Diet, exercise, lifestyle changes: Do they help in PCOS patients?

Romana Dmitrovic, M.D., Ph.D. BetaPlus Center for Reproductive Medicine,

Zagreb

Infertility in PCOS

• Caused by: – Obesity

• Excess androgens • Insulin resistance • Anovulation

Lifestyle modification

1. Diet 2. Exercise 3. Smoking cessation 4. Behavioral techniques

• Reduce adipose tissue, androgenicity and IR – restore ovulation

• Improves dyslipidemia, depression, and quality of life

Criteria NIH 1990 „classic”

Rotterdam 2003 AE-PCOS

Oligomenorrhea + +/- +/- Clinical or biochemical

hyperandrogenism + +/- +

Polycystic ovaries on ultrasound +/- +/- +/-

Wild 2010

- 8 or less menses per year - Acne or hirsutism or androgenic alopecia - Ovarian volume > 10 ml or > 12 follicles less than 9 mm

in at least one ovary

Rotterdam and AE-PCOS criteria – prevalence over 20%

Classic PCOS

• menstrual irregularity and anovulation, hyperandrogenism, total and abdominal obesity, insulin resistance

Ovulatory PCOS • Same as classic PCOS but to a lesser extent

Nonhyperandrogenic PCOS

• polycystic ovaries plus oligomenorrhea • most metabolically favorable profile, often indistinguishable from

normal women

Carmina 2005 and 2009, Dewailly 2006, Welt 2006

75% classic PCOS 25% ovulatory and

nonhyperandrogenic PCOS

Italian PCOS American PCOS P BMI (kg/m2) 29.7 ± 1.0 40.3 ± 1.0 <0.01 Waist:hip ratio 0.83 ± 0.04 0.85 ± 0.02 NS

Systolic blood pressure (mmHg) 126 ± 5 130 ± 3 NS

Diastolic blood pressure (mmHg) 80 ± 4 79 ± 3 NS

Insulin (µU/ml) 18.1 ± 2 29.5 ± 2 <0.01

Glucose:insulin ratio 5.3 ± 1 3.6 ± 0.5 <0.01

Total cholesterol (mg/dl) 183 ± 12 187 ± 8 NS

HDL-C (mg/dl) 48 ± 1 40 ± 2 <0.01

LDL-C (mg/dl) 109 ± 12 116 ± 7 NS

Triglycerides (mg/dl) 91 ± 8 156 ± 18 <0.01 Carmina, Legro et al. Hum Reprod 2003

Obesity

• Positively associated with levels of total T, free T, and FAI, and

negativelly associated with SHBG

• Greater prevalence of oligomenorrhea or amenorrhea, higher fasting insulin levels and greater insulin resistance, leading to anovulation and infertility

Franks 1991, Hamilton-Fairley 1992

Obesity and infertility in PCOS

Obesity and infertility in PCOS

• Pregnancies after losing as little as 5% of initial body weight • Treatment of obesity:

– behavioural counselling – lifestyle therapy (diet and exercise) – pharmacological treatment – bariatric surgery

Pasquali 2003, Guzick 2004, Balen 2006

• Weight loss and lifestyle intervention – First-line therapy in obese women with PCOS seeking pregnancy, and

should be conducted before pregnancy – Lowers relative risk of anovulation – Spontaneous pregnancy rates and response to fertility medication and

success with ART improves

• No proof that weight loss prior to conception improves live

birth rate in obese women with or without PCOS

Hollmann 1996, Palomba 2010, Moran 2011

Obesity and infertility in PCOS

Obesity and gonadotropins

Mulders 2003

How much weight loss?

• 2% to 5% weight loss leads to

21% decline in free testosterone and resuming of regular ovulation

• Long term goal 10–20% weight loss and a waist circumference of less than 88–80 cm

A 24-wk change in SHBG for those completing the lifestyle treatment arm

. Hoeger JCEM 2008

What kind of diet?

• CDC recommendation overestimating by almost 100% (Hall, Sacks 2011)

• Reduced-energy diets (500–1000 kcal/day reduction) are effective options for weight loss and can reduce body weight by 7% to 10% over a period of 6 to 12 months (Bates and Legro 2013)

What kind of diet?

• Hypocaloric diets – Atkins, low fat, low glycemic load

– <30% calories from fat; increased consumption of fiber, whole-grain

breads, cereals, fruits, and vegetables (Marsh 2010)

– increase in SHBG, reduction in fasting serum insulin (Kiddy, 1992)

• Decrease in T and DHEAS after both meals

• Increase in insulin and glucose after the HIFIB meal

Katcher, Dmitrovic, Legro. Fertil Steril 2008

What kind of exercise?

• Insufficient physical activity reason why women with PCOS have a tendency towards overweight/obesity (Wright et al., 2004)

• Exercise alone may not be helpful in weight loss (Bruner 2006)

• 10,000 steps = 30 min daily exercise • 15,000 needed for weight loss

Treatment with lifestyle interventions

Treatment with lifestyle interventions (diet plus exercise) compared with minimal treatment (just weight loss)

– reduction in waist circumference (MD 1.95 cm) – weight loss (MD 3.47 kg) – fasting insulin (MD -2.02 µU/mL) – waist/hip ratio (MD 0.04)

Moran 2011

Conclusions • Obesity and sedentary life style in PCOS is associated with

anovulation, and failure of infertility treatment

• Lifestyle modifications (weight loss and exercise) prior to infertility treatment improves ovulation rates and are recommended as first-line treatment

• The best diet and exercise regimens are unknown, but caloric restriction and increased physical activity are recommended

• The ideal amount of weight loss is unknown, but a 5% decrease of body weight might be clinically meaningful