Recognition and Treatment Approaches

Angela Grassi MS, RD

Sara was a 17-year-old who had difficulties managing her weight since entering puberty at an early age. She seemed to crave carbohydrates “all the time,” even after eating dinner, and she complained that her weight had been increasing at a rate of 1 to 2 pounds per month over the past year. Sara had recently seen a dermatologist for acne on her chin; previously she had no acne problem. She also had recently visited her primary care physician (PCP) for dizziness, feeling shaky, and irregular menses. Her PCP started her on a birth control pill to regulate her periods and diagnosed Sara with hypoglycemia, encouraging her to follow a South Beach-type diet to control her blood sugar and help her lose weight. Nine years later, at age 26, Sara saw an endocrinologist because she could not lose weight, despite her efforts, and because she was experiencing severe hypoglycemia and had elevated serum triglycerides. Sara was diagnosed with polycystic ovarian syndrome.

Polycystic ovary syndrome (PCOS) is an endocrine disorder affecting 5% to10% of women of reproductive age.1 First recognized in 1935 by Stein and Leventhol for its relationship to menstrual disturbances, PCOS is characterized by high levels of androgens (male hormones such as testosterone) from the ovary and it is associated with insulin resistance. Tiny cysts (“poly cysts”) usually, but not always, surround the ovaries and appear as a strand of pearls on ultrasound. The cysts are actually a result of hormonal imbalances, rather than the cause of them.

Additional consequences of an overproduction of androgens in females include excessive hair growth on the face and body (hirsutism), alopecia, acne, skin problems, and irregular or absent periods. Women with PCOS who are insulin resistant—the majority of cases—will experience weight gain in the abdominal area, difficulties losing weight, intense cravings for carbohydrates, and hypoglycemic episodes.

Many of these symptoms are common conditions “normally” experienced during adolescence and can easily be overlooked. In fact, due to these wide-ranging symptoms and because not every woman may recognize them, PCOS can be very difficult to diagnose. Dietitians, who have a unique role in developing ongoing relationships with their adolescent patients, may be able to help connect the pieces of the puzzle by recognizing the signs and symptoms (Table 1) that patients experience and encouraging further diagnostic testing.

Table 1.
Signs, Symptoms, and Factors Suggestive of Polycystic Ovary Syndrome (PCOS)

• Family history of PCOS (especially mother, sister, or grandmother)
• Excessive abdominal weight (waist hip ratio >35 inches)
• Difficulty losing weight despite diet and exercise
• Heavy, irregular (>40 days or frequent bleeding) or absent menses
• Intense carbohydrate cravings
• Hypoglycemic episodes
• Problems with excessive hair growth on face
• Hair loss from head

What Causes PCOS?

The etiology of PCOS remains unknown, although much research has been directed at finding out why it develops. There appears to be a strong genetic component.2 Investigators have noted polycystic-appearing ovaries in young girls prior to puberty, and have postulated that some girls are born with polycystic ovaries.3 Some theories suggest that women may develop PCOS from exposure to high androgen levels in the womb.2,4

Importance of Early Recognition and Treatment

Because PCOS is linked to the development of chronic diseases (eg, type 2 diabetes, heart disease, hypertension, endometrial cancer) later in life, recognition and treatment during adolescence is critical to prevent these conditions. Furthermore, since most adult women with PCOS are not diagnosed until after seeking help for infertility, they experience financial and emotional hardships that could have been avoided if PCOS had been detected earlier in life.

Just as important, many of the signs and symptoms of PCOS can be detrimental to a young woman’s body image. The most notable of these are weight gain, excessive facial and body hair, “dirty-looking” patches on skin (acanthosis nigricans, a clinical marker of hyperinsulinemia), and acne. Such clinical features can have a significant impact on the emotional health of an adolescent at a time when self-image is developing. Depression is common among adolescent girls with PCOS, 5, 6 either due to hormonal imbalances or struggles with body image. Moreover, attempts at weight loss can lead to distorted eating practices or eating disorders.

Diagnosing PCOS

According to current consensus, diagnosis of PCOS is made if two of the following three criteria are present:

1. Oligomenorrhea (period intervals of > 40 days) or amenorrhea
2. Clinical and/or biochemical signs of hyperandrogenism.
3. Polycystic ovaries on an ultrasound, with exclusion of other causes.7

Insight into the possibility of a patient having undiagnosed PCOS can be obtained by posing a few questions (Table 2). Sometimes simply asking a patient if she was ever told that she had abnormal lab results can uncover possible signs of PCOS. I once saw a 15 year-old whom I suspected had PCOS because of her struggles with weight, acne, and irregular periods. When I asked her this question, she revealed she had once been told, prior to receiving birth control pills to regulate her periods, that she had high testosterone levels, but she had never been diagnosed with PCOS.

Table 2.
Questions To Ask Patients with Suspected Polycystic Ovary Syndrome (PCOS)

• “Tell me what your periods are like. Are they heavy, irregular, etc.?”
• “Do you ever feel lightheaded, dizzy, or irritable—and do these get better when you eat?”
• “Have you ever been told by your doctor or healthcare provider that you have any abnormal lab values (test results)?”
• “Do you struggle with excessive facial hair?”
• “What types of foods do you crave and when do you crave them?
• “Do you have dry/rough elbows or any dark patches that look dirty on your body?”

Laboratory tests commonly ordered by physicians to aid in the detection of PCOS are shown in Table 3.

Treatment of PCOS in Adolescents
Symptoms of PCOS in adolescence can be alleviated with diet, exercise, and insulin-lowering medications such as metformin and/or rosiglitazone. 8 Oral contraceptives may be used to restore and regulate menstrual function and hormone levels as well as decrease acne and hirsutism.5 Androgen-lowering medications such as spironolactone or flutamide may also be prescribed.5
The main goals of treatment for an adolescent with PCOS are to regulate menstrual function, reduce androgen and insulin levels, and improve dermatologic symptoms. Often, as insulin levels are reduced, androgen levels are also lowered and menses may become more regulated. Evidence suggests that a moderate weight loss (5% to 7% of total body weight) may significantly improve symptoms and regulate menstrual function.5, 9

Table 3.
Diagnostic Studies Used To Test for Polycystic Ovary Syndrome (PCOS)

• LH (luteinizing hormone)
• FSH (follicle-stimulating hormone)
• DHEAS (dihydroepiandrostenedione sulfate)
• Total and free testosterone
• Fasting glucose
• Fasting insulin (usually part of oral glucose tolerance test)
• HA1c (glycosylated hemoglobin)
• Transvaginal pelvic ultrasound

Dietary Management

Studies are lacking on the proper diet recommendations for adolescents with PCOS, and the ones that are available are conflicting. Some practitioners suggest following a low-carbohydrate diet, while others suggest a low-gylcemic index (GI) diet to manage
insulin levels.9

Dietitians who work with this population have reported that women with PCOS tend to crave carbohydrates, perhaps to a greater extent than women without PCOS.10 Therefore, some adolescents may find that severely limiting intake of carbohydrates is too difficult, and this could contribute to binge eating and weight gain in the long term.

The majority of evidence suggests that the most beneficial diet for adolescents with PCOS is a low-saturated fat and high-fiber diet, with predominantly low-GI carbohydrates.9 The importance of eating often (every 3 to 4 hours) and including protein with meals and snacks to help manage blood sugar levels and prevent hypoglycemia needs to be stressed to the adolescent who tends to skip meals, as the majority of adolescents do.

Physical activity should be encouraged, since it can help bring down insulin levels and manage weight. In making recommendations for physical activity, the adolescent’s struggle with body image and possible resistance to exercise should be kept in mind. In addition, it is important to recommend activities that are appropriate and comfortable to perform for a patient with excess abdominal weight.

Use of Dietary Supplementation in Treating PCOS

–Chromium picolinate. Although still not conclusive, supplementation of chromium picolinate may be effective in lowering glucose and insulin levels in people with diabetes and insulin resistance. A small study involving three women with PCOS and insulin resistance demonstrated encouraging results with chromium supplementation. These women took 1,000 mcg chromium picolinate for
two months, at which time their ability to dispose of glucose improved by 29.5%.11
–Cinnamon. One study demonstrated that intake of 1 to 6 g cinnamon daily for at least 40 days reduced serum glucose, triglyceride, low-density lipoprotein (LDL) cholesterol, and total cholesterol levels in people with type 2 diabetes, suggesting a possible
benefit for people with hyperinsulinemia. 12 Cinnamon can be sprinkled on cereal, peanut butter sandwiches, oatmeal, and other foods.
–Omega-3 fatty acids. Known for their role in treating mood disorders and depression,13 omega-3 fatty acids—including alpha-linolenic acid (ALA), eicosapentanoic acid (EPA), and docosahexanoic acid (DHA)— may also be used with PCOS to reduce insulin and triglyceride levels and aid in regulating hormone levels. 14 Adolescent patients should be advised on ways to incorporate foods
rich in all forms of omega-3 fatty acids into their diet by including fatty types of fish or fish oil supplements, nuts, flax, and olive and canola oil.

Summary

Polycystic ovary syndrome is a complicated endocrine disorder that often goes undiagnosed. Adolescents with PCOS experience many symptoms that can have a significant and long-term impact on their self-esteem and body image, and they are at a higher
risk for the development of an eating disorder.6,15 They are also at risk for chronic diseases and infertility later in life, so early recognition and treatment is important.

Dietitians should screen adolescents they suspect of having PCOS and recommend further diagnostic testing with the patient’s physician, as well as recommend proper dietary management once diagnosed.

References
1. Azziz R, Woods KS, Reyna R, et al. The prevalence and features of polycystic ovary syndrome in an unselected population. J Clin Endocrinol Metab. 2004;89:2745-2749.
2. Xita N, Tsatsoulis A. Fetal programming of polycystic ovary syndrome by androgen excess: evidence from experimental, clinical, and genetic association studies. J Clin Endocrinol Metab. 2006;91:1660-1666.
3. Bridges NA, Cooke A, Healy MJ, et al. Standards for ovarian volume in childhood and puberty. Fertil Steril. 1993;60:456-460.
4. Abbott DH, Barnett DK, Bruns CM, et al. Androgen excess fetal programming of female reproduction: a developmental
etiology for polycystic ovary syndrome? Human Reproduction Update. 2005;11:357-374.
5. Salmi D, Zisser H, Jovanovic L. Screening for and treatment of polycystic ovary syndrome in teenagers. Exp Biol Med. 2004;229:469-477.
6. Himelein MJ, Thatcher S. Depression and body image among women with polycystic ovary syndrome. J Health Psych. 2006;11:613-625.
7. Pfeifer S. Polycystic ovary syndrome in adolescent girls. Seminars in Ped Surgery. 2005;14:111-117.
8. Kolodziejezyk B, et al. Metformin therapy decreases hyperandrogenism and hyperinsulinemia in women with polycystic ovary syndrome. Fertil Steri. 2000;73:1149-1154.
9. Marsh K, Brand-Miller J. The optimal diet for women with polycystic ovary syndrome. Brit J of Nutr. 2005;94:154-165.
10. Omichinski L. Polycystic Ovary Syndrome: An Open Door for Dietetics Professionals (seminar). Food and Nutrition Conference,
Denver, Colo; 2000.
11. Lydic ML, McNurlan M, Komaroff E, et al. Effects of chromium supplementation on insulin sensitivity and reproductive function in polycystic ovarian syndrome: A pilot study. Fertility and Sterility. 2003;80:45-46(abstract).
12. Khan A, Safdar M, Khan MMA, et al. Cinnamon improves glucose and lipids of people with type 2 diabetes. Diabetes Care. 2003;26:3215-3218.
13. Parker G, Gibson NA, Brotchie H, et al. Omega-3 fatty acids and mood disorders. Amer J Psych. 2006;163:969- 980.
14. Bhathena SJ. Relationship between fatty acids and the endocrine system. Biofactors. 2000;13:35-39.
15. Jahanfar S, Eden JA, Nguyent TV. Bulimia nervosa and polycystic ovary syndrome. Gynecol Endocrinol. 1995;9:113-117.

Angela Grassi, MS, RD, is a speaker, author, and consultant in Haverford, Pa. She specializes in polycystic ovary syndrome and eating disorders, and is currently working on her second book, The PCOS Workbook.

Website: www.pcosnutrition.com
Email agrassi@pcosnutrition.com

Reproduced with permission