PCOS: Polycystic Ovarian Syndrome
PCOS is the most common hormonal disorder in reproductive age women (affecting 4-15%) and is the leading cause of female infertility. Since PCOS is a syndrome, this means it is diagnosed by firstly ruling out any other cause and by assessment of symptoms. To get a clear diagnosis you have to have 2 out of 3 of:
1. ovarian dysfunction (meaning irregular or a lack of periods/ovulation),
2. polycystic ovaries diagnosed by transvaginal ultrasound,
3. excess androgens (hyperandrogenism) meaning excess levels of testosterone and other ‘male’ hormones. This in particular is what causes symptoms including acne, hirsutism, loss of head hair, thinning hair.
First let me say, PCOS is almost 100% manageable via diet and lifestyle changes. The next section is not to freak you out into thinking you are doomed forever, but it is encouraging you, if you have PCOS, to start taking action NOW so that you can beat the statistics.
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PCOS women have many other manifestations and morbidities including marked insulin resistance, IR (which is the body not responding appropriately to sugar), excess weight gain or resistance to weight loss.
They have four times the risk for developing type two diabetes and at higher risk for developing gestational diabetes, non-alcoholic fatty liver disease, atherosclerosis, cardiovascular disease, autoimmune disease (particularly Hashimotos Thyroiditis).
Likely due to the hormonal imbalances, a large percentage of PCOS women suffer with mental health conditions such as 5 x the risk of anxiety, 10 x risk of depression and bulimia, with 7 x higher risk of suicide.
Infertility is another symptom of PCOS and 30-50% of PCOS pregnancies end in miscarriage. PCOS women also have a higher rate of pregnancy complications including 3 times the risk of gestational diabetes, preeclampsia and premature delivery. PCOS women are more likely to have a C-section and babies of PCOS women are more likely to have health complications themselves. PCOS woman also have 2.7 times the risk of developing endometrial cancer and a higher risk of ovarian cancer too.
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Western treatment for PCOS: Most see at least 3 doctors before being diagnosed with PCOS, and treatment is almost always just being given the oral contraceptive pill to ‘regulate the menstrual cycle’. Note, if you are on the pill, you do NOT ovulate.
Sadly, the pill can worsen insulin resistance, contribute to weight gain and increase the risk for blood clots, cancer, NAFLD, hypertension, depression and suicide, all of which PCOS women are already at increased risk for. Further side effects of the pill include causing depletions of nutrients including vitamins B2, B6, B12, C and E, folic acid, and magnesium, selenium and zinc which again PCOS women also already have lower levels of.
The pill is not curative, it only is a method of holding symptoms at bay, which is particularly problematic when it comes to the symptom of infertility which is often only realised when people stop taking it to try conceiving!
Women are also often told to lose weight as a primary treatment for PCOS and indeed loosing 5-10% of body weight if you are obese with PCOS does improves fertility, metabolic health and substantially reduces risk of diabetes, cancer and heart disease. This does only help however if you are overweight. If you have ‘lean PCOS’ meaning you have a normal BMI then losing weight will not help.
Metformin is another medication often prescribed to PCOS women to treat insulin resistance. 30% of people on metformin get side effects like nausea, cramps, diarrhoea and vomiting and metformin causes folate and B12 deficiency. Metformin alters your gut microbiome (meaning it changes the diversity of bacteria in your gut) - the exact mechanism behind this is not known, although it may reduce intestinal permeability/leaky gut (which could be positive).
Other medications include statins for high cholesterol, spironolactone for acne and high testosterone, antidepressants and sleeping pills, again which all come with side effects without treating the root cause of PCOS. When they are stopped, the symptoms will come back, and often are worse when they do.
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The exact development of PCOS is unknown and multifactorial but to break it down as simply as possible:
- In PCOS there is increased Luteinising Hormone, LH, which simulates the ovaries to make more androgens (testosterone etc).
- Low levels of Follicle Stimulating Hormone, FSH relative to LH and decreased production of aromatase (an enzyme that converts testosterone into oestrogen) results in extra testosterone and not enough oestrogen, which in turn causes an inability to ovulate.
- Normally, you have a lot of follicles on your ovaries, they all start to develop, and one is picked per month. A boost of oestrogen triggers that one follicle matures + ovulates.
- In PCOS, instead of one being picked and maturing, lots are recruited, none reaching full maturity, and therefore none ovulating. This bunch of immature follicles is what you see as cysts on the ovaries in an ultrasound.
- It continues, the lower-than-normal levels of oestrogen, causes the brain to tell the body to make more testosterone (because it thinks that this will mean we have more to convert into oestrogen, but…. as already mentioned, with low levels of aromatase this doesn’t happen), resulting in even higher-than-normal levels of testosterone…the cycle continues.
- The high testosterone also damages the bodies oestrogen receptors, meaning PCOS women’s bodies are desensitised to the little amount of oestrogen they do have
What that means when we look deeper:
High amounts of androgens, paired with low levels of oestrogen cause a vicious cycle of insulin resistance, gut dysbiosis, leaky gut, inflammation, circadian rhythm disruption & HPA axis dysfunction. These together exacerbate one another, and result in the characteristic symptoms of PCOS.
Insulin Resistance, IR is the most common and prominent mediator in most PCOS cases for BOTH obese and lean women. Our bodies oestrogen receptors do not respond properly to blood sugar levels causing IR. The result is being crap at managing your blood sugar. I’ve gone on about that enough for you to know, but this means craving sugar, massive crashes if you haven’t eaten for a little while, or after you’ve eaten sugar etc.
The IR itself causes increased androgen production and secretion, and increases risk for leptin resistance, which in turn leads tow weight gain and increases obesity risk. 70% of PCOS women are obese, and PCOS symptoms are worse for obese sufferers. Obesity itself is also risk factor for developing PCOS in the first place as it makes the cells in the ovaries more sensitive to LH (where this all started) and increases androgen production (PCOS women already have hyperandrogenism) and worsens IR and inflammation.
Gut Dysbiosis & Leaky Gut
The Intestines also have oestrogen receptors and oestrogen is critical to maintaining the health and integrity of the intestinal lining. Hence, PCOS women have a higher propensity towards ‘leaky gut’ where the usually tight junctions between cells of the gut lining become loose, allowing the escape of bacteria from the gut into systemic circulation. The body realises that there are bacteria in the blood and sets off an immune response (this is called endotoxemia) and the result? Systemic (body wide) inflammation. This inflammation further impairs the already poor insulin receptor function, worsening IR (can you see the cycle starting?)
Obesity and high testosterone in PCOS women both reduce the diversity of the gut bacteria, ‘gut dysbiosis’. This in turn worsens leaky gut. Gut dysbiosis is also a causative factor in PCOS as it alters hormone secretions, gut brain mediators and inflammatory pathways. This is also why PCOS women have a predisposition to IBS (irritable bowel syndrome), bloating, reflux and other digestive issues.
Inflammation
Oestrogen controls inflammation. Without enough oestrogen in PCOS, you get chronic, systemic inflammation. This is exacerbated by the leaky gut, IR and obesity.
Inflammation itself also worsens all other PCOS symptoms. It desensitises insulin receptor function which worsens IR, interferes with follicular development (giving you more cysts o the ovaries) and further drives excess androgen production (hello acne!).
Circadian Rhythm Disruption & HPA axis dysfunction
There are oestrogen receptors in the brain and oestrogen impacts the hypothalamus which is the brain area responsible for controlling the circadian rhythms (your wake-sleep cycle). With PCOS the low oestrogen causes this to go totally off whack. This exacerbates IR, gut dysfunction, inflammation and increases androgens. It also encourages weight gain, contributes to diabetes, heart disease, cancer and mental health disorders.
PCOS women have elevated levels of cortisol (the stress hormone) and low levels of melatonin (the sleep hormone) resulting in what’s called Hypothalamic Pituitary Adrenal, HPA axis dysfunction – AKA stress is literally damaging the exact part of your body responsible for managing stress meaning that cortisol just builds up and up. This is true for both lean and obese PCOS women and if you are obese, well then that causes even more cortisol production too. Elevated cortisol worsens IR, inflammation an contributes to leaky gut and dysbiosis via the gut-brain connection. Differences in melatonin metabolism contribute to insomnia and sleep apnoea, for which PCOS women are 4-10 times higher risk for. Plus, insomnia is exacerbated by mental health problems like anxiety and depression which are also linked to PCOS. Melatonin is also a powerful antioxidant, with low levels of it, oxidative stress is increased, meaning inflammation is increase…. And well, as you can see this exacerbates all the other drivers and symptoms of PCOS.
Can you see how these 4 main factors all just make each other worse and worse? So how can you get out of this vicious cycle?
The conclusion is you need to focus on all 4 of those big issues to make any progress in PCOS. If you just tried to sort out one and not the rest, it would just come back as it’s being caused by all the others, so:
1. Sort out your blood sugar (bye energy crashes)
2. Sort out your gut (bye IBS and bloating)
3. Get rid of unwanted inflammation (bye acne and random joint pain)
4. Manage your sleep-wake and stress cycles (bye to insomnia, constantly feeling on edge, anxiety and depression)
Step 1: Track your menstrual cycle. Even if it’s currently non-existent, download the app. Trust me. Clue/Flow are good free apps. You need to start to listen to your body, and tracking your period is the first step in that communication.
AS ALWAYS DO NOT TAKE SUPPLEMENTS UNSUPERVISED. They are natural, but they really can be dangerous and interact with medications and do other damage.
Regulate Blood Sugar & sex hormones: to increase insulin sensitivity & regulate menstrual cycle
- Adopt a low glycaemic load diet (lists of low GL foods can be found online) but basically, eat complex carbohydrates, and protein with each meal
- Avoid sugary, processed or refined carbohydrates, they contribute to IR, dysbiosis, inflammation and increase risk of obesity, anxiety, depression, endometrial (and other) cancers, heart disease and diabetes, which you are already at higher risk for!
- Consume a teaspoon of cinnamon daily as it regulates blood sugar
- Try Seed Cycling: Consume 1 tbsp of ground flaxseeds and pumpkin seeds daily in the follicular phase (first half, from day 1 of period until ovulation) of the cycle to regulate oestrogen levels. In the luteal phase (from ovulation until next period) consume 1 tbsp sesame and 1tbsp sunflower seeds to boost progesterone levels.
- Herbal teas to the rescue:
o Spearmint and peppermint tea decrease free testosterone levels and prolactin and increase FSH.
o liquorice root tea which contains phytoestrogens that modulate oestrogen and may help inhibit production of testosterone
o Green tea which reduces blood glucose, insulin, testosterone, and is anti-inflammatory
- Can try taking a natural hormone regulator called Vitex Agnus Castus a few drops on the tongue (tincture) per day (do not use if on OCP, oestrogen pills, antipsychotics)
- Can try a daily supplement of Myo-Inositol, 4g in divided doses, avoid use if pregnant and breast feeding – Reduces IR, and androgens, T2DM, gestational diabetes and heart disease risk. It regulates the cycle and promotes ovulation.
Increase gut flora and heal the gut lining
- Increase fibre to 30g per day including plant-based sources, vegetables and complex carbohydrates to balance blood sugar levels. Fibre is fermented by good bacteria in the gut into short chain fatty acids like butyrate and propionate, which basically stops leaky gut and reduces gut dysbiosis
- Consume prebiotic foods including chicory root tea (a great coffee substitute) artichoke, asparagus, garlic, onions and berries which support the growth of beneficial gut bacteria
- Consume probiotic foods like sauerkraut, tempeh, miso and kimchi or a daily probiotic supplement (make sure to get one that contains lactobacillus and Bifidobacterium, I’ve done a post before on what else to look out for when buying a probiotic). Probiotics basically help everything that’s going wrong in PCOS.
Decrease inflammation:
- Omega 3 reduces inflammation and can be found in oily fish (salmon, mackerel, anchovies, sardines, herring). Vegan sources include flax seeds, chia seeds, pumpkin seeds and soybean which also provide fibre, magnesium and zinc. A supplement is probably better as often we struggle to convert vegan sources which contain ALA, into the required form (EPA/DHA) and farmed fish is depleted of omega 3 (this is especially bad in the UK). Even wild fish is high in contaminants such as heavy metals which increase the toxic load on the liver. Bare biology is by far the best omega 3 supplement you can find in the UK.
- Consume organic Extra Virgin Olive oil IT IS SO ANTI INFLAMMATORY. Vegetable oils and margarine should be chucked into the bin. The moment they are processed into oils and especially when you cook with them, they become mega inflammatory.
- Consume ginger and turmeric daily (ant inflammatory and also reduces IR and T2DM risk). Note. curcumin the active polyphenol in turmeric is much more bioavailable when eaten combined with black pepper and a fat source
- Consume anti-inflammatory nettle which also reduces IR, and decreases androgens
- Increase antioxidant status by including 8 fist sized portions of whole vegetables daily.
- 2 of portions of cruciferous vegetables daily to aid liver detoxification of hormones
- Avoid gluten as it contributes to leaky gut and is inflammatory (yes even if you are not gluten sensitive)
- Avoid Dairy which is inflammatory and an independent risk factor for developing PCOS in the first place as the growth hormones in dairy make you more reactive to androgens
Balance the HPA axis and circadian rhythms:
- Increase sources of Magnesium, B vitamins and zinc – PCOS women are found to have lower levels of these vitamins, and our soil is so depleted of magnesium that most of us are deficient in it actually. They are SO important for proper circadian rhythms and HPA axis functioning. Mg also helps reduce IR and oxidative stress therefore lowering inflammation. Consume 2 portions of dark leafy greens, legumes or complex carbohydrates daily. Magnesium citrate supplements of 200-500mg per day also help boost levels and are relatively safe. Caution as that form might cause diarrhoea, if so you can take magnesium bis-glycinate
- Consume foods that boost melatonin including walnuts, olives, grapes, cherries, seeds and legumes
- Expose yourself to natural light first thing in the morning (OPEN. YOUR. BLINDS – DO NOT SIT IN BED IN THE DARK ON YOUR PHONE) and avoid blue light (phones/screens/tvs) 2 hours before bed to regulate circadian rhythms
- Consume nervine teas and adaptogens including ashwaghanda, passionflower, lemon balm and camomile to promote restful sleep and reduce cortisol
- Try meditation/mindfulness for 5-10 mins daily and mindful eating to decrease cortisol and balance the HPA axis (Headspace / Calm are good apps to try).
- Have Epsom salt and lavender essential oil baths – 20mins, 3 x week and 2 big handfuls these are de-stressing and you absorb the magnesium in the salts through your skin.
Items that alleviate all bits of PCOS
Increase levels of Vitamin D - 85% of PCOS women are vitamin D deficient and deficiency worsens PCOS symptoms. Vitamin D helps regulate insulin sensitivity reduces leaky gut and gut diversity, is anti-inflammatory, and regulates the circadian rhythms and HPA axis. Get sun exposure and in the winter consume a supplement (one with K2 is best). The NHS recommends 400IU per day. You can also get vitamin d from eating sun-soaked shiitake mushrooms, organic egg yolks and wild oily fish.
Exercise frequently – In PCOS women exercise improves insulin sensitivity, aids weight loss, reduces dysbiosis, androgens and cysts, lowers inflammation and improves mental health. Yoga in particular helps balance the HPA axis and Hiit and strength training reduce IR, promote weight loss and sweating helps excrete unwanted hormones.
Get acupuncture – acupuncture is a safe and is an effective way to decrease inflammation and cortisol, aid weight loss, sleep and mental health. Acupuncture can help increase fertility and bring on ovulation too.
Eat organic. Organic fruit and veg have more nutrients, antioxidants and fewer toxins than non-organic. Pesticides reduce gut diversity and cause IR and inflammation. Nonorganic animal produce contains antibiotics worsening dysbiosis. If affordability is an issue, look up the clean 15 and dirty dozen to see which foods are a must-avoid.
Avoid endocrine disruptors (BPA, phthalates, dioxins, perchlorate and PFCs) – what is found in plastic, cosmetics, candles etc. If budgets allow drink filtered/mineral water from glass bottles. Women with PCOS have higher levels of BPA in their bodies compared to non-PCOS women. BPA is linked to high androgens and triggers fat accumulation, prevents fat burning and causes gut dysbiosis. Oh and it stays in the body and crosses the placenta and goes to our babies (some postulate that this is how people get PCOS in the first place… but that’s a whole other conversation)
Avoid alcohol, caffeine and other intoxicants which increase androgens, IR and inflammation and affect the gut!
Avoid artificial sweeteners + emulsifiers (aspartame, sucralose and saccharin) cause dysbiosis, weight gain and IR. Emulsifiers like carrageenan (often in organic almond milk) cause inflammation and worsen leaky gut.
2 PCOS superfoods that just do everything you need:
Quinoa
1. A blood sugar regulator: complex carbohydrate, a complete protein with a good fat content.
2. Gut restorative: high amounts of fibre.
3. Anti-inflammatory and antioxidant rich.
4. HPA axis regulator: high amounts of B vitamins, Mg and zinc.
Flax seeds
1. Hormone regulator: are phytoestrogens meaning they modulate oestrogen levels and contain the highest content of dietary lignans which reduce excess serum testosterone levels
2. Gut restorative and decrease dysbiosis: full of soluble fibre
3. Anti-inflammatory: high in omega 3
4. HPA axis regulator: high amounts of Mg and zinc.
The result?
- No more androgens (so bye to acne and hair on your face but not on your head!)
- No more irregular periods – and yes you WILL ovulate, hello fertility!
- No more cysts on those ovaries.
Plus, bye to all the other symptoms, oh and you’ll be less likely to be overweight, get cancer, get diabetes, get heart disease, commit suicide and so much more.
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Want to know and be able to track where you are in this vicious cycle? Here are some tests you can do (some you can get on the NHS, others privately, some offer packs they send to your home for your to do yourself)
Check your BMI/hip-to-waist ratio, are you overweight?
OGTT - Oral Glucose Tolerance Test (75g 2h) and Lipid panel (cholesterol, LDL, HDL, ApoA1, ApoB, Triglycerides) – These check how you react to sugar. Do you have prediabetes, and are you very insulin resistant? Are you approaching that high risk category for heart disease?
Serum Zonulin Family Protein + Comprehensive Stool Test This basically checks if you have leaky gut and if you have low bacterial diversity in your gut. It’s not a need to have test, but might help your nutritionist/practitioner know which bits of the plan to make a focus for you!
Serum hsCRP – C Reactive Protein an assessment how much inflammation there is in your blood. Again, nice to know not need to know.
Comprehensive DUTCH test - Full sex hormone and adrenals panel. PCOS women’s hormones are just all off kilter. This measures all your sex hormones PLUS your response to stress / cortisol. It’s expensive but definitely the most comprehensive assessment you can get. Or ask on the NHS for a full hormone panel.
Antinuclear antibody and Thyroid panel (TSH, Free T4, free T3, Anti TPO, thyroglobulin, antibodies). PCOS women have higher risk of developing auto immune disease particularly Hashimotos. This test lets you know if you are likely to have autoimmune condition.
Vitamin D (25 OH vit D test) as 85% of PCOS women are deficient so worth getting it checked!