What You Need to Know About PCOS
PCOS stands for Polycystic Ovarian Syndrome. It is the most common cause of infertility in America with an estimated 1 in 10 women experiencing it sometime in their lifetime. PCOS is a hormone imbalance that, because it’s a “syndrome,” can present many ways.
I treat patients with PCOS all the time and help many of them to cycle and ovulate regularly and subsequently get pregnant successfully. It is an incredibly common condition, which means there are lots of resources for treatment, which in most cases have an excellent chance at success. Allow me to break it down for you.
What is it?
The primary characteristic of PCOS is trouble ovulating. In some cases that means long cycles because ovulation happens very late in the cycle. Some women stop ovulating and thus stop getting their period entirely, this may last a few months or years for some women. Cycle irregularity like this is typically caused by a hormone imbalance that involves high estrogen, luteinizing hormone, testosterone, and androgens.
These hormones in excess causes several eggs in the ovaries to start developing, but most of them stall out at early stages. This can cause eggs to turn into small cysts in the ovaries - hence the term polycystic ovaries. Typically when an ultrasound is done, if the ovaries are full of several small cysts they are described as looking like a "string of pearls."
These cysts aren't necessarily permanent or painful and they are nearly always benign, so no need to panic if you're told you have cysts on your ovaries. They are actually quite common and can be treated.
Despite the name, polycystic ovarian syndrome, not all women with PCOS actually have polycystic ovaries. In some cases the ovaries are "quiet" because ovulation isn't happening at all, or for some egg development and ovulation may happen quite normally and the ovaries will appear completely normal.
Secondarily, other hormonal symptoms may arise from this imbalance, the most common of which are body hair growth, head hair loss, acne, oily skin or scalp, weight gain or loss, and difficulty loosing weight. PCOS is closely associated with weight gain and difficulty loosing weight, but it's less well known that half of those with PCOS are average or even underweight.
What causes it?
PCOS is closely linked to insulin resistance and may develop as a result of a number of factors. One of the most common and most relevant factors is diet, because of its link to insulin and blood sugar control. Especially if you are used to eating processed, starchy, or sugary foods, this can contribute to the progression of PCOS.
Lack of exercise or sedentary lifestyle can also contribute, since it can further the development of insulin resistance in the body. Exposure to toxins or artificial hormones may also lead to the hormonal imbalances involved with PCOS, especially because many of the foods we eat and products we use may be culprits.
High stress levels can also trigger PCOS symptoms, since stress causes the release of adrenaline and cortisol, which cause the release of blood sugar, increase inflammation, and disrupt hormones. In most cases there are several factors that contribute to the progression of PCOS and a sudden spike in stress levels can commonly be the straw that breaks the camels back and makes those symptoms much more obvious.
In some cases the hormonal imbalances associated with PCOS may have a genetic component and thus run in the family. If this is the case, usually irregular cycles and hormonal imbalances are noticed early on, once puberty has occured.
How is it diagnosed?
The main method of diagnosing PCOS is blood work to check hormone levels. An ultrasound of the ovaries may also be performed, but as described above, some people with PCOS will have normal looking ovaries and need blood work to confirm the condition.
Additional blood work may be ordered to check thyroid, liver, kidney, and adrenal function, as well as Hemoglobin A1C which signals issues with blood sugar regulation and insulin resistance. These are often checked to make sure the PCOS isn't presenting as a symptom of a more serious condition.
If you have very long cycles (consistently 35+ days,) if you have trouble pinpointing ovulation via BBT charting, or if you use OPKs and keep getting faint positives for many days in a row without a clear positive, then see your doctor to get checked for PCOS.
How does it affect fertility?
It really depends on how advanced the PCOS is. Obviously if there's no ovulation happening then conception can't happen at all, and even with fertility meds it may be difficult until the cycle is regulated (I highly recommend acupuncture and herbal medicine for regulating your cycle if you aren't getting a period at all.)
Even when ovulation is happening it is common with PCOS for it to happen late in the cycle, causing sometimes very long or completely irregular cycles. If this is the case it may still be possible to get pregnant but it leaves fair fewer chances to try compared to those who ovulate once a month.
The hormonal imbalances involved with PCOS, particularly excessive androgens, can also affect egg quality so even when ovulation does happen the egg that is released may not be strong enough to develop a healthy embryo. Luckily, these imbalances don't usually cause permanent damage to the eggs. If the hormone levels are balanced and eggs begin to develop normally they can be quite healthy.
How is it treated?
Like many chronic conditions, PCOS can be treated and you don’t necessarily ever “cure” it, but for many the symptoms and hormonal imbalances can regulate to the point they don't cause any issues. Being a syndrome that presents on a spectrum, if it’s mild you may only need minimal intervention, whereas if it’s advanced you may need prolonged and more intensive intervention to keep the symptoms at bay.
As with most conditions, there are several different approaches to treat PCOS. Because of its link to insulin resistance and blood sugar regulation, diet is an important factor but unfortunately not all doctors stress this to their patients. Pharmaceutical options are often recommended for PCOS by most doctors, but there are also holistic means available that not only carry fewer side effects, they can actually help to address the root of the issue, the hormonal imbalance, rather than just masking the symptoms that arise because of it.
In addition, most of these treatment options can be used together to maximize their effect. So even if you pursue hormonal medication to treat your PCOS you can support the process with diet, acupuncture, herbs, and supplements. Let's go over some of the most common treatment options.
Low Glycemic & Low Carbohydrate Diets
Because of PCOS's link to insulin resistance, eating a low glycemic and/or low carbohydrate diet can be effective for helping correct or minimize the effects of the imbalance. It can also help to improve energy levels and may help to loose weight.
How strict your diet needs to be in order to have an effect on your PCOS depends again on the severity of your condition. If advanced, it may be helpful to eat a paleo diet and/or keep your carbohydrate intake low. If your PCOS has a milder presentation then just limiting your high glycemic foods may be sufficient.
Consult your healthcare provider and/or a registered nutritionist before making changes to your diet.
Pharmaceutical & hormonal medications
One of the most common medications to treat PCOS is Metformin, which focuses on weight loss and blood sugar regulation. It's also commonly used for insulin resistance and diabetes. In some cases using Metformin is necessary and can be very helpful for those with PCOS, but many cases aren't considered advanced enough to warrant using it. In addition, as with most pharmaceuticals it carries some side effects, such as digestive upset, weakness, and upper respiratory infections.
While Metformin can help to regulate blood sugar levels and reduce weight, it doesn't necessarily get to the root of the hormonal imbalances, thus may have fairly minimal effect on ovulation and fertility for some. Especially if it's used on its own and without any other support or change to diet.
Hormonal medications are also sometimes recommended depending on what the goal of treatment is. If you don't plan to get pregnant anytime soon but you want to regulate your menstrual cycle, then typically the birth control pill is recommended to induce a regular period. This is often the approach for treating young women who show signs of PCOS, the issue I find is it doesn't address your underlying hormonal imbalances and your body can actually forget how to cycle regularly. If you later want to stop the pill to try to get pregnant, then you may not be able to get a regular period on your own and need to deal with those same hormonal imbalances then.
If the goal is to get pregnant as soon as possible, then Clomid is another popular hormonal medication used for PCOS because it can help to induce egg development and ovulation. The downside is it doesn't always work and it can't be used indefinitely, in fact many doctors won't use it for more than 3-6 cycles. That's in addition to the common side effects of GI upset, headache, and breast tenderness.
Whether or not you should take any medication for PCOS or any condition should be a conversation you have with your doctor. Consult a healthcare professional, for PCOS you should speak with an OBGYN or Reproductive Endocrinologist.
Acupuncture & Herbal Medicine
Chinese medicine is incredibly effective at balancing hormonal imbalances such as PCOS, as well regulating the menstrual cycle, improving ovarian function and egg quality, boosting fertility, and addressing other symptoms that might be present, such as poor digestion, low energy, or menstrual cramping.
Because PCOS can present in several different ways (with or without ovarian cysts, with weight gain or loss, with other endocrine conditions or not) Chinese medicine is also effective at customizing treatment specifically to what's going on with you. There's not such thing as a one-size-fits-all treatment when it comes to acupuncture and herbal medicine, each acu-point, each herb, is chosen specifically for you.
Myo-inositol is one of the most commonly used supplements for PCOS because it works as an insulin-sensitizing agent. It helps to reverse the effects of insulin resistance, which can be dangerous, damaging, and inflammatory to the body.
D-chiro-inositol is another common inositol supplement, but it may actually make PCOS worse, so make sure you are only taking myo-inositol. This supplement is incredibly safe, despite being quite effective, but nonetheless consult your healthcare provider before starting a new supplement routine.
If you're trying to conceive then a good quality prenatal vitamin is also usually recommended, not just because it gives you the nutrients you need to grow a baby, but also the nutrients you need to improve ovarian function and support egg development.
There are other supplements that are often used as part of PCOS treatment, but I find most of them must match up with your unique needs. Work with your healthcare provider to determine what works best for you.
Obviously exercise is important for overall health and most conditions benefit from it, but with PCOS and insulin resistance in particular exercise is a helpful tool to increase insulin sensitivity and actually reverse some of the signs of PCOS.
Many of the studies done that confirm how exercise improves blood sugar levels use moderate walking to test the theory, so you don't necessarily need to go hard at the workouts to make an impact on your hormone levels. Especially if you aren't used to exercising, start with walking for 30 minutes every other day.
If the goal is weight loss, which may further improve the hormonal imbalances and symptoms of PCOS, then some higher intensity exercise, such as cardio and strength training may be needed.
Exposure to hormones & hormone-disrupting toxins
Because PCOS is a condition of excess hormones, it's often advised to reduce your exposure to hormones and hormone-disrupting toxins. The most common source of hormones is animal products, particularly ones that use added hormones. To avoid these added hormones try to reduce or avoid intake of non-organic animal products, including meat, dairy, and eggs.
In general, reducing overall intake of animal products may also be beneficial for PCOS. Going completely vegan may not be necessary, but if you frequently eat animal products then it's worth taking a look at. Speak with your healthcare provider and/or a registered nutritionist before making changes to your diet.
Hormone-disrupting toxins are also an issue because they can often act as hormones in the body, only stronger. Some of the most common sources of exposure are pesticides, plastics (especially when used for food/drink storage,) canned foods, thermal receipts, cosmetics and beauty products, and synthetic cleaning chemicals. I discuss these in greater details in my free e-course: Happier Hormones in 30 days.
Want to learn more?
I discuss PCOS, along with a ton of other topics in Foundations of Fertility - my 6-week masterclass in all things fertility. In fact, we cover hormones and common hormonal imbalances, diet, supplements, herbs, Chinese medicine, cycle charting, and how to evaluate your own fertility. If you're serious about trying to conceive this course is for you!