PCOS and Diabetes, What to Know

Polycystic ovary syndrome (PCOS) is a hormone disorder that is closely linked to diabetes.

PCOS affects up to 1 in 10 women of reproductive years, and it carries several symptoms that can affect fertility.

This article will provide an overview of what PCOS is, how it connects to diabetes, and what can be done to reduce risks.

What is PCOS?

PCOS is a complex condition that is characterized by an abnormally high level of male sex hormones, known as androgens.

All women have a small number of androgens, but when they become too high, they can disrupt the hormone balance of the body, especially the reproductive system.

Women with PCOS may also have cysts on their ovaries (hence the name polycystic ovary syndrome), but this is not always present.

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How is PCOS diagnosed?

PCOS can be challenging to diagnose because there isn’t a single test or sign that confirms the condition.

Instead, doctors take a careful clinical history, perform a physical exam, check for androgen levels in the blood, and may look for the presence of polycystic ovaries on ultrasound. Questions such as menstrual history and weight gain will usually be asked as well.

Typically, if any two of the following factors are present, the diagnosis of PCOS is confirmed:

  • Evidence of excessive androgens

  • Reduced menstrual periods (oligomenorrhea)

  • Polycystic kidneys

What are the Symptoms of PCOS?

The symptoms of PCOS are thought to be primarily caused by the excessive amount of androgens. They include the following:

  • Increase in body hair, especially on the face, legs, and chest (hirsutism)

  • Hair thinning on the head (male-pattern hair loss)

  • Reduced menstrual periods

  • Changes to ovulation and anovulation

  • Weight gain

  • Acne

  • Infertility

  • Pain in the groin region

What causes PCOS?

Experts are not exactly sure what causes PCOS, but it seems to carry a number of specific risk factors:

  • Genetics. Researchers know that genes play a role in why some people get PCOS while others don’t. If a family member has PCOS, there is a higher risk of developing the condition.

  • Environmental factors. Some evidence suggests that exposure to certain toxins such as BPA may be a risk factor for developing PCOS.

  • Insulin resistance. Most women with PCOS have some level of insulin resistance, which is when the body is not able to use its own insulin effectively. Insulin resistance leads to excessive insulin production as the body attempts to normalize blood sugar levels. High insulin, in turn, can contribute to higher androgen levels.

Insulin Resistance – The Link Between PCOS and Diabetes

Insulin resistance is a significant risk factor that links PCOS to diabetes. Insulin is a hormone produced by the pancreas. Its primary function is to control blood glucose (blood sugar) by ferrying glucose into cells to be used for energy.

Insulin resistance occurs when insulin is produced as usual but does not work correctly. In addition to contributing to PCOS, insulin resistance is a hallmark sign of type 2 diabetes. Initially, blood sugars remain normal even in an insulin-resistant state because the pancreas compensates by releasing more insulin.

As stated above, this additional insulin is thought to stimulate androgen production and lead to the clinical manifestations of PCOS.

Eventually, the pancreas burns out and can no longer keep up with insulin demands.

As the dual issues of diminishing insulin production and insulin resistance worsen, blood glucose begins to rise to unsafe levels. This can first be diagnosed as prediabetes – a state where blood sugars are higher than normal, but not yet high enough to be diagnosed as diabetes. If left unchecked, prediabetes will then progress into type 2 diabetes.

This is why over half of women with PCOS go on to develop type 2 diabetes.

What causes Insulin Resistance?

Insulin resistance is closely linked to obesity. Most people with PCOS and type 2 diabetes are overweight or obese. Does this mean that obesity causes PCOS? Not exactly.

The connection is complex as most women with obesity do not go on to develop PCOS. It also is unclear if obesity is a risk factor for PCOS, a consequence of PCOS, or a little of both.

Nevertheless, obesity clearly contributes to insulin resistance and will exacerbate PCOS. Obesity is also one of the primary modifiable risk factors for developing prediabetes or diabetes, which makes it an important target to prevent these issues.

Researchers believe that additional fat tissue can cause a low-grade inflammation that disrupts various signaling hormones involved in insulin action.

Other Risks of PCOS

The high prevalence of diabetes in those with PCOS is undoubtedly alarming, but it is not the only risk associated with PCOS. The following are other potential issues to be aware of:

  • Metabolic syndrome. Metabolic syndrome is a collection of factors that are associated with insulin resistance. They include high waist circumference, high triglycerides, low high-density lipoprotein cholesterol (HDL), high blood pressure, and abnormal fasting glucose. Usually, only two-three of these factors are required for diagnosis. The presence of metabolic increases the chances of developing heart disease.

  • Obstructive Sleep Apnea. Another condition that is associated with both obesity and insulin resistance, obstructive sleep apnea (OSA) is the most common breathing condition in sleep. OSA can cause loud snoring, sleepiness during the day, and poor sleep at night. OSA can impact cognitive function, cardiovascular disease risk, mood, and quality of life.

  • Depression and Anxiety. Women suffering from PCOS are at a higher risk of developing depression and anxiety. This may be due to the uncomfortable side effects of the condition, infertility, or hormonal changes.

  • Endometrial Cancer. Endometrial cancer is cancer of the uterine lining. Research suggests that both obesity and hormone imbalances can contribute to this type of cancer, making PCOS a particularly strong risk factor.

How is PCOS treated?

Treatment of PCOS generally involves managing the symptoms, reducing insulin resistance, and restoring fertility. The treatment goals are highly individualized because different people have different priorities for their treatment.

For example, in some women, reducing acne and hair growth is a major concern, while others are more bothered by their lack of ovulation. Medical providers should be taking patient preference into account when developing a treatment strategy.

  • Hirsutism and Acne. Medications such as oral contraceptives and spironolactone are typically used to control hirsutism and acne. Antibiotics may also be used for acne, and there are light-based therapies available for hirsutism. These treatments may take several months before improvement is seen.

  • Infertility. One of the best methods to restore ovulation and improve fertility is weight loss. Weight loss will improve insulin resistance and thus produce positive downstream effects on PCOS. Medications such as letrozole may also be used to induce ovulation.

  • Menstrual regularity. Oral contraceptives are typically the first medication used to improve menstrual regularity. A medication usually used to treat diabetes, metformin, is also sometimes used as well.

Lifestyle Management

Since lifestyle and weight losses are a primary treatment strategy, both PCOS and diabetes, it will be a good idea to review what you can do to prevent or manage these issues.

  1. Take stock of your current diet habits. The first step in making a lifestyle change is first to identify what you are doing now. Tracking what you eat using a food journal or phone app is an excellent way to identify areas for improvement. Tracking also helps to stay mindful and turn off the “auto-pilot” when it comes to eating behaviors.

  2. Create a calorie deficit of about 500 per day. Reducing calories from your baseline by 500 will cause a weight loss of about 1 pound per week. This is a good rate to target. Using your tracking method from step 1, find out where your calories are coming from.

  3. Do not drink your calories. Drinking juices, sports drinks, or sodas are easy ways to go over your calorie budget and will also supply large amounts of sugar. Water is the best choice, but unsweetened teas, seltzer waters, and sugar-free drinks are other alternatives.

  4. Prepare most of your meals at home. Restaurant foods are almost always higher in fat and calories when compared to foods eaten in the house, and people tend to eat more when eating out as well. Getting in the habit of meal-planning takes some practice.

    Find a few recipes that look good to you and start a grocery list. Start with dinner meals, and use the leftovers for lunch. Breakfast can usually be something easy to grab and go, such as yogurt or fruit. When time is short, use simple sandwiches with eggs, tuna, turkey, or chicken breast in a pinch.

  5. Watch the snacking. It is common for people to snack at night while watching TV or engaging in another mindless activity. The issue with this is that we often lose track of how much we are eating.

    To reduce problematic snacking, first, ask yourself if you are truly hungry or if you are fulfilling another need such as boredom or stress. If it’s not hunger, try to find another activity such as listening to music or going for a walk instead. If hunger does strike, try a healthy snack that is pre-portioned such as light popcorn, yogurt, fruit, carrots with hummus, or a mozzarella cheese stick.

  6. Follow the plate method for portion control. You can use any standard plate to help you keep track of portions. Half of the plate should consist of non-starchy vegetables such as greens, carrots, tomatoes, and cauliflower.

    One-quarter of the plate should include a lean protein such as chicken, turkey, fish, eggs, or tofu. The last quarter of the plate can consist of starchy foods like rice, corn, beans, pasta, and bread. The plate method is designed to be roughly 500-600 calories a meal, which should fit into most meal plans.

  7. Move your body. You should aim to be physically active for at least 30 minutes a day, but any activity is better than nothing. Try taking the stairs instead of the elevator, parking farther away, going for walks, attending a fitness class, or using a home exercise video. Include strength exercises two times per week.

  8. Pick one or two areas to start working on. Trying to change too much at once usually doesn’t work out well and can lead to burning out. Start with a few simple changes that feel realistic. Once these changes become part of your regular lifestyle, you can add additional goals.

The strategies above will go a long way in helping to reverse insulin resistance and improve blood glucose. Skip the fad diets and quick fixes and make it a lifestyle change!

Conclusion

PCOS is a condition caused by insulin resistance and excessive androgen production that affects pre-menopausal women.

It can cause infertility and many other unwanted side-effects. PCOS and diabetes are closely related because insulin resistance and obesity are major risk factors for both conditions.

Lifestyle management, such as losing a modest amount of weight and being physically active, is the first-line management strategy for PCOS, but other treatments are available.

Sources

1. Corbould, A. (2008, October). Effects of androgens on insulin action in women: is androgen excess a component of female metabolic syndrome? Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/18615851.Endometrial Cancer Early Detection,
2. Diagnosis, and Staging. (n.d.). Retrieved from https://www.cancer.org/cancer/endometrial-cancer/detection-diagnosis-staging.html.Huang, P. L. (2009). A comprehensive definition for metabolic syndrome. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2675814/.
3. Merkin, S. S., Phy, J. L., Sites, C. K., & Yang, D. (2016, July). Environmental determinants of polycystic ovary syndrome. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/27240194.
4. PCOS (Polycystic Ovary Syndrome) and Diabetes. (2019, August 12). Retrieved from https://www.cdc.gov/diabetes/basics/pcos.html.Sam, S. (2007, April).
5. Obesity and Polycystic Ovary Syndrome. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2861983/.Vgontzas, A. N., Legro, R. S., Bixler, E. O., Grayev, A., Kales, A., & Chrousos, G. P. (2001, February).
6. Polycystic ovary syndrome is associated with obstructive sleep apnea and daytime sleepiness: role of insulin resistance. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/11158002.
7. Williams, T., Mortada, R., & Porter, S. (2016, July 15). Diagnosis and Treatment of Polycystic Ovary Syndrome. Retrieved from https://www.aafp.org/afp/2016/0715/p106.html.
8. Ye J. Mechanisms of insulin resistance in obesity. Front Med. 2013;7(1):14–24. doi:10.1007/s11684-013-0262-6

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Michael Fornaris

Michael is a registered dietitian and diabetes educator currently working in outpatient nutrition counseling for a large hospital system. He specializes in weight management, diabetes control, prediabetes, and metabolic syndrome.

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