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Tailored Exercise for Polycystic Ovary Syndrome Participants

Sanders, Mary E. Ph.D., FACSM, RCEP

doi: 10.1249/01.FIT.0000416001.86655.4f
COLUMNS: On the Floor

Tailored Exercise for Polycystic Ovary Syndrome Participants.

Mary E. Sanders, Ph.D., FACSM, RCEP, is a clinical exercise physiologist at the Division of Wellness and Weight Management in the School of Medicine and adjunct professor in the School of Public Health, University of Nevada, Reno. She is an associate editor of ACSM’s Health & Fitness Journal ®, editor of the YMCA Water Fitness for Health training manual, and the 1997 IDEA Instructor of the Year. Dr. Saunders is ACSM Exercise Specialist certified and ACSM Registered Clinical Exercise Physiologist certified. Dr. Sanders’ Web site is



When she was 18, Stacey adopted an active lifestyle and started to exercise regularly at the gym, primarily to manage her weight. Her sister was diagnosed with polycystic ovary syndrome (PCOS) and by age 29, Stacey was facing similar challenges, mainly in the form of infertility. At first, she tried on her own to manage her condition. She worked out regularly performing cardiovascular routines via home DVDs and 30-minute workouts on ESPN to manage weight and reduce stress, yet infertility persisted.

When she finally did start treatment at age 30 years, it was difficult to stop exercising at the same intensity she’d become adapted to but accepted it as part of the plan to achieve success. During this period, Stacey meditated, used guided imagery, practiced yoga, and walked at a leisurely stroll to avoid an increase in heart rate and body temperature. This routine continued for 4 months based on recommendations of medical professionals.

During the first treatment cycle, Stacey miscarried at 13 weeks, and after a recovery period of 4 weeks, she returned to pretreatment exercise levels. Exercising within accepted exercise guidelines, she was highly motivated to get back to her pretreatment fitness level. Six months later, she returned to treatment and resumed her lower exercise intensity routine. After 1 month, Camryn was successfully conceived and born on August 14, 2004. Two years later, using the same lifestyle modifications in conjunction with medical management, Caleigh was born on August 24, 2006.

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  • Exercise provides a sense of control over life, when so many other aspects are out of your control. Stress and anxiety management helped me cope and manage my condition while boosting my confidence in being able to bring forth a healthy child.
  • Get professional help early. It took years to learn how to manage stress, and finally, the practices learned from colleagues (dietitians) and exercise professionals provided the coping tools I needed.
  • Take the right steps. When I achieved a healthy body mass index, through activity, healthy diet, and stress management practices, I was able to manage the symptoms of PCOS. Stress hormones are associated with weight gain, but proper coping mechanisms can reduce the impact on your body. When diet, exercise, and stress were managed properly, our third child Carson, born September 15, 2008, was conceived naturally.
  • Don’t allow the condition to make you feel it’s not possible to manage your weight. Take positive steps toward a healthy lifestyle by making the time and putting forth the effort to find the right formula for you to manage your weight.
  • No matter your age, or stage of life, remember to take care of yourself in the same way you would care for another individual that you truly love. PCOS management requires lasting attention. Don’t neglect your healthy behaviors, including proper nutrition and exercise, if you are feeling overwhelmed or stressed. Remember that diet and exercise have lasting changes on your hormones, your weight, and your overall health.
Photo 1

Photo 1

In 2010, Janet Buckworth and Ya-Ting Hsu, authored an article titled “Polycystic Ovary Syndrome: Challenges for Practitioners and Clients,” published in ACSM’s Health & Fitness Journal®. The article provides a comprehensive evidence-based overview of PCOS, signs and symptoms, health effects, and implications of the disorder, and provides specific guidelines for treatment including nutrition and exercise strategies for women with PCOS. You are encouraged to review the article by accessing via the link to develop a foundational understanding of the condition. The purpose of my column is to provide further insights into how fitness professionals can practically apply the information with clients who have PCOS.

Photo courtesy of inCYST Institute for Hormone Health

Photo courtesy of inCYST Institute for Hormone Health

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PCOS is defined as the most common endocrine disorder, of unknown cause, affecting almost 10%, of reproductive-aged women (1,6). The disorder may begin at puberty and is complex. It’s characterized by chronic oligoovation (too few ovulation cycles) or anovulation (suspension or lack of ovulation) and is associated with an excess of functional androgens (i.e., testosterone), which may lead to “masculinizing changes” such as male-pattern hair growth and acne (1,6). The disorder appears most commonly as light or the absence of menstrual periods (6). There is no known prevention, and it’s difficult to identify risk factors for the disorder; however, commonly associated conditions may provide clues for a diagnosis.

Commonly associated conditions (6):

  • obesity
  • obstructive sleep apnea
  • hypertension
  • diabetes mellitus
  • breast carcinoma
  • endometrial hyperplasia (an increase in the number of cells in the tissue excluding tumor formation)/and or carcinoma
  • infertility
  • hyperandrogenism, insulin resistance, and related skin disorders
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Women may or may not desire pregnancy, but any woman diagnosed with PCOS should be treated to reduce risks of the associated conditions, especially endometrial hyperplasia, a possible precursor of endometrial carcinoma. Treatment by health care and allied professionals needs to be individualized and should include lifestyle strategies that especially address weight loss in overweight women, which can lead to the greatest improvement in symptoms (6).

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Physical activity is a key strategy to improving the quality of life for women with PCOS. Other strategies to overcome barriers may require a multifactoral approach that integrates expert help from professionals in nutrition, lifestyle coaching, and exercise. I spoke with Monika Woolsey, a registered dietician with a master’s degree in Kinesiology and CEO of the inCYST Institute for Hormone Health, Santa Monica, CA.

In 1986, Monika became interested in the relation between hormones, behavior, and stress during graduate school while studying the female athlete triad. For more than 3 years, as director of dietary services at Remuda Ranch, Wickenburg, AZ, a center for treating eating disorders, she was able to examine these relationships in a closed clinical setting. In 2000, she authored the American Dietetic Association’s first clinical eating disorder manual (see resources). Her work led to inquiries from women asking for help. They claimed to have an eating disorder and were now diagnosed with PCOS. Monika turned her attention to the link between behavior and PCOS symptoms, resulting in education programs for health and fitness professionals who work with PCOS clients or patients.

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I asked Monika to describe some “on the floor” strategies that health and fitness professionals should consider when working with PCOS clients. The following are her top tips for trainers.

Ask about sleep habits. Obese women with PCOS have a 5 to 10 times greater risk of obstructive sleep apnea compared with obese women without the syndrome (3). Sleep can affect weight management, hormone balance, and behaviors such as choosing to eat breakfast or exercise. Sleep intervention should be regarded as a priority in a PCOS program. Educate participants about proper sleep hygiene and follow-up to determine outcome or refer to a sleep specialist for a baseline sleep study.

Team up with nutrition professionals. PCOS is a complex syndrome with multiple hormone imbalances that challenge positive behaviors. When appetite-regulating hormones, such as leptin and ghrelin, are not balanced, appropriate responses to eating and exercise may be difficult (4,5). It’s advised to refrain from providing specific nutrition advice without formal training in PCOS management. Strategies that work for non-PCOS clients may be counterproductive for PCOS symptom management. For example, a common misconception is that a strong craving for carbohydrates, common to PCOS clients, is related to their insulin resistance. The literature indicates that testosterone levels are actually more closely correlated and responsible for the cravings. Fitness professionals should refer a dietitian who can then follow up with responsive meal planning or refer to other health care providers as needed.

Photo by Beth Wolf, courtesy of Power Up for PCOS

Photo by Beth Wolf, courtesy of Power Up for PCOS

Address anxiety with attention on immediate rewards. Women with PCOS reported a prevalence of anxiety five times greater when compared with healthy women (2). Screening and treatment for mood disorders requires referral to a health care provider and intervention, but we can communicate with clients and design programs that help reduce anxiety.

Anxiety may be caused by the syndrome’s symptoms, or anxiety may be how a woman is “wired,” an inherent personality trait. Feeling anxious may be linked to a woman’s appearance, infertility, overweight, and frustration with the disease, but it’s important to remember that hormone imbalances also have a powerful affect on how a woman feels. Health and fitness professionals should be careful about projecting their personal feelings about a client’s physical characteristics (positive or negative) and avoid assuming that their client’s anxiety will improve simply with physical changes such as weight loss. Too much emphasis on outward appearances may lead PCOS clients into a cycle of disappointment or anxiety. These behaviors can result in eating disorders such as binge eating and late night surfing, which worsens the condition and further increases anxiety. By encouraging women to focus on the immediate benefits of exercise including better sleep, improved mood, and a sense of achievement, we can help them overcome internal hormonal messages and take small steps to overcome barriers. Barriers to exercise may include the following:

  • social anxiety, when a woman is uncomfortable being around other people
  • over stimulation caused by the music or activities associated with a gym environment
  • fear of not exercising perfectly

Be sensitive to your client’s needs and establish trust, so clients can communicate honestly about strategies for reducing anxiety in their program.

Never give up and patiently encourage women to adopt an active lifestyle. Monika tells the story “I worked with a woman who took eight years of encouragement before coming to her first yoga class, and she only came because she knew I was going to be there.”

Foster a sense of “I AM an athlete” in your clients.

Photo by Bryan Mok, courtesy of the inCYST Institute

Photo by Bryan Mok, courtesy of the inCYST Institute

Photo by Beth Wolf, courtesy of Power Up for PCOS

Photo by Beth Wolf, courtesy of Power Up for PCOS

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Teams that Work

Exercise along with weight and stress management programs can positively impact the quality of life for women with PCOS. Health and fitness professionals who understand the signs and symptoms of women with PCOS are better equipped to partner with dietitians and other health care providers for effective care. Together, we’ll have an opportunity to guide women to healthy active lifestyles tailored to meet their needs.

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1. Stacey Frattinger, R.D., ACSM Exercise Specialist certified with Camryn, Caleigh, and Carson.

2. Strength training is recommended on three nonconsecutive days of the week, progressing to 3 sets of 8 to 10 repetitions (1). When coaching women with PCOS, remind them that their hormone levels enhance strength training and provide a physical advantage to becoming strong!

3. Women with PCOS may be anxious about exercising in public. Provide exercise environments that welcome all body types and levels of fitness. Peer support also is important to encourage accountability and long-term participation.

4. Women with PCOS come in all sizes and shapes, so it is important to promote the many benefits of exercise other than weight loss. Photo: inCYST PCOS Move and Soothe Fundraiser, Marina del Rey, CA (Beach photo).

5. Exercising outdoors helps promote healthy sleep cycles. Photo: 1st annual Power Up for PCOS Walk-a-Thon, Nashua, NH.

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Special thanks to models Beth Wolf, Mary Finocchiaro, and Lindsay Thibodeau-Pettengill and to Monika Woolsey, CEO of the inCYST Institute for Hormone Health, officially located in Santa Monica, CA. She can be reached at: I would like to personally thank my colleague, Stacey Frattinger, a clinical RD and ACSM Exercise Specialist certified professional for sharing her story and insights asan inspiration for both trainers and women challenged by PCOS.

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1. Buckworth J, Hsu Y-T. Polycystic ovary syndrome: challenges for practitioners and clients. ACSM Health Fitness J. 2010;14(3):15–20.
2. Dokras A. Mood and anxiety disorders in women with PCOS. Steroids. 2011 Dec 9. [Epub ahead of print].
3. Ehrmann DA. Metabolic dysfunction in PCOS: Relationship to obstructive sleep apnea. Steroids. 2011 Dec 8. [Epub ahead of print].
4. Mitkov M, Pehlivanov B, Orbetzova M. Serum ghrelin level in women with polycystic ovary syndrome and its relationship with endocrine and metabolic parameters. Gynecol Endocrinol. 2008;24(11):625–30.
5. Pehlivanov B, Mitkov M. Serum leptin levels correlate with clinical and biochemical indices of insulin resistance in women with polycystic ovary syndrome. Eur J Contracept Reprod Health Care. 2009;14(2):153–9.
6. Taylor JS, Golding J, Bryant K. Polycystic ovarian syndrome (PCOS). Chapter in The 5-Minutes Clinical Consult. 20th ed. LWW; 2012. p. 1036–7.
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Recommended Resources

Eating Disorders: Clinical Counseling Treatment, American Dietetic Association by Monika Woolsey, 2000.
    InCYST Institute for Hormone Health
      Professional training and education with links to professionals working with clients with PCOS,
        PCOS Association
          Power Up for PCOS
            A network of peer and local support groups promoting proactive choices in nutrition, activity, sleep hygiene, and stress management,
              © 2012 American College of Sports Medicine.