Holistic Care Options for PCOS

What is PCOS?

Polycystic ovary syndrome (PCOS) is a hormonal and metabolic disorder characterized by:

1) Abnormally elevated androgen hormones

2) Menstrual irregularity

• Frequent bleeding at intervals <21 days OR
• Infrequent bleeding at intervals >35 days OR
• Normal bleeding intervals (25-35 days) with a mid-luteal progesterone level (</=5 ng/mL) suggesting no ovulation occured

3)Follicular cysts on the ovaries – which are a fluid-filled sac found on ultrasound that contain an immature egg that often fails to release and lead to ovulation.

Diagnostic criteria for PCOS is met when 2 out of 3 above are present.

PCOS is way more common that you think!

Experts estimate 10% of women have PCOS. Your doctor may also check the following before coming to the conclusion of PCOS:

• Full thyroid panel (Thyroid disease)
• Prolactin (Hyperprolactinemia)
• Pregnancy Test (Pregnancy)
• 17-hydroxyprogesterone levels (Congenital adrenal hyperplasia)

How would you know if you might have PCOS?

Sign & symptoms of PCOS that warrant scheduling an appointment to discuss include:

• Acanthosis nigricans (velvety dark skin – often insulin resistance)
• Alopecia (hair loss on the scalp often insulin resistance or androgens)
• Depression and anixety (often blood sugar dysregulation or androgens)
• Facial hair growth (often related to androgens)
• Facial Acne (often from androgens or inflammation)
• Irregular or absent periods
• Infertility (often due to anovulation)
• Skin tags (often from insulin resistance)
• Sleep difficulties
• Unintentional weight gain

What causes PCOS to develop in the first place?

There is not one “thing to blame” and the pathogenesis is not completely understood. Experts think a variety of the following (a non-exhaustive list) are key players:

• Inflammation: PCOS is associated with chronic low-grade inflammation and often there is an elevated C-reactive protein (CRP); a hypothesis exists that the inflammation stimulates the ovaries to produce androgens.
• Disordered gonadotropin secretion: Normally, the hypothalamus secretes gonadotropin-releasing hormone which stimulates the release of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) by the pituitary. In the ovaries, LH works with FSH to regulate follicle development, ovulation, and the production of steroid hormones (including androgens).Many women with PCOS have high LH levels due to increased GnRH secretion, which can lead to increased androgen production and the development of follicular ovarian cysts.
• Insulin resistance: It has been estimated that 75% of women with PCOS have insulin resistance. Insulin resistance means the insulin is “stubborn” at doing its job which is to help move the sugar from the blood to cells. When insulin isn’t working as it should, often the body compensates by making extra insulin. Eventually, the pancreas might not be able to keep up with producing extra insulin, so the blood sugar levels can rise over time. Women with PCOS have a higher risk of developing type 2 diabetes. Elevated levels of insulin can contribute to high androgens; and high levels of androgens can also increase insulin resistance- so it can be cyclical.
• Endocrine-disrupting chemicals: Endocrine disruptors do what they say – they disrupt endocrine (hormone) function which interferes with the synthesis, secretion, transport, metabolism, binding action, or elimination of hormones. Exposure to endocrine disruptors increases risk of hormone related medical conditions.
• Obesity: Scientists are having a hard time figuring out a clear answer to the question: which one comes first- the chicken or the egg? Does PCOS contribute to weight gain, or does weight gain influence PCOS, or is it another hampster wheel situation. Another wrench to throw in: PCOS can happen in women of any size, so weight is not fully the culprit and it is one factor to consider and address.
• Family History: Gene variants have been linked with PCOS.

So what do we do about PCOS once it has been confirmed:

• Medical management
• Nutrition assessment and intervention
• Address other lifestyle factors like sleep, endocrine disruptor exposure (I wrote another blog all about how to start this process of reducing exposures) and stress management

What does standard care look like when seeing a Physician for PCOS management:

• Oral contraceptives (birth control): Combined oral contraceptives (containing both estrogen and progestin) are considered first-line treatment for menstrual irregularity and hyperandrogenism in PCOS. They artifically improve PCOS symptoms by decreasing LH secretion, reducing androgen production, and increasing SHBG, which binds androgens. Note that hormonal birth control doesn’t correct the underlying cause(s) of PCOS and it is one medication option, assuming a women is not wanting to conceive.
• Weight loss: For patients with PCOS who have BMIs in the overweight or obese categories, weight loss is often advised by doctors. Research shows that both insulin resistance and menstrual function can be improved with as little as 5-10% reduction in body weight.
• Metformin: This prescription works by combating insulin resistance, which can help lower androgens and can improve menstrual function. Metformin is sometimes not well tolerated, but overall effective and safe. Metformin is known for contributing to vitamin b12 deficiency so it is important screen for deficiency, and supplement if needed. Taking a vitamin b12 supplement is generally safe for most people who take metformin and something I usually recommend.
• Other medications used such as Anti-androgen drugs (Spironlactone), Weight loss drugs (Saxenda), and Ovulation induction drugs (letrozole, gonadotropins) are prescribed for a woman with PCOS.
• Surgery and other options like Accupuncture (increase blood flow), In vitro fertilization if difficulty with conceiving with PCOS, Laparoscopic ovarian surgery, or Bariatric surgery are potential paths.

What are nutrition recommendations for PCOS?

There are general standards for diets for PCOS, but ideally each female explores her own “root issues” and address with diet as one strategy; this is going to play out differently for each female. For example, does she have elevated androgens, and/or overweight and/or insulin resistance and/or inflammation and/or vitamin or mineral deficiencies?

Generally speaking, women with PCOS could benefit from a combination of the following below and I individualize and prioritize all of this in consultation:

• Low-carbohydrate diet and/or low glycemic: There is some evidence that a moderately low-carbohydrate diet (about 40% of calories coming from carbohydrate) can decrease insulin resistance in women with PCOS. The goal here is to prevent large spikes in blood sugar (which can increase inflammation and worsen insulin resistance).
• Meditareanean diet: Some women with PCOS have an elevated C-reactive protein (a marker of inflammation) and chronic inflammation needs addressed. One of the best studied diets for addressing inflammation is the Mediterranean diet, which is characterized by a diet including heart healthy fats like olive oil and rich in fruits in vegetables.
• Gluten free diet: although many women with PCOS report positive results from following a gluten-free diet, there is not enough research to support it at this time. It would not hurt to try as long as plenty of fiber is still included in the diet.
• N-acetylcysteine (NAC): NAC is an antioxidant found naturally and research suggests that supplementation with NAC (1200-1800 mg/day) in women with PCOS results in better chances of having a live birth, getting pregnant, and ovulating.
• Adequate Magnesium Intake: Magnesium is required for proper glucose utilization and insulin signaling, and higher intake is linked with decreased insulin resistance. 80% of Americans do not consume adequate amounts of Magnesium, so this is generally safe to either supplement or add more of this in the diet. I often recommend (when appropriate) Magnesium glycinate at 300mg before bedtime.
• Adequate Omega-3 Fatty Acids: Omega-3 supplementation (around 1000mg per day)help improve inflammation and can decreased insulin resistance in women with PCOS. I often recommend Nordic Naturals gel capsules. These taste good and no burping afterwards. However, some studies are conflicting, so more research is needed, but it is conservative option to try. Recommend avoiding if allergic or on blood thinning medications and talking to your doctor before starting.
• Addressing Vitamin D Levels: Low vitamin D levels (<20 ng/mL in bloodwork) have been found in about 75% of women with PCOS. There is some evidence that improving vitamin D status might improve insulin sensitivity and menstruation. Optimal vitamin D status can also help increase energy, which in turn can help with drive to increase health supportive behaviors like exercise; It is important for many reason to have optimal vitamin D levels. Until you have your vitamin D levels checked, taking a maintenance dose of vitamin D in the meantime to help meet basic needs. If deficient, a higher dose will be needed.
• Green tea: Evidence suggests that supplementation with green tea capsules (1000-2000 mg/day for 6-12 weeks) resulted in decreased body weight, fasting insulin, free testosterone, and inflammatory markers in women with PCOS and elevated BMI. Green tea has antioxidants and thus reduces oxidative stress.
• Inositol: Inositol is a pseudovitamin found naturally in plant foods but it can also be produced by the body so it is no longer classified as vitamin. Two forms of inositol are involved in the body effectively using blood sugar and also helping to decrease androgens. I often recommend myo-inositol plus D-chiro in doses of 2-4 g/day; many studies show decreased insulin resistance and improved reproductive functioning in women with PCOS. Ovasitol is a popular brand recommended many by OB/GYNs. It comes in a powder form and contains 2000 mg myo-inositol and 50 mg D-chiro-inositol.

Lot of options to say the least! If you would like a one-on-one assistance schedule a telehealth consult package to order and review your own labwork and come up with an individualized game plan.

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