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