Brandi is a bubbly, successful 34-year-old gallery owner who recently married her college sweetheart, and is hoping to start a family soon. She’s been reading all the books about preparing for a healthy pregnancy and feels like she’s done her best to improve her diet, add some exercise to her life, and start a prenatal vitamin. She’d been on birth control pills since her teens, but stopped them a year ago because she was having migraines. Since then, she’s been practicing natural family planning to prevent pregnancy until she’s ready to conceive, but something is missing – her periods. She’s had two or three menstrual bleeds in the past year, but they’ve been abnormally light and haven’t come at any sort of regular interval. She came to see me to discuss more natural ways to regulate her period so that she could increase her chances of conceiving.
Brandi’s story is a common one. So many women, both in my practice and around the country, were started on birth control pills in their teens to “regulate their cycles” and stayed on them through their teens, twenties, and into their thirties. And while birth control pills certainly play an important role in pregnancy prevention, they are often prescribed as a band-aid for irregular periods in lieu of doing a workup for root causes of hormonal imbalances.
What causes irregular periods?
There are loads of reasons why a woman might have irregular periods. Most of the time in the teen years, it’s what we call an immature HPO axis (HPO = hypothalamus-pituitary-ovary). This means that the brain and the ovaries aren’t quite dancing in sync yet. They are learning to communicate but still stepping one another’s feet. In time, and with lots of practice, their dance becomes fluid and rhythmic.
Other times, irregular periods are due to thyroid issues, being underweight, having a pituitary tumor, adrenal dysfunction or over-exercising. Coming off of birth control alone can cause a prolonged delay in returning to normal menstruation.
In Brandi’s case, after taking a thorough history and checking some basic labs, it was clear that her period irregularity was due to something else altogether: polycystic ovary syndrome (PCOS). So what does this mean and how do we fix it? And where did it come from in the first place? Let’s start to unpack this incredibly common condition.
What is PCOS?
Anytime something in medicine is called a “syndrome” it means that a constellation of symptoms make up the diagnosis. Not all symptoms have to be present for the diagnosis to be made, and we don’t always fully know the cause of the syndrome (irritable bowel syndrome and premenstrual syndrome are other good examples of other medical syndromes).
PCOS is characterized by several metabolic and hormonal symptoms that are consistent with the production of elevated levels of androgens (the family of hormones that includes testosterone). Symptoms may include:
- Excess hair growth, especially on the face, chin, chest, around nipples, or abdomen
- Hair loss in the front of the hairline (“male pattern”)
- Irregular periods, which may mean periods that come infrequently or very heavy menstrual bleeding
Interestingly, despite the name POLYCYSTIC OVARY syndrome, not all women with PCOS have cysts on their ovaries. Ovarian cysts are a common result of irregular periods but some women with PCOS do not have them. The flip side of this is that not all women with cysts on their ovaries have PCOS. Confusing? You bet. It’s even confusing for medical practitioners, and PCOS is often misdiagnosed as a result.
To help make things a little bit clearer, medical practitioners use various criteria to diagnose PCOS. While several criteria exist, the most widely used is called the Rotterdam Criteria, named after the city in which it was developed in 2003. According to the Rotterdam Criteria, PCOS is diagnosed when two out of the following three criteria are met:
- Absent or infrequent periods
- Signs of androgen excess (either via blood testing or on physical exam – like acne, excess hair growth)
- Ovaries with lots of cysts seen on ultrasound
In Brandi’s case, she had 3 periods over a 12 month span, which meets the definition of infrequent periods. When I took her history, she said that she started shaving her chin when she was in her teens because she had some hair growth there. She never told anyone about this because she was embarrassed. As an adult, she had electronic hair removal performed on this area, as well as on her abdomen – she had a thin vertical line of hair that grew between her belly button and her pubic bone. No one had ever told her that this hair growth could be from a hormonal imbalance. She thought it was just hereditary. When we checked Brandi’s labs, she had elevated free and total testosterone. Her insulin was also slightly elevated (which we’ll talk about soon). She didn’t have any other biochemical markers that would explain her symptoms. She had had a pelvic ultrasound a few months prior at her OB-GYN’s office and was told that it was normal.
What causes PCOS?
As with many medical syndromes, the exact cause of PCOS is not fully understood. There are many factors that are associated with PCOS, and that we believe are causative, but it’s not quite as simple as saying that X causes Z. We do know that women with PCOS experience metabolic changes in their bodies that manifest as hormonal imbalances. Because of this, it has been suggested that we change the name from PCOS to “Metabolic Reproductive Syndrome”. So far this hasn’t taken off, but maybe someday we’ll be talking about MRS, not PCOS.
Here’s an overview of the root causes associated with PCOS:
- Insulin resistance: Insulin is a hormone that acts as the key that opens the door to shuttle glucose into our cells. Glucose is meant to be inside of our cells, used for energy production. When glucose is left outside of cells, it has the potential to cause harm to our organs and nerves (like it does in uncontrolled diabetes). Insulin levels rise in the presence of glucose so that doors can be opened to get the glucose where it belongs. However, in both diabetes/pre-diabetes and PCOS, cells become resistant to all of the insulin being pumped out. Imagine a child, eyes closed and hands over ears, saying “lalalalalalalala” as his mom tells him for the fifth time to eat his Brussels sprouts. That’s sort of what insulin resistant cells are doing. Insulin resistance causes glucose levels to remain high in the bloodstream, and in addition, insulin levels themselves are elevated. It’s this high insulin that is believed to be at the root of PCOS symptoms. Excess insulin sends signals to the ovaries to crank out extra testosterone, and thus begins the cascade of PCOS symptoms. Insulin also lowers levels of a protein called sex hormone binding globulin, and this increases testosterone levels, too. Yet, not all women with PCOS develop diabetes or pre-diabetes (although they are higher risk for both). It seems that women with PCOS are less efficient at clearing away the excess insulin than their counterparts with prediabetes, and we think that this may be a differentiating factor between PCOS and other insulin resistance syndromes (1).
- Genetic factors: PCOS seems to cluster in families, meaning that women with PCOS are more likely to have female relatives who also have PCOS. While we don’t know exactly which genes are responsible for this, there are many genetic markers which seem to be associated with PCOS symptoms. Here is a link to a good review article of these genes if you’re interested in geeking out a little. Most of these genes are involved in how hormones are made in the ovaries and adrenal glands, or how hormones are regulated in our bodies. Genetic variations in these genes often result in overproduction of testosterone, which results in the PCOS picture.
- Environmental factors: It’s well established that many of the chemicals that we get exposed to on a daily basis are detrimental to our hormones. We call these chemicals endocrine disrupting chemicals (EDCs) because they get into our bloodstream and either act like hormones or disrupt the natural balance of our own hormone production, leading to hormone-related cancers and hormone conditions like PCOS (2, 3). Where do these chemicals come from? Here’s a short list: plastics, household cleaning products, the makeup and skincare that we put on our bodies, nonstick cookware, and even our drinking water. Scary stuff. While it’s almost impossible to avoid all EDCs, we can do our best to reduce our exposure by being educated about where they are hiding and what safer alternatives exist. The Environmental Working Group has a great guide to EDCs that you can access here. They also have a super helpful website for finding safer skincare products. Beautycounter is my go-to for safer skincare and cleaner cosmetics. I use their products confidently, knowing that what I’m putting on my skin isn’t going to mess with my hormones!
- Weight: Carrying excess weight is a risk factor for PCOS, due to insulin resistance that can accompany excess glucose consumption. Healthy weight loss can reverse PCOS in overweight women and is a first line intervention in any solid PCOS treatment plan. Many people assume that lean women can’t get PCOS, since insulin resistance is generally considered to be a condition of glucose excess and obesity. As a result, lean women are often misdiagnosed with other conditions, and it may take longer for a lean woman to be given a diagnosis of PCOS because her medical providers think that PCOS can’t affect someone who isn’t overweight. This couldn’t be further from the truth. In fact, about 20% of PCOS sufferers are not obese, suggesting that the underlying mechanism of insulin resistance is not always weight related. So why do lean women get PCOS? We’re not entirely sure. We think that the underlying mechanism is still insulin resistance, but it may be more related to genetic factors or weight distribution rather than overall weight. Lean women with more visceral fat (fat on the inside of our bodies around our organs) and more belly fat are more likely to have PCOS (4,5). For these women, dietary changes are still important in order to normalize insulin levels and decrease visceral and belly fat.
- Gut health: The connection between our gut microbiome (the collection of helpful bacteria and other organisms that inhabit our GI tract) and our hormones is complex, but the more we learn about the microbiome, the more we understand about the role it plays in hormonal balance. PCOS is no exception to this. Overgrowth of harmful bacteria and a lack of good bacteria has been correlated with PCOS (6). Women with PCOS have different bacterial profiles in their microbiome, including higher levels of certain bacteria and lower levels of others (7). Several studies have found connections between health of the gut lining and PCOS, suggesting that women with PCOS have alterations in their gut barrier function (8,9).
How do we treat PCOS?
Conventional treatments for PCOS involve birth control pills to make periods more regular and insulin sensitizing medications like metformin. Some women are put on androgen lowering medications like spironolactone, especially if excess hair growth is a concern. While these interventions may be safe and helpful for some women with PCOS, many women seek other options when it comes to balancing their hormones.
In my practice, I aim to get to the root cause of my patients’ concerns. That means digging deep to find what is truly going on “under the hood” and suggesting interventions that aim to heal, not just cover up symptoms. As with any medical condition, it’s important to find a treatment plan that feels right for you – that may involve pharmaceuticals, and it may not. Finding a provider who is willing to work with you and discuss your options is the first step. There are, in fact, many ways to improve or even reverse PCOS that don’t involve pharmaceuticals. We’ll review them here. Remember that before starting any supplements or drastic dietary changes you should consult with a qualified medical provider to make sure that you’re making a safe decision.
Here are my root-cause resolutions for PCOS. For a handy PDF “Root Cause Rez Toolkit,” click here.
- Use food as medicine: Dietary changes are the first intervention I utilize in just about every medical condition that I treat in my practice. It’s wildly true that food can be either medicine or poison for our bodies, and it’s amazing to see what improves when nutrition is optimized. For PCOS, the main dietary agenda is to decrease blood glucose in order to improve insulin sensitivity. This means ditching the sweets and refined carbohydrates and transitioning to a diet that includes lots of nourishing veggies, healthy fats, and lean proteins. For simplicity’s sake, this looks a lot like a Paleo or Pegan type of nutrition plan. Although ketogenic diets are trendy and may have some benefit in PCOS, I don’t recommend following a ketogenic nutrition plan unless you have already optimized your diet and have someone to guide you through doing “keto” correctly. I feel the same way about intermittent fasting, which involves restricting the time periods in which you eat. There is great data about how intermittent fasting can improve insulin resistance (10), but this is more of an advanced dietary approach and isn’t usually the best first step. Further, there haven’t been a ton of studies looking at intermittent fasting and PCOS (yet), so we still don’t truly know if it is a beneficial tool. Instead of getting caught up in current nutritional buzzwords and trends, focus on transitioning to a real, whole foods diet and eating consistently.
In general, a PCOS friendly “diet” looks something like this:
- An abundance of vegetables, at least two servings at each meal.
- Inclusion of cruciferous veggies like broccoli, cauliflower, cabbage, bok choy, brussels sprouts, kale and collard greens for optimal hormone detoxification.
- Lean protein at each meal – eggs, fish, poultry, grass-fed beef, legumes.
- Healthy fats like olive oil, olives, avocados, nuts, and seeds.
- Complex, plant based carbohydrates like sweet potatoes, winter squashes, and root veggies, or whole grains if tolerated; keep servings moderate (about ½ cup per serving) and limited to one or two servings per day.
- Eat at regular intervals throughout the day to keep blood sugar balanced, and include healthy snacks if needed based on hunger cues.
I’ve created a handy PCOS meal plan which is yours FREE. Click here to download. It includes a full week’s worth of healthy, hormone balancing meals and snacks so you can see just how healthy and delicious life can be.
- Ditch the dairy: Conventional dairy is often contaminated with hormones which may affect our own hormone levels. Studies have found correlations with milk intake and PCOS (11). Decreasing dietary dairy may promote weight loss, improvements in insulin sensitivity, and decreased testosterone levels in women with PCOS, especially when coupled with lower carbohydrate dietary plans (12). For women suffering with acne as part of their PCOS, removing dairy may provide additional benefit, since dairy has been associated with acne (13).
- Get moving: Exercise is a well-known way to improve insulin sensitivity and optimize body composition. Find an activity that you love, and stick with it! We are lucky to have exercise gurus literally at our fingertips – there are an abundance of apps, YouTube channels, and podcasts to guide you through at-home workouts. If exercising with others is more motivating for you (like it is for me!) consider joining a gym that has group classes, or doing a trial run of group based fitness like kickboxing, Crossfit, Orange Theory, spinning, ballroom dancing, or whatever lights you up.
- Supplement smartly: Several supplements have been shown to improve insulin sensitivity in women with PCOS and may be an option for some women instead of (or in addition to) insulin sensitizing medications.
Inositol: Inositol is a signalling molecule that is involved in insulin sensitivity. Taken orally, it has been shown to be as effective as the drug Metformin in improving insulin sensitivity in women with PCOS (14).
Berberine: Berberine is a plant derived compound which is also effective at improving insulin sensitivity. In a Chinese study that compared women with PCOS taking berberine with those taking metformin, the women in the berberine group experienced greater improvements in body composition changes as well as cholesterol parameters. Compared to the placebo group, the women on berberine had improved insulin sensitivity (15). A recent meta-analysis found that berberine may be as effective as Metformin at alleviating insulin resistance (16).
Cinnamon: Yes, cinnamon! Cinnamon may help to decrease fasting insulin and insulin resistance in women with PCOS (17). The dose of insulin used in these studies is much higher than the cinnamon you might sprinkle onto your food, but it doesn’t mean that you shouldn’t use cinnamon in your culinary creations. To get clinical improvements, a high potency dose in capsule form is used.
NAC: N-acetyl cysteine is an amino acid which is an important part of our antioxidant system, serving as a precursor to our master antioxidant, glutathione. Supplementation with NAC has been shown to increase ovulation and pregnancy rates and in women with PCOS (18). It has also been shown to improve lipid parameters, fasting blood glucose, and fasting insulin in women with PCOS (19).
Not all women need to take all of these supplements. Choosing which products and which doses are best for you can be tricky, so I recommend working with a practitioner trained in integrative medicine to guide you. For suggested doses of these products, download my Root Cause Rez Toolkit HERE.
What did Brandi do?
Brandi opted to start a low dose of the insulin-sensitizing medication called metformin while she took some time to improve her diet and start her supplements. She realized that a lot of the “healthy” foods she had been eating were actually really high in sugar – flavored Greek yogurt (15g of sugar per serving!), her protein bars (12g of sugar per bar!), and organic granola were the biggest culprits. We got her eating more vegetables, lean proteins, and healthy fats. She started inositol and NAC, in addition to her prenatal vitamin and some omega 3 fatty acids. She kept up her exercise and even increased her frequency because she enjoyed it so much. Within three months, she was having a regular, monthly period and she had lost about five pounds of fat. When we checked her body composition on the InBody scanner in my office, she had also gained two pounds of muscle. When we repeated her labs, her insulin was down and her testosterone levels were in the normal range! She pulled off of the metformin and has maintained these levels with ongoing nutrition and supplementation. She’s planning to start to try to conceive next month and I can’t wait to hear her good news!
If you have PCOS, or think you may have PCOS, I urge you to find a practitioner who will listen to you and help you come up with a comprehensive plan to optimize your hormones and your health. You have the power to change your hormones and live your best life! Want to work with me? Click here to contact my office!