Polycystic ovary syndrome (PCOS) is the most common endocrine disorder of reproductive-aged women around the world and the primary cause of anovulatory infertility. It is formally diagnosed by the presence of two out of three of: oligo-amenorrhea(infrequent or absent menstruation) hyperandrogenism (elevated androgen levels), polycystic ovaries. Classically, physicians have looked for multiple cysts on the ovaries (described as looking like a “string of pearls” when performing an ultrasound), but not every woman diagnosed with PCOS has visible cysts on their ovaries and PCOS can still be diagnosed if the majority of other common symptoms are experienced.
The other most frequent symptoms: difficulty getting pregnant excessive hair growth (hirsutism) oily skin or acne weight gain thinning hair and hair loss anxiety and depression
What is the cause of PCOS?
Most of the symptoms of PCOS are caused by higher-than-normal levels of androgens that interfere with ovulation and cause the follicles to enlarge, forming cysts. Excess androgens produce additional symptoms, including excess hair growth and acne Other manifestations are due to excess insulin.Too much insulin increases the production of androgens, which then cause symptoms of PCOS High levels of insulin can also increase appetite leading to weight gain and increased risk for diabetes.
What are the risk factor for PCOS?
Hormonal imbalances are multi-factorial disorders, caused by a combination of factors such as diet, medical history, genetics, stress levels and exposure to toxins from the environment. Some of the major contributors to hormonal imbalances include: Food allergies and gut issues: New research show that gut health plays a significant role in hormone regulation. Recent studies suggest that disturbances in bowel bacterial flora brought about by a poor diet create a cascade of chemical reactions leading to increased production of androgens Being overweight or obese: a review of clinical studies found that obesity is encountered in 30-70% of PCOS-affected women, and there clearly is a vicious circle of abdominal obesity, insulin resistance, and hyperadrogenemia Weight loss is considered the first-line therapy in obese women with PCOS. High levels of inflammation caused by a poor diet and sedentary lifestyle. Nutrients such as glucose and saturated fat can incite inflammation as well as an unbalance in omega6/omega3 fatty acids ratio. Excessive exercise: a recent systematic review showed that there is an increased risk of anovulation in extremely heavy exercisers due to increased activity of the hypothalamic-pituitary-adrenal (HPA) axis.
Genetic susceptibility: genetic predisposition is one of the main causes of polycystic ovary syndrome (PCOS). The genetic variant(s) can be inherited from either the father or the mother, and can be passed along to both sons and daughters. Toxicity: exposure to pesticides, toxins, viruses, cigarettes, excessive alcohol and harmful chemical are all endocrin disruptors.
Elevated BPA (a chemical used to make plastic containers that store food and beverages, such as water bottles) concentrations in the body are positively correlated with hyperandrogenemia Smoking is associated with worse insulin resistance and metabolic dysfunction in women with PCOS. High amount of psychological stress, and a lack of enough sleep and rest may cause elevated androgens.
What are the standard pharmacologic and surgical treatments?
• Oral contraceptive pill
• Clomiphene citrate: a fertility drug
• Flutamide: it is an anti androgen
• Metformin: an antidiabetic agent
• Progestins: for women that are not able to use the hormone oestrogen
• Spironolactone: a diuretic that lowers androgen levels
• Laparoscopic ovarian drilling: a surgical treatment that may trigger ovulation
Which tests can diagnose PCOS?
There is no specific test that can be used to diagnose polycystic ovary syndrome but several hormone tests may be used to evaluate a woman for PCOS: • Follicle stimulating hormone (FSH) – high in PCOS patients. • Testosterone – usually elevated. • Estrogens – may be normal or elevated • Sex hormone binding globulin (SBGH) – usually low in people with PCOS • Free androgen index another measure of male hormone levels; may be elevated • Anti-Müllerian hormone (AMH) – an increased level is often seen with PCOS A few tests may help rule out other conditions with similar signs and symptoms: • Thyroid-stimulating hormone (TSH) – women with PCOS have higher TSH levels • Cortisol – main stress hormone, high in women with PCOS • Prolactin – can play a part in a lack of menstrual cycles or infertility • 17-hydroxyprogesterone – to rule out the most common form of congenital adrenal hyperplasia • DHEA-S – Frequently mildly elevated with PCOS
A pelvic ultrasound (transvaginal and/or pelvic/abdominal) is used to evaluate enlarged ovaries. Ultrasounds are often used to look for cysts in the ovaries and to see if the internal structures appear normal. In PCOS, the ovaries may be 1.5 to 3 times larger than normal and characteristically have more than 12 or more follicles per ovary measuring 2 to 9 mm in diameter.
Useful functional and nutritional tests
Vitamin D: deficiency has been linked to alterations of LH and sex hormones-binding globulin, testosterone levels, insulin resistance and inflammation
Gut permeability test: gut dysbiosis increases the ovaries production of androgens and interferes with normal follicle development. A recent pilot study found that gut barrier dysfunction may be a contributing factor.
Adrenal stress index: altered cortisol metabolism plays a role in PCOS because it causes abnormalities in the way that many of the sex hormones and thyroid hormones work in the body The saliva adrenal stress test measures cortisol levels throughout the day as well as DHEA. Results from a recent study show that non-obese PCOS women have higher basal salivary cortisol than controls
The holistic approach
The steps of a holistic natural medicine approach are:
1 adress inflammation 2 treat insulin resistance 3 balance the adrenals 4 treat excess androgens 5 address hormonal imbalances 6 balance the thyroid 7 create a healthy environment 8 eat a balanced diet
The primary emphasis is on dietary changes that may improve insulin resistance through a reduction of refined carbohydrates and total calories, and an increase in foods high in fibre such as vegetables, legumes and whole grains. We now know that in women with PCOS, modest reduction in dietary carbohydrates, starches and dairies has numerous beneficial effects on the metabolic profile that may lead to a decrease in circulating testosterone A diet with a higher ratio of protein to carbohydrates improves weight loss and glucose metabolism while also helping mood. A 1:1 protein and carbohydrates ratio keeps insulin levels stable.
Several clinical trials have shown that a low glycemic index diet improves menstrual regularity, insulin resistance, total and high-density lipoprotein cholesterol. Some examples of low glycemic index foods:
• kale, broccoli, asparagus • beans, chickpeas,lentils • grapefruit and apples • walnuts and almonds.
Avoid foods that have a high glycemic index (they make insulin levels jump dramatically) such as pancakes, syrups, sugar, white potatoes, jams, scones, white bread products, pasta, soda, fruit juices, alcoholic beverages
Foods to eat
Soy: in a recent trial, soy isoflavone administration for 12 weeks in women with PCOS significantly improved markers of insulin resistance, hormonal status, triglycWerides, and biomarkers of oxidative stress. Warning: isoflavones found in soy products have oestrogen-like activity that can alter estrogen metabolism
Flax seeds: a case study reported a clinically-significant decrease in androgen levels with a concomitant reduction in hirsutism after flaxseed supplementation (30 g/day) during a four month period
Olive oil and omega 3: good fats are crucial for reducing symptoms and prevent complications of PCOS such as diabetes and cardiovascular events. Olive oil, a monounsaturated fat is very anti inflammatory Omega 3, a polyunsaturated fat, found in abundance in oily fish and in minor quantity in flax seeds and walnuts, improves inflammation and insulin resistance in women with PCOS. A systematic review found that women on a monounsaturated fat-enriched diet had a greater weight loss and this improved the presentation of PCOS.
Pulses and vegetables can boost levels of sex-hormone-binding globulin (SHBG) a protein that binds sex hormones in the blood reducing the circulating levels of free hormones.
Walnuts and Almonds: walnuts increase insulin response and sex hormone-binding globulin and almonds reduce free androgen. Nut intake exerted beneficial effects on plasma lipids and androgens.
Foods to avoid
Refined carbohydrates: refined carbs can cause hyperglycemia which results in inflammation
Soft drinks and fruit juices: during regular soft drinks and fruit juices consumption, fat accumulates in the liver by the primary effect of fructose which increases lipogenesis insulin resistance and inflammation.
Dairies: milk cheese and butter contain insulin-like growth factor (IGF-1) which has insulin-like properties and can increase production of testosterone. Moreover, the amount of estrogens we are exposed to when consuming dairies further disrupts hormone balance
Sugar: several studies have demonstrated that women with PCOS (both normal and overweight) have an exaggerated inflammatory response to sugar ingestion which is correlated with an increase in androgens
Alcohol: excessive ethanol consumption affects virtually any organ and negatively impacts on reproductive health inducing hormonal and metabolic imbalance
Trans fatty acids (TFAs) TFAs can be industrially obtained by hydrogenation of vegetable oils such as in margarine. Modern diets commonly include large quantities of margarine.The inflammatory effects of TFAs can be a contributing factor in PCOS.
Coffee: coffee stimulates the adrenal glands and make the body release more cortisol. Women with PCOS have already increased levels of cortisol, so it is vital to reduce caffeine intake.
Inositol: both myo-inositol and D-chiro-inositol have been shown to effect ovarian function and metabolic factors in women with polycystic ovarian syndrome . The combined therapy of Myo-inositol (MI) and D-chiro-inositol, in the physiological plasma ratio (i.e., 40:1) ensures better clinical results, such as the reduction of insulin resistance, androgens' blood levels, cardiovascular risk and regularization of menstrual cycle with spontaneous ovulation.
Vitamin D and calcium: Vitamin D deficiency is common in women with polycystic ovary syndrome. A study found that vitamin D supplementation (50 000 IU of oral vitamin D3 for 8 weeks) in VD-deficient women with PCOS normalised the menstrual cycle and significantly improved some abnormal clinical parameters such as lipid profile, testosterone, dehydroepiandrosterone sulfate, and insulin resistance Another trial on 104 overweight and obese vitamin D deficient women with PCOS found that supplementation of 1000 mg calcium/d + 50,000 IU/wk vitamin D, for 8 weeks, improved insulin levels, glucose metabolism, lipid concentrations, inflammatory factor and biomarkers of oxidative stress.
B vitamins: administration of B-group vitamins reduces circulating homocysteine in polycystic ovarian syndrome patients treated with metformin
Folate: a recent randomized, double-blind, placebo-controlled clinical trial showed that 8 weeks of folate supplementation (5 mg/d) in women with PCOS had beneficial effects on inflammatory factors and biomarkers of oxidative stress
Vitamin C: antioxidant status is very important in PCOS since oxidative stress seems to be associated with the development of inflammation and insulin resistance in women with polycystic ovary syndrome. Vitamin C is also an essential nutrient for the adrenal glands
Zinc helps the production of reproductive hormones, it regulates blood sugar levels, plays a role in coping with stress (both oxidative and psychological), is involved in the manufacture of thyroid hormones and helps control appetite by affection leptin. Together with vitamin B6 and magnesium is also involved in the production of anti-inflammatory substances.
Alpha Lipoic Acid: a recent trial found that a combination of d-chiro-inositol (DCI) and alpha lipoic acid improved menses and metabolic disorders in women with polycystic ovary syndrome. Preliminary data from a pilot study suggest that the supplementation of myo-inositol and α-lipoic acid in PCOS patients undergoing an IVF cycle can help to improve their reproductive outcome.
COQ10: one study found that a combination of CoQ10 and clomiphene citrate in the treatment of clomiphene-citrate-resistant PCOS patients improved ovulation and clinical pregnancy rates
Magnesium: low serum magnesium is often associated with insulin resistance in PCOS women. Furthermore magnesium deficiency induces anxiety and HPA axis dysregulation
Selenium: a recent randomized, double-blind, placebo-controlled trial found that 200 microgram per day selenium supplementation for 8 weeks among PCOS women had beneficial effects on insulin metabolism parameters, triglycerides and VLDL-C levels.
Chromium: a recent randomized, double-blind, placebo-controlled trial found that after 8 weeks of intervention with 200 μg chromium supplements, pregnancy rate in chromium group was higher than that in the placebo group.
Manganese: helps balance sugar, women with PCOS have lower manganese levels when compared to controls.
N-acetyl cysteine (NAC) is a commonly used safe mucolytic drug, that has also shown potential to improve insulin sensitivity in women with polycystic ovary syndrome In a recent meta-analysis of randomized controlled clinical trials NAC showed significant improvement in pregnancy and ovulation rate compared to placebo.
Arginine: in one study, a combination of both N-acetylcysteine (1200 mg/die) plus L-arginine (1600 mg/die) for 6 months restored menstrual function and improved insulin sensitivity
Carnitine: a recent randomised clinical trial found that adding L-carnitine when treating clomiphene-resistant PCOS patients not only improved the quality of ovulation and the pregnancy rate, but also enhanced the patient lipid profile and body mass index
Probiotics: a randomized, double-blind, placebo-controlled trial found that probiotic supplementation among PCOS women for 12 weeks had favourable effects on weight loss, markers of insulin resistance, triglycerides and VLDL-cholesterol concentrations.
Omega 3: The western diet has an imbalanced omega-6/omega-3 ratio (around 20:1, while the ideal is 1-3:1). The result is an increased risk of obesity and systemic inflammation. Omega-3 fatty acids have beneficial effects on serum adiponectin levels, insulin resistance and lipid profile in PCOS patients and may contribute to the improvement of metabolic complications in these patients Oral 1,500 mg of omega-3 for 6 months reduced hirsutism, acne and insulin resistance.
Grifola fronds (Maitake): a recent study suggests that Maitake mushroom extract induces ovulation in patients with polycystic ovary syndrome and may be useful alone or as an adjunct therapy for patients who failed first-line treatment with clomiphene citrate.
Ganoderma lucidum (Reishi): in a research study exploring plant derived anti-androgens, reishi mushrooms were found to inhibit testosterone levels
Cinnamon extract: a recent systematic review and meta-analysisis found that the consumption of cinnamon is associated with a statistically significant decrease in levels of fasting plasma glucose, total cholesterol, LDL-C, and triglyceride levels, and an increase in HDL-C levels.
Fenugreek seeds: a review of the current evidence for the antidiabetic effect of Trigonella foenum-graecum showed that the action of fenugreek in lowering blood glucose levels is almost comparable to the effect of insulin. It also showed that fenugreek seed powder taken orally decreases serum triglycerides and increases HDL cholesterol significantly
Goat’s rue: is one of the most effective natural agents to stabilize blood sugar. The identification of guanidine and related compounds in Goat’s Rue led to the development of biguanides eg., Metformin.
Panax Notoginseng: Panax Notoginseng saponins possess anti-hyperglycemic and anti-obese activities by improving insulin- and leptin sensitivity
Fenugreek seeds: adjuvant therapy to the fenugreek seeds extract (with metformin) in PCOS women improved the sonographic results and menstrual cyclicity.
Green tea: evidence is mixed for green tea efficacy in PCOS, with some studies showing a decrease in insulin, testosterone and body weight after supplementation and others showing no significant effect on the levels of inflammatory factors
Licorice: a small clinical trial published in 2004 found that licorice root significantly decreases testosterone levels in healthy female volunteers. Warning Licorice raises systolic and diastolic blood pressure!
Vitex Agnes Castus, Cimicifuga racemosa(black cohosh), Paeonia lactiflora: a recent review of clinical studies on herbal remedies (including a total of 33 studies and 762 women with menstrual irregularities hyperandrogenism and/or PCOS) found that herbal extracts of Vitex agnus-castus, Cimicifuga racemosa (black cohosh) and Paeonia lactiflora improved ovulation, metabolic hormone profile and fertility outcomes in PCOS.
Saw Palmetto may reduce acne, excess facial and body hair, as well as hair loss from the scalp.
Spearmint: spearmint tea twice a day for a 1 month period has shown to have significant anti-androgen effects in polycystic ovarian syndrome. After treatment with spearmint teas, there was a significant decrease in free testosterone and increase in luteinizing hormone, follicle-stimulating hormone and estradiol.
Resveratrol: in a very recent double-blind, randomized, placebo-controlled trial, Resveratrol significantly reduced ovarian and adrenal androgens. This effect may be, at least in part, related to an improvement of insulin sensitivity and a decline of insulin level.
Milk thistle has been used for more than 2.000 years to treat liver and gallbladder diseases. (As the liver is the main organ for detoxification, this herb is extremely useful in the treatment of PCOS).
Complementary and alternative medicines for polycystic ovary syndrome.
Acupuncture reduces hyperandrogenism and improves menstrual frequency in PCOS. Acupuncture's clinical effects are mediated via activation of somatic afferent nerves innervating the skin and muscle, which, via modulation of the activity in the somatic and autonomic nervous system, may modulate endocrine and metabolic functions in PCOS.
Mindfulness: a recent randomised controlled trial shows that mindfulness techniques seem promising in ameliorating stress, anxiety, depression and the quality of life in women with PCOS and could be used as an adjunct method to the conventional management of these women. Mindfulness has been shown to reduce psychological distress and exert positive effects on the central and autonomic nervous systems, hypothalamic-pituitary-adrenal axis, and immune system, leading to reductions in blood pressure, glucose, and inflammation.
Yoga: in a study yoga was found to be more effective than conventional physical exercises in improving glucose, lipid, and insulin values, including insulin resistance values, in adolescent girls with PCOS. Yoga practice also leads to better regulation of the sympathetic nervous system and hypothalamic-pituitary-adrenal system, which is crucial to decrease depressive and anxious symptoms.
If this is something you have been diagnosed with, I warmly invite you to book a free hormone health discussion with me. During our 30 minute meeting you can tell me about your experience, your diagnosis and we can work out the best steps for you.