POLYCYSTIC OVARIAN

SYNDROME
DEEPTI VERMA
PCOS – Overview
A study by the department of endocrinology and metabolism (AIIMS)
revealed that about 20-25 percent of Indian women of childbearing age
are suffering from PCOS. Further, it stated that 60 per cent of women
with PCOS suffer from obesity, 35-50 per cent has a fatty liver, about 70
per cent has insulin resistance, 60-70 per cent has a high level of
androgen, and 40-60 per cent struggle with glucose intolerance.
PCOS
Polycystic ovary syndrome (PCOS), also referred to Polycystic Ovarian Disease, is a
set of symptoms due to elevated androgens (male hormones) in females. Signs
and symptoms of PCOS include irregular or no menstrual periods, heavy periods,
excess body and facial hair, acne, pelvic pain, difficulty getting pregnant, and
patches of thick, darker, velvety skin. Associated conditions include type 2
diabetes mellitus, obesity, obstructive sleep apnea, heart disease, mood disorders
and endometrial cancer.
PCOS
Polycystic ovarian syndrome, or PCOS, is a common lifestyle disorder in reproductive women
and a leading cause of infertility. As per estimates, it affects up to 1 in 10 women of child-
bearing age. PCOS is a hormonal disorder that is characterized by imbalances in reproductive
hormones (like estrogen and testosterone) and hormones that regulate blood sugar, fat storage,
and appetite. These hormonal imbalances result in enlarged ovaries with small cysts on the
outer edges.
If not controlled at an early stage, PCOS may lead to many lifestyle disorders in the later stage
of life. PCOS is strongly associated with obesity, but there are also lean women who suffer from
this condition. However, most women with PCOS suffer from insulin resistance, which is also
known as pre-diabetes.
Symptoms of PCOS
Painful or irregular periods
Acne
Increased appetite
Weight gain
Difficulty losing weight
Women with PCOS often develop metabolic syndrome,
Amenorrhoea (missed periods) or irregular periods
Fatigue
Unwanted hair growth (excessive facial hair)
Thinning hair on the head
Mood changes
Sleep problems
Infertility
Depression
increases your risk of heart disease and diabetes.
Anatomy of the Ovaries
The ovaries are oval shaped and about the size of a large grape. They are located on opposite ends of the pelvic
wall, on either side of the uterus. The ovaries are each attached to the fimbria (tissue that connects the ovaries to
the fallopian tube).
 OVARIES ESSENTIALS
The ovaries maintain the health of the female reproductive system.
They secrete two main hormones—estrogen and progesterone.
The ovaries are a pair of ova-producing organs (that is, they produce egg cells) that maintain the health of the
female reproductive system. The ovaries, like their male counterpart, the testes, are known as gonads. This simply
means they are the primary reproductive organs.

In addition to their role in producing ova, the ovaries also have the distinction of being an endocrine gland because
they secrete hormones—primarily estrogen and progesterone—that are vital to normal reproductive development
and fertility.
HORMONES OF THE OVARIES
Ovaries produce and release two groups of sex hormones—progesterone and estrogen. There are actually three
major estrogens, known as estradiol, estrone, and estriol. These substances work together to promote the healthy
development of female sex characteristics during puberty and to ensure fertility.
Progesterone and Estrogen Production and Function
Progesterone and estrogen are necessary to prepare the uterus for menstruation, and their release is triggered by
the hypothalamus.
Once you reach puberty, the ovaries release a single egg each month (the ovaries typically alternate releasing an
egg)—this is called ovulation. The hypothalamus sends a signal to the pituitary gland to release gonadotrophic
substances (follicle stimulating hormone and luteinizing hormone). These hormones are essential to normal
reproductive function—including regulation of the menstrual cycle.
Aetiology
It is a heterogeneous disorder. It can be
◦ Genetic
◦ Environmental

I. GENETIC
◦ Begins in utero and manifests clinically during puberty
◦ Continues during the reproductive years
◦ High androgen levels secreted by ovarian follicle theca cells. It determines hyperandrogenism by acting synergically with
luteinising hormone (LH) on ovarian steroidogenic enzymes
◦ Increases risk of CVD, hypertension, diabetes and metabolic complications especially after menopause.
◦ During fertile period it may cause anovulatory infertility and could be associated with increased prevalence of gestational
complications such as miscarriage, gestational diabetes and pre-eclampsia. Early diagnosis reduces the risk of such
complications.
Aetiology
II. ENVIRONMENTAL FACTORS
◦ Environmental toxins
◦ Diet and nutrition
◦ Socio-economic status
◦ Geography
◦ Exposures during pre-natal period
◦ Epigenetic factors (genes/heridity)
◦ Obesity
Pathology
Pathology
◦ Abnormal Pituitary function – Altered negative feedback loop

◦ Increased GnRH from hypothalamus LH controls the production of female hormones

(estrogen and progesterone) in the ovary and FSH controls the development and
release of eggs in the ovary.

◦ LH receptor is over-expressed in theca cells

◦ Excessive LH secretion relative to FSH by pituitary gland
◦ LH stimulated excessive androgen production in the ovarian theca cells
◦ Excess intra-ovarian androgen results in excessive growth of small ovarian follicles
◦ Low levels of FSH leads to inhibition of follicular maturation leading to anovulation
Pathogenesis
I. HYPERANDROGENISM
◦ More free testosterone
◦ Insulin insensitivity
◦ Lipid abnormalities
◦ Symptoms of excess androgen
◦ 50% - 90% patients have elevated serum androgen levels
◦ Causes hirsutism, acne, male pattern balding, alopecia, deepening of voice

II. INSULIN RESISTANCE

◦ Is independent of obesity
◦ Increased risk for impaired glucose tolerance and type-2 diabetes mellitus
◦ Obese women in PCOS tend to be more insulin resistant than normal weight women
◦ 30% - 40% prevalence of glucose intolerance
◦ 7% - 10% prevalence of type-2 diabetes mellitus
◦ Insulin resistance
◦ It favors anovulation, androgen excess
◦ Insulin resistance worsens over time
Pathogenesis
III. MENSTRUAL DYSFUNCTION
◦ Irregular or no periods
◦ Oligo or Amenorrhea typically begins in the peri pubertal period
◦ Reduction in ovulatory events leads to deficient progesterone secretion
Diagnosis of PCOS
Polycystic means “many cysts.” Interestingly, the National Institutes of Health (NIH) criteria for
diagnosing PCOS do not require the presence of polycystic ovaries by pelvic ultrasound. The NIH
criteria are based on signs of hyperandrogenism (or elevated androgens) and
oligo/amenorrhea. Other key characteristics include infertility, irregular menstruation, acne,
and increased hair growth on the face and body.

PCOS is essentially caused by a hormone imbalance—many of the symptoms are caused by

increased production of androgens. These patients usually have high free testosterone levels.
Androgen excess is the most common endocrine disorder in women of reproductive age.
Androgens are produced primarily from the adrenal glands and the ovaries.
ANDROGENS and PCOS
Androgens are often referred to as the “male” hormones, but these hormones are present and essential in both
men and women. They are vital to normal reproductive function, emotional well-being, cognitive function, lean
muscle function and growth and bone strength. In fact, it’s a fact that women have more androgens than
estrogens circulating in their body. (That said, men produce more androgens than women)
Androgens play many roles in the human body. Some androgen hormone effects include the stimulation of body
and pubic hair growth, sexual desire (libido), muscle growth, and fat cell action and location. In both men and
women, androgens are the precursor to estrogens. The androgen-into-estrogen action is one of the primary roles
of androgen hormones in women.
In women, androgen hormones are created in the adrenal glands, the ovaries, and in fat cells.
High Androgens and PCOS
Peripheral Insulin Resistance

Pancreas releases more Insulin (Hyperinsulinimia)

Stimulates the Ovaries to release Ovarian Androgens Decrease in SHBG (Sex hormone binding globulin) in
the liver , which results in increase in free androgens

Hampers Growth of Ovarian Follicles

More peripheral Insulin resistance

Causes Diabetes
What happens in the Ovaries
Polycystic Ovaries means
1. Presence of 12 or more follicles in either ovary measuring 2 to 9 cms

OR

2. Increase in ovarian volume (More than 10ml)

What Is Hyperandrogenism
◦ Hyperandrogenism is when androgens are higher than they should be or there are clinical
signs that androgens are higher than they should be
◦ There are two “kinds” of hyperandrogenism: clinical and biochemical. Having either kind may
qualify a woman as having PCOS.
◦ Clinical hyperandrogenism is when there are visible signs or symptoms that indicate that
androgen production may be higher than expected. These are things that can be seen or
experienced without medical testing. Biochemical hyperandrogenism is when lab work
shows abnormally high levels of androgen hormones in the bloodstream. In women, normal
testosterone levels range from 15 to 70 nanograms per deciliter (ng/dL) of blood.

◦ In women, normal testosterone levels range from 15 to 70 nanograms per deciliter (ng/dL) of
blood. In adult males its 240 – 950 ng/dl
Dietary Management of PCOS
◦ Cut down on calories, specially in the evening Cumulative Calorie Consumption
◦ Studies have shown that a calorie restricted diet may help 16000
normalize hormones, induce ovulation and treat infertility. Most
health professionals recommend creating a calorie deficit of 14000 14000
3500 – 7000 calories per week for healthy and successful
weight loss. (generally patients are overweight) 12000

◦ It is generally recommended to spread the calories throughout 10500

10000
the day by having 5-6 meals Normal Person
◦ This will keep the metabolism high and reduce craving for 8000
PCOS Patient

sweets and starches

6000

◦ Favor MUFA and PUFA 4000

◦ Monounsaturated and polyunsaturated fats help fight insulin

2000
resistance associated with PCOS (clinical trials demonstrate that
high levels of dietary fat can impair insulin sensitivity
0
independent of body weight changes) 1 2 3 4 5 6 7
Dietary Management of PCOS
◦ Choose low GI carbs
◦ Low GI carbs take longer to digest and cause only a small slow
rise in blood glucose and insulin levels
◦ In addition, low GI foods reduce craving as they provide body
with slow steady supply of energy
◦ Most non-starchy vegetables, legumes and fruits have a low GI
rating while most refined carb rich foods are rated high on
Glycemic Index

◦ Low GI is likened to foods having high fibre content.

Dietary Management of PCOS
◦ Load on B Vitamins
◦ The B vitamins help beat PCOS symptoms
◦ Vitamin B2
◦ It helps convert dietary fat, protein and carbs into energy
◦ Vitamin B3
◦ It helps maintain normal blood sugar levels
◦ Vitamin B5 (pantothenic acid)
◦ It helps with weight loss due to its ability to control fat
metabolism
◦ Vitamin B6 (pyridoxine)
◦ It plays a critical role in maintaining a woman’s hormonal
balance and fertility
◦ It is also needed for proper absorption of Zinc in the
intestines
◦ Vitamins B2, B3 and B6 are essential for normal
thyroid function and metabolism and then can help
reduce excess body weight
Dietary Management of PCOS
◦ Ensure sufficient intake of calcium and Vitamin D
◦ Calcium plays an important role in egg maturation and follicle
development in the ovaries
◦ Vitamin D is essential for promoting calcium absorption from
food in the intestines
◦ Low levels of Vitamin D have also been associated with other
problems related to PCOS including infertility, weight gain and
insulin resistance

◦ Consume foods rich in Zinc

◦ Zinc is known to exert beneficial effects on at least two common
conditions with PCOS namely Acne and Obesity
Dietary Management of PCOS
◦ Eat plenty of foods containing Magnesium
◦ Research indicates that there is a strong link between
magnesium deficiency and insulin resistance associated with
PCOS
◦ Magnesium appears to be the most common micro-nutrient
found to be depleted in insulin resistant people and diabetic
patients (includes foods like pumpkin seeds, almonds, guavas,
peanuts, spinach etc

◦ Eat foods that contain Chromium

◦ Chromium is a component of the glucose tolerant factor (GTF)
which helps maintain normal blood glucose levels by making
insulin more efficient
◦ This will fight insulin resistance which is associated with PCOS
◦ Chromium also promotes weight loss due to its ability to help
control cravings, reduce hunger and control fat in blood
◦ Good dietary sources of chromium include onions, tomatoes,
whole grains, potatoes, red wine, broccoli and whole wheat
breads like chapatis
Dietary Management of PCOS
◦ Consume Green tea
◦ Consuming Green tea leads to weight loss
◦ Decrease fasting insulin
◦ Decreases level of free testosterone

◦ Consume Chamomile tea

◦ Chamomile tea contains phytosterols which reduce androgenic
hormone synthesis specially testosterone

◦ Consume Flaxseeds
◦ They are rich in Omega and Fatty acids
◦ Richest source of dietary lignan
◦ Decrease androgen levels
◦ Normalize lipid levels
Dietary Management of PCOS
◦ Foods to Eat
◦ Green leafy vegetables like palak, methi and bathua
◦ Fruits like Strawberries, guava, pear, lemon, orange, watermelon, apple, kiwi
◦ Vegetables like tomato, capsicum, onion and broccoli
◦ Healthy fats like nuts, flaxseeds, olive oil, mustard oil
◦ Low GI foods like rajma, chhole, lobia, whole cereal
◦ Lean protein like fish, chicken and pulses
◦ Foods to avoid
◦ High GI foods like sugar, bakery, candies
◦ Dairy like butter, cheese, full cream milk
◦ Unhealthy fats like ghee, coconut oil, trans fat
◦ Alcohol
◦ Caffeine
◦ Processed foods like bread and biscuits
◦ Table salt
Dietary Management of PCOS
◦ Healthy Living Guidelines
◦ Minimize whole fat dairy products such as butter and whole milk
◦ Avoid dietary cholesterol consumption
◦ Use low fat cooking methods like baking, broiling, grilling and boiling rather than frying
◦ Use liquid vegetable oils

◦ Optimal Meal Patterns

◦ Eating small frequent meals and snacks not only decreases food cravings but also provides steady flux of energy
and help prevent low blood sugar
◦ Consume breakfast within one hour of walking
◦ Snacks 2-3 hours later
◦ Eat lunch 2 hour later
◦ Another snack 2-3 hours later
◦ Dinner 2 hours later
Nutrients and PCOS
Energy – The energy consumption in PCOS is generally kept low. The patient should be given about 500 Kcal lesser than
required if she is overweight and obese.
The key is to give weight loss as obesity increases the chances of increased testosterone and androgens and also causes
insulin resistance.

Women with PCOS do well with a macro breakdown of 55% carbs, 25% protein, and 20% fat. This will help us to feel more
satiated after meals, provide enough fiber to maintain good gut health and provide us with enough energy for our daily
routine
Carbohydrate
◦ Women with PCOS fear carbohydrates. While it is important to monitor your type and amount of carbohydrates, there is no
reason to fear them as they offer important nutrients for PCOS.
◦ A healthy diet in PCOS should contain whole-grain carbohydrates, 3 to 5 servings of vegetables, and 2 to 4 servings of fruit
each day.
◦ Select green-leafy vegetables whenever possible, and try to limit starchy vegetables like peas, corn, and potatoes. Fruit
makes a great dessert or snack instead of processed sugars like cookies or cake.
◦ Try to avoid white and refined grains, and choose instead whole-grain bread, pasta and cereals.
Fat
Diets high in saturated fat has been linked to heart disease. These diets could be especially dangerous for women with PCOS,
as they already have an increased risk of heart disease.

Visible saturated fat should be avoided especially if female is overweight or obese. PUFA and MUFA is [referred fat. Hence its
advisable to take groundnut oil, mustard oil, sunflower oil, soyabean oil, olive oil etc.

Omega 3 fatty acid is a preferred source of fat in PCOS. Omega 3 fats (fatty fish such as salmon and bluefish, flaxseed, nuts)
as these fats are heart healthy.
For heart health, limit foods high in saturated and trans fats (ie fatty red meat, whole milk dairy, butter and margarine,
chicken skin, fried foods, rich desserts, etc.
Protein
For women with polycystic ovary disease (PCOS) increasing dietary protein may be a helpful strategy for preventing weight
gain, prediabetes and type 2 diabetes— all common complications of the condition.
This is because in addition to fueling the body with calories (along with carbohydrates and fats) and providing the so-called
building blocks for bones, muscles, skin, and blood. Protein helps facilitate digestion and metabolism and plays an integral role
in the synthesis of hormones, including estrogen, testosterone, and insulin, functions that often are impaired in women with
PCOS.
Protein stimulates the release of glucagon, a hormone that raises blood glucose levels and counteracts the action of insulin.
Choose a vegetarian protein as animal proteins are rich in cholesterol and saturated fatty acids, besides animal meat contains
no fibre, which may increase the problem of insulin insensitivity.
Vitamins
Vitamin A: It is a fat-soluble vitamin. It is responsible for antioxidants in the body and steroid metabolism. This
vitamin help women to deal with PCOS
Vitamin B complex (B6, B12, and folic acid): When given to women with PCOS, positive outcomes were noticed.
The hormonal and metabolic patterns become more stable and are beneficial for reproductive outcomes.
Vitamin D: Vitamin D deficiency can have adverse effects on PCOS. Side effects like weight gain, resistance to
insulin, and reduction in the rate of ovulation.
Vitamin E: This Vitamin has positive effects on serum FBS & insulin levels. And this includes overall testosterone
levels as well. This vitamin is used extensively in treating PCOS.
Minerals
◦ Zinc is known to exert beneficial effects on at least two common conditions with PCOS namely Acne and Obesity. It is also an
anti inflammatory and prevents oxidative damage from free radicals

◦ Magnesium - There is a strong link between magnesium deficiency and insulin resistance associated with PCOS
Magnesium appears to be the most common micro-nutrient found to be depleted in insulin resistant people and diabetic
patients

◦ Chromium - Chromium is a component of the glucose tolerant factor (GTF) which helps maintain normal blood glucose levels
by making insulin more efficient. This will fight insulin resistance which is associated with PCOS
◦ Chromium also promotes weight loss due to its ability to help control cravings, reduce hunger and control fat in blood
◦ Good dietary sources of chromium include onions, romaine lettuce, tomatoes, whole grains, potatoes, red wine broccoli,
grape wine and whole wheat bread
Fibre
 Most women with PCOS think more about cutting down on carbs versus increasing fiber. Fiber has numerous health benefits
in the body, including improving insulin resistance, lowering cholesterol and blood sugar, keeping you feeling full longer and
aiding weight management.
Intakes of 40g fiber/day, consisting of both soluble and insoluble fiber, improve insulin sensitivity and reduces circulating
insulin in adults. Fiber, especially soluble fiber, helps to slow the rise and fall of blood sugar and insulin after a meal.
 Researchers found that a high total dietary fiber intake is linked to lower risk of coronary heart disease, compared to a low
fiber intake. Soluble fiber lowers risk of heart disease by decreasing serum total and low-density lipoprotein cholesterol
concentrations and improves insulin resistance.
MILK and PCOS
Since it is said to increase insulin and androgen levels, hence it is recommended limiting its intake. Complete
elimination, however, isn’t the case. Milk and PCOS connection must be understood without any bias in order to
know what really works.
It is important to know the source of a product you wish to consume. Cows are drugged with hormones (oxytocin)
to produce extra milk. This makes the milk unsuitable especially for women with PCOS. Cows are fed chemical-rich
food that also affects the quality of milk produced. However, some studies show that excess milk or dairy results
in acne. Milk increases androgen levels disturbing the hormonal balance in the body.
Under these conditions, almond or soya milk are considered good.
Lifestyle Changes In PCOS
Good for reducing insulin resistance, boosting fertility, stabilising mood
Moderate exercise like brisk walking, jogging, cycling or swimming are all great activities that can help with PCOS.
This type of exercise increases your bodies sensitivity to insulin, which reduces your risk of cardiovascular disease
and type 2 diabetes. Doing 30 minutes or more a day can also help with weight management, symptoms of
depression and anxiety, as well as improving frequency of menstrual cycles and ovulation. And if you’re about to
start IVF, regular light exercise can boost your reproductive success.
Manage Weight
Many, but not all, women with PCOS are overweight. Over time, they may become obese. That can lead to many
health problems, including infertility, type 2 diabetes, and cardiovascular disease.
It is recommended to consume a healthy diet low in fat and calories. Teach patients to keep track of what they eat
by writing it down or using calorie-counting aids. Paying attention to portion size is also key in losing weight.
Sleep Cycle
Insulin resistance is the poor utilization of insulin and a major cause of PCOS symptoms and possible future diabetes. Insulin
resistance increases the production and availability of testosterone, leading to acne, hair problems and other issues.

Sleep disorders causes insulin resistance, which further aggravates the problem of PCOS

The problem is "bidirectional", meaning that insufficient quality sleep disturbs your metabolism and hormones

Not only is insulin resistance made worse, but other hormones are thrown out of balance, including cortisol (stress
hormone), thyroid hormones, growth hormone, leptin, adiponectin, and more. Your nervous and immune systems are
disturbed. Chronic inflammation is increased. You may feel sleepy during the day and find yourself eating more than you
should as an impact of raised ghrelin levels. You may find yourself gaining weight and experiencing other symptoms of
[Link], and in turn, the disturbed metabolism and hormones make quality sleep more difficult. It's a vicious cycle.
Quick Sleeping Tips
 Go to bed at the same time every night and get up about the same time every morning.
Avoid stimulants like caffeine, desserts or sweets in the evening. Also avoid depressants such as alcoholic
beverages.
Quiet your mind. Do you have unstoppable thoughts running through your mind at night? There's always
something to worry about or some incident to hash over repeatedly in your mind. See if you can find a way to
distract yourself from these repetitive thoughts. For example, there are a number of quick meditation
techniques you could use.
Don't watch TV, use your computer or check your smart phone for at least two hours before bedtime. The blue
spectrum of light from electronic devices disturbs your circadian rhythm.
 Get your vitamin D level checked. Women with sleep disorders often have a vitamin D insufficiency. Vitamin D
is super-important for dealing with PCOS.
Get outdoors every day in the bright sun and be physically active.
Quit Smoking
In women with PCOS, smoking is associated with increased free testosterone and
fasting insulin levels, resulting in aggravated insulin resistance
Alcohol and PCOS
Drinking, especially heavy drinking, can aggravate your hormonal imbalance and increase the severity of your
PCOS symptoms.
Research has found that heavy alcohol consumption is associated with menstrual irregularities. These irregularities
include anovulation (where the ovary does not release a ripened egg) and early menopause. In addition, moderate
to heavy alcohol intake has been found to increase the risk of spontaneous abortions and breast cancer.
The liver will use up built up stores of antioxidants and vitamin C to break down the alcohol, leaving you vitamin
and mineral deficient.
Water Intake
Having PCOS can put you at risk for a number of related
metabolic conditions, including diabetes, heart disease, high
cholesterol, and metabolic syndrome. In addition, many women
with PCOS have weight issues. Taking in sufficient fluids is an
important part of maintaining a healthy diet and lifestyle.
Functional Food In PCOS
SOYABEAN - Soy intake reduces metabolic markers for several conditions. For example, soy intake may reduce both
LDL cholesterol and triglyceride levels.
Insulin resistance is another hallmark feature of PCOS. Insulin is a hormone responsible for lowering your blood
sugar levels after a meal. This can make it easier to lose weight, normalize your cycle, and reduce common PCOS
symptoms, like acne.
Soy has shown to significantly reduce androgen levels in women with PCOS.
Improving metabolic health, insulin sensitivity, and lowering high androgen levels can all improve ovulation and
overall fertility.
Functional Food In PCOS
◦ Consume Curcumin (Turmeric)
◦ It reduces blood levels of testosterone
◦ Increases level of hormone estrogen
◦ Reduces blood levels of glucose and fats including bad cholesterol
◦ Increases levels of protective anti-oxidants enzymes like catalase, glutathione and superoxide dismutase
Functional Food
Fenugreek Seeds - Fenugreek contains saponins that help reduce the body’s absorption of cholesterol from fatty
foods. Some studies also indicate saponins to have a role to play in reducing the body’s production of cholesterol,
especially the LDL or bad cholesterol
An unusual amino acid (4HO-Ile), so far found only in fenugreek, has possible anti-diabetic properties such as
enhancing insulin secretion under hyperglycemic conditions, and increasing insulin sensitivity
Fenugreek complements diet and exercise for weight loss. This thermogenic herb aids weight loss by suppressing
appetite, increasing energy in the short term, and potentially modulating carbohydrate metabolism
Yoga and PCOS
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