Find out how losing only 5% of body weight restores ovulation in PCOS patients

1. Diet, exercise, lifestyle changes: Do they
help in PCOS patients?
Romana Dmitrovic, M.D., Ph.D.
BetaPlus Center for Reproductive Medicine,
Zagreb

2. Infertility in PCOS
• Caused by:
– Obesity
• Excess androgens
• Insulin resistance
• Anovulation

3. 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

4. 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

5. 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

6. 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

7. • 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

8. 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

9. • 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

10. Obesity and gonadotropins
Mulders 2003

11. 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

12. 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)

13. 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)

14. • Decrease in T and DHEAS
after both meals
• Increase in insulin and
glucose after the HIFIB
meal
Katcher, Dmitrovic, Legro. Fertil Steril 2008

15. 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

16. 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

17. 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