Metabolic Syndrome in Women With PCOS - Risk Factors, Diagnosis, and Management

What Is Metabolic Syndrome in Women with PCOS?

PCOS (polycystic ovary syndrome) is a medical condition affecting women of reproductive ages. It is characterized by menstrual irregularities, insulin resistance, hirsutism, low fertility, hyperandrogenism, and subsequent metabolic syndrome. A metabolic syndrome is a group of metabolic dysfunctionalities, including visceral obesity, insulin resistance, hyperglycemia, high blood pressure, and altered lipid level in the blood.

What Are the Risk Factors for Metabolic Syndrome in Women With PCOS?

Risk factors for metabolic syndrome include the following–

• Visceral Obesity- Visceral obesity or abdominal obesity is when there is increased fat deposit around the organs and other tissues in the abdomen. Abdominal obesity is known to be a compounding factor for PCOS. Women with PCOS and obesity have an increased risk for metabolic syndrome. It results from improper diet, a sedentary lifestyle, or genetic predisposition. Hyperinsulinaemia (high insulin levels in the blood) causes an increased level of free androgens. Hyperandrogenaemia increases the inclination for central adiposity and, as a result, further worsens insulin resistance and dyslipidemia (abnormal lipid levels in the blood).

• Insulin Resistance and Hyperinsulinaemia- Insulin resistance is a key component of various metabolic changes in this syndrome. Insulin resistance and its consequent hyperinsulinemia cause a rise in insulin secretion, affecting many metabolic functions negatively. Therefore, Hyperinsulinemia can be considered the primary reason for the increased cardiovascular risk in women and the link between the two syndromes (PCOS and metabolic syndrome).

• Atherogenic Dyslipidaemia- Due to insulin resistance, the free fatty acids increase the hepatic production of VLDL (very low-density lipoprotein), increased triglycerides, and decreased HDL (high-density lipoprotein). These alterations in lipid parameters result in atherogenic dyslipidemia. PCOS causes low-grade systemic inflammation, which further accelerates atherogenesis.

• SHBG (Sex Hormone-Binding Globulin) Levels- The levels of SHBG may vary with the BMI (body mass index), insulin resistance, and hyperinsulinemia. A low SHBG is a possible marker for insulin resistance.

• Hypertension- Due to the increased insulin levels and free fatty acids in obese women, there are high chances of developing hypertension.

What Are the Consequences of Metabolic Syndrome in Women With PCOS?

• Heart Diseases - Women with metabolic syndrome and PCOS are at increased risk of coronary heart disease (CHD) and stroke.

• Diabetes- Metabolic syndrome with PCOS confers a five-fold increased risk for diabetes type II, developing impaired glucose tolerance (IGT), and gestational diabetes.

• Cancers- Metabolic syndrome with PCOS has been associated with an increased risk of endometrial, pancreatic, postmenopausal breast, and colorectal cancers. It leads to poor cancer outcomes, an increased rate of cancer recurrence, and mortality.

• Obstructive Sleep Apnoea (OSA)- Due to metabolic syndrome with PCOS and insulin resistance, there is an increase in excessive daytime sleepiness, fatigue, and snoring. It also worsens cardiovascular outcomes.

• Psychological Problems- Depression is common in women with PCOS and metabolic syndrome. These women are more likely to develop depression, anxiety, eating disorders, and dysfunctional relationships.

What Is the Diagnostic Criterion for Metabolic Syndrome in Women With PCOS?

Metabolic syndrome is said to be present if three or more of the following five criteria are met:

1. Elevated waist circumference (over 35 inches).

2. Elevated blood pressure- Blood pressure over 130 mm of Hg (systolic) and 85 mm of Hg (diastolic), or treatment of previously diagnosed hypertension.

3. Elevated triglycerides- Fasting triglyceride (TG) level over 150 mg/dl.

4. Reduced HDL-C (high-density lipoprotein C) levels- Fasting high-density lipoprotein (HDL) cholesterol level less than 50 mg/dl.

5. Elevated fasting glucose levels- fasting blood sugar over 100 mg/dl.

How Is Screening for Metabolic Syndrome in Women With PCOS Done?

There is a need for a structured assessment for the early detection and management of metabolic syndrome in women with PCOS (especially in women of reproductive ages).

The women must be assessed for the following parameters on every visit-

• Obesity.

• Blood pressure.

• Complete lipid profile.

• Cigarette smoking.

• Oral glucose tolerance test.

How to Manage Metabolic Syndrome With PCOS?

Primary intervention for managing metabolic syndrome requires lifestyle modifications to prevent or slow the progression to adverse events. Secondary interventions like medical therapy and surgery can be considered if primary lifestyle changes fail to show results.

Following are the available measures to manage metabolic syndrome in women with PCOS-

• Lifestyle Modifications - As there is no established cure for PCOS, lifestyle changes can substantially improve symptoms.

1. Regular exercise helps to reduce abdominal fat.

2. Dietary regulation- taking small portions of calorie-appropriate meals at frequent intervals.

3. Losing weight (visceral fat).

4. Adequate omega-3 fat intake helps lower inflammatory markers, cholesterol, and triglycerides and increase insulin sensitivity.

Medical Management- With the help of medications like the following-

1. Insulin-Sensitizing Agents

• Metformin- It improves insulin sensitivity. However, it is commonly associated with side effects like- gastrointestinal effects, nausea, abdominal pain, and diarrhea.

• Inositol- These are the compounds that mimic insulin. No side effects are present.

1. Anti-Obesity Agents

• Orlistat- It prevents the breakdown and absorption of dietary fats. It also induces significant weight loss, improved lipid profile, reduced total cholesterol levels, low-density lipoprotein (LDL), and triglycerides. Some side effects are steatorrhoea (excess fat in feces) and abdominal pain.

• Liraglutide- It is an anti-obesity agent associated with a significant reduction in BMI (body mass index).

1. Statins- It improves lipid profiles in women with dyslipidemia. Long-term use can cause liver dysfunction and teratogenicity.

Surgical Management- Bariatric surgery is recommended when lifestyle changes or medical management fails to give good results.

Bariatric surgery can be done in the following cases-

• Class III obesity (BMI more than equal to 40 kg/m2).

• Class II obesity (BMI between 35 to 39.9 kg/m2) and chronic medical conditions such as diabetes and hypertension.

Bariatric surgery reduces cardiometabolic risk factors, cardiovascular events, improved lipid profile, remission of diabetes type II, hypertension, obesity-related cancers, obstructive sleep apnoea, and reduced insulin resistance.

Standard bariatric procedures include-

• Laparoscopic adjustable gastric banding.

• Vertical banded gastroplasty.

• Roux-en-Y gastric bypass.

Conclusion

Despite the high prevalence, metabolic syndrome in women with PCOS is neglected. Therefore, it is vital to implement screening modalities for early diagnosis and institute secondary prevention measures. Lifestyle modification is the primary and universally accepted intervention. However, if it does not help, medical management and bariatric surgeries can be done as the last option.