What is PCOS?
PCOS is an acronym for “Polycystic Ovarian Syndrome” or “Polycystic Ovary Syndrome,” as it is both called. It is the most common endocrine disorder affecting women of reproductive age in North America (1). As many as 1 in 10 women suffer from PCOS, that is at least 5 million women in US alone (1)! Hashimoto’s is even more common but we think of it as more of an autoimmune condition.
PCOS is considered triad of amennorhea (lack of a menstrual cycle over a number of cycles without pregnancy or menopause), obesity, and hirsutism (male pattern hair growth, unwanted facial hair) (2). Initially PCOS was thought to be a hormonal or a sex hormone endocrine problem but now we know it is really much more of a metabolic condition. At the root of the problem is not necessarily progesterone, estrogen or testosterone, but rather insulin resistance.
At the cellular level in PCOS there is insulin resistance, which results is hyperinsulinemia (high insulin in the blood). Your pancreas is producing the insulin but the cellular uptake is not happening because of the cellular resistance. As a result you have excess circulating insulin (hyperinsulinemia).
Hyperinsuliemia is an issue as it leads to stimulation of the ovaries and hyperandrogenism (Testosterone is an androgen) and also decreased synthesis of sex hormone binding globulin (2).
Sex hormone binding globulin (SHBG) is a protein in serum that binds to a number of different hormones (sex hormones and active thyroid hormone). When hormones are bound to SHBG they are functionally ineffective.
But, What does high insulin have to do with my sex hormones?
High levels of circulating insulin stimulates the ovaries to secrete testosterone and stops the liver from producing sex-hormone binding globulin (SHBG). Recall that SHBG binds hormones and renders them inactive. Higher Testosterone production and lower SHBG results in high circulating testosterone/androgen levels.
This accounts for cystic acne (mostly along the jawline, cheeks, chin), facial hair, and male pattern hair loss, that many women with PCOS experience. These “cosmetic” symptoms are what cause the most tremendous social impact, lack of confidence and anxiety/depression in women with PCOS.
Signs & Symptoms of PCOS (2,3):
- Irregular periods, no periods or not ovulating with each cycle
- Multiple follicles developing at the same time on ovaries seen on ultrasound (known as a “string of pearls”)
- Signs of elevated androgens (acne, hirsutism, male pattern baldness)
- Weight gain or inability to lose weight
- Acanthosis nigricans – discolouration or darkening around the skin folds (neck, under fat folds).
- Depression, anxiety, eating disorders especially binge eating (likely to do with the blood sugar dysregulation)
Diagnosis of exclusion: Determined by the Rotterdam Criteria – 2 out of the 3 following are required to make a diagnosis of PCOS (2,3):
- Irregular or no cycle
- Observation of signs of hyperandrogenism (acne, hirsutism, male pattern baldness) OR laboratory indications
- Polycystic ovaries (by ultrasound)
It is important to note that while lab tests can be used to confirm PCOS (LH, FSH, and testosterone) BUT NORMAL labs do not exclude the condition. This is because lab testing can be very variable based on when in the month the labs were completed, your current weight and many other factors.
Why should you be treated for PCOS?
- Improve symptoms of excess androgens (hirsutism, acne, male pattern hair loss)
- Prevent endometrial cancer (increase risk with chronically not ovulating)
- Manage the metabolic abnormalities to reduce risk of type 2 diabetes and cardiovascular disease
- To improve fertility and pregnancy outcomes
Conventional Therapies (1-3):
- Oral Contraceptives: The birth control pill is commonly recommended to reduce male hormone levels and regulate a women cycle. There are risks of using OCP which should be discussed with your doctor. While OCP reduces male sex hormones it has been shown to negatively affect insulin sensitivity, as well as lipid and carbohydrate metabolism. Worsening the underlying cause of PCOS, in my opinion, may not be the best approach.
- Spironolactone: This drug acts as an anti-androgen and helps to lower male hormones and improve symptoms of androgen excess (hirsutism, acne, male pattern hair loss)
- Metformin: This drug is typically used for diabetics. It has anti-inflammation effects, regulates insulin levels, supports a pregnancy, and may restore menstrual cycles in women with PCOS.
Okay, so we know what PCOS & insulin sensitivity is, we know the convention treatment, now what are some natural prescriptions used to treat PCOS.
1. Lose Weight
This might be a no brainer, but those who have a lower body fat percentage see marked improvements in insulin sensitivity over those who are overweight. One of the many challenges with losing weight with PCOS is sugar cravings. Cravings are mostly due to the dysregulation of blood glucose. If you are suffering from cravings I would recommend downloading my Free Guide: 7 ways to curb cravings .
Research shows that an average loss of 13.9 lbs leads to decreased fasting insulin and testosterone levels. In this same study 92% (12/13) of the PCOS women resumed ovulation and 85% (11/13) became pregnant (3).
2. Weight Train
There have been multiple studies that find increases in insulin sensitivity when weight training is applied to a regular workout routine (4-6) .
3. Build Muscle
This goes hand in hand with weight training, but one of the reasons that weight training stimulates an increase in insulin sensitivity is that lifting weights builds muscle. With more muscle you will have more space to store carbs in the form of glycogen and your metabolism will be faster.
4. Tailor Your Nutrition
If you are an individual starting a diet with an extremely high amount of body fat, you may want to consider a higher fat, lower carb approach to dieting. In fact, many studies are supporting the fact that ketogenic dieting (i.e. high fat, moderate protein, very low carb dieting) leads to significant improvements in insulin sensitivity (7,8). To start, I tell clients to download a free Macro Tracker (like MyFitnessPal) and aim for less than 50 grams of net carbs/day. Net carbs = total carbs- fiber.
Another option that I more often recommend is carb cycling combined with intermittent fasting. Download my FREE guide to carb-cycling and intermittent fasting here. In my opinion, carb-cycling would be a longterm option where are a ketogenic diet plan may be used initially to improve insulin sensitivity. This leads to better cortisol cycles for women than a restrictive carbohydrate diet. That being said carbohydrates should come from quality sources like root vegetables, sweet potatoes, squash, quinoa, legumes, vegetables etc.
5. Access Overall Nutrient Status
It is important to consider the entire body when treating PCOS. Addressing any nutrient deficiencies will help to improve health outcomes.
Magneiusm deficiency is incredibly common and in 2009 the World Health Organization estimated that 70% of Americans are deficient in magnesium (9). The issue of magnesium deficiency is so widespread that the WHO put out an article in 2009 looking at supplementing drinking water with Calcium & Magnesium! (9).
Other vitamins to look for is Iron, Iodine, B vitamins, Antioxidants and Vitamin D. Vitamin D is essential for reducing insulin resistance. Often it is recommended that blood levels be maintained between 50 and 80 for optimal health.
6. Supplement Smartly
Green Tea Extract:
For some time, green tea has been known to have significant effects on improving overall health, as well as being a great supplement for burning fat. The epigallocatechin gallate or EGCG content in green tea is what seems to be the active substance that can help the body lose fat and improve insulin sensitivity (10). In one study, supplementation with green tea extract compared to placebo found that the group who supplemented with the polyphenols of green tea improved insulin sensitivity by 13% when a blood glucose tolerance test was administered (10).
Oral administration of D- chiro-inositol improves insulin sensitivity, balances blood sugar, and reduces testosterone. One study also showed that PCOS women while supplementing had improved ovulation, decreased androgen levels, blood pressure and triglycerides (11). By stabilizing insulin and blood sugar you can become more in control of your food craving and appetite. Although lets be clear, in no way will taking d-chiro-inositol make up for a high carbohydrate/high sugar diet.
A dietary source of inositol is legumes. Legumes have been associated with weight loss, improved blood sugar and reduced risk of heart disease. Examples of legumes are chickpeas (garbanzo beans), kidney beans, and non GMO soy.
Chromium picolinate: Chromium enhances insulin activity and thus plays a role in maintaining proper carbohydrate and lipid metabolism in our bodies. It has been used as a supplement to help reduce body weight and alter body composition. Evidence suggests that chromium picolinate increases lean body mass and basal metabolic rate and decreased body fat percentage (12). Note: chromium a common side effect of chromium is headaches.
A 2014 study in PCOS women struggling to conceive looked at the effectiveness of L-carnitine on pregnancy rates. Results showed that the combination of L-carnitine and clomiphene significantly improved ovulation when compared to placebo and clomiphene alone (13). In addition miscarriage rates were lower in the group taking L-carnitine (13). Lastly, it was noted the L-carnitine group had decreases in total cholesterol, triglycerides and LDL while HDL increased (13).
Not only is cinnamon one of my favourite spices it also improves insulin resistance. A small 2014 study looked at cycle regularity and compared cinnamon vs placebo. The group that received cinnamon and significantly more regular cycles (14). I often add cinnamon to baked apples, smoothies, oatmeal, and coffee/tea.
7. Reduce Stress (cortisol)
Cortisol is a major synchronizing hormone for the entire hormone axis. It influences our circadian rhythm, pancreatic function, detoxification functions, inflammatory response, and insulin levels. Elevated cortisol leads to higher liberation of blood sugar and thus insulin. Chronic stress can lead to hyperinsulinemia and insulin resistance (15).
Lifestyle changes that can be made to improve cortisol function are meditation, mindfulness, yoga, practicing good sleep hygiene, reducing over-exercising, carbohydrate cycling, as well as reduce stimulants (coffee, tea). Considering the addition of adaptogenic herbs such as Rhodiola, Ashwagandha, Schisandra, Ginseng, Maitake mushroom for adrenal support may also be beneficial. Note: Maitake mushroom is not only an adaptogen but has been shown to support women with PCOS by regulating blood sugar and insulin while inducing ovulation (16).
8. Heal the Gut
New evidence is immersing that there is a tremendous gut-obesity connection. What you have going on in your gut has a huge impact on what you are craving (more candida = crave more sugar & carbs). Our Micorbiome (gut bacteria) also can cross talk with chemicals in our brain to disrupt appetite and satiety signals. Gut dysregualtion also contributes to inflammation which may predispose you to insulin resistance, PCOS, and obesity (17).
Ensure you are having at least 1 bowel movement /day. Hormones that are metabolized in the liver must be excreted through the bowels. Slow bowels leads to recirculation of hormones back into the bloodstream causing hormone imbalances. To ensure a daily bowel movement ensure you are consuming enough fiber rich fruits and vegetables. If you are reaching your daily fiber goals but still not seeing the desired results consider a probiotic with Lactobacillus and bifidobacterium strains (or fermented foods), and magnesium citrate if needed.
9. Environmental Impact & Detoxification
In order to have healthy hormone balance we need to be effectively detoxifying and eliminating hormone toxins from our environment (Xenobiotics) but also the hormone toxins that are naturally occurring in our bodies (Endobiotics). If our bodies are not eliminating hormones, inflammatory molecules, signally compounds, environmental toxins and drugs from circulation we are at increased risk of the cluster of conditions (The Western Cluster F*#%K we mentioned above).
Bigger issues we are seeing in our society today are pointing to a toxin overload or impaired metabolic detoxification (earlier puberty, fibroid, endometriosis, mood changes, PCOS, type 2 diabetes, obesity, infertility, and autoimmune disease all of which in my opinion have roots in environmental exposure).
To support detoxification we want to reduce environmental exposure (plastic, flame retardants, cosmetics, household cleaners, pesticides, etc), Consume foods that support detoxification as well as try to limit exposure to pesticides. Check out the environmental working group (EWG) to learn about the clean 15 and dirty dozen. Lastly, you may need to consider a botanical or antioxidant supportive detoxification program if detoxification is suspected to be significantly impaired.
Western women, and countries that have been heavily influenced dietarily and lifestyle from Western society, are experiencing what is known as the Western cluster F*&*%. Toxins that women are getting exposed to in my opinion are leading to everything from digestive, autoimmune, diabetes, obesity, CVD, and insulin resistance.
Insulin resistance is extremely common and continues to the development and/or worsening of many of the symptoms associated with the above conditions. The good news is with diet & lifestyle changes you can improve your insulin sensitivity and restore hormone balance & health!
Yours in health,
- Williams, Tracy, Rami Mortada, and Samuel Porter. “Diagnosis And Treatment Of Polycystic Ovary Syndrome”. Aafp.org. N.p., 2017. Web. 26 May 2017.
- Sirmans, Susan M., and Kristen A. Pate. “Epidemiology, diagnosis, and management of polycystic ovary syndrome.” Clinical epidemiology 6 (2014): 1.
- McLuskie, Isabel, and Aisha Newth. “New Diagnosis Of Polycystic Ovary Syndrome”. BMJ (2017): i6456. Web.
- Ahmadizad, Sajad, et al. “Effects of short-term nonperiodized, linear periodized and daily undulating periodized resistance training on plasma adiponectin, leptin and insulin resistance.” Clinical biochemistry 47.6 (2014): 417-422.
- Holten, Mads K., et al. “Strength training increases insulin-mediated glucose uptake, GLUT4 content, and insulin signaling in skeletal muscle in patients with type 2 diabetes.” Diabetes 53.2 (2004): 294-305.
- Ishii, Tomofusa, et al. “Resistance training improves insulin sensitivity in NIDDM subjects without altering maximal oxygen uptake.” Diabetes care 21.8 (1998): 1353-1355.
- Boden, Guenther, et al. “Effect of a low-carbohydrate diet on appetite, blood glucose levels, and insulin resistance in obese patients with type 2 diabetes.” Annals of internal medicine 142.6 (2005): 403-411.
- Sharman, Matthew J., et al. “A ketogenic diet favorably affects serum biomarkers for cardiovascular disease in normal-weight men.” The Journal of nutrition 132.7 (2002): 1879-1885.
- “Calcium And Magnesium In Drinking Water: Public Health Significance”. World Health Organization. N.p., 2009. Web. 26 May 2017.
- Venables, Michelle C., et al. “Green tea extract ingestion, fat oxidation, and glucose tolerance in healthy humans.” The American journal of clinical nutrition 87.3 (2008): 778-784.
- Pizzo, Alfonsa, Antonio Simone Laganà, and Luisa Barbaro. “Comparison between effects of myo-inositol and D-chiro-inositol on ovarian function and metabolic factors in women with PCOS.” Gynecological Endocrinology 30.3 (2014): 205-208.
- Pittler, M. H., C. Stevinson, and E. Ernst. “Chromium picolinate for reducing body weight: meta-analysis of randomized trials.” International journal of obesity 27.4 (2003): 522-529.
- Ismail, Alaa M., et al. “Adding l-carnitine to clomiphene resistant PCOS women improves the quality of ovulation and the pregnancy rate. A randomized clinical trial.” European Journal of Obstetrics & Gynecology and Reproductive Biology 180 (2014): 148-152.
- Kort, Daniel H., and Roger A. Lobo. “Preliminary evidence that cinnamon improves menstrual cyclicity in women with polycystic ovary syndrome: a randomized controlled trial.” American journal of obstetrics and gynecology 211.5 (2014): 487-e1.
- Chandola, Tarani, Eric Brunner, and Michael Marmot. “Chronic stress at work and the metabolic syndrome: prospective study.” Bmj 332.7540 (2006): 521-525.
- Chen, Jui-Tung, et al. “Maitake mushroom (Grifola frondosa) extract induces ovulation in patients with polycystic ovary syndrome: a possible monotherapy and a combination therapy after failure with first-line clomiphene citrate.” The Journal of Alternative and Complementary Medicine 16.12 (2010): 1295-1299.
- Cani, P. D., et al. “Role of gut microflora in the development of obesity and insulin resistance following high-fat diet feeding.” Pathologie Biologie 56.5 (2008): 305-309.