PCOS NUTRITION CENTER BLOG

Did you hear? The newly released International evidence-based guidelines for the assessment and management of Polycystic Ovary Syndrome (PCOS) were released this week. You can download them here.

Designed to provide clear information to assist clinical decision making and support optimal patient care, these guidelines encompass the culmination of the work of over 3,000 health professionals and consumers internationally. I was fortunate to be asked to review and provide feedback on the later draft of the guidelines, before they were published.

The guidelines (all 220 pages of them!) provide recommendations based on the level of evidence available for the different aspects relating to PCOS. These categories include diagnosis, medications and treatments, lifestyle recommendations, and medical complications of the different lifecycle stages of PCOS. The original PCOS guidelines were published in 2011.

These guidelines reflect the newest advancements in PCOS research and offer more insight into better managing and treating PCOS. I appreciate the tremendous efforts of everyone involved in putting these guidelines together. They are a very thorough presentation of the results and evidence of PCOS research. Below you can find guideline highlights.

There are many recommendations I was happy to see included in these new PCOS guidelines, yet some that I feel were overlooked or not considered enough.

In addition to the highlights, here’s my take on what the new guidelines got right and wrong.

International PCOS Guideline Highlights:

• Anti-Müllerian hormone (AMH) levels are not yet adequate for diagnosis.
• Recognition that PCOS is an insulin resistant and metabolic disorder, yet tests for insulin resistance lack accuracy and should not be incorporated into the diagnostic criteria for PCOS at this time.
• Ultrasound should not be used for the diagnosis of PCOS in those with a gynecological age of < 8 years (<8 years after menarche), due to the high incidence of multi-follicular ovaries in this life stage.
• Postmenopausal persistence of PCOS could be considered likely with continuing evidence of hyperandrogenism.
• Depressive and anxiety symptoms as well as eating disorders should be screened, assessed and managed with the need for awareness of other impacts on emotional wellbeing and body image.
• Combined oral contraceptive pills are first-line pharmacological management for menstrual irregularity and hyperandrogenism.
• Letrozole is first-line infertility therapy over clomid.

What the New PCOS Guidelines Got Right

Better Screening for Diabetes

Women with PCOS are at an increased risk for type 2 diabetes and gestational diabetes in pregnancy. It has been shown that once a woman has impaired glucose tolerance or prediabetes, the conversion to type 2 diabetes happens rapidly.

Because of the increased risk for type 2 diabetes, the new guidelines recommend that all women have their glycemic status assessed at baseline (or when diagnosed). Thereafter, assessment of glycemic status should be every one to three years.

An oral glucose tolerance test (OGTT), fasting plasma glucose or HbA1c is recommended to assess glycemic status. In high-risk women with PCOS (history of impaired fasting glucose, impaired glucose tolerance or gestational diabetes, family history of type 2 diabetes or hypertension), an OGTT is recommended.

If a woman with PCOS is planning on becoming pregnant, a 75-g OGTT should be ordered. If pregnant, a 75-g OGTT should be ordered at < 20 weeks gestation (as soon as possible in pregnancy), and all women with PCOS should be offered the test again at 24-28 weeks gestation.

Screening for Mood Disorders

Health professionals and women should be aware of the adverse impact of PCOS on quality of life.

Among PCOS women, there is an increased prevalence of moderate to severe anxiety and depressive symptoms in adults and a likely increased prevalence in adolescents.

For the first time, the new PCOS guidelines recommend routinely screening all adolescents and women with PCOS for anxiety and depressive symptoms at diagnosis and referred to qualified mental health professionals.

Screening for Eating disorders

The revised PCOS guidelines encourage health professionals to recognize that features of PCOS can have a significant impact on body image.

There is an increased prevalence of eating disorders and disordered eating associated with PCOS. As such, women with PCOS should be screened for eating disorders and distorted eating and referred to eating disorder specialists.

Warning about Metformin and B12

Metformin is one of the most common medications recommended to women with PCOS, even though it is still not indicated for its use. Metformin in addition to lifestyle, is often recommended in adult women with PCOS, for the treatment of weight, hormonal and metabolic outcomes.

I was pleased to see the authors of the PCOS guidelines address the fact that metformin use may be associated with low vitamin B12 levels, suggesting the need for doctors to screen women with PCOS who take metformin for a vitamin B12 deficiency. As a reminder, I recommend all women with PCOS who take metformin must supplement their diets with vitamin B12 and get levels checked annually.

Recognition of PCOS Past Menopause

Recent evidence over the past several years has indicated that PCOS symptoms such as hirsutism, persist past menopause and that metabolic complications such as prediabetes or diabetes, worsen with age if not well managed. The guidelines recognize PCOS in later life by stating “postmenopausal persistence of PCOS could be considered likely with continuing evidence of hyperandrogenism.” At last it is validated that PCOS does not disappear once women reach menopause.

What the Guidelines Got Wrong

Recommending Birth Control as Primary Treatment

Oral contraceptives (OCPs) have long been used as a treatment for women with PCOS. Indeed, OCPs can reduce testosterone and regulate cycles, thus reducing the risk for endometrial cancer. However, as discussed in an earlier post, OCP use is not without risk, especially for young women. These risks include increased triglycerides, inflammation, and increased risk for blood clots.

If women with PCOS have increased cardiovascular risk factors like high triglycerides, low HDL, and inflammation, why recommend OCPs, which have been shown to worsen these parameters, as a primary approach? As a side note it was stated that “PCOS specific risk factors such as high BMI, hyperlipidemia and hypertension need to be considered.” Aren’t these factors present in most women?

I was disappointed then to see that OCPs alone be recommended in adult and adolescent women with PCOS for management of hyperandrogenism and/or irregular menstrual cycles. There are other ways to regulate cycles and high testosterone levels without OCPs. Ovasitol for one, is a great supplement to try.  

Overlooking Screening for Sleep Apnea

Obstructive sleep apnea (OSA) has been shown to be common among women with PCOS and sleep loss in general has been shown to contribute to numerous health issues. Treatment for OSA has been shown to improve metabolic complications like insulin resistance and high blood pressure.

I was disappointed to see the PCOS guidelines did not recommend screening for OSA with the intention of improving cardiometabolic risk, citing inadequate evidence for metabolic benefits of OSA treatment in PCOS.

Focus on Weight

An international survey of over 1,400 women with PCOS found that struggles with weight was the most common reported issue. Women with PCOS are fed up with being told to lose weight and their PCOS symptoms will get better. The reality is, lifestyle modifications, including making improvements to the food you eat, how you move your body, sleep, and manage stress can make PCOS better.

Despite this, the authors recommend that all those with PCOS should be offered regular monitoring for weight changes and excess weight. That this weight monitoring be at a minimum of every 6 to 12 months.

What the guidelines got wrong is earlier it was mentioned that professionals should be aware that body image and quality of life affects women with PCOS. They also emphasize the importance of screening for eating disorders, yet their very focus on weight contributes to the development of eating disorders.

Missed the Mark on Nutrition

Lifestyle interventions are recognized as a primary treatment to optimize hormones, general health, and quality of life. But when it comes to nutrition recommendations, here’s where the guidelines really missed the mark. That’s because NO nutrition strategies were recommended in the PCOS guidelines, just calorie restriction to promote weight loss.

So, what about thin women with PCOS? What do they do? “General healthy eating principles should be followed for all women with PCOS as per general population recommendations” is the advice given.

Couldn’t the guidelines offer more to professionals and women with PCOS when it comes to diet?

Definitely research is lacking in the area of nutrition for PCOS. There is not ONE eating plan that is better for women with PCOS than another. The guidelines state this and the evidence supports it. But “tailoring of dietary changes to food preferences, allowing for a flexible and individual approach to reducing energy intake and avoiding unduly restrictive and nutritionally unbalanced diets, are important, as per general population recommendations” isn’t helpful.

We do have evidence that antioxidant rich foods such as the ones used in DASH (Dietary approaches to stop hypertension) diets, work well for women with PCOS. Why not emphasize these foods? Or the evidence that shows low glycemic index, high-fiber foods can reduce insulin levels in PCOS, especially those with high insulin levels?

I was also surprised that their was no mention of vitamin D for PCOS in the guidelines which plays an important role in infertility.

More funding needs to be allocated for well designed PCOS nutrition studies. But couldn’t the guidelines offer more than just caloric restriction and a general balanced diets for women with PCOS? Especially when lifestyle changes are the primary treatment approach?

This is why I emphasize the need for all women with PCOS to work with a registered dietitian nutritionist who specializes in PCOS to get individual recommendations to meet their personal needs.

Weight Loss Medications Recommended

Lastly, and perhaps the one that bothers me the most, is the recommendation for anti-obesity medications. These medications are recommended as experimental therapy in women with PCOS “for the purpose of improving fertility, with risk to benefit ratios currently too uncertain to advocate this as fertility therapy.”

The research is very scant when it comes to weight loss medications for women with PCOS and the safety of these medications in pregnancy is unknown. What if a woman is taking these and gets pregnant?  What happens when women with PCOS stop these medications? From what I have seen, they regain the weight and feel bad about themselves as a result.

Despite the push for weight loss agents with lack of research, the use of inositol, with over 80 studies showing its reproductive and metabolic benefits to PCOS women, of which side effects are rare, was considered experimental.

“Inositol (in any form) should currently be considered an experimental therapy in PCOS, with emerging evidence on efficacy highlighting the need for further research.” This is where I feel the PCOS guidelines really got it wrong by overlooking the benefits of inositol which could help so many women improve their fertility and lower insulin to name a few.

Again, I appreciate all the hard work that went in to revising the new International PCOS Guidelines. Thank you to all that worked so hard on it. There have been many advancements in PCOS research over the past 5 years and the guidelines added many important parts to benefit women with PCOS and those who treat them.

It is my hope that these guidelines help more women to get properly diagnosed in a timely matter and get the appropriate care they need and deserve. Overall evidence in PCOS is lacking and is poor quality. Significant research efforts (and funding) is needed for this common overlooked condition.

Source:

International evidence-based guideline for the assessment and management of polycystic ovary syndrome. Released July 2018

Angela Grassi, MS, RDN, LDN is the founder of The PCOS Nutrition Center where she provides evidence-based nutrition information and coaching to women with PCOS. Angela is the author of several books on PCOS including PCOS: The Dietitian’s Guide, The PCOS Workbook: Your Guide to Complete Physical and Emotional Health, and The PCOS Nutrition Center Cookbook Recognized by Today’s Dietitian as one of the Top 10 Incredible Dietitian’s making a difference in 2014, Angela is the past recipient for The Outstanding Nutrition Entrepreneur Award, The Award in Excellence in Practice in Women’s Health and The Award for Excellence in Graduate Research, from the Academy of Nutrition and Dietetics. Having PCOS herself, Angela has been dedicated to advocacy, education, and research of the syndrome.