Management of Polycystic Ovarian Syndrome: A Qualitative Inquiry among Complementary and Alternative Medicine Practitioners in South Africa

BACKGROUND

 Polycystic ovarian syndrome (PCOS) is a complex reproductive endocrinopathy affecting 4-20% of females of reproductive age. PCOS and its consequent complications such as infertility, diabetes mellitus and cardiovascular disease significantly impact clinical management. Complementary and alternative medicine (CAM), including homeopathy, is gaining recognition in PCOS management. There remains a paucity of formal protocols for managing PCOS within homeopathy and other CAM systems.

AIMS/OBJECTIVES

 This study aimed to explore and document existing therapeutic practices in the management of PCOS from diagnosis to treatment used by practitioners within various disciplines of CAM: viz., homeopathy, ayurveda, unani tibb, traditional Chinese medicine (TCM) and naturopathy, in the context of their unique philosophical background.

METHODS

 In this explorative, descriptive study, data were collected from CAM practitioners in eThekwini Municipality, KwaZulu Natal, South Africa, using semi-structured interviews and analysed using Tesch's and Creswell's methods for qualitative analysis.

RESULTS

 Four themes emerged from the data, namely: CAM philosophical perspectives on PCOS, contributing factors, diagnosis of PCOS, and management of PCOS. Five sub-themes emerged: clinical diagnosis of PCOS, CAM-specific characterisation of PCOS, CAM-specific treatment of PCOS, adjunctive therapies, and lifestyle interventions. Homeopathic management comprised several prescribing methods, the most common ones being miasmatic/constitutional, keynote and clinical, alongside adjunctive therapies and lifestyle interventions. Other CAM modalities adopted similar holistic approaches.

CONCLUSIONS

 This paper offers a comprehensive exploration of the perceptions, clinical investigations and management practices in PCOS by homeopaths and four other CAM modalities - ayurveda, unani tibb, TCM and naturopathy - as documented in the study. Homeopaths and other CAM practitioners employed CAM-specific therapies, along with adjunctive therapies and lifestyle interventions, adopting holistic approaches. Enhancing the quality of life through emotional counselling, stress reduction and lifestyle improvements emerged as shared objectives across modalities. Our findings underscore the need to further explore inter-disciplinary collaboration in PCOS management among registered CAM practitioners, with the potential to expand the scope of comprehensive care for PCOS patients.

Recent Advances in Individualized Clinical Strategies for Polycystic Ovary Syndrome: Evidence From Clinical Trials and Emerging Pharmacotherapies

PURPOSE

Clinical trials are advancing the treatment of polycystic ovary syndrome (PCOS), an endocrine disorder affecting 8-13% of women. Lifestyle interventions, including nutritional plans, physical activity, and stress management, can improve reproductive hormones and metabolic health. Novel pharmacotherapies targeting hormonal, metabolic, and reproductive abnormalities are being explored for individualized treatment. Combination therapies and lifestyle interventions like acupuncture, high-intensity interval training, and vitamin D3 supplementation are also being explored.

METHODS

We conducted a narrative review by searching English-language studies across electronic databases such as PubMed, Science direct, and Google Scholar for articles related to the topics of PCOS and novel drug therapies such as metformin, LIK-066, elagolix, saxenda, exenatide, clomiphene, letrozole, and other diagnostic interventions. Our review excluded preclinical studies and articles not in english.

FINDINGS

In addition to pharmacological treatments, lifestyle interventions such as Tung's acupuncture, high-intensity interval training (HIIT), and vitamin D3 supplementation have proven effective in managing symptoms of PCOS and enhancing overall health outcomes. These interventions offer a complementary approach to traditional medical therapies, emphasizing the importance of integrating lifestyle modifications into the treatment plan for women with PCOS.

IMPLICATIONS

This comprehensive approach underscores the importance of tailored treatments in optimizing clinical outcomes and quality of life for women with PCOS. The aim of this review is to highlight recent advancements in the treatment of PCOS through clinical trials and emerging pharmacotherapies, emphasizing the need for individualized and multifaceted treatment approaches.

Systematic low-grade chronic inflammation and intrinsic mechanisms in polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a prevalent endocrine and metabolic disorder affecting 6-20% of women of childbearing age worldwide. Immune cell imbalance and dysregulation of inflammatory factors can lead to systematic low-grade chronic inflammation (SLCI), which plays a pivotal role in the pathogenesis of PCOS. A significant higher infiltration of immune cells such as macrophages and lymphocytes and pro-inflammatory factors IL-6 and TNF-α has been detected in PCOS organ systems, impacting not only the female reproductive system but also other organs such as the cardiovascular, intestine, liver, thyroid, brain and other organs. Obesity, insulin resistance (IR), steroid hormones imbalance and intestinal microecological imbalance, deficiencies in vitamin D and selenium, as well as hyperhomocysteinemia (HHcy) can induce systematic imbalance between pro-inflammatory and anti-inflammatory cells and molecules. The pro-inflammatory cells and cytokines also interact with obesity, steroid hormones imbalance and IR, leading to increased metabolic imbalance and reproductive-endocrine dysfunction in PCOS patients. This review aims to summarize the dysregulation of immune response in PCOS organ system and the intrinsic mechanisms affecting SLCI in PCOS to provide new insights for the systemic inflammatory treatment of PCOS in the future.

Efficacy of physical activity in polycystic ovary syndrome treatment

PURPOSE OF REVIEW

Physical activity (PA) is acknowledged as an important component of lifestyle therapy in the management of polycystic ovary syndrome (PCOS). The purpose of this current systematic review is to analyze recent literature assessing the role of PA and exercise interventions as potential treatment for PCOS.

RECENT FINDINGS

The recent literature published since 2022 has focused on understanding the specific benefits of different PA modalities on PCOS pathophysiology, suggesting that high intensity exercise may relay greater metabolic improvements, although results are still inconclusive; expanding our understanding of the impact PA has on a wider range of outcomes, including sleep, quality of life, inflammation, and DNA methylation; and recognizing barriers and limitations of implementing efficacious PA interventions for individuals with PCOS.

SUMMARY

Current literature supports a role for PA in improving PCOS-related cardiometabolic and reproductive outcomes; however, there is still a significant evidence gap of high-quality studies assessing optimal exercise regimens as well as strategies for implementing PA interventions in real-world settings for individuals with PCOS.

Exercise in the management of polycystic ovary syndrome: A position statement from Exercise and Sports Science Australia

Polycystic ovary syndrome (PCOS) is the most prevalent endocrine condition amongst females of reproductive age, leading to lifelong cardiometabolic, reproductive, psychological, and dermatologic symptoms as well as a reduced quality of life. Lifestyle interventions, which can include structured exercise programmes delivered by appropriately trained exercise professionals such as clinical exercise physiologists, are considered first-line strategies in PCOS management due to their therapeutic effects on various health outcomes and quality of life. This position statement builds on the 2023 International Evidence-based Guideline for the Assessment and Management of PCOS and describes the role of the exercise professional in the context of the multidisciplinary care team which includes physicians and allied health professionals. This position statement aims to equip exercise professionals with a broad understanding of the pathophysiology of PCOS, how it is diagnosed and managed in clinical practice, and evidence- and consensus-based recommendations for physical activity and exercise in PCOS management. In line with the physical activity recommendations for the general public, individuals with PCOS should aim to undertake between 150 to 300min of moderate-intensity or 75 to 150min of vigorous-intensity aerobic activity per week, or an equivalent combination of both spread throughout the week. Additionally, muscle-strengthening activities on two non-consecutive days per week are recommended to maintain health and prevent weight gain. For further health benefits and to achieve modest weight loss, individuals with PCOS should aim for a minimum of 250min of moderate-intensity or 150min of vigorous-intensity aerobic activity per week, or an equivalent combination of both spread throughout the week, plus muscle-strengthening activities on two non-consecutive days per week. Adolescents with PCOS should aim for a minimum of 60min moderate- to vigorous-intensity activity each day, incorporating muscle- and bone-strengthening activities three times per week. Finally, exercise professionals should consider the significant psychological burden, including weight stigma, and the high prevalence of comorbidities amongst individuals with PCOS and take appropriate measures to deliver safe and efficacious exercise interventions.

The effects of different exercises on weight loss and hormonal changes in women with polycystic ovarian syndrome: a network meta-analysis study

BACKGROUND

Polycystic ovarian syndrome (PCOS) is one of the most common endocrine illnesses. There is evidence that exercise training positively affects on improvement of the pathogenic factors in women with PCOS. On the other hand, some studies reported similar effects of aerobic and resistance exercises or no effect of exercises on the improvement of the pathogenic factors. The aim of the current study was to perform a network meta-analysis of RCTs to evaluate the efficacy of exercises on body mass index (BMI), hormone concentrations, and regular menstruation in women with PCOS.

METHODS

The search was performed from databases of PubMed, Scopus, and Web of Science with the keywords of exercise, resistance exercise, aerobic exercise, endurance exercise, yoga, polycystic ovary syndrome, randomized controlled trial based on the CONSORT, BMI, sex hormone and regular menstruation from inception until April 15, 2022. Bayesian random-effects network meta-analyses were performed to calculate mean difference and 95% credible intervals.

RESULTS

Out of 1140 studies, 19 were eligible for inclusion. The results showed that moderate-intensity aerobic exercise effectively reduces BMI compared to no intervention and Yoga. No other forms of exercise led to weight loss. Additionally, exercise had no impact on sex hormones and regular menstruation. It was concluded that moderate-intensity aerobic exercise is the most effective for reducing BMI in women with PCOS.

CONCLUSIONS

Due to the limitations regarding the small sample size and lack of subgroup and sensitivity analysis, the results of this study demonstrated that moderate-intensity, aerobic exercise is the most effective exercise for reducing BMI, while the other exercises were ineffective. Moderate-intensity aerobic exercise is suggested to decrease the BMI in women with PCOS.

SYSTEMATIC REVIEW REGISTRATION

This systematic review and network meta-analysis study was registered in PROSPERO (CRD42022324839).

Interval training and cardiometabolic health in reproductive-aged females

Physical activity and exercise training are especially important for reproductive-aged females as exercise-induced health benefits can also affect their infants. However, levels of physical inactivity remain high among females in this age group, before, during, and after pregnancy. There is a great need for practical and feasible exercise modes to increase adherence to exercise in this population, and interval training may be a time-efficient training modality. Interval training is a form of exercise involving intermittent bouts of intense effort interspersed with recovery periods of rest or lower-intensity exercise. A substantial amount of research indicates that interval training induces superior cardiometabolic health benefits compared with iso-energetic moderate-intensity continuous exercise. This review provides a comprehensive overview of research on interval training interventions in reproductive-aged females across various life stages, focusing on the cardiometabolic health benefits. We discuss the potential role of interval training in premenopausal females with overweight/obesity, polycystic ovary syndrome, and subfertility, as well as the potential influence of oral contraceptives on cardiometabolic adaptations to interval training. Furthermore, this review also highlights recent findings supporting the beneficial role of high-intensity interval training for cardiometabolic health outcomes during pregnancy. In summary, the existing evidence suggests that interval training can improve several cardiometabolic and reproductive outcomes in females spanning different life stages. However, more research is needed to further strengthen the evidence-base for physical activity recommendations for females in their reproductive years of life.

Vigorous vs. moderate exercise to improve glucose metabolism in inactive women with polycystic ovary syndrome and insulin resistance: a pilot randomized controlled trial of two home-based exercise routines

Objective

To study the impact of vigorous vs. moderate exercise on metabolic parameters in polycystic ovary syndrome (PCOS).

Design

Randomized controlled trial.

Setting

Unsupervised home-based exercise program.

Patients

Patients with PCOS on the basis of the Rotterdam criteria with insulin resistance.

Interventions

Participants were block randomized to a home-based exercise program of 75 minutes of vigorous exercise or 150 minutes of moderate exercise per week, for 8 weeks total.

Main Outcome Measures

Changes in glucose, insulin, and insulin resistance.

Results

In total, 36 participants were randomized, of whom 20 completed the study. The percentage changes from baseline at 4 and 8 weeks for fasting glucose, insulin, and homeostatic model assessment for insulin resistance did not significantly differ between the groups, except for the change in the 8-week glucose level, which was more favorable in the moderate arm (8.06% [standard deviation, 6.44%] in the vigorous group compared with -0.32% [standard deviation, 4.91%] in the moderate group). The absolute values of the main outcomes (fasting glucose, insulin, and homeostatic model assessment for insulin resistance) at baseline and 4 and 8 weeks did not significantly differ between trial arms. When assessing the change from baseline at 4 and 8 weeks, overall and within each trial arm, only the 8-week fasting glucose level was significantly greater than the baseline value in the vigorous arm (93.5 [95% confidence interval, 88.7-98.3] vs. 86.8 [95% confidence interval, 81.1-92.4]).

Conclusions

Unsupervised short-term exercise programs may not achieve significant metabolic improvements in patients with PCOS, regardless of vigorous vs. moderate intensity. Future studies should investigate this question in larger sample sizes and longer or structured exercise programs.

Clinical Trial Registration Number

ClinicalTrials.gov identifier, NCT02303470.

Mass Sportrometry: An annual look back at applications of mass spectrometry in sport and exercise science

Research in sport and exercise science (SES) is reliant on robust analyses of biomarker measurements to assist with the interpretation of physiological outcomes. Mass spectrometry (MS) is an analytical approach capable of highly sensitive, specific, precise, and accurate analyses of a range of biomolecules, many of which are of interest in SES including, but not limited to, endogenous metabolites, exogenously administered compounds (e.g. supplements), mineral ions, and circulating/tissue proteins. This annual review provides a summary of the applications of MS across studies investigating aspects related to sport or exercise in manuscripts published, or currently in press, in 2022. In total, 93 publications are included and categorized according to their methodologies including targeted analyses, metabolomics, lipidomics, proteomics, and isotope ratio/elemental MS. The advantageous analytical opportunities afforded by MS technologies are discussed across a selection of relevant articles. In addition, considerations for the future of MS in SES, including the need to improve the reporting of assay characteristics and validation data, are discussed, alongside the recommendation for selected current methods to be superseded by MS-based approaches where appropriate. The review identifies that a targeted, mostly quantitative, approach is the most commonly applied MS approach within SES, although there has also been a keen interest in the use of 'omics' to perform hypothesis-generating research studies. Nonetheless, MS is not commonplace in SES at this time, but its use to expand, and possibly improve, the analytical options should be continually considered to exploit the benefits of analytical chemistry in exercise/sports-based research. Overall, it is exciting to see the gradually increasing adoption of MS in SES and it is expected that the number, and quality, of MS-based assays in SES will increase over time, with the potential for 2023 to further establish this technique within the field.

The Effect of Tailored Short Message Service (SMS) on Physical Activity: Results from a Three-Component Randomized Controlled Lifestyle Intervention in Women with PCOS

This analysis of secondary outcome measures of a randomized controlled trial was conducted to study the effect of a one-year three-component (cognitive behavioural therapy, diet, exercise) lifestyle intervention (LSI), with or without additional Short Message Service (SMS) support, on physical activity and aerobic capacity in overweight or obese women with polycystic ovary syndrome (PCOS). Women diagnosed with PCOS and a BMI > 25 kg/m² were randomly assigned to LSI with SMS support (SMS+, n = 60), LSI without SMS support (SMS-, n = 63) or care as usual (CAU, n = 60) in order to lose weight. Based on results from the International Physical Activity Questionnaire (IPAQ), we found a significant within-group increase after one year for SMS+ in the high physical activity category (+31%, p < 0.01) and sitting behaviour decreased (Δ -871 min/week, p < 0.01). Moreover, the peak cycle ergometer workload increased within SMS+ (Δ +10 watts, p < 0.01). The SMS+ group also demonstrated a significantly different increase in walking metabolic equivalent of task minutes (METmin)/week compared with CAU after one year (Δ 1106 METmin/week, p < 0.05). Apart from this increase in walking activity, no other between-group differences were found in this trial. Overall, based on within-group results, SMS support seemed to help with improving physical activity and aerobic capacity and decreasing sedentary behaviour.

Diet and Exercise in the Management of Polycystic Ovary Syndrome: Practical Considerations for Person-Centered Care

Polycystic ovary syndrome (PCOS) is a complex multisystem condition associated with life-long reproductive, metabolic, and psychological symptoms. Individuals with PCOS are at an increased risk of cardiovascular disease and type 2 diabetes, with approximately 70% of all PCOS cases presenting with insulin resistance. Lifestyle interventions have historically been recommended as first-line therapies for the management of PCOS-related cardiometabolic disorders. The term "lifestyle management" incorporates a multifaceted approach to dietary, exercise, and behavioral strategies, aiming to promote a healthy lifestyle. This approach has been commonly employed in practice, in particular through exercise and dietary modulation, due to its effect on cardiometabolic outcomes as well as its tolerability. Furthermore, there is evidence to suggest that combining dietary change with exercise may yield the greatest improvements in clinical outcomes. However, such practices require careful consideration and coordination, as there are instances where certain exercise and/or dietary prescriptions may compromise the effectiveness of the respective interventions. Thus, this review aims to provide practical guidance on diet and exercise planning in the routine care of PCOS. Such recommendations include emphasizing realistic and achievable goals, as well as minimizing barriers to lifestyle changes in order to increase the long-term sustainability of this treatment strategy.

Efficacy of high-intensity interval training for improving mental health and health-related quality of life in women with polycystic ovary syndrome

Women with PCOS have substantially greater symptoms of depression and anxiety, and a lower health-related quality of life (HRQoL) compared to women without PCOS. The aim of this study was to determine if high-intensity interval training (HIIT) could provide greater improvements in mental health outcomes than standard moderate-intensity continuous training (MICT). Twenty-nine overweight women with PCOS aged 18-45 years were randomly assigned to 12 weeks of either MICT (60-75% HRpeak, N = 15) or HIIT (> 90% HRpeak, N = 14). Outcome measures included symptoms of depression, anxiety and stress (DASS-21), general HRQoL (SF-36) and PCOS specific HRQoL (PCOSQ) collected at baseline and post-intervention. Reductions in depression (Δ - 1.7, P = 0.005), anxiety (Δ - 3.4, P < 0.001) and stress (Δ - 2.4, P = 0.003) scores were observed in the HIIT group, while MICT only resulted in a reduction in stress scores (Δ - 2.9, P = 0.001). Reductions in anxiety scores were significantly higher in the HIIT group compared to the MICT group (β = - 2.24, P = 0.020). Both HIIT and MICT significantly improved multiple domain scores from the SF-36 and PCOSQ. This study highlights the potential of HIIT for improving mental health and HRQoL in overweight women with PCOS. HIIT may be a viable strategy to reduce symptoms of depression and anxiety in women with PCOS, however, large-scale studies are required to confirm these findings.Trial registration number: ACTRN12615000242527.

Insulin resistance in polycystic ovary syndrome across various tissues: an updated review of pathogenesis, evaluation, and treatment

Polycystic ovary syndrome (PCOS) is a common endocrine disorder characterized by chronic ovulation dysfunction and overabundance of androgens; it affects 6-20% of women of reproductive age. PCOS involves various pathophysiological factors, and affected women usually have significant insulin resistance (IR), which is a major cause of PCOS. IR and compensatory hyperinsulinaemia have differing pathogeneses in various tissues, and IR varies among different PCOS phenotypes. Genetic and epigenetic changes, hyperandrogenaemia, and obesity aggravate IR. Insulin sensitization drugs are a new treatment modality for PCOS. We searched PubMed, Google Scholar, Elsevier, and UpToDate databases in this review, and focused on the pathogenesis of IR in women with PCOS and the pathophysiology of IR in various tissues. In addition, the review provides a comprehensive overview of the current progress in the efficacy of insulin sensitization therapy in the management of PCOS, providing the latest evidence for the clinical treatment of women with PCOS and IR.

Longitudinal affective response to high-intensity interval training and moderate-intensity continuous training in overweight women with polycystic ovary syndrome: A randomised trial

BACKGROUND

Women with polycystic ovary syndrome (PCOS) experience general and PCOS-specific barriers that limit their engagement with exercise and contribute to high attrition from exercise programs, hindering the potential benefits of exercise to address their increased cardio-metabolic risk. A positive remembered affective response can predict future intentions and adherence to exercise prescription.

OBJECTIVES

To compare the longitudinal changes in remembered affect to high-intensity interval training (HIIT) and moderate-intensity continuous training (MICT) in women with PCOS and to determine whether longitudinal changes in remembered affect are correlated with changes in fitness, body mass index, adherence and exercise enjoyment.

METHODS

Physically inactive, overweight women with PCOS were randomly assigned to 12 weeks of either HIIT (n = 15) or MICT (n = 14) (3 sessions per week). Remembered affective valence (Feeling Scale) was collected after each exercise session. Cardiorespiratory fitness (VO2peak) was assessed at baseline and post-intervention. Exercise enjoyment was assessed post-intervention.

RESULTS

The longitudinal changes in the remembered affect were more positive in the HIIT group compared to MICT (β = 0.017, p = 0.047). HIIT was also considered more enjoyable than MICT (p = 0.002). Adherence was high in both groups (>90%). We found a moderate correlation with longitudinal changes between the remembered affect and change in fitness (rs = 0.398) and exercise enjoyment (rs = 0.376) using the combined group, however, these were not statistically significant (p = 0.054 and p = 0.064, respectively).

CONCLUSIONS

HIIT demonstrated a more positive longitudinal remembered affective response and greater exercise enjoyment compared to MICT in overweight women with PCOS.

Key signalling pathways underlying the aetiology of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a common endocrine condition characterised by a range of reproductive, endocrine, metabolic and psychological abnormalities. Reports estimate that around 10% of women of reproductive age are affected by PCOS, representing a significant prevalence worldwide, which poses a high economic health burden. As the origin of PCOS remains largely unknown, there is neither a cure nor mechanism-based treatments leaving patient management suboptimal and focused solely on symptomatic treatment. However, if the underlying mechanisms underpinning the development of PCOS were uncovered then this would pave the way for the development of new interventions for PCOS. Recently, there have been significant advances in our understanding of the underlying pathways likely involved in PCOS pathogenesis. Key insights include the potential involvement of androgens, insulin, anti-Müllerian hormone and transforming growth factor beta in the development of PCOS. This review will summarise the significant scientific discoveries on these factors that have enhanced our knowledge of the mechanisms involved in the development of PCOS and discuss the impact these insights may have in shaping the future development of effective strategies for women with PCOS.

Transforming growth factor β1 impairs the transcriptomic response to contraction in myotubes from women with polycystic ovary syndrome

Abstract

Polycystic ovary syndrome (PCOS) is characterised by a hormonal imbalance affecting the reproductive and metabolic health of reproductive‐aged women. Exercise is recommended as a first‐line therapy for women with PCOS to improve their overall health; however, women with PCOS are resistant to the metabolic benefits of exercise training. Here, we aimed to gain insight into the mechanisms responsible for such resistance to exercise in PCOS. We employed an in vitro approach with electrical pulse stimulation (EPS) of cultured skeletal muscle cells to explore whether myotubes from women with PCOS have an altered gene expression signature in response to contraction. Following EPS, 4719 genes were differentially expressed (false discovery rate <0.05) in myotubes from women with PCOS compared to 173 in healthy women. Both groups included genes involved in skeletal muscle contraction. We also determined the effect of two transforming growth factor β (TGFβ) ligands that are elevated in plasma of women with PCOS, TGFβ1 and anti‐Müllerian hormone (AMH), alone and on the EPS‐induced response. While AMH (30 ng/ml) had no effect, TGFβ1 (5 ng/ml) induced the expression of extracellular matrix genes and impaired the exercise‐like transcriptional signature in myotubes from women with and without PCOS in response to EPS by interfering with key processes related to muscle contraction, calcium transport and actin filament. Our findings suggest that while the fundamental gene expression responses of skeletal muscle to contraction is intact in PCOS, circulating factors like TGFβ1 may be responsible for the impaired adaptation to exercise in women with PCOS.

Key points

Gene expression responses to in vitro contraction (electrical pulse stimulation, EPS) are altered in myotubes from women with polycystic ovary syndrome (PCOS) compared to healthy controls, with an increased expression of genes related to pro‐inflammatory pathways.

Transforming growth factor β1 (TGFβ1) upregulates genes related to extracellular matrix remodelling and reduces the expression of contractile genes in myotubes, regardless of the donor's health status.

TGFβ1 alters the gene expression response to EPS, providing a possible mechanism for the impaired exercise adaptations in women with PCOS.