PCOS Through The Lifecycle

Angela Grassi, MS, RD, LDN Medical Nutrition Therapy for PCOS:
Author of The Dietitian’s Guide to Polycystic • Adult
Ovary Syndrome, The PCOS Workbook &
• Diet & Fertility
PCOS Nutrition Handout Series CD
• Pregnancy & Lactation
(484) 252-9028 • Adolescence
www.PCOSnutrition.com

PCOS: Background
• Most common endocrinopathy in premenopausal women

• Reproductive and cardiovascular features: the intersection of

sex hormones & metabolism:
– Reproductive consequences
– Endocrine/metabolic consequences
– Cardiovascular associations

• A multi-factorial, polygenic disorder with variable phenotypes

• PCOS is under-diagnosed and under-treated

– Multiple cardiovascular risk factors
– High conversion to diabetes & metabolic syndrome

Observed Associations
PCOS: a reproductive disorder • Hypothyroidism
• Obstructive sleep apnea
– Oligomenorrhea, amenorrhea • Non-alcoholic fatty liver disease
– Infertility
• Mood disorders, especially bipolar,
– Pregnancy loss, preterm and eating disorders
stillbirths • Coronary artery disease & T2DM
– Polycystic ovaries
• Metabolic syndrome
– Endometrial carcinoma
…with hirsutism, acne & weight gain

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 Increased prevalence of
Dietitians…
metabolic syndrome in PCOS
70 N H A N E S III • may be the first health care provider to
PCOS recognize the syndrome among their
60
50 patients.
P r e v a le n c e (% )

40
30 • must have the knowledge and skills to
20 recognize and treat patients with PCOS.
10
0
2 0 -2 9 3 0 -3 9
• Are often case managers, directing and
Age referring treatment options.
Apridonidze et al. JCEM 2005

Multi-Disciplinary Team Approach Pathophysiology

• Dietitian • Hypothalamic gonadotropin releasing
• Pediatrician hormone (GnRH) pulses are abnormal →
• Reproductive LH
endocrinologist/endocrinologist
• Dermatologist • Insulin resistance plays a central role
• Therapist and/or family therapist
• Patient

The Vicious Cycle of Insulin

ovary endothelium Resistance
ovary

Weight gain Hyperinsulinemia

testosterone hyperinsulinemia endothelial
dysfunction

acne hirsutism
dyslipidemia
anovulation diabetes Insulin resistance
Overweight hypertension
Acanthosis nigricans
infertility
Sherif 2006 ©

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 Goals of Treatment Traditional Treatment
• Regulate menstrual function, reduce • Oral contraceptives Oligomenorrhea
androgen and insulin levels, improve Hirsutism
dermatological symptoms, and stabilize or Acne
reduce weight. Alopecia
• Prevent long-term complications
– Diabetes • Anti-androgens Hirsutism
– Cardiovascular Disease Alopecia
– Metabolic Syndrome
– Infertility • Clomiphene Infertility

Treatment with insulin sensitizers

Goal: Decrease Insulin Resistance improves fertility & CVD risk factors
1. Diet Decrease Hyperinsulinemia
2. Physical activity
↓testosterone
3. Insulin-sensitizing medication
– Metformin  ovulation
– Actos, Avandia fertility endometrial ca
improve endothelial function
– Byetta
↓ hyperandrogenemia BP, lipids, glucose
Hirsutism, Acne, Alopecia
↓ Cardiovascular risk

Labs To Support Diagnosis Frequently Observed Lab Abnormalities

• Elevated TSH and thyroid peroxidase

• Elevated total testosterone/DHEA-S antibodies
• LH:FSH • Elevated LFTs
• Elevated fasting glucose, HA1C • Elevated WBCs
• Elevated fasting insulin • Elevated C-reactive protein
• Elevated insulin to glucose ratio • Dyslipidemia
– Elevated triglycerides
– Decreased HDL

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 Unique Challenges for
Women with PCOS
• Yo-yo dieters
• Intense cravings
• Hypoglycemia common
What is the best diet
• Hormonal aberrations composition ?
• Dermatological concerns
• Higher prevalence of eating disorders
• Impaired levels of ghrelin & leptin
• Increased anxiety, depression, bipolar, suicide

Low-Fat Diets Study Design

• exaggerate postprandial glycemia Meal 1 Meal 2
• increase TG, decrease HDL High-Fat, 7 day High-Fat,
concentrations Low-Fiber washout Low-Fiber
• promote higher consumption of refined Meal Meal
15 Women (n=7)
carbohydrates with PCOS
• Makes MBS worse
• contribute to hunger, overeating, and Low-Fat, Low-Fat,
High-Fiber High-Fiber
weight gain
Meal Meal
(n=8)

Increased insulin levels after the

Prolonged reduction in testosterone high fiber meal
levels after the high fat meal
140
65 * *‡
Testosterone (ng/dL)

High-Fiber meal
Insulin (μU/mL )

120 *‡
60 * High-Fiber meal 100
55
High-Fat meal 80 *
50
60
45
40 High-Fat meal
40 ‡
20
35
0
0 60 120 180 240 300 360
0 60 120 180 240 300 360
Time (Minutes)
Time (Minutes)
* P<0.05 within groups compared to baseline; ‡ P<0.05 between group comparison * P<0.05 within groups compared to baseline; ‡ P<0.05 between group comparison

4

• Testosterone levels were reduced for 2
hours longer after the high fat meal
• Higher levels of glucose and insulin after
the high-fiber meal
Low vs. High Protein Diets
• 28 overweight or obese PCOS women
• High protein (40% CHO, 30% Pro, 30% Fat) vs.
Low Protein (55% CHO, 15% PRO, 30% Fat)
• Both diets 1400 calories for 3 months
• Weekly nutrition classes; exercise 3x/wk
• Results: No significant difference was found!
Both groups lost weight, improved insulin,
testosterone, menstrual function and other labs.

Moran LJ, Noakes M, Clifton M, Tomlisson L, Norman RJ. Dietary composition in

restoring reproductive and metabolic physiology in overweight women with polycystic
ovary syndrome. J Clin Endocrinol Metabol. 2003;88:812-819.

Very Low-Calorie Diets Low GI Diets

• 114 obese women with PCOS
• 500 calories/day for 4 weeks
• 1,000 calories/day for 7 months
• Results: 54% lost > 5% of body weight,
11.8% remained at pretreatment weight;
both groups showed improvements in
testosterone levels.
• 73 obese adults without diabetes,
ages 18-35
• Measured insulin levels
• Lower carbohydrate (<40% low GI CHO
intake) vs. Low-fat (55% CHO and 20% fat
intake)
• Both reduction of 400 cal/day; 18 months
• Results: those with high insulin levels lost
more weight with lower GI intake
(13 lbs vs. 3 lbs)
Ebbeling C, Leidig MM, Feldman HA, Lovesky MM, Ludwig DS. Effects of a
low–glycemic load vs low-fat diet in obese young adults.
JAMA. 2007;297:2092-2102.

Improvement Without
Low GI Diets
Weight Loss?
• Slow or resistant starches
• Whole grains
• Weight loss of 5% of total body weight is
• Fruits and vegetables effective at improving insulin sensitivity,
• Legumes
…but in moderate amounts
androgen levels, and menstrual function.
• In anovluatory women, weight loss may be
Improvements in:
• Cholesterol needed to ovulate.
• TG • Diet and exercise without weight loss
• Insulin
• Blood pressure improves metabolic parameters.
• Inflammation
• fertility

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 For Reducing Insulin & Weight:
• Lower intake of carbohydrates
What is the best diet • “Almost all” whole grain, high fiber
• Avoidance of sweetened beverages
composition ???
• Spread evenly throughout the day
• Eat frequently (every 3-5 hours)
• Protein matching at all meals and snacks
• Rich intake omega-3s

For Heart Health Protein

• Daily fat intake 35-45% of total daily calories • Lean, protein-rich foods with all meals and
• No more than 7% saturated fat. Trans fats snacks
should be eliminated
• Up to 20% of daily calories from • “Experimenting” for optimal food
monounsaturated fatty acids, and up to 10% combinations
polyunsaturated fatty acids
• Consume fatty fish 2x/week
• Fish oil supplement
• Plant sterols
• Red wine

Benefits of Protein Protein Intake & Fertility

• Delays postprandial response • Nurses’ Health Study-18,000 nurses
• Highest-protein group had 41% more ovulatory
• Decreases hunger infertility.
– Increases satiety • Women with the highest intake of animal protein
had 39% more ovulatory infertility than those
– Decreases ghrelin with the lowest.
• Increases Thermic Effect of Food • Those who consumed the most plant-based
proteins had the lowest amount of infertility.
• Preserves LBM – exceptions were for eggs, dairy, and fish which were
found to increase fertility.

Chavarro J and Willett W. The Fertility Diet.

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 Supplements With
Insulin-Sensitizing Properties
• D - chiro inositol
• Chromium
• Cinnamon
• N-acetyl cysteine
• Alpha lipoic acid
• Magnesium
• Vitamin D3
• Omega-3 fatty acids
Barriers to Physical Activity
• Size
• Muscular shape
• It’s exercise!
The Importance of Nutrition
Counseling for PCOS
In a study on the effects of exercise and
nutritional counseling in women with
PCOS, Bruner et al (2006) found that
nutritional counseling, with or without
exercise, decreased insulin levels and
improved both metabolic and reproductive
abnormalities associated with PCOS.
Role of Exercise
• 3-month exercise program vs. hypocaloric diet
• 19 sedentary women with PCOS
• SET: 25% improvement of insulin sensitivity
without weight loss.
• improved fertility and menstrual cyclicity than
those who followed a hypocaloric diet.
• SET group also had greater improvements in
waist circumference and insulin resistance
despite only a smaller reduction in weight.
The Role of The Dietitian in
Treating PCOS
• Empathetic, supportive, encouraging approach
• Provide education on PCOS and insulin
resistance
• Education on healthy diet and exercise
• Encourage a healthy approach to eating and
exercise rather than focusing on weight loss
• Assess symptom severity (including eating
disorder behaviors)
• Assess medication compliance
The Nutrition Assessment
• Screen any woman for PCOS
– Provide appropriate referral information
• Screen for distorted eating
• Review lab results
• Assess diet
• Educate patient and parents about PCOS
– Insulin resistance
– Connection to symptoms
– Long-term risks
– Role of diet and exercise
• Assess readiness for change
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 Questions to ask a patient
suspected of PCOS: Tools
• “Tell me what your periods are like. Are they heavy,
irregular, absent, etc.?” • Food records
• “What types of foods do you crave and when do you • Mindful eating exercises
crave them?”
• “Do you ever feel lightheaded, dizzy, nauseous, or • Food models and labels
irritability that gets better when you eat?” • Handouts
• “Have you ever been told by your physician or healthcare – How food affects insulin
provider that you have any abnormal lab values?” levels
• “Can you tell me about any excessive body hair that – Food exchanges
you’ve dealt with?” – Managing hypoglycemia
• “Do you have dry/rough elbows, skin tags, or any dark • Scale vs. waist
patches that look dirty on your body?” circumference
• “Does anyone in your family have polycystic ovary
syndrome?” • Lab results
From The Dietitian’s Guide to Polycystic Ovary Syndrome by Angela Grassi

PCOS in Pregnancy Other Concerns in Pregnancy

Higher risk for: • Multiple babies
• Gestational diabetes
• Food fears
-GDM ~ 3.5% in general population
-GDM in PCOS estimated to be 20-50% • Emotional Concerns
-Early OGTT – Weight gain
– Body image issues
• Miscarriage

• Neonatal intensive care stays

PCOS & Pregnancy Metformin in Pregnancy

• Should be considered a state of GDM:
• 10-fold reduction in
-Moderate intake of carbohydrates GDM using metformin
-Even distribution of carbohydrates – Glueck 1992 Fertil
Steril
-Protein matching
• Daily exercise, preferably after meals • Metformin decreased
• Patient education of risks miscarriage
– Jacubovitz 2002
• Appropriate weight gain JCEM

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 Unique Concerns: Guidelines To Establish Adequate
PCOS & Lactation Milk Supply in PCOS:
• Insufficient milk
production
• Pump after feedings for 10-15 minutes on
each breast in the first 2 weeks of initiating
• Failure of breast nursing
tissue to develop
• Frequent feedings with full drainage
• Insulin resistance
• Adequate diet and fluid intake
• Adherence due to
size • Extra breast stimulation by frequent
• Overabundance of nursing or pumping sessions is crucial
milk production • Resources prior to birth

Safety: Metformin & Lactation PCOS in Adolescence

• 61 nursing infants and 50 formula fed infants
born to mothers with PCOS
• took an average of 2.55 grams of Metformin per
day throughout pregnancy and lactation
• Infants followed birth-6 mo.
• “Metformin had no adverse health risks in
regards to growth or motor-social development.”
Glueck C et al. J Pediatr 2006;148:628-32.
• Adolescence is the most vulnerable and
influential stage of PCOS.
• It is in adolescence when symptoms of PCOS
first start to present themselves.
• Changes can be made to diet and lifestyle that
could prevent the worsening of symptoms later
in life and prevent the onset of many health
complications.

Obstacles Affecting Treatment In Summary

• Proper diagnosis/ Lab profile • PCOS is a very complex, under-treated and
under-recognized epidemic
• Patient readiness
• Early detection and treatment are key
• Mental status
• Diet plays an important role in the treatment of
– Anxiety, Depression, Eating disorders PCOS
• Social involvement • RDs can offer lifestyle counseling on weight loss
• Family involvement and diet to improve insulin resistance to reduce
the risk of chronic disease within the PCOS
• Resistance to exercise population

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 PCOS Resources
• www.PCOSnutrition.com
– FREE PCOS nutrition tips
newsletter, articles, resources
– PCOS Nutrition Handout Series CD
– The Dietitian’s Guide to PCOS with
Self-Study Course
– PCOS Handouts on CD

•
– The PCOS Workbook
www.youngwomenshealth.org
– Great resources for Teens with
QUESTIONS? COMMENTS?
PCOS
– Sample meal plans, articles,
information
• www.PCOsupport.org
– Professional database
THANK YOU!
• www.soulcysters.net

• www.ProjectPCOS.org
– Latest PCOS news
– Information, tips, articles

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