Polycystic Ovarian Syndrome (PCOS) is a common endocrine disorder among women of reproductive age that is caused by hormonal imbalances. Women with PCOS often experience irregular periods, excess androgen levels, and polycystic ovaries. Exercise and lifestyle changes are effective management strategies for PCOS as they can help reduce insulin resistance, lose weight, and improve fertility outcomes and overall health. High intensity interval training and resistance training in particular have been shown to improve PCOS symptoms and reduce health risks.

1. Polycystic Ovarian
Syndrome
PCOS

2. Definition
&shape

3. PCOS
A common disorder of the
endocrine system among
women of reproductive age.
Also called:
Hyperandrogenic
Anovulation(HA),
Or
Stein-leventhal Syndrome.
The term Polycystic means
that the ovaries are
enlarged & contain multiple
small follicles.

4. Epidemiology
PCOS is the most common endocrine disorder among women between
the ages of 18 & 44 years
It affects approximately 5% to 10% of this age group.
PCOS is present if any 2 out of 3 criteria are met, in the absence of other
causes for these findings:
1.Oligoovulation or anovulation
2.Excess androgen activity
3.Polycystic ovaries by ultrasound
“Rotterdam Criteria 2003”

5. Normal & Polycystic ovary

6. Causes of
PCOS

7. Causes of PCOS
• The exact cause is not fully understood or unknown, but
genetics may be a factor.
• Thought to be related to abnormal hormone levels.
• Insulin resistance causes hyperinsulinemia which leads to
increasing androgen production by the ovaries and
anovulation.

8. Hormone imbalance
• Many women with PCOS are found to have an imbalance in certain
hormones, including:
a) raised levels of testosterone – a hormone often thought of as a male
hormone, although all women usually produce small amounts of it
b) raised levels of luteinising hormone (LH) – this stimulates ovulation, but
may have an abnormal effect on the ovaries if levels are too high
c) low levels of sex hormone-binding globulin (SHBG) – a protein in the
blood, which binds to testosterone and reduces the effect of
testosterone
d) raised levels of prolactin (only in some women with PCOS) – hormone
that stimulates the breast glands to produce milk in pregnancy

9. Signs and
symptoms

10. Common symptoms of PCOS:
• Acne
• Weight gain & difficulty in losing weight.
• Hirsutism:
a) Extra hair on the face and body.
b) Often women get thicker & darker hair on the face and
more hair on the chest, belly & back.
c) Thinning hair on the scalp or male pattern baldness.
• Irregular menstrual periods.
a) Oligomenorrhea (often less than 9 periods per year).
b) Amenorrhea , Menorrhagia or polymenorrhoea.

12. PCOS Symptoms

13. Diagnosis

14. Diagnosis
I. Medical history:
• Ask about:
Menstrual pattern.
Changes in the weight towards obesity.
Hirsutism.
Acne.
Fertility.
Family history of hormone changes
including diabetes.
II. Physical Examination
• Checking:
 Thyroid
 Skin
 Hair
 Breasts
 Belly
• Blood pressure
• BMI.
• Pelvic examination for enlarged ovaries.

15. Diagnosis
III. Ultrasound examination
• Pelvic ultrasound may show enlarged
ovaries with multiple small cysts.
• 12 or more small follicles should be
seen in any ovary on ultrasound
examination.
• The follicles may be oriented in the
periphery giving the appearance of a
“string of pearls”.
IV. Laboratory tests
• 1.Exclude pregnancy.
• 2.Testosterone: Androgens at high levels can block
ovulation and cause acne and hirsutism.
• 3.Prolactin: which can play a role in amenorrhea
and/or infertility.
• 4.Cholesterol and triglycerides.
• 5.TSH.
• 6.Adrenal gland hormones e.g. DHEA,17-hydroxy
progesterone.
• 7.G.T.T and serum insulin which can show insulin
resistance.
• 8.Elevated LH/FSH ratio (>2:1).

16. Ultrasound examination

17. Differential Diagnosis
• Other conditions that produce similar symptoms
include:
Hypothyroidism.
Hyperprolactinemia.
Adrenal hyperplasia.
Androgen secreting tumors.

18. Complications
of PCOS

19. Complications of PCOS
• Infertility.
• Endometrial cancer:
• Continuous exposure to high levels
of estrogen without progesterone
causes endometrial hyperplasia.
• Diabetes mellitus:
• More than 50% will have diabetes or
pre-diabetes before the age of 40
years.
• Higher risk of gestational diabetes.
• Heart disease:
• Risk of heart attack 4-7 times higher.
• Hypertension.
• Dyslipidemia:
• Elevated levels of LDL cholesterol
and lower levels of HDL cholesterol.
• Sleeping apnea.
• Anxiety and depression.
• Strokes
• Weight gain
• Miscarriage

20. Management

21. Management
I. Healthy lifestyle
• Regular exercises.
• Healthy diet.
• Weight control.
• Quit smoking as
women who smoke
have higher levels of
androgens.
II. Medications
• Metformin
• Oral contraceptive
pills
• Spironolactone
(Aldactone)
• Ovarian wedge
resection.
• Laparoscopic
ovarian drilling:
 Electro cautery is
used to destroy
portions of ovary.
III. Surgical treatment:

22. How does PCOS affect pregnancy?
• PCOS can cause problems during pregnancy for you and for your
baby. Women with PCOS have higher rates of
a) Miscarriage
b) Gestational diabetes
c) Preeclampsia
d) Cesarean section (C-section)
• Your baby also has a higher risk of being heavy (macrosomia) and of
spending more time in a neonatal intensive care unit (NICU).

23. How can I prevent problems from PCOS
during pregnancy?
• You can lower your risk of problems during pregnancy by:
a) Reaching a healthy weight before you get pregnant.
b) Reaching healthy blood sugar levels before you get pregnant. You
can do this through a combination of healthy eating habits,
regular physical activity, weight loss, and medicines such as
metformin.
c) Taking folic acid. Talk to your doctor about how much folic acid
you need.

24. Role of Physical Therapy in PCOS
• Polycystic ovarian syndrome (PCOS) is a common endocrine disorder
affecting female adolescent and adulthood globally.
• The most annoying complications of PCOS are obesity and infertility.
• Exercise is proved to be a best therapeutic and supportive
management in PCOS patients in reducing infertility.
• Exercise reduces the risk and restores fertility and quality of life in
PCOS patients through inducing hormonal changes of testosterone,
androstenedione, combating obesity, metabolic syndrome, reducing
inflammatory markers, and increasing immunity.

25. Role of Physical Therapy in PCOS
• PCOS is associated with metabolic features including elevated levels
of insulin secretion and resistance, diabetes and cardiovascular
disease risk factors such as abnormal cholesterol levels and free
plasma lipids.
• Insulin resistance (IR) and its compensatory hyperinsulinemia are
proposed as significant etiological factors of PCOS.
• All these factors are said to be substantial cause for
hyperandrogenism in PCOS patients.
• Overweight and obesity worsen these underlying hormonal
imbalances by increasing androgen and excess blood insulin levels
thus making the clinical features very evident in women with PCOS.

26. Role of Physical Therapy in PCOS
• Obese individuals exhibit marked skeletal muscle IR as compared
that of lean individuals who are related to higher body mass index
in PCOS women.
• Weight loss in obese individuals improves or reverses IR in skeletal
muscle of PCOS women.
• Obesity tends to aggravate the clinical presentation of PCOS.
Indeed, the incidence of hirsutism and menstrual irregularity is
greater in the obese population as compared to nonobese PCOS.
• Owing to the above reasons, quality of life with PCOS individual
might get worse as it progresses.

27. Role of Physical Therapy in PCOS
• Endurance exercise also increases capillary density, mitochondrial
density, number, hyperplasia of muscle fibers, neural sensitization,
motor learning, and adaptations thereby increasing exercise
capacity and reducing exercise intolerance in PCOS individual.
• Improved blood flow to skeletal muscles, mitochondrial
proliferation, and sensitivity to activity enhance the stability of
essential protein involved in insulin signal transduction in PCOS
patients.

28. Role of Physical Therapy in PCOS
• Benefits Of Exercises For PCOS
• Encourages normal gene expression. In other words, it allows your genes to
work as they were designed.
• Helps to reduce, even eliminate, the insulin resistance common in PCOS.
• Improves your basal metabolic rate (BMR). This means less energy is stored
as fat.
• Creates ‘happy hormones’ and helps to normalize stress levels.
• Can quash cravings. A 10-minute walk has been shown to kill the cravings
for chocolate.
• Aids fat loss and maintenance of a healthy weight.
• Helps bowels to move correctly and remove toxins.
and so much more!

29. • Role of Physical Therapy in PCOS
• Exercise training session .. Warm-up: At least 5–10 min.
• Conditioning phase:
• Aerobic training:
• Frequency: 5 days/week for 12–24 weeks
• Intensity: 20–60 min of aerobic (high-intensity interval training 70%–70% VO2 peak
repetitive exercise bouts of 10 min, six episodes/session with 15 min of active pause 55%–
60% VO2 peak between the bouts. Continuous practice sessions 60%–70% heart rate (HR)
max inculcating large muscles such as running or cycling for 30–60 min)
• Time: 30–45 min. Fatigue-free level
• Mode: Treadmill or bicycle
• Progression: 10% VO2 peak or HR max every 2 weeks. After 4 weeks, new VO2 peak test to
be determined from maximal or submaximal exercise testing.

30. Role of Physical Therapy in PCOS
• Resistance exercise training:
• Frequency: 2–3 days/week for 12–24 weeks
• Intensity: Initial 60%–70% of 1 repetition maximum comprising three sets of
8–10 resistance stations (lateral pull down, military press, chest press,
biceps and triceps curl, abdominal curl ups, split squats, leg curls, and
extensions). 2–3 sets of 8–12 repetition/set.
(1 min rest between set. Avoid Valsalva maneuver during lifting)
• Time: 30–45 min. Fatigue-free level
• Mode: Dumbbell, barbell, thera tubes, and weighted pulley machines
• Progression: Repetitions or sets can be increased based on the rating of
perceived exertion or maximal voluntary contraction using the weights. Cool
down: Calisthenics 5–10 min, active recovery

31. Role of Physical Therapy in PCOS
• High-Intensity Interval Training (HIIT)
• HIIT is a not-so-well-kept secret, and its benefits in PCOS are marked.
• encompasses a broad spectrum of activities such as indoor or outdoor
walking and running, bodyweight circuits, spin classes, and other cardio
machine workouts.
• HIIT is effective for improving 24-hour glycemic control, even though the
amount of exercise in terms of time spent was considerably less.
In a 2017 study, Parker found that 24-minutes of HIIT was as beneficial to
blood sugar control as 38-minutes of lower intensity cycling. You have to be
happy with that!
( Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5220056/ )

32. Role of Physical Therapy in PCOS
• High-Intensity Interval Training (HIIT)
• Because HIIT activities force the body to use up the amount of oxygen it has
in reserves for physical activity (also known as VO2 max), experts argue that
it actually sparks fat burning even after a workout is over, as the body has to
work extra hard to pump oxygen to the blood.
• This means the potential to see weight loss results faster than a normal
workout routine- but can end up being extremely taxing on the body
without proper rest periods.

34. Other Exercises
•Yoga
• Yoga is the most beneficial form of exercise to pick up for PCOS.
Yoga specifically helps with hormonal imbalance and is very
effective in controlling mood swings. There are different kind of
poses you can pick up, some of the helpful ones are:
• Cobbler’s Pose
• Spinal Twist
• Mill churning pose
• Moon salutation

35. Cobbler’s Pose

36. Spinal Twist

37. Mill churning pose

38. Moon salutation

39. Alternative Exercises

40. References
• Dewailly D, Lujan ME, Carmina E, Cedars MI, Laven J, Norman RJ, Escobar Morreale HF.
Definition and significance of polycystic ovarian morphology: a task force report from the
Androgen Excess and Polycystic Ovary Syndrome Society, Hum Reprod Update , 2014, vol. 20
(pg. 334-352)
• "What are the symptoms of PCOS?" (05/23/2013). http://www.nichd.nih.gov. Archived from
the original on 3 March 2015. Retrieved 13 March 2015.
• Teede H, Deeks A, Moran L (2010). "Polycystic ovary syndrome: a complex condition with
psychological, reproductive and metabolic manifestations that impacts on health across the
lifespan". BMC Med. 8 (1): 41. doi:10.1186/1741-7015-8-41. PMC 2909929. PMID 20591140.
• Boomsma, C. M., Fauser, B. C., & Macklon, N.S. (2008). Pregnancy complications in women with
polycystic ovary syndrome. Seminars in Reproductive Medicine, 26, 72–84.
• Rotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group (2004). "Revised 2003
consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome
(PCOS)". Hum. Reprod. 19 (1): 41–7. doi:10.1093/humrep/deh098. PMID 14688154.
• Other source: https://www.womenshealth.gov/a-z-topics/polycystic-ovary-syndrome#17
https://www.researchgate.net/publication/320211314_Exercise_in_polycystic_ovarian_syndro
me_An_evidence-based_review