This article is quite the big one, but is oh-so-juicy and informative. I delve into what Polycystic Ovarian Syndrome is, the signs and symptoms, how it’s diagnosed, the various types, typical mainstream medicine treatment options, as well as diet and lifestyle recommendations, and natural treatment suggestions. Enjoy!
Polycystic Ovarian Syndrome (PCOS) is a reproductive, endocrine and metabolic condition, affecting 1 in 10 women. Unfortunately, for many women it can take years (and multiple health professionals) to get an accurate PCOS diagnosis – if at all – so it is estimated there are millions of women worldwide with undiagnosed PCOS. Failure to get an accurate diagnosis or if left unmanaged, PCOS increases the risk of type 2 diabetes, obesity, cardiovascular disease, and pregnancy complications.
The cause of PCOS is not clearly understood. However, there is a well known link between elevated androgens (male hormones such as testosterone) and blood sugar and insulin imbalances that cause a multitude of symptoms and can disrupt the menstrual cycle.
As the name suggests, Polycystic Ovarian Syndrome isn’t technically a ‘disease’, but a collection of symptoms that has no one definitive cause for each person with the syndrome. It’s a bit like Irritable Bowel Syndrome (IBS), a collection of symptoms with no single definitive cause.
Signs & Symptoms of PCOS:
- Irregular or missing periods
- Excess facial and body hair (hirsutism)
- Head hair loss and/or thinning
- Weight gain and/or difficulties losing weight (but not the case in all PCOS cases – PCOS can occur in lean body sizes too)
- Polycystic ovaries on ultrasound (not always)
- Darkening of skin / skin tags
- Insulin resistance / elevated insulin
- Blood sugar issues / uncontrollable sugar cravings
- Anxiety / depression
- Mood swings
- Fertility challenges
- Elevated androgens
- High Luteinising Hormone (LH) compared to Follicle Stimulating Hormone (FSH)
It’s important to note that not all women with PCOS will experience ALL of the above symptoms. Some will experience many of these symptoms and others will have very few. You can also present with some of these symptoms and not have PCOS.
How is PCOS diagnosed?
When receiving a PCOS diagnosis, it is important to know that PCOS cannot be diagnosed from an ultrasound alone! That’s right, I’ll repeat that again – PCOS CANNOT BE DIAGNOSED FROM AN ULTRASOUND ALONE.
This is because it is possible to have cysts on your ovaries and NOT have PCOS. Not to mention it is also possible to have PCOS and have NO cysts at all. This can make the name ‘Polycystic Ovarian Syndrome’ a little confusing! Dr. Jerilynn Prior, a Canadian endocrinologist, physician and founder of the Centre for Menstrual Cycle and Ovulation Research (CeMCOR) believes a more accurate name for PCOS is ‘Anovulatory Androgen Excess (AAE)’. This is because the name Polycystic Ovarian Syndrome places emphasis on cysts, which as we know isn’t necessary for a PCOS diagnosis, whereas Anovulatory Androgen Excess, speaks to the ovarian dysfunction and androgen excess that are the key issues in this condition. I personally couldn’t agree more with Dr. Jerilynn Prior! Although, I think it will take quite some time before PCOS is officially renamed. So for simplicity, I’ll continue to use the name ‘PCOS’ for the remainder of this article.
There are other causes for cysts on the ovaries aside from PCOS. That is why it is essential when ruling in or out a PCOS diagnosis for a practitioner to take a thorough case history, assess signs and symptoms, and run a series of blood tests (see below) and other investigations for an accurate diagnosis.
The diagnostic criteria that is most widely used is the Rotterdam Criteria.
The Rotterdam diagnostic criteria for PCOS
You must have TWO of the following three criteria:
- Irregular periods (oligomenorrhea) OR no periods (amenorrhea)/no ovulation (anovulation)
- Hyperandrogenism (clinical – acne, hirsutism or less commonly male pattern alopecia OR biochemical – raised free androgen index or free testosterone)
- Polycystic ovaries on ultrasound
Before a true PCOS diagnosis is reached, other causes must first be excluded, such as congenital adrenal hyperplasia, androgen secreting tumours, Cushing syndrome, thyroid dysfunction, and hyperprolactinaemia.
The Androgen Excess and PCOS Society (formerly the Androgen Excess Society) considers hyperandrogenism (excess androgen levels) to be a key feature in PCOS and believes for an accurate PCOS diagnosis, hyperandrogenism must be present and accompanied by signs of ovarian dysfunction – such as anovulation (no ovulation and therefore no periods), oligoanovulation (when ovulation occurs infrequently or irregularly), oligomenorrhea (infrequent menstrual periods – fewer than eight periods per year and/or cycles that are over 35 days), and/or polycystic ovaries.
A note for young women
It can take up to 2 years from menarche (the first period) for cycles to regulate. If cycles are irregular 3 years postmenarche, then further investigation may be warranted. Ultrasound is also not reliable in the diagnosis of polycystic ovaries in adolescent girls and young women as up to 70% of young women can present with naturally more follicles and polycystic ovaries on ultrasound. This is particularly important to know in order to avoid misdiagnosis in this age group.
Recommended Blood Tests for PCOS
When investigating a PCOS diagnosis, there are several blood tests that are important for ruling in or out PCOS.
The top blood tests to determine whether you have high androgen levels are:
- Total and/or free testosterone – usually elevated
- Free androgen index (FAI)
Other blood tests that can be useful in identifying high androgen levels include:
- Sex hormone-binding globulin (SHBG) – SHBG is typically low in PCOS and insulin resistance
- Dehydroepiandrosterone sulphate (DHEAS) – is usually elevated if the adrenal glands are the main driver of PCOS
- Androstenedione – may be elevated
It is also recommended to assess your reproductive hormones as these can also affect your cycles. These include:
- Oestradiol (oestrogen) – may be normal or elevated in PCOS
- Follicle stimulating hormone (FSH) – may be normal or low in PCOS
- Luteinising hormone (LH) – is usually elevated in PCOS
- LH to FSH ratio – a LH:FSH ratio should be 1:1, however, if ratio is 2:1 or 3:1 or more, this may suggest PCOS
Whilst investigating a potential PCOS diagnosis it is best to test other markers to exclude other conditions that have similar symptoms to PCOS, such as:
- Full thyroid panel (including TSH, free T4, free T3, thyroid autoantibodies)
Blood test for insulin resistance:
- Fasting insulin – usually elevated and will definitely be elevated if insulin resistance is your driver of PCOS
- Fasting glucose (this isn’t specifically for insulin resistance, but helpful in determining where your blood sugar levels are at) – may be normal (due to elevated circulating insulin) or elevated
Blood test for inflammation:
- C-reactive protein (CRP) – may be elevated if inflammation is your driver of PCOS
If your test results come back within range and your doctor tells you everything is ‘normal’, this doesn’t necessarily mean your results are ‘optimal’. If your doctor’s interpretation of your results doesn’t add up, you may want to consider taking your results to another practitioner (like me!) to interpret.
Types of PCOS
Did you know there are 4 types of PCOS? Each of the 4 types have a different underlying driver or root cause for how the PCOS type has manifested. When you have been diagnosed with PCOS, it is important to know: what is driving it. As this is key to figuring out how to best treat it, as treatment is different for each PCOS type.
Before we dive into the 4 types of PCOS, it’s worth noting, according to naturopathic doctor Lara Briden, in order to have PCOS, androgen excess must be present and when all other causes of androgen excess have been ruled out. Androgen excess is demonstrated as high androgen levels on a blood test and/or visible symptoms of high androgens, like significant facial hair or jawline acne. If you do not have either of these then it is likely you do not have PCOS.
The 4 types include:
1. Insulin resistant PCOS – this is the most common type of PCOS. This is where you have too much insulin in the body than normal as a result of too much sugar (glucose) in the blood. Insulin is released to help ‘clean up’ the sugar and lower glucose levels. If insulin is constantly being produced and released the body’s cells become resistant to the effect of insulin, thus causing insulin resistance. This then drives your androgen levels to increase, causing facial and body hair growth and acne symptoms, as well as disrupting ovulation and cycles. Insulin resistance also promotes weight gain.
2. Post-Pill PCOS – this is a temporary type of PCOS and is caused by a temporary surge in androgens after ceasing low androgen index forms of birth control such as Yaz, Diana and Brenda, contributing to PCOS symptoms.
3. Inflammatory PCOS – chronic inflammation can stimulate the ovaries to make too much testosterone and is a contributing factor for every type of PCOS. If chronic inflammation is the primary driver, it’s inflammatory PCOS. Other signs and symptoms of inflammation include: unexplained fatigue, bowel problems like IBS or SIBO, autoimmune disease like Hashimoto’s thyroid disease, headaches, joint pain, and/or a chronic skin condition like psoriasis, eczema or hives.
4. Adrenal PCOS – this type of PCOS is when you have elevated DHEAS but normal testosterone and androstenedione levels. DHEAS is made in the adrenal glands, whereas the other androgens are made in the ovaries. Adrenal PCOS is not driven by insulin resistance or inflammation, but rather by the upregulation of adrenal androgens.
The Connection Between the Thyroid & PCOS
Did you know the thyroid and PCOS are connected?
Both PCOS and hypothyroidism (underactive thyroid) actually share pretty similar symptoms, such as fatigue, weight gain, insulin resistance, mood changes, hair loss, irregular cycles, and even polycystic ovaries (to name a few). This is why it is so important to rule out thyroid conditions when investigating a PCOS diagnosis.
Hypothyroidism is known to cause polycystic ovaries and can even worsen PCOS and insulin resistance! This is because in hypothyroidism, there are high levels of prolactin, which can put a stop to ovulation, causing multiple cyst formation on the ovaries. Excess weight and obesity in PCOS is associated with higher TSH (thyroid stimulating hormone) levels, which further stimulates production of fat tissue. Thyroid function also plays a role in insulin sensitivity. In hypothyroidism insulin sensitivity can be decreased leading to and/or worsening insulin resistance.
Hypothyroidism can also worsen PCOS symptoms due to the elevated TSH levels causing decreased sex hormone binding globulin (SHBG) and higher testosterone levels. High prolactin also impacts the ratio of luteinising hormone (LH) and follicle-stimulating hormone (FSH) and increases DHEA from the adrenal glands, all of which impact ovarian function.
There is also a significant link with PCOS and Hashimoto’s thyroiditis, which is an autoimmune thyroid condition. Studies have found an increased prevalence of Hashimoto’s, serum TSH, and thyroid autoantibodies (anti-TPO and anti-Tg) in PCOS patients. Imbalances in estrogen to progesterone levels in PCOS have been linked to the prevalence of autoimmune conditions, including thyroid conditions.
So whether you have PCOS, thyroid dysfunction, or both, it is essential to get the proper testing in order to find the most appropriate treatment strategy for your underlying cause.
Conventional Treatment for PCOS
Unfortunately there are very few effective treatment and management options for PCOS within the medical system. It is far too common for women with PCOS to be told by their doctors to go on the pill (hormonal birth control) to manage their PCOS and then come back to them for fertility drugs when they are ready to have a baby. Sadly, this is not the solution and is incredibly disempowering!
The pill is also often offered to women with PCOS to help regulate their cycles, bring on periods (if they are absent), and balance hormones.
The truth is, the pill or any other form of hormonal contraception cannot do this. It cannot fix or treat PCOS or balance your hormones or regulate your cycle or bring on your period! Yes, technically it can bring on bleeding if your periods have been absent, but any bleeding on hormonal birth control are FAKE periods. The pill works by shutting down your natural hormone production and ability to ovulate. You need to ovulate in order to have a real period!
While the pill can help to manage acne and reduce testosterone levels, it isn’t really fixing anything, but rather masking your PCOS problems. Because when you come off of the pill your symptoms will return either as they were pre-pill or they may come back worse than ever before.
It’s also important to note that since women with PCOS are at risk of developing comorbidities such as cardiovascular disease, type 2 diabetes, obesity, etc., the pill actually increases the risk of hypertension and cardiovascular disease in women with PCOS. Not to mention the pill can also worsen insulin resistance, as well as cause nutrient deficiencies and intestinal permeability.
Metformin is a blood sugar control medication usually prescribed for type 2 diabetes patients. It is also often prescribed to women with PCOS to manage blood sugar, decrease insulin resistance, and improve menstrual cycle regularity. However, metformin does come with a lot of side effects, such as abdominal pain, diarrhoea, nausea, vomiting, headaches, and mood swings.
Spironolactone is a drug usually prescribed to treat high blood pressure and heart failure. But it also works by blocking the effects of androgens like testosterone, which is responsible for the hair growth on the face, chest and stomach, and acne in PCOS. However, this is a temporary solution, as spironolactone works by reducing testosterone levels for as long as you are taking the medication. Once you come off, testosterone levels are likely to rise again, including its symptoms of hair growth and acne. ‘So I’ll just stay on it then’, I hear you say, well, a known side effect of spironolactone is delayed or prevented ovulation. Which is the last thing you want if you are having issues with ovulation in the first place! It’s also best not to try to conceive whilst on this medication either, as it may inhibit implantation or cause miscarriage.
Most women who have tried pharmaceutical options for PCOS management are dissatisfied as they did not find these solutions helpful. Thankfully, there is a lot we can do naturally to support PCOS through diet, lifestyle, herbal medicine, and nutritional supplementation.
Diet & Lifestyle Support for PCOS
Diet and lifestyle modifications are essential for PCOS management. Knowing what to eat when you have PCOS can feel pretty confusing. There is so much information & types of diets out there that claims to be THE solution for your PCOS woes.
In my clinic, I help women tailor their diet to what is best going to suit their individual needs, whilst addressing their root cause of their hormone imbalance. Focusing on addressing blood sugar and insulin imbalances is key for PCOS treatment and management.
The following tips are general guidelines on what you can implement into your diet that will help to support your PCOS:
Eat whole, real, and fresh foods – A diet rich in fresh fruit and vegetables, wholegrains, nuts and seeds, and good quality protein sources ensures you are getting all the nutrients you need for your hormones, as well as to stabilise blood sugar and improve insulin resistance.
Eat plenty of fibre-rich foods – Eating plenty of fibre on a daily basis, not only ensures you are moving your bowels regularly and helping to promote hormone clearance, you are also helping to improve insulin sensitivity and supporting healthy weight loss. Vegetables, such as leafy greens and cruciferous vegetables (broccoli, cauliflower, brussel sprouts, kale, rocket, etc.), as well as wholegrains, flaxseeds and chia seeds are great sources of fibre.
Prioritise proteins, healthy fats, and slow-releasing complex carbohydrates – This is essential for regulating your blood sugar and insulin, helping you to feel full after meals and preventing sugar cravings and crashes, supporting healthy hormone production, and encouraging healthy weight loss in PCOS. Think:
- Proteins: eggs, poultry, oily fish low in mercury (salmon, sardines, and herring), grass-fed red meat (in moderation), legumes, and quinoa.
- Healthy fats: raw nuts and seeds, avocado, olive oil, olives, coconut oil, ghee, wild-caught salmon.
- Slow-releasing complex carbohydrates: sweet potato, pumpkin, beetroot, carrots, brown and black rice, quinoa, buckwheat, millet, rolled/steel cut oats (if not gluten intolerant), and legumes and beans.
Eliminate refined sugar & processed foods from the diet – Eliminating refined sugar from your diet is vital for PCOS management, as this will help with balancing blood sugar and insulin, and reduce inflammation in the body. Think white bread, white pasta, white rice, cakes, cookies, biscuits, sweet pastries and baked goods, chocolate, lollies, junk foods, etc.
Don’t skip meals – Skipping meals such as breakfast can disrupt your blood sugar levels even further and puts your body into ‘survival’ mode, as it’s not sure when it will get food next. Not only does this mess with your hormones but also makes weight loss difficult, as your body will be storing fat to ‘survive’.
Add cinnamon into your food – Cinnamon is the number 1 food to help balance your blood sugar. Simply by adding a ½ – 1 teaspoon of cinnamon in your smoothie, porridge, chia pudding, or bliss balls, can help to stabilise your blood sugar levels and avoid unwanted blood sugar spikes and crashes.
Exercise & Weight loss
Exercise is not only important for weight loss in PCOS (if weight is an issue), but it also is beneficial for improving insulin resistance by increasing insulin sensitivity, androgen levels (in women with PCOS), menstrual cycle regularity and ovulation, and emotional wellbeing. Not to mention exercise promotes overall health.
Research has shown weight loss of 5-10% of total body weight can improve PCOS problems such as insulin resistance, high levels of androgens, reproductive system dysfunctions, and fertility.
A combination of regular cardio (aerobic) and resistance (weight/strength) training has been shown to be beneficial in PCOS. The recommended guidelines for exercise for weight loss is:
- Overall, aim for around 30 minutes of physical activity per day.
- A minimum of 250 minutes a week of moderate-intensity activity (brisk walking, swimming, aqua aerobics, cycling, etc.) or 150 minutes a week of vigorous activity (jogging, running, earobics, team sports, circuit training, etc.), or a combination of both.
- Resistance/strength training on two non-consecutive days of the week. This can include bodyweight exercise like squats, push-ups and chin-ups, free weights, resistance bands, medicine balls, weight machines, and Pilates.
If you are underweight and/or you have adrenal PCOS, the above exercise regime is not recommended. It is best to focus on lower intensity exercise such as walking, yoga, gentle swimming, etc. and prioritise rest and stress-management activities. This is because moderate and vigorous intensity exercise can increase ‘stress’ on the body and further worsen PCOS and cause additional weight loss.
Herbal Medicine & Nutritional Supplementation for PCOS
We are so fortunate to have so many natural solutions for managing PCOS symptoms that focus on addressing the root cause and drivers.
Below are just some of the powerful herbs and nutritional supplements that can help PCOS. Please note this is not an exhaustive list.
- Peony & Licorice – as a combination help to reduce elevated testosterone levels, reduce hyperandrogenism, and support healthy hormone production and regular menstrual cycles.
- Cinnamon – supports blood sugar balance and insulin sensitivity.
- Saw Palmetto – lowers androgens, such as testosterone that is associated with unwanted facial and body hair growth (hirsutism) and acne.
- Spearmint – helps to lower testosterone levels and improves hyperandrogenism symptoms, such as hirsutism, in women with PCOS.
- Tribulus – helps to improve ovulation and ovulatory cycles, sexual function, and reduces androgen levels.
- Inositol – reduces testosterone and insulin resistance, and improves ovulation and regular cycles.
- Chromium – helps reduce insulin resistance and elevated testosterone levels, as well as supports ovulation in PCOS.
- Zinc – can help to reduce high levels of testosterone and improve hirsutism, hair loss, hair thinning, and acne.
- Magnesium – supports blood sugar balance, reduces PMS symptoms and inflammation, and improves insulin resistance.
- Omega 3 – is anti-inflammatory and improves insulin sensitivity.
- Vitamin D – is associated with blood sugar regulation, as well as ovarian reserves, ovarian follicle health, and fertility. Research has found a link between vitamin D deficiency and PCOS and symptom severity.
- N-acetyl-cysteine (NAC) – has shown to improve insulin resistance and menstrual regularity and reduce testosterone levels and hirsutism in PCOS. It can also help to support fertility.
Herb Spotlight: Spearmint tea
Spearmint (Mentha spicata) has anti-androgen properties, which means it can help to lower androgen levels, such as free testosterone in women with PCOS. Why is this important? Well, since high androgen levels are responsible for acne and unwanted facial and body hair growth (hirsutism) in PCOS, spearmint has proven in the research to help reduce these types of PCOS symptoms specifically!
The research shows drinking one cup of spearmint tea twice a day for at least 30 days has significant results in lowering testosterone levels and improving hirsutism (facial hair growth) in PCOS. That’s pretty incredible right?!
So there you have it! I hope you found this article helpful in not only understanding what PCOS is, but in also knowing that you do have options. So many options! And by no means is this an exhaustive list of what you can do to treat and manage PCOS.
If you have been diagnosed with PCOS or think you have PCOS and are in need of support, I’d love to help you. Feel free to book in a 1:1 Naturopathic consultation with me to help you uncover your root cause of PCOS and find the most appropriate PCOS management for your specific needs.
Medical Disclaimer: The herbs and supplements mentioned in this article are for informational purposes only. It is recommended to speak with your healthcare provider, Naturopath, or Nutritionist before starting any new nutritional and/or herbal supplement to determine if it is right for you. The information provided in this article is not to be used as medical advice.
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