Female Health

1. Recent Advances In Obesity And PCOS:
Clinical And Nutritional Management

2. Polycystic Ovarian Syndrome
• PCOS is a common endocrinopathy affecting 4-12% of women of reproductive age.
• PCOS is characterized by oligo/anovulation, clinical and/or biochemical evidence of androgen excess,
obesity, insulin resistance and polycystic ovaries.
• It is associated with a number of comorbidities including:
 Infertility
Increased risk of T2DM and CVD
Psychological burden
Risk of endometrial cancer
1. Khademi A, Alleyassin A, Aghahosseini M, Tabatabaeefar L, Amini M. The Effect of Exercise in PCOS Women Who Exercise Regularly. Asian J Sports Med. 2010 Mar;1(1):35–40.
2. Harwood K, Vuguin P, DiMartino-Nardi J. Current Approaches to the Diagnosis and Treatment of Polycystic Ovarian Syndrome in Youth. HRP. 2007;68(5):209–17.
3. Lathief S, Pal L. Advances in Treatment Options for Polycystic Ovary Syndrome. Journal - Advances in Treatment Options for Polycystic Ovary Syndrome [Internet]. 2012 May 14.

3. Prevalence
• According to WHO estimates PCOS has affected 116 million women (3.4%) worldwide in 2012.
• Globally PCOS prevalence rate ranges from 2.2% to as high as 26%.
• In India, experts have claimed 10% of the women to be affected by PCOS.
• When PCOS is considered on the basis of menstrual disorder, PCOS is prevalent in:
30% - 40% of patients with primary or secondary amenorrhea.
80% of patients with oligomenorrhea.
1. Bharathi RV, Swetha S, Neerajaa J, Madhavica JV, Janani DM, Rekha SN, Ramya S, Usha B. An epidemiological survey: Effect of predisposing factors for PCOS in Indian urban and rural
population. Middle East Fertility Society Journal. 2017 Dec 1;22(4):313-6.
2. Barbosa G, Sá LBPC de, Rocha DRTW, Arbex AK. Polycystic Ovary Syndrome (PCOS) and Fertility. Open Journal of Endocrine and Metabolic Diseases. 2016 Jan 12;06:58.

4. Study
• Cross-sectional survey
Participants
• 1068 girls
• 502 from urban and 572 from rural population
Result
• Prevalence rate of PCOS in India- 6% (based on self-answered questionnaire)
• Incident rate- 8.9% in urban areas, 1% in rural area
• In urban areas- 90.24% girls are aware, in rural areas – 8.34% are aware
• Family history has a strong association
A study conducted by Bharathi et.al (2017):
Bharathi RV, Swetha S, Neerajaa J, Madhavica JV, Janani DM, Rekha SN, Ramya S, Usha B. An epidemiological survey: Effect of predisposing factors for PCOS in Indian urban and rural
population. Middle East Fertility Society Journal. 2017 Dec 1;22(4):313-6.

5. Diagnostic Criteria
NIH/NICHD 1992
• Includes all of the
following:
• Clinical and/or
biochemical
hyperandrogenism
• Menstrual dysfunction
ESHRE/ASRM
(Rotterdam
criteria) 2004
• Includes two of the
• following:
• Clinical and/or
biochemical
hyperandrogenism
• Oligo-ovulation or
anovulation
• Polycystic ovaries
Androgen Excess
Society 2006
• Includes all of the
Following:
• Clinical and/or biochemical
hyperandrogenism
• Ovarian dysfunction
and/or polycystic ovaries
Sirmans SM, Pate KA. Epidemiology, diagnosis, and management of polycystic ovary syndrome. Clin Epidemiol. 2013 Dec 18;6:1–13.

6. Prevalence of PCOS using different
diagnostic criteria
Population NIH/NICHD
criteria
ESHRE/ASRM
(Rotterdam) criteria
Androgen excess
and PCOS society
criteria
Source
929 Iranian women 7.1% 14.6% 11.7% Tehrani et al
820 Iranian women 7% 15.2% 7.92% Mehrabian et al
728 Australian women 8.7% 17.8% 12% March et al
392 Turkish women 6.1% 19.9% 15.3% Yildiz et al
Sirmans SM, Pate KA. Epidemiology, diagnosis, and management of polycystic ovary syndrome. Clin Epidemiol. 2013 Dec 18;6:1–13.

7. Obesity – a significant risk factor in PCOS
Public Health England. ‘Health Matters: Reproductive Health and Pregnancy Planning’. GOV.UK. Accessed 6 October 2020. https://www.gov.uk/government/publications/health-
matters-reproductive-health-and-pregnancy-planning/health-matters-reproductive-health-and-pregnancy-planning.
50% of PCOS women are overweight or obese.

8. Mechanism of Abdominal adiposity with PCOS
Escobar-Morreale HF. Polycystic ovary syndrome: definition, aetiology, diagnosis and treatment. Nature Reviews Endocrinology. 2018 May;14(5):270–84.
Hyperinsulinism
Abdominal visceral adiposity
Androgen Excess
Insulin Resistance
Adipocytes
Adiponectin
TNF
IL-6
Leptin
Target cell
Glucose Transporter
Ovary
Adrenal gland

9. Insulin resistance and Impaired glucose
tolerance in PCOS
Insulin Action in PCOS: Relation with Obesity
• Prevalence of insulin resistance ranges from 50%–70%.
• Hyperinsulinemia produces a hyperandrogenic state by acting as a co-gonadotropin with luteinizing
hormone (LH), increasing androgen production and by reducing hepatic production of sex hormone
binding globulin.
• Women with PCOS are insulin resistant at the level of muscle, adipose tissue and liver.
1. Sam S. Obesity and Polycystic Ovary Syndrome. Obes Manag. 2007 Apr;3(2):69–73.
2. Sirmans SM, Pate KA. Epidemiology, diagnosis, and management of polycystic ovary syndrome. Clin Epidemiol. 2013 Dec 18;6:1–13.

10. Glucose Tolerance in PCOS: Relation with Obesity
• PCOS is associated with high rates of glucose intolerance resulting from defects in insulin
action and β-cell function.
• Obese reproductive-age women with PCOS are at very high risk of glucose intolerance.
Sam S. Obesity and Polycystic Ovary Syndrome. Obes Manag. 2007 Apr;3(2):69–73.
Study
•Prospective, controlled study
Participants
•254 reproductive-age women with PCOS
•80 control women of comparable ethnicity, age and weight
Result
•Prevalence of glucose intolerance in women with PCOS (~40% combined IGT and
T2D) was much higher than control women (14% with IGT and 0% with T2D)
Study conducted by Legro et.al.

11. Clinical Management Strategies
Treatment for PCOS includes
• insulin-lowering drugs
• anti-androgen therapy
• oral contraceptives
• implementation of lifestyle changes, including weight loss if required.
Since PCOS is associated with multiple comorbidities, its treatment options differ
accordingly.
1. Lathief S, Pal L. Advances in Treatment Options for Polycystic Ovary Syndrome. Journal - Advances in Treatment Options for Polycystic Ovary Syndrome [Internet]. 2012 May 14 [cited 2019 Mar 4
2. Douglas CC, Gower BA, Darnell BE, Ovalle F, Oster RA, Azziz R. Role of diet in the treatment of polycystic ovary syndrome. Fertil Steril. 2006 Mar;85(3):679–88.

12. Treatment Options for Targeting Common Symptoms
Lathief S, Pal L. Advances in Treatment Options for Polycystic Ovary Syndrome. Journal - Advances in Treatment Options for Polycystic Ovary Syndrome [Internet]. 2012 May 14 [cited 2019 Mar 4];
• First-line treatment in PCOS management
• Suppresses LH, thereby reducing the stimulant effect of LH on androgen production
• Increases SHBG
• Offers protection against proliferative endometrial pathologies
Combined
Oral
Contraceptives
• Efficacious in mitigating the risk of endometrial pathologies in oligomenorrheic
women
Progesterone-
only Approach

13. Treatment Options for Managing Infertility in patients with PCOS
1. Lathief S, Pal L. Advances in Treatment Options for Polycystic Ovary Syndrome. Journal - Advances in Treatment Options for Polycystic Ovary Syndrome [Internet]. 2012 May 14 [cited 2019 Mar 4];
• Clomiphene Citrate (CC)
• Tamoxifen
Selective Estrogen
Receptor Modulators
(SERMs)
• Letrozole and Anastrozole are successfully used
• Leads to ovulation induction in CC-resistant patients
Aromatase Inhibitors
(AIs)
• In patients who fail to achieve success with SERMs and AIs
• Treatment protocol includes, lower dose step-up, low dose step-
down and combination of CC and low-dose gonadotropin
Gonadotropins

14. Treatment Options for Managing Infertility
Lathief S, Pal L. Advances in Treatment Options for Polycystic Ovary Syndrome. Journal - Advances in Treatment Options for Polycystic Ovary Syndrome [Internet]. 2012 May 14 [cited 2019 Mar 4];
• PCOS patients who fail to respond to SERMs and AIs, bilateral
electrocautery of the ovarian surface is the approach for
restoring ovulation.
• Spontaneous pregnancy rates increase following LOD.
Laparoscopic
Ovarian Drilling
(LOD)
•Spironolactone- Improved menstrual cyclicity and resumption of ovulation
at a dose of 50-200 mg/day.
•Finasteride- Blocks the conversion of testosterone to its more potent form
dihydrotestosterone (DHT) at a dose of 1-5 mg/day.
•Cyproterone Acetate- Efficacious in treating hirsutism at a dose of 2 mg.
Antiandrogens

15. A small to moderate weight loss of
about 5–10%
• Significantly improve IR,
• restore ovulation and improve
menstrual regularity and
conception
• ameliorate hyperandrogenism,
hirsutism and dyslipidemia.
PHYSICAL ACTIVITY
Lifestyle Interventions
DIET & NUTRITION

16. Calorie Restriction & Specific Nutrient
Requirement In PCOS

17. Calorie Restriction
Papavasiliou K, Papakonstantinou E. Nutritional support and dietary interventions for women with polycystic ovary syndrome. Nutrition and Dietary Supplements. 2017;9:63-85
PCOS patients are not always markedly overweight but PCOS is strongly associated with abdominal
obesity and insulin resistance.
Obese PCOS
Negative energy balance (with a deficit of 350–1000
kcal/day) seems to be the key factor leading to successful
body weight and fat loss and amelioration of menstrual
cycle and insulin sensitivity, irrespectively of the adopted
dietary pattern
Calorie Restriction: Weight Management & Body Composition
Dietary Modification &
Healthy Diet

18. Foods that contribute to Obesity
• Ultra-processed products tend to be energy-dense and high in
saturated and trans fat, added sugar, sodium, refined carbohydrates
• Consumption of these products may promote excess energy intake
because of their high energy density, as regulation of food intake
controls volume consumed rather than calories consumed
To achieve calorie deficit, one needs to avoid foods rich in the
following as these are high in calories and have been shown to
contribute to obesity
1. Sugar
2. Fat – Saturated and Trans
3. Sodium/Salt
4. Refined carbohydrates
Poti JM, Braga B, Qin B. Ultra-processed food intake and obesity: what really matters for health—processing or nutrient content?. Current obesity reports. 2017 Dec 1;6(4):420-31.

19. Sugar is a big culprit in causing obesity and other
metabolic consequences in Indians
Rippe JM, Angelopoulos TJ. Relationship between added sugars consumption and chronic disease risk factors:
Current understanding. Nutrients. 2016 Nov;8(11):697.

20. Reducing sugar consumption can help reduce
obesity incidence

21. FSSAI – EAT RIGHT
MOVEMENT
WHO RECOMENDATION
FSSAI AND WHO recommend reducing intake of
sugar in diet
Thus, watching out Sugar intake and selecting foods with Low or No Added
Sugars is important

22. Macro and Micronutrients in
PCOS
American Diabetes Association. Standards of medical care in diabetes -- 2009. Diabetes Care. 2009 Jan;32 Suppl 1:S13-61.

23. Distribution of macronutrients
American Diabetes Association. Nutrition principles and recommendations in diabetes. Diabetes care. 2004 Jan 1;27(suppl 1):s36-..
≤
15–20%

24. Carbohydrates, Low GI and
High Fibre
Dietary
Carbohydrates
• Reduced carbohydrates diet results in:
• Lower measure of cell responsiveness and circulating insulin.
• Improvement in LDL cholesterol particle size, LDL concentration, and post prandial blood lipid
profile.
Glycemic
Index (GI)
• Food with low GI improves-
• Glucose control in PCOS and diabetes.
• Insulin sensitivity and menstrual regularity.
Dietary Fibre
• Food with high fibre -
• Contributes to satiety and weight management
• Helps combat insulin resistance
Paliwal M, et.al. Diet and Nutrition Management in Polycystic Ovary Syndrome. IJFANS. July 2016, Vol. 5, No. 3.

25. 6 RCTs; 202
participants
Lost a mean of 1 kg
more
Body mass, total fat
mass, and body mass
index decreased
significantly
Lipid profile also
improved
Intervention: 5
weeks–6 months
Thomas D, et al. Cochrane Database of Systematic Reviews. 2007; Issue 3, Art. No.: CD005105.
RCTs: Randomized controlled trials.
Impact of low glycemic index
or glycemic load diets in
overweight or obese people.
Low Glycemic Index and Load
Augment Weight Loss

26. 1. Barr S, et al. J Acad Nutr Diet. 2013;113(11):1523–1531. 2. Marsh KA, et al. Am J Clin Nutr. 2010;92:83–92. 3. Sordia-Hernández LH, et al. Clin Exp Obstet Gynecol.
2016;43(4):555–559.
PCOS: Polycystic ovary syndrome.
Benefits of Low Glycemic Index for
Insulin Sensitivity in PCOS
% Change in insulin resistance and
insulin sensitivity
Low glycemic index
helps reduce insulin
resistance and
improves insulin
sensitivity among
women with PCOS.1,2

27. Dietary
Proteins
• Proteins consumed at breakfast as compared with
lunch and dinner are more beneficial.
• Diet should deliver 20-25% of its calories as
protein.
• It helps the patient to lose weight or improve
glucose tolerance.
Paliwal M, et.al. Diet and Nutrition Management in Polycystic Ovary Syndrome. IJFANS. July 2016, Vol. 5, No. 3.
Role of protein in PCOS

28. 1. Paddon-Jones D, et al. AJCN. 2008;87(5):1558S–1561S. 2. Westerterp KR. Nutr Metab (Lond). 2004;1(1):5. 3. Longland TM, et al. AJCN. 2016;103(3):738–746.
Protein and satiety:1,2
• Increases satiety to a greater extent
than carbohydrate or fat
• Facilitates a reduction in energy
consumption
Protein and weight loss/maintenance:1,3
• Increases total weight loss
• Increases the percentage of fat loss
• Promotes the maintenance or accretion
of fat-free mass
• Favors the retention of lean muscle
mass improving metabolic profile.
• Increases thermogenesis—augments
energy expenditure

29. • 2-month, free-living,
randomized, single-blinded
study
• 33 patients with PCOS
• Intervention: first the daily
energy intake was reduced
by 700 kcal; then a 240-
kcal supplement
containing either whey
protein or simple sugars
was added.
Kasim-Karakas SE, et al. ASRM. 2009;92(1):262–270.
PCOS: Polycystic ovarian syndrome; HDL-c: High-density lipoprotein cholesterol.
Protein Supplementation Enhances
Weight Loss in PCOS

30. Mehrabani HH, et al. J Am Coll Nutr. 2012;31(2):117–125.
PCOS: Polycystic ovary syndrome.
Benefits of the hypocaloric diet with high-protein, low glycemic-load diet
Reduced body weight
Decrease in high-sensitivity C-reactive protein
and androgen levels
Increase in insulin sensitivity
Dietary intervention
Conventional hypocaloric diet (15% of daily energy from protein)
Modified hypocaloric diet with a high-protein, low-glycemic load (30% of
daily energy from protein)
Investigated the effects of a high-protein, low glycemic-load diet compared with a conventional hypocaloric diet in obese
women with PCOS
RCT 60 overweight and obese women with PCOS 12 weeks
Benefits of High Protein, Low Glycemic
Index in PCOS

31. Te Morenga L, et al. Nutrients. 2017;9(12):1291.
Standard diet: low fat, relatively high
carbohydrate
Relatively high protein (up to 30% of
energy), relatively high fiber (>30 g/day)
diet
89 overweight or obese women 10 weeks
Results: 19% reduction in insulin sensitivity in the intervention
group when compared to the group consuming the standard diet
Randomized controlled trial
Effect of Moderately High Protein and
Fiber on Insulin Sensitivity

32. Paliwal M, et.al. Diet and Nutrition Management in Polycystic Ovary Syndrome. IJFANS. July 2016, Vol. 5, No. 3.
Dietary fats
• Diet rich in mono saturated fatty acids decreases obesity and insulin resistance.
• Taken no more than 30% of the calorie content of the diet.
Antioxidants
• PCOS is associated with decreased antioxidant concentrations and it is
considered an oxidative state.
• Diet rich in fruits and vegetables, weight reduction, physical exercise, cessation
of smoking & alcohol consumption and an adequate number of sleeping hours to
be adopted to reduce oxidative stress.
Vitamin D
• Hypovitaminosis D is found in 80% of PCOS women.
• Supplementation of vitamin D (50,000 IU/week) restores normal menstrual
regularity and improves hyperandrogenism symptoms.
Role of other nutrients in PCOS

33. Role of nutrient supplementation in PCOS
Adapted from Gunalan et al

34. Inositol supplementation
Roles in:
• Insulin
sensitivity
• Lipid synthesis
• Oocyte
formation
• Oogenesis
Source Subjects Treatment Outcomes
Gerli et al 92 females with
polycystic ovaries
and oligomenorrhea
400 mcg folic acid intake in
placebo group (n=47) and
400 mcg folic acid + 4g
inositol in treatment group
(n=45), for 12-16 weeks
• Higher ovulation rate
• Weight loss
• Folicular maturation
• Circulating HDL
increases
Papaleo et
al
25 females with
PCOS and
oligo/amenorrhea
since childbearing
age
Myo-inositol + folic acid
(inofolic) (2g twice a day),
for 6 months
• Improved menstrual
cycle
• Healthy ovarian activity
• Serum free testosterone
reduces
Recommended dosage : 2-4 g per day
Günalan E, Yaba A, Yılmaz B. The effect of nutrient supplementation in the management of polycystic ovary syndrome-associated metabolic dysfunctions: A critical review. J Turk Ger Gynecol Assoc. 2018

35. Omega-3 supplementation
• Reduce oxidative stress
• Decrease hypertension
• Improve lipid profile and anti-inflammatory activity
• Regulation of abnormal gene expression in PCOS
Source Subjects Treatment Outcomes
Mohammadi and
Rafraf
64 PCOS women;
20-35 years old
Treatment group (n=32)
received 4g/day omega-3
fatty acid; while placebo
group (n= 32) didn’t.
Decreased CV risk:
• Serum paraoxonase I activity
improves
• Improved lipid profile
Oner and
Muderris
45 non-obese
PCOS patients
1500 mg/d omega-3
supplements for 6 months
• HOMA-IR and insulin level
reduces
• LH and testosterone reduces
• SHBG and TNF-α increases
Recommended dosage : 1-4g/day
Günalan E, Yaba A, Yılmaz B. The effect of nutrient supplementation in the management of polycystic ovary syndrome-associated metabolic dysfunctions: A critical review. J Turk Ger Gynecol Assoc. 2018
15;19(4):220–32.

36. Overall Tips on Modification of Diet and
Eating Pattern
• Intake of carbohydrates should count for 50%-55% of the
total energy.
• Diet high in fiber is beneficial.
• Higher protein i.e. 15-25% of daily energy, improves
satiety and insulin sensitivity.
• Eating not more than 30% of daily calories as fat. Avoiding
red meat.
• Consuming at least five portions of fruit or vegetables per
day.
Paliwal M, et.al. Diet and Nutrition Management in Polycystic Ovary Syndrome. IJFANS. July 2016, Vol. 5, No. 3.

37. Overall Tips on Modification of Diet and Eating
Pattern
• Regularly eating and focusing on food intake of three to four meals
per day.
• Not skipping breakfast.
• Calorie intake should be distributed between several meals per day
with low intake from snacks and drinks.
• Avoid foods rich in fats and Sugars
Paliwal M, et.al. Diet and Nutrition Management in Polycystic Ovary Syndrome. IJFANS. July 2016, Vol. 5, No. 3.
Address Emotional eating and sugar cravings

38. Exercise and Physical Activity
• Exercise improves menstrual abnormalities and restores ovulation in obese patients
with PCOS
• According to Thomson et al., 2008, exercise exerts its beneficial effects on body
composition with a 45% greater reduction in fat-free mass.
• Moderate exercise for ≥30 min per preference is essential
1. Paliwal M, et.al. Diet and Nutrition Management in Polycystic Ovary Syndrome. IJFANS. July 2016, Vol. 5, No. 3.
2. Norman RJ, Davies MJ, Lord J, Moran LJ. The role of lifestyle modification in polycystic ovary syndrome. Trends in Endocrinology & Metabolism. 2002 Aug 1;13(6):251–7.

39. Other Lifestyle modification for the management of PCOS
Reduction of psychosocial stress.
Cessation of smoking.
Moderate alcohol & caffeine consumption.
Group interaction/intervention to provide support in
implementing changes.
1. Paliwal M, et.al. Diet and Nutrition Management in Polycystic Ovary Syndrome. IJFANS. July 2016, Vol. 5, No. 3.
2. Norman RJ, Davies MJ, Lord J, Moran LJ. The role of lifestyle modification in polycystic ovary syndrome. Trends in Endocrinology & Metabolism. 2002 Aug 1;13(6):251–7.

40. Key Takeaways
PCOS is defined by a combination of signs and symptoms of androgen excess and ovarian
dysfunction in the absence of other specific diagnoses.
The diagnosis of PCOS requires careful application of well-standardized diagnostic methods.
In India, studies have shown 10% of the women to be affected by PCOS, with increasing incidence
PCOS results from a vicious circle of androgen excess favoring abdominal adipose tissue deposition
and visceral adiposity by inducing insulin resistance and compensatory hyperinsulinism.
Obesity leads to Insulin resistance and hyperinsulinemia are the major pathophysiological
mechanisms underlying PCOS.

41. Key Takeaways
Targets for the pharmacological treatment of PCOS might include androgen excess, oligo-ovulation
and insulin resistance, but lifestyle counselling should be provided in all cases to prevent or treat
obesity.
Healthy diet and Lifestyle intervention improves body composition, hyperandrogenism and insulin
resistance.
Consumption of adequate protein, high protein and low GI foods helps in weight management
Reducing intake of sugar and fat rich foods can contribute to reduction in incidence of obesity
Moderate exercise, reduction of smoking & psychosocial stressors, and dietary modification are the
lifestyle modification principles that would probably be of great benefit.

42. References
1. Khademi A, Alleyassin A, Aghahosseini M, Tabatabaeefar L, Amini M. The Effect of Exercise in PCOS Women Who Exercise Regularly. Asian J Sports Med.
2010 Mar;1(1):35–40.
2. Harwood K, Vuguin P, DiMartino- Nardi J. Current Approaches to the Diagnosis and Treatment of Polycystic Ovarian Syndrome in Youth. HRP.
2007;68(5):209–17.
3. Lathief S, Pal L. Advances in Treatment Options for Polycystic Ovary Syndrome. Journal - Advances in Treatment Options for Polycystic Ovary Syndrome
[Internet]. 2012 May 14 [cited 2019 Mar 4].
4. Bharathi RV, Swetha S, Neerajaa J, Madhavica JV, Janani DM, Rekha SN, Ramya S, Usha B. An epidemiological survey: Effect of predisposing factors for
PCOS in Indian urban and rural population. Middle East Fertility Society Journal. 2017 Dec 1;22(4):313-6.
5. Barbosa G, Sá LBPC de, Rocha DRTW, Arbex AK. Polycystic Ovary Syndrome (PCOS) and Fertility. Open Journal of Endocrine and Metabolic Diseases.
2016 Jan 12;06:58.
6. Sirmans SM, Pate KA. Epidemiology, diagnosis, and management of polycystic ovary syndrome. Clin Epidemiol. 2013 Dec 18;6:1–13.
7. Gambineri A, Pelusi C, Vicennati V, Pagotto U, Pasquali R. Obesity and the polycystic ovary syndrome. International Journal of Obesity. 2002
Jul;26(7):883–96.
8. Escobar- Morreale HF. Polycystic ovary syndrome: definition, aetiology, diagnosis and treatment. Nature Reviews Endocrinology. 2018 May;14(5):270–
84
9. Sam S. Obesity and Polycystic Ovary Syndrome. Obes Manag. 2007 Apr;3(2):69–73.
10. Douglas CC, Gower BA, Darnell BE, Ovalle F, Oster RA, Azziz R. Role of diet in the treatment of polycystic ovary syndrome. Fertil Steril. 2006
Mar;85(3):679–88
11. Paliwal M, et.al. Diet and Nutrition Management in Polycystic Ovary Syndrome. IJFANS. July 2016, Vol. 5, No. 3.
12. Norman RJ, Davies MJ, Lord J, Moran LJ. The role of lifestyle modification in polycystic ovary syndrome. Trends in Endocrinology & Metabolism. 2002
Aug 1;13(6):251–7
13. Günalan E, Yaba A, Yılmaz B. The effect of nutrient supplementation in the management of polycystic ovary syndrome-associated metabolic
dysfunctions: A critical review. J Turk Ger Gynecol Assoc. 2018 15;19(4):220–32.

43. Thank You