by Dr. Jillian Teta
Polycystic Ovarian Syndrome (PCOS): an umbrella term for a spectrum of metabolic dysfunction
Truth is, we don’t know exactly what causes PCOS (Polycystic Ovarian Syndrome). A single, consistent causative factor has evaded researchers and clinicians alike. PCOS, instead, is thought to spring from many different factors, including environmental and genetic ones.
PCOS represents a broad spectrum of symptoms in a wide variety of women. Classically thought as something that only struck women who were overweight, we can easily see that this is not the case, based on the amount of ladies who are lean and struggling with PCOS.
Infertility associated with PCOS can be heartbreaking. The irregular cycles, anovulation, acne, hair growth and weight loss resistance commonly found in women with PCOS are frustrating and perplexing. Considering some of the underlying mechanisms at play provides insight as to how to move forward.
PCOS is not simply a problem of insulin resistance and metabolic syndrome. If that were true, all women with these would also have PCOS, and obviously, that is not true. PCOS begins far higher up in the chain of command, in the brain and nervous system, and how it responds to your internal and external environment.
While it is certainly possible to eat your way into PCOS by over consuming simple starches and sugars and inducing insulin resistance, this is not a universal path by a long shot.
If you are not into physiology and biochemistry and science-y stuff, feel free to skip this section, but it’s important to understand what you’re dealing with. 😉
How PCOS often starts is in the hypothalamus, a structure in your brain. Specifically, the application of a wide variety of stressors will initiate the process. “Stress” in this context means a variety of different things.
Chronic, uncompensated emotional and mental stress, physical stress from over-exercising, over-dieting and under-sleeping; environmental stress from exposure to hormone-disrupting compounds, estrogens, plasticizers and certain classes of pesticides and/or any combination of the preceding factors will increase catecholamines.
This, in turn, is noted by the hypothalamus, which will start releasing increased amounts of CRF (corticotropin-releasing factor).
CRF, in turn, increases cortisol production from the adrenals; increases the production of androgens, and can cause symptoms of depression.
Elevated, uncompensated cortisol will increase blood sugar. Increased blood sugar will lead to increased insulin release.
With chronic high blood sugar and high insulin, you tip towards insulin resistance.
In an attempt to make your body “hear” insulin’s message, the pancreas will make even more insulin. The ovaries are spurred on to make androgens (estrogen and testosterone) via insulin or IGF-1 (insulin like growth factor) receptors on their surface.
The extra insulin and cortisol can create central obesity, typical in metabolic syndrome and PCOS, but there are plenty of lean women with PCOS.
The extra androgens, pumped out by the ovaries, are converted to estrone, by the process of aromatization. This process is accelerated when someone is overweight, as the fat cells are hot beds of aromatization.
Estrone is an estrogen fraction. Estrogen dominance is common in women with PCOS, who often have low absolute levels of progesterone or low relative progesterone in relationship to estrogens.
Estrone, in high amounts, is capable of disrupting another hormone, GnRH (gonadotropin-releasing hormone). The disruption in GnRH in turn leads to a skewing of the release of two other hormones important in the PCOS conversation, LH (luteinizing hormone) and FSH (follicle stimulating hormone).
Too much LH is produced, and too little FSH. Excess LH will drive even more androgen production, which will lead that cycle churning forward and assisted by high insulin.
Too little FSH means follicles never fully develop, so they swell a bit and turn cystic, unable to complete their cycle of maturation and thus ovulation.
High insulin, excessive androgens, elevated estrone and LH/FSH disruption lead to the classic symptoms of PCOS: irregular periods, absent period, infertility, acne, hair growth on the chin, above the lip, around the nipples and under the bellybutton. Tests and imaging studies may determine you are not ovulating, even though there are multiple swollen follicles/cysts on your ovaries.
Interestingly, these swellings/cysts are not always present in all women with PCOS. Excess androgens are also not always found, leading clinicians and researchers to think of PCOS as a wide presentation of symptoms, along the lines of a spectrum. What appears to be a consistent theme in all women with PCOS is GnRH disruption, leading to alteration of LH and FSH. This skewed ratio of high LH and low(er) FSH is responsible for irregular menses and infertility.
Therefore, it is important for all women, who are to be worked up for PCOS to not only have their androgens and fasting insulin tested, but LH and FSH too.
PCOS is therefore thought of as a syndrome on a spectrum – there are many symptoms captured by this umbrella term, but not all symptoms have to be present for a woman to experience PCOS and deal with the consequences of it.
Strategies for PCOS management:
Conventionally, drugs like metformin, birth control pills, progestins/progesterone and spironolactone are used to manage PCOS. This is fine, and often quite necessary, but there are many things that you can do today to help yourself, using your lifestyle, to mitigate the multitude of factors responsible for symptoms. A strictly drug approach, in my view, will be less superior to one that also utilizes food, movement, sleep, stress management and smart supplementation.
An integrative (and commonsense) approach to PCOS management therefore will focus on calming the brain down, re-sensitizing the body to insulin, normalizing cortisol output and balancing androgens. This will dovetail into breaking the dysfunctional loop that skews the LH/FSH ratio responsible for infertility associated with PCOS. This approach holds true even in lean women with PCOS.
Evaluate carbohydrate tipping point: Women that develop PCOS likely have an altered carbohydrate tipping point – the amount of carbohydrates that enable good energy, without being so much as to induce fat gain or blunt fat loss. In a woman who has been dealing with fat loss resistance with PCOS, this is an important step.
Carbohydrates may have to be reduced to improve sensitivity. Carbohydrate intake is best filled with complex carbohydrates from vegetables and tubers, than those made from white sugar or simple starches. In women with sleep disturbance associated with PCOS, timing carbohydrates before bed can have some benefit.
Swap training style: Many women, in a knee-jerk response to weight gain, may find themselves doing more middle intensity/middle duration cardiovascular activity like jogging, biking, aerobics and so forth. These types of activities drive up cortisol and do not release other hormones or compounds that could offset its negative impact.
It would be more efficient for these women to trade these sessions for shorter, more intense workouts with weights, interval and plyometric training, sprints and longer, slower movement like walking. This style of training not only helps the body re-sensitize to insulin, it helps offset the negative feedback loop of cortisol and androgens off the rails.
Prioritize sleep, rest and down time: Consider that sleep acts as an enormous hormonal “reset” button, and that being under-slept is a large factor in the release of excess stress hormones, which drive the underlying pathology of PCOS. Make sure your room is dark and cool, and that there is not a lot of clutter or things to distract you in your bedroom, like unfinished projects or stacks of bills or unopened mail that may stress you out.
Taking time each day to step away from the crush and flow of every day life to take a few deep breaths and re-center is a non-negotiable. Spending time with loved ones, utilizing self care, pursuing hobbies and pleasures that fill your heart and getting some rest will help smooth the rough edges of a frazzled nervous system.
Help your body metabolize androgens appropriately: An imbalance of estrogen, progesterone and testosterone underpin acne and male-pattern hair growth in PCOS, not to mention menstrual and ovulation irregularities.
There are a number of foods that can be incorporated into your daily nutrition that help your body break down and metabolize and excrete estrogen appropriately, decrease aromatization to estrone and have anti-androgen effects. Broccoli, cauliflower, Brussels sprouts, kale, bok choi, cabbage, egg yolk, lemon, spearmint tea, stevia and pumpkin seeds top this list, although there are more.
There are also supplements that contain key food derived ingredients, herbs, vitamins and minerals that have been shown to help balance androgens. The two we use at our clinic are called Metabolic Fembalance – this product helps metabolize estrogen appropriately and divert less estrogen into being made into estrone; and Androgen Complex – is a product that blunts the aromatization of androgens, and improves the response and normalizes the feedback loop between the brain, the pituitary, the adrenals and the ovaries that is classically disrupted in PCOS.
Improve hormonal signaling by improving membrane fluidity: Have you ever heard the phrase, “the rigid break before the flexible”? Not only an interesting six words to ponder philosophically, but exquisitely true for cellular membranes.
Hormones are chemical messengers; little texts sent between the systems and cells of the body to ask another system or cell to do something. In order to receive the message, the cell receptors have to be available to be bound and the cellular membrane must be supple to accommodate this interaction. Membrane fluidity is key not only for hormones, but for all chemical messages.
The way to increase membrane fluidity is to increase your intake of omega-3 fatty acids. Salmon, mackerel and other fatty fish should be consumed regularly. Caviar, walnuts, flax/flax products are also food sources of omega-3 fatty acids. This is not a big list, so supplementation with fish oil or cod liver oil is often recommended, at a dose of about 3 grams daily.
Avoid known endocrine disruptors and estrogens in the environment: Women with PCOS are going to be more vulnerable to hormone-disrupting agents in their environment, because a compromise is already present.
There are a few worth mentioning here, for their strength in the research and prevalence in our everyday lives. BPA (bisphenol A) is a well known endocrine disruptor that is being phased out of most products, but whenever you are buying something in a can or in plastic or any container that has a coating, make sure it says “BPA free”.
Phthalates are another compound to be minimized whenever possible. Phthalates are plasticizers, added to plastics to improve their flexibility and strength. Many food and beverage containers, shower curtains, building materials, glue, paint, waxes, air fresheners, plug ins and even makeup. Avoid vinyl when possible, opting for natural fibers and materials instead, and read labels.
Women with PCOS would be well served to find makeup that does not contain phthalates or heavy metals or other hormone disrupting compounds. Due to consumer demand, there are many lines available that have excellent, clean makeup. Beautycounter and Tarte are some of my favorites, and are well worth checking out.
Conventional dairy products, particularly butter and cheeses, have high amounts of exogenous (environmental) estrogen and plasticizers in them. It is well worth spending your money on organic dairy products if you have PCOS to avoid this excessive exposure.
Following this framework assures that you are covering all of the bases necessary to address the many factors that coalesce to generate PCOS.
If you need more help, or want an in-depth education and framework, check out ME’s PCOS Program