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Review  |   January 2019
Nonpharmacologic Management of Symptoms in Females With Polycystic Ovary Syndrome: A Narrative Review
Author Notes
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to Diana L. Speelman, PhD, Lake Erie College of Osteopathic Medicine, 2000 W Grandview Blvd, Erie, PA 16509-1029. Email: dspeelman@lecom.edu
     
Article Information
Endocrinology / Obstetrics and Gynecology
Review   |   January 2019
Nonpharmacologic Management of Symptoms in Females With Polycystic Ovary Syndrome: A Narrative Review
The Journal of the American Osteopathic Association, January 2019, Vol. 119, 25-39. doi:https://doi.org/10.7556/jaoa.2019.006
The Journal of the American Osteopathic Association, January 2019, Vol. 119, 25-39. doi:https://doi.org/10.7556/jaoa.2019.006
Web of Science® Times Cited: 2
Abstract

Polycystic ovary syndrome is the most common hormone disorder in females of reproductive age, affecting reproductive, metabolic, and cardiovascular health. With an unknown cause and a spectrum of common signs and symptoms, diagnosis is based on consensus criteria, and treatment options often target individual symptoms, with variable effectiveness. Safe, effective complementary and alternative therapies can be used to manage symptoms. The first-line intervention is lifestyle modification, including weight loss when appropriate, with caloric restriction and exercise to maintain a healthy weight. Low-carbohydrate and/or low-glycemic index diets can provide additional benefits, and nutritional supplements may be useful adjuncts. The recommended physical activity regimen should include both aerobic and resistance exercise.

Polycystic ovary syndrome (PCOS) is the most common hormone disorder in females of reproductive age, affecting 5% to 15%.1,2 The most common cause of anovulatory infertility, it can affect female reproductive, metabolic, cardiovascular, and psychological health. Common findings include irregular menses due to oligo-ovulation, subfertility, a higher rate of miscarriage, obesity, insulin resistance, greater risk of type 2 diabetes mellitus, sympathetic hyperactivity, anxiety, and depression.3-6 The prevalence of PCOS is comparable across different races, societies, and geographic locations, although some groups have a predominantly reproductive phenotype and other groups have a more pronounced metabolic phenotype.2,7 
The cause of PCOS remains5 unknown, but the condition is probably due to a combination of genetic, epigenetic, and environmental factors, including in utero exposure to androgens. It thus remains a diagnosis dependent on consensus criteria and the exclusion of other endocrinopathies. The 2003 Rotterdam criteria,8 which are most commonly used, require the presence of at least 2 of 3 features for diagnosis: hyperandrogenism (clinical or biochemical), menstrual irregularity secondary to oligo-ovulation or anovulation, and polycystic ovaries (Table 1). Hyperandrogenism, an absolute requirement according to the 1990 National Institutes of Health consensus criteria and the Androgen Excess Society recommendations for diagnosis, may be identified with a blood test (for elevated free testosterone levels) or by the presence of acne or hirsutism.9 In addition, other potential causes of these features should be ruled out, including congenital adrenal hyperplasia, androgen-secreting tumors, hyperprolactinemia, and thyroid disorders.1,9 
Table 1.
Diagnostic Features of Polycystic Ovary Syndromea
Diagnostic Feature Criteria
Hyperandrogenismb ■ Elevated free (recommended) or total testosterone level
■ Clinical acne (particularly facial and along jaw)
■ Hirsutism (modified Ferriman Gallwey score >8)
■ Alopecia
Menstrual irregularity ■ Menstrual cycles >35 d or ≤8 menstrual cycles/y
■ Cycles tend to be unpredictable
■ Menstrual irregularity secondary to oligo-ovulation or anovulation
Polycystic ovariesc Ovarian volume >10 mL in either ovary or >12 cysts present on either ovary (seen with ultrasonography)

a The Rotterdam criteria8 for diagnosis of polycystic ovary syndrome (PCOS) require at least 2 of the 3 listed features.

b One of the criteria need to be present for hyperandrogenism.

c Polycystic ovaries are not a requirement for diagnosis of PCOS.

Table 1.
Diagnostic Features of Polycystic Ovary Syndromea
Diagnostic Feature Criteria
Hyperandrogenismb ■ Elevated free (recommended) or total testosterone level
■ Clinical acne (particularly facial and along jaw)
■ Hirsutism (modified Ferriman Gallwey score >8)
■ Alopecia
Menstrual irregularity ■ Menstrual cycles >35 d or ≤8 menstrual cycles/y
■ Cycles tend to be unpredictable
■ Menstrual irregularity secondary to oligo-ovulation or anovulation
Polycystic ovariesc Ovarian volume >10 mL in either ovary or >12 cysts present on either ovary (seen with ultrasonography)

a The Rotterdam criteria8 for diagnosis of polycystic ovary syndrome (PCOS) require at least 2 of the 3 listed features.

b One of the criteria need to be present for hyperandrogenism.

c Polycystic ovaries are not a requirement for diagnosis of PCOS.

×
Polycystic ovary syndrome may present around the onset of puberty, although it is more commonly diagnosed in the late teens or early 20s.3,6 Clinical presentation of acne and menstrual irregularity are considered common in adolescence, which can contribute to delayed diagnosis of PCOS. Research indicates that the menstrual cycle should become regular within 1 to 2 years after menarche, underscoring the need to follow up on any reported menstrual irregularities persisting longer, so that interventions and counseling can be initiated sooner to improve the patient's quality of life.10-12 Some adolescents present with obesity and metabolic dysfunction, such as insulin resistance, which can worsen PCOS symptoms, features, and sequelae.6,13 For these patients, it is particularly important to diagnose the disorder as early as possible so these effects can be attenuated. More often, PCOS is not diagnosed until its reproductive effects become apparent, with ovulatory dysfunction leading to subfertility and difficulty getting pregnant, as well as an increased rate of miscarriage.1,3,6,13,14 
Polycystic ovary syndrome can affect multiple aspects of female health throughout the life span. In addition to the well-known reproductive consequences and the triad of features associated with PCOS, females with this disorder often exhibit glucose intolerance, hyperinsulinemia, insulin resistance, dyslipidemia, weight gain, and higher body mass index (BMI), making PCOS a metabolic as well as an endocrine and reproductive disorder.3,6 Females with PCOS are more than 4 times more likely to develop type 2 diabetes than women without the disorder and are at increased risk even if lean.16,17 Females with PCOS are also more likely to develop cardiovascular sequelae, owing in part to obesity and insulin abnormalities. Furthermore, they are reported to have sympathetic hyperactivity, which may contribute to or exacerbate the pathogenesis of the disorder through effects on the ovaries and cardiovascular system, as well as a higher prevalence of anxiety and depression.16-18 
Pharmacologic treatments may be effective in targeting specific symptoms associated with PCOS, but they are often limited in scope. They may be contraindicated in some patients, may produce adverse effects, and are sometimes not effective. For example, hormonal contraceptives may be used to regulate the menstrual cycle but are contraindicated for use in some females with PCOS and may cause weight gain, intermenstrual bleeding, nausea, headaches, mood changes, and decreased libido.21,22 The ovulation-inducing drug clomiphene citrate may be used to help achieve pregnancy, but headache, nausea, visual disturbances, or ovarian hyperstimulation syndrome may occur with its use; furthermore, pregnancy is not achieved in up to 30% of women receiving this treatment.23 Metformin, an insulin sensitizier, is often prescribed for patients with PCOS, including off-label use for improving pregnancy rates; however, it can cause gastrointestinal disturbances, and its safety for use during pregnancy is debated.24-27 A survey of women with PCOS found that they are interested in complementary approaches to managing symptoms, citing a desire for more holistic, potentially safer modalities with fewer adverse effects.28 This review examines the evidence for nonpharmacologic treatment options and their benefits and limitations in women with PCOS. 
Review of the Literature
A search for studies evaluating nonpharmacologic treatments for women with PCOS was conducted by searching PubMed for specific combinations of terms. All searches included at least 1 of the following terms: polycystic ovary syndrome, PCOS, hyperandrogenism, or hyperandrogenemia. Additional keywords included alternative, complementary, nonpharmacologic, natural, diet, dietary, food, nutrient, nutrition, supplement, herb, herbal, vitamin, mineral, exercise, aerobic, training, activity, yoga, or acupuncture PLUS clinical trial, control(led) trial, RCT, randomiz(s)ed control(led) trial, cross-sectional, retrospective, prospective, or women. Citations from review articles were cross-referenced with PubMed literature search results and individually searched if not previously identified by the PubMed literature search results. All approved studies included women with a clinical diagnosis of PCOS as participants in at least 1 group and were written in English. Animal studies were excluded. 
Weight Loss
Up to 88% of people with PCOS are overweight or obese.29 In addition to the standard health concerns for obese patients, some of the signs and symptoms associated with PCOS can be exacerbated by obesity, such as menstrual irregularity, reduced fertility rates, hyperandrogenism, and insulin resistance.30-32 Females with PCOS are reportedly more susceptible to weight gain than women without PCOS.29,33 Furthermore, women with PCOS may have adipose tissue dysfunction.34 Adipose is more than just a storage depot for triglycerides. It is an endocrine tissue capable of secreting and responding to a number of different hormones. One such adipose-derived hormone, adiponectin, exerts insulin-sensitizing and anti-inflammatory effects in the body. Women with PCOS, like persons with diabetes and cardiovascular disease, are reported to have lower than normal serum levels of adiponectin, which is likely tied to the greater prevalance of insulin resistance in this population.33 
Obesity itself does not cause PCOS, but women with PCOS are more susceptible to weight gain than those without PCOS.1,30 Hyperandrogenemic females with PCOS have been reported to have a lower basal metabolic rate than females without the disorder, which may partially explain their higher prevalence of obesity.36,37 Lean women with PCOS reportedly consume fewer calories daily, and fewer calories from carbohydrates, than age- and BMI-matched women without PCOS, further suggesting that their basal metabolic rate is decreased.33 They also have an increased prevalence of insulin resistance, regardless of BMI.38 Insulin resistance promotes preferential storage of fuels in the adipose tissue, as well as metabolic inflexibility (difficulty in switching between carbohydrate and fat oxidation based on fuel availability), which can further contribute to obesity.39 Together, these findings suggest that females with PCOS must be more vigilant in maintaining a healthy BMI to minimize the signs and symptoms, as well as the long-term health sequelae, associated with the disorder. 
Because of the interrelationship between obesity and PCOS, lifestyle modification, particularly weight loss, is the first-line intervention, and weight loss can improve some aspects of health and the quality of life in patients with PCOS.30,40 Treating obesity first and foremost includes dietary restriction of calories to induce weight loss. Although studies of this type are challenging because of substantial attrition among participants, several studies have shown that even a 5% reduction in weight in anovulatory females can improve not only ovulatory function and response to fertility treatment but also metabolic parameters such as insulin sensitivity and body composition.41-43 In addition, hyperandrogenism may be decreased, albeit not eliminated, by weight loss.43 With the reciprocal relationship between insulin and androgens, whereby an increase in one stimulates an increase in the other, decreases in insulin levels can lead to decreases in androgen levels and vice versa.42,43 
Physical activity also contributes to weight loss and confers some additional benefits, but the greatest contributing factor to weight loss is caloric restriction. For patients who elect to undergo bariatric surgery, it has been shown that the resultant weight loss improves menstrual regularity and fertility and reduces hirsutism, further underscoring the relationship between obesity and PCOS presentation and the importance of achieving and maintaining a healthy weight. In addition to caloric restriction and regular physical activity, successful weight loss may also include behavioral or psychological therapy and social support.28 
Dietary Modification
Several studies have investigated the impact of dietary macronutrient composition on health and outcomes in females with PCOS. Carbohydrate intake is of particular interest, given how common hyperinsulinemia and insulin resistance are in both lean and overweight or obese women with PCOS.46 Persistent hyperinsulinemia can result in insensitivity of the insulin target cells and, in turn, can further contribute to hyperinsulinemia and an increased likelihood of type 2 diabetes. Furthermore, insulin resistance and hyperinsulinemia increase androgen levels in females with PCOS, which can make weight loss more difficult and may worsen some of the symptoms associated with the disorder, including menstrual irregularity, acne, hirsutism, and abdominal obesity.47 
Several groups have examined dietary restriction of carbohydrates (40% vs 55% of total calories from carbohydrates) in women with PCOS, with the hypothesis that reduced carbohydrate intake would translate into attenuated insulin release and therefore an improvement in insulin sensitivity and potentially decreased androgen levels. These studies reported weight loss and improvement in PCOS-associated symptoms, including improved insulin sensitivity, with a reduced-carbohydrate diet, as well as with a low–glycemic index diet.48,49 In a small but well-controlled study,50 8 weeks of a reduced-carbohydrate diet resulted in greater weight loss with preferential loss of adipose tissue, improved body composition and fat distribution, and improved postprandial insulin release. Together, these study findings suggest that reducing the percentage of calories that come from carbohydrates can both relieve some symptoms associated with PCOS and improve metabolic health. 
Beyond macronutrients, investigators have looked at different types of diets to determine whether they offer any benefit for females with PCOS. Some foods elicit a greater postprandial insulin response than others; for example, dairy products and starches stimulate greater insulin release than nonstarchy fruits and vegetables. Low-starch/low-dairy diets have been shown to improve fasting and postprandial fatty acid oxidation, reduce BMI and fat mass, and decrease fasting insulin levels 2 hours after a meal. In addition, serum total and free testosterone levels were reported to decrease after 8 weeks of this dietary intervention.51,52 However, it remains unknown whether these changes in insulin sensitivity and androgen levels were due to weight loss, the diet itself, reduced caloric intake, or some combination of these factors. In a larger, longitudinal study that examined the dietary patterns of females with or without PCOS, a Mediterranean-style diet was more common in females with PCOS.53 However, because this dietary pattern has been linked to decreased prevalence of metabolic syndrome and hypertension, as well as lower risk of gestational diabetes, this association may reflect improved diet quality after a diagnosis of PCOS.53,54 
With these findings taken together (Table 2), the current evidence-based dietary recommendation for females with PCOS is to eat a well-balanced diet, with plenty of fruits, vegetables, and whole grains, and to limit calories as needed to maintain a healthy weight.55 A low-carbohydrate diet may further confer benefits in terms of improved insulin sensitivity and body mass composition, with a preferential decrease in fat mass. A Mediterranean-style diet may provide some protection against cardiovascular disease risk factors, but interventional studies are needed to determine whether it offers a benefit for females with PCOS. 
Table 2.
Summary of Study Findings on Dietary Modifications in the Management of PCOS
Dietary Modification and Study Type of Study; Study Sizea Key Findings Summary Recommendations
Reduced-CHO or Low–Glycemic Load Diet
 Barr et al48 Nonrandomized, 12-wk control diet, then 12-wk isocaloric low–glycemic index intervention; 21 participants Improved insulin sensitivity and NEFAs with isocaloric low–glycemic-index diet Strongly recommended; this diet, particularly with reduced calories, may improve weight loss, insulin sensitivity, insulin levels, and body composition; hypocaloric diet and weight loss may improve T levels and lipid profile
 Mehrabani et al49 RCT; conventional hypocaloric diet or high-protein, low–glycemic load hypocaloric diet for 12 wk; 60 obese participants Similar weight loss, T and LDL-C reduction in both diet groups; high-protein, low–glycemic load group had reduced insulin, HOMA-IR, and hsCRP
 Goss et al50 Crossover eucaloric diet intervention with random diet order (reduced CHO diet [40% vs 55% cal] for 8 wk, standard diet for 8 wk, with 4-wk interval between diets); 30 participants Reduced-CHO diet group had greater weight loss, decreased subcutaneous and intra-abdominal fat, thigh intermuscular fat, and lower insulin AUC
Low-Starch, Low-Dairy Diet
 Phy et al51 Prospective, comparison before and after intervention; 8-wk ad libitum low-starch, low-dairy diet; 24 obese participants Reduced weight, waist circumference, waist-to-hip ratio, fasting and 2-h insulin, HOMA-IR, total and free T, and hirsutism Moderate recommendation, with additional studies needed; diet associated with reduced weight and decreased insulin levels, with further studies needed on effects on fuel oxidation and T levels; unclear whether changes are due to weight loss or diet itself
 Pohlmeier et al52 Prospective, comparison before and after intervention; 8-wk ad libitum low-starch, low-dairy diet; 10 obese participants Reduced weight and fasting insulin; reduced fasting and postprandial CHO oxidation, increased fasting and postprandial fat oxidation
Mediterranean Diet
 Moran et al53 Retrospective; dietary patterns from longitudinal study data; 7569 participants from 1973-1978 cohort assessed in 2009 (414 PCOS, 7155 non-PCOS) Mediterranean-style diet independently associated with PCOS status (for each 1-SD increase in diet pattern, 26% more likely to have PCOS). Unable to recommend at this time, with interventional studies needed; women may adopt Mediterranean-style diet after PCOS diagnosis

a All participants were women with PCOS unless otherwise noted.

Abbreviations: AUC, area under the curve; CHO, carbohydrate; HOMA-IR, homeostatic model assessment for insulin resistance; hsCRP, high-sensitivity C-reactive protein; LDL-C, low-density lipoprotein cholesterol; NEFAs, nonesterified fatty acids; PCOS, polycystic ovary syndrome; RCT, randomized controlled trial; T, testosterone.

Table 2.
Summary of Study Findings on Dietary Modifications in the Management of PCOS
Dietary Modification and Study Type of Study; Study Sizea Key Findings Summary Recommendations
Reduced-CHO or Low–Glycemic Load Diet
 Barr et al48 Nonrandomized, 12-wk control diet, then 12-wk isocaloric low–glycemic index intervention; 21 participants Improved insulin sensitivity and NEFAs with isocaloric low–glycemic-index diet Strongly recommended; this diet, particularly with reduced calories, may improve weight loss, insulin sensitivity, insulin levels, and body composition; hypocaloric diet and weight loss may improve T levels and lipid profile
 Mehrabani et al49 RCT; conventional hypocaloric diet or high-protein, low–glycemic load hypocaloric diet for 12 wk; 60 obese participants Similar weight loss, T and LDL-C reduction in both diet groups; high-protein, low–glycemic load group had reduced insulin, HOMA-IR, and hsCRP
 Goss et al50 Crossover eucaloric diet intervention with random diet order (reduced CHO diet [40% vs 55% cal] for 8 wk, standard diet for 8 wk, with 4-wk interval between diets); 30 participants Reduced-CHO diet group had greater weight loss, decreased subcutaneous and intra-abdominal fat, thigh intermuscular fat, and lower insulin AUC
Low-Starch, Low-Dairy Diet
 Phy et al51 Prospective, comparison before and after intervention; 8-wk ad libitum low-starch, low-dairy diet; 24 obese participants Reduced weight, waist circumference, waist-to-hip ratio, fasting and 2-h insulin, HOMA-IR, total and free T, and hirsutism Moderate recommendation, with additional studies needed; diet associated with reduced weight and decreased insulin levels, with further studies needed on effects on fuel oxidation and T levels; unclear whether changes are due to weight loss or diet itself
 Pohlmeier et al52 Prospective, comparison before and after intervention; 8-wk ad libitum low-starch, low-dairy diet; 10 obese participants Reduced weight and fasting insulin; reduced fasting and postprandial CHO oxidation, increased fasting and postprandial fat oxidation
Mediterranean Diet
 Moran et al53 Retrospective; dietary patterns from longitudinal study data; 7569 participants from 1973-1978 cohort assessed in 2009 (414 PCOS, 7155 non-PCOS) Mediterranean-style diet independently associated with PCOS status (for each 1-SD increase in diet pattern, 26% more likely to have PCOS). Unable to recommend at this time, with interventional studies needed; women may adopt Mediterranean-style diet after PCOS diagnosis

a All participants were women with PCOS unless otherwise noted.

Abbreviations: AUC, area under the curve; CHO, carbohydrate; HOMA-IR, homeostatic model assessment for insulin resistance; hsCRP, high-sensitivity C-reactive protein; LDL-C, low-density lipoprotein cholesterol; NEFAs, nonesterified fatty acids; PCOS, polycystic ovary syndrome; RCT, randomized controlled trial; T, testosterone.

×
Nutritional Supplementation
Multiple studies have investigated the efficacy of specific nutritional supplements for improving outcomes in PCOS, with menstrual irregularity often considered a primary outcome measure and secondary outcome measures including (but not limited to) ovulation rates, androgen levels, hirsutism, fasting serum glucose and insulin levels, waist-to-hip ratio, and levels of triglycerides, total cholesterol, luteinizing hormone (LH), and follicle-stimulating hormone (FSH). Nutritional supplements such as vitamins, minerals, and herbal extracts may be taken in conjunction with the diet. Of the supplements studied, calcium plus vitamin D, vitamin D alone, vitamin B complex, chromium, and green tea (Camellia sinensis) capsules were not found to have any significant effect on any of the outcomes measured in the respective studies56; however, other supplements were shown to have some benefits. 
In women with PCOS, omega-3 fish oils were found to reduce total cholesterol levels, significantly reduce fasting glucose and low-density lipoprotein cholesterol levels, and decrease homeostatic model assessment for insulin resistance (HOMA-IR) values in morbidly obese women with PCOS.57 Inositol (vitamin B8) supplementation increased the number of ovulations and the pregnancy rate, reduced total testosterone and androstenedione levels, and improved fasting serum glucose and insulin levels, HOMA-IR values, waist-to-hip ratios, and levels of total cholesterol, triglycerides, and C-reactive protein.58-61 No adverse effects were found for inositol compared with placebo. 
In studies of herbal supplements in females with PCOS, Cimicifuga racemosa plus clomiphene, compared with clomiphene alone, reduced the number of days to ovulation by 3 days, increased pregnancy rates, reduced the rate of miscarriages, and decreased levels of LH and FSH.62 Mentha spicata decreased serum testosterone in one study.63 A clinical trial of Glycyrrhiza species suggested that this herb could decrease testosterone levels,64 and a clinical trial of combination Paeonia lactiflora and Glycyrrhiza uralensis demonstrated reduced free and total testosterone levels.65 A study on P lactiflora and Cinnamomum cassia suggested reduced LH levels and improved ovulation in women with PCOS in a trial of infertility treatment.66 A small pilot study with C cassia supplementation showed improved decreased fasting and 2-hour insulin levels compared with pretreatment levels.65 
In another study, a combination herbal treatment (Cinnamomum verum, Glycyrrhiza glabra, Hypericum perforatum, P lactiflora, Tribulus terrestri) in conjunction with lifestyle modifications, compared with lifestyle modifications alone, was associated with reduced prevalence of oligomenorrhea; decreased BMI, insulin, and LH levels; higher pregnancy rates; decreased depression, anxiety, and stress; and improved quality of life. A mild adverse effect on blood pressure was reported, with both systolic and diastolic values slightly elevated after 3 months of intervention.68 
Although these findings are promising regarding the benefits of nutritional supplementation, particularly with inositol, omega-3 fish oils, and a few herbal supplements, the studies are limited in number and tend to exhibit some bias, often have small sample sizes, and do not always report on adverse effects (Table 3). Although vitamins and herbal supplements may seem attractive as complementary therapeutic options, patients must proceed with caution, as these supplements are not regulated by the US Food and Drug Administration, formulations and purity may vary between companies and even batches from the same company, and products should not be assumed to be safe simply because they are “natural.” Although supplements may confer specific benefits, such effects cannot be endorsed until further research is conducted and regulation of these supplements is improved. 
Table 3.
Summary of Study Findings on Nutritional Supplements in the Management of PCOS
Nutritional Supplement and Study Type of Study; Study Sizea Key Findings Summary Recommendations
Omega-3 Fish Oils
 Mohammadi et al57 RCT (double blind) with daily supplement or placebo for 8 wk; 61 obese participants Increased adiponectin and decreased glucose insulin, HOMA-IR, total cholesterol, and LDL-C compared with placebo; decreased TGs, increased HDL-C in omega-3 group compared with baseline Moderate recommendation for improving metabolic profile, with additional studies needed; improved metabolic profile (blood glucose, insulin sensitivity, lipid profile, adiponectin)
Inositol (Vitamin B8)
 Costantino et al58 RCT (double blind) with folic acid with or without myo-inositol for 12-16 wk; 42 participants Before vs after myo-inositol: decreased total and free T, TGs, BP, insulin AUC; increased insulin sensitivity, ovulation Recommended; improvement in ovulation rate, metabolic profile, and androgen profile
 Gerli et al59 RCT (double blind) with folic acid with or without myo-inositol for 14 wk; 92 participants Greater ovulation frequency; less time to first ovulation; increased HDL-C and weight loss; leptin reduction; more efficacious with lower BMI
 Iuorno et al60 RCT with daily inositol or placebo for 6-8 wk; 20 lean participants Decreased insulin AUC, free T, BP, TGs; more women ovulated
 Jamilian et al61 RCT with myo-inositol or metformin for 12 wk; 60 participants Decreased total T, hirsutism, hsCRP when taking myo-inositol
Herbal Supplements
 Shahin et al62 RCT with clomiphene citrate alone or plus Cimicifuga racemosa (black cohosh); 194 participants with PCOS and infertility With black cohosh: fewer days until hCG injection; greater endometrial thickness; midluteal estrogen, and progesterone; more pregnancies Promising findings, with additional studies needed; in conjunction with clomiphene citrate, may increase pregnancy rate
 Grant63 RCT with twice-daily Mentha spicata (spearmint) or placebo herbal tea for 30 days; 41 participants Reduced free and total T Additional studies needed; small study; placebo was also an herbal tea
 Armanini et al64 RCT with spironolactone with or without Glycyrrhiza species (licorice) for 2 menstrual cycles; 32 participants With licorice: reduced T during first 4 days of combination treatment Additional studies needed; small study, not blinded
 Takahashi and Kitao65 Single-arm clinical trial with daily dose Paeonia lactiflora and Glycyrrhiza uralensisb for 24 wk; 34 participants Reduced T after 4 wk of treatment Additional studies needed; small study, not blinded, no control group
 Ushiroyama et al66 RCT of anovulatory women, with a PCOS subgroup, taking combination P lactiflora and Cinnamomum cassia or placebo daily for 8 wk; 38 participants in PCOS subgroup Reduced LH, ovulation in 50% of PCOS subgroup Inconclusive evidence, additional studies needed; preparation contained additional herbal extracts; no baseline description of subgroup
 Wang et al67 RCT with daily C cassia or placebo for 8 wk; 15 participants Reduction in insulin resistance (fasting and 2-h insulin) before vs after treatment in cinnamon group Additional studies needed; small pilot study
 Arentz et al68 RCT with lifestyle modification with or without combination herbal tablets for 3 mo; 112 overweight participants Improved menstrual regularity and quality of life; decreased BMI, insulin, LH, and BP; reduced depression, anxiety/stress; increased pregnancy rates. Promising findings, additional studies needed; unclear which herbs or combination of herbs, and which lifestyle modifications, had an effect

a All participants were women with PCOS unless otherwise noted.

b Chinese peony/common garden peony and Chinese licorice.

c Five herbal extracts: Cinnamomum verum, Glycyrrhiza glabra, Hypericum perforatum, Plactiflora, and Tribulus terrestris.

Abbreviations: AUC, area under curve; BMI, body mass index; BP, blood pressure; hCG, human chorionic gonadotropin; HDL-C, high-density lipoprotein cholesterol; HOMA-IR, homeostatic model assessment for insulin resistance; hsCRP, high-sensitivity C-reactive protein; LDL-C, low-density lipoprotein cholesterol; LH, luteinizing hormone; PCOS, polycystic ovary syndrome; RCT, randomized controlled trial; T, testosterone; TGs, triglycerides.

Table 3.
Summary of Study Findings on Nutritional Supplements in the Management of PCOS
Nutritional Supplement and Study Type of Study; Study Sizea Key Findings Summary Recommendations
Omega-3 Fish Oils
 Mohammadi et al57 RCT (double blind) with daily supplement or placebo for 8 wk; 61 obese participants Increased adiponectin and decreased glucose insulin, HOMA-IR, total cholesterol, and LDL-C compared with placebo; decreased TGs, increased HDL-C in omega-3 group compared with baseline Moderate recommendation for improving metabolic profile, with additional studies needed; improved metabolic profile (blood glucose, insulin sensitivity, lipid profile, adiponectin)
Inositol (Vitamin B8)
 Costantino et al58 RCT (double blind) with folic acid with or without myo-inositol for 12-16 wk; 42 participants Before vs after myo-inositol: decreased total and free T, TGs, BP, insulin AUC; increased insulin sensitivity, ovulation Recommended; improvement in ovulation rate, metabolic profile, and androgen profile
 Gerli et al59 RCT (double blind) with folic acid with or without myo-inositol for 14 wk; 92 participants Greater ovulation frequency; less time to first ovulation; increased HDL-C and weight loss; leptin reduction; more efficacious with lower BMI
 Iuorno et al60 RCT with daily inositol or placebo for 6-8 wk; 20 lean participants Decreased insulin AUC, free T, BP, TGs; more women ovulated
 Jamilian et al61 RCT with myo-inositol or metformin for 12 wk; 60 participants Decreased total T, hirsutism, hsCRP when taking myo-inositol
Herbal Supplements
 Shahin et al62 RCT with clomiphene citrate alone or plus Cimicifuga racemosa (black cohosh); 194 participants with PCOS and infertility With black cohosh: fewer days until hCG injection; greater endometrial thickness; midluteal estrogen, and progesterone; more pregnancies Promising findings, with additional studies needed; in conjunction with clomiphene citrate, may increase pregnancy rate
 Grant63 RCT with twice-daily Mentha spicata (spearmint) or placebo herbal tea for 30 days; 41 participants Reduced free and total T Additional studies needed; small study; placebo was also an herbal tea
 Armanini et al64 RCT with spironolactone with or without Glycyrrhiza species (licorice) for 2 menstrual cycles; 32 participants With licorice: reduced T during first 4 days of combination treatment Additional studies needed; small study, not blinded
 Takahashi and Kitao65 Single-arm clinical trial with daily dose Paeonia lactiflora and Glycyrrhiza uralensisb for 24 wk; 34 participants Reduced T after 4 wk of treatment Additional studies needed; small study, not blinded, no control group
 Ushiroyama et al66 RCT of anovulatory women, with a PCOS subgroup, taking combination P lactiflora and Cinnamomum cassia or placebo daily for 8 wk; 38 participants in PCOS subgroup Reduced LH, ovulation in 50% of PCOS subgroup Inconclusive evidence, additional studies needed; preparation contained additional herbal extracts; no baseline description of subgroup
 Wang et al67 RCT with daily C cassia or placebo for 8 wk; 15 participants Reduction in insulin resistance (fasting and 2-h insulin) before vs after treatment in cinnamon group Additional studies needed; small pilot study
 Arentz et al68 RCT with lifestyle modification with or without combination herbal tablets for 3 mo; 112 overweight participants Improved menstrual regularity and quality of life; decreased BMI, insulin, LH, and BP; reduced depression, anxiety/stress; increased pregnancy rates. Promising findings, additional studies needed; unclear which herbs or combination of herbs, and which lifestyle modifications, had an effect

a All participants were women with PCOS unless otherwise noted.

b Chinese peony/common garden peony and Chinese licorice.

c Five herbal extracts: Cinnamomum verum, Glycyrrhiza glabra, Hypericum perforatum, Plactiflora, and Tribulus terrestris.

Abbreviations: AUC, area under curve; BMI, body mass index; BP, blood pressure; hCG, human chorionic gonadotropin; HDL-C, high-density lipoprotein cholesterol; HOMA-IR, homeostatic model assessment for insulin resistance; hsCRP, high-sensitivity C-reactive protein; LDL-C, low-density lipoprotein cholesterol; LH, luteinizing hormone; PCOS, polycystic ovary syndrome; RCT, randomized controlled trial; T, testosterone; TGs, triglycerides.

×
Aerobic Exercise and Resistance Training
Most studies on the effectiveness of physical exercise in improving the health of females with PCOS evaluate it in conjunction with dietary modification or nutritional counseling, and findings indicate that regular exercise is important for the maintenance of weight loss but may also provide some additional benefits. A combination of nutritional counseling with endurance and resistance exercise 3 days per week for 12 weeks decreased waist circumference and serum insulin levels in women who completed the dual intervention compared with women who received nutritional counseling alone.69 A 20-week intervention using a low-calorie, high-protein diet in combination with aerobic or aerobic plus resistance exercise improved body composition through preferential reduction in fat mass relative to the diet intervention alone; improvements in blood pressure, lipid profile values, fasting insulin and glucose and androgen levels, and reproductive function occurred across all intervention groups.68 
In studies that focused exclusively on exercise intervention, habitual physical activity (defined as taking >7500 steps per day) in females with PCOS was associated with lower BMI, smaller waist circumference, and lower androgen levels than in sedentary females with PCOS. Furthermore, each 2000-step daily step increment was associated with an decrease in the free androgen index.71 The intensity of physical exercise can also make a difference: vigorous exercise, independent of total exercise expenditure and BMI, has been shown to result in superior metabolic profiles (lower BMI and HOMA-IR values and higher high-density lipoprotein cholesterol and sex hormone–binding globulin levels) in women with PCOS, with every hour of vigorous exercise reducing the odds of metabolic syndrome by 22%.70 
Others have shown that 45 to 60 minutes of exercise thrice weekly for 12 weeks significantly increased insulin sensitivity and reduced central adiposity, although after the intervention women with PCOS still had lower insulin sensitivity than women without PCOS.73,74 However, studies suggest that despite differential expression of insulin resistance genes in women with PCOS, a single session of 40 minutes of exercise in women with PCOS may lead to comparable glucose transporter type 4 translocation and glucose uptake by the skeletal muscle and may increase insulin sensitivity.75,76 Given that insulin resistance seems to play a role in the pathologic mechanism of PCOS, any improvements in insulin sensitivity are likely to be beneficial, and regular exercise is an important means to achieve this goal. 
Beyond improvements in body composition, overall metabolic health, and insulin sensitivity, other benefits of exercise have been reported for women with PCOS. In one small study, women with PCOS were found to have higher circulating leukocyte levels than controls, and these levels were reduced after a 16-week aerobic exercise program in association with increased insulin sensitivity.77 Low-grade inflammation may contribute to adipose dysfunction, is associated with insulin resistance, and is common to both obesity and PCOS. The ability of aerobic exercise to reduce inflammation may represent one mechanism by which this type of intervention benefits women predisposed to metabolic dysfunction. 
Women with PCOS have greater lean muscle mass78,79 and muscle strength than those without PCOS, although this increase is associated with insulin resistance and central obesity rather than physical activity or androgens.80 Resistance exercise can increase lean muscle mass and is recommended by the American College of Sports Medicine and the American Diabetes Association for the prevention and treatment of chronic noncommunicable diseases in healthy adults.81 It is also recognized as an integral component in the management of type 2 diabetes.82 Despite the correlation between lean muscle mass, insulin resistance, and central obesity, resistance exercise alone may reduce hyperandrogenism, as well as improve body composition by decreasing central obesity and increasing lean muscle mass, albeit without significant metabolic improvements.83 However, one study did find a significant decrease in hemoglobin A1C after a 12-week resistance exercise intervention, as well as improvements in quality of life and reductions in depression and anxiety.84 These findings indicate that resistance exercise has benefits distinct from those of aerobic exercise. 
Together, a combination of aerobic and resistance exercise can improve reproductive function, decrease androgen levels, increase insulin sensitivity, and improve body composition, overall metabolic health, psychological health, and quality of life in women with PCOS (Table 4). Such intervention is most effective in conjunction with dietary modification and maintenance of a healthy weight. 
Table 4.
Summary of Study Findings on Physical Activity in the Management of PCOS
Physical Activity and Study Type of Study; Study Sizea Key Findings Summary Recommendations
Aerobic Exercise
 Mario et al71 Controlled cross-sectional study of walking with participants defined as active (>7500 steps/d) or sedentary (<7500 steps/d) by pedometer; 151 participants (84 PCOS, 67 non-PCOS) Active women with PCOS had lower waist circumference, lipid accumulation product, and androgen levels; HOMA-IR and 2000-step increments each independently predicted FAI Strongly recommended; exercise, particularly vigorous exercise, confers improvements in metabolic and hormone profiles; moderate exercise (eg, walking), can also improve metabolic and hormone profiles, and even short bouts provide benefits
 Greenwood et al72 Cross-sectional study with groups for vigorous exercise, moderate exercise, and inactive (DHHS guidelines); 326 participants Vigorous exercise associated with lower BMI, HOMA-IR; higher HDL-C and SHBG; every hour of vigorous exercise reduced odds of metabolic syndrome by 22%
 Harrison et al73 Prospective controlled intervention study with 3 weekly 1-h exercise sessions for 12 wk; 21 obese participants (13 PCOS, 8 non-PCOS) Decreased IR, but not to same level as controls; improvement in IR related to Vo2max
 Scott et al74 Prospective controlled intervention study with progressive 12-wk exercise program; 16 obese participants (9 PCOS, 7 non-PCOS) Small reductions in body fat (less than controls), reduced central adiposity, improved Vo2 peak and insulin sensitivity
 Dantas et al75 Prospective controlled intervention study with 40-min single bout of exercise; 27 obese participants (15 PCOS, 12 non-PCOS) Similar translocation of GLUT4 in controls and PCOS, albeit different pattern of protein phosphorylation (PCOS women still benefit from exercise)
 Covington et al77 Prospective controlled intervention study with 16-wk aerobic exercise program; 16 obese participants (8 PCOS, 8 non-PCOS) Higher levels of circulating leukocytes can be reversed with aerobic exercise; insulin sensitivity and leptin also improved
Aerobic and Resistance Exercise
 Bruner et al69 RCT with nutritional counseling with or without exercise (endurance and resistance) for 12 wk; 12 participants Improved skin-fold thickness and Vo2max; trend toward improved SHBG, LH/FSH in the absence of weight loss; improved waist circumference and insulin in both groups As with aerobic exercise, strongly recommended; most effective in conjunction with dietary changes and healthy weight maintenance
 Thomson et al70 RCT with hypocaloric, high-protein diet only, or diet plus aerobic or aerobic and resistance exercise for 20 wk; 94 obese participants Exercise groups lost more fat mass than diet alone; other improvements in metabolic, hormone, and reproductive profiles were similar across all groups
Resistance Exercise Alone
 Kogure et al83 Prospective controlled intervention study with PRT 3×/wk for 4 mo; 97 participants (45 PCOS, 52 non-PCOS) Reduced T and glucose, but A4 increased and SHBG decreased; decreased waist circumference and increased lean mass Recommended in combination with aerobic exercise, with additional studies needed on resistance exercise alone; resistance exercise can improve body composition and may improve T levels
 Vizza et al84 RCT with PRT 4×/wk or no PRT for 12 wk; 10 participants Increase in lean mass and lower body strength; reduced hemoglobin A1c, waist circumference; improved quality of life, depression and anxiety scores
Yoga
 Nidhi et al88,89 RCT with daily 1-h yoga or conventional exercises for 12 wk; 90 adolescent participants Improved glucose, insulin, HOMA-IR, lipid profile with yoga; reduced AMH, LH, T, and hirsutism; improved menstrual regularity Additional studies needed, particularly in adult and obese women with PCOS; yoga may improve multiple PCOS symptoms

a All participants were women with PCOS unless otherwise noted.

Abbreviations: A4, androstenedione; AMH, anti-Müllerian hormone; BMI, body mass index; DHHS, US Department of Health and Human Services; FAI, free androgen index; FSH, follicle-stimulating hormone; GLUT4, glucose transporter type 4; HDL-C, high-density lipoprotein cholesterol; HOMA-IR, homeostatic model assessment for insulin resistance; IR, insulin resistance; LH, luteinizing hormone; PCOS, polycystic ovary syndrome; PRT, progressive resistance training; RCT, randomized controlled trial; SHBG, sex hormone–binding globulin; T, testosterone; Vo2, oxygen consumption; Vo2max, maximum oxygen consumption.

Table 4.
Summary of Study Findings on Physical Activity in the Management of PCOS
Physical Activity and Study Type of Study; Study Sizea Key Findings Summary Recommendations
Aerobic Exercise
 Mario et al71 Controlled cross-sectional study of walking with participants defined as active (>7500 steps/d) or sedentary (<7500 steps/d) by pedometer; 151 participants (84 PCOS, 67 non-PCOS) Active women with PCOS had lower waist circumference, lipid accumulation product, and androgen levels; HOMA-IR and 2000-step increments each independently predicted FAI Strongly recommended; exercise, particularly vigorous exercise, confers improvements in metabolic and hormone profiles; moderate exercise (eg, walking), can also improve metabolic and hormone profiles, and even short bouts provide benefits
 Greenwood et al72 Cross-sectional study with groups for vigorous exercise, moderate exercise, and inactive (DHHS guidelines); 326 participants Vigorous exercise associated with lower BMI, HOMA-IR; higher HDL-C and SHBG; every hour of vigorous exercise reduced odds of metabolic syndrome by 22%
 Harrison et al73 Prospective controlled intervention study with 3 weekly 1-h exercise sessions for 12 wk; 21 obese participants (13 PCOS, 8 non-PCOS) Decreased IR, but not to same level as controls; improvement in IR related to Vo2max
 Scott et al74 Prospective controlled intervention study with progressive 12-wk exercise program; 16 obese participants (9 PCOS, 7 non-PCOS) Small reductions in body fat (less than controls), reduced central adiposity, improved Vo2 peak and insulin sensitivity
 Dantas et al75 Prospective controlled intervention study with 40-min single bout of exercise; 27 obese participants (15 PCOS, 12 non-PCOS) Similar translocation of GLUT4 in controls and PCOS, albeit different pattern of protein phosphorylation (PCOS women still benefit from exercise)
 Covington et al77 Prospective controlled intervention study with 16-wk aerobic exercise program; 16 obese participants (8 PCOS, 8 non-PCOS) Higher levels of circulating leukocytes can be reversed with aerobic exercise; insulin sensitivity and leptin also improved
Aerobic and Resistance Exercise
 Bruner et al69 RCT with nutritional counseling with or without exercise (endurance and resistance) for 12 wk; 12 participants Improved skin-fold thickness and Vo2max; trend toward improved SHBG, LH/FSH in the absence of weight loss; improved waist circumference and insulin in both groups As with aerobic exercise, strongly recommended; most effective in conjunction with dietary changes and healthy weight maintenance
 Thomson et al70 RCT with hypocaloric, high-protein diet only, or diet plus aerobic or aerobic and resistance exercise for 20 wk; 94 obese participants Exercise groups lost more fat mass than diet alone; other improvements in metabolic, hormone, and reproductive profiles were similar across all groups
Resistance Exercise Alone
 Kogure et al83 Prospective controlled intervention study with PRT 3×/wk for 4 mo; 97 participants (45 PCOS, 52 non-PCOS) Reduced T and glucose, but A4 increased and SHBG decreased; decreased waist circumference and increased lean mass Recommended in combination with aerobic exercise, with additional studies needed on resistance exercise alone; resistance exercise can improve body composition and may improve T levels
 Vizza et al84 RCT with PRT 4×/wk or no PRT for 12 wk; 10 participants Increase in lean mass and lower body strength; reduced hemoglobin A1c, waist circumference; improved quality of life, depression and anxiety scores
Yoga
 Nidhi et al88,89 RCT with daily 1-h yoga or conventional exercises for 12 wk; 90 adolescent participants Improved glucose, insulin, HOMA-IR, lipid profile with yoga; reduced AMH, LH, T, and hirsutism; improved menstrual regularity Additional studies needed, particularly in adult and obese women with PCOS; yoga may improve multiple PCOS symptoms

a All participants were women with PCOS unless otherwise noted.

Abbreviations: A4, androstenedione; AMH, anti-Müllerian hormone; BMI, body mass index; DHHS, US Department of Health and Human Services; FAI, free androgen index; FSH, follicle-stimulating hormone; GLUT4, glucose transporter type 4; HDL-C, high-density lipoprotein cholesterol; HOMA-IR, homeostatic model assessment for insulin resistance; IR, insulin resistance; LH, luteinizing hormone; PCOS, polycystic ovary syndrome; PRT, progressive resistance training; RCT, randomized controlled trial; SHBG, sex hormone–binding globulin; T, testosterone; Vo2, oxygen consumption; Vo2max, maximum oxygen consumption.

×
Yoga
Yoga, a system of postures and breathing techniques intended to improve physical and mental well-being, has become more popular in Western societies in recent decades. Its benefits have been reported in the management of many conditions, including hypertension, asthma, low back pain, arthritis, multiple sclerosis, pain, and stress management. Regular yoga practice has been shown to improve stress reactivity and recovery, quality of life, strength, flexibility, pulmonary and cardiovascular function, memory performance, and cellular aging in healthy people and arterial stiffness and cardiovascular disease risk in overweight or obese people.83-85 
Two studies investigating yoga as an intervention in PCOS found that a 12-week intervention involving daily 1-hour yoga sessions resulted in improved testosterone levels, hirsutism, LH, menstrual regularity, blood glucose, insulin, insulin sensitivity, and lipid profiles in lean adolescent females with PCOS, independent of anthropometric changes.88,89 A pilot study by Patel et al (unpublished data) found that a 12-week intervention involving thrice-weekly 1-hour yoga sessions decreased androgen levels in a population of overweight or obese women (mean age, 31 years) with PCOS, also independent of anthropometric changes. Although larger clinical trials are needed, these data suggest that yoga can be a potent adjunct therapy in women with PCOS, with the ability to reduce hyperandrogenism irrespective of patient BMI or age. Although yoga is probably more effective in combination with aerobic and resistance exercise, the observed effects of yoga alone and its accessibility to individuals of all ages and fitness levels provide unique benefits and make it a powerful therapeutic option for women with PCOS. 
Acupuncture
Sympathetic nervous system hyperactivity in women with PCOS may contribute to the pathophysiology of the disorder, including the development of hyperandrogenism, insulin resistance, and obesity.18,90 Increases in both generalized and localized sympathetic tone have been reported. In particular, increased sympathetic outflow to the adipose tissue and ovaries is associated with PCOS and may represent a therapeutic target.89,91 Acupuncture involves inserting needles into specific anatomic points (acupoints) to stimulate the body's self-healing. It has been explored as an alternative treatment option for PCOS, with some positive findings requiring larger-scale clinical trials for follow-up. Compared with no treatment, women with PCOS who received acupuncture demonstrated modest improvements in ovulation and menstrual regularity, as well as decreased testosterone levels.90 Compared with medication alone, acupuncture alone or with medication decreased LH levels, LH/FSH ratios, and testosterone and fasting insulin levels and increased pregnancy rates, though the improvements were modest and the level of evidence for these findings was fairly low and limited by risk of bias, small sample sizes, and sample heterogeneity.90 
Osteopathic Manipulative Treatment
Osteopathic physicians are able to perform osteopathic structural assessments in patients with PCOS, as well as provide nonpharmacologic therapy through osteopathic manipulative treatment (OMT). Given the prevalence of sympathetic hyperactivity in women with PCOS, OMT may be particularly useful for addressing this aspect of the disorder. Although the current review found no published studies on the use of OMT in women with PCOS, Davis et al found that osteopathic structural assessment can be used to detect tissue texture changes associated with sympathetic hyperactivity, even before its physiologic signs are apparent.93 They also found that weekly OMT can reduce some of the manifestations of sympathetic hyperactivity (Davis et al, unpublished data, 2018). Together these findings underscore the importance of the osteopathic approach in caring for patients with PCOS. Further studies are warranted to determine the specific OMT techniques that may provide benefits for different aspects of this disorder. 
Conclusion
Polycystic ovary syndrome is a complex endocrine, reproductive, and metabolic disorder that affects multiple aspects of female health. Current pharmacologic treatment options are limited in scope, and surveyed women with PCOS have expressed interest in complementary treatment modalities to manage their symptoms. The first-line intervention is lifestyle modification, which includes weight loss (when appropriate) and caloric restriction and exercise to maintain a healthy weight. A low-carbohydrate or low–glycemic index diet is recommended to provide additional benefits for insulin sensitivity and body composition. Nutritional supplements, particularly inositol, may be useful as adjuncts to lifestyle modification, although larger and better-controlled studies are needed. Aerobic and resistance exercise confer unique benefits, and both should be part of the recommended physical activity regimen. Yoga has the potential to relieve multiple PCOS symptoms, even in the absence of weight loss, and it can be practiced by individuals of varying fitness levels and ages. Acupuncture may also provide some benefits as an adjunct therapy for PCOS symptoms. Future studies should investigate the efficacy of using OMT to manage PCOS symptoms, including those related to sympathetic hyperactivity as well as the reproductive and endocrine manifestations of the disorder. In addition, larger studies for each type of nonpharmacologic intervention are needed to determine the generalizability of findings and whether efficacy differs according to ethnic background. 
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Thomson RL, Buckley JD, Noakes M, Clifton PM, Norman RJ, Brinkworth GD. The effect of a hypocaloric diet with and without exercise training on body composition, cardiometabolic risk profile, and reproductive function in overweight and obese women with polycystic ovary syndrome. J Clin Endocrinol Metab. 2008;93(9):3373-3380. [CrossRef] [PubMed]
Mario FM, Graff SK, Spritzer PM. Habitual physical activity is associated with improved anthropometric and androgenic profile in PCOS: a cross-sectional study. J Endocrinol Invest. 2017;40(4):377-384. [CrossRef] [PubMed]
Greenwood EA, Noel MW, Kao CN, et al.   Vigorous exercise is associated with superior metabolic profiles in polycystic ovary syndrome independent of total exercise expenditure. Fertil Steril. 2016;105(2):486-493. [CrossRef] [PubMed]
Harrison CL, Stepto NK, Hutchison SK, Teede HJ. The impact of intensified exercise training on insulin resistance and fitness in overweight and obese women with and without polycystic ovary syndrome. Clin Endocrinol (Oxf). 2012;76(3):351-357. [CrossRef] [PubMed]
Scott D, Harrison CL, Hutchison S, de Courten B, Stepto NK. Exploring factors related to changes in body composition, insulin sensitivity and aerobic capacity in response to a 12-week exercise intervention in overweight and obese women with and without polycystic ovary syndrome. PLoS One. . 2017;12(8):e0182412. [CrossRef] [PubMed]
Dantas WS, Marcondes JA, Shinjo SK, et al.   GLUT4 translocation is not impaired after acute exercise in skeletal muscle of women with obesity and polycystic ovary syndrome. Obesity (Silver Spring). 2015;23(11):2207-2215. [CrossRef] [PubMed]
Dantas WS, Murai IH, Perandini LA, et al.   Acute exercise elicits differential expression of insulin resistance genes in the skeletal muscle of patients with polycystic ovary syndrome. Clin Endocrinol (Oxf). 2017;86(5):688-697. [CrossRef] [PubMed]
Covington JD, Tam CS, Pasarica M, Redman LM. Higher circulating leukocytes in women with PCOS is reversed by aerobic exercise. Biochimie. 2016;124:27-33. [CrossRef] [PubMed]
Carmina E, Guastella E, Longo RA, Rini GB, Lobo RA. Correlates of increased lean muscle mass in women with polycystic ovary syndrome. Eur J Endocrinol. 2009;161(4):583-589. [CrossRef] [PubMed]
Kogure GS, Silva RC, Picchi Ramos FK, et al.   Women with polycystic ovary syndrome have greater muscle strength irrespective of body composition. Gynecol Endocrinol. 2015;31(3):237-242. [CrossRef] [PubMed]
Mario FM, do Amarante F, Toscani MK, Spritzer PM. Lean muscle mass in classic or ovulatory PCOS: association with central obesity and insulin resistance. Exp Clin Endocrinol Diabetes. 2012;120(9):511-516. [CrossRef] [PubMed]
Colberg SR, Albright AL, Blissmer BJ, et al.   Exercise and type 2 diabetes: American College of Sports Medicine and the American Diabetes Association: joint position statement. Med Sci Sports Exerc. 2010;42(12):2282-2303. [CrossRef] [PubMed]
Strasser B, Siebert U, Schobersberger W. Resistance training in the treatment of the metabolic syndrome: a systematic review and meta-analysis of the effect of resistance training on metabolic clustering in patients with abnormal glucose metabolism. Sports Med. 2010;40(5):397-415. [CrossRef] [PubMed]
Kogure GS, Miranda-Furtado CL, Silva RC, et al.   Resistance exercise impacts lean muscle mass in women with polycystic ovary syndrome. Med Sci Sports Exerc. 2016;48(4):589-598. [CrossRef] [PubMed]
Vizza L, Smith CA, Swaraj S, Agho K, Cheema BS. The feasibility of progressive resistance training in women with polycystic ovary syndrome: a pilot randomized controlled trial. BMC Sports Sci Med Rehabil. 2016;8:14. [CrossRef] [PubMed]
Yadav R, Yadav RK, Sarvottam K, Netam R. Framingham Risk Score and estimated 10-year cardiovascular disease risk reduction by a short-term yoga-based lifestyle intervention. J Altern Complement Med. 2017;23(9):730-737. [CrossRef] [PubMed]
Tolahunase M, Sagar R, Dada R. Impact of yoga and meditation on cellular aging in apparently healthy individuals: a prospective, open-label single-arm exploratory study. Oxid Med Cell Longev. . 2017;2017:7928981.
Hunter SD, Dhindsa MS, Cunningham E, et al.   Impact of hot yoga on arterial stiffness and quality of life in normal and overweight/obese adults. J Phys Act Health. 2016;13(12):1360-1363. [CrossRef] [PubMed]
Nidhi R, Padmalatha V, Nagarathna R, Ram A. Effect of a yoga program on glucose metabolism and blood lipid levels in adolescent girls with polycystic ovary syndrome. Int J Gynaecol Obstet. 2012;118(1):37-41. [CrossRef] [PubMed]
Nidhi R, Padmalatha V, Nagarathna R, Amritanshu R. Effects of a holistic yoga program on endocrine parameters in adolescents with polycystic ovarian syndrome: a randomized controlled trial. J Altern Complement Med. 2013;19(2):153-160. [CrossRef] [PubMed]
Li W, Chen Y, Xu L. Association of sympathetic nervous system activity with polycystic ovarian syndrome. Clin Exp Obstet Gynecol. 2014;41(5):499-506. [PubMed]
Lansdown A, Rees DA. The sympathetic nervous system in polycystic ovary syndrome: a novel therapeutic target? Clin Endocrinol (Oxf). . 2012;77(6):791-801. [CrossRef] [PubMed]
Jo J, Lee YJ, Lee H. Acupuncture for polycystic ovarian syndrome: a systematic review and meta-analysis. Medicine (Baltimore). . 2017;96(23):e7066. [CrossRef] [PubMed]
Davis SE, Hendryx J, Bouwer S, et al.   Correlation between physiologic and osteopathic measures of sympathetic activity in women with polycystic ovary syndrome. J Am Osteopath Assoc. 2019;119(1):7-17. doi:10.7556/jaoa.2019.004
Table 1.
Diagnostic Features of Polycystic Ovary Syndromea
Diagnostic Feature Criteria
Hyperandrogenismb ■ Elevated free (recommended) or total testosterone level
■ Clinical acne (particularly facial and along jaw)
■ Hirsutism (modified Ferriman Gallwey score >8)
■ Alopecia
Menstrual irregularity ■ Menstrual cycles >35 d or ≤8 menstrual cycles/y
■ Cycles tend to be unpredictable
■ Menstrual irregularity secondary to oligo-ovulation or anovulation
Polycystic ovariesc Ovarian volume >10 mL in either ovary or >12 cysts present on either ovary (seen with ultrasonography)

a The Rotterdam criteria8 for diagnosis of polycystic ovary syndrome (PCOS) require at least 2 of the 3 listed features.

b One of the criteria need to be present for hyperandrogenism.

c Polycystic ovaries are not a requirement for diagnosis of PCOS.

Table 1.
Diagnostic Features of Polycystic Ovary Syndromea
Diagnostic Feature Criteria
Hyperandrogenismb ■ Elevated free (recommended) or total testosterone level
■ Clinical acne (particularly facial and along jaw)
■ Hirsutism (modified Ferriman Gallwey score >8)
■ Alopecia
Menstrual irregularity ■ Menstrual cycles >35 d or ≤8 menstrual cycles/y
■ Cycles tend to be unpredictable
■ Menstrual irregularity secondary to oligo-ovulation or anovulation
Polycystic ovariesc Ovarian volume >10 mL in either ovary or >12 cysts present on either ovary (seen with ultrasonography)

a The Rotterdam criteria8 for diagnosis of polycystic ovary syndrome (PCOS) require at least 2 of the 3 listed features.

b One of the criteria need to be present for hyperandrogenism.

c Polycystic ovaries are not a requirement for diagnosis of PCOS.

×
Table 2.
Summary of Study Findings on Dietary Modifications in the Management of PCOS
Dietary Modification and Study Type of Study; Study Sizea Key Findings Summary Recommendations
Reduced-CHO or Low–Glycemic Load Diet
 Barr et al48 Nonrandomized, 12-wk control diet, then 12-wk isocaloric low–glycemic index intervention; 21 participants Improved insulin sensitivity and NEFAs with isocaloric low–glycemic-index diet Strongly recommended; this diet, particularly with reduced calories, may improve weight loss, insulin sensitivity, insulin levels, and body composition; hypocaloric diet and weight loss may improve T levels and lipid profile
 Mehrabani et al49 RCT; conventional hypocaloric diet or high-protein, low–glycemic load hypocaloric diet for 12 wk; 60 obese participants Similar weight loss, T and LDL-C reduction in both diet groups; high-protein, low–glycemic load group had reduced insulin, HOMA-IR, and hsCRP
 Goss et al50 Crossover eucaloric diet intervention with random diet order (reduced CHO diet [40% vs 55% cal] for 8 wk, standard diet for 8 wk, with 4-wk interval between diets); 30 participants Reduced-CHO diet group had greater weight loss, decreased subcutaneous and intra-abdominal fat, thigh intermuscular fat, and lower insulin AUC
Low-Starch, Low-Dairy Diet
 Phy et al51 Prospective, comparison before and after intervention; 8-wk ad libitum low-starch, low-dairy diet; 24 obese participants Reduced weight, waist circumference, waist-to-hip ratio, fasting and 2-h insulin, HOMA-IR, total and free T, and hirsutism Moderate recommendation, with additional studies needed; diet associated with reduced weight and decreased insulin levels, with further studies needed on effects on fuel oxidation and T levels; unclear whether changes are due to weight loss or diet itself
 Pohlmeier et al52 Prospective, comparison before and after intervention; 8-wk ad libitum low-starch, low-dairy diet; 10 obese participants Reduced weight and fasting insulin; reduced fasting and postprandial CHO oxidation, increased fasting and postprandial fat oxidation
Mediterranean Diet
 Moran et al53 Retrospective; dietary patterns from longitudinal study data; 7569 participants from 1973-1978 cohort assessed in 2009 (414 PCOS, 7155 non-PCOS) Mediterranean-style diet independently associated with PCOS status (for each 1-SD increase in diet pattern, 26% more likely to have PCOS). Unable to recommend at this time, with interventional studies needed; women may adopt Mediterranean-style diet after PCOS diagnosis

a All participants were women with PCOS unless otherwise noted.

Abbreviations: AUC, area under the curve; CHO, carbohydrate; HOMA-IR, homeostatic model assessment for insulin resistance; hsCRP, high-sensitivity C-reactive protein; LDL-C, low-density lipoprotein cholesterol; NEFAs, nonesterified fatty acids; PCOS, polycystic ovary syndrome; RCT, randomized controlled trial; T, testosterone.

Table 2.
Summary of Study Findings on Dietary Modifications in the Management of PCOS
Dietary Modification and Study Type of Study; Study Sizea Key Findings Summary Recommendations
Reduced-CHO or Low–Glycemic Load Diet
 Barr et al48 Nonrandomized, 12-wk control diet, then 12-wk isocaloric low–glycemic index intervention; 21 participants Improved insulin sensitivity and NEFAs with isocaloric low–glycemic-index diet Strongly recommended; this diet, particularly with reduced calories, may improve weight loss, insulin sensitivity, insulin levels, and body composition; hypocaloric diet and weight loss may improve T levels and lipid profile
 Mehrabani et al49 RCT; conventional hypocaloric diet or high-protein, low–glycemic load hypocaloric diet for 12 wk; 60 obese participants Similar weight loss, T and LDL-C reduction in both diet groups; high-protein, low–glycemic load group had reduced insulin, HOMA-IR, and hsCRP
 Goss et al50 Crossover eucaloric diet intervention with random diet order (reduced CHO diet [40% vs 55% cal] for 8 wk, standard diet for 8 wk, with 4-wk interval between diets); 30 participants Reduced-CHO diet group had greater weight loss, decreased subcutaneous and intra-abdominal fat, thigh intermuscular fat, and lower insulin AUC
Low-Starch, Low-Dairy Diet
 Phy et al51 Prospective, comparison before and after intervention; 8-wk ad libitum low-starch, low-dairy diet; 24 obese participants Reduced weight, waist circumference, waist-to-hip ratio, fasting and 2-h insulin, HOMA-IR, total and free T, and hirsutism Moderate recommendation, with additional studies needed; diet associated with reduced weight and decreased insulin levels, with further studies needed on effects on fuel oxidation and T levels; unclear whether changes are due to weight loss or diet itself
 Pohlmeier et al52 Prospective, comparison before and after intervention; 8-wk ad libitum low-starch, low-dairy diet; 10 obese participants Reduced weight and fasting insulin; reduced fasting and postprandial CHO oxidation, increased fasting and postprandial fat oxidation
Mediterranean Diet
 Moran et al53 Retrospective; dietary patterns from longitudinal study data; 7569 participants from 1973-1978 cohort assessed in 2009 (414 PCOS, 7155 non-PCOS) Mediterranean-style diet independently associated with PCOS status (for each 1-SD increase in diet pattern, 26% more likely to have PCOS). Unable to recommend at this time, with interventional studies needed; women may adopt Mediterranean-style diet after PCOS diagnosis

a All participants were women with PCOS unless otherwise noted.

Abbreviations: AUC, area under the curve; CHO, carbohydrate; HOMA-IR, homeostatic model assessment for insulin resistance; hsCRP, high-sensitivity C-reactive protein; LDL-C, low-density lipoprotein cholesterol; NEFAs, nonesterified fatty acids; PCOS, polycystic ovary syndrome; RCT, randomized controlled trial; T, testosterone.

×
Table 3.
Summary of Study Findings on Nutritional Supplements in the Management of PCOS
Nutritional Supplement and Study Type of Study; Study Sizea Key Findings Summary Recommendations
Omega-3 Fish Oils
 Mohammadi et al57 RCT (double blind) with daily supplement or placebo for 8 wk; 61 obese participants Increased adiponectin and decreased glucose insulin, HOMA-IR, total cholesterol, and LDL-C compared with placebo; decreased TGs, increased HDL-C in omega-3 group compared with baseline Moderate recommendation for improving metabolic profile, with additional studies needed; improved metabolic profile (blood glucose, insulin sensitivity, lipid profile, adiponectin)
Inositol (Vitamin B8)
 Costantino et al58 RCT (double blind) with folic acid with or without myo-inositol for 12-16 wk; 42 participants Before vs after myo-inositol: decreased total and free T, TGs, BP, insulin AUC; increased insulin sensitivity, ovulation Recommended; improvement in ovulation rate, metabolic profile, and androgen profile
 Gerli et al59 RCT (double blind) with folic acid with or without myo-inositol for 14 wk; 92 participants Greater ovulation frequency; less time to first ovulation; increased HDL-C and weight loss; leptin reduction; more efficacious with lower BMI
 Iuorno et al60 RCT with daily inositol or placebo for 6-8 wk; 20 lean participants Decreased insulin AUC, free T, BP, TGs; more women ovulated
 Jamilian et al61 RCT with myo-inositol or metformin for 12 wk; 60 participants Decreased total T, hirsutism, hsCRP when taking myo-inositol
Herbal Supplements
 Shahin et al62 RCT with clomiphene citrate alone or plus Cimicifuga racemosa (black cohosh); 194 participants with PCOS and infertility With black cohosh: fewer days until hCG injection; greater endometrial thickness; midluteal estrogen, and progesterone; more pregnancies Promising findings, with additional studies needed; in conjunction with clomiphene citrate, may increase pregnancy rate
 Grant63 RCT with twice-daily Mentha spicata (spearmint) or placebo herbal tea for 30 days; 41 participants Reduced free and total T Additional studies needed; small study; placebo was also an herbal tea
 Armanini et al64 RCT with spironolactone with or without Glycyrrhiza species (licorice) for 2 menstrual cycles; 32 participants With licorice: reduced T during first 4 days of combination treatment Additional studies needed; small study, not blinded
 Takahashi and Kitao65 Single-arm clinical trial with daily dose Paeonia lactiflora and Glycyrrhiza uralensisb for 24 wk; 34 participants Reduced T after 4 wk of treatment Additional studies needed; small study, not blinded, no control group
 Ushiroyama et al66 RCT of anovulatory women, with a PCOS subgroup, taking combination P lactiflora and Cinnamomum cassia or placebo daily for 8 wk; 38 participants in PCOS subgroup Reduced LH, ovulation in 50% of PCOS subgroup Inconclusive evidence, additional studies needed; preparation contained additional herbal extracts; no baseline description of subgroup
 Wang et al67 RCT with daily C cassia or placebo for 8 wk; 15 participants Reduction in insulin resistance (fasting and 2-h insulin) before vs after treatment in cinnamon group Additional studies needed; small pilot study
 Arentz et al68 RCT with lifestyle modification with or without combination herbal tablets for 3 mo; 112 overweight participants Improved menstrual regularity and quality of life; decreased BMI, insulin, LH, and BP; reduced depression, anxiety/stress; increased pregnancy rates. Promising findings, additional studies needed; unclear which herbs or combination of herbs, and which lifestyle modifications, had an effect

a All participants were women with PCOS unless otherwise noted.

b Chinese peony/common garden peony and Chinese licorice.

c Five herbal extracts: Cinnamomum verum, Glycyrrhiza glabra, Hypericum perforatum, Plactiflora, and Tribulus terrestris.

Abbreviations: AUC, area under curve; BMI, body mass index; BP, blood pressure; hCG, human chorionic gonadotropin; HDL-C, high-density lipoprotein cholesterol; HOMA-IR, homeostatic model assessment for insulin resistance; hsCRP, high-sensitivity C-reactive protein; LDL-C, low-density lipoprotein cholesterol; LH, luteinizing hormone; PCOS, polycystic ovary syndrome; RCT, randomized controlled trial; T, testosterone; TGs, triglycerides.

Table 3.
Summary of Study Findings on Nutritional Supplements in the Management of PCOS
Nutritional Supplement and Study Type of Study; Study Sizea Key Findings Summary Recommendations
Omega-3 Fish Oils
 Mohammadi et al57 RCT (double blind) with daily supplement or placebo for 8 wk; 61 obese participants Increased adiponectin and decreased glucose insulin, HOMA-IR, total cholesterol, and LDL-C compared with placebo; decreased TGs, increased HDL-C in omega-3 group compared with baseline Moderate recommendation for improving metabolic profile, with additional studies needed; improved metabolic profile (blood glucose, insulin sensitivity, lipid profile, adiponectin)
Inositol (Vitamin B8)
 Costantino et al58 RCT (double blind) with folic acid with or without myo-inositol for 12-16 wk; 42 participants Before vs after myo-inositol: decreased total and free T, TGs, BP, insulin AUC; increased insulin sensitivity, ovulation Recommended; improvement in ovulation rate, metabolic profile, and androgen profile
 Gerli et al59 RCT (double blind) with folic acid with or without myo-inositol for 14 wk; 92 participants Greater ovulation frequency; less time to first ovulation; increased HDL-C and weight loss; leptin reduction; more efficacious with lower BMI
 Iuorno et al60 RCT with daily inositol or placebo for 6-8 wk; 20 lean participants Decreased insulin AUC, free T, BP, TGs; more women ovulated
 Jamilian et al61 RCT with myo-inositol or metformin for 12 wk; 60 participants Decreased total T, hirsutism, hsCRP when taking myo-inositol
Herbal Supplements
 Shahin et al62 RCT with clomiphene citrate alone or plus Cimicifuga racemosa (black cohosh); 194 participants with PCOS and infertility With black cohosh: fewer days until hCG injection; greater endometrial thickness; midluteal estrogen, and progesterone; more pregnancies Promising findings, with additional studies needed; in conjunction with clomiphene citrate, may increase pregnancy rate
 Grant63 RCT with twice-daily Mentha spicata (spearmint) or placebo herbal tea for 30 days; 41 participants Reduced free and total T Additional studies needed; small study; placebo was also an herbal tea
 Armanini et al64 RCT with spironolactone with or without Glycyrrhiza species (licorice) for 2 menstrual cycles; 32 participants With licorice: reduced T during first 4 days of combination treatment Additional studies needed; small study, not blinded
 Takahashi and Kitao65 Single-arm clinical trial with daily dose Paeonia lactiflora and Glycyrrhiza uralensisb for 24 wk; 34 participants Reduced T after 4 wk of treatment Additional studies needed; small study, not blinded, no control group
 Ushiroyama et al66 RCT of anovulatory women, with a PCOS subgroup, taking combination P lactiflora and Cinnamomum cassia or placebo daily for 8 wk; 38 participants in PCOS subgroup Reduced LH, ovulation in 50% of PCOS subgroup Inconclusive evidence, additional studies needed; preparation contained additional herbal extracts; no baseline description of subgroup
 Wang et al67 RCT with daily C cassia or placebo for 8 wk; 15 participants Reduction in insulin resistance (fasting and 2-h insulin) before vs after treatment in cinnamon group Additional studies needed; small pilot study
 Arentz et al68 RCT with lifestyle modification with or without combination herbal tablets for 3 mo; 112 overweight participants Improved menstrual regularity and quality of life; decreased BMI, insulin, LH, and BP; reduced depression, anxiety/stress; increased pregnancy rates. Promising findings, additional studies needed; unclear which herbs or combination of herbs, and which lifestyle modifications, had an effect

a All participants were women with PCOS unless otherwise noted.

b Chinese peony/common garden peony and Chinese licorice.

c Five herbal extracts: Cinnamomum verum, Glycyrrhiza glabra, Hypericum perforatum, Plactiflora, and Tribulus terrestris.

Abbreviations: AUC, area under curve; BMI, body mass index; BP, blood pressure; hCG, human chorionic gonadotropin; HDL-C, high-density lipoprotein cholesterol; HOMA-IR, homeostatic model assessment for insulin resistance; hsCRP, high-sensitivity C-reactive protein; LDL-C, low-density lipoprotein cholesterol; LH, luteinizing hormone; PCOS, polycystic ovary syndrome; RCT, randomized controlled trial; T, testosterone; TGs, triglycerides.

×
Table 4.
Summary of Study Findings on Physical Activity in the Management of PCOS
Physical Activity and Study Type of Study; Study Sizea Key Findings Summary Recommendations
Aerobic Exercise
 Mario et al71 Controlled cross-sectional study of walking with participants defined as active (>7500 steps/d) or sedentary (<7500 steps/d) by pedometer; 151 participants (84 PCOS, 67 non-PCOS) Active women with PCOS had lower waist circumference, lipid accumulation product, and androgen levels; HOMA-IR and 2000-step increments each independently predicted FAI Strongly recommended; exercise, particularly vigorous exercise, confers improvements in metabolic and hormone profiles; moderate exercise (eg, walking), can also improve metabolic and hormone profiles, and even short bouts provide benefits
 Greenwood et al72 Cross-sectional study with groups for vigorous exercise, moderate exercise, and inactive (DHHS guidelines); 326 participants Vigorous exercise associated with lower BMI, HOMA-IR; higher HDL-C and SHBG; every hour of vigorous exercise reduced odds of metabolic syndrome by 22%
 Harrison et al73 Prospective controlled intervention study with 3 weekly 1-h exercise sessions for 12 wk; 21 obese participants (13 PCOS, 8 non-PCOS) Decreased IR, but not to same level as controls; improvement in IR related to Vo2max
 Scott et al74 Prospective controlled intervention study with progressive 12-wk exercise program; 16 obese participants (9 PCOS, 7 non-PCOS) Small reductions in body fat (less than controls), reduced central adiposity, improved Vo2 peak and insulin sensitivity
 Dantas et al75 Prospective controlled intervention study with 40-min single bout of exercise; 27 obese participants (15 PCOS, 12 non-PCOS) Similar translocation of GLUT4 in controls and PCOS, albeit different pattern of protein phosphorylation (PCOS women still benefit from exercise)
 Covington et al77 Prospective controlled intervention study with 16-wk aerobic exercise program; 16 obese participants (8 PCOS, 8 non-PCOS) Higher levels of circulating leukocytes can be reversed with aerobic exercise; insulin sensitivity and leptin also improved
Aerobic and Resistance Exercise
 Bruner et al69 RCT with nutritional counseling with or without exercise (endurance and resistance) for 12 wk; 12 participants Improved skin-fold thickness and Vo2max; trend toward improved SHBG, LH/FSH in the absence of weight loss; improved waist circumference and insulin in both groups As with aerobic exercise, strongly recommended; most effective in conjunction with dietary changes and healthy weight maintenance
 Thomson et al70 RCT with hypocaloric, high-protein diet only, or diet plus aerobic or aerobic and resistance exercise for 20 wk; 94 obese participants Exercise groups lost more fat mass than diet alone; other improvements in metabolic, hormone, and reproductive profiles were similar across all groups
Resistance Exercise Alone
 Kogure et al83 Prospective controlled intervention study with PRT 3×/wk for 4 mo; 97 participants (45 PCOS, 52 non-PCOS) Reduced T and glucose, but A4 increased and SHBG decreased; decreased waist circumference and increased lean mass Recommended in combination with aerobic exercise, with additional studies needed on resistance exercise alone; resistance exercise can improve body composition and may improve T levels
 Vizza et al84 RCT with PRT 4×/wk or no PRT for 12 wk; 10 participants Increase in lean mass and lower body strength; reduced hemoglobin A1c, waist circumference; improved quality of life, depression and anxiety scores
Yoga
 Nidhi et al88,89 RCT with daily 1-h yoga or conventional exercises for 12 wk; 90 adolescent participants Improved glucose, insulin, HOMA-IR, lipid profile with yoga; reduced AMH, LH, T, and hirsutism; improved menstrual regularity Additional studies needed, particularly in adult and obese women with PCOS; yoga may improve multiple PCOS symptoms

a All participants were women with PCOS unless otherwise noted.

Abbreviations: A4, androstenedione; AMH, anti-Müllerian hormone; BMI, body mass index; DHHS, US Department of Health and Human Services; FAI, free androgen index; FSH, follicle-stimulating hormone; GLUT4, glucose transporter type 4; HDL-C, high-density lipoprotein cholesterol; HOMA-IR, homeostatic model assessment for insulin resistance; IR, insulin resistance; LH, luteinizing hormone; PCOS, polycystic ovary syndrome; PRT, progressive resistance training; RCT, randomized controlled trial; SHBG, sex hormone–binding globulin; T, testosterone; Vo2, oxygen consumption; Vo2max, maximum oxygen consumption.

Table 4.
Summary of Study Findings on Physical Activity in the Management of PCOS
Physical Activity and Study Type of Study; Study Sizea Key Findings Summary Recommendations
Aerobic Exercise
 Mario et al71 Controlled cross-sectional study of walking with participants defined as active (>7500 steps/d) or sedentary (<7500 steps/d) by pedometer; 151 participants (84 PCOS, 67 non-PCOS) Active women with PCOS had lower waist circumference, lipid accumulation product, and androgen levels; HOMA-IR and 2000-step increments each independently predicted FAI Strongly recommended; exercise, particularly vigorous exercise, confers improvements in metabolic and hormone profiles; moderate exercise (eg, walking), can also improve metabolic and hormone profiles, and even short bouts provide benefits
 Greenwood et al72 Cross-sectional study with groups for vigorous exercise, moderate exercise, and inactive (DHHS guidelines); 326 participants Vigorous exercise associated with lower BMI, HOMA-IR; higher HDL-C and SHBG; every hour of vigorous exercise reduced odds of metabolic syndrome by 22%
 Harrison et al73 Prospective controlled intervention study with 3 weekly 1-h exercise sessions for 12 wk; 21 obese participants (13 PCOS, 8 non-PCOS) Decreased IR, but not to same level as controls; improvement in IR related to Vo2max
 Scott et al74 Prospective controlled intervention study with progressive 12-wk exercise program; 16 obese participants (9 PCOS, 7 non-PCOS) Small reductions in body fat (less than controls), reduced central adiposity, improved Vo2 peak and insulin sensitivity
 Dantas et al75 Prospective controlled intervention study with 40-min single bout of exercise; 27 obese participants (15 PCOS, 12 non-PCOS) Similar translocation of GLUT4 in controls and PCOS, albeit different pattern of protein phosphorylation (PCOS women still benefit from exercise)
 Covington et al77 Prospective controlled intervention study with 16-wk aerobic exercise program; 16 obese participants (8 PCOS, 8 non-PCOS) Higher levels of circulating leukocytes can be reversed with aerobic exercise; insulin sensitivity and leptin also improved
Aerobic and Resistance Exercise
 Bruner et al69 RCT with nutritional counseling with or without exercise (endurance and resistance) for 12 wk; 12 participants Improved skin-fold thickness and Vo2max; trend toward improved SHBG, LH/FSH in the absence of weight loss; improved waist circumference and insulin in both groups As with aerobic exercise, strongly recommended; most effective in conjunction with dietary changes and healthy weight maintenance
 Thomson et al70 RCT with hypocaloric, high-protein diet only, or diet plus aerobic or aerobic and resistance exercise for 20 wk; 94 obese participants Exercise groups lost more fat mass than diet alone; other improvements in metabolic, hormone, and reproductive profiles were similar across all groups
Resistance Exercise Alone
 Kogure et al83 Prospective controlled intervention study with PRT 3×/wk for 4 mo; 97 participants (45 PCOS, 52 non-PCOS) Reduced T and glucose, but A4 increased and SHBG decreased; decreased waist circumference and increased lean mass Recommended in combination with aerobic exercise, with additional studies needed on resistance exercise alone; resistance exercise can improve body composition and may improve T levels
 Vizza et al84 RCT with PRT 4×/wk or no PRT for 12 wk; 10 participants Increase in lean mass and lower body strength; reduced hemoglobin A1c, waist circumference; improved quality of life, depression and anxiety scores
Yoga
 Nidhi et al88,89 RCT with daily 1-h yoga or conventional exercises for 12 wk; 90 adolescent participants Improved glucose, insulin, HOMA-IR, lipid profile with yoga; reduced AMH, LH, T, and hirsutism; improved menstrual regularity Additional studies needed, particularly in adult and obese women with PCOS; yoga may improve multiple PCOS symptoms

a All participants were women with PCOS unless otherwise noted.

Abbreviations: A4, androstenedione; AMH, anti-Müllerian hormone; BMI, body mass index; DHHS, US Department of Health and Human Services; FAI, free androgen index; FSH, follicle-stimulating hormone; GLUT4, glucose transporter type 4; HDL-C, high-density lipoprotein cholesterol; HOMA-IR, homeostatic model assessment for insulin resistance; IR, insulin resistance; LH, luteinizing hormone; PCOS, polycystic ovary syndrome; PRT, progressive resistance training; RCT, randomized controlled trial; SHBG, sex hormone–binding globulin; T, testosterone; Vo2, oxygen consumption; Vo2max, maximum oxygen consumption.

×