1. Polycystic Ovarian Syndrome
Amy Mendez, MPH, RD, LD
Registered Dietitian

2. 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;

3. Presenting problems Oligomenorrhea or Amenorrhea
Hyperandogenism side effects
Hirsutism
Acne
Male pattern balding
Infertility
Obesity/weight gain

5. 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

6. 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 % incidence
Pregnancy Induced Hypertension- 14% incidence
Ovarian Cancer

7. Hyperandrogenism Insulin Resistance

8. 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 fold higher than women, yet they do not demonstrate insulin resistance

9. 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

10. 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),

12. 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
102 cm (40 in)
88 cm (35 in)
The metabolic syndrome is becoming increasingly more common, currently affecting an estimated 47 million American adults.1 It is characterized by a constellation of metabolic risk factors that include abdominal obesity, atherogenic dyslipidemia, hypertension, and glucose intolerance, as well as prothrombotic and proinflammatory states.2 The diagnosis of metabolic syndrome is made when 3 main risk determinants are present.
Of note, some men develop multiple metabolic risk factors when their waist circumference is increased only marginally (eg, 94–102 cm, or 37–39 in). Such individuals may have a strong genetic contribution to insulin resistance. They should benefit from lifestyle changes that are similar to those recommended for men with categorical increases in waist circumference.
The ATP III panel did not find adequate evidence to recommend routine measurement of insulin resistance (eg, plasma insulin), proinflammatory state (eg, high-sensitivity CRP), or prothrombotic state (eg, fibrinogen or PAI-1) in the diagnosis of metabolic syndrome.
References
1. Ford ES, Giles WH, Dietz WH. Prevalence of the metabolic syndrome among US adults: findings from the Third National Health and Nutrition Examination Survey. JAMA. 2002;287:
2. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002;106:
Ford ES et al. JAMA. 2002;287: 12

13. Therapies for hyperinsulinemia
Weight loss (obese PCOS)
Insulin Sensitizers
Troglitozone (Rezulin)
Metformin (Glucophage)
Rosiglitazone (Avandia)
Pioglitazone (Actos)
Dietary therapies

15. 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
<0.001
Cumulative
incidence of diabetes
(%)
31% 20
Lifestyle
<0.001
58%
DPP: Benefit of diet + exercise or metformin on diabetes prevention in at-risk patients 10
1.0
2.0
3.0
4.0
Years
*vs placebo
IFG = impaired fasting glucose
Diabetes Prevention Program (DPP) Research Group. N Engl J Med. 2002;346: 15

16. 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

17. 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

18. 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

19. At this time, no clear evidence that diet composition has significant benefits over the weight loss itself

20. 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?”

21. 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

22. Additional benefits of protective dietary pattern

23. Amy Mendez, MPH, RD, LD Registered Dietitian 843-876-4795 23

25. Surgical options “Ovarian Drilling”
One study showed 87% of study participants conceived within 2 years…

26. PCOS Treatment, not desiring fertility
Weight reduction of 10% to start
Lipid management- statin if necessary
Oral contraceptives to regulate cycles
Add spironolactone if hirsutism a problem after 6 months.