Polycystic ovary syndrome (PCOS) is a common female reproductive-age endocrine disease which affects about 5–10% of female population. The clinical spectrum of PCOS encompasses hirsutism, acne and male pattern alopecia, the sequelae of hyperandrogenism, and infertility as a result of ovulatory disturbance.

PCOS is predominantly characterized by chronic anovulation (no egg produced), insulin resistance and low-grade inflammatory status.

Even at an early age, PCOS women have a clustering of cardiovascular risk factors, such as obesity, insulin resistance, hypertension, impaired cardiopulmonary functional capacity, and metabolic syndrome. Although not part of the current diagnostic criteria of PCOS, obesity has been associated with the syndrome, since its original description by Stein-Leventhal in the 1930s and it is thought to affect 40% to 50% of women with the syndrome.

Preliminary evidence suggests exercise in PCOS may improve reproductive and cardiometabolic parameters. Exercise training (ET) favourably modulates cardiopulmonary function and insulin sensitivity markers in PCOS women. There is preliminary evidence that exercise training in this population may increase ovulation, menstrual regularity, cardiorespiratory fitness and self-esteem while decreasing insulin resistance and body fat. Current clinical practice guidelines suggest exercise and weight loss as management for PCOS.

Research on PCOS –what studies show!

• A study showed that girls with PCOS participated in physical activities much less than did controls (Eleftheriadou, et.al, 2012). This reflected not only the fact that they were less likely to engage in physical activity but also that when they did, it was less frequently and less intensely than controls. Generally, this data agreed with that of Trent et al. who recorded reduced physical activity in adolescents suffering from the syndrome, compared to their healthy peers. Wright et al. in a similar research recorded lower-grade physical activity among adult women with PCOS when compared to a healthy control group.

• In recent years, several studies have shown that aerobic endurance exercise leads to favorable changes in cardiorespiratory function, body composition, and metabolism of women with PCOS (Redman, Elkind-Hirsch & Ravussin, 2011). It seems that the lifestyle changes that combine reducing food intake for weight loss and regular exercise are a preferred treatment strategy in overweight and obese women with PCOS.

• A study showed that exercise training is effective in reducing BMI and improving insulin sensitivity markers in PCOS women, even though no significant changes in sex hormones were observed.

• Exercise may improve menstrual regularity, ovulation rates and pregnancy rates in women with PCOS. Not surprisingly, the meta-analysis of the secondary outcomes found that exercise training in women with PCOS results in significant improvements in many anthropometric and metabolic outcomes (Wang, Zhang & Liu, 2019).

• Overall, preliminary evidence suggests that exercise is of benefit in women of reproductive age with PCOS in terms of cardiometabolic health, but there is insufficient evidence to quantify the effect of exercise on reproductive health outcomes.

• PCOS is characterized by several hormonal and cardiovascular alterations that might expose patients at a higher risk for cardiovascular disease. There is a strong evidence for a direct role of physical activity in the improvement of cardiopulmonary functional capacity, autonomic function and inflammatory pattern (Covington, et. al, 2014).

•  Exercise training is highly recommended in PCOS women and represents a simple therapeutic strategy which can be performed safely and extensively to improve the cardiovascular risk profile in PCOS women. Primary benefit of exercise in PCOS is improving insulin sensitivity, reducing huperinsulinemia, reducing hyperandrogenism, restroring hormonal cyclicity, reducing visceral fat, inflammatory cytokines, improving mental health (Benham et.al, 2018).

Practical applications

• Weight training may increase lean body mass which can improve insulin sensitivity!

• Vigorous aerobic exercise improves insulin sensitivity : minimum 60% VO2 max (75% of maximum HR) , three times per week.

• HIIT (high intensity interval training) may improve insulin sensitivity, reduce insulin resistance and possibly improve other hormonal levels.

• In one study, progression from 6 x 2’/3’ rest at 70% of maximum to 10 x 2’/3’rest at 85-90% over 16 weeks reduced insulin resistance, BMI, visceral fat, bodyfat percentage.

• Possible workout : 4 x 4’/3’ rest, 10 x 1’/1’ rest

SOS: HIIT may not be appropriate for beginners thus; it is advisable to build aerobic fitness for 8-12 weeks before incorporating in your training.

• Alternate aerobic/HIIT and weight training days

Exercise & Diet Recommendations

1. Daily energy requirement of 2,000 – 2,400 kcal for patient of average build who is not too active. Avoid restricting this too much to start with.

 2. Exercise regularly: 30 min of moderate exercise daily will help to maintain body weight. More prolonged or vigorous exercise may be needed to produce weight loss.

3. Eat no more than 30% of daily calories as fat, restricting saturated fat to < 10% total calories. Use low fat spreads and dairy products.

4. Carbohydrate should count for 45 – 55% of the diet initially. Keep intake of refined carbohydrate down. Concentrate on low glycaemic index (GI) foods, those high in fibre and wholegrain foods.

5. Diet of higher protein content may improve satiety and insulin sensitivity. Start with 20% of daily energy as protein, but this may be increased by substituting for carbohydrate in those who have difficulty controlling eating or maintaining weight.

6. Avoid too much red meat. Eat oily fish at least once per week to supply long-chain essential fatty acids (omega-3, polyunsaturated fatty acids).

7. Eat at least five portions of fruit or vegetable per day. This promotes satiety, supplies fibre and maintains the micronutrient content of the diet.

8. Eat regularly and focus food intake on three (maximum four) meals per day. Breakfast is an important meal.

9. Avoid calorie-dense snacks as they promote hyperinsulinaemia and drive hunger. Make sure that drinks are counted in daily calorie intake estimated – fruit juices and alcoholic drinks are often forgotten but are rich in calories and carbohydrates.

10. Even modest weight loss has health benefits. Achieving this requires energy restriction – modest 200 kcal deficit (decreased intake or increased utilisation will lead to 5% weight loss in 6 months for many. A 500 kcal per day energy deficit usually equates to weight loss of up to 0.5 kg/week (Farshchi, Rane, Love & & Kennedy, 2007)