Diet, exercise, life style changes, do they help in PCOS patients?
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Transcript of Diet, exercise, life style changes, do they help in PCOS patients?
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Diet, exercise, lifestyle changes: Do they help in PCOS patients?
Romana Dmitrovic, M.D., Ph.D. BetaPlus Center for Reproductive Medicine,
Zagreb
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Infertility in PCOS
• Caused by: – Obesity
• Excess androgens • Insulin resistance • Anovulation
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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
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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
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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
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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
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• 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
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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
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• 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
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Obesity and gonadotropins
Mulders 2003
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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
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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)
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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)
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• Decrease in T and DHEAS after both meals
• Increase in insulin and glucose after the HIFIB meal
Katcher, Dmitrovic, Legro. Fertil Steril 2008
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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
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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
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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