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

Metabolic mediators of the overweight's effect on infertility in women with polycystic ovary syndrome

Women with polycystic ovary syndrome (PCOS) often experience infertility, potentially mediated by metabolic factors altered by elevated body mass index (BMI). While triglycerides (TG), low-density lipoprotein (LDL), high-density lipoprotein (HDL), and fasting blood sugar (FBS) are known mediators in the BMI-infertility relationship, the extent of their mediation effects remains unquantified in prior studies. This study quantifies the mediation effect of these metabolic factors. We conducted a cross-sectional study on 669 women diagnosed with PCOS at a tertiary hospital in Tehran, Iran, from 2021 to 2023. Data on BMI, TG, LDL, HDL, and FBS were collected, with infertility defined as the inability to conceive after 12 months of unprotected intercourse. Mediation analysis was performed using the Karlson Holm Breen (KHB) method, adjusting for age. Higher BMI was associated with increased levels of TG, LDL, and FBS and decreased HDL, all of which (except for LDL) were linked to infertility. Mediation analysis revealed that after adjusting for age, TG, HDL, and FBS significantly mediated the BMI-infertility association, accounting for 52.98%, 79.19%, and 49.7% of the effect, respectively. Our study identified TG, HDL, and FBS as significant mediators of the BMI-infertility link, with over half of the association mediated through these factors. Targeting metabolic improvements may help reduce infertility risk in this population.

The association between meat consumption and polycystic ovary syndrome in Iranian women: a case-control study

BACKGROUND

In light of the observed association between nutritional factors and polycystic ovary syndrome (PCOS) in recent decades, the present study was conducted to investigate the association between the consumption of various types of meat and PCOS in Iranian women.

MATERIAL AND METHODS

This frequency-matched case-control study included 108 women with newly diagnosed PCOS and 108 age and body-mass-index-matched women without PCOS, as a control group, who were referred to the Yazd Diabetes Clinic and Khatam Clinic between January 2018 and March 2019. The validated 178-item food frequency questionnaire was used to assess the usual dietary intake. Logistic regression analysis was used to estimate the association between meat consumption and PCOS.

RESULTS

The findings of this study showed, the individuals in the third tertile of red meat intake, had higher odds of PCOS in the crude model (Odds Ratio (OR) = 4.29; 95% Confidence Interval (CI), 2.13-8.64; P-value = 0.001) compared with those in the first tertile. These results remained significant after adjustments for energy intake, marital status, physical activity, education, pregnancy history and chronic disease history (OR = 3.87; 95% CI, 1.78-8.40; P-value = 0.001). Higher consumption of red meat increased the risk of PCOS by 3.87 times. Furthermore, higher consumption of processed meats increased the risk of PCOS by 2.15 times (OR = 2.15; 95% CI, 1.05-4.39; P-value and trend = 0.035). We did not find an association between other types of meat consumption and PCOS.

CONCLUSION

The results of the present study showed that a higher consumption of red and processed meat is associated with a higher risk of PCOS, whereas no significant correlation was found between the consumption of poultry, fish, and organ meat and PCOS. However, more studies are needed to support these findings in the future.

Evaluation of Effects of a High-Protein Hypocaloric Diet on Body Composition and Cardio-Metabolic Factors in Women with Polycystic Ovary Syndrome and Overweight or Obesity

Background

The optimal composition of a hypocaloric diet for women with polycystic ovary syndrome (PCOS) remains uncertain. The aim of this study was to evaluate and compare the impacts of a hypocaloric high-protein diet (HPD) versus an isocaloric conventional calorie-restricted diet (CRD) with normal protein intake on the body composition and biochemical profiles of women diagnosed with PCOS combined with overweight or obesity.

Methods

This was a dietary intervention study evaluating the effects of two types of diets on women with PCOS who initiated weight loss independently at the Clinical Nutrition Clinic of Peking Union Medical College Hospital from March 2023 to March 2024 was carried out. Specifically, the records of 72 women with PCOS who were overweight or obese and underwent a 3-month weight management program were examined in a retrospective manner. The hypocaloric dietary intervention was adopted to achieve weight reduction, with either HPD or CRD. Body composition, serum lipids, glucose, insulin, and total testosterone (TT) were evaluated at baseline and post-intervention, and the differences were compared between and within groups.

Results

Both groups achieved significant weight loss, with the HPD group losing an average of -8.9 ± 4.6 kg and the CRD group losing -10.0 ± 9.4 kg, without a significant difference between them (P > 0.05). However, the HPD was superior in preserving fat-free mass (FFM) and fat-free mass index (FFMI), with losses of -1.5 ± 1.6 kg and -0.7 ± 1.1 kg/m², respectively, compared to the CRD group's losses of -4.4 ± 4.2 kg and -2.1 ± 1.9 kg/m² (P < 0.01). Additionally, the HPD group showed a more significant reduction in body fat percentage (-5.3 ± 3.3% vs -3.2 ± 4.5%, P < 0.05). Biochemical indicators were comparable in both groups.

Conclusion

Compared to an isocaloric standard-protein CRD, the dietary intervention with a HPD appears to be more helpful in preserving FFM in women with PCOS during a short-term weight loss program. Further well-designed trials are needed to verify our findings.

Understanding barriers and facilitators to lifestyle management in people with polycystic ovary syndrome: A mixed method systematic review

Polycystic ovary syndrome (PCOS) is an endocrine disorder affecting 10-13% of reproductive-aged women. Lifestyle management through diet and physical activity changes can improve reproductive, metabolic, and psychological comorbidities. The aim of this systematic review is to understand the barriers and facilitators to lifestyle changes from the perspective of people with PCOS and health care professionals (HCP) using the theoretical domains framework and capability, opportunity, motivation, and behavior model. Six databases were systematically searched for qualitative, quantitative, and mixed-methods studies to 22nd September 2022. Quantitative outcomes from quantitative and mixed-methods studies were narratively synthesized and all studies were thematically analyzed. Sixty-eight papers met the eligibility criteria. HCP education on lifestyle management in PCOS was viewed by all to be inadequate, impacting the quality of care and health outcomes. Lifestyle advice delivered by a multidisciplinary team, including dietitians, was identified as a key component for change. All agreed that there was a need for individualized and PCOS-specific lifestyle advice. Weight stigma was identified as negatively impacting both those in larger and smaller bodies with PCOS, reducing the quality of care and affecting self-perception and mental health. People with PCOS perceived that lifestyle management was overly focused on weight loss and fertility, independent of their own personal motivations and goals. Systemic changes, including increasing HCP education on lifestyle management and multidisciplinary collaboration, focusing on lifestyle advice that meets individual needs, and reducing the use of weight-centric care are necessary for long-term sustainable changes and improvements in health outcomes in people with PCOS.

The prevalence of abnormal semen parameters in male partners of women with anovulatory polycystic ovarian syndrome: a retrospective case-control study

PURPOSE

Polycystic ovary syndrome (PCOS) is the leading cause of anovulatory infertility, often requiring ovarian stimulation in affected women attempting to conceive. Male partner semen quality and shared lifestyle factors can significantly impact reproductive outcomes. However, current international guidelines lack evidence-based recommendations on the necessity and timing of semen analysis for the fertility management of anovulatory PCOS women.

METHODS

In a retrospective case-control study, semen analysis results of male partners of 187 anovulatory PCOS women scheduled for ovarian stimulation were analyzed and compared to a control group of 76 male partners of women with bilateral tubal occlusion.

RESULTS

The prevalence of semen analysis results with at least one parameter classified as "borderline" and "pathological" among male partners of women with PCOS eligible to undergo ovarian stimulation was 51.3% and 22.5%, compared to 44.7% and 13.2% in the control group, respectively (p = 0.027). In the PCOS group, male body mass index (odds ratio, OR 1.478, p < 0.001), and smoking status (OR 6.228, p < 0.001) were significant predictors of pathological sperm test results, while no association was observed with any female characteristics (p > 0.05).

CONCLUSION

The high frequency of pathological sperm analysis results provides lacking epidemiological data on semen quality in this population, emphasizing the critical need for early male fertility evaluation prior to ovarian stimulation in PCOS women. Moreover, our findings indicate that the risk prediction for abnormal semen quality cannot be based on the female's data.

Body Composition and Dietary Intake of Women Attending an Infertility Clinic-Polish Observational Study

BACKGROUND AND OBJECTIVES

We aimed to assess the body composition and dietary intake of female patients attending one of the Polish infertility clinics. Additionally, we evaluated if there were any relationships between dietary intake and body composition parameters.

METHODS

The study involved 51 women who met the inclusion criteria. For the nutritional assessment, we used 3-day dietary records. Weight, height, waist and hip circumferences, and body composition were assessed. The participants were divided into three groups, with low (I, n = 12), normal (II, n = 27), and high (III, n = 12) fat tissue content, and then compared in terms of dietary intake.

RESULTS

The lowest protein intake per kilogram of body weight was observed in group III (p < 0.001). In group I, we reported the highest consumption of plant protein in general (p = 0.03) and per kg of body weight (p < 0.001). Higher protein intake per kg body mass was associated with lower values of BMI (r = -0.681; p < 0.001), fat mass (r = -0.641; p < 0.001), waist-hip ratio (r = -0.391; p = 0.005), and abdominal fat index (r = -0.653; p < 0.001).

CONCLUSIONS

Our findings suggest that targeted nutritional counseling focused on optimizing protein intake and emphasizing plant-based sources may improve body composition and potentially support fertility outcomes in women undergoing infertility treatment.

Effects of licorice extract in combination with a low-calorie diet on obesity indices, glycemic indices, and lipid profiles in overweight/obese women with polycystic ovary syndrome (PCOS): a randomized, double-blind, placebo-controlled trial

BACKGROUND

Polycystic ovary syndrome (PCOS) is the most common ovarian dysfunction. Recent studies showed the effectiveness of licorice on metabolic profiles with inconsistent findings. So, we investigated the effect of licorice on obesity indices, glycemic indices, and lipid profiles in women with PCOS.

METHODS

This randomized, double-blind, placebo-controlled trial was performed on 66 overweight/obese women with PCOS. The participants were randomly assigned to receive either 1.5 gr/day licorice extract plus a low-calorie diet (n = 33) or placebo plus a low-calorie diet (n = 33) for 8 weeks. Participants' anthropometric indices and body composition were assessed using standard protocols. Fasting blood sugar (FBS), insulin levels, low-density lipoprotein-cholesterol (LDL-C), total cholesterol (TC), triglyceride (TG), and high-density lipoprotein-cholesterol (HDL-C) were measured using enzymatic kits. The homeostasis model assessment-insulin resistance (HOMA-IR) and HOMA of β-cell function (HOMA-B) were calculated using valid formulas.

RESULTS

Between-group comparisons demonstrated significant differences between the groups in terms of obesity indices (body weight, BMI, and body fat), lipid profiles (TG, TC, LDL-C, and HDL-C), FBS and insulin levels, HOMA-IR, and HOMA-B at the end of the study (P < 0.05). Supplementation with licorice plus a low-calorie diet was also more effective in improving all parameters than a low-calorie diet alone after adjusting for confounders (baseline values, age, weight changes, and physical activity changes) (P < 0.05).

CONCLUSION

The findings showed that licorice consumption leads to improvements in obesity indices, glucose homeostasis, and lipid profiles compared to placebo. Due to possible limitations of the study, further research is needed to confirm these findings.

Obesity, Dietary Patterns, and Hormonal Balance Modulation: Gender-Specific Impacts

Understanding the intricate relationship between nutrition, hormonal balance, and gender-specific factors is crucial for developing targeted interventions to mitigate obesity-related endocrine disruptions and improve metabolic health. This narrative review examines the impact of various dietary patterns on hormonal regulation in both men and women, focusing on their effects on hormonal balance and metabolic health in the context of obesity. Calorie restriction, the Western diet, high-fat diets, low-CHO diets, plant-based diets, and the Mediterranean diet are analyzed in relation to their influence on obesity-related endocrine disruptions and metabolic health. Future research directions include investigating the specific mechanisms underlying dietary influences on hormonal regulation, addressing the gender-specific metabolic differences and body fat distribution, and exploring the dietary needs of individuals undergoing gender transition. Personalized dietary interventions tailored to individual metabolic and hormonal profiles are essential for optimizing health outcomes across the gender spectrum. By integrating gender-specific considerations into dietary recommendations, healthcare professionals can better support individuals in achieving optimal metabolic health and hormonal balance.

Binge eating symptomatology in adolescents with polycystic ovary syndrome

Several factors may contribute to binge eating behaviors in PCOS. However, findings are contradictory and studies in the adolescence are limited. We aimed to evaluate the eating attitudes of adolescents with PCOS and the possible etiological factors underlying the association between PCOS and binge eating symptomology. Between 2019 and 2022, 46 newly diagnosed adolescents with PCOS and 56 controls matched for age and BMI z-score were included. The Eating Disorder Examination Questionnaire, Three Factor Eating Questionnaire-R18, and a questionnaire assessing postprandial reactive hypoglycemia symptom severity were given. Binge eating symptomology, in terms of over, uncontrolled, and emotional eating, were more prevalent in the PCOS group. Uncontrolled, emotional, and binge eating were positively correlated with postprandial reactive hypoglycemia symptom score. Overeating was also associated with clinical hyperandrogenism. Improving the disease outcome and reducing the future complications requires early recognition and management of emotional and uncontrolled eating behaviors in adolescents with PCOS.

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.

Association of dietary inflammatory index with C-reactive protein and interleukin-6 in women with and without polycystic ovarian syndrome

Considering that interventions related to lifestyle, especially nutrition have been proposed as the first line of prevention and treatment of polycystic ovarian syndrome (PCOS), and regarding the proven relationship between PCOS and inflammation, the present study was designed to find out the possible association of Diet Inflammatory Index (DII) with the inflammatory markers like C-reactive protein (CRP) and Interleukin-6 (IL-6), and compare the obtained results in PCOS and non-PCOS women. This case-control study was conducted on 45 PCOS and 40 non-PCOS women. Food intake and DII were measured using a 147-item Food Frequency Questionnaire. All participants were tested for the serum levels of IL-6 and CRP. Finally, the obtained results were compared between the two groups of PCOS and non-PCOS women. Significant differences were observed between the two groups in terms of age, menstrual status and number of pregnancies (P < 0.05). Comparison of DII values showed no significant difference between the two groups of women (P = 0.68), but IL-6 was significantly higher in the PCOS group than in the control group (4.94 ± 1.97 vs. 3.48 ± 1.77, P < 0.001). Also in terms of CRP, no significant difference was observed between the two groups (P > 0.05). The difference of DII between the case and control groups were not significant and Pearson's correlation test did not show a significant correlation between DII and IL-6 (P˃0.05). This result can be due to the influence of several factors affecting the determination of DII such as education level, health status, physical activity level, age, and calorie intake. It seems that diet, especially consumption of more carbohydrates plays a role in causing chronic inflammation, as well as the occurrence and exacerbation of PCOS.

Effect of Dietary Regimen on the Development of Polycystic Ovary Syndrome: A Narrative Review

BACKGROUND

Polycystic ovary syndrome (PCOS) is a common endocrine disorder affecting 4%-20% of women worldwide. The pathogenesis of PCOS is still unconfirmed. Some risk factors for the disease are obesity, insulin resistance, genetic factors, and diet.

AIM

Our aim is to review studies investigating the role of diet in the development of PCOS.

METHOD

We looked into studies published in different databases, such as PubMed, Scopus, Google Scholar, and Web of Science, using specific keywords as per our study topic.

RESULTS

High-carbohydrate, high-fat diets, low-fiber diets, high glycemic index and glycemic load, and Western diets were associated with a higher risk of PCOS. Some vitamins, such as Vitamin D and B9, the Dietary Approaches to Stop Hypertension (DASH) diet, fruits, nuts, and seeds, such as pumpkin and sunflower, are associated with a lower risk of PCOS. The Alternate Healthy Eating Index-2010 (AHEI-2010) diet reduces the risk of hyperandrogenic or oligoanovulatory phenotypes. The review revealed that unhealthy diets encompass high levels of carbohydrates, animal proteins, fats, and processed foods. Despite inconsistent results from certain studies claiming no disparity in the dietary patterns between PCOS patients and healthy controls, the majority of researchers have amassed sufficient evidence linking nutrition to the incidence of PCOS. The review also underscores the significance of the interplay between genes and the environment in the prevalence of PCOS. Individuals possess a genetic predisposition to the condition from birth, and subsequent exposure to detrimental environmental factors, particularly diet and inactivity, trigger epigenetic changes that contribute to the development of the disorder. This study further illuminated the existence of the "lean PCOS" phenomenon, wherein roughly 20% of global PCOS cases exhibit clinical manifestations of the syndrome but maintain a normal or below-average weight.

CONCLUSION

To sum up, the collective body of assessed research indicates that women with PCOS tend to share similar dietary habits, characterized by the consumption of numerous unhealthy foods such as processed foods, animal proteins, carbohydrates, and fats. While some studies present conflicting findings, these contradictions underscore the necessity for further investigation employing extensive cohorts.

Physical Activity, Rather Than Diet, Is Linked to Lower Insulin Resistance in PCOS Women-A Case-Control Study

Insulin resistance (IR) is a prominent feature of polycystic ovary syndrome (PCOS). The importance of lifestyle interventions in the management of PCOS is strongly highlighted and it is suggested that diet and physical activity may significantly influence insulin sensitivity. Therefore, we evaluated the link between diet and physical activity and various indices of insulin resistance, including adipokines secreted by the adipose tissue in 56 PCOS and 33 healthy control women. The original food frequency questionnaire and Actigraph GT3X-BT were used to assess the adherence to the diet recommended in IR and the level of physical activity, respectively. We observed that higher levels of physical activity were associated with lower HOMA-IR and a greater chance of its normal value in PCOS group. No such relationship was observed for other IR indices and adipokines or for the diet. However, we noted a strong correlation between HOMA-IR (Homeostatic Model Assessment of Insulin Resistance) and HOMA-AD (Homeostatic Model Assessment-Adiponectin) in PCOS women. Additionally, when we used HOMA-AD we observed a higher prevalence of IR among PCOS women. Our study supports the beneficial role of physical activity in the management of insulin resistance in PCOS women. Moreover, our findings indicate that HOMA-AD may be a promising surrogate marker for insulin resistance assessment in women with PCOS.

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.

Polycystic Ovary Syndrome: A Disorder of Reproductive Age, Its Pathogenesis, and a Discussion on the Emerging Role of Herbal Remedies

Polycystic ovary syndrome (PCOS) is a very common, complex, and heterogeneous endocrine disorder of women that involves a combination of environmental and genetic factors. PCOS affects women of growing age particularly at the early to late reproductive stage (15-35 years). Currently, PCOS affects 1 in every 10 women worldwide. It is characterized majorly by a raised level of androgens such as testosterone and a large number of ovarian cysts (more than 10) that cause anovulation, infertility, and irregular menstrual cycle. PCOS is also related to other endocrine and metabolic abnormalities, such as obesity, hirsutism, acne, diabetes, insulin resistance, and glucose impairment. PCOS can be treated with allopathic, ayurvedic, and natural or herbal medications along with lifestyle modifications. Herbal medicines remained in demand for numerous reasons such as high cost and side effects associated with the use of allopathic medicine and our traditional norms, which have helped humans to use more herbal products for their health benefits. Estrogenic and nonestrogenic phytochemicals present in various plant species such as Glycyrrhiza glabra L. [Fabaceae], Aloe vera (L.) Burm. f. [Asphodelaceae], Silybum marianum (L.). Gaertn. [Asteraceae], Serenoa repens (W.Bartram) Small [Arecaceae], Actaea racemosa L. [Ranunculaceae], and Angelica sinensis (Oliv.) Diels [Apiaceae] are effective and harmless. Herbal medicines are found to be cost-effective, efficacious, and a highly esteemed source of management/treatment for PCOS than allopathic medicines. In this literature review, diagnosis, signs, and symptoms of PCOS; causes of hormonal imbalance; and risk factors associated with PCOS and their management are discussed briefly, and the focus was to find out the role of herbal remedies in PCOS management.

PCOS patients differ in meal timings rather than total caloric or macronutrient intake in comparison to weight matched controls

BACKGROUND

There is paucity of data related to dietary patterns in women with PCOS with heterogenous phenotypes compared to weight matched healthy women. In the present study, we studied the influence of diet and dietary patterns in relation to BMI and phenotype of PCOS women.

DESIGN

Case control study in a tertiary care hospital.

PATIENTS

168 PCOS women and 102 age matched healthy women were recruited. All were subjected to clinical examination, biochemical, hormonal and dietary assessment based on 2-day dietary recall and direct interview by dieticians.

RESULTS

There was no difference in the total energy and macronutrient distribution among the lean and obese PCOS women compared to weight matched controls. There was a higher junk intake and lower fibre intake among PCOS patients compared to controls. There was no difference in the total energy or macronutrient distribution or meal timings among different phenotypes of PCOS. Around 40% PCOS women had a late/missed breakfast pattern compared to 15% of healthy controls (p-0.00). In multivariable logistic regression analysis, we observed that late breakfast and late lunch patterns were associated with PCOS independent of BMI (OR-3.3[CI- 1.7-6.8] and 3.0 [CI- 1.2-6.9]). Junk intake was correlated with BMI, glucose and cholesterol levels and dairy intake was correlated with hirsuitism score.

CONCLUSION

We demonstrate for the first time that PCOS women differ significantly from weight matched controls in the timings of their breakfast and lunch intake rather than the total caloric intake and macronutrient distribution. Whether correction of meal timings and food choices can improve the phenotypic manifestations of PCOS remains to be seen.

Fat intake pattern in women with polycystic ovary syndrome

RESEARCH QUESTION

Do women with polycystic ovary syndrome (PCOS) have a different fat intake pattern to women without PCOS?

DESIGN

Case-control study of 276 women between 20 and 35 years old from the Murcia region of Spain. Cases (n = 121) attended the Department of Gynaecology and Obstetrics of the University Clinical Hospital and were diagnosed with PCOS using Rotterdam criteria. Controls (n = 155) were women without PCOS attending the gynaecological outpatient clinic for routine gynaecological examinations. Data from clinical, gynaecological and analytical examinations were collected, including a food frequency questionnaire. Associations between fat intake and presence of PCOS and its phenotypes were examined using multiple logistic regression, adjusting for potential confounding factors.

RESULTS

Although no association was found between fatty acid intake and PCOS, significant associations were observed for some PCOS phenotypes. The PCOS phenotype characterized by hyperandrogenism + oligo/amenorrhoea + polycystic ovarian morphology ('H+O+POM') was significantly associated with a higher intake of polyunsaturated fat (odds ratio [OR] 4.0; 95% confidence interval [CI] 1.1-14.2; fourth quartile of highest intake [Q4] versus lowest intake quartile as reference [Q1]) and omega-6 fatty acids (OR 3.5; 95% CI 1.01-12.4; Q3 versus Q1). The 'H+O' phenotype was positively associated with saturated fat intake (OR 6.9; 95% CI 1.1-41.6; Q4 versus Q1).

CONCLUSION

This exploratory study suggests that higher intakes of specific fatty acids are related to some PCOS phenotypes although no association was found for PCOS on a global basis. It is recommended that studies with larger sample size be performed to further explore these associations, thus contributing to establishing recommendations about fat intake adapted to different PCOS phenotypes.

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.

Associations of diet, physical activity and polycystic ovary syndrome in the Coronary Artery Risk Development in Young Adults Women's Study

Background

Current evidence supports the adoption of healthy diet and physical activity (PA) behaviors in patients with polycystic ovary syndrome (PCOS), given the positive effects of those behaviors on physical well-being. An improved understanding of the associations between diet and PA with PCOS is needed to ascertain whether tailored dietary and PA recommendations are needed for this population. Thus, we investigated the associations of diet and PA with PCOS and its isolated features.

Methods

Cross-sectional study. Of the 748 women who were included in this study from the Coronary Artery Risk Development in Young Adults (CARDIA) Women’s Study, 40 were classified as having PCOS, 104 had isolated hyperandrogenism (HA) and 75 had isolated oligomenorrhea (OA). Dietary intake was measured using the CARDIA diet history questionnaire and diet quality was scored using the Alternative Healthy Eating Index 2010; a higher score indicated a better quality diet. Self-reported PA was measured using a validated interviewer-administered questionnaire. Polytomous logistic regression analyses examined the associations between diet and PA with PCOS, HA, and OA status (outcomes), adjusting for age, race, total energy intake, education, and/or body mass index. The threshold for statistical significance was set at p < 0.05.

Results

Mean age of the participants was 25.4 years (SD 3.6) and 46.8% of participants were Black women. There was little to no association of total energy intake, nutrients, diet quality, and PA with PCOS, HA or OA status.

Conclusion

Energy intake, nutrient composition, diet quality, and PA were not associated with PCOS, supporting recent PCOS guidelines of using national recommendations for the general population to encourage health-promoting behaviors among women with PCOS. However, longitudinal studies evaluating changes in diet and physical activity in relation to the development and/or the progression of PCOS are needed to establish a causal association.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-10028-5.

Nutritional and dietary aspects in polycystic ovary syndrome: insights into the biology of nutritional interventions

Polycystic Ovary Syndrome (PCOS) is a complex endocrine disorder, which affects 5-17% of reproductive age women and is often associated with obesity and metabolic impairment. Common treatment strategies are based on exercise, diet and nutrient supplementation since PCOS is often linked with obesity and metabolic impairment. Studies have recommended that nutrition is a key factor in the health maintenance of women with PCOS, however, little is known about the subject in the context of such a disease. This narrative review aims to identify dietary and nutritional aspects of PCOS and discuss the role of nutrients in management of polycystic ovary syndrome in view of clinical trials.

Predicting Risk of Insulin Resistance in a Chinese Population with Polycystic Ovary Syndrome: Designing and Testing a New Predictive Nomogram

BACKGROUND

This research is aimed at establishing and internally validating the risk nomogram of insulin resistance (IR) in a Chinese population of patients with polycystic ovary syndrome (PCOS).

METHODS

We developed a predictive model based on a training dataset of 145 PCOS patients, and data were collected between March 2018 and May 2019. The least absolute shrinkage and selection operator regression model was used to optimize function selection for the insulin resistance risk model. Multivariable logistic regression analysis was used to construct a prediction model integrating the function selected in the regression model of the least absolute shrinkage and selection operator. The predicting model's characteristics of prejudice, disease, and lifestyle were analyzed using the C-index, the calibration diagram, and the study of the decision curve. External validity was assessed using the validation of bootstrapping.

RESULTS

Predictors contained in the prediction nomogram included occupation, disease durations (years), BMI, current use of metformin, and activities. With a C-index of 0.739 (95 percent confidence interval: 0.644-0.830), the model showed good differentiation and proper calibration. In the interval validation, a high C-index value of 0.681 could still be achieved. Examination of the decision curve found that the IR nomogram was clinically useful when the intervention was determined at the 11 percent IR potential threshold.

CONCLUSION

This novel IR nomogram incorporates occupation, disease durations (years), BMI, current use of metformin, and activities. This nomogram could be used to promote the estimation of individual IR risk in patients with PCOS.

Food habits in overweight and obese adolescent girls with Polycystic ovary syndrome (PCOS): a qualitative study in Iran

Background

Polycystic ovary syndrome (PCOS) is a hormonal disorder in women of reproductive age. It seems that over the recent years, PCOS has augmented in adolescent girls due to unhealthy food habits and obesity. So, the present study was conducted to explore the food habits in overweight and obese adolescent girls with PCOS.

Methods

In the present qualitative study, 33 participants were selected using a purposive sampling method. Data were collected through individual in-depth interviews, focus group discussions (FGDs), and field notes. These data were analyzed through the use of conventional qualitative content analysis.

Results

Three main categories were extracted: First, the high consumption of unhealthy food had three sub-categories: “high consumption of fatty and salty foods”, “high consumption of unhealthy snacks”, and “high consumption of sugar-rich foods”. Second, low consumption of healthy food had three sub-categories: “low consumption of dairy products”, “low consumption of fiber-rich foods”, and “low consumption of meat, beans, fish and seafood” Third, inappropriate behavioral habits had three sub-categories: “lack of concentration and consumption of large meals”, “inappropriate dietary and physical activity patterns”, and “skipping the meals and going on arbitrary diets”.

Conclusion

This research through presenting an image of food habits in overweight and obese adolescent girls with PCOS is able to help for designing the necessary interventions to change the food habits, control the symptoms and complications of PCOS, and finally, improve the reproductive health of these girls.

Dietary and Physical Activity Behaviors in Women with Polycystic Ovary Syndrome per the New International Evidence-Based Guideline

Lifestyle modifications are recommended as first-line therapy in polycystic ovary syndrome (PCOS). However, usual dietary and physical activity (PA) behaviors of women with PCOS remain uncertain, likely owing to controversy in diagnostic criteria. Our objective was to contrast the usual dietary and PA behaviors of women with PCOS (n = 80) diagnosed by the 2018 International Evidence-based Guideline for the Assessment and Management of PCOS to that of controls (n = 44). Study outcomes were dietary intake, diet quality (Healthy Eating Index-2015), and PA (questionnaire, waist-worn accelerometers). Women with PCOS met the acceptable macronutrient distribution ranges for carbohydrate, fat, and protein, but did not meet the recommended dietary reference intakes for vitamin D (mean (95% confidence interval); 6 (5–7) μg/d), vitamin B9 (275 (252–298) μg/d), total fiber (24 (22–26) g/d), or sodium (4.0 (3.6–4.4) g/d). Women with PCOS also met the US recommendations for PA. No differences were detected in dietary intake, diet quality, or PA levels between groups (p ≥ 0.11). In conclusion, women with and without PCOS have comparable dietary and PA behaviors. A lack of unique targets for dietary or PA interventions supports the position of the new guideline to foster healthy lifestyle recommendations for the management of PCOS.

Low intakes of dietary fiber and magnesium are associated with insulin resistance and hyperandrogenism in polycystic ovary syndrome: A cohort study

BACKGROUND

Women with polycystic ovary syndrome (PCOS) often have insulin resistance (IR) which may be worsened by obesity. The roles of dietary intake and activity are unclear. Our objectives were to determine whether (a) high caloric intake or inactivity explains obesity in PCOS, and (b) dietary composition is associated with PCOS phenotypes.

METHODS

Eighty-seven women with PCOS and 50 women without PCOS participated in this cohort study at a reproductive medicine center. Data collected included 3-day food and physical activity records, anthropometrics, and metabolic and hormonal assays.

RESULTS

Women with PCOS had increased body mass index (BMI) but similar caloric intake and activity to women without PCOS. There were no differences in protein, carbohydrates, fat, or glycemic load consumption, but women with PCOS consumed less fiber (medians: 19.6 vs. 24.7 g) and less magnesium (medians: 238.9 vs. 273.9 mg). In women with PCOS, those with IR consumed less fiber, less magnesium, and greater glycemic load than those without IR (medians: 18.2 vs. 22.1 g, 208.4 vs. 264.5 mg, 89.6 vs. 83.5). Fiber intake of women with PCOS was negatively correlated with IR, fasting insulin, glucose tolerance, testosterone, and dehydroepiandrosterone sulfate. Magnesium intake was negatively correlated with IR, C-reactive protein, and testosterone, but positively correlated with HDL cholesterol. Fiber intake and BMI accounted for 54.0% of the variance observed in IR.

CONCLUSIONS

Obesity in women with PCOS could not be explained by overeating or inactivity. Increasing dietary fiber and magnesium intakes may assist in reducing IR and hyperandrogenemia in women with PCOS.

Bidirectional Mendelian randomization to explore the causal relationships between body mass index and polycystic ovary syndrome

STUDY QUESTION

What are the causal relationships between polycystic ovary syndrome (PCOS) and body mass index (BMI)?

SUMMARY ANSWER

Bidirectional Mendelian randomization analyses suggest that increased BMI is causal for PCOS while the reverse is not the case.

WHAT IS KNOWN ALREADY

The contribution of obesity to the pathogenesis of PCOS is controversial. To date, published genetic studies addressing this question have generated conflicting results and have not utilized the full extent of known single nucleotide polymorphisms associated with body mass index (BMI).

STUDY DESIGN, SIZE, DURATION

This cross-sectional Mendelian randomization (MR) and genetic association study was conducted in 750 individuals of European origin and with PCOS and 1567 BMI-matched controls.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Cases and controls were matched for BMI as well as for distribution of weight categories (normal weight, overweight, obese). Two-sample MR using inverse variance weighting (IVW) was conducted using a 92-SNP instrument variable for BMI with PCOS as the outcome, followed by two-sample MR with a 16-SNP instrument variable for PCOS with BMI as the outcome. Sensitivity analyses included MR-Egger and maximum likelihood methods. Secondary analyses assessed associations of genetic risk scores and individual SNPs with PCOS, BMI and quantitative androgen-related and glucose homeostasis-related traits.

MAIN RESULTS AND THE ROLE OF CHANCE

Each standard deviation genetically higher BMI was associated with a 4.89 (95% CI 1.46-16.32) higher odds of PCOS. Conversely, genetic risk of PCOS did not influence BMI. Sensitivity analyses yielded directionally consistent results. The genetic risk score of 92 BMI SNPs was associated with the diagnosis of PCOS (OR 1.043, 95% CI 1.009-1.078, P = 0.012). Of the 92 BMI risk variants evaluated, none were associated individually with PCOS after considering multiple testing. The association of FTO SNP rs1421085 with BMI was stronger in women with PCOS (β = 0.071, P = 0.0006) than in controls (β = 0.046, P = 0.065).

LIMITATIONS, REASONS FOR CAUTION

The current sample size, while providing good power for MR and genetic risk score analyses, had limited power to demonstrate association of individual SNPs with PCOS. Cases and controls were not matched for age; however, this was mitigated by adjusting analyses for age. Dietary and lifestyle data, which could have been used to explore the greater association of the FTO SNP with BMI in women with PCOS, was not available.

WIDER IMPLICATIONS OF THE FINDINGS

Increasing BMI appears to be causal for PCOS but having PCOS does not appear to affect BMI. This study used the most comprehensive set of SNPs for BMI currently available. Prior studies using fewer SNPs had yielded conflicting results and may have been confounded because cases and controls were not matched for weight categories. The current results highlight the potential utility of weight management in the prevention and treatment of PCOS.

STUDY FUNDING/COMPETING INTEREST(S)

National Institutes of Health Grants R01-HD29364 and K24-HD01346 (to R.A.), Grant R01-DK79888 (to M.O.G.), Grant U54-HD034449 (to R.S.L.), Grant U19-HL069757 (to R.M.K.). The funders had no influence on the data collection, analyses or conclusions of the study. No conflict of interests to declare.

TRIAL REGISTRATION NUMBER

N/A.

Association between major dietary patterns and polycystic ovary syndrome: evidence from a case-control study

Polycystic ovary syndrome (PCOS) is a multifactorial endocrine disorder in women. Change in lifestyle, especially dietary pattern, might have a role in the prevalence of PCOS. The limited number of studies has made it difficult to draw any conclusion about the relationship of dietary patterns with PCOS. This study aimed to investigate the association between dietary patterns and PCOS. A case-control study was performed on 225 patients newly diagnosed with PCOS and 345 healthy women in Isfahan, Iran. The presence of PCOS was confirmed by expert gynecologists based on Rotterdam criteria. Usual dietary intake was assessed by a 168-item food frequency questionnaire. Dietary patterns were identified by principal component analysis. Three major dietary patterns including Western, plant-based, and mixed were identified that explained 53.93% of the variance in food intake. The top tertile of the Western dietary pattern significantly increased the odds of PCOS (odds ratio (OR), 2.03; 95% confidence interval (CI), 1.12–3.67), both before and after adjustments for covariates. After adjustments for potential confounders, the highest tertile of the plant-based dietary pattern was related to higher odds of PCOS than the lowest tertile (OR, 2.32; 95% CI, 1.23–4.37). In addition, those in the second tertile of the mixed dietary pattern were 66% less likely to have PCOS compared with those in the lowest tertile (OR, 0.34; 95% CI, 0.18–0.61). In conclusion, we found that Western and plant-based dietary patterns were associated with an increased risk of PCOS. Also, moderate adherence to the mixed dietary pattern was associated with a reduced risk of PCOS. Additional studies with a longitudinal design are required to confirm our findings.

The role of a pulse-based diet on infertility measures and metabolic syndrome risk: protocol of a randomized clinical trial in women with polycystic ovary syndrome

Background

Polycystic Ovary Syndrome (PCOS) is an endocrine disorder in women of reproductive age with an estimated prevalence of 5–20% of premenopausal women. The clinical symptoms common to PCOS include menstrual dysfunction, hyperandrogenemia, hirsutism, polycystic ovaries, insulin resistance, and hyperinsulinemia. Women with PCOS are at an increased risk of infertility, obesity and type 2 diabetes mellitus. Insulin resistance and hyperinsulinemia are believed to be key contributing factors to the pathogenesis of PCOS; excessive amounts of insulin are directly associated with the increased ovarian production of androgens and metabolic features of PCOS. Pulse-based diets (e.g., beans, chickpeas) are associated with improved glycemic control and have insulin lowering effects. The purpose of this study is to determine whether a pulse-based diet is more effective than the diet recommended by the National Cholesterol Education Program. The primary outcomes of this study are disease measures related to PCOS, with secondary outcomes including measures related to metabolic syndrome.

Methods

Women with symptoms of PCOS will be recruited for the study and a diagnosis of PCOS will be determined by an obstetrician-gynecologist. Women with PCOS will be randomly assigned to receive either a pulse-based diet or the National Cholesterol Education Program therapeutic lifestyle changes (TLC) diet for 16 weeks while participating in an aerobic exercise program. One hundred participants will be required (drop-out rate of 32%) for recruitment to provide 80% power for detecting a significant difference in fasting glucose (p < 0.05). Measures related to infertility, metabolic syndrome, quality of life, dietary intake and physical activity will be assessed pre- and post-intervention with follow up assessment at 6- and 12-months post-intervention.

Discussion

Polycystic ovary syndrome is the most common endocrine disorder in women of reproductive age and there is currently no recommended diet for this population of women. The multidisciplinary nature of this study, including determination of measures related to metabolic syndrome, infertility and physical activity provide a comprehensive assessment of any benefits associated with a pulse-based diet in women with PCOS. The results of this study will help in providing evidence-based recommendations for the optimum diet to reduce symptoms associated with PCOS.

Trial registration

NCT01288638. Trial registered January 13, 2011.

Dietary fat intake and reproductive hormone concentrations and ovulation in regularly menstruating women

BACKGROUND

Emerging evidence suggests potential links between some dietary fatty acids and improved fertility, because specific fatty acids may affect prostaglandin synthesis and steroidogenesis.

OBJECTIVE

The objective of this exploratory study was to evaluate associations between total and specific types of dietary fat intake and 1) hormone concentrations and 2) the risk of sporadic anovulation in a cohort of 259 regularly menstruating women in the BioCycle Study.

DESIGN

Endogenous reproductive hormones were measured up to 8 times/cycle for up to 2 cycles, with visits scheduled with the use of fertility monitors. Dietary intake was assessed with up to four 24-h recalls/cycle. Linear mixed models and generalized linear models were used to evaluate the associations between dietary fatty acids and both reproductive hormone concentrations and ovulatory status. All models were adjusted for total energy intake, age, body mass index, and race.

RESULTS

Relative to the lowest levels of percentage of energy from total fat, the highest tertile was associated with increased total and free testosterone concentrations (total: percentage change of 4.0%; 95% CI: 0.7%, 7.3%; free: percentage change of 4.1%; 95% CI: 0.5%, 7.7%). In particular, the percentage of energy from polyunsaturated fatty acids (PUFAs) in the highest tertile was associated with increases in total and free testosterone (total: percentage change of 3.7%; 95% CI: 0.6%, 6.8%; free: percentage change of 4.0%; 95% CI: 0.5%, 7.5%). The PUFA docosapentaenoic acid (22:5n-3) was not significantly associated with testosterone concentrations (P-trend = 0.86 in energy substitution models) but was associated with increased progesterone and a reduced risk of anovulation (highest tertile compared with the lowest tertile: RR: 0.42; 95% CI: 0.18, 0.95). Fat intakes were not associated with other reproductive hormone concentrations.

CONCLUSIONS

These results indicate that total fat intake, and PUFA intake in particular, is associated with very small increases in testosterone concentrations in healthy women and that increased docosapentaenoic acid was associated with a lower risk of anovulation.

Polycystic ovarian syndrome (PCOS), related symptoms/sequelae, and breast cancer risk in a population-based case-control study

PURPOSE

Despite the overlap between the clinical symptoms/sequelae of polycystic ovarian syndrome (PCOS) and many known reproductive risk factors for breast cancer, the relationship between PCOS and breast cancer remains unclear, possibly because of the complex heterogeneity and challenges in diagnosing PCOS over time. We hypothesized that PCOS, specific PCOS-related symptoms/sequelae, or clusters of PCOS-related symptoms/sequelae may be differentially associated with pre- versus postmenopausal breast cancer risk.

MATERIALS AND METHODS

Cases were 1,508 women newly diagnosed with a first primary in situ or invasive breast, and the 1,556 population-based controls were frequency-matched by age.

RESULTS

History of physician-diagnosed PCOS was reported by 2.2 % (n = 67), among whom oral contraceptive (OC) use, irregular menstruation, and infertility due to ovulatory dysfunction were common. Using unconditional logistic regression, adjusted odds ratios (95 % CI) for PCOS were increased for premenopausal [2.74 (1.13, 6.63)], but not postmenopausal breast cancer [0.87 (0.44, 1.71)]. We used cluster analysis to investigate whether risk among all women varied by PCOS-related symptoms/sequelae, such as reproductive irregularities, OC use, and components of insulin resistance. In the cluster analysis, odds ratios were elevated among premenopausal women who had a history of OC use and no ovulatory dysfunction [1.39 (1.03, 1.88)], compared to those with fewer number of PCOS-related symptoms/sequelae.

CONCLUSION

PCOS and associated PCOS-related symptoms/sequelae including OC use may play a role in the development of premenopausal breast cancer. Our findings require confirmation in studies with a larger number of premenopausal women with systematically applied diagnostic criteria for PCOS.