Polycystic Ovarian Syndrome (PCOS) is common with as many as 1 in every 10 females experiencing it along with subsequent weight gain that is stubbornly resistant to all efforts. It results from an over-production of male hormones (androgens), and a flow on problem with ovulation. This results in an overproduction of androgens (male hormones) like testosterone, androstenedione and DHEAS, and minimal progesterone from the lack of ovulation.
Elevated androgens is what classifies you as having PCOS
Weight Gain is a Symptom of PCOS
The main symptoms of PCOS are from excess androgens (male hormones) and include:
Weight gain
Irregular menstrual periods
Excess facial hair that is long and dark
Body hair where hair normally doesn't grow (chin, cheeks, nipples, belly)
Thinning hair, or head hair loss where hair should be (male pattern hair loss)
Acne on the lower face like chin, jawline and upper neck
Difficulty falling pregnant (if trying to conceive) due to ovulation issues. Ovulation dysfunction is one of the major causes of infertility and drivers behind couples seeking IVF treatment.
4 Causes of PCOS and Weight Gain Link
The cause of PCOS comes from four (4) different sources. The cause of PCOS must be identified to effectively treat PCOS.
Remember, to start it must be identified that you have PCOS by identifying that you have an excess of androgens. If there is no increase in androgens, then you don't have PCOS. Testing for androgens is discussed below.
The 4 causes of PCOS are:
1. Insulin-resistance PCOS
Is the most common form (70% of all cases) presenting as elevated fasting insulin levels, and weight gain that is resistant to weight loss efforts. It is easily identified as weight gain around the abdomen (apple-shaped). Our waist measurement should be half our height.
Insulin resistance PCOS is from Metabolic Syndrome from unhealthy eating and lifestyle factors, smoking, alcohol, environmental toxins, magnesium deficiency from an acidic diet, and sleep deprivation. Insulin resistance must be reversed to treat this type of PCOS.
Too much insulin impairs ovulation and causes ovaries to produce testosterone instead of oestrogen. Too much insulin stimulates the body to make more Luteinising Hormone (LH) that then stimulates more androgen production. Too much insulin lowers the androgen binding capacity of SHBG resulting in even more free testosterone. This type of PCOS will continue past menopause if not treated.
Signs of insulin resistance can include skin tags, darkening of skin around armpits and neck (Acanthosis nigricans), elevated cholesterol and triglycerides.
Being told you 'just need to lose weight' isn't helpful when you have insulin resistance as it commonly resists all attempts to do so and you need treating to 'unlock' this vicious cycle. Once treated, insulin resistance goes away and weight loss naturally occurs. If you have been put on Metformin to help with insulin resistance, it can cause digestive problems and deplete your body of Vitamin B12. Digestive problems are a known cause of Inflammatory PCOS (see below) so the cycle may not get broken. Natural therapies can escape these unwanted side effects.
2. Post Oral Contraceptive Pill (OCP) PCOS
Is the second most common form which isn't usually long term, but is a temporary surge of male androgens that lasts 1-2 years only. A high LH:FSH ratio (greater than 2:1) is typically the only finding. If you have been put on the OCP to help with acne and insulin resistance, the bad news is that it can make them both worse when you stop taking it, and impact negatively on your mood while taking it.
3. Inflammatory PCOS
Often arising from gut inflammation, digestive issues like dysbiosis, IBS, SIBO, leaky gut, histamine intolerance issues, fatigue, headaches, immunity issues that may be seen with skin issues, and joint pain. Inflammation is a factor in all types of PCOS. An unhealthy gut microbiome can also contribute to insulin resistance (above).
4. Adrenal PCOS
Is the least common form coming in at 10% of cases, and is only relevant if all the other causes of PCOS have been ruled out. PCOS is defined as having elevated androgens, but if the only androgen elevated is DHEAS, then Adrenal PCOS is likely the version you have (assuming Prolactin is not elevated).
The flow chart below helps determine the cause of PCOS.
Diagnosis of PCOS
PCOS cannot be diagnosed by ultrasound! Despite its name, which is now considered an inaccurate description, an ultrasound cannot be used for diagnosis. If you don't ovulate, you don't form a dominant follicle for ovulation in your ovary that month, so all follicles keep growing and you end up with many small follicles (cysts). However, every month your ovaries will look different, hence ultrasound is no longer valid as a diagnostic tool. If you experience pain or have large cysts on your ovaries, then that is a medical matter that should be seen by your G.P.
Hormonal testing should be performed for diagnosis, along with an observation of symptoms. Blood testing on Day 2 for the hormones LH, FSH, Estradiol, Total Testosterone, SHBG, free Testosterone, Prolactin, DHEAS, Androstenedione. Progesterone levels should only be tested on Day 21.
Do you ovulate? Ovulation is known as our 5th Vital Sign. The only way you can make progesterone is by ovulating.
A blood test for progesterone levels will confirm if you have ovulated. Progesterone should be at least 9.5 nmol/L on Day 21 of a standard 28-day cycle (or tested on whatever day is 7 days after ovulation). An optimal reading is 30 nmol/L. A rise in basal body temperature upon waking will also confirm ovulation. There are also ovulation test kits you can obtain from chemists to test for the presence or absence of ovulation.
Presence of excess androgens by symptoms, and blood testing for androgens (test for free testosterone, total testosterone, SHBG, DHEAS).
Prolactin testing will rule in or out PCOS. A high prolactin level rules out PCOS but identifies hypothalamic amenorrhea (explaining why you may not be getting your period). Prolactin also increases DHEAS. Elevated prolactin levels prevent ovulation.
LH (Luteinising Hormone) and FSH (Follicle Stimulating Hormone) testing. The ratio of LH:FSH should be less than 2:1
Insulin testing (fasting) - should be less than 8 mIU/L
Cholesterol and Triglyceride levels
Vitamin D levels
Thyroid function tests (to rule out hypothyroidism which impedes ovulation and makes insulin resistance worse).
Full Blood Count (FBC) to look for signs of inflammation
CRP, ESR to look for signs of inflammation
Test | Comments |
Free Testosterone | Elevated levels |
Total Testosterone | Combined Free and Bound Testosterone which will show as high levels. Total testosterone needs to be tested in conjunction with SHBG |
SHBG (Sex Hormone Binding Globulin) | In Insulin Resistance PCOS the results are typically low to low normal. Post OCP PCOS the result may be higher |
Androstenedione | Elevated and generally occurs with elevated LH. Can also indicate adrenal involvement. If highly elevated it may push up oestrogen. |
DHEAS | If this is the only androgen elevated, then likely Adrenal PCOS |
Luteinising Hormone (LH) and Follicle Stimulating Hormone (FSH) | Testing should be performed on Day 2 of cycle. If LH:FSH ratio is greater than 2:1 this is considered diagnostic for PCOS. Low LH is more likely HA which is commonly misdiagnosed as 'lean' PCOS. |
Fasting Insulin & HbA1c | Fasting insulin levels >10mU/L (Desirable to be <8mU/L for weight loss to occur). HbA1c will show glucose levels over a 3-month period. |
CRP | Can be elevated and used to assess inflammatory PCOS (along with anion gap, monocyte count, platelet count, ESR, and gut function and associated conditions. |
Prolactin | If elevated, this my indicate pituitary issues rather than pure PCOS |
Table showing pathology results for PCOS
Additionally, to be assessed, you need to start by tracking your menstrual periods. This will provide a benchmark for where you are now, and where you will be following treatment.
Important information for a naturopath to know includes the length of your menstrual cycle, and days of bleeding. PCOS is defined by a long cycle length greater than 35 days indicating an anovulatory cycle (lack of ovulation) and hence no progesterone produced that month, as well as a longer number of days bleeding as well.
NOTE: Cycle length greater than 35 days cannot be used as a guide for teenagers where the menstrual cycle is establishing itself.
Notes for calculating menstrual tracking clues:
Day 1 = heaviest day of bleeding (not the slight brownish discharge that may be shed)
Number of days between Day 1 and your next Day 1 = length of your cycle
Number of days of bleeding
Amount of menstrual fluid lost
Cervical fluid - a thick egg-like consistency is fertile mucous and is an indicator of ovulation while thin, watery discharge is not
Pain around ovulation time
Hormonal Cycles in PCOS
PCOS is a vicious cycle once it is established and needs intervention to break the cycle. Persistent anovulation (lack of ovulation) leads to a chronic deficiency of progesterone which leads to increased LH secretion that leads to increased male androgens and decreased aromatase action (decreased enzyme conversion of testosterone to oestrogen) which again leads back to anovulation.
Heavy menstrual flow occurs as the lining of the uterus becomes very thick, so there is lots to 'shed' each month. Insulin resistance compounds the effect of increased LH secretion that leads to increased male androgens and decreased aromatase action. Targeted intervention must be sought to break the cycle.
DUTCH Testing (Dried Urine Testing of Comprehensive Hormones) can be a very valuable test to have performed providing a complete picture of your hormonal health. The DUTCH test is an addendum test following blood testing on Day 2 as described previously.
The DUTCH tests depicts where hormones come from, how they form in the body, and includes nutrients, supplement, herbs and medications that can increase or decrease particular enzymes affecting hormones allowing for optimal health management.
Treatment of PCOS
Treatment varies depending on the type of PCOS you have, but can consist of the following supplements:
The herb Peony (Paeonia lactiflora) inhibits the production of testosterone and promotes healthy aromatase enzyme activity that converts testosterone to oestrogen. The herb Licorice (Glycyrrhiza glabra) lowers testosterone in women and blocks androgen receptors. The 2 herbs work synergistically together. CAUTION: Blood pressure issues can be impacted negatively with Licorice use so care should be taken by working with a qualified naturopath. The two herbs are a wonderful combination that 'kick-start' hormonal regulation, and should not need to be taken for greater than 6 months.
Magnesium to improve Insulin resistant PCOS. Magnesium plays a regulatory role in insulin secretion from the pancreas. Magnesium will also help with sugar cravings.
Alpha-lipoic acid to improve Insulin resistant PCOS, and promote healthy glutathione levels (our body's major antioxidant)
Myo-inositol is an intracellular messenger for insulin and therefore assists insulin resistant PCOS. Additionally, it reduces androgens and supports regular ovulation.
Vitamin D improves insulin sensitivity and promotes healthy maturation of ovarian follicles for ovulation.
The phytonutrient berberine found in many herbs for insulin resistant PCOS, acne assistance, and reducing anxiety. CAUTION: Berberine should be used in conjunction with a naturopath as it can have detrimental effects if not used correctly, or for too long.
Zinc has anti-androgen effects, helps to reduce inflammation that drives PCOS, regulates our stress response and promotes healthy ovulation. Zinc is often depleted after taking the OCP as well.
B Vitamins reduce stress in adrenal PCOS
Healthy Omega 3Â for healthy cholesterol production that generates our sex hormones, and Vitamin D, and they reduce inflammation.
The herb Rhodiola (Rhodiola rosea) is an adaptogen controlling the stress response present in Adrenal PCOS. Withania somnifera (Ashwagandha) is another great inclusion.
There are many wonderful homeopathic remedies that can treat PCOS.
Quit sugar, and avoid wheat, gluten, and dairy. These are often difficult to eliminate so try going cold turkey for 4 weeks, knowing that intense cravings subside after 20 minutes and the majority of cravings will subside after 7 days. Peppermint Essential Oil rubbed into your palms can reduce cravings considerably.
Reduce alcohol, especially beer as it stimulates prolactin. Men get 'man boobs' this way.
Ensure you eat full, satisfying meals with protein, healthy fats and fibre from fruits and vegetables, including starch from potatoes for example, to fill you up.
Have a low carb breakfast, but do ensure you include complex carbohydrates in your diet throughout the day. Not enough could result in hypothalamic amenorrhea (absence of periods).
Include strength training, even using your body as resistance e.g. squats. Just 12 weeks can improve insulin resistance.
Address digestive issues if present
Address Histamine issues if present
Address Hypothyroidism if present as it impedes ovulation and worsens insulin resistance.
Avoid hormone disrupting chemicals in perfumes, plastics, air fragrances etc. It's no surprise that perfumes are not allowed in IVF clinics!
Reduce stress as increased cortisol can cause and make worse insulin resistance.
Establish a healthy Circadian rhythm If you are a 'night type' person you are more likely to have insulin resistance, PCOS, Metabolic Syndrome and weight gain.
PCOS needs treating as it is associated with the long term risk of diabetes and heart disease. This highlights how all our hormones are linked in the body. PCOS is not just a period problem, weight problem, or fertility problem, but a whole-body metabolic and hormonal condition.
PCOS can be treated, and you can begin to enjoy the life you want! Our bodies do heal!
If you would like to discuss your personal circumstances and discuss your symptoms of PCOS, get testing performed, and get on the road to improving your health, then please don't hesitate to make a booking with me.
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References:
Briden L, (2021), 'Period repair Manual'
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