|Year : 2017 | Volume
| Issue : 3 | Page : 123-128
Exercise in polycystic ovarian syndrome: An evidence-based review
Disha Shetty1, Baskaran Chandrasekaran2, Arul Watson Singh3, Joseph Oliverraj3
1 Alva's College of Physiotherapy and Research Center, Moodbidri, Mangalore, India
2 Department of Physiotherapy, Alva's College of Physiotherapy, Moodbidri, Mangalore, India
3 Center for Sport Science Medicine and Research, School of Allied Health Sciences, Manipal University, Manipal, Karnataka, India
|Date of Web Publication||4-Oct-2017|
Center for Sport Science Medicine and Research, School of Allied Health Sciences, Manipal University, Manipal, Karnataka
Polycystic ovarian syndrome (PCOS) is a common endocrine disorder affecting female adolescent and adulthood globally. The most annoying complications of PCOS are obesity and infertility. Exercise is proved to be a best therapeutic and supportive management in PCOS patients in reducing infertility. Exercise reduces the risk and restores fertility and quality of life in PCOS patients through inducing hormonal changes of testosterone, androstenedione, combating obesity, metabolic syndrome, reducing inflammatory markers, and increasing immunity. Earlier systematic reviews and metaanalyses have proved the effectiveness of exercise in PCOS. This current systematic review will add to the current evidence of cumulative effects on exercise and shall be an update to the current proof of physical activity in PCOS patients.
Keywords: Depression, exercise, fertility, physical activity, polycystic ovarian syndrome, quality of life, resistance and endurance training
|How to cite this article:|
Shetty D, Chandrasekaran B, Singh AW, Oliverraj J. Exercise in polycystic ovarian syndrome: An evidence-based review. Saudi J Sports Med 2017;17:123-8
|How to cite this URL:|
Shetty D, Chandrasekaran B, Singh AW, Oliverraj J. Exercise in polycystic ovarian syndrome: An evidence-based review. Saudi J Sports Med [serial online] 2017 [cited 2018 Jan 21];17:123-8. Available from: http://www.sjosm.org/text.asp?2017/17/3/123/215912
| Introduction|| |
Polycystic ovarian syndrome (PCOS) is a common endocrine disorder affecting chiefly the women at reproductive ages (late adolescent and early adulthood). It is caused by the imbalance of female sex hormones. The prevalence rate is about 9.13% in Indian adolescents and 3.7% in young women. A study carried out in an urban population in India showed a prevalence rate of about 22.5% of Rotterdam classification and 10.7% by Androgen Excess Society criteria. The clinical features comprise of reproductive manifestations such as reduced frequency of ovulation, menstrual irregularity, reduced fertility, abdominal obesity, sonographic evidence of ovarian cysts, and high levels of male hormones such as testosterone and androstenedione.
PCOS is associated with metabolic features including elevated levels of insulin secretion and resistance, diabetes and cardiovascular disease risk factors such as abnormal cholesterol levels and free plasma lipids. The causative factors behind PCOS are unknown. The probable cause may be related to the dysregulation in female reproductive hormones as demonstrated in earlier studies., Insulin resistance (IR) and its compensatory hyperinsulinemia are proposed as significant etiological factors of PCOS. All these factors are said to be substantial cause for hyperandrogenism in PCOS patients. Overweight and obesity worsen these underlying hormonal imbalances by increasing androgen and excess blood insulin levels thus making the clinical features very evident in women with PCOS.
| Pathophysiology of Polycystic Ovarian Syndrome|| |
The exact etiology of metabolic syndrome is unknown, but the excessive visceral fat contributes to the development of clinically significant disorders such as IR, dyslipidemia, high blood pressure, impaired fibrinolysis, glucose intolerance, and endothelial dysfunction. Pathogenesis of multiple sclerosis (MS) in PCOS women may be due to (i) IR, (ii) hyperinsulinemia and (iii) glucose intolerance, which are caused mainly due to dysregulation of insulin signal transduction pathways, and (iv) failure in fatty acid uptake in muscle and liver.
PCOS, Polycystic Ovarian Syndrome (COS) is associated with the development of cardiovascular disorders and type 2 diabetes. IR, one of the dynamic components of MS, is observed in about 50%–80% of women with PCOS. Insulin receptors are present in significant amount in ovaries and impairment of insulin signaling in theca cells increases the production of androgens. IR impairs insulin action in tissues, such as skeletal muscle, adipocytes, and liver. In skeletal muscle, the primary effect of insulin is to stimulate glucose uptake and metabolism. In insulin-resistant state, the glucose uptake is markedly reduced in skeletal muscle. Hence, poor exercise capacity due to reduced muscular efficiency, early fatigue, and hence exercise tolerance are inevitable in PCOS patients.
Obese individuals exhibit marked skeletal muscle IR as compared that of lean individuals who are related to higher body mass index in PCOS women. Weight loss in obese individuals improves or reverses IR in skeletal muscle of PCOS women. Obesity tends to aggravate the clinical presentation of PCOS. Indeed, the incidence of hirsutism and menstrual irregularity is greater in the obese population as compared to nonobese PCOS. Owing to the above reasons, quality of life with PCOS individual might get worse as it progresses.
| Exercise and Its Impact on Polycystic Ovarian Syndrome Pathophysiology|| |
Weight reduction may lead to a decrease in glucose intolerance which in turn may lead to improvement in reproductive and metabolic derangements in PCOS. Exercise training has shown significant improvement in irregularity of menstrual cycles and ovulation in about 50% women diagnosed with PCOS which improves body composition. Further weight loss may reduce pulse amplitude of luteinizing hormone (LH) in turn reducing androgen production. The key factor responsible for these effects is the reduction of hyperinsulinemia and IR.
Exercise has shown to modulate insulin sensitivity and lipid metabolism in skeletal muscle. Exercise improves insulin sensitivity by increasing intramyocellular triacylglycerol concentration. Improvement in insulin sensitivity could be due to more efficient lipid turnover resulting in increased muscle lipid uptake, transport, utilization, and oxidation. The literature states the efficacy of exercise training in combating metabolic syndrome in PCOS patients by marking improvements in apolipoprotein, adiponectin in the process of lipid turnover, and uptake in skeletal muscles.
Endurance exercise also increases capillary density, mitochondrial density, number, hyperplasia of muscle fibers, neural sensitization, motor learning, and adaptations thereby increasing exercise capacity and reducing exercise intolerance in PCOS individual. Improved blood flow to skeletal muscles, mitochondrial proliferation, and sensitivity to activity enhance the stability of essential protein involved in insulin signal transduction in PCOS patients.
| Evidence Search Strategy|| |
The literature claiming the effectiveness of exercise in PCOS is searched through electronic databases such as ProQuest and Ovid and public databases such as PubMed Central and Biomed Central. The MeSH items used for searching online are exercise training AND PCOS, physical activity AND PCOS, exercise AND fertility OR ovulation. Only full-text articles published in English are reviewed. Two authors (DS and AW) hand searched the articles, and any consensus among the authors was solved through third author (JO). The research findings are shown in [Table 1].
|Table 1: The current evidence behind effects of exercise on Polycystic Ovarian Syndrome women|
Click here to view
| Recommendation of Exercise Training in Polycystic Ovarian Syndrome|| |
Based on the literature reviewed in [Table 1], the dosage of exercise recommended in PCOS for potential health benefits may be as follows:
Exercise training session
Warm-up: At least 5–10 min.
- Frequency: 5 days/week for 12–24 weeks
- Intensity: 20–60 min of aerobic (high-intensity interval training 70%–70% VO2 peak repetitive exercise bouts of 10 min, six episodes/session with 15 min of active pause 55%–60% VO2 peak between the bouts. Continuous practice sessions 60%–70% heart rate (HR) max inculcating large muscles such as running or cycling for 30–60 min)
- Time: 30–45 min. Fatigue-free level
- Mode: Treadmill or bicycle
- Progression: 10% VO2 peak or HR max every 2 weeks. After 4 weeks, new VO2 peak test to be determined from maximal or submaximal exercise testing.
Resistance exercise training:
- Frequency: 2–3 days/week for 12–24 weeks
- Intensity: Initial 60%–70% of 1 repetition maximum comprising three sets of 8–10 resistance stations (lateral pull down, military press, chest press, biceps and triceps curl, abdominal curl ups, split squats, leg curls, and extensions). 2–3 sets of 8–12 repetition/set. 1 min rest between set. Avoid Valsalva maneuver during lifting
- Time: 30–45 min. Fatigue-free level
- Mode: Dumbbell, barbell, thera tubes, and weighted pulley machines
- Progression: Repetitions or sets can be increased based on the rating of perceived exertion or maximal voluntary contraction using the weights.
Cool down: Calisthenics 5–10 min, active recovery.
| Conclusion|| |
Exercise training and physical activity in PCOS have shown to have a good impact on improving the anthropometric measurements such as body mass index, waist circumference, and metabolic parameters such as total cholesterol, IR, and lipid profile thus reducing metabolic syndrome and other risk factors associated with PCOS. Exercise training should be included in the routine medical management to augment the benefits of ovulation chances, reducing cardiovascular risks and improving the quality of life in PCOS women.
The author Baskaran Chandrasekaran would like to thank Dr. Fiddy Davis Ph.D., Associate Professor/Head, Center for Sport Science Medicine and Research for the valuable suggestion and passion toward research in the field of health promotion and physical activity.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Tal R, Seifer DB, Arici A. The emerging role of angiogenic factor dysregulation in the pathogenesis of polycystic ovarian syndrome. Semin Reprod Med 2015;33:195-207.
Joseph N, Reddy AG, Joy D, Patel V, Santhosh P, Das S, et al.
Study on the proportion and determinants of polycystic ovarian syndrome among health sciences students in South India. J Nat Sci Biol Med 2016;7:166-72.
Joshi B, Mukherjee S, Patil A, Purandare A, Chauhan S, Vaidya R. A cross-sectional study of polycystic ovarian syndrome among adolescent and young girls in Mumbai, India. Indian J Endocrinol Metab 2014;18:317-24.
Stepto NK, Cassar S, Joham AE, Hutchison SK, Harrison CL, Goldstein RF, et al.
Women with polycystic ovary syndrome have intrinsic insulin resistance on euglycaemic-hyperinsulaemic clamp. Hum Reprod 2013;28:777-84.
Legro RS, Arslanian SA, Ehrmann DA, Hoeger KM, Murad MH, Pasquali R, et al.
Diagnosis and treatment of polycystic ovary syndrome: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2013;98:4565-92.
Orio F, Muscogiuri G, Nese C, Palomba S, Savastano S, Tafuri D, et al.
Obesity, type 2 diabetes mellitus and cardiovascular disease risk: An uptodate in the management of polycystic ovary syndrome. Eur J Obstet Gynecol Reprod Biol 2016;207:214-9.
Shabir I, Ganie MA, Zargar MA, Bhat D, Mir MM, Jan A, et al.
Prevalence of metabolic syndrome in the family members of women with polycystic ovary syndrome from North India. Indian J Endocrinol Metab 2014;18:364-9.
Dupont J, Scaramuzzi RJ. Insulin signalling and glucose transport in the ovary and ovarian function during the ovarian cycle. Biochem J 2016;473:1483-501.
Dantas WS, Marcondes JA, Shinjo SK, Perandini LA, Zambelli VO, Neves WD, et al.
GLUT4 translocation is not impaired after acute exercise in skeletal muscle of women with obesity and polycystic ovary syndrome. Obesity (Silver Spring) 2015;23:2207-15.
Jung UJ, Choi MS. Obesity and its metabolic complications: The role of adipokines and the relationship between obesity, inflammation, insulin resistance, dyslipidemia and nonalcoholic fatty liver disease. Int J Mol Sci 2014;15:6184-223.
Ramanand SJ, Ghongane BB, Ramanand JB, Patwardhan MH, Ghanghas RR, Jain SS. Clinical characteristics of polycystic ovary syndrome in Indian women. Indian J Endocrinol Metab 2013;17:138-45.
Sirmans SM, Pate KA. Epidemiology, diagnosis, and management of polycystic ovary syndrome. Clin Epidemiol 2013;6:1-13.
Harrison CL, Lombard CB, Moran LJ, Teede HJ. Exercise therapy in polycystic ovary syndrome: A systematic review. Hum Reprod Update 2011;17:171-83.
Goodman NF, Cobin RH, Futterweit W, Glueck JS, Legro RS, Carmina E; American Association of Clinical Endocrinologists (AACE); American College of Endocrinology (ACE); Androgen Excess and PCOS Society. American Association of clinical endocrinologists, American college of endocrinology, and androgen excess and pcos society disease state clinical review: Guide to the best practices in the evaluation and treatment of polycystic ovary syndrome – PART 2. Endocr Pract 2015;21:1415-26.
Li Y, Xu S, Zhang X, Yi Z, Cichello S. Skeletal intramyocellular lipid metabolism and insulin resistance. Biophys Rep 2015;1:90-8.
Hutchison SK, Teede HJ, Rachon D, Harrison CL, Strauss BJ, Stepto NK. Effect of exercise training on insulin sensitivity, mitochondria and computed tomography muscle attenuation in overweight women with and without polycystic ovary syndrome. Diabetologia 2012;55:1424-34.
Harrison CL, Stepto NK, Hutchison SK, Teede HJ. The impact of intensified exercise training on insulin resistance and fitness in overweight and obese women with and without polycystic ovary syndrome. Clin Endocrinol (Oxf) 2012;76:351-7.
Almenning I, Rieber-Mohn A, Lundgren KM, Shetelig Løvvik T, Garnæs KK, Moholdt T. Effects of high intensity interval training and strength training on metabolic, cardiovascular and hormonal outcomes in women with polycystic ovary syndrome: A pilot study. PLoS One 2015;10:e0138793.
Kong Z, Fan X, Sun S, Song L, Shi Q, Nie J. Comparison of high-intensity interval training and moderate-to-vigorous continuous training for cardiometabolic health and exercise enjoyment in obese young women: A randomized controlled trial. PLoS One 2016;11:e0158589.
Miri M, Karimi Jashni H, Alipour F. Effect of exercise intensity on weight changes and sexual hormones (androstenedione and free testosterone) in female rats with estradiol valerate-induced PCOS. J Ovarian Res 2014;7:37.
Brown AJ, Setji TL, Sanders LL, Lowry KP, Otvos JD, Kraus WE, et al.
Effects of exercise on lipoprotein particles in women with polycystic ovary syndrome. Med Sci Sports Exerc 2009;41:497-504.
Abazar E, Taghian F, Mardanian F, Forozandeh D. Effects of aerobic exercise on plasma lipoproteins in overweight and obese women with polycystic ovary syndrome. Adv Biomed Res 2015;4:68.
] [Full text]
Benrick A, Maliqueo M, Miao S, Villanueva JA, Feng Y, Ohlsson C, et al.
Resveratrol is not as effective as physical exercise for improving reproductive and metabolic functions in rats with dihydrotestosterone-induced polycystic ovary syndrome. Evid Based Complement Alternat Med 2013;2013:964070.
Covington JD, Bajpeyi S, Moro C, Tchoukalova YD, Ebenezer PJ, Burk DH, et al.
Potential effects of aerobic exercise on the expression of perilipin 3 in the adipose tissue of women with polycystic ovary syndrome: A pilot study. Eur J Endocrinol 2015;172:47-58.
Vizza L, Smith CA, Swaraj S, Agho K, Cheema BS. The feasibility of progressive resistance training in women with polycystic ovary syndrome: A pilot randomized controlled trial. BMC Sports Sci Med Rehabil 2016;8:14.
Cheema BS, Vizza L, Swaraj S. Progressive resistance training in polycystic ovary syndrome: Can pumping iron improve clinical outcomes? Sports Med 2014;44:1197-207.
Lara LA, Ramos FK, Kogure GS, Costa RS, Silva de Sá MF, Ferriani RA, et al.
Impact of physical resistance training on the sexual function of women with polycystic ovary syndrome. J Sex Med 2015;12:1584-90.
Ramos FK, Lara LA, Kogure GS, Silva RC, Ferriani RA, Silva de Sá MF, et al.
Quality of life in women with polycystic ovary syndrome after a program of resistance exercise training. Rev Bras Ginecol Obstet 2016;38:340-7.
Thomson RL, Brinkworth GD, Noakes M, Clifton PM, Norman RJ, Buckley JD. The effect of diet and exercise on markers of endothelial function in overweight and obese women with polycystic ovary syndrome. Hum Reprod 2012;27:2169-76.
Conte F, Banting L, Teede HJ, Stepto NK. Mental health and physical activity in women with polycystic ovary syndrome: A brief review. Sports Med 2015;45:497-504.
Ennour-Idrissi K, Maunsell E, Diorio C. Effect of physical activity on sex hormones in women: A systematic review and meta-analysis of randomized controlled trials. Breast Cancer Res 2015;17:139.
Stener-Victorin E, Holm G, Janson PO, Gustafson D, Waern M. Acupuncture and physical exercise for affective symptoms and health-related quality of life in polycystic ovary syndrome: Secondary analysis from a randomized controlled trial. BMC Complement Altern Med 2013;13:131.
Banting LK, Gibson-Helm M, Polman R, Teede HJ, Stepto NK. Physical activity and mental health in women with polycystic ovary syndrome. BMC Womens Health 2014;14:51.
Costa EC, de Sá JC, Costa IB, Meireles Rda S, Lemos TM, Elsangedy HM, et al.
Affect-regulated exercise: An alternative approach for lifestyle modification in overweight/obese women with polycystic ovary syndrome. Gynecol Endocrinol 2015;31:971-5.