As someone who has specialized in treating infertility and reproductive health issues for nearly 20 years, I have seen my fair share of patients with PCOS. Polycystic ovary syndrome (PCOS) is believed to be the most common hormonal disorder in women, running neck in neck with endometriosis. Prevalence of PCOS varies based on the diagnostic tool used, but according to the CDC, it affects an estimated 6% to 12% of US women in their reproductive years. That’s as many as 5 million women in our country, and the health complications that come with it can persist far beyond child-bearing years. It is the most common cause of anovulatory infertility (absence of egg release for fertilization).
Classic symptoms of PCOS include:
- Chronically irregular menstrual cycles (oligomenorrhea)
- Excess weight that is difficult to lose (obesity)
- Excess facial and body hair (hirsutism)
- Severe acne
- Thinning head hair
- Darkening of skin, particularly along the neck creases, groin and underneath breasts
- Skin tags in the armpit and/or neck area
The manifestation of PCOS varies from woman to woman. One in three have what is referred to as ‘lean PCOS’, meaning they don’t have stubborn excess weight, and it’s possible that the only noticeable symptom is a chronically absent or infrequent period.
Health Implications
Often women don’t address the symptoms until they are trying to become pregnant, because we have associated our period with ‘the curse’, and not having one can feel like a welcome reprieve. Unfortunately, this can contribute to persistent health issues down the road, especially if they are overweight.
- Over 50% develop type 2 diabetes
- Higher risk for gestational diabetes, which puts the baby at risk
- Risk for heart disease that increases with age
- High blood pressure
- Cholesterol issues
- Sleep apnea, which also raises the risk for type 2 diabetes
- Stroke risk, due to plaque depositing in the blood vessels leading to clots
It’s also been linked to depression and anxiety.
Diagnosing PCOS
While the exact cause of PCOS is still unknown, it is believed to be a combination of genetic and environmental factors. A patient can present with symptoms ranging from no obvious signs to multiple gynecologic, dermatologic and/or metabolic manifestations. In 2013, a task force of the Endocrine Society issued guidelines for the diagnosis of PCOS. They suggested adopting the following criteria, which requires the presence of two of the following:
- Excess androgens (Determined by labs (testosterone and DHEA) and clinical signs such as acne, excess body hair, male pattern baldness
- Ovulatory dysfunction (Lack of ovulation or infrequent ovulation)
- Polycystic ovaries (Viewed by transvaginal ultrasound.)
Based on the ‘2 out of 3’ consensus, actual polycystic ovaries are not a requirement for the diagnosis of PCOS. However, there are limitations to this method, and it requires a physician to rule out other diagnoses that can cause the same symptoms and/or signs.
| Doctors should rule out the following when diagnosing PCOS: |
| Pregnancy |
| Thyroid disease (hyper- or hypothyroid) |
| Elevated prolactin |
| Hypothalamic amenorrhea |
| Congenital adrenal hyperplasia (a genetic disorder) |
| Cushing’s syndrome (caused by chronically elevated cortisol levels) |
| Primary ovarian insufficiency |
| Androgen secreting tumor (rare) |
| Acromegaly (overproduction of growth hormone by pituitary gland) |
Medical Treatment for PCOS
This is a shining example of where the traditional medical model has resorted to managing symptoms. If a woman isn’t trying to become pregnant, the first line treatment is hormonal contraception (birth control pill) to essentially hijack the hypothalamic-pituitary-ovarian (HPO) axis and mimic a menstrual cycle. The problem is that those aren’t actual periods a woman is having while on ‘the pill’, whether she has PCOS or not. They are medically induced withdrawal bleeds caused by a manipulation of hormone levels.
I was a pharmaceutical rep in my younger days, and sold the world’s most commonly used birth control pill at the time. I’m well versed in just how powerful even so-called low-dose birth control pills can be. While they may be touted as a way to regulate your menstrual cycle, I assure you, that is not what is happening. There are healthier ways to work with your body’s natural instincts to get your menstrual cycles on track.
Another commonly prescribed treatment for PCOS is the off-label use of a diabetes drug called Metformin to help control blood sugar and treat or prevent type 2 diabetes. There are a couple of problems with this approach. First, most doctors won’t insist that the patient make lifestyle modifications with diet and exercise, or they have no effective way of tracking their progress. Metformin is a powerful medication intended to be utilized in conjunction with creating healthy habits to lower blood sugar levels. Second, Metformin is intended to be taken long term, and the research shows that it is ineffective for weight loss. Losing as little as 10% body weight can be enough to regulate menstrual cycles. Metformin’s use is easily overshadowed by interventions such as healthy diet, exercise, improved quality of sleep and stress reduction.
Metformin is, in fact, effective at reducing the chances of developing type 2 diabetes, but at what cost? It doesn’t address the root of the problem. (<— You can add this to my list of quotes.)
The Endocrine Society Clinical Practice Guidelines state that Metformin can improve menstrual irregularities, but has little or no effect on excess body hair, male-pattern baldness, acne or infertility. As for infertility, current research shows that while it may help regulate the menstrual cycle and ovulation and result in higher pregnancy rates, it does not result in more babies being born. In other words, it may help women with PCOS get pregnant, but their likelihood of staying pregnant and delivering a healthy baby doesn’t increase.
And one more not-so-fun fact about Metformin is that it depletes vitamin B12 from the body. This carries health risks as well as fertility risks.
And then there are the common side effects that many people simply can’t tolerate, like:
- Diarrhea
- Bloating
- Nausea
- Heartburn
- Abdominal pain
- Gas
- Headache
- Metallic taste in the mouth
Pro tips for managing PCOS without medication
So, if you just scrolled past everything else to get to this point, I’ll summarize what you missed in one sentence. The traditional medical approach to PCOS only manages symptoms, comes with plenty of common side effects, and has been proven in the research to be less effective at improving overall health status than what I’m about to offer. Keeping in mind that we’re all unique individuals, and there is no one-size-fits-all approach, I will share with you some of the more common tools I use with my PCOS patients.
Tip #1 Clean up your diet.
Eating a healthy diet is important, not just for managing blood sugar, but for reducing inflammation, as well. Elevated blood sugar (glucose) is a common symptom of PCOS, and it can be highly inflammatory to the body. In addition, for those who are carrying excess pounds, studies have shown that losing as little as 10% of your body weight can be enough to normalize ovulation. To be honest, this is a diet we can all benefit from.
*Cut out added sugars and processed foods. (Note: that includes no agave nectar)
*Eat the rainbow. Enjoy lots of leafy greens and colorful vegetables and fruits, and try to keep it to a 2:1 ratio (more veggies than fruit)
*Eat plenty of healthy fats, like olives and olive oil, avocado and avocado oil, real organic butter, wild-caught fish like salmon, sardines, mahi-mahi, mackerel and trout.
*Do not use corn oil or Canola oil.
*Minimize carbohydrate intake. This does NOT mean I recommend a ketogenic diet, which will ultimately work against you. For blood sugar management, I recommend limiting your net carbohydrate consumption to about 60 grams per day, not including green veggies, carrots and beets. Calculate your net carbs like this:
TOTAL CARBS – TOTAL FIBER = NET CARBS
There are several handy smartphone apps that help track your food. I’m not suggesting you count calories or track anything other than your carbohydrates, so if you have an aversion to tracking your food, that should take some of the pressure off.
*Cut out caffeine and alcohol. You can have green tea, even though it has a little caffeine.
*Minimize cow dairy products. An exception I make for those who can tolerate some dairy is organic Greek yogurt, because it’s high in protein.
*No soy
*Eat something every 2-3 hours to help keep the blood sugar stable. Don’t wait until your stomach is growling.
*Hydrate, hydrate, hydrate. Most people who think they’re drinking enough water are missing the mark. I usually encourage people to drink at least 90 ounces a day. If you work at a physical job or exercise regularly, that could easily be increased to 128 ounces (1 gallon) per day. You may actually lose some weight just by being sufficiently hydrated, because your body no longer believes there’s a drought. A common complaint is having to get up to urinate during the night. That’s why I suggest front-loading your day by consuming more water earlier and tapering off by the evening.
Tip #2 Exercise regularly
I typically work with my patients to figure out what types of exercise they feel they can realistically commit to doing at least three times a week. It may be yoga, zumba, brisk walks, weight training, dance, indoor cycling. The list goes on. The key is to find a community, whether it’s online, one-on-one with a trainer, in a group setting or with another family member. Yoga is surprisingly effective at improving blood sugar levels. Make it happen, and rather than seeing it as a chore, try seeing it as grown-up recess or consider it a mindful experience. Moving your body can be very meditative.
Tip #3 De-stress
We all know that stress can be detrimental to our wellbeing, but we live in a stressful world, so how do you accomplish this? I wish I had a magic formula for you, but it means different things to different people, so I try to tailor these recommendations to the individual, as much as possible. These ideas may spark thoughts of what will work best for you.
- A gentle yoga practice, like hatha yoga
- Forest bathing – go out and sit in nature, even if it’s tucked in a city park
- Journaling – the act of being in the moment and writing down your thoughts
- Meditation – silent, guided, chanting. Choose which one suits you best.
- Epsom salts baths
- Massages
- Deep breathing – great for calming down quickly and easy to do. You’ve got to breathe anyway, why not use it to de-stress!
Tip #4 Get good sleep
This is crucial for good health. Our bodies need to recover from the day while we sleep. If the quality and/or quantity of sleep is lacking, it can have a profound effect on wellbeing.
- Make sure your bedroom is dark. Cover any lights that stay on continuously, like those on power strips. Cover LED clocks. Put up room darkening window treatments.
- No screens in the bedroom. The screens from televisions, tablets, laptops and phones emit light that closely mimics daylight. Your brain can’t tell the difference.
- It’s best to stop watching TV and looking at screens 30 minutes before bedtime.
- Utilize the ‘night shift’ setting on your mobile phone.
- Add a blue light dimming app to computers. I use f.lux (https://justgetflux.com/)
- Keep it cool. The ideal ambient temperature for sleep is 65 degrees F. That’s chilly!
- If you consistently wake in the middle of the night, try having a healthy snack about a half hour before bed that is high in protein and fat. It can help regulate blood sugar for better sleep.
- If your partner has bad habits that keep you awake (looking at their phone or watching TV), it’s time to have a talk. Poor sleep contributes to type 2 diabetes and a host of other health issues.
- Side note: Men produce testosterone only when they sleep. Poor sleep can lead to low testosterone levels.
Tip #5 Supplements
Again, there’s no such thing as one-size-fits-all, but here are some supplements that can help those with PCOS.
Inositol is a group of sugars sometimes referred to as vitamin B8, and is a component of cell membranes. It influences the action of insulin on glucose, as well as affecting the chemical messengers in the brain, serotonin and dopamine. Research shows that it is best to supplement both myo-inositol and d-chiro inositol together, however there is debate as to what the appropriate ratio should be. For now, you’ll generally find recommendations for 40:1 myo- to d-chiro-inositol. A daily dose might be 2000 mg myo-inositol and 50 mg d-chiro-inositol. This is what you should be taking instead of Metformin.
Fish Oil provides omega 3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) and plays a key role in reducing inflammation as well as helping to lower levels of triglycerides (energy stored as fat). I recommend around 2000 mg of fish oil daily.
Vitamin D3 is crucial for anti-müllerian hormone (AMH) signalling in the ovaries, FSH sensitivity and progesterone production. Most of us are low in vitamin D, even those of us who spend a great deal of time outdoors, so supplementing 5000 iu of D3 daily is recommended.
N-acetyl-L-cysteine (NAC) is a precursor to glutathione, which is often called the master antioxidant. NAC (600-1200 mg/day) has been shown to regulate insulin receptor function, improve egg quality and lower testosterone levels. Why not just take glutathione? First, it can be expensive to purchase the form of glutathione that your body can actually absorb and utilize. Second, I’m of the belief that if I can provide the tools for my body to do the work it was designed to do, I’m choosing that option.
Zinc is one of our essential trace minerals with antioxidant capabilities and enzyme regulating behavior. Studies show that women with PCOS tend to have lower zinc levels which could contribute to blood sugar issues, insulin resistance and diabetes. Low zinc levels can also contribute to acne and feelings of depression as well. I generally recommend about 60 milligrams daily.
Melatonin is a hormone that we associate with the pineal gland in the brain and regulation of our sleep-wake cycles, but it is also found in the follicular fluid. Studies have found that it is reduced in women with PCOS. Taking melatonin at night before bed may not only help you fall asleep faster, but it provides powerful antioxidant protection and free radical scavenging abilities in the ovaries. There’s no benefit to taking more than the standard 3 mg dose. In this case, more is not better and could just make you drowsy the next day.
There are plenty more options for targeted nutrients to help manage PCOS. Depending on your individual circumstances (e.g. classic PCOS or lean PCOS), supplement recommendations can vary, however the lifestyle advice stays pretty static. Why? Because eating a clean diet low in sugar, exercising, sleeping well, hydrating and managing stress are things we ALL should be doing for better health, and your body will love you for it.
If you’re interested in learning more about managing PCOS without prescription drugs, reach out to Merritt Wellness to speak with me or one of our other qualified functional medicine practitioners.
PCOS (Polycystic Ovary Syndrome) and Diabetes. Centers for Disease Control and Prevention, (2020). https://www.cdc.gov/diabetes/basics/pcos.html
Mohammad, M.B., & Seghinsara, A.M. (2017). Polycystic Ovary Syndrome (PCOS), Diagnostic Criteria and AMH. Asian Pacific Journal of Cancer Prevention, 18(1): 17–21. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5563096/Legro, R.S., et al. (2013), Diagnosis and Treatment of Polycystic Ovary Syndrome: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, Volume 98, Issue 12, pp. 4565–92. https://doi.org/10.1210/jc.2013-2350
