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The Link Between Diabetes and PCOS
November is Diabetes Awareness Month, bringing with it several alarming statistics from the American Diabetes Association:
- There are nearly 26 million adults and children living with diabetes and another 79 million at high risk for developing Type 2 diabetes.
- Diabetes kills more people each year than breast cancer and AIDS combined.
- Recent estimates project that as many as 1 out of 3 American adults will have diabetes in the year 2050.
These are scary statistics, but what do they have to do with infertility? A lot, particularly if you have been diagnosed with polycystic ovarian syndrome (PCOS). Women with PCOS are at higher risk of developing Type 2 diabetes.
Diabetes is a disorder of the metabolism — the way the body breaks down and uses food for growth and energy.
When a person eats, food is broken down into glucose, the form of sugar in the blood. Then the pancreas automatically produces the right amount of insulin to move glucose from the blood into the cells. In a person with diabetes, however, the pancreas either produces little or no insulin or the cells do not respond appropriately to the insulin that is produced. This causes the glucose to build up in the blood and pass out of the body in the urine, and the body loses its main source of fuel.
Type 2 diabetes is the most common form of diabetes. In Type 2, the pancreas is usually producing enough insulin, but the body is not using it effectively — a condition called insulin resistance.
Polycystic ovarian syndrome (PCOS) is also a metabolic disorder and is one of the most common causes of infertility for women. It is characterized by an excess of androgens (male hormones), cysts on the ovaries and irregular menstrual cycles/lack of ovulation.
Women who are diagnosed with PCOS are at increased risk for a condition known as pre-diabetes — blood glucose levels that are higher than normal but not yet high enough to be diagnosed as diabetes. Approximately 30 to 40 percent of women with PCOS have pre-diabetes, and 12.6 percent have Type 2 diabetes, according to "Defining prediabetes in polycystic ovarian syndrome," an article by Mark P. Trolice, M.D., published online in the June 2011 Open Journal of Obstetrics and Gynecology, In addition, the article states that up to 65 to 70 percent of women with PCOS are obese and often have insulin resistance, placing them at overt risk for diabetes.
"The more weight that a woman gains, the more insulin her body produces," says Carolyn Gundell, MS, a nutritionist with Reproductive Medicine Associates (RMA) of Connecticut. "Insulin is actually a growth hormone, and extra levels of insulin in the body promote weight gain. Insulin resistance develops over time when insulin receptors do not respond well. Insulin's main role is to transport our main source of fuel — blood glucose — into our body's cells where it can be used as energy. As insulin resistance increases, insulin receptors become more resistant, and the pancreas will send more insulin into the bloodstream to help lower blood glucose levels. Left uncontrolled, high insulin causes more weight gain, which increases more resistance, producing more insulin —and this chronic stress, wear and tear condition progresses to diabetes."
Women with PCOS are also more likely to experience miscarriage and develop gestational diabetes.
Correcting Insulin Resistance to Improve Fertility and Reduce Risk of Type 2 Diabetes
Insulin resistance is the condition in which the pancreas produces insulin, but the body does not use it properly. Because of the relationship between insulin resistance and PCOS, Dr. Trolice recommends in his article that patients with PCOS should receive a two-hour Glucose Tolerance Test (GTT) or an HgA1C (Glycosylated Hemoglobin) because a fasting glucose alone has a false negative rate of up to 30 percent in diagnosing pre-diabaetes.
Women with insulin resistance may have normal glucose levels, because their body is overcompensating by producing higher levels of insulin to keep their blood glucose levels normal. The higher insulin levels can lead to more fat storage (obesity) and disruption of proper ovarian hormone production, which prevents ovulation.
There is a genetic component to insulin resistance; however, lifestyle factors such as excess weight and lack of exercise contribute greatly to the problem. Losing weight with a healthy diet and exercise is the most effective way to correct insulin resistance, increase fertility and prevent Type 2 diabetes and the resulting complications.
"Many studies show us that the loss of 5 to 10 percent of total body weight can dramatically increase insulin sensitivity and in turn decrease the amount of androgens circulating in the woman's blood and in her ovaries," Gundell says. "Weight loss can then restore ovulation and menstruation."
Gundell recommends a meal plan with less animal and more vegetable protein made up of 25 percent protein, 45 percent complex carbohydrates and 30 percent heart healthy fats to help increase insulin sensitivity, promote weight loss, restore regular ovulation and increase fertility. "Meal plan choices should avoid refined and processed carbohydrates, trans fats, growth hormones and endocrine disruptors," she says.
Exercise should be consistent and daily physical activity that provides enjoyment, stress reduction and physical fitness. "This could mean being involved in a variety of choices throughout the week — from yoga to aerobic to resistance training and at a moderate work out level."
Patients with PCOS and insulin resistance may also be prescribed an insulin-sensitizing medication such as metformin (glucophage), an oral medication approved by the FDA for the treatment of Type 2 diabetes. There is some clinical trial evidence that when metformin is taken with the ovulation-inducing drug clomiphene citrate (Clomid), there is improved ovulation and pregnancy. However, more research is needed.
According to Dr. Trolice's article: "Initial enthusiasm for the application of metformin in PCOS patients has waned as the available evidence is inconsistent regarding its beneficence, particularly in those trying to conceive and in adolescence."
The best thing to do is talk to your doctor and fertility doctor about the best ways to treat PCOS and insulin resistance and reduce your risk for Type 2 diabetes and the complications that can follow.
"The best gift that a parent can give their child is the gift of health," Gundell says, "and it starts long before conception."
For more information on PCOS, visit FertilityAuthority's PCOS Awareness Page.