Ghrelin and measures of satiety are altered in polycystic ovary syndrome but not differentially affected by diet composition

Food Cravings and Obesity in Women with Polycystic Ovary Syndrome: Pathophysiological and Therapeutic Considerations

Polycystic ovary syndrome (PCOS), the most common endocrine disorder in women of reproductive age, constitutes a metabolic disorder frequently associated with obesity and insulin resistance (IR). Furthermore, women with PCOS often suffer from excessive anxiety and depression, elicited by low self-esteem due to obesity, acne, and hirsutism. These mood disorders are commonly associated with food cravings and binge eating. Hypothalamic signaling regulates appetite and satiety, deteriorating excessive food consumption. However, the hypothalamic function is incapable of compensating for surplus food in women with PCOS, leading to the aggravation of obesity and a vicious circle. Hyperandrogenism, IR, the reduced secretion of cholecystokinin postprandially, and leptin resistance defined by leptin receptors' knockout in the hypothalamus have been implicated in the pathogenesis of hypothalamic dysfunction and appetite dysregulation. Diet modifications, exercise, and psychological and medical interventions have been applied to alleviate food disorders, interrupting the vicious circle. Cognitive-behavioral intervention seems to be the mainstay of treatment, while the role of medical agents, such as GLP-1 analogs and naltrexone/bupropion, has emerged.

Prevalence and Etiology of Eating Disorders in Polycystic Ovary Syndrome: A Scoping Review

Polycystic ovary syndrome (PCOS) is the most common endocrine-metabolic disorder affecting females across the lifespan. Eating disorders (EDs) are psychiatric conditions that may impact the development of PCOS and comorbidities including obesity, metabolic syndrome, and type 2 diabetes. The aim of this scoping review was to determine the prevalence of EDs and disordered eating, and to review the etiology of EDs in PCOS. The review was conducted using search terms addressing PCOS, EDs, and disordered eating in databases, including PubMed, Scopus, PsycINFO, and CINAHL. Structured interviews, self-administered questionnaires, chart review, or self-reported diagnosis were used to identify EDs in 38 studies included in the review. The prevalence of any ED in those with PCOS ranged from 0% to 62%. Those with PCOS were 3-6-fold more likely to have an ED and higher odds ratios (ORs) of an elevated ED score compared with controls. In those with PCOS, 30% had a higher OR of bulimia nervosa and binge ED was 3-fold higher compared with controls. Studies were limited on anorexia nervosa and other specified feeding or ED (such as night eating syndrome) and these were not reported to be higher in PCOS. To our knowledge, no studies reported on avoidant/restrictive food intake disorder, rumination disorder, or pica in PCOS. Studies showed strong associations between overweight, body dissatisfaction, and disordered eating in PCOS. The etiologic development of EDs in PCOS remains unclear; however, psychological, metabolic, hypothalamic, and genetic factors are implicated. The prevalence of any ED in PCOS varied because of the use of different diagnostic and screening tools. Screening of all individuals with PCOS for EDs is recommended and high-quality studies on the prevalence, pathogenesis of specific EDs, relationship to comorbidities, and effective interventions to treat ED in those with PCOS are needed.

Effects of high-protein diets on the cardiometabolic factors and reproductive hormones of women with polycystic ovary syndrome: a systematic review and meta-analysis

The optimal dietary regimen for polycystic ovary syndrome (PCOS) has not been identified. High-protein diets (HPDs) are effective for weight control in individuals with metabolic abnormalities, but no systematic meta-analyses have yet summarised the effects of HPDs on PCOS. Seven electronic databases were searched from inception to 30 April 2023, and studies comparing the effects of HPDs and other diets on the anthropometrics, metabolic factors, and hormonal profiles for PCOS were identified. Data were pooled using random-effects models and expressed as weighted mean differences and 95% confidence intervals. The risk of bias was assessed by Cochrane Collaboration tool. Eight trials involving 300 women with PCOS were included. Compared with isocaloric balanced diets (BDs), HPDs significantly reduced fasting insulin (-2.69 μIU/mL, 95% CI [-3.81, -1.57], P < 0.0001, I2 = 46%) and homoeostatic model assessment for insulin resistance (HOMA-IR-0.41, 95% CI [-0.80, -0.02], P = 0.04, I2 = 94%) in women with PCOS. However, HPDs and BDs had comparable effects on weight loss, abdominal adiposity, lipid profiles, and reproductive hormones (all P ≥ 0.05). HPDs may benefit women with PCOS in terms of improving insulin resistance, supporting for their use as one of the dietary management options for PCOS, however further RCTs in larger and broader settings are required to confirm these observations and investigate the mechanism behind it.

Annatto-Enriched Egg Improves the Perception of Satiety in Healthy Adults-Randomized Clinical Trial: EGGANT Study

Diet is one of the factors that prevents the development and death from cardiovascular diseases (CVD). It has been proposed that diets high in protein, which increase satiety, and with a high content of antioxidants, help reduce cardiovascular risk factors. The egg is one of the foods that produces greater satiety and provides antioxidants. In addition, due to its lipophilic matrix, it could improve the bioavailability of other dietary antioxidants such as Annatto.

OBJECTIVE

This study evaluated the effects of egg and annatto-enriched egg consumption on satiety markers and CVD risk factors in healthy adults from Colombia.

METHODS

A parallel randomized clinical trial was conducted, where one hundred and five (n = 105) men and women, divided into three groups, consumed daily for 8 weeks: (a) two eggs (egg group), or (b) two eggs with annatto (egg + annatto group), or (c) two egg whites (placebo group).

RESULTS

The three groups were similar in gender distribution. No significant changes were found over time (before vs. after) in any of the groups nor between the groups in anthropometric variables, physical activity, eating profile, and ghrelin as an objective marker of satiety. In the egg + annatto group, subjective satiety increased (effect size 0.431; p < 0.05) after consumption.

CONCLUSIONS

In healthy adults, the intake of two eggs, or two eggs with annatto daily for 8 weeks, did not result in significant changes in ghrelin; but eggs with annatto tend to increase the perception of satiety.

Moving beyond Weight: A Narrative Review of the Dietary and Lifestyle Management for Reducing Cardiometabolic Risk in Polycystic Ovary Syndrome (PCOS)

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder experienced by women. PCOS is a lifelong condition associated with reproductive, metabolic, and psychological presentations. PCOS is also linked with increased prevalence of cardiometabolic risk factors. While an association between body weight and PCOS has been noted, cardiometabolic risk factors are prevalent in individuals with PCOS across body weights. Currently, no consensus exists as to the most appropriate lifestyle strategy for mitigating cardiometabolic risk in PCOS. A large proportion of the literature is focused on weight loss for individuals with PCOS who are overweight or experience obesity, despite PCOS being prevalent across body sizes. The aim of this narrative review is to assess dietary and lifestyle interventions aimed at reducing cardiometabolic risk in individuals with PCOS across body sizes. A total of 51 articles are included in this review. Overall, randomized controlled trials are limited and most studies focus on weight loss, excluding individuals classified within a healthy body weight range. Studies that modified the dietary pattern without an energy deficit saw improvements in cardiometabolic risk. Thus, less restrictive dietary approaches may be effective at reducing cardiometabolic risk in this population. This review also highlights the need for more sustainable lifestyle interventions that meet the needs of individuals with PCOS of varying body weights.

Obesity and hyperandrogenism are implicated with anxiety, depression and food cravings in women with polycystic ovary syndrome

INTRODUCTION

PCOS is associated with mood/eating disorders. Negative body image due to obesity, acne, hirsutism seems to play significant role, but hormonal derangements are probably implicated.

AIM

To investigate the relation between insulin resistance (IR), obesity and hyperandrogenism with mood and eating disorders in women with PCOS.

METHODS

Forty-nine (60.5%) PCOS women and 32(39.5%) age- and BMI-matched healthy controls were enrolled. Emotional/food disorders were evaluated by using self-administered questionnaires: Eating Attitudes Test (EAT)-26, Beck Depression Inventory-II (BDI-II), Hamilton anxiety scale (HAS) and Food Craving Questionnaire-Trait (FCQ-T).

RESULTS

The two groups had no significant differences regarding age, BMI and HOMA2-IR. PCOS women had significantly higher DHEA-S (p < 0.0001), Δ4Α (p < 0.0001) and Testosterone (p < 0.0001). When the two groups were subclassified according to the BMI, in lean (BMI < 25 kg/m2) or overweight (BMI ≥ 25 kg/m2), no significant differences were found with respect to EAT-26 and HAS. BDI-II was associated with obesity (overweight vs lean PCOS: 20.5 ± 6.4 vs 9.8 ± 3.9; p = 0.037) and hyperandrogenism (overweight PCOS vs overweight controls: 20.5 ± 6.4 vs 14.8 ± 8.1; p < 0.0001; lean PCOS vs overweight controls: 16.7 ± 4.7 vs 14.8 ± 8.1; p = 0.01). Additionally, a significant correlation between BDI-II and DHEA-S (rho = 0.305; p = 0.006), Δ4Α (rho = 0.259; p = 0.02) and Testosterone (rho = 0.328; p = 0.003) was reported. FCQ-T was associated with obesity (overweight PCOS vs lean PCOS: 47.6 ± 9.9 vs 29.3 ± 8.9; p < 0.0001; overweight controls vs lean PCOS: 45.5 ± 15.7 vs 29.3 ± 8.9; p < 0.0001), whereas a correlation between FCQ-T and BMI (rho = 0.593; p = 0.0001), waist circumference (rho = 0.554; p = 0.0001) and HOMA2-IR (rho = 0.328; p = 0.003) was documented.

CONCLUSIONS

Obesity and hyperandrogenism increase the risk of depression and food cravings in women with PCOS, leading to a vicious circle of further aggravation of obesity and metabolic syndrome.

Acute iv CRH administration significantly increases serum active ghrelin in postmenopausal PCOS women compared to postmenopausal controls

PURPOSE

In women with Polycystic Ovarian Syndrome (PCOS), an increased risk of disordered eating has been described. There is growing interest regarding a possible interconnection between psychological states and increased appetite in women with PCOS. Acute stress is characterized by increased Corticotropin Releasing Hormone (CRH) secretion. The aim was to estimate the ghrelin concentrations during CRH test.

METHODS

Twenty postmenopausal women with PCOS and twenty age- and BMI- matched postmenopausal control women were recruited at Aretaieion University Hospital. In the morning (9 am) all subjects had anthropometric measurements (weight, height, waist circumference) and a fasting sample for hormonal measurements. An intravenous (iv) CRH stimulation test conducted over 1 min. Serum active ghrelin levels were measured at 0, 15, 30, 60, 90, 120 min after iv CRH administration.

RESULTS

The postmenopausal PCOS group had a higher waist circumference compared to postmenopausal controls. Active ghrelin concentrations increased significantly from 0 to 15 min, to 30 min, to 60 min, to 90 min and then decreased to 120 min. However, within the postmenopausal control group there were no significant changes in serum active ghrelin levels. Serum active ghrelin concentrations were significantly greater in the postmenopausal control group at 0, 15 and 120 min compared to the postmenopausal PCOS group. At 90 min active ghrelin concentrations were significantly greater in the postmenopausal PCOS group. Delta Area Under the Curve of active ghrelin (ΔAUCghr) was significantly greater in the postmenopausal PCOS group compared to controls.

CONCLUSIONS

In postmenopausal PCOS, but not in postmenopausal controls, iv CRH administration induces increased serum active ghrelin secretion, suggesting a possible anti-stress adaptive mechanism. An increase in serum active ghrelin may induce hunger as a side-effect of this presumed adaptive mechanism.

Diet and Exercise in the Management of Polycystic Ovary Syndrome: Practical Considerations for Person-Centered Care

Polycystic ovary syndrome (PCOS) is a complex multisystem condition associated with life-long reproductive, metabolic, and psychological symptoms. Individuals with PCOS are at an increased risk of cardiovascular disease and type 2 diabetes, with approximately 70% of all PCOS cases presenting with insulin resistance. Lifestyle interventions have historically been recommended as first-line therapies for the management of PCOS-related cardiometabolic disorders. The term "lifestyle management" incorporates a multifaceted approach to dietary, exercise, and behavioral strategies, aiming to promote a healthy lifestyle. This approach has been commonly employed in practice, in particular through exercise and dietary modulation, due to its effect on cardiometabolic outcomes as well as its tolerability. Furthermore, there is evidence to suggest that combining dietary change with exercise may yield the greatest improvements in clinical outcomes. However, such practices require careful consideration and coordination, as there are instances where certain exercise and/or dietary prescriptions may compromise the effectiveness of the respective interventions. Thus, this review aims to provide practical guidance on diet and exercise planning in the routine care of PCOS. Such recommendations include emphasizing realistic and achievable goals, as well as minimizing barriers to lifestyle changes in order to increase the long-term sustainability of this treatment strategy.

Lifestyle management in polycystic ovary syndrome - beyond diet and physical activity

Polycystic ovary syndrome (PCOS) is a common condition affecting reproductive-aged women with reproductive, metabolic and psychological consequences. Weight and lifestyle (diet, physical activity and behavioural) management are first-line therapy in international evidence-based guidelines for PCOS. While these recommend following population-level diet and physical activity guidelines, there is ongoing interest and research in the potential benefit of including psychological and sleep interventions, as well as a range of traditional, complimentary and integrative medicine (TCIM) approaches, for optimal management of PCOS. There is limited evidence to recommend a specific diet composition for PCOS with approaches including modifying protein, carbohydrate or fat quality or quantity generally having similar effects on the presentations of PCOS. With regards to physical activity, promising evidence supports the provision of vigorous aerobic exercise, which has been shown to improve body composition, cardiorespiratory fitness and insulin resistance. Psychological and sleep interventions are also important considerations, with women displaying poor emotional wellbeing and higher rates of clinical and subclinical sleep disturbance, potentially limiting their ability to make positive lifestyle change. While optimising sleep and emotional wellbeing may aid symptom management in PCOS, research exploring the efficacy of clinical interventions is lacking. Uptake of TCIM approaches, in particular supplement and herbal medicine use, by women with PCOS is growing. However, there is currently insufficient evidence to support integration into routine clinical practice. Research investigating inositol supplementation have produced the most promising findings, showing improved metabolic profiles and reduced hyperandrogenism. Findings for other supplements, herbal medicines, acupuncture and yoga is so far inconsistent, and to reduce heterogeneity more research in specific PCOS populations, (e.g. defined age and BMI ranges) and consistent approaches to intervention delivery, duration and comparators are needed. While there are a range of lifestyle components in addition to population-recommendations for diet and physical activity of potential benefit in PCOS, robust clinical trials are warranted to expand the relatively limited evidence-base regarding holistic lifestyle management. With consumer interest in holistic healthcare rising, healthcare providers will be required to broaden their knowledge pertaining to how these therapies can be safely and appropriately utilised as adjuncts to conventional medical management.

Comparison of dietary and physical activity behaviors in women with and without polycystic ovary syndrome: a systematic review and meta-analysis of 39 471 women

BACKGROUND

Lifestyle (dietary and/or physical activity [PA]) modification is recommended as first-line therapy to manage polycystic ovary syndrome (PCOS). Current recommendations are based on healthy lifestyle practices for the general public since evidence for unique lifestyle approaches in PCOS is limited and low quality.

OBJECTIVE AND RATIONALE

We aimed to synthesize evidence on dietary and PA behaviors between women with PCOS and those without PCOS. Primary outcomes were overall diet quality, total energy intake and total PA, and secondary outcomes included macronutrients, micronutrients, food groups, foods, glycemic indices, sedentary time and sitting levels. We conducted this work to identify any unique lifestyle behaviors in women with PCOS that could underlie the propensity of weight gain and obesity in PCOS and be targeted for precision nutrition and PA interventions. These findings could be used to inform future practice recommendations and research that more effectively address complications (weight gain, obesity, diabetes, infertility, cardiovascular disease and mental health) in this high-risk population.

SEARCH METHODS

Databases of MEDLINE, Web of Science, Scopus and CINAHL were searched until 15 February 2022 to identify observational studies documenting dietary and PA behaviors between women with PCOS and without PCOS (Controls). Studies on children, adolescents (<18 years), pregnant or menopausal-aged women (>50 years) were excluded. Data were pooled by random-effects models and expressed as (standardized) mean differences (MD) and 95% CIs. The risk of bias was assessed by the Newcastle-Ottawa scale (NOS).

OUTCOMES

Fifty-four studies (N = 39 471 participants; [n = 8736 PCOS; 30 735 Controls]) were eligible (96%; [52/54] NOS scores ≥ 7). Women with PCOS had higher cholesterol (MD: 12.78, 95% CI: 1.48 to 24.08 mg/day; P = 0.03; I2 = 19%), lower magnesium (MD: -21.46, 95% CI: -41.03 to -1.91 mg/day; P = 0.03; I2 = 76%), and a tendency for lower zinc (MD: -1.08, 95% CI: -2.19 to -0.03 mg/day; P = 0.05; I2 = 96%) intake, despite lower alcohol consumption (MD: -0.95, 95% CI: -1.67 to 0.22 g/day; P = 0.02; I2 = 0%) versus Controls. Also, women with PCOS had lower total PA (standardized mean difference: -0.38, 95% CI: -0.72 to 0.03; P = 0.03; I2 = 98%). Conversely, energy, macronutrients (carbohydrate, fat, protein, fiber), micronutrients (folic acid, iron, calcium, sodium), glycemic index and glycemic load were similar (all: P ≥ 0.06). Most eligible studies reported lower total adherence to healthy eating patterns or poorer consumption of major food groups (grains, fruits, vegetables, proteins, seeds, nuts, dairy) in women with PCOS, as described narratively since variable study methodology did not permit meta-analyses.

WIDER IMPLICATIONS

Collective evidence supports that women with PCOS have a lower overall diet quality, poorer dietary intakes (higher cholesterol, lower magnesium and zinc) and lower total PA, despite lower alcohol consumption versus those without PCOS. Considerable heterogeneity among studies reinforces the need for research to address any relative contributions of other factors (e.g. genetic, metabolic or sociodemographic) to the observed differences. These clarifications may contribute to future evidence-based guideline recommendations on monitoring and managing PCOS in the era of precision lifestyle medicine.

Reshaping the Gut Microbiota Through Lifestyle Interventions in Women with PCOS: A Review

Polycystic ovary syndrome (PCOS) is an endocrine disorder evolving as a global threat to women's health. However, its multifactorial etiology causes difficulty in eliminating it. The interrelation between the gut microbiota and metabolic disorders has been trending recently, giving rise to new opportunities on the etiology and pathogenesis of PCOS. Lifestyle interventions such as healthy diet, physical exercises, and behavioral interventions such as regulation of stress and sleep cycles have been identified to improve the symptoms of PCOS across the endocrinological, metabolic and psychological scales and are recommended as the first line of treatment for PCOS. The impact of the unhealthy lifestyle factors on intestinal dysbiosis that cause PCOS is summarized in this review. This review also provides an insight on the therapeutic approaches that primarily target the gut microbiota and offers novel gut microflora-associated treatment strategies for PCOS. Further, this survey also highlights the need for the implementation of lifestyle management strategies and strongly recommends a healthy and stress-free lifestyle to promote gut health and manage PCOS.

Polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) affects 5-18% of women, and is a reproductive, metabolic, and psychological condition with impacts across the lifespan. The cause is complex, and includes genetic and epigenetic susceptibility, hypothalamic and ovarian dysfunction, excess androgen exposure, insulin resistance, and adiposity-related mechanisms. Diagnosis is recommended based on the 2003 Rotterdam criteria and confirmed with two of three criteria: hyperandrogenism (clinical or biochemical), irregular cycles, and polycystic ovary morphology. In adolescents, both the criteria of hyperandrogenism and irregular cycles are needed, and ovarian morphology is not included due to poor specificity. The diagnostic criteria generates four phenotypes, and clinical features are heterogeneous, with manifestations typically arising in childhood and then evolving across adolescent and adult life. Treatment involves a combination of lifestyle alterations and medical management. Lifestyle optimisation includes a healthy balanced diet and regular exercise to prevent excess weight gain, limit PCOS complications and target weight reduction when needed. Medical management options include metformin to improve insulin resistance and metabolic features, combined oral contraceptive pill for menstrual cycle regulation and hyperandrogenism, and if needed, anti-androgens for refractory hyperandrogenism. In this Review, we provide an update on the pathophysiology, diagnosis, and clinical features of PCOS, and discuss the needs and priorities of those with PCOS, including lifestyle, and medical and infertility treatment. Further we discuss the status of international evidence-based guidelines (EBG) and translation, to support patient self management, healthcare provision, and to set research priorities.

Lifestyle treatment in women with polycystic ovary syndrome: predictors of weight loss and dropout

BACKGROUND

Polycystic ovary syndrome (PCOS) affects 5%-10% of women in their reproductive years. Most women with PCOS struggle with obesity during their entire life. Knowing which determinants contribute to a successful lifestyle change is important to optimize treatment options for women with PCOS.

OBJECTIVE

This analysis of secondary outcome measures aimed to determine factors of ≥5% weight loss and dropout in all arms of the study and separately in the lifestyle intervention (LI) and control (care as usual [CAU]) groups.

STUDY DESIGN

Women diagnosed with PCOS (N = 183) and a Body Mass Index (BMI) above 25 kg/m² were included. Participants were assigned to (1) 20 lifestyle sessions involving cognitive behavioral therapy (CBT), (2) 20 lifestyle sessions involving CBT with additional short message service (SMS), or (3) to control (CAU). A generalized linear regression was performed to identify determinants of ≥5% weight loss. Logistic regression was performed to identify determinants of dropout. All models were corrected by including baseline weight as a covariate.

RESULTS

LI (OR 4.906, p = .001) was associated with ≥5% weight loss, while higher depression scores (OR 0.549, p = .013) had a negative association. Restraint eating was a positive factor for ≥5% weight loss in LI but a negative in CAU. Higher baseline weight (OR 1.033, p = .006), LI with SMS (OR 4.424, p = .002), and higher levels of androstenedione (OR 1.167, p = .026) were associated with dropout.

CONCLUSIONS

Depression and eating behavior were associated with ≥5% weight loss. Women with PCOS should be screened for depression and eating behavior before a LI.

Ghrelin deficiency sex-dependently affects food intake, locomotor activity, and adipose and hepatic gene expression in a binge-eating mouse model

Binge-eating disorder is the most prevalent eating disorder diagnosed, affecting three times more women than men. Ghrelin stimulates appetite and reward signaling, and loss of its receptor reduces binge-eating behavior in male mice. Here, we examined the influence of ghrelin itself on binge-eating behavior in both male and female mice. Five-wk-old wild-type (WT) and ghrelin-deficient (Ghrl^-/-) mice were housed individually in indirect calorimetry cages for 9 wks. Binge-like eating was induced by giving mice ad libitum chow, but time-restricted access to a Western-style diet (WD; 2 h access, 3 days/wk) in the light phase (BE); control groups received ad libitum chow (CO), or ad libitum access to both diets (CW). All groups of BE mice showed binge-eating behavior, eating up to 60% of their 24-h intake during the WD access period. Subsequent dark phase chow intake was decreased in Ghrl^-/- mice and remained decreased in Ghrl^-/- females on nonbinge days. Also, nonbinge day locomotor activity was lower in Ghrl^-/- than in WT BE females. Upon euthanasia, Ghrl^-/- BE mice weighed less and had a lower lean body mass percentage than WT BE mice. In BE and CW groups, ghrelin and sex altered the expression of genes involved in lipid processing, thermogenesis, and aging in white adipose tissue and livers. We conclude that, although ghrelin deficiency does not hamper the development of binge-like eating, it sex-dependently alters food intake timing, locomotor activity, and metabolism. These results add to the growing body of evidence that ghrelin signaling is sexually dimorphic.NEW & NOTEWORTHY Ghrelin, a peptide hormone secreted from the gut, is involved in hunger and reward signaling, which are altered in binge-eating disorder. Although sex differences have been described in both binge-eating and ghrelin signaling, this interaction has not been fully elucidated. Here, we show that ghrelin deficiency affects the behavior and metabolism of mice in a binge-like eating paradigm, and that the sex of the mice impacts the magnitude and direction of these effects.

Providing lifestyle advice to women with PCOS: an overview of practical issues affecting success

Polycystic Ovary Syndrome (PCOS) is a common endocrine disorder affecting up to 13 % of women. Lifestyle interventions are first-line treatments, however attrition in women with PCOS is high. This review summarises current evidence on barriers to lifestyle management in PCOS and suggested strategies for overcoming these challenges, mapped to the Capability, Opportunity, Motivation and Behaviour model.Physical capability for lifestyle changes may be impacted by altered gut hormone regulation and energy expenditure in PCOS. This may contribute to difficulties with weight management. The higher prevalence of eating disorders, disordered eating, fatigue and sleep disturbances are further barriers. Psychological capability may be reduced due psychological symptoms and lack of critical health literacy. Women with PCOS face similar challenges in terms of Opportunity to make lifestyle changes as other women of reproductive age. However, these are complicated by features more common in PCOS including body dissatisfaction. Motivation to adopt healthy lifestyles may be impacted by suboptimal risk perception and intrinsic motivation.To address these barriers, screening for and management of eating disorders, disordered eating, depression, and Obstructive Sleep Apnoea should be undertaken as per international evidence-based guidelines. A weight-neutral approach may be appropriate with disordered eating. Building capability among health professionals to better partner with women with PCOS on their management is essential in addressing health literacy gaps. Behavioural strategies that target risk perception and build intrinsic motivation should be utilised. More research is required to understand optimal self-management strategies, risk perception, energy homeostasis and overcoming attrition in women with PCOS.

Weight gain and lifestyle factors in women with and without polycystic ovary syndrome

STUDY QUESTION

Do extrinsic factors including lifestyle, psychosocial factors and healthcare professional engagement independently contribute to weight gain in women with and without polycystic ovary syndrome (PCOS)?

SUMMARY ANSWER

Women with PCOS had a higher rate of weight gain than women without PCOS which was most marked in those with unhealthy lifestyles.

WHAT IS KNOWN ALREADY

Women with PCOS have a higher prevalence of overweight/obesity and greater weight gain than women without PCOS. The association of lifestyle factors with weight change in PCOS is not known.

STUDY DESIGN, SIZE, DURATION

The study was a population-based observational study with data collected from seven surveys over 19 years (N = 14 127; Survey 1) involving women with and without PCOS.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We used data from the 1973-1978 birth cohort of the Australian Longitudinal Study on Women's Health.

MAIN RESULTS AND THE ROLE OF CHANCE

Women with PCOS gained more weight annually (0.26 kg/year; 95% CI 0.12, 0.39; P < 0.0001) and over 19 years (4.62 kg; 95% CI 3.04, 6.21; P < 0.0001) than women without PCOS (adjusted analyses). For all women, there were positive associations between weight gain and energy intake, sitting time and stress; inverse associations with fibre intake and physical activity (PA); and no associations with diet quality, glycaemic index, healthcare utilization, depression or anxiety. There were interactions between lifestyle factors (energy intake P = 0.006, glycaemic index P = 0.025, sitting time P = 0.041 and PA P = 0.021), PCOS status and time such that weight gain varied between women with and without PCOS according to these factors.

LIMITATIONS, REASONS FOR CAUTION

The limitations of this study include the use of self-reported measures such as diet, PA, sitting time, psychological factors and health care utilization.

WIDER IMPLICATIONS OF THE FINDINGS

While women with PCOS are more prone to weight gain, lifestyle factors have a more profound impact on weight gain in women with PCOS than without PCOS. These study findings have implications for understanding the mechanisms of weight gain in women with PCOS. They also highlight the importance of early lifestyle intervention as soon as PCOS is diagnosed to address modifiable extrinsic factors and prevent excess weight gain and worsening of the clinical features of PCOS.

STUDY FUNDING/COMPETING INTEREST(S)

M.A.A. is funded by the Monash International Tuition Scholarship and Monash Graduate Scholarship and L.J.M. is funded by a National Heart Foundation Future Leader Fellowship. The authors declared no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

An Analysis on the Implementation of the Evidence-based PCOS Lifestyle Guideline: Recommendations from Women with PCOS

Polycystic ovary syndrome (PCOS) is the most common endocrinological disorder affecting women of reproductive age, affecting 8-13% in this group. Women with PCOS are more likely to have excess BMI, which in turn exacerbates the symptoms of PCOS in these women. The latest evidence-based guideline recommends lifestyle management as the first-line treatment for PCOS. However, the implementation of this recommendation through health services faces a significant challenge. As part of the mapping of the implementation plan for lifestyle management in PCOS, citizen panels and semi-structured interviews were conducted to capture the voices of consumers. Women with PCOS expressed the need for multidisciplinary, integrated care as a recurrent theme. Other important considerations included health professionals who listen and are open to learning about PCOS, the empowerment of women to self-manage PCOS and the provision of peer support. Women with PCOS also expressed the key recommendation of focusing on practical skills when providing lifestyle advice. Within that, both individual and group lifestyle sessions were valued for privacy and peer support respectively and delivery by a dietitian is preferred. These recommendations by women with PCOS should be considered when developing the implementation plan for the PCOS lifestyle guideline.

Changes in Ghrelin and Glucagon following a Low Glycemic Load Diet in Women with PCOS

CONTEXT

Altered satiety hormones in women with polycystic ovarian syndrome (PCOS) may contribute to obesity. Diets with a low glycemic load (GL) may influence appetite-regulating hormones including glucagon and ghrelin.

OBJECTIVE

To test the hypothesis that following a 4-week, eucaloric low vs high GL diet habituation, a low vs high GL meal will increase glucagon and decrease ghrelin to reflect greater satiety and improve self-reported fullness.

METHODS

Secondary analysis of a randomized crossover trial.

PARTICIPANTS

Thirty women diagnosed with PCOS.

INTERVENTION

Participants were provided low (41:19:40% energy from carbohydrate:protein:fat) and high (55:18:27) GL diets for 8 weeks each. At each diet midpoint, a solid meal test was administered to examine postprandial ghrelin, glucagon, glucose, insulin, and self-reported appetite scores.

RESULTS

After 4 weeks, fasting glucagon was greater with the low vs high GL diet (P = .035), and higher fasting glucagon was associated with lesser feelings of hunger (P = .009). Significant diet effects indicate 4-hour glucagon was higher (P < .001) and ghrelin was lower (P = .009) after the low vs high GL meal. A trending time × diet interaction (P = .077) indicates feelings of fullness were greater in the early postprandial phase after the high GL meal, but no differences were observed the late postprandial phase.

CONCLUSION

These findings suggest after low GL diet habituation, a low GL meal reduces ghrelin and increases glucagon in women with PCOS. Further research is needed to determine the influence of diet composition on ad libitum intake in women with PCOS.

[Analysis of melatonin concentration and its correlation with ovarian disfunction among obese women of reproductive age]

Одним из новых направлений в изучении нарушений репродуктивной функции у женщин с ожирением являются влияние и рецепторная чувствительность мелатонина на гонадотропную функцию гипофиза и овариогенез с учетом хронологии «светового загрязнения». На современном этапе литературы по влиянию аспектов «светового загрязнения» на проблему ожирения и нарушений репродуктивной функции в отечественной и зарубежной литературе крайне мало. Данный обзор является попыткой объединить вышеуказанную проблему в рамках аспектов влияния «светового загрязнения» и уровня рецепторной чувствительности мелатонина у женщин репродуктивного возраста с ожирением. Поиск литературы проводили в отечественных (eLibrary, CyberLeninka.ru) и международных (PubMed, Cochrane Library) базах данных на русском и английском языках. Приоритетным являлся свободный доступ к полному тексту статей. Выбор источников был приоритетен периодом с 2015 по 2019 гг. Однако с учетом недостаточной изученности выбранной темы выбор источников датировался с 1992 г. Работа выполнена в рамках Государственного задания «Центральные и периферические патофизиологические механизмы развития болезней жировой ткани с учетом клинических и гормональных характеристик», 2020–2022 гг.

Effects of Sleeve Gastrectomy on Fecal Gut Microbiota and Short-Chain Fatty Acid Content in a Rat Model of Polycystic Ovary Syndrome

PURPOSE

Sleeve gastrectomy (SG) is a surgical intervention for polycystic ovary syndrome (PCOS), especially for patients with obesity. Here, we explored the effects of SG on the gut microbiota of rats with PCOS and investigated the association between the intestinal flora and efficacy of SG in PCOS.

METHODS

Dehydroepiandrosterone (DHEA) injection was administered alone and in combination with a high-fat diet to induce PCOS in rats. SG was performed in rats with PCOS, and the effects of SG on the fecal and gut microbiota and the short-chain fatty acid (SCFA) content were observed. Furthermore, the association among gut microbiota, SCFA content and hyperandrogenism or other hallmarks of PCOS was evaluated.

RESULTS

The abundance of Firmicutes reduced and that of Bacteroidetes increased in response to SG in the DHEA-induced PCOS rat model. At the genus level, the abundances of Bacteroides and Blautia increased and those of Ruminococcus, Clostridium, and Alistipes reduced distinctly in the PCOS-SG groups. Moreover, the levels of fecal SCFAs, especially butyric acid, reduced after SG. SG significantly ameliorated PCOS-related symptoms such as hyperandrogenism, disrupted ovary function, and impaired glucose tolerance. Bacteroides and Blautia exhibited a negative correlation and Ruminococcus, Clostridium, and Alistipes exhibited a positive correlation with the levels of fecal SCFAs, luteinizing hormone, testosterone, and inflammatory factors.

CONCLUSIONS

The amelioration of PCOS-related reproductive and metabolic disorders following SG was associated with the regulation of microbial taxa and SCFA content. Our findings provide a novel perspective on the microbial mechanisms in PCOS after SG.

The Association of Serum Levels of Leptin and Ghrelin with the Dietary Fat Content in Non-Obese Women with Polycystic Ovary Syndrome

Women with polycystic ovary syndrome (PCOS) are at an increased risk of developing insulin resistance and abdominal obesity in the state of an improper diet balance. Leptin is a peptide considered to be a satiety hormone that plays an important role in the long-term energy balance, whereas ghrelin is a hormone that controls short-term appetite regulation and is considered a hunger hormone. The aim of the present study was to assess the relationship between serum leptin and ghrelin concentrations and the dietary macronutrient content in PCOS women. We examined 73 subjects: 39 women diagnosed with PCOS by the Rotterdam criteria and 34 healthy controls, matched by the body mass index. The subjects completed a consecutive three-day dietary diary to identify the macronutrient and micronutrient intake. Serum concentrations of leptin and total ghrelin were measured and homeostasis model assessment of insulin resistance (HOMA-IR) was calculated. The studied groups did not differ significantly in terms of the intake of macronutrients (proteins, fats, and carbohydrates) and serum concentrations of ghrelin and leptin (all p > 0.05). In the PCOS group, the serum leptin concentration positively correlated with the intake of total fat (r = 0.36, p = 0.02), total cholesterol (r = −0.36, p = 0.02), saturated fatty acids (r = 0.43, p < 0.01), and monounsaturated fatty acids (MUFA) (r = 0.37, p = 0.02), whereas the serum ghrelin concentration correlated in an inverse manner with the intake of total fat (r = −0.37, p = 0.02), MUFA (r = −0.37, p = 0.02), polyunsaturated fatty acids (r = −0.34, p = 0.03), and long chain polyunsaturated fatty acids (r = −0.38, p = 0.02). In this group, we also found a negative association of HOMA-IR with serum ghrelin levels (r = −0.4, p = 0.03) and a positive relationship with the serum leptin concentration (r = 0.5, p < 0.01) and relationships between HOMA-IR and total dietary fat (r = 0.38, p = 0.03) and MUFA (r = 0.35, p = 0.04) intake. In PCOS women, dietary components such as the total fat and type of dietary fat and HOMA-IR are positively connected to serum leptin concentrations and negatively connected to serum ghrelin concentrations, which may influence the energy balance.

Effects of Dietary Glycemic Index and Glycemic Load on Cardiometabolic and Reproductive Profiles in Women with Polycystic Ovary Syndrome: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Women with polycystic ovary syndrome (PCOS) exhibit cardiometabolic (e.g., insulin resistance) and associated reproductive disruptions. Lifestyle modification (e.g., diet) is recommended as the first-line therapy to manage PCOS; however, a favorable dietary regimen remains unclear beyond energy restriction. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to summarize evidence on impacts of dietary glycemic index (GI) or glycemic load (GL) on cardiometabolic and reproductive profiles to update the International Evidence-based Guideline for the Assessment and Management of PCOS. Databases of MEDLINE, Cochrane, Web of Science, and Scopus were searched through 30 October 2019, and confirmed on 25 March 2020, to identify RCTs (≥8 wk) comparing the effects of diets with lower (LGI/LGL) and higher (HGI/HGL) GI/GL on glucoregulatory outcomes, lipid profile, anthropometrics, and androgen status in PCOS. The primary outcome was HOMA-IR. Data were pooled by random-effects models and expressed as weighted mean differences and 95% CIs. The risk of bias was assessed by the Cochrane tool. Ten RCTs (n = 403) were eligible. Eight evaluated LGI and 2 LGL diets. LGI diets decreased HOMA-IR (-0.78; -1.20, -0.37; I2 = 86.6%), fasting insulin (-2.39; -4.78, 0.00 μIU/mL; I2 = 76.8%), total cholesterol (-11.13; -18.23, -4.04 mg/dL; I2 = 0.0%), LDL cholesterol (-6.27; -12.01, -0.53 mg/dL; I2 = 0.0%), triglycerides (-14.85; -28.75, -0.95 mg/dL; I2 = 31.0%), waist circumference (-2.81; -4.40, -1.23 cm; I2 = 53.9%), and total testosterone (-0.21; -0.32, -0.09 nmol/L; I2 = 8.6%) compared with HGI diets (all: P ≤ 0.05) without affecting fasting glucose, HDL cholesterol, weight, or free androgen index (all: P ≥ 0.07). Some results were contradictory and only described narratively for 2 RCTs that evaluated LGL diets, since inclusion in meta-analyses was not possible. LGI diets improved glucoregulatory outcomes (HOMA-IR, insulin), lipid profiles, abdominal adiposity, and androgen status, conceivably supporting their inclusion for dietary management of PCOS. Further RCTs should confirm these observations and address whether LGI diets improve more patient-pressing complications, including ovulatory cyclicity, infertility, and cardiovascular disease risk in this high-risk population. This review was registered at www.crd.york.ac.uk/PROSPERO as CRD42020175300.

Neurotransmitter, neuropeptide and gut peptide profile in PCOS-pathways contributing to the pathophysiology, food intake and psychiatric manifestations of PCOS

Polycystic ovary syndrome (PCOS) is a major health problem with a heterogeneous hormone-imbalance and clinical presentation across the lifespan of women. Increased androgen production and abnormal gonadotropin-releasing hormone (GnRH) release and gonadotropin secretion, resulting in chronic anovulation are well-known features of the PCOS. The brain is both at the top of the neuroendocrine axis regulating ovarian function and a sensitive target of peripheral gonadal hormones and peptides. Current literature illustrates that neurotransmitters regulate various functions of the body, including reproduction, mood and body weight. Neurotransmitter alteration could be one of the reasons for disturbed GnRH release, consequently directing the ovarian dysfunction in PCOS, since there is plenty evidence for altered catecholamine metabolism and brain serotonin or opioid activity described in PCOS. Further, the dysregulated neurotransmitter and neuropeptide profile in PCOS could also be the reason for low self-esteem, anxiety, mood swings and depression or obesity, features closely associated with PCOS women. Can these altered central brain circuits, or the disrupted gut-brain axis be the tie that would both explain and link the pathogenesis of this disorder, the occurrence of depression, anxiety and other mood disorders as well as of obesity, insulin resistance and abnormal appetite in PCOS? This review intends to provide the reader with a comprehensive overview of what is known about the relatively understudied, but very complex role that neurotransmitters, neuropeptides and gut peptides play in PCOS. The answer to the above question may help the development of drugs to specifically target these central and peripheral circuits, thereby providing a valuable treatment for PCOS patients that present to the clinic with GnRH/LH hypersecretion, obesity or psychiatric manifestations.

Long-term effects of a preconception lifestyle intervention on cardiometabolic health of overweight and obese women

Background

The global prevalence of obesity in women keeps increasing. The preconception period may be a window of opportunity to improve lifestyle, reduce obesity and improve cardiometabolic health. This study assessed the effect of a preconception lifestyle intervention on long-term cardiometabolic health in two randomized controlled trials (RCTs).

Methods

Participants of the LIFEstyle and RADIEL preconception lifestyle intervention studies with a baseline body mass index (BMI) ≥29 kg/m² were eligible for this follow-up study. Both studies randomized between a lifestyle intervention targeting physical activity, diet and behaviour modification or usual care. We assessed cardiometabolic health 6 years after randomization.

Results

In the LIFEstyle study (n = 111) and RADIEL study (n = 39), no statistically significant differences between the intervention and control groups were found for body composition, blood pressure, arterial stiffness, fasting glucose, homeostasis model assessment of insulin resistance, HbA1c, lipids and high sensitive C-reactive protein levels 6 years after randomization. Participants of the LIFEstyle study who successfully lost ≥5% bodyweight or reached a BMI <29 kg/m² during the intervention (n = 22, [44%]) had lower weight (−8.1 kg; 99% CI [−16.6 to −0.9]), BMI (−3.3 kg/m²; [−6.5 to −0.8]), waist circumference (−8.2 cm; [−15.3 to −1.3]), fasting glucose (−0.5 mmol/L; [−1.1 to −0.0]), HbA1c (−4.1 mmol/mol; [−9.1 to −0.8]), and higher HDL-C (0.3 mmol/L; [0.1–0.5]) compared with controls.

Conclusion

We found no evidence of improved cardiometabolic health 6 years after a preconception lifestyle intervention among overweight and obese women in two RCTs. Women who successfully lost weight during the intervention had better cardiometabolic health 6 years later, emphasizing the potential of successful preconception lifestyle improvement.

Insulin, ghrelin and early return of hunger in women with obesity and polycystic ovary syndrome

BACKGROUND & AIMS

Women with polycystic ovary syndrome (PCOS) have greater predisposition to obesity, but the mechanisms are still unknown. Hyperinsulinemia, insulin resistance and low levels of ghrelin are common in this group. For the purposes of the present study, it was assumed that such changes could have an influence on hunger. This study aimed to assess the hunger pattern before and after an ad libitum meal and the association between insulin and plasma ghrelin with hunger perception in women with obesity, with and without PCOS.

METHOD

This cross-sectional study included 53 women with obesity, 30 with PCOS, and 23 controls (with obesity but without PCOS). Insulin, ghrelin, glucose and subjective ratings of hunger (by 100 mm visual analogue scales) were analyzed in a fasting state, preprandially at 12:00 before the ad libitum meal, and postprandially 15, 45, 75 and 135 min after the beginning of the ad libitum meal.

RESULTS

There was a significant increase in hunger one hour after the beginning of the ad libitum meal (75 min) in the PCOS group (p = .01) compared to 15 min, whereas this only occurred after 135 min in the control group (2 h later). The usual energy intake adjusted by the intra-individual variability was higher in the PCOS group than in the control group (2309 ± 461 kcal·d^-1 × 2124 ± 480 kcal·d^-1; p = .04). The concentrations of insulin and ghrelin, in both preprandial and postprandial periods, were not associated with the perception of hunger.

CONCLUSIONS

Women with obesity and PCOS had an earlier return of hunger in the postprandial period after an ad libitum meal, but there was not associated with postprandial ghrelin and insulin levels.

Barriers and Facilitators to the Implementation of Evidence-Based Lifestyle Management in Polycystic Ovary Syndrome: A Narrative Review

Polycystic ovary syndrome (PCOS) is a complex condition that involves metabolic, psychological and reproductive complications. Insulin resistance underlies much of the pathophysiology and symptomatology of the condition and contributes to long term complications including cardiovascular disease and diabetes. Women with PCOS are at increased risk of obesity which further compounds metabolic, reproductive and psychological risks. Lifestyle interventions including diet, exercise and behavioural management have been shown to improve PCOS presentations across the reproductive, metabolic and psychological spectrum and are recommended as first line treatment for any presentation of PCOS in women with excess weight by the International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome 2018. However, there is a paucity of research on the implementation lifestyle management in women with PCOS by healthcare providers. Limited existing evidence indicates lifestyle management is not consistently provided and not meeting the needs of the patients. In this review, barriers and facilitators to the implementation of evidence-based lifestyle management in reference to PCOS are discussed in the context of a federally-funded health system. This review highlights the need for targeted research on the knowledge and practice of PCOS healthcare providers to best inform implementation strategies for the translation of the PCOS guidelines on lifestyle management in PCOS.

Predictors of Lifestyle Intervention Attrition or Weight Loss Success in Women with Polycystic Ovary Syndrome Who Are Overweight or Obese

Background/objectives: Polycystic ovary syndrome (PCOS) is a common condition in reproductive-aged women. Weight management is a first-line treatment for PCOS according to international evidence-based guidelines. However, the factors associated with attrition or success in weight loss interventions are not known for women with PCOS. The objective of this study was to identify characteristics associated with attrition and weight loss success in women with PCOS and overweight or obesity undergoing weight loss interventions. Methods: Four randomised controlled clinical weight loss trials comprising energy restricted diets and/or exercise interventions of 2⁻8 months duration. The interventions were conducted over 2001⁻2007 in outpatient clinical research centres with n = 221 premenopausal women with PCOS and overweight/obesity recruited through community advertisement. The main outcome measures were attrition and ≥5% weight loss at 2 months and study completion. Results: Weight loss was 5.7 ± 2.9 kg at 2 months and 7.4 ± 5.3 kg after study completion (p < 0.001). Attrition was 47.1% and ≥5% weight loss occurred in 62.5% and 62.7% of women at 2 months and study completion respectively. Baseline depressive symptoms (OR 1.07 95% CI 0.88, 0.96, p = 0.032) and lower appointment attendance by 2 months (OR 0.92 95% CI 0.88, 0.96, p < 0.001) were independently associated with attrition. Lower appointment attendance over the whole study was independently associated with not achieving ≥5% weight loss at study completion (OR 0.95 95% CI 0.92, 0.99, p = 0.020). Conclusions: Despite high attrition, successful weight loss was achieved by 63% of women with PCOS in a clinical research setting. Higher baseline depressive symptoms were associated with greater attrition and higher appointment attendance was associated with lower attrition and greater weight loss success. These finding have implications for development of successful weight management programs in PCOS.

Body Composition, Metabolic Characteristics, and Insulin Resistance in Obese and Nonobese Women with Polycystic Ovary Syndrome

Objectives:

The objective was to compare body composition, metabolic characteristics, and insulin resistance between obese (body mass index [BMI] ≥25 kg/m²) polycystic ovary syndrome (PCOS) and nonobese PCOS (BMI <25 kg/m²) women and their age- and BMI-matched controls.

Materials and Methods:

A total of 81 PCOS women (Rotterdam criteria) (obese – 42; nonobese – 39) and 86 controls (obese – 42; nonobese –44) were recruited in this cross-sectional study. All women underwent a detailed assessment of clinical, anthropometric, and metabolic parameters, insulin resistance indices, and body composition measurements with visceral adipose tissue assessment (VAT) (dual-energy X-ray absorptiometry scan).

Results:

Of PCOS women, 27% (80% – obese PCOS; 20% – nonobese PCOS) were diagnosed with metabolic syndrome (International Diabetes Federation criteria), 35% of PCOS women (46% – obese PCOS; 54% – nonobese PCOS) had impaired glucose tolerance, and 7% of PCOS women (2/3^rd – obese PCOS; 1/3^rd – nonobese PCOS) had diabetes mellitus. Insulin resistance was seen in about 80% in obese PCOS women and 20% in nonobese PCOS women based on various insulin resistance indices such as fasting insulin (≥12.2 μU/ml), Homeostasis Model Assessment-Insulin Resistance (≥2.5), and Quantitative Insulin Sensitivity Check Index (<0.33). Total body fat, estimated (Est.) VAT, and corrected Est. VAT (corrected for body weight) were significantly increased (P = 0.0001) in both obese and nonobese PCOS women when compared to those of their age- and BMI-matched controls. However, corrected Est. VAT (corrected for body weight) was not significantly different between obese and nonobese PCOS women.

Conclusion:

Both obese and nonobese PCOS women when compared with their age- and BMI-matched controls were metabolically worse and had more visceral adiposity. Nonobese PCOS poses similar risk as that of obese PCOS in having similar amount of VAT (corrected for body weight).

Cardiometabolic risks in PCOS: a review of the current state of knowledge

INTRODUCTION

Polycystic ovary syndrome (PCOS) is a common endocrine disorder affecting up to 18% women of reproductive age. It is associated with a range of metabolic, reproductive, and psychological features. Current evidence indicates a role of PCOS in the development of metabolic and increased cardiovascular risk factors (CVRF) with implications for compromised cardiovascular endpoint disease, which may have a considerable impact on health and health care costs.

AREAS COVERED

Existing studies examining long-term cardiometabolic health in PCOS are heterogeneous with inconsistent findings. In the current review, we aim to explore and critically review retrospective, prospective, meta-analysis and review articles relating to PCOS on cardiometabolic risk factors and clinical consequences to summarize the evidence, note evidence gaps, and suggest implications for future research.

EXPERT COMMENTARY

Although there is an established association between PCOS and metabolic health, implications on cardiac health are more uncertain with associations observed for CVRF and subclinical disease, yet limited and conflicting data on actual cardiovascular endpoints. There is a lack of population-based long-term studies examining cardiometabolic morbidity and mortality in PCOS with a need for further research to progress toward a better understanding of the long-term cardiometabolic impacts in women with PCOS.

Polycystic ovarian syndrome (PCOS): Long-term metabolic consequences

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women during their reproductive ages, associated with a plethora of cardiometabolic consequences, with obesity, insulin resistance and hyperandrogenemia playing a major role in the degree of such manifestations. These consequences include increased risk of glucose intolerance and diabetes mellitus (both type 2 and gestational), atherogenic dyslipidemia, systemic inflammation, non-alcoholic fatty liver disease, hypertension and coagulation disorders. Whether this cluster of metabolic abnormalities is also translated in increased cardiovascular disease (CVD) morbidity and mortality in later life, remains to be established. Data so far based on markers of subclinical atherosclerosis as well as retrospective and prospective cohort studies indicate a possible increased CVD risk, mainly for coronary heart disease. Future studies are needed to further elucidate this issue.

Source and amount of carbohydrate in the diet and inflammation in women with polycystic ovary syndrome

High carbohydrate intake and low-grade inflammation cooperate with insulin resistance and hyperandrogenism to constitute an interactive continuum acting on the pathophysiology of polycystic ovary syndrome (PCOS), the most common endocrine disorder in women of reproductive age characterised by oligo-anovulatory infertility and cardiometabolic disorders. The role of insulin in PCOS is pivotal both in regulating the activity of ovarian and liver enzymes, respectively involved in androgen production and in triggering low-grade inflammation usually reported to be associated with an insulin resistance, dyslipidaemia and cardiometabolic diseases. Although an acute hyperglycaemia induced by oral glucose loading may increase inflammation and oxidative stress by generating reactive oxygen species through different mechanisms, the postprandial glucose increment, commonly associated with the Western diet, represents the major contributor of chronic sustained hyperglycaemia and pro-inflammatory state. Together with hyperinsulinaemia, hyperandrogenism and low-grade inflammation, unhealthy diet should be viewed as a key component of the 'deadly quartet' of metabolic risk factors associated with PCOS pathophysiology. The identification of a tight diet-inflammation-health association makes the adoption of healthy nutritional approaches a primary preventive and therapeutic tool in women with PCOS, weakening insulin resistance and eventually promoting improvements of reproductive life and endocrine outcomes. The intriguing nutritional-endocrine connections operating in PCOS underline the role of expert nutritionists in the management of this syndrome. The aim of the present review is to provide an at-a-glance overview of the possible bi-directional mechanisms linking inflammation, androgen excess and carbohydrate intake in women with PCOS.

Sleep disturbances in women with polycystic ovary syndrome: prevalence, pathophysiology, impact and management strategies

Polycystic ovary syndrome (PCOS) is a complex endocrine disorder affecting the reproductive, metabolic and psychological health of women. Clinic-based studies indicate that sleep disturbances and disorders including obstructive sleep apnea and excessive daytime sleepiness occur more frequently among women with PCOS compared to comparison groups without the syndrome. Evidence from the few available population-based studies is supportive. Women with PCOS tend to be overweight/obese, but this only partly accounts for their sleep problems as associations are generally upheld after adjustment for body mass index; sleep problems also occur in women with PCOS of normal weight. There are several, possibly bidirectional, pathways through which PCOS is associated with sleep disturbances. The pathophysiology of PCOS involves hyperandrogenemia, a form of insulin resistance unique to affected women, and possible changes in cortisol and melatonin secretion, arguably reflecting altered hypothalamic-pituitary-adrenal function. Psychological and behavioral pathways are also likely to play a role, as anxiety and depression, smoking, alcohol use and lack of physical activity are also common among women with PCOS, partly in response to the distressing symptoms they experience. The specific impact of sleep disturbances on the health of women with PCOS is not yet clear; however, both PCOS and sleep disturbances are associated with deterioration in cardiometabolic health in the longer term and increased risk of type 2 diabetes. Both immediate quality of life and longer-term health of women with PCOS are likely to benefit from diagnosis and management of sleep disorders as part of interdisciplinary health care.

Obesity and Outcome of Assisted Reproduction in Patients With Polycystic Ovary Syndrome

Assisted reproduction, including in vitro fertilization and intracytoplasmic sperm injection, is increasingly being used for the management of infertility in patients with polycystic ovary syndrome (PCOS). However, there are limited data regarding the association between obesity and the outcome of assisted reproduction in this specific population as well as on the effects of weight loss. The aim of the present review is to summarize the existing evidence on the association between obesity and the outcome of assisted reproduction in patients with PCOS. Accumulating data suggest that obesity is associated with lower pregnancy and live birth rates in patients with PCOS who are undergoing assisted reproduction therapy. However, it remains unclear whether weight loss improves the outcome of this therapy. Notably, recent guidelines state that the health benefits of postponing pregnancy to achieve weight loss must be balanced against the risk of declining fertility with advancing age. Therefore, if weight loss is not achieved within a reasonable time period, assisted reproduction therapy should be offered in adequately selected patients with PCOS, regardless of the presence of obesity.

Nutritional management in women with polycystic ovary syndrome: A review study

Polycystic ovary syndrome (PCOS) is endocrine disorder in women of reproductive age, which leads to reproductive, hormonal and metabolic abnormalities. Due to the presence of insulin resistance, PCOS increases the risk of chronic diseases like type 2 diabetes, hypertension, lipid disorders, cardiovascular diseases and malignancies such as breast and endometrial cancer. The actual cause of this syndrome is unknown but environmental factors such as dietary habits play an important role in prevention and treatment and lifestyle modifications are the most important therapeutic strategies in these patients. The approach of the diet therapy in these patients must be to reach specific goals such as improving insulin resistance, metabolic and reproductive functions that will be possible through the design of low-calorie diet to achieve weight loss or maintaining a healthy weight, limit the intake of simple sugars and refined carbohydrates and intake foods with a low glycemic index, reduction of saturated and trans fatty acids and attention to possible deficiencies such as vitamin D, chromium and omega-3. Given the prevalence of overweight and obesity and insulin resistance, a relatively low reduction in weight, about 5%, can improve problems such as insulin resistance, high levels of androgens, reproductive system dysfunctions and fertility in these women.

Linking Stress and Infertility: A Novel Role for Ghrelin

Infertility affects a remarkable one in four couples in developing countries. Psychological stress is a ubiquitous facet of life, and although stress affects us all at some point, prolonged or unmanageable stress may become harmful for some individuals, negatively impacting on their health, including fertility. For instance, women who struggle to conceive are twice as likely to suffer from emotional distress than fertile women. Assisted reproductive technology treatments place an additional physical, emotional, and financial burden of stress, particularly on women, who are often exposed to invasive techniques associated with treatment. Stress-reduction interventions can reduce negative affect and in some cases to improve in vitro fertilization outcomes. Although it has been well-established that stress negatively affects fertility in animal models, human research remains inconsistent due to individual differences and methodological flaws. Attempts to isolate single causal links between stress and infertility have not yet been successful due to their multifaceted etiologies. In this review, we will discuss the current literature in the field of stress-induced reproductive dysfunction based on animal and human models, and introduce a recently unexplored link between stress and infertility, the gut-derived hormone, ghrelin. We also present evidence from recent seminal studies demonstrating that ghrelin has a principal role in the stress response and reward processing, as well as in regulating reproductive function, and that these roles are tightly interlinked. Collectively, these data support the hypothesis that stress may negatively impact upon fertility at least in part by stimulating a dysregulation in ghrelin signaling.

Weight Management Interventions in Women with and without PCOS: A Systematic Review

Polycystic ovary syndrome (PCOS) is a common endocrinopathy among women associated with reproductive, metabolic and psychological features. While weight management is recommended as first-line treatment, it is unclear if women with PCOS achieve similar benefits as women without PCOS. This systematic review thus aimed to compare the efficacy of weight management interventions in women with and without PCOS. Databases were searched until May 2017. The primary outcome was weight and anthropometric, reproductive, metabolic and psychological measures were secondary outcomes. Of 3264 articles identified, 14 studies involving n = 933 (n = 9 high and n = 5 moderate risk of bias) met the inclusion criteria. No statistically significant differences in weight or weight loss following the intervention were found between women with and without PCOS in five studies, with the remaining studies not comparing the difference in weight or weight loss between these groups. Secondary outcomes did not differ significantly between the two groups. This review identified that there is a paucity of high quality research in this area and that more rigorous research is needed.

Neuroendocrine Regulation of Food Intake in Polycystic Ovary Syndrome

Several peripheral and central signals are involved in the sophisticated regulation of food intake. Women with polycystic ovary syndrome (PCOS) are prone to consume a diet higher in saturated fat and foods with high glycemic index and show impaired appetite regulation and measures of satiety. As a consequence, obesity, mostly of the central type, is prevalent in the syndrome and worsens the endocrine and metabolic profile of the affected patients. This review article briefly analyzes the current knowledge about the neuroendocrine mechanisms underlying the interplay between feeding behavior, obesity, and reproductive abnormalities in PCOS.

Ghrelin is independently associated with anti-mullerian hormone levels in obese but not non-obese women with polycystic ovary syndrome

Ghrelin is an endogenous appetite stimulant that may have a role in ovarian function. Women with polycystic ovary syndrome have anovulation and frequently weight management issues; however the associations between ghrelin and hormonal markers in polycystic ovary syndrome have not been well studied. In order to characterize the association between total ghrelin levels and ovarian function and the possible modification of this relationship by obesity, we examined total ghrelin levels and anti-mullerian hormone, total testosterone, and insulin in obese and non-obese women with and without polycystic ovary syndrome. Total ghrelin levels were lower in obese women with polycystic ovary syndrome (n = 45) compared to obese controls (n = 33) (p = 0.005), but similar in non-obese women with polycystic ovary syndrome (n = 20) compared to non-obese controls (n = 21) (p = NS). In the obese polycystic ovary syndrome group, anti-mullerian hormone was associated with ghrelin levels independent of age, insulin, and total testosterone (p = 0.008). There was no association between total ghrelin and anti-mullerian hormone levels in non-obese women with polycystic ovary syndrome, non-obese controls, or obese controls (p = NS). Our results provide evidence for a potential relationship between ghrelin and ovarian function in obese women with polycystic ovary syndrome that was not observed in non-obese women with polycystic ovary syndrome or controls.

MANAGEMENT OF ENDOCRINE DISEASE: Morbidity in polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is the most prevalent endocrine condition in premenopausal women. The syndrome is characterized by hyperandrogenism, irregular menses and polycystic ovaries when other etiologies are excluded. Obesity, insulin resistance and low vitamin D levels are present in more than 50% patients with PCOS, these factors along with hyperandrogenism could have adverse effects on long-term health. Hyperinflammation and impaired epithelial function were reported to a larger extent in women with PCOS and could particularly be associated with hyperandrogenism, obesity and insulin resistance. Available data from register-based and data linkage studies support that metabolic-vascular and thyroid diseases, asthma, migraine, depression and cancer are diagnosed more frequently in PCOS, whereas fracture risk is decreased. Drug prescriptions are significantly more common in PCOS than controls within all diagnose categories including antibiotics. The causal relationship between PCOS and autoimmune disease represents an interesting new area of research. PCOS is a lifelong condition and long-term morbidity could be worsened by obesity, sedentary way of life, Western-style diet and smoking, whereas lifestyle intervention including weight loss may partly or fully resolve the symptoms of PCOS and could improve the long-term prognosis. In this review, the possible implications of increased morbidity for the clinical and biochemical evaluation of patients with PCOS at diagnosis and follow-up is further discussed along with possible modifying effects of medical treatment.

Consuming Two Eggs per Day, as Compared to an Oatmeal Breakfast, Decreases Plasma Ghrelin while Maintaining the LDL/HDL Ratio

Eggs contain high quality protein, vitamins, minerals and antioxidants, yet regular consumption is still met with uncertainty. Therefore, the purpose of this study was to compare the effects of consuming two eggs per day or a heart-healthy oatmeal breakfast on biomarkers of cardiovascular disease (CVD) risk and satiety measures in a young, healthy population. Fifty subjects participated in a randomized crossover clinical intervention; subjects were randomly allocated to consume either two eggs or one packet of oatmeal per day for breakfast for four weeks. After a three-week washout period, participants were allocated to the alternative breakfast. Fasting blood samples were collected at the end of each intervention period to assess plasma lipids and plasma ghrelin. Subjects completed visual analog scales (VAS) concurrent to dietary records to assess satiety and hunger. Along with an increase in cholesterol intake, there were significant increases in both low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol following the egg consumption period (p < 0.01). However, there was no difference in the LDL/HDL ratio, a recognized biomarker of CVD risk, nor in the plasma glucose, triglycerides or liver enzymes, between diet periods. Several self-reported satiety measures were increased following the consumption of eggs, which were associated with lower plasma ghrelin concentrations (p < 0.05). These results demonstrate that compared to an oatmeal breakfast, two eggs per day do not adversely affect the biomarkers associated with CVD risk, but increase satiety throughout the day in a young healthy population.

Polycystic ovary syndrome and risk of endometrial, ovarian, and breast cancer: a systematic review

Background

Polycystic ovary syndrome (PCOS) is a complex endocrine disorder with an estimated prevalence of 4–21% in reproductive aged women. The altered metabolic and hormonal environment among women with PCOS may increase their risk of some types of cancer.

Methods

We performed a comprehensive review of the literature using numerous search terms for all studies examining the associations between polycystic ovary syndrome and related characteristics and cancer published in English through October 2016. This review summarizes the epidemiological findings on the associations between PCOS and endometrial, ovarian, and breast cancers and discusses the methodological issues, complexities, and underlying mechanisms of these associations.

Results

We identified 11 individual studies and 3 meta-analyses on the associations between PCOS and endometrial cancer, 8 studies and 1 meta-analysis for ovarian cancer, and 10 studies and 1 meta-analysis for breast cancer. Multiple studies reported that women with PCOS were at a higher risk for endometrial cancer; however, many did not take into account body mass index (BMI), a strong and well-established risk factor for endometrial cancer. The association with ovarian cancer was less clear, but a potentially increased risk of the borderline serous subtype was reported by two studies. No consistent association between PCOS risk and breast cancer was observed.

Conclusion

The associations between PCOS and endometrial, ovarian, and breast cancer are complex, with the need to consider many methodological issues in future analyses. Larger well-designed studies, or pooled analyses, may help clarify these complex associations.

Relationship between Serum Leptin, Ghrelin and Dietary Macronutrients in Women with Polycystic Ovary Syndrome

Background

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in women. It may involve an impairment in physiologic regulation of leptin and ghrelin. There is limited, controversial data on the relation of dietary components with leptin and ghrelin in PCOS, so the current study has been conducted to explore the effects of different macronutrients on serum levels of leptin and ghrelin in PCOS and healthy subjects.

Materials and Methods

In this case-control study, we randomly choose 30 PCOS pa- tients and 30 healthy age and body mass index (BMI) matched controls. Intake of macronutrients [protein, total fat, saturated, monounsaturated and polyunsaturated fatty acids (PUFA), carbohydrate, dietary fiber] and energy were assessed using 3-day, 24-hour food recall and food frequency questionnaires (FFQ). Fasting hormonal status was measured for each participant.

Results

PCOS women had higher levels of serum leptin, insulin, testosterone, and luteinizing hormone (LH), whereas sex hormone-binding globulin (SHBG) was lower compared to healthy women. There was no significant difference in mean ghrelin concentrations between the groups. Among PCOS women, independent of BMI and total energy intake, we observed an inverse association between leptin concentration and total dietary fat (β=-0.16, P<0.05) and saturated fatty acid (SFA) intake (β=-0.58, P<0.05). This relationship was not seen in the healthy subjects. There was no significant association between ghrelin and macronutrients in PCOS and healthy participants.

Conclusion

Certain habitual dietary components such as fat and SFA may decrease serum leptin, whereas ghrelin is not influenced by these in PCOS women. More studies are needed to better clarify the effects of dietary macronutrients on serum leptin and ghrelin.

Effects of Roux-en-Y gastric bypass surgery on eating behaviour and allopregnanolone levels in obese women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is associated with abnormal eating habits. We examined whether surgical treatment affected allopregnanolone levels and eating behaviour in nine women with PCOS who qualified for Rou-en-Y gastric bypass surgery. Blood samples were obtained to measure sex-hormone-binding globulin, total testosterone, progesterone, and allopregnanolone, and eating behaviour was evaluated using the Three-Factor Eating Questionnaire before surgery and at 6 and 12 months after surgery. Body mass index and total testosterone levels decreased, and progesterone and sex-hormone-binding globulin levels increased after bariatric surgery compared with pre-surgical values. In patients with anovulatory menstrual cycles, both the serum allopregnanolone level and the allopregnanolone/progesterone ratio were unchanged after surgery. The patients had high uncontrolled and emotional eating scores, and low cognitive restraint scores before surgery, and these scores had improved significantly at 6 and 12 months after surgery. The presurgical allopregnanolone levels were significantly correlated with uncontrolled eating. In conclusion, these results suggest that allopregnanolone appear to be part of the mechanism underlying the abnormal eating behaviour of obese PCOS patients by causing the loss of control over food intake. Roux-en-Y gastric bypass surgery can improve eating behaviour and clinical symptoms, and may facilitate weight loss in obese women with PCOS.

Low Starch/Low Dairy Diet Results in Successful Treatment of Obesity and Co-Morbidities Linked to Polycystic Ovary Syndrome (PCOS)

Background

Polycystic Ovary Syndrome (PCOS) affects approximately 15% of reproductive-age women and increases risk of insulin resistance, type 2 diabetes mellitus, cardiovascular disease, cancer and infertility. Hyperinsulinemia is believed to contribute to or worsen all of these conditions, and increases androgens in women with PCOS. Carbohydrates are the main stimulators of insulin release, but research shows that dairy products and starches elicit greater postprandial insulin secretion than non-starchy vegetables and fruits. The purpose of this study was to determine whether an 8-week low-starch/low-dairy diet results in weight loss, increased insulin sensitivity, and reduced testosterone in women with PCOS.

Methods

Prospective 8-week dietary intervention using an ad libitum low starch/low dairy diet in 24 overweight and obese women (BMI ≥ 25 kg/m² and ≤ 45 kg/m²) with PCOS. Diagnosis of PCOS was based on the Rotterdam criteria. Weight, BMI, Waist Circumference (WC), Waist-to-Height Ratio (WHtR), fasting and 2-hour glucose and insulin, homeostasis model assessment of Insulin Resistance (HOMA-IR), HbA1c, total and free testosterone, and Ferriman-Gallwey scores were measured before and after the 8-week intervention.

Results

There was a reduction in weight (−8.61 ± 2.34 kg, p<0.001), BMI (−3.25 ± 0.88 kg/m², p<0.001), WC (−8.4 ± 3.1 cm, p<0.001), WHtR (−0.05 ± 0.02 inches, p<0.001), fasting insulin (−17.0 ± 13.6 μg/mL, p<0.001) and 2-hour insulin (−82.8 ± 177.7 μg/mL, p=0.03), and HOMA-IR (−1.9 ± 1.2, p<0.001) after diet intervention. Total testosterone (−10.0 ± 17.0 ng/dL, p=0.008), free testosterone (−1.8 pg/dL, p=0.043) and Ferriman-Gallwey scores (−2.1 ± 2.7 points (p=0.001) were also reduced from pre- to post-intervention.

Conclusion

An 8-week low-starch/low-dairy diet resulted in weight loss, improved insulin sensitivity and reduced testosterone in women with PCOS.

Short-term intervention with liraglutide improved eating behavior in obese women with polycystic ovary syndrome

AIM

Glucagon-like peptide 1 receptor agonists (GLP-1 RA) stimulate satiety leading to reductions in food intake and body weight. The effects of long- acting GLP-1 RA liraglutide on eating behavior of women with PCOS have not been investigated yet.

METHODS

Thirty-six obese women with PCOS (mean ± SD, aged 31.2 ± 7.8 years, with BMI 38.7 ± 0.1 kg/m(2)), pretreated with metformin (1000 mg BID) were switched to liraglutide 1.2 mg QD sc for 12 weeks. Adiposity parameters and eating behavior as assessed by Three-Factor Eating Questionnaire (TFEQ-R18) were examined at baseline and after 12 weeks.

RESULTS

Subjects treated with liraglutide lost on average 3.8 ± 0.1 kg (p < 0.001). Significant reductions of waist circumference and visceral adipose tissue (VAT) mass, volume and area were demonstrated from liraglutide induction to the end of the study. TFEQ-R18 scores were significantly different pre- and post-liraglutide intervention. After treatment with liraglutide the uncontrolled eating (UE) score decreased from 36.8 ± 24.5 to 19.6 ± 18.4 (p < 0.001) and emotional eating (EE) score decreased from 49.9 ± 33.3 to 28.5 ± 26.9 (p < 0.001). Scores for cognitive restraint (CR) were not changed.

CONCLUSIONS

Short-term liraglutide treatment was associated with weight loss and significantly improved eating behavior in obese women with PCOS.

Polycystic Ovary Syndrome: Important Underrecognised Cardiometabolic Risk Factor in Reproductive-Age Women

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder amongst women of reproductive age. Although PCOS is diagnosed exclusively based on reproductive criteria, it is also a metabolic disorder. Insulin resistance, impaired glucose tolerance, type 2 diabetes mellitus, obesity, and dyslipidemia are more common in women with PCOS than in age-comparable women without PCOS. Many of the metabolic abnormalities that manifest in PCOS are worsened by the concurrent incidence of obesity. However, some of these metabolic perturbations occur even in lean women with PCOS and therefore are rightfully recognized as intrinsic to PCOS. The intrinsic factors that produce these metabolic disturbances are reviewed in this paper. The consequences of obesity and the other metabolic aberrations are also discussed. The metabolic perturbations in PCOS patients lead to chronic low-grade inflammation and to cardiovascular impairments that heighten the risk of having cardiovascular disease. Even though many studies have shown an elevation in surrogate biomarkers of cardiovascular disease in PCOS women, it is still not clear to what extent and magnitude the elevation precipitates more frequent and earlier events.

Comparison of dietary intake and physical activity between women with and without polycystic ovary syndrome: a review

Polycystic ovary syndrome (PCOS) is a prevalent endocrine disorder affecting women of reproductive age worldwide. In addition to deleterious effects on fertility imparted by PCOS, women with PCOS are at increased risk of obesity, diabetes, cardiovascular disease, depression, and certain cancers. Hormonal and metabolic aberrations in PCOS have the potential to influence dietary intake and physical activity levels. There are emerging global data that women with PCOS have different baseline dietary energy intakes compared with women without PCOS. These alterations in diet may exacerbate clinical symptoms and compound risk of chronic disease in patients. Few studies have compared baseline physical activity levels between women with and without PCOS. Although comparisons between studies are confounded by several factors, the data point to no differences in activity levels among PCOS and non-PCOS groups. This review provides an assessment of the current literature on baseline dietary intake and physical activity levels in women with PCOS. Future recommendations to strengthen research in this area are provided, given the implications to aid in the development of effective nutrition-focused interventions for PCOS.