What is PCOS
Poly Cystic Ovarian Syndrome commonly known as PCOS affects 10-20% of women, and many women have not been diagnosed, not realizing that the symptoms they are experiencing are caused by PCOS.
PCOS is NOT an ovarian problem as the name suggests, but a hormonal problem caused by insulin resistance, high testosterone and inflammation. The result of this hormonal imbalance is irregular or failure to ovulate which leads to the formation of many small cysts.
Diagnosis of PCOS is often missed because there is no one perfect test to diagnose PCOS, and while there are many symptoms associated with this condition you don’t need to have all of the symptoms to have PCOS.
There are also different types of PCOS which can also make diagnosis difficult, and this also means that there is not one treatment for PCOS. The treatment that works for your friend may have no benefit for you, if there is a different underlying cause.
Ovarian cysts are formed when ovulation doesn’t occur as it is supposed to. Within each ovary there are sacs called follicles that contain eggs. Normally, one or more eggs are released during each menstrual cycle and this is ovulation. In PCOS the eggs within the follicles do not mature and are not released from the ovaries, instead, they form small cysts in the ovaries and this is seen with an ultrasound and often diagnosed as PCOS.
Not everyone who has cysts has PCOS as you also need to have the clinical signs and symptoms, as well as an imbalance in one or more of the hormones insulin, testosterone, prolactin, estrogen and progesterone.
There are many different symptoms associated with PCOS and you don’t need to have them all, some women may have only 3 or 4 of these symptoms. Depending on what type of PCOS you have will influence the type of symptoms that you experience, and because hormones fluctuate from month to month you may also find that your symptoms change from month to month.
The most frequent PCOS symptoms include:
- irregular periods or absent periods (amenorrhea), though you can still have regular periods yet not ovulate.
- trouble conceiving or infertility, PCOS is the number one cause of infertility
- changes in weight, especially weight gain and trouble losing weight, this affects 60-70% of women with PCOS but you can be slim and still have PCOS
- acne and other skin problems
- insulin resistance and blood sugar imbalances
- high testosterone levels, also known as high androgens
- excessive hair growth, including in places women don’t usually grow hair, such as on the face and abdomen
- hair loss or thinning hair
- depression or anxiety
- low sex drive
If you have the above symptoms of PCOS that does not mean you have PCOS as these symptoms could be related to other health conditions, and the next step would be to do some further testing to assess PCOS, and the type of PCOS that you may have.
How to diagnose PCOS
Conventional medicine doctors often diagnose PCOS with an ultrasound of the ovaries to assess if there are any cysts, and as the name suggests having many cysts would suggest you have PCOS …. but this is not the case.
While an ultrasound can be part of the diagnosis it is important to remember that just because you have cysts does not mean that you have PCOS, and just because you don’t have cysts this does not exclude the diagnosis of PCOS
Essential pathology tests for PCOS
I recommend doing a full sex hormone assessment that measures estrogen, progesterone, testosterone, luteinizing hormone (LH), follicle stimulating hormone (FSH) to assess if you have high testosterone levels, high LH and an imbalance in the estrogen to progesterone ratio.
I also recommend assessing the hormone insulin as high levels of this hormone is one of the drivers behind PCOS, assessing HbA1C and glucose is also important. Other pathology markers include iron studies, HsCRP, zinc, copper, iodine, full blood count, B12 and Vitamin D to assess inflammation and nutritional deficiencies that could be causing a hormone imbalance.
Other PCOS tests to consider
DUTCH hormone test to measure adrenal function and the sex hormones, this test is particularly useful in assessing how well your metabolizing estrogen. The DUTCH test also assesses 5a-DHT which is a more potent form of testosterone and high levels can be an increased risk for hair loss and acne.
GI Map test to rule out gut infections like candida, bacteria and parasitic infections that can be the underlying cause of inflammation and PCOS
Comprehensive thyroid test which assesses TSH, T4, T3, reverse T3 and the thyroid antibodies as symptoms of PCOS can be similar to low thyroid function and low thyroid can cause PCOS.
What causes PCOS
There is a genetic link to PCOS so if your mother or sister has PCOS that does increase the chances of developing PCOS, but it does not mean that you will get PCOS and adopting some of the diet and lifestyle habits will help to prevent a hormone imbalance from occurring.
Even if you do have a strong family history of PCOS and you have PCOS, there is still much that can be done to bring your hormones into balance and reduce your symptoms.
PCOS and insulin resistance
PCOS is often caused by insulin resistance, this is when the tissues and cells do not respond normally to the presence of insulin. When the body is resistant to insulin, the blood sugar will rise, and the pancreas will produce even more insulin in an attempt to reduce the blood sugar.
In many cases the higher amount of insulin is enough to keep the blood sugar within a normal range, however the elevated blood insulin causes the ovaries to increase production of testosterone. High levels of testosterone slow or stop ovulation, and this is where the irregular periods begin, and when you do not ovulate the small cysts will start to form causing the poly cystic ovaries.
The elevated insulin levels also have effects on the conversion of testosterone into estrogen in the fatty tissue which causes even more trouble. High insulin levels cause testosterone to be excessively converted into estrogens which cause sensitivity of the pituitary and increases in LH. Elevated LH levels in some patients also cause increased production of testosterone.
High estrogens cause negative feedback on FSH production from the pituitary, resulting in poor follicle development. And so as you can see, a vicious cycle develops.
Treatment for Insulin resistance
Insulin resistance is the most common cause of PCOS and responds the best to a diet lower in refined carbohydrates, sugars and excess fructose. How low carb you need to go is going to depend on how insulin resistant you are, for some women this is going to be eating 100-150 grams of carbohydrates a day, while other women may benefit from a short term ketogenic approach of less than 50 grams of carbs.
The amount of carbohydrates you eat is also going to change over time, while you may benefit from starting out on a low carb diet, this does not mean that a low carb diet will benefit in the long term. The amount of carbs you need will vary as you become less insulin resistant.
Supplements for insulin resistance.
Besides the dietary changes there are some supplements that can help to speed up the process and results (but you still need to cut the sugars!)
Berberine - Has had many studies showing it’s efficacy in addressing insulin resistance which is why it is effective in treating PCOS, it actually works via a similar mechanism to the drug Metformin which is commonly prescribed for PCOS and diabetes.It is not a forever supplement but is beneficial to take for a few months while you are addressing diet and lifestyle changes.
Herbs and nutrients such as chromium, lipoic acid, Gymnema and Bitter Melon can also help with insulin resistance and blood sugar regulation, you can often find these in a glucose support supplement like the Jarrows Glucose Optimizer.
PCOS and the pill
The contraceptive pill suppresses ovulation and many women start taking it as teenagers (often for acne), and when you stop taking the pill over the next few months ovulation and a regular menstrual cycle should resume. But for some women this does not happen and ovulation does not restart and they develop PCOS, this can be combined with insulin resistance or a separate issue.
It is possible that PCOS was there the whole time and that the pill just suppressed the symptoms, but once you stop the pill, whether this is for fertility reasons or health reasons the symptoms of PCOS occur.
To work out what is driving the PCOS it is important to do a full pathology assessment and in particular look at the levels of prolactin and LH which can remain high once you stop taking the pill.
The classic Chinese formula containing Paeony and licorice is effective at addressing the high LH levels and is often used in many PCOS treatment plans.
If LH is normal but Prolactin is high the herb Vitex Agnus Castus can be effective.
These herbal formulas should only be needed for 4-6 months, if you are not getting significant improvement you may have to look at some of the other causes of PCOS like insulin resistance and inflammation.
PCOS caused by inflammation
Chronic stress, gut infections, gum infections, food intolerances like gluten and casein all promote inflammation. Increased inflammation can increase androgen production and cause PCOS.
With these types of conditions weight may not be a problem, in fact sometimes you can be underweight with these infections and still have a hormone imbalance which is causing PCOS.
High stress also affects cortisol levels and high cortisol will promote insulin resistance.
In addition to the recommended blood tests I also recommend other tests to help identify the underlying cause of the inflammation.
DUTCH hormone test to assess not only the sex hormones but also adrenal function, if you have adrenal issues this can be the underlying cause, or another factor with your high insulin levels.
Comprehensive stool testing with the G.I Map test will help to identify any pathogens like bacteria and parasite infections and candida overgrowth that can be driving inflammation levels and promoting a hormone imbalance that will cause PCOS. The G.I map test also looks at other digestive health markers like digestive enzymes, leaky gut and inflammation.
If you have PCOS caused by inflammation it is not going to be a quick fix and treatment may last 6-12 months. Remember you may have PCOS caused by high insulin or poor diet plus an underlying infection then that may slow down treatment.
Remedies to optimize inflammation will depend on the results of the tests.
PCOS and thyroid function
If you have been diagnosed with PCOS it is also important to assess thyroid function properly as the symptoms like hair loss, weight gain, amenorrhea, and fatigue can be very similar and you don’t want to be treating PCOS if it is actually a thyroid problem.
Women with PCOS are also more likely to have thyroid problems and it can be a contributing factor to the underlying cause.
It is important to get a comprehensive thyroid test that includes TSH, T4, T3, reverse T3 and the thyroid antibodies to rule out an underlying thyroid problem.
Other causes of PCOS
Insulin resistance, hormonal imbalance and inflammation are the main causes of PCOS and would be the first thing that I would address, but there can also be other contributing factors. This is why doing comprehensive testing and taking a thorough health history is important when assessing the cause of PCOS and not just relying on an ultrasound for diagnosis.
Nutrient deficiencies like iodine and zinc, a high intake of artificial sweeteners, low calorie diets and even sleeping issues can increase your stress levels and effect the treatment of PCOS.
Action Steps for PCOS
The first step is to get a comprehensive pathology test that includes all of the sex hormones, blood sugar markers and other pathology tests that I recommended in the “essential pathology tests for PCOS” section.
At Planet Naturopath we can organize this testing for you if you have trouble getting your doctor to do this. Once we have the results we can recommended a specific treatment plan for you.
See a practitioner who is experienced with treating hormonal problems, assessing lab test results and taking a thorough case history who can help work out the type of PCOS you have. This step is important to help you implement a treatment program that will work for you.