If you have PCOS and have been told by your doctor that you have a fatty liver, you aren’t alone. Non-alcoholic fatty liver disease (NAFLD), commonly referred to as fatty liver, is highly prevalent in women with PCOS. Fatty liver has been shown to be 4x higher in women with PCOS. One study showed that fatty liver occurs in 52% of patients with PCOS.
NAFLD is a silent condition. Most people with PCOS won’t know that they have it until getting blood results. Having fatty liver or NAFLD increases the risk of cardiovascular disease. If not treated, fatty liver can progress to more advanced stages of liver damage. Here’s information on what to know about fatty liver and how to prevent or treat it if you have PCOS.
The Link Between PCOS and Fatty Liver
You may be wondering why is fatty liver so prevalent in the PCOS population? Fatty liver occurs as a result of excess triglycerides (fat) stored in the liver which causes inflammation and damage to liver cells. The liver isn’t meant to store fat; its role is to serve as the detox organ for the body filtering out harmful substances.
Most people with PCOS have insulin resistance. IR increases lipolysis, a fancy term for an increased stream of fatty acids to the liver and fat accumulation (hence the term fatty liver).
Fatty liver could also be caused by androgens: androgen excess increases IR, increasing visceral adipose tissue and reducing the fat tissue hormone adiponectin. This may occur becuse of adipose tissue dysfunction and inflammation.
There is no medication to treat fatty liver. The good news: Fatty liver can be improved and prevented by lifestyle changes as discussed below.
Diagnosing Fatty Liver
NAFLD can first be detected by checking levels of your liver function tests, or “LFTs” as the medical community has nicknamed them. LFTs are the liver enzymes alanine aminotransferase (ALT) or aspartate aminotransferase (AST) which become elevated when the liver is damaged. It’s important to know that most all medications pass through the liver and can also raise LFTs. This is why some physicians recommend an ultrasound of the liver or a liver biopsy to confirm a diagnosis of NAFLD.
Associated Factors Contributing to Fatty Liver in PCOS:
Nutrition and Diet for Fatty Liver
Following a Mediterranean style diet that is rich in fatty fish, avocados, olive oil and other monounsaturated fats may be beneficial to improve insulin, fight inflammation, and reduce liver fat. Not sure where to start? The PCOS Nutrition Center Cookbook has 100 Easy and Delicious Whole Food Recipes to Beat PCOS along with a bonus 4-week meal plan.
Get Moving To Improve Fatty Liver
A sedentary lifestyle is one of the contributing factors to NAFLD. Engaging in regular physical activity consisting of aerobic and resistance training, can decrease fatty liver even if weight loss isn’t achieved. Participants who engaged in 30 to 60 minutes of exercise two to three times each week saw significant reductions in liver fat. To make physical exercise a regular routine, prioritize it by scheduling it in your calendar. Performing in activities that are fun and enjoyable to do will also help increase your commitment.
Take Fish Oil
Omega-3 fatty acids like the ones found in cold water fish such as salmon, tuna and trout are effective at reducing triglycerides, inflammation, and insulin in women with PCOS. A study published in the Journal of Clinical Endocrinology and Metabolism showed that women with PCOS who supplemented their diets with 4 grams of fish oil for 8 weeks saw a significant decrease in liver fat and triglycerides. A fish oil supplement such as Nordic Naturals, is probably needed since it’s quite a challenge to eat enough fish to meet the therapeutic amounts of omega-3 fats.
Add a Probiotic
Emerging research is showing that unhealthy bacteria in our guts may contribute to fatty liver disease. Probiotics assist the body’s friendly bacteria to make it even more powerful. Friendly bacteria are important for proper maintenance of our immune system and for the digestion and absorption of food. One randomized controlled study showed that taking a probiotic for three months improved LFTs in patients with NAFLD. For more information on probiotics for PCOS, click here.
Berberine has been shown to be an effective option to reduce fatty liver. A review of 6 randomized control trials involving 500 individuals found that berberine significantly reduced fatty liver in those with non-alcoholic fatty liver disease (NAFLD). Berberine lowered triglycerides and liver function enzymes, and overall improved liver condition. It has been found that berberine improves NAFLD by preventing liver fat build up and promoting fatty acid oxidation in skeletal muscle. For more information about berberine, see our article, 10 Benefits of Berberine for PCOS.
Supplement with N-Acetylcysteine (NAC)
Women with PCOS have been shown to have higher levels of oxidative stress than women without PCOS. Oxidative stress is a contributing factor to diseases like NAFLD. Antioxidants work to fight oxidative stress and have been suggested in the treatment of NAFLD. Vitamin E, a powerful antioxidant is commonly recommended to those with NAFLD. Two randomized controlled trials showed significant improvements in fatty liver in individuals who supplemented their diets with 800 to 1,000 IU/day of vitamin E. No studies have specifically looked at the benefits of vitamin E in women with PCOS. Treatment with high doses of vitamin E should be monitored with caution as it can be stored in fat and become toxic.
N-acetylcysteine (NAC) is another antioxidant that has been shown to be effective at reducing oxidative stress in women with PCOS as well as treat NAFLD. Patients who were treated with NAC (1200 mg/daily) for 3 months showed a significant improvement in LFTs.
Don’t Forget the Choline!
Also be sure to get in adequate amounts of choline. Choline plays an essential role in liver health. A deficiency of choline is associated with higher rates of fatty liver. Most people don’t meet choline requirements. The PCOS Nutrition Center PCOS PRENATAL contains choline. Not sure if you’re getting enough? Check out this article, Don’t Forget the Choline!
Consider Milk Thistle for Fatty Liver
Silybum marianum, commonly known as milk thistle, is an herb native of the Mediterranean and North African regions that is used in the treatment of liver diseases. Some studies have suggested that the active extract of milk thistle possesses antioxidant, anti-inflammatory and anti-fibrotic properties. In a randomized study, Hajaghamohammadi et al showed that milk thistle (140 mg/day) for 2 months decreased LFTs significantly more than metformin in individuals with NAFLD.
Milk thistle has also been shown to help with insulin resistance. In another randomized trial, patients with NAFLD who took a combination of milk thistle and vitamin E for 12 months (200 mg/day) showed improvements in liver enzymes and insulin resistance. Velussi et al showed that treatment with milk thistle for 12 months (600 mg/day) was associated with a reduction of insulin resistance and a significant decrease in fasting insulin levels in people with diabetes.
Non-alcoholic fatty liver disease (NAFLD) in women with PCOS is common and serious, but can easily be reversed with nutrition and lifestyle changes.
Have you been diagnosed with NAFLD and have successfully reversed it with changes to diet and lifestyle? Share what worked for you!
Asfari MM et al. Association of non-alcoholic fatty liver disease and polycystic ovarian syndrome. BMJ Open Gastroenterology 2020;7:e000352.
Falzarano et al. Nonalcoholic Fatty Liver Disease in Women and Girls With Polycystic Ovary Syndrome. The Journal of clinical endocrinology and metabolism, 2022;107(1), 258–272.
Hallsworth K, Fattakhova G, Hollingsworth KG. Resistance exercise reduces liver fat and its mediators in nonalcoholic fatty liver disease independent of weight loss. Gut. 2011;60:1278-1283.
Cusons A, Watts G, Mori T. Omega-3 fatty acid supplementation decreases liver fat content in polycystic ovary syndrome: a randomized controlled trial employing proton magnetic resonance spectroscopy. J Clin Endocrinol Metb. 2009;94(10):3842-3848.
Velussi M, Cernigoi AM, De Monte A et al. Long term (12 months) treatment with an anti-oxidant drug (silymarin) is effective on hyperinsulinemia, exogenous insulin need, and malondialdehyde levels in cirrhotic diabetic patients. J. Hepatol 1997;26(4):871–879.
Manouchehr et al. N-Acetylcysteine Improves Liver Function in Patients with Non-Alcoholic Fatty Liver Disease. Hepat Mon. 2010; 10(1):12–16.
Zhao L et al. Berberine improves glucogenesis and lipid metabolism in nonalcoholic fatty liver disease. BMC Endocr Disord. 2017 Feb 28;17(1):13.
Dr. Hina is a fertility specialist and radiologist working as a IUI Consultant. She is a beacon of hope for couples on their journey to parenthood, specializing in fertility treatment and serving as a trusted IUI consultant. With an impressive 8 years of experience in the field, she has witnessed the transformative power of reproductive medicine firsthand and is driven by a deep passion to help individuals realize their dreams of starting a family. Read More