Overview and Risk Factors
Polycystic ovarian syndrome (PCOS) is a disorder involving excessive androgen production by the ovaries and adrenal cortices. It affects approximately 5% of women in the United States. The etiology is unknown. Hypotheses include excess luteinizing hormone or adrenocorticotropic hormone stimulation of the ovaries, and imbalance of regulatory peptides (insulin, insulin-like growth factor, inhibin, follistatin). Increased circulating insulin decreases the concentration of sex hormone-binding globulins, thereby increasing the amount of unbound free testosterone.
The classic presentation is a triad of hirsutism, anovulation, and obesity, with onset during the peripubertal years; however, it has been recognized in recent years that many women with PCOS are not obese and present only with anovulation and androgenizing effects. Affected women generally have multiple ovarian cysts and may be infertile. They often exhibit insulin resistance, hypothalamic-pituitary axis abnormalities, male-pattern baldness, and acne. Adolescents may also present with precocious puberty or acanthosis nigricans.
Although PCOS is not curable, weight loss and symptomatic treatment can usually control most symptoms.
Risk Factors
Obesity.
Epilepsy. Both epilepsy and anti-seizure medications increase the risk of PCOS.1
Family History. Approximately 40% of first-degree relatives are affected.2
Diagnosis and Treatment
Diagnosis
For diagnosis, 2 of the following 3 criteria should be met, and other diseases with similar clinical presentation should be ruled out3:
Menstrual irregularity. Anovulation, oligo-ovulation, amenorrhea, oligomenorrhea, or irregular bleeding.
Signs of hyperandrogenism. Hirsutism, acne, male-pattern baldness, or elevated serum free testosterone concentration.
Polycystic ovaries, visible on transvaginal ultrasound. An isolated finding of polycystic ovaries in the absence of clinical hyperandrogenism is common and does not indicate PCOS.
Laboratory studies may include measurements of prolactin, blood glucose, and insulin.
A glucose tolerance test is indicated in most cases.
Because coronary artery disease is common in patients with PCOS, cardiovascular risk factors should be evaluated (eg, hypercholesterolemia, hypertriglyceridemia). Smoking should also be discouraged.
Testing for sleep apnea (sleep questionnaire, overnight polysomnography) may be indicated.
Treatment
Weight loss, physical activity, and insulin-sensitizing agents (eg, metformin, thiazolidinediones) are usually necessary to reduce insulin resistance.
Oral contraceptives are used to regulate the menstrual cycle and protect the endometrium in women who are not interested in becoming pregnant.
Hirsutism is treated by hair removal (eg, electrolysis, laser treatment), oral contraceptive pills combined with an anti-androgen medication (eg, spironolactone), or gonadotropin-releasing hormone (GnRH) analogs.
Acne is treated with topical or oral agents.
Treatment of infertility is often necessary if the patient desires pregnancy.
- Weight loss and exercise may be beneficial.
- Clomiphene or metformin are initial choices to induce ovulation.
- Assisted reproductive technologies (eg, in-vitro fertilization) may be necessary.
Nutritional Considerations
PCOS appears to be related to diet and lifestyle factors, particularly insofar as they influence body weight and insulin resistance. Although weight loss is an accepted treatment, even relatively lean women may develop PCOS, suggesting that diet may affect the outcome of this disorder even in the absence of weight change.
A diet that addresses cardiovascular risk factors is appropriate for women with PCOS. Roughly half of women with PCOS are obese,4 and losing as little as 5% to 10% of weight results in resumption of menses and decrease in blood androgen levels.4,5 The composition of the therapeutic diet is a matter of controversy. However, there are several reasons why a diet low in fat and high in fibrous carbohydrates is superior to other weight-loss treatments.
Such a diet helps reverse insulin resistance, which affects 50% to 70% of women with PCOS.4,6 This is particularly important because of insulin's tendency to reduce sex hormone-binding globulin (SHBG) and increase free testosterone concentrations.7 Low-fat, high-fiber diets also reduce body weight and effectively address dyslipidemia (elevated triglycerides, low HDL), elevations of C-reactive protein and homocysteine, and oxidative stress.4 Low-fat, high-fiber diets reduce circulating androgens and increase SHBG.4,8
A diet that emphasizes whole grain intake, as opposed to refined carbohydrates, may improve metabolic defects in PCOS by providing fiber and inositol. Inositol has been repeatedly found in clinical trials to improve insulin action, decrease androgen levels, and improve ovulatory function in both lean and obese women with PCOS.9-11 The benefits of metformin in PCOS appear at least partly due to increasing inositol availability.12
Orders
What to Tell the Family
PCOS can often be effectively treated through weight loss, dietary changes, and medical therapies. Diets that are low in fat and high in fiber are likely to achieve the best results, particularly when coupled with exercise. Families of affected patients would do well to adopt a similar diet and increased exercise to facilitate the patient's adherence and for their own health benefits.
References
1. Bilo L, Meo R, Valentino R, Di Carlo C, Striano S, Nappi C. Characterization of reproductive endocrine disorders in women with epilepsy. J Clin Endocrinol Metab. 2001;86:2950-2956.
2. Azziz R, Kashar-Miller MD. Family history as a risk factor for the polycystic ovary syndrome. J Pediatr Endocrinol Metab. 2000;13(suppl 5):1303-1306.
3. The Rotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Hum Reprod. 2004;19:41-47.
4. Marsh K, Brand-Miller J. The optimal diet for women with polycystic ovary syndrome? Br J Nutr. 2005;94:154-165.
5. Stamets K, Taylor DS, Kunselman A, Demers LM, Pelkman CL, Legro RS. A randomized trial of the effects of two types of short-term hypocaloric diets on weight loss in women with polycystic ovary syndrome. Fertil Steril. 2004;81:630-637.
6. Hahn S, Tan S, Elsenbruch S, et al. Clinical and biochemical characterization of women with polycystic ovary syndrome in North Rhine-Westphalia. Horm Metab Res. 2005;37:438-444.
7. Holte J. Polycystic ovary syndrome and insulin resistance: thrifty genes struggling with over-feeding and sedentary life style? J Endocrinol Invest. 1998;21:589-601.
8. Berrino F, Bellati C, Secreto G, et al. Reducing bioavailable sex hormones through a comprehensive change in diet: the diet and androgens (DIANA) randomized trial. Cancer Epidemiol Biomarkers Prev. 2001;10:25-33.
9. Nestler JE, Jakubowicz DJ, Reamer P, Gunn RD, Allan G. Ovulatory and metabolic effects of D-chiro-inositol in the polycystic ovary syndrome. N Engl J Med. 1999;340:1314-1320.
10. Iuorno MJ, Jakubowicz DJ, Baillargeon JP, et al. Effects of d-chiro-inositol in lean women with the polycystic ovary syndrome. Endocr Pract. 2002;8:417-423.
11. Gerli S, Mignosa M, Di Renzo GC. Effects of inositol on ovarian function and metabolic factors in women with PCOS: a randomized double blind placebo-controlled trial. Eur Rev Med Pharmacol Sci. 2003;7:151-159.
12. Baillargeon JP, Jakubowicz DJ, Iuorno MJ, Jakubowicz S, Nestler JE. Effects of metformin and rosiglitazone, alone and in combination, in nonobese women with polycystic ovary syndrome and normal indices of insulin sensitivity. Fertil Steril. 2004;82:893-902.
