TOPIC: PCOS and NAFLD

If you have PCOS, your doctor may have spoken to you about the correlation between PCOS (Polycystic Ovarian Syndrome) and NAFLD (Non-alcoholic Fatty Liver Disease). What is NAFLD? This diagnosis encompasses a broad spectrum of pathology of the liver, ranging from simple fatty deposits in the liver to severe inflammation, fibrosis, or even cirrhosis.

At the most extreme end of the spectrum, there is irreversible scarring and impaired liver function. When both inflammation and fatty deposits are involved, the disease is termed NASH (Non-alcoholic Steatohepatitis) and a liver biopsy is necessary to diagnose this. As implied by the name, alcoholism does not play a role in the NAFLD spectrum as it does in other liver diseases.

Often NAFLD is asymptomatic and is only caught because of the liver enzymes being high in routine blood work. General symptoms include fatigue, malaise and discomfort in the right upper quadrant of the abdomen, or discomfort in the whole abdomen. A few other symptoms that cause suspicion are jaundice, and chronic itchiness of the skin (puritis).

The underlying commonality between PCOS and NAFLD is insulin resistance. Many in the medical world now accept that insulin resistance is the root cause of the hormonal imbalance and ovarian cysts characteristic of PCOS. When the body stops responding to insulin effectively, excess insulin levels in the blood contribute to ovarian dysfunction which then causes hormone imbalance. The abnormal hormone levels lead to PCOS symptoms like excess hair growth, irregular periods, acne, and difficulty conceiving.

Insulin resistance is also intricately related to the weight gain experienced by at least half of women with PCOS. Excess insulin production, over time, eventually causes insulin production issues that result in type 2 diabetes, a potential complication of PCOS.

Like women with PCOS, people with NAFLD demonstrate insulin resistance to some degree. Since liver and fat cells are some of the primary targets of insulin, it is no surprise that insulin resistance is the mechanism behind the development of NAFLD. In insulin resistance, there is an increased uptake and storage of triglyceride fat into the liver cells. Triglycerides come from both the diet and from body fat (especially in the abdomen) and muscles.

Several new studies within the last few years have confirmed the increased incidence of NAFLD in women with PCOS. Brzozowska et al (Feb 2009) suggest screening all women with PCOS for NAFLD, and that women with PCOS who have evidence of metabolic syndrome should be screened for liver disease at an even earlier age. Criteria for metabolic syndrome include abnormal lipid levels, increased waist to hip ratio, increased BMI (Body Mass Index), elevated triglycerides, high blood pressure, and pre-diabetes or diabetes, among other things.

Researchers in Greece looked specifically at lean young women with PCOS and found that this population did NOT have an increased incidence of NAFLD. In their conclusion, however, they caution that lean women with PCOS should continue to be screened for NAFLD due to the presence of insulin resistance. Zheng and Ding in China also noted that those women with PCOS in their study who had higher BMI and waist-hip ratio were more likely to evidence signs of liver disease, confirming the suspicion that thin women with PCOS may be less susceptible to developing NAFLD.

Until further research is done on thin women with PCOS and liver disease, every woman with PCOS should discuss liver health with her doctor. This is particularly true for women who struggle with weight and other signs of metabolic syndrome.

Dr. Sari Cohen

References:
(1) Brzozowska M. et al. An association between non-alcoholic fatty liver disease and polycystic ovarian syndrome. J Gastroenterol Hepataol. 2009 Feb;24(2): 243-7, PMID: 19215335
(2) Markou A. et al. Hepatic steatosis in young lean, insulin resistant women with polycystic ovary syndrome. Fertil Steril. 2009 Jan 24. [Epub ahead of print], PMID: 19171337
(3) Zheng R. and Ding C. Prevelance of nonalcoholic fatty liver disease in patients with polycystic ovary syndrome: a case-control study. Zhonghua Fu Chan Ke Za Zhi. 2008 Feb: 43(2): 98-101, PMID: 18683746