PCOS in Aging Women
PCOS in Aging Women
Beyond Hormones and Hot Flashes
Once referred to as the “medical black
hole,” the transition from the childbearing years too menopause largely has been ignored in
women with polycystic ovary syndrome (PCOS), a common endocrine disorder.
The majority of studies on PCOS have
examined the reproductive and metabolic disturbances of women of reproductive
age, yet PCOS is a chronic condition the medical community realizes must be
managed throughout a woman’s life.
This article reviews the research that’s
been presented thus far regarding aging women with PCOS as well as the
associated changes in hormones, body composition, and metabolic parameters that
occur. Strategies to implement medical nutrition therapy (MNT) and improve
nutrition counseling also are discussed.
What
Is PCOS?
PCOS is a hormonal imbalance
characterized by high levels of androgens (IEE, male hormones such as
testosterone) from the ovaries and is associated with insulin resistance
. Small cysts called poly cysts usually, but not always, surround the ovaries and appear as a strand of pearls on an ultrasound examination.
. Small cysts called poly cysts usually, but not always, surround the ovaries and appear as a strand of pearls on an ultrasound examination.
The cysts result from but don’t cause
hormonal imbalances. The overproduction of androgens in women causes excessive hair
growth on their face and body (hirsutism), alopecia, acne, skin problems, and irregular or absent
periods. The majority of women with PCOS who are insulin resistant will
experience weight gain in the abdominal area, difficulty losing weight, intense cravings for carbohydrates, and
hypoglycemic episodes.
Now that more is known about the
syndrome and the influence of insulin on the increased risk of type 2 diabetes
and cardiovascular disease (CVD), changes in PCOS beyond the reproductive years
is getting more attention. For example, panelists from the 2012 National
Institutes of Health Evidence-Based Methodology Workshop on PCOS proposed changing
the syndrome’s name to one that doesn’t just focus on the ovaries but
represents the long term health implications associated with the
syndrome. Moreover, longitudinal studies have been conducted with postmenopausal
women who were first studied 20 to 30 years ago to examine changes in PCOS
presentation associated with age. Several studies have attempted to answer
questions about PCOS and aging, such as whether the syndrome gets worse or improves
after menopause and whether it can be cured or it simply disappears.
Fortunately, these studies have successfully answered these questions.
Aging’s
Effect of Reproductive Hormones
As women age and transition through
menopause, estrogen levels naturally decrease. But what effect does aging and
declining estrogen has on reproductive hormones for women with PCOS?
According to new research, it appears
that reproductive hormones in women with PCOS differ from women who don’t have
PCOS after menopause. In fact, the reproductive life span in women with PCOS has been found to
extend beyond that of women without PCOS due to higher adrenal and ovarian androgen
levels.
Surprisingly, women with PCOS are more
likely to experience regular menstrual cycles as they age because of the natural
decline in androgen levels that occurs in response to menopause. For some women
who struggle with infertility, they may have a higher likelihood of pregnancy
as they get older.
Constant long-term exposure to elevated
androgen levels in women with PCOS can have a lasting effect on excessive facial
and body hair, hair loss, and even balding that extends past menopause. Although older women with
PCOS reported fewer hot flashes and episodes of sweating compared with women without
PCOS, they also reported significantly more hirsutism (64% vs. 9%).7 These
dermatological effects can be detrimental to a woman’s self-esteem and body
image.
Knowledge of the hormonal changes and
their impact on symptoms and self-image can help dietitians empathize with and more
effectively counsel older clients and patients with PCOS.
Body
Composition
Only a handful of studies have examined
how PCOS affects body composition in older women. Schmidt and colleagues measured
the height, weight, and waist circumference of women aged 61 to 79 with and without
PCOS and found that as women in both groups aged, they lost height and had
greater waist-to-hip ratios.
Women with PCOS maintained their weight as
they got older, whereas women without the condition gained weight as they aged.
The higher waist-to-hip ratios seen when the women with PCOS were premenopausal
disappeared after menopause unlike the weight gain shown among the women without
PCOS. The women with PCOS also experienced greater increases in BMI due to
their loss in height, supporting similar findings of earlier research.
Elevated waist circumference is
associated with an increased risk of metabolic syndrome, type 2 diabetes, and
CVD in women with PCOS.10-12 In addition, increased waist circumference and BMI can negatively impact body
image, affect selfesteem, and increase the risk of depression in this
population.
Metabolic
Changes With Age
Several studies have shown that as women
with PCOS age, their risk of CVD and type 2 diabetes rises, stressing the need for
early detection and aggressive treatment of the syndrome.
CVD Risk
A study published in The Journal of
Clinical Endocrinology & Metabolism showed that postmenopausal women
with PCOS had greater inflammation than women without PCOS as measured
by high-sensitivity C-reactive protein (CRP) levels, and that these
levels worsened with age.
Moreover, lipid metabolism worsens as
women with PCOS age, especially with regard to triglyceride and HDL
concentrations. In a study, LDL cholesterol levels were found to be similar for
middle-aged women with and without PCOS, although HDL was reduced and
triglyceride levels were higher.
These findings support those of other
researchers who demonstrated an unfavorable lipid profile (e.g, elevated triglycerides
and reduced HDL concentrations) in postmenopausal women with the syndrome.
Glucose, Insulin Metabolism, and Type 2
Diabetes Risk
A study published in Diabetes showed
that the prevalence of type 2 diabetes in middle-aged women with PCOS was 6.8
times higher than that of the general female population of similar age.
Women who had a greater waist
circumference, BMI, or family history of diabetes had a higher prevalence of
type 2 diabetes.
Boudreaux and colleagues found that
obese women with PCOS had a fivefold increased risk of developing type 2 diabetes
compared with age-adjusted controls, indicating that BMI and obesity may be important factors in the
development of type 2 diabetes in women with PCOS.
It has been suggested that there’s a
rapid progression from impaired glucose tolerance to type 2 diabetes in women
with PCOS, and that type 2 diabetes may occur earlier than expected compared with the general population.12
Because of the elevated risk of developing diabetes, the Androgen Excess and
PCOS Society recommends screening for impaired glucose tolerance and type 2
diabetes with a two-hour oral glucose tolerance test every two years in women
with PCOS who have normal glucose levels and annually in those with elevated
glucose levels.
Early detection and treatment of
impaired glucose tolerance with lifestyle changes and insulin-sensitizing
medications (eg, metformin) are crucial to prevent further health complications
in the PCOS population.
MNT
for Older Women With PCOS
Clearly, women with PCOS face lifelong
health risks extending beyond the reproductive years. According to a study by
Talbott and colleagues, “The implication is that the menopausal transition coupled
with a lifelong increase in cardiovascular risk factors (obesity,
hyperinsulinemia, increased LDL and decreased HDLT) continues to create an adverse
environment and a process in women with PCOS that outpaces those of non-PCOS women.”16
Dietitians can provide nutrition counseling and education to older women with the syndrome to help them make positive
changes in their eating habits and subsequently reduce their disease risk and improve
their health.
Weight loss of 5% to 10% of total body
weight has been shown to improve both reproductive and metabolic parameters
associated with PCOS.17 In fact, a range of potential dietary approaches has had favorable effects on weight loss and metabolic parameters in PCOS. One
approach involves modifying the glycemic index (GI) and glycemic load (GL) to
minimize the rise in insulin and glucose from food. Blueberries and apples, for
example, are low-GI fruits that don’t raise insulin and glucose levels to the
degree that high-GI bananas or pineapples do.
Marsh and colleagues compared the
effects of a low-GI diet with a conventional diet (eg, high-fiber and
moderate-to-high GI breads and cereals) in 96 women with PCOS without caloric restriction
for 12 months. Those who followed the low-GI diet had significantly increased
menstrual regularity (95% vs. 63% on a conventional diet) and insulin
sensitivity. Women with high insulin levels at the start of the study
experienced a twofold greater reduction in body fat following the low-GI diet
compared with those on the conventional diet.
Other nutrition strategies for PCOS
involve modifying carbohydrate,
fat, and protein intake or using meal
replacements (eg, nutrition bars and drinks). A study in The American
Journal of Clinical Nutrition showed a high-protein diet (greater
than 40% of calories from protein) without
caloric restriction resulted in greater weight loss (7.7 kg vs. 3.3 kg, or
roughly 17 lbs vs. 7 lbs) and body fat loss despite the lack of caloric
reduction.19 In addition, those following a high-protein diet saw greater
reductions in waist circumference and decreases in glucose than those following
the standard protein diet.
The researchers suggested that the
high-protein diet group lost more weight because of the satisfying effects of
protein on appetite—that is, the women may have felt more satisfied and less
hungry when eating a high-protein diet so they consumed less food overall.
Since older women with PCOS have been
shown to have high CRP levels, they may benefit from a diet that emphasizes anti-inflammatory
foods, including fiber-rich foods (eg, whole grains, fruits, vegetables), red
wine, and omega-3 fats (eg, fatty fish, walnuts, egg yolks). But studies
examining the optimal diet composition specifically for older women with the
syndrome are needed.
There’s no conclusive evidence that one
dietary strategy is superior to another in achieving long-term weight loss and metabolic
improvement, but what’s clear is that older women
with PCOS require MNT interventions to
prevent or improve metabolic abnormalities and reduce the risk of chronic
diseases such as CVD and type 2 diabetes.
Dietary
Supplements
Additional options for older women with
PCOS include dietary supplements, which have been reported to improve insulin sensitivity
as well as metabolic and reproductive parameters.
Taking 1.2 to 4 g daily of Myo-inositol,
for example, has been shown to enhance insulin resistance and lipid and CRP
levels. It also has been shown to improve egg quality and reduce the risk of
gestational diabetes in women with PCOS.
Supplementation with magnesium was shown
to improve glucose and insulin sensitivity in overweight individuals without diabetes.
The antioxidant and amino acid
n-acetylcysteine (1.8 g daily) was shown to improve insulin sensitivity and
lipid profile equally as well as metformin in women with PCOS.24 Cinnamon
(1 to 6 g daily)25 and alpha-lipoic acid
(1,200 mg daily)26 also have been found to have insulin-sensitizing properties.
Clients and patients can purchase these supplements over the counter.
Omega-3 fatty acids offer numerous
health benefits to women with PCOS. They can reduce inflammation, lower triglycerides,
enhance mood, and improve hirsutism and insulin resistance. In a study
published in the Journal of Obstetrics and Gynaecology,
overweight women with PCOS were given 1,500 mg of omega-3 fatty acids daily for
six months. BMI, insulin, and testosterone levels decreased significantly
during treatment.27 Optimal amounts of omega-3 fatty acid supplementation range
from 1 to 4 g daily.
Barriers
to Nutrition Counseling and Weight Management
While MNT and various supplements may
improve the health and well-being of older women
with PCOS, dietitians may encounter unique challenges
when counseling them.
Aging women with PCOS who have struggled
with their weight for most of their lives may be chronic dieters, having
followed numerous different regimens in the past. As a result, they may
distrust their ability to self-regulate food intake and engage in distorted
eating practices, such as restricting, binging, purging, using diet pills and
laxatives, or excessively exercising, potentially adding to the pathogenesis
of PCOS. These women also may hold negative and false food beliefs that need to
be addressed in nutrition counseling sessions. It’s imperative that dietitians screen patients with
PCOS for eating disorders before recommending changes in eating behavior.
There are several physiological factors
that may pose specific barriers to weight management in the PCOS population.
Since insulin is a growth hormone and an appetite stimulant, high insulin levels or insulin resistance may
predispose women with PCOS to gain weight or make losing weight more
challenging.
It’s not uncommon to hear women with
PCOS admit to having strong cravings for sweets or other carbohydrate-rich
foods, even immediately after finishing a meal. Older women with
PCOS may find it particularly more
difficult to manage insulin levels and lose weight than younger women with the
syndrome, as insulin levels have been shown to worsen with age. It also has been
suggested that women with PCOS have impaired appetite regulation, with abnormal
levels of the hunger- and satiety signaling hormone leptin, ghrelin, and
cholecystokinin, posing additional weight management challenges.
Research
Overview
It’s now evident that PCOS doesn’t
disappear as women get older. Reproductive hormones in women with PCOS differ from
those in women without PCOS after menopause. Most importantly, inflammatory and
metabolic parameters worsen with age, putting women with PCOS at
increased risk of lifelong health issues beyond menopause, especially the risk of
developing CVD and type 2 diabetes.
Nutrition management for older women
with PCOS should take into account the risk of long-term complications associated
with the disease.
This supports the need for treatment
involving dietary and lifestyle modifications and insulin sensitizers in older
women with PCOS who have metabolic complications. Early detection and proactive treatment of PCOS is crucial to prevent the long-term metabolic consequences associated with this complex
syndrome. Thus, dietitians play an important role in the management of PCOS.
By Angela Grassi, MS, RDN,
LDN, is founder of the PCOS Nutrition Center, where she provides evidence-based
nutrition information and counseling to women with PCOS around the world, and
the author of The Dietitian’s Guide to Polycystic Ovary Syndrome, The
PCOS Workbook: Your Guide to Complete Physical and
Emotional Health, and the section on PCOS in the Academy
of Nutrition and Dietetics Nutrition Care Manual. She
also was the
2013 recipient of the Award
in Excellence in Practice in Women’s Health and a past recipient of the Award
for Excellence in Graduate Research, both from the Academy of Nutrition and
Dietetics.
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