Polycystic Ovarian Syndrome (PCOS) is a multifaceted endocrine metabolic condition impacting about 5-10% of women throughout their reproductive lifespan. It is influenced by neuroendocrine dysfunction, insulin resistance, chronic low-grade inflammation, and ovarian oxidative stress. Existing medications, including metformin, clomiphene citrate, and anti-androgens, provide only limited advantages and are frequently restricted by side effects such as gastrointestinal intolerance, teratogenic risks, and weight gain. NAE (family Lamiaceae) is a fragrant perennial herb indigenous to the Himalayan and sub-Himalayan areas of Pakistan and Afghanistan. Phytochemical profiling of this plant has revealed high concentrations of flavonoids (luteolin, apigenin, quercetin), phenolic acids (rosmarinic and caffeic acid), terpenoids (nepetalactones), and glycosides. In a preclinical study lasting 30 days that involved Letrozole induced PCOS in Albino Wistar rats, the oral delivery of crude extract (350 and 500 mg/kg) and its methanol/butanol fractions (64 mg/kg; 12.5mg/kg) significantly restored estrous cyclicity, decreased serum LH and testosterone levels, normalized the LH/FSH ratio, enhanced insulin sensitivity (reduced HOMA IR), corrected dyslipidaemia, and reversed ovarian histopathological alterations. Molecular analysis by qRT PCR showed upregulation of IL 4 and downregulation of AR, CYP-17, TLR4, TNF α, and NF κB. Based on this multi targeted preclinical efficacy and a favourable safety profile, this clinical trial will assess the safety and effectiveness of a standardised NAE in women with PCOS, compared to metformin and combination therapy over 4 months.

Polycystic Ovarian Syndrome indicates an increasing health challenge for women of reproductive age, with global prevalence estimates between 6% and 14%. Individuals affected often experience psychological distress, metabolic issues, and difficulties with fertility. The pathophysiology of PCOS consists of three interrelated axes: (i) heightened GnRH pulse frequency results in an increased LH/FSH ratio and theca cell hyperplasia, driving ovarian hyperandrogenism; (ii) peripheral insulin resistance coupled with compensatory hyperinsulinemia further enhances ovarian androgen production; and (iii) chronic oxidative stress and inflammation, driven by cytokines from adipose tissue (TNF α, IL 6) and reactive oxygen species, which hinder follicular development and exacerbate metabolic dysfunction.

Traditional first-line therapies - metformin (insulin sensitizer), clomiphene citrate (ovulation stimulant), and spironolactone (anti-androgen) - each address only a single facet of the syndrome and have notable drawbacks: metformin can lead to dose-dependent gastrointestinal issues; clomiphene elevates the risk of multiple pregnancies and presents anti-estrogenic side effects; spironolactone is teratogenic and is unsuitable for women attempting to conceive. Additionally, none of these agents concurrently tackle hyperandrogenism, insulin resistance, inflammation, and oxidative stress.

Herbal remedies provide a multifaceted, multi-target strategy that corresponds effectively with the intricate pathophysiology of PCOS. NAE shows considerable potential. Its flavonoid fraction (luteolin, apigenin, quercetin) acts as a free radical scavenger, inhibits lipid peroxidation, enhances endogenous antioxidant enzymes (superoxide dismutase, glutathione peroxidase), and down regulates 17α hydroxylase, thereby reducing ovarian testosterone production. The phenolic acids (caffeic acid, rosmarinic acid) inhibit pro-inflammatory cytokines TNF α and IL 6, while improving insulin sensitivity through the enhancement of GLUT 4 translocation in adipose tissue and skeletal muscle. Terpenoids (nepetalactones) influence the hypothalamic pituitary gonadal axis, aiding in the normalization of the LH/FSH ratio, while also offering anxiolytic effects that might alleviate stress-related hormonal disturbances. Glycosides and reducing sugars enhance insulin receptor signaling, stimulate hepatic glycogen production, and block gluconeogenic enzymes like glucose 6 phosphatase.

These mechanistic predictions were confirmed in a carefully regulated animal study. PCOS was established in female Albino Wistar rats through Letrozole (1 mg/kg) given orally dissolved in 0.5% carboxymethylcellulose (CMC) for 21 days. The animals were split into 07 categories, which included untreated control, PCOS control, metformin standard (350 mg/kg), crude NAE (low dose 350 mg/kg, high dose 500 mg/kg), methanol fraction (64 mg/kg), and butanol fraction (12.5 mg/kg), given orally for 30 days. Essential discoveries comprised:

• Hormonal: Significant reduction in serum LH and total testosterone, with normalisation of the LH/FSH ratio (p < 0.01).
• Metabolic: Decreased fasting blood sugar, reduced HOMA IR, enhanced lipid profile (lowered total cholesterol, triglycerides, LDL; raised HDL).
• Ovarian structure: Normal follicular arrangement on H&E staining.
• Gene expression: qRT PCR of ovarian tissue showed an increase in the anti-inflammatory cytokine IL-4, whereas androgen receptor (AR), toll-like receptor 4 (TLR4), Cytochrome-17 (CYP-17), tumor necrosis factor α (TNF-α), and nuclear factor κB (NF-κB) were significantly decreased.

No mortality or signs of hepatorenal toxicity were observed at any dose. Considering this strong preclinical evidence, the current clinical trial aims to apply these results to human PCOS patients. The research will recruit 116 women diagnosed with PCOS according to Rotterdam criteria and having insulin resistance (HOMA IR > 2.00). Participants will be assigned randomly to three parallel groups: (1) NAE extract 500 mg two times a day; (2) metformin XR 750 mg two times a day; (3) a combination of both. The duration of the treatment is 4 months. The main goal is the reestablishment of normal ovulatory menstrual cycles (21-35 days) verified by ultrasound. Secondary outcomes consist of alterations in serum LH, FSH, testosterone, HOMA IR, HbA1c, Fasting Insulin, Body weight, and quality of life specific to PCOS (PCOSQOL). Safety will be assessed via the recording of adverse events, tests for liver and kidney function, and a comprehensive blood count.

Inclusion Criteria:

• Female subjects of reproductive age (18-40 years).
• Subjects with a diagnosis of polycystic ovary syndrome (PCOS) confirmed by clinician diagnostic criteria (Rotterdam criteria).
• Subjects with insulin resistance defined as HOMA-IR > 2.00.

Exclusion Criteria:

• Pregnant or lactating women.
• Subjects with known Cushing's syndrome.
• Subjects with late-onset congenital adrenal hyperplasia.
• Subjects with androgen-secreting tumors.
• Subjects with uncontrolled thyroid disease.
• Subjects with hyperprolactinemia.
• Subjects with diabetes mellitus.
• Subjects with uncontrolled hypertension.
• Subjects with other cardiovascular diseases.
• Subjects with acute or chronic infections.
• Subjects with any known malignancy.
• Subjects with impaired renal function (serum creatinine > 1.5 × ULN).
• Subjects with impaired liver function (serum ALT ≥ 2.5 × ULN).

Female subjects in reproductive age (18-40 years)

Individual participant data will not be shared due to privacy and confidentiality concerns of study participants, and because the study is not funded by external agencies requiring data sharing.

The study record explicitly states it is open-label, meaning no participants, care providers, investigators, or outcome assessors are blinded