Exercise, Nutrition & Supplementation to Manage Polycystic Ovary Syndrome (PCOS)

What is Polycystic Ovary Syndrome?

Polycystic ovary syndrome (PCOS) is the most common hormone disorder in women of reproductive age, affecting 5–15% of women as early as the second decade of life (1).

As the exact causes of the disorder remain unknown, it is diagnosed based upon consensus criteria and the exclusion of other endocrine disorders (see table below), with the Rotterdam criteria most commonly used for diagnosis (2).

PCOS is characterized by hyperandrogenism and oligo-ovulation or anovulation, resulting in acne, hirsutism (excessive growth of dark or coarse hair in a male-like pattern), male-pattern hair loss, irregular menstrual cycles, and subfertility (3).

In addition to the endocrine and reproductive effects, PCOS impacts cardiometabolic and psychological health across the lifespan (4).

Women with the disorder are more likely to develop obesity, type 2 diabetes, cardiovascular disease (CVD), non-alcoholic fatty liver disease (NAFLD), and have a greater risk of developing anxiety, depression, and mood disorders (5).

Table adapted from Shele et al. (5)

In women with PCOS, the ovaries are stimulated to produce excessive amounts of androgens; potentially through hyperstimulation by luteinizing hormone (LH) or the intrinsic dysregulation of steroidogenesis (6).

Besides contributing to the development of many features of the disorder, hyperandrogenism promotes insulin resistance and hyperinsulinemia, which can further aggravate hyperandrogenemia as well as lead to weight gain and obesity (7).

The mechanisms by which androgens specifically affect insulin dynamics are unknown. However, insulin resistance in women with PCOS has been attributed to impaired insulin signaling that affects the metabolic pathway (8).

Insulin resistance, hyperinsulinemia, overweight and obesity are common in women with PCOS and exacerbate the appearance of the disorder, partly by further stimulating steroidogenesis and androgen production (4).

PCOS is a challenging endocrine disorder to treat because of the reciprocal relationship between androgens and insulin, combined with the impact of each on the presentation of the features of PCOS and the unknown etiology of the disorder (9).

In addition to elevated levels of androgens and insulin, adipose-derived hormones are reported to be dysregulated in PCOS and may further contribute to metabolic dysfunction in women with the disorder (10).

How is PCOS diagnosed?

Diagnosis of PCOS is relatively straightforward from a medical perspective. Normal FSH and high levels of LH will show up on a blood test. This is consistent with the excess androgens in the condition; the imbalance between testosterone and estrogen. In addition, serum testosterone levels are usually increased.

A transvaginal ultrasound will show multiple cysts containing follicles in a usually enlarged ovary. There are typically at least 12 cystic follicles, ranging from 2mm to 9mm in size. However, there can be more than this, sometimes up to 50. A biopsy of the endometrium is sometimes indicated.

In addition to the above; additional screening tests are very useful as depicted below:

• Blood pressure
• Blood glucose
• Oral glucose tolerance test
• Fasting plasma insulin levels
• Fasting blood cholesterol levels.

Role of Physical Activity in Managing PCOS Symptoms

One of the first lines of advice for managing PCOS symptoms is weight loss which should be coupled with a healthy, well-balanced diet (11). Women with PCOS are given the general advice to be physically active (9).

Studies have examined different types of exercise and exercise regimens in mitigating PCOS characteristics and improving health and outcomes in women with the disorder.

Recommended Guidelines

Considering the current body of evidence on the impact of various types of physical exercise on hormone health in women with PCOS, the following are recommended guidelines for healthcare providers and patients with PCOS:

• Women with PCOS should be asked about current physical activity type(s), frequency, duration, and intensity. Adolescents and obese patients in particular should be asked about barriers to physical activity and counseled appropriately (5).

• Vigorous aerobic activity at least three days per week for 30 min or more is recommended. A heart rate monitor or VO2max guided intensity levels (≥60% VO2max) are advisable to obtain insulin-related benefits (5).

• Combination exercise that includes progressive resistance training or strength training three days per week on non-consecutive days may provide additional benefits with respect to androgen levels (5).

• Yoga may be a desirable activity to include as a regular physical exercise, although further studies are warranted to confirm its benefits with respect to androgens and insulin responsiveness (5).

Practical application – intense resistance training for PCOS

Intense resistance training diminishes intramuscular glycogen stores quite dramatically. Intense muscle contractions trigger acute changes in glucose and insulin function which help restore glycogen levels. This results in muscles being super-sensitive to glucose uptake after intense resistance exercise.

So essentially, this shuttles glucose into muscle tissue rather than having it float around in the bloodstream. 

The culminating effect of this is increased insulin sensitivity and effective nutrient partitioning – two things that are not happening in PCOS. 

Therefore, we can use resistance exercise to enhance insulin function.

In summary; physical exercise is part of the lifestyle recommendations for women with PCOS. Vigorous aerobic exercise, especially when practiced consistently over the long-term and in conjunction with heart rate and/or VO2max monitoring, can improve measures of insulin sensitivity.

Improvements in androgens are more likely with resistance or strength training, although further studies are warranted for confirmation. The impact of yoga on insulin sensitivity and androgens appears promising and requires additional research.

Optimizing management of PCOS with nutrition and supplementation

Quite often people with PCOS feel as if they are fighting a losing battle when it comes to achieving improvements in their body composition. However, the focus should always be on what they can do, not what they can’t, or what may hinder them. 

Most women with PCOS, regardless of weight, have resistance to insulin. For this reason, changes in lifestyle that lead to improvements in insulin sensitivity should be considered as the first-line therapy in PCOS, especially in cases where there is the problem of excess weight and obesity (12).

In spite of the prevailing belief of the necessity to modify lifestyle factors, comprehensive information on nutritional recommendations for women with PCOS is not available. Let’s take a look at what has been done in order to glean the most essential information possible to help women with PCOS. 

Obesity and weight loss in PCOS

There is a clear connection between PCOS and obesity. The average obese population with PCOS is higher than the average of obesity among healthy women. Obesity, especially abdominal obesity in adolescence and adulthood along with weight gain in puberty are predictors of hirsutism and menstrual disorders in this syndrome (13). 

Obesity may increase risk of certain PCOS features such as increased levels of androgens, hirsutism, infertility, and pregnancy complications, such as preeclampsia and gestational diabetes. In addition, the obesity associated with insulin resistance increases risk of cardiovascular diseases and type 2 diabetes in women (14). 

Several studies have reported the positive effects of 5–10 percent weight loss on reducing the risk factors for cardiovascular disease, type 2 diabetes, endocrine and reproductive parameters in polycystic ovary syndrome (15). 

Disorderliness in appetite regulation is also observed among these women that may cause some problems with weight control. Levels of ghrelin and cholecystokinin, hormones which play essential roles in regulating appetite, are also impaired in these patients (16).

A successful weight loss strategy in this population is obtained through reduced calorie intake (500–1000 kcal per day) along with regular physical activity as well as stress reducing behavioral and psychological therapy, along with social support (17).

Macronutrient composition of weight-loss diets for PCOS

A recent meta-analysis (review of stats from multiple studies) of eight randomized controlled trials involving 327 patients was conducted to assess the effect of a low carbohydrate diet on women with PCOS. 

The primary outcomes included changes in body mass index, homeostatic model assessment for insulin resistance (HOMA-IR), and blood lipids, including total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C), follicle-stimulating hormone (FSH), luteotropic hormone (LH), total testosterone (T), and sex hormone-binding globulin (SHBG).

Based on the current evidence, low carbohydrate diet, particularly long-term low carbohydrate diet and low-fat/low-CHO low carbohydrate diet may be recommended for the reduction of body mass index, treatment of PCOS with insulin resistance, prevention of high LDL-C, increasing the levels of FSH and SHBG, and decreasing the level of T level.

Collectively, the analyzed data indicate that proper control of carbohydrate intake provides beneficial effects on some aspects of PCOS and may represent one of the important interventions improving the clinical symptoms of affected patients (18).

When we talk about carbohydrate, a common term to be familiar with is the glycemic index.

The glycemic index is a number from 0 to 100 assigned to a food, with pure glucose arbitrarily given the value of 100, which represents the relative rise in the blood glucose level two hours after consuming that food. 

There is abundant evidence supporting the advantages of diets with a low glycemic index. This type of diet can improve insulin resistance (19) while foods with a high glycemic index exert opposite effects.

Research has also shown that a low glycemic index diet is associated with reduced of cardiovascular disease, type 2 diabetes, insulin resistance, and metabolic syndrome, as well as a reduced risk of endometrial, breast, and ovarian cancers (20).

Consequently, it seems that the type of carbohydrate intake has a more important role in maintaining metabolic health rather than the total amount received.

Practical application - Carb timing and meal frequency can help

For women with PCOS, consuming the appropriate amount of carbohydrates, at appropriate times is important because it ensures more effective nutrient partitioning. This means glucose will be delivered into muscles to restore glycogen levels and help with protein synthesis/recovery rather than being shuttled to fat cells.

Intense exercise creates a dramatic short-term shift in insulin sensitivity and glucose uptake. Consuming higher glycemic index carbs within this period optimizes results and prevents excess blood glucose levels outside of this time period. 

Sub-optimal carb timing can contribute to hyperglycemia at unsuitable times, consequently worsening insulin sensitivity, which we know is the underlying mechanism of PCOS.

Another powerful intervention is meal frequency. Adequate meal frequency stabilizes insulin levels and enhances baseline metabolic rate. Both of these result in greater fat loss and more efficient insulin function. 

In addition, there is a steady supply of amino acids from frequent feedings which further enhances insulin function and protein synthesis. When combined with a a solid exercise program, this leads to increased lean muscle tissue which will greatly benefit women with PCOS.

Fatty acids and PCOS

Diets high in fat, especially saturated fat and trans-fatty acids reduce insulin sensitivity and increase the risk of type 2 diabetes, metabolic syndrome, and cardiovascular disease (21), while consuming foods containing unsaturated fats reduces the risk of chronic diseases.

This is true especially for the diets containing unsaturated fatty acids and omega-3 that may decrease many risk factors for metabolic disorders seen in women to PCOS, such as high levels of serum lipids, insulin resistance and impaired endothelial function (22).

Until recently, no comprehensive evidence has investigated the effects of omega-3 consumption on PCOS complications. Therefore, a recent comprehensive review polyunsaturated fatty acid investigated the possible effect and related mechanisms (23).

Omega-3 polyunsaturated fatty acids are a promising agent in relieving complications associated with PCOS. There are multiple mechanisms by which omega-3 polyunsaturated fatty acids may exert their beneficial effects on PCOS women. These include anti-obesity, glycemic and hormonal homeostasis, anti-inflammatory, regulation of adipokine production and enhancement of endothelial function (see figure below).

Figure adapted from Salek et al. 2019 (23)

Although studies investigating omega-3 supplements in patients with PCOS reported an improvement in numerous complications and comorbidities, including insulin resistance, dyslipidemia, hyperandrogenism, and regulation of metabolic indicators; there is a distinct shortage of studies investigating the dietary intake of these types of fatty acids (23).

Vitamin D deficiency and PCOS

Research has demonstrated that vitamin D plays roles in various metabolic pathways, including insulin metabolism. Vitamin D deficiency affects the pathogenesis of insulin resistance and PCOS (24).

A recent review proposed an association between vitamin D status and hormonal and metabolic disorders among PCOS cases (25).

The mechanism behind this effect is still unknown, but a possible role for ovarian dysfunction in the mechanisms that regulate apoptosis (programmed cell death) has been reported. Moreover, due to its immune-enhancing role, lack of vitamin D may cause inflammatory responses leading to insulin resistance (26).

Several studies have reported low levels of vitamin D in PCOS.  Hence, supplementation with vitamin D may be effective in modifying hormones and metabolism in these patients.

Minerals and PCOS

Reduced levels of magnesium have been reported in women with high levels of testosterone or insulin resistance. Therefore, magnesium replacement seems to be useful in the adjustment and improvement of insulin resistance.

Furthermore, decreased plasma levels of chromium have been reported in people with type 2 diabetes, suggesting that chromium deficiency may reduce insulin sensitivity (27).

A study where 1000 mcg of chromium picolinate was given to women with PCOS for 2 months resulted in improved glucose levels and insulin sensitivity (28). 

In addition, chromium picolinate is involved in reducing hirsutism and alleviating the symptoms of PCOS (29). 

Amongst the few studies available on PCOS patients, chromium supplementation has been reported to lead to significant reduction of body mass (30).

Also, low selenium levels in PCOS women compared with healthy controls have been reported and expressed a negative correlation between serum testosterone level and selenium (31).

Caffeine and PCOS

Caffeine is a dietary concern relevant to polycystic ovaries in women, which affects ovulation and corpus luteum function through changing hormone levels. Most studies have established that caffeine intake is a risk factor for reduced fertility. Results of a study showed that taking more than 500 mg of caffeine per day increases the risk of infertility (32).

There is some evidence which proposes that there is an association between caffeine intake and the elevated risk of spontaneous abortion (33).

A meta-analysis study revealed a significant relationship between moderate to high doses of caffeine intake with abortion and low birth weight (34).

Although not all studies have confirmed these findings, women with PCOS are recommended to take special precautions to avoid receiving very high doses of caffeine.

Summary

The relationship between PCOS and insulin resistance presents an opportunity to intercede in the dietary habits of women with this condition to prevent or delay the onset of type 2 diabetes and cardiovascular disease.

It’s clear that nutritional management and exercise should focus on weight loss plans. Special attention should be given to the impact of the various components of the diet and proper exercise programming in order to improve insulin sensitivity. 

Two supplements that could help this condition are One+ and ADA Load

One+ combines 23 vitamins and minerals to provide what your body may be lacking. Since insulin resistance is a prominent feature of PCOS, doing what we can to enhance insulin sensitivity and get blood glucose levels under control is paramount. ADA Load is a potent combination of ingredients shown in evidence-based research to reduce blood sugar levels in individuals with high blood glucose.

In addition, a beneficial dietary plan in women with PCOS should contain low amounts of saturated fatty acids with average amounts of unsaturated fatty acids including omega-3.

Also, sufficient intake of fiber-rich diet from whole grains, legumes, vegetables and fruits with an emphasis on carbohydrate sources with low glycemic index is highly recommended.

While improving the symptoms of PCOS, the recommendations above may also reduce the risk of developing chronic diseases associated with insulin resistance (e.g., type 2 diabetes).

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