Polycystic ovarian syndrome (PCOS) is a common cause of infertility affecting 6-20% of women of reproductive age.1
Also once known as Stein-Leventhal Syndrome (1935), PCOS is characterised by an elevated level of male hormones (androgens) and infrequent or absent ovulation (annovulation). Multiple follicles or “cysts” may also (but not always) be present in the ovaries. 2
These changes can lead to a range of hormonal and metabolic effects that can profoundly affect a women’s physical and mental health.
The causes of PCOS are not know however three possible reasons could be:
If your mother or sister has PCOS then this increases the chances that you may have it too.
- Inflammatory response
Women with PCOS may have low-grade inflammation that may increase androgen production. 3
- Excessive levels of insulin.
This hormone secreted by the pancreas acts as a carrier to move sugar (glucose) from the blood stream into body cells where it is utilised for energy production. If the body cells become less sensitive to insulin (i.e. insulin resistant) then the pancreas has to keep producing more insulin to meet the cells energy needs. An excess of insulin can affect the ovaries directly by increasing androgen levels.
As the androgens (e.g.testostrone) increase this leads to:
- Irregular periods
- Excess hair growth (Hirsutism) on the face and body
- Weight gain
- Acne and oily skin
- Increased libido
- Increased muscle bulk
- Deepening voice
- Smaller breasts and size of uterus
- Hair loss
Hormonal changes affecting ovulation
Rising levels of androgens interrupt the normal monthly menstrual cycle.
In a normally healthy ovary, an egg is developed to maturity and then released in a process known as ovulation, for possible fertilisation. Hormones released by the pituitary gland, luteinizing hormone (LH) and follicle stimulating hormone (FSH) aid this ovulation process.
In the case of PCOS an imbalance in the levels of FSH and LH disrupts the egg development and it fails to mature. The follicle surrounding the egg fills with fluid forming a cyst which can measure between 2-6mm in diameter. Overtime multiple cysts can cover the ovary and in 75% of cases the ovaries become enlarged.1
Metabolic changes associated with PCOS
Elevated levels of androgens also lead to changes in metabolic pathways:
- Insulin resistance raises blood glucose levels and the risk of developing Type 2 diabetes is greater in women with PCOS.4
- Weight gain is common and an increased risk of obesity has been found in 50% of women with PCOS. The greater the BMI, the greater the insulin resistance.5,6
- Metabolic syndrome, which is characterised by increased visceral (abdominal) fat ( waist circumference >89cm in women); elevated lipids (triglycerides >1.7mmol/L) lower levels of (protective) HDL cholesterol (<1.3 mmol/L in women) ; elevated blood glucose (5.6mmol/L or higher) and blood pressure (130/85mm Hg), is greater in overweight or obese women with PCOS than non-PCOS sufferers.7,8
- There is a greater risk of cardiovascular disease, atherosclerosis and hypertension.9,10
- Overweight or obese women with PCOS are at greater risk of obstructive sleep apnoea and sleep disordered breathing compared to normal controls. This, coupled with insulin resistance, will lead to feelings of fatigue.11
- Women with PCOS who go on to conceive are at a greater risk of developing complications such as gestational diabetes; pre-eclampsia; cesarean delivery and pre-term and post -term delivery. Their new born are also more at risk of being large for gestational age but not at increased risk of still birth or neonatal death.12
- Women with PCOS share many of the risk factors associated with the development of endometrial cancer e.g. obesity, hyperinsulinism, diabetes and abnormal lipid levels.12
Persistent changes in metabolic and hormonal balance can lead some PCOS sufferers to develop psychological disturbances.
- Women with PCOS have reported a lower quality of life with greater feelings of depression and anxiety compared with healthy controls and these need to be screened for before PCOS treatment is given.13
- The evidence that PCOS is associated with eating disorders is very weak. While those with Bulimia Nervosa do have irregular periods PCOS is not necessarily the cause.14
- Women taking Valproate to control bipolar disorder or epilepsy have been reported with a greater prevalence of menstrual irregularity, PCO and PCOS compared to women taking other medication and healthy controls however more studies are needed.15
Symptoms can occur in childhood or adolescence and continue throughout a womans life varying in the degree of severity depending on her age and changes in body weight.
Your doctor will check these symptoms; conduct a pelvic examination to check for growths, masses and other abnormalities; organise blood tests and possibly also an ultrasound to check the ovaries and thickness of the lining of the uterus.1
While there is no cure for PCOS it is very important that symptoms are treated as they occur to prevent long-term health problems. A Dietitian can provide women with considerable help to manage all the metabolic issues.
Clinical tests of overweight and obese women with PCOS have found weight loss of 5-10% can improve serum lipids; serum testosterone and sex hormone binding globulin; glucose tolerance and fasting insulin; hirsutism; ovulation and menstrual cycle regularity.16
In severe cases of obesity, bariatric surgery has resulted in substantial weight loss and marked improvement in biochemical abnormalities, hirsutism, menstrual cycle regulation and improved fertility but more trials are needed.17
There has been hot debate recently regarding the proportion of macronutrients protein, fat and carbohydrate to the speed of weight loss. In the case of PCOS trials using moderate protein, controlled carbohydrate with low glycaemic index (GI) foods, healthy fats and controlled energy levels has improved weight, fertility and better insulin sensitivity in lean and overweight women with PCOS.18
Using blood lipid profiles a Dietitian can help women to modify their diet to suit. Broadly speaking this will involve replacing unhealthy saturated, trans and hydrogenated fats with healthier poly and monounsaturated fats, carbohydrate control and a reduction in alcohol consumption.
Blood sugar control
As carbohydrate is important for energy systems in the body it does not need to be eliminated but rather controlled. For this to be successful it is not only a matter of controlling amounts but also the time period of meals.
Avoid skipping meals; eat three meals at regular times and include breakfast; space meals no more than 6 hours apart and if very active a healthy snack may also be needed. Choose low GI foods that are high in fibre and lean protein rich foods.
New Zealand activity guidelines recommend at least 30-60 minutes of exercise per day.19 If you are not active then check with your doctor before starting. If you are already active consider changing your routine and trying new activities that are fun.
Keep track of your mood
Some women with PCOS experience fluctuations in their mood, anxiety and depression. If this affects you then discuss this with your doctor.
There is insufficient evidence that taking dietary supplements will benefit PCOS symptoms in fact some herbal supplements may contain active ingredients that interfere with the action of medication given to control insulin sensitivity and blood lipid levels. In the case of vitamin D, folate, calcium and omega 3 fatty acids these nutrients can be improved through a healthy diet so talk to your GP about a blood test to check the levels of these nutrients.20
Dietitian’s are trained to design dietary programs to assist the management of PCOS symptoms so do discuss this with your doctor and contact us for a full nutritional assessment and dietary advice .
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10 tips to prevent weight gain in marriage
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- Conway G, Dewailly D, Diamanti-Kandarakis E, Escobar
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- Didier Dewailly Marla E. Lujan Enrico Carmina Marcelle I. Cedars Joop Laven Robert J. Norman Héctor F. Escobar-Morreale. Definition and significance of polycystic ovarian morphology: a task force report from the Androgen Excess and Polycystic Ovary Syndrome Society. Hum Reprod Update (2013) 20 (3): 334-352.
- Gonzalez F. Inflammation in polycystic ovary syndrome underpinning of insulin resistance and ovarian dysfunction. Steroids March 2012; 77 (4); 300-305. http://www.sciencedirect.com/science/article/pii/S0039128X11003485
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- Lim SS, Davies MJ, Norman RJ, Moran LJ. Overweight, obesity and central obesity in women with polycystic ovary syndrome: a systematic review and meta-analysis Hum Reprod. Update 2012 Nov-Dec:18(6):618-37 Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/22767467
- Lim SS, Norman RJ, Davies MJ, Moran LJ. The effect of obesity on polycystic ovary syndrome: a systematic review and meta-analysis. Obes Rev. 2013 Feb;14(2):95-109. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/23114091
- Moran LJ, Misso ML, Wild RA, Norman RJ. Impaired glucose tolerance, type 2 diabetes and metabolic syndrome in polycystic ovary syndrome: a systematic review and meta-analysis. Hum Reprod Update. 2010 Jul-Aug:16(4):347-63. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/20159883
- Panidis D, Macut D, Tziomalos K, Papadakis E, Mikhailidis K, Kandaraki EA, et al. Prevalence of metabolic syndrome in women with polycystic ovary syndrome. Clin Endocrinol. 2013 Apr;78(4):586-92. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/22888988
- Shi Y, Cui Y, Sun X, Ma G, Ma Z, Gao Q, Chen ZJ. Hypertension in women with polycystic ovary syndrome: prevalence and associated cardiovascular risk factors. Eur J Obstet Gynecol Reprod Biol. 2014 Feb;173:66-70. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/24368020
- Wild RA, Rizzo M, Clifton S, Carmina E. Lipid levels in polycystic ovary syndrome: systematic review and meta-analysis. Fertil Steril. 2011 Mar: 95(3):1073-9. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/21247558
- Vgontzas AN, Legro RS, Bixler EO, Grayev A, Kales A, Chrousos GP. Polycystic ovary syndrome is associated with obstructive sleep apnea and daytime sleepiness: role of insulin resistance. J Clin Endocrinol Metab. 2001;86(2):517-20. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/11158002
- Qin JZ, Pang LH, Li MJ, Fan XJ, Huang RD, Chen HY. Obstetric complications in women with polycystic ovary syndrome: a systematic review and meta-analysis. Reprod Biol Endocrinol. 2013 Jun 26;11:56.
- Janssen OE1, Hahn S, Tan S, Benson S, Elsenbruch S. Mood and sexual function in polycystic ovary syndrome. Semin. Reprod Med. 2008 Jan:26 (1):45-52. Abstract available from:https://www.ncbi.nlm.nih.gov/pubmed/18181082
- 14 Michelmore KF, Balen AH, Dunger DB. Polycystic ovaries and eating disorders: are they related? Hum Reprod. 2001;16(4):765-9. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/11278230
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- Asemi Z, Samimi M, Tabassi Z, Shakeri H, Sabihi SS, Esmaillzadeh A. Effects of DASH diet on lipid profiles and biomarkers of oxidative stress in overweight and obese women with polycystic ovary syndrome: a randomized clinical trial. Nutrition. 2014 Nov-Dec;30(11-12):1287-93. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/25194966
- MOH Physical Activity 2007
- Many more references relating to diet are available on request