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
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 1030 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%
1%
7.8%
Age-matched US women
Gambineri et al. Diabetes 53(9), 2353-2358.
Metabolic Syndrome:
ATP lll Definition
Risk Factor
• Blood pressure
Defining Level
130 or > 85 mm Hg
• Fasting glucose
100 mg/dL
• TG
150 mg/dL
• HDL-C
– Men
– Women
40 mg/dL
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
N = 3234 with IFG and IGT, without diabetes
40
Placebo
P*
30
Metformin
31%
Cumulative
incidence 20
of diabetes
<0.001
Lifestyle
58%
<0.001
(%)
10
0
0
1.0
*vs placebo
IFG = impaired fasting glucose
2.0
3.0
4.0
Years
Diabetes Prevention Program (DPP) Research Group.
N Engl J Med. 2002;346:393-403.
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
• 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
A.M. Herriot et al. J Human Nutr Dietetics 2008
Additional
benefits of
protective
dietary
pattern
Amy Mendez, MPH, RD, LD
Registered Dietitian
843-876-4795
mendeza@musc.edu