Polycystic Ovarian Syndrome (PCOS)

September is PCOS awareness month.  Why should you care? Because it affects 10-15% of women, many of whom are not diagnosed.  That could be you, your friend, or your daughter!

Common signs and symptoms of PCOS include: irregular periods, fertility challenges, excess facial and body hair that is increasing slowly over time, acne (especially if resistant to antibiotics or Accutane), insulin resistance, multiple small cysts in the ovaries, male pattern hair loss, weight gain, and anxiety and depression.   If a couple of these sound relevant to you, or if you have family members with PCOS, or have a mother who struggled with fertility challenges (the work-ups weren’t very good in the past), you should consider getting worked up for PCOS.  

The diagnosis of PCOS is based on two or more of these being met: bloodwork or symptoms of high levels of androgens (such as hair growth, acne, or male pattern hair loss); infrequent menstrual cycles or cycles without ovulation; and/or multiple cysts in ovaries as per transvaginal ultrasound.   The diagnosis is only confirmed when other conditions that can mimic PCOS are ruled out. 

To clarify, you may have PCOS even if you do not have cysts, and there are many women who have cysts but DO NOT have PCOS.

Unfortunately, delays in diagnosis are common, usually, it is fertility concerns that will trigger a workup.   I often see teens being put on the oral contraceptive pill to address acne or irregular menstrual cycles or other symptoms without being worked up, delaying their diagnosis for years.  This is unfortunate because people with PCOS are more likely to develop type 2 diabetes, dyslipidemia, cardiovascular disease, endometrial cancer, and obesity. There are also associations with an increase in acute heart attacks, stroke, and obstructive sleep apnea.   With proper treatment - these risks can be decreased!

Laboratory testing is really helpful to understand one’s specific type of PCOS as PCOS seems to be a combination of hormonal, metabolic, reproductive, inflammatory, environmental, and genetic factors.  We can test hormones to confirm ovulation; blood sugar parameters to understand if insulin resistance is part of your picture (it is in many cases!); we want to rule out other causes of irregular or ovulatory menstrual cycles such as thyroid disease, non-classic congenital adrenal hyperplasia, hyperprolactinemia, and androgen-secreting tumours.  We want to see if inflammation is playing a part in your picture if androgens such as testosterone are high, and assess your Vitamin D. Knowing all of these factors, along with a thorough health history and physical exam helps us to create the most comprehensive and successful treatment plan for you!

One major component of the treatment plan is typically nutritional changes.  The research on diet in PCOS shows that improving nutrition can improve hormones, fertility, and cardiovascular, cholesterol and diabetes risk profile.  We see improvements in both symptoms (the goal!) and bloodwork. 

Caloric restriction to achieve a 5% weight loss can have a significant impact, especially for women with PCOS who are overweight or have insulin resistance…  The type of diet used (keto, low GI, high protein, low fat, etc.) doesn’t matter so much as being supported through the change. This certainly isn’t going to be the right approach for everyone, so it’s important to work with a healthcare provider.  

Credit: Alex Neonakis

Women with PCOS likely do well with a less-processed diet, containing fewer advanced glycation end products (AGEs).  There might also be a role for intermittent fasting (with a 13-hour fasting window), balanced macronutrient profiles (40% carbs, 30% fat, and 30% protein), and certain therapeutic foods (foods intentionally added to the diet), but more research is needed in all of these areas.  

The bottom line is that we want to find a nutritional approach of whole foods that feels good and sustainable and provide lots of support through making changes.  

Supplements and Medications can also play a big role in PCOS.  Which supplements or medications depending on what the goals of treatment are: healthy pregnancy, ovulation, cycle regularity, reduction in hirsutism, decreased acne, insulin sensitivity, weight loss, or supporting mood, etc.  There is a fair amount of research on a few key supplements that help many with PCOS, but depending on the goal and symptoms, medication can sometimes be preferred. With any supplement or medication, the goal is to track symptoms or metrics to ensure that we’re seeing a benefit!

As with any condition, the foundations of health create a strong baseline in PCOS.  Getting solid sleep (a sleep study may be warranted if it is poor as sleep apnea is more common in PCOS),, managing stress, moving the body - especially after meals, getting outdoors, and prioritizing mental health are all going to be important.  

PCOS is a complex condition, but many thrive using Naturopathic Medicine!