Women with PCOS are at risk of developing metabolic syndrome (a pre-cursor to diabetes) and have decreased insulinInsulin is a hormone made by the pancreas. It is responsible for making the body’s cells absorb glucose (sugar) from the blood…. sensitivity, known as insulin resistance, compared with women of similar body weight with normal ovaries. Evidence suggests that insulin resistance is the likely link between PCOS and the metabolic syndrome, [1a], [b], [c], [d], although insulin sensitivity is not always found with PCOS, particularly with non-obese women. Family history seems to be an important factor, as women with PCOS and a positive family history of type 2 diabetes seem to have a higher risk of abnormal insulin sensitivity and secretion.[2]
Insulin resistance worsens with increasing obesity,[3] which is a major feature in women with PCOS. High levels of insulin appear to stimulate and increase blood levels of androgens (male hormones) in PCOS and suppress a proteinProteins are large molecules consisting of chains of amino acids. Proteins are essential nutrients for the human body – they are a building block of… called sex hormone binding globulin (SHBG), a protein that binds to sex hormones and keeps the levels available in the blood at optimum levels. The use of insulin-sensitising drugs (see below) has been shown to decrease blood levels of insulin in both obese and non-obese women with PCOS, and to simultaneously reduce circulating androgens and to improve ovulation. [4] PCOS can cause the ovaries to stop ovulating, which means that the normal cyclic production of estrogen followed by progesteroneProgesterone is one of the main female sex hormones…. either ceases or becomes dysfunctional. Insulin stimulates the ovaries to produce predominantly male hormones, which, in combination with higher insulin and glucose levels, increase weight gain around the waist – a body type that is a risk factor for breast cancer.
Signs that the body is being exposed to higher levels of the male hormones include acne, loss of head hair and an increase in body hair. Lowering insulin levels is crucial for not only treating PCOS but also resolving most other hormonal imbalances, including those leading to breast cancer. Depression or mood swings are also common in women with PCOS and it is also associated with insulin resistance, hormone imbalances and being overweight. Infertility and miscarriages, common consequences of PCOS, also can be very stressful and depressing. Too much stress may aggravate many aspects of the syndrome, including insulin resistance.
Diagnosis
There are a number of blood tests that will probably have been performed by your doctor if you have, or are suspected of having, PCOS. An ultrasound may also be performed to confirm the diagnosis. Blood test results that are generally found in women with PCOS include:
• HIGH androgenAndrogens are often referred to as male hormones. Although both men and women produce them, they are present in much higher levels in men. The… levels (male hormones, such as testosteroneTestosterone is a male sex hormone important for sexual and reproductive development….), luteinising hormone (LH), fasting insulin, prolactin, estradiol and estrone, tryglycerides, total and LDL (‘bad’) cholesterol.
• LOW levels of SHBG, which are decreased by high levels of insulin, as explained above.
How is PCOS Treated?
There are many medications to control the symptoms of PCOS. Doctors most commonly prescribe birth control pills for this purpose. Birth control pills regulate menstruation, reduce androgen levels and help to clear acne. Your doctor may also prescribe an insulin-sensitising medication, such as Metformin (see below). It is important to discuss the risks and benefits of these medications to find out which, if any, is right for you. Metformin is an insulin-sensitising medication, which may be prescribed for PCOS, [5a], [b], [c], [d] although some experts believe this should be prescribed with caution [6] and not ‘as a replacement for increased exercise and improved diet’. [7]
A meta-analysis of 13 randomised, controlled trials including 543 women and published in the British Medical Journal in 2003, found that Metformin has an effect in reducing fasting insulin concentrations, blood pressure, and LDL (‘bad’) cholesterol. However, it was also associated with some unpleasant side-effects, including nausea, vomiting and gastrointestinal disturbance, which limited participation levels in some trials. One of the outcomes measured was the ‘overall ovulation rate’ achieved by metformin alone, or metformin combined with another drug (clomifene). Interestingly, the overall rate of 57% was lower than ovulation rate achieved with lifestyle improvements, that included increased exercise and weight loss. [8] Metformin also interferes with the action of vitamin B12 and may raise your homocysteineHomocysteine is an amino acid found in the blood. Elevated levels of homocysteine have been associated with narrowing and hardening of the arteries, an increased… level. Make sure you are supplementing vitamin B12 if you are on this drug.
Diet
Eating a low-GL diet and maintaining a healthy weight can improve insulin sensitivity and help lessen the symptoms of PCOS. Dairy products also promote high insulin levels so are best avoided. The essential mineral chromiumWhat it does: Helps balance blood sugar, normalise hunger and reduce cravings, improves lifespan, helps protect cells, essential for heart function. Deficiency Signs: Excessive or… is required for normal insulin function and supplementing 200 to 600mcg a day helps reverse insulin resistance. Follow my Low-GL diet, which will not only address symptoms of PCOS but will also help to minimise the chance of associated conditions, as outlined above.
Controlling your blood sugar levels is key to managing this condition. The net result of stress, or a diet too high in sugar and refined carbohydrates, is an inability to keep blood sugar levels stable. When blood sugar levels shoot up – after sugar intake, a stimulant or stressful reaction – the body has to produce more insulin to get the sugar out of the blood and into body cells. Blood sugar then often rebounds too low – and when this occurs, the adrenal hormone cortisolCortisol has been nicknamed ‘the stress hormone’ as it is released in higher levels during the body’s flight or fight response to stress. Levels of… is often stimulated. This scenario of disturbed hormone balance has many undesirable knock on effects on health, including a greater risk for PCOS, PMS and an under-active thyroid gland (see my Special Report, The Great Thyroid Scandal) Ninety per cent of those with PCOS show this kind of hormone imbalance.
Taking simple steps, like combining protein with carbohydrates and eating healthy snacks to help control fluctuations in blood sugar, can greatly improve how your body handles insulin. If you have to have sugar, have xylitolXylitol is a completely natural sweetener that looks and tastes like sugar. It is naturally occurring in many fruits and vegetables….. Foods sweetened with xylitol will have virtually no effect on insulin levels, which makes it a perfect sweetener for people with diabetes as well as those wanting to lose weight. Using xylitol instead of sugar, as well as reducing intake of high-GL, refined carbohydrateCarbohydrates are the primary source of energy for the body as they can be broken down into glucose (sugar) more readily than either protein or… foods, helps to lower the risk not only of PCOS but also of ovarian cysts, fibroids, endometriosis, PMS, hot flushes, weight gain, and depression. You can buy xylitol from Totally Nourish.
Exercise
Regular exercise helps weight loss and also aids the body in reducing blood glucose levels and using insulin more efficiently. Aim for 20 to 30 minutes every day or twice this every other day. Maintaining a healthy weight is crucial in order to combat the debilitating symptoms of PCOS. Several studies have confirmed the link with obesity and infertility. American researchers demonstrated that obese girls at puberty had up to three times the level of free testosterone than non-obese girls. [9] Circulating insulin levels were also high. This scenario increases the risk of developing PCOS, and the health risks associated with it. Obesity also affects pregnancy outcomes and risks are increased for both mother and baby.
Associated conditions
As well as the common symptoms listed above, sufferers from PCOS can experience associated health risks, including a higher risk of miscarriage, high cholesterol, hardening of the arteries (atherosclerosis), high blood pressure, heart disease, type 2 diabetes and infertility. In fact, PCOS is the most common cause of female infertility. However, if diagnosed and treated early, risks for these complications may be minimised. Although PCOS is a complex condition, the good news is, that with the right nutritional approach, you can lose weight, improve your skin, overcome exhaustion, depression and mood swings. With a combination of diet, exercise, supplementation and relaxation, many of these problems can be reduced, or even eliminated.
For example, weight control through diet and exercise stabilises hormones and lowers insulin levels.
Diabetes
Approximately one-third to one-half of all women and adolescent girls with PCOS also has metabolic syndrome, which is associated with increased risk for cardiovascular disease and type 2 diabetes. By the age of 40, up to 40% of PCOS sufferers will have type 2 diabetes or impaired glucose tolerance. [10]
Lifestyle changes, such as improving your diet, combined with increased physical activity and weight reduction should reduce this risk. Insulin-sensitising drugs, such as Metformin, may also be recommended, although long-term studies are needed to determine the safety of these drugs as a long-term prevention. [11] In my opinion, chromium supplementation, at a dose of 200 to 600mcg a day, works just as well and is non-toxic up to 10,000mcg a day.
Gestational diabetes
Gestational diabetes occurs when a woman’s ability to process glucose during pregnancy is impaired. The mother’s high blood glucose levels can lead to a large baby, immature lungs, and problems for the mother and child at delivery. Since PCOS causes high glucose levels, women with PCOS are likely to be screened early for gestational diabetes during pregnancy.
A low-GL diet and/or insulin injections are generally used to manage gestational diabetes. Some doctors allow pregnant women with PCOS to continue taking metformin in pregnancy, while others won’t prescribe it to women trying to conceive. There is no evidence that it causes birth defects, but the long-term effects on the baby are not known. Chromium is an alternative. Women and their doctors should discuss the risks and benefits of medications. Women taking medication usually are monitored more closely.
Infertility
A woman’s ovaries have follicles, which are tiny, fluid-filled sacs that hold the eggs. When an egg is mature, the follicle releases the egg so it can travel to the uterus for fertilisation. In women with PCOS, immature follicles bunch together to form large cysts or lumps. It is thought that a slight elevation of male hormones (androgens) may inhibit the egg’s development and the egg’s failure to mature leads to a lack of ovulation (anovulation) in some women with PCOS. As a result, women with PCOS often don’t have menstrual periods, or they only have periods on occasion.
Some women with PCOS have periods, but do not ovulate. Because the eggs are not released, most women with PCOS have trouble getting pregnant. Women with PCOS may be prescribed fertility drugs, metformin or steroids (to lower androgen levels) to help ovulation take place. However, it would appear that the use of metformin to improve reproductive outcomes in women is limited. This was the conclusion of an analysis by the highly respected Cochrane Collaboration, which showed that the use of metformin, either alone or in combination with drugs to induce ovulation such as clomiphene citrate, does not increase the chance of having a successful pregnancy. They concluded that the long-term use of metformin in reducing the risk of developing metabolic syndrome is questionable. [11] Although they state that metformin is still of benefit in improving pregnancy and ovulation rates, there is no evidence that metformin improves birth rates.
Miscarriage
Women with PCOS have a higher rate of miscarriage. Increased levels of luteinizing hormone, which aids in secretion of progesterone, may play a role. Increased levels of insulin and glucose may also cause problems with development of the embryo. Insulin resistance and late ovulation (after day 16 of the menstrual cycle) also may reduce egg quality, which can lead to miscarriage. The best way to prevent miscarriage in women with PCOS is to normalise hormone levels to improve ovulation, and normalise blood glucose and androgen levels.
Summary
In summary, you can lessen the symptoms of PCOS with drugs, nutrition, exercise and reducing stress. But be aware that this is a lifelong metabolic derangement, which means you’ll need to be carefully monitored by your doctor.
There might come a day when PCOS can be controlled completely through lifestyle, but we’re not there yet. Two very good books to read if you have been diagnosed with PCOS are: PCOS: A Woman’s Guide to Dealing with Polycystic Ovary Syndrome by Colette Harris and Dr. Adam Carey; and PCOS Diet Book: How You Can Use the Nutritional Approach to Deal with Polycystic Ovary Syndrome by Colette Harris and Theresa Francis-Cheung. Colette Harris is a health journalist who herself suffers from the condition.
References:
1a. P.A. Essah et al., ‘The metabolic syndrome in polycystic ovary syndrome’, Clinical Obstetrics and Gynecology, 2007 Mar.;50(1):205-25
b.J. Vrbikova et al., ‘Insulin sensitivity in women with polycystic ovary syndrome’, J. Clin. Endocrinol. Metab, 2004 June;89(6):2942-5
c.J.E. Nestler and D.J. Jakubowicz, ‘Lean women with polycystic ovary syndrome respond to insulin reduction with decreases in ovarian P450c17 alpha activity and serum androgens’, J. Clin. Endocrinol. Metab, 1997 Dec.;82(12):4075-9
d.J.E. Nestler, ‘Role of hyperinsulinemia in the pathogenesis of the polycystic ovary syndrome, and its clinical implications’, Seminars in Reproductive Endocrinology, 1997 May;15(2):111-22
2.D. Cibula, ‘Is insulin resistance an essential component of PCOS?: The influence of confounding factors’, Human Reproduction, 2004 Apr.;19(4):757-9
3. T. Tang et al., ‘Insulin-sensitising drugs (metformin, rosiglitazone, pioglitazone, D-chiro-inositol) for women with polycystic ovary syndrome, oligo amenorrhoea and subfertility’. Cochrane Database of Systematic Reviews 2009, Issue
4. Art. No.: CD003053 4. J.E. Nestler, ‘Obesity, insulin, sex steroids and ovulation’, Int. J. Obes. Relat Metab Disord., 2000 June;24 Suppl 2:S71-S73
5a. M.A. La et al., ‘Metformin treatment of PCOS during adolescence and the reproductive period’, European Journal of Obstetrics, Gynecology, and Reproductive Biology, 2005 July 1;121(1):3-7
b.Tang et al., ‘Combined lifestyle modification and metformin in obese patients with polycystic ovary syndrome. A randomized, placebo-controlled, double-blind multicentre study’, Human Reproduction, 2006 Jan.;21(1):80-9
c. J.E. Nestler, ‘Should patients with polycystic ovarian syndrome be treated with metformin?: an enthusiastic endorsement’, Human Reproduction, 2002 Aug.;17(8):1950-3
d. J.E. Nestler et al., ‘Strategies for the use of insulin-sensitizing drugs to treat infertility in women with polycystic ovary syndrome’, Fertility and Sterility, 2002 Feb.;77(2):209-15
6. R. Homburg, ‘Should patients with polycystic ovarian syndrome be treated with metformin? A note of cautious optimism’, Human Reproduction, 2002 Apr.;17(4):853-6
7. J.M. Lord et al., ‘Metformin in polycystic ovary syndrome: systematic review and meta-analysis’, British Medical Journal, 2003 Oct. 25;327(7421):951-3
8. J.M. Lord et al., ‘Metformin in polycystic ovary syndrome: systematic review and meta-analysis’, British Medical Journal, 2003 Oct. 25;327(7421):951-3
9. . C.R. McCartney et al., Obesity and sex steroid changes across puberty: evidence for marked hyperandrogenemia in pre- and early pubertal obese girls, Journal of Clinical Endocrinology & MetabolismMetabolism is a term that is used to describe the chemical reactions that take place within the body’s cells. The body gets the energy it… 2007, Feb;92(2):430-6.
10. J.M. Lord et al., ‘Metformin in polycystic ovary syndrome: systematic review and meta-analysis’, British Medical Journal, 2003 Oct. 25;327(7421):951-3
11. P.A. Essah et al., ‘The metabolic syndrome in polycystic ovary syndrome’, Clinical Obstetrics and Gynecology, 2007 Mar.;50(1):205-25
12. T. Tang et al., ‘Insulin-sensitising drugs (metformin, rosiglitazone, pioglitazone, D-chiro-inositol) for women with polycystic ovary syndrome, oligo amenorrhoea and subfertility’. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD003053
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