Obesity, insulin resistance and Polycystic Ovary Syndrome

Polycystic Ovary Syndrome (PCOS) affects 12 to 21% of Australian reproductive-aged women and is a major public health concern (1-5). Whilst reproductive features (anovulation, infertility) are prominent, PCOS also has major metabolic [obesity, metabolic syndrome, type 2 diabetes (T2DM), cardiovascular disease risk factors] and psychological features (6-8). Obesity is a major chronic disease, with rising prevalence and diverse health impacts. The interplay between PCOS and weight contributes to the long-term consequences of PCOS, but is not well understood. Women with PCOS demonstrate insulin resistance (IR), which leads to adverse health consequences, both independent of and exacerbated by obesity. Here, I explore the poorly understood interplay between PCOS, IR, metabolic complications and weight. My clinical research aims to assess prevalence and severity of IR in PCOS and explore novel markers of IR: Pigment Epithelium-Derived Factor (PEDF) and vitamin D. Women with PCOS were more insulin resistant than body mass index (BMI)-matched controls. IR was present in 75% of lean women with PCOS, 62% of overweight controls and 95% of overweight women with PCOS. IR was exacerbated by increased BMI. PEDF was not elevated in PCOS, was not associated with IR and was not reduced by exercise training, despite improved IR. It was mainly obesity related and is not a useful marker of IR. Despite similar adiposity, vitamin D levels were lower in overweight women with PCOS compared with overweight controls. Vitamin D was associated with IR in PCOS, but not in the non-PCOS group. PCOS is an insulin resistant state with intrinsic IR, exacerbated by lifestyle/obesity mediated extrinsic IR. Measurement of IR remains a challenge; novel simple markers of IR are needed. New interventions to manage IR, including potentially vitamin D, need to be studied. My epidemiological research examines the natural history of PCOS and the relationship between PCOS, weight and complications. Extensive data from the Australian Longitudinal Study on Women’s Health (ALSWH) was analysed to explore the prevalence of PCOS, the impact of obesity and relationship to reproductive and metabolic complications. We found that weight, body mass index (BMI) and weight gain over 10 years was higher in women reporting PCOS compared to those not reporting PCOS. BMI was the key predictor of PCOS status. Women with PCOS reported less contraception use and higher rates of trying to conceive, higher rates of infertility and use of fertility treatment including ovulation induction, but not increased in-vitro fertilisation. Reported pregnancy loss was higher in PCOS (related to fertility treatment and BMI, but not PCOS per se). The number of children per woman was similar in PCOS and non-PCOS groups, albeit with higher rates of fertility treatment. After conception and delivery, high BMI was negatively correlated with breastfeeding, suggesting the need for greater lactation support for overweight women. PCOS alone does not appear to impact on breastfeeding. PCOS was associated with higher prevalence of gestational diabetes and T2DM, independent of BMI. This suggests that all women with PCOS should be screened pre-conception or early in pregnancy, during pregnancy and in non-pregnant states for gestational diabetes and T2DM. PCOS status was not associated with hypertension, however BMI was, highlighting the need for blood pressure monitoring in overweight and obese women. This thesis addresses key gaps in our understanding of the natural history of PCOS. It provides important insight into aetiology and natural history of PCOS and advances the area by providing greater understanding of the interplay between BMI and PCOS and related complications.