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

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 after weight loss.

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 others involved in a series of controversies.

## **3.1. Metabolic profile**

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

The modified metabolic background associated with PCOS is basically characterized by unbalanced estrogen serum levels due to lack of progesterone production. Left untreated, the main effects of this modified environment leads to atypical endometrial hyperplasia, and

Even though progesterone-based oral contraceptive therapy is often efficacious [19], approximately 30% of women with PCOS fail to respond to such treatment [20] and progress to the development of atypical hyperplasia and further transformation to endometrial cancer [21].

The mechanism of progesterone resistance is determined at molecular level and based on the imbalance of two progesterone receptor (PR) isoforms PRA and PRB. Patients with PCOS have a modified ratio of PRA to PRB receptors present on stromal and epithelial cells of endo-

Progesterone resistance is associated with insulin resistance [20] and this way, a new perspective in the prevention of endometrial hyperplasia can be contoured: targeted therapy on reducing insulin resistance may benefit both endometrial tissue and serum hyperinsulinemia.

Although most of PCOS-diagnosed patients complain about the inability to pursue a pregnancy, it is important to have in mind the situation when women diagnosed and treated for

A recent study states that in women aged 28–33 years old, women with PCOS were less likely to be using contraception (61 versus 79%, P < 0.001) and more likely to be trying to conceive (56 versus 45%, P < 0.001), compared with women not reporting PCOS [22]. However, the same study mentions that fewer women with PCOS (61%) were using contraception than women

Because women with oligomenorrhea ovulate intermittently and rarely use contraception-

As part of the PCOS, infertility secondary to anovulation is usually the main complaint of

Pathological basis of infertility in this particular medical situation resides in the low Folliclestimulating hormone (FSH) serum level, which is responsible for the impossibility of ovarian

follicles to reach maturity due to their persistence in final growth stages.

management in patients with PCOS.

42 Debatable Topics in PCOS Patients

metrium [21].

**2.3. Prevention of endometrial hyperplasia**

endometrial dysfunction-induced infertility [18].

**2.4. Voluntary contraception for patients**

PCOS do not want to obtain a pregnancy.

without PCOS (79%) (P = 0.001) [22].

**2.5. Induced ovulation for patients pursuing pregnancy**

patients diagnosed with this metabolic disorder.

unwanted pregnancy may occur.

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, cardiovascular disease, and diabetes mellitus [27].

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].

#### **3.2. Hormonal profile**

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

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

Lifestyle Changes and Weight Loss: Effects in PCOS http://dx.doi.org/10.5772/intechopen.73298 45

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

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

Finally, we want to emphasize the importance of weight loss, pointing out the uselessness of

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

involved in the PCOS symptomatology.

this fact if the patients fail to maintain their long-term weight.

be inevitable.

lose weight.

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 improved by following a hygienic-dietary diet.
