PCOD (POLYCYSTIC OVARY SYNDROME)

BASIC CONCEPT OF OVULATION

Pituary gland

FSH , LH harmones are released which moves to ovary for giving the signal to get mature

Immature eggs get matured and size increases

 Estrogen releases in blood due to mature eggs and at certain level , eggs are released.
(Ovulation occurs)

WHERE THE PROBLEM ARISES?

If eggs are not matured (as they don’t get signal from pituary)

Fluid filled sac increases insulin and LH harmone (elevated LH to FSH ratio of 3:1. is enough to
disrupt ovulation)

Increased insulin lead to increase in testosterone level and thus ovulation is prevented.
Progesterone level also goes down due to lack of formation of corpus luteum and lead to
many problems (thus for pcos treatment progestin tablets are given )

HARMONES RELATED TO PCOD

Estrogen: Estrogen is the female hormone that is secreted mainly by the ovaries and in small
quantities by the adrenal glands. The most active estrogen in the body is called estradiol. A
sufficient amount of estrogen is needed to work with progesterone to promote menstruation.
Most women with PCOS are surprised to find that their estrogen levels fall within the normal
range (about 25-75 pg/ml). This may be due to the fact that the high levels of insulin and
testosterone found in women with PCOS are sometimes converted to estrogen.

Estrogen dominance can cause many problems thus high estrogen level should be monitored.

Progesterone: Its decreament is the major issue in impairing hormonal balance. Progesterone
is produced by the corpus luteum after ovulation occurs. Progesterone helps to prepare the
uterine lining for pregnancy. For women with PCOS, especially those who are trying to become
pregnant using fertility medications, Progesterone levels are checked about 7 days after it is
thought that ovulation occurred. If the Progesterone level is high (usually greater than 14
ng/ml) this means that ovulation did indeed occur and the egg was released from the ovary. If
the progesterone level is low the egg was probably not released.
Testosterone: All women have testosterone in their bodies. There are two methods to
measure testosterone levels:

 Total Testosterone
 Free Testosterone

Total testosterone refers to the total amount of all testosterone, including the free
testosterone, in your body. The range for this is 6.0-86 ng/dl. Free testosterone refers to the
amount of testosterone that is unbound and actually active in your body. This amount usually
ranges from 0.7-3.6 pg/ml. Women with PCOS often have an increased level of both total
testosterone and free testosterone. Furthermore, even a slight increase in testosterone in a
woman’s body can suppress normal menstruation and ovulation.

Lutenizing Hormone (LH) and Follicle Stimulating Hormone (FSH): LH and FSH are the
hormones that encourage ovulation. Both LH and FSH are secreted by the pituitary gland in the
brain. At the beginning of the cycle, LH and FSH levels usually range between about 5-20
mlU/ml. Most women have about equal amounts of LH and FSH during the early part of their
cycle. However, there is a LH surge in which the amount of LH increases to about 25-40 mlU/ml
24 hours before ovulation occurs. Once the egg is released by the ovary, the LH levels goes back
down.

It is typical for women with PCOS to have an LH level of about 18 mlU/ml and a FSH level of
about 6 mlU/ml (notice that both levels fall within the normal range of 5-20 mlU/ml). This
situation is called an elevated LH to FSH ratio or a ratio of 3:1. This change in the LH to FSH ratio
is enough to disrupt ovulation.

TREATMENT

 Metfomin and Clomiphene (Ovulatory stimulants) are the first line of drugs used for
PCOD. Birth control pill contain anti estrogen (for stopping estrogen dominance) and
high progesterone . Insulin-sensitizing agents, oral contraceptives, spironolactone, and
topical eflornithine can be used in patients with hirsutism.
 Medication used for manifestation for PCOS are for hirutism, Insulin resistance,
infertility, Menstrual irregularities.
 Progesterone rich foods –Fatty fish , Oyesters, Foods rich in vitamin B, Foods rich in
Vitamin C, Iron rich foods
  Anti estrogen foods (to stop estrogen dominance) –Flax seeds, Sesame seeds,
Mushrooms, Cruciferous vegetables (cooked form) , whole grains
 Treatment for PCOS subjects typically includes insulin-lowering drugs, anti-androgen
therapy, oral contraceptives, and the implementation of lifestyle changes, including
weight loss if necessary.
 High insulin cause more fat deposition in PCOD
 Low glycemic index food should be the first choice
 To handle insulin level , diet similar to diabetic can handle.

 In a research 2013, Metformin versus chromium picolinate in clomiphene citrate-

resistant patients with PCOS: A double-blind randomized clinical trial, it was concluded
that chromium picolinate decreased FBS and insulin levels and, thus, increased insulin
sensitivity in clomiphen citrate-resistance PCOS women. However, chromium picolinate
treatment was not associated with any other effects on other hormonal profiles,
including testosterone. These effects were comparable with metformin; however,
metformin treatment was associated with decreased hyperandrogenism. Overall,
chromium picolinate was better tolerated than metformin; nevertheless, no significant
differences were observed between the two groups regarding ovulation and pregnancy
rates.

NUTRITION TREATMENT FOR POLYCYSTIC OVARY SYNDROME (FROM KRAUSE BOOK)

 Obesity – Intitute weight management program of diet and exercise

 Insulin resistance –Restric refined carbohydrates (low glycemic index food) and total
calories, increase high fibre foods, recommend small and frequent meals , monitor
carefully to ascertain benefit from high versus low carbohydrate diet, consider
supplementation with chromium picolinate
 Low serum 25 hydroxy vitamin D - Administer vitamin D3
 Clomiphene citrate resistant infertility – Use short term NAC as adjunct
 Clinical evidence of hypothyroidism – Institute thyroid harmone replacement . Use
foods or supplements with selenium and iodine
GREEN TEA RELATED RESEARCH IN PCOS

 According to 2017 research, Effect of green tea on metabolic and hormonal aspect of
polycystic ovarian syndrome in overweight and obese women suffering from polycystic
ovarian syndrome: A clinical trial, it was found that the consumption of green tea by
overweight and obese women suffering from PCOS leads to weight loss, a decrease in
fasting insulin, and a decrease in the level of free testosterone

INOSITOL RELATED RESEARCH FOR PCOS

What causes insulin resistance so high?

 D-chiro- and myo-Inositols are major components of the two inositol phosphoglycan
mediators of insulin action.
 Myo-Ins and D-chiro-Ins have been shown to play different roles in the physiology and
treatment of PCOS . In the ovary, D-chiro-Ins is involved in insulin-mediated androgen
synthesis , whereas Myo-Ins mediates glucose uptake and follicle stimulating hormone
(FSH) signaling
 D-chiro-Ins is synthetized from Myo-Ins through the epimerase enzyme, which in turn
is stimulated by insulin . The epimerase activity is increased in the theca cells, causing
a deficit of Myo-Ins and this appears to be a critical factor in the pathogenesis of
PCOS.

There are two classes of signalling molecules derived from inositol, the P-IPGs and the A-IPGs,
and they tend to be antagonistic to each other and generally regulate body functions. The state
of insulin resistance seems to be associated with an increase of A-IPG relative to P-IPG and
supplementation of inositol is thought to normalize this ratio

Inositol usually refers to a specific stereoisomer called myo-inositol. Inositols

are pseudovitamin compounds that are falsely said to belong to the B-complex family, and are
found in most foods but in highest levels in whole grains and citrus fruits.

Myo-inositol shows the most promise as a dietary supplement for promoting female fertility,
restoring insulin sensitivity in instances of resistance (type II diabetes and polycystic ovarian
syndrome being the most well investigated), and for reducing anxiety as well. Due to the mixed
benefits to insulin resistance and fertility, myo-inositol is considered a good treatment for PCOS
in women.

In part because of its benefits to fertility and PCOS, as well as the anxiolytic effects potentially
helping symptoms of PMS (dysphoria and anxiety mostly), myo-inositol is sometimes referred
to as a general female health supplement. At times, the anti-depressant effects associated with
this supplement seem to only work in females with males having no benefit.

It is a very safe supplement to ingest, and all side-effects associated with myo-inositol are
merely mild gastrointestinal distress from high doses. High doses (usually in the 12-18 g range)
are required for any neurological effects while lower doses (2-4g) are sufficient for fertility and
insulin sensitizing effects.

 The best sources of Myo-Inositol are fruits, beans, grains, and nuts. Fresh vegetables
and fruits contain more Myo-Inositol than frozen, canned, or salt-free products.
Cantaloupe and citrus fruits(with exception of lemons) are very rich in Myo-Inositol and
oats and bran contain more than other grains. There is very little Myo-Inositol in milk
and yogurt.

RECOMMENDED DOSAGE, ACTIVE AMOUNTS, OTHER DETAILS

For the treatment of polycystic ovarian syndrome (PCOS), myo-inositol is taken in the range of
200-4,000mg once daily before breakfast; the higher dose seems to be used more often and
seems more effective.

Neurological usage of inositol tends to require higher doses, and while antidepressant effects
have been noted as low as 6g at times the standard dose is between 14-18g daily.

If using a soft gel formulation rather than powdered myo-inositol, then only 30% of the same
dose is required to be equivalent. This would mean the 14-18g range for
psychopharmacological effects is now reduced to 4.2-5.4g of myo-inositol soft gels.

ABSORPTION OF INOSITOL

Inositol is taken up into tissue via a sodium-dependent inositol co-transporter that also
mediates glucose uptake (can competitively inhibit inositol uptake) similar to D-chiro-inositol,
although myo-inositol has 10-fold greater affinity for this transporter than does D-chiro-inositol.
The application of a soft gel to inositol (a shell filled with a liquid or semi-solid fluid to remove
any dissolution rate-limiting steps) has been shown to reduce the requirements of 2-4g myo-
inositol powder down to 600-1,200mg of the myo-inositol via softgel and this 30% oral dose has
been found to be equally efficacious in a trial on women with PMS related dysphoria (12g myo-
inositol powder performing equally to 3.6g via softgels).

Different research regarding myo inositol and D-chiro inositol saying myo inositol is more
beneficial.

 According to research 2016 , Inositol Treatment and ART Outcomes in Women with
PCOS, It was concluded that myo-inositol is an insulin sensitizer which appears to have
beneficial effects on ovarian function and response to ART in women with PCOS. It
induces nuclear and cytoplasmic oocyte maturation and promotes embryo
development. In contrast, D-chiro-inositol appears to exert opposite and detrimental
effects on the ovary. While accumulating evidence suggests that myo-inositol improves
the number of mature oocytes retrieved, oocyte quality, and embryo quality in women
with PCOS undergoing ART, data on its effects on pregnancy and live birth rates in these
women is much more limited.
 According to International Journal of Endocrinology Volume 2016, Effects of Inositol(s)
in Women with PCOS: A Systematic Review of Randomized Controlled Trials, Treatment
with the combination of Myo-Ins and D-chiro-Ins has been further investigated by
Benelli et al. who demonstrated that these two molecules, together in a 40 : 1 ratio,
improved the endocrine profile and insulin resistance of obese women with PCOS

FOODS WHICH CONTAIN INOSITOL

Fruits

 Dried prunes (4.70mg/g)

 Cantaloupe (3.55mg/g)
 Orange at 3.07mg/g, it's frozen juice from concentrate (2.04mg/g) and appreciable
levels in both mandarin oranges (1.49mg/g) and nectarines (1.18mg/g)
 Grapefruit (1.99mg/g) and its juice from concentrate (3.80mg/g)
 Lime (1.94mg/g)
 Blackberry (1.73mg/g)
 Kiwi (1.36mg/g)
 Mango (0.99mg/g)
 Dark cherries (1.27mg/g)
  Pear (0.73mg/g)
 Peach (0.53mg/g)
 Apricot (0.52mg/g)
 Watermelon (0.31-0.46mg/g)
 Honeydew (0.46mg/g)
 Pineapple (0.33mg/g)
 Apple (0.24mg/g)
 Papaya (0.08mg/g)

Vegetables

 Navy beans (2.83mg/g), red kidney beans (2.49mg/g), lima (1.10mg/g) and great
northen beans (3.27-4.40mg/g)
 Rutabaga (2.52mg/g)
 Green beans (1.05-1.93mg/g), although canned products are near 0.55mg/g
 Artichoke (0.6mg/g) and the heart (1.16mg/g)
 Okra (1.17mg/g)
 Eggplant (0.84mg/g)
 Brussel sprouts (0.81mg/g)
 Cabbage (0.70mg/g)
 Asparagus (0.68mg/g)
 Spinach (0.66mg/g)
 Collard Greens (0.64mg/g)
 Bell pepper (0.57mg/g)
 Tomato (0.54mg/g)
 Avocado (0.46mg/g)
 Squash (0.32mg/g)
 Onions (0.27mg/g)
 Lettuce (0.16mg/g)
 Cucumber (0.15mg/g)
 Cauliflower (0.15mg/g)
 Mushrooms (0.09-0.29mg/g)
 Carrots (0.12mg/g)
 Beet root (0.12mg/g)

Grains

 Stone ground wheat (11.5mg/g)

 Hamburger bun (4.78mg/g) and hot dog buns (1.15mg/g)
  Bran flakes (2.74mg/g)
 Pumpernickel (1.6mg/g)
 Whole wheat (1.42mg/g) and mixed whole wheat (0.47mg/g)
 Raisin bran (1.07mg/g)
 Rye (0.39-0.47mg/g)
 Oatmeal (0.34-0.42mg/g)
 Pasta (0.31mg/g)
 Wild or brown rice (0.27-0.30mg/g) and specifically white rice (0.02-0.17mg/g)
 White bread (0.25-0.26mg/g)

Meat and Alternatives

 Beef liver (0.64mg/g)

 Ground beef (0.37mg/g)
 Sirloin steak (0.30mg/g) or round steak (0.15mg/g)
 Eggs (0.09mg/g) mostly in the yolk (0.34mg/g)
 Chicken breast (0.30mg/g) and turkey (0.08mg/g)
 Pork chops (0.42mg/g)
 Tuna (0.12-0.15mg/g)
 Sardines (0.12mg/g)
 Crab (0.05mg/g)
 Clams (0.03mg/g) and oysters (0.25mg/g)

Food products tend to contain myo-inositol more often than not, and the most prevalent food
products for this nutrient are whole grain products and citrus fruits whereas dairy and meat
products are relatively poor sources

Supplementation of inositol in the range of 200-4,000mg daily appears to be effective in

improving fertility in women with PCOS, while doses in the 2,000-4,000mg range appear
effective in improving testosterone levels and insulin sensitivity.

DRUG NUTRIENT INTERACTION FOR PCOS

 Combination of estrogen and progesterone – Vitamin B2, B3, B6, B12, Folic acid ,
Magnesium, Zinc, Selenium - causes deficiency of vitamins
 Synthetic progestin –Vitamin B2, B3, B6, B12, Folic acid, Magnesium,, Zinc, Selenium
 Glucophage and metformin – Vitamin B12, Folic acid, and Coq10
  Chromium picolinate increases insulin sensitivity thus sometimes used in pcos
treatment.

SUPPLEMENTS FOR PCOD

 Inositol
 Chromium
 Magnesium
 Omega-3 fatty acids
 Vitamin E

Two supplements found more effective than vitamin D supplemention and chromium
supplementation

Research related N Acetly Cysteine (NAC)

According to 2017 research , Comparison of metformin and N-acetylcysteine on metabolic

parameters in women with polycystic ovarian syndrome, NAC is equally efficacious as
metformin in improving parameters of insulin resistance and metabolic syndrome with minimal
occasional side effects ensuring better compliance for a long-term therapy.

According to many research done, NAC supplementation improves insulin levels,insulin

sensitivity, ovulation, and fertility in women with PCOS and it works as well as metformin.
Both treatments significantly improve insulin resistance and testosterone levels and the results
are comparable.

In women with PCOS undergoing fertility treatment, NAC significantly improves ovulation and
pregnancy rates and works as well as metformin for improving egg and embryo quality. NAC is
much safer and better tolerated than metformin, however.
 Inositol related

 There are two forms of inositol available as supplements: myo-inositol and d-chiro-
inositol. Both are capable of improving menstrual regularity and insulin resistance in
PCOS patients. D-chiro-inositol appears to be better at reducing testosterone levels,
while myo-inositol may be superior for improving metabolic abnormalities such as
insulin resistance
 According to research in 2017, The Combined therapy myo-inositol plus D-Chiro-
inositol, in a physiological ratio, reduces the cardiovascular risk by improving the lipid
profile in PCOS patients, It was concluded that relatively low doses of the two forms and
found that the low-dose combination significantly improved cholesterol, triglycerides,
and insulin resistance in women with PCOS.

DOSAGE FOR SUPPLEMENT

 The most common recommended dose of myo-inositol is 4 grams (4,000 mg) per day,
while that of d-chiro-inositol is 1 gram (1,000 mg) a day, in divided doses.
 Inositol is typically taken with folic acid (400 mcg per day).
 The recommended dose of NAC is 600 mg twice a day.

Reference

www.examine.com

Krause’s Food the Nutrition Care Process (14 th Edition 2016) by L. Kathleen Mahan