TLR4-Associated IRF-7 and NFκB Signaling Act as a Molecular Link Between Androgen and Metformin Activities and Cytokine Synthesis in the PCOS Endometrium

J Clin Endocrinol Metab. 2021 Mar 25;106(4):1022-1040. doi: 10.1210/clinem/dgaa951.


Context: Low-grade chronic inflammation is commonly seen in polycystic ovary syndrome (PCOS) patients with elevated levels of inflammatory cytokines in the endometrium.

Objective: This work aimed to increase the limited understanding of the mechanisms underlying cytokine synthesis and increased endometrial inflammation in PCOS patients.

Methods: Endometrial biopsy samples were collected from non-PCOS (n = 17) and PCOS (n = 22) patients either during the proliferative phase of the menstrual cycle or with hyperplasia. Endometrial explants were prepared from PCOS patients and underwent pharmacological manipulation in vitro. The expression and localization of toll-like receptor 2 (TLR2)/4, key elements of innate immune signal transduction and nuclear factor κB (NFκB) signaling pathways, and multiple cytokines were comprehensively evaluated by Western blotting, immunohistochemistry, and immunofluorescence in endometrial tissues.

Results: We demonstrated the distribution of protein expression and localization associated with the significantly increased androgen receptor, TLR2, and TLR4-mediated activation of interferon regulatory factor-7 (IRF-7) and NFκB signaling, cytokine production, and endometrial inflammation in PCOS patients compared to non-PCOS patients with and without endometrial hyperplasia. In vitro experiments showed that 5-dihydrotestosterone (DHT) enhanced androgen receptor, TLR4, IRF-7, and p-NFκB p65 protein expression along with increased interferon α (IFNα) and IFNɣ abundance. The effects of DHT on IRF-7, p-NFκB p65, and IFN abundance were abolished by flutamide, an antiandrogen. Although 17β-estradiol (E2) decreased p-IRF-7 expression with little effect on TLR-mediated IRF7 and NFκB signaling or on cytokine protein levels, exposure to metformin alone or in combination with E2 suppressed interleukin-1 receptor-associated kinase 4 (IRAK4), p-IRF-7, IRF-7, IκB kinase α (IKKα), p-NFκB p65, IFNɣ, and tumor necrosis factor α protein expression.

Conclusion: Cytokine synthesis and increased endometrial inflammation in PCOS patients are coupled to androgen-induced TLR4/IRF-7/NFκB signaling, which is inhibited by metformin treatment.

Keywords: TLR4/IRF7/NFκB; androgen; endometrial inflammation; innate immune response; polycystic ovary syndrome.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Androgens / pharmacology*
  • Cytokines / biosynthesis
  • Endometrial Hyperplasia / metabolism
  • Endometrial Hyperplasia / pathology
  • Endometrium / drug effects*
  • Endometrium / metabolism
  • Endometrium / pathology
  • Female
  • Humans
  • Interferon Regulatory Factor-7 / metabolism
  • Menstrual Cycle / drug effects
  • Menstrual Cycle / metabolism
  • Metformin / pharmacology*
  • Multiprotein Complexes / metabolism
  • Multiprotein Complexes / physiology
  • NF-kappa B / metabolism
  • Polycystic Ovary Syndrome* / metabolism
  • Polycystic Ovary Syndrome* / pathology
  • Protein Binding
  • Signal Transduction / drug effects
  • Signal Transduction / physiology
  • Toll-Like Receptor 4 / metabolism


  • Androgens
  • Cytokines
  • IRF7 protein, human
  • Interferon Regulatory Factor-7
  • Multiprotein Complexes
  • NF-kappa B
  • TLR4 protein, human
  • Toll-Like Receptor 4
  • Metformin