PCOS : what is it and what the heck to do about it.

Polycystic Ovarian Syndrome (PCOS) has become so UBER COMMON in our world. I would simply love to do a study on how many women actually ovulate each month in 2019 when compared to how many women ovulated each month in 1819…I think the results would be astonishing. PCOS truly is a ‘disease’ of the modern age. I use the term ‘disease’ with caution because really what PCOS is most of the time is an imbalance of hormone levels (most importantly insulin) which is most often triggered by the influence of modern day life: stress, poor sleep, diet, exercise and also epigenetic changes (more on that another time!) Here’s a quick rundown of what PCOS is all about and how you can fix it.

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Polycystic Ovarian Syndrome (PCOS) is a broad term for lack of / delayed ovulation, absent or irregular periods, excess androgens, blood sugar imbalance, and of course, polycystic ovaries (multiple follicles). 

Not all follicles produce eggs that will be ovulated. Follicles are, in essence, “baby eggs” that are immature and not large enough to become a dominant follicle, and only dominant follicles are ovulated in a normal menstrual cycle. In PCOS, a mature, dominant follicle rarely develops, if it develops at all.

And it’s not just the lack of dominant follicles that is problematic; it’s also those multiple “baby follicles:” they can produce estrogen, which can lead to estrogen overload, and this estrogen can get “aromatized” into testosterone, driving androgen excess.


Up to 70% of anovulatory cycles (aka you do not ovulate) are related to PCOS, which is generally diagnosed with blood testing for hyperinsulinemia, elevated blood sugar, androgen and sex hormone levels or with ultrasound to detect multiple follicles. Ultrasound alone is NOT a good way to diagnose PCOS, however, as many women without PCOS have multiple follicles. PCOS needs to be diagnosed with blood work and ultrasound.

While the typical PCOS sufferer is overweight, PCOS can happen to all types of women - 20-25% of cases are in lean women with BMI under 25.

PCOS is incredibly paradoxical: it may be over-diagnosed, under-diagnosed, or misdiagnosed depending on the woman and the practitioner. When it is properly diagnosed, there is a very poor clinical understanding of how it should be managed. Many functional medicine practitioners, including me, have found great success helping women with PCOS using a whole body-mind approach - much like the Core Four in my Baby Making and Beyond program

Signs You Might Have PCOS

  • Skin issues. Acne or hair growth on your chin or upper lip are signs of excess androgens, a marker for PCOS.

  • Hair thinning or hair loss. This is also a sign of excess androgen production.

  • Irregular periods without ovulation (no temp rise when you chart your BBT), a sign of overall hormone imbalance, often driven by androgens.

Blood Work & Ultrasound Testing

  • This is the most important step! Get a full blood sugar and hormone panel that includes progesterone, estrogen, testosterone, DHEA, LH, FSH, prolactin, AMH (anti-mullerian hormone), HbA1C, fasting insulin, cholesterol, and a full thyroid panel. If your practitioner is not willing to order these tests, find a new practitioner or order labs directly.

  • Blood work will likely show low progesterone; high testosterone, DHEA, LH, and AMH; high- to borderline-high HbA1C; and thyroid irregularities.

  • Ultrasounds are used to check for follicles are done in ADDITION to blood work. With PCOS, there are often 12 or more follicles within the ovary, with a diameter of 2-9 mm and/or ovarian volume 10 cm3 or greater. This many follicles do not mean you’ll release multiple eggs; follicles in PCOS are not mature and don’t develop into an egg that gets ovulated.

Common Causes

  • Elevated insulin, insulin resistance, and androgen excess. This is the primary cause of PCOS and should be the target for your treatment strategies. Insulin resistance (IR) occurs when your body’s cells become resistant to the effects of insulin, which is supposed to move glucose (sugar) into the cells when the body senses a rise in blood sugar. In IR, your cells don’t soak up all that glucose - so it stays in your bloodstream, resulting in chronically high blood sugar. The elevated insulin drives the overproduction of almost anything, including an ovarian enzyme called cytochrome P450c17α that increases androgen concentrations in the body. At the same time, if your body stays in this state for too long, the pancreas, which is responsible for making insulin, eventually gets worn out and stops making enough insulin. This is when Type 2 diabetes can develop.

  • Inflammation caused by blood sugar imbalance and high insulin. Inflammation is also a marker for PCOS.

  • A diet heavy in processed foods. This drives high blood sugar and insulin levels without providing adequate nutrients to the body.

  • Uncontrolled stress levels. Cortisol and other stress hormones increase blood sugar and make it harder for glucose to get out of your bloodstream and into your cells. It also makes you crave more sugar. This also applies to exercise stress, which can also lead to hypothalamic amenorrhea due to suppression of the HPA/HPG axes. Learn more about this good stuff in the Hormones and Fertility Modules of Baby Making and Beyond.

Risks Associated with PCOS

  • Infertility because you stop ovulating

  • Should pregnancy occur despite uncontrolled PCOS, there is an elevated risk for gestational diabetes, preeclampsia, and problems with breastfeeding.

  • Depression and mood imbalances

  • Possible increased risk for metabolic disease

  • Liver inflammation

Treatments for PCOS

While drugs are available to address some of the causative factors for PCOS, we also advocate a whole-body approach centered around blood sugar balance. Be sure to read our lifestyle and supplements section and find a practitioner who can help guide your treatment plan.

Drugs prescribed by your caregiver

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  • Metformin is a drug that works by lowering blood sugar and improving the cells’ sensitivity to insulin, which helps insulin levels decrease. This can increase fertility, making it a miracle drug for many women with resistant PCOS. Always take B12 with metformin, as it will decrease your B12 levels.

  • Oral contraceptives are often used to treat PCOS, but they do not address any of the underlying causes like insulin resistance or high stress. They can also deplete certain nutrients critical to a healthy pregnancy, like folate. If your provider offers this as the only solution, consider finding a new provider for a second opinion.

Supplements

In addition to our baseline supplement recommendations found in Baby Making and Beyond, the below supplements might be a worthy addition to your protocol. As always, talk to your provider before adding these into your plan.

  • Melatonin + myo-inositol. Several studies in women undergoing IVF have demonstrated the effectiveness of this combination. The sweet spot seems to be about 3 mg of melatonin (taken nightly as a chewable or drop) combined with 2-4g of myo-inositol.

  • Myo-Inositol. Taken alone, this member of the B vitamin family supports healthy insulin regulation within the body. Women with PCOS seem to be deficient in the insulin signaling pathway (inositol- containing phosphoglycan mediators), which seems to be implicated in the development of insulin resistance. (Papaleo E et al 2009)  Inositol is also important for healthy ovulation and follicle formation, so this is particularly good for women with PCOS who would like to conceive.

  • Choline. Inositol works with choline to help with the proper utilization of insulin in the body.

  • Berberine. This compound is thought to improve insulin sensitivity by upregulating insulin receptors and stimulating glucose uptake in the cells. It might also improve acne, another common complaint in PCOS. Berberine can act as an anti-microbial, which might harm the balance of your gut bacteria if taken for extended periods of time (see below for why).

  • Proboitics: In women who are overweight with PCOS, studies have shown that the gut microbiome actually plays a pretty significant role in PCOS ( due to diminished microbiome diversity) . Take a solid probiotic and alternate strains every bottle.

  • Other nutrients. Ensure you have enough Vitamin D, magnesium (we like topical magnesium or the form magnesium glycinate) and zinc. A practitioner will help you decide what levels are right for you.

A note about maca and Vitex: I can almost always tell if someone has been taking Maca or Vitex when I look at a hormone profile. I’ll see someone with high DHEA who is depleted across the board in estrogen, progesterone, cortisol, and melatonin. Maca is most often the culprit. Maca seems to raise DHEA levels and androgen hormones more than dominant female hormones, like estrogen and progesterone. Meg has also seen Vitex exacerbate PCOS.

Diet & Lifestyle

Refer to the Core Four Nutrition section in Baby Making and Beyond for expanded recommendations, and focus on the following:

Lettuce wrapped grassfed burgers are a GREAT option. I ate these with a big green kale salad. Bonus points for eating your dinner while watching the sunset instead of wheel of fortune.

Lettuce wrapped grassfed burgers are a GREAT option. I ate these with a big green kale salad. Bonus points for eating your dinner while watching the sunset instead of wheel of fortune.

  • Higher protein and fiber, and lower sugar and carbs. Eat plenty of protein and lower-carb fiber-rich plants, and incorporate some starches that feed gut flora and improve insulin levels.  (Bindels et al. 2017)

  • Organic and grassfed when possible. Watch sourcing of your animal products. Organic and grassfed likely contain fewer exogenous hormone contaminants and fewer potentially inflammatory fats.

  • Focus on an anti-inflammatory foods. Watch your consumption of excess Omega 6 fats from modern processed foods. It may also be appropriate to reduce nut and seed consumption. Reduce or eliminate processed foods, simple sugars and ALL alcohol.

  • Not keto, I repeat, not Keto, but lower-ish carb. Full-on keto can raise cortisol levels, so we’d only recommend this approach with the guidance of a health professional. Eliminating processed carbs, grains, and the highly carb-rich plants, like sweet potato and higher-carbohydrate fruit, might help.

  • No calorie restriction or dieting. Consider consulting a nutritionist or health care provider who can help you figure out how much you should be eating.

  • Intermittent fasting. Fasting for short periods of time can improve insulin sensitivity in some women, but we recommend consulting with a practitioner first to ensure it will help you. If you feel absolutely miserable while fasting, it’s probably not the right solution for you. In this case, you can simply choose a 12-hour daily “eating window” (first bite or sip of anything that’s not water starts the clock; keep your meals and snacks within that 12 hour window), AND/OR try small and frequent (5-6) protein rich meals during the course of the day to help re-sensitize your cells to insulin and keep blood glucose regulated. Experiment and see which approach works for you.

  • Cinnamon. It’s delicious, and several studies suggest it helps improve blood sugar response.

  • Get your hormones and stress in check. Test for and correct thyroid and adrenal issues, ensure your exercise is appropriate and your stress is managed, and make sure you’re sleeping.

Sometimes the best thing you can do is just chill out and watch the sunset……..

Sometimes the best thing you can do is just chill out and watch the sunset……..

Primal Fertility Series: PCOS

PCOS and Fertility

PCOS or Polycystic Ovarian Syndrome affects thousands of women in North America. In fact, it’s estimated that approximately 20% of women in North America have cysts on their ovaries and it’s by far, the most common gynaecological ‘complication’ I see in my office each day.

What is PCOS?

PCOS is a complex endocrine condition characterized by a combination of pearl like strands of ovarian cysts, blood sugar dysregulation, hormonal imbalance and irregular or absent menstruation. Women with classic PCOS are overweight or obese and suffer from elevated blood sugars and excess estrogen. Women with a ‘less classic’ version of PCOS, may be normal weight or underweight, suffer from low estrogen and have some hypothalamic  dysfunction. Sounds complicated! That’s because it is! I like to think of PCOS as a hormonal response to a high stress life.

PCOS and the Menstrual Cycle

Let’s break it down….

In healthy women, the hypothalamus produces GnRH (gonadotropin-releasing hormone) which signals to the pituitary to produce LH (luteinizing hormones and FSH (follicle stimulating hormone). The release of GnRH is pulsatile in women with regular menstrual cycles. This normal pulsatile release of GnRh signals some of the follicles in the ovary to begin maturing and for the ovaries to release estrogen and progesterone. This estrogen/progesterone signal is recognized by the pituitary gland. As the follicles begin maturing, they release and increase the hormone estrogen over time. The rising estrogen level signals the pituitary gland to curb release of FSH. This communication allows for ovulation to occur. When you ovulate, you are able to conceive…hurray!

In women with PCOS, cycles are irregular as the hypothalamus loses it’s “rhythm” and becomes either hypersecretory or suppressed leading to an imbalance in FSH/LH and a subsequent imbalance in estrogen/progesterone/testosterone.  This imbalance causes the growing follicle to stay ‘immature’, leading to ovulation failure aka anovulatory cycles. When you don’t ovulate, you are unable to achieve a pregnancy, thus resulting in infertility. Boooo

What is even more of a bummer is that this ‘immature’ follicle continues to make estrogen leading to an imbalance and overall estrogen dominance in the system. This excess estrogen can further disturb the hormonal cycle by converting to testosterone (also called aromatization, which happens when there is too much estrogen in the system). Too much testosterone causes facial hair, hair loss among a host of other issues all of which google will tell you about J

So, what causes PCOS?

Good question! Although you can look up the “causes of PCOS” in any medical textbook, I think the real causes of this complicated hormonal condition are intensely individual and multifaceted but all are linked to some form of STRESS in the body.

Here are some more common causes

Metabolic stress: Insulin Resistance

Women who have PCOS and insulin resistance often suffer from metabolic syndrome and are overweight/obese. This can be a direct result of consuming a ‘Standard American Diet’ (SAD) with too many refined or processed foods. Insulin resistance causes chronic high blood sugar and can wreak havoc with your hormonal system by directly stimulating the production of testosterone. More testosterone essentially inhibits ovulation and affects fertility by contributing to progesterone and estrogen imbalance.

 

Hypothyroidism

It’s widely recognized amongst the medical community that hypothyroidism is a leading cause of PCOS. In the Paleo community, many women struggle with acquired hypothyroidism and low T3 levels as a result of chronic carbohydrate and overall caloric restriction. Carbohydrates, specifically glucose, are necessary for T4 to T3 conversion in the liver. Without adequate T3, hormonal signalling is thrown off resulting in cystic ovaries.

Genetics

Some studies demonstrate PCOS to have a genetic link. If your grandmother, mother or sister have it, you’re more likely to have it. There is some great epigenetic research suggesting that exposure to excess androgens during fetal development may predispose you to PCOS in your fertile years. This excess androgen exposure could occur if your mom suffered from PCOS.

Stress

Stress disregulates the hypothalamic Pituitary Axis and can trigger a cycle of low sex hormones and elevated cortisol and imbalanced DHEA levels. If it’s persistent, it can cause a woman to stop menstruating and lead to a diagnosis of Hypothalamic Amenorrhea (or amenorrhoea if you’re a Brit).  During the diagnostic process, many of these women will also be given the diagnosis of PCOS after they have a pelvic ultrasound. Women experiencing this ‘stress induced’  PCOS may suffer from many types of stressors including: under-eating (especially restricting carbohydrate sources) and being underweight. These women tend to be classic “A” types and are perfectionists. Many also have stressful occupations. In fact, I most often see these women working in health care.  

Inflammation

It has been found that many women with PCOS also have low-grade inflammation. White blood cells produce substances to fight infection, this is known as inflammatory response. Food allergies, gluten exposure or exposure to environmental toxins, ‘chronic cardio’ or endurance athlethics may all contribute to a chronic inflammatory response.

Profiles of Women with PCOS

Mary has stressful job. She doesn’t sleep properly and is constantly giving to others, ignoring her own needs. Her periods are erratic and she craves sugar and needs caffeine to keep her going.

Susan craves sweets and consumes of large amounts of sugars in her diet. Susan is overweight and has a hard time shedding this unwanted weight, despite following a classic prescription for diet and exercise. She has thinning hair and is starting to develop acne and dark coarse chin hairs.

Carrie has a history of being a vegan/vegetarian for 10 years. She has a diet high in refined soy products, grains and inflammatory vegetable oils. She’s slim but has very little muscle mass. Her friends call her ‘skinny fat’. She has hypoglycemia and suffers from wild mood swings when she goes more than a few hours without eating.

Erica strives to achieve the perfect “0” body. She under eats, over-exercises and restricts carbohydrates in an effort to stay thin.  She’s ‘tired- but –wired” and noticed that her menstral cycles got longer and longer. She now hasn’t had a period in a few months and would like to become pregnant.

Peggy experienced had an accident where she lost her spouse. She was diagnosed with PTSD, has a hard time sleeping, has irregular periods and hypoglycemia.

What’s common in all of these situations?

STRESS!!

Stress tells the body that it is not ‘okay’ and interferes with many of our delicate hormonal pathways. A diagnosis of PCOS doesn’t mean you are infertile for life, but it does indicate that some diet and lifestyle changes need to occur.

Meg ‘the Paleo Midwife’s’ suggestions for the treatment of PCOS

Find a care provider that will look beyond the standard treatment of Metformin and Oral Birth Control. These drugs do not address the causes of your PCOS and only serve to treat (without great success) your symptoms. A multi-faceted holistic approach including diet and lifestyle modification combine with targeted supplementation is the best approach. Find a care provider who can offer comprehensive Lab testing, which may include: 

  • Salivary and blood hormone testing. Salivary is a better indicator of how much hormone is in your TISSUE not just floating around in your blood, which is not where it is needed.
  • Pelvic ultrasound
  • IgG allergy testing or a 7-week guided elimination diet. This rules out any hidden metabolic stressors.
  • Iron and micronutrient testing.

Reduce your EMOTIONAL stress: 

My  Midwife friend Kathleen and I taking time to enjoy a sunset and let our bodies relax. 

  • Take a yoga class (not power or hot yoga). I recommend Jivamuti or a gentle restorative practice.
  • Learn to meditate and actually do it. Even 5-15 mins each day can make significant differences to your body’s hormonal pathways.
  • Make a list of things that contribute to your stress and try to find realistic ways of reducing these stressors.
  • Make another list (as you can tell, I like lists) of the things that you are grateful for and help you REDUCE your stress. E.g. your kitty, your family or spending time in nature.

Reduce your METABOLIC stress

If you are overweight:

  • Adopt a clean paleo/primal/ancestral diet. Doing a 21-day sugar detox may be beneficial.
  • Reduce carbohydrate intake to 50-100g/day and/or about 25% of your daily macronutrient percentages.  Ensure your carbohydrate sources are from mostly glucose containing starches/sugars. Excess fructose can contribute to inflammation and insulin resistance. Consider increasing activity levels and include sprints, which have been shown to aid in insulin sensitivity.

If you are underweight:

  • Consider gaining a bit of weight. Ensure you are getting at minimum 1
  • 400-1500 calories/day (increasing 100-200 cals/wk until you are at this level).
  • Include 100-150g starchy carbohydrates/day and reduce exercise, especially ‘chronic cardio’. Try sprinting a few times a week combine with shorter weight bearing activity. The Purely Twins Lori and Michelle have a great little program that’s well priced and very supportive towards healing from PCOS.

SLEEP: 8-10 hrs / night and practice good sleep hygiene.

Want more info?

Send me an email or download Stefani Ruper’s PCOS Unlocked The Manual. This is a great resource I recommend to all of my clients suffering with hormone/fertility issues. She also has a great blog at www.paleoforwomen.com