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.
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.
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
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
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.
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:
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.