Polycystic Ovary Syndrome Unique Concerns During Pregnancy and Lactation

By Angela Grassi, MS, RD, LDN

Todays Dietitian
Vol. 10 No. 12 P. 38
For many women with PCOS, conceiving is only the first hurdle. These women face particular challenges,
but RDs can help them achieve healthy pregnancies by addressing their special emotional, health, and
dietary needs.
Polycystic ovary syndrome (PCOS) is identified as a state of hyperinsulinemia and hyperandrogenism.
Affecting 8% to 10% of reproductive-age women, it is the main cause of ovulatory infertility in the United
States.1
Pregnancy can be an exciting time for women with PCOS, especially because so many of them may have
been trying to conceive for years, with or without fertility treatments. In addition, being pregnant is a sign
of femininity, and it may be a relief to some women who have felt masculine due to their male shape and
symptoms such as excess hair growth and balding.
However, having PCOS and being pregnant does pose some concerns. Some women who have
undergone fertility treatments may carry multiple babies and will have special dietary and medical needs.
Also, because many women with PCOS have hormonal imbalances and are overweight or obese, they
are at higher risk for miscarriage and complications such as gestational diabetes mellitus and
hypertensive disorders during pregnancy.2-6 Proper medical management and medical nutrition therapy
are imperative to prevent the onset of these complications and optimize fetal growth and development.
Emotional Concerns
Many women with PCOS who are able to conceive may have misconceptions about eating healthfully
during pregnancy. Popular diet guidelines for PCOS (mostly from the Internet) recommend a very lowcarbohydrate diet, but current evidence does not support it. Women who follow these recommendations
may feel apprehensive about eating foods containing carbohydrates during pregnancy, including fruits,
vegetables, legumes, and grainsall of which provide important vitamins, minerals, and fiber and are
essential for fetal growth and development. Women may also be inclined to limit carbohydrates out of fear
of gaining too much weight or to prevent gestational diabetes mellitus. (Currently, no evidence supports
limiting carbohydrates during pregnancy to prevent gestational diabetes mellitus.) Dietitians should screen
patients with PCOS for negative attitudes toward food and weight and convey the importance of
consuming whole grain and whole food carbohydrates in sufficient amounts.
On the other hand, some women may think pregnancy gives them license to eat anything they want. For
the first time, they may feel less pressure to restrict their intake in a society preoccupied with thinness. If
these women were very restrictive with their diet prior to conceiving, this could lead to binging during
pregnancy, resulting in excessive weight gain. Additionally, women who already struggle with anxiety and
depression may feel that these conditions are exacerbated during pregnancy and may turn to food for
emotional support. A study published in the Journal of the American Dietetic Association in 2005
found that pregnant women who reported high stress, anxiety, and fatigue consumed more
carbohydrates, fats, and protein and less vitamin C and folate.
It is common for a woman who followed a prepregnancy limited-carbohydrate diet to abandon this way of
eating while pregnant, turning to once-forbidden refined carbohydrates and high saturated fat-containing
foods. As one patient put it, I am pregnant now and do not have to worry about managing my insulin
levels or my weight. Such an attitude can lead to excessive weight gain during pregnancy, increasing the
chances of adverse health risks such as gestational diabetes mellitus.

Body image issues can also be of concern during pregnancy, as those who have struggled with their
weight most of their lives may fear that their weight will spiral out of control. They may also have difficulty
accepting weight gain and growing larger in general. Women with PCOS also carry their weight in their
midsection and may not appear pregnant until their third trimester, causing some to struggle with body
image concerns of failing to look pregnant. After gaining a reasonable 7 pounds and while in her second
trimester, one of my patients admitted wanting to eat extra food to purposely gain more weight because
she wasnt showing and wanted the attention she saw other pregnant women receiving.
Health Concerns
Because most women with PCOS have hormonal imbalances and are overweight or obese, they are at a
higher risk for miscarriage and complications such as gestational diabetes mellitus, preeclampsia,
macrosomia, and preterm labor during pregnancy.7-13 Research has also indicated that infants born to
women with PCOS have higher rates of admission to neonatal intensive care units.14 Many physicians
with whom I have worked recommend initiating an oral glucose tolerance test sooner in women with
PCOS. They recommend testing at 20 weeks gestation to screen for gestational diabetes mellitus and, if
normal, repeat it by the standard screening time for all pregnant women between 24 and 28 weeks
gestation. Proper medical management and medical nutrition therapy are imperative to prevent the onset
of medical complications and optimize fetal growth and development. Postmeal physical activity, such as
walking for 10 to 20 minutes, can help manage blood pressure and insulin resistance by controlling
postprandial hyperglycemia.
For women with PCOS, pregnancy should be considered a state of pre-gestational diabetes mellitus and
as a precaution, diet guidelines should reflect those for gestational diabetes mellitus. A slight reduction in
carbohydrate intake of 35% to 40% of total calories is therefore suggested and consistent with the
American Diabetes Association guidelines for gestational diabetes mellitus. The majority of carbohydrates
should be of whole grain and high-fiber quality, with at least 28 grams each day (the dietary reference
intake requirement) for optimal glucose and insulin control. Dietetics professionals must convey the
importance of distributing carbohydrates evenly throughout the day and encouraging three meals and two
to four snacks, as well as an evening snack to manage glucose levels throughout the night. All meals and
snacks must include protein-rich foods to help stabilize glucose levels. Due to the high rate of miscarriage
and gestational diabetes mellitus related to elevated insulin levels, women with PCOS should limit or
avoid simple carbohydrates, including sweetened beverages (eg, juices, soft drinks, sports drinks),
candies, and desserts.
Metformin is recommended for pregnant women with PCOS, as it can reduce the incidence of
preeclampsia, macrosomia, gestational diabetes mellitus, preterm labor, and the risk of miscarriage.8,9 A
study showed that at dosages between 1.5 and 2.55 grams per day, metformin did not affect the birth
weight, length, growth, or motor-social development of 126 infants compared with their control
counterparts.15 Metformin helps prevent gestational diabetes mellitus and improve pregnancy outcomes
in women with PCOS by helping reduce preconception and pregnancy weight gain, hyperinsulinemia, and
insulin resistance and secretion.2,3
Do Women With PCOS Have More Difficulty Breast-Feeding?
Because of the many hormonal imbalances associated with PCOS, researchers have speculated that
some women may have difficulty breast-feeding and producing an adequate milk supply for their infants.
The hormonal aberrations in PCOS involve insulin, progesterone, and estrogen, all of which are important
to breast development and milk-secreting ability.16 Lisa Marasco, MA, IBCLC, is a lactation consultant
who began studying the connection between PCOS and low milk supply after seeing two patients with
PCOS in one day who had problems with milk production. In her thesis, she studied a group of 30 women
with lactation failure and found that more than one half of them were obese, 57% had a history of
infertility, and 67% experienced oligoamenorrhea or amenorrhea. According to Marasco, some women
with PCOS may have more difficulty producing adequate milk because the breast tissue fails to undergo
the normal physiological changes during pregnancy needed to prepare for lactation or perhaps because
not enough breast tissue existed prior to pregnancy (hypoplasia). Women with PCOS have low levels of
progesterone, which is needed for alveolar growth and breast tissue development. Insulin also plays a

role in milk production, and having insulin resistance may contribute to lactation problems in women with
PCOS, according to Marascos research.
As a precaution, lactation consultants recommend that all women with PCOS pump after feedings for at
least 10 to 15 minutes on each breast to help establish an adequate milk supply in the first two weeks of
initiating nursing. Frequent feedings with full drainage can also help maximize milk production, as can
consuming an adequate amount of food and fluid each day. For mothers with a low milk supply, extra
breast stimulation via frequent nursing or pumping sessions is crucial. Skin-to-skin contact is also
encouraged to boost milk production.17
Milk supply problems may be prevented or ameliorated by establishing early intervention strategies during
pregnancy. This may include obtaining resources for local breast-feeding support groups and preparing to
work with a board-certified lactation consultant soon after giving birth. Good breast-feeding management,
including proper latch and positioning, are imperative to successful milk production and proper infant
growth and development.
According to Marasco, all of these tactics will help establish the foundation to good milk supply, yet they
do not address the underlying problems. Although not scientifically tested, goats rue, fennel, kale,
verbena, chasteberry, and fenugreek are herbal supplements reputed to increase milk supply and
possibly stimulate breast growth.18,19 Using progesterone supplements and metformin during pregnancy
may also help support an adequate milk supply in women with PCOS and possibly support breast
development during pregnancy. Marasco has tried metformin with a number of PCOS moms with low
supply and, in some cases, metformin alone increases milk production. However, she adds, Metformin is
not going to help much if the woman does not have enough breast tissue in place to begin with.
Medications such as metoclopramide can also be prescribed to boost milk supply. Interestingly, while
some women with PCOS experience low milk supply, others report an overabundance of milk production.
Evidently, this area needs more research.
Is Metformin Safe to Use While Breast-Feeding?
Since many women choose to take metformin during pregnancy for the benefits discussed previously,
they may be inclined to continue taking metformin while they breast-feed to prevent a rebounding of
PCOS symptoms after birth, control insulin levels, and possibly help produce an adequate milk supply.
However, the use of metformin during lactation is controversial.
Limited information exists about whether metformin is safe to take while breast-feeding, as the risks to the
infant are still unknown. The few studies that are available have consisted of relatively limited sample
sizes, and results show that while metformin does cross into the milk supply, it is in clinically insignificant
amounts with no adverse effects on infants.20-22 The most recent and largest study was conducted
among 61 nursing infants and 50 formula-fed infants born to mothers with PCOS who took an average of
2.55 grams of metformin per day throughout pregnancy and lactation.23 The infants were followed up to 6
months of age, with results showing that the breast-fed infants of mothers who took metformin had no
adverse health risks in regard to growth or motor-social development.23
However, as I researched this article, numerous pediatricians, obstetricians, and reproductive
endocrinologists offered conflicting advice about whether to take metformin while nursing. Some
physicians do not feel comfortable advising women to breast-feed while taking the medication because of
the lack of evidence supporting safety, especially because research has indicated that metformin does
cross into the milk supply. Other physicians say they have been instructing moms to stay on metformin
while breast-feeding as infants have already been exposed to it in utero (metformin does cross the
placenta) and because it does not appear to be teratogenic, cause hypoglycemia, or pose any adverse
health risks. Until more long-term and larger studies are conducted, women with PCOS who plan to
breast-feed while on metformin should discuss their options with their physician and carefully make a riskbenefit analysis beforehand. If a woman does decide to take metformin while nursing, monitoring the
infants health and feeding habits frequently is advised.21,22

Summary
The joyous time of pregnancy can pose additional concerns to women with PCOS, as they are at a higher
risk for miscarriage and obstetrical complications such as gestational diabetes mellitus, preterm labor,
pregnancy-induced hypertension, and macrosomia. Some women may be resistant to eating
carbohydrate foods while others may consume too many of them, posing additional risks to mother and
fetus. Dietitians must educate patients about the benefits of a good diet and lifestyle to sustain a healthy
pregnancy. In general, PCOS in pregnancy should be considered a state of pre-gestational diabetes
mellitus and dietary guidelines should resemble those for gestational diabetes mellitus. In addition, some
women with PCOS may have difficulty breast-feeding and producing an adequate milk supply for their
infants due to hormonal imbalances. Dietitians can play an integral part in the health of women with
PCOS during pregnancy and throughout the lactation period.
Angela Grassi, MS, RD, LDN, is the author of The Dietitians Guide to Polycystic Ovary
Syndrome and The PCOS Workbook: Your Guide to Complete Physical and Emotional Health.

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