short-term metabolic and cardiovascular effects of 
metformin in markedly obese adolescents with normal glucose tolerance. Pediatric diabetes. Dec 
2008;9(6):567-576. 
15. 
Flannery CA, Rackow B, Cong X, Duran E, Selen DJ, Burgert TS. Polycystic ovary syndrome in 
adolescence: impaired glucose tolerance occurs across the spectrum of BMI. Pediatric diabetes. Feb 
2013;14(1):42-49. 
16. 
Bruce AS, Holsen LM, Chambers RJ, et al. Obese children show hyperactivation to food pictures in 
brain networks linked to motivation, reward and cognitive control. International journal of obesity. Oct 
2010;34(10):1494-1500. 
17. 
Bruce AS, Lepping RJ, Bruce JM, et al. Brain responses to food logos in obese and healthy weight 
children. The Journal of pediatrics. Apr 2013;162(4):759-764 e752. 


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18. 
Yeckel CW, Weiss R, Dziura J, et al. Validation of insulin sensitivity indices from oral glucose 
tolerance test parameters in obese children and adolescents. The Journal of clinical endocrinology and 
metabolism. Mar 2004;89(3):1096-1101. 
19. 
Matsuda M, DeFronzo RA. Insulin sensitivity indices obtained from oral glucose tolerance testing: 
comparison with the euglycemic insulin clamp. Diabetes care. Sep 1999;22(9):1462-1470. 
20. 
DeFronzo RA, Matsuda M. Reduced time points to calculate the composite index. Diabetes care. Jul 
2010;33(7):e93. 
21. 
Platt AM, Egan AM, Berquist MJ, Dreyer ML, Babar G, Ugrasbul F. Health-related quality of life, 
depression, and metabolic parameters in overweight insulin-resistant adolescents. Journal of pediatric 
health care : official publication of National Association of Pediatric Nurse Associates & Practitioners. 
Mar-Apr 2013;27(2):120-126. 
22. 
Ibanez L, De Zegher F. Flutamide-metformin plus an oral contraceptive (OC) for young women with 
polycystic ovary syndrome: switch from third- to fourth-generation OC reduces body adiposity. Human 
reproduction. Aug 2004;19(8):1725-1727. 
23. 
Ibanez L, Diaz M, Sebastiani G, et al. Treatment of androgen excess in adolescent girls: ethinylestradiol-
cyproteroneacetate versus low-dose pioglitazone-flutamide-metformin. The Journal of clinical 
endocrinology and metabolism. Nov 2011;96(11):3361-3366. 
24. 
Ibanez L, de Zegher F. Low-dose flutamide-metformin therapy for hyperinsulinemic hyperandrogenism 
in non-obese adolescents and women. Human reproduction update. May-Jun 2006;12(3):243-252. 
25. 
Burgert TS. Glucose and insulin metabolism in obese youth. Pediatric endocrinology reviews : PER. 
Dec 2006;3 Suppl 4:555-559. 
26. 
Burgert TS, Dziura J, Yeckel C, et al. Microalbuminuria in pediatric obesity: prevalence and relation to 
other cardiovascular risk factors. International journal of obesity. Feb 2006;30(2):273-280. 
27. 
Burgert TS, Taksali SE, Dziura J, et al. Alanine aminotransferase levels and fatty liver in childhood 
obesity: associations with insulin resistance, adiponectin, and visceral fat. The Journal of clinical 
endocrinology and metabolism. Nov 2006;91(11):4287-4294. 
28. 
Bruce AS, Bruce JM, Ness AR, et al. A comparison of functional brain changes associated with surgical 
versus behavioral weight loss. Obesity. Feb 2014;22(2):337-343. 
  
 
 


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Appendix A 
 
 
ULTRASOUND ACQUISITION FOR CMH IRB STUDY 16010020 
 
Before the exam:  
1. Ensure the participant has a semi-full bladder for appropriate resolution.  
 
Right and Left Ovary 
1. Identify ovary in longitudinal plane. Optimize focus and depth.  
2. Place the label (side, plane) in top left hand corner of the screen so it does not obstruct the 
ovary.  
3. Capture a cine loop through the ovary in the longitudinal plane, starting midline and moving 
laterally. 
4. Identify ovary in orthogonal (transverse) plane. Optimize image quality like above.  
5. Capture a cine loop through the ovary in the orthogonal (transverse) plane, starting inferior to 
the ovary moving superior towards the head.   
6. Obtain still images of the ovary in the longitudinal and transverse (orthogonal) planes. 
a. Measure and record the length and width of the ovary in each plane.  
Uterus 
1. Identify the longitudinal plane of the uterus. Optimize focus and depth. Gain can be adjusted, if 
required. 
2. In the midsagittal plane, capture an image of the endometrial lining.  
a. Measure and record the endometrial thickness. 
3. Obtain a cineloop through the uterus in the sagittal plane. 
 
Export the Exam: Entire Participant Exam File – may be performed in bulk or ongoing  
1. Unlock the USB key with the key code/ password and insert it into the drive on the side of the 
ultrasound machine. A blue light will flash on the side of the key to acknowledge that the device has 
been activated. 
 
2. Press the “New Patient Exam” hard key. 
 
3. Click “Archive” from the Patient Archive menu on the left side of the screen.  
 
4. Click “Export” from the Data Transfer menu on the left side of the screen.  
 
5. The Save As screen will appear. 
a. From the “Save in:” drop-down menu, select the USB key. 
b. Type the Participant ID into the “File Name:” field. 
c. From the “Save as type:” drop-down menu, select “dicomdir”  
d. Select “Save.” 
 
 
 
 


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Export files within the Exam: SaveAs 
Note: if sonographers wish to conduct data transfer via this mechanism, a folder on the USB with the 
participant ID will need to be created on the USB prior to the scan.  
1. Unlock the USB key with the key code/ password and insert it into the drive on the side of the 
ultrasound machine. A blue light will flash on the side of the key to acknowledge that the device has 
been activated. 
 
2. Select the image(s) and/or cineloop(s) you wish to transfer. 
 
3. Click the “Save As” icon on the lower left side of the screen.  
 
4. The Save As screen will appear. 
a. From the “Save in archive:” drop-down menu, select the USB key. 
b. From the “Store” options, select the “Image Only” radio button. 
c. From the “Compression:” drop-down menu, select “JPEG” 
d. From the “Quality” drop-down menu, select “100”  
e. From the “Save as type” drop-down menu, select “Raw Dicom” 
f. Select “Transfer.” 
 
 
Eject the USB Key 
1. Push “F3” on the keyboard.  
 
2. Select “Stop Device” on the dialog box. 
 
3. Select “OK” once the device can be safely removed.