A Non Pharmaceutical Approach to PCOS

Polycystic Ovarian Syndrome, also known as PCOS, is a lifelong condition of reproductive hormonal imbalances in women. PCOS can be diagnosed at any point beginning at puberty. However, as a leading cause of infertility, many women go undiagnosed until trying to get pregnant, usually in their 20s to 30s. It is estimated that 5-10% of women in childbearing years have PCOS. PCOS risk increases with obesity, and there also seems to be a hereditary component.  

Interest in non-pharmaceutical treatments for PCOS is high. In a study of 657 women, 99% reported "yes" when asked, "If your PCOS could be safely and effectively helped by something else besides fertility drugs or birth control pills, would that interest you?". This may be due to the side effects and safety concerns that come along with the drugs previously mentioned. Functional medicine provides many possibilities for a more holistic approach, giving women more options than just pharmaceuticals.

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What is PCOS?

Imbalances in women's reproductive hormones characterize PCOS. To be diagnosed with PCOS, a woman must have two of the three following symptoms:

• High levels of androgens (testosterone, dihydrotestosterone (DHT), and dehydroepiandrosterone (DHEA)) in the blood or signs of high levels of androgens such as facial hair or dark hairs on the body
• Irregular periods or absence of periods due to lack of ovulation
• Ovarian growths that are seen on ultrasound (while PCOS implies that these are cysts, these are actually immature follicles that have stopped developing)

PCOS also puts women at risk for the following conditions:

• Heart disease
• Infertility
• Obstructive sleep apnea
• Type 2 diabetes
• Obesity
• Insulin resistance
• Metabolic syndrome
• Endometrial hyperplasia (thickening of the lining of the uterus, which can lead to endometrial cancer)
• Mood disorders
• Autoimmune thyroid conditions

PCOS Symptoms

PCOS sufferers can have the following symptoms:

• Oily skin
• Acne, especially on the chin and jawline
• Thinning hair and baldness
• Weight gain, especially in the abdominal area
• Acanthosis nigricans: patches of dark, thickened, velvety skin
• Hirsutism: dark hair growth on the chest, face, abdomen, and upper thighs
• Infertility
• Cycle irregularities: amenorrhea (not getting periods) or oligomenorrhea (infrequent/skipping of periods)
• Heavy periods

What Causes PCOS?

While we don't know the exact cause of PCOS, some physiological processes play an essential role in the disease's progression.

Insulin Resistance

Insulin, a hormone made in the pancreas that takes blood sugar (glucose) and moves it into the cell, which can then be converted into energy (ATP). Women with PCOS tend to have insulin resistance, where the cells no longer respond well to insulin and therefore do not allow insulin (or glucose) inside the cell. When this happens, we have higher insulin and glucose levels in the bloodstream. This is problematic because insulin will cause the ovaries to make more androgens, which can worsen PCOS symptoms.  

Androgens

Androgens including testosterone, DHT, and DHEA, are often referred to as "male hormones," although women make them, too. In women with PCOS, androgens are usually elevated. Researchers now believe the origin of this phenomenon starts in the brain. During a normal menstrual cycle, pulses of gonadotropin-releasing hormone (GnRH) are slow, then increase during ovulation before declining again. In response to these pulses, two pituitary hormones, follicle-stimulating hormone (FSH) and luteinizing hormone (LH), are released. FSH and LH direct the ovary on when to do certain functions, such as producing estrogen and progesterone, and when to ovulate. However, in women with PCOS, the rapid pulses of GnRH are extended, which leads to a persistent elevation of LH, often resulting in the blockage of ovulation, higher androgens, and higher estrogen.

Elevated androgens can cause several pathophysiological changes. There are follicles within each ovary that hold eggs. Every cycle, many follicles will start to develop, and one will be chosen to be released, a process called ovulation. Elevated androgens will cause the development of those follicles to cease, instead causing them to enlarge. These enlarged follicles are what can look like cysts on ultrasounds. This process will prevent one of the follicles from ovulating, leading to irregular periods.

In addition, progesterone is only made after ovulation. If ovulation does not occur, no progesterone will be made, which can cause its own slue of symptoms. Elevated androgens are responsible for the symptoms of hirsutism, acne and oily skin, and hair loss.

Inflammation

Women with PCOS tend to have low-grade, chronic inflammation that may cause an increase in androgen production.

Genetics

It seems that there is a genetic predisposition to PCOS. Knowing if any female relatives have PCOS may help to assess risk.  

Functional Medicine Labs to Test for Root Cause of PCOS

Functional medicine testing can help practitioners develop an individualized treatment protocol based on the results.

Insulin Sensitivity

The Homeostatic Model Assessment, or HOMA-IR test, assesses insulin resistance through an algorithm using fasting insulin and fasting glucose levels. Glucose, insulin, and Hemoglobin A1c (HbA1c), an average of glucose over the past six weeks, are also necessary to properly evaluate blood sugar.

Androgens/Hormones

It is essential to check reproductive hormone levels when assessing PCOS. The DUTCH Complete is a hormone test that evaluates urine metabolites, allowing the physician to understand how the patient's body is making hormones and, more importantly, how the hormones are being metabolized or broken down. This test looks at testosterone, DHT, and DHEA in addition to the other female reproductive hormones and their metabolites. This test also shows adrenal markers which can be incredibly important for a PCOS patient, as androgens are also made in the adrenal glands.

Inflammatory Markers

hs-CRP and Homocysteine should also be evaluated, as inflammation can contribute to PCOS and cause worsening of the sequelae of cardiovascular disease. In addition, a Comprehensive Lipid Panel should also be checked due to the increased cardiovascular risk associated with PCOS.

Gut Health

There is a strong association between gut health and metabolic syndrome. Running a Comprehensive Stool test can help assess general gut health so an individualized nutrition treatment plan can be made.

Other Lab Test to Check

• Follicle Stimulating Hormone and Luteinizing Hormone (FSH & LH) can be helpful in monitoring and assessing improvements throughout PCOS treatment. It's important to note that blood should be drawn for these tests during specific days of the cycle for accurate results.
• Anti Mullerian Hormone (AMH) can be helpful for PCOS infertility patients as it can give insight into egg count.
• Sex Hormone Binding Globulin (SHBG) is a molecule that binds to testosterone and helps to lower levels. It is often low in women with PCOS but can be increased with treatment.
• Prolactin is a hormone secreted from the pituitary gland in the brain. High levels can affect estrogen and progesterone levels and cause galactorrhea or nipple discharge. It's estimated that around 30% of PCOS patients have elevated prolactin levels. High prolactin in the absence of PCOS can cause similar symptoms and may be due to tumors in the pituitary gland, so it's important to check levels and investigate the cause.
• A Thyroid Panel is useful since thyroid hormones and reproductive hormones are tightly intertwined. A meta-analysis showed that women with PCOS are at a greater risk for developing subclinical hypothyroidism. Antibodies must be included on the thyroid panel to check for autoimmune thyroid conditions, as women with PCOS are also more likely to have an autoimmune thyroid condition.
• Adrenal hyperplasia is a condition that causes excess hormone production by the adrenal glands, including androgens. An adrenocorticotropic hormone (ACTH) stimulation test is the gold standard for diagnosis. It’s important for the physician to rule out this condition before making a PCOS diagnosis as the symptoms of both are similar.
• Pelvic ultrasound may be helpful in the diagnosis of PCOS to identify ovarian cysts (follicles). However, it's important to reiterate that not all women who have cysts have PCOS, and women who do not have cysts may still have PCOS.
• Continuous Glucose Monitors (CGM) are wearable devices that give real-time glucose levels. CGMs can track blood sugar and help women with PCOS make dietary changes that would benefit their blood sugar and, thus, insulin sensitivity.

Non-Pharmaceutical Approach to PCOS

Nutrition

A review published in the journal, Nutrients, discusses the benefits of a low glycemic index diet and the ketogenic diet on various markers related to PCOS. In the review, the authors concluded that focusing on general healthy diet principles, including low saturated fat, high fiber, and low fructose intake, may be enough to manage PCOS.

PCOS patients are also typically deficient in key vitamins and nutrients such as B vitamins, vitamins D, K, E, and minerals like zinc, selenium, and chromium. Foods containing these nutrients are important to incorporate into the diet to counteract these deficiencies.

Complementary and Alternative Medicine

Inositol: inositols are compounds that we innately make and are also found in certain fruits, nuts, and grains. A review published in the journal, Molecule, in 2020 concluded that treatment with Myo-inositol and d-chiro-inositol resulted in improved ovarian functioning, including ovulation and improved metabolic functioning. Another meta-analysis of over 400 women showed inositol to lower free testosterone levels, improve insulin sensitivity, increase sex hormone binding globulin, and regulate menstrual cycles.

Berberine: Berberine is a plant extract used for blood sugar regulation for thousands of years in Chinese medicine. A review in the Archives of Gynecology and Obstetrics assessed five studies of 1,078 women. In two of the studies, despite no change in overall weight loss, there was a reduction in visceral fat, a direct risk factor for cardiovascular disease, and an improvement in insulin sensitivity. Three of the studies showed an improvement in the ovulation rate. Lastly, one study showed an improvement in cholesterol markers. It's important to note that the authors of this study concluded that berberine was safe to take due to the few side effects reported in all five studies combined.  

NAC: is used to help reverse insulin resistance in PCOS patients by improving the insulin response to glucose.  

Vitamin D: Vitamin D plays a physiologic role in ovarian follicular development and luteinization via altering anti-müllerian hormone (AMH) signaling, follicle-stimulating hormone sensitivity and progesterone production. Low 25(OH) D levels are also found to be significantly correlated with insulin resistance in women with PCOS. Therefore it’s important to test for vitamin D levels in PCOS patients and supplement as necessary.

Cucurmin: A systematic review on 447 patients from seven randomized controlled trials were included in the meta‐analysis. Results showed that the ingestion of curcumin decreased body mass index and has beneficial effects on serum markers of inflammation, weight loss and glucose and lipid metabolism in patients with PCOS.

Lifestyle Changes

One of the first lines of advice for managing PCOS symptoms is weight loss coupled with a healthy, well-balanced diet and exercise. A review of 46 studies showed that rigorous exercise and resistance training might benefit women with PCOS by reducing androgen levels and improving insulin sensitivity.

Sleep is essential for everyone to restore bodily functions. In women with PCOS, it may be of even higher importance. Sleep deprivation has been linked to obesity, insulin resistance, and type 2 diabetes. One study found that obese women with PCOS had more disturbed sleep than non-obese women or obese women without PCOS. Focusing on the quality and quantity of sleep may benefit women with PCOS.

Another focus should be to avoid other chemicals in the home. Non-organic foods, cleaning supplies, and personal care products contain endocrine-disrupting toxins. This means that these chemicals can behave like hormones in your body and throw off your hormone balance.

Summary

Polycystic Ovarian Syndrome is a common condition characterized by hormone and metabolic parameters. One of the leading causes of infertility, PCOS can manifest as an array of physical and psychological symptoms.  

Functional medicine testing can help assess the root cause of PCOS. Many research-backed non-pharmaceutical approaches can be taken to help alleviate PCOS symptoms.