Metabolic effects of PCOS

Here at Sirona Health, we want to ensure that we prevent disease, rather than reacting when it has already occurred.  We also prioritise personalisation of your health advice, using cutting edge research to help you optimise your health.

PCOS is one of the most common hormone disorders in women of reproductive age with a global prevalence between 7-12%, depending on the diagnostic criteria used. It has been suggested that up to 70% of women with PCOS remain undiagnosed.  One of our first priorities at Sirona Health is therefore to offer testing for PCOS so that you can know if you are at higher risk of developing metabolic complications such as type 2 diabetes mellitus.

Metabolic syndrome

Patients with PCOS are at high risk for metabolic diseases.  Metabolic syndrome is a condition that includes insulin resistance, obesity, raised cholesterol and triglycerides, and raised blood pressure.  Metabolic syndrome affects 33% of women with polycystic ovary syndrome (PCOS) and has been less well researched than other features such as infertility, anovulation and hirsutism.  Insulin resistance, which is thought to be the first step in the development of metabolic syndrome, seems to be a core part of PCOS, affecting 35-80% of women[1], although it is not currently included in the diagnostic criteria.  PCOS is also associated with chronic low-grade systemic inflammation, which worsens insulin resistance and accelerates heart disease.

Type 2 diabetes mellitus

Polycystic ovarian syndrome (PCOS) represents one of the highest risk factors for development of type 2 diabetes mellitus in young women.[2]

Type 2 diabetes mellitus is a condition in which you have high blood glucose levels, and over time this excess glucose can cause damage to many organs and tissues in the body. Type 2 diabetes mellitus develops because to functions involving insulin management are not working correctly in the body.  The first is that the body becomes resistant to insulin, meaning that insulin doesn’t have as great an effect on the cell.  There second is that pancreas, where insulin is created, does not produce insulin in response to a spike in glucose in the normal way.[3]

The UK and international guidelines all stipulate that women should be offered an oral glucose tolerance test (OGTT) at the time of diagnosis with PCOS.  They then differ in their future recommendations, with screening being offered to either only those with abnormalities detected at the initial screen or to all women with PCOS, screening being done between every 1-3 years, and testing being the OGTT or HbA1c.

The current strategy for diabetes screening in PCOS using traditional markers of dysglycemia (fasting blood glucose or HbA1c) appears to be too little, too late.[4][5]

Five stages of evolving beta-cell dysfunction during progression to diabetes. Diabetes2004;53(Suppl 3):S16-21. doi:10.2337/diabetes.53.suppl_3.S16 pmid:15561905

Currently screening only identifies the progression to diabetes at stage 3 or 4, when diabetes is likely to occur within 3 years, but at Sirona Health we aim to try to detect changes at stage 1 or 2.  This will give you more time to implement lifestyle changes to prevent further progression.  OGIS (oral glucose insulin sensitivity) is not available on the NHS but provides information on both insulin sensitivity and insulin production.  The OGIS requires three samples for measurement of plasma glucose and insulin: fasting, 90 minutes, and 120 minutes.[6]

If you are identified at being at risk of developing type 2 diabetes mellitus, then here at Sirona Health, we can support you in implementing lifestyle measures, but we can also consider prescribing metformin, a medication which helps to reverse insulin resistance.[7][8]

Non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) is metabolic condition which is strongly associated with insulin resistance.  It is a build-up of fat, specifically triglycerides, within the cells of the liver which isn’t caused by drinking alcohol.  Normally the liver cells only have very little fat within them, <5%, but this is raised in NAFLD. 

The exact cause for NAFLD is unknown.  It has been shown to be more prevalent in women with PCOS, affecting around 40% which is over double the rate in women without PCOS, particularly in women with raised androgens.  It is also more prevalent in women with a raised BMI, who have type II DM, raised lipids, raised blood pressure or who are on tamoxifen.

The NHS does not offer screening for the condition as it isn’t cost effective.  Diagnosis of NAFLD is strictly only possible with a biopsy of the liver but this is an invasive procedure and is therefore not recommended due to the risks in involved.  At Sirona Health we can measure your liver function blood tests and you refer you for an ultrasound scan if you have risk factors for developing NAFLD, to measure the amount of fat within the liver.  This will diagnose 80-90% cases of NAFLD.  If you would like the most sensitive test, one that is as accurate as liver biopsy, then we can organise a MRI scan for you. We can also do blood tests to check your liver function, blood sugar and platelet count to assess your NAFLD score.  If NAFLD is diagnosed, then you should have blood tests to check for progression of metabolic syndrome and liver function tests or have an Enhanced Liver Fibrosis (ELF) test at least every 3 years to check for disease progression.  If you don’t have the condition but are at continued risk of developing it, you should be screened again every 3 years

References

[1] Amisi CA. Markers of insulin resistance in Polycystic ovary syndrome women: An update. World J Diabetes. 2022 Mar 15;13(3):129-149. doi: 10.4239/wjd.v13.i3.129. PMID: 35432749; PMCID: PMC8984569.

[2] Polycystic ovary syndrome is a risk factor for type 2 diabetes: results from a long-term prospective study. Diabetes 2012;61:2369-74. doi:10.2337/db11-1360 pmid:22698921

[3] Quantification of the relationship between insulin sensitivity and beta-cell function in human subjects. Evidence for a hyperbolic function. Diabetes1993;42:1663-72. doi:10.2337/diab.42.11.1663 pmid:8405710

[4] Current diagnostic criteria identify risk for type 2 diabetes too late. Lancet Diabetes Endocrinol2023;11:224-6. doi:10.1016/S2213-8587(23)00039-6 pmid:36803366

[5] Five stages of evolving beta-cell dysfunction during progression to diabetes. Diabetes2004;53(Suppl 3):S16-21. doi:10.2337/diabetes.53.suppl_3.S16 pmid:15561905

[6] Development and assessment of the disposition index based on the oral glucose tolerance test in subjects with different glycaemic status. J Physiol Biochem2016;72:121-31. doi:10.1007/s13105-015-0458-0 pmid:26660757

[7] From Prediabetes to Type 2 Diabetes Mellitus in Women with Polycystic Ovary Syndrome: Lifestyle and Pharmacological Management. Int J Endocrinol2020;2020:6276187.

[8] An observational study of reduction of insulin resistance and prevention of development of type 2 diabetes mellitus in women with polycystic ovary syndrome treated with metformin and diet. Metabolism2008;57:954-60. doi:10.1016/j.metabol.2008.02.011 pmid:18555837