Polycystic Ovarian Syndrome (PCOS) is the most common hormone and metabolic syndrome in women. If you have been diagnosed with PCOS, you have probably already scoured the internet in an effort to understand “what supplements to take” to help manage this condition. I wrote this article to highlight the most evidence-based, effective supplements to help you cut through the marketing gimmicks and budget your dollars on treatments that can actually help.

Symptoms of PCOS can include a collection of the following:

• Irregular periods (less frequent than every 35 days) or absent periods
• Signs of elevated testosterone, such as acne or excess hair growth
• Blood work results that demonstrate elevated testosterone levels
• Numerous cysts on the ovaries, found via pelvic ultrasound
• Elevated insulin (i.e. evidence of insulin resistance)
• Weight gain, or difficulty losing weight
• Difficulty getting pregnant.

PCOS can present with very mild symptoms that may go undiagnosed for years, or symptoms can be quite bothersome. It is treated with a combination of dietary and lifestyle support, and medication (in some cases). Check out this article more information about nutrition and lifestyle support for PCOS.

A key component of managing PCOS is addressing insulin resistance in cells. Many women with PCOS are prescribed the medication metformin, a diabetes drug, for this reason; this has been shown to be effective in mitigating some of the PCOS symptoms, although many women don’t tolerate the side effects (gastrointestinal discomfort).

Here are the current top 5 supplements that support insulin, metabolism and hormones in women with PCOS.

1. Inositol

Inositol is a vitamin-like substance that helps with cellular insulin signalling. There are several different types of inositol. Women with PCOS have abnormal ratios of inositol in the ovaries, which worsens hormone signalling and oocyte (egg) quality. Supplementation with inositol, more specifically, myoinositol, helps to:

• Improve insulin sensitivity in fat cells
• Normalize insulin levels
• Improve ovulation rates
• Normalize periods
• Improve egg quality prior to fertility treatments
• Reduce the chances of being diagnosed with Gestational Diabetes in pregnancy (and if it is diagnosed, it helps to reduce the severity)
• Improve metabolic parameters (hormone levels, including insulin and testosterone)
• Improve hormone balance (estrogen, progesterone, testosterone)
• Improve cardiovascular outcomes (cholesterol, glucose, blood pressure)
• Support weight loss

The ideal dose is 4 grams of myoinositol per day. This is often given in a powder form, which can be added to water and sipped throughout the day.

Does the type of inositol matter?

Yes it does. You will find myoinositol (MI) and D-chiro-inositol (DCI) in various supplements. Studies show that myoinositol is the most effective form of inositol for PCOS outcomes. While one study showed that D-chiro-inositol may be effective, later studies failed to replicate these results. Further, high doses of DCI have been considered toxic to the ovaries and oocyte maturation. While both DCI and MI are both naturally found in cells and are in fact both important for cell signalling, it is the specifically MI that is deficient and correlated with insulin resistant conditions. For this reason, I recommend that my patients avoid D-chiro-inositol and stick with myoinositol, only.

Inositol vs. Metformin

A meta-analysis comparing metformin to inositol found that both treatments were effective in lowering glucose, fasting insulin, estrogen and Sex Hormone Binding Globulin (SHBG). Myoinositol was more effective at lowering testosterone and demonstrated better pregnancy rates. Inositol is a good alternative to metformin in women who don’t tolerate metformin, or who would like an alternative option.

2. NAC (N-Acetyl-Cysteine)

NAC is an amino acid derivative that helps the body make antioxidants. It is taken in capsule form. In women with PCOS, NAC has been shown to:

• Improve insulin resistance
• Reduce glucose and insulin resistance
• Improve period regularity
• Improve egg (oocyte) quality
• Reduce miscarriage rates (in women resistant to clomiphene, a fertility drug)

Dosing ranges from 1.8-3g per day in divided doses. This is an excellent supplement for all women with PCOS, but especially those who are planning to conceive. It takes a minimum of 6 months on this supplement to see changes in body composition and androgen symptoms (hair growth, or hirtutism). In women with a history of clomiphene resistance, it should ideally be used for 2-3 months prior to another round of clomid.

3. Vitamin D

Vitamin D deficiency is extremely common in women with PCOS. Vitamin D receptors in the body help regular genes that are critical for blood sugar and fat metabolism.

In women with PCOS, correcting vitamin D deficiency and optimizing levels has been shown to:

• Reduce fasting insulin scores
• Improve the development of follicles and normalize the menstrual cycle
• Improve mood
• Supports fertility

I recommend that all my patients with PCOS have their blood vitamin D levels checked about once a year. While it is private pay expense (at least in BC - approximately $60-80), it is well worth the investment, given how critical vitamin D is for metabolism in PCOS.

4. Omega 3 Fatty Acids

Omega 3 fatty acids have anti-inflammatory, cholesterol-lowering, and metabolism-supporting effects, as demonstrated in many studies in various types of chronic illness. One systematic review examined the studies on omega 3 fatty acids in women with PCOS specifically. Mounting evidence points towards omegas as a helpful nutrient to help lower insulin resistance, cholesterol, weight and support metabolism in women with PCOS.

Specifically, studies on omegas in PCOS found that they helped to:

• Improve fasting insulin and HOMA scores (insulin resistance score)
• Reduce testosterone, hirsutism (hair growth) and improved blood hormone profiles
• Support weight loss, reduce waist circumference and BMI
• Reduce inflammatory markers
• Improve mood and general health

I generally recommend that my patients obtain a minimum of 2000mg fish oil per day (480mg EPA and 360mg DHA).

Tip: be sure to invest in a good quality omega 3 fish oil and always store it in the fridge.

5. Berberine

Berberine is a herbal extract commonly used to treat inflammation, diabetes, high cholesterol and infertility in women with PCOS. Several studies indicate that berberine has similar effects to metformin on improving blood sugar and decreasing cholesterol in patients with type 2 diabetes.

In women with PCOS who are seeking general health support, berberine can specifically help to:

• Decrease testosterone levels and improve hormone profiles
• Decrease blood sugar and insulin resistance
• Decrease cholesterol
• Improve ovulation rates

Berberine is particularly helpful for women with PCOS who want to support their fertility. Specifically, it can help to increase ovulation rates; further, it can help to improve fertility treatment outcomes (via IVF or IUI). Berberine has been shown in studies to:

• Improve ovulation rates (as effective as metformin)
• Lower the amount of fertility medications required during ovarian stimulation procedures
• Reduce the rates of Ovarian Hyperstimulation Syndrome (a condition that women with PCOS are more prone to when going through fertility treatments)
• Improve fertility treatment outcomes (specifically improve live birth rates, when combined with lifestyle changes)

Berberine typically comes in capsules of 500mg and needs to be taken 2-3 times a day.

In conclusion…

Specific supplements can be an excellent addition to a woman’s PCOS management plan. There are a million “PCOS supplements” on store shelves; this is why it is helpful to look at the research to understand what is actually worth the investment.

Every woman with PCOS is unique, and so too should her treatment plan be. This is why I emphasize testing and regular checkup visits with my patients with PCOS. This allows us to adjust treatment plans at every stage of life. A PCOS hormone balancing plan may need to be adjusted as a woman approaches the time in her life where she wants to start a family. I tell my patients to begin this conversation with me 6-12 months in advance, so we proactively test her and adjust her treatment plan.

If you found this article helpful, check out the following articles:

• Treating the Root Cause of PCOS
  

Yours in Hormone Health,

Dr Kathleen Mahannah ND

Dr. Kathleen Mahannah is Naturopathic Doctor licensed by the College of Naturopathic Physicians of British Columbia.  Her practice focusses in women's health and hormone balancing using natural medicine and Hormone Therapy, particularly for women in perimenopause and menopause. Dr. Mahannah completed a Degree in Physical Education and Health from University of Toronto, and Diploma of Exercise Science from Capilano College, before obtaining her Diploma of Naturopathic Medicine. She has been practicing for over 6 years in North Vancouver, BC, Canada. Learn more about Dr. Mahannah here.

References

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With thanks to Dr. Jordan Robertson, ND (Confident Clinician 2021)

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