Polycystic Ovarian Syndrome (PCOS)

Polycystic Ovarian Syndrome (PCOS) is the most common endocrine disorder in women of reproductive age, affecting approximately 5-10% of this population. The presentation can vary from person to person and there are many underlying factors that can contribute to PCOS symptoms. Treatment options will vary depending on the individual, so it is best to work with a practitioner to get the proper testing and to determine a treatment plan that is best for you.

How do you diagnose PCOS?

The diagnostic criteria, known as the Rotterdam criteria suggests a diagnosis if 2 or more of the following are present:

• Amenorrhea or oligomenorrhea
  • Amenorrhea: the absence of a menstrual cycle for at least 3 months.
  • Oligomenorrhea: irregular menstrual cycles that are longer than 35 days. This means there are 35 or more days from day 1 of your period until your next period begins.
• Hyperandrogenism (elevated androgens) – this can be biological or clinical
  • biological: increased androgens on blood testing, such as testosterone, DHEA-S or androstenedione
  • clinical: having symptoms associated with increased androgens such as acne, oily skin, hair loss on the scalp or hirsutism (course hair growth in areas such as the face, between the breasts, on the abdomen or inner thighs).
• Polycystic ovaries on transvaginal ultrasound – It is normal to have multiples follicles growing in the ovary at one time. Polycystic ovaries are typically characterized by 12 follicles per ovary. However due to advancements in technology, we often use 25 follicles or an ovarian volume of 10mL or more. 
  • the cysts in polycystic ovarian syndrome are not true cysts, they are immature follicles. 

Because only two of these criteria are required in order to be diagnosed with PCOS, there are several combinations that can occur. For example, you can have Ovulatory PCOS in which you have regular menstrual cycles, but have symptoms of hyperandrogenism and have confirmed polycystic ovaries. Another example includes Non-Polycystic Ovaries in which there is abnormal menstrual cycles and hyperandrogenism, but no confirmed cysts on the ovaries. Therefore, you are able to meet the criteria of Polycystic Ovarian Syndrome without having polycystic ovaries.

What are the symptoms of PCOS?

It used to be thought that there was a specific phenotype for PCOS that included symptoms such as obesity, abnormal hair growth, acne and male-pattern baldness. However, today there are many presentations of PCOS which may include all or very few of these characteristics. Some of the common symptoms of PCOS include:

• irregular or absent menstrual cycles
• acne
• oily skin
• weight gain or difficulty losing weight
• hirsutism – abnormal thick hair growth in areas of the body which may include the chin, neck, abdomen, chest, back, inner thighs and hands
• hair loss on the scalp, particularly in the frontal and temporal areas
• acanthosis nigricans – dark patches of skin in the armpits, on the neck or between the breasts
• skin tags
• anxiety
• depression
• infertility or difficulties conceiving 

The “cysts” that are often visualized in PCOS aren’t actually fluid filled cysts, but are rather clusters of immature follicles in the ovary. In a normal cycle, each month there are follicles that develop, grow and mature. The dominant follicle contains the egg that is ovulated and is either fertilized or shed through the menstrual cycle. Since the follicles never fully develop in PCOS, ovulation often does not occur and therefore fertility may be a challenge that is faced. However, you CAN get pregnant with PCOS – you may just need additional support to encourage ovulation. 

What are the common causes of PCOS?

Insulin Resistance

One of the most common underlying factors that drives PCOS is insulin resistance. This occurs when our cells are not as sensitive to insulin as they should be.

Normally, when we eat carbohydrates our body breaks them down into glucose, or sugar, molecules. In order to move sugar out of the bloodstream and into the cells for energy, insulin must be present. When insulin binds to its receptor, it basically opens a door for glucose to enter the cell. In insulin resistance, the receptors for insulin are not very sensitive so glucose cannot enter efficiently. This leads to elevated blood glucose, similar to what is seen in diabetes. Our pancreas pumps out more insulin to deal with this glucose, which results in elevated insulin in the blood as well.

Insulin resistance contributes to elevated triglycerides, cortisol and inflammation.  There is also an increased risk for cardiovascular disease and type 2 diabetes.  Additionally, elevated insulin can directly inhibit ovulation and causes the ovaries to produce more androgens. 

Signs of insulin resistance

• skin tags
• acanthosis nigricans – dark patches of skin on the back of the neck or under arms
• weight gain or difficulty losing weight
• feeling shaky or light-headed if you skip a meal

Adrenal dysfunction

Our adrenal glands are two small glands that sit on top of our kidneys. They secrete a hormone called cortisol in response to stress. With todays busy and lifestyle, our adrenal glands are constantly pumping out cortisol to deal with every day stressors. Eventually, this can lead to adrenal dysfunction where we end up with elevated, or tanked cortisol levels.

Cortisol is an important survival hormone. In primitive times when we were stressed or had to run from a threat, our adrenal glands would secrete cortisol. This causes glucose to be dumped into the bloodstream for energy to escape from the threat. Today, our stress looks quite different – maybe it’s traffic, our job, finances, intense exercise or fasting. However, our body still responds the same way: increases cortisol and blood glucose.

Because we are not utilizing this excess blood sugar, it is stored as glycogen in the liver so we can break it down later. When these stores are full, it is stored as fat. This can lead to elevated triglycerides and inflammation. As insulin is required to deal with excess blood glucose, over time high cortisol can also lead to insulin resistance.

Inflammation

A common finding in PCOS is chronic low grade inflammation. This is different than acute inflammation such as a hurt elbow, that gets red and inflamed. In chronic inflammation, we often don’t experience obvious symptoms but it can have huge consequences long term.

In PCOS, inflammation contributes to androgen production and insulin resistance. On the other hand, elevated androgens, adrenal dysfunction and insulin resistance can all contribute to inflammation – so PCOS is often a vicious cycle where there is more than one underlying factor involved.

A common source of inflammation is gut dysfunction. It is important to rule out gut dysbiosis, food sensitivities and improve the overall health of our gut when treating PCOS. Diet is foundational here.

Hormonal imbalances

This is a common finding in PCOS, however our hormones are often influenced by other driving factors such as inflammation, insulin resistance and adrenal dysfunction.

In many cases there are elevated androgens, such as testosterone and DHEA, due to increased production from the ovaries and adrenals. Insulin resistance also drives this production. This may contribute to symptoms of acne, oily skin, hirsutism (abnormal hair growth) and hair loss.

Progesterone is often low in PCOS due to anovulation. Because progesterone is secreted from the empty follicle (corpus luteum) after ovulation, we must ovulate in order to have adequate progesterone. In PCOS, ovulation is often irregular which leads to low levels of progesterone.

LH (luteinizing hormone) and FSH (follicle stimulating hormone) are two hormones that are commonly tested in PCOS. They are secreted from the anterior pituitary, and signal to the ovaries. FSH is important for the growth and maturation of follicles, where one follicle holds the egg to be ovulated. LH is important for triggering ovulation. Often times LH is 2-3x higher than FSH, and this is seen on blood work. This is due to an altered pulsation of GnRH (gonadotropin releasing hormone) from the hypothalamus in the brain. The pulsations are often fast, which favors LH secretion. Therefore, the follicles often remain immature and ovulation doesn’t take place. This leads to multiple follicles on ultrasound, or “polycystic ovaries”.

A note on endometrial hyperplasia

A risk factor that should be taken into consideration in patients with PCOS is endometrial hyperplasia.. With delayed or absent periods, the uterine lining continues to build but is never shed. After several months there is an increased risk for abnormal cellular growth and potentially endometrial cancer. It is important to have a period every 3 months to reduce this risk. While working on underlying causes of menstrual cycle dysfunction, a drug-induced cycle using synthetic progesterone (often called Provera) may be recommended by your doctor.

Treatment options for PCOS

The conventional treatment options for PCOS often include metformin, the birth control pill or androgen reducing drugs such as spironolactone. These options are helpful and work well for improving insulin resistance, ovulation and lowering androgens but they often come with unwanted side effects. 

There are many naturopathic treatment options that have shown to be successful and comparable to certain drugs for PCOS. This may include:

• Myo-inositol – this is a powdered supplement that is added to water daily. It can improve ovulation, insulin resistance and egg quality. Myo-inositol has been found to be comparable to Metformin at improving insulin sensitivity and menstrual cycle length, but with less side effects ^1,2.
• N-acetyl cysteine (NAC) – NAC is a precursor to glutathione, which is an important antioxidant in PCOS. Studies have shown that NAC is comparable to Metformin at improving insulin resistance, menstrual regularity, lipid profiles, androgen levels and egg quality ^3,4,5. For more information on n-acetylcysteine and PCOS, read this blog post.
• Vitamin D – many people living in North America are deficient in Vitamin D. Low levels are associated with inflammation and hormone dysfunction. Studies have found that vitamin D is crucial for ovulation, implantation and reducing the risk of miscarriage ^6,7,8.
• Diet
  • a low glycemic diet is beneficial in PCOS patients because it helps to control blood glucose levels, which is important when there is insulin resistance or insensitivity. 
  • Reduce added sugars – refined sugars such as white or brown sugar as well as natural sugars such as maple syrup, honey, agave, coconut sugar should all be minimized. These all affect our blood sugar and insulin in similar ways. Of course, it is best to choose a more natural option when necessary, but reduction is key.
  • Reduce processed foods or refined carbohydrates – avoid anything that comes in a package or has a long list of ingredients. Foods such as store bought breads, pasta, muffins, cookies, baked goods, white rice should all be minimized.  Focus on carbohydrates from vegetables and fruit, sweet potato, quinoa, brown rice etc.
  • Include healthy fats – fats are important for hormone production and blood sugar regulation. Include foods such as coconut oil, avocados, nuts and seeds, eggs, olive oil and cold water fish such as salmon.
  • Vegetables – this should be at least half of your plate. Aim for lots of green leafy veggies. The more colors the better!
  • Fruit – try to focus on low glycemic fruit such as berries rather than sweeter fruit such as grapes or pineapple. Choose whole fruit over fruit juices as fibre in whole fruit helps to stabilize blood sugar.
  • Lean protein – chicken, turkey, fish or legumes will help keep blood sugar levels stable. Aim to have healthy fat and protein at each meal.
  • Reduce dairy – this is especially important if you are prone to acne. Dairy stimulate insulin and increases sebum production. Try alternatives such as unsweetened nut, soy or oat milk rather than cows milk. 
• Spearmint tea  – one study found that consuming 2 cups of spearmint tea per day for 30 days reduced androgen levels in PCOS patients. This can support reducing symptoms such has acne, hair growth on the body or hair loss on the scalp⁹.
• Exercise – moderate intensity physical activity can improve insulin resistance, assist in weight loss, improve ovulation and elevate mood. 

Overall thoughts

PCOS is a very complex condition that can manifest differently in every individual. Often times there are many underlying causes present, as one imbalance can contribute to another.

PCOS can have a significant impact on mental health and self-confidence. You are not alone if you are dealing with this. There are so many options to help improve your symptoms.

It is important to seek appropriate care from your medical doctor and naturopathic doctor in order to receive proper testing and a treatment protocol that is specific to you. If you have any questions or would like to work together to resolve your symptoms, feel free to reach out – I’d be happy to help!

Dr. Gina Neonakis, ND

References

1. Pundir J, Psaroudakis D, Savnur P, Bhide P, Sabatini L, Teede H, et al. Inositol treatment of anovulation in women with polycystic ovary syndrome: a meta-analysis of randomised trials. BJOG: An International Journal of Obstetrics & Gynaecology 2017;125:299–308.
2. Fruzzetti F, Perini D, Russo M, Bucci F, Gadducci A. Comparison of two insulin sensitizers, metformin and myo-inositol, in women with polycystic ovary syndrome (PCOS). Gynecological Endocrinology 2016;33:39–42.
3. Javanmanesh, F., Kashanian, M., Rahimi, M., & Sheikhansari, N. (2015). A comparison between the effects of metformin andN-acetyl cysteine (NAC) on some metabolic and endocrine characteristics of women with polycystic ovary syndrome. Gynecological Endocrinology, 32(4), 285-289.
4. Oner, G., & Muderris, I. I. (2011). Clinical, endocrine and metabolic effects of metformin vs N-acetyl-cysteine in women with polycystic ovary syndrome. European Journal of Obstetrics & Gynecology and Reproductive Biology, 159(1), 127-131.
5. Cheraghi E, Mehranjani MS, Shariatzadeh MA, Esfahani MHN, Ebrahimi Z. N-Acetylcysteine improves oocyte and embryo quality in polycystic ovary syndrome patients undergoing intracytoplasmic sperm injection: an alternative to metformin. Reproduction, Fertility and Development 2016;28:723.
6. Li N, Wu H, Hang F, Zhang Y, Li M. Women with recurrent spontaneous abortion have decreased 25(OH) vitamin D and VDR at the fetal-maternal interface. Brazilian Journal of Medical and Biological Research 2017;50.
7. Bärebring L, Bullarbo M, Glantz A, Hulthén L, Ellis J, Jagner Å, et al. Trajectory of vitamin D status during pregnancy in relation to neonatal birth size and fetal survival: a prospective cohort study. BMC Pregnancy and Childbirth 2018;18
8. Pal L, Zhang H, Williams J, Santoro NF, Diamond MP, Schlaff WD, et al. Vitamin D Status Relates to Reproductive Outcome in Women With Polycystic Ovary Syndrome: Secondary Analysis of a Multicenter Randomized Controlled Trial. The Journal of Clinical Endocrinology & Metabolism 2016;101:3027–35.
9. Grant, P. (2009). Spearmint herbal tea has significant anti-androgen effects in polycystic ovarian syndrome. a randomized controlled trial. Phytotherapy Research.