Role of Nutrition in Management of PCOS

Educational Materials

1. Associate Clinical Prof. Dr. Aisha Elbareg, MD, PhD
Senior Consultant in (Obs & Gyn)/Reproductive
Medicine, Faculty of Medicine, Misurata .LIBYA

Role of Nutrition in
Management of PCOS

2. Disclosure
I have no actual or potential conflict
of interest in relation to this
presentation.

3. •Polycystic ovary syndrome (PCOS) is one of the
most frequent metabolic and reproductive
disorders in reproductive age women.

•Worldwide prevalence rate of 5%–10% .

•First identified by Stein & Leventhal in 1935.

4. Exact pathophysiology or initiating
event are unknown!!

5. PCOS- Pathophysiology
Multifaceted disease involving:
Uncontrolled ovarian steroidogenesis
Aberrant insulin signalling
Excessive oxidative stress
Chronic inflammation
Genetic/environmental factors

6. This disorder may be caused by a conjunction of
two independent genetic defects: one that
produces elevated LH secretion and another that
produces insulin resistance. Thus, polycystic ovary
syndrome develops as a result of the synergistic
action of increased LH levels and hyperinsulinemia
on the ovary.
defect" hypothesis PCOS-dual"

7. -Diagnostic Criteria
2 out of 3 required for
diagnosis:
Ovulatory dysfunction
Clinical and/or biochemical
signs of hyperandrogenism.
Polycystic ovaries.
Exclusion of alternative causes
of androgen excess.


Rotterdam Consensus workshop:
(ESHRE &ASRM-2004)

8. be considered What other diagnosis should
?by clinicians
 Late-onset congenital adrenal hyperplasia
 Androgen producing neoplasms
 Cushing syndrome
 Hyperprolactinemia
 Hypothyroidism

9. Obesity (~ 50% of women with
PCOS) , abdominal obesity,(waist-
hip ratio > 0.85),with increased
levels of androgens, hirsutism,
Menstrual disorders, infertility and
pregnancy complications


Insulin resistance (up to 80% of
women with PCOS)

Metabolic syndrome (1 in 3
women with PCOS)

Associated morbidities

10. 72% of overweight/obese
women with PCOS were
insulin resistant compared to
26% in Lean PCOS

11. Type II Diabetes mellitus (7 fold)
Cardiovascular diseases.
Psychological disorders
Obstructive sleep apnea
Endometrial Cancer
•Spontaneous Abortions, Impaired GTT, Gestational
Diabetes & HTN, Small for Gestational Age




Associated morbidities

12. management -PCO
The management targets the symptomatology
for which patients usually present:
Irregular menstruation, infertility, hirsutism, acne.
Usually requires the collaboration of an inter-
disciplinary team including: a gynecologist, an
endocrinologist, a dermatologist, a pediatrician, a
psychologist, and a psychiatrist

13. Management -PCOS
Attention to lifestyle including:

•Diet
weight reduction
•Exercise

14. Modest reduction in weight (5% and more)

Benefits Include:
Increased regularity of menstrual cycles
Decreased levels of androgens
Improvement in lipid levels
Decreased risk of diabetes
Improves insulin sensitivity

First Step in Treatment…
Diet & Exercise

15. ESHRE Guidelines 2018:
Pharmacological treatments for non-infertility
indications:
•Insulin sensitizing agents: Metformin(most useful
with BMI> 25kg/m²
•Metformin + COCP (with lowest estrogen
dose:20μgm.)
•Anti-androgens must be used with contraception
(to prevent male fetal virilization).
•Anti-obesity drugs: for example: (Orlistat) GI
lipase inhibitor that decrease absorption of
ingested fat by up to 30%.
•
Management -PCOS

16. Pharmacological treatments for infertility
indications:
1
st
line: Letrozole( Femara): (multiple
pregnancy less compared with clomiphene
citrate(CC).
CC
 Metformin alone or CC+ Metformin
Gonadotrophins /Laparoscopic Surgery
ART: IVF ± ICSI

17. Food Supplements
&
herbal medicine
in PCOS

18. Green Tea
The consumption of green tea by overweight and
obese women suffering from PCOS leads to
weight loss, a decrease in fasting insulin, and a
decrease in the level of free testosterone.

20. Inositol and PCOS

•Myo-inositol and D-chiro-inositol.
•Myo-inositol was classified as a member of Vit B
complex (Vit B8), found to be synthesized by body.
•It is present in food such as fruits, beans, grains,
and nuts
•Elevated concentration in human follicular fluids
appear to play a positive function in follicular
maturity.

22. •Inositol is a component of the inositolphospho-
glycans (IPGs) which are “secondary messengers” in
insulin signaling.

•Myo-inositol increased ovulation rates and
improved metabolic factors.
•Myo-inositol decreased insulin and testosterone
levels and improved metabolic factors.

•Myo-inositol improved insulin sensitivity and
decreased LH and LH/FSH ratio.

Inositol and PCOS

23. Myo-inositol and Egg Quality in Women with PCOS
•Myo-inositol decreased the number of days
of stimulation, and decreased degenerated
oocytes without compromising total number
of oocytes retrieved.
• Myo-inositol increased number of oocytes
retrieved and embryos transferred, and
improved embryo scores.

24. inositol-chiro-+ D inositol-Myo
•A combination of myo- and D-chiro-inositol, in the
body’s physiological ratio of 40:1, is more
beneficial than either alone.
• Improved metabolic parameters more than myo-
inositol alone after 3 months of treatment in
overweight women with PCOS improved lipid
profile in obese women with PCOS.
•This combination (vs. D-chiro-inositol alone)
improved egg and embryo quality, and pregnancy
rates, in women with PCOS undergoing IVF.

25. Inositol: Treatment considerations
•Inositol is safe and relatively
inexpensive.
•Reasonable evidence of benefit in
PCOS, but may be counterproductive
in non-PCOS patients
•Typical recommended daily dose: 2 grams, bid
•Typical treatment regimen of 3-6 months
•Myo-inositol vs. Metformin- in one study, women
taking 4 g myo-inositol had higher pregnancy rates
and percentage restored ovulation than women on
1500 mg Metformin

26. NAC is an antioxidant & amino acid.
Derivative of the amino acid L-cysteine, an essential
precursor used by the body to produce glutathione.
Glutathione is an antioxidant produced by the body
to help protect against free radical damage, and is a
critical factor in supporting a healthy immune
system.
NAC has also been found to reduce inflammation,
heart disease and most recently, insulin.


ysteine (NAC)cacetyl -N

28. Improved menstrual regularity but has not been
shown to help improve fertility in women with
PCOS.
NAC may help improve insulin resistance in
women with PCOS who have high insulin levels
and could be used with metformin or if
metformin isn't an option.
NAC also seems to have a favorable effect of
lowering cholesterol, TG and testosterone.


and PCOS acetylcysteine-N

29. NAC showed significant improvement in pregnancy
and ovulation rate as compared to placebo.
No significant difference in rates of the
miscarriage, menstrual regulation, acne, hirsutism,
and adverse events, or change in body mass index,
testosterone, and insulin levels with NAC as
compared to placebo.
More studies are needed



and PCOS acetylcysteine-N

30.  Combination of CoQ10 and clomiphene citrate in the
treatment of clomiphene - citrate – resistant PCOS
patients improves ovulation and clinical pregnancy rates.
It is an effective and safe option and can be considered
before gonadotrophin therapy or laparoscopy.


and PCOS10 CoQ

31. fatty acid3 -Omega

33. Novel drug for PCO -3Omega
Play important role in immune regulation, insulin
sensitivity, cellular differentiation and ovulation.
Improve excessive oxidative stress-caused
folliculogenesis disorders and hyperinsulinemia in
pcos.
reducing inflammation and proinflammatory
cytokines
Increase insulin sensitivity Reduce cholesterol
absorption and LDL-C synthesis, improve LDL
receptor activity in liver

34. (OH) D25 Vitamin D

36. The concentration of Vit D is low in PCOS patients, (3 of
every 4 women with PCOS may have Vit.D deficiency).
Association of Vit D deficiency with insulin resistance,
metabolic and hormonal disturbances in PCOS and
obesity.
obesity-associated vitamin D insufficiency is potentially
related to the suboptimal bioavailability of vitamin D3
from cutaneous and dietary sources due to its
accumulation in cutaneous depots.
Vitamin D might directly increase insulin sensitivity by
stimulating the expression of insulin receptors in
peripheral tissues..

.
(OH) D25 Vitamin D

37. Overall, the co-administration of vitamin D and
omega-3 fatty acid for 12 weeks had beneficial
effects on mental health parameters, serum
total testosterone, hs-CRP, plasma TAC and
MDA levels, and gene expression of IL-1 and
VEGF among women with PCOS

38. Can improve insulin sensitivity, normalize blood
sugar.
Regulates the effect of insulin on ovarian androgen
biosynthesis, theca cell proliferation, and
endometrial growth.
Improves insulin-mediated glucose disposal.
As a rich source of vitamins, minerals and
antioxidant.
Reverse chronic inflammation caused by attack of
free radicals

Backed Remedy For PCOS-ScienceFenugreek: A

40. fenugreek seed extract (Furocyst), 2 capsules
of 500 mg each/day
Contains insulin sensitizing compounds (Saponins,
flavonoid) which improves insulin sensitivity.
Significant decrease in LH/FSH ration was
observed.
Significant reduction in ovarian volume and
follicular cyst size.
Significant improvement in menstrual cycle ,
improved pregnancy rate

41. Cinnamomum zeylanicum, is an herbaceous plant.
It is one of the most important spices used by
people all over the world.
Different flavonoids and Polyphenols isolated from
cinnamon have free-radical-scavenging activities
and antioxidant properties.
Cinnamon

43. Cinnamon significantly decreased serum fasting
blood glucose, insulin, insulin resistance, total
cholesterol, LDL, and increases HDL.
Decreases serum triglyceride and body mass index.
Improves menstrual regularity .
Cinnamon

44. In conclusion, 1.5 g of cinnamon supplementation
for 12 weeks improved antioxidant status and
lipid profile, and menstrual regularity in women
with PCOS.
Cinnamon

45. Chamomile and its Calming Effect on PCOS

46. Chamomile is one of the most ancient medicines in
the world.
Chamomile contains phytosterols, coumarin and
Phytosterols.
Phytosterols (which are cholesterol-like compounds)
have been previously found to reduce androgenic
hormone synthesis, especially testosterone.
 It has impacts on GABA neurotransmission, improve
LH peak and trigger ovulation

Chamomile and its Calming Effect on PCOS

47. Synbiotic pomegranate juice (SPJ)
Nutrition, Metabolism and Cardiovascular Diseases
JOURNAL, July 2018
Effect of synbiotic pomegranate juice on glycemic, sex
hormone profile and anthropometric indices in PCOS: A
randomized, triple blind, controlled trial.
SPJ in the form of a new beverage can improve insulin resistance, insulin, testosterone level,
BMI, weight and waist circumference in PCOS.
SPJ can improve insulin resistance, testosterone level, BMI, weight
and waist circumference in PCOS thanks to its rich source of
phytochemicals with high antioxidant activity.

48. Flaxseed

49. Flaxseed
A food generally renowned for its omega-3
fatty acid content.
Also is one of the richest sources of dietary
lignan.
Suggested to decrease androgen levels with
concomitant reduction in hirsutism.
Suggested to normalize lipid levels.

50. Silymarin
Milk Thistle Extract
•Having anti-inflammatory
substances.

•Significant reduction in inflammatory
markers and significant changes
follicular layers thickness.

• It can be concluded that, Silymarin
is effective in symptoms of this
syndrome.

52. Curcumin
Beneficial effect of Curcumin in Letrozole induced
polycystic ovary syndrome, Sushma Reddy et
al./Asian Pacific Journal of Reproduction2016;
5(2): 116–122

This study involving rats and found that Curcumin is
as effective as clomiphene citrate in treating PCOS.
The possible mechanisms for the improvement in
symptoms are
It reduces the blood levels of testosterone . In addition, it
causes a significant increase in the level of hormone
estradiol.

53. A marked reduction in the blood levels of glucose and
fats including bad cholesterol.
An increase in the levels of protective antioxidant
enzymes like catalase, glutathione and superoxide
dismutase.

54. combined nutritional supplements including
herbal medicine and lifestyle interventions are
effective and most likely safe in management of
women with PCOS