Management of lean PCOS

Andon Hestiantoro

Reproductive Immunoendocrinology Division

Department of Obstetrics and
Indonesian Reproductive Medicine
Research and Training Center
Gynecology Faculty of Medicine
Universitas Indonesia Dr. Cipto
Mangunkusumo Hospital
Jakarta
 Materi diskusi

• Prevalence and characteristic of lean PCOS in

RSCM
• Etio-pathogenesis of lean PCOS
• Management of lean PCOS
 Sign and Symptoms

Polycystic Ovary
Oligomenorrhea/amen
orrhea Hiperandrogenism

The most prevalence endocrinopathy in reproductive age

women The prevalence is around 5-15 %
 Diagnostic Criteria PCOS
NIH criteria (1990) Rotterdam Concensus(2003) AES Criteria (2006)
Most include all of Most include two of Requires all of the following :
the following : the following :  Hyperandrogenism
 Hyperandrogenism  Anovulation or  Ovarian dysfunction
and/or Oligoovulation  Exclusion of possible
hyperandrogenemi  Clinical or bio chemical related disorders
a signs of hyper
androgenism
 Anovulation or oligo-
ovulation  Polycystic ovaries
 Exclusion of possible
related disorders

The presence of polycystic All possible related disorder Emphasizes that the
ovaries is not necessary for must be ruled out for diagnosis of PCOS should not
diagnosis diagnosis of PCOS to made be made without evidence
of hyperandrogenism
Prevalence of lean PCOS in Yasmin Kencana RSCM

Hestiantoro A, Witjaksono A. Yasmin Clinic 2010

Three risk factors in lean PCOS

Insulin
Chronic low resistance
grade
inflammatio
n

Vitamin D
deficiency

Lean PCOS
 Characteristic of lean PCOS patients at RSCM
Characteristic Value
Age (years) 29,66 ± 5,08
BMI (kg/m2) 24,81 (22,23-28,71)
AMH (ng/ml) 7,51 (6,20 – 8,88)
Length of infertility (years) 4 (1,25 – 6,00)
Vitamin D 25-OH (ng/ml) 9,50 (7,70 – 12,75)
WC > 80 cm
Intake of fiber (gram) 9,57 ± 3,02
Waist circumference (cm) 85,14 ± 9,98
Wear hijab
Ye 29 (58,0)
s 21 (42,0)
No
Exposure to sunlight
< 60 minutes per day 46 (92,0)
> 60 minutes per day 4 (8,0)
Exposure to cigarette smoke
Yes 20 (40,0)
No 30 (60,0)
Hestiantoro A, Sri Negoro Y. Yasmin Clinic 2014
Waist circumference and metabolic syndrome based on
country/ethnic group
Country / Ethnic groups Waist circumference
Male > 94 cm
Europids
Female > 80 cm
Male >90 cm
South Asians
Female >80 cm
Male >90 cm
Chinese
Female >80 cm
Male >90 cm
Japanese
Female >85 cm
Male >90 cm
Indonesia
Female >80 cm

www.idf.org/webdata/docs/MetSyndrome_FINAL.pdf
Waist circumference, Triglycerides and Insulin levels

Brouwers MCGJ, et al. Clin Sci 2007;113: 375-381

Central obesity
Adapted from : Bohler H, et al. Fertil Steril 2010;94:795-
 Clinical symptom and biochemical marker for
insulin resistance
• Obesity (BMI>27 Kg/m2)
• Waist circumference (WC) > 80 CM
• Subscapula skinfold > 50 mm
• Achantosis nigricans
Achantosis nigricans
• Fasting Insulin > 30 mU/liter (>10.2)
• Fasting glucose : Fasting insulin < 4.5
(<10)
• Serum trigliseride > 5.5 mmol/liter

*Muharam Natadisastra
Correlation between waist circumference and insulin resistance in PCOS

PCOS with PCOS without

WC (cm) Total
insulin insulin resistance
resistance

>80 43 (84,3%) 22 (53,7%) 65

<80 8 (15,7%) 19 (46,3%) 27

total 51 (100%) 41 (100%)

OR = 4.64 , 95% CI = 1.75-12.2

Hestiantoro A, Fatati I. In preparation for publication

 Visfatin as a marker for abdominal visceral
fat

Visfatin
Adipokine which is
predominantly expressed in and
secreted from adipose tissue Chan TF, et al. Fertil Steril 2007;88:401-
5
Cut-Off value for visfatin influencing insulin
resistance in PCOS

Variable AUC Cut-Off Sensitivity Spesificity

Visfati
n
Visfatin 0.679 0.78 mg/dl 72 % 56 %
Hestiantoro A, Fatati I. Yasmin Clinic
 Characteristic of PCOS patients at RSCM
Characteristic Value
Age (years) 29,66 ± 5,08 Fiber
BMI (kg/m2) 24,81 (22,23-28,71) intak
AMH (ng/ml) 7,51 (6,20 – 8,88) e
Length of infertility (years) 4 (1,25 – 6,00)
Vitamin D 25-OH (ng/ml) 9,50 (7,70 – 12,75)
Intake of fiber (gram/day) 9,57 ± 3,02 < 10
Waist circumference (cm) 85,14 ± 9,98 gram /
Wear hijab day
Ye 29 (58,0)
s 21 (42,0)
No
Exposure to sunlight
< 60 minutes per day 46 (92,0)
> 60 minutes per day 4 (8,0)
Exposure to cigarette smoke
Yes 20 (40,0)
No 30 (60,0)
Hestiantoro A, Sri Negoro Y. Yasmin Clinic 2014
Dysbiosis of Gut Microbiota (DOGMA); a novel theory for
PCOS

Tremellen K, et al. Medical Hypotheses 2012; 79: 104-

Hiperandrogenism
Infertility
Menstrual
disfunction

Vitamin D

Deficienc
y
Lipid
accumulation

Insulin
Resistanc
e
 The goal of management in lean PCOS
Problem Goal / Aim Terapi

>10% reduce body

Central Obesity weight Diet, Exercise, Life style

Lack of activity Good fitness Exercise 30-60 mnt per day

Atherogenic Diet Fat reduction intake Diet = Fat<25%

Normal menstrual cycle

Resistensi insulin or Ovulation Metformin or TZD

Vitamin D deficiency Normal level Vitamin D3

Lack of fibre intake Intake fibre >10 gram/day Apple, Carrot, etc
Tremellen K, et al. Medical Hypotheses 2012; 79: 104-
 Exposure to
• Sunlight
5-10 minutes of direct exposure to the arms
and legs = 3000 IU of vitamin D3

• In a study of 69 healthy subjects age 18-29 in

Boston, 36% had 25 OH vit D level < 20
ng/ml at the end of winter. The prevalence
decreased to 4% by the end of summer.
(Tangpricha Am J Med 2002)

• Multiple studies show vitamin D def. common

in sunny areas when most of the skin is
shielded from the sun (Saudi Arabia, United
Arab Emirates, Turkey, India and Lebanon)
 The source of Vitamin D

Sunlight exposure
5-10 minutes of direct
exposure to the arms and
legs
= 3000 IU of vitamin D3

Holick M. NEJM 357;3:266-

280.
 Conclusion
• Three risk factors in lean PCOS are
– Insulin resistance
– Chronic low grade inflammation
– Vitamin D deficiency
• Management in lean PCOS
– Life style changes
– Exercise
– High fiber intake
– Balance nutritional intake