PCOS: The Fatty Liver and Sleep Apnea Connection

Polycystic ovarian syndrome is usually characterized by menstrual irregularities and hormone imbalances [1]. A common trend I see in PCOS patients clinically, is suboptimal sleep, of which there are several causes. Another intriguing connection is the one between sleep apnea and fatty liver.

As you’ll learn here, many of the underlying hormonal issues found in PCOS directly relate to sleep apnea and fatty liver [2].

Sleep Disturbances are Common in PCOS

PCOS is a complex endocrine disorder, which affects sleep too. Clinic based studies show that obstructive sleep apnea and excessive daytime sleepiness occur more frequently in those with PCOS compared to women without PCOS [2].  It is true sleep disturbances are independently related to obesity (which is also common among women with PCOS), but these sleep abnormalities are observed in women with PCOS with normal weight too [2].

Clinically, decisions need to be make whether to focus treatment on sleep or focus on PCOS and hope the sleep corrects itself. We know PCOS is related to hyperandrogenism (excess circulating male sex hormones), as well as insulin resistance. Both hyperandrogenism and insulin resistance lead to changes in cortisol and melatonin secretion – reflecting altered hypothalamus-pituitary-adrenal dysregulation [2].

The relationship between PCOS and sleep has been an emerging topic in the field of research over the past decade, with clear relationships being established [2]. In fact, Figure 1 below shows historically, how much research has been done on PCOS and sleep. As you'll see it is an emerging trend in research.

Hyperandrogenism and the Sleep Apnea Connection

PCOS is associated with increased male sex hormones (hyperandrogenism). We also know obstructive sleep apnea is an androgen-driven process, hence men being more prone. So women with PCOS with hyperandrogenism need to be aware of their increased risk of sleep apnea [3].

Sleep apnea in women with PCOS leads to 7.6 times the chance of fatty liver, which will be discussed more below.

Insulin Resistance & Fatty Liver and the Sleep Apnea Connection

PCOS is also associated with insulin resistance, and (non-alcoholic) fatty liver disease is often a long term consequence of insulin resistance. Oxidation and inflammation are driving forces which push fatty liver into even more serious conditions (such as liver cirrhosis).

Obstructive sleep apnea is sleep characterized by cessations of breathing during sleep and may occur with other sleep disturbances [2]. When we stop breathing, we suffer oxidative damage.

We also know sleep apnea (which is common in women with PCOS) is linked with a 7.6x increased risk of developing fatty liver [3]. This happens due to chronic intermittent hypoxia (poor oxygen delivery to the cells). Poor oxygen delivery to our tissues will increase insulin resistance and fat accumulation in the liver. Combined, the presence of fatty liver with sleep apnea leads to a 2.6x higher risk of progressing to liver fibrosis.

Treatment Should Focus on PCOS, Insulin Resistance and Sleep Apnea Simultaneously

The common treatment for sleep apnea is the CPAP (continuous positive airway pressure) treatment. In women with PCOS suffering from sleep apnea, the CPAP is shown to be beneficial; improving insulin sensitivity and also reducing sympathetic output and reducing diastolic blood pressure (all good things) [4].

Focusing on sleep apnea directly is helpful, but the clear connections between other hormonal imbalances prove how important it is to treat the underlying causes and all contributing factors.