Buckworth, Janet Ph.D., FACSM; Hsu, Ya-Ting M.A.
PURPOSE AND OVERVIEW
The purpose of this review is to introduce health and fitness professionals to polycystic ovary syndrome (PCOS). PCOS is the single most common endocrine disorder of reproductive-aged women (12). Chances are that fitness professionals in a variety of settings will come in contact with women who have PCOS. PCOS is a complex disorder that has multisystemic effects, such as obesity, acne, hirsutism (excessive hair growth), irregular menstrual cycles, and insulin resistance (7). If untreated, PCOS can lead to diabetes, hypertension, cardiovascular disease, and gynecologic problems, such as infertility and increased risk of cancer. Care involves both medical interventions and lifestyle changes, in particular, exercise and diet to promote weight management. In this review, you will learn about the signs and symptoms of PCOS, psychological and physical health issues, dietary recommendations, and exercise programming for women with PCOS.
WHAT IS PCOS?
Etiology and Symptoms
PCOS is an endocrine disorder affecting almost 10% of reproductive-aged women (3). Drs. Stein and Leventhal first described this disorder in the 1930s when they noticed a connection between amenorrhea and multiple ovarian cysts (9). Other symptoms also were associated with these polycystic ovaries, including overweight/obesity and "masculinizing changes," such as male-pattern hair growth and acne, which were later linked to excessive levels of androgens (testosterone). It was not until the 1980s that Dr. Burghen and colleagues identified the effects of insulin resistance as part of this syndrome (9). Signs and symptoms of PCOS vary widely, and diagnosis is thus difficult, involving assessment of insulin resistance, blood tests to measure hormone levels, and the presence of typical symptoms.
Symptoms of PCOS usually begin in adolescence around puberty and get worse over time (3,12). The symptoms can be unmasked or amplified in response to weight gain, which may be the case for women in their late teens and twenties (3). Although more than two thirds of women in the United States who are diagnosed with PCOS are overweight or obese (7), there are women with some of the primary characteristics of this syndrome who have normal weight. Hallmarks of PCOS are insulin resistance, hyperandrogenism, and chronic anovulation/menstrual irregularity. Excessive insulin and androgens are especially troublesome and lead to a myriad of physical signs, symptoms, and risks for diseases later in life.
Impaired glucose tolerance or insulin resistance is 5 to 10 times more likely in someone with PCOS, even if she is not overweight (9). There is evidence that the progression toward insulin resistance begins at an early age and can have multiple effects, such as fatigue, weight gain, low blood glucose, and acanthosis nigricans (Table 1). High concentrations of insulin also increase androgens by contributing to a thickening of the ovarian theca, the connective tissue surrounding an ovarian follicle, which will consequently produce elevated levels of androgens, specifically testosterone (9). Insulin has another role in fostering excessive active testosterone. When cells become resistant to insulin, the pancreas secretes more insulin into the bloodstream to foster glucose transport into the cells (5,9). In blood, insulin is bound to the same carrier protein that testosterone uses, and the competition from the excess insulin for carriers leads to increased "free" or unbound testosterone (5,9). The increased production of androgens from the theca and the increase in unbound testosterone allow the expression of masculine characteristics in women with PCOS, such as male-pattern hair growth and lipid abnormalities, as well as acne, oily skin, excessive sweating, and sometimes thinning of head hair.
Menstrual irregularities from a persistent lack of ovulation may be one of the symptoms that bring women with PCOS to a health care provider (10). During a normal cycle, hormones fluctuate to cause ovulation. Women with PCOS have an increase in estrogens and androgens because of abnormal hormonal control (12). Levels of estrogens and androgens that stay higher than normal cause the problems previously mentioned, as well as menstrual cycle difficulties. For example, continuous estrogen release leads to a thickening of the uterine lining, which causes the irregular heavy menstrual bleeding that some women with PCOS experience.
There is a strong genetic contribution to PCOS, and women with PCOS may see other women in their family with some of the symptoms (5). Their family members also should be evaluated for PCOS, so they can receive treatment and reduce their risk of long-term complications, such as metabolic syndrome (a cluster of risk factors: abdominal obesity, abnormal blood lipids, hypertension, and insulin resistance).
Implications for Women's Health
One of the most common features of PCOS is anovulation (10). Women with PCOS can gain weight, have a difficult time losing weight, and develop physical characteristics of excess androgens, such as unwanted facial hair and acne. Excessive androgens and insulin resistance also foster increases in abdominal fat. Long-term health problems include difficulty getting pregnant and increased maternal and fetal complications from pregnancy, especially if the woman is obese (9). In fact, PCOS is a common cause of infertility in women. Impaired glucose tolerance puts these women at risk for type II diabetes, even at a young age, and especially if they are obese (3,9). Women with PCOS also have seven times the risk of a myocardial infarction compared with women without PCOS (1). There is also an increased risk of endometrial and ovarian cancer, as well as high blood pressure (9).
Women with PCOS have psychological issues related to their quality of life (7,12). They can feel self-conscious and worry about excessive hair growth on their face and arms, and weight gain that seems out of their control. Many of the participants in The Ohio State University (OSU) support group for women with PCOS report anxiety and frustration over their appearances. However, there also is relief from knowing why they have these symptoms and from finding ways to alleviate or minimize some of them. For example, metformin, a drug that increases the sensitivity of tissues to insulin, may help with weight loss, reduce high levels of circulating insulin and androgens, and improve other symptoms associated with excessive insulin and androgens, such as hirsutism and acne (7,10). For women who are overweight or obese, weight loss (∼10% of body weight) can also resolve many of the signs and symptoms of PCOS (7,10).
Women diagnosed with PCOS also can feel the psychological strain of realizing that they have a lifelong condition with no cure (12). Trouble getting pregnant and higher rates of miscarriage are physiological dynamics of PCOS that can have psychological effects. More than half of women with PCOS have some depression, and many are anxious about their appearances (9). This "social physique anxiety" can be a barrier to exercise because they may be uncomfortable working out in public facilities, although exercise is one of the primary recommended lifestyle treatments.
Weight reduction is one of the central goals in the treatment of PCOS. The focus should be on lifestyle modification with a goal of 5% to 10% weight loss (7). Program components should include structured exercise, dietary recommendations, and behavioral management training to promote long-term weight loss and to prevent weight gain (7). For example, the PCOS support group established at OSU through the Student Health Service includes a multidisciplinary team that provides medical information about PCOS, nutritional guidelines, individual exercise prescriptions, behavioral skills training, psychological counseling, and guidance on dealing with health insurance and prescription costs.
Weight management should be one aim of treatment not only because obesity has been associated with long-term health risks, but also because obesity increases insulin resistance and the consequent additional increase in circulating insulin and unbound testosterone (7). Unfortunately, weight loss is even harder because of insulin resistance and impaired fat metabolism. Additional problems come from increases in abdominal fat with PCOS. Abdominal (visceral) fat secretes less leptin, a hormone involved in feelings of satiety, compared with subcutaneous fat, and less leptin leads to lower satiety levels (5).
Nutritional guidelines for women with PCOS are typically patterned after those that are prescribed for individuals with diabetes because women with PCOS tend to be insulin resistant regardless of their weight (2,3). Individuals with insulin resistance have extreme fluctuations in both insulin and blood glucose, which can cause reactive hypoglycemia and stimulate hunger and food intake. Therefore, appropriate glycemic control is critical and can be achieved by decreasing total carbohydrates, eating foods with a lower glycemic index (GI) (e.g., high-fiber foods and complex carbohydrates), and eating more protein. Foods with lower GI have been shown to improve insulin sensitivity, decrease triglycerides, and increase high-density lipoprotein cholesterol level (2). Protein intake can improve glucose and insulin responses, as well, and higher intake of protein can increase satiety and may help to increase postprandial thermogenesis. Increased consumption of unsaturated fatty acids has been shown to improve insulin sensitivity in healthy, obese, and type II diabetic patients (2,12), but fat intake should not be more than 30% of total calories. Nutritional guidelines for women with PCOS, especially those with insulin resistance, are summarized in Table 2. A registered dietitian can help women with PCOS to develop a healthy eating plan that will complement an exercise program to promote weight management.
Exercise is a crucial component in lifestyle modification foster weight management and to improve insulin sensitivity. A recent study compared the effects of a three-month supervised aerobic training program (stationary biking at 60%-70% of V˙O2max for 30 minutes, 3 days/week) with a control group in women with PCOS (13). The women in the exercise group and not the control group had a significant reduction in body mass index and waist circumference. Other research with sedentary overweight individuals has shown that regular aerobic exercise even without weight loss improved insulin resistance and plasma lipase activity, which is also usually impaired in individuals with insulin resistance (7). Therefore, regardless of weight status, women with PCOS need to be encouraged to engage in regular moderate-intensity aerobic exercise for improvements in insulin resistance (7).
Integrating resistance training with aerobic exercise has additional benefits for women with PCOS. Aerobic exercise will increase cardiorespiratory endurance, and resistance training can increase muscle mass and facilitate fat loss. Resistance training can thus counteract loss of muscle mass caused by caloric restriction when individuals attempt to lose weight. Resistance training now is considered an effective way to influence weight, alter body composition, and improve insulin sensitivity and glycemic control (2,4).
PHYSICAL ACTIVITY RECOMMENDATIONS
There is still limited research to indicate an optimal exercise prescription for PCOS, but we suggest a combination of aerobic, resistance training, and lifestyle activity (Table 3). Our recommendations are largely based on non-PCOS studies in which subjects had similar characteristics, such as obesity/overweight or insulin resistance/diabetes. We have adapted exercise guidelines and strategies recommended by the American Heart Association, the American Diabetes Association, and studies conducted on women with PCOS (6,7,11). Any exercise program for individuals with contraindications to exercise should be monitored by a qualified exercise specialist.
We also have included recommendations for promoting exercise and physical activity (Table 4). These suggestions should be implemented with sensitivity to body image issues and the psychological stress of living with a chronic disorder. Fitness professionals should support women with PCOS to persist with diet and exercise to achieve health benefits regardless of their weight. Some women with PCOS may not need to lose weight, and those who are overweight may take longer to lose weight compared with women without PCOS.
Lack of time is one of the primary barriers to regular exercise for most people. Although lack of time is an obstacle for women with PCOS, fatigue also is often reported as a major reason for not exercising. Fatigue is one of the symptoms of this disorder and should be addressed as a real concern, but one that can be overcome. Suggesting short manageable bouts of moderate activity spread throughout the day is a way to deal with feeling too tired to exercise in one long session. Breaking up exercise throughout the day also can be used to help with food management. For example, a short brisk walk after eating a meal or snack facilitates glucose uptake (8), marks the end of the meal and potential overeating, and can help make activity a habit by linking it with an established behavior, that of eating.
Fatigue can be physical, but part of it may be from stress and depression, which are common in women with PCOS (9). Informing them that moderate-intensity exercise can paradoxically relieve mental fatigue and be energizing is the first step, but it also is important to help them find an activity they enjoy or a way to make exercise more enjoyable, such as listening to upbeat music or working out with friends. Information about the benefits of exercise for relieving stress, reducing symptoms of PCOS, and reducing weight can be motivating, but the activity still must be something they will enjoy doing. Support groups with an exercise component are helpful for women with PCOS and can make exercise fun. Support groups also reduce the feeling of being alone with PCOS and provide models of other women managing PCOS. See Table 4 for other suggestions of promoting regular exercise and physical activity.
CONDENSED VERSION AND BOTTOM LINE
Polycystic ovary syndrome is the most common endocrine disorder of reproductive-aged women, and weight management is one of the most effective treatments to manage symptoms and improve quality of life. Exercise plays a critical role in promoting weight loss as well as preventing weight gain. Fitness professionals can have a positive impact on the health of women with PCOS by promoting regular exercise and being sensitive to the signs and symptoms of this disorder and the psychological stress of living with PCOS.
The authors thank Maureen Latanik, Ph.D., for helpful comments on an earlier draft of this manuscript.
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