Exercise in polycystic ovarian syndrome: An evidence-based review

Abstract

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

Full text

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© 2017 Saudi Journal of Sports Medicine | Published by Wolters Kluwer - Medknow
1
22
Alva’s College of Physiotherapy and Research Center, 2Department of
Physiotherapy, Alva’s College of Physiotherapy, Moodbidri, Mangalore,
1Center for Sport Science Medicine and Research, School of Allied
Health Sciences, Manipal University, Manipal, Karnataka, India
Mr. Baskaran Chandrasekaran,
Center for Sport Science Medicine and Research, School of Allied
Health Sciences, Manipal University, Manipal, Karnataka, India.
E‑mail: baskaran.c@manipal.edu
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.[1] The prevalence rate is
about 9.13% in Indian adolescents and 3.7% in young women.[2]
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.[3] 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.[1]
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.[1] 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.[1,2] Insulin
resistance (IR) and its compensatory hyperinsulinemia are
proposed as significant etiological factors of PCOS.[4] All these
factors are said to be substantial cause for hyperandrogenism
in PCOS patients.[1] 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.[5]
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
Exercise in polycystic ovarian syndrome: An
evidence-based review
ABSTRACT
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 meta‑analyses 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
Review Article
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Oliverraj J. Exercise in polycystic ovarian syndrome: An evidence-based
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Shetty, et al.: Evidence of exercise in PCOS
124 Saudi Journal of Sports Medicine / Volume 17 / Issue 3 / September-December 2017
intolerance, and endothelial dysfunction.[6] 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.[6]
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.[7] Insulin receptors
are present in significant amount in ovaries and impairment
of insulin signaling in theca cells increases the production
of androgens.[8] 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.[9]
Obese individuals exhibit marked skeletal muscle IR as
compared that of lean individuals who are related to higher
body mass index in PCOS women.[10] 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.[11] 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.[12] Exercise training has
shown significant improvement in irregularity of menstrual
cycles and ovulation in about 50% women diagnosed
with PCOS which improves body composition.[13] Further
weight loss may reduce pulse amplitude of luteinizing
hormone (LH) in turn reducing androgen production.[14] 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.[15] 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.[16]
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.[17] 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.[10]
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.
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.
Conditioning phase:
Aerobic training:
• 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.
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Saudi Journal of Sports Medicine / Volume 17 / Issue 3 / September-December 2017
Contd...
Table 1: The current evidence behind effects of exercise on Polycystic Ovarian Syndrome women
Source Study design Participants Method Exercise intervention Inference Evidence
grade
Intensity Duration Freq uency
Aerobic exercise training on PCOS
Almenning
et al., 2015[18]
Pilot three-arm
parallel RCT
31 PCOS
patients
Assigned to
high-intensity
interval training,
traditional
strength training,
and control
HITT - 4 sessions of
4 min. With 90% HR
maximum: 3 min of
70% HR
Resistance training:
8 exercise/three
sets/10 reps
10 week
Control group:
>150 min of
calisthenics
3 days/week Insulin resistance
reduced and improved
flow-mediated
vasodilatation
1b
Kong et al.,
2016[19]
Parallel RCT 31 PCOS
patients
HITT compared
to moderate
to vigorous,
continuous
exercise
HITT - 8 s cycle:
12 s rest. Continuous
exercise 60%-80%
VO2 peak
HITT - 20:40 min
rest
Both 4 days/
week for
5 weeks
No difference in body
weight reduction
Testosterone and
estradiol reduced in
HITT
Physical enjoyment
more in HITT and less
time
1b
Miri et al.,
2014[20]
Animal RCT 30 PCOS rats
versus ten
controls
Relation between
exercise and sex
hormones in rats
Moderate (70%-75%)
and low (50%-55%
VO2 peak)
60 min Six sessions/
week,
8 weeks
Higher testosterone
and androstenedione
in PCOS rate
No difference in body
weight
2b
Hutchison
et al., 2012[16]
Dual-arm RCT 44 individuals
(16 PCOS,
13 non-PCOS
overweight)
Mitochondrial
biogenesis
and lipid after
exercise in
overweight PCOS
and normal
Moderate (70%) or
vigorous (90%-95%
VO2 max)
60 min Six 5 min
intervals with
2 min
Significant
improvement in
insulin resistance
whereas no change
in mitochondrial
biogenesis and lipids
3b
Brown et al.,
2009[21]
Two-arm RCT
(exercise
compared with
usual care)
37 PCOS
patients
Individualized
exercise
prescription from
STRRIDE study
versus usual care
group
50% VO2 peak in
treadmill
60 min/session 12 weeks Decreased large VLDL
chylomicrons
Improvement in HDL
Improvement in insulin
resistance
2b
Abazar et al.,
2015[22]
Case-control 24 PCOS
patients
Compared with
aerobic exercise
and usual care
60%-70% HR
maximum
60 min 3 weeks for
12 weeks
Reduced body
composition and lipid
profile in PCOS
3b
Benrick
et al., 2013[23]
Case controlled
animal trial
Not specified
PCOS-induced
rats
Compared
resveratrol
alone and with
exercise
Ran on treadmill
1-1.5 km/day
Not available 5 days/week
and 5 weeks
Exercise decrease
adipose and insulin
resistance than
revertol
Both did not reduce
the bone mass loss in
PCOS individuals
4
Covington
et al., 2015[24]
Case–control
(8 PCOS and
eight control)
16 individuals
(8 PCOS and
eight control)
Effect of aerobic
exercise on
lipolysis
55% VO2 ma x
(progressive energy
expenditure)
16 we ek s 5 days/week Improved lipolysis
and lipid uptake
regulation
Improved insulin
sensitivity
2c
Resistance exercise training on PCOS
Vizza et al.,
2016[25]
Two-arm parallel
pilot RCT
15 PCOS
patients
Assigned to
progressive
resistance
exercise and no
exercise (usual
care)
Not specified 60 min for
12 weeks
Four
sessions/
week
Increased BMI, lean
body mass, and
reduced HbA1C
Reduction in
depression
2b
Cheema et
al., 2014[26]
Nonsystematic
review
108 PCOS Relation to
exercise,
hormones, and
insulin resistance
60% 1 RM (15 reps)
progress to 70%-85%
1 RM (8-12 reps)
2-3
nonconsecutive
days/week
Two sets of
5-8 types
of 3 sets for
12 weeks
PRT improves insulin
sensitivity
Regulates weight and
fertility
2a
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Shetty, et al.: Evidence of exercise in PCOS
126 Saudi Journal of Sports Medicine / Volume 17 / Issue 3 / September-December 2017
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
Table 1: Contd...
Source Study design Participants Method Exercise intervention Inference Evidence
grade
Intensity Duration Freq uency
Lara et al.,
2015[27]
Case-control
study
43 PCOS
women
Evaluated
resistance
exercise over
sexual function
and emotional
status
70%-90% (1 RM) for
8-15 reps
Three
nonconsecutive
days
16 weeks Increases sexual
excitement,
lubrication, and
emotional status
regulation
3a
Ramos et al.,
2016[28]
Case-control
study
43 PCOS
versus 51
healthy
females
Quality of Life
after resistance
exercise training
for 16 weeks
60% 1 RM with 5%
every week 3 series
of 10 reps/set
Not specified 16 weeks Improved functional
capacity domain of
SF36
3a
Physical activity and li festyle modifications on PCOS
Thomson
et al., 2016[29]
Three
randomized
parallel group
trial
41 overweight/
obese PCOS
patients
Assigned to one
of three groups:
Diet, combined
diet and aerobic
exercise,
combined diet,
aerobic and
resistance
exercise
Walking/jogging,
resistance training
(not specified)
25 min 5 days/week Diet with aerobic or
combined aerobic and
resistance exercise
is better than diet
alone in reducing
depression, improved
exercise barriers
2b
Conte et al.,
2015[30]
Systematic
review
456 PCOS
patients
Exercise
compared with
usual care
Not available Not available Not available Of 73 studies initially
recruited, only
seven studies were
included. Though
training seemed to
be antidepressive,
inconclusive evidence
exists
3a
Ennour-Idrissi
et al., 2015[31]
Meta-analysis of
RCTS
18 RCTS (1994
PCOS)
Physical activity
with no physical
activity
Not available Not available Not available Significant
reduction in sex
hormones (estradiol,
testosterone,
androstenedione) after
physical activity in
PCOS patients
1a
Stener-
Victorin et al.,
2013[32]
Two-arm RCT 72 PCOS Individual effects
of acupuncture
and exercise
over usual care
Self-paced brisk
walk, cycle faster
than normal walk
>120 beats/min
30 min Three days/
week for
16 weeks
Anxiety and
depression reduced
across all the group
Fertility domain
improved with
exercise group
2b
Banting et al.,
2014[33]
Cross-sectional 217 women
(154 PCOS)
Relation between
physical activity
and mental
health in PCOS
patients
Not available Not available Not available PCOS women are
better in physical
activity but more
anxious than non-
PCOS
2c
Costa et al.,
2015 [34]
Single time
observational
trial
14 o b e se
PCOS
individuals
Effect of A RE
in aerobic
capacity. GPS
and HR monitors
were used to
gauge physical
activity
Warm- up - 5 min
Pleasurable intensity
- 40 min
Cool dow n - 5 min
40 min 1 day GPS and HR monitor
with affective words
through phones
improved physical
activity intensity and
joy in PCO S patients
2c
ARE=Affect regulated exercise, PCOS=Polycystic ovarian syndrome, RCT=Randomized controlled trial, HR=Heart rate, RM=Repetition maximum, Reps=Repetition, GPS=Global positioning system,
HITT=High intensity interval training, VLDL=Very low density lipoprotein, HDL=High-density lipoprotein, BMI=Body mass index, HbA1C=Glycated hemoglobin, PRT=Progressive resistance training
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• 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.
Acknowledgments
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
Nil.
Conicts of interest
There are no conflicts of interest.
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