**4. What lifestyle changes should be adopted for women with PCOS?**

Although the last decades have been revolutionary in terms of understanding this pathology, its etiology is not elucidated, hence we cannot talk about the existence of a curative treatment, but rather of symptomatic treatments. The spectacular evolution in this field also refers to the many symptomatic treatments, whose efficiency, although relatively high, address each symptom in part and not the pathology as a whole. The change in lifestyle, with all the developments in the last decades, still seems the most approachable and most effective treatment method, at the same time covering a broad spectrum of symptoms.

When we talk about lifestyle changes, we refer to a healthy lifestyle that involves exercise and weight loss. Although in many cases, patients are able to lose weight and lead a healthy lifestyle for a while, the difficulty they encounter is to maintain this lifestyle and their weight in the long run.

A solution to this problem is the behavioral treatment by "Burtyn and co." designed specifically to help with this–a complex program that not only helps patients to lose weight efficiently but also to maintain their weight in the long term or even continue to lose more over time. Patients undergo this program for a period of 4–6 months under the supervision of a group of specialists: nutritionists and psychologists [33]. Patients learn how to choose healthy foods, how to ration their portions and how to get social support. After setting objective targets in terms of daily caloric intake, time spent on physical exercise and other behavioral changes, patients share in weekly or bi-weekly group sessions the obtained results. Specialists recommend patients to expect a weight loss of 0.5–1 kg per week, mentioning that the final target is a 10% decrease in weight relative to their initial weight [33]. They argue that by a comprehensive behavioral approach, patients manage to decrease 8–10 kilograms in weight

and that about 80% of patients starting this program manage to complete it [34]. However, specialists mention that in the absence of weight maintenance therapy, regaining weight will be inevitable.

The National Institute of Health also recommends psychotherapeutic and social support for these patients in order to manage to maintain their weight in the long run or even to further lose weight.

## **4.1. What diets do we choose in order to lose weight?**

total testosterone level [28] and in androstenedione [29] as a result of lifestyle changes and weight loss. There is, however, controversy in terms of improving the level of SHBG and free androgen index (FAI) [29]. However, in all cases, an improvement in hirsutism will result

While the level of FSH increases as a result of lifestyle changes and weight loss, more by means of physical exercise than a result of diet [29], the level of LH does not seem to be

In PCOS treatment, we aim to restore both normal menstrual function and fertility. In some cases, there may also be a decrease in ovarian volume and a reduction in the number of follicles [30] following weight loss and lifestyle changes. Ovulatory menstrual cycles can be obtained for obese women with PCOS, even when the weight loss is relatively low [31], thus increasing considerably the chances of getting pregnant. However, not all patients equally respond to these measures even if their weight loss is similar [24]. Hollmann et al. describe an 80% improvement

in ovulation rate and 29% in the pregnancy rate in the case of a 10% weight loss [32].

**4. What lifestyle changes should be adopted for women with PCOS?**

method, at the same time covering a broad spectrum of symptoms.

Although the last decades have been revolutionary in terms of understanding this pathology, its etiology is not elucidated, hence we cannot talk about the existence of a curative treatment, but rather of symptomatic treatments. The spectacular evolution in this field also refers to the many symptomatic treatments, whose efficiency, although relatively high, address each symptom in part and not the pathology as a whole. The change in lifestyle, with all the developments in the last decades, still seems the most approachable and most effective treatment

When we talk about lifestyle changes, we refer to a healthy lifestyle that involves exercise and weight loss. Although in many cases, patients are able to lose weight and lead a healthy lifestyle for a while, the difficulty they encounter is to maintain this lifestyle and their weight

A solution to this problem is the behavioral treatment by "Burtyn and co." designed specifically to help with this–a complex program that not only helps patients to lose weight efficiently but also to maintain their weight in the long term or even continue to lose more over time. Patients undergo this program for a period of 4–6 months under the supervision of a group of specialists: nutritionists and psychologists [33]. Patients learn how to choose healthy foods, how to ration their portions and how to get social support. After setting objective targets in terms of daily caloric intake, time spent on physical exercise and other behavioral changes, patients share in weekly or bi-weekly group sessions the obtained results. Specialists recommend patients to expect a weight loss of 0.5–1 kg per week, mentioning that the final target is a 10% decrease in weight relative to their initial weight [33]. They argue that by a comprehensive behavioral approach, patients manage to decrease 8–10 kilograms in weight

when using the Ferriman-Gallwey (FG) score as an objective measuring method.

improved by following a hygienic-dietary diet.

**3.3. Reproductive potential**

44 Debatable Topics in PCOS Patients

in the long run.

Regarding the type of diet, there are no clinically relevant data to prove the efficacy of any of them in the case of patients suffering from PCOS. However, based on food principles and taking into account that a decrease in carbohydrate intake would lead to a decrease in hyperinsulinemia, which in turn would lower insulin resistance, low-carbohydrate diets would be favored. Nevertheless, a comparative study between a high protein/low carbohydrate diet (40% carbohydrate, 30% protein, and 30% fat) and a low protein/high carbohydrate diet (55% carbohydrate, 15% protein, and 30% fat) proved the same efficacy in both cases [26] in terms of weight loss, waist circumference decrease and effects on insulin sensitivity. The same study emphasizes the importance of a calorific deficit in PCOS treatment, noting that the differences in dietary compounds are relatively insignificant when comparing their effect on metabolic and reproductive improvements [26]. A meta-analysis of 48 clinical trials involving a total of 2886 patients concludes that regardless of the type of diet and macronutrient on which they are based, there will be a relatively comparative weight loss–the same thing happening with maintaining weights at follow-up for 6 months and 12 months [35]. The impact of the type of macronutrients used in the diet is still debated. What is certain is that less energy intake than energy consumption will result in a weight loss. Thus, high-level metabolic studies conclude that a caloric intake of less than 1000 kcal/day will show results in all cases, with no exception.

New diet hypothesis have emerged over the last few years, and here we want to mention the fast-paced ones, which are still under investigation and seem to be ground-breaking. Researchers believe that patients with PCOS might have significant benefits in terms of PCOS symptoms but also complications in the medium to long term if approaching this type of diets. The data we currently have on intermittent fasting diet obtained on rodent models are promising in terms of results. Thus, intermittent fasting diets, as compared to diets based on energy restriction of continued iso-energetic type, improve insulin sensitivity [36], provide protection for the cardiovascular system [37], and increase the lifespan of the rodent in the model. [38] Moreover, 3 days or more of the fasting will result in at least a 30% decrease in circulating insulin levels, glucose levels, and insulin-like growth factor 1 (IGF-1), which plays a key role in the metabolic homeostasis and changes associated with aging [39]. Current theories take into account the possibility that this type of diet can improve the symptoms of hyperandrogenism, based on the argument that improving insulin resistance would reduce compensatory hyperinsulinemia and ultimately the excess of androgen involved in the PCOS symptomatology.

Finally, we want to emphasize the importance of weight loss, pointing out the uselessness of this fact if the patients fail to maintain their long-term weight.

#### **4.2. What is the importance of physical exercise?**

Physical exercise is definitely a part of the lifestyle changes. Studies show that the type, frequency or duration of the exercise do not influence the results that patients get from it. It has been shown that regular, aerobic exercise of moderate intensity does not only contribute to weight loss and improved insulin resistance, but also improves reproductive outcomes, including ovulation and regulation of menstrual cycles. The recommendation for patients with PCOS in view of the improve reproductive and cardio metabolic outcomes is – aerobic physical activity of moderate intensity for 90 minutes per week [40].
