Living With(out) PCOS

Polycystic Ovarian Syndrome (also known as PCOS, PCO, Syndrome O and Polycystic Ovary Disease or PCOD) is, without a doubt an increasing problem with as many as 1 in 15 women in the world suffering from this disease (some suggest it may be as high as 1 in 5). PCOS is a condition of hormonal imbalance in which insulin resistance and high androgen levels are present, and often includes other variations of hormone imbalance. The effects of these imbalances include reproductive, cardiovascular, and metabolic dysfunctions. Symptoms include male pattern hair growth (excess and darker hair on the face, abdomen, or chest), acne, and irregular periods as well as ovarian cysts, high BMI’s, and subfertility (difficulty becoming pregnant). The severity of PCOS varies from woman to woman, as do the symptoms. It is possible to have PCOS without ovarian cysts, without overweight, and without fertility trouble. However, these are the most familiar complaints, and PCOS is often thought of primarily as a dysfunction of the reproductive system, though the risk of heart disease and diabetes is greatly increased in women with PCOS, as is the risk for cancer, if left untreated long-term.

The precise cause of PCOS is unknown, though there are significant correlations with poor diet and high levels of toxicity, and most experts agree that insulin plays a prominent role. As such insulin resistance is sometimes pointed to as the “cause” of PCOS, but what is causing the insulin resistance itself? Genetics? Environmental toxins? Diet? I would venture to suggest that it’s a little bit of all those things. Genetics may not “cause” insulin resistance, but may cause someone to be predisposed to insulin resistance. With the appropriate diet and lifestyle, someone who is predisposed to a particular disease or dysfunction may never actually fall ill. But with improper diet, poor lifestyle habits, and exposure to excessive environmental toxins, genetic predisposition can be the difference between health or chronic illness.

Many medical professionals view PCOS as a problem to be managed at best, often prescribing drugs like metformin which is intended to increase insulin sensitivity (studies do show that it reduces insulin, testosterone, and glucose levels). There is increasing evidence, however, that PCOS may be controlled and even reversed through proper lifestyle changes, supplementation and bio-identical hormone replacement therapies, instead of merely "managing" it. Any time you desire cure, you must first discover and then address the cause of the illness. Conventional medicine is in the habit of looking to hide symptoms with drugs, rather than discover the root of the problem and heal it, and this is reflected in the fact that many doctors will put a patient diagnosed with PCOS on drugs before giving lifestyle changes a try (this is likely due to the fact that doctors are trained to go to drugs first. If, however, a doctor has been further educated and knows that lifestyle can play a role in any condition of ill health, he/she has probably also learned that most of their patients will be non-compliant because eating right and exercising is "too hard", making drugs the "best" choice).


Diet & Lifestyle Changes

One of the first places to start when trying to control or reverse PCOS ought to be diet. Evidence is piling up that shows that a low-carbohydrate diet is essential for managing PCOS. Scientific studies are now backing up anecdotal evidence of practitioners like the late Dr. Atkins, who put his PCOS patients on his famous low-carb diet. Those with absent cycles had their cycles return in just a couple months and in all PCOS patients signs of high androgen levels began to subside after the same time on the diet. A study published in The American Journal of Clinical Nutrition showed significant improvements in women with PCOS when they went on a carbohydrate restricted diet. All the women who completed the study saw significant improvements in weight reduction, waist circumference, body fat, insulin, total testosterone, and free androgens. 57% of the study participants also saw significant improvements in their menstrual cycle regularity. Another study published in the same journal showed similar positive results, detailing their research on protein versus glucose on women with PCOS. This study showed an immediate drop in cortisol and DHEA levels during a protein challenge, and a spike in cortisol and DHEA levels during an Oral Glucose Tolerance Test. DHEA is a precursor hormone and is often too high in those with PCOS, as is cortisol. The study concluded that:

“Glucose ingestion caused significantly more hyperinsulinemia than did protein, and it stimulated cortisol and DHEA. Protein intake suppressed ghrelin significantly longer than did glucose, which suggested a prolonged satietogenic effect. These findings provide mechanistic support for increasing protein intake and restricting the simple sugar intake in a PCOS diet.”

Dr. Michael Fox of the Jacksonville Center for Reproductive Medicine has a successful practice with an astonishing natural pregnancy achievement rate amongst his patients who follow his dietary guidelines, which includes highly restricted carbohydrate intake. He says the low-carb world has "transformed" their practice. Prior to their switch to a very low-carb diet (VLCD), their success rate was around 40%. Now with a VLCD their patients enjoy a pregnancy achievement rate of over 90%! Dr. Fox says that, "Again, in simple fashion, we looked at physiology and realized that insulin is released only in response to dietary carbohydrates. Thus, elimination of carbohydrates should resolve the problem. This, in fact, is the effect that we have seen. " To read an enlightening interview of Dr. Fox, check out The Heart Scan Blog. It is important to note that Dr. Fox reports in his interview very little change in their success rates with only moderately low-carbohydrate diets (such as South Beach), and stresses that it was the VLCD that so vastly improved their outcomes.

Low-carb diets are not "one size fits all", which is a potential shortcoming of a lot of popular low-carb diets. A great way to customize your diet to your unique physiology is to get a glucose meter and test your blood regularly after any foods that you think could be provoking a higher insulin response than you want (levels shouldn't go above 100, as anything past that begins to increase your cardiovascular risk). Ideally a low carbohydrate diet will contain lots of fresh, non-starchy vegetables, lean meats, healthy fats (such as coconut oil, olive oil, and grass-fed butter), some nuts and seeds, and moderate fruits. Berries are the ideal fruit when you do have some as they are more nutrient rich, and lower in sugar than other fruits.

Reducing carbohydrate should be the goal, but don't forget that increasing protein intake is also important (in other words, don't get on a low-carb diet and think that means it is time to pig out on bacon, which is mostly fat. Fat isn't evil, but shouldn't be the singular macronutrient that replaces carbohydate, but instead a combination of healthy fats and protein is essential). Ideal protein intake, according to natural fertility specialist Gabriela Rosa (BHSc, ND, Post Grad NFM, DBM, Dip Nut, MATMS, MNHAA), is around .75g per pound of bodyweight for women who are attempting to become pregnant, are pregnant, or lactating. This means that a 140 pound woman should set her protein intake goal at around 105g of protein per day, barring any other cause for that number to be increased. Another essential element in the fight against PCOS, however, is exercise, which also increases your need for protein, which ought to be kept in mind when determining your personal daily protein goal.

As stated above, exercise is also key for those with PCOS. Exercise helps to maintain (or regain) proper hormone balance, and this effect is best achieved through weight-bearing exercises. Weight lifting helps you to maintain muscle mass, and lose weight (this is another reason sufficient protein intake is essential -- losing weight without sufficient protein consumption will result in loss of muscle mass, so while you may be losing weight, it's not the kind of weight you want to shed). Both weight loss and the hormone balancing associated with exercise make it a crucial addition to your lifestyle changes.

As is the case with most illnesses, a wholistic approach must be taken for best results. One shouldn't presume to treat heart disease by popping a couple fish oil capsules each day, nor would we tell a lung cancer patient that quitting smoking will cure them. We must look at each aspect of a persons lifestyle from diet, to exercise, to sleep habits, and beyond, and make healthful changes. So what about sleep habits, then? It's an issue that shouldn't be ignored, whatever your health condition may be, but as it relates to PCOS one Netherlands study published in the Journal of Clinical Endocrinology & Metabolism, found that insulin sensitivity decreased in study participants by 19-25% after only one night of poor sleep. Imagine the havoc persistent poor sleep produces in the body!

Detoxification is also helpful in those with PCOS, as toxins can adversely affect hormone production. Heavy metals and other toxins block hormone receptors which can cause or at the very least contribute to the hormone imbalances that define PCOS. The average American lifestyle no longer includes significant physical activity, which can impair natural detoxification pathways such as sweating and regular bowel movements. Safe detoxification programs may include the use of high quality chlorella, zeolite, and MicroSilica. Talk with a qualified health-care practitioner about your options.

Stress reduction methods should also be employed. Chronic stress increases cortisol, insulin, and testosterone levels. Reducing stress and learning to take a few minutes each day to relax and perhaps perform some deep breathing exercises can prove very helpful in lowering chronic stress.

Supplements

B12, B6, and Folic Acid:

Women with PCOS tend to be deficient in vitamin B12 – there also seems to be a correlation between taking metformin (a drug commonly prescribed to women with PCOS) and increased B12 deficiency. In one study, the longer a patient was on metformin, and the higher the dose, the more significant their B12 deficiency became. Regardless of whether you are on metformin or not, it is important to have sufficient levels of B12 (and also B6 and folic acid) as it reduces homocysteine levels (homocysteine is an amino acid that, when too high, damages cells), which in turn reduces the risk of heart disease and insulin resistance.

Fish Oil:

Because PCOS is an inflammatory condition, reducing inflammation should be emphasized. Fish oil is an excellent anti-inflammatory. It has now been shown in studies to reduce insulin resistance (in some studies by as much as 70%), reduce the risk of heart disease, high blood pressure, depression, high triglycerides, etc., which are all concerns for women with PCOS. It improves the rate of glycogen storage and enhances insulin secretion from beta cells in the pancreas. Both of these actions improve glucose and insulin control.  Between 3-12 grams taken in divided doses three times a day has been shown to be most effective in women with PCOS.

Vitamin D:

Low levels of vitamin D are associated with weight gain and insulin resistance. Supplementing with doses of at least 4,000-6,000IU a day should raise vitamin D to a more optimal level. It is ideal to get a blood test to find out what your level actually is and supplement accordingly.

Cinnamon:

Cinnamon is commonly used by naturopathic physicians to help lower postprandial glucose levels. Any time you eat something with any sugar in it (even fruit!), sprinkle it with cinnamon first, or take a cinnamon capsule – cinnamon slows gastric emptying, which in turn slows the bodies glucose response.

Anti-Androgens:

Attacking the hormonal imbalance of PCOS from as many sides as possible is the swiftest way to achieve the desired results (a return to full health). With that in mind we turn now to the “antiandrogens”, or supplements that will lower high androgen levels.

Saw Palmetto has been shown to be effective for reducing androgen levels. Testosterone is converted in the body into dihydrotestosterone, or DHT. This is far more “potent” than testosterone, and is often the cause of troubling symptoms such as hirsutism (male pattern hair growth) and hair loss. Saw Palmetto reduces these symptoms by inhibiting DHT production, promoting the breakdown of DHT, and inhibiting DHT from binding to its cell receptors. A recent British study showed that women with PCOS have significantly higher levels of 5-alpha-reductase, which is the enzyme responsible for converting testosterone into DHT. 5-alpha-reductase is inhibited by Saw Palmetto. Typical dosages of Saw Palmetto in treating PCOS are around 320mg daily.

Saw Palmetto does have some potential side effects but they are mild and can be reduced or eliminated by reducing the dosage of Saw Palmetto slightly, or taking it every other day instead of daily. Side effects include GI disturbances such as loose stool or flatulence, and may potentially cause breast tenderness.

Spearmint tea is my favorite natural antiandrogen – it tastes fantastic when iced and sweetened with a little stevia! It’s more like a twice-daily treat than medicine, and has been shown in studies to reduce testosterone levels. Spearmint tea doesn’t reduce total testosterone but it does reduce the amount of free testosterone, which is the problem-causing testosterone – only the free testosterone is metabolically active, so reducing that reduces symptoms. A study was done in 2007 specifically using spearmint tea with test subjects with PCOS and they all showed a reduction in their testosterone levels.


Bio-Identical Hormone Replacement Therapy

Visiting a doctor is essential at some point in order to determine the specific hormone imbalances that you need to address, and to confirm that you do have PCOS and not some other constellation of hormone imbalance. Hopefully your doctor is familiar with PCOS already, as well as bio-identical hormones. In case your doctor isn't familiar with this condition though, here is a list of blood tests you should ask to have run:

Follicle Stimulating Hormone (FSH)
Luteinizing Hormone (LH)
Thyroid Panel (TSH, T4, Free T3 and Free T4)
DHEA
Testostrone
Prolactin
Sex Hormone Binding Globulin (SHBG)
17-hydroxyprogesterone
Estrogen
Fasting Glucose
Fasting Insulin
Blood Lipids (including triglycerides and HDL/LDL cholesterol)
Homocysteine

It is important to be aware that not all of these tests must come back abnormal for you to be properly diagnosed as having PCOS. Multiple follicles in the ovaries, menstrual irregularities, and excess hair growth and acne may be enough for a diagnosis.

After your bloodwork comes back, your doctor should recommend appropriate bio-identical hormone replacement therapy to help give your body that extra nudge it needs to get back into balance. This should almost certainly include thyroid medication (it is rare to find anyone these days who doesn't need a few grains of Armour or other bio-identical thyroid medication), and varying combinations of other bio-identical hormones.