What is PCOS?

Polycystic ovary syndrome (PCOS) is a common endocrine disorder and is one of the more common causes of sub-fertility.

PCOS is believed to affect 4-21% of people with ovaries depending on the population and criteria used to diagnose.

Typically the Rotterdam Criteria is used to establish a diagnosis which requires two of the following three key features:

1. Oligo or an-ovulation.

 

2. Clinical and/or biochemical hyperandrogenism.

This means high sex hormones; either via blood test or by symptoms such as acne, hirsutism (course, dark facial or body hair), hair loss from the scalp (particularly the centre/crown).

 

3. Polycystic ovaries on ultrasound.

The cause of PCOS is not fully understood, it is a condition with a strong genetic component; 20-40% of folx with a first degree relative with PCOS will develop PCOS themselves (compared to 4-6% in the general population) [1].

Signs & Symptoms of PCOS

Reproductive Metabolic Psychological/Emotional

Hyperandrogenism

Acne

Hirsutism (facial/body hair)

Oligomenorrhea or amenorrhea

Oligo-ovulation or an-ovulation

Infertility

Insulin Resistance (IR)

Impaired glucose tolerance

Type 2 Diabetes Mellitus

Increased cardiovascular risk profiles

Dyslipidemia

Altered fibrinolytic (blood clotting) system.

Dysthymia / Mood disorders

Self-esteem

Lower reported QoL

Symptoms vary with age

PCOS is often described in relation to reproductive years with intervention focussing on concerns such as menstrual or ovulatory disturbances impacting fertility. However it has become increasingly recognised that PCOS is a health concern across the life-span and that the effects are experienced in a number of different ways as we age. It’s important to keep in mind that PCOS is complex and presents differently from person to person, you may find that your experience of PCOS is unique.

Hyperandrogenic features (think acne, hirsutism, hair loss) are most prominent in adolescents (not shown in image above).

Reproductive features typically dominate during reproductive years, and fertility concerns are prominent in folx in their 20s & 30s, particularly if oligo or an-ovulation is a symptom – more on this below.

Metabolic challenges increase with ageing and will typically dominate the clinical picture from around the onset of menopause.

Psychological & emotional concerns (such as low mood, anxiety, body image concerns and eating disorders) may present challenges at any time in the life span.

Note there are variations in symptoms based on ethnicity too, for example folx from Asian communities present with fewer hyperandrogenic dermatologic features, such as acne, hirsutism and hair loss, and with more pronounced metabolic challenges – independent of weight gain/status.

Indigenous folx, appear to share in both a higher prevalence and degree of clinical severity of PCOS.

The literature fixates on a propensity to weight gain for folx across the lifespan – we will explore this in the adiposity and PCOS section below.

 

Fertility Challenges & PCOS

It’s important to note that fertility is not always impaired or inevitable and that there are many folx who conceive and maintain a pregnancy through to birth despite a diagnosis of PCOS. 

40% of folks with PCOS will have fertility challenges and it is thought that 80% of folks with anovulatory fertility challenges have PCOS [2,3].

Folks who have PCOS and oligo- or amenorrhoea are likely to require induction of ovulation, and in these circumstances the sooner appropriate treatment for induction of ovulation is sought, the better the chances of a timely pregnancy [4].

On the matter of seeking weight loss prior to IVF, a recent systematic review and meta-analysis evaluating the effect of weight loss via lifestyle intervention in folks at higher BMI bands with anovulatory conditions shows no benefit of weight loss interventions  (including dietary restriction and exercise alone or combined) on IVF conception rates and should therefore not be used as a hurdle to or withholding of treatment [5].

With that in mind, family planning considerations such as seeking to conceive (where possible and practical, unassisted or assisted) before the ages of 30-35 years is recommended [3].


Cardiovascular risk

PCOS is associated with increased risk for cardiovascular disease, however it’s unclear if the risk is from PCOS itself (the combined effects of insulin resistance, dyslipidemia/high cholesterol, and central adiposity) or other established CVD risk factors such as family history, hypertension, age, cigarette smoking and physical inactivity [1].

Prevalence of high blood pressure in folx with PCOS is increased and unassociated with BMI, further supporting the growing evidence that cardiometabolic abnormalities appear to be independent of weight status. (For those interested in the how….  Aldosterone is the hormone responsible for maintaining blood pressure. PCOS is associated with higher circulating aldosterone when compared to age- and BMI-matched controls. Hyperinsulinemia accompanying insulin resistance may also affect blood pressure via autonomic system stimulation)[1,6].

Interestingly, subclinical markers for cardiovascular disease (ie. not cardiovascular disease but signs of early stages) such as coronary artery calcium scores, c-reactive protein, carotid intima-media thickness and endothelial dysfunction are more likely to be increased in folx with PCOS, however there remains conflicting evidence as to whether PCOS independently increases the risk of clinical cardiovascular disease [1].

The take home here is… “PCOS should be considered a significant risk factor for CVD, regardless of BMI” [1]. 

Don’t panic! However, it is worthwhile engaging in heart health screening regularly – that’s blood tests and a GP review every 1-3 years depending on age and previous history of dyslipidemia (“high cholesterol”). 

We will explore what we can do with lifestyle approaches to promote heart health in the next post – Part 2: Nutrition considerations & caring for PCOS.

 

adiposity and PCOS

Increased central adiposity appears to impact the experience of PCOS – mediating reproductive and metabolic symptoms as well as intersecting with mental and emotional wellbeing.  I won’t go into PCOS, adiposity and mental health here – because that’s an entire post in itself, but I do want to stress that much of the conversation we are having in this space squares the blame of emotional and psychological distress at body size, body dissatisfaction and “self esteem”. We simply are not talking about weight stigma, harassment and oppression and the profound affect trauma (mediated by the three) have on health.

It is also important to keep in mind that because reproductive symptoms may be more severe for folx at higher weight who therefore present for diagnosis and treatment more frequently, “contributing to an over-exaggeration of the association between ob*sity and PCOS” [6] .

The relationship between body weight and PCOS is often discussed in the context of high BMI exacerbating PCOS symptoms. 

However little air time is given to the evidence that the propensity to accumulate adipose tissue/increasing adiposity may be a symptom of PCOS itself. 

How? (It’s important to note here that the IR in PCOS is mechanistically different to that we associate with high BMI) Insulin resistance which is present in up to 75% of folx with PCOS leads to high levels of circulating insulin. This in turn stimulates ovarian steroid production and inhibits the production of sex hormone binding globulin in the liver → the result is increased circulating free androgens / hyperandrogensim. Chronic exposure to free androgens appears to be involved in the accumulation of central adipose tissue. Adipose tissue is an important storage and metabolic site for various lipid-soluble steroids, such as androgens, contributing to hyperandrogenism [1,6].

There appears to be a propensity for accumulation of central adipose tissue, for folks with PCOS and this in part may be explained by metabolic factors intrinsic to PCOS itself – insulin resistance, reduced post-prandial thermogenesis (heat produced after a period of eating – think of this as how busy your body is getting) and basal metabolic rate (think of this as “baseline metabolism”).

In interpreting the information about PCOS and body weight we should be mindful that there is considerable variability in adiposity in folx presenting with PCOS, varying by geographic location and ethnicity.

For example, in the following countries women with PCOS were noted to have a BMI higher than 30: 

Spain – 20%

China – 43%

Italy – 38%

United States – 69%

Interestingly, Asian women who experience more metabolic features of PCOS (less hyperandrogenic dermatologic features) also appear to do so independent of weight gain/status [8].

What does this mean in practice? 

If we don’t know if the chicken came before the egg, or the egg before the chicken, then it begs the question why are we hedging lifestyle intervention on modifying a chicken when the egg may very well precede… analogies aside…

The evidence is unclear on whether the association between PCOS and higher weight (and the propensity to acquire central adiposity) goes one way or another or if indeed the relationship is interconnected and goes both ways!? Yet, despite this we continue to seek weight loss as a first line intervention. With very little success might we add!

Furthermore, a summary of (widely referred to) evidence and development of guidelines in the assessment and management of PCOS sought to answer the following clinical question [7]:

“In women with PCOS, are diet interventions (compared to no diet or different diets) effective for improving weight loss, metabolic, fertility, and emotional wellbeing outcomes?

Evidence-based recommendations:

5.3a Weight loss should be targeted in all [folx] with polycystic ovary syndrome and body mass index 25 kg/m2 (overw*ight) through reducing dietary energy (caloric) intake in the setting of healthy food choices, irrespective of diet composition. — level C.

5.3b Prevention of weight gain should be targeted in all [folx] with polycystic ovary syndrome through monitored caloric intake, in the setting of healthy food choices, irrespective of diet composition. — level D.”

In short – the evidence is low quality and often relies on consensus of opinion from within the profession. We also know that trying to lose weight is not only unlikely for most, many more folks actually increase their weight in the process.

When we look at the evidence used to support statements such as “weight loss of approximately 5-10% improved metabolic and reproductive symptoms of PCOS” this statement is based on highly heterogeneous research methods and outcome measures [7,8]. 

Conclusion

PCOS is highly complex endocrine condition affecting many folx with ovaries in our community. PCOS presents with highly variable symptoms impacting reproductive, metabolic and psychological/emotional domains of health. 

The focus of lifestyle interventions remains weight management, despite long term weight loss and maintenance being unsuccessful for the majority and with risk of harm to individuals including yo-yo dieting, weight cycling, development of disordered eating or an eating disorder.

Folx with PCOS do appear to have increased risk for the development of a number of health concerns, with particular attention given to reproductive and fertility challenges in earlier years giving way to a shifting focus to cardiovascular and metabolic health (in relation to CVD and type two diabetes mellitus). Commencing regular and early screening for cardiovascular risk factors and HbA1c, with engagement in accessible health promoting behaviours (discussed in the follow up post) might be where the most gains are to be made for folx caring for PCOS independent of intentional weight loss.

Coming Next

Part 2: Nutritional and lifestyle considerations when caring for PCOS (The Non-Diet Edition).

Part 3: Review of the current evidence for supplements and PCOS.

References

[1] Osibogun O, Ogunmoroti O, Michos ED. Polycystic Ovary Syndrome and Cardiometabolic Risk: Opportunities for Cardiovascular Disease Prevention. Trends in cardiovascular medicine. 2019 Sep 4.

[2] Artini, P. G., Obino, M. E. R., Sergiampietri, C., Pinelli, S., Papini, F., Casarosa, E., & Cela, V. (2018). PCOS and pregnancy: a review of available therapies to improve the outcome of pregnancy in women with polycystic ovary syndrome. Expert Review of Endocrinology & Metabolism, 13(2), 87–98. doi:10.1080/17446651.2018.1431122 

[3] Teede H, Deeks A, Moran L. Polycystic ovary syndrome: a complex condition with psychological, reproductive and metabolic manifestations that impacts on health across the lifespan. BMC Med. 2010;8:41.

[4] Franks S. How should I counsel a young woman with PCOS about fertility?. InSociety for Endocrinology BES 2016 2016 Oct 14 (Vol. 44). BioScientifica.

[5] Best D, Avenell A, Bhattacharya S. How effective are weight-loss interventions for improving fertility in women and men who are overw*ight or ob*se? A systematic review and meta-analysis of the evidence. Human reproduction update. 2017 Nov 1;23(6):681-705.

[6] Lim SS, Davies MJ, Norman RJ, Moran LJ. Overw*ight, ob*sity and central ob*sity in women with polycystic ovary syndrome: a systematic review and meta-analysis. Human reproduction update. 2012 Jul 4;18(6):618-37.

[7] Teede HJ, Misso ML, Deeks AA, Moran LJ, Stuckey BG, Wong JL, Norman RJ, Costello MF, Guideline Development Groups. Assessment and management of polycystic ovary syndrome: summary of an evidence‐based guideline. Medical Journal of Australia. 2011 Sep;195:S65-112.

[8] Moran LJ, Pasquali R, Teede HJ, Hoeger KM, Norman RJ. Treatment of ob*sity in polycystic ovary syndrome: a position statement of the Androgen Excess and Polycystic Ovary Syndrome Society. Fertility and sterility. 2009 Dec 1;92(6):1966-82.

ABOUT THE AUTHOR

Jessica Campbell BSc PgDip, is a Non-Diet Nutritionist & Medical Student passionate about weight inclusive healthcare practices, eating disorder prevention & therapies.

Jess has stepped out of clinical nutrition work and now supports the team in group practice providing food and body positive nutrition and dietetic care and eating disorder recovery services in person and online New Zealand wide.

 

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