Therapeutic lifestyle modifications play important role in PCOS management
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Key takeaways:
- Dietary changes or physical activity implementation improves menstrual regulation, glycemia and fertility.
- Women with PCOS also experience a higher risk for obstructive sleep apnea and insomnia.
DENVER — For women with polycystic ovary syndrome, therapeutic lifestyle modifications help to regulate menstruation, improve glucose metabolism and increase fertility, according to a speaker at the Lifestyle Medicine Conference.
PCOS is the most common and treatable cause of infertility, but 70% of cases go undiagnosed, according to Mahima Gulati, MD, FACE, DipABLM, FACLM, associate professor of endocrinology at Quinnipiac University in Hamden, Connecticut. PCOS is diagnosed by the presence of two of the following:
- signs or symptoms of high androgens;
- irregular or absent menses; and
- polycystic ovaries identified via ultrasound.
Gulati noted that therapeutic lifestyle modifications are the cornerstone of PCOS management. In her experience, women with PCOS taking metformin 1,000 mg twice daily who also implemented therapeutic lifestyle changes — such as substantially reducing consumption of ultra-processed foods and exercising at least 30 minutes daily — experienced regulated menstrual periods, glycemic improvements, normalized serum testosterone levels and lipid parameters, improved skin health and spontaneous conception without the need for IVF.
“If I give somebody a drug, and I intend to give it only to regularize their period, but their liver gets better, their skin gets better and their lipids get better, we call it a PCOS trophic effect,” Gulati said during the presentation. “They are affecting other target organs other than just what I intended. So, this is kind of a pills for all ills.”
International evidence-based PCOS guidelines recommend weight and lifestyle management, including diet, physical activity and behavior, as first-line therapies for managing PCOS. In a meta-analysis published in The Journal of Clinical Endocrinology & Metabolism, researchers assessed different diets, such as Dietary Approaches to Stop Hypertension (DASH), Mediterranean and calorie restriction, for managing PCOS and found that dietary therapy improves various parameters, including BMI, body weight and waist circumference. These improvements were also observed in a meta-analysis comparing diet with metformin therapy.
A 2023 review published in BMC Endocrine Disorders looked at studies of different modalities of physical activity, aerobic, resistance and combinations of high-intensity interval training and observed improvement in BMI, body fat percentage, waist circumference and total cholesterol.
In addition, Gulati highlighted a study from 2018 that evaluated studies of sleep disturbances and PCOS and found that women with PCOS had a higher risk for obstructive sleep apnea vs. women without PCOS. According to Gulati, elevated energy levels can lead to obstructive sleep apnea, which also elevates the risk for insomnia due to women with PCOS having disrupted rhythm or melatonin secretion. Disrupted sleep also worsens PCOS, Gulati noted: If a woman is chronically sleep deprived then she will experience more inflammation and insulin resistance.
Gulati also highlighted how smoking increases the risk for metabolic syndrome, high blood pressure, increased fasting insulin and increased testosterone levels compared with not smoking.
“Tobacco is such a big oxidative stress for the body. So, no wonder all these cardiometabolic parameters in women with PCOS reverse with tobacco [cessation],” Gulati said. “We need to consider [advising] PCOS patients to quit smoking because that aggravates their cardiometabolic risk.”
In addition, alcohol consumption of less than one drink weekly among women with PCOS is independently associated with histologic nonalcoholic steatohepatitis. Finally, in vitro and animal studies demonstrated that marijuana, cocaine and opioid use all may disrupt ovulatory function, fertility and menstruation, Gulati said.
References:
- Cowan S, et al. BMC Endocr Disord. 2023;doi:10.1186/s12902-022-01208-y.
- Fernandez RC, et al. Nat Sci Sleep. 2018;doi:10.2147/NSS.S127475.
- Shang Y, et al. J Clin Endocrinol Metab. 2020;doi:10.1210/clinem/dgaa425.
Perspective
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PCOS is the most common hormonal disorder of women, affecting between 10% and 15% of all women globally. It is associated with increased risks for diabetes, heart disease, stroke, anxiety, depression, eating disorders, menstrual irregularity, infertility, pregnancy complications, hirsutism, female scalp hair loss and acne, among other issues. Treatments for PCOS vary, depending on what the symptoms and signs requiring treatment are, and may include combination estrogen and progestins, antiandrogens and insulin sensitizers, accompanied by cosmetic and other therapies.
The rate of obesity among women with PCOS is slightly higher than that of the general population, although it is important to recognize that most women with PCOS are not obese. Even in the U.S., with its massive obesity epidemic, the rate of obesity among PCOS women is 40% to 50%, with more than half of women with PCOS not being obese. Nonetheless, the rate of obesity in women with PCOS is increasing, just as it is for the general population.
Lifestyle modification, including dietary regulation and control and enhanced weight bearing and non-weight bearing exercise, has been advocated for women with PCOS. Improved sleep behavior is also critical. While it is clearly indicated for women with PCOS who are overweight or obese, we should recognize that lifestyle improvements will benefit the vast majority of women with PCOS.
However, it is also important to recognize that lifestyle modification is but one of many avenues for treating PCOS and should not be used as the sole therapy for women with PCOS. It is also important to recognize that, even under study conditions, the vast majority of women fail to remain compliant with their prescribed diet and exercise regimen. We should advocate for lifestyle modification for all PCOS women, as we should in all our patients, but should understand that it is difficult to maintain and needs to be used in combination with other targeted therapies.
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Gulati M. Lifestyle medicine’s role in common hormonal disorders. Presented at: LM2023 Lifestyle Medicine Conference; Oct. 29-Nov. 1, 2023; Denver (hybrid meeting).
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