Polycystic Ovarian Syndrome

Amy Mendez, MPH, RD, LD

Registered Dietitian

What is PCOS?

• The most common endocrine disorder affecting women of childbearing age

• 5-20% of reproductive age women

Knochenhauer,et al. J Clin Endocrinol Metab. 1998;83;3078-3082.

Presenting problems

• Oligomenorrhea or Amenorrhea

• Hyperandogenism side effects– Hirsutism– Acne– Male pattern balding

• Infertility

• Obesity/weight gain

http://pcosinfo.com/wp-content/uploads/2008/12/hair-loss2.jpg

PCOS diagnosis

• 2003 PCOS Consensus Workshop new diagnostic criteria (need at least 2 of 3)– Hyperandrogenism (clinical or serum)

• Ex: testosterone

– Chronic Anovulation (avg menses >45 days)– PCOS ovaries on ultrasound

• Exclude other diseases

Long term risks of PCOS

• Type 2 DM- 17-45% incidence

• Dyslipidemia

• Endometrial Cancer

• Hypertension -39% incidence

• MI- risk factors predict 7 fold increase

• Gestational DM- 17-38% incidence

• Pregnancy Induced Hypertension- 14% incidence

• Ovarian Cancer

Hyperandrogenism

Insulin Resistance

Unlikely that the insulin resistance is a result of the hyperandrogenism

• IR remains after BSO

• Pre-pubertal women with acanthosis nigricans are hyperinsulinemic several years before hyperandrogenism occurs

• Some women with point mutations in the insulin receptor have been shown to have PCOS

• Normal men have androgen concentrations 10-30 fold higher than women, yet they do not demonstrate insulin resistance

Elevated Insulin levels

• Studies show that women with PCOS have higher insulin levels than obese controls

• Chang et al, 1983 showed that non-obese PCO pts had higher basal and serum insulin levels than controls

Type 2 Diabetes

Undiagnosed DM IGT

PCOS 7.5% 31.1%

PCOS-non obese 1.5% 10.3%

Age-matched US women 1% 7.8%

Gambineri et al. Diabetes 53(9), 2353-2358.

Metabolic Syndrome:

ATP lll Definition Risk Factor Defining Level• Blood pressure 130 or > 85 mm Hg

• Fasting glucose 100 mg/dL

• TG 150 mg/dL

• HDL-C– Men 40 mg/dL– Women 50 mg/dL

• Waist circumference– Men 102 cm (40 in)– Women 88 cm (35 in)

Ford ES et al. JAMA. 2002;287:356-359.

Therapies for hyperinsulinemia

• Weight loss (obese PCOS)

• Insulin Sensitizers– Troglitozone (Rezulin)– Metformin (Glucophage)– Rosiglitazone (Avandia)– Pioglitazone (Actos)

• Dietary therapies

DPP: Benefit of diet + exercise or metformin on diabetes prevention in at-risk patients

Diabetes Prevention Program (DPP) Research Group. N Engl J Med. 2002;346:393-403.

Years

N = 3234 with IFG and IGT, without diabetes

0

0

10

20

30

40

1.0 2.0 3.0 4.0

Placebo

Metformin

Lifestyle

Cumulative

incidence of diabetes

(%)

31%

58%

P*

<0.001

<0.001

*vs placebo

IFG = impaired fasting glucose

Effect of weight loss

• Diet-induced weight loss of 12.4 kg in 13 obese, insulin-resistant women with PCOS improved: – Fasting insulin – Peak insulin– Insulin AUC– Insulin Sensitivity

Dietary Composition

• 45 women with PCOS

• Randomized to: – high protein (HP; 40% carb, 30% protein;

n=14)– Low protein (LP; 55% carb, 15% protein; n=14

• 12 weeks energy restriction, 4 wk maintenance

High Protein vs Low Protein

• Improvements seen for both groups:– Pregnancies– Menstrual cyclicity– Lipid profile– Insulin resistance– Weight– Abdominal fat

• HP group: HDL remained consistent, LP group: HDL dropped during weight loss

At this time, no clear evidence that diet composition has significant

benefits over the weight loss itself

Reactive Hypoglycemia

• 64 lean women with PCOS

• 50% prevalence of reactive hypoglycemia– Altuntas, et al. Eur J Obstet Gynecol Reprod Biol 2005

• Would a low glycemic load diet pattern be effective to reduce post-prandial hyperinsulinemia?

• Would this dietary pattern reduce “carbohydrate cravings?”

Low Glycemic Load Diet

A.M. Herriot et al. J Human Nutr Dietetics 2008

• 88 patients with PCOS referred for nutrition counseling

• Retrospective audit of records at RD and MD visits

•Subjective reports of hunger and carbohydrate cravings improved

Additional benefits of protective

dietary pattern

Amy Mendez, MPH, RD, LD

Registered Dietitian

843-876-4795

mendeza@musc.edu