*2.1.4. Impaired glucose tolerance or type 2 diabetes mellitus*

Impaired glucose tolerance (IGT) or even type 2 diabetes mellitus (T2DM) are common in patients with PCOS with a prevalence rate of 30–40% for impaired glucose tolerance and 7.5–10% for type 2 diabetes mellitus [13, 14]. The risk of patients with PCOS to develop these pathologies is considerably higher than in healthy patients. In these cases as well obesity appears to play an important role–impaired glucose tolerance and diabetes mellitus have an increased prevalence in obese patients (31.3% IGT and 7.5% T2DM) in comparison to nonobese patients (10.3% IGT and 1.5% T2DM) suffering from PCOS.

#### *2.1.5. Cardiovascular disease*

Polycystic ovary syndrome—in spite of many years of research—is still a controversial topic. We have come to know in detail its clinical manifestations such as metabolic disorders, menstrual and ovulatory dysfunctions, and clinical hyperandrogenism. However, not knowing its etiology, most of the treatments suggested to patients with PCOS are symptomatic, not

Following numerous studies and research on PCOS and despite that the exact mechanism is not completely understood, the conclusions of most researchers are the same; lifestyle change and weight loss have beneficial effects on the entire panel of symptoms associated with this

**2.1. Management of underlying metabolic disorders, reduction of risk factors for** 

Under the metabolic disorders, which are commonly encountered in patients with PCOS, it is worth mentioning: obesity, insulin resistance, metabolic syndrome, dyslipidemia, and type

Some researchers state that the obesity rate in the case of the women with PCOS is even up to 70%, but most agree that at least half of the women with PCOS suffer from obesity

(waist circumference > 88 cm) [3]. Of the nonobese patients, one-third has increased intraabdominal fat [4]. There is no specific data on why the prevalence of obesity is much higher in women with PCOS, but most researchers attribute it to the hyperinsulinemia resulting from the insulin resistance, an important factor of adipogenesis, lipogenesis, and lipolysis

Insulin resistance and reactive hyperinsulinemia are definitely implicated in the physiopathological mechanism of PCOS. With respect to insulin resistance, some authors consider it to be uncorrelated to the degree of the obesity [6], while others argue that the obesity, especially the central one, seems to increase the metabolic and clinical features of insulin resistance [7]. Although obese patients seem to be more affected by insulin resistance, this also occurs in the

The metabolic syndrome is commonly associated with PCOS, with a prevalence ranging between 33 and 47% [9]. Both PCOS and the metabolic syndrome have features that generate an increased risk of cardiovascular diseases–if this risk is independent of PCOS or it is caused

) [2] and in most cases, it is of a central distribution

addressing to the underlying cause, but rather each symptom in part.

**2. Which are the main goals when treating PCOS?**

**type 2 diabetes and cardiovascular disease**

(body mass index (BMI) = 19–25 kg/m<sup>2</sup>

cases of nonobese patients with PCOS [8].

*2.1.2. Increased insulin resistance*

*2.1.3. Metabolic syndrome*

syndrome.

40 Debatable Topics in PCOS Patients

*2.1.1. Obesity*

2 diabetes mellitus.

inhibition [5].

It is not known exactly to what extent PCOS would be an independent risk factor for cardiovascular diseases but, unquestionably, through associated pathologies (obesity, increased resistance to insulin, IGT, T2DM, and/or dyslipidemia), it contributes to an increased risk [15].

#### **2.2. Improvement of hyperandrogenic symptoms (hirsutism, acne, scalp hair loss)**

Most experts consider that hyperandrogenism is the main characteristic of PCOS [16], whether is biochemically or clinically identified. Alteration in insulin action as well as enzymatic defaults has been discussed as possible pathogenic theories.

Studies suggest that the androgenic hyper-responsiveness that characterizes women with PCOS is probably due to the factors controlled by insulin sensitization rather than luteinizing hormone (LH), adrenocorticotropin hormone (ACTH), or ovarian steroids *per se* [16]. Multiple molecular and cellular pathways seem to be involved in the production of androgenic hormones, most of them involving ovarian theca cells, insulin receptors, Cytochrome P450 17α-monooxygenase (P450c17) activity as well as components of mitogen-activated protein kinase (MAPK) insulin pathway.

The clinical correspondence of this intricate biochemical processes have incredible impact on patients' quality of life and psychological status. Virilising signs and symptoms, acne and hirsutism are most often the first elements to lead to the clinical suspicion of PCOS.

Obesity is a key metabolic entity in some PCOS patients. Because of its undeniable influence on insulin resistance, it has become a target to treat when identified. PCOS women, who are obese tend to have higher hirsutism and acne scores than their lean counterparts [16]. The consequent importance of weight loss is therefore essential to be taken into account. It is certified in medical literature that a weight loss of 5–10% can reduce hyperandrogenism and insulin levels [17]. Lifestyle modifications reside once again as the first step therapeutical management in patients with PCOS.

Aiming to treat this frequent cause of anovulation, there are two ways to ensure the wellbeing of the patient based on each woman's choice: evaluating the options for further contraception

Lifestyle Changes and Weight Loss: Effects in PCOS http://dx.doi.org/10.5772/intechopen.73298 43

With respect to the latter, inducing ovulation stillremains a medical challenge in some patients with PCOS. There are a few known therapeutical approaches for achieving this: medical treatment with clomiphene citrate, tamoxifen, aromatase inhibitors, metformin, glucocorticoids, or gonadotropins or surgically management by laparoscopic ovarian drilling [23]; in vitro fertilization is also taken into consideration when all the other options failed to induce pregnancy.

Taking into account the morpho-clinical picture of the patients with PCOS and common sense, lifestyle changes and weight loss would, at first glance, be effective. It seems simple that by adopting a healthy lifestyle and weight loss, as with the patients who do not suffer from this pathology, it would improve the metabolic profile, reduce the risk of diabetes mellitus, cardiovascular disease or endometrial hyperplasia. Moreover, there are studies that discuss the complete or at least partial disappearance of the symptoms [24] and PCOS phenotype

Studies with various degrees of evidence have been conducted in an attempt to quantify their effect in patients with PCOS. While some parameters are certainly improved, there are still

An improved lifestyle will undoubtedly improve the distribution of the adipose tissue and will in most cases lead to weight loss. A weight loss of between 5 and 10% will ameliorate IGT and will decrease the prevalence of the metabolic syndrome and diabetes mellitus [25].

Research suggests that these interventions are associated with lower fasting insulin levels and insulin resistance [26], and consequently a decreased risk for metabolic syndrome, cardiovas-

It has been shown that improvement of the lipid profile resulting from weight loss and lifestyle changes is nonuniform. Thus, in the case of some patients, a significant decrease in cholesterol levels will be observed while in others the change will be insignificant [24]. However, in all cases there will be a significant increase of high density lipoprotein (HDL)–cholesterol levels (thus reducing the risk of cardiovascular disease) and a decrease of triglyceride levels [24].

During the treatment, we also seek to improve the hormonal profile since PCOS being a pathology with deep hormonal implications. Unanimously, studies describe a decrease in the

**3. Why are lifestyle changes and weight loss important in women** 

or starting a therapeutical plan for inducing ovulation.

**with PCOS?**

after weight loss.

**3.1. Metabolic profile**

**3.2. Hormonal profile**

others involved in a series of controversies.

cular disease, and diabetes mellitus [27].
