A deep dive into: PCOS
Polycystic ovarian syndrome, also known as PCOS, is a complex condition.
I say that because it takes a skilled clinician to be able to sift through the symptoms, identify the potential root cause, and provide an effective treatment plan for it (that’s NOT birth control).
Every day we’re learning more and more about this condition. The debate is still out there on if it’s driven by hormones or insulin resistance but with most things related to pathology, every pathway so intricately affects one another that the road to disease is more circular and interconnected than we think.
When we look at PCOS, there’s the classic picture and then there’s cases that only involve a few of the symptoms. Symptoms can range from irregular cycles, hirsutism, blood sugar dysfunction, infertility, acne, weight gain, male pattern hair loss, darkening of the skin (armpits, back of neck, groin - known as acanthuses nigoracans), anxiety and/or depression, food cravings, chronic inflammation, and fatigue.
PCOS is generally diagnosed based off of having 2 of the following 3 criteria: elevated androgens, polycystic ovaries on ultrasound, and ovulatory dysfunction.
However, what we’re learning now is that PCOS doesn't really have to do with cysts on the ovaries. Seeing cysts on an ultrasound can’t diagnose or rule out PCOS. What does point us in the direction of PCOS is if there’s high androgens with no other explanations (meaning causes like high prolactin and congenital adrenal hyperplasia have been ruled out).
The way that PCOS presents depends on the subtype of PCOS. This can be categorized into four types:
Insulin resistant-PCOS: Insulin resistance drives the ovaries to produce more testosterone instead of estrogen and stimulates the pituitary gland to make more LH which further drives increased androgen production.
Inflammatory-PCOS: Chronic inflammation can drive the ovaries to produce too much testosterone. In this case, it’s important to uncover the root cause of what is driving inflammation in the body which can range from variety sources such as digestive issues (IBS, leaky gut, dysbiosis, etc), food sensitivities, allergies, and more.
Post-pill PCOS: When these symptoms arise after discontinuing oral birth control pills with no previous history of PCOS-like symptoms before the pill.
Adrenal-PCOS: DHEA-S is your adrenal androgen, so if this is the only androgen that comes up as high on lab testing it may be an indicator that it’s due to an abnormal stress response.
The most common (and infuriating) response to women who have PCOS is to put them on the pill.
That is NOT the answer. In fact, it could potentially make PCOS worse depending on the underlying cause, especially if you have insulin resistant-PCOS which an estimated 50-70% of women with PCOS have some degree of insulin resistance.
As we talked about, the increase in testosterone is being driven by insulin telling the ovaries to produce more. Insulin is also inhibiting SHBG in the liver which leads to higher circulating testosterone and that’s when we start to see some of classic symptoms including acne, hirsutism, and male pattern hair loss. What we know about the pill is that it increases risk of insulin resistance. So not only are we slapping a big ole bandaid on the issue, but we’re potentially making the root cause worse.
Let’s keep in mind that during the 5 minute doctor’s visit most women have, they may not even be receiving lifestyle recommendations on how to manage their blood sugar and reduce insulin resistance. So we’re taking someone who already has an issue of insulin resistance, giving them a medication that can amplify it, and potentially making it even worse by neglecting to educate them on how important their lifestyle choices like diet and exercising can be.
So what should we be doing for women with PCOS?
Some general ways to treat include:
Hormonal support: Using anti-androgenic herbs can be a powerful tool in seeing a difference in PCOS. A well studied combination is a tincture of white peony + licorice used in women with high androgens due to PCOS. Other considerations include spearmint for hirsutism and the eclectic use of fennel from traditional Iranian medicine to gently nudge progesterone and estrogen back into place (fennel is what I personally used thanks to my mom & grandma’s recommendations). In some clinical studies, the combination of myoinositol + folic acid has shown improvement in ovulation and conception better than metformin!
Balance blood sugar: Eating a whole foods based diet with no processed foods, added sugars, simple carbs, and alcohol is important as well as eating regularly timed and balanced meals. Each meal should have the proper balance between healthy fats, protein, and complex carbohydrates to prevent blood sugar spikes. Some supplemental help for blood sugar can include fenugreek, alpha lipoic acid, cinnamon, vitamin D, and D chiro-inositol.
Support detox pathways: Reduce environmental toxins and support your liver through a healthy diet rich in liver friendly foods (citrus, cruciferous vegetables, garlic, beets, etc.) and with additional supplementation such as milk thistle, NAC, glutathione, and B vitamins. Make sure you are having regular bowel movements and sweating daily to further support detox pathways.
Reduce inflammation: This can most easily be down through diet as our diets tend to be one of the biggest drivers of inflammation. Adhering to an anti-inflammatory diet with removal of top allergens like gluten and dairy can be very helpful. Herbs that can be used to help decrease inflammation include ginger, turmeric, and green tea.
Exercise: The type of exercise matters. Too much can increase inflammation & cortisol and further drive insulin resistance and focusing on strength training and lifting heavy can promote excess androgens. Optimal exercise includes yoga, walking, gentle bike rides, and light hiking.
Support adrenals: Practice stress management through journaling, meditation, yoga, therapy, and anything else that brings comfort and build stress resiliency using vagus nerve toning exercises like diaphragmatic breathing and using adaptogenic herbs like Schisandra or Rhodiola (be careful with Ashwagandha because studies have shown it may increase LH and androgens).
Remember, balancing hormones takes time.
Don’t be discouraged if after a month your symptoms have improved little or not at all. Usually hormones take a minimum of 3 months to start to see a substantial difference with the ideal timeframe to see long term changes being 6-12 months of treatment.
I hope this post was helpful to anyone wondering if they have PCOS and what the next steps may be. As I discussed in my previous post, I had post-pill PCOS after discontinuing birth control and it took me a while to understand what was happening to my body and how to address it outside of conventional treatment (birth control + metformin).
As always, none of the information I post is medical advice. This is free health education because I strongly believe that more information needs to be easily accessible, especially when it comes to women’s health. If you suspect you have PCOS or have a current diagnosis and want to seek alternative care, I highly encourage you to bring a naturopathic or integrative doctor on your healthcare team.
With love,
Dr. Paria Vaziri, ND
