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MAEDICA – a Journal of Clinical Medicine
Mædica - a Journal of Clinical Medicine 2021; 16(3): 516-521
RReevviieeww https://doi.org/10.26574/maedica.2021.16.3.516
Dietary Patterns and
Polycystic Ovary Syndrome:
a Systematic Review
Maria XENOU, Kleanthi GOUROUNTI
Department of Midwifery, University of West Attica, Athens, Greece
ABSTRACT
Background: Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders
affecting women of reproductive age. The goal of this study was to present the suitable diet recommended by
the international literature for women with polycystic ovary syndrome to alleviate their symptoms.
Methods: A systematic search of electronic databases containing medical topics was conducted.
Results: A total number of 123 articles were retrieved and seven of them were relevant to our chosen topic
concerning the diet-related polycystic ovary syndrome. According to research, it seems that diet plays a very
important role on the clinical picture and laboratory findings of PCOS. According to the included studies,
the change in the diet of women brought positive results in terms of clinical appearance of the syndrome.
Τhis review presents the type of diet that is deemed helpful in the clinical and laboratory picture of the
syndrome.
Conclusion: In the future, more research should be conducted on a larger population with PCOS and for
a longer period of time, during which subjects would be given a specific diet. It would also be important to
compare diet to mild exercise and dietary supplementation.
Keywords: polycystic ovary syndrome, PCOS, polycystic ovaries, amenorrhea,
PCOS and nutrition, diet and PCOS, diet in women with PCOS, nutrition in women with PCOS,
dietary changes in women with PCOS, eating habits in PCOS.
BACKGROUND study, diagnostic criteria include: a) hyperan-
drogenism, including hypertrichosis and/or hyper-
olycystic ovary syndrome (PCOS) is one androgenemia; b) oligomenorrhea and/or poly-
of the most common endocrine disor- cystic ovary disease; and c) exclusion of other
ders affecting 6-10% of reproductive causes of androgen hypersecretion or associated
age women worldwide (1). There have disorder (2).
Pbeen many attempts to define PCOS. Polycystic ovary syndrome is characterized by
Nevertheless, even today this abnormality is not a phenotypic heterogeneity. However, some clini-
fully understood due to the complexity and hete- cal symptoms and disorders, particularly menstru-
rogeneity of the clinical picture. After a thorough al disorders, are observed in the majority of pa-
Address for correspondence:
Maria Xenou
Tel.: +30 6979515534
Email: marizaxenou@hotmail.gr
rd th
Article received on the 23 of July 2021 and accepted for publication on the 10 of September 2021
516 Maedica A Journal of Clinical Medicine, Volume 16, No. 3, 2021
Diet anD PCOS
tients. Oligo- or anovulation is among the most It should also be noted that the microbiome
important disorders, which leads to oligomenor- may have an important role in PCOS. The hy-
rhea or amenorrhea. Clinical hyperandrogenism pothesis that alterations in the microbiome are
(including hirsutism, alopecia, acne, and acantho- involved in the genesis of PCOS has been postu-
sis nigricans) and biochemical hyperandrogene- lated. Most of the surveys conducted so far have
mia, usually assessed by detecting laboratory focused on the connection between intestinal
markers of androgen growth (3), are also identi- bacteria with sex hormones and insulin-resistance
fied. In addition, obesity and infertility are ob- – a relationship with hyperandrogenism has been
served in 70-80% of women with PCOS (4). Fi- described in the first case, and chronic low-grade
nally, according to guidelines of the International inflammation by activating the immune system,
PCOS Network, the image of the ovaries is as fol- with increased production of proinflammatory cy-
3
lows: ovarian volume >10 cm and/or at least tokines (which interferes with insulin receptor
20 follicles 2-9 mm in size in at least one ovary is function, causing insulin resistance/hyperinsu-
required (5). The etiology of PCOS appears to be linemia), in the second case; also, the role of gas-
multifactorial. Causes include hypothalamic-pitu- trointestinal hormones such as Ghrelin and pep-
itary disorders, ovarian or adrenal disorders, ge- tide YY (PYY), bile acids, interleukin-22 and
netic factors, and hyperinsulinemia due to insulin Bacteroides vulgatus has been highlighted. The
resistance. lower genital tract microbiome would be affected
Often, women with PCOS have insulin resis- by changes in PCOS patients too (7).
tance – their bodies can make insulin but cannot
use it effectively, increasing their risk for type 2 Aim
diabetes. Women with PCOS, especially if they
are overweight, have a greater risk of developing The goal of the present study is to find which is
other serious health problems such as diabetes the suitable currently recommended diet in the
(more than half of women with PCOS develop literature for women with PCOS to alleviate their
type 2 diabetes by the age of 40), gestational dia- symptoms. q
betes (which puts the pregnancy and the baby at
risk and can lead to type 2 diabetes later in life for METHODS
both the mother and child), heart disease, hyper- systematic search of electronic databases
tension, high LDL-cholesterol and low HDL-cho- A containing medical literature was conducted
lesterol, sleep apnea (6). Polycystic ovary syn- (PubMed and Scopus). This review aimed to de-
drome is also linked to depression and anxiety, tect articles containing quantitative studies on
though the connection between the two condi- PCOS in relation to nutrition, which were written
tions is not fully understood (6). in English between 2011 and 2021. The selection
Polycystic ovary syndrome has a variety of criteria included prospective quantitative studies
therapeutic approaches due to heterogeneity in that used samples of women aged between 19 to
its clinical manifestation. Initially, lifestyle changes 64. The terms used to select the articles were
are suggested, including more exercise and pro-
per nutrition. These changes not only lead to “polycystic ovary syndrome”, “PCOS”, “nutri-
weight loss, reduced insulin resistance, lower inci- tion”, “diet” “no supplements”, “no exercise”.
dence of type 2 diabetes and reduced hyperan- The resulting articles were then evaluated by
drogenism, but also enhance women's fertility as their title. Articles with a title that was not com-
menstruation is restored. When pregnancy is not patible to the purpose of the systematic review
sought, the main treatments include birth control were excluded. Afterwards, abstracts of the re-
pills, progesterone, and metformin. If pregnancy maining studies were appraised, and those that
is sought and weight loss does not help ovulation, did not meet the inclusion criteria and purpose of
menstruation can be induced with clomiphene the systematic review have been also excluded.
citrate with or without metformin, aromatase in- Titles and abstracts were reviewed by two au-
hibitors, gonadotropins, and ovarian drilling. In thors. For the remaining studies, a search for their
case none of the above ways leads to pregnancy full text version was done, and finally, those that
then, the patient is encouraged to use in vitro fer- did not meet the purpose of the review were re-
tilization (5). jected. q
Maedica A Journal of Clinical Medicine, Volume 16, No. 3, 2021 517
Diet anD PCOS
FIGURE 1. Flow
diagram illustrating
the article filtering
process
RESULTS been also found. However, there was a correla-
total number of 123 articles were retrieved, tion between weight and free testosterone. Re-
A but only seven of them were relevant on searchers concluded that this diet led to an in-
diet-related polycystic ovary syndrome. creased oxidation of fasting fat after a meal in
In 2014, Pohlmeier and his colleagues (8) stu- overweight and obese women with PCOS, which
died the effect of diet on metabolic disorders of was not significantly correlated with changes in
BMI, fasting insulin, or testosterone.
PCOS. Ten obese women with this syndrome In 2015, Phy and his colleagues (9) conducted
were selected and they followed a diet for eight a prospective study to observe whether a low
weeks. Research has been done to determine if starch diet and dairy products would lead to
this low-starch and dairy diet would improve oxi- weight loss, improvement of insulin resistance
dation of fasting fat and postprandial fat after a and reduction of testosterone. Their study in-
liquid dinner of saturated fat. The diet contained volved 24 obese women with PCOS who fol-
pure animal protein, non-starchy vegetables and lowed a low starch and dairy diet for eight weeks.
fruits, nuts, seeds, and oils, red wine and full-fat Their daily diet contained pure animal protein,
cheese. The results of the study showed a de- fish and shellfish, eggs, non-starchy vegetables,
crease in fasting insulin and the two-hour insulin low-sugar fruits, avocados, olives, nuts, seeds, fats,
curve. A beneficial change in waist-buttocks ratio, red wine, fresh high fat cheese. Grains, beans,
free fat, body mass, fasting glucose or two-hour other dairy products, and sugar (concentrated
glucose curve, HbA and free testosterone has fruit juices, raw sugar, honey, agave nectar, etc)
1c
518 Maedica A Journal of Clinical Medicine, Volume 16, No. 3, 2021
Diet anD PCOS
were excluded from the diet because of their po- study involved 112 women with PCOS and
tential to raise blood sugar. Regularly eating foods 112 women as a control group who followed the
with high sugar content can overload the body’s Mediterranean diet between 2014 and 2019. Ac-
ability to produce enough insulin. After the cording to the results, women with PCOS con-
eight-week test, there was a significant reduction sumed less virgin olive oil, legumes, fish, and nuts
in all body measurements. Diet had also improved than the control group did. In addition, they con-
insulin sensitivity and total and free testosterone. sumed fewer complex carbohydrates, fiber, un-
This intervention seemed auspicious as weight saturated fatty acids, monounsaturated fatty acids,
loss in patients with PCOS was difficult. n-3 polyunsaturated fatty acids and more simple
In 2017, a survey was conducted by Szczuko carbohydrates, total fat, saturated fatty acids,
and his associates in Poland (10), in an attempt to polyunsaturated fatty acids, and n-6. In conclu-
find whether a particular diet affected the inflam- sion, there seems to be a direct correlation be-
matory factors. Thus, a three-month study was tween the adherence to the Mediterranean diet
performed on 24 women with PCOS. The re- and women with PCOS and a different body
searchers intervened in their diet that contained composition characterized by low polyhydroxyal-
five meals a day. The products used as sources of kanoates (PHAs) and no fat. These data could
carbohydrates (five portions per day) were oat- support a therapeutic role of individual foods and
meal, whole grain rye or graham bread, brown nutrients of the Mediterranean diet in PCOS,
rice, groats (wheat, millet, and buckwheat), spo- helping to reduce the inflammatory condition that
radically potatoes, and whole meal pasta. The paves the way for insulin resistance and hyperan-
carbohydrate products selected for the diets were drogenemia. In addition, PHAs are an indicator of
characterized by lowered glycemic index (GI). the clinical severity of PCOS.
The products recommended in diets as source of In 2019, in Iran, Shishehgar et al (12) conduc-
proteins (one portion of meat and two portions of ted a study to determine the effect of low-calorie
dairy products per day) included eggs, lean meat hypocaloric diet on human variables and insulin
without skin (turkey, chicken), fish, mainly sea fish resistance in women with or without PCOS as
(sole, salmon, tuna), semi-skimmed pasteurized well as the effect of this diet on clinical and hor-
milk and dairy products (2% fat quark, natural yo- monal characteristics of women with PCOS. All
ghurt, and buttermilk), nuts and seeds (almonds, participants were urged to eat lean meat, whole
pumpkin seeds, sunflower seeds, sesame seeds, grains, low-fat dairy, non-starchy vegetables, and
and poppy seeds), and legumes (soy, red lentils, vegetable oils, and were prohibited from consu-
beans, and peas). The products chosen as sources ming fast food or high-salt foods. The results of the
of fat (two portions per day on average) were raw mentioned study showed that this diet led to simi-
oils (rapeseed oil, and olive oil), oily fruits (e.g., lar benefits in the anthropometric and metabolic
avocado) as well as nuts, fish, meat, and dairy characteristics of obese women with or without
products. Fruits and vegetables with low GI were PCOS. In addition, in women with PCOS, men-
also included in diets. They were present in every strual cycles and biochemical and clinical features
meal to supplement the diet with vitamins and improved after six months. Thus, low testosterone
minerals. Patients were recommended to use levels and an increase in sex hormone binding
braising, roasting, cooking in water, and steaming globulin (SHBG) were observed in women with
as heat treatment techniques to prepare their PCOS. Decreased insulin due to weight loss and
food. The results of this research showed that reduced hyperandrogenemia were also seen.
there was no significant difference between the In 2020, Kazemi et al (13) conducted a
two phenotypes of PCOS. The three-month re- cross-sectional study to determine which dietary
duction diet facilitated the synthesis of inflamma- plan affected ovarian morphology. A survey was
tory mediators but was probably too short to as- conducted on 111 women with PCOS. Four dif-
sure the suppression of inflammatory reactions. ferent diet plans were used: 1) healthy eating in-
Two years later, in 2019, Barrea and his col- dex (HEI-2015); 2) alternative healthy eating in-
leagues conducted a cross sectional/case control dex (HEI-2010); 3) alternative Mediterranean diet
study in Italy (11). They examined whether the (aMED); and 4) dietary approaches to stop hyper-
Mediterranean diet was related to PCOS and tension. The study concluded that the aMED and
whether these women followed this regime. The DASH diets improved the appearance of the ova-
Maedica A Journal of Clinical Medicine, Volume 16, No. 3, 2021 519
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