By Bana Zeitoun

What is PCOS  is a complex disorder that usually begins

during puberty and affects women of reproductive age characterized in most cases by multiple small cysts that develop on the ovaries.

the ovaries are firm and globular with a thick, white capsular surface that may show bulges from underlying cysts . (Ginsberg & harvard,1976)

Introduction Causes :

Polycystic ovary syndrome is related to an imbalance in sex hormones.

Female sex hormones include :

1) estrogen 2)progesterone

3) male hormone called androgene

(Ginsberg and Havard,1977)

Hypothalamic peptideSecrete

GnRHStimulate

Pituitary gland

FSHLH

Stimulate growth and maturation of 60-20 follicle

Stimulate

Estrogen

Progesterone

Introduction Concentration of LH increase relative to

that of FSH the ovary synthesise androgen

Increase androgen production in women with PCOS is augmanted by increase LH and is assossiation with anovulation .

Introduction

Possible Complications 1)Increased risk of endometrial cancer 2) Infertility 3) Obesity (BMI over 30 and waist

circumferance greater than 35) 4) conditions, such as high blood pressure, heart problems, and diabetes

5)Possible increased risk of breast cancer

Introduction Diagnosis Difficult to diagnosisHeterogeneous symptomsVary over time

Transvaginal ultrasound is one of the main tools to diagnosing PCOS. The images found on the ultrasound, in conjunction with the results of blood tests and a thorough patient history and physical, are used to diagnose this syndrome.

Diagnosis of PCOS by ultrasounds

Symptoms of PCOS •The feature of (PCOS) usually begins around

menarche (Ehermann, 2005).

•The typical biochemical features of PCOS include hyperandrogenaemia and an increase of serum luteinising hormone (LH) and testosterone with normal follicle stimulating hormone

Symptoms of PCOS

pcos symptoms

Insulin resistance

Histrutism

Acne Amenorrhoea Low HDL

High tostosterone High Triglyceride

Obesity

Acne

Hirsutism

PCOS & insulin resistancePCOS woman ↑ insulin resistance hyperinsulinemia increase androgene via : ● direct stimulation IGF1 receptor in ovary

→ androgen secretion ● ↑ sensitivity pituitary to GnRH

●↓ SHBG (Six hormon binding globuline) (Gambineri et.al,2002) .

Increase LH

PCOS & Obesity More than 40% of PCOS patients are obese (Guzick .2004).

Even in individuals with a non obese BMI, a higher waist-to-hip ratio is seen in those with PCOS

At least one abnormal lipid level is seen in 70% of women with PCOS The pattern of dyslipidemia (sharpless ,2003 ).

weight loss may be expected to have several beneficial effects upon clinical, endocrinological and metabolic features of obese women presenting with PCOS(barber,2006 )

Relationship between PCOS & obesity▪Nutrition in clinical practises Page 56

Hypothalamus

GNRH( inappropriate

increase )

Pitutary

Pancreas

Insulin resistance

hyperinsulinemia

Fat cells

Obesity

Ovary

Androgene excess

Hyberandrogenemia

PCOS

LHFSH

(no change

Adrenal

Liptin

Study : heterogeneity in the responsiveness to long-term life style intervention and predictablity in PCOS women

Methods One hundred PCOS women meeting the criteria for selection were invited to participate and 65 of them agreed. Lifestyle intervention had consisted of a 1200–1400 kcal/day diet for 6 months, followed by mild calorie restriction and physical activity. The protocol, which was similar at baseline and follow-up, included anthropometry, clinical evaluation, pelvic ultrasound, and laboratory investigations. The mean follow-up period was 20.4±12.5 months.

Results  After the follow-up period, women were reclassified into three groups according to the persistence (group 1, 15.4%), partial (group 2, 47.7%), or complete (group 3, 36.9%) disappearance of the categorical features of PCOS (hyperandrogenism, menses, and ovulatory dysfunctions).

Duration of the follow-up and extent of weight loss were similar among the three groups, as were fasting and glucose-stimulated insulin and indices of insulin resistance. Baseline waist circumference, waist to hip ratio (WHR), and androstenedione blood levels were negatively correlated with a better outcome .

Conclusions Responsiveness to

weight loss in overweight/obese PCOS women varies considerably and more than one third of women may achieve full recovery. These findings add new perspectives to the impact of obesity on the pathophysiology of PCOS.

(Pasqulali et.al ,2010)

PCOS & NUTRITION ►dietary management of insulin resistance

▪ Reducing glycaemic load (GL) can reduce postprandial glucose levels and the resulting hyperinsulinaemia that characterizes this condition.

▪ the best way to achieve a reduction in GL – reducing glycaemic index (GI) or reducing carbohydrate intake (Moran et.al ,2003) .

▪ Low GI foods for everyday use include: dense, whole intact grain/fruit breads; muesli and porridge; legumes, pasta and noodles; orchard fruits; low-fat dairy products.

▪ Moderate GI foods for occasional use include: wholemeal bread; basmati rice; couscous; baby potatoes; tropical fruit; dried fruit; sugar (white, raw, brown).

▪ High GI foods that should be avoided include: short-grain rice; millet; any food made from refined white wheat and rice flours (e.g. white breads, sweet biscuits and crackers); any breakfast cereal made with puffs, bubbles, flakes and extruded shapes or processed foods with glucose, glucose syrup or maltose as ingredients.

(legro et.al ,2005)

▪ If carbohydrate intake is reduced, it must be replaced by either fat or protein – both of these strategies have potential problems for women with PCOS

(Marsh & Miller ,2005)

Dietary interventionReduce carbohydrate – replace with MUFA

Reduce carbohydrate – replace with protein

Reduce GI of diet

Effect on GL Reducing carbohydrate from 55 to 40 % and replacing with MUFA will reduce GL by about 40 units

Reducing carbohydrate from 55 to 45 %

and increasing protein from 12 to 25 % , will reduce GL by about 35 units

Maintaining a higher-carbohydrate diet , but reducing

average GI from 70 to 50 will reduce GL by

about 50 unit .

Possible benefits▪ Increased HDL

▪ Reduced TG

▪Traditional Mediterranean diets have been

associated with a reduced risk of CVD

and some cancers

▪Reduced TG

▪ Increased weight loss

▪ Increased satiety

▪ Increased satiety▪Increased HDL▪Reduced TG▪Improved insulin

sensitivity▪Reduced risk of type 2

diabetes mellitus▪Reduced risk of CVD▪Reduced risk of some

cancer

Dietary intervention

Reduce carbohydrate – replace with MUFA

Reduce carbohydrate – replace with protein

Reduce GI of diet

Possible risks ▪Possibility of weight

gain or reduced weight loss with higher fat intake

▪ Higher risk of type 2 diabetes associatedwith higher red meat intake

▪Effects on kidney function and bone mineral density remain unclear

▪Increased risk of some cancers with higher intake of animal protein and reduced intake of whole grains, fruit and

vegetable

(Marsh &miller ,2005)

► Fat and PCOS

▪ LC n−3 PUFA supplementation reduced plasma bioavailable testosterone concentration.

(phelan et.al ,2010)

▪ PUFAs and their products, might serve as natural ligands for peroxisomal proliferator-activated receptor (PPAR y) .as syanthetic (PPAR y) are used for treatment of insuline resistance of PCOS .

(Kasim-Karacas et.al,2004 )

▪ each 2 % increase in energy intake from trans fats when substituted for unsaturated fats or carbohydrates, the risk of ovulatory infertility increased by (50-73)%

( connor ,2010 )

The long chain (LC) n-3 PUFA : EPA ,DHA and ALA (alpha linolinc acid ) have emerged as particularly potent biological regulators

DHA and EPA together   aid PCOS and fertility because they can help with hormone regulation and they are anti-inflammatory

Fish oil contains fatty acids EPA , DHA. while ALA is rich in ground flax seeds 1 tablespoon per day of ground flax seed is recommended to achieve 2 grams of ALA per day, and between 500-1000 mg. each of DHA , EPA and ALA is recommended to help with symptoms of PCOS. (ward ,1977)

Fish oil is harvested from cold water fish like salmon, mackerel, sardines, trout, herring, tuna, eel and anchovies. These fish are high in omega-3 essential fatty acids (EFAs), which break down into (EPA) and (DHA).

Fish oil, when used as a supplement, has been shown to have insulin-sensitizing effects

Fish oils in conjunction with vitamin E have been shown to decrease levels of insulin and growth hormone it was shown that when women lost 5% or more of their body weight (cusson et.al ,2009)

Study: Differential effects of walnuts vs. almonds on improving metabolic and endocrine parameters in PCOS

Objective: was to compare the effects of MUFA- rich almonds vs. n-3/n-6 PUFA-rich walnuts on metabolic and endocrine parameters in PCOS.

Methods: Thirty-one PCOS patients randomly received either walnuts or almonds containing 31 g of total fat per day for 6 weeks. At the beginning and at the end, anthropometric parameters, fasting lipids, phospholipids-fatty acids, inflammatory markers, androgens, oral glucose tolerance tests )OGTT( and frequently sampled

Results:• Weight remained stable. •Walnut •Within group, walnuts increased the n-3/n-6 essential PUFA in the diet and plasma phospholipids.•Walnuts decreased low-density lipoprotein-cholesterol by 6% •Walnuts increased insulin response during OGTT by 26%. •Walnuts increased sex hormone-binding globulin from 38.3±4.1 to 43.1±4.3 nmol/l

Almonds 1( low-density lipoprotein-cholesterol by 10%

2( Almonds reduced free androgen index from 2.6±0.4 to 1.8±0.3

Conclusion Nut intake exerted beneficial effects on plasma lipids and androgens in PCOS. )Kalgonkar et.al,2010(

► PCOS & vitamins ● vitamin A : play a role in the treatment of PCOS-

related acne. Literature supports that individuals with severe acne have low serum vitamin A levels.

● vitamin D : Addition of vitamin D to theca cells removed from the ovaries resulted in decreased androstenedione production basally and in the presence of (LH)

precaution of vitamin D :Increased consumption of milk

products to increase vitamin D and calcium intake is not recommended in the PCOS population

● vitamin E: Vitamin E lowered C-reactive protein levels and therefore improved the inflammation status of PCOS patients

Major mineral and trace mineral in PCOS

Element Function based on literature review

reserchRecommended

supplementation Magnesium and highcalcium :magnesium ratio

Literature shows that PCOS patients have lower serum magnesium levels than normal controls. Low levels are associated with insulin resistance, cardiovascular problems, diabetes

mellitus,hypertension .

Magnesium, 300 mg twice daily for insulin resistance in

PCOS

Calcium Calcium is required for the interrelationship of calcium metabolism, egg maturation, and normal

follicular development.

1000-1300 mg/d )RDA for age(

Element Function based on literature review

research Recommended supplementation

Boron Low levels inducehyperinsulinemia in vitamin D–deprived rats. Adequate boron enhances efficacy of vitamin D Boron may enhance vitamin D

effect on PCOS patients .

Not able avail

Chromium Daily supplementation ofchromium has been shown to improve glucose tolerance in PCOS patients

A small study )5 women( found a 38%improve in glucose disposal rates with1000 _g/d trivalent chromium

200 _g/d

Zinc High levels of zinc have been shown to increase testosterone levels in zinc

deficient individuals .

Zinc supplementation should be discouraged in PCOS

patients. Nutrition in clinical practices ,2008 .page 67

PCOS & functional food► spearmint tea

▪ The study population consisted of females with PCOS and hirsutism with documented levels of elevated androgen hormone levels .

▪ Patients were randomized to two groups. The first were asked to drink two cups of spearmint tea for a period of 30 days. The second group were given a placebo tea.

▪ Methods: At the beginning and end of the trial period all patients had their serum androgens checked, their clinical degree of hirsutism was assessed and the patients were given a questionnaire regarding their hirsutism .

• Result : The research trial demonstrates that the use of spearmint herbal tea has significant measurable anti-androgen effects in patients with hirsutism due to PCOS.

•continued with the treatment for a longer period of time then the reductions in androgen hormone levels would have translated into improvements .

(Grant,2008)

► Dairy product

▪ Studies show that high intake of milk and dairy products may increase the risk of infertility due to ovulatory dysfunction.

In addition dairy foods may be beneficial to ovarian function, and that not all dairy foods have the same relation to fertility.

▪ intake of low-fat dairy foods, but not high-fat dairy foods, has been associated with clinical manifestations of androgen excess , a component of PCOS  which may also lead to

anovulatory infertility ( chavarro et.al ,2007)

▪ intakes of skim milk, low-fat milk, sherbet and cottage cheese to be associated with an increased frequency of physician-diagnosed acne (Adebamowo et a,2005) 

►Herbal & pcos ● Licorice : ▪the testosterone-lowering effects of licorice appear to have been helpful in the treatment of PCOS

▪ might be useful for other expressions of androgenization, such as alopecia, hirsutism, or other effects, including those following menopause (Bargener ,1999)

▪ its also initiate ovulation, normalise follicle development and improve fertility and support adrenal function(Bolloush ,2003)

▪ its help in the Initiate ovulation, normalise follicle development, and improve fertility and reproductive system .

Tribulus Wild yams Rehmannia Unicort rootShatavari

Gymnema Goats rue Fenugreek sarsaparilla Siberian ginsengBitter herbs

▪have a significant effect with reduce insuline resistance

(Bolloush ,2003)

PCOS & medical treatment ● Metformin : long-term treatment with metformin

added to hypocaloric diet induced, in comparison with placebo, a greater reduction of body weight and abdominal fat, particularly the visceral depots (pasquaki et.al ,2000)

●Clomiphene citrate (Clomid, Serophene) : fertility medicines and gonadotropin injections (LH and FSH)

● Androgen-lowering spironolactone (Aldactone) : This reduces hair loss, acne, and abnormal hair

growth on the face and body (hirsutism).

Conclusion Women with PCOS should consider her diet as an

important treatment , as it can highly impact her ability to cope with this syndrome and affect her future health and overall quality of life. increasing the percentage of healthy fats and protein in the diet and decreasing refined carbohydrates (sugar, sweets, white bread / baked goods, white rice and pasta, soda, etc.) will aid in glucose control. In addition,exercise, both aerobic and strength training, can significantly improve insulin sensitivity ,weight loss and glucose control. 

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