A Functional Medicine PCOS Protocol: Comprehensive Testing, Therapeutic Diet, and Supplements

Polycystic ovary syndrome is the most common endocrinopathy in reproductive-aged females worldwide. In the United States, approximately 7% of female patients are affected. Polycystic ovary syndrome increases the risk of infertility and cardiovascular and metabolic diseases. Metabolic syndrome and type 2 diabetes mellitus are twice and four times as common in patients with polycystic ovary syndrome. Four billion dollars are spent annually to diagnose and treat PCOS, not including the healthcare costs associated with the condition's comorbidities. Given these statistics, polycystic ovary syndrome is a women's health concern that cannot go unaddressed. (7, 23)

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What is PCOS?

Polycystic ovary syndrome (PCOS) is a common hormonal disorder that affects reproductive-age women. It is characterized by a combination of symptoms, including irregular menstrual cycles, excess androgen production (male hormones), and multiple small cysts on the ovaries. PCOS disrupts the normal hormonal balance in a woman's body, leading to a range of manifestations such as irregular menstrual cycles, infertility, acne, excessive hair growth, and weight gain. (17) 

PCOS Symptoms

According to the Rotterdam Consensus, PCOS can be diagnosed with the presence of at least two of the following three criteria:

• Chronic ovulatory dysfunction
• Hyperandrogenism
• Polycystic ovaries (as visualized on imaging): at least 12 follicles measuring 2-9 m in diameter and/or an ovarian volume of at least 10 mL in at least one ovary

Chronic ovulatory dysfunction can be confirmed by irregular menstrual cycles (oligomenorrhea), the absence of menstruation (amenorrhea), and the absence of ovulation (anovulation) (16).  

Hyperandrogenism can be diagnosed clinically by the presence of excessive acne, androgenic alopecia (hair loss), or hirsutism (male-pattern excessive hair growth); or chemically by elevated serum levels of total, bioavailable or free testosterone or dehydroepiandrosterone sulfate (DHEA-S). 

Metabolic symptoms are also common in patients with PCOS because of the insulin resistance associated with the condition, including high blood sugar, high cholesterol and triglycerides, high blood pressure, and excess body weight. (3)

What Causes PCOS?

One of the primary causes of PCOS is hormonal imbalance, specifically involving insulin and androgens. Insulin resistance, a condition in which the body fails to respond effectively to insulin, disrupts normal hormone regulation and triggers the ovaries to produce excessive amounts of androgens. These male hormones interfere with the ovulation process and result in the formation of cysts in the ovaries. The elevated levels of androgens also lead to the characteristic symptoms of PCOS, such as acne and excessive hair growth. (3, 17)

Genetics also play a role in the development of PCOS. Studies have identified several genes that may contribute to the risk of developing the condition. These genes are involved in hormone regulation, insulin action, and the production of androgen receptors. Having a close family member with PCOS increases the likelihood of developing the condition, suggesting a hereditary component. (7, 13)

Environmental and lifestyle factors also contribute to the development and severity of PCOS. Obesity, sedentary lifestyle, and poor diet can exacerbate insulin resistance and hormonal imbalances. Excess body weight amplifies the production of insulin, aggravating the symptoms of PCOS. Additionally, high stress levels, inadequate sleep, and exposure to endocrine-disrupting chemicals can further disrupt hormone regulation, potentially increasing the risk of PCOS. (9, 13)

Functional Medicine Labs to Test for Root Cause of PCOS

Functional medicine testing helps doctors holistically evaluate patients with PCOS. Using various lab panels aids in assessing the multiple organ systems that influence and can be affected by PCOS. 

DUTCH Test

The DUTCH panels are some of functional medicine practitioners' most commonly used hormonal panels. The DUTCH Plus and DUTCH Complete panels require several urine and salivary collections over one day to measure estrogen, progesterone, androgens, cortisol, organic acids, and their respective breakdown products. These tests analyze how the body makes and metabolizes reproductive hormones and can provide insight into underlying causes of dysfunctional stress responses and sleep patterns. 

The DUTCH Cycle Mapping test may be advantageous over the other DUTCH panels for patients with PCOS because it follows estrogen and progesterone levels throughout an entire cycle to map out hormonal patterns associated with the various phases of the menstrual cycle. Unlike single-day tests, this panel will better evaluate patterns associated with anovulatory cycles, as is typical with PCOS. 

Serum Hormonal Testing

Estrogen, progesterone, testosterone, and DHEA can also be measured in the serum. Some providers prefer assessing hormones via the serum; however, single blood tests cannot provide insight into how hormones fluctuate throughout the menstrual cycle, nor do these results help evaluate hormonal metabolism. Measuring sex hormone binding globulin (SHBG) with testosterone helps identify how much testosterone is bound in circulation, rendering it inactive. In PCOS, SHBG levels are often lower than optimal (17). 

Additional hormones are often ordered for patients with suspected PCOS because specific hormonal patterns are commonly seen in these patients. Although these hormones are not required for diagnosis, they can help to confirm a PCOS diagnosis clinically. Prolactin is often elevated in patients with PCOS (17). In healthy women, the ratio between LH and FSH usually lies between 1 and 2; in women with PCOS, this ratio becomes reversed and might reach as high as 2 or 3 (10).

Follicular cells of the ovaries produce anti-Mullerian hormone (AMH), which can correspond to a woman's ovarian reserve (2). Given the polycystic nature of PCOS, the level of AMH is two- to three-fold higher in women with PCOS compared to that in healthy women of childbearing age. 

Thyroid Panel

Thyroid dysfunction can interfere with the healthy cycling of reproductive hormones. Women with PCOS are more likely to develop subclinical hypothyroidism and autoimmune thyroiditis (20). A thyroid panel, including TSH, total and free levels of T4 and T3, and thyroid antibodies, should be ordered at least annually to screen for thyroid conditions. 

Cardiometabolic Panel

Given the increased risk, a comprehensive cardiometabolic panel should include a lipid panel, diabetes panel, hs-CRP, vitamin D, and CMP to screen for dyslipidemia, hyperglycemia and insulin resistance, and kidney and liver disease.

Comprehensive Stool Analysis

Dysbiosis has been associated with insulin resistance and ovarian dysfunction (3). Therefore, gut function testing and microbiome assessment should be considered with a comprehensive stool analysis as part of a root-cause diagnostic evaluation of PCOS.  

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Conventional Treatment for PCOS

Conventional medicine relies on pharmaceutical medications to address common health concerns related to PCOS symptomatically. Weight loss is recommended for patients who are overweight. Clomiphene and letrozole are first-line medications for infertility to induce ovulation. Metformin is the first-line medication for hyperglycemia. Hormonal contraceptives (i.e., oral contraceptive pills, dermal patches, or vaginal rings) for irregular menses and dermatologic manifestations. (23) 

Functional Medicine Treatment Protocol for PCOS

While the above medications can be helpful for the quick resolution of unwanted symptoms, they do not correct the underlying pathologies associated with PCOS and its clinical manifestations. Therefore, discontinuing any of the above medications will result in the return of symptoms. Thus, functional medicine aims to decrease inflammation, correct insulin resistance, and balance hormones to restore regular ovulation and glucose metabolism.

Therapeutic Diet and Nutrition Considerations for PCOS

Diet is an effective intervention for improving ovarian health, fertility, and metabolism. Therefore, dietary advice should be offered to all PCOS patients as part of first-line treatment. A 2022 systematic review and meta-analysis concluded that low-carbohydrate diets most effectively optimize hormonal outcomes for patients with PCOS. Positive laboratory findings associated with a low-carb diet include: increased SHBG and decreased AMH, free androgen index, and total testosterone. Additionally, patients experience increased rates of clinical pregnancy, regular ovulation and menstruation, reduced miscarriage, and improved clinical symptoms of hyperandrogenism. This review also noted that the magnitude of improvement and duration of dietary compliance were directly related. (15) 

Additionally, in a time where intermittent fasting is trending, it should be noted that specific patterns in meal timing and distribution can significantly influence clinical outcomes in patients with PCOS. High-caloric intake at breakfast with reduced intake at dinner, compared to skipping or eating a low-calorie breakfast and a high-calorie dinner, improves insulin sensitivity and ovulation rates. (8) 

Supplements Protocol for PCOS

Consider using the following dietary and herbal supplements to support a holistic treatment plan and expedite positive clinical outcomes. 

OvaBlend™

Vitanica's OvaBlend™ combines seven ingredients to synergistically support healthy blood sugar regulation and ovulation. Highlighted ingredients of this formula include: 

• Green tea reduces inflammation and increases SHBG. 
• Chromium, cinnamon, and NAC support healthy glucose metabolism and improve insulin sensitivity. 
• Saw palmetto inhibits the conversion of testosterone to dihydrotestosterone (a stronger form of testosterone); clinical reductions in hair loss and acne can be observed by inhibiting this conversion. 

Dose: 2 capsules three times daily

Duration: 3 months

Ovasitol®

Myo- and D-chiro forms of inositol are often recommended for PCOS, given the ample research that shows inositol improves the rate of ovulation, hormonal balance, hormonal acne, and metabolic markers. Additionally, inositol is associated with more regular menstrual cycles. Ovasitol® contains a combination of myo-inositol and D-chiro-inositol in the body's naturally occurring ratio of 40:1. Research shows taking these two forms, in this ratio, is more beneficial than taking either form of inositol alone. 

Dose: 4,000 mg daily

Duration: 3 months

Vitamin D

Vitamin D helps to modulate immune and inflammatory pathways, blood sugar, and ovarian function. Vitamin D deficiency has been associated with insulin resistance, inflammation, and women's hormonal conditions. (3, 21)

Dose and Duration: determined by laboratory values; typical maintenance doses range from 2,000-5,000 IU daily

When to Retest Labs

Substantial shifts in hormonal patterns can be observed three months after initiating a treatment protocol, although many patients will begin to notice clinical improvements before this. Functional medicine doctors generally wait 3-6 months after starting a treatment protocol to follow up with patients and reorder labs to assess the efficacy of and the patient's response to the treatment plan. 

Learning More About PCOS

• Magazine Article: Top 6 Functional Medicine Labs to Test for Root Cause of PCOS
• Magazine Article: Why Do Some Women Get Ovarian Cysts?
• Pre-recorded Class: How To Use The Dutch Test for PCOS
• Podcast: Empowering Women with PCOS: A Functional Medicine Approach with Dr. Natalie Underberg

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Summary

Polycystic ovary syndrome is a common women's health complaint associated with significant medical complications and health concerns. While conventional medicine has tools to address the symptoms of PCOS, functional medicine doctors use advanced diagnostic testing to get to the root of hormonal imbalances and insulin resistance known to cause PCOS and its various comorbidities. It is possible to get your hormones and metabolism back on track using functional medicine, alleviating the troublesome symptoms associated with the condition.