Nutrition: A Cornerstone in Managing PCOS

Polycystic Ovary Syndrome (PCOS) affects between 12 and 17% of women, according to diagnostic criteria and the populations studied (1, 2). Diagnosis is primarily based on the Rotterdam criteria, where at least two of the following three criteria must be present: polycystic ovaries detected by imaging, oligo-ovulation or anovulation, and/or signs of hyperandrogenism, such as hirsutism, acne, or biochemical evidence of elevated androgen levels (2).

Pathophysiology and Etiology

The etiology of PCOS is still not well understood, although recent research suggests it is a multifactorial condition, involving genetic, environmental, and epigenetic factors (3). This syndrome is characterized by hormonal imbalances, insulin resistance, low-grade chronic inflammation, and metabolic disturbances that affect both reproductive and metabolic health in women (3). Regardless of body mass index (BMI), approximately 75% of women with PCOS experience insulin resistance (4), which may be partly attributed to a higher level of visceral adiposity compared to women without PCOS (5). Furthermore, low-grade inflammation, often linked to excess visceral fat, exacerbates insulin resistance by producing pro-inflammatory cytokines that interfere with insulin signaling and worsen metabolic abnormalities. Excess insulin stimulates certain enzymes in the ovaries and adrenal glands that increase androgen production, worsening hyperandrogenism symptoms (3).

Why Suggest Nutritional Support?

Managing PCOS is essential due to the numerous complications it can lead to, such as increased risks of infertility, pregnancy complications (gestational diabetes, preeclampsia), and endometrial cancer (3). PCOS is also associated with metabolic diseases like type 2 diabetes, cardiovascular diseases, fatty liver disease, and difficulties managing weight (3). The psychological impact is also significant, with symptoms of anxiety, depression, and poor body image. Nutritional therapy, with or without medical treatment (such as oral contraceptives, metformin, anti-androgens, and cyclic progestins), remains fundamental for women with PCOS as a form of preventive medicine and helps improve their symptoms (3, 6, 7).

Managing PCOS

To date, there is no single recommended nutritional therapy for managing PCOS. Nutritional therapy is therefore personalized, based on individual needs and preferences, and primarily aims to improve intake of certain key nutrients (e.g., fibre, vitamin D, magnesium, omega-3s), increase insulin sensitivity, regulate body weight, and reduce inflammation.

Because they are associated with chronic inflammation and oxidative stress, anti-inflammatory diets such as the Mediterranean, Nordic, and Okinawan diets are beneficial for managing PCOS. Combined with exercise, they improve menstrual regularity and promote spontaneous pregnancies in overweight women with infertility related to PCOS, with or without metformin (6). A 2022 clinical study compared a low-calorie Mediterranean diet low in carbohydrates (with a carbohydrate intake of less than 20%) to a low-fat hypocaloric diet in 72 overweight women with PCOS. Participants on the low-carb Mediterranean diet showed significantly greater improvements in menstrual cycle regularity, anthropometric parameters, hormonal levels, insulin resistance, and lipid profiles after 12 weeks of treatment (8). The DASH diet has also shown beneficial effects in managing symptoms and treating PCOS. According to the latest evidence from a 2024 systematic review and meta-analysis, this diet showed the greatest effectiveness in improving insulin resistance, blood sugar levels, fasting insulin, and triglycerides in participants with PCOS (7).

Supplements and Probiotics

Inositols, especially myo-inositol and D-chiro-inositol, could be a complementary approach by modulating insulin signaling, lowering blood sugar levels, reducing androgen levels, and improving menstrual cycle regulation. According to data from a 2023 meta-analysis, inositols have fewer side effects than some traditional pharmacological solutions, making them an especially appealing alternative when metformin is poorly tolerated (9). Omega-3 supplementation (about 2 to 4 g per day for 6 to 24 weeks), particularly EPA/DHA, shows promising effects in reducing systemic inflammation and insulin resistance in women with PCOS (10, 11). It appears to lower hs-CRP levels and increase adiponectin (an anti-inflammatory adipokine and insulin sensitizer), according to evidence from a 2024 meta-analysis (11). Evidence also suggests that cinnamon supplementation (0.5 to 1.5 g per day for 8 to 52 weeks), which is rich in antioxidants, improves certain markers of insulin resistance in women with PCOS (12).

Recent research is exploring the role of the gut microbiome in the pathophysiology of PCOS. Reduced gut bacteria diversity and impaired gut barrier function may contribute to systemic inflammation and worsen symptoms. Studies show that the use of prebiotics and probiotics (such as L. casei, L. acidophilus, B. bifidum) reduces hyperandrogenism symptoms and improves insulin resistance (11, 13, 14). Since the type and dosage of supplements are not yet well established, it remains optimal to integrate these nutrients through diet. Dietitians will help your patients incorporate a variety of fermented foods rich in probiotics, as well as a diversity of fibre- and prebiotic-rich foods into their daily routines, which can help reduce inflammation.

PCOS is a complex condition characterized by hormonal imbalances, insulin resistance, and low-grade inflammation, requiring a multidimensional treatment approach. The dietitians at TeamNutrition will guide your patients in optimizing their body composition, finding concrete strategies to integrate a diet tailored to their needs (e.g., improving fertility, normalizing blood sugars, etc.), preventing long-term metabolic complications, and helping them navigate supplement recommendations.

References

1. Skiba, M. A., Islam, R. M., Bell, R. J., & Davis, S. R. (2018). Understanding variation in prevalence estimates of polycystic ovary syndrome: a systematic review and meta-analysis. Human reproduction update, 24(6), 694-709.
2. Lauritsen, M. P., Bentzen, J. G., Pinborg, A., Loft, A., Forman, J. L., Thuesen, L. L., ... & Nyboe Andersen, A. (2014). The prevalence of polycystic ovary syndrome in a normal population according to the Rotterdam criteria versus revised criteria including anti-Müllerian hormone. Human reproduction, 29(4), 791-801
3. Di Lorenzo, M., Cacciapuoti, N., Lonardo, M. S., Nasti, G., Gautiero, C., Belfiore, A., ... & Chiurazzi, M. (2023). Pathophysiology and nutritional approaches in polycystic ovary syndrome (PCOS): a comprehensive review. Current Nutrition Reports, 12(3), 527-544.
4. Teede, H. J., Misso, M. L., Costello, M. F., Dokras, A., Laven, J., Moran, L., ... & Norman, R. J. (2018). Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Human reproduction, 33(9), 1602-1618.
5. Satyaraddi, A., Cherian, K. E., Kapoor, N., Kunjummen, A. T., Kamath, M. S., Thomas, N., & Paul, T. V. (2019). Body composition, metabolic characteristics, and insulin resistance in obese and nonobese women with polycystic ovary syndrome. Journal of human reproductive sciences, 12(2), 78-84.
6. Salama, A. A., Amine, E. K., Hesham, A., & Abd El-Fatteh, N. (2018). Effects of anti-inflammatory diet in the context of lifestyle modification (with or without metformin use) on metabolic, endocrine, inflammatory and reproductive profiles in overweight and obese women with polycystic ovary syndrome: Controlled clinical trial. Can. J. Clin. Nutr, 6, 81-106.
7. Juhász, A. E., Stubnya, M. P., Teutsch, B., Gede, N., Hegyi, P., Nyirády, P., ... & Juhász, R. (2024). Ranking the dietary interventions by their effectiveness in the management of polycystic ovary syndrome: a systematic review and network meta-analysis. Reproductive Health, 21(1), 28.
8. Mei, S., Ding, J., Wang, K., Ni, Z., & Yu, J. (2022). Mediterranean diet combined with a low-carbohydrate dietary pattern in the treatment of overweight polycystic ovary syndrome patients. Frontiers in Nutrition, 9, 876620.
9. Greff, D., Juhász, A. E., Váncsa, S., Váradi, A., Sipos, Z., Szinte, J., ... & Horváth, E. M. (2023). Inositol is an effective and safe treatment in polycystic ovary syndrome: a systematic review and meta-analysis of randomized controlled trials. Reproductive Biology and Endocrinology, 21(1), 10.
10. Albardan, L., Platat, C., & Kalupahana, N. S. (2024). Role of Omega-3 fatty acids in improving metabolic dysfunctions in polycystic ovary syndrome. Nutrients, 16(17), 2961.
11. Moslehi, N., Zeraattalab-Motlagh, S., Rahimi Sakak, F., Shab-Bidar, S., Tehrani, F. R., & Mirmiran, P. (2023). Effects of nutrition on metabolic and endocrine outcomes in women with polycystic ovary syndrome: an umbrella review of meta-analyses of randomized controlled trials. Nutrition reviews, 81(5), 555-577.
12. Heshmati, J., Sepidarkish, M., Morvaridzadeh, M., Farsi, F., Tripathi, N., Razavi, M., & Rezaeinejad, M. (2021). The effect of cinnamon supplementation on glycemic control in women with polycystic ovary syndrome: A systematic review and meta‐analysis. Journal of food biochemistry, 45(1), e13543
13. Shamasbi, S. G., Ghanbari-Homayi, S., & Mirghafourvand, M. (2020). The effect of probiotics, prebiotics, and synbiotics on hormonal and inflammatory indices in women with polycystic ovary syndrome: a systematic review and meta-analysis. European journal of nutrition, 59, 433-450.
14. Gholizadeh Shamasbi, S., Dehgan, P., Mohammad-Alizadeh Charandabi, S., Aliasgarzadeh, A., & Mirghafourvand, M. (2019). The effect of resistant dextrin as a prebiotic on metabolic parameters and androgen level in women with polycystic ovarian syndrome: a randomized, triple-blind, controlled, clinical trial. European journal of nutrition, 58, 629-640.