For many years I’ve been frustrated with the diagnosis of PCOS for my patients. PCOS is a syndrome – which means it’s a cluster of symptoms that have no other medical explanation. This is a poor representation of what’s going on women’s bodies who have PCOS. There are established mechanisms that show us what causes PCOS, and give us a road map about what to do about it. And I am going to discuss those mechanisms with you in this post.
To be diagnosed with PCOS, you need to have 2 out of the 3 following criteria:
- menstrual irregularlity
- hyperandrogenism and/or hirsutisim (high male hormones in the blood and/or male pattern hair growth like on the chin)
- polycystic ovaries on ultrasound
These three points are called the Rotterdam criteria, which were established in 2003 — which is 17 years ago and, in my opinion, is very outdated!
Luckily, because I am a naturopathic doctor, I look beyond these symptoms to figure out the real source of dysfunction. The type of dysfunction on a biochemical level is how we determine what TYPE of PCOS you have.
The most common symptoms of PCOS are:
- Irregular cycles – cycles that skip, or that are long
- Chronic an-ovulation (consistently not ovulating each cycle)
- Hair growth, like hirsutism on chin and neck
- Obesity or weight gain
- Jawline, neck or chin acne
- Hairloss (sometimes)
Other common symptoms that aren’t always recognized as PCOS symptoms are: blood sugar issues including hypoglycemia (low blood sugar levels), feeling HANGRY or spacy or irritable in between meals, brain fog that eating relieves, and stress.
There are 4 types of PCOS:
- insulin resistant PCOS
- ovarian androgen PCOS
- adrenal androgen PCOS
- inflammation driven PCOS (this can include Post-birth control pill PCOS)
Insulin resistant PCOS means that chronic blood sugar issues have created “insulin resistance” which means that your cells are no longer sensitive to the signal of insulin. Insulin is a hormone created by the pancreas that circulates in the bloodstreams and “opens the door” to allow cells to take up glucose (fuel). When diet is high in processed sugar and carbohydrates, along with obesity, blood sugar spikes are common, which cause spikes of insulin and a flooding of insulin into the blood stream. This leaves cells overwhelmed with the signal of insulin so they begin to ignore it, ultimately leading to insulin resistance.
I commonly treat insulin resistant PCOS with a blood sugar stablizing diet – high in vegetables, high in fiber, high in protein, moderate fat, and low proceessed sugars and carbohydrates. I will also use supplements including inositol, berberine, chromium, and biotin. In fact, studies have show that 500 mg of berberine three times per day was superior to the use of the drug metformin, which is the first line treatment for PCOS.
Ovarian androgen PCOS means there is an increase in testosterone and DHEA-S from the ovaries. There are many reasons for this, one of those is that excess insulin leads to an increase in adrogen production form the ovaries. Another is LH, or leutenizing hormone, which is the signal from your brain to your ovaries to stimulate ovulation. LH will chronically go up over time as the ovaries become less responsive and less healthy to create an ovulation response, triggering the brain to release more LH. The combination of elevations of insulin and LH leads to an increase in ovarian androgen production. Increased insulin levels also inhibits production of SHBG by the liver, leading to higher levels of free androgens.
I commonly treat androgen excess with supplements like saw palmetto, pygeum, and nettles. Zinc is helpful too. Sometimes the use of bio-identical progesterone is warranted.
Adrenal androgen PCOS means there is an increase in testosterone and DHEA-S from the adrenal glands. The main reason for this is chronic stress. Stress also (commonly) leads to blood sugar issues. As more and more insulin remains in the blood stream, the conversion of adrostenedione (another male hormone) to testosterone is facilitated at a greater rate, leading to higher levels of circulating androgens. Stress can be physiological, mental, emotional or spiritual – so it’s important to find the stress and remove it, or practice stress management.
Supporting the hypothalamic pituitary adrenal axis is crucial for balancing adrenal health. Many herbal adaptogens are amazing for helping the body adapt to stress and calm the overactive or stimulate the underactive HPA axis. I commonly use herbs like ashwagandha, rhodiola, eluetherococcus, panax ginseng, licorice, and holy basil to suppor the adrenal glands. These herbs should be recommended to you by a medical professional who knows your exact medical history. They are powerful herbs that really work, but they are not a one-size fits all type of approach.
Inflammation driven PCOS is due to the fact that high levels of insulin are inflammatory AND/OR there is another source of inflammation in the body that is throwing off the menstrual cycle, leading to anovulatiory and long irregular cycles. It’s important to assess the body holistically to find the source of the dysfunction and remedy it. Sometimes inflammation driven PCOS can be caused by metabolic syndrome that commonly occurs in overweight women with PCOS.
Estrogen can also be an issue in PCOS. Elevated synthesis of estrogens occurs because increased aromatization (conversion of testosterone to estrogen) of the increasing levels of androgens caused by increased insulin or via production from ovaries. High levels of insulin also add to the conversion of adrostenedione to testosterone, and then aromatization of that testosterone. The estrogen pool is also affected by the fact that low levels of progesterone, due to long cycles and chronic anovulation are contributing to a low progesterone/estrogen ratio.
So all that’s cool – but why do I have hairs growing on my chin?? I’ll tell you.
Increased androgens leads to hirsutism. Increase in ovary stimulation due to LH leads to enlarged/cystic ovaries. The body is trying to fix chronic anovulation by increasing LH, but ovulation often does occur due to decreased FSH levels, since no egg will be matured for release. Women with PCOS often have lower levels of FSH, and FSH is needed to “prep the egg” and mature eggs for ovulation. Up to 15-20 follicles are stimulated each cycle, and the that egg matures first will be the “chosen one” that gets to be ovulated.
Fertility issues with PCOS arise because dysregulations in FSH/LH means there is no egg readied and ovulated, so fertilization and conception cannot occur. High estrogen/progesterone ratio adds to the oligo-ovulation issue and infertility. Progesterone is often low in women who have PCOS because progesterone is only made with ovulation OR if a woman falls pregnant. Sometimes bio-identical progesterone can be very useful in PCOS women, but it needs to be taken under the care of a qualified practioner. Progesterone is not a fit for all women with PCOS.
Treatment for increasing fertility in PCOS women usually starts with treating the reason behind the woman isn’t ovulating regularly each month. Here I love to use menstrual cycle symptom tracking along with basal body temperature tracking to assess if a woman is beginning to ovulate consistently, and later when to time intercourse so fertilization can occur and a baby can be made!
Vitex, beta-carotene, B-vitamins, zinc, and seed cycling can be very beneficial for a woman who is trying to acheive regular cycles for pregnancy or general health. Vitex is an herb that is used in a low dose (around 200 mg), taken each morning, and can improve ovulation. Vitex should not be taken long term, and I do not use it in my patients for over 6 months at one time.
Other treatments that can be helpful for women with PCOS are eliminating food allergies and sensitivities, especially dairy. Other inflammatory foods are often removed, like gluten and soy, with much benefit, though that effect differs on the person. I will often recommend liver support as well to help lessen the burden on the liver that comes from the need to detox excess hormones from the system.
The last type of PCOS that I will mention, that I see commonly in my patients (though I don’t usually call it PCOS – I call it ovarian dysfunction instead) is irregular and anovulatory cycles after stopping the birth-control pill. This is so common, I see it almost weekly. The reason why it can take time for cycles to restablish after coming off the pill is because the synthetic hormones in the pill block the brains stimulating signals to the ovaries to get them to produce hormones. So it’s like your ovaries and your brain need to learn how to communicate again, and your ovaries need time to “relearn” how to establish a menstrual cycle rhythm again.
Treatment of post-pill PCOS includes a variety of approaches I already discussed above.
PCOS is not a life-long sentence. I hope you were able to clearly see how the biochemistry of PCOS is KNOWN – so we can do something about it. You don’t have to suffer – you can regulate your cyle and become pregnant naturally with a natural medicine approach!
For more explanation on this topic – see my video on my YouTube channel here.