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presented by
Martha McKittrick RD, CDE
Website: MarthaMcKittrickNutrition.comBlog: CityGirlBites.com Contact: [email protected] Twitter: @citygirlbites
Provide background information on PCOS
Discuss the role of insulin resistance in PCOS
Diagnosing & treating PCOS
Provide the RD with guidance for lifestyle education for the patient with PCOS
Part One: Background Information on PCOS
PCOS was first identified by Stein & Leventhal in 1935
They described a group of women who were obese and infertile, with enlarged ovaries and multiple cysts
Few of these original features are now considered consistent findings in PCOS
PCOS is possibly the most common hormone abnormality that exists!
Up to 10% of all females have PCOS
6 million American women have PCOS
#1 cause of anovulatory infertility
PCOS is a complex hormonal disturbance that affects the entire body
It has numerous implications for general health and well being
It can affect all females – from adolescence to post menopause
Accounts for ~ $40 billion yearly in the U.S. Dr. Azziz
80%+ show PCO on ultrasound (but having PCO does not mean PCOS!)
40 – 80% will have a fertility problem
60 - 80% hirsuitism
40 - 70% scalp hair thinning (alopecia)
75 - 90% irregular menstrual periods
40 - 60% acne
70% - hyperlipidemia (often low HDL, high LDL)*
10% - acanthosis nigricans
* Legro RS, et al, Am. J. Med. 111, 607-613 (2001).
Acanthosis nigricans
Hirsutism
Alopecia
Insulin resistance (up to 80% of women with PCOS)
Metabolic syndrome (~ 1 in 3 women with PCOS)
Increased risk of diabetes/prediabetes (> 50% will get this by age 40)
Obesity (~ 50% of women with PCOS)
Endometrial Cancer
Obstructive sleep apnea
HTN
Mood disorders
Increased incidence of mood disorders (i.e. depression or anxiety, or to engage in bingeing). Certain features of PCOS may contribute to the increased risk of mood disorders. For example:
Abnormal levels of androgens and other hormones are related to mood disorders
Obesity is linked to mood disorders as well as to abnormal hormone levels. Studies show that the risk of mood disorders is even greater among women with PCOS who are also obese
http://www.nichd.nih.gov/health/topics/PCOS/conditioninfo/Pages/default.aspx
Heart disease
Inflammation
Pregnancy complications
Conclusions: Women with PCOS
Obesity, Cig. Smoking, Dyslipidemia, HTN, IGT, Subclinical Vascular Dz = At risk
Whereas those with metabolic syndrome and/or type2 DM = High risk
http://www.pcoschallenge.org/symposium/2014-presentations/pcos-preventing-cardiovascular-disease-gregorry-pokrywka.pdf
The absence of the important cardiometabolic risk factor represented by obesity often misguides clinicians when lean PCOS patients are evaluated
Actually, IR even in lean women represents an important risk factor for glycometabolic and cardiovascular sequelae
http://www.sciencedirect.com/science/article/pii/S001502821400315X
Research suggests that PCOS associated with long-term, low-grade inflammation polycystic ovaries to produce androgens
Inflammation is associated with hardened arteries major risk factor for heart attack & stroke.
? inflammation results from obesity and metabolic dysfunction or whether it’s an independent symptom of the disorder
Spontaneous Abortions- increased in high BMI/PCOS pts
Impaired Glucose Tolerance
Gestational Diabetes
HTN
Small for Gestational Age http://www.pcoschallenge.org/symposium/2014-
presentations/pcos-improving-feritliy-mark-perloe.pdf
Likely a Genetic & Environmental component
Genetic. Research has found subtle changes in insulin receptor gene which may alter its function in the ovaries. It is known that insulin is capable of stimulating the ovaries to produce testosterone which causes many of the symptoms of PCOS
Combination effect of pituitary lutenizing hormone (LH) & insulin on stimulating the ovary to produce excessive male hormone (androgens). Obesity magnifies this.
Intrinsic enzymatic abnormalities have been demonstrated in the ovaries as well as the adrenal glands
Part Two: Role of Insulin Resistance in PCOS
IR is a condition where cells do not adequately respond to insulin
IR appears to result from several defects in the relationships among insulin, its receptor, and the genome
IR increases with age and is aggravated by obesity IR is exacerbated at puberty and in pregnancy
http://www.pcospregnancy.net/insulin-resistance.htm
Stimulation of ovarian and adrenal androgen production
Stimulation of pituitary luteinizing hormone (LH) secretion
Inhibition of hepatic sex hormone binding globulin (SHBG) production, leading to a reduced total testosterone in men and increased free testosterone in women
Increased risk of miscarriage
Increased BP Low HDL, high TG Increased apolipoprotein B levels Small dense LDL cholesterol particles Increased fibrinogen levels Increased C reactive protein and other
inflammatory markers Increased thickening and pigmentation of
skin (acanthosis nigricans) Premature atherosclerosis
Can also lead to
Increased food cravings
Weight gain and/or difficulty losing weight
Diagnosing Insulin Resistance is tricky!!
Insulin levels vary throughout the day
Normal range is up to 18, however many experts feel any number over 8 is high
Test Interpretation Fasting insulin 8-14 mU/L mild IR(not very accurate test!) > 14-18 moderate –
severe
Fasting glucose/insulin < 4.5 (< 7.0 in adolescents)ratio
Oral glucose tolerance Normal: 2 hr < 140test Impaired: 2 hr 140-199
Diabetes: 2 hour glucose ≥200
HOMA (Homeostasis Model Assessment) < 2 = normal, 2.2 - 3 = moderate, > 3 = severe
Hyperinsulinaemic glucose clamp “gold standard” – but rarely used
Other clues of IR:Elevated LH/FSH ratioLow SHBGLow HDL and/or TGUpper-body obesity
Acanthosis nigricans BMI > 25 (or waist circumference > 35” in women)
Fam hx of type 2 diabetes or glucose intolerance Age > 40
Study: 72% of overweight/obese pts with PCOS were IR compared to 26% lean
Hypothesized that lean PCOS pts could be affected by an “intrinsic” form of IR whereas obese patients have a combined form of IR due in part to the syndrome itself and in part to the weight excess. In fact, lean PCOS patients could be considered to be a “unique model” to study the natural history of IR per se, because the IR occurs in the presence of normal glucose
http://www.sciencedirect.com/science/article/pii/S001502821400315X
10.3% of lean PCOS have IGT and 1.5% have diabetes. In long-term f/u, 16% of women who had been treated for PCOS 20–30 yrs. earlier had developed DM by menopause. The etiology of the insulin resistance is unclear, but suppression of the excess androgens does not alter the insulin resistance
Even in lean PCOS, a higher waist-to-hip ratio is seen in those with PCOS compared to those without PCOS. This is supported by the higher proportion of visceral adiposity measured by ultrasound in lean PCOS patients compared to weight-matched control subjects
Obese women with PCOS have greater insulin resistance than weight-matched control subjects or lean PCOS subjects http://clinical.diabetesjournals.org/content/21/4/154.full
Part Three : Diagnosing and Treating PCOS
Symptoms and physical exam
Hormonal testing
Ultrasound
Much controversy on what the proper diagnostic criteria are!
Using the Rotterdam criteria, a woman with 2 of the 3 cardinal features that characterize PCOS may have the condition:
Hyperandrogenism (androgen excess) based on:-sx: acne, excessive hirsutism or male-pattern hair loss -elevated circulating levels of androgens (usually
testosterone)
Ovulatory dysfunction – can be manifested as oligomenorrhea or infrequent menstruation
Small cysts on the ovaries as seen on ultrasound.
Legro BMC Medicine (2015) 13:64
http://womenshealth.gov/publications/our-publications/fact-sheet/polycystic-ovary-syndrome.html#j
Individualization is essential
Regulation of cycle Promote weight loss Correction of metabolic abnormalities
- Cholesterol, glucose, insulin resistance, blood sugar, HTNDecrease androgens - Skin, hairImprove FertilityImprove overall well-being
Traditional: the individual symptoms were treated
◦ BCP, anti-androgens, fertility treatments
More recent: targets insulin resistance as well as the individual symptoms
◦ Traditional treatments as above as well as weight loss/exercise and insulin sensitizing agents (ISA)
Lowers blood glucose Slows release of glucose from liver Decreases insulin resistance in muscle
Lowers androgen and insulin levels May lower LDL May aid in weight loss Off label usage in PCOS Helps overweight and normal weight
women achieve ovulation
Gastrointestinal intolerance in 30% (take with meal)
Contraindications:- Creatinine ≥1.4 mg/dL (for women)- Liver disease (or risk thereof: alcohol
abuse/binge drinking)- Other risks for lactic acidosis: pulmonary
disease, congestive heart failure
Dosages range from 500-1000 mg bid. Start slow!!
May need B12 supplement
Has been shown to restore regular menstruation in > 90% amenorrheic adolescents, restoring ovulation in 80%
More effective at restoring ovulation than clomiphene
Potentiates the effect of clomiphene Taken during the 1st trimester, reduces
miscarriage rate by 80%
However – not every women needs Metformin!
Benefits Include:
Increased regularity of menstrual cycles Decreased levels of androgens Improvement in lipid levels Decreased risk of diabetes Improves insulin sensitivity
Part Four: Lifestyle Counseling Tips
- exercise- nutrition- counseling session - practical tips
Weight training ? Card
io?
HIIT?
Movement ?
- Enhances both GLUT4-dependent and hypoxia-dependent glucose transport in skeletal muscle
- Increases skeletal muscle vascularization, mitochondrial neobiogenesis and eventually tissue mass
- Repartitions intracellular fat, thereby improving its utilization
- Fat mass loss
Physical Activity and Insulin Sensitivity The RISC Study Diabetes. 2008 Oct; 57(10):
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2551669/
Aerobic exercise increases insulin sensitivity (especially in skeletal muscle) from ~ 25-50% in all ages, gender, body weights
A systemic review of 20 studies found that supervised resistance training improved glycemic control and
insulin sensitivity in a wide variety of study groups
*however this review showed that RT compliance and glycemic control are generally less without supervision
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4129661/#R278
HIIT demonstrates improved insulin sensitivity
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4129661/#R278
RISC Study: activity has beneficial effects on insulin sensitivity
Total accumulated activity was the important factor rather than intensity of the activity. More movement during the day as well as from exercise, accumulated to exert a beneficial effect on insulin sensitivity
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4129661/#R278
Increases insulin sensitivity
Decreases blood pressure
Raises HDL, decreases TG
Burns calories
Increases lean mass
Aids in stress management
Lowers fasting glucose
Anything is better than nothing Get a baseline and increase from there Ideally 3 aerobic and 2 weight training
sessions a week (but not many can do this!) Suggest some HIIT sessions in motivated fit
patients Increase everyday movement Consider activity tracker Beware of “over-exercisers”
In PCOS, women who self-reported 8 hours of sports activities per week had improvement in acne and menstrual irregularities
Exercise as the primary intervention without attendant weight loss (< 5% weight loss) improved insulin sensitivity and free testosterone index and induced ovulation in 9 of 18 obese PCOS patients Julie L. Sharpless, MD http://clinical.diabetesjournals.org/content/21/4/154.full
No one eating plan works for everyone
Realistic, livable eating plan
Long term healthy diet to decrease health risks
If overweight, lose 5-10% of body weight
Low glycemic seems to work best
•PMH•Symptoms (menstrual history, skin, hair, weight)
•Labs (full lipid profile, glucose, insulin, GTT)
•Meds (BCP, anti-androgen, insulin sensitizer, etc.)
• Family hx of PCOS, diabetes, heart
disease
Obtain medical history (including fam. hx), as well as labs, meds, supplements
Ask about symptoms Obtain weight, diet history Ask about “food/mood/energy level” link Provide education on PCOS Discuss exercise Address sleep, mood, sitting time Develop individually tailored meal plans Set realistic goals Maintain supportive demeanor Develop referral network
Hormonal imbalance
Explain insulin resistance
How food affects insulin & glucose levels
Importance of weight loss (even 5-10% of body weight
Role of exercise in lowering insulin levels
Lose weight if overweight
Exercise
Do not smoke
Low glycemic index diet
Medications (insulin sensitizing agents)
Do you feel tired soon after eating a highcarb meal and / or does this meal trigger sugar cravings?
Do meals higher in protein and fat make youfeel more energetic?
Do you feel very tired or irritable if you go for more than 4
hours without eating?
Do you constantly crave carbs?
Is your LDL cholesterol high? Are your triglycerides high?
Calorie control if weight management needed
Low glycemic
Ideally combine “healthy” carb + protein + fat at meals. Promotes satiety and may help prevent insulin spikes
Anti-inflammatory foods
Heart healthy diet
Consume adequate omega 3 fats (supplement if needed)
Magnesium rich foods
Adequate sleep
Stress management
Exercise: cardio & weight train & movement
Pay attention to how foods make you feel
Supplement if needed (Vit B12, Vit D, ? Omega 3, others?)
Endocrine disruptors BPA Phthalates (some) Pesticides Perchlorate Cosmetics, Fragrances ArsenicHormonesAntibiotics I don’t really address these – just food for thought!
Be Fruitful Victoria Maizes MD Integrative Healthcare Symposium, NYC
Inositol and PCOSInositol and PCOS
•Inositols are C6 sugar alcohols of cyclohexane
•There are 9 stereoisomers of inositol, including
myo-inositol and D-chiro-inositol
•Inositol is a component of the inositolphosphoglycans (IPGs) which are “secondary messengers” in insulin signaling
•Insulin resistance appears to be a main underlying metabolic derangement in PCOS, possibly due to a defect in IPG signaling
•Published studies confirm that inositol supplementation can improve insulin sensitivity, reduce serum levels of insulin, testosterone, and LH, and induce ovulation in women with PCOS
Myo-inositol and hormone, metabolic, and Myo-inositol and hormone, metabolic, and ovulation induction effects in women with PCOSovulation induction effects in women with PCOS
•Myo-inositol increased ovulation rates and improved metabolic factors. Gerli, 2007
•Myo-inositol decreased insulin and testosterone levels and improved metabolic factors. Costantino, 2009
•Myo-inositol improved insulin sensitivity and decreased LH and LH/FSH ratio. Artini, 2013
•Myo-inositol improves insulin resistance and hormonal parameters in non-obese women. Genazzani, 2014
Myo-inositol and Egg Quality Myo-inositol and Egg Quality in Women with PCOSin Women with PCOS
•Myo-inositol decreased the number of days of stimulation, reduced E(2) levels at hGC administration, and decreased degenerated oocytes without compromising total number of oocytes retrieved. Papaleo, 2009
•Myo-inositol increased number of oocytes retrieved and embryos transferred, and improved embryo scores. Ciotta, 2011
•Myo-inositol, but not D-chiro-inositol, improved egg and embryo quality during ovarian stimulation. Unfer, 2011 -
•In women without PCOS, myo-inositol significantly reduced number of ooctyes retrieved, with no change in clinical pregnancy rate. Lisi, 2012
Myo-inositol + D-chiro-inositolMyo-inositol + D-chiro-inositol
•Research indicates that a combination of myo- and D-chiro-inositol, in the body’s physiological ratio of 40:1, is more beneficial than either alone.
• This combination improved metabolic parameters more than myo-inositol alone after 3 months of treatment in overweight women with PCOS. Nordio and Proietti, 2012
•This combination improved lipid profile in obese women with PCOS. Minozzi, 2013
•This combination (vs. D-chiro-inositol alone) improved egg and embryo quality, and pregnancy rates, in women with PCOS undergoing IVF. Colazingari, 2013
Inositol: Treatment considerationsInositol: Treatment considerations
•Inositol is safe and relatively inexpensive
•Reasonable evidence of benefit in PCOS, but may be counterproductive in non-PCOS patients
•Available from multiple sources online or in retail outlets
•Typical recommended daily dose: 2 grams, bid
•Typical treatment regimen of 3-6 months
•Myo-inositol vs. Metformin- in one study, women taking 4 g myo-inositol had higher pregnancy rates and percentage restored ovulation than women on 1500 mg Metformin (Raffone, 2010)
NAC is an antioxidant & amino acid
Derivative of the amino acid L-cysteine, an essential precursor used by the body to produce glutathione
Glutathione is an antioxidant produced by the body to help protect against free radical damage, and is a critical factor in supporting a healthy immune system.
NAC has also been found to reduce inflammation, heart disease and most recently, insulin
http://www.pcosnutrition.com/links/blogs/nac-and-pcos.html
Improved menstrual regularity but has not been shown to help improve fertility in women with PCOS.
NAC may help improve insulin resistance in women with PCOS who have high insulin levels and could be used with metformin or if metformin isn't an option.
NAC also seems to have a favorable effect of lowering cholesterol, TG and testosterone
http://www.pcosnutrition.com/links/blogs/nac-and-pcos.html
Systematic review and meta-analysis of randomized controlled clinical trials
8 studies with a total of 910 women with PCOS were randomized to NAC or other treatments/placebo. RESULTS:
NAC showed significant improvement in pregnancy and ovulation rate as compared to placebo
No significant difference in rates of the miscarriage, menstrual regulation, acne, hirsutism, and adverse events, or change in body mass index, testosterone, and insulin levels with NAC as compared to placebo.
More studies are needed
Obstet Gynecol Int. http://www.ncbi.nlm.nih.gov/pubmed/25653680 2015
Combination of CoQ10 and clomiphene citrate in the treatment of clomiphene-citrate-resistant PCOS patients improves ovulation and clinical pregnancy rates.
It is an effective and safe option and can be considered before gonadotrophin therapy or laparosc
http://www.ncbi.nlm.nih.gov/pubmed/?term=Coenzyme+Q10+and+pcos opic ovarian drilling