Polycystic Ovarian Syndrome (PCOS): diagnosis, causes and approaches to treatment
In this article one of the Steve Grant Health trusted practitioners and specialists in the area of female health Lara discusses PCOS diagnosis, causes and approaches to treatment.
Polycystic Ovarian Syndrome (PCOS) is a common hormonal condition affecting approximately 1 in every 5 – 10 women of reproductive age worldwide. The primary symptom of PCOS is irregular or long cycles; additional symptoms include excess hair growth on the chin, cheeks, upper lip, neck, nipples and belly (also known as hirsutism), hair loss, acne, difficulty losing weight, low sex drive and infertility. Long term associated risks of PCOS include heart disease and diabetes.
PCOS essentially comes down to an inability to ovulate which then has a knock-on effect of an overproduction of male hormones that are known as androgens. Given that ovulation is about so much more than just making babies (it’s our body’s way of producing hormones that are essential for bone health, heart health, skin health and mood, to name just a few) if we aren’t ovulating, it’s essential for us to figure out why.
But before we do that, let’s discuss:
How to diagnose PCOS
Firstly, it’s really important to note that an ultrasound alone is insufficient for diagnosing PCOS.
When it comes to actual cysts on the ovaries, the Androgen Excess Society state that “The finding of polycystic ovarian morphology in ovulatory women not showing clinical or biochemical androgen excess may be inconsequential.” It’s also important to note that the absence of cysts on the ovaries can’t be used to rule out PCOS either because you can have irregular periods and excess androgens and normal cysts on ultrasound but still have PCOS.
The Rotterdam Criteria is what it most typically used to diagnose PCOS. It states only two of the following three criteria need to be met for diagnosis:
- Infrequent or no ovulation
- Raised male hormones seen as either physical signs + symptoms (such as excess hair growth, acne + hair loss) OR on blood tests
- Polycystic ovaries as seen on ultrasound
However, The Androgen Excess Society released a report in 2009 concluding that “Based on the available data, it is the view of the AE-PCOS Society Task Force that PCOS should be defined by:
- The presence of hyperandrogenism (clinical and/or biochemical)
- Ovarian dysfunction (oligo-anovulation and/or polycystic ovaries)
- And the exclusion of related disorders.*”
* Related disorders include hypothyroidism, raised prolactin, side effects from certain psychiatric medications and rare pituitary or adrenal diseases.
The Androgen Excess Society emphasises that raised androgens (male hormones) need to be part of the PCOS picture – it essentially defines PCOS as a condition of lack of ovulation (with irregular or long cycles) together with raised male hormones.
Despite the above criteria, diagnosis can be tricky – that’s because no two women will present with the same symptoms: one woman might be slim, have acne, chin hair, irregular periods and cysts on her ovaries while another woman might be overweight, have thinning of her hair, have long cycles and no cysts on her ovaries. As a result, many women go undiagnosed for years or get misdiagnosed in the process – and that can be incredibly frustrating and disheartening.
What Causes PCOS?
There is no one cause of PCOS but certain situations increase the risk of developing PCOS.
Researchers have established that a genetic susceptibility (having a condition in families) puts one at risk of PCOS but it does not make it an inevitable fate. Genes express themselves based on their environment so even though someone may have the genes that make ovulating more difficult or increase the likelihood of overproducing male hormones, their current environment (nutrition, lifestyle and stress) will ultimately determine whether or not this actually happens.
It’s often said that that genes load the gun and the environmental factors pull the trigger.
Let’s look into these environmental factors further:
Insulin-Resistance and PCOS
One of the main players for the majority of women with PCOS is insulin-resistance. Insulin is a hormone and its role is to get glucose from the blood to the cells of the body for energy production – insulin is essentially “a key” that “opens” the cells. When we’re dealing with insulin resistance, the insulin receptors are no longer as sensitive to the “key” – this means that more insulin is made by the pancreas in attempt to get the message to the cells to open up. The problem with this though is that high levels of insulin lead to inflammation and have a direct impact on ovulation in a number of ways. Firstly, high levels of insulin cause the ovaries to make testosterone instead of estradiol. Studies suggest that these high levels also stimulate the pituitary gland to produce excess luteinizing hormone which has the knock-on effect of the production of even more androgens (male hormones). Finally, high levels of insulin cause a drop in sex hormone binding globulin (SHBG) production – SHBG is a protein that binds sex hormones so that they can leave the body without causing any damage in the process; when levels of SHBG are low, there’s an increase of free testosterone.
But when we back it up to establish how problems occurred with insulin in the first place? It usually comes down to eating a lot of sugar (particularly in the form of excess fructose) and refined foods.
In my situation, a bread, processed food and sugar-based diet were only part of my insulin-resistance picture as stress played a massive role – I was SO stressed out my brackets at the time my period disappeared for more than a decade. And here’s why: when we’re stressed, our bodies can’t tell the difference between a real physical threat, and perceived threat and they respond in the same way: by triggering the “fight or flight” response. In fight or flight, our bodies are preparing for what they think is about to be an attack by a wild tiger; this kind of attack requires energy which, in such a situation, is made by the release of the stress hormone, cortisol. Cortisol mobilises internal sources of glucose from the liver and muscles to be able to fuel cells to be able to fight or get the heck out of there. This is a good thing – except when it happens about 17 times a day – because it results in high levels of glucose which require high levels of insulin which further fuel the insulin-resistant and androgen-production picture outlined above.
Other factors that contribute to insulin resistance include lack of sleep, smoking, the birth control pill and imbalances in gut bacteria.
The tell-tale sign of insulin-resistance is usually apple-shaped obesity. However, it’s extremely important to note that you can be normal weight or even underweight and still be insulin resistant – as was the case for me.
Inflammation and PCOS
Research has found that PCOS is an inflammatory condition.
We’ve just seen above that high insulin can lead to chronic inflammation. Other factors that can create chronic inflammation include poor or inadequate sleep, stress, certain inflammatory foods, food sensitivities, lack of physical activity, imbalances within the gut bacteria, presence of parasites, exposure to toxins, excess alcohol consumption and smoking.
Inflammation in the short term is beneficial: it’s our body’s natural way of protecting itself through stimulating the immune system to produce chemicals called cytokines. You’ve experienced it as the redness, heat and tenderness after stubbing your toe or getting a paper cut.
The problem with inflammation is when it becomes chronic. When this happens, the inflammatory cytokines (chemical messengers of the immune system) interfere with hormonal communication throughout the body by disrupting hormonal receptors. Chronic inflammation also causes the ovaries and adrenal glands to make more male hormones (or androgens) which simply exacerbates the PCOS cycle.
Beyond hormonal interference, physical signs + symptoms of chronic inflammation typically include joint pain, skin conditions such as dermatitis or acne, unexplained exhaustion as well as digestive symptoms such as bloating. If you have any of these, together with irregular cycles and evidence of raised male hormones, then addressing the root cause of your individual chronic inflammation is where you’ll want to begin in addressing the environmental factors driving your PCOS.
How to test for PCOS
There is not one test for PCOS – and considering all of the above, about how differently different individuals can present with PCOS, we can hopefully understand that.
But let’s see what testing can be done to piece your individual puzzle together.
Approximately 70% – 80% of women with PCOS will be insulin resistant. Severe insulin resistance can be detected on a fasting insulin blood test where levels should be below 10 mIU/L. Fasting glucose levels and HbA1C levels are also useful to assess the severity of insulin resistance. Another way to test for insulin resistance is through the insulin glucose challenge test – this test is the same as a glucose challenge test with insulin levels measured in addition to glucose levels.
Testosterone levels should be in the range of 0.5 – 3.5 nmol/L and are usually high with PCOS.
Free Androgen Index is another measure of male hormones and levels should be less than 5. Again, this will typically be raised with PCOS.
It’s important to note here that testosterone is made in the ovaries, androstenedione (another ‘male hormone’) is made in both the ovaries and the adrenal glands and DHEA-S (dehydroepiandrosterone sulphate, another ‘male hormone’) is made only from the adrenal glands. The adrenal glands are where cortisol, the ‘stress’ hormone, is also made. If DHEA-S is raised, other reasons for it being raised need to be ruled out. Once this has happened, a high DHEA-S indicates that the triggering of PCOS likely started with stress.
LH + FSH
Luteinizing Hormone is the hormone that triggers ovulation. This should be between 2 – 10 iu/l and it is usually raised in women with PCOS. High levels of LH prevent ovarian follicles developing properly and cause the ovaries to make male hormones.
In addition to this, we typically find that follicle stimulating hormone (the hormone that stimulates the ovaries to mature an egg) is low in comparison to LH. A relatively broad normal range for FSH is 2 – 8 iu/l.
The timing of testing for LH + FSH is key. Even if you have an irregular period, you want to test these hormones on day 3 of your cycle so as to see what these levels are when they should be at their lowest.
A thyroid panel including thyroid stimulating hormone (TSH), free T3, free T4 and thyroid antibodies should also be considered as hypothyroidism has been shown to worsen insulin resistance, other cardiovascular risk factors and interfere with ovulation.
Low Vitamin D levels exacerbate PCOS symptoms as Vitamin D plays a key role in optimal ovarian function as well as insulin sensitivity. Optimal levels should be between 75 – 125 nmol/L.
Prolactin is a hormone that is produced by the pituitary gland in the brain. Levels above 500 mU/l can cause an increase in the male hormone DHEA and therefore negatively impact ovulation. Levels are usually raised following a traumatic event.
SHBG – we’ve already come across sex hormone binding globulin (SHBG) which is a protein produced in the liver and is required in optimal levels so as to keep sex hormone levels in check. In people with PCOS, we typically find that levels are too low which results in high levels of unbound hormones, such as testosterone, floating around the body. In certain instances, these levels can be too high which means that there aren’t enough free hormones available – this is typically seen after coming off the pill, with a high intake of phytoestrogens or owing to stress.
As you can likely tell, testing is not straightforward, and results need to be interpreted together with your clinical picture of not ovulating (with long or irregular cycles) and raised male hormones (as seen in the tests themselves or in physical signs and symptoms).
PCOS Treatment: Conventional approaches
Hormonal Birth Control
Like many others, I was offered the pill as a ‘solution’ to ‘regulate my cycle’ but to this day I am still baffled that this was even an option – the pill stops ovulation and when we’re dealing with PCOS, one of the primary issues that we want to address is the inability to ovulate so taking something to stop what we want to happen in the first place really makes no sense?
Yes, the pill does suppress androgen production which is helpful but only beneficial for as long as you remain on the pill. Once it’s discontinued, we typically find that androgen production is even worse than what it was to begin with as a result of the androgen surge that can result when stopping the pill.
In addition to this, the pill has been shown to worsen insulin resistance – one of the main drivers of PCOS.
The pill also comes with additional side effects that include negatively impacting our beneficial gut bacteria (that can make it even more difficult lose weight) as well as depleting the body of B vitamins and zinc – nutrients that are essential for optimal overall and ovarian health.
The take home message with the pill is that when we’re wanting to address the root cause of PCOS concerns, it does little to support us with that aim.
Metformin is a drug that is typically given to people with Type 2 Diabetes so as to re-sensitise the body to insulin and reduce the absorption of glucose. This at least attempts to target insulin resistance, which as we know well by now, is one of the main drivers of PCOS. Even though useful, studies show that improving diet and lifestyle are more beneficial than clomid and metformin for managing PCOS.
The side effects of Metformin include digestive issues, metallic taste in the mouth (for some) as well as stripping the body of vitamin B12. If you are on metformin, or choose to take it, please be sure that vitamin B12 levels are checked (and replenished) every 3 – 6 months.
This drug is a diuretic (rids the body of excess salt and water by increased urine formation) and actually intended for high blood pressure, liver cirrhosis and congestive heart failure. It’s used in the instance of PCOS to block the effects of androgens so as to lessen symptoms of acne and hair growth. It usually takes up to 6 months to notice the impact, is only effective when taking it and it can lead to irregular and abnormal periods – again, somewhat ironic when dealing with PCOS.
Natural Approaches for PCOS: Nutrition
When it comes to PCOS, ideally we’d want to get back to whole, unprocessed foods full of fibre, colours and anti-inflammatory properties. This would be a diet full of colourful vegetables, fruits, cur cumin, cinnamon, olive oil, avocados and well sourced oily fish.
This is simply a good starting point. Below are a few factors and foods that we would then want to adjust intake of or avoid because of their impact on either worsening insulin resistance or inflammation.
A great starting point to address insulin resistance is to show sugar, particularly fructose, the back door. Fructose is a type sugar that can impair insulin sensitivity and enhance appetite but only at quite high quantities. And by avoiding fructose, I don’t mean avoiding fruit – yes, there is fructose in fruit but nowhere even close to the amount that’s needed to impact insulin sensitivity negatively. So please, even with PCOS, insulin resistance or weight struggles, 2 – 3 portions of fresh fruit/day can likely be included in your intake (not fruit juice which lacks the fibre or dried fruit which has a greater concentration of sugar). What we’re talking about here is added fructose in the form of chocolates, sweets, sauces, packaged + processed foods, sugary drinks, yogurts + breakfast cereals and the likes. A lot of these foods also contain high fructose corn syrup (which is not the same as fructose) but which has been linked to increased inflammation, insulin resistance and non-alcoholic fatty liver disease. Other foods to watch out for on the fructose front include dates (especially in the form of energy balls), honey and fruit juices – even though they’re “natural”, they still contain high quantities of fructose.
In order to improve insulin sensitivity, you will need to be strict with avoiding the high fructose and sugary foods listed above until things start to shift (so that does not mean forever!). Please understand from the beginning that this can be an extremely challenging (but not impossible) thing to do. To ease matters, try to do this when you aren’t dealing with numerous other external stressors and ensure that you’re getting sufficient sleep. Also know that your tastes will change and your cravings will dampen once you start to eat more healthily. There are certain supplements to consider too which will be discussed later on.
Reducing carbohydrate intake is the next step to address insulin resistance. This isn’t because carbs are bad at all – this is simply because carbs do cause more of a spike in blood sugar and therefore insulin so reducing them until you become more insulin sensitive can be beneficial. What I typically suggest with my PCOS clients with insulin resistance is carbohydrate back-loading. This is where breakfast and lunch are predominantly fat and protein based and carbohydrates (in the form of sweet potatoes, purple potatoes, normal potatoes, black, brown, wild or white rice) are included in a small portion at dinner. The theory behind this is that the insulin receptors are more sensitive to insulin by the time carbs are introduced in the evening if they haven’t been stimulated as much throughout the day. The other reason for including carbs in the evening is to support sleep by relaxing the nervous system and by replenishing glycogen stores to keep blood sugar levels stable.
So that brings us onto the Keto Diet for PCOS. Achieving a state of ketosis requires a reduction in carbohydrate intake to less than 30g/day (almost as many carbs as in 1 sweet potato). Once in this state, the body then uses ketones as its primary source of fuel. The Keto diet can help to address insulin resistance, achieve weight loss and reduce chronic inflammation which as we’ve already looked into, would all beneficially impact PCOS symptoms. However, the downside to this diet is that because it’s low in resistant starch, in the long term it can starve our gut bacteria which are dependent on resistant starch as their primary source of fuel. This can then lead to imbalances within gut bacteria that can then lead to inflammation and insulin resistance which is obviously not helpful for PCOS. In addition to this, a long-term low carb diet can actually result in losing your period – that’s because we all require a certain amount of carbohydrate to ovulate, and that amount is different for everybody. It’s also important to remember that there are other ways to address insulin resistance without having to go into ketosis. And for the 30% of women with PCOS where stress is the main driver, going on a low carbohydrate diet will likely exacerbate matters by putting more strain on the adrenal glands.
Hopefully you’ll see by now that there’s not one diet for PCOS because it’s a syndrome with different drivers as the root cause – so when it comes to carbohydrates, although reducing them can be useful for the 70% of women with insulin resistant PCOS, it’s most definitely not the answer for everybody.
As we’ve established, PCOS is an inflammatory condition. The types of food we eat can therefore either help to quench inflammation or add fuel to the inflammatory fire. If they’re the latter, it’s not to say we should demonise these foods but rather to be aware that they could be contributing to chronic inflammation for certain people.
Ah the controversy surrounding this protein found in certain grains! Some people won’t go near it with a barge pole and others would give up their right arm to show their allegiance to gluten. What’s going on? As with everything, certain factors come into play when it comes to gluten such as our digestive health and of course, our genetic susceptibility. Severe reactions to gluten will typically show up as positive for coeliac disease on a blood test – it’s important to note though that gluten consumption has to be somewhat high a few weeks prior to testing otherwise you could get a false negative result. In addition to this, you might test negative for coeliac disease but actually still have an issue with gluten. This is known as non-celiac gluten sensitivity (NCGS) – research is beginning to acknowledge NCGS: where gluten causes an inflammatory response within the body (experienced as everything from acne, joint pain, brain fog, eczema, autoimmune disease, headaches, depression, inability to lose or gain weight) but might not have any digestive symptoms.
What does this mean for PCOS? If you have PCOS and have an issue with gluten, it could be causing an inflammatory response and as we’ve already established, because inflammation is one of the main drivers of PCOS, it could therefore be worsening your symptoms.
The best way to establish whether gluten is an issue for you is by taking a step back from it completely for 6 – 8 weeks (this is approximately how long it takes for any immune reactions you might be having to gluten to dampen) and see how you feel – it is recommended to get guidance on how to go about doing this. If you don’t feel any better after this time then it is likely that you need to dig a bit deeper than your gluten intake.
Again, dairy is something that won’t be a problem for everyone but may be pro-inflammatory and contribute to insulin resistance for some. Dairy products contain something called insulin-like growth factor (IGF-1) – this has a similar structure to insulin and it may cause the storage of glucose in fat cells as well as triggering the production of testosterone. Studies have shown that not only do women with PCOS have twice as much IGF-1 as other women without PCOS, but they are also more sensitive to the effects of it.
The other issue with dairy is linked to a protein called A1 casein. Most dairy products in the west contain A1 casein and this protein can cause the immune system to react with those pro-inflammatory cytokines through an enzyme reaction. Unfortunately testing for A1 casein sensitivity isn’t widely available but signs and symptoms include eczema, asthma, sinus issues, hay fever and the likes.
Again, one of the best ways to establish whether this is an issue for you is to take a step back from it completely for a period of time and see how you feel – it is recommended to get guidance on how to go about doing this. If you don’t feel any better after this time then it is likely that you need to dig a bit deeper than your dairy intake.
Well sourced goat and sheep products are fine to include as they don’t contain A1 casein. These will also cover calcium requirements, together with green leafy veg, bony fish, sesame seeds and almonds.
One of the main reasons alcohol is a concern is because it’s metabolised by the liver. The liver is the largest organ in the body with heaps of functions including detoxifying hormones as well as helping to stabilise blood sugar levels (therefore linked to insulin). If liver health is compromised then these functions get compromised and when it comes to addressing PCOS, if alcohol is in the picture, that usually means that we’ll only get so far. Alcohol is also considered an ”anti-nutrient” because it can block absorption of certain nutrients, such as zinc, and depletes the body of glutathione – an extremely potent anti-oxidant molecule needed by every cell in our bodies. Alcohol also negatively impacts gut health which as we know, can have an impact on insulin sensitivity, inflammation and weight loss.
Vegetables oils such as canola, soy and sunflower oil contain Omega 6 polyunsaturated fat; Omega 6 oils are necessary for health in small amounts (with the best sources being nuts and seeds) but in large amounts, these oils can contribute to the pro-inflammatory process and should therefore be avoided when attempting to address inflammation and insulin resistance. PCOS studies have also shown that higher levels of Omega 6 in blood correlates with higher levels of testosterone.
Trans fats, often listed as hydrogenated or partially hydrogenated fats on food labels, are found in all processed foods to help increase their shelf-life. They are so bad for overall health that even regulators of the food industry have begun to ban them. Just a small amount of trans fats (4g/day) has been linked to interference with ovulation. They have also been shown to block absorption of essential fatty acids which are particular vital when addressing insulin resistance.
Again, everyone is different – these are simply starting points to factor in when attempting to address the main drivers of PCOS from a food perspective.
Natural Approaches for PCOS: Lifestyle
When it comes to PCOS, it should be pretty clear by now that food forms only part of the picture – you can be eating the most suitable diet for you but if you’re dealing with stress (in its many forms) or are exposed to endocrine disrupters, chances are you’ll only get so far in addressing the root cause of your PCOS.
PCOS & Stress
We’ve already explored some of the physiological links between psychological stress and PCOS. If you’re living in the 21st century, it’s very likely that you’ll be dealing with some form of stress in your life – be it work, finances, relationships or health concerns. These are all completely understandable but when it comes to PCOS, it’s essential that we find a way of supporting ourselves through the stressors of everyday life. With many of my clients who are extremely busy city workers, we start simply with including some intentional breathing into their day – be it two to three minutes mid-morning and mid-afternoon. Doing this helps to support the “rest and digest” nervous system. From there, we then look at introducing guided meditation – I recommend using resources such as Headspace, Calm, One Giant Mind or Tara Brach. For some people, this is enough but quite often we find huge benefit through getting in additional support from a Mindfulness Coach such as David.
It’s also important to note, that stress comes in many shapes and forms with psychological stress just being one of them.
PCOS & Exercise
The next one might surprise you: too much exercise. Yes, exercise is extremely beneficial when addressing PCOS because it can help to reduce body fat, improve insulin sensitivity and level out certain hormones but like many confused and frustrated women I see who are working out hard everyday but end up GAINING weight, you might actually be doing too much. That’s because exercise is a temporary stressor to the body and in order to reap the benefits of all of the above (reducing body fat and improving insulin sensitivity), your body does need time to rest and recover. This always seems counter-intuitive if we’re going by the way too basic understanding of the calories in vs calories out equation: eat less and move more. But take that temporary stressor and turn it into overtraining and we could be dealing with chronically high levels of cortisol that negatively impacts sleep, gut health, mood, weight (particularly around the abdomen) and you guessed it, period health.
So how much is too much? Again, because everyone is different, the answer to that will be too. But if you’re dealing with chronic muscle and joint pain, ongoing struggles with your period, exhaustion regardless of length of sleep, getting sick regularly, difficulty focusing and/or “plateauing” with weight, it’s worthwhile taking a step back from the duration, frequency or type of workout. Reduce your cardio and endurance sessions to shorter 20 minute high intensity intervals. Consider strength training 2 – 3 times/week which is especially helpful for insulin sensitivity. Move everyday just by walking or with gentle yoga. And then always, always be sure to eat enough. When it comes to exercise, I work closely with my clients with Shaun Brooking, a movement specialist who understands just how individual our bodies are in this realm.
PCOS & Sleep
Not getting enough sleep is a biggie when it comes to PCOS. Again – you could be eating the most suitable diet for your body, exercising not too much and not too little but be sleep deprived? And Houston, we’ve got a problem! That’s because lack of sleep has been linked to insulin resistance (as well as impaired glucose tolerance) and chronic inflammation, our two main drivers of PCOS!
So, if you have PCOS, aim to be in bed at roughly the same time each day (ideally by 10pm) and get yourself a solid 8 hours of sleep. A couple of great ways to get good sleep include ditching any screens for at least an hour before bedtime (two if possible), dimming the lights in the evening, creating a wonderful evening ritual best suited to you (think candles, epsom salt baths and diaphragmatic breathing), saving your bed only for sleep (and sex – obvs), investing in some tip top blackout curtains and putting your phone as far away from your bedside as possible.
PCOS & Endocrine disrupters
Endocrine disrupters are what we know as BPA, pesticides and certain toxins. They’re called ‘endocrine disrupters’ because they’ve been shown to do exactly that: disrupt the endocrine (or hormone) system by altering the way in which hormones are used or metabolised within the body. Research indicates a link between BPA exposure and PCOS so much so that exposure is thought to be a possible cause of increasing the risk of developing PCOS.
What can we do to reduce exposure? Switch up your cosmetics – I love Content Beauty for all things make up and toiletries and Awake Organics for one of the best natural deodorants out there. Look at cleaning household products and switch those out for great alternatives from Ecover or Method. Buy organic where possible – I love and always recommend Riverfords or Abel&Cole to clients. Store all food in glass containers (studies show that the plastic – even BPA-free options – leech chemicals into food) and get yourself a decent reusable water bottle.