Did you know that September is Polycystic Ovarian Syndrome (PCOS) awareness month? When another health problem affecting women gets its own month, it means it’s finally being recognized as a real problem, and not enough patients (and health care professionals) are aware of it yet. PCOS is in fact the most common hormone disorder of reproductive age women. Often it takes years for symptoms to be recognized and diagnosed; some women have very mild symptoms that even further delay a medical work up and proper treatment. So, what exactly is PCOS and why does it matter? While this condition does have a genetic component, more and more research is pointing to problems with high carbohydrate diets, blood sugar problems, and environmental toxins as contributing factors to the increasing incidence of PCOS in women.

What exactly is PCOS?

Polycystic Ovarian Syndrome is a hormone imbalance and blood sugar regulation problem that affects up to 12% of women. Symptoms typically begin a few years after girls first get their periods. Symptoms arise due to blood sugar problems that cause high testosterone and androgens in the blood, along with abnormal levels of female hormones contributing to irregular or absent periods. Women with PCOS ovulate irregularly, if at all, which means they end up having low progesterone, which in turn contributes to more imbalances and health problems. At present, the cause of PCOS is poorly understood, but we do know that problematic blood sugar regulation, known as “insulin resistance,” is a major culprit in the development of PCOS in women.

There is no “one” test used to diagnose PCOS; rather, a collection of 2 or more of the following symptoms is needed to diagnose PCOS (after ruling out other conditions that may mimic it):

• An absence of a period for months on end (amenorrhea), or skipped periods (oligomenorrhea), or lack of ovulation,
• High testosterone or other androgen hormones, based on blood testing,
• The presence of symptoms arising from high testosterone, such as: acne, unwanted hair growth on the face, chest or abdomen, or male-pattern hair loss,
• Ultrasound confirmed presence of “multiple cysts” on the ovaries (i.e. polycystic ovaries). However, despite the name “polycystic ovarian syndrome” it isn’t necessary to have cysts on the ovaries to be diagnosed with PCOS.

These symptoms are used to define PCOS in a woman; however, there are other important health implications that arise as a result of this syndrome. Women with PCOS are at a higher risk of:

• Being overweight or obese, or having difficulty losing weight,
• Developing Metabolic Syndrome or type 2 diabetes,
• Having difficulties getting pregnant due to abnormal periods and lack of ovulation,
• If periods stay absent for years, these women have a higher risk of abnormal cells growing in the endometrial lining (the inner layer of the uterus) which may become cancerous.

PCOS can present as very mild symptoms and may elude diagnosis for years. Other women have more prominent and bothersome symptoms that prompt treatment with hormone medications, diabetes medications or laser hair removal. Either way, addressing the root cause of PCOS is very important in order to have healthy hormones, support fertility, and prevent the development of health complications such as diabetes and cardiovascular disease.

I want to reassure you that PCOS is very treat-able! While it is a ‘life long’ condition, we can absolutely balance hormones, restore insulin sensitivity, and support normal fertility and pregnancy in women with PCOS. In order to do so, we must understand and address the underlying causes of this condition.

Understanding the root causes of PCOS

In order restore hormone balance and optimize insulin function, we have to address the underlying factors that contribute to the presence and progression of this syndrome. The cause of PCOS is not well understood; while there is a genetic component, we now know that problematic blood sugar and insulin resistance are central features that contribute to elevated androgens, absence of ovulation, and abnormal estrogen and progesterone (more on this shortly). Moreover, research is also pointing to environmental toxins as contributing factors to the rise in PCOS today.

With multi-factorial factors that contribute to the development of PCOS, our treatment plan must also address all of these various factors. The root causes of PCOS that I address with my patients are:

• Insulin resistance and blood sugar dysfunction,
• Elevated testosterone and androgens, and the subsequent symptoms (unwanted hair growth, acne, male-pattern hair loss),
• Specific nutrient deficiencies,
• HPO Axis (Hypothalamic Pituitary Adrenal axis) dysfunction,
• Environmental toxins and overwhelmed detoxification.
  

This may seem like a long list of problems to address, but let me assure you, PCOS can be treated and managed using natural medicine, healthy dietary changes, supportive hormone herbs, and targeted nutrient supplementation. In my PCOS series of articles, I’ll lay out exactly how I go about supporting women in each of these realms.

Firstly, what is insulin resistance?

Insulin is the hormone that is responsible telling the body cells to open up the door and bring in sugar (glucose) from the bloodstream. It’s like a key that opens the door and welcomes glucose in. When a healthy person eats a meal, carbohydrates are broken down and our blood glucose levels rise. With all this glucose in the blood, the pancreas is triggered to release insulin so it can do its job: get glucose out of the bloodstream and into the body cells. However, women with PCOS tend to develop insulin resistance, which means that the body cells are resistant to “listening” to insulin. Essentially, the body cells don’t respond properly to insulin telling them to “open the door to glucose”. This results in the pancreas trying to release more and more insulin in an attempt to get glucose out of the bloodstream.

Why is this problematic? I’ll explain.

Firstly, this is what happens in type 2 diabetes, and women with PCOS are at a higher risk of developing diabetes. When blood glucose remains chronically high, in the long term it can cause damage to blood vessels, eyes, kidneys, and increase our risk of cardiovascular disease.

Insulin causes hyper-stimulation of the ovaries, contributing to the development of cysts and increased androgens in the blood (i.e. testosterone). This in turn produces the bothersome hair growth, acne, and other androgen-related symptoms.

High insulin in the blood decreases Sex Hormone Binding Globulin (SHBG), which in turn increases testosterone and androgens (again). To make matters worse, women with PCOS have a harder time turning their androgens into estrogen (a process called aromatization). Without sufficient estrogen, there isn’t a strong enough hormone trigger to cause ovulation. In turn, when there is no ovulation, there is very little production of progesterone as a result. One hormone imbalance leads to yet another hormone imbalance.

High insulin is associated with lower adiponectin, which is a hormone secreted by fat cells that regulates lipid and glucose metabolism. This contributes to abnormal cholesterol and weight gain.

To make matters more challenging, most women face chronic stress, poor sleep patterns, suboptimal dietary choices, and adrenal fatigue, all of which contribute to high blood glucose and insulin resistance as well.

It’s clear that insulin regulation plays a central role in PCOS; therefore, addressing the diet and using targeting supplements to improve insulin sensitivity and reduce the risk of diabetes is paramount in the treatment of PCOS.

How do you treat insulin resistance?

The main medical treatment for blood sugar problems in women with PCOS is metformin. This is the same medication used to manage type 2 diabetes. Metformin acts to reduce blood sugar and improve insulin sensitivity; but you can do the same thing through diet and select supplements to improve insulin resistance.

Dietary recommendations to improve insulin resistance

• Choose whole foods and eliminate processed and refined packaged foods.
• Eliminate white refined flour, white rice, potatoes and starchy veggies, sugar, and other simple carbohydrates. These break down to glucose instantly in the blood and cause sugar surges.
• Increase your intake of fiber, such as nuts, seeds, psyllium husk, and flax seeds.
  
• Eat at regular intervals; don’t skip meals.
• Always include a healthy protein or fat with your snacks or meals. In other words, ensure you have a good balance on your plate between carbohydrates (vegetables, starchy veggies, grains), proteins (pastured organic meat, fish, or legumes), and healthy fats (such as olive oil, avocado, nut butters, fish, etc.)
• Eliminate soda and sugar from the diet.
• Aim for approximately 125-150 grams of protein per day (about 25-30% of your caloric intake from protein, depending on height, weight and activity level)
  
• Increase your intake of colourful and especially green veggies and cruciferous veggies such as kale, collards, broccoli and cauliflower.

Supplements and herbs for blood sugar regulation

• Inositol. is is a signalling molecule that has been shown to improve blood sugar regulation. The most effective form is myo-inositol. 
• Chromium picolinate. This is a mineral which helps to reduce insulin resistance.
• Cinnamon. This warming herb has been shown to improve insulin resistance. Use generously in baking, in your coffee or tea, or as toppings to nut butter or other snacks.
• Vitamin D3. If you are deficient in vitamin D, this can worsen blood glucose. Speak to your ND to see if a blood test for your vitamin D test is a good idea for you, and what dosing is most appropriate.

Lifestyle recommendations to improve insulin sensitivity

• Exercise directly increases muscle use of glucose and improves insulin sensitivity. For beginners, start with 30 minutes of walking per day, and gradually increase to 1 hour of cardiovascular exercise on MOST days of the week, and incorporating a resistance-training program into your routine.
• Healthy weight loss. For women with PCOS who are overweight, losing only 2-5% of their body mass helps to improve insulin sensitivity.
• Adequate, quality sleep. When we are chronically stressed, our circadian rhythm gets out of whack. We need healthy sleep patterns to release melatonin, a potent anti-inflammatory molecule and sleep supporter. Poor sleep worsens stress on the body, which in turn worsens blood sugar.
• Stress management. By the same token, creating supportive stress management routines is important for our overall health and for our blood sugar. Incorporate exercise, yoga, meditation, walks in nature, or other stress relievers into your regular routine.

If you’ve been diagnosed with PCOS, work with your naturopathic provider to empower yourself with the knowledge and direction you need to reverse symptoms, enhance your health and regulate your hormones. I work with my patients every step of the journey so they have what they need to feel vibrant and beautiful in their skin. If you want to learn more about PCOS, check out my other articles or book an appointment with me to get started on your own personal treatment program.

Yours in hormone health,

Dr. Kathleen Mahannah ND

References:

Lucidi, R. (2018) Polycystic Ovarian Syndrome. Medscape. Retrieved online from https://emedicine.medscape.com/article/256806-overview#a1