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DOI: 10.1111/j.1471-0528.2009.02177.x
www.bjog.org
_ 2max ) and
Objective To assess maximal aerobic capacity (VO
muscle strength in overweight and obese women with polycystic
ovary syndrome (PCOS) and determine their relationship with
metabolic and hormonal factors.
Design Cross-sectional study.
Setting Clinical Research Unit.
Population Overweight and obese women with PCOS (n = 10)
syndrome, obesity.
Introduction
Polycystic ovary syndrome (PCOS), characterised by
chronic anovulation, menstrual dysfunction and hyperandrogenism, is a common reproductive endocrine disorder1 affecting 7% of women of reproductive age.2
PCOS is also associated with an increased prevalence of
a number of metabolic risk factors including obesity,
abdominal obesity, insulin resistance and compensatory
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2009 The Authors Journal compilation RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology
Methods
Participants
Ten women with PCOS and 16 non-PCOS controls,
matched for age, body weight and level of habitual activity,
were recruited by public advertisement (Table 1). These
participants were a subset of women who completed
additional exercise testing from a previous study.30 All
participants were overweight or obese (body mass index
[BMI]: 2745 kg/m2), premenopausal, sedentary women
aged 2544 years and had been weight stable (<2.0 kg
weight change) for at least 3 months prior to enrolment.
Presence of PCOS was diagnosed according to the
Rotterdam criteria.31 Menstrual irregularity was defined as
cycle length <21 days or >35 days or variation between
consecutive cycles of >3 days. Exclusion criteria included
smoking, uncontrolled hypertension, cancer, liver, renal,
haematological, CVD, diabetes, Cushing syndrome, androgen secreting tumours, late-onset 21-hydroxylase deficiency,
thyroid dysfunction, hyperprolactinaemia or pregnancy.
Participants with a history of angina or any other cardiac,
pulmonary or physical symptom that would potentially
limit exercise performance were also excluded. All women
provided written informed consent and the study protocols
Age (years)
Body weight (kg)
BMI (kg/m2)
Waist circumference (cm)
Triglycerides (mmol/l)
Total cholesterol (mmol/l)
High density lipoprotein
cholesterol (mmol/l)
Low density lipoprotein
cholesterol (mmol/l)
Fasting glucose (mmol/l)
Fasting insulin (mu/l)
HOMA2
C-reactive protein (mg/l)
Testosterone (nmol/l)
Free testosterone (pmol/l)
Sex-hormone binding
globulin (nmol/l)
Free androgen index
PCOS
(n = 10)
33.6
89.9
34.1
108.7
1.5
4.8
1.4
6.7
11.3
5.5
12.9
0.5
0.7
0.2
2.7 0.7
5.2
14.3
1.6
5.5
3.2
66.4
23.9
1.0
11.2
0.9
3.7
1.2
33.4
13.4
22.6 24.2
Control
(n = 16)
36.8
96.5
35.5
112.1
1.7
5.2
1.3
4.8
15.1
4.9
12.8
0.7
1.1
0.3
3.0 0.6
5.2
11.5
1.5
4.2
2.1
44.6
24.1
0.5
5.9
0.8
2.6
0.5
14.4
9.2
11.2 9.2
P-value
0.22
0.22
0.52
0.56
0.44
0.25
0.16
0.30
0.92
0.70
0.99
0.97
0.03
0.05
0.96
0.11
2009 The Authors Journal compilation RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology
1243
Thomson et al.
Study design
All women attended the clinic on three occasions, separated
by at least 2 days for testing. At the first visit, after a minimum 3 hours fast, height, weight and waist circumference
were measured before a graded maximal treadmill exercise
_ 2max . At the second visit,
test was performed to measure VO
following a minimum 3 hours fast, muscular strength was
assessed. At the final visit, after an overnight fast, a blood
sample was drawn for measurement of blood lipids,
C-reactive protein (CRP), glucose, insulin and hormonal
markers. Participants were advised not to consume any
alcohol or participate in any vigorous physical activity
24 hours before each visit. Habitual daily physical activity
levels were assessed using a validated questionnaire,32,33
which provides an index of routine physical activity over
the past 12 months, including occupational, sport and
leisure time activities.
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2009 The Authors Journal compilation RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology
Biochemical analyses
Fasting blood samples were collected for measurement of
serum sex hormone binding globulin (SHBG), testosterone, free testosterone, total cholesterol, high density lipoprotein cholesterol (HDL-C), low density lipoprotein
cholesterol (LDL-C), triglycerides, high sensitivity
C-reactive protein (CRP) and plasma glucose and insulin
as previously described.41,42 The free androgen index
(FAI) was calculated as testosterone/SHBG X 100. The
homeostatic model assessment (HOMA2), used as a surrogate measure of insulin resistance, was estimated using
fasting glucose and insulin concentrations and the
HOMA2 online calculator.43
Statistical analysis
Data were checked for normality and non-normally distributed variables (insulin, triglycerides, HOMA2, CRP, testosterone and FAI) were log transformed prior to analysis.
Subjects with a CRP>10 mg/l (n = 1 PCOS, n = 1 control)
were excluded from the CRP analysis. Group differences
were determined using unpaired Students t-tests. Chisquare test was used to compare categorical data. Pearsons
correlation analysis was used to determine relationships
between variables. Statistical analyses were performed using
SPSS for Windows 14.0 (SPSS, Chicago, IL, USA). Data is
presented as means SD and the level of statistical significance was set at P 0.05.
Results
Participant characteristics, physical measurements, metabolic risk markers and hormonal parameters are presented
in Table 1. The groups were well-matched for age and
BMI. The groups were also well-matched for physical activity levels with no difference between the groups for any of
the physical activity indices (PCOS versus Controls; total
physical activity score, 7.2 0.8 versus 7.2 1.5, P = 0.91;
work activity index, 2.8 0.4 versus 2.6 0.7, P = 0.47;
sports activity index, 1.6 0.2 versus 1.9 0.8, P = 0.30;
leisure-time activity index, 2.8 0.5 versus 2.6 0.7,
P = 0.52). Testosterone and free testosterone were significantly higher in PCOS compared with controls (P 0.05;
Table 1). There were no significant difference between
PCOS
(n = 8)
Control
(n = 14)
1.2
11.1 1.1
0.31 2.48 0.31
4.1
25.7 3.8
12.4 113.2 10.4
0.11 1.13 0.06
8.2 177.8 7.8
1.6
16.7 2.2
P-value
0.99
0.13
0.90
0.11
0.85
0.18
0.50
2009 The Authors Journal compilation RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology
1245
Thomson et al.
35
35
r = 0.54, P = 0.007
30
VO2max (ml/kg/min)
VO2max (ml/kg/min)
r = 0.55, P = 0.005
25
20
15
30
25
20
15
10
10
80
100
120
140
160
WC (cm)
35
10
30
40
35
r = 0.52, P = 0.01
r = 0.55, P = 0.005
30
VO2max (ml/kg/min)
VO2max (ml/kg/min)
20
Insulin (mU/L)
25
20
15
30
25
20
15
10
10
0
10
CRP (mg/l)
12
HOMA2
_ 2max ) and (A) waist circumference (WC), (B) fasting insulin, (C) CRP and (D) HOMA2.
Figure 1. Relationship between cardiorespiratory fitness (VO
Analysis was carried out on log-transformed data for insulin, HOMA2 and CRP.
Discussion
This study showed that in overweight and obese women,
the diagnosis of PCOS was not related to aerobic exercise
capacity, perceptions of exertion during aerobic exercise or
muscle strength compared to age and BMI matched controls with similar surrogate measures of insulin resistance.
_ 2max and insulin resisAn inverse association between VO
tance and waist circumference and muscle strength and
waist circumference was also determined.
_ 2max ) is generally considMaximal aerobic capacity (VO
ered the best indicator of the capacity to perform aerobic
exercise. Our results are in agreement with two previous
_ 2max between
studies that showed no difference in VO
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2009 The Authors Journal compilation RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology
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1247
Thomson et al.
Disclosure of interests
RT, JB, LM, PC, RN and GB have nothing to disclose. MN
has received lecture fees from Meat and Livestock Australia.
Contribution to authorship
RT was responsible for the analysis and interpretation of
data and drafting of the manuscript. GB was responsible
for the conception and design of the study, acquisition of
data and contributed to the analysis and interpretation of
data and the writing of the manuscript. JB, LM, MN, PC,
and RN contributed to the design of the study, interpretation of the data and drafting of the manuscript. Each
author revised critically the manuscript and provided final
approval of the version to be published.
Funding
National Health and Medical Research Council Program
Grant to Robert Norman, The University of Adelaide
1248
Acknowledgements
We gratefully acknowledge Anne McGuffin, Kathryn
Bastiaans and Julia Weaver for coordinating the trial;
Rosemary McArthur, Ruth Pinches, Sue Evans and Deborah
Roffe for nursing expertise; and Mark Mano and Candita
Sullivan for assisting with the biochemical assays. j
References
1 Dunaif A. Insulin resistance and the polycystic ovary syndrome:
mechanism and implications for pathogenesis. Endocr Rev
1997;18:774800.
2 Norman RJ, Dewailly D, Legro RS, Hickey TE. Polycystic ovary
syndrome. Lancet 2007;370:68597.
3 Apridonidze T, Essah PA, Iuorno MJ, Nestler JE. Prevalence and characteristics of the metabolic syndrome in women with polycystic
ovary syndrome. J Clin Endocrinol Metab 2005;90:192935.
4 Ehrmann DA, Liljenquist DR, Kasza K, Azziz R, Legro RS, Ghazzi MN.
Prevalence and predictors of the metabolic syndrome in women with
polycystic ovary syndrome. J Clin Endocrinol Metab 2006;91:4853.
5 Legro RS. Polycystic ovary syndrome and cardiovascular disease: a
premature association? Endocr Rev 2003;24:30212.
6 Laukkanen JA, Kurl S, Salonen JT. Cardiorespiratory fitness and physical activity as risk predictors of future atherosclerotic cardiovascular
diseases. Curr Atheroscler Rep 2002;4:46876.
7 Blair SN, Kohl HW 3rd, Paffenbarger RS Jr, Clark DG, Cooper KH,
Gibbons LW. Physical fitness and all-cause mortality. A prospective
study of healthy men and women. JAMA 1989;262:2395401.
8 Wei M, Gibbons LW, Kampert JB, Nichaman MZ, Blair SN. Low
cardiorespiratory fitness and physical inactivity as predictors of mortality in men with type 2 diabetes. Ann Intern Med 2000;132:60511.
9 Lakka TA, Venalainen JM, Rauramaa R, Salonen R, Tuomilehto J,
Salonen JT. Relation of leisure-time physical activity and cardiorespiratory fitness to the risk of acute myocardial infarction in men. N
Engl J Med 1994;330:154954.
10 Fleg JL, Pina IL, Balady GJ, Chaitman BR, Fletcher B, Lavie C, et al.
Assessment of functional capacity in clinical and research applications: an advisory from the Committee on Exercise, Rehabilitation,
and Prevention, Council on Clinical Cardiology, American Heart
Association. Circulation 2000;102:15917.
11 Norman RJ, Davies MJ, Lord J, Moran LJ. The role of lifestyle modification in polycystic ovary syndrome. Trends Endocrinol Metab
2002;13:2517.
12 Moran LJ, Brinkworth G, Noakes M, Norman RJ. Effects of lifestyle
modification in polycystic ovarian syndrome. Reprod Biomed Online
2006;12:56978.
13 Bertoli A, Daniele N, Ceccobelli M, Ficara A, Girasoli C, Lorenzo A.
Lipid profile, BMI, body fat distribution, and aerobic fitness in men
with metabolic syndrome. Acta Diabetol 2003;40:s1303.
14 Molnar D, Porszasz J. The effect of fasting hyperinsulinaemia on
physical fitness in obese children. Eur J Pediatr 1990;149:5703.
15 Ugur-Altun B, Altun A, Tatli E, Arikan E, Tugrul A. Relationship
between insulin resistance assessed by HOMA-IR and exercise test
variables in asymptomatic middle-aged patients with type 2 diabetes. J Endocrinol Invest 2004;27:45561.
2009 The Authors Journal compilation RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology
36 Howley ET, Bassett DR Jr, Welch HG. Criteria for maximal oxygen
uptake: review and commentary. Med Sci Sports Exerc
1995;27:1292301.
37 Wasserman K, Hansen J, Sue D, Whipp B. Principles of Exercise Testing and Interpretation, 2nd edn. Philadelphia, PA: Williams &
Wilkins, 1994.
38 Gross M, Hoffman G, Phillips C, Wray J. Intramachine and intermachine reliability of the Biodex and Cybex II for knee flexion and
extension peak torque and angular work. J Orthop Sports Phys Ther
1991;13:32935.
39 Pincivero DM, Gear WS, Sterner RL. Assessment of the reliability of
high-intensity quadriceps femoris muscle fatigue. Med Sci Sports
Exerc 2001;33:3348.
40 Kim HJ, Kramer JF. Effectiveness of visual feedback during isokinetic
exercise. J Orthop Sports Phys Ther 1997;26:31823.
41 Moran LJ, Noakes M, Clifton PM, Wittert GA, Williams G, Norman
RJ. Short-term meal replacements followed by dietary macronutrient
restriction enhance weight loss in polycystic ovary syndrome. Am J
Clin Nutr 2006;84:7787.
42 Noakes M, Keogh JB, Foster PR, Clifton PM. Effect of an energyrestricted, high-protein, low-fat diet relative to a conventional
high-carbohydrate, low-fat diet on weight loss, body composition,
nutritional status, and markers of cardiovascular health in obese
women. Am J Clin Nutr 2005;81:1298306.
43 Wallace TM, Levy JC, Matthews DR. Use and abuse of HOMA modeling. Diabetes Care 2004;27:148795.
44 Ekkekakis P, Lind E. Exercise does not feel the same when you are
overweight: the impact of self-selected and imposed intensity on
affect and exertion. Int J Obes (Lond) 2006;30:65260.
45 Fornitano LD, Godoy MF. Exercise testing in individuals with morbid
obesity. Obes Surg: DOI 10.1007/s11695-008-9692-7 (E-pub ahead
of print).
46 Ugur-Altun B, Altun A, Tatli E, Tugrul A. Factors related to exercise
capacity in asymptomatic middle-aged type 2 diabetic patients.
Diabetes Res Clin Pract 2005;67:1306.
47 Regensteiner JG. Type 2 diabetes mellitus and cardiovascular exercise
performance. Rev Endocr Metab Disord 2004;5:26976.
48 Van De Borne P, Hausberg M, Hoffman RP, Mark AL, Anderson EA.
Hyperinsulinemia produces cardiac vagal withdrawal and nonuniform sympathetic activation in normal subjects. Am J Physiol
1999;276:R17883.
49 Valensi P, Nguyen TN, Idriss S, Cazes P, Karam G, Paries J, et al.
Influence of parasympathetic dysfunction and hyperinsulinemia on
the hemodynamic response to an isometric exercise in non-insulindependent diabetic patients. Metabolism 1998;47:9349.
50 Ovalle F, Azziz R. Insulin resistance, polycystic ovary syndrome, and
type 2 diabetes mellitus. Fertil Steril 2002;77:1095105.
51 DeUgarte CM, Bartolucci AA, Azziz R. Prevalence of insulin resistance in the polycystic ovary syndrome using the homeostasis model
assessment. Fertil Steril 2005;83:145460.
52 Carmina E, Napoli N, Longo RA, Rini GB, Lobo RA. Metabolic
syndrome in polycystic ovary syndrome (PCOS): lower prevalence in
southern Italy than in the USA and the influence of criteria for the
diagnosis of PCOS. Eur J Endocrinol 2006;154:1415.
53 Diamanti-Kandarakis E, Panidis D. Unravelling the phenotypic map
of polycystic ovary syndrome (PCOS): a prospective study of 634
women with PCOS. Clin Endocrinol (Oxf) 2007;67:73542.
54 Carmina E, Azziz R. Diagnosis, phenotype, and prevalence of polycystic ovary syndrome. Fertil Steril 2006;86 (Suppl 1):S78.
55 Cussons AJ, Watts GF, Burke V, Shaw JE, Zimmet PZ, Stuckey BGA.
Cardiometabolic risk in polycystic ovary syndrome: a comparison of
different approaches to defining the metabolic syndrome. Hum
Reprod 2008;23:23528.
2009 The Authors Journal compilation RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology
1249
Thomson et al.
1250
66 Ridker PM, Hennekens CH, Buring JE, Rifai N. C-reactive protein and
other markers of inflammation in the prediction of cardiovascular
disease in women. N Engl J Med 2000;342:83643.
67 Giallauria F, Palomba S, Maresca L, Vuolo L, Tafuri D, Lombardi G,
et al. Exercise training improves autonomic function and inflammatory pattern in women with polycystic ovary syndrome. Clin
Endocrinol 2008;69:7928.
68 Karelis AD, Tousignant B, Nantel J, Proteau-Labelle M, Malita FM,
St-Pierre DH, et al. Association of insulin sensitivity and muscle
strength in overweight and obese sedentary postmenopausal
women. Appl Physiol Nutr Metab 2007;32:297301.
69 Stenholm S, Rantanen T, Heliovaara M, Koskinen S. The mediating
role of C-reactive protein and handgrip strength between obesity
and walking limitation. J Am Geriatr Soc 2008;56:4629.
70 Cesari M, Kritchevsky SB, Baumgartner RN, Atkinson HH, Penninx
BWHJ, Lenchik L, et al. Sarcopenia, obesity, and inflammation
results from the Trial of Angiotensin Converting Enzyme Inhibition
and Novel Cardiovascular Risk Factors study. Am J Clin Nutr
2005;82:42834.
71 Bross R, Casaburi R, Storer TW, Bhasin S. Androgen effects on body
composition and muscle function: implications for the use of androgens as anabolic agents in sarcopenic states. Baillieres Clin Endocrinol Metab 1998;12:36578.
72 Bhasin S, Storer TW, Berman N, Callegari C, Clevenger B, Phillips J,
et al. The effects of supraphysiologic doses of testosterone on muscle size and strength in normal men. N Engl J Med 1996;335:17.
73 Rolland Y, Lauwers-Cances V, Cristini C, Grandjean H, Banks WA,
Morley JE, et al. Disability in obese elderly women: lower limb
strength and recreational physical activity. Obes Res Clin Pract
2007;1:3951.
74 Wright CE, Zborowski JV, Talbott EO, McHugh-Pemu K, Youk A.
Dietary intake, physical activity, and obesity in women with polycystic ovary syndrome. Int J Obes Relat Metab Disord 2004;28:1026
32.
2009 The Authors Journal compilation RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology