The True Underlying Factors of PCOS & What You Can Do About It
I have met too many frustrated women at my clinic in Sydney, who have struggled to find answers and adequate treatments for their hormonal imbalances and the array of side effects that come with the condition PCOS.
They have been told that the oral contraceptive pill (OCP) will treat this condition by ‘regulating’ their period, except that it does NOT regulate periods, it completely shuts down your ability to ovulate and produce hormones.
If this sounds like you, you’re in the right place
I am here to break down the confusion around the underlying causes of this condition and simple steps you can take to regain control of your hormones and your life.
Polycystic Ovarian Syndrome (PCOS) is the most common disorder of women of reproductive age: up to 18-20% of women are affected with an estimate of 400 000 Australian women having PCOS
The name ‘PCOS’ immediately suggests a condition where multiple cysts appearing on the ovaries must be the cause of hormonal imbalance in the body. This couldn’t be more wrong – It is a complex metabolic and endocrine disorder that appears to cause an abnormality in ovarian function, as opposed to the other way round, which its name may suggest
So what is wrong with this name and why should it be changed?
The term “polycystic ovary” is misleading – what appears to be many small cysts are in actual fact small antral follicles arrested part-way through the process of folliculogenesis – their growth and maturation have been inhibited and are not cysts. These are known as atretic follicles, an ovarian follicle in an undeveloped state, and can be viewed on the ovaries of almost all women who aren’t ovulating, regardless of the underlying cause.
It’s important to understand that PCOS is not a ‘disease’
It is a constellation of symptoms of which some women may present with particular symptoms but not others. It is a ‘syndrome’ and hence will affect each woman differently. It’s also important to understand that each woman will develop a varied set of symptoms in a variety of different ways.There is no one size fits all approach.
Some of the symptoms and related problems associated with PCOS include:
An irregular period or absent period (lack of ovulation)
Difficulty losing weight
Excess facial hair (hirsutism)
Excess hair on arms, legs and around nipples
Hair loss (male-pattern baldness)
Anxiety and depression
Difficulty falling pregnant
Discolouration/darkening of skin at neckline and under armpits
But you don’t have to have ALL of these symptoms or problems to be diagnosed with PCOS, nor does the appearance of multiple cysts on the ovaries indicate that you have PCOS.
Interestingly, The National Health Institute (NIH) classifies PCOS diagnosis by:
- Oligoanovulation (irregular periods)
- Elevated androgens
- Exclusion of other potential causes (thyroid diseases, Cushings syndrome, androgen-secreting tumours, hyperprolactinaemia)
It does not include ultrasound detection of cysts.
So what are the underlying causes PCOS?
The majority of women (at least 70%) with PCOS have insulin resistance, which is a primary cause of their metabolic and reproductive disorders. The causes of insulin resistance are complex and multi-factorial
Obesity is common in PCOS, often with a central distribution of adiposity. But you do not have to be overweight or obese to be insulin resistant – this appears to be influenced by intrinsic abnormalities of post-receptor insulin signalling, abnormal insulin secretion, or polymorphic genes controlling insulin action
Many women who have a thin appearance and are not overweight can have underlying insulin resistance driving PCOS. It is imperative to get testing to confirm if this is the case for you.
Insulin resistance plays a key role in driving elevated androgen levels (e.g. testosterone, DHEA), and it reduces sex-hormone-binding globulin (SHBG) directly and independently. Elevated androgens drive the production of inflammatory chemicals in the body (known as ‘cytokines’), which results in insulins resistance…and the vicious cycle continues.
>Insulin resistance > Elevated Androgens > Increased Inflammation > Repeat
Conventional medical management places a strong emphasis on pharmaceuticals which appear to be only moderately effective in treating individual symptoms. Pharmaceuticals are also frequently non-effective, have side effects and are contraindicated in some women with PCOS.
The most common conventional treatment for menstrual irregularity is the oral contraceptive pill (OCP), which suppresses ovulation and is merely a band-aid solution. In fact, the oral contraceptive pill actually worsens insulin resistance
Metformin is a drug associated with increased menstrual cyclicity, improved ovulation, and a reduction in circulating androgen levels. It improves insulin sensitivity and hyperandrogenism, but is commonly associated with side effects such as nausea, vomiting and gastro-intestinal disturbances
Galega officinalis (Goat’s Rue) is a herbal medicine that contains the active ingredient of the drug (Guanide) as well as chromium salts. The drug Metformin (biguanide) is a synthetic guanidine used in the treatment of insulin resistance
NATURAL TREATMENT STRATEGIES
- Addressing insulin resistance is imperative – until you find and treat the root cause of the many symptoms related to PCOS, nothing will change.
- If you take the oral contraceptive pill, your symptoms may improve but it is simply masking the cause while making it worse, and it will return. Dietary, lifestyle and targeted prescription strategies are all employed in natural medicine
- A smaller percentage of women who have PCOS are not insulin resistant, which is why you need to have the appropriate testing done to uncover what the cause of your symptoms are.
Reducing inflammation is a key treatment strategy
- PCOS is associated with elevations of C-reactive protein (CRP), a key marker of systemic inflammation, and is associated with other inflammatory chemicals in the body. Unsurprisingly, increased oxidative stress in women with PCOS has also been documented
- Treating the underlying inflammation and insulin resistance is crucial as this is what is impairing the ability of the ovaries to produce hormones and promote ovulation, as well as elevating ovarian and adrenal androgen levels.
- Another key treatment strategy is to restore a healthy gut microbiome and gut-wall integrity – when there is dysbiosis (microbial imbalance) in the gut, intestinal permeability can result with an increase of lipopolysaccharide into systemic circulation, which may be responsible for an increase in androgen production and altered follicle development
- A recent study assessed the diversity of bacteria in women diagnosed with PCOS – compared with controls, they had least bacterial diversity. Once again, gut health and microbiome restoration is crucial!
- Dysbiosis and lack of microbial diversity may be one of the sources of underlying inflammation that needs to be addressed.
ACTION PLAN – WHAT YOU CAN DO NOW
1. Testing – it is important to get appropriate pathology completed to understand what the cause of your PCOS is so treatment can be clearly outlined (and to find out if you even have PCOS) – although most women have insulin resistance, some women do not.
- Glucose Tolerance Test (GTT)
- Fasting Insulin
- Testosterone + DHEA (usually elevated)
- Sex Hormone Binding Globulin (SHBG) (usually low)
- Luteinizing hormome (LH) (usually elevated)
- Follicle-stimulating hormone (FSH) – (often normal or low)
- ALT (liver enzyme) – can be elevated in PCOS
- C-reactive Protein (CRP) – marker of chronic inflammation
- Vitamin D – low levels can sustain insulin resistanc
There are many other tests that may be appropriate, but these are the relevant ones for uncovering PCOS and what your underlying causes are. Your GP or naturopath can order these and other testing for you.
2. Address Dietary Factors & Nutritional Deficiencies:
A Low GI/Low Carb Diet is often a popular approach to PCOS because of the insulin resistance factor. I agree with this recommendation but tell my clients not to fear carbs all together: carbohydrates from 1-2 pieces of whole fruit per day, sweet potatoes, brown rice and other starch + non-starch vegetables are fantastic nutrient-dense foods that should be included in your diet regularly alongside adequate protein and healthy-fats.
The carbs that SHOULD be avoided are highly concentrated sources of fructose:
- Dried fruit (INCLUDING dates – watch out for those bliss balls or ‘protein’ balls)
- Table sugar
- Corn Syrup
- Hidden sugars in foods such as yoghurts & muesli bars – check your labels, Sugar is hidden in almost all packaged foods! Especially many of the ‘health-food’ bars
An anti-inflammatory diet should generally be well rounded with plenty of fresh vegetables and fruit, whole-grains and legumes (great prebiotic foods), nuts and seeds, herbs and spices, lean protein, fish, and other sources of essential fatty acids (e.g. avocado, olive oil, macadamia oil, coconut oil, organic grass-fed butter, tahini). It is important to avoid inflammatory-fats from heated vegetable oils and trans-fats including:
- Safflower Oil
- Corn Oil
- Sunflower Oil
- Grapeseed Oi
- lSoybean Oil
If your periods are heavy and/or painful, I would suggest not eating any cows dairy as the A1 casein can drive inflammation and symptoms. Goat and sheep dairy contains a different A2 casein that does not drive inflammatory symptoms, so replacing cows dairy with these sources is highly advisable.
The best way to effectively and pro-actively work on modifying your diet is by completing a diet diary and having it reviewed and modified by your nutritionist or naturopath according to your individual needs.
Unless you have renal failure, Magnesium is a superstar mineral that should be a priority for supplementation (it should really be in the water supply) – deficiency is very common and is important for sensitising to insulin, normalising stress hormones, reducing sugar cravings, and helping with sleep quality. The best forms come in a glycinate, citrate and amino acid chelate form, doses should be between 200-600mg/day (caution with higher doses if prone to looser bowel movements).
Zinc is another important mineral as it has androgen receptor blocking effects, helps acne symptoms, promotes ovulation and like magnesuim is depleted during episodes of high stress. It is also heavily depleted by the oral contraceptive pill, and primarily obtained from red meat and animal products – those of you on a vegetarian or vegan diet may especially need to supplement with zinc for a period of time. Zinc needs to be in a delicate ratio with Copper – although most people do well taking zinc, it should not be taken indefinitely and can be tested for alongside copper levels with your GP or naturopath. Dosages can range from 10-50mg, although should be prescribed and dosed by your practitioner.
Dietary modification, magnesium and zinc uptake are crucial elements to any PCOS treatment plan, because until you correct major nutritional deficiencies and dietary modifications, nothing else will work properly.
Once you have addressed all of the crucial factors above, additional treatments can proceed according to your individual needs, many of which may include:
- Berberine – a plant constituent present in herbs such as Phellodendron amurense and Hydrastis canadensis
- Alpha-Lipoic-Acid (ALA)
- N-Acetyl-Cysteine (NAC)
- Glycyrrhiza glabra & Paeonia lacteriflora
- Vitamin D
These should be prescribed by your practitioner on an individualized basis, according to your particular needs. The clinical reality is that no treatment plan will be strictly protocol driven – everyone present so uniquely, there may be other treatments prescribed that seem unrelated to a PCOS diagnosis but are important for your particular holistic treatment plan.
3. Stress Management – stress, emotional disturbances and related psychiatric conditions wreak havoc on female reproductive physiology. If you are chronically stressed and not getting quality sleep, this is basically another signal from the body to shut down ovulation and prevent the implantation of an embryo. Incorporating techniques into your lifestyle have a dramatically beneficial impact on overall health
Meditation & Mindfulness Practises – these can be overwhelming if you’ve never delved into them. There are many great apps around now, I usually recommend…
Insight Timer – a free app with a huge library of guided meditations with a variety of themes, and a platform to connect with other meditators around the globe.
MBSR Workbook is another fantastic resource for learning how to incorporate mindfulness into your every day life. You can join many different public facebook groups for open discussion on meditation and mindfulness inspiration, and are usually abundant with many different resources.
Yoga – a fantastic tool to incorporate into your lifestyle – on a physical level the ultimate goal of yoga is to shift our nervous system into the parasympathetic ‘rest and digest’ state, so that the body can function optimally. There are an array of benefits to a consistent yoga practise on a physical mental, emotional and spiritual level which are so condusive to healing. Yin-yoga is an especially restorative style of yoga. Check out your local studios today, where you can usually sign up to an unlimited monthly pass for a discounted price. Talk with your local instructors about breathing and meditation techniques for home – yoga instructors are a great source of knowledge and inspiration
Counselling & Psychotherapy – hormonal conditions can understandably take their toll and your emotional and mental health. Finding a qualified professional to help you through your struggles, learn about yourself and practise healthy coping mechanisms can be a great source of relief.
4. Take the next step! As a clinical naturopath my clinic in Surry Hills (Sydney) offersw holistic treatment plans and thorough investigation of a range of hormonal conditions including PCOS
I have successfully helped many women struggling with PCOS – Combining the practises of functional + integrative medicine and the philosophies of naturopathic medicine, we can get to the root cause of your PCOS and create in individualised plan to treat PCOS properly.
A final word on PCOS:
The name of this condition and its diagnostic prerequisites will probably be modified in the future because of the great variation in severity of symptomatology and the fact that it is an indistinct syndrome – in 2013 an independent panel convened by the National Institutes of Health (NIH) recommended assigning a new name for the disorder that more accurately reflects the complex metabolic, hypothalamic, pituitary, ovarian and adrenal interactions that characterise the syndrome. The name “polycystic ovary syndrome” is perceived as confusing by primary care physicians as well as women affected by it, and there is much support for a change to reflect the broader clinical syndrome
I wonder what it will be?
Yours in health,
Wholistic Medical Centre (Surry Hills)