Semaglutide alleviates ovarian ferroptosis in polycystic ovary syndrome and is associated with reduced GPX4 promoter hypermethylation.

Polycystic ovary syndrome (PCOS) is associated with ovarian granulosa cell dysfunction. Ferroptosis, a regulated cell death driven by lipid peroxidation, represents a novel pathological mechanism. Hypermethylation of the glutathione peroxidase 4 (GPX4) promoter may contribute to its suppression. While glucagon-like peptide-1 receptor agonists (GLP-1 RAs) improve metabolic features of PCOS, their direct effects on ovarian ferroptosis and the underlying epigenetic mechanisms are unclear. To explore the therapeutic potential of GLP-1RAs across PCOS phenotypes, we employed a hyperandrogenism-induced rat model and a letrozole plus high-fat diet mouse model, treating them with exenatide or semaglutide, respectively. Phenotypic assessment included estrous cycle monitoring, ovarian histology, and serum hormone profiling. Ferroptosis was evaluated using a multi-parametric approach, including iron deposition (Perls' staining), lipid peroxidation (MDA), redox status (GSH/GSSG), ultrastructural analysis (TEM), and expression of key regulators. The methylation status of the GPX4 promoter was analyzed by methylation-specific PCR (MSP) and bisulfite sequencing (BSP), alongside the expression of related epigenetic modifiers (DNMTs, TET1). In vitro studies using DHT-stimulated primary granulosa cells further validated the semaglutide effects. GLP-1 RA exenatide alleviated the polycystic ovarian morphology in rats with PCOS, semaglutide treatment not only alleviated PCOS phenotypes but also reversed ovarian ferroptosis markers, restored GPX4 expression, and reduced the GPX4 promoter hypermethylation and DNMTs levels, with efficacy comparable to 5-azacytidine. In vitro, semaglutide corrected DHT-induced GPX4 hypermethylation and ferroptosis in granulosa cells. This study demonstrates that semaglutide alleviates PCOS phenotypes and reverses ovarian granulosa cell ferroptosis. These beneficial effects may be related to the alleviation of GPX4 promoter hypermethylation. Our findings extend the therapeutic rationale for semaglutide in PCOS beyond metabolic benefits, suggesting potential direct ovarian protection via epigenetic modulation.